2020 @dentallib Om P Kharbanda Orthodontics, Diagnosis and Management

Orthodontics: Diagnosis and
Management of Malocclusion and

Dentofacial Deformities
THIRD EDITION
Om P. Kharbanda
MDS (Lucknow), M Orth RCS (Edinburgh), M MEd (Dundee), FDS RCS
(Edinburgh) Hon., FAMS, Fellow Indian Board of Orthodontics Honoris
Causa
Professor and Chief

Head, Division of Orthodontics and Dentofacial Deformities Centre for
Dental Education and Research All India Institute of Medical Sciences
Ansari Nagar, New Delhi, India
Founder Chief
National Referral and Research Institute of Higher Dental Studies All India
Institute of Medical Sciences, Ministry of Health, Government of India
Director
WHO-Collaborating Centre National Centre of Excellence for the
Implementation of National Oral Health Programme Ministry of Health,
Government of India
Chief
KL Wig Centre for Medical Education, Technology and Innovation (CMET-
i) All India Institute of Medical Sciences, New Delhi
Visiting Professor
Discipline of Orthodontics, Faculty of Dentistry, University of Sydney,
Sydney, NSW, Australia Invited Postgraduate Faculty, Department of
Orthodontics, Dental School, University of Western Australia Perth, WA,
Australia, Department of Dentistry and Oral Health, La Trobe Rural Health
School, La Trobe University, Bendigo, Australia
President
Indian Orthodontic Society (2008-2009), Indian Society for Dental Research-
IADR India Division (2016-2018), Indian Society for Cleft Lip, Palate, and
Craniofacial Anomalies (2009-2010), International College of Dentists
Section VI (2017-2018)
Table of Contents
Cover
Title page
Copyright
Dedication
Foreword
Contributors
Preface to the third edition
Acknowledgements
List of videos
Section I: Historical aspects of orthodontics:

ancient, yesteryears, yesterdays, today and
tomorrow
Chapter 1.1: History of dentistry and significant events that

revolutionised dentistry
The origin of the term Orthodontia
History of dentistry before Christ was born (BC)
The beginning of dentistry as a profession: early to middle ages

(AD)
The development of dentistry as a science
Dentistry in 19th century
Dentistry in 20th Century
Dentistry in 21st Century
Key Points
References
Chapter 1.2: History of orthodontics
Orthodontics in ancient times
Orthodontics in 17–18th century and European dominance
American dentistry and orthodontics in mid-19th century
Contribution of Edward Hartley Angle to the orthodontic

profession (1855–1930)
The first three decades of 20th century, 1900–30: Beginning of
biological foundation of orthodontics
Orthodontics during 1960–70
Orthodontics during 1970–80: pre-adjusted appliances
Orthodontics during 1980–90: clinical success with twin block

popularised functional appliance
Orthodontics beyond 2020
Key Points
References
Chapter 1.3: History of orthodontic speciality in India
History of formal dental education in India
Postgraduate dental education
The first MDS orthodontics course in India
Key Points
References
Section II: Fundamentals of orthodontics
Chapter 2: Adverse consequences of malocclusion and benefits of

orthodontic treatment
Introduction
Adverse consequences of malocclusion
Benefits of orthodontic treatment
Limits of orthodontic therapy
Key Points
References
Chapter 3: Epidemiology of malocclusion and orthodontic treatment

needs
Need for recording malocclusion prevalence
Methods of recording malocclusion for epidemiological data
Reasons for large variations in malocclusion prevalence
Ethnic trends in malocclusion prevalence
Quantification of malocclusion
Orthodontic treatment needs
Key Points
References
Chapter 4: Classification and methods of recording malocclusion
Recognition of malocclusion
Historical review
Systems of classification of malocclusion
Angle’s classes of malocclusion
Strang’s classification based on the body of mandible
Skeletal classification (Fig. 4.19 A–C)
Simon’s classification and canine law
Incisor classification (1964)
Katz’s premolar classification (1992)
Ackerman and Proffit’s classification (1969)
Classification in primary dentition (Baum 1959)
Key Points
References
Chapter 5: Recording the severity of malocclusion: orthodontic indices
Introduction
Qualitative methods of recording malocclusion
Quantitative methods of recording malocclusion
Diagnostic classification index
Handicapping malocclusion assessment record (HMAR)
Dental aesthetic index (DAI)
Index of orthodontic treatment needs (IOTN)

Peer assessment rating (PAR)
Index of complexity, outcome and need (ICON)
American Board of Orthodontics (ABO) grading system and

discrepancy index(DI)
Key Points
References
Chapter 6: Psychological implications of malocclusion and

Introduction
Psychological implications of malocclusion
Psychological factors motivating patient to seek orthodontic

treatment
Motivational factors in adults
Orthognathic surgery patients
Functional factors
Traumatic occlusion
Articulation of speech
Cleft lip and palate
Malocclusion due to trauma
Key Points
References
Section III: Growth of face and craniofacial
complex
Chapter 7: Development of teeth, dentition and occlusion
Introduction
Molecular basis of tooth development
Stages of tooth development
Aberrations in tooth development
Dental eruption and development of occlusion
Dental eruption
Age related changes in dental arches
Key Points
Chapter 8: Prenatal development of the foetus concerning the

craniofacial region
Introduction
Pre-somite period (14–21 days)
Post-somite period (32–56 days)
Development of craniofacial structures
Genetic regulation of craniofacial development
Clinical implications
Key Points
Chapter 9: Concepts of growth and development
Introduction
Factors affecting somatic growth
Canalised growth
Methods of growth assessment
Graphical representation of height
General interpretations of graphical data
Mechanism of bone formation
Basic concepts involved in bone growth
Principles of skeletal growth
Theories of growth
Current concepts of the functional matrix: the molecular basis
Bone as an osseous connected cellular network (CCN)
Genomic thesis
Epigenetic antithesis and resolving synthesis
Current views on growth at the turn of the 21st century
Key Points
References
Chapter 10: Postnatal growth of face and craniofacial region
Introduction
Timing of growth
Growth in adolescence and puberty
Growth spurts
Growth of the craniofacial complex
Growth trends and patterns
Growth rotations
Growth of the soft-tissue integument of face
Growth of the soft tissue of midface
Ageing and soft-tissue integument of face
Key Points
References
Chapter 11: Functions of stomatognathic system and their

implications on occlusion
Orofacial function and craniofacial development
Mastication
Swallowing (deglutition)
Respiration
Speech
Deleterious oral habits
Non-nutritive sucking habits
Tongue thrusting habit
Mouth breathing habit
Bruxism
Nail biting
Lip biting
Key Points
References
Section IV: Orthodontic diagnosis
Chapter 12: Clinical evaluation
Introduction
Features of malocclusion in deciduous dentition
Clinical assessment of a child with developing or established

malocclusion
Examination of face
Evaluation in vertical dimensions of face in lateral profile
The lips
Dynamics of smile and its orthodontic implications
Functional examination of TMJ
Speech and malocclusion
Dental alignment and speech
Clinical examination of child for suspected deleterious habit(s)
Examination of oral health and periodontium
Examination of dentition and occlusion
Clinical assessment of an adult seeking orthodontic treatment
Key Points
References
Chapter 13: Diagnostic records and their evaluation
Introduction
Minimum set of orthodontic records
Analysis of arch length during mixed dentition
Factors influencing estimation of the tooth size–arch length

analysis
Tooth size–arch length discrepancy
Tooth size ratio

Facial photographs
Orthopantomogram (panoramic radiography of the maxilla and

mandible)
Assessment of growth
Analysis of supplementary records and investigations
Key Points
References
Chapter 14: Practical clinical photography
Why photography in orthodontics
Camera basics
The digital basics
The science of photography
Using flash for intraoral photograph
Practical tips
Intraoral images
Facial photography
Key Points
References
Section V: Radiation and non-radiation imaging
in orthodontics
Chapter 15: Cephalometrics: historical perspectives, methods and

landmarks
Introduction
Longitudinal growth studies
The cephalometric apparatus (Fig. 15.2)
Posteroanterior (PA) cephalogram
Fundamentals of cephalometric analysis
Cephalometric landmarks
Key Points
References
Chapter 16: Downs’ analysis
Introduction
Basis of Downs’ analysis
Reference planes
Graphic presentation
Population groups
Key Points
References
Chapter 17: Tweed’s analysis
Introduction
Facial triangle and clinical implications
Key Points
References
Chapter 18: Steiner’s analysis
Introduction
Rationale on the choice of landmarks
Composite analysis
Steiner’s norms for various ethnic groups
Key Points
References
Chapter 19: Ricketts’ 12-factor analysis
Robert Murray Ricketts
Ricketts’ cephalometric analysis
Ricketts’ 12-factor summary analysis
Key Points
References
Chapter 20: Vertical linear dimensions of face and Sassouni’s analysis
Introduction
Sassouni’s cephalometric analysis Jarabak’s6 ratio of anterior
and posterior facial heights Signs of vertical growth rotation
Key Points
References
Chapter 21: Cephalometric analysis of the soft tissue of the face
Introduction
Methods of obtaining a soft tissue profile on a cephalogram
General appraisal of the soft tissue profile Soft tissue
cephalometric analysis
Schwarz analysis
Subtelny analysis (1959)
Steiner’s S line
Holdaway’s analysis
Merrifield’s profile line: Z angle
Ricketts’ E line
Inclination of nasal base
Mentocervical angle
Submental neck angle
Arnett’s soft tissue cephalometric analysis (STCA)
Bergman’s comprehensive analysis
Indian norms
Key Points
References
Chapter 22: Posteroanterior cephalometric analysis
Introduction
Evaluation of PA cephalogram
Grummons’ analysis (Figs 22.3 and 22.4)
Frontal vertical proportions
Ricketts’ analysis
Limitations of PA cephalometry
Key Points
References
Chapter 23: Interpretation and clinical applications of cephalometric

data in diagnosis, treatment planning and prognosis
Introduction
Interpretation of cephalometric variables
Floating norms
Morphometrics
Key Points
References
Chapter 24: Lateral, PA and 3D cephalometric superimposition
Introduction
Superimposition of lateral cephalogram on cranial base structures
Superimposition on cranial planes
Ricketts Five-step method of cephalometric superimposition
I-point and I-curve superimposition
Regional superimpositions
Superimposition of PA cephalogram
Superimposition requirements of American Board of Orthodontics
Automatic superimpositions
3D superimposition
Key Points
References
Chapter 25: Errors in cephalometrics
Introduction
Five features of a good cephalogram
A good PA cephalogram
Errors during making a cephalogram
Errors during X-ray tracing
Errors of cephalometric landmark identification
Errors in cephalometric measurements
Digital cephalometry
Calibration and magnification correction of digital images
Calibration and magnification correction of analogue films

scanned to digital images
Key Points
Section VI: Digital orthodontics
Chapter 26: Digital and computerised cephalometrics
Introduction
Acquisition of digital image
DICOM
Computerised cephalometric analysis
Cephalometrics without X-rays
Digital radiography/cephalometry
Computed radiography/cephalometry
Direct digital radiography (ddR) (Fig. 26.4)
CR radiography/cephalometrics
Steps in computerised cephalometric analysis
Key Points
References
Chapter 27: 3D data acquisition and orthodontic triad
Introduction
Digital workflow in orthodontics
Non-radiation 3D face scanning
‘4D’ imaging
3D Skeletal imaging
Key Points
References
Chapter 28: 3D digital models
Introduction
Evolution of dental scanners
Intraoral scanners/direct scanners
Indirect scanners (impression/model scanners)
Digital model orientation
Coordinate system
ABO method of orientation of digital models (Fig. 28.6)
Clinical applications of digital models
Key Points
References
Chapter 29: Three-dimensional imaging in orthodontics
Introduction
Basic concepts and terminologies in radiology
Principles of radiation safety and protection
Evolution, historical perspective and limitations of two-

dimensional imaging in orthodontics
Fundamental principles of CT and CBCT
Types of CT scanners
Operational principles of CBCT
Classification of CBCT scanners
Field of view (Fig. 29.7)

Image artefacts (Fig. 29.8)
Applications of MDCT imaging
Applications of CBCT in orthodontics
Imaging goals and protocols
Limitations of CBCT
Radiation safety pertaining to CBCT
Radiation guidelines
Non-radiation imaging techniques
Research and recent advances in 3D orofacial imaging
Key Points
References
Chapter 30: Three-dimensional cephalometry
Evolution of 3D imaging: from 2D to 3D imaging
3D volumetric imaging
Indications of CBCT imaging
Evolution of 3D cephalometric measurements
Craniofacial anatomical structures visualisation and 3D landmarks
3D cephalometric analysis
Automatic landmark detection and cephalometric analysis

Three dimensional virtual orthognathic surgical planning
Key Points
References
Chapter 31: 3D volumetric analysis, and clinical implications of the

upper airway and sinuses
Introduction
Imaging modalities of upper airway space
Radiological anatomy of upper airway
Segmentation of paranasal air sinuses
Reliability of using CBCT and imaging software for volumetric

airway analysis
Factors affecting the volumetric airway measurements
Clinical implications of volumetric airway analysis
Clinical relevance of paranasal air sinuses volume
Recent advancements
Key Points
Section VII: Removable orthodontic appliances
Chapter 32: Role of removable appliances in contemporary

orthodontics
Introduction
History of removable appliance Indications of removable
appliances
Advantages
Limitations and disadvantages
Treatment effectiveness Hawley appliance and bite plate
Expansion of the arch Steps in appliance fabrication and
clinical management Laboratory requisition and appliance
design Considerations for efficient removable appliance
Appliance delivery and activation Indications of removable
appliances therapy Correction of cross-bite of anterior teeth
due to a local cause Correction of anterior proclination Class
II division 2 malocclusion Correction of ectopic canine
Integration with fixed appliance Avoidable complications of
removable appliances Crozat appliance

Key Points
References
Chapter 33: Invisible removable appliances: The Clear Aligners
Introduction
Historical development
Overview of steps in clear aligner treatment
The Invisalign system
The Clear Smile system
The K Clear system from K-Line Europe
The ClearPath system
The Donatello aligners
Orthodontic tooth movement in treatment with aligner
Aligners and root resorption
Discomfort and acceptability
Key Points
References
Section VIII: Orthodontic armamentarium

Chapter 34: Concept of orthodontic operatory design
Introduction
Ideal orthodontic office
Orthodontic operatory
Reception area (waiting area)
Consultation room
Records room and laboratory
Sterilisation area
Office decor
Indoor plants
Parking provision
Paperless orthodontic office
Key Points
Chapter 35: Instruments and equipment in orthodontic use
Introduction
Instruments for specific use in orthodontics
Instruments for banding
Separators placing plier
Chapter 36: Components of fixed orthodontic appliance

Introduction
Evolution of fixed orthodontic appliance: antiquity to the

‘orthodontia’
Pierre Fauchard era: founder of modern dentistry and

orthodontics (1728–46)
Foundation of orthodontics
Building treatment into appliance
The era of pre-adjusted appliance and modern orthodontics
Components of fixed orthodontic appliance
Limitations of current bracket and appliance systems
Futuristic appliance design
Appliance and treatment customisation
Bracket customisation
Key Points
References
Chapter 37: Orthodontic archwires: material and their properties
Introduction
Evolution of orthodontic wires
Stainless steel wires
Cobalt–chrome wires
Nickel–titanium wires
Copper NiTi
β-Titanium wires
Titanium wires
Nickel-free stainless steel and TMA wires Titanium–niobium–
aluminium (Ti–Nb–Al) shape memory alloy

wires
Dual flex archwires
Supercable wire Turbo wire or braided nickel–titanium
rectangular wire Variable modulus orthodontics
Aesthetic wires Shape memory polymers (SMP) in orthodontics
Effects of oral environment on orthodontic archwires and brackets
Key Points
References
Chapter 38: Rubber and synthetic elastic accessories
Introduction
Elastic bands Storage and dispensing of elastics

Instructions on wearing of elastics
Complications of use of natural latex elastics
Force decay
Elastomeric accessories
Elastic chains (power chains)
Ligation of archwire to brackets with elastic module
Key Points
References
Chapter 39: Bonding orthodontic appliances
Introduction
Historical aspects of adhesion on dental tissues
Enamel etching
Bonding agents
Orthodontic bonding adhesives
Bonding techniques in orthodontics
Direct bonding technique
Bonding to amalgam and Co–Cr/Ni–Cr alloys
Bonding to porcelain surfaces
Indirect bonding technique

Lingual-bonded retainers
Fixed lingual retainer using DuraLay resin transfer
Fixed lingual retainer failures
Curing of the adhesive composite
Key Points
References
Section IX: Contemporary orthodontic treatment
Chapter 40: The biological basis for orthodontic tooth movement
Introduction
Forces in orthodontics
Optimal orthodontic force
Theories of OTM
Phases of tooth movement
Alveolar bone response to orthodontic force
Cellular behaviour in sites of PDL tension and compression
Blood vessel reorganisation and neovascularisation
Neural responses to mechanical forces
Does inflammatory responses follow orthodontic force

application?
OTM–inflammation or mechanotransduction?
Iatrogenic effects of orthodontic mechanics
Key Points
References
Chapter 41: Principles of biomechanics and appliance design
Introduction
Basics of biomechanics
Intrinsic characteristics of materials
Orthodontic archwire materials
Characteristics of ideal appliance
Key Points
References
Chapter 42: Preservation of normal occlusion and interception of

malocclusion during early mixed dentition
Introduction
Management and preservation of arch length
Space maintenance appliances
Serial extraction protocol

Anterior cross-bite in deciduous and mixed dentition
Unilateral cross-bite with mandibular shift
Dental anomalies and malocclusions during mixed dentition
Key Points
References
Chapter 43: Orthodontic treatment with contemporary fixed appliance

Phase I: laying the foundation
Introduction
First appointment and records
Designing a treatment plan and execution strategy
Banding and bonding
Separation of teeth
Bracket positioning
Buccal tubes
Bracket positions on anterior and premolars
Key Points
References
Chapter 44: Anchorage in orthodontic practice
Introduction
Anchorage loss
Anchorage sources for removable appliance
Anchorage for fixed appliance
Factors affecting anchorage requirements
Treatment planning anchorage savers
Key Points
References
Chapter 45: Tweed philosophy, biomechanics and principles of

treatment
Tweed’s journey as Angle’s Student to an accomplished

orthodontist
Human face as related to orthodontic diagnosis
Treatment planning—Tweed’s objectives of treatment
The standard edgewise appliance
Stages of treatment
Tweed principles as applied to clinical practice at AIIMS
Key Points
References
Chapter 46: Orthodontic treatment with contemporary fixed

appliance. Phase II: major tooth movements
Introduction
Steps of the active orthodontic treatment
Levelling and alignment
Bite opening
Space closure
Retraction of incisors into extraction spaces
Key Points
References
Chapter 47: The pre-adjusted edgewise appliance
Pre-adjusted appliance
Evolution of building the treatment into brackets
The first integrated pre-adjusted appliance system and philosophy

by C. F. Andrews
The features of straight wire appliance
The biomechanics
Roth’s philosophy of functional occlusion and pre-adjusted

appliance
MBT appliance and philosophy of treatment
Limitations of pre-adjusted appliance
Treatment customisation
Key Points
References
Chapter 48: Orthodontic treatment with self-ligating bracket systems
Introduction
Self-ligation in orthodontics
Active self-ligating brackets
Passive self-ligating brackets
Biomechanics and stages of treatment with self-ligating bracket

system
Features of self-ligation and their impact on biomechanics
Stages of treatment and archwire sequence
Biomechanical challenge of self-ligation brackets versus

conventional brackets
Evidence on claims of self-ligating brackets
Key Points
References
Section X: Non-extraction treatment
Chapter 49.1: Non-extraction treatment with maxillary expansion and

interproximal reduction
Introduction
Methods to gain space to resolve limited crowding and protrusion
Preservation of leeway or ‘E’ space for resolution of crowding in

the lower arch
Expansion of the narrow maxilla and arch development
Diagnosis of maxillary transverse deficiency and case selection
Study models
Posteroanterior cephalogram
Clinical and histological basis of maxillary expansion
Types of expansion appliances
Rapid maxillary expansion (RME)
Indications for RME
Contraindications for RME
Design of RME
Structural and functional effects of RME
Adverse effects of RME
Activation schedule
Forces involved in RME
Slow maxillary expansion
Parallel expansion screw

Wire framework expander appliances
NiTi expander
Retention and relapse
Rapid vs. slow expansion
Mini-implant attached rapid palatal expansion
Retention Schedule
Interproximal reduction
Key Points
References
Chapter 49.2: Non-extraction treatment with non-compliance molar

distalisation
Introduction and historical review
Palatal acting appliance
Skeletal anchorage
Biomechanics of molar distalisation
Timings of molar distalisation
Clinical efficacy and anchorage loss
Key Points
References
Section XI: Class II malocclusion
Chapter 50: Class II division 1 malocclusion: features and early

intervention of growing maxillary excess
Introduction
Clinical findings
Nature of class II malocclusion
Interception of developing class II malocclusion
Treatment of growing maxillary excess
Key Point
References
Chapter 51: Evolution of functional appliances and treatment with one

piece removable appliances
Introduction
Classification of functional appliances
Activator or monoblock
Balters’ bionator
Frankel appliance
Relative indications of activator/bionator/Frankel appliance
Key Points
References
Chapter 52: Treatment approaches with twin block appliance
Introduction
Clinical examination
Skeletal maturity indicators
Diagnostic records and analysis
Fundamentals of bite recording
Appliance design and construction
Clinical management
Treatment effects of removable functional appliance
Modification of twin block
Key Points
References
Chapter 53: Interception and treatment of mandibular retrusion with

non-compliant fixed functional appliances
Introduction
Rigid fixed functional appliances
Herbst appliance
Mandibular anterior repositioning appliance (MARA)

Mandibular protraction appliance (MPA)
Flexible fixed functional appliance (FFFA)
Hybrid fixed functional appliances
Effects of fixed functional appliance
Implant supported FFA
Key Points
References
Chapter 54: Mode of action of functional appliances
Introduction
Effects of functional appliances
Condyle glenoid fossa complex (CGF) remodelling and

neuromuscular adaptations
Clinical evidence of CGF remodelling
Condyle adaptation based on growth relativity hypothesis
Molecular and genetic control on CGF remodelling
Can the mandible be grown longer than it’s pre-determined

genetic potential?
Key Points
References
Chapter 55: Dentofacial orthopaedics for class II malocclusion with

vertical maxillary excess
Introduction
Case selection Appliance concept and desired effects Clinical
management of the appliance Treatment effects van Beek
activator
Key Points
References
Chapter 56: Management of class II malocclusion with fixed appliance
Introduction
Class II treatment options Treatment sequence
Occlusion and profile after extraction treatment Factors affecting
soft tissue profile outcome Key Points
References
Chapter 57: Class II division 2 malocclusion
Introduction
Features of class II division 2
Aetiology
Treatment considerations
Stability and retention
Key points
References
Section XII: Class III malocclusion
Chapter 58: Class III malocclusion in growing children
Introduction
Prevalence of skeletal class III malocclusion
Aetiology of class III malocclusion
Components of class III malocclusion
Ethnicity and gender differences
Diagnosis of class III malocclusion
Prediction of class III skeletal growth
Management
Maxillary protraction appliances
Bone anchored maxillary protraction (BAMP)

Micro-implant supported maxillary protraction
Camouflage treatment
Orthognathic surgery
Key Points
References
Chapter 59: Orthodontic treatment of borderline class III malocclusion
Introduction
Nature of skeletal class III malocclusion
Clinical features of a class III face (Fig. 59.2A–B)
Maxillo-mandibular relationship
Classification of class III malocclusion by Delaire
Glenoid fossa and cranial base
Growth considerations in treatment of class III patients
Borderline class III patient
Treatment approaches
Retention protocol
Key Points
References
Section XIII: Newer trends in orthodontics
Chapter 60: Temporary anchorage devices
Introduction
Historical perspective
Definition and classification
Safe zones for MSI
Miniscrew placement protocol
Loading of implant
Miniscrew removal
Direct versus indirect loading
Biomechanical considerations in a miniscrew anchorage system
Risks and complications with the use of MSIs
Failures in miniscrews
Key Points
References
Chapter 61: Surgically facilitated rapid tooth movement (SF-RTM)

Introduction
Historical perspective (Table 61.1) Biological basis of SF-RTM
Techniques of alveolar surgery Corticotomy facilitated orthodontic
treatment (CFOT) Osteotomy facilitated orthodontic treatment
(OFOT) Mono-cortical tooth dislocation and ligament distraction
(MTDLD) Surgery first
Key Points
References
Chapter 62: Orthodontic considerations of inter-disciplinary treatment
Introduction
Objectives of inter-disciplinary treatment Pre-restorative/pre-
orthodontic periodontal status Conditions commonly treated with
inter-disciplinary care Communication
Key Points
Reference
Chapter 63: Evidence-based orthodontics

Introduction
A historical perspective of evidence-based orthodontics
A hierarchy of evidence
Evidence-based clinical practice in orthodontics
Key Points
Section XIV: Impactions and transpositions
Chapter 64: Orthodontic aspects of impacted anterior teeth
Introduction
Prevalence/incidence of impactions
Aetiology of tooth impaction
Diagnosis of an impacted tooth
Treatment considerations for impacted teeth
Relocation of an impacted tooth
Extraction of impacted tooth
Key Points
References
Chapter 65: Transposition of teeth

Introduction
Prevalence
Aetiology
Management of complete transpositions in the maxillary arch
Management of complete transposition in mandibular arch (Fig.

65.3)
Key Points
References
Chapter 66: Auto-transplantation of teeth in orthodontic practice
Introduction
Indications in orthodontic practice
Case selection
Surgical sequence and technique
Orthodontic tooth movement of auto-transplanted teeth
Auto-transplantation versus osseointegrated dental implants
The success of auto-transplantation
Key Points
Section XV: Surgical aspects of orthodontic
treatment
Chapter 67: Ortho-surgical management of skeletal malocclusions
Introduction
Pre-surgical orthodontic treatment
Motivational factors involved in seeking orthognathic surgery
Case selection for orthognathic surgery
History and clinical evaluation
Diagnostic records and investigations
Cephalometric and computer-based prediction technology
3D models
Stereophotogrammetry (3dMD™)
Special considerations during surgical treatment planning
Steps involved in an orthognathic surgery procedure
Retention and follow-up after orthognathic surgery
Complications following orthognathic procedures
Key Points
References
Chapter 68: Maxillomandibular distraction osteogenesis for
orthodontist
Definition and biological basis
Historical perspective and philosophy of maxillo-mandibular

distraction osteogenesis
Indications
Contraindications
Advantages of distraction osteogenesis over orthognathic surgery
Disadvantages
Classification of distractors
Surgical considerations
Orthodontic considerations
Maxillary transverse distraction osteogenesis (Fig. 68.10A–C)
Mandibular transverse distraction osteogenesis (Fig. 68.11A–D)
The future of maxillomandibular distraction osteogenesis
Key Points
References
Section XVI: Treatment of complex

malocclusions
Chapter 69: Malocclusion and asymmetries of the face
The essence of facial symmetry
Aetiology
Identifying the asymmetry
Evaluation of facial symmetry in three planes of space
Prevalence of dentofacial asymmetries
Key Points
References
Chapter 70: Dental midline deviations
Midline deviations
Definition and evaluation
Reference planes
Prevalence of midline deviations (Tables 70.1, 70.2)
Clinical presentation of dental midline deviations
Aetiology of the dental midline shift (Figs 70.6–70.12 and

Table 70.3)
Management of dental midline shifts of purely dental origin
Retention protocol
Key Points
References
Chapter 71: Asymmetry of occlusion
Definition and criteria of asymmetric occlusion
Development of asymmetries within dental arches
Common traits of asymmetrical occlusion
Prevalence and features of asymmetrical occlusion
Management
Class II subdivision malocclusion
Molar distalisation (Fig. 71.10)
Asymmetric extractions
Orthopaedic asymmetrical approach
Class III subdivision malocclusion
Key Points
References
Chapter 72: Cant of occlusal plane in transverse direction
Introduction and definition
Aetiology of occlusal cant
Prevalence
Clinical presentation and diagnosis
Reference planes
Management
Key Points
References
Chapter 73: Asymmetries of the face
The essence of facial asymmetry
Types of facial asymmetry
Prevalence
Classification of facial asymmetry
Aetiology
Evaluation of facial asymmetry
Management strategy
Key Points
Chapter 74: Temporomandibular disorders and orthodontics
Introduction
What are TMDs?
Historical relationships between orthodontists and TMDs
Orthodontic treatment and TMD
Centric relation and orthodontics
Functional occlusion and orthodontics

Articulators for orthodontic diagnosis
Management of TMD signs and symptoms
Patient self-directed care and education
Home care instructions
Psychological approaches to treatment
Oral appliances (splints)
TMD informed consent in orthodontics
Key Points
References
Section XVII: Expanding role of orthodontist

and inter-disciplinary care
Chapter 75: Inter-disciplinary management of cleft lip and palate
Introduction
Developmental aspects of CL ± P
Syndromic and non-syndromic clefts
Aetiology of CLP
Intrauterine diagnosis
Risk of recurrence
Sex ratio
Laterality of CLP
Classification of cleft
Inter-disciplinary team care
Feeding appliance
Presurgical orthopaedics
Impression of a cleft child
Surgical anatomy of cleft lip and palate
Primary surgery for cleft lip
Speech in cleft patients
Treatment steps and approach
Distraction osteogenesis (DO)
Prosthetic management
Recent advances in the cleft care
Key Points
References
Chapter 76: Orthodontist’s roles in upper airway sleep disorders
Introduction
Epidemiology
Pathophysiology of sleep disorders
Diagnosis and treatment protocols
Key Points
References
Section XVIII: Steps in conclusion of

orthodontic therapy
Chapter 77: Orthodontic treatment with contemporary fixed appliance

Phase III: finishing and detailing
Introduction
Pre-finish assessment Steps in attaining goals for finishing and
detailing of occlusion Settling the occlusion
American Board of Orthodontics—objective grading system
Assessment criteria
European Board of Orthodontics Post-orthodontic occlusion
scheme for extraction treatment and

complex malocclusion situations
Key Points
References
Chapter 78: Deband, debracketing and delivery of retention appliance
Introduction
Deband/debond procedures
Advanced techniques
Final cleanup and polishing
Key Points
References
Chapter 79: Post-orthodontic care and management of white spot

lesions
Introduction
Prevalence and distribution of WSLs
Aetiopathogenesis of WSLs
Detection of white spot lesions
Prevention of white spot lesions and the role of fluoride
Nanotechnology in the control of biofilms
Post-orthodontic care
Key Points
References
Chapter 80: Maintenance of the outcome results, retention and relapse
Introduction
Riedel’s nine rules of retention and relapse
Other factors influencing relapse and retention
Relapse in orthognathic surgery
Relapse in cleft lip and palate
Retainer appliances
Clear plastic retainers
Tooth positioners
Hawley retainer
Anterior and posterior bite plates
Fixed lingual retainers
Active retainers
Retention protocol
Retention schedule
Adjunctive periodontal procedures for successful orthodontic

results
Current status of research and evidence affecting orthodontic

practice
Key Points
References
Index
Copyright
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Orthodontics: Diagnosis and Management of Malocclusion and

Dentofacial Deformities, 3e, Om P. Kharbanda
Copyright © 2020, 2013, 2009 by RELX India Pvt. Ltd. (formerly

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Dedication
Dedicated to
my mother and father

who taught me: “Knowledge” is the most precious
possession one can ever acquire
My wife Renu and son Sidharth

for their patience, strength and armour
my patients
who gave me the opportunity to serve
students
who are the very purpose of this book
Foreword
It is my pleasure and honour to write this Foreword for this amazing

treatise on each and every aspect of orthodontics by my friend, Om P.
Kharbanda. I have had the pleasure of knowing OP, as I affectionately
call him, for more than three decades. OP and I both received our
early orthodontic education at King George’s Medical College
(KGMC), Lucknow, India though quite a few years apart. Like so
many graduates of our alma mater, OP chose the path of academics
and research. With each passing year, he has enormously contributed
to the field of orthodontics and helped raise the standard of education
care and research in India, Southeast Asia and Australia.
He moved up the faculty ranks at the prestigious All India Institute
of Medical Sciences, New Delhi to lead the Orthodontics Division and
as the Chief of the Centre for Dental Education and Research. Despite
all his academic responsibilities, he has led organisations such as
Indian Orthodontic Society, Indian Society for Cleft and Craniofacial
Anomalies, Indian division of IADR and WHO committees to raise the
standard of oral care in India and adjoining countries.
With all the kudos mentioned earlier, he is presenting here the third
edition of his book, “Orthodontics: Diagnosis and Management of
Malocclusion and Dentofacial Deformities”. It is quite an
accomplishment! This book has been quite popular as can be seen by
the need for the third edition. Numerous chapters have been revised
and 22 new chapters have been added. OP has divided this book in
very well-organised 18 broad sections. Each section has numerous
chapters. There are a total of 80 chapters in the book encompassing
1259 pages. OP has arranged all chapters in a logical manner with
appropriate illustrations and cases to explain various concepts.
Another beauty of this book is that OP has been able to bring together
experts in various areas of orthodontics to write these chapters. A total
of 37 academicians, researchers and clinicians from Japan, USA,
Australia, Europe and India have contributed to this book.
The chapters cover treatment of every possible malocclusion and
dentofacial deformities including interdisciplinary approaches. The
chapters include the latest information based on published research
and innovative ideas.
This book is ideal for postgraduate students and practising
orthodontic clinicians alike. The undergraduates will find this book as
an A–Z compendium on the subject. I am sure this edition will be
highly sought after, as were the previous ones.
Again, I congratulate Om P Kharbanda for this magnificent book.
Ravindra Nanda BDS, MDS, PhD
Editor-in-Chief, Progress in Orthodontics
Professor Emeritus
Retired Head, Department of Craniofacial Sciences
Retired Chair, Division of Orthodontics
U Conn Orthodontic Alumni Chair
University of Connecticut
Farmington, CT, United States
Contributors
George Anka, DDS, MS, Private Practice, WIOA Secretary General
Smile Forever Orthodontic Medical Corporation
Tama, Tokyo, Japan
Rajiv Balachandran, BDS, MDS, Fellow Cleft and Craniofacial

Orthodontics
Division of Orthodontics and Dentofacial Deformities, Centre for
Dental
Education and Research, All India Institute of Medical Sciences
New Delhi, India
Prashanti Bollu, MBA, MS, DMD

Program Director, Orthodontic Residency
AEODO/MBA Residency
Program, Roseman University of Health Sciences, Henderson, NV
United States
Bala Chakravarthy Neelapu, PhD

Academy of Scientific and Innovative Research (AcSIR)
CSIR-Central
Scientific Instruments Organisation, Chandigarh, Punjab, India
Prabhat Kumar Chaudhari, BDS, MDS, Assistant Professor

Dental Education and Research, All India Institute of Medical Sciences
New Delhi, India
M. Ali Darendeliler, BDS, PhD, Dip Orth, Certif Orth, Chairman,

Discipline of Orthodontics, Faculty of Dentistry
University of Sydney, Surry Hills, NSW, Australia
Shailesh Deshmukh, BDS, MDS, M Orth RCS (Edinburgh) FDS,

RCS (Edinburgh) Hon, Professor, Department of Orthodontics and
Dentofacial Orthopaedics,
Bharati Vidyapeeth Deemed University, Faculty of Dentistry:
Diplomate
Indian Board Orthodontics, Pune, Maharashtra, India
Mithran Goonewardene, BDSc, Certif Ortho, FICD, Discipline

Lead and Program Convenor, Orthodontics
UWA Dental School, The University of Western Australia
Nedlands, WA, Australia
Charles S. Greene, DDS, Clinical Professor Emeritus

Department of Orthodontics
UIC College of Dentistry, Chicago, IL, United States
Abhishek Gupta, PhD

Academy of Scientific and Innovative Research (AcSIR)
CSIR-Central Scientific Instruments Organisation, Chandigarh
School of Computer Science and Engineering, Shri Mata Vaishno Devi
University, Katra, Jammu and Kashmir, India
Anurag Gupta, BDS, MDS, PGDMLS, Former Senior Research

Fellow
Centre for Dental Education and Research, Division of Orthodontics
and Dentofacial Deformities, All India Institute of Medical Sciences
New Delhi, India
Akhter Husain, BDS, MDS, Professor and Head

Department of Orthodontics and Dentofacial Orthopaedics, Yenepoya
Dental College, Yenepoya University, Mangalore, Karnataka, India
Balakrishnan Jayan, BDS, MDS, FCLR, FISDA

Senior Specialist (Orthodontics)
Armed Forces Medical College, Pune
Commandant and Dental Adivisor (IAF)
Air Force Institute of Dental Sciences, Bengaluru, Karnataka, India
Abhijeet Kadu, MDS, Graded Specialist (Orthodontics and

Dentofacial Orthopedics)
12 CORPS Dental Unit, Jodhpur, Rajasthan, India
Varun Kalra, BDS, MDS, D Orth, RCS, DDS, MS, Clinical

Associate Professor Orthodontics
University of Pittsburgh, Pittsburgh, PA, United States
Sanjivan Kandasamy, BDSc (UWA), BSc Dent (UWA), Grad Dip

Clin Dent (Melb), Doc Clin Dent (Melb), M Orth RCS (Edin),
FRACDS (Ortho), FDS RCS (Edin), Clinical Associate Professor
The University of Western Australia, Perth, WA, Australia
Sunil D. Kapila, BDS, MDS, PhD

West Endowed Chair of Orthodontics at University of California, San
Francisco (UCSF)
Robert W Browne Endowed Professor and Chair, Chief Executive
officer and Chief Dental Officer UCSF Dental Center, Professor and
Eugene E. West Endowed Chair, Division of Orthodontics, UCSF
Dental Center, San Francisco, CA, United States
Priyanka Kapoor, BDS, MDS, Associate Professor

Faculty of Dentistry, Jamia Millia Islamia, New Delhi, India
Om P. Kharbanda, BDS, MDS (Lucknow), M Orth RCS

(Edinburgh), M MEd (Dundee), FDS RCS (Edinburgh), Hon,
Fellow Indian Board of Orthodontics Honoris Causa
Professor and Chief
New Delhi, India
Vinod Krishnan, BDS, MDS, M Orth RCS (Edinburgh),

PhD, Professor and Head
Department of Orthodontics and Dentofacial Orthopaedics,
Sri Sankara Dental College Varkala, Thiruvananthapuram, Kerala,
India
Mugdha Mankar, BDS, MDS, Associate Professor

Government Dental College and Hospital, Nagpur, Maharashtra,
India
Apoorva Mathur, BDS, MDS, PhD Scholar

and Dentofacial Deformities, All India Institute of Medical Sciences,
New Delhi, India
Nitika Monga, BDS, MDS, Fellow Cleft and Craniofacial

Orthodontics, Centre for Dental Education and Research, Division
of Orthodontics and Dentofacial Deformities, All India Institute of
Medical Sciences
New Delhi, India
Ram S. Nanda, BDS, MDS, MS, PhD, Professor Emeritus,

Formerly, Founder, Professor, Chairman, Division of Development
Dentistry, University of Oklahoma College of Dentistry
Oklahoma City, OK, United States
Sridevi Padmanabhan, BDS, MDS, Professor and Head,

Department of Orthodontics, Sri Ramachandra University, Porur,
Chennai, India
Donald J. Rinchuse, DMD, MS, MDS, PhD

Corporate Orthodontic Practice
Former Professor and Orthodontic Program Director, Seton Hill
University, Greensburg, PA, United States
Karthik S, BDS, MDS, Senior Resident

Centre for Dental Education and Research, Division of Orthodontics,
New Delhi, India
Rajesh Sagar, MBBS, MD, Professor, Department of Psychiatry
All India Institute of Medical Sciences, New Delhi, India
Nanda Kishore Sahoo, BDS, MDS, FIOBMS, Professor and Head

Armed Forces Medical College, Pune, Maharashtra, India
Vilas Samrit, BDS, MDS, Assistant Professor

New Delhi
Harish Kumar Sardana, PhD, ME, MBA, Chief Scientist and Head-
Computational Instrumentation Division
CSIR-Central Scientific Instruments Organisation
Chandigarh, Punjab, India
Viren Sardana, MBBS, MTech, Scientist-Biosignal Analysis,

Medical Imaging and Machine
Learning in Healthcare
CSIR-Central Scientific Instruments Organisation
Chandigarh, Punjab, India
Priyanka Sethi Kumar, BDS, MDS, Assistant Professor

Santosh Dental College and Hospital, Ghaziabad, Uttar Pradesh, India
Shailendra Singh Rana, BDS, MDS, Fellow in Cleft and

Craniofacial Orthodontics, Division of Orthodontics and
Dentofacial Deformities, Centre for Dental Education and Research,
All India Institute of Medical Sciences New Delhi, India
Lokesh Suri, BDS, MDS, MS, Associate Professor

Tufts University, School of Dental Medicine, Boston, MA
United States
Parul Taneja, BDS, MDS, MS, Private Practice

Chelsea, MA, United States
N.G. Toshniwal, BDS, MDS, Professor and Head
Department of Orthodontics and Dentofacial Orthopaedics
Pravara Institute of Medical Sciences, Rahata, Maharashtra India
Maria Orellana Valvekens, DDS, MS, PhD, Professor

Clinic Director
Department of Stomatology and Oral and Maxillofacial Surgery
Orthodontic Clinic
Erasme Hospital - ULB
Brussels, Belgium
Gauri Vichare, BDS, MDS, M Orth RCS (Edinburgh), Diplomate:

Indian Board of Orthodontics, Professor
Bharti Vidyapeeth University Dental College, Pune, Maharashtra,
India
Neeraj Wadhawan, BDS, MDS, Former Senior Research Officer

Dental Education and Research, All India Institute of Medical Sciences
New Delhi, India
Preface to the third edition
Both as a student and professional, learning about orthodontics can be
a daunting task as basic textbooks and classroom lectures are usually
unable to connect their content with the complexities of clinical
reality. It is also hard to find the knowledge of diverse and wide-
ranging domains of orthodontics in a comprehensive manner. With
each edition, this textbook has aimed to become a solution to this
challenge.
The second edition of this textbook was released in 2012 by Prof
Roberto Justus, the then President of the World Federation of
Orthodontics. The book’s success is validated by its popularity
amongst postgraduates across the board, who not only found it handy
but also considered it as an ’all in one’ guide for clinical case studies
and a template for further reading through the essential references
cited in the text. Building upon the extensive feedback from a wide-
ranging group of readers, and in line with the fast-changing
advancements in the field of orthodontics, the third edition of the
textbook of Orthodontics has improved upon the previous edition by
including critical up-to-date information that will be of value to
students, educators and practising professionals.
In addition to the revision of information up-to-date with the latest
guidelines, a host of new essential sections and chapters have been
added, causing the number of chapters to increase from 58 in the
second edition, to 80 chapters in this edition. Great emphasis has also
been given to the organisation and the order in which the information
is delivered. The sections and chapters have been meticulously
arranged to promote continuous learning for the reader, more so for
the students, as they progress from day 0 to final year of their
postgraduate orthodontic program, and eventually into clinical
practice. The first few sections address the fundamentals of
orthodontics, followed by clinical applications, which are supported
with actual clinical cases and post-orthodontic, follow-up records.
Additional efforts have also been taken to explain complex laboratory
and clinical procedures using relevant photographs and line
diagrams. This edition is also more illustrative with additional
supporting drawings, flowcharts and boxes. Furthermore, the
addition of real-life case scenarios and technique videos promote
assimilated learning and understanding of the subject.
Chapters that have undergone significant revision include:
Epidemiology of Malocclusion and Orthodontic Treatment Needs
(Chapter 3), Functions of Stomatognathic System and their
Implications on Occlusion (Chapter 11), Three-Dimensional Imaging
in Orthodontics (Chapter 29), Invisible Removable Appliances: The
Clear Aligners (Chapter 33), Orthodontic Archwires: Material and
Their Properties (Chapter 37), Bonding Orthodontic Appliances
(Chapter 39), Non-Extraction Treatment With Maxillary Expansion
and Interproximal Reduction (Chapter 49.1), Non-Extraction
Treatment With Non-Compliance Molar Distalisation (Chapter 49.2),
Treatment Approaches With Twin Block Appliance (Chapter 52),
Class III Malocclusion in Growing Children (Chapter 58), Inter-
Disciplinary Management of Cleft Lip and Palate (Chapter 75) and
Post-Orthodontic Care and Management of White Spot Lesions
(Chapter 79).
A host of new sections have been included: Historical Aspects of
Orthodontics (Section I), Digital Orthodontics (Section VI),
Orthodontic Armamentarium (Section VIII) and Treatment of
Complex Malocclusions (Section XVI). Additional chapters include:
Development of Teeth, Dentition and Occlusion (Chapter 7), Practical
Clinical Photography (Chapter 14), Interpretation and Clinical
Applications of Cephalometric Data in Diagnosis, Treatment Planning
and Prognosis (Chapter 23), Tweed Philosophy, Biomechanics and
Principles of Treatment (Chapter 45), The Pre-Adjusted Appliance
(Chapter 47), Orthodontic Treatment With Self-Ligating Bracket
Systems (Chapter 48), Evidence-Based Orthodontics (Chapter 63) and
Auto-Transplantation of Teeth in Orthodontic Practice (Chapter 66).
The book provides 72 hardbound and 8 exclusive online chapters:
Development of Teeth, Dentition and Occlusion (Chapter 7), Prenatal
Development of the Foetus Concerning the Craniofacial Region
(Chapter 8), 3D Volumetric Analysis, and Clinical Implications of the
Upper Airway and Sinuses (Chapter 31), Concept of Orthodontic
Operatory Design (Chapter 34), Instruments and Equipment in
Orthodontic Use (Chapter 35), Evidence-based Orthodontics
(Chapter 63), Auto-transplantation of Teeth in Orthodontic Practice
(Chapter 66), Asymmetries of the Face (Chapter 73). In addition, the
students will have unlimited access to 12 online videos to assist in
mastering the most needed skills expected of an orthodontist.
This edition intends to provide up-to-date, comprehensive
information on scientific evidences and aims to impart clinical
competency and knowledge through real-life scenarios, photos and
videos. This edition has been revised to encompass all the essential
aspects of Orthodontics, Dentofacial Orthopaedics, Dental and Facial
Deformities and recent advances in technology.
I hope that the methodology, approaches and information provided
in this book will be educationally rewarding to the readers. I am sure
the book will find its worth with students, educators and practitioners
of orthodontics alike.
Om P. Kharbanda
Acknowledgements
I take this opportunity to sincerely thank all those who have
influenced me and have shaped my personal and professional life and
attain academic journey in the profession. My vocation has showered
blessings on me to feel enriched and satisfied in professional and
personal life.
First and foremost, I express my heartfelt gratitude to my parents,
mentors and teachers who have nurtured me to rise and have made
me capable of publishing this book. Over the years my endeavour to
achieve excellence in orthodontic education, clinical care and research
has been supported and contributed by my colleagues, research
scholars and postgraduate students. Their contribution to the
academic and professional growth of the orthodontic discipline and in
the attainment of pre-eminent status of the orthodontics in India and
its recognition at the international level is appreciated. The patients at
CDER-AIIMS, who have entrusted me with the opportunity to serve
them, have played an important role for me in learning and teaching.
My thanks to the nursing and technical staff at the department whose
contributions are hidden yet significant in the overall functioning of
the clinics and provision of clinical care, the essence of orthodontics.
I want to thank my colleagues who have selflessly contributed their
wealth of knowledge. The contribution of Prof Ram S. Nanda, Prof M.
Ali Darendeliler, Prof Sunil D. Kapila, Prof Gauri Vichare, Prof Vinod
Krishnan, Prof Akhter Husain, Prof Sridevi Padmanabhan, Assoc Prof
Varun Kalra, Doctors Lucia Cevidanes, Parul Taneja, Lokesh Suri, P.
Hari, Anurag Gupta, B. Jayan, S.K. Roychowdhary, N.K. Sahoo, S.S.
Chopra, Neeraj Wadhawan, Priyanka Sethi Kumar, S. Ghosh, Vilas
Samrit and Prabhat Kumar Chaudhari is sincerely acknowledged. I
also like to thank my colleague Doctors Sandeep Sabharwal, Priyanka
Kapoor, Priyanka Gupta, Varun Malhotra, Sankalp Sood, Anurag
Negi, Poonam Chaudhary, Anil Nafria, S. Raja, Mugdha Mankar,
Rahul Minotra, Shailesh Dongre, Nitika Monga, Heemanshu Dave,
Sushma Chaurasia, Bhagabati Prasad Dash, Pranav Meena, Pradnya
Patil, Shailendra Singh Rana, Ashish Prasad, Swati Verma, Karthik S.,
Tabassum, Jitender, Aditya Talwar, Abhijeet Jaiswal, Saraa Angel,
Hamza Parvez Siddiqui, Sunil Kumari, Pinky Singh, Greeshma S.
Gothankar, Kanistika Jha, Hitesh, Kaleem Fatima, Rijul Agarwal, V.
Sarath Kumar, Sukeshana Srivastav, Priyanka Rawat, Madhanraj S.
and Pradeep D.A. for their contribution at various stages of writing
the book. I would also like to thank and place on records case/figure
credits as under: Figs 2.1, 37.9, 75.26 Dr Neeraj Wadhawan; Figs 12.15,
12.16 Dr Pradip Sangroula; Fig. 75.26 Dr R.K. Kazanchi; Figs 11.8, 32.1,
32.8, 49.1.1A, 49.1.4C–E, 51.6,7,8, 55.2, 55.7 ORTHOLAB, Netherlands;
Figs 11.9, 21.3, 21.4, 21.7, 21.8, 21.9, Fig. 58.3 Dr Tabassum; Fig. 32.4 Dr
N.K. Ahuja; Fig. 29.14, 29.15 Dr Lucia Cevidanes; Figs 33.2 A, Clear
Smile through Dr Joseph P. Geenty, Wollongong, NSW Australia; Figs
33.5 Align Technology; Fig. 33.10, K-Line Europe GmbH; Fig. 33.11 Dr
Phiroza Venkataraman; Figs 46.4, 46.6, 46.14, 60.9, 75.15, 75.19, 75.20
Dr Nitika Monga; Fig. 34.1 ZYETA Bangalore, India; Fig. 42.2, 42.3 Dr
Philippa Sawyer; Figs 12.10 B, 77.1, 60.8, Case 2 in Chapter 60, 53.10
Dr Vilas Samrit; Figs 2.4, 12.23, 46.7, 46.7, 50.7, 52.18, 55.1, 57.5, 59.2 Dr
Rajiv B; Fig. 50.7, 58.16 Dr Rajeev Mishra; Fig 49.1.7, 77.13 Dr
Shailendra Singh Rana; Fig 49.1.13 Dr Greeshma S. Gothankar; Case 3
in Chapter 60, Pranav Sapawat; Fig. 46.22 Dr Priyanka Gupta; Fig.
58.10 Dr Karthik S.; Fig. 46.24, 70.11 Dr Sakshi Katyal; Figs 46.18,
50.12, 52.23 Dr Anil Nafria; Fig. 46.29 Dr Jitender; Fig. 48.16 Courtesy
Dr Lars Christiansen; Figs 46.12, 60.5, 60.9, 49.2.30, 5.24 Dr
Heemanshu Dave; Figs 46.34, 55.1 Dr Poonam Chaudhary; Figs 32.7,
46.37 Dr Varun Kalra; Fig. 53. 3 Dr Anshuman Bhattacharya; Fig. 52.5
Dr Sushma Chaurasia; Fig. 52.27 Fixed Twin Block Courtesy Dr
William Clark; Fig. 56.3, Dr Ayaz; Figs 29.17, 77.14, 56.2 A, B Dr
Mugdha Mankar; Figs 58.12B, 58.14B Dr Priyanka Kapoor; Figs 57.6
Dr. Sankalp Sood; Figs 51.9, Dr Sandeep Sabharwal; Figs 29.20, 29.21,
29.22, 52.22, Dr Shailesh Dongre; Chapter 68.3 Dr Ajoy
Roychoudhury, Fig. 45.8, 49.2.21, 55.6, 57.8 Dr Raja S; Fig. 60 Case 1 Dr
P. Hari and Dr Varun Malhotra; Figs Case 1 in Chapters 60, 56.1, 60.14
Dr P. Hari; Fig. 61.2 Dr Donald J Ferguson; Fig. 61.9 Dr R.S. Wats; Fig.
67.9.1 Dr Deobra Harris; Fig. 67.10.1 Dr Sivabalan Vasudavan; Fig.
67.12 Dr Claude Mossaz; Fig. 67.15.1 Prof Jean-Pierre Joho; Figs 75.1,
75.11 75.21, 75.26 Dr R.K. Khazanchi; Fig. 75.7 Dr Ajay Bajaj.
Dr Rajiv B., who volunteered and nearly worked as an Assistant
Editor, also coordinated tremendous work with Chetan Kumar Thapa,
Ashish Kumar Jena, Bhupender Singh and Mr Anand K. Jha. I could
not have completed this project in this shape and time without their
support.
At Elsevier, I had tremendous support from Shabina Nasim, Anand
K. Jha and Nimisha Goswami and they deserve a special mention for
their immense contribution in bringing out the work in its present
form. While all efforts have been made to obtain permissions, citations
and acknowledge sources of text, images, case studies and
contributors, omissions, if any, which are unintentional may be
considered as admitted.
My wife Renu and son Sidharth are most sincerely acknowledged
for their patience and unconditional support at all times in my life.
List of videos
S. Title Text citation
No.
1. AutoCEPH Fig. 26.2
2. Creation of a digital model Fig. 28.3
3. Banding the molars Fig. 36.16
4. Flawless bonding Fig. 39.5
5. First order bends, second order bends and Figs. 45.8, 45.9
third order bends
6. Utility arch Fig. 46.19
7. Twin block Appliance design and construction, page 790
in Chapter 52
8. Bite registration Fig. 52.16
9. Implant insertion Fig. 60.5
10. Universal connector Fig. 60.5
11. Implant removal Fig. 60.9
12. Functional shift Fig. 70.11
For complete videos please visit to HYPERLINK

“http://www.medenact.com”
SECTION I
Historical aspects of orthodontics:
ancient, yesteryears, yesterdays,
today and tomorrow
Chapter 1.1: History of dentistry and significant events that

Chapter 1.2: History of orthodontics
Chapter 1.3: History of orthodontic speciality in India
CHAPTER 1.1
History of dentistry and
significant events that
O.P. Kharbanda
CHAPTER OUTLINE

Orthodontosie and orthodontia
Orthodontics and dentofacial orthopaedics
Orthodontics and dentofacial deformities
History of dentistry before Christ was born (BC)
The beginning of dentistry as a profession: early to middle ages
(AD)
The development of dentistry as a science
Pierre Fauchard, ‘The Surgeon Dentist’
World’s first dental journal
Professionalisation of dental education
The dental drill
Discovery of X-rays
Bonding in dentistry
High-speed dentistry
Branemark era
Advances in restorative materials
Regenerative dentistry
Multi-detector row CT and CBCT
Dentistry in 21st century
Application of 3D technology and CAD-CAM
Key Points
Orthodontosie and orthodontia
The term Orthodontosie was coined by Joachim Lefoulon, a
Frenchman in 1841, in his book Nouveau traite de l’art du dentiste. The
term roughly translates into ‘Orthodontia’. Joachim Lefoulon used an
elastic gold archwire on the palatal side to treat crowding and
irregular teeth. The gold arch piano wire exerted shaping effect on
alveolar process and spring effect on teeth, which is an essential
concept of orthodontics.1
Orthodontics and dentofacial orthopaedics

An English philologist, Sir James Murray (1909), realised that the
suffix ‘ia’ appropriately referred to a medical condition (e.g. amnesia)
and suggested the term orthodontics. It took many years, till 1930s,
before the term Orthodontics was used by professionals. ‘Dentofacial
Orthopaedics’, suggested in 1976 by B. F. Dewel, has been added to
better describe the whole compass of an orthodontist’s bailiwick.2
Orthodontics and dentofacial deformities

To represent the extended role of orthodontics in treating and
contributing to the management of developing and developed, mild to
complex dentofacial deformities’ the Centre for Dental Education and
Research at All India Institute of Medical Sciences chaired by
Professor O.P. Kharbanda preferred to use the term Orthodontics and
Dentofacial Deformities. The term Dentofacial Deformities was coined
to be added with orthodontics to avoid confusion for medical
professionals, who considered dentofacial orthopaedics synonymous
to maxillofacial trauma and referred jaw fracture patients to the
orthodontic department. The first textbook, with the title Diagnosis and
Management of Malocclusion and Dentofacial Deformities, was published
by Elsevier India in 2009.
The story of orthodontics and its development is closely linked to
the history of dentistry. Here are some notable excerpts.
History of dentistry before Christ was
born (BC)
Historical evidence on dental ailments and descriptions can be found
in Indus valley, Greece, and Egyptian civilisations. The Indus Valley
Civilisation has yielded evidence for the earliest form of dentistry,
which dates back to 7000 BC. The oldest proof of a dental filling was
found in 2012 in Slovenia. A 6,500-year-old jawbone demonstrated a
deep cavity impacting the dentin layer of the tooth which was packed
with beeswax.3,4
5000 BC. Tooth decay was thought to have been caused by worms
and this belief continued to prevail as late as 1300s. During these years
a French surgeon, Guy de Chauliac, continued to promote the belief
that worms caused tooth decay.
2600 BC. The earliest known reference to a person identified as a
dental practitioner was the description on the tomb built following the
death of Hesy-Re, an Egyptian scribe, called the first ‘dentist’. An
inscription on his tomb includes the title ‘the greatest of those who
deal with teeth, and of physicians’. The Egyptians bound replacement
teeth together with gold wire5 (Fig. 1.1.1A).
FIGURE 1.1.1 (A, B). This image is from The National Museum of
Dentistry in Baltimore. The “treatment” in the mandible shown here was
done at the turn of the 20th century. Vincenzo Guerini, who wrote A
History of Dentistry and who made models of ancient dentistry
examples which he supposedly saw in his travels to Egypt. The
Egyptian mummy was supposedly 2000 years old. Source:
https://commons.wikimedia.org/wiki/File:Ancient_Egypt_Dentistry.jpg,
https://de.wikipedia.org/wiki/Datei:Ancient_Egypt_Dentistry2.jpg
1700–1550 BC. The Ebers papyrus, the ancient medical treatise

written sometime before 3000 BC, provides detailed advice on treating
wounds in the mouth. Of the 11 recipes, which pertain to oral issues, 4
relate to remedies for loose teeth.4,6
700 BC. Pre-Roman Civilization: The Etruscans (a pre-Roman
civilisation in Italy) travelled far across seas and gathered new
information. Both human and animal teeth were used as the first
prosthetics, beginning around 700 BC7 (Fig. 1.1.1B).
500–300 BC. Greek and Roman Dentistry: Around 500–300 BC, both
Hippocrates and Aristotle wrote about dentistry, including how teeth
erupt, treatment of cavities, gum disease, extraction, and even an early
form of orthodontics involving the use of wire to help secure loose
teeth.
At the same time, one ancient Greek mummy, with a mouth full of
cavities, such that it caused a sinus infection which eventually killed
him was found. Fortunately, they continued to advance in dentistry,
and in 100 BC, Celsus, a Roman medical writer, described oral
hygiene, and methods to stabilise teeth, as well as how to treat
toothaches, teething pain, and jaw fractures.8
The beginning of dentistry as a
profession: early to middle ages (AD)
The Etruscans prepared crowns and fixed bridgework with gold. A
medical text in China mentions the use of ‘silver paste’, a type of
amalgam for filling cavities in teeth sometime in 700 AD.
In 1530, Artzney Buchlein published The Little Medicinal Book for All
Kinds of Diseases and Infirmities of the Teeth, the first book devoted
entirely to dentistry in Germany. The text was written for barbers and
surgeons who treated diseases of the mouth.
In 1575, Ambroise Pare, famous French surgeon, published his
Complete Works. His text included practical information about
dentistry such as tooth extraction and the treatment of tooth decay
and jaw fractures.
The development of dentistry as a
science
Pierre Fauchard, ‘The Surgeon Dentist’
Pierre Fauchard, a French surgeon (Fig. 1.1.2A), published The Surgeon
Dentist, A Treatise on Teeth (Le Chirurgien Dentiste) in 1723. Dr Pierre
Fauchard is credited as being the Father of Modern Dentistry because
his book was the first to describe a comprehensive system for the
practice of dentistry, including basic oral anatomy and function,
operative and restorative techniques, and denture construction.
FIGURE 1.1.2 (A) Pierre Fauchard the Father of Modern Dentistry
(1678–March 22, 1761). (B) Prototype of bandeau used to align teeth
by tying them on rigid plate. Reproduced with permission. Source:
Wahl N. Orthodontics in 3 millennia. Chapter 1: Antiquity to the mid-
19th century. Am J Orthod Dentofacial Orthop. 2005 Feb;127(2):255–
9.
In 1746, Dr Claude Mouton was the first to suggest gold crown and
post to be retained in the root canal. The first commercial production
of non-metal porcelain teeth was introduced by Samuel Stockton
(1825). His S.S. White Dental Manufacturing Company supplied
commercially manufactured porcelain teeth and established and
dominated the dental supply market throughout the 19th century.
World’s first dental journal

World’s first dental journal began publication in 1839. It was named
the “American Journal of Dental Science”. The process of vulcanisation
invented by Charles Goodyear during the same years greatly
influenced the dental profession owing to low cost, and ease of
moulding rubber to the mouth. The vulcanised rubber soon became
the denture base material of choice for making false teeth. In 1864, the
moulding process for vulcanite dentures was patented; that meant an
onerous licensing fee. Dental profession continued to fight it for the
next 25 years.
Professionalisation of dental education

The opening of the first dental school with DDS (Doctor of Dental
Surgery) degree in 1840 at Baltimore, USA, marked the
professionalisation of dental education. The Baltimore College of
Dental Surgery was founded by Horace Hayden and Chapin Harris in
1840 and this School awarded the first professional dental school
degree, the DDS degree. This school later merged with the University
of Maryland in 1923. The American Society of Dental Surgeons, the
world’s first national dental organisation, was also founded in 1840
and was dissolved in 1856.
Between 1845 and the turn of the 19th century, major inventions in
chemistry and physics changed the world of medicine and dentistry,
like the successful demonstration of tooth extraction using ether,
discovery of X-rays and synthesis of local anaesthesia. The dental
drills, foot engine and electric drill were discovered during this time.
In 1845, Dr Horace Wells, a dentist had conducted a demonstration
of dental extraction under general anaesthesia with nitrous oxide, the
laughing gas, but it was regarded a failure when the patient cried out.
A year later, in 1846, another dentist, William Morton, conducted the
first successful public demonstration of the use of ether anaesthesia
for surgery.
The dental drill

The first dental drill, the foot engine was first commercially
manufactured as a foot-treadle dental engine under patent by James B.
Morrison in 1871. Morrison’s inexpensive, mechanised tool supplied
with dental burs with enough speed to cut enamel and dentin
smoothly and quickly, revolutionising the practice of dentistry
(Fig. 1.1.3). Much later, an American, George F. Green, received a
patent for the first electric dental engine, a self-contained motor and
handpiece (Fig. 1.1.4).
FIGURE 1.1.3 First foot dental drill was commercially available in
1871. This foot engine is a proud possession of the author who
used it in 70s as a dental student.
FIGURE 1.1.4 The dental electric drill that revolutionised

restorative dentistry.
(http://mcnygenealogy.com/pics/picture.php?/213/categories).
Discovery of X-rays
Wilhelm Roentgen, a German physicist, in 1885, discovered X-rays
which had a great impact on medical practice. The first dental X-ray of
a living person in USA was taken in 1896 by a prominent New
Orleans dentist, C. Edmund Kells.
Nineteenth century witnessed major changes with scientific discovery
of formulation of local anaesthesia, the first bonding system, the acid
etch, high-speed air drills and the most significant being the concept
of osseointegration. In 1905, Alfred Einhorn, a German chemist,
formulated the local anaesthetic procaine, later marketed under the
trade name Novocain.
Bonding in dentistry
Oskar Hagger, a Swiss chemist, developed the first system of bonding
acrylic resin to dentin in 1949 and a few years later, in 1955, a simple
method of increasing the adhesion of acrylic fillings to enamel was
described by Michael Buonocore using acid etch technique.
High-speed dentistry
John Borden (1957) first introduced a high-speed air-driven contra-
angle handpiece. The Airotor attained speed up to 300,000 rotations
per minute and was an immediate commercial success, launching a
new era of high-speed dentistry9,10 (Box 1.1.1).
Box 1.1.1 Landmark events in the history of

dentistry from BC to 2010
BC The first and most enduring explanation for what causes tooth decay was the tooth worm,
as depicted in the ivory sculptures, which was first noted by the Sumerians.
2600 The earliest known reference to a person identified as a dental practitioner was the
BC description on the tomb built following the death of Hesy-Re, an Egyptian scribe, often
called the first ‘dentist’.
1700– The Edwin Smith Papyrus/Ebers Papyrus is an ancient Egyptian medical text. It is the
1550 oldest known surgical treatise on trauma. This contains 11 recipes, which pertain to oral
BC issues
700 BC Human and animal teeth were used as the first prosthetics, beginning around 700 BC. The
Etruscans (a pre-Roman civilization in Italy) actually made some basic leaps in dentistry
500– Hippocrates and Aristotle wrote about dentistry, including how teeth erupt, treatment of
300 BC cavities, gum disease, extraction, and even an early form of orthodontics involving the use
of wire to help secure loose teeth
166– The Etruscans practiced dental prosthetics using gold crowns and fixed bridgework.
201
AD
700 A medical text in China mentions the use of ‘silver paste’, a type of amalgam for filling
cavities in teeth.
1210 A Guild of Barbers was established in France.
1530 Artzney Buchlein published The Little Medicinal Book for All Kinds of Diseases and Infirmities of
the Teeth the first book devoted entirely to dentistry, in Germany.
1575 In France, Ambroise Pare, known as the Father of Surgery, published his Complete Works.
1723 Pierre Fauchard, a French surgeon published The Surgeon Dentist, A Treatise on Teeth (Le
Chirurgien Dentiste). Surgeon Pierre Fauchard is credited as being the Father of Modern
Dentistry.
1746 Claude Mouton described a gold crown and post to be retained in the root canal.
1825 Samuel Stockton began commercial manufacture of porcelain teeth under S. S. White
Company.
1839 The American Journal of Dental Science, the world’s first dental journal, began publication.
1840 Horace Hayden and Chapin Harris found the world’s first dental school, the Baltimore
College of Dental Surgery, and established the Doctor of Dental Surgery (DDS) degree.
(The school merged with the University of Maryland in 1923).
1846 Dentist William Morton conducted the first successful public demonstration of the use of
ether anaesthesia for surgery.
1871 James B. Morrison patented the first commercially manufactured foot-treadle dental
engine.
1895 Wilhelm Roentgen, a German physicist, discovered the X-ray. In 1896, prominent New
Orleans dentist, C. Edmund Kells, took the first dental X-ray of a living person in the US.
1899 Edward Hartley Angle classified the various forms of malocclusion. Credited with making
orthodontics into a dental specialty.
1905 Alfred Einhorn, a German chemist, formulated the local anaesthetic procaine, later
marketed under the trade name Novocain.
1955 Michael Buonocore described the acid etch technique, a simple method of increasing the
adhesion of acrylic fillings to enamel.
1957 John Borden introduced a high-speed air-driven contra-angle handpiece. The Airotor
obtained speed up to 300,000 rotations per minute and was an immediate commercial
success, launching a new era of high-speed dentistry.
1980 Per-Ingvar Branemark described techniques for the osseointegration of dental implants
1990 New tooth-coloured restorative materials plus increased usage of bleaching, veneers, and
implants inaugurated an era of aesthetic dentistry.
1972, Discovery of multi-detector row CT (MDCT) added new dimensions in 3D imaging of
1988, living structures. Computed axial tomography (CT) was invented in 1972 by British
1996 engineer, Godfrey Hounsfield of EMI Laboratories, England and by South Africa–born
physicist, Allan Cormack of Tufts University, Massachusetts. Discovery of CBCT
originated at a small town named Verona in Italy in 1988. The NewTom or maxiscan was
the first CBCT system in the world, installed in 1996.
1990 First dental CAD-CAM was invented in Zurich by Siemens and sold by SIRONA.
….
1997 FDA approved the erbium YAG laser, the first for use on dentin, to treat tooth decay.
1998 National Institute of Dental Research was renamed National Institute of Dental and
Craniofacial Research to more accurately reflect the broad research base.
2000…. Regenerative dentistry and stem cell research including banking of primary tooth pulp
tissue for regeneration, proposed in the new millennium.
2010 3D printing in dentistry, oral and maxillofacial surgery and orthodontics.
Branemark era
The history of modern dentistry will always be remembered as before
and after Branemark era. In 1980, Per-Ingvar Branemark described
techniques for the osseointegration of dental implants and this was
perhaps the most thrilling and useful innovation that had influenced
the practice of dentistry and patient satisfaction in the century.
Dentistry in 20th Century
The 20th century saw the advances and refinements in materials,
aesthetic dentistry and induction of sophisticated technology. The first
commercial home tooth bleaching product was marketed in 1989.
Advances in restorative materials

A year later in 1990, a new era of aesthetic dentistry began with the
introduction of tooth-colour restorative materials, veneers, increased
usage of bleaching, and implants. In 1997, FDA (Food and Drug
Administration) approved the erbium YAG laser, the first for use on
dentin, to treat tooth decay.
The need for broad research base in dentistry led to renaming ‘The
National Institute of Dental Research’ to ‘National Institute of Dental
and Craniofacial Research’, in 1998.
Regenerative dentistry
By 2000, regenerative dentistry and stem cell research, including
banking of primary tooth pulp tissue for regeneration turned out to be
the most exciting and promising area of dentistry. Regenerating a
functional and living tooth is one of the most promising therapeutic
strategies for the replacement of a diseased or damaged tooth.11
Multi-detector row CT and CBCT

Discovery of computed tomography added new dimensions in 3D
imaging of living structures. Computed axial tomography (CT), which
changed the world of medical imaging from 2D X-rays to 3D imaging
was invented by British engineer, Godfrey Hounsfield of EMI
Laboratories, England and by South Africa-born physicist Allan
Cormack of Tufts University, Massachusetts in 1972. Discovery of
cone beam computed tomography (CBCT) originated at a small town
named Verona in Italy in 1988.12 The NewTom or maxiscan was the
first CBCT system in the world, installed in 1996.13
Dentistry in 21st Century
Application of 3D technology and CAD-
CAM
François Duret, in the 1970s, conceptualised and adapted the use of
digital technology used in industry to dentistry. The most significant
and useful application was digital impression making either directly
in the mouth or indirectly on a model. These clinical applications were
the outcomes of research as a part of his thesis exercise having the title
‘The optical imprint’.
The 3D scan of impressions is transferred to production milling
machines through a process of computer-assisted manufacturing
(CAM) to create dental restorations such as inlays and crowns. First
dental CAD-CAM was invented in Zurich by Siemens and sold by
SIRONA.14,15 Dr Anderson developed Procera System. He attempted
to fabricate titanium copings by spark erosion and introduced CAD-
CAM technology into the process of composite veneered restorations.
This system later developed as a processing centre networked with
satellite digitizers around the world for the fabrication of all ceramic
frameworks.16,17 Dr Mormann developed CEREC System, an
innovative approach to fabricate same day restorations at the chair
side in the dental office.18
With the induction of 3D printing in dentistry, particularly in the
streams of oral and maxillofacial surgery and orthodontics, future
dentists and patients are now looking at quality control in
rehabilitation, and customised lingual and labial appliances. 3D
printing has numerous applications in dentistry, although the full
potential of this technology is yet to be explored.19,20
Key Points
The art and science of dental practice has evolved since ancient
Egyptians times to modern era of high speed, precision and lately
digitalisation. The science of dentistry has contributions from the
fields of medicine, engineering, computer sciences, material sciences
and many more.
References
1. Weinberger BW. Historical résumé of the evolution
and growth of orthodontia. J Am Dent Assoc.
1934;21:2001–2021: Cited from Wahl N. Orthodontics
in 3 millennia. Chapter 16 Late 20th-century fixed
appliances, Am J Orthod Dentofacial Orthop. 2008
Dec;134(6):827-30. PMID: 19061811.
2. Dewel BF. Editorial: Orthodontosie, orthodontics, or
dentofacial orthopedics. Am J Orthod. 1976;70(3):328:
Sep; PubMed PMID: 1066971.
3. http://www.ancient-origins.net/human-origins-
science/jewel-capped-teeth-golden-bridges-9000-
years-dentistry-001427; [accessed 28.11.2016, 9:44
pm].
4. http://www.ancient-origins.net/human-origins-
science/jewel-capped-teeth-golden-bridges-9000-
years-dentistry-001427; [accessed 1.12.2016, 8:44 pm].
5. http://www.ada.org/en/about-the-ada/ada-history-
and-presidents-of-the-ada/ada-history-of-dentistry-
timelinehttps://en.wikipedia.org/wiki/Dentistry.
6. http://www.messagetoeagle.com/ancient-history-of-
dentistry/#ixzz4QsTqiLMk.
7. http://fortworthtexasdentist.com/history-of-
dentistry-part-1-ancient-dentistry/. [accessed
2.12.2016 at 644 AM].
8. http://fortworthtexasdentist.com/history-of-
dentistry-part-1-ancient-dentistry/; [accessed
28.11.2016, 9:55 pm].
9. http://www.ada.org/en/about-the-ada/ada-history-
and-presidents-of-the-ada/ada-history-of-dentistry-
timeline; [accessed 2-12-2016 at 638 AM].
10. https://en.wikipedia.org/wiki/Dentistry; [accessed
28.11.2016 at 845 PM].
11. Chai Y, Slavkin HC. Prospects for tooth regeneration
in the 21st century: a perspective. Microsc Res Technol.
2003;60(5):469–479: Apr 1; Review. PubMed PMID:
12619122.
12. www.imaginis.com/ct-scan/brief-history-of-ct.
13. Mozzo P, Procacci C, Tacconi A, Martini PT, Andreis
IA. A new volumetric CT machine for dental imaging
based on the cone beam technique: preliminary
results. Eur Radiol. 1998;8(9):1558–1564: PubMed
PMID: 9866761.
14. Duret F, Preston JD. CAD/CAM imaging in dentistry.
Curr Opin Dent. 1991;1(2):150–154: Apr; Review.
PubMed PMID: 1777659.
15. http://digital-dental-cadcam.com/history-of-cad-cam/;
[accessed 6.12.2016 6.20.11 am].
16. Andersson M, Odén A. A new all-ceramic crown: a
dense-sintered, high-purity alumina coping with
porcelain. Acta Odontol Scand. 1993;51(1):59–64: Feb;
PubMedPMID: 8451925.
17. Andersson M, Carlsson L, Persson M, Bergman B.
Accuracy of machine milling and spark erosion with
a CAD/CAM system. J Prosthet Dent.
1996;76(2):187–193: Aug; PubMed PMID: 8820812.
18. Mörmann WH. The origin of the Cerec method: a
personal review of the first 5years. Int J Comput Dent.
2004;7(1):11–24: Jan English, German PubMed PMID:
15317305.
19. AndonoviĆ V, Vrtanoski G. Growing rapid
prototyping as a technology in dental medicine. Mech
Eng Sci J. 2010;29:31–39.
20. Dawood A, Marti B, Sauret-Jackson V, Darwood A.
3D printing in dentistry. Br Dent J.
2015;219(11):521–529: Dec; Review. Erratum in: Br
Dent J. 2016 Jan 22;220(2):86. PubMed PMID:
26657435.
CHAPTER 1.2
History of orthodontics
CHAPTER OUTLINE

Orthodontics in 17–18th century and European dominance
Pierre Fauchard father of modern dentistry and first
fixed appliance
Contributions of Joachim Lefoulon
American dentistry and orthodontics in mid-19th century
Contribution of Edward Hartley Angle to the orthodontic
profession (1855–1930)
Edward Angle‘s inventions and teachings
The first three decades of 20th century, 1900–30: beginning of
biological foundation of orthodontics
Orthodontics during 1930–40: Functional appliance
and cephalometrics
Orthodontics during 1940–50: Tweed’s concepts of
growth
First multidisciplinary cleft clinic, Lancaster
Orthodontics during 1950–60: emphasis on
cephalometrics
Contributions of Charles H. Tweed (June 1895–January
1970)
Orthodontics during 1970–80: pre-adjusted appliances
Evolution of pre-adjusted appliances and bonding:
hallmark of contemporary orthodontics
Orthodontics during 1980–90: clinical success with twin block
popularised functional appliance
Temporary anchorage devices: major game changer in
orthodontic practice
Autotransplantation of teeth in the management of
space
Robotic orthodontics
Key Points
In Ancient times, irregular teeth have been located in the skulls of
Neanderthal man who existed about 50,000 BC. Ancient Greeks and
Etruscan artefacts exhibit designed devices/appliances to exert
pressure on teeth. Archaeologists have discovered Egyptian mummies
with crude metal bands wrapped around individual teeth. It is
speculated that catgut was used to close the gaps1 (Fig. 1.1.1B).
Hippocrates era, 400 BC to 16th century. Ancient Greek physicians
mentioned dental irregularities as early as 400 BC. Celsus (in Rome, 25
BC–50 AD) advised the removal of deciduous teeth once the
permanent teeth have erupted and treatment of crooked or irregular
teeth could be attempted by pressure exerted by the finger. He stated,
‘If a second tooth should happen to grow in children before the first
has fallen out, that ought to be shed is to be drawn out, and the new
one daily pushed toward its place by means of the finger until it
arrives at its just proportion’.1 In all probability, Pliny the Elder was
the first to use (AD 23–79), mechanical treatment, which was filing
elongated teeth to bring them into proper alignment.1
Galen (129–199), suggested treatment of irregular teeth by filing of
the teeth to gain space. It was Fabricius (1619) who suggested
extraction of teeth in case of crowding.2 Following years saw some
evolution in dental profession in France where dental surgeons could
undergo formal training and practice correction of dental
irregularities.
Orthodontics in 17–18th century and
European dominance
Pierre Fauchard, father of modern dentistry
and first fixed appliance
Pierre Fauchard (1678–March 22, 1761), a French physician is known
as ‘father of modern dentistry’ for his innumerable scientific
contributions. He is also known for the first description of ‘brace’ the
‘bandeau’, the forerunner of Angle’s E Arch appliance (Fig. 1.1.2 A, B).
The bandeau was made of gold. It was used as a firm arch to which
irregular teeth were tied using waxed linen or silk threads. He
discovered that the teeth position could be corrected, as the teeth
would follow the pattern of the brace.
Dr Fauchard, The Surgeon Dentist, is also known for writing the first
complete scientific description of dentistry, ‘Le Chirurgien Dentiste’,
published as early as 1728. Dr Fauchard who worked in Royal French
Navy, joining, Alexander Poteleret, at the age of 15, was greatly
influenced by surgeon major, Alexander Poteleret, and got interested
in diseases of the mouth, which caused much suffering in sailors on
long voyages. Dr Fauchard studied medicine and later practised at
Angers University Hospital. He moved to Paris in 1723, at the age of
45 years, where he completed the first 600-page manuscript. Next
5 years were spent on modifying and updating the text based on
feedback from his peers; by the time it was published in 1728 in two
volumes, it swelled to 783 pages.3
‘Le Chirurgien Dentiste’ is considered to be the first major
description of dentistry. It described the basic oral anatomy, and
function, signs and symptoms of oral pathology, operative methods
for removing tooth decay and restorations, periodontal disease,
orthodontics, replacement of missing teeth, and tooth transplantation.
Dr Fauchard described a labial arch made of ivory for use in
orthodontics.2
The second edition was published in 1746, and the third one in
1786. In 1733, the book was translated into German language.
Dr Fauchard collected examples of treatment of irregular teeth to
describe them particularly well, concerning the eruption of teeth, he
wrote: ‘... teeth erupt sooner or later, depending on the children’s
forces’, with their ‘temperament’ being possibly so big as to present
with teeth already at the time of birth. He described, among other
things: a rédressement force using a ‘pelican’, where the tooth was
moved within the socket. He then ligated the tooth to its neighbours
until healing took place. At that time, most attention was paid only to
the alignment of teeth almost exclusively in the maxilla. He also
suggested interproximal polishing and splinting of the tooth with a
follow-up treatment bringing about the desired result within a
week.1,2
During these years (1722–66), Phillip Pfaff, a surgeon dentist, for the
first time described taking the impression with sealing wax. However,
he denied that milk teeth have roots, which was later contradicted by
John Hunter (1728–93), a British surgeon, inspector-general of
hospitals, also worked in orthodontics and found out that milk teeth
do have roots. His observations included that, once they have erupted,
they no longer grow in width, but that crowding is the result of tooth
movement. He determined that milk molars are bigger than pre-
molars, but front milk teeth are smaller than permanent teeth.2
John Hunter (1728–93) was first to investigate the growth in
animals, using pigs’ mandibles. A metal ring that was inserted at the
front edge of the ascending mandibular ramus in growing animals
that moved to the centre due to the opposition at the front edge and
resorption at the hind edge of the mandible.
The inclined plane. John Hunter was first to use an inclined plane
made of silver in the anterior tooth-bearing area of the jaws to treat
prognathia and a metal arch with ligatures. Adam Anton Brunner was
first to use an inclined plane in 1771. However, it was L. J. Catalan
who propagated an inclined plane around 1808 as its construction.
The inclined plane is now named after him.
First plaster models. In 1836, Friedrich Christoph Kneisel, a
German dentist, was first to use plaster models to record
malocclusion. He used chin straps for correction of prognathic
mandible and hence, became the first to use a removable appliance.
Kneisel (1797–1887) also wrote the 21-page ‘Der Schiefstand der Zähne,
dessen Ursachen und Abhilfe einer neuen, sicheren und schmerzlosen
Heilmethode’ [Dental malpositioning, its causes and remedies using a
novel, safe and painless method]. The first regulatory plate was made
by Christopher Starr Brewster in 1840; it was made of caoutchouc.
Contributions of Joachim Lefoulon

The year 1841 is perhaps one of the historic years in the dental
profession, when Joachim Lefoulon, in his book Nouveau traite de l’art
du dentiste, used the term Orthodontosie, which the Americans
simplified to ‘orthodontia’ and, later, to ‘orthodontics’.4
An elastic gold archwire was tied on the palatal side to treat dental
crowding. The wire has dual effect on relief of dental crowding and
also a moulding shaping effect on the alveolar process, it can be said
that this appliance was the first step towards ‘orthodontics’.1
Lefoulon, suggested malocclusion can be caused by these factors:
(1) Constitutional differences brought about by social, economic,

and geographic conditions
(2) Prenatal conditions
(3) A disease process, such as scrofula and
(4) Abnormal pressures during the speech.
The first molar band was fixed with a screw, in 1841 by J. M. Alexis
Schangé. His book Précis sur le Redressement des Dents described an
adaptable band clamp that was fixed to the tooth using a screw. He
was also the first to mention a need for a period of retention after the
treatment.
The first classification of malocclusion. Georg Carabelli in 1842
presented first ever classification of malocclusion. He presented a
novel classification of various types of occlusion, which was highly
regarded in the German-speaking world for quite some time.
William Henry Dwinelle (1819–96) was the first to use screws and
the first elastic rubber for orthodontics in 1846.
The first report on bone remodelling (1859). John Tomes was the
first to show remodelling processes in the alveolar bone with bone
resorption in the direction pressure is exerted, and bone apposition on
the side of relief.2
American dentistry and orthodontics in
mid-19th century
In the United States before the 1830s, there was no formal professional
education or a dental degree. The physicians, barbers, or charlatans
performed the work and procedures in mouth. The literature has little
contributions from American authors related to orthodontics until
18801 and the term Malocclusion was not known.
During mid-19th century, significant developments took place
which contributed to evolving a dental profession with formal
education and training. In 1839, the American Journal of Dental Science,
the world’s first dental journal, had begun publication and a year
later, the world’s first dental school, the Baltimore College of Dental
Surgery was founded. The first formal dental degree, DDS degree was
awarded from Baltimore.
It is at Baltimore College of Surgery that the first lectures on
‘irregularities’ of the teeth were given to undergraduates by Chapin
Harris. Norman Kingsley, who is considered ‘Father of Orthodontia in
the USA’, lectured students on the causes and correction of
malocclusion (1872).
Before 1910, orthodontics was taught as a branch of prosthetics, the
techniques for correction of irregular teeth with little or no emphasis
on science.
Norman William Kingsley, 1866. Dr Kingsley suggested prosthetic
treatment of cleft lip and palate and introduced extraoral traction
device. His student, Walter Harris Coffin, in 1881 (Fig. 1.2.1), found an
innovative method for regulation of irregular teeth using a bent W
spring made of piano wire embedded on both sides into vulcanite,
later replaced by acrylic. The spring is free to expand in the middle
and thereby used as expansion appliance to move two sides of the
alveolar process in the maxilla.
FIGURE 1.2.1 The W spring made of piano wire by Walter Harris
Coffin (1881). Source: Wahl N. Orthodontics in 3 millennia. Chapter 2:
entering the modern era. Am J Orthod Dentofacial Orthop 2005
Apr;127(4):510–5.
John Nutting Farrar (1839–1913). Dr Farrar authored text on

orthodontics ‘Irregularities of the Teeth and Their Treatment’ first in
1888, which went through six editions; and more than 90 articles on
gingival pathologies and irregularities of the teeth. Farrar opined that
forces for moving the teeth should not be continuous and suggested
the theory of intermittent force. He developed a screw to deliver this
kind of force in controlled increments by activating the device ‘about
1/240 inch every morning, and the same in the evening’.
Around the same years Dr George B. Crozat (1893–1966) developed
a universal wire device, which is more popularly known as Crozat
appliance and Crozat retainer (Fig. 1.2.2; Box 1.2.1 A, B, C).
FIGURE 1.2.2 Dr George B. Crozat (1893–1966) developed a
universal wire device, which is more popularly known as Crozat
appliance and Crozat retainer. Source: Wahl N. Orthodontics in 3
millennia. Chapter 5: the American Board of Orthodontics, Albert
Ketcham, and early 20th-century appliances. Am J Orthod Dentofacial
Orthop 2005 Oct;128(4):535–40.
Box 1.2.1A Origin and worldwide contributions in

orthodontics from 400 BC to 19th century
Years Events
400 Hippocrates era: Dental irregularities mentioned the first time
BC
25 Celsus recommended the removal of milk teeth once the permanent teeth have erupted, and
BC– the straightening of crooked or irregular teeth by pressure exerted with the finger
50
AD
129– Galen suggested treatment of the irregular teeth by filing of the teeth to gain space
199
1619 Fabricius suggested extraction of teeth in case of crowding
1678– First description of ‘brace’ or the ‘bandeau’, the forerunner of Angle’s E Arch appliance
1761 given by Pierre Fauchard. Bandeau was used as a firm arch to which irregular teeth were
tied using waxed linen or silk threads
1722– Phillip Pfaff, a surgeon dentist, for the first time described taking the impression with
1766 sealing wax
1728– John Hunter, a British surgeon, inspector-general of hospitals, also worked in orthodontics
1793 and found out that milk teeth do have roots. He was also the first to investigate growth of
mandible in animals
1771 Adam Anton Brunner was the first to use an inclined plane in 1771. However, it was L. J.
Catalan who propagated an inclined plane around 1808 as his own construction
1836 Friedrich Christoph Kneisel, a German dentist, was first to use plaster models to record
malocclusion. He used chin straps for correction of prognathic mandible and hence, became
the first to use a removable appliance
1841 Joachim Lefoulon, in his book Nouveau traite de l’art du dentiste, used the term ‘Orthodontia’.
He used an elastic gold archwire on the palatal side to treat crowding
M. Alexis Schangé described an adaptable band clamp that was fixed to the tooth using a
screw; he was probably the first to realise that treatment should be followed by a period of
retention
1842 Georg Carabelli presented a novel classification of types of occlusion
1846 Claude Lachaise and Elisha Gustavus Tucker were the first to use the elasticity of rubber
straps for orthodontic purposes
1859 John Tomes was the first to show remodelling processes in the alveolar bone
1872 Norman Kingsley, considered as the ‘Father of Orthodontia in USA’, lectured students on
the causes and correction of malocclusion at Baltimore College of Dental Surgery
1878– Edward H. Angle’s contributions are listed in Box 1.2.2
1930
1881 Walter Harris Coffin found an innovative method for regulation of irregular teeth using a
bent W spring made of piano wire embedded on both sides into vulcanite, later replaced by
acrylic
1888 John Nutting Farrar wrote on irregularities of the teeth and their treatment
1890 Intermaxillary elastics proposed by Dr Case and Dr Baker. However it became popular as
Baker’s Anchorage
Box 1.2.1B Origin and worldwide contributions in

orthodontics, 20th century
Years Events
1900 George B. Crozat developed a universal wire device, which is more popularly known as
Crozat appliance and Crozat retainer
1908 Charles A. Hawley published ‘Determination of Normal Arch and its Application to
Orthodontia’ and introduced the retainer appliance that bears his name: Hawley’s appliance
1911 Albin Oppenheim, an Austrian-Hungarian born physician turned orthodontist, was the first
to report tissue changes more so in bone during orthodontic tooth movement. His first
article on this subject was published in Vienna
1915 Albert H. Ketcham, one of the first to introduce the roentgenogram and photography into
The International Journal of Orthodontia and Oral Surgery was started in 1915
John V. Mershon introduced the removable lingual arch based on the principle that teeth
must be free and unrestricted for adaptation to normal growth
1918 Alfred Rogers introduced the concept of myofunctional therapy
1921 Dr Case published his major work, ‘A Practical Treatise on the Techniques and Principle of
Dental Orthopedia and Prosthetic Correction of the Cleft Palate’
1924 Concept of orientation of face beyond teeth was introduced. Paul Simon’s Gnathostatics
1931 ‘A New X-ray Technique and its Application to Orthodontia’ This pioneering technique
lead to a new era of understanding of face, skull and science of orthodontics
Bolton’s point: In recognition of Mrs Chester C. Bolton and her son Charles B. Bolton who
funded manufacture of first cephalostat head holder and x-ray apparatus, which was
installed at anatomical laboratory of the Western Reserve University
1933 Dr. Andressen revived Monoblock appliance first developed by Pierre Robin in 1902 to new
appliance called Activator. Dr Robert E. Moyers and Sam Pruzansky inducted
electromyography to study the effect of musculature on occlusion
Bjork’s study on normal variations and mechanism of prognathism as well as relationship
between facial build and the bite in representative material
1946 Dr Kooper established first dedicated interdisciplinary clinic for patients with cleft lip and
palate and craniofacial anomalies; what is now famous as Lancaster Cleft Centre
1950– Key contributions of Dr Charles H. Tweed: Induction of cephalometry in clinical practice
1960 and the emphasis by a number of authors like William B. Downs in 1952 followed by C. C.
Steiner 1953, C. H. Tweed 1953, S. E. Coben 1955
1952 ‘Textbook of Functional Jaw Orthopaedics’ was released by Karl Häupl
1960– Standardization of edgewise mechanism by Charles J. Tweed and popularization of
1970 extraction philosophy treatment with light wire appliance by P. R. Begg at Adelaide,
Australia. Dr Begg promoted reduction of tooth substance by extractions and created
modified Ribbon Arch bracket, and multiple-loop light-force wire appliance, known as
Begg’s Light wire technique. His book was first published in 1965
1970s Robert Murray Ricketts greatly influenced orthodontic thinking by his critical evaluation of
existing cephalometric analysis. He evolved bracket modification towards building
prescription in .018 inch slot 1970s. The first cephalometric analysis diagnostic system to
project treatment plus growth in treatment planning (VTO) and computer generated
method for projecting growth was also developed by him
Ricketts also developed the quad helix, utility arches, sectionalisation and most
significantly, bioprogressive philosophy, a biological approach to diagnosis and
treatment. He recognised and used facial proportions to treat dental and skeletal
problems called the Divine Proportion
CF Andrews introduced straight wire appliance
1969 Newman introduced bonding in orthodontics
1980– The duo of clinicians McLaughlin and Bennett, made the MB (McLaughlin–Bennett)
1990 appliance popular. The MB prescription was later further modified by Trevisi and is now
widely known as MBT prescription
1987 Ceramic brackets first introduced in the market
1990s Temporary anchorage devices (TADs) another game changer in orthodontic practice with a
successful case report by Creekmore and Eklund
1990 DIGI-CEPH, computerised cephalometric analysis system, developed at All India Institute
of Medical Sciences in collaboration with Indian Institute of Technology (IIT) New Delhi
Box 1.2.1C Origin and worldwide contributions in

orthodontics, 21st century
Years Events
2000 Concept of 3D printing emerged in Nagoya, Japan by Hideo Kodama who invented the
onwards first fabricating technology and methodology for rendering plastic into 3D with a
polymer that was exposed to ultraviolet rays
2006 The integration of CBCT (cone beam computed tomography) skull, CBCT models, non-
radiation 3D facial scanning put to use for ‘real life’ like planning more so the effects of
orthodontic treatment on facial profile
2006 Dolphin Imaging company introduced its 3D module which is able to import and
process 3D datasets from MDCT, CBCT, MRI and high definition facial camera systems
2007 ‘Universal Connector’ Developed at AIIMS by O.P. Kharbanda for indirect Miniscrew
anchorage.
Around The first commercial venture with robotic wire bended wire supplies in the United States
2010 with the name SureSmile/Orametrix
2010 Auto-CEPH, the advanced computerised cephalometric system, was developed as a
collaborative work by O.P. Kharbanda and H. S. Sardana working at All India Institute
of Medical Sciences, New Delhi and Central Scientific Instrument Organisation,
Chandigarh
Around Plaster-free clinics wherein intraoral scanners are in use which allow 3D scanning of
2010 dental structures; this helps to produce digital models, virtual planning and print plastic
models
2015 ‘CollobDDS’ a network enabled digital diagnosis and interactive platform developed by
a team of clinicians and scientists from various disciplines. Orthodontics and Radiology
at AIIMS, imaging scientists at CSIO Chandigarh and IIT Mumbai and IT team at NIC
New Delhi
2018 Algorithm for automated 3D cephalometric analysis and automated volumetric analysis
through CBCT developed at CSIO AIIMS collaboration. Lead scientists. H. S. Sardana
and O.P. Kharbanda, A. Gupta and B. C. Neelapu
Contribution of Edward Hartley Angle
to the orthodontic profession (1855–
1930)5–8
‘It is well known that Dr Edward H. Angle is the nestor of
orthodontia. To him, more than to any other individual is this science
indebted. His life has been spent nursing and developing it’,
Cited from ‘A Biographical Portrait of Edward Hartley Angle, the
First Specialist in Orthodontics’, written by Peck S.6 in a three part
series and the Editorial for the first issue of The International Journal of
Orthodontia in 1915 by Martin Dewey, DDS, MD, one of his most
accomplished students, the following write-up gives a brief record of
E. H. Angle.
“No personality central to the history of orthodontics stimulated as
much progress, excitement, and polarity as Edward Hartley Angle,
MD, DDS (1855–1930), the acknowledged founder of this clinical
speciality. Early in the 20th century, he dominated the emergence of
‘orthodontia as a science and a speciality’. This inventive doctor gave
malocclusion the primacy and order it needed.”
Edward Hartley Angle spent his boyhood on his parents’ farm in
District, ‘Ballibay’, Herrick Township, Bradford County,
Pennsylvania. His mother Isabel, in the year 1874, introduced HART
(Angle’s nickname) at age 18 years to a nearby dentist to learn
dentistry as an office apprentice. Later, Angle enrolled himself at
College of Dental Surgery in Philadelphia for the DDS programme.
The DDS programme was then arranged in two 6-month terms spaced
over a nominal two years.
In 1878, Edward Angle initiated his profession by setting up a
general practice of dentistry in the centre of town at Bradford County
seat, Towanda. In 1881, his health deteriorated, and he decided to
abandon dentistry on his physician’s advice to live in an outdoor
environment. Angle moved to live in Minneapolis, Minnesota where
his health improved. While Angle was contemplating to abandon
dentistry to avoid physically demanding dental profession, he set up a
lucrative sheep-raising business in Montana with his friends and
brother. Unfortunately, a record-breaking deep freeze that year killed
off the entire herd and he lost all his savings.
By mid-1882, he moved back to practice again. His curiosity,
attention and indulgence in ‘regulating’ the ‘irregular teeth’ continued
to flourish. The breaking point in his career was his announcement
that he would be practising orthodontia and no other forms of dental
treatment or therapy. ‘With this decision, he became the first
acknowledged exclusive specialist in orthodontics in the world’.
Dr Angle was lecturing orthodontics in several schools. In 1886, 31-
year-old Edward Angle was appointed a professor of histology and
lecturer on comparative anatomy and orthodontia at Minnesota
Hospital College in Minneapolis.
In 1887, Angle was the youngest of the speakers at Ninth
International Medical Congress in Washington DC in the section on
‘Dental and Oral Surgery’. His talk titled Notes on Orthodontia with a
New System of Regulation and Retention, demonstrated his classification
of tooth movements and his novel orthodontic devices, such as piano
wire in a soldered ‘pipe’ (tube) and the jackscrew and traction screw.
He used ‘lantern slides’ to show his presentation, a new lecturing aid
in those days. His presentations led to some passionate and
inflammatory discussions with eminent dentists accusing Angle of
presenting old stuff with his claims. Transactions of the Ninth
International Medical Congress contained his edited paper titled
‘Notes on Orthodontia’, commonly referred as ‘First Edition’ of his
classic textbook on the treatment of malocclusion. However, Angle
considered that his first edition was his 14-page chapter appended to
Loomis P. Haskell’s new book on dental laboratory procedures
published in 1887, Extracts of Notes on Orthodontia with a New System by
[sic] Regulation and Retention.
Edward Angle’s inventions and teachings

(Figs. 1.2.3 and 1.2.4)
With his talent of mechanical innovations and his zeal to treat patients
and teach, he continuously evolved new methods and appliances. He
had 46 patents to his credit, 45 during his lifetime, and 46th appearing
after his death. Angle continued to edit his book, adding his
experience and innovations. The seventh and last edition of the 628-
page text was published in 1907. His contribution and events are
given in Box 1.2.2. He initiated the first formal exclusive school in
orthodontia, ‘The Angle School of Orthodontia’ at 1023, N. Grand
Avenue, Saint Louis, MO, USA in 1903. Angle organised the first
orthodontic society (1900) meeting, the American Society of
Orthodontists, which is now the American Association of
Orthodontists (AAO). He developed several appliances (Figs. 1.2.5
and 1.2.6), Pin and tube (Fig. 1.2.7), Ribbon arch (Fig. 1.2.8) and finally
the best gift to orthodontic profession, the Edgewise appliance
(Fig. 1.2.9). The edgewise appliance with its modifications is still in
use as the mainstay fixed appliance around the world.
FIGURE 1.2.3 Edward Hartley Angle’s model of ideal occlusion
was based on this ancient skull which he called ‘Old Glory’.
This skull had been presented to Angle by Richard Summa, one of
Angle’s first students and an amateur archaeologist. Source: Wahl N.
Orthodontics in 3 millennia. Chapter 12: Two controversies: early
treatment and occlusion. Am J Orthod Dentofacial Orthop 2006
Dec;130(6):799–804.
FIGURE 1.2.4 The newspaper advertisement of Angle School of
Orthodontia. Source: Wahl N. Orthodontics in 3 millennia. Chapter 2:
Apr;127(4):510– 15.
Box 1.2.2 Chronology of major contributions of

Edward H. Angle, June 1, 1855–August 11, 1930
Year Event
1855 Edward Hartley Angle (HART) was born on June 1, 1855. His boyhood home was on his
parents farm in District 1, ‘Ballibay’, Herrick Township, Bradford County, Pennsylvania.
As a child, HART had an innovative mind for mechanical artefacts.
1874– HART at age 18 had his training in dentistry with a nearby dentist as an office apprentice.
1876
1878 Graduated as a dentist with DDS from Pennsylvania College of Dental Surgery in
Philadelphia. The DDS programme was then arranged in two 6-month terms spaced over a
nominal 2 years.
1878 He began practising dentistry in Towanda, the county seat of Bradford County,
Pennsylvania. He was very much interested in regulating teeth and worked on mechanical
devices to that effect.
1886 Edward Angle was appointed a professor of histology and lecturer on comparative anatomy
and orthodontia. A few years later, he was appointed to a rare position of professor of
orthodontia, at the University of Minnesota which he retained till 1892.
1887 Angle’s first contribution to orthodontic literature was ‘Notes on Orthodontia’ published in
the International Transactions of the Medical Congress, which has also been called the ‘First
Edition’ of his classic textbook on the treatment of malocclusion.
1889 Patented a jackscrew mechanism, the first of his 46 patents.
1890 First formal exclusive school in orthodontia, ‘The Angle School of Orthodontia’ was started
at 1023, N. Grand Avenue, Saint Louis, MO, USA.
1892 The year was a watershed in Angle’s professional development: he announced that he
would be practising orthodontia to the exclusion of all other dental therapies. With this
decision, he became the first acknowledged exclusive specialist in orthodontics in the world.
1892 Dr Angle continued to teach at several universities. He was a professor of orthodontia at the
American College of Dental Surgery (1892–98) Chicago.
1896– Professor of orthodontia in the Dental Department of Marion-Sims College of Medicine, St
1899 Louis.
1897– He taught in the Dental Department of Washington University, St Louis.
1898
1899 Angle’s classification of malocclusion, published in Dental Cosmos.
1899 June 6, 1899 patented the E-arch, his expansion archwire mechanism.
1900 Founded the Angle School of Orthodontia in St Louis. The course duration was 5-weeks.
Early Angle organised the first orthodontic society (1900) meeting, the American Society of
1901 Orthodontists, which is now the American Association of Orthodontists (AAO).
1906– Dr Angle retired from active practice of orthodontia in St Louis.
07
1907 Released 628-page text of the seventh edition of ‘Treatment of Malocclusion of the Teeth’.
1907 Founded the American Orthodontist, the first journal in the world devoted exclusively to
orthodontics; forerunner of the Angle Orthodontist.
1910 Patented ‘Pin and tube’ appliance.
1916 Patented ‘Ribbon arch’.
1917 Late 1916, Angle moved to southern Pasadena, California. In 1917, at request of James C.
Angle (no relation), he reopens the Angle School of Orthodontia at his home in Pasadena.
1922 His students contributed to erect exclusively devoted building to the education and training
of orthodontics.
1924 The school was chartered as the ‘Angle College of Orthodontia’.
1925 Patented ‘Edgewise appliance’. The edgewise appliance with modifications, is the one most
commonly used appliance today in orthodontics.
1927 Angle College of Orthodontia closed unofficially.
1930 After his death, his students and followers founded Edward H. Angle Society of
Orthodontia (now ‘Orthodontists’).
1930s Anna Hopkins’ ‘Mother Angle’ became secretary of the American Society of Orthodontists.
She was also appointed a founding co-editor of the Angle Orthodontist, and honorary chair of
the Angle Society executive committee.
1930 November 17, 1930, The Angle Orthodontist, a scientific journal devoted exclusively to
orthodontics, was founded in Chicago in Dr Angle’s memory by the newly reorganised
Edward H. Angle Society of Orthodontia.
FIGURE 1.2.5 Angle’s non-compliance functional Class II
corrector. Source: Wahl N. Orthodontics in 3 millennia. Chapter 9:
functional appliances to mid-century. Am J Orthod Dentofacial Orthop
2006 Jun;129(6):829–33.
FIGURE 1.2.6 E arch appliance by E. H. Angle was introduced in

1887.
The adjustable clamp bands closely adapted to the teeth. The E arch
appliance was used to expand the arches.
FIGURE 1.2.7 Pin and tube appliance (1910) was developed to
control movement of the tooth root.
The wire was inserted from occlusal direction and held in a vertical tube
with pins soldered on wire. Source: Wahl N. Orthodontics in 3
millennia. Chapter 5: the American Board of Orthodontics, Albert
Ketcham, and early 20th-century appliances. Am J Orthod Dentofacial
Orthop 2005 Oct;128(4):535–40.
FIGURE 1.2.8 Ribbon arch appliance in 1915 replaced

cumbersome pin and tube appliance, where soldering was
replaced with brass pins in a slot cut in the tube contemporary to
edgewise bracket.
The rectangular wire was held in place in a ribbon mode with pins.
FIGURE 1.2.9 (A-J) First edgewise appliance by Edward H. Angle
in 1928.
The edgewise appliance of 0.022 ‘X0.028’ slot was introduced by
Angle. It was described in a series of articles in Dental Cosmos, 1928
and 1929.
Angle (Figs. 1.2.10 and 1.2.11) taught orthodontics to 198 disciples

which includes Charles H. Tweed. Most of them (185) completed
formal training with him and received certificates of course
completion and 13 had some training. Dr Angle was very choosy to
accept a dentist for training in orthodontia; not everyone who applied
were lucky enough to work under him. His disciples included 6
Canadians and 27 from 15 countries outside North America and were
leaders in the field in promoting the science of orthodontics in their
country (Box 1.2.2).
FIGURE 1.2.10 Angle E. H. Source: Peck S. A biographical portrait of
Edward Hartley Angle, the first specialist in orthodontics, Part 1. Angle
Orthodont 2009;79:1021–7.
FIGURE 1.2.11 Anna Hopkins and Edward H. Angle. Source:
Reproduced with permission from Wahl N. Orthodontics in 3 millennia.
Chapter 2: entering the modern era. Am J Orthod Dentofacial Orthop.
2005 Apr;127(4):510–5.
The first three decades of 20th century,
1900–30: Beginning of biological
foundation of orthodontics
The first decade of the 20th century was marked by ‘Great Extraction
Debate’ by Angle—Case on extraction versus non-extraction treatment
controversy and dental manufacturers selling standardised
orthodontic appliances which could be modified by the dentists by
simple soldering and adapted to fit.9
Dr Calvin Suveril Case (1847–1923) (Fig. 1.2.12), a graduate of Ohio
and professor of prosthetic dentistry and orthodontia at the Chicago
College of Dental Surgery in 1890, devised original appliances and
suggested use of intermaxillary elastics. Both Dr Case and Baker were
to claim originality on intermaxillary elastics. Dr Case was a strong
advocate of the relationship of malocclusion to facial improvement
and ‘face first’ approach whereby facial improvement was a guide to
orthodontic treatment.9
FIGURE 1.2.12 Dr Calvin Suveril Case (April 24, 1847–April 16,
1923) is known for the reintroduction of the concept that the
removal of certain teeth will enable the correction of
malocclusion. Source: Wahl N. Orthodontics in 3 millennia. Chapter 2:
Apr;127(4):510–15.
He is known for the reintroduction of the concept that the removal

of certain teeth will enable the correction of malocclusion. His
suggestions met great opposition from many, particularly those who
followed Angle’s philosophy which stated that ‘there shall be a full
complement of teeth, and that each tooth shall be made to occupy its
normal position’. The climax of this conflict was a debate in 1911 at
the annual meeting of the American Dental Association, which was
then called National Dental Association. The debate led to
unpleasantness, bitterness and animosity among those supporting and
not supporting the concept. However, the positive outcome of the
debate was the initiation of thought process towards rationalisation
and objective evaluation of extraction procedure.10
In 1921, Case published his major work, A Practical Treatise on the
Techniques and Principle of Dental Orthopedia and Prosthetic Correction of
the Cleft Palate.8 He published 123 articles and attempted bodily tooth
movement and was also the first to use light wires (.016 and .018 in.).1
During these years, standardised appliances was made available
mounted on cards and sold by dental supply companies. By the use of
a few simple soldering techniques, the dentist could make a required
‘fitting’, as it was called.9 During these years Charles A. Hawley
(1861–1929) published Determination of Normal Arch and Its Application
to Orthodontia and introduced the retainer appliance that bears his
name (1908).11
Second decade of 20th century 1911–20. This decade was marked
by a review of the cases and thought process on individual case
planning from non-extraction to extraction in select cases, and the
opening of formal orthodontic education from men-centred private
orthodontic training schools to institutionalised education.
Two major and classical contributions were made by Millo
Hellman, who was a Professor of Dentistry at Columbia University
and Research Associate and who also worked as Research Associate in
Physical Anthropology, American Museum of Natural History in
New York. He showed that the dimension of the human face, as
represented by the group studied, is greatest in width, less in height
and least in depth and that with growth, the greatest dimension
increases least and the smallest most. He linked the growth stages of
the face according to the sequence of eruption and shedding of
deciduous teeth and appearance of permanent teeth.12,13
‘Since 1912, he turned his attention to research in the science of
anthropology and its relation to the growth and development of the
human dentofacial complex. Hellman sought an explanation of the
development of human dental occlusion, linking the phenomenon of
occlusion with the evolution of the dentition as a whole. He
introduced craniometric measurements and a classification of dental
development’.9
Albin Oppenheim (Fig. 1.2.13), an Austrian-Hungary born
physician turned orthodontist, was the first to report tissue changes
more so in bone during orthodontic tooth movement. His first article
on this subject was published in Vienna (1911). Others who
contributed to the new information on fundamentals in orthodontics
included Albert H. Ketcham (1870–1935), one of the first to introduce
roentgenogram and photography into orthodontic practice. Dr
Ketcham reported and described apical root resorption and guided
creation of the American Board of Orthodontics (1929), which was
formally incorporated in 1930.
FIGURE 1.2.13 Albin Oppenheim (January 8, 1875–November 20,
1945), an Austrian-Hungary born physician turned orthodontist,
was the first to report tissue changes more so in bone during
orthodontic tooth movement. Source: Wahl N. Orthodontics in 3
millennia. Chapter 4: the professionalization of orthodontics
(concluded). Am J Orthod Dentofacial Orthop 2005 Aug;128(2):252–
7.
John V. Mershon introduced the removable lingual arch based on

the principle that teeth must be free and unrestricted for adaptation to
normal growth (1909).
Alfred Rogers introduced the concept of myofunctional therapy
(1918).
The International Journal of Orthodontia and Oral Surgery was started
in 1915.14
The invention of Edgewise appliance which provided 3D control on
tooth movement by Edward Hartley Angle appeared in 1928.15 ‘The
mechanism as devised by Angle, who died shortly after launching his
invention, was only used for a short length of time. However, all
subsequently invented therapeutic techniques incorporated the
mechanical principles underpinning Edgewise, paying tribute in this
way to a great invention’.16
The most notable shift in scientific thinking during this decade was
introduced by Paul Simon which related to the concept of the
orientation of face beyond teeth in three planes of space called
gnathostatics (1924) (Fig. 1.2.14).
FIGURE 1.2.14 Simon’s gnathostatic approach to orient the face
in three dimension given by Paul Simon (1924). Source: Wahl N.
Orthodontics in 3 millennia. Chapter 7: Facial analysis before the
advent of the cephalometer. Am J Orthod Dentofacial Orthop 2006
Feb;129(2):293–8.
On the technological front, on August 13, 1913, Harry Brearley in

Sheffield created a steel with 12.8% chromium and 0.24% carbon,
argued to be the first ever stainless steel. However, it was in 1929 that
Dr Lucien de Coster, a Belgian, used stainless steel to fabricate
appliances, substituting gold thereby bringing the orthodontic
treatment within reach of all.17
Orthodontics during 1930–40: Functional

appliance and cephalometrics
During this decade and the next, a significant development took place
with an innovative appliance, the newer concept in oral function and
diagnosis. In Europe, the Monoblock appliance introduced by Pierre
Robin in France (1902) resurrected in 1909 as the forerunner of a new
appliance by Andresen, the Activator, and the philosophy of
functional jaw orthopaedics was born18 (Fig. 1.2.15).
FIGURE 1.2.15 In Europe, Viggo Andresen, in the year 1933,
introduced the Activator and the philosophy of functional jaw
orthopaedics was born. Source: Wahl N. Orthodontics in 3 millennia.
Chapter 9: Functional appliances to midcentury. Am J Orthod
Dentofacial Orthop 2006;129(6):829–33.
During the next decade, Dr Robert E. Moyers and Sam Pruzansky

inducted electromyography to study the effect of the musculature on
occlusion. This induced further investigation in uses of the removable
appliance-activators.9
Angle Orthodontist, journal volume 1 no. 2, 1931, published a
landmark article by B. Holly Broadbent titled ‘A New X-ray
Technique and Its Application to Orthodontia’. This pioneering
technique led to a new era of understanding of face, skull and science
of orthodontics. He presented a skull holder, a head holder an
instrument for accurate orientation of head to FH (Frankfort
horizontal) plane and in relation to source of the X-ray, and the
technique of cephalometry tracing and measurements.19 The
cephalometric apparatus was based on head holder developed by B.
Holly Broadbent and T. Wingate Todd (Fig. 1.2.16).1
FIGURE 1.2.16 Craniostat developed by Holly B. Broadbent and
T. Wingate Todd as a precursor to the first cepahlometric head
holder. Source: Hans MG, Palomo JM, Valiathan M. History of imaging
in orthodontics from Broadbent to cone beam computed tomography.
Am J Orthod Dentofacial Orthop 2015 Dec;148(6):914–21.
The very first study of facial growth was supported by the

generosity of Mrs Chester C. Bolton and her son Charles B. Bolton
who funded the manufacture of first cephalostat head holder and X-
ray apparatus, and that was installed at the anatomical laboratory of
the Western Reserve University. Bolton Point was named to recognise
the donors’ contribution to this study.
Orthodontics during 1940–50: Tweed’s

concepts of growth
The face and its growth studies by cephalometry remained the
mainstream research during this decade. This decade also changed
how cephalometry influenced and supported the treatment
approaches from absolute and rigid philosophy of non-extraction
treatment to rationalised extraction treatment based on incisor
mandibular plane angle (IMPA) by Charles H. Tweed (Fig. 1.2.17).
FIGURE 1.2.17 Charles H. Tweed (June 24, 1890–January 1970),
the man who talked about growth trends, judicious extraction
based on Tweed triangle and mastered the use of edgewise
appliance introduced by his guru E. H. Angle.
The landmark studies on facial growth were contributed from

North America and Europe. Dr Wilton M. Krogman (1903–87), an
anthropologist, made outstanding contributions to orthodontics. He
used the principles of physical anthropology to the dentofacial
complex with craniometry and roentgenographic cephalometry. He
was the first to study the growth of the face and introduced a set of
criteria for growth and development of the child and adolescent.
Krogman Center for Research in Child Growth and Development at
Philadelphia is named in honour of his classical contributions on
growth.20
Another major contribution to facial growth was by Allan G. Brodie.
He reported the growth patterns of the human head from the third
month of life to the eighth year. His research was published in the
American Journal of Anatomy in 1941 and greatly influenced
orthodontic thought process and laid a foundation for future
research.21
The classical work ‘The Face in Profile: An Anthropological X-ray
Investigation on Swedish Children and Conscripts’ by A. Bjork also
appeared these years. His study aimed to examine normal variations
and mechanism of prognathism as well as the relationship between
facial build and the bite in representative material.22
Charles H. Tweed (1895–1970) advocated upright lower incisor
positioning on mandibular base which is fundamental to facial
aesthetics. He introduced the judicious use of extractions for gaining
space and philosophy of an Edgewise appliance.
First multidisciplinary cleft clinic, Lancaster

In Lancaster, Philadelphia, Dr Herbert K. Cooper (1897–1978) founded
an integrated clinic for cleft lip and palate in Lancaster in 1938. Dr
Cooper believed that an integrated team of plastic surgeon, dentist
and speech therapist are required to solve the problems of the cleft
palate patients. By 1946, the first integrated centre for treatment of
oro-facial deformities and communicative disorders was established.
Dr Cooper thus established the first dedicated interdisciplinary clinic
for patients with cleft lip and palate and craniofacial anomalies, which
is now famous as Lancaster Cleft Centre.23
A new form of rubber tooth positioner (TP) was introduced by Dr
Kesling. The tooth positioner was used to finish unsettled occlusion
after major orthodontic treatment to an ideal cusp–fossa
relationship.24
Orthodontics during 1950–60: emphasis of
cephalometrics
Two major areas of contribution in this decade were: First, the
induction of cephalometry in clinical practice and the emphasis on the
same by a number of authors like William B. Downs in 1948, 1952,
1956, C. C. Steiner (1953), C. H. Tweed (1953), S. E. Coben (1955), R. M.
Ricketts (1966), V. Sassouni (1969), H. D. Enlow (1969) and many
more.25,26 Second, in 1952, ‘Textbook of Functional Jaw Orthopaedics’
released by Karl Häupl, MD, Professor of Dental Surgery, University
Dental School, Innsbruck, co-authored by William J. Grossman,
Orthodontic Consultant and Lecturer in Orthodontics, University
College Hospital Dental School, London, and Patrick Clarkson,
Consultant Plastic Surgeon, the Queen Alexandra Hospital, London.
This 408 pages book contained an extensive 536 illustrations and 309
figures. The price was 60 shillings.27
This decade was marked by standardisation of an edgewise
mechanism by Charles J. Tweed and popularisation of extraction
philosophy treatment with light wire appliance by P. R. Begg at
Adelaide Australia. Dr P. Raymond Begg (Fig. 1.2.18), Angle’s
student, on return to Australia worked with a metallurgist to develop
the Australian orthodontic wires in the 1940s; which will deliver
gentle forces for a longer duration.28
FIGURE 1.2.18 P. Raymond Begg in Adelaide Australia (13

October 1898–1983), Disciple of E. H. Angle from Adelaide who
eventually developed new brackets and wires to be used with light
wire technique.
He justified reduction of tooth material based on his research related to
attritional occlusion of Australian Aboriginals. Image courtesy of the
Australasian Begg Society of Orthodontists. Source:
http://www.beggsociety.org/dr-pr-begg; [accessed 30.12.2016
10:41:08].
He looked at occlusion of Australian Aboriginals and suggested

proximal wear with ageing is a phenomenon which is missing in the
modern population.29 He promoted the reduction of tooth substance
by extractions and created modified Ribbon arch bracket, and
multiple-loop light-force wire appliance, known as Begg’s light wire
technique. His book was first published in 1965.30–32
Contributions of Charles H. Tweed (June

1895–January 1970)
‘Angle gave orthodontics the edgewise bracket, but Tweed gave
orthodontists a way to use it. Tweed, the innovative and perceptive
diagnostician and master clinician, kept his promise to his mentor,
Edward Angle. He devoted all 42 years of his professional life to the
use and refinement of Angle’s invention, the edgewise appliance’.33
Dr Tweed was refused admittance to Angle school in the first
instance, in 1925. He eventually joined the course in 1927 and they
worked closely together for the last 2 years of Angle’s life. Dr Tweed
banded his patients with an edgewise appliance; Angle acted as the
advisor. The records were reviewed by Angle every four months. This
was a very productive time during Tweed’s education and for the
evolving edgewise appliance. In 1932, the first report of cases treated
was published in The Angle Orthodontist. It was titled ‘Reports of Cases
Treated with the Edgewise Arch Mechanism’.34
Tweed, a true disciple of Angle held the conviction of non-
extraction treatment to adhere to the line of occlusion concept. He
noticed failures in his treated cases, after which he re-examined the
records in detail to realise that the patients who had pleasing facial
balance and harmony also had mandibular incisors that were upright
over basal bone, which was not possible to achieve in all types of cases
of malocclusion. He re-treated some of these patients with extraction
of first premolars, and presented at a meeting for which he was
heavily criticised. His mechanism was soon popularised. Tweed
created a study club, which later in 1947 transformed into Charles H.
Tweed Foundation for Orthodontic Research. He published articles on
facial triangle35–37 and also two volumes on clinical orthodontics in
1966.38
Orthodontics during 1970–80: pre-
adjusted appliances
The decade from 1970 to 1980 saw tremendous developments in the
fields of facial growth, technology, appliance philosophy and
fundamental understanding of biological processes related to
orthodontic tooth movement.
Classical work by A. Bjork and V. Skiller on growth rotation during
facial growth studies after inserting implants greatly influenced
orthodontic thinking. Arne Bjork following completion of his PhD
thesis in human genetics was particularly interested in craniofacial
growth. His classical work has not and cannot be emulated and is
among the few best studies available on facial growth in humans.39–43
During these years, Robert Murray Ricketts greatly influenced
orthodontic thinking by his critical evaluation of existing
cephalometric analysis. He evolved bracket modification towards
building prescription in 0.018-in. slots in 1970 (Fig. 1.2.19)
FIGURE 1.2.19 Robert Murray Ricketts (May 5, 1920–June 17,
2003), inventor of bioprogressive therapy, computerisation in
cephalometry, divine proportions and growth prediction.
He developed the first computerised cephalometric analysis

diagnostic system to project treatment plus growth in treatment
planning (VTO) and computer generated method for projecting
growth. He gave new perspectives to early orthodontics and
developed new appliances systems including quad helix, utility
arches, sectionalisation and most significant, bio-progressive
philosophy, a biological approach to diagnosis and treatment. He
recognised and used facial proportions to treat dental and skeletal
problems called the divine proportion.44–56
Charlie J. Burstone (Fig. 1.2.20), who extensively researched on
bioengineering principles of the orthodontic appliance also introduced
sectional arch mechanics, titanium molybdenum alloy wire in
collaboration with A. J. Goldberg that added newer dimensions to the
orthodontic mechanism. Dr Charlie Burstone in collaboration with Dr
H. Legan also developed cephalometrics for orthognathic surgery
(COGS) analysis for patients requiring orthognathic surgery.
FIGURE 1.2.20 Charles J. Burstone, April 4, 1928–February 11,

2015,
extensively researched on bioengineering principles of orthodontic
appliance and introduced sectional arch mechanics, titanium
molybdenum alloy wires and COGS analysis.
Dr Ram Swaroop Nanda (Fig. 1.2.21), a prolific writer and
researcher, sensitised the orthodontic fraternity on significant
contribution of facial growth in the success or failure of orthodontic
treatment.
FIGURE 1.2.21 Ram Swaroop Nanda

founded department of orthodontics, Dental College at King George’s
Medical University and later became Chairman at the Department of
Orthodontics, University of Oklahoma, USA. He made significant
contributions to orthodontic research more so in the field of facial
growth and its implications in orthodontic treatment.
Evolution of pre-adjusted appliances and
bonding: hallmark of contemporary
orthodontics
Although the beginning of the thinking process to build treatment
into brackets had started as early as the 1960s,57 the first fully pre-
adjusted appliance was invented after the classical work of Dr L. F.
Andrews by the publication of six keys to normal occlusion in 1972.58
(Fig. 1.2.22). The original straight wire appliance (SWA) by Andrews
was later modified by many clinicians including Roth in 1976.59,60
FIGURE 1.2.22 Lawrence Andrews known for six keys to normal
occlusion and developing the straight wire appliance (SWA).
Reproduced with permission. Source: Andrews LF. The 6-elements
orthodontic philosophy: Treatment goals, classification, and rules for
treating. Am J Orthod Dentofacial Orthop. 2015 Dec;148(6):883-7.
Bonding in orthodontics was a major game changer that

revolutionised clinical orthodontics. Although Buonocore as early as
1955,61 reported a simple method of increasing adhesion of filling
materials on enamel surfaces, it was Newman who introduced
bonding in orthodontics in 1969.62,63 The late 1970s saw the evolution
of better adhesives, bracket base modifications and clinical studies
which evolved bonding technology as the acceptable method of
attaching orthodontic auxiliary on tooth surfaces. It took several years
before developing light cure self-adhesive. The first study on light-
curing appeared in 1979, but it was not until 1993 that the first
commercial product came into the market (Transbond XT Light Cure,
3M Unitek).64
Orthodontics during 1980–90: clinical
success with twin block popularised
functional appliance
Reports on success of myofunctional appliance with a new concept of
24 h of wearing time introduced by William Clark of Fife, Scotland
surprised orthodontic fraternity. Twenty four hours wear of appliance
was possible by changing the very basic design of Monoblock to Twin
block (Fig. 1.2.23).
FIGURE 1.2.23 William C. Clark, a practicing orthodontist in Fife
Scotland is known for inventing Twin block appliance in 1977.
Refinement of pre-adjusted appliance continued with many

‘prescriptions’ appearing in the market. However, it was the magic of
duo clinicians McLaughlin and Bennett which made the MB
(McLaughlin–Bennett) appliance very popular. The MB prescription
was later further modified and is now widely known as MBT
prescription.65–69 The ceramic brackets were commercially introduced
in 1987.70
During these years, Dr Tom M. Graber (May 27, 1917–June 26, 2007)
remained the most revered educationist in the field of orthodontics.
He contributed 28 books including the most popular standard
reference ‘Orthodontics: Current Principles and Techniques’. In 1985,
he was chosen as the fifth editor-in-chief of the American Journal of
Orthodontics, a position he held for 15 years71 (1990–2000).
Temporary anchorage devices: major game

changer in orthodontic practice
With a successful case report by Creekmore and Eklund, 1983 by
using vitalium screw below anterior nasal spine to open the deep bite,
the possibility of skeletal anchorage was introduced in the clinical
orthodontic literature.72 Similar outcome was achieved for the
intrusion of lower incisors by Kanomi (1997) (Fig. 1.2.24). He
implanted mini-bone-screw of 1.2 mm diameter and 6 mm long in the
alveolar bone between root apices of mandibular incisors and did
intrusion of the mandibular incisors.73 Following years, clinicians and
researchers from Korea worked and promoted temporary anchorage
devices (TADs) in clinical practice.74 During the same years, J.
Sugawara from Sendai, Japan worked and introduced the concept of
skeletal anchorage system. Earlier he has reported treatment of a case
with open bite using skeletal anchorage in 199975. During these years,
the percentage of patients receiving extraction treatment declined. The
over zealous premolar extraction treatment approach during
adolescent years led to premature sagging of faces later in life76. The
extraction treatment was also linked to temporomandibular disorder
(TMD) and the subject caused much concern to orthodontists
following a lawsuit, Brimm versus Malloy in 1987, in which it was
claimed that orthodontic treatment has caused TMD77. The
introduction of TADs and skeletal anchorage system were welcome
armamentarium for these allowed more cases to be treated with non-
extraction approach. Secondarily, demonstration of successful molar
distalisation with palatal supported anchorage systems and demand
for fuller profile has encouraged orthodontists to undertake non-
extraction treatment options.
FIGURE 1.2.24 Ryuzo Kanomi from Japan reported temporary
anchorage with mini screws of 1.2 mm diameter in 1997.
Autotransplantation of teeth in the

management of space
Although Hale as early as 1956 suggested auto-transplantation,78 it
was Andresen and his group who reported techniques and follow-up
of autotransplanted premolars. Premolars are now considered a viable
alternative for orthodontic space management in cases of missing
maxillary anterior teeth.79–86
First cone beam computed tomogram (CBCT) machine was developed
in a factory near Verona in Italy in 1996 (Fig. 1.2.25). Turn of the
century witnessed the emergence of digital technology and
automation in orthodontics as a reality.
FIGURE 1.2.25 Factory at Verona in Italy where the first CBCT

machine, NewTom, was invented and manufactured in 1996.
The concept of 3D printing emerged in Nagoya, Japan by Hideo

Kodama who invented the first fabricating technology and
methodology for rendering plastic into three dimensions with a
polymer that was exposed to ultraviolet rays. Later, in 1984, Chuck
Hull, independently innovated a process by which objects could be
rendered in layers with a process of stereo lithography which was
used more often in craniofacial model surgery. By the 2000s, 3D
printers had advanced to the point that they could print objects in
various shapes not only from plastics but metals as well. Additive
manufacturing and 3D printing are synonymous today.87
With adaptation of 3D surface scanning in orthodontics, plaster-free
digital models became a reality and so is the virtual treatment
planning. The sophistication of software and technology has led to 3D
printing and popularised clear alignment systems, customised bracket
designs and mechanised robotic wire bending.88,89
Robotic orthodontics
Dr Rohit Sachdeva is the cofounder of Orametrix Inc. (OraMetrix Inc.,
Richardson, TX, USA) who developed the Suresmile system.
OraMetrix Inc. was founded in 1998. This was the first such
commercial venture with robotic wire bent wire supplies in the USA
with the name Suresmile/Orametrix (Fig. 1.2.26).
FIGURE 1.2.26 Rohit Lal Sachdeva, Indian-ethnic orthodontist
born in Kenya and works in USA.
His collaborative research culminated in the development of both
copper nickel–titanium and titanium niobium alloys and titanium
brackets for use in orthodontics. He owns over 90 patents. Sachdeva
co-founded the OraMetrix Inc. (OraMetrix Inc., Richardson, TX, USA)
and developed the Suresmile system.
The first articles that present the development and the clinical
procedure of the Suresmile system were published in the Journal of
Clinical Orthodontics and American Journal of Orthodontics and
Dentofacial Orthopedics authored by Rohit Sachdeva.90–92
This century also witnessed the integration of CBCT skull, CBCT
models, non-radiation 3D facial scanning put to use for ‘real life’ like
planning, more so to know the effects of orthodontic treatment on
facial profile. Advancements in the process of segmentation have
allowed extraction of selected data and image processing in volume
data.
In 2006, Dolphin Imaging company introduced its 3D module that
can import and process of three-dimensional (3D) datasets from
MDCT, CBCT, MRI and high-definition facial camera systems.93
The current trend in orthodontics is heading towards plaster-free
clinics wherein intraoral scanners are in use. Intra oral scanners
permit 3D scanning of dental structures, which helps to produce
digital models, virtual planning and print plastic models. The
orthodontic appliance can be prepared on 3D printed models either
with conventional techniques or pressure moulding material. The
integration of skeletal morphology obtained from CBCT, 3D non-
radiation imaging of face (3D-MD), and volume rendering allows
planning in three dimensions and permits visualisation of effects of
various orthodontic/ortho surgical treatment on face (Fig. 1.2.27).
FIGURE 1.2.27 Hypothetical model of future orthodontic

treatment.
The modern office is also likely to use clear aligners, customised

appliances and devices to enhance the rate of orthodontic tooth
movement which may include the use of low-level lasers, some
vibration devices or even drugs.
Author’s hypothetical concept would include developing a micro
sensor that will be placed in the mouth to monitor and control
orthodontics from a remote location by an orthodontist!
Key Points
Orthodontics, the science and art of correction of dental irregularities
and improvement in face began since Egyptian times. Irregular teeth
are also mentioned in Hippocrates literature. American and European
clinicians have made tremendous contributions in its evolution to
sophisticated techniques based on deep understanding of biological
process of craniofacial development and tooth movement. Future of
orthodontics lies in knowing more about its biological aspects at the
molecular level and in 3D technology.
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CHAPTER 1.3
History of orthodontic speciality
in India
CHAPTER OUTLINE
History of formal dental education in India

The first MDS orthodontics course in India
Course curriculum
Indian Orthodontic Society (IOS) and its role in
education and faculty development
Key Points
History of formal dental education in
India
The very first formal dental school in India was established by Dr R.
Ahmed in 1920 at Calcutta, West Bengal (Fig. 1.3.1). The college
started with a 1-year LDSc diploma, duration of which increased to
2 years in 1922 and 4 years in 1936–37 (Box 1.3.1). The first dental
faculty, formed at Mumbai in 1957, offered Bachelor of Dental Surgery
course.1 At present, India has more than 300 dental colleges,
recognised by Dental Council of India, that offer Bachelor of Dental
Surgery (BDS) qualification.2 It was in 1933 that a series of lectures on
the subject of orthodontics were delivered for the first time in a
teaching institution, that is, at Nair Hospital Dental College by H. D.
Merchant. In 1937, orthodontics was accepted as a separate subject3.
FIGURE 1.3.1 Padma Bhushan Dr Rafiuddin Ahmed (24
December 1890–1965) is known as father of dentistry in India.
In 1920, Dr Ahmed founded the first dental college of India, which was
financed by starting the New York Soda Fountain in Calcutta. Dr
Ahmed published the first Student’s handbook on Operative Dentistry
in 1928. Dr R. Ahmed was the first elected President of the Dental
Council of India, serving from 1954 to 1958. Source: The IDA Times.
July 2015, vol. XI, issue 7, p. 6.
Box 1.3.1 Chronology of formal dental and
orthodontic education in India
1920 Dr R. Ahmed established the first formal dental college in India in 1920 at Calcutta, West
Bengal. The college started with a 1 year LDSc diploma. In 1922, the duration of course
was increased to 2 years.
1933 Bai Yamunabai L. Nair Hospital Dental College started in Bombay. In 1946, it was taken
over by the Municipal Corporation of Bombay. In 1954, it was affiliated to Bombay
University.
1933 De’Montmorency Dental College and Hospital, Lahore. Regular BDS course started with
Panjab University in1936. First postgraduate course in dentistry started in 1945. Dr K. L.
Shourie was amongst the first recipients of MDS degree who eventually headed the
Dental Council of India as President.
1940 CEM Dental College, Bombay. 1945—Affiliated to Bombay University. 1960—Became
Govt. Dental College, Bombay.
1943 ‘Health Survey and Development Committee’ by the Govt. of India. Chairman Sir Joseph
Bhore. Recommendations paved the way for enactment of the Dentists Act 1948 and
formation of the Dental Council of India.
March Dentists Act (XVI of 1948) reviewed, assent of the President of India.
29, 1948
April Dental Council of India formed by the Govt. of India by a special notification.
12, 1949
1953 The first Indian Dentists Register was prepared and placed before the council.
1957 Formation of the first dental faculty in India, at the University of Bombay.
1959 Dental Council of India laid down regulations and the syllabus for the Master’s degree
courses. Universities were encouraged to establish post-graduate course in seven
specialties, including Orthodontia.
1959/60 MDS Orthodontia course started at Government Dental College and Nair Hospital,
Mumbai.
1960 Approval of Govt. of India to a minimum basic qualification for appointment of teaching
staff for Master’s degree courses (MDS).
1963 The Government of UP state sanctioned starting of PG courses at Lucknow Dental
College.
1964 MDS Orthodontia started at Dental College and Hospital, King George’s Medical College,
Lucknow University, Lucknow.
1965 The first formal Dental Council regulations containing syllabus of Master’s degree courses
were published.
1965 Indian Orthodontic Society started as a study group in Bombay (now Mumbai) way back
in the year 1963. It was formally established as the Indian Orthodontic Society on October
5, 1965 by seven orthodontists.
1966 MDS Orthodontia started at Bangalore.
1967 The Indian Orthodontic Society held its first conference in the year 1967 in New Delhi.
1969 MDS Orthodontia started at Government Dental College, Trivandrum.
1970 MDS Orthodontia started at Government Dental College, Ahmedabad.
1972 MDS Orthodontia started at Manipal; first non-government dental institute.
1975 MDS Orthodontia started at Government Dental College, Madras.
1978 MDS Orthodontia started at Government Dental College, Hyderabad.
1985 MDS Orthodontia started at Government Dental College, Nagpur.
1983 DCI course regulations for Master’s programme were created.
1986 AIIMS New Delhi starts first full time 3 years residency programme for Masters in
Orthodontics.
1993 Indian Orthodontic Society conducts National Workshop on Postgraduate Orthodontic
Education in Mumbai. Recommends higher case load.
1993 Dental Council of India passed a resolution (DE-1(SC)-93/2064 28.10.1993) for MDS course
duration for 3 years.
1995 With the signing of the charter of the World Federation of Orthodontics at San Francisco,
USA in 1995, the Indian Orthodontic Society became a part of the World Federation of
Orthodontics.
1999 Indian Orthodontic Society established ‘Indian Board of Orthodontics’, the first such
board in the field of dentistry in India and the third in the world.
2006 National workshop at All India Institute of Medical Sciences to update curriculum in all
nine specialties of dentistry.
2007 Revised regulations for MDS course.
2009 First SAARC orthodontic conference held in New Delhi with Prof. O.P. Kharbanda as the
founder President.
2008, Dental Council of India released the revised regulations for MDS course amendments.
2012
2013 Asian Pacific Orthodontic Conference held in Delhi, 2013.
2014 National Oral Health Programme (NOHP) launched. NOHP is an initiative of the
Ministry of Health, Government of India aimed to strengthen the public health facilities of
the country for an accessible, affordable and quality oral health care delivery. Centre for
Dental Education and Research, All India Institute of Medical Sciences was designated the
Centre of Excellence for implementation of NOHP.
2014 The first WHO collaborating centre on Oral Health was established at Centre for Dental
Education and Research, All India Institute of Medical Sciences, New Delhi.
2016 The Centre for Dental Education and Research, All India Institute of Medical Sciences,
New Delhi became Cochrane Oral Health Global Alliance partner, as the first partner not
based in a primarily English-speaking country.
2016 World Implant Orthodontic Conference held in Goa, 2016.
January First formal batch admitted to advanced fellowship in Cleft Orthodontics started at
2017 Department of Orthodontics Centre for Dental Education and Research, All India Institute
of Medical Sciences, New Delhi, under Prof. OP Kharbanda.
2017 Government of India approves creation of first National Level Referral and Research
Institute for Higher Dental Studies (NRRIDS) at Centre for Dental Education and
Research, All India Institute of Medical Sciences, New Delhi
Before the 1950s, facilities for postgraduate dental education hardly
existed in India. In the 1940s, Master’s Degree in Dentistry (MDS) was
awarded by the one and only college of dentistry, De’Montmorency
College of Dentistry at Lahore, now in Pakistan. The Dental Council of
India (DCI) was incorporated under The Dentists Act 1948 to regulate
dental education and the profession throughout India. In 1959, the
DCI laid down regulations and the syllabus for the Master’s degree
courses. They recommended seven specialities for post-graduate
education in dentistry, including orthodontia.1–4
The first MDS orthodontics course in
India
The MDS courses in India including orthodontia were established in
1959/1960 simultaneously at Nair Hospital Dental College and
Government Dental College and Hospital in Mumbai. Both colleges
were affiliated with University of Bombay.1,4,5 MDS started at
Lucknow in 1964, Bangalore 1966, Trivandrum 1969, Ahmadabad
1970, Manipal 1972, Madras 1975, Hyderabad 1978, Nagpur 19854,
AIIMS 19866 and many more colleges followed. By the 1970s, the
number increased to seven dental schools that offered MDS course in
orthodontics with 31 admissions/year. Half of these belonged to the
two dental colleges in Bombay (Fig. 1.3.2). The dental profession and
education showed steady growth until the 1980s and showed
incredible growth during 1990s with private entrepreneurs taking the
lead. The number of postgraduate departments grew to 48 in 2005,
reaching an enormous strength of 186 by 2014.2 Also, many Indian
dental graduates are pursuing higher dental education in orthodontics
in Russia, China, Philippines besides UK and USA. Their exact
number cannot be ascertained.
FIGURE 1.3.2 First and second batch of MDS orthodontics
students at Mumbai. Dr K. L. Shourie, Dean is seen sitting in the
centre.
MDS orthodontics programme at AIIMS, New Delhi began in 1986

as full time three years program on similar regulations for MS/MD of
medical disciplines.6
Course curriculum
The first formal Dental Council regulations containing syllabus on
Master’s courses were published in 1965.7 The subsequent detailed
revision of the course regulations by the Dental Council of India in
1983, contained exhaustive guidelines in all the nine specialities of
dentistry.8
Traditionally, orthodontic training in India has been widely
influenced by teachers who were trained in the USA.3 The orthodontic
equipment and materials were imported from the USA. The MDS
courses started at Mumbai and later at Lucknow and Nair Hospital
Dental College, were chaired by teachers trained at North American
Universities in edgewise techniques. Dr Prem Prakash first time
introduced edgewise technique at Sir CEM Dental College in
Bombay.3 However, scarce availability of these materials and high
import cost, led to them consider other options, including Begg’s
appliance. While the dental school in Lucknow with professor Ram
Nanda as its first chair continued to teach Tweed’s edgewise
technique, there was a major drift towards the use of Begg’s appliance
in other institutions in India. In 1970s, Begg’s tubes and brackets were
manufactured in India. The low cost and the ease of availability of
these materials further popularised the Begg’s technique in India.
During the 1980s, the advent and popularisation of pre-adjusted
appliances have led to a gradual drift by the orthodontic practitioners
to adopt pre-adjusted appliance systems. Some practitioners found a
comfort zone in TIP EDGE technique, a combination of Begg’s
appliance with control of the edgewise system, whereas others moved
on to the so-called ‘straight wire appliance’ (SWA).
During the 1980–90s, many references on functional appliances and
their proven clinical efficacy in growth, modification influenced the
thinking across the USA and the Indian orthodontic fraternity.
Teaching institutions in India started using functional appliances
more often than before. In the year 1990, author had a visit to Scotland
to get first-hand exposure with twin block from Dr William Clark. Dr
Kharbanda introduced, used and extensively researched twin block
appliance at AIIMS. Slowly, twin block, percolated throughout India.
It is perhaps the most widely accepted and used functional appliance
(Table 1.3.1).
Table 1.3.1
Postgraduates programmes in India and sub-continent.*
† Only one orthodontist with MDS qualification from India.
* On 2014.
The DCI has made some efforts to change the curriculum in all the
nine postgraduate specialities of dentistry, through their revised
curriculum.9,10 Subsequently, updated guidelines on syllabus and
curriculum were established in 2007. These guidelines have
undergone amendments from time to time.11,12 MDS course was
extended to three years duration in 199413,14 (Box 1.3.1).
Indian Orthodontic Society (IOS) and its role in

education and faculty development
The IOS started as a study group in Bombay (now Mumbai) way back
in the year 1963. It was formally established as the Indian Orthodontic
Society on October 5, 1965 by seven orthodontists. Late, Dr H. D.
Merchant was the founder president and Dr Naishadh Parikh, the
founder secretary and treasurer (Fig. 1.3.3) and other founder
members included Drs A. B. Modi, Prem Prakash, H. S. Shaikh, Keki
Mistry, and Mohan Das Bhatt. The Indian Orthodontic Society, is the
first dental speciality society in India.15
FIGURE 1.3.3 Dr H. D. Merchant, Founder President of the Indian
Orthodontic Society. Source: Directory of Indian orthodontic society
Member’s Directory 2010.
The Indian Orthodontic Society held its first conference in the year
1967 at New Delhi. This was followed by regular conferences, usually
every year, which are attended by a large number of orthodontists
from within the country and abroad. Indian Orthodontic Society held
its Golden Jubilee conference in 2016 at Hyderabad. IOS publishes a
quarterly scientific journal named Journal of Indian Orthodontic
Society (JIOS) since 196815 and an IOS newsletter since 2009.
‘Indian Board of Orthodontics’ was established in 1999, first such
board in the field of dentistry in India and the third in the world.15
With the signing of the charter of the World Federation of
Orthodontics at San Francisco, USA in 1995, the Indian Orthodontic
Society became a member of the World Federation of Orthodontics.
First SAARC orthodontic conference was held in Delhi in 2009 and
the first Asian Pacific Orthodontic Conference too in Delhi in 2013
(Fig. 1.3.4). Indian Orthodontic Society in collaboration with World
Implant Orthodontic Society hosted the 8th World Implant
Orthodontic Conference in 2016. A brief overview of orthodontic
programs in the Indian Subcontinent is given in Table 1.3.1.
FIGURE 1.3.4 First SAARC orthodontics conference held at New

Delhi, 2009.
India has a large orthodontic fraternity with a significant presence

at regional and international forums, which include the SAARC
Orthodontic Society, Asia Pacific Orthodontic Society and World
Federation of Orthodontists.
The Indian orthodontic curriculum, examination pattern, education
are regulated by the Dental Council of India (DCI) except at All India
Institute of Medical Sciences and Post Graduate Institute of Medical
Education and Research, Chandigarh, which are immune to Dental
Council of India through special acts of the parliament. These act
gives liberty to create and implement their own curriculum and
examination pattern in these two preeminent institutes.
Key Points
The very first formal dental school in India was established by Dr R.
Ahmed in 1920 at Calcutta, West Bengal. The first dental faculty,
formed at Mumbai in 1957, offered Bachelor of Dental Surgery course.
The Dental Council of India (DCI) was incorporated under The
Dentists Act, 1948 to regulate dental education and the profession
throughout India.
In 1959, the DCI laid down regulations and the syllabus for the
Master’s degree courses in seven specialities, including orthodontia.
In 1986, All India Institute of Medical Sciences (AIIMS), New Delhi
started first full time 3 years residency programme for Masters in
Orthodontics. In 1993, DCI passed a resolution for MDS course
duration for 3 years throughout India.
Indian Orthodontic Society was established on October 5, 1965, in
Mumbai and started its journal in 1968. Indian Board of Orthodontics
was established in 1999. It was the first such board in the field of
dentistry in India and the third orthodontic board in the world. With
the signing of the charter of the World Federation of Orthodontics at
San Francisco, the United States of America in 1995, the Indian
Orthodontic Society became a part of the World Federation of
Orthodontics.
The first WHO collaborating centre on Oral Health in India was
established at Centre for Dental Education and Research, AIIMS, New
Delhi in 2014. The Centre for Dental Education and Research, AIIMS,
New Delhi became Cochrane Oral Health Global Alliance partner, as
the first partner was not based in a primarily English-speaking
country, in 2016.
The first formal batch for an advanced 2 years post-MDS fellowship
in ‘Cleft and Craniofacial Orthodontics’ started at Centre for Dental
Education and Research, AIIMS, New Delhi in 2017. In the same year,
the Government of India approved the creation of India’s first
National Level Referral and Research Institute for Higher Dental
Studies (NRRIDS) at Centre for Dental Education and Research,
AIIMS, New Delhi.
References
1. History of Dental Council of India: Souvenir released
on the occasion of Silver Jubilee of DCI; 1973. p. 59–
67,70–73.
2. www.dciindia.org.
3. Parikh NH, Modi AB. Fifty years of orthodontic
education. Proceedings of the 22nd Indian orthodontic
conference and golden jubilee of orthodontic education in
India. Indore; 1987.
4. Jayna P, Chauhan DN. Development of the
orthodontic speciality in India. In: Proceedings of the
23rd Indian orthodontic conference. 1988.
5. Joshi MR. How I became an orthodontist: history,
mystery and my story “Genesis” souvenir. In: 39th
Indian Orthodontic Conference. Davangere, India; 2004.
6. Curriculum of the All India Institute of Medical
Sciences, New Delhi; 2004.
7. Dental Council of India Master’s Degree Courses
Regulations; 1965.
8. Dental Council of India MDS Course Regulations;
1983.
9. Dental Council of India Master’s Degree Courses
Regulations; 1988.[Unpublished].
10. Dental Council of India MDS Course revised
regulations; 2007.
11. Government of India Dental Gazette Extra ordinary
No. 139 dated 20.8. 2008 First Amendment for MDS
curriculum; 2007.
12. Government of India Dental Gazette Extra ordinary
No. 140 dated 21.5.2012 Second Amendment for MDS
curriculum; 2007.
13. Dental Council of India letter no: DE-1(SC)-93/2064
28.10.1993.
14. Dental Council of India letter no: DE-1(SC)-94/2695
27.10.1994.
15. Directory of Indian Orthodontic Society 2003, i-iv
Published by Editor ET Roy 153 9th Cross Gokulum
IIIrd Stage Doctors Corner, Mysore 570002, India.
SECTION II
Fundamentals of orthodontics
Chapter 2: Adverse consequences of malocclusion and benefits

of orthodontic treatment
Chapter 3: Epidemiology of malocclusion and orthodontic
treatment needs
Chapter 4: Classification and methods of recording
malocclusion
Chapter 5: Recording the severity of malocclusion: orthodontic
indices
Chapter 6: Psychological implications of malocclusion and
CHAPTER 2
Adverse consequences of
malocclusion and benefits of
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Adverse consequences of malocclusion
Consequences due to poor aesthetics
Alteration in functions of stomatognathic system
Loss of tooth substance and function
Increased susceptibility to dental trauma
Proneness to dental diseases
Improved aesthetics/enhanced self-image
Reduction in trauma to maxillary anterior teeth
Improved oral functions
Oral health benefits
Health of temporomandibular joint
Critical appraisal of the benefits of orthodontic treatment
Orthodontic treatment
Orthodontics supported with implants and skeletal
anchorage system
Limits of dentofacial orthopaedic treatment
Distraction osteogenesis
Key Points
Introduction
Malocclusion is seen to be associated with adverse physical,
psychological and social effects including longevity of dentition and
oral health and therefore adversely affects the quality of life (QoL).1 A
systematic review has suggested an association, albeit modest,
between malocclusion/orthodontic treatment need and poor health-
related quality of life (HRQoL), and that they coexist in the same
population.2 Most studies suggest an association between
malocclusion/orthodontic treatment need and oral health-related
quality of life (OHRQoL) scores. Anterior segment spacing and
anterior mandibular overjet are significantly associated with an
impact on OHRQoL. School children with malocclusion are more
likely to experience an adverse impact on OHRQoL than those
without malocclusion.3
Severe crowding and severe protrusion result in lower self-esteem
compared with those with mild afflictions.4 Dental aesthetics has a
role in social life and finding a job. Persons with ideal smiles are
perceived more intelligent and have a greater chance of finding a job
when compared with persons with non-ideal smiles.5
Malocclusion can manifest in a wide range and variations such as
an inconspicuous rotation of a tooth, its slight malposition in the arch
or a minor diastema between teeth, to more severe forms of crowding,
spacing, superior protrusion, retrusion in isolation or combinations of
several traits of tooth malpositions and abnormal dental relations.
Dental malalignments may be limited to or extended to one or more
teeth, within an arch (intra-arch), or both the arches and in improper
relations of tooth/teeth between the upper and lower arches (inter-
arch) (Figs. 2.1,A 2.2 and 2.3).
FIGURE 2.1 Improved aesthetics and enhanced self esteem
following orthodontic treatment are evident in this girl.
(A) Poor facial aesthetics in a 12-year-old girl who is unable to close
her lips due to malocclusion. She had significant proclination of
maxillary incisors and a lower lip trap. Both of her maxillary central
incisors and left lateral incisor are chipped. (B) She underwent
comprehensive orthodontic treatment and aesthetic restoration of
fractured tips of the incisor teeth resulting in significant improvement in
aesthetics.
FIGURE 2.2 Severe crowding in both the maxillary and
mandibular arches, which contributes to difficulty in plaque
removal leading to gingival disease.
FIGURE 2.3 Erupted mesiodens causing poor aesthetics.
The deviations in tooth or teeth positions may be local or a

consequence of architectural deviations of the underlying
dentoalveolar structures, skeletal bases of maxilla and mandible and
craniofacial structures. The imbalance in harmony of face and
occlusion is reflected through soft-tissue drape of the face, which
usually follows underlying skeletal and dental architecture.
More severe forms of malocclusion are associated with facial
skeletal malrelations and constitute a group of dentofacial deformities.
The common facial deformities are:
• mandibular prognathism with or without maxillary
hypoplasia or midface deficiency;
• mandibular retrognathia;
• skeletal anterior open bite often associated with long-face
syndrome or skeletal deep bite;
• facial asymmetry.
Facial asymmetry with chin deviation associated with

temporomandibular joint (TMJ) ankylosis is often seen in children of
Indian subcontinent. Facial trauma affecting TMJ during early
childhood, if not treated well, may cause partial or complete TMJ
ankylosis, and thereby hinder the growth of the mandible. Facial
asymmetry is also seen in malunited fractures of the facial skeleton,
tumour(s) of the condylar cartilage such as unilateral condylar
hyperplasia (Figs. 2.4 and 2.5).
FIGURE 2.4 Impacted maxillary left canine in a patient with facial
asymmetry of the face.
Her upper and lower incisors are crowded along with buccal cross-bite
on the left side. This case was diagnosed with maxillary hypoplasia,
unilateral hyperplasia of the mandible right side and significant facial
asymmetry, which are better appreciated on a 3-D cone beam
computed tomography volumetric image.
FIGURE 2.5 A case of gross facial asymmetry associated with

unilateral condylar hyperplasia of the left side.
Note a significant cant of occlusal plane and adaptation of the maxilla
maintaining the occlusal contacts.
Complex deformities of the face can be a manifestation of more

severe forms of systemic diseases or syndromes affecting cranio-facial
region. Among congenital defects affecting the face, clefts of the lip
and palate are the commonest.
Common syndromes affecting the face
• Pierre Robin sequence

• Apert syndrome
• Down syndrome
• Crouzon syndrome
• Hemifacial microsomia/Goldenhar syndrome
• Treacher Collin syndrome.
Adverse consequences of
malocclusion
Major direct effects of malocclusion are proneness to dental diseases
and loss of tooth substance. Malocclusion leading to an unaesthetic
facial appearance may result in a low social image and psychological
disturbances. A person’s QoL can be further affected due to
compromised functions of the oral cavity: mastication, respiration and
speech. It can also be affected by the abnormal loss of tooth substance
such as that due to attrition of teeth. Severe forms of posterior cross-
bite and deep traumatic bite lead to reduced jaw function and
masticatory ability and occasionally problems with TMJs.
Indirect consequences of malocclusion are connected with
proneness to periodontal diseases and increased susceptibility to
dental caries. Traumatic bite can lead to occlusal trauma while
crowded dentition is associated with proneness to dental caries.
In a spaced dentition, lack of tight proximal contacts between the
teeth leads to the compromised function of spillways, reducing the
natural cleansing action of food in removing the plaque and thereby
leading to increased proneness to dental caries and periodontal
disease.
Consequences due to poor aesthetics

The face is the most exposed part of the human body, an organ of
expression and communication. When the aesthetics are
compromised, a patient may develop negative body image and
psychological disturbances which could manifest as poor performance
at school, poor interpersonal and workplace relationships, lost job
opportunities, poor matrimonial alliances and consequences
thereupon. It is well known that severe deformity of the face and
severe malocclusion can lead to introverted personality behaviour and
psychological stress (Fig. 2.6).
FIGURE 2.6 Malocclusion in a patient with hemifacial
microsomia, associated with bilateral absence of ears and cleft of
the palate.
A team of multiple specialists is required to treat and rehabilitate such a
deformity. He has been provided an implant supported ear prosthesis.
Children with buck teeth may get bullied at school which may have
devastating and long-lasting effects. Physical appearance does appear
to play a role in these children, which includes facial and dental
appearance, although these tend not to be primary factors. Teasing
related to dental appearance appears to be particularly hurtful.6
Concern about existing deformities may vary among individuals,
races, people with different socioeconomic backgrounds and diverse
ages. The individual’s adjustment to his/her imperfections in dental
alignment could be variable and there is no evidence that children
with visible irregularities will, in general, be emotionally
handicapped.7
Mild to moderate malocclusion can create negative impacts on daily
performance and cause psychological stress, especially interpersonal
sensitivity and depression in young adults.8
Alteration in functions of stomatognathic
system
Essential functions of the stomatognathic system that can be adversely
affected with malocclusion are masticatory performance, deglutition,
speech and respiration.
Masticatory performance
Masticatory performance is evaluated by the ability of a person to
grind food and the chewing force he/she can exert. It is likely to be
compromised when occlusion is less than optimum, more so in
association with specific traits of malocclusion.
The diminished number of occlusal contacts and quality of contacts
lead to reduced ability to pulverise food into smaller particle sizes in
the same number of strokes/unit of time compared with someone with
normal abilities.9 Subjects with malocclusion have been found to chew
food of larger particle sizes compared with the normal occlusion
group.10 English et al.11 found median particle sizes for class I, II, and
III malocclusion groups to be approximately 9, 15 and 34% larger,
respectively, compared with those with normal occlusion.
Malocclusion associated with frequent interference in normal
masticatory movements shows altered activities of the muscles
involved in mastication and poor coordination of muscle functions.
Individuals with scissors bite or cross-bite of the buccal segment show
a lack of coordination of muscular activities more so on the affected
side. Research studies have shown that, when measured by kinematic
parameters, dental malocclusions were associated with significantly
lower skilfulness of masticatory jaw motion.12
Patients with anterior open bite are unable to bite using their
incisors and hold objects between their front teeth.
Articulation and quality of speech

Speech articulation can be adversely affected in severe open bite,
skeletal class III malocclusion with negative overjet, and in severely
malpositioned teeth.13,14
Articulation errors occur primarily on the sibilants (s, z) and (sh, ch,
j, dz), which are characterised mostly by combined visual and
auditory distortions. Errors on the stop consonants (p, b, m, t, d, n)
occur less frequently and consist of isolated visual distortions. While
most subjects having class II malocclusion, with or without open bite,
could assume a variety of tongue and mandibular postures that
allowed them to approximate an (s) or (z), these compensations in
subjects with class III malocclusion do not occur. In these cases, the
tongue remains distal to the mandibular incisors, causing scattering of
the air stream. In a study conducted in Poland on class III patients
with mandibular prognathism, almost all patients exhibited speech
disorders and severe articulation defects.
Abnormal respiration, snoring and obstructive sleep

apnoea
Obstructive sleep apnoea (OSA) is associated with narrowing of the
pharyngeal airway which is thought to arise from a combination of
abnormal anatomical features of the craniofacial structures and
functional impairment of the muscles of the upper airway.
Retroposition of the facial skeleton leads to reduced oropharyngeal
dimensions and hence, makes a person prone to snoring and sleep
apnoea. Patients with a retrognathic/small mandible are at greater risk
of developing snoring and OSA. In these patients, the tongue assumes
a more posterior and inferior position to accommodate itself in a
smaller oral cavity, which further compounds the narrow existing
airway. Children born with a retrognathic mandible such as in Pierre
Robin sequence require immediate attention in holding the mandible
forward to prevent asphyxia. Orthodontists have traditionally
constructed appliances to hold the mandible forward to assist them in
breathing. Patients with retrognathia due to TMJ ankylosis do suffer
from OSA and benefit significantly after mandibular lengthening
procedures.15
Loss of tooth substance and function
Traumatic deep bite is one of the causes of pain in lower anterior teeth
and on the anterior palate. Supraerupted mandibular incisors cause
trauma on the anterior palate while retroclined upper incisors
impinge on the labial gingiva of the lower incisors.
Attrition of teeth can also be an outcome of single-tooth
malposition, which hinders normal masticatory functions. Deep bite
affects the anterior teeth causing wear on the labial/incisal edges of
mandibular incisors and the palatal surfaces of maxillary incisors. The
extent of attrition may vary depending upon the severity of deep bite
and the interference it offers during functional jaw movements (Fig.
2.7).
FIGURE 2.7 Loss of tooth substance of the maxillary and

mandibular incisors associated with deep bite.
Loss of enamel further leads to wearing away of dentine and can

cause pain and sensitivity of the affected teeth, followed by pulp
exposure and consequent complications including periapical abscess
formation.
Many adults report with complaints of their front teeth getting
worn out, unaware of existing traumatic deep bite. The rate of tooth
substance wear may vary greatly from individual to individual. In
other situations, the attrition of tooth substance leads to periodontal
and endodontic complications. These patients do present difficulties
for prosthetic rehabilitation due to lack of interocclusal space required
for the placement of the prosthesis. Traumatic deep overbite may
result in unprotected incisors, adversely affecting the life of the
dentition. Teeth in cross-bite also end up in attrition due to functional
hindrances.
Increased susceptibility to dental trauma

Proclined maxillary anterior teeth are more prone to traumatic
injuries, more so if the lip coverage is inadequate. A significant
relationship was found between the severity of trauma to protrusion
of maxillary incisors and the amount of lip coverage.16–21 The extent of
dental injury does vary from slight chipping of the incisors to
avulsion, which is related to the type of injury.
Dental trauma and overjet have been linked to increased proneness
to traumatic dental injuries (TDI) in children.
Children in primary dentition with overjet and anterior open bite
are more prone to TDI. A recent systematic review suggests that
males, older children (1–2 years/2–3 years/3–4 years) and those with
inadequate lip coverage, overbite, or overjet are more likely to have
TDI in the primary dentition.22
Several other studies have linked proneness to TDI with increased
overjet in children and adolescents. Increased overjet with inadequate
coverage increased the risk.
It has been reported that, among 6- to 13-year-old children having
fractured or traumatic injuries to anterior teeth, the highest proportion
was found with class II division 1 malocclusion and inadequate
upper-lip coverage.23 In general, children with overjet of more than 3
mm with inadequate lip coverage are at a higher risk of sustaining
crown fracture of the incisors.24 There is a 13% increase in the risk of
trauma for every millimetre of increase in overjet.25 An increase in
overjet of more than 3 mm doubled the incidence of coronal fracture
while an overjet of more than 6 mm increased the incidence
fourfold.26 Soriano et al. have suggested the critical trauma
susceptibility value of overjet of 5 mm or greater.27,28 In general, boys
with overjet are more prone to injuries than girls.29
Recent studies have reiterated these observations. Among
adolescents, the teeth most affected by dental trauma are the maxillary
central incisors. Boys run a 2.03-times higher risk of crown fracture
than girls, and children with an overjet size >3 mm are 1.78 times
more likely to have dental injuries. Also, children with inadequate lip
coverage are 2.18 times more likely to present TDI than children with
adequate lip coverage.30,31
In short, overjet, lip competence, and short lip line are important
predisposing factors to coronal fracture of the anterior teeth while the
severity of the fracture was mainly determined by increase in the
overjet.32
Can early orthodontics using a functional appliance help

to reduce traumatic dental injuries
The findings of a higher incidence of dental trauma in patients with
increased overjet, suggest that these patients are likely to be benefitted
with early orthodontic interventions before the age of 11 years.
Proneness to dental diseases

Occlusion trauma
Occlusal trauma associated with developing cross-bite during early
mixed dentition is often seen with increased mobility of affected
mandibular incisor(s) and loss of gingival attachment.
Periodontal disease
Severe crowding is seen associated with increased plaque
accumulation and gingivitis.33 Bollen et al. (2008) in a systematic
review reported a correlation between the presence of a malocclusion
and periodontal disease. Subjects with greater malocclusion have
more severe periodontal disease. Periodontal health is also dependent
on the oral health status of an individual. Therefore, malocclusion per
se cannot be implicated as the sole aetiology of periodontal disease
but suggests an association. Large overjet has been associated with
greater susceptibility to poor oral hygiene and gingivitis caused by
dryness of the mouth (Figs. 2.8–2.10).
FIGURE 2.8 Severe deep bite causing trauma to the
periodontium of the mandibular incisor teeth.
FIGURE 2.9 Occlusal trauma from a single tooth in cross-bite
has caused gingival recession of the right mandibular central
incisor.
FIGURE 2.10 Beginning of gingival recession in the mandibular
incisors caused by trauma from malposed teeth and twin
supernumerary teeth.
Dental caries
Malocclusion has been implicated and associated with dental caries as
a result of disturbed alignment, greater plaque formation and
difficulties related to its complete removal (Fig. 2.11).
FIGURE 2.11 Crowding of teeth causes difficulties in effective

plaque removal making them susceptible to dental caries and
periodontal diseases.
Interproximal caries on the maxillary right central and lateral incisors
associated with crowding in this 14-year-old girl.
The author has come across many children and adults seeking
orthodontic treatment for several functional reasons besides concern
for aesthetics and improvement in appearance. Some of the common
concerns are:
• lnability to keep lips closed, which causes discomfort. Such

patients are usually associated with a superior protrusion or
bidental protrusion.
• Problems with clarity and errors in articulation of speech,
common cause being anterior open bite.
• Appearance of spacing between teeth. The spacing becomes
progressively larger. Such patients are usually adult females
who have deep anterior traumatic bite causing periodontal
migration of teeth.
• Sensitivity to cold and hot foods in front teeth.
• Front teeth getting worn or completely worn-out front teeth
and complications thereof.
• Pain in TMJ and non-specific symptoms of pain in the
orofacial region (Box 2.1).
Box 2.1 Consequences of malocclusion
1. Consequences due to poor aesthetics

a. Negative body image
b. Psychological disturbances
2. Compromised functions of the stomatognathic system
a. Poor masticatory performance
b. Difficulty in articulation and lack of clarity of certain
words
c. Altered respiration leading to snoring and obstructive
sleep apnoea (OSA)
3. Loss of tooth substance and function
a. Attrition and loss of tooth structure
b. Hypersensitivity of teeth
c. Pulp exposure and related complications
4. Increased susceptibility to trauma
High frequency of fractures of maxillary incisors and associated
complications
5. Proneness to dental diseases
a. Bone loss and gingival recession due to occlusal
trauma
b. Poor oral hygiene and periodontal disease
c. Proneness to dental caries due to increased plaque
accumulation in crowded dentition
6. Temporomandibular joint disturbances
The very purpose of orthodontic treatment varies from individual
case to case and so would the expected benefits which need to be
derived both in the short and long term.
The perceived benefits and measurable benefits are influenced by
patients’ and parents’ perception of malocclusion, the motivational
reasons of the patient for undergoing treatment, the severity of
malocclusion, and the complexity of disfigurement and its impact on
oral health (Figs. 2.1B, 2.12 and 2.13).
FIGURE 2.12 Aesthetic and health-related benefits of orthodontic
treatment in an adult female patient.
(A) This woman had severe periodontitis, aggravated by crowding of
the lower and upper anterior teeth. She was unhappy with her
appearance too. (B) Comprehensive orthodontic treatment with fixed
mechanotherapy was carried out. Crowding in the lower arch was
resolved with an extraction of the right lower central incisor, which
suffered severe bone loss. Proximal recontouring of the upper anterior
teeth was necessary to minimise proclination of teeth as the crowding
was resolved. Residual overjet and midline shift are the major concerns
with single incisor extraction treatment in the lower arch. Retention in
such cases is usually prolonged; it could extend for a lifetime.
FIGURE 2.13 Apparent benefits of inter-disciplinary orthodontic
treatment in an adult female.
Note the consonant smile arc. Improved axial and sagittal relations of
the upper anterior teeth are contributory to the maintenance of healthy
dentition. (A) The contours of the incisal edges were lost due to
constant grinding by the general dentist to prevent migration of teeth to
relieve occlusion trauma. (B) The orthodontic treatment restored the
mid line. The canine has a Maryland bridge with an additional tooth
provided to camouflage excessive space. The bridge helps to maintain
the integrity of the arch and serves as a retention appliance. The lost
incisal edges were restored with tooth-coloured composites. (C) The
occlusion at five years follow-up.
Improved aesthetics/enhanced self-image

In general, orthodontic treatment aims to improve the aesthetics, self-
image, body concept and social well-being in a majority of cases.
Improvement in dentofacial aesthetics following orthodontic
treatment enhances self-confidence and self-esteem in most patients.34
Dissatisfaction with dental appearance has a strong predictive effect
on how orthodontic treatment helps to improve a person’s self-
esteem. School students who had received orthodontic treatment
showed greater self-esteem than those who had not.35
Assessment of the impact of aesthetic improvement as a result of
orthodontic treatment can generate a significant improvement in adult
patients’ QoL.36 Socially, malocclusion and its treatment can affect
perceived attractiveness by others, social acceptance and perceived
intelligence. People with a better appearance may be perceived as
socially more acceptable and superior performers.
The benefits of orthodontic treatment are the outcome of a synergy
of a variety of improvements that are dental, facial and functional in
nature. Improved aesthetics is the outcome of dental alignment,
reduced proclination and improved facial profile. The ability to keep
the lips closed and overall improvements in static and dynamic smile
help a person feel good and socially more acceptable.
Reduction in trauma to maxillary anterior teeth

Early correction of a severe superior protrusion in class II
malocclusion helps to reduce risks of trauma to maxillary anterior
teeth. It also prevents teasing and nicknames at school and offers
significant psychological benefits to the child.
A recent Cochrane review of risk ratio analyses for new incisor
trauma showed that providing early treatment using a functional
appliance reduced the risk of trauma by 33%. In other words, early
treatment using functional appliances prevents the incidence of incisal
trauma in 1 out of every 10 patients. Orthodontic treatment for young
children, followed by a later phase of treatment when the child is in
early adolescence, appears to reduce the incidence of new incisal
trauma significantly compared with treatment that is provided in a
single phase when the child is in early adolescence.37
Benefits of orthodontic treatment in adult patients

requiring oral rehabilitation
In adult patients, a recent meta-analysis revealed that oral health
impact profile (OHIP-14) scores were significantly lower, which
means they had a better OHRQoL after receiving treatment for
malocclusion, as well as in individuals without malocclusion or
orthodontic treatment need, compared with those with such a
condition (independent groups). OHIP-14 scores are valid and reliable
measures of OHRQoL.38
Orthodontic treatment significantly improves patients’ self-esteem
and QoL. Adult patients undergoing interdisciplinary treatment with
periodontists, prosthodontists or orthodontists get psychological
benefits because of the need for oral rehabilitation as a result of the
motivation for improved occlusion and smile esthetics.39
More severe forms of malocclusion, especially in those who require
treatment involving a combination of surgery, can be associated with
greater distorted self-image. Patients who have undergone
orthognathic surgery experience psychosocial benefits, including
improved self-confidence, body and facial image and social
adjustment.40,41 General HRQoL, OHRQoL, and psychosocial function
show significant improvements after bilateral sagittal split osteotomy,
and the improvements are stable between 2 and 5 years after
surgery.42 Patients with class III malocclusion, especially those with
large mandibular prognathism, are benefitted the most.
Improved oral functions

Treatment of malocclusion can offer physical health benefits such as
improvement in masticatory performance, clarity in articulation,
prevention of dental and gingival trauma and improved respiration.
Improvement in masticatory performance: Alterations of the occlusal
contacts following orthodontic treatment produce a significant
mechanical advantage for masticatory performance. In orthognathic
surgery patients, the major changes relate to normalisation of patients’
masticatory muscle attachments physiologically by altering sensory
and proprioceptive inputs.43
‘The correction of malocclusion through orthodontic treatment
becomes an important resource with which to improve occlusal
contacts and, consequently, the masticatory performance of an
individual’.44 Research studies using jaw motions measured by
kinematic parameters have shown that orthodontically improved
occlusion, either with or without premolar extraction, is associated
with more skilful masticatory jaw motions.12
The interventional procedures that are undertaken to guide
erupting teeth and intercept incipient malocclusion are primarily
aimed at achieving a normal occlusion. Impacted and submerged
teeth when brought into alignment contribute to achieving occlusion
with proper masticatory efficiency and a need for further actions to
treat pathologies caused by their impaction.
A noticeable tendency towards normalisation in masticatory
patterns has been recorded after orthognathic correction of severe
class II and class III malocclusion.45 Although class III patients after
orthognathic surgery report better mastication performance than
before, it takes up to 5 years to confirm a significant improvement in
masticatory performance.46
Reduction in obstructive sleep apnoea

Craniofacial abnormality is reported as one of the major causes of
OSA syndrome. The common findings are retroposition of the
mandible, reduced cranial base flexure measured at the nasion–sella–
basion angle, and a lower position with displacement of the hyoid
bone.47 Craniofacial abnormality could be genetic or caused by
environmental factors, such as when aggravated by mouth breathing.
Removal of obstructions to facilitate mouth breathing and orthodontic
treatment to allow normal growth of the mandible facilitate patency of
the airway and therefore are likely to reduce the possibility of OSA
developing in future.48 A number of orthodontic appliances have been
advocated to advance the mandible to facilitate breathing by
increasing the upper-pharyngeal airway space and reducing its
collapsibility.49–52 These have been shown to be effective in mild to
moderate degrees of OSA.
Oral health benefits

The oral health benefits of orthodontic treatment are those related to a
reduction of occlusal trauma, such as in deep bite and anterior cross-
bite. Interceptive orthodontic treatment instituted to correct anterior
cross-bite results in a reduction of mobility and stops further
progression of gingival recession. Similarly, the correction of deep bite
helps achieve optimum oral health of the periodontium by the
elimination of occlusal trauma to it. It also prevents tooth substance
loss and therefore longevity of the dentition.
Long-term functional benefits of orthodontics are associated with
overall improvement in aesthetics, reduction in periodontal disease,
longevity of dentition, and therefore improved QoL.
Health of temporomandibular joint

The presence of malocclusion and disturbed occlusion has been
implicated as a potent aetiological contributor to TMJ-related pain,
clicking and TMJ dysfunction syndrome. The literature is not very
clear with some studies reporting an indirect relation where
temporomandibular disorder (TMD) symptoms have shown a
heterogeneous range of improvement from no change to complete
elimination. In general, TMD symptoms have been shown to improve
with age.53
Critical appraisal of the benefits of orthodontic

treatment
Zhang et al. (2006),54 based on a review of studies into the benefits of
orthodontic treatment, found conflicting evidence regarding claims of
psychological and physical benefits. This study has challenged
traditional views on the impact of malocclusion and its treatment on
the physical, social and psychological health of a patient (QoL). They
concluded that evidence to support these claims were conflicting
owing to differences in study designs, populations studied and
methods of assessment of physical, social and psychological health.
Hence, this study underrates the benefits of orthodontic treatment
perceived in day-to-day practice. A more recent meta-analysis
(2009),55 to assess the current evidence of the relationship between
malocclusion/orthodontic treatment need and QoL, considered papers
for evidence at two levels according to the criteria of the Oxford
Centre for Evidence-based Medicine. An observed association
between standardised HRQoL and malocclusion/orthodontic
treatment need was detected. However, the strength of the association
could be described as modest at best.
These studies put forward the need for further research through
well-planned study designs, sample sizes and methods of assessment
of physical, social and psychological health benefits to substantiate or
refute the claims. These studies should be so well designed and
employ such uniform criteria that they are amenable to meta-analysis.
Orthodontic treatment essentially entails the movement and
adaptation of dental and dentoalveolar structures and the alteration of
neuromuscular and soft-tissue structures around teeth and jaws. The
new dental and skeletal positions acquired have to be in balance with
the functional needs of the stomatognathic system, which has the
primary functions of mastication, speech, deglutition and respiration.
The goals of orthodontic treatment and/or combined orthognathic
surgery are to provide functionally and aesthetically acceptable
occlusion, which is in harmony with the functional needs of the
stomatognathic system.
Orthodontic tooth movement can be more realistically carried out on
correction of inclinations, labiolingual movement and some intrusion.
Extrusion of teeth is easier to perform than intrusion. The teeth in
their new positions should remain stable with their roots surrounded
by healthy alveolar bone and gingiva; biologically, there can only be
limited labial movement of maxillary teeth. Greater palatal movement
of maxillary teeth is a reality, but limited by bone at the palatal
contours. Similarly, maxillary teeth can only be expanded buccally to
a limited extent (Table 2.1; Figs. 2.14 and 2.15).
Table 2.1
Limits of orthodontic, orthopaedic and surgical
movements in three planes of space (in millimetres)
Source: Proffit WR, Ackerman JL. Diagnosis and treatment planning.
In: Graber TM, Swain BF, editors. Orthodontics: current concepts and
techniques, St. Louis, Mosby, 1985.69
FIGURE 2.14 The limits of treatment in the maxilla.
The ideal position of the upper and lower incisor in anteroposterior
(AP)M and vertical planes is shown in the centre of the diagram.
Possible movements of maxilla/teeth with orthodontics, growth
modification, and orthognathic surgery in the vertical and sagittal
directions are depicted. (A) While it is possible to retract the anterior
teeth by 7 mm and procline them in the 2-mm range, when combined
with orthopaedic treatment, these can be extended to 12 mm of sagittal
retraction and 5 mm of protraction movement. Combined with
orthognathic surgery, this range goes to 15 mm of de-impaction and 10
mm of protraction movement. These are the extreme limits of tooth/jaw
movement which are also influenced by many biological factors,
anatomical considerations, and behaviour of the soft tissues. In
general, the range of maxillary movement is slightly more for vertical
extrusion than intrusion and retraction than protraction. (B) Transverse
limits on the buccal expansion of the maxilla are quite stringent,
especially on the mandible.
FIGURE 2.15 The limits of tooth/jaw movement in the mandible.
The graph represents the limits of possible alterations in the
mandible/teeth in the vertical and sagittal direction. (A) While it is
possible to move the teeth forward by up to 5 mm with orthodontics,
and by up to 10 mm with orthopaedic correction and surgery, this limit
extends no further than 12 mm. Dentofacial orthopaedic treatment is
more effective on the mandible to enhance mesial movement/reposition
and/or growth rather than restricting its growth, whereas orthognathic
surgery has greater limits on sagittal reduction than sagittal protraction.
(B) The vertical limits for the movement of teeth on the mandible are
almost the same as the maxilla. However, transverse expansion and
contraction of the mandible are somewhat smaller than the maxilla.
Based on the concept of Proffit WR.69
Tooth movement in the anterior segment of the mandibular arch is

governed by the limited alveolar bone contours around the incisors.
Expansion of the mandibular arch beyond adaptation to expanding
the maxillary arch is not an orthodontic reality.
Orthodontics supported with implants and

skeletal anchorage system
The introduction of miniscrew implants and a skeletal anchorage
system has expanded the possibilities of orthodontic tooth movement,
especially in the treatment of complex malocclusion. Temporary
anchorage devices can provide absolute anchorage whereby they
allow maximum retraction possible in the extraction spaces. Implant-
supported systems or other skeletal anchorage systems can help carry
out enhanced movement of teeth or a group of teeth (Table 2.2).
• En masse distalisation of maxillary buccal segments by 4 mm.

En masse distalisation of the maxillary arch using a skeletal
anchorage system in adult patients can be achieved combined
with simultaneous traction of the first and second molars.56
• Intrusion of buccal segments (i.e. maxillary molars) by 2.3 mm.
In adult patients with severe open bite, absolute intrusion of
the molars can be achieved supported by miniscrews as the
anchorage device.57 In experimental studies on adult female
beagles with fully erupted dentition, the second premolars
were intruded an average extent of 1.8 mm after 4 months and
4.2 mm after 7 months using a bone-anchored device.58
• Intrusion of buccal segments of the mandibular molars.
Sugawara reported successful treatment of nine adult open
bite patients using skeletal anchorage system. The average
amount of intrusion of the mandibular first and second molars
was 1.7 mm and 2.8 mm, respectively.59 Experimental studies
on dogs showed that mandibular molars could be intruded by
3.4 mm on average over 7 months.60
Table 2.2
The anterior segment retraction performed with
conventional technique and supported with miniscrew-
enhanced anchorage
The miniscrew supported anchorage groups show greater retraction and less anchorage loss.
NM, Not mentioned; U6M, upper molar mesial point; L6M, lower molar mesial point; U6A,
upper molar apex.
The active intrusion of buccal segments allows anticlockwise

rotation of the mandible and thereby helps in closing open bite in
vertical growers and adults.
Limits of dentofacial orthopaedic treatment

Dentofacial orthopaedic treatment in growing children can produce
more significant changes than orthodontics alone. Functional
appliances have the capability to enhance sagittal repositioning of the
mandible that brings about changes in oral cavity volume and skeletal
bases, besides dentoalveolar structures. In general, overjet up to 12–15
mm is correctable using an orthopaedic appliance. Corrected overjet is
often the outcome of a combination of retroclination of maxillary
incisors, some proclination of mandibular incisors and acquiring a
forward position of the mandible.
Although there are no definite guidelines based on negative overjet
to suggest maxillary protraction or camouflage treatment of class III
malocclusion, in general, cases with normal mandible and deficient
maxilla are more suited for maxillary protraction. A familial type of
severe class III malocclusion may not respond to conventional
dentofacial orthopaedic treatment, even though diagnosed early. In
these cases, diligent observation and diagnosis would be needed to
ascertain whether the malocclusion should be interfered with, in
growing age or treated later with orthognathic surgery.
Malocclusions that are beyond the possibilities of treatment with
orthodontics alone and patients who are beyond the favourable age
for possible dentoskeletal orthopaedic growth modification can be
managed with the combined approach of orthognathic surgery and
orthodontics.
The nature of malocclusion, the magnitude of the problem and the
complexity of the skeletal and dental relationships are the basis of a
treatment plan that can determine whether the deformity can benefit
from orthodontics alone or would require a combination of jaw
surgery and orthodontics.
Orthognathic surgery of the facial skeleton permits repositioning of
the maxilla and mandible in all three dimensions of space. However,
there are biological limits to such changes which have been classically
summarised by Proffit and Ackerman69 (Figs. 2.14 and 2.15). In the
opinion of orthodontists, a positive overjet greater than 8 mm, a
negative overjet of 4 mm or greater, and a transverse discrepancy
greater than 3 mm are not orthodontically treatable.70
The amount of change possible in the three planes of space have
been quantified for both the maxilla and mandible, for orthodontics
alone, or for orthodontics with orthognathic surgery (Figs. 2.14 and
2.15).
Distraction osteogenesis
Research studies on biological principles and technological advances
in the development of multi-planner devices of distraction
osteogenesis now allow a larger range of skeletal movements such as
maxillary protraction, especially in cleft patients, and mandibular
lengthening in patients with TMJ ankylosis where orthognathic
surgery has limitations. Multi-planner distraction devices allow
lengthening in more than one vector and can be tailored. Using
modern distraction appliances, supported by 3D-virtual model
visualisation, and an interdisciplinary approach, complex
malocclusions can now be treated successfully.
Table 2.1 summarises the limits of orthodontic treatment,
dentofacial orthopaedics and orthognathic surgery. The values shown
in the table are the extreme limits of movements, but it does not
necessarily follow that these treatment effects are always possible or
would be stable in the future.
In general, the range of possible movements in the vertical and
sagittal directions for the mandible and maxilla is greater than in the
transverse plane (i.e. expansion and constriction are minimal,
especially in the mandible).
Key Points
Orthodontic treatment should be perceived first from the patient’s
point of view, and the reason(s) for seeking orthodontic treatment
should be clearly identified.
The professional’s goals of orthodontic treatment are aimed at
achieving functional occlusion and optimisation of oral health, which
need to be blended with patients’ expectations on aesthetic
improvement.
Orthodontic treatment should be complemented by other dental
procedures such as periodontal surgery, prosthodontic rehabilitation
and aesthetic dentistry procedures to provide optimum dental health.
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CHAPTER 3
Epidemiology of malocclusion
and orthodontic treatment needs
O.P. Kharbanda
CHAPTER OUTLINE
Need for recording malocclusion prevalence

Methods of recording malocclusion for epidemiological data
Angle’s classification and limitations
Federation Dentaire Internationale (FDI)/ World Health
Organisation (WHO) method
Reasons for large variations in malocclusion prevalence
Ethnic trends in malocclusion prevalence
Prevalence for malocclusion around the world
Prevalence of malocclusion in Europe
Prevalence of malocclusion in Africa
Prevalence of malocclusion in China and Mongoloid
races
Prevalence of malocclusion in India
Prevalence of malocclusion in tribal population
Key Points
Need for recording malocclusion
prevalence
Population-based surveys of dental diseases are a prerequisite for
systematic planning of the oral health needs of the society, to plan the
health care delivery and to evaluate the efficacy of the preventive and
therapeutic measures introduced.
Most of the earlier surveys on dental diseases were targeted to
record dental caries and periodontal disease while malocclusion
received comparatively much less attention. Malocclusion is not a
disease per se but a variation in the arrangement of teeth, morphology
of jaws, face and cranium. These deviations have a large spectrum of
presentations with mild to most severe forms. Moreover, the mere
presence of a trait or traits of malocclusion alone may not be the
definite indication for treatment. Desire and need of orthodontic
treatment are also influenced by awareness, socioeconomic factors,
availability of the experts, ethnic trends and values, besides functional
aberrations caused by malocclusion. There have also been issues on
agreement on uniform criteria of recording malocclusion, and this
may as well have been a hidden reason for the limited number of
studies in the past on prevalence of malocclusion.
With the development of objective metric criteria and evolution of
indices of malocclusion to a significant validity, information on
malocclusion and treatment needs is now being made available from
around the world.
Methods of recording malocclusion for
epidemiological data
Angle’s classification and limitations
Angle’s classification (1899)1 of malocclusion has been used in
population surveys to report on the prevalence and distribution of the
different types of malocclusion. It provides information according to
class differentiation into three distinct classes, that is Class I, Class II
and Class III. Although Angle’s classification was designed not as a
tool for epidemiology, it is perhaps the most used method for the
purpose of population surveys on malocclusion.
There are obvious limitations in recording malocclusion with
Angle’s classification. These are: it does not reveal the severity of the
class of malocclusion, and it does not consider the patient’s profile
and skeletal relationship. The intra-examiner and inter-examiner
errors are usually large which may nullify the differences, if any,
among population groups. There are also difficulties in recording the
‘class’ when it is unilateral, particularly in mutilated dentitions.
Successively, additions were therefore made to record traits of
malocclusion in three planes of space or traits of malocclusion such as
tooth rotations, crowding, open bite, closebite, cross-bite, arch
constriction etc. by many researchers.2–9
The method of recording malocclusion developed by Bjork et al.6 is
based on defined items of the recorded symptoms. The registration of
the malocclusion was divided into three parts (Box 3.1):
1. Anomalies in the dentition: Tooth anomalies, abnormal

eruption and misalignment of individual teeth.
2. Occlusal anomalies: Deviations in the positional relationship
between the upper and the lower dental arches in the three
planes.
3. Deviation in space conditions: Spacing and crowding.
Box 3.1 Summary of qualitative methods of
recording and measuring malocclusion
Angle1 Classification of molar relationship devised as a prescription for treatment
Stallard2 The general dental status, including some malocclusion symptoms, was recorded
No definition of the various symptoms was specified
McCall 3 Malocclusion symptoms recorded include: molar relationship, posterior cross-bite,
anterior crowding, rotated incisors, excessive overbite, open bite, labial or lingual
version, tooth displacement, constriction of arches
No definition of these symptoms was specified
Sclare4 Specific malocclusion symptoms were recorded, which include Angle’s classification
of molar relationships, arch constriction with incisor crowding, arch constriction
without incisor crowding, superior protrusion with incisor crowding, superior
protrusion without incisor crowding, labial prominence of canines, lingually placed
incisors, rotated incisors, cross-bite, open bite and closebite
No definition of these symptoms was specified
Symptoms were recorded in an ‘all-or-none’ manner
Fisk 5 Dental age was used for grouping patients
Three planes of space were considered:
1. Anteroposterior relationship: Angle’s classification, anterior cross-bite, overjet
(mm), negative overjet (mm)
2. Transverse relationship: Posterior cross-bite (maxillary teeth biting buccally or
lingually)
3. Vertical relationship: Open bite (mm), overbite (mm)
Additional measurements include labiolingual spread (Draker7), spacing, therapeutic
extractions, postnatal defects, congenital defects, mutilation, congenital absence,
supernumerary teeth
Bjork et Objective registration of malocclusion symptoms based on detailed definitions. Data
al.6 obtained could be analysed by computers
Three parts:
1. Anomalies in the dentition: Tooth anomalies, abnormal eruption, malalignment of
individual teeth
2. Occlusal anomalies: Deviations in the positional relationship between the upper and
lower dental arches in the sagittal, vertical, and transverse planes
3. Deviation in space conditions: Spacing or crowding
Proffit and Five-step procedure of assessing malocclusion (no definite criteria for assessment
Ackerman8 was given):
1. Alignment: Ideal, crowding, spacing, mutilated
2. Profile: Mandibular prominence, mandibular recession, lip profile relative to nose
and chin (convex, straight, concave)
3. Cross-bite: Relationship of the dental arches in the transverse plane, as indicated by
buccolingual relationship of posterior teeth
4. Angle’s classification: Relationship of the dental arches in the sagittal plane
5. Bite depth: Relationship of the dental arches in the vertical plane, as indicated by
the presence or absence of anterior open bite, anterior deep bite, posterior open bite
and posterior collapse bite
WHO/FDI Five major groups of items were recorded (with well-defined recording criteria):
(1979)9 1. Gross anomalies
2. Dentition: Absence teeth, supernumerary, malformed incisor, ectopic eruption
3. Space conditions: Diastema, crowding, spacing
4. Occlusion:
a. Incisal segment: Maxillary overjet, mandibular overjet, cross-bite, overbite, open
bite, midline shift
b. Lateral segment: Anteroposterior relations, open bite, posterior cross-bite
5. Orthodontic treatment need judged subjectively: Not necessary, doubtful,
necessary, urgent
Kinaan Five features of occlusion measured:
and 1. Overjet (mm)
Bruke10 2. Overbite (mm)
3. Posterior cross-bite (number of teeth in cross-bite, unilateral, or bilateral)
4. Buccal segment crowding or spacing (mm)
5. Incisal segment alignment (classified as acceptable, crowded, spaced, displaced, or
‘rotated’, following defined criteria)
Source: Cited with permission from Tang ELK, Wei SHY. Recording and
measuring malocclusion: a review of the literature. Am J Orthod
Dentofacial Orthop 1993;103:344–5111
This comprehensive method of recording of malocclusion was used

in many surveys and has the advantage of data being analysed
through computer systems.
Federation Dentaire Internationale (FDI)/World

Health Organisation (WHO)9 method
The registration of malocclusion developed by Bjork et al.6 eventually
evolved with several modifications by the working groups of FDI
from 1969 to 1972. The method was field tested during 1973–1976 and
was further subjected to several modifications.12,13 The final version
contained additional modifications that were carried out in
collaboration with WHO. The recording form was named ‘Dentofacial
anomalies assessment form’. It was made available through WHO
publication ‘Oral Health Surveys’ (1979). The recording criteria were
based on the principles of agreement on the recording of individual
traits of malocclusion to be grouped in a simplified manner. It should
also serve as a basic reference tool in the development of the methods
for assessing the need and demand for orthodontic treatment (Figs. 3.1
and 3.2).9
FIGURE 3.1 Anteroposterior molar relationships.

The scale refers to the relative position of the upper left molar. The
arrows indicate anteroposterior molar relations in a normal occlusion
situation (codes 0) and at lower class limits of codes 1–4 (no upper
class limits are defined for codes 2 and 4). Source: Based on:
Bezroukov V, Freer TJ, Helm S, Kalamkarov H, Sardo IJ, Solow B.
Basic method for recording occlusal traits. Bull World Health Organ
1979;57(6):955–61. PubMed PMID: 317023; PubMed Central PMCID:
PMC2395850.9
FIGURE 3.2 Buccal and lingual posterior cross-bite. Source:
Based on: Bezroukov V, Freer TJ, Helm S, Kalamkarov H, Sardo I J,
Solow B. Basic method for recording occlusal traits. Bull World Health
Organ 1979;57(6): 955–61. PubMed PMID: 317023; PubMed Central
PMCID: PMC2395850.9
Each trait was grouped based on the degree of deviation from norm
or severity. To simplify the complexity of criteria and time involved in
examination, codes and criteria are listed on the recording form itself.
Assessment of dentofacial anomalies and status of occlusion were
suggested to be recorded on permanent dentition in three parts:
1. Dental examination: Anomalies of development, congenitally

missing teeth, supernumerary teeth, malformed teeth,
impacted, missing due to trauma or extraction and retained
deciduous teeth.
2. Intra-arch examination: Crowding, spacing, anterior
irregularities and upper midline diastema.
3. Inter-arch examination: The molar relationship, posterior open
bite, posterior cross-bite, overjet, overbite, midline deviation,
anterior open bite and soft tissue impingement.
The sociopsychological effects of occlusal features on an individual,
their family and peers were not taken into consideration, as an
objective method of measuring these factors had not been
established.10
Reasons for large variations in
malocclusion prevalence
In the past, accurate comparisons of malocclusion from different
studies were difficult because of several reasons listed in Box 3.2.
These included lack of uniform criteria for registration of
malocclusion and its traits, faulty sampling techniques and errors of
examinations and recording of data.
Box 3.2 Factors that directly or indirectly

contributed to large variations in reporting the
prevalence of malocclusion
1. Lack of demarcation between prevalence of malocclusion in

population vs. frequency distribution of malocclusion among
patients visiting hospitals (some authors called it incidence)
2. Lack of uniform objective criteria in some studies for recording
malocclusion or method of registration of malocclusion
3. Selection procedure employed in identification of the locations
in population-based studies
4. Sampling technique
5. Sample size
6. Variations in age group
7. Age group combination(s)
8. Ethnic variations
9. Sex difference
10. Inter-examiner variability
11. Intra-examiner errors
Only a few surveys on children and young adults have been done to
record malocclusion on a sample representative of the population for
their size or distribution of age groups. Populations sample from
different age groups particularly those from early mixed and mixed
dentition where occlusion in a state of flux offer inaccurate recordings
and make comparisons difficult with those of permanent dentition. It
is, therefore, recommended that a malocclusion survey should be
conducted during the late mixed or early permanent dentition stage.
By this stage of development, the growth of the face is close to
completion; moreover, permanent teeth up to the 2nd molars will
have erupted in the oral cavity, while maxillary canines have fully
erupted or erupting. The adult occlusion or malocclusion is close or
nearly established by this age (Box 3.3). The sample size of a target
population, for example, school going population can be calculated
based on a known prevalence of the disease/malocclusion using the
formula given in Box 3.4.
Box 3.3 Suggested criteria for recording

malocclusion/treatment needs of a society
1. Age group +10 years

2. Sample size should be calculated by target population
(population size) and established earlier prevalence of 45% by
Kharbanda et al.
3. Area district/state should be categorically specified
4. By whom? By trained personnel who are calibrated on the use of
recording malocclusion traits
5. Criteria and method of registration: Uniform and objective
criteria that can be quantified
Box 3.4 Suggested method for calculation of

sample size for prevalence of malocclusion
The sample size is calculated
by using the formula:
Under the assumption that: p = prevalence of malocclusion, that is 45% in the age group of 12–16
years based on previous study (Kharbanda et al.).
Selected with cluster sampling technique
q = 100 − p, that is, 55
L = allowable error (10% of p)
n = required sample
Ethnic trends in malocclusion
prevalence
Variations in the prevalence of malocclusion have been found
between different races or ethnic groups. The prevalence of
malocclusion varies greatly in different parts of the world, in different
ethnic groups, and among people of different races.14–22
In general, prevalence of malocclusion is reported high among
whites than blacks14 and more in urban than rural children.23–26
Individual races are known for specific traits of malocclusion like
bimaxillary protrusion is more common in Negroes22 while
Polynesians of Pukapuka Island27 and Mongoloids of China, Japan,
Taiwan, and Korea have a high prevalence of skeletal class III
malocclusion.28–31
The prevalence of class II malocclusion is found to be high among
Caucasians. In the United States of America, it was found to be 34% in
whites and 18% in blacks.16 It has been reported that prevalence of
class II malocclusion was 31% in Danish children population25 while it
was as low as 8% in Johannesburg,32 11% in Kenya,33 16.4% in Saudi
Arabia34 and 14.6% in Delhi, India.35
Prevalence for malocclusion around the world

America and Canada
Proffit et al.14 published findings of the prevalence of malocclusion
and orthodontic treatment need in the United States. The findings
were based on National Health and Nutrition Estimates Survey III,
which was conducted from 1989 to 1994, on 14,000 subjects in the age
group of 8–50 years, representing 150 million subjects. Angle’s
classification along with irregularity index and occlusal contact
discrepancies were recorded. Findings were presented for age group
8–11, 12–17, and 18–50 years. Among 8–17 years age group, 70%
children had malocclusion of which 50–55% were class I, 15% class II
and 1% class III. More than 50% children had crowding in the maxilla
and/or mandible or both.
Earlier estimates of the prevalence, severity, and need for treatment
of malocclusion in youths of 12–17 years of age in the United States
were published by the Division of Health Examination Statistics in
1977.15 The data on which the report was based were obtained in oral
examinations in 40 scientifically selected locations situated in 25
states, covering designated sections of the country. The statistical
findings were based on 90% of a probability sample of 7,514 youths
representative of approximately 22.7 million non-institutionalised
children in the United States. About 54% of those examined were
found to have neutrocclusions. Proportionately, more black (62%)
than white youths (52%) were found to have neutrocclusion.
Neutrocclusions are characterised among other deviations by
crowding, rotations, spacing, ectopic eruptions and loss of teeth.
Distocclusion was found more in white youths (34%) than in black
youths (18%). About 14% children of the sample studied were
reported to have mesiocclusion. More than 10% were estimated to
have severe overbites of 6 mm or more of the incisor teeth. Cross-bites
of varying severity were found in 12%, and 38% had up to three
displaced teeth, with the remainder having four or more teeth
displaced.
About 25% were found to have definite malocclusion for which
treatment was considered to be ‘elective’. Treatment was considered
‘highly desirable’ in 13% and ‘mandatory’ for an additional 16%. An
estimated 10.2 million youths/adults had specific occlusal defects such
as severe incisor overbites or open bites, which required ‘evaluation
by orthodontists to determine the need for treatment’.
Canada (Table 3.1)

Payette and Plante,36 in a sample of 1,201, 13- and 14-year-old Quebec
school children using Grainger’s orthodontic treatment priority index
(TPI), reported that 32% of the children were in Angle’s class II molar
relation; 18% had an overjet of 5 mm, and more than 50% had one or
more teeth in minor or major displacement. Treatment was mandatory
or highly desirable for 13.7%, and only 2.9% of the students were
under treatment. According to Harrison and Davis,20 61% native
children of British Columbia in the age group 7–15 years had
malocclusion.
Table 3.1
Prevalence of malocclusion in American, Canadian and
Columbian population groups
M: Male; F: Female. *NHANES—National Health and Nutritional Examination Survey.
South America
A survey of 4,724 children (age 5–17 years) randomly selected from a
population that attended Dental Health Services was conducted in
Bogotá, Columbia. Based on their dental development, these were
grouped into four developmental stages (DS Stage I–IV).
Registration of malocclusion was performed according to the
method suggested by Bjork et al., and the need for orthodontic
treatment was evaluated according to the index used by Swedish
National Board of Health. A large percentage (88%) of children had
some form of dental and or occlusal anomaly from mild to severe
type; half of which, that is, 44% had occlusal anomalies and 1/3rd, that
is, 30% as space discrepancies. Urgent need for orthodontic treatment
was recorded in 3% and great need in 20% subjects examined. Little
need in 35% and moderate need in 30% subjects were recorded.21
Prevalence of malocclusion in Europe25,37–46

(Table 3.2)
A large proportion of the population (nearly 80% and more) studied
among European countries seems to have some form of occlusal
anomalies. Although these data are not exactly indicative of the need
for orthodontic treatment, a high prevalence of malocclusion points to
the widespread existence of the problem and perhaps is an outcome of
a strict recording protocol. It is also obvious that prevalence of class II
malocclusion is high in Europe among Caucasian population. The
prevalence of class II malocclusion in the Danish children was found
to be 31%25 and in Hungary 47.2%.41
These observations on class II malocclusion in Europe are
considerably high compared to the prevalence of class II malocclusion
in Africa, Arabia and India.
Table 3.2
Prevalence of malocclusion in Scandinavian and
European population groups
IOTN: Index of Orthodontic Treatment Needs B: Boys; G: Girls; M: Male; F: Female.
Prevalence of malocclusion in Africa22,24,47–50

The prevalence of malocclusion in Kenya, Nigeria and Tanzania is
recorded high, ranging from 72% to 86% of the sample surveyed,
though most of it constitutes class I type of malocclusion. The class II
malocclusion among children in Kenya has been reported to be 7.9%,
while in Nigeria it is seen only in 1.7%. Studies on children in Africa
have shown that the proportion of class II malocclusion is obviously
much low compared to a high prevalence of class II malocclusion
prevalent in Caucasian population groups (up to 50%) (Table 3.3).
Table 3.3
Prevalence of malocclusion in Africa
M: Male; F: Female.
Specific malocclusion traits were highest for crowding, rotations,

posterior cross-bite and maxillary overjet. It is interesting to note that
frequency of frontal open bite was 8% in children from Nairobi50 and
19.5% children from Benin City in Nigeria have midline diastema.49
Prevalence of malocclusion in China and

Mongoloid races29,51(Table 3.4)
According to Fu et al., the prevalence of malocclusion among Chinese
children was 67.82%. A study by Lew et al. on 1,050 Chinese school
children (aged 12–14 years) reported a high incidence of class III
malocclusions in Chinese compared to Caucasians. However, the
incidence of class II malocclusions was quite similar to those reported
in Caucasians. Crowding occurred in about 50% of cases.
Table 3.4
Prevalence of malocclusion in Indian subcontinent,
China and Iran
Prevalence of malocclusion in
India51,59–64(Tables 3.4 and 3.5)
India is a large country with its inhabitants being multiracial and
multiethnic. Indian population has been broadly divided into seven
ethnic groups based on anthropometric measurements and skin
colour. These are Indo-Aryans, Sytho-Dravidians, Mongolo-
Dravidians, Mongoloids, Dravidians, Aryo-Dravidians and Turko-
Iranians. The Indo-Aryans occupy eastern Punjab and Kashmir; the
Sytho-Dravidians inhabit hilly tracts of Madhya Pradesh. Mongolo-
Dravidians are seen in West Bengal and Orissa while Mongoloids are
distributed in a belt along the Himalayan region, Assam and north-
eastern states, and Dravidians inhabit southern India especially Tamil
Nadu, Andhra, Kerala, southern Bihar and coastal Orissa. Aryo-
Dravidians inhabit northern India. Turko-Iranians inhabit Baluchistan
and the Frontier Province, which are now in Pakistan. The differences
between craniofacial and denture pattern among these groups are
known. A small number of studies in India have been done on a well-
defined methodology using sufficient sample of subjects but not
necessaryily with appropriate study design.51
The prevalence of malocclusion in southern Indian city of
Thiruvananthapuram, in the age group of 12–15 years, was reported
as 49.2%. Of this, class I malocclusion was 44%, class II 4.9% and class
III 0.3%.55 According to another study from Bangalore conducted on
1,033 school children aged 5–15 years, the prevalence of malocclusion
was 51.5%. Prevalence of class II malocclusion was 4.0% and class III
0.9%.64
Phaphe et al.56 reported prevalence of malocclusion in 12–14 years
old urban school population in Bagalkot (Karnataka). The
malocclusion distribution was Class I—17.8%, Class II—30.1%, Class
III—1.6%. Another study by Narayan et al.57 showed that the
prevalence of malocclusion was 83.3% in schoolchildren (age group
10–12 years) in Kozhikode District, Kerala. Prabhakar et al.58 reported
distribution of prevalence of malocclusion in Chennai school children.
It was Class I—21.8%, Class II division 1—27.7%, Class II division 2—
9.5%, and Class III—4.5%. Reddy et al.59 reported prevalence of
malocclusion as Class I—21.8%, Class II division 1—27.7%, Class II
division 2—9.5%, Class III—4.5% in Nalgonda school children.
Table 3.5
Prevalence of malocclusion and its traits (%) in children
in Delhi (n = 2,737) in the age group of 10–13 years35
Kharbanda et al.35,52,53 reported prevalence of malocclusion in Delhi

based on the school survey of 5,554 children in the age group of 5–13
years. The sample size was calculated based on sampling design to
represent the entire school-going population of Delhi in three
subdivided locations, that is urban, peri-urban and rural. Two types of
schools were considered—the convent and government. The schools
all over Delhi were identified along with their strength of the children
population. Statistical sampling technique determined the numbers of
children to be recorded for representative age (5–13 years). The
sample data were primarily presented in two major groups: the mixed
dentition group which comprised of 2,817 school children in the age
group of 5–9 years and the late mixed/permanent dentition groups, in
the age group of 10–13 years, which comprised of 2,737 children. He
used WHO Dentofacial Anomaly assessment form to conduct the
survey and used computerised data punching and analysis.
In younger age group (5–9 years), a majority of children in Delhi
exhibited class I molar relation (91.6%), while only 6% exhibited class
II molar relation. Malocclusion distribution according to Angle’s
classes was in agreement with their deciduous molar relationship: that
was a mesial step (90.3%) and distal step (8.6%). Crowding in
mandibular anterior teeth was the most common trait of malocclusion
(11.7%). There was no difference in the prevalence of malocclusion
between males and females.
The prevalence of malocclusion in children in Delhi of age 10–13
years was 45%. Class I malocclusion was 26%, class II 15% and class III
3.5%. In another study from North India, the prevalence of
malocclusion in rural children in Haryana (age group 12–16 years)
was 55%.54 (Fig. 3.3).
FIGURE 3.3 Prevalence of malocclusion in children of Delhi.
There is a definite ethnic trend in the prevalence of the type of

malocclusion in India from north to south. The prevalence of class II
malocclusion in Bangalore and Thiruvananthapuram is reported close
to 5%, which is much low compared to the 10–15% class II
malocclusion in Delhi and Haryana. Also, the southern population has
an ethnic affinity for bimaxillary protrusion. Children from Iran
exhibited a rather high prevalence of class II (27.5%) and class III
(7.8%) malocclusion compared to North Indian children.63
Prevalence of malocclusion in tribal
population65
Indian tribal children living in remote villages of Mandu in the central
part of India exhibited a very low prevalence of malocclusion and its
traits, as compared to the urban Indian children. The majority of them
(85.6%) were free from any anomalies of occlusion. The prevalence of
malocclusion was only 14.4%. A majority of these (10.5%) were of
mild malocclusion, and a lesser number (3.7%) had moderate to severe
malocclusion. The ‘handicapping malocclusion’ was observed in 0.2%
only (Fig. 3.4). The prevalence of distomolar (class II) relationship was
3.8% of which full cusp distoclusion was 0.6% only. The overjet and
overbite were 0.4% and 0.3%. The crowding of anterior teeth in the
maxillary arch was 6.4% and in the mandibular arch 7.8%.
FIGURE 3.4 Distribution of normal and abnormal malocclusion in
tribal children in India.
The treatment needs of a population group cannot be known from the
data on the prevalence of malocclusion alone. The prevalence of
malocclusion is aimed to record traits of occlusion/malocclusion as
observed by a professional irrespective of their implications on quality
of oral health and or social or aesthetic concerns of the individual. The
mere existence of a dental irregularity like a diastema or rotation of a
tooth may not warrant orthodontic treatment until there is a concern
for it or it is causing a definitive oral health hazard such as a traumatic
bite or functional occlusal interferences. The concerns for a dental
deformity may be least for one individual while it may cause anxiety
in another. The same dental malocclusion may be of no significance to
a person at a given age, say during childhood but may be of great
concern at a different point of time/age when he grows up or is
motivated by the need for his vocation or social needs.
To quantify malocclusion, each trait of malocclusion is given a
numerical value and weight. The summed up single score/value
signifies the quantification of malocclusion called index. These
malocclusion indices were essentially developed as a tool of
prioritisation of treatment in a social setting for public health system
mainly in Europe and Scandinavia and not as a tool to record the
prevalence of malocclusion in the first instance.21
Earlier studies used methods developed by Bjork et al.,6 HMAR—
Handicapping Malocclusion Assessment Record,66 Swe NBH—
Swedish National Board of Health (1967).67 Index of Orthodontic
Treatment Needs (IOTN) developed in UK67,68 (1989) has been widely
used in UK and Europe while the Scandinavian countries used
Norwegian method, NorHS—Norwegian Health Service70 and
Swedish method Swe NBH—Swedish National Board of Health.65
Other indices that have been in frequent use are:
MSI—Malocclusion Severity Index71

DAI—Dental Aesthetic Index72,73
ICON—Index of Complexity Outcome and Need74
The need for orthodontic treatment across population groups from
different parts of the world75–99 are given in Tables 3.6–3.9. It is clear
that 25–40% of the children with malocclusion fall under the category
of moderate to severe need for treatment. According to estimates from
these tables, it appears that at least 5% adolescents have some kind of
malocclusion of nature, which requires urgent treatment and for
nearly one-third of the children, treatment is desirable.
Table 3.6
Orthodontic treatment needs in America, Brazil and
Australia
Table 3.7
Orthodontic treatment needs in Scandinavia and Europe
B, Boys; G, Girls; M, Male; F, Female.
Table 3.8
Orthodontic treatment needs in Asia, Middle East and
Africa
MSI, Malocclusion Severity Index; IOTN, Index of Orthodontic Treatment Need; IPION, Index
for Preventive and Interceptive Orthodontic Needs; HMAR, Handicapping Malocclusion
Assessment Record; NOTI, Norwegian Orthodontic Treatment Index, Nor HS, Norwegian
Health Service; WHO, World Health Organisation; FDI, World Dental Federation; Exam,
Based on orthodontic evaluation of need; DAI, Dental Aesthetic Index; ICON, Index of
Complexity Outcome and Need.
Table 3.9
Orthodontic treatment needs of Indian children
Each of the indices has its criteria and nomenclature to denote need
of treatment. The Dental Aesthetic Index (DAI) has been used to
assess orthodontic treatment needs by several researchers in the recent
past96–104 (Table 3.9). Several studies are now pouring in from
different parts of the world on orthodontic treatment needs using
treatment priority indices.
Of the six studies to assesses orthodontic treatment needs in India
and Nepal, four used DAI, and other two have used IOTN. Chauhan
et al.101 conducted a cross-sectional study of 1,188 school going
children in a hilly state of India. He observed orthodontic treatment
need in 12.5% children only while in the neighbouring state of
Haryana, Damle102 reported 23.6% children had the dental anomaly of
which medium, high and very high treatment needs were 15%, 5%
and 3.4%. Tak et al.103 and Sanadhya et al.104 reported nearly one-
third of 33% children in need of orthodontic treatment among
children in Udaipur and fisherman in Gujarat. A smaller proportion of
children needed orthodontic treatment when evaluated with IOTN in
Himachal Pradesh based on the aesthetic component of IOTN
whereas little need for orthodontic treatment was in 86.15%, moderate
need in 8.90%, and great need in 4.95%.100 However, when evaluated
professionally for dental health component (DHC) of the IOTN, little
need was recorded in 31.6% and moderate need in 30.85% children.
In Dubai,98 school children hailing from many countries and ethnic
groups were assessed using IOTN. Researchers reported that 53.2% of
the study sample would benefit from orthodontic treatment, and
14.4% were profiled, as ‘treatment required’. Similar observations
were made in Russia97 by using the indices IOTN and DAI. The need
for orthodontic treatment was 38.8% and 54.5%, respectively. In
Brazil,96 the prevalence of normative orthodontic treatment need in
12-year-old children assessed with the DAI was 65.6%. The need
perceived by the caregivers was 85.6%, and by the children was 83.8%.
In Casablanca, Morocco99, 84.2% of the subjects needed some
orthodontic treatment, and 15.8% needed no treatment. The
assessment was carried out using Bjork’s method and the Index of
Swedish National Board of Health (SweNBH).
It appears that although objective and quantification of
malocclusion have been evolved, the data on ‘orthodontic treatment
need’ varies according to the each of the index used.
A major influencing factor seems to be a discrepancy between the
aesthetic component of treatment, which is the ‘perceived need’ by a
individual and ‘need of treatment’ evaluated by a professional. For
example, in Himachal Pradesh, a hilly town of India, the need for
treatment using aesthetic component (AC of IOTN) index was low
while dental health component was much higher.
Similarly, in a study at Belgium,105 it was suggested that IOTN as a
clinical assessment tool for orthodontic treatment need should be
reinforced by OHRQoL measures, like the oral aesthetic subjective
impact scale (OASIS) expressing patients’ perceived treatment need.
It is obvious that certain types of malocclusions should receive high
treatment priority, though they may not be assessed as high on
aesthetic need: These conditions are, severe deep bite, reverse overjet,
skeletal maxillary protrusion, developing pre- and post-normal
occlusions. Other deviations that fall under the urgent need for
treatment include cross-bites with functional shift, impacted canines,
impaction of maxillary incisors and extreme aplasia.
Need for orthodontic treatment is greatly influenced by cultural,
socioeconomic differences and therefore those with the mild or
moderate type of deformities falling under single score cannot be
equated across the world.
Key Points
The frequency of occurrence of class I malocclusion is greatest
followed by class II and class III. However class II malocclusion is the
most common reason for seeking orthodontic treatment.
Angle’s classification and prevalence are not the true representation
of the treatment needs of the given population.
Orthodontic indices, which have been developed to quantify the
malocclusion and give either a numerical value or scale, have been
greatly utilised in UK, Europe, Australia and Scandinavia to prioritise
the treatment in social setting and in public health delivery of care.
IOTN is in vogue for recording the malocclusion needs of the
population. IOTN takes in consideration both the dental health and
aesthetics components of the malocclusion (DHC, AC).
These indices cannot be universally applied for these do not
consider the racial and ethnic affiliations of the occlusion. Some of the
racial and ethnic characteristics of the face and occlusion should be
accepted by the professionals as norm and not necessarily the
malocclusion.
It is obvious that certain malocclusion types need urgent treatment
while treatment for minor deviations depends on individual’s social
and aesthetic needs
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CHAPTER 4
Classification and methods of
recording malocclusion
O.P. Kharbanda
CHAPTER OUTLINE
What constitutes a malocclusion?
Why classify malocclusion?
Historical review
Georg Carabelli’s Classification
Norman Kingsley
Intra-arch malocclusion
Inter-arch malocclusions
Systems of classification of malocclusion
Angle’s concept of malocclusion
Ideal facial beauty
Functional class III or pseudo class III
Controversy of subdivision
Bimaxillary protrusion
Bidental protrusion
Lischer’s modification
Dewey’s modification
Strang’s classification based on the body of mandible
Skeletal classification
Simon’s classification and canine law
Limitations of Simon’s classification
Incisor classification (1964)
Katz’s premolar classification (1992)
Advantages
Disadvantages
Ackerman and Proffit’s classification (1969)
Classification in primary dentition (Baum 1959)
Flush terminal plane relationship
Key Points
The human face has infinite variations in its constitution and
expression. Heterogeneous mixing of people from across the globe,
the gene–environment interaction and genetic mix-up has led to ‘new
look’ faces, wherein jaw size, dentition and occlusion are significant
components. There are ethnic variations in the profile (e.g. in India,
people from the north, south and northeast are of different ethnic
stock and therefore exhibit significant variations in face form).
What constitutes a malocclusion?

In the strict sense of definition, any deviations from normal occlusion
(Fig. 4.1) can be termed as malocclusion, which may vary from a very
slight variation of a tooth position in the arch to significant
malpositioning of a group of teeth or the jaws.
FIGURE 4.1 Class I molar and canine relation, normal overjet,

and overbite.
The norm when referring to occlusion is itself a range, but what

quantum of deviation constitutes a malocclusion is still not clearly
defined. The evaluation and definition of occlusion are determined by
the intra-arch dental alignment and arch forms, the inter-arch
relationship of each of the individual teeth, and their harmony with
underlying skeleton bases (i.e. maxilla, mandible and cranium). It is
expected that normal occlusion comprises a normal overjet and
overbite, buccal occlusion and compensating curves besides alignment
along the line of occlusion (Figs. 4.2 and 4.3).
FIGURE 4.2 Overjet: labial/buccal overlap; overbite: vertical
overlap.
FIGURE 4.3 Buccal overjet, cross-bite and scissors bite.
(A) Normal buccolingual relationship of the posterior teeth showing
buccal overjet. (B) Bilateral buccal cross-bite, (C) Unilateral scissors
bite.
The soft-tissue integument of the face should be in harmony with

dentition and occlusion leading to a pleasing profile. All muscle
attachments including functional components should harmonise to
produce optimum aesthetics and function. The norm therefore
includes preservation of the health and function of the components.
These functions include speech, deglutition, respiration and
mastication.
The concept of malocclusion, therefore, is greatly influenced by
definition of the norm and its range. There could be an innumerable
number of deviations that may be within the defined range while
many beyond it would be termed as malocclusion.
Malocclusion deviations may be limited to within the arch and/or as
a single or a group of teeth with those in the opposite arch in the
anteroposterior (sagittal), lateral (transverse) and vertical
(superoinferior) planes of space.
The concept of aesthetics and beauty varies across the globe and
races, while some features could be peculiar to ethnicity. A median
diastema is considered to be a sign of beauty in some African races.
The concept of beauty has evolved with evolution and civilisation. It
changes with time to some extent.
Why classify malocclusion?

For ease of communication among professionals and understanding
the nature of deviations, terminologies have been coined to categorise
malocclusion. A classification is specific to an aim, which includes
documentation, and to some extent, an approach to a treatment plan.
Strang (1938)1 suggested that the classification of malocclusion
should also include a direction to a systematic plan of treatment.
He said ‘I would define classification as a process of analysing cases
of malocclusion for the purpose of segregating them into a small
number of groups, which are characterised by certain specific and
fundamental variations from normal occlusion of the teeth; which
variations become influential and deciding factors in providing the
fundamental data for the preparation of a systematic and correlated
plan of treatment’.
Historical review2,3
The earliest scientific description of malocclusion was given by
Samuel S. Fitch in his book A System of Dental Surgery (1829). He was
the first to classify malocclusion into four states of irregularity.
Friedrich Christopher Kneisel (1836) in Der Schiefstand der Zähne
(Dental malpositioning) described malpositions of the teeth as general
obliqueness and partial obliqueness when all teeth or only some teeth
in the arch are malpositioned. Jean Nicolas Marjolin (1832–39)
differentiated the obliqueness of teeth and anomalies of the dental
arch.
Georg Carabelli’s Classification

Georg Carabelli (1842) described abnormal relationships of the upper
and lower dental arches in a systematic manner and coined the term
Edge-to-edge Bite and Overbite.
His classification was based on the positions of incisors and canines
(Box 4.1).
Box 4.1 Classification of malocclusion by Georg

Carabelli
Mordex normalis: normal occlusion

Mordex rectus: edge-to-edge occlusion
Mordex apertus: open occlusion
Mordex prorsus: protruding occlusion
Mordex retrosus: retruding occlusion
Mordex tortuosus: zig-zag occlusion
Norman Kingsley
Norman Kingsley (1880),4 an eminent orthodontist, contented himself
by classifying malocclusion into two broad categories based on
aetiology:
• developmental malocclusion
• accidental malocclusion.
Edward H. Angle (1899, 1900, 1906, 1907)5–8 gave a detailed

description of malocclusion breaking it down into three classes based
on the assumption that the position of the maxillary first molar and
canine were stable in the maxilla and the corresponding lower
teeth/jaw showed deviations in anteroposterior positions. He
classified all malocclusions into class I, class II and class III. Later on,
in his work, he gave a detailed description of normal occlusion, line of
occlusion, facial lines and quantification of each class, regarding the
relationship between full-cusp deviation and half-cusp deviation.
Other classification systems or modifications are:
1. Calvin Case (1905–21)9,10 evolved a rather complicated

classification in which anatomical groups were broken down
into five classes from the treatment standpoint of view.
2. Benno Lischer (1912)11 developed the terms Distocclusion and
Mesiocclusion.
3. Martin Dewey (1915)12 modified and developed four different
types of Angle’s classes.
4. Paul Simon’s (1920)13–16 philosophy towards the classification
of malocclusion was based on gnathostatics and canine law.
5. Ballard and Wayman (1964)17–19 developed the British
classification based on incisor overjet, which was based on the
work of Backlund and further modified by Williams and
Stephens (1992).
6. Morton Katz (1992)21,22 based his classification on premolars.
7. Ackerman and Proffit’s classification (1969)23 included a Venn
diagram.
Intra-arch malocclusion (Figs. 4.4–4.6)
Angle used the following nomenclature to describe deviations from
normal tooth positions (Box 4.2).
Box 4.2 Nomenclature for abnormal tooth

positions
1. Buccal or labial occlusion: a tooth outside the line of occlusion

2. Lingual occlusion: a tooth inside the line of occlusion
3. Mesial occlusion: a tooth farther forward (mesially) than normal
4. Distal occlusion: a tooth farther backward (distally) than normal
5. Torso occlusion: a tooth turned on its axis
6. Infra occlusion: a tooth insufficiently elevated in its socket
7. Supra occlusion: a tooth occupying a position of great elevation
Other tooth malpositions can be described as:
1. Rotation: a tooth movement around its long axis

2. Transposition: a situation where two teeth have exchanged places
FIGURE 4.4 Traits of malocclusion.

Crowding of teeth.
FIGURE 4.5 Spaced anterior dentition in the maxillary arch.

(A) Proclination of maxillary incisor teeth. (B) Retroclination of maxillary
incisor teeth.
Inter-arch malocclusions
Inter-arch malocclusions can be in the sagittal, vertical or in transverse
plane. Whereas most of the classification systems described are in the
sagittal plane the other planes are given in the following subsections.
Vertical plane malocclusions

Deep bite or increased overbite: Deep bite refers to a condition where
there is an excessive vertical overlap of the upper to the lower anterior
teeth (Fig. 4.7).
FIGURE 4.7 Traits of malocclusion: Deep bite in which the
maxillary incisors are retroclined.
Open bite: Open bite is a condition where there is no vertical overlap

between the upper and lower teeth. Thus, a gap may exist between the
upper and lower teeth when the patient bites in centric occlusion.
Open bite can be in the anterior or posterior region (Fig. 4.8A, B, C, D).
FIGURE 4.8 Open bite.

(A) Edge-to-edge bite with a tendency for open bite. (B) Open bite. (C)
Moderate open bite. (D) Severe open bite.
The terms Supraocclusion and Infraocclusion are used for vertical

problems in dentition. Supraeruption of teeth like a maxillary molar
erupting below the line of occlusion and infraocclusion when a tooth
or teeth do not erupt up to the line of occlusion (Fig. 4.9A, B).
FIGURE 4.9 Supra and infra occlusion.
(A) Supraocclusion of the left maxillary first molar. (B) Infraocclusion of
the maxillary premolars on left side.
Transverse plane malocclusions include various types of cross-bites

and scissor bites.
Cross-bite: Cross-bite refers to an abnormal transverse relationship
between the upper and lower arches. Cross-bite may affect a single
tooth, a group of teeth or an entire arch. It may affect anterior (Fig.
4.10A, B) or posterior teeth on their own or both in combination.
Posterior cross-bite can be unilateral or bilateral (Fig. 4.10C).
(A) Anterior cross-bite of one tooth. (B) Group of anterior teeth. (C)
Bilateral buccal cross-bite. (D) Scissors bite.
Scissors bite: Scissors bite refers to a condition in which a tooth or

group of teeth in the mandibular buccal arch are lingual to the lingual
cusps of the maxillary teeth (Fig. 4.10D).
Rotation and torsiversion. A tooth may be so rotated along its long
axis that its lingual surface almost appears to be labial (Fig. 4.11).
FIGURE 4.11 Severe rotation and torsiversion of the right
maxillary incisor.
Sagittal plane malocclusions

Sagittal plane malocclusions include increased overjet and anterior
cross-bite.
Systems of classification of
malocclusion
Angle’s concept of malocclusion
Edward H. Angle considered the first permanent molar’s position as a
reference to judge normality and very lucidly described it as:
‘In normal occlusion, the mesiobuccal cusp of the upper first molar
is received in the sulcus between the mesial and distal buccal cusps of
the lower, the slight overhanging of the upper teeth bringing the
buccal cusps of the bicuspids and molars of the lower jaw into the
mesiodistal sulci of their antagonists, while the upper central incisors,
lateral incisors and cuspids teeth overlap the lower anterior teeth
about one-third the length of their crowns. The mesial and distal
inclines of the mesiobuccal cusp of the upper first molar are received
between the mesial and distal buccal cusps of the lower first molar,
and the inclines of the distobuccal cusp are received between the
distobuccal cusp of the first lower and the mesiobuccal cusp of the
second lower’ (Fig. 4.12).
FIGURE 4.12 Key ridge and class I molar relation.
Later, Angle (1906)7 published his classic article in Dental Items of

Interest entitled ‘The upper first molars as a basis of diagnosis in
orthodontics’ where he espoused the virtues of the maxillary first
molars. He believed the upper first molars were the key to occlusion
because the upper first molars
1. Are the largest in size.

2. Are the firmest in their attachment.
3. Have a key location in the dental arches.
4. Help to determine the dental and skeletal vertical proportions
due to the height of their crowns.
5. The maxillary first molars occupy a normal position in the
arches far more often than any other teeth because they are the
first permanent teeth and are less restrained in taking their
position.
6. The maxillary first molars also more or less control the
positions of other permanent teeth.
7. Have the most consistent timing of eruption.
8. Determine the inter-arch relationship of all teeth upon their
eruption and locking with the mandibular first molars.
Angle’s conviction that the first molar position in the maxillary arch
was constant was also supported by Atkinson24 who suggested the
relative constancy of the maxillary first molar and its association with
a bone buttress of the zygomatic process under its maxillary process,
which he called the key ridge. Atkinson has shown that maxillary first
molars bear the greatest stresses of occlusion and mastication; they are
located in the key ridge, the area of the maxilla with condensed bone.
In deciduous dentition, it is the second deciduous molar from which
the permanent dentition develops, and the position of the key ridge
moves back to the first molar as an adjustment with function.
For comparison with the normal, two reference norms are of
particular importance: (i) the line of occlusion of the dentition and (ii)
the harmony line of the face.
Angle wrote:
i. The line of occlusion. ‘When the teeth are in normal occlusion

the line of greatest occlusal contact will be found to pass over
the mesial and distal inclined planes of the buccal cusps of the
molars and bicuspids and the cutting edges of the cuspids and
incisors of the lower arch, and along the sulcus between the
buccal and lingual cusps of the upper molars and bicuspids,
henceforward, crossing the lingual ridge of the cuspids and
the marginal ridges of the incisors at a point about one-third
the length of their crowns from their cutting edges. This we
shall call the line of occlusion’.
Angle continued, ‘This line describes more or less of a parabolic
curve, and varies somewhat within the limits of the normal,
according to the race, type, temperament, etc. of the individual’
(Fig. 4.13).
ii. The harmony line. Angle gave great importance to the soft-
tissue profile and believed that malocclusion destroyed the
profile. He considered the profile of Apollo, the Greek
mythological God, as so faultless in form that to change it in
the least would be to mar the wonderful harmony of
proportions. As Fuseli puts it, ‘Shorten the nose by, but the
tenth of an inch and the God would be destroyed’ (Fig. 4.14).
FIGURE 4.13 Line of occlusion.

As described by Edward Angle (1899), the line of occlusion is a
smooth, parabolic curve passing through the central fossa of each
upper molar and across the buccal cusps and incisal edges of the
lower teeth, thus specifying the occlusal as well as the inter-arch
relationship once the molar position is established.
FIGURE 4.14 Harmony line of Apollo.
Ideal facial beauty

Angle also described other parts of the face, ‘Ideal facial beauty
consists in a short, finely curved and prominent upper lip; a full,
round, but less prominent lower lip, and a strongly marked
depression at the base of the lower lip giving roundness and character
to the chin’. Angle gave special importance to the lower part of the
face, so much so that he found that a beautiful outline is a constant
feature in handsome profiles while the upper half of the face may
show variations.
The harmony line in such profiles is a straight line extending from
the most prominent points of the frontal (glabella) and mental (chin)
prominences, and the middle of the ala of the nose.
Angle used the Roman numerals I, II and III to designate the three
main classes of anteroposterior arch (i.e. Class I or normal, Class II or
distal and Class III or the mesial relationship of the cusps of the
mandibular first molars to the maxillary first molars). He employed
the Arabic numerals 1 and 2 to denote divisions of the classifications
and termed unilateral deviations as subdivisions.
a. Class I. Relative position of the dental arches, which are
mesiodistally normal, and malocclusion is usually confined to
the anterior teeth (Fig. 4.15).
b. Class II. Retrusion of the lower jaw, with distal occlusion of the
lower teeth.
i. Division 1. Narrow upper arch, with lengthened and
prominent upper incisors; lack of nasal and lip
function as seen in people who breathe through
their mouths (Fig. 4.16A).
Subdivision. Same as above, but with only one lateral
half of the arch involved, the other being normal, also
seen in people who breathe through their mouths
(Fig. 4.16B).
ii. Division 2. Slight narrowing of the upper arch;
bunching of the upper incisors, with overlapping
and lingual inclination; normal lip and nasal
function (Fig. 4.13, Fig. 4.16C).
Subdivision. Same as above, but with only one lateral
half of the arch involved, the other being normal;
normal lip and mouth function.
c. Class III. Protrusion of the lower jaw by at least one premolar
width, mesial occlusion of the lower teeth; lower incisors and
cuspids inclined lingually (Fig. 4.12).
Subdivision. Same as above, but with only one lateral half of the
arch involved, the other being normal (Fig. 4.17).
FIGURE 4.15 Angle’s classification.
Class I malocclusion.
FIGURE 4.16 Class II malocclusion.

(A) Class II, division 1 malocclusion. (B) Class II subdivision
malocclusion. (A) Note class II molar and canine relation on right side
(R) and (B) class I molar and canine on left side (L). (C) Class II,
division 2 pattern of malocclusion. Note deep bite, retroclined upper
central incisors, and proclined upper lateral.
FIGURE 4.17 Class III malocclusion.
Functional class III or Pseudo class III

This condition requires special mention because treatment of this class
of malocclusion is entirely different from the true class III situation.
The differentiating feature of this condition is that the dental occlusion
is class III in maximum intercuspation or habitual occlusion, while it is
actually class I in centric occlusion. Here the disturbance is a
functional one, where as a result of dental interference, the mandible
is deviated anteriorly to achieve a ‘bite of convenience’. Thus, a static
evaluation will give a class III reading, but functional examination at
postural rest and at first dental contact shows that the mandible is
closing in a normal class I way (Fig. 4.18).
FIGURE 4.18 Functional component in class III malocclusion.

(A) Initial contact during closure. (B) Incisor in full cross-bite in centric
occlusion.
Important diagnostic features for this condition can be located in

study models, such as obvious occlusal interference in the form of
single- or multiple-tooth cross-bite and a severely constricted
maxillary arch both anteroposteriorly and transversely.
Angle also recognised the existence of cases in which one side is
class II and the other side class III. However, he discounted these as
being very rare.
The virtues of Angle’s classification are given in Box 4.3. Despite
several limitations (Box 4.4), this system is of great use in clinical
settings and in orthodontic research.25–28-->
Box 4.3 Virtues of Angle’s classification
1. Simplicity
2. It is practical, easy to understand and can be applied in day-to-
day clinical practice
3. Three anteroposterior classes can also be applied to underlying
skeletal types seen on a cephalogram (i.e. class I, class II, and
class III skeletal relations); although the dental relationship
may or may not confirm to underlying skeletal malocclusion or
vice versa
4. Angle had a brilliant eye for normality and in the pre-
cephalometric era could identify dental or skeletal abnormal
situations
5. The classification has stood the test of time and is the most
widely used classification
Box 4.4 Drawbacks of Angle’s classification2 4 – 2 8

Angle’s classification suffers from many limitations:
1. Angle grouped all possible malocclusions in three classes of

anteroposterior deviations. The range of discrimination from
class I to class II (disto) to class III (mesio), which was initially
full-cusp width of the maxillary first molar (1899), was further
modified to half-cusp width (1904, 1907).
2. Angle evaluated all teeth at the harmony line and initially used
the maxillary first molars and canines as reference points
(1899), which later was modified with greater emphasis given
to the maxillary first molar (1904, 1907).
3. Angle’s conviction that the maxillary first molar was the most
stable landmark was later found not to be consistently true.
There can be anatomical variations in the location of the
maxillary first molar in the maxillary arch and the jaw
bones.24,25
4. Angle presupposed that all malocclusions were predominantly
exhibited in the anteroposterior direction and accordingly
classified them on the basis of sagittal deviations. Vertical and
transverse deviations were not considered.
5. Angle’s classification is based on the dentition alone and does
not take into account the underlying craniofacial relationship.
6. The classification does not indicate the severity and complexity
of malocclusion and hence, does not point out the need for
treatment.
7. The classification does not draw attention to the aetiological
factors associated with malocclusion.
8. The classification cannot be applied to deciduous dentition and
requires considerable experience for its correct evaluation in
the transition and deciduous dentition stages.
9. Not suitable for measuring orthodontic treatment needs.
10. Angle’s classification is difficult to apply when there is an
associated discrepancy between the right and left sides or where
tooth movements have occurred because of factors such as
crowding and premature loss of deciduous teeth.
11. Inter-examiner and intra-examiner errors in categorising Angle
class II, division 2 malocclusions are relatively high.27
12. The classification does not consider bimaxillary/bidental
malocclusions.
Angle had a brilliant eye for normality, and even in those days
when cephalometrics was not known he could identify and classify
normal and abnormal dental as well as skeletal situations. Angle had a
logical and irrefutable philosophy on occlusion, on which he based his
classification system. He simplified his overall philosophy in his
version of classification, which even after being criticised and
modified by many authors has stood the test of time.
Controversy of subdivision
There are differing opinions in the literature regarding the designation
of side in subdivision cases. Clinicians all over the world feel that
some room for ambiguity in classifying subdivision cases is still
present even after decades of using this classification. According to
Angle, the subdivision is the occurrence of unilateral malocclusion
whereby one side is normal and the other is abnormal, but he did not
mention whether the subdivision is the normal or abnormal side.
Siegel in 200229 did a survey in the United States on this issue and
found that about 65% of respondents thought the subdivision side
was the affected or class II side, while the remaining 35% had
differing or non-committal opinions. In general, opinion favours the
affected side as the -subdivision.
Another type of malocclusion is bimaxillary protrusion, in which both
the jaw bases are placed ahead on the anterior cranial base. Here both
the SNA and SNB angles are increased, but the angle ANB is in the
normal range.
Bidental protrusion
A category often used in clinical practice to describe tooth positions in
the upper and lower jaws is bidental protrusion. In this situation, the
anterior teeth in the maxillary and mandibular jaws are abnormally
proclined. Such a situation may be encountered either in skeletal class
I, class II, or class III cases.
Lischer’s modification11
Lischer (1912) substituted the terms class I, class II and class III given
by Angle with the terms Neutro-occlusion, Disto-occlusion, and
Mesio-occlusion. He devised a suffix version to describe
malpositioned teeth as follows:
1. Linguoversion
2. Labioversion
3. Mesioversion
4. Distoversion
5. Infraversion
6. Supraversion
7. Torsiversion or twisted tooth
8. Perversion or impacted tooth
9. Transversion or wrong sequential order.
Dewey’s modification12
Dewey (1915) divided Angle’s class I into five types and Angle’s class
III into three types. There were no modifications for class II. He
considered the same molar relationship as in Angle’s classification.
Modifications of class I malocclusion
Type I. Crowded anterior teeth

Type II. Maxillary incisors in labioversion
Type III. Anterior cross-bite
Type IV. Posterior cross-bite
Type V. Molars are in mesioversion due to shifting following loss
of a tooth anterior to the first molars; all other teeth are in a
normal relationship.
Modifications for class III malocclusion
Type I. The dental arches are well developed and appear normal,
but have an edge-to-edge incisor relationship.
Type II. Normal incisor overlapping is present. Usually, the lower
anterior teeth are crowded and placed lingually, thereby
presenting as a normal sagittal relationship in the anterior
region.
Type III. The maxillary incisors are in cross-bite. The maxillary
arch is usually underdeveloped, while the mandibular arch is
either well developed, normal, or overdeveloped with teeth in
normal alignment. Consequently, there is crowding in the
anterior region.
Strang’s classification based on the
body of mandible1
Strang (1938) emphasised that the body of the mandible should be the
determining factor in classification and not the teeth. He further
clarified that it is difficult to make an observation on jaw placement
alone since it would be extremely subjective. He emphasised six
processes that arose in a case study and devised a classification on the
basis of this case study, one that would determine the true
classification of each case and furnish data to outline a comprehensive
plan of treatment.
He suggested visual demonstration of overlap among parts of a
complex structure like malocclusion. A collection or overlap is called a
set, and this set would have some common properties of both.
These six processes that arose in the case study for the purpose of
classification are:
1. Study of the inclined plane relationship.

2. Study of the axial inclination of each dental unit.
3. Visual analysis of the relationship of the interproximal line of
the central incisors in the two arches and comparison of the
relationship of these lines to the midsagittal plane of the head.
4. Noting any rotated buccal teeth, especially the maxillary
molars.
5. Study of intraoral and profile radiographs.
6. Study of facial photographs, from both frontal and profile
view.
With these fundamental facts in mind, definitions of the various

classes can be given as follows:
Class I. All cases of malocclusion in which the body of the mandible
and its superimposed denture are in a correct mesiodistal relationship
with the cranial anatomy. Of these two factors, the position of the
body of the mandible is more important.
Class II, division 1. Cases of malocclusion in which the body of the
mandible and its superimposed denture are in a distal relationship
with the cranial anatomy and in which the maxillary incisors are in
labial axial inclination.
Class II, division 1, subdivision. Cases of malocclusion in which the
body of the mandible and its superimposed dental arch is in a distal
relationship with the cranial anatomy on one side only and in which
the maxillary incisors are in labial axial inclination.
Class II, division 2. Cases of malocclusion in which the body of the
mandible and its superimposed denture is in a distal relationship with
the cranial anatomy and in which the maxillary central incisors are in
vertical or lingual axial inclination.
Class II, division 2, subdivision. Cases of malocclusion in which the
body of the mandible and its superimposed denture are in a distal
relationship with the cranial anatomy on one side only and in which
the maxillary central incisors are in vertical or lingual axial inclination.
Class III. Cases of malocclusion in which the body of the mandible
and its superimposed dental arch is in a mesial relationship with the
cranial anatomy.
Class III, subdivision. Cases of malocclusion in which the body of the
mandible and its superimposed dental arch is in a mesial relationship
with the cranial anatomy on one side only.
Skeletal classification (Fig. 4.19 A–C)
Skeletal classification is a working classification that has evolved over
the years as a result of clinical experience. In fact, it is based on
Angle’s classic classification and Strang’s interpretation of it.
FIGURE 4.19 Skeletal classification of malocclusion.

(A) Skeletal class I malocclusion. (B) Skeletal class II malocclusion. (C)
Skeletal class III malocclusion.
Skeletal class I: An orthognathic face (Fig. 4.19A) with the following

important features:
1. Straight profile
2. Normal ANB angle: 2° ± 2
3. Normal facial angle (downs): 82–95° (mean 87.3°)
4. Angle of convexity (downs): +10 to −8.5° (mean 0°).
Skeletal class II: A retrognathic face that may be due to a prognathic

maxilla or retrognathic mandible (Fig. 4.19B). Important features are:
1. Convex profile
2. Increased ANB angle
3. Reduced facial angle
4. Increased angle of convexity
5. Severe backwards rotation of the mandible may also be
present.
Skeletal class III: A prognathic face at chin that may be due to a

prognathic mandible or retrognathic maxilla (Fig. 4.19C). Possible
significant features are:
1. Concave profile
2. Prominent chin
3. Decreased ANB angle
4. Increased facial angle
5. Reduced angle of convexity.
Simon’s classification and canine
law13–16
Simon (1920) was very critical of Angle’s classification since it did not
correctly record the relationship of dental malocclusion in relation to
the cranium. Angle also did not record malocclusion three
dimensionally.
Simon developed a technique to demonstrate and record the
relationship between the teeth, occlusion and the supporting bony
framework based on the instrument and technique of the
gnathodynamometer. Simon’s philosophy for his classification of
malocclusion was based on the canine law, which implied that in
normal cases, the maxillary canines are in a definite relationship with
the Simon plane in the cranium. The relationship is called the ‘law of
the canine’. He described malocclusion in relation to three reference
planes (Fig. 4.20):
1. The median sagittal plane. An anthropometric plane that

passes through the nasion–basion in the skull. However, in
living organisms, Simon suggested the midpalatal raphe as a
reference point to imagine the midsagittal plane of the
face/cranium.
2. The Frankfort plane. Determined by eye to ear points with the
eye point being the lowest point on the inferior margin of the
orbits. The ear point is located at the intersection of the helix
and margin of the tragus of the ear.
3. The orbital or Simon plane. A plane perpendicular to the
interpupillary plane and median plane, it is determined by the
above geometry and passes through the point where the line
joining the orbital plane would intersect the constructed
median plane.
FIGURE 4.20 Simon’s philosophy for the classification of
malocclusion was based on canine law.
He described malocclusion in relation to three reference planes: 1. The
median sagittal plane. 2. The Frankfort plane. 3. The orbital or Simon
plane.
Malocclusion is defined and classified in reference to these three

planes in the anteroposterior, vertical and transverse dimensions.
According to Simon, the orbital plane passes through the distal axial
aspect of the canine in a normal arch relationship. This is known as
the law of the canine.
The basis of Simon’s classification is given in Box 4.5. In addition to
the preceding differential diagnostic information, the relation of the
vault of the palate to the face and the cranium may also be determined
by means of the three planes of the face.
Box 4.5 Basis of Simon’s classification
1. The arch form and inclination of the tooth axis are determined
from the median sagittal plane:
Contraction: a part or the entire dental arch is contracted towards
the raphe or median sagittal plane. The abnormality may be
mandibular, alveolar, dental, anterior, posterior, unilateral or
bilateral.
Distraction: a part or all of the dental arch is wider than usual
from the raphe or median sagittal plane.
2. The angle between the Frankfort horizontal and the occlusal
plane, the form of the occlusal curve, and the inclination of the
teeth axes are determined from the Frankfort plane:
Attraction: the distance between the occlusal plane and the
Frankfort horizontal is comparatively shorter than normal. This
distance is as a rule normally shorter in younger than older
persons and in some ethnic groups.
Abstraction: the distance between the occlusal plane and the
Frankfort horizontal is comparatively longer than normal.
3. Sagittal symmetry and inclination of the axes of the teeth are
determined from the Simon plane:
Protraction: the teeth, one or both dental arches and/or jaws are
too far forward. Normally, the orbital plane passes through the
distal incline of the canine.
Retraction: the teeth, one or both dental arches and/or jaws are
retruded too far. The orbital plane passes anteriorly to the
canines too far.
Limitations of Simon’s classification

The basis for using the canine as a stable reference landmark has been
shown to be much weaker than using the first molar. The maxillary
canines are the last teeth to erupt in the arch and therefore likely to be
disturbed by several environmental factors. They do not occupy a
stable position in the maxilla in several instances.
Simon’s important contribution was the gnathodynamometer. It
was not sustained for long, since a better method of visualising the
relationship between occlusion and its skeletal bases was developed
through cephalometrics.
Incisor classification (1964)17–19
Ballard and Wayman (1964) devised the incisor classification in the
United Kingdom. This classification was based on the work of
Backlund (1963)18 and concentrated on the overjet and overbite
relationship of the incisors. The shift from molars to using incisors as
the basis for classification was felt necessary because the incisors are
easy to examine and overjet and overbite can be recorded rapidly with
a basic knowledge of occlusion.
The incisor classification was found to be a useful means for a quick
representation and communication of occlusion. Hence, it was
incorporated into the British Standards for classification for
epidemiological usage by general dentists (Fig. 4.21, Box 4.6).
FIGURE 4.21 Incisor relationship.
(A) Class I. (B) Class II, division 1. (C) Class II, division 2. (D) Class III.
Box 4.6 British incisor system classification of

malocclusion
1. Class I: the edges of the lower incisors occlude with or lie

directly below the cingulum plateau of the upper central
incisors. If the overbite is incomplete, the lower incisors are
repositioned along their long axis until they meet the upper
incisors.
2. Class II: the edges of the lower incisors lie posterior to the
cingulum plateau of the upper central incisors. There are two
divisions of class II:
i. Division 1: the upper central incisors are of average
inclination or are proclined; overjet is thus increased.
ii. Division 2: the upper central incisors are retroclined;
overjet is usually within normal limits but overbite is
often increased.
3. Class III: the edges of the lower incisors lie anterior to the
cingulum plateau of the upper central incisors.
Katz’s premolar classification
(1992)20–22
Morton Katz (1992) shifted the focus from the molars, canines and
incisors to the region of premolars for the purpose of classifying
malocclusion. He highlighted the shortcomings of Angle’s molar-
based system of classification in which the subjective assessment of
the molar relationship led to reduced inter-examiner and intra-
examiner reliability.
Additionally, he found that if Angle’s system of classification is
followed rigidly, some cases that fall in the class I category do not
have proper buccal occlusion. Hence, he proposed a modification to
Angle’s system of classification based on premolar occlusion, which
used an objective approach of measuring the anteroposterior
discrepancy with calipers.
Premolar class I. Premolar class I is identified when the most anterior
upper premolar fits exactly into the embrasure created by distal
contact of the most anterior lower premolar. This definition applies
when a full complement of premolars is present (i.e. whether one
upper premolar opposes two lower premolars, two upper premolars
oppose one lower premolar, or only one premolar is present in each
quadrant).
In essence, these relationships represent perfect interdigitations and
the value is 0 mm on the calipers (Fig. 4.22A).
FIGURE 4.22 Katz’s premolar classification.
(A) Katz’s premolar classification exhibiting deviation measuring 0 mm,
which is normal class I premolar relation. (B) Katz’s premolar
classification exhibiting premolar relation deviation measuring 3 mm,
which is class II, division 3 deviation.
Premolar class II. Premolar class II is when the most anterior upper
premolar is occluding mesial to the embrasure created by distal
contact of the most anterior lower premolar. The measurement takes a
plus sign (Fig. 4.22B).
Premolar class III. Premolar class III is when the most anterior upper
premolar is occluding distal to the embrasure created by distal contact
of the most anterior lower premolar. The measurement takes a minus
sign (Fig. 4.23A).
FIGURE 4.23 Katz’s premolar classification.

(A) Right-side premolar deviation is half-cusp class II 4-mm deviation
and (B) Katz’s classification as applied to deciduous dentition note 0
mm deviation of deciduous first molars.
For deciduous and mixed dentition cases in class I, the centre axis of
the upper first deciduous molar should split the space between both
lower deciduous molars (Fig. 4.23B).
In the event of an upper first deciduous molar being lost
prematurely, a line drawn through the centre axis of the edentulous
space should bisect the embrasure between the two lower deciduous
molars.
Advantages
The benefits of the premolar classification system are:
1. This system provides a quantitative treatment objective that is

needed to attain excellent buccal occlusion.
2. It provides some flexibility concerning finishing a case in
functional class II or class III buccal occlusion while keeping
buccal interdigitation as the prime goal.
3. In deciduous and mixed dentition cases, the emphasis is
shifted from the permanent first molars to the region of
current importance (i.e. the deciduous molar region).
Disadvantages
The disadvantages of this system are:
1. Premolars are commonly missing, malformed or

supernumerary. Hence measurement is not always possible.
2. Severely rotated and ectopically erupted premolars present
problems.
3. Katz’s premolar classification does not consider deviations of
facial balance and aesthetics.
Ackerman and Proffit’s classification
(1969)23
Ackerman and Proffit’s classification system is a holistic approach to
recording malocclusion based on complete diagnostic records like
dental casts, facial photographs and radiographs including a
cephalometric head film. A classification may be made, however, by
careful observation of the patient’s occlusion and facial appearance.
This would require some experience of careful evaluation of facial
structures and occlusion.
Ackerman and Proffit have synthesised two schemes: Angle’s
classification and the Venn diagram. A Venn diagram offers a visual
demonstration of interaction or overlap among parts of a complex
structure. A collection or group in this system is defined as a set, and
all elements contained in a set have some common properties (Fig.
4.24A).
FIGURE 4.24 (A) The interrelationships of two sets (X and Y). X and
Y in 1 represent sets which have no overlapping qualities. Both sets
are contained in a universe or frame of reference represented by the
box which encloses them. In 2, the sets X and Y share common
qualities in the area of overlap. In 3, all Ys have qualities of X. Y in this
case is called a subset. 4 shows that elements of the universe are
contained in sets X and Y. (B) Sets are defined on the basis of
morphologic deviations in representing features of malocclusion using
a Venn diagram. G, group. Source: Reproduced with permission from
Ackerman JL, Proffit WR. The characteristics of malocclusion: a
modern approach to classification and diagnosis. Am J Orthod
1969;56(5):443–54.
This classification system follows a definite sequence by evaluating

various dentofacial characteristics in steps numbered 1 to 5 as well as
their inter-relationship (Fig. 4.24B). The overlap and inter-relationship
of sets from 3 to 5 results in groups 6 − 9. The overlap of sets 3–4
results in trans-sagittal, 3–5 transvertical, 4 and 5 sagittovertical, and 3
− 5 in transverse sagittovertical groups.
Step 1. Group 1 or the universal group consists of malalignment and
asymmetry in the dental arch(es).
Step 2. Group 2 (profile) is the soft-tissue profile considered here.
Step 3. Group 3 (type) includes deviations in the transverse plane.
Step 4. Group 4 (class) includes deviations in the anteroposterior or
sagittal plane.
Step 5. Group 5 (bite) includes deviations in the vertical plane.
Group 6 includes deviations in the transverse and sagittal planes.
Group 7 includes deviations in the sagittal and vertical planes. Group
8 includes deviations in the vertical and transverse planes. Group 9
includes deviations in the transverse, sagittal and vertical planes.
Thus, by various permutations and combinations of the findings
from these groups, some nine groups of malocclusion may be
identified, wherein group 1 denotes normal occlusion with good facial
aesthetics and group 9 denotes the most complex malocclusion with
deviations in all the categories mentioned above.
This system has significant advantages over Angle’s system of
classification (Box 4.7).
Box 4.7 Strengths and limitations of Ackerman

and Proffit’s classification
Strengths Limitations
1. Only cases with arch length problems are recognised 1. Very detailed and therefore time
2. Influence of the dentition on the profile is considered consuming and tedious
3. Malocclusion can be recorded in all the three planes 2. Does not include aetiology
of space 3. Only the static view of occlusion is
4. Skeletal and dental problems can be segregated at considered
appropriate levels 4. Communication is not easy without
5. Diagnosis is inherent in this methodology thorough knowledge of the system
6. Quantification and assessment of severity of
malocclusion can be done in this system
7. Can serve as an aid in treatment planning
8. Useful teaching tool
9. The classification can be modified to be used on
computers for large surveys and data analysis
10. Computer compatibility makes it amenable to data
storage, retrieval and processing
Classification in primary dentition
(Baum 1959)30
Flush terminal plane relationship (Fig. 4.25)
The mandibular deciduous second molar is usually wider
mesiodistally than the maxillary second deciduous molar
giving rise to a flush terminal plane relationship. When a line is
drawn on the distal surface of the upper second deciduous
molar, it falls along the distal surface of the lower deciduous
second molar. As the first permanent molars erupt, they will be
in an end-on molar relationship in the presence of complete
deciduous dentition having a flush terminal plane. This
relation develops into a class I molar relationship following
exfoliation of the lower deciduous second molar as a result of
mesial migration of the lower permanent first molars.
Distal step. In cases where the upper deciduous second molar is
ahead of the lower deciduous second molar, it gives rise to a
distal step. This can lead to a class II molar relationship in
permanent dentition.
Mesial step. In cases where the lower deciduous second molar is
ahead of the upper deciduous second molar, it gives rise to a
mesial step. This can either lead to a class I molar relationship
or a class III molar relationship in permanent dentition.
FIGURE 4.25 Occlusion during deciduous phase is classified
based on the terminal plane.
(A) Mesial step. (B) Straight terminal plane. (C) Distal step.
Key Points
Malocclusion is essentially a problem of the teeth, jaws and facial
structures affecting all the three dimensions of space. However, it is
more often expressed and recognised first in an anteroposterior
relationship or disturbance in a sagittal relationship. Angle’s method
of three classes has stood the test of time due to its simplicity and ease
of communication.
In essence, a classification is only part of the diagnosis and a means
of communication, both oral or as a transcript, describing the type of
deformity. Angle’s classification is still the most widely used system.
References
1. Strang RHW. A discussion of the Angle’s
classification and its important bearing on treatment.
Angle Orthod. 1938;8:182–208.
2. Weinberger BW. Historical résumé of the evolution
and growth of orthodontics. In: Anderson GM, ed.
Practical orthodontics. 8th ed. St. Louis: Mosby; 1955.
Orthod Dentofacial Orthop. 1990;98(2):176–183:
4. Kingsley NW. Oral deformities. New York: Appleton
& Co; 1880.
Cosmos. 1899;41(18):248–264: 350–7.
6. Angle EH. Treatment of malocclusion of the teeth
and fractures of the maxilla. 6th online ed. Angle’s
system. Philadelphia: SS White Dental
Manufacturing Company; 1900 p. 6–8,44–59.
7. Angle EH. The upper first molar as a basis of
diagnosis in orthodontics. Dent Items Interest.
1906;28:421–426.
8. Angle EH. Malocclusion of the teeth. 7th online ed.
Philadelphia: SS White Dental Manufacturing
Company; 1907.
9. Case CS. Principles of occlusion and dentofacial
relations. Dent Items Interest. 1905;27:489–527.
10. Case CS. Techniques and principles of dental
orthopedia. New York: Leo Bruder; 1963: (reprint of
1921 edition) 16-18.
11. Lischer BE. Principles and methods of orthodontia.
Philadelphia: Lea and Febiger; 1912.
12. Dewey M. Classification of malocclusion. Int J Orthod.
1915;1:133–147.
13. Simon PW. On gnathostatic diagnosis in orthodontics.
Int J Orthod. 1924;10:755–758.
14. Simon PW. Fundamental principles of a systematic
diagnosis of dental anomalies. Boston: Stratford Co;
1926: (translated by BE Lischer) 320.
15. Simon PW. The simplified gnathostatic method. Int J
Orthod. 1932;18:1081–1087.
16. Sved A. An analysis of the most important diagnostic
methods used in orthodontia (II). Angle Orthod.
1931;1:139–160.
17. Ballard CF, Wayman JB. A report on a survey of the
orthodontic requirements of 310 army apprentices.
Dent Pract Dent Rec. 1965;15:221–226: PubMed PMID:
14250714.
18. Backlund E. Facial growth, and the significance of
oral habits, mouthbreathing and soft tissues for
malocclusion. A study on children around the age of
10. Acta Odontol Scand. 1963;21(Suppl. 36):9–139:
19. Williams AC, Stephens CD. A modification to the
incisor classification of malocclusion. Br J Orthod.
1992;19(2):127–130: PubMed PMID: 1627523.
20. Katz MI, Sinkford JC, Sanders Jr CF. The 100-year
dilemma: what is a normal occlusion, and how is
malocclusion classified? Quintessence Int.
21. Katz MI. Angle classification revisited. 1: is current
use reliable? Am J Orthod Dentofacial Orthop.
1992;102(2):173–179: PubMed PMID: 1342781.
22. Katz MI. Angle classification revisited 2: a modified
Angle classification. Am J Orthod Dentofacial Orthop.
1992;102(3):277–284: PubMed PMID: 1510054.
23. Ackerman JL, Proffit WR. The characteristics of
malocclusion: a modern approach to classification
and diagnosis. Am J Orthod. 1969;56(5):443–454:
24. Atkinson SR. Orthodontics is a life factor. Am J Orthod
Oral Surg. 1939;25:1133.
25. Baldridge JP. A study of the relationship of the
maxillary first molars to the face in class I and class II
malocclusion. Angle Orthod. 1941;11:100–119.
26. Baldridge JP. Further studies of the relation of the
maxillary first permanent molars to the face in class I
and class II malocclusions. Angle Orthod.
1950;20(1):3–10: PubMed PMID: 15419458.
27. Rinchuse DJ, Rinchuse DJ. Ambiguities of Angle’s
classification. Angle Orthod 1989 Winter;59(4):295–8
28. Gravely JF, Johnson DB. Angle’s classification of
malocclusion: an assessment of reliability. Br J
29. Siegel MA. A matter of class: interpreting subdivision
in a malocclusion. Am J Orthod Dentofacial Orthop.
2002;122(6):582-6: PubMed PMID: 12490867.
30. Baum LJ. Developmental and diagnostics aspects of
primary dentition. Int Dent J. 1959;9:349–366.
CHAPTER 5
Recording the severity of
malocclusion: orthodontic indices
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Commonly used indexes
Qualitative methods of recording malocclusion
Quantitative methods of recording malocclusion
Occlusal index (OI)
Treatment need indices
Handicapping malocclusion assessment record (HMAR)
Index of orthodontic treatment needs (IOTN)
Dental health component
Aesthetic component
Limitations of IOTN
Rules and conventions for recording PAR
Index of complexity, outcome and need (ICON)
Treatment need
American Board of Orthodontics (ABO) grading system and
discrepancy index (DI)
Assessment criteria to normal occlusion and treatment
outcome
Key Points
Introduction
Recording of malocclusion and its severity among population groups
is required for the following purposes:
1. To document the prevalence of types of malocclusion in

population groups.
2. To document types and severity of different malocclusions.
3. Scientific studies on the development of malocclusion/normal
occlusion according to age.
4. Measurements of malocclusion/traits of occlusion can be used
to objectively quantify the outcome of orthodontic treatment.
5. Recording of the severity of malocclusion can help prioritise
the treatment in a given society, which is particularly
important where public health care setting makes the
provision of orthodontic treatment.
6. Epidemiologic studies are necessary for planners to devise a
mechanism for human resources training/capacity building
and provision of health care services.
Indices measure malocclusion using numerical or categorical values

and enable quantitative or qualitative assessment of malocclusion.
Commonly used indexes

• Diagnostic classification index
• Treatment need indices
• Treatment outcome index
• Treatment complexity index
Qualitative methods of recording
malocclusion
Since the time E. H. Angle (1899, 1904, and 1907) gave his
classification of malocclusion into three distinct classes; several
modifications have emerged over the years. It was soon realised, those
qualitative methods of classifications were not suitable for measuring
the severity and hence treatment need for quantification. The World
Health Organisation/Federation Dentaire Internationale (WHO/FDI)’s
basic methods for recording malocclusion (1979)1 followed recording
of symptoms of malocclusion with carefully defined criteria. This
method of recording malocclusion was primarily derived from the
principle developed for identifying and recording individual traits of
malocclusion by Bjork et al. (1964).2
Indices measure malocclusion using numerical or categorical values
and enable quantitative or qualitative assessment of malocclusion.
• Diagnostic classification index

• Treatment need indices IOTN, DAI
• Treatment complexity index, for example, ABO, ICON
• Treatment outcome index, PAR and ABO
Quantitative methods of recording
malocclusion3
Efforts to quantify malocclusion by assigning each trait a ‘score’ and
assigning ‘weightage’ to the attributes/traits of occlusion,
(malocclusion), which are detrimental to oral health or aesthetics,
have evolved over the years. A major issue with recording a
malocclusion in its real objective sense and severity of the problem lies
in its recording and its validity during mixed dentition period. The
occlusion changes dramatically from mixed to permanent dentition
and on several occasions, it may improve and not necessarily worsen.
The index of recording malocclusion should be valid with time and
should exclude symptoms of normal developmental changes in
occlusion. It should be ‘sensitive’ to record basic orthodontic defect.
Therefore, an index that records a score of malocclusion should
exhibit either an increase in score (worsening of malocclusion) or
remain constant (malocclusion does not worsen), presuming that self-
correction of the basic defect of malocclusion does not occur from
transitional stage to permanent dentition stage.
Some indices were developed primarily for the epidemiological
purpose of recording the malocclusion while others were developed
to grade the severity of malocclusion and to distinguish between
malocclusion requiring urgent treatment or a priority of treatment
over others. Some prominent indices are:
1. Occlusal index (OI) by Summers (1966)4,5 (primarily for

epidemiological purposes)
2. Treatment priority index (TPI) by Grainger (1967)6
3. Handicapping malocclusion assessment record (HMAR) by
Salzmann (1968)7
The requirements for an index are summarised in Box 5.1.

Box 5.1 Requirements for an index of occlusion
1. Status of the group is expressed by a single number which

corresponds to a relative position on a finite scale with definite
upper and lower limits; running by progressive gradation from
zero, that is, absence of disease, to the ultimate point, i.e.,
disease in its terminal stage
2. The index should be equally sensitive throughout the scale
3. Index value should correspond closely with the clinical
importance of the disease stage it represents
4. Index value should be amenable to statistical analysis
5. Reproducible
6. Requisite equipment and instruments should be practicable in
actual field situation
7. Examination procedure should require a minimum of
judgement
8. The index should be facile enough to permit the study of a large
population without undue cost in time or energy
9. The index would permit the prompt detection of a shift in group
conditions, for better or for worst
10. The index should be valid during time
Source: Reproduced with permission: Tang EL, Wei SH. Recording

and measuring malocclusion: a review of the literature. Am J Orthod
and Dentofacial Orthop 1993;103:344–51
Occlusal index (OI)
OI was developed as a valid tool for measuring the
occlusion/malocclusion for epidemiological purposes. A scoring
scheme for each stage of dental development (i.e. deciduous, mixed,
and permanent dentition stages) was formulated, and different
scoring forms were used for subjects in each stage. Following nine
characteristics are included:
1. Dental age
2. Molar relation
3. Overbite
4. Overjet
5. Posterior crossbite
6. Posterior open bite
7. Tooth displacement (actual and potential)
8. Midline relations
9. Missing permanent maxillary incisors
It defines two divisions and seven malocclusion syndromes (Box

5.2).
Box 5.2 Occlusal index of Summers (1966)
Division I (normal) and division II (distal molar relation)
1. Syndrome A: overjet and anterior open bite

2. Syndrome B: distal–molar relationship, positive overjet,
overbite, posterior crossbite, midline diastema and midline
deviation
3. Syndrome C: congenitally missing incisors
4. Syndrome D: potential tooth displacement and tooth
displacement
5. Syndrome E: posterior open bite
Division III (mesial molar relation)
6. Syndrome F: mesial molar relation, negative overjet, overbite,

posterior crossbite, midline diastema and midline deviation
7. Syndrome G: mixed dentition analysis and tooth displacement
The scores of all ‘syndromes’ were clubbed in arriving at the final

OI score. The syndrome with the highest score and the other scores
were considered by adding half of the sum of the remaining scores to
the highest score among the seven syndromes. The absence of any
occlusal disorder would be scored as zero.
The OI had developed different scoring schemes and forms for
patients in different stages of dental development from dental age 0 to
1–6.
Treatment need indices

Treatment priority index
It was developed by Grainger (1967) to assess the severity of common
types of malocclusion and hence provide a means of ranking patients
according to the severity of malocclusion, the degree of handicap or
priority of the treatment (Box 5.3).
Box 5.3 Treatment priority index by Grainger

(1967)
Weighted and defined measurements
1. Upper anterior segment overjet

2. Lower anterior segment overjet
3. Overbite of upper anteriors over lower anteriors
4. Anterior open bite
5. Congenital absence of incisors
6. Distal molar relation
7. Mesial molar relation
8. Posterior crossbite (maxillary teeth buccal to normal)
9. Posterior crossbite (maxillary teeth lingual to normal)
10. Tooth displacement
11. Gross anomalies
Malocclusion syndromes
1. Maxillary expansion syndromes

2. Overbite
3. Retrognathism
4. Open bite
5. Prognathism
6. Maxillary collapse syndrome
7. Congenitally missing incisors
The handicap malocclusion defined by Grainger included the

following:
1. Unacceptable aesthetics
2. Traumatic conditions predisposing to tissue destruction
3. Significant reduction in masticatory function
4. Speech impairment due to malocclusion
5. Unstable occlusion
6. Gross or traumatic defects
A few manifestations of malocclusion such as midline diastema and

slight asymmetries were rejected as being of little public health
significance. TPI is quite similar to OI, but the major difference is that
it does not consider potential tooth displacement and also omitted
mixed dentition analysis. Therefore, it is deemed inadequate for
assessing the occlusion of deciduous or mixed dentition.
TPI is a valid epidemiologic indicator of malocclusion. However,
values recorded in transitional dentition are not predictive of severity
in permanent dentition.
Handicapping malocclusion
assessment record (HMAR)
It was developed by Salzmann (1968). The purpose of developing the
HMAR was to provide a means for establishing priority for treatment
of handicapping malocclusion. Handicapping malocclusion and
handicapping dentofacial deformity were defined as conditions that
constitute a hazard to the maintenance of oral health and interfere
with the well-being of patient by adversely affecting dentofacial
aesthetics, mandibular function or speech (Box 5.4).
Box 5.4 Handicapping malocclusion assessment

record by Salzmann (1968)
Weighted measurements consist of three parts:
1. Intra-arch deviation
a. Missing teeth
b. Crowding
c. Rotation
d. Spacing
2. Inter-arch deviation
a. Overjet
b. Overbite
c. Crossbite
d. Open bite
e. Mesiodistal deviation
3. Handicapping dentofacial deformities
a. Facial and oral clefts
b. Lower lip palatal to maxillary incisors
c. Occlusal interference
d. Functional jaw limitation
e. Facial asymmetry
f. Speech impairment
The HMAR allocates scores for dental irregularities and arch
malrelationships, which are multiplied by a weighting factor before
the total score is assigned. Orthodontists from various parts of the
United States had tested the relative point values, based on clinical
orthodontic experience. HMAR also records and weighs functional
problems, unlike any other index. The recording is done on specially
designed forms either on orthodontic models or during clinical
assessment. Additional scores are allocated for dentofacial deviations
such as cleft lip and palate, facial asymmetry and functional
disabilities. The assessment is rapid and does not require special
instruments.
The usefulness of any of the indices is judged by the ‘reliability’ to
produce the same score of measurement when one or more examiners
would assess a case of malocclusion at any given time or interval.
Research has shown that Summers’ OI has the least amount of bias, is
best correlated with clinical standards and has the highest validity
during a ‘time’.
In 1990, American Association of Orthodontists had taken a view
not to consider rating classification or coding system as a scientifically
valid measurement for the need of orthodontic treatment (AAO
Bulletin, St Louis, 1990, Fall).
It was developed by Cons et al.8 It is a relatively simple index that can
be obtained intraorally, without the use of radiographs. DAI has been
accepted by WHO as a cross-cultural index.9 It was integrated into the
items of international collaboration study of oral health outcomes by
the WHO in 1989.10
It consists of 10 components, each having their respective weighting
(Table 5.1).
Table 5.1
Components and weight used in DAI

Dental aesthetic index (DAI) components Weight
No. of missing incisor, canine or premolar teeth in maxillary and mandibular arches 6
Crowding in the incisal segments (no. of segments crowded) 1
Spacing in the incisal segments (no. of segments spaced) 1
Midline diastema in millimetres 3
Largest anterior irregularity on the maxilla in millimetres 1
Largest anterior irregularity on the mandible in millimetres 1
Anterior maxillary overjet in millimetres 2
Anterior mandibular overjet in millimetres 4
Vertical anterior open bite in millimetres 4
Anteroposterior molar relation; largest deviation from normal either left or right, 0 = 3
normal, 1 = 1/2 cusp either mesial or distal
Constant 13
Total DAI
score
The cut-off point of any treatment need index is the value below
which the severity of malocclusion is so minor that there is no definite
need for treatment and all values above that point indicate
malocclusion for which treatment is mandatory. The recommended
treatment cut-off point of DAI is 31 (Table 5.2).11
Table 5.2
Cut-off point of DAI scores

DAI scores Severity levels
<25 Minor or no anomaly (no or slight treatment need)
26–30 Definite malocclusion (treatment elective)
31–35 Severe malocclusion (treatment highly desirable)
≥36 Handicapping malocclusion (treatment mandatory)
Limitations of DAI. Although DAI is easy to use, there is a lack of

assessment traits such as buccal crossbite, open bite, centreline
discrepancy and deep bite. Though these may not be important from a
dental aesthetic point of view, they could affect the need for
orthodontic treatment from functional point of view.12,13
Index of orthodontic treatment needs
(IOTN)14–16
It was developed in the UK by Shaw et al. and is another mechanism
of prioritising and thereby classifying malocclusions according to
treatment needs. This is particularly useful where the resources
available for treatment are limited. This index ranked malocclusion
regarding the significance of various occlusal traits for the person’s
dental health and perceived aesthetic impairment, with the intention
of identifying those persons who would be most likely to benefit from
orthodontic treatment. The index incorporates a dental health
component (DHC) and an aesthetic component (AC).
Dental health component

Of the two parts of the IOTN, DHC is in most frequent use. This
represents an attempt at synthesis of the current evidence for the
deleterious effects of malocclusion and the potential benefits of
orthodontic treatment. Each occlusal trait thought to contribute to the
longevity, and the satisfactory functioning of the dentition is defined
and placed into five grades, with clear cut-off points between the
grades.
DHC has five grades (Box 5.5), categorising cases from grade 1 (no
need for treatment) to grade 5 (great need). The DHC may be applied
clinically and to study casts. When applied to study casts, there are
minor differences in the definition of some traits.
Box 5.5 IOTN and its dental health components
Grade 1 (no treatment required)
1 Extremely minor malocclusions including displacements less

than 1 mm
Grade 2 (little)
2a Increased overjet greater than 3.5 mm but less than or equal to 6

mm with competent lips
2b Reverse overjet greater than 0 mm but less than or equal to 1
mm
2c Anterior or posterior crossbite with less than or equal to 1 mm
discrepancy between retruded contact position and inter-cuspal
position
2d Displacement of teeth greater than 1 mm but less than or equal
to 2 mm
2e Anterior or posterior open bite greater than 1 mm but less than
or equal to 2 mm
2f Increased overbite greater than or equal to 3.5 mm without
gingival contact
2g Pre-normal or post-normal occlusion with no other anomalies.
Includes up to half a unit discrepancy
Grade 3 (moderate) or borderline need
3a Increased overjet greater than 3.5 mm but less than or equal to 6

mm with incompetent lips
3b Reverse overjet greater than 1 mm but less than or equal to 3.5
mm
3c Anterior or posterior crossbite with greater than 1 mm but less
than or equal to 2 mm discrepancy between retruded contact
position and inter-cuspal position
3d Displacement of teeth greater than 2 mm but less than or equal
to 4 mm
3e Lateral or anterior open bite greater than 2 mm but less than or
equal to 4 mm
3f Increased and complete overbite without gingival or palatal
trauma
Grade 4 (great) or treatment required
4a Increased overjet greater than 6 mm but less than or equal to 9

mm
4b Reverse overjet greater than 3.5 mm with no masticatory or
speech difficulties
4c Anterior or posterior crossbite with greater than 2 mm
discrepancy between retruded contact position and inter-cuspal
position
4d Severe displacements of teeth greater than 4 mm
4e Extreme lateral or anterior open bite greater than 4 mm
4f Increased and complete overbite with gingival or palatal trauma
4h Less extensive hypodontia requiring prerestorative
orthodontics or orthodontic space closure to obviate the need
for a prosthesis
4l Posterior lingual crossbite with no functional occlusal contact in
one or both buccal segments
4m Reverse overjet greater than 1 mm but less than 3.5 mm with
recorded masticatory and speech difficulties
4t Partially erupted teeth, tipped and impacted against adjacent
teeth
4x Presence of supernumerary teeth
Grade 5 (very great) treatment required 4× existing

supernumerary teeth
5a Increased overjet greater than 9 mm

5h Extensive hypodontia with restorative implications (more than
one tooth missing in any quadrant) requiring prerestorative
orthodontics
5i Impeded eruption of teeth (except third molars) due to
crowding, displacement, presence of supernumerary teeth,
retained deciduous teeth and any pathological cause
5m Reverse overjet greater than 3.5 mm with reported masticatory
and speech difficulties
5p Defects of cleft lip and palate
5s Submerged deciduous teeth
Various features of the malocclusion are noted and measured, with

a specially designed ruler (Fig. 5.1).
FIGURE 5.1 Index of orthodontic treatment need (IOTN) – DHC

ruler.
The European Orthodontic Society first published the scan scale.
Overjet: This section is split into two, the upper half records positive
overjet, the lower half reverse overjet. Contact point, displacement and
open bite: This section consists of four lines. Each line is assigned a
grade. The greater the contact point, displacement or open bite, greater
the grade. c, Competent lips; Dev, Deviation; G + P, Trauma gingival
and palatal; Inter-dig, Inter-digitation; I, Incompetent lips; O.B.,
Overbite. Source: Evans MR, Shaw WC. Eur J Orthod 1987;9:314–8.
DHC recognises most severe defect/deformity, which is used to

grade the case rather than summing up all the deviations.
Aesthetic component
The AC consists of a 10-point scale illustrated by a series of numbered
photographs. This scale was developed based on attractiveness as
rated by lay persons and selected as being equidistantly spaced
through the range of scores. A rating is allocated for overall dental
attractiveness rather than the specific morphologic similarity to the
photographs (Fig. 5.2).
FIGURE 5.2 The10-point scale for the AC.
The pictures depicted are selected based on the best matches to first
set published by Shaw et al.14
The dental attractiveness (unattractiveness) score provides an

indication of treatment needs on the grounds of aesthetic impairment,
and by inference, may reflect the social and psychological need for
orthodontic treatment.
Limitations of IOTN
This index places emphasis on the alignment of teeth alone. In certain
ethnic groups, like in India, class I bimaxillary protrusion is a common
finding and treatment need is essentially for aesthetic reasons to
improve the profile whereas arch alignment and the intra-arch
relationships are normal. The second major limitation is that all the
children with cleft lip and palate are grade 5, that is, the most severe
malocclusion irrespective of the type and severity of the defect. In
some instances, a cleft lip and alveolus case may present only with a
minor disturbance in occlusion like a rotated lateral or central incisor.
Such a minor malocclusion would be categorised to grade 5 owing to
its co-presence with cleft lip and palate deformity.
Peer assessment rating (PAR)15,16 was developed by the British
Orthodontic Standards Working Party, which consisted of 10
experienced orthodontists in 1987. Following a series of meetings
where over 200 study models were analysed, it was agreed that
individual features should be assessed to obtain an estimate of
alignment and occlusion. Their aim was to quantify the changes that
occurred after orthodontic treatment and therefore, measure the
treatment success based on the initial severity of malocclusion.
A weighting score is given to the various traits of occlusion. The
ratings are applied on the study models, and no considerations are
made for improvement in profile, underlying skeletal bases or
functions. The dental casts are assessed with the help of a specially
designed ruler (Fig. 5.3). Each component of the index is marked on
the ruler to allow rapid assessment and remind the examiner of each
component. The reliability and validity of the PAR index have been
tested.
FIGURE 5.3 Index for treatment standards (PAR) ruler.
The PAR index consists of 11 components
1. Upper right segment

2. Upper anterior segment
3. Upper left segment
4. Lower right segment
5. Lower anterior segment
6. Lower left segment
7. Right buccal occlusion
8. Overjet
9. Overbite
10. Centreline
11. Left buccal occlusion
1–6. Upper right segment, upper anterior segment, upper left

segment and lower right segment, lower anterior segment, lower left
segment.
The scoring method involves the recording of occlusion features of
alignment, crowding, spacing, and impacted teeth. The shortest
distance between the contact points of adjacent teeth parallel to the
occlusal plane is determined as contact point displacement and is
measured using the PAR index ruler. The greater the contact point
displacement, the greater is the score. The contact point between first
second and third molars are not scored. The scoring grades are given
below. A tooth is regarded as impacted if the space between the two
adjacent teeth is less than or equal to 4 mm. Impacted canines are
recorded in the anterior segment. If there is potential crowding in the
mixed dentition, the average mesiodistal widths are used to calculate
the space deficiency.
7,11. Right buccal occlusion and left buccal occlusion
Buccal occlusion is evaluated in all the three planes of space, that is,
anteroposterior, vertical and transverse. The buccal segment
relationship includes an assessment on both left and right sides of the
dentition. The recording zone is from the canine to the last molar.
Temporary developmental stages and submerging deciduous teeth
are excluded. The buccal segment score is the sum of the
anteroposterior, vertical, and transverse scores.
8. Overjet
The next step involves scoring the overjet in the incisor region, both
positive overjet as well as the anterior teeth that are in crossbite. The
overjet is measured at the most prominent incisor and recorded to the
labial aspect of the incisal edge. The PAR ruler is held parallel to the
occlusal plane and radial to the line of the arch. The presence of
crossbite in the region of canine is also included under this section.
9. Overbite/Open bite
The vertical overlap at four incisors is recorded as overbite or open
bite. Overbite is recorded in relation to the coverage of the lower
incisors or depending on the degree of open bite present. A tooth with
the greatest overlap is recorded.
10. Centreline. The midline discrepancy is recorded in reference to
the lower incisor.
If a lower central incisor has been extracted, the measurement is not
recorded (Tables 5.3–5.8).
Table 5.3
Displacement scores
Score Discrepancy
0 0–1 mm
1 1.1–2 mm
2 2.1–4 mm
3 4.1–8 mm
4 Greater than 8 mm
5 Impacted teeth
Table 5.4
Mixed dentition crowding assessment using average mesio-distal widths

Upper
Canine 8 mm
1st premolar 7 mm Total = 22 mm (impaction < = 18 mm)
2nd premolar 7 mm
Lower
Canine 7 mm
1st premolar 7 mm Total = 21 mm (impaction < = 17 mm)
2nd premolar 7 mm
Table 5.5
Buccal occlusion assessments

Score Discrepancy
Anteroposterior
0 Good interdigitation, Class I, II and III
1 Less than half unit discrepancy
2 Half a unit discrepancy (cusp-to-cusp)
Vertical
0 No discrepancy in intercuspation
1 Lateral open bite on at least two teeth greater than 2 mm
Transverse
0 No crossbite
1 Crossbite tendency
2 Single tooth in crossbite
3 More than one tooth in crossbite
4 More than one tooth in scissors bite
Temporary developmental stages and submerging deciduous teeth are excluded.
Table 5.6
Overjet measurements
Score Discrepancy
Overjet
0 0–3 mm
1 3.1–5 mm
2 5.1–7 mm
3 7.1–9 mm
4 Greater than 9 mm
Anterior crossbites
0 No discrepancy
1 One or more teeth edge to edge
2 One single tooth in crossbite
3 Two teeth in crossbite
4 More than two teeth in crossbite
Table 5.7
Overbite measurements
Score Discrepancy
Open bite
0 No open bite
1 Open bite less than and equal to 1 mm
2 Open bite 1.1–2 mm
3 Open bile 2.1–3 mm
4 Open bile greater than or equal to 4 mm
Overbite
0 Less than or equal to one-third coverage of the lower incisor
1 Greater than one-third, but less than two-thirds coverage of the lower incisor
2 Greater than two-thirds coverage of the lower incisor
3 Greater than or equal to full tooth coverage
Crossbites including the canines are recorded in the anterior segment.
Table 5.8
Centreline assessments
Score Discrepancy
0 Coincident and up to one-quarter lower incisor width
1 One-quarter to one-half lower incisor width
2 Greater than one-half lower incisor width
Rules and conventions for recording PAR

• All scoring is accumulative
• There is no maximum cut-off level
• Increased overjet, contact point displacements, etc. associated
with poor restorative work are not recorded
• Contact point displacements between deciduous teeth and
between deciduous and permanent teeth are not recorded
• Spaces are not recorded if the patient is to receive a prosthetic
replacement.
• Canines—Ectopic canines, which have erupted in the palate
should be recorded as an anterior crossbite in the over jet
section
• Impactions: If a tooth is unerupted due to insufficient space or
is ectopic, it is recorded as impacted
• Incisors: Spacing in the anterior segment resulting from
extraction, agenesis or avulsion of incisors or canines is
recorded using the following protocol
If orthodontic space closure is appropriate, then space is recorded.

If increasing the space is appropriate (for prosthetic replacement),
then space is only recorded if it is less than or equal to 4 mm
• When recording an overjet, if the tooth falls on the ruler line,

the lower score is recorded
• If a lower incisor has been extracted or is missing, an estimate
of the lower dental midline is made
The process of PAR begins with training and calibration on PAR.

The pre- and post-treatment scoring is charted on PAR Scoring
Sheet.17
The unweighted scores are multiplied to the recommended
weightings, and a total score is obtained for pre-treatment and post-
treatment study models. A perfect occlusion would have a score of 0,
and the worst malocclusion would have a score of 50 or more. The
pre-treatment and post-treatment scores are compared for percentage
change. The change in score has been organised in three major
categories.
• Greatly improved: minimum 22 point reduction

• Improved: at least 30 points reduction
• Worse or no different: less than 30 points reduction
A normogram (Fig. 5.4) was developed which suggests the

improvement in three major categories. The pre-treatment PAR score
is plotted on the x-axis against the post-treatment PAR score on the y-
axis. The intersect can be determined to identify the PAR outcome
category as above.
FIGURE 5.4 PAR normogram. Source: Reproduced with permission

from Shaw WC, Richmond S, O’Brien KD, Brook P, Stephens CD.
Quality control in orthodontics: indices of treatment need and treatment
standards. Br Dent J 1991 Feb 9;170(3):107–12 PubMed PMID:
2007067.)14
In UK, NHS (National Health Services) orthodontic contract for all

performers are expected to monitor treatment outcomes for 20 cases
plus 10% of the remainder of their caseload every year using the PAR
index as a statutory requirement18.
Based on severity and perceived treatment difficulty DeGuzman et
al.19 validated the PAR index, by using the opinion of an American
panel of orthodontists. Eleven orthodontists examined a sample of 200
sets of study casts and rated them for malocclusion severity and
perceived treatment difficulty (Table 5.9).
Table 5.9
PAR weightings according to US orthodontists19
Statistical techniques were used to evaluate the predictive power of

the components of malocclusion on the panel’s scores. Weightings
were calculated from the partial regression coefficients and, when
these weightings were applied to the PAR index, the association
between the panel’s opinion and the PAR index scores was increased.
Major limitations of IOTN and PAR
1. The epidemiological studies on assessment of treatment need

using IOTN have suggested contradictory scores on treatment
categorisation using the dental DHC and the AC. While one
component may suggest a need for treatment and the other
suggesting no treatment at all.
2. In general, the IOTN or PAR indices were validated against UK
experts dental opinion only, but this may not reflect the views
of orthodontists in other countries.19
3. Changes in facial profile/aesthetics or cephalometric
parameters which indicate the skeletal components of
malocclusion are not considered.
4. It has been a general opinion that PAR index is lenient on
residual extraction spacing, unfavourable incisor inclinations,
and rotations.20
5. PAR assessment can be unduly harsh on treatments where the
aims were limited to correction of a certain anomaly.
6. Some of the cases show no benefit from treatment using PAR.
These cases included mild malocclusions, adult cases with a
history of multiple early extractions, malocclusions with
impacted teeth in the buccal segment.21
7. A high weight is applied to overjet and the application of one
weighting system to all malocclusions.22
8. PAR takes no account of unwanted treatment effects on oral
tissues such as periodontal destruction, decalcification and
root resorption.21
9. The occlusion is assessed in static and not functional in aspects,
that is, dynamic occlusion.
10. The IOTN index places emphasis on the alignment of teeth
alone. In certain ethnic groups, like in India and its
subcontinent, class I bimaxillary protrusion is a common
finding and treatment need is essential for aesthetic reasons to
improve the profile, whereas arch alignment and the intra-
arch relationship may be near normal.
11. Children with cleft lip and palate anomaly are graded 5 of
IOTN, which is the most severe malocclusion. In some
instances, a cleft lip and alveolus case may present only with a
minor disturbance in occlusion like a rotated lateral or central
incisor next to alveolus of the cleft site.
12. PAR is a valid and reliable measure of the dento-occlusal
effects of treatment but does not consider treatment difficulty,
which may influence treatment aims and treatment outcome.
A low pre-treatment PAR score does not confer reduced
treatment difficulty or treatment time.
Index of complexity, outcome and need
(ICON)
Daniels and Richmond (2000)23 developed the index of complexity,
outcome and need (ICON), which was expected to serve as a means to
compare orthodontic treatment thresholds across the world and
permit international comparison and professional standardisation of
treatment outcomes. The ICON was developed in a joint effort of 97
orthodontists across nine countries and is arguably more valid than
the PAR index. ICON is considered highly valid and reliable.23–26
This index is comprised of an assessment of dental aesthetics, the
presence of crossbite, analysis of upper arch crowding (or the
presence of impacted teeth in either arch), buccal segment
anteroposterior inter-digitation and the anterior vertical relationship.
The scoring protocols are described in Table 5.10.
1. Dental aesthetics. The dental AC of the IOTN (Shaw et al.14) is

used. The dentition is compared to the illustrated scale graded
from 1 for the most attractive to 10 for the least attractive
dental arrangement. Once this score is obtained, it is
multiplied by the weighting of 7.
2. Upper arch crowding/spacing. The sum of mesiodistal crown
diameters is compared to the available arch circumference,
mesial to the last tooth on either side. Once the
crowding/spacing discrepancy has been worked out in
millimetres, it is reduced to the ordinal scale (0–5) according to
the protocol and multiplied by the weighting of 5.
3. Crossbite. In the anterior segment, a tooth in crossbite is
defined as an upper incisor or canine in edge-to-edge or
lingual occlusion. Crossbite in posterior segment includes
buccal and lingual crossbites consisting of one or more teeth,
with or without mandibular displacement. When the crossbite
is present in the anterior or posterior segments or both, the
raw score of 1 is given which is multiplied by the weighting of
5.
4. Overbite (anterior vertical relationship). This trait included
open bite and deep bite. If both traits are present, only the
highest scoring raw score is counted and multiplied by the
weighting of 4.
5. Buccal segment anteroposterior relationship. The
anteroposterior or cuspal relationship of canine, premolar and
molar is scored according to the protocol for each side. The
raw scores for both sides are added together and then
multiplied by the weighting of 3.
Table 5.10
Protocol for occlusal trait scoring according to ICON
The index contains five components (occlusal traits) with weighting for each problem, all of
which must be scored
Treatment need
The pre-treatment study models are examined, and occlusal traits are
scored according to the protocol. The five occlusal trait scores are then
multiplied by their respective weightings and summed. If the
summary score is more than 43, treatment is indicated (Table 5.11).
Table 5.11
ICON cut-off values for treatment need and outcome decisions

Treatment need cut-off 43
Treatment outcome cut-off 31
Use of index to assess treatment complexity
To assess treatment complexity, a five-grade complexity scale is used.
The index scoring method is applied to the pre-treatment models
(Table 5.12).
Table 5.12
Complexity grade and score range used in ICON

Complexity grade Score range
Easy <29
Mild 29–50
Moderate 51–63
Difficult 64–77
Very difficult >77
Use of index to assess treatment outcome acceptability

To assess treatment outcome, the index scoring method is applied to
the post-treatment models only. If the summary score is less than 31,
then the outcome is acceptable.
To assess the degree of improvement, the post-treatment score is
multiplied by 4 and the result is subtracted from the pre-treatment
score (Table 5.13).
Table 5.13
Improvement grade and score range used in ICON

Improvement grade Score range
Greatly improved >−1
Substantially improved −25 to −1
Moderately improved −53 to −26
Minimally improved −85 to −54
Not improved or worse < − 85
Strengths of ICON over the limitations of IOTN and PAR

Richmond has listed these as follows.
1. Measuring a single set of traits on pre-treatment or post-

treatment models is used to calculate ICON scores.
2. It is a quick method and requires no special device except an
ordinary millimeter ruler and an AC scale developed by Shaw
et al.14 used in IOTN.
3. A single index is valid for treatment need, complexity, and
outcome assessments.
4. ICON is more universally accepted in contrast to IOTN/PAR,
which is mainly used in the UK.
5. The index can be used starting with the late mixed dentition
onwards.
6. The index incorporates AC of IOTN. ICON, by the remaining
four traits and their weight, permits patients with an aesthetic
score more than 5 to enter the treatment category and those
with many lesser aesthetic conditions.
7. The new index takes care of crowding/spacing assessment,
remaining extraction space and posterior impactions, and
therefore is designed to address the limitations of the PAR
index in this respect.
8. This index is rather simple to use and faster than separate
indices for various facets of orthodontic treatment.
9. Onyeaso et al.27 investigated relationship between ICON, DAI,
PAR, and ABO objective grading system. They found overall
good agreement between the ICON and the other indices. The
ICON was reported to appear as a reasonable means of
assessing the standard of orthodontic treatment regarding
complexity, need and outcome. It also eliminates the need of
using various indices for a given malocclusion.
American Board of Orthodontics (ABO)
grading system and discrepancy
index(DI)28–32
American Board of Orthodontics (ABO) formed a committee in 1994,
to evolve a system to objectively evaluate post-treatment dental casts
and panoramic radiographs of the examinees. To enhance the
reliability of the examiners and provide the examinees with a tool to
assess the adequacy of their finished orthodontic results, the Board
has established a model grading system of evaluating the final dental
casts and panoramic radiographs. Objective Grading System for
candidates was developed systematically through a series of four field
tests over a period of 5 years and finally initiated at the February 1999,
ABO Phase III examination in St. Louis. The Board encourages
examinees to score their cases with this scoring system to determine if
they meet the American Board standards. The ABO gauge is used to
measure discrepancies on a numerical scale as low as 0.5 mm for each
of the variables.2
Discrepancy index (DI) evaluates the case difficulty and treatment
complexity. It is a development which was initiated in 1998 and
finally matured in 2003.
DI evaluates case complexity based on the criterion of case difficulty
by assessing dental models and cephalometric parameters. Case
complexity is defined as a combination of factors, symptoms, or signs
of a disease or disorder, which form a syndrome.
The DI is an objective method to describe the complexity of the
treatment for a patient based on observations and measurements
taken from standard pre-treatment orthodontic records, including
dental study models and cephalometric and panoramic radiographs
and ‘others’.
The clinical features of a patient’s condition include assessment of
overjet, overbite, anterior open bite, lateral open bite, crowding,
occlusion, lingual posterior crossbite and buccal posterior crossbite.
Cephalometric parameters include ANB angle, IMPA, and SN-GoGn
angle.
Because it is impossible to cover every clinical situation, the ‘other’
category permits the scoring of other commonly occurring conditions,
which are not covered as above. An additional 2 points are scored for
each of the following: missing or supernumerary teeth ectopic
eruption, transposition, anomalies of tooth size and shape, CR-CO
discrepancies, skeletal asymmetry, the excess curve of Wilson. Each
‘Other’ condition must be noted on the scoring sheet.
The greater the total cumulative scores of these conditions in a
patient, the greater the complexity and challenge to the orthodontist.
Each variable is given weightings which are depicted in the DI form
(Box 5.6).
Box 5.6 ABO discrepancy index scoring sheet

Source:
https://www.americanboardortho.com/media/1186/discrepancy-
index-worksheet-for-print.pdf
A new version of DI sheet introduced in 2011–12 is shown in Box

5.6.22 All the cases submitted for ABO certification should follow DI. It
is used by the AAO Board in determining the criteria for case
submission.
American Board of Orthodontics objective grading system29–31
(http://americanboardortho.com/about/articles/Objective
GradingSystem1998.pdf)
ABO grading system is based on the objective assessment of
treatment outcome, which has evolved over the years since 1995. The
most recent update is ‘The American Board of orthodontics grading
system for dental casts and panoramic radiographs revised June 2012’.
The underlying purpose of establishing ABO grading system is to
insure reliable, objective evaluation of orthodontic records. The
objective evaluation allows examinees to grade their results before the
clinical examination and know if their treatment outcome results meet
criteria of the board. The criteria also help as a self-assessment tool to
maintain the quality of treatment outcome in tune with standards set
for the diplomates.
The ABO conducted clinical examination field tests in 1995, of
which 15 criteria of occlusion were measured on each of the final
dental casts and panoramic radiographs. The first test showed that
85% of the inadequacies in the final results occurred in 7 of the 15
criteria. The seven criteria were: alignment, marginal ridges,
buccolingual inclination, overjet, occlusal relationships, occlusal
contacts and root angulation, interproximal contacts.
The second field test conducted in 1996 verified the results of the
first test and reported difficulties in establishing inter-examiner
reliability. It was felt there was a need to develop a measuring
instrument to make the measuring process more reliable.
The third field test in 1997 marked the use of a modified scoring
system with the addition of an instrument to measure the various
criteria more accurately. Once again the overwhelming majority of the
inadequacies in the finished results occurred in the seven categories as
mentioned before. It was also recommended to add interproximal
contacts to existing criteria, making it to a total of eight. The test
instrument was suggested for some improvements. The fourth field
test was conducted in 1998—ABO evaluation process. The new and
improved measuring instrument was used. The outcome saw the
refinement of the measuring and calibration process of examiners to
establish the validity or cut-off for passing this portion of the clinical
examination.
In 1999, the ABO decided to officially initiate the use of the model
grading system for examinees. The same grading system is used by
examinees to self-assess the outcome of the case and select cases
which are suitable for them to successfully pass the examination
process since the same system will be used by the examining
directors. The ABO gauge is used to measure discrepancies on a
numerical scale as low as 0.5 mm for each of the variables (Fig. 5.5).32
FIGURE 5.5 ABO measuring gauge.

(A) This portion of the gauge is in 1 mm increment and is used to
measure discrepancies in alignment, overjet, occlusal contact,
interproximal contact, and occlusal relationships. (B) This portion of the
gauge has steps measuring 1 mm in height and is used to determine
discrepancies in mandibular posterior buccolingual inclination. (C) This
portion of the gauge has steps measuring 1 mm in height and is used
to determine discrepancies in marginal ridges. (D) This portion of the
discrepancies in maxillary posterior buccolingual inclination. Note: Third
molars are not scored unless they substitute for the second molars.
A sum of score represents the total deviation from ideal occlusion.

Higher the score, greater are the discrepancies. In general, a case
report that scores 30 or more points will generally not be considered
to pass that portion of the clinical examination although several other
criteria of records/case treatments were included in the overall
assessment.
Assessment criteria to normal occlusion and

treatment outcome
The eight criteria assessed to attain normal occlusion and qualities of
treatment outcome are:
1. Tooth alignment: The incisal edges of anterior teeth,

mesiobuccal and distobuccal cusps of mandibular posterior
teeth and central fossae of maxillary posterior teeth should be
well aligned.
Anterior region. The incisal edges and lingual surfaces of the
maxillary anterior teeth and the incisal edges and labioincisal
surfaces of the mandibular anterior teeth were chosen as the
guide to assess anterior alignment. In the maxillary and
anterior mandibular regions, proper alignment is characterised
by coordination of alignment of the incisal edges and lingual
incisal surfaces of the maxillary incisors and canines and the
incisal edges and labial incisal surfaces of the mandibular
incisors and canines.
Posterior region. In the maxillary posterior region, the mesiodistal
central groove of the premolars and molars is used to assess the
adequacy of alignment. In the maxillary arch, the central
grooves (mesiodistal) should all be in the same plane or
alignment.
In the mandibular arch, the buccal cusps of the premolars and
molars are used to assess proper alignment. In the mandibular
posterior quadrants, the mesiobuccal and distobuccal cusps of
the molars and premolars should be in the same mesiodistal
alignment.
2. Marginal ridges: The marginal ridges of adjacent teeth should
be at the same vertical level or within 0.5 mm of the same
level. Marginal ridges help to establish good occlusion.
Radiographically, the cementoenamel junction (CEJ) should be
at the same relative height, resulting in a flat bone level
between adjacent teeth.
3. Buccolingual inclinations: There should not be a significant
difference between the buccal and lingual cusps of maxillary
and mandibular—premolars and molars with all cusps within
1 mm of straight edge.
To establish proper occlusion in maximum intercuspation and
avoid balancing interferences, there should not be a significant
difference between the heights of the buccal and lingual cusps
of the maxillary and mandibular molars and premolars.
4. Occlusal relationship: The mesiobuccal cusp of maxillary first
molar must coincide within 1 mm of the buccal groove of the
mandibular 1st molar and buccal cusps of maxillary molars,
premolars, and the canines must align within 1 mm of the
interproximal embrasures of mandibular posterior teeth.
5. Occlusal contacts: Occlusal contacts are measured to assess the
adequacy of the posterior occlusion. Maximum inter-cuspation
should be established between the buccal cusps of the
mandibular posterior teeth and lingual cusps of the maxillary
posterior teeth. Each functional cusp should be in contact with
the opposing arch.
6. Overjet: In the anterior region, the mandibular incisal edges
should be in contact with the lingual surfaces of the maxillary
anterior teeth. In the posterior region, the mandibular buccal
cusps and maxillary lingual cusps are used to determine
proper position within the fossae of the opposing arch.
7. Interproximal contacts: All of the maxillary and mandibular
teeth should be in tight contact with one another, as viewed
from the occlusal surfaces.
8. Root angulation: Root angulation can be assessed using
panoramic radiographs. The roots of the maxillary and
mandibular teeth should be parallel to one another and
oriented perpendicular to the occlusal plane.
This objective grading system for assessing the final occlusal results
of orthodontic treatment has helped in the assessment of highest
standards of clinical excellence in final ABO examinations and
development of quality graduate education programmes.
European Board of Orthodontics.33
European Board of Orthodontics (EBO) suggests evaluation of
occlusion be conducted on the study models taken within four weeks
of de-bonding labelled as red and one year after treatment cast
labelled as green. EBO guidelines on evaluations are more realistic to
quote, ‘the board promotes, as a general rule, that the final occlusion
should be as precise as is appropriate for the case in question’. The
board encourages to evaluate models according to the ‘six keys to
normal occlusion’ given by Andrews in 1972.
Key Points
A quantitative method of evaluation of the extent of abnormality from
a given standard requires grading the abnormality and assigning a
score based on the severity of the problem, which is perceived by the
degree of aesthetic/functional impairment produced.
Each index is designed with a definite purpose and should be valid
in its applications.
Significant occlusal changes during transitional dentition make it
difficult to assign an index of potential tooth displacement.
The OI of Summers has a provision based on stages of dental
development.
This index was primarily developed for recording malocclusion in
surveys. IOTN is practical in clinical settings and possibly could be
used for epidemiological surveys.
ABO DI and evaluation criteria is a useful self assessment tool and
should be used by the postgraduate students to assess their
performance and by the clinicians to sustain high quality orthodontic
treatment.
References
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webadapted.pdf.
CHAPTER 6
Psychological implications of
malocclusion and orthodontic
treatment
O.P. Kharbanda
Rajesh Sagar
CHAPTER OUTLINE
Introduction
Psychological implications of malocclusion
Psychological factors motivating patient to seek orthodontic
treatment
Severity of malocclusion
Self-perception of malocclusion
Parental perception of malocclusion
Gender
Peer pressure
Self-esteem
Patient’s personality traits
Social class, availability and affordability
Functional factors
Traumatic occlusion
Inability to close lips
Malocclusion associated with dentofacial deformities
Key Points
Introduction
The face is perhaps the most important component of an individual’s
physical appearance. Since times immemorial, we have been
fascinated by beautiful faces. Aesthetics apart, ‘the face’ lends a
distinctive character and identity to an individual. A beautiful face has
been associated with a pleasing personality, and it permeates our
entire developmental process. Hence, undoubtedly, a major
motivation for seeking orthodontic treatment is to enhance the dental
and facial aesthetics, besides improvement of function and status of
oral health.
A balanced face is the outcome of intricate proportion and balance
between the hard tissues, that is, the craniofacial skeleton and
dentoalveolar structures and their soft tissue drape in function and at
rest. A dental and/or skeletal malocclusion may upset this balance and
hence may lead to dissatisfaction with life in an individual. The
deformities of the mouth and the face, which comprise the
communicative zone, affect an individual’s self-esteem more
adversely. Therefore, aesthetics comprises of not only face but also the
teeth, the jaws and the occlusion.
Psychological implications of
malocclusion
The adverse effects of poor facial aesthetics, motivating a person to
seek orthodontic treatment can be broadly divided into:
Low self-esteem and maladjustment

Quality of life and psychological stress
Restriction of social activities
Adverse occupational outcomes.
• Low self-esteem and maladjustment: The motivation to seek

orthodontic treatment is strongly related to an individual’s
perception of the extent to which his dentofacial appearance
deviates from the social norm. The psychosocial handicap
imposed by an un-aesthetic dental appearance may have a
negative impact on the personality of children who are often
subjected to ridicule in the form of teasing, name calling and
sometimes even mobbing by their peers.1 This mental anguish
imposed in early life may evoke feelings of inadequacy in the
child which may well sustain for life, leading to a maladjusted
individual.
• Poor quality of life (QoL) and psychological stress:
Malocclusion symptoms and its severity also affect
individuals’ quality of life and may considerably contribute to
psychological stress and anxiety. Psychosocial impact
increases with the severity of malocclusion and may influence
individual’s self-confidence and social life. A study reported
lower disease-specific QoL in patients who had a non-surgical
correction of a malocclusion.2 Some studies have found a
significant reduction in depressive symptoms and
improvement in disease-specific oral health-related QoL and
anxiety after surgery.3,4
• Restriction of social activities: Attractive individuals are
believed to have more social appeal and attractiveness. It
affects the perception of social characteristics like:
■ Perceived friendliness
■ Popularity among peers
■ Academic performance.
• Adverse occupational outcomes: Malocclusion may become a
big social handicap, as the affected individual may find it very
difficult to smile, talk in public or interact with people. Facial
appearance may have important implications for job
opportunities, with attractive faces having the edge over the
less attractive ones. Hence, malocclusion is closely related to
an individual’s social performance and well-being.
Psychological factors motivating
patient to seek orthodontic treatment
Motivation, according to the social cognitive theory, is a dynamic and
reciprocal interaction of a triad of three factors:
1. Personal factors
2. Behavioural factors
3. Environment
Not all of these factors interact equally. For some, social influences
and environment predominate, whereas, for others, personal
experiences, feelings and personality traits may play a major role. The
order and degree to which these factors influence an individual’s
motivation and expectation from orthodontic treatment are governed
by:
• Age
• Gender
• Socio-economic set-up
However, the degree of psychological distress is not directly

proportional to the severity of the dentofacial anomaly. Hence, a
rotated lateral incisor or a small median diastema may produce a
more negative body image in one person than a gross anomaly in
another.
Motivating factors differ in different age groups. A factor which is
of utmost importance to a teenager may not be all that significant for
an adult in seeking orthodontic treatment. Teenagers find it difficult
not to follow the norms and values of their desired reference group.
These norms are strongly influenced by the environment, including
the media portrayal of an ideal body image.
The perception for attractive preference is gradually inculcated
under the influence of following factors.
1. Severity of malocclusion
2. Self-perception of malocclusion
3. Parental perception of malocclusion
4. Gender
5. Peer pressure
6. Self-esteem
7. Patient’s personality traits
8. Social class/cultural reasons
9. Affordability
10. Availability of specialist orthodontic care
Severity of malocclusion
It is one of the primary reasons for seeking orthodontic treatment,
particularly ‘large overjet’ or protruding teeth or severely irregular
teeth. A child with severe malocclusion is more likely to seek
orthodontic treatment (keeping the other governing factors like the
socio-economic status, affordability, availability of services, parent’s
attitude, in common) than a child with a mild irregularity of teeth.
The other factors that may influence the need for treatment are the
social class, awareness and concern. Anterior or forwardly placed
teeth are usual cause of teasing in school and therefore may generate
concern and reason for orthodontic treatment. In a study done in
Finland,5 parents of 473 children were screened for child’s
dental/facial appearance, reasons for seeking orthodontic treatment
and the referral paths. Almost all (85%) of the 313 parents of children
under age 16 years expressed concern about their child’s teeth of
which 44% reported that the child had been teased about in school. It
was the child who first noticed the need for treatment, overjet and
malalignment of teeth being the main reasons for teasing.
Self-perception of malocclusion
The concern for a deviation or a trait of malocclusion does not directly
correlate with the severity of the problem. A child may be concerned
and develops anxiety for a minor tooth deviation while others may
not be concerned for major irregularities. Such perception and concern
would be dependent, to a large extent, on parents’ perception of
malocclusion which may get transferred to a child or else a child may
develop his/her concerns which to some extent may be linked with
awareness and education, besides child’s personality and priority for
well-being and self-image.
Gosney,6 in a study among British children population referred for
orthodontic treatment, observed that some were unaware or relatively
unconcerned about a pronounced malocclusion whereas others
showed great concern over a relatively mild irregularity. The concept
of self-image and concern for the deformity may vary and change
with age. Many children may not seek orthodontic treatment in
childhood but seek treatment when they grow to adulthood and
become aware of its need for social or functional reasons.
Parent’s satisfaction with their orthodontic treatment can be an
important consideration in motivation and perceived the need of
orthodontic treatment for their children.
Parental perception of malocclusion

Baldwin and Barnes7,8 observed that mother is usually the mobilising,
deciding and determining person in the family regarding the decision
for orthodontic treatment. They noted that in such cases the mother
usually came from a higher socio-economic background than the
husband, and may have had orthodontic problems of her own in the
past. It has been observed that father tended to be less involved in the
decision for treatment and if father alone was the main factor, it was
usually for the daughter’s treatment. The following factors among
parents were found responsible for bringing children for orthodontic
treatment:
• The parents attempt to resolve problems of their self-concepts

by way of identification with the child and his treatment.
• Feeling of guilt about their own hereditary deformity, among
any of parents.
• View orthodontic treatment as a social status symbol.
• It has also been observed that children living with divorced
mother who often develop psychological shortcomings are
often given orthodontic treatment as a ‘psychic gift’ in
compensation for being deprived of father.9
• They attempt resolution of an insoluble family health problem
by displacement on to the child’s orthodontic problem and
treatment.
The presence of these factors would mean that the child may be
withdrawn from the motivation for treatment or from participation in
the decision to seek the treatment. If this occurs in a child with a
minor malocclusion, the child may have no incentive for cooperation
during treatment and may turn uncooperative. Given above factors, it
is wise for the dentist/orthodontist to know about the patient’s
attitude towards treatment and make sure that the patient, if possible,
becomes an active participant of the treatment team that comprises of
the patient, the parent, and the orthodontist. An uncooperative
attitude of the patient can lead to several problems during treatment
and unsuccessful results.
Gender
Although the prevalence of malocclusion is equal among males and
females, more girls seem to be seeking orthodontic treatment than
boys. This is the reflection of the so-called ‘sex stereotyping’ wherein
the society has higher values and expectations on physical
attractiveness in females than males. It has also been found that
females are more critical of their dental appearance and dissatisfied
with the appearance of their dentition than males.10,11 Bergman and
Eliasi12 studied psychological effects of malocclusion and the attitudes
and opinion about orthodontic treatment in Singapore and Sweden
population groups (Fig. 6.1A–B). One of the significant conclusions
was that features of facial aesthetics are perceived differentially by
females and males. Complexion was more important for facial
aesthetics according to male and female Singapore population and
male Stockholm population. However, face shape is an important
feature for facial aesthetic according to Stockholm female population.
There is also a difference in males in Singapore and males in Sweden.
It has been reported that females are more concerned about their
dental defects as compared to males, and the concern is more likely
among individuals belonging to the higher socio-economic class.
FIGURE 6.1 (A and B) Reasons for seeking orthodontic treatment do
vary with ethnic and social factors. Source: Reproduced with
permission from Bergman L.12
Peer pressure
Peer pressure is perhaps one of the reasons for seeking dental advice.
It has been well found that many school children may seek advice on
the need for ‘braces’ like their peers. Some students may consider it as
a matter of excitement while others may take ‘braces’ as an
embarrassment. There are differences in perception of wearing
‘braces’ in school population and referred population for orthodontic
treatment.
There may be a general problem in acceptance of ‘braces’ in a
particular class of population while in another it may be a ‘badge of
honour’. Familiarity with appliance may reduce resistance to wear the
appliance. However, communication among peers and difficulties
with chewing of food, pain due to appliance breakages, difficulties in
speaking, extra efforts in the maintenance of oral hygiene and
extraction of a tooth (teeth) may discourage others from undergoing
Shaw et al.13 suggested and it has been the author’s clinical
observation too, that exposure to the sight of an appliance may
stimulate demand for similar ‘objects’ or treatment.
The studies on patients’ perception of orthodontic treatment needs
and professional assessment of orthodontic treatment needs do vary.
There have been some studies that have used the index of orthodontic
treatment need (IOTN) as a professional ruler to assess the need and
patients/parents questionnaire on subjective need. The IOTN has two
components: namely, dental health component (DHC) and aesthetic
component (AC). The DHC has to be assessed by a professional who
has been calibrated for the same. A study by Shue-Te et al.,14
conducted at various orthodontic offices in San Francisco (California,
USA) on patients and their pre-treatment study models, confirmed
that AC was the significant motivating factor for seeking orthodontic
treatment.
Self-esteem
It is obvious that dentofacial deformities can constitute a source of
emotional suffering, varying in degree from embarrassment to mental
anguish. To understand better this somatopsychic factor, one must
consider the concept of body image. An individual develops a
conscious image of his/her appearance, which is usually a pleasing
one. When it is not personally pleasing, the individual develops
anxieties about himself, which, if unresolved, may lead to mental
illness.15 Two aspects have to be considered in relation to dentofacial
defects.
The first is the individual’s attitude towards his/her body—an
attitude resulting both from his/her own reaction to the defect and
from what he/she perceives others reactions to be. A child who is
teased about his/her defect will tend to have a body image different
from that of a person without a dentofacial defect. The second aspect
is the response of others to the disability. This involves the degree to
which one’s relationship with others is altered because of how they
respond to the defect with a lack of acceptance from mild amusement
to horror. One’s body image is rarely identical with an objective
representation of the body, the severity of the disfigurement having
no direct proportional relationship to the degree of anxiety it
produces.
Roots16,17 stated that the first and foremost psychological effect of
dentofacial deformity manifests itself as an inferiority complex. The
sense of inferiority is a complex, painful emotional state characterised
by feelings of incompetence, inadequacy and depression in varying
degrees. Feelings of inferiority depend on an individual’s comparison
of himself with others. This sense of inferiority does not become a
serious problem until the child enters school. He/she is then brought
to realise his/her differences from the others and finds that he/she is
not able to enjoy company of his/her peers. When the individual
reaches adolescence, a sense of despair and a negative philosophy of
life, mixed with all kinds of peculiar personal traits, may have been
established.
In a study by Secord and Backman,18 an attempt was made to
determine whether or not some dentofacial characteristics related to
physical attractiveness drew consistent stereotypic judgements about
the individual. They studied the protrusion of the maxillary teeth,
protrusion–recession of the chin, and alignment of the teeth. From
their study, it appeared that some personality characteristics are
stereotyped because of an individual’s dentofacial appearance.
Studies have shown that the primary psychological impact of a
malocclusion does not result from the response of others to the
dentofacial irregularity but the individual’s own reaction to the
deformity. It has also been observed that children with malocclusion
often lack love and attention from their parents and as a result are
frustrated and depressed which may lead to introvert tendencies.
Patient’s personality traits

Personality traits can also be considered as motivational factors that
may affect cooperation during orthodontic treatment. Traits of
cooperative and uncooperative patients are summarised in Table 6.1.
Table 6.1
Psychological factors and personality traits affecting cooperation during

A cooperative patient An uncooperative patient
Psychosocial factors
It could be related to their greater concern about Those children who have a poor relationship
problems/aesthetics with parents at home and with teachers and
peers at school
Treatment has been initiated by the child himself Treatment has been decided by the parents
and decided by the parents with child being taken without child being taken into confidence
into confidence
Children with excellent family rapport Children from broken families
Personality traits
Usually around 14 years or younger Usually around 14 years or above with
superior intelligence
Enthusiastic High headed
Outgoing Independent
Energetic Aloof
Self-controlled Temperamental
Responsible Impatient
Determined Often nervous
Trusting Individualistic
Determined to do well Self-sufficient
Forthright Intolerant
Obliging Disregards wishes of others where his
decisions are involved
Hard working Easy going
Social class, availability and affordability

Certain health and cosmetic procedures are more valuable and
popular in social classes, which may also be indirectly influenced by
affordability as well as availability. Orthodontic treatment or braces
may be considered in a group of children in schools of high socio-
economic class as a symbol of prosperity. Those who are not having
braces may think they are missing on something and should have it
since they can afford it and also orthodontic specialists are available in
their neighbourhood (Fig. 6.1).
Adults seeking orthodontic treatment can be grouped into three
categories:
• Those seeking treatment with the sole objective of

improvement in their facial attractiveness.
• Those seeking treatment because of referral by their general
dentists for reasons such as prosthodontic rehabilitation,
periodontal disease or traumatic occlusion.
• Those seeking treatment as a part of orthognathic surgery for
correction of dentofacial anomalies.
Adults who seek orthodontic treatment are often self-motivated. In

a study by Riedman et al.19 to evaluate course and outcome of
orthodontic treatment in adults from the patients’ and operators’
point of view, it was found that in 75% of adult patients,
dissatisfaction with the dental aesthetics was the prime motive for
seeking treatment. Adults are better and more cooperative patients in
the maintenance of oral hygiene, wearing of elastics and keeping
treatment appointments for, they are self-motivated and have definite
objectives in mind. They are also better patients for they spend their
own money and decide their own orthodontic treatment. Nattrass and
Sandy20 concluded that adults seeking orthodontic treatment could be
excellent patients with high motivation and cooperation. Rarely
orthodontic treatment of an adult may be imposed by the spouse, and
in such situations, the adult patients’ behaviour may or may not be
the same as the one with self-motivation.
Among adult orthodontic patients, a large group may be those
referred by a general dentist or other dental specialists for
interdisciplinary orthodontic care. Prosthodontics is a common reason
for referral, which may include either space closure or uprighting of a
tilted molar or space gain for lost space in the anterior region.
Migration of teeth associated with periodontal disease in adults with
traumatic occlusion is a frequently encountered phenomenon. In such
cases, orthodontic treatment may follow periodontal therapy.
The orthodontic tooth/teeth movement may also be required for
aesthetic dental treatment, and procedures may include
intrusion/extrusion of a tooth, shifting of teeth to correct midline
problems, create space for veneers/laminates to restore microdontic or
peg-shaped lateral incisors.
Surgical orthodontic management of dentofacial skeletal
deformities is usually deferred till adulthood except in a few
situations. Early orthognathic surgery is indicated in cases of
extensively growing mandible due to condylar hyperplasia, or in
children with TMJ (temporomandibular joint) ankylosis where
condylar cartilage may have to be substituted with a costochondral rib
graft.
The adult orthognathic patients display psychological traits and
profiles different from others. Cunningham et al.21 investigated the
psychological profile of orthognathic patients prior to starting
treatment and compared it with controls. The orthognathic patients
displayed higher levels of anxiety and lower body image. The facial
image esteem was also found lower but of borderline significance.
Williams et al.22 studied factors of patients’ motivation for undergoing
orthognathic surgery in 326 patients. The major motivations for
having treatment was to have straight teeth (80%), prevent future
dental problems (65%), and improve self-confidence (68%). Females
sought treatment to improve their self-confidence and smile to
improve their social life.
Functional factors
Many malocclusions are related to poor function and this is another
major drive for seeking orthodontic treatment in many individuals.
The functional problems are often caused by malocclusions such as:
• Class II division 2
• Open bite
• Severe crowding or displaced anterior teeth
• Malocclusion associated with skeletal dentofacial deformities
of developmental origin and facial trauma
• Congenital defects of the face such as cleft lip and palate
Traumatic occlusion
Many young adults and children who have a reasonably near normal
face profile may have severe problems related to occlusion where
nature of malocclusion may affect the longevity of dentition. The
classical example are children with class II division 2 malocclusion
who often have a round–square face with a little irregularity of
maxillary incisors but 100% or more vertical overlap of anterior teeth.
Such a traumatic bite, which is detrimental to the health of
periodontium, may cause early loss of lower anterior teeth.
In other situations, deep bite, if not treated may cause attrition of
teeth and therefore by adulthood, the lower anterior teeth may be
significantly worn out. It may not be possible to provide any
rehabilitation of lower anterior teeth due to lack of any clearance for
crowns or removable partial denture.
Cases with severely crowded, irregular incisors and lingually
positioned maxillary incisors may cause difficulty in production of
linguoalveolar sounds (/t, d/).
Hypodontia/missing teeth cause inter-dental spacing, which may
lead to lateral or forward displacement of the tongue during speech
resulting in distortion of sounds. Lingual–alveolar phonemes (e.g. /s,
z/) followed by lingual-palatal phonemes (/j, sh, ch/) are most affected
by spaces in the dental arch.
In class III cases, sibilant and alveolar speech sounds are most
commonly distorted or affected (s, z, t, d, n, l). In these cases, there is a
difficulty in elevating the tongue tip to the alveolar ridge.
Most patients may not be aware of the cause of speech problems
and may end up with a speech therapist who may refer such persons
to dentist/orthodontist. In a study in Melbourne, Australia, Coyne et
al.23 researched the community perceived importance of correcting
various dentofacial anomalies. They found that correction of the
functional problem such as ‘difficulty in chewing or speaking’ was
considered critical. The correction of other factors such as ‘top teeth
that strike out in front’, ‘bottom teeth which strike out in front’ or
‘crooked or crowded front teeth’ were also considered necessary. They
also found a large percentage of respondents who considered the need
for ‘straight teeth and nice smile’ important in their lives.
Inability to close lips

Many others seek orthodontic treatment for reasons such as the
inability to keep the lips sealed at rest or excessive tooth exposure
during speech or smile. These adults are conscious of their body
image, but there are those too who have genuine functional problems.
Malocclusion associated with dentofacial

deformities
Others who may seek orthodontic help may be affected by either
abnormal growth of the facial skeleton or may suffer from abnormal
faces due to underlying systemic disease or genetic disorders. The
common causes are Addison’s disease (anterior open bite),
Mongolism (mandibular prognathism) and Pierre Robin sequence
(mandibular deficiency).
Abnormal facial growth in otherwise normal healthy children is
often encountered as an abnormally growing lower jaw—mandibular
prognathism, which may or may not be accompanied by a mid-face
deficiency. Such children if remain untreated during childhood may
end up as adult patients who would require a combination of
orthognathic surgery and orthodontics for the correction of facial
deformities.
Operated children with cleft lip and palate exhibit mid face
hypoplasia caused by restriction of the maxillary growth in
transverse, anteroposterior and vertical dimensions. Such children
may also exhibit overgrowth of the mandible and therefore would
require orthognathic surgery and orthodontics for the correction of
the facial deformity. In general, children with cleft lip and palate tend
to have lower self-esteem than non-cleft patients. Children with cleft
lip and palate have problems of social adjustments due to
compromised facial aesthetic and poor performance in school
associated with impaired hearing, poor articulation and inability to
effectively communicate.
An injury to face during childhood may affect the growth of the
condylar cartilage. The severity of injury may vary from haemorrhage
in TMJ to fracture of the condyle. Many such children, in the
developing world and Indian subcontinent, may remain unattended.
These kids may ultimately exhibit restricted mouth opening of
varying degrees which gradually may become more severe leading to
complete trismus caused by ankylosis of TMJ. The consequences of
injury to TMJ manifest in the form of deviated chin to the affected side
and consequential facial asymmetry. Facial asymmetry and restricted
mouth opening could be major reasons for seeking orthodontic
consultation in such children.
Key Points
Orthodontists treat dentofacial deformities that interfere with the well
being of patient by their adverse effect on aesthetics and function.
Most patients seek orthodontic treatment with the primary objective
of ‘improvement in facial appearance’, which may have an effect ‘on
their overall personality’. Hence, a concept of self-body image is
involved.
A majority of orthodontic patients are young adolescents who are
developing human beings and hence, are highly emotional and
reactive to the environment and circumstances. The orthodontic
treatment is quite demanding on the part of the patient not only
regarding extra strain in maintaining oral hygiene, wearing elastics
and headgear but also in frequent visits to an orthodontist for a long
period.
The cooperation of patient during treatment is important in
determining treatment duration and outcome. The cooperation or
non-cooperation is further dependent upon patient’s underlying
personality trait, and orthodontic treatment may further aggravate
anxiety of such nervous patients. Hence, during the early course of
treatment itself, the orthodontist should not only accurately plan the
timing of treatment and the choice of mechanotherapy for good and
stable results but also understand the patient and his
guardians/parents, as persons.24
References
1. Cunningham SJ, Feinmann C, Ibbetson R. Disorders
of appearance. In: Feinmann C, ed. The mouth, the
face and the mind, 7. Oxford, UK: Oxford University
Press; 1999:131–156.
2. Tajima M, Kohzuki M, Azuma S, Saeki S, Meguro M,
Sugawara J. Difference in quality of life according to
the severity of malocclusion in Japanese orthodontic
patients. Tohoku J Exp Med. 2007;212(1):71–80.
3. Nicodemo D, Pereira MD, Ferreira LM. Self-esteem
and depression in patients presenting angle class III
malocclusion submitted for orthognathic surgery.
Med Oral Patol Oral Cir Bucal. 2008;13(1):48.
4. Azuma S, Kohzuki M, Saeki S, Tajima M, Igarashi K,
Sugawara J. Beneficial effects of orthodontic
treatment on quality of life in patients with
malocclusion. Tohoku J Exp Med. 2008;214(1):39–50.
5. Kilpelainen PV, Phillips C, Tulloch JF. Anterior tooth
position and motivation for early treatment. Angle
Orthod. 1993;63(3):171–174.
6. Gosney MB. An investigation into some of the factors
influencing the desire for orthodontic treatment. Br J
Orthod. 1986;13:87–94.
7. Baldwin DC, Barnes ML. Some psycho-social factors
motivating orthodontic treatment. International
Association of Dental Research, 43, Abstract no. 461;
1965.
8. Baldwin DC, Barnes ML. Patterns of motivation in
families seeking orthodontic treatment, programs
and abstracts of papers. J Dent Res. 1966;44:412:
(Abstract).
9. Sims MR. Psychological disturbances associated with
a mutilated malocclusion. J Clin Orthod.
1972;6(6):341–345.
10. Shaw WC. Factors influencing the desire for
orthodontic treatment. Eur J Orthod. 1981;3:151–162.
11. Sheats RD, McGorray SP, Keeling SD, Wheeler TT,
King GJ. Occlusal traits and perception of
orthodontic need in eight grade students. Angle
Orthod. 1998;68(2):107–114.
12. Bergman L, Eliasi F. Sociocultural influence on
attitudes about orthodontic treatment and treatment
need, Institute of Odontology, Karolinska Institute,
and Huddinge, Sweden.
http://www.ki.se/odont/cariologiendodonti/978/Lisbeth
Bergman Farah Eliasi.pdf page 215-44.
13. Shaw WC, O’Brien KD, Richmond S. Quality control
in orthodontics: factors influencing the receipt of
female orthodontic treatment. Br Dent J.
1991;170:66–68.
14. Shue-TeYeh M, Koochek AR, Vlaskalic V, Boyd R,
Richmond S. The relationship of 2 professional
occlusal indexes with patients’ perceptions of
aesthetics, function, speech, and orthodontic
treatment need. Am J Orthod Dentofac Orthop.
2000;118:421–428.
15. Silverman M. Orthodontics and body image. Pa Dent
J. 1971;38(8):10–15.
16. Weiss J. Body image in orthodontics. J N J State Dent
Soc. 1973 Fall;45(1):14–17.
17. Roots WR, Face value. Am J Orthod. 1949;35:697–703.
18. Secord PF, Backman CW. Malocclusion and
psychological factors. J Am Dent Assoc.
1959;59:931–938.
19. Riedmann T, George T, Berg R. Adult patients’ view
of orthodontic treatment outcome compared to
professional assessments. J Orofac Orthop.
1999;60(5):308–320.
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orthognathic patients different? Eur J Orthod.
2000;22(2):195–202.
22. Williams AC, Shah H, Sandy JR, Travess HC.
Patients’ motivations for normal treatment and their
experiences of orthodontic preparation for
orthognathic surgery. J Orthod. 2005;32(3):191–202.
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24. Kharbanda OP. Psychological considerations in
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SECTION III
Growth of face and craniofacial
complex
Chapter 7: Development of teeth, dentition and occlusion

Chapter 8: Prenatal development of the foetus concerning the
craniofacial region
Chapter 9: Concepts of growth and development
Chapter 10: Postnatal growth of face and craniofacial region
Chapter 11: Functions of stomatognathic system and their
implications on occlusion
CHAPTER 7
Development of teeth, dentition
and occlusion
A. Mathur
S.S. Rana
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
The origin and evolution of dentition
Growth factors
Epithelial mesenchymal interactions
Determination of number, type, positioning of tooth
germs
Initiation and bud stage
Cap and bell stage
Role of microRNAs in tooth development
Hyperdontia/supernumerary teeth
Taurodontism
Diastema
Peg shaped teeth
Dental eruption and development of occlusion
Pre-dentate period
Gum pads
The primary dentition period
Mixed dentition period (6–12 years)
Second transitional period (10–12 years)
Dental eruption
Pre-emergent phase
Post-emergent phase of eruption
Post-eruptive phase
Overbite
Overjet
Key Points
Introduction
The development of dentition starts from around 6 weeks of
intrauterine life with the initiation of tooth buds. The sequence of
events in the development of eruption of teeth leading to the
establishment of functional occlusion are governed by an intricate
balance of the complex, yet predetermined biological phenomenon
comprising of genes, signalling ligands, their receptors and mediators.
Precise genetic control inherent in the cellular milieu, epigenetic
factors, many local/environmental factors directly or indirectly
influence the development of dentition and occlusal relationships. The
orchestration of these events and their timings are critical to the
development of a functional, aesthetic, stable occlusal relationship.
The understanding of the developmental process of dentition is
essential for appreciating the disturbances leading to malocclusion,
which could be limited to teeth, jaws or involve a component of the
craniofacial abnormalities syndromes. The orthodontist should be able
to recognise developing normal or abnormal occlusion and envisage
the final position of erupting teeth, such that, the dentition can be
guided into its proper position. This should be in harmony with the
underlying craniofacial structures, and result in healthy functions of
the stomatognathic system.
The origin and evolution of dentition

The human dentition, is the result of evolution over many ages
resulting in the development of highly specialised oral appendages
called ‘teeth’. During evolution from reptiles to mammals, dentition
evolved from polyphyodont (having several sets of teeth in
succession) to diphyodonts in humans (consisting of two sets of
dentition that appear in succession); also from homodonts, where all
teeth are similar, to heterodonts, showing different tooth types. This
gave rise to a chronological order of appearance of each tooth within
its set, the sequence of eruption; in conjunction with synchronised
development of teeth and jaws, to establish functional
interrelationships of teeth, called occlusion.1,2
Growth factors
Growth factors are signalling molecules that help adjacent cells to
communicate with each other through specific cell membrane
receptors. They act inter-cellularly between embryonic cells,
stimulating cellular differentiation and proliferation.5 Families of
growth factors involved in tooth development are epidermal growth
factor (EGF), fibroblastic growth factor (FGF), transforming growth
factor (TGF), its receptor ectodysplasin A (EDA), bone morphogenic
proteins (BMP) (member of TGF β family) and platelet-derived
growth factor (PDGF).6
Various signalling pathways via transcription factors act on specific
promoter/enhancer regions of DNA to regulate target gene
expression.2 Gene expression is the activation of a gene that results in
the production of polypeptide/protein, which further activates or
deactivates other genes with the help of transcription factors (growth
factors).7 Mutation in genes involved in major signalling pathways
results in genetic defects. More than 200 genes have been found
involved actively in the development of teeth and for updates on the
same reader can visit http://bite-it.helsinki.fi.
Epithelial mesenchymal interactions

Tooth development or odontogenesis is governed by an array of
epithelial–mesenchymal interactions formed by a cascade of complex,
pre-determined, inter-dependent communications between adjacent
layers of the epithelium and ectomesenchyme, mediated by multiple
signalling pathways resulting in growth and differentiation of
embryonic cells. Teeth are appendages that develop from epithelial
cells of the mucosa lining the stomodeum or the primitive oral cavity,
along with the ectomesenchyme cells which originate from the cranial
neural crest cells. A cascade of interactions occur within the two
layers, the epithelium, and the underlying mesenchyme, as well as
between the two sequentially and reciprocally under the influence of
multiple cell signalling pathways for tooth formation. These pathways
affected by genetic modulation determine the organisation patterning
of dentition in each species.3,4
Determination of number, type, positioning of

tooth germs
Determination of specific tooth types at their correct position in the
jaws is referred to as patterning. Patterning is a spatial temporal event
comprising of regional development of incisors, canines, premolars,
molars, which occur at different ages. This involves the process of
induction, competence and differentiation. It occurs around
embryonic day 10 (E10) in the mouse.7,8
The dental epithelium appears to be the point of the origin of
signals for number and positioning of tooth primordium. The
epithelium shows expression of Fgf-8, which is critical in the
establishment of the oral–aboral axis. Pitx2 appears in the stomodeum,
subsequently localised in dental placodes; whereas Pax9 may be
responsible for instructing the mesenchyme to respond to epithelial
signals and regulation of signalling molecules produced by it. Once
the signals initiating tooth development have conferred the ability for
tooth development to the ectomesenchyme, the dental papillary cells
maintain it.5,9 Fig. 7.1 shows the pathways involved in the
determination of tooth type.
FIGURE 7.1 Pathway involved in regulating determination of
tooth type in murine dentition.
Green colour denotes expression in dental epithelium and yellow
denotes expression in dental mesenchyme. Bmp4 and Fgf8 are
expressed in murine epithelium of future incisor and molar,
respectively. A positive feedback loop is created by Bmp4 with islet 1
as it induces Msx1 expression in the region of presumptive incisal
ectomesenchyme, repressing Pitx1 and Barx1 expression in molar
ectomesenchyme. FGF-8 induces expression of Pitx1 and Barx 1 in
ectomesenchyme of future molar. lsl 1: LIM homeodomain protein
islet1.
A particular set of homeobox genes present within the

ectomesenchyme, the odontogenic homeobox code, directs the final
morphology of the tooth primordium.9 It includes the Lim-homeobox
domain genes transcription factors Lhx-6 and 7.7,8
Other genes involved in the tooth development like Otlx-2, Dlx-2,
Msx-1, Msx-2 and Lef-1 are expressed at the same time. Dlx-1, Dlx-2
Barx-1 genes are involved specifically in the development of molar
teeth9–11 (Box 7.1).
Box 7.1 Odontogenic homeobox genes

Homeobox genes are a big family of master genes that oversee
patterns of morphogenesis, cell differentiation and positioning during
embryonic development in vertebrates, including humans. The
homebox has about 180 base pairs. Two subfamilies of the HOX genes
can be identified: 1. The clustered homeobox or class I homeobox
genes and 2. The non-clustered or divergent homeobox genes. The
ectomesenchyme of the oral part of the 1st branchial arch shows
expression of members of Alx, Barx, Dlx, Lhx, Pitx, Msx and Gsc
classes.
Initiation and bud stage
Expression of several genes in the ectomesenchyme marks the site of
tooth germ initiation including Pax-9 and Activin-A. Fgf-8 induces
Pax-9, that is, in turn, inhibited by BMP2 and 4. Fgf-8, BMP2 and
BMP4 are expressed in non-overlapping areas. Tumour necrosis
factor, fibroblast growth factor, Bmp, Shh, Wnt pathways are involved
in signalling pathways of organogenesis from the 9th to 11th
embryonic days to initiate tooth epithelium. Ectodysplastin, a
signalling molecule belonging to the TNF family, mediates signalling
between the ectodermal components in tooth germs.5,9 Transient
signalling centres appear in the epithelium during key morphogenetic
stages, first appearing in dental placodes during budding of
epithelium, subsequently during bud to cap transition.4
At E11.5 in the mouse embryo and at 37 days in humans in utero,
tooth morphogenesis begins as localised thickenings of the oral
epithelium within the dental placodes. At around 6th week of human
embryogenesis, they form dental lamina, followed by invagination of
the actively proliferating dental epithelium into the underlying
mesenchyme. The paracrine signals are produced during this stage by
the ectoderm that mediates cell communication, initiating tooth
development.
The bud stage is represented by the first epithelial incursion into the
ectomesenchyme of the jaw between E12.5 and E13.5 in mice
corresponding to 55–56 days of human embryonic development.
BCL11B is necessary for proper timing of epithelial proliferation by
down-regulation of epithelial Bmp-4-Shh, and its invagination to
produce a tooth bud. BMP-4 acts as a paracrine molecule that induces
and maintains the gene expression of Shh-Bmp-2 at bud stage. Msx1,
PDGF-A, Pax9, Lef1, Activin βA, Runx2 contribute to the transition
from bud to cap stage. Enamel knot formation involving various
pathways occurs at this transition stage.12,13
Cap and bell stage
The cap-shaped ectoderm surrounding the papilla at E14 is referred to
as the enamel organ. The appearance of a transitory yet important
structure in the dental epithelium, the primary enamel knot (PEK),
controls the formation of cusps. Multicuspid teeth show an
appearance of secondary enamel knots (SEK) which appear where
infolding of inner epithelium takes place, displacing the stellate
reticulum, giving it a shape resembling a bell. The marking of the bell
stage for primary teeth is at 14 weeks. The height of the cusps
correspond to the timing of appearance of secondary EKs.14
The key signalling molecule for EK formation is BMP-4. In teeth
destined to be multicuspid, EDA expression around PEK is stimulated
by BMP-2, BMP-4, BMP-7 and establishes the locations of SEK. Wnt/β-
catenin signalling is an important signalling pathway required for
maintenance of the enamel knots, thus tooth shape
determination.1,12,15
By the end of E16, EKs show apoptosis balanced by cell
proliferation occurring simultaneously in the dental epithelium. This
proliferation involves factors like FGF-4, FGF-9, HGF, Sp6, Tβ4, YAP,
EGF.15,16
Odontoblasts differentiate from mesenchymal cells adjacent to inner
enamel epithelium in the dental papilla laying down predentin. Twist
1 expression is seen at this time at the interface.17 Meanwhile, at
around 18 weeks, differentiation of cells of the inner enamel
epithelium adjacent to the freshly layered dentin differentiate into
enamel forming cells called ameloblasts. They secrete the enamel
matrix which ultimately mineralises. At the same time, root formation
begins with the formation of root dentin, cementum, periodontal
ligaments, which hold the tooth in its socket after the eruption8 (Fig.
7.2; Box 7.2, Box 7.3).12,16,18,19
FIGURE 7.2 Signalling and transcription factors mediating tooth
development.
A. At initiation, signals from epithelium activate a set of transcription
factors (Wnt, Fgf8, Shh, Bmp, Eda, Pitx2) in mesenchyme leading to
mesenchymal condensation (MC) and formation of dental placode
(DP). Bmp4 is one of the first genes to be expressed at the site of
presumptive dental epithelium. Shh regulates proliferation of dental
epithelium (DE) cells to produce tooth bud. B. Epithelial Bmp induces
expression of Bmp4 in mesenchyme, correlating with shift in
odontogenic potential to dental mesenchyme (DM) at bud stage.
Eda,Edar, Pitx2 expressed in DE. Runx2, Dlx1,2, Fgf3,10 are also
expressed in DM. C. Primary enamel knot (EK) appears in DE. Lef1
regulates expression of Fgf4 in the epithelium, which in turn induces
Runx2 expression in the DM through Msx1. Runx2 further induces
expression of Fgf3 regulating expression of Shh in EK. The Wnt
cannonical pathway functions through β-catenin acting on Bmp4
mediated by TCF/Lef. D & D1. EK is fully functional and expresses Shh
and Fgf4 that regulate dental papilla formation in adjacent
mesenchyme and proliferation of DE to form cervical loops (CL). Fgf3
and Runx2 show remarkable expression in mesenchyme induced by
FGF signals from DE. Mesenchymal Bmp4 targets p21, resulting in
exiting of EK by inducing apoptosis. Other factors are also expressed.
E & E1. Early bell stage shows slit-1 expression which initiates
proliferation within SEK and Fgf4 which promotes proliferation of
adjacent DE and DM cells. Bmp4; Wnt5a,6,10a expression is also
seen. Tgf β/ Bmp signals odontoblast induction. After which they signal
back to DE for ameloblast induction through Bmp2,4,Tgfβ1. Shh from
DE supports ameloblast differentiation along with Tgf β1, Wnt3, Eda
and follistatin. Ameloblasts express Sp6 & Msx2.
Box 7.2 Odontogenesis
• Histodifferentiation: The changes that occur after initiation of

the tooth bud and its proliferation, wherein a mass of similar cells
differentiate into morphologically and functionally different cell
types seen from cap stage to bell stage is termed as
histodifferentiation.
• The highest level of histodifferentiation of the enamel organ is
seen during the bell stage just before the formation of dentin and
enamel begins. During this stage, the ameloblasts and
odontoblasts assume their distinctive phenotype.
• Morphodifferentiation: Another phenomenon occurring during
this stage is morphodifferentiation, in which the crown of the
tooth acquires its final shape and the future DEJ (dentoenamel
junction) is given its outline.
Box 7.3 Odontogenesis (hard tissue formation)
• Apposition: After morphodifferentiation, the process of

deposition of extracellular matrix forming the dental hard tissues
is called apposition. The appositional growth of hard tissues is
layer by layer which is characterised by regular, rhythmic
deposition of dentin and enamel matrix.
• Calcification: Here the matrix laid down by the ameloblasts and
osteoblasts undergoes mineralisation.
Role of microRNAs in tooth development

microRNAs (miRNAs) are short, non-coding nucleotide sequences
expressed endogenously to regulate gene function post-
transcriptionally; thereby influencing the expression of protein coding
genes. Differential expression of miRNAs in the dental, epithelial-
mesenchymal layers affects the differentiation of ameloblasts,
odontoblasts, dental follicle pulp cells through regulation of signalling
molecules, transcription factors and some important membrane
proteins. An example is MiR-135a, which regulates the enamel
formation by targeting BMP cell signalling pathway. Within the dental
epithelium, they are also seen to be differentially expressed in the
epithelium of molars and incisors.5 Various studies on mice showed
that Dicer1 knockdown (required for maturation of miRNs), resulted
in prominent dental anomalies like multiple branched enamel-less
incisors, extra incisors, severely misshapen incisors, molars, cuspless
molars, and change in incisor patterning caused by a defect in
ameloblast differentiation. Their role has also been elucidated in tooth
eruption.2,20
Aberrations in tooth development can be grouped as alterations in
number, morphology and size (Box 7.4).
Box 7.4 Cell signalling pathways involved at

different stages of tooth development expressed
from different areas/parts of the developing
tooth
Signalling molecules expressed Transcription factors expressed
Oral ectoderm:
BMP Pitx2
FGF Sox2
SHH
WNT
TNF
Dental placode and enamel knot:
BMP P21
FGF Msx2
SHH Lef1
WNT Edar
Odontogenic mesenchyme Lhx6,7
BMP Msx 1,2
FGF Dlx1,2
ACTIVIN Pax9, Gli2,3, Osx
Dental lamina
WNT Frizzled-6
Condensed dental mesenchyme and dental papilla mesenchyme
BMP Lhx6,7
FGF Msx 1,2
WNT Dlx1,2
Pax9
Gli2,3, Runx2, Klf4
Root analogue
Follistatin Notch
Activin
FGF10
BMP4
Crown analogue
FGF3,9,10 Notch
Activin
BMP4
Tooth agenesis: Tooth agenesis is the congenital absence of one or

more teeth which can affect the entire dentition, called anodontia (ano,
Greek for none); more than one tooth but less than six called
hypodontia (hypo, Greek for less); or more than six teeth called
oligodontia (oligo, Greek for few).21,22
Hypodontia can occur sporadically or inherited as a non-syndromic
familial form or as part of a syndrome. Its incidence varies from 1.6%
to 9.6%.23 Hypodontia is more common in females than males (ratio
3:2).
In the primary dentition, the incidence of hypodontia ranges from
0.5% to 0.9% showing racial disparity. Agenesis of a deciduous tooth
is nearly always followed by agenesis of the corresponding permanent
tooth.9
In permanent dentition, most commonly affected teeth are
maxillary lateral incisors and mandibular second premolars.
Hypodontia can be seen associated with maxillary canine—1st
premolar transposition, mandibular lateral incisor—canine
transposition, palatally displaced maxillary canines, microdontia,
malformation of other teeth, taurodontism, impacted teeth, delayed
formation and eruption, small roots, enamel hypoplasia, altered
craniofacial growth and cleft lip and palate.22–24 The prevalence of
oligodontia (congenital absence of more than six teeth excluding 3rd
molars) is 0.0%–1.1%.25
Tooth agenesis can result in malocclusion due to excess space as
well as deficiency in the growth of the alveolar processes associated
with the missing teeth, causing malpositioning of the remaining teeth
by their supra eruption, tipping and drifting. Tooth agenesis in buccal
segment results in atrophy of bone leading to less than optimum bone
height. Dental anomalies frequently seen associated with tooth
agenesis are: microdontia, peg-shaped maxillary lateral incisors, short
roots, taurodontism, ectopic canines, palatally displaced canines,
conicality of canines, reduction in number of molar and premolar
cusps, infra positioned/ankylosed primary molars, ectopic eruption of
1st molars, delayed development, eruption, enamel hypoplasia; they
pose a definite challenge to the orthodontist.26
Hyperdontia/supernumerary teeth
The presence of extra teeth than normal is termed as hyperdontia or
supernumerary teeth. The most common supernumerary teeth are
mesiodens which appear in the midline of the maxilla. The prevalence
of supernumerary teeth in primary dentition is between 0.3% and
0.8%, while in permanent dentition, it is greater, about 1.5%–3.5%.
More than 90% of supernumerary teeth show a predilection for
occurrence in the maxilla. They are mostly impacted but
approximately one fourth of supernumerary teeth erupt in the
anterior maxilla. They occur as a single tooth or multiple teeth,
unilateral or bilateral, in one or both arches. Multiple supernumerary
teeth are rare in non-syndromic individuals.24
The genetic factors associated with the above anomalies have been
listed in Box 7.5.20,23–34
Box 7.5 Genentic basis of dental anomalies
I. Disturbances in tooth development at initiation and bell stage

Genetic factors
1. Tooth
Non-syndromic Syndromic
agenesis
a. Anodontia MSX1 PTH1R (CLPED1 syndrome)
PAX9 IKBKG/NFKBIA (Anhidrotic ectodermal
dysplasia)
ANOS1, FQF8, PROK2 FGFR1 (Kallmann
syndrome)
b. Hypodontia
PAX9 mutation—lost ADAMTS2 (Ehlers Danlos syndrome)
molars ANTXR1 (GAPO syndrome)
MSX1 mutation— COL1A1/2 (Osteogenesis imperfecta)
premolars CREBBP (Rubinstein-Taybi syndrome)
EDA mutation SLC26A2 (Diastrophic dysplasia)
WNT10A EVC (Ellis-van Creveld syndrome and
GREM2 Weyers acrofacial dysostosis)
FGF10 (Lacrimoauriculodentodigital
syndrome)
FLNB (Larsen syndrome)
FOXC1 (Axenfeld-Rieger syndrome type3)
FGFR2 (Apert syndrome)
GJA1 (Occulodentodigital dysplasia)
JAG1 (Alagille syndrome)
IKBKG (Incontinentia pigmenti)
IRF6 (Van der Woude)
KMT2D/KDM6A (Kabuki syndrome1/2)
BBS (Bardet-Biedl syndrome)
NSD1 (Sotos syndrome)
OFD1 (Orofacio-digital syndrome)
p63 (Hay-Wells syndrome)
PITX2 (Axenfeld-Rieger syndrome type1)
PVRL1 (Cleft lip/palate-ectodermal dysplasia)
RECQL4 (Rothmund Thomson syndrome)
RSK2 (Coffin-Lowry syndrome)
TGIP1, SIX3, ZK2 SHH (Holoproscencephaly)
TBX3 (Ulnar-mammary syndrome)
TFAP2B (Char syndrome)
TCOF1, POLR1C/D (Treacher Collins)
WNT10A (Odonto-oncho-dermal dysplasia)
c. Hyperdontia
Loss of Ectodin (inhibitor APC (Adenomatous polyposis, Gardner
of BMP signalling) syndrome)
Ectodysplasin (Eda) (Wnt AXIN2
signalling mediator) FGF10, FGFR2/3 (Lacrimo-auriculo-dento-
Adenomatous polyposis digital syndrome), FGFR2 (Apert syndrome)
coli (Apc) (Wnt modifier) RUNX2 (Cleidocranial dysplasia)
Overexpression of β- MID1 (Opitz G/BBB syndrome)
catenin TRPS1 (Tricho-Rhino-Phalangeal syndrome)
Gas1—Shh protein EVC (Ellis-van Creveld syndrome)
antagonist TN-XB, COL3A1, COL5AI/2, COL1A1 (Ehler
Inactivation of Sprouty2 Danlos syndrome)
(Spry2) and/or Spry4 ROR2 (Robinow syndrome)
Sp6 (a zinc finger NHS (Nance-Horan syndrome)
transcription factor known CREBBP/EP300 (Rubinstein-Taybi syndrome)
as Epfn) BCOR (Oculofaciocardiodental syndrome)
Osr2
d. Oligodontia
AXIN2 AXIN2 (Oligodontia-colorectal cancer
PAX9 syndrome)
EDA1, EDAR, EDARADD EVC2 (Ellis-van Creveld syndrome)
LRP6 KREMEN1 (Ectodermal dysplasia)
LTBP3 MSX1 (Witkop syndrome)
SMOC2 TFAP2B (Char syndrome)
WNT10A
MSX1
II. Disturbances in tooth development at early bell stage
2. Enamel Genetic factors
defects
Msx2
Lama3
Sp3
Sp6
Smoothened
Gdnf
Periostin
TGFβ1
Eda
Follistatin
Wnt3
AMELX
Ameloblastin
Tbx1
Enamelin
Mmp20
Connexin 43
Sprouty2,4
Noggin
III. Disturbances in tooth development at late bell stage
3. Dentin Genetic factors
defects Dspp
DMP1
Msx2
Sp6
Sp3
Noggin
Taurodontism
It is a condition most commonly seen in molars, in which body of the
tooth pulp chamber is enlarged at the expense of the root, resulting in
the formation of bull like teeth. It results from a disturbance during
the development of Hertwig’s epithelial root sheath. It is found to be
associated with isolated hypodontia or syndromic hypodontia.35
Diastema
Loss of function of either of the two genes, Spry2, which is expressed
in the epithelium, and Spry4, expressed in mesenchyme during tooth
development results in the formation of teeth in a region, called the
diastema that is generally toothless.
Peg shaped teeth
A peg lateral is a maxillary lateral incisor that is conical in shape,
broadest cervically, tapers incisally, to a blunt point. Peg shaped teeth
grow from a single lobe instead of four. Peg shaped maxillary central
incisors are less common. They are mainly defined by genetic factors,
but can also be a result of endocrinal disturbances. Genes involved in
the formation of peg shaped teeth are EDAR, EDARADD and GJA1
(small teeth). They can be present along with other anomalies such as
tooth agenesis, canine transposition and over retained primary teeth.
Early correction is required for correct development of the
stomatognathic system.9
Dental eruption and development of
occlusion
The development of occlusion is a complex process that starts at birth
from pre-dentate period to adulthood.
Pre-dentate period
At birth, the newborn has a small face, large head and small chin. The
body weight of the newborn is 5% of adult weight while brain size
accounts for 25% of adult size.36 About half of the total postnatal
growth of brain occurs during the first year of life and reaches to
about 75% of its adult size until the end of the second year.
Plastic bite
At birth, mandibular condyles exhibit hinge movements, called plastic
bite, which essentially means rhythmic biting related to a pattern of
opening and closing the jaw, simultaneous with touching the gums.
The plastic bite is seen up to 5 months of age.
Gum pads
At birth, the alveolar processes, are called gum pads. Dental groove
divides gum pad into labial and lingual parts. Transverse groove
further divides gum pad into ten segments in each jaw. Each of the
segment houses a developing tooth sac. The transverse groove
between canine and first molar called lateral sulcus, is helpful in
predicting inter-arch relationship. The maxillary arch is wider and
longer than its counterpart. The gum pads contact the mandible arch
around the molar region and space between the upper and lower gum
pads in anterior region. This space between upper and lower gum
pads is called an infantile open bite. Transverse development of both
jaws occurs mainly due to the presence of a suture in the median
plane of the maxilla, and synchondrosis in the mandible. The
synchondrosis in the mandible calcifies at about 6 months to 1 year of
age. The suture in the median plane of the maxilla remains until the
completion of the development of dentition; therefore, maxillary
expansion is a possibility till puberty.
Salient features of oral cavity of a newborn
• Tongue is interposed between lips

• Maxillary gum pad is wider, overlap mandibular gum pad
• Vertical gap exists in between upper and lower lip pad
anteriorly
• Both jaws grow rapidly, 6–8 months of age
The primary dentition period

Primary dentition is necessary for mastication, development of
speech, growth of the alevolar processes, the jaws, neurosensory
maturation of the stomatognathic system and aesthetics. Oral motor
behaviour related to masticatory skills are achieved at the time of
emergence of the primary dentition through the alveolar mucosa.37
The contact of opposing first primary molars is essential to the
development of occlusion, providing a neuromuscular substrate for
more complex mandibular and tongue functions.
At the age of 4–6 months, mandible starts to descend; the tongue
begins its up down movements and the intraoral space increases. At
this age, the anatomical relationships of the face begin to change. The
physical neurological changes at this age are responsible for the
change in the sucking pattern.
The primary dentition maintains the developing crowns of
permanent teeth under their roots.
Eruption sequence of primary teeth

Mandibular deciduous central incisors are usually the first primary
teeth to emerge. The primary teeth erupt in the following sequence: A-
B-D-C-E. After 1 year, transverse and vertical development of anterior
regions of jaws is limited. Posterior parts of the jaws show continued
growth in distal molar regions for providing space for the developing
molar to emerge. Teeth do not begin to move towards occlusion plane
until their crown formation is completed.
Features of occlusion in primary dentition

Occlusion of twenty primary teeth is established by 2.5–3 years of age.
The dental arches are half round or ovoid in shape. The curve of Spee
is almost flat, overjet, overbite are minimal. The deciduous incisors are
more upright compared to their permanent successors.
Primate/anthropoid spaces
Between the age of 4 and 5 years, interdental spaces appear due to the
rapid development of jaws. The spaces between incisors in the
primary dentition are called secondary or developmental spaces. A
spaced primary dentition is considered good for it will enable the
accommodation of permanent successors without crowding. The
distinct spaces between the mandibular canine–the first primary
molar and between the maxillary lateral incisor–the primary canine
are called primate spaces (Simian spaces/anthropoid spaces)38 (Fig
7.3A–B).
FIGURE 7.3 (A and B) Primate space: These are often found distal to
deciduous lateral in the maxilla, decciduous canine in the mandible.
From 4 years of age to the eruption of the permanent molars, the
sagittal dimensions of the dental arches remain nearly unchanged.
Only minor changes occur in primary dentition arches during 3.5–6
years of age, mainly in transverse dimensions.34 The deciduous
maxillary inter-canine distance is 1.7 mm greater in spaced dentition
than in closed dentitions. The mandibular inter-canine distance is 1.5
mm higher in spaced dentitions. A high prevalence of spacing in
primary dentition is seen more frequently in males than in females.
The sagittal occlusion relationship has no direct bearing with spacing
except in posterior cross-bite, where it is less frequent, and open bites,
where it is more frequent.39
The absence of spacing in deciduous dentition, the presence of
overjet and a straight terminal plane are suggestive of incipient
malocclusion.
During the growth of the jaws, the canine and molars remain in
positive contact relation. During this period, all mandibular teeth
occlude slightly lingual to maxillary teeth. The mandibular deciduous
molars occlude slightly mesial to their antagonist due to the difference
in mesiodistal crown dimension of the maxillary-mandibular central
incisors. The terminal plane relationship is one of the significant
indicator of possible future sagittal occlusion in the permanent
dentition.
Exfoliation of primary teeth

Exfoliation of the primary dentition is a physiologic event; each
exfoliation must occur at the proper time during the transition of
dentition. An orchestrated physiologic sequence of eruption of the
successor teeth affects several adjustments leading to the
establishment of normal occlusion. Careful monitoring and control of
these events through diligent clinical examination, appropriate
radiograph surveillance can prevent many abnormal exfoliations/or
eruption disturbances.
Early exfoliation
Variations in the age of eruption or exfoliation of primary teeth are
not uncommon. A variation of 6–10 months for early or delay in
exfoliation can be considered within normal range. Early loss of
primary teeth is one of the most common problems during the
transitional stage of dentition, resulting in loss of arch space required
for the permanent successors. Local factors include iatrogenic
extraction of deciduous teeth due to extensive caries, traumatic injury,
early exfoliation due to abnormal root resorption. The systemic factors
associated with early loss are hypophosphatasia, rickets, acrodynia,
leukaemia, juvenile periodontitis, Papillon-Lefèvre syndrome to name
a few.
Space loss due to early shedding of primary teeth has detrimental
effects on permanent occlusion.40 The rate of space closure is higher in
the maxilla than in the mandible. The greatest amount of space
closure/unit of time occurs in the maxillary primary second molars
followed by mandibular primary second molars regions. Owen
concluded that that space closure in the maxilla is predominantly
caused by mesial movement of the molar teeth posterior to the
extraction space. In the mandible, space closure is mainly caused by
distal movement of the teeth anterior to space. A tooth mesial to the
affected molar can drift distally into space. Therefore, loss of space or
arch length can occur from both mesial and distal directions.41
Highest rate of space loss happens in the first year after extraction,
especially in the first 6 months.42
In situations of premature loss of mandibular primary cuspids, the
anterior arch is less stable, the incisors may be tipped lingually by
hyperactivity of the mentalis muscle. Lingual tipping of the lower
incisors directs the erupting permanent cuspid to slide labially which
may enhance the depth of the curve of Spee and deep bite.
Delayed exfoliation
Delayed exfoliation of primary teeth can also pose problems for the
eruption of their successors, consequently adversely affecting the
development of normal occlusion. Vigilant clinical examination, serial
monitoring can help in the early detection of intervention of the
retained teeth. Delayed exfoliation or retention of deciduous teeth
beyond their age of exfoliation can also result from a congenital
absence of the successor tooth follicle and ankylosis of deciduous
tooth, or trauma. The systemic factors include familial patterns,
endocrine disturbances, syndromic or congenital defects such as
cleidocranial dysostosis.
Timing of extraction of a deciduous incisor to accommodate an
erupting permanent successor is controversial. The permanent
mandibular incisors typically erupt lingual to primary dentition. With
time, due to the influence of the tongue, continued alveolar growth,
permanent incisors move into their designated normal labial
positions. If exfoliation of primary incisor is delayed or deciduous
tooth/teeth are retained, the labial positioning of permanent incisors is
adversely affected. A tooth is considered retained if not exfoliated by
the age of 8.2 years (primary central incisor) or 8.4 years (primary
lateral incisor). Such a retained tooth would require extraction to
facilitate normal eruption of the successor’s tooth. A firm primary
incisor whose root has failed to resorb past the shedding schedule
would also require extraction.43
Mixed dentition period (6–12 years)

Mixed dentition period is critical for the normal or abnormal
development of the occlusion. The position of the distal surfaces of
upper and lower primary second molar guide the eruption path of
permanent molars. A distal step terminal plane relationship is
indicative of a developing class II malocclusion.44 The straight
terminal plane relationship of deciduous dentition may change into a
class I molar relation in favourable growth pattern cases or class II in
children with unfavourable growth. A mesial step terminal plane is
the most favourable for developing in a dental class I molar
relationship45 (Fig. 7.4).
FIGURE 7.4 Transition in occlusal pattern adjustment. Source:
Adapted from Moyers RE. Handbook of orthodontics. 4th ed. Chicago:
Mosby; 1988.
The first transitional stage

The first transitional stage of the mixed dentition lasts from 6 to 8
years of age. During this stage the first permanent molars erupt, the
primary incisors are exfoliated and replaced by permanent incisors.
Before a permanent molar reaches the occlusal level, the molar
relationship is dictated by the distal terminal plane of second primary
molars. During formation, the crowns of the maxillary molars face
dorsally (not in occlusal direction). As the maxilla grows forward,
space is created posteriorly, permitting appositional enlargement of
the maxillary tuberosity. During this period, with a rapid growth at
tuberosity regions, the first permanent molars rotate; by the time the
crown pierces the gingiva, it is facing towards the occlusal plane. At
seven years of age, the upper central and the lower lateral incisors
erupt. The upper lateral incisors erupt at the age of 8 years.
Early mesial shift

The erupting permanent mandibular first molars push the primary
molars mesially, closing the primate space distal to the primary
canines, thereby converting the straight terminal plane to a mesial
step relationship. Consequently, the first molars emerge to establish a
class I molar occlusion relationship. This phenom-enon is termed as
early mesial shift. Early mesial shift is contributed by primate spaces,
growth of the mandible and attrition of de-ciduous teeth allowing
mandible to shift forward. (Fig. 7.5).
FIGURE 7.5 Early mesial shift.
The permanent mandibular molars emerge into class I molar relation
on eruption in dentition. Such an occlusion develops either in a pre-
existing mesial step deciduous molar relation or in a spaced primary
dentition; Lower primary molars move mesially, which allow the lower
permanent molars to erupt in class I relationship, called early shift.
Incisor liability
The erupting permanent incisors are larger in their mesiodistal
dimensions compared to their deciduous predecessor and therefore
require more space to be accommodated in the alveolar arches. The
additional arch length required for erupting permanent incisors is
called incisor liability. Incisor liability is 7.6 mm in the maxillary, 5
mm in the mandibular arch respectively. Incisor liability is
accommodated through the spaced primary dentition and continued
growth of the bony alveolar segments.
Mechanism of anterior teeth adjustment during eruption

The permanent mandibular incisors develop lingually to the resorbing
roots of the primary incisors, forcing it labially to be exfoliated. As
soon as the primary central incisors have exfoliated, continued
eruption and tongue activity guide the permanent incisors labially to
their final location between the tongue, the lip and facial musculature.
Their labiolingual position of teeth is determined by the state of
equilibrium of the forces between lingual and labial musculature. The
lower lateral incisors erupt in a slight transitory state of crowding at
the age of 8–9 years. This minor crowding is relieved by arch
development at the time of the canine eruption. If crowding in lower
incisors is moderate then the extra space is achieved by the slight
increase in width of the dental arch across the canines, by the labial
position of the permanent incisors relative to primary incisors and
movement of mandibular canine into primate space.
When primary mandibular dentition has no interdental spacing, the
permanent mandibular lateral incisors emerge by moving the primary
mandibular canines laterally. The absence of spacing in the primary
dentition is followed by crowding in the permanent dentition, which
occurs in around 40% of cases. The average tooth accommodation
derived from interdental spacing is about 3.8 mm in the maxillary
arch and 2.7 mm in the mandibular arch. The inter-canine arch width
increases about 3.0 mm in each arch. The anterior positioning of
permanent incisors leads to increase in arch length of about 2.2 mm in
the maxillary dentition and about 1.3 mm in the mandibular arch.
These mechanisms together result in a total increase in space
availability of around 9.0 mm in the maxillary dentition and 7.0 mm in
the mandibular dentition.38,46–48
Inter transitional period

During this period, lasting about two years, the first permanent
molars, four permanent incisors, the deciduous canines, first and
second deciduous molars constitute the dental arches. During this
period, no significant changes occur in the dentition.
Second transitional period (10–12 years)

The second transitional period is characterised by the eruption of the
lower canines, lower-upper first premolars at the age of 10 years
followed by an eruption of the upper-lower second premolars and the
upper canines.
Late mesial shift

The second transitional period is completed with the eruption of
second molars at the age of 12 years. In this period, class I permanent
molar occlusion is achieved by a late mesial shift of the mandibular
permanent molars. The difference in the combined mesiodistal
dimensions of the primary canine, first and second molar in each
quadrant is greater than the combined mesio-distal dimensions of the
permanent premolars and canine. This excess of space, i.e, Leeway
space is greater in the mandibular arch compared to the maxillary
arch. The erupting permanent molars migrate mesially in the occlusal
path, more mesial in the mandible and thereby establishing a class I
cusp to fossa relationship. These movements transform the straight
terminal plane relationship of primary molars into a mesial step
relationship. This phenomenon occurs mostly with closed primary
dentition where interdental spaces do not exist and primary second
molars are in a straight terminal plane relationship. In this condition,
an early mesial shift is not possible. The permanent maxillary,
mandibular first molars emerge into a cusp-to-cusp relationship but
move to a class I relationship later. This change has been referred to as
the late mesial shift. The late mesial shift is facilitated with the use of
leeway space (Fig. 7.6).
FIGURE 7.6 Late mesial shift to class I occlusion.
(A) The permanent first molars emerge into straight terminal plane
relationship. (B) With the shedding of deciduous molars, both upper
lower first molars move mesially into leeway space. The lower molar
moves mesially more than upper. Class I molar relationship is
established much late hence, the name late mesial shift.
Leeway space
Leeway space is the difference between the sum of the mesiodistal
widths of the primary canine, first and second molars to permanent
canine first and second premolars. The unerupted canine, premolars
are on an average 1.7 mm smaller per quadrant in the lower arch and
0.9 mm per quadrant in the upper arch49 (Fig. 7.7).
FIGURE 7.7 Leeway space.
Primary dentition preserves space for the permanent dentition to allow
class I molar relationship, by greater mesial shift of permanent molars
in lower arch compared to upper arch.
The physiologic mesial shift of the molars shows more variability in

addition to the utilisation of the leeway space.50 The amount of
average mesial shift of the maxillary mandibular first molars on each
side is usually 2.2–2.3 mm, respectively, values somewhat larger than
the average leeway space.51 These observations signify that the molar
relationship is significantly influenced by the growth difference
between the jaws during transitional dentition period.51
Ugly duckling stage

At the age of 8–10 years, the maxillary permanent canines start
erupting. The maxillary canine moves from the high position in the
maxilla somewhat from near lateral wall of the pyriform fossa
towards occlusal plane guided by the distal surface of root of the
maxillary lateral incisor. The erupting crown of the permanent cuspid
exerts a pressure on the root of the permanent lateral incisor on either
side, converging the roots towards midline and crowns away from the
midline, and thus creating spaced teeth. At this stage of transitional
dentition, the child looks aesthetically unpleasing. Broadbent called
this transitional spacing of teeth during the late mixed dentition stage
the ‘Ugly Duckling Stage’52 (Fig. 7.8).
FIGURE 7.8 (A–C) Transition spacing of teeth during canine eruption,

Broadbent called it ugly duckling stage because the child doesn’t look
aesthetic in this stage.
As the permanent cuspid continues to erupt, the approximate level

of the crowns of the lateral incisors exerts a pressure against the
crown of the permanent lateral incisor that has an uprighting effect,
which moves the permanent lateral crown towards the midline. The
ugly duckling stage is a transitional stage of normal dental
development and self correcting after full eruption of the maxillary
canines.
Permanent canine eruption is also essential for the transition of
juvenile chewing pattern to adult chewing pattern at the age of 12
years.53
The sagittal skeletal growth of the maxilla and mandible shows a
varying difference. Overall, the mandibular sagittal growth exceeds
that of the maxilla by 1.79 ± 3.45 mm. This difference significantly
influences the change in a molar relationship during the transitional
dentition. Thus, physiologic mesial shifts may be influenced by
leeway space and by the enhanced growth of the craniofacial skeleton.
It has been seen that maxillary first molars may be under a greater
influence of growth than are the mandibular first molars.51
Dental eruption
The term “Eruption” in dentistry was earlier used to denote the
emergence of the tooth through the gingiva. However, a complete
definition includes continuous movement of the tooth from the dental
bud stage to occlusal contact.54 The mechanisms of eruption for
primary or permanent teeth are similar; many histologic changes
occur around the tooth structure to accommodate tooth eruption. In
general, permanent mandibular teeth tend to erupt before maxillary
teeth (Box 7.6).
Box 7.6 Genes associated with non-syndromic and

syndromic anodontia
Non-syndromic Syndromic
Conditional inactivation of FGF-8 in dental epithelium PTH1R
Overexpression of BMPR1a in transgenic mice/functional EDA (Anhydrotic ectodermal
inactivation of FGFR2b or SHH dysplasia)
Msx1,2, FGFR1 (Kallman syndrome)
Dlx 1,2,5 IKKY (Incongenita pigmenti)
Runx2 IRF6 (Van der Woude)
Pax9, Pitx2 P63,pitx-2 (Hay-Wells
syndrome)
Lef1 PVRL1
Gli1,2,3 TBX3 (Ulnar mammary
syndrome)
Lhx6,7,8 TFAP2B (Char syndrome)
Prx1,2 Treacle (Treacher Collins)
ActβA ENT10A (Odonto-oncho-
dermal dysplasia)
OFD1 (Orofacial digital
syndrome)
Based on emergence from gingiva, eruption phase of teeth can be

divided into two stages.55
Pre-emergent phase
During this phase, the developing tooth moves inside the alveolar
bone towards gingiva but cannot be seen clinically. This movement
begins once the root formation has started. Each tooth starts moving
towards future occlusal plane approximately at the time of its crown
completion. When the crown of a tooth is being formed, there is a very
slow labial or buccal drift of the tooth follicle within the bone.
Growing teeth move in various directions to maintain their position in
the expanding jaws. Pre-eruptive movement within the crypt wall
occurs during bone remodelling. Successional tooth germs develop on
the lingual aspect of their primary predecessors, in the same bony
crypt, as the jaw develops they shift from their positions. All
movements in this phase take place within the crypts of the
developing crowns before root formation.56
Intra-bony eruption of permanent teeth involves resorption of
alveolar bone and roots of the primary predecessor tooth. Failure of
tooth eruption can occur due to non-resorption of roots of the
predecessor’s tooth or bone or a faulty eruption mechanism. Primary
failure of eruption (PFE) is a known condition associated with lack of
eruption potential of the first molars. The rate of bone resorption and
the speed of tooth eruption are controlled by separate physiological
mechanisms.
During the process of eruption, the apical location of the root
remains at the same level while the crown shows occlusal movement
through a thrust generated by the proliferating apical tissues. A
mechanical or physical barrier to the erupting tooth crown will either
stunt the root formation at proliferating apical area or will shift in the
opposite direction, inducing resorption of unconventional sites. This
often causes a distortion of root form, which is called dilaceration.
Post-emergent phase of eruption

It starts after the emergence of the tooth from gingiva until it reaches
the occlusal level. The speed of eruption is faster during this stage,
giving it the term Post-emergent spurt. This eruption phase begins
with the initiation of root formation, ends when the teeth reach
occlusal contact, called pre-functional phase. Eruption does not stop
once the tooth has come to occlusion, but continues to compensate for
the vertical growth of the face. On an average, a molar tooth erupts
about 10 mm after having reached the occlusal contact. It is also
important to know that eruption of a tooth causes the alveolar bone to
grow. In other words, each tooth makes its own alveolar bone. This
has a clinical bearing: if a tooth fails to erupt, no alveolar bone will
develop; if a tooth is lost, alveolar bone is gradually lost. For
permanent teeth, the interval from the time of crown completion or
the beginning of eruption until the tooth is in full occlusion is
approximately 5 years.
Post-eruptive phase
The post-eruptive, or functional phase begins when the teeth reach in
occlusion. During this period, the teeth continue to move occlusally,
alveolar processes increase in height, roots continue to grow to
accommodate jaw growth, alveolar bone density increases, principal
fibres of the periodontal ligament establish themselves.
Post-eruptive changes have been divided into three categories:
1. Juvenile occlusal equilibrium: This is a phase of very slow

eruption that parallels the rate of vertical growth of jaws.
2. Circumpubertal occlusal eruptive spurt: This is the second
phase of the active eruption, coinciding with the skeletal
growth spurt. The compensatory alveolar growth occurs to
maintain the freeway space and increase in the lower facial
height. This phase has a faster rate of the eruption, which
slows between the ages of 11–16 years as facial growth reaches
maturity.
3. Adult occlusal equilibrium: This is an extremely slow rate of
eruption that occurs throughout life, in order to maintain facial
height in response to situations such as occlusal tooth wear or
tooth loss in one arch and overeruption of the tooth in the
opposing arch.
Timing and sequence of eruption of permanent teeth
Each tooth has genetically and biologically controlled timing (age) and
sequence of eruption. It is expected that permanent tooth counterparts
should erupt within six months. Teeth usually erupt when three-
fourths of their roots are completed.57 If the predecessor of the
permanent tooth is retained after three-fourths of its root formation is
complete, it is advisable to extract the retained tooth. A major tooth
eruption occurs between 8 p.m. and 1 a.m. In the morning hours,
eruption stops; rather it starts to intrude tooth slightly.58 Variation in
the eruption of permanent teeth may be produced by racial
differences, sexual dimorphisms, economic status, nutrition, localised
pathosis and other external influences.
Extraction of the primary predecessor has a profound effect on
occlusal development. Posen, from the data of the Burlington study,
reported that children who had undergone unilateral
extraction/shedding of primary molars at or before 4 or 5 years of age
exhibited delayed eruption of the successive premolars. However, if
primary molars are extracted after the age of 5 years, delay in eruption
of premolars is reduced. However, if primary molars are prematurely
lost at 8, 9, 10 years of age, premolar eruption is greatly accelerated.59
As long as the eruption times are not too far from the average
schedule, they are unlikely to create a gross abnormal situation of
occlusion. The age of eruption somewhat varies in girls and boys, with
the dentition in girls erupting an average of 5 months earlier than that
in boys.
The sequence of eruption of permanent teeth

The most common eruption sequence in the maxillary arch is: 6-1-2-4-
3-5-7-8 6-1-2-4-5-3-7-8; in the mandibular arch is: (6-1)-2-3-4-5-7-8, (6-
1)-2-4-3-5-7-8.60 The usual order of permanent teeth eruption is as
follows from first to last: First molar-mandibular central, lateral
incisors–maxillary central incisors–maxillary lateral incisors–
mandibular canines–first premolars–second premolars—maxillary
canines–second molars–third molars (Fig. 7.9).
FIGURE 7.9 Chronology of permanent teeth. Source: Based on the
data from Logan WH, Kronfeld R. Development of the human jaws and
surrounding structures from birth to the age of fifteen years. Journal of
the American Dental Association. 1933 Mar 1;20(3):379–428.
Moores et al. reported that the utilisation of spaces depends on the

sequence of shedding or eruption of the posterior teeth, the molar and
occlusion.61 Following are the possible aberrations in the sequence of
the eruption and their impact on development of occlusion.
• The eruption of second permanent molar before the second

premolar tends to cause mesial migration or tipping of the
first permanent molar that could lead to palatal blocking out
the second premolar.62
• If maxillary canine erupts at about the same time or before the
maxillary first premolar, the canine probably will be forced to
erupt labially.
• It is desirable that the mandibular canines erupt before the
first and second premolars. This sequence aids in maintaining
adequate arch length and thereby preventing lingual tipping
of the incisors. Lingual tipping of the incisors causes a loss of
arch length and development of deep bite.
• If the permanent maxillary first molars emerge before the
mandibular molars, just the reverse of the early mesial shift—
an abnormal class II relationship will occur, a reduction in the
maxillary arch length will result.
• The event of premature loss of first primary molar and the
active eruption of permanent lateral incisor will often result in
a distal movement of the primary canine and an
encroachment on the space needed by the first premolar is
likely. This condition is frequently accompanied by a shift in
the midline toward the side of the tooth loss.
• If during the time of eruption of the first permanent molar, the
first primary molar is lost, a strong forward force will be
exerted on the second primary molar, causing it to tip into the
space designated for the first premolar. After the loss of the
first primary molar, a shift of the midline towards space
occurs.
• The loss of the second primary molar will usually have a less
detrimental effect on the occlusion in the anterior segment
than the loss of a first primary molar. However, an
irregularity may develop in the permanent molar relationship.
Early loss of the second primary molar is invariably followed
by mesial drifting of the first permanent molar and possible
impaction of the second premolar.
Ankylosis of primary or permanent teeth is an anomaly of fusion

between cementum–alveolar bone that can occur during tooth
eruption. Ankylosis is more common in primary molars than in the
permanent dentition. Primary tooth ankylosis is frequently seen
during the transitional dentition which can cause hindrance to
eruption of the permanent successor and hamper vertical alveolar
growth. This, in turn, can result in problems for occlusion, such as
deflection or impaction of the successor tooth, lateral open bite,
anterior cross-bite, a deep curve of Spee and over-eruption of the
opposing tooth.
Ankylosis can be related to the non-continuous resorption process
of the roots of the primary teeth. An ankylosed tooth that fails to erupt
leads to a vertical deficiency in the occlusal level as the adjacent teeth
continue erupting. If the vertical defect is large, one may think about
early ankylosis. On the other hand, late ankylosis denotes less (1–2
mm) vertical deficiency in the occlusal level.
Ectopic eruption
Ectopic eruption of a tooth means that the tooth erupts away from the
normal position. Sometimes, a tooth erupts ectopically because of an
abnormal initial position of the tooth bud. Upper first molars and
canines are most commonly observed to erupt ectopically, followed
by lower canines, upper premolars, lower premolars, upper lateral
incisors.
• The maxillary first molars are known for ectopic eruption

behaviour. The first molar may erupt too far mesially, making
a contact with the distal root of the second primary molar. The
ectopically erupting first permanent molar could cause severe
resorption of the roots of the second primary molar, leading to
its early exfoliation. Consequently the first permanent molar
may not erupt or erupt too far mesially, resulting in space loss
and future crowding of that quadrant.
Prediction of tooth emergence

Tooth eruption timing is a decisive factor which influences strategy in
space management. Dental eruption is also an indicator of the overall
development of a child or estimation of the dental age.
Dental age can be measured based on the number of erupted
unerupted teeth, stage of dentition (deciduous, mixed, permanent),
shedding pattern, stage of crown formation of developing teeth and
stage of root formation.
The dental age has been based on two different methods of
assessment. The most commonly used method is the recording age at
which the primary or the permanent teeth erupt. The second method
involves the use of radiographs of the unerupted teeth for rating the
development of the tooth from calcification of crown to root
completion. The commonly used method of dental development
stages is given by Demirijan et al.63 Dental age is discussed in detail in
Chapter 52.
Grøn’s findings in a study on 874 children (434 boys and 440 girls)
using intraoral radiographs, indicated that the stage of root formation
is more closely associated with tooth emergence than chronologic age
or skeletal age.64 Smith Buschang studied the growth of the
mandibular canine and premolar roots. He found that as a percentage
of tooth length, roots grow with decreasing velocity between 7 and 14
years of age.65 Around 13 years of age, all permanent teeth—except
third molars—are fully erupted. Girls, in general, show early eruption
compared to boys.
Dentoalveolar compensations in permanent dentition sustain the
molar relationship immune to skeletal growth difference between
maxilla and mandible. This dentoalveolar compensation includes
horizontal adjustments as well as a vertical development of the
dentition including rotational changes of the occlusal plane. When the
growth of the mandible is more than the maxilla, the difference is
mainly compensated for by the mesial displacement of the maxillary
first molar as well as rotation of the occlusal plane in the counter-
clockwise direction. Adjustment of the anterior occlusion takes place
by the mesial displacement/labial inclination of the maxillary incisors
as well as the lingual inclination of the mandibular incisors.
In the case where maxilla grows more than the mandible, the
discrepancy is mainly compensated by the mesial displacement of the
mandibular molars. The maxillary molars show minimal mesial
displacement. The occlusal plane also shows minimal rotational
change. Anterior occlusion is adjusted by lingual tipping of the
maxillary incisors and mesial displacement/labial tipping of the
mandibular incisors.66 Factors like greater cuspal height, tighter
occlusion in the permanent dentition might translate to the
dentoalveolar component on the opposite arch along with skeletal
growth.
Third molar eruption crowding

Effect of third molar eruption on dentition is an important aspect of
discussion for the orthodontist. Third molar formation and eruption
timing are greatly variable. The third molars‘ crown appear anytime
from the age of 5 years to the age of 16 years and usually erupt
between the ages of 18 and 24 years.67 The influence of erupting third
molars on worsening the mandibular incisor crowding is debatable.
Older studies show that third molars are significantly associated with
the occurrence of crowding in the lower arch.62–72 However, more
recent studies concluded that the third molar had no significant
relation with lower anterior crowding, therefore, prophylactic
extraction of the third molar is unjustifiable for prevention of
crowding.73–78 Current systematic reviews do not favour prophylactic
extractions of third molars to prevent post-treatment relapse of
mandibular incisor crowding.79 However, if extraction is planned it is
better to remove it before adulthood to prevent complications.80
The size of teeth

The size of teeth is largely genetically determined. However, marked
racial differences do exist, as with the Lapps (Saami) a population
with perhaps the smallest teeth, and the Australian aborigines, with
perhaps the largest teeth.81 Gender-size dimorphism differences
average about 4%, are the greatest for the maxillary canine and the
least for the incisors.82 Disharmony between the size of the teeth and
bone is often encountered.
With age, dimensional changes occur in lengths, width, arch
circumference of both arches.
Inter-canine width
It is measured as the distance between the crown tips of the cuspids.
During 6–16 years of age, inter canine width increases in the maxillary
arch by 5 mm and 4 mm on average in males and females,
respectively. There is no or little change between ages 2 and 6 years.
Inter-canine width increases due to maxillary alveolar process
divergence during the eruption of primary and permanent dentition.
In the mandible from 2 to 18 years of age, the intercanine width
increases by 3 mm and 2.5 mm in males and females, respectively.
Arch width increase occurs mostly during the eruption of the
permanent incisors and reach its maximum size at the time of
exfoliation of the primary cuspids83 (Table 7.1).
Table 7.1
Distance between deciduous or permanent, maxillary or
mandibular canines at different tooth eruption stage.
Intermolar or bimolar width
Bimolar width is measured at the mesiolingual cusp tips of the first
permanent molars. In the maxilla, it increases 4 mm between 6 and 12
years of age in both sexes and 2 mm in mandible in both sexes. Due to
the molar convergent path of eruption in the mandible, no appreciable
increase in molar width is noticed. However, in maxilla, a greater
increase in bimolar width occurs due to permanent first molar
occupying a position farther distally. The maxillary first molars erupt
with a buccal inclination. According to Spillane and McNamara,
during the early mixed dentition, if an inadequate transpalatal width
is evident in a narrow dental arch (less than 31 mm), it is unlikely that
the child will reach adequate arch dimensions through normal growth
mechanisms.84
In the anterior segment, the increase in arch circumference is
contributed by the labial inclination of the permanent incisors and
increase in the inter-canine width, which occurs during the eruption
of permanent incisors. However, the arch length in the buccal segment
gets shortened due to the forward movement of the first permanent
molars after the loss of the primary molars. This reduction of the arch
circumference occurs at the time of eruption of the bicuspids, during
growth of mandible and the uprighting of the incisors in the late
teens. In the mandibular arch, there is an overall decrease in
circumference during 5 to 18 years of age with a mean value of 4.48
mm and 3.39 mm in females and males respectively. However, in the
maxilla, an average of 1 mm change has been observed.83 (Table 7.2).
Table 7.2
Average arch length of maxillary and mandibular
dentition of male and female at different tooth eruption
stages.
Overbite
The development of overbite during deciduous dentition period
occurs with the eruption of the deciduous canines. During mixed
dentition, overbite develops during the eruption of the permanent
incisors. The overbite in permanent dentition develops during the
eruption of the permanent canines and premolars.
During the eruption of permanent teeth occlusally, the amount of
mandibular growth significantly influences the development of incisal
overbite. If mandibular and maxillary growth were nearly equal, the
existing pattern of incisal overbite of deciduous dentition is
maintained in mixed dentition. If mandibular growth is much less
than maxillary growth, deep incisal overbite is unavoidable. If
forward growth of mandible is greater than maxilla, shallow overbite
will be produced in mixed dentition compared to deciduous
dentition.48
Overbite of deciduous dentition is likely to influence the incisal
overbite in mixed dentition stage. Slight overbite during deciduous
dentition becomes moderate during the mixed dentition; if severe
overbite is present in deciduous dentition, it becomes worse at
permanent dentition stage.
The sequence of eruption of canine and premolar has an effect on
permanent dentition overbite. The mandibular permanent canines
erupt before the exfoliation of 2nd deciduous molars. The lower
permanent canine size is larger than its predecessor’s tooth, extra
space is needed for accommodation of this permanent mandibular
canine. This additional space is gained through labial tipping along
with the alveolar growth of the anterior portion of the arch. However,
in the maxillary arch, the sequence of eruption is different from
mandibular arch. In the maxillary arch, canine erupts after the
premolar eruption, generally, the canine and second premolar erupt
following eruption of the first premolar. The room for the wider
permanent canine can be provided from the deciduous second molar
exfoliation, when erupted upper first premolar is pushed distally. The
sequence of events suggest that maxilla has less forward growth
compared to mandible which contributes to a decrease of the
overbite.48
The pattern of overbite is different for males and females. The
overbite increased in females from 7 to 32 years of age with a mean
value of 0.38 mm while it decreased in males with a mean value of
−0.38 mm. The overbite increased for both genders in between 7 and
12 years of age. However, from 12 to 32 years, overbite decreased with
the greatest decrease between 15 and 32 years.85
Overjet
The overjet increases between 7 and 10 years of age following which,
overjet decreases up to the age of 32 years. The greatest decrease in
overjet occurs between 12 and 15 years. The total reduction of overjet
from 7 to 32 years of age was −0.40 mm and −0.58 mm in females and
males, respectively.85
Key Points
The initiation, formation, eruption, the sequence of eruption and its
related events are under strong genetic control.
An understanding of the complex processes of occlusal
development is helpful in recognition of developing malocclusion
during initial stages.
1. The process of evolution has significantly influenced the form

and function of human teeth.
2. Epithelial–mesenchymal interactions are a cascade of reciprocal
interactions between the epithelium and mesenchyme that
provide the basis of signalling in craniofacial growth and
development, including odontogenesis.
3. The various stages of odontogenesis involve intricate genetic
signalling. Disturbances at any of the stages of development
may result in anomalies affecting the dentition and ultimately
occlusion.
4. Oral motor behaviour skills are evolved at the time of
emergence of the primary dentition through the alveolar
mucosa.
5. Half round dental arches, an almost flat curve of Spee, minimal
overjet, overbite, more upright deciduous incisors are the
salient features of deciduous dentition occlusion.
6. The distinct spaces between the mandibular canine and the first
primary molar; between the maxillary lateral incisor and the
primary canine are called primate spaces (Simian
spaces/anthropoid spaces).
7. In spaced primary dentition, the first molar mesial shift which
occurs due to use of primate space leads to change in terminal
plane relationship to class I relationship in permanent teeth.
8. The difference between the amount of space needed for
permanent incisors to the space available for them is called
incisor liability. Incisor liability is usually 7.6 mm and 5 mm in
upper and lower arch, respectively.
9. In closed primary dentition, where no interdental spaces exist,
molars are in a straight terminal plane relationship, late molar
mesial shift occurs which utilise the leeway space.
10. Physiologic mesial shifts may be influenced by leeway space
and skeletal growth.
11. The erupting maxillary canine is likely to push the root of the
maxillary lateral incisor towards midline thereby displacing the
crown away from midline creating spaces. This clinical
condition is called ugly duckling stage.
12. The usual order of permanent teeth eruption is as follows from
first to last: First molar-mandibular central, lateral incisors–
maxillary central incisors–maxillary lateral incisors–mandibular
canines–first premolars–second premolars—maxillary canines–
second molars–third molars.
13. The intercanine width increases in the maxillary arch by 5 mm
and 4 mm on average in males and females, respectively from 6
to 16 years of age. In the mandible from 2 to 18 years of age, the
intercanine width increases by 3 mm and 2.5 mm in males and
females, respectively.
14. Bimolar width increases 4 mm between 6 and12 years of age in
both sexes of the maxilla and 2 mm in both sexes in the
mandible.
15. The development of overbite at deciduous period occurs during
the eruption of the deciduous canines; in mixed dentition, this
occurs during the eruption of the permanent incisors; in
permanent dentition, this occurs during the eruption of the
permanent canines-premolars.
16. Mandibular growth rotation is the major determinant of
overbite control during developing dentition.
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CHAPTER 8
Prenatal development of the
foetus concerning the craniofacial
region
Neeraj Wadhawan
Ram S. Nanda
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Pre-implantation period
Pre-somite period (14–21 days)
Somite period (21–31 days)
Genetic regulation of somitic development: notch
signalling
Neurulation
Development of the neural crest
Development of the skeleton
Pharyngeal apparatus
Pharyngeal arches
Foetal stage
Development of the face
Formation of eyes
Formation of ears
Formation of nasal cavity
Formation of nasolacrimal ducts
Development of palate
Epithelial mesenchymal interactions in palate fusion
Development of mandible
Development of tongue
Genetic regulation of craniofacial development
Genetic fields
Craniofacial syndromes due to defective genetic control
Branchial arch syndromes
Synostosis syndromes
Key Points
Introduction
The human foetus develops from the fertilisation of an oocyte by a
sperm to form a zygote. The event usually occurs while the oocyte is
still in the fallopian tube (Fig. 8.1). Following fertilisation, a series of
significant changes take place in the zygote, giving rise to an embryo.
The sequence of events can be summarised as shown in Fig. 8.2.
FIGURE 8.1 Initial stages of embryonic development from the

time of fertilisation to implantation in the uterine mucosa.
It is the blastocyst stage at which implantation occurs within the uterine
wall on approximately the sixth day after fertilisation.
FIGURE 8.2 Stages of foetal development.

Most significant events of life occur during the first trimester, and it is
hence designated here a longer distance than the second and third
trimesters.
Broadly speaking, the intrauterine period is divided into the1,2
1. Preimplantation period: the first 7 days following fertilisation.

2. Embryonic period: from the seventh day to the eighth week after
fertilisation.
3. Foetal period: from the ninth week of the term, characterised by
growth and expansion of already-established body structures
with little differentiation or new-organ formation. A highlight
of the foetal period is the establishment of ossification centres
and the starting of foetal movements.1
The embryonic phase can be further divided into the1–3
1. Pre-somite phase: encompasses the second and third weeks after

fertilisation, characterised by differentiation of the three germ
layers and formation of the embryonic adnexa (foetal
membranes) from the inner cell mass.
2. Somite phase: lasts from the 21st to the 31st day (approximately
the fourth to early fifth week), characterised by formation of
the dorsal metameric segments of the body (neural tube,
somites, etc.), establishment of the basic body plan, polarity
and patterns of the major organ systems.
3. Post-somite phase: lasts from the 32nd to the 56th day (late fifth
to the eighth week), characterised by the development of
external body features and further development and
differentiation of the basic structure.2
Weeks 4 through 8 are especially important because majority of

tissues and organ systems differentiate during the period from the
original three germ layers (Table 8.1).1–3 The embryonic period can
also be divided by morphogenetic development of the embryo, into 23
stages starting from -fertilisation (Fig. 8.3). These are popularly known
as Carnegie stages,4 named after the Carnegie Institute in Washington,
DC, and are based on the works of Streeter (1942)5 and O’Rahilly and
Müller (1987).6
Table 8.1
Chronological sequence of events during the embryonic period

Time from Significant events in craniofacial region
conception
(days)
14 Primitive streak appears; formation of oropharyngeal membrane
17 Neural plate formation commences
20 Appearance of neural folds; formation of neural crest. Otic placodes appear
21 Neural folds fuse; migration of neural crest cells starts
24 Frontonasal process and mandibular arch appear; optic vesicles and olfactory
placodes appear
26 Second arch forms; maxillary process starts to differentiate; adenohypophyseal
pouch appears
28 Third and fourth arches develop; dental lamina appears and oropharyngeal
membrane disintegrates
32 Lateral nasal process appears; otic and lens vesicles form
33 Medial nasal process develops; nasal pits form, are wide apart and face laterally
37 Nasal pits face ventrally; formation of upper lip starts and nasolacrimal groove
appears
41 Medial nasal and maxillary processes fusion starts; nasal cavity separates from oral
cavity and upper lip continuity established
44 Primary palate formation ensues; nose tip forms; eyelids start to form; nasal pits
migrate medially and nasal septum forms
47–48 Nasal fin disintegrates (failure to disintegrate predisposes to cleft lip); rima oris
reduces in width and mandible ossification starts
50–51 Lidless eyes and nasal pits move medially
54 Eyelids develop; nostrils take final position and auricle of ear develops
56–57 Eyelid closure commences; eyes still wide apart; face assumes human appearance;
head elevated off the thorax; mouth opens; palatal shelves elevate and maxillary
ossification starts
60 Palatal shelves fuse; tooth buds form
Source: Adapted from Sperber GH, Sperber SM, Guttmann GD.

Craniofacial Embryogenetics and Development. 2nd ed. Shelton: Peoples
Medical Publishing House; 2010. p. 21.
FIGURE 8.3 Selected Carnegie stages of human embryonic
development from the 28th to 56th day.
Carnegie stages divide the human embryonic period into 23 stages
from the time of fertilisation to the beginning of the foetal period by
important embryonic events.
Pre-implantation period1–3
During the first 2–3 days, the single-celled zygote, 140 µm in size,
divides progressively to form a 16-celled cluster called a morula. With
further cell division, the morula forms a 100-celled structure called a
blastocyst, which implants in the uterus at around seventh-day post-
conception. Within the blastocyst, a fluid-filled cavity develops which
divides the cells into the outer sphere of cells and an inner cell mass.
The outer sphere of cells forms the trophoblast while the inner cell
mass forms the embryo. The trophoblast is responsible for
development of the chorionic villi and thus, is important for the
nutrition of the developing embryo.
Pre-somite period (14–21 days)1–3
During the second week, two important events occur: (1) the
trophoblast layer starts to differentiate into a bilaminar structure
which contributes to the formation of the chorionic villi and (2) the
inner cell mass divides to form a bilaminar structure (Fig. 8.4A–D).
The bilaminar structure is made up of the epiblast (ectoderm), which
consists of columnar cells and forms the floor of the amniotic cavity
and the hypoblast (endoderm), which consists of squamous or
cuboidal cells forming the roof of the yolk sac. Meanwhile, the
coelomic cavity develops in the extraembryonic mesoderm (loose
tissue adjacent to the embryo), which enlarges progressively to
surround the embryo completely except at the stalk where the
trophoblast cells form the chorionic plate. This is the site where later
the chorion would develop. By the end of the second week, the axis of
the embryo starts to grow with the appearance of the node at the
rostral end (Fig. 8.5A and B).
FIGURE 8.4 Early stages of development of the human embryo.

(A) A 7-day-old human blastocyst showing the trophoblastic and
amniotic layers. A small amniotic cavity is developing. (B) A 9-day-old
human blastocyst showing the hypoblast layer extending to enclose a
cavity called the exocoelomic cavity (primary yolk sac). (C) A 12-day-
old blastocyst showing the exocoelomic cavity and the amniotic cavity
increasing in size. Extraembryonic mesoderm fills the gap between the
cytotrophoblast layer and the exocoelomic cavity. (D) A 13-day-old
blastocyst showing formation of extraembryonic coelom as a result of
the breakdown and coalescence of fluid-filled spaces in the
extraembryonic mesoderm. Cells from the hypoblast migrate to
displace the exocoelomic cavity away from the embryo proper and
encase a new space called the secondary yolk sac. The exocoelomic
cavity is reduced to a remnant called the exocoelomic cyst.
FIGURE 8.5 Cut section through the amniotic cavity of a third-

week embryo showing the dorsal surface of the embryo proper.
(A) Formation of the primitive node and primitive streak defines the axis
and poles of the embryo. (B) Showing dorsal migration of surface
epiblast cells along the primitive streak towards the rostral end of the
embryo (arrows). Subsequently, cells derived from the epiblast also
invaginate between the epiblast and the hypoblast laterally to form the
intraembryonic mesoderm (lines).
The node develops under the signalling influence of the genes

Nodal, Hedgehog, FGF (fibroblast growth factor), Wnt and BMP (bone
morphogenic protein). The activity of the node, through the ciliary
movement of the cells, contributes to leftward fluid flow, which
causes the development of left–right asymmetry in the developing
embryo. At the same time, localised thickening of the endoderm at the
midcephalic region gives rise to the pre-chordal plate under the
influence of the Sonic Hedgehog (SHH). This pre-chordal plate has
been shown to have a head-organising or molecular-organising
function producing signals that pattern the forebrain and help in
differentiation of the eye fields. Defects of signalling in this region are
known to cause holoprosencephaly or agenesis of the corpus
callosum. The pre-chordal layer also contributes an endodermal layer
to the oropharyngeal membrane (a membrane which separates the
oronasal cavity from the pharyngeal cavity during early
development).
Early in the third week, the epiblast proliferates and differentiates
to give rise to the third layer of cells called the mesoderm through a
process called gastrulation, thus establishing the trilaminar structure
of the embryo. The proliferation of the epiblast starts at the caudal end
of the embryo leading to the formation of a caudocranial groove. This
groove is called the primitive streak. The primitive node marks the
cranial limit of the primitive streak. From the primitive streak, the
rapid proliferation of cells leads to formation of the intraembryonic
mesoderm, which proliferates in all directions between the ectoderm
and the endoderm. By the end of the third week, the mesoderm layer
is well established and separates the ectoderm and endoderm
throughout the embryo except in two places: the cloacal membrane in
the caudal region and the pre-chordal plate at the cranial midline area,
where the endoderm and ectoderm are tightly adherent. The
formation of the three germ layers is a critical landmark during early
development of the embryo. The pre-chordal plate is the future region
of the buccopharyngeal membrane. From here on, further
development of the embryo occurs through the growth and
differentiation of the three basic germ layers; namely, the ectoderm
(first layer), the mesoderm (second layer) and the endoderm (third
layer) (Fig. 8.6A–D). The neural crest layer, considered by some as the
fourth germ layer, is essentially a derivative of the ectodermal layer.
The various derivatives of the three germ layers are summarised in
Table 8.2.
FIGURE 8.6 Sections through a developing embryo in the third
week.
(A) Midsagittal section of the embryo shows the development of the
embryonal axis and the primitive notochord. (B and C) Transverse
section shows the formation of the third germ layer and the developing
notochord. (D) Transverse section through the cranial end of the
primitive streak in a third-week embryo showing gastrulation (at the
plane marked in Fig. 8.6A). Cells from the epiblast layer differentiate
and migrate extensively between the epiblast and hypoblast to form
intraembryonic mesoderm (the third germ layer).
Table 8.2
Derivatives of the three germ layers

Layer Derivatives
Ectoderm
Surface Epidermis, hair, nails, glands of the skin, tooth enamel, mammary glands,
ectoderm adenohypophysis and placodal derivatives (inner ear, lens)
Neural tube CNS (brain and spinal cord), retina, neurohypophysis and pineal body
ectoderm
Neural crest Neurons and glia of peripheral nervous system (sensory, sympathetic and
parasympathetic systems), Schwann cells, chromaffin cells of adrenal medulla,
melanocytes, pharyngeal arch cartilage, most of the facial skeleton and facial
connective tissue (from ectomesenchyme), dentin and cementum, middle ear bones
Mesoderm (head)
Pre-chordal Several eye muscles
plate
Paraxial Several eye muscles, skull bones, head muscles and some connective tissue
mesoderm
Cardiogenic Heart
mesoderm
Mesoderm (trunk)
Notochord Intervertebral discs (nuclei pulposi)
Paraxial Most of the body skeleton, muscles of trunk and limbs, dorsal dermis and connective
tissue
Intermediate Kidneys, ureters, somatic gonad, adrenal cortex, blood and blood vessels
mesoderm
Lateral plate Connective tissue and muscles of viscera, serosa, primitive heart, blood and lymph
(somatic and cells, smooth muscle, spleen and adrenal cortex
splanchnic)
Endoderm
Endoderm Epithelial lining of the respiratory tract, lungs, gut, bladder and a part of urethra;
parenchymal cells of tonsils, thymus, thyroid, parathyroid, liver, and pancreas;
epithelial lining of tympanic cavity and auditory tube
Source: Adapted from

http://conlonlab.org/courses/materials/medsmats/adultderivatlves.htm
Finkelstein MW. Overview of general embryology and head and neck
development. In: Bishara SE, editor. Textbook of Orthodontics.
Philadelphia: Saunders; 2001.
Meanwhile, cells of the primitive streak proliferate further in the

cranial direction and contact the pre-chordal plate (Fig. 8.5B). These
cells further invaginate the underlying tissue to form a structure
called the notochord. The notochord represents the early midline axis
of the embryo helping to establish the axial skeleton. It also induces
formation of the neural plate in the overlying ectoderm, which later
gives rise to the neural ectoderm.
Somite period (21–31 days)1–3

The somite period is characterised by establishment of the primordia
of most of the important organ systems such as the gut, kidneys,
adrenals, heart, lungs and others. Between the 21st and 31st days, the
embryo changes form from a flat disc to a tubular structure.
Simultaneously, rapid growth of the developing central nervous
system on the dorsal aspect leads to folding of the embryo over its
ventral aspect, thus forming a C-shaped structure at around 4 weeks
(Fig. 8.7A and B). The folding leads to incorporation of the secondary
yolk sac into the embryonic structure. The secondary yolk sac
contributes to formation of the gut.
FIGURE 8.7 Schematic diagram showing folding of the embryo

over its ventral aspect due to exaggerated growth on the dorsal
aspect.
c, caudal; r, rostral.
Genetic regulation of somitic development:

notch signalling
Formation of the axial and appendicular skeletal elements in the body
is under tight control between osteoblastic and osteoclastic activity
and their interaction with pre-existing cartilage that is to undergo
ossification. The principal genes that are involved in this process are
those that are predominantly expressed in the pre-somite mesoderm
(PSM); belonging to the Wnt, FGF-FGFR and notch signalling
pathways. Genes regulating these signalling pathways are expressed
spatially in the PSM in a so-called oscillating fashion to regulate the
sequential formation of somites. Of these, special attention has been
focussed on Notch signalling pathways for their important role in
skeletogenesis (osteoblastogenesis and osteoclastogenesis),
somitogenesis and chondrogenesis (Fig. 8.8A and B). Experiments
have shown that mice lacking Notch 1, display delayed and irregular
somite segmentation. Notch is also essential for rostral−caudal
signalling in the developing somites. It has been shown that mice
lacking Notch ligands DLL1 and DLL3 show loss of cephalocaudal
gradient and irregular segmentation of somites.
FIGURE 8.8 Notch signalling works by an oscillating mechanism

through which a close network of multiple genes in the Notch
system sequentially upregulate and downregulate protein
synthesis in a periodic and regulated pattern.
The two principal genes responsible for this are the Hes and the Delta.
Alternating upregulation and downregulation of protein synthesis are
responsible for the segmentation and development of somites along
the developing neural tube.
Controlled osteoblastic activity is also closely regulated by the

inhibitory actions of Notch on developing osteoblasts. This is done by
the inhibitory action of Notch on osteoblastic markers Alp, Ocn,
Col1A1 and Runx2. Runx2 is considered the master regulator of
osteoblast differentiation. Similar actions of Notch on
osteoclastogenesis have been documented by its activation of RANKL
and OPG.
Neurulation
Neurulation is the process of development of the neural plate,
neuroectoderm and the neural tube. During the third week of
development, the notochord induces the overlying ectoderm to
thicken and differentiate into the neural plate. Experiments have
shown that chordamesoderm (a median strip of mesodermal cells
extending through the length of the embryo) and the pre-chordal plate
(in the anterior region) also play a significant role in inducing neural
plate formation. Moreover, chordamesoderm may be responsible for
developing the organisational plan of the head.
The process of neurulation can be divided into primary and
secondary neurulation. While primary neurulation is associated with
the formation of a hollow tube by the proliferation of cells of the
neural plate, secondary neurulation leads to formation of the medullary
cavity (neural tube) from a solid core of cells. Both processes are
different although interlinked intricately. A few important genes
essential for neural tube formation include Pax3, SHH and Open
Brain.
The developing neural tube consists of three sets of cells: (1) the
inner layer of cells (neural tube) which will form the future spinal
cord and the brain; (2) neural crest cells and (3) epidermal cells.
Neural crest cells migrate across the embryo eventually and have a
significant role in development of the facial structure, apart from the
developing peripheral neurones. The neurulation process can be
divided into four distinct but spatially and temporally overlapping
stages: (1) formation of the neural plate; (2) shaping of the neural
plate; (3) bending of the neural plate to form the neural groove and (4)
closure of the neural groove to form the neural tube. Early bending of
the neural plate occurs at specific places called the hinge region of the
plate. The cells in the region are called median hinge point cells and
are derived from the portion of the neural plate just anterior to
Hensen’s node. Later stages show hinge points also develop along the
dorsolateral regions of the neural plate called dorsolateral hinge
points. The neural plate grows caudally towards the primitive streak
(Fig. 8.9). At around the 20th day post-conception, the lateral edges of
the neural plate elevate to form the neural folds, which enclose a
neural groove in the midline (Fig. 8.10A–D).
FIGURE 8.9 Schematic diagram of a horizontal section through

the dorsal surface shows growth of the neural plate.
The primitive streak shortens only marginally, while the embryo and the
neural plate continue to grow. This pattern of development reduces the
relative size of the primitive streak. Source: Modified from Larsen WJ,
Sherman LS, Potter SS, editors. Human Embryology. London: Churchill
Livingstone; 2001, Figure 2.13.
FIGURE 8.10 (A–D) Transverse section through the developing
embryo showing folding of the neural plate to form the neural tube.
Source: Modified from Kandel E, Schwartz JH, Jessel TM, editors.
Principles of Neuroscience. 4th ed. McGraw-Hill;2002.
At the 22nd day post-conception, the neural folds start to fuse with
the counterpart of the other side over the neural groove. The fusion
occurs first in the region of the future occipital area (area of the third
to fifth somites) and proceeds both cranially and caudally to produce
the neural tube. The neural tube is the primordium of the central
nervous system, and its anterior end enlarges to form the three
segments of the brain: the forebrain, midbrain and hindbrain. Around
the same time, the lens and otic placodes begin to form as outgrowths
from ectoderm at the cranial end of the embryo. These later give rise
to the eye and the inner ear, respectively.
Development of the neural crest

The neural crest refers to a special collection of cells that arise in the
crest of the neural folds during the process of neurulation (Fig. 8.11A–
D). It consists of pluripotent cells, ectomesenchymal in origin, induced
by interaction, Wnt activation and BMP inhibition signal pathways.
These cells are characterised by their tendency to extensively migrate
along the natural cleavage planes between the three germ layers,
usually beginning at about the time of closure of the neural tube (Fig.
8.12). They divide as they migrate, giving rise to cell masses that are
much bigger at the destination than at their origin. Once they reach
their pre-determined location, they differentiate into specific tissues
according to the morphogenetic fields and give rise to many
important tissues both in the head and neck (Fig. 8.13) as well as in the
trunk region.
FIGURE 8.11 Schematic diagram of the transverse section
through the dorsal end of the embryo showing the formation of
neural crest cells (neurulation) in the lateral aspect of the neural
folds.
FIGURE 8.12 Schematic diagram showing neural crest cell

migration in the trunk region of a chick embryo.
The path I cells travel ventrally through the anterior portion of the
sclerotome. Path II cells travel along a dorsolateral route below the
surface ectoderm. Source: Reproduced with permission from Gilbert
SF, Sunderland MA, editors. Developmental Biology. 6th ed. Sinauer
Associates;2000, Figure 13.2.
FIGURE 8.13 Migration of cranial neural crest cells into the head
and the branchial arches to form structures of the face and neck
including bones and cartilages.
They also produce pigment cells and cranial nerves. Source: Modified
from Gilbert SF, Sunderland MA, editors. Developmental Biology. 6th
ed. Sinauer Associates;2000, Figure 4.16.
Broadly speaking, there are four varieties of neural crest cells,

according to their final destination and differentiation:
1. Cranial neural crest cells: give rise to structures in the head and
neck.
2. Trunk neural crest cells: form the melanocytes and dorsal root
ganglia of sensory nerves.
3. Vagal and sacral neural crest cells: generate parasympathetic
ganglia.
4. Cardiac neural crest cells: can develop into melanocytes,
neurones, cartilage and connective tissue (of the third, fourth
and sixth pharyngeal arches). They also produce
musculoconnective tissue of the large arteries arising from the
heart.
In the head and neck region, they form the complete mesenchyme
of the upper facial region and surround the mesodermal cores of the
lower facial region. Cells that migrate ventrally and caudally
encounter pharyngeal endoderm that induces formation of the
pharyngeal arches. The cells, which migrate to the trunk region, give
rise to neural, endocrine and pigment cells (Table 8.3).
Table 8.3
Major neural crest derivatives

Organ Cranial neural crest Trunk neural crest
system
Nervous Sensory ganglia of cranial nerves: V, VII, IX, X; Sensory spinal ganglia;
system satellite cells of sensory ganglia, parasympathetic satellite cells of these ganglia;
ganglia of cranial region; oligodendroglia parasympathetic ganglia of
trunk region; Schwann cells of
peripheral neurons
Pigment Melanophores, xanthophores, erythrophores and Melanophores, xanthophores,
cells iridophores erythrophores and
iridophores
Endocrine Calcitonin producing cells, carotid body (type I cells); Adrenal medulla;
system parafollicular cells of thyroid neurosecretory cells of heart
and lungs
Mesodermal Cranial vault; nose and orbit skeleton; otic capsule; Nil
cells maxilla, minor part of sphenoid
(skeleton)
Mesodermal Dermis, fat, smooth muscles of skin, ciliary muscles Nil
cells of eye, cornea, connective tissue of glands of head
(connective and neck; odontoblasts, part of prosencephalon and
tissue) mesencephalon; semilunar valves of heart and
connective tissue in aorta
Muscles Ciliary, dermal smooth muscles and vascular smooth Nil
muscles
Source: Adapted from Carlson BM. Foundations of Embryology. 6th ed.

India: Tata McGraw Hill;2007. p. 474.
Development of the skeleton1–3

Following formation of the neural plate and the notochord, the
intraembryonic mesoderm differentiates into three types of cell
masses depending upon
1. Lateral plate mesoderm

2. Intermediate mesoderm
3. Paraxial mesoderm
Lateral plate mesoderm and intermediate mesoderm give rise to a

variety of tissues and organs throughout the body. The lateral plate
mesoderm give rise to the heart, blood vessels and blood cells of the
circulatory system and more. The intermediate mesoderm connects
the paraxial mesoderm with the lateral plate; eventually, it
differentiates into urogenital structures consisting of the kidneys,
gonads, their associated ducts, and the adrenal glands. Paraxial
mesoderm is of greater concern to dental professionals as it is
intimately associated with the development of cranial structures.
Paraxial mesoderm develops adjacent to the notochord along the
dorsal surface of the embryo. On further differentiation, its rostral end
gives rise to elevated masses of tissues in the cranial region called
somitomeres. These somitomeres are situated in the paraxial region of
the notochord. Caudal paraxial mesoderm gives rise to similar
structures in the more caudal part of the embryo called somites. Each
somite has three basic parts differing in location, each of which gives
rise to different tissues:
1. Sclerotome: the ventromedial part gives rise to the vertebral

region except in occipital region.
2. Dermatome: the lateral part gives rise to the dermis of the skin.
3. Myotome: the intermediate part gives rise to the muscles of the
trunk and limbs and some craniofacial muscles.
Approximately 42–44 paired somites are known in the human

embryo, of which 4 are occipital and 8 are cervical (somitomeres in the
craniofacial region) (Fig. 8.14).
FIGURE 8.14 Schematic representation of a 29-day-old embryo
from the dorsal aspect showing somites.
Pharyngeal apparatus
The pharyngeal apparatus consists of a series of bilaterally paired
arches, pouches (clefts), grooves and membranes. The pharyngeal
arches are seen as paired tubal elevations on the ventral surface of the
embryo on either side of the midline. They are partially separated on
the external surface of the embryo by fissures called pharyngeal
grooves or clefts while the pharyngeal pouches partially separate the
arches on the internal aspect. The pharyngeal membranes represent
the tissue interposed between pouches and clefts and connect adjacent
arches.8
Pharyngeal arches
Development of the tissues of the neck and the major part of the face
is largely dependent on mesoderm of the cranial somitomeres. The
cells of the somitomere mesoderm migrate into the ventral region of
the embryo at the rostral end and, with a minor contribution from
mesoderm of the lateral plate, form the future pharyngeal arches. The
pharyngeal arches arise as outgrowths on the ventral surface of the
embryo rostral to the foregut in relation to the ventral surface of the
rhombencephalon during the fourth week of intrauterine life.
Each pharyngeal arch has all three embryologic cell layers.
Ectoderm forms the pharyngeal groove or cleft, while endoderm
forms the pharyngeal pouch. Between the two layers lies a
mesodermal core that comprises mesodermal cells and cells of the
neural crest. Mesodermal cells are responsible for formation of a large
variety of body structures while neural crest cells are responsible for
development of large parts of head and neck structures. These neural
crest cells are derived from specific segments of the hindbrain
(rhombomere) with minor overlap between segments.
Neural crest cells from rhombomeres 1 and 2, together with caudal
midbrain-derived crest cells populate the first arch. Crest cells from
rhombomere 4 populate the second arch, while rhombomeres 6 and 7
contribute to the third, fourth and sixth pharyngeal arches. It should
be noted that rhombomeres 3 and 5 run out of neural crest cells and
whatever few cells they do produce, die by apoptosis under the
influence of gene BMP4.8
Each pharyngeal arch has its specific apparatus: a specific cartilage
that forms the skeleton of the arch, a nerve that supplies the muscles
and mucosa derived from the arch, and an artery (called the aortic
arch) (Fig. 8.15).8,9 All these components are well developed in the
first and second arches except for the arteries.8,9 The pharyngeal
arches play a major role in the formation of the face, oral cavity, teeth,
nasal cavity, pharynx, larynx and neck (Tables 8.4 and 8.5).
FIGURE 8.15 Cut section through the branchial arches in a

developing embryo.
Each arch has its neurovascular supply and cartilage. The arches are
grooved on the external surface by pharyngeal clefts and the internal
surface by pharyngeal pouches. The arches are lined externally by
ectoderm and internally by endoderm between which lies each arch’s
mesodermal core. The fifth arch disappears during development.
Table 8.4
Derivatives of pharyngeal arches
Br., Branch; CN, cranial nerve; n., nerve.
Source: Modified from Hiatt JL, Gartner LP. Textbook of Head and Neck
Anatomy. 3rd ed. Lippincott Williams & Wilkins: Baltimore; 2001.
Table 8.5
Derivatives of pharyngeal pouches

Pouch Derivatives
First Tympanic cavity and lining of tympanic drum mastoid air cells, auditory tube
Foramen caecum
Second Pharyngeal tonsils, palatine tonsils, lingual tonsil
Third Inferior parathyroid,
thymus
Fourth Superior parathyroid, thymus, epiglottis
Fifth Ultimobranchial body, parafollicular cells of the thyroid
Source: Adapted from Development of the nervous system. In:

Patestas MA, Gartner LP editors. A Textbook of Neuroanatomy.
Blackwell Publishing; 2006. p. 15.
Genetic influences in pharyngeal arch development and
expression
In the past, it was presumed that the most important regulator of
pharyngeal arch formation and patterning was the neural crest cell
population. However, it is now believed that endoderm is the most
important organiser of the pharyngeal arches. The Tbx1 gene, which is
specific to endodermal derivatives, is a key gene regulating formation
and development of pharyngeal arches. The gene is itself under the
influence of retinoic acid. FGF signalling is also known to play a key
role in endoderm pouch formation and differentiation. Thus,
endoderm serves as an important element in differentiation of the
pharyngeal region. It initiates segmentation in the head region by
undergoing evagination to reach the ectoderm (outpocketing). This
process is central to pharyngeal arch formation under the partial
influence of Tbx1 and RA. Additionally, FGF and Wnt signalling have
been shown to be important in endodermal pouch formation and
pharyngeal segmentation.10
The Dlx family comprises six genes that are expressed in the
pharyngeal arches during development and differentiation. Of these,
Dlx1 and Dlx2 are specifically expressed in the proximal segment of
the first pharyngeal arch and problems in these cause developmental
malformations in the upper and lower jaws, while targetted
disruption of Dlx5 causes malformation of Meckel’s cartilage. In
addition, two specific genes, which interact with Dlx, are endothelin
(EDX) (considered an upstream regulator of Dlx) and HAND.
Therefore, first pharyngeal arch patterning and, consequently, upper
and lower jaw formation are regulated primarily via an
Edn/Dlx/HAND signalling axis. This signalling mechanism has been
validated in mouse, avian and aquatic models as well as in humans
with auriculocondylar syndrome.
The Hox genes play a key role in body plan organisation along the
anterior−posterior axis. Hox genes are not expressed in the first
pharyngeal arch; however, they are expressed in the neural crest cells
of the second to sixth pharyngeal arches. In general, each pharyngeal
arch is under the control of one Hox group gene. So the patterning is
such that the derivatives of the first arch are under the influence of the
Dlx cluster, while differentiation of the second to sixth pharyngeal
arch derivatives is under the influence of the Hox cluster. In the
absence of Hox signalling, multiple supernumerary first-arch
structures may develop from other pharyngeal arches.
The post-somite period is characterised by the growth and
morphodifferentiation of previously established organ systems. The
head becomes large and pre-dominates over the small body. The
somites become less conspicuous on the external surface. The face
starts to show development of the eye, ear and nose, which start to
resemble the human form. Meanwhile, limb buds start to grow, and
the first foetal muscular movement may occur at the later end of the
stage.
Foetal stage
The foetal period is characterised by rapid growth of the organ
systems previously established. Little differentiation of new-tissue
systems is seen, and the main emphasis remains in the differential
growth of various systems. With the growth of the body, the head,
which occupies approximately half of the body length initially, gets
reduced to about one-quarter at birth. Establishment of the primary
ossification centres also occurs during this period.
The principal contribution to development of the face is from five
primordia; namely, a single frontonasal process (FNP), paired
maxillary processes, and paired mandibular processes.
Development of the face

Development of the head depends to a large extent upon prior
development of the brain. As discussed earlier, the brain starts to
develop at the rostral end of the neural tube as a series of three
vesicles: the prosencephalon (forebrain), mesencephalon (midbrain)
and rhombencephalon (hindbrain; rhombomeres 2–7).
Differentiation of the human face takes place between the fourth
and seventh weeks of intrauterine life (Fig. 8.16A–F).
FIGURE 8.16 Schematic view of embryonal face development
between the fourth and eighth weeks.
(A) 4-week-old embryo. Note the prominent swellings of the developing
mandibular processes of both sides. The mandibular processes have
fused in the midline. The maxillary processes are starting to bud from
the first arch. The frontonasal process is yet to descend in the midline.
Primitive nasal placodes and optic vesicles (not visible in the picture)
are starting to form. (B) 5-week-old embryo. The maxillary processes
are established and are migrating towards the midline. The descent of
the frontonasal process is evident. The frontonasal process divides to
give rise to lateral and medial nasal processes, which surround the
nasal pit of each side. The nasal pits begin to deepen and are placed
wide laterally. The lens placodes develop on the lateral aspects of the
developing face. (C) Five-and-a-half-week-old embryo. The
hyomandibular cleft divides the mandible from the neck region. The
nasal pits start to face ventrally. The nasolacrimal groove starts to form.
The upper lip starts to form by fusion of the lateral nasal process with
the maxillary process. (D) 6-week-old embryo. The primitive eye is well
established on the lateral aspects of the face. The nasolacrimal groove
is forming. The descent of the frontonasal process and the medial
movement of the maxillary processes continue. The medial nasal
process and the maxillary process start to fuse separating the nasal
and oral cavities. (E) 7-week-old embryo. The medial nasal process
fuses with the maxillary processes of the respective sides to complete
the upper lip. The maxillary process also fuses with the mandibular
process at the lateral margins to form the rima oris. The eye is well
formed but lidless and is moving medially to its future position. The ear
tubercles establish around the hyomandibular cleft on the lateral
aspect. (F) 8-week-old embryo. The facial structure is easily
recognisable. Eye closure commences and the eyes continue to
migrate medially. The nasal pits also migrate medially. The rima oris
reduces significantly in size laterally. The external ears are developing.
In the fourth week, the face and neck region becomes segmented
and located under the forebrain of the embryo. Brain tissue exerts an
organising influence in the developing face. The prosencephalic
centre, a mass of specialised mesodermal tissue derived from pre-
chordal mesoderm of the primitive streak, induces differentiation of
the visual apparatus, the inner-ear part of the auditory apparatus, and
the upper one third of the face.
Similarly, the rhombencephalic centre induces differentiation of the
middle and lower third of the face, including the external and middle
ears.
The FNP develops under the influence of the forebrain. The
forebrain establishes multiple signalling centres in ectoderm that
covers the future FNP region under the control of the SHH gene. This
signalling ensures proper descent of the FNP and its differentiation
into midline organ structures. The face and the forebrain are made by
the FNP (middle and front), maxillary processes (laterally placed) and
mandibular processes (caudally placed), the hyoid arch, and the
glossopharyngeal arch by the end of the fourth week.
By the fifth week, nasal placodes appear along the inferior and
lateral portion of the FNP. Further development of nasal placodes in
the medial direction in a horseshoe manner leads to formation of
medial and lateral nasal processes. The area between the two
processes gets progressively depressed to form the nasal pits. These
later invaginate to form the nasal cavities. Later, in the fifth week,
continued medial movement of the maxillary prominences pushes the
widely separated nasal prominences more medially into the position
of the future nostrils. The fusion between the median nasal and
maxillary processes, which occurs between the seventh and eighth
weeks, contributes to the central part of the nose and the philtrum of
the lip. Lateral nasal processes form the outer parts of the nose, while
the maxillary processes form the bulk of the upper lip and cheeks. The
maxillary processes also fuse with the respective mandibular
processes at the seventh to eighth week forming the angle of the
mouth.
Formation of eyes
The eyes develop from a single median set of cells, the optic
primordium, originating in the neural plate in the ventral anterior
region of the diencephalon. Under genetic control from the cyclops
gene, cells from the lateral parts of the optic primordium differentiate
into bilateral lens placodes, while the central part is suppressed. The
lens placodes initially are located on the lateral sides of the developing
face, but migrate medially with growth of the cerebral hemispheres
during the fifth to ninth week, after which little movement is seen.
Simultaneous invagination of the lens placodes occurs and, with
formation of the optic vesicles, the eyeballs start to take their final
shape.
Formation of ears
The ear has three parts that have different origins. The external ear
develops in the neck region as auricular hillocks surrounding the first
pharyngeal groove. The internal ear forms from the otic placodes,
which develop on the lateral aspect of the developing head under the
influence of the rhombencephalon. The placode later invaginates into
the underlying tissue to form a vesicle, which later differentiates into
the inner ear. The middle ear originates from the first pharyngeal
pouch.
Formation of nasal cavity

The nose arises from the FNP and its derivatives, the median and
lateral nasal processes, and the cartilaginous nasal septum. Early in
the development, the nasal pits become separated from the oral cavity
on the external surface by fusion of the medial and lateral nasal
processes with the maxillary process (Fig. 8.17A–D). The nasal pits
invaginate the underlying mesenchyme to form the anterior nares.
Posteriorly, the nasal cavity is separated from the stomatodaeum by
the oronasal membrane. The nasal pits continue to deepen and, with
disintegration of the oronasal membrane around the seventh week,
the posterior nares (primary choanae) are established. Although the
nostrils become patent early in life, they remain plugged with a solid
structure of epithelial tissue till late in development.
FIGURE 8.17 Development of the nasal cavity.

(A) The primitive nasal pit is separated from the oral cavity by the
oronasal membrane. (B) Breakdown of the oronasal membrane leads
to free communication between the oral and nasal cavity. (C)
Deepening of the nasal pits leads to increase in size of the nasal cavity.
The olfactory bulb also starts to establish. The primary palate starts to
form. (D) Formation of the palate divides the nasal cavity from the oral
cavity. Development of the nasal conchae divides the nasal cavity into
the superior, middle and inferior meatus.
Meanwhile, the mesenchyme of the FNP at the site of the future

nasal septum develops thickenings, from which originates the nasal
capsule, and medial mesenchyme thickenings, which are the
precursor to nasal septal cartilage. The two lateral mesodermal
thickenings (the ectethmoid) give rise to the paired ethmoidal
(conchal) and the nasal alar cartilages. The tissue from the
mesoethmoid develops downwards in the median plane to meet the
palatal shelves in the midline dividing the nasal cavity into two
halves, while the ectethmoid forms the lateral superior, middle, and
inferior conchae.
Formation of nasolacrimal ducts3

The nasolacrimal ducts are bilateral epithelial-lined tubes, which
consist of the lateral nasal process and the maxillary process at the line
of fusion (Figs. 8.18A-C and 8.19). The ducts connect the nasolacrimal
sac to the nasal cavity and function to drain lacrimal secretions from
the eye. The duct originates from the embryonic nasolacrimal groove,
which runs from the medial end of the eye to the nasal pits. This
groove separates the lateral nasal process from the maxillary process.
During the initial stages of formation, the epithelium over the groove
proliferates and invaginates the underlying mesenchyme as a solid
cord of cells. Soon, the epithelia of the lateral nasal process and the
maxillary process grow over the invaginated epithelium and fuse with
each other. The invaginated epithelium subsequently breaks down to
form the hollow lacrimal duct and the lacrimal sac. The ducts become
completely patent only after birth. Aberrations in the formation of the
nasolacrimal duct lead to formation of oblique facial clefts.
FIGURE 8.18 Formation of the nasolacrimal duct.
The nasolacrimal duct forms by invagination of the epithelial cellular
layer. The solid cord of cells later degenerates to form a patent duct.
Development of palate11
The primitive stomatodaeum initially is a small chamber with no
barrier between the oral and the nasal cavities. The oropharyngeal
membrane limits it posteriorly. At about the 28th day, the
oropharyngeal membrane disintegrates to provide continuity between
the stomatodaeum and the gut. The stomatodaeum is now called the
oronasopharyngeal chamber.
The palate starts to form during the fifth and sixth weeks. It is
derived from the following structures: (1) two medial nasal processes
(MNPs; derivatives of the FNP) and (2) two maxillary processes.
The primary palate forms first. During the fifth week of intrauterine
life, the MNPs of the two sides extend backwards into the oral cavity
for a short distance and fuse in the midline to give rise to the primary
palate. Around the seventh week, two palatal processes evolve as
outgrowths from the maxillary processes, one on each side, and
develop downwards on either side of the developing tongue. Later,
with the expansion and growth of the stomatodaeum (the anterior or
oral portion of the digestive tract of an embryo), the tongue descends
downwards allowing for the vertically developing palatal shelves to
elevate and approach each other in the midline (Figs. 8.20 and 8.21). In
the anterior region, the shelves elevate and approximate by a
rotational (hinge-like) motion, while remodelling occurs along with
rotation in the posterior regions. It must be noted that the shelves are
incapable of rotation and elevation until the tongue withdraws from
between them. The two shelves coalesce in the midline by dissolution
of the overlying epithelium and subsequent fusion of the underlying
mesenchyme. Fusion starts first in the anterior region of the palate at
around the ninth week and then progresses posteriorly (Fig. 8.22A–F).
Complete fusion of the palate occurs between the 10th and 12th
weeks. Non-fusion beyond the 12th week indicates a cleft lip and
palate.
FIGURE 8.19 The nasolacrimal duct originates as the

nasolacrimal groove around the sixth week after fertilisation.
It extends from the medial end of the developing eye to the primitive
stomatodaeum and grooves between the lateral nasal process and the
maxillary process on each side.
FIGURE 8.20 Scheme of fusion of palatal shelves in the midline.
Fusion of palatal shelves takes place with the developing tongue
descending. The palatal shelves grow towards each other and fuse
with the breakdown of the covering epithelium through a process of
EMT. The fusion begins from anterior to posterior. A lack of fusion can
lead to the formation of a visible or occult cleft.
FIGURE 8.21 Coronal section through the palate showing the
elevation of palatal shelves.
(A) The palatal shelves initially develop in a downward direction
alongside the tongue. The tongue occupies a major part of the oronasal
cavity. (B) With the descent of the tongue, space is created, and the
shelves elevate and move medially towards the midline. The descent of
the tongue is critical to an elevation of the palatal shelves. The palatal
shelves meet in the midline and fuse with each other.
FIGURE 8.22 Axial section at the level of the palate showing the
fusion of palatal shelves.
(A–C) The primary palate grows posteriorly, while the palatal shelves
grow medially to approximate in the midline. (D–F) Fusion starts
anteriorly and proceeds posteriorly. The uvula is the last structure to
form.
For fusion of the palatal shelves, it is imperative that the epithelial

cells of the approximating segments lose their epithelial cell-like
behaviour and thin down to allow fusion. This requires these
epithelial cells to acquire fibroblast-like characteristics; this is a highly
specialised and tightly regulated process called epitheliomesenchymal
transformation (EMT). This process is a fundamental embryologic
process, which is also seen in invasive epithelial carcinomas.12
Failure of fusion of the palatal processes leads to the formation of a
cleft lip and/or palate. The exact nature of the defect depends upon
the timing and severity of the insult and the place where the processes
fail to fuse. Understanding the embryological basis of the
development of the palate is essential in understanding the
pathogenesis, location and extent of clefts (Fig. 8.23).
FIGURE 8.23 Embryonic origin of the various structures of the palate

and face as seen from the occlusal aspect.
Epithelial mesenchymal interactions in palate

fusion
As mentioned, EMT is central to fusion of embryonic processes and is
tightly regulated by genetic mechanisms. Recent studies have
identified the key components of the signalling pathways that drive
palatal shelf outgrowth. SHH expressed by palatine process
epithelium is a early key signal that drives palatal shelf outgrowth as
it encourages the underlying mesenchyme to promote palatal cell
proliferation and outgrowth.
FGF, another factor expressed abundantly in oral ectomesenchyme,
has a significant role in epithelial mesenchymal proliferation. While
FGF10 is expressed abundantly in mesenchymal tissues, FGFR2 is
expressed in the oral epithelium. FGF expression causes proliferation
and development of these tissues. Interestingly, SHH and FGF10 form
a positive feedback loop thus inducing palatal shelf proliferation.13
Studies have shown that FGFR1 and FGFR2 are expressed through all
stages of palate development, while FGF4, FGFR1, FGFR2 and the
downstream effector STAT1 show expression throughout the palatal
epithelia during shelf elevation.14
Recent studies on the role of BMP in palatal fusion indicate a
complex interaction. BMP1 is expressed in developing epithelium and
mesenchyme via the BMPR1A (bone morphogenetic protein receptor
type 1A) receptor. While disruption of epithelial expression has not
been shown to cause cleft formation, mesenchymal disruption of the
same has led to palatal clefts. The role of the Noggin gene has been
linked closely to the regulation of expression of BMP. Also, Osr2,
ADAMTS9 gene and ADAMTS20 gene have all been linked to
regulation of BMP expression.
Anteroposterior growth of the palatal process depends on the
signalling of some genes whose differential expression causes the
gradient of growth. This includes several transcription factor genes
including BarH-like homeobox 1 (Barx1), mesenchyme homeobox 2
(Meox2), short stature homeobox 2 (Shox2), T-box transcription factor
22 (Tbx22), meningioma 1 (Mn1) and Msh homeobox 1 (Msx1). While
Msx1 and Shox2 are predominantly expressed in the anterior part of
the shelves, Meox2 and Tbx22 mRNAs are restricted to the posterior
region of the developing palate.
Elevation of the palatal shelves is characterised by an increase of
glycosaminoglycans in tissue levels. Although the genetic
mechanisms are poorly understood, two specific gene expressions
linked to shelf elevation have been found to be the Osr2 and the FGF2.
It is known in the literature that palatal shelf elevation is
asynchronous and both shelves elevate at slightly different times.
The forces behind scheduled palatal shelf fusion have long been
debated. Broadly speaking, three theories have been proposed, each
having its evidence. They include:
1. EMT of the midline epithelial seam (MES) allows for the

intervening epithelium to be incorporated into the
mesenchyme of the intact palate.
2. Senescence of MES cells by either apoptotic or non-apoptotic
mechanisms.
3. Migration of MES cells occurs in the oral and/or nasal direction
thus leaving a path for mesenchymal fusion.
At the molecular level, TGFβ expression (especially TGFβ3) has

been strongly linked to apoptosis of MES cells. Animal models with a
knockout of the same gene have shown the development of cleft
palate due to non-destruction of MES cells. In addition to Tgfβ, the
following have been shown to be important for MES disruption:
Runx1, β-catenin and members of the Snail family transcription
factors (snail1 and snail2) (Fig. 8.24).
FIGURE 8.24 Many molecular events control palatal fusion.

Transforming growth factor β (Tgf-β) signalling, which acts via the Alk5
and Tgf-βr2 receptors to activate Smad2/Smad4 and the p38 MAPK
pathways, which together regulate p21 expression in the midline
epithelial seam. These, in parallel with the transcription factors Snail1
and Snail2, promote midline epithelial seam apoptosis and
disintegration through protein caspases. Anterior palatal fusion is
facilitated by Runx1, which is expressed in the midline epithelial seam.
Development of mandible
During the fourth week of embryonic life, following the formation of
the primitive stomatodaeum, the two mandibular processes start
moving towards each other in the midline. Like other such processes,
they contain a core of neural crest cells covered on each side by
ectoderm and endoderm, respectively. Fusion of the two processes
occurs during the sixth week of intrauterine life. During the fifth to
sixth week of intrauterine life, a definite cartilage covered by a
fibrocellular membrane develops in the location of the future body
and ramus of the mandible. It arises from the otic capsule and extends
up to the midline following the gentle arch where the future body of
the mandible will develop. The main body of the cartilage is closely
associated with the developing mandibular nerve, while the proximal
ends are associated with the otic apparatus where it will give rise to
the malleus and incus bones of the middle ear. The body of the
cartilage is covered by a well-defined fibrocellular perichondrium.
During the second half of the sixth week the mandible body starts
to form as fibrocellular condensations lateral to that part of Meckel’s
cartilage in the future canine region. Ossification centres soon start to
form in this fibrous tissue (seventh week) in the area of the future
mental foramen. Simultaneously, Meckel’s cartilage starts to
disappear backwards from this region, being replaced by a fibrous
tissue structure. Eventually, around the 10th week of intrauterine life,
the pre-dominant part of Meckel’s cartilage disappears, while the
remaining part ossifies eventually to form the sphenomandibular
ligament. The muscles of mastication start to develop from
condensations of the surrounding mandibular arch mesenchyme at
around the 10th week of intrauterine life.
The mandible is the second bone to ossify in the body after the
clavicle. Ossification starts from single ossification centres close to and
lateral to the future mental foramen where the inferior alveolar nerve
divides into the mental and incisive branches (Fig. 8.25). Ossification
proceeds medially to enclose the nerve within a hollow cavity (future
inferior alveolar canal). Simultaneously, ossification proceeds
anteriorly and posteriorly to form the primordial body of the
mandible. Anteriorly, the developing bones fuse in the midline, while
posteriorly, ossification stops at the level of the future lingula.
FIGURE 8.25 Developing mandible (ossification areas) in relation

to Meckle’s cartilage and mandibular nerve.
The ramus of the mandible forms by the subsequent extension of

ossification, upwards from the lingula into the mesenchyme of the
first branchial arch. Simultaneously, ossification centres also develop
in the condylar region and the area of the anterior border of the
ramus. Ossification extends from these centres inferiorly to fuse with
ossification occurring in the adjacent mandibular mesenchyme.
There are three areas of the mandible that are derived from
endochondral ossification of secondary cartilages, while the rest of the
mandible forms by intramembranous ossification. These are the
condylar process, the coronoid process, and the symphyseal area. The
coronoid process forms by ossification of coronoid cartilage,
transiently during the first 4 months of intrauterine life and is rapidly
ossified into the coronoid process and the anterior half of the
developing ramus. Condylar cartilage starts developing around the
12th week of intrauterine life. It is rapidly replaced by ossifying bone
at the inferior end starting in the 14th week of intrauterine life, while
the superior end maintains its cartilaginous nature. It eventually gives
rise to the condylar process of the mandible and the major part of the
posterior ramus. The junction between Meckel’s cartilage and
mandibular arch mesenchyme is marked by the mandibular foramen.
Symphysis of the mandible shows the formation of two symphyseal
cartilages, which develop independent of Meckel’s cartilage but in
close vicinity of it. These cartilages take variable times to ossify, but
are completely obliterated within 1 year of birth.
Development of tongue
Embryologically, the tongue develops from contributions from the
first and third pharyngeal arches, with a minor contribution from the
fourth arch. The anterior two-thirds of the tongue develop from the
first pharyngeal arch, whereas the posterior one-third develops from
the third arch (Fig. 8.26). The posterior-most part of the tongue may
have influences from the fourth arch as well. The skeletal muscles of
the tongue develop from the occipital somites, which are derivatives
of the paraxial mesoderm.
FIGURE 8.26 Development of the tongue.

(A and B) During the fifth and sixth week, two lateral lingual swellings
develop in the mucosa of the first pharyngeal arch in the paraxial plane.
Simultaneously, a median swelling arises in the midline alongside the
lingual swellings anterior to the copula. (C) Seventh week post-
fertilisation. The lateral swellings and tuberculum impar fuse to form the
structure of the tongue. Further growth and differentiation of tissues
lead to the formation of an adult structure. (D) Adult tongue.
Late in the fourth week or early in the fifth week, two lateral
swellings arise in the epithelium of the floor of the primitive pharynx
anterior to the foramen caecum, due to division of the underlying
mesenchyme. Simultaneously, a medial swelling arises in between
them called the tuberculum impar. The foramen caecum marks the
boundary of fusion between the first and second arches. It also
represents what is left of the tissues of pharyngeal mesenchyme that
descend to form the thyroid gland. Rapid enlargement of the lateral
lingual swellings that fuse in the midline covering the tuberculum
impar forms the anterior two-thirds of the tongue. The posterior third
of the tongue develops from the hypobranchial eminence distal to the
foramen caecum. The hypobranchial eminence is comprised primarily
of mesenchyme from the third arch that grows over the mucosa of the
second arch to eliminate it from the tongue. The line of demarcation
between the body and base is called the terminal sulcus, and the
foramen caecum is found in the midline of this structure. The taste
buds develop in the seventh week of intrauterine life from the
interaction between the special visceral afferent nerves (eighth and
ninth cranial nerves) and the tongue epithelium.
Innervation of the tongue reflects its embryologic origin. The
anterior sensory two-thirds are supplied by the trigeminal nerve,
lingual branch and Chorda tympani and the posterior one-third by the
glossopharyngeal nerve (third arch), while the posterior-most part of
the tongue may be innervated by the vagus nerve (fourth arch). Motor
supply of the muscles of the tongue is by the hypoglossal nerve except
palataoglossus which is supplied by motor fibres of vagus nerve.
Interestingly, it has been suggested that the foetus not only may have
the ability to taste but also may be able to monitor its intraamniotic
environment using it.15
Genetic regulation of craniofacial
development
Differentiation of a single-celled zygote into a highly complex
organism is a marvel of nature. The development and differentiation
of a cell into multiple cells that are committed to evolve into different
organs and tissues is a complex process that is controlled to a large
extent by gene expression. ‘It is well understood that the mechanisms
of craniofacial development are under genetic control. It is helpful to
consider those genes involved in embryogenesis as encoding a set of
instructions or rules of assembly. Implementation of these one-
dimensional rules, via gene expression and protein interaction,
produces the three-dimensional embryo’.16
Genetic fields
Different genes regulate the various cellular processes of the embryo.
Each gene has its genetic field (area) of influence, and the various
genetic fields overlap with each other to regulate overall growth and
development. Genetic control of craniofacial embryogenesis is via the
Hox genes, which are responsible for controlling morphogenesis of
the head and neck region. However, the neural crest cells destined for
the first branchial arch do not express the Hox genes related to the
homeotic homeobox.16 It is the subfamilies of the homeobox genes,
which are more diverged from the ancestral Hox genes, that are
expressed in spatially restricted patterns within the first branchial
arch.17,18 Other homeobox-containing genes, which are expressed in
the maxillary and mandibular arches and developing facial primordia,
are Msx-1, Msx-2, Dlx1-6 and Barx-1 (Fig. 8.27). Members of the Msx
gene family (especially Msx-1 and Msx-2) are prominently expressed
in the neural crest-derived mesenchyme of developing facial
prominences, and there is now strong evidence for the role of these
genes in specification of the skull and face.19 Similarly, neural crest
cell migration into the pharyngeal arches is under strict control of
genes. The Wnt gene is necessary for the induction of neural crest
cells, while the ErbB4 gene produced in neural ectoderm1 is necessary
for neural crest cell migration.
FIGURE 8.27 Schematic representation of homeobox gene

expression in the branchial arches.
The maxillary (Mx) and mandibular (Md) processes of the first branchial
arch are populated by neural crest cells from the distal midbrain and
rhombomeres r1 and r2. The hindbrain contributes to the proximal
region (represented by the Dlx genes) and the midbrain crest to the
distal region (Otx-2); in other words, crest cells populating the
mandibular arch have different axial origins. Neural crest cells
expressing classical Hox genes from the r3 populate the second
branchial arch and so on. Source: Reproduced with permission from
Meikle MC. A century of progress: advances in orthodontics since the
foundation of the British Society for the Study of Orthodontics. J Orthod
2008;35:176–90, Figure 6.
Members of the multigene Dlx (distal-less) family are expressed in a

complex pattern within the embryonic ectoderm and mesenchyme of
the maxillary and mandibular processes.15 Other important genes in
craniofacial development are the goosecoid (Gsc), orthodontical (Otx),
SHH and Indian hedgehog (Ihh) genes.20 These homeobox genes act
by exerting control on the growth factor family and the
steroid/thyroid/retinoic acid superfamily. The regulatory molecules in
the mesenchyme, such as FGF, epidermal growth factor, transforming
growth factor-alpha (TGF-α), transforming growth factor-beta (TGF-β)
and BMPs, are the vehicles through which homeobox gene
information is expressed in the coordination of cell migration and
subsequent cell interactions that regulate growth (Table 8.6).20,21
Table 8.6
Genetic regulation of cellular function

Gene Protein encoded Function
Cartilage
Marker genes
COL2A1 Type II collagen
IIA isoform Marker for chondroprogenitor cells
IIB isoform Marker for differentiated chondrocytes
COL9A1 Type IX collagen Interact with proteoglycans
ACAN Aggrecan Cartilage-specific proteoglycan
COL10A1 Type X collagen Marker for hypertrophic chondrocytes
Regulatory Transcription
genes factors
SOX9 Sox 9 Signals chondrocyte differentiation
Growth
factors/receptors
IHH Ihh Stimulates chondrocyte proliferation and PTHrP
FGF FGF/FGFR Inhibits chondrocyte proliferation and hypertrophy
TGFB1 TGFβ-1/TGFβR Stimulates chondrocyte differentiation and hypertrophy
BMP BMP/BMPR Stimulates chondrocyte hypertrophy
PTHrP PTHrP/PTHrPR Stimulates chondrocyte proliferation
RAR RAR Stimulates chondrocyte hypertrophy
Bone
Marker genes
ALPL Alkaline Potential Ca2+ carrier, hydrolyse inhibitors of mineral deposition
phosphatase such as pyrophosphates
COL2A1 Type I collagen Serves as a scaffold for mineralisation
BSP Bone sialoprotein Nucleator of mineralisation
SPP1 Osteopontin Inhibits mineralisation and promotes bone resorption
BGLAP Osteocalcin Inhibits mineralisation
SPARL Osteonectin May mediate deposition of hydroxyapatite
Regulatory Transcription
genes factors
RUNX2 Cbfal/Runx2 Required for osteogenic commitment and differentiation
SP7 Osterix Required for osteogenic differentiation
TWIST Twist Positive regulator of osteoblast differentiation
MSX2 Msx2 Inhibits osteoblast differentiation
Growth
factors/receptors
FGF FGF/FGFR Stimulates proliferation and differentiation
Generates survival signalling
TGFB1 TGFβ-1/TGFβR Modulates bone remodelling
BMP BMP/BMPR Increases Cbfal/Runx2 expression and stimulates differentiation
IGF IGF Stimulates cell proliferation, differentiation and matrix production
PDFGB PDGF Signals cell proliferation and recruits progenitor cells by
stimulating chemotactic migration
BMP/BMPR, Bone morphogenic proteins/receptors; FGF/FGFR, fibroblast growth
factors/receptors; IGF, insulin-like growth factor; Ihh, Indian hedgehog; PDGF, platelet-derived
growth factor; PTHrP/PTHrPR, parathyroid hormone-related peptide/receptors; RAR, retinoic
acid receptors; TGFβ/TGFβR, transforming growth factors/receptors.
Source: Based on Mao JJ, Nah HD. Growth and development:

hereditary and mechanical modulations. Am J Orthod Dentofacial
Orthop 2004;125:676–89.
Craniofacial syndromes due to defective
genetic control
Several syndromes of the craniofacial region have their origin in
mutations in FGF receptor genes, transcription factors, MSX2, the core
binding factor 1 gene (CBFA1), etc. For example, in cleidocranial
dysplasia a mutation in CBFA1 causes defects in the membranous
bones of the cranial vault and the clavicles. This is attributed to
defective signalling between the periosteum and the chondrocytes.
Similarly, the Treacher Collins syndrome (TCS) locus has been
mapped to the long arm of chromosome 5. Mutations of this part of
the chromosome affect the production of ‘treacle protein’, which
results in the anomaly. Apert, Crouzon and Pfeiffer syndromes result
due to mutations in the FGF receptor gene that is known to affect
sutural development in mice and humans.
Although genetic regulation of tissue growth is under strong check
mechanisms, anomalies of cell migration, differentiation or replication
do occur. These anomalies occur either due to mutation of particular
genes or due to environmental factors, which lead to the failure of
check mechanisms or interplay between the two. Since a small
population of cells gives rise to multiple structures during
embryogenesis, problems occurring early in life lead to widespread
manifestations, many of which are so characteristic that they can be
grouped into syndromes.
Environmental factors, usually grouped as teratogens, do not act
continuously. They only act at the time of exposure causing insult to
the developing foetus. Since specific events occur during specific
periods of gestation, the type of anomaly depends upon the particular
time during which exposure to a teratogen occurred (Fig. 8.28).
FIGURE 8.28 Possible teratogenic exposure during pregnancy.
The early period of development is very susceptible to teratogens.
Exposure during the first or second week would either cause
termination of the foetus or early cellular damage, which can be
compensated for by rapidly dividing cells. The next few weeks are
periods of organogenesis and exposure, which can lead to significant
birth defects (red). Periods during which exposure only leads to minor
birth defects are highlighted in light blue. Source: Modified from Moore
KL; Reichrath J, Reichrath S, editor. Notch Signalling in Embryology
and Cancer. Springer: Texas; 2012. p. 116.
Cleft lip and palate are among the most common congenital
anomalies. Cleft lip occurs due to non-fusion of the MNP with the
maxillary process, while cleft palate occurs due to non-fusion either
between the two palatal processes or between the palatal process and
the FNP (primary palate). Also, in very rare circumstances, the two
MNPs may fail to fuse giving rise to atypical midline clefts. Such clefts
are usually associated with other anomalies related to midline
structures, and in many cases may not be compatible with life.
Depending on the location, clefts may be classified broadly into (1)
cleft lip, (2) cleft lip and alveolus, (3) cleft lip and palate and (4)
isolated cleft palate. The exact nature and extent of the defect depend
upon the time, location, duration and the nature of the insult.
However, the nature of the defect is in synchrony with the
embryologic sequence of palatal development. The critical time for
formation of the upper lip is between the fifth and eighth week, while
for the palate, it is between the seventh and tenth week. Hence,
processes during early phases of intrauterine life lead to formation of
a cleft lip, while those acting later contribute to palatal clefts.
Interestingly, although cases of cleft lip can occur in isolation, they are
usually associated with some form of palatal cleft. Also, an isolated
cleft palate is usually considered a separate entity as its incidence,
aetiology and genesis are different from other types of clefts.
Many craniofacial defects are related to problems with the
differentiation or migration of neural crest cells. Neural crest cells are
particularly prone to insult due to their long paths of migration. The
defects range from complete disruption in the development of the
neurocranium (anencephaly), which is usually incompatible with life,
to milder defects like single-tissue malformations (malformations of
the external ear). Usually, disruption of neural crest cell activity leads
to the development of craniofacial syndromes like branchial arch
syndromes and craniosynostosis syndromes.
Branchial arch syndromes22

Defects in the development of branchial arches lead to branchial arch
syndromes (Table 8.7). These may be of both genetic and
environmental origin. Since formation of the face is primarily
concerned with the first and second branchial arches, syndromes
relating to these two arches are of major concern for dental
professionals. The most common and important syndromes include
Treacher Collins syndrome (TCS), oculo-auriculo-vertebral syndrome
(OAVS), and auriculocondylar syndrome (ARCND, question mark
ears). TCS and ARCND are autosomal dominant with nearly complete
penetrance and a wide spectrum of clinical variability. The phenotype
of the latter has several overlapping features with OAVS, but OAVS
may exist in both sporadic and autosomal-dominant forms.
Table 8.7
Frequently seen branchial arch syndromes
Source: Adapted from Passos-Bueno MR, Ornelas CC, Fanganiello
RD. Syndromes of the first and second pharyngeal arches: a review.
Am J Med Genet A 2009;149A:1853–9.
Synostosis syndromes23
Premature fusion of the cranial sutures leads to the development of
craniosynostosis. Craniosynostosis is a relatively common condition
with a prevalence of 1 in 3000. More than 100 synostosis syndromes
have been defined, and many are associated with limb deformities
suggesting a common pathway of development. Common craniofacial
craniosynostosis syndromes include Apert, Pfeiffer, Crouzon, Muenke
and Saethre–Chotzen syndromes (Table 8.8). The majority of these
syndromes, in contrast to branchial arch syndromes, are non-genetic
in origin. The sagittal suture is most commonly affected followed by
the coronal suture.
Table 8.8
Common synostosis syndromes
Source: Adapted from Cassidy SB, Allanson JE, editors. Management of

Genetic Syndromes. 3rd ed. Wiley-Blackwell: New Jersey; 2010. p. 228.
Crouzon syndrome, which occurs due to prenatal fusion of the
superior and posterior sutures of the maxilla along the wall of the
orbit, is the most frequently occurring synostosis syndrome. Due to
growth cessation at the sutures, the midface remains underdeveloped
with characteristic bulging eyes. The fusion may extend posteriorly
into the cranium, producing distortions of the cranial vault.
Synostosis leads to reduced space for the growing brain, therefore,
increased intracranial pressure may develop which would necessitate
surgical intervention. Surgical decompression at the sutures is
frequently required.
Key Points
Development of the foetus from an embryo is an intricate and
complex process that occurs during the 9 months of gestation. Life
originates as a single-celled zygote and differentiates rapidly into cell
masses forming the embryo proper, which further develops and
differentiates into the foetus.
The critical period of organogenesis lasts from the fourth to eighth
week, during which time the imprints of various organ systems are
created. After the embryonic phase, there is very little new-tissue
differentiation, and the growth of already-formed tissues pre-
dominates to give an increasingly large size to the foetus.
The complex process of foetal development is under strong genetic
regulation. The migration of cell populations, differentiation of
tissues, timing of cell division, programmed cell death and many
other processes are controlled by genes. Any malfunction of a gene,
which may be inherent or occurs due to disruptive environmental
influences, may result in a variety of congenital malformations, which
may or may not be compatible with life.
Orthodontists should be familiar with normal intrauterine
development and abnormal development of the face, which has
obvious clinical implications in orthodontic practice.
References
1. Sperber GH, Sperber SM, Guttmann GD. Craniofacial
embryogenetics and development. 2nd ed. Shelton:
People’s Medical Publishing House; 2010.
2. Cummins MR. A survey of human development
from fertilisation to birth. In: Cummings MR, ed.
Human heredity: principles, issues. 9th ed. Belmont:
Brooks/Cole Cengage; 2010:157.
3. Carlson BM. Foundations of embryology. 6th ed.
India: Tata McGraw Hill; 2007: p. 519.
4. Drews U. Human development. In: Drews U, ed.
Colour atlas of embryology. Stuttgart: Thieme;
1995:40.
5. Streeter GL. Development horizons in human
embryos. Description of age group XI, 13 to 20
somites, and age group XII, 21 to 29 somites. Carnegie
contrib embryol. 1942;30:211–245.
6. O’Rahilly R, Müller F. Developmental stages in
human embryos. Washington, DC: Carnegie
Institute; 1987.
7. Reichrath J, Reichrath S, eds. Notch signalling in
embryology and cancer. Texas: Springer; 2012:116.
8. Moore KL, Persaud TVN. The developing human:
clinically oriented embryology. 6th ed. Philadelphia:
Saunders; 1998.
9. Cobourne MT. Construction for the modern head:
current concepts in craniofacial development. J
Orthod. 2000;27(4):307–314.
10. Frisdal A, Trainor PA. Development and evolution of
the pharyngeal apparatus. Wiley Interdiscip Rev Dev
Biol. 2014;3(6):403–418.
11. http://www.indiana.edu/
∼anat550/hnanim/face/face.html. Accessed on 26th
Feb 2018.
12. Development of face. In: Nanci A, ed. Ten Cate’s oral
histology. 8th ed. Atlanta: Elsevier; 2013: p. 35.
13. Bush JO, Jiang R. Palatogenesis: morphogenetic and
molecular mechanisms of secondary palate
development. Development. 2012;139(2):231–243.
14. Hilliard SA, Yu L, Gu S, Zhang Z, Chen YP. Regional
regulation of palatal growth and patterning along the
anterior-posterior axis in mice. J Anat.
2005;207(5):655–667.
15. Bradley RM, Mistretta CM. Fetal sensory receptors.
Physiol Rev. 1975;55(3):352–382.
16. Ferguson MW. A hole in the head. Nat Genet.
2000;24(4):330–331.
17. Rivera-Pérez JA, Mallo M, Gendron-Maguire M,
Gridley T, Behringer RR. Goosecoid is not an
essential component of the mouse gastrula organizer
but is required for craniofacial and rib development.
Development. 1995;121(9):3005–3012.
18. Johnston MC, Bronsky PT. Prenatal craniofacial
development: new insights on normal and abnormal
mechanisms. Crit Rev Oral Biol Med.
1995;6(4):368–422.
19. Mossey PA. The heritability of malocclusion: Part 1—
genetics, principles and terminology. Br J Orthod.
1999;26(2):103–113.
20. Bannister LH, Berry MM, Collins P, et al. Gray’s
Anatomy. 38th ed. Edinburgh: Churchill Livingstone;
1995: pp. 426–442.
21. Sarnat BG. Effects and noneffects of personal
environmental experimentation on postnatal
craniofacial growth. J Craniofac Surg.
2001;12(3):205–217.
22. Passos-Bueno MR, Ornelas CC, Fanganiello RD.
Syndromes of the first and second pharyngeal arches:
a review. Am J Med Genet A. 2009;149A(8):1853–1859.
23. Gripp KW, Zackai EH. Craniosynostosis syndromes.
In: Cassidy SB, Allanson JE, eds. Management of
genetic syndromes. 3rd ed. Hoboken, NJ: Wiley–
Blackwell; 2010:228.
CHAPTER 9
Concepts of growth and
development
O.P. Kharbanda
Neeraj Wadhawan
Ram S. Nanda
CHAPTER OUTLINE
Introduction
Canalised growth
Catch-up growth
General interpretations of graphical data
Growth velocity and face
Intra-membranous ossification
Endochondral ossification
Basic concepts involved in bone growth
Displacement
Growth centre
Ossification centre
Growth site
Growth field
Epiphyseal growth
Periosteal and endosteal growth
Sutural growth
Remodelling
Cortical drift
Enlow’s V principle of growth
Enlow’s counterpart principle of growth
Theories of growth
Brash’s remodelling theory (1930s)
Sicher’s theory of sutural growth dominance (1940s)
Scott’s theory of cartilaginous growth dominance
(1950s)
Functional matrix theory (1960s)
Types of functional matrices
Enlow–Hunter growth equivalent theory (1960s)
Petrovic’s servosystem theory (1970s)
Current concepts of the functional matrix: the molecular basis
The concept of mechanotransduction
Bone as an osseous connected cellular network (CNN)
Genomic thesis
Epigenetic antithesis and resolving synthesis
Current views on growth at the turn of the 21st century
Key Points
Introduction
Growth and development are two fundamental biological processes
which define the existence of life. Since the time a child is born, up to
senescence, both processes continue to occur in different capacities
and at a different pace to evolve the organism and impart it with its
characteristics and life. The two processes are linked and overlap so
intricately that actual separation of them may be impossible.
Growth,1,2 in general, may be defined as the physiologic increase in
size, weight and mass of a living organism. At the macroscopic or
clinical level, growth is exemplified by an increase in height and
weight, while at the microscopic level, it is accompanied by an
increase in the number of cells and their size. Growth in multicellular
organisms is more frequently allometric (disproportional among
adjacent structures) than isometric (proportional among structures). In
jaws, growth results in an increase in the size of the jaws along with
adjacent structures, growth in the size of condyles, and the eruption of
teeth.
Development1,2 refers to a stage of growth and maturation that
encompasses morphogenesis, differentiation and acquisition of
functionality. Development means progress towards maturity.
Maturation is the stage of stabilisation brought about by growth and
development. While an organ or the organism grows, its tissues
develop towards particular functions and become mature, as pointed
out by Moyers.
Development=Growth+Differentiation+Translocation
Development at the cellular level can be described as differentiation
and maturation of progenitor cells into terminally differentiated cells,
such as from mesenchymal cells to mature osteoblasts or from
proliferating chondrocytes to hypertrophic cells. At the sub-cellular
level, it is exemplified by self-assembly of immature collagen fibrils
into mature and functional collagen fibres or the mineralisation of
osteoid to mature bone (Box 9.1). At the clinical level, the increasing
capacity of the maturing mandibular condyle to withstand mechanical
stresses can be viewed as development.
Box 9.1 Differences between growth and

development
Growth Development
Is largely an anatomic/physical phenomenon Is an anatomic and functional phenomenon
characterised by increase in physical dimensions characterised more by acquisition of
functionality, increasing complexity and
differentiation of function
Is usually unidirectional leading to increase in Is a multi-directional, multi-dimensional and
proportions; however, it may also cause reduced multi-functional phenomenon
proportions like reduction in size of the thymus
after puberty
Increase is quantitative Increase is qualitative
Active growth stops after a certain age (reduces to Development continues till senescence
very low baseline levels) (adulthood)
The process of development and evolvement towards so-called

maturity will also involve some decay in, for example, development of
the dentition and oral functions requiring the shedding of deciduous
teeth.
Development requires systematic changes in a definite direction in
all aspects from size and proportion of the body to the ways of
thinking, living and feeling. Thus, development is the entire process of
change in which all aspects of a person are inter-related and
integrated. The physical changes occurring in a boy during puberty
will also influence his behaviour and his process of thinking:3
• Development involves systematic changes throughout the

entire life period.3
• Developmental changes are inter-related.3
• Development proceeds in a definite direction.3
The human life cycle and growth after birth can be split into eight
stages. These are
1. Infancy: this period extends from birth to 18 months of age.
2. Early childhood: this period ranges from 18 months to 3 years.
3. Middle childhood: this phase extends from 3 to 5 years.
4. Late childhood: this period ranges from 5 to 12 years.
5. Adolescence: this is a period of transition from childhood to
adulthood, which usually extends from 12 to 20 years.
6. Early adulthood: this stage extends from 20 to 30 years.
7. Mature adulthood: this period ranges from 30 to 65 years.
8. Old age: this period ranges from 65 years till death.
Why do we need to study growth (Box 9.2)? The growth of an

organism is the inter-play between its genetic makeup, which will
direct the formation, size, and shape of the face, and the environment
in which it thrives. While the genotype provides the underlying
architecture, the environment acts to alter it to the form which may be
best suited to the existing conditions. Both modulators, however, may
have a positive or negative influence on the growth of the organism.
Differentiating the contribution of each may become important for
prevention of an impending disorder and its treatment. In the
epidemiological scenario, growth assessment provides valuable data
for the drafting and implementation of health-related schemes.
Box 9.2 Why do we need to study growth?
1. Growth assessment reveals much about the general health of the

individual
2. In many instances, the first suspicion of an underlying disorder
may be altered growth
3. Growth may help in predicting and anticipating the ultimate
body size of a child including the craniofacial region and hence,
in modifying treatment according to expected changes in facial
form
4. Growth may be used to plan the timing of orthodontic treatment
5. The assessment of differential growth helps in identifying the
cause of malocclusion and hence treatment may be planned
accordingly
6. Medical alteration of growth as in growth hormone therapy may
be used advantageously in children with reduced jaw length
Physical growth is an excellent indicator of the general health and

nutritional status of a child, and its assessment is deemed vital for
monitoring overall health. Since humans are neotenous organisms
with a long growth span, they are highly prone to environmental
influences (Box 9.3). Children with chronic diseases, nutritional
deficiencies, hormonal imbalances and metabolic disorders usually
have restricted/delayed growth and maturation. In many instances,
abnormal physical growth may be the first indicator of an underlying
disturbance, both genetic and environmental.
Box 9.3 Common causes of short stature (all these

factors affect growth as well)
1. Intra-uterine growth retardation (low birth weight)

2. Chronic diseases and disturbances of organ systems:
a. Cardiac, renal, hepatic, haematologic, gastrointestinal
and pulmonary systems
b. Chronic infections like AIDS and tuberculosis
3. Nutritional disturbances:
a. Decreased caloric intake
b. Protein energy malnutrition
c. Micronutrient deficiency like zinc and iron
4. Endocrinologic disorders:
a. Growth hormone deficiency
b. Glucocorticoid excess: Cushing syndrome
c. Growth hormone insensitivity: efficiency of IGF 1
(insulin-like growth factor)
d. Hypothyroidism
e. Poorly controlled diabetes mellitus
f. Pseudohypoparathyroidism
5. Chromosomal aberrations:
a. Turner syndrome
b. Down syndrome
6. Skeletal disorders:
a. Achondrodysplasia
b. Chondrodystrophy
7. Inborn errors of metabolism:
a. Mucopolysaccharidosis
b. Various metabolic storage diseases like Hurler disease,
Niemann–Pick disease
8. Psychosocial dwarfism (functional)
9. Chronic drug intake:
a. Corticosteroids
b. Methylphenidate and other amphetamines
10. Normal variation of growth:
a. Familial tendency for short stature/genetic
b. Constitutional delay in growth
Source: Data taken from Lifshitz F, editor. Pediatric Endocrinology, vol.

1, 5th ed, Boca Raton: Informa Healthcare, CRC Press; Crocetti M,
Barone MA, Oski FA. Oski’s Essential Paediatrics, Philadelphia, PA:
Lippincott Williams & Wilkins; 2004; Fujieda K, Tanaka T. Diagnosis
of children with short stature: insights from KIGS. In: Ranke MB, Price
DA, Reiter EO, editors. Growth Hormone Therapy in Pediatrics—20 Years
of KIGS, Basel: Karger; 2007. pp. 16–22; Matfin G, Disorders of
endocrine control of growth and metabolism. In: Hannon RA, Pooler
C, Porth CM, editors. Porth Pathophysiology: Concepts of Altered Health
States. Toronto: Lippincott Williams & Wilkins; 2009. p. 986.
Craniofacial growth usually follows the trend of general skeletal

growth, and therefore systemic growth retardation does influence the
craniofacial region. Altered growth would affect not only the
treatment plan but also the timing of treatment and prognosis of the
case. It must be remembered that orthodontic treatment is based on
the premise of physiologic response of oral tissues to orthodontic
forces and is thus highly dependent on the patient’s general health.
For example, mandibular hypoplasia may occur due to genetic pre-
disposition to a short mandible or environmental influences like
trauma to temporomandibular joint disorders (TMJs) or systemic
diseases/malnutrition. The treatment plan for each condition would be
different depending upon the aetiology and stage of maturation. For
example, when augmentation of jaw growth using functional
appliances is scheduled, it is best carried out in periods of growth
spurts. In case growth is complete, mandibular advancement by
means of orthognathic surgery will be the suitable option.
An individual’s growth is determined by a host of known and
unknown determinants that can be broadly classified as genetic and
environmental. These factors are as follows:
1. Heredity. Every individual has a basic pattern of growth that is

dictated by his genome. The ultimate size of different parts of
the body, rate of growth, functional differentiation,
development of tissue functions, onset of the pubertal spurt
and its duration, and final height are just a few of the factors
where genes have primary control.
2. Environment. Environmental factors play a significant role in
altering growth and development, although it is hard to
determine the exact extent of their role.
i. Nutrition. Children exposed to prolonged
malnutrition show stunting of growth and slow
maturation. Protein energy malnutrition leads to
altered skeletal and muscular growth; vitamin D
deficiency affects bone growth and maturation,
vitamin A and E deficiency alter the growth and
development of the epithelium, while vitamin B1
deficiency alters the development of the neurones
leading to altered mental status.
In malnourished children, tooth calcification takes
precedence over bone calcification, and the bones
develop better than the muscles and adipose tissues.
The body parts that are growing fastest at the time of
deprivation suffer the most. The intensity of delay
and the arrest of growth are directly related to the
severity and the length of time for which the child
suffers from malnutrition.
ii. Illness. Diseases, especially chronic ones, can affect
the relative rate of growth in a transitory or a
permanent manner depending on the nature and
severity of the disturbance. Such diseases include
tuberculosis, allergies, chronic renal disease,
poliomyelitis and related disorders.
iii. Injuries. Damage to nerves, muscles, tendons may
retard growth.
iv. Race. Several factors like birth weight, the rate of
growth and age at menarche have been attributed to
racial differences. However, it is not clear whether
these factors are ethnic influences or a reflection of
the environmental influences these races are
subjected to.
v. Climate. More adipose tissue is laid down in people
living in colder climates. Seasonal variations affect
the velocity of growth in humans. October,
November and December are months of greatest
increase, in contrast to those of April, May and June
in which growth is minimal. However, no
significant differences in rates of growth and
maturation have been demonstrated in children
raised in different climates.
vi. Socioeconomic factors. Higher socioeconomic group
children tend to grow taller, are heavier, and
experience earlier onset of the pubertal spurt than
children from lower socioeconomic status. Although
no general rule can be applied and the reason for
this variation is not known, it is presumably related
to nutritional differences as well as other habits of
rest, exercise and general care available to
socioeconomically higher classes.
vii. Exercise. Physical activity may affect growth by
increasing motor skills, fitness and well-being.
Unsubstantiated claims have also been made that
exercise enhances the rate of growth.
viii. Order of birth. First-born children tend to weigh
less at birth and may have a higher IQ.
ix. Secular trends. A trend of increase in size and
earlier maturation has been noticed over the past
100 years. Today’s 15-year-old boys are 5 in. taller
than 15-year-old boys of 50 years ago giving an
average increase of 1 in. for every decade. This
difference is due to both accelerations of maturation
and final adult size.
There has also been a downward secular trend in the age of

menarche. Although the reasons for secular trends are not fully
understood, it is likely that better nutrition and health, particularly in
infancy, are mainly responsible.
Canalised growth
The ultimate growth of an organ is the consequence of the inter-play
between genetic and environmental influences. Genetic makeup
decides the basic body plan, while the environment moulds the
organism. Ideally, if an organism grew in an -environment which is
feasible for unrestrained growth, growth would follow a particular
pre-defined curve, mostly dictated by genetic makeup, until the final
size and shape are reached just as if growth were channelled along a
pre-defined canal. Waddington called this phenomenon canalisation
or homeorrhesis.5 He used the term Canalisation to describe the
growth seen in children who grew in an unrestrained environment.
The growth of these children followed or paralleled a particular
centile just as if growth were occurring at a pre-defined rate and form
(Fig. 9.1).
FIGURE 9.1 Canalisation of growth: the typical Waddingtonian

representation of a genetic landscape.
This diagram shows multiple, more or less canalised pathways that
preexist the ball’s downhill journey. Source: Loison L. Canalization and
genetic assimilation: reassessing the radicality of the Waddingtonian
concept of inheritance of acquired characters. Semin Cell Dev Biol
2019;88:4–13.
Paediatricians have used and interpreted the concept of canalisation

with the rider that infants and growing children should stay within
one or two growth channels, and therefore any crossing of height
centiles warrants further evaluation for reasons of extraordinary
growth. However, research studies now suggest that the crossing of
centiles in the very strict sense should not be considered. In the
clinical setting, centiles should still be taken seriously, at least at first
until a medical cause for their being crossed has been excluded.6
Catch-up growth
However, no individual ever grows in an unrestrained environment.
Right from the time of delivery when a child is born and leaves the
protected environment of the mother’s womb, the child is exposed to
the outside environment. Humoral and other adjustments restrain
temporary slowing of growth. Similarly, illnesses (short or
prolonged), altering seasons or nutritional factors do influence
modulation of growth. Whenever the growth of an organism is
hindered due to environmental influences the body tends to respond
by an exaggerated growth session when the circumstances become
favourable. This phenomenon is called catch-up growth. Hence, catch-
up growth may be defined as growth that occurs following an insult
or injury that leads to temporary cessation or reduction of growth.7
More accurately, it is defined as the height velocity that exceeds
reasonable limits for the age of the child for at least 1 year after a
period of depressed growth.7 Although the catch-up phenomenon
leads to accelerated growth, whether it can adequately compensate for
the functional disturbances caused is questionable. Other factors that
influence catch-up growth are chronological age, height, weight,
duration and severity of the illness/insult. Catch-up velocity in height
can reach at least four times the normal velocity for the chronological
age.
Assessment of physical growth and nutrition can be assessed by direct
measurements of height and weight using the following indices:
• weight for age;

• height for age;
• height for weight;
• mid-arm circumference.
The first three indices are essentially used for studying nutritional
status by pediatricians and endocrinologists. Mid-upper arm
circumference (MUAC) is the circumference of the left upper arm,
measured at the mid-point between the tip of the shoulder and the tip
of the elbow (olecranon process and the acromium). MUAC is
recommended for use with children between 6 and 59 months of age
and for assessing nutritional status. It is most useful in evaluating
acute energy deficiency in adults during a famine. The primary
determinants of MUAC, arm muscle and subcutaneous fat, are
important determinants of survival in starvation. MUAC is a more
sensitive index of tissue atrophy than low body weight.8
In orthodontic clinical practice, we consider height for age to get an
impression about the child’s overall development. An unusually tall
or short child for his/her age reporting with malocclusion may require
further investigation and consultation with a paediatrician.
Assessment of height for age has more relevance for an orthodontist
since the timings of facial growth follow skeletal growth in general.
Height for age should be the method of choice (Fig. 9.2). Average
gains in height for age are outlined below.
1. Birth length
a. Average birth length is 20 in. (50 cm)
b. Length doubles by age 4 years
c. Length triples by age 13 years
2. First-year growth: 9 − 11 in. (23 − 27 cm)
3. Second-year growth: 4 − 6 in. (10 − 14 cm)
4. Third-year growth: 3 − 4 in. (7.5 − 10 cm)
5. Annual growth until puberty: 2 − 3 in. (6 − 7 cm)
6. Pre-puberty growth: 2 in. (5 cm)
7. Pubertal growth
a. For boys it is 4 − 6 in. (10 − 14 cm)
b. For girls it is 3 − 5 in. (8 − 12 cm)
FIGURE 9.2 Correct method of measuring the height of a child.
Changes in height with time are correlated closely to overall

physical growth of an individual. Sequential recording of height and
rate of changes and timings in it can be used to study the pattern of
development of an individual, as well as identify pubertal growth
spurts. The height of the person in question is measured either in a
standing, sitting or lying down position.
Population height charts are obtained by plotting graphically serial
measurements of the heights of various subjects of a particular
race/community at different time intervals. When an individual is to
be evaluated, his/her data can be plotted on a graph and compared
with population means. Chart data can be interpreted in the following
two ways:
• Distance curve: indicates a point on the graph the subject has

reached in height (Fig. 9.3A). By comparing it with population
means, prediction of future growth may be forecast.
• Velocity curve: indicates the rate of gain in height over a period
(Fig. 9.3A and B). These types of charts are especially useful
for identifying the onset of growth spurts during which rapid
increments in height are obtained. Height velocity is
expressed in centimetres per year.
FIGURE 9.3 (A and B) Percentile height for age charts for girls and
boys plotted as a distance curve. Source: CDC growth charts 2000,
http://www.cdc.gov/growthcharts/. (C and D) Distance and velocity
curve for Indian population children. Source: Indian Academy of
Pediatrics,
http://iapindia.org/files/growthchart/IAP%20Girls%20Height%20&%20Weight%20chart%205-
18%20years.pdf and
http://iapindia.org/files/growthchart/IAP%20Boys%20Height%20&%20Weight%20chart%205-
18%20years.pdf.
The value thus obtained is then compared with age-specific

population norms (means), provided as height-for-age charts, of that
particular state/country. Deviations are measured by reference to
population percentiles. A child falling out of two standard deviations
on either side of the mean (2nd to 98th percentile) of the population5 is
considered to be unhealthy and would require detailed medical
evaluation. The Indian -Academy of Pediatrics has created standard
charts for Indian child population.9
Peak height velocity (PHV) is defined as the maximum rate in gain
of height during adolescence. It is considered an excellent indicator of
overall somatic and skeletal growth13,14 and a good indicator of facial
growth (Fig. 9.4).15 PHV occurs at a mean age of 13.5 years in boys
and 11.5 years in girls. Pubertal growth accounts for about 20% of
final adult height, the total averaging 23 − 28 cm in females and 26 −
28 cm in males. An average growth spurt lasts 24 − 36 months.10
Legs grow first and are followed by sitting height growth. To
predict the years from age for PHV the following variables are
required: gender, date of birth, date of measurement, height, sitting
height and weight.11 Also, the closer an individual is to these events,
the more accurate the prediction. Therefore, the ideal age of prediction
is 9 − 13 years in females and 12 − 16 years in males. The information
can be calculated when uploaded to a formula set up for PHV. The
prediction is based on white Caucasian children11 (Figs 9.4A,B and
9.5).
FIGURE 9.4 Graphic representation of average height for age

changes from 0 to 18 years.
(A) Distance curve. (B) Velocity curve. Note that the adolescent growth
spurt occurs earlier in females during which time the average female is
taller than her male counterpart. Also note that the adolescent growth
spurt is more prolonged in males and males show a higher peak height
velocity than females. Source: Reproduced with permission from
Tanner JM, Whitehouse RH, Takaishi M. Standards from birth to
maturity for height, weight, height velocity and weight velocity in British
children. Arch Dis Child 1966;41:454–71.
FIGURE 9.5 Idealised velocity curve of human growth for boys
(solid line).
The purple line is a sixth polynomial curve fit with the velocity data. The
polynomial curve does not fit well with real growth curve data due to
pulses in the mid-childhood spurt (MCS) and the adolescent spurt (AS).
The human velocity curve cannot be fitted adequately by a single
continuous mathematical function. Two or more functions are required.
A, adolescent; C, childhood; I, infancy; J, juvenile; M, mature adult.
Source: Reproduced from Ulijaszek SJ, Johnston FE, Preece MA. The
Cambridge Encyclopaedia of Human Growth and Development.
Cambridge: Cambridge University Press; 1998. p. 464.
General interpretations of graphical
data
When serial height measurement data from a group of individuals is
plotted, certain observations become apparent. First, growth data
from individuals, when plotted independently, show sharp spikes and
falls representing the changes in gain of height from birth to
adulthood. These spikes highlight the variability of growth amongst
different individuals and at different times. However, when the mean
of the growth data from a population is plotted, the spikes are lost and
the curves become smooth.
Second, since every individual has his/her own growth trend. A
population growth chart shows wide variation in mean values and
large standard deviations. Thus, if the growth of an individual varies
considerably from population data, it would not necessarily mean that
there is some underlying disorder affecting normal growth. Usually, a
child is considered to be abnormal if his/her growth does not fall
within two standard deviations of the mean (i.e. 2nd to 98th
percentiles).12
Children with early-onset pubertal timing have reduced adult
height and leg length, and subjects with a low childhood body mass
index have reduced adult sitting height. Thus, childhood body
composition and pubertal timing have impacts on trunk growth and
the growth of long bones.13
The following classical observations were made by Tanner et al.14 in
British school children using height, velocity and distance curves:
1. When the distance curves of boys and girls are compared, the
girls’ curve crosses the boys’ curve at about 10 years of age, the
beginning of the pubertal growth spurt, which occurs earlier in
girls.
2. From 10 to 13 years of age, girls are on average taller than the
boys. At age 14 boys overtake girls in height.
3. The rate of growth is seen to decrease from birth to adolescence
followed by a marked increase in height in both sexes at the
time of the adolescent spurt (pre-pubertal acceleration,
circumpubertal acceleration).
4. Pre-pubertal acceleration occurs earlier in females (10½–11
years) than males (12½–13 years). The spurt lasts for about 2–
2½ years in both sexes.
5. During the spurt, boys grow about 8 in. in height, whereas girls
grow about 6 in.
6. Menarche always follows the peak velocity of the adolescent
spurt, which is characterised by rapid slowing of growth.
7. In girls, 98% of their final height is attained by 16½ years,
whereas boys reach the same stage between 17 and 18 years.
The observations of Tanner et al. have been substantiated by many

workers. However, due to changes in secular trends over time and
inherent variation in populations, some differences have been found.
These include:
1. The adolescent growth spurt shows high variability of onset in

both sexes (average age of onset is 10–12 years in girls and 13–
14 years in boys).
2. The spurt in both genders lasts for around 3–3½years with a
longer duration in boys on average.
3. After 16 years in girls and 18 years in boys, a little gain in
height can be expected.15-17
Growth velocity and face

In general, the onset of height, facial height, facial size and
mandibular length occur in an orderly fashion. The difference in
timing between height and facial size growth spurts is statistically
significant. In boys, the onset for height, facial size and mandibular
length occur more or less simultaneously at 11.9, 12.0 and 11.9 years,
respectively. In girls, the peak of the growth spurt in height, facial size
and mandibular length occurs at 10.9, 11.5 and 11.5 years.
Height peaks significantly earlier than both facial size and
mandibular length. In boys, the peak in height occurs slightly (but
statistically significantly) earlier than do the peaks in the face and
mandible: 14.0, 14.4 and 14.3 years.18
The skeletal system during the prenatal period undergo either intra-
membranous ossification or endochondral ossification. After birth,
secondary ossification starts and forms the epiphyses of long bones
and the extremities of irregular and flat bones. The bones are
remodelled throughout life. The process of remodelling is required to
maintain their shape (in response to physical demand), their function
and calcium homoeostasis in the body. Several factors affect the
growth and remodelling process of the bone including ageing.19
Intra-membranous ossification
Bones formed in the membrane are characterised by direct deposition
of osteoid material by osteoblasts in a fibrous matrix, which then
slowly calcifies to form the bone. Most of the skull’s vault bones are
produced by intra-membranous ossification.20,21
Endochondral ossification
Endochondral ossification is the process that results in both
replacement of the embryonic cartilaginous skeleton during
organogenesis and growth of long bones until adulthood is reached.
This type of ossification starts in intra-uterine life and continues till
early adulthood when growth ceases. Chondrocytes play a central role
in this process, contributing to longitudinal growth through a
combination of proliferation, extracellular matrix secretion and
hypertrophy. Terminally differentiated hypertrophic chondrocytes
then die, allowing invasion by a mixture of cells that collectively
replace cartilage tissue with bone tissue.20,21
Ossification centres develop within the cartilage from which
calcification starts. Slowly, osteoblasts replace the entire cartilage
matrix with osteoid, which calcifies to form mature bone. Most of the
bones of the cranial base are formed by endochondral ossification.
Basic concepts involved in bone
growth
Displacement
Displacement is described as the change in position of an object
following the application of force. In this chapter, the term will be
used for body tissues (namely, bone), and force is the growth of body
tissues. The displacement of bones occurs with growth in two ways:
1. Primary displacement of a bone occurs due to its growth, which

causes it to move from its original position. For example,
displacement of the chin anteriorly due to the increasing
mandibular length.
2. Secondary displacement (also called translatory growth) is an
illustration of growth at a location subsequent to actual growth
occurring in a distant part of the skeletal system. The structure
in question is displaced from its position due to the growth of
adjacent structures. For example, growth of the spheno-
occipital synchondrosis leads to anterior dis-placement of the
frontomaxillary complex.
Growth centre
A growth centre is defined as tissue(s) that have innate growth
potential and do not require the presence of an extrinsic stimulus for
growth (e.g. nasal septal cartilage). It should be noted that all growth
centres are growth sites, but not all growth sites are growth centres.
Ossification centre
An ossification centre is the site where bone calcification begins, and
bone starts replacing fibrous tissues laid down for bone formation, or
it replaces cartilage. The primary centre of ossification, for example, in
long bones lies in the diaphysis and secondary ones in the epiphysis.
Growth site
Growth sites are tissues that do not have innate growth regulation,
but merely respond to extrinsic influences to cause growth (e.g.
condylar cartilage).
Growth field
The outside and inside surfaces of bone are completely blanketed by a
mosaic-like pattern of growth fields. Each growth field has either a
resorptive or a depositive influence, and there may be multiple
growth fields on the same surface in different locations. Simultaneous
resorption and deposition at different sites of the same bone is a
constant ongoing process and leads to bone remodelling/growth.
Principles of skeletal growth22
Epiphyseal growth
Initial growth of a long bone occurs at the primary ossification centre
located in the middle portion of the bone called the diaphysis; later,
secondary ossification centres develop on either end of the diaphysis
in the region of the epiphysis. It is at the junction of the diaphysis and
epiphysis that major growth in length occurs. This junction is known
as the epiphyseal plate and is composed of hyaline cartilage. When
growth ceases the epiphyseal plate loses its cartilaginous nature,
calcifies and merges with the diaphysis forming a continuous long
bone. This phenomenon is called epiphyseal plate closure (Fig. 9.6).
FIGURE 9.6 A long bone has diaphysis, epiphysis and
metaphysis regions.
The bone grows along the long axis by growth at the epiphyseal
cartilage (plate). Attainment of adulthood is marked by the capping of
epiphyses and fusion of the epiphyseal cartilage, which ceases the
further growth potential of the bone.
Periosteal and endosteal growth

Healthy bone comprises an external periosteal layer and an internal
endosteal layer. Endosteal bone contains a mixture of cortical and
trabecular bone in varying amounts. The apposition of bone on
selective periosteal surfaces and simultaneous resorption at other
related surfaces contributes to bone growth. However, periosteal
growth is not merely a matter of the addition of bone to the outer
surface and resorption from the inner surface. Endosteal resorption
and the addition of bone from within the cancellous spaces are also
necessary to maintain the appropriate thickness of the cortical layer of
bone.
The process of balanced apposition and resorption facilitates
growth of the skull vault, and helps in shaping the nasal and oral
cavities and the sinuses.
Principles of skeletal growth22
Skeletal growth occurs through various processes that occur
concomitantly. Some of the important concepts that find relevance in
this context are as follows.
Sutural growth
Sutural growth is entirely different from epiphyseal growth. Growth
at the sutures does not occur because of the innate potential of sutural
tissue to proliferate. Instead, these tissues respond to the tension
created within them by the growth of adjacent soft tissues. A classic
example is the growth of the cranial vault. During the early years of
life the cranial vault enlarges in size primarily by growth at the
sutures due to the tension created at the suture sites by the rapidly
expanding brain. Later, after ossification of the sutures the cranial
cavity expands by growth at the cranial base and surface remodelling
of the vault.
It must be remembered that tension causes sutural growth. When
there is compression (lack of tension), as in parts of the cranial base
and mandibular condyle, endochondral bone formation ensues. The
histologic mechanism of sutural response was well described by Koski
in 1968 (Fig. 9.7).
FIGURE 9.7 Growth at sutures.
Essentially two concepts are in vogue. (1) The three-layer theory
wherein intermediate connective tissue between the sutures
proliferates, which makes the bone grow. (2) According to the five-layer
theory, the ends of the bone at sutures have a two-layered periosteal
system where primary bone growth takes place. Intermediate
connective tissue allows adjustments for bony growth. Source:
Reproduced with permission from Koski K, Cranial growth centre: facts
or fallacies. Am J Orthod 1968.
Remodelling
Remodelling of bone occurs at different sites concurrently with
increase in bone size. Remodelling is a process for progressive
adjustment of bones to maintain their shape, proportions and
functions. Growth in any area of the bone requires compensatory
changes in other parts to maintain functional integrity. Remodelling
can be of two types: (1) surface and (2) structural.
Surface remodelling occurs on the surface of the bone and leads to
changes in topography.
Structural remodelling/Wolff’s law causes a change in the inherent
architecture of the bone and may lead to change in the density and
mechanical properties of the bone. For example, alignment of the
trabeculae along the line of force would be a type of structural bone
remodelling (Wolff’s law), while development of surface
elevations/fins for the attachment of muscles and tendons, like the
pterygoid plates, are a type of surface remodelling.
Remodelling or bone turnover occurs throughout life, which is
primarily controlled through paracrine cell signalling to osteoblasts
and osteoclasts. Approximately 10% of the skeletal mass of an adult is
remodelled each year.
Cortical drift
Cortical drift is a remodelling mechanism wherein the bone, or one of
its surfaces, moves through space by selective bone deposition and
resorption on cortical surfaces. Cortical bone has an inner endosteal
surface and an outer periosteal surface. Drift is brought about by
deposition on one side and resorption on the opposite side of the same
cortical plate. The classical example of cortical drift is provided by
growth of the facial surface of the maxilla (Fig. 9.8). While the entire
maxilla is translated downward and forward the anterior surface of
the maxilla shows resorptive patterns and moves in the opposite
direction. It must be understood that a surface of the cortical plate
may be depository at one stage and resorptive at another stage.
FIGURE 9.8 Cortical drift in maxilla.

The anterior surface of the bone shows resorption along the entire
surface except for the anterior nasal spine. Bone resorption leads to
deepening and contouring of the bone surface, which gives the bone its
typical facial surface characteristics. Note that, even though cortical
drift occurs opposite to the direction of primary and secondary growth,
the entire maxilla is displaced in a downward and forward location in
the direction of growth. This seeming paradox can be understood in
panel B. (B) While workers on the platform remodel the wall by
selective removal moreover, the addition of bricks, the whole wall
moves forward as the platform on which it is situated itself moving
forward.
Another example of cortical drift is growth in the ramus of the

mandible (Fig. 9.9). John Hunter24 was the first to observe that the
mandible grew posteriorly by resorption of the anterior surface and
deposition at the posterior surface of the ramus. Humphrey,25 through
a famous experiment in pigs, showed the importance of cortical
remodelling. Humphrey showed that a wire placed initially on the
posterior surface of the ramus in growing pigs was located near the
centre of the ramus after the experiment. Relocation of the wire was
caused by surface remodelling of the ramus characterised by bone
deposition at the posterior border and bone resorption at the anterior
border. Cortical drift causes the body of the mandible to become
longer and yields additional space in the alveolar arch to
accommodate the molars.
FIGURE 9.9 Cortical drift in mandible.

The mandible grows primarily at four sites: (1) condylar, (2) coronoid,
(3) alveolar and (4) body. Growth at the alveolar process facilitates the
eruption of teeth. While growth at the condyle leads to an increase in
ramus height, the increase in body length occurs primarily by cortical
drift. Surface resorption at the anterior border of the ramus and
deposition at the posterior border lead to increase in the overall length
of the body of the mandible.
Enlow’s V principle of growth22

Enlow noted that many craniofacial bones, or their parts, have a V-
shaped configuration (funnel-shaped in three dimensions). He
pointed out that these bones grew by the addition of bone on the
inside of the V with removal of bone from the outside. This concept of
bone growth is called the V principle of Enlow (Fig. 9.10). According
to this principle, bone deposition occurs on the inner side of the V
while resorption takes place on the outside surface, which leads to
widening of the V configuration; at the same time, the structure
translates from its original position and moves towards the wide end
of the V.
FIGURE 9.10 Enlow’s V principle of growth.
All structures with a V-shaped configuration grow by deposition along
the inner surface of the V and resorption along the outer surface. At the
same time, the structure grows in size due to both growth and
relocation and expands progressively to achieve the shape of a bigger
V from A to B.
Palatal remodelling
Growth of the hard palate viewed in the coronal section shows
resorption occuring on the outer (nasal) surface and deposition on the
inner (palatal) surface. Progressive remodelling, along with growth at
the mid-palatal suture and secondary displacement due to the growth
of nasal bones, increases the width of the palate and causes it to its
vertical descend. (Fig. 9.11A).
FIGURE 9.11 Enlow’s V principle applied to maxilla and
mandible.
(A) The palatal surface of the maxilla descends downwards due to
growth and surface changes. The oral surface of the palate shows
deposition while the nasal surface shows resorption, which contributes
to the descent of the palatal contour. (B) The mandible, when viewed
from above, also indicates a V-shaped configuration, which enlarges
posteriorly by condylar growth and as a result of ramus-to-corpus
remodelling. The corpus grows posteriorly due to resorption at the
anterior border of the ramus and deposition at the posterior border.
Ramus-to-corpus remodelling
Growth of the mandible also occurs in concordance with the V
principle. When viewed from above, the condyle and ramus expand
in a posterior and lateral direction due to growth in the body, ramus
and the condyle itself (Fig. 9.11B). Growth is accompanied by
progressive relocation of the entire ramus in a posterior direction.
Resorption occurs on the anterior edge, with a resultant lingual shift
of the anterior part of the ramus to become added to the corpus.
Enlow’s counterpart principle of growth

Enlow’s counterpart principle of growth simply states that growth of
any given facial or cranial part relates specifically to other structural
and geometric counterparts in relation to it. There are many structures
in the craniofacial skeleton that can be construed as counterparts.
These include:
1. The nasomaxillary complex and the anterior cranial fossa

2. The middle cranial fossa and the width of the ramus
3. Maxillary tuberosity and lingual tuberosity.
However, most had their shortcomings and were rejected

consequently. However, each laid the foundation for further research.
Only recently, as a result of understanding the genetic and molecular
pathways, have we gained some insight into how growth is regulated
at the cellular level. The relevant theories of growth are discussed in
the following sections.
Theories of growth
Anatomists in the 16th century knew very little about skeletal growth
till Duhamel carried out experiments on young pigeons and published
his findings in 1740. He tied silver wire rings to the thigh-bones of
young pigeons, which he later found in the medullary cavity instead
of embracing the exterior of the shaft where he placed the rings in the
first instance. He called the theory interstitial expansion.
Subsequently, John Hunter explained how the mandible grows in
the posterior region during intra-uterine life and after birth to
accommodate developing tooth buds. He compared how the
mandible and jaws grow to accommodate developing dentition in
foetuses 3 − 4 months old and 7 − 8 months old, babies 12 months old
and 18 months old, and adults up to 18 years. He then switched over
to experiments using madder feeding on animals. Madder feeding
was first described in England by Belchier in 1736. When madder is
added to animal feeds, newly formed bone can be distinguished from
older bone. His experiment proved that, besides internal resorption
and external deposition, external surfaces do undergo absorption.
Later, James Brash proved, in animal experiments on pigs, that
resorption takes place on the anterior surface of the -ramus and bone
addition on the posterior border of the ramus. The mandible grows by
extension of all its borders in all directions except the coronoid
process.
To understand the basic principles and intricacies of growth, many
theories have been advocated over the years. These include:
1. Brash’s27–29 remodelling theory (1930s)

2. Sicher’s theory of sutural growth dominance30–32 (1940s)
3. Scott’s theory of cartilaginous growth dominance33–35 (1950s)
4. Functional matrix theory36–38 (1960s)
5. Enlow–Hunter growth equivalent theory39–41 (1960s)
6. Petrovic’s42–44 servosystem theory (1970s)
7. Current concepts of the functional matrix: the molecular
basis45–49
a. The concept of mechanotransduction50–56
b. Bone as an osseous connected cellular network
(CCN)57–60
c. Genomic thesis
8. Epigenetic antithesis and resolving synthesis
9. Current views on growth at the turn of the 21st century61–71
Brash’s27–29 remodelling theory (1930s)

James Couper Brash, an anatomist, proposed that bone grow only by
surface remodelling—selective addition on one surface and resorption
on the other. Later, he proved in animal experiments on pigs that
resorption takes place on the anterior surface of the ramus and bone
addition on the posterior border of the ramus. The mandible grows by
extension of all its borders in all directions except the coronoid
process. When a wire was placed around the ramus of a growing pig,
11 weeks later it was seen deeply buried in the hind of the ramus and
projected free at the front indicating that apposition took place on the
posterior border and resorption on the anterior border.
Subsequently, skeleton growth research continued to use madder
feed to animals to study bone growth. The skeletal vault, for example,
expands by deposition on outer surfaces and resorption of the inner
vault. He further stated that growth of the jaws is characterised by the
deposition of bone at the posterior surfaces of the maxilla and
mandible. It is now clear that bone does not grow interstitially
through the mitotic activity of osteocytes (Fig. 9.12). The main tenets
of this theory as summarised by Carlson are:
• growth of the jaws is characterised by deposition of bone at

the posterior surfaces of the maxilla and mandible, sometimes
described as Hunterian growth of the jaws; and
• calvarial growth occurs via deposition of bone on the
ectocranial surface of the cranial vault and resorption of bone
endocranially at its surfaces.
FIGURE 9.12 Schematic representation of the remodelling theory

of craniofacial growth using the cranial vault as a model.
Increase in the size of the cranial vault occurs by adding bone via
periosteal deposition on the outer, ectocranial surface and resorption of
bone on the inner, endocranial surface of the vault. The growth of the
jaws takes place principally via deposition of bone on the posterior
surface of the maxillary complex and mandibular ramus. Sutures and
cartilages play no role in the growth of the craniofacial complex.
Reproduced with permission from Carlson.44
The theory underestimates or totally ignores the role of sutures and

cartilages of the craniofacial skeleton in the growth of bone.
Sicher’s theory of sutural growth

dominance30–32 (1940s)
Sicher’s theory came from evidence he gathered by observing the
staining of bones of animals fed on madder and observations of
pathological states. Madder contains alizarin, which gets incorporated
in developing bones and causes intrinsic staining. Sicher concluded
erroneously that sutures were causing the growth since they were the
sites of active staining in experiments (Fig. 9.13).
FIGURE 9.13 Schematic representation of the sutural theory of
craniofacial growth using the cranial vault as a model.
Increase in the size of the cranial vault takes place via primary growth
of bone at the sutures, which forces the bones of the vault away from
each other. The growth of the midface takes place via intrinsically
determined sutural expansion of the circummaxillary suture system,
which forces the midface to descend downward and forward.
Mandibular growth takes place via intrinsically determined growth of the
cartilage of the mandibular condyle, which pushes the mandible
downward and forward. Reproduced with permission from Carlson.44
According to Sicher’s theory the primary event in craniofacial

growth was proliferation of the connective tissue between bones that
caused them to grow and elongate. Replacement of proliferating
connective tissue by bone was, of course, necessary for the
development of functionally adequate bones. For example, Sicher
thought that it was growth of the cranium due to apposition at the
sutures that determined the adult facial form. Similarly, the maxilla
grew forward due to growth of the circumaxillary sutural system.
Sicher recognised the endochondral nature of the cranial base and
credited interstitial growth at synchondroses for growth at the site,
much like the epiphyseal plates of long bones. He felt that growth at
these places was intrinsic and genetically regulated primary growth.
The mandible was treated differently in Sicher’s scheme. He treated
the mandible like a long bent bone that grew at both ends. He
proposed that the mandible grows both by interstitial growth (like
long bones) and by apposition (at its periosteal covering). However,
appositional growth pre-dominated over interstitial growth. Growth
at the condyle was credited with providing displacement of the
mandible and creating space for development of dentoalveolar
processes. Sicher stressed that growth at the sutures and the cartilages
was under strong genetic control with a minor contribution from local
environmental factors.
Sutural theory had few merits in explaining growth. First, the role
of the local environment in causing periosteal remodelling was
accepted and the role of genetic factors was thought to be secondary,
as had been observed experimentally. Second, due importance was
given to the growth of bones at the cartilaginous union, which is
consistent with contemporary understanding. However, sutural
theory could not explain the massive craniofacial structural alterations
that were observed in subjects with soft-tissue deformities of the
central nervous system and craniofacial tissues. Third, experiments by
Scott and colleagues revealed that cranial sutures grew by direct
ossification of connective tissue without any cartilaginous precursor,
while Sicher believed them to be similar to synchondroses. Since there
was no cartilaginous precursor, growth at the sutures should be
environmentally affected, as is the case with periosteal growth. This
view contrasted with that of Sicher, who felt that sutural growth was
genetically determined.
Scott’s theory of cartilaginous growth

dominance33–35 (1950s)
Scott recognised that cartilaginous parts of the craniofacial skeleton
played a major role in establishment of the nasal capsule, mandible
and cranial base during prenatal development. Scott believed that
much of the control of facial growth exerted by cartilage in utero was
carried over into postnatal life. He argued that growth of the nasal
cartilage was the primary factor determining the growth and
displacement of the mid-face forward and that it was under strong
genetic control (Fig. 9.14). Similarly, growth at the cartilages of cranial
base synchondroses, which led to elongation of the cranial base, was
primarily under genetic influence.
FIGURE 9.14 Schematic representation of the nasal septum
theory of craniofacial growth.
Growth of the nasal septal cartilage pushes the mid-face downward
and forward relative to the anterior cranial base. This results in
separation of the mid-facial suture system, which then fills in via
secondary, compensatory sutural bone growth. Reproduced with
permission from Carlson.44
Scott considered sutures to be secondary in their contribution to

craniofacial growth and merely making an adjustment to the
separation of bones brought about by cartilaginous growth. Scott
believed that early growth was under strong genetic control, while
later growth was controlled more by functional influences. He
considered periosteal growth to be under intrinsic genetic control.
Like Sicher, he considered that synchondroses behave in a similar
fashion as epiphyseal plates and contributed to the elongation of the
cranial base, are under strong intrinsic genetic influence.
He thought that the mandible, like the nasal and cranial base
cartilages, grew as a result of growth at the condyles. However,
condylar cartilage was thought to be like costal cartilage, which grew
only to maintain contact with the articulating bones as the mandible
grew downwards and forward, but did not serve as the driving force
behind mandibular growth. He argued ‘the head of the condyle is
very similar to the two ends of the clavicle and it is probably more
accurate to state that growth of the clavicle takes place so as to
maintain contact with the sternum at one end and the scapula at the
other, rather than to say that growth of the clavicle thrusts the scapula
away from the sternum’.
Functional matrix theory36–38 (1960s)

The functional matrix theory was proposed by Melvin Moss.
According to this theory, ‘the origin, growth and maintenance of all
skeletal tissues and organs are secondary and compensatory
responses to events and processes, occurring in related non-skeletal
tissues, organs and functioning spaces, called the functional matrices’.
Moss refuted any intrinsic genetic regulation of growth in the
tissues that produce bone in the postnatal skeleton. Moss felt that
initiation of bone growth was undoubtedly due to intrinsic genetic
factors, but that further morphologic differentiation, as well as
maintenance of bone already formed, was under the influence of the
soft-tissue environment and functional spaces. He proposed that ‘all
skeletal units arise, exist, grow are maintained, and respond
morphologically while totally embedded within their periosteal
functional matrices’.
To clarify this theory, it is necessary to discuss the terms Skeletal
Unit and Functional Matrix in detail. Skeletal units may be composed
of bone, cartilage or tendinous tissues. These are not equivalent to an
entire bone in the classical sense. A single bone may be composed of a
number of skeletal units, in which case they are termed Micro-skeletal
units. When adjoining portions of a number of neighbouring bones
are united to function as a single cranial component, we term this a
macro-skeletal unit—the endocranial surface of the calvaria is an
example (Fig. 9.15).
FIGURE 9.15 Schematic representation of the functional matrix
hypothesis of craniofacial growth.
Primary growth of the capsular matrix (brain) stimulates secondary
growth of the sutures and synchondroses, leading to overall
enlargement of the neurocranium (macro-skeletal unit). The functions
of the temporalis muscle exert a pull on the periosteal matrix and bone
growth of the temporal line (micro-skeletal unit).44
Types of functional matrices

There are two types of functional matrices: (1) periosteal and (2)
capsular. A periosteal functional matrix consists of muscles, blood
vessels, nerves and glands adjacent to the skeletal unit. These cause
changes in related osseous tissue by indirectly causing selective
deposition and resorption of bone. For example, consider the matrix of
the temporalis muscle and the coronoid process. Research has shown
that removal or denervation of the temporalis muscle result in
reduction in the size of the coronoid process or its total disappearance
in some cases. Conversely, hypertrophy or hyperactivity of the
temporalis muscle increases the size of the coronoid process.
The craniofacial region can also be divided into matrix systems that
are called cranial capsules. The cranial components comprising the
neural region exist within the neurocranial capsules, while those
forming the facial region lie within the orofacial capsule. Similar
statements can be made with respect to the orbital and otic regions.
The various cranial and orofacial skeletal units are surrounded and
protected by their respective capsular functional matrices.
Let us consider the neural capsule. It consists of the brain,
leptomeninges and cerebrospinal fluid. In the neural capsular
functional matrix model, calvarial skeletal tissues during growth of
the brain are passively translated in space in response to the
expanding neural mass. In a normally growing child, this expanding
brain leads to sutural growth, resorption of the neural surfaces and
deposition at the outer surfaces of the bones surrounding the brain. In
a hydrocephalic patient, however, there is little sutural growth due to
excessive intra-cranial pressure, and the result is a translation of
calvarial bones through space without adaptive changes in contour or
maintenance of sutural contact.
The orofacial capsular functional matrix is a little more complicated.
Apart from the regular constituents, it also encloses functional air
spaces (oral cavity, nasal cavity, pharynx and sinuses). Moss
contended that these spaces also constituted a critical part of the
functional matrix as survival of the body demands that they grow and
maintain adequate patency. Growth of the facial bones is controlled
by alterations within orofacial matrix systems, which cause both
surface remodelling and translatory changes in adjacent orofacial
bones (Figs 9.16 and 9.17).
FIGURE 9.16 The neurocranial and orofacial capsular matrices.
The neural capsular matrix consists of the brain and the meninges, and
the orofacial matrix comprises the soft tissue of the orofacial region
including the skin, subcutaneous connective tissue, muscles,
ligaments, blood vessels, nerves and free air spaces. In either case,
the skeletal units are housed entirely within their respective capsular
matrices.
FIGURE 9.17 Expansion of the neurocapsular matrix consequent
to increase in the size of the neural tissue housed in the skull.
Increase in the size of the skull occurs by the translation of bones and
remodelling with formation of outer and inner tables and a diploic area
in between. Based on the concept of Melvin Moss.
When applied to the mandibular condyle, Moss’s theory also

explains regeneration of condylar cartilage in response to functional
stimulation. Condylar cartilage has long been considered a primary
growth centre. However, research showed that bilateral removal of
condylar cartilage in growing animals did not inhibit growth of the
mandible or alter its spatial relationship with other bones provided
proper function be maintained. Similar results were seen during the
treatment of patients who lost their condyles due to trauma. Rigorous
physiotherapy in such patients led to regeneration of the complete
condyle. This phenomenon can be explained by the functional matrix
concept in that condylar cartilage primarily adapts to the demands
imposed by the surrounding periosteal matrices of the pterygoid and
temporalis muscles, amongst other components.
Enlow–Hunter growth equivalent theory39–41

(1960s)
Confusion and debate continue as new thoughts and theories are
proposed. In the 1960s, Enlow and Hunter proposed that there were
four morphogenetically distinct regions in the human skull; the
mandible, the middle face, the upper face and calvaria. The middle
face, the cranial base and the mandible are directly contiguous with
each other, and the growth events that occur in one necessarily affect
the nature of reciprocal, complementary growth processes in portions
of the other two.
Growth occurs at sutures, periosteal and endosteal surfaces, and
synchondroses. Growth is a combination of complex remodelling at
periosteal and endosteal surfaces as well as translation of whole bones
in space. The cartilaginous nasal septum and cranial base displace
other cranial and facial bones during growth and sutures respond
secondarily to maintain contact with adjacent bones. Sutures and
periosteal growth are controlled primarily by growth of adjacent
structures and function. The face, according to Enlow–Hunter, can be
seen as consisting of specific horizontal and vertical equivalents that
match each other in general size or position if a harmonious face is to
exist. For example, the anterior cranial base, the maxilla and the body
of the mandible represent growth equivalents in the horizontal
direction.
‘The forward displacement of the nasomaxillary complex by the
elongation of the spheno-occipital segment is associated with a
“growth equivalent” in the separate mandible’. This growth is
provided by the increased anterior–posterior distance in the ramus,
which bridges the pharynx. Thus the ramus provides horizontal
growth equivalent to elongation of the spheno-occipital segment.
‘A critical balance of growth exists between different areas, and
mutual adjustments and progressive reciprocal adaptation occur
between them during continued growth’. Some key morphogenetic
sites exist in different regions of the face and cranium, which are
directly inter-dependent and mutually inter-related in respective
growth activities. Events occurring in any one of these critical regions
directly influence the course of events in equivalent areas of other,
separate individual anatomical parts.
This theory is supported by Petrovic who attempted to define the
cybernetic feedback control loops existing in the biological system.
This work and that of McNamara, who altered the muscle function in
primates to evaluate alterations in facial form, together form an
experimental basis for explaining some of the mechanisms of the
Enlow–Hunter theory (Fig. 9.18).
FIGURE 9.18 Form and growth relationship between architectural

equivalents. Source: Enlow DH, Moyers RE, Hunter WS, McNamara
Jr JA. A procedure for the analysis of intrinsic facial form and growth:
an equivalent-balance concept. Am J Orthod 1969;56(1):6–23.
Petrovic’s42–44 servosystem theory (1970s)

Alexandre Petrovic proposed a cybernetic model known as the
servosystem theory. Cybernetics was originally defined as the science
of automatic control and communication in both animals and
machines. It indicated that control depended on a flow of information
and that the laws governing control were universal.42
Discontinuities in occlusal relationships and the
regulation of facial growth
According to the cybernetic view espoused by Jean Lavergne and
Alexandre Petrovic, the craniofacial growth process consists of growth
signals and feedback mechanisms. Growth of the anterior cranial base
and mid-face is through intrinsic cell tissue–related properties
common to all primary cartilages and mediated by the endocrine
system. It brings about changes in occlusion thus producing unstable
occlusions and mandible growth occurs to compensate for the
discrepancy caused by occlusion. This mid-face growth also serves as
a rate-limiting factor for growth of the mandible.
Petrovic referred to this as the comparator—that is, the constantly
changing reference point between positions in the upper and lower
jaws. Second, proprioceptors within the periodontal regions and the
TMJ perceive even the smallest occlusal discrepancy and tonically
activate the muscles responsible for mandibular protrusion.
Third, muscles protruding from the jaw act directly on the cartilage
of the mandibular condyle and indirectly through the vascular supply
to the TMJ, stimulating the condyle to grow. Finally, the effect of
muscle function and responsiveness of condylar cartilage is influenced
both directly and indirectly by hormonal factors acting principally on
condylar cartilage and the musculature.
This entire cycle is continuously activated as a servomotor as long
as the mid-face upper dental arch continues to grow and mature and
appropriate extrinsic, hormonal and functional factors remain
supportive.44 It can clearly be stated that the mandibular condyle does
not function as a locus of control. Rather, the most important role for
this cartilage is in establishing and maintaining the integrity of the
TMJ (Fig. 9.19).
FIGURE 9.19 Servosystem theory of craniofacial growth, with
emphasis on the growth of the mandible.
Anterior growth of the mid-face (A) results in a slight occlusal deviation
between the maxillary and mandibular dentitions (B). Perception of this
occlusal deviation by proprioceptors (C) triggers the protruder muscles
of the mandible to become more active tonically (D) in order to
reposition the mandible anteriorly. Muscle activity and protrusion in the
presence of appropriate hormonal factors (E) stimulate growth at the
mandibular condyle (F). Reproduced with permission from Carlson.44
Current concepts of the functional
matrix: the molecular basis45–49
The functional matrix theory lacks evidence to explain the sequence of
events through which extrinsic stimuli caused adaptive responses in
skeletal structures (i.e. the flow of signals generating the required
response). This issue has been addressed in more recent research that
has focussed on inter-cellular signalling, communication and signal
transduction from the macromolecular matrix to the micro-molecular
matrix.
The concept of mechanotransduction

Mechanotransduction is similar to cellular signal transduction.
Mechanotransduction is the process by which macro-cellular extrinsic
stimuli are converted into cellular signals that can be internalised by a
cell and processed so that a suitable adaptive response can be
generated. It can be of many types such as mechanoelectrical and
mechanochemical.
Osseous mechanotransduction is a highly specialised and unique
mechanism by which bone cells respond to extrinsic stimuli. Moss
stressed that ‘mechanotransduction occurs in single bone cell and
bone cells are computational elements that function as a multi-cellular
connected cellular network’. Its unique nature can be highlighted by
the following facts:
1. Unlike other mechanosensory cells, bone cells are not

specialised for such stimuli.
2. These cells show aneural transmission of signals.
3. Bone cells show multiple adaptational responses to a single
force, in contrast to a singular response by other tissue cells.
4. The changes brought about by stimuli are confined to a single
bone to which the signal is transduced (Fig. 9.20).
FIGURE 9.20 Mechanotransduction pathways describing how
exogenous forces induce ultimate changes in macroscopic shape
such as the shape of the mandible.
(A) Force can be induced on biological tissues from either muscular
contraction or exogenous sources such as headgear or fixed
orthodontic appliances. Force can either be static or cyclic. (B) Tissue
strain and cell deformation result from application of endogenous or
exogenous forces, leading to deformation of cell membrane and
cytoskeleton. (C) Genes are regulated via mechanotransduction
pathways. (D) Bone and cartilage cells proliferate (shown as one cell
dividing into two daughter cells), differentiate and produce extracellular
matrix molecules (i.e. growth and development) macroscopically visible
as changes in the shape of the mandible from newborn to adult.
Source: Reproduced with permission from Mao JJ, Nah HD. Growth
and development: hereditary and mechanical modulations. Am J
Orthod Dentofac Orthop 2004;125:676–89.
Although bone cells are under constant stress, only stresses that
exceed threshold values can produce the necessary compensatory
adaptations through a triad of processes. Both osteocytes and
osteoblasts are competent for intra-cellular stimulus reception,
transduction and subsequent inter-cellular signal transmission. It has
been shown that osteoblasts directly regulate bone deposition and
maintenance and indirectly regulate osteoclastic resorption.50,51
Mechanotransduction is known to be mediated by at least two
processes: (1) ionic and (2) mechanical. Ionic (electrical) processes
involve the transport of ions across the osteocytic plasma membrane,
which triggers an internal cellular response. The flow of these ions is
thought to occur across voltage-gated channels or even through the
gap junctions between adjacent osteocytes. The passage of K+, Na+ and
Ca2+ ions across strained osteocytes has been proven experimentally.52
A morphogenetically significant strain range of 1000–3000 has been
shown to be effective in causing osteocytic adaptive responses.53
Electrical processes include several, nonexclusive
mechanotransductive processes which include electromechanical and
electrokinetic involving the plasma membrane and extracellular
fluids. Electric field strength may also be a significant parameter.54
Electrokinetic stimuli (streaming potentials) in the range of 2 mV can
initiate both osteogenesis and osteocytic action potentials.55
Mechanical processes directly (in the absence of the intra-cellular,
transductive process) may themselves be a strong stimulus altering
cellular responses through the transmembrane molecule integrin,
which may transduce stimuli directly into the nuclear membrane. This
cytoskeletal lever chain, connected to the nuclear membrane, may
have the potential to activate the osteocytic genome.56
Bone as an osseous connected cellular
network (CCN)
The term CCN implies that a network exists between adjacent tissue
cells through specialised structures in the cell membranes. The
specialised structures include tight junctions and gap junctions,
amongst others. These junctions serve to rapidly spread stimuli across
connected cells.
It has been proven that an extensive CCN exists in bone and that the
principal components in this CCN are gap junctions.57 Connexin,43 a
cytoskeleton protein, is the major constituent of this network.58 Gap
junctions not only connect osteocytes to neighbouring osteocytes but
also superficial osteocytes to periosteal and endosteal osteoblasts. This
network is so well established that it may be said that bone tissue is
hard-wired.59,60
Gap junctions allow the passage of ionic currents and biochemical
molecules, as well as the bidirectional flow of signals, in contrast to
inter-neuronal (chemical) synapses. It has been proposed that
mechanotransduction processes are so fast that secondary messengers
may be rendered redundant. According to Edin and Trulsson,61 ‘a
CCN is operationally analogous to an “artificial neural network,” in
which massively parallel or parallel–distributed signal processing
occurs. It computationally processes, in a multi-processor network
mode, the inter-cellular signals created by an electrical type of
mechanotransduction of periosteal functional matrix stimuli’.61
Moss also stressed the multi-layer organisation of the CCN wherein
cells are organised into layers, which sequentially process signals
from input to output. Signalling is deemed multi-directional, which
also serves as feedback control.
Genomic thesis
Broadly speaking, the genomic thesis claims that the genome contains
all the information needed for the growth and development of an
organism from intra-uterine life to senescence. Explicitly, it holds the
necessary information to regulate (cause, control and direct): (1) the
intra-nuclear formation and transcription of mRNA and (2)
importantly, without the later addition of any other information, to
regulate also all of the intra-cellular and inter-cellular processes of
subsequent, and structurally more complex, cell, tissue, organ and
organismal morphogenesis.49 The proponents of this theory argue that
‘all (phenotype) features are ultimately determined by the DNA
sequence of the genome’.37
Epigenetic antithesis and resolving
synthesis
This concept of Moss49 aims to find a middle path to solve the
controversy of genomic versus epigenetic control of biologic
processes.
Epigenetic factors include ‘(1) all of the extrinsic, extra-organismal,
macro-environmental factors impinging on vital structures (e.g. food,
light and temperature), including mechanical loadings and
electromagnetic fields, and (2) all of the intrinsic, intra-organismal,
biophysical, biomechanical, biochemical and bioelectric micro-
environmental events occurring on, in, and between individual cells,
extracellular materials, and cells and extracellular substances’. Thus,
as far as Moss is concerned, even orthodontic stimuli may be
considered to be epigenetic stimuli that regulate or alter craniofacial
growth (Fig. 9.15).
‘Environmental factors thus play a decisive role in all ontogenetic
processes. However, it is the organism itself that, as an integrated
system, dictates the nature of each and every developmental response.
The living organism self-organises its own internal structuring, in
continuous interaction with the environment in which it finds itself’.62
Current views on growth at the turn of
the 21st century
Advances in the field of molecular biology and developmental
genetics have identified a number of genes that are involved in
morphogenesis of the craniofacial skeleton. Regulatory genes and
gene products influence craniofacial morphogenesis. Genes as a result
of a biochemical process provide factors that may affect the receptivity
and responsiveness of cells to intrinsic and extrinsic stimuli. There is
the possibility to activate these genes and produce growth factors that
may have positive, targeted and predictable effects on postnatal
craniofacial growth. Several studies into wound healing, skeletal
growth associated with distraction histogenesis and orthopaedic
forces, and alteration of neuromuscular function indicate that trauma,
mechanical forces and function may be the types of epigenetic factors
that activate expression of regulatory genes influencing postnatal
growth.61–67
Thus, the issue is not the fact that intrinsic factors within the
genome regulate morphogenesis, but that the complex -interaction of
cells and tissues with remote extrinsic factors within both the body
and the environment are triggers or switches for gene expression that
influences postnatal growth and responsiveness to clinical treatment.
In light of these technological advances, previous theories given by
orthodontists over the last 80 years stand the test of time and scrutiny.
The factors operating within an epigenetic milieu include the position
of genes on the chromosome to the interaction of cells and entire
organisms with the external environment. Genes are turned on and off
by factors both within and outside the genome to produce specific
traits and to influence susceptibility to variations in development and
growth.68–70 New paradigms in craniofacial growth will continue to
emerge.71
Key Points
Growth is a complex phenomenon, which is controlled largely by (1)
genetic regulation and (2) epigenetic influences, including the
environment. Genes control the basic development of the
organism/organ systems (i.e. the ontogeny and basic morphology),
while the environment influences their further development and
characterisation in terms of size, shape, function etc.
Both processes are intricately linked, and the precise role and extent
of influence of each are inseparable. While genetic makeup imparts
the development and functionality to the organism/organ system,
environmental influences alter its form to perform best function.
This alteration of the genetically determined code occurs through
many known and unknown processes, one of which is the functional
matrix, both macroscopic and microscopic. The feedback mechanisms
generated by the environment allow for modification of the
expression of the genetic code, which over a period of centuries leads
to the evolution of higher forms with increased specialisation and
complexity.
This plasticity of genetic material is the hallmark of living
organisms and provides for the continuous evolution of life forms.
Although the genes and environment influence growth, sentients are
not able to explain precise mechanism and much more remains to be
understood.
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CHAPTER 10
Postnatal growth of face and
craniofacial region
O.P. Kharbanda
Ram S. Nanda
Neeraj Wadhawan
CHAPTER OUTLINE
Introduction
General body growth from infancy to adulthood
Timing of growth
Growth spurts
Growth spurts before and after birth
Pre-pubertal spurt
Pubertal spurt (adolescent spurt, pre-pubertal
acceleration and circumpubertal acceleration)
Mini growth spurts
Growth of the craniofacial complex
Growth of the cranium from birth to adulthood
Growth of the nasomaxillary complex
Growth of the sinuses
Growth of the mandible
Growth rotations
Matrix versus intra-matrix rotation
Effect of mandibular rotation on occlusion
Growth of the soft-tissue integument of face
Ageing and soft-tissue integument of face
Key Points
Introduction
Postnatal growth in humans is defined as growth occurring in the first
20 years of life. Although growth continues to occur throughout life,
for most body tissues, it reduces to very low levels following
attainment of adulthood, defined as adult levels of growth.
Interestingly, a few body tissues continue to grow throughout life at
more or less similar rates such as hair and nails.
Postnatal growth can be divided into three phases:1
1. Infancy (first year of life)

2. Childhood (1–14 years)
a. Early childhood (1–6 years)
b. Middle childhood (6–10 years)
c. Late childhood (10–14 years)
3. Adolescence (14–20 years).
Alternatively, postnatal growth can be divided into five stages:2 (1)

infancy, (2) childhood, (3) juvenile, (4) adolescent and (5) adulthood.
General body growth from infancy to

adulthood
Humans have a long growth period stretching from birth to 20 years
of age.1 During this period, the child’s overall growth includes
physical growth, which manifests as change in the proportions of
body parts, mental, psychological and compositional growth.
Various organs grow at different times differing in quantity and
intensity. Hence, it would be unwise to consider a child as a miniature
version of an adult.
Changes in the physical proportions of a child are perhaps the most
dramatic events during active skeletal growth periods. At the time of
birth the head of a child is relatively greater compared with the rest of
the body, occupying approximately 30% of total body volume. With
continued growth of the skeleton, the head assumes a relatively
smaller proportion of the body occupying only about 10% of total
volume (Fig. 10.1).1 The trend is opposite to the rest of the body. With
growth, the volume of the lower limbs increases from 15% at birth to
30% in adults, while that of the trunk increases from 45% to 50%. This
phenomenon has been called the cephalocaudal gradient of growth
implying differential growth of various body parts in such a way that
parts farthest away from the head grow at a faster rate than parts that
are closer.
FIGURE 10.1 Schematic representation of body proportions at

different ages.
Initially, the head occupies a relatively large proportion of total body
length. As the child grows, the body occupies an increasingly larger
proportion of total body volume.
The large size of a child’s head also makes the child top heavy with
a higher centre of resistance.1 This, coupled with lack of
proprioceptive development and lack of balance, may contribute to
the fact that children fall on their heads more often than adults. The
skeleton starts to mature from the head downwards with the skull
showing maturity before the trunk, which itself is ahead of the limbs.
However, proportion wise, the limbs usually grow faster than the
trunk, which in turn, grows faster than the head.
The body shows changes not only in physical proportions but also
in composition. Proportion wise, the muscle mass, adipose tissue and
skeleton all show an increase, while the percentage of the neuronal
mass decreases (Table 10.1). This reduction is not due to regression of
the nervous system, but seems so because of a relative increase in the
mass of the remaining systems. Additionally, elemental changes also
occur leading to a 17% reduction in total body water, 40% increase in
both fat and protein and 250% increase in minerals.1
Table 10.1
Relative body composition in newborns and adults (percentage)

Body component Newborns Adults
Skin and adipose tissue 26 25
Nervous system 15 3
Muscles 25 43
Skeleton 18 18
Body organs (viscera) 16 11
Source: Based on Krogman WM. Child growth. Ann Arbor, MI:

University of Michigan Press, 1972.
Timing of growth
Growth is a continuous process, but the rate of growth varies in
different individuals, and various organs show differential growth
rates even in the same person. While some of the tissues show an
excessive rate of growth at an early age, other organs grow much
later. Moreover, different body tissues have different growth rates and
ultimate sizes. Hence, while some body parts like limbs attain a
significant increase in proportions, others like the pituitary gland
would not show a similar trend.
In 1930, Richard Scammon3 made an attempt to depict human body
growth in graphs, popularly known as Scammon’s growth curve.
Scammon’s growth curves are limited to the first 20 years of human
life. He untangled the complex growth of body tissues into four basic
curves, which he called the lymphoid, neural, general and genital
curves (Fig. 10.2). The starting reference point is taken at birth and is
referred to as 0%. At 20 years, it is assumed that all growth is
complete, and hence, is called 100% growth.
FIGURE 10.2 Growth of various body tissues as described by
Scammon.
3 Body tissues can be broadly divided into four types: neural, general,
lymphoid and reproductive. Neural tissues show rapid growth in initial
years followed by little growth after 10 years. Lymphoid tissue achieves
nearly 200% of its final size by 10–12 years followed by involution of
the thymus and spontaneous regression, which continues till the onset
of adulthood. General body tissues follow an S-shaped curve, while
genital tissues show very slow growth initially but rapid growth during
adolescence.
The general growth curve pertains to most body organs, the skin,
viscera, most organs and organ systems, muscles, cartilage and bone.
This curve follows an S-shaped pattern and shows a steady increase
from birth to 5 years, then reaches a plateau phase till about 10 years
of age. The general growth curve shows another phase of rapid
growth during adolescence before it finally reaches the plateau phase
by adulthood. The periods of rapid increase seen in this curve
correspond to the periods of growth spurts.
The lymphoid curve represents tissues associated with humoral
immunity such as the thymus, tonsils and adenoids, and lymph
nodes. These tissues show 200% growth between 10 and 15 years of
age followed by a reduction to 100% mainly due to involution of the
thymus by 20 years of age.
The neural curve includes the CNS (central nervous system) and its
surrounding calvaria—namely, the brain, spinal cord, optic apparatus
and related bony parts of the skull, upper face and vertebral column.
This curve shows a rapid spurt during childhood, which corresponds
to rapid growth of neural tissues during the period. By the age of 8
years, the brain is nearly 95% of its adult size. This rapid growth spurt
is followed by a plateau phase of slow but steady growth that
continues till adulthood.
The genital curve includes the growth of primary sex apparatus and
all secondary sex traits. This curve remains relatively quiescent till
about 10 years of age after which it starts to upswing rapidly due to
the rapid growth of genital organs in the pre-pubertal and pubertal
periods.
Scammon’s principles still find relevance today and, although his
interpretation was an oversimplification of an immensely intricate and
complicated phenomenon, nonetheless, it provided significant
overview of human morphological growth.
The general growth curves of males and females are quite similar until
the time of puberty is reached. However, during adolescence, the
differences between the growth of boys and girls become marked due
to the release of sex hormones and development of secondary sexual
characteristics. The androgenic hormones in males act to increase
muscle mass and bone structure to give the male body the distinctive
heavy look while female hormones act to redistribute fat deposits in
the pelvis region to give the female body its feminist character. In
boys, the shoulder area shows more development than the pelvis,
while girls show the opposite trend.1 Gonadal hormones also act to
stimulate the growth of secondary sexual characteristics in both sexes.
While males show an increase in the size of external gonads, female
hormones promote breast development as well as the distinctive
pattern of pubic hair. The development of secondary sexual
characteristics marks the end of the period of active growth and is
associated with capping of the epiphysis of long bones.
Growth spurts
Growth of the body does not occur in a linear fashion. Instead, periods
of relative quiescence are interrupted by periods of rapid skeletal
growth, which are called growth spurts. In humans, two major
growth spurts are documented:2
1. Pre-pubertal spurt. Increased growth occurring at around 6–7

years of age is sometimes called the pre-pubertal spurt. The
pre-pubertal spurt is not consistent in all children and may not
be obvious in many children.
2. Pubertal growth spurt. The pubertal growth spurt is the most
constant spurt associated with rapid gain in height at around
the time of puberty. It ends with the appearance of the
secondary sexual characters of an adult.
Apart from these, there are other inconsistent periods of growth in

every child when rapid growth is interspersed with phases of relative
quiescence.
Growth spurts before and after birth

Rapid rates of growth seen during infancy are sometimes called the
growth spurts of infancy. Beginning in foetal life, serial ultrasound
measurements document significant growth of the long bones, skull
and abdomen during measurements taken only 2 days apart
interspersed with periods where no significant growth is seen for up
to 25 days at a stretch. Postnatal studies of infants between 2 days and
21 months postpartum document increases of up to 1.6 cm in 24 hours
interspersed by periods of very little measurable growth for intervals
as long as 2 months.2
Pre-pubertal spurt
The pre-pubertal spurt is also called the mid-childhood growth spurt.4
It is a small and inconsistent spurt seen in both sexes at around 6–7
years of age. The very presence of this growth spurt is questionable;
some authors have documented such a growth spurt in both sexes,
some have documented it only in the male sex, while some have not
even documented it. The mid-childhood growth spurt is associated
with adrenarche, an endocrine event related to the release of
androgenic hormones.2 The secretion of adrenal androgens causes a
transient spurt in height, accelerated bone maturation, redistribution
of body fat and appearance of pubic and axillary hair. Interestingly,
this phenomenon is unique to humans and a few animals like the
chimpanzee.
Pubertal spurt (adolescent spurt, pre-pubertal

acceleration and circumpubertal acceleration)
The pubertal spurt is the more predictable growth spurt and occurs
earlier in females than males. It is linked to increased secretion of sex
steroids (oestrogen in females and aromatisation of testosterone to
oestrogen5 in males), in conjunction with growth hormone secretion.
Just before the adolescent growth spurt, height gain enters a quieter
period followed by sudden and rapid increases in height, which
makes its onset. This phase of the growth spurt can be divided into
two stages6—stage I and stage II:
1. Stage I is the period of accelerated skeletal growth which

corresponds to the upswing phase as seen on a growth curve.
It is associated with rapid increase in standing height in both
sexes, most of which is contributed by increase in the length of
the trunk. This stage starts around 10½–11 years in females
and around 13 years in males, the difference being 2 years on
average.1,6,7 It lasts for about 2–3 years in both sexes (11–13
years in females; 13–15 years in males). There is an average
gain of about 15 cm in females and about 16.5 cm in males.6
Peak height velocity (PHV) during this stage may reach 9.8
cm/year for males (at around 14 years of age) and in females
around 8.1 cm/year (at 12–13 years of age).7
2. Stage II corresponds to the phase when growth decelerates. It
lasts for about 3 years (13–16 years in females; 15–18 years in
males).6 During this phase, both sexes gain about 6 cm in
height, most of which is contributed by growth of the lower
limbs.6 Following conclusion of the growth spurt, rapid
reduction in height velocity occurs, and females attain 98% of
their final height by about 16 years while males reach the same
by around 18 years.1 In females, menarche occurs 1 year after
PHV.1,7 Little skeletal growth occurs after the onset of
menarche.
Although the growth rate is rapid during the spurt, it is not

consistent during the whole period. Growth velocity is very high to
begin with and reaches a maximum at PHV, followed by a slow yet
steady decrease in the rate of height gain until adulthood.
As with other characteristics of growth, significant differences in
growth spurts are seen amongst individuals as well as between
various ethnic groups and populations when it comes to timings,
duration (length), age of onset of menarche, total amount of height
gain and other variables.
Mini growth spurts2

One of the hallmarks of growth is the extreme variability in the
timing, amount and direction of growth. Growth not only varies
between seasons or months but also on a day-to-day basis. Every day,
periods of exaggerated growth may be interspersed with times of little
or no activity. These are called mini growth spurts.
Growth cycles have been found on a weekly and daily basis
corresponding to rhythmic changes in the levels of circulating
hormones. A person may be slightly taller when he/she gets up in the
morning and by evening, be shorter by up to 1–2 cm due to the effect
of gravity compressing the inter-vertebral discs. On a weekly basis, a
small but rapid burst of growth may be seen interspersed with times
of very little activity (Fig. 10.3). This has given credence to the dual
effector hypothesis.
FIGURE 10.3 Mini growth spurts.

Growth velocity data for lower-leg length (knee height) of an 8–9-year-
old boy, measured once weekly. Mini growth spurts occur from week to
week; a longer-term cycle of increase and decrease in the size of
spurts is also apparent. Source: Reproduced from Ulijaszek SJ,
Johnston FE, Preece MA. The Cambridge encyclopedia of human
growth and development. Cambridge: Cambridge University Press;
1998; Data from Hermanussen M, et al., Periodical changes of short
term growth velocity (mini growth spurts) in human growth. Ann Hum
Biol 1998;15(2):103–9.
The dual effector hypothesis states that the growth of any organ
occurs in two stages:
1. Differentiation stage: a stage during which specific types of cells
differentiate themselves from stem cells. This is a stage of
relative quiescence.
2. Expansion stage: a stage of rapid proliferation of differentiated
cells, which causes physically measurable saltatory growth.
Growth of the craniofacial complex8,9
The craniofacial region is composed of various skeletal and soft-tissue
components, which grow in harmony with the rest of the body. In
general, the growth and development of the craniofacial complex and
the timing of its growth spurts correlate well with the growth and
development of the rest of the body in general. These trends hold true
even though the different components of the craniofacial complex
have different rates and timings of growth and maturation.
To simplify understanding the complexities of growth of the
craniofacial region, we present our discussion according to anatomical
components.
Anatomically, the craniofacial skeleton can be divided into the
viscerocranium and the neurocranium. The neurocranium is
represented by skull vault and cranial base, which surrounds the
brain, eyes and middle or inner ear, while the viscerocranium includes
the bones of the face and jaws. Each component bone has a specific
embryologic origin and therefore a different process of ossification
(Table 10.2).
1. Neurocranium. The neurocranium in adults is formed by eight

bones:
a. Four singular bones centred in the midline: frontal,
ethmoidal, sphenoidal and occipital.
b. Two sets of bilateral bones: temporal, parietal. The
neurocranium has a dome-like roof, a calvaria
(skullcap), and a floor or cranial base (basicranium).
The bones forming the calvaria are primarily flat
bones (frontal, temporal and parietal) formed by
intra-membranous ossification. The bones of the
cranial base (chondrocranium) are primarily formed
by endochondral ossification (sphenoidal and
temporal) or from more than one type of
ossification. The ethmoid makes a minor midline
contribution to the neurocranium and is primarily
part of the viscerocranium.
2. Viscerocranium. The viscerocranium forms the anterior part of
the cranium and consists of the bones surrounding the mouth,
nose and most of the orbits. It consists of 15 irregular bones:
a. Three singular bones lying in the midline:
mandible, ethmoid and vomer.
b. Six bones occurring in pairs: maxillae, inferior nasal
conchae, zygomatic, palatine, nasal and lacrimal
bone.
Table 10.2
Bones of craniofacial complex: their ossification and derivation

Bone Ossification Embryonic origin
Bones of neurocranium
Occipital bone (upper portion) Membranous Paraxial mesoderm
Occipital bone (lower portion) Endochondral
Parietal Membranous
Temporal bone Endochondral Paraxial mesoderm
Petrous Endochondral Paraxial mesoderm
Mastoid Membranous Neural crest
Squamous
Frontal Membranous Neural crest
Sphenoid Endochondral
Ethmoid (cribriform part) Endochondral
Bones of viscerocranium
Sphenoid (pterygoid process) Membranous Neural crest
Ethmoid Endochondral
Maxilla Membranous 1st branchial arch
Nasal Membranous (maxillary process)
Lacrimal Membranous
Vomer Membranous
Palatine Membranous
Zygomatic Membranous
Temporal bone Membranous
Tympanic part Endochondral 1st arch (maxillary
Styloid process process)
Inferior nasal turbinate Endochondral 2nd branchial arch
Mandible Membranous 1st arch (maxillary
Malleus Endochondral process)
Incus Endochondral 1st arch (mandibular
Stapes Endochondral process)
Hyoid Endochondral 2nd branchial arch
Superior part, lesser cornu; inferior part and Endochondral 2nd branchial arch
greater cornu 3rd branchial arch
Source: Modified from Moore K, Dalley KF, editors. Clinically oriented

anatomy. 5th ed. Philadelphia, PA: Lippincott, Williams & Wilkins;
2006. p. 887, 888; and Baker E, Schuenke M, Schulte E, Schumacher U.
Head and neck anatomy for dental medicine. Thieme: Stuttgart; 2010. p. 2.
The maxilla, mandible, palatine, zygomatic and squamous temporal

are formed in arch directly by membranous ossification. The malleus,
incus, stapes and styloid processes of the temporal bone, and hyoid
bone form through endochondral ossification.
Growth of the cranium from birth to adulthood

Essentially, the skull-to-face proportions at birth manifest as a large
head and a smaller face. As the child grows, the postnatal period
witnesses larger growth of the face, which then stands out from the
cranium.
The head of a newborn is about 55%–60% of adult head breadth,
40%–50% of adult height and 30%–35% of adult depth. The cranium-
to-face ratio in a newborn is 8:1.10 With continued development,
especially of the lower face, the ratio changes to 1:2 in adulthood.10
Cranial vault
At birth, the sutures of the cranial bones do not inter-digitate,
separated as they are from each other by areas of interposed
connective tissue. These areas are called fontanelles (Fig. 10.4). There
are six fontanelles at the time of birth: two unpaired and two paired.
The unpaired fontanelles include the anterior and the posterior
fontanelles. The anterior fontanelle is large and square in shape, while
the posterior fontanelle is smaller and triangular in shape. The paired
fontanelles include the sphenoidal and mastoid fontanelles, both of
which lie on the lateral sides of the skull. All the fontanelles are
occluded with fibrous connective tissue except the mastoid fontanelle
which is occluded by cartilage (also known as synchondrosis).11
FIGURE 10.4 Fontanelles in a young skull.

At birth the sutures are wide and the skull is relatively softer than that of
an adult.
Fontanelles allow deformation of the head and thus help the large
head of the foetus pass through the birth canal. They also help in
accommodating the rapidly enlarging brain in early childhood. They
close at different times after birth (Table 10.3). The first to close is the
posterior fontanelle at 3 months, and the last is the anterior at 36
months. With the fusion of the fontanelles, the remaining growth and
remodelling of the cranial vault occur mainly at the sutures, and
hence the neural curve of growth. Increase in the size of the brain
creates tension at the sutures, which leads to new bone deposition in
the area. Remodelling of the outer and inner surfaces of cranial bones
also occurs to allow contour changes with growth.
Table 10.3
Cranial fontanelles and their characteristics
The cranial cavity achieves 87% of its adult size by the age of 2
years, 90% by 5 years and 98% by 15 years of age.12 Between 15 years
and adulthood, additional growth changes occur secondary to
pneumatisation of the frontal sinuses and thickening of the anterior
part of the frontal bone. The cranial vault and base also grow by
surface remodelling. In side the cranium, elevated bony partitions and
depressions partially segment the cranial fossa. The elevated
partitions are a depository, and depression portions are resorptive.
Remodelling of the cranial fossa causes resorption in the inside and
deposition on the outside surface leading to a cortical drift of the
fossa.
Cranial base
Cranial base is the most stable structure among the facial structures,
and its growth is affected least by functional matrices. Cranial base
synchondroses are important growth centres of the craniofacial
skeleton and the last sites in the cranium to terminate growth.13,14 The
growth of the cranial base is multi dimensional and therefore can alter
the structure, line angles and placement/cause displacement of
various facial parts attached (Fig. 10.5).
FIGURE 10.5 The cranial base expands in a three-dimensional
format due to angulation of the sutures and synchondrosis at the
cranial base.
Growth of the cranial base occurs at the synchondroses and by

surface remodelling. A synchondrosis is similar to a two-sided
epiphyseal plate with proliferating cartilage cells in the centre, where
mature cartilage cells and ossification occur in both directions away
from the centre. Early in embryonic life, centres of ossification develop
within cranial base cartilage. The remaining primary cartilages
between the centres of ossification form synchondroses after birth.
There are five major synchondroses in the cranial base: intra-
ethmoidal, intra-sphenoidal, intra-occipital, sphenooccipital and
sphenoethmoidal. The intra-ethmoidal and intra-sphenoidal
synchondroses close before birth. The intra-occipital synchondrosis
closes before 5 years, while the sphenoethmoidal synchondrosis closes
around 6 years of age (Fig. 10.6). The sphenooccipital synchondrosis
contributes most to growth of the posterior cranial base as it is the last
cranial base suture to ossify. The sphenooccipital synchondrosis closes
by 13–15 years of age. Growth at the sphenooccipital synchondrosis
causes elongation of the middle portion of the cranial base as a result
of primary displacement, while growth at the posterior part leads to
flexion in the cranial base14,15 since the posterior part of
sphenooccipital synchondrosis has a greater amount of bone
formation in its inferior part than its superior part.
FIGURE 10.6 Synchondrosis at the base of skull.

Major growth of the anterior cranial base is complete by 5 years of age
with the fusion of the sphenoethmoidal synchondrosis.
Growth of the nasomaxillary complex

The nasomaxillary complex consists of the bones and cartilages of the
nose and maxilla. Growth of the nasomaxillary complex occurs by
primary growth, secondary displacement and surface remodelling
(Fig. 10.7). Condylar cartilage is secondary cartilage covered with
fibrous connective tissue. The principal sites of nasomaxillary growth
are now discussed.
FIGURE 10.7 Composite growth and direction of displacement of

maxilla.
The maxilla displaces downward and forward due to sutural growth at
its posterior margins, while surface resorptive changes lead to
deepening of its facial surface.
Cranial base contribution

Growth of the cranial base has a major secondary displacement effect
on the anterior cranial fossa and nasomaxillary complex causing their
forward displacement, while a minor effect is also seen on the
mandible. As the middle cranial fossa grows, it displaces the maxilla
in an anterior and inferior direction. Secondary displacement is an
important growth mechanism during the primary dentition period
(till 6–7 years of age), but becomes less important as growth of the
cranial base slows down.
Growth at sutures
The maxillary complex is attached to the cranium by
zygomaticomaxillary sutures, frontomaxillary sutures,
zygomaticotemporal sutures and pterygopalatine sutures. Growth at
these sutures leads to anterior and vertical descent of the maxilla.
Growth at the median palatine suture enhances transverse dimensions
of the maxilla. Following the cessation of cranial base development at
6–7 years, growth at the sutures and nasal septal cartilage are the
primary contributors to further growth of the maxilla.
Role of the nasal septum

Nasal septal cartilage plays a significant role in maxillary growth.
Growth of the cartilaginous part of the vomer and the perpendicular
plate of the ethmoid contribute to downward and forward growth of
the maxilla. This growth also creates space in the posterior region in
the area of a tuberosity for the eruption of the permanent molars.
Nasal cartilage has innate growth potential and serves as a primary
growth centre, in contrast to the mandibular condyle. Experiments
have shown that early loss of septal cartilage is associated with
midface deficiency.16,17
Surface remodelling and growth at alveolar process

Deposition at the posterior end of the maxilla (tuberosity) causes an
increase in anteroposterior dimensions (length) (Fig. 10.8), while
surface resorption at the facial surface gives the maxilla its
characteristic contour as a result of its functional needs. Deposition on
the palatal surface and resorption at the nasal surface of the palatal
process lead to downward drift of the palate, which increases the size
of the nasal cavity. At the same time, growth of the alveolar process
contributes to enhancing the depth of the palate. Surface remodelling
also contributes to increase in the width of the maxilla and expansion
of the nasal airway (Fig. 10.9). Deposition on the buccal aspect of the
alveolar process along with growth across the mid-palatine suture
contribute to increase in width.
FIGURE 10.8 Sagittal section through the zygomatic arch.

Growth of the maxilla in length occurs primarily through deposition of
bone on the infratemporal surface. Growth at the zygomaticomaxillary
suture helps increase the transverse width of the maxilla and length of
the zygomatic process of the maxilla. The alveolar process develops
and descends with the eruption of teeth.
FIGURE 10.9 (A–C) Surface remodelling changes seen in a coronal
section of the maxilla at the section level (dotted line). Areas of
simultaneous resorption (–) and deposition (+) along the various
surfaces of the maxilla and palatine bone occur in concordance with
the V principle and causes the nasal cavity to widen, the sinus to
expand, and the palate to descend.
Growth of the sinuses

The sinuses are air-filled cavities within the craniofacial skeleton.
They have important biological functions such as pneumatisation of
the skeleton and humidification of inspired air. The sinuses grow by
resorption of adjacent bony surfaces. The origin and development of
the sinuses are summarised in Table 10.4. While most sinuses achieve
near adult size by 12 years, the frontal sinus continues to enlarge till
20 years, which may contribute to the forward shift of the nasion.
Table 10.4
Development of sinuses
Sinus
(adult Foetal appearance Postnatal appearance
volume)
Maxillary Day 65 as bud along inferolateral Present at birth; two spurts between 1–4
(15 mL) surface of nasal capsule years and 4–8 years
Ethmoid 3rd month from lateral nasal wall Present at birth; two growth spurts: 0–3
(14 mL) years, 7–12 years
Frontal (6– 4th month by upward extension of Seen radiologically at 7–12 years; reaches
7 mL) nasal capsule in frontal recess adult size by 20 years
Sphenoid 3rd month as evagination in posterior Seen radiologically at 3–4 years; further
(7.5 mL) capsule in sphenoethmoidal recess posterior extension begins by the 7th year
Source: Modified from Wang PH, Abdalkhani A. Embryology,
anatomy and physiology of the nose and paranasal sinuses. In: Snow
JB, Wackym PA, editors. Ballenger’s otorhinolaryngology: head and neck
surgery. 17th ed. Shelton: People’s Medical Publishing House; 2009. p.
457.
Growth of the mandible8

Mandibular growth occurs by a combination of surface remodelling
and growth at the condylar cartilage (Fig. 10.10). The important sites
of mandibular growth are now discussed:
1. Condylar growth. The mandibular condyle is an important site

for mandibular growth. Condylar cartilage is phylogenetically
and ontogenetically unique and differs in histological
organisation from other growth cartilages involved in
endochondral bone formation. It is a secondary fibrocartilage
and is covered with poorly vascularised fibrous connective
tissue. Growth of the condyle occurs by proliferation of
fibrocartilage, which subsequently gets ossified into bone. This
causes an increase in the overall length of the mandible, while
displacing the chin downwards and forwards (Fig. 10.11). The
rate and directions of condylar growth are influenced by both
intrinsic and extrinsic factors.
It is important to note that condylar cartilage is a site of growth
but not a growth centre as it has little innate growth potential.
When transplanted to other sites, it ceases to grow, in contrast
to growth centres such as synchondroses and nasal septal
cartilage. Additionally, mandibular condylar cartilage is not
essential to growth of the mandible. This is exemplified by the
fact that loss of mandibular condyle following traumatic
injuries does not lead to growth retardation of the mandible,
provided functions of the mandible are maintained.17–19 In
cases where jaw mobility is restricted in the aftermath of
trauma leading to a fibrous union at the condyle, growth of the
mandible gets hampered.
2. Ramus-to-corpus remodelling. Growth of the ramus occurs in all
three dimensions: superiorly, posteriorly and transversely. The
growth vector of the mandible is posterior and superior, and
ramus remodelling occurs in a similar direction. Superior
growth leads to increase in ramus height, which is primarily
due to growth at the condyle. Posterior growth of the ramus
occurs by cortical drift and surface remodelling at the junction
of the ramus and the body of the mandible (corpus) (Fig.
10.12). The ramus grows posteriorly by selective deposition at
the posterior border and resorption at the anterior border. This
also lengthens the corpus and provides space for the
developing molars. The pattern is continued up to the
beginning of the coronoid notch, where the anterior surface
becomes depository in response to functional demands
imposed by the temporalis muscle.
The lingual tuberosity forms the boundary between the ramus
and the corpus of the mandible. With growth, the lingual
tuberosity remodels backwards by selective resorption at the
anterior surface and deposition at the posterior surface.
Transversely, the ramus widens as it grows posteriorly (Fig.
10.13A–D). This is caused both by growth of the corpus, V-
shape configuration of which pushes the ramus outwards as it
grows backwards, as well as by selective deposition and
resorption patterns on the posterior and anterior surfaces of the
ramus. Below the inferior alveolar canal and along the posterior
border of the ramus, the medial surface is resorptive, while the
lateral surface is depository. Above the alveolar canal, along
with the anterior border up to the coronoid notch, the medial
surface is depository, while the lateral surface is resorptive (Fig.
10.14A–D).
3. Coronoid process. Remodelling of the coronoid process also
follows the V principle, just like the ramus. There is resorption
on the buccal side and deposition on the lingual side of the
coronoid process under the action of the temporalis muscle.
4. Body of the mandible. Increase in the length of the mandible
occurs by remodelling at the anterior border of the ramus,
while increase in height occurs by development of the alveolar
process in response to tooth eruption. When seen from the
side, the entire inferior border is deposito-ry, while resorption
is seen in the antegonial notch area. Laterally, on the buccal
surface, the mandibular foramen drifts backwards and
upwards as deposition takes place on the anterior rim and
resorption takes place on the posterior rim of the foramen.
When the body of the mandible is seen in cross-section,
remodelling patterns widen the base of the mandible laterally.
On the medial side, below the inferior alveolar canal,
resorption occurs, while on the buccal side, the process of
deposition continues. The opposite trend is seen on surfaces
above the inferior canal. This causes the alveolar process of the
mandible to incline medially over the body (Fig. 10.14A–D).
5. Alveolar process. The alveolar process develops as the teeth
erupt in response to functional demands. Where there is
partial anodontia, growth of the alveolar process is hampered.
For example, in children with ectodermal dysplasia, alveolar
processes are virtually non-existent in areas where teeth fail to
develop.
6. Growth at the chin. Growth at the chin occurs primarily by
surface remodelling, which usually has an inconsistent pattern
depending significantly on the growth pattern of the
individual. Despite this, the chin of the human generally
becomes prominent with age. Chin prominences are due to
deposition of bone on the anteroinferior surface and resorption
anterosuperiorly at the root apices of the mandibular incisors
(Fig. 10.12) and due to late mandibular rotation in a forward
direction. The entire remodelling process and growth rotation
along with development of the alveolar process give the
anterior surface of the chin an S-shaped contour. The deepest
point on this contour is labelled point B in cephalometric
tracings. On the lingual side, along with the alveolar process,
deposition is seen, while the inferior surface may be
resorptive.
FIGURE 10.10 Summary of postnatal growth of the mandible.

Growth is a composite of primary growth and surface remodelling. The
arrows indicate the direction of growth. Source: Based on Enlow DH,
Harris DB. A study of the postnatal growth of the human mandible. Am
J Orthod 1964;50:25.
FIGURE 10.11 Growth at the condyle leads to anterior and
inferior displacement of the mandible due to increase in the ramus
and body length.
When changes are studied with the superimposition point at the chin,
the mandible can be seen to grow posteriorly and superiorly.
FIGURE 10.12 Surface changes in the mandible when viewed
from the side.
The ramus shows deposition at the posterior border and resorption at
the anterior border. The inferior border of the mandible is depository
except the antegonial notch, which is resorptive.
FIGURE 10.13 Growth of the mandible confirms the ‘V’ principle.
However, surface changes and primary growth act in different
directions. While the alveolar process moves mesially due to surface
changes in the molar region causing contraction of the V (A), growth at
the condyle acts to expand the V (B). (C) The overall growth vector (Y).
(D) Expansion according to the ‘V’ principle is evident when a young
mandible is compared with an adult mandible.
FIGURE 10.14 Schematic representation of growth changes at
the posterior body and ramus of the mandible.
The arrows show the direction of changes. (A) The body grows
posteriorly by deposition at the posterior end of the ramus. (B and C)
Section at the level of the last erupted molar. The sign (+) shows
deposition and (–) shows resorption. (D) The alveolar process in the
posterior region remodels mesially due to surface remodelling.
Every individual has a certain basic pattern of craniofacial growth.
Broadly speaking, facial growth can be divided into one of the
following types:
1. Horizontal growth pattern

2. Vertical growth pattern
3. Average growth pattern is some what between the horizontal
and vertical growth patterns.
In the horizontal growth pattern, there is a tendency for the

mandible to rotate upward and forward. The lower anterior facial
height is relatively short with a tendency for deep bite. Such persons
have a squarish face, a low mandibular plane angle, well-developed
jaw elevators, increased biting force, and broad dental arches. Their
jaw bones are dense and hence orthodontic tooth movement through
this bone may sometimes become difficult, especially in adult cases.
In the vertical growth pattern, the growing mandible rotates
downwards and backwards. Anterior facial height is increased,
especially the lower anterior face height. The muscular forces of the
jaw elevators such as the temporalis and masseter are weak compared
with horizontal growers, and there is a tendency for anterior open
bite. The dental arches are narrower and jaw bone density is relatively
less.
Growth trends are contributed by and reflect, at least in part, the
trends in growth rotation of the mandible. Rotational growth of the
mandible can be assessed by observing the following anatomic
landmarks on a lateral cephalogram:
1. Inclination of the condylar head

2. Curvature of the mandibular canal
3. Shape of the lower border of the mandible
4. Inclination of the symphysis
5. Inter-incisal angle
6. Inter-premolar or inter-molar angles
7. Lower anterior face height.
Growth rotations20–22
As the craniofacial region grows, many intricate events occur within
and outside the mandible to maintain its structural integrity and
function. As facial bones grow, they cause downward and backward
rotation of the mandible. This is compensated by ramus growth and
internal remodelling within the corpus. Much-needed information
came from the classical work of Arne Björk, who through implant
studies provided significant insights into growth rotations of the
mandible.
To understand growth rotations, the mandible must be visualised as
a long bone that is bent at both ends to join the skull at
temporomandibular articulation. The central diaphysis part is hence
free to rotate (Fig. 10.15A–D). According to Bjork, ‘from the
standpoint of growth, the mandible may be regarded as a more or less
unconstrained bone, for it may change its inclination in several ways’.
FIGURE 10.15 The mandible as a bent long bone.

(A–D) The mandible can be considered a long bone bent at both ends
such that the body is made of diaphyseal bone and the epiphysis
constitutes the condyles. The diaphyseal region may be considered the
corpus of the mandible to which various functional processes are
attached (muscle and ligament attachment), such as the coronoid
notch, mylohyoid ridge, and alveolar process (attachment of teeth). The
corpus is the structure intricately related to growth changes of the
condyle, while functional processes relate more to functional
environmental influences. Source: Based on Moyers RE, editors.
Handbook of orthodontics. 2nd ed. Yearbook Medical Publishing; 1988,
p. 60.
Growth at the condyles shows large variations in amount and

direction, especially during the pubertal spurt; it usually does not
occur in the direction of growth of the ramus. Instead, it occurs in a
direction that is slightly forward, has a curved path, and varies
significantly among individuals depending upon growth trends.
Variation of up to 45 degrees has been documented.
Rotation of the mandible occurs as a result of interaction between
growth at the condyles and surface remodelling of the various areas of
the mandible. It can be of two types: forward or backward. A critical
factor deciding the type of rotation and the clinical effects thereof is
the centre of rotation, which may be located at the condyle, the
incisors or any place in between.
1. Forward rotation. Forward rotation is characterised by clockwise

rotation of the mandible. It can be of three types (Fig. 10.16A, B
and C):
• Type I. The centre of rotation resides at the
temporomandibular joint. With mandible rotation,
the condyles and the lower incisors move superiorly
giving rise to deep bite with concomitant under
development of the lower anterior face height.
Individuals with an extreme pattern of this type have
characteristic facial features such as reduced depth of
the antegonial notch, a brachycephalic head type,
anterior deep bite and strong muscular pattern of the
face.
• Type II. The nature of the mandibular growth is such
that the centre of rotation gets located at the incisal
edges of the lower anterior teeth. This occurs when
posterior face height increases disproportionately in
relation to anterior face height. This may occur under
two conditions: (1) inferior relocation of the middle
cranial fossa and (2) disproportionate increase in the
ramus height. Alternatively, conditions associated
with lack of tooth eruption like primary failure of
eruption may lead to cessation of posterior tooth
contact. Excessive loading of masticatory forces leads
to wearing away of the anterior teeth, thus resulting
in loss of anterior face height and forward rotation of
the mandible.
• Type III. In between the two extremes described
above, there are conditions wherein the centre of
rotation lies between the condyle and incisor edge.
Subjects with large anterior overjet will fall in this
category. In such cases, the centre of rotation is
displaced backwards to the level of the premolars.
Such cases present with basal anterior deep bite. In
type II and III rotators, the mandibular symphysis
typically swings forward to reveal a characteristically
prominent chin.
2. Backward rotation. Backward rotation is characterised by
downward and clockwise movement of the mandible (Fig.
10.16D, E). Two types of backward rotation are recognised:
• Type I. The centre of rotation lies at the
temporomandibular joint. Such rotations may be seen
when the middle cranial fossa does not develop
adequately or when bite-raising appliances are given.
It results in increase in anterior face height. The
mandible is mostly normal in size.
• Type II. Here the centre of rotation lies at the most
distal occluding molars. Such a pattern is seen when
condylar cartilage shows less growth than the rest of
the structures leading to smaller vertical height of the
ramus. This pattern leads to rotation of the chin
downwards and backwards making it less prominent.
The soft tissues of the chin may or may not follow,
resulting in the characteristic double chin in the latter
case. The lower incisors become retroclined over the
base. Such cases are especially prone to development
of anterior open bite, which is difficult to correct
orthodontically.
FIGURE 10.16 Growth rotation in the mandible.

Mandibular rotation. (A) Forward rotation with the centre located at the
joints, (B) Forward rotation with the centre located at the incisors. (C)
Forward rotation with the centre located at the premolars. (D)
Backward rotation with the centre located at the joints. (E) Backward
rotation with the centre located at the last occluding molars. Source:
Reproduced with permission from Björk A. Prediction of mandibular
growth rotation. Am J Orthod 1969;55(6):585–99.
Matrix versus intra-matrix rotation20–22

Relocation of the mandible occurs to maintain occlusion and harmony
with the growing upper face. In order to compensate the demand of
the growth, descent of the upper face and dentition, the mandible
undergoes several changes which include rotation of the mandible at
its condyles called matrix rotation and within the mandible itself. The
latter is termed as intra-matrix rotation. The overall effect being total
rotation of the mandible as a whole.
To assess and distinguish the relative contribution of the two types
of growth rotations, it is important to identify stable areas of reference
around which rotations occur. A few locations or areas within the
mandible that are relatively stable include the mandibular canal,
inferior margins of developing third molar tooth buds before
initiation of root formation, the anterior aspect of the chin and the
inner border of the inferior surface of the symphysis. The anterior
aspect of the chin (the radiographic pogonion area) is considered
extremely stable, with surface changes seen at the bony contours both
above and below it. The mandibular canal is also relatively stable,
with the trabecula around it showing little change in orientation
during surface remodelling (Fig. 10.17A–C).
1. Matrix rotation. Matrix rotation occurs when the whole

mandible rotates with the condyle as the centre. This rotation
takes place in the form of an arc. This type of rotation is seen
when bite opening is facilitated by dental eruption or when
excessive vertical maxillary growth rotates the mandible
downwards.
2. Intra-matrix rotation. Intra-matrix rotation occurs within the
mandibular corpus (i.e. the body of the mandible). The main
contributor being the surface remodelling of the corpus. It
contributes to development of the angle of the ramus,
prominence of the chin and development of the antegonial
notch. This type of remodelling may be extremely evident in
cases where posterior teeth fail to erupt and the centre of
rotation shifts to the incisor region. In such cases, the inferior
border of the ramus becomes convex and prominent with loss
of the antegonial notch.
FIGURE 10.17 Concept behind matrix and intra-matrix growth
rotation.
(A) Matrix rotation occurs when the mandible moves around an axis
located at the condyles. (B&C) Intra-matrix rotation occurs due to
remodelling changes around the corpus of the mandible. (B) Forward
intramatrix rotation. The anterior part of the corpus is lifted up from the
matrix, leading to apposition below the symphysis and the anterior part
of the lower border. The posterior part of the corpus is pressed
downward into the matrix, resulting in resorption. (C) Backward
intramatrix rotation: Backward intramatrix rotation resulting in resorption
below the symphysis and apposition below the angle. Apposition may
occur at the chin point. The centre of rotation is situated in the corpus.
Source: Based on the concept of Björk A, Skieller V. Normal and
abnormal growth of the mandible. A synthesis of longitudinal
cephalometric implant studies over a period of 25 years. Eur J Orthod
1983;5(1):1–46.
Total rotation of the mandible is the sum of matrix and intra-matrix

rotation, which occur in varying intensity and amount. The two types
of rotations may occur in the same direction complementing each
other or may occur in opposite directions negating each other’s effect.
In most instances, intra-matrix rotation accounts for most of total
rotation, although there is great variability.
Effect of mandibular rotation on occlusion

Both types of rotation patterns affect teeth positioning in both the
arches. In forward rotators the inter-premolar and inter-molar angles
are larger, leading to posterior teeth being more upright on the jaw
base. The lower anterior teeth are also guided forward resulting in
alveolar prognathism. However, since all mandibular teeth show
mesial migration of the mandibular base, the lower incisors have a
tendency to show crowding, which is called ‘packing’.
In contrast, in patients with backward rotation, the inter-premolar
and inter-molar angles are small, which means that the premolars and
molars are inclined forward in relation to the maxillary bases, which is
an important consideration when planning anchorage during
orthodontic treatment. The lower teeth also tend to become more
upright on the jaw bases, thus reducing alveolar prognathism and
increasing incisor crowding.
Growth of the soft-tissue integument of
face
The face remains the focus of attention for most patients and is the
main reason for seeking orthodontic treatment. An improvement in
occlusion alone may not be sufficient to satisfy and fulfil the real goals
of orthodontic treatment. Therefore, to achieve the goals of occlusion
and facial aesthetics, it is also pertinent to be aware of growth and age
changes in the soft-tissue integument that occur from childhood to
adolescence, from adolescence to adulthood and later with ageing.
Growth of the underlying skeleton and changes in the profile are
well known, and it is anticipated that the soft-tissue integument will
follow the skeletal profile and growth of the face. However, it may not
be true except for growth of a hard-tissue or soft-tissue chin. Growth
of the remaining face follows a pattern independent of the underlying
facial skeleton.23
Growth at chin. The bony chin grows from a receded profile at birth
to catch up and even become prominent after puberty. Boys usually
show more prominent chin than girls though the total amount of
growth occurring may be similar. Girls attain full growth early and
undergo no change or little change till adulthood after puberty, while
boys are late to catch up and may show some more growth after the
pubertal growth spurt.23
Therefore, the difference in timings of growth at the chin seems to
be critical when gender is considered. The soft-tissue integument at
the chin follows the pattern of the skeletal chin and therefore
contributes to straightening the profile. The bony chin continues to
grow downward and forward, and the soft-tissue integument follows
the same pattern throughout life.
In addition to catch-up growth at the chin, straightening the
convexity of the skeletal face profile further contributes to reduction in
maxillary prognathism. It has also been observed that the relative
position of the alveolar process at point A and B in Fig. 10.18 does not
change after 9 years of age.
Soft-tissue profile of the midface. The complete soft-tissue profile in the
upper part of the face does not follow the same pattern as the chin.
Overall growth in soft-tissue thickness at the midface is much greater
than at the chin. The soft-tissue profile, which includes the position of
the lips, straightens as much as the skeletal pattern as a result of soft-
tissue growth of the lips and nose, which continue to show an
increase. The upper lip’s thickness and position are affected by growth
of the nose23 (Figs 10.18–10.21).
FIGURE 10.18 Change in soft tissue profile, from 3 months to 18

years.
Based on tracings of serial roentgenograms of a case obtained from
the files of the Bolton Study at Western Reserve University.
Progressive decrease in skeletal convexity can be seen. Source:
Reproduced with permission from Subtelny JD. The soft tissue profile,
growth and treatment changes. Angle Orthod 1961 Apr;31(2):105–22.
FIGURE 10.19 Change in skeletal profile from 3 months to 17
years.
Based on tracings of serial roentgenograms of a case obtained from
the files of the Bolton Study at Western Reserve University.
Progressive forward positioning of the chin is evident. Source:
Reproduced with permission from Subtelny JD. The soft tissue profile,
growth and treatment changes. Angle Orthod 1961 Apr;31(2):105–22.
FIGURE 10.20 The bony and soft tissue chin follow similar trend.
Serial tracings depicting forward positioning of a soft-tissue chin with
forward positioning of a skeletal chin. Source: Reproduced with
permission from Subtelny JD. The soft tissue profile, growth and
treatment changes. Angle Orthod 1961 Apr;31(2):105–22.
FIGURE 10.21 Growth of the nose.

Serial tracings superimposed on the sella–nasion plane (registered on
the nasion) depicting downward and forward growth of the nose at 5,
11 and 18 years. Source: Reproduced with permission from Subtelny
JD. The soft tissue profile, growth and treatment changes. Angle
Orthod 1961;31(2):105–22.
The nose. The soft-tissue nose grows downward and forward along
with the maxillary complex. When the nose is included in the total
profile of the face, the convexity of the face increases because
progressive growth of the nose makes the facial profile more convex.
The nose continues to grow throughout life.24 However, the ratio of
nose length to depth (horizontal dimensions) varies at different ages.
Nose growth between 9 and 16 years is the same for males and
females (Figs 10.22 and 10.23).
In boys, the growth spurt for nasal growth appears between 10 and
16 years. According to Chaconas,25 girls demonstrate earlier nose
growth than boys, and boys show greater overall incremental growth.
Between 9 and 15 years, the nose tip grows 1 mm/year anterior to the
facial plane for both males and females. Growth of the nose occurs
more in length than in depth.
Gender differences are seen for growth in nose depth (horizontal)
and length. Girls show greater increase in horizontal growth of the
nose than boys who exhibit more significant growth in nose length.
The lips. Orthodontic clinicians are also interested in being aware of
changes in the lips during adolescence and adulthood. Both the upper
and lower lips grow in length till 15 years of age. Along with lip
length, the lip also increases in thickness until 15 years, particularly in
the vermillion region, after which it slows down. Progressive increase
in length of the lips shows a steady relationship with the alveolar
process.23
Upper-lip length growth in both males and females is complete by
15 years. However, total growth of the lips is much more in boys than
girls.26
The vertical relationship of the upper and lower lips on incisor
levels remains constant after 9 years indicating that the effect of
overall change in the position of incisors on craniofacial growth is
compensated for by the same amount of soft-tissue growth at lip
length. The maxillary incisor crowns are covered for 61% of their
height by the upper lip and the rest by the vermillion part of the lower
lip.23
After 9 years, the incisors tend to be upright on the support-ing
skeletal bases (e.g. the lower incisors in relation to the bony chin).
Similarly, the maxillary incisors become more intrusive in relation to
the facial plane of the skeletal profile. Although the alveoli of the
mandibular incisors in this area are upright, there is excessive growth
of the chin, which helps to maintain a constant angular relationship
with the jaw profile.23
In general, when the alveolus process tends to reduce, so do the
lips, and when dentoalveolar structures tend to be protrusive once
again so do the lips.23
The upper and lower lips become significantly more retruded in
relation to the aesthetic line between 15 and 25 years. The same trend
continues between 25 and 45 years.27
Sexual dimorphism in facial growth. Nanda et al.26 in a sample of
Caucasian children from 7 to 18 years, all of whom had class I
occlusion at adulthood, reported longitudinal changes in the soft-
tissue profile on lateral cephalograms. They reported that for most
parameters, females acquired more growth as a percentage of their
adult size (at age 18) than males. The nose seems to establish early in
girls as does the chin, while for males the nose had not attained adult
size even at 18 years (Table 10.4).
Increments in nose height, depth and inclination are substantially
complete in girls by 16 years, while they continue to increase in males
up to and beyond 18 years.26
Growth in boys and girls is similar in both magnitude and direction.
On the other hand, timing of the greatest changes in the soft-tissue
profile occurs earlier in females (10–15 years) than in males (15–25
years).27
Eli28 reported that soft tissue continues growing after hard tissue
ceases to grow. Thus, soft-tissue development is independent of
underlying hard-tissue change. Females were found to have
completed almost all of their soft-tissue growth at 12 years and boys at
17 years. Continuing growth contributes to males having greater soft-
tissue dimensions in many parameters. Overall, the studies
demonstrate that development of the nose is a continuous process and
that growth occurs throughout adulthood. The nose follows a forward
and downward direction. Over time, we can see the progression of an
upturned blunted nose to a more downturned pointed nose. The lips
follow a different pattern. As the lower lip moves downward and
forward, the upper lip also moves downward and forward early on,
but then begins to move backward in advanced age. The chin follows
the same overall pattern as the nose and progresses downward and
forward28 (Fig. 10.22).
FIGURE 10.22 Male and female growth trends for the nose: dark
color 10–13 years and light colour 13–16 years.
(A) Class I male; (B) class I female. Source: Reproduced with
permission from Chaconas SJ. A statistical evaluation of nasal growth.
Am J Orthod 1969 Oct;56(4):403–14.
FIGURE 10.23 Growth curve for nose depth derived from a cross-
sectional study on 2,500 normal subjects from birth to 97 years.
Source: Taken from Zankl et al (2002).
Ageing and soft-tissue integument of
face
Based on a longitudinal study of the same subjects over 18 years of
age to 42 years, it was found that even though most hard-tissue
growth for males is complete by 25 years, soft-tissue growth continues
unequivocally after 25 years. The profile of males becomes straighter
and the lips retrude more, a result not observed in females. Both sexes
show an increase in all nose dimensions.29
A classical work on patterns of growth in the craniofacial skeleton
of subjects aged between 17 and 73 years by Behrents30 confirmed that
changes in soft-tissue growth are of greater magnitude than osseous
changes. The nose shows a continued downward and forward pattern
of growth at all ages examined. Males have larger noses at the
beginning of adulthood and grow more during adulthood. Both sexes
demonstrate a nasal tip profile that becomes more acutely angled with
time.
Eli28 reported that the nose begins to droop in advanced age. The
nose becomes more pointed and downturned. The upper lip also
begins to retract as age increases, while the lower lip continues to
move downward and forward. Areas along the chin also progress in a
downward and forward pattern (Fig. 10.24).
FIGURE 10.24 Facial profile and nose changes in a group of

subjects in a longitudinal follow-up study at age 6–8, 16–18, 25–29
and 50–66.
(A) Note the difference in growth directions of the nose, nose tip, lips,
and chin (the connecting lines suggest growth directions). (B) Lines
indicate the direction of growth. Source: Eli JT. A longitudinal study of
the soft-tissue profile and growth of the nose from childhood through
adulthood (Dissertation). St Louis: St Louis University; 2005.
Key Points
Growth of an individual occurs in phases with periods of observable
growth interspersed by no evident growth. This is applicable not only
to major growth spurts but also growth on a daily basis.
Mini growth spurts occur on a daily, weekly and monthly basis,
while the principal spurt is the adolescent growth spurt.
During adolescence, a child grows at a significantly faster rate,
which is typified by the attainment of peak height velocity (PHV).
Growth of the craniofacial complex correlates well with general
growth of the body. Body growth can be individualised into the
growth of various functional complexes such as the cranial vault,
cranial base, nasomaxillary complex and mandible.
Individual bones grow by a variety of processes such as sutural
growth, symphyseal growth, displacement and surface remodelling.
The mandible is a peculiar bone, which behaves like a long bone
bent at both ends. Growth rotations and patterns particularly
influence growth of the mandible.
The soft-tissue integument does not follow the skeletal pattern.
Also, there is a significant difference in how males and females grow.
Soft-tissue changes, particularly of the nose and lips, are of great
concern to orthodontists since they continue to alter throughout life.
Orthodontic therapeutic interventions and prognosis are influenced
by the growth status and growth trend of a patient. For all orthodontic
patients, growth assessment should be carried out as routine and a
due consideration should be integrated on remaining hard and soft
tissue growth, pattern of growth, sexual dimorphism of growth and
growth with aging in planning the treatment.
Functional jaw orthodontic therapy takes advantage of the
remaining growth of the craniofacial region to change, alter or redirect
growth of the developing jaws.
References
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Bishara SE, ed. Textbook of orthodontics.
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2. Ulijaszek SJ, Johnston FE, Preece MA. The
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PA: Saunders; 1972:893–928.
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20. Björk A. Prediction of mandibular growth rotation.
Am J Orthod. 1969;55(6):585–599.
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C H A P T E R 11
Functions of stomatognathic
system and their implications on
occlusion
O.P. Kharbanda
Shailendra Singh Rana
Anurag Gupta
CHAPTER OUTLINE
Orofacial function and craniofacial development

Mastication
Plastic bite
Adult mastication
Orthodontic implications
Stages of swallowing
First stage
Second stage
Third stage
Respiration
Speech
Types of thumb sucking
Interception of thumb sucking habit
Beta hypothesis
Causes of tongue thrusting
Types of tongue thrusting
Clinical features of tongue thrusting swallow
Clinical features
Clinical assessment of mode of respiration
Cephalometric analysis
Rhinomanometric examination
ENT perspective
Bruxism
Aetiology
Clinical features
Nail biting
Aetiology
Complications
Lip biting
Key Points
Orofacial function and craniofacial
development
The orofacial skeletal and dental development are intimately
interdependent on the development of functions of the orofacial
structures. When a child is born, the neuromuscular components of
the oral cavity primarily serve to fulfill the most basic needs of
feeding, maintenance of the airway and gratification of emotional
needs and speech. Maturation of these oral functions occurs from
anterior to posterior, that is, at birth, lip functions develop relatively
early, followed by posterior part of the tongue and lastly, the
pharyngeal structures. Prolonged retention of primitive functions or
development of an abnormal function, adversely affects the growth of
the jaw and teeth.
Mastication
It is a complex function that utilises not only the muscles, teeth, and
periodontal supportive structures but also the lips, cheeks, tongue,
palate, and salivary glands.
Plastic Bite
In a newborn, mastication is confined to hinge movements of the
lower jaw, called ‘plastic bite’, which facilitates suckling and
swallowing of milk and liquids. Suckling is an non-learned, primitive
reflex in Homo sapiens. At this stage of life, an infant tries to
communicate with the world through the sensory pathways present in
the oral structures of lips and tongue. The suckling action helps in
feeding the baby, and also creates an emotional bond with the mother
who builds the first trust for him to the outside world. Suckling
involves more muscles in addition to those of orofacial function.
During suckling, head is extended, tongue elongated and placed low
on the floor of the mouth, with jaws apart and the lips pursed around
the nipple and mandible is somewhat protruded. The suckling reflex
is the most primitive of all reflexes, and yet it is the well-developed
reflex at this stage. Suckling is a nibbling action of the lips on the
nipples of the mother’s breast that causes smooth muscle contraction
of milk ducts to release secretion. The tongue of the infant is so closely
placed next to the lips and tunnelled so as to cause the milk to flow
into the pharynx and oesophagus.
When an infant learns to take solid food, the muscles of cheek,
tongue and lips gets involved, but the activity of lips is reduced. Lips
keep the food from falling out of mouth during the peristalsis like
action of the tongue and cheeks, as the bolus is pushed towards the
pharynx. The bolus of food is mixed with saliva by the action of
tongue and is forced between the gum pads or the erupting teeth. The
eruption of primary teeth and establishment of occlusion facilitates
mastication and deglutition.
Adult mastication
Mastication in an adult is a complex phenomenon caused by chewing
strokes. Movement pattern of chewing stroke is tear shaped. It can be
divided into an opening phase, and a closing phase and closing phase
is further subdivided into the crushing phase and the grinding phase
(Fig. 11.1). Mandible frontal plane tracing shows that single chewing
stroke in the mouth opening phase drops downward from the
intercuspal position to a point where the incisal edges of the teeth are
about 16–18 mm apart. It then moves laterally 5–6 mm from the
midline as the closing movement begins. The first phase of closure is
the crushing phase during which the food is trapped between the
teeth. At this point, the teeth are so positioned that the buccal cusps of
the mandibular teeth are almost directly under the buccal cusps of the
maxillary teeth on the side to which the mandible has been shifted. As
the mandible continues to close, the bolus of food is trapped between
the teeth and grinding phase starts to shear and pulverise the bolus of
food (Fig. 11.1).
FIGURE 11.1 Frontal view of chewing stroke.
During chewing, the greatest amount of force is placed on the first

molar region.1 Dolichofacial subjects have a significantly smaller
maximum molar bite compared to mesofacial and brachyfacial
subjects.2,3 Female maximal biting load ranges from 79 to 99 lb (35.8–
44.9 kg), whereas a male’s biting pressure varies from 118 to 142 lb
(53.6–64.4 kg).4
Adults with weak muscles have greater variation in facial
morphology than those with healthy muscles.5 Increased masticatory
muscle function is often associated with an anterior growth rotation
pattern and well-developed angular, coronoid, and condylar
processes in the mandible.6
Swallowing is a series of coordinated voluntary, involuntary, and
reflex muscular activity that moves a bolus of food from the oral
cavity through the oesophagus to the stomach. Stabilisation of the
mandible is necessary for swallowing. The mandible must be
stabilised so that contraction of the suprahyoid and infrahyoid
muscles can control a proper movement of the hyoid bone needed for
swallowing.
In the infantile swallow or visceral swallow, the mandible is
stabilised by placing the tongue forward and between the gum pads
and by facial muscles that are innervated by the seventh cranial
nerve.7 Whereas in an adult, swallowing also called somatic swallow,
the mandible is stabilised by teeth contact, which is controlled by
muscles of mastication, innervated by the fifth cranial nerve.
The suckling reflex and infantile swallowing pattern persist for
about a year after birth and slowly diminish as posterior teeth erupt
and intake of semi-solid food starts.8 Mature swallow is well
developed by 18 months.
The average tooth contact during swallowing is about 683 ms, that
is more than three times of mastication.9 The force applied to the teeth
during swallowing is approximately 66.5 lb, which is 7.8 lb more than
the force applied during mastication.9
The swallowing cycle occurs 590 times during a 24-h period: 146
cycles during eating, 394 cycles between meals while awake, and 50
cycles during sleep.10 Lower levels of salivary flow during sleep result
in less need to swallow.11
Stages of swallowing
Swallowing can be divided into three stages for discussion.
First stage
In infants, the visceral swallowing pattern or infantile swallowing is
present at birth. It is characterised by a forward movement of the tip
of the tongue during swallowing (Fig. 11.2A). Visceral swallowing
facilitates suckling and is considered normal at this age because the
tongue is relatively large compared to the mandible. Swallowing also
occurs during the last months of foetal life, and it appears that
swallowed amniotic fluid may be a critical stimulus to activation of
infant’s immune system.
FIGURE 11.2 (A) Infantile swallow, (B) mature swallow, (C) persistent
infantile swallow.
In somatic swallow, the first stage of swallowing is voluntary and

begins with the selective parting of the masticated food into a bolus.
This separation is performed mostly by the tongue. The tip of the
tongue rests on the hard palate just behind the incisors (Fig. 11.2B).
The bolus is placed on the dorsum of the tongue and pressed lightly
against the hard palate which initiates a reflex wave of contraction in
the tongue that pushes the bolus backwards. The lips are sealed, and
the teeth are brought together. As the bolus reaches the back of the
tongue, it is pushed down the pharynx.
Second stage
In the pharynx, a peristaltic wave caused by contraction of the
pharyngeal constrictor muscles carries it down to the oesophagus. The
soft palate is raised to get in touch with the posterior pharyngeal wall,
sealing off the nasal passages. The hyoid bone and the base of tongue
move forward, whereas epiglottis blocks the pharyngeal airway to the
trachea and leads the food to the oesophagus. During this stage of
swallowing, the pharyngeal muscular activity opens the pharyngeal
orifices of the eustachian tubes, which are normally closed.12
Third stage
The third stage of swallowing consists of passing the bolus through
the length of the oesophagus and into the stomach. When food passes
through the oesophagus, the hyoid bone, palate and tongue return to
their original positions. In the upper section of the oesophagus, the
muscles are mainly voluntary and can be used to return food to the
mouth when necessary for a complete mastication. In the lower
section, the muscles are entirely involuntary.
Abnormal swallowing or persistence of infantile swallowing leads to
abnormal development of the facial morphology and occlusion.
Anterior open bite is the most logical consequence of infantile
swallowing.
Respiration
Like mastication and swallowing, respiration is an inherent reflex
activity. Studies show that in the infant, respiration is carried out
through the nose, with the tongue in proximity to the palate,
obturating the oral passageway.13 Infants are obligate nasal breathers
and respiration maintains the patency of the pharyngeal airway. At
birth, infant airway must be established immediately on delivery and
must be retained after that. As we know that humans are primarily
nasal breathers but in some physiological conditions like during
exercises, we also partially breathe through the mouth. There is a
transition to partial oral breathing when ventilator exchange rates
above 40–45 L/min are reached.14 If the nose is partially obstructed,
the work associated with nasal breathing increases, and at a certain
level of resistance to nasal airflow, the individual switches to partial
mouth breathing. This crossover point varies among individuals but is
usually reached at resistance levels of about 3.5–4 cmH2O/L/min.15
Nasal obstruction for an extended period leads to the development of
mouth breathing pattern. The anatomical structures of upper airway
may contribute to obstruction in the airway. Upper airway includes,
hypopharynx, oropharynx (velopharynx and retroglossal constitute
the oropharynx), nasopharynx, and nasal cavity (Box 11.1).
Box 11.1 Common causes of upper airway

obstruction and their treatment
Area of obstruction Structure involved Treatment procedure
Nasal cavity Hard tissue Septoplasty
1. Nasal septal deviation Turbinoplasty
2. Turbinate hypertrophy
Soft tissue Mild-to-moderate allergic
1. Allergic rhinitis rhinitis: H1antihistamines
2. Nasal polyp Severe allergic rhinitis: Intranasal steroids
Surgical removal
Nasopharynx Adenoid hypertrophy Adenoidectomy
Maxillary retrognathia Maxillary advancement
Oropharynx Tonsillar hypertrophy Tonsillectomy
Soft palate redundancy Uvulopalatopharyngoplasty (UPPP)
Retrognathia Mandibular advancement,
Genioglossal advancement
Obstruction of the upper airway could result from a variety of

reasons, but the primary pathophysiological mechanism is the
imbalance between the negative intraluminal pressure (pharyngeal
airway lumen pressure) and positive extraluminal pressure.
Extraluminal pressure is provided by the tissues that comprise and
support the pharyngeal airway; these include soft tissues, fat
deposition within the para-pharyngeal structures, pharyngeal
oedema/inflammation, adenotonsillar hypertrophy and macroglossia,
myoneural factors and skeletal factor.16
During inspiration, the volume of the thorax increases, and the
pressure decreases, allowing for airflow into the lungs. A decrease in
pressure results in a relative negative intraluminal pressure within the
upper airway, predisposing collapse. Collapse is prevented due to
reflex activation of pharyngeal dilator muscles. During expiration,
intraluminal pressure initially increases, which acts to dilate the upper
airway. At the end of expiration, intraluminal pressure begins to fall
to a point at which the airway can collapse.
The patency of upper airway is ensured with a balance between
collapsing forces and dilating forces.17 Collapsing forces are related to
pharyngeal wall negative intraluminal pressure during inspiration
and pressure from the para-pharyngeal tissue. Dilating forces are
predominately related to pharyngeal dilator muscle tone and airway
traction from lung expansion.18
To maintain airway patency, dilating force should be more than
collapsing forces. A group of pharyngeal muscles act to dilate the
airway; the genioglossus is the largest airway dilator and the most
extensively studied.19 When it contracts, the tongue moves anteriorly,
and the pharyngeal airway dilates at the retroglossal level.20
Speech
Development of speech takes place during the first year of life (Box
11.2). It also follows the anterior to the posterior pattern of maturation
like the swallowing pattern. First, the bilabial sounds like /b/ and /p/
are produced. Later on, tongue tip consonants /t/, /d/, and sibilant
sounds like /s/ and /z/ are produced. /r/ sound, which is produced by
a posterior positioning of the tongue develops very late. Although all
mammals apparently masticate, swallow, and breath, speech is
limited to human beings. Speech is a learned activity dependent on
maturation of organism, unlike reflexive activity of swallowing,
respiration and mastication.
Box 11.2 Stages of development of speech
Stage Age Articulation

I 0–8 weeks Reflexive crying and vegetative sounds
II 8–20 weeks Cooing and laughter
III 16–30 weeks Vocal play
IV 25–50 weeks Reduplication of babbling: consonant-vowel syllables
V 50+ weeks Non-reduplicating babbling
VI Around 1 year First words
The habit has been defined simply as any task or function that is
repeatedly done and is a part of the subconscious act. Orofacial habits
influence the form of the orofacial structures because of their
repetitive nature and longer duration (Fig. 11.2C).
Klein, as early as 1952, recognised that bone is susceptible to
pressure from environment and extremely susceptible to the guidance
and influence of pressure and stimulus. ‘Pressure habits
(unintentional pressures) also affect alveolar bone and move teeth in
the bone because the bone-building cells on the receiving end of the
stimulus cannot differentiate whether that stimulus is intentional
(planned orthodontic treatment) or whether it is unintentional
(abnormal pressure habit).’ Therefore the pressure habits are a major
etiological factors in the production of malocclusion more so during
developing occlusion.21
Within this broad category of unintentional pressure, Klein further
divided habits into:
1. Intrinsic pressure (within mouth)

a. Thumb sucking
b. Finger sucking
c. Tongue thrust swallow
d. Mouth breathing
e. Tongue, lip, cheek, blanket-sucking
f. Nail, lip, tongue biting
g. Macroglossia, overgrowth of the tongue
h. Incorrect swallowing, anaesthesia throat
2. Extrinsic pressures: example incorrect pillowing
3. Functional pressures: malocclusion seen in musicians.
Prevalence of orofacial habits

Some studies have been carried out around the world to gauge the
problem of thumb sucking and pacifier sucking habits in children. In
Delhi, the prevalence of oral habits in school going children (5–13
years) was found 25.5%.22 Tongue thrusting was seen in 18.1%
followed by mouth breathing observed in 6.6% children (Fig. 11.3).
FIGURE 11.3 (A) Prevalence of various oral habits, (B) relative

distribution of various oral habits.
Non-nutritive sucking habits include thumb sucking, finger sucking,
lip sucking. Occasionally cases of cheek sucking are also seen though
very rare. Non-nutritive sucking habits may continue till 2 years of
age, when these practices normally stop with a transition to mature
swallow.
Thumb sucking starts as early as 15 weeks of intrauterine life and is
considered a normal act till 4 years of age. Beyond this age, thumb
sucking, if continued, would hinder normal development of occlusion.
Thumb sucking refers to placing the thumb or fingers into the mouth
many times every day and night, exerting a definite sucking
pressure.23 The habit can be repetitive and forceful associated with
strong cheek and lip contractions (Fig. 11.4). Several theories have
been put forward to explain thumb sucking habit.
FIGURE 11.4 Intensive thumb sucking at the age of 3 years (A–C).

The thumb used is cleaner due to the frequent use of the mouth.
Constant irritation from the teeth may cause the formation lead to the
formation of a callus (D). The untoward effects of thumb sucking are
influenced by intensity, frequency and duration of the habit. (E) Thumb
sucking leads to open bite. It can also lead to the maxillary protrusion
and a recessive chin resulting in class II malocclusion. (F) The pulp
side of the thumb used for sucking that rests on incisal edges shows
injury caused due to continued rubbing by the incisors. Interceptive
orthodontics and psychological guidance to the child and family
counselling can help to discontinue the habit which may bring about the
normalisation of facial growth at this age.
Freudian theory of psychoanalysis is linked to the psychosexual

development of humans. This theory regards thumb sucking as a
symptom of a deeper emotional disturbance or neurosis.
Eysenck’s learning theory views it as a form of neurotic symptom
itself and not caused by underlying neurosis. If the symptom (habit) is
eliminated, the neurosis will also be reduced. Most of the habit
breaking appliances work on the learning theory.24
Palermo theory regards thumb sucking as arising out of a
progressive stimulus and rewards reaction which would
spontaneously disappear unless it becomes an attention-getting
mechanism.25
Sear’s oral drive theory believes that the thumb sucking habit is
intimately related to the prolongation of breastfeeding.26 The longer
the baby is breastfed, stronger will be its oral drive and more prone it
is to thumb sucking.
Types of thumb sucking

How children place the thumb has been studied using
cineradiography by Subtelny,27 who grouped them as A–D.
1. Group A (50%): Thumb was inserted in the mouth

considerably beyond the first joint or the knuckle. The thumb
occupied a significant portion of the palate pressing against
the palatal mucosa and alveolar tissue. The lower incisor
pressed and contacted the thumb in the region of the first joint.
2. Group B (24%): The thumb did not go entirely into the vault
area of the hard palate, however, It entered the mouth up to
and around the first joint or just anterior to it.
3. Group C (20%): The thumb placed into the oral cavity and
approximated the vault of the hard palate as in group A.
However, the lower incisor did not touch or contact the
thumb.
4. Group D (6%): The thumb did not progress appreciably into
the mouth. The lower incisor contacted at a level near the
thumbnail.
Effects of digit sucking on oral structures.28–30 The result of any

pressure habit is dependent upon the trident of the following factors:
1. Duration
2. Frequency
3. Intensity
Digit sucking results in the development of features of class II

malocclusion. Proclination of the upper incisors is the first and the
most common sign of persistent thumb sucking (Fig. 11.5).
FIGURE 11.5 Thumb sucking in a young girl.

Placement of thumb and abnormal perioral muscle behaviours (A and
B). Thumb sucking caused a retrognathic mandible and superior
protrusion (C). Class II malocclusion caused by thumb sucking (D and
E). Note: Proclination of maxillary anterior teeth and large overjet
contributed by backwardly held mandible by the wrist resting on the
chin. (D and E) A class II malocclusion and overjet.
The proclination is self-maintaining because of the cushioning effect

of lower lips, and upper lip becoming redundant. These proclined
incisors are prone to accidental trauma. The pathophysiology of the
thumb sucking habit and its effects on face and occlusion are
explained in Flow chart 11.1.
1. Exaggerated mentalis muscle activity may be seen because of

the effort of the lower lip to attain a lip seal with upper lip.
2. Maxillary arch shows constriction due to abnormal and
excessive pressure from the buccal musculature which is not
balanced by the tongue on palatal side, oral space being
occupied by the thumb during the sucking habit. Posterior
cross-bite tendency may occur.
3. Mandibular incisors may be retroclined or upright.
4. Mandible shows downward and backwards rotation due to
lowered position while sucking.
5. An increase in the ANB (A point, nasion, B point) angle is seen
contributed by maxillary prognathism and mandibular
retrognathism.
6. The patient may develop tongue thrusting in anterior open bite
like situation created by thumb sucking.
FLOW CHART 11.1 Pathophysiology of thumb sucking induced class
II division 1 malocclusion and tongue thrust swallow.
Interception of thumb sucking habit

An initial consultation with the paediatric dentist or the orthodontist
will help in formulating a line of treatment, which is dependent upon
the age of the patient and severity of the condition.
As in children below 2 years non-nutritive sucking habit is common
and normal, parents must be warned towards any possible deficit in
attention or poor feeding for the child. If there is no apparent cause,
then this habit should self-correct with time.
For the thumb sucking habit persisting beyond 2 years, that is up to
4 years of age, attention must be given towards the child regarding
love and care. With both parents working, the child may suffer from
attention deficit which should be taken care of.
In children older than 4 years, signs of malocclusion should be
treated with a reminder therapy. Mocking and scolding should be
avoided at all times. Attention diverting activities such as outdoor
sports could help.
In older patients (more than 7 years) with moderate to severe form
of malocclusions like an anterior open bite or posterior cross-bite,
definitive orthodontic appliance therapy should be initiated.
Methods used for interception of the thumb sucking habit have
been outlined in Box 11.3.
Box 11.3 Treatment of thumb sucking
Indication Modalities
Reminder In an older child of at Chemical method
therapy least 6–7 years who Application of a bitter and malodorous chemical like
wants to break the habit asafoetida, Cayenne pepper dissolved in a volatile
but is unable to do so liquid may be used
Restrictive methods
Application of bandages to thumb, finger, elbow may
be done. Bandages on the thumb will take away the
pleasure from the act. Bandaging the elbow will prevent
bending the elbow to suck thumb
These appliances should Intraoral appliances
be used in age group of Palatal cribs, spurs
3½–4½ years
Corrective In late mixed or Expansion appliance like quad-helix with spurs
therapy permanent dentition
when the malocclusion
has set in
Beta hypothesis31
Dr Knight Dunlap (1929)30 of Johns Hopkins University discovered
the concept of negative practice. It is interesting to know that he used
to repeatedly make a typographical error in typing the word ‘the’ as
‘hte’. One day, he decided to start typing ‘hte’ instead of ‘the’. A few
days later, he serendipitously discovered that his often made
typographical error was self-corrected! Thus was born the concept of
‘negative practice’ or ‘beta hypothesis’. When applied to oral habits, a
child is encouraged to watch himself in a large mirror while sucking
digit. The sight of oneself sucking thumb will hamper the pleasure
derived from the activity, and the child will slowly avoid indulging in
the same.
In addition, the orthodontic appliance therapy is recommended
which includes habit breaking fixed and removable type of
appliances.
The tongue is a powerful muscular organ which exerts tremendous
pressure during swallowing at frequent intervals, 24 h a day, during
the sleep time as well as during the day.
In tongue thrusting habit, a normal-sized tongue or one that is
overdeveloped thrusts itself between the upper and lower teeth each
time the patient swallows, producing an anterior open bite.
Sometimes, the patient allows the tongue to rest in the open bite space
between the act of deglutition, preventing the bite from closing.
Tongue thrusting also permits the molars to supraerupt, a condition
which further complicates the problem of correcting open bite, even if
tongue thrusting habits have been corrected32–34 (Figs. 11.2C and 11.6).
Rix (1953)35 recognised two sharply contrasting types of tongue
behaviour:
1. The non-dispersing behaviour of the tongue. Those cases in

which the tongue does not come forward to exert any force on
the lingual surface of upper and lower incisors. The lips may
or may not contract excessively. The upper and lower incisors
are upright or retroclined.
2. Dispersing behaviour of the tongue. Those cases in which the
actions of tongue and lips are associated with a dispersal of
upper and lower incisor relations.
Causes of tongue thrusting

Maturational factors
Tongue thrusting may develop as a sequel of prolonged thumb
sucking and retained infantile swallow. A transitional period from
infantile swallow to mature swallow also exhibits tongue thrusting.
Anatomic factors
A large tongue cannot be contained in normal volume of the oral
cavity or a narrow oral cavity cannot accommodate a normal sized
tongue leading to tongue thrust habit. A true anatomical cause of
tongue thrust habit is macroglossia. The enlarged tongue exerts
pressure against the lingual surfaces of the anterior teeth, causing
them to become spaced. Indentations on the tongue often appear
where the tongue pushes against the teeth. Adenoids and tonsils
cause the tongue to be positioned anteriorly to prevent blocking of the
oropharynx.
Tongue thrusting is also called an adaptive behaviour. If large
spaces are present anteriorly in the upper and lower teeth, then the
tongue will try to move into these spaces to achieve the anterior seal.
Types of tongue thrusting

Moyers36 classified tongue thrusting into three types:
1. Simple tongue thrusting: Characterised by teeth together

swallow.
2. Complex tongue thrusting: Characterised by teeth apart
swallow.
3. Retained infantile swallow.
Clinical features of tongue thrusting swallow

The clinical features seen in the tongue thrusting condition are
dependent on the type of tongue thrusting:
Simple tongue thrusting (Fig. 11.6)

Generalised spacing and proclination may be seen in the upper and
lower anterior teeth.
FIGURE 11.6 (A,B,C) Anterior open bite caused by tongue thrusting
habit. (A) at rest (B) initiating of swallowing (C) tongue thrust position,
tip of the tongue resting on lower incisor and protruding through the
open bite.
Increased overjet, reduced overbite or presence of an anterior open

bite may be seen.
Exaggerated perioral musculature activity during the swallowing
action.
Simple tongue thrust is usually associated with a history of digit
sucking.
Correction of malocclusion will correct the habit.
Complex tongue thrusting

Complex tongue thrust is a more complicated type of swallowing
pattern associated with chronic nasorespiratory issues such as mouth
breathing, tonsillitis, or pharyngitis.
When the tonsil is inflamed and enlarged, the root of the tongue
exerts a force on the tonsil and causes pain. To avoid pain, tongue is
postured forward which also facilitates the airway space for
breathing. In the complex tongue thrust, the mandible is stabilised by
the tongue. Hence, combined contractions of the lip, facial, and
mentalis muscles, and a lack of contraction of the mandibular
elevators are found. The tongue spreads laterally in between the
occlusal surfaces of upper and lower teeth. The malocclusion with a
complex tongue thrust has a poor occlusal fit and a generalised
anterior open bite.
Retained infantile swallow

The transition from the infantile swallowing pattern to an adult
swallowing behaviour occurs after 6 months, with tooth eruption. The
infantile swallow is retained suggesting that the transition to an adult
swallowing behaviour has not occurred.
Open bite may not conform to the anterior segment alone extending
to buccal segments and ordinarily, they occlude on only one molar in
each quadrant.
Diagnosis of tongue thrusting swallow
1. Extraoral examination shows an exaggerated perioral

contraction during swallowing. Increased vertical dimension
of the face due to over eruption of the molars into the freeway
space is evident.
2. Intraoral examination shows an appearance of open bite and
spacing between teeth. A forced tongue may cause gushing of
saliva through the spaced dentition (Fig. 11.7).
FIGURE 11.7 (A and B) Mild spacing in the upper anterior due to

abnormal tongue posture. (C) Saliva drooling out during swallowing
habit.
Interception and treatment of tongue thrusting

The approach to interception and treatment of tongue thrusting are
age and severity dependent. In children below three years, no active
intervention is instituted while children above this age can be trained
for tongue swallowing exercises. Tongue thrusting treatment would
necessitate that anatomic obstruction like macroglossia and enlarged
tonsils are taken care of by appropriate therapy in consultation with
ENT surgeon. An abnormally enlarged tongue could be associated
with a tumour/cysts in the floor of the mouth. These conditions
should be investigated and treated accordingly.
Modalities of treatments
Treatment of tongue thrusting requires a positive attitude and strong
desire by the patient to overcome abnormal habit supported with
suitable mechanotherapy instituted by the orthodontist. Some of the
commonly used removable appliances include upper Hawley’s plate
with tongue cribs, roller balls for tongue exercise (Fig. 11.8).
Modalities of treatment for tongue thrusting are outlined in Box 11.4.
FIGURE 11.8 Fixed habit breaking appliances (A). Fixed appliance

soldered on molar bands for tongue thrusting/thumb sucking (B). Pearl
exerciser fixed on molar bands for tongue thrusting (C). Lip bumper for
lower lip sucking.
Box 11.4 Management of tongue thrusting
Modalities
a. Reminder Palatal appliances
therapy Palatal cribs, spurs, palatal rolling ball
b. Corrective (i) Removal of obstruction
therapy Surgery for adenoids and macroglossia
(ii) Closure of anterior open bite, posterior open bite and/or anterior spaces with
either a fixed or removable orthodontic appliance
(iii) Tongue exercises
a. Elastic band swallow
The elastic band is kept on the tip of the tongue against the palate and
swallowing is practised
b. Water swallow
To keep water in mouth and a mirror in hand and swallowing is practised daily
c. Candy swallow
A candy is placed between the tongue and palate and swallowing is practised
d. Speech exercises
Patient practises syllables like c, g, h, k while keeping an elastic band between
the tongue and the palate
(iv) Lip exercises
Patient practices stretching of lips so as to achieve anterior lip seal
Altered mode of breathing through the mouth is an adaptation to
obstruction in nasal passages.37 The obstruction may be temporary
and recurrent. More often it is partial than complete. The airway
resistance may be enough to force the subject to breathe through the
mouth.
Causes of obstruction to nasal passages are:
1. Allergenic rhinitis
2. Enlarged tonsils or adenoids (Fig. 11.9)
3. Deviated nasal septum
4. Nasal polyps
5. Enlarged nasal turbinates.
FIGURE 11.9 (A) Enlarged tonsils. (B) The cephalogram shows

complete obliteration of upper airway due to enlarged tonsils and
adenoids. The gray line is suggestive of the upper airway, which is
blocked.
Effects of oral breathing on developing face and occlusion (Flow

chart 11.2)
FLOW CHART 11.2 Pathophysiology of mouth breathing following
reduced nasal breathing.
Long-standing nasal obstruction has adverse effects on the

craniofacial morphology during periods of rapid facial growth, more
so in children with dolichocephalic facial pattern. A nasal resistance of
two to three times of the normal would be sufficient to alter the
pattern of respiration from nasal to oral, especially during the night
when a person is in the supine position. Daytime borderline cases may
become mouth breathers during night.
A majority of the mouth breather patients develop class II
malocclusion. Enlarged tonsils may force the child to posture the
mandible and tongue much forward to facilitate breathing leading to
class III occlusion.
Oral respiration also leads to excessive vertical eruption of the
buccal teeth in response to a lack of occlusal contacts. The over
erupted teeth exert a downward vector of force on the mandible,
causing the lower jaw to rotate down and back in a ‘clockwise’
direction. According to the ‘compression theory’, given by Norland
(1918),38 constriction of the maxillary arch is related to lowered
posture of the tongue which happens due to nasal obstruction to
facilitate breathing. A lowered tongue is less capable of balancing the
lateral pressures of the cheek muscles on the maxillary arch. The
pressure differential across the hard palate in the absence of nasal
airflow further contributes to a narrow, high-arched hard palate.
Adenoid facies was the term coined by C. V. Tomes (1872) to describe
dentofacial changes associated with chronic nasal airway obstruction.
Studies by Linder-Aronsen, in the 1970s and 80s39–42 over two
decades, have confirmed the relationship between nasal obstruction
and abnormal craniofacial and dental patterns. Subjects with nasal
obstruction have an increased lower anterior face height associated
with unfavourable ‘clockwise’ rotation of the mandible in a more
vertical and posterior direction, open bite, buccal cross-bite, and
retrognathia. In growing patients the following adenoidectomy,
changes could reverse to normal once and nasal breathing is
established.
Harvold43,44 through classical studies on artificially nasally
obstructed monkeys suggested that neuromuscular alterations
maintain an open oral airway contributed to the abnormal skeletal
and dental changes by affecting normal growth. These changes
showed patterns of dentofacial adaptations dependent upon the mode
of respiration. Elongation of their face with the development of
malocclusion was found in monkeys who maintained their airway
oral breathing by protruding and lowering the mandible.
Solow and Kreiborg (1977)45 put forward the soft tissue stretch
theory in which they suggested that the obstruction to the airway is a
major causative factor in determining the facial morphology (Flow
chart 11.3) and head posture.
FLOW CHART 11.3 Stretch theory by Solo and Kreiborg illustrating
the development of mouth breathing.
According to Cheng,46 impacts of the severity of nasal obstruction

may have varying adverse effects on the facial development, and this
may vary in different facial types. A brachycephalic or broad-faced
pattern with strong facial musculature and a deep bite may be less
affected by nasal obstruction, whereas preexisting dolichocephalic
pattern with a narrow, more elongated craniofacial pattern may be
more susceptible to these changes due to adverse influences of nasal
obstruction.
Clinical features
The term Respiratory Obstruction Syndrome was used to describe the
constellation of characteristic features associated with obstruction of
the nasal airway during the years of facial growth. Other standard
terms are the Long Face Syndrome and Vertical Maxillary Excess
(VME).47
The clinical features of adenoid facies include:
• Excessive lower anterior face height
• Incompetent lip posture
• The excessive appearance of maxillary anterior teeth, ‘gummy
smile’
• A nose that appears to be flattened, nostrils that are small and
poorly developed
• Steep mandibular plane
• Posterior cross-bite
• Open-mouth posture
• A short upper lip and a fuller lower lip
• A narrow V-shaped upper jaw with a high narrow palatal
vault
• A class II skeletal relationship
• Gingivitis of upper anterior teeth
Above features contribute to ‘adenoid facies’. Diagnosis of mouth

breathing is based on the history of open mouth by the care givers and
clinical features as described earlier.
Clinical assessment of mode of respiration

1. Water holding test: The patient is asked to hold water in his
mouth. Inability to keep the mouth closed for more than 2 min
confirms nasal obstructions and therefore mouth breathing
habit.
2. Mirror condensation test: A two-surface mirror is placed under
the nose. If the upper / nasal surface condenses, then breathing
is through the nose, but if the condensation occurs on the
lower / oral surface, then the breathing is through the mouth.
3. Cotton wisp test: A small wisp of cotton (butterfly shaped) is
placed below the nostrils in a butterfly shape. A careful
observation of the moving fibres of cotton will suggest
breathing pattern. If the upper / nasal side of fibres are
displaced, then the breathing is through the nose. If the lower
cotton / oral side of fibres are displaced, then it is mouth
breathing habit.
Lateral view may show a presence of enlarged adenoids, tonsils and
obstruction in the pharynx.
Cephalometric analysis for nasopharyngeal airway show altered
parameters suggestive of a vertical growth pattern and narrow
pharyngeal space. These parameters are discussed in great detail in
the chapter on ‘Obstructive Sleep Apnea’.
VME cases also exhibit typical cephalometric features that make a
ready diagnosis.
Rhinomanometric examination
Nasal resistance and airflow are measured with the help of a
rhinomanometer. Nasal resistance is 0.36 ± 0.21 Pa/cm3/s for healthy
children and higher in nasal disease children 0.56 ± 0.75 and decreased
with age.48
A high value of nasal resistance signifies nasal obstruction and
mouth breathing.
Simultaneous nasal and oral respiratory technique (SNORT).
SNORT is a highly accurate method for quantifying respiratory mode,
wherein both nasal and oral respiration are simultaneously recorded
and calibrated. The apparatus for such measurement consists of a
Plexiglas chamber in which the subject’s head is enclosed. The
apparatus is a series of valves, flowmeters, differential air pressure
transducers, and a physiograph for the recording of respiratory
activity. The readings of both oral and nasal respiration are registered
in waveforms which can be later converted into a digital format. The
modern equipment and associated computer configuration permits a
temporal characterisation of inspiratory and expiratory parameters of
both nasal and oral airflow, nasal airway resistance computation at
predetermined flow rates, and the calculation of estimates of the
minimum cross-sectional area of the nasal air passage.
Effective orthodontic therapy necessitates elimination of the nasal
obstruction to allow for normalisation of the function of facial
musculature surrounding the dentition and normal development of
the facial bones. An orthodontist must communicate to an
otolaryngologist if he/she finds mouth breathing habit and seek
his/her opinion before considering any orthodontic or habit breaking
treatment. The cause and effect relationship between nasal obstruction
and orofacial development has now been clearly documented
although genetic predisposition to narrow respiratory passage is now
well understood. Early intervention to enhance nasal breathing is now
an accepted mode of therapy in cases of established cause of
obstruction. If instituted early during childhood much of the adverse
effects of craniofacial growth are reversed.49 Various orthodontic
appliances have been designed to discourage mouth breathing and
encourage nasal breathing. Oral screens have been used previously for
this purpose.
ENT perspective
Adenoidectomy with or without tonsillectomy is a most common
treatment for nasal obstruction in children in established cases.
Allergic rhinitis with turbinate hypertrophy should be treated with
partial inferior turbinate resection, either with electrocautery or
cryosurgery.
Timing of surgical interventions should be chosen with great care
for the management of mouth breathing.
Adenoidectomy/adenotonsillectomy does not have significant benefits
when performed early (less than 4 years or in the primary dentition)
compared to later in childhood as far as skeletal growth is
concerned.50 Another study also favours the delay in surgical
intervention for obstructed airway because with increasing age, the
severity of obstruction gets partially compensated with growth.51
Management of mouth breathing requires a close consultation with
an ENT surgeon. Fig. 11.10 shows remarkable improvement in
nasopharyngeal and oropharyngeal airway after adenotonsillectomy.
The mandible is also postured in better position to facilitate breathing.
FIGURE 11.10 (A) Improvement in nasopharyngeal and oropharynx

airway after adenotonsillectomy. (B) The mandible is also postured in a
better position to facilitate breathing.
Essentially, maxillary expansion without extrusive mechanism is

the answer to expanding the narrow maxilla. Rapid maxillary
expansion (RME) has been reported to reduce nasal resistance and
promote nasal respiration.
Bruxism
Bruxism in the simplest term refers to the clenching and gnashing of
the teeth against each other. Ramfjord and Ash52 described it as
nocturnal, subconscious activity but can occur in the day or night and
may be performed consciously or subconsciously. Sleep bruxism is an
entity that is very common with children. The adults may bruxise in
either day or night.
Aetiology
Emotional tension seems to be the major cause of bruxism. Occlusal
interferences such as due to faulty restorations can initiate bruxism.
Childhood bruxism may be related to other oral habits such as chronic
biting and chewing of toys and pencils, thumb- and finger-sucking,
tongue thrusting, and mouth breathing. Endocrine disorders,
particularly those relating to hyperthyroidism, may lead to bruxism.
Many hyperkinetic children also have a habit of bruxism.
Gastrointestinal disturbances from food allergy can cause chronic
abdominal distress leading to bruxism.
• Persistent, recurrent urologic dysfunction may be responsible

for nocturnal bruxism.
• Nutritional and vitamin deficiencies are possible factors for
inducing tooth grinding.
• Athletes indulge in bruxism due to increased muscular
activity.
• Allergy plays a definite role in nocturnal bruxism as evidenced
during exacerbations of perennial allergic rhinitis, asthma
attacks, upper respiratory tract infections, and excessive
exposure to pollens, etc.53
• Neurological disturbances like lesions in the cerebral cortex,
epilepsy are also associated with bruxism.
Clinical features
• Teeth that are abnormally worn down, flattened or chipped
• Atypical occlusal facets—worn tooth enamel, exposing the
dentin of the tooth.
• Increased tooth sensitivity
• Jaw pain or tightness in the jaw muscles
• Earache because of severe jaw muscle contractions
• Headache and chronic facial pain
• Chewed tissue on the inside of the cheek
• Hypertrophy of masseter muscle
• Teeth grinding and clenching.
Nail biting
• Nail biting (NB) or onychophagia is ‘putting one or more
fingers in the mouth and biting on nail with teeth’.54 It usually
starts after 3 or 4 years of age and increases from childhood to
adolescence, and then decreases in adulthood55,56 In a group
of patients with temporomandibular joint pain and
dysfunction, nail biting was found in about 24.1% subjects.57
Aetiology
• Emotional tension seems to be the cause of NB.
• Genetic58 and environmental factors are associated with NB
onset and severity.59
• NB may be associated with psychiatric disorders. Three most
common co-occurring psychiatric disorders in clinical sample
children with NB are attention deficit hyperactivity disorder
(ADHD) (74.6%), oppositional defiant disorder (36%) and
separation anxiety disorder (20.6%).60
Complications
• Gingival infections (swelling, abscess)
• Increased carriage of Enterobacteriaceae and Escherichia coli
• Trauma (to nail bed or nail matrix) or infection can cause
increased rate of nail growth, nail bed shortening, herpetic
whitlow, acute paronychia and acute osteomyelitis
• Apical root resorption
• Malocclusion, crowding of incisors
Management of nail biting

Non-pharmacological and pharmacological both methods are used for
management of NB.
Non-pharmacological management of nail biting
1. Punishment of the child is not suggested for the management

of NB. When the child realises that the parents have noticed
the habit, he or she certainly will insist on it, to become the
focus of attention.61
2. Mild cases / infrequent nail biting requires no treatment.61 For
serious cases, treatment should involve removal of the
emotional factors inducing the habit, and more attention,
affection and support to the affected child may help. However
parent’s education might be the best treatment for these
children.62
3. Apply bandages to patient’s fingers and application of a bitter-
tasting material helps.63
4. Busy hands-on activity such as handicrafts or a musical
instrument, might also be effective in keeping the hands away
from the mouth.
5. For enhancing child’s self-confidence and self-esteem, a
multidisciplinary approach should be used.
Pharmacological management of nail biting

Pharmacological agents like selective serotonin reuptake inhibitors
(SSRI), tricyclic antidepressants (TCA), N-acetyl cysteine (NAC),
dopamine agonists, and lithium have been studied for NB. However,
one randomised double-blind study on NAC compared with placebo
found that it was not superior to placebo.64
Lip biting
Lip biting habit is often associated with signs of anxiety or nervous
behaviour and could be associated with a large overjet. When the
overjet is large, the lip is trapped between labial surfaces of the lower
incisors and protruded upper incisors leading to lip trap and excessive
activity of the mentalis muscles to attain lip seal during functions of
swallowing. The consequence are upright or lingually inclined lower
incisors which worsens the malocclusion.
Lip biting habit could lead to injury on the lower lip, ulcers,
haematoma and other painful conditions.
The lip sucking is little different from lip biting which is often
associated with lip trap. Lip trap and overjet could be the outcome of
the lip sucking or overjet could lead to lip trap and worsening of
overjet.
These children would need treatment based on the aetiology of
malocclusion. The lip trap and excessive lip activity can be helped
with a lip bumper (Fig. 11.8C),65 which prevents lip pressure on the
lower incisor; their labial position gets normalised with tongue
pressure. The lost arch length can also be gained with this method.
Key Points
Development of mature and complex orofacial functions progresses
slowly yet meticulously through various age-related phases from
infancy to adulthood. In the formative years, infantile and altered
orofacial functions may remain for an unusually longer period, such
that they become a habit.
The deleterious habits should be managed in a holistic approach
based on their aetiology. The de-veloping malocclusion should be
intercepted and treated accordingly.
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SECTION IV
Orthodontic diagnosis
Chapter 12: Clinical evaluation

Chapter 13: Diagnostic records and their evaluation
Chapter 14: Practical clinical photography
CHAPTER 12
Clinical evaluation
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Comprehensive clinical evaluation is fundamental to
diagnosis
Face features of normal growth during early years of life
Facial asymmetry
Features of malocclusion in deciduous dentition
Primate spaces
Edge-to-edge incisor relation/negative overjet
Posterior cross-bite
Signs of potential malocclusion just before eruption of
permanent incisors
Leeway space and incisor liability
Clinical assessment of a child with developing or established
malocclusion
Orthodontic evaluation of a child during mixed dentition
stage
Dentition and occlusion
Normal physical growth
Examination of face
Overall shape of face and cephalic index
Facial symmetry
Examination of face in profile
Evaluation in vertical dimensions of face in lateral profile
Gonial angle
Transverse facial proportions
Examination of nostrils
Examination of zygoma or cheekbones
Nasolabial angle
The lips
Smile position lip level
Lower lip
Chin button
The labiomental sulcus
Dynamics of smile and its orthodontic implications
Nature of smile
Evaluation of smile
Tenderness on palpation
Joint sounds
Range of motion
Trauma and dislocation
Speech and malocclusion
Parts of speech
Assessment of speech in relation to malocclusion and
dental anomalies
Dental alignment and speech
Lip seal
Velopharyngeal seal
Anomalies of tongue
Clinical examination of child for suspected deleterious habit(s)
Intraoral examination
Frenum
Palate
Tongue
Examination of oral health and periodontium
Failure of eruption
Clinical assessment of an adult seeking orthodontic treatment
Key Points
Introduction
Comprehensive clinical evaluation is
fundamental to diagnosis
Diagnosis in orthodontics is unlike medicine. Orthodontic diagnosis
involves recognition of a condition of malocclusion, its severity and a
background plan to normalise the condition of malocclusion in the
context of the patient’s age, sex, chief concern, oral health and ethnic
origin. The diagnosis and treatment planning are often interlinked
and can be influenced by a multitude of considerations such as social
and financial limitations of the individual and psychological profile to
name a few.
Diagnosis and treatment planning in orthodontics are intricately
linked and overlap in their entire process. Comprehensive diagnosis is
fundamental to any plan of treatment and its successful execution.
‘Eyes cannot see what brain does not know’ truly implies in
orthodontics. An orthodontist should have a deep understanding of
one of the most intricate and complex systems of the body,
‘stomatognathic system’ to visualise abnormalities in anatomy and
function.
The stepwise process of diagnosis is discussed in two parts: (1)
clinical examination and evaluation and (2) interpretation of
diagnostic records and investigations.
Patient’s history, a detailed social, personal, medical and dental
history, should precede any clinical examination. It is important to
know the developmental milestones of a young child. The physical
development of the child vis-à-vis his/her chronological age, skeletal
age and dental maturation is of great importance. The child’s social
and personal history aims to elicit concern for the dental and
orthodontic care, number of siblings in the family, any history of
orthodontic treatment of parents or siblings, socioeconomic status and
attitude. Information is gathered with respect to:
• Height to weight
• Obesity
• Any sickness/or any medication
• Juvenile diabetes
• Psychological problems
• Performance in school
• Any adjustment problems
• Family: single/divorced/happy family and not so happy family
The medical history is elicited to rule out any systemic or local

disease, which may adversely affect the growth of skeletal system,
craniofacial structures, muscles, dentition and occlusion. History is
also helpful in identifying environmental factors related to nutrition,
growth status, dental/oral health, caries, breathing pattern and
deleterious habits that might influence the development of occlusion.
The family history of orthodontic treatment and evaluation of
parents, siblings for their facial forms, occlusion and malocclusion
may give clues on the child’s facial form when he/she grows into
adulthood. History of a familial disease, which may interfere with
normal development of face, teeth and jaws, should be elicited.
Facial forms and malocclusions that have a strong familial tendency
are:
• Severe deep bite

• Class II division 2 pattern
• Skeletal open bite
• Mandibular prognathism
• Bimaxillary protrusion
• Mandibular retrognathism
• Severe crowding/spacing
• Median diastema
Common problems of familial origin/genetics affecting face and

jaws are:
• Cleft lip and/or palate
• Ectodermal dysplasia
• Cherubism
Common problems of familial origin affecting dentition:
• Peg-shaped or missing lateral incisors

• Hypodontia, Anodontia, Oligodontia
• Supernumerary teeth
• Macro or microdontia
• Amelogenesis imperfecta/dentinogenesis imperfacta
History of orthodontic treatment in either of the parents should

warrant a watch for possible malocclusion in the offspring under
examination.
Clinical assessment of a child with a potential for malocclusion
An orthodontist may often be encountered with a standard question
by the parents, ‘Is my baby going to have braces when he/she grows
up?’
In a clinical setting, this is a rather simple question asked by the
parents but one that is most difficult to answer even by a very
experienced clinician. To be precise, such a question can only be
answered after obtaining a detailed history and clinical examination
of the child. It is of utmost importance that the findings elicited on
history and clinical examination should be supplemented with
diagnostic investigations to reach a definitive conclusion. However, in
certain situations where the child is still growing, the occlusion is not
entirely established, one may not be able to give a definitive answer.
In such a situation, one may like to wait and watch for the occlusion
to establish and the deformity to develop to its fullest extent. Clinical
examination is a critical component of diagnosis. The clinical
assessment of a child with a potential for malocclusion can be broadly
grouped according to the developmental stages of the child, his/her
face and dentition.
Orthodontic evaluation at any stage of a child’s growth involves:
• Physical development and skeletal growth
• Development of face and jaws
• Development of dentition and occlusion
• Occlusal relationships in centric occlusion and function
• Normal/altered functions of the stomatognathic system
• Examination of tongue
• Recurrent throat infections
Face features of normal growth during early

years of life
A newborn child’s face appears flat at birth with the head occupying a
considerably larger dimension compared to the face and a receding
chin. By 3 years, the child has a head closer to that of adult size, and
after that, the changes in the head size are minimal. In contrast, the
face grows rapidly in all three dimensions, that is, in width
(transverse), length (sagittal) and in height (vertical) between the ages
of 3–6 years. The facial convexity is reduced, while the chin is trying to
catch up with the maxilla. The condylar growth exceeds that of
vertical descent of maxilla, and therefore, the mandibular plane angle
remains nearly unchanged. A cephalogram will show a rather large
ANB (close to 5 degree) compared to adults (2 degree), and therefore
some facial convexity is acceptable.
In general, by 36 months, all deciduous teeth have erupted, and
deciduous occlusion is fully established. The deciduous incisors are
more upright compared to their permanent successors and their
crowns appear rather wide due to the relatively short crown height.
Overjet and overbite are minimal. The deciduous molars show a
mesial step or a flush terminal plane. Often spaces of about 2–3 mm
are seen mesial to the deciduous canines in the maxilla and distal to
the deciduous canines in the mandible. These spaces are known as
primate spaces (Fig. 12.1).
FIGURE 12.1 (A, B) Primate spaces: these are often found distal to
deciduous lateral incisor in the maxilla and deciduous canine in the
mandible. First described by Baume 1950.
Features of potential malocclusion
• Absence of primate spaces

• Severe proclination or a large overjet
• Reverse overjet
• Functional shift
• Intensive thumb sucking habit
Above features in deciduous occlusion are rather unusual and

should be viewed as a precursor to future malocclusion. A reverse
overjet in the deciduous dentition stage should be viewed with a
suspicion for the habitual forward posture of the mandible or a
skeletal class III malocclusion.
A child’s face should be examined from the front as well as from a
lateral profile view. A very young child may not permit a formal
evaluation, which can be carried out while he/she is kept busy with
toys and play. The following characteristics of the facial form,
dentition and/or presence of environmental aetiological factors should
alert for a possible need for detailed examination/need for further
observation in the future interception for malocclusion.
Gross abnormalities of facial form are shown in Tables 12.1–12.3
Table 12.1
Syndromes affecting face and jaws associated with mandibular deficiency and
class II malocclusion
Condition Features Aetiology
Hemifacial Unilateral dysplasia of the ear, hypoplasia of Most cases sporadic; few familial
microsomia mandibular ramus, cardiac and renal instances; pedigrees compatible with
(Goldenhar abnormalities autosomal dominant and autosomal
syndrome) recessive transmissions
Pierre Robin Micrognathia; cleft palate and glossoptosis. Heterogenous
sequence This condition may occur as an isolated
malformation complex or part of a broader
pattern of abnormalities
Treacher Dysplastic low set ears; downslanting Genetic/autosomal dominant
Collins palpebral fissures; micrognathia
syndrome
Table 12.2
Syndromes affecting face and jaws where midfacial deficiency is a major feature
and could present as class III relationship
Conditions Features Aetiology
Apert’s Craniosynostosis; midfacial deficiency; proptosis; Genetic/autosomal
syndrome hypertelorism; downslanting palpebral fissures; symmetric dominant
syndactyly of the hands and feet
Crouzon’s Craniosynostosis; maxillary hypoplasia accompanied by Genetic/autosomal
syndrome relative mandibular prognathism; shallow orbits; proptosis dominant
Achondroplasia Short-limbed dwarfism; enlarged head; depressed nasal Genetic/autosomal
bridge; lordosis; high palate dominant
Down Small cranium, midface and nasal bone depression, flat malar Genetic/trisomy 21
syndrome processes, upward slanting eyes, and strabismus
Table 12.3
Syndromes associated with mandibular prognathism

Condition Features Aetiology
Basal cell Macrocephaly; frontal and parietal bossing; Genetic/autosomal
naevus (Gorlin) prognathism; multiple jaw cysts; multiple basal cell dominant
syndrome carcinomas; bifid ribs
Klinefelter’s Mandibular prognathism; skeletal disproportion; Commonly XXY karyotype
syndrome gynaecomastia; small testes but XXXY and XXXXY also
occur
Osteogenesis Fragile bones; blue sclera; deafness; mandibular Autosomal dominant
imperfecta prognathism (common type)
Severe retrognathia/micrognathia
Small and backwardly placed chin could exist in isolation or one of
the features of a syndrome. Micrognathia is characterised by
mandibular hypoplasia causing a receded chin. It is found in about 1
per 1,000 births. Common defects associated with small mandible are
Pierre Robin sequence and Treacher Collins syndrome. Trauma
during birth, like injury by forceps delivery can cause damage to the
TM joint and cause delayed/impaired mandibular growth.
Pierre Robin sequence

This anomaly includes severe micrognathia, glossoptosis and
posterior cleft palate or an arched palate (Fig. 12.2). The cleft of the
soft palate along with a low postured and backwards positioned
tongue may cause difficulty in breathing and cyanosis in a newborn. If
cyanosis or respiratory problems persist in a newborn, tracheostomy
or surgery to fix the tongue in a forward position may be required.
The growth of the mandible usually catches up as the child grows.
FIGURE 12.2 Severe retrognathia: A child with severe

retrognathic lower jaw. Such a situation warrants detailed medical
examination by the paediatrician.
Pierre Robin syndrome sequence is a common cause of such a clinical
presentation. Pierre Robin sequence is associated with cleft palate,
mandibular retrognathia, and glossoptosis. This condition may occur as
an isolated malformation complex or part of a broader pattern of
systemic abnormalities.
Treacher Collins syndrome

Important features of the Treacher Collins syndrome are: a facial
appearance resembling that of a bird or fish, missing malar bone
prominence; eyes have a slant with palpebral fissures inclined
downwards. Radiographically, characteristic features are obliquity of
orbit, small malar bones and minuscule maxillary antrum.
Down syndrome
A prominent chin with hypoplastic maxilla could be suggestive of
Down syndrome. Down syndrome is a group of abnormalities that
occur in children who are born with an extra (third) copy of
chromosome number 21, the so-called trisomy 21, in their cells. It is a
relatively common congenital disability, affecting between one in 800
and one in 1,000 live births. A typical moon face characterise the
children with Down syndrome. Other features include a flat face,
slanted palpebral fissures, varying degrees of mental retardation,
cardiac defects, simian crease (single palmar line) and hypotonia. The
severity of symptoms varies widely from person to person, with the
degree of mental retardation ranging from mild to severe.
A prominent chin with or without a flat face (deficiency of middle
one-third of the face and lack of zygomatic bone prominence) calls for
a detailed examination of the mid face.
A prominent chin that is not habitual, that is, child closing his teeth
in centric occlusion with a reverse overjet, should alert the clinician to
suspect a skeletal mandibular prognathism.
Facial asymmetry
It may affect the whole of the face, or the lower face, which may show
up in the form of a deviated chin. Facial asymmetry can be seen in
many congenital disorders affecting face and jaws. These include
congenital defects such as the unilateral absence of a condyle,
agnathia, cleft lip and palate and devel-opmental abnormalities such
as the underdevelopment of one side of mandible due to trauma to
temporomandibular joint (Fig. 12.3).
FIGURE 12.3 Facial asymmetry.

A girl reported with chief complaints of gradually increasing asymmetry
of the face (A–C). She had unilateral condylar hyperplasia of the left
condyle that gradually caused a shift of the lower dentition and the
midline to the right side (D–F).
Ankylosis of the temporomandibular joint

It is the most common condition causing asymmetry in Indian
subcontinent, and is often related to an undiagnosed injury of the
TMJ, malunited fracture(s) of the TMJ or injury to TMJ during a
forceps delivery. The growth of the affected side of the mandible is
restricted, thereby resulting in a small corpus with a deviation of the
chin to the affected side. There would be a cant of the occlusal plane,
affected side being at a higher level. Severe forms can sometimes be
mistaken for agenesis of the condyle.
Features of malocclusion in deciduous
dentition
An anterior open bite and a superior protrusion are often associated
with prolonged thumb sucking or macroglossia (large tongue).
Primary true macroglossia is a rare entity. Macroglossia may be
secondary to systemic diseases, the commonest cause being
amyloidosis. Tongue may be pushed up due to pathological
conditions in the floor of the mouth. A large overjet is usually a
consequence of prolonged thumb sucking with the wrist resting on
the chin.
Primate spaces
Humans have a continuous tooth row (no spaces) in the adult
dentition. In about half of the children, however, there are diastemas
in the deciduous dentition. These correspond in location to the Ape
diastema. In the dental literature, these spaces are called as ‘primate
spaces’. In other words, primate spaces are naturally occurring spaces
in the ‘normal’, primary dentition, existing distal to the primary
mandibular canines and mesial to the primary maxillary canines.
These were first described in detail by Baume1–3 and later by Foster
and others.4–7 Facal-García5 recorded primate spaces in 3-year-old
Caucasians and found that the prevalence of spacing was more
frequent in males than in females. The presence or absence of spacing
was not directly related to occlusion except in cases of posterior cross-
bite, where it was less frequent, and open bites, in which spaces
appeared more often than usual. Ohno et al.6,7 recorded primate
spaces and interdental spaces in the deciduous dentition by sex and
arch in Indian children in Delhi aged 5–7 years. He also looked into
the relationship of these spaces with morphological characteristics of
the deciduous dental arches. The results were as follows:
There was a wide variation in the pattern of the interdental spacing.
Most common areas of spacing were mesial to the maxillary
primary canine (primate spaces) and distal to the mandibular primary
canine (developmental spaces) for the studied age group.
The mandibular primate spaces were considerably less frequent
than the maxillary ones.
A lack of primate spacing can be one of the indicators of insufficient
growth in the dental arches and hence, an indicator to the tendency
for the crowded dentition (Fig. 12.4).
FIGURE 12.4 A young girl, 3-year-old, with deciduous dentition

and occlusion.
(A–C) She has poor oral hygiene, there is presence of visible plaque,
and signs of cervical caries in the lower left canine. She has deep bite
and lack of spacing in the dentition. Such an occlusion has greater
potential for developing a malocclusion. High caries susceptibility, if not
controlled, will lead to carious teeth.
Attrition of the deciduous dentition allows a forward posturing of

the mandible in near edge-to-edge bite and freedom in jaw
movements and thereby enhances the growth of the mandible (Fig.
12.5).
FIGURE 12.5 Features of deciduous dentition at the age of 6

years.
(A–C) Spacing in the anterior dentition, edge-to-edge bite, and attrition
of the deciduous teeth are indicators of good alveolar growth and
sagittal forward repositioning of the mandible. Such a clinical situation
often leads to eruption of normal alignment of permanent teeth and
possibly a class I molar relation.
Edge-to-edge incisor relation/negative overjet

An edge-to-edge bite during primary dentition may be habitual or
functional. Such an incisor relationship warrants a detailed clinical
examination to rule out the functional for-ward shift from a true
mandibular excess. It also necessitates the consideration of the
morphology of mandible and chin for any signs of skeletal
mandibular prognathism. Such a case of class III malocclusion should
also be examined for deficiency of mid face, which is not an
uncommon finding.
Further evaluation of the parents and siblings is required for any
signs of class III skeletal/dental relationship. Either parents or a family
member may have a class III pattern of variable severity, that is, from
faint traces of prognathism in dentition/occlusion in the sagittal plane
to a well-established mandibular prognathism.
Posterior cross-bite
A posterior cross-bite of a single tooth should not be viewed with
suspicion towards incipient malocclusion. A unilateral posterior cross-
bite of two or more teeth may be associated with some amount of
deviation of the lower jaw to the opposite side and may show some
degree of midline shift. Unilateral posterior cross-bite may be the
outcome of a narrow maxilla associated with prolonged thumb or
finger sucking. Mouth breathing can also cause narrow maxilla and
thereby premature contacts with the mandibular teeth. The lower jaw
tends to avoid the prematurities resulting in a convenience swing of
the mandible occluding in unilateral cross-bite.
Signs of potential malocclusion just before

eruption of permanent incisors
Active growth of jaws coupled with the attrition of deciduous teeth
brings about the following alterations in occlusion. The crowns of the
deciduous incisors may further shorten, thereby worsening the width
to height ratio of deciduous crowns. The deciduous incisor crowns
may appear broad and short. There may be an edge-to-edge bite of
incisors, and lack of overjet, which also brings about a mesial step
relationship of the deciduous molars (Fig. 12.6). The anterior dentition
is spaced. Lack of spacing in the deciduous dentition, the presence of
overjet and a straight terminal plane are indicators of incipient
malocclusion. Children with such an occlusion need to be kept under
observation for the potential development of class II malocclusion.
FIGURE 12.6 Deciduous dentition and occlusion at 6 years.

(A–C) The dentition has attrition and edge-to-edge bite. Note the
mandibular central incisors have erupted without any crowding or
rotations. The molars are in class I occlusion relation, a sign of early
mesial shift, which in this case seems to be facilitated due to the
forward shift of mandible.
Several factors are associated with the transition to normal

occlusion in permanent dentition from an existing primary dentition.
Some naturally occurring indicators which must be clinically
evaluated are: spacing in dentition, primate spaces and, the terminal
plane relationship of the deciduous molars (i.e. straight/mesial
step/distal step), leeway space and incisor liability. According to
Baume, type 1 primary dentitions with wide spacing between the
teeth lead to a normal alignment of permanent dentition more
frequently than type 2 dentitions with closed contacts between the
teeth.
It has been reported in a long-term study that straight terminal
plane relationship may change into a class I molar relation in
favourable growth pattern cases or class II in children with
unfavourable growth8. A mesial step terminal plane is the most
beneficial situation for developing a dental class I relationship in the
permanent dentition. Distal step relationship is an indicator of future
class II molar relationship.
Leeway space and incisor liability

Leeway space is described as an excess arch length available
consequent to combined smaller mesiodistal widths of canines and
premolars to their deciduous counterparts. Leeway space amounts to
0.9 mm per side in the maxilla and 1.7 mm per side in the mandible
which plays a significant role in the development of class I molar
relation. Additional space is needed to accommodate large permanent
incisors compared to small primary incisors, and this is termed as
incisor liability. It averages 7.6 mm for the maxilla and 6 mm for the
mandible.
Clinical assessment of a child with
developing or established
malocclusion
Orthodontic evaluation of a child during
mixed dentition stage
By the age of 9–10 years, the growth of the skull and maxilla is nearly
complete. However, the mandible continues to grow in a downward
and forward direction till the completion of puberty. The maxillary
dentition accordingly descends to catch up with the mandible while
the mandibular teeth erupt to maintain an occlussal relationship.
The face should be evaluated at the frontal and lateral profile.
Lateral aspect reveals the pattern in a sagittal plane
(convex/straight/concave) whereas the frontal view indicates the facial
form (broad/average/narrow or square/oval/tapered) and symmetry.
Also, it should also be assessed for the vertical proportions by
measuring the anterior and posterior facial heights and their relative
proportions to each other. An increase in the anterior lower face
height should be reconfirmed with the associated steepness of the
mandibular plane.
Accordingly, the face may be categorised into normal, vertical or
horizontal types. The frontal examination should include an
assessment of the shape of the nose, the size of the nostrils, nose tip
and nasal bridge. Lips are examined at rest and during smiling. The
child should be carefully observed for any deviations and midline
shifts during jaw closure and at rest.

Rapid changes take place in the face and dentition with the eruption
of permanent first molars (6 years molars) and incisors. The
orchestrated events of shedding of deciduous dentition, the eruption
of permanent teeth, the growth of the underlying skeletal bases,
maturation and function of overlying soft tissue integument and
functional growth of the organs of respiration, mastication,
deglutition and speech are all under strong genetic control, more so
before birth.
After birth, the development of a normal occlusion is likely to be
influenced by environmental factors, which affect the normal physical
and skeletal growth of a child and development of the dentition.
Hence, a thorough understanding of physical growth, skeletal growth
and their association with the developing face is fundamental to
orthodontic diagnosis.
Another major contributor to the development of normal occlusion
is the integrity of deciduous dentition, which can be taken as a full
complement of deciduous dentition free from dental caries or the one
with proper restorations.
Premature extractions of deciduous teeth call for space maintenance
protocol to avoid space loss by the erupting adjacent teeth. The
conditions include loss of a tooth due to trauma. Establishment of
normal occlusion can only be facilitated by the presence of a full
complement of permanent teeth, with normal morphology and size.
These teeth should timely replace the shedding deciduous dentition.
The other major factors that can influence the development of
occlusion are the mode of respiration and behaviour of the tongue.
Normal physical growth

First and foremost, the clinical assessment of a child begins with a
look at his/her physical development and overall presentation in
behaviour. A child who is normal in height according to his/her
chronological age and not overly overweight or underweight is likely
to be free from any endocrinal/skeletal disorder that may influence
facial growth. (A record of weight and height related to age are used
for evaluation of physical growth).
Extraoral examination per se begins with the face in the state of
rest, occlusion and function. The child should be examined in an
environment, which is friendly (not threatening) and conducive to
understanding and enhancement of confidence in
dentist/orthodontist. It may be a good idea to spend a few minutes
talking to parents and child in the waiting room or in consultation
room on a subject that might interest a child and indulge him in
conversation. This would help elicit information on socio-cultural
aspects of the child and his family. Conversations like ‘How are you
doing?’, ‘Have you had to miss your work to make this
appointment?’, ‘How far is child’s school from house?’, ‘How did you
travel to reach the clinic?’ and similar conversation give multifold
benefits. It gives you time to understand the child and his parents
along with an opportunity to observe the child, his face, action of lips,
posture during smile and rest. It will give you information on their
concern about the malocclusion, reason for visiting the office, concern
for the problem, their attitude, and awareness about orthodontic
treatment and oral health. The number of siblings and the nature of
the job of the parents provide some information on the parent’s
possible motivation for an orthodontic consultation.
Examination of face
Examination of the face should preferably be carried out with a child
sitting upright on a chair/or standing straight and not on a reclining
chair, as it will not give you the best view of the frontal and lateral
profile. There are several ethnic/racial variations of facial forms.
Facial characteristics of each person are unique to him in many
ways; therefore, the consideration of their ethnic/racial features has to
be kept in mind. For example, a Mongoloid face seen from a frontal
profile would be certainly different from an African and both would
be different from a Caucasian. While examining the child from the
frontal view, the child should be relaxed, and the examiner should
stand in front of the child and look for the following.
Overall shape of face and cephalic index

The overall shape of the face, including skull may fall in one of the
three types:
• Long and thin which is often associated with the ectomorphic

body type.
• Broad and square could be associated with the endomorphic
body type.
• Ovoid face (between A and B) is usually seen in meso- or
endomorphic body types.
Mongoloid’s faces are broad and flat while Africans and Islanders
may show thick lips and prominent cheekbones, with the Caucasians
falling in between the two. The shape of the head can be objectively
evaluated by using the cephalic index.
Cephalic index
Cephalic index is a ratio (in percentage) of the maximum breadth to
the maximum length of the skull or head.9 The principle employed by
Anders Retzius10 was to take the longer diameter of the head, the
anteroposterior diameter, as length. If the shorter or transverse
diameter (width) falls below 75%, the skull may be classified as long
(dolichocephalic), while if it exceeds 80%, the head is broad
(brachycephalic). There are population differences in head forms that
influence the face type (Fig. 12.7).
FIGURE 12.7 Cephalic index.

(A) Dolichocephalic. (B) Mesocephalic. (C) Brachycephalic.
The individuals who are having a dolichocephalic head type also

have a proportionately narrower and longer face than those with a
brachycephalic head form. Their cranial base flexure is more open or
flat, resulting in a protrusive upper face and a retrusive lower face.
They have a tendency for class II malocclusion. These features are
characteristic of Caucasians. The opposite, that is, a closed cranial
flexure usually characterises the brachycephalic head, which
embodies a wider, flatter, more upright type of face. The face appears
broad and flat with a tendency for class III type of malocclusion and a
prognathic mandible or a bimaxillary protrusion. There are many
combinations of dolichocephalic, and brachycephalic head forms.
Some authors have used the terms, ultra-dolicocephalic hyper-
dolichocephalic, hyper-brachycephalic and ultra-brachycephalic for
extreme facial types (Table 12.4).11
Table 12.4
Head classifi cation according to the cephalic index

Ultradolichocephalic x–64.9%
Hyperdolichocephalic 65.0–69.9%
Dolichocephalic 70.0–74.9%
Mesocephalic 75.0–79.9%
Brachycephalic 80.0–84.9%
Hyperbrachycephalic 85.0–89.9%
Ultrabrachycephalic 90.0–x%
Cephalic index
Facial index
In anthropometry, facial proportions are described as index of
morphological facial height, measured from the nasion (N) to
gnathion (Gn) anatomical landmarks, divided by the bizygomatic
width, measured from the right to the left zygion (Zyr–Zyl).
The terms used in the facial index are derived from Greek, where
the word for face is prosopon. According to this classification system,
numerical values given in table describe the face as euryprosopic,
mesoprosopic and leptoprosopic.
Facial index is calculated as given in Figs. 12.8, 12.9 and Table 12.511
FIGURE 12.8 Facial index: calculated as the ratio between the

morphological face height (N–Gn) and bizygomatic width (Zyr–Zyl). (A)
Euryprosopic face; (B) mesoprosopic face and (C) leptoprosopic face.
Source: Reproduced with permission from Franco FC, de Araujo TM,
Vogel CJ, Quintão CC. Brachycephalic, dolichocephalic and
mesocephalic: Is it appropriate to describe the face using skull
patterns? Dental Press J Orthod. 2013 May–Jun;18(3):159–63.
FIGURE 12.9 Skull classified as hyperleptoprosopic (facial index =

96.2%) in relation to its predominantly vertical facial morphology (A)
and hyperbrachycephalic (cranial index = 87.3%) in terms of shape (B).
Source: Reproduced with permission from Franco FC, de Araujo TM,
Vogel CJ, Quintão CC. Brachycephalic, dolichocephalic and
mesocephalic: Is it appropriate to describe the face using skull
patterns? Dental Press J Orthod. 2013 May–Jun;18(3):159–63.
Facial symmetry
Examination of the face should include evaluation of the symmetry of
the structures of the right and left side of the face. Some degree of
facial asymmetry is seen in nearly everybody and is considered
normal since the right, and left sides of the face are not exact mirror
images of each other. It is important that facial symmetry should be
examined both in the rest position of the mandible and in occlusion.
Midline of nose, lips, chin and face should be co-incident. Deviated
nostrils and nose are frequently seen in operated cases of cleft lip and
palate. If the deviation of chin appears from rest to centric position, it
is indicative of premature contact on the functional closure of the
mandible.
Table 12.5
Face classification according to the facial index

Hypereuryprosopic x–79.9%
Euryprosopic 80.0–84.9%
Mesoprosopic 85.0–89.9%
Leptoprosopic 90.0–94.9%
Hyperleptoprosopic 95.0–x%
Facial index%
Facial asymmetry may exhibit itself as a deviation of the chin to

either side. The face usually appears smaller on the one side or larger
on the contralateral side. A deviated chin to either side, both in
occlusion and rest position should alert the consultant to look for
either deficient growth of the lower jaw on one side (which is usually
the side which appears normal) or excessive growth.
Size and distance of eyes from the midline of the face is of
significant importance. A decrease in the interorbital distance
(hypotelorism) or an increased distance (hypertelorism) should be
carefully noted. In healthy subjects, the width of the base of the nose
should be approximately the same as the inter-inner-canthal distance,
while the width of the mouth should approximate the distance
between the irises.
One of the important parts of facial examination is to note the
relationship between skeletal and dental midline since this cannot be
determined from the dental casts. The relationship of the dental
midline of each arch to the skeletal midline of that jaw is evaluated,
that is, the lower incisor midline is related to the midline of the
mandible, and the upper incisor midline is related to the midline of
the maxilla and all are related to each other.
Evaluation of symmetry is best performed by examining a face from
under the chin while the head is tilted backwards. Such a view is
necessary for the assessment of the facial asymmetry particularly of
the nostrils zygoma and upper lip (Fig. 12.8).
Examination of face in profile

The examiner should stand at the side of the patient while the patient
is asked to stand and look straight preferably into a mirror. An
imaginary line is drawn connecting the bridge of the nose, the base of
the nose and the chin. The nose can be a big distractor; smaller noses
tend to mask retrognathic face to look straighter, while a very
prominent nose gives a false feeling of a convex profile in an
otherwise normal profile. The facial profile could fall in one of three
types (Fig. 12.10A–C, Box 12.1).
FIGURE 12.10 (A) Convex profile. (B) Orthognathic profile. (C)
Concave profile.
Box 12.1 Examination of face
Lateral
view
Profile Convex h/straight h/concave h/bimaxillary protrusion h
Nose Small h/normal h/prominent h
Nasal Normal h/deep h/flat h
bridge
Chin Recessive h/normal h/prominent h
Ears Their shape, size and any abnormalities. (Occasionally ear tags and some minor
malformations of the ear are seen which may need correction with plastic surgery at
appropriate age)
Nasolabial Acute h/normal h/obtuse h
angle
Labiomental Normal h/flat h/deep h
sulcus
Vertical Face height at lower third: normal h/increased h/decreased h
FMA Average h/large h/small h
Gonial Large (open) h/small (close) h/Normal h
angle
Lower Any signs of deformity h/abnormal contours h
border of
mandible
Mark 3 for the observation,
FMA = Frankfort Mandibular plane Angle
Convex profile
The chin is recessive, and the upper lip is prominent. It is obvious that
a line drawn from the three points (nasal bridge, upper lip, under the
nose and chin) would make an angle at the base of the nose. A convex
profile may be just a posterior divergent pattern when the chin is
recessive. It may make a straight line from the nasal bridge to the base
of the upper lip to the chin. However, if the straight line falls
backwards towards the neck, then it is called posteriorly divergent.
Convex and posteriorly divergent profiles are features associated with
skeletal class II malocclusion, which may be present in isolation or a
combination of various degrees of the maxillary protrusion and
mandibular retrusion.
Straight profile
A line is drawn from the nasal bridge to the base of the nose and the
chin, which makes a straight line and is nearly vertical, slightly
posteriorly divergent or anteriorly divergent. This characterises a
straight profile.
Concave profile
A concave profile is associated with a mandibular protrusion or
retrognathic maxilla or both. In lateral view, a line connecting base of
nasal bridge, bone base of nose and chin makes an acute angle at the
base of nose outside and obtuse angle towards the face.
The facial profile among ethnic groups from the southern part of India
(mostly Dravidians/Sytho-Dravidians), Negroid, certain races from
Indonesia and Islanders is unique in many aspects. These ethnic
groups have significant protrusion of the upper and lower dentition,
and thereby of the mid face, upper and lower lips. The chin may be
normal/retrusive (Fig. 45.28 A). These population groups have
otherwise a normal class I occlusion, but for the proclination of the
upper and lower dentition, Bidental protrusion when associated with
protrusion of apical bases called bimaxillary protrusion, which reflects
as protrusive upper and lower lips.
Classification of the facial profile according to Downs
William B. Downs12 described four basic facial types as viewed on the
lateral profile keeping chin prominence as a significant consideration
and a major point of reference. His classification of profile type was
given essentially in relation to cephalometric analysis.
1. Retrognathic with recessive chin (convex profile)

2. Mesognathic with straight profile normal chin (straight profile)
3. Prognathic, where chin is prominent (Concave profile)
4. Prognathism when the mandible is large.
Evaluation in vertical dimensions of
face in lateral profile
The vertical facial proportions between anterior and posterior face are
primarily grouped as neutral, horizontal or vertical face types based
on the direction of lower jaw/angulations of the lower border of the
mandible to an imaginary horizontal plane extending from the
external auditory meatus to the infraorbital ridge, called the Frankfort
horizontal plane. This line is also called eye–ear plane. With the child
sitting or standing upright with eye–ear plane parallel to the floor, try
to imagine an angle between eye–ear plane and the lower border of
the mandible. This angle is more appropriately abbreviated as FMPA.
An FMPA angle greater than 30 degree point to a vertical growth
pattern, which signifies that lower anterior face height is larger than
normal.
Similarly, a subject with 20 degree or less angle is grouped as a
horizontal grower.
The children who fall somewhat between 20 and 30 degree are
considered neutral growers.
The vertical or horizontal growth trend is not a unique feature of a
particular malocclusion type but can exhibit with any of the classes of
malocclusion; class I, class II or class III.
A mandibular plane angle smaller than 20 degree is often associated
with a decreased lower anterior face height, which is obviously
compensated by an increase in ramus height. Such type of facial
pattern is unique to class II division 2 type of malocclusion. However,
these can also be seen in class I or class III malocclusion.
Gonial angle
The horizontal/vertical type of face would also necessitate a look at
the gonial angle. A large gonial angle would be associated with a
short ramus and increase in lower anterior face height; thus, also
indicating a steep mandibular plane angle.
A small gonial angle is related to good growth of ramus height, a
decreased or normal lower anterior face height and a flat mandibular
plane. Closed/smaller angle is a feature of class II division 2
malocclusion. Small gonial angle can be associated with class I deep
bite cases and occasionally skeletal mandibular prognathism with
extreme horizontal growth pattern. Small gonial angle has also been
observed in children with hypertrophy of masseter muscles.
Vertical facial proportions in frontal profile

In the vertical plane, the face can be divided into three equal parts:
from the hairline–nasion, nasion–base of the nose, and base of nose–
chin (Fig. 12.11).
FIGURE 12.11 Facial proportions vertical in height: upper third

(trichion-nasion), middle third (nasion-subnasale) and lower third
(subnasale-menton).
Face can also be divided in upper face height (nasion-subnasale) and
lower face height (subnasale up to menton).
The common aberration in facial height as viewed from the front is

an increase or decrease in lower one-third of the face. An increase in
lower anterior facial height is often associated with open bite tendency
while a decrease is often seen in deep bite cases.
Transverse facial proportions
In the frontal view, the face is divided into five equal segments by
vertical lines. The ‘ideal’ measurements are:
1. The mid-segment is formed between two vertical planes

passing at the inner canthus of the eyes. In a well-balanced
face, these planes should pass through the base of the ala of
the nose (Fig. 12.12).
2. The second segment is formed on either side of the plane
passing at the inner canthus of the eyes and the plane passing
through the outer canthus of the eyes. This outer plane usually
should be coincident with the gonial angle.
3. The outer two-fifth segments primarily represent ears, and
their widths may have to be improved by the plastic surgeon if
the ears are disproportionate with the rest of the face. The
width of the mouth normally should be equal to the
interpupillary distance.
FIGURE 12.12 Transverse facial proportion.
Golden proportions of face13

Divine proportions have been beautifully illustrated in the
drawings of the human body by Leonardo da Vinci. Divine
proportions are seen in relation to width as well as the height of the
face. The mathematical formula for the perfect face has been defined
based on a simple mathematical ratio of 1:1.618, otherwise known as
phi, or the divine proportion. Only one formula has been consistently
and repeatedly observed in all objects that are beautiful, be it art,
architecture or nature, but most importantly in facial beauty. Ideal
facial proportions are universal regardless of race, sex and age, and
confirm to divine proportions. If the width of the face from cheek to
cheek is 10 in., then the length of the face from the top of the head to
the bottom of the chin should be 16.18 in. to be in ideal proportion.
The ratio of phi also applies to many other facial proportions (Fig.
12.13A–D).
FIGURE 12.13 Golden proportions of face.

(A) Divine proportion constitute a ratio of 1:1.618. (B) Height of face to
width of face ratio. (C) Ratio of transverse dimensions of face. (D) Ratio
of vertical face heights.
Examination of nostrils
Size and shape
The narrow nostrils can be associated with mouth breathing habit. A
child may have a deviated nasal septum, and one side of the nose may
be blocked. History of allergic rhinitis and recurrent throat infection
calls for evaluation by an ENT expert.
Examination of zygoma or cheekbones

The prominence of the cheekbones and the infraorbital area should be
noted, and so their fullness. A deficient maxilla is a major contributor
to the chin appearing more prominent. Lack of cheekbones
prominence is suggestive of a deficient maxilla.
Nasolabial angle
It is the angle formed by the tangent drawn along the lower border of
the nose and the tip of the upper lip, that is upper lip anterior. The
range of this angle is 85–105 degree. Decreased nasolabial angle is
seen in patients having proclination of anterior teeth or a prognathic
maxilla; whereas increased nasolabial angle is seen in patients with
retrognathic maxilla or retroclined maxillary incisors. If the nasolabial
angle is open (>105 degree), retraction of anterior teeth orthodontically
and surgically should be avoided in treatment planning. Fitzgerald et
al.14 reported the nasolabial angle to be 114 ± 10 degree among white
Caucasian adults. No statistically significant differences were
demonstrated between the values for men and women, but the
women did have a slightly larger nasolabial angle (Fig. 12.14A–C).
FIGURE 12.14 Nasolabial angle:

(A) Normal, (B) Acute and (C) Obtuse.
The lips
At rest, upper lip should generally provide lip seal in gentle contact
with lower lip without showing signs of excessive muscle movement.
With the lips relaxed, the inner labial gap should be in the range 1–4
mm. Females generally show a larger gap. It is also dependent on lip
length and vertical dentoskeletal heights.
The upper lip is considered competent when a lip has a good
muscle tone, is usually not dry and is in gentle contact with or slightly
apart from the lower lip, at rest.
Upper lip can be averted, flaccid and short, thus unable to provide a
good lip seal at rest or during respiration. Such an upper lip is called
incompetent upper lip. Most mouth breathers have incompetent
upper lip. The increase in the inter labial gap is seen with short upper
lip and/or maxillary vertical excess and skeletal open bite. A short
upper lip (lip length 18 mm or less) leads to increased interlabial gap
and excessive incisor display at rest and during a smile (Fig. 12.15). A
decreased interlabial gap can be associated with maxillary deficiency,
long upper lip, ageing and mandibular retrusion with a deep bite.
FIGURE 12.15 Incompetent lips.
Lip redundancy is seen with vertical maxillary deficiency and

mandibular retrusion with a deep bite. With balanced lip and skeletal
lengths, the lips should ideally close from a relaxed, separated
position without the lip, mentalis, or alar base strain.
Smile position lip level

When examining the patient in a smile, different lip elevations are
observed in normal and abnormal skeletal pattern. Three-quarters of
the upper incisors’ crown height to 2 mm of the gingival display are
considered normal/ideal exposure. The gingival display is slightly
more in females than in males. Variability in gingival exposure during
smile is related to lip length, vertical maxillary length, maxillary
anatomic crown length and magnitude of lip elevation while smiling.
The excessive gingival show can be linked either to the short upper lip
or a vertical maxillary excess (VME) or both. In contrast, some
children have a thin upper lip and short face height with less than
optimum incisor show.
Lower lip
Lower lip should be examined for its position and depth of mental
sulcus. A lower lip that is associated with a small/retropositioned
mandible will usually get trapped in the overjet behind the upper
incisors. The protruding incisors do not permit lower lip to attain a lip
seal with upper lip, which may be falsely interpreted as upper lip
being incompetent. This clinical condition is more aptly termed as a
‘Lip trap’. These children will show excessive muscle strain in the chin
and lower lip during swallowing (Fig. 12.16). Chin should be
evaluated for its sagittal position in space (prominent or recessive)
and action of the muscles during swallowing. Anatomically long
lower lip can be associated with class III malocclusions.
FIGURE 12.16 Lower lip trap and deep labiomental sulcus.
Chin button
The chin should be evaluated independently of the lateral profile. It
may be normal, recessive or prominent. In certain malocclusions like
class I bimaxillary protrusion; the chin button may be flat while in
other situations like class II division 2, the mandible is positioned
backwards but the chin button could be prominent due to excessive
soft tissue thickness.
The labiomental sulcus

Labiomental sulcus is the groove between chin button and lower lip.
A thin or no sulcus can be seen when chin button is recessive while in
cases with a prominent chin button, sulcus is deep. A retrognathic
mandible and eversion of the lower lip, which is trapped behind the
proclined upper incisors, will cause a deep labiomental sulcus (Fig.
12.16). In class II division 2 situations, deep labiomental sulcus is the
outcome of excessive activity of the mentalis muscle whereby chin
becomes more prominent, and there is a deep bite with retroclined
maxillary incisors.
Dynamics of smile and its orthodontic
implications
A smile is perhaps the most pleasant and wanted expression by each
one of us. The nature of smile denotes underlying human expressions
which may have a far deeper impact than a thousand spoken words.
Smile, of a child denotes innocence, of a mother denotes care, of youth
denotes carelessness and freedom, and of an aged a great satisfaction
of his life and achievements. Nature of smile does vary with mood,
and it can only be purely perceived in the backdrop of its emotions.
Facial expressions, the posture of lips, occlusion and arrangement of
teeth, buccal corridors, the shape of teeth, their proportions, contours,
gingival colour, texture, contour and several other aspects constitute
components of the smile.
Some authors have tried to group these as Macro, Mini and
Microcomponents of smile.15–17
Subjects with malocclusion obviously do not have a pleasant smile.
A gummy smile is something which is most apparent to a lay person.
A gummy smile is essentially an excessive show of the incisors and
gingiva. Protruded, proclined and crowded incisors may contribute to
unnatural show of teeth. A child with a narrow maxillary arch would
show excessive dark spaces in the corners of the mouth (buccal
corridors) or similarly, an arch, which is too broad, will encroach
upon the buccal corridors and therefore show of the buccal corridors
in minimised. Similarly, a subject with dentofacial deformity,
particularly like the one with unilateral condylar hyperplasia or like
the one with ankylosis, exhibits a transverse cant of the occlusal plane,
which would affect the smile adversely. It is, therefore, important to
recognise deviations from the normal smile of an individual, locate
and focus on the factors, and visualise a plan of treatment that will
restore the smile to a normal pattern.
Nature of smile
Nature of smile can be broadly grouped into posed and spontaneous
smile.
Posed smile
It is voluntary and is often controlled and learnt. It is a fairly
reproducible human expression which can be sustained. In other
words, it is a social smile. It is often a professional smile similar to the
one posed by the air hostess/receptionist and public relation personnel
(Box 12.2).
Box 12.2 valuation of posed smile
Variable Normal smile Not good smile

Smile arc Consonant Non-consonant
Smile index Average Increased/decreased
Morley’s ratio 75–100% (Normal) Disturbed
Buccal corridors Average Obliterated/excessive
Smile line Average High/low
Occlusal plane No canting Canting of occlusal plane
Spontaneous smile
It is natural, involuntary and spontaneous, often characterised by far
greater lip elevation than in a posed smile. It bursts forth, comes
suddenly, full of emotions, and may be the initiation point of laughter.
Evaluation of smile (Box 12.2)

The process of evaluation of the smile should be carried out in a
systematic manner involving all components that structurally and
functionally constitute a good or not so good smile. A smile should be
assessed/viewed in frontal, sagittal and oblique views. It should be
interpreted both in its static form and in dynamic character.18,19
Another dimension to smile analysis is time, that is, the features of a
smile should be considered with age.
Gingival display
The first and foremost observation about a smile is visibility of
maxillary teeth. Normally, the display of teeth and the gingival line is
about 1 mm or just above the cervical margins of teeth in posed smile.
The gingival exposure may vary according to sex and age. On an
average, the smile line in women is 1.5 mm higher than men and less
in aged compared to young adults.
1. High smile line. The nature of a high smile line is characterised

by the show of teeth beyond 2 mm of their gingival lines. It can
be contributed by a combination of components such as:
a. Dentogingival: abnormal dental eruption.
b. Muscular: it is caused by hyperactivity of the
elevator muscles of the upper lip or an anatomically
short upper lip.
c. Dentoalveolar/skeletal: due to an excessive
protuberance or vertical growth of the maxilla often
called VME.
d. Dental: excessive overjet and overbite.
2. Low smile line. It is the line where teeth visibility is less than
normal. This may be due to small incisors, vertical maxillary
deficiency, thin lips or their combination.
Buccal corridors and arch form20,21

These have been much researched by the prosthodontists since long to
know the best location on the ridge for arranging artificial teeth. The
implications in orthodontic treatment are relatively new.
Buccal corridor(s) is defined as the distance between the lateral
junction of the upper and lower lips and the distal points of the
canines during smiling. The buccal corridor is often represented by a
ratio of the inter commissural width divided by the width from the
first premolar to first premolar (Fig. 12.17A). The buccal corridors
have less light available as we view from anterior towards posterior
teeth, which makes them appear darker and smaller. This is an
essential feature of a good smile.
FIGURE 12.17 Buccal corridors.
(A) Normal buccal corridors, (B) Excessive buccal corridors or dark
spaces associated with narrow maxillary arch, (C) Obliterated buccal
corridors often seen in wide arch.
Arch form and transverse arch dimensions have received

considerable attention in the totality of smile analysis for their effect
on buccal corridors and visibility of incisors in relationship to
contours of the lower lip. An arch that is narrow or collapsed may
present inadequate transverse smile characteristics due to undue large
buccal corridors or dark spaces (Fig. 12.17B). Excessive wide arch can
obliterate these spaces resulting in a denture-like smile (Fig. 12.17C).
The arrangement of teeth, morphology and colour

The lips in pleasing smile rest on well-arranged teeth in a nice arch
form, which varies with facial types. Clinical heights of the crowns,
contact areas, their tip (mesio distal angulations) and torque
(labiolingual inclination) contribute to the aesthetics of the smile. The
morphology and proportions of the individual tooth and relative
proportions of the teeth in the arch should confine to the divine
proportions and therefore the quality of smile. The widths of central
incisor–lateral incisor: canine, follow the mathematical ratio of 1:1.618,
otherwise known as phi, or the divine proportion. The colour of teeth
also indirectly influences the overall impression, growing darker from
midline towards the corner of the mouth.
Smile arc
A smile arc is normally formed as a smooth curvature of the lower lip
that follows the maxillary teeth and arch form during a smile. It is
perhaps the most significant contributor to the quality of smile. The
smile arc may be in consonant or non-consonant relationship with
maxillary dentition.22
1. Consonant relationship of smile arc is one where the upper
incisors rest on the vermilion border of lower lip on posed
smile that follows a smooth curve (Fig. 12.18A).
2. Non-consonant or flat smile arc is characterised by a flat
anterior arc line on the curvature of lower lip during posed
smile. The maxillary arch may be flat or far from being flat
such as in anterior open bite (Fig. 12.18B).
FIGURE 12.18 Smile arc.

(A) Consonant smile arc, (B) Non-consonant smile arc.
Assessment of smile arc or incisor–smile relationships both with lips

in rest and in smile has considerable influence on a treatment plan and
treatment mechanics.
Smile index
Ackerman and Proffit17 first described smile index. Smile index
represents the area within the vermilion borders of the upper and
lower lips during the social smile. The smile index is determined by
dividing the inter-commissural width by the inner labial gap during a
smile (Fig. 12.19). It is increased in clinical situations where decreased
incisor show is present, and decreased where the increased incisal
show is present.
FIGURE 12.19 The smile index is determined by dividing the
intercommissure width by the interlabial gap during social smile.
Morley’s ratio23
It depicts the percentage of incisor show on posed smile with respect
to the clinical crown height. The average ratio is 75–100%. A greater
Morley ratio would necessitate appropriate measures to decrease the
incisor show. Common contributors to increased incisor show are
VME, palatal plane tipping downwards in the anterior region and
short upper lip or greater crown height. Smaller ratio depicts less than
normal incisor show due to a vertically deficient maxilla, increase in
the length of the upper lip or a short clinical crown height.
The transverse cant of the maxillary occlusal plane

The transverse cant of the occlusal plane does affect the quality of the
smile. Transverse cant can be due to differential eruption and
placement of the anterior teeth or skeletal asymmetry of the mandible
resulting in a compensatory cant of the maxilla. Clinical visualisation
in frontal and transverse dimension permits the orthodontist to
visualise any tooth-related and/or skeletal asymmetry. Transverse
cant can be better appreciated when a subject is asked to hold a
tongue blade (a long ice-cream stick) in the mouth between the
premolars of the opposite sides while keeping his/her head upright,
Frankfurt horizontal plane parallel to the floor. Clinician then
estimates the parallelism/cant of tongue blade in reference to the inter-
pupillary line (Fig. 12.20).
FIGURE 12.20 Cant of occlusal plane in transverse plane is often

seen in cases of facial asymmetry.
This man has unilateral condylar hyperplasia of the left side leading to
a transverse cant of occlusal plane.
Lately, smile design has emerged as a cosmetic inter-disciplinary

speciality of dentistry. Smile enhancement through a variety of
restorative and aesthetic procedures and orthodontics is a sought-after
clinical practice.24,25 Many procedures are used which might involve
extensive recontouring of teeth to alter their shape, proportions, and
colour, using aesthetic laminates or composite restorations. The
microdonts, discoloured teeth due to hypoplasia or fluorosis,
fractured or chipped enamel, attrition or erosion of teeth, unusually
large canines or similar morphological issues are now successfully
treated with bleaching, aesthetic restorations or laminates or crowns
or a combination thereof. Also, the gingival and periodontal structures
are also considered seriously for alterations/surgery to give near
perfect contours.26 The zenith of the gingival contours can also be
improved for normalisation of the smile. The objectives of smile
design and implementation strategies should be based on 360 degree
review of all the components of smile including consideration of the
age of the patient.
A detailed assessment of a patient with malocclusion would be
incomplete without examination of the TMJ. The functions of
mastication, deglutition, speech, and respiration depend largely on
the movements of the mandible and its relationship to stable cranial
base. The TMJ is classified as a compound movable articulation
between the condyle and the inferior surface of the squamous part of
the temporal bone. Interposed between the condyle and articular
eminence is the articular disc, which divides TMJ into two separate
joint cavities. In the superior joint, the movement is gliding or
translatory whereas, in the inferior joint, it is rotatory or hinge type.
Evaluation of TMJ requires a thorough understanding and
examination of the articulatory system. The articulatory system
comprises of three components:
• The temporomandibular joint

• Muscles of mastication
• Occlusion
A detailed examination of TMJ should start with a carefully

recorded history from the child and/or parents, which should include
questions such as:
Has there been any injury to the face or jaw which has caused
chewing difficulties?
Is it difficult or painful while yawning on or around the ears?
Do the jaw joints make click, feel stiff, and get stuck or locked?
Are there any episodes of being unwell with headaches and pain on
or about the ears?
Tenderness on palpation
Children may complain of pain in or in front of the ear. Tenderness on
palpation of the joint in the area implies inflammation, generally as a
result of acute or chronic trauma. The pulp of index finger should be
placed in the immediate preauricular area; gently applying pressure
on the lateral pole/head of the condyle while the jaw is opened/closed.
The level of pain and discomfort on each side should be assessed and
compared. The little finger with pulp facing the condylar head should
also be gently placed in the external auditory meatus to evaluate the
motion of the condyles.
Joint sounds
There are two types of joint sounds to look out for:
Click—single explosive noise
Crepitus—continuous ‘grating’ noise.
Click
A click represents a sudden distraction of two wet surfaces,
symptomatic of some kind of disc displacement. Click may frequently
be felt by the patient, and this may be the reason to seek a professional
consultation. Click can be heard more so with a special stethoscope
with double drum heads for simultaneous review of both the joints.
The diagnosis of a joint click, and therefore treatment, depends on
whether the click is present in one joint or both, is associated with
pain or not, is consistent or intermittent. As the joints are under
auscultation, the patient is asked to open the mouth gently. The
timings and the intensity of click are recorded. A click heard later in
the opening cycle may represent a greater degree of disc
displacement.
Crepitus
It is the continuous noise heard during jaw opening and closing
movement of joint, often caused by the worn articulatory surfaces of
the joint. This occurs commonly in patients with a degenerative joint
disease.
Range of motion27–29
The range of motion is the only truly measurable parameter, of jaw
movements since the others are more subjective. Movements to be
measured are:
Incisal opening—pain-free limit
Incisal opening—maximum (forced)
Lateral mandibular excursions
Mandibular deviations on a pathway of opening
Incisal opening
It is measured from the upper incisal tip to the lower, with the patient
opening to his/her maximum, comfortable, pain-free range. This is
then compared to the normal range of motion.
The maximum (forced) limit is also recorded. It is important to
determine whether a limitation of vertical movement is due to pain or
due to physical obstruction. Mouth opening may be restricted due to
pain in cases of muscular problems whereas limited mouth opening
due to a physical barrier is a feature of disc displacement.28
Lateral excursions
The lateral movement is measured from upper midline to lower
midline, when the patient is asked to move the mandible to its
maximum extent, from one side to another.
Mandibular deviation
When the jaw is opened, the path it follows should be smooth, and
consistent with no lateral deviations. Deviations from the norm are
either lasting or transient and are suggestive of internal derangements
of different varieties.
The normal range of mouth opening is 53–58 mm. A child at the age
of 6 years can open his/her mouth 40 mm or beyond. If the incisal
mouth opening is less than 40 mm, it is suggestive of restricted mouth
opening. In lateral excursions, a movement less than 8 mm is
considered as restricted.
Trauma and dislocation
External trauma to the face and jaws can often cause mandibular or
condylar fracture or more commonly traumatic arthritis, but rarely is
a cause of a chronic disorder. In the absence of an anatomical defect,
dislocation is rare and is usually caused by trauma. A child with a
fracture of the condyle or dislocation would present with a deviation
of the mandible. The mandible deviates to the same side whereas in
dislocation, the mandible deviates to the opposite side.
Due consideration should be given to the presence of any of the
symptoms or signs of TMJ disorder while planning the orthodontic
treatment in an adult or a child. A careful and conscious decision has
to be made before undertaking any orthodontic therapy (Box 12.3).
Box 12.3 ummary of TMJ examination
Right side Left side

Palpation peri-auricular area and TMJ
tenderness, its extent and severity
Auscultation of TMJ
Click
Crepitus
Range of jaw motion mm mm
Lateral jaw movement
Anterior mouth opening measured at incisors
Speech and malocclusion30–35
Speech and language acquisition is a complex, intricate
developmental process occurring most dramatically in the first year of
life. Speech is a motor act of verbal communications. By means of
speech, we are able to describe our thoughts and feelings and can
understand those of others who employ the same language.
Language is a system of communication. It may be written, spoken,
or gestured. Speech is the means of associating spoken symbols of
language. Scientists have yet to understand how and why so many
languages developed across different parts of the world and in
different societies. Development of speech takes place during the first
year of life (Table 12.6).
Table 12.6
Stages of development of speech

Stage Age Articulation
I 0–8 weeks Reflexive crying and vegetative sounds
II 8–20 weeks Cooing and laughter
III 16–30 weeks Vocal play
IV 25–50 weeks Reduplicated babbling: consonant vowel syllables
V 50+ weeks Non-reduplicating babbling
VI Around 1 year First words
Parts of speech
Speech consists of four parts:
Voice—sound produced by air passing between the vibrating vocal
cords of the larynx.
Articulation—the movement of the speech organ used in producing
a sound, that is, the lips, tongue, teeth, mandible, palate, and so forth.
Rhythm—variation of quality, length, timing and stress of a sound,
word, phrase, or sentence.
Language—knowledge of words used in communicating ideas.
There are three possible mechanisms by which malocclusion and
speech may be inter-related:
1. There may be a cause-and-effect relationship where occlusal or

structural anomalies affect articulation of speech.
2. Problems of articulation may be coincidental to malocclusion.
3. Conditions that affect central nervous system leading to poor
motor control and possible distorted morphogenesis. These
may be genetic or metabolic.
Dental anomalies and malocclusion can affect speech production to

a considerable extent, although the ability of the patient to
compensate for abnormal dental relationships should never be
underestimated.
Assessment of speech in relation to

malocclusion and dental anomalies
The evaluation of a child with malocclusion and dentofacial
deformities should include an assessment of the speech for
articulation, fluency and voice.
The orthodontist’s responsibility is first to be able to recognise the
defective articulation or speech sound and to look for the presence of
dental structures or malocclusion, if any, that could have adversely
affected the speech.
The clinician while talking to the patient informally performs the
subjective assessment. If speech problems are suspected, a
professional opinion by the speech therapist is required.
Following factors related to oral cavity and dentition may affect
articulation of speech.
Speech is mainly produced by two valves:
Articulation components of the oral cavity: palate, teeth, lip seal and
tongue.
Velopharyngeal valve, soft palate and pharyngeal walls.
Fig. 12.21 depicts the malocclusion and its relationship with the
speech and sound production.31
FIGURE 12.21 Malocclusion and its relationship to speech sound

production. Source: reproduced with permission from Leavy KM,
Cisneros GJ, LeBlanc EM. Malocclusion and its relationship to speech
sound production: Redefining the effect of malocclusal traits on sound
production. Am J Orthod Dentofacial Orthop 2016;150(1):116–23.
The following conditions may affect production and quality of

speech.
Dental alignment and speech30–32
The three dental anomalies that have a negative impact on sound
production are an open bite, mandibular prognathism and small
mandible. Recent studies have found that an open bite, and bilateral
cross-bites are two major traits of malocclusion associated with sound
errors.
Cases with severely crowded, irregular incisors and lingual position
of maxillary incisors may have difficulty in production of
linguoalveolar sounds (t, d).
Hypodontia/missing teeth or similar conditions cause interdental
spacing and may cause lateral or forward displacement of the tongue
during speech resulting in distortion of the sounds. Liguoalveolar
phonemes (s, z) followed by lingual, palatal phonemes (j, sh, ch) are
most affected by space in the dental arch.
In class III cases, sibilant and alveolar speech sounds are most
commonly distorted or affected (s, z, t, d, n, l). In these cases, there is
difficulty in elevating the tongue tip to the alveolar ridge.
In a recent study, Leavy and co-workers31 reported that the severity
of sound errors is directly related to the severity of handicapping
malocclusion.
Most errors are related to the production error, particularly with the
/s/ and /t/ sounds.
Nearly 20% of malocclusion subjects had sound errors. Although
tongue protrusion or lingual protrusion, a visual error, was noted in
80% of the subjects with malocclusion, it is not considered a sound
error by itself.
An open bite (>2 mm) should be considered as a major trait of
malocclusion that can adversely affect the production of sound. Open
bite is associated with sound production errors, both auditory and
visual distortions. Palatal height and lingual elevation or tongue
position at rest may account the variability for the production of /s/
and /t/ sounds.32
Lip seal
A competent lip seal is required for control of air and production of
bilabial sounds. Class II malocclusion with large overjet may impede
lip closure during eating and drinking. Bilabial sounds (p, b, m) may
be distorted, being produced by the upper incisors articulating with
the lower lip (labiodental manner). The incomplete lip seal is also seen
in children with an operated cleft lip, which may be short and
immobile.
Children with anterior open bite tend to move tongue forwards into
the interdental space resulting in lisping/ distortion of speech sounds.
Sounds involved are those that involve the tongue tip to contact
alveolar ridge (t, d, n, l) and palate (s, z) (sibilants).
Velopharyngeal seal
It is an essential mechanism involved in speech production. For all
vowels and consonants except nasal consonants, the nasal cavity is cut
off from the pharyngeal cavity, and the air stream passes into the oral
cavity. This ensures adequate and constant intraoral pressure during
the speech. The velopharyngeal seal is achieved by lifting up of the
soft palate, forward movement of the posterior wall of the pharynx
and inward movement of the lateral pharyngeal walls. Inability to
achieve a velopharyngeal seal partially or wholly is called
velopharyngeal insufficiency. It is commonly seen in cleft palate cases
due to short and not so mobile soft palate.
A fistula in the palate would cause nasal escape and nasality as
viewed in unoperated cleft children or children with postoperative
fistula following palatal repair.
Anomalies of tongue34
Anomalies such as ankyloglossia or tongue tie may hinder free tongue
movements and may result in distortion and substitution of tongue tip
sounds (linguoalveolar). The sounds affected are (l, t, d, n, s) and (z)
because of restricted elevation of tongue tip.
In macroglossia, the abnormally large tongue may affect the
production of all speech sounds involving the tongue such as
dentolingual (th), linguoalveolar (t, d, n, l), and palato-lingual (ch, j,
sh). Primary macroglossia is a rare condition. It may be associated
with conditions like Beckwith–Wiedemann syndrome.
Microglossia, another anomaly of tongue characterised by an
abnormally small tongue may be associated with syndromes
exhibiting hypodactyly. It may lead to abnormal speech because of the
inability of the tongue tip to contact the teeth, palate or alveolus
sufficiently.
Speech in a cleft child35

A child operated for cleft lip and palate may have an inadequate
velopharyngeal seal and persistent oronasal fistula resulting in air
escaping into the nasal cavity. The child is unable to maintain
adequate intraoral pressure, and consequently, speech is impaired.
Inability to maintain proper intraoral pressure leads to the
development of compensatory speech behaviours. Such responses
tend to undermine rather than enhance speech performance.
Individuals with velopharyngeal insufficiency use greater
respiratory efforts compared to normal children. Their air volumes
during speech are approximately twice that of standard speakers.
Another compensatory change in speech is in tongue carriage. A child
with velopharyngeal insufficiency tends to position the tongue to
reduce the nasal escape of the air stream so that an adequate and
constant pressure can be maintained in the oral cavity. An
orthodontist should assess all such factors which could influence
normal speech production more so those related to the presence of
malocclusion.
Clinical examination of child for
suspected deleterious habit(s)
A potential orthodontic patient may have one of the following
deleterious habits, namely mouth breathing, tongue thrusting and
thumb or finger sucking. Other habits include finger or nail biting and
pencil biting.
While examining a child suspected of having mouth breathing, one
can elicit a lot of information from the parents about the past medical
history of the child. A child with a recurrent throat infection, recurrent
allergies may be a mouth breather. Such a child may show a long
narrow face and dry upper lip that is often flaccid and everted. The
gingiva in the upper anterior region may appear dry and inflamed.
The nostrils may be relatively small and blocked. A differential
diagnosis of habitual or an anatomical aetiology of mouth breathing is
discussed in the chapter on deleterious oral habits. An ENT
examination can ascertain cause and locate the obstruction in the
respiratory passage. In a clinical setting, often it is pertinent to
ascertain if the child is a nasal breather or not.
Tongue thrusting or infantile swallowing or abnormal swallowing
pattern can be responsible for superior protrusion, the spacing in the
dentition or bidental protrusion. A child should be asked to relax, wet
his/her lips with his tongue and swallow his/her own saliva. The
doctor should diligently observe the behaviour of the tongue. Infantile
swallow would require a contact of the tongue with the lower lips to
maintain a lip seal. Severe tongue thrusters with spacing push saliva
through the interdental spaces, which may be seen gushing out in the
vestibules while the child performs the act of swallowing. A severe
type of tongue thrusting may be associated with the anterior open
bite. Lateral tongue thrusting with posterior open bite is uncommon
but not a rare entity.
Thumb sucking or finger sucking beyond 4–5 years is considered
abnormal and if continued may show its unwanted effects on
dentofacial development. There may be an open bite with class II
tendency, that is, recessive chin and protrusion of the upper lip due to
proclination of the incisors. A finger sucker child may not like to
reveal his/her history, which should be ascertained from the parents/
guardian. Dentofacial alterations of thumb sucking are governed by
the frequency, intensity and the position of the thumb/finger in
mouth. The thumb or the finger being sucked can also be confirmed as
it would appear cleaner and whiter having been in the mouth longer,
compared to the other fingers. Occasionally, a child may have an
anxious habit of excessive nail biting or pencil holding between teeth.
This may lead to some damage to teeth and nails depending upon the
frequency and duration of the habit.
Intraoral examination (Table 12.7)

Examination of soft tissues of oral cavity
A thorough examination of the oral cavity should precede any
evaluation of the dentition and occlusion. Any abnormality in
colour/texture or structures in oral cavity, mucosa and tongue should
be noted. Presence or absence of any growth in the soft tissues and
hard tissues may be recorded and accordingly investigated. In a
healthy mouth, no growths are expected. However, bumps,
odontome(s) or dentigerous cysts could be an accidental finding on
inspection and palpation.
Table 12.7
Summary of intraoral clinical examination*

* Make note/mark 3 for each observation.
Frenum
Maxillary and mandibular freni should be examined for number,
thickness and levels of attachment. The most common aberration of
frenum is thick upper fibrous frenum that may be associated with
median diastema. The upper frenum should be looked for its
thickness and level of attachment. A fibrous and thick frenal
attachment that is low may hinder diastema closure. In such a
situation, further examination should involve a gentle pull of the
frenum along with the upper lip, and one should look for any signs of
blanching at the incisive papilla. A blanching of incisive papilla
indicates a low frenal attachment, which may have clinical
implications during closure of the diastema.
The other freni, buccal (U and L) and labial lower freni are not of
great importance regarding orthodontic examination. However, lower
lingual frenum is important to look at and examine the extent to
which tongue can be protruded. A tongue-tie, associated with thick
lower lingual frenum and low fibrous attachment may hinder free
movements of the tongue to its maximum extent. Although often not
of orthodontic significance, tongue-tie may be responsible for
hindrance in the proper articulation of speech.
The other common finding in children is the presence of enlarged
tonsils and history of recurrent throat infections.
Any abnormal growth/aberrations of oral mucosa or such findings
should alert the orthodontist for detailed examination and history.
Palate
From an orthodontic point of view, the examination of the
morphology of the palate is of vital importance. The deep palate is
often associated with vertical growth pattern (long thin face, increased
vertical dimension of the anterior face). Such a child may also be a
mouth breather. A broad, shallow arch or a broad squarish face may
be associated with horizontal growers/or situations like class II
division 2 pattern.
Examination of uvula/soft palate may reveal a notch or a bifid
uvula. Such a finding should alert the orthodontist for a more detailed
examination by palpation to look for a notched posterior nasal spine
or signs of an occult cleft of the palate only.
Tongue
The tongue should be examined for its colour, shape and size. The
lingual frenum and its mobility should be assessed. A large tongue or
macroglossia could lead to lateral open bite and spacing in the
dentition.
Having had an overview of the oral cavity and a detailed
examination of the abnormality if any, a record should be made if any
of these findings point towards the presence of an underlying
systemic disease. The concerned specialist should be referred to for
further investigations.
Examination of oral health and
periodontium
The next in order of review involves assessment of gingival and
periodontal health and the level of oral hygiene, followed by the
status of dental caries and its sequel. A record of the quality and
morphology of the dental hard tissues should be made to exclude the
defects of enamel and dentine like amelogenesis imperfecta and
dentinogenesis imperfecta or hypoplastic teeth.
The mouth should be examined for the eruption status of teeth
concerning chronological age and skeletal growth of the child, vis-á-
vis shedding of deciduous teeth. The record should be made of a
premature loss of deciduous teeth and the need for maintenance of
space. In the mixed dentition, the deciduous second molars should be
given a special importance since they maintain the integrity of the
arch during the transition from mixed to permanent dentition. Early
loss of the deciduous molars would lead to mesial drift of the erupting
permanent first molar(s) and thereby malocclusion. Several factors
would have to be considered at this stage including a radiological
assessment to evaluate the eruption status of successor’s tooth.
Unilateral, premature loss of a deciduous tooth is often seen with
the mandibular deciduous canine, which may require further
examination of a possible or existing midline shift. A gentle palpation
of the dentoalveolar apparatus, both buccal and lingual, is done to
locate teeth that are close to the eruption and may be helpful to sort
out extraction of the retained deciduous teeth.
It is also important to note the presence or absence of any signs of
missing teeth or microdontia. Abnormalities of tooth number may be
seen as supernumerary teeth, which may be erupted/partially erupted
or impacted. The commonest location of supernumerary teeth is in the
anterior region of the maxilla. Unusual rotation of an erupting
maxillary incisor with abnormal diastema should raise suspicion
about a possible presence of a supernumerary tooth (Fig. 12.22A, B).
FIGURE 12.22 (A) Dichotomy of maxillary lateral incisors contributing

to crowding in the maxillary arch. (B) Erupted mesiodens.
Failure of eruption
Failure of eruption of maxillary anterior teeth even after the loss of
deciduous teeth should also possibly arouse suspicion of the
possibility of the presence of physical barrier in men. A
supernumerary tooth may appear as a dichotomous tooth, maxillary
laterals being the commonest. A generalised delay in eruption can be
seen in gingival fibromatosis (Fig. 12.23). Physical signs of delay of
growth and development accompanied with delayed eruption of teeth
would need a consultation with a paediatrician to exclude any
systemic disease. Extremely delayed dentition requires further
radiological assessment and investigation for endocrine functions
with endocrinologist. We have encountered hypothyroidism as the
commonest systemic condition associated with unusual delay in
eruption of permanent teeth.
FIGURE 12.23 Siblings showing signs of familial gingival

fibromatosis. Fibrosed gingivae make a physical barrier to the eruption
of teeth and hence delayed eruption and crowding.
Fractured or discoloured teeth that have not been treated

adequately should be noted and may require vitality tests or
radiographs with subsequent consultation with the pedodontist or
endodontist.
A complete intraoral examination involves the recording of dentition
and occlusion. Malocclusion should be assessed in three planes of
space, that is, sagittal (anteroposterior), transverse and vertical. The
recording can be summarised as in Table 12.7. It may be noted that the
observations are made while the child is asked to close in centric
occlusion. It is common for the child to slide the mandible forward
while an examination is in progress, and this may give a false picture
of occlusal relations (Fig. 12.24).
FIGURE 12.24 Anterior functional shift/pseudo class III malocclusion

in an 8-year-old girl. Top row, initial premature contact that leads to
forward slide of the mandible. Bottom row, centric occlusion in anterior
cross-bite.
In case a functional shift of the mandible is detected, wax bite

recordings are made in centric occlusion and centric relation.
Premature contacts causing forward or lateral shift during closure are
located. The study models with a wax bite in centric relation and
occlusion allow a more detailed evaluation of occlusion.
Any abnormality(ies) in position/deviations of individual tooth or
group of teeth within arch or intra-arch should be noted. The intraoral
examination is usually followed by preparation of records for further
detailed analysis and treatment planning.
Clinical assessment of an adult seeking
More adults are now seeking orthodontic treatment than ever before.
Some adults are compelled and motivated for the treatment for
professional and personal reasons. Others are those who are seeking a
better quality of life and convinced of the benefits of orthodontic
treatment through friends and relatives. A few may seek treatment for
the reasons of oral health and functional problems. Some of the adult
patients may have been referred to the plastic surgeons for
enhancement of their profile.
The orthodontic assessment, therefore, needs to be carried out to
given reasons for seeking orthodontic treatment.Clinical evaluation in
adults is more focused, starting with the chief complaints of the
patient. Growth is complete, so malocclusion is fully established. The
examination of the face follows the same principles as discussed
above. However, the objectives of the treatment may have to be
modified and redefined based on oral health status of the
periodontium and aesthetic/functional needs of the adult seeking
orthodontic treatment. The following aspects of dentition, occlusion
and treatment needs are critical in the evaluation of an adult for
orthodontic treatment:
• Psychological/social needs of treatment

• Periodontal status: a need for soft tissue procedures
• Caries susceptibility, the status of existing restorations
• Smile assessment
• Assessment of real need and objectives for treatment
• Pre-orthodontic periodontal/restorative treatment
• Post-orthodontic periodontal/restorative treatment
• Interdisciplinary assessment for the above and dental aesthetic
treatment like veneers/laminates
• Marital status/siblings/plans for parenthood/medications such
as hormones/existing medical condition and medications if
any
Key Points
Orthodontic examination and diagnosis start first with formal and
informal meeting with child and parents. A detailed history is
followed by a detailed, intricate examination of physical growth, face,
soft tissues and oral cavity, including functions of stomatognathic
systems.
A close and diligent clinical study evaluation of malocclusion and
functional examination is a critical component of orthodontic
diagnosis. A detailed examination cannot be done in a hurry and
would require each of the listed components to be recorded and
evaluated for its possible impact on oral health and orthodontic
treatment. The clinical examination is followed by making required
records and investigations leading to a comprehensive diagnosis and
treatment plan.
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CHAPTER 13
Diagnostic records and their
evaluation
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
The essential or minimum diagnostic records
Additional records and investigations
Orthodontic study models
Pre-treatment study models
Progress/stage and post-treatment study models
Evaluation of study models
Analysis of arch length during mixed dentition
Radiographic method
Non-radiographic method
i. Moyer’s analysis
ii. Tanaka and Johnston method
Combination method
i. Staley and Kerber method
ii. Nance’s analysis
Factors influencing estimation of the tooth size–arch length
analysis
Incisor inclination and position
The curve of Spee
Carey’s analysis
Tooth size ratio
Bolton’s analysis
Facial photographs
Extraoral photographs
Intraoral photographs
Evaluation of photographs
Orthopantomogram (panoramic radiography of the maxilla and
mandible)
Chronological age
Peak growth velocity
Skeletal maturation
Cervical vertebrae maturation index (CVMI)
Dental age
Facial growth spurts
Analysis of supplementary records and investigations
PA view cephalograms
Stereophotogrammetry
Technetium 99m scan
3D CT and cone beam CT
Key Points
Introduction
Orthodontic records are an essential supplement to history and
clinical diagnosis for the formulation of a comprehensive treatment
plan. Records in medicine in general and orthodontics, in particular,
are of greater significance since they are the only evidence of pre-
treatment occlusion, which is irreversibly altered by the treatment.
The records are essential to back reference and analyse treatment
outcome, success and failures. They are the most reasonable evidence
to patient–doctor and medico legal disputes. Records are most useful
aid in education and research.
The production, retention and archiving of precise and accurate
patient records is an essential part of the orthodontists’ professional
responsibility. Records must be permanent, lasting, durable and
should remain unaltered. The vital information required to diagnose a
malocclusion and develop an orthodontic treatment plan consists of a
record of detailed history, and clinical examination (Chapter 12) and
other essential diagnostic investigation records. These include the 3D
imprint of the existing malocclusion/occlusion through study models
or intraoral scans, the face in profile through photographs, craniofacial
skeleton through cephalograms and status of dentition via X-ray (S).
Additional investigations must be performed in cases of complex
situations. This chapter is devoted to diagnostic investigation records
and their interpretation.
The essential or minimum diagnostic records

The minimum set of orthodontic records includes study models,
clinical photographs, panoramic and lateral cephalometric X-rays.
Although in recent times concern views on the essentiality of X-rays
are drifting to exclude those children whose malocclusion is such that
X-rays will not add substantial information to clinical findings.
Additional records and investigations

These may include additional X-rays such as occlusal views, PA
cephalogram, tomograms of TMJ, 3D computed tomograms, and
biochemical studies related to bone metabolism, and technetium scan.
The nature and severity of deformity and search for aetiology would
decide the type of further investigations to be carried out.
Orthodontic study models
The study models are the first in the order of records to be obtained
and of greatest importance in orthodontic diagnosis and treatment
planning. Plaster study models are prepared from well-extended good
quality alginate impressions. The digital models can be obtained
through either intraoral scanning or 3D scanning of the impression(s).
These replicas allow the teeth and associated dentoalveolar segments
to be examined from all possible views, the buccal, lingual and
occlusal, which may not be possible clinically.
Good study models will show dentition, dentoalveolar structures
and well-defined sulci, frena and palate. An impression for a good
study model should extend over all teeth and well into the sulci; if
necessary, the orthodontic impression tray may be modified by the
addition of wax to ensure full coverage of the dentition and extension
to record vestibular depth. Good and error free alginate impressions
showing surface details without distortion or voids are prerequisites
for preparing a set of clean and accurate plaster models. Beading wax
is usually applied to the periphery of the orthodontic impression tray
to extend the alginate deep into the sulci. Alginate impressions should
be poured immediately or within 15 minutes of its recording to avoid
distortions due to dimensional changes. After thorough washing and
gentle air dry, impressions are poured with orthodontic grade white
stone plaster. Models are mounted on bases and so trimmed in the
laboratory that when placed on their bases, patient’s occlusion is
replicated.
Parts of a study model: An orthodontic study model consists of two
parts (Figs. 13.1 and 13.2).
1. Anatomic region. The anatomic part of the study model consists

of the actual impression of the dental tissues and arch and its
surrounding structures.
2. Artistic region. The artistic part of the study model consists of a
symmetrical plaster base that supports the anatomic portion
and helps in analysing the occlusion and orientation of the
study models.
FIGURE 13.1 Orthodontic study models.

(A,B,C) Well-trimmed dental study models in centric occlusion are a
prerequisite and are the most important orthodontic diagnostic record.
FIGURE 13.2 Parts of orthodontic study models and preparation
guidelines.
A, B. These figures serve as a guide for preparation of orthodontic
study models.
The ratio of the anatomic portion to the artistic portion should be

3:1. Preferably both the anatomic and the artistic parts should be
poured in the same orthodontic grade dental stone.
Each set of study models should be trimmed to the most exacting
specifications (American Board of Orthodontics recommendation),1
smoothened with fine grade sandpaper, and polished to a high gloss
finish, clearly inscribed with the patient’s particulars on the back of
the model bases.
• Name or initials
• Unique hospital identity (UHID) number/registration number
(ID)
• Age/DOB, sex
• Date of impression
• Stage of treatment, that is, pre-treatment/stage/post-
treatment/follow-up
The maxillary model should be symmetrical with the top of the

model being parallel to the occlusal plane. The back of the model
should be perpendicular to the midline of the palate as indicated by
the orientation of the mid-palatal raphe. The plaster model, when
placed on its back, should be such that the top of the cast or the model
should be parallel to the occlusal plane of the teeth. The anatomical
base of the maxillary model should be 13 mm thick. The total height of
the cast should measure 35–40 mm from the occlusal surface to the top
of the model. It is advisable to use mid-palatal raphe as a guide since
the dental midlines are often not coincident with the skeletal midlines.
With the mandibular cast in occlusion with the maxillary cast, the
bottom of the lower base should be parallel to the upper base. The cast
should be such that the base of the lower model is equal in thickness
to that of the maxillary model. The total height of both casts in
occlusion should be about 70–75 mm.
The angle between the lateral surfaces of the maxillary cast should
be 65 degree to the posterior surface, whereas, it should be 55 degree
for the mandibular cast. Posterior corners of the cast are perpendicular
to a line formed between the intersection point of the posterior and
lateral surfaces and the intersection point of the lateral and frontal
surfaces of the cast on the opposite side. The length of the corner
segments should be 13–15 mm. The models should be polished and
trimmed with exacting symmetry and specifications. ABO allows a 5
degree tolerance in base angles.
In day-to-day practice, dental models can be mounted on
preformed plastic bases. Occlusion for dental plaster models is
determined by placing the separated, properly trimmed study casts on
a flat surface and then bringing them together into maximum
intercuspation.
Pre-treatment study models

The study models are prepared to record the initial/baseline
malocclusion of the patient.
i. Study models enable a direct assessment of the malocclusion

and facilitate measurements of the dental arches, the size of
teeth, and calculation of the space required for the correction
of malocclusion.
ii. Pre-treatment study models also serve as a replica of the
occlusion and dentition to objectively record traits of
malocclusion like overjet, overbite, canine relation and buccal
segment relation.
iii. Study models help in assessing the nature and severity of the
malocclusion and are a valuable aid in total space analysis,
being an essential requisite for this invaluable diagnostic
procedure.
iv. They are used to assess and record the dental anatomy, the
intercuspation of the teeth and also to detect the abnormalities
like localised enlargement or distortion of the arch form.
v. The molar relation can be assessed from the lingual aspect also,
and this is an advantage, as occlusion cannot be assessed from
the lingual aspect when examining the patient clinically.
vi. Dental midlines can be matched with the use of the study
models. For determining the skeletal midline, the facial
examination has to be carried out, as this cannot be established
with the study models alone.
vii. They also help in explaining the treatment plan to the patient
and parents and are also helpful in the assessment of the
treatment progress and in motivating the patient.
viii. Study models also help to give the patients a clear
perspective as to what the prescribed treatment will
accomplish.
ix. It is a three-dimensional presentation aid that allows patients
to see their mouth structure and more quickly identify what is
wrong. The patient can touch it, handle it and see it from all
sides rather than only looking at a picture.
x. The use of study models in case presentation allows a ‘co-
diagnosis’ approach. We can also explain, using a model of
perfect teeth, the steps that should be undertaken to rectify the
problem.
Progress/stage and post-treatment study

models
Orthodontic study models occasionally prepared, as ‘progress’
records during treatment are called ‘stage models’, and those made on
the completion of treatment are known as ‘post-treatment models’.
Progress study models provide a means of recording the sequential
progression from pre-treatment through mid-treatment to completion
of therapy and several years after that.
The pre- and post-treatment and follow-up models are used to
evaluate treatment outcome, and the follow-up models are used to
record relapse. Numerous research studies have been conducted
using study models as the records. They also serve as a useful
teaching aid.
Evaluation of study models

The first step in assessing study models involves an assessment of the
symmetry. Any gross asymmetry in occlusion or dentition would be
apparent and should be recorded.
Grids and occlusograms are placed over the occlusal arches of
models to determine the exact location and amount of asymmetry in
the arch.
After that, the characteristics of dentition, their number, mesiodistal
width, rotations, crowding, ectopic positions, or the presence of
supernumeraries are assessed. The findings of intraoral examination
on dentition are reconfirmed on the models.
This is followed by an assessment of the arch form
(V/narrow/square) (Fig. 13.3), arch widths (inter-canine, inter-
premolar and inter-molar), arch length and arch perimeter. The arch
form, arch widths and arch length have considerable implications in
orthodontic diagnosis for these govern the effective space available to
accommodate dentition, govern stability of the treatment outcome and
aesthetics to a great extent. These considerations, in association with
anteroposterior movements of the dentition, will determine the
requirements for extraction if any or otherwise non-extraction
treatment plan.
FIGURE 13.3 Arch forms.

(A) V shaped, (B) becoming parabolic, (C) wide/square.
Palatal depth can be assessed using Korkhaus three-dimensional

bow divider instrument. In a case of cleft cases, the type of cleft, its
extent, any palatal fistula should be recorded.
Study models are also used to record the lateral and excursive paths
of the mandible and are important when restorative dentistry is being
planned. The study models are mounted on an articulator in centric
relation for evaluating CR–CO (centric relation–centric occlusion)
discrepancies, which may coexist in a malocclusion.
Korkhaus palatal index

Korkhaus2 considered palatal vault depth in relation to posterior arch
width. Palatal height is measured on a mid-sagittal plane in the region
of upper 1st molars at the level of the occlusal plane. The height is
defined as the perpendicular distance from the connecting line
between midpoints of fissures of both upper 1st molars to the palate.
The following formula is used (Fig. 13.4):
FIGURE 13.4 Korkhaus cast measurement instrument.

Korkhaus device is designed to simultaneously measure arch width,
arch depth and palatal depth.
High palatal depth values are indicative of narrow maxilla, and

smaller values suggest a shallow palate.
Analysis for arch length

To treat a case with extraction or non-extraction approach is one of the
most critical decisions in orthodontic treatment planning. The decision
is based on several factors; one of considerable significance is space
analysis.
Space analysis entails calculation of the amount of space available
for alignment of the teeth and the amount of space required to align
them (total tooth material or TTM) correctly.
Arch perimeter is measured as the length of the dental arch mesial
to the first molars on either side. Arch perimeter can be measured in
two ways:
1. By contouring a piece of soft brass wire to the line of occlusion

such that it passes from mesial first molar of one side to the
other side, over contact points of the posterior teeth and incisal
edges of the anterior teeth (Fig. 13.5A).
2. By dividing the dental arch into segments that can be
measured as straight-line approximations of the arch.
FIGURE 13.5 Measuring the arch perimeter.

(A) An arch perimeter is measured from mesial of the first molar of one
side to mesial of the first molar on another side with the help of a soft
brass wire, which is contoured as a curve following the contact points
of teeth in a smooth curve looking at basal skeletal arches. (B)
Alternatively, the arch perimeter can be measured between mesial of
first molars in segments.
The arch perimeter is the sum of the lengths of the segments

connecting points 2, 4, 6, 8, 10, and 12. Points 2 and 12 are contact
points mesial to the permanent first molars. Points 4 and 10 are
contact points mesial to the first premolars. Points 6 and 8 are contact
points distal to the central incisors (Fig. 13.5A and B).
Total tooth material

The amount of space required can be determined by measuring the
mesiodistal width of each tooth mesial to the first molar on either side
and then summing up the mesiodistal widths of the individual teeth.
The mesiodistal width of each tooth should be measured as close to
the contact point as possible (Fig. 13.6).
FIGURE 13.6 Measuring the arch length.

(A) The arch length is measured from mesial of the first molar to
another side of the first molar with the help of soft brass wire. The wire
is contoured as a curve following the contact points of teeth in a
smooth curve looking at basal skeletal arches in the buccal region and
at the base of the maxilla, which is the post-treatment position of the
anterior teeth. (B) Alternatively, the arch length can be measured from
mesial of the first molar to another side of the first molar in segments
as shown in the figure.
The instruments used for the measurement of the tooth dimensions

are either a sliding or digital Vernier caliper.
If the arch perimeter is more than the total tooth material (TTM) (as
determined by sum of the mesiodistal widths of teeth mesial to first
molars), then the spacing between the teeth can be expected. On the
other hand, if the TTM or the space required is greater than the
amount of the space available, there is arch length/perimeter
deficiency, and crowding would occur (Figs. 13.6 and 13.7).
FIGURE 13.7 Measuring the tooth size.
The vernier caliper is used for the measurement of mesiodistal width of
the individual tooth. The total tooth material is the sum of mesiodistal
widths of teeth mesial to the first molars.
Arch length versus arch perimeter
Arch length and arch perimeter are two different entities that have
often been misused to denote each other.
While arch perimeter is measured as a geometrical dental arc,
formed by the teeth at their incisal/cuspal edges, arch length is the
one, which denotes basal perimeter on the skeletal bases, where the
teeth should be placed in normal alignment.
In the case of a normal occlusion with a correct labiolingual
placement of anterior segment, the arch length and arch perimeter
would have similar values. While in a case with proclined maxillary
anterior teeth, the arch perimeter would be greater.
Measuring arch length on the maxillary arch requires an
experienced eye to visualise the correct placement of incisors on the
basal arch. It may be a good idea to look at the dentoalveolar segment
and proclination of the anterior teeth, from a lateral view while
holding the model at eye level. One needs to look at the anterior
contour of the alveolus and locate the deepest point on the labial sulci.
The maxillary cast is then placed on a flat base such as a table and
viewed from the top of the occlusal surfaces and palate to make a
judgment about the proclination of the incisors and location of the
base of the maxilla just occlusal to the anterior nasal spine.
The arch length is measured by contouring a piece of brass wire on
the occlusal view, such that it is aligned along the dentoalveolar
segments from the posterior to the anterior, the ideal position of the
teeth. The incisor edges would be about 2 mm labial to the deepest
point on the labial segment of the alveolus, which governs the anterior
limit of the maxilla. In other words, the clinician has to visualise post-
treatment position of the incisal edges, and that is the point of
placement of the brass wire in the anterior segment. In lateral
segments, the archwire follows the contact points on the maxillary
teeth. In case the arch is narrow or wide, adjustments have to be made
accordingly. The length of the brass wire is marked mesial to first
molars and measured on a ruler.
The available arch length implies the actual arch length of the
dentoalveolar segments on the bony bases where all teeth in the arch
need to be accommodated in normal alignment without
crowding/spacing, with proper mesiodistal angulation (tip) and
labiolingual position (torque).
If there is not enough room on the basal arch to accommodate the
teeth in proper alignment and position, the outcome is
crowding/protrusion, or a combination of both.
Arch length deficiency

Children exhibit arch length deficiency because either the arch length
is too small to accommodate the size of the teeth or the child may start
with an adequate arch length but may develop a deficient arch length
from a variety of environmental factors such as proximal caries or
early loss of deciduous molars. Tooth size arch length discrepancies
can express as premature exfoliation of primary canines when the
permanent lateral incisors erupt more so in the lower arch. The
eruption of the permanent incisors either too far labially or lingually
outside the line of the arch is indicative of arch length deficiency.
Midline shift due to unilateral loss of primary canine in the mandible
is of common occurrence.
Analysis of arch length during mixed
dentition
The permanent incisors of children are much larger in mesiodistal
widths than their corresponding primary incisors. In some situations,
eruption of the permanent incisors result in marked crowding during
mixed dentition. For these children, a tooth size arch length analysis
can provide answers about future crowding and the basis for an
appropriate treatment plan. Methods of analysis of arch length during
mixed dentition are:
1. Radiographic
2. Non-radiographic
3. A combination of above.
Radiographic method
To analyse the space requirement in mixed dentition, it is necessary to
estimate the size of unerupted permanent teeth on radiographs and
calculate the space required using study models (Figs. 13.8 and 13.9).
Traditionally, IOPA radiographs have been used to measure the
mesiodistal widths of the unerupted teeth.
FIGURE 13.8 (A) The Orthopantomogram (OPG) is taken to evaluate

the number, position and eruption status of the successive teeth in the
dental arch. The red arrow indicates measurement of the mesiodistal
width of a second premolar. (B) Intraoral, periapical radiograph (IOPA)
of a child in mixed dentition. The mesiodistal widths of canines and
premolars are directly measured on radiograph taken by long cone
method.
FIGURE 13.9 The space available in the arch of a case of mixed

dentition can be measured with a caliper.
The space required is the sum of the mesiodistal widths of unerupted
first premolar and second premolar. The combined mesiodistal width of
deciduous canine and two molars is greater than combined mesiodistal
width of permanent canine and two premolars. The difference is called
leeway space.
Disadvantage
The measurement of tooth size from the radiograph is not free from
error due to the inherent distortion of the radiographic image.
Radiographic methods are based on the principle that if we measure
an object, which can be seen both on the radiograph as well as in a
cast, then we can compensate for the enlargement of the radiographic
image. The amount of distortion can be calculated, and the correct
mesiodistal width of the crown of the unerupted tooth can be
calculated by using the following formula:
X1 = width of unerupted tooth whose width is to be determined
X2 = width of the unerupted tooth on the radiograph
Y1 = width of erupted tooth as measured on the cast
Y2 = width of the erupted tooth as measured on a radiograph
As the accuracy of this method is dependent on the quality of the

radiographic image, periapical films are preferred over panoramic
films.
Advantage
This method is a very easy, practical and relatively accurate method
that does not require any prediction tables and can be used in
maxillary and mandibular arches.
Non-radiographic method
Researchers have calculated correlation among the size of anterior and
posterior teeth. By measuring the size of an erupted anterior tooth, it
is possible to predict the size of the unerupted canine/premolar from
the prediction table. The main advantage of non-radiographic
prediction methods is that they can be performed by measuring the
erupted mandibular incisor(s) without the need of additional
measurements from radiographs. However, these measurements are
less accurate and have a larger standard error as compared with the
correctly adjusted radiographic methods.
i. Moyer’s analysis3
This mixed dentition analysis utilises Moyer’s prediction tables.
Prediction is based on the premise that there is a reasonably good
correlation between the size of erupted permanent incisors and the
unerupted canines and premolars. A person with large teeth in one
part of the mouth will have large teeth elsewhere also, presumably
having been controlled by the same genetic mechanism (Table 13.1).
Table 13.1
Moyer’s analysis probability tables for predicting the
sizes of unerupted cuspids and bicuspids
Advantages
• It can be done with equal reliability by the beginner and an

expert.
• It is not time consuming and does not require any special
equipment.
• It can be done on the mouth as well as on the cast.
• Mandibular incisors are used for the prediction of both the
mandibular and maxillary cuspid and bicuspid widths.
Step by step procedure for the use of Moyer’s probability tables
• Measure and obtain the Mesiodistal widths of the four

permanent mandibular incisors and find that value in the
horizontal row of the appropriate table (sex-wise).
• Read downward in the appropriate vertical column to obtain
the values for the expected width of the cuspids and
premolars corresponding to the level of probability.
• Moyer used 75% of probability rather than the mean of 50%
since the values distribute generally towards crowding and
spacing. Crowding is a much more serious clinical problem
and 75% predictive values thus protect the clinician on the
safe side.
The amount of space available for the eruption of permanent

canines and premolars is determined by measuring the distance
between the distal surface of lateral incisor and the mesial surfaces of
the first molar.
The predicted value is compared with the available arch length to
determine the discrepancy. If the predicted value is greater than the
available arch length, crowding of the teeth can be expected. Whereas,
if the predicted value is lesser than the available arch length, it will
result in the spacing of the teeth.
ii. Tanaka and Johnston method4

Tanaka and Johnston developed prediction tables that were similar to
those of Moyer’s. While information on correlation coefficients and
standard errors of Moyer’s method, was not available, the correlation
coefficient (r) of Tanaka and Johnston method were 0.63 for maxillary
teeth and 0.65 for the mandibular teeth. The standard error was 0.86
mm for the maxillary teeth and 0.85 mm for the mandibular teeth.
• Estimated width of the mandibular canine and premolars in

one quadrant is determined by adding 10.5 mm to the
measured value of half of mesiodistal width of four
mandibular incisors.
• Estimated width of the maxillary canine and premolars in one
quadrant is determined by adding 11 mm to the measured
value.
This is a reasonably accurate method of mixed dentition space

analysis and does not require either radiographs or reference tables.
Combination method
i. Staley and Kerber method5–7

This method uses both IOPA X-rays and measurements on dental
casts. A revision of Hixon and Oldfather mixed dentition prediction
method (1958) was undertaken by Staley and Kerber on the same
group of subjects used initially by Hixon and Oldfather8. These
subjects were among those who participated in the Iowa Facial
Growth Study.
Based on equations and computerised data analysis, significantly
improved prediction equations were developed. A graph was made
for clinical use in the prediction of mandibular canine and premolar
widths in mixed dentition patients. This prediction chart is accurate to
the nearest 0.1 mm. Their method requires measurement of the
incisors on models or directly in the mouth and of mandibular
premolars on radiographs.
Step by step procedure for analysis:
1. Measure and add up widths of mandibular central and lateral

incisors on one side.
2. Measure the widths of unerupted premolars from IOPA
radiograph of the same side.
3. Sum of 1 + 2.
4. Use the prediction graph to calculate widths of unerupted
canine and premolars.
For example, in a patient, if the sum of the central and lateral incisor
cast widths and the radiographic widths of the first and second
premolars on the right side are 28.0 mm one finds 28.3 mm on the
horizontal axis and follows it upward to the prediction line, which
runs diagonally across the graph. From the point of intersection on the
prediction line, one moves left to the vertical axis to find the estimated
sum of the right canine and premolar widths (approximately 22.0
mm) (Fig. 13.10).
FIGURE 13.10 Hixon and Oldfather prediction graph.
Staley and Kerber developed a prediction chart based on Hixon and
Oldfather which is accurate to the nearest 0.1 mm. Teeth numbers are
according to ADA/Universal tooth numbering system. 20 (lower left 2nd
premolar), 21 (lower left 1st premolar), 22 (lower left canine), 23 (lower
left lateral incisor), 24 (lower left central incisor), 25 (lower right central
incisor), 26 (lower left lateral incisor), 27 (lower right canine), 28 (lower
right 1st premolar), 29 (lower right 2nd premolar), X-ray.
If measurements were available for only one side of the arch, it can
be reasonably assumed that the prediction for one side would be
similar to that of the opposite side of the arch.
• Measurement of severely rotated premolars on radiographs is

best avoided.
• A long-cone periapical radiographic technique should be used
in conjunction with this method.
The simple computations and the convenient graph make this

prediction method suitable for clinical use. The standard error of
estimate for the prediction graph is 0.44 mm (Fig. 13.10).
All the methods used to predict the widths of unerupted premolars
and canines in the mixed dentition patient are subject to some error.
Methods and estimates with minimal error are obviously preferable to
those with larger errors.
Staley and Kerber method was comparatively more accurate than
the Hixon and Oldfather method.
The reasons for improvement were:
• Use of a computer, which employed 16 significant digits in its

computations. Hixon and Oldfather did not have the use of an
electronic computer.
• Oldfather’s measurements were taken on one side of the arch
only, most commonly the left side, whereas measurements
were taken on both sides of the arch for the Staley and Kerber
method.
• Hixon and Oldfather used a Boley gauge that read to the
nearest 0.1 mm, whereas Helios dial callipers reading to the
nearest 0.05 mm were used in the Staley and Kerber method.
• Premolars that were rotated on the radiographs were not
measured and excluded for data analysis in the Staley and
Kerber method but were measured by the Hixon and
Oldfather method and included in data analysis.
Formulation of probability charts and prediction graphs

for mixed dentition analysis in South Indian children9
Moyer’s prediction tables were formulated primarily for American
whites. Considerable differences in tooth size measurements have
been reported in different ethnic groups. Keeping ethnic variations in
mind, Subba Reddy and coworkers formulated probability charts, and
prediction tables for South Indian children to predict the mesiodistal
width of unerupted canines and premolars, from the mesiodistal
measurement of the erupted mandibular incisors. Their sample was
derived from school children from Kerala, Karnataka, Andhra
Pradesh and Tamil Nadu. Children under the age of 12–15 years that
had fully erupted permanent mandibular incisors and permanent
mandibular and maxillary canines and premolars, having normal
occlusion were chosen. They reported values of correlation
coefficients (r value) in the range from +0.54 to +0.78, and standard
error of estimate from 0.232 to 0.820. Norms were formulated which
could be used for the Indian population.
ii. Nance’s analysis10

Nance concluded that the length of the dental arches from the mesial
surfaces of the permanent first molars of one side to the opposite
always shortened during the transition from the mixed to the
permanent dentition. His analysis takes into account the reduction in
arch length which is consequent to the mesial migration of the
permanent first molars occurring after the loss of deciduous second
molars.
Procedure
• The actual width of four mandibular incisors is measured on

the cast.
• The width of the unerupted canine premolars is measured
from the radiographs.
• In case one of the premolars is rotated, the width of the
premolar on the opposite side may be used.
• The total value indicates the amount of the space needed to
accommodate all the permanent teeth anterior to the first
permanent molars.
• The space available for the permanent teeth is determined
with a brass wire passing over the buccal cusp and incisal
edges of teeth from the first molar to first molar.
• Subtract 3.4 mm (in the mandibular arch) and 1.8 mm (in the
maxillary arch) from the total space available to accommodate
a decrease in the arch length as a result of the mesial drift (late
mesial shift – leeway space) of the permanent first molars.
Space required – space available = amount of discrepancy

Factors influencing estimation of the
tooth size–arch length analysis
Several factors may affect overall calculations and decisions on the
exact nature of the discrepancy. These are mainly related to their
labiolingual placement or proclination and curve of Spee.
Incisor inclination and position11

Orthodontic movement of lingually inclined incisors in a labial
direction increases whereas the lingual movement of the incisors
decreases the arch perimeter. According to Tweed, inclining the lower
incisors, one degree labially increases arch perimeter by 0.8 mm and
vice-versa. The inclination of the lower incisors is measured by the
angle formed by the long axis of the mandibular incisor with the
mandibular plane on lateral cephalogram. The anteroposterior tooth
position can be determined by measuring the perpendicular distance
of the incisal tip of the mandibular incisor with the nasion-B line.
The curve of Spee12

The depth of the curve of Spee is measured as the greatest depth of
the curve on both sides of the arch in the premolar region. Flattening
the curve of Spee can be achieved either by supra-eruption of
premolars, the intrusion of incisors or a combination of both. Incisor
intrusion requires additional space in the bony bases, or otherwise,
proclination will result. A curve of occlusion formula is used to
determine the additional space needed to flatten the curve of Spee.
The greatest depth of the curve is measured by placing a rigid
plastic square sheet on the occlusal surfaces of a study model, in
contact with the permanent molars and mandibular incisors. The
deepest point between the plastic plate and the buccal cusps is
measured with a Boley gauge. The depths of the curve on the right
and left sides are added, and two divides the total. An additional 0.5
mm is added to provide the total space required for levelling the
curve of Spee (Fig. 13.11).
FIGURE 13.11 Curve of Spee is the depth at the lowest tooth on a

plane from the incisor to the erupted last molar.
Carey’s analysis13
The discrepancy between the arch length and the tooth material is a
common cause of malocclusion. Carey’s analysis helps in determining
the extent of this discrepancy.
Arch length is determined by contouring a piece of brass wire
touching the mesial surface of first molars, passed over the buccal
cusp of premolars and along the incisors from one side to the other
such that it is aligned along the dentoalveolar segment where the
teeth should be ideally positioned, that is, if the anterior teeth are well
aligned and not protrusive, the wire passes over the incisal edge of
anterior. In case the incisors are proclined, then the wire is passed
along the cingulum of anterior teeth whereas if the anterior teeth are
retroclined, the wire in the anterior segment passes labial to the teeth.
The tooth material is determined by sum of the mesiodistal width of
the teeth anterior to the first molars (i.e. 2nd premolars to 2nd
premolars).
• If the difference between the arch length and the tooth

material is between 0 and 2.5 mm, it indicates minimum tooth
material excess and proximal stripping can be considered to
reduce the tooth material, or it can be treated with a non-
extraction approach.
material is between 2.5 and 5 mm, it indicates the need to
extract 2nd premolars.
material is more than 5 mm, it indicates the need to extract 1st
premolars.
Tooth size ratio
Bolton’s analysis14
Premise
Bolton’s analysis considers the ratio of the tooth material of the
maxillary arch to the mandibular arch, that is, mesiodistal widths of
upper and lower teeth. The combined and individual widths of
maxillary and mandibular teeth have a pre-determined proportion to
maintain normal occlusion relationship. An alteration in this balance
would lead to unsatisfactory occlusion which is exhibited as improper
intercuspation, overjet or spacing.
Bolton’s analysis is carried out by measuring the mesiodistal widths
of permanent teeth (except 2nd and 3rd molars) and then comparing
the summed widths of the maxillary to the mandibular anterior teeth,
and the total width of the upper and lower teeth with a standard
(Table 13.2).
Table 13.2
Bolton’s ratio chart
The anterior ratio (AR) is derived by the following formula:
Sum of MD of anterior mandibular six anterior teeth/sum of MD of
maxillary anterior six teeth × 100
Bolton’s analysis helps in determining disproportion in size

between maxillary and mandibular teeth. If there is a maxillary tooth
material excess, then it would lead to a large overjet, whereas if there
is a mandibular excess, it will lead to crowding or negative overjet.
The overall ratio (OR) is derived by the following formula:
Sum of mesiodistal widths of mandibular 12 teeth/sum of
mesiodistal widths of maxillary 12 teeth × 100
An anterior ratio less than 77.2% indicates maxillary anterior tooth
material excess whereas anterior ratio more than 77.2% indicates
mandibular anterior tooth material excess. An overall ratio of less than
91.3% indicates maxillary tooth material excess whereas the overall
ratio of more than 91.3% indicates mandibular tooth material excess.
Royal London Space Analysis (RLSA) takes into account all
possible factors that can influence use of space or make the space
available. The analysis is done in two steps (Fig. 13.12). First step
involves calculation of need for space and second step involves effect
of treatment procedures including growth. The effects of favourable
and unfavourable growth are also considered.15,16
FIGURE 13.12 Royal London space analysis.

The residue should be zero in both arches. It may be necessary to
adjust the treatment objectives to achieve this, but these must remain
attainable and not simply manipulated in order to achieve the zero
residue.
The values obtained are charted as + or −.

First step takes in to consideration crowding and spacing, occlusal
curves, arch width, anteroposterior position of labial segments,
mesiodistal angulation, and incisor inclination. The second part of the
analysis, involves effect of treatment procedures, such as extractions,
tooth-size modifications, distal or mesial molar movements, as well as
natural growth. However any space planning should be regarded
only as a useful guide, for several factors which includes growth,
biological response, and patient compliance are beyond the complete
control of the clinician.
RLSA is a reliable space analysis however it impact on decision-
making process in the treatment is questionable.17 The analysis is not
a robust model for treatment planning.18
Facial photographs19
Evaluation of facial photographs primarily involves the recording of
the findings on clinical examination for future reference and
confirmation of the clinical observations though a detailed analysis. It
may be noted that conventional photographs are two-dimensional
pictures of the three-dimensional structures. Therefore, these do not
substitute a keen and close examination of the face by the clinician.
Photographs are static images, though the recently introduced
video imaging and dynamic analysis overcome this limitation to a
great extent.
The clinical facial photographs are mainly grouped as extraoral and
intraoral.
Extraoral photographs
Extraoral facial full face photographs should be taken with the frame
from slightly above the scapula, at the base of the neck. The superior
border should be slightly above the top of the head and the right
border slightly ahead of the nasal tip in lateral profile. The left border
ends just behind the left ear. Hair should be pulled up and tied behind
to permit visualisation of the whole face.
The following views are routinely taken for orthodontic diagnosis
and treatment planning (Fig. 13.13).
The American Board of Orthodontics (ABO) requirements on facial
photographs include lateral and frontal profile and a frontal photo in
smile.
The facial photographs are taken with the subject in natural head
position and a relaxed mood. Some clinicians prefer to shoot photos
with the Frankfort plane orientation, using the cephalostat head
frame. The cephalostat head holder permits repeated orientation of
the face during and after treatment and thereby may permit a
standardised comparison. Taking an extraoral photo in the same
orientation as before in a head holder can eliminate the differences
perceived in profile due to the head tilt. Taking photos without head
holder which is an accepted method should include both ears visibly
exposed. Eyes should be open, and the person should be looking
straight ahead. Glasses are removed. The soft tissue areas of concern
and diagnostic value should be recorded in these photos. White, or
light, background, free of shadows and distractions is achieved with
quality lighting.
To evaluate the relationship of the lips and teeth during a smile, a
45 degree smile view can be added.
Intraoral photographs (Figs. 13.13 and 13.14)

Intraoral photographs supplement clinical findings of occlusion,
which are also recorded through the dental study models. Also, the
intraoral photos help review hard and soft tissue findings that exist
before treatment. These include white spot lesions, fluorosis, enamel
hypoplasia and gingival clefts. The following views are essential:
• Frontal
• Right and left buccal views
• Occlusal view of the maxilla and mandible
FIGURE 13.13 The standard set of extraoral and intraoral
photographs.
Additional views such as bird’s eye view may be needed for patients
with facial deformities, and cleft lip and palate patient.
FIGURE 13.14 Intraoral photos can record and document arch

forms and occlusion in the case of facial asymmetry and class III
pattern.
Note green line at mid sagittal plane corresponds to the maxillary
dental mid line. The mandibular mid line in red is shifted to left side.
Photographs for functional shift
In a case of a midline shift and facial deviation, which can be
observed during closing and opening, additional views may be
recorded. These include:
• Extraoral views: face at rest and in centric occlusion

• Intraoral views: frontal view at initial contact on closing, and
frontal view with the centric relation
These views are most useful in differentiating jaw deviations or

skeletal malocclusions (arising due to premature occlusal contacts)
from the true skeletal differences, particularly in growing children.
The analysis of the facial photographs is covered in the examination
of the face itself.
Evaluation of photographs
Analysis of face heights
Frontal analysis
Divide the face vertically into facial thirds by horizontal lines at the
hairline, nasal base and menton.
In the middle third, philtrum height is significant in its relationship
to the incisors and commissures of the mouth. The commissure height
should not be more than 2–3 mm greater than the philtrum height in
adults. In adolescents, philtrum height could be several millimetre
short. A short philtrum height in adults makes the maxillary lip line
unaesthetic.
The base of the nose has a ‘Gull in flight’ contour. Nares should be
barely visible when the head is in natural head position. The
columella should be slightly lower than and parallel to the alae when
viewed in any direction. The contour of the alae from the base of the
nose to its tip should be in the form of an S.
The lower third of the face comprises the upper lip which makes the
upper one-third and the lower lip and chin which make up the rest of
the lower two-thirds of the lower third of the face.
Transverse relationships
The transverse facial proportions follow the rule of fifths, that is the
face is divided into five symmetric and equal parts, and each segment
should be of one eye width.
A central fifth of the face

It is delineated by inner canthus of the eye. A line from the inner
canthus should coincide with the ala of the base of the nose, that is,
the intercanthal distance should be equal to the alar base width. This
is, however, influenced by ethnic characteristics.
The medial fifth of the face

The width of the mouth and interpupillary distance should be the
same. The line from the outer canthus should coincide with gonial
angles of the mandible, that is, the bigonial width should be equal to
the outer canthal distance.
Outer fifths of the face

From the outer canthus of the eye and gonial angles to the helix of the
ear. Racial characteristics influence this proportion to a great extent.
Profile
Lip–chin–throat angle
The angle between the lower lip and deepest point along the neck chin
contour, should be approximately 90 degree. An obtuse angle is
unaesthetic and more so as the angle increases. This often reflects:
• Chin deficiency
• Retropositioned mandible
• Lower lip procumbency
• Excessive submental fat
• Low hyoid bone position
Neck–chin–angle
Cervicomental angle should be approximately 90 degree. The angle is
more obtuse in females as compared to males. The soft tissues sag in
older individuals and contributes to less than ideal submental form.
Worm’s eye view

It is a supplemental aid in diagnostic photographic records. It is taken
with the patient’s head hyperextended to about 45 degree. It is useful
to assess asymmetry and projection of anterior cranial vault, orbital
areas and cheeks. Nasal deformities are also well documented and
studied in this view. It is especially recommended in cleft lip and
palate patients where bony deformities of one or both sides become
comprehensible. The deformities of the soft tissues of the lip and nose
area are also well studied from this view.
A worm’s eye view helps to evaluate the upper lip, nose and chin
deformities. This view is often required for evaluation of the lip
contour and nasal deformity in cleft lip and palate children. The
subject is better described in the chapter on cleft lip and palate and
facial asymmetry.
Cephalometric evaluation
(Cephalogram-lateral view) (Figs. 13.15–13.18)
FIGURE 13.15 Skeletal pattern and profile.

(A) Class I, (B) Class II large ANB, (C) Class III negative ANB.
FIGURE 13.16 (A) High angle and (B) low angle skeletal pattern:
cephalograms of two class II malocclusion patients.
FIGURE 13.17 Typical skeletal pattern of class II division 2 case.
Bony chin is retrognathic, the soft tissue chin is thick, and there is a
deep labiomental sulcus. The mandibular plane is flat and there is a
lack of antegonial sulcus.
FIGURE 13.18 A 13-year-old young girl with the chief complaint
of protrusion of front teeth.
On routine investigations, a cystic radiolucency was accidentally
discovered in the midsymphyseal region. It is somewhat visible on a
lateral cephalogram and obvious on OPG.
The clinician needs to carefully evaluate the lateral cephalogram of

the head for any gross abnormalities and pathology which may be
accidental findings in an otherwise normal child. These include fusion
of cervical vertebrae radiopacities in the cranium, lack of union of
sutures, stones in the submandibular gland or bony pathologies in the
radiograph. A number of other pathologies may be accidental
discoveries. These include supernumerary teeth, missing teeth,
odontome, taurodont or such variations of dental hard tissues.
The other important feature that needs to be related to the clinical
examination is the slope of the mandibular plane and gonial angle. A
close look at a lateral cephalogram should reconfirm the clinical
observations of ‘face’ regarding growth pattern, that is,
• Skeletal sagittal relationship: class I/class II/class III

• Growth trend: horizontal/vertical/normal
• Proclination of maxillary and mandibular anterior dentition
These observations are further confirmed by cephalometric

analyses.
Lateral cephalogram also helps the clinician in examining the
respiratory passage which may be narrow due to inherent anatomical
variations or narrowed with enlarged adenoids. Cephalograms should
also be evaluated for the assessment of soft tissues in particular
thickness at the chin.
In a nutshell, a cephalogram helps the clinician to diagnose the
components and the severity of malocclusion along with the growth
trend (Fig. 13.16).
Orthopantomogram (panoramic
radiography of the maxilla and
mandible)
Orthopantomogram (OPG) or the panoramic view of the mandible
and maxilla provides a host of information on a single film. It
provides an overview of the bony structures of the jaws and teeth
including the TMJ and dentition which may be useful, particularly in
growing children with mixed dentition where a host of information is
needed on eruption status, shedding of teeth and so on.
The technique of making an OPG involves the rotation of the film in
a cylindrical cassette and radiograph tube simultaneously around the
structures to be radiographed, that is mandible and maxilla. The
technique produces an image, which is somewhat magnified and
distorted than the conventional radiographs. Also, the magnification
may be unequal in different parts. The midline structures of the face
and dentition show greater variation than the lateral parts. The
information gathered from the OPG can be reconfirmed by other
radiographs needed for the estimation of the size and length of roots,
extent of carious lesions like proximal caries and size of the bony
lesions which may appear larger than their actual size on OPG.
An OPG should be oriented on a viewer with the left of the face to
the right of the clinician as if the patient is facing the clinician. The
OPG is throughly scanned with vigilant eyes for any abnormal
pathology or any variation from normal anatomy, which may require
further investigation. A good diagnosis can be made from a film
which has been taken and developed correctly. With the availability of
the digital OPG, it is now possible to easily adjust the contrast and
brightness of the film.
Evaluation of the OPG involves an assessment of:
1. Bony structures and symmetry (mandible, midface and TMJ)

2. Dentition and associated structures
3. Vertebra and parts of skull
4. Soft tissues
Bony structures and symmetry (mandible, midface and

TMJ)
Evaluation of the mandible can begin with the examination of the
temporomandibular joint (TMJ) and its compartments. Abnormal
situations that can exist include an abnormal flattening of the condyle
or articular eminence or any variation in size and or morphology.
It is necessary that a comparison be made between left and the right
side structures. Abnormal findings of common occurrence in condyles
include unilateral condylar hyperplasias, flat condyle heads and signs
of trauma to the condyle including malunited fracture. The condylar
fractures/haematomas are relatively common findings in younger
children, which may manifest as malunited fractures, healing fracture
lines, flat condyle heads or condyles with decreased or absent disc
space, suggestive of possible ankylosis.
While examining the body of the mandible, one should look for the
anatomical structures like the external oblique ridge, the mental
foramen, and the mandibular canal. From an orthodontic point of
view, the right and left sides should be symmetrical for ramus height,
corpus length, gonial angle and overall shape of the mandible. An
unusually short ramus is often associated with a vertical growth
pattern and skeletal open bite.
The presence of a sharp and accentuated antegonial notch is an
indicator of the hampered growth of the mandible. A prominent
antegonial notch is often seen in the cases of ankylosis of the TMJ. A
large gonial angle (open gonial angle) is observed in vertically
growing skeletal class III subjects.
Evaluation of the midface involves an assessment of symmetry of
the structures between the left and right side. A gross asymmetry will
appear on the OPG. The structures that are readily seen on the OPG
are:
• Contours of the maxilla (which limits at the tuberosity in the

2nd/3rd molar region)
• Pterygomaxillary fissure
• Zygomatic buttress/zygomaticomaxillary sutures
• Orbital rims and infraorbital foramen
• Maxillary sinus
• Floor of the mid nasal septum and the conchae
Any abnormality or pathology that is readily seen on the OPG

should be recorded. The abnormalities that may be specifically looked
for in an otherwise healthy OPG include:
• Symmetry of the structures between left and the right side for
the shape and size.
• Any deviation of the nasal septum, which may be responsible
for the partial or full obstruction of the nasal passage.
• Thickened concha in the nasal floor blocking the nasal
passages.
• Prominence of the orbital rims (a hypoplastic maxilla may
show an absence of rims prominence).
• Level of the orbital rims (an abnormal transverse cant of the
maxillary plane can be an indicator of the maxillary
deformities).
• A discontinuity of the maxillary alveolus and cleft can be
indicators of the bony cleft seen in the cleft lip and palate
patients.
Dentition and associated structures
• An OPG provides a bird’s eye view of the entire dentition and

its supporting bone. It is extremely helpful during the mixed
dentition stages, where it is important to ascertain the
number, size, eruption status of the teeth or the presence of
root abnormalities, missing or supernumerary teeth.
• An orthodontist should attempt to move teeth only if sufficient
amount of bone is available. Then the complement of teeth
present should be ascertained, which becomes all the more
important if the patient is in mixed dentition stage so that one
can relate it to the chronological age. This helps in the decision
to maintain space in cases where there is a premature loss of
deciduous teeth. Further, the decision of serial extractions
depends upon the stage of the eruption of premolars and
canines, which can be assessed on the OPG.
• The OPG X-ray may also aid in identifying the state of the
eruption of third molars.1 OPG gives an overview of the
presence of caries, restorations, periapical pathosis, bone loss,
furcation involvement, impacted/unerupted teeth,
internal/external root resorption, retained roots and marginal
bone height and also the path of eruption of teeth. Evaluation
of impacted teeth hold great importance as the angulations
and position of the impacted tooth can determine their
prognosis.
• OPG is extremely helpful in monitoring the eruption of the
permanent teeth, particularly in cases of suspected maxillary
canine impactions.
The examination of the orthodontic patient should include an
assessment of the growth status of the individual especially that of the
craniofacial complex since different parts of the face grow at different
rates and times. The developmental status of a child can be assessed
using growth indicators such as the peak growth velocity in standing
height, chronological age, radiographic assessment of skeletal
maturation, and staging of dental development. Skeletal maturational
status can have considerable influence on the diagnosis, treatment
goals, treatment planning, choice of mechanotherapy and the eventual
outcome of the orthodontic treatment.
Chronological age
There can be variation in the developmental status of the child about
the chronological age because of the ethnic differences, nutritional
status, metabolic and endocrine disorders and unknown
environmental influences. Hence, chronological age by itself is not an
accurate indicator of the stage of skeletal development of the child.
Peak growth velocity

Annual measurements of an individual’s stature over a long period
can be used to illustrate growth in one of the following two ways:
1. Distance curve or cumulative curve

2. Velocity curve or incremental curve
The distance curve is drawn by plotting the stature of a child

against age to indicate the height achieved at each age. Velocity curve
indicates the rate of growth of a child over a period. Height velocity is
expressed as centimetres per year. This subject has been discussed in
detail in Chapter 9.
Skeletal maturation
The standard age old, reliable and perhaps the most widely used
method for skeletal age evaluation is the hand–wrist bone analysis
which is performed on a radiograph. However, for an orthodontic
patient, assessment of hand–wrist radiograph entails additional ionic
radiation exposure to a growing child in addition to the routine
radiographic records. Greulich and Pyle reported a precise sequence
of hand and wrist bone ossification on hand–wrist radiographs. Since
their work in the 1950s, it has remained one of the most standard
work on skeletal growth and its association with chronological
age.20,21
Fishman (1982)22 developed the system for the evaluation of skeletal
maturity on a hand–wrist radiograph and investigated its association
with craniofacial growth. He called it skeletal maturation assessment
(SMA), which is based on skeletal maturity indicators.
The system uses only four stages of bone maturation:
1. Epiphyseal widening of the phalanges

2. Ossification of the adductor sesamoid of the thumb
3. Capping of epiphyses over their diaphyses
4. Fusion of epiphyses and diaphysis.
These stages of bone formation are found at six anatomical sites

located on the thumb, third finger, fifth finger and radius.
Eleven maturity indicators of the skeleton are depicted in Box 13.1.
Box 13.1 Skeletal maturity indicators (SMI)

Width of epiphysis as wide as diaphysis
1. Third finger—proximal phalanx

2. Third finger—middle phalanx
3. Fifth finger—middle phalanx ossification
4. Adductor sesamoid of thumb capping of epiphysis
5. Third finger—distal phalanx
7. Fifth finger—middle phalanx fusion of epiphysis and diaphysis
8. Third finger—distal phalanx
9. Third finger—proximal phalanx
11. Radius
He simplified SMI as given in the above scheme. One needs to first

look for the presence of adductor sesamoid on a thumb. If adductor
sesamoid is seen, the SMI applicable will be of sesamoid or an SMI-
based on fusion or capping (Box 13.1).
If adductor sesamoid is not seen, applicable SMI will be of early
epiphyseal widening.
Fishman found that alterations in maturational development are
directly related to growth velocity. Accelerations and decelerations in
the rate of general growth are accordingly seen in maturational
development in hand–wrist radiographs.
Maximum growth velocity for stature height occurred when
capping of epiphysis over diaphysis takes place in the middle phalanx
of the third finger in males and the distal phalanx of the third finger in
females.
Both mandible and maxilla reached maximum growth rate when
capping of epiphysis over diaphysis occurred in middle phalanx of
the fifth finger in the male group and middle phalanx of the third
finger in case of females.
The growth of the maxilla and mandible continues late after
completion of the structural height. It was mandible that showed
completion much later compared to the maxilla. Females tend to show
greater growth velocities and earlier maturation in stature in the
maxilla while mandibular velocities are higher in males. After the
growth completion, growth velocities diminish more rapidly in
females than in males.
Cervical vertebrae maturation index (CVMI)

The size and shape changes in the bodies of five cervical vertebrae
(second through sixth) are an accurate indicator of skeletal maturity.
These can be assessed on a lateral cephalogram. Since the pioneering
work of Lamparski, much research has been done in this field and its
association with skeletal maturity and craniofacial growth.23
It is now well established and proven through a series of studies
that changes in the shape of the 2nd to 4th cervical vertebrae
represented by concavity of the inferior edge and vertical height can
help determine skeletal maturity and residual growth
potential.24–26Lately, it has been demonstrated that this method was
valid regardless of the race of the subject analysed.27
Dental age
The dental age has been based on two different methods of
assessment. The most commonly used method is the observation of
age at which the primary or the permanent teeth erupt. The second
approach involves the rating of the tooth development from crown
calcification to root completion by using radiographs of the unerupted
and developing teeth. The commonly used method of dental
development stages are given by Demirijan et al.28 as follows:
Stage D. Crown formation is completed down to the
cementoenamel junction. The superior border of the pulp chamber in
the uniradicular teeth have a definitely curved form, being concave
towards the cervical region. Projections of the pulp horns, if present,
give an outline shaped like an umbrella top. Beginning of root
formation is seen in the form of a spicule.
Stage E. Walls of the pulp chamber now form straight lines whose
continuity is broken by the presence of the pulp horn, which is larger
than in the previous stage. Root length is less than the crown height.
Stage F. Walls of the pulp chamber now form a more or less an
isosceles triangle. The apex ends in a funnel shape. Root length is
equal to or greater than the crown height.
Stage G. Walls of the root canal are now parallel, and its apical end
is still partially open.
Stage H. The apical end of the root canal is completely closed. The
periodontal membrane has a uniform width around the root and the
apex.
The canine stage F indicates the initiation of puberty and stage G is
indicative of peak height velocity (PHV).
The use of dental age as a means of evaluating the developing age
of the child is not reliable because of the wide variations in the timing
of eruption, the influence of local and environmental factors, and the
fact that several or no teeth may erupt during the same time interval.
Facial growth spurts

Both boys and girls experience growth spurts in linear dimensions of
the cranial base, maxilla, and the mandible. It has been reported that
maximal overall vertical facial growth (N–Me) is coincident with
maximum standing height growth velocity.29
A modest correlation has been found between mandibular growth
rate (Ar–Po) and standing height growth velocity during the pubertal
growth spurt in males and females.
Peak mandibular growth velocity was preceded by the appearance
of sesamoid in 0.72 years for males and 1.09 years for females. Hence,
an appearance of adductor sesamoid on hand–wrist can give a
definite clue on the mandibular growth.
Hence, PHV, the state of SMA and the dental development could
provide a reasonable clue to the facial development.
PHV shows maximum correlation with the craniofacial growth.
Thus, in clinical practice, the successive height of the patients
attending the orthodontic clinic should be measured. That would be
helpful in identifying the period of growth spurts of the patients
which can be related to the craniofacial growth.
Analysis of supplementary records and
investigations
PA view cephalograms30–32
Besides taking lateral cephalograms for diagnosis and treatment
planning of an orthodontic case, a posteroanterior (PA) cephalogram
is required for the assessment of dental and skeletal widths and
skeletal asymmetries.32
PA cephalogram holds unprecedented importance in planning for
orthognathic surgery (when taking lateral and frontal VTOs), in the
treatment of facial deformities, and evaluation of the improvements in
facial or dental proportions or symmetry in transverse dimensions.
Common clinical conditions that warrant a need for PA
cephalograms for detailed analysis include the following.
Facial asymmetry associated with ankylosis of the TMJ

It has been associated with undiagnosed injury to the TMJ, malunited
fracture(s) of the TMJ and injury to TMJ during a forceps delivery.
The growth of mandible on affected side is restricted; thus on PA
cephalogram, a small ramus and corpus can be visualised with the
deviation of the chin to the affected side. There would be a cant in the
occlusal plane, which is higher on the affected side. With bilateral
ankylosis of the TMJ, both the sides are affected resulting in a small
chin, obliteration of the TMJ spaces and short ramus and corpus
length. Such cases can sometimes be mistaken for agenesis probably
because it may be impossible to identify the condyle.
Unilateral condylar hyperplasia

Unilateral condylar hyperplasia is a slow and progressive
enlargement of the condylar head resulting in excessive growth of the
mandible on the affected side and dentoalveolar and skeletal
compensations of the maxilla. It is usually seen after 10 years of age.
The PA cephalogram reveals deviation of the chin to opposite side.
The affected side exhibits a large mandibular corpus and ramus.
Condylar hyperplasia may manifest itself as a bilateral condition with
excessive growth of mandible on both the sides, presenting as an
increased transverse dimension with bulbous condyles.
Facial asymmetry
Facial asymmetry with large mandibular length can be a feature of
class III malocclusion. The large mandibular length may be
accompanied by a small or normal maxilla.
Congenital hyperplasia of the face

It is recognised at birth or soon afterwards, establishing an important
differentiation from the hyperplastic condyle, which is not evident
until the age of 10 years. The characteristic feature of this condition is
a progressive asymmetry of jaws. On serial cephalograms, it is seen
that the affected side jaws grow at a faster rate than the opposite side.
Though enlargement is present, the shape and structure of the bone
are normal.

The most common cause of asymmetry seen in PA cephalograms is
cleft lip and palate. Clefts may be unilateral or bilateral. It may be cleft
of lip, palate or alveolus, complete or incomplete. In every case, a
certain amount of asymmetry is present which can be objectively
evaluated on a PA cephalogram.
Radiography ascertains the margins of the cleft. When unoperated,
a radiolucency may be detected between the central or lateral incisor
area or lateral incisor or canine area, at the site of cleft. It is possible to
analyse the precise alteration in the outline of the maxilla and facial
bone and to localise region of a collapse of the dental arch and
adjacent maxilla. Usually, there is no alteration in lateral extent of
maxillary antrum in cleft cases. Operated cases of unilateral and
bilateral cleft lip and palate exhibit smaller transverse widths of the
maxilla and a comparatively large mandible.
Congenital and chromosomal abnormalities

They affect the craniofacial region, usually present with some facial
asymmetry and therefore, would need a detailed examination on PA
cephalogram and possibly 3D CT scan.
A PA cephalogram would require a careful and attentive evaluation
of the dentofacial and associated structures. This is usually followed
by a detailed cephalometric analysis. A comprehensive analysis of the
PA cephalogram can be performed with the tracing of the bony and
dental structures to be studied (refer to chapter on PA
cephalometrics).
The stereophotogrammetry image-based capture system is the most
promising method of recording the soft tissues. This procedure
involves the use of a pair of stereo-video cameras to capture a stereo-
image pair of each side of the face. The software then allows the
construction of a photorealistic 3D facial model. The model can be
rotated, translated and dilated on the computer screen. The stero
images can be integrated with 3D CBCT data. Two sets of data are
converted into a standard 3D file format, which can handle 3D models
with or without associated texture files.
During the planning procedure, the bone and teeth position can be
visualised accompanied by a corresponding soft tissue coordinate
change. The generic mesh would then be draped with a cartography
of the patient’s face to produce a texture-mapped image of the face.
Stereophotogrammetry has surgical and orthodontic prognostic
implications though the accuracy of the soft tissue generic mesh to the
3D CT model has not been assessed using this method of 3D planning.
With the advances in 3D photography such as 3dMD and integrated
3D photography in CBCT machines, the 3D soft and hard tissue
superimpositions are much more precise and straightforward.
Technetium 99m scan33
This technique involves imaging the skeleton using gamma emitting
isotopes or labelled radio-pharmaceuticals which when injected into
the blood stream, gets concentrated in the areas of active proliferation
or areas high in cellular activity (Fig. 13.19).
FIGURE 13.19 A case of facial asymmetry in a 21-year-old boy.
Left condyle was actively growing which was confirmed by TC scan
showing hot spot. (A) PA cephalogram shows deviation of chin to left
side. (B) OPG shows large condyle of the mandible. (C) Whole body
scan. (D) SPECT scan shows hot spot in left condyle in all the three
views.
The subject under investigation is given an injection of 20 mCi of

99mTc-labelled hydroxyethylidene diphosphonate (HEDP) in 1–2 mL
of sterile saline solution. Patient is instructed to drink a lot of fluids
during the interval between the injection and scanning. The patient is
then scanned using gamma cameras. Gamma camera provides much
better counting statistics as they detect and record all photons arising
from the field of view. The radiation dose is comparable to that of
routine radiological investigations.
In the case of inflammation, there is an increase in blood flow and
an increased metabolic activity due to the reactive bone formation.
The bone scan reflects this reactive process by a locally increased
concentration of gamma emitting isotope or labelled
radiopharmaceutical recorded as ‘hot spots’.
Conventional radiographs can only detect a trabecular bone
destruction if greater than 1–1.5 cm in diameter or loss of
approximately 50% of bone mineral, but bone scan can detect before
any radiographic abnormality is visible. A radiograph indicates
radiolucency and radiodensity which is suggestive of the bone
destruction and repair. A bone scan shows the dynamic response of
bone to the turnover processes, be it physiologic or pathologic such as
neoplastic, traumatic or inflammatory, which can be detected much
before it is visible on a radiograph.
Indications for bone scan in orthodontics

In orthodontic practice, a scan is usually recommended in cases of
abnormally growing facial bone(s), the commonest condition being
unilateral condylar hyperplasia. Technetium scan is indicated in
condylar hyperplasias to confirm the activity of the condylar active
growth site. Some surgeons would like to confirm the cessation of the
activity of condylar hyperplasia by a scan before surgery is planned.
Technetium scan can also be useful in skeletal class III cases to
reconfirm the cessation of the active growth before undertaking
orthognathic surgery.
Precautions:
• Not to be done within 10 days of the menstrual cycle in

females of child-bearing age.
• Not to be scheduled within 48 h of another nuclear medicine
procedure utilising technetium.
3D CT34 and cone beam CT

Cone beam computerised tomography was developed as an
evolutionary process of conventional computerised tomography
whereby 3D reconstruction of the objects is attained at lower doses of
radiation compared to MDCT. CBCT utilises single rotation of the
radiation source which captures the area of interest on a two-
dimensional detector. However, in a conventional CT, multiple slices
are obtained and stacked to get a 3D image.
CBCT has many applications in orthodontic diagnosis and
treatment planning, particularly in cases of facial asymmetries, jaw
deformities, cleft palate (Fig. 13.20) and canine impactions (Fig. 13.21).
It is a very useful aid in assessing bone abnormalities such as
ankylosis, dysplasia, growth abnormalities, fractures, and osseous
tumours. Cone beam CT with 3D reconstruction is a valuable
diagnostic advancement for complex cases needing major
reconstructive surgery.
FIGURE 13.20 3D reconstruction from CBCT of patient with

impacted left upper and left lower canines.
(A) Volume rendered image. Maximum intensity projection (MIP) of (B)
lateral view (C) OPG (curved linear projections). (D) Postero-anterior
view.
FIGURE 13.21 CBCT applications for impacted canines in maxilla

and mandible.
Cross-sectional (A) Raysum OPG derived from CBCT image. (B) OPG
derived from CBCT minimal thickness. (C) Cross-sectional image
derived from CBCT showing impacted left upper canine. (D) Cross-
sectional image derived from CBCT showing impacted left lower
canine.
The clinical examination and a combination of 2D radiographs may

not provide sufficient information on precise location relationship
with adjacent teeth required for the management of unerupted and
impacted teeth. 3D imaging provides invaluable additional
information about precise location, relation to the adjacent tooth
structures and root resorption. This information helps in planning
effective surgical procedures that minimise the risk of damage to
contiguous vital structures and prognosis of the treatment.
The main advantage of CBCT over the conventional CT is its low
radiation dosage which is 20% of the conventional CT or equivalent to
that of full mouth radiographs.
Key Points
Diagnosis in orthodontics is a rather complex issue, inseparable from
treatment planning. The diagnosis starts with the history itself
whereby social history, socioeconomic status of the parents, family
values, the number of siblings, history of orthodontic treatment in the
family, and such information would provide clues on the concern for
the problem, attitude towards treatment and expected level of
cooperation during treatment.
These factors often superimpose the entire planning and
considerations for the treatment.
The assessment of the malocclusion should include the analysis of
the soft tissues and underlying skeletal structures both at rest and in
function.
The malocclusion should be looked regarding its aetiology and the
possible presence of the environmental factors. The physical and
skeletal growth of the child has a direct bearing on the facial growth
and eruption of the dentition. The prediction of growth, occlusion and
facial form at maturity is the most challenging and yet an essential
component of the orthodontic diagnosis. Newly added dimension to
the diagnosis is the growth of the soft tissue integument of the face,
particularly lips, chin and nose which show sexual dimorphism.
Based on the clinical observations, analysis of diagnostic records
and history, a problem list is generated. Some factors would influence
the timings and approach to the treatment of malocclusion.
Accordingly, the problems list would have to be revised and
treatment strategies are devised to suit the individual needs. No two
children with similar malocclusion would be treated with similar
biomechanics and approach. Diagnostic records are invaluable aid in
the diagnosis and treatment planning.
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CHAPTER 14
Practical clinical photography
Akhter Husain
CHAPTER OUTLINE

Camera basics
What is a single lens reflector camera (SLR)?
The lens
The digital basics
The computer
Monitor resolution
The software
Resolution
Optical versus interpolation resolution
Printing resolution
File formats
White balance
The aperture: f-stop
Shutter speed
ISO or film speed
Flash synchronisation
The exposure
Depth of field
Ring light
Practical tips
Camera shakes and image stabilisation
Working distance
Magnification
Proper aligning
Consistency in colour
Intraoral images
Other accessories for intraoral photography
Facial photography
Frontal view
Profile view
Oblique/three-quarter view
Smile
Key Points
Biomedical imaging, including clinical photographs is an important
part of the healthcare information system, for documentation,
education and communication through visual information. Pictures
help to visualise the changes and evaluate treatment progress
instantly. The photographic imaging is also an integral component of
the research publications. It is most relevant in orthodontics, in
particular, for submitting the case records to qualifying fellowship
and other examinations. Profile photographs are used in interactive
treatment planning through the web and serve as evidence for legal
protection.
Clinicians may not always have access to the services of a
professional photographer. Therefore, with a little effort, doctors can
learn to take clinical photographs with acceptable and possibly even
astounding results. But the mysteries and intricacies of photography
have been a deterrent to many clinicians. This chapter is written in the
light of fast advancing technology in photography thus eliminating
what has become obsolete.
Camera basics
Let us understand some basic features of a camera. The market is
filled with hundreds of types and models of cameras from the most
basic to highly professional. In fact, a digital camera is a hot selling
gadget of the millennium.
The most suitable type of camera for any professional work is the
digital single lens reflector (DSLR) camera. They can range from entry
level to highly sophisticated professional DSLRs. For clinical
photography, we do not need a highly advanced camera body. Just a
basic DSLR body of any brand is suitable as long as the selection of
lens and flash is right.
What is a single lens reflector camera (SLR)?

The single lens reflector (SLR) camera is a system where the camera
body, the lens, the flash and other accessories can be integrated to suit
any picture-taking situations, say through a microscope to
photographing heavenly bodies through the telescope, or anything in
between. DSLR cameras allow the image of the object to be reflected
directly through the lens to be recorded on the sensor (Figs. 14.1 and
14.2).
FIGURE 14.1 The SLR camera body.
SLR is the most advanced and popular in high-end and professional
photographic system available, primarily because they are system
cameras with interchangeable parts, allowing customisation. (Source:
https://commons.wikimedia.org/wiki/File:Nikon_D7000_Digital_SLR_Camera_02.jpg
FIGURE 14.2 How SLR camera works?

A single-lens reflex camera (SLR) uses only one optical path to see the
image as well as to capture (unlike other breeds, like twin reflex or
range finders) by using a mirror and prism system permitting the
photographer to view through the lens and see exactly what will be
captured.
Primarily a SLR camera has a better build quality, and besides with
the advantages of interchangeable lens facility, it provides an accurate
viewing and focusing mechanism, and an unbeatable range of
exposure options and photographic modes. The SLR camera allows
the use of sophisticated and advanced features like a dedicated
flashlight and microscopic adapters. SLR camera has the additional
facility of the ‘depth of field’ preview button, which helps you to
check the area of sharpness before you shoot.
The lens
The camera lenses are classified as standard lenses similar to the
human field of vision (around 50 mm focal length) to wide-angle
lenses for taking landscapes (less than 50 mm) to tele lenses to capture
distant images (in hundreds of millimetres) (Fig. 14.3).
FIGURE 14.3 Lenses serve as the camera’s ‘eye’.

Based on their focal lengths, they are basically classified as normal
(around 50 mm), wide angle (less than 50 mm) and tele (more than 50
mm). (Courtesy: Dr. Matrishva Vyas, Nagpur)
A zoom lens is a lens with variable focus facility, which is flexible

for composing the shot, and single lens can be used from wide angle
to distant shot (Tele) depending on the range. These lenses are
preferred mostly by travel photographers for the convenience they
offer of photographing a wide range of objects without changing lens
and saving time not to miss the event/action or a mobile object such as
a bird or animal (Fig. 14.4). The close-up photos are those taken from a
relatively shorter distance from the object and aim to capture fine
details of smaller objects, for example, a single flower or petals or
wings of a small insect. The close-up photography can be performed
with a special macro lens. In clinical situations, we generally take
close-up photography.
FIGURE 14.4 A close up ring lens.

They are an inexpensive alternative to the dedicated macro lens. You
can screw one or more onto your lens and you are ready to shoot really
close. (Source:
https://commons.wikimedia.org/wiki/File:Tamron_Close-
up_Filter_Set.jpg)
Macro lens (Fig. 14.5): The macro lens is a unique lens, which
allows focusing on an object at a closer distance than a standard lens
of equal focal length. They cover the entire focusing range; hence, they
are ideal lenses for both intraoral and extraoral photography. They
possess higher quality optical system, are simple to use and allow
good working distance. In some, the macro lens is designed to
determine the magnification which can be standardised. However, a
practical and cheaper option for close-up photography with a
standard lens is to add a close-up lens in front of it. They are simple,
clear glass accessory lenses used to increase the magnification. These
are available in sets identified as 1, 2, 3 and 4. These numbers are
called dioptres, similar to those used in spectacles.
FIGURE 14.5 ‘Macro’ lenses specifically designed for close-up

work and optimized for high reproduction ratios.
Longer focal lenses provide greater working distances for a given
magnification.
While you procure diopters just make sure you get the proper
thread diameter to fit onto the standard lens of your camera. Close-up
lenses are satisfactory when used with a 50 mm lens.
The digital basics
Though forming of images in both conventional and digital
photography function through optics, the process of capturing and
storing them is different for analogue and digital systems. In
traditional photography, it is a photochemical process recorded on
film by light, and the digital camera uses a light-sensitive electronic
sensor, a device that contains tightly packed definite lines of rows and
columns of sensors. When light strikes these sensors, electronic signals
are generated, which are processed into a digital file which gets stored
in digital form on a memory card.
Digital photography has significant advantages; primarily, it is cost
effective after the initial investment. The images can be improved or
refined; colours can be balanced. Images can be stored as digital files
and can be retrieved and viewed on the monitor quickly, and there is
no ageing of photos. In these days of paperless office, it’s a great boon.
Furthermore, your comments, in spoken notes about the picture can
also be recorded as wave files, and of course, the transmission via web
to across the world is feasible.
The only disadvantage could be in losing all data, by mistake.
Hence, care has to be taken to back up the images stored in
appropriate devices.
The computer
There are two general classes of small computers: the Apple
Macintosh and the PC, both of which are suitable.
Monitor resolution
Interestingly, whether it is a 72 dpi image or a 300 dpi image, both
appear the same on a monitor and the extra dots are wasted for
viewing. But if a picture has fewer dots than what the monitor
supports, the picture will be less clear and look jagged or pixelated.
The monitor is a relatively low-resolution instrument, and it can
display only between 72 and 100 dots per inch, depending on the
screen resolu-tion that you have set which is generally either 800 × 600
or 1024 × 768. Hence, if you want images just for viewing on the
monitor or post it on the web page or send through an e-mail, then
72–90 dpi, the size of the monitor screen, is the maximum that is
required. For publication purpose, a minimum of 300 dpi resolution is
required.
The software
Plenty of softwares are available for editing the photographs, to
catalogue, to store and to retrieve the images. Adobe photoshop,
acdsee to name a few (Fig. 14.6A–B). Dolphin software has a built-in
photo editing, photo viewing options including creation of photo
collage as per American Board of Orthodontics.
FIGURE 14.6 (A and B) Software for photograph editing. (C) Though

present-day cameras provide very-high resolution images, there is
provision to shoot at different lower resolutions and various file formats
to suit your requirements.
Resolution
The term Megapixel is perhaps the most over-rated feature in a digital
camera. Many consider megapixel as the most important feature in a
camera. Besides resolution, it is the type of sensor found in the camera
that makes a huge difference regarding colour accuracy and tonal
range and the software support.
Resolution is the fineness of detail of the image represented by the
picture elements that make up the image (pixels). This is given as
horizontal and vertical numbers, as well as a total number of pixels
that make up the image. One million pixels make one megapixel. For
example, an image of 2048 width and 1536 height contains 3145728
pixels and therefore 3.1 megapixels.
Camera manufacturers give us a choice depending upon our
requirement. What do you want to do with your image? If it is for
viewing on a monitor or to send an e-mail, then a relatively lower
setting is sufficient. If it is for taking a hard copy, say a printout then
you need a higher resolution image; there again a bigger size print
will need a bigger resolution depending on what you want to print, a
poster or a postage stamp size (Fig. 14.6C).
A 3 MP camera gives a good quality 6” × 4” picture while a 4 MP is
good enough for a 7” × 5” picture. Good quality 10” × 8” or bigger
pictures can be achieved by using a 5 MP camera.
Just 3 MP are sufficient for routine clinical photography. Since
present-day cameras come with a choice of settings, a tendency is to
shoot with very high resolutions, which unnecessarily increases the
file size. You also loose the convenience of working with lower file
sizes.
Optical versus interpolation resolution

A digital image has no absolute size or resolution. It has no physical
size; all it has is a certain number of pixels in each dimension. This can
be increased or decreased using software. This process is known as
resampling. When it reduces or throws away unneeded pixels, it is
called downsampling (Fig. 14.7).
FIGURE 14.7 Interpolation.
Size of any digital image can be increased or decreased using
softwares by a process of interpolation.
There are two kinds of resolution, optical and interpolated. The

optical resolution is the absolute number with which an image is born
with, and the interpolated one is that which is invented by the
imagination of the computer, from thin air! In other words, it is
possible to print our image at any size, but at the cost of the quality.
That is, larger print size for a given image, lower the quality.
Similarly when an image size for printing is reduced, the print
quality improves.
Printing resolution
Printing needs more dots per square inch than the monitors, as the
number of dots placed on the paper must be sufficiently high so that
the eye cannot detect artefacts.
The best resolution for printing for offset publishing in books and
journals would be 300 dots per inch (dpi). More than that cannot be
appreciated as better, to the human eye.
If you ever try to get a bigger print out of a smaller file, the quality
will decrease, and it will look jagged or blurred.
File formats
A file format is a particular set of standards and instructions that
determine how the image is stored. Though there are dif-ferent file
formats, the most commonly used are JPEG. The pro-fessionals and
the journals usually insist on TIFF or RAW files for print
reproduction, though the file size is larger, for better quality print.
JPEG: (Joint Photographic Experts Group)
It is the most popular and compatible with almost all softwares. It
was developed primarily for storage as well as transmission over the
Internet. JPEG format use a very clever compression that discards all
the information that is least noticeable, hence giving only a marginal
loss of quality for a massively reduced file size.
In digital cameras, it is possible to store a large number of images
on a given memory card in this format. On most digital cameras there
is a setting for image quality at different degrees of compressions,
represented by fine, standard and basic settings.
The level of compression can also be varied depending upon the
selected quality level scale
On a scale of 1 to 10, 5-6 gives a good result.
RAW: Raw files offer ultimate image quality as they retain all the
data from the sensor. These are the images taken directly from the
sensor without undergoing processing in the camera. The processing
has to be done on the computer with the supplied or recommended
software, and they can be saved as standard JPEG or TIFF formats
separately. Though the process is time consuming it allows lots of
controls to adjust the exposure, white balance, sharpness, contrast and
saturation.
Many D-SLRs give the option to save both RAW and JPEG versions
of the shots separately.
White balance
It is important to understand that digital cameras need to establish the
quality of light, based on the percentage of each colour it is made of,
each time the camera takes a photo and has to compensate for the
effect of light on white (Fig. 14.8).
FIGURE 14.8 White balance is the process of capturing realistic
colours by determining white in an image which can vary with
different colour temperatures from various light sources.
All cameras have an auto adjust feature which is fairly accurate or

gives us an option to choose this white balance as under sunny sky,
cloudy sky, tungsten and fluorescent.
Care has to be taken to prevent a colour cast. The flashlight is
similar to day-light colour temperature.
The name of the game is to let the right amount of light to reach the
sensor to produce an image. This can be done in one of two ways; first
through varying the aperture of the lens, the size of the opening that
works similar to the iris in the eye which contracts or dilates
depending on the brightness of the light and second through varying
the duration of the aperture opening.
The length of time of the aperture opening is controlled through
shutter speed mechanism contained in the camera body, the one that
opens and closes suddenly to let in the light and hence determines the
exposure time, measured in fractions of a second.
The aperture: f-stop (Fig. 14.9)

The opening in the lens can be made larger or smaller by the circle of
blades surrounding it, controlled by rotating the ring on the lens
barrel. In present-day cameras, aperture setting is controlled using an
electronic dial. The different apertures are referred to as ‘f’ numbers,
which are marked as 2, 3.5, 5.6, 8, 11 and 22, etc. (geometric multiples).
The numbers on aperture ring are such that one setting allows only
half as much light as the preceding one and double as much as the
next one would. In other words, they are doubled as ascending values
and halved as descending values and are referred to as ‘f stops’.
FIGURE 14.9 Aperture settings.

Aperture is the opening in the lens. These f numbers are f/2.8, f/4,
f/5.6,f/8,f/22, etc. Smaller numbers means larger apertures and larger
numbers means smaller apertures.
Besides controlling the amount of light, the aperture also influences

the range of focus known as the ‘depth of field’. Wider the aperture,
lesser the depth of field. For example, if you ‘open up’ the setting from
f/11 to f/8, the aperture admits twice as much light. If you ‘step down’
from f/11 to f/16, the aperture reveals only half as much light. In
aperture setting, bigger the number, smaller is the aperture. Keep in
mind two numbers, 1 and 1.4. Double them alternatively to get the
whole series in order.
Shutter speed
The shutter speed controls the length of the exposure time. Shutters
have speeds ranging from 1/8000 s to a few seconds. They are marked
as 30/60/ 125/250/ 500/1000, etc. that are binary multiples. A shutter
speed shown as ‘120’ is 1/120, which means that the shutter is open
only for a fraction of a second. Each speed will allow half as much of
light to strike the sensor as the preceding one and double as the
succeeding one. For example, 1/30 will allow twice as much light as
1/60 would. It is interesting to note, the difference between any two
readings of an aperture is similar to the difference between the same
two shutter speeds regarding letting in the light (Fig. 14.10).
FIGURE 14.10 Various combinations of aperture and shutter
speeds can be set to receive the same amount exposure.
ISO or film speed

The third factor that affects the exposure is the ISO or FILM SPEED
setting, the sensitivity of the sensor, which can be set to low or high
depending upon available light conditions. This measure of the
sensor’s sensitivity to light, are available in a vast range from ISO 25
to ISO 3200 or even more. Smaller the number, lesser the sensitivity
used in brighter situations. Conversely, in low light situations, high
ISO can be employed, but it has to be kept in mind that higher the
setting, greater is the noise produced, resulting in grainy images. The
standard for flash or bright daylight would be between 100 and 200
ISO.
Flash synchronisation
It is the shutter speed that is needed to be set for flash photography,
which is generally 1/250 of a second. As the duration of the electronic
flash is in milliseconds, it needs to fire off when the shutter is fully
open; hence, it requires a minimum shutter speed to be set. This could
vary from one camera model to another. Any shutter speed set more
than that would lead to a partially lit picture. However, if you select a
‘Programme Mode’ this gets automatically set to a predetermined
synchronised speed whenever the flash is used.
The exposure
The shutter speed and aperture have to work in tandem to control the
exposure of an object to the sensor. Several different pairs of settings
can give the same amount of exposure, that is, for every change in the
shutter speed you can make a balance or compensate for a change in
aperture size so that you end up with the same amount of exposure
(Fig. 14.11).
FIGURE 14.11 Various exposure modes. One can chose to shoot

in any one of the various modes like aperture priority, shutter
priority manual or programme modes.
The light meter in the camera senses the intensity of light and
adjusts either the aperture or the shutter speed or both depending on
the exposure mode that is to give the right exposure. In any camera,
the different exposure modes available are:
A: (Aperture priority) here we set the desired aperture and the
camera decides the shutter speed.
S: (Shutter priority) here we set the shutter speed and the camera
decides the corresponding aperture
M: (Manual mode) here you can set both the settings in tandem to
capture the right amount of light, referring to the built- in meter. Here
you can set the desired adjustments manually.
P: (programme mode) here both aperture and shutter are
established by the computer chip depending on the application made
by the manufacturers. This button is for those who don’t want to get
into the intricacies and just let the camera decide the exposure.
Present-day cameras do an excellent job at this setting and hence are
suitable for general photography or in urgent situations where you
don’t get enough time as in photo journalism.
Depth of field
If you view any photograph (especially close-up shots or one shot
with longer tele/-lenses), not all areas in the picture are in sharp focus
(Fig. 14.12A–D). The area of sharpest focus is called a point of critical
focus. The zone of good focus is called depth of field. The depth of
field is not evenly divided on each side of best focus; it is lesser in
front. This problem does not arise while photographing flat objects
like coins or stamps. The depth of field depends on the focal length of
the lens, the aperture used and the distance between the object and the
lens. The smaller the lens aperture, greater the depth of field and this
is particularly critical for close-up work. The more you magnify, the
less is the depth of field. When you focus on incisors, the canine can
go out of focus. Generally, in clinical photography, we need the
maximum depth of field. We should aim for at least f/16 and up to f/32
for very close-up work where depth is important. Flash photography
helps here. When a flash is not available or insufficient, one can try
using a faster ISO setting.
FIGURE 14.12 Smaller the aperture used, more is the depth of
field; these toy frogs are shot at extreme aperture settings.
A, B Photographs captured using small depth of field. C, D
Photographs captured using large depth of field.
The depth of field preview button: Most 35 mm SLRs have a depth of

field preview button. This facilitates previewing the sharpness and
depth of field, though the image looks darker when this button is
pressed.
As mentioned earlier, with a flash light accessory, you can use smaller
apertures for greater depth of field, which also prevents camera or
subject movement from causing blur. The pop-up flash built in the
camera or the one mounted on the hot shoe is not good enough to
light up the oral cavity uniformly (Fig. 14.13).
FIGURE 14.13 Macro flash systems: the ideal set up. (Courtesy:
Dr. Matrishva Vyas, Nagpur)
The easy way out is to use a macro flash, which could be in a ring
form or having two small individual flashes on either side of the lens
(most preferred). With such a flash, you can photograph objects as
close as 2 in. from the lens. These have the advantage of simplicity of
operation especially when it is dedicated, which makes life easier as it
can be used in programme mode.
If the flash is not dedicated (third party), like Vivitar, Nissan (Fig.
14.14), then it should be used in manual mode only. As the shutter
speed for any flash photography is fixed, the aperture needs to be
adjusted. The disadvantage of ring flash is that light comes from all
directions and gives no shadow which produce low contrast and poor
colour separation, and the crisp details are lost.
FIGURE 14.14 Ring flash. (Courtesy: Dr. Matrishva Vyas, Nagpur)
Ring light
Recently, there was the introduction of a ring light, which is a
continuous light source that uses a string of LEDs around a ring form
to encircle the lens (Fig. 14.15). This can also be used just like a ring
flash but is less bright. The advantage is that it does not require any
dedication or even a connection to the camera and can also be used to
capture videos. This works well with an aperture priority or manual
mode. Focusing is the most important step. It is recommended that
focusing should be done using only manual mode, as it is easier to
focus exactly where its needed and also helps standardise
magnification.
FIGURE 14.15 Ring light.
Getting set to shoot requires that you are fully equipped with the
camera, lens, light conditions and have accordingly adjusted the
settings.
Practical tips
Camera shakes and image stabilisation
(Fig. 14.16)
Holding the camera in a steady grip is critical as even a slight
movement while clicking can result in a blurred image, seen routinely
in low light situations, where a flash is not used. The camera should
be held against your forehead with elbows pulled to your body, legs
slightly apart. Preferably take a breath and exhale before pressing the
shutter. While doing it, it is important to hold the camera firmly on
the right hand, which is also used to click and use the left hand to
focus.
FIGURE 14.16 Camera holding posture.
In flash-less photography, the rule of thumb is that the shutter

speed should not be slower than roughly the reciprocal of the focal
length of the lens used. Example: 1/60 s for a 50 mm lens or say 1/250 s
for 200 mm lens.
Image stabilisation: These specially made lenses have floating
optical elements connected to a spinning gyroscope which
compensates for vibration to a great extent, enabling us to take hand-
held photos almost two stops slower than regular ones. It is a good
idea for longer exposures, to stabilise the camera on a tripod.
Working distance
The distance between the front of the lens and the subject being
photographed is called working distance. Sufficient distance is
preferred as it gives space to work with. The difference between a 50
mm macro and a 100 mm macro is that the working distance is double
in the latter for the given magnification. Longer the focal length,
further away you can be from the subject to produce the image of the
same size.
Photographing the teeth and other supporting structures pose
particular challenges in standardising a series of photos during
different sequences or stages of treatment. They are of utmost
importance, especially in presentations or publications. The
magnification, composition, colour, exposure, etc. has to be
standardised.
The author recommends that the photos are always taken in
‘landscape’/horizontal format only for standardisation purpose.
Magnification
An important tip to get consistent photos regarding magnification
would be to use the macro lens in manual focus mode in a
predetermined magnification marking on the lens barrel for all similar
works. Each time one must align to this line on the lens and focusing
is done by moving the camera front and back, without using the
focusing ring. The author suggests having two marking in different
colours, one for intraoral im-ages and the other for facial photographs.
Proper aligning
Most SLR cameras come with an option of having grid lines to assist
in proper alignment of the object under photography in the
viewfinder. Grid is much helpful in aligning the midlines and
transverse occlusal plane during intraoral photography and also
compose the face during extraoral photography.
Consistency in colour
Never use dental chair light as it gets patchy and also has a different
colour temperature than daylight or flashlight. Always use the same
correct white balance setting. The intraoral, as well as extraoral views,
should be shot in the same sequence as it helps to catalogue them
sequentially in the software. Poor shots are better discarded then and
there in the camera itself.
Intraoral images
Frontal
The patient is made to sit comfortably in the upright position with
face properly oriented. Lips and cheeks can be well retracted using
properly sized retractors Self-retracting lip retractors are most
suitable, or two retractors can also be used with the help of an
assistant or a cooperative patient himself. Make sure the patient is
biting in centric occlusion.
• Occlusal plane and midline should be centred and aligned

with the help of viewfinder grid.
• Working distance standardised and manual focus is used.
• The focus is attained by moving the camera back and forth till
sharp focus is achieved on the canines to maximise the depth
of field and produce a sharp image from incisors to molars.
• There should be an equal display of posterior dentition on
both sides.
Lateral: (right and left) buccal

Central incisor to the distal surface of first molars needs to be
captured. (More posterior if possible.)
Anterior view should display the entire ipsilateral maxillary central
incisor.
Occlusal plane is to be levelled and distance standardised as before.
The lens is placed as perpendicular as possible to the buccal surfaces
of posterior teeth to prevent distortion or parallax error.
All attached gingiva should be visible.
Two retractors of different sizes are advised. The bigger side of the
cheek retractor is to be used on the opposite side to lift the lips and
smaller on the side under photography. The assistant is asked to pull
the same side as much as possible (4–6 cm more) for a very short time
to facilitate a maximum view of the molar. Minimal retractor should
be seen in the image.
Occlusal views/mirror views

Include both upper and lower occlusal pictures, and these need to be
symmetrical. The mirrors are better warmed in luke warm water and
air dried before placing in the mouth to prevent fogging. Assistants’
fingers need to kept away.
Upper occlusal
Patient’s head is tilted back by asking the patient to look at the ceiling,
open wide and breathe in. The patient himself can hold the mirror as
the assistant pull up lips preferably by two segmented cheek
retractors to expose all teeth from incisors to second molars.
Mid palatal raphae is centred.
Frame with an entire arch with minimal soft tissue displayed.
Lower occlusal
Neck bent back half way (not so far as in the upper occlusal), the
mirror is placed at an angle from distal to second molars. Lips are
pulled down and outwards. The tongue could be retracted behind the
mirror or placed low.
Labial surface of central incisor parallels to the bottom of the frame.
Midline centred in the frame.
All intraoral photographs should be free of distractions (i.e. cheek
retractors, labels, fingers). Photographs should be free of saliva and air
bubbles and the dentition should be clean and free from food debris.
Other accessories for intraoral photography

The following accessories are commonly used in clinical photography:
(Fig. 14.17): (A) intraoral mirrors, (B) cheek retractors, (C) lip retractor,
(D) occlusal contrasters and (E) anterior contrasters.
FIGURE 14.17 (A) Intraoral mirrors; (B) Cheek retractors; (C) Lip
retractor; (D) Occlusal contrasters; (E) Anterior contrasters.
Intraoral mirrors
They are available in different shapes and sizes. They could be either
highly polished stainless steel mirrors or rhodium coated mirrors.
Glass mirrors can also be used if it is front side coated as rear coated
mirrors produce double images.
Facial photography
The term Portrait Photography symbolises mainly casual or glamour
photography. The idea there is to highlight the attractive features,
hide the defects and give an overall aesthetic lift by using different
techniques of lighting. Now what we are looking at is what the author
would call facial photography which is ‘more of a science than Art’.
The idea is to reveal the truth rather than hide the blemishes.
A slightly longer than standard lens, say a 105 macro lens, used for
intraoral photography can double up as a perfect portrait lens too.
Wider lenses can give severe distortions.
High quality white light is the key to shoot facial photographs. The
simple flash mounted on camera gives far from ideal pictures
invariably producing harsh shadows.
This straightforward, direct front lighting also creates a two-
dimensional flat image losing all depth which is needed to get an idea
of the third dimension the facial contours. Front flash can also cause
red eye defect.
Multiple light units and professional studio equipment are used in
different positions to get desired effects. It is worth it though it
demands a need for some extra space. A standard setup is shown here
which can be slightly modified by some trial and error till you get it
perfect.
There are different ways to eliminate the shadows that are created
by the flash. The author has developed a simplified method, which
gives near perfect studio quality pictures without elaborate space
requirements and complicated setup.
This is a combination of two flashes used in tandem on the camera
itself. A regular flash with tilt mechanism unit fixed on the hot-shoe
mount, is used to bounce the light off the ceiling to give a soft general
lighting and a ring flash attached to the front of the lens which acts as
the frontal fill in light. This procedure eliminates harsh shadows on
the background and gives crisp details as well.
The exposure can be reliable if dedicated flash units are used in TTL
mode, or in manual setting. A bit of experimenting by using different
apertures can yield professional results.
Another method I recommend is to use one or two slave flash units
directed at the background that triggers off cordless when the master–
slave (from the camera) fires off.
If you want to add a colour to your background, one could use a
coloured gel over these background flash units; the third method is to
use a bright light box in the background such as an X-ray viewer
which nullifies the shadow that is created by flash.
The patient is made to sit upright in natural head position with both
ears equally visible, lips at rest or smiling as required, looking directly
into the lens on a rotating stool against a white matte background.
Avoid colours, or curtains, keep the background at least 2–3 ft. behind
the patient. The following views are recommended for orthodontic
patient records.
1. Frontal view with lips relaxed

2. Frontal view smiling
3. Profile view with lips relaxed
4. Three-quarter view, comfortable
5. Three-quarter view smiling.
In the case of any gross asymmetry, bilateral profiles may be taken

in addition to submental view.
Figure 14.18 shows clinical photographic arrangement according to
American Board of Orthodontics.4
FIGURE 14.18 Intraoral and extraoral images.
Frontal view
It helps in assessing major disproportion and asymmetries in
transverse and vertical planes. It is essential for the camera to be
placed perpendicular to the facial midline during exposure. Patient’s
eyes are open and looking into the camera. The ears are completely
exposed. The patient is requested to take off any distracting eyewear
or jewellery. The approximate centre of the frame is the tip of the
nose.
Profile view
The camera is placed parallel to the facial mid sagittal plane, with
head oriented to Frankfort’s horizontal plane, eyes looking straight
(tip of the eyelashes of the opposite side is not recommended as it
often leads to some rotation), and the ears uncovered, face turned
towards right side, lips in relaxed position, with entire head and neck
to be visualised.
Oblique/three-quarter view
Make sure that about half of opposite upper lid eyelashes show.
Smile
As broad a grin as possible, with the teeth showing, is particularly
required for detailed smile analysis.
The hair should be pulled back and spectacles should be removed.
Key Points
Clinical photography requires learning a few tricks and mastering the
photographic equipments.
The digital photographs enable us to review what you have shot
and retake, which is a great advantage over film photography.
A good quality camera, appropriate light, and right camera settings
is all that you need to take GREAT SHOTS.
References
1. Ahmad I. Digital dental photography. Part 1: an
overview. Br Dent J. 2009;206(8):403–407: Apr 25;
2. Ahmad I. Digital dental photography. Part 2:
purposes and uses. Br Dent J. 2009;206(9):459–464:
May 9; PubMed PMID: 19424242.
3. Ahmad I. Digital dental photography. Part 3
Principles of digital photography. Br Dent J.
2009;206(10):517–523: May 23; PubMed PMID:
19461616.
4. Ideal photographs and radiographs.
https://www.americanboardortho.com/media/1206/example-
photos-radiographs.pdf.
SECTION V
Radiation and non-radiation
imaging in orthodontics
Chapter 15: Cephalometrics: historical perspectives, methods

and landmarks
Chapter 16: Downs’ analysis
Chapter 17: Tweed’s analysis
Chapter 18: Steiner’s analysis
Chapter 19: Ricketts’ 12-factor analysis
Chapter 20: Vertical linear dimensions of face and Sassouni’s
analysis
Chapter 21: Cephalometric analysis of the soft tissue of the face
Chapter 22: Posteroanterior cephalometric analysis
Chapter 23: Interpretation and clinical applications of
cephalometric data in diagnosis, treatment planning and
prognosis
Chapter 24: Lateral, PA and 3D cephalometric superimposition
Chapter 25: Errors in cephalometrics
CHAPTER 15
Cephalometrics: historical
perspectives, methods and
landmarks
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
First cephalostat
Cephalogram: definition
2D to 3D cephalometrics
Cephalometric norms
Bolton-Brush growth study
Burlington growth study
Other growth studies
The cephalometric apparatus
Head holder
Fundamentals of head orientation
Radiographic apparatus
Principles of cephalometry
Patient positioning for recording a cephalogram
Technique of taking a cephalogram
Submentovertex projection (jug handle view)
Waters’ projection
Indications and uses of cephalograms
Features of a good cephalogram
Location of anatomical structures on a cephalogram
Unexpected findings on a cephalogram
Fundamentals of cephalometric analysis
Cephalometric norms
Cephalometric norms for Indians
Floating norms
Tracing a cephalogram
Landmarks on the cranial base
Landmarks on the mandible
Landmarks on the maxilla
Dental landmarks
The landmarks on PA films
The soft tissue landmarks on face
Soft tissue landmarks on front view of face
Upper airway cephalometric landmarks
Key Points
Introduction
The clinical speciality of orthodontia began with the sole aim to
straighten the crooked teeth for creating beautiful smiles. Soon the
focus shifted to face, the most noticeable part of the human body and
the centre of communication both with words and without words.
Face gradually assumed increasing importance in orthodontics along
with methods of correcting unevenly aligned teeth.
As the human fascination with beautiful faces took a further
stronghold, the focus of orthodontics shifted from teeth to the overall
facial framework comprising of the craniofacial skeleton and
dentoalveolar structures enveloped under the soft tissue drape, which
constitutes the face.
During Angle’s era, orthodontists assumed that the alignment of the
full complement of teeth on their respective jawbones was sufficient to
create a state of balance and harmony of the face. However, it was
soon realised that this may not always be true.
A proper occlusion with a full set of teeth does not necessarily
guarantee a pleasant face, more so in cases with underlying skeletal
dysplasia. The horizon of orthodontics expanded further to
encompass the underlying jaw bases, their relationship to each other,
and their spatial relationship to the cranium. It became apparent that a
beautiful face was the outcome of a harmonious balance of all of its
constituent parts. The science of jaw proportions and measurements
became much more relevant to orthodontics. The advent of
cephalometrics, the origin of which can be traced to 19th-century
anthropometrics and physical anthropology made it possible for the
orthodontist to look much more in depth, beyond the teeth.
Anthropologists devised and used several instruments to measure
variations in the dimensions of the human body. To measure the
height and breadth directly on the skull, they used a tool called
craniometer. The direct measurement of the human head could be
performed with a similar anthropometric instrument called
cephalometer (measurement of the head) but with much less accuracy
compared to the craniometry. The advent of radiology allowed
measurements of skull bones on radiographs through the process
known as cephalometric radiology.
The use of radiograph to photograph the human skeleton on a special
film is perhaps one of the most useful applications of physics in
medicine. Hofrath, a prosthodontist in Germany and Broadbent, an
American orthodontist, independently, yet in the same year (1931),
devised the ‘head holder’, which was used to orient the head and face
to a predetermined standardised position to make a standardised
radiograph of the skull.
Bolton added a scale to the head holder, converting it into the
Broadbent–Bolton cephalometer. Earlier, August J. Pacini (1922), an
anthro-pologist had laid the foundation by using lateral skull
radiograph in his anthropologic craniometric studies. A ‘head
position’ was desired which could be used to reproduce the head in
the previous position. That would mean that the ‘head holder’ could
be used to orient head in the same predetermined orientation and if
radiographs were taken, repeatedly in the same position,
measurements would not be distorted.
The other factors that were also standardised included the distance
between radiographic film and head. The radiographic film was
always kept on the left side of face close to the head. The distance
between the mid-sagittal plane (MSP) of the subject and source of
radiation was kept constant at 5 ft. The peak kilovoltage (kVp) and
milliampere (mA) that influence the image quality were also
standardised (15 kVp and 5 mA for adults).
A conventional cephalogram is taken with the Frankfort horizontal
(FH) plane oriented parallel to the floor. The FH plane is essentially an
anthropological landmark which has been extensively used in
craniometry. The FH plane which extends from upper margin of
external auditory meatus to lowest point on the infraorbital ridge was
mostly called as Von Ihering line (1872). This orientation plane was
accepted by the Anthropological Congress held in Frankfurt (1884)
and became popular as Frankfurt plane.
The instrument capable of taking a standardised radiograph of the
skull and face is called cephalostat, and the radiographic film with an
image recorded with this technique is called cephalogram.
First cephalostat1–3
The Broadbent cephalometer soon became popular, and it was
extensively used to study infinite variations of the human face. The
instrument which was initially used as a research tool to study the
growth of the face and jaws was quickly inducted into clinical
orthodontics. The research findings have had significant clinical
implications in diagnosis and treatment planning of growing and non-
growing children with deviations of teeth, face and jaws.
Cephalometrics soon become the language in which the poetry of
orthodontics began to be written.
Cephalogram: definition
Cephalogram is a standardised radiograph of the skull which is
obtained by orienting the skull parallel to the FH plane or a
predetermined position, which is reproducible. Natural head position
(NHP) is the second orientation that is used to record cephalogram X-
ray. The science of study and analysis of cephalogram(s) is called
cephalometrics.
2D to 3D cephalometrics
The lateral cephalogram as conventionally used is a 2D image of a 3D
skull. Efforts were made to construct a 3D model of the face by
integrating lateral and PA cephalograms. Development of the
computed tomography (CT) scan permits evaluation of any part of the
bony tissue at any depth in all the three dimensions of space. Later
research has focused on the 3D reconstruction of a face from CT scans.
With the discovery of low radiation computed scanning, cone beam
CT (CBCT), supported by sophisticated software capabilities, virtual
modelling of the skull, face and jaws has become a reality.
Cephalometric norms
The cephalograms were utilised to measure the lengths, heights and
proportions of the craniofacial and dentoalveolar structures.
Numerous angles were drawn from the stable bony landmarks in the
skull, which were used to analyse the orientation of jawbones to their
respective bases and the skull. These parameters helped to assess the
direction and amount of growth.
Cephalometrics added a much deeper dimension to the study of the
growth of human face. The findings from serial cephalograms of
growing subjects provided information on timing, velocity and
direction of the cranial and facial growth. The research findings from
longitudinal growth studies of the face had an impact on traditional
clinical thinking to consider growth implications in treatment
planning and selection of treatment modality.
It was soon discovered that there were large variations of the
human face not only from those with dentofacial deformities but also
amongst ideal or normal faces. Hence, it became apparent that there
was a need to develop ‘norms’ based on ideal/normal faces which
could be used as a standard template to compare and study the
abnormalities and deviations. These norms were developed specific to
age, sex and race.
Important cephalometric studies where serial cephalograms were
taken in a group of children over the years are:
1. Bolton-Brush growth study4

2. Burlington growth study5
No more such studies are now permitted because of ethical

considerations related to harmful effects of ionising radiation.
Bolton-Brush growth study

The Bolton-Brush growth study comprises the world’s most extensive
source of longitudinal human growth data. The Bolton-Brush study
began in 1928, as two closely aligned but independent medical
research projects. While the Brush study, looked at the physical and
mental growth of healthy children, the Bolton study focused on the
development of the head, face and neck.
The Brush enquiry was the first research project supported by Brush
Foundation, established by Charles Francis Brush, the renowned
inventor, scientist and owner of General Electric (GE) Company, in
memory of his son who died of blood poisoning at the age of 34 years.
The Bolton study originated as an outgrowth of the work of B.
Holly Broadbent Sr., an orthodontist and was funded by the late
Frances Payne Bolton—a congress woman and her son Charles
Bingham Bolton and hence, the name. The research tool primarily
comprised of annual serial cephalograms of 4,631 children aged 5–18
years (Fig. 15.1). They also recorded nutritional, dental, medical health
and yearly batteries of psychological and mental tests. The study
centre was located at Case Western Reserve University, Cleveland,
Ohio, USA.
FIGURE 15.1 Bolton Brush study set up at Western Reserve
University Cleveland, USA
. Source: Reproduced with permission from Hans MG, Palomo JM,
Valiathan M. History of imaging in orthodontics from broadbent to cone
beam computed tomography. Am J Orthod Dentofacial Orthop
2015;148(6):914–21.
Testing for the Brush enquiry ended in 1942, while recruitment for
the Bolton study ended in 1959. The two collections were officially
merged in 1970 into a massive pool of information comprising of
22,000 physical reports, 90,000 mental and psychological reports, and
over 50,000 radiographs of head and neck plus major bones of the
body.
Later Dr Broadbent Jr. developed cephalometric standards for
understanding and assessing the growth of the craniofacial complex
in 1975. It was found that face and skull continue to grow and change
throughout life. The researchers also learnt that women undergo a
little growth spurt during pregnancy due to hormonal changes.
Burlington growth study

The study was conducted by Dr Frank Popovich, at the Burlington
Growth Centre, established in 1952 at the University of Toronto,
Canada. It comprised of longitudinal data collected over a time span
from 1952 to 1972. The original sample size comprised of 1,258
children aged 3, 6, 8, 10 and 12 years, 111 siblings and 312 parents. The
goal initially was to develop parameters to study the success of
orthodontic treatment. Complete orthodontic records were taken for
all children consisting of:
Study models
Profile and frontal photographs
Lateral (rest, open bite and occlusion), posteroanterior, 45 degree
oblique cephalograms
Carpal radiographs (hand-wrist)
Anthropometric measurements
These records were obtained annually for the 3-year-old children; at
ages 6, 9, 12, 14, 16, 20 years for the original 6-year-old children and at
12 and 20 years for the original 12-year-old children. Recently, the
sample was extended to 40 years for the original 3-year-old sample
and to 70 years for the original parents’ sample. To date, there are
8,000 sets of records and 46,746 cephalograms on file. The sample is
thus one of the world’s most important collections of longitudinal
craniofacial growth and development data.
Probably, the major contribution made by Dr Frank Popovich to the
science of orthodontics was the development of the Burlington
craniofacial growth templates. These model templates plotted the
amount and direction of craniofacial growth that occurs in males and
females from the age of 4–20 years. These models are used as a
diagnostic tool in orthodontics to aid in cephalometric analysis.
Transverse, anteroposterior and vertical measurements from the
templates provide information related to the skeletal unit size and
spatial orientation of the maxilla, mandible and the cranial base. These
measurements also provide information related to the position of the
molars and incisors. All of these facts became an important part of the
Other growth studies

Denver Growth Study: University of Oklahoma, Oklahoma City, OK
Fels Longitudinal Study: Wright State University, Dayton, OH
Forsyth Twin Sample: Forsyth Institute, Cambridge, MA
Iowa Facial Growth Study: University of Iowa, Iowa City, IA
Matthews Growth Study: University of the Pacific, San Francisco,
CA
Michigan Growth Study: University of Michigan, Ann Arbor, MI
Oregon Growth Study: Oregon Health and Science University,
Portland, OR
These cephalometric collections including Bolton and Burlington
studies can be assessed at www.aaoflegacycollection.org.
The cephalometric apparatus (Fig. 15.2)
The basic components of the equipment comprise of:
A cephalostat/head holder
An image receptor system
A radiographic apparatus
Head holder
The cephalometric ‘head holder’ is the key device which is used to
orient the head to a specific relation to the ‘radiographic film’ in
superoinferior (vertical) and rotational (right to left—mid-sagittal)
plane. The head holder consists of adjustable ear rods. These are made
of metal/acrylic/and lately carbon fibres, which provide additional
strength. Nonmetallic ear rods are radiolucent.
Components of head holder/cephalostat
• Adjustable ear rods

• Orbital pointer
• Nasal support
• Film cassette holder
Fundamentals of head orientation

The X-ray film and head (object to be imaged) should be oriented to
each other in such a manner to avoid distortion of the structures
recorded on the film. It is desired that radiograph cassette holder be
kept close to the left side of the face, as close as possible within the
mechanical limits of the equipment. The radiograph cassette is placed
parallel to the mid-sagittal plane (MSP) of the head. The head holder,
which consists of two ear rods, when inserted in the external auditory
meatus aligns the head so that X-rays pass through the head without
any rotation and hence, strike the radiographic film at 90 degree
passing through the transmeatal axis of the head. The structures
which are closest to the film (anatomical structures on the left side)
show maximum sharpness and least magnification. When exposed
from the right side, the magnification factor is highest for the right
side structures and least for the left side. Modern cephalometric
machines are equipped with laser beams that indicate the true vertical
and horizontal planes (Fig. 15.2).
FIGURE 15.2 A conventional cephalometric apparatus.
The superoinferior orientation of the head is achieved by making

the anthropological Frankfort horizontal plane parallel to the floor.
This orientation of head is accomplished through the ear rods and the
orbital pointer. The head holder is so adjusted to the height of the
patient that insertion of ear rods in the external auditory meatus can
be accomplished gently with the orbital pointer kept at the orbitale;
the FH plane is achieved parallel to the floor. The modern cephalostat
has somehow got away with the orbital pointer. Therefore, the
superoinferior orientation is to be judged by the radiology technician.
The head is supported with a ‘nasal support’, which prevents
movement from the established position. The cassette holder is
movable and is aligned to the left of the head.
The neck and cervical spine should not be under any strain, and the
head remains without any rotation from left to the right.
Image receptor system

The complex arrays of parts comprising the image receptor system for
a cephalometric technique are:
• Extraoral film
• Cassette
• Intensifying screens
• Grid
• Soft tissue shield
Radiographic film
The film consists of an emulsion of silver halide crystals suspended in
gelatin-coated over a base of cellulose acetate. The size of the film is
standardised at either (8 × 10 in.), that is, (203 × 254) mm, or (10 × 12
in.), that is, (254 × 305) mm.
Cassette
Cassette is a light-tight box used to pack the intensifying screens and
the X-ray film.
Intensifying screens
Intensifying screens reduce patient exposure dose and increase image
contrast by intensifying the photographic effect of radiographs. These
are built in the film cassette.
Grid
The grid consists of alternate radiopaque strips of lead and
radiolucent strips of plastic. The radiopaque strips absorb the
secondary radiations, whereas the radiolucent strips allow the
primary X-ray beam to pass through to the film.
The digital X-ray units have substituted X-ray film with a image
sensor and images are viewed on-screen on a computer monitor. The
cephalometric analysis can be performed on-screen or the image can
be printed as a hard copy on the film (Fig. 15.3).
FIGURE 15.3 A modern digital cephalostat machine combined

with OPG.
(A) Digital cephalostat. (B) Image on screen. Cephalostat seen in the
picture has X-ray radiation originating from left side of face, right side
being closest to the sensor, which is in contrast to standard film-based
cephalostat.
Soft tissue shield

Soft tissue shield consists of an aluminium wedge placed over the
cassette or the window of the radiographic apparatus and serves as a
filter to reduce over-penetration of x-rays into the soft tissue profile.
Radiographic apparatus
The radiographic housing comprises:
• Radiographic tube
• Filters
• Collimators
• Transformers
• Coolant
The radiographic tube consists of the cathode, the anode and an

electric power supply. The anode is oriented at 15–20 degree to the
cathode to decrease the size of the effective focal spot to (1 × 1) mm2 or
(1 × 2) mm2 (Enron Line Focus principle). Long wavelengths are
filtered out by aluminium filters. The beam now passes through a
rectangular diaphragm (collimator) which determines the shape and
the cross-sectional area of the beam.
Principles of cephalometry
X-ray exposure is always on the right of the patient so that the
structures nearest to the radiographic film (left side) show the least
amount of magnification and maximum sharpness.
Distance between the X-ray source and mid-sagittal plane (MSP) of
the head is standardised at 5 ft.
The distance between the MSP of the patient and the radiographic
film is 15 cm or less.
X-ray beam is directed perpendicular to the MSP of the subject,
centred at the external auditory meatus, usually passing within 4 cm
of it.
The kVp, mA and exposure time are usually standardised for the
adult patient. However, these are usually adjusted according to the
age, race and nutritional status of the patients and other such factors
which may alter the bone density.
Most cephalometric equipments are designed to accommodate up
to 6.5 ft. of patient height.
It may be worth mentioning that in Europe and Australia a different
version of cephalostat is used. The European system has a larger
distance of X-ray source to MSP of the subject, which is 2 m and
patient exposure is done from the left side, the right side being nearer
to the radiographic film.
Types of cephalogram according to patient orientation

The three common cephalometric views are:
1. Lateral cephalogram
2. PA cephalogram
3. 45-degree view
Also, the cephalometric equipment can also be used for taking:
1. Waters’ view
2. Submentovertex (base) projection
The most commonly used cephalogram in orthodontics is the lateral

cephalogram, followed by PA cephalogram. The other views are more
useful for assessing specific structures like maxillary sinus (Waters’
view), zygomatic arch (submentovertex view/jug handle view).
Patient positioning for recording a

cephalogram
To allay apprehension before undergoing a medical investigation, the
child should be explained the steps about the procedure of recording a
cephalogram. An anxious child/person is more likely to move from an
established position during radiation exposure and thereby produce
an error in the cephalogram.
There are essentially two schools of thought about head positioning
for cephalogram:
1. Orientation along the FH plane. Anthropologic Frankfort

horizontal plane is defined as a line connecting the superior
border of external auditory meatus with the infraorbital rim.
This plane is usually 10 degree inferior to the canthomeatal
line, which runs from the outer canthus of the eye to the tragus
of the ear rods and orbital pointer.
2. Orientation according to NHP. The second school of thought
believes in recording the cephalogram in natural head position
(NHP). The natural head position is adopted by an individual
in everyday stance, where pupils are centred and individual
looks straight forward defining the true horizontal. This
position is said to be reproducible for an individual6 within a
range of 4 degree which justifies its use for recording the
cephalogram.
Technique of taking a cephalogram

The radiation protection cervical collar should be used and for
younger age group, radiation protection through lead apron is
instituted.
1. Conventionally, a cephalogram is taken along the FH plane.

The subject is asked to stand in a relaxed position under the
cephalostat head holder, which is first raised beyond the
height of the subject, with ear rods at a maximum opening and
orbital pointer/nose support turned upward to avoid injury to
the patient.
2. The cephalostat (head holder) is brought down (it should be
left at highest position after use by each case) gently to a level
to place the ear rods in external auditory meatus. At this stage,
it is necessary to look for any strain on the neck. The
cephalostat height should be adjusted for an unstrained neck
position and not vice versa, where at times, the head holder
may be slightly high or low with the subject trying to either
extend his neck or flex down. Once ear rods are in place, and
the subject is comfortable, the FH position is gently
manoeuvred—by tilting the chin/forehead up and down,
rotating superoinferiorly around the transmeatal axis.
3. The earlier models of head holders were provided with an
orbitale pointer. Orbitale, the thickest portion of the inferior
orbital rim is gently palpated, and the orbital pointer is then
moved to touch the skin in this region. Thereafter, the oriented
position is secured by a nasal support, which rests gently on
the nasal bridge.
4. The child is asked to relax, and a centric occlusion position is
checked before making the exposure. All cephalograms are
taken in centric occlusion if not indicated otherwise.
5. It is also important to ask the child to keep the lips in a relaxed
position while holding the teeth in centric occlusion. Trying to
keep teeth together with strained lips would provide incorrect
information on soft tissue parameters.
6. It goes without saying that patient’s information for the
documentation should be readily available in the film, critical
being the name, hospital registration number, unique health
identification numbers (UHID) (which enables an easy track of
the patient’s details) and the date of cephalogram.
7. Cephalograms can also be obtained with the mandible in rest
position/on first tooth contact in certain situations where there
is a functional shift of the mandible. The functional shift can be
in protrusive or in lateral excursions. In the case of the anterior
functional shift, it is important to make a cephalogram at first
tooth contact or in a forced centric relation, which may be
possible to attain in some cases. Such cases can be supported
with a wax bite to obtain a cephalogram.
8. Once machine and patient are adjusted for type of X-ray being
taken, the film is exposed to radiation. Most cephalometric
machines are tuned to 65 kVp and 10–15 mA. The exposure
varies with age of the patient, the standard being 23 s.
Submentovertex projection (jug handle view)

The jug handle view is indicated for visualisation of the facial
asymmetries and extent of displacement of the condyles or
mandibular rotations following maxillofacial trauma or in evaluating
the outcome of orthognathic surgery. The patient is placed in a head
holder with ear rods, gently and in place, but face towards the X-ray
source. The subject is asked to extend the neck so that the
canthomeatal line makes an angle of 10 degree to the radiographic
cassette holder. The X-rays pass perpendicular to film or image
receptor, passing below the mandible. This provides an excellent view
of zygomatic arches, in cases of fracture, if the film is adjusted for
underexposure.
Waters’ projection
Waters’ projection is indicated for evaluation of maxillary sinus
diseases, thickening of sinus mucosa, polyps, and carcinoma of
maxillary antrum and pyramidal fractures of the maxilla. The
radiograph is taken with the patient facing the image receptor, chin
touching the image receptor and the head tilted backwards to the
extent of canthomeatal line making a 37-degree angle. The X-ray beam
would pass through the area of the nasal cavity and maxillary sinuses.
Indications and uses of cephalograms

Cephalometrics was originally developed as a research tool to
understand the growth of human face. The understanding of facial
growth, racial variations of dentofacial structures and understanding
the location, severity and aetiology of malocclusion has enabled better
treatment options, helped to design appropriate interceptive
orthodontic/orthopaedic procedures and predict prognosis, and
evaluate treatment outcome and results.
A pre-treatment/diagnostic cephalogram is indicated to evaluate
growth trend in a child and his/her potential for malocclusion.
Pre-treatment cephalogram of a case of malocclusion helps to
establish:
1. The severity of dental malocclusion.

2. The severity of skeletal malocclusion.
3. Identify the location of dysplasia.
4. Evaluate soft tissue integument of the face and its relationship
to the dental hard tissues and skeleton of the face.
5. Evaluate nasopharyngeal airway, soft palate and position of
the tongue.
6. Aids in treatment planning, decision-making on
extraction/growth modifications/surgical orthodontics and the
type of mechanotherapy to be employed.
7. Design and plan retention strategy.
8. Stage and post-treatment cephalograms are taken to monitor
the progress of treatment and treatment outcome.
Serial cephalogram is taken at a 1-year interval to assess growth

trend.
Features of a good cephalogram

Besides a blend of sharpness, contrast and density which constitute a
good radiographic film, the other essential features of a cephalogram
are those related to head positioning (Fig. 15.4). A cephalogram is
taken with the objectives in mind that there should be a minimum
amount of magnification of the cranium and dentofacial structures
with the left and right side showing a perfect overlap, that is single
shadow. A cephalogram provides highest possible projection
resolution in which structures smaller than 0.1 mm can be discerned.
FIGURE 15.4 (A) Lateral cephalograms show a good contrast and
sharpness of skeletal, dental and soft tissue structures. Note a near
perfect overlap of right and left structures, teeth in centric occlusion and
unstrained lip posture. The neck is unstrained and ear rods nearly
concentric. (B) Soft tissue profile contrast has been enhanced with the
application of radio-opaque barium gel along the mid-line of face.
A posteroanterior cephalogram (PA ceph) is essentially used to
evaluate cranium, face, jaws and dentition in transverse and vertical
dimensions. It is used to assess facial asymmetry or symmetry in
children with developmental deformities such as:
• Arrested growth of the mandible due to injury to the TM joint.

• Excessive growth of the mandible as in unilateral condylar
hyperplasia.
• Facial asymmetry due to hemifacial hypertrophy/atrophy.
• Facial asymmetry due to trauma.
• Developmental or congenital face asymmetry.
• PA cephalograms are also used to evaluate transverse
maxillary deficiency or excessive width of the mandible.
• The outcome of maxillary expansion can also be assessed on
PA cephalograms.
It is important to mark (L) or (R) side of the head while taking a PA

view radiograph. A cephalogram taken in a correct position in the
head holder should exhibit external auditory meatus (EAM) shadows
(either rings or around radiopaque marker) in a horizontal plane.
However, this aspect may have to be ignored in children with gross
craniofacial deformities. PA cephalogram would exhibit temporal
bones, orbits, frontal and ethmoid sinuses, maxilla and its antrum,
nasal cavity, palatal floor, and the mandible from the condyle to the
symphysis.
A PA cephalogram is indicated for the evaluation of symmetry of
right and left sides and efforts should be made to distinguish any
apparent difference from true deformity from left to right side. The
rotation of head around a transverse axis may exhibit itself as facial
asymmetry.
Location of anatomical structures on a
cephalogram
1. Calvarium and base of the skull. The boundaries of the skull are
readily visible as radiopaque shadows extending from the
nasal bridge, frontal bone, parietal and occiputs encircling the
brain. The mastoid region shows air spaces. At the base of the
skull, the sellaturcica would appear as a rounded radiolucent
shadow which has anterior and posterior boundaries limited
by anterior and posterior clinoid processes.
2. The sphenoid sinus. It is seen below the anterior cranial base.
3. The frontal sinus. It can be readily seen as a pear-shaped
radiolucent shadow just above the nasal bone.
4. The orbital ridges. They appear as thick radiopaque margins
surrounding the radiolucent orbits. Dense radio-opacity is
seen at the inferior orbital margins and the orbitale point.
5. The maxillary sinus. It is a radiolucent shadow whose inferior
border is formed on the cephalogram by the superior border of
the hard palate, which extends anteriorly to make the anterior
nasal spine and posteriorly to merge with the soft palate. A
shadow of the posterior wall of the nasopharynx is easily
discernible and so is the anterior wall.
6. The mastoid sinus. It is seen as a large radiolucency usually
slightly posterior to the location of the auditory meatus, which
appears just above and distal to the condyle of the mandible.
Just below the occipital bone, an anterior triangular shadow
seen in the cervical spine is the anterior arch of the first
cervical vertebra.
7. The cervical column. It would show the vertebra and their
process.
8. The pterygopalatine fissure. It appears as a long tear drop
radiolucent shadow below sphenoid sinus and posterior to the
posterior wall of the maxillary sinus. Occasionally, it may be
possible to discern foramen rotundum in the cranial part of the
pterygopalatine fissure. The most caudal point on the base of
the sphenoid makes the anterior boundary of the foramen
magnum which makes the basion.
9. The condyles. They appear just below the petrous part of the
sphenoid and may be seen as a single shadow on a good
radiograph or appear as two slightly separated radiopaque
shadows. The opaque shadow extends inferiorly and
anteriorly from the condylar head forming the neck of the
condyle and extending anteriorly as the coronoid process of
the mandible. The posterior border of the ramus may appear
as a single line (rarely), or the slightly separated border of the
right-hand side with the two shadows gently merging down at
the gonion and lower border of the mandible.
10. Mandibular symphysis. It shows dense boundaries with dense
radiopaque shadows of the genial tubercles. The hyoid bone is
clearly visible below the mandible in a lateral view.
Unexpected findings on a cephalogram

A cephalogram should be grossly evaluated for normal anatomy as
well as for any possible pathology which may be an expected or
incidental finding.
1. Signs of either excessive or poor bone density of generalised

nature could be suggestive of systemic diseases such as
osteopetrosis or rickets.
2. An unusually large sella may be suspected for a pathology of
the pituitary gland.
3. Fibrous dysplasia is not uncommon in children and cotton
wool radiopacities may appear in radiographs much before
their clinical presentation and could be an accidental finding
on cephalogram taken for orthodontic purposes.
4. The shadows of maxillary antral polyps, sinusitis and large
turbinate in nasal cavity could be readily seen in lateral
cephalograms as well as any radiopacities or fluid levels in the
sinus.
5. Narrow nasopharynx may be the outcome of enlarged
adenoids which should be observed with diligence and may
require further investigations and specialist consultation with
the ENT surgeon.
6. The other commonly seen incidental findings on lateral
cephalograms are supernumerary or missing teeth, odontomas
and cysts of the maxilla and the mandible.
7. A prominent antegonial notch is often suggestive of hampered
mandibular growth.
8. A marked decrease in the joint space in the condyle should
warrant for more investigations such as radiograph of the TMJ.
Fundamentals of cephalometric
analysis
The cephalometric analysis involves the location of specific landmarks
on the cephalogram, which are used to make measurements of either
angular or linear variable. The angular variables reflect the spatial
relationship of the anatomical parts. The changes measured on the
serial cephalograms with treatment or without treatment indicate
alterations in the spatial relationship and therefore directions and
sometimes, the amount of change that has occurred due to growth
and treatment.
Linear measurements may be in anteroposterior or vertical direction
on a lateral cephalogram, and in transverse and vertical directions on
a PA cephalogram. These can be used as absolute values to quantify
dentofacial/cranial structures in sagittal, transverse and vertical
directions. The ratio can be calculated for certain measurements and
changes in ratio with time (growth) or treatment would be indicative
of their relative alterations.
Numerous cephalometric analyses have been suggested in the
literature by several authors and researchers. The limitations and
benefits of one analysis over others have been analysed and
researched. Some analyses are more useful for research purposes
while others are used for clinical applications in day-to-day practice.
We intend to limit our discussion to some practical aspects of
cephalometric analysis from Chapters 16 to 26. For more detailed and
extensive reading, a book on cephalometrics is recommended.
Cephalometric norms
It is known that most biologic variables like height, relative
proportions of body parts, and other biological parameters are
distributed according to some ‘normal range values’. There are
deviations from the mean /average yet within acceptable range, which
are called ‘norms’. Values beyond the range of normal are considered
as abnormal.
Morphological variations of human body and face can be attributed
to ethnic background/race/age and gender. Since malocclusion is not a
disease but a morphological variation of facial structures, in many
instances, orthodontists have tried to treat malocclusion to ‘normal
occlusion’ and also used facial skeleton as a template to match their
treatment objectives. They devised a norm model of dentofacial
structures using cephalogram as a tool of subjects with the pleasing
profile, well-balanced facial proportions and normal occlusion. The
‘norm’ values are being used to formulate treatment objectives for
cases of malocclusion.
Soon it was realised that there was a need to develop ‘norms’ for
different races. Several studies from across the world were devoted to
the development of cephalometric norms. The first available
cephalometric ‘norms’ were available for Caucasians.
Cephalometric norms for Indians

The earliest cephalometric studies in India were conducted at Bombay
as a part of MDS dissertations on Gujarati population by Kotak (1961),
Seshadri (1964); on Maharashtrians by Shetye (1962); on Parsis and
Maharashtrians by Sidhu (1969). Cephalometric studies in India were
being done till the 1990s.7,8
The first comprehensive study on cephalometric norms of North
Indians was published by Nanda and Nanda.9 Since then, many
studies have been conducted across India, and these have been
compiled into a booklet which has been published by the Indian
Orthodontic Society. Detailed and comprehensive cephalometric
norms for North Indians were developed by Kharbanda et al., which
is now used in day-to-day clinical practice.7,8
Floating norms10
It has now been realised that a case of malocclusion cannot be treated
to a template of ‘norms’, which have been derived from mean values
of a certain select group of subjects with excellent occlusion and
harmonious facial proportions. There are several limitations to
treating individuals to match with ideal norms especially with those
of skeletal type of malocclusion.
Attempts were therefore made to derive ‘norms’ for an individual
based on his skeleton and dental pattern.
Floating norms are individual norms that vary (float) by the
variation of the correlated measurements (guiding variable). Each
cephalometric variable is not independent but guided by the
underlying craniofacial pattern. Hence, its deviation from a ‘norm’
alone would not be an indicator of dysplasia. In certain situations, a
deviation of a cephalometric variable may be acceptable if a certain
relationship with other components (cephalometric variable) is
maintained.
Tracing a cephalogram
The cephalogram is labelled for the subject’s initial hospital
identification number and date of the radiograph. The hospital ID
number can be used to track all other details of the patient. The
cephalogram, like other radiographs, should be handled properly and
cared for to prevent any scratches, marks and wrinkles. It should be
kept in its paper cover sleeve and envelope without any folds, stored
in a cool place away from direct sunlight or excessive light exposure.
The following armamentarium is required for a good tracing to be
performed:
1. An X-ray illuminator/mounted on a tracing table with soft

light. The tracing table should be mounted in a room with
minimal brightness. The tracing table should also have a
control switch for controlling the intensity of light.
2. Tracing paper of good quality. Pre-cut sheets are available in 8
× 10 in. size from orthodontic suppliers.
3. Sharp 7H pencil and HB pencil.
4. Geometric set squares and protractor.
5. Tooth templates, usually supplied by orthodontic suppliers.
6. Good quality dust free eraser and transparent adhesive tape.
The cephalogram is usually traced with a tracing paper mounted,

keeping the face profile on the right side of the operator. Mount the
tracing paper using adhesive tape, on the left-hand border of the
cephalogram.
The following information is recorded on the corner of a tracing
paper:
• Name of patient
• Registration no
• Date of birth, age and sex
• Date of X-ray
• Stage of treatment
The tracing
1. Clean the tracing table, make it dust free using soft cotton
cloth.
2. Switch on the illumination.
Tracing paper should be mounted on the radiographic film in such

a way that the lower border of the paper extends about one inch
below the chin point. An orientation cross is marked on the
cephalogram film at the top left corner of the film with the help of a
sharp pointed tool. This orientation cross is transferred to the tracing
paper which serves as an orientation guide. The transfer guide helps
to orient the tracing paper back on to a cephalogram correctly. The
tracing paper is held with transparent tape on the left side. The use of
an opaque matte of blotting paper to mask all portions of the film
except the immediate areas being traced reduces eye strain and allows
far more accurate tracings in ‘faded’ areas. Excess light can be reduced
in areas of delicate, darker facial structures by looking through a black
paper cone. Fine detail may be revealed by lifting the tracing paper
from the film for an unobstructed view of the section to be studied.
All tracings should be done with a pencil with a chisel point.
The distinction between the left and right sides in bilateral
structures is difficult and is a common source of error particularly in
the teeth region. Hence, it is an acceptable practice to go by the
average of right and left structures if the skeletal or major dental
asymmetry is not involved. On the lateral film, most structures are
bilateral and if symmetrical, they double the resistance to X-ray
penetration; hence, a better contrast. Practically, even if the face is
perfectly oriented and if the bilateral structures are symmetrical, they
are not necessarily superimposed because the radiations are not
parallel but divergent. Therefore, if a double image is seen on the film,
it does not mean asymmetry. It is recommended to trace the left side
routinely since it is less magnified and more accurate.
Accurate tracing of a cephalogram is an art and requires
considerable experience in identification of the skeletal and dental
structures. The author prefers to start tracing with the soft tissue
profile of the patient, which starts at forehead going down to the
contour of the neck. Use of soft tissue filters has greatly enhanced the
visualisation of the soft tissue contours. One should not attempt to
make his own judgement about any of the contours. Smooth lines
which are visible should be followed.
The next structure which needs to be carefully traced is the bony
nasion. Outer cortex of frontal bone is traced towards the nasal bone.
It follows the nasal bone anteriorly and completes it by joining back to
the frontal bone. The frontonasal suture is often visible which should
be traced for a better anatomical presentation of the tracing.
The sella (S) appears as a sharp radiolucent shadow, except at the
anterior clinoid process. However, it is possible to demarcate the
boundary of sella by its sharp outline overshadowed by rather less
dense anterior clinoid process. Trace the anterior cranial base starting
from the cranial side of the frontal bone, going backwards to the
anterior clinoid process, sella, and posterior clinoid process and follow
the sphenoid bone—up to the spheno-occipital suture which gives a
faint outline.
The porion (Po) is located either as machine porion which is the
outer border of the metal rings seen in ear rods or anatomical portion
which is an elliptical shadow seen superoposterior to the condylar
fossa in the body of sphenoid bone. The sphenoid is a difficult area,
and considerable experience is needed to locate the anatomical porion
accurately.
The next important anatomical structure to be traced are the orbital
rims which appear as condensed arc like shadows below the anterior
cranial base, descending downwards and anteriorly where they often
get more radiopaque. Orbitale is located here, as the inferior point on
the orbital rim.
The maxillary sinus is seen as a radiolucent shadow just below the
orbital rims. The superior boundary of the palatal shadow is traced
anteriorly to form ANS which merges anteriorly into the anterior
alveolar process, the deepest point here being point ‘A’. The oral side
of palate can be traced starting at the cingulum of the maxillary
incisor backwards smudging on to the soft palate. The posterior nasal
spine (PNS) is often not clearly demarcated due to the overlying
shadow of the developing third molar.
The pterygopalatine fissure which appears as an inverse teardrop-
shaped structure marked by sharp, dense radio-opaque line
surrounding a greyish radiolucent shadow, the thin hair-like part of
the shadow merges down often into the superior border of the palate.
The thick triangular shadows below the orbital arches are the
maxillary process of the zygoma making a radiopaque buttress
descending backwards, towards maxillary first molar, can be traced
gently. The triangular density in this area signifies the key ridge.
Further, the superior border of the condyle is traced, continuing in
an anterior direction extending into pterygoid fossa, which is often
not clearly demarcated. Further, mesially, the coronoid process is
traced. It is not possible to see and trace the anterior border of the
ramus. The condyle is traced posteriorly and inferiorly which
completes the posterior border of the mandible ramus. The inferior
border of the body of the mandible is traced next. In case, two borders
are seen, both the borders are traced, and a dotted line is used to draw
a border which is average of both.
The mandibular symphysis is traced from the junction of alveolus
with the mandibular incisor, going downward into a deeper point (B),
following the contour of the chin (Pogonion) turning around
(gnathion) and completing the lingual boundary of the mandible.
The first molars and most prominent incisors are traced in both
jaws.
Commonly used cephalometric landmarks are depicted in Figs.
15.5–15.7.
FIGURE 15.5 3D CBCT reconstructed image of a skull marked

with landmarks commonly used on a lateral cephalogram.
FIGURE 15.6 Multiplanar reformatted image of the skull.
Image from slice in the midline of the skull. The condyle, ramus and
body of the mandible are not seen because they lie lateral to midline.
FIGURE 15.7 Multiplanar reformatted image of the skull from

slice at condyle and ramus of the skull.
The condyle, ramus and body of the mandible are seen; however,
structures such as sella, sphenoid and nasal spine are not seen at its
entire anteroposterior length being in the midline.
Landmarks on the cranial base

1. Sella (S). It is defined as a constructed point in the medial plane
and is defined as the centre of sella turcica.
2. Entrance to sella (Se). It is defined as the mid-point to the
entrance of sella turcica.
3. Nasion (N/Na). Defined as the most anterior point of the
frontonasal suture in the mid-sagittal plane.
4. Pterygomaxillary fissure (Pt). The pterygomaxillary fissure is a
vertical fissure which descends at right angles from the medial
end of the inferior orbital fissure. It is a triangular interval,
formed by the divergence of the maxilla from the pterygoid
process of the sphenoid.
5. Pterygomaxillare (Ptm). It is defined as a point located at the
intersection of the nasal line (NL) and the pterygomaxillary
fissure.
6. Porion (Po). Po point is an anthropologic landmark identifiable
on the skull on the superior border of the external auditory
meatus. Of the two main approaches to its definition, one was
anatomical and the other was pragmatic (machine porion).
a. Machine Porion: The superior point of the image of
the cephalostat ear rod is taken as machine porion.
Since right and left metal rings rarely overlap in
con-centricity, average of two is taken.
b. Anatomical Porion: Savara and Takeuchi11 defined
it as the most superior point on the roof of the
external auditory meatus at the border of the
external cartilaginous ear canal, it being identical to
the most superior point of the cephalostat ear rod.
7. Articulare (Ar). Ar is defined as the point of intersection of the
images of the posterior border of the ramal process of the
mandible and the inferior border of the basilar part of the
occipital bone. In 1947, Bjork introduced the term articulare.12
8. Basion (Ba). Defined as the most anterior point on the anterior
margin of the foramen magnum where the MSP of the skull
intersects the plane of the foramen magnum.13
9. Orbitale (Or). Defined as the most inferior point of each
infraorbital rim.
10. Bolton point (Bo). The highest point of the curvature of the
occipital condyle and the basilar part of the occipital bone and
located behind the occipital condyle.
Landmarks on the mandible

1. Condylion (Co). Defined as a point located on the superior
posterior contour of the mandible.14
2. Centre of ramus (Xi). Defined as the geometric centre or the
centroid of the ramus by Ricketts in 1972. The deepest point on
the subcoronoid incisures (R1) is selected, and a second point
(R2) is selected directly opposite to that on the posterior border
of the ramus. R3 is picked at a depth of the sigmoid notch; R4
is a point directly inferior in the lower border of the ramus. By
using these four points, the centroid of the ramus (Xi) is
selected by forming a rectangle and joining the corners (see
Chapter 19, Ricketts’ 12-factor analysis).15
3. Centre of condyle (Dc). It is defined as the geometric centre or
the centroid of the mandibular condyle.
4. Gonion (Go). Gonion is defined as a point on the external angle
of the mandible projected in a lateral cephalogram by bisecting
the angle formed by tangents to the posterior border of the
ramus and the inferior border of the mandible.16 The most
posterior and inferior point on mandible corpus is also called
anatomical gonion.
5. Menton (Me). Defined as the most inferior point on the
mandibular symphysis.17
6. Gnathion (Gn). Defined as the most anteroinferior point on
mandibular symphysis.
7. Pogonion (Pg). Defined as the most anterior point on
8. Centre of symphysis (D). Defined as the geometric centre or the
centroid of the mandibular symphysis.
9. Protuberance menti (supra pogonion) (Pm). Defined as the
superoposterior point on mandibular symphysis changing
from concave to convex.
10. Infradentale (Id). Defined as the most anterosuperior point on
labial aspect of mandibular alveolus or the apex of the septum
between the mandibular central incisors.
11. Supramentale (B). Defined as the deepest point on the profile
curvature from pogonion to infradentale.18
Landmarks on the maxilla

1. Anterior nasal spine (ANS). The most anterior midpoint of the
anterior nasal spine of the maxilla.
2. Posterior nasal spine (PNS). It is defined as the sharp and well-
defined posterior extremity of the nasal crest of the hard
palate.
3. Prosthion (Pr). It is defined as a craniometric point that is the
most anterior point in the midline, on the alveolar process of
the maxilla.
4. Subspinale (A). The craniometric point, that is, deepest and the
most posterior point in the midline, on the alveolar process of
the maxilla.
Dental landmarks
1. Tip of lower incisor (TLI). Defined as the incisal tip of the most
prominent mandibular central incisor.
2. Tip of upper incisor (TUI). Defined as the incisal tip of the most
prominent maxillary central incisor.
3. The apex of lower incisor (ALI). Defined as the root apex of the
most prominent mandibular central incisor.
4. The apex of upper incisor (AUI). Defined as the root apex of
the most prominent maxillary central incisor.
5. Labial surface lower incisor (LLI). It is defined as the anterior
most point on the labial surface of the most prominent
mandibular central incisor.
6. Labial surface upper incisor (LUI). It is defined as the anterior
most point on the labial surface of the most prominent
maxillary central incisor.
7. Cusp tip of upper molar (TUM). It is defined as the
mesiobuccal cusp tip of the upper first molar.
8. Root apex of upper molar (AUM). It is defined as the apex of
the mesiobuccal root of the maxillary first molar.
9. Cusp tip of lower molar (TLM). It is defined as the cusp tip of
the mesiobuccal cusp of the mandibular first molar.
10. Root apex of lower molar (ALM). It is defined as the apex of
the mesiobuccal root of the mandibular first molar.
11. The anterior point on the occlusal plane (OpA). It is defined in
the following ways:
a. The anterior point of the bisecting occlusal plane is
defined as the point bisecting the vertical overlap of
the upper and lower central incisors.
b. In the case of the maxillary occlusal plane, the
anterior point on the occlusal plane is the incisal
edge of the most prominent maxillary central
incisor.
c. When the mandibular occlusal plane is taken into
consideration, the anterior point is the incisal edge
of the most prominent mandibular central incisor.
12. The posterior point on the occlusal plane (OpP). It is defined in
the following ways:
a. The posterior point of the bisecting OpP is the point
where the mesiobuccal cusp of the maxillary molar
meets with the mandibular molars.
b. In the case of the maxillary OpP, the posterior point
on the OpP is the mesiobuccal cusp tip of the
maxillary first molars.
c. When the mandibular OpP is taken into
consideration, the posterior point is the mesiobuccal
cusp tip of the mandibular first molars.
The landmarks on PA films

Skeletal and dental landmarks on PA ceph
The bilateral points marked on the PA ceph are conveniently
abbreviated with addition of R and L for the right and left side.19 The
landmarks are described in detail in Chapter 22.
The soft tissue landmarks on the lateral profile

of the face (Fig. 15.8)
1. Glabella G Gl (Chaconas SJ et al.)20: The most prominent point

in the MSP of forehead
2. Soft tissue nasion Nsn’ (Ram S. Nanda)21 Na’ (Chaconas SJ et
al.): The point of deepest concavity of the soft tissue contour of
the root of the nose.
3. Pronasale Pn (Chaconas SJ et al.)20 Pnr (Ram S. Nanda) Pr
(Bowker and Meredith)22 no (Holdaway) nasal tip NT (Arnett
GW): The most prominent point of the nose
4. Nasal crown NC (Chaconas SJ et al.): A point along the bridge
of nose halfway between soft tissue nasion and pronasale
5. Subnasale Sn (Chaconas SJ et al.): The point where the lower
border of the nose meets the outer contour of the upper lip
6. Superior labial sulcus Sis SLs (Bowker and Meredith) SLS
(Bailey LJ)23 Soft tissue subspinaleA’(Chaconas SJ et al.): The
point of greatest concavity in the midline of the upper lip
between subnasale and labralesuperius
7. Labrale superius Ls (Bowker and Meredith) LS’ (Ram S.
Nanda) LS (Bailey LJ): The median point in the upper margin
of the upper membranous LI
8. Stomion St (Chaconas SJ et al.): The midpoint between
stomion superius and stomion inferius
9. Stomion inferius Sti: The highest point of the lower lip
10. Labrale inferius Li (Bowker and Meredith) Li’ (Ram S. Nanda)
LI (Bailey LJ): The median point in the lower margin of the
lower membranous lip
11. Inferior labial sulcus ILS (Bailey LJ): The point of greatest
concavity in the midline of the lower lip between labrale
inferius and menton
12. Soft tissue pogonion Pos, pgs (Ram S Nanda) Pog’ (Bowker
and Meredith) sPg (Bailey L J): The most prominent point on
the soft tissue contour of the chin
13. Menton soft tissue Ms,me’: The constructed point of
intersection of a vertical coordinate from menton and the
inferior soft tissue contour of the chin
FIGURE 15.8 Soft tissue landmarks used by Chaconas SJ et al.
Soft tissue landmarks on front view of face

These are mostly bilateral landmarks (Fig. 15.9)
1. Endocanthion, En: Inner commisure of palpebral fissure

2. Exocanthion, Ex: Outer commisure of palpebral fissure
3. Zygion, Zy: Most prominent point on the cheek area
4. Nasal alare Ala: Most lateral point of alar contour, upper lip
point
5. Upper lip point, Ulp: Highest point of upper vermilion
6. Cheilion, Ch: Lateral extent of labial commisure
7. Tragion, T: Tip of tragus
8. Subaurale, Sba: Lowest point of earlobe
9. Soft tissue gonion, Go’: Most lateral point on the mandibular
angle close to bony gonion
FIGURE 15.9 Bilateral soft tissue landmarks on face.
Upper airway cephalometric landmarks (Fig.

15.10)24
1. ANS. The tip of the median, sharp bony process of the maxilla
2. Genial tubercle, GE. Representing the most posterior point of
the mandibular symphysis and the antero-inferior part of the
tongue
3. Lower pharyngeal wall, LPW. Intersection of the perpendicular
line from V to the posterior pharyngeal wall
4. Middle pharyngeal wall, MPW. Intersection of the
perpendicular line from U to the posterior pharyngeal wall
5. Upper pharyngeal wall, UPW. UPW, point of intersection of
the line perpendicular to the posterior pharyngeal wall from
the PNS
6. Pterygo-maxillare, PM. The point at the junction of the
pterygo-maxilla and the PNS
7. PNS. The most posterior point at the sagittal plane on the bony
hard palate
8. Hyoid bone H. The most anterosuperior point on the body of
the hyoid
9. Vallecula V. The intersection of the epiglottis and the base of
the tongue
10. The tip of the tongue T
11. Uvula U. The tip of the uvula
FIGURE 15.10 Cephalometric landmarks for airway space.
Besides those mentioned above, many more landmarks on

craniofacial skeleton, dental structures, airway space and soft tissue of
the face can be defined. A host of cephalometric measurements are
calculated. These are described in next few chapters on cephalometric
analyses.
Cephalometric analysis is the process of evaluating skeletal, dental
and soft tissue relationship of a patient by comparing measurements
performed on the patient’s cephalometric tracing with population
norms for respective measurement(s), to come to a diagnosis of the
patients’ orthodontic problem.18 The cephalometric analysis
essentially involves evaluation of the patient’s:
1. Skeletal pattern
2. Dentition and its pattern (denture pattern)
3. Soft tissue pattern of face
4. Nasopharyngeal airway
5. Growth trend: The cephalometric analysis has been described
in Chapters 16–22. In addition, researchers and clinicians have
continuously strived to locate better and useful variables,
updated information, which can only be located in recent
journals.
Key Points
The advent of cephalometrics has significantly influenced science and
practice of orthodontics. It has been the most used research and
clinical investigation tool in the hands of orthodontists.
It drew so much attention that most patients were being treated to
norms.
It has been now realised that cephalometrics should be used to
locate the nature and severity of dysplasia and its influence on
treatment planning should be limited to individual needs of the case.
Cephalometrics is not the only but one of the most useful tools for an
orthodontist to arrive at a better decision for his patients’ treatment.
Cephalometric radiology has progressed from analogue to digital
images, from the hand tracing to computerised analysis and from 2D
to 3D.
Current thinking has evolved the revival of greater emphasis on
examination of soft tissue of face yet with due consideration of
underlying skeletal and dental structures. Knowledge of
cephalometrics is fundamental to orthodontics. It’s correct
interpretation and appropriate application in day-to-day practice
come only with a considerable experience.
References
1. Broadbent BH. A new radiograph technique and its
application to orthodontia. Angle Orthod.
1931;1:45–66: reprinted in Angle Orthod 1981; 51:93-
114.
2. Hofrath H. Die Bedeutung der Röntgen Fern-und
Abstandsaufnahmefür die Diagnostik der
Kieferanomalien. Fortschr Orthod. 1931;1:232–242:
Cited from: Baume LJ Maréchaux SC. Uniform
methods for the epidemiologic assessment of
malocclusion. Am J Orthod. 1974 Aug;66(2):121-9.
Review; PubMed PMID: 4601927.
3. Bolton CB. First roentgenographic cephalometric
workshop—proceedings of 1st roentgeno-graphic
cephalometric workshop. Am J Orthod.
1958;44(12):899–900.
4. http://dental.cwru.edu/bolton-brush/index.html.
5.
http://www.aaoflegacycollection.org/aaof_collection.html?
id=UTBurlington.
6. Solow B, Siersbaek-Nielsen S. Cervical and
craniocervical posture as predictors of craniofacial
growth. Am J Orthod Dentofacial Orthop.
1992;101(5):449–458: May; PubMed PMID: 1590294.
7. Kharbanda OP, Sidhu SS, Sundaram KR.
Cephalometric profile of Aryo Dravidians Part I. J
Indian Orthod Soc. 1989;20:84–88.
Cephalometric profile of Aryo Dravidians: Part II. J
9. Nanda R, Nanda RS. Cephalometric study of the
dentofacial complex of North Indians. Angle Orthod.
1969;39(1):22–28: Jan; PubMed PMID: 5250522.
10. Franchi L, Baccetti T, McNamara Jr JA. Cephalometric
floating norms for North American adults. Angle
Orthod. 1998;68(6):497–502: Dec; PubMed PMID:
9851346.
11. Savara B, Takeuchi YS. Anatomical location of
cephalometric landmarks on the sphenoid and
temporal bones. Angle Orthod. 1979;49(2):141–149:
12. Bjork A. The face in profile. Svensk Tandlarkare
Tidskrift. 1947;40:30.
13. Seward S. Relation of basion to articulare. Angle
6973298.
14. Nohadani N, Ruf S. Assessment of vertical facial and
dentoalveolar changes using panoramic radiography.
Eur J Orthod. 2008;30(3):262–268: Jun; Epub 2008 Jan
21; PubMed PMID: 18209215.
15. Ricketts RM. A principle of arcial growth of the
mandible. Angle Orthod. 1972;42(4):368–386: Oct;
16. Legrell PE, Nyquist H, Isberg A. Validity of
identification of gonion and antegonion in frontal
cephalograms. Angle Orthod. 2000;70(2):157–164: Apr;
17. Chang HP, Liu PH, Chang HF, Chang CH. Thin-plate
spline (TPS) graphical analysis of the mandible on
cephalometric radiographs. Dentomaxillofac Radiol.
2002;31(2):137–141: Mar; PubMed PMID: 12076055.
18. Glossary of orthodontic terms. Dentaurum, Germany.
19. RMO diagnostic services. Course syllabus, 1989;
Chapter 1 14-1833-40, Chapter 3, 23-35.
20. Chaconas SJ, Bartroff JD. Prediction of normal soft
tissue facial changes. Angle Orthod. 1975;45(1):12–25:
Jan; PubMed PMID: 1054930.
21. Nanda RS, Meng H, Kapila S, Goorhuis J. Growth
changes in the soft tissue facial profile. Angle Orthod.
1990;60(3):177–190: Fall; PubMed PMID: 2389850.
22. Bowker WD, Meredith HV. A metric analysis of the
facial profile. Angle Orthod. 1959;29:149–160.
23. Bailey LJ, Collie FM, White Jr RP. Long-term soft
tissue changes after orthognathic surgery. Int J Adult
Orthodon Orthognath Surg. 1996;11(1):7–18: PubMed
PMID: 9046623.
24. Agostinho HA, Furtado IÃ, Silva FS, Ustrell Torrent J.
Cephalometric evaluation of children with allergic
rhinitis and mouth breathing. Acta Med Port.
2015;28(3):316–321: PubMed PMID: 26421783.
CHAPTER 16
Downs’ analysis
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Original sample and the primary reference plane
Reference planes
Skeletal pattern
Denture pattern
Population groups
Key Points
Introduction
William B Downs introduced a method of recording the skeletal and
denture (dental) pattern to measure facial form on a cephalogram in
1948.1 Although several analyses have been introduced since then,
Downs’ analysis is still in use and gives reasonable information on the
lateral skeletal and denture profile of the subject.
Downs felt that there are four basic facial types as viewed in lateral
profile:
Retrognathic with recessive chin

Mesognathic with straight profile average chin
Prognathic, where the chin is prominent
Prognathism when the mandible is large.
Original sample and the primary reference

plane
Downs’ norms were based on 20 Caucasian subjects of age range 12–
17 years of both sexes. All individuals possessed clinically excellent
occlusion. The Frankfort horizontal plane was used as a reference
plane because of its clinical visibility and its familiarity to clinicians.
Downs considered the sagittal position of the ‘chin’ of greater
importance in determining the four basic facial types. He felt that the
subjects with malocclusion, whose skeletal pattern variation is within
the range of his norms, could be treated to standards. However,
subjects whose skeletal and dental patterns were severely beyond the
range could not be treated to a harmoniously balanced face within
Downs’ range of deviation. Although facial pattern varied from
orthognathic to a mild state prognathic, the face was still considered
harmonious and balanced.
Downs’ analysis provides information by which we can determine
whether the individual’s pattern shows comparatively harmonious
relations or not and whether dysplasia present in a person is in the
facial skeleton, the dentition or in both.
His analysis was not presented as the basis for a treatment goal
rather it was a method for examining and quantifying the
relationships of the skeletal components of the face, that is, maxilla
and mandible and its dentition, essentially the incisors.2,3
Reference planes
Downs used the following reference planes (Figs 16.1–16.3):
1. Facial plane. A line is drawn from Nasion (N) through

pogonion (Pg).
2. Mandibular plane. A tangent from the Gonion and the lowest
point of the symphysis, gnathion (Gn).
3. Occlusal plane. It is drawn by bisecting the overlapping cusps
of first molars and the incisal overbite. The cases in which the
incisors are grossly malposed, Downs recommended drawing
the occlusal plane through overlapping cusps of the premolars
and the molars.
4. Y-axis. It is formed by drawing a line from sella turcica (S) to
gnathion (Gn).
5. FH plane. It is drawn using the superior border of machine
porion (Po) and orbitale (Or).
FIGURE 16.1 Skeletal reference planes and variables according
to Downs.
Skeletal reference planes: (1) F–H plane Po–Or; (2) Facial plane N–Pg;
(3) Y-axis plane S–Gn; (4) Mandibular plane Go–Me; (5) A–B plane; (i)
Facial angle; (ii) Mandibular plane angle; (iii) Y-axis angle.
to Downs.
Skeletal angular variables: (i) Angle of convexity; (ii) A–B plane angle.
to Downs.
Dental variables: (i) Cant of occlusal plane; (ii) Interincisal angle; (iii)
Incisor mandibular plane angle; (iv) Mandibular incisor to occlusal
plane angle; (v) Protrusion of maxillary incisors (in mm).
Skeletal pattern (Figs 16.1, 16.2; Table 16.1)

1. Facial angle. It is measured as a posterior inferior angle at the
intersection of the facial plane with Frankfurt horizontal plane;
it essentially indicates the degree of recession or protrusion of
the mandible in relation to upper face at the point where FHP
is related to the facial plane. An increase in facial angle is
suggestive of chin protrusion. Mean 87.8°, range 82°–95° (Fig.
16.1).
2. Angle of convexity (N–A–Pg). This angle measures the degree
of the maxillary basal arch protrusion at its anterior limit
relative to the facial profile. It is suggestive of mid-face sagittal
positioning. Mean 0°, range –8.5° to 10°. This parameter
suggests that mandible represented by Pg can show a
considerable variation in its anteroposterior position from a
neutral sagittal position. The range varies from –6.5°, that is,
mild retrognathia, to 10°, that is, mild prognathic.
3. A–B plane angle. A–B plane is a measure of the relation of the
anterior limit of the apical bases to each other, relative to the
facial line. Mean –4.6°, range 0 to –9°.
4. Mandibular plane angle (MP–FHP). According to Downs, the
mandibular plane is tangent to the gonial angle and the lowest
point of the symphysis. Downs considered value of
mandibular plane with reference to 90°.
Mean 21.9°, range 17°–28°. High mandibular plane angle suggests
an unfavourable hyper divergent facial pattern. High
mandibular plane angle complicates treatment and prognosis.
5. Y-axis. It is also called as growth-axis angle, measured as the
posterior inferior angle on S–Gn–FHP. The Y-axis indicates the
degree of downward and forward position of the chin in
relation to the upper face. A large Y-axis is indicative of the
clockwise rotation of the mandible. Y-axis does not give an
indication of the size of the lower jaw but the direction in
which it is growing. Mean 59.4°, range 53°–66°.
Table 16.1
Downs’ cephalometric norms
F, Female; M, Male; yrs, Years. 1–5 variables represent skeletal pattern and 6–10 represent
dental pattern.
Denture pattern (Fig. 16.3; Table 16.1)

6. Cant of the occlusal plane. It is suggestive of the
anteroposterior tilt of occlusal plane in relation to the cranial
base. Its importance lies in treatment mechanics, and it should
not be altered unfavourably. Mean 9.3°, range 1.5°–14°.
7. Interincisal angle. It is indicative of protrusiveness of upper
and lower incisors. Acute angle obviously means proclined
incisors. Small angle is seen in class I bimaxillary protrusion
cases. A large angle is seen in class II division 2 cases and cases
with a deep bite. Mean 135.4°, range 130°–160°.
8. Mandibular incisor to the occlusal plane. The angle measured
is the complement of the angle formed by the intersection of
the long axis of the lower incisor with the occlusal plane. Mean
14.5°, range 3.5°–20°.
9. Incisor–mandibular plane angle. It indicates inclination of the
lower incisor on to the mandibular plane. The deviation of
incisors is indicated as plus or minus from the 90° mean.
Larger the angle; greater is its contribution to the acuteness of
inter incisor angle. Mean 1.4°, Range –8.5° to 7°
10. Protrusion of maxillary incisors. The measurement is made
from upper incisor edge to A–Pg line. This linear
measurement indicates the amount of maxillary dental
protrusion. Mean 2.7 mm, range =−1.0 mm to +5.0 mm (Table
16.1).
Hellman in 1937 introduced polygonal portrayal of dimensional
values in facial growth. A Downs’ polygon was suggested by Vorhies
and Adams5, whereas the vertical centre line shows average/normal
values. Left side shows a low range and on the right side, a high range
of standard deviation. The polygon represents the anteroposterior
deviation of the face with left side representing more of class II type
and right side representing class III type of pattern (Fig. 16.4). It is an
effective method of quantitatively and qualitatively illustrating a static
cephalometric analysis. It enables a clinician to rapidly assimilate the
data in a visual form and serves as an excellent aid in case
presentation.
FIGURE 16.4 Adams and Vorhies polygon with Downs’ norms.
Downs’ norms for Indians were investigated by Kotak,6 Nanda,7

Sidhu,8 Valiathan (Indian Residents of Washington DC),9
Kharbanda10,11 and in several studies at the Lucknow University
(Table 16.1).12
Population groups
It was observed that Indian faces possess racial characteristics more so
in a dental pattern. North Indians possess a facial skeleton which is
close to Caucasians except that they seem to have slightly higher
values for Y-axis and angle of convexity suggestive of a somewhat
protrusive midface. North Indians also possess a characteristic dental
pattern which is characterised by an increase of incisor-mandibular
plane angle and acuteness of the interincisal angle.
Keralite Indians exhibit a skeletal pattern which is different from
North Indians and certainly much different from Caucasians.
Keralite Indians, show higher mean values of FMA and Y-axis
suggesting a more vertical (hyper divergent) facial pattern. Keralites
also exhibited increased angle of convexity, which proposes a midface
protrusion. The AB plane to N-Pog angle is also greater for them,
which is contributed by the superior protrusion. They exhibit a
decreased value of the interincisal angle (119.0°) and increased values
of lower incisor to the mandibular plane angle (+13.8°) which is
suggestive of proclined upper and lower incisors which contribute to
their bidental protrusive facial profile. The increased linear distance of
maxillary incisor A-Pog line (8.3 mm) among them further adds to the
superior protrusion.
Koreans exhibit large facial angle and tendency for an acute
interincisal angle.
Key Points
Downs’ analysis mostly gives an indication of the skeletal profile of a
subject with ‘nasion’ as the reference point. The facial angle suggests
anteroposterior positioning of the mandible, whereas the angle of
convexity would suggest relative protrusion of maxilla, to the
mandible, while AB plane to N–Pg gives information on how maxilla
and mandible denture bases are oriented in relation to skeletal facial
profile (N–Pg) line.
The Y-axis provides information on the growth direction of the
lower jaw in relation to the cranium, and the mandibular plane angle
would provide information on the vertical relationship of the upper
and lower jaw bases. The occlusal plane angle supplements
information arrived from skeletal patterns in terms of inclination of
the dental occlusal plane with the skeletal pattern.
The interincisal angle gives information on relative proclination of
anterior teeth. The dental protrusion measured as interincisal angle
can be contributed by lower incisor proclination which is evaluated
through incisor-mandibular plane angle. The sagittal position of the
upper incisor is assessed by measuring the distance of the tip of upper
incisors to the A–Pg line.
Hence, by evaluation of the 10 parameters, it may be possible to
assess the skeletal pattern of a subject in terms of skeletal convexity of
the profile, position of mandible and maxilla, in an anteroposterior
and vertical relationship to the cranium. The relative protrusiveness of
the dentition on their respective dental bases and the relative
anteroposterior position of the maxillary incisor in relation to maxilla
are also assessed.
References
1948;34(10):812–840: PubMed PMID: 18882558.
2. Downs WB. The role of cephalometrics in
orthodontic case analysis and diagnosis. Am J
Orthodont. 1952;38(3):162–182: Mar 1.
3. Downs WB. Analysis of the dentofacial profile. Angle
Orthodont. 1956;26(4):191–212.
4. Park IC, Bowman D, Klapper L. A cephalometric
study of Korean adults. Am J Orthodont Dentofac
Orthoped. 1989;96(1):54–59.
5. Vorhies JM, Adams JW. Polygonic interpretation of
cephalometric findings. Angle Orthod.
1951;21(4):194–197: PubMed PMID: 14894865.
6. Kotak VB. Cephalometric evaluation of Indian girls
with neutral occlusion. J Ind Can Dent Assoc.
1964;36:183–197.
7. Nanda R, Nanda RS. Cephalometric study of the
dentofacial complex of North Indians. Angle Orthod.
1969;39(1):22–28: PubMed PMID: 5250522.
8. Sidhu SS, Shourie KL, Shaikh HS. The facial, skeletal
and dental patterns in Indians—a cephalometric
study. J Ind Orthod Soc. 1970;2(27–38):52.
9. Valiathan A. Downs’ cephalometric analysis on
adults from India. J Indian Dent Assoc.
1974;46(11):437–441: PubMed PMID: 4535424.
Cephalometric profile of Aryo Dravidians. Part I. J
Cephalometric profile of Aryo Dravidians. Part II. J
12. Kapoor DN. A hand book of cephalometric norms for
Indian Ethnic Groups. In , Kumar, J., editor.
Vellore:Indian Orthodontic Society; 1987.
CHAPTER 17
Tweed’s analysis
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
FMA and its relationship with IMPA
Head plate correction
Tweed’s norm for Indians and Asians
Key Points
Introduction
Tweed’s analysis1 (originally undertaken in 1954) is primarily based
on inclination of the mandibular incisors to the basal bone and the
latter’s association with the vertical relation of the mandible to the
cranium.1–3 Tweed’s analysis is clinically oriented. It sets the goals
and suggests a plan of orthodontic treatment.
Tweed’s cephalometric analysis had its beginning in clinical
orthodontics where he found that those cases of malocclusion having
a pleasing outcome, harmonious profiles and stable occlusion
following orthodontic treatment had a common, consistent feature of
occlusion: patients’ mandibular incisors were upright on their skeletal
bases.
Clinical observations supplemented and quantified on
cephalograms led to development of the diagnostic triangle. Tweed’s
diagnostic triangle is simple and basic, yet provides a definite
guideline in treatment planning.
Landmarks used in the construction of Tweed’s triangle were the
Frankfort horizontal plane, the mandibular plane and the long axis of
the mandibular incisor (Fig. 17.1).
FIGURE 17.1 Planes and angles used in Tweed’s analysis.
FMA, Frankfort mandibular plane angle; FMIA, Frankfort mandibular
incisor angle; IMPA, incisor–mandibular plane angle.
Angle’s philosophy of orthodontic treatment was based on the
assumption that once the cuspal interdigitation of teeth had achieved
a healthy fit, the stimulation occasioned by orofacial function would
result in growth of the basal bone structures (i.e. the maxilla and
mandible). The growth achieved by establishing a normal occlusion
would accommodate the full complement of teeth and result in a
balanced, harmonious face.
Hence, little or no thought was given to inclination of the
mandibular incisors and the mesiodistal relationship between the
teeth and their respective jaw bones. In the era of Angle, Charles
Tweed, a disciple of Edward Angle, strictly adhered to the philosophy
of non-extraction.
However, in the following years Tweed became aware of his
inability to create balance and harmony of the face in more than a few
patients. Moreover, he noticed significant relapse in some of his
patients thus casting doubt over the long-term stability of non-
extraction.
At this juncture, he embarked on a critical review of treatment
records (1934), which prompted him to conduct a study into the
features and characteristics of occlusion, dentition and the faces of
‘normal’ people who never had orthodontic treatment. His initial
impression was based on clinical examinations alone. The relationship
of the teeth to the basal bone was carefully noted, especially the
inclination of the incisor teeth.
He found that in an average non-orthodontic normal subjects, the
incisal inclination was approximately 90 degrees to the mandibular
plane. His study showed a variation of 10 degrees in inclination of the
mandibular incisors to the mandibular plane in subjects with normal
occlusion. Further, from his records he noted that most of the cases
where there were relapses, the incisor–mandibular plane angle
(IMPA) deviated significantly from the ideal of 90 degrees.
Therefore, he concluded that for an orthodontist to attain facial
aesthetics and occlusion similar to that found in non-orthodontic
normals, the mandibular incisors should be positioned in the 85–95
degrees range with a mean of 90 degrees. Based on his observations of
the lower IMPA and its association with variation in the Frankfort
mandibular plane angle (FMA), he consistently found a third angle of
the triangle: the Frankfort mandibular incisor angle (FMIA). Tweed
found that extraction of teeth was necessary for patients with a FMA
more than 30 degrees.
He observed that when the FMA is higher than 35 degrees, it was
physically impossible to fully compensate for inclination of the
mandibular incisors (i.e. make them upright). The prognosis is not
good in such cases, and the orthodontist is limited to creating stable
end results and establishing harmony and balance in facial aesthetics.
Clinical research set the norm for FMA as 25 degrees with a normal
variation of 17–35 degrees. Since the sum of the three angles of a
triangle is 180 degrees, then in a normal case with 25 degrees of FMA
and 90 degrees of IMPA the third angle (FMIA) would expected to be
65 degrees.
His clinical observations were further supported by a cephalometric
study. The sample size consisted of 100 people, chosen on the basis of
the balance and harmony of their facial aesthetics. The average of the
three angles was as follows (Table 17.1):
• FMA, 25 degrees
• IMPA, 90 degrees
• FMIA, 65 degrees.
Table 17.1
Tweed’s cephalometric norms
F, Female; M, male.
FMA and its relationship with IMPA

Tweed observed that patients whose FMA was more than 30 degrees
demonstrate nature’s way of compensating for inclination of the
mandibular incisors to the mandibular plane. The IMPA was found to
be as little as 77 degrees and the FMIA to be around 65 degrees. The
occlusal plane converges towards the mandibular plane as a result of
the excessive height of the mandibular incisors compared with molar
height.
In patients with an FMA of 25 degrees, give or take 4 degrees (21–29
degrees), the FMIA was found to be 65–70 degrees. The occlusal plane
did not converge posteriorly as sharply towards the mandibular plane
as it did in patients with a large FMA. The patients whose FMA was
below 20 degrees rarely demonstrated an IMPA greater than 94
degrees. Their FMIA reading ranged from 68 to 85 degrees. The
occlusal plane converged less sharply towards the mandibular plane
and in some cases it was parallel to the mandibular plane.
Tweed, therefore, postulated that the FMIA is critical in
determining facial harmony. Hence, any orthodontic treatment plan
should consider correcting IMPA up to a minimum of 77 degrees for
higher FMA and a maximum of 105 degrees for lower FMA subjects.
Head plate correction

Tweed also made use of IMPA correction on a cephalogram according
to his treatment objectives and called it head plate correction. He
marked the IMPA with white India ink directly onto the X-ray film of
the head plate. He accordingly calculated the space requirements in
the arch based on the amount of change required to place the lower
incisors correctly over the basal arch. Orthodontists across America
and Europe in the 1970s treated cases according to the IMPA goals of
Tweed’s triangle. In India too, during the early 1970s, orthodontic
treatment planning was based on IMPA norms of Caucasians.
Tweed’s goals are:
• For an FMA of 30 degrees the mandibular incisors should be

corrected so that the FMIA ranges from 65 to 70 degrees
(prognosis usually indicates the need for extractions).
• For an FMA of 25 degrees, give or take 4 degrees, effort should
be made to attain an FMIA of 68–70 degrees.
• For an FMA of 20 degrees the IMPA should not exceed 94
degrees.
In his analysis, Tweed stressed the importance of the FMIA and

recommended that it should be maintained at 65–70 degrees. As an
example a case with an FMA of 21 degrees, FMIA of 51 degrees and
IMPA of 108 degrees should be corrected to get an IMPA of 90
degrees. With this correction the FMIA would be 69 degrees, which is
within the recommended range. This would necessitate extractions
(Table 17.2).
Table 17.2
Prediction of the IMPA according to the FMA of an
individual patient as given by Kharbanda et al. based on
cephalometric data of north Indians (degrees)
Based on the strong but negative correlation between the IMPA and FMA. The corresponding
values of the IMPA for Caucasians are less by 10 degrees for each FMA. L-IMPA, lower limit
of IMPA; U-IMPA, upper limit of IMPA.
Tweed’s norm for Indians and Asians4–7

Kharbanda and Sidhu observed that a sample of north Indian adults
with class I occlusion and a balanced facial profile exhibited an FMA
close to Tweed’s norm. They reported a mean FMA of 23.49 degrees
(range 13–35 degrees). IMPA values ranged from 81 to 117 degrees
with a mean of 101.77 degrees. Therefore, the values for FMIA were
found in the 36–74 degrees range with a mean of 53.87 degrees. This
study also found a highly significant and negative correlation between
the FMA and IMPA. Using linear regression analysis, they devised a
table and nomograph to estimate the IMPA for an individual patient
based on his/her FMA (Fig. 17.2, Table 17.2).
FIGURE 17.2 Prediction of the IMPA according to the FMA of the

individual patient as given by Kharbanda et al. based on
cephalometric data of north Indians.
FMIA, Frankfort mandibular incisor angle; IMPA, incisor–mandibular
plane angle.
The IMPA values of Nepalese, Koreans and Mongoloids are close to

a mean of 95 degrees, which is 5 degrees greater than Caucasians but
less than Indians.
Based on these observations and trends in the IMPA–FMA
relationship, it may be possible to use the same principle for any
ethnic group when we know the mean FMA and IMPA.
Interpretations and comments

• In most Indian studies, the FMA has been found close to
Tweed’s norm, and the FMIA value has been found to be
around 55 degrees, which is quite low compared with
Tweed’s mean of 65 degrees.
• In all studies conducted on Indian population groups the
IMPA was found to be close to 100 degrees (i.e. 10 degrees
more than the value observed in Caucasians) suggesting that
Indians have more proclined mandibular incisors than
Caucasians.
• It has been observed that there is a negative correlation
between IMPA and FMA. This is highly significant indicating
that any increase or decrease in FMA can be corrected by
inverse change in the IMPA to maintain good facial harmony.
Key Points
Tweed’s analysis is simple and clinically useful. Tweed’s norms
should only be considered as guides and not absolutely achievable
objectives. The treatment goals of IMPA should be considered
according to the facial pattern (i.e. FMA).
Racial/ethnic variations of norms should not be overlooked when
outlining goals and planning treatment.
References
1. Tweed CH. The Frankfort-mandibular incisor angle
and prognosis. Angle Orthod. 1954;24(3):121–169.
2. Tweed CH. Was the development of the diagnostic facial
triangle as an accurate analysis based on fact or fancy?
Am J Orthod. 1962;48(11):823–840.
1969;55(6):651–657.
4. Kharbanda OP, Sidhu SS, Sundram KR.
Cephalometric profile of north Indians: Tweed’s
analysis. Int J Orthod. 1991;29(3–4):3–5: Fall–Winter.
5. Ashima V, John KK. A comparison of the
cephalometric norms of Keralites with various Indian
groups using Steiner’s & Tweed’s analyses. J Pierre
Fauchard Acad. 1991;5(1):17–21.
6. Bhattarai P, Shrestha RM. Tweeds analysis of
Nepalese people. Nepal Med Coll J.
2011;13(2):103–106.
7. Kim JH, Gansukh O, Amarsaikhan B, Lee SJ, Kim
TW. Comparison of cephalometric norms between
Mongolian and Korean adults with normal
occlusions and well-balanced profiles. Korean J
Orthod. 2011;41(1):42–50.
CHAPTER 18
Steiner’s analysis
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
SN plane
ANB angle
NA and NB planes
Interincisal angle
Composite analysis
Skeletal analysis
Dental analysis
Steiner chevrons
Interpretations and applications
S Line
Steiner’s norms for various ethnic groups
Key Points
Introduction
Cecil C. Steiner looked at the subject of cephalometrics and realised
the potential it had for practical use in treatment planning and not
merely as a diagnostic tool.1–4
Steiner was greatly influenced by the works of Downs, Wylie and
other prominent workers in the field of cephalometrics at that time,
and their influence is clearly reflected in his analysis. He selected
parameters from various analyses developed by several authors, and
then critically evaluated, modified and included them in his analysis.
Steiner’s composite analysis is accepted as providing the most useful
clinical information (gleaned from several studies). He used only a
few parameters from each of them, which resulted in improved
treatment planning. Steiner proposed the appraisal of various parts of
the skull separately as:
• Skeletal analysis
• Dental analysis
• Soft-tissue analysis
• Logical use of reference planes and parameters
• Using the sella–nasion (SN) plane instead of the Frankfort
horizontal (FH) plane.
SN plane
The FH plane was traditionally the logical choice of anthropologists as
the porion and infraorbital points (Po-Or Plane) were easily visible in
dry skulls. Most cephalometric analyses adopted the FH plane for use
in cephalometry. Steiner highlighted difficulties in accurate location of
the porion point and its relative variation, which could be observed in
successive radiographs. Inability to precisely locate the porion point
affected the correct orientation of the FH plane.
On the contrary, the sella and nasion points were easily discernible
on a lateral cephalogram and could be located with relatively higher
accuracy. Moreover, the sella and nasion points had another
advantage. They were located in the mid-sagittal plane of the head,
and moved minimally with any deviation of the head from the real
profile position. Hence, keeping these findings in mind, Steiner
considered the SN plane a better, more accurate, and predictable
alternative to the FH plane.
ANB angle
Impressed by Richard Riedel,5 Steiner used the sella–nasion–A point
(SNA) and sella–nasion–B point (SNB) angles to compare the position
of the chin in the lower jaw with other structures of the cranium and
the upper jaw and the A point–nasion–B point (ANB) angle to
compare relative discrepancy between the maxilla and mandible.
NA and NB planes
Steiner suggested assessing the upper and lower incisors by
comparing their relative position and angulations to the nasion–A
point (NA) and nasion–B point (NB) planes as a guide. He felt there
were more direct reference planes on the lower jaw than the
mandibular plane (MP), which is not a straight-line reference plane,
but a curved one and a highly variable one. Although he cited the
above limitation, he continued to use the MP angle as a reference for
evaluating the lower incisors.
Initially, even the distance of the upper molars (U6’s) was measured
from the NA, to be used as a reference at a later date to determine if
any migration of molars (U6’s) had occurred over time.
Interincisal angle
Downs’6 method of measuring the interincisal angle was retained as
an additional method of appraising the angulation of these teeth to
each other. Moreover, Downs’ philosophy of evaluating the occlusal
plane to determine the position of teeth in occlusion to the face and
skull was also retained.
Wylie7 and Johnson’s method of determining any malformation of
the mandible was incorporated in the analysis, and Riedel’s Gonion–
Gnathion (Go–Gn) plane was used to represent the body of the
mandible. According to Steiner the mandibular plane can be drawn
between the gonion and gnathion.
Composite analysis
Skeletal analysis
Skeletal analysis entails relating the upper and lower jaws to the skull
and each other (Fig. 18.1):
1. SNA angle. According to Riedel, the SNA angle is measured as

an inner angle from the SN plane to the NA line (mean 82
degree).
2. SNB angle. The SNB angle is the inner angle fromed by the SN
plane to the NB line (mean 80 degree).
3. ANB angle. The ANB angle has a mean value of 2 degree.
4. SND angle. The SND angle is the angle formed between the SN
plane and a line from the nasion to point D. Point D is the
centre of mandibular symphysis (mean 72 degree).
5. MP angle. The MP angle is the inclination of the MP to the SN
plane (Go–Gn × SN). It represents the vertical relation the
mandible to the cranium. Excessively high or low angles are
unfavourable for treatment (mean 32 degree).
6. SL distance (Wylie). The SL distance (Wylie) can be visualised as
a perpendicular line drawn from the pogonion to the SN
plane, at a point designated ‘L’. Linear measurement of the SL
distance (mean 51 mm) represents the effective size of the
mandible.
7. SE distance (Wylie). The SE distance (Wylie) is a linear
measurement from point E to S. It can be visualised as a
perpendicular line drawn from the SN plane to the most distal
point of the mandibular condyle, at a point designated as ‘E.’
The SE distance (mean 22 mm) is the most distal location of the
condyle with the teeth in occlusion. The SL and SE distances
are useful in assessing changes in the position and effective
length of the mandible.
FIGURE 18.1 Skeletal variables used by Steiner.
Dental analysis (Fig. 18.2)

8. Maxillary incisor position (Wylie). The maxillary incisor position
is measured in terms of its inclination and linear distance to
the NA line (mean angulation of the long axis of the maxillary
incisor to the NA line is 22 degree).
9. Maxillary incisor position (Wylie). The mean linear distance of
the maxillary incisor to the NA line is 4 mm.
10. Mandibular incisor position (Wylie). The mandibular incisor
position is measured in terms of angulation and linear
distance to the NB line. The linear distance of the lower incisor
to the NB line is 4 mm.
11. Mandibular incisor position (Wylie). Mean angulation of the
mandibular incisor to the NB line is 25 degree.
12. Interincisal angle (Downs). The interincisal angle measures the
relative position of the upper incisor to lower incisor as
interpreted by Downs (mean 131 degree).
13. Upper incisor to SN plane. The upper incisor to SN plane
provides information on proclination/retroclination of the
maxillary incisors in relation to the SN plane independent of
the interincisal angle. Clinically, this measurement is of
particular importance in evaluating the torque of the upper
incisors (mean 104 degree).
14. Mandibular incisor to MP angle. The same interpretation as
Downs except that Steiner considered its actual measurement,
unlike Downs (mean 93 degree).
15. Occlusal plane angle (Downs). Same interpretation as Downs
(mean 14.5 degree). The occlusal plane is drawn through the
region of overlapping cusps of the first premolars and first
molars.
16. Maxillary permanent first molar to NA line (Wylie). Measurement
of the maxillary permanent first molar to NA line (Wylie) is
useful in evaluating the molar position in the maxilla, which
may be necessary to evaluate loss of anchorage following
mechanotherapy (mean 27 mm).
17. Mandibular permanent first molar to NB line (Wylie).
Measurement of the mandibular permanent first molar to NB
line (Wylie) is similar to the maxilla and is useful in
determining whether the lower molar has moved in relation to
the NB plane during treatment (mean 23 mm).
FIGURE 18.2 Dental variables used by Steiner.
The maxillary and mandibular first molars are measured at their

mesial contact points.
Steiner chevrons
Steiner found that some acceptable dental compromises naturally
occur in different skeletal maxillomandibular relations (i.e. ANB
values). Based on his observations, he devised a novel method of
treatment planning for non-growing patients.
He concluded that it might not be possible to correct dentition
according to ideal norms in non-growing patients whose skeletal
relations cannot be altered. The imperative here is to come up with an
acceptable compromise for the dentition, one that will mask the
underlying skeletal deformity as much as possible. This can be
achieved using Steiner’s sticks, which allow calculations to be carried
out for a particular ANB value. These calculations help define our
orthodontic goal and help in making the extraction or non-extraction
decision in non-growing subjects. Fig. 18.3 gives the values of norms
for an ANB of 2 degree.
FIGURE 18.3 Steiner suggested using average measurements as
norms.
The two lines on the graph represent the long axis of the upper and
lower incisor. The ANB angle is written on top of the apex of the long
axis of the upper incisor. In this figure it is 2 degrees. The outside
values (4 mm) are the upper-incisor-to-NA and lower-incisor-to-NB
distances. The inside values are upper incisor to NA and lower incisor
to NB in degrees. Source: After Steiner CC. Cephalometrics in clinical
practice. Angle Orthod 1959;29:8–29.
Any change in the ANB means objectives for the position of the
lower incisor and upper incisor with respect to the NA line and NB
lines will not be ideal. According to Steiner, overall treatment
planning is based on several parameters including discrepancy and
anchorage requirements, estimated position of the pogonion, and
average acceptable compromise based on clinical experience. He
called them rough estimates; they may vary but are good starting
points.
Interpretations and applications

The method of cephalometric analysis devised by Steiner is intended
and designed for application of cephalometric data to clinical practice
(Fig. 18.4).
FIGURE 18.4 The ANB angle is often used for the placement of
incisors in their respective bases.
The figure shows Steiner’s recommendations for the incisor
relationship for varying ANB angles. These are only suggested guides
and should be modified for individual needs. Source: Steiner CC.
Cephalometrics in clinical practice. Angle Orthod 1959;29:8–29.
For example, a patient whose SNA and SNB angle values were high
and whose ANB angle was normal would be considered to have an
average/normal sagittal jaw relationship with a unique facial type.
Steiner laid greater emphasis on the position of incisors and its
inclination in relation to denture bases. He considered it one of the
most vital indicators of malocclusion and important in case diagnosis.
Measurement of the upper-molar position to the NA line serves as a
reference for future use when analysing the amount of anchorage loss.
Similarly, the position of the lower molar to the NB line is measured
as a reference to evaluate the future lower-molar position. A standard
norm for these lines would be of little use because the number of teeth
intervening, variations in their size, and the likelihood of their
malposition would influence measurements.
To locate the mandible for comparison purposes during and after
treatment, pre-treatment SL and SE distances are used as reference
measurements. Any change in these measurements represents an
alteration in anteroposterior position and effective length of the
mandible.
Steiner advocated locating the centre of the condyle in occlusion
and the at-rest position of the mandible. He did this by tracing a line
between them, which allowed the path and distance of opening of the
mandible at the gnathion and centre of the condyle to be determined.
The Gn -Gn’ distance varies a great deal in different individuals and
often varies considerably during treatment. This parameter may
represent freeway space to a great extent. However, he hoped it
would gain greater importance in future for treatment planning.
S Line
Soft-tissue analysis provides a means of assessing the balance and
harmony of the lower facial profile. The facial contour line is called
Steiner’s S line. A line is drawn on the soft-tissue contour of the chin
to the middle of the S formed by the lower border of the nose. In a
well-balanced face the lips should touch the line. The S line partially
excludes the effect of nasal growth on the soft-tissue profile. Fig. 18.5
shows landmarks leading up to the S line and its relationship with the
lips in an ideal profile.
FIGURE 18.5 The plane used by Steiner to define the relationship
between the lips and the S line, which is drawn from the soft-
tissue pogion to the sub-nasale. Based on Steiner CC.
Cephalometrics in clinical practice. Angle Orthod 1959;29:8–29.
Steiner’s norms for various ethnic
groups
Clinicians and researchers across the globe have tried to calculate
values according to Steiner’s composite analysis appropriate for their
countrymen.8–17 The important ones for Indians have been by
Kharbanda et al.,13,14 Ashima and John,16 and others at the University
of Lucknow.17 For Malays see Mohammad et al.,8 for Nepalese see
Sharma et al.,9 for see Koreans Park,10 for Mongoloids see Kim,11 and
for Filipinos see Naranjilla et al.12 These are compiled in Table 18.1
and Table 18.2. A close look at the data shows subtle differences,
major ones being Koreans and Malays who seem to have a higher
mean value for the SN–Go–Gn angle, while Keralites and Filipinos
have the acutest interincisal angle.
Table 18.1
Steiner’s cephalometric norms
ANB, A point–nasion–B point; F, female; Gn, gnathion; Go, gonion; M, male; SE, sella–E
point; SL, sella–L point; SN, sella–nasion; SNA, sella–nasion–A point; SNB, sella–nasion–B
point; SND, sella–nasion–D point.
Table 18.2
Steiner’s cephalometric norms
F, Female; LI, lower incisor; L6, lower first molar; M, male; MP, mandibular plane; NA,
nasion–A point; NB, nasion–B point; OP, occlusal plane; SN, sella–nasion; UI, upper incisor;
U6, upper first molar.
Key Points
Steiner used those cephalometric variables which are easily
identifiable and least prone to errors in location.
He considered linear and angular relations of the incisors in their
respective skeletal bases of great significance in treatment planning
and end objectives of treatment.
References
1. Steiner CC. Cephalometrics for you and me. Am J
Orthod. 1953;39(10):729–755.
2. Steiner CC. Cephalometrics in clinical practice. Angle
Orthod. 1959;29(1):8–29.
3. Steiner CC. The use of cephalometrics as an aid to
planning and assessing orthodontic treatment: report
of a case. Am J Orthod. 1960;46(10):721–735.
4. Steiner CC. Cephalometrics as a clinical tool. In:
Kraus BS, Reidel RA, eds. Vistas in orthodontics.
Philadelphia: PA: Lea and Febiger; 1962:131–161.
5. Riedel RA. An analysis of dentofacial relationships.
Am J Orthod. 1957;43(2):103–119.
1948;34(10):812–840.
7. Wylie WL. The assessment of anteroposterior
dysplasia. Angle Orthod. 1947;17(3):97–109.
8. Mohammad HA, Hassan A, Hussain SF.
Cephalometric evaluation for Malaysian Malay by
Steiner analysis. Sci Res Essays. 2011;6(3):627–634.
9. Sharma JN. Steiner’s cephalometric norms for the
Nepalese population. J Orthod. 2011;38(1):21–31: doi:
10.1179/14653121141209.
10. Park IC, Bowman D, Klapper L. A cephalometric
study of Korean adults. Am J Orthod Dentofacial
Orthop. 1989;96(1):54–59.
11. Kim JH, Gansukh O, Amarsaikhan B, Lee SJ, Kim TW.
Comparison of cephalometric norms between
Orthod. 2011;41(1):42–50.
12. Naranjilla MA, Rudzki-Janson I. Cephalometric
features of Filipinos with Angle Class I occlusion
according to the Munich analysis. Angle Orthod.
2005;75(1):63–68.
Cephalometric profile of Aryo-Dravidians, Part I. J
Cephalometric profile of Aryo-Dravidians, Part II. J
15. Sidhu SS, Shourie KL, Shaikh HS. The facial, skeletal
and dental patterns in Indians—a cephalometric
study. J Indian Orthod Soc. 1970;2(27–38):52.
16. Valiathan A, John KK. A comparison of the
Fauchard Acad. 1991;5(1):17–21.
17. Kapoor DN. Indian cephalometric norms. Indian
Orthodontic Society. 1996.
CHAPTER 19
Ricketts’ 12-factor analysis
O.P. Kharbanda
CHAPTER OUTLINE

Skeletal landmarks
Dental landmarks
Basic reference planes
Measurements to locate the chin in space
Measurements to locate denture in face
Measurements to determine the profile
12th Factor: Soft tissue evaluation
Key Points
Robert M. Ricketts attended dental school in Indiana and was a
scholar in orthodontics at the University of Illinois. He was a student
of Allan G. Brodie and a follower of Downs. He was founder of the
American Institute of Bioprogressive Education and was instrumental
in establishing the Foundation for Orthodontic Research (FOR). Dr.
Ricketts was an expert and authority on the science of human
craniofacial development and did extensive research work on
cephalometrics, growth prediction and computer-aided diagnosis. He
laid great emphasis on changes occurring in the face as a result of
growth and integrating this into treatment planning.
Ricketts’ approach to selection of landmarks and parameters was
primarily based on the pattern of facial growth.1–3 Two types of
landmarks were used by him (Fig. 19.1). The first types were skeletal
landmarks and second dental landmarks. His 11 factor analysis of
skeleton and dental relationship later had the addition of 12th factor
which encompasses evaluation of soft tissue profile.
FIGURE 19.1 Landmarks used in Ricketts’ summary analysis.
Skeletal landmarks
1. A point. The A point is the deepest point on the curve of the
maxilla between the anterior nasal spine and the dental
alveolus.
2. ANS (anterior nasal spine). The tip of the ANS.
3. Ba (basion). The most inferior posterior point of the occipital
bone at the anterior margin of the occipital foramen.
4. Pt (pterygoid) point. The intersection of the inferior border of
the foramen rotundum with the posterior wall of the
pterygomaxillary fissure.
5. CC (centre of the cranium) point. The CC point is a
cephalometric landmark formed by the intersection of two
lines—the basion–nasion (Ba–NA) and pterygoid–gnathion
(Pt–GN).
6. CF (centre of the face) point. The CF point is a cephalometric
landmark formed by the intersection of the line connecting the
porion and orbitale and a perpendicular line through the Pt.
7. DC. A point selected in the centre of the neck of the condyle
where the Ba–NA planes coincide.
8. Go (gonion). The intersection of the line connecting the most
distal aspect of the condyle to the distal border of the ramus
(ramus plane) and the line at the base of the mandible
(mandibular plane).
9. Pm (protuberance menti). A point selected at the anterior
border of the symphysis between the point B and the pogonion
where the curvature changes from concave to convex.
10. Po (pogonion). The most anterior point of the mid-sagittal
symphysis tangent to the facial plane.
11. Xi point. A point located at the geometric centre of the ramus.
The location of the Xi point (Fig. 19.2) can be found
geometrically by drawing a line through the porion–orbitale
(FH) and perpendicularly through the PT vertical (PTV). This
can be done
a. By constructing planes perpendicular to the FH and
PTV.
b. Making such planes tangent to points (R1, R2, R3
and R4) on the borders of the ramus.
c. Ensuring such planes form a rectangle enclosing the
ramus.
d. The Xi point is located at the centre of the rectangle
at the intersection of the diagonals.
FIGURE 19.2 Construction of the Xi point according to Ricketts.

(A) Reference planes FH and PTV are used to draw R1, R2, R3 and
R4 on the borders of the ramus. (B) The Xi point is located in the centre
of the rectangle where the diagonals intersect. FH, Frankfort horizontal;
PTV, pterygoid vertical.
The R1 point of the mandible is the deepest point on the curve of

the anterior border of the ramus, one-half the distance between the
inferior and superior curves.
The R2 point of the mandible is located on the posterior border of
the ramus.
The R3 point of the mandible is located at the centre and most
inferior aspect of the sigmoid notch of the ramus.
The R4 point of the mandible is on the border of the mandible
directly inferior to the centre of the sigmoid notch of the ramus.
Dental landmarks
1. A6 (upper molar). A point on the occlusal plane located
perpendicular to the distal surface of the crown of the upper
first molar.
2. B6 (lower molar). A point on the occlusal plane located
perpendicular to the distal surface of the crown of the lower
first molar.
3. TI point. The point of intersection of the occlusal and facial
planes.
Basic reference planes (Fig. 19.3)
FIGURE 19.3 Planes used in Ricketts’ summary analysis.

DC, a point selected in the centre of neck of the condyle, where basion
nasion plane crosses it; Or, orbitale; A, subspinale; S, sella; N, nasion;
Pr, porion.
The basic reference planes are:

1. Horizontal reference plane.
Frankfort horizontal (FH) plane, which is constructed by
connecting the porion and the orbitale.
2. Vertical reference plane.
The pterygoid vertical plane (PTV) is constructed by drawing a
line perpendicular to the Frankfort plane at the posterior
margin of the pterygopalatine fossa.
The intersection of the FH and PTV has been found to be stable
(i.e. change in the location of this point as a result of patient
growth is minimal). Therefore, serial cephalometric tracings of
a patient superimposed at this point are recommended.
3. Facial axis.
The facial axis is a line from the Pt point through the
cephalometric gnathion which normally intersects the Ba–NA
plane at a right angle.
4. Cranial base: basion–nasion line.
The border between the face and the cranium can be defined by
the Ba–NA line. The angle between the BA–NA line and the
Frankfort plane is 30 degrees in a normal Caucasian adult.
5. Occlusal plane.
The occlusal plane can be constructed by a line bisecting the
overbite of the molars and passing through the overbite of the
first bicuspids. In an adult Caucasian, the plane passes just
inferior to the Xi point, nearly bisecting the angle of lower facial
height. It is almost parallel to the FH and palatal plane.
Ricketts 12-factor summary analysis is a simplified version of his
detailed and comprehensive cephalometric analysis. It provides an
overview of the patient’s craniofacial and dental growth direction.
Cephalometric norms are based on research studies of normally
growing individuals and may not truly reflect growth in a patient
with malocclusion and abnormal growth (Table 19.1).
Table 19.1
Ricketts’ norms at 9 years and growth changes
FH, Frankfort horizontal; PO, pogonion; PTV, pterygoid vertical.
Source: RMO & Diagnostic Services (1989).

Measurements to locate the chin in space
1. Facial axis angle.
The facial axis angle is formed by the intersection of the Ba–NA
line and the facial axis. The angle describes the direction of
growth of the mandible at the chin. A larger angle indicates
horizontal mandibular growth, while a smaller angle is
suggestive of more vertical growth. The facial axis angle
remains stable in a normally growing child or reduces a little
(Fig. 19.4).
2. Facial depth angle.
The facial depth angle is formed by the intersection of the facial
plane and the FH plane. This angle gives the clinician an
indication of growth of the mandible (pogonion) in the sagittal
direction. This facial depth angle increases 1 degree every 3
years as the mandible grows forward and downward. In
adulthood the mean measurement is 90 degrees (Fig. 19.5).
3. Mandibular plane angle.
The mandibular plane angle is formed by the intersection of the
mandibular plane and the FH plane. High mandibular plane
angles are seen in dolichofacial patients with weak musculature
or vertical growth problems. Low mandibular plane angles are
found in brachyfacial types with strong musculature and deep
bite who tend to have square jaws. This angle tends to decrease
1 degree every 3 years until maturity as a result of growth and
adaptive changes that occur in the mandible during normal
development (Fig. 19.6).
4. Lower facial height.
Lower facial height can be given as the angle formed by
intersection of a line from the ANS–Xi point and the corpus
axis (Xi–Pm). A larger angle indicates divergence of the
mandible and maxilla or vertical growth. The angle of lower
facial height does not usually change significantly with age.
However, this angle would be affected by treatment mechanics
(i.e. it may open or close the bite). Low values of angle are
suggestive of a horizontal facial pattern (Fig. 19.7).
5. Mandibular arc.
The mandibular arc is the angle formed by intersection of the
condylar axis (DC–Xi) and distal extrapolation of the corpus
axis. It describes the configuration of the mandible. A large
angle is indicative of a strong and square mandible, while a
small angle represents a lower jaw with a short ramus and
vertical growth. Smaller value of the angle suggests a short
ramus and vertical growth. The norm for a 9-year-old child is
26 ± 4 degrees. It decreases approximately 0.5 degree per year
with growth.
6. Measurements to determine convexity (Fig. 19.8).
Facial convexity is the distance in millimetres from point A to the
facial plane when measured perpendicular to the plane.
Normal growth shows more anterior growth of the mandible
than the maxilla and decreases in its measurement with age. At
maturity the norm is 9 mm indicating that point A lies along
the facial plane. High convexity indicates a class II skeletal
pattern, while negative convexity indicates skeletal class III
(Fig. 19.9).
FIGURE 19.4 Facial axis angle.
Ba, basion; N, nasion; Gn, gnathion; Pt, pterygoid.
FIGURE 19.5 Facial depth angle.
Pr, porion; Or, orbitale; N, nasion; Po, pogonion.
FIGURE 19.6 Mandibular plane angle.
Gn, gnathion; Go, gonion; Pr, porion; Or, orbitale.
FIGURE 19.7 Lower facial height.
ANS, anterior nasal spine; Xi, constructed geometric centre of face;
Pm, protuberance menti.
FIGURE 19.8 Mandibular arc.
DC, centre of neck of the condyle; Xi, constructed geometric centre of
face; Pm, protuberance menti.
FIGURE 19.9 Convexity of point A.
N, nasion; ANS, anterior nasal spine; A, sub spinale; Pm, protuberance
menti.
Measurements to locate denture in face

7. Lower incisor protrusion.
Lower incisor protrusion is a linear measurement relating the
position of the tip of the lower central incisor to the
maxillomandibular relationship. The plane that is used to
describe this relationship intersects both the A point and the
pogonion (A–Po). The distance from the tip of the incisor is
measured perpendicular to this plane. The position of the lower
incisor has been associated with aesthetics and stability (as
suggested by Tweed). Labial or lingual movement of the lower
incisors affects the arch length (Fig. 19.10).
8. Mandibular incisor inclination.
Mandibular incisor inclination (also called lower incisor
inclination) is an angular measurement formed by intersection
of the long axis of the lower central incisor and the A–Po plane.
The measurement also relates the lower incisors to the
maxillomandibular relationship (Fig. 19.11).
9. Upper molar position.
The upper molar position is a linear distance between the most
distal point of the maxillary first permanent molar and the PTV
measured parallel to the occlusal plane. This measurement
indicates the position of the upper denture. It is also indicative
of whether or not the upper molar can be moved distally
without impacting the maxillary second and third molars. The
norm is the patient’s age (in years) plus 3 mm. At least 21 mm
of the maxilla (±3 mm) is generally needed in later years for
proper eruption of the second and third molars (Fig. 19.12).
10. Interincisal angle.
The interincisal angle depicts cumulative proclination of the
upper and lower incisors. It does not quantify proclination of
other maxillary/mandibular teeth (Fig. 19.13).
FIGURE 19.10 Lower incisor protrusion.
A, subspinale; Pm, protuberance menti.
FIGURE 19.11 Mandibular incisor inclination.
ANS, anterior nasal spine; Pm, protuberance menti.
FIGURE 19.12 Upper molar position.
A6, Upper molar; B6, lower molar.
FIGURE 19.13 Interincisal angle.
Measurements to determine the profile

11. Maxillary depth is used to determine the profile.
It can be given as the angle formed by intersection of the FH
plane with a line from the N point to point A. The maxillary
depth angle relates the horizontal position of the maxilla at
point A to the cranium (NA) (Fig. 19.14).
In general, the maxillomandibular relationship is described in
relation to the facial plane. Horizontally, the maxilla and
mandible of the average face are in alignment, both falling
along the facial plane. The vertical relation of the maxilla to the
mandible can be described by the lower facial height and the
intersection of the ANS–Xi and Xi–Pm planes. The norm for
this measurement is 45 degree. The maxillary first molar is
normally 21 mm anterior to the PTV. The relationship of
maxillary to mandibular first molars is such that the maxillary
molar is 3 mm distal to the mandibular molar.
FIGURE 19.14 Maxillary depth.
12th Factor: Soft tissue evaluation

12. Lower lip to E plane.
A 12th factor is also used now (i.e. lower lip to E plane). Lower lip
protrusion is evaluated by measuring the lower lip from an
aesthetic line constructed by joining the tip of the nose to the
tip of the chin (Fig. 19.15). The lower lip is in contact or a mm
ahead of E line while upper lip is behind this line.
FIGURE 19.15 Ricketts’ E line and relationship with upper and

lower lips.
Key Points
Ricketts’ cephalometric analysis essentially tries to orient the face and
mandible to the cranium.
His 12-factor analysis was fundamental to a treatment approach
that places great emphasis on the pattern of growth and facial growth.
The ultimate objective was to integrate growth into the best possible
treatment plan.
Ricketts also advocated using posteroanterior cephalogram and
arcial analyses of growth, methods of growth prediction that are given
in appropriate chapters.
References
1. Ricketts RM. Cephalometric analysis and synthesis.
Angle Orthod. 1961;31(3):141–156.
2. Ricketts RM. Perspectives in the clinical application
of cephalometrics: the first fifty years. Angle Orthod.
1981;51(2):115–150.
mandible. Angle Orthod. 1972;42(4):368–386.
CHAPTER 20
Vertical linear dimensions of face
and Sassouni’s analysis
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Wylie and Johnson the pioneers of vertical analysis of
face
Anterior facial height
Sassouni’s cephalometric analysis
Planes
Arcs
Jarabak’s ratio of anterior and posterior facial heights
Signs of vertical growth rotation
Key Points
Introduction
The vertical proportions of the face are critical in determining the
aesthetics and harmony of the face. The role of the vertical dimension
in the aetiology of various anteroposterior problems was realised in
the mid-20th century. Traditionally orthodontists perceived
malocclusion as an anteroposterior problem. The focus gradually
shifted towards three dimensional evaluation, the vertical dimensions
reflecting the major characteristics of facial types and so the
malocclusion.
Wylie and Johnson the pioneers of vertical

analysis of face
As early as 1947, Wylie1 made some commendable attempts at
devising a method for rapid evaluation of facial dysplasia in the
vertical plane. He used the following linear dimensions in the
anteroposterior plane to localise dysplasia of the maxilla and
mandible using the Frankfort horizontal (FH) plane as a reference:
1. Glenoid fossa–sella
2. Sella–pterygomaxillary (Ptm)
3. Ptm–maxillary first permanent molar (buccal groove)
4. Ptm–anterior nasal spine (ANS) (maxillary length)
5. Mandibular length: a vertical line drawn on the mandibular
plane from the posterior condyle surface to the pogonion.
If the first four linear dimensions representing the maxilla and

upper face are longer than average then the upper face would be
prognathic, and if the mandibular length is large then the lower face
would be more prognathic (Fig. 20.1A and B).
FIGURE 20.1 Rapid evaluation of facial dysplasia according to
Wylie and Johnson.2
(A) Parameters and average values for a 11½-year-old female: 1,
glenoid fossa–sella; 2, sella–Ptm; 3, Ptm–buccal groove of first molar;
4, Ptm–ANS maxillary length; 5, mandibular length. (B) In a face with
larger vertical dimensions yet the same anteroposterior (AP)
dimensions a longer mandible will compensate such that the profile is
maintained. ANS, Anterior nasal spine; Ptm, pterygomaxillary.
These linear values are not to be judged in an absolute sense but

should be considered in proportionality. The relative proportions of
some dimensions may vary but may show other compensatory
proportions that deviate in an appropriate direction. For example, a
large maxillary length can be offset by a short cranial base.
In 1952, Wylie and Johnson2 used a vertical dimension approach for
understanding the proportions of the anterior and posterior face.
Anterior face height was divided into upper face height—nasion (N)
to ANS—and lower face height—ANS to menton (Me). Posterior
vertical height was measured from the summit of the condyle to the
gonial angle. When mandibular length is large the lower face will be
more prognathic (Fig. 20.2).
FIGURE 20.2 Analysis of vertical face heights and ratios.
ANS–Me, Lower anterior face height; Ar–Go, lower posterior face
height; N–ANS, upper anterior face height; N–Me, anterior face height;
S–Ar, upper posterior face height; S–Go, posterior face height.
Anterior facial height

Anterior face height can be divided into upper face height (N–ANS)
and lower face height (ANS–Me). A ratio of 45:55 is considered
normal. Increase in lower face height is suggestive of downward and
backward rotation of the mandible, anterior open bite, short ramus,
large gonial angle or combinations of two or more of these features in
varying degrees of severity.
Sassouni’s cephalometric analysis3–5
Although several authors have tried to understand the role and
importance of the vertical dimension and its effect on the
anteroposterior dimensions of the face, Viken Sassouni’s work3 was
the first to put great emphasis on it for orthodontic treatment
planning.
Sassouni’s analysis was the first cephalometric method to categorise
both vertical and horizontal relationships, and the interaction between
the vertical and horizontal proportions of face.
Sassouni constructed a series of planes, arcs and axes on a profile
cephalostatic radiograph in order to study the structural configuration
of the skull for the purposes of growth analysis, diagnosis and
treatment (Fig. 20.3A and B).
FIGURE 20.3 (A) Landmarks, planes, and arcs used by Sassouni (B)
Landmarks, planes, and arcs used by Sassouni. These three arcs
represent A, profile in arc; B, profile post-arc and C, profile pre-arc
Planes
1. Mandibular base plane (OG). The OG is tangent to the inferior
border of the mandible.
2. Occlusal plane (OP). The OP passes through the mesial cusps of
the permanent first upper and lower molars and the incisal
edges of the upper and lower central incisors.
3. Palatal plane (ON). The ON is perpendicular to the mid-sagittal
plane, passing through the anterior and posterior nasal spines
(ANS–PNS).
4. Anterior cranial base. The anterior cranial base is structurally the
floor of the anterior cerebral fossa. In a lateral radiograph,
there are two contours: the upper is the roof of the orbit
including the lesser wing of the sphenoid, and the lower is
posteriorly the sphenoethmoid area and anteriorly the
cribriform plate.
Anterior cranial base plane or basal plane (OS). The basal plane is
parallel to the axis of the upper contour of the anterior cranial
base and tangent to the inferior border of the sella turcica.
5. Ramus plane (RX). The RX is tangent to the posterior border of
the ascending ramus.
In a well-proportioned face the following four planes meet at point

O:
1. The plane tangent to the sella and parallel with the anterior
cranial base (OS)
2. Palatal plane (ON)
3. Occlusal plane (OP)
4. Mandibular plane (OG).
Based on the point of convergence of these planes, a face’s vertical

proportionality can be appraised. The relation of the four planes to the
common point O permits classification of four facial types:
1. Type I: anterior cranial base plane does not pass through O.

2. Type II: palatal plane does not pass through O.
3. Type III: occlusal plane does not pass through O.
4. Type IV: mandibular base plane does not pass through O.
These types can be further classified into two subdivisions:
• Subdivision A: when the plane in each of these types does not

meet the other three at point O it may pass above that point.
• Subdivision B: when the plane in each of these types does not
meet the other three at point O it may pass below that point.
Sassouni considered the face to be well proportioned when the axes
of these four planes extended posteriorly meet at a common
intersection that is posterior to the occipital contour O.
Arcs
Using O as the centre, Sassouni constructed the following two arcs:
• Anterior arc. The anterior arc is the arc of a circle between the
anterior cranial base plane and the mandibular base plane,
with O as the centre and O–ANS as the radius.
• Posterior arc. The posterior arc is the arc of a circle between the
anterior cranial base plane and the mandibular base plane,
with O as the centre and O–SP as the radius (SP is the most
posterior point on the rear margin of the sella turcica).
Sassouni’s approach was popularised as arcial analysis. Based on

his observations and research, he classified all malocclusions into
three classes each consisting of three types of craniofacial patterns:
1. Class I: neutral, open bite and deep bite.

2. Class II: neutral, open bite and deep bite.
3. Class III: neutral, open bite and deep bite.
Essentially, neutral or skeletal open bite (vertical pattern) and deep

bite (horizontal pattern) can exist in any or all of the three types of
anteroposterior dysplasia of the jaws.
A well-proportioned face as defined by Sassouni is expected to
possess normal occlusion. On the contrary, of 50 persons examined
and found to have normal occlusion only 16 had a well-proportioned
face. Since the norm concept cannot be accepted as absolute for the
individual, Sassouni advocated measuring proportionality in the
individual as a basis for growth diagnosis and treatment planning
(Fig. 20.4).
FIGURE 20.4 Neutral, hyperdivergent and hypodivergent facial
patterns can exist in class I, class II or class III type malocclusions
based on the work of Sassouni.
Jarabak’s6 ratio of anterior and
posterior facial heights
The ratio between the anterior to posterior vertical heights is
reportedly more relevant than absolute values of measurements.
Jarabak described the facial vertical pattern on this basis (Figs 20.5 and
20.6A–D). He described three types of face pattern in the vertical
plane:
1. Neutral
2. Hypodivergent
3. Hyperdivergent
FIGURE 20.5 Three types of facial growth according to the ratio

of total posterior to total anterior face heights.
FIGURE 20.6 Facial growth rotations.
(A) Vertical; (B) neutral; (C) horizontal and (D) superimposition of A, B,
C.
Neutrals
Neutrals are usually associated with facial height ratio (FHR) of 59%–
63%. These are the commonest face types. Growth of the face and
mandible follows a downward and forward direction and there is
little change in the ratio between anterior and posterior face height.
Hyperdivergents
Hyperdivergents show excessive anterior face height and/or reduced
posterior face height. These subjects show reduced height of the
ramus and increased mandibular plane angle.
Hyperdivergent growth patterns are associated with a facial height
ratio (FHR) of 58% or less. The face rotates downwards and
backwards with growth. Anterior face height increases more rapidly
than posterior face height or, in other words, the ramus height is
smaller and the gonial angle tends to open (i.e. is larger than normal).
These facial patterns are commonly associated with rotational growth
changes and exhibit several other features on craniofacial morphology
such as a prominent antegonial notch and inclinations of the condylar
head, palatal plane (ON) and cranial base.
Hypodivergents
Hypodivergents have an FHR of 64% or more. In hypodivergent
children the ramus height is well developed and gonial angles tend to
be smaller. They show a horizontal growth pattern (i.e. low values for
mandibular to sella–nasion plane) and in many cases small anterior
face heights. Hypodivergents have square face and low mandibular
plane angle. These subjects exhibit either reduced anterior face height
or increased posterior face height. Those with a class II division 2 type
of pattern fall into this category.
Young growing children who fall into one of these categories,
predictively follow a facial pattern established much early. However,
those who fall into grey overlapping zones may evolve into any of the
three types.
The three facial types may be associated with malocclusions and
anteroposterior skeletal dysplasia. Siriwat and Jarabak6 reported that
the neutral pattern is dominant in class I and class II malocclusions.
The hypodivergent pattern is dominant in class II division 2 and class
III malocclusions.
More males tend to be hyperdivergent, while females are more
likely to be hypodivergent. FHR is strongly associated with ramus
height, gonial angle, mandibular plane angle, palatal plane inclination
and sum of saddle, articular, gonial angles.
The mean face heights and FHRs of a population of north Indians
are depicted in Table 20.1.
Table 20.1
Analysis of vertical facial heights7
a Significant difference.
Signs of vertical growth rotation
The signs of vertical growth rotations include
• a short ramus;
• a prominent antegonial notch (a sign of restricted mandibular
growth);
• a large gonial angle, particularly the lower gonial angle;
• anterior inclination of the condylar head;
• higher values for the sum of the cranial base (N–S–Ar),
articular (S–Ar–Go), and gonial angles (Ar–Go–Me);
• upward swing of the palate at the ANS is an indication of
posterior maxillary excess causing the gonial angle to open.
These findings can be reversed for other extremes of horizontal

facial type. Inclination of the palatal plane is another indicator of facial
type.
The diversity of facial height patterns is the outcome of a distorted
facial and cranial morphology affecting several bones and growth
rotations of the mandible. For practical purposes, we consider
children with a high mandibular plane angle and low Jarabak FHR as
vertical growers and low mandibular plane angle and high Jarabak
FHR as horizontal growers. The ratio between anterior and posterior
height is more relevant than absolute values. The vertical face pattern
has considerable bearing on orthodontic treatment planning from the
point of view of anchorage management, extraction/non-extraction
decisions, prognosis/treatment outcome, and effect of therapy on the
facial profile (in particular, on the chin).
Key Points
A well-balanced face has good proportions in all three dimensions of
space. Orthodontists traditionally look at malocclusion as
sagittal/anteroposterior deviations. Alterations in transverse (widths)
and vertical (heights) dimensions may contribute to sagittal
discrepancy or be expressed as sagittal discrepancy.
It has been found that face types (vertical or horizontal) are
established very early in childhood. Within the normal range of
occlusion, neutral, horizontal or vertical face types do exist.
Craniofacial structures exhibit certain characteristics that can be both
qualitative and measured in terms of absolute numerical values of
face heights and as ratios.
References
1. Wylie WL. The assessment of anteroposterior
dysplasia. Angle Orthod. 1947;17(3):97–109.
2. Wylie WL, Johnson EL. Rapid evaluation of facial
dysplasia in the vertical plane. Angle Orthod.
1952;22(3):165–182.
3. Sassouni V. A roentgenographic cephalometric
analysis of cephalo-facio-dental relationships. Am J
Orthod. 1955;41(10):735–764.
4. Sassouni V. A classification of skeletal facial types.
Am J Orthod. 1969;55(2):109–123.
5. Nanda SK, Sassouni V. Planes of reference in
roentgenographic cephalometry. Angle Orthod.
1965;35(4):311–319.
6. Siriwat PP, Jarabak JR. Malocclusion and facial
morphology is there a relationship? An
epidemiologic study. Angle Orthod.
1985;55(2):127–138.
7. Kharbanda OP, Sidhu SS, Sundrum KR. Vertical
proportions of face: a cephalometric study. Int J
Orthod. 1991;29(3):6–8: Review, Fall–Winter.
CHAPTER 21
Cephalometric analysis of the soft
tissue of the face
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Need for soft tissue analysis
Methods of obtaining a soft tissue profile on a cephalogram
General appraisal of the soft tissue profile
Soft tissue cephalometric analysis
Schwarz analysis
Subtelny analysis (1959)
Steiner’s S line
Holdaway’s analysis
Merrifield’s profile line: Z angle
Ricketts’ E line
Mentocervical angle
Arnett’s soft tissue cephalometric analysis (STCA)
I. Intramandibular
II. Interjaw
III. Orbit to jaw
IV. Total face
Bergman’s comprehensive analysis
Indian norms
Key Points
Introduction
It has long been recognised that response of the soft tissue integument
to orthodontic treatment may not be judged correctly by merely
analysing dental occlusion or osseous structures. The soft tissue of the
face requires an independent appraisal besides skeletal and dental
analysis to comprehensively diagnose and plan the treatment to meet
objectives of orthodontic treatment leading to a pleasing profile.
Need for soft tissue analysis

Soft tissue behaviour
The soft tissue integument of the face is dynamic. Its response and
behaviour to orthodontic treatment is not reciprocated in a manner
similar to that of osseous or dental structures.
Soft tissue varies considerably in morphology, thickness, postural
tone and expression and so its response to dental and skeletal
correction differs in different individuals and at different times (i.e.
age of treatment).
Soft tissue growth is independent of the hard tissue of

the face
Soft tissue growth of the face follows a curve independent of that of
hard tissues. Different parts of the soft tissue of the face such as the
nose, lips and chin have independent growth curves that are age
related and exhibit definite sexual dimorphism. These factors should
be taken into consideration when planning orthodontic treatment.
Methods of obtaining a soft tissue
profile on a cephalogram
The soft tissue cephalometric analysis can be performed on a good-
quality cephalogram, one that shows reasonable to excellent soft
tissue details of the facial profile and related structures. The
cephalogram should be obtained with the lips in a relaxed position
without any strain on lips and chin. The soft tissue profile of the face
can be recorded by using one of the following techniques.
Techniques of recording soft tissue on a cephalogram
1. Attaching an aluminium or copper wedge covering the area

behind the soft tissue profile to block X-rays is the most
commonly used method in day-to-day practice.1
2. Using a radiopaque barium meal, same as a contrast in
abdominal radiography: The barium meal is painted on the
midline structures of the face from forehead to below the chin.
This technique was popular until the 1980s, but is no longer
used because of it is a messy procedure.
3. Adopting a thin lead wire on the midline contours of the face
extending from forehead to chin is another way of providing a
good profile line on a cephalogram. However, it requires
considerable time and experience to position the wire in such a
way as to conform accurately to facial profile.
4. Soft tissue could be recorded better by reducing the kilovoltage
during radiation exposure.
5. Simultaneous exposure of non-screen film and screen film in
the same cassette is a good way of recording hard and soft
tissues.
6. Jacobson2 advocated reducing film density over the anterior
bony landmarks when using the black-paper in the cassette.
7. Painting an absorbing dye on the intensifying screen.1
8. Arnett et al.3 advocated placing metallic markers on the right
side of the face to mark the profile.
9. With current developments of digital cephalometry which has
nearly replaced film based cephalograms, photo editing
features are being used to locate facial profile on digital
cephalometric pictures.
The commonly used landmarks on soft tissue profile of a
cephalogram are depicted in Fig. 21.1.
FIGURE 21.1 Cephalometric landmarks of the soft tissue of the

face.
General appraisal of the soft tissue
profile
The soft tissue profile can be evaluated by dividing the face into four
regions for easy and methodical analysis.
• upper one-third;
• middle one-third;
• lower one-third;
• chin/neck region.
Upper one-third of face

It extends from hairline to bridge of nose. Although orthodontic
treatment does not alter the shape of the forehead or the nose, we
should consider the shape of these structures when evaluating
patient’s profiles.
Middle one-third of face

Important soft tissue landmarks to be considered are the glabella and
nose. The nose comprises the radix, nasal dorsum, supra tip
depression and tip of the nose. It is particularly important to note the
prominence of the glabella, the dorsum hump of the nose and the tip
of the nose (whether tilted upwards or not).
Upper one-third of lower face

This region contains the columella, nasolabial sulcus and upper lip.
The upper lip may vary in thickness, length, posture and tonicity.
These factors are vital in determining the response of the upper lip to
orthodontic treatment. Upper lip strain and a short lip are common
findings in patients with severely proclined upper incisors. When the
upper lip is strained the normal contour of the upper lip is altered and
thickness of the lip is unequal at the base of the nose as is the
vermilion border. Holdaway4,5 devised an effective method to identify
upper lip strain and quantify the same.
Other important features to note are lip thickness as well as dental
and skeletal protrusion or retrusion. Thick lips may show an acute
nasolabial angle even in the absence of dental protrusion. Similarly,
thin lips may show an obtuse nasolabial angle in the absence of dental
retrusion.
Lip eversion may be present in some individuals and is often
associated with acute nasolabial angles. It may not be corrected on
retraction of teeth. Lips should be examined for competency of the lip
seal and inner labial gap. If found incompetent, any relationship they
have with dental protrusion should be investigated.
Lower two-third of lower face

This region contains the lower lip, mentolabial sulcus and soft tissue
chin. The lower lip is notorious in showing variations in thickness,
length, tonicity and posture (particularly, everted lower lip). Some
patients have a thick soft tissue chin that may mask a retrognathic
mandible, appearing as a normal. A deep mentolabial sulcus may be
associated with a prominent chin. Vertical overclosure (skeletal deep
bite) cases show soft tissue redundancy in this area which manifests as
a deep mentolabial sulcus.
Conversely, a patient with a long face may show a shallow
mentolabial sulcus. Chin prominence may be flattened in vertical
growers. Changes in the soft tissue chin are amongst the most
predictable orthognathic surgical outcomes and hence need careful
evaluation.
Chin/neck region
The contour of the throat is important here from the orthognathic
surgery point of view when mandibular advancement or setback are
the plan of the treatment. Important features to note here are the lip–
chin–throat angle, chin–throat length and cervicomental angle.
Nasolabial angle
This is the angle formed by the upper lip and the base of the nose. It is
constructed at the intersection between the upper lip tangent and
columella tangent. A large range of 90–110 degree has been reported
with a normal value of 102 ± 4 degree.6
Scheideman et al.7 drew a horizontal line parallel to the postural
horizontal through the subnasale (Sn) and further divided the
nasolabial angle into the columella tangent to the postural horizontal
and the upper lip tangent to the postural horizontal. The upper angle
averages 25 degree and the lower averages 85 degree. In some cases
the nasolabial angle is found to be normal but oriented abnormally.
This angle can be affected by:
I. Dental protrusion or retrusion

II. Skeletal protrusion or retrusion
III. Lip thickness
IV. Nasal tip
V. Upper lip posture.
Upper lip prominence

Upper lip prominence is measured as the perpendicular distance from
the labrale superior to the line extending from the subnasale (Sn) to
the soft tissue pogonion (Pog). Legan and Burstone6 measured this
distance as 3 mm. Bell et al.8 utilised a vertical reference line through
the Sn, in which case the upper lip is estimated to be 1 mm ahead of
this line.
Lower lip prominence

In normal cases, Legan and Burstone6 estimated the labrale inferius to
be 2 mm anterior to the Sn–Pog line, while Bell et al.8 found the lower
lip to be on the Sn vertical or 1 mm behind it.
Interlabial gap
A small vertical gap between the upper and lower lips has been found
to be acceptable by clinicians and researchers. A range of 0–3 mm for
this vertical distance has been given. An interlabial gap of 2 mm is
considered acceptable.6
Horizontal nasal prominence7

Horizontal nasal prominence is measured from the glabella vertical as
the horizontal distance from the tip of the nose to this line. Horizontal
nasal prominence (glabella (G) true verti-cal to pronasale (P)) and
nasal height (vertical distance from galbella (G) to subnasale (Sn))
have a ratio of 1:3 (G–P:G–Sn).
Chin prominence
The soft tissue chin prominence is measured as the horizontal distance
from a line perpendicular to the Frankfort horizontal plane (FHP)
passing through the Sn. The mean value is 3 mm.
Chin thickness
Soft tissue chin thickness should be evaluated in relation to
underlying hard tissue such as thickness of chin, microgenia,
micrognathia, retrognathia or prognathia of the mandible. Soft tissue
chin thickness varies in different individuals and various types of
malocclusion. Some children with class II division 2 malocclusion
have significant chin thickness, which masks a retrognathic mandible.
Soft tissue chin thickness has been observed to be thin in class II
division 1 high-angle cases and class I bimaxillary cases.
Middle-third to lower-third ratio

The ratio between G–Sn and Sn–Me’ is approximately 1:1.
Measurement is taken perpendicular to the true horizontal plane. This
proportion is also known as the upper-to-lower-face ratio and is used
to analyse anterior proportions in the vertical dimension.
Upper lip to lower lip height ratio

The length of the upper lip (Sn–Stms) should be approximately one-
third of the total lower third of the face (Sn–Me). Also, the distance
Stmi–Me should be about two-thirds. Thus, the Sn–Stms/Stmi–Me
ratio is 1:2.
Soft tissue cephalometric analysis
There are numerous soft tissue analyses in the literature, some
designed for clinical applications and others for research. The most
important ones are:
Schwarz analysis9,10
A. M. Schwarz devised a profile analysis using a lateral cephalometric
radiograph in 1938. He used the spina–palate plane which separates
the dentition from the skull.
Landmarks used in the Schwarz analysis include the
O: orbital
Tr: trichion
n: soft tissue nasion
Sn: subnasale
pg: soft tissue pogonion
gn: soft tissue gnathion
Constructed reference lines include the
H line: similar to the FH plane

Pn line: perpendicular to the H line at the soft tissue nasion
Po line: perpendicular from the orbital to the H line
T line: the oblique tangential line is constructed by joining the Sn
to the pg.
The area between the two perpendicular lines constructed is termed

the gnathic profile field (GPF) by Schwarz. Normally, the upper lip
touches the Pn line, and the lower lip lies one-third posterior to the
width of the GPF. In the ideal case the T line bisects the vermillion
border of the upper lip and touches the anterior vermillion curvature
of the lower lip Fig. 21.2.
FIGURE 21.2 Profile analysis by A. M. Schwarz (1929).
(A) Normally, the upper lip touches the Pn line, and the lower lip lies
one-third the width of the GPF posterior to it. (B) In the ideal case, the
T line bisects the vermilion border of the upper lip and touches the
anterior vermilion curvature of the lower lip.
Subtelny analysis (1959)11
Subtelny was the first to document downward and forward growth of
the nose with maturity. He also found that not all parts of the soft
tissue profile directly follow underlying skeletal structures. He
studied growth changes in the facial integument, which was one of
the first longitudinal cephalometric studies to include the soft tissue of
the face. Subtelny devised a means of cephalometric analysis of the
angular profile. This analysis provides information on convexity of
the profile and distinguishes convexity amongst
• the skeletal profile

• the soft tissue profile
• a full or total soft tissue profile including the nose.
Skeletal profile convexity

This is determined by measuring the angle n–A–pg. The mean value is
177 degree in females and 179 degree in males.
Soft tissue profile

It is determined by the angle n–Sn–Pog’ The mean value is 161 degree
in females and 162 degree in males. Some authors report that facial
convexity is relatively stable after the age of 6 years, others find it does
not change till much later.11
Total soft tissue profile

It is measured by n-no-Pog’. Convexity of the nose is included because
the nose has a marked influence upon overall cosmetics of the soft
tissue profile. In men, the average value is 133 degree, while in
women it is 131 degree. Bishara found that total facial convexity
increases with age.12 All male and female subjects demonstrated an
increase in total facial convexity from the age of 5 years to adulthood
(Fig. 21.3).
FIGURE 21.3 Subtelny’s analysis: Soft tissue facial convexity.
Steiner’s S line
Steiner’s S line is drawn from the Pog to the midpoint of the S-shaped
curve between the Sn and nasal tip. Normally, the upper and lower
lips touch the S line. The lips lying behind this line are too retrusive,
while those lying ahead are protrusive (Figs 21.4 and 21.5).
FIGURE 21.4 Steiner’s S line.
FIGURE 21.5 Soft tissue planes by various authors

(1) Soft tissue facial line; (2) Steiner’s S line; (3) E plane by Ricketts;
and (4) Holdaway’s H line.
Holdaway’s analysis4,5
Holdaway’s analysis introduced the concept of the harmony line or H
line that is drawn as a tangent to the chin and the upper lip.
Holdaway’s analysis contains 11 measurements as follows (Fig. 21.6):
i. Soft tissue facial angle. The soft tissue facial angle measures a
line drawn from the soft tissue nasion (Na or n) to the soft
tissue chin (Pog or pg) measured along the FHP. A
measurement of 91 degree is ideal, with an acceptable range of
±7 degree. This measurement is helpful in categorising
whether a case is prognathic (>91 degree) or retrognathic (<91
degree). There is a large range of 7 degree therefore it must be
carefully correlated with other parameters.
ii. Skeletal profile convexity. Skeletal profile convexity is a
measurement from point A to Downs’ facial plane (N–pg).
Although it is not a soft tissue measurement it provides a good
assessment of skeletal convexity in relation to the lip position.
The ideal measurement ranges from 2 to +2 mm and provides
a guideline to achieve the dental relationship needed to
produce facial harmony.
iii. Holdaway’s H angle. Holdaway’s H angle measures the H
line to the soft tissue facial plane (Na–Pog). Measurements of
7–15 degree are in the ideal range and are correlated with
skeletal profile convexity. Ideally, as skeletal convexity
increases the H angle must also increase if a harmonious drape
of soft tissues is to be realised in varying degrees of profile
convexity. The H line signifies that as skeletal convexity
increases so does convexity of the soft tissue profile if the
entire facial complex is to be one of balance and harmony. This
angle measures prominence of the upper lip in relation to the
overall soft tissue profile. The H angle increases as we go from
concave to convex skeletal patterns. Changes in the H angle
reflect the direction of growth, especially of the mandible. This
measures change during treatment or observation periods in
the same patient and helps quantify differences between one
patient and another.
iv. Nose prominence. Nose prominence can be measured using a
line perpendicular to the FHP and running tangent to the
vermillion border of the upper lip. This measures the nose
from its tip in front of the line and the depth of the incurvation
of the upper lip to the line. Although nasal form is judged on
an individual basis, measurements less than 14 mm are
considered small, while those above 24 mm are considered
large.
v. Superior sulcus depth. Superior sulcus depth is measured as
the distance between a line perpendicular to the FHP and
tangent to the upper lip. A range of 1–4 mm is acceptable, with
3 mm being ideal. During orthodontic treatment or surgical
orthodontic procedures, efforts should be made not to allow
this measurement to become less than 1.5 mm. Decreased
values are suggestive of upper lip strain.
vi. Soft tissue chin thickness. Soft tissue chin thickness is
recorded as the horizontal distance between hard tissue and
soft tissue facial planes (N–Pg/n–Pog’). Average values are
between 10 and 12 mm. In a very thick soft tissue chin, it is
best to leave the lower incisors in a more anterior position so
as to provide much-needed lip support.
vii. Upper lip thickness. Upper lip thickness is measured near
the base of the alveolar process, at about 3 mm below point A.
It is at a level just below the point at which nasal structures
influence the drape of the upper lip. This measurement is
useful when comparing the lip thickness overlying the incisor
crowns at the level of the vermillion border and when
determining the amount of lip strain or incompetency present
as the patient closes his/her lips over protrusive teeth.
viii. Upper lip strain. Upper lip strain is commonly seen on
cephalograms of patients with proclined upper lips. In this
situation the patient habitually tries to close his/her lips so as
to hide proclined teeth. In doing so the normal thickness of the
upper lip is not recorded on the cephalogram. While taking the
cephalogram, it is always advisable to ask the patient to relax
his/her lips by licking them and keeping them in repose. When
lip strain is present, strain measurement can be done
horizontally from the vermillion border of the upper lip to the
labial surface of the crown of the most proclined incisor.
The difference between two measurements if more than 1 mm is
suggestive of Lip strain. The usual lip thickness at vermillion
border is 13–14 mm. If this measurement is less than the
thickness of the lip (beyond the acceptable range), then the lips
are considered to be strained. The difference between the two
measurements is called the strain factor. It also reveals the
amount of retraction needed to produce normal lip form and
thickness. It is important to note that inherent lip thickness
matters when predicting response of the lips to retraction.
Thick lips do not retract significantly. The ratio between change
of position of the upper lip and linear retraction of maxillary
incisors is usually 1:3.
When lip thickness at the vermillion border is larger than the
basic thickness measurement, this usually identifies a lack of
vertical growth of the lower face with a deep overbite and
resulting lip redundancy.
ix. Upper lip sulcus depth. The upper lip sulcus depth is
measured from the Sn to the H line. The ideal is 5 mm, with a
range of 3–7 mm. When the skeletal convexity of a patient is
from –3 to 5 mm the lips can usually be aligned nicely along
the H line, especially when the superior sulcus measurement is
at or near 5 mm. With short and thin lips, 3 mm will be
adequate. In longer and thicker lips, 7 mm may give excellent
balance. If this measurement is 8 or 9 mm with no evidence of
lip strain or lack of harmony of facial lines, the extraction of
premolars may not be necessary.
x. Lower lip to the H line. The lower lip to the H line is measured
from the most prominent point on the outline of the lower lip.
The ideal is 0–0.5 mm anterior to the H line with from 1 mm
behind to 2 mm in front of the H line. Lack of chin may be a
factor when the lower lip appears very prominent. Sliding
genioplasty surgical procedures can be very beneficial in some
of these cases.
xi. Inferior sulcus to the H line. The inferior sulcus to the H line
is measured from the point of greatest incurvation between the
vermillion border of the lower lip and the soft tissue chin to
the H line. The contour in the inferior sulcus area should fall
into harmonious lines with the superior sulcus.
FIGURE 21.6 Landmarks and plane used by Holdaway.

Merrifield’s profile line: Z angle13–15
Merrifield’s line much like the H line is tangent to the soft tissue chin
and to the most anterior point of either the upper or lower lip—
whichever proclined the most—and extending this line upwards to
the FHP. Its average value is 80 ± 5 degree. Ideally, the upper lip
should be tangent to the profile line, whereas the lower lip should be
tangent or slightly behind it. This angle expresses the full extent of lip
protrusion in malocclusions.
Ricketts’16,17 E line
R. M. Ricketts suggested using an aesthetic (E) plane to evaluate the
relationship between the nose, lips and chin. Ricketts’ E line is drawn
from the tip of the nose to the soft tissue chin (Fig. 21.7). A quick
method to look at one profile is to imagine a line tangent from the
lower chin to the nose tip. Cephalometrically, Ricketts’ E line is drawn
from the tip of the nose to the soft tissue chin. Normal values suggest
that the upper lip is 4 mm behind the E line, while the lower lip lies 2
mm behind this reference line. It is important to mention that this
reference line is influenced a great deal by growth of the nose and also
varies with age and sex. Ricketts recommended that lip position
should be analysed using the nose–chin line as a reference point.
These values are for Caucasians and clearly cannot be applied to all
races.
FIGURE 21.7 Ricketts’ E line.
Nose inclination is an important consideration because sometimes the
nasal base is tipped upwards thereby increasing the nasolabial angle
and sometimes it is tipped downwards thereby decreasing the
nasolabial angle (Fig. 21.8).
FIGURE 21.8 Inclination of nasal base.
Mentocervical angle
The mentocervical angle is formed by intersection of the E line and a
tangent to the submental area. The range of average values is 110–120
degree (Fig. 21.9A).
FIGURE 21.9 Mentocervical angle (A) and submental neck angle

(B).
The submental neck angle is formed by a submental tangent and a
neck tangent. It varies between the sexes. In males its normal value is
126 degree and in females its average value is 121 degree (Fig. 21.9B).
The soft tissue assessment is summarised in Box 21.1
Box 21.1 Soft tissue assessment sheet used to

measure facial traits. If a facial trait is in the
normal range it should be maintained. Growth,
orthodontic tooth movement, and surgical
procedures should be maintained as normal
facial traits when trying to move other facial
traits into the normal range. Grey indicates major
areas affected by orthodontic treatment
Arnett’s soft tissue cephalometric
analysis (STCA)
The STCA of William Arnett et al.3 is a comprehensive method to
analyse the integumental profile. This approach signifies the diagnosis
and treatment planning philosophy of Arnett et al.3 and Bergman.18
The authors believe that clinical findings as a result of examination
and model analysis are important when proceeding with STCA (Fig.
21.10A–E). Merrifield et al.15 described a novel method of obtaining a
good soft tissue profile in which radiopaque metallic markers are used
to mark key midface structures. These markers are placed on the right
side of the face on landmarks such as the orbital rim, cheekbone, alar
base and neck–throat point. After placing the markers the
cephalogram is recorded with the patient’s head in its natural
orientation (NHP).
FIGURE 21.10 Soft tissue comprehensive analysis (STCA) by
William Arnett.
(A) TVL projections used in Arnett STC analysis OR, = orbital rim, CB,
= cheek bone, AB, = alar base, SP, = subpupil. (B–E) Harmony values
in four areas of facial balance. (B) Intramandibular harmony. (C) Inter-
jaw harmony. (D) Orbital rim to jaw. (E) Total face harmony.
The true vertical line (TVL) is a line passing through the Sn and
perpendicular to the natural horizontal head position. The vertical or
horizontal position of soft tissue and hard tissue landmarks are then
measured relative to the patient’s natural horizontal head position or
TVL. The STCA can be used to diagnose the patient in five different
but interrelated areas:
1. Dentoskeletal factors
2. Soft tissue components
3. Facial lengths
4. TVL projections
5. Harmony of parts.
While the first three factors are common to several other analyses
the reader should refer to Table 21.1 for the norms. The TVL
projection and harmony of parts are discussed in the following two
sections.
TVL projections are anteroposterior measurements of soft tissue
and represent the dentoskeletal position plus the soft tissue thickness
overlying hard tissue landmarks. The horizontal distance for each
landmark, measured perpendicular to the TVL, is termed the
landmark’s absolute value (Fig. 21.10A). The Sn may frequently be
coincident with anteroposterior positioning of the TVL, but may not
be so in some cases. For example, the TVL must be moved forward in
cases of maxillary retrusion in which the nose is overlong, depressed
or flat orbital rims, cheek bones, and alar bases, poor incisor support
for the upper lip, upright upper lip, thick upper lip and retruded
upper incisor. In such cases, clinical examination is necessary to
corroborate cephalometric findings. Harmony values were created to
measure both the structural balance and harmony of the nose. They
are based on the concept that the position of each landmark relative to
other landmarks determines facial balance. Harmony values represent
the horizontal distance between two landmarks measured
perpendicular to the TVL. Harmony values examine four areas of
balance: intramandibular, interjaw, orbit to jaw and total face.
I. Intramandibular
Intramandibular harmony values are when chin projection is assessed
relative to the lower incisor, lower lip, soft tissue B point and neck–
throat point.
II. Interjaw
Interjaw harmony values indicate the interrelationship between the
base of the maxilla to the chin, soft tissue B point to soft tissue A point
and upper lip to lower lip (Fig. 21.10C).
III. Orbit to jaw

Orbit-to-jaw harmony values determine the position of the soft tissue
inferior to the orbital rim relative to the upper jaw (OR–A) and lower
jaw (OR–B) (Fig. 21.10D).
IV. Total face

Total face harmony values determine the interrelationship of the
upper face, midface and chin via a facial angle (G–Sn–Pog). The
forehead is then compared with the upper jaw (G–A) and chin (G–
Pog).
Such an analysis is essentially used to demonstrate the implications
of changes in the soft tissue of the face expected from orthognathic
surgery and orthodontics.
Bergman’s18 comprehensive analysis
Robert Bergman suggested composite tissue analysis be undertaken
from 13 points along the facial profile, 2 points on the labial mucosa
and 1 at the tip of the upper incisor. He presented an organised,
comprehensive approach to soft tissue analysis using lateral
cephalometric head films.
He emphasised that soft tissue cephalometric analysis should not, of
course, substitute comprehensive clinical examination of the patient.
He devised a table to evaluate each parameter and included it as a
part of routine diagnosis and treatment planning. Based on
information on standard facial traits and a patient’s soft tissue features
as suggested by him, an individualised norm can be established for
each patient to optimise facial attractiveness. He made it very clear
that before orthodontic or orthognathic treatment is instituted,
answers to the following four questions be found.18
(1) What is the quality and quantity of the trait, that is, soft tissue
parameters?, (2) How will future growth affect the trait?, (3) How will
orthodontic tooth movement affect the existing trait (positively or
negatively)? and (4) How will surgical bone movement correct the bite
will affect the trait (positively or negatively) (Fig. 21.11).
FIGURE 21.11 Bergman’s composite analysis.
There are 13 points along the facial profile, 2 points on the labial
mucosa and 1 at the tip of the upper incisors that are used to measure
soft tissue traits.
His analysis of soft tissue not only evaluates the existing profile but
takes growth, the effect of orthodontic tooth movement, and the effect
of orthognathic surgery into consideration.
Indian norms19–26
It has become increasingly clear over the years that there are clinically
significant variations in craniofacial morphology and soft tissue
among the various ethnic groups. Clinicians and researchers have
highlighted the redundancy of applying Caucasian norms to people of
different ethnicities and in different parts of the world.
A number of studies have been done to develop cephalometric
norms for the Indian population and for different ethnic groups
including norms for soft tissue.
Although the soft tissue parameters of Indians are by and large the
same as Caucasians, they do differ significantly in some parameters.
Parameters that differ significantly are profile, lip, and soft tissue chin.
Soft tissue chin seems to be deficient in the south Indian Tamil
population when compared with Caucasian norms (Table 21.1).
Table 21.1
Cephalometric values for the soft tissue of the face for
Indian racial (ethnic) groups compared with those of
Caucasians
F, female; M, male; pg, pogonion; Pog’ soft tissue pogonion.
Orthognathic surgery norms have also been developed which not

only show differences between Indians and other races but also
significant differences between north and south Indian population
groups.27–31
Key Points
Orthodontic treatment objectives are aimed at attainment of a
harmonious, well-balanced face and stable occlusion. The soft tissue of
the face shows great variations in thickness and presentation, which
may mask the underlying skeletal pattern. The current thinking
behind orthodontics primarily focusses on the face. Soft tissue analysis
is an integral and significant component of orthodontic diagnosis.
Norms are only a guide. Soft tissue analysis should take account of the
race, skeletal pattern, sex and age of a person.
References
1. Tyndall DA, Matteson SR, Soltmann RE, Hamilton
TL, Proffit WR. Exposure reduction in cephalometric
radiology: a comprehensive approach. Am J Orthod
2. Jacobson A, Caufield PW. Introduction to
radiographic cephalometry. Philadelphia: Lea and
Febiger; 1985:25–27.
3. Arnett GW, Jelic JS, Kim J, Cummings DR, Beress A,
Worley Jr CM, Chung B, Bergman R. Soft tissue
cephalometric analysis: diagnosis and treatment
planning of dentofacial deformity. Am J Orthod
4. Holdaway RA. A soft-tissue cephalometric analysis
and its use in orthodontic treatment planning, part I.
Am J Orthod. 1983;84(1):1–28.
5. Holdaway RA. A soft-tissue cephalometric analysis
and its use in orthodontic treatment planning, part II.
Am J Orthod. 1984;85(4):279–293.
6. Legan HL, Burstone CJ. Soft tissue cephalometric
analysis for orthognathic surgery. J Oral Surg.
1980;38(10):744–751.
7. Scheideman GB, Bell WH, Legan HL, Finn RA,
Reisch JS. Cephalometric analysis of dentofacial
normals. Am J Orthod. 1980;78(4):404–420.
8. Bell WH, Jacobs JD, Quejada JG. Simultaneous
repositioning of the maxilla, mandible, and chin:
treatment planning and analysis of soft tissues. Am J
Orthod. 1986;89(1):28–50.
9. Schwarz AM. Textbook of orthodontics (Lehrang der
Gebissregelung), first four volumes. Berlin and
Vienna: Urban and Schwarzenberg; 1937.
10. Schwarz AM, Roentgenostatics:. a practical evaluation
of the X-ray head plate. Int J Orthod Dent Child.
1938;2(4):396–399.
11. Subtelny JD. A longitudinal study of soft tissue facial
structures and their profile characteristics, defined in
relation to underlying skeletal structures. Am J
Orthod. 1959;145(7):481–507.
12. Bishara SE, Jakobsen JR, Hession TJ, Treder JE. Soft
tissue profile changes from 5 to 45 years of age. Am J
Orthod Dentofacial Orthop. 1998;Dec;114(6):698–706:
13. Merrifield LL. The profile line as an aid in critically
evaluating facial esthetics. Am J Orthod.
1966;52(11):804–822.
14. Merrifield LL. Analysis—concepts and values, part II.
J Charles H. Tweed Int Found. 1989;17:49–64.
15. Merrifield LL, Klontz HA, Vaden JL. Am J Orthod
Dentofacial Orthop. Differential diagnostic analysis
system.. 1994;6:641–648.
Angle Orthod. 1961;31(3):141–156.
17. Ricketts RM. Perspectives in the clinical application of
cephalometrics: the first fifty years. Angle Orthod.
1981;51(2):115–150.
18. Bergman RT. Cephalometric soft tissue facial analysis.
Am J Orthod Dentofacial Orthop. 1999;116(4):373–389.
19. Grewal H, Sidhu SS, Kharbanda OP. A cephalometric
appraisal of dento-facial and soft tissue pattern in
Indo-Aryans. J Pierre Fauchard Acad. 1994;8(3):87–96.
20. Kalra JPS, Kharbanda OP. Facial profile changes
related to orthodontic tooth movement—a
cephalometric study. J Indian Orthod Soc.
1996;27:93–105.
21. Kalha AS, Latif A, Govardhan SN. Soft-tissue
cephalometric norms in a South Indian ethnic
population. Am J Orthod Dentofacial Orthop.
2008;133(6):876–881: doi: 10.1016/j.ajodo.2006.05.043.
22. Sachan A, Srivastav A, Chaturvedi TP. Soft-tissue
cephalometric norms in a north Indian ethnic
population. J Orthod Sci. 2012;1(4):92–97: doi:
10.4103/2278-0203.105877.
23. Rathore AS, Dhar V, Arora R, Diwanji A. Analysis of
cephalometrics for orthognathic surgery:
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H, Bejoy PU. Soft tissue cephalometric norms for
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Health. 2014;6(5):51–59.
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CHAPTER 22
Posteroanterior cephalometric
analysis
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Setup for PA cephalometry
Head positioning for PA cephalogram
Landmarks on a PA cephalogram
Planes in a PA cephalogram
Grummons’ analysis
Horizontal planes
Mandibular morphology
Maxillomandibular comparison of asymmetry
Dental relations
Skeletal relations
Dental to skeletal
Jaw to cranium
Internal structure
Key Points
Introduction
The posteroanterior (PA) cephalogram is an effective tool in
evaluating craniofacial structures in transverse and vertical
dimensions. It allows looking at the facial skeleton from the relative
view of the right–left face and upper–lower face. Initial attempts at
analysing the craniofacial skeleton on PA cephalograms were limited
to absolute linear measurements such as face widths and heights, and
later ratio and volumetric comparisons were added to evaluate
relative asymmetries.1–4
Setup for PA cephalometry

Correct orientation of the patient is of utmost importance before
exposing him/her to X-ray radiation. The cephalostat head holder is
rotated 90 degrees so that the patient faces the X-ray cassette/sensor
and the central X-ray beam passes through the skull in a PA direction
bisecting the transmeatal axis perpendicularly.
The patient is held in a fixed position by the ear rods of a head
holder. The standard distance from the X-ray source to the ear rods is
5 ft. Reproduction of the head position is crucial because if the head is
tilted the vertical-dimension measurements will not be accurate.
Head positioning for PA cephalogram

The correct head orientation is the basis of accurate measurements in
PA cephalometry. The method of correct head orientation is given
below.
1. Conventionally, the head can be positioned with the tip of the

nose and forehead in light contact with the film cassette holder
sensor. This position is good for evaluation of craniofacial
anomalies that require special attention to the upper face.
2. The standard method is by keeping the Frankfort horizontal
plane (FHP) parallel to the floor, while the patient is facing the
X-ray film cassette as close as permissible within the limits of
nose prominence.
3. To ensure correct orientation of the head in the FHP, patient
positioning should be guided by scribing a line on the ear rod
assembly at a point 15 mm above the ear rod. The height of the
orbit is about 3 cm, and the lateral canthus is essentially at the
centre of the orbit, or 15 mm. The patient should be oriented
such that his ear canals tuck snugly against the top of the ear
rods with the head positioned so that the lateral canthus of the
eye is located at the same level as that line.5
4. Orienting the head in the natural head position.6
5. Cephalograms should be taken with the mouth of the patient
slightly open in cases of significant mandibular displacement.7
Signs of a good head position on PA cephalogram X-ray film

include
1. The head position and inter-maxillary occlusal relationship that

appear on an X-ray should first be checked using an intraoral
photograph of the patient, study casts or by clinical evaluation
of the occlusion.
2. In a properly oriented PA cephalogram the top of the petrous
portion of the temporal bone lies near the centre of the orbit.4
A PA cephalogram would require careful visual evaluation of
dentofacial and associated structures. This is usually followed by
detailed cephalometric analysis.
A PA cephalogram should first be assessed in order to exclude any
possibilities of a pathology of hard and soft tissues involved or
unusual findings. Each cephalogram should be labelled for patient
details, with name of hospital, ID of patient, and date of cephalogram
being the most critical. Other important features include
1. Orbits: whether normally inclined or oblique and whether

equal or disparate in size.
2. Ramus of the mandible: whether present, absent or
underdeveloped as seen in unilateral or bilateral hypoplasia.
3. Angle of mandible: whether obtuse or acute. An obtuse angle is
usually seen on the unaffected side in ankylosis.
4. Body of mandible: whether present, absent or developed on both
sides to an equal extent or not. May deviate to either side in
certain situations.
5. Chin: whether present in the centre or deviated to one side as
seen in cases of asymmetry of the mandible.
6. Malar bones: whether equally prominent on either side or just
one side as in craniofacial syndromes.
7. Maxillary antra: whether equal on both sides and whether
development is normal or not.
8. Width of dental arches: may be underdeveloped or
overdeveloped on either side or both sides.
9. Cant of occlusal plane: can be compared at a single glance in a
PA cephalogram. It may be tilted to the affected side in
temporomandibular joint ankylosis cases.
10. Nasal widths: may be equal or unequal as in unilateral
hypoplasia.
Detailed analysis of a PA cephalogram can be carried out by tracing
the bony and dental structures to be studied. Horizontal and vertical
reference planes help in the determination of facial asymmetry in
vertical and horizontal directions by observing the relative orientation
of landmarks to these planes.
Landmarks on a PA cephalogram
Tracing/digitisation of a PA cephalogram should be carried out by
orienting it in front of the examiner as he/she is looking at the patient
(i.e. the patient’s right should be on the examiner’s left). Tracing
should begin with the midline structures. The bilateral points marked
on a PA cephalogram are conveniently abbreviated with the addition
of R and L for the right and left side: Important landmarks used in a
PA cephalogram are given in Figs 22.1 and 22.2.8
1. Z point (zygomatic). Bilateral points on the medial margin of the

zygomaticofrontal suture at the intersection of the orbits (ZL,
left and ZR, right).
2. ZA, AZ (centre of the roof of the zygomatic arch). It is abbreviated
as ZA for the left side and AZ for the right side.
3. EL, ER (Euron point). The most lateral point on the side of the
head in the region of parital bone.
4. J point. Bilateral points on the jugal process at the intersection
of the outline of the tuberosity of the maxilla and zygomatic
buttress (left and right).
5. AG (antegonial tubercle: mandible). Points at the lateral inferior
margin of the antegonial protuberance (GA, left and AG,
right).
6. Cg (crista galli).
7. ANS (anterior nasal spine). Tip of the ANS just below the nasal
cavity and above the hard palate.
8. Cd (condylon). The most superior part of the condylar head (left
and right).
9. A1 point. A point selected at the interdental papilla of the upper
incisors at the junction of the crown and gingiva.
10. B1 point. A point selected at the interdental papilla of the lower
incisors at the junction of the crown and gingiva.
11. ME (mental). The most inferior midline point on the
FIGURE 22.1 A PA cephalogram is developed and oriented for

the purpose of tracing in such a way as to give the
anteroposterior view (i.e. the film is placed in such a way that the
orthodontist is actually facing the patient).
This orientation greatly helps the orthodontist simultaneously compare
facial photos and dental casts when evaluating frontal dysplasia.
FIGURE 22.2 Commonly used landmarks for PA cephalogram

analysis.
Tracing a PA cephalogram requires considerable experience. It is a
much more cumbersome process compared to that happens with
tracing a lateral cephalogram. An orthodontist must be fully conversant
with the detailed anatomy of the skull and its structures. The landmarks
on a PA cephalogram are: A6L, the most prominent contour of the
upper left first molar; A6R, the most prominent contour of the upper
right first molar; AGL, anti-gonial left; AGR, anti-gonial right; ANS,
anterior nasal spine; B3L, tip of left lower canine; B3R, tip of right lower
canine; B6L, most prominent contour of lower left first molar; B6R, most
prominent contour of lower right first molar; Cg, crista gall; CL, conca
left; CR, conca right; JL, jugal process left; JR, jugal process right; ME,
menton; ZAL, zygomatic arch left; ZAR, zygomatic arch right; ZL,
zygomatic suture left; ZR, zygomatic suture right.
Planes in a PA cephalogram
Various horizontal and vertical planes are drawn on a PA
cephalogram so that different analyses can determine asymmetry,
linear dimensions and angles.
Median sagittal reference (MSR) plane

The MSR plane has been selected as a key reference line because it
closely follows the visual plane formed by the sub-nasale and
midpoints between the eyes and eyebrows. It generally runs in a
vertical direction from the Cg through the ANS to the chin area and is
typically nearly perpendicular to the Z plane. The Z plane is defined
as a line joining the zygomaticofrontal suture of one side to the other.
If the location of the Cg is in question, an alternative method of
drawing the MSR plane is to draw a line from the midpoint of the Z
plane through the ANS. The position of the ANS will be altered in
facial asymmetry involving the maxilla.
If there is upper facial asymmetry, the MSR plane can be drawn as a
line from the midpoint of the Z plane through the midpoint of the Fr–
Fr line (foramen rotundum of one side to the other). To avoid any
such bias, a best fit vertical line is drawn in the centre connecting the
midpoints of lines joining the zygomaticofrontal sutures (Z–Z),
centres of the zygomatic arches (ZA), medial aspects of the jugal
processes (J) and the antegonial notch (AG–GA) of both sides.
The best fit line and all lines constructed as perpendiculars through
the midpoints between pairs of orbital landmarks have shown
excellent validity.9
Besides vertical reference lines, horizontal best fit lines have to be
constructed to ascertain asymmetry in the vertical plane. All
horizontal lines connecting bilateral cranial landmarks can adequately
serve as reference lines to analyse vertical asymmetry from PA
cephalograms as long as landmark identification error is acceptable
(Fig. 22.3).
FIGURE 22.3 Transverse planes used in PA cephalometric

analysis.
Grummons’ analysis (Figs 22.3 and
22.4)
Grummons’2 analysis is a comparative and quantitative PA
cephalometric analysis and is not related to normative data. It consists
of a number of components:
1. Horizontal planes
2. Mandibular morphology
3. Volumetric comparison
4. Maxillomandibular comparison of asymmetry
5. Linear asymmetry assessment
6. Maxillomandibular relation
7. Frontal vertical proportions.
FIGURE 22.4 Volumetric comparison between left and right side
for analysis of facial asymmetry.
Horizontal planes
Four planes can be drawn to show the degree of parallelism and
symmetry of facial structures. Three planes connect the medial aspects
of zygomaticofrontal sutures (Z–Z), centres of ZA and medial aspects
of jugal processes (J). Another plane is drawn at the menton parallel to
the Z plane. The MSR plane has been selected as a true vertical
reference line.
Mandibular morphology
Left and right triangles are formed at the heads of the condylar
processes or condyles (Co), antegonial notches (AG), and the menton
and then compared. The ANS–ME line parallels the visual dividing
line from the sub-nasale to the soft-tissue menton in the lower face.
Linear values and angles can be measured at the same time as the
anatomy is determined. Much as the case with horizontal planes,
these data are very sensitive to head rotation.
Volumetric comparison
Two ‘volumes’ (polygons) are calculated from the area defined by
each Co–GA–ME and the intersection with a perpendicular from Co to
MSR. A computer can superimpose one polygon on top of the other to
provide a percentile value of symmetry.
Maxillomandibular comparison of asymmetry

Drawing perpendiculars from J and GA to the MSR plane and
connecting lines from Cg to J and GA produces two pairs of triangles,
each bisected by the MSR plane. If there is perfect symmetry the four
triangles become two: J–Cg–J and AG–Cg–GA.
Linear asymmetries
Vertical offset and linear distances are measured from the MSR plane
to Co, C, J, AG and ME.
Maxillomandibular relation
To allow tracing of the functional posterior occlusal plane a 0.014-in.
wire is placed across the mesioocclusal areas of the maxillary first
molars. The wire should extend about 3 mm buccally to make it easy
to recognise on the head film.
Distances are measured from the buccal cusps of the upper first
molars (on the occlusal plane) along the J perpendiculars. The AG,
MSR and ANS–ME planes are also drawn to depict dental
compensations for any skeletal asymmetries in horizontal or vertical
planes (maxillomandibular imbalance). Midline asymmetries of the
upper and lower incisors and ME–MSR are also provided.
Skeletal and dental measurements are made along the Cg–ME line
with divisions at the ANS, A1 and B1. The following ratios can be
calculated:
1. Upper facial ratio: Cg–ANS/Cg–ME

2. Lower facial ratio: ANS–ME/Cg–ME
3. Maxillary ratio: ANS–A1/ANS–ME
4. Total maxillary ratio: ANS–A1/Cg–ME
5. Mandibular ratio: B1–ME/ANS–ME
6. Total mandibular ratio: B1–ME/Cg–ME
7. Maxillomandibular ratio: ANS–A1/B1–ME.
These values can be compared with the common facial aesthetic

ratio and measurements.
Ricketts’ analysis provides normative data of the parameters
measured, which is helpful in determining vertical, transverse dental
and skeletal problems (Table 22.1). It has five components:
1. Dental relations
2. Skeletal relations
3. Dental to skeletal
4. Jaw to cranium
5. Internal structure.
Table 22.1
Ricketts’ norms for posteroanterior cephalometric
analysis
AG, Antegonial; ANS, anterior nasal spine; AZ, zygomatic arch (right side); J, jugal; ZA,
zygomatic arch (left side); ZL, zygomatical suture (left side); ZR, zygomatical suture (right
side).
Dental relations
The dental relations (Fig. 22.5) comprise:
1. Molar relation left (A6–B6).

2. Molar relation right (A6–B6).
Molar relations indicate the difference in width between the
upper and lower molars measured at the most prominent
buccal contour of each tooth. They are used to describe the
buccal/lingual occlusion of the first molars.
3. Intermolar width (B6–B6). Intermolar width is measured from
the buccal surface of the mandibular left first molar to the
buccal surface of the mandibular right first molar. This is
helpful in determining the aetiology of cross-bite.
4. Intercanine width (B3–B3). Intercanine width is measured from
the tip of the mandibular right canine to the tip of the left
mandibular canine.
5. Denture midline. The denture midline is measured from the
midline of the upper arch to the midline of the lower arch.
FIGURE 22.5 Dental relations as measured on a PA cephalogram
according to Ricketts’ analysis.
1. Molar relation right; 2. molar relation left; 3. inter-molar width; 4.
inter-canine width.
Skeletal relations
The skeletal relations (Fig. 22.6) comprise:
1. Maxillomandibular width right.
2. Maxillomandibular width left.
Maxillomandibular widths are measured from the jugal process
to the frontal facial plane (constructed from the medial margins
of the zygomaticofrontal sutures to the AG point). They are
used to measure skeletal cross-bite.
3. Maxillomandibular midline. The maxillomandibular midline is
measured by the angle formed by the ANS–ME plane to a
plane perpendicular to the ZA–AZ plane.
4. Maxillary width (J–J). Maxillary width is measured as the
transverse distance from J to J.
5. Mandibular width (AG–GA). Mandibular width is measured as
the transverse distance from AG to GA.
FIGURE 22.6 Skeletal and dental relations as measured on a PA
cephalogram according to Ricketts’ analysis.
5. Maxillo mandibular midline; 6. maxillary width; 7. mandibular width;
8. molar relation right to jaw right; 9. molar relation left to jaw left.
Dental to skeletal
The dental to skeletal relations (Fig. 22.6) comprise:
1. Lower molar to jaw left (B6 to J–GA left).

2. Lower molar to jaw right (B6 to J–AG right).
Lower molar to jaw measurements are from the buccal surface of
the lower molars to a plane from the jugal process to the
antegonial notch.
3. Denture–jaw midline. The denture–jaw midline is measured
from the midline of the denture to the midline of the jaws
(ANS–ME).
4. Occlusal plane tilt. Occlusal plane tilt describes the difference in
height of the occlusal plane from the ZL–ZR plane.
Jaw to cranium
The jaw to cranium relations (Fig. 22.7) comprise a single entity,
postural symmetry, which is measured by the difference in angles (left
and right) formed by a plane from the zygomatic suture to the
antegonion and the antegonion to the zygomatic arch. It is used to
determine the cause of asymmetries.
FIGURE 22.7 Jaw to cranium relationship as measured on a PA
cephalogram according to Ricketts’ analysis.
10. Postural symmetry (ZR-AG-AZ)-(ZL-GA-ZA); 11. nasal width; 12.
nasal height; 13. facial width.
Internal structure
The internal structure comprises:
1. Nasal width. Nasal width is measured from the widest aspects

of the nasal cavity. It may be used in determining the cause of
mouth breathing.
2. Nasal height. Nasal height is measured by the distance from the
ZL–ZR plane to the ANS.
3. Facial width. Facial width is measured at the AZ–ZA points. It
essentially describes width at the ZA and can be useful in
maxillary expansion decision making.
Maxillomandibular differential value and ratio3

The maxillomandibular differential value and ratio obtained from a
PA cephalogram help us in estimating transverse deficiency and the
amount of expansion required. A maxillomandibular differential
value is the difference between the mandibular width (AG–GA,
antegonion–antegonion) and the maxillary width (J–J). A differential
in total width of about 20 mm is considered satisfactory.10 Definite
ratio exist between the maxillary and mandibular width and the nasal
cavity to the maxilla, which helps us in determining the relative
transverse problem in the arches. The ratio of the maxilla to mandible
is about 80%, and that of the nasal cavity to maxilla ranges from 40%
to 42%.
There are some errors inherent in cephalometry that are more
pronounced in a PA cephalogram. There may be variations in X-ray
projection, measuring system and landmark identification. Errors may
also be associated with faulty head positioning (e.g. excessive tilt of
the head), which is more difficult to control in PA than in lateral
cephalograms. Cants of the occlusal and transverse planes are sensitive to
head rotation and tilt. Therefore, correct head position is critical while taking
a PA cephalogram.
Key Points
PA cephalograms are essential diagnostic aids in cases with facial
asymmetry. They can answer important aspects of facial symmetry
such as maxillomandibular width, occlusal plane level, dental to
skeletal midline, skeletal midlines and chin location. They help in
determining true asymmetry from apparent asymmetry.
PA cephalograms are used to assess the location and quantification
of a skeletal class III transverse problem and to predict upper-canine
impactions. PA cephalograms are used to measure the amount of
maxillary expansion required and the amount that has occurred with
treatment. Contemporary cephalometric analysis software has the
provision of measuring PA cephalogram with accuracy.11
References
1. Chebib FS, Chamma AM. Indices of craniofacial
asymmetry. Angle Orthod. 1981;51(3):214–226:
2. Grummons DC, Kappeyne van de Coppello MA. A
frontal asymmetry analysis. J Clin Orthod.
1987;21(7):448–465: PubMed PMID:3476493.
3. Ricketts RM, Grummons D. Frontal cephalometrics:
practical applications. Part 1. World J Orthod.
2003;4:297–316.
4. Grummons D, Ricketts RM. Frontal cephalometrics:
practical applications. Part 2. World J Orthod.
2004;5(2):99–119: Summer. PubMed PMID:15615129.
5. Bench R. Provocations and perceptions in craniofacial
orthopedics. Denver, CO: Rocky Mountain
Orthodontics; 1989 Cited from Ricketts RM,
Grummons D. Frontal cephalometrics: practical
applications, Part 1. World J Orthod 2003;4:297-316.
6. Lundström F, Lundström A. Natural head position as
a basis for cephalometric analysis. Am J Orthod
PMID:1539551.
7. Faber RD. The differential diagnosis and treatment of
crossbites. Dent Clin North Am. 1981;25(1):53–68:
8. RMO diagnostic services. Course Syllabus. 1989
Chapter 1, 14-18, 33-40, Chapter 3, 23-35.
9. Trpkova B, Prasad NG, Lam EWN, Rabound D,
Glover KE, Major PW. Assessment of facial
asymmetries from posteroanterior cephalograms:
validity of reference lines. Am J Orthod Dentofacial
Orthop. 2003;123:512–520: PubMed PMID:12750669.
10. Vanarsdall Jr RL. Transverse dimension and long
term stability. Semin Orthod. 1999;5:171–180: PubMed
PMID:10860069.
11. Sangroula P, Sardana HK, Kharbanda OP, et al.
Comparison of reliability and validity of
posteroanterior cephalometric measurements
obtained from AutoCEPH© and Dolphin®
cephalometric software programs with manual
tracing. J Indian Orthod Soc. 2018;52(2):106–114.
CHAPTER 23
Interpretation and clinical
applications of cephalometric
data in diagnosis, treatment
planning and prognosis
O.P. Kharbanda
Rajiv Balachandran
CHAPTER OUTLINE
Introduction
Interpretation of Cephalometric variables
Maxilla
Mandible
Sagittal discrepancy
Vertical
Dental parameters
Soft tissue
Cranial base
Floating norms
Harmony box
Morphometrics
Procrustes analysis
Key Points
Introduction
In last six decades, cephalometric studies have made a significant
impact on the orthodontic literature. These cephalometric analyses
have been created from a combination of different cephalometric
variables to describe the dental and craniofacial morphology. Most of
the analyses are based on the population NORMS, which have been
statistically synthesised from the population mean. These norms
provide an average craniofacial pattern which makes a basis for a
comparison of an individual’s dental and craniofacial pattern, to
identify the deviations. It is important that comparisons should only
be made with the norms derived for the similar population/race, age
and sex.
The extensive information on the cephalometric measurements may
be useful in part or full, that varies considerably from case to case
basis. For a clinician to make sense out of numbers, requires a great
skill on interpretation and correlation for a CASE in hand. Set of rules
in cephalometrics cannot be universally applied, as each individual is
a different entity in structure and function.
The various shortcomings or inconsistencies of different
cephalometric measurements have also raised the question of the
validity of a single parameter or measurement for the evaluation of a
trait of craniofacial anatomy. For example, the norm ANB of 2 degree
cannot be used for all the subjects with different craniofacial pattern
(Downs’ face types, Orthognathic, Retrognathic, Prognathic and
Prognathism).1 Segner2 showed that for retrognathic faces the ANB
lies near 0 degree whereas in a prognathic face this comes close to 4
degree. The ANB value of 2 degree seems appropriate only for the
orthognathic face.
These limitations led to the concept of using composite
cephalometric measurements for craniofacial analysis and floating
norms. The composite analysis involves using cephalometric
parameters from various cephalometric analyses rather than using
single measure for the evaluation of the position or deviation of
different anatomical structures (Tables 23.1–23.8).
Table 23.1
Sagittal position and inclination of the Maxilla

Authors
1. SNA angle (degree) Riedel Anteroposterior position of maxilla in
2. Pt A to Nasion perpendicular McNamara relation to cranial base
(mm) Inclination of maxilla in relation to cranial
3. Maxillary depth (degree) Ricketts base
4. SN-PP, Inclination of maxilla Bell, Proffit, and
(degree) White
5. Maxillary length, ANS-PNS Bell, Proffit, and
(mm) White
6. Effective maxillary length, McNamara
Co-Pt A (mm)
Table 23.2
Mandible
1. SNB angle (degree) Riedel • Anteroposterior position of Mandible in
2. Facial angle (degree) Downs relation to cranial base
3. Nasion perpendicular to Pog McNamara
(mm)
4. Nasion perpendicular to Point B • Length of the mandible
(mm)
5. Effective mandibular length, Co- McNamara
Gn (mm)
6. Mandibular length, Go-Pg (mm)
Table 23.3
Maxillo-mandibular relation
1. A–B plane angle Downs
2. Angle of convexity (degree) Downs
3. ANB angle (degree) Riedel11
4. AXD angle (degree) Beatty12
5. AXB angle (degree) Freeman13
6. WITS, AO-BO (mm) Jacobson
7. Maxillary/mandibular difference (mm) McNamara
8. App-Bpp distance (mm) Nanda and Merrill
9. AF-BF Distance (mm) Chang14
10. MM Bisector (mm) Foley7
11. Beta angle (degree) Baik and Ververidou15
12. YEN angle (degree) Neela16
13. W angle (degree) Bhad17
14. Anteroposterior Dysplasia Indicator (APDI) Kim and Vieta18
15. FH to AB plane angle (FABA) (degree) Sang and Suhr
16 Pi-angle (degree) Kumar S19
17. Pi-linear (mm) Kumar S19
Table 23.4
Vertical maxilla mandibular relation with each other and to cranial base
Authors
1. FMA (degree) Downs
2. SN-GoGn (degree) Riedel
3. Y-axis (degree) Downs
4. Facial axis (degree) Ricketts
5. Upper anterior face height, N to ANS (mm) Jarabak
6. Lower anterior face height, ANS to Me (mm) Jarabak
7. Total posterior face height, S-Go (mm) Jarabak
8. Total anterior face height, N-Me (mm) Jarabak
9. Jarabaks ratio (%) Jarabak
10. Ramus height (mm) Wylie
11. Gonial angle (degree) Bjork
12. Basal plane angle (degree) Jarabak
Table 23.5
Anterioposterior position of maxillary incisor in relation to maxilla, cranial base

Authors
1. Upper incisor to NA (mm) Steiner
2. Upper incisor to NA (degree) Steiner
3. Upper incisor to A-Pog (mm) Downs
4. Upper incisor to SN (degree) Steiner
5. U1-palatal plane (degree) Burstone
6. U1-Pt A (mm) Burstone
Table 23.6
Anteroposterior position of mandibular incisor in relation to mandible

Authors
1. Lower incisor to NB (mm) Steiner
2. Lower incisor to NB (degree) Steiner
3. IMPA (degree) Downs
4. Lower incisor to A-Po line (mm) McNamara
Table 23.7
Interdental
1. Overbite (mm) —
2. Overjet (mm) —
3. Interincisal angle (degree) Downs
Table 23.8
Soft tissue
1. Soft tissue profile N- Subtenly • Soft tissue profile
SN-Pog • Upper and lower lip position and its relation to
2. Nasolabial Angle Legan and total profile
(degree) Burstone
3. Upper lip to E line Ricketts
(mm)
4. Lower lip to E line Ricketts
(mm)
5. Upper lip to S line Steiner
(mm)
6. Lower lip to S line Steiner
(mm)
7. H angle (degree) Holdaway
8. Z angle (degree) Merrifield
9. Lip strain (mm) Holdaway
10. Upper lip length (mm) Holdaway
11. Lower lip length (mm) Holdaway
12. Upper lip thickness Holdaway
(mm)
13. Lower lip thickness Holdaway
(mm)
14. Interlabial gap (mm) Legan and
Burstone
Interpretation of cephalometric
variables
The major purpose of any cephalometric analysis or measurement is
1. To evaluate the subject for presence of skeletal and dental

malocclusion, location of dysplasia
2. If present, to measure the degree of severity of dysplasia. The
information thus gathered is used to plan the orthodontic,
orthopaedic or surgical treatment.
This chapter describes critical evaluation and interpretation of the

cephalometric variables to their clinical applications.
Maxilla (Table 23.1)

The maxilla related parameters are used to evaluate the position and
orientation of the maxilla. Each of these parameters has its limitations.
The variation in SN plane and FH plane seems to affect the values of
SNA, and Pt A to N perpendicular and Maxillary depth, respectively.
However, the variation on SN plane is small when compared to the
FH plane.3 The error in landmark plotting of ANS point may cause
variation in maxillary length.
The point A land mark is often difficult to be identified precisely in
cephalograms. Jacobson et al. proposed a method of constructing
point A which resembles true point A where there is a difficulty to
locate the A point. They suggested that a point plotted 3.0 mm labial
to a point between the upper third and lower two thirds of the long
axis of the root of the maxillary central incisor as an alternative.4
Mandible (Table 23.2)

Measuring the position, and size of the mandible is an important
aspect of cephalometric analysis. The two commonly used reference
planes are SN and FH plane. The variation in these reference
structures will result in variation in the mandibular parameters.5
Geometrically the mandible is more away from these cranial reference
planes compared to the maxilla, so the variation in the mandibular
parameters will be greater. If the parameters defining the same
anatomical entity gives contradictory values, it has to be checked for
the variation of reference structures and corrected accordingly or
given due consideration during interpretation.
Sagittal discrepancy (Table 23.3)

The sagittal maxillomandibular relation is given utmost concern in the
orthodontics. Various parameters defining the intermaxillary
relationship have been introduced over the time. Sometimes most of
the reference structures used for these measurements are at fault,
since then various reference planes, both anatomical and constructed
planes, and analyses have been introduced over the time by different
authors. These analyses have both advantages and limitations
associated with it, which has to be understood thoroughly to use these
parameters in a clinical situation (Fig. 23.1).
FIGURE 23.1 Cephalometric parameters showing maxillo-
mandibular relation.
(A) 1. AXD angle, 2. Yen angle, 3. MM bisector, 4. AF-BF distance; (B)
5. AXB angle, 6. App-Bpp distance, 7. Beta angle; (C) 8. Pi-angle, 9.
Pi-linear, 10. W angle, 11. FH to AB plane angle (FABA); (D) I + II + III
= APDI.
The most commonly used anteroposterior indicator is ANB angle.

The variation in certain landmarks and lines affects the ANB angle,
such as6
1. Position of nasion either anteroposterior or superoinferior

2. Inclination of SN plane
3. Inclination of jaws
4. Degree of facial prognathism
To overcome the shortcomings of ANB angle, various new
measurements have been introduced. Few of the commonly used
alternatives for ANB angle are WITS, MM bisector, APP-BPP, AF-BF.
The common pattern between these parameters is they use point A
and Point B perpendicular projection on the reference planes and
measure the distances between them. Only the reference planes used
are different between these measurements. Foley et al.7 and Palleck et
al.8 showed that the MM bisector is more reliable than functional or
bisected occlusal plane measurements, especially for longitudinal
measurements. Similarly, Oktay et al.6 compared ANB, WITS, AF-BF,
and APDI measurements and reported that these sagittal parameters
could be used interchangeably for sagittal jaw discrepancy
assessment.
Santo9 suggested that one should be careful while using ANB and
Wits to assess the sagittal relationship of the jaws, especially in high
occlusal plane angle. Ishikawa et al.10 studied seven sagittal
parameters to compare prediction accuracy of postpubertal jaw
relationships and to evaluate inter-changeability among the seven
parameters. They showed that the ANB angle and the angle of
convexity showed better prediction accuracy for post-pubertal jaw
relationships. Also, they recommended the conjunctive use of the
ANB angle, the Wits appraisal, and the APDI for assessment of
anteroposterior jaw relationships.
Vertical (Table 23.4)

The vertical face pattern is a major contributor in the perception of
facial attractiveness. Vertical proportions of face are also one of the
important determining factors for diagnosis and planning appropriate
orthodontic treatment. The typical angular parameters are, FMA, SN-
GoGn, Y-axis, facial axis and linear parameter are UAFH, LAFH,
TAFH, TPFH, Jarabak’s ratio. As we have discussed earlier, the
reference plane variation may lead to the misinterpretation of the
cephalometric parameter. Most of the angular parameters are based
on the FH, SN and Ba–Na reference planes. The variation of FH and
SN plane was discussed earlier. Similarly, the Ba–Na plane used for
facial axis also shows variation since the Basion is not readily
traceable.
Paranhos et al.20 showed that the y-axis is inadequate to determine
the vertical facial skeletal pattern of the patients with significant
sagittal discrepancy due to the forward and backwards position of Gn
point. Ahmed et al.21 evaluated the vertical parameter for assessment
of borderline cases. They found that SN-GoGn and FMA to be the
most reliable indicators, and Facial height ratio (LAFH-TAFH) was the
least reliable indicator for the assessment of vertical growth pattern.
Paranhos et al.22 showed that the Sn-GoGn is the best parameter to
define the facial type.
Dental parameters (Tables 23.5–23.7)

The positions of upper and lower incisors relative to each other and
the basal bone are of prime importance to orthodontics. A thorough
understanding of the points and reference structure is necessary for
interpretation of these parameters. For example, the U1-N-Pog is
dependent on the position of the maxilla and chin. Ishikawa et al.23
showed that U1-SN, L1-SN, SN-OP are most appropriate
cephalometric parameters for describing the compensation pattern in
different sagittal jaw relationship. The interincisal angle, which is
most commonly used variable, may not represent the correct position
of the upper and lower incisor for it can be influenced both by the
position of incisors and of the jaws.
Similarly, the facial pattern also has effects on the position of teeth,
and one should give due consideration during interpretation. The
vertical growth pattern subjects may have more upright incisor
relationship than the normal growth pattern subjects. One should
correlate all these factors while interpreting the cephalometric
measurement.
Soft tissue (Table 23.8)

Various parameters have been introduced to analyse the soft tissue
profile and lip position. The size and position of the lip has a
significant influence in treatment planning, especially in extraction
cases. Buschang et al.24 evaluated the validity of five profile planes, E-
line, Steiner’s S1-line, B-line, Sushner’s S2-line, H-line, to describe the
horizontal changes of the lower lip during orthodontic treatment (Fig.
21.5). They found that these five planes cannot be used to measure the
changes in lower lip position and it may be more effective at
evaluating the relative position of the lower lip at a single point in
time. The soft tissue profile is greatly influenced by growth and
maturation and shows a significant sexual dimorphism with males
and females face behaving differently.
Similarly, the nasolabial angle, which is an important parameter for
deciding the extraction or non-extraction treatment planning, may be
influenced by the inclination of the nose, which will give the normal
reading instead of the presence of the procumbent lips in case of
upward inclination of the nose. Therefore, it is pertinent that each
variable should not be just looked at in absolute numbers but due
consideration should be given to the variables that are likely to
influence the value. The cephalometric values should also be related
to clinical evaluation.
While interpreting the cephalometric analysis, one should consider
various factors before arriving at the final diagnosis, which includes
1. Age, growth related changes in different cephalometric

parameter
2. Sex
3. Race and ethnicity
Cranial base (Table 23.9)

The maxilla and mandible articulate under the cranial base, are
directly influenced by the cranial base flexion and growth. Some
authors suggested an obtuse cranial base angle in class II malocclusion
in contrast to less obtuse (sharp) cranial base angle in Class III
malocclusion. The short anterior cranial base length may associate
with the Class III malocclusion, and maxillary retrognathism.25
Similarly the position of the TM joint is affected by the cranial base
angle or the orthocephalisation of the cranial base.26–28 In contrast,
Andria et al. reported that the cranial base angle does not have an
influence on the position of the chin in the profile, the incisor
relationships, the alveolar points A and B. According to them
posterior cranial angle (BaS–FH) and length have a negative
correlation with these parameters.29 The sum of the cranial angles
may provide information on the overall growth pattern of the
mandible.
Table 23.9
Cranial base
Authors
1. Cranial base length, S- Bjork • Cranial base length and its relation to the position of
N (mm) glenoid fossa and mandible
2. Saddle angle (degree) Bjork
3. Articular angle Bjork
(degree)
4. Gonial angle (degree) Bjork
5. Sum of cranial angle Bjork
(degree)
Floating norms
It has now been realised that a case of malocclusion cannot be treated
to a template of NORMS, which have been derived from mean values
of a select group of subjects with excellent occlusion and harmonious
facial proportions. There are several limitations to treating individuals
to match with ideal norms especially with those of skeletal type of
malocclusion. Attempts were therefore made to derive ‘norms’ for an
individual based on his skeleton and dental pattern.
Floating norms are personal norms that vary (float) in accordance
with the variation of the correlated measurements (guiding variable).
Each cephalometric variable is not independent but guided by an
underlying craniofacial pattern. Hence, its deviation from a ‘norm’
alone would not be an indicator of dysplasia. In certain situations, a
deviation of a cephalometric variable may be acceptable if a certain
relationship with other components (cephalometric variable) is
maintained.
A significant correlation between the sagittal and vertical
parameters was first demonstrated by the Solow based on the study
using the data from 102 dental students, who had not received
orthodontic treatment. This led to the concept of ‘craniofacial pattern’
and substituting the population-based norms with new norm
constructed from the variability of association of the suitable
cephalometric variables.30
Steiner13 first described the combination of a cephalometric variable
for a different craniofacial pattern. He used ANB angle to assess the
position of lower incisor. Similarly, Tweed31 employed FMIA as a
guiding angle in his diagnostic triangle. Hasund et al.32 were the first
ones to describe the norm based on the concept of craniofacial pattern.
Various authors have introduced the floating norms to describe the
variation of different cephalometric variables like ANB angle33 and
lower incisor position.34 The first comprehensive analysis for the
assessment of craniofacial pattern using floating norms was described
by Segner2 for European adults.
The cephalometric measurements, for the assessment of craniofacial
pattern, which showed evidence of significant correlation with each
other are given in Table 23.10.
Table 23.10
Cephalometric correlation for assessment of craniofacial pattern

S. No Parameters
1. SNA Position of maxilla
2. SNB Position of maxilla
3. NL-NSL Inclination of maxillary plane
4. ML-NSL Inclination of mandibular plane
5. N-S-Ba Cranial base angle
ML, Mandibular line; NL, nasal line; NSL, Nasion Sella Line.
Once the statistical correlation with one another is evident, the

linear regression with the corresponding r2 value and the standard
error (SE) is computed and illustrated in a graphical box-like form,
called a Correlation box, or Harmony box.
Harmony box
The commonly used harmony box was constructed by Segner and
Segner-Hasund. The calculated values for each cephalometric
measurement using the regression equation are illustrated in the
graphical box-like form (Fig. 23.2).
FIGURE 23.2 Segner-Hasund harmony schema.
The box contains values of cephalometric variables, horizontal line and
the standard error (SE) for each measurement. The box is divided into
three zones—retrognathic, orthognathic and prognathic—depending on
the ANB value.2, 32
For an individual subject with harmonious skeletal configuration,

all the variables will be in the same horizontal line. This straight
horizontal line connecting all the cephalometric measurement inside
the box represents the harmony line of the subject. The individual
horizontal line can be traced as a best-fit line among the cephalometric
values. The other two lines above and below the horizontal straight
line represent the SE range for the each measurement. Together the
harmony line and SE range are called as harmony schema.35 Any
deviation beyond this schema indicates an aberrant skeletal pattern.
The graphical representation of the floating norm helps to identify
1. The facial type of the subject, whether retrognathic,

orthognathic or prognathic
2. To assess the harmonious relationship
3. To determine the parameter which is not harmonious for the
individual patient, which helps in planning the treatment
especially orthognathic surgery.
Step by step procedure for using the floating norms is given in Fig.
23.3; Flowchart 23.1.36
FIGURE 23.3 Floating norms step by step method using
hypothetical norms.
Red lines on each parameter show values for the patient. Red dots on
the left side shows corresponding SNA value of each parameter. Red
ellipse shows the average of the SNA values (82.6 degree), which is
called as harmony point. The harmony schema is placed over the
floating norms where the harmony line coincides the harmony point. All
the other values are within the harmony schema except the SNB,
shows the retrognathic mandible. A, Subpsinale; B, Supramentale; Ba,
Basion; ML, Mandibular line; N, Nasion; NSL, Nasion-Sella line; NSP,
A perpendicular line through the Sella point; S, Sella.
FLOWCHART 23.1 Step by step procedure for using the floating
norms. Also see steps as described in Figure 23.3.
Morphometrics
The traditional method of landmark based linear or angular
measurements is used to define the craniofacial pattern and to classify
the subjects. These measurements may not provide the complete
description about the craniofacial shape since these analyses are based
on the particular reference structures and population based norms.
The reference structures most commonly used are the cranial base
structures. The variation in cranial base among the population may
lead to variability in the linear and angular measurements rather than
the variation in the maxilla or mandible.37,38
Also, the validity of various cephalometric and clinical parameters
for selecting the homogenous samples for the longitudinal and cross
sectional studies is questionable due to the variability of these
cephalometric measurements. To address these shortcomings
landmark based geometric morphometric analysis has been utilised to
analyse the craniofacial shape and pattern.
Morphometrics is a method of analysis of the shape and size. These
include: Procrustes superimposition, principal component analysis
(PCA), Euclidean distance matrix analysis, finite element scaling
analysis, and thin-plate splines methods.38
Procrustes analysis
Procrustes analysis is a mathematical method that involves scaling,
translation, rotation and subsequent centring of the two or more
cephalograms by minimising the distance between the corresponding
landmarks using the least squares method. As a result, the best fit
between the shapes can be achieved. The resulting mean shape is
called as ‘consensus’ (Fig. 23.4). The major differences between the
conventional and Procrustes methods are37,38:
1. The shapes are resized to achieve a better fit

2. All points receive equal weighting instead giving more
importance to particular few parameters
3. There is no need for the corresponding landmarks to coincide.
FIGURE 23.4 Procrustes superimposition using 14 skeletal and 3

dental landmarks.
1. Nasion, 2. Sella, 3. Basion, 4. Porion, 5. Articulare, 6. Gonion, 7.
Menton, 8. Pogonion, 9. Gnathion, 10. B-point, 11. A-point, 12. Anterior
nasal spine, 13. Posterior nasal spine, 14. Orbitale, Four dental
landmarks were placed on the 15. mesiobuccal cusps of the maxillary,
16. mandibular first molars, 17. Incisal edge of maxillary incisor. The
blue bold dots show the consensus points for each landmark.
Once the Procrustes superimposition performed, the directional

changes have to be calculated. It can be done using Principal
component analysis (PCA). PCA provides the components from
maximum variation to a minimum, which is called Principal
components (PC). This also can be illustrated graphically to visualise
the variation in different components. Wellens et al. suggested
combined method using Procrustes superimposition and PCA and
cephalometric variables (ANB angle, Wits appraisal, and GoGnSN
angle) for craniofacial analysis.39
Key Points
The fundamental goal of the cephalometric analysis is to determine
the relationship of various skeletal, dental and soft tissue components
with each other and to the cranium. There is no such gold standard
cephalometric analysis available, to describe the craniofacial pattern
completely. While interpreting the cephalometric analysis one must
think the facial structures as a whole, not as an isolated anatomical
entity like dentition, jaws and soft tissue, and try to elucidate the
correlation between them.
The excitement of use of cephalometrics and to treat the cases to
specific norms has subsided in the last few years, more so, with
greater emphasis on the soft tissue outcome of the face. It is well
known that each face is a unique entity by itself in terms of
craniofacial morphology and functions. No fixed set of ‘numbers’ can
be applied to achieve optimum aesthetic. However, it is also clear that
ultimate goal of orthodontic treatment is to achieve ‘Harmony’ and
balance of soft tissue, skeletal and dental or occlusal component,
which is stable and healthy. Therefore ‘Harmony’ can be better
interpreted with ‘proportions and ratios’ in three dimension of space.
The numbers guide to locate, the severity of dysplasia and location
is a great help to the clinicians in planning orthodontic versus
functional versus surgical treatment. The relationship of alveolar base
and dental hard tissue more so in the alveolus region of maxillary and
mandibular incisors is readily visible in the cephalogram, and it helps
to institute required biomechanics. Cephalometrics also helps to
evaluate nasopharyngeal airway, a significant aspect of an orthodontic
treatment plan. Also, cephalometric helps clinicians to evaluate the
treatment outcome.
The cephalometrics is an indispensable tool for an orthodontist, and
it takes considerable experience and a sharp ‘eye’ to get best out of
this technology.
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CHAPTER 24
Lateral, PA and 3D cephalometric
superimposition
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Reference colors for stages of treatment
Stable landmarks for superimposition
Superimposition of lateral cephalogram on cranial base
structures
De Coster’s Method
Bjork’s method of structural superimposition
Methods of tracing and superimposition
Bolton plane
Superimposition on SN
Limitations, in use of S-N plane
Superimposition on SE-N plane
Superimposition on FH plane
Ricketts Five-step method of cephalometric superimposition
Method of superimposition and rationale
Superimposition requirements of American Board of
Orthodontics
3D superimposition
Key Points
Introduction
Superimposition is the process of placing two images upon each other,
registering on structures and landmarks that are relatively stable.
Longitudinal cephalometric superimpositions are needed in clinical
practice for evaluation of treatment changes brought about by
orthodontic and orthopaedic interventions and growth. The essence of
superimposition is to be able to precisely quantify the changes in
maxilla, mandible and dentition on serial cephalograms and be able to
differentiate the changes caused by growth and those by orthodontic
treatment. Researchers and clinicians have used various landmarks
and methods of superimposition on cephalograms some of which are
more stable landmarks than others.
Traditionally two or more cephalograms were hand traced in
different colours and then superimposed on stable cranial/facial
landmarks. In current day practice with digital cephalometry, the
superimposition can be undertaken ‘on screen’ on the computer
monitor, and the tracings can be printed on paper or transparent
sheets.
Reference colors for stages of treatment

A uniform colour scheme is usually followed by the different stages of
cephalogram. According to American Board of Orthodontics three or
two tracings are required as under:
Pre-treatment tracing: Black

Interim-stage treatment tracing: Blue
Post-treatment tracing: Red
At the Department of Orthodontics, Centre for Dental Education

and Research, All India Institute of Medical Sciences, we like to follow
up the case with additional X-rays and the tracings which are coded
with green colour.
Follow-up tracing: Green
Invent of 3D imaging and cone beam computed tomography

(CBCT) has enabled a virtual view of craniofacial and dental
structures, which can also be visualised in different positions with
superimposition.
Stable landmarks for superimposition

Soon after the discovery of Broadbent’s cephalometer, cephalometrics
has been extensively used by anatomists and orthodontists to find out
variations in craniofacial morphology and growth of the human face.
Longitudinal and cross-sectional studies have shown that the growth
of the face occurs in all three dimensions, at different rates and
various sites with its structures changing their relative spatial
positions in space with time. Some cranial structures establish their
relative size and form early in life than the others, while others
continue to actively grow till adulthood.1,2
Traditionally cranial base structures were used to superimpose the
lateral cephalogram taken at an interval (or at intervals) to either
study the growth of the face and dental arches or evaluate changes
due to treatment. The cranial base was considered stable since
majority of the growth of the middle cranial base (90–95%) was
thought to be completed at 7 years of age.3
The anatomical anterior cranial base (ACB) extends from foramen
caecum to nasion, the middle cranial base from foramen caecum to
hypophyseal fossa and posterior cranial base from hypophyseal fossa
to foramen magnum (Fig. 24.1A– B).
FIGURE 24.1 The cranial base.
(A) The internal bone structures as viewed from the top and (B) the
mid-sagittal section of the skull. The anterior part of the cranial base
extends from foramen caecum to nasion (red dashed line), middle part
from foramen caecum to hypophyseal fossa (yellow dashes) and
posterior part from hypophyseal fossa to foramen magnum (blue
dashed line).
The anterior segment of the cranial base, which extends to a

relatively short distance from foramen caecum to nasion, continues to
grow into adulthood as a result of growth at bony and frontal sinuses.
The posterior segment of the cranial base that extends from
hypophyseal fossa to the foramen magnum continues growth into
early adulthood as a result of the activity of the spheno-occipital
synchondrosis (SOS). It is the middle segment of the cranial base,
which extends from the anterior boundary of the hypophyseal fossa to
the foramen caecum anteriorly, and completes its growth earliest in
life, reaching 62% of the adult size at birth, 94% between 4 and 7 years
of age and 98% of the adult size between 8 and 13 years of age.4 The
ACB structures are internally stable after the fusion of the
sphenoethmoid, frontoethmoid, and inter-sphenoid synchondroses by
about 8 years of age.5,6 Therefore, these structures were considered as
a stable reference for cephalometric superimposition. The points easily
identifiable on radiographs and reproducible with accuracy were
chosen for superimposition.
Superimposition of lateral cephalogram
on cranial base structures
De Coster’s method
De Coster used bony anatomy of the anterior contour of the cranial
base from anterior half of the sella turcica to the region of the foramen
caecum and the internal outline of the frontal bone as sufficiently
stable support for meaningful superimposition of the cephalograms
(Fig. 24.2A).7
FIGURE 24.2 (A) Cranial base superimposition. As depicted here in

heavier outline, only the cranial base structures between the dashed
vertical lines are employed for superimposition. Emphasis is placed on
the elements of De Coster’s ‘basal line’8; the posterior half of sella
turcica and structures in the region of nasion are ignored. W denotes
‘wing point’, the point at which the averaged outline of the greater
wings crosses the jugum. A long arbitrary line with crosses on each
end—a ‘fiducial line’—is drawn above the orbital plates of one tracing.
The cranial base superimposition then is used to pass this line through
to the other tracings in the series. (B) The drawings of the basal lines of
a family of four children. The first one has a short basal line while the
lines of the three other children are longer and are the same. The first
girl was slightly retarded and had probably an encephalic disease in
early childhood or before birth. Source: Cited with permission from De
Coster L. A new line of reference for the study of lateral facial
teleradiographs. Am J Orthod 1953 Apr;39(4).7
Later, De Coster on a study of 200 families reported that all the

children of the same family have the similar cranial baselines. He re-
emphasised the known research findings on the baseline being fixed
from 7 years of age onwards with a relatively fixed frame of the facial
bones; the variations in facial bones being only of metric in character
(Fig. 24.2B).8 He proposed that the study of the shape of the cranial
base anatomy is of great importance and gives valuable indications
both in treatment and prognosis.
The stable landmarks on cranial base are:
1. The anterior lip of the sella turcica in its midst

2. The sphenoid ethmoidal suture
3. The planum or upper surface of the sphenoid body
4. The roof of the ethmoid masses
5. The endocranial side of the frontal bone
Richardson found that De Coster’s cribriform plane was only

moderately successful as far as reproducibility was concerned.9
Applying the results of his investigation into the reproducibility of
cephalometric landmarks did not favour the usage of this line, which,
however, might find preference on grounds other than
reproducibility.
The most practical method of superimposition is therefore on SN
line with registrations at ‘S’.
Bjork’s method of structural superimposition

This structural method of superimposition was used to describe and
study the pattern of overall growth of face in reference to the stable
structures of the cranial base growth of the maxilla and mandible,
their direction, quantification of displacement, and mandibular
rotation. Bjork’s structural superimposition method uses cranial base
reference structures in the superimposition of three or more lateral
cephalograms taken at sufficient intervals to discern growth
changes.10–12
Tracing superimpositions are seen with pre-treatment tracings in
black and post-treatment in red colour.13
Methods of tracing and superimposition
The first and foremost step involves marking of the landmarks to
draw nasion–sella line (NSL) and a perpendicular line through the
sella point (NSP) with a pencil directly on the first/initial
cephalogram. The sella point and the cross lines are then transferred
from the initial to the subsequent/stage cephalograms. When nasion is
displaced vertically during growth it is projected onto the transferred
NSL. The serial cephalograms are then superimposed according to the
structures on the first cephalogram, using natural stable reference
landmarks/bony structures (Fig. 24.3A–D).
FIGURE 24.3 Structural method of superimposition according to

Bjork.
(A) Landmarks by A. Bjork on cranial base. 1, The inner contour of the
anterior wall of sella turcica; 2, The mean intersection point of the lower
contours of the anterior clinoid processes and the contour of the
anterior wall of sella, Walkers’ point; 3, The anterior contours of the
middle cranial fossae; 4, The contour of the cribriform plate; 5, Details
in the trabecular system in the anterior cranial base; 6, The contours of
the bilateral fronto-ethmoidal crests; 7, The cerebral surfaces of the
orbital roofs. (B) The principles of superimposition of profile
radiographs using structures in the anterior cranial base (ACB) as
reference. (C) The sella point is marked on the first profile radiograph in
a series. It is found by bisecting the sagittal diameter of the sella turcica
and the height from tuberculum sellae to the floor. It has been reported
that during growth sella turcica increases in size by apposition on
tuberculum sellae and by resorption at the posterior wall and at the
floor. (D) By superimposition of profile radiographs from three or more
stages of untreated individuals, a logical sequence of growth changes
should be expected. The points, nasion (n), articulare (ar),
pterygomaxillare (pm), the anterior nasal spine (ANS) (sp) and
pogonion (pg) should follow a logical path during normal growth.
Source: Cited from www.angle-society.com/case/guide.pdf.13; Kind
courtesy of Per Rank; Reproduced with permission from Björk A,
Skieller V. Normal and abnormal growth of the mandible. A synthesis of
longitudinal cephalometric implant studies over a period of 25 years.
Eur J Orthod 1983 Feb;5(1):1–46. PubMed PMID: 6572593.12
Sagittal position
1. The inner contour of the anterior wall of sella turcica just below
anterior clinoid process (stable after 5–6 years of age).
2. The inner contours of the middle cranial fossae (stable after 12–
14 years of age).
Vertical
1. The mean intersection point of the lower contours of the

anterior clinoid processes and the contour of the anterior wall
of sella (Walkers’ point, 1972). It is considered stable after 5–6
years of age.
2. The contour of the cribriform plate. It is stable after 4 years of
age.
3. Details in the trabecular system in the ACB. It is stable after 4
years of age.
4. The contours of the bilateral frontoethmoidal crests (stable after
4 years of age).
5. The contour of the median border of the cerebral surfaces of
the orbital roofs (stable after 5–6 years of age).
These anatomical structures are either hand traced or with the

advent of computerisation traced on-screen on digital images, which
are obtained directly from digital cephalo-meter or by scanning the
hard copies of the radiographic films. The most critical and important
step involves calibration of image sizes and matching the correction of
magnification among two or more images.
By way of superimposition of profile radiographs on anatomical
structures and method described above, from three or more stages of
growing subjects, major changes should be expected at the points,
nasion (n), articulare (ar), pterygomaxillare (pm), the anterior nasal
spine (sp), and pogonion (pg).
In untreated subjects the earlier-mentioned points have a logical
positional relation at the different stages of growth. For example, the
frontoparietal suture from about 7–8 years of age is expected to lie
more posteriorly on later cephalograms and the occipital bone is
continuously lowered, which is most clearly seen at its inner contour.
The pattern of growth will not be similar in subjects with skeletal and
dental malocclusions and can be altered with orthodontic
treatment/orthopaedics.
Mandibular superimposition
The profile superimposition of the cephalogram does not provide
sufficiently accurate information on mandible growth due to known
remodelling of the mandibular body more so at its lower border. The
mandibular superimposition is considered separately on the following
stable anatomical structures (Fig. 24.4A–B):
FIGURE 24.4 Mandibular and maxillary superimposition.
(A) The anterior contour of the chin is made to coincide on two
radiographs. 1, Anteriorly, the radiographs are orientated in a vertical
direction by 2, the inner contour of the cortical plate at the lower border
of the symphysis and by 3, any distinct trabecular structure in the
symphysis. Posteriorly, the radiographs are vertically orientated by 4,
the contour of the mandibular canal and by 5, the lower contour of a
mineralised molar germ before root development begins, and possibly
also of a premolar germ; 6, the anterior contour of the ramus. (B) A
superimposition of mandible using landmarks. (C) Maxillary
superimposition is done on the anterior contour of the zygomatic
process of the maxilla. Source: Reproduced with permission from Björk
A, Skieller V. Normal and abnormal growth of the mandible. A
synthesis of longitudinal cephalometric implant studies over a period of
25 years. Eur J Orthod 1983 Feb;5(1):1–46. PubMed PMID:
657259312; Cited from www.angle-society.com/case/guide.pdf.13
Reproduced with permission Kind courtesy of Per Rank.
1) The anterior contour of the chin. 2) The inner cortical structure at

the inferior border of the symphysis. 3) Trabecular structures in the
symphysis. 4) Trabecular structures related to the mandibular canal. 5)
The lower contour of a molar germ from the time mineralization of the
crown is visible until the roots begin to form.
Bjork has suggested some practical steps for superimposition of the
mandible. On the first or initial cephalogram a reference line is drawn
in the mandible with a pencil from the anterior contour of the chin to
the contour of the mandibular canal. If the mandibular canal is not
preeminent, lower contour of a molar germ can be used.
The subsequent cephalograms are then superimposed on natural
stable five reference structures listed above and the constructed
reference line is transferred with a pencil to the remaining
radiographs. To facilitate superimposition, the reference line is given a
fixed length. The cephalograms are first orientated sagittally by the
anterior contour of the chin which is made to coincide on two X-rays.
Anteriorly, the radiographs are orientated in a vertical direction by the
inner contour of the cortical plate at the lower border of the
symphysis, and by any distinct trabecular structure in the symphysis.
Posteriorly the radiographs are vertically orientated by the contour of
the mandibular canal and by the lower contour of a mineralised molar
germ before root development begins, and possibly also of a premolar
germ (Fig. 24.4B).12
Maxillary superimposition (Fig. 24.4C) is essentially considered on
the anterior contour of the zygomatic process of the maxilla, more so
between the orbital rim area key ridge. Alternatively, a relatively less
stable landmark can be maxillo-zymatico-temporal sulcui located on
the lateral contours of the orbit. These lines are used for the sagittal
reference line. For the vertical orientation of the maxilla the nasal floor
orbital contours at the orbitale point is the reference point. The tracing
is so located so as to consider 2/5 lowering on the nasal floor and 3/5
high placement at orbitale to accommodate the growth of the nasal
floor which descends and orbitale which moves up with growth.13
Bolton plane
Bolton in his early studies on the growth of face proved that in early
infancy and childhood before the growth of the brain case is complete,
certain cranial areas changed in size at one time while the other areas
of the head remained fixed during the same period.14
He used a plane at the base of the cranium as the ‘stable’ reference
to study the growth of the face. According to Broadbent, his study
data of seven years has substantiated the stability of Bolton nasion
plane of orientation and its registration point in the sphenoidal area as
the most fixed point in the head. The Bolton plane is drawn
connecting the following points (Fig. 24.5):
1. Anterior limit. Nasion that is defined as the junction of frontal

and nasal bones in the midplane.
2. Posterior limit. It is a landmark that is the highest point in the
profile of notches at the posterior end of condyles on the
occipital bones behind foramen magnum. It is called Bolton
Point. The right and left occipital condyles (OCs) are close
enough to appear as a single shadow on a lateral cephalogram.
FIGURE 24.5 Tracings of 9 and 14 and 1/2 developmental years.
Note relative stability of Bolton plane during the age range when most
orthodontic cases are treated. Source: Reproduced with permission
from Broadbent BH. The face of the normal child. The Angle Orthod
1937 Oct;7(4):183–208.14
Broadbent registration point is the midpoint of the perpendicular

from the centre of the sella turcica to the nasion-postcondylar plane or
Bolton plane. This point has been conveniently called registration
point ‘R’ which is used to register tracings of the same individual
taken at different times or of two different individuals for comparison.
The extension down from the plane of registration usually passes
obliquely through the face at an acute angle to the plane of occlusion.
Therefore, Broadbent suggested the use of two additional reference
planes; he suggested the use of FH plane and vertical orbital plane to
record the changes in the face from more constant Bolton landmarks.
Superimposition on SN
Brodie used sella–nasion line registered at ‘S’ as a method of
orientation and superimposition of cephalograms.1,2 This is the most
popular and practical method used for orientation and
superimposition of lateral cephalograms. The ‘Sella’ was considered a
stable point for it distinguishes cranial base from the face, presuming
that the major cranial base growth is completed by 7 years of age.15
Two or more hand-drawn tracings or computerised images are
superimposed on SN plane registration at ‘S’. Resultant changes are
seen in the location of teeth and structures consequent to growth or
orthodontic treatment including growth. Since most patients are
beyond 7 years of age, we commonly use SN plane for orientation to
evaluate changes in growth or by treatment in the face and dental
structures.
Both S and N planes are located in the mid-sagittal planes which
make it an easily identifiable reference point (Fig. 24.6A–B). The use of
SN plane was hugely popularised by Steiner, and therefore this
method of superimposition is more popularly called as the Steiner’s
method.16
FIGURE 24.6 (A) Superimposition on S-N plane with registration at S.

shows treatment changes in a class II division 1 malocclusion patient
treated with two-phase appliance therapy. Black—pre-treatment, blue
after completion of phase of functional appliance therapy, red at
completion of treatment. (B) Superimposition on S-N plane with
registration at S shows treatment changes in a case of class I
bimaxillary protrusion treated with fixed appliance therapy after all first
premolar extractions. Black—pre-treatment, blue after completion of
space closure, red—post-treatment.
Steiner suggested superimposition of lateral tracing on S-N plane

registration at ‘N’ thus causing the lines NA to superimpose. The
record of anteroposterior growth is thus expressed posterior to these
lines.
To evaluate changes in the maxilla alone, the tracing is moved
vertically parallel to the S-N plane till drawings of the maxilla, like
palatal contour, is superimposed as best fit. The movement of
maxillary teeth can now be visible.
The movement of teeth within mandible is assessed by
superimposition of the mandible over the best-fit cross-section of
symphysis of the mandible, keeping the lower border parallel.
For registering the changes in the location of the mandible and its
relationship to craniofacial structures, the tracings are superimposed
on the line S-N, registered at ‘S’.
Distances between points ‘L’ and ‘E’ represent the anteroposterior
lengths of the mandible (Figure 18.3). This measurement is an
indication and not an accurate measurement of change in the length of
the mandible because these measurements do get affected by a change
in inclination of the occlusal plane with the opening of bite.
Limitations, in use of S-N plane

The use of SN plane should be viewed with limitations on remaining
growth at sella. There is a change in the relative position of the sella
consequent to the remaining active growth at the posterior cranial
base at synchondroses and enlargement of the pituitary gland,17
enlargements of sphenoidal air sinuses, and minor remodelling of the
fossa. Sella may move posteriorly and inferiorly while there is an
anterosuperior (sometimes anteroinferior relocation) relocation of the
nasion with the growth of the fontal sinuses.
Superimposition on SE-N plane

Stramrud18 advocated the use of sellaethmoidale (SE) to overcome the
variation associated with growth direction at nasion; however,
research studies have indicated that SN and SE were closely correlated
from adult to 3 years of age.
Superimposition on FH plane
Several authors have used the FH plane as a reference plane for
superimposition. However, when compared with S-N plane, FH plane
is found to be more variable. Wei has studied and tested the
variability of five commonly used cephalometric planes.19 The S-N
plane was least variable and FH plane was reasonably stable.
Ricketts Five-step method of
cephalometric superimposition
Roberts Murray Ricketts recommended and propagated the four-step
method of lateral head film superimposition to evaluate treatment
changes. This method accounts for the normal growth changes that
occur in the face during the period of orthodontic treatment, which
was at an average of two years.20,21 The fifth-step was later added by
Ricketts by superimposition on aesthetic plane.
This method has rationalised the treatment changes using average
growth trend and increments, that is direction and the amount of
growth calculated per annum from longitudinal growth data. Ricketts
used points and planes that are stable and true (better) representations
of skeletal changes. Two or more cephalograms taken at an interval
usually pre-treatment and post-treatment are utilised to graphically
visualise and quantify skeletal changes in maxilla and mandible, and
dental changes in upper and lower molars and incisors.
This method utilises the following landmarks:
1. Basion—Ba
2. Nasion—N
3. Pterygoid point—Pt
4. Anterior limit of maxilla—A
5. Anterior nasal spine—ANS
6. Posterior nasal spine—PNS
7. Protuberance menti—Pm
8. Centroid of mandibular ramus—Xi
Among the earlier-mentioned landmarks of special reference are

basion, pterygoid point, Pm, and the centroid of mandibular ramus.
Basion (Ba). A point selected near the base of the anterior border of
the occipital condyle, at the anterior border of foramen magnum or
the end of the clivus plane as it intersects with the roof of the
nasopharynx (Fig. 24.7A–B).
FIGURE 24.7 (A and B) A skull at midsagittal section showing basilar

portion of occipital bone and frontonasal suture area. Basion (Ba) is
located on the anterior rim of foramen magnum at vertex of the angle of
the clivus and nasopharyngeal roof. Nasion (N) is located at margin of
nasal bone at the frontal junction. The connection of basion to nasion
(Ba-N) forms a line of separation of the face from the skull and hence a
basicranial axis for growth and structure reference.
Pterygoid point (Pt). A point selected on the lower lip of the foramen
rotundum (Pt). It is not to be confused with the pterygoid maxillary
fissure (PTM), which is located at the junction between the pterygoid
plates and the tuberosity of the maxilla. By taking the lower lip of the
foramen rotundum, as seen on the lateral film, the point has been
described as pterygoid point (Pt). This point is used as a reference
centre (least change) and has substituted the use of point sella for
longitudinal comparison.
Protuberance menti (Pm). A point at which the outline of the chin
starts to recede in the profile, or the top of the crest of the bony cortex
in the outline of the symphysis in the area of the mental protuberance.
Xi point. Centroid of mandibular ramus is labelled as ‘Xi’ point. This
point is selected by measurement on the mandible and is located at
the halfway point between the lowest point of the sigmoid notch and
a point immediately inferior to it on the lower border of the ramus in
the Frankfort horizontal (FH) orientation (also midway of the
minimum depth of the ramus). The Xi point also proved to be a strong
biologic point representing the mandibular foramen and the centre of
rotation of the mandible (also see Fig. 19.2).
1. Basion-nasion plane; Basion connected to nasion becomes the

basion-nasion plane (Ba-N).
2. Central axis; A line from Pt to cephalometric gnathion (GN),
selected at the intersection of the facial plane and mandibular
plane, constitutes the central axis.
3. Corpus axis; The planes or axis between Pm and Xi forms a
plane constituting the corpus axis.
4. The true occlusal plane is drawn through the bisection of the
buccal tooth overlap.
Method of superimposition and rationale

Position I is aimed at evaluating the skeletal face at chin in sagittal
and vertical position. The tracings are superimposed on Ba-N plane
with registration at Pt. The Ba-N plane has been considered to be
stable in the longitudinal growth studies. The position I mainly
consider the change in the central axis which is a real representative of
the rotation and growth direction of the mandible. The standard
growth direction of the mandible is downward and forward without
much change (Fig. 24.8A). However, a clockwise or anticlockwise
rotation (opening or closing of facial axis) is influenced by the
unfavourable growth or shifts in the maxillary dentition and skeleton,
due to orthodontic or orthopaedic treatment such as cervical headgear
or orthopaedic occlusal splint appliance (Fig. 24.9A).
FIGURE 24.8 Growth changes and rationale of superimposition
according to Ricketts’ methods four steps.
(A) The superimposition done on the Ba-N plane and registered at the
facial axis crossing at Pt point, the intersection with the facial axis (Pt–
Gn) exhibits changes in the chin and directional effects of mandibular
rotation. According to Ricketts, facial axis is the best reference for
evaluation of growth direction. It virtually does not change in normal
growth trend (mean of 0 degree and standard deviation of change 1.5
degrees in 5 years). The upper molar shows a corresponding
downward and forward movement during the ages 8–13 years as
shown in the tracing. (B) In normal growth and without any treatment,
Ba–N plane registered at nasion (N), the angle Ba–N–A shows a
constant relationship with a mean change of 0 degree and a standard
deviation of 1.0 degree in 5 years (ages 8–13 years). (C) Ricketts
suggest evaluation of maxilla with palatal plane (ANS–PNS)
superimposed and registered at ANS. With normal growth, maxillary
molars erupt greater than incisor and a forward drift of the dentition. (D)
Mandibular corpus axis (Xi–Pm) when superimposed and registered at
Pm exhibits changes in mandible and dentition. The mandibular
occlusal plane elevates, molar erupts vertically from corpus axis and
there is a slight lingual drift of incisors from Pm. The mandible also
shows change with posterior growth greater at Xi than at the condyle.
FIGURE 24.9 Lateral cephalometric superimpositions according
to Ricketts in a case (PS) of class II division 1 malocclusion
treated with twin block appliance followed by a short phase of
fixed appliance therapy.
Black—pre-treatment, blue after completion of the period of functional
appliance therapy, red at the conclusion of treatment. (A) Position I is
aimed at evaluating the skeletal face at chin in sagittal and vertical
position. (B) Position II is aimed to evaluate changes in the maxillary
skeleton. (C) Position III employs superimposition on the palatal plane
at ANS and PNS with registration at ANS. (D) Position IV determines
changes in the position of mandibular dentition with respect to the
mandibular base. (E) Superimposition on Ricketts, E line.
It is critical to quantify the amount of change occurring due to

growth or due to the orthodontic or orthopedic treatment. Growth
reports of Ricketts suggest that the central axis was found to be 90
degree in the sample of 3-year-old, and the same in adult samples. The
clinical deviation (CD) of this morphology is 3 degree from the 90
degree. The central axis does change in the individual with growth
during the transition from the mixed to the permanent dentition. An
extreme of 6 degree of change has been noted. Ricketts reported that
in the absence of treatment, the average change was found to be 0
degree and the standard variation was discovered to be 5 degree over
the 5-year period. A statistical assumption suggests that only 2.5%
patients would be expected to open or close an average of 1.4 degree
change in the central axis in one year. Therefore if a patient under
treatment shows up opening or closing of the central axis angle, it is
quite likely to be the result of orthodontic treatment.
Position II is aimed to evaluate changes in the maxillary skeleton.
The superimposition tracings are moved to nasion on the same Ba-N
plane. The angle used is Ba-N-A angle. This angle represents the
anterior limit of the maxilla and corresponds to growth at point N.
The average value being 66 degree. The angle Ba-N-A shows little or
no change in an individual with an average increase of 0.5
degree/year. The angle is influenced by factors which effect protrusion
or retrusion of maxillary anterior teeth and hence clinicians may
assume that any large change could be the outcome of the orthodontic
treatment. However, a distinction needs to be made on changes in the
maxillary skeleton base vis à vis local change at alveolus which is
confirmed at position III (Figs 24.8B and 24.9B).
Position III employs superimposition on palatal plane at anterior
nasal spine (ANS) and posterior nasal spine (PNS) with registration at
ANS. Based on the facts that significant descent of the palate is
achieved by remodelling resorption and minor changes at sutures, the
changes in molars and incisors are tiny during growth. Any
significant change occurring at molars and incisors is considered to be
the outcome of the orthodontic treatment. The change at point A from
ANS explains the amount of change in the maxilla (Figs 24.8C and
24.9C).
Position IV determines changes in the position of mandibular
dentition with respect to mandibular base.
Traditionally mandibular plane has been used to evaluate the
position of the molars with respect to the mandible; however, based
on the research work by Bjork it has been observed that the lower
border of the mandible at gonial angle undergoes significant
remodelling during growth while the mandibular molars erupt in
mesial vertical directions. Therefore Ricketts proposed the use of
‘corpus axis’. The corpus axis is formed by joining Xi point the
centroid of the ramus and Pm point anteriorly which shows least
change on the chin with growth.
As the Xi point also represents the centre of rotation of the mandible
the relation of corpus axis with occlusion plane assumes significant
importance. The occlusal plane drawn through the bisection of the
buccal teeth, overlap passes closely to the Xi point in a remarkably
high percentage of cases and thereby showing a definite correlation.
The standard variation is only 0.68 mm/year. The change in the
occlusal plane with respect to corpus axis would, therefore, thought to
be mostly brought about by the orthodontic treatment.
When tracings are superimposed on the corpus axis, registered at
Pm, anteroposterior measurement of molars and incisors on the
occlusal plane may serve as excellent parameters for the evaluation of
tooth movement in the lower arch (Figs 24.8D and 24.9D).
Position V was later added by Ricketts by superimposition on
aesthetic plane which is drawn from tip of the nose to the chin. The
linear the distances between this plane and both the lips are
measured. The superimposition is done on the aesthetic plane where
the occlusal plane crosses it (Fig. 24.9E).
This five-position treatment evaluation is aimed at achieving
diagnostic assistance and evaluating the real outcome of therapy for
the clinician. Although the face grows in all the three dimensions of
space, this method is based on measurements taken on lateral
cephalograms and hence has inherent limitations of not been able to
discern the changes in the width of the face. This method of
superimposition has been in use at All India Institute of Medical
Science (AIIMS), New Delhi, India since the late 1980s.
Standerwick et al. proposed a new orientation plane for the purpose
of cephalometric superimposition.22,23 The ACB is oriented parallel
and referenced at I-point/I-curve on the occipital condyles (OCs), from
which the other landmarks are measured (Fig. 24.10A–B).
FIGURE 24.10 (A) Dry skull in norma lateralis radiograph; arrows

pointing to the superimposition of the occipital condyles (OCs) (bottom
arrow) and the remnant of the spheno-occipital synchondrosis (SOS,
top arrow). (B) Tracing of the superimposed OCs as seen on a lateral
cephalometric radiograph: I-point is the most anteroinferior point on the
condyle; U-point is the midpoint between O’ and I-point; I-curve from U-
point to the midpoint of the inferior contour (SIA or remnant). Source:
Reproduced with permission from Standerwick R, Roberts E, Hartsfield
J Jr, Babler W, Kanomi R. Cephalometric superimposition on the
occipital condyles as a longitudinal growth assessment reference: I-
point and I-curve. Anat Rec (Hoboken) 2008 Dec;291(12):1603–10.
PubMed PMID: 18833570.22
Landmarks for the use of the OC as a posterior cranial base

reference are I-point, U-point, and I-curve (Ic).
I-point is the most anteroinferior point on the OC in norma lateralis.
U-point is the midpoint between I-point and O prime (O′) as
defined by Frankel.24
Occipital point O′ is the intersection of the ventrocaudal contour
and the anterior outlines of the OCs.24
Ic is the external contour from U-point to the midpoint of the
inferior surface of the OC in normalateralis.
Authors found that OC referenced at I-point/Ic and oriented to the
ACB superimposition (OC-ACB) more accurately displayed
longitudinal growth patterns and differences between orthodontic
treatment effects consistent with previous growth studies using
implants as radiographic markers.
They suggested that since OCs are directly under the craniofacial
centre of the gravity and that the growth pattern observed with
superimposition referenced at I-point/Ic is a continuation of the fetal
unfolding growth pattern, the use of I-curve is an accurate method of
superimposition of growth/treatment changes. Traditional ACB
superimposition ignores the contribution of the spheno-occipital
synchondrosis relative to increases in distance between anterior and
posterior cranial bases.
Advantages
1. When two methods were compared, that is the traditional

method, ACB registered on the anterior curvature of sella
turcica versus registration on I-point while maintaining ACB
parallel, it was found that I-point registered superimpositions
consistently displayed a facial growth pattern that was more
consistent with the classic necropsy specimens of children and
the cephalometric studies superimposing on implant markers.
2. By superimposition at I-point, the physiologic movement of
sella turcica, development of the airway and proportional
craniofacial development is better displayed than with
traditional ACB superimposition (Fig. 24.11).
FIGURE 24.11 (A) Growth changes are shown by superimpositions
referenced on the OCs while maintaining a parallel relationship for the
ACB in a representative subject. (B) Tracings of the same series of
films are superimposed on the ACB; black is age 4 years 9 months,
blue is 6 years 6 months, red is 10 years 6 months, and green is 14
years 0 month. Notice that physiologic movement of sella turcica,
development of the airway and proportional craniofacial development is
better displayed with I-point superimposition. Source: Reproduced with
permission from Standerwick R, Roberts E, Hartsfield J Jr, Babler W,
Kanomi R. Cephalometric superimposition on the occipital condyles as
a longitudinal growth assessment reference: I-point and I-curve. Anat
Rec (Hoboken) 2008 Dec;291(12):1603–10. PubMed PMID:
18833570.22
1. Maxillary superimpositions include the following methods:
a. Superimposition along anterior nasal spine (ANS)
and posterior nasal spine (PNS) plane registered at
ANS.25
b. Superimposition along ANS and PNS plane
registered at PTM.26
c. Superimposition on infratemporal fossa and
posterior part of the palate.27
d. Superimposition on best fit of internal palatal
structures.28
e. Superimposition on anterior border and tip of key
ridge.29
f. Best fit method. American Board of Orthodontics
(ABO) has adopted the anatomical maxillary
superimposition method using maxilla.
Maxillary anatomical approach recommends registration on the
lingual curvature of the palate and the best fit on the maxillary
bony structures to assess maxillary tooth movement.30
2. Mandibular superimposition on stable landmarks has been
used by Björk and Skieller.12 The mandibular superimposition
method advocated by the ABO is to register on the internal
cortical outline of the symphysis with the best fit on the
mandibular canal to assess mandibular tooth movement and
incremental growth of the mandible.
PA cephalograms are not as often superimposed as lateral
cephalograms. These are indicated for evaluation of correction of
midline asymmetry, the growth of the face in transverse and vertical
dimensions, evaluate effects of maxillary expansion on nasal widths,
and evaluate treatment outcome in transverse dimensions.
Traditionally superior and lateral orbital contours have been
considered as stable reference points after 8 years of age.31 Krogman
and Sassouni discussed crista galli as a reference point between two
orbits to draw a mid-sagittal reference plane. The MSR plane is used
for evaluation of symmetry and superimposition of the subsequent
films.32 Comparing PA cephalogram with computed tomography
(CT), it was reported that PA measurements using the mid-sagittal
reference plane on a perpendicular plane lying through the midpoint
of the right and left latero-orbitales were closest to those of 3D33 (Fig.
24.12). The horizontal reference plane can be a line connecting the two
ear rods or ZA-AZ.
FIGURE 24.12 Cephalometric superimposition of a PA
cephalogram.
The PA cephalogram superimposition is shown using MSR plane and
trans-zygomatic plane (AZ-ZA).
Superimposition requirements of
American Board of Orthodontics34
All anatomical structures should be identified accurately in
preparation for the marking of landmarks and the drawing of
reference lines.
ABO guide lines recommend use of the same template to trace the
maxillary and mandibular incisor and molars so as to maintain
consistency in shape and size of teeth.
The soft tissue outline of the facial profile is required for each
tracing.
All measurements must be recorded on the tracing and on the Case
Management Form.
The FH line is drawn on all tracings.
Craniofacial tracings are superimposed on the anterior cranial base
(ACB).
The mandibular plane is drawn as a constructed plane from
constructed Gonion to constructed Menton and not the anatomical
landmarks.
The method of recording and construction of the mandibular plane
is depicted in Figs 24.13–24.15..
FIGURE 24.13 Cephalometric tracing, land marks and method of
depiction of values according to ABO requirements.
FIGURE 24.14 Cephalometric tracing method of construction of

mandibular plane according to ABO requirements.
FIGURE 24.15 Method of superimposition according to ABO
requirements.
(A) Maxillary superimposition and (B) mandibular superimposition, (C)
cranial base.
Imaging scientists and computer programmers have worked
automatic landmark identification on digital cephalograms and
automatic superimposition. Efforts are in progress, and two
approaches have been used.
1. Features of curve detection and best-fit superimposition on the

anterior cranial base (ACB).
The process is conducted in three stages.35
Stage I: To digitise and calibrate the cephalogram
through the CCD camera, in case images are not
digital.
Stage II: To extract the feature curves for the cranial
base using the best orient edge detector and Hough
transform, and for the mandible using the Laplacian
of Gaussian and grouping.
Stage III: To automate the superimposition based on the
clinically available procedure and finally to display
the associated results.
This procedure should typically take 5–6 min of
computation. Chen et al. reported a high precision
with this method which for the cranial base
superimposition was about 0.312 cm, and the
mandible was about 0.005 cm (Figs 24.16 and 24.17).
2. Larson et al. have inducted X-ray 3D program developed by
Dental Research Center for Biomaterials and Biomechanics at
the University of Minnesota. This software was originally
developed for assessing bone loss around implants.36 It uses a
mathematical algorithm to match a selected area on one
radiographic image to the most similar area on a second
image. Studies report that successful image matching was
achieved using image matrices of 800 × 600 pixels and a sigma
value of 20. Authors have tested if rotated images of a skull
could be superimposed using this software. This software was
used to superimpose the images using the entire topology of
the selected region and to match it as accurately as possible to
the other radiograph in the region of the sphenoid plane,
cribriform plate, and the greater wings of the sphenoid bone.
Images up to rotations of 10 degrees and brightness variation
less than 10% were reasonably accurate.
Automatic landmark identification and superimposition is an
exciting area of research which has a great promise in
enhancing the speed and accuracy.
FIGURE 24.16 (A) The extracted feature curve in the cranial base for
superimposition. (B) The final result for cranial base cephalometric
superimposition. Source: Cited with permission from Chen YT.34
FIGURE 24.17 (A) The feature curve obtained using the grouping
method. (B) The final result for mandible cephalometric
superimposition. Source: Cited with permission from Chen YT.34
3D superimposition
The superimposition of 3D CBCT images is used for evaluation of
growth related changes and evaluation of treatment effects. In 2D
cephalometric superimposition two commonly used methods are
landmark based method and structural method. Similarly, 3D CBCT
images from two different time points can be superimposed using
landmark based method or mathematical algorithm methods. In
landmark based method, three are more landmarks on two or more
CBCT images are used for superimposition.37 Once the initial
superimposition is made, the software program allows operator to
move the CBCT images manually for further fine tuning (Fig. 24.18).
FIGURE 24.18 Landmark- based method of superimposition of
CBCT data in a patient treated with protraction facemask.
(A) Pre- (grey) and post-CBT (green) images with three landmarks. (B)
Software performs superimposition automatically. (C) Poor
superimposition of the stable anatomical structure.
The mathematical methods include: 1) voxel based superimposition,

2) software based technique using information therapy, 3) ICP
method, 4) triple voxel based superimposition.37–39
Voxel based superimposition method is an automated
computerised superimposition method, which eliminates observer
dependent landmark plotting. In this method the stable anatomical
structures, ACB, grey values of each voxels between two CBCT
images are compared by the software program (Fig. 24.19).39 In this
way the software computes the rotation and translation required in
three dimensions to align the post treatment CBCT images according
to pre-treatment CBCT image. It does not depend on the precision of
the 3D surface models.
FIGURE 24.19 Voxel-based superimposition of a patient treated
with protraction facemask.
(A) The region of interest (ROI), ACB is defined by the operator for
superimposition. (B) Software performs voxel-based registration on
ACB automatically. (C) Perfect superimposition of ACB structures.
Cevidanes et al.5,40,41 used voxel based superimposition method on

the ACB structures for both growing and non-growing subjects. Nada
et al.42 showed that voxel-based image registration on both the ACB
or the zygomatic arches could be considered as an accurate and a
reproducible method for CBCT superimposition. Also they suggested
that the left zygomatic arch could be used as a stable structure for the
superimposition of smaller FOV CBCT scans, where the ACB is not
visible.
Key Points
Cephalometric superimposition has been extensively used to assess
growth and treatment changes since its introduction and has been a
major research tool in the hands of orthodontists. Serial cephalograms
have been superimposed on stable cranial points to study changes in
the face, jaws and dentition.
The immutability of cranial base as fixed reference is only relative
and not absolute. Moreover, growth and treatment changes occur in
all the three dimensions of bony structures which cannot be precisely
evaluated on a 2D radiograph.
The 3D visualisation and volume rendering images obtained
through CBCT have opened up new vistas of studies in craniofacial
morphology and studies on growth.
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CHAPTER 25
Errors in cephalometrics
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Errors during X-ray tracing
Errors of cephalometric landmark identification
Systematic errors
Random errors
Calibration and magnification correction of digital images
Calibration and magnification correction of analogue films
scanned to digital images
Key Points
Introduction
It must be well appreciated and realised that a cephalogram is an X-
ray taken in a standard orientation of the head and obtained through a
cephalostat technique. A cephalogram is a two-dimensional X-ray
picture of three-dimensional structures of the dentition, face and head.
A cephalogram provides highest possible projection resolution in
which structures smaller than 0.1 mm can be discerned. This
projection resolution with cephalogram is superior to that of
conventional computed tomography (CT).
It is presumed that structures of the right and left side of face/head
would be exactly overlapping each other when X-rays traverse
perpendicular to the mid-sagittal plane at the transmeatal axis of the
head. However, the fact that the structures of head on left side of the
face are closer than the right side, some amount of magnification of
right side structures is technically unavoidable. Therefore, the left side
structures show less magnification compared to the right side
structures and this is the reason for not having a perfect overlap of the
right and left anatomy.
The appearance of double shadows on a cephalogram should be a
routine and not an exception. Most of the cephalometric machines
accept 5% enlargement as an acceptable limit. Magnification is an
inherent limitation of a cephalogram.
Besides the blend of sharpness, contrast and density of an X-ray film,
the other essential features of a cephalogram are those related to
accuracies of head positioning in the cephalostat. Besides hard tissue
features, a cephalogram should also exhibit a clear soft tissue shadow
of the facial contour. The soft tissue is substantially recorded by
limiting the radiation intensity in the region with the use of soft tissue
filters built in the film holder cassette or provisioned in the sensor
holder of the digital cephalogram apparatus.
(i) The smooth curve of the cervical spine. A cephalogram that is

taken without straining the neck would show 6–7th vertebra of
the cervical spine in a smooth curve.
(ii) Concentricity of ear rods. The radiopaque metallic rings of the
ear rods present as two shadows in the region of the external
auditory meatus (EAM). The ring of the right side appears
slightly larger in diameter compared to left side due to the
magnification factor. However, it is the concentricity which is
important. Lack of the concentricity would be caused by axial
rotation of the head to the left or right or vice-versa. Larger
ring (right side ear rod shadow) being more anterior than the
left indicates axial rotation of neck to the left and reverse
location will suggest axial neck rotation to the right.
Some cephalometric systems have a small metal palette
embedded in the centre of plastic ear rod which would appear
as radio-opaque rounded shadows in the centre of the EAM.
Ideally, these two shadows should perfectly coincide, but it is a
rare phenomenon to be seen in day to day life.
(iii) Overlap of the right and left side structures. There should be
a minimal discrepancy in a horizontal and vertical overlap of
the right to left side structures. A difference of the condylar
heads coupled with a marked discrepancy or significant
separation of the posterior border of the ramus of the
mandible and lower border of the body of mandible suggest
improper head positioning. A cephalogram with a large
discrepancy may have to be discarded, and a repeat
radiograph is advised. However, while asking for a repeat
radiograph, consideration of risks and cost associated with
radiation vis-à-vis, the actual benefit of a more accurate
cephalogram in treatment decision should be kept in mind.
A slightly distal placement of the posterior border of the ramus
and superior placement of the lower border of the mandible on
the right side compared to the left side structures is a normal
finding.
Other structures that can help in determining the accurate
positioning of the head while recording a cephalogram are
shadows of orbital rims and the pterygopalatine fissure.
(iv) Teeth in centric occlusion. A child may quite often move
his/her jaw from centric occlusion position, or open the
mandible. It is always better to check the occlusion clinically
/on study models and reconfirm on his cephalogram. A
simpler and practical technique would be to match the overjet
seen on a cephalogram with the one measured in a mouth or
on dental study models mounted into correct occlusion.
Vertical separation of teeth would appear as double shadows
of the cusp tips of molars in the vertical direction or a
radiolucent shadow onto the occlusal surfaces of teeth.
(v) Unstrained lips. A cephalogram taken in a relaxed posture of
lips would show a natural outline of the face from forehead
down to the region of the Adam’s apple. Similarly, a
cephalogram taken with care would also exhibit shadows of
the soft palate and anatomical contours of the upper airway
(Fig. 25.1).
FIGURE 25.1 A good quality lateral cephalogram.
It is important to mark (L) or (R) side of the head while taking a PA
view radiograph. A cephalogram taken in a correct position in the
head holder should exhibit EAM shadows (either rings or around
radio-opaque marker) in a horizontal plane. However, this aspect may
have to be ignored in children with gross craniofacial deformities. PA
cephalogram would exhibit temporal bones, orbits, frontal and
ethmoid sinuses, maxilla and its antrum, nasal cavity, palatal floor
and the mandible from the condyle to the symphysis (Fig. 25.2; PA).
FIGURE 25.2 A good quality PA cephalogram.
A Posteroanterior cephalogram is indicated for the evaluation of

symmetry of right and left sides. Efforts are made to distinguish any
apparent difference from true deformity from left to right side. PA
cephalogram is much more technique sensitive compared to lateral
cephalogram. An imprecise orientation of the head could exhibit as
right to left asymmetry or cant of occlusal plane. While axial rotation
of head may appear as asymmetry of left to right tilt (or vice-versa)
leads to transverse cant of occlusal plane. The rotation of head around
a transverse axis may exhibit itself as facial asymmetry.
Sources of errors at random in making a cephalogram are mostly
associated with improper positioning or orientation of head in
cephalostat.
1. A strain on the neck. Cephalostat machine needs to be

adjusted to patient’s height whether the patient is
standing/sitting in a relaxed posture. The ear rods should
gently be placed in the EAM.
Strain in the neck could be due to the error in vertical positioning
of the ear rods. In either case, the up and down position of the
machine, that is lower or higher than the comfortable for the
height of the patient will lead to strain on the neck. To adjust a
discrepancy in the height of the machine, either the child has to
strain up the neck or bent himself down (Fig. 25.3).
2. Axial rotation of the head. The rings apart in anteroposterior
direction suggest that radiations are not passing perpendicular
to the mid-sagittal plane. It signifies rotational error of head
positioning in a cephalostat (Fig. 25.4).
3. Head tilt
a Similarly, there may be a superoinferior discrepancy
in the concentricity of rings which would suggest a
right or left side tilt of the head (Fig. 25.5).
b Head tilt forward or backward, that is not parallel to
FH plane. The head tilts forward or backwards will
affect the airway and tongue and hyoid position
(Fig. 25.6).
4. Teeth not in occlusion. Teeth apart not in occlusion or patient
biting on incisal edges will give an erroneous reading of the
parameters related to the mandible (Fig. 25.7A–C).
5. The strain on lips: Excessive strain on lips in an effort to close
the lips is an common error while taking a cephalogram. A
cephalogram in centric occlusion should be taken with lips in a
relaxed posture. The way patient poses himself/herself during
exposure would affect soft tissue measurements (Fig. 25.8).
6. Metallic artefacts All metal hair clips, ear rings should be
removed prior to X-ray as their radiopaque shadows are likely
to mask the anatomical landmarks.
FIGURE 25.3 Strain on the neck (marked with arrow), poor

positioning of the head in cephalostat.
FIGURE 25.4 Effect of axial rotation of the head to the left seen
as double shadow in the posterior border of the ramus.
FIGURE 25.5 Head tilt to right/left side seen as double shadow in
lower border of the mandible.
FIGURE 25.6 The head is tilted upwards leading to FH plane not
parallel to the floor.
Also a poor contrast of the film makes it unsuitable for cephalometric
measurements.
FIGURE 25.7 (A) Common error while making a cephalogram with

posterior teeth out of occlusion. Class II div 2 patients tend to bite in
incisal edge during exposure. (B) Same patient with buccal teeth in
centric occlusion. Occlusion on cephalometry should always be double
checked with centric occlusion relation in the mouth. (C) Slight mouth
opening at the centric occlusion.
FIGURE 25.8 The strain on the lip, upper lip and chin in an effort
to keep the lips closed.
Patient with bidental protrusion shows strain in upper lip and puckering
of the chin.
Errors during X-ray tracing1
Other sources of error in cephalometric measurements could be
contributed by imprecise tracing of the X-ray film. The other
contributing radiographic factors include contrast and sharpness of X-
ray film, which is in turn dependent upon the speed of film, exposure
parameters, use of intensifying screen and processing of X-ray films.
With the development of digital radiography, these issues have been
resolved by the image processing capabilities of the software through
the process of optimisation.
A neat and clean tracing is necessary for optimal visualisation of the
cranial/dental structures. The accuracy of tracing is the most
important consideration in identification of the landmarks and
making measurements. A common unnoticed and avoidable error is
related to proper fixing of the tracing paper on the cephalogram.
Therefore, each time tracing should be done with the tracing paper
perfectly oriented to match the orientation lines drawn on the
cephalograms.
Errors of cephalometric landmark
identification
It has been reported that variability of landmark identification is five
times greater than measurement variability. Observer’s experience in
locating a landmark and his understanding of the precise definition of
landmarks are important factors that influence landmark
identification errors. Studies on reproducibility of landmark
identifications have reported that each landmark has its own envelope
of landmark identification error. Some landmarks are more consistent
and accurate to be located while others show consistent variability.
This variability is independent of observers, that is those landmarks
with inconsistent variability show a similar trend of error of
placement by the same operator or a number of operators. Some
landmarks show the consistent variability of placement identification
in the X axis, while others exhibit in Y axis while other landmarks
show inconsistent pattern (Table 25.1).2–5
Table 25.1
Cephalometric landmark accuracy (meta-analysis of six studies)5, 6

High error possibilities
X coordinate Y coordinate
Orbitale (2.08 + 0.24) A
Bolton point B
Menton Pog
ANS Apex of upper incisor
P Apex of lower incisor
Least error possibilities
B ANS
Ptm Ptm
S S
Go N–Me
Ar Me–Go
Na A
The errors of cephalometric measurement have been classified as

systematic errors and random errors.
Systematic errors
Systematic errors (or bias) are those that occur due to imprecise
location marking of the landmark by a single operator or by two
separate operators. Mr X, who consistently locates ‘Or’ point slightly
superior would add an inherent systematic intraoperator error to all
the cephalograms traced by him.
Similarly, two operators may always locate the point ‘Or’, based on
their judgment in a different location and hence a systematic error is
introduced. Such an error of bias for comparison of studies can arise
between two operators or a single operator over a time.
Random errors
Random errors occur due to difficulties in landmark identification or
guessing. These are classified as intraoperator and inter-operator
errors. Single operator over the time may improve or change
landmark location identification with experience.
In general, up to 0.6 mm of discrepancy in the site of the landmark
in considered acceptable. It is precisely 0.56 for X coordinates, and
0.59 for Y coordinates.5
Richardson7 in his study had two judges register cephalometric
landmarks, lines, and angles on ten cephalograms at an interval of 10
weeks. He found that ordinary cranial landmarks have a margin of
error of 1 mm.
Orbitale and Bolton points show higher variability.
Vertical deviations are more on landmarks that are on curves like
points A and B.
Horizontal differences have been observed in particular for menton
(Me), Spinanasalis (ANS) and pterygomaxillary fissure (Ptm).
Midtgard et al.6 conducted a study on reproducibility of 15
commonly used landmarks and measurements of errors in seven
cranial distances. When a clinician was asked to mark the same
landmark on two consecutively taken lateral cephalograms, the
differences were apparent, which varied from landmark to landmark.
Roughly, the same variance in values was observed in estimating the
positions of landmarks on the same cephalogram on two occasions
with an interval of one month.
The greatest difference was found for landmark orbitale with a
mean of 2.08 mm ± 0.24.
On an average, a difference of 1 mm was observed for landmarks
supramentale (1.27), pogonion (1.21), spinanasalis anterior (1.17), the
apex of upper incisor (1.12) and lower incisor (1.09).
The means of the differences in cephalometric measurements
accounted for most of the part, depends upon the uncertainty of
observer in exactly locating the landmarks whether on two
consecutive films of a subject or on the same cephalogram film at one
month apart.
The greatest degree of certainty has been found for landmarks
sellaturcica (0.41 mm) and articulare (0.52 mm).
While the greatest accuracy of measurement was seen for Me–Go
and N–Me, the biggest inaccuracy has been found in estimating the
soft tissue measurements of nasion-subspinale (n-ss) and nasion-
supramentale (n-sm).
Trpkova et al.8 conducted a meta-analysis of the cephalometric
landmark, identification and reproducibility. Only six studies fulfilled
strict inclusion criteria. They reported: B point and Na point for X
coordinate, and ANS and A point for Y coordinate are the landmarks
that showed the greatest consistency among six studies.
On X coordinate Ar and Or and on Y coordinate P and Or showed
significant bias.
The landmarks B, A, Ptm, S and Go on the X coordinate and Ptm, A
and S on Y coordinate presented with an insignificant mean error and
small values for total error. Therefore, these measurements may be
considered to be reliable for cephalometric analysis of lateral films
(Table 25.1).
Every effort should be made to minimise error of measurement of
cephalometric variables which could affect judgments in diagnosis
and quality of research.
Accuracy in measurements is directly dependent on the sensitivity of
the measuring instruments and measuring at correct landmarks. Most
hand instruments are calibrated to measure up to half a degree/half a
millimetre. Errors could occur in measuring a variable by selecting a
wrong point(s) due to human error or fatigue factor. Errors could
occur due to several analyses being carried out on a single sheet of
tracing paper, which could overlap landmarks and planes leading to
inaccurate measurements.
With the use of computerised cephalometric analysis software, the
errors of making measurements with hand instruments and
calculations of ratios have been eliminated.
With the digitisation of orthodontic cephalometry, various software
programs have been introduced for onscreen landmark plotting and
measurements. Several authors have evaluated the accuracy of these
new computerised software programs compared with traditional
method. McClure et al.9 showed that there is no difference in
landmark identification error between the conventional manual and
digital methods. Point A, ANS and Condylion showed statistically
significant differences in X, Y and Y axis respectively, however, they
were unlikely to be of clinical significance.
Chen et al. evaluated effects of differences in landmark
identification on the cephalometric measurements between traditional
and digitised cephalometry. They showed that the inter-observer
errors of cephalometric measurements on digitised images were
comparable with those from original radiographs.10 On the other
hand, distortion may occur while scanning the analogue film to a
digital format for onscreen landmark plotting and measurement.
Bruntz et al.11 found 0.8 mm vertical enlargement and 0.4 mm
horizontal reduction distortion between the original and the scanned
image. The printed hard copy from the scanned digital radiographs
showed 1.1 mm vertical and 0.4 mm horizontal enlargement.
Calibration and magnification
correction of digital images
Radiograph calibration is one of the important prerequisites for the
cephalometric analysis (Fig. 25.9). Digitisation of a cephalogram
without calibration will introduce significant errors of
measurements.12
FIGURE 25.9 Pictorial representation for calculation of

radiographic magnification or enlargement.
Digital cephalograms displayed on the screen will not provide the

life-size image as it can be displayed in various sizes depending on the
display monitor size. The size of digital cephalogram has to be
calibrated first before landmark plotting. It is the first step in the
digital cephalometric analysis. This can be done in two ways:
1. Cephalograms can be calibrated by digitising two points on the

ruler within the digital cephalograms (Fig. 25.10). The image is
calibrated by matching the image to actual measurements of
the distance between two points. Say the 20 mm scale appears
on screen 14 mm. By calibration, the ‘14 mm’ ruler scale will
alter the ruler to ‘20 mm’ on screen, and the whole image of
cephalogram thus gets calibrated. The calibrated image is
saved, which is used for the purpose of digitisation of the
points.
2. Using the Dots Per Inch value (DPI), of the image (Fig. 25.11).
Most of the recent software programs will have both the
options for calibrating the digital image. This method works
on a sophisticated digital technology where the image size is
calibrated by distributing DPI to the original image size.
FIGURE 25.10 Calibration using the metal scale present in the

digital cephalogram in ‘Auto CEPH’© cephalometric software.
Two points have been marked on the scale that measures 40 mm.
FIGURE 25.11 Calibration using DPI of the digital cephalogram in
‘Auto CEPH’© cephalometric software.
Calibration and magnification
correction of analogue films scanned
to digital images
The image magnification or reduction in size can happen due to the
scanning the analogue film to create a digital cephalogram.
Scanning the analogue film for digital tracing may introduce
additional magnification/reduction error from scanning. Therefore
this cephalogram has to be calibrated for both magnifications, one
results from diverging X-ray beam and another from scanning process
itself. The conventional analogue cephalograms have to be scanned
with a ruler visible, 100 mm scale to avoid errors during scanning
(Fig. 25.12). On screen, calibration is performed by plotting two points
of known length on the ruler as given for a digital cephalogram above.
FIGURE 25.12 Image calibration metal scale of 100 mm length
was scanned along with the analogue film cephalogram for
calibration in cephalometric software. Reproduced with permission
from Cohen JM. Comparing digital and conventional cephalometric
radiographs. Am J Orthod Dentofacial Orthop. 2005 Aug;128(2):157–
60. PubMed PMID: 16102396.
The magnification correction. The image magnification can happen

due to the Inherent magnification of cephalograms due to diverging
X-ray pattern in both conventional analogue and direct digital
cephalogram. The amount of magnification can be corrected to obtain
true size measurements. However, the older cephalograms that do not
have the metal scale the magnification factor can be calculated by
using the geometric principle. The equation is given later.13
Key Points
Magnification = (source to patient’s mid-sagittal plane + patient’s mid-
sagittal plane to film)/source to patient’s mid-sagittal plane.
Much of cephalometric errors are related to head positioning in the
cephalostat, strain on the neck, improper occlusion and strained lips.
The quality of film processing, chemicals and exposure control are
significant factors that influence the contrast and sharpness of X-ray
film.
With digital technology, much of these issues have been taken care.
Precise identification of landmarks holds the key to accurate
measurements. The experience of the operator has considerable
influence on precise identification of the landmarks, especially certain
landmarks that are not so easily identifiable on the X-ray.
Some landmarks show consistent errors in identification in ‘X’ axis
while others in ‘Y’ axis.
In general, an error of landmark identification up to 0.5 mm (in
either X or Y axis) is considered acceptable.
Accurate landmark identification is the basis of correct measurements on a
cephalogram.
Computerised cephalometry has helped to make multiple
measurements with accuracy and speed. However, the precise
accuracy of measurements is indeed controlled by the proper
identification of the landmarks by the operator where experience and
knowledge play a crucial role. The digital imaging has helped to
visualise the landmarks with the tools of magnification, image
enhancement and image processing functions of the software. The
most critical step in digital image revolves around onscreen calibration of the
image and accurate location of the landmarks by the operator.
References
1. Gravely JF, Benzies PM. The clinical significance of
tracing error incephalometry. Br J Orthod.
1974;1(3):95–101: Apr; PubMed PMID: 4525738.
2. Baumrind S, Frantz RC. The reliability of head film
measurements. 1. Landmark identification. Am J
5283996.
measurements. 2. Conventional angular and linear
measures. Am J Orthod. 1971;60(5):505–517: Nov;
4. Houston WJ, Maher RE, McElroy D. Sherriff M.
Sources of error in measurements from
cephalometric radiographs. Eur J Orthod.
1986;8(3):149–151: Aug; PubMed PMID: 3464438.
5. Vincent AM, West VC. Cephalometric landmark
identification error. Aust Orthod J. 1987;10(2):98–104:
6. Midtgård J, Björk G, Linder-Aronson S.
Reproducibility of cephalometric landmarks and
errors of measurements of cephalometric cranial
distances. Angle Orthod. 1974;44(1):56–61: Jan;
7. Richardson A. An investigation into the
reproducibility of some points, planes, and lines used
in cephalometric analysis. Am J Orthod.
1966;52(9):637–651: Sep; PubMed PMID: 5222437.
8. Trpkova B, Major P, Prasad N, Nebbe B.
Cephalometric landmarks identification and
reproducibility: a meta analysis. Am J Orthod
Dentofacial Orthop. 1997;112(2):165–170: Aug;
9. McClure SR, Sadowsky PL, Ferreira A, Jacobson A.
Reliability of digital versus conventional
cephalometric radiology: a comparative evaluation of
landmark identification error. Semin Orthodont.
2005;11(2):98–110: Jun 30 WB Saunders.
10. Chen YJ, Chen SK, Yao JC, Chang HF. The effects of
differences in landmark identification on the
cephalometric measurements in traditional versus
digitized cephalometry. Angle Orthod.
2004;74(2):155–161: Apr; PubMed PMID: 15132440.
11. Bruntz LQ, Palomo JM, Baden S, Hans MG. A
comparison of scanned lateral cephalograms with
corresponding original radiographs. Am J Orthod
Dentofacial Orthop. 2006;130(3):340–348: Sep; PubMed
PMID: 16979492.
12. Dibbets JM, Nolte K. Effect of magnification on lateral
cephalometric studies. Am J Orthod Dentofacial
12165775.
13. Cohen A, Laviv A, Berman P, Nashef R, Abu-Tair J.
Mandibular reconstructionusing stereolithographic
3-dimensional printing modeling technology. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod.
2009;108(5):661–666: Nov; Epub 2009 Aug 28;
SECTION VI
Digital orthodontics
Chapter 26: Digital and computerised cephalometrics

Chapter 27: 3D data acquisition and orthodontic triad
Chapter 28: 3D digital models
Chapter 29: Three-dimensional imaging in orthodontics
Chapter 30: Three-dimensional cephalometry
Chapter 31: 3D volumetric analysis, and clinical implications of
the upper airway and sinuses
CHAPTER 26
Digital and computerised
cephalometrics
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Direct digital image
Direct digitisation
Indirect digitisation
DICOM
Cephalometrics without X-rays
Direct digital radiography (ddR)
Charge coupled device
Complementary metal oxide semiconductor system
(CMOS)
Steps of using CR system
Design characteristics of photostimulable phosphor
cassettes
Steps in computerised cephalometric analysis
Key Points
Introduction
The term Computerised Cephalometrics entails the use of advanced
specialised software through computers to make cephalometric
measurements for quick and accurate analysis and store data for ease
of retrieval and transfer. There could be several versions/levels of
digital cephalometrics depending upon the capabilities or options of
the supporting analysis ‘software’ used for cephalometric analysis.
The simplest version of computerised analysis software is the one
that substitutes the use of protractor and ruler to make measurements
of craniofacial angular/linear measurements and ratios without
making any lines on a cephalogram. These digital cephalometric
systems that were developed in 1970s–1980s used ‘Disc Operating
Systems’ (DOS) and had limited capabilities of data analysis and
treatment planning. These systems were then upgraded to be
compatible with Windows and Mac systems with several advanced
functions.
Computerised cephalometrics has since then advanced with newer
developments in computer hardware technology; image capture
(scan) and image transfer, and on-screen image quality of the
visualising monitors. The software used by the architecture engineers
was inducted in the cephalometric analysis. Although most
cephalometric analysis software was designed for 2D measurements,
the more sophisticated specific software were later developed for
reconstruction of 3D images for the 3D studies of the face and
craniofacial structures through CT scan and lately CBCT.
Research and knowledge on the growth of craniofacial structures,
soft tissue changes that occur from adolescence to adulthood, due to
ageing, with orthodontic treatment and following orthognathic
surgery were integrated to be accounted for treatment planning. The
above information was built in as advanced functions of
cephalometric diagnostic systems.
Robert Murray Ricketts spent a significant time in the development
of computerised cephalometric systems and integration of growth
prediction data and visual treatment objectives (VTO). He was the
pioneer and known as the father of computerised orthodontics.1-5 The
computerised cephalometric systems were developed in collaboration
with Rocky Mountain Orthodontics at Denver, Colorado, USA.6
The advancements in computer technology helped to render
quality, accuracy and speed to image (cephalometric image)
management. The enhanced knowledge in growth and soft tissue
behaviour following orthodontic treatment and orthognathic surgery
has been of immense help in orthodontic treatment planning,
predictions of growth and simulation of orthognathic surgery. The
technological advancements both in computer technology, digital
image manipulation and research in orthodontic literature continue to
pour in and are being integrated to update and enhance the
‘capabilities’ and quality of computerised cephalometrics.
Computerised cephalometrics is often confused with digital
cephalometrics. Digital cephalometrics primarily involves the
recording of a cephalometric image on a non-film medium as a ‘digital
image’, which is manipulated through computers and viewed on
screen. It substitutes analogue film with the digital image, and it is
possible to do a simultaneous analysis of this image utilising
cephalometric software (Boxes 26.1 and 26.2).
Box 26.1 dvantages of digital over the

conventional cephalometry
Advantages of digital
SN Limitations of conventional cephalometry
cephalometry
1. Requires outline of dental and skeletal structures to be The process of landmark
transferred on a tracing paper which involves a significant identification is on screen. The
effort and time. tracing of contours is generally
not required.
2. Needs precise calibrated measuring hand instruments. The software is calibrated and
therefore makes accurate
measurements.
3. Measurement accuracy is dependent on the accuracy of Measurement accuracy is
lines and accurate drawing of planes and angles. dependent on precise marking of
landmarks.
4. Measurement accuracy is sensitive to human errors. Measurement accuracy is
sensitive, software dependent.
Hence human measurement error
is eliminated.
5. Requires several calculations to be performed on a single One time digitisation of
tracing. May need multiple tracings to do several analysis. identification of landmarks can be
used for multiple analysis.
6. It is time-consuming and cumbersome. Many practitioners Quick
avoid cephalometric calculations for it encroaches upon
the clinical time and efforts required to perform the
analysis.
7. Storage of data and records need space. Digital Storage of data requires
less physical space.
8. Results may not be reproducible. Results are reproducible.
9. Can not be instantly communicated to remote locations. Digital data can be easily and
instantly communicated.
10. Graphics display requires tracing. Graphic display can be generated
quickly in different colours.
11. Report processing is time consuming. Report processing is instant.
Box 26.2 Advantages of digital radiography
1. Radiation exposure can be greatly reduced (up to 70%).

2. Need for the X-ray film developing and processing is eliminated
and therefore all the technique and chemical related errors
associated with it are also eliminated.
3. Multiple ‘original images’ can be made available to multiple
stations simultaneously without intermediate copying of the
images as with screen-film radiographs.
4. Digital images of X-rays can be transmitted to the end user from
the place of radiography within hospital set-up using local area
network (LAN) or wide area network (WAN) without any
deterioration in any details of image spatial frequency.
5. The image data can be saved on a storage data and mailed. The
images can also be transferred through Internet and
teleradiology.
6. The digital image can be manipulated and enhanced through
image processing algorithms and post-processing functions of
the software.
7. Digital data storage saves space.
8. Ease of data retrieval.
9. Superimposition of cephalograms/on photographs is possible.
10. Can be viewed anywhere through mobile apps.
Computers are a medium to store and retrieve ‘digital image’ taken

through either CMOS/CCD sensors or storage phosphor plates.
Digital radiology image achieved through the photostimulable
phosphor plate (PSP) is called computed radiography (CR) while
radiology image obtained on CCD/CMOS sensors, and processed on
screen is called direct digital radiography (ddR).
Indirect digital image acquisition The digital image of a cephalogram
can be obtained by either scanning an analogue cephalogram X-ray
film or capturing an image of X-ray film using a digital camera. This
image can be transferred to a computer and made available on the
screen. This digital image of analogue X-ray film can be utilised for
cephalometric analysis using cephalometric analysis software. Such a
process is called indirect acquisition of the digital image. The
cephalometric images thus obtained requires to be calibrated for the
purpose of analysis.
Direct digital image

The other process of on-screen digitisation involves image captured
through either a sensor Flat Panel Detector (FPD) or Charge Coupled
Device (CCD) or Complementary metal-oxide semiconductor (CMOS)
sensor, which has replaced the analogue X-ray film. The other option
of obtaining digital X-ray image is through the PSP technology also
called CR.
Direct digitisation
The cephalometric software mainly locates X and Y coordinates of a
cephalometric point and this information is sent to the computer
software and through algorithms the relative position, planes and
angles can be calculated.
The location of the X–Y coordinate of a point can be performed
through a ‘Digitiser’ by using the digitising tablet and a cursor. The
cephalogram film or a tracing is placed on ‘Digitiser’ which is backlit,
using soft light. The points are digitised using a crossbar or a
digitising pen. Such a process is called direct digitisation. Use of
onscreen digitisation has replaced digitisation through the digitiser.
Indirect digitisation
It will involve location and digitisation of cephalometric points on a
computer monitor screen with a mouse cursor. The on-screen image
may be obtained either through indirect acquisition (scan or digital
picture of a cephalogram) or direct acquisition methods, that is digital
radiography (dR)/or ddR.
Modern computer software programs are capable of dynamic
manipulations of digital images through processes like changing
algorithms and windowing that permit alteration of the contrast and
density of the image without permanently altering the original file.
Hence raw data image can be preserved.
Optimisation is the key word in digital imaging which means that
digital computerised radiographic imaging and direct digital imaging
has superior capabilities by possibilities to optimise each function
from image production, image display, archiving and image retrieval
being independent developments. The synergistic and multitask
outcome of these capabilities has significantly enhanced diagnostic
capabilities in radiodiagnosis.
DICOM
For all medical applications, radiological image quality standards
including workflow and data management have been set up. Digital
Imaging and Communications in Medicine (DICOM) standard
involves handling, storing, printing and transmitting information in
medical imaging. The National Electrical Manufacturers Association
(NEMA) holds the copyright to this standard.
The limitations of conventional cephalometry and advantages of
computerised cephalometry are given in (Box 26.1).
A host of cephalometric analysis software and hardware systems have
been developed over the years, which can calculate the cephalometric
values, once suggested points are located. The analysis and other
software capabilities have progressed significantly since indirect
digitisation where an analogue film was kept on a digitiser, and X–Y
coordinates for the points were digitised. One such system was
developed in the early 1990s at Delhi in a collaborative effort between
IIT and Orthodontic Department at AIIMS, named DIGI-CEPH7 (Fig.
26.1). It was a DOS based system. Later systems utilised better
hardware and software where digitisation can be undertaken on a
screen on the digital cephalometric image.
FIGURE 26.1 Computerised cephalometrics using direct

digitisation.
(A) On screen menu of DIGI-CEPH. (B) A digitiser is used to locate X–
Y coordinate, which is connected to a computer. The points to be
digitised are chosen for the required analysis on screen through
software function. Point mode allows placement of a single point while
stream mode is used to draw profile or contours. Cephalometric
software, such as DIGI-CEPH calculates the variables and stores the
data. The data is retrieved either on screen or printer in a tabular form.
A plotter or laser printer can print graphic display of the profiles. Close-
up of backlit digitiser showing switches for different modes of
digitisation. The cross bar of the digitiser cursor is used to locate the
cephalometric points either on the X-ray tracing or directly on the film
placed on a backlit box. (C) Graphics display of skeletal and facial
contours, generated through DIGI-CEPH.
‘Auto-CEPH© ’ (http://ci.csio.res.in) is one such cephalometric

analysis software, designed and developed by Central Scientific
Instruments Organisation (CSIO) in collaboration with Orthodontic
Department at All India Institute of Medical Sciences (AIIMS), New
Delhi. This user-friendly cephalometric analysis system offers on-
screen digitisation capabilities with automated analyses and
comparison with chosen ethnic group. It can generate data on 16
standard lateral analyses and PA analysis in a fraction of seconds after
digitisation. It creates superimposition and graphic presentation of
profiles (Fig. 26.2A–D).
FIGURE 26.2 AutoCEPH©

http://ci.csio.res.in was developed as an advanced step to DIGI-CEPH
by Scientists and clinicians at CSIO Chandigarh and Orthodontic
Division at Centre for Dental Education and Research AIIMS, New
Delhi. (A and B) AutoCEPH© can carry out 16 standard lateral analysis
and provides various tools for accurate marking of anatomical
landmarks. Its unique features include viewing the uploaded X-ray in
different pseudo-colours (yellow in this image) for precise marking of
certain landmarks. There is a special feature of marking a landmark in
a zoomed-up window, which gets automatically marked on the original
image. A for point B and B for point orbitale. (C) Analysis report
generated by AutoCEPH application after all the landmarks required for
a particular analysis has been marked. Various parameters computed
along with their values, patient’s details and cephalogram can be
viewed in the report. The report may also be printed or exported to
other file formats as desired. (D) PA cephalogram and its marking in
AutoCEPH. Various graphics can be visualised after the landmarks
have been marked and median sagittal reference is chosen.
More advanced software(s) have several functions, such as growth

prediction, orthognathic surgical planning and simulation of
treatment results. These functions and outputs have inherent
limitations for accuracy. With the induction of cone beam, CT in
orthodontics newer software(s) is capable of handling 3D images
(Boxes 26.3 and 26.4).
Box 26.3 Various cephalometric analysis software

available
S. Cephalometric
Marketed by
No. softwares
1. AutoCEPH© Developed by CSIO Chandigarh and CDER; AIIMS, New Delhi, India,
Web-based cephalometric platform available free on http://ci.csio.res.in
2. AOCephTM American Orthodontics, Sheboygan, USA
3. AUDAXCEPH® Audax d.o.o. Ljubljana, Slovenia (https://www.audaxceph.com/)
4. Cef-X 2001 CDT, Cuiabá, Brazil
5. CLINIVIEWTM Instrumentarium Dental, Tuusula, Finland
ORTHOTRACE
6. Dolphin® Dolphin Imaging, Chatsworth,California, USA
7. Dr.Ceph F.Y.I.Technologies, Ozone, Arkansas, USA
8. Facad® Ilexis AB, Linköping, Sweden
9. JOE Rocky Mountain Orthodontics, Denver, Colorado, USA
10. Nemoceph NX Nemotec, Madrid, Spain
11. OnyxCeph® Image Instruments GmbH, Frankfurt, Germany
12. OrisCeph® Elite Computer Italia, Vimodrone, Italy
13. OrthoGoTM SOREDEX, Tuusula, Finland
14. PlanmecaRomexis® PLANMECA USA, Inc. Roselle, Illinois, USA
15. Quick Ceph Quick Ceph Systems, San Diego, California, USA
16. Smile Ceph Glace Software, Imola, Italy
17. TOTALCEPH Torc Software Ltd., Istanbul, Turkey
18. Viewbox® dHAL Software, Kifisia, Greece
19. VistadentTM GAC International, Bohemia, New York, USA
20. Winceph® Rise CorpoRn, Sendai, Japan
Box 26.4 Showing the current forms of

cephalometric software
Cephalometrics without X-rays8-10
Sonic digitisation is the process of digitisation of face/skull without
making the cephalogram. The system uses sound waves to record the
position of a landmark. As this system does not make use of X-rays,
the hazards of radiations are eliminated.
This concept was first introduced in orthodontics by Dolphin
Imaging System (USA). The system makes use of a head holder like
the one used in cephalostat to orient the skull/face.
A handheld digitiser is used to identify landmarks on a face for the
landmarks like orbitale, nasion and porion. For the other landmarks
like sella/root apex, their position and spatial localisation are
calculated by mathematical algorithms.
The system of sonic digitisation is relatively less accurate for
skull/hard tissue parameters because it is not possible to correctly
locate all the landmarks although the errors associated with
identification of cephalometric landmarks, errors of tracing and
distortion of X-ray images are eliminated. The DIGIGRAPH sonic
digitisation is more accurate for soft tissue surface landmarks and
values of linear measurements but relatively less precise than
cephalometric for other skeletal and dental parameters.
Digital cephalometry and radiography imply acquiring a digital
image rather than an analogue image. It is used for diagnosis and
treatment planning on the computer screen and, if required, several
analogue copies can be printed from the digital image.
Main advantage of digital imaging is reduction in radiation dose
from 40% to 50%,11,12 instant image availability, besides image
archiving, its transport to a multiuser, locally or in remote areas.13,14
DR has slowly evolved from the use of photostimulable phosphors
plate (PSP) called computed radiology (CR) to direct digital
radiography (digital images are stored on the sensor) ddR.
Eastman Kodak Company (1975) patented a device that used
thermoluminescent infrared stimulable phosphors thereby releasing a
stored image. Its application was to improve microfilm storage. FUJI
Photo Film Company made use of photostimulable phosphors to
record a reproducible radiographic image and patented the
technology in 1980. Thus digital radiology (DR) was born.15
It makes use of photostimulable phosphors that replaces silver halide
crystals of a conventional film. The photostimulable phosphors when
contacted by radiation energy cause them to become fluorescent,
releasing a high fraction of the absorbed energy, while some remnant
energy is stored in the phosphors, essentially as a latent image (Fig.
26.3).
FIGURE 26.3 Structure of phosphor screen cassette used in

computerised radiography (CR).
When PSP is stimulated with infrared, high-frequency helium–neon

laser or white light, photostimulable phosphors release light
proportional to the stored energy which can be detected by a
photomultiplier tube (PMT) to generate an electrical signal that is
ultimately reconstructed into a digital radiographic image. An optical
filter is used to filter out the laser light from the luminescent light of
the CR screen during read-out. The electrical signal from the PMT is
sent to the analogue-to-digital converter where it is converted to
digital bits or binary coded numbers. In addition to converting image
data to digital data, the converter may manipulate the data and
correct any deviations in it using an input look-up table (LUT). Each
CR screen must be erased after use or before use if the cassette has not
been in use over 24 h. The reader erases the plate using fluorescent
white light.
Direct digital radiography (ddR) (Fig.
26.4)
It is based on amorphous silicon technology that uses a caesium
iodide scintillator to perform X-ray detection. These systems are called
charge coupled device (CCD) or CMOS systems. These sensors are
also used in digital cameras.
FIGURE 26.4 The principle of horizontal scans used in direct

digital radiography (ddR).
Charge coupled device

It converts light image into a form that can be stored on a tape. An
integrated circuit is made up of a grid, which is constituted of
‘pixels/electron well’. On exposure, stored electric charge is converted
into values of brightness and location which makes a digital image.
The data is sent to a computer, processed and displayed. Scintillator is
an essential component of CCD device which helps to de-tect X-ray
signals. It converts X-ray radiation into photons that are conducted
through a fibre optic layer. CCD converts these photons to electronic
signals which convert the analogue sig-nal to a digital signal.
Complementary metal oxide semiconductor

system (CMOS)
It is an integrated circuit like a CCD. However, image quality is
poorer than CCD. Improved versions of CMOS/active pixel sensor
(APS) system have been developed by ‘NASA’ and ‘JET propulsion
laboratories’ in 1993. The APS allows embedding of microprocessors
and other circuits right in the sensor chip itself. It offers several
advantages over CCD which include possible smaller individual
pixels, less power requirement, lower cost and long lasting sensors.
Direct digital radiography (ddR) offers full resolution images that
are displayed and stored in about 8 s and therefore have greater
advantages over CR which requires plate processing.
The ddR is compatible with DICOM standards. DICOM standards
have been developed by the American College of Radiology
Manufacturers Association to define the connectivity and
communication protocols of medical imaging devices and therefore
can be connected on workflow through LAN or WAN. WAN is a
geographically dispersed telecommunications network. The term
distinguishes a broader telecommunication structure from a LAN.
Conventional digital cephalometry systems had to scan a patient’s
head for up to 8–18 s. The major disadvantage of this technique was
that if the patient moved during the exposure, the image had to be
taken again.
The Newer technology captures the image in just over one second,
drastically reducing the risk of blurred images and significantly
improving patient’s comfort. With ‘one shot’, the entire skull is
exposed in a fraction of a second (just like film), so that movement of
the head is no longer a problem. The image is clearer, and patient
comfort is improved. There is no need for the user to change working
practices, as the methods are the same as systems using silver halide
films—but with none of the disadvantages.
Advance digital cephalometric systems now use 3D volumetric
images. The advanced slicing windows can help display any slice of
choice within the 3D volume.
It uses conventional cephalostat machines that are modified to receive
PSP plates.
Hardware components of CR system
1. PSP plate and cassettes

2. Cassette reader
3. Barcode scanner
4. Remote operator panel for entering patient data
5. Printer and/or workstation.
Picture archiving and communication system (PACS) is a network

of computers into which a CR unit may input data for display and
storage. The CR imaging system consists of a clinical workstation for
reviewing and printing from PACS.
Steps of using CR system

Once the study is selected, that is cephalogram/panorex and the
cassette is barcoded; the radiology technologist may proceed using the
cassette just as they would a like screen-film cassette.
1. Patient information data is entered into the CR unit (it can be

accessed through barcode of the patient if provided by the
hospital records).
2. The appropriate algorithm of the X-ray is selected
(cephalogram/OPG/TMJ).
3. It may also be essential to enter cassette’s unique barcode into
the CR system so the reader can identify the image and
process it according to the pre-selected algorithm.
4. The patient is correctly positioned in the apparatus and
exposed to X-rays.
The chronology of the image processing following exposure is as
follows:
1. The exposed cassette is placed on the reader where the cassette

is mechanically opened and the photostimulable plate
removed.
2. Inside the reader, a laser is passed over the plate in raster
fashion using a wavelength of 633 nm to stimulate
luminescence of the phosphors.
3. This stimulated luminescence releases the latent image in the
form of light that is filtered and collected on to a PMT.
4. The PMT converts the light signal into an electrical signal that
is then converted from analogue-to-digital data bits by a
special converter.
5. The raw data is subjected to algorithms and LUTs that
interpolate data points and allow for manipulation of digital
information. It is optimised through a process of image
segmentation.
6. Finally, the image is presented on the monitor. All of this takes
place in a matter of seconds rather than minutes as in
conventional screen-film image processing
7. Once the image is acquired to the satisfaction, it can be stored
as a digital image or processed for printing.
8. The image can be available in the archives and retrieved as and
when required for computerised cephalometric analysis.
Design characteristics of photostimulable

phosphor cassettes
The basic component of CR image capture is the photostimulable
phosphor screen and cassette. The cassette front is made of carbon
fibre and the backing of aluminium. The structure of a
photostimulable phosphor screen from within outward is: aluminium
panel, lead layer, black cellulose acetate layer, estar support, a
phosphor layer, and an overcoat to protect the phosphor (Fig. 26.3).
The phosphor is coated on to the base (estar) using polymers that
act as glue to hold it. Then a clear coat solvent is coated over the
phosphor to seal it, protecting it from physical damage. A black
reflective base under the phosphor helps improve image resolution by
reducing dispersion of light as the laser exposes the phosphors at
reading; the black base also allows for a thicker phosphor layer into
which photon energy is trapped. These are all mounted on to a lead
sheet that absorbs excess photons and reduces backscatter, and to an
aluminium panel that is mechanically removed from the cassette
during scanning.
On the back of the panel, there is a label which indicates the speed
of the cassette, which in CR imaging is the brightness of the phosphor.
Speed is also used in calculating the exposure index.
How PSP works? Photostimulable phosphor screens are composed
of europium-activated barium fluoro halide crystals (BaFX:Eu2+),
where X is a halogen of iodine or bromine. Photostimulable
phosphors generate fluorescence from radiation energy just as do
analogue screens; however, to release the latent image contained in
the storage phosphors the screen must be subjected to light from a
finely collimated laser beam. The equipment utilises light in the
wavelength of about 633 nm to release a storage phosphor’s latent
image. During photostimulation of the storage phosphor screen, light
is emitted which has a wavelength of 400 nm. Light emitted from CR
screens during photostimulation is filtered and collected by a PMT(s)
and converted to an electrical signal that can be digitised (Box 26.5).
Box 26.5 dvantages and limitations of CR systems

(storage phosphor plate PSP)
Advantages Limitations
Existing X-ray apparatus can be modified for High Cost
use with PSP
PSP is reusable Less spatial resolution than film
Wider exposure range and fewer retakes Phosphor tends to decay with time
Reduction in radiation exposure Images may initially appear different from film-
based images
Steps in computerised cephalometric
analysis
A number of cephalometric software are available in the market each
one has its own merits and a few limitations concerning user-friendly-
ness and data process documentation. Some of the common and
popular ones are listed in Box 26.3. The software functions can have
simple to advance capabilities, including networking and
collaborations.
Common to them is that an orthodontic specialist who identifies
and digitise anatomical landmarks on digitised images. The software
performs the cephalometric analysis using lateral and PA
cephalograms. Over many deliberations towards need assessment of
such an indigenous tool, a classified set of requirements has emerged.
Currently, some developing countries like India, require
cephalometric software with basic functionality. Apart from the basic
features, network software provides additional functionality to
centralise the database or repository, and collaborative software is
useful within these countries to share the expert consultation. An
indigenous version must be cost effective, reliable, user-friendly and it
must be equipped with the population based normative data for
chosen ethnic group. Keeping in mind about the need for India and
Indian subcontinent, we have designed ‘AutoCEPH©’
(http://ci.csio.res.in). The data from lateral and PA digital
cephalograms has been tested for reliability against a manual and
known and reliable software and found suitable for use.16,17 A high
level of agreement (ICC > 0.9) for cephalometric measurements on
lateral was obtained from both the computerised software Dolphin®
and AutoCEPH© in comparison with manual tracings.16 AutoCEPH
has been tested for its reliability and accuracy of soft tissue
measurements and superimposition capabilities.18,19
The steps include image acquisition (Ceph Image), image
calibration, selection of the analysis to be performed, location of the
points/on-screen digitisation of the landmarks and saving seek
analysis and generation of a report.
In case additional and optional analysis is required these software
functions are built in the system. Most software programs have the
capability to undo/redo the incorrectly marked landmarks,
graphically exhibit the points marked and even show planes, angles,
and values. It is possible to generate contours and outlines of the hard
and soft tissue structures for graphic representation. The software
capabilities allow cephalometric superimposition of multiple stages of
treatment stages of treatment.
Steps for the process of computerised cephalometrics are outlined in
a Flowchart 26.1.
FLOWCHART 26.1 Steps in the process of using cephalometric
software.
Key Points
Digital cephalometrics has eased out much of errors and limitations
associated with analogue film processing and storage.
The quality of digital images should follow DICOM standards. The
digital images can be instantly viewed on screen and thus save time.
The cephalometric analysis software has automated process of
cephalometric analysis to a great extent. The options of growth
prediction and treatment outcome may not be accurate and should be
interpreted with a great caution. There could be several
versions/levels of computerised cephalometrics depending upon the
capabilities or options of the supporting analysis ‘software’ used for
cephalometric analysis.
The crux of cephalometry is an accurate identification of the
landmarks that lay in mind and hands of the orthodontist. The
artificial intelligence (AI) is now being incorporated into the
automation of cephalometry.
References
1. Ricketts RM. The evolution of diagnosis to
computerized cephalometrics. Am J Orthod.
1969;55(6):795–803: Jun; PubMed PMID: 5253967.
2. Ricketts RM, Bench RW, Hilgers JJ, Schulhof R. An
overview of computerized cephalometrics. Am J
Orthod. 1972;61(1):1–28: Jan, Review; PubMed PMID:
4550123.
3. Ricketts RM. The value of cephalometrics and
computerized technology. Angle Orthod.
1972;42(3):179–199: Jul; PubMed PMID: 4504536.
4. Ricketts RM. An update on the status of
computerized cephalometrics. Aust Orthod J.
1978;5(3):89–104: Feb; PubMed PMID: 285711.
5. Ricketts RM. Perspectives in the clinical application
of cephalometrics. The first fifty years. Angle Orthod.
1981;51(2):115–150: Apr; PubMed PMID: 6942666.
6. RMO diagnostic services Course Syllabus. Denver,
Colorado, USA; 1989.
7. Kharbanda OP, Sidhu SS, Guha SK, Anand S. DIGI-
CEPH manual AIIMS and IIT. New Delhi; 1990.
8. Chaconas SJ, Engel GA, Gianelly AA, Gorman JC,
Grummons DC, Lemchen MS, Nanda RS. The
DigiGraph work station Part 1. Basic concepts. J Clin
2089065.
9. Alexander RG, Gorman JC, Grummons DC, Jacobson
RL, Lemchen MS. DigiGraph work station 2. Clinical
management. J Clin Orthod. 1990;24(7):402–407: Jul;
10. Chaconas SJ, Jacobson RL, Lemchen MS. DigiGraph
work station. 3: accuracy of cephalometric analyses. J
Clin Orthod. 1990;24(8):467–471.
11. Visser H, Rödig T, Hermann KP. Dose reduction by
direct-digital cephalometric radiography. Angle
11407766.
12. Nessi R, Garattini G, Blanc M, Marzano L, Pignanelli
C, Uslenghi C. Digitalcephalometric teleradiography
with storage phosphors comparative study. Radiol
Med. 1993;85(4):389–393: Apr, Italian; PubMed PMID:
8516464.
13. Forsyth DB, Shaw WC, Richmond S. Digital imaging
of cephalometric radiography Part 1: advantages and
limitations of digital imaging. Angle Orthod.
1996;66(1):37–42: Review; PubMed PMID: 8678344.
14. Forsyth DB, Shaw WC, Richmond S, Roberts CT.
Digital imaging of cephalometric radiographs Part 2:
image quality. Angle Orthod. 1996;66(1):43–50:
15. http://www.ceessentials.net/article11.html.
16. Mahto RK, Kharbanda OP, Duggal R, Sardana HK. A
comparison of cephalometric measurements obtained
from two computerized cephalometric softwares
with manual tracings. J Indian Orthod Soc.
2016;50(3):162–170.
17. Sangroula P, Kharbanad OP, Sardana HS, et al.
Comparison of reliability and validity of PA
cephalometric measurements obtained from 2
computerized cephalometric analysis software with
manual tracing. J Indian Orthodont Soc. 2018: In print.
18. Chauhan A. Reliability and validity of cephalometric
superimposition measurements: a comparison of
conventional and computerized cephalometric
analysis software. New Delhi: Centre for Dental
Education and Research, AIIMS; 2017: [Thesis].
19. Meena P. Reliability and validity of cephalometric
superimposition measurements: a comparison of
conventional and computerized cephalometric
analysis softwares using Ricketts superimposition
method. New Delhi: Centre for Dental Education and
Research, AIIMS; 2018: [Thesis].
CHAPTER 27
3D data acquisition and
orthodontic triad
Rajiv Balachandran
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Contemporary digital office equipments and procedures
Laser scanning
‘4D’ imaging
3D Skeletal imaging
Computed tomography (CT)
CT image reconstruction
The properties of a CT image
Cone Beam Computed Tomography (CBCT)
3D digital dental scanners
Contact scanners
Non-contact scanners
Key Points
Introduction
Contemporary orthodontic diagnosis and treatment planning requires
an extensive clinical examination and evaluation of diagnostic
records. Besides routine records, which include plaster study models,
radiographs and photographs,1 three-dimensional (3D) digital
scanning of the face and craniofacial skeleton supported with
advanced software functions can provide more detailed, in depth and
accurate information. 3D information can be of immense value in
considering different treatment options, simulate treatment outcome
and maintain records without using physical storage space.
Recent technologies include 3D imaging of craniofacial skeleton
with low-dose computed tomography (CT), such as CBCT, non-
radiation facial scanning, digital models, virtual treatment planning,
their integration and 3D printing. The focus in orthodontics has
shifted towards analyses of the subject in 3D of space and in function.
The terminology used in 3D imaging is provided in Box 27.1
Box 27.1 The terminology used in 3D imaging
Absorbed It is the measure of energy absorbed by any type of ionising radiation per unit mass of
dose any type of matter. SI unit Gray (Gy), traditional unit rad.
Equivalent It is used to compare biologic effects of different types of radiation on a tissue or
dose organ. SI unit Sievert (Sv), traditional unit rem.
Effective It is used to estimate the risk in humans. SI unit Sievert (Sv).
dose
CCD Charge coupled device
CMOS Complementary metal oxide semiconductors
Frame rate The speed at which individual images are acquired in a CBCT technology
Voxel A voxel is a unit of graphic information that defines a point in three-dimensional (3D)
space. It is a 3D equivalent of a pixel, which is used to define a point in two
dimensional space with its x and y coordinates.
FOV Field of view as to be decided in a CBCT set-up
Precession Orientation of the spinning protons oscillate with a slight tilt from a position
absolutely parallel with flux of external magnet, this tilting of spin axis is called
precession
Larmour The rate or frequency of precession
frequency
DICOM DICOM—Digital Imaging and Communications in Medicine—is the international
standard for medical images and related information (ISO 12052). It defines the
formats for medical images that can be exchanged with the data and quality necessary
for clinical use.4 The Dicom standard was established by the American College of
Radiology and the National Electric Manufacturers Association.
Metadata Metadata are information that describes the image. In any file format, there is always
information associated with the image other than the pixel data. This information
called metadata, and it is stored at the beginning of the file as a header.5
PACS PACS, or picture archiving and communication system, works with DICOM
technology for storage, retrieval and access of medical images. PACS is a
computerised means of replacing the roles of conventional radiological film: images
are acquired, stored, transmitted, and displayed digitally. When such a system is
installed throughout the hospital, a filmless clinical environment results.6
.stl STL (STereoLithography) is a standard file format used for 3D printing. It is created by
3D Systems. This format approximates the surfaces of a solid model with triangles.7
.obj OBJ (or .OBJ) is a geometry definition file format first developed by Wavefront
Technologies. Along with the three-dimensional coordinates this file contains texture,
colour and reflection of the face image which have been scanned.8
Hounsfield The Hounsfield unit (HU) is a quantity commonly used in computed tomography
unit (CT) scanning to express CT numbers in a standardised and convenient form.
Hounsfield units, created by and named after Sir Godfrey Hounsfield, are obtained
from a linear transformation of the measured attenuation coefficients.9
Bundled Software that is sold with a computer or other hardware component as part of a
software package. Bundled viewer for CBCT images is a software supplied with the CBCT
image data for the purpose of viewing and making few measurements.
The workflow in orthodontics can be defined as a sequence of clinical
and laboratory processes through which the goals of orthodontic
treatment can be achieved. A typical sequence of procedures in
orthodontics diagnosis, treatment planning and execution of
treatment involves,
• Clinical case history taking

• Obtaining records
■ Photographs
■ Radiographs
■ Study/working models
• Case analysis
• Appliance design and fabrication in orthodontic laboratory
• Appliance delivery
• Evaluation of treatment
In the past decade, with the introduction of 3D face scanning, CBCT

imaging and intraoral/desktop 3D scanners, the orthodontic clinical
practice has entered into the digital era. These recent digital
technologies have brought a paradigm shift in orthodontic practice by
providing smooth digital workflow from diagnosis to execution of
Contemporary digital office equipments and

procedures2,3(Figs. 27.1 and 27.2)
• 3D face scanning
• 3D scanning of craniofacial skeleton with Cone beam CT
• Scanning of dentition and occlusion (Direct intraoral
scanning/impression/model scanning of dental arches
• Virtual patient creation by integration of these technologies
■ Analysis of digital models of the dental arches
■ 3D cephalometry
■ 3D orthodontic VTO
• Virtual treatment planning and dental set-up
• Appliance design and fabrication
• Treatment execution
■ Customisation of brackets
■ Robotic wire bending
■ 3D printing of models and clear aligners
• Monitoring treatment
FIGURE 27.1 Contemporary clinical orthodontics.
FIGURE 27.2 Comprehensible digital orthodontics.

Evaluation of treatment changes.
The 3D evaluation of facial soft tissue morphology is vital in the
orthodontic practice. Face can be scanned with radiation methods
with MDCT or alternatively and preferably methods which allows 3D
topography evaluation but without hazards of the X-rays. Several
attempts have been made in the past to measure the 3D complexity of
the human face, which includes stereophotogrammetry, image
subtraction technique, laser scanning, light luminance scanning and
video systems.10 Recent advances in computer technologies have
made 3D facial scanning accessible in day-to-day clinical practice.
Laser and stereophotogrammetry surface imaging are widely used in
medical/dental fields.11,12
Laser scanning
Laser scanning systems have been widely used in anthropometric
studies. The first laser scanning system for routine clinical use was
introduced by Moss et al.13 in 1991. The major drawbacks of laser
scanning systems are longer capture duration (8–10 s), lack of ability
to record soft tissue texture, and need for safety of eyes during
scanning, which may interfere with natural facial expression.14
Stereophotogrammetry is a method that utilises means of
triangulation and using two cameras in stereo configuration for
recording depth, to create 3D face image. The main advantages of this
method are14,15
1. Rapid image capture

2. Excellent surface texture, therefore
3. Accurate landmark identification
Commercially available 3D facial imaging systems are:
1. 3dMD
2. Axis three
3. Di3D
4. Genex
5. 3D-shape
6. Canfield Scientific Vectra 3D
7. Fuel 3D
8. Motion View Facial Insight 3D
3dMD is a 3D medical imaging system. It is available in various

modules for different body parts. 3dMD face analysis system can
capture facial contours in 180–200 degrees from ear to ear in the ultra-
fast speed of fewer than 1.5 ms that means cameras can record the
images unaffected by the movement, which is unavoidable in children
(Fig. 27.3).
FIGURE 27.3 3D photograph of the face courtesy 3dMD. Source:
Metzger TE, Kula KS, Eckert GJ, Ghoneima AA. Orthodontic soft-tissue
parameters: a comparison of cone beam computed tomography and
the 3dMD imaging system. Am J Orthod Dentofacial Orthop
2013;144(5): 672–81. PubMed PMID: 24182583.
The system work through two modular units of six machine vision
cameras and an industrial-grade flash system synchronised in a single
capture. The geometric accuracy of the 3dMD system is <0.2 mm root
mean square (RMS) or even better depending upon the mode with 3D
image rendering speed of 7–9 s. It automatically generates a
continuous 3D polygon surface mesh with a single x, y, z coordinate
system from all synchronised stereo pairs. The 3dMD software
automatically maps all of the colour information to the mesh. The
system accurately documents the patient’s natural head position and
multiple facial expressions noninvasively during various stages of
treatment cycle.16
In medical as well as the dental field, the 3dMD System is now
considered the standard reference system for 3D anthropometric
analysis. The system has been used to study the growth of the face, to
evaluate treatment changes, the outcome of surgical treatment and
modifications of face with ageing.
‘4D’ imaging
The assessment of facial soft tissue structures has traditionally relied
on the 2D static photographs and video techniques. The 3D method of
evaluation face has been introduced recently for this purpose.
The assessment and quantification of facial muscle movements are
critical for diagnosis, surgical treatment planning and evaluation of
surgical outcome in patients with facial deformities such as cleft lip
and palate. For this purpose, the motion capture
stereophotogrammetry systems were introduced. Four-dimensional
(4D) facial imaging can be defined as a time sequence of 3D models of
facial animations.17
The 4D technology acquires accurate 3D surface information at
approximately 60 frames per second from various coordinated
standpoints for up to a 10-min acquisition long resolution cycle.18 The
commercially available 4D imaging systems are
1. 3dMDfaceTM dynamic system (3dMD, Atlanta, GA)

2. 4D capture system (DI3DTM, Dimensional Imaging, Glasgow
3D Skeletal imaging
Computed tomography (CT)
CT: The first CT scanner was invented by Sir Godfrey N. Hounsfield
in 1967, an engineer at British EMI Corp. Since the invention of first
CT, the CT technology has evolved in four generations and lately the
MDCT has been evolved to facial structures as Cone Beam CT.
The first generation scanner gantry consists of one detector
mounted on side and X-ray tube on the opposite side and fixed rigidly
together. The collimated X-ray beam of pencil width was used. The
size of beam used was 3 mm width (in right to left direction) and
13mm of slice thickness (z axis, head to toe direction). It is this beam
width in z-axis that typically specifies the slice thickness to be imaged.
The tube and detector scan the image slice-by-slice, as stacked slices in
axial direction, using narrow X-ray beam. There are two basic
movements of gantry while scanning the image:
1. Translation
The linear motion of tube and detector from left to right to scan a
single axial slice
2. Rotation
Rotation of gantry to scan same axial slice from different angle
This combination of linear translation and rotation is called

translate-rotation movement. The data collection from these translate-
rotation movement was accomplished in 5–6 min.19
Imagine a subject skull cut into thin slices of same thickness in axial
direction from head to neck and stacked over one another to create a
3D skull. By obtaining the image information of each such a slice and
stacking it over one by one in an orderly manner will give us the 3D
image of the skull.
CT image reconstruction
Hounsfield envisioned that each such scanned slice composed of 3D
tissue voxel (Fig. 27.4) with the attenuation coefficient of µ. This is
called as reconstruction matrix.
FIGURE 27.4 (A) 3D square represented by isotropic voxels a,

represents that all dimensions of the voxel are same. (B) 3D
rectangular voxels seen in conventional CT a,b, represents that the
dimensions of the voxel are unequal.
The X–Y axes are within the axial plane and Z direction is along the
axis of the subject, which is the direction of X-ray tube movement.
The reconstruction matrix: The number of rows and columns, and
area of the slice to be imaged, determine the voxel size. The objective
of CT image reconstruction is to determine how much attenuation of
the narrow X-ray beam occurs in each voxel of the reconstruction
matrix. When the X-ray with intensity of No is passed through the
image slice, the tissues in the path attenuate the X-ray beam and when
it reaches the detector the intensity is Ni. Ni is the total sum of
attenuation values by the voxels along path of X-ray.19,20
For example, consider a simple 2×2 matrix as shown in Fig. 27.5.
When this object is scanned from 0, 45, 90, 135 degrees the sum of
attenuation values from the different paths composed of various
combinations of these four voxels. This can be written as an algebraic
equations
FIGURE 27.5 2X2 reconstruction matrix.

By solving the equations algebraically the four unknowns, µ11, µ12,
µ21, µ22 (attenuation value of each voxel), can be calculated. This is
called iterative algorithm, which was originally used by Hounsfield.
Using larger reconstruction matrix and computer power more
detailed information of inner anatomical structures with small voxel
size can be obtained. The first CT machine utilised 80 × 80 matrix to
keep reconstruction time reasonable. Since then the X-ray sources,
acquisition geometries, and detectors have been rapidly evolved. Also
various reconstruction algorithms are introduced. Current CT
machines use filtered back projection reconstruction algorithm.
The properties of a CT image

The CT numbers (in Hounsfield unit, HU) are calculated from these
attenuation values, u, of each voxel from the earliest days of CT
imaging. The formula used for CT number calibration is
In this equation, uvoxel is voxel attenuation coefficient of the tissue

voxel, uwater is the attenuation coefficient of water, and K is an integer
constant. The original Hounsfield scanner had the K value of 500, but
later it was standardised as 1,000. The proper X-ray generator
calibration is important for accurate and reproducible CT numbers
since the attenuation coefficients are affected by X-ray beam energy.
Recent CT scanners determine the uwater value by periodic calibration
scanning of water.19
Cone Beam Computed Tomography (CBCT)

The basic principle of CBCT is same as conventional CT. However, the
geometry, detector and reconstruction algorithm are different from
the CT scanning. In CBCT systems the X-ray beam forms a conical
geometry in contrast to conventional fan-beam geometry in
conventional CT. In CBCT scanning Flat panel detector (FPD) is used
in contrast to multiple-row detectors in MDCT. The most frequently
used reconstruction algorithm in CBCT is a modified Feldkamp
algorithm. The Feldkamp algorithm is a 3D adaptation of the filtered
backprojection method used in conventional CT. The major difference
between CBCT and MDCT is the isotropic nature of acquisition and
reconstruction.19,20 Box 27.2 helps in understanding the major
differences between CT and CBCT technologies and their own uses
accordingly.
Box 27.2 Differences between CT and CBCT

technologies
CBCT technology CT technology
Type of Cone shaped Fan shaped
beam
Scan Rapid scan time (10–70 s) More scan time, it takes some minutes for
time a scan to complete
Dose Range 5–1073 µSv Range: mandible 761–3324 µSv; maxilla
104–1202 µSv
Artefacts There is more noise and movement artefacts Inferior as compared to CBCT
compared to CT, lesser metal artefacts
compared to CT
Soft Poor soft tissue contrast It has bone and soft tissue windows,
tissue making useful for determining various
soft tissue details
3D digital dental scanners

3D digital scanners are used to create a digital map of the 3D surface
of an object. There are two main categories of 3D surface scanners21:
1. Contact scanners
2. Non-contact scanners
Contact scanners
The contact scanners map the surface of an object through physical
touch using probe like instruments. The coordinate measuring
machine is an example for contact scanners, in which the measuring
probe is designed to move over a surface of the object to determine the
coordinates of the surface points of the object.21
Non-contact scanners
The non-contact scanners use radiation or light source and detect its
reflection or distortion.
Several technologies using different optical components and
structured light sources utilised by 3D digital scanners.21,22
1. 3D laser scanners
2. Photogrammetry
3. Interferometric techniques
4. Structured light method
5. Confocal microscopy
3D laser scanner and Photogrammetry uses the principles of

triangulation to obtain the 3D surface images. Triangulation is a
technique for determining the location of a point by forming triangles
to it from known points.23 A laser beam, object and detector (CCD) are
used to triangulate the point in the 3D object. The sensor records the
incident laser beam on the object to locate the exact position of the
point at which the laser beam hits the object. As the positions of both
the detector and laser source and the angle between them are known,
the position of the surface in 3D space can be determined using
triangulation method. The photogrammetry also uses same
triangulation method, however instead of laser beam it uses serial
photographs of the object.
Interferometry uses the principle of interference to measure the
shape and size of the object. The laser or white light can be utilised for
the purpose. Interference is the phenomenon in which two waves
interact to form a resultant wave of greater, lower or same
amplitude.24 The light of different wavelengths is projected along a
single beam onto the object to be scanned. The interference between
the wavelength will take place depends on the distance between the
source and the object surface, which used to map the surface of the
object in three dimensions.
The structured light method of 3D scanning involves the projection
of a known pattern of the image, often an array of black (dark) and
white (bright) lines or a ‘checkerboard’ of black and white squares,
onto an object say face. By analysing the deformation (warping) of the
known image pattern, we can mathematically reconstruct the surface
virtually.21,25 The structured light method requires a camera,
projector, dark room and object.
Confocal laser scanning microscopy is a technique for obtaining
high-resolution images and 3D reconstruction. Images are taken
point-by-point, line-by-line, or multiple points at once and
reconstructed with a computer, rather than projected through an
eyepiece. In this technique, a laser beam passes through a pinhole
aperture and focused by an objective lens into a small focal area.
Scattered and reflected laser light is then recollected by the objective
lens. The limited detector aperture blocks any light that is not coming
from the focal point. The out-of-focus light is eliminated and results in
a sharper image.4
Examples are 3D intraoral scanners/ model or impression scanner
technologies (Fig. 27.6).
FIGURE 27.6 Common digital imaging technologies.
(A) Triangulation. (B) Parallel confocal imaging. (C) Accordion fringe
interferometry. Source: van der Meer WJ, Andriessen FS, Wismeijer D,
Ren Y. Application of intraoral dental scanners in the digital workflow of
implantology. PLoS One. 2012;7(8):e43312.
The 3D triad in orthodontics

Accurate information of soft facial tissue, facial skeleton and dentition,
can be referred as a triad, is key to comprehensive records. The
important role of 3D imaging modalities in the virtual orthodontic
diagnosis, treatment planning and treatment evaluation is undeniable.
The 3D information about soft tissue face, dentition and craniofacial
skeleton obtained through three different sources, i.e. face scanner,
intraoral scanner and CBCT can be intimately integrated to give a
comprehensive information for total analysis. This integrated system
is called orthodontic triad.5
When these 3D technologies are combined using 3D software
programmes, the orthodontic/surgical planning can be performed
digitally. The integrated approach using these 3D data not only
provides a smooth digital workflow in orthodontics but may also offer
reduced errors related to materials, appliance fabrication and operator
skills.6
The combined virtual patient model consists of CBCT reconstructed
skeletal structures, with superimposed textured soft tissue surface
from a 3D face scan, and dental structures obtained from 3D dental
scanner. One of the potential areas for 3D integration in treatment
planning and simulation is orthognathic surgical planning. Using
various commercial software programmes, 3D virtual planning and
simulation of the proposed surgical plan can be performed multiple
times. 3D virtual planning using CBCT data requires fusion of digital
dental cast for good representation of dental surfaces since the CBCT
suffers from scattering artefacts or metallic artefacts at the occlusal
level. Incorporation of digital models into the CBCT image provides
adequate accuracy of dentition for final splint generation at the end of
virtual orthognathic surgical planning. Several procedures have been
introduced for integration of 3D models into the CBCT data.7–9,26
Apart from the 3D face scan 2D face photographs can also be used for
the creation of the virtual head of the patient using 2D photo wrap
function is a function feature of software programmes (Fig. 27.7).
FIGURE 27.7 The 3D integration of CBCT data of face, digital

model obtained from 3D model scanner and 2D face photograph
wrapped over the CBCT image for orthognathic surgical
simulation (Dolphin Imaging and Management Systems,
Chatsworth, CA).
Key Points
For more than a century orthodontic community has strived for 3D
assessment of patient facial structures to support the clinical
examination. With the technological advancement in imaging
technology and digitisation, now it is possible to produce integrated
3D virtual patient face model.
It is proven that 3D imaging and 3D image fusion provide
advantages over the conventional methods for diagnosis, treatment
planning, appliance design and fabrication, and treatment follow-up.
The advanced technology which not only requires high investment
also has downside on radiation hazards of CBCT. Therefore the
judicious use technology is proposed.
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craniofacial anthropometric measurement of 3D
digital photogrammetric images. Cleft Palate Craniofac
J. 2008;45(3):232–239: May; PubMed PMID:;1;
18452351.
12. Sykes JM, Amin SH, Hatcher DC, Kim J. 3D analysis
of dentofacial deformities: a new model for clinical
application. Facial Plast Surg Clin North Am. 2011
Nov;19(4):767–771: x. doi: 10.1016/j.fsc.2011.08.001.
Review. PubMed PMID:;1; 22004866.
13. Moss JP, Coombes AM, Linney AD, Campos J.
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with asymmetry of the face. Proc Finn Dent Soc.
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14. Gwilliam JR, Cunningham SJ, Hutton T.
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dimensional facial scans. Eur J Orthod.
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15. Ayoub AF, Wray D, Moos KF, Siebert P, Jin J, Niblett
TB, Urquhart C, Mowforth R. Three-dimensional
modeling for modern diagnosis and planning in
maxillofacial surgery. Int J Adult Orthodont
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JD, Wales C, Ayoub AF. The clinical application of
three-dimensional motion capture (4D): a novel
approach to quantify the dynamics of facial
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2014;43(7):907–916: Jul; Epub 2014 Feb 28. PubMed
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18. Temporal-3dMD systems (4D) 3dMD [Internet] [cited
2017 Mar 14]. Available from:
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surface-motion-capture-4d/.
19. Goldman LW. Principles of CT and CT technology. J
Nucl Med Technol. 2007;35(3):115–128: Sep; quiz 129-
30. Review. PubMed PMID:;1; 17823453.
20. Miracle AC, Mukherji SK. Conebeam CT of the head
and neck, part 1 physical principles. AJNR Am J
Neuroradiol. 2009;30(6):1088–1095: Jun; Epub 2009
May 13. Review. PubMed PMID:;1; 19439484.
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Wenger N, Barbour ME, Alemzadeh K, Zhang L,
Sandy JR. 3D surface imaging in dentistry – what we
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22. Taneva E, Kusnoto B, Evans CA. 3D scanning,
imaging, and printing in orthodontics. In: Bourzgui
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23. Triangulation. In: Wikipedia [Internet]; 2017 [cited
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949086 Epub 2012 Sep 23. PubMed PMID:;1;
CHAPTER 28
3D digital models
O.P. Kharbanda
Rajiv Balachandran
CHAPTER OUTLINE
Introduction
Indirect scanners (impression/model scanners)
Desktop scanners
CT based scanner
Coordinate system
ABO method of orientation of digital models
Anterior orientation of maxillary model
Levelling the maxillary occlusal plane
Quantitative measurements
Visual analysis of the occlusion and analysis of occlusal
contact area
Virtual set-up
3D surgical planning and splint generation
Evaluation of treatment changes
Key Points
Introduction
E-models (Fig. 28.1) are three-dimensional (3D) digital mod-els that
help to eliminate the need for traditional plaster models in
orthodontic practice.1 The digital models can be acquired through
scanning the objects, that is teeth and gums either directly in mouth
through use of intraoral scanners or indirectly by scanning the
impression or the plaster study models on a desktop scanner.
FIGURE 28.1 Virtual study models using Maestro three-

dimensional (3D) scanner.
There are essentially three different technologies to produce digital

models:
1. Intraoral scanners
2. Impression/model scanners
3. 3D CT-based uses alginate/rubber base impressions of the
dental casts.
E-models definitely offer great advantage of speed and accuracy

inherent to the 3D digital technology, however it comes with an
attached cost and maintenance of sophisticated equipment (Box 28.1
and Box 28.2).
Box 28.1 Advantages of E-models

Digital models deliver significant benefits that leverage the power of
digital technology to advance the practice of orthodontics.
1. E-models eliminate the production, storage and archiving costs

of plaster models, freeing up the physical space and allow
online digital file storage with 24-h access.
2. They eliminate the geographic barriers of plaster models and
paper files for multiple site practices and empower dental
professionals with access via the Internet from any location.
3. Digital models allow easy and seamless communication
between orthodontists, general dentists, oral and maxillofacial
surgeons, and patients and therefore facilitate comprehensive
interdisciplinary treatment planning.
4. Most of the digital models viewing software include analytical
tools to facilitate quick and easy measurements of teeth and
arch length.
5. As E-models can be measured directly on the screen, this is
time-saving, and therefore enhances the efficiency in
orthodontic diagnosis, treatment planning and patient
education processes.
6. The orthodontist can use the 3D virtual model of teeth and then
plot the precise individual tooth movements for the entire
course of treatment.
Box 28.2 Disadvantages of E-models

Digital models have some inherent problems:
1. Digital models are technique sensitive as the whole procedure of

making the E-models depends upon the proper scanning of the
teeth and adjacent hard and soft tissues. There should be no
vibration or shaking of the hand while scanning and also there
should be no patient movement. Although this may not apply
to 3D CT-based methods, time lost in transporting impressions
and resultant distortion could be a contributor to inaccuracy if
not taken care of. Current technology has to a great extent
taken care of some of the issues outlined above.
2. A personal touch or feel is absent with the use of digital models.
A digital image can only be seen on a computer or printed on
paper. There are no actual study models.
3. Conventional study models made from plaster are better
appreciated as these can be seen and felt by the patient.
4. With digital models, there are chances of data loss as all the
information is stored on the computer.
The virtual models are becoming more prevalent in recent days2,3 and
are likely to eliminate the plaster and impressions from clinical
practice. Duret first introduced the concept of scanning dental arch in
1973.4 The first orthodontics scanning system was developed by
OrthoCADTM (Cadent, Carlstadt, NJ, USA) in 1999 and followed by E-
modelsTM (Geodigm Corp., Chanhassen, MN, USA) in 2001.5
The digital scanner can work by either by a direct or an indirect
method. The direct method involves using an intraoral scanner to
capture the 3D data directly in the patient’s mouth for obtaining 3D
models. Indirectly, digital models can also be obtained by scanning
alginate impressions and plaster models with a desktop scanner or
computed tomography (CT) imaging technology.
The first 3D intraoral scanner was introduced by CEREC 1
(Siemens, Munich, Germany). It was based on the technology using an
infrared camera and optical powder (titanium oxide powder) on the
teeth to create a 3D model. With the advancement of the technology,
recent scanners do not require powdering method for scanning. The
advantages of direct method are6:
1. Convenient for patients with a gag reflex

2. Cleft lip and palate subjects
3. Patients with risk of aspiration and respiratory distress during
taking of the dental impressions
There are more than 10 intraoral scanners that are in use in

dentistry. Few commercially available systems are:
1. iTero™, Cadent Inc., Carlstadt, USA

2. CEREC AC Bluecam, Sirona, Bensheim, Germany
3. Lava™, 3M ESPE, St. Paul, USA
4. Trios – by 3SHAPE A/S (Denmark)
5. Lythos™, Ormco Corporation
6. CS 3500, Carestream
7. PlanScan® marketed by Planmeca
Intraoral scanners use most advanced technology for 3D scanning of
an object by using either white light or Laser light, which when
reflected is captured back through a device. The intraoral scanners are
based on different optical technologies, such as confocal microscopy,
optical coherence tomography, active and passive stereovision and
triangulation, interferometry and phase shift principles7 (Fig. 27.6).
Based on algorithms, tens or hundreds of thousands of measurements
are taken per inch, resulting in a 3D representation of the object’s
shape.8
The intraoral scanners help the patient and orthodontist by
providing flawless digital workflow in clinical practice from scanning
to virtual treatment planning, and the issue of appliances.9 iTero
intraoral scanner operates on the principle of parallel confocal
imaging to produce powderless digital impression. The iTero Element
scanner system consists of:
1. High definition multi-touch 19 in. display screen

2. Scanner sleeve
a. Blue protective sleeves—protects the lens when not
in use
b. Disposable sleeves for single patient use
3. Wand
a. The video camera in the wand contains the laser
light source, the focusing motor and analogue to
digital converters.
The latest iTero Element scanner is capable of capturing 20 scans

per second with a scan capture time of 40–50 ms. A mean time is taken
in making upper and lower scanner impression and recording the bite
is 11 min 58 s with the range of 6–18 min.10
Steps of taking a complete scan with the hand-held scanner is given
in Flowchart 28.1, (Fig. 28.2).9
FLOWCHART 28.1 iTero® ElementTM scanner scanning Protocol for
Invisalign®
FIGURE 28.2 Intra oral scanner.

(A–B) Intra oral scanner. (C) Scanning procedure. (D) Digital model of
scanned lower arch.
Indirect scanners (impression/model
scanners)
The indirect scanners are scanners, which creates 3D digital models
from impression or plaster model. A 3D scanner consists of a light
source, one or more cameras, and a motion system supporting several
axes for positioning the scanned object towards the light source and
camera(s).
Desktop scanners (Fig. 28.3)
FIGURE 28.3 (A) Maestro desktop scanner. (B) Projection of
structured light pattern over the study model.
To make E models, the orthodontist/laboratory uses 3D images that

are recorded through laser scanner.11,12 This laser scanner uses a
flashing white light, much like a video camera that digitally maps the
teeth or plaster models into precise, high-resolution, 3D electronic
records. These pictures of teeth are sent to the computer to build a
complete impression model of the patient’s teeth and are stored on the
computer’s hard disc, which can be assessed like any other digital
picture. The models are viewed as 3D images on the screen and are
relatively accurate in dimension. The E models can be transported as
graphic files from one orthodontist to another, and to the patients or
can be put on the web. Table top scanners also produce e-models from
dental impressions. For accuracy, rubber base impression is preferred
over alginate impression.
CT based scanner
In this method, the rubber base impressions and bite of a patient are
transported in a special tray to an industrial scanner that works like a
CT scan of the skull. Highly sophisticated software functions are used
to construct a 3D image of the dentition/oral structures. The artistic
portion of the models is then superimposed for presentation and
aesthetics. These models can be viewed from all possible views on the
computer screen. ‘OrthoProof’ of Holland utilises this method.13 This
service is commercially available in Europe, USA and Australia. E-
Models have dimensional accuracy, high resolution and great life like
clarity.
Few commercially available 3D desktop scanners are
1. Ortho Insight 3D™ (Motion View Software, LLC, Chattanooga

TN)
2. R series, 3 Shape (Copenhagen, Denmark)
3. Maestro 3D (AGE Solutions, Piza, Italy)
3D scanners allow scanning of study models without the need for a

base. The accompanying software programmes allow the creation of
virtual base from the 3D virtual base library (Fig. 28.4).
FIGURE 28.4 Creation of virtual base in Maestro 3D Dental Studio
Viewer.
ABO 2013 base specification is used in this model.
Orientation digital model is necessary for repeatable measurements.
In 3D space, X, Y and Z axes and origin (0, 0, 0) have to be defined to
quantify the changes in 3D.
Coordinate system
Choi et al.14 suggested the coordinate system for the 3D virtual model.
The X–Z horizontal plane is parallel to the occlusal plane constructed
by bilateral mesiobuccal cusp tips of the first molars and the midpoint
of the central incisors. Which includes the origin (0, 0, 0), which is the
junction of the incisive papilla and palatine raphe. The X–Y sagittal
plane, which is perpendicular to the horizontal plane, is made up of
the origin point and one arbitrary point on the mid-palatal suture. The
Y–Z frontal plane is the section inclusive of the origin and
perpendicular to both the sagittal and the horizontal planes. The
measuring points were the midpoint on the edge of the upper central
incisors and the mesiobuccal cusp tips of the upper first molars (Fig.
28.5).
FIGURE 28.5 Digital model orientation according to Choi et al.

The X-Z, X-Y and Y-Z planes are defined on the virtual models.
ABO method of orientation of digital
models (Fig. 28.6)15
FIGURE 28.6 Digital model orientation according to American

Board of Orthodontics.
The digital model orientation is defined relative to the world

coordinate system. The orientation of the model set is achieved
relative to the maxilla.
Anterior orientation of maxillary model

The origin (0, 0, 0) is defined as the intersection of mid-sagittal (Y–Z)
and occlusal (X–Y) planes at a point that lies approximately half-way
between the most anterior and most posterior teeth. The x, y and z-
axes are defined as
When patient is in standing position
1. X axis is left to right

2. Y axis is posterior to anterior
3. Z axis is inferior to superior
Levelling the maxillary occlusal plane
The maxillary occlusal plane should coincide with the X–Y plane
(transverse plane or axial plane). This is done visually such that the
first and second bicuspid cusp tips and first molar cusp tips are, on
average, equidistant vertically from the reference lines.15
1. Quantitative measurements
2. Visual analysis of the occlusion and analysis of occlusal contact
area
3. Virtual set-up
4. 3D surgical planning and splint generation
5. Evaluation of treatment changes
Quantitative measurements (Fig. 28.7)

FIGURE 28.7 Tooth width and arch length measurements on
virtual models using Maestro 3D Dental Studio Viewer.
3D digital models can be used to measure linear, angular and

volumetric measurements using the accompanying software. A
systematic review by Fleming et al.16 performed a systematic analysis
of the literature on the validity of digital models for transverse
measurements, and linear measurements include; tooth size; Bolton’s
ratio; arch length and crowding; irregularity index; inter-arch occlusal
features; occlusal indices; and time taken to perform measurements.
They concluded that digital models offer a high degree of validity
when compared to direct measurement on plaster models; differences
between the approaches are likely to be clinically acceptable.
Akyalcin et al.17 evaluated the accuracy of 3D digital models
acquired from an intraoral scanner compared with both manual and
cone beam CT measurements of the same dental anatomy. Digital
models from the direct digital acquisition of the dental structure were
near perfect to the manual method and superior to the CBCT
measurements.
Luu18 performed a systematic review of the literature to assess the
reliability and validity of linear measurements using virtual vs. plaster
study models. The authors stated that ‘Virtual study models are
clinically acceptable compared with plaster study models with regard
to intrarater reliability and validity of selected linear measurements’.
Another systematic analysis by Rossini et al.19 showed that digital
models are as reliable as traditional plaster models, with high
accuracy, reliability and reproducibility.
Using accompanying bundled software 3D digital models can also
be ‘sliced’ into layers in any preferred orientation plane to reveal the
surface contours of the dental anatomy (Fig. 28.8).
FIGURE 28.8 Cross-section measurements (Maestro 3D Dental

Studio Viewer).
Visual analysis of the occlusion and analysis

of occlusal contact area
The accurate identification and quantification of occlusal contacts is
one of the critical factors in defining optimal occlusion. Conventional
methods utilise articulating paper, shim stocks and wax bites for
identification of occlusal contacts. 3D digital models provide 360°
view of inter-cuspal relations, which is not possible in clinical and
conventional methods. Also using recent software the cusp-to-cusp
and cusp-fossa relation can be visualised as a colour coded map. Jang
et al.20 and Lee et al.21 showed a method for evaluation of occlusal
contact area of Class I and Class II subjects using 3D scanned model
and specialised software (Fig. 28.9).
FIGURE 28.9 Occlusal inspection (Maestro 3D Dental Studio

Viewer).
Virtual set-up
The study models provide information on the tooth dimensions, arch
length discrepancy, occlusal relationship and asymmetry evaluation.
Traditionally plaster were used for the simulation of a treatment plan.
In 1956, Kesling22 suggested the ‘Diagnostic Set-up’, in which each
tooth is separated at its base and proximal contacts and repositioned
in duplicate study models to simulate the treatment. However, this
setup involves complex laboratory procedures and is time consuming.
As an alternative to the traditional method, virtual setup was
introduced in the last decade. The virtual setup is less time consuming
than the traditional plaster model based set-up. Also, the virtual setup
can be more accurate since there is no loss of tooth material during the
separation of teeth by cutting through the plaster models (Fig. 28.10).
FIGURE 28.10 Virtual set up and aligner fabrication (Maestro 3D

Dental Studio Viewer).
Steps in virtual method
1. Creation of 3D virtual model using direct or indirect scanner

2. Creation of virtual base
3. Tooth segmentation for virtual alignment. The segmentation
process is equivalent to cutting process in the conventional
method. The segmentation is a semiautomatic method, which
is carried out by marking mesial and distal points on each
tooth. Then the software defines the cutting line for each tooth,
which can be manually corrected.
4. After segmentation, the desired tooth movement is done using
software tools.
5. The applied tooth movement can be quantified and visualised
during the virtual setup process and, when required, tooth
movement can be easily reversed.
6. Also dental arch expansion, interproximal reduction and teeth
extraction can be evaluated in a virtual setup multiple times.
The advantages of virtual setup over conventional methods are:
1. It is less time consuming

2. Accurate
3. The planned teeth movement can be visualised and measured
in virtual setup using superimposition method
4. If the planned treatment is not accepted, an alternate plan can
be made within minutes
5. The final virtual setup can be used to gradually move the teeth
into the planned position by fabricating series of aligners from
a series of 3D printed models23
3D surgical planning and splint generation

The 3D virtual surgical planning involves virtual osteotomies,
repositioning of skeletal structures and surgical splint fabrication
using 3D printing technology. Dental anatomy from the CBCT image
may not be accurate enough for splint fabrication due to the presence
of artefacts. Virtual 3D models can be used for this purpose to
overcome this problem. Scanned models can be incorporated into the
CBCT image using image fusion techniques available in various 3D
imaging software. The precise overlapping of 3D models and
corresponding anatomic structures in CBCT image can be achieved
(Fig. 28.11).
FIGURE 28.11 3D surgical planning and splint generation

Dolphin (Dolphin Imaging and Management Systems, Chatsworth,
CA).
Once the final treatment simulation was done the surgical splints
can be generated from these virtual models for surgical procedures.24
Evaluation of treatment changes

Traditionally the dental changes have been evaluated using lateral
cephalogram superimpositions in anteroposterior direction only. The
evaluation of 3D dental changes requires sophisticated 3D imaging
techniques and methods.
On the other hand, the 3D digital models can be used to evaluate
the intra-arch and inter-arch changes from orthodontics, surgical and
growth modification procedures in 3D space by the superimposing
two or more digital models.
The digital models paved the way to analyse the spatial changes in
three planes for each tooth within each dental arch. For the
cephalometric superimposition, we need a stable structure, which is
not affected by growth and treatment. Similarly, the 3D
superimposition of digital models requires a stable reference area.
Several studies have evaluated the palatal rugae as a reference area for
3D digital model superimposition.14,25–27 Superimposition of dental
casts involves scanning of pre and post treatment models followed by
superimposition using stable landmarks, at least three, in palatal
rugae area (Fig. 28.12).
FIGURE 28.12 3D superimposition of digital models using

landmarks on palatal rugae area (Maestro 3D Dental Studio
Viewer).
Key Points
Digital 3D models complement the orthodontic diagnosis and
treatment planning through computerised treatment simulations of
virtual models or/and in combination with the other 3D imaging
modalities like CBCT, 3D face scan. With technological advancement,
reduced operational cost and improved efficiency, 3D scanners will
replace the conventional plaster based models.
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CHAPTER 29
Three-dimensional imaging in
orthodontics
O.P. Kharbanda
Sunil D. Kapila
Rajiv Balachandran
CHAPTER OUTLINE
Introduction
Basic concepts and terminologies in radiology
Electromagnetic radiation
Principles of radiation safety and protection
Units of measuring radiation
Evolution, historical perspective and limitations of two-
dimensional imaging in orthodontics
Panoramic radiographs
Intraoral radiographs
Digital radiography
3D imaging in medicine and dentistry
Fundamental principles of CT and CBCT
Field of view
Image artefacts
Diagnostic assessments
TMJ assessment
Airway
Craniofacial morphometrics and cephalometry
Orthodontic treatment planning
Assessment of treatment outcomes
Imaging goals and protocols
Limitations of CBCT
Ultrasonography
Magnetic resonance imaging
Research and recent advances in 3D orofacial imaging
Virtual models
Indirect bonding of brackets, computer-aided bracket
design and wire bending
Virtual orthodontic patient
Key Points
Introduction
Radiology has long played a critical role in orthodontic diagnosis,
treatment planning, treatment simulation and assessment of treatment
progress and outcomes. The field of radiology emerged and
developed manifolds to improve diagnosis by incorporating various
other modalities, which involved non-radiation sources and
techniques.
Basic concepts and terminologies in
radiology
The word ‘radiation’ has originated from the Latin word ‘radius’,
which describes the phenomenon of different forms of energy that are
produced by a source and progresses in circles. Radiation may occur
in two forms: particulate and electromagnetic.
Electromagnetic radiation
It is the movement of energy through space as a combination of
electric and magnetic fields. X-rays are electromagnetic radiations,
which are produced extra-nuclearly from the interaction of electrons
with large atomic nuclei in X-ray machines. They usually have a
wavelength approximately between 10–1 and 10–2 nm (Fig. 29.1).
FIGURE 29.1 Line diagram showing various wavelengths and

frequencies of different radiation sources.
Radiation has both direct and indirect effects on the living system.
When the energy of the photon or secondary electrons ionises
biological macromolecules, the effect is direct.
Alternately, an indirect effect is when a photon may be absorbed by
water in an organism resulting in the production of free radicals,
which in turn produce changes to the biological molecules.1
Radiation-related injuries in any organism are primarily of two
types
1. Deterministic effects. This term implies that the radiation

damage occurs and that the damage is dependent on the
amount of radiation received. These include changes in the
blood count, hair loss, tissue necrosis, or cataract.
2. Stochastic effects. Here, the probability of suffering from a
disease caused by radiation is proportional to the amount of
radiation received years before. Examples include cancer or
leukaemia.
Principles of radiation safety and
protection
The sources of radiation are of two major types:
1. Natural radiation. These could be derived from cosmic sources

and terrestrial sources, which include radioactivity from soil
and radioactive decay products of uranium. The other sources
include radon, which by itself is a decay product in the
uranium series.
2. Man-made sources. The major bulk of it includes the medical
diagnostic and treatment sources. The other sources include
consumer and industrial products, nuclear science research,
mining and nuclear accidents.
Units of measuring radiation

a. Absorbed dose. It is the measure of energy absorbed by any
type ionising radiation per unit mass of any kind of matter.
Systeme Internationale (SI) unit is Gray (Gy), traditional unit is
rad.1
b. Equivalent dose. It is used to compare the biologic effects of
different types of radiation on a tissue or organ. SI unit is
Sievert (Sv), traditional unit is rem.1
c. Effective dose. It is used to estimate the risk in humans. SI unit
is Sievert (Sv).1 The effective doses of various techniques,
which are used during the oral radiographic examination and
from other natural sources are given in Table 29.1.
Table 29.1
Radiation doses from various sources of X-rays from dental to some natural1
Dental/natural Effective dose/exposure
Dental
Intraoral periapical (IOPA)2 10 µSv
Full mouth survey (IOPA)3 35 µSv
Cephalometric4 3–6 µSv
Panoramic5 9–26 µSv
Various skull views6 220 µSv
CT (maxilla)7 104–1202 µSv
CT (mandible)7 761–3324 µSv
CBCT effective doses for any Adult Large FOVs 46–1073 µSv
protocol7 Medium FOVs 9–560 µSv
Small FOVs 5–652 µSv
Child Large or medium 13–769 µSv
FOVs
Small FOVs 7–521 µSv
Natural
Natural background radiation 8 µSv
Air travel from London to New York8 51 mrem per 100 block
hours
Air travel from New York to Chicago9 39 mrem per 100 block
hours
Air travel from Athens to New York9 63 mrem per 100 block
hours
Air travel from Los Angeles to Honolulu9 26 mrem per 100 block
hours
Evolution, historical perspective and
limitations of two-dimensional imaging
in orthodontics
Broadbent in USA and Hofrath in Germany independently yet in the
same year 1931 introduced traditional cephalometry. Roentgeno-
cephalometry the standardised 2D X-ray which has been widely used
as a clinical tool and research technique for studying craniofacial
growth and orthodontic treatment.
Limitations of 2D cephalometry. According to Quintero et al., there
are several reasons for limited validity of 2D cephalometry’s scientific
method and its applications, these are:10
1. The conventional head film is a 2D representation of a three-

dimensional (3D) object. The structures are displaced vertically
and horizontally in proportion to their distances from the film
or recording plane.11
2. Cephalometric analyses are based on the assumption of a
perfect superimposition of right and left sides of the mid-
sagittal plane, but this is infrequently observed because facial
symmetry is rare and because of relative image displacement
of right and left sides. Hence accurate assessment of structures
away from the mid-sagittal plane is impossible.11
3. Significant radiographic projection errors are associated with
image acquisition. These include magnification, distortion,
errors in patient positioning and projective distortion inherent
to the film/patient/focus geometric relationships.11,12
4. Manual data collection and processing in cephalometric
analyses have shown to have low accuracy and precision.
Manual tracings of anatomic structures used for cephalometric
analysis incorporates intra- and inter-observer errors.
Conventional analyses utilise linear and angular
measurements defined in a coordinate system that varies
across patients and in longitudinal assessments.11
5. Errors in landmark identification due to lack of well-defined
anatomic outlines, hard lines and shadows, landmark locations
are poorly described in at least one of the planes of space that
depends on head orientation and observer experience.11
Despite these limitations, cephalometric has been widely used, and

many cephalometric analyses have been developed over the years for
orthodontic assessment.
Panoramic radiographs
Panoramic radiography provides broad coverage of the teeth and
surrounding structures. It is an excellent screening tool but not an
exact diagnostic tool. It has many shortcomings related to the size,
location, and form of images created. These discrepancies arise
because the panoramic images are made by creating a focal trough
within a generic form and size.13 Panoramic radiographs can display
distortions when used for assessment of relationships of unerupted
teeth to other teeth, as well as adjacent anatomic structures.
Panoramic images also represent the maxillary sinuses and
temporomandibular joint articulations with distortions, and apart
from gross deformities, it is not the imaging modality of choice to
identify conditions associated with these anatomic structures.
Intraoral radiographs
A limited or full mouth series (FMX) consists of bitewing and
periapical projections. There is controversy of using FMX in
orthodontics due to radiation concerns. Serious consideration should
be given to the cost/benefit ratio that takes into account the
radiographic exposure, diagnostic value, and need for medicolegal
documentation.10
Intraoral radiography also includes occlusal X-rays, which may be
necessary as a supplement to periapical or panoramic radiography to
assess unerupted teeth, such as impacted canines, supernumerary
teeth (e.g. mesiodens).
Limited area projection images such as bitewing, periapical and
occlusal X-rays provide localised information about the presence, size,
morphology, coronal and periradicular structures of erupted and
unerupted teeth. As the assessment of caries development is essential
before the start of orthodontic treatment and during the treatment,
bitewing radiography is the X-ray modality that provides the most
detailed information regarding coronal dental caries.
Digital radiography
Together, computers engineers, mathematics, and electronics
broadened the scope of radiology to modern digital radiology. Since
the introduction of the first direct digital system in 1987, a variety of
these systems has become available in dentistry in recent years. With
the rapid technological progression in dentistry, digital radiographic
machines have become smaller and portable, and have shown the
comparable resolution to conventional films.
3D imaging in medicine and dentistry

Recent decades have seen the development of computed tomography
(CT), magnetic resonance imaging (MRI), nuclear medicine and
ultrasonography imaging modalities that have revolutionised dental
and medical diagnosis.
MDCT can be defined as the use of the X-ray–based imaging
method to produce 3D images usually displayed in the form of image
slices. The original CT technology, which is used extensively in
medical diagnosis, is designated as medical CT and the newer
modality used primarily in dentistry is cone beam CT (CBCT). The
recent development and application of cone beam imaging in
dentistry provide most of the benefits of CT imaging for many dental
applications at substantial savings of dose and cost.
Fundamental principles of CT and
CBCT
The first clinical CT scanner was introduced by Sir Godfrey N.
Hounsfield in 1967.14 Data acquisition was based on translate–rotate,
parallel-beam geometry wherein pencil beams of X-rays were directed
at a detector opposite the source, and the transmitted intensity of
photons incident on the detector was measured. The gantry then
captures X-ray attenuation data by both translation and rotation.
Although X-ray sources, acquisition geometries and detectors have
rapidly evolved since Hounsfield’s original scanner, the theory behind
CT has not changed15 (Figs 29.2 and 29.3).
FIGURE 29.2 Rotating type of anode is used in CT and CBCT

machines for better dissipation of heat produced.
FIGURE 29.3 Comparison of basic functioning difference between (A)
CT and (B) CBCT technologies.
CT scanners can be divided into two categories based on acquisition
X-ray beam geometry, namely, fan beam and cone beam.15 In fan-
beam scanners, an X-ray source and solid-state detector are mounted
on a rotating gantry. Data is acquired using a narrow fan-shaped X-
ray beam transmitted through the patient. The patient is imaged slice-
by-slice, usually in the axial plane, and interpretation of the images is
achieved by stacking the slices to obtain multiple 2D
representations.16 The linear array of detector elements used in
conventional helical fan-beam CT scanners is a multi-detector array.
This configuration allows multi-detector CT (MDCT) scanners to
acquire up to 64 slices simultaneously, compared with single-slice
systems thereby allowing generation of 3D images at substantially
lower doses of radiation than single detector fan-beam CT arrays.16
Current cone beam machines scan patients in three possible positions:
(i) sitting, (ii) standing and (iii) supine. The four components of CBCT
image production are: (i) acquisition configuration, (ii) image
detection, (iii) image reconstruction and (iv) image display.17
Imaging in CBCT is accomplished by using a rotating gantry to
which an X-ray source and detector are fixed. The X-ray source and
digital sensor revolve synchronously around rotation fulcrum fixed
within the centre of the region of interest. A divergent cone-shaped
source of ionising radiation is directed through the middle of the ‘area
of interest’ onto an area X-ray detector [Flat Panel (FP)
Detector/CMOS] on the opposite side. During the rotation, multiple
(from 150 to more than 600) sequential planar projection images (base
images) of the field of view (FOV) are acquired in a complete (360°) or
sometimes partial (180°, 270°), arc (Fig. 29.4). This procedure varies
from a traditional medical CT, which uses a fan-shaped X-ray beam in
a helical progression to obtain individual image slices of the FOV and
then stacks the slices to obtain a 3D representation. In helical CT
imaging, each slice requires a separate scan and separate 2D
reconstruction.18
FIGURE 29.4 In CBCT, a complete or partial rotation of gantry
around subject head produces the multiple sequential base
images.
From these base images, volumetric dataset composed of isotopic
voxels is reconstructed by software programmes.
The speed at which individual images are acquired is called the

frame rate and is measured in frames, that is projected images per
second. The maximum frame rate of the detector and rotational speed
determines the number of projections that may be acquired.17
The detector is of two types. An image intensifier tube/charge-
coupled device combination (CCD) or flat panel (FP) imager. The
principal determinants of voxel size in CBCT are the tube focal spot
size, X-ray geometric configuration and pixel size of the detector.
Primary reconstruction. After the basic projection frames have been
acquired, the process of creation of volumetric data set is called
primary reconstruction. The CBCT software handles this process. The
display is the critical step, which is the compilation of all available
voxels and presentation to the radiologist for interpretation.
Secondary reconstruction. The orthogonal projection slices (MPR
slices, sagittal, axial, coronal) of the volumetric dataset is generated by
the software, which is called as secondary reconstruction14,15,17 (Fig.
29.5).
FIGURE 29.5 Secondary reconstruction.
The orthogonal projection slices (MPR slices) of the volumetric dataset
is generated by the secondary reconstruction using software. (A) Axial,
(B) coronal, (C) sagittal.
There are several types of scanners available in the market. These
scanners can be categorised based on the patient positioning and FOV.
Based on the patient positioning19 (Fig. 29.6):
1. Supine position
2. Sitting position
3. Standing position
FIGURE 29.6 Types of CBCT scanners based on patient

positioning.
(A) Supine position (NewTom 5G). (B) Sitting position (iCat NG). (C)
Standing position (NewTom VGi). Source: Courtesy: Manufacturers.
Field of view (Fig. 29.7)
FIGURE 29.7 Field of view (FOV).
(A) The cylindrical shape and measurement characteristics of FOV. (B)
FOV range of iCat Next Generation CBCT machine.
FOV could be defined as the area of interest to be covered during

the scanning procedure. The size of the FOV depends on the size and
shape of the detector, the geometry of beam and the ability to
collimate the beam.17 Collimation of the beam eliminates the photons
outside the intended FOV, therefore limits the radiation exposure to
the region of interest. The selection of appropriate FOV for each
patient, based on his disease representation is essential, as FOV has a
strong correlation with radiation dose and exposure.20 In general,
increasing the FOV increases the exposure because a larger area is
scanned. The indications of CBCT imaging in orthodontics based on
the FOV are given in Table 29.2.
Table 29.2
Indications of CBCT imaging in orthodontics18, 20, 21
FOV can range from local involving a few teeth to large involving
head and face. All machines are not designed for entire range of FOV.
The FOV are17:
1. Localised region: FOV less than 5 cm
2. Single arch: FOV 5 cm to 7 cm for single upper or lower arch
scanning
3. Interarch: FOV 7 cm to 10 cm
4. Maxillofacial: FOV 10 cm to 15 cm for mandible to nasion
5. Craniofacial: FOV more than 15 cm for the lower border of the
mandible to the vertex of the head
Radiation doses: Radiation dose of the CBCT imaging depends on

various factors, which includes kVp, mAs, FOV, voxel size. Apart
from these other scanner-related parameters such as scanning time,
receptor sensitivity, the degree of rotation, filters and collimation also
influence the radiation dose. One should strictly adhere to the ALARA
guidelines when prescribing the CBCT imaging.
Image artefacts (Fig. 29.8)
FIGURE 29.8 (A) Beam hardening artefact (due to the presence of

metal with low atomic number the lower energy radiations are absorbed
leaving the higher energy photons (harder)). This can be seen as
hypodense streaks. (B) Proton starvation artefact (alternated
hypo/hyperdense streaks, arousing from metal with high atomic
number due to complete absorption of photons).
An image artefact may be defined as a visualised structure in the

reconstructed data that is not present in the object under
investigation.22 The resulting artefacts include noise, beam hardening,
cupping artefacts, scatter, motion artefacts, streaks, ring artefacts,
partial volume artefacts, proton starvation and metal artefacts.23
Artefacts relating to CBCT can be categorised into three groups:
1. Physics-based
2. Patient-based
3. Scanner-based
Physics-based artefacts result from the physical processes involved

in the acquisition of CT data. Patient based artefacts are caused by
factors, such as movement or the presence of metallic materials.
Scanner-based artefacts result from imperfections in scanner
function.23
Dentistry was quick to adopt MDCT imaging in routine clinical
practice. CT imaging has been used virtually in all fields, including
orthodontics. CT not only provides 3D sections of the various parts of
the body but also helps reconstruction that cannot be done with the
use of the conventional radiography.
MDCT provides different sections of the body in both bone and
soft-tissue window, thereby allowing complete delineation of the
structures of the body. It finds its application in all spheres, which
include impacted teeth, facial asymmetry, TMJ evaluation,
orthognathic surgeries and airway (Figs. 29.9 and 29.10). The MD CT
imaging is useful in detecting the extent of the various pathologies of
the jaws. It includes various soft-tissue pathologies. This is an
advantage of MDCT over other imaging techniques whereby both soft
and hard tissue pathologies are observed in the same imaging
modality.
FIGURE 29.9 Reformatted (derived) views.
(A) panoramic and maximum intensity projection (MIP) of (B) lateral
cephalogram. (C) Submentovertex view and (D) PA cephalogram
shows the facial asymmetry with the mandibular deviation towards left
side.
FIGURE 29.10 The 3D reconstruction of a patient with Pierre

Robin syndrome.
There is frank asymmetry of the face. As is observed from the lateral
reconstruction, there is a prominent antegonial notch on the right side
as compared to the left side. This view is further strengthening the fact
that right condyle is more immature as compared to the left side
condyle. The external acoustic meatus is absent on both sides. The
regions for placement of ear implant-based prosthesis are clearly
appreciable. The mandibular retrognathism is another important
feature. The information on extent and nature of deformity is useful in
orthodontic surgical planning and evaluation of treatment outcome.
MDCT is most useful in 3D reconstructions of the anatomical parts.

3D cephalometry is also an important clinical application of CT
imaging in orthodontics. MDCT has its limitation in regular usage in
orthodontics. While CT imaging provides several advantages over
conventional radiography, high radiation dose to the patients and its
cost related issue are few important aspects, which limits its
applications in regular dental practice.2
Lower radiation doses of CBCT compared to MDCT has encouraged
use of this technology for dental and craniofacial applications. Various
applications of CBCT in orthodontics could be broadly covered under
the following parts24,25:
1. Diagnostic assessments
a. Root form and length
b. Unerupted tooth position
c. Facial asymmetry
d. Clefts and bone defects
e. Pathologies
2. TMJ assessment
3. Airway
4. Craniofacial morphometrics and cephalometry
5. Orthodontic treatment planning
6. Assessment of treatment outcomes
Diagnostic assessments
CBCT is an excellent tool for assessment of root length, form, tooth
position, facial asymmetry, TMJ, airway, intra-bony pathologies, clefts
in the bone and other non-pathological defects.26
CBCT is a valuable tool for assessment of pre-orthodontic and post-
orthodontic root resorption. It is considered a better imaging tool
compared to orthopantomogram for determining root angulations
and variation of their anatomy from normally accepted views.
Unerupted teeth. CBCT imaging is precise in determining not only
the labial/lingual relationship but also the exact angulation of
impacted teeth (Figs 29.11 and 29.12). These 3D images are beneficial
in determining the proximity of adjacent roots, which can be
invaluable in determining the ease of uncovering and bonding.25,26
Apart from this it provides information regarding the degree of
resorption of adjacent teeth root. These information are important in
treatment planning to move the impacted tooth in the arch and to
avoid the risk of root resorption of adjacent teeth. The imaging
software programmes also allow 3D reconstruction as well as MPR
slices, proving better view of unerupted teeth.
FIGURE 29.11 Palatal impacted left maxillary canine in oblique

3D position.
Orthodontic biomechanics can be planned to avoid damage to roots
adjacent incisors and premolar.
FIGURE 29.12 (A) MIP and multiple cross-sectional 1-mm-thick
sections of left anterior canine region reveal the presence of buccally
placed, mesioangular impacted canine. Cross-section images show
root resorption of left upper lateral incisor root due to pressure from the
impacted canine. (B) Sagittal slice shows labially placed impacted right
upper incisor and the axial image shows the presence of a mesiodens
palatal to the incisors. This information on the relationship of
supernumerary teeth with roots is important during the planning of
orthodontic tooth movements.
CBCT also provides a precise assessment of the alveolar bone
height, defects, variations and their relationship with the adjacent
teeth structures.
Facial asymmetry. Direct measurements of facial and mandibular
body structures allow rapid evaluation of facial asymmetry.
Evaluation of mandibular asymmetry by CBCT imaging eliminates
positioning problems. It can be difficult to evaluate the structural
asymmetry of orthodontic patients using cephalometric and
panoramic radiographs. Superimposition of structures, patient
positioning, and distortion can be frustrating and unreliable. For
instance, the comparison of the condyle and ramus lengths can be
important to the occlusion of an orthodontic patient.
Cleft and bone defects. The imaging is an indispensable tool for the
evaluation of alveolar bone defect, position and level of bone in
adjacent teeth, presence of supernumerary teeth and orthognathic
surgical planning.27 CBCT provides greater advantage over the
conventional imaging with radiation exposure is lesser than the CT
imaging. CBCT imaging can be used for better determination of post-
surgical graft volume and spatial placement, subsequent eruption of
canine through bone graft, prosthetic implant placement, and to
monitor orthodontic and surgical treatment.28,29
TMJ assessment
Conventional tomography has been used extensively for the
evaluation of TMJ hard tissues; however, technique sensitivity and the
length of the examinations made it a less attractive diagnostic tool for
the dental practitioner. CBCT images not only can be taken in the
office but also viewed from different angles and an almost infinite
number of slices. CBCT images of the TMJ have been shown to
provide greater reliability and accuracy than tomographic or
panoramic views in detecting condylar erosions. Follow-up CBCT
images made over an extended period can be important to the
orthodontist in evaluating the process of any degenerative changes
that he/she may suspect. Current software solutions allow the
visualisation of TMJ osseous elements isolated (segmented) from
other surrounding structures.
Airway
Using lateral cephalometric radiographs, the airway is evaluated in a
2D manner, which has its own limitation, that is flat projection is seen
in a sagittal or coronal plane. A 3D view of the airway can be readily
available with CBCT imaging. Using CBCT images filtered to show
airway, it is possible to quantify the volume of the airway and sinuses.
The most constricted location of the airway can be found, and the
axial view of this region can be quantified (Fig. 29.13).
FIGURE 29.13 Airway analysis using CBCT image shows airway

area and volume of oro-pharynx and minimum constricted area.
Craniofacial morphometrics and

cephalometry25
CBCT imaging allows for analysis of size, shape and volumetric
differences in bilateral structures, as well as growth changes in 3D.
The greatest potential use of CBCT is its capability of providing both
conventional 2D and 3D cephalometric images in one acquisition.
CBCT data can be manipulated by Ray sum technique to generate
simulated panoramic, lateral, submentovertex, and posteroanterior
cephalometric images. Cephalograms reconstructed from CBCT data
have accuracy similar to conventional cephalometry, cephalograms,
whereas measurement errors from CBCT images are lower than those
from cephalograms. 3D measurements from CBCTs can be made in
several visualisation modes, including multiplanar (MPR), volume
rendered (VR) and shaded surface display (SSD). Of these, point-to-
point measurements made in the MPR mode are highly accurate when
compared with physical skull measurements.
Orthodontic treatment planning

CBCT provides accurate information regarding the bone volume, bone
quality, and location of adjacent structures, which are necessary for
proper placement of temporary anchorage devices (TADs).30
Additionally, CBCT scans enable clinicians to mirror the normal
side onto the discrepant side to simulate and visualise the desired
result and plan surgery to facilitate correction (Fig. 29.14).
FIGURE 29.14 Application of mirroring techniques to aid in

surgical treatment planning.
The mirroring technique is applied only after virtual correction of
positional asymmetry of the mandible. Pre-surgical models, in grey and
white, of a patient with right hemi-mandibular hypertrophy. Virtually
simulated correction of mandibular yaw and roll is shown in purple. In
the virtual simulation, the mandible was reoriented with the left condyle
as the centre of rotation before mirroring to correct asymmetrical
mandibular yaw and roll, to place the chin in a clinically acceptable
location while preserving the facial width. The mandible was rotated 6
degrees counterclockwise in the frontal plane and 5 degrees clockwise
in the axial plane. After the virtual correction of yaw and roll of the
mandible, the teal model is the mirror model using the mid-sagittal
plane. Note the overlays between the purple/grey and teal/grey models
to help plan surgical displacements. Images courtesy Dr. Lucia H.S.
Cevidanes
Assessment of treatment outcomes24

CBCT is now considered as a tool for determining treatment outcomes
in patients undergoing maxillary expansion; patients after alveolar
bone graft placement and treated cleft lip/palate patients; and those
who underwent orthopaedic corrections and orthognathic surgery
(Fig. 29.15).
FIGURE 29.15 Photographs and 3D colour maps of surgery

outcome showing 7 mm of mandibular setback and 9 mm of
maxillary advancement 1 year post-surgery.
Images courtesy Dr. Lucia H. S. Cevidanes.
Repeated CBCT acquisitions for assessment of treatment progress

and/or outcomes raise additional concerns of increased radiation
exposure to patients, and the routine clinical use of multiple CBCT is
controversial.
Imaging goals and protocols25
CBCT imaging goals in orthodontics include detection of anatomical
features, as well as morphological measurements. Anatomical features
include orthodontic landmarks and various anatomic descriptions
that help to differentiate between normal and abnormal structures.
An imaging protocol for orthodontic purposes takes several factors
into consideration. The desired FOV is determined by the region of
interest. The FOV may be small (individual teeth or quadrant),
medium (both arches, including TMJ) or large (full head).
1. The smaller FOV is used for assessing individual teeth.

2. Medium FOV includes the mandible, the maxilla or both. These
are indicated when extra information regarding occlusal
relationships and facial asymmetries are needed.
3. The largest FOV includes the whole head and helps clinicians
to visualise relationships among skeletal bases, between teeth
and skeletal bases, etc.
Limitations of CBCT
The major limitation of CBCT image is noise that reduces image
clarity due to high scatter radiation. The evaluation of soft tissue is not
excellent using CBCT imaging due to poor soft tissue resolution. Also,
the CBCT image quality is affected by image artefacts like streaking,
shading, rings and distortion due to high areas of attenuation.
Published reports indicate that the effective dose varies for various
full FOV CBCT devices, ranging from 36.5 to 182.1 µSv, depending on
the type and model of CBCT equipment and FOV selected.31,32
Comparing these doses with multiples of a single panoramic dose or
background equivalent radiation dose, CBCT provides an equivalent
patient radiation dose of 5–74 times that of a single film-based
panoramic X-ray, or 3–48 days of background radiation. Patient
positioning modifications (tilting the chin) and use of additional
personal protection (thyroid collar) can substantially reduce the dose
by up to 40%. Comparison with patient dose reported for
maxillofacial imaging by conventional CT (approximately 2000 µSv)
indicates that CBCT provides substantial dose reductions of between
98.5% and 76.2%.31,32 Threshold dose values for known deterministic
effects are given in Table 29.3.
Table 29.3
Threshold dose values for deterministic effects24

Deterministic effect Dose equivalent threshold (single exposure) (Gy)
Permanent sterility
Males 3.5–6.0
Females 2.5–6.0
Lens opacity 0.5–2.0
Cataracts 5.0
Haematopoietic depression 0.5
The radiation dose of CBCT imaging is influenced by several factors
such as kVp, mAs, FOV, voxel size, scanning time, receptor
sensitivity, number and degree of rotations, collimators, and filters
used.19 Each types of CBCT scanners uses a different kind of
geometries and protocol for scanning purpose, therefore the amount
of radiation exposure also varies. Although radiation dose of CBCT
scanning is lower than MDCT, using CBCT as a screening purpose in
orthodontics is strictly contraindicated.33 Clinicians should strictly
adhere to the ALARA (as low as reasonably achievable) principle
while prescribing CBCT to a patient. The Image Gently Campaign
suggested six-step plan to minimise radiation exposure to children. It
strongly advises the use of CBCT imaging on an individual basis with
clinical justification and only when the conventional low dose
radiographs are unable to provide sufficient information (Fig. 29.16).34
International guidelines such as SEDENTEXCT,20 American
guidelines21 are available and should be followed for the use of CBCT
imaging in orthodontics.
FIGURE 29.16 Radiographic guidelines in orthodontic practice.
Ultrasonography
Ultrasound imaging is a diagnostic medical procedure that uses high-
frequency sound waves to produce dynamic images (sonograms) of
organs, tissues or blood flow inside the body. Human hearing is in the
20–20,000 Hz range. The frequency of an ultrasound wave is above
20,000 Hz, and that of medical ultrasound is 2.5–15 MHz. Ultrasound
was first commercially available in 1964. An ultrasound wave is
generated when an electric field is applied to an array of piezoelectric
crystals located on the transducer surface. Electrical stimulation
causes mechanical distortion of the crystals resulting in vibration and
production of sound waves. The sound waves emitted from the
transducer are transmitted into the body, reflected off the tissue
interface, and returned to the transducer. These are then converted
into an electric signal, which is processed and displayed as an image
on the screen. The conversion of sound to electrical energy is called
the piezoelectric effect.
Ultrasound is widely used in medicine as a diagnostic, therapeutic
and operative tool.35,36 In craniofacial region, ultrasonography is used
in diagnosis, follow-up and quantification of normal and
hypertrophied jaw muscles, salivary gland tumours, soft-tissue cyst,
and lymph nodes, etc.37,38 Ultrasonography has been used for the
long-term documentation of myofunctional treatment39,40 (Fig. 29.17)
and also as a diagnostic tool for the dynamic functional analysis of the
tongue,36 and in the measurement of soft-tissue thickness for optimal
placement of orthodontic miniscrew.41,42
FIGURE 29.17 Measuring the thickness and AP diameter of
masseter muscle before and after twin block therapy.
(A) Ultrasound probe placement while recording thickness and AP
diameter of the masseter muscle; diagrammatic representation of
probe placement while recording the length. (B) Ultrasound probe
placement while recording the length; diagrammatic representation of
probe placement.
The various applications of low-intensity pulsed ultrasound

(LIPUS) are:
1. To enhance both the bone growth into titanium porous-coated

implants43 and bone healing after fractures44,45 and
mandibular osteodistraction.46,47
2. To minimise root resorption and accelerate healing of the
resorption by reparative cementum over 4 weeks of
simultaneous tooth movement and LIPUS application.48
3. To enhance the growth of lower incisor apices and accelerate
the rate of eruption in teeth that received ultrasound and
distraction osteogenesis in rabbits by inducing dental tissue
growth.49
Magnetic resonance imaging

MRI uses the magnetic properties of the hydrogen atom and its
interaction with large external magnetic field and radio waves to
produce highly detailed images of the human body. Earlier MRI was
known as nuclear magnetic resonance (NMR). The hydrogen nucleus
contains one proton and possesses a significant magnetic moment.
Also, hydrogen is very abundant in the human body.
By placing the patient in a large external magnetic field, the nuclei
of the hydrogen atoms tend to spin in one of the two directions. These
hydrogen atom nuclei can transit their spin orientation or process
from the direction of the magnetic field to the opposite orientation. To
spin the nuclei in the other direction, the coil emits a radio-frequency
(RF) that causes this transition. The frequency of energy required to
make this transition is specific, and is called the Larmour frequency
(Figs 29.18 and 29.19).
FIGURE 29.18 The proton as a tiny bar magnet.
FIGURE 29.19 Single proton in an external magnetic field;

precessional frequency; many protons in the magnetic field.
The signal that is used in creating MRI images is derived from the
energy released by molecules transitioning or processing from their
high-energy to a low-energy state. This exchange of energy between
spin states is called resonance, and thus the name MRI.
NMR phenomena were discovered independently by Bloch and
Purcell in 1946 for which they were awarded the Nobel Prize in
physics in 1952. In dentistry, MRI was first used for imaging the
temporomandibular joint by Helms et al. in 1984. In the field of
orthodontics the first MRI, a study of TMJ following Herbst appliance
therapy was published in 1998.
MRI is becoming increasingly popular in orthodontics, being a non-
invasive and non-ionising imaging procedure. The significant
advantage of MRI over other imaging modalities is its ability to
distinguish among various soft tissues.
The important applications in orthodontics are
1. In the diagnosis of TMJ disorders. Disc position, condylar

erosions, adhesions, perforations and joint effusion.50,51 MRI
has been found as accurate as arthro-tomography in
confirming disc displacement and more accurate in disclosing
gross arthrosis than tomography. Disc perforations are better
disclosed by arthrography.52
2. In evaluating the TMJ adaptations following functional
appliances. TMJ adaptations following Herbst (Fixed
Functional Appliance: FFA) appliance has been well
documented in literature using MRI.53–56 TMJ adaptations
following removable functional appliances using MRI have
been studied by Chintakanon et al. and Wadhawan et al.57,58
3. In evaluating the jaw muscles and craniofacial morphology.
MRI has been used in several studies for measuring cross-
sectional area and volume of the jaw muscles59,60 (Figs
29.20–29.22).61–64 It has also been used in measuring the
muscle volume in response to myofunctional appliance.65 3D
reconstruction of jaw muscles is possible using software
applications like 3D Doctor (Able Software Corp., Lexington,
USA).
FIGURE 29.20 Sagittal MR localiser showing planning for

obtaining continuous 4 m (without any gap) thick axial scans of
the head including the masseter muscle.
FIGURE 29.21 T1-weighted axial section of head showing right
and left masseter muscle.
FIGURE 29.22 3D MMR views of the right masseter muscle in (A)

axial, (B) coronal, (C) sagittal planes.
In addition to these, it is being used in diagnosing tumours of the

parotid gland, masseteric muscle hypertrophy and in post-surgery
follow-up.
Recently, MRI spectrometry and dynamic MRI have been used to
assess jaw functions in conditions like bruxism and obstructive sleep
apnoea.
Research and recent advances in 3D
orofacial imaging23
Virtual models
Plaster casts which have been in use in orthodontics, evaluate
patient’s alignment, arch width, occlusion, tooth mass and soft tissue.
Smaller voxel size and innovative software have led to the ability to
reconstruct virtual orthodontic study models without the need to
obtain alginate impressions; however, an establishment of precise
occlusion is still a challenge particularly for clinical cases of skeletal
malocclusions.
CBCT data can be used to produce 3D models without the need for
alginate impressions. Also, these virtual models can be studied and
measurements can be made on the computer, as is possible with those
fabricated currently by the OrthoCad system (Cadent, Inc., Carlstadt,
New Jersey) using impressions.
Indirect bonding of brackets, computer-aided

bracket design and wire bending23
Currently, in this technique, brackets adhere to accurate stone models
in the desired position. This bracket set-up is then transferred from
the models to the patient using various types of trays and composite
material. This laboratory fabrication is done either in the orthodontic
office or at an outside facility. Construction of ‘hardcopy’ models from
the CBCT images could allow this indirect bonding to occur in either
of these laboratory sites. If accomplished in an outside laboratory, the
digital image could be electronically transferred to the laboratory with
no pouring up or mailing of impressions involved. The same CBCT
file used for the virtual models described earlier could be used for the
indirect bonding procedure.
A number of commercial products including Suresmile, Invisalign,
Insignia (Ormco) and Incognito (3Munitek) now utilise computer-
aided appliances design.66–69 Caution must be exerted with the use of
virtual biomechanic set-ups. Even though some digital set-up models
display roots, no information of root form/position is obtained from
3D virtual models scanned from impressions, further construction of
root surface models from CBCT are time consuming, and the precision
of root models has not been validated till date.
Virtual orthodontic patient70

Reconstructing 3D soft and hard tissue models from sequential CBCT
slices using a surface rendering technique followed by extraction of
facial features from 3D soft tissues is a reality (Fig. 27.7). Three
digitised colour portraits were texture-mapped onto the 3D head
mesh. A combination of 3D CT skeletal maps with 3D laser–based
study models has also been attempted.
Other researchers tried to combine 3D skeletal data based on
cephalograms with 3D laser-scanned dental models to overcome the
problems associated with CT skeletal data. However, this technique
cannot be used for prediction of soft tissue changes following
treatment, which minimises its applicability.
A new method of combining and mapping patients’ facial textures
(based on stereophotogrammetry) onto CBCT skeletal and soft tissue
data integrated with intraoral scans provides a comprehensive virtual
patient. A number of treatment planning options can be viewed
virtually along with the changes in facial profile in 3D. The best
options can be chosen. These type of virtual planning is definitively
more useful in patients with dentofacial deformities.
Key Points
3D imaging is an ever-expanding field of dentistry, with evolving
techniques and methods that enhance its ease of use by orthodontists.
CBCT offers advantages for imaging in orthodontics. As a result,
CBCT is being adopted in many dental practices; however,
understanding of its benefits and specific clinical applications and
rationale use is a must.
The CBCT can describe craniofacial anatomy accurately and
provide comprehensive information regarding anatomical
relationships and individual patient findings for improved diagnosis,
treatment planning and prognostication.
Research and development of future applications of CBCT such as
simulation, growth prediction, forensics dentistry modelling and
manufacturing are ongoing.
Further research is underway for enhancing non-radiation
technologies for imaging anatomy including that for use on the face in
static and dynamic states.
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CHAPTER 30
Three-dimensional cephalometry
Rajiv Balachandran
Abhishek Gupta
Viren Sardana
O.P. Kharbanda
CHAPTER OUTLINE
Evolution of 3D imaging: from 2D to 3D imaging

Major limitations of 2D cephalometry
2D cephalogram from 3D data
CBCT derived cephalograms vs. conventional 2D
cephalograms
Evolution of 3D cephalometric measurements
Craniofacial anatomical structures visualisation and 3D
landmarks
How landmarks on 3D volume rendered images differ
from 2D cephalogram
Image orientation and 3D reference system
Step-by-step procedure to 3D cephalometry
Automatic landmark detection and cephalometric analysis
Three dimensional virtual orthognathic surgical planning
Key Points
Evolution of 3D imaging: from 2D to 3D
imaging
Craniofacial imaging is one of the essential tools for orthodontic
diagnosis and treatment planning. Before the advent of cephalometry,
craniometry and anthropometry methods were used to study the
human skull. Craniometry method involves direct measurements on
the dry skulls. This method has an advantage of precise and direct
measurements of the skull (s) but cannot be used on humans.
Anthropometry, on the other hand, is a method of measuring
skeletal dimensions in living subjects. Various soft tissue landmarks
on underlying skeletal structures are used for obtaining skull
measurements. The anthropometric measurements can be used to
study the growth of an individual but for the significant disadvantage
of imprecise measurements introduced by variation in the soft tissue
thickness.
Cephalometric radiography is a technique, which provides the
advantages of combined craniometry and anthropometry
measurements. Landmark-based two-dimensional lateral
cephalometric analyses have been routinely used by the orthodontist
for more than a half century.1–4 Later PA cephalometric was added to
make measurements in the transverse plane. However, the 2D
radiographic representation of three-dimensional (3D) craniofacial
anatomical tissues has a few inherent drawbacks.5–8
Major limitations of 2D cephalometry

1. Non-linear magnification
2. Distortion
3. Overlapping of bilateral anatomical structures
4. Difficulty in location and measurements of hidden anatomical
structure
The quest for true 3D anatomic imaging in medicine/dentistry was
fulfilled with the advent of computed tomography (CT) in the early
1970s. The first use of 3D imaging in the field of dentistry was
introduced in 1980 for the analysis of craniofacial deformity and first
software for simulation was introduced in 1986.9 However, the use of
this technology in dentistry especially in orthodontics was limited due
to its higher radiation dose delivery and cost.10 MDCT has been in use
for the diagnosis and planning of craniofacial deformities.
The introduction of low radiation CBCT, and advanced software
functions has opened up a new and exciting arena of craniofacial
imaging.
The 3D spatial imaging of a patient is significantly useful to
understand the complex biological architecture which is far superior
to projected 2D x-ray image. 3D volumetric image of a body part can
be obtained through radiation modalities that is multi-slice computed
tomography (MDCT) and cone beam computed tomography (CBCT)
and non-radiation imaging which is magnetic resonance imaging
(MRI) and 3D facial photos.
The software tools available for 3D evaluation are:
• Mimics (Materialize Co., Belgium)

• Dolphin (Dolphin Imaging and Management Systems,
Chatsworth, CA)
• AMIRA (AMIRA, Mercury Computer System Inc., Berlin,
Germany)
• Vitrea (Vital Images Inc., Plymouth, MN)
• Maxilim (Medicim, Sint-Nikaas, Belgium)
• Anatomage (San Jose, CA)
These software tools allow viewing, analyses and

marking/annotation of the volumetric images on 2D computer screen.
Advanced software functions provide the facility to rotate the patient
image by 360 degrees to visualise the anatomy from a different
perspective as well as internal structures. The measurements obtained
through 3D volumetric image are comparable to the measurements
obtained directly on anatomical structures.
Though the radiation dose delivery of CBCT is lesser than
conventional CT, it is well above the combined radiation dose of a
lateral and a PA cephalogram, a panoramic x-ray and a set of intraoral
radiographs.11
2D cephalogram from 3D data

In addition to 3D volumetric information, multiple 2D lateral/PA
cephalograms can be obtained from a CBCT data, these digital images
are called as derived cephalograms. Derived cephalogram is a
projection of 3D anatomical structure on a 2D plane, which is
equivalent of the conventional 2D cephalogram. 2D cephalogram can
be obtained in more than one method of the software function. The
use and need are decisive in selecting the type of 2D image.
These are:
1. Ray-sum
2. Maximum intensity projection (MIP)
3. Hemifacial projection
a. The ray-sum image is a 2D image generated by the
overlapping of all CBCT slices on one plane (Fig.
30.1).
b. MIP image is created by the overlapping of only
those CBCT slices that have a significantly high
intensity of anatomical structures (Fig. 30.2).
c. Hemifacial projection overlapping of CBCT slices
either from mid-sagittal to left-most sagittal or mid-
sagittal to right-most sagittal on a 2D plane is called
as left-hemifacial projection and right hemifacial
projection image respectively. It is significantly
useful for the patients with asymmetrical faces (Fig.
30.3).
FIGURE 30.1 Ray-sum image.
FIGURE 30.2 Maximum intensity projection (MIP).
FIGURE 30.3 Hemi-facial projection.
There are two projection methods to derive cephalograms from

CBCT data.12
a. Orthogonal projection. The orthogonal projection uses parallel

(non-diverging) rays algorithm to create a cephalogram from
CBCT data. The orthogonal projection provides cephalograms
with proper overlapping of bilateral structures and 1:1 image
(Fig. 30.4).
b. Perspective projection (Fig. 30.5). The perspective projection
simulates geometry of conven-tional cephalometric method by
using diverging rays algo-rithm. The perspective
cephalograms from CBCT data could replicate the inherent
magnification of conventional 2D cephalograms with high
accuracy, and they could be used in comparison with 2D
cephalograms.13 (Fig. 30.5).
FIGURE 30.4 Orthogonal projection.

FIGURE 30.5 Perspective projection.
CBCT derived cephalograms vs. conventional

2D cephalograms
Comparison of CBCT derived cephalograms, and conventional 2D
cephalograms showed that angular and linear measurements were
similar.14–16 The difference between the conventional and CBCT
derived orthogonal projection cephalograms can be compensated by
correction of mid-sagittal magnification.12 Lamichane et al.13 showed
that by constructing a perspective lateral cephalogram from a CBCT
scan, one could replicate the inherent magnification of a conventional
2D lateral cephalogram with high accuracy. The magnification of
conventional cephalograms can be reproduced in perspective
projection derived cephalograms by setting source-to-object and
object-to-film distances identically to the respective standard
cephalometer distances.
Additional conventional cephalograms are not required once the
CBCT data has been acquired. Also, longitudinal data derived from
conventional cephalograms could be considered as the source of the
norms for derived cephalograms from CBCT. The derived
cephalograms can also be used for longitudinal research with
conventional cephalogram data.12,15
CBCT imaging has many advantages over conventional radiographs,
but for the radiation dose which discourages its use as the first choice
of imaging modality in routine orthodontics. CBCT imaging provides
enhanced 3D information of impacted/unerupted teeth, root
resorption, supernumerary teeth, TMJ and other craniofacial
abnormalities. The CBCT imaging should be justified on an individual
basis and recommended following a thorough clinical examination. It
should be advised only when the CBCT imaging is likely to provide
additional information that could change the course of treatment and
improve treatment outcome.
Indications of CBCT imaging in orthodontics are11,17:
1. Small FoV
a. Impacted teeth
b. Supernumerary teeth
c. Hypodontia
d. Root resorption
2. Medium
a. Cleft lip and palate
b. TMJ evaluation
3. Large
a. Orthognathic surgical planning
b. Other craniofacial deformities
Evolution of 3D cephalometric
measurements
The first 3D cephalometric analysis was introduced by Park et al.18 in
2006. It is a MDCT based 3D analysis of craniofacial morphology. 3D
measurements of the zygoma, maxilla, mandibular region and facial
convexity were analysed in 30 Korean patients. Measurements were
obtained using cephalometric landmarks which are already defined
for 2D lateral/PA cephalograms and also found good reproducibility
compared to 2D cephalograms.
The first comprehensive 3D cephalometric analysis was introduced
by Swennen et al.19 Since 2006 a number of analysis have been
proposed based on MDCT and CBCT data20–25 (Table 30.1).
Table 30.1
Evolution of 3D cephalometric analysis
In 2015, group of researchers at All India Institute of Medical
Sciences New Delhi and Central Scientific Instruments Organisation
(CSIO), Chandigarh26 demonstrated a comparison of 3D
cephalometric measurements computed automatically and manually.
These 3D measurements were obtained from various 2D
cephalometric analyses which are used in routine clinical practices.
Xia et al.27 proposed cephalometric analysis method to assess the size,
position, orientation, shape and symmetry. Table 30.1 shows the
evolution of 3D cephalometric analysis.
3D facial photograph obtained through non-radiation imaging
technology such as 3dMD can be superimposed on CBCT volumetric
data which provide a virtual face for evaluation, planning virtual
treatment. The use of 3D imaging, along with an evaluation of the
fourth dimension (4D), the ‘time’, provides an understanding of facial
changes with growth and age.
This 4D analysis may involve ‘Dynamic imaging’ such as smile,
facial expressions or recording the growth or age related changes over
the period of time.28
3D cephalometry is not as simple as just adding a ‘third’ dimension
to a conventional 2D cephalometric analysis. There are many complex
issues in 3D analysis. These are related to reference systems, size,
position, orientation and shape. The location of 3D landmarks and
assessing the measurements are a complex computational processes.
Understanding these basic principles is essential for the correct use of
3D cephalometry.27
Craniofacial anatomical structures
visualisation and 3D landmarks
The CBCT images contain 3D information of scanned structures as
stacked 2D base images in the axial direction, which in turn produces
a 3D volumetric image. With the help of software, desired slices can
be reconstructed from these base images to visualise anatomical
structures of interest. The most commonly used slices for visualising
an anatomical structure is multi-planner reconstruction (MPR), which
consist of three mutually orthogonally projected planes namely axial,
coronal and sagittal (Fig. 30.6). Each slice is a 2D representation of 3D
structure from mutually orthogonal perspective views (X, Y and Z).
FIGURE 30.6 MPR slices and volume rendered image.
How landmarks on 3D volume rendered

images differ from 2D cephalogram
3D space requires three mutually perpendicular axes to define any
point in space. MPR slices fulfill this requisite and are used for
accurate landmark identification in three dimensions. The
conventional cephalograms are ray-sum images, and landmark
definition and plotting involve only two dimensions in sagittal view
namely X and Y (anteroposterior and superoinferior respectively).
These 2D landmark definitions are not of much help while analysing a
3D volumetric image. The 3D, ‘Z axis’, may lead to uncertainties in
landmark plotting. 3D landmarks need, in contrast to conventional
landmark definitions, to be defined in three planes for each 2D slices,
axial, coronal and sagittal, for accurate landmark identification (Table
30.2A–C; Fig. 30.7).
Table 30.2a
Definition of hard tissue 3D landmarks
Table 30.2b
Definition of pharyngeal airway 3D landmarks
Table 30.2c
Soft tissue landmarks
FIGURE 30.7 3D surface landmarks on a volume rendered image
of the facial skeleton.
Plotting of a landmark on 2D cephalogram is simple by using a

computer screen while the same on 3D images is slightly different.
Plotting a landmark on a 3D image requires identification of the same
on a definite MPR view by scrolling through them in all the three
planes according to MPR definition of each landmark. This aspect of
landmark identification is most critical for the precise location of the
landmarks. Once, the anatomical location has been visualised in all
three MPR views, the landmark is then plotted on the screen. The
same location is reconfirmed on the 3D volume-rendered image for an
enhanced level of accuracy (Fig. 30.8). This procedure of landmark
plotting on a 3D image brings precision at a higher level. However,
the process is time-consuming and requires more experience and
effort.
FIGURE 30.8 Image shows 3D landmark plotted in MPR as well
as volume rendered image using Mimics software.
Nasion landmark is plotted in coronal slice and landmark position can
be double checked in axial and coronal slices.
Image orientation and 3D reference system

Assessment of 3D volumetric image may be influenced by the
experience of operator and orientation of image being assessed.19 3D
landmarks have advantages over 2D traditional landmarks that 3D
landmarks are less influenced by head positioning errors.29 However,
landmark identification on 3D volumetric and MPR slices is more
subjective due to the complex and curved nature of craniofacial
anatomic structures. Standardising the radiographs orientation is one
of the crucial steps before landmark plotting. Even though the patient
head position is standardised while the acquisition of CBCT,
sometimes it may be necessary to reorient and reformat the 3D image
data before landmark plotting.
The landmarks definitions are based on their position such as
anterior, posterior, inferior, superior and middle in MPR slices. As the
MPR slices are generated from base images, the image orientation
may influence the MPR slices. Different image orientation results in
different MPR slices which have different anatomical landmarks on it.
For example, lateral flexion (sidewise rotation) of the head results in
the mid-sagittal slice, which does not pass through all mid-sagittal
landmarks even though there is no obvious skeletal deformity.
Various studies have evaluated the reliability and reproducibility of
commonly used 3D landmarks and reported good inter and intra-
observer agreement.30,31 Gupta et al.32 reported that the orientation of
volumetric data has no significant influence on the accuracy of
landmark identification, proper orientation of CBCT image results
easier landmark plotting and less time consuming especially for
midline structures and curved anatomical structures. In contrast,
Ruellas et al.33 suggested that the orientation of serial CBCT images is
crucial for the assessment of directional 3D changes. The most
common orientation method involves aligning Frankfort horizontal
plane and transorbital plane horizontally and mid-sagittal plane
vertically of volume-rendered images.
A coordinate reference system is defined as a coordinate-based
local, regional or global system to locate geographical entities. In 2D
lateral cephalometry, various reference planes (lines) have been used
as a reference. Most commonly used 2D reference lines may include
FH plane,1 SN plane,2 Na–Ba plane.3 Similarly, in 3D imaging,
reference planes are used for localisation of landmark and 3D
measurements.
3D cephalometric reference planes for orientation of 3D image are
(Fig. 30.9; Table 30.3).
1. Natural head position (NHP)

2. A plane is passing through one 3D landmark and
parallel/perpendicular to one plane (mid-sagittal plane)
3. Plane passing through two 3D landmarks and
parallel/perpendicular to one plane (S–N plane)
4. A plane passing through three or four 3D landmarks (maxillary
plane, mandibular plane, FH plane)
FIGURE 30.9 The orientation of volume rendered image.
(A) Transorbital line coincides with the Axial plane and in frontal view
glabella, ANS was oriented to match with the mid-sagittal line (Red
line). (B and C) The Frankfort horizontal plane in lateral view aligned to
coincide with axial line and anterior margin of right and left external
acoustic meatus aligned to coincide with the coronal line (Green line).
(D) A line passing through the medial point of right and left
frontozygomatic suture in frontal view aligned to coincide with the axial
line (Blue line). (E) On top view the crista gali, cribriform plate mid-
sagittal structures oriented to match with the mid-sagittal line (Red
line).
Table 30.3
Reference planes for 3D cephalometric analysis

S. no. Reference plane Landmarks used
1 NHP NA
2 FH plane PoR-OrR-OrL or
OrR-OrL-PoL
3 SN plane S and Na
4 Mandibular plane GoR-Me-GoL
5 Maxillary plane ANS-PNS
6 Mid-sagittal plane Cg-ANS-Me
These reference planes can be defined by using the minimum set of

three landmarks.
3D cephalometry bridges the gap between radiology and
orthodontic/surgical treatment planning by producing 3D volumetric
images and actual 3D measurements. The potential applications of
CBCT based 3D cephalometry include treatment planning of complex
orthodontic treatment, facial asymmetry cases, surgical planning and
functional airway analysis.
The advantages of 3D cephalometry are:
1. Precise 3D measurements
2. 3D spatial image
3. Anatomical landmarks can be plotted in volume
4. 360 degree views of craniofacial structures
5. No other cephalometric modality is required
Various studies evaluated the measurements performed on the 3D

images. Most of the 3D measurements were based on the common 2D
measurements methods and few were based on structure only visible
on the 3D image. The commonly used 3D cephalometric
measurements are given in Tables 30.4–30.6.
Table 30.4
Linear cephalometric measurements

S. Linear measurement
Reference analysis
no. parameters
Bilateral measurements
1. ZyL-ZyR Swennen analysis, PA-Grummons analysis
2. FzL-FzR PA-Grummons analysis, PA-Ricketts analysis
3. JL-JR PA-Grummons analysis, PA-Ricketts analysis
4. GoL-GoR Swennen analysis
5. CoL-CoR Swennen analysis
6. OrL-OrR —
Mid-sagittal measurements
7. N-Me Swennen analysis, analysis of vertical facial heights,
8. N-ANS Swennen analysis, analysis of vertical facial heights,
9. N-Gn Jarabak analysis
10. ANS-Me Swennen analysis, analysis of vertical facial heights, McNamara
analysis, PA-Grummons analysis
11. ANS-PNS Swennen analysis, Bjork analysis
12. S-N Swennen analysis, Bjork analysis, Jarabak analysis
Mid-sagittal to bilateral measurements
13. GoL-Pg Swennen analysis, Bjork analysis
14. GoR-Pg Swennen analysis, Bjork analysis
15. GoL-Gn Jarabak analysis
16. GoR-Gn Jarabak analysis
17. GoL-N Jarabak analysis
18. GoR-N Jarabak analysis
19. GoL-S Swennen analysis, analysis of Vertical facial heights, Jarabak analysis
20. GoR-S Swennen analysis, analysis of vertical facial heights, Jarabak analysis
21. CoL-GoL Swennen analysis
22. CoR-GoR Swennen analysis
23. CoL-Pg Swennen analysis
24. CoR-Pg Swennen analysis
25. CoL-A McNamara analysis
26. CoR-A McNamara analysis
27. CoL-Gn McNamara analysis
28. CoR-Gn McNamara analysis
Table 30.5
Angular cephalometric measurements

S. no. Angular measurement parameters Reference analysis
Mid-sagittal measurements
1. S-N-A Stenier’s analysis, McNamara analysis, Jarabak analysis
2. S-N-B Stenier’s analysis, Jarabak analysis
3. A-N-B Stenier’s analysis, Jarabak analysis
4. N-A-Pg Subtelny analysis
Mid-sagittal to bilateral measurements
5. N-GoL-Me Bjork analysis
6. N-GoR-Me Bjork analysis
7. N-GoL-Gn Jarabak analysis
8. N-GoR-Gn Jarabak analysis
9. CoL-GoL-Me Swennen analysis
10. CoR-GoR-Me Swennen analysis
Planar measurements
11. A-B X N-Pog Downs analysis
12. S-N X GoL-Gn Stenier’s analysis, Jarabak analysis
13. S-N X GoR-Gn Stenier’s analysis, Jarabak analysis
14. ANS-PNS-Horizontal_Plane Swennen analysis
14. ANS-PNS-Horizontal_Plane Swennen analysis
15. Me-GoL-Horizontal_Plane Swennen analysis
16. Me-GoR-Horizontal_Plane Swennen analysis
Table 30.6
Ratio of cephalometric measurements

S. no. Ratio parameters Reference analysis
1. N-Me/N-ANS Analysis of vertical facial heights
2. S-GoL/N-Gn Analysis of vertical facial heights, Jarabak analysis
3. S-GoR/N-Gn Analysis of vertical facial heights, Jarabak analysis
4. S-GoL/N-Me Analysis of vertical facial heights
5. S-GoR/N-Me Analysis of vertical facial heights
6. GoL-Gn/S-N Jarabak analysis
7. GoR-Gn/S-N Jarabak analysis
Step-by-step procedure to 3D cephalometry

1. CBCT images are stored and supplied in DICOM format along
with bundled viewing software. Most bundled softwares have
a capacity of visualising MPR slices but not 3D volume
rendering. Various third party software is available for this
purpose. In this case study, Dolphin 3D imaging software was
used for treatment planning.
2. The first step involves uploading the DICOM image files into
Dolphin or similar imaging software using unique
identification number.
3. After uploading the DICOM image first step involves
orientation of CBCT image (Fig. 30.10).
4. After image orientation, 3D cephalometric analysis can be
performed directly on volume rendered image or by landmark
based method.
5. This method involves measuring the linear, and angular
measurements on volume rendered image using a measuring
tool (Fig. 30.11).
6. Alternatively, 3D landmarks can be plotted on MPR slices and
volume rendered images using 3D landmark definitions. The
3D cephalometric software automatically performs 3D
cephalometric measurements.
FIGURE 30.10 Image orientation using FH plane.
FIGURE 30.11 3D cephalometry analysis using Dolphin imaging

software (Dolphin Imaging and Management Systems,
Chatsworth, CA).
(A) Linear measurements on volume rendered image. (B) Grummons
analysis.
Fig. 30.11 shows 3D analysis of a patient with facial asymmetry due
to unilateral condylar hyperplasia of the right side using Dolphin
imaging software. The analysis provides both 3D linear and angular
measurements and projected 2D measurements.
Automatic landmark detection and
cephalometric analysis
3D cephalometric analysis, unlike 2D analysis, involves landmark
plotting on MPR slices and volume rendered image. Landmark
plotting of 3D data on a 2D computer screen makes it more complex
and may reduce precision for landmark plotting. Hence, to identify
and plot a cephalometric landmark on the 3D volumetric image using
2D computer screen is challenging in routine clinical practice due to
following constraints.
1. Time-consuming procedure compared to plotting on 2D

radiographs
2. Requires extensive training for the observers with the software
tool
3. Variations due to human perception (reproducibility and
repeatabilit y)
Automatic cephalometric analysis can be either semi-automatic or

fully automatic. The semiautomatic approach requires operator
intervention like contour tracing before final analysis. Invivo-5
(Anatomage, San Jose, CA) utilises a semi-automatic approach where
an observer performs tracing of the contours on the anatomical
geometry. Then, a landmark is detected by the software on the
anatomy based on traced contour, automatically.
The fully automatic technique will not require landmark
identification or calculations once volume rendered DICOM image is
imported into the software. Automatic landmark detection can be
performed using training-based, model-based, knowledge-based and
hybrid approaches34, 26. Gupta et al.26 evolved a knowledge-based
method for automatic detection of cephalometric landmark and
detected 25 landmarks with comparatively less error. Based on these
landmarks, 51 cephalometric measurements (28 linear, 16 angles and 7
ratios) were identified which are used in conventional 2D
cephalometric analyses. These measurements are listed in Tables 30.4–
30.6. The accuracy of these measurements was found as similar to a
manual marking of landmarks. The automatic detection of landmarks
followed by automatic analysis35 would become a reality in the years
to come.
Three dimensional virtual orthognathic
surgical planning
The 3D virtual ortho-surgical planning has several advantages over
the conventional methods.36 The conventional method of treatment
simulation using plaster models requires various laboratory steps and
time consuming. Also, the splint construction and final jaw
positioning summates all the errors in previous steps.37
Unlike the conventional method, the 3D virtual planning using
CBCT image and the 3D digital model allows multiple simulations.
The 3D virtual planning allows the clinician to perform a range of
virtual osteotomies and corrections in all three planes (Pitch, Roll,
Yaw). The final splint generation with 3D printing allows smooth
digital work flow in more efficient manner.
Key Points
Current shreds of evidence supports the potential uses of 3D
cephalometry in virtual orthognathic diagnosis and treatment
planning. Comparisons with bilateral differences in 3D measurements
and using mirror images greatly improves diagnosis and treatment
planning of facial asymmetry cases.
However, 3D cephalometry is not routinely used in day to day
clinical practice due to the lack of evidence of standardised
cephalometric method.38 Also 3D landmark plotting is more time
consuming and complicated for routine use. With the advancement in
low dose imaging technology and the automation in analysis, 3D
cephalometry will eventually replace the conventional methods in
near future.
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CHAPTER 31
3D volumetric analysis, and
clinical implications of the upper
airway and sinuses
Bala Chakravarthy Neelapu
Harish K. Sardana
Rajiv Balachandran
O.P. Kharbanda
Karthik S
CHAPTER OUTLINE
Introduction
Imaging modalities of upper airway space
Segmentation methods
Manual segmentation
Automated/Semiautomated
Thresholding
Region growing
Segmentation of upper airway
Reliability of using CBCT and imaging software for volumetric
airway analysis
Factors affecting the volumetric airway measurements
Clinical implications of volumetric airway analysis
Clinical relevance of paranasal air sinuses volume
Recent advancements
Key Points
Introduction
The postural relationships of the head, jaws and tongue, which gets
established immediately after birth with the opening of the airway, do
get altered with time to meet physiological demands and to maintain
the patency of the airway.1 The intimate anatomical and functional
proximity of craniofacial and upper respiratory structures influences
the facial and dental growth. A healthy respiratory function is
essential for the harmonious growth and development of the
maxillofacial structures.2 Craniofacial skeletal development can be
affected by abnormal patterns of nasal/oral respiration during
growth.3–5 The abnormal influences might affect tooth eruption,
dental arch form and possibly the direction of mandibular and
maxillary growth. The relationship between pharyngeal and
craniofacial structures has been evaluated extensively.6–8
The pharyngeal airway and paranasal air sinuses constitute the
upper airway (Fig. 31.1). The pharyngeal airway has three major
regions: the nasopharynx, oropharynx and hypopharynx. The skeletal
support for the upper airway is provided superiorly by the cranial
base, posteriorly by the cervical spine, anterosuperiorly by the nasal
septum and anteriorly the maxilla, mandible and hyoid bone.
Structures encroaching upon the upper airway include the nasal
conchae, adenoids, soft palate, tongue and the pharyngeal and lingual
tonsils.
FIGURE 31.1 Airway volume of oropharynx and minimum
constricted area (using Dolphin 3D soft ware by Dolphin Imaging
& Management Solutions, Chatsworth, CA).
ANS, Anterior nasal spine; PNS, posterior nasal spine.
Paranasal sinuses are air-containing cavities lodged inside the skull

and facial bones, which assure harmony in facial growth and make the
bony skull lighter. In addition, sinuses carry out physiological
functions of humidification and warming of inhaled air. The sinuses
also have an inbuilt mechanism for protection against trauma.9 There
are four-paired air sinuses that border the nasal cavity, namely
maxillary sinus, frontal sinus, ethmoidal sinus and sphenoidal sinus.
Volumetric analysis of upper respiratory tract is helpful in the proper
diagnosis of obstructive sites in the pharyngeal airway and presents a
unique opportunity for orthodontists to collaborate with other
medical specialities to improve a patient’s health and treatment
outcome.10–12
Imaging modalities of upper airway
space
The most commonly used imaging modality for airway assessment in
orthodontics is a lateral cephalogram. A lateral cephalogram provides
a simple and inexpensive method for the evaluation of upper
airway.13 Most cephalometric airway studies examine the hard and
soft tissues surrounding the airway, rather than the airway space
directly. The airway is evaluated by measuring the narrowest
anteroposterior points in the naso pharynx and oropharynx, which
limits the understanding of volumetric changes in the upper airway.
The inherent limitations of the two-dimensional (2D) radiograph have
lead to the creation of new methods for three-dimension (3D) airway
analysis.14,15
In an attempt to overcome the shortcoming of 2D lateral
cephalograms for assessing airway, various non-invasive methods
have been introduced.
1. Non-radiation methods
a. Acoustic reflection
b. MRI
2. Radiation methods
a. Fluoroscopy
b. CT
c. CBCT
These 3D imaging methods allow us to accurately evaluate surface

and sub-surface volume of the upper airway. Each method has its
own inherent advantages and disadvantages.
Acoustic reflection is a non-invasive technique based on the
analysis of a sound wave reflected from the airway. It does not
involve radiation exposure and also does not provide a high-
resolution anatomic representation of the airway or soft-tissue
structures.16
Magnetic resonance imaging (MRI) technique is an ideal modality
for airway imaging and particularly in patients with sleep apnea
because it provides an excellent upper airway and soft-tissue
resolution, accurately determines cross-sectional area and volume,
and allows imaging in the axial, sagittal and coronal planes. MRI has
an equal resolution, but much greater contrast than CT. Imaging is
performed in a supine position. It requires longer operating time that
results in motion artefacts affecting the quality. Dynamic imaging is
possible with ultrafast MR imaging. Fast MRI can obtain two images
per 1 s, which allows multidimensional views and visualisation of the
dynamic shape of the pharyngeal airway during inspiration and
expiration.16
Fluoroscopy provides dynamic upper airway imaging with
significant radiation exposure. It is not sensitive enough to measure
changes in airway size or the detailed motion of the soft tissue
structures surrounding the upper airway and no capability of cross-
sectional (axial or sagittal) imaging.16
Computed tomography is obtained as 1–2 mm slices in axial or
coronal planes or both, from the patient in the supine position. The
slices are combined and reconstructed into 3D images. Radiation
exposure limits ability to perform series of CT studies. Dynamic
imaging (images in 50 ms) can be performed with an electron beam
(ultrafast computed tomography).16
Cone beam CT is now more frequently used for the assessment of
the upper airway and paranasal air sinuses.17–21 Advantages of CBCT
include 3D images with 1:1 reproduction, isotropic voxel size, less
acquisition time and a low radiation dose than multi-detector CT
(MDCT). Limitations on the use of CBCT include low contrast range,
limited soft tissue visualisation, increased noise and scattering and
inability to be used for estimation of Hounsfield units (HU). Although
this modality has some limitations, CBCT offers a better risk-to-benefit
ratio in the evaluation of upper airway dimensions, particularly in
diagnosis and management of OSA patients.
The airway is identified as an irregularly shaped, elongated, low-
density (dark) area anterior to the cervical part of the vertebral
column. Upper airway comprises of four airway sub-regions: nasal
cavity, nasopharynx, oropharynx and hypopharynx. The nasopharynx
extends from the skull base to the level of the hard palate, the
oropharynx extends from the level of the hard palate to the level of
the hyoid bone and the hypopharynx extends from the level of the
hyoid bone to the caudal cricoid cartilage (Fig. 31.2).
FIGURE 31.2 The segmented airway sub-regions using Mimics

version 10 (Materialise, Leuven, Belgium).
The nasal cavity is separated into three distinct chambers or

turbinates on either side by three osseous processes, namely inferior,
middle and superior nasal conchae. The nasal septum is identified
along the midline of the nasal cavity, and it is not fully ossified. Any
deviation in nasal septum contributes to the asymmetry between the
right and left nasal cavities. The nasal structures are best visualised in
the coronal view at the level of maxillary molars.
Nasopharynx communicates anteriorly with the nasal cavity through
posterior nasal choanae, middle ear cavity via the eustachian tubes
posterolaterally and with the oropharyngeal cavity inferiorly. The
base of the skull forms the superior boundary of the nasopharynx, and
the inferior boundary is the soft palate and Passavant’s ridge. The
lateral boundaries are the superior constrictor muscles/visceral fascia.
The adenoid tissues are located in the midline of the roof of the
nasopharynx. The torus tubarius is a soft tissue process on either side
of the nasopharynx that separates it from the eustachian tube. Just
posterior to the eustachian tube lies the pharyngeal recess or fossa of
Rosenmuller and it is included in the evaluation.
Oropharynx: Below the nasopharynx lie the oropharynx and the oral
cavity. The oral cavity is located inferior to the nasal fossa and the
maxillary sinuses. The oropharynx is the area directly inferior to the
nasopharynx and posterior to the oral cavity. The soft palate forms the
superior border. Oropharynx begins at the circumvallate papillae
anteriorly and includes the posterior one-third of the tongue. The
lateral wall consists of lymphoid tissue called palatine tonsils. The
posterior oropharyngeal wall is related to the second and third
cervical vertebrae. On either side of the oropharyngeal airway are
bilaterally symmetrical soft tissue masses; the tonsils and faucial
pillars.
Hypopharynx extends from the level of the hyoid bone to the lower
level of the cricoid cartilage. It is divided into the following three
regions: the pyriform sinus, the posterior wall and the post-cricoid
region. The pear-shaped pyriform sinus is situated on either side of
the pharynx bounded laterally by thyrohyoid membrane and thyroid
cartilage. The posterior and lateral walls of the hypopharynx merge
with the cricopharyngeus. The post-cricoid region is the anterior wall
of the lower hypopharynx and is the interface between the
hypopharynx and larynx.
Segmentation methods
The construction of a patient-specific 3D model of the airway and
paranasal air sinuses from CT/CBCT image requires an accurate
segmentation of a region of interest. The segmentation process could
be defined as the construction of 3D virtual surface models to best
match the volumetric data. Segmentation of a specific structure and
removing all other structures of non-interest will aid in better
visualisation and in the computation of volumes. Segmentation of
airway can be performed manually or automatically.
Manual segmentation
Manual segmentation requires the operator to outline the boundaries
of a particular structure on each slice in coronal, axial and sagittal
views. The operator marks several points and the software draws line
between each point. After the line segmentation, the data are
transformed into a 3D reconstruction image. The extension in x-, y-
and z-direction is measured parallel to the object coordinate system of
the CT dataset. The software automatically determines the first and
last voxel in each coordinate direction. For the volume computation,
the number of voxels belonging to each segment are counted and the
result is multiplied by the volume of one voxel in cm3. The result
obtained by manual segmentation method is more accurate and
allows for a better operator control. Inaccuracies can arise due to the
imprecision of human vision error making it a tedious procedure. It is
a time consuming procedure when compared to automatic and semi-
automatic methods. Hence, the use of manual segmentation method is
almost impractical for clinical applications.
Automated/Semiautomated
Segmentation techniques in medical imaging can be broadly divided
into three classes.22
1. Structural techniques: For example, 3D edge detection

techniques, isosurfaces and level sets.
2. Stochastic techniques: For example, thresholding approaches
and clustering algorithms.
3. Hybrid approaches: For example, region growing and artificial
neutral networks.
There is no segmentation method that provides acceptable results
for every type of medical data set. Some methods can be applied to a
variety of data set, but methods specialised for a particular situation
give better results. Often a segmentation approach could consist of
more than one segmentation algorithm applied one after the other.
The automatic segmentation of the upper airway region particularly
nasal cavity and paranasal sinuses from CBCT scan presents with
difficulty due to noise artifacts and the complex anatomical structures.
The automated methods do not allow the necessary operator control
to correct the segmentation per 2D slice. So the automated
segmentation results are inaccurate when compared to manual
methods. Though the existing software programmes have plugins to
segment the airway, these plugins are the basic segmentation tools
such as threshold based and region growing segmentation techniques.
Thresholding
Thresholding approach is the simple and effective technique in getting
segmentation done in volumes with a very good contrast between
regions. This technique is used as the first step towards segmentation
of the volume of a structure. The threshold value of a particular region
of interest is used which can consist of single or multiple values. If a
single value is used, all voxels with intensities more than the
threshold value is grouped into one segment and voxels less than the
threshold value is grouped into another segment. If it is extended to
multiple thresholds, a region is defined by two threshold values, a
lower limit and an upper limit. The region confined between these
threshold values is segmented. Using single threshold value can
generate errors, especially in volume analysis, but it is certainly more
reproducible than the use of a dynamic threshold. The threshold
interval selection also influences the upper airway segmentation and
volume measurement. The segmentation can be based on: (i) fixed
threshold based segmentation and (ii) interactive threshold based
segmentation. In fixed threshold based segmentation, the threshold
value chosen by the observer is fixed value for a patients’ full data;
whereas in interactive threshold based segmentation the threshold
value may be varied in according to observer’s perception of the
patient’s data. It has been observed that interactive threshold based
segmentation has a high reliability but poor accuracy because this
technique is based on the operator’s visual discrimination of the
airway boundaries, can be influenced by factors, such as lighting
conditions, fatigue, grey-scale ability and visual acuity. Fixed
thresholding eliminates operator subjectivity in boundary selection.
The main drawback of thresholding technique is that depending on
the grey threshold, values similar to air (e.g. thin mucous tissues or
secretions) or identical to air (e.g. noise), or air surrounding the
patient, will be erroneously added in the segmentation. It is sensitive
to noise and intensity in homogeneities. So it cannot be applied to
MRI and ultrasound volumes.
Region growing
Region growing technique is the simplest among the hybrid
techniques. This technique requires placement of seed points by the
user in the region of interest (ROI). The software creates a segmented
region based on a seed point placed. The main drawback of this
technique is that it requires manual interaction to place seed point
(Fig. 31.3). If the ROI is not selected properly, the region will grow
into other regions and segmented accordingly. It is also sensitive to
noise and partial volume effects causing the extracted region to have
holes and disconnections. Mostly in clinical practice, clinicians are
using this region-growing feature to segment airway regions using a
3D tool.
FIGURE 31.3 The placement of seed point for airway volume
analysis (using Dolphin 3D v11.7, Dolphin Imaging & Management
Solutions, Chatsworth, CA).
Commonly used 3D tools to visualise the data acquired from CBCT
include Dolphin 3D (Dolphin Imaging & Management Solutions,
Chatsworth, CA), Mimics (Materialise, Leuven, Belgium), In Vivo
Dental (Anatomage, San Jose, CA). Dolphin 3D provides a quick
upper airway segmentation, but the threshold interval units (grey
levels) are not compatible with other imaging software. Mimics
software provides quick and easy airway segmentation. It has the best
segmentation control and sensitivity. ITK-Snap is a non-commercial,
open source software but it is not as user friendly as Dolphin 3D and
In Vivo Dental.
Segmentation of upper airway

Automatic segmentation of upper airway and paranasal sinuses has
been studied extensively.23–26 All these studies have segmented upper
airway and paranasal sinuses as a single region; segmentation of the
sub-regions (maxillary sinus, frontal sinus, ethmoidal sinus,
sphenoidal sinus, nasal cavity, nasopharynx, oropharynx and
hypopharynx) is a tedious task. Later the semi-automatic
segmentation techniques for evaluating the volume of airway sub-
regions were proposed. These studies used anatomical boundary
definitions to select a volume of interest (VOI) and locate seed point in
selected VOI. A seed point is further converged towards the
boundaries in the selected VOI. The boundary definitions of each sub-
region depend on the pre-defined anatomical landmarks. The exact
definitions of upper airway remain undefined, as the anatomical
limits vary greatly. The anatomical and technical boundary definitions
of pharyngeal airway sub-regions are given in Table 31.1 and of
paranasal air sinuses in Table 31.2. All the required landmarks exist
on the mid-sagittal plane (Table 31.3). Hence, mid-sagittal plane has to
be identified from the whole CBCT scan data. The boundary limits on
mid-sagittal plane are shown in Fig. 31.4.
Table 31.1
Anatomical boundary definitions of upper airway sub-regions

Regions Limits Definitions for the region of interest Landmarks
Nasopharynx Anterior Line perpendicular to FH plane passing through PNS in 1. PNS
sagittal view 2. C2sp
Posterior Line perpendicular to FH plane passing through C2sp
Upper Soft tissue contour of the pharyngeal wall
Lower Line parallel to FH plane passing through PNS, in sagittal
view
Lateral Soft tissue contour of the pharyngeal lateral walls
Oropharynx Anterior Line perpendicular to FH plane passing through PNS, in 1. PNS
sagittal view 2. C3ai
3. C2sp
Upper Line parallel to FH plane passing through PNS, in sagittal
view
Lower Line parallel to FH plane passing through C3ai
Hypopharynx Anterior Line perpendicular to FH plane passing through PNS 1. PNS
2. C2sp
3. C3ai
4. C4ai
Upper Line parallel to FH plane passing through C3ai
Lower Line parallel to FH plane passing through C4ai
Nasal cavity Anterior Line connecting ANS to the tip of nasal bone to N 1. PNS
2. ANS
3. S
4. N
5. Tip of
nasion
Posterior Line extending from Sella to PNS
Upper Line connecting N to S
Lower Line extending from ANS to PNS
Lateral Plane perpendicular to FH plane passing through the
lateral walls of the maxillary sinus
ANS, Anterior nasal spine; N, nasion; PNS, posterior nasal spine; S, sella.
Table 31.2
Anatomical boundary definitions of paranasal air sinuses
S. no. Regions Volume cropping criteria Landmarks

Limits Definitions for region of interest extraction
Lower Line parallel to FH plane passing through
PNS
Lateral Sagittal plane perpendicular to FH plane
passing through the lateral walls of the
maxillary sinus
1 Frontal Anterior Line perpendicular to FH plane passing 1. PNS
sinus through PNS 2. Nasion
Posterior Line perpendicular to FH plane passing
through PNS
Upper —
Nasion
Lateral Sagittal plane perpendicular to FH passing
through the lateral walls of the maxillary
sinus
2 Sphenoid Anterior Line perpendicular to FH plane passing 1. PNS
sinus through PNS 2. C2sp (superior–
posterior point of
second cervical)
through C2sp
Upper —
PNS
maxillary sinus
3 Ethmoidal Anterior Line perpendicular to FH plane passing 1. Nasion
sinus through Nasion 2. PNS
through PNS
Upper Line parallel to FH plane passing through
Nasion
PNS
maxillary sinus
4 Maxillary Anterior Sagittal plane perpendicular to the FH plane, —
sinus passing through the most anterior point of
the maxillary sinus
Posterior Sagittal plane perpendicular to the FH plane,
passing through the most posterior point of
the maxillary sinus
Upper Sagittal plane parallel to the FH plane,
passing through the most upper point of the
maxillary sinus
Lower Sagittal plane parallel to the FH plane,
passing through the most lower point of the
maxillary sinus
Lateral Axial plane perpendicular to the FH plane
passing through lateral walls of the maxillary
sinus
PNS, Posterior nasal spine.
Table 31.3
Landmark definitions in three-dimension
S. no. Landmark Landmark Sagittal Coronal Axial

definitions
1 C2sp Superior–posterior Superior–posterior Superior and Superior first
extremity of the extremity of the middle point visible point
odontoid process odontoid process in on odontoid on odontoid
of C2 mid-sagittal plane process process
2 C3ai Most anterior– Anterior–inferior point Inferior and Inferior first
inferior point of of the body of C3 in middle point visible point
the body of C3 mid-sagittal plane on C3 on C3
3 C4ai Most anterior– Anterior–inferior point Inferior and Inferior first
inferior point of of the body of C4 in middle point visible point
the body of C4 mid-sagittal plane on C4 on C4
FIGURE 31.4 Boundaries of the division of upper airway sub-
regions.
R1- The nasal cavity; R2- nasopharynx; R3- oropharynx; R4-
hypopharynx.
Nasal cavity has a complex anatomy, which requires extensive

manual intervention for accurate segmentation when compared to
other pharyngeal sub-regions. The region of interest (ROI) of nasal
cavity consists of few parts of sphenoidal sinus and ethmoidal sinuses.
Hence, these regions have to be separated manually. Smith et al.27
have proposed a method to segment nasal cavity using coronal view
of the CBCT data. Fig. 31.5 shows the manual segmentation of nasal
cavity using a coronal view.
FIGURE 31.5 Nasal cavity.

(A) Region of interest (ROI) extractions for segmentation of nasal cavity
using a coronal view. (B) 3D view of the segmented nasal cavity
Mimics version 10 (Materialise, Leuven, Belgium).
Although the nasopharynx is a less complex structure compared to

the nasal cavity, the multifaceted boundary needs keen attention
during segmentation. The intersection of sphenoid sinus into the
region of nasopharynx at the boundary is a challenging area for
segmentation. Fig. 31.6 A shows the method used for segmentation of
nasopharynx. The seed point is located in the R2 region for
segmentation of nasopharynx. In the selected ROI, sphenoid sinus is
also present but seed point is located in nasopharynx region. In the
selected mid-sagittal plane, the sphenoid sinus and nasopharynx are
visualised as two different regions. In other slices (of the complete
volume), there may be some inter-connection between these two
regions, which allows the seed point to be grown in the sphenoid
sinus region. This intersected region between sphenoid sinus and
nasopharynx region can be eliminated by visualising every slice and
editing the required slice manually. This intersected region can also be
eliminated by using the Boolean operations in Mimics software. This
intersected region can be subtracted from the originally segmented
region to detect nasopharyngeal region individually. Fig. 31.6B shows
the segmented 3D model of nasopharynx region.
FIGURE 31.6 Nasopharynx.

(A) ROI extractions for segmentation of nasopharynx using the mid-
sagittal plane. (B) 3D view of the segmented nasopharyngeal region
Oropharynx can be easily segmented based on few anatomical

landmarks and the boundary limits as mentioned in Table 31.1. Fig.
31.7A shows the selection of ROI for segmentation of oropharynx. The
seed point is located in the R3 region shown in Fig. 31.7A. The located
seed point grows into the other parts of the oropharyngeal region for
complete segmentation of oropharyngeal volume. Fig. 31.7B shows
the segmented oropharyngeal volume.
FIGURE 31.7 Oropharynx.
(A) ROI extractions for segmentation of oropharynx using the mid-
sagittal plane. (B) 3D view of the segmented oropharyngeal region
using Mimics version 10 (Materialise, Leuven, Belgium).
Hypopharynx is also segmented like the oropharynx. The boundary

limits of hypopharynx are given in Table 31.1. Fig. 31.8A shows the
selection of ROI for a hypopharyngeal region. For the segmentation of
hypopharynx, landmarks required for selection of ROI are: C2sp, C3ai,
C4ai and PNS. The seed point is located in the R4 region (Fig. 31.8A).
This seed point automatically grows into the complete volume of the
hypopharynx. The segmentation of the hypopharyngeal volume is
shown in Fig. 31.8B.
FIGURE 31.8 Hypopharynx.

(A) ROI extractions for segmentation of hypopharynx using the mid-
sagittal plane. (B) 3D view of the segmented hypopharyngeal region
using Mimics version 10 (Materialise, Leuven, Belgium).
Maxillary sinus: The ROI in the slice for maxillary sinus is selected (Fig.
31.9A). Once the ROI is selected, seed point should be located in the
selected ROI, which is automatically grown by region growing
algorithm. The segmented volume may comprise of other regions
such as a nasal cavity and ethmoidal sinuses. The intersected volume
can be separated using the Boolean operations (Fig. 31.9B).
FIGURE 31.9 Maxillary sinuses.

(A) ROI extractions for segmentation of maxillary sinuses using a
coronal plane. (B) 3D view of the segmented maxillary sinuses using
Sphenoidal sinus: The boundary limits for segmentation of

sphenoidal sinus are shown in (Fig. 31.10A). The seed point is located
in R6 region. The segmented volume may contain few parts of the
nasopharynx and ethmoidal sinuses, as the inferior and anterior
borders of sphenoidal sinus are located close to the nasopharynx and
ethmoidal sinus. These intersected regions can also be eliminated by
using the Boolean operations as explained earlier. The segmented
sphenoid sinus volume can be visualised (Fig. 31.10B).
FIGURE 31.10 Sphenoid sinus.
(A) ROI extractions for segmentation of sphenoid sinus using the mid-
sagittal plane. (B) 3D view of the segmented sphenoid sinuses using
Frontal sinus: The boundary limits for segmentation of frontal sinus

requires three landmarks: PNS, Nasion and tip of the nasal spine (Fig.
31.11A, Table 31.2). The seed point is located in the R5 region shown
in Fig. 31.11A, later this seed point grows and segments the complete
volume of frontal sinuses using dynamic region growing algorithm.
Fig. 31.11B shows the segmented frontal sinus volume.
FIGURE 31.11 Frontal sinus.

(A) ROI extractions for segmentation of frontal sinus using the mid-
sagittal plane. (B) 3D view of the segmented frontal sinuses using
Ethmoidal sinus: The boundary limits for selection of ROI is shown

in Fig. 31.12A. The seed point is located in R7 region (Fig. 31.12A). The
original volume selected may comprise of the sphenoid sinus, nasal
cavity and frontal sinus along with ethmoidal sinus, as the selected
ROI comprises of these regions. The intersected volume can be
separated using the Boolean operations. Fig. 31.12B shows the
segmented ethmoidal sinus.
FIGURE 31.12 Ethmoidal sinus.

(A) ROI extractions for segmentation of ethmoidal sinus using the mid-
sagittal plane. (B) 3D view of the segmented ethmoidal sinuses using
Reliability of using CBCT and imaging
software for volumetric airway analysis
The research on density values of air, water and soft tissues using a
soft tissue equivalent phantom indicated that the airway volume
acquired from CBCT is nearly a 1:1 representation of the real volume
and thus concluded that the measurement of the air space surrounded
by soft tissues was accurate. A systematic review that evaluated the
utility of lateral cephalogram to predict 3D airway parameters
concluded that CBCT volumetric airway measurements correlated
better with airway measurements from CBCT-generated lateral
cephalogram than conventional lateral cephalogram. It was also
suggested that the nasopharyngeal and oropharyngeal area
measurement from conventional lateral cephalogram could be used as
an initial screening measurement to predict the upright upper airway
3D volume.28 The use of CBCT has proved to be an accurate method
for measuring anterior nasal volume, pharyngeal volume and a
minimal cross-sectional area in both nasal and pharyngeal area. These
results are confirmed in comparison with acoustic reflection, which is
an accepted tool for studying the airway. Studies also have shown that
CBCT scanners offer an alternative to multi-detector row computed
tomography (MDCT) scanners in the assessment of the oropharynx
morphology.18
There is no established protocol for the threshold that must be used
when airway volume is measured. Alves et al.29 measured the volume
of a negative airway model using Dolphin software at different
threshold values and compared it with the volume of water required
to fill the airway model; which they considered as gold standard.
They found that the threshold value of the 73 used in Dolphin 3D
software was the most accurate to measure airway volume. The
overfilling of selected boundaries is observed while using a threshold
value of 73 in some cases, and hence a threshold value of 50, which is
a midpoint of the threshold range provided by the manufacturer, can
be used for upper airway segmentation. If a single threshold value is
used to measure the airway at both pre-treatment and post-treatment
stage and when images are acquired using the same machine with
same scan protocol, we expect no effect from these variables in airway
measurement.
Factors affecting the volumetric airway
measurements
Airway changes with age and gender: Studies have shown that the
pharyngeal structures continue to grow rapidly from 6 to 18 years of
age in both sexes.30,31 The changes in the airway dimensions also
exhibited sexual dimorphism.32,33 It can be observed that the most
stable period to evaluate the airway dimensions will be 16–18 years.
Head posture: Airflow demands trigger reflex changes in the
posture of the head, mandible and tongue.34 Children with enlarged
tonsils have an extended head posture and an anteroinferior posture
of the tongue.35 It is also important that during the scanning the
patient maintains maximum intercuspation, does not swallow, cough,
speak or do any motor response other than breathing quietly because
these activities can alter the position of the tongue.34
Jaw positions: There is a significant change in airway dimensions
between open and closed jaw positions. The nasopharynx volume
increases with opening while the upper airway soft tissue thickness,
nasal cavity volume, oropharynx volume, most constricted area and
soft palate area is decreased. The area of most constriction also
appeared to move to the location of the oropharynx with the opening
of the jaw or remain in its original position at the oropharynx.36
Craniofacial morphology: Although it was perceived that
craniofacial morphology in different types of malocclusion has a
definite effect on airway dimensions, a current systematic review
found insufficient evidence that the upper airway dimensions differ in
various sagittal skeletal patterns.
Supine versus upright CBCT: The patient positioning during data
acquisition is of great importance in obtaining an accurate 3D image.
The cross-sectional area in the upright position is larger than in the
supine position. In OSA patients, it is recommended to obtain scan in
the supine position to reflect the apneic episodes that occur during
sleep.
Respiratory cycle: Airway space size and morphology vary when
the patient inhales or exhales. It has been shown that the most
restricted region in a subject who is awake, sitting upright and quietly
breathing appears primarily in the oropharynx region.37 If an OSA
patient was an obligatory mouth breather or if the CBCT scan time
was long, the patient would undergo multiple breathing cycles, thus
causing some motion artefact that can affect the resolution of the
airway boundaries.
Technical considerations: The upper airway volume assessment
depends on segmentation accuracy, image quality and threshold
interval selection.38 The CBCT image quality is influenced by several
factors such as the CBCT device’s settings, patient positioning and
management, volume reconstruction and DICOM export. When
scanning is performed with high settings (small voxel size, longer scan
time), the CBCT images are obtained with better spatial resolution.39
Longer scan times might produce motion-related artifacts that could
have some influence on the segmentation accuracy. 3D definition of
the different anatomical regions of the upper airway should be
standardised.40
Clinical implications of volumetric
airway analysis
Airway following mandibular advancement in skeletal class II
malocclusion: It has been observed that the children with skeletal
Class II malocclusions had smaller airway dimensions. So when the
mandible is repositioned forward with functional appliances (FAs) an
increase in the airway space can be anticipated. FAs lead to increase in
the airway dimensions, specifically in the oropharyngeal region.41 The
skeletal and dentoalveolar effects such as the mesial movement of the
lower dentition and the labial flaring of the lower incisors, could cause
anterior traction on the tongue and hyoid bone, thereby causing the
adaptive changes of the soft palate and leading to an increase in
pharyngeal airway dimensions.41,42 A forward repositioning of the
mandible and hyoid bone along with adaptive changes of the soft
palate leads to an increase in the airway dimensions, which may help
decrease the airway resistance and the potential risk of OSA.
Studies on long-term effect of FAs combined with fixed appliances
on growing Class II subjects indicated that the increase in upper
airway dimensions was stable and maintained. The remaining growth
potential, age and gender, and the presence of adenoid during
treatment phase could also influence the effect of FA on the airway.
Rapid maxillary expansion (RME): RME has proved to be a
successful means of increasing the nasal permeability and reducing
airway resistance.43 The breathing pattern changes from oral to nasal
with improvement in nasal patency after rapid palatal expansion.
RME in growing patients with transversal maxillary constriction
might be associated with a short-term increase in the total upper
airway volume and most of the regional airway volumes.44 Therefore,
RME is not recommended alone as a treatment tool for sleep-
disordered breathing or improving nasal breathing without a need for
expansion.45
Airway changes following maxillary protraction: CBCT have been
used for the assessment of the effect of protraction facemask on upper
airway.46 Facilitation of maxillary growth with a maxillary protraction
appliance contributes to a significant increase in the upper airway
dimensions. The benefits are greater with bone-anchored devices than
traditional tooth-borne facemask device.
Orthognathic surgery: The effect of different orthognathic surgeries
varies according to malocclusion types. Orthognathic surgery of
skeletal class II malocclusion showed that mandibular advancement
could widen the oropharyngeal and hypo-pharyngeal airway space,
and maxillary setback can narrow the nasopharyngeal airway space.
Some relapse related to the width of the oropharynx and
hypopharynx occurs on the long-term observation. The hyoid bone
moves superiorly and forward with the advancement of the mandible.
In skeletal class III patients, the upper airway volume decreases
significantly after isolated mandibular setback surgery. After bi-
maxillary surgery involving maxillary advancement and mandibular
setback surgery, upper airway volume is not greatly affected,
although the minimum CSA decreases significantly.47 The upper
airway volume is increased after maxillomandibular advancement
surgery, which has been proved to be effective in the treatment or
reducing the severity of OSA.48
OSA: The most relevant anatomical characteristic of the upper
airway related to the pathogenesis of OSA is a small mini-cross
sectional area.49 The other most commonly used airway parameters in
OSA patients are the anterior–posterior and lateral dimensions. The
presence of OSA is associated with an increase in upper airway
length, a more oval airway shape and decreased lateral dimensions
(Fig. 31.13). The most common site of obstruction during sleep occurs
at the level of the oropharynx, with extension to the hypopharynx.50 It
has been shown that the likelihood of occurrence of OSA is 3.9 times
higher when the lateral dimension of the oropharynx measures less
than 17 mm.51 There is a high probability of severe OSA if the cross-
sectional airway area is less than 50 mm2, moderate OSA if the airway
area is between 60 and 100 mm2 and a low probability of OSA if the
airway is greater than 110 mm2.52 A CT study on 25 adult patients
diagnosed with OSA has shown that most constrictions occur in the
oropharynx with a mean airway volume of 13.89±5.33 mm3 and
surface area of 61.68±12.95 mm2.53
FIGURE 31.13 Airway volume of oropharynx and minimum

constricted area in severe obstructive sleep apnea (OSA) in a
subject (using Dolphin 3D, Dolphin Imaging & Management
Solutions, Chatsworth, CA).
Maxillomandibular advancement combined with genial tubercle

advancement (GTA) procedures have been accepted as the single
surgery that results in successful outcomes for patients with severe
OSA.54 CBCT volumetric airway analysis has been used to measure
the treatment outcome following such surgeries. Even at slightly less
advancement, postoperative CBCT examination revealed that the
oropharyngeal volume was doubled in size, and the surface area of
the minimal axial slice was more than three times in size compared
with the pre-treatment records.
CBCT is static, not dynamic imaging, and static imaging correlates
poorly with OSA. Hence a significant dynamic airway changes can be
expected in OSA patients with dynamic 3D computed tomography
imaging.
Extraction therapy and effects on airway: Pliska et al.55 using CBCT
imaging showed that orthodontic treatment does not cause clinically
significant changes in the volume or the minimally constricted area of
the upper airway based on 3D studies. The airway changes after
premolar extraction, and maximum anchorage in adult patients are
mainly morphological changes with anteroposterior dimension being
compressed in airway cross-section, rather than a decrease in the size
of the airway itself.56 These results suggest that dental extractions in
conjunction with orthodontic treatment have a negligible effect on the
upper airway in adults.
Clinical relevance of paranasal air
sinuses volume
Maxillary sinus studies evaluating the relationship between cleft lip
and palate and sinus dimensions found that the volume of the
maxillary sinus was affected negatively in cleft lip and palate
patients.57 The mouth breathers show a lesser maxillary sinus volume
than normal breathers.58 Impacted teeth affect maxillary sinus
volume.59 When the impacted canines were closer to the maxillary
sinus and aligned with orthodontic treatment, there was a significant
increase in maxillary sinus volume.
A recent study suggested that orthodontic treatment time and
biomechanics were affected by maxillary sinus volume in extraction
cases.60 Studies have reported that sinus expansion is greater after
posterior teeth are extracted, particularly in adult patients.61 When a
tooth is moved through the maxillary sinus a compensatory new bone
apposition before bone resorption in the direction of tooth movement
is required for maintaining the integrity of the sinus wall. In cases
with a more vertical extension of sinus into the alveolar ridge in front
of the teeth to be moved, it poses difficulty in achieving bodily
movement of teeth.
The frontal sinus aplasia/abnormality has been found to be
associated with syndromes involving hypo-plastic nasomaxillary
complex, for example Binder’s syndrome while the frontal sinus is
enlarged in subjects having mandibular prognathism. A 3D study
using CBCT to compare the frontal and sphenoid sinus volume
between skeletal Class III subjects and skeletal Class I subjects showed
that frontal sinus volume of skeletal Class III subjects did not show
any significant difference when compared to skeletal Class I subject,
whereas the sphenoid sinus volume was greater in class III subjects.62
Recent advancements
Newer CBCT scanners have reduced the acquisition time to around 10
s, which will allow control of the respiration phase.40 The CBCT can
be used to not only evaluate airway obstruction but to also predict
difficulties in intubations by using volumetric reconstruction
methods.
The Hitachi MercuRay (Hitachi Medico Technology, Tokyo, Japan)
has a stationary mode of a 10-second recording, which can evaluate, in
real time, movement of the oral and pharyngeal region, such as in
respiration or swallowing. This stationary 10-second mode may prove
to be extremely useful in evaluating amount of the airway changes in
a mid-sagittal view of an awake subject while sitting upright.32
Key Points
The 3D volumetric techniques are now integrated with diagnostic aids
in the orthodontics.
1. The upper airway volume extracted from CBCT images is

almost a 1:1 anatomic representation with an adequate contrast
between airway space and the upper pharyngeal soft tissues.
2. CBCT data is useful in the anatomic assessment of the airway
passage and the adjacent soft tissues, particularly in OSA
patients. This technology assists in the identification of risk
factors contributing to the OSA. The findings of airway
obstruction may be incidental which can prompt an
orthodontist a timely referral to the concerned specialist for the
further investigation and diagnosis.
3. It is critical to understand that the airway volume is not a static,
but a dynamic measure. It is affected by swallowing, phases of
respiration and positioning during scan acquisition. The
accuracy of upper airway measurement depends on image
quality, threshold selection and segmentation method used.
4. The convergence of various 3D imaging techniques has enabled
the introduction of aerodynamic methods like computational
fluid dynamics (CFD) that simulates the patient’s airflow
characteristics.
Although a significant amount of research has been done on

volumetric evaluation of airway using CBCT, the assessment of the
functional part of the airway is still a challenge to the researchers and
the clinicians.
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SECTION VII
Removable orthodontic
appliances
Chapter 32: Role of removable appliances in contemporary

orthodontics
Chapter 33: Invisible removable appliances: The Clear Aligners
CHAPTER 32
Role of removable appliances in
contemporary orthodontics
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Recent advances in the removable appliance
History of removable appliance
Indications of removable appliances
Advantages
Treatment effectiveness
Hawley appliance and bite plate
Passive components
Retentive components
Active springs
Expansion of the arch
Steps in appliance fabrication and clinical management
Clinical considerations
Clinical procedures
Laboratory requisition and appliance design
Considerations for efficient removable appliance
Appliance delivery and activation
General considerations
Activation of the appliance
Anterior bite plane
Posterior bite plane
Activation of the active wire components
Follow-up for activation
Methods of disinfection
Indications of removable appliances therapy
Correction of cross-bite of anterior teeth due to a local cause
Case report
Case study
Correction of anterior proclination
Case study
Class II division 2 malocclusion
Correction of ectopic canine
Integration with fixed appliance
Avoidable complications of removable appliances
Crozat appliance
Key Points
Introduction
By definition, removable appliances are those, which can be removed
and inserted in the mouth by the patient.
Although the scope and use of the removable appliances have now
reduced significantly as a primary therapeutic appliance of choice for
comprehensive orthodontic treatment, these appliances are suitable
and efficient in the treatment of certain traits of malocclusion when
used in isolation or tandem with fixed appliance system.
Conventionally, a majority of orthodontic retainers are removable
appliances.
A majority of the functional appliances (FA) are removable, though
this group of appliances is considered as a separate entity.
Recent advances in the removable appliance

The transparent aligners, first introduced in the United States in 1999,
were aggressively promoted by ‘Invisalign’. These clear aligners do
have an aesthetic edge over visible fixed appliance as ‘invisible braces’
due to their transparent colour and lack of metal components. Clear
aligners are now made available by many orthodontic traders in
different names throughout the world. The clear aligners are
discussed in detail in a separate chapter.
History of removable appliance
Historically, the development of the fixed appliances preceded that of
removable appliances.1 Pierre Fauchard, father of modern dentistry, in
his 2- volume opus entitled, ‘The Surgeon Dentist: Treatise on the
Teeth’ published in 1728 described the bandeau, an expansion arch
consisting of a horseshoe-shaped strip of precious metal to which the
teeth were ligated.
Removable appliance. A German dentist Friedrich Christoph Kneisel
(1797–1847) was the first to use plaster models to record malocclusion
in 1836. He also used chin strap for his prognathic patients, which
perhaps was the first removable orthodontic appliance. He also used a
removable plate quite similar to the bite plate used nowadays (Fig.
32.1).
FIGURE 32.1 A contemporary Hawley appliance and its

components.
Further evolution of the removable appliances was linked to the

development of the process of rubber vulcanisation. The invention of
vulcanite by Charles Goodyear in 1839 significantly reduced the cost
and weight of dental plates and other appliances. The earlier attempts
to commercialise the new material were not practical because of
unstable properties of the rubber. It softened when heated and was
partially soluble in water. Later when Goodyear accidentally
discovered ‘sulphur cross-linking’, rubber became a functional
material.
Discovery of polymethyl methacrylate (PMM) and its use in
dentistry substituted vulcanite plates with acrylic for orthodontic
appliances.
The labial bow was first introduced by Charles Hawley sometime
around 1919 (Fig. 32.1).
Adams’ arrowhead clasp is perhaps the most widely used clasp for
retaining removable appliance.
This clasp is a modification of the original Jackson’s clasp (1906) and
is superior in retention properties of arrowhead clasp given by
Schwarz.2
The modified arrowhead clasp, which is popularly known as
‘Adams’ clasp’ was introduced by Adams in 1950.3
Removable appliances have developed and evolved considerably over
time from their original design. However, their inherent mechanical
properties are such that they are most effective only for simple tipping
of teeth. Multiple simultaneous tooth movements with apical control
are not possible with them.4 They are most effective in correcting:5
1. Cross-bite
2. Ectopic tooth position
3. Anterior spacing and overjet
4. Deep bite
5. Targeted yet limited interventions in the mixed dentition5
6. As an adjunct to more complex treatment with fixed
appliances.
However, they are less efficient in treating:5
1. Crowding
2. Rotations
3. Intra-arch tooth movements and
4. Correction of molar relationships
Advantages
1. Simple to fabricate, use and adjust, hence may require minimal
chair time in the hands of an expert.
2. Less orthodontic scars compared to fixed appliances such as
decalcification, dental caries under molar bands and white
spots around bonded brackets and gingivitis.
3. Cost-effectiveness.
4. Removable appliances are the appliances of choice in the first
stage of the correction of a posterior cross-bite.6
5. They are used commonly during mixed dentition for the
treatment of a variety of interceptive procedures. If one
considers the factors of risk and the relationship between work
volume and effect, removable appliances deserve preference.7
It can be removed by the patient and therefore in non-compliant
patients, treatment may be disrupted. However, the ability to remove
the appliance at socially sensitive occasions is a great advantage for
some patients such as TV anchors and news readers.
1. Limited control over tooth movement.

2. Only certain types of malocclusion can be corrected.
3. Tooth movement in the three-dimensions of space is not
possible.
4. May hinder with speech and eating.
5. Appliances may be lost or broken.
6. Residual monomer of acrylic resin may cause allergy and
irritation.
Treatment effectiveness
When treatment effectiveness was measured by improvement in
occlusal index (OI) scores, a severity of malocclusion obtained from
pre-treatment and post-treatment study casts revealed that treatment
efficiency and the treatment results of the removable appliance were
found to be inferior to those of the fixed appliance.8 Hence, the use of
the removable appliances should be limited to the specific indications
or as an adjunct to the fixed appliance therapy.
Hawley appliance and bite plate
These are synonymous with removable appliances that are made of
acrylic base plate and wire components.
Components of a Hawley-type removable appliance are as follows
(Figs 32.1 and 32.2):
1. Passive components or body or plate

2. Retentive components
3. Active components: springs, labial bow
Passive components
The body of the appliance usually covers palate up to the second
molar region. The acrylic plate is made of self-cure acrylic or heat cure
material on a dental cast of patient’s dental impression. Following
acrylisation, the appliance should be left embedded in water
overnight before delivery to ensure that any residual monomer should
either react with PMM or is leached out.
The wire components of the appliance such as a labial bow, clasps
and springs are retained in the acrylic body. The acrylic body should
be of sufficient thickness to ensure optimum strength and rigidity to
hold wire components. Fibre-reinforced composite (FRC) can be
added during acrylisation to reinforce polymeric parts of a removable
orthodontic appliance.
The acrylic body provides anchorage to the appliance by its
intimate contact with the oral mucosa and contour of the palate. Well-
adapted acrylic extensions into the inter-dental embrasures and
retentive wire components, which anchor on to the teeth, ensure the
stability of the appliance. The appliance should be well fitting, not to
cause any undue pressure on oral soft and hard tissues and remain
stable.
Retentive components
Retentive elements of the appliance are made of stainless steel (SS)
wire which retain the appliance in the oral cavity mostly through
clasp-like structures wrapped around teeth or between the teeth.
Although several types of retentive clasps have been designed, the
simpler ones are better for the ease of fabrication and adjustment.
Commonly used retentive clasps are:
• Ball end hooks/pin head

• Passive labial bow
• Arrowhead clasp: single or double
• Delta clasp
• C-clasp
• Adams’ clasp
Wire dimensions used for making components of removable

appliances (RA) are tabulated in Table 32.1.
Table 32.1
Suggested wire dimensions for different components of
removable appliances
Ball end hooks, pin head hooks and single arrowhead clasps: These
provide retention by engaging their head into the buccal interdental
embrasures gingival to the contact point. The retention clasps are
mostly used in the posterior segment commonly between the
premolars. The clasps should be well adapted on the embrasure to
minimise any interference with teeth in the opposite jaw during
occlusion.
C-clasp: C-clasp and wrap around clasps provide retention due to
their placement on the crown gingival to maximum contour of the
buccal surface of the premolars and molars.
Adams’ clasp or double arrowhead clasp: Devised by C.P. Adams is
most commonly used retention clasp which engages the first molar
and is often a major retaining device. It is a modification of Jackson’s
clasp (Fig. 32.2B). The double arrowhead clasp can be modified to
serve additional functions such as holding elastics for traction with
modification in its original design. The most useful modification is a
traction hook or a loop. The arrowhead clasp can also be modified by
soldering a hook on its buccal bridge or by making a helix in the
horizontal arm to engage the elastics (Fig. 32.2D).
FIGURE 32.2 Retaining clasps.

(A) C clasp and pin head clasp. (B) Jackson’s clasp. (C) Modified
Adams’ clasp with built-in helix. (D) Modified Adams’ clasp with
soldered hook. (E) Triangular head clasp.
Delta clasp: It is a modification of Adams’ clasp, an excellent

retentive clasp to be used on premolars. Delta calsp is recommended
by William Clark as a retaining component of the lower twin block on
the premolars.
South end clasp: It is a short labial bow wrapped around two central
incisors designed to hold the appliance in the anterior end.
Labial bow: Conventionally, the labial bow is made as a wraparound
wire around six anterior teeth, up to distal contact point of the
canines. The loops usually are made about two-thirds the width of the
canine’s mesiodistal width. The height of loops is extended 2–3 mm
beyond the free gingival margin of the canine (Fig. 80.7B). The long
labial bow can extend distal to the first premolars, second premolars
and even wrap around distal to the last erupted molar as the case may
necessitate.
A passive labial bow serves to anchor the appliance in situ and
maintains the position of the teeth. When activated with sufficient
relief on the palatal surface of the anterior teeth, it slowly retracts the
anterior segment. A labial bow is an effective device to retrocline, the
labially proclined incisors. Retroclination of the incisors makes them
look longer due to the extrusion associated with lingual tipping.
Extrusion of maxillary incisors is rather difficult to control, which
results in further increase in deep bite, and increased incisor visibility
(Fig. 32.3). A conventional labial bow has a very limited range of
action.
FIGURE 32.3 A, B) The bite opening should be achieved before

initiation of incisor retraction. (C) The labial bow activation is initiated
after bite opening and due trimming of acrylic on palatal surface of the
plate to provide relief for the anterior teeth. (D) After incisor retraction.
The lingual crown tipping is associated with some amount of extrusion.
A modification of removable appliance, where elastic traction force

can be used to enhance lingual tooth movement and also prevents
extrusion or causes effective intrusion, involves a conversion of labial
bow loops into hooks, at a level higher than the gingival contour of
the canines. A light elastic (2.5 ounces Begg elastic) substitutes labial
bow, which runs from either side of the hooks and below the small
tags of light cure composite attachments temporarily bonded on
incisors to receive the rubber band. The modified labial bow is a
compromised substitute of an intrusion arch used in full fixed
appliance.
Several modifications of the labial bow are suggested. These include
reverse loop labial bow (Fig. 32.4A–B), Mills labial bow (Fig. 32.4C)
and Roberts’ retractor (Fig. 32.4D).
FIGURE 32.4 Modified labial bows.

(A–B) Reverse loop labial bow. (C) Mills labial bow. (D) Roberts’
retractor.
Roberts’ retractor: It has an efficient spring design made from 0.5 mm

diameter SS wire. The distal arm is supported with a tube. The
retractor is adjusted just below the helix on the mesial arm of the loop
by compressing the loop. The appliance produces light forces, which
are efficient for the correction of proclination of teeth. Activation up to
3 mm/visit is recommended (Fig. 32.4D).9
Hawley appliance is used as a retainer device following completion
of extraction or non-extraction treatment. The labiolingual position of
the anterior teeth is maintained by incorporation of the first order
bends in the labial bow, similar to the intensity of the prescription of
the fixed appliance used in the treatment of the malocclusion (Fig.
80.9).
Active springs
The active springs are made of 18/8 stainless steel medium spring
temper hard wire.
Labial or buccal tipping of anterior teeth can be achieved with a Z
spring. Z spring is the most commonly used spring to correct cross-
bite of maxillary central/laterals (Fig. 32.5). The spring activates by
PUSH from lingual surface of a tooth.
FIGURE 32.5 Z cantilever spring (0.5 mm wire) for labial

movement of anterior teeth.
Palatal tipping of the anterior teeth is achieved with an active labial

bow.
Mesial/distal tipping of tooth: The mesiodistal tipping is possible with
finger spring (Fig. 32.6A). The amount of activation and length of the
free arm has significance in the delivery of force. Longer the activation
arm greater is the range of action.
FIGURE 32.6 Springs used for mesial/distal tipping of teeth.

(A) Finger spring/single cantilever spring. (B) Buccal canine retractor.
(C) Palatal canine retractor.
A palatally originating finger spring can be designed for distal

tipping of the canine (Fig. 32.6B).
Finger springs can be used to regain space in the anterior segment,
which has been partially lost due to the migration of adjacent teeth.
Space loss can occur in the anterior region in children with missing
lateral incisors when canine tends to erupt mesially.
Finger springs can also be used for closure of spaced dentition, like
a diastema, which does not require bodily tooth movement.
Ectopically erupting buccal canine: The canine retractor is prepared as
a closed helix in the premolar region. It is a method for alignment and
retraction of the canine (Figs 32.6B and 32.7). Fig. 32.7A–C shows use
of buccal canine retractor on buccally placed canines. The palatal
canine retractor is aesthetically acceptable (Fig. 32.6C).
FIGURE 32.7 anine retraction spring (A, B, C) Buccal canine retractor
was used in this patient for alignment of buccally placed canines.
Expansion of the arch
Maxillary and sometime mandibular arch expansion can be achieved
with the incorporation of a parallel expansion screw or jack screw
(Fig. 32.8). The expansion of the dental arch is produced in transverse
dimension.
FIGURE 32.8 Removable expansion appliance.
Orthopaedic dentoalveolar protraction of the anterior segment of

the maxilla can also be achieved with a special expansion screw
placed in the desired direction.
Three-dimensional expansion screws can simultaneously produce
transverse and anteroposterior movement of the teeth.
Steps in appliance fabrication and
clinical management
Clinical considerations
1. The most important consideration when treating a patient with
RA alone should be: ‘Is this the best appliance’ for the type of
correction required? or ‘Would the treatment with removable
appliance under consideration can result in a compromised
treatment outcome?’
2. The treating orthodontist and the patient should be aware of
the limitations of orthodontic treatment with the removable
appliances. Treatment with removable appliance can be a
conscious decision, based on several considerations including
the cost of treatment.
3. The diagnosis and treatment plan should be clearly formulated
and documented. Malocclusion situations may require more
than one appliance or a series of appliances, and if so, the
sequence of mechanotherapy should be planned in advance
including retention protocol.
4. Patient’s oral hygiene status, periodontal health and caries
susceptibility should be assessed. All prophylactic or
therapeutic procedure required for the optimisation of oral
health should be instituted before initiation of the orthodontic
treatment.
5. Treatment with removable appliance does not in any way
ignore the fundamentals of orthodontic treatment planning
and diagnosis.
Clinical procedures
1. Removable appliances can be fabricated on good quality dental
working models prepared from fresh alginate impressions.
Duplicate study casts can be prepared. The first set can be used
as working models and the second set is retained for diagnosis
and records.
2. Patient’s identification by name or hospital registration number
should be clearly labelled along with the date.
3. A wax bite in centric occlusion is recorded, which serves as a
guide to articulate the models without errors.
4. In patients with dual bite, midline shift and functional shift,
more than one wax bite may be required. Usually, two wax
bites are recorded. First one is taken in occlusion and second at
first contact in occlusion.
5. Dental working models should be carefully examined for
details of the recording of the tissues that need to be covered
with acrylic, the retentive area and teeth to be moved. The
dental casts should be checked for any air bubbles and
undercuts that should be blocked with plaster. Frenum
locations are highlighted especially those which are likely to
interfere with the appliance.
Laboratory requisition and appliance
design
The orthodontist should clearly draw the extension of the appliance,
thickness and inclination of the bite plane, the design of retentive
components, labial bow and the active components such as springs.
The dimension and temper of the wire of each of the components
should be clearly written. Any special considerations such as
undercuts or high attachments of the frenum should be highlighted.
Should there be a change or modification of the conventional wire
framework due to anatomical considerations, mechanical
requirements or nature of the malocclusion should be clearly
indicated. The design of the appliance is drawn on the model and
Orthodontic Laboratory Requisition Card.
The appliance is accordingly fabricated for the wire framework,
double-checked and later cured in cold cure acrylic, finished and
trimmed. The finished appliance is stored in water at room
temperature and when transported should be sealed in a watertight
container or poly packs. The packs should be clearly labelled with
patient details. The working models are preserved till the time
appliance is delivered to the patient, as these may be required for any
modifications of the appliance.
Considerations for efficient removable
appliance
Wires of medium hardness are used for making springs. The wires
show work hardening during the process of wire bending, which is in
certain situations used to clinical advantage.
A helical bend in a spring gets work hardened and therefore shows
springiness in the direction of bending. The placement of a spring for
the desired direction of tooth movement should accordingly vary.
For canine retraction into the extraction space of the first premolar,
a labial helical canine retraction spring should be placed between
second premolar and first molar (Figs 32.6B, 32.7). Alternatively a
palatal spring, placed lingually to canine would produce the same
movement in archival fashion, the destination being more palatal than
desired Fig. 32.6C.
Appliance delivery and activation
General considerations
1. The appliance should be well fitting in the mouth and over the
dental arches with gentle pressure and should retain well. A
check should be made for any sharps or bubbles with the pulp
of the index finger. Sharps in acrylic or wire components are
the common cause of ulcers and injuries on soft tissues.
2. All wire ends should be blunt and located/adapted so as not to
cause any irritation and trauma to oral tissue. Only a
comfortable appliance can encourage a patient of its use and
develop the confidence in the treating doctor.
3. The appliance should be carefully evaluated for any undue
extensions on the palate, movements of lower lingual area and
frenum of the tongue. Any injury or excessive pressure arising
from wire components such as clasps on inter-dental papilla,
gingival and oral mucosa from loop(s) of the labial bow should
be checked.
4. The palatal extension of the acrylic plate at finish line should be
thin gently merging with the palatal mucosa. It should be
smooth on the tongue and not cause any irritation or gagging.
5. The lingual flanges of the lower appliance should have
sufficient thickness at borders, which are rounded and smooth
similar to a full denture border. It should not impinge on
lingual frenum. The undercuts should be blocked on plaster
models before appliance fabrication.
Activation of the appliance

It is usually deferred till sufficient bite opening is achieved, especially
while retracting maxillary incisors. However, correction of anterior
cross-bite, maxillary expansion and canine retraction can be initiated
as soon as the patient is comfortable with the appliance.
Anterior bite plane
The purpose of anterior bite plane is to disengage posterior teeth,
create an interocclusal gap and thereby allow supra-eruption of the
buccal segment. The forces generated by the elevators and retractors
of the mandible are transmitted to the lower anterior teeth, which can
prevent their supra-eruption, cause some amount of intrusion and
flare them labially, all of which contribute to the flattening (bite
opening) of the lower curve of Spee.
The bite plane thus becomes a major active component of the
appliance and requires a careful consideration of:
• Height of the bite platform.

• The inclination of bite platform.
Height of active bite plane

Anterior bite plane is expected to be at a height (thickness) so as to
create at least 2–4 mm of interocclusal gap amongst posterior teeth.
Essentially, the depth of curve of Spee and occlusal level of lower
incisors would govern the height of bite plane in the anterior region.
In severe deep bite where lower incisors are excessively supra-
erupted, a little thickness of acrylic in the anterior region would be
sufficient to disengage the posterior teeth while in other situations of
minimal deep bite a much thicker bite plate would be required.
Unusually high bite plane may cause undue pain and trauma to the
masticatory muscles, TMJ and lower incisors. This may also cause
unfavourable clockwise rotation of the mandible, which may not be
desired. The excessive height of bite plane would also lead to
undesired forces on lower incisors resulting in their labial
proclination. It is desired that anterior bite plane may be gradually
raised as clinician monitors the bite opening in progress.
The inclination
A bite plane that is vertical to the long axis of lower incisors is desired,
which is expected to generate forces parallel to the long axis and
therefore causes intrusion of the incisors.
A forward or reverse inclination is desired in mild class II cases,
where along with bite opening, settlement of the posterior occlusion
to class I are the objectives. In essence, very development of the
functional appliance is linked to the accidental discovery of settlement
of posterior occlusion to class I, following wearing of a retention bite
plate in a girl child who had residual mild class II molar relation at the
time of debonding.
The appliance with a reverse incline is useful in growing children
with a mild superior protrusion, deep bite and mandibular retrusion.
The effects of the appliance are opening of bite and forward posturing
of mandible similar to those of a functional appliance. Reverse bite
plane is also used as a retention device during settlement phase or
following active twin block appliance therapy.
Some clinicians would like to ‘lock’ the lower incisors in a desired
forward position of the mandible by the creation of incisal edge
indentations in the bite platform. This technique works well, but it can
transmit the forces of retractors of the mandible to the lower incisors,
causing them to flare labially. Hence, a strict vigil on incisor
proclination would be desired.
Posterior bite plane

The posterior bite plate is desired in a removable appliance to
disengage lingually locked upper anterior teeth.
A posterior bite plate is also needed to enhance the maxillary
expansion when used independently or in conjunction with bonded
fixed mechanotherapy. A unilateral cross-bite is often the outcome of
convenient shift of the mandible due to bilateral maxillary
constriction. A maxillary expansion appliance with posterior bite
plane would disengage the mandible from its laterally locked position
and enhance maxillary expansion. Posterior bite plane is also useful in
bilateral posterior cross-bite with similar benefits.
Activation of the active wire components

The active wire components of the removable appliances, that is
springs or labial bow make a point contact with the tooth surface.
They are likely to produce tipping movements. The centre of rotation
of a tooth is about 40% of the length of root from root apex.10 A
tipping force on the crown is likely to tip the root in the opposite
direction.
While tipping type of tooth movement may not be desired in most
of the situations, it can, however, be minimised with judicious
application of point of force application as close to the centre of
rotation as possible within the clinical and bioengineering limits of
clinical crown and appliance.
The tooth movement with tipping forces is usually 1–2 mm/month.
The springs can be activated 2–3 mm during initial insertion and
followed up at monthly intervals. Use of a light force of 20 g is enough
to produce tipping movement of single-rooted tooth. Over activation
of the appliance should be avoided.
Over activation of the appliance can lead to a disastrous outcome
such as pulpitis, pulp necrosis and root resorption.
The appliance is issued with the instructions of its proper use and
care. The child should be demonstrated insertion and removal of the
appliance and asked practice while in the clinic. Parents or guardian
should be also briefed and explained the use of the appliance and
supervise the child in its proper use (Box 32.1).
Box 32.1 Guidelines of removable appliance

activation
1. The path of tooth movement should be free of any obstructions

(a common mistake with the beginners).
2. The retraction/tipping of maxillary incisors should not be initiated
until sufficient bite opening has been achieved. Early retraction
of the anterior maxillary teeth will further cause extrusion and
relapse.
3. Activated labial bow appliance without sufficient relief of
acrylic base plate for incisor retraction is a common mistake.
The palatal acrylic is so trimmed that it would allow greater
movement of the incisors at the cingulum, thereby minimising
tipping at the incisal edge.
4. The conventional labial bow should uniformly touch labial
surfaces of all the teeth being retracted. To retract a single
malpositioned incisor, labial bow activation should be minimal
and gentle. Heavy forces can produce pain, pulpitis leading to
a non-vital tooth.
5. For distal canine retraction, enough acrylic should be removed
in the alveolus area to accommodate large buccolingual
dimensions of the distally moving maxillary canine.
6. To minimise tipping and rotation during canine retraction, the
point of contact of the activated spring arm should be as
gingival as possible without damaging the gingiva.
7. The free end of the retraction spring should gently touch the
mesial surface of the canine at its neck on its entire labiolingual
thickness. It is slightly extended to passively turn around on
labial surface for palatal canine retractor and palatal surface for
labial canine retractor.
8. The premolar should be prevented from mesial tipping and
anchorage loss with the ‘C’ clasp on its mesial proximal surface.
It may require to be gently activated in a distal direction if the
anchorage loss is anticipated.
Follow-up for activation

The orthodontist would review the patient back in about a week’s
time or even next day to check for any discomfort or difficulties,
which should be resolved immediately. Further follow-ups are
usually scheduled on monthly basis. However, nature of malocclusion
and type of activation could alter this schedule as the need may be.
During bite opening, if no other major tooth movements are being
undertaken in a cooperative child, the review can be extended for 8
weeks or so.
Speech problems: Problems with articulation are encountered
immediately on insertion of the appliance in the mouth. The coverage
of the palate by the plastic component of the removable appliance and
bite plane interfere with the normal positioning of the tongue in the
mouth. Altered tongue posture, encroachment on the tongue space
and a lack of sensory contact with palate make pronouncing words
difficult. The labiodental and labio-palatal sounds such as ‘s’, ‘f’ and
‘th’ sound, for example are most affected. Regular and persistent wear
of the removable appliance allows the tongue to adapt quickly to its
new environment. Normal speech patterns will return shortly usually
by one week.
Increased caries susceptibility: The use of removable appliances may
lead to the creation of new retentive areas and additional surfaces for
plaque, which favour the local adherence and growth of mutans
streptococci (MS) which favours high risk for caries. Therefore,
children under orthodontic treatment with removable appliance
should remain under careful monitoring for risk of caries
development.11
Methods of disinfection
There is a concern with the formation of biofilm on the appliance
surface and adherence of contamination by oral bacteria and biofilm.
Spraying with Periogard, which contains 0.12% of chlorhexidine
gluconate, showed significant efficacy in reducing MS
colonies/biofilms on acrylic surfaces.12
Retention: The last appliance of the series of active appliances can be
converted into a passive retention appliance. The maxillary expander
could be sealed in the mid line with light cure composite or acrylic
once the desired expansion has been achieved. A definite retention
appliance protocol varies with the type of malocclusion and
mechanics used (refer to chapter 80).
therapy
1. Anterior cross-bite
2. Correction of deep bite
3. Anterior proclination
4. Class II division 2 malocclusion
5. Ectopic canines
6. Integration with fixed appliance
Correction of cross-bite of anterior
teeth due to a local cause
This is effectively achieved with the help of Z spring(s) palatal to the
incisor(s). The posterior bite plate on premolar–molar area disengages
the incisors, and the Z spring(s) causes labial tipping of locked
incisor(s) quickly. This is especially true during early mixed dentition
stage where the correction may take place in a few weeks. This is an
appliance of choice for correction of anterior cross-bite to be used by
the general dentist Fig. 32.5.
Case report
Cross-bite of a maxillary incisor in a case of class I
occlusion
Case AN, a young girl in mixed dentition stage had her incisors, first
premolars and first molars erupted in class I occlusion. The maxillary
right central incisor erupted in cross-bite and showed signs of attrition
on the incisal third of the labial surface due to functional interference
caused by lower incisors. The right maxillary lateral incisor was
rotated mesio-palatally with a tendency for a cross-bite. The arches
were sufficiently wide with no signs of arch length deficiency. This
young girl was treated with an upper removable appliance (URA)
having palatally placed Z springs. The appliance was retained with
Adams’ clasps and posterior bite plate sufficient to disengage the
anterior locked bite. The labial bow was not required. Cross-bite
correction was rapid and required no retention following correction of
anterior cross-bite of local origin (Fig. 32.9).
FIGURE 32.9 Correction of anterior cross-bite of the right
maxillary central incisor with an upper removable appliance.
Case AN, female: (A) Pre-treatment study models. (B) Post-treatment
study models, cross-bite is corrected. Note attrition of labial enamel
due to traumatic bite.
Correction of deep bite

The appliance with its bite plane promotes supra-eruption of buccal
teeth, which leads to a bite opening. There is a simultaneous forward
positioning of the mandible. A growing class II patient, who has a
favourable growth pattern or a horizontal grower with mild to a
moderate superior protrusion, can be efficiently treated with this
mode of therapy used judiciously and effectively.
Case study
Case MS, a young girl in mixed dentition stage, had her first molars
erupted to half cusp class II on the right side and little more severe
class II on the left side with a tendency for class II relationship, an
overjet of 6 mm and deep bite. The lower incisors were in contact with
the palate. Maxillary arch was slightly oval and narrow in the anterior
region.
Treatment with a removable appliance and anterior bite plate
successfully caused a forward shift of the mandible resulting in class I
molar relation, an opening of bite and a good arch form. Such a case
needs to be under constant observation as the bite plate has produced
a functional appliance-type effect. It is hoped that this child would
have a normal growth pattern of the face and continue to grow
normally leading to class I occlusion (Fig. 32.10).
FIGURE 32.10 Case study: bite opening.

(A, C) Pre-treatment models of a young patient in early mixed dentition
stage. Note a V-shaped arch, end on molar relation, deep bite and
large overjet. (B, D) Marked with arrows, post-treatment occlusion.
Improved arch form, improved labial inclination of maxillary incisors and
bite opening. Note spacing mesial to maxillary first molars caused by
modified arrowhead clasp.
Correction of anterior proclination
Dentoalveolar protrusion with mild spacing can be effectively treated
with URA. Case selection is the key to success. A young child whose
maxillary incisors are proclined, which are NOT likely to interfere
with lower incisors and unlikely to extrude a lot, can be treated with
URA. In more mature patients, difficulties of bite opening and
availability of the space should be carefully evaluated while
considering retraction of the anterior teeth.
Case study
An adult patient with spacing in the lower anterior segment and large
spaces of 4 mm distal to right maxillary lateral incisor 2.5 mm distal to
left maxillary lateral has class I molar relation (Fig. 32.11). It appeared
that maxillary anterior tooth material also had Bolton discrepancy,
and thereby exhibiting increased spacing in the upper arch coupled
with proclination.
FIGURE 32.11 Case study: space closure.

(A) Pre-treatment study models of an adult female with dental
proclination and spacing in upper and lower arches. Such cases often
are associated with tongue thrusting habit, which should be
simultaneously treated. (B) Post-treatment. The upper and lower
incisors are correctly placed on denture bases, spaces are closed, and
both arch forms have improved. The maxillary central incisors are
under torque, which is a limitation of the removable appliance. Residual
spaces distal to 2/2 are due to their small mesiodistal widths. These
spaces can be corrected with aesthetic composite build-up, thus
restoring the contact points.
The patient was treated with upper and lower removable

appliances. Lower labial bow efficiently retracted lower incisors in the
available spaces, thereby placing them rather upright on the basal
bone. The bite platform of the maxillary arch prevented their
extrusion while being retroclined.
The maxillary appliance was activated for retraction of the
maxillary incisors into the spaces available, and the over jet created by
retraction of lower incisors.
Maxillary incisors retroclined to normal labiolingual inclination and
overjet was normalised. However, a good proximal contact could not
be achieved between maxillary laterals and canines. As there was an
apparent Bolton discrepancy with smaller size central incisors and
laterals. Restoration and aesthetic buildup with tooth coloured
composite serves as an adjunct to orthodontic therapy in such clinical
situations.
Class II division 2 malocclusion is characterised by a distally
positioned mandible due to the retroclined maxillary incisors and
severe deep bite. In growing children once the retroclined maxillary
incisors are placed in correct inclination, the lower jaw tends to
reposition forward. Patient (AS) who had a classical class II division 2
malocclusion, deep bite and mild anterior crowding responded
favourably to bite opening and proclination of maxillary central
incisors with Z springs. The maxillary arch was aligned with a
combination of retroclination of maxillary lateral and proclination of
central incisors (Fig. 32.12).
FIGURE 32.12 Case study: class II division 2 malocclusion.
Class II division 2 case treated with URA. (A, C) Pre-treatment. A
typical class II division 2 pattern. Retroclined central incisors lock the
mandible distally. The lower anterior arch has mild crowding. (B) Post-
treatment. Z springs palatal to maxillary centrals and labial bow aligned
maxillary anteriors in a combination of major labial movement of
centrals and some palatal movement of maxillary laterals load was
used for treatment. With bite opening and labial inclination of centrals,
mandible is unlocked and repositioned forward resulting in class I
buccal occlusion, normal overjet and overbite. (A) Red lines in indicate
class II molar relationship. (B) Which improved to class I molar and
canine relationship. (C) Arrows show the direction of the movement of
the incisors.
A favourably inclined bite plane, labial bow and Z springs brought

out successful treatment of this class II division 2 malocclusion.
Dentoalveolar growth in mandible provided enough space for mildly
crowded mandibular anterior teeth for their self-alignment.
Correction of ectopic canine
The high and labially placed canine can be aligned to a reasonable
degree of normal position and axial inclination with the canine
retractor appliance. Cases where canine root tip is favourable, that is
placed distally and the crown is mesially inclined are good candidates
for removable appliance treatment, provided there is enough space in
the arch to accommodate them.
Fig. 32.13 represents a case, which required extraction of all first
premolars, treated with a removable appliance.
FIGURE 32.13 Case study: correction of ectopic canine.
(A) Pre-treatment models showing moderate crowding in both upper
and lower arches, blocked out, right maxillary canine, upper midline
shift to the right side. This patient was treated with upper and lower
removable appliance following extraction of all first premolars, ‘ × ’
indicates sacrificed tooth. (B) Post-treatment models. The canines were
first distalised with canine retractors followed by correction of cross-bite
of right maxillary lateral and alignment/retraction of anteriors into
residual spaces. The right maxillary lateral incisor shows attrition due to
occlusal interferences and needs to be restored with tooth-coloured
composite. A more significant challenge in these cases lies concerning
anchorage control and judicious use of the labial bow, canine retraction
springs and Z springs.
Integration with fixed appliance
URA with posterior bite plate is integrated with fixed appliance
during unlocking the anterior teeth, which are in cross-bite. Appliance
with anterior bite plate does help in the rapid dental expansion of the
posterior segment when used in conjunction with the fixed appliance.
URA is a useful adjunct for bite opening in subjects with extreme
horizontal growth pattern who show significant supra-eruption of
posterior teeth. Such patients whose incisor visibility is already
compromised would not greatly benefit with the intrusion of anterior
teeth with fixed appliance. Anterior bite plate in such cases is used
either in conjunction with fixed appliance or as a pre-fixed appliance
modality.
Avoidable complications of removable
appliances
1. Pain in teeth due to over activation of the wire components.
The activation should be gentle and should not produce a
force of more than 20–40 g/tooth.
2. Appliance activated, but tooth has no freedom to move. This
might result in severe pain, non-vitality and tooth extrusion.
3. Ulcers in the palate: Check for acrylic pimples on tissue
surfaces of the appliance. Acrylic pimples can be avoided by
filling up air bubbles on the working dental cast before
acrylisation.
4. Ulcers in oral cavity due to sharp ends of wires: Check
appliance outside the mouth before delivery. Check on
delivery in patient’s mouth.
5. Gagging is usually due to an over extended base plate or a
thick rough appliance. Base plate should not compromise
volume of the oral cavity.
6. Excessive forces can cause unwanted tooth movement. The
case (Fig. 32.14A–B) shows unwanted excessive tipping of
maxillary central incisor root caused by over activation of
finger spring.
FIGURE 32.14 Overactivated finger springs.

(A) Pre-treatment. (B) Excessive tipping of crowns due to overactivated
finger springs distal to the central incisors.
Crozat appliance
Crozat appliance is a removable appliance, which is made free of
acrylic. Crozat appliance is made of wire framework and active wire
components. The complexity of its design and fabrication compared to
the simple design of Hawley appliance necessitates that it should be
fabricated by an expert technician.
The Crozat appliance can serve and do all functions of an active
removable appliance. It is an metal appliance without any acrylic
components. The wire components are soldered or laser welded. 13
The treatment sequence of Crozat appliances takes place in three
phases:
In the first phase, using the basic appliance, expansion of the molars
and premolars is induced and also derotation of the first molars if
necessary (Fig. 32.15).
FIGURE 32.15 Basic upper Crozat appliance. Source: Parker WS.

A perspective of the Crozat appliance with case reports of its present
use. Am J Orthod 1985;88(1):1–21.
In the second phase, canines and second molars are aligned or

rotated. Therefore, the basic appliance has to be adapted passively on
the cast and then the corresponding springs are soldered on (Fig.
32.16).
FIGURE 32.16 Crozat appliance stage II. Source: Wahl N.
Orthodontics in 3 millennia. Chapter 5: the American Board of
Orthodontics, Albert Ketcham, and early 20th-century appliances. Am J
Orthod Dentofacial Orthop. 2005 Oct;128(4):535–40. PubMed PMID:
16214639.
In the third phase, the movement of single teeth or tooth segments

towards buccal palatal, mesial or destal, extrusion or intrusion of
teeth, rotations of incisors or premolars and transverse expansion in
case of relapse are achieved. The retention period starts after the third
phase.
This appliance can also be used in the mandibular arch. The
complexity of design, difficulties in its fabrication and limitations in
achieving all types of tooth movement has almost eliminated the use
of Crozat appliance.
Key Points
Removable appliances need a careful use and thoughtful design by
the clinician with regard to anchorage and type(s) of tooth movement
required. A communication with the orthodontic technician and clear
instructions to the laboratory technician are must. The spring designs
should be preferably drawn on the laboratory requisition form with
the specified size of the wire to be used for each of the components
and modifications from the conventional design if any desired for
individual patient’s need.
Removable appliances do have a significant role in an orthodontic
armamentarium, particularly during interceptive orthodontics, in
conjunction with fixed appliance therapy and during the retention
phase.
References
antiquity to the mid-19th century. Am J Orthod
PMID: 5750547.
2. Jackson VH. Orthodontia. Dent Cosmos 1906; 48:278
Schwarz AM. Die Zahn, Mund and Kieferheilkunde.
Muinchen Berlin: Urban and Schwarzenberg; 1954. p.
450-457. Quoted from Adams CP. The design and
construction of removable appliances. 2nd ed. Bristol:
John Wright Sons; 1957. p. 49.
3. Adams CP. The modified arrowhead clasp. Dent Rec.
1950;70:143–144: PubMed PMID: 24537839.
4. Ward S, Read MJ. The contemporary use of
removable orthodontic appliances. Dent Update.
2004;31:215–218: PubMed PMID: 15188527.
5. Kerr WJ, Buchanan IB, McColl JH. Use of the PAR
index in assessing the effectiveness of removable
orthodontic appliances. Br J Orthod.
1993;20(4):351–357: PubMed PMID: 8286305.
6. Jacobs SG. Teeth in cross-bite: the role of removable
appliances. Aust Dent J. 1989;34(1):20–28: PubMed
PMID: 2650668.
7. Herren P. Indications and contraindications for
removable and fixed orthodontic appliances. SSO
Schweiz Monatsschr Zahnheilkd. 1975;85(3):291–308:
8. Tang EL, Wei SH. Assessing treatment effectiveness
of removable and fixed orthodontic appliances with
the occlusal index. Am J Orthod Dentofacial Orthop.
1990;98(6):550–556: PubMed PMID: 2248234.
9. Isaacson KG, Muir JD, Reed RT. Removable
orthodontic appliances. Oxford: Wright; 2002.
10. Yettram AL, Wright KW, Houston WJ. Centre of
rotation of a maxillary central incisor under
orthodontic loading. Br J Orthod. 1977;4(1):23–27:
11. Batoni G, Pardini M, Giannotti A, Ota F, Giuca MR,
Gabriele M, Campa M, Senesi S. Effect of removable
orthodontic appliances on oral colonisation by
mutans streptococci in children. Eur J Oral Sci.
2001;109(6):388–392: PubMed PMID: 11767275.
12. Lessa FC, Enoki C, Ito IY, Faria G, Matsumoto MA,
Nelson-Filho P. In-vivo evaluation of the bacterial
contamination and disinfection of acrylic baseplates
of removable orthodontic appliances. Am J Orthod
Dentofacial Orthop. 2007;131(6):705: e11-7. PubMed
PMID: 17561044.
13. Available from: http://www.o-
atlas.de/eng/kapitel6_191.php. Accessed on 10-04-18
at 9.00 am.
CHAPTER 33
Invisible removable appliances:
The Clear Aligners
Maria Orellana Valvekens
CHAPTER OUTLINE
Introduction
Overview of steps in clear aligner treatment
Indications for the Invisalign appliance
Steps and treatment stages with Invisalign system of
clear aligners
Steps and treatment stages with K-Line system of clear
aligners
Indications and limitations of the K-Line appliance
Steps and treatment stages with the Donatello aligners
Indications and limitations of the Donatello aligners
Orthodontic tooth movement in treatment with aligner
Key Points
Introduction
The very need for orthodontic treatment by a majority of adult
patients is derived with a desire for enhancement of dental alignment
and facial aesthetics. Although buccal fixed metallic appliances are
efficient treatment systems, the reluctance of their use is mainly due to
metal look, poor aesthetics and fear of pain. Clear plastic aligners’
offer an excellent alternative to unaesthetic orthodontic treatment
with labial fixed appliances (Figs 33.1 and 33.2).
FIGURE 33.1 The clear aligner.

FIGURE 33.2 A case of mild crowding treated with clear aligner
system.
This case has been treated with Clear Smile system. Source: Case
courtesy Dr. Joseph Greenty Wollongong, NSW, Australia.
The clear aligner appliance(s) is nearly transparent, colourless and

almost invisible. As these devices are removable, they allow the
patient an additional option to be without braces for social and
professional engagements. The oral hygiene is not a problem with this
appliance and most patients adapt to it very quickly.1 The success of
these types appliances is intimately related to the compliance in
wearing the appliance for a minimum number of hours and following
the required schedule of changing the aligners as per sequence
assigned to the case. Patients are asked to wear the aligners for a
minimum of 22 h/day. Thus, patient compliance is paramount in clear
aligner therapy.
Some of the patients seeking clear aligner treatment are those who
have previously received orthodontic treatment using fixed
appliances and have had a relapse or are unsatisfied with treatment
outcome. They do not wish to have fixed appliances for the second
time. Aesthetics in adult patients may be critical to their profession.
Most patients are not willing to show off metal or partially clear fixed
appliances with archwires when they smile. A new group of patients
who may prefer clear aligners are teenagers who wish to improve
their aesthetics but are not interested at the cost of compromised
appearance associated with fixed appliances.2
However, the effectiveness of the technique has been historically the
target of numerous controversies. In the last few years, greater clinical
inputs from several experts, clinicians and technological advances
have enhanced understanding in their use and improved the
effectiveness. With the published literature and clinical evidence of
efficacy, the system of clear aligners has now been established as an
effective alternative to conventional full fixed appliances in most
types of malocclusion conditions. Numerous modifications and case
reports are available in the literature on the successful treatment of
different types of malocclusion with this therapeutic modality. The
appliance has also been used in conjunction with partially fixed
appliance, or full fixed appliance in the treatment of complex
malocclusions.3–10
The sequential clear plastic aligners were first introduced by Align
Technology Inc. (Align Technology, Santa Clara, CA) in 1999 with the
trade name of Invisalign.11 It was originally marketed to orthodontists
only. After settling a class action lawsuit originated by a group of
general dentists, Invisalign made this technology and mode of therapy
is available to general dental practitioners as well.12 Since then, such
aligners have been made available through many orthodontic
manufacturers’ technologists throughout the world.13 However, it
seems that through extensive marketing and research, Invisalign has
become synonym name associated with this type of treatment
modality that most of the orthodontists and general practitioners are
now familiar with this name.
The origin of a system to align teeth perhaps date back to the time of
H.D. Kesling14 more popularly known as ‘Kesling set-up’. The
procedure of Kesling set-up involved taking the impressions when
you are close to the end of orthodontic treatment. Each tooth usually
anterior to the first molars was separated on the plaster models with
the help of a fine plaster cutting saw, their appliance denuded and
then teeth were set-up in an ideal occlusion, so-called ‘the finished set-
up’. A rubber positioner was prepared in the lab using the final set-up
on plaster models, which when used in the mouth moved the teeth to
pre-defined positions according to the set-up. The appliance could be
used as a retainer or an active appliance to recover the minor relapse
after orthodontic treatment.14 The Pre-finisher appliance marketed by
T(ooth) P(ositioner) Orthodontics is based on the principles of
diagnostic set-up.
Kesling set-up, when used on pre-treatment models, is popularly
called ‘Kesling diagnostic set-up’ and is a great tool in orthodontic
treatment planning to visualise the final tooth positions on the basal
bones, and a possible explanation for treatment by an extraction or
non-extraction. Kesling diagnostic set-up also indicates the final
occlusion in various combinations of tooth extraction, for example a
lower incisor extraction (Fig. 33.3A–F).
FIGURE 33.3 Kesling set-up.
(A) Initial study models; (B) stripping the tooth stumps with a steel bur,
taking care to maintain the mesial–distal dimension of each tooth,
without removing the dentogingival limit. (C) Mounting the teeth. (D)
Setting the tooth stumps with heated red wax. (E) Mounting of teeth on
the upper and lower left side as far as the first molars. (F) Finished
setup model. Source: Araújo TM, Fonseca LM, Caldas LD, Costa-Pinto
RA. Preparation and evaluation of orthodontic set-up. Dental Press J
Orthod 2012;17(3):146–165.
Sheridan et al.15–17 introduced the technique of interproximal tooth

reduction (IPR) for resolution of the lower incisor crowding and
alignment of teeth with the help of labio-lingual clear plastic retainer.
His appliance is named ‘Essix appliance’. The method adopted by
Sheridan required newest of dental study model to fabricate each
appliance, making this technique cumbersome and time-consuming
for patient, orthodontist and laboratory technician alike.
The Essix appliance is indicated for the correction of mild crowding
or malocclusions. The tooth movement is caused either by spot-
thermo-foaming with particular pliers (Fig. 33.4) or by a mounting
procedure. In the second method, the surface of the tooth to be moved
in question is altered by the sequential addition of small layers of
composite on the tooth surface to be pushed and trimming the
appliance to create space for the tooth movement.12
FIGURE 33.4 The Essix appliance.
Essix appliance is a light, transparent and almost invisible

removable device, which is snapped over teeth following orthodontic
treatment as a retainer. The appliance is a lower canine-to-canine
retainer or full arch made of hard thermo-plastic sheet, which is
resistant to wear.
Overview of steps in clear aligner
treatment
1. Case records and case selection
2. High-quality impressions or intraoral scans
3. 3D virtual set-up and treatment progress stages
4. Approval of treatment steps on the web
5. Construction of aligners’ delivery to treating doctor
6. Issue of aligners and review
7. Finishing and retention
The process of orthodontics case evaluation diagnosis necessitates

that complete set of essential pre-treatment records include study
models, clinical photographs, OPGs, cephalograms and all other
relevant X-rays required for the orthodontic diagnosis and treatment
planning for the case of malocclusion in question are prepared. A
tentative plan needs to be formulated and discussed with the patient.
For the purpose of clear aligner treatment, high-quality impressions or
intraoral scans are required. It is critical that high precision dental
impressions are made of polyvinyl siloxane (PVS) material. The bite is
also recorded on a wax sheet. The impressions should extend beyond
the last tooth and cover a fair amount of soft tissues all around
without any voids or defects. The physical impressions are converted
into digital format through 3D scanning and are required to be sent to
the selected vendor.
Highly sophisticated hardware and software functions allow the
vendor to scan these impressions, create virtual images of each of the
tooth and study models for visualisation as 3D records and also
virtual set-up. The higher functions of the software allow data
segmentation and create virtual set-up similar to Kesling set-up in
many permutations and combinations to arrive at a final occlusion. In
case, the records are obtained through intraoral scanners; the virtual
records are already available to the vendor through cloud or web. The
accuracy of virtual set-up and aligners is directly dependent on the
quality of the dental impressions, or the quality of scans obtained
through intraoral scanning process.
The experts use sophisticated software functions to calculate arch
length tooth size discrepancy including possible alignment of the
teeth, various extraction plans and also the recommendations sent by
the treating orthodontists and need of the patient. Once the treatment
plan and outcome of the treatment are prepared, the treating
orthodontist is requested to access the plan and consider for approval
or modifications if any. After approval, the treatment steps are now
created which symbolises the stages of progression of orthodontic
tooth movement and corresponds to the number of aligners.
These aligners are created, numbered packed and shipped to the
treating doctor.
The aligners are now issued to the patient with specific instruction
and plan and a follow-up protocol is observed. The treatment
response is evaluated from time to time, and in case this does not
follow the expected outcome, there is a possibility of an alternate redo,
at least once. On achieving the desired occlusion at the completion of
the active phase, a retention protocol is initiated.
The Invisalign system initially offered treatment of minor and simple
malocclusion. Over the years, this system has evolved to treat more
complex cases of malocclusion and those requiring extractions. The
appliance has also evolved for use with attachments on tooth surfaces.
The latest innovations of Invisalign have permitted a more precise
control of the orthodontic movements. One of these innovations is the
new aligner material, Smart Track, introduced in 2013. According to
the manufacturer, this new material ensures better control of tooth
movement. It also offers a lower and uniform force level over time as
well as a tighter fit of the aligners. Patients have reported improved
comfort when utilising the new material.18 Further, it has been
demonstrated that aligners, which employ the Smart Track
technology, achieve faster movement (in the order of 57%) compare to
the original material (EX30).10
The Smart Force innovation of Invisalign refers to the geometric
attachments and accessories to provide better execution and control of
complex orthodontic movements. It is customised to each tooth using
virtual modelling taking into account the width, long axis and contour
of the entire tooth. A study conducted by Invisalign have shown an
increase of 30% in cases of extrusion of upper canines and 50% in the
movements of torque of upper incisors upon the implementation of
these innovations. The mechanics of treatment with Invisalign
aligners, in general, shouldn’t be different than other modalities of
treatment. However, treatment with aligners presents certain unique
characteristics regarding anchorage and movement of teeth (Fig. 33.5).
FIGURE 33.5 The story of evolution of the Invisalign system.
Courtesy Align Technology.
The Smart Stage innovation is an advanced algorithm that would

determine the most optimal action by each stage of the treatment. Due
to these innovations, recently Invisalign has recommended changing
of aligners weekly instead of every 2 weeks. A study comparative of
200 cases performed by Invisalign has shown no difference regarding
movement achieved and predictability. However, this indication is left
to the criteria of each practitioner.
Indications for the Invisalign appliance

Nowadays, and with the new improvements in the system, there are
almost no contraindications ‘per se’. It is up to the practitioners to
decide the cases that are to be treated by aligners. However, certain
aspects are harder to handle, and it is important to anticipate the
dental movements and possible problems that may need to be
encountered.
Anatomy of the crown: the area of contact between the aligner and the
crown will influence the success of the aligner and thus the
predictability of the movements. For example, it is not uncommon to
find partially erupted clinical crowns in adolescents patients. Thus, it
is important that the placement of attachments improve the retention
of the aligners. On the other hand, in the adult patient that may
present with gingival recession problems, it is recommended to cut
the aligners more occlusal and limit the number of attachments to
facilitate insertion and removal of the aligners.6
In some cases, it is recommended the utilisation of elastics and
buttons and to include a precision cut in the prescription of the
particular case. Regarding anteroposterior correction, the most
predictable results are obtained in 2–4 mm class II and with sufficient
clinical crowns. In cases of more than 4 mm class II, a combination of
treatment with distaliser appliances is recommended.19
Steps and treatment stages with Invisalign

system of clear aligners
1. A collection of high-quality records. The pre-treatment
records are obtained for documentation and purpose of
comprehensive diagnosis and treatment planning. The
essential records include extra and intraoral photographs,
lateral (and PA if required) cephalograms OPG and relevant X-
rays. High quality impressions are obtained with a
polyvinylsiloxane material. The bite is also recorded. The
impressions are sent to the Invisalign office. Since 2007, the
iTero scanner, has replaced the need for traditional dental
impressions. In 2013, Align Technology introduced the iTero
imaging system available as a single hardware platform with
software options for restorative or orthodontic procedures. It
has a direct connectivity with Invisalign and has the option to
show patients the outcome of their Invisalign treatment.
2. Interactive treatment planning. The clinicians download the
virtual treatment set-up, stage by stage at the dedicated
Internet site and if required request for modification of
treatment/tooth movement sequence. This step is called ‘Clin
Check’. In 2016, Invisalign launched the new Clin-Check Pro
5.0 that provides a 3D modelling of the whole treatment (Fig.
33.6).
Once the step-by-step progress of the patient’s treatment is
reviewed by the treating doctor, he may ask for any changes at
this stage concerning the sequence of tooth movement or plan
of the treatment. Once precise treatment plan and course of
tooth movement has been finalised, the aligners are made and
dispatched to the orthodontist.
3. Clinical management with Invisalign aligners. Some aligners
for a patient vary according to the severity of the malocclusion.
Invisalign offers the following treatment modalities:
a. Invisalign Full: It is the most commonly used course
of therapy. “Invisalign Full” is used for treating
complex malocclusion conditions.
b. Invisalign Lite: Providing for less complex alignment
problem cases, Invisalign Lite uses up to 14 aligners.
c. Invisalign i7: This was developed for the cases of
minor dental corrections. It comprises up to seven
aligners.
d. Invisalign Teen: With teenagers, there is commonly a
period of rapidly shifting changes occurring as they
grow. Invisalign Teen was developed to help
accommodate these issues with some special
features.
FIGURE 33.6 ClinCheck the interactive treatment planning

system by Invisalign. Source: Available from:
http://www.clinicalandete.com/fotos/clincheck_invisalign_clinica_dental_landete_mostoles.jpg
Historically, each aligner was supposed to be worn for 2 weeks, and
patient visits the doctor every 4–6 weeks. The new G7 features,
introduced in 2016, allow the patients to change aligners every week.
However, it is the practitioner’s discretion and the type of movement
required which decides the schedule of change of the aligners. The
appliance is recommended to be removed during eating and to brush
the teeth. The patient should be warned to safeguard the appliance as
its chance of being lost is great due to its colour-less structure.
Subjects with spaced dentition are quick to respond and treat easily.
However, some more complex situations such as class II division 1
would require use of attachments (Fig. 33.7).
FIGURE 33.7 A case of class II subdivision treated with Invisalign

system and class II elastics.
(A) Pre-treatment. (B) Post-treatment at end of 22 aligners treatment.
Courtesy Dr Orellana Valvekens.
Current technology of Clear Smile corrector system is predominantly
suitable for mild malocclusions such as crowding 4 mm/arch and
spacing up to 5 mm and similar overjet.20 As a general rule, any non-
extraction treatment case that could be treated with fixed appliance
without inter-arch mechanics is likely to be suitable (Figs 33.1 and
33.2). Once, a case is selected by the doctor, the following records are
to be submitted to ‘Clear Smile’ office:
1. Essential records include completed Clear Smile Treatment

Planner Form, upper and lower high-quality study models or
PVS impressions and bite records. It is desirable that OPG/full
mouth intraoral radiographs, lateral head film and facial
photographs may also be provided, although they are not
essential.
2. Case set-up and training correctors: At this stage, a treatment
plan and approximate number of appliances needed are
predicted and if treatment is accepted then set of PVS
impressions is submitted. The first correctors to be received are
training correctors, which are a passive set of aligners to test
the accuracy and enhance the acceptance of active aligners.
Treatment proceeds with a group of correctors from 1 to 12 or
more.
3. Active treatment: It starts with the first group of corrector
group 1. Each group of correctors has four sets (four upper
and four lower) or four only for single arch treatment.
Correctors are changed every 2 weeks. New PVS impressions
are submitted after each three groups, that is at groups 4, 7 and
10. Tooth movements are visualised as a pictorial
representation through a form ‘Movement Tracker’.
A more complex case of retreatment is depicted in Fig. 33.8.

FIGURE 33.8 A case of crowding in both the arches treated with
Clear Smile system.
(A) Pre-treatment occlusion. (B) Post-treatment occlusion.
K-Line Europe GmbH is a company located in Düsseldorf,
Germany.21,22 Beside the K Clear system, the company also provides a
variety of non-invasive aesthetic products such as K Lamina, K Smile
and K Jewels, as well as the anti-snoring device, K Silencer (Fig. 33.9).
FIGURE 33.9 K Clear aligner.
Steps and treatment stages with K-Line

system of clear aligners
The practitioners use the web portal to register the case and send
clinical photos, radiographs and all required patient records.
1. Either 3D scans or impressions are sent to the company.

2. Within 3–5 days, a digital treatment plan is formulated and
uploaded to the portal, where the practitioner can view and
discuss the plan. The treating practitioner gets the chance to
ask for modifications and advice through the web portal chat
section.
3. Upon confirmation, the K Clear aligners are produced and
shipped within an average of 14 days. Dental support and
troubleshooting are available all through the treatment
duration.
4. The cases are usually done in phases to avoid the need for mid-
course corrections and to monitor the case progress and ensure
patient commitment to treatment.
Indications and limitations of the K-Line

appliance
With the use of K Clear accessories, even more, challenging cases can
be treated using clear aligners. This doesn’t overcome the fact that
fixed orthodontic treatment is still mandatory in many cases. K Clear
accessories include composite engagers, precision force indentations,
clear buttons, hooks, elastics, thermoforming pliers, Carriere molar
distaliser, interproximal reduction (IPR) strips and IPR gauges.
Indications for K Clear system:
• Dental spacing up to 5 mm dentoalveolar discrepancy

• Diastema
• Dental crowding up to 5 mm dentoalveolar discrepancy
• Increased overjet
• Anterior open bite of dental origin up to 4 mm
• Anterior deep bite
• Anterior cross-bite
• Posterior cross-bite
• Dental class II and class III corrections
• Anterior space regaining
• Eruption guidance in growing patients
A wide range of movements can be done using K Clear aligners

including arch expansion, rotations, extrusion, intrusion, mesialisation
and distalisation movements. Movements are aided by accessories as
clear buttons and elastics for more precision and speed like extrusion
movements and mesiodistal axial correction. Cases treated include
non-extraction, as well as extraction cases (lower incisor or premolars
extraction):
• Spacing cases more than 5 mm dentoalveolar discrepancy

• Crowding cases more than 5 mm dentoalveolar discrepancy
• Rotated teeth more than 30 degrees
• Crown/root torquing
• Open bites more than 4 mm
Composite engagers of several shapes are used in K Clear system

for more precise force control and distribution, anchorage, better grip
and retention. However, the unique design of the K Clear aligners
with 2 mm gum coverage decreases the number of composite
engagers needed during treatment as compared to other systems.
Composite engagers are specially designed for each tooth, and a
custom made template is fabricated to aid in bonding the composite
engagers. A case each of severe crowding, deep bite and open bite are
depicted in Figs 33.10 and 33.11.
FIGURE 33.10 Crowding, deep bite and retroclination case before

and after treatment with K Clear. Source: Courtesy of K-Line Europe
GmbH.
FIGURE 33.11 Anterior open bite case before and after treatment
with K Clear. Source: Courtesy of Dr Phiroza Venkataraman through
K-Line Europe GmbH.
ClearPath is a USFDA approved technology that fabricates series of
clear wafer-thin transparent plastic removable aligners that gently
guide the teeth from their present to the desired position. The system
aims to address most dental malocclusions, ranging from crowding,
spacing, cross-bites, open bites, deep bites, proclinations and
rotations. ClearPath has made several advancements over classic
aligner systems almost eliminating the use of attachments, buttons,
engagers and elastics. There are, however, only three conditions
where ClearPath recommends the use of elastic button technique
(EBT) namely:
1. Extrusion of anteriors by >1–2 mm

2. Rotation of cuspids and bicuspids by >40–50 degrees
3. Translation/bodily movements >4–5 mm
These advancements have been made by incorporating ultra-high

resolution scanning, high pressure thermoforming of aligners and
some proprietary dental laboratory techniques in the manufacturing
of the aligner tray, which give an excellent SNUG FIT, one of key USP
of ClearPath system, resulting in eliminating the use of
buttons/engagers/attachments.
ClearPath does use IPR and dentoalveolar expansion, which is a
primary mode of gaining space, wherever required. This system,
however, is not indicated for any mixed dentition or skeletal cases and
does not aim to correct complex malocclusions in the anterior–
posteriors relationship. Owing to advancements as mentioned earlier
in design and planning, ClearPath aligner does not cover gingiva at all
and finishes just short at the gingival margin, enhancing the comfort
of the aligner trays.
ClearPath has recently improved its virtual set-up into a 3D form
that enables doctors to virtually evaluate their patient’s post-treatment
predicted results in 360 degrees real-time.
Cases treated with ClearPath are depicted in Fig. 33.12.
FIGURE 33.12 A case of anterior cross-bite and class III treated

with ClearPath system.
(A) Pre-treatment occlusion. (B) Post-treatment occlusion.
Harnessing the power of digital facilities, 3D dental printing has
evolved from a traditional process to a process that is faster, more
scalable and more efficient. The Donatello aligners are 3D printed
objects manufactured with an optimised technology that is purposely
fit for aligners. The entire process is a patented process licensed by a
Swiss company: 3D Objects AND Data Software (Taverne,
Switzerland).23 The company provides a complete, easy to use
software and hardware that allows each orthodontist or dental clinic
to print their patient’s orthodontic aligners independently. The
Donatello solution drives efficiency and cost-savings through
eliminating delivery times.
The workflow for clinicians is simple and easy to use. It ensures a
high-quality service in the shortest time frame of the market so that
operators can print aligners with convenience, whenever they need
them.
Steps and treatment stages with the Donatello

aligners
1. The Orthodontist uses the web portal to register the case, send
clinical photos, 3D scans or impressions radiographs and all
required patient records.
2. Within 3–5 days, a precise digital treatment plan is formulated
and uploaded to the portal. At this point, using our dedicated
software ‘Optimizer’, the dentist can view and modify the
programme. Treating dentist gets the chance to make
modifications as per his/her convenience and clinical expertise.
3. Upon confirmation, the Donatello aligners’ preparation is
generated and uploaded on the portal, ready to be printed.
4. The cases can be printed step by step, to allow any mid-course
corrections and to monitor the case progress and ensure
patient commitment to treatment.
Indications and limitations of the Donatello

aligners
Inside the dental community, there is a growing evidence that aligners
can be used not only to treat simple and moderate cases but with the
clinical experience of each operator, more complex cases or parts of
complex cases can be treated with aligners, especially in the adult
population. Donatello procedures to obtain 3D printed aligners
combines the best of the IGES and STL standard formats to fit the
dental clinical needs in relationship with the material and produces
aligners ready to be printed for clinicians and given to patients for
treatment. These files are obtained at the beginning of the procedure,
from intraoral scans or stone model scans, and represent the initial
success key factor of the entire process.
Donatello digital accessories such as 3D printed engagers, precision
force indentations, clear buttons, hooks, elastics, thermoforming
pliers, distaliser, IPR strips and IPR gauges can support customised
treatment plan.
Indications for Donatello aligners are as follows:
• Dental spacing
• Diastema
• Overcrowding
• Increased overjet
• Anterior or posterior open and deep bite of dental origin
• Dental class II and class III corrections
• Anterior space regaining
• Eruption guidance in growing patients
• Malalignment in adult population for periodontal migration
• Severely rotated teeth more than 30 degrees
• Crown/root torquing
Accessories, as clear buttons and elastics, aid some movements for

more precision and speed such as extrusion movements and
mesiodistal axial correction. A wide range of movements can be done
using Donatello aligners including arch expansion derotation
extrusion, intrusion, mesialisation and distalisation movements.
3D printing offers storage scalability by using computer storage
(instead of real physical) to store and reprint all aligners on demand.
The 3D data and plans are archived, can be viewed and manufactured
‘on demand’. Composite engagers of dedicated shapes (specifically for
3D printing process) are used in Donatello aligner system for more
precise force control and distribution, anchorage, better grip and
retention. However, the unique design of Donatello aligners decreases
the number of composite engagers needed during treatment as
compared to other systems. Composite engagers are specially
designed for each tooth, and a custom made template is fabricated to
aid in bonding the composite engagers.
Orthodontic tooth movement in
treatment with aligner
Aligners exert intermittent orthodontic forces that produce tooth
movement. Because of the nature of the forces that they applied, it has
been suggested that tooth movement with aligners doesn’t follow the
classical stages of tooth movement.24,25 Light continuous forces are
perceived as intermittent forces by the periodontium due to the
viscoelastic nature. Therefore, intermittent forces can produce
negative effects in the periodontium.26 It has been demonstrated that
the vast majority of orthodontic tooth movement during any 2-week
aligner prescription cycle occurs during the first week of the cycle.27
After the publication of these findings and performing their
research, Align Technologies decided to implement a 1-week protocol
on their full cases treatments. The accuracy of anterior tooth
movement using the Invisalign system and mean accuracy has been
reported at as low as 41%; whereas lingual constriction was reported
at 47.1%; and the least accurate movement was extrusion at 29.6%.28 A
more recent study showed that bodily tooth movements such as molar
distalisation, incisor torque, as well as premolar derotation could be
accomplished using clear aligners (Invisalign). Upper incisor torque
and pure premolar derotation are challenging movements using
removable thermoplastic appliances. Over-corrections or case
refinements may be needed due to the ClinCheck simulation
predicting more movement than what may occur.29
Can distalisation movements be achieved with clear aligners? A
study of Invisalign cases showed that distalisation movement with
Invisalign was possible and not associated with the significant distal
tipping of the distalised molars. The molar distalisation is greatly
successful because each aligner has self-limiting 0.25-mm activation,
meaning that any tip created by the aligner during space closure is
probably due to insufficient moments being generated to control root
movement. Rectangular and vertical attachments located on the
buccal aspect of the distalising molars would be needed to create a
sufficient moment to oppose the tipping movement.30
A lot of progress has been made regarding understanding the effect
of clear aligners in orthodontic tooth movements. Still, further studies
are required to elucidate the ability of clear aligners in achieving
different types of tooth movements.
Orthodontic root resorption is a multifactorial phenomenon
influenced by force and type of tooth movement, root anatomy,
genetic disposition and an individual biological variability.31 Several
publications described a positive correlation between increased force
levels and increased root resorption, as well as between increased
treatment time and increased root resorption.32
Clear aligners apply intermittent forces to the teeth such as many
active removable appliances. It has been proposed that the pause in
treatment with periodic force allows the resorbed cementum to heal
and prevent further root resorption.
Current views based on large cohort studies indicate that that the
predisposition to experience root resorption with clear aligners
(Invisalign) was similar to that of using fixed appliances.33 This study
was in agreement with a previous one that found that from all the 100
participants patients that were treated with aligners had a minimum
of 2 teeth with root length reduction when resolving anterior
crowding.34
There is no clear evidence-based answer to the relationship between
root resorption and orthodontic treatment with clear aligners. More
research would be needed in this area to have a clear understanding
of this topic.
It is widely known that orthodontic treatment and appliances
occasionally cause discomfort, pain or functional limitations. Clear
aligner therapy seems to be particularly attractive to patients in
comparison to the lingual technique. Patients show high acceptance as
they become accustomed to the aligners very quickly and do not
suffer much impairment. In fact, it was shown that adults treated with
Invisalign aligners experienced less pain and fewer negative impacts
on their lives during the first week of orthodontic treatment than
those treated with fixed appliances.35 This also applies to gingival
condition and general patient well being. Patients treated with
Invisalign reported a better periodontal health and greater satisfaction
during orthodontic treatment than patients treated with fixed
orthodontic appliances.36
Clear aligner therapy results in less pain compared to classic full-
fixed appliance at approximately 3 days after starting treatment or
adjustment. At the end of the treatment, patients also reported less
pain with clear aligner treatment compared to the full-fixed appliance.
The aligner deformation often caused more pain and discomfort.37
Key Points
Treatment with clear aligners offer great advantage of aesthetics, oral
hygiene, minimal chair time and can be considered as a good
treatment alternative. Latest developments in technique and
technology have overcome many of the early limitations of this
treatment modality. Today, there are many companies that have
developed clear aligner systems. In this chapter, we have discussed a
few common in the market.
References
1. Phan X, Ling PH. Clinical limitations of Invisalign. J
Can Dent Assoc. 2007;73(3):263–266.
2. Boyd RL. Esthetic orthodontic treatment using the
invisalign appliance for moderate to complex
malocclusions. J Dent Educ. 2008;72(8):948–967.
3. Boyd RL, Miller RJ, Vlaskalic V. The Invisalign®
system in adult orthodontics: mild crowding and
space closure cases. J Clin Orthod. 2000;34:203–212.
4. Boyd RL, Wlaskalic V. Three-dimensional diagnosis
and orthodontic treatment of complex malocclusions
with the Invisalign® appliance. Semin Orthod.
2001;7:274–293.
5. Miller RJ, Duong TT, Derakhshan M. Lower incisor
extraction treatment with the Invisalign® system. J
Clin Orthod. 2002;36:95–102.
6. Joffe L. Invisalign®: early experiences. J Orthod.
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7. Chazalon JF. Invisalign 15 years later has it become a real
alternative to fixed appliances? Rev Orthop Dento Faciale.
2016;50:275–301.
8. Patel, Dipakkumar N. Effect of Aligner Material,
Duration and Force Level on Tooth Movement
[Master of Science Thesis]. University of Florida:
2014.
9. Simon M, Keilig L, Schwarze J, Jung BA, Bourauel C.
Forces and moments generated by removable
thermoplastic aligners: incisor torque, premolar
derotation, and molar distalization. Am J Orthod
10. Chisari JR, McGorray SP, Nair M, Wheeler TT.
Variables affecting orthodontic tooth movement with
clear aligners. Am J Orthod Dentofacial Orthop.
2014;145(4):S82–891.
11. Available from: www.invisalign.com.
12. Vicéns J, Russo A. Comparative use of Invisalign by
orthodontists and general practitioners. Angle Orthod.
2010;80(3):425–434.
13. Clear Smile corrector system information pack, 2006,
Australia, New Zealand. Available from:
www.clearsmile.com.au.
14. Kesling HD. The philosophy of the tooth positioning
appliance. Am J Orthod Oral Surg. 1945;31:297–304.
15. Sheridan JJ. Air-motors tripping. J Clin Orthod.
1985;19:43–59.
16. Sheridan JJ. Air-rotor stripping update. J Clin Orthod.
1987;21:781–788.
17. Jacobson A. The Essix appliance technology:
applications, fabrication and rationale. Am Orthod
Dentofacial Orthop 2003;124(6):749 Sheridan JJ,
Hillard K, Ambruster P. CTAC International, Inc;
2003; 130 pages.
18. Bräscher AK, Zuran D, Feldmann Jr RE, Benrath J.
Patient survey on Invisalign® treatment comparen
the SmartTrack® material to the previous aligner
material. J Orofac Orthop. 2016;77(6):432–438.
19. Wilmes B, Nienkemper M, Ludwig B, Kau CH, Pauls
A, Drescher D. Esthetic class II treatment with the
Beneslider and aligners. J Clin Orthod.
2012;46(7):390–398: quiz 437.
20. Available from: https://www.clearsmilealigner.com.
21. Available from: kline-europe.de.
22. Available from: http://www.clearpathdental.com.
23. Available from: www.3dobj.ch.
24. Krishnan V, Davidovitch Z. Cellular, molecular, and
tissue-level reactions to orthodontic force. Am J
Orthod Dentofacial Orthop. 2006;129(4):e1–32.
25. Castroflorio T, Gamerro EF, Caviglia GP, Deregibus
A. Biochemical markers of bone metabolism during
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Angle Orthod. 2017;87(1):74–81.
26. Nakao K, Goto T, Gunjigake KK, Konoo T, Kobayashi
S, Yamaguchi K. Intermittent force induces high
RANKL expression in human periodontal ligament
cells. J Dent Res. 2007;86(7):623–628.
27. Drake CT, McGorray SP, Dolce C, Nair M, Wheeler
TT. Orthodontic tooth movement with clear aligners.
ISRN Dentistry 2012;2012:657973 PMCID:
PMC3424837.
28. Kravitz ND, Kusnoto B, BeGole E, Obrez A, Agran B.
How well does Invisalign work? A prospective
clinical study evaluating the efficacy of tooth
movement with Invisalign. Am J Orthod Dentofacial
Orthop. 2009;135(1):27–35.
29. Simon M, Keilig L, Schwarze J, Jung BA, Bourauel C.
Treatment outcome and efficacy of an aligner
technique—regarding incisor torque, premolar
derotation and molar distalization. BMC Oral Health.
2014;14:68.
30. Ravera S, Castroflorio T, Garino F, Daher S, Cugliari
G, Deregibus A. Maxillary molar distalization with
aligners in adult patients: a multicenter retrospective
study. Prog Orthod. 2016;17:12.
31. Weltman B, Vig KW, Fields HW, Shanker S, Kaizar
EE. Root resorption associated with orthodontic
tooth movement: a systematic review. Am J Orthod
32. Roscoe MG, Meira JB, Cattaneo PM. Association of
orthodontic force system and root resorption: a
systematic review. Am J Orthod Dentofacial Orthop.
2015;147(5):610–626.
33. Iglesias-Linares A, Sonnenberg B, Solano B, Yañez-
Vico RM, Solano E, Lindauer SJ, Flores-Mir C.
Orthodontically induced external apical root
resorption in patients treated with fixed appliances
vs removable aligners. Angle Orthod. 2017;87(1):3–10.
34. Krieger E, Drechsler T, Schmidtmann I, Jacobs C,
Haag S, Wehrbein H. Apical root resorption during
orthodontic treatment with aligners? A retrospective
radiometric study. Head Face Med. 2013;9:21.
35. Miller KB, McGorray SP, Womack R, Quintero JC,
Perelmuter M, Gibson J, Dolan TA, Wheeler TT. A
comparison of treatment impacts between Invisalign
aligner and fixed appliance therapy during the first
week of treatment. Am J Orthod Dentofacial Orthop.
2007;131(3):302: e1-9.
36. Azaripour A, Weusmann J, Mahmoodi B, Peppas D,
Gerhold-Ay A, Van Noorden CJ, Willershausen B.
Braces versus Invisalign®: gingival parameters and
patients’ satisfaction during treatment: a cross-
sectional study. BMC Oral Health. 2015;15:69.
37. Fujiyama K, Honjo T, Suzuki M, Matsuoka S, Deguchi
T. Analysis of pain level in cases treated with
Invisalign aligner: comparison with fixed edgewise
appliance therapy. Prog Orthod. 2014;15:64.
SECTION VIII
Orthodontic armamentarium
Chapter 34: Concept of orthodontic operatory design

Chapter 35: Instruments and equipment in orthodontic use
Chapter 36: Components of fixed orthodontic appliance
Chapter 37: Orthodontic archwires: material and their properties
Chapter 38: Rubber and synthetic elastic accessories
Chapter 39: Bonding orthodontic appliances
CHAPTER 34
Concept of orthodontic operatory
design
Prabhat Kumar Chaudhari
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Consultation room
Sterilisation area
Office decor
Indoor plants
Parking provision
Key Points
Introduction
The office and workplace should be pleasant and conducive to
efficient functioning. An orthodontist will move to a new office or do
a major remodelling or redesign of an existing office two or three
times during his life career. An orthodontist is likely to spend most of
his waking hours in the office.1 Hence orthodontic office should be
designed to make the time spent there as pleasant, comfortable,
productive and efficient as possible not only for doctors but also for
staff and patients.
Good design is an important component in strategic planning
around any project. Design can be a strategic asset when applied early
in the process of planning an orthodontic office. The design team can
include but is not limited to, an orthodontic office design specialist or
orthodontist itself, an architect, an interior decorator and building
contractor.1 Proper selection of these individuals is the most
important single step in the entire design process. Good design has a
vital role to play in communicating orthodontist mission and vision
and conveys his/her professional identity in an effective manner.
Walking into a well-designed office creates an initial pleasant
impression to the patients and their guardians, which could influence
decision making in the choice of an orthodontist. Conversely, a poorly
designed office may undermine client’s faith, professional goals and
objectives.
A typical orthodontic office should have operatory area (treatment
rooms) and support areas for treatment operatory and furnished with
the administrative and patient reception areas. Salient features of ideal
orthodontic office are (1) ideal space requirement for orthodontic
office is 500–800 square feet (sqft) and (2) it must have operatory
room, patient consultation and reception room. In a typical scenario,
500–800 sqft office would suffice for a beginning orthodontic practice
and could suffice for next 10–15 years. For an ideal orthodontic office
floor plan, location, design and space considerations should be
thoughtfully created. A concept plan and scheme are presented in Fig.
34.1 and Table 34.1, however individual needs could influence
alterations in the layout.
FIGURE 34.1 Schematic diagram showing ideal orthodontic
office floor plan.
Note: Glass door with frosting for all the enclosed spaces except the X-
ray room. Source: Courtesy ZYETA Bangalore, India.
Table 34.1
Showing component of orthodontic office and space requirement (Total area =

500–800 sqft).
The need of orthodontic operatory varies from country to country and
individual needs. In general, there are three types of orthodontic
operatory:
1. Private
2. Semi-private
3. Open way
Private or individual treatment rooms are ideal for the privacy of

patients as there is only one dental chair in each room (Fig. 34.2).
Private operatory is best for adult orthodontic patients. For maximum
efficiency, all the individual treatment rooms should be identical in
layout and functionality to facilitate a doctor to perform any regular
procedure in any treatment room with ease and efficiency. Semi-
private treatment rooms have an incomplete partition between dental
chairs to provide a visual obstruction. Semiprivate operatory provides
a reasonable privacy to the patient.
FIGURE 34.2 Photograph showing private orthodontic operatory.
Source: https://pixabay.com/photos/dentist-dental-office-dentistry-
2530983/
The idea of open bay operatory is widely accepted now. Open-bay

treatment rooms are extremely helpful in practices with space
constraints to accommodate the maximum number of dental units
(Fig. 34.3). Disadvantages of open bay operatory are that there is no
privacy for the patients during treatment. Such operatory is
recommended in teaching institutions and hospitals as well as large
voluminous private practices. A store room should be strategically
planned near to operatory room for proper inventory (stock) control
and management. Salient features of orthodontic operatory are
presented in Box 34.1.
FIGURE 34.3 Open way orthodontic operatory. Open bay design
is excellent for teaching institutions. Source:
https://pxhere.com/en/photo/547576
Box 34.1 Salient features of orthodontic operatory
• There is three basic types of operatory namely, private,

semiprivate and open way type.
• Private operatory is best for adult orthodontic patients.
• Open way operatory is recommended for teaching institutions
and hospitals with high voluminous private practice.
• For smooth traffic control, there should be minimum 2.5–3 ft
space all around the dental chair.
• Length of dental chair is 6 ft, and its width is 2 ft in a reclined
position.
• There should be a minimum space of 6 ft between two dental
chairs in an open way operatory.
• It is utmost important that when a chair is not in use, it should be
kept in ‘Z’ position.
A general rule in dental office design is to have a minimum space of

2.5–3 feet (1 ft = 12 inches= 30 cm) all around the chair for smooth
traffic in the treatment room.2 The length of dental chair is 6 ft and its
width 2 ft in reclined position. A good width for the open bay
treatment area is 12–15 ft.2
The length of the open bay depends on the number of chairs that is
going to accommodate. There should be a minimum space of 6 ft
space between two dental chairs in an open way operatory.2 The
distance between chairs is measured from the center of the chairs. If
there is an operatory that will eventually accommodate more than two
chairs, there should be two chairs on 12 ft centres, with chairs added
as needed until the required chairs are on 6 ft centres.2 It is advisable
that beginners in practice may initiate with one or two chairs in the
bay and add more dental units as the business grows.
A unique feature of the orthodontic office design is the placement of
delivery units. These delivery systems can be behind the doctor and
patient, besides the patient or over the patient. While the final choice
is usually up to personal preference of the orthodontist, it should
function well in a properly designed treatment room. It is utmost
important that when a chair is not in use it should be kept in ‘Z’
position or zero position.
Ergonomics should be taken into consideration while deciding on
the position of the dental chair, the area around the chair, locations of
the cabinetry for ease of functioning and to prevent unnecessary strain
on the doctor and staff. As dental professionals are highly susceptible
to back problems in the long term, it is advisable to maintain proper
back posture while working on the patient. Hence doctors are advised
to use the dentist seat that provides the extended hip and thigh
posture like a Saddle and Ghopec stools instead of conventional
dentist’s seating chair with 90-degree hip angle (Fig. 34.4).3
FIGURE 34.4 Three designs of dental stools.

(A) Conventional doctor’s stool, (B) Salli multiadjuster (Saddle stool),
(C) Ghopec stool. Source: Adapted from De Bruyne MA, Van
Renterghem B, Baird A, Palmans T, Danneels L, Dolphens M.
Influence of different stool types on muscle activity and lumbar posture
among dentists during a simulated dental screening task. Appl Ergon
2016;56:220–26.
The location of the compressors and suction units are important

when planning the clinic layout. They should be placed away from the
treatment rooms, preferably in a separate mechanical room, so that the
sounds are contained. The compressor and suction pipes should be
under the floor, and half-inch-thick pipes are preferred to prevent any
leakage. Many orthodontic offices now provide ceiling-mounted
television screens and headsets for patients. It is a well-known fact
that the presence of natural elements or even images of natural
elements make people relax. So, that orthodontic office should be
planned for it accordingly.
Entrance to the orthodontic office and reception area reflects the
personality of an orthodontist (Fig. 34.5). People tend to make a
judgement based on the hundreds of little items they notice visiting an
office. Hence the entrance and reception area must convey the
message and vision of orthodontic office that patient surely has come
to right place.4 An orthodontic office must have adequate waiting
room seating with the number of treatment chairs. A minimum area of
60 sqft is required to accommodate six to nine people.5 In
urban/suburban areas, a three-to-one ratio, three waiting room seats
for each treatment chair is sufficient. In communities where the
practice may be drawing from up to a 50–100 km radius, the waiting
room may have to be up to four or more times the size of the
treatment bay. The patient is often accompanied by more than one
guardian.2 Furniture in waiting room should be smart and
contemporary. A magazine rack strategically placed near the entrance
to the treatment room lets the patient drop the magazine off on his
way into the treatment area. Literature placed in magazine rack
should not be just related to the orthodontics, but it should have
publications of various other interests like home decoration magazine,
car magazine and comic books. Salient features of reception area
(waiting area) are presented in Box 34.2.
FIGURE 34.5 Reception smart, neat and soothing. Source:
https://commons.wikimedia.org/wiki/File:Reception_area.jpg
Box 34.2 Salient features of reception area

(waiting area)
• Design and ambience of reception area must speak the message

and vision of orthodontic office.
• A minimum of 60 sqft is required for waiting area to
accommodate 6–9 people.
• A magazine rack and water dispenser should be strategically
placed in the waiting area.
• Literature placed in the magazines rack should be of varied
interests–like the home decoration, comics book, beauty and tour,
besides about orthodontics.
The waiting should relate to clean and tidy restroom and facilities
for water/tea/coffee which makes the children and parents feel like at
home and feel relaxed.
Consultation room
The design of meeting room should be simple: with a table, open
shelves, a place to display models and appliances and space on the
walls for diplomas. There should not be any personal papers and
pictures on the walls. Orthodontic consultation room should have
minimum space of 80 sqft, but if the same room is utilised as meeting
cum patient education and case discussion centre, then it requires 80–
120 sqft area. The consultation area should be as functionally planned
as a treatment area. It is equally important and should always be
maintained by staff in a ‘ready’ condition. Salient features of
orthodontic consultation room are presented in Box 34.3. A few years
ago, most orthodontists conducted three appointments before
appliances were placed. The initial meeting is for introduction with
the patient and parents to make them aware on orthodontics. A
second appointment was scheduled for record taking. Then the third
appointment was a consultation to set the treatment plan, fee and
payment plan. Because everyone is busy, now most orthodontists
have shifted to two or a single appointments only for initiating the
treatment.
Box 34.3 Salient features of orthodontic

consultation room
• Design of the consultation room should be simple.

• There should not be any personal picture, papers, in the
consultation room except doctor diplomas.
• Orthodontic consultation room should be a minimum of 80 sqft
area.
• Consultation area should be functionally planned as a treatment
area.
• It should always be in ‘ready condition’.
• Because of busy life in today’s world, before the placement of
brace, now most of the orthodontists shifted to two or only one
appointments for consultation.
The records room should contain a dental chair for impressions, a
work counter, printer, scanner and similar items. A separate
workstation adjacent to dental chair should be planned for an
intraoral scanner to incorporate digital impression in practice. It is
desirable to have this room connected to the consultation room to
access for patients’ records while the mother remains in the discussion
area. It may contain cephalometer/panoramic X-ray unit for smaller
offices. For a larger practice, it is recommended that the X-ray room
should be a separate room from the area in which impressions are
taken. The guidelines of radiation protection regarding X-ray room
design should be followed which may vary from country to country.
In India, we follow guidelines of atomic energy regulatory board
(www.aerb.gov.in) when designing space and the wall thickness of
the room that houses the X-ray unit. Digital X-ray records have
replaced the analogue X-ray films, and manual analysis has been
substituted with computerised analysis with software. Therefore,
newer office designs do not have a provision for a dark room. For
photography in the records room, there should be two cameras, one
for intraoral and one for extraoral, to provide an acceptable
photographic record. In an orthodontic office, the laboratory is 40–60
sqft. A separate space to keep staff uniforms and coats is useful in the
lab area. Salient features of record room are presented in Box 34.4.
Box 34.4 Salient features of record room
• Record room should be in close proximity with consultation

room.
• Record room should contain a chair for impression and
workstation.
• For photography in the record room, there should be two
cameras one for intraoral and one for the extraoral, to provide an
acceptable photographic record.
• If the cephalometer and panoramic X-ray unit is placed in record
room, then record room should be constructed as per guidelines
of radiation safety by Atomic Energy Regulatory Board (AERB),
Government of India.
• Laboratory and dark room should be well connected with record
room.
Sterilisation area
The sterilisation room should be most strategically located, because of
the essential functions that are to take place there. The sterilisation
equipment should be arranged in order of steps of sterilisation
namely, scrub sink, ultrasonic cleaner, autoclave and storage
equipment. A minimum space of 40–60 sqft with 12–16 ft of counter
space for sterilisation procedures would be ideal.4 Counter space in
the sterilisation area can be designed as an L-shaped surface, a U-
shaped surface or as two parallel linear surfaces. Salient features of
sterilisation area presented in Box 34.5.
Box 34.5 Salient features of sterilisation room
• Sterilisation area should be strategically planned near to

inventory control room in the orthodontic office.
• A minimum space of 40–60 sqft with 12–16 ft of space for the slab
is ideal for a sterilisation procedure.
• The sterilisation equipment should be sequentially placed based
on the recommended steps in sterilisation.
Office decor
The orthodontic office should be clean, well lit, and decorated
preferably with bright colours. When an office is too sophisticated,
and everything is too perfect, kids feel uncomfortable. The design and
operation of an office should be prepared with the children in mind.
Professional interior decorators provide excellent ideas and worth the
fee they charge. Interior designers can develop colour themes
throughout the room to attract the eye of the patient and assist
movement through the office. Colour themes for the floors, fixtures,
equipment, walls, and ceilings should be coordinated, if possible.
Using innovative ideas can assist in developing ambience that are
conducive to patient management. The salient features of office decor
are presented in Box 34.6.
Box 34.6 Salient features of office decor
• The orthodontic office should be clean, well lit and decorated

with bright colours.
• Use of innovative ideas for office decor is beneficial in developing
an atmosphere conducive to patient care.
• There should be an emphasis on using natural light and power-
saving concepts as the natural light provide a relaxing stress-free
ambience and a connection to nature.
Light can break or build the environment, and it is an integral part

of the architectural design of an orthodontic office. In the treatment
room, lighting should be evenly distributed, shadow free with the
emphasis on the possibility of use of natural lights and power-saving
concepts. The windows that are located allowing natural light provide
a relaxing stress-free atmosphere and a connection to nature. The use
of LED lighting is an excellent option for lighting in the orthodontic
office.
Painted office wall is usually inexpensive and easy to clean. A
combination of paint and wallpaper in certain areas like waiting area
and consultation room is recommended to enhance the office look.
The flooring of orthodontic office should be as per the colour scheme
of office.
Indoor plants
Bringing indoor plants into the orthodontic office livens it up
naturally. It is a trick that has been used by interior designers for
years. We experience less stress when there are plants around us.
With indoor plants, the orthodontic office is more relaxed but, at the
same time, more stimulating and enjoyable. Besides giving the natural
life-like feeling in the clinic, indoor plants also purify the air in the
clinic. It is recommended to have one large plant (8-in diameter pot or
larger) or two smaller plants (4- to 5-in pots) placed at every 129 sqft.6
In orthodontic office or clinic, indoor plants should be placed in a
position so that each person has greenery in view. It is recommended
to choose right plants suitable to grow in the office environmental
conditions. Some orthodontists have aquariums in their office waiting
area, which could be an attraction for kids during subsequent
appointments.
Parking provision
Adequate parking space should be available at the clinic. If the
location of the orthodontic office is going to be in a city or a popular
location, make sure it must have ample parking for visitors. If the
busy city plans do not permit free parking, directions should be
provided to the nearest paid parking. Not having adequate parking
can turn off patients especially who drive a car. If there is non-
availability of parking at the clinic, then free or discounted parking
slots should be booked at the nearest public parking place. If possible,
the doctor may employ a security personnel who can also assist
patients with finding parking spots.
Most advanced orthodontic office in contemporary society is a
paperless office. In a busy practice, it is challenging and cumbersome
to keep track of patient files and treatment records. Solution to this
problem is eliminations of paper from daily operations.7 Several
orthodontists now consider that paperless process is a reality to
enhance the practice efficiency. The first requirement for paperless
operation is that orthodontist must be willing to change his/her
practice into a high-tech operation.7 All paper records and manual
systems must be replaced by a central, computerised practice
management programme. Thus, all patient records will be available at
every workstation.8 The computer system should be designed
considering the security of the data and the possibility of a malicious
incursion. Provision should be made for locating the required number
of computers, scanners, and networking equipment along with the
necessary electrical outlets and hard-wired and wireless connections.9
Even if orthodontist do not want to go completely paperless, office
efficiency will be enhanced by integrating all the practice tools into
one system.
Key Points
1. Selection of right location of the orthodontic office is critical. An
excellent location of the clinic can take practice to a newer
height, while an average site could keep the practice in
oblivion.
2. Demographic considerations like proximity to the school,
hospitals, growing neighbourhoods and referring dentists are
very important.
3. The ambience conveys the message that ‘exceptional care is
rendered here’.
4. Reception area should be child-friendly so that children can be
kept entertained and occupied while waiting for their turn to
be seen.
5. Reception area must provide an adequate seating area with
facilities for water/tea/coffee for a warm and friendly
environment.
6. Sterilisation and inventory control should be located near to
operatory.
7. Consultation room should be well connected to the record room
and operatory.
8. Treatment area should never be reduced from a floor plan. In a
case of multiple operatories in an orthodontic office, all of them
should be identical.
9. There should be a minimum space of 2.5–3 ft all around the
dental chair for smooth traffic control in the treatment room.
10. Window in treatment room should be strategically placed (e.g.
north facing) to avoid direct sunlight.
11. There must be a provision for staff recreation facilities for
maximum work efficiency.
References
1. Hamula W, Bucher B. Creating your next office. J
Clin Orthod. 2000;34(12):723–730: Dec; PubMed
PMID: 11314205.
2. Jacobson S. Orthodontic office planning. J Clin
4523063.
3. De Bruyne MA, Van Renterghem B, Baird A,
Palmans T, Danneels L, Dolphens M. Influence of
different stool types on muscle activity and lumbar
posture among dentists during a simulated dental
screening task. Appl Ergon. 2016;56:220–226: doi: 10
1016/j. apergo. 2016. 02. 014 Sep; Epub 2016 Mar 11.
4. Hamula W. Orthodontic office design. Business
office. J Clin Orthod. 1980;14(3):171–175: Mar;
5. Varghese J, Doshi V. Orthodontic office design:
principles and practice. Semin Orthod.
2016;22:289–296.
6. https://www.saevus.in/can-breathe-better-air-every-
day/. Accessed on 12/12/2018.
7. Hamula W, Hamula DW. Orthodontic office design:
the paperless practice. J Clin Orthod. 1998;32(1):35–43:
8. Keim RG. The paperless office. J Clin Orthod.
2005;39:61–62.
9. Haeger RS. Establishing an all-digital office. J Clin
15735358.
CHAPTER 35
Instruments and equipment in
orthodontic use
Prabhat Kumar Chaudhari
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Instruments for specific use in orthodontics
Band cutting scissors
Band crimping (pinchable) plier
Double beak pliers
Band (crown) contouring pliers
Mershon band pusher
Band seater (bite stick)
Band plugger (director or pusher) with scaler
Instruments for bonding
Boone gauge
Wire bending instruments
Wire cutting instruments
Distal end cutter
Pin and ligature cutter (straight and curved)
Heavy duty (hardwire) cutter
Face bow bending/cutting pliers
Clasp forming pliers
Adams plier
Adams spring forming plier
Universal plier (Young style universal plier)
Arch forming instruments
Bird beak pliers (# 139 wire bending plier)
Light wire pliers (standard)
Jarabak light wire pliers
Tweed’s pliers (ribbon arch or rectangular arch bending
plier)
Three prong pliers (three jaw or triple beak pliers)
Arch forming turret
De La Rosa band contouring pliers
Utility pliers
Weingart pliers
Howe’s pliers
Loop forming pliers
Nance loop forming pliers
Tweed’s loop forming pliers
Omega loop forming pliers
Instrument for debonding and debanding
Posterior band remover
Bracket debonding pliers
Adhesive removing plier
Miscellaneous items
The CORREX tension gauge
Dontrix orthodontic stress and tension gauge
Boley gauge
Mosquito forceps
Mathieu needle holder/Mathieu ligature plier
Tucker or director
Cheek retractors
Equipment used in orthodontic office
Dental chair
Spot welder
Pressure moulding machine
Maintenance and care of orthodontic instruments
Cleaning and disinfection
Sterilisation and storage
Key Points
Introduction
In orthodontics, the terms Instrument and Equipment often used
interchangeably. Specifically, an instrument is defined as a tool
designed for precision work, for example surgical instrument, ligature
cutter and distal end cutter. Equipment in dentistry and orthodontics
usually include a dental chair, spot welders, model trimmers,
polishing lathe and pressure molding machine used in a laboratory.
Instruments for specific use in
orthodontics
Orthodontic instruments are used in conjunction with fixed and or
removable appliances. It is essential for an orthodontist to have
knowledge of working principles and the indication(s) of a specific
use of each of the instrument. Appropriate selection of instruments is
of utmost importance for any medical procedure including
orthodontics treatment.1
Most orthodontic instruments are made up of stainless-steel (SS).
Stainless steel is the material of choice for its properties of high
resistance to corrosion. Orthodontic instruments have an
ergonomically designed shape and screw joint to meet orthodontic
requirements. Gold brazing of SS instruments prolongs their life and
use. The tools are designed without sharp ends (round tips) for
patients’ comfort and safety and serrations on working ends for
improved grip. Cutting edges of the instruments are made of either SS
or tungsten carbide. Except for the disadvantages of more brittleness
as compared to SS, the tungsten carbide tips have following
advantages:
1. More durability
2. Precise cutting performance
3. Sharp cutting edge
4. Three times stiffer than SS
5. Denser than steel, hence resistant to scratches
6. The cutting edge maintains sharpness and alignment
7. Extra grip.
Controlling the movement of a tooth requires a firm attachment on
that tooth. The orthodontic band cemented to the tooth, is one of the
practical means of obtaining such an attachment. The continuing
development and refinement of materials and techniques for bonding
of orthodontic attachments to the teeth has emerged as the viable
alternative to banding. Banding in contemporary clinical orthodontics
has limited and specific indications. These are:
• Teeth that will receive substantial forces against the

attachments. For example, upper first molar in the case of
headgear therapy and loop mechanics.
• Teeth need both labial and lingual attachments.
• Teeth with shorter clinical crowns.
• Tooth surfaces that are incompatible with strong bonding,
such as amalgam restorations, porcelain veneers and
fluorosed/hyoplastic enamel.
Banding of the teeth is the first clinical step to start orthodontic

treatment. It includes placement of separators, followed by band
pinching and cementation of a pinched band or pre-fabricated band.
Separators are placed 24–48 h in advance of banding appointment.
Orthodontic instruments and armamentarium required for banding
tray setup are presented in Box 35.1. Salient features and functions of
most commonly used banding instruments are presented here.
Box 35.1 Instruments and armamentarium for

orthodontic tray setup for banding
• Separators placing pliers

• Elastomeric separators
• Orthodontic band material or preformed bands
• Band cutting scissors
• Orthodontic band pinching pliers
• High volume suction/saliva ejector
• Prophy handpiece
• Rubber cup
• Pumice
• Mershon band pusher
• Band contouring pliers
• Posterior band remover
• Band seater
• Dental floss
• Cotton wool rolls
• Glass ionomer cement
• Weston spatula
• Mitchell trimmer
• Air/water syringe/3-in-1 syringes
It is used for placing elastic separators inter-proximally before the
banding of a tooth for orthodontic braces. Separators placing pliers is
a single-ended instrument with Barrel shaped angled beak and a
handle. The handle is adapted for a palm grasp. Barrel shaped tip
prevents the slippage of the module, which reduces the risk of tissue
damage. It is used for expanding elastic separators before positioning
them interdentally. The angled beak offers convenience of module
insertion in the proximal contacts of the buccal segment as well in the
anterior segment. (Fig. 35.1).
FIGURE 35.1 Separator placing pliers.

(A) Separator placing Pliers. (B) Elastic separator and Barrel shaped tip
stretching of elastic separator.
Band cutting scissors

Band cutting scissors is available either in straight or curved tungsten
carbide tips with long or short cutting pattern. It is used for cutting of
thin metal band or band material up to 0.006 in. (Fig. 35.2).
FIGURE 35.2 Band cutting scissors.
Band crimping (pinchable) plier (Fig. 35.3)

Band crimping (pinchable) pliers are available as set separate for the
right and the left side. It has a band clamping portion and a handle.
Each of the band clamping portions has an elevated surface and
depression. The purpose of the high edge is to provide a friction
contact with the portion of band strip to prevent it from slipping. It is
used for the preparation of band. The two sets of pliers are used in
both the arches with right upper also for the left lower and vice versa.
FIGURE 35.3 Band pinchable pliers.
(A) Working end. (B) Both right and left band pinchable pliers.
Double beak pliers

Double beak pliers is separately available for anterior and posterior
band fabrication. Double beaks pliers are used for forming bands in
the mouth and of immense importance before bonding was
established as a routine clinical practice (Fig. 35.4).
FIGURE 35.4 Double beak pliers.
Band (crown) contouring pliers

Band (crown) contouring pliers is a single ended pliers with two beaks
on one end and handle on the other end. One beak is concave while
the other is convex (ball shaped) allowing contouring of bands. The
ball-shaped beak of the pliers is placed on the inside surface of the
band and hand pressure is used to improve the contour before the
final placement of the molar band. It can be used to re-contour band
edges that sometimes get distorted during band placement. This pliers
is ideal for contouring and adapting the orthodontic band to tooth
anatomy (Fig. 35.5A).
FIGURE 35.5 (A) Band (crown) contouring pliers. Source:
http://www.hu-friedy.com/products/crown-and-band-contouring-
pliers.html. (B) Band (crown) crimping pliers. Source:
http://www.mwdental.com/supplies/orthodontics/band-crimping-
plier.html.
Another variation of the band-contouring pliers is band (crown)

crimping pliers (Fig. 35.5B). It is used to contour the gingival surface
of the preformed bands to provide better tooth anatomy and improve
mechanical fitting on the clinical crown.
Mershon band pusher

Mershon band pusher is a single-ended instrument with a rectangular
(or square) working end/tip on one end and a cylindrical hollow
handle on another end. Its rectangular tip with serrated surface is
meant to transfer the force to push bands through the proximal
contact points. The edge of the rectangular pad is serrated to facilitate
grip at the occlusal margin of the band. Its cylindrical hollow handle
allows keeping it light for better operator grasp. It aids in the
placement and seating of orthodontic bands. It is used to push the
band to seat or to adapt it to exactly to the contour of the teeth. It can
also be used for modifying the coronal portion of the band to the tooth
(Fig. 35.6).
FIGURE 35.6 Photograph showing Mershon band pusher. Source:

http://www.nexadental.com/mershonbandpusher.aspx.
Band seater (bite stick)

Band seater has triangular/square bite pad of soft metal pad/tip
embedded in plastic or wooden handle. Edge of the biting pad is
serrated to facilitate grip over the band. The band seater is used for
the same purpose as the band pusher. However, instead of finger and
hand pressure, the patient’s bite force is used to push the molar band
through the proximal contact points. The metal part is held against the
band edge, and the broad spatula like reverse part provides a biting
area for the opposite molar. The band seater is useful during try in on
band selection and cementation (Fig. 35.7).
FIGURE 35.7 Band seater (bite stick). Source:

http://www.whiteoakorthodontics.com/in-ha-bite-stick-band-seater.html.
Band plugger (director or pusher) with scaler

Band plugger is a double-ended instrument with band pusher or
plunger on one end and scaler on another end. Historically, Mitchell’s
trimmer was intended to be used for trimming the cementoenamel
junction with the spoon like end of the instrument after a tooth had
been prepared for a crown.2 Its use in orthodontics includes removing
excess cement after removal and placement of orthodontic bands (Fig.
35.8).2 It can also be used after debonding brackets in the removal of
excess cement with a conventional hand piece and a de-bonding bur.
While one end is used to seat or place orthodontic bands during try-in
and in cementation phases another sharp scaler like head remove
excess material after cementation or bonding of bands.
FIGURE 35.8 Band plugger (director or pusher on one end and
cement removing scaler on another end).
with scaler. Source:
https://www.pattersondental.com/Supplies/ProductFamilyDetails/PIF_79348.
Instruments for bonding

Precise bonding is critical to the final tooth alignment and positioning
at the completion of orthodontic treatment. Accurate placement of
pre-adjusted appliances decreases the need for finishing bends and
reduces unnecessary tooth movement. Bonding involves four basic
steps namely cleaning, enamel conditioning, sealing and bonding.
Proper use of instruments and armamentarium for each step is very
important for successful bonding procedure. Orthodontic instruments
and armamentarium required for bonding tray setup have been
presented in Box 35.2. Salient features and functions of most
commonly used bonding instruments are presented here.
Box 35.2 Instruments and armamentarium for

orthodontic tray setup for bonding
• Brackets
• High volume suction, low volume suction/disposable saliva
ejector
• Air/water syringe/3-in-1 syringe
• Prophy handpiece, prophy cup and flour of pumice
• Cheek retractors
• Acid etch
• Bonding agent (composite)
• Dappen dish to dispense etchant
• Composite
• Curing light
• Teflon-tipped flat plastic
• Boone gauge
• Bracket positioning height (commonly known as MBT) gauge
• Direct bond bracket tweezers/bracket holding tweezers
Boone gauge (Fig. 35.9)

Boone gauge is most frequently used bracket-positioning aid. It has a
flat surface and fixed metal pin with or without lead pencil lids.
FIGURE 35.9 Boon gauge. Source:

https://www.orthotechnology.com/shop/instruments/boone-gauge-
stainless-steel.
The occlusal–gingival placement of the bracket is marked with this

instrument. Flat surface rests on the incisal/occlusal surface of a tooth
and fixed metal pin scribes mark for bracket heights of 3.5, 4, 4.5 and 5
mm. While marking in the incisal region, the marker should be
perpendicular to the labial surface, and in the canine, premolar and in
molar region it should be parallel to the occlusal surface.
Bracket positioning {commonly known as

MBT(McLaughlin, Bennett, Trevisi) gauge} gauge
Bracket positioning gauge4 is made up of aluminium (or SS). It has a
flat surface and fixed metal blade. This device simplifies the seating of
the bracket on the teeth with exactly at the correct height from the
incisal edge. It accurately measures the height of the bracket
placement from the incisal edge at 2, 2.5, 3, 3.5, 4, 4.5, 5 and 5.5 mm
(Fig. 35.10).
FIGURE 35.10 MBT bracket positioning gauge.
Direct bond bracket tweezers

Direct bond bracket tweezers is a single-ended instrument with two
flat beaks on one end and handles on the other end. Flat beaks are
with serration to securely hold the single bracket when placing onto
tooth during direct bonding. Applying pressure on the handle open
the working end and releasing closes working end to grasp the
bracket securely (Fig. 35.11).
FIGURE 35.11 Direct bond bracket tweezers. Source:
http://www.hu-friedy.com/products/slim-direct-bond-bracket-
tweezers.html.
Wire bending instruments
Major wire bending instruments are used for wire cutting, clasp
forming, arch forming and loop forming pliers. Instruments used for
the manipulation of wires have been presented in the Box 35.3. Brief
descriptions of instruments used for wire bending are presented here.
Box 35.3 Commonly used instruments for wire

bending and manipulation
• Wire cutting instruments

Distal end cutter
Pin and ligature cutter (straight and curved)
Maun’s heavy duty wire cutter (hard wire cutter)
Face bow bending/cutting plier
• Clasp forming pliers
Adams plier
Young universal plier
• Arch forming instruments
Bird beak plier
Light wire plier
Tweed plier (ribbon arch or rectangular arch bending
plier)
Three jaw plier (three prong or triple beak plier)
Turret
De La Rosa arch contouring plier
• Utility pliers
Weingart plier
Howe’s pliers
• Loop forming
Nance loop forming plier
Tweed loop forming plier
Omega loop forming plier
Wire cutting instruments

Distal end cutter (Fig. 35.12)
Distal end cutter can cut the orthodontic archwires from 0.014 in. to
0.022 x 0.028 in. both extra-orally and intra-orally.1 It cuts and securely
holds distal ends of archwire extending through the molar tube.
Securely holding the free end of the wire is a ‘safety’ mechanism not
to lose small metal shrapnel in the patient’s mouth. Tungsten carbide
tips provide a long-lasting performance to the distal end cutter. It is
used to cut and hold the excess of orthodontic archwire protruding
out of the molar tube.
FIGURE 35.12 Distal end cutter. Source: http://www.hu-
friedy.com/products/universal-cut-and-hold-distal-end-cutter.html.
Pin and ligature cutter (straight and curved) (Fig. 35.13)

Pin and ligature cutter should only be used to cut small gauges of
dead-soft SS ligature wire and soft pins. Its small and delicate beaks
can easily be damaged if they are utilised for any other purpose. The
cutting edge of pin and ligature cutter is placed mesial to the beak. It
is used to cut pins (in Begg’s technique), ligatures and light wires up
to 0.015 in.1 It can also be used to cut elastics and power chains. Pin
and ligature cutter with cutting tips angled at 45 and 90 degrees
especially used in the posterior area with lingual orthodontics.
FIGURE 35.13 Pin and ligature cutter.
(A) Straight. (B) Curved. Source: http://www.hu-
friedy.com/products/orthodontics/cutters/pin-ligature/pin-and-ligature-
cutter.html; http://www.hu-friedy.com/products/orthodontics/cutters/pin-
ligature/lingual-pin-and-ligature-cutter.htm.
Heavy duty (hardwire) cutter

Heavy-duty pliers are used for cutting high gauzes wire outside the
mouth. The beaks of this wire cutter are sufficiently sturdy to cut most
gauges of orthodontic wire (up to 1.3 mm diameter).1 It is extremely
important for the operator to remember never to use this wire cutter
intra-orally, and to always hold on to the wire with fingers securely
on either side of where the cut is to be made. These pliers are non-
sterilisable under cold or heat sterilisation, however, can be cleaned
with surface disinfectants (Fig. 35.14).
FIGURE 35.14 Heavy duty (hard wire) cutter. Source:

http://www.toclaboratory.com/mauns-heavy-duty-cutter/p225?
currency=EUR.
Face bow bending/cutting pliers

The face bow bending plier is ideal for bending and cutting the outer
bows of face bow. It can be used to bend wires up to a diameter of 1.8
mm (Fig. 35.15).
FIGURE 35.15 Face bow bending/cutting pliers. Source:

https://www.osecompany.com/products/orthopli-face-bow-adjustment-
plier-070/.
Clasp forming pliers

Adams plier
Adams plier5 has two smooth rectangular beaks. The distance
between the hinge pin and the tips of the beaks is short. The sides of
the beaks are flat without grooves (Fig. 35.16). When the beaks are
closed, there should be a gap at the hinge tapering evenly to contact at
the tips. The gap at the hinge should be 0.6 mm. This ensures that a 1.0
mm wire can be held firmly, keeping the surface of the beaks parallel.
When a wire is gripped at the tips of the beaks, there is no tendency
for the wire to slip out of the plier. Adam’s pliers is used to fabricate
Adam’s clasp. It is also used for adjustment of headgear and the face
bow.
FIGURE 35.16 Adams pliers. Source: http://www.hu-
friedy.com/products/adams-pliers.html.

Adams spring forming pliers has two beaks; one beak is rounded the
other is square/flat ended (Fig. 35.17). It is similar to the light wire
plier. It is used to adjust springs on orthodontic removable appliances.
It can also be used to smoothen and contour archwires.
FIGURE 35.17 Adams spring forming pliers. Source:

http://www.toclaboratory.com/adams-spring-forming-pliers-65/p237.
Universal plier (Young style universal plier) (Fig. 35.18)

Universal plier is similar to Adams spring forming plier with one
round beak with different diameter and one flat beak. It is used to
adjust headgear, face bows and Adam’s clasps on removable
appliances. This plier has universal applications in wire bending and
adjustment of most removable appliance wire components.
FIGURE 35.18 Universal pliers/young style universal pliers.
Source: http://www.shop.mipis.com/en/pliers/6441--young-130-
max.html.
Arch forming instruments

Bird beak pliers (# 139 wire bending plier) (Fig. 35.19)
Bird beak pliers (# 139 wire bending plier)6 is a single ended pliers
with two beaks at one end (pyramidal and cone-shaped beaks) and a
handle on another end. Bird beak plier is perhaps the most versatile
pliers in orthodontics for working with round wires. The bird beak
plier is used to bend a variety of archwires up to .028 in. (.71 mm). It is
utilised to place various horizontal, vertical loops, helices and bends
in the light wires as well as to contour heavier lingual arches. The
pyramidal beak is used to place a sharp bend in the archwire, whereas
loops and more gradual bends are placed with the cone-shaped beak.
FIGURE 35.19 Bird beak pliers (# 139 wire bending plier). Source:
http://www.hu-friedy.com/products/bird-beak-pliers.html.
Light wire pliers (standard) (Fig. 35.20)

Light wire plier has longer more gradual tapered beaks than bird beak
plier. Slender beak makes it easier to bend small diameter of loops. It
comes with or without serrations of the flat beak. It is similar to the
Adams spring forming plier. It is used to bend and place loops in an
orthodontic archwire. It can be used to make arch form and spring
preparation. It is used to bend the orthodontic wire up to 0.020 in.
diameter.
Jarabak light wire pliers (Fig. 35.21)

The Jarabak light wire plier has a shape, which is slightly different
from the original light wire plier. It has three set of precision grooves
to assure accurate bending and closing loops. Flat tip is serrated for
firm gripping. It serves the same function as light wire pliers and can
be used to bend hard spring wires up to 0.020 in. (0.5 mm) diameter.
FIGURE 35.20 Photograph showing light wire plier (standard).
Source: http://www.hu-friedy.com/products/light-wire-bird-beak-
pliers.html.
FIGURE 35.21 Jarabak light wire pliers. Source: http://www.hu-
friedy.com/products/jarabak-pliers.html;
http://www.ebay.co.uk/p/orthodontic-jaraback-pliers-for-forming-and-
bending-loops-ortho-supplies-tools/1073427691?
_trksid(p2047675.l2644.
Tweed’s pliers (ribbon arch or rectangular arch bending

plier) (Fig. 35.22)
Tweed Arch Bending Pliers (# 142 wire bending pliers) is a standard
size instrument with beaks of .060″ wide that are parallel at .020″
opening. and hardened edges, to prevent the wire scoring and to
preserve the smooth contact area with the wire. It is ideal for bending
square or rectangular archwires up to 0.022 by 0.028 in. This plier is
especially useful for bending utility archwires, torquing, de-torquing
the ends of archwires. Classic Tweed arch forming plier is great for
adjusting torque in rectangular wires, and bend offsets and 90-degree
bends. Parallel beaks provide precision bending of the wire at 90
degrees angles.
FIGURE 35.22 Tweed’s ribbon arch pliers (ribbon arch or
rectangular arch bending pliers). Source: http://www.hu-
friedy.com/products/rectangular-arch-bending-pliers.html.
Three prong pliers (three jaw or triple beak pliers) (Fig.

35.23)
The three prongs or three beaks plier is used mostly to bend those
large round archwires up to 0.030 in. (0.76 mm) that are difficult to
manipulate with the bird beak. The plier is utilised by placing the wire
between the two beaks on one side and single beak on the other side.
By pressing the handles towards each other, the wire is gradually bent
around the single beak. The closer the handles are squeezed together;
the sharper is the angle that is placed in the wire. Three beaks plier is
helpful for placing long ‘V’ bend in an orthodontic archwire. The plier
is most useful in the intraoral and extraoral adjustments of the quad
helix appliance.
FIGURE 35.23 Three jaw pliers (three prong or triple beak pliers).
Source: http://www.hu-friedy.com/products/three-jaw-pliers.html.
Arch forming turret (Fig. 35.24)

Turrets are used to give an arch form to the archwire in the edgewise
and pre-adjusted appliances. It is available with or without torque
option. The straight length of the archwire is directly wound in the
turret to provide the desired curvature to suit the patients arch form.
The turrets are colour coded for their slot and torque. There is no
universal guideline on colour coding of turrets. The Leone company
use following colour coding. Turrets are available in six different
colour coded versions/colours namely blue (for rectangular wires
0.016 in. up to 0.021 in. without torque), black (for wires 0.016 × 0.022
in. with torque), gold (for rectangular wires 0.018 in. torque), silver
(for rectangular wires 0.022 in. torque), purple (for wires 0.016 × 0.016
with torque) and green (for round wires 0.020 in.).
FIGURE 35.24 Arch forming Turrets.
(A) Zero torque. (B) Torque forming turret. Source: http://www.wolfram-
dental-shop.at/pub/Leone.pdf.
De La Rosa band contouring pliers (Fig. 35.25)

Designed to form and contour archwires using round or rectangular
wire. The beak has grooves of 0.4 mm (0.016 in.) 0.46 mm (0.018 in.)
and 0.56 mm (0.022 in.). Its guiding grooves help to accentuate the
curvature in the archwire. The pliers is helpful in contouring utility
arch and loops to follow arch curves.
FIGURE 35.25 De La Rosa band contouring pliers. Source:
http://www.ixion-instruments.co.uk/products/de-la-rosa/.
Utility pliers
Weingart pliers (Fig. 35.26)
The name speaks for its multiple uses in clinical practice. It has
accurately closing serrated tips, which help in easy and secure
grasping of the archwire. The bend in the beak facilitates easy
grasping of the archwire and guiding into buccal tubes.7 It is used to
guide and move the archwire in and out of placement. It is used to
bend the ends of an archwire. It is capable of bending hard wires up to
a diameter of 0.020 in. (0.5 mm).
FIGURE 35.26 Weingart utility pliers. Source: http://www.hu-
friedy.com/products/weingart-pliers-long.html.
Howe’s pliers (Fig. 35.27)

Howe’s pliers7 is multipurpose orthodontic pliers. These are two
types: straight and curve. Straight Howe’s’ pliers has a long slender
lip-safe beak with serrated tips for grasping. Special tip design of
straight Howe’s pliers makes it suitable to seat individual anterior
bands. Curved Howe pliers is long, slender, curved lip-safe tips,
which increases its efficiency in posterior areas. Tips of curved
Howe’s pliers are bend at 40 degrees for better access. It is used to
grasp bands and archwires during placement and removal, and to tie
metal ligatures.
FIGURE 35.27 Howe’s Pliers.
(A) Straight. (B) Curved. Source:
http://www.hufriedy.com/products/catalogsearch/result?
q=offset=hows=plier.
Loop forming pliers

Nance loop forming pliers (Fig. 35.28)
Nance loop forming pliers is ideally suited for fanning different loops
and adjusting pre-shaped arches for the fixed appliance technique. It
has four step beaks, which are ideal for bending loops of different
heights in both round and rectangular wires. Both edges of thin blades
are stepped in 3, 4, 5 and 6 mm height of the loop. All working edges
are carefully bevelled to avoid wire damage. These plier can bend the
wire up to a diameter of 0.028 in. (0.7 mm).
FIGURE 35.28 Nance loop forming pliers. Source: http://www.hu-
friedy.com/products/nance-loop-forming-pliers.html.
Tweed’s loop forming pliers (Fig. 35.29)

Tweed loop forming pliers has the serrations for 0.055, 0.075 and 0.090
in. (1.4, 1.9 and 2.3 mm) diameters for creating bull and helical loops
on wires up to 0.022 × 0.025 in. (0.56 × 0.64 mm). The cylindrical beak
is electro-etched to prevent wire slippage. Concave beak has slight
parallel serrations to hold wire at 90-degree angle while forming the
loop.
FIGURE 35.29 Tweed’s loop forming pliers. Source: http://www.hu-
friedy.com/products/tweed-loop-forming-pliers.html;
http://www.ebay.co.uk/gds/Orthodontic-Pliers-for-Orthodontists-and-
Dental-Professionals-/10000000177868992/g.html.
Omega loop forming pliers (Fig. 35.30)

Omega loop forming pliers is used to bend and form loops in
orthodontic archwires. Grooves in beaks facilitate bending of loops
into archwires. Graduated cones at 0.045, 0.060 and 0.075 in. (1.14, 1.52
and 1.91 mm) are designed to form precise omega loops on wires up
to 0.022 × 0.025 in. (0.56 × 64 mm).
FIGURE 35.30 Omega loop forming pliers. Source: http://www.hu-
friedy.com/products/omega-loop-forming-pliers.html.
Instrument for debonding and debanding

Orthodontic instruments and armamentarium required for debonding
and debanding tray setup have been presented in Box 35.4. Salient
features and functions of most commonly used instruments are
presented here.
Box 35.4 Showing instruments and

armamentarium for orthodontic tray setup for
debonding
• Posterior band removing pliers

• Bracket debonding pliers
• Adhesive removing pliers
• Conventional handpiece and debonding burs
• How(e) pliers
• Scaler
• Prophy handpiece, prophy cup and flour of pumice
Posterior band remover (Fig. 35.31)

Posterior band remover is used to remove posterior orthodontic
bands. It has two beaks; one may have a nylon tip (may be
replaceable). When removing a band, the nylon tip is placed on the
occlusal surface, and the curved beak is placed at the gingival edge of
the band.
FIGURE 35.31 Posterior band remover. Source: http://www.hu-
friedy.com/products/long-posterior-band-removing-pliers.html.
Bracket debonding pliers (Fig. 35.32A and B)

Debonding pliers7 is used to remove the bonded brackets. It is used on
steel, plastic and ceramic brackets. The wide tips wedge between both
the edges of the base of the bracket and the tooth surface (incisal–
gingival direction), easily lifting off the bracket. Anterior debonding
pliers is used to debond the brackets from maxillary and mandibular
anterior teeth (Fig. 35.32A). It can also be used to scale remaining
materials from the tooth surface. Posterior debonding pliers have a 60-
degree angled tip, allowing better access to posterior areas. It is used
to debond the brackets from maxillary, mandibular posterior teeth,
and removal of lingual brackets (Fig. 35.32B).
FIGURE 35.32 Bracket debonding pliers (A&B). Source:
http://www.hu-friedy.com/products/straight-bracket-removing-
pliers.html; http://www.hu-friedy.com/products/lingual-bracket-
removing-pliers.html.
Adhesive removing plier (Fig. 35.33)

A plier with a blade that removes adhesive from tooth surface after
debonding.
FIGURE 35.33 Adhesive/Bonding composite removing pliers.
Source: http://www.hu-friedy.com/products/adhesive-removing-
pliers.html; http://www.hu-friedy.com/products/adhesive-removing-
pliers.html.
Miscellaneous items
The CORREX tension gauge (Fig. 35.34)
An ideal instrument for measuring small mechanical forces. The
CORREX tension gauge for orthodontic use comes in two ranges of
force. The feeler tip is the flat or rounded type. The smaller one
measures the force or tension from 0–200 g and a large one from 250–
2000 g rounded or flat type of feeler tip. Placing the feeler tip to lift the
spring or to bring it to the desired position for measurement uses it. It
is important to keep the feeler tip at the right angles to the direction of
force always. Changes to this angle will result in erroneous readings.
FIGURE 35.34 Correx tension gauge.
Dontrix orthodontic stress and tension gauge (Fig.

35.35)
Precisely determines the exact force of elastics, springs and wires. It
has a slip fork over the wire to determine the force of a coil spring.
The notch may be used to push archwire or finger spring to its seated
position. The hooked end is used to draw elastic to its working
position. Two varieties are available for orthodontic use. The light
duty measures the force up to 4 ounces and a larger one up to 16
ounces.
FIGURE 35.35 Dontrix orthodontic stress and tension gauge.
Boley gauge (Fig. 35.36)

Boley gauge is vernier, metric calliper used to measure tooth, arch and
facial dimensions and thickness of various dental materials.
FIGURE 35.36 Boley gauge. Source: http://www.hu-
friedy.com/products/boley-gauge.html.
Mosquito forceps (Fig. 35.37)

Mosquito forceps is used to grasp and place orthodontic power chain
and modules. The beak is serrated for a better grasp.
FIGURE 35.37 Mosquito forceps (Haemostat). Source:
http://www.hu-friedy.com/products/4-straight-halsted-mosquito-
hemostat.html.
Mathieu needle holder/Mathieu ligature plier (Fig. 35.38)

Mathieu needle holder/Mathieu ligature plier is used to grasp and
place ligature wires and elastic modules. Beaks are serrated for a
better grasp. The handle has a locking mechanism and a spring
mechanism that help the operator to open and close the plier quickly.
FIGURE 35.38 Mathieu needle holder/Mathieu ligature pliers.
Tucker or director (Fig. 35.39)

Double ended hand instrument with notches to help hold wire when
ligating. It is used to tuck excess ligature wire out of the way to reduce
tissue trauma. The notch in working end allows the operator to apply
pressure to the archwire to seat it for ligation.
FIGURE 35.39 Wire tucker or director.
Cheek retractors
The orthodontic office must be equipped with cheek retractors (Fig.
35.40A) of both paediatric and adult sizes. Cheek retractor with
tongue guard and suction attachment (Nola dry system) is an
excellent system for maintaining a dry field. (Fig. 35.40B).
FIGURE 35.40 (A) Cheek retractor. (B) All-in-one device for isolation
during orthodontic bonding: Nola dry field system contains cheek
retractors, tongue guard and inbuilt suction holes and connectors.
Dental photography mirror
Dental photographic mirrors both adult and paediatric sizes (Fig.
35.41) and tongue separator/tongue guard (Fig. 35.42) are essentials in
a day-to-day practice.
FIGURE 35.41 Dental photographic mirror.

FIGURE 35.42 Tongue separator/tongue guard.
Equipment used in orthodontic office (Box

35.5)
Dental chair (Fig. 35.43)
Selection of proper dental chair is a very important step for
orthodontic practice not only for the comfort and the ergonomics of
the operator but the efficiency and profitability of the entire
orthodontic office. The dental chair must serve the physical needs and
complement the clinical requirements of the orthodontist and the staff
members. The dental unit is consisting of dental chair and operational
unit.
Box 35.5 Showing commonly used equipments in

orthodontic office
• Dental chair
• Spot welder
• Pressure moulding machine
FIGURE 35.43 Dental chair design for orthodontic office. 1. Dental
Chair: The chair could be adjusted as up and down, backrest front and
back for different requirement; 2. Assistant Console: Assistant to
control the function of the water heating and spraying; 3. Footswitch:
To control the dental chair movement; 4. Imaging System: The imaging
system for diagnosing; 5. Light Adjusting Arm: The arm to adjust angle
and direction of operation light; 6. Operation Light: Operation light for
diagnosing, operation or examining; 7. Balance Arm: The arm to
connect the instrument tray; 8. Instrument Tray: Assistant device
receptacle; 9. X-Ray Viewer: A device to check the intraoral X-ray film;
10. Extended Tray: A tray which set some stuff during using; 11. Foot
Control: The foot control button to control the moving of dental chair;
12. Cuspidor: Cuspidor for the patient to drain and clean; 13. Post-
mounted service console: The main control system of the dental unit;
14. Chair Base: The main base of the dental chair.
The correct chair positioning helps the operator to have a good

visibility and accessibility of the oral cavity. If orthodontists maintains
proper position and posture during treatment, the doctor is less likely
to get strain, fatigue, be more efficient and fewer chances of getting
musculoskeletal disorders.8
The patient should be seated in the dental chair in a well-supported
state. An adjustable/articulated headrest should always support the
patient’s head. The chair height should be kept low, backrest should
be upright, and armrest should be adjustable while making the patient
to seat in the dental chair. Patient position can vary with the operator,
type of procedure and area of the oral cavity. However, most
commonly used chair position in orthodontic practice is almost supine
or reclined 45 degrees. The orthodontist and the assistant should sit in
the proper positions for treatment. Usually sitting position is
preferred in modem orthodontic practice to relieve stress on
operator’s leg and support the operator’s back. The operator should
sit in a position so that the level of operator’s elbow should be placed
at same level as the level of the oral cavity.
Spot welder (Fig. 35.44)

Welding9–10 is the process of joining of two similar metals or alloys
though the application of heat, pressure and time without addition of
filler material to produce a localised union between two parts. In the
clinical practice of orthodontics, spot welding is most commonly used
method of welding for the construction of orthodontic appliances like
to spot-weld the bands, attachment to the bands.
FIGURE 35.44 A heavy duty spot welder, annealing/heat
treatment and soldering unit.
Spot welding uses the principle of electric resistance. Resistance

welding is one of the oldest of the electric welding processes in use
worldwide today. A combination of heat, pressure and time make the
weld. As the name resistance welding implies, it is the resistance of
the material to be welded to current flow that causes a localised
heating in the parts. Resistance spot weld is unique because the actual
weld nugget is formed internally on the surface of the base metal. The
resistance spot weld nugget is formed when the interface of the weld
joint gets heated due to the resistance of the joint surfaces to electrical
current flow. In all cases, of course, the current must flow, or the weld
cannot be made. The pressure of the electrode tips on the workpiece
holds the part in close and intimate contact during the making of the
weld. Remember that resistance spot welding machines are not
designed as force clamps to pull the workpieces together for welding.9
Spot welder has three basic parts (Fig. 35.45):
1. Electric transformer: This reduces the voltage of the main

supply to a low value, which is safe to handle.
2. Copper electrodes: Copper is the base metal used for resistance
spot welding tong and tips. These convey the current to the
workpiece (metal to be welded). Copper has high electrical
and thermal conductivities, but when metals to be welded are
placed between the electrodes, the resistance of the metal
produces intense localised heating and fusion of piece.
3. Pressure mechanism: To keep the workpiece pressed into
contact.
FIGURE 35.45 Line diagram showing resistance spot welding

machine with work piece. Source: https://www.millerwelds.com/-
/media/miller-
electric/files/pdf/resources/bookspamphlets/resistance.pdf.
The effect of pressure on the resistance spot weld should be

carefully considered. The primary purpose of pressure is to hold the
parts to be welded in intimate contact at the joint interface. This action
assures consistent electrical resistance and conductivity at the point of
the weld. The tongs and electrode tips should not be used to pull the
workpieces together. The parts to be welded should be in intimate
contact before pressure is applied. Proper pressures, with close
contact of the electrode tip and the base metal, tend to conduct heat
away from the weld. Higher currents are necessary with greater
pressures and, conversely, lower pressures require less amperage
from the resistance spot welding machine. This fact should be
carefully noted, particularly when using a heat control with the
various resistance spot welding machines.
The chrome–nickel steel alloys (austenitic) have very high electrical
resistance and are readily joined by resistance spot-welding. The
consideration of great importance with these materials is rapid
cooling through the critical range, 800–1400 °F. The rapid quench
associated with resistance spot welding is ideal for reducing the
possibility of chromium carbide precipitation at the grain boundaries.
Of course, the longer the weldment is held at the critical temperatures,
the greater the possibility of carbide precipitation. Cleaned electrodes
and selection of right settings of spot welding are key to optimum
welding. Under heating will cause weak weld while overheating will
lead to burning and weak joint or perforations.
Pressure moulding machine (Fig. 35.46)

Versatile pressure moulding machine11–12 is used for orthodontic and
dental applications.
FIGURE 35.46 Pressure moulding machine (Biostar®). Source:

http://www.libraltraders.com/equipments/pressure-molding-
machine.html.
Components (Fig. 35.47)

Heating element: Found on the left side of the machine, swivels from
front to back and is used to soften thermoplastic sheets.
FIGURE 35.47 Components of pressure moulding machine

(Biostar®). Source:
https://www.greatlakesortho.com/commerce/associated_files/Bio
starScanBiostarVManual_S178.pdf.
Pressure chamber: Compartment where the thermoplastic sheets

material is held, heated, and formed over a dental model.
Locking handle: Holds chamber in moulding position and allows
air pressure to enter the chamber.
Clamping frame: Secures thermoplastic sheets to a chamber.
Pellet drawer: Contains overflow of pellets.
Barcode scanner: Automatically enters the correct processing
information for the thermoplastic sheets.
Plug with fuse: Built-in plug with a two 8-amp fuse compartment.
Pressure controller: Air pressure adjustment dial to control the
amount of pressure that is used within the Biostar.
Compressed-air connection: Connects to laboratory air pressure
source. Most machines require 6 bars of pressure to perform correctly.
On/off switch: Power switch.
Code button: Programmes heating and cooling operating times for
material heating and pressure forming.
Air button (Air): Removes air pressure from the chamber.
Air button (Air): Erases information placed in memory.
Time button (illustration of the clock): Allows operator to
programme heating and pressure moulding times, separately
manually.
The pressure moulding machine is used for multiple purposes in
orthodontics. It can be used to prepare retainer by moulding a
thermoplastic sheet or plastic sheet on a model or create single or a
line of aligners. The machine is also used for making soft night
guards.
Maintenance and care of orthodontic

instruments
First step in the care of instruments is careful handling of the
instruments, that means it should only be used where it is indicated,
for example, ligature cutter should only be used to cut ligature wire
not the distal end of the archwire extending from the molar tube. The
operator should always be vigilant to avoid dropping of the
instrument by mistake. Prolonging the life of instruments is an
ongoing challenge for orthodontic offices. For proper care and
maintenance of instruments following steps should be performed in
Box 35.6.
Box 35.6 Key guidelines for the maintenance and

care of orthodontic instruments
• Do not use tap water (community water supply) for any

sterilisation procedure and always dry the instruments after
rinsing.
• The used instruments should be first cleaned in an ultrasonic
cleaner for 5–10 min using high quality, nonaggressive solution
with rust inhibitors, having a neutral pH.
• Ultrasonic cleaning may loosen inserts and dull the sharp edges
of the instruments. Hence, all the cutters should be reshaped at
every 6–9 months, or as necessary.
• An acceptable temperature for most of the orthodontic
instruments is up to 185 °C (395 °F). Temperature higher than this
may cause discolouration of instruments.
• Do not heat sterilise the instruments with plastic or rubber
components, as it will tend to distort and discolour.
• Always sterilise the instruments (pliers’) in the open position.
Because of non-stainless (ferrous material inserted tips) nature of
the majority of the orthodontic pliers’ tip, dry heat sterilisation is
preferred to avoid corrosion. It operates at a temperature of 160
°C for 1–2 h.
• Because of the high levels of moisture in the autoclave process,
autoclaving is recommended for instruments with 100% stainless
steel or tungsten carbide inserted tips. For autoclaving, the
temperature required is 121 °C for 20 min at 15 pounds pressure.
• For heat, sensitive instruments like pliers with plastic and rubber
attachments, cold sterilisation in Glutaraldehyde solution for a
minimum period of 10 h is recommended.
• Drying instruments before packaging lessens the chances of
rusting. Avoid wetting the paper packagings. Corroded
instruments should be discarded as corrosion may be transferred
to the other instruments during the sterilisation process.
• Apply a light coat of silicon spray (non-petroleum lubricant)
every week or as needed depending on the use.
Cleaning and disinfection

The used instruments first should be scrubbed, cleaned immediately
by removing debris, cement, adhesives and blood. The contaminants
should be removed before they dry and stick on the instruments. After
that the instruments go through the cleaning in an ultrasonic unit for
5–10 min preferably with a non-rinse general-purpose solution (e.g.
Orthodontic Solution by Ortho-Direct Inc., USA). Tips of the
instruments should be open during cleaning of instruments in the
ultrasonic unit. The ultrasonic solution must contain rust inhibitors
and lubricants to prevent rusting and stiffness of the joints of the
pliers. It is also critical to use the correct amount of solution. If there is
too much solution, the mixture is slimy and cloudy. If there is not
enough solution, the rust inhibitors or the desperately needed
lubricants do not protect the pliers. The orthodontic solution should
be used in 40:1 concentrate that means 1 part makes 40 parts of the
solution. The solution should be changed daily to maintain the
potency of the rust inhibitors and lubricants. No rinse formula allows
the instruments to go right from ultrasonic cleaner into steriliser that
means no need to rinse after ultrasonic cleaning with rinse free
general-purpose solution. After ultrasonic cleaning, the pliers are
dumped out onto a very absorbent towel, thoroughly dried and
racked for the sterilisation. Drying instruments before packaging
lessens the chances of rusting and avoids wetting the paper
packaging.
If these steps are not followed, instruments may corrode or
discolour during sterilisation.
It is recommended to use distilled water or reverse osmosis water
for mixing of the no rinse ultrasonic solution or rinsing of instruments
after ultrasonic cleaning. Because water in municipal supplies (tap
water) can contain high levels of chlorine, chloramines, iron and
sulphur, plus other trace elements that can damage the pliers. Tap
water used to dilute cleaning solutions and for rinsing pliers before
sterilisation also can cause severe damage. Chemicals in tap water can
also neutralise rust inhibitors causing a corrosive effect on pliers tips.
Sterilisation and storage

Standard pliers tips insert of orthodontic instruments are made up of
ferrous material, 100% SS or tungsten carbide. Ferrous material is
unyielding, resistant to abrasion, flexible without fracturing in thin
cross-section, and durable, but has a non-stainless characteristic.
Because of the non-stainless characteristics of the majority of the
orthodontic pliers tips, dry heat sterilisation remains the sensible
choice for the safety and efficiency in a busy orthodontic practice.
A high level of moisture in the autoclave process can be damaging
to ferrous pliers tips. Therefore, wet heat sterilisation is recommended
only for instruments made of 100% SS or with tungsten carbide
inserted tips. After sterilisation cycle is complete, instruments (pliers)
should be lubricated with silicon (non-petroleum) lubricants before
storage.
No matter how well we care for instruments, they lose their
sharpness eventually, so each pliers must get reconditioning at every 6
months. This routine servicing helps in keeping the tips of the pliers
aligned and sharp. The edges of the pliers also should be sharpened,
and the body of the pliers are buffed and polished to discourage
rusting.
Prevention of corrosion of orthodontic pliers is ongoing challenge.13
Corrosion is an electrolytic process in which the contact of two
dissimilar metals or dissimilar areas within a single metal sets up a
potential difference resulting in an electron flow. The electron flow
leaves behind reactive ions that readily combine with atmospheric
oxygen to form oxides (rust). Conditions such as extreme
temperatures, physical abrasion, galvanism or reactive extraneous
ions that disrupt the chromium oxide layer will render the steel
vulnerable to corrosion. Instruments made of carbon or 400 series steel
are more susceptible than those of 300 series steel.
To reduce corrosion of orthodontic pliers, cleaning and disinfection
should be performed as recommended above using distilled water
and drying the instruments before packaging. Chrome plated
instruments and SS instruments should be sterilised separately
because the electrolyte action can carry carbon particles from the
exposed metal of chromium plated instrument and get deposited on
SS. It is better to keep the instruments in wrapping. Salient features of
maintenance and care of orthodontic instruments have been presented
in the Box 35.6.
Key Points
Orthodontists should acquire the information about the instruments
and equipments from the manufacturer and follow the guidelines
provided by the manufacturer on their use, maintenance and
sterilisation protocol.
In addition the operatory staff and a sterilisation room personnel
should follow the protocol of cleaning and drying and sterilisation.
Care for equipments and instruments minimises interruptions and
promotes efficiency.
References
1. Chaconas SJ. Orthodontics: postgraduate dental
handbook series. Littleton, MA: PSG Publishing;
1980.
2. Dattani A, Hayes SJ. Mitchell’s trimmer: who was
Mitchell and what was he trimming? Br Dent J.
2015;219(9):459–461.
3. Sheridan SC. Basic guide to dental instruments. 1st
ed. Wiley-Blackwell; 2006: pp. 169–225.
4. McLaughlin R, Bennett J. Practical techniques for
achieving improved accuracy in bracket positioning.
Orthod Perspect. 1999;6:21–24.
5. Adams CP. Design, construction and use of
removable orthodontic appliances. 5th ed.
Butterworth-Heinemann; 1984.
6. Tweed CH. Clinical orthodontics, vols. I and II St.
Louis: C. V. Mosby; 1966.
7. Boyd LRB. Dental instruments: a pocket guide. 4th
ed. St. Louis: Elsevier; 2012: pp. 383–451.
8. De Bruyne MA, Van Renterghem B, Baird A,
Palmans T, Danneels L, Dolphens M. Influence of
different stool types on muscle activity and lumbar
posture among dentists during a simulated dental
screening task. Appl Ergon. 2016;56:220–226.
9. Handbook for resistance spot welding. Miller Electric
(https://www.millerwelds.com/-/media/miller-
electric/files/pdf/resources/bookspamphlets/resistance.pdf
10. Pattabiraman V, Pai SS, Kumari S, Nelivigi N, Sood R,
Kumar SA. Welding of attachments in orthodontics:
technique recommendations based on a literature
search. J Indian Orthod Soc. 2014;48(1):42.
11. Application manual pressure moulding technique-
SCHEU dental technology.
http://www.libraltraders.com/equipments/pressure-
molding-machine.html.
12. Biostar® Scan/Biostar®V Operation Manual. Great
lakes orthodontics. New York.
http://www.greatlakesortho.com/.
13. Jones M, Pizarro K, Blunden R. The effect of routine
steam autoclaving on orthodontic pliers. Eur J Orthod.
1993;15(4):281–290.
CHAPTER 36
Components of fixed orthodontic
appliance
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Evolution of fixed orthodontic appliance: antiquity to the
‘orthodontia’
Pierre Fauchard era: founder of modern dentistry and
orthodontics (1728–46)
Pre-Angle era (19th century)
Angle era (20th century)
Begg appliance
Lewis modification of edgewise bracket
The era of pre-adjusted appliance and modern orthodontics
Andrews’ straight-wire appliance
Roth’s modification
Tip edge appliance
McLaughlin, Bennett and Trevisi (MBT) system
Components of fixed orthodontic appliance
Passive components
Active components
Limitations of current bracket and appliance systems
Key Points
Introduction
Evolution of fixed orthodontic appliance systems and their
components are closely linked to the development of the science of
metals, technology, milling instruments and lately advances in
computer technology.
Most modern appliances are manufactured through computer-
aided designing (CAD) and computer-aided manufacturing (CAM).
The research studies on facial growth, a better understanding on
occlusion, histological and molecular studies on the biology of tooth
movement, analysis of treatment outcome, the experience of clinicians,
and perception of patients over the years have together influenced the
design of modern orthodontic appliance systems.
Discovery of special metals and their unique features such as shape
memory and consistent delivery of forces for long duration have been
integrated into active components of the orthodontic appliance such
holding clips of as self-ligation brackets and springs. The
contemporary orthodontic appliance is precise, relatively small, more
gentle to biological tissues and more predictable on final tooth
positions.
Evolution of fixed orthodontic
appliance: antiquity to the ‘orthodontia’
Historically, our ancestors placed a high value on health and
aesthetics of the dental apparatus. In both prose and poetry of
classical Greece and Rome, there are numerous references to teeth
showing appreciation, not only of their usefulness but also as a
contributing factor to the beauty of women and of correct enunciation
in oratory.
Hippocratic writings (400 BC) have references to correction of
irregularities of the teeth as ‘among those individuals whose heads are
long in shape, some have thick necks, strong members and bones;
others have strongly arched palates, their teeth disposed irregularly,
crowding one on the other and they are molested by a headache and
otorrhoea’.1 In a Roman tomb in Egypt, Breccia found some teeth
bound with a gold wire.2
Pierre Fauchard era: founder of modern
dentistry and orthodontics (1728–46)
Pierre Fauchard, a French dentist and the author of Le Chirurgien
Dentiste is credited with the original thoughts on fixed plates
‘bandeau’ to align teeth.1,3 He suggested the use of ligature wires and
gold or silver mechanical devices. Thus, he was the originator of
Edward Hartley Angle’s E arch and the modern banding of the teeth.
Extending what Fauchard had written, Etienne Bourdet also discussed
the orthodontic practice in his Art of the Dentist in AD 1757. In
general, his appliance consisted of perforated metal bands either labial
or lingual as anchorage for the ligatures applied to the teeth to be
moved.1,3
Pre-Angle era (19th century)
The scientific foundation of orthodontics was laid in with great
contributions by the clinicians and researchers during the second half
of the 18th century. To name a few, Chapin A. Harris (1806–60) used
gold caps on molars to open the bite and knobs soldered to a band for
tooth rotations,3 Amos Westcott (1840s) placed chin cups on his class
III patients and used a telescopic bar in the maxilla to correct a cross-
bite (1859),4,5 D. William Dwinelle introduced jackscrew in 1849,3 A
modification of the screw called the crib was introduced by J.M.A.
Schange in 18411,6 and C.R. Coffin,6 who introduced a new design for
an expansion appliance in 1871, that still bears his name. He
embedded spring-action piano wire, bent into a ‘W’ shape into a
vulcanite plate, separated the plate in the middle and activated the
spring so that its halves pressed the alveolar process to the outside.
Emerson C. Angell was probably the first person to advocate the
opening of the median suture to provide space in the maxillary arch
(1860).3
John Nutting Farrar made significant contributions based on
research findings (1876–86).1 He suggested an intermittent use of
orthodontic forces that must not exceed certain fixed limits. He
preferred metallic apparatus operated by screws and nuts, which
according to him produced good results, without pain or nervous
exhaustion compared to the use of elastics.
He suggested precise activation of the appliance to move the tooth
at the rate of 1/240 of an inch two times a day, the faster rate being
pathological. His significant contributions compiled in ‘Treatise on
Irregularities of the Teeth and their Correction’ (1888) made him
known as the father of American Orthodontics.
Dr Norman W. Kingsley’s dental activities early in his career (1865)
became directed to orthodontia and his first writing on the subject
description of the ‘jumping bite’ was forerunner of the functional
appliances. His book A Treatise on Oral Deformities (1880) is considered
the first textbook with a scientific treatment of irregularities of the
teeth. He also described appliances for cleft palate and introduced the
headgear to apply extraoral force and provide occipital anchorage.3,7
The use of intermaxillary elastics with rubber bands to correct
protrusion was advocated by Henry A. Baker (1893), which was
popularly called Baker anchorage.8
Eugene Talbot in 1891 made the earliest attempt applying an
accurate analysis of the cast that reflected measurements of the jaws
with registering callipers and the T-square with a graduated sliding
indicator.1
While Bonwill said, ‘in vying with nature in matching the teeth,
there must be more than mere mechanics, more than being capable of
filling a tooth or treating an abscess—we must be dental artists’; he
developed what is known as the Bonwill equilateral triangle (1891).
He advocated a speciality of orthodontia many years before Angle. He
further stated ‘Really, in every city, someone should make use of this
special practice, and the profession should encourage such practice by
sending cases for inspection and consultation’.3
Angle era (20th century)

Angle made an immense contribution to orthodontia not only he gave
to this profession a complete system of diagnosis and treatment
appliance, but also his philosophy on malocclusion and appreciation
of beauty and life. He believed in simplification and standardisation
of appliances. ‘In art, in everything, the one supreme principle is
simplicity’, he often said. With founding of the first school of
orthodontia in 1900, modern orthodontics began with his teachings
only.1
E arch
Inspired by the Bandeau of Pierre Fauchard, Angle’s first invention on
appliances was E arch. It consisted of clamp bands, attached
expansion arch and ligatures to tie the teeth.9 This system had a poor
control on tooth movement. Thus, the next appliance was modified by
adding a tube on the band and pins on the main rigid wire. The pin
and tube appliance was thus founded. The fabrication of the appliance
demanded a very high degree of skill in precisely obtaining the
parallelism between the pin and the tube on the archwire which
required to be redone on each appointment. The appliance offered a
poor rotational control10 (Fig. 36.1).
FIGURE 36.1 Pin and tube appliance by Edward H. Angle. Source:

Wahl N. Orthodontics in 3 millennia. Chapter 5: the American Board of
Orthodontics, Albert Ketcham, and early 20th-century appliances. Am J
Orthod Dentofacial Orthop 2005 Oct;128(4):535–40.
Ribbon arch bracket: The next step was to cut half of the tube in
length to house a flat wire. The tube partially cut to accommodate
wire was the first ever bracket made with a vertical slot called ribbon-
arch appliance. The gold ribbon-arch (1916) of 0.022 in. or 0.036 in.
dimensions was secured firmly with pins. This appliance offered an
effective rotational control but weak in control of mesiodistal tooth
movement. As a result, the premolar teeth could not be bodily moved
(Fig. 36.2).11
FIGURE 36.2 Ribbon arch appliance by Edward H. Angle. Source:

Angle EH10.
Edgewise bracket. It was in the year 1928 when Angle introduced

the latest and the best in orthodontics, the marvellous piece of a
precious metal, (gold alloy) 0.050 in. dimensions that have a slot-like
cut running in it in the mesial to distal directions, and one which
could house a piece of 0.022 × 0.028 in wire inserted in its slot at the
edge (reverse of ribbon mode) to deliver a three-dimensional (3D)
control on the teeth. These brackets were required to be soldered on
gold bands. The modern bracket designs are derivatives or extensions
of this fundamental design of the bracket introduced more than 80
years ago by Angle (Fig. 36.3).
FIGURE 36.3 First edgewise appliance by Edward H. Angle.
(A) Shows a band, which is 0.125 in. wide, long, and 0.004 in. thick,
with a bracket brazed to the centre of its labial surface. The outer ends
of the bracket are bevelled from the slot to the edges of the band. (B)
Shows another band of the same dimensions as that shown in A, but
bearing a somewhat different type of horizontally slotted bracket, the
portions of the bracket above and below the slot, instead of being
bevelled, form overhanging flanges or wings. (C and D) Shows the two
types of bracket bands, seated within the brackets of which are
segments of two types of elastic arch material of which the arches are
to be made. (E) Edgewise bracket without wings, (F) Edgewise bracket
with wings, (G, H) Show diminutive staples of precious metal, to be
attached by solder to bands, arches and so on. The ligatures are of two
dimensions: 0.010 and 0.015 in., and are made of a special quality of
brass to afford the maximum toughness and softness. Source: A–G
Drawings based on the concept of Angle EH12 for Figure J Angle EH13.
Although the edgewise bracket was thought to be a great system,

which is expected to provide a 3D control, the small dimensions of
mesiodistal width offered poor rotational control especially on teeth
with large mesiodistal dimensions. The problem was partly solved by
soldering gold eyelet to be placed mesial and distal to the bracket. The
ligature wire tied from the eyelet to the archwire affected rotational
correction.12,13
During Angle’s era, the treatment philosophy hovered around the
non-extraction approach. In subsequent year’s, information on the
growth of the face, research findings from histological studies about
tooth movement with variable levels of force, and advances in the
development of material alternatives to gold significantly influenced
the thinking on appliance design and treatment philosophy.
Clinical and cephalometric research findings of Charles H. Tweed14
studies on attritional occlusion by P.R. Begg greatly changed
orthodontic thinking towards extraction approach in the management
of malocclusion. Clinicians and technologists continued their work on
improvement of appliance design to conserve anchorage, use of
lighter forces and possibly minimise wire-bending.
Begg appliance
P. Raymond Begg-assisted Angle in teaching the new edgewise
mechanism. Practicing in Adelaide, Australia, Begg experienced
difficulties with the edgewise system in attempting to close extraction
spaces and reducing deep overbites. He, therefore, developed a light
wire bracket in 1933. This new bracket was primarily a ribbon arch
bracket turned upside down. It was the first bracket system that used
single, round, stainless steel wire of 0.016 in. diameter or less. Begg
also developed a highly resilient, stainless steel ‘Australian’ wire in
1940s, replacing the precious metal and advocated differential light
force technique in 1956 (Fig. 36.4).15–17
FIGURE 36.4 Begg bracket and round tubes used by P.R. Begg.
(A) Begg’s light wire bracket a modification of original ribbon-arch
bracket. The open end of the cut slot is swapped upside down. (B) The
round tube. (C) One point safety brass pin used to hold the round wires
in the slot which allow tipping during stage 1 and stage 2 of the Begg’s
treatment stages. (D) Hook shaped lock pin for use during stage III. (E)
Uprighting spring made by 0.014-in. Australian wire. (F) Rotating spring
right. (G) Rotating spring left.
Lewis modification of edgewise bracket

The edgewise bracket too was continuously modified with clinical
experience on its limitations. Paul D. Lewis soldered curved rotation
arms or ‘wings’ to a single bracket that contact the inside of the
archwire (Fig. 36.5).18
FIGURE 36.5 Lewis brackets.
(A) Lewis bracket. (B) Alexander bracket. Alexander modified Lewis
bracket with a power arm and a hole in each of the rotation wings.
Bracket slot: 0.018/0.022 in.
Swains Siamese Bracket. In order to achieve better rotational

control, Brainerd F. Swain (1949) attached two edgewise brackets to a
single base at a distance of the width of a single bracket and thus twin
or Siamese bracket was born (Fig. 36.6).19
FIGURE 36.6 Standard edgewise weldable brackets.
(A) Single, (B) Small/Junior Siamese, (C) Medium Siamese, (D) Large
or wide Siamese and (E) Extra large/extra wide Siamese.
The original edgewise brackets were milled in gold and soldered on

gold bands. With the discovery of stainless steel which provided an
excellent combination of strength and resistance to corrosion; the need
for costly gold brackets was eliminated.
Several attempts were made in the first half of the 20th century at
‘building treatment into the appliance’, a phrase coined by Joseph R.
Jarabak.20
Glendon Terwilliger was one of the first to attempt soldering
brackets onto bands into tip and torque positions.21
Holdaway (1952) suggested that the brackets in the mandibular
buccal segments could be angulated by an amount proportional to the
severity of the malocclusion (Fig. 36.7).22
FIGURE 36.7 Holdaway’s method of placing the brackets at

angulation.
(A) Shows mesiogingival angulations of premolar and molars
attachment to upright and distally tip the mesially inclined buccal teeth.
(B) After uprighting of the buccal segment, the extent to which brackets
are angulated will vary according to the severity of the problem and
type of malocclusion. Holdaway suggested 2–3 degree to maintain the
teeth in upright position in bimaxillary protrusions and 10–12 degree in
Class II cases. A lower 0.018 in. round wire is tied, on which a sliding
yoke with an incorporated intermaxillary hook distal to the lateral incisor
is placed for transmitting force mesial to the bicuspid bracket [Drawings
based on the concept given by Holdaway (1952)].
However, it was Ivan F. Lee (1959) who advocated building torque

into bracket itself. The first commercially viable torque brackets for
anterior teeth were marketed by Unitek (Monrovia, California). At the
1960 American Association of Orthodontists (AAO) meeting, Jarabak,
with James A. Fizzell, demonstrated the first bracket to combine
torque and angulation.23
Around these years Robert Murray Ricketts had already visualised
and believed that lighter forces which are within biological limits are
required for efficient tooth movement than those generated by the
traditional edgewise appliance. He evolved a philosophy called
‘Bioprogressive Therapy’ and the appliance of Siamese brackets (1953)
of the 0.018 in. slot (1956–58). He devised preformed bands, angulated
and torqued brackets and tubes in 1959 (Fig. 36.8).24–26 These
developments set the stage for the production of standardised, pre-
adjusted orthodontic appliances. He also advocated treating
‘segments’ of dental arches and the use of ‘utility arch’ therapy in
1960.26,27
FIGURE 36.8 Ricketts’ bracket system.
He used single as well as Siamese brackets with torque values
originally suggested by Jarabak.
The era of pre-adjusted appliance and
modern orthodontics
Andrews’ straight-wire appliance
Another 12 years had passed before Lawrence F. Andrews announced
an appliance whose brackets were designed for each tooth, so that, on
being aligned on an archwire, the teeth would assume ideal
positions.28–30 Based on his ‘six keys to normal occlusion’, he called
his design straight-wire appliance (Fig. 36.9). Building on the
innovations of Lee and Jarabak, Andrews cut the appropriate amount
of torque into each bracket and angulated the bracket concerning its
base. It was the first bracket to combine torque, angulation, ‘in and
out’, and offset. These developments were the real beginning of pre-
adjusted appliance era (Table 36.1). The bracket system and bio-
mechanics developed by C.F. Andrews was available as straight-wire
(SW) appliance.
FIGURE 36.9 Distinct features of pre-adjusted appliance vis-à-vis
standard edgewise appliance.
(A) Left top and bottom pictures: standard edgewise appliance
necessitates the creation of ‘first order’ bends in the archwire. To
maintain natural arch form and compensate for the variable labiolingual
thickness of the crowns of central incisor, lateral incisor and canine. A
molar offset is required to maintain molar rotation. (B) pre-adjusted
appliance use archwires form without bends. The variable thickness of
bracket bases and buccal tubes and built-in contoured base of the tube
eliminate the need for first order bends. (C) Each tooth in the arch has
its unique distal tip. Second order bends are given in the archwire to
maintain distal tip and prevent mesial anchor loss of the buccal
segment. (D) The tip of the tooth is built in the bracket by milling the
slot at an angle specific for each of the tooth. (E) Each tooth in the arch
has its unique labiolingual inclination called torque. Torque bends (3rd
order bends) are given in the archwire to maintain correct labiolingual
inclination of the teeth. Each tooth requires its value of torque. In
general, anterior teeth have +ve crown torque (palatal root torque)
while teeth in buccal segment need a −ve crown torque (buccal root
torque). (F) The required torque in the bracket is built in the base of
each of the tooth thereby eliminating the need for incorporation of
torque in the wire in most of the instances.
Table 36.1
Andrews’ prescription of straight-wire appliance
Roth’s modification
Subsequently, Ronald Roth modified the straight-wire appliance.31,32
The purpose of Roth’s set-up was to provide corrected tooth positions
before appliance removal that would allow the teeth in most instances
to settle in non-orthodontic normals studied by Andrews. Roth
followed a principle that natural teeth should be positioned from a
gnathological standpoint, in other words, occlusion should
incorporate the ‘six keys to normal occlusion’ with mandible in
gnathological-centric relation, that is, seated in the condylar reference
position. Therefore, the idealised tooth positions should achieve
centric relation closure, mutually protected occlusion and elimination
of excursive interferences.
Roth’s prescription has extended prescription values to finish to an
‘end of appliance therapy’ goal in which all tooth positions are slightly
overcorrected and from which the teeth will most likely settle into
non-orthodontic normal positions (Table 36.2).
Table 36.2
Roth’s prescription of pre-adjusted appliance system
Tip edge appliance

Another interesting, intelligent modification of the bracket was
chopping off part of the edgewise bracket onto either ends but the
opposite surfaces of the slot that permitted initial controlled tipping
(Begg’s type tooth movement) and final edgewise torque and tip
control with straight wires. These brackets were called ‘Tip Edge’
system, introduced by Peter C. Kesling (Fig. 36.10A–D).33
FIGURE 36.10 Tip edge bracket.

(A) Edgewise bracket with conventional archwire slot. (B) Diagonally
opposed corners (x and y) of the slot are removed to permit mesiodistal
tipping in a predetermined direction. (C) Tip edge bracket slot can
control desired tip angle through horizontal surfaces and torque from a
rectangular wire between central ridges or pivots. (D) Features of tip
edge brackets for the maxillary right canine. Internal components of the
‘propellor’ slot include; a and a, crown tipping control surfaces; b and b,
root uprighting control surfaces; c and c, vertical and torque control
ridges or pivots; d, rotational control surface. (Based on the concept
given by TP, Orthodontics, La Porte, Ind, USA).
McLaughlin, Bennett and Trevisi (MBT) system

In the early 1990s, Drs Richard McLaughlin, John Bennett and Hugo
Trevisi collaborated with 3M to develop the MBT Versatile+ appliance
system.
McLaughlin and Bennett34 formulated their prescription for pre-
adjusted appliance by adding a ‘theoretical bracket placement chart’
based on the distance from the incisal or occlusal edge to the centre of
the clinical crown (Table 36.3).35
Table 36.3
McLaughlin, Bennett, Trevisi (MBT) prescription of pre-
adjusted appliance
The fundamental principle of building treatment into the appliance
itself to eliminate or minimise wire-bending has continued from a
universal prescription to prescriptions for racial variations, and now
the latest being individualised, customised prescription of the
appliance to meet the needs of the individual patient.
Components of fixed orthodontic
appliance
The components of the fixed orthodontic appliance can be grouped
into two major categories:
1. Passive components:
a. Brackets
b. Bands
c. Buccal and lingual tubes
d. Intraoral orthodontic accessories such as lingual
buttons, cleats and hooks.
e. Anchorage appliances
- Transpalatal arches
- TAD
2. Active components: On activations, these are capable of
initiating and sustaining biological tooth movement. These
include:
a. Wires and wire components built by orthodontist
b. Springs
c. Elastomerics
The contemporary fixed appliance has evolved over the years with
the developments in metallurgy, alloys and nonalloy materials,
manufacturing technology, and the advent of computer technology
with their applications in the manufacturing process of precision parts
such as brackets and accessories.
Passive components
Brackets
The bracket slot design, size, and its components have largely been
governed by the final desired tooth position at the end of orthodontic
treatment, which in turn is influenced by the concept and definition of
normal occlusion.
The research and understanding of the anatomical and functional
basis of occlusion have greatly influenced the design of bracket slot
the so-called prescription of the bracket.
The standard edgewise brackets are either single or twin without
any slot angulations or provision of variable thickness or labiolingual
position of teeth in the arch or the labiolingual inclinations of their
roots.
The contemporary pre-adjusted orthodontic bracket is custom made
in its labiolingual thickness to influence the labiolingual position of
the tooth in the arch. It has a bracket slot cut at an angle in the
mesiodistal direction that determines the anatomical tip of the tooth,
and it has built-in torque at the base of the bracket that governs the
labiolingual inclination of the tooth crown and root.
The bracket design ‘prescription’ is aimed to achieve a unique
anatomical and physiological position of the tooth in the dental arch
in three-dimensions of space. Other factors include tooth’s
relationship to the neighbouring teeth and to those with opposing
arch in the state of static and functional occlusion. The anatomical
contours of the tooth/teeth and the biomechanical considerations in
3D controls have also affected the ultimate size, design and shape of
the brackets.
Contemporary brackets have the following bracket parts:
• Bracket-base bonding surface

• Bracket body and slot
• Bracket body–base interface
• Wings
• Power arm.
Most conventional metal brackets are made up of high- quality

stainless steel for its unique properties of resistance to corrosion and
sufficient strength to withstand forces of deformation, when full size
activated stainless steel wires, are inserted into the slots. The stainless
steel of 316- and 318-type steel is used for manufacturing orthodontic
brackets. These grades of steel are known for excellent corrosion
resistance and high resistance to chloride attack.
Stainless steel brackets have been in extensive use and have shown
reasonable strength, bio-acceptability and proven track record of
clinical acceptability. Most modern brackets are bondable.
Low nickel-stainless steel brackets were developed to minimise
nickel release in the mouth and thereby reduce allergic reactions. New
stainless steel 2205 alloys have shown less crevice corrosion when
compared with nickel-titanium and beta-titanium.36
Based on material composition, brackets can be broadly grouped as
metal and nonmetal brackets.
Nonmetal brackets with metal slots have been developed to
overcome the high frictional resistance offered by porcelain surfaces
and in plastic brackets to overcome their deformation (Table 36.4).
Table 36.4
Classification of brackets based on their composition

Nonmetal brackets with
Metal brackets Nonmetal brackets
metal slot
Stainless steel (SS) 316 and 318 types Porcelain brackets Porcelain with metal slots
Low nickel SS 2205 type Zirconium brackets
Nickel-free pure titanium/titanium alloy (Ti– Polycrystalline
6Al–4V) alumina
Brackets of cobalt–chromium Single crystal
alumina
Gold alloy brackets Polycarbonate Polycarbonate with metal
slots
Bracket-base
Bracket-base of bondable brackets is made up of the stainless steel
sheet which is contoured to the best-fit labial contour of each tooth.
The bondable surface is modified to provide mechanical retention at
composite bracket interface. It has either integral built-in undercuts to
provide mechanical retention for composite tags or 60-gauge wire
mesh welded to the base. Manufacturers have used 80/100/150 gauge
mesh. The mesh gauge is further micro-etched by spraying metal alloy
onto the base to enhance mechanical locking of bonding composite.
Wang et al.37 investigated the influence of various bracket-base
designs on bond strength and debonded interface on six types of
metal interlock brackets of different sizes and with different base
designs. They concluded that the size and design of a bracket base
could affect bond strength. The bracket, with a circular concave base
design, produced greater bond strength than the brackets, with mesh
bases. Among the brackets with mesh-type bases, the larger the mesh
spacing, the greater was the bond strength.
Bracket body and slot

The bracket body is the most vital part, which houses the slot. Modern
brackets are a modification of the original edgewise brackets
introduced by Angle. The original brackets were of 0.050 in. width
made of gold alloy. The slot in the bracket was milled to the size of
0.022 × 0.028 in., where 0.022 in. is the occluso-gingival height (width
of the slot) of the slot and 0.028 in. is the labiolingual depth. The
bracket slot can house a round, square or a rectangular wire. A
maximum of 0.0215 × 0.0275 in. dimension rectangular wire or 0.022
in. round can be housed in 0.022 × 0.028 in. bracket.12,13 Soon it was
realised that a tiny (0.050 in.) edgewise bracket was less effective in
rotational control on the tooth, especially the one with large crown
width, that is, the central incisor.
Bracket body–base interface

The orthodontic bracket body is joined to the bracket base with a low-
fusing brazing alloy as a standard manufacturing process. There are
several issues related to the addition of intermediary brazing alloy,
which contains cadmium. Cadmium is a known cytotoxic, and
therefore its use in living tissues should be avoided. The low-fusing
alloy also undergoes corrosion leading to detachment of bracket body
from base. Modern orthodontic brackets are either laser welded or
produced by metal injection moulding (MIM) process. The laser weld
technique eliminates intermediary metal phase and has shown
acceptable clinical performance. Brackets manufactured by MIM are
one-piece appliances. These brackets may have higher surface
porosity caused by the shrinkage of manufacturing components
during sintering. Porosity makes the brackets susceptible to corrosion.
The hardness of these brackets has also been found lower than
conventional stainless steel brackets. Future technological
developments should address these issues.
Wings
The bracket body has wings in occlusal and gingival margins which
are built to have smooth edges for comfort on lips, cheek, mucosa and
a smooth under curve to hold the liga-ture wires or modules to tie the
wire.
Power arm
Power arm is an extension of the distal wing with a rounded ball end
in the gingival direction. Its main function is to provide an arm close
to the centre of resistance of tooth to which retraction spring/elastics
can be engaged. Brackets for canines and premolars are frequently
provided with power arms.
Twin brackets or Siamese brackets (Fig. 36.6)

To enhance the rotational control on a tooth, two brackets were joined
at a distance of a single bracket width (0.050 in.), and hence twin or
Siamese brackets were born.19 The mesio-distal width of a Siamese or
twin bracket varies according to the tooth crown dimension. It is the
smallest for mandibular incisor crown (junior Siamese) and the largest
for the maxillary incisors (wide Siamese) and molars (extrawide). For
canines, premolars, and maxillary laterals the medium Siamese
brackets are used.
Pre-adjusted brackets
Conventionally, during the pre-bonding era, the standard edgewise,
stainless steel brackets were welded on stainless steel bands. The
bands were pinched, contoured on the tooth crowns, welded and
cemented. Soon it was realised that to achieve proper labiolingual
placement of teeth in the alveolus, their mesiodistal angulation and
labiolingual inclination, three types of bends were required to be
introduced in the archwire. These bends are:
1. labiolingual (first order) (Fig. 36.9A–B)

2. up and down/tip bends (second order, tip back bends) (Fig.
36.9C–D) and
3. torque (third order) (Fig. 36.9E–F).11
To compensate for the variable labiolingual placement of the

anterior teeth, the wire bends were substituted by enhancing the
bracket base thickness of maxillary lateral incisors.
Andrews (1972) did an organised research on the non-orthodontic
normal occlusion and summarised his findings as six keys of
occlusion.28 After the introduction of the first prescription of the pre-
adjusted appliance, significant changes were suggested by Ronald
Roth who added extra values to make a provision for overcorrection
(Fig. 36.11).
FIGURE 36.11 Design features of a contemporary pre-adjusted
bracket.
Later in the early 1990s, Drs Richard McLaughlin, John Bennett and
Hugo Trevisi collaborated with 3M to develop the MBT Versatile + .
Appliance System. McLaughlin suggested negative torque in
mandibular incisors.6 Some clinicians prefer to use smaller
dimensions of bracket slots of 0.018 × 0.022 in. The surveys on
orthodontic practices have shown that a majority of orthodontists
prefer to use 0.022 × 0.028-in. slot brackets.
Bracket identification
The identification mark with the inbuilt prescription has become
imperative so that each bracket is identifiable for the tooth number
and occlusal-gingival orientation. Identification mark is the key to the
clinician to bond designated bracket on each tooth in a proper
orientation. Most manufacturers place the identification mark on the
distal gingival wing of the bracket. They distinguish maxillary and
mandibular brackets with a distinct colour. A German manufacturer
(Dentaurum) has patented marking of Federation Dentaire
Internationale (FDI) tooth number on the mesh of each bracket. Some
manufacturers follow a rhomboid design of the base and wings which
facilitates correct orientation of bracket parallel to mesial and distal of
inclines clinical crown and horizontally parallel to incisor edge. The
midline orientation mark indicates the long axis of the bracket which
facilitates bracket orientation in tune with the long axis of the clinical
crown.
Buccal tubes
These are housed on the first and second molars and are usually 0.25
in. long or smaller with internal dimensions of 0.022 × 0.028 in.
Development in technology and pre-adjusted philosophy has also
necessitated changes in buccal tube designs. Although bondable tubes
are used by some orthodontists, weldable tubes are more common in
use (Fig. 36.12). Maxillary molar tubes are often a combination of
rectangular edgewise and round tube called double tube.
FIGURE 36.12 Buccal tubes.
(A) Single, (B) Double, (C) Triple and (D) Single convertible tubes.
The tube with 0.022 × 0.028-in. inner diameter rectangular tube is

the main tube and 0.045-in. internal diameter round tube for
headgear. The tube has a built-in offset to compensate for molar
rotation. The base of the tube (offset) at the mesial end is thinnest and
thickest at the distal end. When a plane archwire is inserted in the
buccal tube, the variable thickness of the base of the tube is expressed
in distolingual rotation of the molar. The tubes are also so designed
for their prescription which would enhance anchorage, that is, these
are tipped mesio-gingivally and produce sufficient torque for a
natural buccolingual inclination of the molars. Some prescriptions and
clinicians prefer ‘triple buccal’ tube (auxiliary edgewise tube) for the
use of two active archwires simultaneously.
Self-ligating brackets
In a conventional bracket system, each bracket slot houses the wire
which is retained in the slot either with a ligature wire or module.
Self-ligation systems, although not new, have lately been the fastest
adaptations in bracket designs which clinicians have adopted in day-
to-day use. The ligature and modules are replaced with an integrated
mechanism within bracket, which holds the wire in the slot and hence
the name. As early as 1935, Stolzenberg38 visualised and
conceptualised the self-ligating system. Wildman39 (1972) and later
Herbert Hansen40 (1980) made significant refinements and
popularised self-ligating brackets (Fig. 36.13). The mechanism of
holding the wire in the slot is either a built-in lid/cover which can
slide over to the slot or it can be a mechanism such as an active ‘clip’.
It seems that all future brackets will have one or other kind of self-
ligation mechanism (refer to chapter 48 on self ligation).
FIGURE 36.13 Self-ligating brackets.
Advantages
Self-ligating bracket systems offer several advantages over
conventional brackets:
1. Need to untie and tie the wire into bracket slots is eliminated.
2. Hence, each appointment time for the change of wire is shorter.
3. This results in great reduction of chair time.
4. Less chair time per patient cuts down the overhead cost of the
clinical time.
5. There is a reduced friction between wire and holding clip.
Hence lighter forces are required, which, in turn, leads to
reduced anchorage demand.
6. Secure wire ligation, independent of the operator.
7. Freedom from odour and swell up of elastomeric ligature ties
and thereby improved oral hygiene.
8. Longer appointment intervals.
9. Greater efficiency and turnover of patients hence enhanced
profits.
Disadvantages
The main disadvantages are:
1. Most self-ligating brackets are bulky (except a few)

2. Failure of ligating mechanism which entails replacement with a
new bracket of a relatively high cost.
The self-ligating brackets offer measurable benefits over

conventional systems, although many improvements are desirable.41
Aesthetic self-ligating brackets are the latest development in the field
of brackets. It appears that the future of orthodontic bracket designs
will continue to improve the limitations of the current ligation
mechanism. In the near future, self-ligating brackets will substitute
conventional ligation of brackets.
Aesthetic brackets42
The demand for aesthetic brackets or even possibilities of orthodontic
treatment without any visible appliance has always been there. The
demand for aesthetic appliances is increasing particularly in adults
seeking orthodontic treatment. The initial efforts to make orthodontic
appliance relatively aesthetic were directed to minimise the size of the
visible metal on the tooth surfaces. The development of bonding
technique has eliminated large visible stainless steel bands, which is a
great welcome towards the aesthetic appliance.
Later efforts were made to miniaturise the stainless steel brackets
within limits without compromising the mechanical and
biomechanical requirements of the appliance.
Lingual orthodontic appliances

The lingual brackets do satisfy the aesthetic criteria of an orthodontic
appliance, but with operator related difficulties of working on the
lingual surfaces, they require extra time. With developments of
customised lingual appliance and preformed set of wires, the chair
time is significantly reduced. The lingual appliances are known to
cause considerable discomfort. Not all types of malocclusions are
treatable with lingual appliance systems.
Polycarbonate plastic brackets

Plastic brackets are made of polycarbonate. These were first marketed
in the early 1970s. Plastic brackets suffer from inherent problems of
the poor strength and survival in the oral environment. Lack of
sufficient strength and stiffness results in bond failures, wing fractures
and permanent deformation or creep in the brackets, thereby
decreasing the efficiency of the active wire force, particularly of the
torque. These brackets also tend to absorb stains and odours and may
get dirty within a short time in the oral environment. Some of the
drawbacks were overcome with the refinement of the material to
high-grade medical polyurethane brackets and polycarbonate brackets
reinforced with ceramic or fibreglass fillers. Metal sheets were
introduced in the bracket slot to prevent deformation hence delivery
of effective torque was possible.
Ceramic brackets
These were introduced in the 1980s, offering many advantages over
the traditional aesthetic appliances. The ceramic brackets are
composed of either polycrystalline or monocrystalline aluminium
oxide depending on their distinct method of manufacturing. The first
ceramic brackets were monocrystalline, which were milled from
single crystals of sapphire using diamond tools.
The polycrystalline sapphire (alumina) brackets are manufactured
and sintered using special binders. Most of these brackets are
manufactured by the ceramic specialists’ factories rather than the
orthodontic manufacturers because of the unique technology
employed in their manufacture.
Lately, polycrystalline zirconium or zirconium (ZrO2) brackets have
been introduced as an alternative to alumina ceramic brackets. These
brackets have greater toughness but are opaque and less aesthetic
although cheaper (Fig. 36.14). Clinical performance of alumina
ceramic brackets has continued to improve, and these brackets are
likely to remain in the mainstream of the aesthetic labial brackets in
the near future (Table 36.5). Monocrystalline brackets are more
aesthetic owing to their better optical clarity.
FIGURE 36.14 Ceramic brackets with metal slot.
Table 36.5
Advantages and disadvantages of ceramic brackets

Advantages Disadvantages
Superior aesthetics and enamel-like translucency Enhanced frictional resistance
Better colour stability Frequent bracket breakage
Higher strength Iatrogenic enamel damage
Resistance to wear and deformation Difficulties in debonding
Intraoral orthodontic accessories

In addition to brackets and tubes, other components of fixed appliance
include several types of attachments that are required to enhance
rotation, generate force couple and for placement of elastic bands (Fig.
36.15). These are:
1. Cleats
2. Lingual buttons
3. Ball-end hooks
4. Vertical tubes and palatal tubes.
FIGURE 36.15 Lingual attachments.
(A) Lingual button, (B) Lingual tubes and (C) Lingual cleats.
These attachments can be bondable or weldable. The weldable

lingual cleats/buttons are required on molar bands. Some
manufacturers provide pre-weld bands, which are supplied with
lingual cleats welded to them, should they be required in future
during the treatment. Bondable lingual buttons are often required on
rotated teeth, like premolars and incisors. Most of the buccal tubes are
now available with built-in hooks. The ball-end hooks can be welded
on bands if buccal tubes do not have a built-in provision for them.
Orthodontic bands
Before the bonding era, orthodontic bands were the carrier for
brackets, tubes and other attachments, which were welded or
soldered. The bands were cemented using orthodontic cement. With
the proven clinical success of bonding, banding on anterior teeth and
premolars has almost vanished from clinical practice.
The ‘bands’ are now mainly limited to the first and second molars
(Fig. 36.16). Traditionally, molar bands were made from
biocompatible stainless steel rolls of different width and thickness:
• Lower incisors: 0.125 × 0.003 in.

• Maxillary incisors, canines and premolars: 0.125 ×0.004 in.
• Molars: 0.150 × 0.004 in./0.160 × 0.006 in.
FIGURE 36.16 (A) Left molar band with a pre-welded triple buccal
tube. (B) Left lower molar band with pre-welded double buccal tube.
The availability of custom-made bands has eliminated the need for

band pinching, which is a time-consuming and arduous process for
both the operator and the patient. Bonding has eliminated the need for
bands on anterior teeth and premolars; however, bands are still in use
on molars. The preformed bands are available in different sizes and
most of the instances; they fit nicely on careful selection. Molar bands
may require minor modification to suit abnormal morphology of
molars such as a short occlusal-gingival height of clinical crowns or
prominent cusps.
Active components
Orthodontic wires
The orthodontic archwires are the primary force-generating
components of the fixed appliance. These are discussed in detail in a
separate chapter in this section (Chapter 37).
A number of ligature wires and accessories are used for wire
ligation. Soft SS wires are used as ligatures (Fig. 36.17).
FIGURE 36.17 Ligature wires and modules.

(A) The ligature wire of soft annealed SS 0.008–0.012-in. archwire. (B)
Kobayashi hooks made of 0.012 or 0.014 in. annealed SS wire is used
as a power arm or intermaxillary hook and (C) Elastomeric ligature
modules.
Ligature wire of ‘dead soft’ temper allows ligating and tying to be

done with minimal work hardening of the wire. Ligature wires of
0.010, 0.011, 0.012 in. dimensions are used.
Elastic modules are now being used more often as ligature
substitutes, and these discussed are in the chapter 38.
Coil springs
Orthodontic tooth movement requires the application of a force-
delivering system that should provide optimal and continuous force
to achieve the desired results. Coil spring is one of the efficient force-
delivering systems used in orthodontics. Coil springs may be either
open coils (spaced) or closed coils (Fig. 36.18).
FIGURE 36.18 Open coil springs.

(A) NiTi coil spring available on the spool. (B) Sentalloy open coil
spring by GAC. (C) Sentalloy stop wound open coil spring. These coil
springs are packaged in long lengths. A standard lumen of 0.030/0.035
in. is used. The open coil springs are available in force values of
50,100,150 and 200 g. The clinician selects the spring force and length
as per clinical needs. After determining the length of coil needed, the
spring wire is cut at the centre of the tight spiral indicated by red
arrows.
Open coil springs
Open coil springs are compressed between two teeth or a group of
teeth. The deactivation force is transmitted to the teeth via brackets
that help move the units apart and hence used for opening the spaces
(Fig. 36.18). The opening coil springs work by push action.
Originally, coil springs were made of stainless steel or Co-Cr-Ni
alloys. The coil springs are made of 0.009 or 0.010 in. spring hard
wires with a lumen of 0.032 or 0.035 in.; stainless steel open coil
springs are usually compressed to 60% of their initial length.43
Nickel-titanium (NiTi) open coil springs

The invention of NiTi alloy wires and later development of a new
generation of springs made of superelastic NiTi wires (Sentalloy) has
transformed the force delivery in orthodontics. The Sentalloy springs
are capable of delivering a constant force during deactivation due to
their unique property of superelasticity. These alloys can exert a
constant, light continuous force for a long period. The springs are
used for molar distalisation and to create space for the impacted
tooth/teeth.
Sentalloy open coil springs are available in the force range of 50,
100, 150 and 200 g. These coils are made up of 0.010 in. wire to the
lumen of 0.035 in. The open coil springs are usually compressed to the
one-third of its initial effective length.
Gurin lock can be used as a stop (Fig. 36.19A–D). The initial free
length of the open coil spring is 15 mm. According to the
manufacturers, this spring when compressed by 12 mm to 3 mm
length and deactivated delivers an almost constant force up to 9 mm
of deactivation beyond which force will decrease. No permanent
deformation of the coil was found.20 Studies have found that the
effective force values are somewhat lower as compared to the claims
of the manufacturers.43
FIGURE 36.19 (A–D) Gurin lock has multiple uses such as molar stop
or a stop with an intermaxillary hook on the wire. (A) Gurin lock, (B)
Gurin lock with an intermaxillary hook, (C) Gurin lock as ‘stop’ and (D)
Intermaxillary hook with compressed coil spring and class II elastics.
Closed coil springs44–46

The stainless steel closed coil springs have vanished in use since the
introduction of NiTi closed coil springs. The prefabricated NiTi closed
coil springs are used for retraction of the maxillary canines into
extraction spaces. The springs are also very useful for en masse
retraction of the anterior teeth, especially in the upper arch. A more
sophisticated use of the springs is in orthodontic alignment of the
impacted teeth. Authors have particularly found these useful in cases
with palatally impacted canines and incisors.
NiTi springs of 9 mm length are more often used. The springs come
in a predetermined force range. For cuspid retraction, 150-g force
spring is chosen, engaged on molar tube hook, pulled mesially and
activated to be engaged to canine power arm.
Sentalloy closed coil springs are made from Japanese super-elastic
NiTi wire and are tiny structures. These closed coil springs are
available in 100, 150 and 200 g. The effective initial length of this
spring is 3 mm. The springs are activated to the length of 15 mm, that
is, 5 times the initial length. The deactivation force of this spring is
close to the values of the spring until 0.5 mm of its activation then it
gradually falls. The open and closed coil springs have definite uses in
clinical orthodontic practice (Fig. 36.20).
FIGURE 36.20 Closing coil springs are usually made of 0.010 in

dimension wire in a lumen of 0.030 in.
These are available in 9 or 12 mm lengths. Japanese NiTi alloy wire
springs are tiny, available in 3 mm length.
Rubber elastics, elastomeric chains and accessories make integral

component of orthodontic armamentarium. These are listed and
described in detail in Chapter 38.
Limitations of current bracket and
appliance systems
Although fully programmed pre-adjusted bracket systems are now
available, they have limitations in treatment delivery for individual
patient needs. The universal bracket prescription is not suitable for
variations in face types and severity of malocclusion. Treatment with
a standard prescription of brackets implies all cases should be finished
in the same manner, in spite of variation in the original malocclusion,
the facial characteristics of the patient and the mechanics involved in
the treatment. The most crucial question is: should all malocclusions
finish in a similar predefined torque, tip and arch forms? The answer
is obvious, ‘no’.
The prescriptions build in the brackets may poorly or incorrectly
express since the bracket position on the tooth will broadly govern the
magnitude and direction of expressed teeth movement. Even with
most expert hands, absolute accuracy in bracket positioning is not
possible. Consequently, bracket repositioning may be required in
some cases at the time of finishing and detailing, resulting in
increased treatment time. Other limitations are a loss of torque and
rotational control during retraction. Therefore, some amount of wire
bending is unavoidable.
Extensive research and adaptation of digital technology have greatly
influenced clinical orthodontics. The plaster models are being
replaced with digital models. This has allowed treatment
customisation either through exactly predictable wire sequences using
a standard prescription or brackets.
Digital models are prepared directly from the scan of dental structures
and occlusion through handheld 3D scanner or scanning the
impression. The virtual set-up thus created, offers cast measurements
and treatment planning with various permutations and combinations
of tooth movements and extraction plans. Each tooth can be separately
moved as a 3D object and treatment is simulated. The operator can
consider various treatment alternatives by moving the teeth with the
mouse or with selected menus, by extracting teeth, or by reducing
teeth mesially or distally to simulate interproximal reduction (IPR).
The changes in the x, y and z coordinates of individual teeth with the
planned therapy can be displayed to show teeth movements and to
estimate case difficulty.
Once the treatment goals and final tooth positions are finalised, a
customised appliance is designed and fabricated to match the
individualised requirements of the patient. At this stage, the operator
can implement therapy by ‘virtual bracket placement’ and select the
archwire sequence and progression. He/she can select from a library
of commonly available brackets and prescriptions. The software will
account for the tip, the torque, and the offset built into the selected
prescription of brackets.
The input on material properties of the wires (modulus of elasticity
and stiffness) is obtained through advanced features of the software,
which will predict approximate force values applied to each tooth.
Then the treatment can be simulated, and the results of each archwire
sequence displayed to show the anticipated clinical result.
The system has been developed by SureSmile/OraMetrix Inc.
USA.47 This information is sent via the Internet to a server at
OraMetrix, Inc., where indirect bonding trays and archwires are
created and shipped to the orthodontist. The indirect bonding trays
are produced by stereolithography and contain the individual bracket
positions selected by the orthodontist. The archwires are produced
with a wire-bending robot in the sizes and shapes selected by the
orthodontist. Investigations into the precision of the bends with
stainless steel wire show less than one degree of error in bends and
twists. This level of precision is extremely difficult, if not impossible,
to replicate by hand.
Dynamic bracket customisation is another concept whereby each of
the functions of the bracket can be enhanced as and when needed
during the course of orthodontic treatment.
• Bonding base. The concave part is bonded on to the tooth; the

convex part receives the adjustable screw of the tipping base.
• Tip base. It is an adjustable component that can be
individualised to meet the patient’s individualistic
requirements by inducing the desired tip and tightening the
screw component.
• Torquing top. This comprises four wings attached to the
tipping base with flexible NiTi springs that can be locked to
the individualistic requirements of the patient.
The individual components would provide the orthodontist with

the versatility of changing the prescription to the patient’s needs
during treatment as and when required. For example, in case of loss of
torque, brackets can be reprogrammed to meet the treatment needs.
Key Points
Orthodontic brackets and tubes are passive components that transmit
orthodontic forces to the teeth generated by active components such
as wires and springs. A number of other new intraoral accessories
such as buttons and cleats are required as supplement brackets for
complex tooth movements. Gadgets of appliances and accessories
have been developed by the clinicians and manufacturers. Merely
possessing those are not enough. The secret of orthodontics lies in the
effective use of the appliance systems in a given situation to deliver
the best treatment outcome.
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CHAPTER 37
Orthodontic archwires: material
and their properties
O.P. Kharbanda
Anurag Gupta
CHAPTER OUTLINE
Introduction
Definition
Wire dimensions
Austenitic stainless steels (300 series)
Properties of stainless steel wires
High tensile wires
Multistrand and coaxial wires
Cobalt–chrome wires
Composition
General properties of Co–Cr–Ni alloy
Heat treatment of Co–Cr–Ni alloy wires
Useful properties of NiTi wires
Limitations of NiTi wires
Copper NiTi
β-Titanium wires
Composition
General properties of β-titanium wires
Limitations of TMA wires
Titanium wires
Nickel-free stainless steel and TMA wires
Titanium–niobium–aluminium (Ti–Nb–Al) shape memory alloy
wires
Dual flex archwires
Supercable wire
Turbo wire or braided nickel–titanium rectangular wire
Variable modulus orthodontics
Aesthetic wires
Optiflex wires
Plastic/teflon-coated NiTi
Shape memory polymers (SMP) in orthodontics
Effects of oral environment on orthodontic archwires and
brackets
Factors promoting corrosion
How orthodontic metals resist corrosion
Effect of fluoride
Arch forms and preformed archwires
Mushroom-shaped lingual arch forms
How ideal are ‘ideal’ arch forms
Key Points
Introduction
The optimal force delivery system in orthodontics should be able to
deliver desired force, for the duration without frequent visits or
change, hygienic and affordable. Force delivery system should be
possible with minimum patient compliance and least operator
indulgence. Orthodontic forces are generated by
1. wires and their configurations including springs;

2. elastics and rubber bands; and
3. forces from muscles/functional spaces.
In orthodontics, wires and their multiple configurations are the

primary source of the force delivery system. Force system depends on
the wire alloy composition, physical structure and appliance design.
As the idiom goes, ‘an orthodontist is as good as the archwire he
uses’. The orthodontic archwire is one of the most important active
elements of the orthodontic armamentarium and thus requires special
consideration.
Definition
In engineering terms, a wire is a flexible structural or machine
component having a working length many times that of its cross-
sectional dimension and has the capability of transmitting force along
that length.1 In orthodontic language, archwire refers to a wire
secured to two or more teeth through fixed attachments to cause,
guide or control orthodontic tooth movement.2 ADA specification no.
32 includes orthodontic wires excluding precious metals and ligature
wires. The desirable properties of the orthodontic wires are
summarised in Box 37.1. Since most wires are made with metal and
alloys a number of engineering terms are used in reference to the
materials. These are summarised in Box 37.2.
Box 37.1 Properties of metal orthodontic wires
Aesthetics: The wire should be least visible in the mouth. This
property becomes very important when using ceramic brackets.
While this is a very desirable property but there should be no
compromise on mechanical properties.
Biocompatibility and environmental stability: Biocompatibility
refers to resistance to corrosion and tissue tolerance to elements in the
wire. The corrosive behaviour is tested according to the international
standards ISO 10271. Environmental stability ensures that the
desirable properties of the wire are maintained for extended periods
of time. This property ensures that the wire is not harmful when in
use in the mouth.
Biohostability: The ease with which a wire tends to accumulate
bacteria, spores or viruses is called biohostability. An ideal archwire
should be a poor biohost.
Coefficient of friction: Friction is resistance to motion of one
material with respect to another closely approximated material. In
orthodontics, friction describes the ease of movement of brackets over
the wire. If the coefficient of friction is less, sliding during alignment
and space closure will be easier and with less strain over the anchor
segments.
Formability: This property describes the ease with which a
material may be permanently deformed. Formability allows the wire
to bend a wire into desired configurations such as loops, coils, and
stops without fracturing the wire. This property is dependent on the
number of slip planes in the crystal lattice of the alloy. More the slip
planes, the easier is to deform the wire. Lattice has more slip planes
than HCP. Formability is measured by employing 90 degree cold
bend test. The wire which can be given the maximum number of
bends without fracturing can be termed most formable. This property
is opposite of springback or flexibility because the most flexible wire
can be given least number of bends.
Joinability: This denotes the ability to attach auxiliaries to
orthodontic wires by welding or soldering.
Range: The distance that the wire bends elastically, before
permanent deformation occurs. Clinically, this means the distance to
which an archwire can be activated without exceeding the limits of
the material. To relate range, stiffness and strength, we can say that
the range limits the amount the wire can be bent, and the stiffness is
the indication of the force required to reach that limit. The
combination of both is the property of strength.
Resiliency: Resiliency describes the amount of energy stored in a
body when it is elastically deformed. Resiliency is the area under the
elastic portion of the stress–strain curve. The resilience of a wire
represents the energy absorbing capacity of the material that is a
combination of the strength and stiffness. A highly resilient wire will
be able to exert force for a larger range and sustain the activation for a
longer period of time. Hence, resilient wires give better control and
need fewer wire changes.
Solderability: The ease with which attachments can be soldered to
the wire.
Spring back: Spring back refers to a clinically applicable term for
maximum elastic deflection, maximum flexibility, the range of
activation, the range of deflection or a working range. It is the extent
to which a wire recovers its shape after deactivation.
Mathematically, Spring back = Yield strength/elastic modulus.
Wires should have a large spring back, which means that the wire
will regain its original shape even after being greatly deformed. This
would mean fewer wire changes.
Stiffness: It basically refers to the resistance of the wire to
deformation. Stiffness also the measures the force the wire is capable
of delivering for a particular amount of deflection. Low stiffness or
load-deflection rate implies that the wire will apply low forces, which
will be more constant as the appliance deactivates. Burstone believes
that the stiffness of a wire is related to both the material and cross-
section. A stiff wire will not be easily deformed and hence used in
situations where teeth need to be maintained in their positions.
Strength: Strength of a wire is defined as the force required to
activate an archwire to a specific distance. Stiffness and strength are
many times confused with each other. Yield strength proportional
limit and ultimate tensile strength are various measures of strength
(see terminologies for definitions). It can also be defined as a product
of stiffness and range. Strength = Stiffness × Range.
Toughness: Toughness is defined as the force required for
fracturing a material. It can be measured as the total area under the
stress—strain graph. Clinically, this property is seen when giving
bends in a wire and when giving deflections.
Weldability: It is the ease with which the wire can be joined to
other metals, by actually melting the work pieces in the area of the
bond. A filler metal may or may not be used in the process. Both the
soldering and welding included in the broad category of joinability.
The ability to attach auxiliaries to orthodontic wires by welding or
soldering provides an additional advantage when incorporating
modifications to the appliance.
Zero stress relaxation: If a wire is deformed and held in a fixed
position, the stress in the wire diminishes with time, but the strain
remains constant. This is known as stress relaxation. At molecular
level, this occurs due to slippage of particles over each other when
subjected to forces leading to loss of activation in the wire. Zero stress
relaxation is the property of a wire to give constant light force, when
subjected to external forces. This property is desirable if a wire is to
provide constant forces for a longer period of time, especially in
springs and loops.
Box 37.2 Some common terms and their

definitions related to metals used in orthodontics
Flexibility: When a material can undergo a large deformation (or
large strain) with minimal force, within its elastic limit, it can be
termed as flexible.
Maximal flexibility is the strain that occurs when a wire is stressed
to its elastic limit.
Modulus of elasticity: According to the Hooke’s law, the stress and
the strain are directly proportional to each other in the elastic portion
of the graph. The ratio of the stress in the spring and applied force
(but only within its proportional limit) is called modulus of elasticity
and is a constant for a given material.
Elastic limit: It describes the greatest load, to which the wire can be
subjected, such that it returns to its original form. If 0.1% deformation
is allowed then it is quantified as the elastic limit. After this point,
when the load on the wire is removed, it does not return back to its
original length.
Hysteresis: The difference between the energy required to activate
the wire by deflection and that released by it during deactivation is
called energy loss or hysteresis.
Proportional limit: It is the point on the graph at which a
permanent deformation is first observed. Although the definitions
differ, the elastic limit and proportional limit, for all practical
purposes, represent the same point.
Strain: It is the internal distortion produced by the load. It is
defined as deflection per unit length.
Strain or work hardening or cold working: It is the process of

plastically deforming metal at a temperature lower than at which it
recrystallises new grains. This temperature is usually one-third to
one-half of its absolute melting point. Cold working disrupts the
normal atomic arrangement and incorporates strain across the grain
boundaries.
Stress: It is the internal distribution of a load applied to a material.
It is usually defined as force per unit area (F/A).
Tensile stress is caused by a load that tends to stretch the body.
Compressive stress is caused by a load that tends to compress the
body.
Shear stress is caused by a load that tends to slide one part of a body
over another.
Ultimate tensile strength: The maximum force that a wire can
withstand before it fractures, is denoted as the ultimate tensile strength.
This is always higher than the yield strength, and clinically, it is
usually the indicator of the maximum force that the wire can deliver.
Yield strength: This denotes the amount of stress on the stress–
strain graph that causes a certain amount of permanent deformation
(usually 0.1%) is calculated. This is called the yield strength.
Bauschinger effect: The phenomenon is named after German
engineer, Johann Bauschinger, in 1886. Essentially, the Bauschinger
effect describes the reduction in yield stress of a metal when the
direction of deformation is reversed. If you permanently deform a
metal in one direction, then its yield stress is reduced in the opposite
direction. The effect does not apply in the direction to which the
metal has been strained. Actually, this can be used to advantage after
wire bending because of residual stresses left in the material,
improving its elastic properties in the direction to which the wire has
been deformed.
Brittleness: This is considered being the opposite of toughness. A
brittle material cannot undergo plastic deformation.
Sensitisation: When stainless steels are heated up to temperatures
between 800–1200oF carbon reacts with chromium to form chromium
carbide, hence chromium tied up, as the carbide cannot contribute to
the corrosion resistance of the metal. This phenomenon is called
sensitisation. The carbon inactivates the chromium at the grain
boundaries opening them to corrosion.
Stabilisation: This is the process by which carbon is made
unavailable for the sensitisation. Steel that has been treated to reduce
the available carbon is called stabilised steel.
Crack propagation: Crack propagation is seen especially in high
tensile wires which have a high density of dislocations and lattice
imperfections. The dislocations pile up, and form a minute crack. The
stress concentration at this point is very high, so that only small stress
can result in crack propagation. The crack continues to propagate,
and it appears at the surface some distance from the point where it is
bent. This fracture appears as if the skin of the wire has been peeled
off from the main wire.
Cyclic fatigue: If there is repeated cyclic stress of a magnitude
below the fracture point of a wire, then fracture of the wire can occur.
This is due to cyclic fatigue.
Heat treatment: It refers to a general process of using thermal
energy to change the characteristics of metallic alloys as in tempering,
precipitation hardening or annealing. In a clinical setting different
wires are heat treated according to manufacturer’s recommendations.
A wire is considered heat-treated when it appears straw coloured.
Annealing: It is the process of reversing the effects of cold working
such as strain hardening, distorted grains, etc. by simply heating the
metal. In a clinical setting, a wire is considered annealed when it
appears red hot.
Wire dimensions
The wire dimension expressed in terms of thousands of an inch/mm,
mil, gauge. Dimensions of wire are judged by its cross-sectional
dimensions. The most popular international standards for adhering to
this specification are mentioned in International Organisation for
Standardisation (ISO/CD) 15841. The German standards as in
DeutschesInstitutfürNormunge.v (DIN) 13971 are stringent than ISO
standards and are followed by some manufacturers.
• Round wires are available in the dimensions of 0.010, 0.012,

0.014, 0.016, 0.018, 0.020 and 0.022 in. (Boxes 37.3 and 37.4).
• Square wires are available in 0.016 × 0.016 in.
• Rectangular wires are available in 0.016 × 0.022, 0.017 × 0.025,
0.018 × 0.025, 0.019 × 0.025 and 0.0215 × 0.0275 in. dimensions.
A rectangular wire, therefore, has a thickness and width
which corresponds the bracket slot. The standard size of
bracket slots is 0.022 × 0.028 or 0.018 × 0.028 in. (Box 37.5).
Box 37.3 Wires cross-section/types and material

(Fig. 37.1A-C)
Wire cross-section Wire strands Wire material
Round Single stranded Metals and alloys
Square Multistranded Shape memory polymers (SMP)
Rectangular Twisted or braided Polymers (composite)
Combination of round and rectangular Co-axial Metals with synthetic coatings
Box 37.4 Round wires
• Larger deflection hence can be engaged in teeth with Rolling of wire in the
discrepancy of alignment bracket slot
• Easy to bend and create shapes, loops Cannot effectively cause
• Increased play allows tipping movement torque
• Reduced friction
Box 37.5 Rectangular and square wires
Can allow a bodily tooth Difficult to bend and give shape Rarely free of torque
movement High friction
Precise 3-D control Difficult to engage in clinical situations where teeth are
Better orientation to positioned discrepancy
bracket
Better control of tooth
movement
Root position can be
monitored
The thickness (height) of a rectangular wire is usually the smaller

dimension, and it fills the height of the slot of the bracket. It is the
dimension in the plane of the bend.
The width of a rectangular wire is usually the larger dimension, and
it fills the depth of the slot of the bracket. Hence in edgewise mode, a
0.017 × 0.025 in. rectangular wire has a thickness of 0.017 in. and width
of 0.025 in. A wire can also be used in ribbon mode (flat wire), that is
of greater thickness than the width (Fig. 37.1D).
FIGURE 37.1 (A) Three types of cross sections. (B) Bi-dimensional

wires (C) Conventional/edgewise mode and Ribbon mode.
Modes of rectangular wire are as follows:
• Edgewise/conventional
• Ribbon arch mode
Properties of ideal archwire (Box 37.6):
Box 37.6 Properties of ideal archwire
Elastic in nature (obey Hooke’s Law)

High spring back capacity
Flexibility and resiliency
Large working range
Excellent biocompatibility
Poor biohostability
Smooth surface—less coefficient of friction (dry and wet state)
Able to deliver light continuous forces
Cost effective/affordable
The orthodontic archwires have evolved over time mainly with the
development of metallurgy and science of alloys and their testing of
their properties in mouth and outside the mouth.
Early era. The correction of dental irregularities dates back to 400 BC
by hippocrates with some kind of tying. Catgut and silk thread were
also used. But gold ligatures are the first ever reported wires in
orthodontics. Noble metals such as gold, platinum and silver were
used to manufacture wires because of their ductility, formability,
biological safety and inertness in the oral environment.
Wires in the 1880s. The precursor of the orthodontic wire used in
treatment in the late 1800s was the ‘arch bow’. The typical arch bow
was a round threaded stiff wire drawn from a nickel–silver or
platinum–gold alloy to a diameter of 0.032–0.036 in. attached to the
bands using nuts. Angle’s ribbon arch appliance utilised a gold–
platinum alloy combination as the archwire.
Dr Edward H. Angle (1887) introduced ‘Neusilver’ or nickel– silver
alloys, also called German silver, in the United States. In reality, these
were alloys of Cu 65%, Ni 14% and Zn 21% that did not contain any
silver. He was able to obtain favourable clinical properties by cold
working to various degrees.3 But this was strongly opposed as they
tend to discolour in the mouth.
The 1990s. The stainless steel (SS) alloys were used for orthodontic
appliance fabrication in 1919. The wires of noble metal were replaced
by SS wires which were much less the cost and yet exhibited desired
properties of corrosion resistance in the oral environment, excellent
strength and desired spring back and these indeed replaced noble
metals primarily because of their desirable properties such as
corrosion resistance, excellent strength and low-cost, spring back.
In 1950, the Elgin Watch Company (USA) developed Elgiloy (Co–
Cr–Ni) which has useful properties of excellent formability and
exhibits necessary strength after heat treatment. The alloy was
adapted for use in orthodontic archwires. These wires were corrosion
resistant and inexpensive.
In 1963, William Buehler developed the nickel–titanium alloy. It
was introduced into dentistry by George Andreasen because of its
property of shape memory effect (SME). This alloy could regain its
original preset shape on heating. These wires are much advanced now
and remain the mainstay wires in initial alignment stages.
Burstone and Goldberg introduced wires made of a new alloy called
TMA or ‘Titanium-molybdenum alloy’. TMA wires found a
significant uses in clinical orthodontics for these alloy wires have
useful mechanical properties for enhanced performance compared to
steel.
21st century. In search of improving aesthetics of orthodontic
appliances, tooth coloured wires like Optiflex wires and Teflon-coated
wires have been introduced. These wires of nonmetallic look are
indicated in combination with aesthetic ceramic or plastic brackets
(Tables 37.1–37.3).
Table 37.1
Metal composition and properties of orthodontic wires
A-NiTi, austenitic/nickel–titanium; B-Ti, beta-titanium; Cu-NiTi, copper/nickel–titanium; M-NiTi,
martensitic nickel–titanium.
Table 37.2
Grades and wire dimensions of AJW wires

A. Australian (AJW) orthodontic wires are available in different grades and diameters
Wire grade Size (diameter), inches
Regular 0.012–0.024
Regular + 0.012–0.020
Special 0.012–0.020
Special + 0.012–0.024
Premium 0.012–0.020
Premium + 0.010–0.018
Supreme 0.008–0.011
B. Australian (AJW) pulse straightened wires
Grade Diameter in inches
Special plus 0.014, 0.016, 0.018
Premium 0.020
Premium plus 0.010, 0.011, 0.012, 0.014, 0.016, 0.018
Supreme 0.008, 0.009, 0.010, 0.011, 0.012
Table 37.3
The shape of wire (round, square or rectangular) vis-a-
vis wire properties
r, diameter; l, length
Newer developments are in the direction of developing wires from

shape-memory polymers (SMP). SMP are dual-shape materials
belonging to the group of ‘actively moving’ polymers that can change
from one shape to another. First, a temporary shape is obtained by
mechanical deformation and the second is obtained from the
subsequent fixation of that deformation.
By late 1930s, thorough research and efficacy in clinical applications
established SS as the mainstay orthodontic wire material replacing
noble metals. Steels are iron-based alloys that usually contain less than
1.2% carbon. SS contains a minimum of 10%–13% chromium and 8%
of nickel that gives it ‘rust-free properties’ and so the name.4 SS
consists of mainly three types:
• Ferritic SS (400 series)

• Austenitic SS (300 series)
• Martensitic SS (400 series)
Austenitic stainless steels (300 series)

Austenitic steels are used for the purpose of orthodontic wires and
bands. This family of alloys was named after the British metallurgist
Robert Austen. All American Iron and Steel Institute (AISI) numbers
in the series of 300 are austenitic. These alloys are the most corrosion
resistant of all the SS due to the presence of significant amount of
nickel and chromium.
AISI 302 is the primary type of steel containing 18% chromium, 8%
nickel and 0.15% carbon.
AISI 304 has similar composition, but carbon content is 0.08%. Both
302 and 304 may be designated as 18–8 SS.4
Low carbon AISI Type 316L and nickel free ASTM Type F2229 wires
are also available.5
Properties of stainless steel wires6,7

Formability: SS wires have excellent formability and can be bent into
various designs without fracture within limits. These wires have the
lowest coefficient of friction and are ideal for use during retraction
mechanics.
Stiffness: SS is a relatively stiff material showing low flexibility and
the small range of action, hence cannot withstand large activations or
recover shape entirely from the initial deformation. A steep load-
deflection rate means that forces delivered by the SS wires dissipate
rapidly over a very short amount of deactivation.
Soldering: SS wires have ease of joining as they can be easily
welded or soldered. Usually, the welded areas need a solder
reinforcement.
Biocompatibility: In general, the SS wires have excellent
biocompatibility and high corrosion resistance in the oral
environment. Sensitivity due to leaching of Ni and Cr has been
reported, but these are restricted to a minuscule percentage of the
population.
Low cost: Cost factor is also favourable for these wires because
these are quite inexpensive.
Round orthodontic wires are manufactured by a proprietary
drawing sequence that involves several stages with intermediate
annealing heat treatments. Rectangular orthodontic wires are
manufactured from round wires by drawing process utilising a Turk’s
head apparatus. Therefore, the edges of the rectangular wires may be
somewhat rounded which limits their torque expression.
High tensile wires

A.J. Wilcock Sr, engineer and entrepreneur, in collaboration with P.R.
Begg developed pre-heat treated cold drawn steel wires that had the
advantage of being more resilient and having higher tensile strength.
These wires were designed exclusively for use with Begg’s light
wire technique. These wires (AJW) are graded according to the
increasing order of resiliency and yield strength. The resilient wires
are highly brittle and break easily and are relatively more expensive
than SS wires. As these wires developed in Australia were to be used
with Begg’s technique, they are popularly called Australian wires.
AJW wires are available according to the straightening processes
(Table 37.2, Figs 37.2–37.3).
FIGURE 37.2 The grading of the AJ Wilcock wires.
FIGURE 37.3 How to bend a AJ Wilcok wire?
Australian wire is preferably bent slowly around square beak of the bird
beak pliers.
Spinner straightening: It is a mechanical process of straightening
resistant materials usually in the cold drawn condition. The wire is
pulled through rotating bronze rollers which twist the wire into
straight shape. The disadvantages of this process are that this results
in permanent deformation and decreases yield strength value as the
wires are strain softened.
Pulse straightening: It is a recent and more accepted method of
wire straightening. Here the wire is pulled in a special machine, which
permits lower diameters of high tensile wires to be straightened. The
surface has a smoother finish and therefore lower friction. Pulse
straightened wires are better in properties regarding ultimate tensile
strength, high load-deflection rate, significantly higher working range
and lower frictional resistance.
Multistrand and coaxial wires

The multistrand wires are much less stiff than solid wires of the same
diameter. The stiffness of two thin wires laid parallel to one another,
as in the twin-wire, when engaged in the bracket slots, is double the
stiffness of each, whereas doubling the diameter of a round archwire
component increases its stiffness to 16 times (d4). Multistrand wires
are often constructed from three to six thin wires twisted or braided
upon one another.8
The diameters of multiflex wires after twisting are 0.0148, 0.0150,
0.0155, 0.0175 and 0.0186 in. Many researchers have found the
properties of these wires to be comparable with nickel–titanium wires.
Co-axial wires have a core wire around which multiple thin wires are
braided.
Cobalt–chrome wires3,6,7
In the 1950s, the Elgin Watch Company (USA) developed an alloy
which had a unique property of excellent formability. Co–Cr–Ni
alloys belong to a group of alloys called Stellite alloys. This alloy was
later marketed by Rocky Mountain Orthodontics as Elgiloy. Ricketts’
bio-progressive therapy popularised the use of Co–Cr wires for
making many wire designs.
Composition
A typical composition for Co–Cr alloy is cobalt 40%, chromium 20%,
nickel 15%, molybdenum 7%, manganese 2%, carbon 0.16%, beryllium
0.04% and iron 15.8%. Carbon forms carbides with many metallic
constituents such as cobalt, chromium and molybdenum, and
strengthens the alloy on treatment called as ‘precipitation hardening’.
The carbides that precipitate bring about the change in the formability
and ductility of the alloy.9
General properties of Co–Cr–Ni alloy

Co–Cr–Ni alloys have the best formability among all the wires and
can tolerate complicated archwire designs. The resiliency of these
alloys can be increased by heat treatment for excellent clinical
performance. These alloys deliver low and constant forces for a longer
duration when used as resilient springs and have greater resistance to
fatigue and distortion than SS. Co–Cr–Ni alloys have high yield
strength on heat treatment. Co–Cr–Ni alloys have a good
biocompatibility and high corrosion resistance in the oral
environment. These wires have good joinability and can be soldered
or welded with ease. These wires have a low coefficient of friction like
SS. After heat treatment, stiffness is a bit higher than SS. Cost factor
although higher than SS is still not a deterrent (Fig. 37.4).3,6,7,9
FIGURE 37.4 Load Deflection curve.
The stiffer wires made from stainless steel and Co–Cr–Ni have a steep
load-deflection curve in contrast to those of NiTi wires that have much
flatter graphs. Thus SS and Co–Cr–Ni exert more force than NiTi wires
while loading and unloading.
Co–Cr alloys are available commercially as Elgiloy (Rocky

Mountain Orthodontics), Azura (Ormco Corporation) and Multiphase
(American Orthodontics Corporation).
Elgiloy wires by Rocky Mountain Orthodontics Company are
supplied in four tempers which indicate the level of resilience. The
composition of all these tempers is reported to be the same, the
difference being in the wire processing methods.7,9
1. Blue (soft): The blue wire is the softest of the four wire
tempers; it can be bent easily into the desired shapes. It is
recommended for use when considerable wire bending is
needed such as multiple loop wires.
2. Yellow (ductile): It is more resilient than blue Elgiloy but can
also be bent with relative ease.
3. Green (semi-resilient): It is more resilient than yellow.
4. Red (resilient): Red Elgiloy wire is the hardest and most
resilient Elgiloy and provides high spring qualities. Careful
manipulation is recommended when using this wire because it
withstands only minimal working. Heat treatment makes red
Elgiloy remarkably resilient but brittle.
Chrome cobalt wires have a high modulus of elasticity suggesting

that they deliver twice the force of beta-titanium and four times the
force of nickel–titanium archwires. The elastic modulus of Elgiloy blue
ranges from about 160 to 190 GPa when under tension, while after
heat treatment it increases to range from about 180 to 210 GPa.
Similarly, the yield strength varies from 830 to 1000 MPa under
tension and 1100 to 1400 MPa after heat treatment. A common
misconception is that Elgiolly blue has less elastic force delivery as
compared with SS because of the ‘feel’ of the former. However, in
reality, the values are similar. Another clinical use of Elgiolly blue is
the fabrication of fixed lingual quad-helix appliance, which produces
slow maxillary expansion in the treatment of maxillary constriction.
Heat treatment of Co–Cr–Ni alloy wires

As already mentioned, Co–Cr–Ni wires have a smaller spring back
than SS due to high formability, an exception being red Elgiloy. This
property can be improved by adequate heat treatment. The
recommended temperature for heat treatment is 900 °F (482 °C) for 7–
12 min in a heat treatment furnace. Heat treatment of blue Elgiloy
increases its strength, resistance to deformation and resilience. About
10% increase in the elastic modulus and 20%–30% increase in the yield
strength can be achieved with heat treatment. Optimum levels of heat
treatment are confirmed by a dark straw colouration of the wire or by
use of temperature indicating paste provided by the manufacturer.8
The soft temper blue Elgiloy is popular in making multiple loops
because the wires can easily be manipulated into the desired shape,
and then heat treated to provide substantially increased values of
yield strength.
The other tempers of Elgiloy are less popular than the soft temper
because wires made from them have low formability and are
somewhat higher in cost than SS. The advantage of these wires over
SS wires includes the greater resistance to fatigue and distortion.
Nitinol was developed for space programme by William F. Buehler, a
research metallurgist at Naval Ordinance Laboratory, now called
Naval Surface Weapons Center in Silver Springs, MD, in 1960.
Nitinol is an acronym derived from the elements, which comprise
the alloy (Ni—nickel, Ti—titanium, Nol—Naval Ordinance
Laboratory). NiTi wires were introduced in orthodontics in 1971 by
George Andreasen.7,8,10
Nitinol alloy has two forms—austenitic at high temperature;
moreover, martensitic at low temperature and it can change its
crystalline form from martensitic to austenitic with a change in
temperature. Buehler termed the temperature at which this change
took place as the ‘temperature transition range’ or TTR.10 The wire’s
shape was formed at a very high temperature, far above the TTR in
austenitic form. It could be then cooled below the TTR and deformed
to any configuration in martensitic form exhibiting superelasticity. As
the wire is warmed through the TTR, it would then recover its original
shape (austenitic) completely exhibiting the property of shape
memory. Temperature cannot bring about phase transition from
austenitic to martensitic. This transformation is possible by
introducing stress called as SIM (stress-induced martensitic)
transformation.
Nitinol wires were supposed to have characteristics of low stiffness,
high reversibility and excellent spring back property. However, as it
was manufactured by a work hardening process, this initial wire did
not show any phase transition effects of shape memory or
superelasticity. This family is now referred to as martensitic NiTi (M-
NiTi).6
NiTi wires may be classified as follows.
Martensitic stabilised alloys: These alloys do not possess shape
memory or superelasticity because the cold working of the wire
creates a stable martensitic structure. These are the non-superelastic
wire alloys such as ‘nitinol’.
Martensitic active alloys: Such alloys employ the thermoelastic
effect to achieve shape memory; the oral environment raises the
temperature of the deformed archwire with the martensitic structure
so that it transforms back to the austenitic structure and returns to the
original shape. Examples are Neo-Sentalloy and copper NiTi wires.
Austenitic active alloys: These undergo a stress-induced
martensitic (SIM) transformation when activated. These alloys display
superelastic behaviour. The reverse transformation from martensite
back to austenite takes place during unloading or deactivation.
Examples are Japanese NiTi wires.
Useful properties of NiTi wires

Shape memory: Andreasen defined shape memory phenomenon as
‘Ability of wire to return to a previously manufactured shape when it
is heated through a transition temperature range (TTR)’.9 This unique
feature of the alloy allows the wire to be plastically deformed or
stretched at a temperature below the transition temperature and
maintain such form until it is heated through the TTR. Shape recovery
to original pre-heated form will occur upon reheating to TTR,
provided the deformation has not exceeded elongation limits of 8%–
10%.
At the high temperature, the alloy is in the austenitic state. It is
made up of the lattice in which the units are cubic, that is BCC. When
this arrangement is disturbed by external influence, the BCC structure
of austenite converts to a hexagonal (HCP) that is a martensitic state.
Reverse transformation on heating restores the parent crystal
structure and orientation.
Superelasticity: It is the ability of the wire to sustain or deliver a
near-constant force over a wide range of activation. Instead of
temperature, stress is used to bring about changes in crystalline
structure, that is austenite to martensite and back to austenite.
This SIM transformation manifests itself in the almost flat section of
the load-deflection curve. Martensitic transformation begins when an
external force is applied such that the stress exceeds a given amount.
Even when additional force is added, the stress levels in the wire
come to a plateau due to the gradual stress-induced martensitic
transformation. This phenomenon is termed as superelasticity. On the
contrary, if the stress is diminished, the NiTi alloy returns to the
previous shape without retaining the permanent deformation (Fig.
37.5).
FIGURE 37.5 NiTi-deflection curve.

Point A stress–strain curve is illustrating superelasticity due to the
stress-induced transformation from the austenitic to the martensitic
phase. Points A–B shows a purely elastic deformation of austenitic
phase. The stress at point B is the minimum stress required for
martensitic transformation to start. At point C, the transformation is
completed. In the region C–D, wire undergoes elastic deformation on
continued stressing. At point D, the yield strength of the material is
reached. At E, it undergoes plastic deformation/failure. If the stress is
released before reaching point D say at C, elastic unloading occurs of
the martensitic structure along the line C’–F. Point F indicates the point
at which reverse transformation to austenite begins. This continues to
point G, where austenite is completely restored. Points G–H represents
the elastic unloading of the austenite. Source: Reproduced with
permission from Kusy RP, Dilley GJ. Elastic property ratios of a triple
stranded stainless steel archwire. Am J Orthod 1984;86(3):177–88.
Hysteresis: The unloading curve of a NiTi has an energy loss

involved with it. Loss of energy means that the force it delivers is not
the same (or less) as the force applied to activate. This energy loss is
known as hysteresis. Because of this noncollinear path of loading and
unloading, they are pseudoelastic in nature rather than purely elastic.
The primary clinical interest of hysteresis is that the force delivered by
the wire is lower than the force needed to activate the wire.
Due to its low modulus of elasticity and high strength, its resistance
to deformation is great, and the working range is large, hence,
delivering low constant forces and thereby allowing big activations
with fewer archwire change to accomplish the same range of tooth
movement.
Limitations of NiTi wires

NiTi wires have very low formability in the clinical setting. These
wires cannot be welded or soldered due to the passivating nature of
titanium dioxide which is strongly adhered to the metal surface. The
frictional forces in the nitinol wire are very high due to high Ti
content, and therefore these wires are unsuitable for sliding tooth
movements such as retraction on the wire.
NiTi wires have highest nickel content among the appliances used
in orthodontics which is 55%. Although they are greatly
biocompatible, however, high nickel content could be
disadvantageous by causing hypersensitive reactions.
For such patients, Ti or epoxy-coated wires are recommended.
Japanese NiTi wires have superior properties of delivering a
constant force over an extended period.11
Copper NiTi
Copper NiTi alloy wires were introduced by Rohit Sachdeva and
Suchio Miuasaki in 1994. This alloy contains 5%–6% of copper and
0.2%–0.5% chromium in addition to nickel–titanium added to bring
down the TTR to oral temperature. Copper is added to enhance the
thermal properties of a nickel–titanium alloy. An unloading force
more closely approximates loading force due to reduced mechanical
hysteresis. This property makes it easier to insert larger sized
rectangular wires without creating undue patient discomfort.12
Advantages of Cu-NiTi over other NiTi alloys are as follows.
1. Relatively, loading force is 20% less for the same degree of

deformation of wire which makes it possible to engage
severely malposed teeth with less patient discomfort.
2. Decreased hysteresis and flattening of unloading curve result
in a more consistent force.
3. More resistance to permanent deformation, therefore, exhibits
better spring back than others.
4. The patient can control the deactivation of the engaged wire by
cold application, thereby reducing discomfort.
Four different types of copper NiTi archwires with precise and

constant transformation temperature enable the clinician to select
archwire on a case/situation-specific basis (Box 37.7).
Box 37.7 Four types of Cu-NiTi wires and clinical

applications thereof
Type 1 (AF-15°C): It generates very high forces, hence has limited
clinical indications.
Type 2 (AF-27°C): This is most popular and generates moderate-to-
high forces. Indicated in patients who have an average or higher pain
threshold and in patients where rapid tooth movement is required.
Type 3 (AF-35°C): These generate forces in the mid-range and are
indicated in patients who have a low to normal pain threshold, in
patients whose periodontium is slightly compromised, and when
lower forces are desired.
Type 4 (AF-40°C): These wires generate very low forces and are
indicated in patients who are sensitive to pain, patient’s
compromised periodontal condition and when the patient is
irregular, noncompliant and the orthodontist does not want things to
get out of hands.
AF: Austenitic final temperature.

β-Titanium wires
β-Titanium wires were introduced to orthodontic profession as a
‘titanium molybdenum alloy’ or TMA by Burstone and Goldberg in
1980s.13
Composition
Alloying titanium with molybdenum, niobium, vanadium, iron,
chromium and manganese stabilises Ti in β-phase at room
temperature. Minimum additions of 6.5% Mn, 4% Fe, 8% Cr, 7% Co
and 13% Cu are added for complete retention of beta-phase after
quenching process.4,6,13
General properties of β-titanium wires

These wires show high flexibility and recover their shape fully from
the initial deformation.5,6,8 Spring back properties are not lost during
the bending operation when forming complicated loops.
β-Titanium has a low modulus of elasticity. Thus, lower forces will
be produced even for larger activations. The forces delivered by the β-
titanium wires dissipate over a longer duration of deactivation.
Hence, these do not need frequent activation. The initial forces are not
high in magnitude and are well within the physiological range.
β-Titanium is a resilient wire, has high tensile strength and is
readily formable. A continuous arch with ‘T’, vertical, helical and ‘L’
loops, can be formed in both round wire and rectangular wire.
In general, the β-titanium wires have better biocompatibility and
high corrosion resistance in the oral environment. The absence of
nickel is an advantageous feature hence can be used in patients with
hypersensitivity to nickel.
These wires show passivating effect due to the presence of TiO2.
They possess the property of true weldability—no solder is
necessary to unite the metal.
Limitations of TMA wires
TMA wires are considered as an almost ideal wire, the main
disadvantage of TMA is their high coefficient of friction due to very
high titanium content (85%) and therefore is not suitable for use
during retraction mechanics. Hence, their use is restricted to
frictionless mechanics like loops and springs.14
Nitrogen ion implantation on the wire surface has reported to cause
surface hardening and decrease frictional force by as much as 70%,
but others did not report any difference in the clinical performance of
ion-implanted or non-ion-implanted wires. The cost factor is
unfavourable because these are expensive wires.15
Titanium wires
Mr A.J. Wilcock Jr (1988) developed a Ti wire that is harder near to
alpha-phase represented by Ti-6A1-4V and comprising 90% titanium,
6% aluminium and 4% vanadium for orthodontic purposes. This
group of titanium wires has not been very popular because of several
shortcomings that include poor workability, poor formability,
brittleness and high cost. However, these wires are quite resilient,
hence used for root torquing in finishing stages.16
Nickel-free stainless steel and TMA
wires
To overcome the issue of nickel allergy, nickel-free austenitic SS wires
have been developed. The steel is alloyed with 15%–18% chromium,
3%–4% molybdenum, 10%–14% manganese and about 0.9% nitrogen
to compensate for the nickel. These wires are available as a single-,
triple- or six-strand SS wires and TMA arches, for example
Noninium® or Rematitan wires by Dentauram.
Connecticut New Arch (CNA) wire:
• CNA wires are an improved version of beta-titanium

archwires. CNA is a nickel-free alloy that takes intricate bends
and is half as stiff as stainless steel.
• Does not break as easily as TMA wire.
• Has a smooth, high polish finish which provides much less
friction than TMA.
• Maintains the shape of the loops much better than TMA. Once
a loop is formed, it maintains the intended shape.
Titanium–niobium–aluminium (Ti–Nb–
Al) shape memory alloy wires
The shape memory NiTi alloy for its unique properties of shape
memory and superelasticity is widely used. However, this alloy
contains a high proportion of nickel and therefore may induce
hypersensitivity. These wires are not recommended for nickel-
sensitive patients.17,18
Although TMA has been used for a nickel-free orthodontic wire,
however, this wire does not have shape memory and superelastic
property. Therefore, various nickel-free shape memory and
superelastic alloys have been developed. Nickel-free titanium-based
shape memory alloys (SMAs) composed of nontoxic elements have
been systematically investigated.
Titanium–niobium–aluminium (Ti–Nb–Al) alloy, which has the best
mechanical performance among these nickel-free shape memory and
superelastic alloys, was developed as a result of advances in
processing technology.19
The Ti–Nb–Al wires can be used as a substitute for Ni–Ti wires. The
Ti–Nb–Al expansion spring exerted lighter and continuous force and
facilitated safe and efficient tooth movement. The tooth movement
pattern was smooth because of the mechanical properties of Ti–Nb–Al
alloy.
Dual flex archwires
These are special NiTi archwires that have two types of wire materials
and cross-sections in the anterior or posterior sections of the same
archwire20. This type of wire affords multiple functions in the same
wire, thereby improving control and reducing treatment time (Fig.
37.6).
FIGURE 37.6 Dual-flex wire.

These wires have a flexible anterior portion and stiffer buccal segments
which facilitate alignment of anterior teeth without losing anchorage
control.
The anterior portion of combined wire is made of a Titanal alloy

and posterior part is of SS separated by cast ball hooks mesial to
canine bracket. Titanal is a nickel–titanium alloy manufactured by
Lancer Pacific. It consists of three types: (1) Dual Flex-l, (2) Dual Flex-2
and (3) Dual Flex-3.
The Dual Flex-1: It consists of an anterior section made of 0.016-in.
round titanal and a posterior section made of 0.016-in. round steel.
The flexible front part quickly aligns the anterior teeth, and the rigid
posterior portion maintains the anchorage and molar control. It is
during the initial stages of treatment for leveling and alignment. They
are very useful with the lingual appliance, where the anterior inter-
bracket span is very small.
The Dual Flex-2: It consists of a flexible front segment composed of
a 0.016 × 0.022-in. rectangular titanal and a rigid posterior segment of
round 0.018-in. steel. The rectangular anterior titanal segment, when
engaged in the bracket slots, impedes movement of the anterior teeth
while closing the remaining extraction sites by mesial movement of
the posterior teeth.
The Dual Flex-3: It consists of a flexible anterior part of a 0.017 ×
0.025-in. titanal rectangular wire and a posterior part of 0.018 square
steel wire. The Dual Flex-2 and 3 wires provide anterior anchorage
and control molar rotation during the closure of posterior spaces and
initiate considerable torque in the anterior segment.
Supercable wire
In 1993, Hanson introduced superelastic NiTi coaxial wire which he
called ‘Super Cable’. This wire comprises seven individual NiTi
strands woven together in a long, gentle spiral to maximise flexibility
and minimise force delivery. Supercable demonstrates very low and
physiologically optimum orthodontic forces. It exerts much less force
compared with a solid nickel–titanium wire. Full slot engagement by
0.018-in. super cable can be achieved even in severe crowding and
rotation cases because of its low force delivery. This wire was
specially developed to be used with SPEED self-ligating bracket
system.
Turbo wire or braided nickel–titanium
rectangular wire
These preformed braided NiTi wires combine the advantages of
highly resilient NiTi with rectangular braided wire. The braiding
process increases the superelastic properties of NiTi. This wire
provides early torque control due to its rectangular cross-section. Its
indications for use are early torque control and mid-treatment
engagement of second molars.
Bioforce: A BioForce wire is a superelastic shape memory nickel
titanium wire that provides gradually increasing forces from anterior
to posterior segment, all within one archwire. The archwire has a
smooth surface to reduce the friction. The process of an ionisation
implanting process alters the surface of the archwire without
negatively affecting the wire’s unique superelastic properties. During
the ion beam implantation nitrogen replaces nickel on the top and
changes the surface to titanium nitride. BioForce wires with Ion Guard
result in a significant reduction in friction during tooth movement.
• Superelastic, shape memory, thermally active NiTi wire

• Graded force delivery from anteriors to posteriors on
thermodynamic activation
• Reduced wire changes and increased patient discomfort
• Anteriors–light forces–tipping movement–less root resorption
• Bicuspids–moderate forces–prevent unwanted rotation
• Molars–heavy forces–bodily movement–great root movement
control–prevent dumping of roots
Variable modulus orthodontics
In this new approach proposed by Burstone of force control, wire size
remains relatively constant, and the material of the wire is selected by
clinical requirements. This meant that the orthodontist could control
the stresses on the teeth from the beginning of the treatment by using
rectangular wires with lower stiffness and gradually moving on to
stiffer wires. Hence even during the initial stages of the tooth
movement, a low modulus rectangular wire can be used that confers a
three-dimensional control, and at the same time exert fewer stresses
on the dentition. For example, NiTi wires with very high spring back
were chosen over steel wires with loops in the initial stages of
treatment to align severely malaligned teeth. Towards the end of
therapy, when the stiff wires are needed, steel wire became the wire of
choice (Box 37.8).
Box 37.8 Advantages of the variable modulus

approach in orthodontics
1. The stresses exerted by the appliance can be controlled using

different materials and kept at an optimum level all through
various stages of the treatment.
2. This approach allows better torque control over the dentition
from the very initial stages.
3. Segmented mechanics may be followed where posteriors will
have a heavy stabilising rectangular wire like 0.019 × 0.025 in.
SS and the anteriors may have a round or rectangular braided
wire.
4. Since the stiffness of different rectangular wire materials is
different in different planes, the operator has the choice of
using the same wire either edgewise or ribbon arch mode.
5. As and when needed the material stiffness of the wire can be
increased keeping the dimension constant so as to better
express the torque.
6. This approach is less taxing on the clinical chair time.
To quantify this approach, Burstone gave material stiffness numbers

(Ms) to each wire material. Steel was given an arbitrary (Ms) of 1.0
based on an average modulus of elasticity of 25,000,000 psi for 0.016-
in. diameter SS wire.22
Aesthetic wires
The need for an aesthetic appliance could only be partially met with
the introduction of a aesthetic brackets. The concern for a visible wire
remained a deterrent for those who wanted invisible or a aesthetic
braces. Some efforts have been directed to create a aesthetic wires.
These are coating the alloy wire with tooth coloured material or
creating wire from a material which is tooth-coloured and yet has the
properties of a alloy.
Optiflex wires
Talass23 introduced the first optiflex wire (Ormco, USA) to combine
optimum mechanical properties with a highly aesthetic appearance.
The wire is made of clear optical fibre and it comprises three layers:
1. A silicon dioxide core provides the force for moving teeth.

2. A silicon resin middle layer that protects the core from
moisture and adds strength.
3. A stain-resistant nylon outer layer that prevents damage to the
wire and further increases its strength (Fig. 37.7).
FIGURE 37.7 Diagram showing the layers of aesthetic wires such

as an OptiflexTM wire.
A. The inner most core is made of silicon dioxide that provides the
force. B. The middle layer is made of silicon resin that protects the core
from moisture and adds strength. C. The outer layer is made of stain-
resistant nylon.
The wire can be either round or rectangular and is manufactured in

various dimensions. Its mechanical properties include a broad range
of action and the ability to apply light, continuous force. Sharp bends
must be avoided, as they could fracture the core. Optiflex has
practically no deformation. It is a highly resilient archwire that is
especially effective in the alignment of crowded teeth.
Plastic/teflon-coated NiTi
Plastic covered, tooth coloured superelastic nickel–titanium archwires
are available as Nitanium (Tooth Tone). It is claimed to have lower
friction and blends with natural dentition as well as ceramic, plastic
and composite brackets. It is stain and cracks resistant.
These wires are available as round (0.014, 0.016 and 0.018 in.) and
rectangular (0.016 × 0.022 in., 0.018 × 0.022 in.) wires. Many companies
are now offering plastic-coated NiTi wires. Tooth-coloured teflon-
coated wires are no genuine substitute for alloy wires as they do not
match the properties due to coating. The coated wires begin to lose
their plastic coating in the mouth and take up the food stains making
them unacceptable.
Shape memory polymers (SMP) in
orthodontics
Polymers intrinsically exhibit shape memory effects (SMEs) that are
derived from their highly coiled constituent chains that are
collectively extensible via mechanical work. The energy may be stored
indefinitely (shape fixed) by cooling below the glass transition
temperature, Tg, of an amorphous polymer, or the melting point, Tm,
of a crystalline or semicrystalline polymer.
After shape fixing, the polymeric sample can later perform
mechanical work and return to a stress-free state when heated above
the critical temperature, Tcπt, mobilising the frozen chains to regain
the entropy of their coiled state.
In comparison to shape memory alloys, thermally stimulated SMP
do have the advantages of greater recoverable deformations,
exceeding to several hundred percent strain. Facile tailoring of
transition temperatures through variation of the polymer chemistry
and processing ease at low cost.
Jung and Cho24 prepared SMP with cyclohexylmethacrylate (PCL)
to form an orthodontic wire. The wires are more aesthetic than
conventional metal and also from available aesthetic wires. These
wires are
1. transparent;
2. low density;
3. efficient shape recovery (90%); and
4. superior aesthetics.
The SMP wires can provide tooth support for a longer duration.24
Effects of oral environment on
orthodontic archwires and brackets
Wires and orthodontic attachments are continuously exposed to insult
in the oral environment. The metals in the mouth are subjected to the
process of corrosion.
Metal corrosion is an electrochemical process in which a metal
surface exposed to a conducting aqueous electrolyte usually becomes
the site for two simultaneous chemical reactions: oxidation and
reduction (redox).25
Metals wires and orthodontic attachments are constantly affected by
acidic foods and liquids, such as soft drinks, which will supposedly
promote the cathodic reaction of corrosion and, consequently, the
anodic reaction (dissolution of the metal) as well.
Corrosion leads to the leaching of the metal ions in the oral cavity
due to the process of biodegradation in the oral cavity. Because of its
ionic, thermal, microbiological and enzymatic properties, the oral
environment is favourable to the biodegradation of metal wires and
their alloys, with consequent release of metal ions in the oral cavity.26
Along with the release of elements from metals or alloys, corrosion
of orthodontic wires can lead to roughening of the surface and
weakening of the appliances and can severely affect the ultimate
strength of the material, leading to mechanical failure or even fracture
of the orthodontic materials appliance part.
Significant corrosion products of SS are Fe, Ni and Cr. Of these, Ni
and Cr are most crucial because of their carcinogenic and allergenic
potentials. Although it has been found that nickel and chromium are
released from SS and nickel–titanium archwires, any significant or
consistent increase in nickel blood levels could not be found during
the first 4–5 months of orthodontic therapy (Fig. 37.8, Box 37.9).27–30
FIGURE 37.8 Wire corrosion.
(A) Stress corrosion is seen in wires when they are deflected leading to
changes in the charges on their surfaces. Consequently, free electrons
get generated that lead to electrolytic corrosion. (B) Pitting corrosion is
seen in the nicks, notches or surface irregularities on the surface of the
wires. Reducing atmosphere is created in these nicks and notches that
ultimately lead to corrosion
Box 37.9 Corrosion of orthodontic alloys in

mouth
1. Pitting corrosion: This refers to the corrosion occurring in pits

which are manufacturing defects present on the wire before
placement into the oral cavity. These are often sites of easy
attack.
2. Galvanic corrosion: This corrosion occurs when two metals are
joined, or even the same metal after different types of treatment
(soldering). The difference in the reactivity of the metals results
in the formation of a galvanic cell. Stainless steel has active and
passive areas depending on the depletion and regeneration of
the passivating film.
3. Intergranular corrosion: This refers to sensitisation caused by
precipitation of chromium carbides at the grain boundaries.
4. Fretting corrosion: This refers to the corrosion which occurs in
areas where wire and brackets contact each other. Due to the
friction, there is surface destruction and rupture of the oxide
layer.
5. Stress corrosion: This corrosion occurs in the region that is
highly stressed. Bending of wires to engage into malaligned
teeth causes areas of the wire to be subjected to different
degrees of tension and compression. This will alter the
electrochemical behaviour of the alloy, and certain areas will
behave as anodes and others as cathodes.
6. Fatigue corrosion: The temperature changes cause cyclic fatigue
of a wire and the resistance of the material to fracture
decreases.
Factors promoting corrosion

1. Surface irregularities present on the wires.
2. Improper handling like creating nicks or notches.
3. Flaming the wire may remove the passivating layer.
4. Loss of electropolished surface leads to corrosion.
5. Oral conditions, such as the temperature, the quantity and
acidity of saliva, the presence of certain enzymes, and the
physical and chemical properties of solid and liquid food, may
influence corrosion processes.
6. TiO2 film on NiTi wires provides a good protection against
corrosion.30
How orthodontic metals resist corrosion

Formation of the passive oxide films on the surface of the metals such
as SS, CoCr and titanium alloys resists corrosion. However, even
though these protective oxide films are present on the metal surface,
metal ions can still be released.31 Because the protective oxide layer is
susceptible to both mechanical and chemical disruption, the oxide film
can also slowly dissolve as the metal is exposed to oxygen from the
surrounding medium. Acidic conditions and fluoride-containing
products can contribute to these processes.26
As a matter of fact, the corrosion and deterioration of certain metals
and alloys have been related to the acidic environment of the buccal
cavity and with the presence of fluoride ions in several kinds of
toothpaste and mouthwash solutions.32,33
Effect of fluoride
Clinically available fluoride-containing products have a variety of
fluoride concentrations (Fluoride 250-10,000 mg/L) and pH values
(3.5–7). Prophylactic fluoride gels with a low pH was found to be
more effective in the increase of calcium fluoride (CaF2) formation.34
Titanium corrodes not only in the presence of sodium fluoride (NaF)
in acidic solution but also at high pH values if the NaF concentration
is considerably high.35
The fluoride Ions degrade the protective titanium oxide film formed
on titanium and titanium alloys. The contact of electrolyte with the
metal is possible through the pores of the oxide layer that can contain
several oxides of different stoichiometries such as TiO, Ti2O3, or TiO2.
The TiO2-based passive film on the Ni–Ti and Ni–Ti–Cu archwires are
more susceptible to fluoride-enhanced corrosion, while the Nb2O5-
based passive film on the Ti–Nb archwire show much lower
susceptibility. It is a proven fact that corrosion of orthodontic devices
occurs, but the impact of corrosion on orthodontic treatment and on
patient’s health is still not fully understood.
Arch forms and preformed archwires

The dental arch form is unique to every individual. The arch form has
been the subject of study and interest of anthropologists, anatomists,
dentists, prosthodontists and orthodontists in particular. Engineers
and computer specialists have tried to work out arch forms with
mathematical equations.
In a case of malocclusion, teeth are placed in aberrant positions in
response to the oral environment and to accommodate skeletal
discrepancies. Orthodontists aim to establish a normal occlusion and
arch form. The dentition confines to orthodontic archwires which are
prepared to maintain the best suitable arch form for an individual.
Orthodontists have worked out following means as a guide to prepare
arches:
1. Bonwill–Hawley arch form (1905)
2. Catenary curve by MacConaill and Scher (1949)
3. Brader arches (1972)
4. Pentamorphic arch forms (1979)
5. Cubic interpolatory spline: Begole (1980)
Bonwill–Hawley arch form:35 It is based on an equilateral triangle,

whose base represents the intercondylar width. The six anterior teeth
can be arranged on the arc of a circle, the radius of which is
determined by the combined mesiodistal widths of maxillary central
incisors, laterals and canines up to the distal margin of the twin
bracket from where the premolars extend distally in a straight line
and the second and third molars turning towards the midline.
Bonwill–Hawley chart is prepared for each case of malocclusion,
and used as a template guide to prepare and coordinate arches
archwires (Fig. 37.9).
FIGURE 37.9 Bonwill–Hawley arch form.
Catenary curve: MacConaill and Scher36 suggested catenary curve

as the basis of human dental arch form. This curve could be described
as formed by a metal chain when hung from its two ends at a given
width and length. They stated that the catenary curve is the simplest
form in which the teeth can be arranged. This form was also
supported by the work on the embryonic arch form by Burdi and
Lillie,37 which found that as early as 9.5 weeks in utero, the human
arch is in catenary shape (Fig. 37.10).
FIGURE 37.10 Catenary curve.
A metal chain hanging from its two ends at a given width best
represents a catenary curve. A significant drawback of this form is that
for a given intermolar width, the intercanine width is usually found to be
rather narrow which may not suit all face types.
Brader arches (1972):38 His theory suggested mathematically that

the shape of the maxillary arch is best described by a trifocal ellipse.
These arch forms show constriction in the second molar region (Fig.
37.11).
FIGURE 37.11 The shape most closely corresponds to a trifocal
ellipse with the teeth occupying portion of the constricted side of
the ellipse.
The trifocal ellipse is the most popular arch form in current usage. This
is a mathematically derived shape using the formula PR = C.21 P =
Pressure, R = Radius, C = Constant.
Ricketts and Engel (1979):39 They developed the pentamorphic arch

forms using dental records from Rocky Mountain Data Systems
(RMDS), USA. Five distinct types of arches were sorted. These were
normal, tapering, ovoid, narrow tapered and narrow ovoid.
In clinical use, three types of arch forms have been categorised
according to the type of arch shapes found commonly in general
population. These are narrow or V-shaped, ovoid and square or U-
shaped (Fig. 37.12).
FIGURE 37.12 Most natural arch forms fall in either of the three
primary forms.
(A) Narrow or V-shaped. (B) Oval. (C) Square or U-shaped
James Currier (1969):40 He first used a computerised polynomial

least square fitting programme. He found that the ellipse fitted well
for a maxillary arch, whereas parabola showed best fit for the
mandibular arch.
Cubic interpolatory spline: Individualised arch forms like cubic
interpolatory spline by Begole41 were used to represent natural
human arch forms. While initially this method was used to evaluate
the changes in the arch form before and after treatment, this method
can now be used to develop preformed archwires for a particular
population. Latest in the search is the development of a computerised
curve-fitting programme (beta function) by Braun et al.42 to represent
the natural human arch form. They have found that beta function is
much more accurate than the previous methods of outlining the arch
form.
Mushroom-shaped lingual arch forms

Natural variations in facial–lingual tooth dimensions are significant
enough on the lingual aspects to require routine first-order bends
distal to the cuspids, mesial to the molars and sometimes at the
maxillary laterals. Fujita43 introduced the concept of ‘mushroom-
shaped archwire’ in conjunction with the lingual appliance (Fig.
37.13). Various compensatory offsets are as follows:44,45
FIGURE 37.13 The archwire on the lingual side of teeth

resembles a mushroom.
This mushroom wire typically has premolar and molar offsets and are
available in SS, NiTi and beta-titanium wires.
Cuspid to bicuspid offset. A 2–4 mm, 90° bends are placed between
cuspid and bicuspid.
Molar offset. A lingual offset of about 1 mm is often indicated
between the bicuspids and molars.
Lateral offset. In some cases, the maxillary lateral incisors may
require a labial offset (0.5–1 mm)) to compensate for a significant
change in facial–lingual thickness from the central incisors to the
laterals.
Now computer software has been used to construct ideal arch
drawing like the DALI programme and robotic technology like
Bending Art System (Orthomate) to fabricate precise archwires.46
How ideal are ‘ideal’ arch forms

While a number of manufacturers are supplying the so-called ‘natural
and ideal arch forms’, it is for the orthodontists to decide which arch
form is to use for the individual patient. No two subjects are alike in
their arch form morphology.
The conventional arch forms may cause expansion of intercanine
widths, particularly in the mandibular arch. Also, the incidence of
round tripping of the anterior teeth has also been reported when
trying to restore the intercanine width to pre-treatment dimensions
after prolonged use of these so-called ‘ideal’ (over-expanded) forms.
In a study by White, catenary arches and Rocky Mountain Data
System (RMDS) arches were found to have closer fits over natural
arches in the American population. Bonwill–Hawley and Brader
arches showed poor fits. Using the Beta function, Braun et al.47
evaluated the shape of some popular preformed NiTi arches and
found them to be over-expanded in the mandibular intercanine region
by about 5.95 mm and by about 8.23 mm in the maxillary intercanine
region when compared with the natural human arches.43
To overcome the problem of modifying the natural arch dimensions
and characteristic, photograph or photocopies of occlusal surfaces of
the pre-treatment study models in 1:1 magnification are used as a
guide. In this manner, a permanent record of the pre-treatment
intercanine width is available for giving appropriate shape to the
archwires.
This is the age of customised archwires. The concepts like Suresmile
technology,12 which scans the teeth, arranges them in ideal occlusion
and uses robots to construct customised arch forms, are now
becoming a reality in clinical practice. The digital CAD/CAM
technology and robotic wire bending is, for sure, to substitute
traditional study models and manual wire bending shortly.
Key Points
Constant research in metallurgy has brought numerous advances in
orthodontic wire materials. Given such a wide spectrum of wires, the
orthodontist is not constrained in his/her armamentarium, but at the
same time, he/she must be thoroughly conversant with the
biomechanical properties to make their best use to patients’ clinical
advantage.
References
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9573877.
2. Thurow RC. Edgewise orthodontics. St. Louis: MO:
Mosby; 1982:21–68.
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5. Verstrynge A, Van Humbeeck J, Willems G. In-vitro
evaluation of the material characteristics of stainless
steel and beta-titanium orthodontic wires. Am J
6. Kapila S, Sachdeva R. Mechanical properties and
clinical applications of orthodontic wires. Am J
7. Rajić-Meštrović S, Lapter M. Mechanical Properties
and Clinical Applications of Orthodontic Wires. Acta
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10393574.
CHAPTER 38
Rubber and synthetic elastic
accessories
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
The rubber
Elastic bands
Lumen dimensions
Tube thickness
Storage and dispensing of elastics
Extra-oral elastics
Complications of use of natural latex elastics
Allergy
Non-latex elastics
Missing rubber bands and bone loss
Cytotoxicity
Force decay
Uses of power chains
Force delivery and force degradation
Pre-stretching effects
Environmental effects
Ligation of archwire to brackets with elastic module
Elastic modules
Gross line ligature
Elastic thread
Elastic separators
Key Points
Introduction
Rubber elastics and polyurethane chains are extensively used
orthodontic armamentarium for intraoral use. Rubber bands also have
extraoral applications for use in headgears and facemask. It was
Henry Albert Baker who first used intermaxillary elastics to produce
orthodontic force and became famous as Baker’s Anchorage in the
1920s.
The rubber
The source of elastic material is either natural rubber or synthetic
polyurethane from the petrochemical industry. Both natural and
polyurethane or synthetic rubbers have a common property of
returning to their original dimensions, quickly, after being stretched to
a limited deformation. This property of resiliency is used to generate a
continuous force to be applied to a tooth or a group of teeth to achieve
tooth movement.1
Natural rubber is obtained from the sap of the trees of rubber Hevea
brasiliensis, which has been used by ancient Indian and Mayan
civilisations. It is purified and mixed with gum, ammonia,
antioxidants and anti-ozone agents, and then further processed for
various uses. Good quality rubber elastics tolerate oral environment to
a sufficient level and duration which makes them useful for intraoral
use.
The latex polymer chains in orthodontics were introduced in the
1960s and had become an integral part of the orthodontic materials.
These chains in various forms have multiple uses and have simplified
the orthodontic treatment to a great extent.
Synthetic latex elastics (poly rubber elastics) are made of the elastic
polymer which has urethane linkage and is synthesised by extending
polyester or a polyether glycol with a di-isocyanide.
The synthetic rubber elastics exceed in their properties when
compared with natural rubber. However, they tend to distort
permanently and lose their elastic property over a long duration in the
mouth.
Elastic bands
Elastic bands are manufactured by slicing the rubber tube of different
lumen and thickness of walls. The lumen of the elastic band and
thickness of its wall determine the force value when stretched.
Lumen dimensions
The lumen of the elastic band is usually expressed in parts of an inch.
For example, a 5/16-in. rubber band would mean that the lumen of the
elastic band is 5 parts of the 16 parts of an inch.
Tube thickness
Elastics are made from the rubber tubings of different thickness,
mainly three types (thin, medium and thick) that determine if the
elastic is light, medium or heavy in terms of its force value. So, within
each of the category of sizes of lumen existing each of three types of
elastic bands (light, medium and heavy) is possible.
The orthodontic elastics can be grouped in the following categories
(Box 38.1):
1. According to use, that is as extraoral or intraoral

2. According to force value (light, medium, heavy and extra
heavy)
3. According to lumen size (Fig. 38.1)
4. According to their use/placement in the arches (interarch or
intraarch)
5. According to colour.
Box 38.1 Classification of orthodontic elastics
1. According to use intra- and extraoral

2. According to force values (usually expressed in ounces)
Light (2 OZ)–56.7 g
Medium light (3.5 OZ)–128 g
Medium heavy (5 OZ)–141.8 g
Heavy (6.5 OZ))–184 g
Extra heavy (8 OZ)–226.8 g
Strength ratings are based on the elastics being stretched 3 times of listed diameter
3. According to lumen size (Fig. 38.1)
2/16” = 1/8” = 3.18 mm
3/16” = 3/16” = 4.76 mm
4/16” = 1/4” = 6.35 mm
5/16” = 5/16” = 7.94 mm
6/16” = 3/8” = 9.5 mm
8/16” = 1/2” = 12.7 mm
10/16” = 5/8” = 15.8 mm
12/16” = 3/4” = 19.1 mm
4. According to their use/placement in the arches
Class I or intraarch or intra-maxillary
Interarch or intermaxillary
Class II
Class III
Cross elastics
Vertical elastics
M elastics
W elastics
Box elastics
5. According to colour (size may vary according to manufacturer)
Purple 1/8”
Green 3/8”
Red 1/8”, 1/4”
Blue 1/4”
Orange 3/8”
Yellow 5/16”
FIGURE 38.1 Size of elastics.

Orthodontic elastics are available in various sizes according to the
inner diameter (lumen) expressed as a part of an inch. All of them are
available as light, medium and heavy force values.
Intraarch elastics are used for retraction of the anterior segment or
space closure within an arch. Interarch elastics are used for
simultaneous action on upper and lower arches.
Class II, interarch elastics are utilised for the retraction of maxillary
anterior teeth, maxillary canine retraction and to counteract the labial
vector of the torque force on maxillary incisors.
They are also used for a mesial shift of the lower buccal segment,
that is correction of class II molar relation to class I.
Elastics in class III fashion from upper molars to lower anterior arch
segment are used for mesial molar movement of the upper arch,
retraction of the lower anterior teeth and anchorage preparation in the
lower arch.
Elastics for open bite closure are applied in a box shape in the
anterior region for extrusion of teeth and in an oblique fashion
extending on the right of maxillary to the left of the mandible or vice
versa for the correction of midline. Settling elastics can be used in
various forms between upper and lower arch buccal segments such as
M or W (Fig. 38.2).
FIGURE 38.2 Intra-oral elastics are named according to the
pattern of their placement.
(A) Class II elastics. (B) Class III. (C) Oblique elastics. (D) Cross-
elastics for the correction of the cross-bite of molars. (E) Box elastics.
(F) M elastics. (G) W elastics. (H) Triangular elastics.
Class II elastics on one side and class III on other side are worn for
the correction of mild midline asymmetry.
Storage and dispensing of elastics
The elastics should be stored away from sunlight, and exposure to
heat should be avoided.1 Sunlight and heat would cause the loss of
their properties.
Manufacturers dispense elastics, rubber bands in sealable opaque
colour pouches to prolong their shelf-life and loss of force. A fresh
batch of elastics should be used, and the ones with reputed
manufacturing company are more reliable for force values and their
force degradation in the oral environment.
Different manufacturers follow either a colour coding or children-
friendly signs such as animals or birds to denote different elastics.
This is much helpful for children to get them interested in the use of
elastics, and communicate with staff regarding their use or when
changing from one type to another or using two different kinds.
Elastic placement should be carefully demonstrated to child and
parent/guardian with specific instructions of wear. The elastic location
can be graphically labelled on the pouch.
The elastic should be worn continuously at all the time except
during meals if not indicated otherwise. When worn continuously,
they exert a constant force and produce favourable tooth movement
with least discomfort to the patient and minimum tooth loosening and
damage to the investing tissues. If the force applied is more than the
recommended, due to inappropriate size or thickness of the band, it
may cause undesired tooth movements such as anchor loss or undue
elevation of teeth. Lingual rolling, rotation, mesial and lingual
displacement with possible soreness and looseness of teeth are usual
complications on lower molars associated with the use of class II
elastics.
On the other hand, if these elastics are worn intermittently on a
part-time basis, this will cause the teeth to move more slowly, with
more loosening in their socket. It causes discomfort and sometimes
pain even with wearing of light elastics which therefore prolong the
treatment duration.
It may be noted that the rubber elastics should not be stretched
beyond three times of their internal diameter. Research on rubber
elastics has shown that the major force decay of the synthetic rubber
elastics occurs within first 24 h of their use in the mouth.
Extra-oral elastics
Extra-oral elastics are anchored from face bow to cervical headgear or
face bow to high pull strap (Fig. 38.3). These elastics are thick and
strong and supplied as (Box 38.2):
• Light 8 OZ–230 g
• Heavy 14 OZ–400 g
FIGURE 38.3 Extra-oral elastics or heavy elastics.
These have been now mostly replaced with safety modules of
headgear.
Box 38.2 Extra-oral elastics: size and force values
Sr. no Size in inches Force value (g)

1 1/4 227
2 5/16 227
3 3/8 227
4 1/2 227
5 5/16 455
6 1/2 455
The heavy pull elastics are also called jumbo elastics. These elastics
are 1/16 in.
For the cumbersome process of use of elastics and risks of
associated injury, safety release modules for headgear have replaced
their use (Figs 38.4 and 38.5).
FIGURE 38.4 Safety modules.
Safety modules for headgear have replaced the use of rubber elastics.
FIGURE 38.5 Measuring force using the Dontrix measuring

gauge.
Complications of use of natural latex
elastics
Allergy
Allergy to latex can range from a simple skin rash to shock (which is
rare). The amount of latex exposure needed to produce sensitisation or
an allergic reaction is unknown, but frequent exposure to latex
proteins increases the risk.
Allergic stomatitis from rubber bands is known to occur to those
who are allergic to latex.2 Non-latex elastics should be used, and
advice of a dermatologist should be sought in such situations.
History of allergies is useful in such situations.
Non-latex elastics
These are available as a substitute of latex for those children who are
allergic to latex; however, they show the greater decay of force in a
simulated oral environment. Therefore, great improvements in the
physical properties of the silicone band are required before they can
fully substitute for latex.3
Missing rubber bands and bone loss

The orthodontic rubber bands may slip over the tooth crown and may
be retained in the gingival crevicular sulcus.4,5 It causes significant
bone loss and tooth mobility. Such a clinical situation in an
orthodontic patient should be suspected for a missing rubber band.
The missing rubber band may be tough to locate by the dentist, and
the child may be unaware of such a mishap, except pain and tooth
mobility.
Extreme caution should be observed in the use of intraoral elastics.
All attempts should be made to anchor the elastic bands to the
orthodontic hook only. Thorough instructions for their placement and
removal administered to the child and parents can minimise such
accidents. The only possible solution to locate a missing rubber band
in the mouth is to develop a harmless radiopaque medium that can be
safely incorporated into elastic.
Cytotoxicity
The preservatives and other chemicals used in the rubber bands may
produce cytotoxicity to the oral/gingival tissues. The potential for
nitrosamine formation from accelerating agents used for vulcanisation
and from other nitrosatable amines, which may be present in rubber
exposed to salivary nitrite, is known.6 Fiddler et al. reported the
presence of N-nitrosodibutylamine and N-nitrosopiperidine from
eight brands of elastic rubber bands used in orthodontics.7
Force decay
Good quality rubber bands tolerate oral environment to a sufficient
level which makes them useful for intraoral use. The rubber bands
show a disintegration of force within the first hour of their placement
in the mouth. About 30% of force decay is seen within 24 h, of which
15% occurs within the first hour. Therefore, elastics need to be
replaced every day for the optimum force delivery. The properties of
elastics are also influenced by the purity of latex material, shelf-life of
the elastics and several other factors of manufacture control and oral
environment.
The force values do get affected by the salivary contents and pH,
bacteria, forces of mastication and various foods and temperature
which make the rubber to break down due to the formation of knotty
tearing mechanism in its structure causing it to swell up and hence
resulting in poor force delivery.
The latex polymer power chains in orthodontics were introduced in
the 1960s and had become an integral part of the orthodontic material.
These chains in various forms have multiple uses and have simplified
the orthodontic treatment to a great extent. Synthetic latex elastics
(poly rubber elastics) power chains are intended for the delivery of
continuous force of recommended force value for an extended period
of time with much of the comfort. These accessories are used in
following forms:
1. Elastic chains or power chains

2. Elastic module
3. Elastic ligature
4. Elastic separators
5. Elastic thread
They are available in four configurations (Fig. 38.6):
• Continuous/closed chain
• Short link chain or short filament
• Medium link chain or medium filament
• Long link chain or long filament
FIGURE 38.6 Orthodontic elastic chains are available according

to the length of the filament.
These are available as continuous, short, medium and large filaments.
They can be available as clear, grey and of various colours.
These power chains have various uses depending on how and at

what stage they are placed in the arch. Their uses can be listed as
follows:
• Final space closure or arch consolidation

• Canine retraction
• Diastema closure
• Rotational correction
• Closure of extraction spaces
• Selective shift of the midline.
The power chains are available in either grey, transparent or

coloured. They are available as long chains of various lengths (10 ft, 15
ft) rolled on an easy to handle spools. The power chains are also
available in the form of small pieces of two or more modules at
variable lengths to accommodate space closure of the mandibular
anterior teeth and diastema. Some orthodontist may like to use the
power chain during arch constriction or final space closure as means
of ligation of the arch wire from one molar to another molar.
Uses of power chains

The selection of power chain would be based on the purpose and
clinical situation. A case with little space of 1 mm or so between teeth
would require a continuous chain, while one with large spaces would
require a long link chain to be ligated. The chains can be stretched
75%–100% of their original length. Earlier it was recommended that
synthetic chains should be pre-stretched to additional one-third length
for the optimum force delivery. However, recent research has
questioned this clinical practice.
To prevent salivary contamination of the spool of a chain, the
clinician should first decide a number of modules required to be used
and accordingly cut a little longer chain from the spool with a sterile
instrument. The chain should not be used directly in the mouth from a
spool at a free end, which results in its contamination by saliva.
Force delivery and force degradation

Most of the chains lose 50%–70% of the initial force during the first
day of the loading in the mouth, and this outcome is variable from
manufacturer to manufacturer.8,9 It would also greatly depend on the
storage conditions and age of the product. It may be prudent to check
the initial force levels of the chain in question under use with force
measuring instrument. It should be reviewed on subsequent visits to
make a judgment of the particular brand and type of chain in use for
the force decay levels. It has been found that an initial force would
reduce to half on the second day in the mouth and after that the decay
of force values is little for the next 3 weeks.1,10
Pre-stretching effects
It is recommended that chains should be stretched up to one-third of
their original length to prestress the polymer chain. Pre-stretching is
expected to prevent rapid decay of force on an application in the
appliance in the oral cavity.
Some authors have reported that 100% pre-stretching of their
original length for 10 s before loading resulted in improvement of
force decay from 4% to 6%, which was clinically insignificant.11
However, Brooks and Hershey12 found that pre-stretching of power
chains for 1 day retained 15%–20% more force after 24 h and 10%
more force after 4 weeks. The clinical value of pre-stretching is
questionable.13
Environmental effects
It has been reported that immersion of power chains in alkaline
glutaraldehyde solution for the purpose of disinfection does not
considerably affect their properties.14 The alkaline pH of the saliva has
a slightly deleterious effect on the force decay of the chains.
In an intraoral environment, synthetic ligatures undergo enzymatic
degradation, temperature-related relaxation and absorption of lipids,
which in turn induce plasticising effects. Orthodontic mechanics that
rely on elastomeric ligation or traction such as full correction of
rotations, torque expression and absolute space closure might be
adversely affected by the ageing-induced decrease in the creep of
these appliances. Therefore, either clinician should shorten the period
between the appointments or use steel ligatures while such mechanics
are in place.8
Ligation of archwire to brackets with
elastic module
Elastic modules
Elastic modules are primarily single elastomeric ligatures which have
virtually replaced steel ligatures. The modules are available in grey,
clear and almost all colours. Provision of new colour at next
appointment could help the young children excited about the
treatment.
Advantages
The modules are easy to place on brackets, save chair time and are
much comfortable to the patients compared with steel ligature ties.
They also have an advantage of delivering a less traumatic force of
ligation compared to the ligature wire and therefore provide less
trauma during the initial stages of alignment of the arches. Their
placement takes less chair time. The modules have smooth borders
without pigtails, so less irritation to lips and cheek mucosa. The good
quality modules should give reasonable tie control over a 6-week
period.
Disadvantages
Elastic modules do absorb water from saliva, swell up and absorb
odours and are unable to deliver constant force over a long period of
time. Discolouration and staining with coffee/tea, spices and mustard
is definitely a problem. In India and Asia where turmeric is a part of
everyday food, all modules and power chains do get a dirty yellow
colour in the mouth.
Gross line ligature

It is a twisted or braided cord which is supplied in different thickness.
It has a property of shrinkage when moistened, provides light force,
which makes it suitable for the movement of periodontally involved
teeth. After completion of movement, it holds the teeth in their new
position and thus acts as a retentive device. It can be used for the
closure of diastema and correction of rotated teeth, particularly, when
periodontal health is not so good.
Elastic thread
Elastic thread is used for correction of rotations, orthodontic tooth
movement of surgically exposed impacted teeth, closure of minor
spaces and numerous other intraoral applications. They are available
as a clear thread which is smooth with a nonporous surface and exerts
light, continuous long lasting predictable force. However, tying may
be difficult.
Elastic tubing is similar to a thread, but with a hollow core which
collapses when tied, thereby resulting in tighter knots, that will not
slip. Recently, a rectangular thread has been introduced, when tied its
knot does not loosen, unlike the round thread.
Elastic separators
These are available as small rings which when placed around the
contact points of the teeth gently cause separation of the teeth. They
are supplied in different colours by the different manufacturers. These
can be easily placed either with floss or with separator placing pliers.
Key Points
Rubber elastics and polyurethane power chain modules and similar
accessories are an integral armamentarium of day-to-day orthodontic
consumables. An orthodontist should have a good understanding of
how these materials behave in oral environment and their force decay
pattern values. Much of the care is needed in their storage and
instructions for use.
Rubber and polyurethane accessories do eventually get affected
adversely with the salivary contents and pH, bacterial growth, forces
of mastication and various foods and temperature which make rubber
to swell up and break down with the formation of the knotty tearing
mechanism.
Irrational use of power chains can generate undesired forces which
can lead to anchorage loss.
References
1. Wong AK. Orthodontic elastic materials. Angle
2. Kelso JM. Allergic contact stomatitis from
orthodontic rubber bands. Ann Allergy Asthma
Immunol. 2007;98(1):99–100: PubMed PMID:
17225730.
3. Hwang CJ, Cha JY. Mechanical and biological
comparison of latex and silicone rubber bands. Am J
4. Vandersall DC, Varble DL. The missing orthodontic
elastic band, a periodontic-orthodontic dilemma. J
Am Dent Assoc. 1978;97(4):661–663: PubMed PMID:
281408.
5. Zager NI, Barnett ML. Severe bone loss in a child
initiated by multiple orthodontic rubber bands: case
report. J Periodontol. 1974;45(9):701–704: PubMed
PMID: 4608985.
6. Holmes J, Barker MK, Walley EK, Tuncay OC.
Cytotoxicity of orthodontic elastics. Am J Orthod
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7. Fiddler W, Pensabene J, Sphon J, Andrzejewski D.
Nitrosamines in rubber bands used for orthodontic
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8. Baty DL, Storie DJ, von Fraunhofer JA. Synthetic
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University of Louisville, Louisville, Kentucky; 1990.
Quoted from Baty DL, Storie DJ, von Fraunhofer JA,
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13. Kim KH, Chung CH, Choy K, Lee JS, Vanarsdall RL.
Effects of prestretching on force degradation of
synthetic elastomeric chains. Am J Orthod Dentofacial
Orthop. 2005;128(4):477–482: PubMed PMID:
16214630.
14. Jeffries CL, von Fraunhofer JA. The effects of 2%
alkaline glutaraldehyde solution on the elastic
properties of elastomeric chain. Angle Orthod.
1991;61(1):25–30: PubMed PMID: 1901464.
CHAPTER 39
Bonding orthodontic appliances
O.P. Kharbanda
Priyanka Kapoor
Anurag Gupta
CHAPTER OUTLINE
Introduction
Historical aspects of adhesion on dental tissues
Enamel etching
SEM classification of etching pattern
Acid concentration and duration of the etching
Alternatives to acid etching
Bonding agents
Evolution of bonding agents
Advanced bonding agents
Armamentarium required for direct bonding
Steps in the direct bonding procedure
Direct bonding on enamel variant surfaces
Bonding on unconventional tooth surfaces
Bonding to amalgam and Co–Cr/Ni–Cr alloys
Armamentarium required for indirect bonding
Steps in an indirect bonding technique
Advantages of lingual-bonded retainers
Basic designs of lingual retainers
Fixed lingual retainer using DuraLay resin transfer
Adhesive remnant index
Key Points
Introduction
Aesthetic and functional considerations in orthodontic appliances
have led to a paradigm shift from soldered brackets on bands on
individual teeth to the present times of direct and indirect bonding of
brackets (Box 39.1).
Box 39.1 Advantages and limitations of bonding

in orthodontics
Sr.
Advantages of bonding Limitations of bonding
No.
1 Improved aesthetics Weaker attachment than a cemented band
2 Improved patient comfort The attachment may not be suitable for orthodontic
forces such as Kloehn headgear or lingual
auxiliaries
3 Higher accuracy in placement of Technique sensitive procedure
brackets
4 Reduced gingival irritation The smaller size of brackets and better access to
tooth cleaning surfaces do not guarantee better
gingival health
5 Oral hygiene maintenance becomes Loss of enamel with etching
simpler compared to banded appliance
6 An absence of bands allows IPR or a Bracket bond failures do occur, and subsequent
proximal restoration during appliance in bonds are not equally reliable
situ
7 Lowered risk of caries Enamel demineralisation and white spots around
bonded attachments
8 Save cost and time Re-bonding is more time consuming
9 Elimination of band spaces at debond Risk of accumulation of plaque if adhesive extends

beyond bracket base
10 Bonding of attachment to porcelain or Loss of enamel during debonding although
amalgam is possible recovery is a possibility with re-mineralisation
11 No increase in arch length by the Risks of enamel cracks during debond procedures
presence of band material on proximal
surfaces of teeth
IPR, Interproximal reduction.
Initially, fixed orthodontic appliances were soldered onto the band

and cemented on the tooth. Gold clamps date back to 1907 that were
used during Angle’s era.1 In the next few years, orthodontics was
practised with full mouth banding using soldered pitch fit bands,
followed by the practice of prefabricated and welded stainless steel
bands in orthodontic treatment. Full arch banding had several
shortcomings such as additional chair side time, interdental space
after removal of bands, gingival and chemical irritation and, above all,
unaesthetic presentation. Newman in 1965 was the first to
demonstrate a bonded orthodontic attachment, and his group did
extensive research in this field.2–6
Historical aspects of adhesion on
dental tissues
The advent of direct bonding of resin to enamel surface by Buonocore
in 1952 was a significant breakthrough in dentistry in general and
orthodontics in particular. The landmark events that evolved bonding
in dentistry/orthodontics are compiled in Table 39.1. Buonocore
advocated the use of acid for alteration of enamel surface to render it
more amenable to adhesion. He conditioned enamel with 85%
phosphoric acid for 30 s which made it receptive for bonding to the
resin.7 The mechanism for this attachment, as proposed by Buonocore
and Matsui, was the creation of ‘resin tags’ into the enamel. The acid
etching removed the surface enamel, leading to the creation of a
porous outer enamel in the range of 10–50 µm. By increasing the
wettability and the surface area after etching, a low viscosity, resin can
penetrate this porous layer to create resin tags which allow bonding.8
The composite to phosphoric acid etched enamel surface offers shear
bond strength in the range of 17–20 MPa to resist the contraction
forces of the bonding interface by the composite. Although
orthodontic bonding primarily involves retention on the enamel
surface, newer adhesive systems are capable of simultaneous
adhesion to enamel and dentin.
Table 39.1
Few important events related to bonding

Years Authors Important events
1955 Buonocore Introduced etching tooth surfaces with phosphoric acid—85%
phosphoric acid for 30 s
1962 Bowen Bowen’s Resin—bisphenol A-glycidyl dimethacrylate
1965 Newman Epoxy resin bonding orthodontic resins—diglycidyl ether of
bisphenol-A with a polyamide curing agent
1968 Smith Bracket bonding with zinc polyacrylate cement
1972, Silverman and Pioneers of indirect bonding technique
1976 Cohen
1973 Retief Etching modifications:
1974 Silverstone 50%phosphoric acid concentration
1977 Gorelick 30%–50% phosphoric acid concentration
2005 Zachrisson and 35%–38% orthophosphoric acid
2010 Büyükyılmaz
Øgaard and
Fjeld
Üs¸umez and
Erverdi
1977 Zachrisson First detailed published large sample data on posttreatment
evaluation of direct bonding
1979 Takao Fusayama Total etch technique
1979 Maijer and Smith Crystal growth technique
1982 Nobuo Nakabayashi Resin reinforced hybrid layer
1992 J. Kanca et al. Moist bonding technique
1993 Hermsen and 10% Maleic acid, polyacrylic acid as etchants
1997 Vrijhoef
2007 Olsen and
Bishara
Bas¸-Kalkan and
Orhan
1999 Sondhi A Sondhi Rapid-Set Indirect Bonding Adhesive
Enamel etching
SEM classification of etching pattern
Silverstone and Saxton suggested three basic patterns of dissolution of
enamel after acid etch.9,10 The first two patterns (Types 1 and 2) show
the removal of enamel prism cores and prism peripheries,
respectively. Type 3 pattern of enamel dissolution is more indistinct.
The enamel etch pattern has later been modified into six distinct types
(Box 39.2).
Box 39.2 Six distinct microscopic patterns of

enamel following acid treatment
Sr.
Types Description
No.
1 Type I Honeycomb appearance with enamel prism centres lost. Most favourably present in
coronal buccal surfaces of teeth
2 Type Cobblestone appearance with enamel prism edges lost. Most favourably present in
II coronal buccal surfaces of teeth
3 Type Pitted enamel with a map like appearance. Most favourably present in the middle
III part of buccal surfaces of teeth
4 Type Granulation of enamel with numerous holes with no preferential dissolution of cores
IV or peripheries. Most commonly found in cervical areas and less in occlusal areas
5 Type No prism outlines with smooth and flat enamel surface and decrease in irregularities
V for resin penetration. It can be seen in teeth with fluoride treatment or in fluorosis and
locally in occlusal regions of teeth
6 Type Stark difference observed between ground (G) enamel and unground (UG) enamel
VI surface on application of phosphoric acid for 90 s
Acid concentration and duration of the etching

Different concentrations of phosphoric acid and duration have been
tried for effective etching by various authors.2,11 Research findings
suggest that 50% phosphoric acid for 60 s has been shown to produce
the substrate monocalcium phosphate monohydrate that is easily
removed after rinsing. A phosphoric acid concentration of 27%
produces dicalcium dihydrate that is not easily rinsed off. Hence,
based on dissolution of calcium and depth of etching, a concentration
of 30%–40% phosphoric acid was considered most suitable in studies
conducted by Silverman et al.12 and follow-up outcomes in 1977.13
Current practice guidelines recommend the application of 37%
orthophosphoric acid gel for 30 s.14
Milder acids such as 10% phosphoric acid, 10% maleic acid and
2.5% nitric acid have been effectively tested. The physiology of
etching and bonding to enamel and dentin is entirely different,
primarily due to the composition of inorganic hydroxyapatite in
enamel being 95% while that of dentin being 45% and more regular
arrangement of hydroxyapatite in enamel than dentin. Furthermore,
the presence of 0.5–4 µm smear layer on dentin acts as a diffusion
barrier and complicates the dentin bonding.8
Alternatives to acid etching

1. Lasers: Lasers used in orthodontic bonding are hard tissue
lasers like Erbium:YAG (Er:YAG) lasers (wavelength of 2940
nm) and Erbium, Yttrium-Scandium-Gallium-Garnet
Chromium-doped (ErCr:YSGG) lasers (wavelength of 2780
nm). Microscopically, type 1 etching pattern (honeycomb
appearance) may be obtained with the correct duration,
frequency and power settings. Özer and Basaran15 (2008)
recommended a distance of 1 mm or a non-contact mode for
laser etching.
2. Air abrasion: Surface abrasion is caused by forceful propulsion
of aluminium oxide (Al2O3) particles with high air pressure.
However, it can produce bond strengths only half of acid
etching. Studies have proved that etching with
orthophosphoric acid followed by sandblasting method
improves bond strength than when etched with phosphoric
acid alone.1
3. Crystal growth: Crystal growth technique was introduced by
Maijer and Smith in 1979 as an alternative method to acid
etching for bonding brackets.16 Etching with the polyacrylic
acid solution containing residual sulphate ions produced a
crystalline deposit on enamel in addition to slight etching that
bonds the composite firmly to the enamel surface and resists
mechanical removal. The crystal grow in a pattern called
‘spherulitic habit’. The crystals were shown to be calcium
sulphate dihydrate. It was found that maximum density of
long, needle-shaped crystals grew on the enamel surface after
conditioning for 30–60 s with 40% polyacrylic acid containing
3.8% of sulphate ions. The crystalline interface produced a
tensile bond strength equivalent to that of a conventionally
acid-etched surface. At debonding, the fractures occurred
mostly in the crystal/resin interface when the brackets were
pulled off the teeth.7 However, the remnants could be
removed easily with an ultrasonic scaler and pumice,
apparently leaving the fluoride-rich outer enamel surface
smooth and intact.
Advantages of crystal bonding technique are as follows:
1. There is a minimal loss on the outer (fluoride-rich) enamel

layer.
2. The enamel surface is not significantly damaged.
3. Few, if any, resin tags are left behind the enamel.
4. A reasonable bond strength for clinical practice is achieved.
5. Debonding and cleanup are much more comfortable with
minimal iatrogenic damage.
6. The crystal interface offers a possibility of incorporation of
fluoride or other antiplaque agents to provide an
anticariogenic action.
Bonding agents
Evolution of bonding agents
Bonding, in general, has revolutionised adhesive dentistry. The
material scientists and clinicians have strived to develop better
handling and mechanical properties of these materials.
The first-generation bonding agents: The transformation in resinous
adhesives has also seen a revolutionary change since the time of
Buonocore. Buonocore7 (1955) demonstrated that the use of
glycerophosphoric acid dimethacrylate containing resin would bond
to acid-etched dentin due to the interaction of this bifunctional resin
molecule with the calcium ion of hydroxyapatite. Later in 1963, he
suggested that substances which could displace water from tooth
surfaces be incorporated into the adhesives. In the late 1960s,
Buonocore claimed that it was the formation of resin tags that caused
the primary adhesion of resins to the acid-etched enamel.
Subsequently, in 1967 he introduced the composite or filled resins
which incorporated microscopic particles of glass or quartz into the
resin base. Due to its compromised bond strength in water, Bowen
recommended NPG-GMA (N-phenyl glycine glycidyl methacrylate),
which is believed to form water resistant bonds with dentinal calcium.
This further led to the development of the next generations of dentin
bonding agents (DBA).
The second-generation bonding agents: The second generation
primarily contained phosphorous esters of BIS-GMA (bisphenol A-
glycidyl methacrylate) or HEMA (hydroxyethyl methacrylate) that
form ionic bonds of phosphate of resin with calcium of tooth, but its
commercial availability is limited presently.
The third-generation bonding agents: The third generation of DBA had
more bond strength as they removed the smear layer to improve the
penetrability and also prevented microleakage.
The fourth-generation bonding agents: The fourth generation bonding
agents are clinically successful bonding agents and in use till today.
They are based on etch, prime and bond process where etching
removes the smear layer, opens tubular dentin, decalcifies peritubular
and intertubular dentin, removes hydroxyapatite in dentin to allow
penetration of primer but also makes it more prone to collagen
collapse. The primer molecules, HEMA, BPDM or 4 META, that have
both hydrophilic and hydrophobic groups subsequently wet the
dentin surface, raise its surface energy so that the resinous material
can bind and form a resin reinforced layer or hybrid layer. A relatively
moist surface of dentin prevents the collapse of unsupported collagen
network and form an optimal hybrid layer. Hence, newer DBA
generations were hydrophilic where after etching with 10%
phosphoric acid or maleic acid for 15 s, rinsing, drying with
compressed air, a hydrated glistening surface was maintained. The
primers used were able to displace moisture, cause penetration of
resin primers into demineralised dentin and when light cured, it
copolymerised with unfilled resins as well as composite.
The fifth-generation bonding agents: It is a one bottle system, primer
and adhesive were clubbed into a single step following etching with
37% phosphoric acid. The hybrid layer formed by this system tends to
be more susceptible to water degradation as the primer is hydrophilic
in nature.
The sixth-generation bonding agents: These are ‘SEP’ self etching
primers). This system eliminates wash and the dry step after etching.
Following acid etching of the enamel, the primer is cured by a light
source. The pH of primer is critical 1.8–2.2, hence, frequent renewal is
required. The advantage is that collagen collapse by airdrying is
avoided. Studies indicate these bonding agents adhere well to dentin
(41 MPa), whereas bond to enamel is at least 25% weaker than fourth
generation system.
The seventh-generation bonding agents: They are first, no-mix, self-etch
adhesives provided in a single container as it combines all the steps:
etching, priming and adhesion in bonding. However, incorporating all
of the chemistry in a single vial, for a viable period poses a significant
challenge. Additionally, this generation of adhesives has proven to
have the lowest initial and long-term bond strength that may be
considered as a disadvantage.
The eighth-generation bonding agents: Voco America introduced
Futurabond DC which contains nano-sized fillers with an average
particle size of 12 nm that increases the penetration of resin monomers
and hybrid layer thickness, which in turn improves mechanical
properties of bonding agent.
Advanced bonding agents

Self-etching primers (SEP)17 were introduced almost 20 years back to
eliminate separate enamel or dentin preconditioning and moist post-
rinse control. The pH of acidic functional monomers used in SEP is
higher than phosphoric acid etchants. SEP are provided in an aqueous
solution to aid in ionisation of functional monomers, and they
comprise of HEMA that increases the wettability of dentin surface and
additional bi- or multifunctional monomers that establish cross-
linking of the matrix. Currently, SEP may be classified as follows:
• One-step adhesives: Available as a single solution comprising of

both hydrophilic and hydrophobic acidic functional
monomers, water and organic solvents. It is an all-in-one
adhesive system combining etching, priming and bonding. It
is also called ‘universal or multimode adhesive’; it may be
used in etched or unetched enamel and dentin.
• Two-step adhesives: They comprise of a hydrophilic etching
primer that concurrently etches and primes the tooth surface,
after which the solvent evaporates, and a layer of hydrophobic
bonding agent seals the dentin. Their etching aggressiveness
can be graded on their acid dissociation constants (pKa
values): ‘strong’ (pH < 1) ‘intermediately strong’ (pH ≈ 1.5),
‘mild’ (pH ≈ 2) and ‘ultramild’ (pH ≥ 2.5). Of these, strong SEP
show etching similar to phosphoric acid and can be used for
enamel bonding while mild can be effectively used for dentin
bonding, as it removes the smear layer and forms a thin
hybrid layer.
Thus, SEP have broad applicability from their use as silane for glass
ceramics to being used as primers for metal alloys and polycrystalline
ceramics.
Moisture insensitive primer (MIP) is effective in unconventional
areas like tooth impaction where isolation from moisture is an issue as
they give effective bond strength in the presence of moisture.
Hybrid bonding agents—another breakthrough in adhesion science
during the 1990s was a hybridisation of technology underlying resin
composites and glass ionomer cement to form materials having
characteristics of both salt matrix and resin matrix called resin
ionomer hybrids.18 They overcome all disadvantages of traditional
glass ionomer such as longer setting time, shorter working time,
cracking on drying, moisture sensitivity, low fracture toughness and
abrasion resistance. Their nomenclature has changed from visible
light-cured glass ionomers (VLC-GIC) to light-activated water-based
cement. The resin-based glass ionomer (RM-GIC) is dual cured by
employing both acid-base reaction as well as addition polymerisation
(either light or chemically activated). RM-GIC offers two significant
advantages of adhesion and fluoride release. LC-GIC is different from
chemically activated GIC. DBA is not recommended beneath it. Their
strength and fluoride release are more excellent than compomers.
Compomers are another hybrids between ionomers and composites
with intermediate properties but are anhydrous (do not contain
water). Hence initial setting occurs by free-radical polymerisation, but
eventually the acid-base reaction also occurs by absorption of water in
vivo. They are primarily similar to composites.
Nanocomposites—a new class of polymer nanocomposites
containing nanofillers of 0.005–0.01 µm in size is the latest addition.
Nano-filled composites have advantages of increased strength,
smoother texture, less bacterial adhesion and less polymerisation
shrinkage. However, a study by Bishara et al.19 have concluded that
nano-filled composites may be comparable to the traditional
orthodontic adhesive for bonding of brackets if there is a modification
in its consistency to be more flowable to adhere to bracket base. Nano-
filled dental adhesives are also being tested with eighth generation
bonding agent for reduction in microleakage and greater bond
strength.
The bonding agents and technique have evolved over the years;
however, an ideal bonding agent which should mimic the natural
tooth enamel/dentine is yet to be discovered.
The bonding adhesives have evolved from two-paste mix with self-
cure system to no mix light cure system. Most contemporary
adhesives are hybrid nanocomposites which are supplied in a
dispensable dark tube for convenience in handling. The adhesive
composite and primer between the etched enamel surface and mesh of
the bracket base when light cured provide micromechanical retention
of the attachment. The required bond strength is enough to resist the
orthodontic force applications (Boxes 39.3 and 39.4).
Box 39.3 Prerequisites of an ideal bonding agent
The essential requirements of an orthodontic bonding agent are

1 It should be biologically safe in the oral cavity
2 It should have sufficient bond strength for orthodontic applications. In general a minimum
bond strength of 8 MPa is required. Most bonding agents offer bond strength of 7–15 MPa
3 It should not harm dental hard and oral tissues
4 It should work in the oral environment
5 It could be removed with ease without harming dental tissues
Box 39.4 Handling properties and clinical

performance of orthodontic adhesive
Handling properties and clinical performance
1 An orthodontic bonding material should have adequate fluidity and wettability
2 It should be easy to manipulate with adequate working and setting time
3 It should have adequate shelf-life
4 It should attain optimum strength quickly for early wire placement
5 It should withstand stresses of masticatory forces and thermal recycling in the oral cavity, that
is it must produce a durable bond
6 It should be dimensionally stable with minimal shrinkage or expansion
7 It should induce enamel re-mineralisation

It should have antimicrobial properties or at least poor biohostility
8
9 It should have a similar refractive index as of attachment like plastic and ceramic bracket
10 It should not discolour or stain with time

1. Direct bonding technique: DB, pioneered by Buonocore in 1955,
refers to directly bonding brackets on the tooth surface.
Although it is convenient, reduces chair-side time, the precise
positioning of brackets largely depends on the experience of
the clinician.
2. Indirect bonding technique: This technique was introduced by
Silverman et al. in 1972.12 Indirect bonding refers to the
positioning of brackets on working casts with the aid of water
soluble or intermediary adhesives followed by construction of
a transfer tray to transport the brackets to patient’s mouth.
Indirect bonding leads to precise bracket positioning, although
is more technique sensitive and time consuming than direct
bonding. In orthodontics, Sondhi indirect bonding technique is
popular.20
Direct bonding technique involves adhesion of orthodontic bracket or
an attachment onto tooth surface in clinic, and this is the way most
orthodontists practice. Direct attachments include brackets and buccal
tubes. However, the expansion appliances and Nance button are still
being attached to the molar bands (Fig. 39.1).
FIGURE 39.1 Bonding is preferably carried out by a four-handed

approach with the orthodontist and the dental assistant (or dental
resident, as seen above) working in unison.
The orthodontist carries out the main bonding procedure while the
assistant is incharge of maintaining an isolated oral environment for
bonding, and assists with instrumentation and use of LED.
Armamentarium required for direct bonding

1. Well-functioning dental unit with a three-way syringe. The
water quality is important, and so is the quality of the
compressed air. The compressed air should be free of moisture
and oil. The water should be free of any turbidity and sterile.
An efficient noiseless suction with disposable suction tubes is a
must. A good bonding can be performed in a cool hassle free
environment.
2. Armamentarium required for bonding procedure:
a. Low-speed hand-piece, polishing brushes and oil-
free polishing paste
b. Bracket height marker and a bracket positioner
c. Bonding tweezers (set of six or more)
d. A push scaler
e. Cheek retractors
f. Tongue guard in various sizes
g. Absorbent cotton rolls
h. Dry angles to prevent flow from the parotid duct
i. High-speed saliva ejector
j. Nola dry field system. It can substitute items (e) and
(f)
k. Disposable brushes/sponge applicators and
disposable micro tips
l. Bonding agent complete with an etchant, primer
and composite
m. Efficient light curing unit
n. Suction tips.
The instruments are arranged in a ‘tray set-up’ labelled as ‘bonding

tray’. The instruments and armamentarium should be sterilised before
use (Figs 39.2–39.4).
FIGURE 39.2 Nola dry field system.
FIGURE 39.3 Armamentarium required for bonding procedure.

Light cure adhesive bonding agents are preferred over self-cure
bonding agents.
FIGURE 39.4 Armamentarium required for bonding procedure.
Cleaning and polishing of teeth is carried out with pumice powder paste
and bristle cup brush. Bonding tweezers and bracket positioning gauge
are essential bracket positioning devices.
Steps in the direct bonding procedure (Fig.

39.5)
FIGURE 39.5 Application of etchant on the teeth surfaces.
(A) Achievement of proper isolation with use of the Nola dry field
system. (B) Application of etchant on the teeth surfaces. (C) The
etchant is washed off, first with a gentle stream of water followed by a
mixed stream of water and air, and then gently with dry air (free from oil
and moisture contamination) to view frosted enamel surface produced
by enamel etching. (D) Suction line should be double-checked and
secured to ensure maintenance of proper isolation and dry fields: no
contamination should occur during and immediately following bonding
procedure. (E) Primer is applied on the etched tooth surface(s) with a
clean brush. (F) Bracket height locations are then marked to aid in
correct bracket placement. These locations are usually the LA point in
most bracket prescriptions or else the standard bracket placement
chart for standard edgewise prescription can be used.
A child/patient must be thoroughly explained the steps involved in

bonding and preferably make him watch someone undergoing
bonding or by sharing a brief video to allay the apprehensions. The
teeth to be bonded should be examined for the quality of enamel,
aesthetic or metal restorations and any white spots, cracks or other
defects. The findings should be documented in the case file and
through photographs. Any fractured cusp tips or attrition of teeth
should also be recorded and accounted for while marking the height
for each of the attachment. Bracket positions are visualised, and the
long axis of each tooth is examined.
The sequence of bonding the teeth should be prediscussed with the
assistant. The patient, the orthodontist and assistant take an
appropriate position for ease and comfort of working in four-handed
dentistry set-up. The bonding procedure should be performed in a
friendly and relaxed environment with full attention and focus. All
cell phones or intrusions which are likely to compromise the level of
attention and therefore may affect the quality of bonding outcome
should be avoided. The steps of the bonding are as follows.
1. Cleaning: A primary requisite of bonding is the removal of

organic pellicle and plaque. The patient is asked to undergo a
thorough brushing before his appointment. He undergoes a
session of polishing. Polishing is performed with rubber cup or
small polishing brushes using low-speed (>20000 rpm)
micromotor using low abrasive high-quality oil-free pumice
flour. The polishing with pumice is believed to remove the
organic pellicle layer and exposes the prismless layer of
enamel for resin penetration, resulting in a 50% increase in
bond strength.
2. Isolation of teeth for bonding (Fig. 39.5A): The dental arch
under bonding is isolated from moisture contamination. A
control of saliva and blood contamination is essential for
achieving bond strength. Cheek retractors, lip expander and
vacuum suction are used to isolate the teeth. Prefabricated
cotton rolls or absorbent triangles also help when placed at
appropriate sites. Absorbent triangles are placed close to the
opening of the parotid ducts and cotton rolls under the tongue.
Too many rolls may cause discomfort as well. Nola dry Field
system is efficient and smart, and the author prefers to use the
same. However, in younger children, one may have to manage
with cheek retractor and tongue guard combination. The
bracket positions are marked which is followed by enamel
conditioning.
3. Enamel conditioning (Fig. 39.5 B): The phosphoric acid gel is
applied on the tooth crown with a brush or with an injection
syringe containing acid in gel form. The acid etchant
application should be limited to enamel area directly under the
bracket base. The gel is applied in a gentle dabbing action with
a soft brush to avoid fracturing of enamel rods. Etching time
from 15 to 30 s is appropriate; however, time increases for
fluorosed teeth and deciduous teeth due to the presence of
aprismatic enamel.
4. Rinsing (Fig. 39.5C): Etching is followed by rinsing of a tooth
with abundant water supply for approximately 20–30 s.
Rinsing helps to remove debris and soluble calcium salts left as
residue after enamel pretreatment.
5. Drying the etched enamel: Rinsing with water is followed by
gentle cleaning with air and water spray, and finally with an
air spray to dry the etched tooth surface. A frosty white/chalky
appearance is an indicator of optimum etching. The usual
drying duration is 15 s. Overdrying is to be avoided. It is
pertinent to re-emphasise here that air quality has a significant
bearing on the ultimate bond strength. The air should be
entirely free from moisture or any oil remnants. While drying,
care should be taken that tooth/teeth remain isolated without
any contamination with saliva or another source of moisture
including a breath through the mouth. Contamination of
etched surface with saliva leads to the formation of an
adherent layer which can compromise the bond strength or
lead to bond failure altogether. Therefore, in such situations re-
etching should be considered.3 Although acid etching
enhances the micromechanical retention of composites to the
tooth structure, it also poses specific risks like the removal of
10 µm enamel or fluoride in the exterior layer of the enamel.
Also, it may produce a roughness of enamel due to over-
etching which is prone to staining or fracture.
6. Application of primer/coupling agents (Fig. 39.5E): Primers
comprise of monomers, hydrophilic coupling agents (e.g.
HEMA) in a solvent carrier like acetone or ethanol. These are
low viscosity resins that are applied as a thin layer with the
help of a micro-brush on etched enamel surface and mesh on
the bracket base. During this step, the dental light should
either be dimmed or switched off. A 10 s exposure with LED
light is sufficient to leave a firm film of primer over the tooth
surface to be bonded. The primer penetrates the surface
removed by acid etching to polymerise and form
micromechanical bonds with the enamel base. In general, the
primer is air dried for 15 s at some distance followed by light
curing (10 s).
7. Adhesive application and bracket positioning (Fig. 39.5F):
Involves application of direct bonding composite on bracket
base, transfer to the tooth surface, its correct orientation and
light curing.
Two types of bonding material are available based on their curing
properties that are self-cure bonding materials and light cure
bonding materials. Light cure bonding agents are preferred
owing to their better bond strength and handling properties.
The light cure bonding composite is a medium flow sticky
composite which is available in a syringe for ease of
dispensing. The assistant keeps the bracket ready in the
bonding tweezers with a sufficient amount of bonding
adhesive uniformly spread over the bonding mesh and
transfers to the orthodontist in the correct direction for the
bracket to the specific tooth under bonding. The orthodontist
should precisely place the bracket and should adjust the height
and mesiodistal placement. Each bracket is likewise
transferred. Following a final evaluation and adjustments, if
any, the brackets are light cured.
8. Curing of adhesive: Initially, the curing light is used 1–2 s per
tooth in a rapid sequence to partially set the bonding material.
This step facilitates some gain of strength by the bonding
material that does not allow drift of the bracket during the
removal of the excess. After removal of the excess, the bonding
agent is cured for the complete polymerisation, 20 s per tooth
or as recommended by the manufacturer. While curing the
metal brackets, the light gun is directed from edges of the
bracket base and lingual sides of the teeth. For plastic and
ceramic brackets, it is directed on to the brackets.
Transillumination with a mirror attached to the light gun may
also be used to cure the adhesive.
9. Removal of excess bonding material: Removal of excess
material is done with a curved scaler. Some clinicians
recommend removal of the excess resin with an oval (No. 7006,
No. 2) or tapered (No. 1172) tungsten carbide (TC) bur only
after the complete setting of the bracket. An excess bonding
material around the margins of bracket base must be removed
for the following reasons:
a. minimise gingival irritation,
b. reduce plaque build-up around the periphery of
bonding base,
c. minimise decalcification
d. excess composite around bracket bases becomes
discoloured in the oral environment and is
unaesthetic. Brackets free of excess composite
appear neater and cleaner.
10. Review of bonded attachments and wire ligation: At this
stage of completion of bonding of the required teeth, all
brackets and attachments are carefully reviewed for their
correct position and any interference from cusps of opposite
arch. It is pertinent that direct impingements should be
avoided by raising the bite in the molar premolar region with
the application of glass Ionomer blobs. With most bonding
agents available in the market, sufficient bond strength is
achieved in 7–10 min and brackets are ready to receive the
archwire.
Direct bonding on enamel variant surfaces

Bonding on teeth with fluorosis
Teeth with high fluoride content are considered more resistant to an
acid etching and typically show a type 5 etching pattern with
indistinguishable prism outlines. Studies show that even with
extended etching times, moderate to severe fluorosis of teeth show
only 40% of the average bond strength. In cases of severe fluorosis of
teeth, the option of banding the teeth is a better choice.
Nonvital teeth
The enamel of nonvital and root canal treated teeth is rendered brittle,
hence the bond strength may be affected. Standard bonding steps are
used, however, extreme care is required during debond to avoid
enamel fracture.
Impacted teeth
Inability to achieve complete moisture control on surgical exposure of
the impacted tooth makes the bonding difficult. MIP was developed
for bonding in such difficult situations where achieving total moisture
control is not possible. MIP is a hydrophilic primer which can
polymerise in the presence of moisture. It is crucial that the MIP layer
be placed on noncontaminated etched enamel. MIP has shown an
acceptable bond strength of about 14–15 MPa on bonding to
contaminated surfaces which were comparable to Transbond XT
bonding to non-contaminated surfaces.21,22 Although the bond
strength of Transbond XT is reduced from 26.9 MPa (non-
contaminated surface) to 14.2 MPa (contaminated) surface, the latter
still showed clinically acceptable values. If the contamination occurs
after primer application, then a clinically acceptable value of about
19.6 MPa was achieved. For hydrophilic primers, bond strengths were
significantly better (23.7 MPa) only when reprimed after
contamination. Hence, although the MIP do offer better bond
strengths yet more important is the technique and repriming, if
necessary.
The author (OPK) in his experience has not encountered failures of
bonding with conventional material with the following
considerations. The selection of an attachment should be as small and
well-contoured to the anatomy of a similar erupted tooth. The
moisture control is achieved by controlling the seepage of blood by
packing tiny pieces of gauge soaked in local anaesthesia with
adrenaline into the space around tooth and bone with a push scaler.
After an etchant is applied, a gentle wash is done with water spray,
which is sucked, without injuring the tissues around. Another
assistant maintains a continuous flow of gentle air over the tooth until
the bonding is complete. The bondable attachment is preligated with a
closed coil NiTi spring. Such a provision eliminates undue
manipulation of the attachment to connect it with traction assembly
and thereby reducing the chances of bond failure.
Bonding on unconventional tooth surfaces

With an increase in adult patients seeking orthodontic treatment, it
has become imperative to innovate and modify bonding techniques to
their needs. It is not uncommon to find patients having metal crowns
or full porcelain or partial veneers on their teeth. At times banding
may be technically impossible on the abutment teeth of fixed bridges.
Amalgam fillings are also encountered particularly on the buccal
surfaces of the molars. To bond, the brackets and tubes on these
unconventional surfaces are quite a challenge.
Bonding to amalgam and Co–Cr/Ni–Cr
alloys
1. If amalgam restorations are present in a limited area, enamel
around the restoration can be conditioned with 37%
orthophosphoric acid following a bout of sandblasting. If there
is a large amalgam restoration, sandblasting with 50 µm
aluminium oxide powder for 3 s and a 30-s waiting period is
recommended.1,23,24
2. Use intermediate resins that improve bond strengths like All
Bond 2 (Bisco), Enhance or Superbond C and B.
3. Use of newer adhesives that bond chemically to precious and
non-precious metals like 4-methacryloyloxyethyl trimellitate
anhydride (4-META) and 10-methacryloyloxydecyl
dihydrogen phosphate (10-MDP), bisphenol A-glycidyl
methacrylate (BIS-GMA) resins. These agents act as a coupling
agent that promotes adhesion to composite resins, enamel,
ceramic powders,5 and dental alloys by their postulated ability
to chemically bond to the oxidised surface of non-precious
metals.
Panavia EX which is a filled BIS-GMA resin has been found to bond

firmly to polished amalgam surfaces which may be due to a chemical
bond. The surface characteristics of the amalgam appear to be more
influential on the strength of the bond than does the nature of the
resin. Bond strengths were found to be within the range of 3.4–6.4
MPa in comparison with 13.2 MPa for etched human enamel.
Chemical preparation of glazed ceramic may be done with 9.6%
hydrofluoric acid (HFA) or acidulated phosphate fluoride and then
treated with silane coupling agent to increase the bond strength.1
Zachrisson23 recommends the following techniques for bonding to
porcelain surfaces:
1. Isolation is very critical in this technique not just to prevent

contamination with saliva and water but also to prevent soft
tissues contact with HFA.
2. Barrier gel such as Kool-Dam prevents flowing of etchant onto
the gingival tissue.
3. Deglaze the area slightly larger than bracket base by
sandblasting with 50 µm aluminium oxide for 3 s.
4. Etch porcelain with 9.6% HFA for 2 min.
5. Carefully remove gel with cotton roll and then rinse using high
volume suction.
6. Dry with air, apply silane coupling agent and bond bracket
conventionally.
Indirect bonding was introduced primarily to aid visualisation of the
bracket in all three dimensions on study models for precise bracket
placement. The studies have proved that the location of brackets with
respect to the vertical and horizontal position on the tooth as well as
its angulation is more accurate with indirect bonding than direct
bonding. Other advantages of indirect bonding are ease of bracket
placement with a reduction in chair-side time, minimal compensatory
bend requirement and comfort for the patient as well as the clinician.
The only drawback is that it is more technique sensitive and requires a
laboratory set-up with a trained technician.
Armamentarium required for indirect bonding

Indirect bonding requires the following armamentarium:
1. Bonding adhesives:
a. Two-component mix systems (ENDUR, Concise)
b. No mix activator-paste systems (SYSTEM 1)
c. No mix two-liquid system (Sondhi’s Rapid Set
Indirect Adhesive, 3M Unitek): This adhesive was
specifically designed for indirect bonding with
features like increased viscosity by using
approximately 5% silica filler particles and an early
set time of 30 s so that the complete tray setting
does not take more than 2 min. Either Adhesive pre-
coated (APC, 3M Unitek) brackets are used, or
Transbond XT can be bonded to individual brackets
for the custom base.
2. Bonding system can be either a light cure or self-cure system.
3. Transfer tray types are as follows:
a. Addition silicone
b. Vacuum-formed
Steps in an indirect bonding technique
1. Clinical stage step I
2. Laboratory stage
3. Clinical stage step II
A popular technique of Sondhi’s rapid set indirect adhesive is

described here.24
Clinical stage step I

The patient undergoes a dental health review and oral prophylaxis.
Accurate maxillary and mandibular impressions are taken in
alginate and poured with type IV stone for the preparation of working
casts.3 The study models are carefully trimmed, and any bubbles or
voids are taken care before laboratory set-up.
Laboratory stage
1. Markings: Horizontal and vertical markings required for

accurate bracket positioning are done on upper and lower
teeth based on the malocclusion and tooth shape (Fig. 39.6A–
E).
2. Separating media: Models are coated with a thin layer of
separating medium with a brush, preferably Al-Cote (Dentsply
International, Inc., York, PA), after which they are allowed to
dry for approximately an hour.
3. The positioning of brackets: Brackets need to be positioned on
upper and lower teeth on the cast. In the case of APC
(3M/Unitek) adhesive-coated brackets, they are removed from
sealed blister packs and placed on teeth at the predetermined
markings or with the help of a bracket gauge and the excess
adhesive is removed. In a case of non-coated brackets,
Transbond XT Light Cure Adhesive or a similar bonding agent
is applied to the bracket base mesh, and then the bracket is
carefully adapted to the tooth surface. Until the time all
brackets are placed, and their positions reaffirmed, the casts
should be placed in a black box to avoid exposure to light.
4. Curing of adhesive: The casts are then placed for curing in the
TRIAD (TRIAD 2000, Dentsply International, Inc.) curing unit
for 10 min to allow comprehensive curing of all areas, even the
areas where access to light is limited. Another option is to use
a LED curing unit.
5. Making of indirect bonding tray: Before construction of
bonding tray, the hooks and other components that serve as
undercuts should be preferably blocked with either wax or
Mor-Tight (TP Orthodontics, La Porte, IN). Trimming of these
areas otherwise is problematic in the bonding tray.
The tray is made of 1 mm thick Bioplast sheet overlayered with a
1-mm thick Biocryl sheet that is vacuum formed in a pressure-
moulding unit. The softer inner tray warrants perfect seating
on the brackets while the hard outer shell provides strength.
The hard part of the tray is trimmed away up to contour of
gingival heights for greater adaptability and comfort (Fig.
39.6F–G).
The model along with the tray is socked in clean water to desolve
the separating media. Alternatively, bonding tray can also be
made with addition silicone by mixing putty with an activating
agent. Subsequently, this material is placed in the shape of a
small button on individual brackets followed by residual
material rolled in the shape of a cylinder and placed on the
teeth, covering the occlusal and lingual surfaces completely.
6. Removal of bonding tray: The tray is removed with finger
pressure or teasing with the help of a scaler. It is again cured
for a minute in the TRIAD unit to permit curing of the residual
resin.
7. Cleaning of tray: To remove any separating media and debris,
the trays should be placed in an ultrasonic cleaner, cleaned
initially with a dishwashing detergent (e.g. Dawn, Proctor and
Gamble) for 5 min, followed by water for additional 5 min. The
final step is rinsing the tray and drying to make it free from
any residue or moisture. It is advisable to sandblast the
adhesive bases with a micro-etching unit and a fine aluminium
oxide particle (50 µm). In the case of impurities on the
adhesive custom bases, an acetone is applied to clean the
adhesive base and air-dried.
FIGURE 39.6 (A) Long axes of teeth marked in black pencil. (B) First
molar slot height determined in black pencil using a bracket placement
marker gauge. Measurement of distance between two horizontal lines
on the first molar with a drawing compass. After joining the marked
points, premolars and molars slot heights are determined. (C) Plan
vertical position of incisor and canine brackets and transfer to the cast
using a bracket placement marker gauge. (D) Final aspect of bracket
bonding guide in A. frontal and B. lateral views. (E) Bracket bonding
with light-curing adhesive over drawn guide lines, respecting slot height
and the long axis of each tooth. (F) Trim excess 1 mm-ethylene-vinyl
acetate (EVA)-soft tray. (G) Trim Crystal and soft trays with a
carborundum disk, 2–3 mm above the cervical margin, on both
buccal/labial and palatal surfaces. (H) Vertical slits cut on soft tray with
sharp-point scissors above mesial and distal bracket wings. (I) Acid-
etching teeth surfaces after prophylaxis and applying adhesive.
Application of a single layer of adhesive to the base of each bracket. (J)
Fit the transfer tray to teeth without exerting too much pressure. Once
confirmed the correct position through the clear tray, light-cure the
adhesive. (K) Remove the Crystal tray, pushing it in the occlusal
direction. (L) Remove the soft tray. Use Mathieu pliers to pull off areas
above the slits, liberating retention. Follow by completely removing the
tray. (M) End of the indirect bonding procedure. Source: reproduced
with permission from: Nojima LI, Araújo AS, Alves Júnior M. Indirect
orthodontic bonding-a modified technique for improved efficiency and
precision. Dental Press Journal of Orthodontics. 2015 Jun;20(3):109–
17.
Clinical stage step II (Fig. 39.6I–M)
1. Patient preparation: Patient is appropriately seated on the chair

with patient’s apron. The patient is shown the bonding trays
and explained the procedure of bonding to allay his fear and
get full cooperation during bonding.
2. Examination of tray: The method of indirect bonding may be
accomplished with a single tray for full arch or may have to be
sectioned into anterior or posterior segments. The trays are
carefully examined for remnants of separating medium or tray
fragments sticking to the adhesive on a bracket base.
3. Bonding technique:
a. Moisture contamination of teeth may be prevented
by cotton rolls, cheek retractors, Tongue Away (TP
Orthodontics) and Dri-Angles. NOLA dry-field
system is an excellent choice, all-in-one system for
orthodontic purposes.
b. Drying of teeth by an air syringe is followed by
dabbing (not rubbing) the etchant onto the tooth
surface for 30 s. Etchant has to be limited to the
required tooth surface and should not contact skin
or gingiva or flow into interproximal areas. This is
followed by rinsing with water spray for 15 s.
Extreme caution should be taken against saliva
contamination.
c. In case, transbond MIP is applied on a tooth surface,
air drying for 3–5 s is recommended. No light
curing is required.
d. If bonding is done with Sondhi indirect bonding
resin, then the teeth should be wholly desiccated
and enamel should give a frosty appearance. If
frosty appearance is absent, re-etching should be
done.
e. This resin comprises of two liquids, Resin A and
Resin B, that separately poured in two wells. Resin
A is meant to be applied on the tooth surface with a
brush and Resin B on the bracket base.
4. Positioning the indirect bonding tray on teeth. While placing
the tray on the teeth of one arch, equal pressure needs to be
applied to the buccal, labial and occlusal surfaces for 30 s
approximately and an overall curing time of 2 min prior to
tray removal. This may then be repeated for opposing arch.
5. Tray removal: Scaler is required to remove the tray from
lingual to buccal. Caution is to be taken while removing tray
around wings of brackets. Excess resin is scaled from
interproximal contacts to keep the proximal dental contact
open that can be checked by dental floss.
The stresses of removal can be reduced by making cuts in the tray at

various locations. An in-vitro study compared the bracket transfer
accuracy of five kinds of transfer trays (Fig. 39.6F). Of the double
polyvinyl siloxane, double vacuum-form, polyvinyl siloxane vacuum-
form, polyvinyl siloxane putty and single vacuum-form trays used in
the study; silicone-based trays performed better concerning accurate
bracket transfer while vacuum-formed trays showed less consistent
results (Fig. 39.6G–M).43
The adhesive resins in combination with stainless steel wires have also
been used for orthodontic retention purposes, since the mid-1970s.25,26
The main drawback with fixed retainers includes bond failures that
have been predicted to be 6%–25%.27 The progress towards modern-
bonded retainers is as follows:
1. Knierim in 1973 was first to report the construction of bonded

fixed retainers.28
2. Use of 0.015–0.0195 in. stainless steel 3-stranded thin wires was
suggested by Zachrisson.29,30
3. Use of 0.0215 in 5-stranded stainless steel wire was proposed
by Dahl and Zachrisson which decreased wire-fatigue
fractures and loosening of the wire.31
4. Use of fibre reinforced composites for both passive and active
retainers preferences was suggested in 2004.32
5. Use of round orthodontic wires as retainers has also been
proposed.33
6. Use of 0.0215 in. diameter 5-stranded Penta in either stainless
steel (Masel Orthodontics, Carlsbad, CA) or gold-coated
version (Gold’n Braces, Palm Harbor, FL), again is suggested
by Zachrisson in 2007.34
Advantages of lingual-bonded retainers

1. Lingual bonded retainers are invisible hence aesthetically
acceptable.
2. Patient comfort and compliance
3. Recommended in patients with compromised periodontal
support.
4. Effectiveness and reliability in the long term and permanent
retention.
Basic designs of lingual retainers

1. Canine-to-canine mandibular retainers are rigid and effective
in maintenance of inter-canine width but ineffective in
inhibition of tooth rotations (Fig. 39.7B).
2. In extraction cases the lower lingual retainer is bonded on each
tooth from mesial occusal pit of the second premolar from one
side to another.
In the maxillary arch the palatal fixed bonded retainer can be
used in segments like four incisors or two central incisors.
3. Flexible spiral wire (FSW) retainers bonded individually on the
lingual surface of teeth provide excellent retention device and
permit physiological mobility of teeth (Fig. 39.7A).
FIGURE 39.7 (A) Spiral wire retainers bonded individually on the

lingual surface of teeth. (B) Canine to canine rigid bonded mandibular
retainer.
Techniques for bonding of FSW are as follows:
1. Retainer construction and adaptation

Take the maxillary or mandibular cast and bend the
multistranded wire (0.0175 in. coaxial wire) in a gentle curve on
the lingual aspect of teeth and cut the desired extent of a
retainer (2-2 or 3-3).
2. Preparation for bonding
a. Isolation of arch with lip retractors, cotton rolls and
salivary ejectors is done.
b. Pumicing of lingual surfaces of teeth is done
followed by copious rinsing and drying.
3. The stabilisation of wire prior to bonding lingual retainer.
Some of the alternatives for stabilisation are given here:
a. Band separators are inserted through alternate
interdental contact points’ contact that is between
central and between lateral incisors and canines.
Retainer wire is adapted on the lingual surface
above the cingulum region and stabilised between
the tooth surface and separator.35
b. Modified Kesling’s separators for stabilising lingual
retainer wire.36 For wire stabilisation, Kesling’s
separator made of 0.014 in. AJW Special plus wire
was modified to include a perpendicular bend in
lower arm to form a ‘U’ to hold the wire with
pressure. Interdental space opening may be
prevented by a figure of eight ligature tie on labial
surface.
c. A labial wire assembly is prepared with hard round
stainless-steel wire (0.8–0.9 mm) incorporating
helices at the ends distal to canine and either
ligature wire (0.010 in.) attached at one end. The
lingual retainer is ligated to the tooth surface with
the help of this assembly.
d. The retainer wire is held in place by short ligatures
extending interdentally from occlusal contact point
and below gingival contact point of each tooth to tie
over the labial archwire.
e. Red elastics can be extended from lingual to the
labial surface of teeth beneath the brackets, and the
retainer wire can be fixed to the lingual surface with
the help of these red elastics.37
f. The impression of the lower arch segment with
brackets and archwire in place is made and a cast is
prepared. The lingual flexible wire retainer is
prepared in the lab with 0.0175 SS multistrand wire.
g. The lingual retainer is bonded prior to debond
process. The brackets/archwire serve as a holding
device for precise positioning of the retainer
assisted with dental floss.
4. Bonding of retainer
a. Acid etching of the tooth surface, rinsing and
drying to obtain a frosty appearance.
b. Priming the lingual surface with resin and light
cure.
c. Light cured flowable composite is preferred for
bonding onto the middle surface of the tooth and
wire. Light curing of each tooth is done for 20 s.
d. Transfer the retainer gently into the tiny blobs of
the composite. The composite should flow under
and all around the wire at the designated contact
site of the wire on each tooth’s lingual surface. The
curing is completed thereafter.
5. Finishing and polishing of retainers: Removal of excess
adhesive material is usually not required except at the occlusal
pits of the second premolars. Any remnant adhesive tags may
be gently removed with a round TC/or finishing bur.
Fixed lingual retainer using DuraLay
resin transfer
DuraLay Resin (Reliance Dental Manufacturing, USA) has been used
for the fabrication of a jig for accurate transfer of retainer wire
adapted on the cast to the patient’s mouth.38 A working cast of the
patient’s arch is made in the appointment before debonding. The
desired length of multistranded wire is bent to precisely adapt to the
lingual surface of teeth on the cast. A separating medium (DuraLay
separating medium) is applied to the cast and adapted wire is placed
in the cast. DuraLay resin is mixed and poured on the interdental area
between the second premolar and first molar (in the case of 3-3
retainer) on both the sides. After setting, the wire is transferred to the
patient’s mouth using the resin guide where it is fixed with utility
wax. Bonding of teeth is done at each tooth with a preferable order
from centre towards the terminal ends.
Predisposing factors of failure of fixed lingual retainers are as follows:
1. Technique sensitivity—moisture and saliva contamination

causing bond failures, difficulty in the adaptation of the wire,38
occlusal prematurities, the experience of practitioners in
handling the procedure are critical to the success of the
bonding.39
2. The material of wire—adequate flexibility of wire governed by
quality and diameter of the retainer wire, properties of
bonding material the manner in which deficiencies are
handled in terms of wetness or dryness of the bonding field
and occlusal trauma to the wire contribute to the longterm
success.39
3. Patient-related factors—excessive salivation, patient
compliance, eating patterns, structural differences in the
enamel such as fluorosis.40 Failure rates or detachments are
highest in first 6 months of bonding while fractures of wire
peaked after approximately a year of bonding.
Two basic types of curing systems are: (1) self-cure, (2) light-cure.
For self-cure bonding agents such as Unite (3M Unitek, Monrovia,
CA) and Rely-O-Bond (Reliance Orthodontics, Itasca, IL), it is critical
to be quick and swift to ensure correct bracket placement without
significant alterations. After placing the bracket on the tooth, the
operator has about 5–10 s for ensuring precise bracket orientation.
When the operator is satisfied with the position and orientation of the
bracket, then he must gently yet firmly press the bracket against the
tooth surface within this working time. This step is critical to ensure a
uniform flow of the intermediary resin into mesh and enamel micro-
pores and ensures a thin yet uniform layer in the entire bonding area.
The brackets can be ligated after 7–10 min.
Curing lights for light cure bonding composites, it is imperative
that the light source be compatible with the bonding adhesive.
Various light sources available for curing the resin in orthodontic
bonding are compiled in Table 39.2.
1. Light emitting diode (LED) (Fig. 39.8): LED for the

polymerisation of dental adhesive are efficient systems, and
their use is prevalent in restorative dentistry as well as
orthodontics. The main advantages lie in 95% use of the light
produced towards polymerisation and much less heat
compared to halogen light source. LED light source uses
minimal electricity and has 10,000 h of bulb life.14
Compatibility of the light source should be checked with the
materials to be cured. LED lamps are compatible with dental
materials comprising of camphorquinone.41
2. Halogen light: Since 1970, Quartz tungsten halogen light
(QTH) has been chosen for curing by integrating a blue filter
for encompassing light in the wavelength of 400–500 nm. The
LED curing lights have replaced halogen light in clinical
practice.
Recommended time for composite resin curing is 20 s and for
light-cured resin-modified glass ionomer cement (RM-GIC) is
40 s. However, there is a significant amount of energy
dissipated as heat with only 1% of the energy being translated
into light. Other disadvantages of halogen light include a short
span of light source (approximately 100 h) bulb life and
diminished curing efficacy due to lamp or filter or reflector
degradation. Besides, its long-term use may cause drying of
retina, cataract, decrease in elasticity and affect the quality of
the eye lens.1,41
3. Plasma arc light: Plasma arc light emits continuous frequencies
in the wavelength of 380–490 nm, and hence, the requirement
of filters is less than halogen light. The irradiation time of 1–3 s
is recommended for composite resins while 3–5 s for curing
individual metal bracket and even lesser time for a ceramic
bracket. Although the time taken for curing taken is less than a
halogen light, chances of pulpal temperature increase are three
times that by halogen light source.1
4. Argon laser: This laser is monochromatic and emits
wavelengths in the range of 457.9–514.5 nm that is compatible
with the wavelength of photoinitiator camphorquinone. The
bond strength achieved with LASER curing light is similar to
LED.
Table 39.2
Curing lights used for curing orthodontic attachments
FIGURE 39.8 Cord free LED unit.
Bond failures: It refers to the removal or loosening of the bracket

from the tooth surface. Two main sites or types of bond failure occur
between brackets and tooth surface which are as follows:
1. Adhesive–enamel bond failure: Whereby mostly adhesive is

left on bracket and less on the tooth surface.
The contamination of etched surface with saliva is the single most
significant reason of enamel–adhesive bond failure. Other
causes of such type of bond failure include inadequate rinsing
or drying after etching, over-etching and use of expired
bonding materials.
2. Adhesive–bracket bond failure: Whereby adhesive is left on a
tooth.
It occurs due to displacement of the bracket while initial set,
contaminated bracket mesh, insufficient bonding material,
incomplete curing of material or undue forces on the bracket
from occlusion.
Adhesive remnant index

The amount of adhesive remaining on the tooth surface after
debonding is measured by adhesive remnant index (ARI) given by
Artun and Bergland.42 It is developed as a scoring system:
• Score 0—no adhesive left on the tooth surface

• Score 1—less than half of adhesive left on the tooth surface
• Score 2—greater thanhalf of adhesive left on the tooth surface
• Score 3—all adhesive left on tooth surface with a bracket mesh
impression
Bond failure rates can be minimised by using the prescribed

protocol of bonding. The procedure of bonding is highly technique
sensitive.
Key Points
Successful bonding is an art, which needs to be mastered in the
background of understanding the fundamentals of bonding and
material properties. A tremendous improvement in the science of
bonding has been witnessed with the development of newer bonding
adhesives, self-etching and moisture insensitive primers, indirect
bonding resins, light curing units as well as techniques in bonding.
Although we have come a long way from fully traditional banding
set-up, present bonding systems require less chair side time, are more
precise, have a better bond strength and can be applied to a variety of
clinical situations, the search for the ideal bonding material is still on.
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24555689.
SECTION IX
Contemporary orthodontic
treatment
Chapter 40: The biological basis for orthodontic tooth movement

Chapter 41: Principles of biomechanics and appliance design
Chapter 42: Preservation of normal occlusion and interception
of malocclusion during early mixed dentition
appliance Phase I: laying the foundation
Chapter 44: Anchorage in orthodontic practice
Chapter 45: Tweed philosophy, biomechanics and principles of
treatment
appliance. Phase II: major tooth movements
Chapter 47: The pre-adjusted edgewise appliance
Chapter 48: Orthodontic treatment with self-ligating bracket
systems
CHAPTER 40
The biological basis for
orthodontic tooth movement
Vinod Krishnan
CHAPTER OUTLINE
Introduction
Theories of OTM
The pressure–tension hypothesis
Bone bending theory
Fluid–dynamic theory
Second messenger concept in orthodontics
Mechanosensing, transduction and response
Alveolar bone response to orthodontic force
Cellular behaviour at sites of PDL tension and compression
Blood vessel reorganisation and neovascularisation
Does inflammatory responses follow orthodontic force
application?
OTM–inflammation or mechanotransduction?
Iatrogenic effects of orthodontic mechanics
Pain with orthodontic mechanotherapeutics
External apical RR with orthodontics
Key Points
Introduction
Orthodontic tooth movement (OTM), the complex biomechanical
process is initiated with mechanical force application. Soon after force
application, it evokes a plethora of reactions in paradental tissues at
both cellular and molecular level.
Basic research, on the cellular and molecular levels have revealed
meaningful information about the mechanism of
mechanotransduction, and about the signalling systems controlling
the interactions between cells during periods of tissue remodelling.
These microscopic events lead to major tissue changes, such as
alveolar bone remodelling, periodontal fibre reorganisation, neo-
angiogenesis and excitation and release of neurotransmitters to effect
the tooth movement process. The generation and propagation of
signalling cascades and associated tissue remodelling in response to
applied mechanical load, form the central theme of OTM. Orthodontic
forces affect the extracellular matrix (ECM) and the cells of the dental
pulp, periodontal ligament (PDL), alveolar bone and gingiva. These
effects are both physical and biochemical in nature, and are frequently
intertwined and interdependent.1
This chapter discusses the cellular, molecular and tissue level
reactions to the applied mechanical forces and provides the reader
with basic knowledge about histological as well as chemical changes
incident to OTM. It also explains various tissue reactions, PDL,
alveolar bone, blood vessels, neural elements in response to
orthodontic force application along with a brief overview regarding
biological background of various deleterious effects of orthodontic
forces.
Orthodontic force is defined as ’force applied to teeth for the purpose
of effecting tooth movement, generally having a magnitude lower
than an orthopaedic force’, whereas orthopaedic force is defined as a
’force of higher magnitude in relation to an orthodontic force, when
delivered via teeth for 12–16 h/day, is supposed to produce a skeletal
effect on the maxillofacial complex’. Orthodontic mechanotherapy is
mainly aimed at fostering tooth movement by inducing remodelling
and adaptive changes in paradental tissues. To effect this outcome,
only small amounts of force, ranging from 20 to 150 g per tooth, may
be required. But craniofacial orthopaedics is aimed at delivering
higher magnitudes of mechanical forces, more than 300 g, in attempt
to modify the form of craniofacial bones.
The hypothesis claiming the existence of an optimal orthodontic force
was proposed by Storey and Smith in 19522, while comparing tipping
movement of canines with bodily movement of pre-molars and
molars. The proposal suggested the existence of an ideal force
magnitude, which elicits maximal biologic response, and results in a
maximal rate of OTM. Burstone3 defined optimal force as the one
capable of generating maximal cellular response from the tooth
supporting tissues, including apposition and resorption of alveolar
bone, while maintaining the vitality of these tissues. Traditionally,
orthodontic forces have been categorised as ’light’ or ’heavy’, and it
was assumed that light forces are gentler, and therefore more
physiological than heavy forces.4 It is impossible, with the available
instrumentation, to measure with precision the amount of force
applied to roots or parts thereof, under any mode of treatment. Hence,
with this limitation in mind, it is stated that to engender adequate
biological response in the periodontium, light forces are preferable,
due to their ability to evoke frontal resorption of bone. Unlike these
light forces, heavy forces often cause necrosis (hyalinisation) of the
PDL and undermining bone resorption3 and have been implicated in
root resorption (RR). According to the current concept, optimal force
may differ for each tooth and for each individual patient. Clinically,
the relationship between orthodontic force magnitude and rate of
tooth movement during active treatment is now being considered to
be a practical tool in identifying optimal forces on an individual basis.
Theories of OTM
The biological foundation of force induced tooth movement has been
extensively investigated.
The pressure–tension hypothesis

The study of tooth movement through histological analysis by
Sandstedt5, Oppenheim6 and Schwarz7 led them to hypothesise, that a
tooth moves within the periodontal space by generating a ‘pressure
side’ and a ‘tension side’. The hypothesis explained that on the
pressure side, the PDL displays disorganisation and diminution of
fibre production. Here, cell replication decreases seemingly due to
vascular constriction. On the tension side, stimulation produced by
stretching of PDL fibre bundles results in an increase in cell
replication followed by proliferative activity leading to an increase in
fibre production (Figs 40.1 and 40.2). Schwarz detailed the concept
further, by correlating the tissue response to the magnitude of the
applied force with the capillary bed blood pressure.7 He concluded
that, the forces that are delivered as a part of orthodontic treatment
should not exceed the capillary bed blood pressure (i.e. 20–25 g/cm2 of
root surface). If one exceeds this pressure, compression could cause
tissue necrosis through ’suffocation of the strangulated periodontium’.
Application of even greater force levels will result in physical contact
between teeth and bone, yielding resorption in areas of pressure and
undermining resorption or hyalinisation in adjacent marrow spaces.
FIGURE 40.1 Illustrating pressure–tension hypothesis.
Application of orthodontic force results in pressure on certain areas of
the periodontal ligament while tension on the others. Bone under
pressure shows resorption while on the tension side, deposition takes
place.
FIGURE 40.2 (A) Sagittal section, 6 μm thick, of maxillary canine of 1-

year-old female cat, after 14 days of distal tipping with 80 g force. B,
alveolar bone; P, canine PDL; R, canine root. Shown here is distal side
of canine, where PDL had been compressed. Compressed PDL
contains necrotic (hyalinised) zone, which is being removed by cells
from surrounding viable PDL; adjacent alveolar bone, which is
undergoing undermining and indirect resorption. Haematoxylin and
eosin staining; ×320. (B) Sagittal section, 6 μm thick, of maxillary
canine of 1-year-old female cat, after 14 days of distal tipping with 80 g
force. B, alveolar bone; P, canine PDL; R, canine root. Shown here is
mesial side of canine, where PDL had been stretched. New bony
trabeculae are seen extending into widened PDL space in the direction
of applied force. Haematoxylin and eosin staining; ×320. Source:
Reproduced with permission from Krishnan V, Davidovitch Z. Cellular,
molecular, and tissue-level reactions to orthodontic force. Am J Orthod
Dentofacial Orthop 2006;129(4) 469.e1–32.
Histological evaluation of PDL following orthodontic force

application showed changes in cell population and increases in
cellular activity. There is an apparent disruption of collagen fibres in
the PDL, with evidence of cell and tissue damage. The first sign of
hyalinisation is the presence of pyknotic nuclei in cells, followed by
appearance of areas of acellularity or cell free zones (Fig. 40.3). The
resolution of the problem starts when cellular elements like
macrophages, foreign body giant cells and osteoclasts from adjacent
undamaged areas invade the necrotic tissue. These cells also resorb
the underside of bone immediately adjacent to the necrotic PDL area
and remove it together with the necrotic tissue. This process is known
as undermining resorption.7,8 Reitan,9 in his classic papers on
histological changes following orthodontic force application, reported
that hyalinisation refers to cell free areas within the PDL, in which the
normal tissue architecture and staining characteristics of collagen in
the processed histologic material have been lost.
FIGURE 40.3 Neighbouring sections from the compressed area

of the mesiolingual root of a rat maxillary first molar after tooth
movement for 7 days.
The hyalinised zone (H) between the alveolar bone (B) and root (T)
reveals a fibrillar structure. Resorption of alveolar bone occurs from the
marrow spaces (arrows). Note the resorption lacuna in the dentine at
the periphery of the hyalinised zone (arrowhead). (A) Haematoxylin and
eosin stained sections. (B) Tartrate resistant acid phosphatase (TRAP)
stain highlighting TRAP-positive cells in the adjacent marrow spaces
and at the margin of hyalinised tissue. (C) Compressed area after 10
days. Hyalinised tissue almost removed with resorption lacunae on
both the bone and dentine surfaces. The multi-nucleate cells within the
necrotic tissue (arrows) and lining the surface of the dentine
(arrowheads) were shown in adjacent sections to be TRAP positive.
Haematoxylin and eosin stain. Bars measure 50 μm. Source: Reprinted
with permission from Oxford University Press. Brudvik P, Rygh P.
Multinucleated cell remove the main hyalinised tissue and start
resorption of adjacent root surfaces. Eur J Orthod 1994;16(4):265–73.
The ongoing discussion suggests that inflammation may be at least

partly responsible for cellular recruitment and tissue remodelling in
areas of force application. This process may in turn lead to activation
of frontal resorption (where osteoclasts line up in the margin of the
alveolar bone adjacent to the compressed PDL, producing direct bone
resorption), as well as undermining resorption. The next phase of
bone remodelling consists of loss of bone mass at PDL pressure areas
and apposition at tension areas.10 This succession of events formed the
central theme of the pressure–tension hypothesis.
Bone bending theory

Baumrind, reconsidering the pressure–tension hypothesis, has
pointed out a conceptual flaw in it.11 He considered the PDL to be a
continuous hydrostatic system, and suggested that any force delivered
to it would get transmitted equally to all regions. He recognised that
only part of the periodontium where differential pressures, as
mentioned in pressure–tension hypothesis, can be developed, is solid,
that is, bone, tooth and discrete solid fractures of the PDL.
Consequently, Baumrind proposed an alternative hypothesis in 1969,
known as the bone–bending theory. This hypothesis states that
orthodontic forces routinely produce alveolar bone deflection, and
that these strains are accompanied by resultant changes in the PDL.11
Farrar12 was the clinical investigator who was the first to suggest
that alveolar bone bending plays a pivotal role in OTM. This
hypothesis was later confirmed with the experiments of Baumrind11
in rats and Grimm13 in humans. According to them, the forces applied
will produce bending of the bone, tooth, as well as of solid structures
of the periodontium. Bone was found to be more elastic than the other
two tissues, and to bend far more readily in response to force
application. The active biologic processes that follow bone bending
involve bone turnover, and renewal of cellular and inorganic
fractions. These authors further stated that ’reorganisation proceeds
not only at the lamina dura of the alveolus, but also on the surface of
every trabaculum within the corpus of bone’. The force delivered to
the tooth is dissipated throughout the bone by development of stress
lines, and further force application becomes a stimulus for altered
biological responses of cells, which in turn modifies the shape and
internal organisation of bone. With the help of this theory, and
gaining support from Wolff’s law, these authors could explain the
relative slowness of en-masse tooth movement, the rapidity of tooth
movement towards an extraction site and the relative rapidity of tooth
movement in children. The deposition and resorption of bone in
response to its bending by orthodontic forces is evidently an attractive
hypothesis, but it seemed to contradict the current orthopaedic
dogma14, which states that ’any mechanical compression stimulates
bone formation and tension stimulates resorption’. Epker and Frost15
described the change in shape of the alveolar bone circumference
resulting from stretching of the PDL fibres. This fibre stretching
decreases the radius of the alveolar wall, that is, bending of bone in
the tension zone, where apposition of bone takes place. In areas of
PDL tension, the interfacing bone surface assumes a concave
configuration, in which the molecules are compressed, while in zones
of compressed PDL, the adjacent alveolar bone surface becomes
convex. Hence, there is no contradiction between the response of
alveolar bone and other parts of the skeleton to mechanical loading.
The confusion in this regard has resulted from the usage of the same
descriptions for different tissues.
Zengo et al.16 measured the electric potential in mechanically
stressed dog alveolar bone during in vivo and in vitro experiments
and demonstrated that the concave side of orthodontically treated
bone is electronegative and favours osteoblastic activity, whereas the
areas of positivity or electrical neutrality, that is, convex surfaces,
showed elevated osteoclastic activity (Fig. 40.4). It has been proposed
by Davidovitch et al.17,18, that a physical relationship exists between
mechanical and electrical perturbation of bone. Bending of bone
causes two classes of stress generated electrical effects. Their
experiments with administration of exogenous electrical currents in
conjunction with orthodontic forces demonstrated enhanced cellular
activities in the PDL and alveolar bone, as well as rapid tooth
movement. Taken together, these findings led to the suggestion that
bioelectric responses (piezoelectricity and streaming potentials)
propagated by bone bending incident to orthodontic force application
might be functioning as pivotal cellular first messengers. Borgens19
could observe generation of endogenous ionic currents evoked in
intact and damaged mouse bones, once electric current is applied to
fracture sites and classified these currents as stress generated
potentials or streaming potentials, rather than piezoelectric currents.
In contrast to piezoelectric spikes, the streaming potentials were
having long decay periods. This finding led him to hypothesise that
the mechanically stressed bone cells themselves, not the matrix, are
the source of the electric current. Davidovitch et al.17,18 have
suggested that piezoelectric potentials result from distortion of fixed
structures of the periodontium–collagen, hydroxyapatite or bone cell
surface. But in hydrated tissues, streaming potentials (the electro
kinetic effects that arise when electrical double layer overlying a
charged surface is displaced) predominate as the interstitial fluid
moves. They further reported that mechanical perturbations on the
order of about 1 min/day are apparently sufficient to cause an
osteogenic response, perhaps due to matrix proteoglycan related
strain memory.
FIGURE 40.4 Hypothetical model of the role of stress-induced
bioelectric potentials in regulating alveolar bone remodelling
during orthodontic tooth movement.
The force, F, applied to the labial surface of the lower incisor displaces
the tooth in its socket, deforming the alveolar bone convexly towards
the root at the leading edge, and producing concavity towards the root
at the trailing edge. Concave bone surfaces characterised by
osteoblastic activity are electronegative; convex bone surfaces
characterised by osteoclastic activity are electropositive or electrically
neutral. Source: Reproduced with permission from Zengo AN, Bassett
CA, Pawluk RJ, Prountzos G. In vivo bioelectric potentials in the
dentoalveolar complex. Am J Orthod. 1974;66(2):130–9.16
Fluid–dynamic theory
Bien20 investigated the roles of different morphological components of
PDL to intrusive force. According to them, there are three distinct but
interacting fluid systems that are involved in providing response to
intrusive forces in PDL: (1) the vascular system enclosed within the
blood vessel and lymph vessel walls; (2) the system of the periodontal
membrane comprising of cells and periodontal fibres; and (3) the
interstitial fluid continuum that permeates the spaces between the
cells, fibres, blood vessels, tooth and bone. During the intrusive cycle
there appears to be exhaustion of the extracellular fluids from the
periodontal membrane into the vascular reservoir of the marrow
space through the many minute perforations in the tooth alveolar
wall. The hydrodynamic damping coefficient is time dependent, and
therefore the damping rate would be determined by the size and
number of the perforations. As a momentary effect, the fluid that is
trapped between the tooth and the socket tends to move to the
boundaries of the film at the neck of the tooth and the apex, while
acting to cushion the load and is referred to as ’squeeze film effect’. As
the squeeze film became depleted and as the pressure continued, the
second damping effect occurs after exhaustion of the extracellular
fluid, the ordinarily slacked fibres tighten. It is suggested that as the
tooth is intruded, the randomly oriented periodontal fibres, which
crisscross the blood vessels, tighten, then compress and constrict the
vessels that run between them, causing stenosis of the blood vessels.
This causes the vessels to balloon creating a backpressure. Thus high
hydrodynamic pressure heads can be created suddenly in the vessels
above the stenosis. At the stenosis, a drop of pressure would occur in
the vessel in accordance with Bernoulli’s principle that the pressure in
the region of the constriction will be less than elsewhere in the system
(Fig. 40.5).
FIGURE 40.5 The constriction of a blood vessel by the
periodontal fibres.
The flow of blood in the vessels is occluded by the entwining
periodontal fibres. Below the stenosis, the pressure drop gives rise to
the formation of minute gas bubbles, which can diffuse through the
vessel. Source: Bien SM. The pressure gradient in the periodontal
vasculature. Trans N Y Acad Sci. 1966 Feb;28(4):496–506.
Second messenger concept in orthodontics

Sutherland and Rall21 established the second messenger basis for
hormone actions in 1958. The ’second messenger hypothesis’
postulates that target cells respond to external stimuli, chemical or
physical, by enzymatic transformation of certain membrane-bound
and cytoplasmic molecules derivatives, capable of promoting the
phosphorylation of cascades of intracellular enzymes. Therefore,
temporal increases in the tissue or cellular concentrations of second
messengers are generally viewed as evidence that an applied
extracellular ’first messenger’, such as an orthodontic force, has
stimulated target cells. Jones et al.22 detailed events that occur in bone
cells during the early moments following the application of
mechanical stress. That report is based on the assumption that stress
in any form—compressive, tensile or shear, will evoke a diverse set of
reactions within the cell, leading to the development of strain. In
osteoblasts, the first measured response to physiologic levels of stress
is an increase in intracellular free calcium, and an increase in
membrane potential through activation of K+ channels. This increase
in calcium concentration is related to the activation of phospholipase
C, which releases inositol triphosphate within 10 s. Elevated levels of
phospholipase C maintain the high calcium concentration throughout
the period of stress application, by keeping the mechanosensitive ion
channels open and by further activation of protein kinase C through
diacylglycerol after 3–4 min of force application. Phospholipase A is
activated, which acts on stores of arachidonic acid, leading to
detection of prostaglandins in the culture medium after about 10 min.
This event is followed by release of products of the lipoxygenase
pathway (leukotrienes and hydroxyeicosatetraenoic acids (HETEs)),
followed by an elevation in the concentration of cAMP. The
phosphorylation reactions mediated by this cyclic nucleotide in the
nucleus as well as in the cytoplasm lead to cellular synthetic and
secretory activities. The detailed view of biomechanical theory
describing cellular responses to tooth moving forces as well as the role
of second messenger system is depicted in Flowchart 40.1.
FLOWCHART 40.1 The biomechanical theory of cellular
response to mechanical force application.
It is evident from the ongoing discussion that neither of these

hypotheses could provide conclusive evidence on the detailed nature
of the biological mechanism of tooth movement. Histological,
histochemical and immunohistochemical studies performed in the
20th century, as well as early in the 21st century, have demonstrated
that multiple phenomena, both physical and biological, are involved
in the process of tooth movement. When mechanical forces are
applied, cells, as well as the ECM of the PDL and alveolar bone
respond concomitantly, resulting in tissue remodelling activities.9
During the early phases of tooth movement, PDL fluids are shifted,
producing cell and matrix distortions, as well as interactions between
these tissue elements. In response to these physico-chemical events
and interactions, cytokines, growth factors, colony stimulating factors
and vasoactive neurotransmitters are released, initiating and
sustaining the remodelling activity, which facilitates the movement of
teeth.
Mechanosensing, transduction and response

Krishnan and Davidovitch23 have stressed upon the roles of
mechanosensing, transduction and responses by various cells of
mineralised and non-mineralised paradental tissues upon orthodontic
force application. According to them, orthodontic forces are applied to
teeth and are transferred to paradental tissues, both mineralised and
non-mineralised, cells of which contain mechanosensing molecules,
which respond to structural changes in the ECM. In this situation,
osteocytes, as well as alterations in gingival architecture, seem to play
a major role in alveolar bone remodelling. On the other hand,
fibroblasts are mainly involved in PDL remodelling events, such as
reorganisation, synthesis and degradation of ECM components. OTM
alters the neutral state of both mechanoreceptors and nociceptive PDL
nerve fibres. These somatosensory neurons transmit signals from
peripheral tissues to the central nervous system, the effect of which is
a release of biologically active proteins contributing to a local
neurogenic inflammation. In addition to this, the physical distortion of
nerve endings in the paradental tissues is an early important
phenomenon in the chain of events that lead to activation of the
remodelling process. At the same time, endothelial cells help to
remodel existing blood vessels, as well as form new ones in response
to mechanical forces. Applied mechanical stresses cause remodelling
of the ECM, activating signalling pathways mainly through integrin
dependent mechanisms. These initial steps are followed by actin
polymerisation, activation of type I collagen genes,
neovascularisation, and remodelling of blood vessels. The entire
process is self-limiting, once sufficient changes are obtained to nourish
the associated structures.
Krishnan and Davidovitch23 emphasised upon the fact that each
paradental tissue contains its own cellular networks and extracellular
elements, remodelling of which is required to facilitate the tooth
movement process. They have synthesised all these events in an effort
to comprehend and streamline the cellular and molecular events
associated with orthodontic force application. The pathway which
outlines all the tissues involved to facilitate tooth movement process is
provided as Flowchart 40.2
FLOWCHART 40.2 The sequence of orthodontic tooth

movement, illustrating the roles played by mineralised and non-
mineralised tissues along with the associated blood vessels and
neural elements.
CGRP, Calcitonin gene-related peptide; SP, Substance P.
In 1962, Burstone3 suggested that if the rates of tooth movement were
plotted against time, there would be three phases of tooth movement
—the initial phase, a lag phase and a post lag phase (Fig. 40.6). The
initial phase is characterised by a period of very rapid movement,
which occurs immediately after application of force to the tooth. This
rate can be largely attributed to the displacement of the tooth within
the PDL space. Immediately following the initial phase, there is a lag
period, where relatively low rates of tooth displacement occur, or no
displacement happens at all. It has been suggested that the lag is
produced by hyalinisation of the PDL in areas of compression. No
further tooth movement will occur until cells complete the removal of
all necrotic tissues. The third phase of tooth movement follows the lag
period, during which the rate of movement gradually or suddenly
increases.
FIGURE 40.6 Stages of tooth movement in rats.

Tooth movement showing the three characteristic phases: (1) early
compression phase (day 1), (2) delayed hyalinisation period (days 4
and 5), and (3) late rapid tooth movement (day 5 to the end of the
experimental period). Source: Reproduced with permission from
Mohammed AH, Tatakis DN, Dziak R. Leukotrienes in orthodontic tooth
movement. Am J Orthod Dentofacial Orthop 1989;95(3):231–7.
Two other studies24,25 have proposed a new time/displacement

model for tooth movement (Fig. 40.7). These studies, performed on
beagle dogs, divided the curve of tooth movement into four phases.
The first phase lasts from 24 h to 2 days, and represents the initial
movement of the tooth inside its bony socket. It is followed by a
second phase, where there is an arrest in tooth movement lasting for
approximately 20–30 days. After the removal of necrotic tissue formed
during the second phase, tooth movement is accelerated in the third
phase and continues into the fourth phase. The third and fourth
phases comprise the bulk of the total movement of the tooth during
FIGURE 40.7 Cellular reactions related to the different stages of

an orthodontic tooth movement. Source: Reproduced with
permission from Melsen B, Cattaneo PM, Dalstra M, Kraft DC. The
importance of force levels in relation to tooth movement. Semin Orthod
2007;13(4):220–33.
Cellular and tissue reactions start in the initial phase of tooth
movement, immediately after force application. Because of the
compression and stretch of fibres and cells in PDL pressure and
tension areas, respectively, the complex process of recruitment of
osteoclast and osteoblast progenitors, as well as extravasation and
chemoattraction of inflammatory cells begins. In the second phase,
areas of compression are easily recognised by the distorted
appearance of the normal PDL fibre arrangement. The disruption in
blood flow due to this distortion leads to the development of
hyalinised areas, and to an arrest of tooth movement, which may last
from 4 to 20 days. Only removal of necrotic tissue and bone resorption
from adjacent marrow spaces (indirect resorption) and from the
direction of the viable PDL (undermining resorption) allows the
resumption of tooth movement. This comprehensive process requires
the recruitment of phagocytic cells, such as macrophages, foreign
body giant cells and osteoclasts, from adjacent undamaged areas of
PDL and alveolar bone marrow cavities. These cells act in tandem to
remove or eliminate necrotic tissues from compressed PDL sites and
from adjacent alveolar bone. In areas of PDL tension, quiescent
osteoblasts (bone surface lining cell) are enlarged, and start producing
new bone matrix (osteoid). New osteoblast progenitors are recruited
from the population of fibroblast-like cells (pericytes) residing around
PDL capillaries. These pre-osteoblasts proliferate and migrate towards
the alveolar bone surface, along the stretched Sharpey’s fibres.
Simultaneously, PDL fibroblasts in tension zones begin multiplying
and remodelling their surrounding matrix.
The third and fourth phases of OTM, also known as the acceleration
and linear phases, respectively, start about 40 days after the initial
force application. The pressure sides of teeth exhibit collagen fibres
without proper orientation. Here, irregular bone surfaces are found,
indicative of direct or frontal resorption. However, a recent report has
presented data on hyalinisation zones at the pressure areas even
during this stage, especially in areas where high forces were applied.26
This finding suggests that the development and removal of necrotic
tissue is a continuous process during tooth displacement, instead of
being a single event. The tension sides in the third and fourth phases
clearly show bone deposition, as evidenced by alkaline phosphatase
positive osteoblastic cells.
Alveolar bone response to orthodontic
force
Bone cells (osteoblasts, osteoclasts and osteocytes) are sensitive to
their mechanical environment, and their adaptive response can alter
both the mass and the morphology of bones. Osteocytes, the cells
embedded individually inside lacunae in the mineralised bone matrix,
comprise over 90%–95% of all bone cells, and are connected to each
other and to cells of the bone surface by cytoplasmic processes or
dendrites. Within a few minutes of the onset of mechanical loading,
glucose 6-phosphate dehydrogenase (a marker of cell metabolism) is
elevated in osteocytes and bone surface lining cells.27 By 2 h, c-fos
mRNA is evident in osteocytes, and by 4 h, transforming growth
factor β and insulin-like growth factor mRNA are increased in these
cells. Applied mechanical stress causes flow of bone interstitial fluid,
evoking shear stress in the mineralised ECM, leading to deformation
of the alveolar bone osteocytes in the lacunae and of the dendrites in
the canaliculae. This deformation perturbs the integrin molecules,
which act as a tethering protein, opening hemi channels in strained
osteocytes, allowing the release of prostaglandins.28
Signals emanating from a strained osteocyte pass through gap
junctions to adjacent osteocytes, bone surface lining cells and
osteoblasts. These signals lead to the synthesis and deposition of
osteoid matrix on the osteocytic lacunar wall, as well as on the bone
surface. The secreted bone matrix proteins consist of type I collagen
(about 90% of the organic matrix), which provides strength, structure
and elasticity to mature bone tissue. It also regulates
expression/secretion of other non-collagenous proteins, such as
osteocalcin, osteopontin, osteonectin and bone sialoprotein. It is
apparent that bone formation is coordinated by expression of many
molecules, such as growth factors, transcription factors and
inflammatory cytokines. The committed osteoblast is also able to
attract more osteoblasts to the site by its apoptosis, to
induce/stimulate osteoclastogenesis through the receptor activator of
nuclear factor kappa-B (RANK), receptor activator of nuclear factor
kappa-B ligand (RANKL), Osteoprotegerin (OPG) pathway, or to
become a highly differentiated cell, persisting for a very long period of
time inside the bone matrix as an osteocyte.29
Osteoclasts, generated from monocyte/macrophage lineage through
RANK/RANKL pathway create an isolated micro-environment
between themselves and the exposed, cell free bone, and proceed to
secrete protons via an electrogenic H+ ATPase (proton pump). The
potential intracellular alkalinity induced by massive proton transport
is prevented by electrochemical chloride/bicarbonate exchanges. The
chloride that enters a cell is transported to the resorptive micro-
environment via a channel, charge coupled to the H + ATPase, thus
generating HCl, producing ambient pH of approximately 4.5. This
acidity within the degradation phase mobilises the mineral
component, exposing the organic matrix, which is later degraded by
collagenolytic lysosomal protease, cathepsin (secreted by
osteoclasts).30
Cellular behaviour in sites of PDL
tension and compression
Orthodontic forces, static or dynamic, continuous or intermittent,
create strains in the treated teeth and their surrounding tissues. These
strains are not uniform throughout the entire treated region, but
rather develop a quilt of areas where tension or compression prevail,
creating favourable conditions for tissue remodelling. The behaviour
of cells in these strained locations is of great clinical interest, because it
determines the outcome of orthodontic treatment. He Y et al.31
demonstrated that the PDL cells were found to respond differently to
tensile and compressive strains, in terms of synthesis and degradation
of ECM components. A 10% compressive strain (0.5 Hz), decreased
collagen (COL1A1) mRNA, type I collagen, and fibronectin levels in
these cells. In contrast, a 10% tensile strain increased COL1A1 mRNA,
matrix mettalloproteins (MMP) 2 mRNA and tissue inhibitors of
matrix mettalloproteins (TIMP2) mRNA. These findings demonstrate
that under tensile forces, both MMP and TIMP are synthesised at
similar levels, promoting synthetic activity, whereas under
compressive loads, the synthesis of MMP is increased, but without a
change in TIMP, thus promoting degradation. Recently, with light and
transmission electron-microscopic observations, Anastasi et al.32
showed that the type I collagen immunofluorescence staining
intensity is increased in the PDL pressure side, while in the tension
side it displays a diminution of staining after 72 h of treatment. Type
IV collagen staining is reduced in both sites, but is increased gradually
after 7 days of treatment, while fibronectin staining pattern is
gradually increased in the pressure side and reduced in the tension
side.
Blood vessel reorganisation and
neovascularisation
Blood vessels in the PDL are active participants in tissue remodelling
events during orthodontic treatment. They provide gases and
nutrients required for all metabolic activities of their surrounding
tissues, in health and disease. The ECM surrounding the vessels
provides critical support for the vascular endothelium. Endothelial
cells anchorage in the ECM through integrin is considered essential
for efficient mitogen activates protein kinase activation by cytokines.
During angiogenesis, proliferating and migrating endothelial cells
organise to from new three-dimensional capillary networks, with the
help of the ECM (which serves as a three-dimensional malleable
scaffold).23 By generating mechanical contractile forces within the
ECM, endothelial cells are able to establish tension based guidance
pathways that allow them to form interconnected cords.33
This strain activates signalling pathways mainly through integrin
dependent mechanisms. These initial steps are followed by actin
polymerisation, activation of type I collagen genes,
neovascularisation, and remodelling of blood vessels. The entire
process is self-limiting, once sufficient changes are obtained to nourish
the associated structures. A collagen type I gene is involved in
acquiring shape changes by the endothelial cells. Over the course of
several days, these structures mature, to form hollow tubes through a
process involving development and coalescence of intracellular
vacuoles.34 With the help of light and transmission electron-
microscopic observations. Anastasi et al.32 showed a reduction in
number of blood vessels after 72 h of treatment, and an increase in
their number after 7 days of treatment.
Innervations of dental and paradental tissues are mainly constituted
by neurons that originate in the trigeminal ganglia and mesencephalic
trigeminal nucleus. Neural fibres from the trigeminal ganglia are
located in the cervical and middle root areas, while those from the
trigeminal nucleus are located in the apical periodontal area. The
nerve endings consist mainly of mechanoceptors (Ruffini-like
endings) and nociceptors. Under normal physiological conditions,
these receptors remain quiescent, but contain various neuropeptides,
such as calcitonin gene related peptide (CGRP) and substance P (SP).35
OTM alters the neutral state of both mechanoceptors and nociceptive
PDL nerve fibres. These somatosensory neurons transmit signals from
peripheral tissues to the central nervous system, the effect of which is
a release of biologically active proteins contributing to a local
neurogenic inflammation. The release of neuropeptides, such as CGRP
and SP in the PDL was reported to occur in response to orthodontic
forces.35 As, most PDL neurons are wrapped around blood vessels,
including capillaries, endothelial cells are probably the first to interact
with neuropeptides released from the mechanically strained nerve
endings. This interaction entices the endothelial cells to bind
circulating leukocytes, and facilitate their migration out of the
capillaries into the PDL. The arrival of these leukocytes in the PDL
signifies the onset of an acute inflammation, which is an essential part
of the tissue remodelling that, enables mechanical forces to move teeth
into new locations. Monocytes, lymphocytes and mast cells express
receptors for neuropeptides, which help in transducing signals intra-
cellularly to evoke cellular responses, such as cytokine release,
production of other neuropeptides, changes in the expression of
mediators, or direct release of inflammatory mediators.36 Moreover,
CGRP and SP also serve as vasodilators, increasing vascular flow and
permeability, and plasma flow out of the capillaries. The leucocytes
migrating out of the capillaries release a plethora of signalling
molecules (cytokines, growth factors and colony stimulating factors)
that interact with various dental and paradental target cells,
stimulating them to start and sustain the tissue remodelling process
that is the core of tooth movement.35
Does inflammatory responses follow
orthodontic force application?
Orthodontic forces induce an aseptic inflammatory response rather
than a reaction to an invasion by micro-organisms through a wound.
Nonetheless, the classical signs of inflammation (redness, swelling,
pain and reduced function) are similar in both cases. Inflammatory
cytokines produced by leukocytes, platelets and native cells, which
includes lymphocyte and monocyte-derived factors, colony
stimulating factors, growth factors and chemotactic chemokines are
often involved in tissue reactions associated with orthodontic forces.37
In periodontal tissues, cytokines are produced by immune cells,
fibroblasts and osteoblasts, and participate in regular tissue turnover
and in induced bone remodelling events. Both these procedures are
mediated by pro- as well as anti-inflammatory cytokines under the
influence of distinct cytokine subsets. Dudic et al.,38 identified
elevated levels of IL-1β,SP and PGE2 in gingival crevicular fluid from
both compression and tension sites of moving teeth, with higher
concentrations found in tension sites. Recently, Ren and Vissink37
reported the differential expression patterns of three cytokines (TGF-
β, IL-10 and TNF-〈) in PDL compression and tension sites during
tooth movement. Ignotz et al.39 reported an augmented expression
pattern for TGF-β mRNA at both sites of PDL compression and
tension, which induces proliferation and chemotaxis of PDL cells,
upregulates COL-I, recruits osteoblast precursors inducing their
differentiation, downregulates MMPs and upregulates TIMPs
enhancing production of bone matrix proteins. Andrade et al.40
reported that compression site PDL cells express increased amounts of
TNF-〈, which stimulate the production of MMPs elevating the levels
of RANKL to be directly involved in bone resorption. In contrast,
simultaneous up regulation of OPG and down regulation of RANKL
expression by the anti-inflammatory cytokine IL-10 inhibits bone
resorption.37 The dual role of cytokines in the remodelling of
mineralised and non-mineralised connective tissues can be briefed as
that a pro-inflammatory cytokine, such as IL-1 and TNF-〈, promotes
resorption and inhibits apposition, while anti-inflammatory cytokines
promote apposition and inhibit resorption.
It can be concluded that orthodontic forces are capable of creating
aseptic and transitory inflammation at both PDL compression and
tension sites. Although a clear cut microscopic and/or computerised
tomographic demarcation between areas under compression and
tension is not always possible, because these zones are often overlap
each other, the bulk of research outcomes to date points to the fact that
the reaction at each of these areas differs clearly on the molecular and
cellular levels. Future research will continue to increase our
knowledge about this dichotomy.
OTM–inflammation or
mechanotransduction?
Meikle41 trying to differentiate between the two phenomena stated
that ’describing OTM as an inflammatory process marks it as a
pathological event, whereas in reality, it can be considered as an
exaggerated form of normal physiologic turnover combined with a
foci of tissue repair leading to remodelling of cementum and alveolar
bone’. However, this opinion disregards the fact that the application
of orthodontic forces to teeth is accompanied by pain and reduced
function, two of the cardinal signs of inflammation. The inflammatory
process is the mechanism whereby the body tries to return an injured
area to normal. In orthodontics, inflammation repairs the damage
caused by mechanical forces. Supporting the role of inflammation was
observation of chemokines at the site of OTM. The roles of
chemokines are mainly in promoting chemotaxis, differentiation and
activation of osteoclasts favouring bone resorption. The role of CCR2–
CCL2 axis as well as CCL3 and CCR1 was demonstrated and
confirmed through rat experiments by Taddei et al.42 Apart from that,
the role of RANKL expression for the purpose of osteoclast
differentiation with continuous force application in rats was
demonstrated earlier by Kim et al.43 All these studies point to the fact
that inflammation of aseptic nature do exist due to tissue injury with
orthodontic force application.
The attention towards unveiling the responses created by
orthodontic forces lead to more research on cellular signalling
mechanisms incident to mechanical forces, which included
mechanosensing, transduction and response. Harell et al.44 and Sandy
and Farndale45 have demonstrated release of prostaglandins and
second messengers as primary responses from any cell type incident
to mechanical strain. Masella and Meister46, through their review,
outlined the genetic control of osteoblast and osteoclast differentiation
and the roles of genes in bone remodelling process. They stated that
the osteoblast generation from stem cells require 10 h post force
application and it is a five-generation process with active involvement
of Cbfa1 and osterix. They could outline at least 24 genes and 60
proteins to be implicated in positive and negative regulation of
osteoclastogenesis and osteoclast function. They concluded that
orthodontic force causes physical distortion of PDL and alveolar bone
cells and the ECM, triggering many biochemical cascades that affect
the PDL and alveolar bone ECM, cell membrane, cytoskeleton, matrix
of nuclear proteins and genome. Following this, Henneman et al.1
proposed a theoretical model based on mechanobiology to explain
tooth movement, consisting of four stages: (1) matrix strain and fluid
flow, (2) cell strain, (3) cell activation and differentiation and (4)
remodelling. Krishnan and Davidovitch23 favouring the
mechanotransduction hypothesis of OTM, were successful in
outlining a pathway, which included all paradental tissue reactions to
orthodontic force.
All these data point to the fact that the tooth movement process
cannot be labelled as either inflammatory or genetic or
mechanotrandsuction in nature. All the factors have well defined roles
in the process. While initial reactions to orthodontic forces are
inflammatory in nature, as evidenced by the release of cytokines and
other inflammatory mediators, this helps in cellular stimulation and
initiation of signalling events. Proper mechanotransduction events are
essential for cellular response, which is genetic expression and protein
synthesis. All the events have to occur in concert for better response to
the mechanical forces, which we apply.
Iatrogenic effects of orthodontic
mechanics
Orthodontic treatment affects not only the teeth and their surrounding
tissues, but also the extraoral tissues, the psychological status, and the
systemic health of the patient. If orthodontic treatment is to benefit the
patient, the advantage it offers should outweigh the potential
damages, it might create. Although success prevails in most
orthodontically treated cases, failures, imperfections and difficulties
do sometimes occur. The iatrogenic effects of orthodontic treatment
are: white spot lesions47, periodontal deterioration48, and external
apical root resorption (EARR). To reduce and minimise the prevalence
and extent of these negative outcomes, it is strongly recommended
that all practicing orthodontists, as well as residents, be keenly aware
of and thoroughly familiar with the aetiology of all possible untoward
effects of the treatment mechanics they employ because of their
litigious and ethical implications.
Iatrogenic effects of orthodontic treatment can occur at any stage,
resulting from failures to49:
• Formulate a correct and comprehensive diagnosis.

• Consult with the appropriate general practitioner.
• Refer appropriately to specialists in other areas of medicine
and dentistry.
• Refrain from adopting an incorrect or dangerous treatment
strategy.
• Perform treatment at the appropriate time/schedule.
• Alter the original treatment plan in mid-treatment due to
unforeseen developments.
• Successfully resolve the malocclusion.
• Establish proper communication with the patient.
• Provide proper follow-up care.
Force application and its duration, direction and magnitude
determine the nature of inflammatory changes that might occur
during the course of treatment. Research has also shed light on the
elevated levels, both useful and harmful to the human body, of
signalling molecules in the gingival crevicular fluid of moving teeth.
Inappropriate mechanics, poor oral hygiene and abnormal force
application can lead to intraoral iatrogenic damage to teeth and
paradental tissues.50 These effects may impact all components of the
craniofacial complex, including the dental enamel, pulp, cementum,
gingiva, PDL, bone, cartilage and muscle. Apart from this, it can also
have extraoral as well as systemic effects, which are damaging for the
health of orthodontic patients.51 The intraoral, extraoral and systemic
iatrogenic effects of orthodontic mechanotherapeutics are outlined in
Table 40.1.
Table 40.1
Iatrogenic effects of orthodontic force application and mechanics

Tissue affected Effect
Intraoral effects
Gingiva and periodontal ligament Gingivitis
Periodontitis
Gingival recession
Dark triangles
Poor gingival contours
Alveolar bone Crestal bone resorption
Dental roots Root resorption
Early closure of the apex
Enamel Decalcification
Fracture
Excessive wear
Pulp Pulpitis
Internal root resorption
Soft tissues (buccal and labial mucosa) Ulcerations due to appliances
Direct trauma
Effect of clumsy instrumentation
Soft tissue cleft formation
Extraoral effects
Face Direct trauma from headgear components (facebow)
Eye damage from displaced headgear bow
Chemical burn from etchant
Thermal burns from overheated instruments
Nickel-induced sensitivity
Allergy
Cytotoxicity
Profile damage
Temporomandibular joint Dysfunction
Condylar resorption
Systemic risks
Cross infection Operator to patient
Patient to operator
Growth Unfavourable growth direction and/or amount
Psychological effects
Depression
Teasing
Abnormal/patient/parent behaviour
Poor cooperation
Treatment results
Unfavourable results
Unable to maintain results
Failed treatment
Profile damage
Pain with orthodontic mechanotherapeutics

Pain, which includes sensations evoked by and reactions to the
noxious stimuli, is a complex experience and often accompanies each
and every orthodontic appointment. This, among the most cited
negative effects of orthodontic treatment, is of major concern to
patients as well as clinicians.52 One survey rated pain as number one
among the greatest dislikes during treatment and fourth among major
fears and apprehensions prior to orthodontic treatment.53 Another one
report has even stated that 8% of study population discontinued
treatment because of pain.54 It is reported that orthodontic procedures
will reduce the proprioceptive and discriminating abilities of the
patients for up to 4 days. This will result in lowering of pain threshold
and disruption of normal mechanisms associated with proprioception
input from nerve endings in the PDL.55 At the same time, there will be
pressure, ischaemia, inflammation and oedema in the PDL space. It is
clear from the existing literature that all orthodontic procedures, such
as separator placement, archwire placement and activations,
application of orthopaedic forces and debonding produce pain in
patients. It is also clear that fixed appliances produce more pain than
removable or functional appliances and there exists little correlation
between applied force magnitude and pain experienced.
There exists a non-linear relationship between age, gender,
psychological state and cultural background in pain perception
following placement of orthodontic appliance. The relationship
between psychological well being of the patient and orthodontic pain
perception is proven beyond doubt. It is clear from the published
literature that girls express more pain than boys and adolescents
report higher levels of pain than pre-adolescents and adults. There is
no doubt about that the perception of orthodontic pain. Orthodontic
pain is a part of inflammatory reactions causing changes in blood flow
following orthodontic force application. This is known to result in the
release of various chemical mediators eliciting a hyperalgesic
response. Recent research has started revealing the molecular basis of
orthodontic pain with demonstration of the presence as well as
elevation in levels of various neuropeptides released. Researchers
concluded that NFP-, CGRP-, VIP- and NPY- containing nerve fibres
play an important role in blood flow regulation, tissue remodelling
and modulation of pain perception during tooth movement.35
Burstone3 classified a painful response to orthodontic mechanics in
two ways. One depends on the relationship of force application with
pain and the other according to the time of onset. According to that
author, the degree of pain perceived in response to the amount of
force application can be divided into three:
1. First degree: The patient is not aware of pain unless the

orthodontist manipulates the teeth to be moved by the
appliance, for example, using instruments, such as a band
pusher or force gauge.
2. Second degree: pain or discomfort caused during clenching or
heavy biting—usually occurs within first week of appliance
placement. The patient will be able to masticate a normal diet
with this sort of pain.
3. Third degree: if this type of pain appears, the patient might be
unable to masticate food of normal consistency.
Based on time of onset, Burstone3 classified pain as follows:
1. Immediate: which is associated with sudden placement of

heavy forces on tooth, for example, hard figure of eight tie
between the central incisors to close a midline diastema.
2. Delayed: produced by variety of force values from light to
heavy and represents hyperalgesia of periodontal membrane.
This type of pain response decreases with time. That is, the
pain reaction might start as third degree and becomes second
or a first-degree with passage of time.
Existing literature supports the use of non-steroidal anti-

inflammatory drugs (NSAIDs) for pain control, even though other
methods (such as anaesthetic gel, bite wafers, transcutaneous electrical
nerve stimulation, low level laser use and vibratory stimulation) have
been reported. The major concern regarding NSAIDs was the
interference produced on inflammation associated with tooth
movement process. Low doses administered for a day or two in initial
stages will not affect the tooth movement process as such. The current
trend is directed towards use of pre-emptive or pre-operative
analgesics, which are administered at least 1 h before every
orthodontic procedure.
External apical RR with orthodontics

External apical root resorption (EARR) or RR, is an undesirable as well
as the least predictable sequelae of orthodontic treatment. It can occur
during the middle or post-treatment phase raising questions about
longevity of treated dentition and stability of treatment results. It has
been proven beyond doubt that along with other factors, orthodontic
force application can act as a stimulus to initiate the process. The effect
of force system applied during mechanotherapy has been analysed by
Jarabak and Fizzell56 and concluded that the magnitude of force as
well as rigid fixation of archwire with brackets or use of full size
rectangular wires in bracket slots to be most important factors pre-
disposing a tooth to resorptive process. It can be inferred from the
published literature that all types of malocclusion are prone to RR,
when exposed to orthodontic treatment.57 The reason they mentioned
was intrusion mechanics necessary to correct deep overbite in these
cases as well as excessive labial torque needed for correcting incisor’s
palatal inclination. Comparing resorption potential between cases
treated with extraction and non-extraction modalities, authors
concluded that both have potential to produce damage, with
extraction therapy being more detrimental.58 McNab et al.59 reported
a higher incidence as well as amount of RR in patients treated with
Begg appliance. They concluded that the incidence rate of RR increase
3.72 times higher when extractions were performed as part of Begg
appliance therapy.
Out of various tooth movements, intrusion and torquing are most
commonly being associated with the resorption process. Displacement
of root apex horizontally or torquing has been proven beyond doubt
to produce RR.58 The highest incidence of RR is reported to occur
when 3–4.5 mm of torquing movement was performed.59 Evaluation
for tooth vulnerability to resorption process in literature resulted in
common agreement among authors, that maxillary incisors are more
prone to the process. Majority of studies published reported central
incisors to be more susceptible to the process60–62 except for two
recent studies, which favour lateral incisors.59,63 Among different
shaped root ends (normal, blunted, dilacerated, pipette shaped,
pointed and incomplete), least resorption was observed in blunted
type and highest in pointed or tapered type.58
Review of published literature reveals numerous reports with
positive as well as negative association of various factors pre-
disposing a patient to resorption process. Mirabella and Artun64
evaluated the individual variation expressed in various patients in
1995. They concluded that, long, narrow and deviated roots increased
the risk for resorption process. Some reports describing positive
correlation between various habits—lip/tongue dysfunction with
history of thumb sucking and nail biting—could be observed. This
was explained by the presence of increased overjet producing jiggling
forces from soft tissues over a period of time. Dental anomalies, such
as tooth agenesis, peg shaped laterals, dens invaginatus,
taurodontism, ectopic eruption and abnormally short root were
evaluated for their predisposing nature recently.
A series of studies conducted at University of Sydney evaluated the
mineral content loss with light as well as heavy force application from
root cementum to conclude that there is actual loss with orthodontic
mechanotherapeutics.65–67 They could not observe any significant
difference in mean hardness and elastic modulus between treated and
untreated premolar cementum, which gradually decreased from
cervical to apical regions of the buccal and lingual surfaces. The
interesting finding was that the mean volume of the resorption crater
in the light-force group was 3.49-fold greater than in the control
group; while that heavy-force group was 11.59-fold greater than in the
control group. Further with electron probe microanalysis, they
evaluated the calcium (Ca), phosphorus (P) and fluoride (F)
concentrations in human first premolar cementum after the
application of light and heavy orthodontic forces and observed trend
towards an increase in the mineral composition (Ca, P and F) of
cementum at various areas of PDL compression in the areas of tension
there observed a significant decrease in the Ca concentration with no
alteration in fluoride concentration.68
Brezniak and Wasserstein69, in their review described RR according
to its severity. According to them, there are
1. Cemental or surface resorption—only outer layers are

resorbed, which are fully regenerated or remodelled.
2. Dentinal resorption with repair—cementum and outer layers of
dentin are resorbed and is repaired with cementum alone
producing morphological alterations.
3. Circumferential RR—full resorption of hard tissue components
of root apex occurs resulting in root shortening.
They clearly state that, when root loses apical material beyond
cementum, no regeneration is possible. The reparative process begins
2 weeks after the force is discontinued and the effects are evident
within 6–8 weeks. Acellular cementum is laid down in initial stages
followed by cellular cementum. According to various authors, the
process starts from either peripheral region, bottom or all directions
and individual variations seem to be very high as far as repair is
concerned. Progress periapicals/panoramic radiographs forms a
useful aid in detecting mid treatment resorption process. Literature
review supports temporary halt in orthodontic treatment for a period
of 4–6 months before resumption.69,70 It is usually seen that the
resorptive process ceases and reparative process starts within this
period. Literature supports the view that there will be no apparent
increase in resorption after termination of active orthodontic
treatment.
Key Points
Rapid advances made in all biological fields have enabled us to better
understand the mechanisms involved in OTM. It is now known that
OTM is produced by mechanical means that evoke biological
responses. These two entities, mechanics and biology, act in concert to
produce desirable and predictable alterations in the form and function
of the dento-alveolar complex. The actual performers of this force-
induced remodelling are the native cells of the treated teeth and their
surrounding tissues.
Other important cellular participants in this remodelling process are
derivatives of the neuro-vascular and immune system. Cells and
tissues use mechanosensing, transduction and response phenomena to
respond to applied mechanical forces. This reaction is typified by the
aseptic inflammatory reaction, which is initially acute, becoming
chronic a few days after the activation of the orthodontic appliance.
Acute inflammation is reintroduced to the paradental tissues each
time the appliance is reactivated.
This growing body of knowledge on the response of the cells to
mechanical loads should illuminate useful paths in clinical
orthodontics, as well as assist us in identifying and discarding
harmful methods of mechanotherapy. Future orthodontics will,
therefore, increasingly become biologically correct and consequently
patient-friendly.
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CHAPTER 41
Principles of biomechanics and
appliance design
Varun Kalra
CHAPTER OUTLINE
Introduction
Force
Centre of resistance
Moments
Couples
Centre of rotation
Moment to force ratio
Types of tooth movement
Static equilibrium
Analysis of common force systems produced by
orthodontic appliances
Centre V-bend
Off centre V-bend
Step bend
Basic properties of orthodontic wires
Load-deflection rate = load/deflection
Other factors
Stainless steel
Nickel–titanium
Titanium–molybdenum
Application of principles and properties
Key Points
Introduction
An understanding of the basic principles of mechanics is essential to
evaluate the force systems generated by an orthodontic appliance.
These mechanical principles are found within a branch of engineering
called mechanics. Mechanics describes the effects of forces on bodies.
A clinician would obviously like treatment to proceed as efficiently
from point A to point B with the least amount of side effects and
surprises. To this end, a thorough knowledge of the principles of
biomechanics is essential.
To design efficient orthodontic appliances, one needs to consider:
1. The type of force system required to produce a given centre of

rotation, and
2. The properties of materials so that one can use appropriate
materials, wire sizes and loop configurations to produce
optimum forces and moments.
Force
A force is defined as the action of one body on another that changes or
tend to change the shape or motion of that second body. Force acts in
a straight line and can either be a push or a pull. In the metric system,
the unit of force is gram. Force is a vector, having both magnitude and
direction.
Centre of resistance
The centre of resistance (CRes) of a tooth is a point on the tooth where
a single force would produce a translation, that is, all points on the
tooth moving in parallel straight lines (Fig. 41.1). The CRes of a healthy
tooth is about 2/5th the length of the root from the alveolar crest to the
apex (Fig. 41.2). In a healthy maxillary central incisor, CRes is about 10
mm apical to the bracket on the crown of the tooth.
FIGURE 41.1 The centre of resistance of a tooth is a point on the
tooth where a single force would produce a translation, that is, all
points on the tooth moving in parallel straight lines.
CRes, Centre of resistance; F, force.
FIGURE 41.2 The centre of resistance of a healthy tooth is about
2/5th the length of the root from the alveolar crest to the apex.
Moment
If a force is applied at any point on the tooth other than the CRes, the
tooth will have a tendency to rotate (although CRes will also move in
the direction of the force). This rotational tendency is called the
moment of the force (Fig. 41.3). The rotational tendency can be either
in a clockwise (Cw) or counterclockwise (Ccw) direction. For example,
if a distally directed force is applied to the bracket of a maxillary
central incisor the tooth will have a tendency to rotate in a Cw
direction.
FIGURE 41.3 If a force is applied at any point on the tooth other
than the centre of resistance, the tooth will have a tendency to
rotate although CRes will also move in the direction of the force.
This rotational tendency is called the moment of the force. CRes, Centre
of resistance.
The magnitude of the moment is determined by the amount of force

applied, multiplied by the perpendicular distance between the point
of force application and CRes of the tooth, M = F × D (Fig. 41.4). As
mentioned earlier, in a healthy maxillary central incisor CRes of the
tooth is about 10 mm apical to the bracket. Therefore, 100 g of distally
directed force applied at the bracket will produce, 100 g × 10 mm =
1000 g-mm Cw moment.
FIGURE 41.4 The magnitude of the moment is determined by the

amount of force applied, multiplied by the perpendicular distance
between the point of force application and CRes of the tooth.
M = F X D. D, Distance.
It is important to remember that the magnitude of the moment is

dependent on both the amount of force and the perpendicular
distance from CRes. Therefore, we can at times dramatically increase or
decrease the magnitude of the moment by altering the distance of the
point of force application.
Couple
If two equal and opposite parallel forces, that are not along the same
line are applied on a tooth, the tooth undergoes pure rotation around
the CRes. Two equal and opposite non-collinear forces are called a
couple. The magnitude of the moment generated by a couple is
dependent on the magnitude of the force and the distance it acts from
the CRes. It is the sum of the moments created by the two forces that
make up the couple (Fig. 41.5).
FIGURE 41.5 The magnitude of the moment generated by a
couple is dependent on the magnitude of the force and the
distance it acts from the centre of resistance.
It is the sum of the moments created by the two forces that make up
the couple. D = Distance.
In the edgewise system, couples can be created by engaging the

wire into the edgewise bracket. For example, Fig. 41.6A, to achieve a
first order (buccolingual) couple, the wire is angulated so that when it
is engaged into the bracket slot, it produces a buccal force on the
mesial aspect of the bracket and an equal lingual force on the distal
aspect of the bracket. To create a second order (mesiodistal) couple,
the wire is angulated to produce equal and opposite extrusive and
intrusive forces on the mesial and distal aspects of the bracket (Fig.
41.6B). To create a third order couple (root torque), one needs to place
a twist (torque) in a rectangular wire such as to produce an intrusive
force on the buccal aspect and extrusive force on the lingual aspect of
the bracket for lingual root torque (Fig. 41.6C), or vice versa for labial
root torque.
FIGURE 41.6 (A) To achieve a first order (buccolingual) couple, the

wire is angulated so that when it is engaged into the bracket, it
produces a buccal force on the mesial aspect of the bracket and an
equal lingual force on the distal aspect of the bracket, or vice versa. (B)
To create a second order (mesiodistal) couple, the wire is anguated to
produce equal and opposite intrusive and extrusive forces on the
mesial and distal aspects of the bracket, or vice versa. (C) To create a
third order couple (root torque), one needs to place a twist (torque) in a
rectangular wire such as to produce an intrusive force on the buccal
aspect and extrusive force on the lingual aspect of the bracket (lingual
root torque), or vice versa (buccal root torque).
Centre of rotation
The centre of rotation (CRot) is any point around which the tooth
rotates. Unlike the CRes of a tooth, which remains constant, the centre
of rotation of the tooth can vary. In fact, it is this capacity to move the
centre of rotation that allows the orthodontist to create controlled
tipping, bodily movement or root movement of the tooth.
Moment to force ratio

If a single force is applied on the crown, the tooth will rotate in a way
that the centre of rotation is very close to and just apical to the CRes of
the tooth. In this type of movement, the crown moves in the direction
of the force and the apex of the root moves in the opposite direction.
This type of movement, with the root moving in the opposite
direction, however, is rarely desirable. If we do not want the root apex
to move in the opposite direction, then we need to apply a moment on
the tooth that will counteract the tipping moment that is being
generated by force. The ratio of the moment (torque or mesiodistal
angulation of the wire) that we apply to counteract the tipping and the
force we apply on the crown gives the moment to force ratio (M:F).
Types of tooth movement

Uncontrolled tipping. In uncontrolled tipping, a single force is applied
at the crown, whereby the tooth rotates around a point just apical to
the CRes. The crown moves in the direction of the force and the apex of
the root moves in the opposite direction. The CRes of the tooth also
moves in the direction of the force (Fig. 41.7A).
FIGURE 41.7 (A) Uncontrolled tipping. In uncontrolled tipping, only a
single force is applied at the crown, whereby the tooth rotates around a
point just apical to the centre of resistance. The crown moves in the
direction of the force and the apex of the root moves in the opposite
direction. The centre of resistance of the tooth also moves in the
direction of the force (CRes, Centre of resistance). (B) Controlled
tipping. A force of 100 g applied in a distal direction at the bracket
results in a 1000 g-mm clockwise tipping moment. If we apply a Ccw
moment of 600 g-mm (M:F = 6:1), then, although this counter moment
is not sufficient to totally negate the effect of the clockwise tipping
moment. However, it is sufficient to decrease the amount of tipping by
moving the centre of rotation to the apex of the root. The centre of
resistance also moves in the direction of the force (Cw, clockwise;
CCw, counterclockwise). (C) Bodily movement. If we were to increase
the counterclockwise moment to 1000 g-mm, then this would exactly
offset the tipping moment, and the tooth would translate bodily without
any tipping. The centre of rotation is at infinity (Cw, clockwise; CCw,
counterclockwise). (D) Root torque. If we increase the moment to force
ratio beyond 12:1, the centre of rotation moves to the crown. First, it
moves to the incisal edge, and any further increase in the moment to
force ratio moves it to the bracket. In this situation, the apex of the root
moves back in the direction of the applied force, and the crown may
actually move forward in the opposite direction (Cw, clockwise; CCw,
counterclockwise).
Controlled tipping. In our previous example of a healthy maxillary

central incisor, we stated that CRes is about 10 mm apical to the
bracket. Therefore, a force of 100 g applied in a distal direction at the
bracket results in a 1000 g-mm Cw tipping moment. If we apply a
Ccw moment of 600 g-mm (M:F = 6:1), then although this counter
moment is not sufficient to totally negate the effect of the Cw tipping
moment. However, it is sufficient enough to decrease the amount of
tipping by moving the centre of rotation to the apex of the root.
Therefore, in controlled tipping, the crown tips back in the direction of
the force but the root apex does not move forward in the opposite
direction (Fig. 41.7B). The CRes also moves in the direction of the force.
This kind of movement may be indicated when retracting excessively
proclined maxillary incisors.
Bodily movement. In our example, if we were to increase the Ccw
moment to 1000 g-mm then this would exactly offset the tipping
moment, and the tooth would translate back bodily, without any
tipping (Fig. 41.7C). The centre of rotation in this situation is at
infinity. This kind of movement is often required when retracting a
canine into an extraction site.
Root movement. If we increase the moment to force ratio beyond 12:1,
the centre of rotation moves to the crown. First, it moves to the incisal
edge, and any further increase in the moment to force ratio moves it to
the bracket. In this situation, the apex of the root moves back in the
direction of the applied force, and the crown may actually move
forward in the opposite direction (Fig. 41.7D). This type of movement
is often utilised if the maxillary central incisors are retroclined
following retraction in an extraction case.
Static equilibrium
Newton’s third law of motion states that for every action there must
be an equal and opposite reaction. As an active orthodontic appliance
in the mouth does not move instantaneously, the net force system
produced by the appliance as a whole must be zero. To meet the
requirements of equilibrium, the sum of all forces present in the
horizontal direction must be zero; the sum of all forces present in the
vertical direction must be zero, and the sum of all moments present
must be zero. In other words, for a body to be in equilibrium:
However, one should bear in mind, although from a mechanical

perspective there may be an equal and opposite reaction at the two
ends of an appliance; the clinical response in terms of tooth movement
is rarely the same at the two ends. As seen in Fig. 41.8, the compressed
coil spring is exerting 100 g of distally directed force on the canine and
an equal and opposite, 100 g of mesially directed force on the central
incisor. Clinically, the central incisor will move mesially as it has
space mesial to it. However, the canine, which has a number of large
teeth distal to it is not likely to move distally. Similarly, 100 g of
intrusive force produced by an intrusion arch provides optimum force
for the intrusion of the anterior teeth. However, the heavy forces of
occlusion, especially in a low angle deep bite case, are likely to
prevent extrusion of the molars by the 100 g of extrusive force on
them. Other factors that come into play include inter-digitation of
cusps of teeth, especially in adults that might have a ‘socked in’
occlusion.
FIGURE 41.8 The compressed coil spring is exerting equal and
opposite forces on the canine and lateral incisor.
However, clinically, the lateral incisor will move mesially as it has space
mesial to it. However, the canine, which has a number of large teeth
distal to it, is not likely to move distally.
Analysis of common force systems produced

by orthodontic appliances
Equal and opposite forces
A simple force system involves pushing two teeth apart with a
compressed coil spring. The spring generates two equal and opposite
forces on each end. The spring is in equilibrium as there are no
moments involved and the sum of the two equal and opposite forces
is zero.
Centre V-bend
If an archwire with a centred V-bend is inserted into brackets on two
teeth a certain distance apart, the angulation of the wire produces two
equal and opposite moments on either side. There are no forces
produced, and as the moments are equal and opposite, the system is
in equilibrium1 (Fig. 41.9).
FIGURE 41.9 Centre V-bend.
If an archwire with a centred V-bend is inserted into brackets on two
teeth, a certain distance apart, the angulation of the wire produces two
equal and opposite moments on either side. There are no forces
produced, and as the moments are equal and opposite, the system is
in equilibrium.
A clinical application of the centre V-bend is seen in the K-loop

molar distalising spring2 (Figs 41.10 and 41.11). The K-loop consists of
two vertical loops in a 0.017 × 0.025 in. beta titanium wire. As the
spring is compressed between the first premolar and the molar, it
produces a distal force on the molar and mesial force on the first
premolar. As both these forces are applied at the level of the bracket
and are coronal to the CRes of the teeth, they produce a Cw tipping
moment on the molar and a Ccw tipping moment on the first
premolar.
FIGURE 41.10 K-loop molar distalising appliance.
FIGURE 41.11 K-loop molar distalising appliance ligated in place.
If we want to reduce or eliminate the tipping of these teeth, we can

add a V-bend in the spring, centred between the molar and first
premolar. This centred V-bend produces two equal and opposite
moments, which oppose the tipping moments generated by a force.
Depending upon the moment to force ratio generated by the V-bend,
one can either reduce or eliminate tipping of these teeth.
Fig. 41.12 shows pictures of a patient treated with the K-loop molar
distalising appliance utilising a centre V-bend.
FIGURE 41.12 Patient treated with a K-loop molar distalising

appliance.
(A) Pre-treatment at the time of insertion of K-loop appliance. (B) Post-
distalisation with K-loop appliance. (C) Post-treatment occlusion.
Off centre V-bend

When an archwire with a V-bend is inserted into brackets on two
teeth, a certain distance apart in such a way that the V-bend is closer
to one tooth than the other (off centre), the angulation of the wire to be
inserted into the bracket closer to the V-bend is greater than that on
the other end (Fig. 41.13A). When engaged into the brackets this
greater angulation causes a greater moment on the tooth closer to the
V-bend, and the smaller angulation of the wire on the other end
causes a smaller moment in the opposite direction (Fig. 41.13B). This
does not meet the requirements of equilibrium as we are still left with
a net Cw moment at the molar. Some force system has to come into
play that causes a Ccw moment on the appliance. This Ccw moment
on the appliance is generated as a result of an intrusive force on the
canine and an equal and opposite extrusive force on the molar. The
requirements of equilibrium are now met (Fig. 41.13C).
FIGURE 41.13 (A) Off centre V-bend. When an archwire with a V-

bend is inserted into the brackets on two teeth, a certain distance apart
in such a way that the V-bend is closer to one tooth than the other (off
centre), the angulation of the wire to be inserted into the bracket closer
to the V-bend is greater than that on the other end. (B) When engaged
into the brackets the greater angulation causes a greater moment on
the tooth closer to the V-bend, and the smaller angulation of the wire
on the other end causes a smaller moment in the opposite direction.
This does not meet the requirements of equilibrium as we are still left
with a net clockwise moment on the appliance. (C) To meet the
requirements of equilibrium, a force system has to come into play that
causes a counterclockwise moment on the appliance. This
counterclockwise moment on the appliance is generated as a result of
an intrusive force on the canine and an equal and opposite extrusive
force on the premolar.
It should be noted that as the severity of the off centre V-bend

increases, the deflection characteristics of the wire may cause no
moment at all on the other end, or even cause a small moment in the
same direction as the larger moment.
An off centre V-bend can produce moments on both ends if the wire
is inserted in the bracket slot on both ends (2-couple appliance).
However, if a wire with an off centre V-bend is inserted into the
bracket slot on one end and simply tied down as a one point contact at
the other end, then it only produces a couple on the end that is
inserted into the slot. Such an orthodontic appliance is called a 1-
couple appliance.3
An example of a 1-couple orthodontic appliance is a molar
uprighting spring. The molar uprighting spring consists of a long
lever arm with a tip-back bend placed closer to the molar, such that
when the wire is engaged in the molar tube, the front end of the
spring lies below the premolar brackets (Fig. 41.14A). As the front end
of the spring is pulled up and hooked over the premolar segment as a
simple point contact, it produces a Ccw moment on the molar. We
know that an orthodontic appliance is always in equilibrium,
therefore, with a Ccw moment on the molar there has to be a Cw
moment being generated somehow in the system to prevent it from
spinning in a Ccw direction. The effect of the Cw moment is produced
by an intrusive force on the premolar segment and an equal and
opposite extrusive force on the molar, thereby meeting the
requirements of static equilibrium (Fig. 41.14B).
FIGURE 41.14 (A) Molar uprighting spring before activation. (B) As
the front end of the spring is pulled up and hooked over the premolar
segment as a simple point contact; it produces a counterclockwise
moment at the molar. To achieve equilibrium, the effect of the
clockwise moment is produced by an intrusive force on the premolar
segment and an equal and opposite extrusive force on the molar,
thereby meeting the requirements of static equilibrium.
Another good use of the off-centre V-bend is the intrusion arch (Fig.
41.15). Fig. 41.16 shows the equilibrium diagram of the force systems
generated by the intrusion arch.
FIGURE 41.15 Intrusion arch.
FIGURE 41.16 Equilibrium diagram of part of the force systems

produced by the intrusion arch.
Step bend
If a wire with a ’step bend’ is inserted in the brackets of two adjacent
teeth, two moments are produced that are equal and in the same
direction. An intrusive force is generated on one end of the appliance
and equal, and opposite extrusive force is exerted on the other end,
such that they exert a moment opposite to the ones being generated
on the two teeth (Fig. 41.17).
FIGURE 41.17 Step bend.

If a wire with a ’step bend’ is inserted in the brackets of two adjacent
teeth, two moments are produced that are equal and in the same
direction. An intrusive force is generated on one end of the appliance
and equal, and opposite extrusive force is exerted on the other end,
such that they generate a moment opposite to the ones being
generated on the two teeth.
In the first part of this chapter, we discussed the types of force

systems required to produce a given centre of rotation and analysed
the force systems generated by various geometries, including the
concept of equilibrium. In the next section, we will discuss the
properties of wires as they relate to helping us design appliances that
produce optimum magnitude and duration of forces and moments.
Basic properties of orthodontic wires
The basic properties of an elastic material can be defined by the
stress–strain curve in response to an external load. Load and
deflection are external characteristics, and analogous to these, stress
and strain are internal properties. Stress is the internal distribution of
load, defined as the force per unit area (Fig. 41.18). The strain is the
internal distortion produced by the load and is defined as deflection
per unit length (Fig. 41.19).
FIGURE 41.18 Stress is the internal distribution of load, defined
as the force per unit area.
FIGURE 41.19 Strain is the internal distortion produced by the
load and is defined as deflection per unit length.
The deflection properties of a wire can be studied if a load is

applied to one end of a beam while the other is rigidly supported. If
the wire is supported on both ends, as often is the case in orthodontic
appliances, one can still apply similar principles although in a more
complex fashion. Fig. 41.20 represents a load-deflection diagram of a
beam. It can be seen that from 0 to PMax (maximal elastic load), there
is a linear relationship between load and deflection, as the load
increases, the deflection increases proportionately. At PMax, a point is
reached where deflection is no longer proportional to load. The
behaviour of the wire up to PMax is in the elastic range and to the
right of it is in the plastic range.4 Up to PMax, the wire will return to
its original shape if the load is removed, however, beyond that, the
wire begins to undergo permanent deformation until it reaches PUlt
(ultimate load), the point at which point the wire breaks.
FIGURE 41.20 Load-deflection diagram of a beam.

From 0 to PMax (maximal elastic load) there is a linear relationship
between load and deflection, as the load increases, the deflection
increases proportionately. At PMax, a point is reached where deflection
is no longer proportional to load. The behaviour of the wire up to PMax
is in the elastic range and to the right of it is in the plastic range. Up to
PMax, the wire will return to its original shape if the load is removed,
however, beyond that, the wire begins to undergo permanent
deformation until it reaches PUlt (ultimate load) at which point the wire
breaks.
A load-deflection curve gives information on a particular wire or

spring. However, stress–strain curves provide similar information on
a given alloy, regardless of the configuration. In Fig. 41.21, 0 to EL
(elastic limit) is a straight line, denoting that stress is proportional to
strain. The ratio of stress to strain is called the modulus of elasticity
(E). EL is the point up to which the greatest stress can be applied
without permanent deformation. Yield point and proportional limit
lay close to EL, although different by definition. Eventually, at the
ultimate stress level, the wire will fracture.
FIGURE 41.21 Stress–strain curve of an alloy.
0 to EL (elastic limit) is a straight line, denoting that stress is
proportional to strain. The ratio of stress to strain is called the modulus
of elasticity (E). EL is the point up to which the greatest stress can be
applied without permanent deformation. Yield point and proportional
limit points lay close to EL, although different by definition. Eventually,
at the ultimate stress, the wire will fracture.
Strength. Strength is a measure of the maximum load that a wire can

withstand. The point at which any permanent deformation is first
observed is called the proportional limit or elastic limit. The point at
which 0.1% permanent deformation has occurred in the wire is called
the yield strength, and the load at which the wire ultimately breaks is
called the ultimate strength. Strength is measured in g/cm2.
Stiffness. Stiffness is the force magnitude delivered by the wire and
is proportional to the slope of the elastic portion of the load-deflection
curve. Stiffness varies directly and linearly with the modulus of
elasticity (E). Stiffness and springiness are reciprocal properties, that
is, a wire that is stiffer is less springy, and vice versa. In a load-
deflection graph, the more vertical the slope, the stiffer the wire, and
the more horizontal the slope, the less stiff or more springy the wire.
The modulus of elasticity of stainless steel is about 26 × 106 psi,
whereas, that of beta titanium is about 10 × 106 psi. Therefore, a
stainless steel wire is more than twice as stiff as beta titanium. In other
words, a spring made of beta titanium will deliver less than half the
force generated by a similar spring made of stainless steel. In most
orthodontic applications, a wire or spring with low stiffness is
desirable as it provides low forces over a longer duration.
Range. Range or spring back is a measure of how far a wire or
spring can be deflected without taking a permanent set. It is
determined by the horizontal distance on the load-deflection curve up
to the yield point. A spring made of beta titanium can be deflected
about twice as much as a similar spring made of stainless steel before
it starts to undergo permanent deformation. A higher range is
generally desirable as it allows for a low load deflection rate and
increased time between appointments.
Load-deflection rate. The load-deflection rate is defined as the amount
of force generated per unit of activation. For example, if a spring is
activated 3.0 mm and it generates 150 g of force, the load deflection
rate of the spring would be 150 g/3 mm = 50 g/mm of activation.
Load-deflection rate = load/deflection

A vertical loop in a rectangular stainless wire may generate up to 1000
g of force per mm of activation. On the other hand, a different design
of loop, incorporating an increased amount of wire and made of beta
titanium, may produce only 50 g of force per mm of activation. It is
desirable for an appliance to have a low load-deflection rate since
such an appliance would produce a lower, more constant force that is
active over a longer duration.
Resilience. Resilience is the area under the stress–strain curve up to
the yield point. It represents the energy storage capacity of the wire
and is determined by a combination of strength and springiness.5 A
stainless steel wire that has undergone more work hardening during
production is more resilient as its yield point has been extended
further out and it can hold more energy before it takes a permanent
set.
Formability. Formability is the area between yield point, at which the
wire begins to take a permanent set, and failure point, at which the
wire breaks. It represents the capacity of the wire to be bent into loops
and other shapes. If the distance from yield point to ultimate strength
is very small, the wire breaks easily while bending and is termed
brittle. Formability is a desirable property in a wire. Stainless steel and
beta titanium are quite formable, whereas, nickel–titanium is difficult
to form.
Friction. When one object moves over another, friction at their
interface produces resistance to the movement. The amount of friction
generated is dependent upon, the area of contact, the force with which
the two opposing surfaces contact, and the type of surface coming into
contact. When a tooth is moved along an archwire via sliding
mechanics, the tooth tips and the mesial and distal ends of the bracket
dig into the wire, increasing the amount of frictional resistance. This in
turn, may result in loss of anchorage or binding, which results in
decreased or no tooth movement.6
One way to overcome the effects of friction while retracting teeth is
to incorporate loops into the archwire. However, this may not always
be very practical, in which case a wire with a slick surface, which
generates the least amount of frictional resistance would be desirable.
The newly introduced self-ligating brackets reduce the frictional
resistance between the wires and bracket appreciably.
Other factors
Other than the properties inherent in a material, the characteristics of
a spring can also be dramatically affected by other factors:
Diameter. Doubling the diameter of the wire, for example, from
0.010 to 0.020 in. increases the stiffness, or force by the fourth power,
or 16 times. In a more practical example, a spring made of 0.018-in.
wire will produce nearly twice as much force as a similar spring made
of 0.016-in. wire. Reducing the diameter of the wire, however, has a
negative effect on the strength of the wire. Halving the diameter
reduces the strength by the third power, or eight times. Change in
diameter has a less dramatic effect on the range of action; doubling the
size of the wire decreases the range by a factor of two.
Length. Doubling the length of the wire between the attachments
decreases the stiffness by the third power, or eight times; and
increases the range by the second power or four times. Doubling the
length of the wire only reduces the strength by half.
In practical terms, although reducing the diameter of the wire
dramatically reduces the force, unfortunately, it also dramatically
reduces the strength of the wire. In selecting a wire for a particular
application, first one should make sure that it has enough strength so
that it does not distort (yield strength) or break (ultimate strength)
during use in the mouth. Having chosen a particular diameter of the
wire to provide adequate strength, the amount of wire incorporated
into the spring can be increased to decrease the force and increase the
range.
Placement of additional wire. Not only is it important to incorporate
additional wire into spring to decrease the load-deflection rate and
increase the range, location of wire is placement is critical. A common
method to increase the amount of wire in the spring is by
incorporating a helix or loop. For example, a helix is often added to a
finger spring in a removable appliance to increase the amount of wire
in the spring and its range of action. When such a spring is loaded,
there is zero bending moment at the free end and maximum bending
moment where the wire emerges from the acrylic. Larger the bending
moment, greater the tendency for the wire to distort. Therefore, the
place to incorporate the helix would be close to where the spring
emerges from the acrylic where the bending moment is the highest,
and not in the middle of the spring.
The direction of loading. When a wire is bent, stresses are built up in
the material at the site of the bending. If the wire is loaded in the same
direction as the bend, the wire resists further deformation. However,
if the wire is loaded in a direction that tries to undo the bend, the
pent-up stresses in the wire help to distort the wire more easily. For
example, if an open U-loop is used to open space it is compressed in
the direction of the bend in the ‘U’ and therefore is more resistant to
deformation. However, if the same loop is used to close space by
pulling the loop apart, the built-up stresses in the wire get a chance to
release, and the wire distorts more easily.
Stainless steel
Since mid-century, stainless steel has been the mainstay of orthodontic
wires. It possesses high yield strength, 26 × 103 psi and ultimate
strength, 330 × 103 psi, and is quite formable. It has a high modulus of
elasticity, 26 × 106 psi, therefore, the wire is quite stiff and produces
high forces. However, the stiffness can be reduced, and the range
increased by bending loops or other configurations into the archwire.
An added advantage of stainless steel is its reasonable price.
Most stainless steel wires contain 18% chromium and 8% nickel,
which make the material resistant to rust. During production, cold
working hardens the wire and annealing softens it. By increasing the
amount of cold working during production, the yield strength of the
wire can be increased, thereby making the wire more resilient. These
highly resilient stainless steel wires are sometimes termed ‘super’
wires. However, increasing the yield strength decreases the amount of
formability and these super wires can be brittle and need care while
bending.
Nickel–titanium
In the 1970s, a nickel–titanium alloy called nitinol was introduced into
orthodontics. Nitinol was originally developed by William Buehler for
the space programme, and in that application, one was able to use the
shape memory property of the alloy. The nitinol wire has a low
stiffness (E = 4.8 × 106 psi), and the range of action is about four times
that of stainless steel. Nickel–titanium is not very formable, therefore,
it is difficult to place bends in it. As the wire has large spring back and
produces low forces, it is used in the initial stages of treatment for
alignment and levelling of the teeth.
Some of the later nickel–titanium alloys, Chinese NiTi (Ormco) and
Japanese NiTi (GAC) displays the characteristic of superelasticity. As
a result of phase transformation of the material, the deactivation part
of the curve has a fairly flat area. This plateau in the load-deflection
curve represents superelasticity.7,8 Superelasticity indicates that the
wire can be deflected a large distance without much change in the
level of force (Fig. 41.22).
FIGURE 41.22 Superelasticity.

The plateau in the unloading part of the load-deflection curve
represents superelasticity. Superelasticity indicates that the wire can be
deflected a large distance without much change in the level of force.
Titanium–molybdenum
In the 1980s, a beta titanium alloy was introduced to orthodontics by
Burstone and Goldberg.9 The elastic modulus of beta titanium is about
10 × 106 psi. Therefore, a spring made of beta titanium will produce
only 40% of the force of a similar spring in stainless steel. Moreover,
the range of deflection of beta titanium is about twice that of stainless
steel. The wire has reasonable formability. The low force and large
range of action of the wire make it very suitable for retraction springs
and space closing, looped archwires. The wire is expensive as
compared to stainless steel, but its properties make it the wire of
choice for specific applications.
An ideal appliance should:
Possess adequate strength to not distort or break during use.

Control the magnitude of forces.
Control the magnitude of moments.
Control the moment to force ratio.
Produce low load-deflection rate.
Preferably be able to multi-task.
Produce the least amount of side effects. It will be frictionless or
generate low friction.
Require the least amount of patient cooperation.
Be user-friendly, both for the operator and the patient.
Be reasonably priced.
Application of principles and properties

An example of an appliance using the principles listed above is the K-
SIR (Kalra-simultaneous intrusion retraction) archwire.10 The K-SIR
archwire is used for en masse retraction of the six anterior teeth in first
premolar extraction cases that require maximum anchorage as well as
intrusion of the anterior teeth for correction of deep overbite.
The K-SIR archwire consists of a closed vertical loop made in 0.019 ×
0.025 in. beta titanium wire. There is a centre V-bend placed between
the molars and canines to produce two equal and opposite moments
to prevent tipping of these teeth into the extraction site as space is
closed (Fig. 41.23A).
FIGURE 41.23 (A) The moments produced by the centre V-bend
(dashed line) in the K-SIR archwire counter the tipping moments
caused by the activation force. (B) The off centre V-bend in the K-SIR
archwire causes a large tip back moment on the molar as well as an
intrusive force on the anterior teeth and an extrusive force on the
molars.
In addition, a key component of this wire is an off centre V-bend

that is placed closer to the molar. This off centre V-bend causes a large
Cw moment on the molar, which tries to tip the crown of the molar
back. On the other hand, the force from the activation of the loop to
close spaces tends to tip the crown of the molar forward. As the forces
generated by the activation of the loop are kept quite low, the large
moment from the off centre V-bend which tries to tip the crown of the
molar back is sufficient to prevent the molar from coming significantly
forward.
From the equilibrium diagram, we can see that the off centre V-
bend also results in an intrusive force on the anterior teeth and an
extrusive force on the molars (Fig. 41.23B). The light intrusive force is
optimal for the intrusion of the anterior teeth, whereas, the equal and
opposite extrusive force on the molars is unlikely to cause extrusion of
the molars as it is countered by the forces of occlusion.
The K-SIR archwire produces low forces and a low load-deflection
rate as a result of using beta titanium wire and incorporating a fair
amount of wire in the spring. Using 0.019 × 0.025 in. dimension wire
provides adequate strength and also adequate stiffness to generate the
required moments. The wire controls the moment to force ratio on
both ends, resulting in bodily movement of both, the molars and the
canines.
Bypassing the second premolar provides a large inter-bracket
distance between the canine and first molar, allowing one to utilise the
effects of the off centre V-bend. The appliance multi-tasks, in that it
retracts the six anterior teeth en masse and also intrudes them at the
same time. The archwire uses frictionless mechanics, is not dependent
upon the patient to wear a headgear to conserve molar anchorage and
limits any side effects by keeping the forces low.
Key Points
A major part of orthodontics involves moving the abnormally
positioned tooth (teeth) into the desired position in the mouth through
a variety of systems that are created through a passive bracket and
active components of wires.
The most active component of the appliance system is ‘force’. The
application of ‘optimum force’ to produce tooth movement in the
desired direction, requires a thorough understanding of the principles
of engineering and the force producing system.
The intensity and duration of force are governed by the material
properties and design of the wire.
Type of tooth movement will be governed by the point of
application of force and moment generated.
A clinician is a bioengineer who should have a clear understanding
of the mechanical principles of tooth movement in the biological
environment of the oral cavity.
References
1. Burstone CJ, Koenig HA. Creative wire bending—the
force system from step and V bends. Am J Orthod
2. Kalra V. The K-loop molar distalizing appliance. J
Clin Orthod. 1995;29(5):298–301.
3. Lindauer SJ. The basics of orthodontic mechanics.
Semin Orthod. 2001;7(1):2–15.
4. Burstone CJ. Application of bioengineering to clinical
orthodontics. In: Graber TM, Swain BF, eds.
Orthodontics: current principles and techniques. St.
Louis: Mosby; 1985.
5. Proffit WR, Fields Jr HW editors. Mechanical
principles in orthodontic force control. St. Louis:
Mosby; 2000.
6. Kapila S, Sachdeva R. Mechanical properties and
clinical applications of orthodontic wires. Am J
7. Burstone CJ, Qin B, Morton JY. Chinese NiTi wire—a
new orthodontic alloy. Am J Orthod.
1985;87(6):445–452.
8. Tonner RI, Waters NE. The characteristics of super-
elastic Ni-Ti wires in three-point bending. Part I: the
effect of temperature. Eur J Orthod.
1994;16(5):409–419.
9. Burstone CJ, Goldberg AJ. Beta titanium: a new
orthodontic alloy. Am J Orthod. 1980;77(2):121–132.
10. Kalra V. Simultaneous intrusion and retraction of the
anterior teeth. J Clin Orthod. 1998;32(9):535–540.
CHAPTER 42
Preservation of normal occlusion
and interception of malocclusion
during early mixed dentition
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Goals of preventive and interceptive orthodontics
Management and preservation of arch length
Factors influencing the rate of space loss
Factors influencing the plan of a space maintenance
Potential benefits of space maintaining appliances
Disadvantages of space maintaining appliances
Passive appliances
Active space maintainer or space regaining appliance
Controversies with serial extraction
Benefits and indications of serial extraction
Relative contraindications
Steps in serial extraction
Self-alignment/driftodontics
Anterior cross-bite in deciduous and mixed dentition
Anterior cross-bite in deciduous dentition
Anterior cross-bite in early mixed dentition
Unilateral cross-bite with mandibular shift
Aetiology
Early treatment
Dental anomalies and malocclusions during mixed dentition
Orthodontic aspects of supernumerary teeth
Supplemental tooth/dichotomy
Supernumerary premolars
Management of supernumeraries
Hypodontia
Key Points
Introduction
The objectives of the preventive and interceptive orthodontics are to
minimise or eliminate possible aetiological factors of malocclusion
during the period of occlusion development, thereby helping in the
attainment of normal occlusion.
Interceptive orthodontics implies the interception of a potentially
developing malocclusion and/or reduction of the deformity so that the
duration and complexity of the comprehensive treatment is reduced
to a great extent.
Goals of preventive and interceptive

orthodontics
1. Preservation of health and integrity of the primary dentition
and occlusion. A healthy primary dentition will:
a. Stimulate the underlying denture bases to grow
normally
b. Preserve the arch length
c. Guide the eruption of permanent successors to their
normal position.
2. Prevention and interception of environmental influences on
malocclusion like mouth breathing habits, non-nutritive
sucking habits, abnormal muscle function and occlusal
prematurities.
3. Guidance on developing dentition and management of
eruption anomalies.
4. Prevention of premature loss of primary teeth, which is
particularly significant in the buccal segment. All deciduous
teeth should be restored to normal function and mesiodistal
dimensions so as to maintain the integrity of the arch and
‘leeway space’.
a. A significant number of cases with labial impaction
of maxillary canine(s) are due to arch length
deficiency caused by mesial drift of maxillary
molar(s).
b. An early loss of deciduous first or second molars in
the mandibular arch is likely to cause the erupting
first molar to drift forward and thereby may cause
impaction of the unerupted second/first premolars
and contribute to crowding in mandibular anterior
segments.
5. Early interception of deep bite, open bite, class II and class III
problems can reduce the burden of complicated orthodontic
treatment.
Management and preservation of arch
length
Management and preservation of space in the mixed dentition require
a thorough understanding of the child’s behaviour and parent’s
awareness and attitude.
A child’s requirement to undergo dental treatment for space
management is governed by a number of considerations like caries
susceptibility, food habits, oral hygiene, social and economic status of
parents, attitude and awareness of the family/parents towards
orthodontic/dental treatment, access to dental care and above all the
benefits expected out of treatment vis-à-vis inputs required in
managing the space.
Provision of space maintainer necessitates a thorough analysis of
the case especially with respect to development and root formation of
the unerupted teeth. For instance, space maintenance may or may not
be needed if second premolars are congenitally absent. Space
maintainer may not be necessary even in conditions where 1/2–2/3 of
succedaneous tooth root is formed. It is mandatory to arrive at the
complete diagnosis with respect to tooth size and arch length
discrepancy by means of arch length measurements, such as Nance
method and analysis of the size of unerupted tooth material using an
appropriate methodology.1
The arch length and space requirements are quantified. The
craniofacial skeletal pattern, status of occlusion, and neuromuscular
behaviour are factored while planning orthodontic management of
space.
The immediate consequences of early loss of primary maxillary first
molars are primarily distal drift of deciduous canines and incisors,
causing space loss of about 1 mm in the arch. The space loss is more
significant during the first 6 months, and therefore space maintainer
should be pre-fabricated prior to extraction; which can be inserted at
the same sitting as extraction of the deciduous molar.
Factors influencing the rate of space loss
1. Muscular pattern: space loss is rapid in ectomorphic children
with a vertical craniofacial growth trend.
2. Space loss is relatively slow in children with horizontal
craniofacial growth trend, such as in class II division 2 type of
pattern.
3. Abnormal musculature/habits, such as non-nutritive sucking
may accentuate rate of space loss.
Factors influencing the plan of a space

maintenance
1. Time elapsed since extraction/loss of the deciduous tooth.
2. Age of the child and dental age.
3. The amount of bone between the erupting permanent tooth
crown and oral cavity.
4. The eruption of neighbouring teeth.
5. Path of the eruption of the permanent successor.
6. Congenital absence or presence of a supernumerary tooth.
7. Molar occlusion and facial type.
8. Patient’s oral hygiene and status of dental health.
9. Caries susceptibility and food habits.
10. Parent’s and child’s attitude towards dental treatment.
11. The amount of root formation of the succedaneous permanent
tooth.
Potential benefits of space maintaining

appliances
1. Reduced prevalence or severity of:
a. Crowding, ectopic eruption
b. Tooth impaction
c. Cross-bite
d. Excessive overbite and overjet
e. Poor molar relationship.
2. Considerable savings of cost by reducing the need for future
Disadvantages of space maintaining

appliances
• Soft tissue impingement.
• Interference with eruption of adjacent teeth.
• Pain, plaque accumulation and increased susceptibility to
dental caries.
• Undesirable tooth movement.
• Inhibition of alveolar growth and prevention of eruption of
tooth if not removed in time.
• Broken, dislodged or lost appliances.
On the basis of data of 16 papers published between 1987 and 2007,

which satisfied the inclusion criteria, Laing et al.2 reported that there
is limited evidence to recommend for or against the use of space
maintainer to prevent further severity of malocclusion in permanent
dentition.2
The space maintenance appliance can be passive, that is to preserve
arch length or space of the missing deciduous tooth or active to regain
and maintain the deciduous tooth space partially lost due to migration
of neighboring teeth.
Passive appliances
Band and loop space maintainer
The most commonly used space maintainer is the band and loop
design, which can be fabricated on a deciduous second molar to
maintain space created by premature extraction of deciduous first
molar, when first permanent molar erupts. The band and loop can be
constructed either before the extraction of a deciduous tooth and
cemented immediately after extraction or can be fabricated post-
extraction.
A pre-fabricated band is selected for the tooth, which is most often a
deciduous molar or permanent first molar. The band is left on tooth
while an alginate impression is made. The band is removed and
transferred to alginate impression at its appropriate position and
orientation. A dental stone cast is poured. A wired framework is made
and soldered. The appliance is polished. It can be cemented
immediately after extraction with fluoride releasing glass ionomer
cement (GIC). Check for occlusion and any interferences with the
teeth in the opposite arch or impingement on soft tissues (Fig. 42.1).
FIGURE 42.1 A child in early mixed dentition stage and high
caries susceptibility has been provided with band and loop space
maintainer.
The child is a severe mouth breather, has a long narrow face. His
cephalogram shows a vertical pattern of facial growth and adenoids
compromising the oropharynx. A child with above type of severe
malocclusion needs early orthodontic consultation and comprehensive
treatment planning.
Removable partial denture

A removable partial denture can be fabricated in situations of multiple
extractions, such as in maxillary dentition, which also serves as a
space maintainer (Fig. 42.2).
FIGURE 42.2 A partial denture for missing deciduous molars in

the right maxilla. Source: Courtesy Dr Philippa Sawyer, Paedodontist,
Sydney, Australia.
Distal shoe space maintainer

The appliance is indicated for guiding the unerupted permanent first
molar into the position after the premature loss of or extraction of
second primary molar.3 This can be prepared with the molar band as
the technique described above or as a single sitting appliance with
stainless steel crown as a retainer.4 A stainless steel crown is fitted on
the primary molar. A stainless steel extension is soldered to the crown
and extended to the former distal contact of primary second molar to
guide the eruption of the first molar (Fig. 42.3). After the first molar
erupts in the mouth, distal shoe space maintainer is replaced with a
more stable space maintainer like band and loop maintainer.
FIGURE 42.3 Distal shoe space maintainer and eruption guide
appliance.
(A) The distal shoe is soldered on SS crown of a lower first deciduous
molar. (B) The affected tooth is extracted. (C) The appliance with the
crown is cemented in place immediately following extraction. Source:
Courtesy Dr Philippa Sawyer, Paedodontist, Sydney, Australia.
Bonded space maintainer

The successful advent of bonding on tooth surfaces has also been
inducted in paediatric dentistry in the maintenance of space. A rigid
wire framework can be bonded between lower first molar and
deciduous lower molar.5
Others have used glass fibre reinforced composite resin space
maintainer. The space maintainer is prepared chair side and fixed
with adhesive bonding. It is easy to fabricate, does not require
impression and band making and is aesthetic.6,7
Lower lingual arch (LLA)

LLA is an excellent space maintainer where multiple deciduous teeth
are to be extracted due to dental caries. LLA can be a passive arch to
maintain the arch length or can be activated to upright mesially
tipped first molars to some extent (Fig. 42.4).
FIGURE 42.4 Lower lingual arch (LLA).
(A) LLA soldered on first molar bands. (B) Active LLA has a U loop,
which can be activated to regain the lost space by uprighting the
mesially tilted molar.
LLA can also be used when a unilateral primary canine is lost

prematurely; disrupting the integrity of the arch and causing a shift in
the midline. In such cases, the contralateral deciduous canine may be
extracted and a LLA is cemented. The purpose of LLA here is to
prevent lingual uprighting of incisors and hence loss of arch length.
The LLA is made of 0.036-in. steel wire. It can be a fixed lingual
arch, which is soldered to the lingual side of molar bands or a
removable one, which can be inserted and removed by the dentist.
The removable lingual arch has a male and female assembly and a
lock. The lingual vertical tube (female) is welded on to the molar
bands while the vertical inserts (male) are prepared by bending a
closed vertical loop in the lingual arch. An arch can be used to regain
small spaces and upright mesially tilted molars. The LLA can be
retained in mouth till the eruption and settling of premolar buccal
occlusion. Thereafter the LLA can continue to serve the purpose of
anchorage enhancer should there be a need for a comprehensive
phase of orthodontic treatment. Therefore molar bands should always
carry buccal tubes.
Nance button as a space maintainer

In maxillary arch a Nance button arch cemented on first molars serves
useful purpose to prevent mesial migration of first molars when
multiple deciduous teeth have been extracted.
Active space maintainer or space regaining
appliance
An active space maintainer would be used to regain the space lost due
to tipping and migration of adjacent teeth into the extraction space(s),
that is, loss of arch length. The important factors to be considered are:
1. Type and severity of existing malocclusion.

2. Radiographic evidence of the presence of the permanent
successor for which space is being regained; its space
requirements for accommodation in the dental arch and dental
age vis-à-vis eruption status.
A space regainer appliance is fabricated with the sole objective of

either uprighting a mesially tipped mandibular molar or distalising a
maxillary first molar; however, the mechanics involved can be quite
intricate.
A space regaining procedure should be attempted following
complete space analysis and thorough diagnosis with regard to future
comprehensive orthodontic treatment based on the nature of
malocclusion, craniofacial skeletal pattern and remaining growth. A
space regaining procedure could be the initial step towards more
comprehensive treatment procedures that may follow or be required
at a later date.
A sectional fixed appliance with an open coil spring compressed
between brackets of the first premolar and molar tube is used to create
space for the erupting second premolar. This is the most common
space-regaining appliance (Fig. 42.5).
FIGURE 42.5 Active space maintainer or space regaining
appliance.
Mandibular arch
Sectional or full fixed appliance.

Lip bumper can help upright the mesially tipped lower molar(s)
and regain lost space.
Sectional expansion screw serves the same function as a sectional
fixed appliance.
Maxillary arch
Sectional or full fixed appliance.

Maxillary molar distalisation.
Molar distalisation with extraoral appliance.
Intraoral molar distalisation.
Maxillary molar distalisation is a part of comprehensive orthodontic

therapy and may constitute interception of malocclusion in mixed
dentition stage when attempted to regain space lost due to the mesial
migration of the maxillary molar associated with early loss of
deciduous molar. These methods have been described in great detail
in Chapter 49.2 on non-extraction treatment (Tables 42.1A–42.2B).
Table 42.1A
Space maintainer in the maxillary arch: primary dentition
Table 42.1B
Space maintainer in the mandibular arch: primary
dentition
Table 42.2A
Space maintainer in the maxillary arch: mixed dentition
Table 42.2B
Space maintainer in the mandibular arch: mixed
dentition
a Most versatile appliance in the mixed dentition stage. LLA can be used as arch length
regainer/conservation of E space.
Serial extraction is an interceptive procedure, which is more
appropriately termed as eruption guidance. It can be defined as an
interceptive orthodontic procedure that helps to resolve tooth
crowding of 8 mm or more by the serial creation of space in the arch
during the development of occlusion by a system of tooth removal,
which usually begins with a deciduous tooth (often deciduous canine
and sometimes deciduous first molar), leading to the extraction of all
first premolars.
The serial extraction procedure is a major component of the
comprehensive orthodontic treatment, which lasts from early mixed
dentition stage to permanent dentition when a phase of full-banded
fixed mechanotherapy of lesser duration is needed.
The principle of early treatment, associated with the extraction of
primary teeth followed by the removal of permanent teeth, was first
described by a Frenchman Robert Bunon in his ‘Essay on the Diseases
of the Teeth’, published in 1743, over 255 years ago! Kjellgren, a
Norwegian, is credited for coining the term ‘Serial extraction’8.
According to Dale ‘the term is somewhat dangerous because it
tends to create a misconception of simplicity. It is, in fact, misleading.
It implies that there is nothing more involved than the mere extraction
of teeth. Hotz’s term, Guidance of Eruption, or the term Guidance of
Occlusion is better’.9,10
One of the major considerations to undertake serial extraction
procedure is the prediction and assessment of growth and severity of
crowding during early childhood and early mixed dentition. ‘The
most crucial decision that we as specialists in orthodontics are
required to make the correction of a malocclusion: should we extract
teeth or not?’ To add the dimension of time, to complicate it with
growth and development, and to carry it out in a serial manner is even
more demanding! Serial extraction is not easy, as so many mistakenly
believe, and it should never be initiated without a comprehensive
diagnosis! One can extract teeth with the greatest of ease during serial
extraction procedures, but if the basic principles of diagnosis are
ignored, the result will be failure and disappointment. It will not only
be injurious to the patient, but it will also hurt the reputation of the
practitioner and, ultimately, our speciality of orthodontics. ‘Serial
extraction (based on a thorough knowledge, a sound diagnosis)
carried out carefully and properly on a selected group of patients can
be, most assuredly, a beneficial and valuable treatment procedure’.10
Controversies with serial extraction

Most difficult part of the procedure is the decision to undertake this
procedure. ‘Serial extraction is used much less now than a generation
ago because it is hard to be certain that crowding in the early mixed
dentition is severe enough to make the extraction decision at the
time’.11 On the other hand, there is much controversy about the best
way to treat class I crowding. Data shows that, in moderate crowding,
starting treatment just at the end of the mixed dentition and
maintaining leeway space facilitates non-extraction treatment.12
For a patient with crowding in the early mixed dentition, there are
three possibilities:
1. Wait until the second deciduous molars are ready to exfoliate.

Intervention is required if there is early loss of the deciduous
canines;
2. Proceed with serial extraction; or
3. Expand the arches at that time.
All these approaches are effective; the question is not whether they
work, but whether they produce a better result that justifies the
greater duration, expense and burden of treatment.
Benefits and indications of serial extraction
Serial extraction or eruption guidance procedures in extremely severe
crowding can reduce the duration and complexity of the
comprehensive treatment.13
Indications for serial extractions are:
• A child with a potential for moderate to severe crowding.

• A child with no abnormal craniofacial skeletal growth pattern.
• A child who will be available for long-term follow-up and
further comprehensive orthodontic treatment.
The most appropriate indication of serial extraction is a child who is

in early mixed dentition stage; has large tooth size—jaw size
discrepancy and a class I skeletal base. Such children are characterised
by blocked out malposed incisors; there is usually a premature loss of
deciduous canine on one side, and possibly a midline shift. Serial
extraction can be a choice in select class II cases. However, it should be
contraindicated in the majority of class III and class II cases especially
those with a tendency for a deep bite.
A growing child having class II malocclusion with a lower normal
arch and mild crowding in the maxilla or dentoalveolar protrusion
can be treated with extraction of upper first premolars alone thereby
leaving maxillary molars in class II relationship.
Class II division 2
In situations, serial extraction may be the treatment modality of choice
where the skeletal discrepancy is not being considered to be resolved
with functional jaw orthopaedics, arch length discrepancy is large,
and a severe deep bite has caused gingival recession and space cannot
be gained by labial movement of either maxillary/mandibular incisors.
Relative contraindications
Deep bite
Mild crowding
Class II division 2 pattern
Class III tendency
Congenital absence of teeth
Extreme facial types and serial extraction

Extreme facial type, that is, vertical or horizontal growth pattern in the
cases where there is a minimal protrusion and upper and lower
incisors are vertical on denture bases should not be considered for
serial extraction.
A case of serial extraction should be considered only if non-
extraction treatment modalities(s) cannot be successfully applied. It
may be well visualised that extraction of first premolars in the
mandibular arch entails that corresponding maxillary first premolars
would need to be extracted to maintain the harmony in occlusion.
In severe hypodivergent patients with strong musculature, efforts
should be made to avoid extractions. The arch length may be possibly
gained by levelling the curve of Spee and some labial tipping of
mandibular incisors.
In high angle cases with tooth size jaw size discrepancy, it may be
imperative to extract teeth to relieve crowding, upright mandibular
incisors and assist in the correction of open bite tendency. However,
anchorage preservation is imperative as the teeth migrate forward
very easily.
Steps in serial extraction

The serial extraction procedures necessitate a periodic diligent clinical
and radiological review of eruption sequence and events during
transitional occlusion. In the maxilla, the favourable sequence of
eruption, in which eruption of premolars is followed by canine is
rarely disturbed; however, in the mandible, it does vary, with canines
erupting prior to the first premolars.
The purpose of serial extraction is to hasten and enhance eruption
of first premolars and early extractions so that canines can erupt
distally into extraction spaces thereby allowing anterior crowding to
resolve spontaneously. The period required for fixed orthodontic
appliance is minimised. Hence, a conventional sequence to follow is
D4C, in mandible and maxilla. In the mandibular arch, a unilateral
premature loss of deciduous canine indicates arch length deficiency.
The contralateral deciduous canine should be extracted to prevent
midline problems.
The loss or extraction of deciduous canines often causes lingual
tipping of mandibular incisors due to pressure from lip musculature
and deep bite. The deciduous canines may need to be extracted when
a radiographic examination of these teeth show evidence of definite
resorption in the form of crescents in the roots in cases with a
dentoalveolar protrusion and minor crowding.
With the extraction or loss of deciduous canines, lower incisor
crowding is often resolved or minimised. At certain treatment stage,
radiographs are required to evaluate dental age or root formation of
the premolars. The deciduous molars are extracted when premolars
show half of root length. Extraction of first premolars is considered as
soon as they erupt in the oral cavity. Three methods have been
proposed for serial extraction therapy:
1. Dewel’s method (CD4) usually followed in lower arch

2. Tweed’s method (D4C) can be followed in either arch
3. Nance method (D4C). It is similar to the Tweed’s Method.
The sequence of extraction to be followed is D4C in situations

where canines and premolars show the equal status of the eruption,
that is, half of root formation and canines are likely to erupt prior to
first premolars. The objective is to hasten eruption of first premolar(s)
so that they can be extracted. Such children require a very close
observation on frequent recalls with serial radiographic examinations.
The timing of extraction of premolars is critical for the successful
outcome. The serial extraction procedure can bring successful
outcome in carefully selected cases when performed with diligence,
the timings of eruption of premolars and canines being critical.
Jimmy Boley14 has described serial extraction as a useful procedure
in cases with tooth size arch length discrepancy. ‘I have used this
approach to treatment for over 30 years and have been pleased with
the results the vast majority of time’.14 In addition to the conventional
approach, he has also suggested extraction of all deciduous canines,
deciduous first molars and premolars in one sitting under sedation. In
mixed dentition, if the discrepancy is 8 mm or more, premolars can be
removed without adverse sequelae.
Self-alignment/driftodontics
In certain clinical situations in mixed dentition may suggest a severe
tooth size arch length discrepancy. In these situations when such a
discrepancy is suspected, examination of parents and siblings can
suggest facial pattern and occlusion at adulthood. Such a patient
should undergo a detailed full set of records and comprehensive
space analysis. Timely extractions and careful watch on eruption
pattern can lead to natural migration of un-erupted canine in to first
premolar extraction space and minimise active orthodontics.
Case PM has normal profile, mixed dentition, maxillary and
mandibular canines have not yet erupted. There is space deficiency to
accommodate canines. Her mother and brother had similar type of
facial pattern and severe malocclusion for which they had undergone
comprehensive orthodontic treatment following extraction of all first
premolars. Based on history, familial pattern and large arch length
tooth size discrepancy of the case this girl was considered for
extraction of all first premolars, to allow eruption of canines and self-
alignment (Fig. 42.6A and B). The canines have erupted in occlusion
with minimal crowding. An orthognathic profile is maintained.
Minimal orthodontics with fixed appliance will now be required for
closure of remaining spaces, finishing and detailing of occlusion.
FIGURE 42.6 Case for self alignment/driftodontics
(A) Pre-treatment records. Case PM. 12/04/14. Potential crowding with
a family history of orthodontic treatment of mother and brother allowing
all first premolar extraction. Early mixed dentition clinical profile is good.
(B) Case PM. 7/05/16. The maxillary and mandibular canines have
erupted and migrated into spaces created by premolar extraction.
Timely extraction of premolars has facilitated the canines to move
distally along with eruption. The second phase of orthodontic treatment
with fixed mechanotheraphy will be much shorter.
Anterior cross-bite in deciduous and
mixed dentition
Anterior cross-bite in deciduous dentition
Anterior cross-bite in deciduous dentition is a rather uncommon
clinical finding but not rare. A young child with a cross-bite of
deciduous teeth may present with a little prominence of the chin and a
flat middle third of the face including zygomatic process.
Two important considerations in diagnosis are pertinent with such
children. It is relevant to examine siblings and parents of such
children to rule out the familial tendency for maxillary hypoplasia
and/or mandibular prognathism. A child should also be examined for
any premature contacts while closure to rule out functional shifts or
habitual forward closure.
A thorough clinical examination should include cephalometric
analysis and study models. The purpose is to evaluate skeletal
components of maxillary deficiency and/or any signs of mandibular
prognathism.
Therapeutic approach
The main issue with regard to the treatment of such children is to
assess the possible success of available growth modulation appliance
during the early period of growth. With current knowledge, it is
difficult to predict the severity of prognathism with accuracy. A child
with familial/hereditary class III of severe nature is unlikely to
respond to conventional dentofacial orthopaedic treatment and may
require a wait and watch for a possible orthognathic surgery at
adulthood. In non-familial mild class III situation, treatment with
orthopaedic appliances like Frankel functional regulator III, and/or
facemask therapy combined with rapid maxillary expansion (RME)
has been reported with success in mixed dentition phase.
Another view is to intervene with a bonded palatal expander and
facemask therapy during deciduous dentition itself (Fig. 42.7A–G).
Treatment is continued during early mixed dentition. A fully bonded
fixed appliance therapy is instituted at a later stage. Also, see Chapter
58.
FIGURE 42.7 Anterior cross-bite in deciduous dentition.

(A) Case VT 5-year old boy has an anterior cross-bite of deciduous
incisors. He appears to have slight midface retrusion/lower face
prognathism. His treatment was initiated with a chin cup, which radially
leads to correction of the anterior cross-bite. Pre-treatment. (B) After
chin cup therapy and correction of anterior cross-bite. (C–E) After rapid
maxillary expansion and facemask. Incisors erupted in normal overjet.
(F) Post-treatment cephalogram. (G) Follow-up, class I molar and
incisor relationship is attained. A long-term follow-up is required till the
completion of the eruption of permanent dentition and establishment of
occlusion.
Anterior cross-bite in early mixed dentition

During early development of dentition, one or more incisors may
erupt in cross-bite.
The cross-bite may be due to local causes, limited to permanent
teeth eruption in the anterior segment, or it could be a symptom of a
more severe skeletal malrelationship, extending from anterior to
posterior region.
Local causes of anterior cross-bite

The most common local cause of anterior cross-bite is a retained
deciduous incisor. An erupting mesiodens or unerupted
supernumerary teeth in pre-maxilla can also divert eruption path of
erupting incisors palatally. A lack of space in anterior segment and
trauma are also amongst the common causes.
A premature contact in the anterior region may lead the mandible
to shift to a convenient occlusion resulting in complete anterior cross-
bite and/or unilateral buccal cross-bite. Cross-bite of local origin must
be differentiated from a more severe form due to the underlying
skeletal pattern associated with maxillary hypoplasia and/or a large
mandible. A small maxilla can be seen in children with trisomy 21
(Mongolism) and children operated for cleft lip and palate.
A palatally/lingually erupting upper incisor could be a reason for
occlusal trauma to mandibular incisors, which may get displaced
labially out of the arch and show gingival recession and mobility.
Such a malocclusion would require immediate intervention to
prevent, gingival recession, the mobility of the affected tooth/teeth or
their early loss due to persistent occlusal trauma.
Treatment of anterior cross-bite of local origin
1. Removal of local cause, such as a retained deciduous tooth/root

stump and/or a mesiodens.
2. Provision of sufficient space required for the erupting tooth.
3. Correction of anterior cross-bite using any of the following
options:
Upper removable appliance (URA) with Z spring and posterior
bite platform—works well if sufficient space is available in the
arch. It is imperative that design of the Z spring required to
move and rotate the incisor is most favourable from the point
of view of biomechanical advantage. Failure to provide a
suitable rise in posterior bite either through a built-in occlusal
table in URA or temporary occlusal rise with glass ionomer on
deciduous molars would lead to treatment failure and injury to
the periodontium of the teeth under orthodontic force. Springs
are made with 0.018-in. spring hard temper SS wire with two
helices (Fig. 42.8).
FIGURE 42.8 Anterior cross-bite of one or two teeth of local
origin can be corrected with a removable appliance.
(A–B) Pre-treatment. (C) Maxillary appliance with buccal bite and
springs palatal to maxillary central incisors radially corrects the cross-
bite. The labial vector of force was created from a Z spring palatal to
the each of the central incisor in cross-bite. It is critical that buccal bite
is raised sufficiently for jumping the lingually locked teeth in cross-bite
(see Chapter 32 on removable appliances). If left untreated, occlusal
trauma does cause bone loss of the affected mandibular incisor(s) and
may lead to their premature loss. The benefits are the prevention of
trauma to lower incisors and interception of the developing class III
malocclusion. (D) Post-cross-bite correction. Treatment duration of 6
weeks.
A 2 × 4 fixed orthodontic appliance can help to a quick resolution of

the cross-bite. A 2 × 4 appliance comprises of, molar bands with tubes
on maxillary first molars/deciduous second molars. The four
maxillary incisors are bonded with brackets. A light wire with molar
stops and increased arch length of 1–2 mm is ligated to produce a light
continuous labial force on incisors from the built-in helices. The active
treatment period may vary from 6 to 16 weeks. Correction of cross-
bite is rapid.
Anterior cross-bite/negative overjet of skeletal origin is often
associated with a posterior cross-bite, which may be unilateral or
bilateral. Comprehensive management of skeletal cross-bite is given in
chapter on growing class III malocclusion (Chapter 58) (Fig. 42.7E–G).
Retention
Once cross-bite of local origin is corrected, the active appliance is
discontinued. However, it must be ensured that maxillary incisors
have 1–2 mm of overjet and sufficient overbite to prevent relapse.
Unilateral cross-bite with mandibular
shift
It may be seen in deciduous, mixed or permanent dentition.
Aetiology
Functional prematurities are considered an important aetiological
factor in causing a shift of the mandible. A narrow maxilla results
from poor transverse development either because of genetic causes or
environmental influences like mouth breathing, non-nutritive sucking
habits and prolonged use of pacifiers. Clinical evaluation should
include upper and lower study models with bite recorded in centric
occlusion and centric relation. A premature contact or point of
deflection of the mandible from centric relation can be identified by
careful observation of the closing and opening of jaw movements.
A class II molar relationship may be present on the side of the shift,
while on non-cross-bite side, a class I relationship is maintained.
Untreated functional unilateral cross-bites may produce facial
asymmetry in adulthood.
Early treatment
Elimination of environmental influences, such as mouth breathing and
non-nutritive sucking habits causing a narrowing of the maxilla is a
pre-requisite along with a definitive treatment. The following
treatment modalities may be considered:
1. Occlusal equilibration
2. Maxillary expansion
1. Occlusal equilibration. It involves identification of premature

contact points and their influence in deflection of the
mandible. The exact locations of premature contact(s) are
marked and dental tissue is carefully ground with high-speed
diamond conical stone. Care should be taken to maximise the
benefit with bare minimal loss of tooth structure, more so if
grinding of a permanent tooth is involved. A small percentage
of children (0%–9%) with unilateral cross-bite in deciduous
dentition show spontaneous self-correction.15,16
2. Maxillary expansion. It should preferably be achieved either
during early mixed dentition or late deciduous dentition
(before 8 years) to take advantage of active maxillary growth
and possible mid-palatal suture expansion and gain in arch
length if required for correction of minor crowding in the
maxillary anterior region.
Maxillary expansion schedule

Expansion schedule for the upper removable appliance (URA) is slow,
which is one-quarter turn (0.25 mm)/3rd day/ every week. A faster
expansion tends to displace the removable orthodontic appliance in
the mouth. The treatment duration varies depending upon the
severity of maxillary collapse. The same appliance may be used as a
retainer for a period of 6–8 months.
Rapid maxillary expansion

Rapid maxillary expander works at a faster rate of expansion usually
1–2 quarter turn (0.25–0.5 mm)/day. The cross-bite correction is very
rapid occurring in 2–6 weeks. A midline diastema may appear and
would close spontaneously following recoiling of stretched trans-
septal group of gingival fibres. Slight over expansion of the maxilla
whereby buccal slopes of maxillary lingual cusps touch lingual slopes
of the mandibular buccal cusps is a desired clinical practice. This over
expansion makes allowance for the relapse particularly of the buccal
tipping of the molars. Once the desired expansion has been achieved,
the metal expander can be fixed with light cure composite resin to
prevent further opening/un-opening. The appliance can be retained as
a retainer for another 6 months.
The RME is also associated with an anterior forward and
downward rotation of maxilla, which may cause downward and
backwards rotation of the mandible and slight anterior open bite,
especially in high angle cases. Benefits of RME in vertically growing
children should be carefully weighed against potential undesired
effects on molar extrusion and autorotation of the mandible. In such
cases, bonded appliance is preferable over the banded appliance.
Quad helix treatment to expand the maxillary arch creates optimum
conditions for normal growth of jaws/TMJ/face by elimination of
lateral bite.17 A systematic review has shown that spontaneous
correction of this condition can occur in 16%–50% subjects if left
untreated. However, success rate with quad helix appliance and RME
is nearly 100%. Expansion plates are relatively less effective (51%–
100%) and occlusal grinding can help but not certainly (27%–90%).18
Removal of premature contacts of the deciduous teeth is effective in
preventing a posterior cross-bite from being perpetuated to the mixed
dentition and adult teeth.19
Hence, most effective mode of therapy based on evidence can be
questionable. Each case should be treated on the merit of its severity
and type of problem, be kept under long-term follow-up; if needed
therapy should accordingly be modified.
Dental anomalies and malocclusions
during mixed dentition
Orthodontic aspects of supernumerary
teeth
Supernumerary teeth can be found in both the arches and all
segments; however, the anterior maxillary segment is the most
common site. Both supernumerary teeth and anodontia are of
common occurrence in the cleft region of the maxillary alveolus.
Supernumerary teeth during mixed dentition may erupt, or be seen
in various stages of formation and eruption. They may remain
asymptomatic and be only discovered during routine radiographic
examinations. They can be single, twins or multiple (odontoma).
Supernumerary teeth in the maxillary anterior region

Supernumerary teeth and mesiodens are common in premaxilla.
Presence of unerupted or erupting supernumerary teeth can affect
occlusion in the following manner.
1. Delayed eruption or impaction of the tooth in proximity.

Maxillary incisors are often affected.
2. Crowding rotation/labial tipping.
3. Displacement of roots of adjacent teeth.
4. Root resorption.
5. Cyst formation and thereby delay the eruption of neighbouring
teeth.
6. Dilacerations.
Diagnosis and location of supernumerary teeth and their effects either
on the eruption of teeth or their hindrance in successful orthodontic
treatment should be evaluated. In many instances, supernumerary
teeth need to be extracted for spontaneous correction of rotation and
crowding. In the case of a supernumerary tooth causing a physical
barrier to the eruption path of a permanent tooth, a surgical
orthodontic approach may be required. While in some cases where
active root formation of affected tooth/teeth is evident, removal of the
barrier may result in spontaneous eruption; in other situations, an
orthodontic guidance may be needed.
Supplemental tooth/dichotomy
Supplemental tooth or dichotomous lateral incisor is not an
uncommon finding in the maxillary arch. Such a tooth is the cause of
crowding and/or protrusion and may need to be extracted. It is
difficult to distinguish the dichotomous tooth owing to the very close
resemblance of morphology to its origin.
It is even more difficult to choose a dichotomous tooth for an
extraction. The tooth of choice for extraction is based on the following
considerations:
1. The tooth which least resembles contralateral tooth should be

considered for extraction.
2. The root morphology should be evaluated, and one with
normal root length should be preserved.
3. In the case of other factors being common, the preferred choice
of the tooth to be extracted will be based on difficulty/ease of
orthodontic alignment.
In general, a tooth with normal morphology and good root length

similar to contralateral tooth should be retained19 (Fig. 42.9).
FIGURE 42.9 A dichotomous right maxillary lateral incisor.
Timely intervention by extraction of the dichotomous tooth (one with
poor crown form and root) allowed quick alignment of the lateral incisor
and space for the erupting canine. (A) Pre-treatment, (B) Post-
treatment.
Supernumerary premolars
The supernumerary premolars are seen in maxilla and mandible with
higher occurrence in the lower jaw. These occur three times more in
males than females.20
The supernumerary premolars may be single, paired or multiple,
unilateral/bilateral and often discovered during routine radiographic
examinations. These premolars may cause impaction/delayed
eruption of the premolars. Multiple supernumerary teeth may occur
as a non-syndromal entity with a familiar predisposition.
Management of supernumeraries
Treatment depends on the type, position of the supernumerary tooth
and its effect or potential effects on adjacent teeth. The management of
a supernumerary tooth should form part of a comprehensive
treatment plan and should not be considered in isolation. The
supernumerary teeth may warrant removal. However, extraction is
not always the treatment of choice for supernumerary teeth and may
be monitored without removal (Box 42.1).
Box 42.1 Treatment options for the

supernumerary teeth: removal versus long-term
observation
Sr.
Indications for removal Indications for observation
No.
1 The spontaneous eruption of the supernumerary tooth has The satisfactory eruption of
occurred. related teeth has occurred.
2 When it inhibits the eruption of the permanent tooth. No active orthodontic
treatment is envisaged.
3 Causes altered eruption or displacement of the permanent There is no associated
tooth. pathology.
4 There is an associated pathology. Active orthodontic alignment Removal would prejudice
of a tooth in proximity to the supernumerary is envisaged. the vitality of the related
teeth.
5 Its presence would compromise secondary alveolar bone The general health condition
grafting in cleft lip and palate patient. of the patient.
6 The tooth is present in bone designated for implant placement.
Hypodontia
The most frequently missing teeth in the order of frequency are:
maxillary laterals followed by mandibular and maxillary second
premolars. Hypodontia is seen more frequently in the maxilla than in
mandible. A maxillary lateral incisor may be missing unilaterally or
bilaterally. A unilateral absence of maxillary lateral is associated with
small or microdontic contralateral lateral incisor. Bilateral microdontic
lateral incisors are often encountered in clinical practice. An OPG
taken at the age of 7 years in a normally growing child should show
all the teeth in various stages of formation except third molar buds,
which are seen around 9 years of age.
Missing maxillary lateral incisors

The absence of a calcifying tooth bud should alert the dental
practitioner/orthodontist to consider a congenitally absent tooth in its
total plan. Absent or microdontic maxillary laterals have been
associated with increased incidence of maxillary canine impaction. An
orthodontist should remain alert and watch canine eruption in such
cases.
Other important consideration may be to plan either maintenance of
space for the rehabilitation of missing laterals or orthodontic space
closure. Occlusion and craniofacial pattern have a considerable
influence on planning the treatment.
Treatment options
1. A case with class I occlusion with the normal profile but

missing laterals would require space maintenance for the
missing maxillary lateral incisors. The missing tooth will be
eventually rehabilitated with either a bridge or an implant.
2. A child who otherwise may need all first or upper first
premolar extractions as a part of comprehensive orthodontic
treatment for the correction of superior
protrusion/crowding/class II molar but with missing laterals
could be treated differently. Space requirements of the
maxillary arch are accommodated in the space available by the
missing laterals. The canines substitute the laterals, and first
premolars substitute the canines.
An all four-extraction case is converted to two premolar extractions,

in the lower arch only. A case with requirements of space in the upper
arch only is converted to a non-extraction case.
The upper first premolars are preserved, which substitute for the
maxillary canines. A compromised aesthetics may be a major concern
with such a treatment plan. Restorative techniques with composite
resin are used to modify the maxillary teeth; to shape canines and
premolars to look like laterals and canines.
Mandibular second premolar

Radiographic examination of child with ankylosed deciduous second
molar in the mandible is likely to show the absent second premolar.
Therefore, any extraction plan must precede a radiographic evaluation
for presence of all permanent teeth. Some less common anomalies like
dilaceration, fusion or gemination should not be missed during
radiographic examination. These dental anomalies of tooth size or
morphology can affect eruption and would influence development of
the dental arch. The timing of intervention and type of intervention
from orthodontic and aesthetic view should be considered based on
the following considerations:
1. Decision to retain or extract the tooth with aberrant

morphology
2. Endodontic treatment
3. Aesthetic veneering which may be a procedure of choice in
gemination/fusion.
Key Points
Interception of malocclusion is aimed at minimising the severity of
malocclusion or correction before it is fully established.
The choice of procedure should be based on comprehensive
analysis of diagnostic records. The correct timings are critical so is
monitoring of outcome till normal occlusion is fully established.
References
1. Ngan P, Alkire RG, Fields Jr H. Management of space
problems in the primary and mixed dentitions. J Am
Dent Assoc. 1999;130(9):1330–1339.
2. Laing E, Ashley P, Naini FB, Gill DS. Space
maintenance. Int J Paediatr Dent. 2009;19(3):155–162.
3. Barbería E, Lucavechi T, Cárdenas D, Maroto M.
Free-end space maintainers: design, utilization and
advantages. J Clin Pediatr Dent. 2006;31(1):5–8.
4. Brill WA. The distal shoe space maintainer chair side
fabrication and clinical performance. Pediatr Dent.
2002;24(6):561–565.
5. Simsek S, Yilmaz Y, Gurbuz T. Clinical evaluation of
simple fixed space maintainers bonded with flow
composite resin. J Dent Child (Chic).
2004;71(2):163–168.
6. Kargul B, Caglar E, Kabalay U. Glass fiber reinforced
composite resin space maintainer: case reports. J Dent
Child (Chic). 2003;70(3):258–261.
7. Kargul B, Caglar E, Kabalay U. Glass fiber-reinforced
composite resin as fixed space maintainers in
children: 12-month clinical follow-up. J Dent Child
(Chic). 2005;72(3):109–112.
8. Kjellgren B. Serial extraction as a corrective
procedure in dental orthopedic therapy. Acta Odontol
Scand. 1948;8(1):17–43.
9. Hotz R. Active supervision of the eruption of teeth
by extraction. Eur Orthod Soc Trans. 1947:34–47: 1948.
10. Dale JG. Serial extraction…nobody does that
anymore! Am J Orthod Dentofacial Orthop.
2000;117(5):564–566.
11. Proffit WR. The timing of early treatment: an
overview. Am J Orthod Dentofacial Orthop. 2006;129(4
Suppl.):S47–S49.
12. Gianelly AA. Treatment of crowding in the mixed
dentition. Am J Orthod Dentofacial Orthop.
2002;121(6):569–571.
13. Little RM, Riedel RA, Engst ED. Serial extraction of
first premolars—postretention evaluation of stability
and relapse. Angle Orthod. 1990;60(4):255–262.
14. Boley JC. Serial extraction revisited: 30 years in
retrospect. Am J Orthod Dentofacial Orthop.
2002;121(6):575–577.
15. Thilander B, Wahlund S, Lennartsson B. The effect of
early interceptive treatment in children with
posterior cross-bite. Eur J Orthod. 1984;6(1):25–34.
16. Kutin G, Hawes RR. Posterior cross-bites in the
deciduous and mixed dentitions. Am J Orthod.
1969;56(5):491–504.
17. Kecik D, Kocadereli I, Saatci I. Evaluation of the
treatment changes of functional posterior crossbite in
the mixed dentition. Am J Orthod Dentofacial Orthop.
2007;131(2):202–215.
18. Petrén S, Bondemark L, Söderfeldt B. A systematic
review concerning early orthodontic treatment of
unilateral posterior crossbite. Angle Orthod.
2003;73(5):588–596.
19. Harrison JE, Ashby D. Orthodontic treatment for
posterior crossbites. Cochrane Database Syst Rev.
2001;1: CD000979.
20. Solares R, Romero MI. Supernumerary premolars: a
literature review. Pediatr Dent. 2004;26(5):450–458.
CHAPTER 43
Orthodontic treatment with
contemporary fixed appliance
Phase I: laying the foundation
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Designing a treatment plan and execution strategy
Banding and bonding
Separation of teeth
Metal-based separators
Elastomeric separators
Molar bands
Bracket positioning
Prebond evaluation
Buccal tubes
Bracket positions on anterior and premolars
Occlusogingival placement or bracket height
Rotational position
Slot angulations
Key Points
Introduction
Comprehensive orthodontic treatment with contemporary fixed
appliance (CFA) therapy follows an organised sequence and order of
events. In most instances, it follows a standardised protocol, though
variations from case to case are observed in their implementation.1,2
This chapter describes the step-by-step sequence of events in
orthodontic consultation and instituting orthodontic appliance in a
mouth.
The first interaction with the patient and his/her family is conducted
in a meeting room which offers a relaxed and friendly environment
and not in a typical dental clinic setting (Fig. 43.1). The meeting is
aimed to elicit the following information:
1. Concerns of parents and patient.

2. Any medical and dental history which limits or contraindicates
3. Motivation for seeking orthodontic treatment.
4. Patient’s and parents expectations on aesthetic and functional
benefits.
5. Commitment to dental/orthodontic treatment.
6. Social and economic status.
7. Overall personality of the patient.
FIGURE 43.1 The first consult.
The patient should preferably be greeted with a friendly gesture, which
could be done in the waiting area.
The patient and his/her parents may be mailed an information

brochure on orthodontic treatment or instructed by the secretary to
visit the doctor’s website before the first appointment with an
orthodontist. This first interactive meeting can be extended to a formal
recording of the detailed history and clinical examination and if
possible to prepare first case records.
Minimal/essential diagnostic records include upper and lower
study models and clinical photographs which should include five
extraoral views and five intraoral views. A lateral cephalogram and
OPGs are now considered essential, although many clinicians would
insist on these records only if clinical situations warrant. In addition,
X-rays are avoided for reasons of cost and hazards of radiation.
Supplemental records such as PA cephalogram and radiographs of
TMJ may be obtained if indicated or as the case may be. Some
clinicians like to complete the records in more than one sitting with
non-X-ray records in the first appointment and X-ray-related records
in the second appointment to avoid patient’s fatigue.
Designing a treatment plan and
execution strategy
Orthodontic treatment should be designed to address the patient’s
concerns and his/her general and oral health. The patient and his/her
guardian must be informed of all phases of treatment proposed,
including retention and follow-up, need for patient’s compliance and
commitment required, and any other limitations on treatment
outcome posed due to dental or medical conditions of the patient (Fig.
43.2). Also, cost and financial aspects may have to be clearly defined
and agreed upon.
FIGURE 43.2 Second consultation.

Treatment plan and steps of its execution are discussed with guardian
and patient with complete records. They should be explained all
possible treatment options, prognosis and commitment required during
treatment.
Consideration must be given to minimise the number of visits for
orthodontic treatment to reduce the burden of care due to travel, and
missed school and working man-hours. Oral health education and
practice of prevention of dental diseases should be reinforced before
and during orthodontic treatment. Plaque control should be
emphasised and also the eating habits. Regular dental recall visits
should continue with the family dentist for the care of oral hygiene
and caries.
The objectives of orthodontic treatment should be directed towards
the attainment of optimal results for individualised patient needs. The
ideal treatment plan may not always be possible or practical to
implement and should be discussed and mutually agreed upon before
initiating any treatment procedures.
Treatment outcome should be aimed at optimising the periodontal
and dental conditions, arch form and occlusion while minimising risks
such as gingival recession, loss of supporting bone, root resorption,
dental caries or decalcification of the teeth. The patient and his/her
parents should be educated on undesirable treatment effects which
are likely to be observed during or after treatment and modalities to
avoid or minimise them.
The posttreatment outcome should be envisaged based on the
complexity of the problem and magnitude of the treatment
performed. The clinical observations, history, growth analysis and
information derived from diagnostic cast measurements and
cephalometric analysis are used to formulate a formal problem list,
and goals of treatment are outlined.
Treatment planning includes prioritisation of problems to be
attended, modalities of treatment, treatment strategies and
biomechanics involved at each step. Retention plan is also considered
at this stage and duration of retention, and possible prognosis and
treatment outcome are envisaged.
The planned treatment approach is discussed in detail with the
patient and his/her parents. It is expected that a person undergoing
orthodontic treatment and his/her parents would be made familiar
and explained all possible steps and consequences of orthodontic
treatment including possible risks.
The increased demand on oral hygiene and expected care of
appliance require alterations in food habits and should be a
component of discussion during this session. Extractions of teeth, if
any, are suggested, and appropriate referral is made to a
general/family dentist. At this appointment, a schedule is set up for
separators followed by banding/bonding and first follow-up.
Banding and bonding
The first banding/bonding appointment includes re-emphasis on good
oral hygiene maintenance and insertion of separators for the molar
bands. These separators are usually eight in number and are given
mesial and distal to first molars, which are often the terminal teeth of
the archwires.
Separation of teeth
There are two types of orthodontic separators:
1. Metal-based separators
a. Brass wire
b. Kesling separators.
2. Elastic/rubber-based separators
a. Elastic ring separators
b. Dumbbell separators.
Metal-based separators
a. Metal-based separators include separation with soft brass wire
of 0.5–0.6 mm diameter. The use of brass wire separators has
been abandoned for difficulties associated with its sterilisation
and pain associated with separation.
A piece of brass wire is inserted through buccal gingival sulcus
below contact points between the two teeth required to be
separated (usually between first molar and second molar and
second premolar and first molar), turned around the contact
point on the occlusal surface and twisted in a buccal position
usually with Howe pliers. Extra wire is cut leaving a small
twisted pigtail. The twisted end is gently tucked gingivally.
This technique though effective in separation of teeth is
associated with pain, encourages plaque formation and poses
difficulties in controlling separating force.3
b. The Kesling separators are available commercially as
preformed springs made up of highly springy Australian
special wires of 0.016- or 0.018-in. dimensions. These delicate
yet effective springs are designed to produce gentler forces
and self-retention between the two teeth. The separator has
two arms, one arm passing gingival to the contact point and
another arm occlusal to the contact point. The two arms are
joined with a helix which generates force. The gingival arm
has a sharp end which helps it to negotiate through interdental
gingival sulcus, from buccal to lingual side. The occlusal arm is
longer with a built-in vertical arm to lock the spring on the
lingual side to prevent its slippage. The springs are left for 24–
48 h. The gentle force from helix causes the teeth to separate. A
sufficient gap is created at contact points enough to gently slip
the orthodontic band (usually made of 0.18-in. thick band
material) around the molar (Fig. 43.3).
FIGURE 43.3 A Kesling separator.

These can be easily fabricated chairside or in the laboratory with 0.14-
in. Australian wire and are also available commercially in different
sizes. Kesling separator is efficient in creating the separation of teeth
with gentle forces.
Elastomeric separators
a. Elastic ring separators are made of synthetic polyurethane
polyester elastomeric material. These elastic separators are
commercially available as separator rings in dark colour (blue
is most common) which makes them easy to distinguish from
gingival tissues and the teeth (Fig. 43.4A–F). The ring is
usually 0.18 in. in diameter, held between the special separator
placing pliers stretched to almost double or more and slipped
between the contact points of the teeth to be separated, circling
the contact point. Due to high strength and memory to regain
its original size, it exerts force to move the teeth. It takes 12–24
h for separation to create a space of more than 0.16 mm.4
The separators can slip through into gingival tissues and may be
difficult to locate. Hence good quality separators incorporate
radio opaque material for localisation on dental X-rays. Ring
elastic separators can also be placed with dental floss as shown
in Fig. 43.5A–G.
b. Dumbbell elastic separator works on a similar principle as the
ring separator. The dumbbell sheet is pulled to be stretched, to
be slipped between the contact points. It works on the
principle of regaining its shape leading to separation of the
teeth. Dumbbell separators are placed when anterior contacts
are so tight that the ‘O’ ring elastic is not effective in creating
separation. A patient is scheduled 30 min before banding for
the placement of these types of elastics.5
FIGURE 43.4 Elastomeric separators.
(A) The blue separators can be placed around contact area of posterior
teeth to be separated with special pliers. (B–E) Steps in the placement
of separators. (F) Separators in place.
FIGURE 43.5 (A–F) Elastomeric separators can also be placed with
the help of floss. (G) Separator in place.
Selection of the type of separators goes with the preference of the

orthodontist. Most orthodontic offices used elastic ring separators
than any other type. The second banding appointment is scheduled
24–48 h after placement of the separators. A good separation is a must
for proper selection of preformed bands or band making.
Molar bands
Preformed bands with pre-weld tubes work well for their industry-
level quality of welding. The trick to successful banding of molars lies
in the proper selection of the bands, a thorough contouring, and
festooning and cementation (using manufacturer’s recommendation
on mixing). Proper band cementation should ensure isolation of teeth,
good seating and cleaning of excess cement.
Common causes of loss of buccal tube are either poor welding or
masticatory trauma from impinging cusps of opposite molar or both.
Therefore, it is mandatory to check for the clinical crown height of the
molars, especially in the mandible. The buccal tube height is
accordingly tailored to avoid any impingement from buccal cusps of
maxillary molars.
The author prefers to use appliance system in 0.22-in. slot size. All
lower mandibular first molar bands have lingual cleat or button to
permit the use of couple forces if such a need arise during orthodontic
treatment. All maxillary molars should have double buccal tubes;
round tube being gingival. The maxillary first molars should have
triple tubes if one plans to use a utility arch. Triple buccal tubes are
also needed when enhanced anchorage is a plan supported by a mini-
screw. The maxillary first molars should also be pre-welded with
lingual tubes if the treatment plan involves removable transpalatal
arches or maxillary expansion.
The author prefers to place molar bands and undertake bonding of
one arch, usually the lower arch, including insertion of the first
archwire. Bonding and archwire ligation of the second arch are
completed on next appointment which is fixed at the mutual
convenience of the patient and doctor.
Another logical sequence of appliance placement involves
completing the cementation of four molar bands in both the arches in
one appointment followed by full bonding of upper/lower arches and
insertion of the archwires in the next appointment. Orthodontists,
who prefer indirect bonding, can complete the entire bonding and
upper/lower arches in a single appointment. This tremendously saves
the travel cost at minimal loss of working hours for parents and
absence/leave from school.
Bracket positioning
Accurate bracket and tube positioning is the first and single most
critical step to the entire orthodontic process. The precise bracket
positions determine ultimate teeth positions and therefore the quality
of orthodontic treatment. Improperly placed tubes/brackets will carry
with them teeth into unwanted positions, would necessitate multiple
and complex wire bends and adjustments which will lead to round
tripping of tooth movements, longer duration of treatment and poor
treatment outcome. Accurate bracket positioning requires a close
clinical and radiological examination of each of the tooth that is under
consideration for bonding or banding.
Prebond evaluation
1. Clinical evaluation begins with the evaluation of clinical crown
heights and their morphology. Some patients may have short
clinical crown heights, while others present teeth of good
average or even longer than average crown heights (Fig.
43.6A–C).
2. The clinical crown heights of the maxillary and mandibular
first molars would determine the occlusal–gingival height of
the terminal end of the archwire slot (buccal tube), which in
most cases would be used as the reference for bracket height
for the rest of the arch. A partially erupted tooth may pose
problems with accurate bracket placement in first instance.
3. Any fractured or chipped incisor or one with attrition should
be recorded. The freshly erupted canines may show up undue
long canine tip or in contrast situations of deep bite canine tip
gets flat due to attrition caused by occlusal interferences. The
bracket heights should be accordingly tailored keeping an
estimate of normal anatomy of the tooth.
4. It is of utmost importance to evaluate the zenith of gingiva in
six maxillary anterior teeth. Inaccurate bracket placement such
as those in partially erupted incisor or severely rotated tooth
may disturb zenith height when the teeth are aligned in
normal occlusion. Any discrepancy in zenith heights of teeth,
that is from right to left side or a deviation of the normal ratio
among six anterior teeth, should be taken into consideration.
5. Crowding of teeth may not allow direct access to the precise
location of the bracket placement. Such situations would need
either skipping of bonding on the tooth until such time
sufficient space is available following alignment of the
neighbouring teeth or placement of a smaller size bracket
should be considered for an interim period of alignment which
will be replaced with a correct bracket at precise location.
6. Teeth with unusual root/crown tip should be carefully
evaluated for their bracket positions that will be based in
relation to the crown axis and not the position these teeth
occupy in the arch, in the state of malocclusion.
7. Another critical consideration would be evaluation of the
labiolingual clearance available on mandibular anterior teeth
in occlusion. Patients with deep bite should be evaluated for
availability of sufficient labiolingual clearance to house
brackets on labial surfaces of the mandibular incisors.
8. Maxillary canine tips should be evaluated for the impingement
they may exhibit on the wings of the mandibular canine
brackets.
9. Normal morphology of teeth and size facilitate the correct
bracket positioning. Anomalies in tooth shape and size are
often seen in maxillary lateral incisors. Common aberrations
are microdontic maxillary lateral incisor of varying severity.
Bracket positions may need to be tailored accordingly, and so
is the base.
10. Teeth with prosthesis will require a detailed evaluation on the
type of material used and possible implications in bonding.
FIGURE 43.6 The crown height can influence the level of bracket
height.
Individuals may have (A) average, (B) short and (C) longer than
average clinical crown heights.
The bracket selection for contemporary edgewise system involves

0.022 or 0.018-in. slot twin brackets with wings. A standard edgewise
set-up houses slots without any tip and torque, though most standard
edgewise brackets have a built-in base to compensate for the first-
order bends, that is a variable thickness of the bracket base which is
contoured to follow the labial tooth surface anatomy to facilitate
bonding.
Most contemporary preadjusted brackets nowadays have common
features with respect to the design. Most brackets are twin. have
contoured base to follow the anatomy of tooth’s labial surface, have a
mark indicating long axis of bracket which is used as a guide to
coincide with the facial longitudinal axis of the clinical crown (FACC),
bracket base with a convex gingival border to follow gingival contour
and a flat horizontal margin to follow the incisal/occlusal plane (Fig.
43.7).6 All the teeth are marked with an identification system to
differentiate them for maxillary/mandibular arch and right to left side.
The commonly used bracket prescriptions are Andrews, Roth and
MBT.
FIGURE 43.7 Bracket placement begins with a visualisation of
the long axis of the crowns along with their roots.
Irrespective of appliance system or bracket prescription, accurate

bracket positioning is critical. The precise bracket positioning in
occlusogingival placement, its mesiodistal location in the tooth crown
and relationship of the bracket slot to the long axis of the clinical
crown (which also represents the long axis of the tooth from crown to
root tip) are prerequisite to achieve excellent occlusion. When a full-
sized wire is housed in the brackets, brackets positions dictate the
final status of the teeth.
The principles of bracket positioning are common to all the
contemporary edgewise/preadjusted bracket systems. L. F. Andrews,
the inventor of preadjusted appliance (straight wire appliance),
suggested the bracket be placed at the coronal midpoint (LA point),
coincident with the facial longitudinal axis of the clinical crown.1,6
Bracket positioning gauge is used to mark and place the brackets at
a fixed height from the reference position (Fig. 43.8A, B).
FIGURE 43.8 Two types of bracket position measuring aids.
Most gauges have four standard settings of 3.5, 4, 4.5 and 5 mm. All
gauges utilise anatomical incisal margin as a reference point for
measuring bracket height. (A) The Boone gauge employs replaceable
pencil lead markers to mark measurement on tooth crown at a prefixed
measurement. (B) MBT bracket holder cum marker. It can hold the
bracket at slot for precise location at a preselected height.
Buccal tubes
The buccal cusp tip of the mandibular first molar is used as a
reference point. The buccal tube is positioned to align its mesial end to
a vertical line bisecting mesiobuccal cusp of the mandibular first
molar when viewed from the occlusal view. The selected molar band
is first seated lingually followed by seating through buccal, gently
pushing it till occlusal band margins are seated slightly gingival to
mesial and distal occlusal marginal ridges. The buccal tube/archwire
slot should be parallel to the occlusal surface or tipped gingivally at it
mesial end by 5 degrees which enhances anchorage by keeping the
molar upright. The tube is approximately 3.5 mm gingival to cusp tip
or located in the middle of the clinical crown height occlusogingivally,
free from any impingement of maxillary cusps in centric occlusion. A
well-adapted band does not rock, fits snugly and does not excessively
impinge on gingival tissues. It should be festooned to lie gently in the
gingival sulcus and so as not to damage any periodontal tissue.
Maxillary first molar bands are selected for appropriate size and fit.
The diagnostic plaster model can be used as a guide. The maxillary
molar band is first seated on the distal and gradually slipped to be
seated with the help of a Mershon band pusher or a band seater stick
to utilise biting force.
The band is seated in such a way that the archwire slot or the main
buccal tube is located in the middle of the height of clinical crown, or
3.5–4 mm gingival to cup tip of the mesiobuccal cusp. From the
occlusal view, the entrance of the mesial of the buccal tube should line
up with the mesiobuccal cusp tip. As the band is seated, the tube slot
should be horizontal and parallel to the crown marginal ridges (Figs.
43.9–43.12).
FIGURE 43.9 Tube placement on a maxillary first molar.
The tube is placed parallel to the occlusal plane of the tooth.
FIGURE 43.10 Occlusal view indicating the correct mesiodistal
position of the tube.
FIGURE 43.11 Inaccurate buccal tube placement in angulation.

(A) The buccal tube is tipped gingivally at the mesial end. (B) Tipped
occlusal at the mesial end.
FIGURE 43.12 Inaccurate mesiodistal placement of the buccal
tube.
(A) Placed distally. (B) Placed mesially.
A more extended tube height may cause extrusion of the molar

relative to rest of the arch. A discrepancy in mesial to distal heights
may cause undue tipping. An uneven seating on the buccal relative to
the lingual may lead to torque errors.
Both the right and the left bands should be checked to make sure
the tubes are in the same vertical position on the crowns.
At this stage, anchorage savers if planned should be adjusted and
inserted into the appliance system. Anchorage savers in the maxillary
arch include a trans-palatal arch or Nance button, while the
translingual arch is common to mandibular arch.
Bracket positions on anterior and
premolars
The fundamentals of bracket placement are common to all the
contemporary edgewise preadjusted bracket systems. L. F. Andrews
recommended each bracket to be placed at LA point which usually
coincides with the midpoint of clinical crown height at its longitudinal
facial axis. Roth has suggested that brackets could be placed slightly
incisal to LA point propounded by Andrews to have a better torque
control on the incisors.
Three major considerations in bracket placement are as follows:
1. Occlusogingival placement or bracket height.

2. Mesiodistal position on the tooth crown or rotational position.
3. Relationship of the bracket slot to the long axis of the clinical
crown of the tooth.
Occlusogingival placement or bracket height

A standard scheme on bracket heights is given in Table 43.1 and Fig.
43.13.
Table 43.1
Standard scheme on bracket slot height

FIGURE 43.13 Bracket heights.
A conventional scheme for bracket heights used for standard edgewise
set-up.
The bracket height chart is written according to Palmer notation.

This system of notation is simpler in orthodontic use in sorting and
organising the bracket for each tooth. This notation numbers the teeth
starting with the central incisors as 1, the laterals as 2, and the canines
as 3. The first and second premolars are 4 and 5, respectively; the first
molars are 6 and the second molars are 7.
When brackets are placed in an ideal position, the marginal ridges
of the premolars and molars line up at the same level on insertion of
full-size arch in the bracket slots. The buccal tube/archwire slot height
is usually 3.5 mm from the marginal ridge/occlusal table of the first
molar with second premolars being at the same level or 0.5 mm
gingival when they fully erupt.
Brackets positions on maxillary central incisors follow same height
as molars with lateral incisors being 0.5 mm occlusal, while maxillary
canines at 0.5 gingival compared with central incisor.7 This is the
standard scheme to maintain normal occlusion relations and gingival
zenith height relations of the six maxillary anterior teeth (Figs.
43.14A–C and 43.15A, B).
FIGURE 43.14 Bracket positioning aids.
(A, B) Boone gauge for marking bracket position from incisor
margin/cusp tip. (C) Bracket positioning with MBT bracket holder.
FIGURE 43.15 Bracket position for rotational control.

(A, B) The bracket is placed in the centre of the crown at equal
distance from mesial and distal surfaces. The bracket margin follows
incisal edge which is approximately perpendicular to long axis of the
crown. For standard edgewise appliance, slot follows the same
landmarks.
In situations when clinical crowns are longer, the bracket heights

may be accordingly increased on maxillary central incisors/molars,
while remaining teeth follow a scheme of difference in bracket
heights. This scheme places incisal edges of laterals slightly gingival
on the occlusal plane compared with the maxillary central incisors,
while maxillary canine tips are placed slightly occlusal. The premolars
usually follow the height of maxillary central incisors (Figs. 43.16,
43.17A, B).
FIGURE 43.16 Bracket position for rotational control.
(A, B) Bracket positions for the maxillary canine. Mesiodistal position
should be viewed in an occlusal view in mouth mirror.
FIGURE 43.17 Correct bracket placement on maxillary premolars.

(A) Buccal view. (B) Occlusal view.
All the four mandibular incisors are at the same level of occlusal
plane, hence the bracket slots for the mandibular central and lateral
incisors are kept at the same height from incisal edge, which is usually
in the range of 3.5–4 mm (Fig. 43.18). The mandibular canine bracket
height is slightly more gingival, which is 0.5 mm greater than that of
lateral incisor when measured at the incisal tip. Such an arrangement
on canine heights may result in a vertical canine relation to that of the
opposite arch in centric occlusion. The brackets in correct axial
relations would help to place canines in centric relations with that of
the opposite arch to give a gentle glide to eccentric relations during a
lateral functional shift of the mandible.
FIGURE 43.18 Mandibular incisor brackets are placed at same
height from incisal edge on all the four incisors.
Rotational position
The rotational control on tooth is influenced by the bracket width and
mesio-distal location on the tooth crown. All brackets are positioned
on tooth crowns in such a way that they generate a full rotational
control. The designated bracket specific to each tooth is placed at a
central point on the clinical crown mesiodistally. The lateral margins
of the wings remain equidistant from the mesial and distal marginal
ridges of the tooth crown. The correct position of the bracket can only
be evaluated in occlusal view in a dental mirror (Fig. 43.19A, B).
FIGURE 43.19 Inaccurate mesiodistal placement errors in

relation to the maximum mesiodistal width of the clinical crown
for a maxillary incisor bracket.
(A) The bracket is off centre, more towards the mesial contact point. (B)
Bracket is more towards the distal contact point.
The placement of molar tube is guided by the mesiobuccal cusp tip

of the molars. The mesial end point of the tube coincides with the
vertical line dropped at mesiobuccal cusp tip. This position places the
tube almost in the middle of the mesiodistal crown length in most
instances.
Slot angulations
The bracket slot and its relation with respect to the long axis of the
clinical crown determine ultimate crown/root tip. As a general rule,
the bracket slots are supposed to be parallel to the occlusal/incisal
plane which makes the slot perpendicular to the long axis. This
bracket slot–long axis relations in a standard edgewise bracket (free
from any built-in prescription) of tip would place the roots almost
vertical and parallel to each other. The preadjusted brackets have
built-in tips to maintain normal mesiodistal tip of the tooth roots. The
occlusal margin of the bracket base is therefore used as a guide to
place brackets parallel to the occlusion plane of the incisors/premolars
(Fig. 43.20A, B).
FIGURE 43.20 Inaccurate bracket slot placement errors in

relation to the incisal edge or occlusal plane and with long axis fo
clinical crown for a maxillary incisor bracket.
(A) Bracket tilting mesially. (B) Bracket tilting distally.
Cuspid teeth are difficult teeth to place brackets in correct position.

The prominent developmental ridge on crown usually corresponds
with FACC. The vertical marking on bracket should generally follow
the labial developmental ridge on the canine crown.
The premolars follow the same guiding principles of FACC. The
brackets are centred on the maximum convexity of the clinical crown
both occlusogingival and mesiodistal. The mesial and distal marginal
ridges represent the tooth occlusal plane, which helps in the
placement of the bracket in parallel and visualises long axis of the
tooth.
Modern brackets are either rhomboid or trapezoidal in shape; the
mesial and distal margins of the bracket base and wings are tapered
gingivally to follow the anatomy of the crowns and therefore facilitate
visual placement for correct orientation of the bracket.
To view correct bracket heights, the orthodontist should position
himself in direct vision in front of the patient. The rotational position
should be viewed separately for each tooth in occlusal view in a
dental mirror. Each bracket base has a marked centre line which is
used to orient the bracket in correct inclination to the FACC.
Bracket positioning errors in occlusogingival placement lead to
inaccurate marginal ridge relations of the buccal segment which does
not allow proper seating in cusp to fossa relationship with opposite
arch. On anterior segment, this reflects an uneven relationship on an
occlusal plane and would show up variable gingival zeniths. Proper
mesiodistal positions help attain a control of tooth rotation, thereby
establishing intra-arch contact points and cusp fossa relation with
opposite arch. Undue root tip in the long axis of teeth can be an
outcome of bracket slot not being placed at the right angle to the long
axis of the crown. Such a clinical situation could lead to complex
problems during and after orthodontic treatment such as difficulties
in space closure and attainment of good occlusion.
Key Points
‘Well begun is half done’ is valid for orthodontics. A multitude of
factors governs the success of orthodontic treatment. Hence, before an
orthodontic treatment is initiated, a whole plan of events is foreseen.
Accurate bonding and banding are the most critical procedural steps
in orthodontic mechanotherapy because bracket positions dictate the
final tooth positions at finishing.
The absolute precise positioning of the brackets with human hands
are impossible because of several inherent limitations. Therefore, the
modern technology involves 3D virtual models and computer-guided
placement positions by using the indirect bonding technique8
References
1. Creekmore TD, Kunik RL. Straight wire: the next
generation. Am J Orthod Dentofacial Orthop.
1993;104(1):8–20.
2. Carlson SK, Johnson E. Bracket positioning and
resets: five steps to align crowns and roots
consistently. Am J Orthod Dentofacial Orthop.
2001;119(1):76–80.
3. Brass Separators. Available at:
https://www.smlglobal.com/brass-separators.
Accessed on 26/03/18.
4. Davidovitch M, Papanicolaou S, Vardimon AD,
Brosh T. Duration of elastomeric separation and
effect on interproximal contact point characteristics.
5. Dumbbell Separators. Available at:
http://www.ortho-
center.gr/en/elastomerics/separating-
elastics/dumbbell-separators. Accessed on 26/03/18.
Orthod. 1972;62(3):296–309.
7. Tweed CH. Clinical orthodontics. St. Louis: MO:
Mosby; 1966:84–93.
8. Available at: http://www.suresmile.com/. Accessed
on 26/03/18.
CHAPTER 44
Anchorage in orthodontic practice
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Anchorage loss
Anchorage sources for removable appliance
Teeth as an anchor unit
Developmental abnormalities and pathology of tooth
form
Extraoral sources: headgear and facemask
Factors affecting anchorage requirements
Nature of malocclusion
Classification of anchorage requirements
Craniofacial pattern
Type of tooth movement
Friction
Transpalatal arch
Translingual arch
Nance palatal arch
Modified Nance button
Vertical holding appliance
Utility arches
Mini implants and skeletal anchorage system
Key Points
Introduction
Force is an active ingredient of the appliance, the only drug in the
practice of orthodontics. An orthodontic appliance consists of an
active member and a reactive member.
An active member of appliance generates force to initiate and
conduct tooth movement. The active components are housed in the
body of the appliance, which is secured in the mouth through an
‘anchor unit’.
In 1923, Louis Ottofy defined anchorage as ‘base against which
orthodontic force or reaction of orthodontic force is applied’.1
Most recently, Daskalogiannakis defined anchorage as ‘resistance to
unwanted tooth movement’.2
Graber defined anchorage in orthodontics as ‘nature and degree of
resistance to displacement offered by an anatomic unit when used for
the purpose of effecting tooth movement’.3
Anchorage loss
The force involved in tooth movement follows Newton’s third law of
motion which states, ‘for every action, there is an equal and opposite
reaction’. Tooth movement of the reactive member during orthodontic
treatment is termed as anchorage loss. It is undesirable in most of the
instances.
1. Mesial anchorage loss. Traditionally, anchorage concerns have

been mainly against the mesial movement of the anchor teeth.
Conventionally, anterior teeth are pulled using buccal
segments as anchors. The unwanted mesial movement of the
buccal teeth, which is termed as ‘anchorage loss’, compromises
the amount of retraction of the anterior teeth.
2. Vertical and transverse anchorage loss. Earlier researchers and
clinicians were concerned mainly with anchorage loss in an
anteroposterior direction. However, the treatment outcome
should also consider changes in vertical or transverse
relationships which can influence a tooth or a group of teeth at
critical positions and hence, the occlusal plane. Most
orthodontic mechanics are extrusive in nature and to be able to
prevent extrusion is an arduous task. Extrusion of posterior
teeth can result in downwards and backwards rotation of the
mandible.
Anchorage sources for removable
appliance
The body of the removable appliance is a base plate made of the
acrylic material. The appliance body is intimately adapted to oral
tissues and therefore derives anchorage from tissue contact against the
palate and lingual surface of the mandible. Close contact of the plate
with oral tissues, the palatal rugae and slope, resists the slide of the
upper appliance. This type of anchorage is a classic example of the
‘tissue-born anchorage’.
The acrylic, which extends into the interdental spaces and
embrasures further secures the appliance in situ. The base plate
transmits the force all over the dentition as well as to the underlying
hard and soft tissues. Base plate should be extended sufficiently to
cover tissue surfaces as well as the tooth surfaces to serve this
purpose. Modifications of the base plate such as bite planes also
reinforce anchorage by transmitting the muscular forces from
mandible.
The removable appliance also derives anchorage from the clasp and
pinheads, which securely fit on the teeth. These provide retention and
help in distribution of force.
Hence, removable appliances derive anchorage from oral tissues
and teeth.
The anchorage control is rather more complex with fixed appliances,
where the major source of the anchorage is the teeth themselves.
Movement of a group of teeth, like the one required during en masse
retraction of the anterior segment against buccal segment, with fixed
appliance entails a heavy burden on anchor teeth. Anchor units can be
enhanced in their anchorage value by incorporation of more teeth, or
modification in biomechanics through ‘anchorage savers’ or extraoral
anchorage using headgear.
Teeth as an anchor unit

Teeth offer an excellent anchorage: However, they are housed in a
biodynamic environment suspended in the alveolar bone through the
periodontal ligament, which reacts to force. Root surface area of the
tooth determines its anchorage value. One may consider moving a
tooth with smaller root surface area against a tooth with a large root
surface area, which is called an anchor (Fig. 44.1).
FIGURE 44.1 Principle of optimum and differential force.
(A) Reciprocal anchorage—both teeth across the midline have same
root surface area. Reactions to applied force will cause tooth
movement towards each other. (B) Right mandibular central incisor is
reinforced with right lateral incisor. Jointly they offer higher resistance
to force. With the same amount of force as in part A, the left incisor will
move towards the midline. However, if the force levels are of
magnitude higher for a single tooth (causing rear resorption) but high
enough for two teeth (causing frontal resorption), left central incisor will
serve as anchor tooth and two teeth receiving optimum force will initiate
frontal resorption to move towards single incisor. It is an example of
differential anchorage. (C) A mandibular canine when retracted against
mandibular second premolar and first molar and an optimum force is
applied, the canine will move towards the second premolar. (D) The
anchorage is further reinforced with the second molar.
Stationary anchorage: An anchor tooth or source, which does not

move against the forces of teeth to be pulled is stationary anchorage.
In a real sense, only the extraoral source of anchorage derived from
headgear would be a stationary anchorage. The anchor tooth being
housed in a bioactive environment would show some degree of
movement and hence cannot be classified as a stationary anchorage in
a real sense.
Reciprocal anchorage: Teeth may need to be pulled against each
other to close spaces, for example a midline diastema in the upper
arch can be closed by tying them with a tight elastic thread and hence
called reciprocal anchorage (Figs. 44.1A and 44.2).
FIGURE 44.2 Reciprocal anchorage.
Differential force: The experimental work by Storey and Smith

confirmed evidence for the concept that for each tooth, optimum force
values differ based on its root surface area. Hence if the incisors have
to be moved, pitted against molars, a light force, which is optimum for
the incisor movement, would be insufficient for the first molar with a
greater root surface area and therefore a greater movement of the
incisor would occur. Correspondingly, a higher force, which is
optimum for the molar, is likely to first initiate movement of the molar
before the incisor could move. The concept of differential force was
proposed by P. R. Begg in late 1930s, and based on this philosophy he
developed the light wire technique.
The following influences anchorage value of tooth:
• Root surface area

• Root length
• Root shape
• Angulation of the anchorage tooth with respect to the forces
applied.
Other factors that can influence the anchorage are:
• Bone density
• Craniofacial pattern and muscle mass.
Root surface area: The anchorage value of a tooth is a function of its

root surface area. Greater the root surface area, greater will be its
anchorage value. Molars have a larger root surface area with upper
first molar having the largest value. Canines come next in root surface
area followed by premolars and incisors with the least value for lower
central incisor. To avoid anchorage loss, the sum of the root surface
area of anchor teeth should exceed the sum of root surface area of
teeth to be moved (Fig. 44.3).
FIGURE 44.3 Root ratings have been calculated based on root

surface area (cm2) of each tooth.
Multirooted teeth have large root surface areas, hence offer more
resistance and need more force to move compared to teeth with
smaller root surface area. The concept was introduced by Robert Lee
of Australia and used by Roberts M. Ricketts in bioprogressive
technique. Combined root surface areas of second premolar and first
molar is close to that of three anterior teeth. Therefore, in maximum
anchorage cases additional/alternate anchorage conservation methods
are utilised which include the use of second molar, anchorage savers
such as TPA, headgear or mini screw for en masse retraction of
anterior. In some situations anterior retraction is performed in two
stages, canine retraction followed by incisor retraction. Brian Lee
suggested that for optimal tooth movement a force of 200 g/cm2 of root
surface is required. Ricketts, however, felt that their calculations on
force values are higher and a reduction of 25% is required. Therefore
he suggested 150 g/cm2 as the optimum force value.
Root length: The longer the root in the alveolus, larger the
resistance to movement. Canine with longer root offers higher
resistance as an anchor. These factors and their consequences should
be considered in orthodontic treatment planning.
Root shape. Triangular-shaped root offers higher resistance to
movement than a conical or ovoid-shaped root.
Angulation of tooth: The principle of the anchor while putting up a
tent or anchoring a ship is applied to the movement of teeth in the oral
cavity too. A tooth that is tilted distal so that the forces derived are at
90 degrees to the pull is likely to offer greater resistance. Tilting the
anchor teeth to favourable angulations was termed by Charles H.
Tweed as ‘anchorage preparation’ (Fig. 44.4).
FIGURE 44.4 Fixed appliances derive anchorage from the teeth.

Anchorage source and anchorage preparation in fixed appliance.
Tooth with larger root surface area offers greater anchorage. A group
of teeth can be tied together to enhance anchorage. The second molar
can be bonded to reinforce the anchorage. Tweed suggested
anchorage preparation with the help of second order or tip back bends.
Anchorage preparation in the lower arch involves the use of class III
mechanics to prevent the root tips of buccal teeth from moving forward.
After the introduction of built-in tip mechanisms in the pre-adjusted
bracket systems, tip back bends are rarely used. Molar stops and
active omega loop enhance anchorage by preventing mesial movement
of anchor tooth.
Developmental abnormalities and pathology of

tooth form
Developmental abnormalities like dilacerations increase the resistance
to tooth movement whereas teeth with abnormalities resulting in
short root are not good anchor teeth. An ankylosed tooth acts as an
excellent anchor and is a biological source of absolute anchorage.
Intentional ankylosis is used in orthodontics to create anchorage
source, for example intentional ankylosis of the maxillary deciduous
canines is performed to create an anchor for the protraction facemask.
Periodontium: A relative equilibrium exists between the forces
acting on a tooth and the resistance of the periodontium maintaining
the position of the teeth. The resistance is offered by active
stabilisation due to metabolic effects in the periodontal ligament.
Active stabilisation can overcome prolonged forces up to 5–10 g/cm2.
Periodontal disease can reduce the anchorage value of a tooth by
affecting PDL fibres and reduced bone support.
Basal bone: The volume of osseous tissue that must be resorbed for
a tooth to move a given distance represents its anchorage value. Dense
bone offers more resistance to resorption than spongy bone. The dense
cortical bone is more resistant to resorption than medullary bone. A
mandibular alveolar process having a thick and dense bone offers
greater anchorage compared to the maxilla.
Muscular anchorage: Muscular forces when redirected to a
favourable action on the teeth like for removable functional appliances
and lip bumper, serve as a source of the anchorage. A lip bumper
transmits the force of hyperactive lower lip to the molars and can thus
aid in their uprighting.
Extraoral sources: headgear and facemask

Headgear: Very early in history, orthodontists realised the limitations
of using teeth as an anchorage source and thus the headgears were
used to obtain extraoral anchorage. Headgears obtain support from
the back of the neck, cranial bones and can provide three-dimensional
anchorage control depending upon the type of headgear and direction
of the force. Forces are transmitted from headgear strap to teeth via
facebow or J hooks (Fig. 44.5).
FIGURE 44.5 (A–C) Stationary anchorage from extraoral source is

derived from headgear. Source: Dept of Orthodontics, Faculty of
Dentistry University of Sydney, Australia.
facemask: facemask is an orthopaedic device used for the

protraction of growing maxilla in children with midface hypoplasia.
The anchorage for the protraction force is obtained from facial bones.
Delaire and Petit’s facemasks obtain anchorage from forehead and
chin. Grummons’ facemask obtains support from the forehead and
zygomatic area. Hickham protraction headgear gets anchorage from
the chin and back of the head.
Factors affecting anchorage
requirements
Conventionally, retraction of the anterior segment is required to close
the space created by extraction of first premolars. The premolar
extraction spaces are closed using buccal segments as anchor teeth.
Anchorage demands depend upon several factors such as the nature
and complexity of malocclusion, total arch length discrepancy
(TALD), growth pattern, the type of tooth/teeth movements required,
the craniofacial pattern of the individual and age.
The total discrepancy is based upon the sum of crowding, the
amount of retraction required and space required for levelling the
curve of Spee. A high discrepancy demands maximum anchorage to
close extraction spaces. Crowding cases demand maximum anchorage
control during the initial stages of levelling and alignment. Whereas,
increased overjet and protruded dentition as in bimaxillary cases
demand maximum retraction and therefore, demand high anchorage
during retraction.
Classification of anchorage requirements

Gianelly and Goldman4 suggested the terms maximum, moderate and
minimum to indicate the extent to which the teeth of the active and
reactive units should move when a force is applied.
Nanda5 classified anchorage into three categories: A, B, and C
depending on how much of the anchorage unit contributes to
extraction space closure (Fig. 44.6).
FIGURE 44.6 Three types of anchorage requirements.
(A′) Space available for a retraction after extraction of the first premolar.
(A) Maximum anchorage or group A. (B) Moderate anchorage or group
B (50% mesial movement of the teeth in the buccal segment and 50%
distal movement of the anterior teeth). (C) Minimum anchorage or
group C (75% mesial movement of the buccal teeth and 25% distal
movement of the anterior segment). (D) Absolute anchorage.
Group A space closure—includes 75%–100% space closure from

anterior retraction and 25% closure from posterior anchorage
movement. There is a critical posterior anchorage.
Group B space closure—includes an equal amount of anterior and
posterior tooth movement to close the space.
Group C space closure—includes 75%–100% posterior protraction.
There is a critical anterior anchorage and a non-critical posterior
anchorage.
With the introduction of skeletal anchorage systems (SAS) and
temporary anchorage devices to the orthodontic armamentarium,
100% anchorage conservation is a possibility and hence additional
category of Group D is added.
Craniofacial pattern
Given the same amount of discrepancy and type of malocclusion, the
variance in the craniofacial pattern of an individual would influence
the anchorage offered by the anchorage units. The biting force, which
is, in turn, to a great extent, influenced by the musculature would
offer resistance by virtue of the ability to maintain inter-cuspal
position and inter-digitation. The second major factor would be the
craniofacial pattern, that is vertical or horizontal. The vertical growers
tend to lose anchorage faster compared to the horizontal growers, for
they have less biting force compared to horizontal growers.
Type of tooth movement

Anchorage varies with the type of tooth movement, whereby, bodily
movement requires more anchorage than tipping. The contemporary
system of pre-adjusted appliance necessitates high demands of
anchorage during the initial stages of the treatment as the first few
wires tend to unravel malocclusion according to the expression of
bracket prescription whereby tooth axis alignment, tip and crowding
are being unravelled simultaneously to bring the teeth in a position
called ‘slot line up’.
Friction
Friction between wires and bracket slot adds to the resistance against
tooth movement, which is more so in sliding mechanics. Retraction
force should first overcome the static friction at the bracket wire
interface to initiate tooth movement and continue to overcome kinetic
friction during tooth movement. So, to counteract frictional resistance
additional force is applied for anterior retraction, which can strain
posterior anchorage.
The major part of the treatment planning and concern essentially
revolves around maintenance of the anchorage in the three
dimensions of space. Anchorage control during fixed appliance
therapy necessitates provision in the biomechanics which includes a
distal tip of the anchor teeth, banding second molars, making a molar
stop, and retraction of the anterior segment in two stages. The two-
stage retraction of the anterior teeth was practised by Charles Tweed
and followers of his philosophy of anchorage control. In two-stage
space closure, the canines are retracted into extraction spaces first. On
the completion of canine retraction, the canine in each buccal segment
is tied to the second premolar and the first molar which reinforces the
existing anchorage. The incisor retraction is then completed using the
enhanced anchorage. In this system, the treatment duration is
increased but the anchorage control is much better. In addition,
anchorage savers are incorporated. These include:
• Transpalatal arch (TPA)

• Translingual arch (TLA)
• Nance palatal arch
• Modified Nance arch
• Vertical holding appliance (VHA)
• Utility arch.
Transpalatal arch
Robert A. Goshgarian introduced transpalatal arch (TPA)6. It
transversely spans across the palate between the upper first molars,
with an omega loop in the midline. The TPA is effective as an
anchorage maintenance device as well as an active orthodontic
appliance (Fig. 44.7).
FIGURE 44.7 Soldered transpalatal arch.
TPA can be used for molar stabilisation and anchorage, correction

of molar rotation, molar distalisation and also for torquing the molars.
This TPA resists the mesial movement of the molars and particularly a
tendency of molars to rotate in a mesial direction around the palatal
root.
TPA can be of fixed or removable type. Fixed (soldered) TPA is
fabricated in 0.036 in. stainless steel wire with the wire contacting the
band in mesiolingual line angle. Removable TPA is fabricated in 0.032
in. round TMA or Elgiloy wire. The midline omega loop is usually
oriented distally with 1–1.5 mm clearance in the palatal area.
The maxillary molars can be actively intruded using intrusion TPA
in high angle cases. It can provide vertical control by the intrusion of
molars. By placing an omega loop in mesial direction and increasing
the clearance in palatal area, tongue pressure places an intrusive force
on TPA, thereby preventing molars’ extrusion.
Translingual arch
Translingual arch (TLA) is used in mandible and it functions as an
anchorage device. It is usually made out of 0.036 in. stainless steel
wire, which extends along the lingual contour of the mandibular
dentition from one side of the first molar to the other side of the first
molar. An adjustment loop can be placed in the region of second
deciduous molar or second premolar (Fig. 44.8).
FIGURE 44.8 Soldered translingual arch.
Nance palatal arch6

The Nance palatal arch is used in the upper arch as an anchorage
device during levelling and alignment, in molar distalisation cases
and as a space maintainer. It consists of 0.036 in. SS wire, connecting
upper first molars and an anterior loop portion covered by acrylic,
which rests on the slope of the anterior palate. It can provide sagittal
anchorage reinforcement and is used as an anchorage saver during
levelling, alignment and canine retraction (Fig. 44.9A).
FIGURE 44.9 (A) Nance button is used to reinforce anchorage. It also
prevents extrusion of the molars caused by an orthodontic mechanism.
(B) Modified Nance button attached to maxillary first molar on one side
and premolars on another side.
Modified Nance button

Modified Nance button is used during molar distalisation to prevent
mesial movement of premolars and incisors and also after
distalisation to prevent mesial movement of the molars (Fig. 44.9 B).
Studies found that the Nance button can reinforce the anchorage to
some extent. It is not an ‘absolute anchorage saver’ device.7,8
Vertical holding appliance

Vertical holding appliance (VHA) is essentially a modification of the
transpalatal arch with an acrylic pad. It is fabricated with banded
maxillary permanent first molars connected with a 0.040-in. chrome–
cobalt wire with a dime-size acrylic button at the sagittal and vertical
level of the gingival margin of the molar bands. The acrylic button is
away from the palate by 2 mm or more. Four helices are incorporated
into the wire configuration for flexibility. The VHA uses tongue
pressure to reduce the vertical dentoalveolar development of the
maxillary permanent first molars. The presence of an acrylic button is
supposed to enhance the intrusion force exerted by the tongue. VHA
is particularly useful in high angle patients where prevention of
eruption of posterior teeth during mechanotherapy is difficult. In high
angle patients, control of anterior vertical dimension was possible
with this appliance compared to a group, which used tip-back bends
for the posterior teeth in conjunction with a high-pull anterior J hook
headgear.9
Utility arches
A utility arch is a continuous wire that extends across both buccal
segments but engages only the first permanent molars and two
incisors (2 × 2) or four incisors (2 × 4). It was popularised by Ricketts
as an integral part of bioprogressive therapy. Ricketts recommended
its fabrication in 0.016 × 0.016 in. blue Elgiloy wire but the modern
recommendation is 0.016 × 0.022 in., 0.017 × 0.025 in. beta-Ti wire. It is
used as a space maintainer in mixed dentition and also following
molar distalisation to prevent mesial movement of the molars.
Mini implants and skeletal anchorage system

Temporary anchorage devices (TAD) in the form of miniscrews and
its variants have been integrated in orthodontic armamentarium.
These devices provide excellent source of the anchorage. This aspect
of orthodontic therapy is discussed in Chapter 60.
Key Points
Anchorage is the most critical aspect of orthodontics. Much of the
treatment planning hovers around the calculation of anchorage
requirements and appliance for effective anchorage control. The
anchorage savers do offer extra assistance to anchorage, most recent
armamentarium in orthodontics was the introduction of mini screw
implants (MSI) and skeletal anchorage system (SAS). The MIS and
SAS offer absolute anchorage control.
References
1. Ottofy L. Standard dental dictionary. Chicago: Laird
and Lee Inc; 1923.
2. Daskalogiannakis J. Glossary of orthodontic terms.
Leipzig: Quintessence Publishing; 2000.
3. Graber TM. Orthodontics: principles and practice.
3rd ed. Philadelphia: Saunders; 1996.
4. Gianelly A, Goldman H. Biologic basis of
orthodontics. In , Cope, J.B., editor. Temporary
anchorage devices in orthodontics: a paradigm shift.
Philadelphia: Lea and Febiger; 1971 Semin Orthod
2005;11:3-9.
5. Nanda R. Biomechanics in clinical orthodontics.
6. McNamara JA, Brudon WL. Orthodontic and
orthopedic treatment in the mixed dentition. Ann
Arbor: Needham Press; 1993.
7. Ngantung V, Nanda RS, Bowman SJ. Posttreatment
evaluation of the distal jet appliance. Am J Orthod
8. Bondemark L, Thornéus J. Anchorage provided
during intra-arch distal molar movement: a
comparison between the Nance appliance and a fixed
frontal bite plane. Angle Orthod. 2005;75(3):437–443:
9. Deberardinis M, Stretesky T, Sinha P, Nanda RS.
Evaluation of the vertical holding appliance in
treatment of high-angle patients. Am J Orthod
PMID: 10842113.
CHAPTER 45
Tweed philosophy, biomechanics
and principles of treatment
O.P. Kharbanda
Mugdha Mankar
CHAPTER OUTLINE
Tweed’s journey as Angle’s Student to an accomplished

orthodontist
Human face as related to orthodontic diagnosis
The diagnostic facial triangle
Growth trends of the face
Head plate correction or cephalogram correction
Total arch length discrepancy calculation by Tweed
Treatment planning—Tweed’s objectives of treatment
Early treatment or mixed dentition treatment guidance
Treatment philosophy
Bonwill–Hawley chart
First order bends
Second order bends or up and down bends
Anchorage preparation in the mandibular arch
Anchorage preparation in the maxillary arch
Anchorage and goals of FMIA for large ANB
Third order bends (torque)
Significance of occlusal plane maintenance
Stages of treatment
Bite opening mechanics and control of its adverse effects
on incisors
Anchorage conservation
Space closure
Incisor retraction
Finishing and detailing objectives
Tweed principles as applied to clinical practice at AIIMS
The protocol on treatment planning
Edgewise mechanics
Canine retraction
Incisor retraction
Finishing and detailing
Key Points
Dr Tweed, an Institution ‘Let us all remember this fact, clinical findings

and scientific research should be closely wedded, only then many of
our complex problems in orthodontics be solved, not before’.
Charles H. Tweed Jr1
Tweed’s journey as Angle’s Student to
an accomplished orthodontist
Dr Charles Tweed (Fig. 45.1) knew Edward H Angle as best friend
and benefactor since 1927.2 Angle and Tweed worked closely together
during the last 2 years of Angle’s life. Angle discovered and designed
the edgewise appliance; Charles Tweed practised and taught us how
to make the best out of ‘latest and the best’ of that time.
FIGURE 45.1 Charles H. Tweed.
Tweed practised edgewise appliance, made progress records every

4 months, packed them in suitcases and carried them from his practice
at Phoenix to Pasadena at Angle’s Home. Angle, the advisor, studied
the records and outlined a treatment plan for the next 4 months.
Tweed practised exclusive edgewise orthodontics and held to Angle’s
firm conviction that the practitioner must adhere to the line of
occlusion concept that is synonymous with ’harmony, balance,
symmetry, beauty, art and permanence of normal tooth positions’,
and never extract teeth. This conviction lasted for 3 years after Angle’s
death.
Tweed became disheartened with his work after six and a half years
of orthodontic practice under the direct guidance of Dr Angle. The
two most important reasons being:
1. non-extraction, treatment created protrusive faces and

2. the post treatment occlusion were unstable.
Many of his treated patients showed a lack of balance and the

beauty, which was to some extent being compromised with strict
adherence to the non-extraction principle. Tweed noticed significant
relapse in some cases thus casting doubt over the long-term stability
of the results.3
Tweed subsequently started to analyse the treatment records (1934),
results of which prompted him to conduct a study on the features and
characteristics of occlusion, dentition and faces of ‘normal’ people
who never had orthodontic treatment. His initial impression was
based on clinical examinations alone. The relationship of teeth to the
basal bone was carefully noted, especially inclination of the incisors.
He found that in average non-orthodontic normal, the incisal
inclination was approximately 90 degrees when related to the
mandibular plane. Further, from his records of treated cases, he also
noted that in a majority of cases, which showed relapse; the incisor–
mandibular plane angle deviated significantly from the ideal of 90
degrees. And thus he realised the importance of placing incisors
upright on the basal bone, and to correct incisor proclination
extraction of teeth became essential and retreatment was instituted in
patients with relapse.
He put up a tremendous exhibit of records of his 100 patients
treated first without extractions and then retreated with extractions at
the American Association of Orthodontists meeting, in 1940. Tweed’s
presentation was not readily accepted, and he was severely criticised
by many orthodontists of the era!3
Criticism did not deter him from his conviction and treatment
planning on a case-to-case basis. Charlie, as he was called by his
friends never attended a meeting without plaster, to show how he
treated the cases even in his 70s!3
Human face as related to orthodontic
diagnosis
Charles H. Tweed focused his clinical observations on the normal
facial aesthetics, including their deviations and the position of the
mandibular incisors as related to the medullary bone of the body of
the mandible. A conviction was built, which was later proved through
his research leading to the development of the diagnostic facial
triangle. The rule included cases, which had normal growth pattern
and also those with a diminished growth of both the maxilla and
mandible but where the directional growth of the jaws was not
markedly disturbed towards vertical or horizontal.
Tweed observed that true class III cases or those cases where the
growth vector of the jaws was perverted, from being a downward and
forward to too much forward and less downward; did not withstand
the rule. The more procumbent the mandibular incisors, the less the
mandibular prominence was observed; inversely, the more upright
the mandibular incisors, the more pronounced mandibular
prominence was observed1.
The diagnostic facial triangle

Tweed’s cephalometric analysis had its beginning in clinical
orthodontics where he found that the cases of malocclusion with a
pleasing outcome, harmonious profiles and stable occlusion following
orthodontic treatment had a common, consistent feature of occlusion:
their mandibular incisors were upright on their skeletal bases.
The clinical observations supplemented and quantified on
cephalograms led to the development of the diagnostic triangle.
Tweed’s diagnostic triangle is simple and basic, yet provides a definite
guideline in treatment planning (Fig. 45.2) (Fig. 45.3).
FIGURE 45.2 (A) Diagnostic facial triangle.
Landmarks used in the construction of Tweed’s triangle FH plane
(FHP), mandibular plane (MP) and the long axis of the mandibular
incisor. FMA, Frankfort mandibular plane angle; FMIA, Frankfort
mandibular incisor angle; IMPA, incisor mandibular plane angle. (B)
The facial triangle in a case of malocclusion.
FIGURE 45.3 Tweed diagnostic triangle in different classes of
malocclusion.
(A) Class I bimaxillary protrusion. (B) Class I with vertical growth
pattern. (C) Class II average growth pattern. (D) Class III with
horizontal growth pattern.
Extraction or non-extraction treatment

Tweed concluded that if an orthodontist was to attain facial aesthetics
and occlusion similar to that found in non-orthodontic normal, then
the mandibular incisors should be positioned in a range of 85–95
degrees with a mean of 90 degrees to the mandibular plane. On the
basis of his observations on the lower incisor mandibular plane angle
(IMPA) and its association with variation in Frankfort mandibular
plane angle (FMA), he found that a consistent finding was a resultant’
third’ angle of the triangle, which was Frankfort mandibular incisor
angle (FMIA). The inclination of the mandibular incisors to the basal
bone and its association with the vertical relation of the mandible to
the cranium is fundamental to Tweed’s diagnostic facial triangle.4–6
Tweed found that extraction of teeth was necessary for patients
with FMA more than 30 degrees.
He observed that when the FMA ranges upward from 35 degrees, it
was physically impossible to correct and compensate the inclination of
the mandibular incisors, that is, make them less than upright.
Prognosis is not good in such cases, and the orthodontist is limited in
his efforts to create stable end results and establish harmony and
balance of facial aesthetics.
The results of this clinical research established the norm for FMA as
25 degrees with a normal variation of 16–35 degrees. This resulted in
the development of the second angle of the diagnostic facial triangle.
As the sum of the three angles of the triangle is 180 degrees, it is
expected that in a normal case with 25 degrees of FMA and 90 degrees
of IMPA the third angle, which is FMIA, would be 65 degrees.
His clinical observations were further supported by a cephalometric
study. The sample size consisted of 100 people, chosen on the basis of
balance and harmony of facial aesthetics. The averages of the three
angles were as follows (Table 17.1):
1. FMA – 25 degrees
2. IMPA – 90 degrees
3. FMIA – 65 degrees.
FMA and its relationship with IMPA.

Tweed observed that the patients in whom FMA was more than 30
degrees, demonstrated nature’s compensation of inclination of
mandibular incisors when related to the mandibular plane. IMPA was
found as little as 77 degrees. FMIA angle was around 65 degrees. The
occlusal plane converged towards the mandibular plane posteriorly,
because of excessive height of mandibular incisors as compared with
the molar height.
In patients with FMA of 25 ± 4 degrees (21–29 degrees), FMIA was
found to be 65–70 degrees. The occlusal plane did not converge
posteriorly as sharply towards the mandibular plane as it did in
patients with large FMA. The patients in whom FMA was below 20
degrees, rarely demonstrated IMPA greater than 94 degrees. Their
FMIA reading ranged from 68 to 85 degrees. The occlusal plane
converged less sharply towards the mandibular plane. In some cases,
it was parallel to the mandibular plane.
Therefore, he postulated that FMIA is critical, and hence while
planning orthodontic treatment, IMPA should be compensated for a
minimum of 77 degrees for higher FMA and to a maximum of 105
degrees for lower FMA. Dr Tweed used white India ink to directly
mark on the cephalogram which he called the head plate. The three
angles were measured and recorded in white ink on the lower left
corner of the cephalogram. The size of angle ANB was then measured,
and the value was written below the previously mentioned angular
measurements.
The ‘cephalometric eye’: Tweed emphasised training the eyes for a
keen observation to match clinical profile with visual examination of
the cephalogram. He practiced viewing the cephalogram on the
shadow box, and then a long look was taken at the patient seated in
the chair, with his head aligned in the Frankfort plane. Face
proportions were compared with the bony framework
simultaneously.7
Growth trends of the face
In my opinion, a thorough concept of the normal growth pattern of the

child’s face or any face is as important to orthodontists, if not more so,
as complete mastery of the science of occlusion.
Charles H. Tweed1
Growth trend of an individual was a factor that had to be
contended with during treatment. Hence, Tweed followed a routine
before any mechanical treatment, which made possible to determine
the type of facial growth. He included lateral cephalogram in the
records of all young children undergoing pre-orthodontic guidance
programme. After 12–18 months a second cephalogram would be
taken and the tracings made from the cephalograms were
superimposed on the SN plane and registered at S point. Observations
were then made to conclude the growth trend.7
Essentially, Tweed described the growth of the face as being normal
when mandible and face grow in unison in downward and forward
direction with no change in angle ANB. He called it Type A and when
mandible growing more rapidly than the maxilla with decrease in
angle ANB, he called it Type C.
The most undesirable face growth type is Type B growth, which is
downward and forward with the middle face growing forward more
rapidly than the lower face. The ANB angle is slightly larger ranging
from 6 to 12 degrees, and it increases with age. The prognosis and
distribution is given in charts (Fig. 45.4A–C).
FIGURE 45.4 The growth trends, treatment mechanics and
prognosis.
(A) Treatment mechanics and Type A growth trend. (B) Treatment
mechanics and Type B growth trend. (C) Treatment mechanics and
Type C growth trend.
Head plate correction or cephalogram

correction
Tweed also utilised IMPA correction on a cephalogram according to
his treatment objectives and called it head plate correction. He
accordingly calculated the space requirements in the arch based on the
amount of change required to place the lower incisors correctly over
the basal arch. Orthodontists across America and Europe treated cases
according to the IMPA goals of Tweed’s triangle. In India too, during
1970s, the treatment planning was based on using Tweed’s norms of
IMPA as a guideline (Box 45.1).
Box 45.1 Tweed’s norms of IMPA according to

FMA
FMA > 30 Mandibular incisors are compensated so that FMIA ranges from 65 to 70
degrees degrees (average 65 degrees)
Prognosis – fair extraction is usually indicated
FMA = 25 ± 4 Efforts should be made to attain FMIA of 68–70 degrees
degrees FMIA varied from 70 to 75 degrees with FMA of 21 degrees and FMIA of 65
degrees when the FMA approached 30 degrees
FMA < 20 IMPA should not exceed 94 degrees
degrees FMIA ranged from 68 degrees to as much as 80 degrees
In his analysis, Tweed stressed the importance of FMIA and

recommended that it should be maintained at 65–70 degrees. As an
example, a case with FMA-21 degrees, FMIA-51 degrees and IMPA-
108 degrees should be corrected to IMPA of 90 degrees. With this
change, FMIA would be 69 degrees, which is within recommended
range. This would necessitate removal of dental units.
Total arch length discrepancy calculation by

Tweed7
Tweed described a method of arch length discrepancy calculation,
which accounted goals of IMPA. Available arch perimeter is measured
from the mesial surfaces of the mandibular first molar on either side,
around the dental arch. The arch perimeter is noted on the analysis
chart (Fig. 45.5).
FIGURE 45.5 Tweed’s method of calculation of total arch length
discrepancy.
The total tooth material was then obtained from the measurements
of widths of erupted permanent teeth from orthodontic study models
and width of unerupted mandibular cuspid and two premolars from
intraoral radiographs, in case of mixed dentition.
Tweed used this method to calculate crowding and spacing. He
used a formula of head plate correction to calculate the total arch
length needed. The goals of IMPA are outlined and estimated long
axis of the mandibular incisor position is drawn. The linear distance
from original incisor edge position to incisor edge was doubled. This
value added to the calculated crowding or subtracted from spacing
will give a total arch length discrepancy.
Here goals of the IMPA are important, which will vary from race to
race and also individual to individual according to FMA and soft
tissue thickness (Fig. 45.5). His treatment philosophy and objectives
entailed towards healthy oral tissues, best balance and harmony of the
face, the stability of the dentition and efficient chewing mechanism
(Fig. 45.6).
FIGURE 45.6 Treatment planning—Tweed’s objectives of
treatment planning.7
Treatment planning—Tweed’s
objectives of treatment
Early treatment or mixed dentition
treatment guidance
Tweed advocated the principle of early treatment guidance and mixed
dentition treatment. Treatment in mixed dentition differs from that in
the permanent dentition where growth is either completed or almost
complete, and the malocclusion has developed to a more or less static
form. Young children with their faces, jaws and teeth, continuously
undergoing growth changes and adjustments, must be understood
and taken into consideration during diagnosis and treatment.
Tweed’s serial extraction sequence

Serial extraction should begin if the diagnosis revealed that a
discrepancy existed between teeth and the basal bone structures, the
following being the sequence was adopted by Tweed:
1. At approximately 8 years of age, all four first deciduous molars

were extracted. After 4–10 months, the first premolar teeth
were seen erupted to the gum level.
2. The first premolars were extracted as soon as their crowns
were seen through the alveolar bone. Deciduous cuspids were
removed at the same time.
■ This procedure should be completed 4–6 months prior
to the eruption of the permanent cuspids. So when
the cuspids erupt they migrate posteriorly into good
positions and minor irregularities of the mandibular
incisors correct themselves as these teeth tip lingually
or posteriorly; as directed by the subjected functional
forces.
■ Tweed warned against the removal of deciduous
cuspid as a means of self-correction of irregularities
of incisors and particularly the mandibular incisors.
As the permanent cuspid would then erupt more
rapidly than the first premolar, this undesirable
movement would make removal of the first premolar
much more difficult. In addition, the retention of the
first premolar would force the cuspid eruption into
mesial positions that would require mechanical
treatment later.
Treatment philosophy8
Dr. Tweed focussed on enhancing anchorage prior to retraction of the
anterior teeth, which he called anchorage preparation. The purpose
was to prepare the anchor teeth in the most efficient manner for
retraction of the anterior teeth without losing the original position of
anchor teeth.
He prepared the anchorage by a distal tilt of the buccal segment in
such a manner and mechanism without moving the roots forward into
a mesial tip. He prepared anchorage in one arch at a given time and
while used other arch and headgear for support. The principle of
anchorage preparation on molars is analogous to the pegs used for
tying the rope of the tents at a favourable angle.
Similarly, he performed consolidation of the spaces in one arch at a
time using opposite arch to support the anchorage. For his concern on
anchorage control, he evolved mechanics and treatment stages not to
let the anchorage loss happen under any circumstances.
The bracket system used in a standard edgewise system include Twin
brackets of 0.022 in. × 0.028-in. slot size. Four types of SS twin brackets
are used (Fig. 45.7).
• Junior Siamese for mandibular incisors

• Medium Siamese for maxillary lateral incisors, canines and
premolars
• Wide Siamese maxillary central incisors and first molars
• Extra wide for very large first molars
FIGURE 45.7 Four sizes of Siamese or twin brackets with 0
degree tip and flat base used by Tweed.
Junior Siamese, medium Siamese, large Siamese and extra large
Siamese.
Buccal tubes with hooks on the terminal molars, which can be

second molars if erupted or the first molars.
The maxillary molar tube is a double buccal tube with the round
tube for housing the face bow or headgear of 0.045-in. internal
diameter.
The brackets and tubes have a flat base.
The slot of the brackets is parallel to the incisal edge of the teeth or
parallel to the occlusal plane being at right angle to the long axis of the
teeth.
To maintain the normal labiolingual position of the teeth in the arch
and create a favourable mesiodistal inclination of the roots, the first
and second order bends are incorporated in the archwire.
The third order or torque bend is given for the optimum
labiolingual placement of the roots in relation to alveolar bone.
Bonwill–Hawley chart
Tweed recommended the use of individualised arch form and created
an arch form using Bonwill–Hawley chart for each patient by
measuring the mesiodistal widths of maxillary central and lateral
incisors and the mesiodistal width of the canine.
The sum of six anterior teeth dimensions was used to create the first
circle, which determined the anterior arch form. This chart provides
an individualised inter-cuspid width, which would be maintained
throughout the treatment.
To conform the natural arch form, attain anchorage and move the
teeth in the correct labiolingual inclination, the archwires require
incorporation of certain bends. These bends are grouped as
First order bends

Second order bends
Third order bends
First order bends (Figs. 45.8 and 45.9)
The first order bends are those, which are required to compensate for
the variation in the labiolingual thickness of the central incisors,
lateral incisor and canines in the anterior segment.
FIGURE 45.8 Steps in contouring an arch form from a straight

length of wire.
(A) An initial arch form acquired through a turret, midline is marked
which should be consistently referred while making arch forms. (B)
Further compression to the stage of crossing over the legs. (C)
Manipulating the arch to follow patient’s. Bonwill Hawley chart and
making marks for midline and first-order bends. (D) Lateral incisor inset
is in place (E) completed first order bends. I’- Midline marking, II’-
mesial contact point of lateral incisor, III’- distal contact point of lateral
incisor, IV’- Marking for canine eminence.

FIGURE 45.9 First order bends.
(A) The normal arch form. (B) Maxillary anterior arch form with first
order bends. (C) If the first order bends are not provided the labial
surfaces fall in a contour, which is aesthetically and functionally not
desired. (D) Mandibular anterior arch form with first order bends. (E) If
the first order bends are not provided the labial surfaces fall in a
contour, which is aesthetically and functionally not desired. (F) Toe in
bends for the maxillary first molar. (G) Toe in bends for the mandibular
first molar.
In the buccal segment, the first order bends are required to
accommodate the prominence of the mesiobuccal cusp of the first
molars and a change in the path of the buccal curve distal to the
mesiobuccal cusp towards the midline of the palate, which determines
a parabolic curve of the arch.
In the mandibular arch, the first order bends in the incisor region
are not required for the mandibular lateral incisors since the
labiolingual thickness of the central and lateral incisors are nearly the
same.
The extent of each bend is dictated by the variation in labiolingual
thickness of individual tooth so that a smooth curve of incisors and
canines on their lingual surface can be achieved. In case first order
bends are not provided in the archwire, the labial contours of the teeth
in the anterior region will confirm to the arch shape, which is not the
anatomically and aesthetically normal position.
Lack of the first-order bend in the molar region will result in
distobuccal rotation of the first molars (Fig. 45.9 F, G):
First order bends are, lateral inset, canine eminence, molar offset or
anti-rotation bend. First order bend in between premolar and molar is
also known as anti-rotation or toe-in bend and the size vary from
individual to individual.
The upper and lower archwires should always be coordinated for
the arch shape and arch widths in the canine and molar region (Fig.
45.10). A good quality Tweed pliers is a must to place the bends. The
archwire is held firmly with the pliers while bends are placed with
thumb pressure. All first order bends are placed as in-out bends with
out disturbing the plane of the wire. The first order bends are
provided bilaterally using 0,1,3,5,6 as guides suggesting quantification
of bending movement of the free end of the archwire in labiolingual
deflection on the Bonwill chart.
FIGURE 45.10 Coordinated upper and lower arches with the first
and second order bends.
Second order bends or up and down bends

These bends are second in order of placement and hence the name.
The second order bends are of great significance in standard edgewise
technique biomechanics.
The second order bends are placed in the occluso-gingival direction
to maintain the final angulation of teeth (Fig. 45.10). In the incisal area,
second order bends (artistic bends) provide the ideal root angulation
to these teeth in mesiodistal direction.
In posterior region, second order bends maintain the distal tipping
of the premolars and molars and cause bite opening (pseudo bite
opening).
Types of second order bends (Fig. 45.11):
• Short second order bends (Step up/Step down bend)

• Long second order bends
• V bend (Neutral, Step up, Step Down)
• Tip back bends
• Artistic positioning bends, long V bend
FIGURE 45.11 (A) Second order bends. (B) Long second order
bends. (C) Artistic positioning bend/fly bend/long V bend. (D) V bend.
(E) Tipback bend.
Short second orders bends given in buccal segment are more

vertical than long second order bends.
Step up or step down bend can be an independent or a component
of a ‘V’ bend or a second order bend.
V bend is often provided in the canine/incisor region next to lateral
incisor. The apex of the V bend is always gingival.
The heights of the mesial and distal arms of the V bend determine
its action in occluso-gingival plane as: (a) Neutral (when mesial and
distal arm of the V bend are of same height), (b) Step up when mesial
arm is shorter in height (to maintain or open the bite) and (c) Step
down when mesial arm is greater in height (to close open bite).
The length of legs of the V bend could be altered (fabricated
dissimilar) to produce intrusion or extrusion in the segment lying
anterior and posterior to the V bend. V bend, if fabricated with equal
heights of the legs shall not produce any intrusive or extrusive forces
and moments into the segments lying anterior and posterior to the V
bend. Such a V bend, when introduced in any part of the wire, shall
provide a neutral area bearing zero forces and moments.
The V bend also serves as a neutral zone or differentiates between
anterior and posterior segments of the archwire. Therefore, it is
possible to incorporate lingual root torque in the incisal segment and
progressive buccal root torque in the premolar molar segment.
V bend also gives a reference location for the soldering attachment.
The second order bends, that is, one in the vertical direction, located
in the buccal segment can be activated to create the distal tip of the
crowns of the teeth to enhance anchorage. The activated second order
bends are called tip back bends. Second order bends are sometime
considered as a synonym of the tip back bends.
Tip back bends are second order bends, however, all second order
bends are not tip back bends.
Artistic positioning bend or long V bend is a fly bend given in the
incisal segment to place the roots of the teeth in a correct mesiodistal
tip (second order). These bends can be incorporated in the archwire
during the incisor retraction and at the stages of the finishing.
How to place second order bends

Placing the second order bends requires a technique to hold the
archwire firmly with good quality Tweed pliers and bending the wire
with fingers only in occlusal–gingival direction.
The steps of making second order bends are given in (Fig. 45.12).
FIGURE 45.12 Steps in fabrication of second order bends (A–D).
The second order bends are converted into tip back bends by
making a gentle sweep in reverse curve of Spee in the lower arch and
accentuated curve of Spee in the maxillary arch.
Anchorage preparation in the mandibular arch

Anchorage preparation in the mandibular arch is usually carried out
after levelling is completed and the brackets are ready to receive
0.0215 × 0.0275 in. edgewise wires, which can be seated gently in the
slots without any difficulty. Usually, the mandibular arch is prepared
first. The maxillary arch functions as a stabilised unit during this stage
with a 0.0215 × 0.0275 in. stainless steel wire with very mild second
order bends and anterior lingual crown torque so that there is no
mesialisation of the maxillary denture during the use of class III
elastics.
The mandibular archwire should be free of adverse torque and
degree of tip-back on the terminal molars should be such that when
the archwire is placed in the buccal tubes it will cross the cuspid teeth
at their dento-enamel junctions (the tip usually varies from 15-30
degree).
After placing the archwire in the molar tubes of the terminal molars,
when it is raised and ligated to the brackets on the first molar teeth,
the mesial cusps of the terminal molars are elevated, and the first
molars are depressed. At this point, the archwire will lie gingival to
the brackets on the second premolar teeth.
When the archwire is engaged in the slots of the second premolar
brackets, first molars are elevated and the second premolars are
depressed. Thus the force necessary to tip the terminal molars is
transferred to the second premolar teeth. Now the archwire lies
gingival to the first premolar brackets.
When canines are engaged, the canines are depressed, and the first
premolars are elevated. Thus all the distal tipping forces on premolars
and molars are neutralised by the depressing force on the canines.
This depression is not too rapid as canine has a very large root with
well-supported alveolar bone. Now archwire lies gingival to the
incisors brackets.
When the archwire is ligated to the incisors brackets, the action is
the elevation of the canines and depression of the incisors. These teeth
are too small and depressed very rapidly.
The cuspids and incisors react as a single unit to resist the
depressing action of the distal tipping of the terminal molars.
At this time, there is an alteration of the occlusal plane. The occlusal
plane drops down in its anterior quadrant. If no force other than those
within the archwires are utilised and if the archwires are left in the
mouth for a long period, the end result will be anterior open bite and
this is not desirable.
The alteration of occlusal plane however, can be prevented with the
use of the anterior box elastics.
By doing this, the roots of the mandibular buccal quadrants displace
mesially without much distal tipping of the crowns. This is because
the second order bends remain as second order bends rather than
becoming distal tip bends.
However, when class III elastics are applied along with anterior box
elastics, the crowns of the mandibular buccal segment tip distally to
the desired degree of anchorage preparation with a minimum amount
of mesial root displacement. Class III elastics facilitate mandibular
anchorage and counteract the mesial force of the second order bends
on roots of buccal teeth. An intermediate pull headgear has to be worn
in the maxillary arch to counteract forces of class III elastics on
maxillary molars (Fig. 45.13).
FIGURE 45.13 The mechanics of tip bends for anchorage

preparation in the mandibular arch.
The crowns of the teeth in buccal segment tip distally without roots
moving forward under the influence of tip back bends and class III
elastics.
Anchorage preparation in the maxillary arch

The anchorage thus prepared in the mandibular arch is utilised for
enhancing maxillary anchorage and distal en masse movement of the
maxillary arch. The mandibular arch at this stage bears a stabilising SS
wire of 0.0215 × 0.0275 in. bearing same and passive bends as the
previous wire.
The archwire with second order bends in the maxillary arch is
ligated. The mesial and bite opening forces of second order bends in
the maxillary arch are neutralised with class II elastics in day time
from mandibular terminal molars to inter-maxillary hook at V bend of
the maxillary arch. The distalising forces of the class II elastics worn in
daytime and head gear worn at night time contributes to anchorage
preparation and distal en mass movement of the maxillary arch
converting a class II molar buccal relations in to class I. If the class II
elastics are not worn, the uncontrolled forces move the root apices of
the teeth of the buccal segment in mesial direction without distal
movement of the crown. In such instances, mesial displacement of the
teeth in the buccal quadrants of both arches results in a bimaxillary
protrusion malocclusion from class II malocclusion.
Importance of coordination in second order bends8

The second order bends could act in a correct direction only if they
were precisely coordinated. Second order bend in the posterior region
with a flat wire in the anterior teeth would not produce the desired
results of distal crown movement in posterior teeth but will produce
mesial root movement and elongation of mesial cusps of molars.
Coordination of the second order bends implies that an equal
degree of lingual crown torque be placed in the anterior teeth. The
labial vector of the force is neutarilised with class II elastics or
headgear and an enhanced curve of Spee.
Tweed prepared anchorage to the great extent and grouped it as
(Fig. 45.14A–C):
First degree anchorage
Second degree anchorage
Third degree anchorage
FIGURE 45.14 First, second and third degree anchorage.
(A) Anchorage preparation first degree. (B) Anchorage preparation
second degree. (C) Anchorage preparation third degree.
Tweed’s principles of biomechanics and preservation of anchorage

are as valid as they were during his times. However in current
scenario, information on use of biological forces in teeth movement,
advancement of material sciences, lead to the development around of
the sophisticated wires. The anchorage conservation through other
methods like vertical holding appliance (VHA), Nance anchorage
saver, mini screw implants and skeletal anchorage system (SAS) have
replaced the tedious and painful steps required in anchorage
preparation according to Tweed’s method.
Anchorage and goals of FMIA for large ANB

In adults with large ANB-upward from 7 to 12 degrees (and when
sometimes enhanced by a Type B subdivision growth trend); first or
second-degree anchorage should be prepared. Third-degree
anchorage (or total/absolute anchorage) must not be prepared. This
could result in an unsightly retrusion of both maxillary and
mandibular teeth. One could compromise and accept FMIA
angulations as low as 50 degrees rather than the usual 65 degrees.
Some mesial movement of the teeth in buccal segments could also be
considered desirable. This procedure has been described by Tweed to
save oneself from incorrectly treating the patients with Type B growth
trend.7
Third order bends (torque)

Torsional bends along the long axis of the rectangular archwire are
called third order bends or torque (Figs. 45.15–45.18).
FIGURE 45.15 (A–D) Torsional bends along the long axis of the
rectangular archwire—third order bends or torque.
FIGURE 45.16 Labial and lingual root torque.
FIGURE 45.17 Torque in anterior segment.

FIGURE 45.18 Steps for buccal/lingual root torque in posterior
region.
Steps in incorporation of anterior torque suggested by Tweed are

depicted in Fig. 45.19. The torque movement requires a complete
understanding of the mechanics of the force, centre of rotation and
centre of resistance. A lingual/palatal root torque, when applied to the
central incisors at the brackets, which are usually placed at the height
of 4 mm from the incisor edge, will necessitate that centre of rotation
is at the incisal edge with no reciprocal labial movement of the crown.
Therefore, the labial vector of the force will need to be neutralised, by
the class I force or making the entire maxillary arch in one unit or use
of class II elastics.
FIGURE 45.19 Steps in placement of lingual root torque in the
anterior segment.
(A) Hold the archwire mesial to ‘V’ bend, (B) the mesial part of the wire
should be bent towards gingival direction. This bend has to be given
extending up to the midline by moving the plier towards midline. This
procedure has to be followed in the opposite side of the archwire. (C)
The entire archwire including the buccal segments have the palatal root
torque. Note the palatal inclination of molar stops. (D) The palatal root
torque has to be neutralised. This is done by using two Tweed pliers as
shown in the figure. (E) Note the vertical position of molar stops in the
archwire after neutralising the palatal root torque from the buccal
segments of the archwire. (F) The torque in anterior segment is still
maintained.
Active torque
• Torque in an archwire is said to be active when it is capable of

affecting a torque movement of teeth in a segment.
Passive torque
• A passive torque in an archwire is said to be present when the
torque does not produce torque movement on full
engagement of the wire. The purpose of the passive torque is
to maintain the already achieved torque or maintain the
labiolingual inclination of the roots. The torque in the buccal
segment could be of the same intensity, that is continuous
type or may increase or decrease in the progression of the
arch, that is progressive torque (Fig. 45.20).
Progressive posterior torque (as defined by Tweed) implies
progressive torque from second molar forward, which is
progressively less and dissipated at about cuspid area. The
quantity of torque as measured in degrees progressively
increases from canine to the second molar.
Continuous posterior torque implies to a same degree of torque
in the entire posterior segment of the wire distal to a V bend.
Method of checking the torque is given in Fig. 45.21.
FIGURE 45.20 (A) Continuous and (B) progressive buccal root
torque.
FIGURE 45.21 Method of checking the torque.
(A) Anterior. (B) Buccal.
Most subjects with malocclusion would require a palatal root torque

of the maxillary incisors (except class II division 2 patients), neutral
torque in the canines or somewhat buccal torque and progressive
buccal root torque starting at premolars, progressively increasing in
the distal region up to second molars.
The torque between anterior and posterior segments is distributed
through a neutral zone in the wire, which lies at V bend. A neutral
zone in the archwire is of particular importance if the third order or
torque is incorporated in anterior and posterior segments of the arch.
The discontinuation of torque values at neutral zone thus created
between the two segments confirms complete expression of the torque
on the prescribed segment with fewer side effects on the other
segment.
For example when an archwire has been fabricated with lingual
root torque in the anterior region and passive in the buccal segment
(no torque is required), on ligation the archwire its vertical placement
into the posterior segment will be altered; this shall eventually change
the three-dimensional relationships of the archwire within the bracket
slots in the posterior teeth as compared to the one with which it was
fabricated. Therefore, incorporation of a break into the archwire with
such V bends reduces the severity of occurrence of the above
situations undesired effects.
Mandibular incisors should be carefully evaluated for their
labiolingual root position in relation to buccal and lingual alveolar
plate. The mandibular incisors may need labial root torque for
uprighting or lingual root torque to control IMPA and the positions of
the roots, which should be placed in the middle of the labial and
lingual plates.
Making torque corrections in the canine area should be understood
completely and practised cautiously because of the location at the
junction of two diverging planes of the archwire.9
Significance of occlusal plane maintenance7

The behaviour of the occlusal plane during and following orthodontic
treatment needs to be under constant observation. Studies on the
growth processes of non-orthodontic children have found that there is
little change in the angle formed by the occlusal plane and the
Frankfort plane with age. But very frequently the occlusal plane
would lose its integrity during the orthodontic treatment; dropping
down anteriorly and getting elevated posteriorly.
During Tweed’s era, such control of forces was unattainable
without the use of extraoral devices.
Contemporary orthodontic armamentarium is well equipped with
intraoral device to control the vertical growth of the occlusal plane to
some extent by using VHA, mini screws (MSI) or skeletal anchorage
(SA) devices. These devices provide assistance and enhance
anchorage.
Stages of treatment
Tweed technique recommends the use of twin or Siamese brackets on
all erupted teeth including first molars for effective control.
Treatment with full arch banding. The bracket heights and buccal
tube position are given in the Table 43.1. The bracket positioning with
standard edgewise brackets is given in Chapter 43.

Multiple loop wire is the first choice for initial alignment of a crowded
arch and is prepared from 0.016 in. stainless steel or elgiloy wires.
In extraction cases the loops are designed to allow distal canine
movement and not to cause any labial proclination of the incisors.
Multiple looped wires when prepared with diligent observation on
required tooth movement can initiate tooth movements in one or more
planes, that is, axial (derotaion), mesiodistal/labiolingual (sagittal) and
vertical (occlusion–gingival). A careful observation of the pre-
treatment tooth positions and possible sequence of teeth movements
determine the design of the loops and helices.
Blue elgiloy wire is preferred owing to the ease of bending forms
and a large range of action following heat treatment. The severity of
crowding and malposition of the teeth to be corrected would
determine the shape of each loop and number of loops. A stepwise
alignment is followed in severe crowding and large discrepancy cases.
Multiple teeth movements and large activations would produce high
force and unexpected movements. Notwithstanding these forces, and
unable to find space, anterior teeth start moving in the direction of
least resistance leading to their proclination. An important
consideration here is that molar stops should not be fabricated in a
multiple loop wire to ensure free slide of the wire distally through the
molar tubes during anterior alignment. Molar stops are built in for the
patients under going non- extraction treatment.
The mechanical principle followed during alignment encompasses a
slow transition from multiple loops to light round wires followed by
lighter/small edgewise wires and later rigid edgewise wires.
The wire size progresses from 0.014 in. round to 0.020 in. and
followed by 0.019 × 0.022 in. rectangular and full size 0.0215 × 0.0275
in. wire.
Similarly, the bends incorporated into the initial wires (first order
and second order bends) are very mild, and their intensity is increased
slowly till the required amount has been prescribed in subsequent
wires to attain a desired intensity. Additionally, third order
movements; if required can be initiated with the small dimensions
edgewise wires and slowly increased in intensity with the subsequent
wires.
All wires should be coordinated for arch form and arch widths in
canine and molar region.
Following sequence of levelling from small dimensions to larger
dimensions of round wire, the first set of edgewise wires is fabricated
from 0.017 × 0.025 in. SS wires. These set of archwires are coordinated
for arch form, shape and widths, contain first order bends and mild
second order bends and curve of Spee in the lower and accentuated
curve of Spee in the maxillary arch. The wires are heat treated and
ligated with a posterior to anterior sequence.
Author (MM) would like to introduce a method of levelling and
alignment with a single archwire fabricated after careful and precise
analysis of type of tooth movement required for each tooth and
organising a sequence of movements which will not adversely affect
the anchorage and cause any round tripping. This method has been
termed as Precision Multiloop (PM Design)10 and could be applied to
labial as well as lingual orthodontics with similar ease (Fig. 45.22A–
H).
FIGURE 45.22 Treatment sequence with standard edgewise
appliance (SEA).
(A) Teeth arranged in class II division 1 malocclusion (B) Maxillary and
mandibular multiple loop wires in 0.016 in. SS, arch form and
coordination should begin from the first wire. (C) Wires ligated and
teeth movement achieved. (D) 0.016 in. SS with first and second order
bends molar stops after heat treatment. (E) 0.016 in. SS archwires
ligated and tooth movement achieved. (F) A gradual shift to higher
dimension wires. 0.018 in. SS with first, second order bends, molar
stops, the curve of Spee, RCS after heat treatment. (G) 0.018 in. SS
wires ligated and movement achieved. (H) 0.020 in. SS wires first and
second order bends, molar stops, an increased curve of Spee and RCS
ligated after heat treatment.
Bite opening mechanics and control of its

adverse effects on incisors
Bite opening mechanics in standard edgewise appliance (SEA) system
include incorporation of an accentuated compensatory curve in the
maxillary and a reverse curve of Spee in the mandibular arch. An
accentuated curve implies that the wire is more occlusal at the
premolar segment as compared to the anterior and molar segment of
the arch before ligation. By a strictly mechanical point of view, it could
be expressed that this wire should result in an eruption of premolars
and some intrusion at the anterior and posterior parts of the arch. An
admixture of biology, however, reveals an entirely different picture.
Depending upon the vertical muscular support from the muscles of
mastication; the molars might provide a range of reactions from no
change to a significant extrusion. The premolars follow the molars and
would show extrusion only when the intra- and inter-arch forces
overcome the force of the vertical chain of muscles. There is no true
intrusion of the anterior segment which can be accounted solely to the
accentuated curve of Spee in the archwire. The occlusal plane is
depressed in a gingival direction at the anterior segment by an
admixture of intrusion and proclination, out of which proclination
takes the primary measure.11 The extent of proclination is directly
proportional to the vertical muscular forces providing resistance to
the vertical/distal movements of premolar and molar teeth and
Indirectly proportional to the resistance provided by the anterior
arch/alveolar bone towards mesial movement and the labial
musculature.
The Tweed treatment principles, if assimilated correctly, provide
solutions in these difficult situations too. A thorough assessment of
the patient’s characteristics on initial diagnosis and later subsequent
appointments to observe the reactions to initial force applications
could help a clinician to choose the right amount and combination of
forces.
Following precautions are a necessity to facilitate correct tooth
movement affected by a curve of Spee in the wire:
1. A wire with an accentuated curve of Spee should be flattened

anteriorly, such that a flat wire instead of a curve is ligated in
the anterior part of the arch. An edgewise wire is always
preferable to a round wire, which bears lingual crown torque
in the flattened anterior part of the arch, which increases the
resistance of the anterior segment to proclination.
2. A great effort and caution are needed to maintain the arch
length. Molar stops are handy. Bent in molar stops with
second order bends are incorporated to keep the molars
upright. These can be made 1 mm mesial to the mesial end of
the buccal tube and gently tied back to prevent the
proclination of the anterior segment.
3. Preferably, undertake bite opening with accentuated curve of
Spee in the wire in one arch at a time, so that the other arch
could be used as anchorage to support the anterior segments.
For example, mild class II elastics during bite opening in the
maxillary arch support to maintain the anterior limit of the
maxillary arch, the intrusive forces on the anterior segment
could thus freely express themselves while the protrusive
forces are obstructed.
If the molar position in the mandibular arch is to be maintained,
some anchorage saver should be added. However, if
mesialisation is a plan for molar correction anchorage
preparation/anchorage savers need not be utilised in the
mandibular arch at this stage. Molars stops in the mandibular
arch are not fabricated. Class II elastics support mesial
migration of the molars and prevent labial tipping of the
maxillary incisors.
4. Accentuated curve of Spee wires prescribed along with a
removable or a fixed anterior bite plane are a effective method
of bite opening.
5. Dr Tweed used high pull headgear attached to the incisors
through J hook along with class II elastic for controlled bite
opening.
6. Step up bends are also incorporated to correct the vertical
discrepancy.
The arches are later prepared in the next size of archwires, that is,
0.019 × 0.025 in. SS and later 0.021 × 0.025 in. SS with similar wire
bends to maintain the corrections achieved with the previous
archwires as well to prepare the arches for the further steps, that is,
canine/en masse retraction.
Anchorage conservation
Anchorage preparation is done in one arch at a time. Mandibular arch
is usually done first. An archwire is made in 0.021 × 0.025 in. SS wire.
A high pull headgear in conjugation with standard edgewise
therapy is effective in maintenance of the anchorage and expression of
lingual root torque on the maxillary incisors by preventing labial
flaring at the incisal edges.
The J-hook headgear is worn with the inter-maxillary elastics in
upper arch, 14 h/day. Class II elastics are worn during the day while
the headgear is worn at night and some part of the day. The
compliance appliance has been delivering consistently inspiring
results owing to the heavy posterior anchorage and distalisation in
growing patients; achieved not only over the dentition but also the
maxilla.
The high pull headgear, if followed skilfully produces clinical
results most welcomed by the patient and the operator.
As a general rule, a patient prescribed with a compliance appliance
should be recalled more often during the early phase of treatment
appointments. It has been inspiring to observe patient’s development
towards appliance acceptance with an operator’s continuous belief
oriented support. Secondly, but importantly, initial reactions to the
combination of forces from wires and headgear should be assessed
continuously at each recall. Extraoral reactions are slow to occur but
intraoral dental reactions are not! (Fig. 45.23A–H).
FIGURE 45.23 Anchorage preparation.
(A) Anchorage preparation is started in one arch at a time with the
mandibular arch first. Maxillary stabilising arch 0.021 × 0.025 in. SS
with; first, mild second order bends, molar stops. Mandibular 0.021 ×
0.025 in. SS with; first, second order bends (terminal bend twice the
previous one), molar stops, lingual crown torque. Maxillary anchorage
reinforced with headgear to support mandibular anchorage preparation
with class III elastics. (B) Completed mandibular anchorage
preparation. (C) Distal en masse movement of the maxillary arch.
Mandibular stabilising archwire. The same 0.021 × 0.025 in. SS, wire
which is now passive with all tooth movements achieved. Maxillary
0.021 × 0.025 in. SS with first, second order bends (last bend twice the
previous one), molar stops, the same amount of palatal root torque in
anterior teeth and an excessive curve of Spee. Headgear along with
class II elastics and anterior vertical elastics to control excessive
vertical intrusive forces from headgear and curve of Spee. (D–F)
Anchorage preparation. (D) Completed distal enmasse movement of
the maxillary arch. (E) Maxillary archwire. (F) Set of coordinated
maxillary and mandibular; archwires for anchorage preparation.
The occlusal plane (OP) provides the most important early detection
of incorrect forces. The OP should be monitored for its anterior and
posterior vertical position (A–P cant) and horizontal bilateral
symmetry (Transverse cant) in molar and anterior region, if it is being
developed through the force or if it is being corrected; as compared to
the previous/pre-treatment position.
Archwires should be checked if midpoint was precisely matched
with the arch midline, removed, rechecked for all bends if correctly
positioned, symmetry in positioning of first order bends from the
midline, the canine offset and the molar offset, intensity of
compensating curve on both sides if it is symmetrical and positioning
from the midpoint of the soldered hooks used for engagement of the J
hooks.
Headgear forces should be rechecked for direction, intensity, and
lengths of the rigid and elastic components of the headgear assembly.
Forces should be corrected at these initial appointments till the
operator is satisfied that a correct combination of forces has been
prescribed. In this way the patient as well the operator learn and grow
with the appliance during first few appointments, and further
compliance is also predicted as good.
Methodical and indispensable inclusion of the second

molar in treatment
The inclusion of second molars in the treatment plan is indispensable.
The arches are as a general rule treated up to the second molar. In
particular situations, methodical incorporation of the second molars is
planned to aid in treatment.
A larger posterior anchorage includes insertion of heavy wires for
example 0.019 × 0.025 in. SS with second order bends, and
consolidating first and second molar tubes together with steel
ligatures during anterior space closure.
In situations where the mandibular molars require mesialisation for
the correction of posterior relation to class I, for example in some class
II cases, the first molar and second molar are not consolidated with
ligature tie. The mandibular first molar is mesialised first followed by
the second molar. The second molar in this clinical situation provides
smooth mesialisation of the first molar by guiding and stabilising the
distal end of the archwire (Flowchart 45.1, Box 45.2).
FLOWCHART 45.1 Analysis of second order bends.
Box 45.2 Directional forces from two types of

headgears used
Space closure
In maximum discrepancy/high anchorage cases such as severe
crowding and bimaxillary protrusion, the canines are retracted
individually to their distal positions into the extraction spaces.
Partial canine retraction implies to distalisation of the canines until
enough space has been created mesial to the tooth for alignment of the
incisors. Two stage space closure i.e. canine retraction followed by
incisor retraction is the norm in Tweed technique (Fig. 45.24A–G).
FIGURE 45.24 Maxillary and mandibular canine retraction.
(A) Canine retraction is started with the extraction of maxillary first
premolars. Two sets of canine retraction jigs are used, the first set is
used for partial retraction while the second set is used for complete
retraction. (B) Active first jig for partial canine retraction, maxillary
anchorage reinforced with the help of headgear, open coil spring
activated through the mesial hook on the jig with class II elastics. (C)
Active second jig for complete canine retraction. (D) Mandibular first
premolars are now extracted, pictures showing canine retraction in the
mandibular arch. (E–G) Mandibular canine retraction. (E) Mandibular
partial canine retraction wire with jigs, maxillary anchorage reinforced
with headgear and class III inter-maxillary elastics are given for
activation of open coil springs through the mesial hook on the jig. (F
and G) After partial mandibular canine retraction, complete retraction is
achieved with an open coil spring inserted onto the wire mesial to the
canine and is activated by ligating it to the mesial hook on the molar in
a compressed position.
The maxillary base wire is formed in 0.0215 × 0.0275 in. SS wire. The
archwire is reduced, posterior to V bend to the dimensions of 0.019 ×
0.022 in. The maxillary arch form is coordinated with mandibular
stabilising wire. A long canine eminence is built in the retraction wire
so that canine is distalised and housed with a canine eminence, a
normal position in the arch. The wire has molar stops and coordinated
first and second order bends in place.
Canine retraction jig is fabricated in 0.019 × 0.025 in. SS wire, which
engages the archwire mesial and distal to the canine. The jig should
slide freely over the archwire in mesio-distal direction. An open coil
spring is now slid over the archwire that should lie between the
mesial lumen of the jig and the mesial bracket surface of the canine.
The jig is used to distalise the maxillary canine with 5/16 medium
class II elastics engaged over the hook of the jig. High pull headgear
with J-hook is used during the night time. In cases where molar
correction is needed with a mesial migration of the lower molar, stops
are not fabricated in the mandibular arch. Class II elastics are worn
day and night. Night time head gear is not used. The canine moves
bodily with bracket smoothly gliding in the distal direction over the
SS wire while the anterior corrections are maintained by the same
rigid wire. A distal rotation tie and distal position of the bracket
controls the disto-palatal rotation of the canine during the process of
distal bodily movement. A figure of 8 ligature tie to four incisors
keeps them in contact and prevents flaring affected by the stretching
of transseptal fibers.
For bimaxillary protrusion cases class I force is prescribed from the
hook at the mesial lumen of the jig and the molar hook with the help
of class I elastic; the jig is an attempt designed to compresses the open
coil spring mesial to the canine bracket thus initiating the canine
movement distally. This mechanical principle is observed in
maximum discrepancy cases where the molar position in both arches
is to be maintained.
Before ligation of the main wire, the brackets and tubes on each
buccal segment are tied with a ligature in a figure of 8 fashion
converting them into a consolidated unit.
Similarly, four incisors are converted to a single unit with soft
ligature tie in a figure of 8 fashion. This ligature should be passive
enough to consolidate the anterior segment. It should not have an
active force if present will cause mesial crowding of the roots and
slow down the incisor retraction.
The archwires are coordinated and ligated. The maxillary and
mandibular canines receive distal rotation tie over a long canine
eminence. The purpose of the distal rotation tie is to hold the canine
without distal palatal rotation while it slides over the wire over the
distance of a mesiodistal width of a premolar.
Complete canine retraction implies distalisation of the canine into
premolar extraction space. Following partial canine retraction, the jig
may pose a mechanical hindrance, which can be overcome either by
making a jig of smaller length or by activation of open coil spring with
a ligature tied to the terminal molar in a compressed mode.
After complete canine retraction, the canine bracket is also included
in the consolidated buccal unit.
Incisor retraction
Mandibular arch, incisor retraction is carried out using a bull loop, a
variation of the vertical closed loop. It is fabricated in a 0.021 × 0.025
in. SS wire with all first, second and third order bends maintained as
in the previous wire. The corrected curve of Spee should be
maintained during this stage. Second order bends should be long.
In cases, where the molar relation has been decided to be corrected
by mesialisation of the mandibular molars; partial retraction of the
canine is carried out to align the incisor segment. Subsequently, en-
masse retraction is carried out with four bull loops fabricated into the
wire, one each distal to the lateral incisors and distal to the canine on
either side. The mandibular molar thus moves mesially to correct the
molar relationship (Fig. 45.25A–D).
FIGURE 45.25 Maxillary and mandibular incisor retraction.
(A) Mandibular incisor retraction wire 0.021 × 0.025 in. SS with bull
loops and soldered molar stops. The wire is activated by opening the
loop by active ligation of the molar stop with a mesial hook on the
molar. The wire is activated in increments till complete retraction is
achieved. (B) Maxillary incisor retraction wire has been prepared with a
0.021 × 0.025 in. SS with a T loop distal to lateral incisors and no molar
stop and is activated by cinching the wire posteriorly behind the molar
tube. Note mesial leg of the loop is 1 mm shorter than the distal leg in
both the arches to maintain the corrected bite; the last picture is
showing partial retraction of the incisors. (C) Arch forms at the
beginning of the retraction process to the completion of partial
retraction of the incisors in the maxillary arch and complete retraction of
incisors in the mandibular arch. (D) Anterior retraction and extraction
space closure are later continued on a plain wire with all necessary
bends, and active molar stops along with inter-maxillary (class II)
elastics. Molar stops in the mandibular wire from this stage should be
passive and flush with the mesial end of the molar tube to maintain the
retracted crown positions and corrected arch length.
Maxillary arch, incisor retraction is carried out with the help of a

headgear force over a base wire, which is full size with adequate
torque in the incisor segment, step up V bend and mild long second
order bends for free slide through the tube during incisor retraction.
The wire requires reduction distal to V bend to 0.019 × 0.025 in.
dimensions. The principle of force application remains same as in the
case of canine retraction in class II molar cases where day time class II
elastics and night time high pull headgear is used. The space closure is
achieved usually at the rate of 0.9 mm/ month. The retraction
mechanism in the lower arch requires frequent activations once in 4–6
weeks. A diligent and careful watch is required on root positions,
unwanted tooth movements, torque loss or loose bands. The appliance
may require activation for accentuation on torque.
Finishing and detailing objectives

The final space closure should have achieved the major objectives of
orthodontic treatment on molar relations, arch forms and coordination
and a normal over jet. The purpose of finishing and detailing is to
optimise finer tooth positions for aesthetics and achieve functional
stable occlusion.
1. Anterior occlusion
2. Posterior occlusion
3. Functional occlusion (Fig. 45.26A–D)
FIGURE 45.26 (A–D) Finishing and detailing. At the stage of deband.
Artistic finishing bends are incorporated at this stage to correct the

mesiodistal tip of the incisors, which often show root convergence at
the end of space closure. All wires prescribed after complete space
closure should bear molar stops along with class II elastics to maintain
the corrected arch length, the anterior torque and all mesiodistal
crown positions during further finishing root corrections. If the wire is
unsupported posteriorly and active torque bends are still remaining in
the wire, it will slide mesially through the molar tubes and tip the
anterior crowns labially; also the second order artistic bends would
not act efficiently with such a posteriorly unsupported wire.
During the stage of finishing the archwire should remain
consolidated. Arch consolidation is achieved with a figure of 8
ligature from right terminal molar to left terminal molar and molar
stops tied back to the tubes. The molar stops are fabricated or soldered
1 mm mesial to the mesial end of the molar tube so that they can be
actively tied back.
Arches, which require major corrections during finishing stages are
taken care of, differently. Such arches constitute cases in which some
or more teeth might have lost attachments between the appointments
and have lost integrity or teeth, which were left unligated and out of
the arch due to varied considerations. One of the most important and
often irrepressible factor hindering excellent finishing is related to is
the time constraint. In such situations, an arch is chosen which is most
well aligned and levelled out of the two. This arch now functions as a
stabilising arch and bears a 0.021 × 0.025 in. SS passive wire with all
required bends. The opposite arch is prescribed a smaller dimension
edgewise wire with all corrective bending. It is preferable that a 0.021
× 0.025 in. SS wire reduced posteriorly to smaller dimension is used as
a corrective wire. Non-sugared chewing gums are prescribed for
bilateral chewing at this stage. The tooth movements are also
sometimes enhanced by a justified use of short 1/8 in. 2 ounce elastics
in a required pattern. These could be short class II, short class III,
triangular, W or their combinations. The use of elastics should be
considered only when it outweighs its side effects of producing
indeterminate and sometimes unwanted tooth movements and the
opening of the mandibular angle. If used, the patient should be on a
continuous recall with not extending the length of elastic wear for
more than 3 weeks.
Debonding/debanding premolar and canine brackets are removed
first while maintaining the corrected arch length with molar stops and
sometimes open coil springs mesial to the molars which are activated
by compressing against the molar hooks.7 Following achievement of
functional stability of the occlusion in the canine premolar region, and
maintaining the anterior teeth that have been completely through with
the artistic corrections, the entire arch is debonded/debanded. The
retainers are prescribed and post-treatment records made.
Retainers are prepared on impressions made before debonding, the
brackets on which are scraped out before forming the fitted labial bow
of the wrap-around retainer. This confirms retainer placement
immediately after debonding. In cases with pre-treatment spacing, the
long labial bow spans around last molar tooth.
Tweed principles as applied to clinical
practice at AIIMS
Treatment plan protocol
Banding or bonding
The initial wires
The bite opening
Enhancing the anchorage
Canine retraction
Incisor retraction
Department of Orthodontics, CDER, AIIMS’s tribute to Dr Tweed

and his teachings.
The author has served as postgraduate faculty at AIIMS New Delhi
since 1985. Author continued to teach the principles of edgewise
orthodontics. The postgraduate students learn wire bending for
Bonwill–Hawley chart, and create first and second order bends in
coordinated archwires in round SS wires (0.016, 0.018 in.) and
edgewise wires of full size, that is 0.022 × 0.028 in.
Each student goes through 10 sets of archwires on a typodont for
the treatment of class II division 1 malocclusion Type B growth trend.
This lays the foundation of first, second and third order bends and a
deep concept and concern for anchorage control including use of
headgears.
Orthodontic students learn the use of modern wires and
contemporary orthodontic mechanisms but not losing the sight of the
fundamentals of Tweed principles of anchorage control, bodily
movement of canines and retraction of incisors without losing the
torque.
The protocol on treatment planning

In clinical practice, the goals of IMPA are designed based on
cephalometric data for the Indians. Tweed’s goals of 90 degrees IMPA
would overcalculate the arch length discrepancy.
Kharbanda et al.12 reported that their sample of North Indian adults
with class I occlusion and balanced facial profile exhibited FMA close
to the Tweed’s norm, mean 23.49 degrees (range 13–35 degrees).
However, the IMPA values ranged from 81 to 117 degrees with a
mean of 101.77 degrees. Therefore, the values for FMIA were found in
the range of 36–74 degrees with a mean of 53.87 degrees. This study
also found a highly significant and negative correlation between FMA
and IMPA. Using a linear regression analysis, a table and a
normograph were devised to estimate IMPA for an individual patient
based on his FMA.
Tweed’s analysis is simple and clinically useful. Though, his norms
should be considered only as a guide and not absolute achievable
objectives. The treatment objectives of IMPA should be considered
according to a facial pattern, that is, FMA. Racial/ethnic variations of
norms cannot be overlooked while outlining goals and planning the
treatment.12–15
Edgewise mechanics
We use 0.022 × 0.028 in. slot twin bondable brackets, which are
commercially available as a SET, identifiable with tooth number and
colour-coded for the maxillary and mandibular arch. The molar tubes
used are a double buccal tube on maxillary first molars and single
tube on lower molars.
Anchorage control is planned from the very beginning and is a
major consideration during planning the treatment. Anchorage savers
such as Nance palatal button soldered to first molars and second
molars, VHA, quad helix appliance, a trans-lingual arch in the lower
jaw, and mini screws are considered in routine. Anchorage planning is
based on arch length discrepancy, depth of the curve of Spee, facial
type, growth trend and space needed for the correction of molar
relationship.
We prefer to use mini screw implant in class I bimaxillary cases to
enhance anchorage control both in vertical and sagittal direction. SAS
is used in select cases of borderline orthognathic surgery.
Anchorage is also controlled with the appropriate use of mild
second order bends but anchorage preparation is not achieved, rather
an active root thrust is achieved on molars with a distal anchor bend
at the molar stop.
Molar stops are used to maintain arch length except at the stage of
incisor retraction.
Levelling and alignment is achieved with multiple looped archwires
with the major thrust to distalise the canines into extraction spaces
and prevent labial flaring of the incisors.
The arch form, coordination of arch forms between upper and lower
wires more so for inter canine and inter molar widths receives highest
attention.
Bite opening is achieved through a variety of mechanics. The
mechanics of bite opening includes use of reverse curve in elgilloy
wires and accentuated curve in the maxillary arch with control of
labial proclination vectors of force. It also includes use of Ricketts and
Burstone intrusion arch (Fig. 45.27). The selection of bite opening
mechanics is influenced by the nature of malocclusion, and
relationship of dentition with lips and smile.
FIGURE 45.27 Maxillary intrusion arch.
Canine retraction
The maxillary and mandibular canine retraction is performed with
class I mechanics on a rigid SS base wire of 0.019 × 0.022 in. SS wire.
The wire with molar stops and mild active anchor second order bends
is ligated. We use 150 g nickel titanium spring of 9 mm stretched from
buccal tube tied to the power arm of the canine. The effective rate of
tooth movement is 0.8–0.9 mm per month and it takes about 8 months
time to achieve complete canine retraction. A long canine eminence is
provided extending up to the mesial of second premolar on each side.
At the completion of canine retraction the canines are tied to second
premolar and first molars using a soft ligature in a figure of 8 fashion.
At this stage the new set of wires is made for incisor retraction.
Incisor retraction
Incisor retraction is performed through asymmetrical bull loop in the
maxillary arch and a vertical teardrop loop in the mandibular arch.
The teardrop loop/T loop is positioned just distal to the lateral
incisors. The looped incisor retraction wire is prepared from a 0.021 ×
0.025 in. SS. If prepared from 0.019 × 0.025 in. SS greater torque needs
to be incorporated into the anterior segment than the previous wire to
resist the play from a reduction in wire size as well as the retraction
tipping.
The amount of compensating curve is maintained as in the previous
wires; it is increased if bite deepening is observed after canine
retraction. The mesial leg of the loop is fabricated 1 mm smaller in
height than the distal leg. The wire should bear long second order
bends so that adequate wire is available mesial to the brackets; to slide
out distally as well as provide space for loop activation in case of the
teardrop/T loop wire. An accentuated sweep in the curve of Spee also
suffices to resist mesial migration of buccal segment in the upper arch.
Like wise a reverse curve is incorporated in the mandibular wire.
In current practice the loops are prepared in TMA wire, which
delivers a constant bite opening and retraction force. Most critical
aspect of incisor retraction involves control of torque in the anterior
segment, which is achieved with careful monitoring on torque loss
and incorporation of additional torque as and when required. The
incisor retraction looped archwires are activated by a gentle cinch of
the annealed ends of the wire at the distal ends of the buccal tubes.
The edgewise appliance places the roots of the teeth nearly parallel.
The correct mesiodistal tip is achieved with artistic positioning bends
in the arches as shown in Fig. 45.27. The artistic bends include a fly
bend in the centre line of the maxillary incisors, of greater severity
than the ones between the centrals and laterals on the either side. The
torquing wires are made in full size SS wires of 0.0215 × 0.0275 in. Any
discrepancies in arch form, marginal ridges and occlusal contacts and
intercuspation are settled at this stage. The case treated by
conventional edgewise mechanics shown in Fig. 45.28.
FIGURE 45.28 Bimaxillary case Anjali.
(A) Case AJ. Pre-treatment severe bidental protrusion, maximum
anchorage requirement. Anchorage conservation and maximum
retraction is a challenge due to vertical skeletal pattern. (B) Case AJ.
Anchorage is reinforced with Nance button in maxillary arch and trans-
lingual arch in mandibular arch. Two-stage space closure was done.
Canine retraction was initiated with 150 g NiTi spring, using friction
mechanism, over 0.019 × 0.025 in. SS base wire. The arch length is
maintained with built in molar stops. A V bend is placed in the arch
somewhat between lateral incisor and canine bracket on either side.
The torque at canine is 0 degree with gentle buccal torque progression
up to first molar. Long canine eminence is provisioned, so that while
canine is distalised in the arch, its root moves gently within the
maxillary alveolar bone avoiding contact with labial cortical plate.
Failure to keep root of the canine in correct position slows down canine
retraction, dumping the root against labial cortical plate leads to
anchorage loss. Mild curve of Spee in the upper arch and reverse
curve of Spee in the lower arch helps in maintaining the bite. Both the
arches are well coordinated and heat-treated before ligation. (C) Case
AJ. Anchorage is reinforced with Nance button in maxillary arch and
trans-lingual arch in mandibular arch. Second stage of two-stage space
closure involves incisor retraction. Anchorage is reinforced by using a
trans-palatal arch and figure of 8 ties from first molar to canine one
each of the buccal segment. Four incisors are also made in a single
unit with soft ligature ties. (D) At the completion of upper and lower
incisor retraction-finishing wires are prepared. Both the arches should
be well coordinated for arch form, curvature in the incisal area, inter-
canine width, inter-molar width and overall shape of the arch. Rigid
wires are good for the arch form coordination. Arches are also carefully
evaluated for incisor root torque and mesiodistal tip of the teeth. If need
be the final torque and tip are incorporated in the wire. Arch length and
tight contacts are maintained by figure of 8 ligature wires from one
molar to molar on the other side. Molar stops are soldered 1 mm mesial
to the mesial margin of the buccal tube. The archwires are tightly
secured to the tubes through the molar stops. (E) Post treatment profile
occlusion and X-rays show a balanced facial profile, consonant smile,
class I molar and canine relations, excellent cusp to fossa relationship,
excellent arch form, good contacts and normal over jet and overbite.
Wires are tightly secured to the tubes through the molar stops. OPG
depicts normal mesio-distal tip of the teeth and cephalogram depicts
excellent torque of the maxillary and mandibular incisors. (F) Pre-finish
and post-orthodontic treatment cephalograms show a marked reduction
in proclination of upper and lower incisors resulting in improvement of
the inter-incisal angle from 114 degrees to 133 degrees.
Key Points
An understanding of fundamentals of biomechanics and 3D control of
tooth movement with edgewise mechanics are essential to each
orthodontic student to be able to comprehend the functioning of the
contemporary pre-adjusted appliance. Students at the orthodontic
department AIIMS course are trained at the basic intricacies of SEA.
They learn to use principles of Tweed’s technique as applied to
modern appliances and contemporary wires. They are able to produce
results similar to any appliance in the market.
This approach provides a smooth transition from SE to PEA the
most widely used appliance today and also helps to introduce the
techniques of SE during treatment with PEA, as requirements of
individual case prevail; for the knowledge of SE is forever at hand and
mind wherever this graduate goes!
References
1. Tweed CH. The Frankfort-mandibular plane angle in
orthodontic diagnosis, classification, treatment
planning, and prognosis. Am J Orthod Oral Surg.
1946;32:175–230.
2. Tweed CH. The application of the principles of the
edge-wise arch in the treatment of malocclusions: I.
Angle Orthod. 1941;11(1):5–11.
3. Cross JJ. The Tweed philosophy: the Tweed years.
Semin Orthod. 1996;2(4):231–236.
and prognosis. Angle Orthod. 1954;24(3):121–169.
5. Tweed CH. Was the development of the diagnostic
facial triangle as an accurate analysis based on fact or
fancy? Am J Orthod. 1962;48:823–840.
1969;55(6):651–657.
7. Tweed CH. Clinical orthodontics. 1st ed. Saint Louis:
CV Mosby; 1966.
edge-wise arch in the treatment of malocclusions: II.
Angle Orthod. 1941;11(1):12–67.
9. Strang RH. A discussion of torque force as available
in the edgewise arch mechanism. Angle Orthod.
1932;2(2):88–111.
10. Mankar MP, Chachada A, Atram H, Kulkarni A.
Precision multiloop (PM Design) with space closing
circles for lingual orthodontics. J Indian Orthod Soc.
2016;50(5):88–93.
11. Pandis N, Polychronopoulou A, Sifakakis I, Makou
M, Eliades T. Effects of levelling of the curve of Spee
on the proclination of mandibular incisors and
expansion of dental arches: a prospective clinical
trial. Aust Orthod J. 2010;26(1):61–65.
12. Kharbanda OP, Sidhu SS, Sundram KR.
Cephalometric profile of north Indians: Tweed’s
analysis. Int J Orthod. 1991;29(3–4): 3–5 Fall–Winter.
13. Ashima V, John KK. A comparison of the
Fauchard Acad. 1991;5(1):17–21.
14. Bhattarai P, Shrestha RM. Tweeds analysis of
Nepalese people. Nepal Med Coll J.
2011;13(2):103–106.
15. Kim JH, Gansukh O, Amarsaikhan B, Lee SJ, Kim TW.
Comparison of cephalometric norms between
Orthod. 2011;41(1):42–50.
CHAPTER 46
contemporary fixed appliance.
Phase II: major tooth movements
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Steps of the active orthodontic treatment
Sectional arches
Continuous archwires
Loops and helices
Types of loops
Characteristics of the force system in loop mechanics
Bite opening
Levelling of the curve of Spee
Maxillary and mandibular incisor intrusion
Space closure
Two stage space closure
Canine retraction on a continuous wire
Sectional method or frictionless mechanism
Clinical applications of canine retraction loops and
springs
Retraction of incisors into extraction spaces
Key Points
Introduction
The very purpose of the active phase of treatment is to align teeth in a
good arch form and level the brackets, thereby positioning the teeth in
their correct occlusogingival placement and mesiodistal angulations.
The teeth crowns are so placed in labiolingual or buccolingual
positions in the alveolus to follow natures contours of an arch. In a
pre-adjusted appliance these tooth positions are achieved through
built-in variable thickness of bracket bases and buccal tubes while in
the standard edgewise appliance system, first order bends are
incorporated in the archwire for the same. The teeth should also
become free from any axial rotations. The correct labiolingual
inclinations or torque of the teeth are accomplished during the phase
of incisor retraction and space consolidation. Space closure is followed
by a phase of finishing and detailing of occlusion before the bands and
brackets are removed.
Steps of the active orthodontic
treatment
• Levelling and alignment
• Bite opening
• Space closure
• Finishing and detailing
A careful and attentive examination of the periodontal health is a
routine and must be carried out before the initiation of the active
orthodontic treatment, i.e. levelling and alignment. Teeth in unusual
locations with rotations or clinical suspicion of periodontal disease
should also undergo radiological assessment. Particular attention is
paid to the teeth with severe rotations or teeth displaced out of the
arch.
• A marked labially/abnormally positioned (Fig. 46.1A–D) or

rotated tooth with poor periodontal support would require
careful planning, not to compromise periodontal health
during alignment (Fig. 46.2A–B).
• Patients with severe bidental protrusion should be evaluated
on a lateral cephalogram for the relationship of the roots of
incisors with the labial and lingual cortical plates. The alveolar
process at the anterior part of the mandible is likely to be thin,
which necessitates careful handling of the tooth movement
(Figs 46.3A–B and 46.4A–C).
• Similarly, any tooth with marked abnormal mesiolingual root
angulation should be evaluated for required modification of
conventional archwire design (Fig. 46.5A–B) or modification
in the position of the bracket.
FIGURE 46.1 (A–D) A case with severe crowding. It is imperative to
plan the first alignment mechanics carefully, not to compromise
periodontal health during alignment.
FIGURE 46.2 (A) Patient with traumatic deep bite. (B) Gingival
recession in mandibular left central incisor would require a careful
planning of tooth movement, not to cause their proclination.
FIGURE 46.3 (A and B) A patient with bidental, bimaxillary protrusion
with thin labial cortical plates in the anterior region of maxilla and
mandible.
FIGURE 46.4 (A–C) Patient with a bimaxillary protrusion, and vertical

growth trend. The mandible has thin labial and lingual cortical bone in
the incisor area. Also, note gingival recession on mandibular canines
and fractured maxillary central incisors.
FIGURE 46.5 (A) Unfavourable root angulation of the right and left
mandibular canine. (B) Favourable root angulation of the right and left
maxillary canines.
The process of teeth alignment should be initiated only when

sufficient space is made available for them on the denture bases. At
this stage, clinicians should be aware of precise space requirements,
required anchorage and the anchorage savers to be instituted. The
planned-extractions are carried out, and the patient is re-reviewed for
an accuracy of placement of bands and brackets causing any
interference in occlusion. Should any alterations be required, these
must be carried out before aligning wires are placed in the mouth.
In a non-extraction case, the alignment of the teeth would require
one of the following options for the space to be created:
1. Proclination of teeth
2. Arch expansion
3. Proximal recontouring of teeth
4. Molar distalisation
In an extraction case, first alignment mechanics should be designed

to initiate distal tooth movement of canines into extraction spaces to
alleviate the crowding. The aligning wires create an occlusogingival
movement of the teeth to level them to correct marginal ridge
relationship with simultaneous correction of rotations.
Highly placed canines and abnormally positioned teeth are moved
to occupy their place in the arch. This process of gradual alignment of
teeth slowly transforms the malocclusion into coordinated arches,
which should follow a smooth curve. Efforts are also made to
coordinate mandibular dental arch form and width to match the
maxillary arch. Care should be taken to maintain inter-canine and
inter-molar widths if not indicated otherwise.
The levelling and alignment can be performed either by continuous
arches or sectional arches. The sectional arches may be needed in
situations of severe crowding or where teeth are placed in aberrant
positions.
Sectional arches
Sectional arches may be required to unravel initial crowding where a
continuous arch is not possible to ligate due to limitations posed by
the nature of malocclusion or traumatic bite. Often such a situation is
seen in mandibular canines that need to be moved distally to create
arch space for the crowded lateral and central incisors. A closed ‘T-
loop’ is fabricated in 0.016 × 0.022 in. SS or 0.017 × 0.025 in. TMA or
elgiloy wire, anchored at first molar, ligated to canine brackets, is
gently activated by a distal cinch (Fig. 46.6).
FIGURE 46.6 (A) A case of severe crowding. (B) Sectional loop

mechanics was used to align left maxillary canine and multiple looped
round archwires in the lower arch. (C) Levelling is progressing in both
arches with round wires. Note a sectional piggyback NiTi wire is
engaged in left maxillary canine for vertical alignment.
Continuous archwires
Shape memory archwires
The levelling and alignment of the entire arch are usually initiated
with highly resilient, shape memory archwires with a low load-
deflection rate. A typical levelling wire extends from bonded last
tooth (first or second molar) on one side to the other side. Initial
levelling is often undertaken with smaller dimension wires such as
0.014 in. NiTi wires or flexible spiral wire, gradually progressing for
higher size wires upto 0.020-in. steel or rectangular 0.019 × 0.025 in.
rigid steel wires. Nickel–titanium (NiTi) wires work well for relief of
mild to moderate crowding and rotations.
The preformed nickel–titanium wires can be deflected to a large
range of tooth movement and yet generate lighter forces. This
property is utilised to align blocked out or high labially placed
canines. The main disadvantage of such a system is difficulty in
controlling the arch form. Wire-bracket friction is a variable factor as
the moving teeth displace along the archwire with this approach,
making it difficult to accurately predict moment to force (M/F).
Sectional NiTi wires can also be used to align a malpositioned tooth in
a piggyback manner where rest of the arch is ligated with a stiff wire.
With this arrangement, a light continuous force is exerted to bring the
displaced tooth into the alignment while reciprocal force is distributed
over the anchor teeth (Fig. 46.6C).
Multiple loop archwires

A multiple loop archwire is comprised of a combination of one or
more loops of different designs to suit the malocclusion requirements.
The multiple looped wires are tied to brackets to exert moving forces
on the tooth roots. This approach is called friction-free—when
activated, the archwire loops distort from their original configuration;
as the tooth (or teeth) moves, the loop gradually returns to its
undistorted (pre-activated) position, delivering the energy stored at
the time of activation. Groups of teeth can, therefore, be moved with
more accurately defined force systems for more precise anchorage
control to achieve treatment goals more readily than methods in
which friction plays a role.
A multiple looped archwire is made with 0.016-in. blue elgiloy or
0.014 in. special or special plus Australian archwires. The author likes
to use 0.014–0.016-in. soft blue elgiloy wire for making loops owing to
its easy formability. The bracket prescription tends to express as the
treatment progresses and gradually wires with higher dimensions are
used, hence, minimising the play between wire and bracket slot (Fig.
46.7A–D).
FIGURE 46.7 Levelling and alignment with multiple loop

archwires.
(A) Pre-treatment. (B) Multiple loop wires. (C) Levelling in progress with
0.018 in. SS wire. (D) Post debond.
Initial multiple looped archwires are designed to push the canines

distally into extraction spaces, thereby leaving enough room for the
alignment of the incisors. It is not necessary to engage all the teeth,
with full seating of archwires in brackets from the very beginning.
Severely displaced teeth may require loose ties in the first wire and as
the treatment progresses it may be possible to engage the fully seated
archwire in the slot. The teeth tend to upright and derotate, crowding
is unravelled, the arch form began to appear, and one can slowly
progress to an archwire with higher dimensions and attain an arch
form close to the natural shape.
The elgiloy and SS archwires are required to be heat treated before
ligation. Ends of the archwire should be checked for the free slide in
buccal tubes.
Assessment of root angulation of canine is an important
consideration while choosing and designing the mechanics of its
retraction. A malpositioned canine with favourable root angulations
(having distally placed root apices), would move faster into extraction
spaces. A buccal canine with distal crown mesial root tip may
necessitate a multiple loop wire with appropriate wire bends to
correct unfavourable root angulation before it can be moved into
extraction space. Such teeth movements are easy to accomplish with
looped wires of appropriate designs. It is possible for an orthodontist
to create loops with a design to create required flexibility and tailored
tooth movement in mesiodistal, occluso gingival and axial (rotational
effect) directions.
At the completion of levelling and alignment stage, all rotations are
corrected; good arch form is accomplished with a series of round
archwires ranging from 0.016 to 0.022 in. At the completion of
levelling a rectangular archwire of 0.019 × 0.025 in. dimensions should
be passively seated in the bracket slots. In cases with severe crowding,
half to more than half of extraction space may have been utilised by
distally moving canines during the relief of the crowding.
Loops and helices
The dictionary meaning of a loop is ‘a branch of anything that returns
to the main part’. The use of loops in orthodontics can be traced back
to 1915 when Robinson made the first loop in the wire.1 P. R. Begg2 of
Australia extensively used vertical loops for control of rotation, space
opening and space closure. He invented special wires with high
resiliency and spring back properties for light wire technique and
used them in a variety of ways for making uprighting springs and
torquing auxiliaries. Stoner incorporated various loops in edgewise
mechanism in the 1960s.3 However, loops are not in vogue now,
probably due to over-dependence on properties of nickel–titanium
wires. The fabrication of looped archwire requires dexterity,
consumes significant clinical time in their fabrication and, moreover,
necessitates extravigilance and care, posing a significant problem in
maintaining oral hygiene. The multiple looped archwires also cause
discomfort of the oral cavity at least during the initial days after
placement. However multiple loop wires are the most efficient system
in the management of severe crowding.
Types of loops
In general, loops can be classified as:
1. Simple loops: loops without helix

2. Springs: loops with a helix
Based on shape (Fig. 46.8) loops can be classified as:
1. Vertical loops: primarily used for tooth movement in

horizontal axis. The vertical loops can cause mesiodistal or
labiolingual tooth movement.
2. Horizontal loops: mostly used for tooth movement in vertical
axis or occluso gingival tooth movement.
3. The combination of horizontal and vertical loops: can be
activated to perform tooth displacement in a horizontal axis
and vertical axis and to correct rotations or root uprighting
depending upon the mode of activation.
FIGURE 46.8 Commonly used loops and helices.

The multiple looped wires are fabricated with multiple of one or more
types of loops. The making of looped wire is a thoughtful and intricate
process of formulating tooth movement and activating the loop
mechanics.
The loops can also be an open or closed type.
Vertical loop
The open vertical loops are used primarily to open space. A loop is
activated by compressing the legs, which when assume the original
positions, move the teeth apart (Fig. 46.9). A coiled base or helix
incorporates more wire in the loop which makes the forces lighter and
increases its range of action.
FIGURE 46.9 Open vertical loop acts best when compressed.
(A) Open loop when compressed generates force to separate the free
arms. Open free arm of safety pin is pressed to be held in safety loop.
(B) Open loop is activated by compressing the vertical arms. (C)
Compressed arms tend to open the space.
Double vertical loop

Double vertical loop contoured on each side of a given tooth can be
used to move a labially or lingually displaced tooth into a line through
the labiolingual spring quality inherent in the horizontal section
between the two loops. It can also be used to correct a rotated tooth.
The loops are so contoured to affect desired rotational activity on the
brackets (Fig. 46.10).
FIGURE 46.10 Open double vertical loop can be used to align a

rotated tooth and produce labiolingual alignment.
(A) The position of open loops. (B and C) Labiolingual flexibility in
archwire and denoted with possible labial movement in the direction of
arrow.
Closed vertical loop

A closed vertical loop is used primarily to close a space in the dental
arch. The closed loop is activated by pulling the horizontal arm(s)
which are tied to a tooth or a group of teeth (Fig. 46.11). The space
closure occurs by frictionless mechanics, that is the archwire carries
the teeth along without sliding.
FIGURE 46.11 (A and B) The closed vertical loop is activated by pull
action.
Horizontal loop
Its incorporation in the wire design permits the force reduction in a
vertical or occlusogingival direction allowing immediate bracket
engagement in situations where there is a large vertical discrepancy in
positions of neighbouring teeth. The horizontal loop can be designed
for tooth or group of teeth or segment of an arch. For example, the
horizontal loop can be designed for intrusion of a extruded incisor or
two incisors or six anterior teeth all together. Other clinical situation
can be a need for levelling a segment of the arch by depressing or
elevating the anterior or posterior segment and in opening the bite.
Double horizontal loop
It is most efficient when working on an individual tooth, placed above
or below the line-of-occlusion (Fig. 46.12A–B). It can be most
efficiently activated in the occlusogingival and labiolingual plane but
not in a mesiodistal plane. When used with rectangular wire, it can be
effective in tipping the root of a tooth, mesially or distally. One loop
can be contoured to elevate a tooth (segment of an arch) while second
loop can be shaped to depress the tooth (segment of an arch). Its
horizontal arm can be used to tip tooth roots or align labial/lingual
malpositioned tooth.
FIGURE 46.12 (A) Double L-loop to align highly placed maxillary

canine. (B) After alignment.
Omega loop
The omega loop is a variation of the open vertical loop. It is shaped
like the Greek letter Ω, so is the name. It tends to distribute stress
more evenly through the curvature of the loop instead of
concentrating the stress at the base of the loop. It is used to give the
last tooth in the arch a bodily root thrust, to enhance molar anchorage
(Fig. 46.13).
FIGURE 46.13 Omega loop is used to generate active root thrust
on the molar.
It serves like a molar stop and enhances the anchorage.
Combination of vertical and horizontal loop
Box loop
Box loop is a combination of vertical and horizontal arms that are
designed in such a manner as to have a short section of wire that can
be activated in one or more planes of space. Such a design increases
the total amount of effective wire length which enables greater force
reduction capacity and greater range of action than any other loop.
This flexibility permits direct bracket engagement on a severely
displaced tooth in the arch. The free horizontal arm is inclined to the
bracket slot in such a manner that, when engaged, it moves the root of
a tooth in a mesial or distal direction. When it is used to tip the root of
a tooth, the crown of the tooth to be moved must be so anchored with
a neighbouring tooth to prevent its tipping in the opposite direction
(Fig. 46.14A–B).
FIGURE 46.14 (A) Box loop is activated to upright mesially inclined

root of right mandibular canine. (B) After correction. Note change in
axial inclination of the root.
Bent-in stop loop

It is usually made as a molar stop. It is located at the mesial end of the
molar tube. The molar stops determine the length of the arch mesial to
first molars on either side. Molar stops are used to maintain arch
length or increase arch length by slightly opening the loop or by
incorporating active loop components. Active loop components will
tend to procline the anterior teeth. Such a technique is used to align
the teeth with mild crowding in non-extraction cases.
The inclusion of loop component in the archwire increases the
resiliency of the wire, reduces force level and increases the range of
action by adding an archwire in the inter-bracket span. The force of
any loop may further be reduced by coiling the wire at the apex one or
more times creating a helix. Open loop is most efficiently activated
through compression of the legs. This phenomena is called
bauschinger effect.
The activity of a loop is dependent upon two types of force built up
in the loop: (i) the spring of the legs themselves that act as
independent levers and may be activated in any direction and (ii) the
activity developed in the curvature at the apex of the loop.3
Characteristics of the force system in loop

mechanics4
For efficient clinical use of loops following characteristics of the force
system should be kept in mind:
• Force magnitudes and direction

• Low load–deflection rates
• Proper moment-to-force (M:F) ratio for producing the desired
movement
• Force constancy that is control over the change in M:F ratio
with respect to deflection
The type of tooth movement is largely dictated by the ratio M:F

generated by the appliance at the attachments. The M:F ratio is the
relationship between the applied force and the counterbalancing
couple, its value is the determinant of the type of tooth movement
expected (Box 46.1).
Box 46.1 Effect of moment to force ratio on tooth

movement
Tooth movement M:F
Controlled tipping 7:1
Translational movements 10:1
Root movement 12:1 or more
These ratios are based on the assumptions that the root lengths are
12 mm, alveolar bone condition is normal, axial inclinations of the
teeth are normal, and the centre of resistance is located apically at a
distance 0.40 times the root length when measured from the alveolar
crest to the apex.5
Increased loop height greatly raises the M:F ratio. Placing a helix
somewhere in the apical portion of the loop increases M:F ratio
further.6 When a loop is placed closer to one bracket, the M:F ratio
increases for the nearer tooth. It is called V bend effect.7
Bite opening
Correction of deep bite and its maintenance are pre-requisites for
anterior retraction and space closure. It is also required to establish
normal vertical overlap of maxillary anterior teeth, which are a major
determinant of the functional occlusal relations. Vertical relations of
the anterior segment with lip at rest and at functions determines the
smile of an individual.
During retraction of incisors and space closure, there is a further
tendency for the incisors to lose their labiolingual inclination and
extrude. Hence suitable mechanism should be instituted, which
maintains the normal vertical relations achieved during bite opening.
Bite opening is also aimed at placing the maxillary incisors in correct
vertical and labiolingual relationship with lips that have considerable
influence on the aesthetics and smile line. According to Robert Keim,
whatever the primary cause of the deep bite—whether it is an infra
eruption of the posterior teeth or over eruption of the anterior teeth—
the cardinal guide in our decision-making process must be the lip-
smile line relative to the anterior dentition. If this is not properly
established, the smile resulting from our treatment mechanics may not
be acceptable, even if the occlusion is well established.8
Several methods can accomplish correction of deep overbite. The
choice of mechanism to be employed is guided by the nature of deep
bite, its severity, and underlying skeletal relations. In simplicity, bite
opening can be achieved by planned anterior intrusion, posterior
extrusion, or a combination of both. Methods of deep bite correction
can be broadly grouped as:
1. Levelling of curve of Spee

2. Maxillary incisor intrusion
3. Mandibular incisor intrusion
Levelling of the curve of Spee

Levelling of the curve of Spee is a major contributor to bite opening. A
true intrusion of the mandibular incisors needs to be accomplished
where the supra-eruption of the mandibular incisors contributes the
deep bite. A deep bite associated with a low mandibular plane angle
such as in class II division 2 malocclusion can permit extrusion of
lower molars with suitable mechanism.9 Pseudo intrusion/relative
intrusion of the mandibular incisors is obtained either by the distal
tipping of the molars or allowing mandibular molars to supraerupt in
growing children and flaring of incisors. Mechanics employed are
described below.
Bite plate
An anterior bite plate is a useful adjunct to fixed orthodontic
appliance in levelling the curve of Spee in growing children where
teeth in buccal segment erupt to level the deep curve of Spee.10,11 The
bite plate when used judiciously in patients with a low mandibular
plane angle, can also initiate some active intrusion of upright lower
incisors. However, if the inclines of the bite plane and long axis of the
mandibular incisors are not favourable, it may have an adverse effect
by causing undue proclination of the mandibular incisors. This mode
of therapy for deep bite correction in growing children is time tested
for its effectiveness, but for the drawback of patient’s compliance
dependence (Fig. 46.15A–B).
FIGURE 46.15 (A) Bite plate serves as a useful adjunct for levelling
deep curve of Spee. (B) It allows eruption of buccal teeth and mild
intrusion/labial proclination of the mandibular incisors.
Reverse curve wires

A considerable amount of levelling of a curve of Spee in mandibular
arch is obtained while levelling is in progress with fixed appliance
therapy.12 Further, the archwires with a reverse curve of Spee (RCS),
made of superelastic alloy, such as nickel–titanium are used to open
the bite actively. These preformed wires made of shape memory alloy
deliver gentle intrusion force on incisors and extrusion of the buccal
segment. The unwanted effects include difficulties in control of
proclination of anterior teeth, poor control on extrusion of the buccal
segment and arch form (Figs 46.16 and 46.17).
FIGURE 46.16 (A and B) Levelling curve of Spee with round arches

cause labial tipping of incisor teeth.
FIGURE 46.17 Reverse curve of Spee (RCS) wires cause
extrusion of the buccal segment.
Preformed RCS wires may cause extrusion at unwanted sites as their
shape may not always conform to arches/malocclusion in different
individuals.
Second order bends

Mild second order bends when employed judiciously perform distal
tip of the molars, which make them upright, raise their mesial
marginal ridges to open the bite. Tip back bends at the molars exert
intrusive forces at the incisors.
Case Study
A case of class I severe bimaxillary protrusion treated with all first
premolar extraction using standard edgewise mechanics is depicted in
Fig. 46.18A–E.
FIGURE 46.18 (A) Case PS pre-treatment severe bi-dental
protrusion, maximum anchorage requirement. Anchorage conservation
and maximum retraction is a challenge due to vertical skeletal pattern.
(B) Pre-finish evaluation at the completion of upper and lower incisor
retraction. Finishing wires are prepared. Both the arches should be well
coordinated for arch form, curvature in the incisal area, inter-canine
width, inter-molar width and overall shape of the arch. (C) Post-
treatment profile occlusion photos show a balanced facial profile, class
I molar and canine relations, excellent cusp to fossa relation, excellent
arch form, good contacts and normal overjet and overbite. (D) Post-
treatment follow-up. Excellent maintenance of occlusion class I molar
and canine relations, excellent cusp to fossa relationship, excellent
arch form, good contacts and normal overjet and overbite. (E) Pre-,
mid-, post-treatment and follow-up cephalograms. Post-treatment and
follow-up cephalograms depict excellent soft and hard tissue profile.
Maxillary and mandibular incisor intrusion
Intrusion with step-up bend
Placement of step bends in the continuous levelling wires, and base
wires are adjunct to correct a deep overbite. This method of correction
combines extrusion of the adjacent cuspids and posterior teeth and
perhaps some intrusion of the incisors. Step-up bends are indicated
when there is a step between the anterior and posterior occlusal
planes, in cases with moderate-to-minimal incisor display, and class I
occlusion cases. The primary drawback of this approach is the
resultant indiscriminate posterior extrusion versus anterior
intrusion.13
Intrusion arches
The intrusion of the upper and lower incisors, without significant
extrusion of the buccal segment, has been described by Ricketts,
Burstone and Nanda using continuous intrusion arches as follows:
1. Utility arch of Ricketts

2. Intrusion arch by Burstone
3. Connecticut intrusion arch (CTA)
4. Intrusion with anchorage derived from a mini screw
The components for intrusion system are: (i) the posterior

anchorage unit, (ii) anterior segment and (iii) vestibular segment.
The buccal segment consists of first molar and premolar(s), which
are so levelled to house rigid stainless steel wire of full dimensions
(0.021 × 0.025 in. SS). Transpalatal and translingual arches are used to
reinforce the anchorage to counteract reactionary forces generated by
the utility arches. The triple buccal tube is required on maxillary
molar bands and double buccal tube on mandibular molar bands for
the use of utility arches. The sectional buccal segment wire is housed
in the main edgewise tubes while utility arch is housed in auxiliary
tubes.
The anterior segment consists of four incisors requiring intrusion.
Absolute alignment of anterior teeth is not necessary when
performing intrusion since minor alignment can happen coincidently
with an intrusion.
Intrusion arches can be made from non-heat-treated, 0.016 × 0.016
in. blue elgiloy wire or 0.017 × 0.025 in. TMA (titanium–molybdenum
alloy) or 0.016 × 0.022 in. TMA wires. Using TMA wires allow the
design of the intrusion arch to be simplified that eliminates a need of
helices to achieve the low load–deflection rate. It is recommended to
avoid placing the wire into the slots as it may lead to an expression of
the torque present in the wire.14 The incisal segment is ligated to the
anterior aligning wire or placed incisal to the brackets. Connecticut
Intrusion Arches (CTA) are available in preformed wires made of
highly resilient shape memory nickel–titanium alloys (CNA, Beta III
Nickel-Free Archwire).
Ricketts’ utility arch15

Introduced more than 50 years ago, the utility arch proposed by R. M.
Ricketts is a versatile system of upper and lower intrusion, which can
be modified for simultaneous retraction of the anterior teeth.
Other contemporary intrusion arches seem to have evolved keeping
the principles of force system of Ricketts utility arch. Better
understanding through research on force analysis and development of
TMA wires have helped to devise arches which require a fewer
activation. The utility arch can be employed to serve different
objectives when it is in a passive or active state.
1. Passive utility arch is used to perform the following functions:

a. It maintains arch length in mixed dentition and
prevents worsening of the vertical bite.
b. It can help to attain proper transverse development
of the maxillary dentition by keeping the arch from
deleterious influence of the buccinator mechanism.
c. In permanent dentition, it is primarily used to
preserve anchorage and maintain the bite.
2. Active utility arch can be modified to perform the following
functions:
a. Active intrusion of the maxillary anterior teeth.
b. Active intrusion of the mandibular anterior teeth.
c. Intrusion and protraction. This type of movement is
required to align and intrude retroclined maxillary
central incisors such as in class II division 2
malocclusion.
d. For anterior intrusion and retraction
e. Can be used during retraction or at finishing.
Ricketts utility arch is made from non-heat-treated 0.016 × 0.016 in.

blue elgiloy wire.
Parts of Ricketts utility arch

Utility arch consists of two molar segments, buccal bridges, and two
vertical arms on both sides and an anterior segment. The molar
segment is inserted in the buccal tube, a vertical arms of 4–5 mm
emerges in the region of 2nd premolars. The vertical arm follows into
a horizontal extension, called vestibular segment, passing at the level
of the marginal gingival edge without touching it. It is followed by the
anterior vertical segment somewhat between lateral incisors and
canines usually near their contact points. It is 4–5-mm long in the
mandible and 5–8 mm in the maxilla. Anterior vertical arms of either
side are joined by the curved incisal segment (Figs 46.19 and 46.20A–
C).
FIGURE 46.19 Parts of Ricketts’ utility arch 0.016 × 0.016 in. blue
elgiloy wire or 0.017 × 0.025 in. TMA wire.
(A) Maxilla. (B) Mandible.

FIGURE 46.20 Retraction and intrusion utility arch in the
mandible.
(A) Utility arch is ligated. (B) A gentle cinch. (C) The archwire can be
further activated by occlusal directed tip back bend (30–45 degrees) in
mesial to the posterior vertical segment.
The intrusion utility arch is activated by making a 45 degrees

anchor bend at the molars. Bench et al.16 recommends the placement
of buccal root torque in the mandibular molar region to anchor the
roots of the molars in the cortical bone. This type of force produces
lingual crown torque that is counter-balanced by placing 10 mm of
expansion in the molar region of the utility arch during appliance
fabrication. A slight retraction/lingual force is commonly applied by
cinching back the molar segment to alter the force vector, thus
preventing undue flaring of incisors while true intrusion is taking
place (Fig. 46.20B).
A retrusion utility arch performs functions of anterior intrusion and
retraction simultaneously and contains loops. It is activated by
cinching, like the previously described intrusion arch.
A protrusion utility arch protrudes and intrudes the upper and the
lower incisors. It is usually used in class II division 2 therapy.
Typically when activated Ricketts utility arch produces 40–80 g of
force, which is sufficient to intrude four incisors. However, since the
anterior segment of the arch is housed in the brackets of incisors, it is
not possible to know the exact amount of force delivered because the
force system is statically indeterminate. To counteract the extrusive
force on molars anchorage control with headgear may be required.
A case of class I crowding with excessive gingival display like
vertical maxillary excess treated with modified Ricketts’ utility arch
depicted in Fig. 46.21A–E.
FIGURE 46.21 (A) Case SG. She has crowding in both upper and
lower arches with anterior maxillary alveolus and incisors are hanging
down looking like a vertical maxillary excess. (B) After levelling the
maxillary arch, incisor intrusion was performed with a 0.017 × 0.022 in.
TMA, Ricketts’ intrusion arch. Additional bends to step up were
required for central, and lateral incisors, as shown in the wire, with
maximum intrusion being effective at central incisors and least on
canines. (C) Post-treatment profile and smile photos show marked
improvement in the relationship of the upper lip with maxillary incisors.
A marked intrusion of the maxillary incisors had made a significant
difference in aesthetic improvement and smile. (D) Pre- and post-
treatment extraoral front smile photograph. (E) Pre- and post-treatment
cephalograms show improvement in maxillary incisor overbite caused
by the intrusion of the maxillary incisors.
Intrusion arch by Burstone17
Charles J Burstone recommended intrusion arch prepared from 0.017
× 0.025 in. TMA wire to generate consistently low forces for a longer
duration for the effective intrusion. It is desirable that the forces be
generated by a spring mechanism with a low load-deflection ratio in a
determinate force system. Therefore, Burstone suggested that
intrusive segment of the archwire not be seated in the bracket system
rather it is tied to an anterior segment in a piggyback fashion. The use
of wires made from alloys that have high memory and low load-
deflection rates, produce small increments of deactivation over time
and thus reduce the number of reactivation appointments.
Continuous intrusion arch

Burstone intrusion arch when activated causes extrusion of the buccal
segment and intrusion of the anterior segment. Extrusion of the
molars is caused by the moment, which is generated in the opposite
direction to the intrusive force. The extrusive force magnitude on
molars is same as that of intrusion force. In frontal view, the extrusive
force is delivered buccal to the centre of resistance of the maxillary
molars which creates a moment that can increase the maxillary arch
width. Extrusive forces are in part counteracted by the forces of
occlusion generated during chewing. Several modifications in this
mechanism have been proposed to maximise anterior intrusion and
minimise the extrusion of the molars and unfavourable effects on
molar arch width. These are:
1. Increasing the size of the buccal segment by splinting the

buccal segment in the sectional arch.
2. Keeping the intrusive force on the anterior segment as low as
possible.
3. Counteracting the extrusive force on the buccal segment. A
high-pull headgear (which is actually not required when forces
are kept low except in high angle cases where anchorage
control is difficult) can be used. Vertical molar control can be
attained with enhanced anchorage supported with mini screw
implant, thus eliminating a need for extraoral anchorage.
4. A passive trans-palatal arch is used to maintain inter-molar
distance or counteract the contraction forces on the arch width.
It is not clear that what amount of force is considered optimal for

the effective intrusion of the anterior segment. Commonly, 10–20 g of
force/tooth is advocated for maxillary anterior intrusion (Fig. 46.22A–
D).18,19
FIGURE 46.22 Burstone continuous intrusion arch 0.017 × 0.025

in. TMA wire.
(A) Pre-treatment. (B) Levelling completed. (C) Intrusion arch in situ.
(D) After bite opening.
Three-piece intrusion arch

Three-piece base arch20 is useful in those clinical situations where a
continuous type of intrusion arch is contraindicated. When incisors
are undue flared, the application of intrusive force at the brackets
tends to further worsen their axial inclinations by producing a large
counter clockwise moment. The three-piece utility arch is
advantageous, for it shifts the point of application of force more distal,
close to the lateral incisors which are the anticipated centre of
resistance of the group of teeth (Fig. 46.23A–C).
FIGURE 46.23 (A) Burstone continuous intrusion arch. The green

arrow indicates intrusion on anterior segment, while the purple arrow
indicates a possible extrusive effect on the buccal segment. The curved
arrow indicates a moment created at the centre of resistance. (B)
Three-piece intrusion arch for the anterior intrusion. Arrows indicate the
intrusion of incisors, extrusion and the distal tip of the anchorage unit.
(C) Burstone three-piece intrusion arch with retraction mechanism.
The three-piece intrusion arch consists of the following parts:
1. The posterior-anchorage unit

2. The anterior segment with a posterior extension
3. The intrusion cantilevers
4. A power chain/elastic
The three-piece base arch is similar to the continuous arch in that it

requires a stable anchorage unit for the posterior teeth and a separate
anterior segment. Instead of a continuous utility archwire, a separate
tip back spring is activated on the right and left buccal segments. The
anterior wire segment is ligated on four incisors, bent gingivally distal
to the lateral incisors, and then bent horizontally creating a step of
approximately 3 mm. The distal part of this arm extends posteriorly to
the distal end of the canine bracket, where it forms a hook. This
anterior wire segment should be made of 0.021 × 0.025 in. SS wire to
rigidly keep the segment in arch form. The anterior segment allows
distal placement of the intrusive force to the centre of resistance of
anterior segment, which is a pre-requisite in situations of undue flared
incisors. The elastic chain can be attached to the hook to facilitate
simultaneous intrusion and retraction or to redirect the force parallel
to the incisor’s long axis for bodily intrusion (Fig. 46.24).
FIGURE 46.24 An incisor intrusion with three-piece Burstone

intrusion and retraction arch.
Connecticut intrusion arch (CTA)21

CTA was developed at Dental School, University of Connecticut and
introduced as preformed nickel–titanium wires in 1998. The CTA was
essentially designed for the intrusion of anterior teeth. It can also be
utilised to perform other functions with suitable modifications:
1. Molar tip back for enhanced anchorage and class II correction

2. For incisor flaring (Class II Div 2 cases)
3. Correction of minor open bite
4. Levelling of anterior occlusal cants
The CTA is available as preformed arch made of 0.016 × 0.022 in.

and 0.017 × 0.025 in. separately for maxillary and mandibular arches
with anterior segment length of 34 mm and 28 mm. The arches are
made from NiTi alloy nickel free β III CNA, which is considered a
material of choice for the properties of delivering light, continuous
forces under large activations, high memory and low-load-deflection
rate. CTA arches are expected to deliver a force of 40–60 g apically
along the centre of resistance to perform anterior intrusion. The force
is generated by activating the V bend, which is placed mesial to the
first molars. The incisors should have a point contact with the
intrusion arch for effective intrusion without flaring. The arch is
passively cinched back to prevent incisor flaring. Transpalatal arches
are recommended to maintain arch width and enhance molar
anchorage (Fig. 46.25).
FIGURE 46.25 Connecticut intrusion arch (CTA).
Intrusion with anchorage derived from mini screw

Intrusion with an application of force directly on incisors from mini
screws is effective in the successful intrusion of maxillary incisors. It
can be accomplished by application of light continuous force
generated from superelastic NiTi closed coil springs that can generate
intrusion force of 80 g. Two mini screws of usually 1.2 mm in diameter
and 6 mm in length are placed distal to the maxillary lateral incisors at
the mucogingival junction. Polat-Ozsoy et al.22 have reported a true
intrusion of upper incisors with a clinically acceptable change in the
axial inclination of the upper incisors.
Anterior space closure in a continuous wire mechanism can be
achieved where retraction forces are generated from mini screws,
which are placed in the buccal vestibules. Force vectors are designed
to enhance anterior intrusion while anterior retraction is in progress.
This method has been found useful in greater vertical control over
conventional methods like J-hook headgear.23Also, see Chapter 60.
Space closure
Following the completion of levelling and alignment, and bite
opening retraction of anterior teeth into extraction spaces is initiated.
It can be accomplished as either en- masse, that is all the six teeth
together or in two stages that is canine retraction followed by four
incisors.
Two stage space closure

Two-stage space closure that is canine retraction followed by incisor
retraction has been a standard practice with edgewise practitioners. A
variety of methods have been in use to perform bodily canine
retraction in continuous archwire mechanism and also with sectional
springs. Extraction space closure by en masse retraction of anterior
teeth is usually practised where anchorage requirements are mild to
moderate.
Step I: Canine retraction
1. Continuous wire or frictional method

2. Sectional method or frictionless technique
Step II: Retraction of four incisors
1. Continuous wire or frictional method

2. Frictionless technique
Canine retraction on a continuous wire

This method of canine retraction involves a rigid base wire such as
round 0.022-in. SS or 0.019 × 0.025 in. SS wire to prevent dumping of
the archwire when a retraction force is applied on the canine. A stiff
wire is a pre-requisite to prevent deepening of the bite and
maintaining an arch form. Tweed recommends the use of a full size
base archwire that is 0.022 × 0.028 in. wire, which is reduced in
anodiser to 0.019 × 0.025 in. dimensions distal to V bend, to facilitate
canine retraction.
Anchorage is reinforced with active molar stops (activated distal tip
15–30 degrees in standard edgewise system) and figure of 8 ligature
tie of second premolar unit with a first molar. Four incisor brackets
receive a figure of 8 ligature tie with 0.009-in. soft SS ligature. A mild
curve of Spee for the maxillary arch and RCS in the lower arch helps
sustain bite opening, which tends to deepen in such mechanics. The
canine can be distalised by a force of about 150 g which can be
generated in one of the following mechanisms:
Push methods
Open coil spring (lumen 0.030 in.), mesial to the canine bracket is
activated either by intra-arch ligature or extraoral J-hooks through a
jig or inter-arch class II elastics for maxillary canines and class III
elastics for mandibular canines (Fig. 46.26).
FIGURE 46.26 Canine retraction using frictional mechanics via

push force with open coil spring.
Canine retraction by using sliding mechanics can also be carried out
with an open coil spring placed initially in an inactive form mesial to the
canine bracket and then activated by tying back to the molar tube with
a ligature wire. In this situation, a push force is applied by the spring for
canine distalisation.
Pull method
Force can be applied with one of the followings auxiliaries:
1. Elastomeric ring/E module/intra-arch elastic
2. Close coil spring
a. Stainless steel springs
b. Nickel–titanium close coil springs/sentalloy springs
In the sliding mechanics, the retraction force is usually generated

from an elastic/spring mechanism, which is distally attached to anchor
molar tooth and activated onto the power arm of the canine (Figs
46.27 and 46.28). Force activation being far from the centre of
resistance, the tooth under force experiences moment in two planes of
space. Consequently, tooth bracket undergoes a ‘stick-slip’ action
along the archwire and thus space closure is slowed. Frictional forces
compromise the transmission of desired force levels. A portion of
applied force is lost to overcome the friction between wire and bracket
to initiate and continue with the tooth movement. Therefore the
selection of wire and bracket is based on least friction offered at wire
bracket interface. Highly polished stainless steel wires provide the
least friction on smooth surfaces in slots of steel brackets (Figs 46.27
and 46.28A–B). Preformed NiTi close coil spring of 150 g, 9 mm length
is an excellent choice for canine retraction. The spring is ligated at the
molar hook on first premolar and tied to the power arm of the canine
bracket. The activated spring delivers sustained force of without any
force decay and hence promotes continuous tooth movement. NiTi
springs (Sentalloy) have replaced the use of SS coil springs, which
need frequent activation and generate higher force.
FIGURE 46.27 Maxillary canine retraction on a rigid rectangular
SS wire with pre stretched power chain.
FIGURE 46.28 Maxillary canine retraction using NiTi coil spring

of 150 g.
(A) Right and (B) left side.
Sectional method or frictionless mechanism

Several springs have been devised to bodily retract the canine into
extraction space. Distal canine movement is accompanied with mesial
root/distal crown tip, distopalatal rotation of the crown and the
collapse of the arch width. Therefore clinicians have researched and
devised springs that generated a favourable M:F ratio for distal
translation of the canine, prevent distopalatal rotation, enhance buccal
anchorage and generate the required force for a longer time to
minimise the need for frequent activations.
Commonly used canine retraction loops are:
1. T-loop
2. Ricketts’ canine retraction spring
3. Gjessing spring
4. Opus loop
T-loop
It was designed by Burstone6 to produce 350 g of force, which was
later modified to produce 230–256 g of force, increasing the length of
vertical arm by 1.5 mm.24
The T-loop is fabricated either in 0.016 × 0.022 in. stainless steel wire
or 0.017 × 0.025 in. beta-titanium wire. TMA is the material of choice
for its excellent spring-back properties coupled with good formability.
The contemporary T-loops is now designed to deliver 125–150 g of
retraction force (Fig. 46.29 (i)A–D).
FIGURE 46.29 (i) A sectional T-loop located in the mouth for
canine retraction, for high anchorage situation.
The T-loop is placed in premolar/molar region. (A–B) Burstone T-loop
is fabricated in 0.017 × 0.025 in. TMA wire. Its dimensions are length
10 mm, a height of loop 2 mm, the height of mesial leg 5 mm and distal
leg 4 mm. T-loop is checked in the mouth for its position by inserting in
a maxillary molar tube. (C) Pre-activation of T-loop. Activated T-loop in
position in a maxillary buccal tube. (D) T-loop pulled down and forward,
ligated in canine bracket. (ii and iii) (A) Pretreatment. (B) Canine
retraction using T-loop in progress. (C) Canine retraction completed.
Amount and location of the additional length of the wire that is

incorporated into the formation of a retraction spring or loop is
critical. The loop should be designed to include additional wire length
in apical part to increase the M:F ratio, which facilitates the translation
of the canine.
The T-loop has lower load-deflection ratio than vertical loop of a
similar vertical height and same size of wire.6
Activation of T-loop
Even though a high moment of activation can be produced by the T-
loop as compared to other loops, it might not be sufficient to produce
a translation. The moment created needs to be enhanced by increasing
the angulations of the extremities of the loops, in a procedure known
as pre-activation.
When a closing T-loop is activated, the anterior and posterior
portions of the archwire deflect away from a parallel orientation.
When the closing loop archwire is engaged into the brackets, a
second- and third-order couple (moment) is felt by the anterior and
posterior sections of the wire. The moments are acting on the
archwire, in turn, are delivered to the teeth as the wire deactivates.
Pre-activation of T-loop is done by placing bends at six locations in the
T-loop. However recent studies show that the T-loops pre-activated
by curvature delivered lower horizontal forces and higher M:F and
load-deflection ratio than did those pre-activated by concentrated
bends. Hence, T-loop activation should be preferred by curve bends to
achieve translation of teeth.25,26
Clinical applications of T-loop

A pre-activated T-loop in segmental canine retraction can be inserted
in the auxiliary buccal tube with its loop in the middle of arch from
canine to mesial of molar and activated by gentle cinching. It is
expected to deliver 150 g of force to produce canine retraction at the
rate of 0.87 mm/month.27 No new activations are required until 3 mm
of space closure is produced. The activation is required to proceed
with further retraction (Fig. 46.29 (i), 46.29 (ii) and 46.29 (iii)). A spring
left in place without activation will produce exaggerated root
correction followed by increased space at the extraction site.28
Ricketts canine retraction spring29

Ricketts evolved a canine retractor which is a combination of a double
closed helix and a crossed T-loop. The loop design is said to deliver
30–50 g of force per mm of activation when produced in 0.016 × 0.016
in. blue elgiloy wire. The height of the spring is 12 mm, and the
diameter of each helix is 2 mm. At initial placement, the gable bend is
90 degrees, and the rotation angle is 20 degrees. The spring is
activated by distal cinching to produce 50 g of force per mm of
activation.
Ricketts recommended activation of spring by 2–3 mm to produce a
retraction force of 120 g. The incorporation of the gable angle of
horizontal arm increases M:F ratio which helps to prevent distal
tipping of the canine and thereby achieve bodily movement.
However, with deactivation, there is a decrease in force value,
increase of M: F ratio which induces tooth intrusion and mesial
tipping of the tooth crown. When mesial and distal arms are gabled at
45 degrees M:F ratio of 11.8 is produced by the retraction force of 100
g, but as forces fall to 50 g, M:F ratio rises to 20. The increase in leg
length (H1) decreases stiffness and increases the anti-tilt-couple. The
increase in the length (H2) reduces the stiffness and the anti-tilt couple
(Fig. 46.30).
FIGURE 46.30 Ricketts

’ spring used for canine retraction with segmental or frictionless
mechanics.
Ricketts’ spring is usually made using 0.016 × 0.016 in. blue elgiloy
wire. The height of the spring is 12 mm, and the diameter of each helix
is 2 mm. At initial placement, the gable bend is 90 degrees and the
anti-rotation angle is 20 degrees. Spring is activated by distal cinching
to produce 50 g of force per millimetre activation.
Clinical application
Ricketts’ spring is made in elgiloy wire and involves a considerable
amount of dexterity and wire bending which an orthodontist is
expected to possess. The clinical time consumed in wire bending can
be minimised either by using preformed springs or bending it in a
laboratory set-up on a study model. In our clinical practice, we found
Ricketts loop efficient on canine retraction does not tax the anchorage
but offer a poor control on distopalatal rotation. Due to its double
helix design, it is bulky. Therefore oral hygiene could be a problem.30
Gjessing canine retraction spring31

Gjessing canine retraction spring is usually made using 0.016 × 0.022
in. SS or TMA wire. The predominant active element of the spring is
the ovoid double helix loop extending 10 mm in height apically and
has a maximum width of 5.5 mm. The smallest occlusal loop has a
diameter of 2 mm. A 45 degrees sweep is incorporated into the distal
end of the loop, and a 15 degrees anti-tip bend is placed in the mesial
leg.
The anti-tip M:F produced is 11:1. Anti-rotation bends of 35 degrees
are given to generate an anti-rotation M:F ratio of 7:1. On activation,
spring will generate 150–200 g of force, which is suitable for canine
retraction. The gently rounded form of loops avoids the effect of sharp
bends on load/deflection and through the use of the greatest amount
of wire in the vertical direction; reduction of horizontal
load/deflection is maximised. At the same time, minimising horizontal
wire length increases rigidity in the vertical plane. The smaller
occlusal loop is incorporated to lower levels of activation on insertion
in the brackets in the short arm (couple) and is formed so that
activation further closes the loops. Incorporation of a segment of a
circle (sweep) in the distal leg of the spring is an adjustment with the
purpose of eliminating undesirable moments acting at the second
premolar bracket and tending to move the root apex too far mesially.
Activation
Activation to 140–160 g of force is obtained by pulling the wire distal
to the molar tube until the two sections of the double helix are
separated by 1 mm. Activation is repeated every 4 weeks, and the
canine is expected to undergo approximately 1.5 mm of controlled
movement with each activation.32
Clinical application
The Gjessing spring is constructed to resist rotational and tipping
tendencies during retraction—not to correct rotations and extreme
deviations in an inclination of the canine. Therefore, levelling of the
buccal segments must be terminated before insertion of the spring.
The circular loop is pulled forward to contact the distal aspect of the
canine bracket and is secured by a gingival bend of the anterior leg
(Fig. 46.31).
FIGURE 46.31 Gjessing spring for canine retraction with

segmental or frictionless mechanics.
Gjessing spring is usually made using 0.016 × 0.022 in. SS or TMA
wire. The predominant active element of the spring is the ovoid double
helix loop extending 10 mm in height apically and has a maximum
width of 5.5 mm. The smaller occlusal loop has a diameter of 2 mm. (A)
A 45 degrees sweep is incorporated into the distal end of the loop, and
a 15 degrees anti-tip bend is placed in the anterior leg. The anti-tip M:F
ratio produced is 11:1. (B) Anti-rotation bends of 35 degrees are given
to generate an anti-rotation M:F ratio of 7:1. On activation 150–200 g of
force is applied for canine retraction.
Opus loop33
It is a closing loop capable of achieving inherent, constant M:F ratio of
8.0–9.1 without residual moments for en masse space closure. The
Opus loop is designed to generate uniform stress distributions on
periodontal ligament to produce rapid tooth movement with fewer
chances of traumatic side effects. The design is based on Castigliano’s
theorem to derive equations for M:F ratio regarding loop geometry.
The ascending legs are at an angle of 70 degrees to the plane of the
brackets and 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.
Opus loop has a significant mechanical advantage over other loops
(T-loop and vertical loop) when deactivated there are no residual
moments; therefore this design of loop can produce a real rest period
when deactivated (Fig. 46.32).
FIGURE 46.32 Design and dimensions of Opus loop as given by
Siatkowski.
7,33
Clinical application and activation

Because there are no residual moments induced in this loop via gable
or other bends or twists, the loop’s neutral position is precisely the
spacing of the vertical legs as bent that is if the horizontal spacing
between the vertical legs is 1 mm when the archwire is formed, there
will be no activation force after the archwire is tied in. It is, therefore,
possible to achieve precisely the defined activation force desired by
simply increasing the horizontal spacing between the vertical legs by
the activation amount in millimetres. Therefore this loop has strength
over other loops regarding residual moments where it is extremely
difficult for the clinician to judge the amount of activation force being
delivered after the archwire is tied in (Table 46.1).
Table 46.1
Activation (in mm) necessary to achieve various
activation forces for the Opus loop formed in 0.016 ×
0.022 in. SS, 0.018 × 0.025 in. SS, and 0.017 × 0.025 in.
TMA wires.
Source: Siatkowski RE. Continuous archwire closing loop design,

optimisation, and verification. Part II. Am J Orthod Dentofacial Orthop.
1997 Nov;112(5):487–95.
Clinical applications of canine retraction loops

and springs
Numerous springs have been designed which leave an operator in a
dilemma on the choice of one over other. The main reasons for
choosing one configuration over another are the desired
biomechanical properties and simplicity of design and fabrication.
Three important criteria that influence their effectiveness are:
• Loop position
• Loop pre-activation
• Loop design
Loop position. Traditionally the loop was placed closer to the teeth
in cases requiring anterior retraction in order to enable repeated
reactivation. Recent research, however, has shown that a change in
loop position can augment or reduce the posterior anchorage. Thus
the loop is offset to the posterior for enhancing posterior anchorage
and towards the anterior for enhancing anterior anchorage.
Current research suggests that the moments occurring through
activation alone are insufficient in producing an adequate force
system necessary for root control. Thus, gable bends or pre-activations
are placed in the springs under the desired tooth movement. From a
biomechanics stand point, the gable bends act to increase the
moments delivered to the teeth and augment the moments that occur
during activation of the closing loop.
A vertical loop has high load/deflection ratio whereby any
activation above 1.4 mm causes its permanent deformation. The
further moment at the apex is more than that at the wire in the
bracket. It gives greater control over displacing an apex of the canine
mesially than a single force applied to a canine by a wire or elastic;
however, as the M:F ratio is so low (2.2) it is not capable of producing
translation or even controlled tipping.6
T-loop offers higher M:F than the vertical loop (5.3), it still requires
gable bends or pre-activation for translation movement resulting in
the in the production of residual moments. Therefore precise
activations are very difficult. With large activations, a clinical error of
1 mm or so of a few degrees is not that significant as compared to
vertical loop (Fig. 46.29A–D).6
Gjessing spring combines optimal moments in the mesiodistal and
labiolingual directions for a loop working with an optimal force for a
long distance.
The overwhelming problem in the construction of sectional
retraction springs is the biomechanical requirement of a low
load/deflection ratio to secure constant tension in the periodontal
membrane throughout an extended range of spring activation and a
wire design to produce M:F ratios robust enough to prevent tipping
and rotation of the tooth to be retracted.31
Ricketts loop spring is more flexible than U-loop which allows a
large clinical activation of 2–3 mm to obtain a reasonable force for
movement of the canine. The low stiffness is due to both the flexural
rigidity of the wire and due to double loop design. The spring has low
M: F ratio of 3 mm when gable bends are not placed. The placement of
gable bends increases M:F ratio but as activation force decrease and
M:F ratio increases it will tend to cause intrusion of the tooth and
mesial tipping as it returns to its unstrained configurations.30
Retraction of incisors into extraction
spaces
At the completion of canine retraction the canines are ligated to the
second premolar and first molar with soft ligature. At this stage, the
anterior space closure is initiated.
Base arch
Retraction of the anterior segment into extraction spaces can be
performed on a rigid archwire such as 0.019 × 0.025 in. SS, which
offers adequate control on the arch form and torque yet freedom to
slide through the buccal tube and brackets which have slot size of
0.022 × 0.028 in.
Traditionally, anchorage for retraction force has been derived from
molars. High anchorage requirements dictate the use of face bow to
reinforce molar anchorage or retraction by using high pull headgear.
Successful use of mini screws has eliminated the need for the use of
extraoral anchorage. Implants offer a great control on anterior
retraction and possibilities on designing biomechanics for three-
dimensional controls on retraction process.
However, for best control on torque, a full-size wire is
recommended. The archwire is fabricated to slide freely through
second premolar brackets and molar tubes without losing any buccal
torque while in an anterior segment this wire should offer complete
control on the arch form, maintain normal distal tip of incisors,
promote torque control and should not allow deepening of the bite.
Therefore, an astute clinician will select the wire material, its design
and direction of force application to get the best outcome of anterior
retraction. The position of anterior teeth dictates its relationship with
lips that is critical to facial aesthetics. Round wires and smaller
rectangular wires provide less than adequate control of torque, and
overbite. Tables 46.2, 46.3.
Table 46.2
Effective usefulness of wires according to wire material
composition, size and shape during stages of
Table 46.3
Advantages and disadvantages of sliding mechanism.
Sl.
No.
1. Simplicity: minimal archwire Space closure is slow due to friction
bending
2. Predictable results There is a general tendency to over activate the elastics which
does not give sufficient time for teeth to upright: uncontrolled
tipping
3. Archwire helps maintain the Tendency for loss of the anchorage
occlusal plane and chosen
arch form
4. Reactivation procedure is Tendency for deepening of the bite
simple
Standard edgewise appliance

A full-size stainless steel wire is selected and prepared into a good
arch form on existing stage model or in the mouth. The archwire is
held with Tweed pliers to orient existing torque in the wire in a
favourable mode, for example the maxillary wire should be held to
express palatal root torque. The wire is marked for midline and V
bends are placed slightly closer on distal contact points of lateral
incisors. These bends are 1 mm shorter on the mesial arm to help
sustain bite opening. The required torque is estimated by holding the
incisal segment of the wire in front four or six brackets by looking at
the angle formed by the raised distal arms to incisor long axis (Fig.
46.33). Required anterior torque is accordingly instituted in the
anterior segment. Sufficient progressive buccal root torque is
instituted in buccal segments of the archwire. V bends receive inter-
maxillary hooks of 0.024-in. stainless steel or 0.028-in. brass wire. The
archwire is given a gentle sweep for the curve of Spee, or long second
order bends if the anchorage preparation has been done, heat treated
and ligated.
FIGURE 46.33 Anterior torque control is a pre-requisite for
anterior retraction.
Incisor retraction is instituted in one of the following methods:
1. In class II malocclusion where lower molar correction is

required to be achieved by mesial migration patients are
advised to use heavy class II elastics.
2. In the case of maximum anchorage requirements, night-time
headgear with J-hooks is used at maxillary inter-maxillary
elastics. Class II elastics should be used with great caution,
especially in patients with vertical growth trend. Prolonged
use of class II elastics with heavy forces may lead to a deep
bite, lower molars to roll in lingually, extrude, and most
dangerously adversely affect mandibular incisors by
proclining them. A close watch on occlusion is therefore
warranted.
In a situation such as bimaxillary protrusion intra-arch mechanics is

used for the retraction. Class I retraction forces are applied from molar
tubes hooks to inter-maxillary hooks or the power arms of canine
brackets in one of the following methods:
1. An elastic module is tied to a molar hook, stretched twice of its

lumen with a soft steel ligature, actively tied to canine power
arm or inter-maxillary hook to generate distalisation force on
anterior segment.
2. A close coil 150 g NiTi springs with a defined force plateau is
activated from molar tube to canine power arm or the
intermaxillary hook. The base wire of 0.019 × 0.025 in.
rectangular SS wire is used in a 0.022-in. slot bracket system.
This wire -provides good rigidity while allowing the wire to
slide through the slots.
Tweed34 recommends use of full size 0.0215 × 0.0275 in. archwire

that is reduced to 0.019 × 0.025 in. distal to V bends for free sliding
mechanism for space closure. Anterior segment receives mild lingual
root torque while a buccal segment is incorporated with buccal root
torque. In the maxilla, retraction is achieved by high pull headgear at
night and class II elastics during day time.
In mandibular archwire, a bull loop is made on either side in mid of
first premolar extraction space region. Molar stops are soldered 2 mm
mesial to the molar tube. A mild RCS is incorporated. Maxillary and
mandibular archwires are coordinated checked in the mouth for
width arch form and any adverse torque, heat treated and ligated. The
bull loop is activated by pull action at the molar stop which is
activated and ligated to with molar tube. This is a frictionless method
of space closure.
Vertical loop for space closure

Vertical loops fabricated from 0.018 × 0.025 in. stainless steel wire are
used to retract the incisors. The appliance generates very high forces
(in order of 1000 g or more) when activated by only 2 or 3 mm, which
causes discomfort to the patient and ‘overpower’ the moments,
resulting in loss of anchorage and root control. ‘Dumping’ of the teeth
towards the extraction site may be a common side effect. With better
wires and improved designs of a loop, this appliance is of historical
importance now.
Bi-dimensional technique35
It is an edgewise technique in which brackets of two different slot size
are used. While central and lateral receive 0.018 × 0.022 in. slot
brackets, molars and premolars of canines receive 0.022 × 0.028 in.
brackets/tube. The main advantage of using bi-dimensional system is
excellent torque and axial control on incisors while space closure is
instituted without a need for reduction of the size of the main
archwire in the buccal segment. The 0.018 × 0.022 in. wire in buccal
segments remains relatively free of friction to allow sliding during
space closure.
In a pre-adjusted appliance plain 0.019 × 0.025 in. rectangular SS wire
should be used in a 0.022 in. bracket slot system. Anchorage is
reinforced with second molar bonding. The addition of anchorage
savers such as trans-palatal arch and mini screw implants is much
needed. Intra-arch mechanics is used for application of force from
anchor molars or mini screw. For optimal retraction force and efficient
control on teeth movement, a power arm is attached to canine/lateral
incisor segment. It has been estimated that a power arm of 3–5 mm is
good for controlled lingual crown tipping anterior teeth during space
closure.
Two methods of force application are used in an intra-arch
mechanics. An elastic module is tied to a molar hook, stretched twice
of its lumen with a soft steel ligature, actively tied to power arm to
generate retraction force on the anterior segment. Recent retraction
methods include the use of a close coil 150 g NiTi springs with a
defined force plateau. At AIIMS, we usually follow two-stage
retraction in moderate to high anchorage cases. The canine retraction
is completed which is followed by incisor retraction as shown in case
of class I type one malocclusion (Fig. 46.34I–VI).
FIGURE 46.34 (I) Case AG, A case of class I type 1 malocclusion
treated with all first premolar extraction and 2 stage space closure. Pre-
treatment. (II) Levelling. (III) Canine retraction initiated. (IV) Incisor
retraction initiated. (V) Finishing of occlusion. (VI) Case AG, A case of
class I type 1 malocclusion treated with all first premolar extraction and
2 stage space closure. Post-treatment.
Continuous T-loop
A continuous archwire with bilateral T-loops is used for incisor
retraction in two-stage retraction as well for en mass retraction of six
anterior teeth. Closing loops are made from beta-titanium wire of
0.017 × 0.025 and 0.019 × 0.025 in. dimensions.
The T-loop described by Burstone is designed for activation up to 6
mm. The mesial vertical arms of the T-loop are made short by 1–1.5
mm to sustain the bite opening and prevent worsening the bite, an
unwanted effect of anterior retraction. The T-loop archwire receives a
gentle sweep in the buccal segments to enhance anchorage. Others
have suggested a V bend closer to anchor tooth to control anchorage.
T-loops are activated by gentle cinch of the wire distal to the molar
tube. The activation of the ‘T’ loop retraction archwire will produce
extrusion and lingual torque roots as well as horizontal force on the
incisors. Therefore adequate torque on the incisor segment and gable
bend mesial to the T-loop are necessary to sustain bite opening and
torque on anterior teeth while they are being retracted.36
At full 6 mm activation, tooth movement occurs in three phases:
tipping, translation and root movement. The size of the wire had only
a small effect on the M:F ratio generated. For a symmetrically centred
spring, an initial activation produces an M:F ratio of 6:1, which results
in tipping movement of the teeth into the extraction space. With 2 mm
deactivation (spring activation = 4 mm), the M:F ratio increases
towards 10:1 which results in translation of the segments towards
each other. With 1–2 mm space closure (spring activation = 2 mm), the
M:F ratio increases to 12:1 and higher resulting in root movement.
Clinically, the spring should not be reactivated until all three phases
of tooth movement have been expressed.
Asymmetrical ‘T’ archwire (Fig. 46.35A–F)

Asymmetrical ‘T’ archwires are used for simultaneous bite opening
and anterior space closure with reduced loop size. This asymmetric ‘T’
archwire has a loop that is placed distal to the upper lateral incisors. It
is made in 0.016 × 0.022 in. TMA wire for 0.018 in. slot brackets or
0.019 × 0.025 in. TMA for 0.022 in. slot brackets. The vertical portion of
the loop should be 5 mm, the anterior loop 2 mm, and the posterior
loop 5 mm.37
FIGURE 46.35 (A) Asymmetrical T-loop wire, activated for ligation.
(B) Before activation. (C) Short-arm of the loop compressed. (D) Long-
arm of a loop is opened in the occlusal direction. (E) Loop after pre-
activation. (F) Another method of pre-activation by incorporating a bend
in the gingival horizontal arm of T-loop.
Care is taken to ligate canine, second premolar and molar(s) as one

unit with SS ligature wire. This prevents opening up of the contact
point between canine and second premolar and reinforces anchorage.
At this stage lower lingual holding arch or a Nance button if in place
should be removed. A gentle curve of Spee in the upper arch and
exaggerated reverse curve in lower arch help maintain the bite
opening and prevent anchorage loss. It usually takes about 4–6
months to complete the incisor retraction. Care should be taken not to
lose any torque during retraction.
Bull loop/double keyhole loop

Dr Harry Bull introduced a new concept of retraction loop in 1951.
The loop is designed such that the two legs are tightly abutting each
other. Tweed used this method for incisor retraction in the
mandibular arch. Since those days the only wires used in orthodontics
were made of stainless steel, such loops generated a higher magnitude
of force. To incorporate greater flexibility to the appliance and
increase a range of action at low force values two Bull loops were
fabricated on either side of the arch. This principle has been used in
key hole archwire by Roth. The loops are activated by cinching the
wire at distal of a tube, so as to separate the loops to the thickness of a
dime that is about 1.5–2 mm.
Ricketts incisor retraction technique38
Ricketts utilises sectional arch mechanics that is arch divided into
sections and treated and involves two-step space closures. First, the
canines are retracted with the help of retraction springs. Then the
mandibular incisors are consolidated and retracted with either by
contraction utility arch or double delta followed by maxillary incisor
retraction with either contraction utility, torquing contraction utility
or stepped up double delta loop archwire.
Opus loop has several advantages over other loops for closing
spaces. It has an acceptable M:F ratio and it does not need any pre-
activation bends, thus making it possible to obtain the desired tooth
movement and to provide periods for the periodontium to recover.
The archwire 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 can be done. 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.
No activation should be placed on the Group C side. After space is
completely closed on the Group A or B side, space closure can then
begin on the Group C side with a unilateral activation chosen.39
Mushroom loop space closing archwires

Nanda40 recommended the use of preformed continuous archwire
with mushroom loops for en masse retraction of anterior teeth. These
arch forms are made from CNA-β titanium with an archival
configuration which decreases the load-deflection rate and therefore
produces gentle continuous forces. The archwire is fabricated from
0.017 × 0.025 in. size of wires. The loops are activated up to 5 mm and
reactivated every 6–8 weeks (Fig. 46.36).
FIGURE 46.36 Mushroom loop is made from 0.017 × 0.025 in.
CNA wire.
Kalra simultaneous intrusion and retraction archwire41

Kalra simultaneous intrusion retraction (KSIR) archwire can be used
for en masse retraction of the six anterior teeth in first premolar
extraction cases that require maximum anchorage as well as intrusion
of the anterior teeth for correction of deep overbite. The KSIR
archwire consists of a closed vertical loop made from 0.019 × 0.025 in.
beta titanium wire. There is a centre V bend placed between the
molars and canines to produce two equal and opposite moments in
order to prevent tipping of these teeth into the extraction site as space
is closed. The appliance is especially useful in class II division 1
malocclusion being treated with extraction of upper first premolars
only (Fig. 46.37A–F).
FIGURE 46.37 (A–F) Kalra simultaneous intrusion retraction (KSIR)
appliance for simultaneous intrusion and retraction. Source: Courtesy:
Dr VarunKalra, and USA.
Monitoring space closure

The anterior space closure requires a careful monitoring on rate of
retraction which is usually 0.9 mm/month, any change in overbite and
torque control of incisors. Patient is followed usually at 6 weeks
interval. The other major concern during anterior retraction is
anchorage control, which should be instituted before the beginning of
anterior retraction and monitored at each visit. Should there be a sign
of loss, appropriate modifications need to be implemented. Following
space closure and coordination of both arches for arch form and shape
the final and last phase of active orthodontics begins. The finishing
and detailing of the occlusion may take another few months to make
the case ready for debond. Contemporary fixed appliance treatment
with preadjusted appliance system uses simpler and efficient
biomechanics of en-masse anterior space closure. The details are given
in the chapter on the preadjusted appliance.
Key Points
The secret of achieving efficient space closure using closing loop
mechanics is the design of the loop and its activation. Ideal loop
design should most notably accommodate large activation, deliver
small and nearly constant force, be comfortable and easy to fabricate.
The author recommends the T-loop formed from 0.019 × 0.025 in.
TMA wire or preformed mushroom loop wires made from 0.017 ×
0.025 in. CNA wires which offer an efficient mechanism for incisor
retraction.
A good understanding of mechanics is required when using
retraction loops or springs because minor errors in mechanics can
result in significant errors in tooth movement. Also, wire-bending
skills and extra chair time are required. The retraction loops may be
uncomfortable for some patients. The orthodontist should choose an
appliance best suited for the clinical situation and the one for which
he has the full understanding. The contemporary fixed preadjusted
appliance has almost eliminated the use of looped wires which have
been substituted with superelastic wires. Two-stage retraction is
rarely required except in maximum anchorage cases. Availability of
anchorage savers and intraoral noncompliance MSI-supported
anchorage has lead to better control and improved results using
efficient biomechanics for en-mass retraction and extraction space
closure.
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beta-titanium T-loop springs preactivated by
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Dentofac Orthop. 2011;140(2): e53-8 Aug; PubMed
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27. Keng FY, Quick AN, Swain MV, Herbison P. A
comparison of space closure rates between
preactivated nickel-titanium and titanium-
molybdenum alloy T-loops: a randomized controlled
clinical trial. Eur J Orthod. 2012;34(1):33–38: Feb; Epub
2011 Mar 17. PubMed PMID: 21415288.
28. Burstone CJ. The segmented arch approach to space
closure. Am J Orthod. 1982;82(5):361–378: Nov;
29. Ricketts RM. Development of retraction sections.
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30. Shaw MM, Waters NE. The characteristics of the
Ricketts maxillary canine retractor. Eur J Orthod.
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31. Gjessing P. Biomechanical design and clinical
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CHAPTER 47
The pre-adjusted edgewise
appliance
O.P. Kharbanda
CHAPTER OUTLINE
Evolution of building the treatment into brackets
The first integrated pre-adjusted appliance system and
philosophy by C. F. Andrews
The measurements of non-orthodontic normal models
The six keys of normal occlusion and goals of orthodontic
treatment
The compound contour of the bracket base
The slot sitting features
The auxiliary features
Features of convenience
First fully programmed bracket series
The biomechanics
Roth’s philosophy of functional occlusion and pre-adjusted
appliance
Functional occlusion
Roth’s modification of SWA
MBT appliance and philosophy of treatment
The MBT appliance design
The MBT biomechanics
Key Points
The ‘edgewise’ appliance introduced by Edward H. Angle, which he
named as the ‘Latest and Best’ in orthodontics, provided excellent
three-dimensional control of tooth movements. The rectangular
bracket slot was greater in depth (0.028 in.) than the height (0.022 in.)
and used rectangular wires to accomplish the full control.1 Charles H.
Tweed later taught us how to use the edgewise appliance effectively
and brought about the discipline of ‘order of bends’ to be built in the
archwire. The ‘first order bends’ compensate for labiolingual
inadequacies of the bracket base to match the anatomical variations in
the thickness of clinical crowns and arch form. The ‘second order
bends’ are built in the archwire to enhance anchorage and place tooth
crowns and roots in a correct mesiodistal tip. The most importantly
‘third order bends’ or the torque bends were devised to place roots of
the teeth in harmony with their skeletal bases and create an
anatomically and functionally optimum occlusion. The torque bends
are different in the anterior and buccal segment.2–4
The process of complicated wire bending for the optimal position of
teeth when brackets are seated on a full complement would
necessitate 76 primary bends (46 bends for angulation, inclination and
offset and 30 bends for prominence and occlusal gingival slot
position).5
Evolution of building the treatment into
brackets
Several clinicians, therefore, incorporated modification of bracket to
avoid or minimise wire bending. Holdaway6 suggested bracket
angulation near extraction site to avoid second order bends and
aesthetic positioning bends (Fig. 47.1.1A–C). Lewis7 developed
winged brackets for effective derotations and added bars for
uprighting of the teeth (Fig. 47.1.2A–C). Jarabak was first to cut a slot
in the bracket at an angle and Fizzell to mill the bracket slot at an
angle to create the torque. Jarabak and Fizzell8 were first to introduce
a bracket with built in torque and angulation (Box 47.1). Lee9 is
credited with the first commercially viable pre-torqued brackets.
Ricketts10 used 7, 14 and 22 degrees torqued brackets in his bio-
progressive technique (Box 47.2).
FIGURE 47.1.1 Building the treatment in the brackets.

(A) Holdaway suggested angulation of the brackets so that the mesial
tipping of the anchor molar and second premolar can be prevented and
anchorage is enhanced. The second orders bends can be eliminated
which offer great friction and are cumbersome to be accurately
duplicated in each subsequent wire change. The angulation of the
bracket on canines is so placed that during retraction the root tip moves
along the crown, so that roots of the teeth at extraction site are parallel.
(B) Standard edgewise brackets on incisors lead to loss of natural
mesiodistal root tip, which is later accomplished with artistic positioning
bends. (C) Jarabak suggested elimination of the artistic positioning
bends required at the end of the treatment and during incisor retraction
by angulating the brackets.
FIGURE 47.1.2 (A–C) Peter Lewis suggested a new approach to

prevent rotations and tipping of the teeth. The mesial and distal bars
are effectively used to prevent undesired tipping.
Box 47.1 Evolution of building the treatment into

brackets pre-SWA era
Clinician Year Contribution
Glendon 1941 Attempted soldering brackets into tip and torque positions
Terwilliger
Holdaway 1952 Angulating brackets in the mandibular buccal segment proportional to the
severity of malocclusion
Ivan F. Lee 1959 Torque bracket for anterior teeth (LEE TORQUE, Unitek, USA)
Jarabak and 1960 Demonstrated bracket having combined torque and angulation
Fizzel
Box 47.2 Evolution of building the treatment into
brackets SWA and after 1970
The original edgewise brackets have a uniform thickness of the

base, that is the distance between the base of the bracket and the
centre of the slot is the same. When edgewise brackets are assigned on
teeth the anatomical arrangement of the arch is lost, or in other words,
they become irregular in the labial facial side at the labial/buccal
surfaces of the crowns (Fig. 47.2.1A–B).
FIGURE 47.2.1 (A) Standard edgewise bracket distance between
bracket base and centre of the slot is the same in each bracket.
Therefore when the brackets are placed, they become as irregular in
the facial prominence as the crown. (B) With the unbent archwire
ligated, the facial surface of each crown becomes equidistant from the
embrasure line, which is undesirable.
An attempt to place the bracket at an angle to achieve the desired

tip requires bracket base to be bent over the contours of the tooth
crown. A mismatch of the bracket base and tooth contour leads to
rocking of the bracket (Fig. 47.2.2A–B).
FIGURE 47.2.2 Rotational effect.
(A) The bracket base of standard edgewise bracket is bent to follow the
contour of the tooth surface. (B) When the bracket is angulated on the
tooth to accomplish tip, a rocking potential is created.
The bracket does not fit properly on the labial contour of the tooth
and tends to rock occlusally or gingivally.11 The effect of 90 degree
angle of bracket slot to the base will lead to undue torque of the tooth
(Fig. 47.2.3A–B).
FIGURE 47.2.3 (A and B) Untorqued edgewise brackets located at

LA-point.
The undesirable effects include occlusal gingival displacement of
the teeth. The effects are more pronounced when full-size wires are in
place. The occlusal-gingival errors are corrected with compensatory
second order bends in the archwire. The unwanted torque effects, that
is labiolingual displacement of roots-crown are also the consequence
of a standard slot of the edgewise bracket. Therefore it is pertinent to
incorporate compensatory torque in the wire. A trained edgewise
orthodontist spends a considerable time in the process of archwire
bending. Each subsequent archwire requires the bends and torques to
be replicated, which requires precise and meticulous wire bending by
skilled hands (Fig. 47.3).
FIGURE 47.3 Effect of standard edgewise brackets.
(A) The standard edgewise bracket can unintentionally cause rocking
of bracket occlusally or gingivally. (B) When the vertical components of
the brackets are cited parallel to FACC and base point cited at FA
point, the angle of the slot varies to many different angulations. (C)
When standard edgewise brackets are placed, the teeth tend to lose
their mesiodistal angulations, and all roots tend to be parallel which is
not desirable. The blue lines show their original tip.
As edgewise brackets are placed with their slots parallel to the

occlusal plane or the incisal edge of the teeth, the teeth tend to lose
their natural mesiodistal inclination, become more or less upright.
Therefore additional second order or artistic bends are required to
finish the occlusion.11
Tweeds philosophy involved a greater emphasis on anchorage
conservation with tip back bends, heavy forces for retraction with
loops made in edgewise wires with the incorporation of torque and V
bends. His challenges were resolved with the developments of pre-
adjusted straight wire appliance.
Major shortcomings of edgewise bracket are listed in Box 47.3.
Box 47.3 The major shortcomings of edgewise

appliance
1. Brackets bases are perpendicular to bracket stem

2. Brackets bases are not contoured occlusogingivally
3. Slots are not angulated
4. Bracket stems are of an equal faciolingual thickness
5. The maxillary molar offset is not built-in
The first integrated pre-adjusted
appliance system and philosophy by C.
F. Andrews
The previous attempts to incorporate torque and slot inclination in the
bracket were based on empirical observations and experience of the
clinicians. The need for a scientific rationale and detailed study of
occlusion paved the way for the creation of programmed straight wire
appliance. The study by of Andrews lead to formulated six key to
normal occlusion.12
Andrews’ constant clinical experience and observations of variation
in treatment outcome and apparent inadequacies in treatment records
displayed at meetings, though they were treated to Angle’s concept of
class, I cusp to fossa relations lead him to redefine the goals of
occlusion and features at the end of treatment. He well thought that
treated malocclusion should have a semblance to the natural dentition
and occlusion when no malocclusion is present.
The measurements of non-orthodontic normal

models
Andrews began to systematically quantify features of dental casts of
individual who (1) had a negative history of orthodontic treatment, (2)
were straight and pleasing in appearance, (3) had a bite which looked
correct and (4) in his judgment would not benefit from orthodontic
treatment. One hundred twenty non-orthodontic normal models
gathered over the years (1960–1964) from various sources, and six
consistent characteristics were zeroed down. Also, 1150 treated cases
were studied to observe to match the six characteristics and when
anyone of absent influenced another character of normal occlusion or
were predictive of incomplete treatment. His observations were
synthesised into six keys of normal occlusion which he considered in
relation to treatment outcome.
The six keys of normal occlusion and goals of

orthodontic treatment12
Key 1. Molar relationship. In addition to Angle’s concept of the cusp
to fossa relationship of the mesiobuccal cusp of the maxillary first
molar and buccal groove of mandibular first molar, Andrews found
that the distal surface of the distobuccal cusp of the upper first
permanent molar made contact and occluded with the mesial surface
of the mesiobuccal cusp of the lower second molar. Greater the
intimacy of the distal surface of the distobuccal cusp of the upper first
permanent molar to the mesial surfaces of the mesiobuccal cusp of the
lower second molar, the better the prospects for -normal -occlusion.
The maxillary premolars and canines exhibit a cusp–-embrasure
relationship on buccal and a cusp–fossa relationship on their lingual
occlusion. The orthodontic treatment, therefore, should aim to attain
this key of the molar relations (Fig. 47.4A–E).
FIGURE 47.4 (A) Molar relationship as the key I as observed by C. F.
Andrews in non-orthodontic normal. (B) Improper molar relationship.
(C) Improved molar relationship. (D) More improved molar relationship.
(E) Proper molar relationship. Crown tip or crown angulation. The long
axis of crown measured from line 90 degrees to occlusal plane. (F)
Positive crown tip. (G) Negative crown tip. (H) Ordinarily occluded teeth
demonstrate the gingival portion of crown more distal than the occlusal
portion of the crown. (I) A rectangle which when angulated occupies
more mesiodistal space than a non-angulated rectangle (i.e. upper
central and lateral incisors).
Key 2. Crown angulation, or the mesiodistal ‘tip’. The tooth
angulation in mesio-distal direction by Andrews confines to crown
only and not the entire tooth (crown and root). Crown angulation is
judged at the ‘mid-development ridge’ of the crowns of incisors,
canines and premolars and the ‘dominant vertical groove’ on the
buccal surface of the molars. Each tooth has its unique angulation or
crown tip in the mouth while in normal occlusion. The tip is viewed
as a gingival portion of the clinical crown being distal to the incisal
portion.
The quantum of the crown tip is depicted in degrees. The crown tip
is an angle between the long axis of the crown and an imaginary line
vertical to the occlusal plane. In normal occlusion, a ‘plus reading’
expected whereby the gingival portion of the long axis of the crown is
distal to the incisal portion. In a reverse situation when the gingival
portion of the long axis of the crown is mesial to the incisal portion a
‘minus reading’ is assigned. The distal tip of the crowns is responsible
for a normal arch form and lack of which will be seen as spacing and
poor proximal contact points. Presuming the tooth crown as a piece of
a rectangular structure when placed tipped, will occupy more space
(Fig. 47.4F–I).
Key 3. Crown inclination (labiolingual or buccolingual inclination).
Crown inclination refers to the labiolingual or buccolingual
inclination of the long axis of the tooth crown and not the inclination
of the long axis of the entire tooth. The crown inclination of each tooth
in the arch has a unique scheme which constitutes a normal
functioning occlusion and health of the dentition. In general, the
anterior teeth have their incisal edges placed labially to the gingival
portions which have sometimes been referred as torque.
The crown inclination or torque is measured about the occlusal
plane. An angle formed between a vertical line from the occlusal plane
and a line that is tangent to the middle of the labial or long buccal axis
of the clinical crown, as viewed from the mesial or distal represents
crown inclination. A plus reading is given if the gingival portion of
the tangent line (or of the crown) is lingual to the incisal portion. A
minus reading is assigned when the gingival portion of the tangent
line (or of the crown) is labial to the incisal portion. In normal
occlusion, anterior teeth have a positive crown inclination, and buccal
segments have a negative crown inclination. The buccal crown
inclination is progressive from canine to second molar (Fig. 47.5).
FIGURE 47.5 (A) Crown inclination is determined by the resulting

angle between a line 90 degrees to the occlusal plane and a line
tangent to the middle of the labial or buccal clinical crown. (B) Lingual
crown inclination generally occurs in normally occluded upper posterior
crowns. The inclination is constant and similar from the canines
through the second premolars and slightly more pronounced in the
molars. (C) The lingual crown inclination of normally occluded lower
posterior teeth progressively increases from the canines through the
second molars. (D) Improperly inclined anterior crowns result in all
upper contact points being mesial, leading to improper occlusion. (E) A
demonstration, on an overlay, that when the anterior crowns are
properly inclined the contact points move distally, allowing for normal
occlusion. (F) Spaces resulting from normally occluded posterior teeth
and insufficiently inclined anterior teeth are often falsely blamed on
tooth size discrepancy.
A. Anterior teeth (Central and lateral incisors). Normal inclinations

of anterior teeth are essential for normal distal positioning of the
contact points of the upper teeth in their relationship to the lower
teeth, permitting proper occlusion of the posterior crowns. The crown
inclinations are sufficient to prevent over eruption of anterior teeth
and to deepen the bite. The proper inclination of the anterior crowns
leads to the seating of the buccal cusp to fossa relations and contact
points. Even in situations when buccal teeth are seated well, the
improper inclination will result in spaces somewhere between the
anterior and posterior teeth (Fig. 47.5D–F).
B. Upper and lower posterior teeth (canines through molars). A
lingual crown inclination in the buccal teeth progressively increases
from the canines through the second molars.
Key 4. Rotations. Teeth should be free from unusual rotations.
When the teeth are rotated, say molars, they encroach upon the arch
length (Fig. 47.6).
FIGURE 47.6 A rotated molar occupies more mesiodistal space,
creating a situation unreceptive to normal occlusion.
Key 5. Tight contacts. The arch should be free of spaces. The teeth
should meet tightly at proximal contacts points. Lack of contact points
is suggestive of improper occlusion except in conditions of tooth size
problems, such as microdontic lateral incisors. Such conditions will
require restorative work to create contact points.
Key 6. Occlusal plane. The plane of occlusion in non-orthodontic
normal is flat to slightly curved. A deep curve of Spee represents less
than excellent orthodontic treatment (Figs 47.7 A–C).
FIGURE 47.7 (A) Flat to a slightly curved curve of Spee is the sixth
key of Andrews’ normal occlusion. (B) deep curve of Spee results in a
more confined area for the upper teeth, creating spillage of the upper
teeth progressively mesially and distally. (C) A reverse curve of Spee
results in excessive room for the upper teeth.
Key 7 is a new addition to the Andrews six keys. A normal Bolton

ratio is needed for proper occlusion and lack of which will not allow
proper coordination of upper and lower arches in the position of tight
contacts. These situations can exist when there is a mandibular
anterior excess or microdontic incisors, the maxillary laterals are
affected most.
He also decided the location of the bracket on the crown of each of
tooth based on the their contours in occlusogingival direction and
mesiodistal direction (Fig. 47.8A–C).
FIGURE 47.8 Location of bracket area on the tooth surface and
determining the contours of the tooth crown surface in
mesiodistal and occlusogingival directions.
(A) Bracket area. (B) Vertical contour. (C) Horizontal contour.
The values of crown prominence, maxillary molar offset, crown

angulation and crown inclination (maxillary arch) (Fig. 47.9A–D) and
crown prominence, crown angulation and crown inclination of the
mandibular arch (Fig. 47.10A–C) were collected. This data constituted
the ‘norms’ which were used as reference values in designing the
straight wire appliance.
FIGURE 47.9 Maxillary arch measurements.
(A) Crown prominence. (B) Maxillary molar offset. (C) Angulation. (D)
Inclination.
FIGURE 47.10 Mandibular arch measurements.
(A) Crown prominence. (B) Inclination. (C) Angulation.
The information he gathered was crystallized in evolving first pre-

adjusted appliance that are called ‘straight wire -appliance’ or more
popularly abbreviated as SWA.
Andrews’ appliance was undoubtedly much superior appliance to
existing standard edgewise appliance system. The new terminology
were given by Andrews pertaining to straight wire appliance (Box.
47.4, Fig. 47.11).
Box 47.4 Terminology

LACC or Long axis of clinical crown.
The LA Point centre of the clinical crown at LACC.
FACC or Facial axis of clinical crown.
Andrews plane: An imaginary plane that would intersect the
crowns of properly positioned teeth at the LA point, assuming no
curve of Spee. Fig. 47.11
Bracket Base: The most lingual portion of the bracket stem.
Bracket Stem: The portion of a bracket between the bracket base
and the most lingual portion of the slot (the slot base) excluding tie-
wings.
Slot Base: The lingual wall of the slot.
Slot Point: The centre point of the slot axis.
Base Point: On the bracket base, the point that would fall on a
lingual extension of the slot axis.
Slot Axis: The buccolingual (or labiolingual) centreline of the slot.
It is equidistant from those same portions of the crown as occlusal or
gingival. A line connecting these points has been termed as Andrews
Plane/line. In full straight-wire technology, the extended plane also
includes the base point and the slot axis. (If there is a curve of Spee,
the geometric form would technically be a curved surface instead of a
plane.)
Crown Angulation: Is described in mesiodistal direction also
known as crown tip. Andrews quantified the tip and designated with
signs − or + . The degree of the crown tip is the angle formed by the
long axis of the clinical crown (as viewed from labial or buccal
perspective) and a line perpendicular to the occlusal plane. A ‘plus
reading’ is awarded when the gingival portion of the LACC is distal
to the incisal portion. A ‘minus reading’ is given when the gingival
portion of the LACC is mesial to the incisal portion.
Crown Inclination: Andrews described crown inclination in
Labiolingual direction. Each tooth in the arch has its unique crown
inclination in labiolingual direction. Tweed called it torque. Andrews
denoted − and + signs to the readings, based on the prominence of the
gingival portion of the tooth crown. Crown ‘plus’ or ‘minus’. A plus
reading is given if the gingival portion of the crown is lingual to the
incisal portion (Figure 5B). A minus reading is earned when the
gingival portion is labial or buccal to the incisal portion.
FIGURE 47.11 (A–D) Andrews’ plane and the LA point.
The main features of the appliance are (Flowchart 47.1)11:
1. Slot sitting features (treatment effects)

2. Auxiliaries (for efficient mechanics)
3. Features of convenience/comfort for the patient’s mouth. The
highlights of the SWA included compound contours of the
bracket base and torque in the base.
FLOWCHART 47.1 Design features of fully programmed brackets.
The compound contour of the bracket base

The perfect seating of the bracket base is an essential requirement of
an bracket, and therefore the SWA brackets were designed with a
compound contour of the base that mirrors the labial contour of each
tooth (Fig. 47.12A–B). A bracket with a compound contour, when
positioned at the clinical crown will not have potential to cause
unwanted effects on the tooth inclination, tip and occlusogingival
variation (Figs 47.13A–B and 47.14A–C).5,11
FIGURE 47.12 (A) Midtransverse plane of the slot, stem, crown must
be same. The base must have same inclination as of facial plane of
crown contoured occlusogingivally. (B) Midsaggital plane of slot, stem,
crown must be same. Base must have same inclination as of facial
plane of crown at FA.
FIGURE 47.13 (A and B) Midsaggital plane: Base contoured

mesiodistally.
FIGURE 47.14 The effect of standard edgewise, pre-torqued and
straight wire brackets when placed at LA points.
Pre-torqued fully pre-adjusted bracket, straight wire appliances. (A)
Standard edgewise. (B) Pre-torqued edgewise brackets (far right) two
such brackets superimposed. (C) Pre-adjusted straight wire brackets.
The slot of the centre of the bracket, the base and centre of the
clinical crown, when aligned to the same plane can accept a
rectangular wire bent along the dental arch form at the crowns (Fig.
47.15A). The compound contour for each tooth bracket provides a
consistent location of the bracket on tooth crown.
FIGURE 47.15 (A) Compound contour design. Compound contour

design mirrors both the mesiodistal and the occlusogingival anatomy of
the middle third of every tooth’s clinical crown. This allows every
straight wire appliance to fit snugly on the tooth for maximum efficiency.
Compound contours greatly enhance accurate bracket placement on
the centre of the crown. (B) Torque-in-base is the ‘key feature’ of the
pre-adjusted appliance which allows the centre of the slot and the
centre of the base on the same plane. Torque-in-base is the key to the
uniformity of straight wire bracket placement, ensuring high levels of
predictability and accuracy in result.
Torque in the base

The centre of the bracket slot and the centre of the base are always on
the same plane for consistent and easy bracket placement. The bases
of the brackets are inclined for each tooth type, to achieve proper
tooth ‘torque’ the centre of each slot being at the same height as the
middle of the clinical crown (Fig. 47.15B).
This feature of the bracket is called ‘Torque in the base’. This
particular feature of the pre-adjusted bracket were patented by Dr C.
F. Andrews.5
The varied thickness of the base of each bracket was used for
compensation of ‘first order bends’. The crown tip was incorporated
in the slot of the bracket.
The brackets were created through the process of metal injection
moulding (MIM) and not milling, and later brackets were designed
through a process of CAD–CAM.
In addition to major design changes Andrews appliance -included
The slot sitting features

These features are required in three planes of the individual teeth in
midtransverse, midsagittal, midfrontal plane.
Slot features in midfrontal plane. An elimination of first order
bends slot sitting features in frontal plane.
The first order bends are eliminated by virtue of the variable
thickeness of the bracket bases to compensate for the anatomical
variation of the anterior teeth and molar position and the position of
the teeth in the arch.
Within an arch, the bracket slot points are designed for the same
distance between them and the crown’s embrasure line. The same
time the distance between the slots points and the face of the each
crown when measured along their respective, midtransverse planes,
must be inversely proportional to the distance between each crown’s
face and its embrasure line thereby eliminating the need for first order
bends.
Slot features in midtransverse plane. Slot sitting features eliminate
the need of second order bends to compensate for occlusogingival
disharmony in slot sitting and third order bends for inclination and
other bends to deal with inherent side effects of wire bending.
When each of the bracket is sited correctly, each slot’s
midtransverse plane should be aligned with that of the crown,
regardless of crown’s position. When the teeth are optimally
positioned, the midtransverse plane of all the crowns, stems and slots
in an arch will coincide with the Andrews plane. These features are
derived from the combination of the following three features.
I The midtransverse plane of the slot, stem and crown must be

the same
II The base of the bracket for each tooth type must have the same
inclination as the facial plane of the crown at FA point and
III Each bracket’s inclined base must be contoured
occlusogingivally to match the curvature of the crown.
Slot features in midsagittal plane. The midsagittal plane of bracket

slot, stem and crown must coincide. The plane of the bracket base at
its base point must be identical to the facial plane of the crown at FA
point. In all the crowns the angle is 90 degree except for maxillary
molars it is 100 degree to the midsagittal plane, to account for the
unequal facial prominences of molar buccal cusps. It is important that
the base of each bracket must be contoured to match the mesiodistal
radius of the area of the crowns it is designed to fit. This features
prevents play between the base and the crown that might cause the
midsagittal plane of the bracket to be mesially or distally to the
crown’s midsagittal plane.
The auxiliary features

The auxiliary features are:
• Power arms
• Hooks
• Rotation wings
• Utility tubes
• Face bow tubes
These additional components of the SWA and all new brackets

facilitate easy of application of force for class II elastics, retraction
springs, bite opening utility arch and headgear for enhanced
efficiency of the appliance.
The bracket design with a power arm allowed placement of traction
force close to the centre of resistance of the tooth. Bracket hooks help
in easy placement of short elastics.
Features of convenience
The convenient features make the use of appliance more comfortable
and easy for the patient and an orthodontist.
These features included, gingival tie wings of the posterior brackets
designed more buccally for ease of placement of ligatures (Fig.
47.16A–B). The smaller height of the occlusal wings on premolars is
created to avoid occlusal interferences (Fig. 47.16C–D). Similarly, the
brackets, outer most, labial/buccal surface is not flat but contoured for
lip comfort (Fig. 47.16E).
FIGURE 47.16 Features of convenience.
(A) Gingival tie wings on posterior brackets. A conventional brackets
are in contact with gingiva causing irritation. When the gingival wing of
the bracket is extended further laterally, the design offers ease of
ligation and oral hygiene. (B) Facial surfaces of incisor and canine
brackets parallel their bases. (C–D) The bases of fully programmed
brackets are so inclined and wings are so designed to avoid occlusal
interferences from opposite arch. (E) The outer most bracket surfaces
and profile are so contoured to support lip comfort.
First fully programmed bracket series

Andrews called his prescription and combination of brackets types as
fully programmed straight wire appliance. The original SWA was
designed for treatment of malocclusion that did not require any
extractions of teeth or for non-extraction treatment.
Further, Andrews designed translation brackets, required for bodily
mesial and distal translation of a group of teeth such as required in
extraction treatment (Flowchart 47.2). The translation brackets provide
angulation13 and rotation counter moments by virtue of modified
bracket tip and anti-rotation values. He called this appliance as ‘fully
programmed appliance’ for translation movements by using a
required combination of brackets for mesial and distal treatment
needs of each patient.
FLOWCHART 47.2 Andrews extraction bracket series.

The biomechanics
The Andrews pre-adjusted appliance relied on canine retraction on
round stainless steel base wire, using a power chain from the molar.
Round wire and heavy forces from power chain caused dumping of
canine and bite deepening. The teeth close to the extraction site tends
to rotate, and tip to the extraction site.
The space closure in SWA was achieved using ‘sliding mechanics’.
The use of sliding mechanics eliminated using of looped mechanic
required in an edgewise system that required complicated wire
bending and change of wire over time.
The force levels initially used by Andrews with closed coil stainless
steel spring was in the range of 600 g force, same levels as used by
looped mechanics in edgewise appliance by Tweed. To compensate
for unwanted effects on teeth movement with bio-mechanics as
advised above and prevent tipping and rotation at extraction site,
Andrews developed brackets with a modified prescription which he
called extraction series of SWA brackets. The SWA appliance was
designed to achieve optimum occlusion that confirmed to six keys of
occlusion advocated by Andrews.
The anchorage as when needed could be enhanced with the use of
headgear.
Roller coaster effect: Difficulties were encountered with treatment
mechanics in the early days of SWA. The heavy forces and possibly
the increased tip in the anterior brackets caused deepening of the
anterior bite, with the creation of a lateral open bite. This undesired
consequence of SWA became known as the ‘roller coaster’ effect. This
effect is also caused by highly placed canine, distally tipped canine,
rapid space closure using resilient wires.
Roth’s philosophy of functional
occlusion and pre-adjusted appliance
In addition to the stated concept of features of occlusion given by
Andrews as six keys, Ronald Roth advocated idealised tooth positions
to achieve centric relation closure, mutually protected occlusion and
elimination of excursive interferences during functional jaw
movements. Using the Andrews straight wire appliance, Roth had
noticed that to achieve the desired tooth position it was necessary to
make certain changes in Andrews SWA prescription. This led to the
concept of overcorrected tooth position before appliance removal.
Roth stated that it was possible to treat a vast majority of cases using
his prescription of over correction and still meet the objectives of
‘Andrews six keys to normal occlusion’14,15 (Fig. 47.16D-E).
Functional occlusion
Roth treatments goals are similar to the Andrews six keys but not
identical. The final tooth positions in Roth philosophy varied slightly
than the Andrews prescription to achieve the functional occlusion
goals. Roth’s concept of functional occlusion differs from static
occlusion. In static occlusion, only the position of teeth is considered
upon closure. In functional occlusion, both the tooth position and jaw
movements are considered.14,15 Essential features to achieve good
functional occlusion before appliance removal as suggested by Roth
are:
1. Centric position of condyles

2. There should be 4 mm vertical overbite
3. Mild (2–3 mm) overjet
4. The tip of the upper canines should be mesial to the
embrasures between the lower canines and first bicuspids
(second bicuspids in case of extraction case)
5. 1 mm cuspid overjet
The Ronald Roth published two major articles on straight wire

appliance. He shared his experience of SWA in first 5 years’
experience14 and 17 years’ experience.15
His studies and experience with SWA appliance are summarised
below.
1. Roth often felt the need to incorporate extra bends more at

extraction sites to achieve optimum tip and rotation free teeth.
2. The sliding mechanics of space closure on a rectangular wire
was associated with a major disadvantage, the friction.
3. At the end of de-bonding, ‘settling of teeth’ in occlusion was
required. The occlusion as suggested by Andrews was seldom
achieved.
Roth’s modification of SWA

1. Overcorrection of teeth, positions to compensate for the loss of
prescription and a provision for relapse.
2. The anterior brackets were placed more incisally from
Andrews centre of the clinical crown.
3. The ‘Tru-Arch Form’ was developed.
4. Better anchorage control with use of the triple tube for head
gear and double tube for lip bumper on the principles of bio
progressive therapy/ Burstone’s mechanics.
5. Additional hooks on each tooth bracket for the use of short
class II/III elastics to promote occlusion settling.
6. A broad, coordinated anterior arches for anterior guidance.
7. With technological advances in bonding and metallurgical
science, better and precise brackets were manufactured. The
newer flexible wires were incorporated.
8. Roth used bonded twin brackets with enhanced design and
features, used multi-strand and nickel–titanium wires. He
achieved excellent results through overcorrection of teeth
positions and by keeping functional occlusion in mind.
9. Roth used double keyhole loop (Fig. 47.17) for space closure
which though provided retraction with a frictionless
mechanics at lower forces required an addition of gable bend
to compensate for unwanted tipping.
10. Apart from the three-dimensional control of Andrews SWA,
Roth incorporated overcorrection as a fourth-dimensional
control.
FIGURE 47.17 Double key hole loops for retraction and enmass
space closure used in the pre-adjusted appliance.
MBT appliance and philosophy of
treatment
During the years 1989 and 1997, McLaughlin and Bennett16–21 refined
SWA mechanics, and they suggested specific modifications in the
bracket design, use of newer technology wires, and sliding mechanics
for space closure with use of continuous light forces.
The MBT appliance design

Five major changes were introduced to the SWA22
1. Modified tip in the maxillary and mandibular anterior

segments
2. Modified torque in the maxillary and mandibular incisors
3. Modified torque in the mandibular posterior segment
4. Modified torque in the maxillary posterior segment
5. Torque options in the maxillary and mandibular canine
brackets.
Modified tip in the maxillary and mandibular anterior

segments
With reduced force level (200 g) required for retraction in sliding
mechanics, the tip value of Andrews non-orthodontic normal model
values seem to be adequate. They suggested appliance by reverting
close to original tip values suggested by Andrews (Fig. 47.18A–B).
FIGURE 47.18 (A and B) The recommended tip measurements for
the MBTTM bracket system are Andrews’ original tip prescription
values, which give less distal root tip in the upper and lower anterior
segments thereby less taxing on anchorage.
Modified torque in the maxillary and mandibular incisors

Additional palatal root torque for the maxillary incisors and
additional lingual crown torque for the mandibular incisors was
recommended. The rectangular wires of choice for space closure and
finishing are 0.019 × 0.025 in. Since these arches did not precisely fit
the bracket slot and hence provided insufficient palatal root torque for
the maxillary incisors and labial root torque for the mandibular
incisors. Therefore the torque loss due to the undersize wire was
compensated by increased torque values in the bracket slots (Fig.
47.19).
FIGURE 47.19 Extra torque was built in the MBTTM bracket system in
the incisor and molar region compared to the original SWA.
Modified torque in the mandibular posterior segment

Additional lingual crown torque and uprighting of the mandibular
posterior teeth incorporated to prevent the creation of steep curve of
Wilson (Fig. 47.19).
Modified torque in the maxillary posterior segment

Additional 5 degrees of buccal root torque incorporated in the
maxillary molar brackets to avoid hanging palatal cusp (Fig. 47.19).
Torque options in the canine brackets

The maxillary canine have torque values of 0, +7, 7. Three canine
torque values recommended for mandibular canines are: 0, +6, -6
degrees. The 0 degrees brackets were most commonly used and +6, -6
degrees can be used when the mandibular canine roots were more
labially or lingually displaced, respectively (Fig. 47.20).
FIGURE 47.20 (A–C) Three torque or labiolingual inclination are for

upper canines.
The MBT biomechanics

The MBT treatment mechanics included an accurate bracket
positioning with the help of gauge, unlike Andrews on LA point with
eyeballing. After 1997, they developed three arch forms which are
ovoid, tapered and square arch forms.
Authors have beautifully illustrated how during initial stages of
levelling, tip built into anterior brackets increases the tendency of
anterior teeth to slant forward (Fig. 47.21). In extraction cases figure of
8 with 0.010 in. ligature wires (lacebacks) helps to prevent cuspid
tipping during levelling and aligning (Figs. 47.22.1 and 47.22.2). The
main archwire bent-back at the distal end of the buccal tube of the
terminal banded molars, further minimises labial tipping of the
incisors (Fig. 47.22.3). However, this causes enhanced taxation on the
anchorage and extra measures are required to conserve the anchorage.
FIGURE 47.21 Effect of initial archwires on anterior teeth with

pre-adjusted brackets: tip built into anterior brackets increases
tendency of anterior teeth to tip forward.
FIGURE 47.22 Canine lace back (1) Figure-8 .010 in. ligature wires
(lacebacks) used in extraction cases to prevent cuspid tipping during
levelling and aligning. (2) Effects of lacebacks on cuspids during
levelling and aligning. (A) Tooth after bracket placement. (B) Immediate
but minimal distal tipping effect from laceback. (C) Gradual uprighting
in response to archwire force. (3) To counter the effects of tipping on
teeth the gentle cinch of archwire is recommended distal to the terminal
molar. However this causes enhanced anchorage requirements.
Canine lace back with ligature wire is recommended during

levelling and aligning stages. The gentle force from lace back first
causes a minimal distal tipping effect which transforms into gradual
uprighting of canine in response to archwire force. Effects of cuspid
bracket tip with cuspids in upright or distally tipped position leads to
extrusion of incisors and undesirable bite deepening (Fig. 47.23).
Therefore, during the initial stages of treatment with a preadjusted
fixed appliance, anchorage requirements are enhanced which
necessitate additional methods of anchorage conservation that include
headgear for a short-term and banding of the second molars (Fig.
47.24). Banding the second molars facilitates the process of vertical
bite control (Fig. 47.25).
FIGURE 47.23 Effects of cuspid bracket tip with cuspids in upright or

distally tipped position: extrusion of incisors and undesirable bite
deepening.
FIGURE 47.24 Anchorage control during stages of levelling and

alignment. Headgear, class III elastics, lacebacks, and bent-back
archwires are used for anchorage control.
FIGURE 47.25 The second molar pick up in the arch enhances
bite opening effect.
The space closing mechanism in the preadjusted appliance differs

from the conventional methods (Fig. 47.26), whereby a sliding
mechanics and light elastic forces are preferred (Fig. 47.27). In the
cases of a severe overjet, incisor retraction leads to poor palatal root
torque. The lower incisors are labially inclined and buccal segments
may remain in mild class II relationship. In such a situation additional
incisor torque needs to be incorporated in the archwire(s). The
maxillary incisors require palatal root torque while some amount of
labial root torque may be needed in the lower incisor segment. The
anchorage control is the most critical aspect of biomechanics at this
stage (Fig. 47.28).
FIGURE 47.26 Closing loop mechanics with standard edgewise
appliance.
FIGURE 47.27 (A) Space closure with light forces: elastic module
attached to anterior archwire hook with ligature wire running forward
from molar. (B) Modification with elastic module attached to first molar
hook instead of archwire hook.
FIGURE 47.28 In severe overjet case, inadequate incisor torque
produces upright upper incisors, labially inclined lower incisors,
and slightly class II posterior relationship.
1. All malocclusions are finished in an occlusion with a similar
predefined torque and tip values that may not be functionally
and aesthetically acceptable in all facial types.
2. Lacks individualisation.
3. Requires wire bending to fulfil the individual needs like
rotation correction and, alignment of the severely displaced
tooth.
4. Finishing and detailing could be a problem in large skeletal
facial disharmony.
5. Small variation in bracket placement can result in significant
deviations in tooth position.
One of the major disadvantages of existing straight wire appliances is
that it lacks individualisation. Customisation can be achieved through
customised wire bending and bracket designing. With current
technology, it is now possible to design customised orthodontic
appliance according to the individual patient’s anatomical contours of
the teeth and needs. The use of an indirect bonding and robotic wire
bending will increase in treatment efficiency. The customisation of the
appliance system through intraoral scanning and CAD-CAM bracket
design computer technology has already been used extensively in
SureSmileTM technology23 and lingual orthodontics.24
Key Points
Dr Angle gave us edgewise bracket for three dimensional control of
the tooth movement; Tweed mastered and invented philosophy of its
use and wire bending to compensate for the undesired effects of a
standard bracket. Although several clinicians attempted building the
treatment into the bracket, so that wire bending is minimised or
eliminated, it was Andrews masterstroke in systematically analysing
and synthesizing the requirements of occlusion to be achieved from a
bracket system and appliance that changed the world of orthodontic
appliance design. He built-in the treatment features into bracket
which eliminated in and out bends, second order bends and torque or
third order bends. The first fully programmable bracket system he
developed was commercially known as straight wire appliance.
Ronald Roth added a functional component of occlusion to the static
six keys of occlusion objectives of Andrews. He further refined the key
features of the appliance to achieve perfect ‘slot line up’ and added
features of overcorrection to minimise relapse. The refinement of the
technology, in manufacturing the brackets from milling to MIM to
CAD-CAM and, most recent CNC milling has allowed quality,
accuracy and complex anatomy of brackets with features of the
design, and comfort. The force levels required gradually reduced, the
continuous wire force available through newer technology wires, and
precision in bonding has resulted in quality treatment outcome and
objectives of occlusion attainable.
It is well known that no two faces are alike, and so are the
dissimilarities that exist is the dental morphology and requirements of
teeth position to harmonise with facial and racial variations. Bracket
customisation is perhaps the only answer to this complex issue.
The objectives of occlusion described above may not be entirely
attainable in cases of malocclusion with facial deformities and large
skeletal problems, which may constitute 15–20% of all malocclusion
cases.
References
edge-wise arch in the treatment of malocclusions: I.
Angle Orthod. 1941;11(1):5–11.
edge-wise arch in the treatment of malocclusions: II.
Angle Orthod. 1941;11(1):12–67.
4. Tweed CH. Clinical orthodontics. 1st ed. Saint Louis:
CV Mosby; 1966.
5. Andrews LF. Straight wire the concept and
appliance. San Diego, CA:. 1989:LA10.
6. Holdaway RA. Bracket angulation as applied to the
edgewise appliance. Angle Orthod. 1952;22:227–236.
7. Lewis PD. Principles for use of the edgewise bracket
with rotation arms. Angle Orthod. 1959;29:182–188.
8. Jarabak JR, Fizzell JA. Paper presented at the 56th
annual meeting of the American Association of
Orthodontists. Washington, D.C; 1960. Cited from:
Wahl N. Orthodontics in 3 millennia. Chapter 16:
Late 20th-century fixed appliances. Am J Orthod
9. Wahl N. Orthodontics in 3 millennia Chapter 16. Late
20th-century fixed appliances. Am J Orthod Dentofac
19061811.
1976;70(3):241–268: Sep; PubMed PMID: 786034.
11. Andrews LF. The straight-wire appliance. Br J Orthod.
1979;6(3):125–143: Jul 1.
4505873.
13. Andrews LF. The 6-elements orthodontic philosophy:
treatment goals, classification, and rules for treating.
1976;10(11):836–850: Nov; PubMed PMID: 1069735.
15. Roth RH. The straight-wire appliance 17 years later. J
Clin Orthod. 1987;21(9):632–642: Sep; PubMed PMID:
3482093.
16. McLaughlin RP, Bennett JC. The transition from
standard edgewise to preadjusted appliance systems.
J Clin Orthod. 1989;23(3):142–153: Mar; PubMed
PMID: 2606968.
17. McLaughlin RP, Bennett JC. Anchorage control
during leveling and aligning with a preadjusted
appliance system. J Clin Orthod. 1991;25(11):687–696:
Nov; PubMed PMID: 1814949.
18. McLaughlin RP, Bennett JC. Bracket placement with
the preadjusted appliance. J Clin Orthod.
1995;29(5):302–311: May; PubMed PMID: 8617853.
19. Bennett JC, McLaughlin RP. Controlled space closure
with a preadjusted appliance system. J Clin Orthod.
1990;24(4):251–260: Apr; PubMed PMID: 2094736.
20. McLaughlin RP, Bennett JC. Finishing and detailing
with a preadjusted appliance system. J Clin Orthod.
1991;25(4):251–264: Apr; PubMed PMID: 1939626.
21. Bennett JC, McLaughlin RP. Overjet reduction with a
preadjusted appliance system. J Clin Orthod.
1992;26(5):293–309: May; PubMed PMID: 1430180.
22. McLaughlin RP, Bennett JC. Evolution of treatment
mechanics and contemporary appliance design in
orthodontics: a 40-year perspective. Am J Orthod
Dentofac Orthop. 2015;147(6):654–662: Jun; PubMed
PMID: 26038069.
23. Sachdeva RC. SureSmile technology in a patient-
centered orthodontic practice. J Clin Orthod.
2001;35(4):245–253: Apr; PubMed PMID:;1; 11345571.
24. Wiechmann D, Rummel V, Thalheim A, Simon JS,
Wiechmann L. Customized brackets and archwires
for lingual orthodontic treatment. Am J Orthod
Dentofacial Orthop. 2003;124(5):593–599: Nov;
CHAPTER 48
Orthodontic treatment with self-
ligating bracket systems
Shailesh Deshmukh
Vilas Samrit
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Evolution of self-ligating brackets
The SPEED™ appliance
In-Ovation
Damon system
SmartClip appliance
Biomechanics and stages of treatment with self-ligating bracket
system
Features of self-ligation and their impact on biomechanics
Stages of treatment and archwire sequence
Damon bracket system
SmartClip appliance
Biomechanical challenge of self-ligation brackets versus
conventional brackets
Evidence on claims of self-ligating brackets
Key Points
Introduction
The contemporary orthodontics entails orthodontic tooth movement,
through a force, which is applied through archwires and is
transmitted to the teeth via brackets. The archwire is held in to the
brackets often with a ligature or similar arrangement.
In the earliest era of orthodontics, silk was used for securing the
teeth to the ‘bandeau’ the rigid metal band around the teeth. Later at
the beginning of 20th century, the fixed appliances evolved and
became popular, the gold ligatures were used.1 After the introduction
of stainless steel, stainless steel ligatures became the universally
accepted mode of ligation. Stainless steel ligation is cheap, robust, not
easily deformed and permits ligation of the archwire to the bracket
and at a distance. However, the force generated through friction is
much higher, limiting the tooth movement during early stages of
treatment. The potential drawbacks are trauma to the oral mucosa due
to a loose end or displaced tag, additional time required to place and
remove ligation and enhanced friction that may not be desired.
With the availability of elastomeric modules in the late 1960s, faster
placement and removal of ligation, as well as a reduction in traumatic
incidences, became possible.2 However, due to their degradation
properties, elastomeric ligatures fail to achieve full archwire
engagement in the bracket.3 Also, much higher friction between
archwire and bracket was present compared to stainless steel
ligature.4
Stainless steel ligature and elastomeric ligature are the most
common conventional ligation systems used in orthodontics. The
limitations of these ligation systems are presented in Box 48.1.
Box 48.1 Limitations of conventional ligation
• Wire ligation is a time-consuming clinical procedure.

• The archwire secured in brackets with ligature wires offer
significant friction to initiate and continue with the tooth
movement.
• Ligatures provide poor securing mechanism for less than full size
wires which can compromise control on tooth movement.
• For elastomerics, the force decays over time and therefore tooth
control is not optimal.
• Both wire and elastomeric ligatures sometimes become displaced.
• Oral hygiene is potentially impeded.
To overcome the limitations of stainless steel ligature and elastomeric
modules, efforts were made to step up a new ligation device within
the bracket, and it is called self-ligation system. The term Self-Ligation
in orthodontics implies that the orthodontic bracket can secure the
archwire in place with an inbuilt locking mechanism. The self ligation
bracket systems have a movable component to close off the bracket
slot and thereby creating a fourth wall of the bracket slot which
transforms the bracket slot into a tube, thus, called self-ligating
brackets.
The closing mechanics may actively hold the undersize wire in to
the depth of the bracket slot called active self-ligation or may just close
the bracket slots like a lid called passive self-ligation system.
Properties of an ideal ligation system are summarised in Box 48.2.
Box 48.2 Properties of an ideal ligation system5
• The ligation should be secure and robust. It is highly desirable

that once ligated, the system is resistant to inadvertent loss of
ligation. Wire ligation is good while elastomeric is inferior due to
its force decay.
• It should ensure full bracket engagement of the archwire.
Archwire can be fully engaged in the bracket slot and maintained
there with certainty. Wire ligatures maintain the engagement
once achieved while elastomeric exert insufficient force and
subsequent degradation of elastic property causing loss of full
engagement.
• It should exhibit low friction between bracket and archwire.
• It should be quick and easy to use.
• It should assist in the maintenance of good oral hygiene. They
should not accumulate plaque and interfere with oral hygiene.
• It should be comfortable for the patient. It should not get
displaced between appointments and cause trauma or
discomfort. Elastomerics are good in this respect, but wire
ligatures require careful tucking in of the ends to avoid soft tissue
trauma, and can occasionally be displaced between
appointments, cause discomfort and may be the reason for an
unscheduled clinic appointment.
Evolution of self-ligating brackets

The first self-ligating bracket, ‘Russell Lock’ edgewise attachment was
introduced as early as 1935 by Stolzenberg, aiming to reduce ligation
time and improve clinical efficiency.6 It consisted of a primitive
mechanism of a circular threaded opening in the face of the bracket. It
had an edgewise slot for round wire up to 0.022 in. or rectangular
wire up to 0.022 × 0.028 in. The flat threaded screw was used for
fixation or removal of archwire by simply turning the key (Fig. 48.1).
FIGURE 48.1 Russell attachment.

The Russell attachment was first designed by Stolzenberg.8
Later in 1971, A. J. Wildman introduced passive Edgelok self-

ligating brackets.7 It consisted of a round body with a rigid labial
sliding cap. A special instrument was required to open the slot by
moving the slide. The cap could be closed with finger pressure,
converting the bracket slot into a tube. These brackets were bulky and
inconvenient while with opening and closing of the slide (Fig. 48.2).
FIGURE 48.2 Edgelok bracket.

It was first designed by AJ Wildman.8
Dr Franz Sander in 1974 introduced another design of self-ligating

brackets with a variable slot called Mobil-lock.8 These brackets had a
rigid semi-circular disk, which could be turned with the help of a
screw driver to open or close the labial surface of the slot. The
resulting labial face of the slot was narrow, giving poor rotational
control. The difficulty of access to open or close the premolar brackets
was another disadvantage of these brackets (Fig. 48.3). Many
clinicians in collaboration with industry developed and evolved
different types of self ligation mechanism, used and further improved
for clinical efficacy and comfort. Contemporary self ligating bracket
system are nearly perfect. The state of the art porcelain self ligation
brackets are also available. (Box 48.3).
FIGURE 48.3 Mobil-lock bracket.
It was first designed by Franz Sanders.8
Box 48.3 Evolution of self-ligating brackets

Major developments have occurred in self-ligating brackets
regarding robustness and ease of use, and these have rapidly grown
in popularity. Many orthodontic practitioners have found them
superior in patient and operator comfort besides reduction in chair
time. Some clinicians have begun using exclusively self-ligating
brackets in their practice. The requirements of ideal self-ligating
brackets are presented in Box 48.49
Box 48.4 Ideal requirements of self-ligating

brackets
Adopted from Eliades and Pandis’ textbook on Self-ligation in
orthodontics.9
1. The self-ligating brackets should be easy to open and close with

low forces applied to the teeth during these procedures and
with all archwire sizes and materials.
2. It should never open inadvertently, allowing a loss of tooth
control.
3. It should have a ligating mechanism that never jams or breaks
or distorts or changes in its performance through the treatment
period.
4. It should have a positively held open clip/slide position so that
the clip or slide does not obstruct the view of the bracket slot or
the actual placement of the archwire.
5. Self-ligation brackets should be tolerant of a reasonable excess of
composite material without obstructing the clip/slide
mechanism.
6. It should permit easy attachment and removal of all the usual
auxiliary components of an appliance, such as elastomeric
chain, undertie ligatures, laceback ligatures, without interfering
with the self-ligating clip/slide.
7. It should permit easy placement and removal of hooks/posts
and possibly other auxiliaries on the brackets.
8. It should have a suitably narrow mesiodistal dimension to take
an advantage of the secure archwire engagement and permit
large inter bracket spans.
9. It should have the performance expected of all orthodontic
brackets regarding bond strength and smoothness of contour.
10. It should perform similarly to a conventional twin pre-adjusted
bracket with additional built-in convenient features of
comfortable self-ligation for saving chair side time and comfort
to the patient.
The bracket has a flexible component (spring clip) that encroaches on
the slot from labial or buccal aspect and presses against the archwire.
This component being flexible, can store and release energy through
elastic deformation. Some examples of active brackets system are:
SPEED appliance (Strite Industries Ltd, Cambridge, Ontario, Canada)
and In-Ovation (GAC International Inc., Bohemia, NY). Proponents of
active clip claim that it provides a ‘homing’ action on the wire when
deflected, thereby providing more control with the appliance.10 These
brackets have a flexible clip that creates a passive slot depth of 0.0175
× 0.020 in. With small round wires, the bracket is passive, but with
full-size wires, the flexible clip is deflected and provides an active
seating force on the archwire.
The SPEED™ appliance11

The first active self-ligating bracket, SPEED™ appliance was
introduced in 1980 by Dr G. Herbert Hanson as a miniaturised bracket
with wingless design and super-elastic nickel titanium spring clip.
The SPEED is a fully adjusted edgewise appliance available in 0.018
and 0.022 in. slot size. Every SPEED bracket has two horizontal slots;
the archwire slot and the auxiliary slot. The auxiliary slot is located to
the occlusal of the archwire slot and is 0.0165 square in. dimension.
The SPEED Mushroom Hook™ is a miniaturised integral hook, which
is available in all brackets. This uniquely shaped hook easily grasps
and securely holds any style of intraoral elastomeric. These hooks are
positioned on the distal side of each bracket.
The clip can be moved occlusal using an explorer tip inserted into
the labial window in the face of the spring clip. Alternately, the
bracket can be opened by applying a light occlusally directed sliding
force to the gingival dimple indent. The slot can be closed by applying
finger pressure over the clip in the gingival direction (Figs. 48.4 and
48.5).
FIGURE 48.4 SPEED bracket. Source:
http://speedsystem.com/HTML/clinician/what_is_SPEED.html.
FIGURE 48.5 (A) Opening. (B) Closing SPEED bracket. Source:
http://speedsystem.com/HTML/clinician/how_to_open_&_close_SPEED/How_To_Open_SPEED.h
In-Ovation12
In-Ovation brackets were introduced by Michael C. Alpern in 2000.
They are similar to SPEED brackets but have a true twin design.
However, they were large sized and had difficulty in opening and
closing the clips.13 In 2002, smaller brackets for anterior teeth were
introduced as In-Ovation R (reduced). These brackets have sliding
spring clips labially, extending fully through the vertical channel in
the bracket body. Aesthetic brackets In-Ovation C were introduced in
2006. These are made from a ceramic material with a rhodium
processed clip for enhanced aesthetics.
The clip slides easily with a gentle pressure that is applied occlusal
to the v-notched clip at the gingival side of the bracket, using the
explorer or similar instrument. The clip can be closed in a similar
manner as SPEED brackets with finger pressure on the incisal curve
(Fig. 48.6).
FIGURE 48.6 In-Ovation bracket. Source:

https://www.dentsply.com/en-us/orthodontics/brackets/self-ligating-
brackets.html#tabs=In-Ovation%20R/Interactive%20Control.
The bracket has a rigid, movable component to entrap the archwire.
This component just closes the slot, converting the bracket slot into a
rigid tube, and does not apply active force to the wire. Archwire
remains passive at bracket clip interface within the bracket slot
regardless of its size. Among the examples of the passive self-ligating
brackets are Damon® system [(‘A’ Company, San Diego,
California)/(Ormco Corporation, 1717 W. Collins Ave., Orange, CA)
and SmartClip (3M Unitek 3M Center, St Paul, MN)]. Proponents of
passive slide claim that there is less friction in the appliance during
sliding mechanics. Thus, the forces generated by the archwire are
transmitted directly to the teeth and supporting structures without
absorption or transformation by the self-ligation device.
Damon system14,15
This self-ligation system was originally introduced in 1996 by Dr
Dwight Damon. The philosophy of Damon brackets is based on the
principle of using the threshold force, that is, the force just enough to
initiate tooth movement. Damon bracket has a passive self-ligating
design with conventional tie-wings. The first bracket of Damon series
Damon SL (‘A’ Company, San Diego, CA) had a large sliding door
which sometimes opened inadvertently due to the exterior position of
the slide. With evolution, the brackets have become more comfortable
for the patient. The slide mechanism has become more reliable,
simpler to open and close. The next generation Damon brackets
(Damon 2™) introduced in 2000 (Ormco Corporation, 1717 W. Collins
Ave., Orange, CA), the slide was placed in the shelter of the tie-wings
to eliminate the inadvertent slide opening.
The third-generation Damon brackets (Damon 3™) introduced in
2004 were made up of clear material and stainless steel for aesthetics.
It has an improved, easy and secure mechanism for opening and
closing, but the separation of metal from the reinforced resin
component remained the main drawback.16 Recently launched all
metal variants, Damon 3MX™ and Damon Q™, in addition to
improved properties, has an additional vertical slot permitting
placement and removal of drop-in hooks in this bracket.15 These
brackets require a special probe-like instrument for opening the slot.
Alternately, a dental probe can be used. The slot can be closed by
moving the slide back by gentle finger pressure (Fig. 48.7A–E).
FIGURE 48.7 Damon brackets.

(A) Damon SL; (B) Damon 2; (C) Damon 3; (D) Damon MX; (E) Damon
Q. Source: Harradine N. The history and development of self-ligating
brackets. Semin Orthod 2008; 14:5–1816;
http://www.calmaldental.com.my/wp-content/uploads/2016/05/damon-
q.jpg.
SmartClip appliance17
SmartClip self-ligating brackets were originally designed by Gary L.
Weinberger and introduced by 3M Unitek, (St Paul, MN, USA) in
2004. It consists of two nickel-titanium clips attached on mesial and
distal aspects of the bracket. When force is exerted on the clips
through the archwire, these clips open and close through elastic
deformation. These are the only self-ligating brackets with true twin
design, where the clinician has the option of selectively engaging the
archwire in only one clip, in a case of severely malaligned teeth. Also,
they have a tie-wing design which allows the use of E-chain when
needed.18
The smart nitinol clips present some resistance to insertion and
removal of the archwire. For wire insertion, a double ended
instrument is used which has a rectangular notch on one end allowing
the clinician to direct the archwire into bracket slot by applying gentle
pressure to pass the archwire through the clips. The opposite end of
the instrument is used as a torque key for easy insertion of the
rectangular archwires.
The disengagement plier is used to disengage archwires from the
bracket slot. The instrument has two hooks to engage the wire, while
its central part holds on the buccal surface of the brackets, the wire
can be disengaged from the bracket slot by pressing the handles
together.
The archwire insertion and removal of these brackets was
uncomfortable due to high clip forces. However, with an improved
version of these brackets introduced in 2009 as SmartClip SL3
brackets, there is a significant reduction of clip force. The aesthetic
version of these brackets was introduced as Clarity SL in 200719 (Figs.
48.8 A–B and 48.9A–D).
FIGURE 48.8 SmartClip self—ligating brackets.

(A) SmartClip SL3; (B) Clarity SL. Source: 3M™ self-ligating appliances
with intelligent clip technology technique guide.23
FIGURE 48.9 (A) Unitek wire insertion instrument. (B) Hand
instrument for wire disengagement for SmartClip appliance. (C)
Engaging. (D) Removing the archwire. Source: 3M™ self-ligating
appliances with intelligent clip technology technique guide.23
Biomechanics and stages of treatment
with self-ligating bracket system
Frictional effects of the force of ligation impede efficient tooth
movement. The force required to move the teeth must overcome the
friction created by the ligature-archwire contact surface. The force of
ligation with conventional systems of steel ligature/elastomeric
module ranges anywhere between 30 and 200 g or even more.20 Light
forces with low friction are the mechanical basis of any self-ligating
system.20,21 In these brackets, there is no discernible force of ligation
(passive ligation).22 Therefore, one can use lighter forces with self-
ligating brackets.
As with conventional brackets, bracket positioning is of paramount
importance for effective and efficient completion of orthodontic
treatment with self-ligating bracket systems. Although basic tenets of
the biomechanics of self-ligating brackets versus conventional
brackets remain the same, the clinical handling of the mechanics is
different in self-ligating brackets. Self-ligating bracket system allows
archwire ligation with little or no force of ligation; consequently, there
is little or no friction between securing device and the wire. A nearly
total freedom for the archwire in the bracket slot and least friction lead
to faster tooth movement during sliding. This can also lead to loss of
torque control. Therefore, tooth movement is kept under vigilant
observation more so, during the space closure and finishing stages of
treatment.
Features of self-ligation and their
impact on biomechanics
The biomechanics and use of the brackets by the clinician differ with
each of the self-ligation bracket systems. The bracket design and
closing mechanism differ, and so is the point of delivery of force, and
sequence of the wires to be used. Damon and In-Ovation brackets are
single piece brackets while the SmartClip bracket is a twin bracket.
A single piece bracket like Damon, when closed with the lid, gets
converted into a tube and hence the force delivery at the bracket wire
interface needs to be understood, analogues to a wire tube interface.
In the authors’ experience, self-ligating brackets with movable slides
pose a greater difficulty in a full closure of the slide, when the tooth is
rotated (Fig. 48.10).
FIGURE 48.10 In-Ovation R bracket on 43 with partially open
slide.
The features of twin bracket in a self-ligation system are available in

SmartClip. It has a clip each at the mesial and distal margin of the
bracket slot. Therefore, an archwire in SmartClip bracket can be held
like a conventional twin bracket at any given time during treatment.
The movable clip in single self-ligating brackets snaps and secures the
archwire in the bracket slot. The SmartClip twin bracket can allow
selective engagement of the archwire in either of the twin tie-wings23
(Fig. 48.11).
FIGURE 48.11 SmartClip bracket on 33 with selective

engagement of wire in mesial tie wing.
The mesiodistal dimension of the self-ligation brackets differs from
manufacturer to manufacturer, and so does the profile thickness. For
example, a SmartClip bracket is wide compared to a SPEED bracket,
and therefore rotational control on the tooth will vary accordingly.
Each self-ligating system has its uniqueness regarding slot
configuration, force delivery and torque control and therefore it is
critical to follow the recommended archwire selection and sequence
for treatment to be effective, as well as efficient with the chosen
systems. The self-ligating bracket system responds efficiently to the
light forces when the recommended archwire sequencing is followed,
throughout treatment.23
Stages of treatment and archwire
sequence
The six treatment stages of orthodontic treatment: (1) Anchorage
control, (2) levelling and aligning, (3) overbite control, (4) overjet
reduction, (5) space closure and (6) finishing and detailing are similar
in conventional, as well as self-ligating bracket systems.
‘The self-ligation technology and the thought process that
accompanies have an impact on our diagnosis and treatment
planning, chair time, archwire sequencing, and overall clinical
efficiency’.24 It is critical to remember that whichever self-ligating
system the orthodontist uses, archwire sequencing is the most
important aspect of effective treatment with self-ligating systems.
Damon bracket system

Self-ligation gained popularity with the introduction of the ‘Damon
system’. Dr Damon promoted Damon self-ligating brackets citing
features of light forces, the efficiency of low-friction mechanics, non-
extraction treatment solutions and shorter treatment time compared to
conventional pre-adjusted brackets. According to him, Damon system
has the blending of passive self-ligating brackets and high-technology
archwires which when carefully selected, dispense the applied force in
the range of ‘Optimal Force Zone’, which he called ‘Biozone’. He
emphasised ‘true biomechanics’ was sustaining the force levels to
‘Biozone’. ‘Biozone’ implies that applied forces are just sufficient to
stimulate cellular activity without completely occluding blood vessels
and therefore produce efficient tooth movement. He feels that it is
‘not’ possible to stay in the ‘Biozone’ when we use elastic modules
and steel ligatures for ligation since binding and friction become an
inherent part of the mechanics of orthodontic treatment.25
Precise bracket bonding is a prerequisite in any system and so is for
the Damon brackets which are bonded on all the teeth, including
second molars. The second molars are not engaged until the second
phase of treatment. The classic archwire sequencing is as follows.
Light wire phase

The initial wires are round wires usually 0.014 or 0.016 in. NiTi
superelastic (NiTi SE) wires. This phase of treatment involves the
initiation of tooth movement, levelling, correction of anterior rotations
and partial correction of posterior rotations, arch form development,
and preparing the brackets for receiving the next archwire. The NiTi
SE wire 0.016 in. is required in severely crowded adult cases that are
not quite ready for the second phase archwire.
High-tech edgewise phase

The second molars are normally engaged by the previous archwires in
this phase. This phase involves the use of 0.016 × 0.025 in. NiTi SE
wires. These wires are the workhorse of the second phase and placed
in upper and lower well-prepared arches. If this wire is too difficult to
engage, 0.014 × 0.025 in. NiTi SE wire should instead be used. The
smaller dimension wire (0.014 × 0.025 in. NiTi SE) serves as a
transition wire. Smaller dimension of wire is more often required in
the lower arch where inter-bracket distance is relatively smaller. The
0.018 × 0.025 in. NiTi SE has to be used as a follow-up archwire if 0.014
× 0.025 in. NiTi SE is used. This is an excellent wire to prepare the arch
for insertion of the working stainless steel transition wire.
For intrusion, 0.017 × 0.025 in. NiTi SE with preformed curves and
reverse curve of Spee is used. In class II division 2 cases, additional
torque can be achieved with 0.019 × 0.025 in. NiTi SE with 20 degrees
palatal root torque in the anterior segment. If torque requirement is
minimal and the only intrusion of the central incisors is needed, same
wire without torque is recommended.
During this phase of treatment, full alignment of teeth along with
rotation correction is achieved, and torque control and bite opening
are initiated. Duration of this phase is 20–30 weeks. The archwire is
kept for 8–10 weeks followed by the next archwire for 4–6 weeks.
Major mechanics phase
During this phase of treatment, 0.019 × 0.025 in. stainless steel
archwires are the archwires of choice. The stainless steel rectangular
archwire offers sufficient rigidity to maintain the arch form and its
integrity. The rigid properties with low friction of the wire are needed
during anteroposterior correction and space closure. The wire is also
good for maintenance of the anterior vertical and posterior
buccolingual positions of the teeth in the arch.
However, a relatively low dimension posted SS wire of 0.016 × 0.025
in. should be used in the lower arch when more play is desired. The
0.016 × 0.025 in. SS wire is also a nice finishing archwire in the lower
arch if all the torques are acceptable.
This phase of treatment continues for 8–10 weeks.
Finishing phase
In most cases, the working archwires are also used as finishing wires.
Based on requirements of each case or when some detailed adjustment
to individual tooth is required, β-titanium (TMA) wires of 0.019 ×
0.025 in. or 0.017 × 0.025 in. are recommended for achieving optimum
torque and perfect alignments through wire bending. Settling elastics
may be used to develop good occlusal contact.
SmartClip appliance
The SmartClip brackets are available in prescription with 0.018 × 0.025
in., as well as 0.022 × 0.025 in. slot sizes with MBT prescription.
Non-Extraction Treatment
The sequence of wires with non-extraction treatment with 0.022 ×
0.025 in. slot size brackets is as follows:
1. The initial wires are light NiTi wires of smaller dimensions.

The 0.014 in. heat activated (HA) NiTi archwire is used for
relief of crowding and alignment. Smaller dimension archwire
(0.012 in. NiTi) is recommended in cases with severe
crowding.
2. As we begin to align and stabilise the arch form, higher
dimension wires are used. These are either twin wires of 0.016
NiTi + 0.014 in. NiTi in tandem, that is together, or single 0.018
in. NiTi wire.
3. Subsequent to the correction of all the imbrications, the arch
form is further stabilised and teeth are positioned better with
0.019 × 0.025 in. HA NiTi wires. This wire is the most
important wire as it ensures proper levelling of the arches.
Passive insertion of this wire into the brackets will not occur if
there is a discrepancy in the alignment of the teeth.
4. The final finishing is obtained with heavier wire of 0.019 ×
0.025 in. NiTi or TMA/β III Titanium.
Non-extraction treatment with 0.018 × 0.025 in. slot size brackets

necessitates the use of smaller dimensions of wires at each of the
stages of treatment. The following wire size and sequence is preferred:
1. 0.014 HA NiTi or 0.012 in. NiTi in very severe crowding cases

2. 0.014 NiTi + 0.014 in. NiTi (tandem) or 0.016 in. NiTi
3. 0.016 × 0.025 in. HA NiTi or 0.017 × 0.025 in. HA NiTi
4. 0.017 × 0.025 in. NiTi or TMA/β III Titanium
Here too, the 0.017 × 0.025 in. HA NiTi wire is the most important
wire to ensure proper alignment and levelling of the arches and arch
stabilisation.
Extraction treatment
The sequence and size of wires does not change much when treatment
with extractions is carried out using 0.022 × 0.025 in. slot size brackets.
The sequence is as follows:
1. 0.014 HA NiTi or 0.012 in. NiTi (in very severe crowding cases)
3. 0.019 × 0.025 in. HA NiTi
4. 0.019 × 0.025 in. NiTi
5. 0.019 × 0.025 in. TMA/β III Titanium
6. 0.019 × 0.025 in. SS (rarely)
To ensure seamless retraction mechanics with low forces and low

friction, levelling of the arches is critical in self-ligating brackets. There
is no room for error, and one should not proceed with retraction
mechanics unless and until the 0.019 × 0.025 in. HA NiTi wire engages
passively into all the bracket slots to ensure low friction mechanics
throughout the retraction phase of treatment. Space closure can be
carried out on 0.019 × 0.025 in. NiTi wires in non-deep bite cases.26
The finishing wire is 0.019 × 0.025 in. TMA or β III Titanium, and it
expresses adequate torque. The use of SS wires is nowadays extremely
rare in SmartClip brackets.
The 0.019 × 0.025 in. SS wires may be used for retraction and to
express torque in severe deep bite cases and cases, where one has lost
torque during the retraction phase.
The archwire sequence in extraction treatment with 0.018 × 0.025 in.
slot size brackets is similar to the non-extraction protocol.
1. 0.014 HA NiTi or 0.012 in. NiTi (in very severe crowding cases)
3. 0.016 × 0.025 in. HA NiTi or 0.017 × 0.025 in. HA NiTi
4. 0.016 × 0.022 in. SS closing loop archwire
5. 0.017 × 0.025 in. NiTi or 0.017 × 0.025 in. TMA/β III Titanium
In severe crowding cases where lateral incisors are blocked out, and
initial retraction of canine is required to make space for lateral incisor,
0.016 in. SS (in 0.018 in. slot) or 0.018 in. SS (0.022 in. slot) round wire
may be used to partially retract the canine during aligning and
levelling stage of treatment. The 0.016 × 0.025 in. HA NiTi or 0.017 ×
0.025 in. HA NiTi wires ensure the final aligning and levelling and
arch stabilisation. Retraction is carried out on a 0.016 × 0.022 in. SS
closing loop wire with appropriate α and β bends. The finishing wire
is either 0.017 × 0.025 in. NiTi or 0.017 × 0.025 in. TMA/β III Titanium
wire.
Biomechanical challenge of self-
ligation brackets versus conventional
brackets
The orthodontist confronts certain biomechanical challenges while
dealing with the self-ligating bracket system mainly due to the excess
play between the bracket slot and archwire. These biomechanical
challenges are related to rotational control and torque expression.
Rotational control: In self-ligating bracket systems, the interplay of
wire to bracket limits absolute correction of the rotations. Rotation
control is affected by the mesial-distal size of the bracket slot and the
mesiodistal width of the locking mechanism. With the self-ligating
mechanism (clips) on the mesial and distal ends of the brackets, the
SmartClip and Clarity SL appliance systems offer more rotation
control compared to other self-ligating brackets. Positioning the
bracket slightly off-centre on the tooth helps with rotational control.
However, owing to bracket-wire interplay, residual rotations can be a
challenge with self-ligating brackets (Fig. 48.12). Though the lower
incisor brackets in the SmartClip appliance have a reduced depth of
the slot of 0.0270 in., compared to the depth of the slots of rest of the
brackets (0.0275 in.) (Fig. 48.13), the rotation correction problem is not
fully resolved. Therefore, with the SmartClip appliance, tandem wires
are used to correct these rotations.
FIGURE 48.12 Persistent minor crowding in mandibular incisors
following 0.018 NiTi archwire for 8 weeks.
FIGURE 48.13 Reduced depth of slot in lower anterior SmartClip

brackets. Source: Trevisi H. SmartClip self-ligating appliance system:
concept and biomechanics, 1st ed. London: Elsevier.26
The use of tandem archwires is of significance in the levelling and

alignment phase of treatment for the SmartClip and Clarity SL
appliance systems. Following the initial 0.014 in. HA NiTi archwire, it
is recommended to insert a second round nitinol classic archwire,
0.014 in. in the 0.018 in. slot, or 0.016 in. in the 0.022 in. slot. In other
words, when the initial archwire is completely passive, rather than
removing these archwires, a second archwire is placed directly on top
of the initial archwire, forming a tandem archwire. The combination
of these two round archwires provides maximum control of the
vertical, horizontal and rotational dimensions. Proceeding to
rectangular archwires should begin only after the tandem archwires
have been placed and have expressed themselves. Use of the tandem
archwire technique prepares the brackets for simple and easy
insertion of a rectangular archwire.
The tandem wires prepare the brackets for correction of fine
imbrications and maintenance of inter canine width. This situation is
more often encountered in the lower anterior teeth (Fig. 48.14). With
careful consideration, it is possible to attain good control on inter-
canine width. In authors’ experience and research, the change in inter
canine width is minimal when using self-ligating brackets, with or
without tandem wires. The lower incisor proclination was also not
observed.27
FIGURE 48.14 Correction of fine imbrications with tandem wire.

(A) Pre-treatment, (B) mid-treatment, (C) crowding correction with
tandem wires—0.014 NiTi HA + 0.016 NiTi.
It is interesting to note the configuration of the tandem wires in the

lower incisor SmartClip bracket is self-adjusted according to the need,
that is tooth position to be corrected. The two wires position
themselves automatically according to the required tooth movement
that could be either in the buccolingual (B-L) or occlusogingival (O-G)
directions (Fig. 48.15A–B). If tooth requires B-L movement, the smaller
dimension archwire will position itself buccolingually. If tooth
requires more O-G levelling, the archwires will position themselves
occlusogingivally. If the wires position themselves in the O-G
direction, and there is a severe rotation, one of the wires will be more
inclined to disengage spontaneously. In such cases, the authors would
suggest using two 0.014 in. NiTi wires. The second archwire will have
a higher probability of placing itself along one of the horizontal walls
of the slot, and it will, therefore, be held in place by the clip (O-G). Fig.
48.16 shows 0.014 and 0.016 in. wires in tandem will occupy 0.0283 in.
of the bracket slot space, which is beyond the bracket depth, therefore
exerting undue pressure on the clips. However, this will not produce
breakage of the SmartClip.
FIGURE 48.15 (A) Buccolingual disposition of the wires, (B) occluso-

gingival disposition of the wires.
FIGURE 48.16 0.0283 in. space occupied by 0.014 in. NiTi+ 0.016
in. NiTi wires.
This does not produce breakage of nitinol clip. Source: Courtesy Dr
Lars Christiansen.
Torque considerations: Torque is a force system produced by a

twist in an archwire that creates a couple when interacted with a
bracket slot. During orthodontic treatment, torque loss is often seen
during space closure phase of treatment. One needs to understand
that the expression of torque is always less when incorporated in
conventional pre-adjusted bracket systems due to the slope (play)
between the archwire size and the bracket. This is because of the twist
effect of a relatively smaller dimension archwire in a small area of
torque application (bracket slot). Also, the effective torque expressed
on the teeth is always less than the prescribed torque in the bracket
system. The expressed torque will always depend on the surface
contact area of bracket and archwire. The play between a 0.019 × 0.025
in. wire when tied into the 0.022 × 0.025 in. bracket slot is said to be
10.5 degrees (Fig. 48.17), and the play of a 0.017 × 0.025 in. wire tied
into a 0.018 × 0.025 in. bracket slot is 4.5 degrees.
FIGURE 48.17 10.5 degrees play between 19 × 25 in. wire and
0.022 in. bracket slot.
In conventional brackets, the wire is ligated forcefully, and still,

there is a play between the archwire and bracket slot leading to the
lack of complete torque expression. So naturally, in self-ligating
brackets where ligatures are absent, torque expression can be expected
to be much less due to this wire-bracket interplay. Therefore, the
orthodontist has to take extra care during space closure so as not to
lose the torque. This can be mainly achieved by using extremely light
forces for retraction of the teeth.
Some of the options for effective torque expression are:
1. Additional selective torque can be incorporated in the wire

(Fig. 48.18).
2. Retraction wires: Use keyhole loop (Closing loop) archwires
either 0.019 × 0.025 in. SS or β III Titanium. Cinch the wire
while closing spaces. This step achieves an intimate contact of
the wire with the bracket base helping achieve good torque
control during space closure.
3. The manufacturers of Damon and the SmartClip appliance
systems also provide brackets with variable torque
prescriptions, so one can select appropriate torque brackets to
suit the requirements of the malocclusion.
4. As the SmartClip bracket is a twin bracket, the orthodontist can
ligate it whenever required to achieve the necessary torque.
This is called the ‘active on demand’ feature.
5. The SmartClip bracket can house large size wires of 0.0215 ×
0.028 in. The smart clip bracket loses its passive state and
becomes active with these full-size wires. The clip does not
fully close as the bracket depth is only 0.0275 in. Ligatures
become unnecessary in this state as intimate contact of the
archwire bracket system is achieved. But when one uses this
wire, the levelling has to be perfect. Otherwise, the wire will
not be fully seated into the bracket slot, and the patient will
experience excruciating pain.
FIGURE 48.18 Upper palatal torque and lower labial torque.
Initial aligning and levelling with self-ligating brackets: Initial

aligning is rather fast with self-ligating bracket systems (Fig. 48.19).
The initial light wires tend to move the teeth faster because of the free
sliding of the archwires. ‘Walking’ of the archwire is a very common
phenomenon encountered with self-ligating brackets (Fig. 48.20).
Therefore, the free ends of the archwire should be cinched back
loosely, or crimpable stops should be placed anterior to the crowding.
Dimpled archwires also prevent undue walking (Fig. 48.21).
Alternatively, a ball of the composite can be bonded to the archwire
between the central incisors that serves the same purpose as the
dimpled archwire.
FIGURE 48.19 Very quick initial alignment and levelling.

FIGURE 48.20 Walking of archwire.
FIGURE 48.21 Dimpled NiTi initial aligning wire.
Space closure mechanics with self-ligating appliances: In all

systems of self-ligating brackets, it is recommended that the elastic
chain should be engaged to the brackets under the archwire for
maximum efficiency and reduced friction in anterior space closure.
During retraction mechanics, space may open up between the
anterior teeth if the teeth are not consolidated with ligature wire. This
is due to the pull of trans-septal fibres (Fig. 48.22). Therefore, it is
advisable to consolidate all the anterior teeth with ligature wire or
power chain, under the archwire.
FIGURE 48.22 Lack of consolidation of anterior teeth with

ligature wire leading to opening of anterior spaces during
retraction mechanics.
Extraction space closure should be carried out with the use of

extremely low forces.28,29 The Sentalloy NiTi coil springs deliver a
constant amount of force. Alternatively, Alastik modules and metal
ligatures can be used for space closure as they too deliver light
continuous forces. This will efficiently close the extraction spaces and
also prevent anterior torque loss. Space closure can be carried out on
0.019 × 0.025 in. SS or NiTi wires.
FIGURE 48.23 Bracket slots tipped toward extraction sites.
Source: Courtesy Dr Robert Waugh.
One needs to understand that there should be no or minimal

friction during initial alignment, that is tipping, rotational and in-out
movements, cuspid retraction with lacebacks and all forms of sliding
mechanics used for space closure and space opening. But friction is
required during torque control, in maintaining the corrected rotations,
tip and in-out control and in maintaining arch form.
FIGURE 48.24 Bracket slots tipped towards extraction sites.

Source: Courtesy Dr Robert Waugh.
To optimise the use of sliding mechanics with self-ligating brackets,

the wire should lie completely passive in the bracket slots before any
retraction force is applied. Sufficient time must be allowed for the
expression of distal root movement of the teeth during retraction. The
active tie back, elastic chain or coil spring should not be changed
frequently. For retraction and torque settling to be effective and
efficient, once space closure is done, the clinician should leave the
passive tieback for 6 weeks, so spaces do not open again; this
expresses built-in torque and permits tissue adaptation. A list of
clinical tips for efficient biomechanics with SLB system is compiled in
Box 48.5.
Box 48.5 Some efficiency tips for self-ligating

brackets
1. Archwire sequence is crucial and should be followed according

to the manufacturers guidelines.
2. Maximum correction of the position of the teeth should be
achieved on initial light wires.
3. Use cooled HA NiTi wires. This helps in more comfortable
insertion and removal of the wire in any bracket system. The
cooled wire gently clicks into the bracket without pushing on
the adjacent brackets. A simple way to make the wire cold is to
tell the patient to swish cold water (50 °F/10 °C), before
insertion of the wire.
4. Frequent wire changes should be avoided to allow full
expression of the each of the wire.
5. Whenever needed, friction can be introduced into the self-
ligating system during treatment by selectively tying the wire
into the bracket slots.
6. During space closure with NiTi or TMA,
a. High torque brackets for upper and lower canines
should be used.
b. The slots should be tipped toward the extraction site
at initial bonding (artificial gable bends) (Figs. 48.23
and 48.24).
c. Use lace-backs early to avoid flaring of anterior teeth.
d. Allow the initial rectangular wires to level out
passively before initiating space closure.
e. Reinforce archwires with modified oscar tubing. Oscar
tubing can be made by cutting a 0.022 × 0.025 in.
rectangular tube and chamfering the ends (Fig. 48.25).
Evidence on claims of self-ligating
brackets
Many claims are made by the manufacturers in the promotion
literature regarding the advantages of SLB, sometime claiming
superiority of one type of self-ligating bracket over another. For self-
ligation, the core features of secure archwire engagement, lower
resistance to sliding during initial stages, more rapid and convenience
of archwire ligation removal and reduction in clinical chair time
during wire change are supported in the literature. Other claims are
discussed below.
1. More certain full archwire engagement

Full engagement is a feature of self-ligation because a clip/slide
prevents any unintentional partial engagement. Additionally,
there is no problem of decay of the force as with elastic
ligatures. Wire ligatures do not stretch to the extent that
elastomeric modules do and therefore meet the requirement of
full engagement, but they are time intensive in their
application.
2. Low friction between the bracket and the archwire
self-ligating bracket reduces friction dramatically compared to
elastomeric rings with conventional brackets and seems to be
an inherent characteristic of self-ligating brackets.30 When
small round wire lies passively in the slot, the self-ligating
brackets produce significantly less friction than conventionally
ligated brackets.22,31
However, with large rectangular wires, the friction is not lowered
when compared with the conventional brackets.32,33
A systematic review concluded that there is insufficient evidence
to claim that with large rectangular wires, in the presence of
tipping and/or torque and arches with considerable
malocclusion, self-ligating brackets produce lower friction
compared with conventional brackets.34
3. Less chairside assistance needed
The operator can open and close the self-ligating brackets easily
without any assistance.
4. Faster archwire removal and ligation
The self-ligating brackets were developed to speed up the process
of archwire ligation. Several authors have shown self-ligating
brackets to be better in this respect. Harradine35 compared the
speed of ligation in Damon SL and conventional brackets and
reported that single archwire required an average of 9 sec less
time to close the Damon slides than was required to ligate the
conventional brackets. Similarly, a single archwire required an
average of 16 sec less time to open the Damon slides than was
required to remove the conventional ligatures. In another
study, the authors have shown time reduction of 10–12 min and
2–3 min per patients with SPEED brackets compared with tying
steel ligatures and modules respectively.36 Other studies have
also supported the improved speed of archwire changes when
using self-ligating brackets.20,37
5. Pain and discomfort
Discomfort is a potential side effect during fixed appliance
therapy and may influence the treatment outcome and desire to
undergo treatment. Proponents and manufacturers of self-
ligating bracket system suggest that lower force levels are
produced during tooth alignment which is biologically
compatible and, therefore, possible pain reduction associated
with orthodontic tooth movement.
Pain perceived using self-ligating brackets and conventional
brackets has been compared in published clinical trials.38–42
None of these studies provides sufficient evidence that self-
ligating brackets are superior to conventional brackets
regarding pain reduction (Box 48.6).
6. Initial orthodontic alignment
An assumption has been made that due to low friction, alignment
of teeth occurs more rapidly compared to conventional
brackets. Various clinical trials have tried to find out evidence
on the efficiency of SL brackets by considering the rate of
mandibular incisor alignment.38,39,43–45 Considering these trials,
there is no conclusive evidence to prove that treatment with
self-ligating brackets brings about a faster alignment of teeth in
initial stages (Box 48.7).
7. Periodontal health
According to the manufacturers and some studies, self-ligating
brackets allow better hygiene. They claim that self-ligating
brackets are less susceptible to bacterial colonisation due to
their shape and absence of elastomeric and metal ligatures.
The study reported the higher level of bacteria on tooth surfaces
with conventional brackets ligated with elastomeric compared
with the self-ligating brackets using ATP-driven
bioluminescence. Though the results of this 5-week study
indicated that self-ligating brackets promote less retention of
oral bacteria, longer clinical trials were recommended.46 Other
studies evaluating the effects of self-ligating brackets and
conventional brackets with stainless steel ligature on dental
plaque retention and microbial flora found similar changes in
the number of micro-organisms around both the bracket
systems.47,48
Systematic reviews also failed to provide substantial evidence
highlighting the need for long-term follow-up.49 Non-
significant differences in the periodontal status of adolescents
undergoing orthodontic treatment with either conventional or
self-ligating bracket were detected.50
8. Treatment duration and number of visits
Initial studies comparing the effectiveness and efficiency of
Damon SL to the conventional brackets showed that the
patients treated with Damon SL had significantly lower
treatment time and required significantly fewer
appointments.35,51 However, the randomised controlled trials
comparing their treatment efficiency found no significant
difference between treatment with a self-ligating bracket
system and a conventional ligation system52–54 (Box 48.8).
FIGURE 48.25 Oscar tubing on archwires during sliding on NiTi

wire.
Box 48.6 Studies related to pain and discomfort

with self-ligating brackets
Box 48.7 Studies related to initial orthodontic
alignment with self-ligating brackets
Box 48.8 Studies related to treatment duration
and number of visits
Key Points
Self-ligating brackets are not a new concept. Self-ligating brackets
have undergone numerous modifications and transformation over the
last 35 years. Despite claims regarding the clinical superiority of self-
ligating brackets, there is insufficient evidence to support their use
over the conventional appliance systems for the duration of treatment
or fewer visits.
Self-ligating brackets are new tools which permit one more clinical
option for both the orthodontist and the orthodontic patient. They
should be chosen according to clinician’s skill and experience rather
than on the promises of better or more efficient outcomes. The self-
ligating brackets certainly offer ease of placement and removal of
wires and therefore less chair or clinical assistance besides freedom
from poking of sharp ligatures, thereby enhancing patient comfort.
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35. Harradine NW. Self-ligating brackets and treatment
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36. Berger J, Byloff FK. The clinical efficiency of self-
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37. Turnbull NR, Birnie DJ. Treatment efficiency of
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38. Miles PG, Weyant RJ, Rustveld L. A clinical trial of
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alignment. Angle Orthod. 2006;76(3):480–485: May;
39. Scott P, Sherriff M, Dibiase AT, Cobourne MT.
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bracket system: a randomized clinical trial. Eur J
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40. Fleming PS, Dibiase AT, Sarri G, Lee RT. Pain
experience during initial alignment with a self-
ligating and a conventional fixed orthodontic
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41. Pringle AM, Petrie A, Cunningham SJ, McKnight M.
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levels associated with 2 orthodontic fixed bracket
systems. Am J Orthod Dentofac Orthop.
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43. Pandis N, Polychronopoulou A, Eliades T. Self-
ligating vs conventional brackets in the treatment of
mandibular crowding: a prospective clinical trial of
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Makou M, Eliades T. Salivary Streptococcus mutans
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1 treatment efficiency. Angle Orthod.
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25853795 2015.
SECTION X
Non-extraction treatment
Chapter 49.1: Non-extraction treatment with maxillary

expansion and interproximal reduction
Chapter 49.2: Non-extraction treatment with non-compliance
molar distalisation
CHAPTER 49.1
Non-extraction treatment with
maxillary expansion and
interproximal reduction
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Factors influencing extraction decision
Non-extraction cases
Methods to gain space to resolve limited crowding and
protrusion
Preservation of leeway or ‘E’ space for resolution of crowding in
the lower arch
Expansion of the narrow maxilla and arch development
Diagnosis of maxillary transverse deficiency and case selection
Clinical evaluation of a case for maxillary expansion
Study models
Evaluation of dental inclinations, arch widths and
symmetry
Clinical and histological basis of maxillary expansion
CBCT classification of mid-palate growth
Indications for RME
Design of RME
Manipulation of RME
Structural and functional effects of RME
Maxillary skeletal effect
Nasal cavity
Activation schedule
Quad helix/tri-helix appliance
NiTi expander
Mini-implant attached rapid palatal expansion
Retention schedule
Introduction
Indications
Contraindications
Steps in interproximal reduction
Precautions and complications
Techniques of IPR
Key Points
Introduction
Non-extraction orthodontic treatment implies the correction of
malocclusion and thereby improvement in facial profile, aesthetics
and smile without sacrificing any permanent tooth/teeth.
Historically, orthodontic treatment and balance of profile were
considered by maintaining a full complement of teeth. Space required
to align the crowded teeth and retraction to correct protrusion was
expected to be gained by ‘expansion’ using appliances such as ‘E arch’
which would simultaneously expand the jaw and allow the alveolus
to develop as the teeth were aligned.
Several concerns were raised with this method and philosophy of
treatment mainly due to poor profile outcome, unstable occlusion,
relapse of crowding and iatrogenic undesirable periodontal effects in
many of the treated cases. In many instances, poor facial aesthetics
were the result of bimaxillary protrusion, which was created to house
the full dentition on poorly developed denture bases.1,2
Work and research of Charles H. Tweed, P. R. Begg and Robert
Strang3–5 supported reduction of dental units to relieve crowding, and
to improve protrusion and stability of occlusion.
The hesitation to accept extraction for suitable cases slowly turned
into a routine orthodontic practice. The four first premolar extractions
followed by a course of fixed orthodontic appliance became a routine
orthodontic treatment. However, overzealous extraction of premolars
in adolescent patients led to poor treatment outcome after growth was
completed. Other problems were as follows:
1. Dished in faces; these children grew up with so-called

‘orthodontic profiles’.
2. Large dark spaces in buccal corridors.
3. The stability of lower incisor crowding was not always
guaranteed because many other factors influenced the stability
of dentition.
Premolar extraction treatment has also been linked with
temporomandibular joint (TMJ) disorders. Witzig and Spahl6
suggested that premolar extraction caused posterior displacement of
the condyle in the glenoid fossa, resulting in the perforation of the
disc which discouraged orthodontists to think about extraction plans
and think of alternative treatment modalities.
Factors influencing extraction decision

The decision to extract or not to extract should not be an ‘empirical’
one but based on sound judgment derived after a thorough clinical
evaluation and study of the orthodontic records. Important
considerations are as follows:
1. Space requirements in the arch.

2. Profile of the patient, and possible soft tissue thickness, posture
and thickness of lips, shape and prominence of nose, ethnicity
of the subject, and most importantly the remaining growth of
the craniofacial skeleton.
3. Remaining active growth and age changes of the ‘soft tissue’
integument have considerable bearing on the extraction
decision. The growth of the facial skeleton and soft tissue also
shows a great deal of sexual dimorphism and it should form a
major consideration.
4. In a case of mixed dentition, it is imperative that due
consideration be given to molar relationship, possible
transverse relationship of the maxilla/mandible (dentition), as
well as the type of growth/craniofacial type, that is, a
horizontal growth pattern or vertical.
5. ‘Leeway space’ and its best utilisation in the attainment of class
I molar relationship and resolution of crowding should be
foreseen based on accurate ‘tooth size’ discrepancy, growth
potential and growth trend of the face.
6. A case with apparent hereditary ‘tooth size’ discrepancy and
potential crowding of more than 8 mm, which cannot be
treated without extraction, should not be attempted for non-
extraction treatment.
In the last two decades, orthodontic treatment strategies have been

swinging towards non-extraction treatment and several methods,
which were not so popular before, were lately modified for adaptation
to current practice. Intraoral molar distalisation is one such example.
Non-extraction cases
A child with skeletal class I bases and acceptable profile, with minimal
space requirements to relieve crowding or mild protrusion, can
possibly be best treated without sacrificing permanent tooth/teeth.
Methods to gain space to resolve
limited crowding and protrusion
1. Use of ‘leeway space’ or ‘E’ spaces.
2. Maxillary skeletal expansion and arch expansion:
a. Rapid maxillary expansion
b. Arch development with slow expansion devices
and wire framework expansion appliances such as
quad helix and its variations.
3. Interproximal reduction of tooth substance.
4. Maxillary molar derotation.
5. Molar distalisation.
6. Proclination of teeth on denture bases. The retroclined anterior
teeth can be proclined to relieve 2–3 mm of crowding, within
permissible limits of soft tissue accommodation without
compromising periodontal support and thickness of labial
cortical plates.
7. Functional appliances to correct the sagittal discrepancy,
transverse development and enhancing the volume of the oral
cavity. Frankel appliance and twin block with maxillary
expansion screw are known to produce transverse maxillary
expansion and arch development.
Preservation of leeway or ‘E’ space for
resolution of crowding in the lower
arch
‘E’ space can be effectively utilised to relieve crowding up to 4 mm. E
space is preserved by holding the molars from migrating mesially and
thereby utilising the E space either for the relief of crowding or for
reducing proclination of anterior teeth. The lingual arches of 0.036-in.
SS wire are prepared as passive arches. These arches are soldered on
molar bands of first molars and contact cingulum of mandibular
incisors (Fig. 49.1.1).
FIGURE 49.1.1 (A) Lingual arch to preserve arch length in the

mandible. Leeway space can be used to resolve minor crowding. (B)
The distal lingual rotation of the maxillary first molar may lead a buccal
class II molar relation. The active transpalatal arch can readily correct
distal lingual rotation leading to a class I occlusion.
Brennan and Gianelly preserved ‘E’ space with lingual arch in

children with 4–5 mm incisor crowding and could resolve it in 68% of
their sample and 19% had adequate space with an only marginal
additional arch length increase of 1 mm/side. The maxillary arch was
not required to be expanded.7
During follow-up of 107 patients, there was a marginal increase in
inter-canine and inter-premolar width and a very slight 0.4 mm loss of
leeway space. The stability of such an outcome is expected to be
satisfactory as reported by Dugoni et al. in their study of 9 years post-
retention8 follow-up.
The common modalities are lower lingual arch and upper
transpalatal arch or Nance button. Fully bonded fixed appliance
therapy is successfully used in cases with minimal or no tooth-size
arch length discrepancy (TSALD).
A case of non-extraction treatment is presented in Fig. 49.1.2.
FIGURE 49.1.2 (A) Pre-treatment (B) Post-treatment. A young girl

treated for minor deviations of class II malocclusion (right side) spacing
and rotations with fixed mechano-therapy.
Expansion of the narrow maxilla and
arch development
Dental and skeletal expansion of the maxilla is required for the
adjustment of transverse discrepancy with the mandible. Expansion of
the maxilla is mostly indicated to correct a buccal unilateral or
bilateral cross-bite and to gain arch length for the relief of minor
crowding or reduce proclination of the maxillary anterior teeth.
Maxillary skeleton expansion constitutes a significant component of
the comprehensive treatment plan to provide better nasal respiration
in children with increased nasal resistance exhibiting as mouth
breathing habit/snoring or a partial obstructive sleep apnea (OSA).
In moderate crowding subjects, the decision of non-extraction
treatment with expansion or extraction approach depends on soft
tissue profile and hard tissue structures. For a patient with a large
nose and chin, it is advisable to expand the arch, so that labiodental
sulcus does not diminish. Also in patients with thin lips, expansion is
preferable over extraction treatment to create fuller lips and decrease
dark spaces.
However, in some situations, significant expansion of the dental
arches may not be feasible. These conditions are mainly the limitations
posed by the anatomy of the dental alveolus where dental expansion
will lead to their roots moving labially or buccally creating
fenestration or dehiscence of the cortical plates and thus endangering
their periodontal health.
Over-expansion of the arches can move teeth ‘off their bony bases’
and into positions where the ‘soft tissue equilibrium is changed’, and
the results are not stable.
During the early mixed dentition stage (children up to ages 9–10),
maxillary expansion may require the use of lower forces because the
midpalatal bony suture has not yet fused. In children aged 12 years
and above who are in late permanent dentition, greater forces may be
required to achieve maxillary expansion. On an average, every 1 mm
increase of the inter-premolar width leads to gain in the arch length by
0.7 mm.9
Diagnosis of maxillary transverse
deficiency and case selection
Transverse dimension diagnosis includes a systematic evaluation of
the face and dentition in the frontal view, the sagittal dental
relationships and the transverse skeletal relationships.
Clinical evaluation of a case for maxillary

expansion
Frontal examination of the face requires careful attention to chin
position for any lateral deviation, which may be indicative of a
unilateral cross-bite. A deviated chin needs detailed evaluation to
arrive at the cause of facial asymmetry. However, immediate concern
in a growing child should focus on any functional interferences of
occlusion or a narrow maxilla. A narrow maxilla may lead to lateral
jaw deviation which can clinically exhibit as a unilateral cross-bite. In
primary or early mixed dentition, interference caused by a deciduous
canine or retained incisor can cause a lateral shift of the mandible. The
mere fact that most unilateral cross-bites do not spontaneously correct
and that functional changes are rarely detected in children; an
untreated lateral shift can develop into asymmetry of the mandible by
adulthood.10 If the cross-bite and the functional shift are treated
during early mixed dentition, the asymmetry can be largely
eliminated.11
In the absence of a lateral shift, chin asymmetry and unilateral
cross-bite are suggestive of a unilateral skeletal asymmetry. Bilateral
cross-bite occlusion may be seen without lateral shift and chin
asymmetry.
In sagittal advancement, transverse discrepancies can be relative or
absolute. A relative transverse discrepancy exists when the posterior
teeth show inappropriate transverse cusp–fossa relationships in
centric relation, but properly occlude when the canines are brought in
class I occlusion. For example, some class III malocclusions exhibit
posterior cross-bites that disappear when the mandible is brought to
occluding in class I canine relationship. This would be considered a
relative transverse discrepancy. In contrast, if a cross-bite still exists
when the casts are articulated into a class I canine relationship, then
the transverse discrepancy is absolute.
Study models
Evaluation of dental inclinations, arch
widths and symmetry
The dental buccal cross-bite can be present with a normal transverse
width of the maxilla. The teeth in the buccal segment are palatally
inclined, leading to dental cross-bite. However in skeletal cross-bite,
palatal vault is constricted and dentoalveolar process mostly lean
buccally. The buccal crown inclinations of the molars seen at 7 years
of age progressively become perpendicular to the transverse occlusal
plane.12 Any deviation from this trend indicates dentoalveolar
compensations. Posterior dental compensations can also occur as
variations in arch form and symmetry.
The maxillary arch in the cross-bite side is usually narrower than
the non-cross-bite side, and the mandibular arch on the cross-bite side
is generally broader than the non-cross-bite side. A transpalatal width
of 35–39 mm is suggestive of the bony base, adequate to accommodate
a permanent dentition of average size.13
The rule of 34/27. Handelman reported norms of trans-arch widths
of 34.3 ± 2.8 mm for the first molar and 26.8 ± 2.3 mm for the first
premolar. The mandibular widths were 32.4 ± 2.9 mm for the first
molar and 25.1 ± 2.8 mm for the first premolar. This data has evolved
into the 34/27 rule for the maxilla and 32/25 for the mandible. A
maxilla with trans-arch widths below 34 mm for the first molar and
27 mm for the first premolar would benefit from the expansion. A
mandible with trans-arch widths below 32 mm for the first molar and
25 mm for the first premolar would benefit from the expansion.14
Maxilla–mandible differential. The expansion required can be
determined by measuring a distance between the most gingival
extension of buccal grooves on the mandibular first molars on either
side. When the groove do not distinct terminal on the buccal surface,
measure between points on the grooves located in the middle of the
buccal surfaces.
The maxilla is measured as a distance between the tips of the
mesiobuccal cusps of the maxillary first molars, The average maxilla–
mandible differential in persons with normal occlusion is +1.6 mm for
males and +1.2 mm for females. One should overexpand the molars 2–
4 mm beyond the required width to allow for post-expansion relapse.
These estimates assume a malocclusion will be treated to a class I
molar relationship.
Maximum limit of expansion varies between individuals and
according to the severity of the malocclusion, but 10–12 mm should be
considered as the upper limit of maxillary skeletal expansion
correction.15
Posteroanterior radiographs are helpful in assessing the presence and
magnitude of maxillary or mandibular asymmetry and transverse
discrepancies.16 This approach compares the left-to-right mandibular
anteogonial width to the left-to-right maxillary jugal width and
estimates skeletal transverse discrepancies and amount of expansion
needed. The maxillomandibular differential is estimated between the
mandibular width (AG–GA) and maxillary width (J–J’). A transverse
differential of about 20 mm is considered satisfactory.17 The ratio of
the maxilla to mandible is about 80% and the ratio of the nasal cavity
to maxilla ranges from 40% to 42%. Ruest has shown that class II div.
1 malocclusions are 3 mm smaller in the maxillary skeletal width than
of class I (normal) and at age 18.18
Clinical and histological basis of
maxillary expansion
In general, the effect of expansion on the maxillary bases diminishes
as age advances. Patients age governs the choice of expansion
appliance. Therefore it is pertinent to study the fusion of the palatine
suture. Melson studied postnatal development of the hard palate by
histologic and microradiographic means on autopsy material aged 0–
18 years. The growth in length of the hard palate until the age of 13–15
was due to growth in the transverse suture and to apposition on the
posterior margin of the palate. After this age, the sutural growth was
found to cease, whereas the apposition seemed to continue for some
years.19 Based on her findings she grouped the postnatal development
of the palate into three stages.
Postnatal stages of palatal development and suture fusion.
• Stage I. Covering the infantile period, the mid-palatal suture is

broad and ‘Y-shaped’ with the vomerine bone placed in a ‘V-
shaped’ groove between the two halves of the maxilla.
• Stage II. The stage II corresponds to the juvenile period. The
suture becomes more wavy and longer in the vertical aspect.
The junction between maxilla and palatine bone becomes
higher and assumes more of a ‘T-shape’.
• Stage III. The stage III corresponds to the adolescent period.
The suture is characterised by a more tortuous course with
increasing interdigitation which mechanically interlocks as in
a ‘jigsaw puzzle’. The interdigitation of the articulation
between the palatine bone and the maxilla did not permit
separation without the occurrence of fracture.19 Closure of
mid-palatal suture progresses more rapidly in the oral than in
the nasal surface of the palatal vault, and the intermaxillary
suture starts to close more often in the posterior than in the
anterior part.20
CBCT classification of mid-palate growth
A novel method for individual assessment of mid-palatal suture
morphology using cone beam computed tomography defines five
stages of maturation of the mid-palatal suture.21
• Stage A. The mid-palatal suture is almost a straight high-

density sutural line with no or little interdigitation.
• Stage B. The mid-palatal suture assumes an irregular shape
and appears as a scalloped high-density line. Patients at stage
B can also have some small areas where two parallel,
scalloped, high-density lines close to each other and separated
by small low-density spaces are seen.
• Stage C. The mid-palatal suture appears as two parallel,
scalloped, high-density lines that are close to each other,
separated by small low-density spaces in the maxillary and
palatine bones (between the incisive foramen and the palatino
maxillary suture and posterior to the palatinomaxillary
suture). The suture can be arranged in either a straight or an
irregular pattern.
• Stage D. The fusion of the mid-palatal suture has occurred in
the palatine bone, with maturation progressing from posterior
to anterior. In the palatine bone, the mid-palatal suture cannot
be visualised at this stage, and the parasutural bone density is
increased (high-density bone) compared with the density of
the maxillary parasutural bone. In the maxillary portion of the
suture, fusion has not yet occurred, and the suture still can be
seen as two high-density lines separated by small low-density
spaces.
• Stage E. Fusion of the mid-palatal suture has occurred in the
maxilla. The actual suture is not visible in at least a portion of
the maxilla. The bone density is the same as in other regions of
the palate.
Subjects from 5 to almost 11 years of age did not exhibit any fusion
of palate.
Stages A and B typically were observed upto 13 years of age,
whereas stage C was noted primarily from 11 to 17 years but
occasionally in younger and older age groups. Fusion of the palatine
(stage D) and maxillary (stage E) regions of the mid-palatal suture was
completed after 11 years only in girls. From 14 to 17 years, 3 of 13
(23%) boys showed fusion only in the palatine bone (stage D). Adults
most frequently had a fusion of the mid-palatal suture (stages D
and E).
Accordingly, stages A and B, a conventional rapid maxillary
expansion (RME) approach, would have less resistance to forces and
probably more skeletal effects than at stage C, when there are many
initial ossification areas along the mid-palatal suture. Patients in
stages D and E might be better treated by surgically assisted RME
because of the fusion of the mid-palatal suture that has already
occurred partially or fully, hampering the RME forces from opening
the suture21 (Fig. 49.1.3A, B).
FIGURE 49.1.3 Stages of mid-palate fusion based on CBCT data.
(A) Schematic drawing of the maturation stages observed in the mid-
palatal suture. It is an over simplification of the sutural morphology and
should not be used for diagnosis. Sutural morphology can vary
between stages, and diagnostic criteria are based on the decision tree
in B and the definitions of the five stages. (B) Decision tree for
classification of the maturation stages of the mid-palatal suture.
Source: Angelieri F, Cevidanes LH, Franchi L, Gonçalves JR,
Benavides E, McNamara JA Jr. Midpalatal suture maturation:
classification method for individual assessment before rapid maxillary
expansion. Am J Orthod Dentofacial Orthop 2013;144(5):759–69.
Emerson C. Angell documented the first case of orthodontic maxillary
expansion to correct a transverse deficiency in 1860. He used a
jackscrew appliance in a 14-year-old girl to create space for a labially
displaced canine.22 Maxillary expansion appliances can be broadly
grouped into two categories: fixed or removable appliances. Typical
expansion screw device consists of the long body divided into two
halves. Each half has a threaded inner side that receives one end of a
double-ended contrarotating threads screw. The screw has central
bossing with four holes. Each turn yields approximately one-fourth of
a millimetre of activation to the appliance.
Based on the expansion protocol an expander can be called a rapid
expansion appliance or a slow expansion appliance (Fig. 49.1.4A–E).
FIGURE 49.1.4 Modalities of maxillary arch expansion.
(A–D) Parallel expansion screws. (A) Upper removable appliance with
maxillary expanders. (A′) The parallel screw. Conventional standard
removable expansion appliance. The pitch of the screw is 1 mm. Each
quarter turn expands the arches by 0.25 mm. (B) Maxillary expansion
with Z spring to align minor crowding. (B′) Corrected malocclusion. (C)
Limits of dental expansion. (C’) Banded HYRAX expander. (D) Acrylic
and framework HYRAX appliance can be cemented or bonded. (E)
Banded fan shaped RME appliance for greater anterior expansion.
Expansion of the upper jaw is termed ‘rapid’ when expansion
appliance is activated at a rate of 0.5–1 mm/day which is made
possible by either two quarter turns of the screw/day or two quarter
turns twice in a day.22
Rapid maxillary expansion (RME) results in rapid correction of the
cross-bite occurring in 2–6 weeks. A midline diastema may appear
which is suggestive of the mid-palatal split. This diastema would close
spontaneously due to the recoil of the stretched trans-septal group of
gingival fibres. Slight over expansion of the maxilla whereby lingual
slopes of maxillary lingual cusps touch mandibular buccal cusps is a
desired clinical practice (Fig. 49.1.5). This over-expansion makes
allowance for the relapse particularly of the buccal tipping of the
molars. Following the completion of the expansion, the appliance is
left passive to serve as a retainer for another 6 months.
FIGURE 49.1.5 Clinical effects of RME.
(A) Pretreatment. A case of the narrow maxilla and lateral shift of the
mandible and anterior cross-bite associated with mouth breathing and
recurrent throat infection. (B) The child was treated with RME and
facemask. (B′, B″) Note midline diastema, and signs of midline split on
occlusal radiographs. (C) Spontaneous closure of midline diastema due
to stretch generated by the trans-septal group of gingival fibres.
Mid-palatal suture opening during orthodontic treatment with RME

amounted to 12%–52.5% of the total screw expansion. After the
treatment of RME, the mid-palatal suture seems to undergo
recalcification, so the expansion of the mid-palatal suture is stable.
This systematic review could not find consistent evidence on whether
the mid-palatal sutural opening was parallel or triangular.23
The osteogenic reaction in the expanded mid-palatal suture and
orthodontically induced osteogenesis in the PDL of adjacent incisors
show different reactions. The widened PDL resulted in direct
osteogenic induction of new bone, whereas the adjacent expanded
suture experienced haemorrhage, necrosis and a wound healing
response. Vascular invasion of the blood clot in the expanded suture is
a prerequisite for new bone formation.24
Indications for RME
1. A narrow maxilla in absolute terms. A discrepancy of 4 mm or
more discrepancy between the maxillary and mandibular first
molar and premolar widths.14
2. Class III malocclusion with narrow maxilla/pseudo class III of
dental and skeletal in nature.
3. A narrow maxilla in conjunction with nasal stenosis.
4. A severe cross-bite involving multiple teeth.
5. When the maxillary molars are buccally inclined, a
conventional dentoalveolar expansion will tip them further
into the buccal musculature, therefore a rapid expansion is the
modality of choice. In another situation of dentoalveolar
compensations to a narrow maxilla, the mandibular molars
may be lingually inclined. An attempt to place the mandibular
dental segments on skeletal base would result in cross-bite and
a need for maxillary skeletal expansion.
6. RME in the early mixed dentition appears to be an effective
procedure to enhance the rate of eruption of palatally
displaced maxillary canines (65.7%) when compared with an
untreated control group.25
1. In general, subjects with anterior open bites, steep mandibular
planes and convex profile are not indicted for RME.14 An
increased mandibular plane angle is not an absolute
contraindication for RME therapy.26
2. Age. The upper age limit is when the synostosis of the mid-
palatal suture has occurred. However, with adjunctive
surgery, this is surmounted.
3. Poor periodontal health provides insufficient anchorage
support.
4. A condition where maxilla and mandible both are constricted
with a long face, this is a normal condition for this type of face.
Design of RME
RME appliance can be broadly grouped into a bonded appliance or
banded appliance the way these are retained in the mouth.
The banded expansion appliance is attached to teeth through bands
on the maxillary first molars and first premolars. The original design
of RME proposed by Hass included an additional cover of the palatal
vault with acrylic. This appliance design has been discarded due to
the difficulty associated with keeping it clean, more so on the palatal
surface. Consequently, all wire framework hygienic expander or
HYRAX appliance was introduced.
Banded appliances cannot be used in deciduous and early mixed
dentition. The alternate appliance design involves a wire framework
and acrylic components which help to cement the appliance. Similar
RME appliance design is also indicated in subjects with high FMA.
The molar extrusion can be minimised by extending the occlusal
acrylic over buccal surfaces.
This appliance design is particularly useful in class II conditions, as
molar extrusion would cause a backward and downward rotation of
the mandible resulting in an increase in facial convexity and the
vertical dimension of the lower face.27 The bonded expansion
appliance provides a bite block type of effect to facilitate the correction
of anterior cross-bite in class III young subjects.28 The bonded
appliance design can also be used in the permanent dentition for its
ease of delivery and some useful clinical effects. The need for the
placement and removal of separation elastics, band adaptation and
transfer into alginate impression, precision wire bending and
soldering is eliminated.
Cemented hygienic rapid expansion (HYRAX) appliance. The
design of the cemented HYRAX appliance is extremely critical: the
acrylic component of the plate should cover the crowns of the teeth,
leaving only 1 mm of clearance at the gingival margins along the
buccal and palatal aspects. This ensures a maximum surface area for
retention and sufficient clearance at the gingival margins to allow
maintenance of good oral hygiene. The acrylic extensions should have
a chamfer finish to minimise food retention. Acrylic occlusal coverage
does not need to be more than 1–2 mm in thickness and holes should
be drilled into it to allow excessive cement to escape. With the
introduction of contemporary glass ionomer cement, the retention of
cemented expanders has improved significantly, and there is no
longer need to use composite or acrylic-based materials that require
acid-etching procedures.
Whatever the type of appliance, the screw should be mounted high
in the palatal vault as much as possible. The screw is mounted in the
midline of the vault with the thread axis in line with the anterior
border of the first permanent molars.
Manipulation of RME
When the cemented or banded maxillary expander is inserted, the
expansion is not initiated on day 1 so as to allow the patient to get
accustomed to the appliance.
The rapid expansion of the maxilla is started at the next
appointment scheduled a week later. The rate of expansion is
0.5 mm/day, that is one-quarter turn twice daily. To facilitate easier
turning of the screw by the patient, the screw is so mounted that the
thread is rotated from front to back. The patient should be reviewed
every week during the active activation of the appliance. The
appliance has the maximum capability of approximately 50 turns,
although that much activation is rarely needed. Expansion of 10–
12 mm (40–48 quarter turns) should be considered as the upper limit
of maxillary skeletal expansion correction.7
Structural and functional effects of
RME
Maxillary skeletal effect
RME results in its effect on the mid-palatal suture. RME also leads to
an activity at the suture sites which attach the maxilla with the
cranium. RME splits the maxilla in two halves at midpalatal suture in
a V form. The apex of the V-shaped split of the maxilla lies at its
frontonasal suture and base at the mid-palatal suture. In AP direction,
the base of V-shaped slit lies between 2 central incisors and apex at
posterior nasal spine. The transverse skeletal maxillary increase is
significant at a younger age and also stable (prepubertal growth peak)
than skeletally mature individuals (pubertal and postpubertal growth
peak). The long-term transverse skeletal maxillary increase is
approximately 25% of the total appliance adjustment (dental
expansion) in prepubertal adolescents but not significant for
postpubertal adolescents. Quality studies on long-term effects of RME
on sagittal and vertical changes in maxilla and mandible are lacking.29
Alveolar bone: Alveolar bone in the area adjacent to anchor teeth,
shows buccal bending. This is due to the resilient nature of alveolar
bone.
Maxillary anterior teeth: The appearance of midline spacing is the
most reliable clinical evidence of maxillary separation. By 3–5 months
midline diastema closes as a result of recoil of trans-septal fibre
traction.
Maxillary posterior teeth: The buccal segment shows some tipping
and extrusion.
Mandible: The maxillary expansion leads to tipping and extrusion
of the buccal segment which directly affects the mandible leading to a
downward and backward rotation of the mandible. This can be
measured as an increase in mandibular plane angle.
Nasal cavity
RME leads to an increase in nasal volume. An increase in the width of
the nasal cavity can be quantified on PA cephalogram, and it is
maximum at the base of the nasal cavity. A similar gradient is also
found in an anteroposterior direction with the greatest increase being
in the anterior region. RME has a potentially positive effect on the
nasal septum asymmetry during childhood, but no significant change
in adolescence from RME in patients with nasal septal deviation
(NSD) should be expected.30
The unwanted effect of the expansion is an extrusion of the buccal
segment. However, these effects could be little and probably
transitory.
The bonded/cemented design of maxillary expansion appliance is
now an accepted and viable appliance of choice for the narrow
maxilla, regardless of the patient’s craniofacial pattern. The patients
with a vertical facial pattern are not an absolute contraindication for
receiving the RME.
In growing subjects, heavy forces in the short-term evaluation
moved anchored teeth and the alveolar bone at the same time and
with the same magnitude and direction. In the long-term evaluation,
an uprighting of anchored teeth was observed.
Root resorption of the anchor teeth is unavoidable adverse reaction
during RME. Adverse tissue changes after RME are reversible, and
active root resorption appeared along with increased filling with
cellular cementum after 3 months.31 Two-dimensional periapical
radiographs do not fully reveal the amount of external root resorption
associated with maxillary expansion therapy, except for frank apical
root resorption. Three-dimensional cone beam computed tomography
radiography displays statistically significant root volume loss
associated with maxillary expansion therapy. However, when
considering volume-loss percentages, no statistical significance was
found.32
Activation schedule
A. Schedule by Timms33:
• Up to 15 years: 180 degrees daily rotation of the screw
can be met with a turn of 90 degrees both during
morning and evening (one quarter turn 90 degrees
equivalent to 0.25 mm).
• Over 15 years: Increasing resistance to maxillary
separation may cause a force build-up and pain to
patients in this age group with turns of 90 degrees, so
the total overall daily rotation of 180 degrees is split
into four turns of 45 degrees in a day.
B. Schedule by Zimring and Isaacson34:
• Young growing patients: Two turns each day for 4–
5 days and later one turn/day till the desired
expansion is achieved (two turns equivalent to 180
degrees, 0.5 mm).
• Non-growing adults: Two turns each day for first
2 days, one turn/day for next 5–7 days and one turn
every alternate day till desired expansion is achieved.
Isaacson et al. using force dynamometers reported that a single
activation expansion screw produced 3–10 pounds of force.
Cumulative loads of 20 pounds and above have been recorded after
multiple daily turns of the screw. Residual loads were demonstrated
at the termination of appliance activation, which dissipated by about
6 weeks.35
Expansion of upper jaw is termed slow when expansion takes place at
a rate of 0.5 mm/week. Expansion schedule for the upper removable
appliance (URA) is slow, which is one-quarter turn (0.25 mm)/third
day/ every week (Fig. 49.1.6A–D). A faster expansion tends to displace
the appliance in the mouth. The treatment duration varies depending
upon the severity of maxillary constriction.
FIGURE 49.1.6 (A) W arch. (B) Quad helix appliance. (C) Removable
type of quad helix appliance housed in the lingual tubes on maxillary
first molar bands. (D) Method and sites of activation of the quad helix. I.
The use of three beak pliers and its bending effect. II, III. Activation of
the palatal arms for lateral expansion of the buccal segments (blue). IV.
The maxillary molar region expansion by activation at the anterior
bridge arm of the quad helix appliance. V. Expansion in the molar and
buccal segments. VI. Activation for near parallel expansion in the molar
and buccal segment. VII, VIII. Expansion activation at the helix: VII at
anterior helix and VIII at posterior helix. IX. The maxillary expansion on
activation at anterior bridge and bilateral helix in the molars regions.
Expansion screw design of the maxillary expansion has an acrylic
body which houses a parallel screw. The appliance is retained with
clasps on the teeth, and the acrylic plate is split in the mid-palate.
After desired expansion is complete, the expansion screw and palatal
split are sealed with acrylic. The same appliance may be used as a
retainer for a period of 6–8 months. An occlusal coverage is desired in
some cases to disengage occlusion to facilitate expansion.
All wire framework maxillary expansion appliances are mainly
indicated for dental arch development. The appliance can be
welded/soldered to the lingual part of the first molar bands, or it can
have a removable design which is housed in the lingual sheets on the
maxillary first or second molars.
Coffin spring is perhaps the oldest design of the wire type of
maxillary expander which was housed in an acrylic body.
Quad helix/tri-helix appliance

Quad helix appliance is a modification of Coffin’s W-spring and was
described by R.M. Ricketts initially to treat cleft palate patients who
exhibited significant collapse.
The incorporation of four helices into the W-spring increases the
flexibility, control on the region of expansion and an increase in the
range of activation. The length of the palatal arms of the appliance can
be tailored to suit the requirements of the arch in cross-bite.
The quad helix appliance is constructed of 0.038-in. SS wire and
soldered to bands which are cemented to either the maxillary first
permanent molars or the deciduous second molars, depending on the
age of the patient (Fig. 49.1.7). The quad helix appliance works by a
combination of buccal tipping and skeletal expansion in a ratio of 6:1
in prepubertal children. Chaconas et al. reported that an initial 8 mm
of expansion prior to cementation creates approximately 14 ounces of
force.36 This force magnitude is sufficient to produce tooth movement,
but generally is not enough to create all orthopaedic effect on adults
when the mid-palatal suture is closed. However, in children with
deciduous or early mixed dentition stages of development, the
resistance at the patent suture is often less than that in the
dentoalveolar area. Therefore, this appliance is capable of
orthopedically widening the maxilla in children.
FIGURE 49.1.7 Non-extraction treatment of mild crowding and
transposition of left maxillary canine–premolar: A case study.
The maxillary expansion was achieved with quad helix appliance and
the arch length and space in the mandibular arch was managed with
the lower lingual arch. (A) Pretreatment records. A young boy with
buccal cross-bite of the right maxillary first molar superior protrusion,
mouth breathing habit and narrow nasopharynx as seen in the lateral
cephalogram. (B) The child underwent adenoidectomy and maxillary
expansion with quad helix appliance in the maxilla and lower lingual
arch.(C) Posttreatment records showing marked improvement in soft
tissue and skeletal profile. His breathing pattern also improved. The
occlusion is class I with excellent intercuspation and coordinated
arches.(D) Digital study models showing the changes in transverse
dimension.
The expansion was considered adequate when the occlusal aspect of

the maxillary lingual cusp contacted the occlusal slope of the
mandibular buccal cusp bilaterally in centric relation. This slight
overexpansion of approximately 2–3 mm has been recommended to
compensate for uprighting of the buccally tipped teeth once retention
is discontinued. The quad helix appliance is maintained in the
expanded but passive position for a 6-week retention period after the
adequate expansion is achieved. Sometimes the appliance can leave an
imprint on the tongue. However, this will rapidly disappear following
appliance removal.
Treatment with quad helix appliance aimed to expand the the
maxillary arch creates optimum conditions for normal growth of
jaws/TMJ/face by elimination of lateral forced bite.37
A systematic review has shown that spontaneous correction of this
condition can occur in 16%–50% subjects if left untreated. However,
the success rate both with quad helix appliance and RME is nearly
100%. Expansion plates are relatively less effective (51%–100%) and
occlusal grinding can help but not certainly (27%–90%).38 Removal of
premature contacts of the deciduous teeth is effective in preventing a
posterior cross-bite from being perpetuated to the mixed dentition
and adult teeth.38 Hence, most effective mode of therapy based on
evidence can be questionable. Each case should be treated on the merit
of its severity and type of problem, be under long-term follow-up.
NiTi expander
Wendell V. Arndt introduced NiTi expander to orthodontic
profession.39
Its central component is fabricated from a thermally activated NiTi
alloy and rest of the appliance, including lateral palatal arms are made
of stainless steel. The action of the NiTi is made possible by
harnessing nitanium’s properties of shape memory and transition
temperature.40 Nickel–titanium expanders do not require activation
once fitted into the lingual tubes. The activated appliance produces
effective derotation of the unfavourable rotated molars and
simultaneous expansion (Fig. 49.1.8). The nickel titanium expander
has a transition temperature of 94 °F. When it is chilled before
insertion, it becomes flexible and can easily be bent to facilitate
placement. As the mouth begins to warm the appliance, the metal
stiffens, the shape memory is restored, and the expander begins to
exert a light, continuous force on the teeth and the mid-palatal suture.
A 3 mm increment of expansion exerts only about 360 g of force.40
FIGURE 49.1.8 Maxillary expansion and left molar derotation with
nickel–titanium maxillary expander.
(A) Pretreatment lateral photographs. (B) Post-treatment lateral
photographs. (C1) Pre-treatment, (C2) NiTi palatal expander in situ,
(C3) post-treatment occlusal. Note that NiTi expander has corrected
unfavourable rotation of the left maxillary first molar and collapse of the
buccal segment.
Nickel titanium expanders are available in eight different

intermolar widths, ranging from 26 to 44 mm that generate forces of
180–300 g. The 26–32 mm sizes have softer wires that produce lower
force levels for younger patients. The clinician determines the
appropriate size by measuring the amount of expansion needed, then
adding 3 mm for overcorrection. The simple way to determine the
appropriate size is to measure the mandibular intermolar distance at
the central fossa.
Freeze-gel packs, provided in the expander kits, can be placed
around the expander assembly in preparation for insertion in the
lingual sheets. This will cool the appliance enough to allow easy
insertion into the lingual sheaths. The expander should be handled by
the molar attachments during placement to avoid warming the nickel
titanium. The passive appliance will lie slightly outside the molar
bands. Distorting the nickel titanium for insertion produces an initial
activation that is sufficient to expand the molars and bicuspids while
rotating the molars distally.
Baccetti et al. observed that posterior cross-bite and mid-palatal
rotation of the maxillary first molars were improved.41 The NiTi
expander is effective in molar derotation and dentoalveolar
expansion. Author prefers to use NiTi appliance in cleft patients who
exhibit significant molar rotation and anterior arch collapse.
Hicks observed that the amount of relapse is related to the method of
retention after expansion. With no retention, the relapse can amount
to 45% as compared with 10%–23% with fixed retention and 22%–25%
with removable retention.42 Bell also concluded that slow expansion is
less disruptive to the sutural systems. The slow expansion that
maintains tissue integrity apparently needs 1–3 months of retention,43
which is significantly shorter than the 3–6 months recommended for
rapid expansion.44 Most researchers advocate a retention phase of no
less than 3–6 months. Achievement of good intercuspation is the key
to retention. Conventional Hawley appliance is a useful retainer. The
author recommends continued use of expansion appliance by
converting it to a retainer by sealing the split part with acrylic. This
saves time and cost and has great acceptability by the patients. The
Essix type of retainer may not have the adequate rigidity to counteract
relapse forces (Box 49.1.1).
Box 49.1.1 Summary of maxillary the expansion

appliances
There are two schools of thought concerning the speed of palatal
expansion responsible for split at midpalatine suture. Advocates of
‘rapid’ expansion (1–4 weeks) believe that it results in minimum tooth
movement (tipping) and maximum skeletal displacement. The
increase in maxillary base width is brought about by RME in contrast
to slow expansion which mainly causes dental expansion.
Advocates of ‘rapid’ expansion (1–4 weeks) believe that RME
results in minimum tooth movement (tipping) and maximum skeletal
displacement. The increase in maxillary base width is brought about
by skeletal expansion in contrast to significant dental changes in the
slow expansion. The slow expanders can generate forces from 1000 to
2000 g; however, active force to the maxilla reduces close to 450–900 g
only. These force levels are insufficient to split a progressively
maturing midpalate suture.42,45
When performed before the pubertal peak, RME leads to significant
and more effective long-term changes at the maxillary and
circummaxillary structures. When performed after the pubertal
growth spurt, maxillary adaptations to expansion therapy shift from
the skeletal level to the dentoalveolar level.46 RME results in greater
widening at the canines than at the molars (with a 3:2 ratio) resulting
from skeletal (sutural openings), dental (tipping) and alveolar
(bending and remodelling) changes. As a child matures, more force is
required, and less skeletal expansion and more dental tipping occur.
Children showed 50% skeletal and 50% dental expansion, whereas the
adolescent showed 35% skeletal and 65% dental expansion in
response to RME. After orthodontic appliance removal, the dental
tipping and alveolar bending components of transverse expansion
tend to relapse.47
Maxillary arch width increase ranges from 3.8 to 8.7 mm with slow
expansion of as much as 1 mm/week using 900 g of force.42 Skeletal
changes estimated to be 16%–30% of the total change and vary with
age. The rate of RME is 0.25–0.5 mm/day and can result in an increase
in intermolar width of up to 10 mm. Skeletal changes are
approximately 50% of the total change.
With several controversies on the ratio of skeletal versus dental
changes and long-term outcomes and stability of the results, some
serious research is required to resolve these issues.48
Mini-implant attached rapid palatal
expansion
Mini-implant supported expander appliance is both tooth and bone
born; it can be designated a hybrid hyrax.49
The skeletal anchored expansion appliance is capable of splitting
mid palatal suture in adults and therefore this procedure has become
popular with increasing demand for orthodontics in adult patients
(Fig. 49.1.9).
FIGURE 49.1.9 MIS supported maxillary expansion appliance.

(A) Hybrid RPE advancer before activation. Two miniscrews are
inserted into anterior palate; laboratory abutments ‘keyed’ to
miniscrews anchor HYRAX expansion screw and provide support for
facemask protraction. (B) Significant maxillary expansion after 12 days
of RPE activation. Photo kind courtesy Dr Benidict Wilmes.
Retention Schedule
Retaining an expanded maxilla is a challenging task. Normally, an
active appliance after the completion of the expansion is sealed in the
split area with cold cure acrylic or light cure composite and left in
place for at least 6 months.
Introduction
Interproximal reduction of enamel to accommodate minor crowding
has been in practice as a treatment option with certain limitations. The
treatment with proximal re-contouring of the teeth can be extended
from incisors to premolars and allows some of the cases to be treated
with non-extraction approach.
Interproximal reduction is known by several names.
1. Slenderisation
2. Proximal recontouring
3. Reproximation
4. Air rotor stripping
5. Odontoplasty
6. Enameloplasty
Indications
The reduction in tooth material is aimed to resolve either tooth size–
jaw size discrepancy, improve Bolton’s ratio, prevent relapse of lower
anterior crowding or gain space in the arch to resolve minor
crowding.
1. The interproximal reduction of tooth material to gain

arch length is based on the premise of the increasing the
popularity of non-extraction treatment. Such a treatment
protocol can resolve up to 4 mm of anterior crowding by
proximal stripping of incisors. Overall (anterior + posterior)
proximal reduction gives 9 mm space. This type of reduction is
indicated in children and adults who have otherwise good
profile and occlusion. Essentially these are class I, type 1
malocclusion cases.
2. Proximal contouring is recommended in cases with all first
premolar extractions to balance the disturbance in Bolton’s
ratio.
3. Besides being a space gaining procedure proximal
recontouring is also getting popular as an adjunct to
maintaining long-term stability of the alignment of lower
incisors.
4. Aesthetic contouring has also been in practice where there are
minor irregularities on anterior tooth edges, macrodontic teeth
and malformed teeth.
5. Transposed teeth are aesthetically contoured to mimic the
tooth they replace.
6. Interproximal reduction of the mandibular incisors is done to
minimise relapse in cases of disturbed Peck and Peck ratio.
Interproximal contouring in the lower arch alone should consider

several other factors such as tooth size of lower incisors, their
relationship to the basal arch, total discrepancy, depth of the curve of
Spee and the goals of buccal occlusion.
Contraindications
1. A patient with poor oral hygiene practice is not a good choice
for IPR. A patient undergoing proximal re-contouring should
have good oral hygiene or demonstrate the ability to perform
good oral hygiene practice.
2. A patient with low susceptibility to dental caries is more
acceptable compared with high caries incidence in the mouth.
3. Subjects with poorly formed enamel due to hypoplasia,
abnormal enamel thickness, fluorosis or a genetic disorder of
the dental hard tissues are not suitable for IPR. These cases are
at higher risks of damage of tooth structure and caries if
undertaken for proximal reduction of tooth enamel.
Enamel thickness
Enamel thickness varies considerably among individuals, males and
females, teeth and ethnicity.
The enamel thickness on anterior teeth is 0.6–0.8 mm and 50% of
reduction, that is the reduction of enamel between 0.3 and 0.4 mm
(300–400 µm) is considered safe. Stroud et al. reported that enamel
thickness on molars was significantly larger than premolars. The
mesial enamel was less thick compared with the distal side. Total
combined enamel thickness on two premolars and two molars was
10 mm. According to their predictions, a 50% reduction of enamel on
eight posterior teeth makes a gain of 9.8 mm of space.50
Sheridan et al.51 suggested that 1 mm enamel can be removed from
the buccal contact points (0.5 mm on either side) and it should not
exceed 0.75 mm (0.35 mm on each proximal surface) in lower incisor
due to thinner proximal walls. The ethnic variation in proximal
enamel thickness has to be taken into account while planning IPR.
Box 49.1.2 shows upper limits of amount of enamel to be removed.
Box 49.1.2 Upper limits of possible enamel

removal in mm
Based on the data: Fillion D. Apport de la sculpture amélaire

interproximale à l’orthodontie de l’adulte (2e partie). Revue Orthop
Dento Faciale 1993;27:189-214. Cited from: Frindel C. Clear thinking
about interproximal stripping. Journal of Dentofacial Anomalies and
Orthodontics. 2010 Jun;13(2):187–99.
Caries susceptibility and periodontal health
The roughness or irregularities introduced by the interproximal
reduction may facilitate the plaque accumulation, thereby increasing
the caries susceptibility, periodontal tissue breakdown and increased
sensitivity. Also, the reduction of enamel may bring the teeth root
closer, which may cause thin interdental bone leading to periodontal
attachment loss. Zachrisson et al.52 studied the long-term outcome of
interproximal reduction performed with fine diamond disks with air
cooling, followed by polishing. They concluded that the IPR did not
increase dental caries, gingival problems or alveolar bone loss. Also,
the distances between the roots of the teeth in the mandibular anterior
region were not reduced. Koretsi et al.53 conducted a systematic
review to investigate the effect of IPR on caries susceptibility. They
did not find evidence for increased caries susceptibility on IPR-treated
cases.
Bolton’s ratio
A tooth size discrepancy (TSD) may exist as a disproportion of sizes of
individual teeth. Correct proportions of teeth are an essential
component of good occlusion and aesthetics. It has been reported that
11%–13.5% of the orthodontic population have overall Bolton ratio
problems and 22.7%–30.6% of the orthodontic population have
anterior Bolton ratio problems.54
It is imperative that measurements of mesiodistal widths of the
teeth should be made with greatest care and accuracy. The digital
callipers in the mouth connected to computers have significantly
reduced the errors encountered in the use of sharp hand-held dividers
on dental models.
Proximal recontouring can satisfy the abnormal Bolton ratio and
hence improve occlusion. It has been reported that anterior maxillary
excess may be seen in class II malocclusion2 and mandibular tooth
size excess in class III patients.55
Bolton ratio does get altered in cases treated with all first premolar
extractions owing to the abnormally small size of the lower first
premolars, while removal of larger second mandibular premolars
improves overall ratio.
‘Interproximal enamel reduction can be used to correct the ratio and
ensure well-aligned and properly occluding dentitions. In certain
circumstances the ratio may even indicate the feasibility of extracting
one lower incisor’.56
Proper Bolton’s ratio is called ‘7th key’ to normal occlusion. Other
six keys were described by Andrews.
Peck and Peck ratio

Another matter of tooth dimension proportions is the ratio of
mesiodistal dimensions (MD) of lower incisor to that of labiolingual
thickness measured at cingulum. Peck and Peck57 suggested a range
of 88%–92% for mandibular central incisors and 90%–95% for
mandibular lateral incisors. A large ratio suggests need for proximal
recontouring.
Prevention of relapse due to late mandibular crowding

Proximal recontouring is also expected to bring about broader
proximal contact area and wider area of inter-radicular bone.
A good long-term stability of lower incisors can be expected using
proximal recontouring and over-correction without the use of
retainers.58 Boese evaluated 40 patients’ posttreatment for 9 years who
were treated for crowded mandibular arches treated by extraction of
premolars, but never retained. These patients underwent
circumferential supracrestal fiberotomy (CSF) and reproximation of
varying degrees. A mean of 1.69 mm ± 0.64 enamel was removed
during various phases. He concluded that ‘reproximation, when
precisely and conservatively performed increased long-term stability
of mandibular anterior segment’.59,60
Steps in interproximal reduction

Livas et al.61 summarised the sequential clinical steps to be followed
in the IPR.
1. Comprehensive planning
Determine the required enamel reduction using study model
analysis, diagnostic set-up and calibrated radiographs.
2. Access to the interproximal areas
In case of rotation of teeth, the interproximal area cannot be
accessed for reduction purpose, which requires initial levelling
and alignment of teeth. Further use of coil spring, separator
and wooden wedge can improve the visibility and access to the
interproximal area.
3. Protection of the soft tissues
The protection of interdental tissue using 0.020–0.030 in. brass or
steel indicator wire or wedge. Zachrisson recommended the
four handed approach for tongue protection while using a
revolving diamond disc. On the other hand, Livas et al.
suggested an oscillating perforated diamond disc for IPR.
4. Interproximal enamel removal
The interproximal reduction from mesiodistal enamel using
manual or mechanical methods. One should be careful and
conservative in initial stripping procedure. The enamel should
be removed in small quantity increments, and symmetrically
from all planned contact areas. Do not remove maximum
permissible enamel at one site in one go. The amount of
reduction can be quantified using the thickness or leaf
measuring gauges.
5. Finishing and polishing of enamel surfaces
The edges or corners of interproximal areas should be rounded
and smoothened. Various methods are:
a. Cone-shaped triangular diamond bur
b. Finishing diamonds
c. Finishing sand and cuttle discs and
d. 37% phosphoric acid gel can be used for this
purpose.
6. Topical fluoride treatment
The topical fluoride gel application is recommended after IPR to
amplify the re-mineralisation of abraded interproximal surface.
Zachrisson recommends the use of topical fluoride application
only in the presence of thermal sensitivity.
Precautions and complications

Proximal recontouring is an irreversible process and must be
undertaken after careful diagnosis and observation of dental anatomy
and dimensions of the tooth/teeth (Box 49.1.3).
1. The procedure should be done judiciously and precisely.

2. Hand or air-rotor stripping can produce heat and care should
be taken to cool the tooth to prevent a rise in pulp temperature
to prevent subsequent pulpitis.
3. The procedure should be undertaken after teeth have been
aligned for proper access, convenience and to avoid reduction
of labial or lingual enamel.
4. Excessive enamel reduction makes teeth sensitive, undesirably
prone to caries and can damage periodontal fibres.
5. Use of correct instruments and polishing of enamel to prevent
plaque accumulation. Stripping with coarse strips and burs
can leave deep grooves of the size of 10–25 µm which can
serve as a retentive house for plaque.62
6. A bite wing radiograph of buccal segment provides a good
view of enamel thickness on premolars and molars. An IOPA
radiograph of anterior teeth should help the clinician to judge
the approximate thickness of proximal enamel on incisors.
Enamel thickness greatly varies among individuals and in
ethnic groups.
Box 49.1.3 Advantages and disadvantages of

various IPR techniques
Technique Merits Demerits
Diamond • Hand held, slow, better control • Injury to surrounding tissues such as lips
strip • Flexibility helps to maintain the and cheek are greater
contour • Slow hence time-consuming
• Can be one sided or double sided • Difficult access on buccal teeth
• Can be used when the teeth are so
rotated that a disk is not appropriate
Diamond • Fast, less time consuming • More chances for injury while using high
disc • Better control for buccal teeth IPR speed rotating instrument in the
• The smoothest enamel surface is proximity to a patient’s tongue, chicks,
achieved when using polishing after lips
IPR • Reduced visibility while using the disc
guards
Burs • Deactivated points suggested by • Leave the roughest enamel surface after
Sheridan will not create ridges in the IPR compared to diamond disc and metal
proximal enamel strips
• Tungsten and diamond burs can be • Difficult to strip in one tooth without
used for taking proximal bulk from touching adjacent teeth
amalgam and composite restorations
Oscillating • Reduced risk of cutting into the soft • Time-consuming procedure when
diamond tissue compared with air rotor stripping (ARS)
strip • Smoother enamel surface
Chemical • Roughest surface enamel after IPR
mechanical
method
Techniques of IPR
Diamond strips
Conventionally, the proximal enamel reduction has been carried out
with hand-held fine diamond strips. The success of bonding has made
it possible to access proximal tooth surface with the appliance in situ,
which was not possible with banding.
Up to 0.2–0.4 mm of enamel thickness is removed (200–400 µm)
which is 50% of acceptable enamel reduction. Several manufacturers
have developed safe-sided proximal recontouring kits. The diamond
strip can be housed in hand-held saw frames which are used gently
with care not to generate heat and cause deep abrasions. The abraded
tooth surfaces should be made smooth with polishing discs. The
interproximal reduction should be carried out after resolving the
crowding; for uniform access to interproximal surfaces, and to prevent
damage to surfaces of other teeth (Fig. 49.1.10A, B).
FIGURE 49.1.10 Commercially available enamel reduction
accessories.
(A) QwikStrip Interproximal Strips, Dentsply International Raintree
Essix, Sarasota, FL. (B) SpaceFile IPR Files, Dentsply International
Raintree Essix, Sarasota, FL.
Air-rotor for reduction of interproximal enamel on

posterior teeth
Sheridan described the technique of air-rotor reduction on buccal
segment.63,64 Sheridan recommends the use of 699L, a small tapered
crosscut fissure carbide bur for initial reduction. He does not
recommend the use of finely tapered diamonds for initial reduction.
An indicator wire of 0.018 in. is inserted below the contact point
buccolingually, which protects the underlying gingiva. The proximal
recontouring is done till the wire can be gently lifted occlusal to the
contact point. Finishing is done with 135 EF stiletto-shaped ultra-fine
finishing diamond (Figs 49.1.11A–F, 49.1.12A–D, and 49.1.13).
FIGURE 49.1.11 Reduction of the interproximal enamel of buccal
teeth for the relief of anterior crowding according to the method
described by Sheridan.
(A) Pretreatment. (B) Separation of teeth with push coil spring or
separator. (C) Proximal reduction of the distal surface of second
premolar and mesial of the first molar. (D) Proximal reduction of mesial
surface of second premolar and distal of the first premolar. (E) Proximal
reduction of mesial surface of first premolar and distal of canine. (F)
Anterior teeth are aligned.
FIGURE 49.1.12 IPR kit and instruments.
(A) Safe-Tipped Bur Kit, Dentsply International Raintree Essix,
Sarasota, FL. (B) Galaxy Diamond Discs and Safety Guards;
Orthodontic Supply & Equipment Co., Inc., Gaithersburg, MD. (C)
Oscillating segment disc, KOMET USA, Rock Hill, SC. (D) Diamond
Disc Safety Guard, The Orthodontic Company, Bristol, United
Kingdom.
FIGURE 49.1.13 IPR gauge set.
Dentsply International Raintree Essix, Sarasota, FL, USA.
Based on SEM analysis of recontouring procedures, Leclerc

proposed following techniques.65
1. Initial use of diamond disc followed by diamond bur

2. Use of 16 and 30 blade tungsten carbide bur for finishing
3. Use of polishing paste
A well-polished enamel surface can also be obtained by using a

tungsten carbide bur with eight straight blades followed by Sof-Lex
disks (3M).66
Chemical mechanical method

The chemicomechanical method of tooth enamel reduction has been
reported to be more physiologic since it does not leave furrows (15
µm deep). Use of 37% phosphoric acid in combination with
mechanical microabrasion using diamond-coated metal strips and
finishing strips create a relatively smooth enamel surface that has the
potential to heal in oral environment and artificial re-mineralisation
by using calcium fluoride solution that promotes crystal growth.67
Key Points
Non-extraction treatment should be considered after careful planning,
more so if the plan is to expand the maxilla and or undertake
reduction of the tooth substance. Each procedure has its specific
indications. The maxillary expansion is indicated for a narrow maxilla
to normalise the transverse dimensions within the constraints of
anatomical limitations and functional balance of the oro-facial
neuromuscular system. Any attempt to widen the normal maxilla
beyond a certain limit will jeopardise the periodontal health of the
teeth and will be unstable.
The interproximal reduction (IPR) is a double-edged sword and if
not undertaken with due consideration of available enamel thickness
and oral health, may lead to the irregular shape of the teeth, abnormal
proximal contact relations and therefore increased susceptibility to
dental caries and periodontal disease. The treatment procedures using
transparent aligners often recommend IPR in an attempt to sell on
non-extraction treatment. Any such procedure when undertaken
should be based on the sound treatment plan and not just by the
recommendations of the supplier.
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CHAPTER 49.2
Non-extraction treatment with
non-compliance molar
distalisation
O.P. Kharbanda
CHAPTER OUTLINE

Indications of intraoral molar distalisation
Pendulum appliance
Pendulum X
Pendulum K
Buccally acting appliance
Treatment outcome of FCA appliance
Skeletal anchorage
Mini screw supported distalisation system (MISDS)
Key Points
Molar distalisation has a long history in orthodontics. This treatment
strategy has been in practice with the success of Kloehn headgear and
facebow1–3 in bringing about restraint on the sagittal growth of the
maxilla and to create distal movement of maxillary molars in young
growing children. The primary indication for the use of Kloehn
headgear is to intercept development of class II malocclusion and
thereby correct growing superior protrusion. However, the success of
this appliance is ‘compliance dependent’.
Several other methods have also been used for the distal movement
of maxillary molars such as force generated by use of class II elastics
directed to drive the maxillary dentition distally either through a jig
suggested by Tweed or modular arches such as 3D Wilson arch4,5
(Fig. 49.2.1).
FIGURE 49.2.1 The components of the 3D bimetric distalising

arch. Source: Wilson RC, Wilson WL. Enhanced orthodontics. Denver:
Rocky Mountain Orthodontics. 1988.
Mandibular molar distalisation is required for the correction of class

III malocclusion.6
The search for simple, noncompliance system of intraoral molar
distalisation continued in the late 1970s and 1980s. Repelling
magnets7,8 open coil springs, and superelastic wires were tested.9,10
Japanese NiTi coils were used to distalise the first molar using mesial
arch segment anchorage by Gianelly9 and later superelastic NiTi wires
were activated and held with a specially designed crimped stop on the
principles used by Locatelli et al.10
Dr Bondemark used repelling magnets to distalise the maxillary
molar. However, they proved to be less effective compared with
previously known methods.11 The magnets have several other
disadvantages. The most critical aspect lies in adjusting a optimum
distance between two repelling magnets. In addition the magnets are
bulky and oral hygiene maintenance is cumbersome.
Hilgers in 1992 introduced the use of distal force application on
palatal aspect of maxillary molars with a spring designed in TMA
wire that was anchored in palatal acrylic button. He called it
pendulum appliance12 (Fig. 49.2.2).
FIGURE 49.2.2 Repelling magnets for molar distalisation. Source:

Steger ER, Blechman AM. Case reports: molar distalization with static
repelling magnets. Part II. Am J Orthod Dentofacial Orthop. 1995
Nov;108(5):547–55.
The pendulum appliance used modified Nance button anchored to
premolars to derive the anchorage. TMA wire springs embedded in
acrylic when activated by 30 degrees generated a constant force 100 g,
and at 60-degree activation, 200+ g force sufficient to distalise the
maxillary first molar (Fig. 49.2.3).
FIGURE 49.2.3 Pendulum appliance.

This appliance uses a modified Nance button to derive anchorage from
the palate and the wire framework embedded in palatal acrylic button
which is either bonded or banded with premolars.
During same years Jones and White introduced a buccal sectional

assembly, which is popularly called Jones Jig (1992)13,14 (Fig. 49.2.4).
FIGURE 49.2.4 Jones Jig.
(A) Sectional jig assembly. (B) Activated sectional jig assembly and
modified Nance appliance in situ.
Kalra introduced a buccally placed TMA loop, for molar distal

movement known as the K loop (1995).15
Distal Jet, a modification of spring loaded appliance from modified
Nance button, was introduced in 199616 (Fig. 49.2.5).
FIGURE 49.2.5 A) Pre-treatment (B) Post-treatment. Distal Jet

appliance.16
Around those years Fortini (1999) used a combo approach from

palatal as well as buccal, for distal bodily movement of the molar and
called it First Class Appliance (FCA).17
Keles and Sayinsu introduced what they called intraoral bodily
molar distaliser again from the palatal approach18 (Fig. 49.2.6).
FIGURE 49.2.6 A) Keles molar distaliser. (B) Palatal view. Source:
Keles A, Sayinsu K. A new approach in maxillary molar distalization:
intraoral bodily molar distalizer. Am J Orthod Dentofacial Orthop
2000;117:39–48.18
Since then some modifications and improvements in appliances

have been introduced to buccal, or palatal or a combination of both
buccal and palatal forces. Intraoral molar distalisation is now an
accepted modality of treatment in orthodontic practice for treatment
of select cases. The intraoral molar distalising appliances are tabulated
in (Box 49.2.1).
Box 49.2.1 Classification of Intraoral molar

distalisation appliance
1. Dental/conventional anchorage derived appliances

a. Buccal appliance
– Jigs with class II elastics
– Repelling magnets
– NiTi springs and wires
– Jones Jig
– K loop
b. Palatal appliance
– Pendulum appliance
– Modifications of pendulum appliance
– Fixed piston appliance by Greenfield (1995)
– Distal Jet spring loaded palatal appliance
c. Buccal and palatal appliance
– First class appliance
2. Skeletal anchorage using miniscrews/skeletal anchorage system
a. Palatal anchorage
– Bone anchored pendulum appliance (BAPA)
– Miniscrew supported pendulum appliance
– Palatal supported all wire framework Beneslider
TAD supported buccal Jig
– TAD supported long arm buccal jig
– TAD supported jig on fixed appliance
– AIIMS Universal Connector supported Jones Jig
3. Combination of buccal and palatal application of force
a. Dual force distaliser supported with Nance button
anchored with TAD
Bone screw anchored, miniscrew (TAD) supported molar

distalisation and skeletal anchorage system to distalise the maxillary
and mandibular molars, and the entire arch are recent additions to the
armamentarium on molar distalisation. These include both buccal and
palatal sourced bone anchored devices. The buccal sourced skeletal
system includes skeletal anchorage system by Sugawara et al.,19
Bollard mini-plate supported buccal force by Cornelis and De Clerck20
and miniscrew anchored sliding jig by Lim and Hong21 (Fig. 49.2.7).
FIGURE 49.2.7 Maxillary molar distalisation with bone anchored

anchorage system.
Cornelis and De Clerck (2007) used bollard mini-plate and miniscrews
(left, 5-mm length; right, 7-mm length) as anchorage with elastics
applied between the mini-plate and a sliding hook anterior to a closed-
coil spring. M, Mini-plate; N, neck; F, fixation unit. Source: Cornelis MA,
De Clerck HJ. Maxillary molar distalization with mini-plates assessed
on digital models: a prospective clinical trial. Am J Orthod Dentofacial
Orthop. 2007;132(3):373–7.20
The palatal source bone anchored are as follows: Bone Anchored

Pendulum Appliance (BAPA) by Kircelli et al.22 (Fig. 49.2.8);
miniscrew implant supported distalisation system by Papadopoulos23
(Fig. 49.2.9); miniscrew supported skeletonised Distal Jet appliance by
Kinzinger et al.24 (Fig. 49.2.10); miniscrew supported Dual Force
Distaliser by Oberti et al.25 (Fig. 49.2.11); miniscrew implant
supported distalisation system (MISDS) by Benislider26 (Fig. 49.2.12)
and and skeletal frog appliance by Ludwig et al.27
FIGURE 49.2.8 Bone Anchored Pendulum Appliance (BAPA).

(A) Pretreatment occlusal view; (B) after distalisation. (C) Pretreatment
cephalometric radiograph; (D) postdistalisation radiograph. Source:
Polat-Ozsoy O, Kircelli BH, Arman-Ozçirpici A, Pektas¸ ZO, Uçkan S.
Pendulum appliances with 2 anchorage designs: conventional
anchorage vs bone anchorage. Am J Orthod Dentofacial Orthop
2008;133(3):339.e9-339.e17.29
FIGURE 49.2.9 Miniscrew implant supported distalisation system

(MISDS) used by Papadopoulos (2008). Source: Papadopoulos MA.
Orthodontic treatment of class II malocclusion with miniscrew implants.
Am J Orthod Dentofacial Orthop 2008;134(5):604.e1-16.23
FIGURE 49.2.10 Skeletonised Distal Jet appliance by Kinzinger
et al. (2009). Source: Kinzinger GS, Gülden N, Yildizhan F, Diedrich
PR. Efficiency of a skeletonized distal jet appliance supported by
miniscrew anchorage for noncompliance maxillary molar distalization.
Am J Orthod Dentofacial Orthop 2009;136(4):578–86.28
FIGURE 49.2.11 Miniscrew supported Dual Force Distaliser (DFD)
appliance by Oberti et al. (2009). Source: Oberti G, Villegas C, Ealo
M, Palacio JC, Baccetti T. Maxillary molar distalization with the dual-
force distalizer supported by mini-implants: a clinical study. Am J
Orthod Dentofacial Orthop 2009;135(3):282.e1-5.25
FIGURE 49.2.12 Beneslider molar distalisation appliance.
Photo kind courtesy Dr Benidict Wilmes.
Indications of intraoral molar distalisation

In general, children with normal or horizontal growth pattern are
more suitable for maxillary molar distalisation. Maxillary molar
distalisation is considered with the following aims in mind.
1. To distalise (normalise) the mesially migrated maxillary molars

due to their premature mesial drift. Such a situation may exist
unilaterally or bilaterally.
2. To correct class II dental relationship of no more than half-cusp
severity and mild maxillary dentoalveolar protrusion. The
mandibular arch either requires no or need minimal
orthodontics. The profile of such a patient is normal or slightly
protrusive at the upper lip due to the dental/dentoalveolar
protrusion.
3. In class I occlusion patients, molar distalisation may be
indicated to gain space to resolve minor crowding in the
anterior segment. Up to 4 mm of crowding can be addressed
with molar distalisation.
4. To obtain space for erupting canines more so by utilising the
Leeway space and minor distal movement of the molars.
5. To recover anchorage loss during active orthodontic treatment.
Contraindications of molar distalisation
1. Subjects with high FMA or vertical growth trend. Discrepancy

more than 4 mm and where the profile is not favourable.
2. MD is associated with some amount of distal tipping and
extrusion action which might have adverse effects on
occlusion. It may lead to anterior open bite in patients with
vertical growth trend.
Pendulum appliance
Hilgers introduced pendulum appliance in 1992.12 The appliance used
modified Nance button for anchorage and TMA wire springs to apply
force from the palatal side for molar distalisation.
A. Appliance Fabrication
The pendulum appliance consists of anchorage derived from
premolars. Bands on first premolars and soldered palatal extensions of
0.036-in. SS wire are embedded in an acrylic button in the rugae area
and contour of the anterior palate. The maxillary first molars are
provided with a welded lingual tube on each of the molar band. Two
palatal springs are made of 0.032 in. TMA wire, embedded in the
Nance button on either side of the midline. The right and left
pendulum springs consist of a re-curved molar intrusion wire, a small
horizontal adjustment loop, a close helix and a loop for retention in
the acrylic button. The activated springs deliver 150 g of force
sufficient to distalise the molar partly by bodily and partly by tipping
movement. The rate of molar distal movement can be evaluated at the
cervical margin of the molar to a distance from the second premolar.
Steps in using a pendulum appliance Fig. 49.2.13A–H.
1. Case selection, records, complete diagnosis and a

comprehensive treatment plan.
2. Treatment sequence.
FIGURE 49.2.13 Pendulum appliance fabrication and insertion in
the mouth.
(A) Occlusal view of the case selected for pendulum appliance. (B)
Occlusal view of pendulum appliance. The molar bands, lingual tubes
are in place. The first premolar bands are soldered with palatally placed
stainless steel wires which are engaged in the acrylic to serve as
modified Nance appliance. The pendulum springs made with 0.032 in.
TMA wire and engaged in the lingual tubes of molars in a passive state.
(C) Acrylisation completed. (D) After acrylisation the distalisation
springs are activated towards midline by 60 degrees from the passive
position in the molar tubes. (E) Finished appliance. (F) Activated
appliance for ready for insertion in the patient’s mouth. (G) Pendulum
appliance inserted in the mouth. (H) The pendulum appliance springs
are inserted into the lingual tubes of the molar bands on both the
sides.12
A. Appliance Fabrication
The molar bands are selected and welded with both buccal and
lingual tubes. The oral lingual sheets are of 0.036 in. dimension. The
molar bands are transferred to the impression and study model. In the
case of erupted premolars, bands are also prepared on first and
second premolars and transferred to the model. Molar distalising
spring(s) are fabricated in 0.32 in. TMA wire and embedded in the
Nance button which is also attached to a wire framework that is either
soldered to the premolars or bonded on the occlusal surfaces of the
premolars. The spring is bent parallel to the mid-palate line.
The springs are extended as close to the centre of the palatal button
as possible to maximise their range of motion, to allow for easier
insertion into the lingual sheaths and to reduce forces to an acceptable
range.12 The spring has a re-curved molar insert segment, a horizontal
adjustment loop, a closed helix and a segment with a loop which can
be held in the acrylic part of the Nance button. Nance button
appliance is then prepared in acrylic with wire framework of the
premolars and two springs embedded in the acrylic. The acrylic
button can be fabricated in high strength cold cure acrylic.
B. Appliance Cementation
The anterior part of the pendulum appliance which is Nance button
and anchorage unit of the premolars is fixed first, followed by the
cementation of the molar bands.
C. Appliance Activation
After insertion of the pendulum, spring arm of each spring checked
for activation and inserted gently into the lingual sheath. The
pendulum spring is pulled forward with fingers, the mesial end of the
required loop is held with a Weingart pliers and spring end is seated
in the lingual sheath. The horizontal adjustment loop allows for some
lingual compression of spring during placement.
On insertion about one-third of activation is lost with 60 degrees of
remaining activation force of 150–200 g. The molars move distally
following the arc of the spring opening towards the midline of the
appliance (Fig. 49.1.3).
Reactivation of the appliance is done usually every 3 weeks.
Activation of spring is done by holding the helix with pliers and
pushing the spring distally towards the midline and then re-inserted.
Once a decision to undertake molar distalisation has been agreed
upon, the following sequence of appointments is required.
D. Molar Stabilisation
Following distalisation, molar(s) can be stabilised in a new position
with a fully bonded appliance. An omega loop mesial to molars works
well to prevent their mesial movement.
Hilgers has suggested the use of Insta Nance; a 0.036-in. preformed
lingual crib inserted into lingual tubes. Insta Nance stabilises the
molars and allows the upper premolars to drift distally as the trans-
septal fibres reorient. A 0.036 in. wire preformed lingual crib is
inserted into the lingual sheaths. A small ball of triad light-cured
acrylic is formed over the retention loop of the crib in the vertical
portion of the palatal vault, smoothed with a moistened finger and
cured with a light source for 1 min. Hilgers strongly recommends
insta Nance for he found it to be the most stable and dependable way
to maintain molar positions, and it can be fabricated chairside on the
same appointment as the pendulum appliance removal.
An upper utility arch in a fully bonded arch is also a good option
for maintenance of distalisation. Here the tip back bands are the ones
which apply distal thrust to the molars.
The other option involves using a fixed appliance with molar stops
supported with insta-Nance appliance for intra-arch space closure and
anterior retraction.
The potential consequences of palatal spring activation which
moves in an arc are as follows: (1) palatal movements of the molars
and (2) distal tipping of the molars.
As the molar is driven distally, it moves on an arc towards the
midline of the appliance, in other words, towards cross-bite. This
tendency can be counteracted by opening the adjustment loop slightly
for the purpose of expansion and molar rotation. Distal root tip can
also be produced by adjusting this horizontal loop on the pendulum
spring. Tipping back the re-curved portion of the spring at the loop
causes a more direct distal movement of the molars.
Pendulum X
When a maxillary expansion is indicated in a narrow maxillary arch,
the molar distalisation and maxillary expansion can be carried out
simultaneously. An expansion screw can be incorporated into the
centre of the Nance button (Fig. 49.2.15). The screw activation is
initiated after a week. The schedule of expansion is usually one-
quarter turn every 3 days, to produce a slow, stable expansion.
Figs 49.2.14A, B depict a case treated with pendulum appliance.
FIGURE 49.2.14 A case treated by pendulum appliance.
(A) Case GR pretreatment. A young girl with skeletal mid class II molar
and canine relations and lack of lip seal. This young girl underwent non
extraction treatment with molar distalisation using pendulum appliance
followed by fixed appliance therapy.(B) Posttreatment follow-up shows
a well-balanced soft tissue and skeletal profile and a well-settled class I
molar and canine relationship.
FIGURE 49.2.15 Pendulum X appliance.
Pendulum K
The standard pendulum appliance was modified by Kinzinger et al.
by integrating a distal screw into its base and by a pre-activation of
the pendulum springs for sustained bodily distalisation. Activation of
spring provides a continuous force of 150 g. Pendulum K appliance is
expected to minimise or prevent altogether all the side effects through
the incorporation of a distal screw into the Nance button which is
further supported by the initial application of an uprighting and a toe-
in bend in the region of the pendulum springs30,31 (Fig. 49.2.16).
FIGURE 49.2.16 Pendulum K appliance. Source: Kinzinger GS,
Diedrich PR. Biomechanics of a modified Pendulum appliance—
theoretical considerations and in vitro analysis of the force systems.
Eur J Orthod 2007;29(1):1–7.
The bone anchored pendulum appliance (BAPA) is an another

modification suggested first by Kircelli et al.22,29 Using similar
principles of skeletal anchorage, many designs were proposed using
one or two screws or a bone plate.
The skeletal anchorage device is used to hold the Nance palatal
button with a bone anchored screw which means the premolars and
incisors remain unaffected by the reciprocal forces generated by the
distalising springs. The net gain is better molar distalisation without
anchorage loss.
Efficacy of pendulum appliance

A recent systematic review has reported that the pendulum appliance
showed mean molar distalisation of 2–6.4 mm, distal tipping of molars
from 6.67° to 14.50° and anchorage loss with mean premolar and
incisor mesial movement of 1.63–3.6 mm and 0.9–6.5 mm,
respectively. The BAPAs showed mean molar distalisation of 4.8–
6.4 mm, distal tipping of molars from 9° to 11.3° and mean premolar
distalisation of 2.7–5.4 mm.33
Buccally acting appliance

Sectional jig assembly
Buccal sectional jig assembly is a sectional assembly which derives
anchorage from modified Nance button, soldered to second premolars
and first deciduous molars. The Jones Jig uses open coil spring of
nickel–titanium to deliver 70–75 g of force over a compression range
of 1–5 mm to the molars.
The jig is inserted into the round and rectangular buccal tubes of the
maxillary first molar and tied securely on to the gingival hook on the
jig. The spring is activated by pulling it distally with a ligature wire
around the mesial end, tied on to the cleat on second premolar band.
The child is reviewed for progress every 4–5 weeks, and reactivation
can be done easily as and when required.
According to Jones and White13, rapid molar correction can take
place in 90–120 days in cases where class II dental relationship is
primarily due to the mesiobuccal rotation of the maxillary first molar.
In more severe cases, the correction may take 120–180 days. The
children with more horizontal growth tendency may take a longer
treatment time.
Components of the Jones Jig are depicted in Fig. 49.2.17.
FIGURE 49.2.17 Jones Jig (American orthodontics) is used as a
noncompliance intraoral molar distalisation appliance.
Gulati and Kharbanda14 prepared a sectional jig assembly by

soldering rectangular wire on a round 0.036 in. SS wire.
A case treated with modified Jones Jig with 16 years follow-up is
given in Figs 49.2.18–49.2.20. Another case of bilateral molar
distalisation is shown through figures Figs 49.2.21–49.2.24.
FIGURE 49.2.18 Molar distalisation with modified sectional jig

assembly Case AS.
Case: Boy, AS, 11 years, mild skeletal class II dental class II, >left side
lack of space to accommodate 23 midline shift mild crowding lower
arch. Not willing for all four or two upper first and single first premolar
extraction on left side. Treated with molar distalisation on left side first,
followed by right side with modified Jones Jig appliance.
FIGURE 49.2.19 (A) Rapid distalisation of left maxillary molar with

modified Jones Jig. (B) Modified Jones Jig. (C) Postdistalisation
cephalogram.
FIGURE 49.2.20 (A) Fully bonded standard edgewise appliance. (B)
Posttreatment occlusion. (C) Follow-up 16 years. Note the flexible
spiral wire (FSW) retainer in situ.
FIGURE 49.2.21 Bilateral maxillary molar distalisation with Jones
Jig appliance. Case DE.
A young girl with normal profile and naso-labial angle. There is a
insufficient space to accommodate the maxillary canines on both the
sides.
FIGURE 49.2.22 Bilateral maxillary molar distalisation with Jones
Jig appliance.
FIGURE 49.2.23 (A) Retraction of teeth in the buccal segment into
space achieved with molar distalisation. (B) Nance holding appliance to
hold molars. (C) A fully bonded fixed appliance is used to finish the
occlusion. (D) Pre-debond cephalogram and OPG.
FIGURE 49.2.24 (A) Posttreatment profile and occlusion. (B). Pre-
stage and pre-debond cephalogram.
The main features of this Jones Jig are round gingival tube is placed
as gingival as possible permitted by the clinical crown height and
hence the application of the force. Higher application of distalising
force resulted in a comparatively low (3.5 degrees) of distal tipping. In
their sample mean distal movement was 2.78 mm, the second molars
accompanied the first molars and moved distally by nearly the same
amount. There was a 1.00 mm increase in the overjet and 2.60 degrees
mesial tip of the second premolars. However, there was a clockwise
rotation of the mandible of 1.30 degrees that was statistically
significant, which was the result of molar extrusion (1.60 mm).
K loop molar distaliser introduced by Kalra in 199515 used the
concept of modified Nance button attached to premolars either
bonded or attached through steel bands.
The molar distalising force is applied through a sectional assembly
of TMA wire consisting of twin loops engaged between anchor
premolars and buccal tube on the first molar.
The K-loop assembly is prepared from 0.017 × 0.025 in. TMA wire,
the height of the loops being 8 mm or more, with 1.5 mm width. The
mesial and distal legs are provided with a vertical step of 1.5 and
1 mm distal to the mesial margin of the buccal tube and mesial to the
distal margin of the premolar bracket, which serve as stops. The two
arms are bent occlusal by 20 degrees. The vertical loops are so
separated and related to each other in a manner to appear like a K
(Kalra) when the sectional assembly is held vertically (Fig. 49.2.23).
The K-loop can be activated at three points, as shown in the figure,
by separating two vertical loops and third at the junction of the two
loops. The K-loop assembly is placed with 2 mm of activation. While
most distalising appliances result in undesirable tipping of the molar,
the V-bend in the K-loop moves the molar crown and its root distally.
Preformed K-loop is made of CNA beta titanium which produces
gentle continuous forces for efficient and effective tooth movement
(Figs 49.2.25 and 49.2.26).
FIGURE 49.2.25 K-Loop molar distaliser placing the K-Loop

activation.
(A) Insert the K-Loop into the first molar tube and first premolar bracket.
Place a mark just mesial to the molar tube and distal to the premolar
bracket. (B) Place 1.5 mm high step bend 1 mm distal to the molar
mark and 1 mm mesial to the premolar mark. (C) Insert K-Loop in place
and ligate into premolar bracket. Place a cinch back bend mesial to the
premolar bracket as shown.
FIGURE 49.2.26 Reactivating the K-Loop.

Usually done after 6–8 weeks. The K-Loop can be reactivated only
once. (a) Remove K-Loop from the mouth; (b) open the loop 1.5 mm at
‘1’; (c) open the loop 1.5 mm at ‘2’; (d) open the loop at ‘3’ to gain
original configuration; (e) place loop again, following ‘activation’
instructions.
Keles molar distaliser was designed to minimise the undesirable

side effects of the pendulum spring which causes a distopalatal
rotation and a tendency for a cross-bite and significant tipping. The
Keles molar slider translates the molars along a sliding road which is
housed in the palatal molar tube of 0.045 in. internal diameter. The
anchorage is derived from premolars and Nance button.
A heavy NiTi coil spring (2 cm long, 0.045 in. diameter and 0.016 in.
thick) is placed between the lock on the wire and the tube, in full
compression. The amount of force generated by the full compression
of the 2 cm open coil is about 200 g.
This force system allows consistent application of force at the level
of the centre of resistance of the first molars. The patients are seen
once a month when the spring is activated by compressing the spring
by making an adjustment of the lock using a special wrench. After the
distalisation, the appliance is removed, and the molars are stabilised
by a Nance appliance.32
Buccal and palatal appliance

The first class appliance (FCA) for rapid molar distalisation, desgined
by Fortini et al.17 utilised a buccal component of active force and a
palatal guiding device so that unwanted effects can be minimised.
FCA allows distal molar movement in a ‘double-track’ system from
palatal and buccal side although primarily force application is from
the buccal mechanism. The double track provides a control
mechanism that does not allow scope for molar rotations or
contractions. The appliance consists of a vestibular and a palatal
component. The screws are 10 mm long, with four holes for activation.
The vestibular screws are seated into closed rings that are welded to
the bands of the second deciduous molars or the second premolars.
The conventional pre-adjusted rectangular tube is used, and the
additional formative screw is soldered occlusal to the tube, so that
they will not interfere with subsequent insertion of the archwire
(Fig. 49.2.27). Split rings, welded to the second premolar or second
deciduous molar bands, control the vestibular screws.
FIGURE 49.2.27 First Class appliance.
Occlusal view of the FCA: (A) before molar distalisation; (B) after molar
distalisation. The appliance can be transformed into a modified Nance
holding arch. Source: Illustration published in orthodontic treatment for
the class II noncompliant patient: current principles and techniques by
MA Papadopoulos. Copyright Elsevier, 2006. Papadopoulos MA,
Melkos AB, Athanasiou AE. Noncompliance maxillary molar
distalization with the first class appliance: a randomized controlled trial.
Am J Orthod Dentofacial Orthop 2010;137(5):586.e1-586.e13.34
Palatal components. The palatal assembly is similar to Nance

button, but much wider covering a large part of the palate to engage a
butterfly shape wire assembly of 0.045 in. dimensions. The butterfly
wire assembly is soldered to the second bicuspid or deciduous molar
bands. The wires are distally inserted into 0.045-in. tube sections
welded to the palatal sides of the first molar bands.
The palatal assembly allows the molars to be distalised without
undesirable tipping. Nickel–titanium coil spring (0.010 in. wire, 0.45
in. diameter), approximately 10 mm each in length is compressed
between the bicuspid solder joints on either side. These springs are
designed to balance the action of the vestibular screws, preventing
molar rotations and development of posterior cross-bites.
The first class appliance is activated at the formative screw a quarter
turn in a counterclockwise direction (clockwise as viewed in a mirror)
once per day for bilateral distalisation.
After completion of molar distalisation, appliance is transformed
into modified Nance holding arch.
The appliance is removed from the mouth, and the bands on the
second premolars and the screws and palatal coil springs are
eliminated. The first molar bands are crimped with a hard wire cutter
to stabilise the molar in the distal position. The modified appliance is
then re-cemented after disconnecting the butterfly wire assembly from
the premolars and removing the screw (Fig. 49.2.27A, B).
Treatment outcome of FCA appliance

Following data analysis of 17 subjects treated with FCA, the authors
report a rapid molar distalisation and correction of class II molar
relationship on an average of 2.4 months. The maxillary molar
distalisation contributed to only 70% of the space created anterior to
the first molars remaining 30% being anterior anchorage loss.17
The maxillary first molars moved distally an average of 4.0 mm per
side, with a mean distal tipping of 4.6 degrees. Anchorage loss
measured at the second premolars was 1.7 mm with 2.2 degrees of
mesial tipping. The maxillary central incisors proclined slightly
during treatment (2.6 degrees), with minimal increase in overjet
(1.2 mm). No significant changes in sagittal or vertical skeletal
relationships were observed.
In another RCT study on FCA, the rate of molar movement was
1.00 mm/month, which, however, was associated with distal tipping
of the first molars (8.56 degrees) and anchorage loss of the anterior
dental unit in terms of overjet increase (0.68 mm), and mesial
movement (1.86 mm) and inclination (1.85 degrees) of the first
premolars or first deciduous molars. The maxillary first molars also
moved buccally (1.37 mm), but no significant distal rotation
occurred.34
In general, FCA is an effective molar distalisation method; however,
its significant advantage over others methods seems to lie in
preventing molar rotation and not in bodily movement and or
anchorage loss.35
Skeletal anchorage
Mini screw supported distalisation system
(MISDS)
The extraction treatment in class II malocclusion with molar
distalisation was introduced by Papadopoulos.23
The active unit for palatal placed distaliser is an apically positioned
wire tubes and nickel–titanium open-coil springs, as described by
Keles et al.
The anchorage unit uses Nance button that is further supported
with miniscrew implants in the paramedian region of the palate for
temporary and stationary anchorage to resist the anteriorly oriented
reciprocal forces during molar distalisation and anterior retraction.
Two miniscrew self-drilling implants (Aarhus Mini-Implant System,
Medicon eG, Tuttlingen, Germany) are used to anchor the MISDS to
prevent rotation of the appliance in case of asymmetrical force
application. Two MIS are a better choice for unilateral distalisation or
bilateral application of forces of different magnitude. The size of the
MIS is selected using CBCT measurements in the region of insertion.
Two MIS also enhance the stability of anchorage unit increasing their
resistance to the mesially directed reciprocal forces of the coil springs.
The point of force application of the palatally positioned open
nickel–titanium coil springs of the MISDS passes through the CRes of
the maxillary molar; therefore, an almost pure bodily distal movement
is produced, and distal molar crown tipping can be avoided.
After molar distalisation, with MISDS a slight chairside
modification provides maximum anchorage for anterior tooth
retraction with conventional full fixed appliances. The molars are
guided to slide on the horseshoe type of palatal archwire, which runs
parallel to the maxillary occlusal plane, no rotation of these teeth is
expected during distalisation.
The authors like to place MIS on a palatal site, 6–9 mm posterior to
the incisive foramen and 3–6 mm away from the mid-palatal suture in
the paramedian area.
After molar distalisation, the appliance is converted into a skeletally
anchored stabilisation appliance to retain the maxillary first molars in
position. The device also acts as an anchoring unit for anterior tooth
retraction. A simple chairside procedure can be performed intraorally
by simply removing the coil springs and shifting the stop screws to
contact the mesial and distal aspects of each headgear tube.
The optional stabilisation period can be 2–3 months. During this
period, the spontaneous distal drift of all teeth anterior to the molars
from the pull of the trans-septal fibres can be completed. After this
stabilisation period, a second phase of comprehensive orthodontic
treatment with full fixed appliances can finalise the treatment of class
II malocclusion by retracting the anterior teeth and finishing
(Fig. 49.2.28A, B).
FIGURE 49.2.28 Mini implant screw supported molar distalisation

system (MISDS).
(A) Progress intraoral photographs 6 months after start of MISDS
treatment; molars have been distalised. Note initial drifting of the
premolars and the canines. (B) Progress intraoral photographs after
drifting of the premolars and the canines. Source: Papadopoulos MA.
Orthodontic treatment of class II malocclusion with miniscrew implants.
Am J Orthod Dentofacial Orthop 2008;134(5) 604.e1-16.23
The Beneslider26 is a distalisation appliance anchored to the mini-

implants in the anterior palate. Two benifit mini-implants are placed
in the anterior palate about 5–10 mm apart along the line of force. The
mini-implants are inserted in the area of the mid-palatal suture. The
maximum insertion moments recorded in a series of cases on mini-
implants placement in the anterior and median regions of the suture
range from 8 to 25 Ncm, which can be regarded as adequate for
primary stability.
Two mini screw implants are coupled with a Beneplate. The molar
distalising force is delivered through a skeleton of the system which is
attached and takes anchorage from the implants. The two open-coil
springs (240 g for children and 500 g for adults), activated by pressing
the activation locks against the coil springs.
Molar distalisation with TAD anchorage: Author suggested and
used TAD supported indirect anchorage through a universal assembly
connector for enmass retraction in severe anchorage cases. Based on
the principles of a universal connector with TAD, a simple yet
effective assembly has been suggested for buccal application of molar
distalisation force. Anchorage is derived using second premolar and
TAD connected through a universal connector. Jones Jig with 75–100 g
of force is used.36
• Preparation of molars and premolars: Molar bands with molar

tubes having a 0.022 × 0.028 in. main slot and gingivally
placed headgear tube are cemented on the maxillary first
molars. An edgewise bracket is bonded to the second
premolar tooth through which Jones Jig can be activated by
tying it with the ligature.
• Implant insertion and indirect anchorage: Miniscrew implants
1.5–1.4 mm diameter and 8 mm long is placed in the buccal
inter-radicular bone between maxillary second premolar and
first molar using self-drilling and self-tapping method with
adequate aseptic precautions. For the preparation of anterior
anchorage unit, 0.017 × 0.025 in. SS wire is connected from the
miniscrew implant bracket head slot to second premolar
bracket.
• Jones Jig appliance13: One arm of the Jones Jig fitted into the
0.045-in. headgear tube and the other arm were fitted into the
main 0.022 in. slot of the maxillary first molar band. After
fitting the Jones Jig into the corresponding tube and slot, the
appliance is activated by tying the activation loop back with a
0.010 in. ligature to the anchor tooth bracket. Thus, the
appliance uses buccal anchorage and a force of 70–75 g
delivered by a 0.040-in. nickel–titanium spring to move the
maxillary first molar distally. The coil are reactivated at 4–5-
week intervals until the desired change in the first molar
relationship to class I is achieved.
After removal of the appliance and retrieval of TADs, a smaller,

easier-to-clean Nance button (insta-Nance) is placed immediately to
hold the molars and allow the upper buccal segments to drift distally
as the trans-septal fibres reorient. A full fixed orthodontic therapy
using 0.022 × 0.028 in. slot appliance is instituted to complete the
TAD connected to the first premolar through universal connector, a
source of anchorage, served as a simple yet reliable technique for
preventing the major drawback associated with Nance button
regarding anchorage loss (Figs 49.2.29–49.2.32).
FIGURE 49.2.29 MIS-supported molar distalisation.

Initiation of distalisation using Jones Jig appliance 90 g force/side with
TAD as anchorage reinforcement.
FIGURE 49.2.30 MIS-supported molar distalisation. Pretreatment

records.
A 12-year-old young girl with mid-class II occlusion with superior
protrusion. Mandible appears slightly retrognathic.
(A) Bilateral TAD-universal connector molar distalisation system. (B)
Occlusal view before and after molar distalisation. (C) Buccal view R&L
molars in class I relationship. (D) Cephalogram and OPG show distinct
molar distalisation. (E) A space consolidation and (F) detailing of
occlusion with full fixed appliance.

Posttreatment records show a significant improvement in facial profile
and occlusion.
All intraoral noncompliance molar distalisation appliance are known
to cause distal crown tipping, extrusion and distal rotation of the
maxillary molars. Therefore, the maxillary molar distal movement
measured at centroid is much less than measured at the occlusal
plane. The molars tend to rotate either buccal or palatal depending
upon the point of application of force, that is buccal or palatal. The
reciprocal forces of molar distalisation are counteracted by anchorage
derived from modified Nance button. The unwanted effects are mesial
movement and inclination of the premolars. Moreover, proclination of
the incisors is inherent with these appliances. The CRes of anchorage
dental units is located between the root apices of the premolars.38 The
premolars and the canines incline and move mesially leading to
incisors proclination which is, termed as anterior anchorage loss.
The maxillary molar, on the other hand, has its centre of resistance
somewhere at the trifurcation of roots. Consequently, the point of
force application is limited by the biological limitations and hence
some amount of distal tipping is unavoidable. Distal tipping is also
influenced by the eruption status of the second molars; a fully erupted
second molar does not pose a challenge in distal movement, while a
second molar partially erupted at the level of neck of the first molar
may serve as a fulcrum leading to significant tipping of the first molar
during distalisation.
Most molar distalisation appliance cause some distal palatal
rotation and narrowing of the intermolar width, which is greater with
pendulum appliance. Pendulum appliance or its variations cause
distopalatal rotation of the maxillary first molar as the tooth is
distalised along the arc of the activation of the spring (Figs 49.2.33
and 49.2.34).
FIGURE 49.2.33 Biomechanics of maxillary molar distalisation.
(A) Forces and moments generated by cervical head-gear. (B) Forces
and moments generated by noncompliance distalisation appliances,
such as the sectional jig assembly, with a force system buccally
positioned. (C) Forces and moments generated by noncompliance
distalisation appliances, such as the pendulum appliance, with a force
system palatally positioned. Source: Reprinted from MA Papadopoulos
with permission of the Argentinean Orthodontic Society.34
FIGURE 49.2.34 Biomechanics of maxillary molar distalisation

with noncompliance distalisation appliances.
(A) Forces and moments generated by the appliance at treatment start.
(B) Situation after molar distalisation: distal crown tipping can be
observed as a side effect and anchorage loss in terms of incisor
proclination and mesial movement and inclination of the premolars and
canines. Source: Reprinted from MA Papadopoulos with permission of
the Argentinean Orthodontic Society.34
The intraoral maxillary molar distalisation has been in practice prior
to, during and after the eruption of the second maxillary molar.
However, the problem of anchorage loss is regarded much less before
the eruption of second molars.
Hence, recommended time for maxillary molar distalisation is
either during mixed or late mixed dentition. The most opportune time
to move maxillary first molars distally is before eruption of second
molars’.39
Kinzinger et al. found that during distalisation the maxillary first
molars tipped more when the second molars were unerupted and that
the erupted second molars tipped more when the third molars were
unerupted (i.e. at the budding stage).40
Investigators have researched clinical efficacy and anchorage loss
following molar distalisation and post-distalisation phase.41,42
Based on a pooled sample of seven published studies on pendulum
appliance (sample size 247) and two studies on Jones Jig (82 subjects),
the findings are the following.43,44
The rate of distalisation. Maxillary molar is distalised at the rate of
0.75–1 mm/month on an average. It has been reported that the distal
movement of the molar is accompanied with a significant amount of
distal tipping. The distal molar tip was found to be 8.38 ± 1.8 degrees
for pendulum appliance and 7.67 ± 3.4 degrees for Jones Jig.
Anchorage loss. The force applied to move molar distally utilises
premolars as anchorage. The consequence is mesial movement of
anterior teeth, an increase in anterior crowding, labial movement of
maxillary incisors and their buccal tipping. On an average, for every
4 mm of molar distalisation 1 mm anterior anchorage is lost.
Bone anchored molar distalisation: TAD supported and bone
anchored distalisation appliance are expected to minimise anterior
anchorage loss.
The distal movements of the maxillary molars in the studies with
comparable distalisation techniques were from 3.9 to 6.4 mm. At the
same time, the maxillary incisors remained stable. However,
distalisation of the molars was associated with 3.0–12.20 degrees of
distal tipping.25,28,29,42,45-48
In a study at AIIMS where TAD supported Jones Jig was used the
amount of premolar anchorage loss was negligible (0.61 mm). The
mean molar distalisation (T1) measured on dental casts at the central
fossa of maxillary first molar was 4.18 mm.
On cephalometric evaluation at the centroid, molar distalisation
was measured as 2.82 mm which is 68% of total distalisation at
occlusal level. This indicates that significant amount of tipping (mean
8.92 ± 2.24 degrees) is associated with the distal molar movement.45
Intraoral noncompliance molar distalisation is now an accepted
mode of therapy. Case selection and control of anchorage loss are
critical for a successful therapy.
Key Points
Essentially, four ‘tools’ are available to an orthodontist to gain space
in the dental arch:
1. Molar distalisation
2. Proximal recontouring
3. Maxillary expansion
4. Labial proclination of teeth
The choice of methodology is essentially dependent upon the

nature of malocclusion, the age of the patient, profile, skeletal and
dental pattern. There is no ‘cook book’ approach to non-extraction
treatment strategies. The key to success is proper case selection and
use of an effective method(s).
With respect to intraoral molar distalisation, the challenge lies in
control of the distal tipping of the molar and prevention of loss of
buccal anchorage after molar distalisation.
With my clinical experience I am more comfortable and efficient
with buccally directed force for ease of manipulation and patient
comfort. With regard to TAD-supported molar distalsiation, palatal
approach is efficient; however, it comes with additional cost and
discomfort. In adult patients, the palatal MSI-supported appliance is
preferable.
Case selection and proper application of biomechanics to the
patients’ advantage is the key to success.
References
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24. Kinzinger G, Gülden N, Yildizhan F, Hermanns-
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JA. The skeletal frog appliance for maxillary molar
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31. Kinzinger G, Syrée C, Fritz U, Diedrich P. Molar
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with sliding mechanics: a case report. J Orthod.
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33. Al-Thomali Y, Basha S, Mohamed RN. Pendulum and
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34. Papadopoulos MA, Melkos AB, Athanasiou AE.
Noncompliance maxillary molar distalization with
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43. Kharbanda OP, Negi A. Molar distalization with
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SECTION XI
Class II malocclusion
Chapter 50: Class II division 1 malocclusion: features and early

intervention of growing maxillary excess
Chapter 51: Evolution of functional appliances and treatment
with one piece removable appliances
Chapter 52: Treatment approaches with twin block appliance
Chapter 53: Interception and treatment of mandibular retrusion
with non-compliant fixed functional appliances
Chapter 54: Mode of action of functional appliances
Chapter 55: Dentofacial orthopaedics for class II malocclusion
with vertical maxillary excess
Chapter 56: Management of class II malocclusion with fixed
appliance
Chapter 57: Class II division 2 malocclusion
CHAPTER 50
Class II division 1 malocclusion:
features and early intervention of
growing maxillary excess
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Prevalence
Clinical findings
Presentation during deciduous and early mixed dentition
Occlusal and craniofacial characteristics from deciduous
to mixed dentition
Occlusal and craniofacial findings of class II malocclusion
during late mixed/permanent dentition stage
McNamara’s classification
Moyers classification
Clustering approach of phenotype characters
Interception of developing class II malocclusion
Orthodontic interventions during deciduous dentition
Orthodontic interventions during early mixed dentition
Indication and uses of Kloehn facebow
Components of a facebow
Clinical management Kloehn facebow
Effects of facebow
Key Points
Introduction
Class II malocclusion comprises a group of specific skeletal, dental
and facial features exhibiting mandibular retrusion. Class II
malocclusion implies a distal positioning of the lower dental arch and
chin, and a protrusive midface and proclination of the maxillary
incisors. Class II malocclusion exists in vertical facial types as well as
well as horizontal face types (Fig. 50.1).
FIGURE 50.1 Class II malocclusion.
Note overjet and a retrognathic mandible.
Class II malocclusion is second in frequency, distribution and

prevalence among Angle’s malocclusion classes. However, it is the
most frequently encountered and treated malocclusion in orthodontic
practice. In general terms, a class II malocclusion is synonymous with
a distal position of the lower molar or mandible or protrusion of the
maxilla and maxillary teeth or their variable combinations.
Prevalence
The prevalence of Angle’s class II malocclusion varies among
population groups. It is high among Caucasians and lowest among
the primitive races (Table 50.1). Class II malocclusion is observed in a
wide spectrum of presentation and severity.
Table 50.1
Prevalence of class II malocclusion
Clinical findings
Presentation during deciduous and early
mixed dentition
A distal step relationship of second deciduous molars is an indication
of a developing class II malocclusion during the mixed dentition. The
occlusal traits of class II malocclusion in the deciduous dentition
include a distal terminal plane at the second deciduous molars, distal
canine relation, large overjet and overbite.1 Other findings include a
narrow maxillary basal bone and reduced or no spacing in the
deciduous dentition.
The class II subjects have a narrow maxillary arch resulting in a
negative transverse discrepancy between maxillary and mandibular
intermolar widths in the mixed dentition (−4.1 ± 3.0 mm). TD is close
to zero in subjects with class I occlusion (controls).2
Subjects with class II malocclusion also show a significantly
retruded mandible and a shorter mandibular length (Co–Pg) on
cephalometric examination.1,2 The maxilla can also be displaced
forward in class II subjects with or without a difference in the length
of the mandible.
Occlusal and craniofacial characteristics from

deciduous to mixed dentition
A distal step deciduous molar relationship is never a self-correcting
situation in growing children.3 However, children with a straight
terminal plane may develop into a class I molar or a class II molar
relationship influenced by the mandibular growth and adjustment of
occlusion during the late mixed dentition. In a clinical sense, it infers
that when we encounter a class II distal molar relation early in the
mixed or permanent dentition, interceptive and corrective therapy
needs to be planned. A growing class II malocclusion is unlikely to
improve more so when unfavourable environmental influences
continue to affect the development of face and occlusion. These
adverse influences are: recurrent throat infections, obstructive or
adaptive mouth breathing habit, thumb sucking and lip sucking
habits.
During the transition from deciduous to mixed dentition, the
craniofacial skeletal pattern shows an abnormal and variable pattern
of growth in class II children compared to the control group of normal
occlusion. The upper jaw becomes more prominent due to larger
increments of sagittal growth leading to maxillary protrusion relative
to the cranial structures.
The mandible grows at a lesser pace in class II children than
children with normal occlusion. A more backwards and downward
inclination of the mandibular body leads to worsening of the facial
angle. Other variations in class II subjects consist of constriction of the
maxilla at both the skeletal and dentoalveolar levels and narrowing of
the base of the nose. In general, the occlusal and skeletal features of
class II malocclusion during deciduous dentition may remain stable or
worsen into the stage of mixed dentition. There are certainly no
favourable changes leading to self-correction of established class II
pattern into a class I occlusion.
Occlusal and craniofacial findings of class II

malocclusion during late mixed/permanent
dentition stage
A child with class II malocclusion presents with a protrusive midface
and/or a retrusive chin. They often report with complaints of a
superior protrusion, front teeth jutting out or showing too much. This
is often accompanied by a large overjet, deep bite (open bite can be
seen in some) and a class II (distal) molar, premolar and canine
relationship. These children have an aberrant pattern of muscle
activity of the facial musculature such as a flaccid upper lip,
hyperactive mentalis and lower lip trap under the procumbent upper
incisors. The aetiology may be attributed to mouth
breathing/prolonged thumb sucking which can be elicited on carefully
recording the history of the patient.
The underlying craniofacial pattern of class II children has been
extensively investigated. Most of the studies have concentrated on
angular, sagittal and vertical measurements on lateral cephalograms.
A few studies are also available on transverse dimensions using PA
cephalograms. A class II skeletal pattern may be associated with a
prognathic maxilla, retrognathic mandible, or a combination of these
in varying severity.
In young growing children class II division 1 malocclusion exhibits
a narrow maxilla and dentoalveolar structures along with increase in
the vertical height.4
McNamara’s classification
Two major types of skeletal combinations in class II children have
been defined by McNamara.5
1. In the first group, mandibular retrusion is the single most

characteristic feature contributing to class II pattern. The
skeletal maxillary protrusion is not the significant finding, but
often the maxilla is normal. This type of craniofacial pattern
has been attributed to aberrant environmental factors such as
abnormal muscle function which causes altered occlusal inter-
digitations.
2. In the second group, a combination of maxillary and
mandibular skeletal retrusion is often found in association
with altered mode of respiration that is mouth breathing.
These children with maxillary and mandibular retrusion show
a greater vertical development of the face. An excessive labial
proclination and forward position of the maxillary anterior
teeth is a common finding in this type of class II division 1
malocclusion. The maxillary first molars are more mesially
positioned. The anterior segment of the maxilla is more
protrusive and superiorly positioned. The excessive anterior
cranial base length and enlarged frontal and maxillary sinus
may be a contributing factor in the development of class II
division 1 malocclusion. The mandible and dentition could be
identical to those of the controls in size, form and position.
Moyers classification
Moyers et al.6 stated that while within a population class II
malocclusion cases could be clustered quite unambiguously the
distinction between class I and class II is not that obviously distinct.
Based on advanced analytical computer-based statistical methods of
cephalometrics records of 697 North American children, they
segregated six horizontal class II types and five vertical class II types
of pattern.
I. Horizontal types class II—A, B, C, D, E, F

II. Vertical types class II—1, 2, 3, 4, 5
Horizontal types class II. It is designated as A, B, C, D, E and F (Fig.

50.2A–F, Box 50.1). While types B, C, D, E have distinct craniofacial,
dental and growth pattern, types A and F are somewhat loose in their
description.
FIGURE 50.2 Diagrammatic representation of the horizontal
facial types in class II.
The large rectangles symbolise the maxilla and the mandible, and the
small squares represent the first molars, incisors are represented as
vertical lines when normal, angled when in labioversion. The ideal
profile seen in orthognathism is depicted by a dotted line. (A) Moyers
horizontal class II: Type A normal skeletal profile, mandibular dentition
normal, maxillary dentition is protracted, greater-than-normal incisal
overjet. (B) Moyers horizontal class II: Type B midface prominence,
mandible of normal size, flat anterior cranial base (ACB). (C) Moyers
horizontal class II: Type C maxillary and mandibular retrognathism,
dental protraction and dental procumbency. (4) Moyers horizontal class
II: Type D maxillary retrognathism, dental protraction, mandibular
retrognathism. (5) Moyers horizontal class II: Type E prominent
midface and normal or even prominent mandible. Bimaxillary
protrusion, both dentitions have a tendency to be forward. (6) Moyers
horizontal class II: Type F A large heterogeneous subgroup of less
severity, not well-defined rigid syndromal class II type but, rather, a
loose collection of cases displaying some skeletal class II
characteristics. Source: Reproduced with permission from Moyers RE,
Riolo ML, Guire KE, Wainright RL, Bookstein FL. Differential diagnosis
of class II malocclusions. Part 1. Facial types associated with class II
malocclusions. Am J Orthod. 1980 Nov;78(5):477–94. PubMed PMID:
6933855.6
Box 50.1 Class II malocclusion: types

Type Normal skeletal profile Orthognathic
A Normal occlusal plane maxilla/orthognathic mandible
Normal maxilla/mandible
Normal mandibular dentition
Maxillary dentition placed forward in class II molar,
increased overjet and bite
Orthognathic maxilla/orthognathic mandible
Type Class II skeletal profile Prognathic
B Midface prominence maxilla/orthognathic mandible
Normal mandible
Flat anterior cranial base
Type Smaller facial dimensions than other class II types Retrognathic
C Maxilla and mandible retrognathic maxilla/retrognathic mandible
Lower incisors tipped labially
Upper incisors upright/tipped labially
Squarish gonial angle
Flat anterior cranial base
Type Normal midface Orthognathic
D Small mandible maxilla/retrognathic mandible
Mandibular incisors upright/lingually inclined
Maxillary incisors tipped labially
Type Prominent midface Bi max
E Normal
These are bimaxillary protrusions
Maxillary/mandibular incisors proclined
Type No specific features to be well defined, but has a loose
F collection of cases
with some class II characteristics
Source: Reproduced with permission from Moyers RE, Riolo ML,

Guire E, Wainright RL, Bookstein FL. Differential diagnosis of class II
malocclusions. Part 1. Facial types associated with class II
malocclusions. Am J Orthod 1980 Nov;78(5):477–94.6
Type A is more of a dental in nature, and type F, which was the

largest subgroup in their sample showed features which are not
distinctly class II yet away from class I.
Class II type A has a normal skeletal profile and normal position of
maxilla and mandible. The occlusal plane is normally inclined. The
maxillary dentition is protracted resulting in increased overjet and
deep bite.
Class II type B has midface prominence due to a large maxilla and
normal mandible. The anterior cranial fossa tends to be flat.
Class II type C has a normal or diminished midface. The profile is
retrognathic due to severe retrognathic mandible. It is a severe form of
class II horizontal type with a short maxilla, shorter mandible,
reduced gonial angle and a flat anterior cranial base (ACB).
Class II type D is associated with normal or slightly diminished
midface; maxillary incisors are extremely labially inclined. Gonial
angle can have extreme variations.
Class II type E is an extreme variation of class II with bimaxillary
protrusion type class II pattern. There is a prominent midface
associated with normal or even large mandible. Both skeleton and
dentition have a forward/labial tendency.
Class II type F is rather an ambiguous type of malocclusion where
class II features are not distinctly defined. It is a milder form of B, C, D
or E type of class II pattern, but the skeletal profile is in less severe
forms.
Vertical types class II. Five types of vertical types are segregated
which are not as clearly distinguished as the four of horizontal type
(B, C, D, E) of class II. All the vertical patterns may not be seen in each
of horizontal type of class II rather there are certain vertical
associations with horizontal types. For example in horizontal type A
and F, vertical measurements are normal or close to normal (Fig. 50.3).
FIGURE 50.3 Moyers five vertical types of class II malocclusion.
Solid red lines represent the normal position of the cranial base, palatal
plane, occlusal and mandibular planes. Broken purple lines represent
the variation from normal for each vertical types.
Vertical type 1 is suggestive of ‘long face syndrome’ or ‘steep

mandibular plane angle’ type of class II. The functional occlusal plane
is also steep associated with a palatal plane that is tipped downward.
Vertical type 2 is associated with a squarish type of face. The
anterior cranial fossa is more horizontal than normal, and so are the
mandibular plane, functional occlusal plane and palatal plane. The
incisors tend to be upright in a deep bite. The gonial angle is squarish.
Vertical type 3 is a distinct class II associated with skeletal anterior
open bite and increased anterior face height. The palatal plane is
tipped anteriorly upward and the mandibular plane is steep.
Vertical type 4 is a rare and severe anomalous vertical class II type.
The mandibular plane, functional occlusal plane, and palatal plane are
markedly tipped downward, which leaves the lip line high on the
alveolar process of the maxilla. The gonial angle is obtuse.
Vertical type 5 is somewhat seen in bimaxillary protrusion
horizontal class II where the face is squarish. The mandibular plane
and functional occlusion plane are normally associated with a small
gonial angle resulting in a skeletal deep bite.
In brief, each case of class II malocclusion cannot be placed in a
single category or type, and it may have a combination of sagittal,
vertical and transverse deviations of varying severity.
Clustering approach of phenotype characters

Research is ongoing on phenotype and genetic identification of class II
malocclusion at the University of Iowa.
A cephalometric study by Sara Lee on 309 class II caucasian adult
patients of both sexes analysed for 63 cephalometric variables. These
were reduced to seven principal components (PC) that explained 81%
of the variation of class II sample. Each PC represents a specific
phenotype or trait of the malocclusion. Furthermore, five distinct
clusters have been identified that divide this malocclusion into
homogeneous phenotypic groups. The seven PC are:
1. Vertical trends/mandibular plane angle—cranial base

2. Maxillary incisor angulation
3. Mandible horizontal and vertical lengths
4. Position of the maxilla, especially in regards to the maxillary
incisor angulation
5. Facial taper and mandibular incisors
6. Position of the maxilla and cranial base inclination
7. Overjet and WITS values
1. The PC1 explained most of the variation. The first component

describes the vertical dimension in regards to the angulation of
the mandibular plane to the cranial base. The verticality of
craniofacial component plays a significant role in determining
the treatment approach and treatment response may differ in
patients with a flat plane versus a steeper plane.
2. PC2 refers to maxillary incisor inclination. Maxillary incisor
proclination is a significant feature distinguishing class II
subdivisions.
3. PC3 differentiates the range of mandibular lengths present in
class II patients. Subjects with class II malocclusion may
present with a smaller size of the mandibles, however, some
subjects may have normal size mandibles and are class II
skeletally based on a malpositioned maxilla. For each patient
the affected jaw size and position will affect the treatment.
4. PC4 signifies the position of the maxilla, especially in regards
to the maxillary incisor angulation.
5. PC5 deals with mandibular incisors proclination, which is
variable.
6. PC6 deals with the position of the maxilla and is seen by the
distance from A-point to nasion perpendicular, where the low
extreme has A-point set back from N perpendicular, and the
high extreme has A-point much more forward of that line,
depicting a more protrusive maxilla. The inclination of the
anterior cranial base can create variation in the measurements
based on these landmarks. Below normal values of angles,
SNA and SNB angles can be a reflection of maxillo-mandibular
retrusion, or can be an outcome of a low sella or high nasion
point creating a steeper cranial base.
7. PC7 describes the overjet a reflection of the differences in the
underlying skeletal discrepancy. It is obvious that the patient
on the high end is a more severe class II, while the low end has
normal overjet and may have only mild class II skeletal
tendencies.7
In addition to the above findings, studies are in progress to explore

the characterisation of the class II malocclusion integrating
measurements on lateral cephalograms, photographs, 3-D cast and
CBCT. Further studies correlating above data with DNA and
environmental data will be researched to identify the causative gene
for developing a class II malocclusion. The ultimate objective is to
decide an individualised plan of treatment.8
Interception of developing class II
malocclusion
The objectives of early intervention of growing class II malocclusion
are to modify the abnormal functions of the stomatognathic system
such as breaking the habits, oral respiration, tongue thrust or
abnormal swallowing.
A majority of studies have documented therapeutic benefits of
functional appliance therapy which is aimed to restrain maxillary
growth or normalise the sagittal position of the maxilla. The clinical
parameters are focused on sagittal correction of the malocclusion
although the benefits of the therapy are three directional and do
increase the volume of the oral cavity and structures in the near
vicinity. Favourable skeletal changes which can modify the growth
pattern can also occur depending on individual growth potential. The
benefits are extended to normalisation of abnormal neuromuscular
functions.
There have been two major approaches to tackle growing class II
skeletal relationship. While Americans approached it with the use of
head gear to restrain the maxillary growth, European orthodontists
perceived it primarily a problem of retrognathic mandible, and
therefore used the appliance to place the mandible forward. Current
thinking has merged the two approaches and treatment is planned
based on an individual’s craniofacial morphology and growth trend
(Fig. 50.4).
FIGURE 50.4 Clinicians perspective of class II malocclusion.
Orthodontic interventions during deciduous

dentition
Only limited orthodontic interventions are possible during the
deciduous dentition stage for the interception of developing class II
malocclusion.
Maintenance of healthy primary dentition. All efforts are directed
towards the maintenance of the healthy primary dentition and thus
integrity of arch length. Healthy dentition is a prerequisite to the
development of the normal occlusion. Oral health education of the
family and children, home care, and the measures that minimise the
occurrence of dental caries significantly contribute to a caries free
mouth. Restoration of carious teeth to their correct anteroposterior
dimensions is absolutely essential especially proximal carious lesions
on deciduous molars. The sole purpose is that permanent first molars
should occupy the space distal to second deciduous molars and
should not prematurely migrate forward.
Interception of deleterious oral habits. Non-nutritive sucking habits
such as prolonged thumb and finger sucking are taken care of with
appropriate counselling and interceptive habit breaking appliance. A
child with a recurrent throat infection, nasal blockages or allergies
should undergo ENT consultation and suggested treatment to
facilitate normal breathing, essential for the normal development of
the face.
Orthodontic interventions during early mixed

dentition
An essential approach to the interception of class II malocclusion
involves redirection of the growth to a favourable pattern and
elimination of aberrant muscle behaviour and/or deleterious habits,
thereby allowing the face, jaws and occlusion to grow in abnormal
occlusion.
Cases requiring treatment of maxillary excess and short mandible
would need a more aggressive approach which involves dentofacial
orthopaedic treatment.
More severe forms of class II dysplasia such as an extreme vertical
type of pattern and those with open bite may benefit partially or not
benefit at all with interceptive procedures alone. These cases would
require a surgical approach at an appropriate stage of their occlusal
and skeletal development.
Interception of growing maxillary excess involves guiding alveolar
growth using headgear orthopaedic force. The -cervical headgear was
introduced by Silas Kloehn for treating class II during mixed
dentition.9,10 Kloehn was the earliest advocate of orthopaedic forces to
change positions of teeth and so influence the changes of the alveolar
process in the maxilla. During normal cranio-facial and alveolar
growth, alveolus and teeth move forward and these can be
intercepted. Thus if the maxilla is restrained in class II patients,
mandible will follow its normal growth and reach to a normal
relationship with the maxilla. A cervical headgear/high pull head gear
with a facebow is used to restrain maxillary growth and distalise the
upper dentition to class I occlusion.
Indication and uses of Kloehn facebow

1. Kloehn facebow can be used to act upon maxillary molars
alone to achieve dental effects or orthopaedic effect on
maxillary dentoalveolar segments.
2. It can be used to distalise maxillary molar(s), which have
mesially migrated due to the premature loss of the deciduous
molars.
3. Kloehn facebow has also been used to reinforce anchorage in
the maxillary arch.
4. It is used in combination with maxillary splint appliance to
achieve orthopaedic effects on the maxillary skeleton, through
a removable appliance: activator headgear approach.
Components of a facebow
Kloehn facebow is made from rigid stainless steel wire framework. It
has a horseshoe shape/dental arch form of inner bow of 0.045-in.
diameter and an outer bow of 0.071-in. diameter. The inner bow
follows curves/arch form of the maxillary arch while long arms of the
outer bow lie on either side of face extending close to the tragus of the
ear. Both bows are laser welded or soldered in incisor region strong
enough to withstand orthopaedic forces that are applied to the inner
bow through extraoral traction system either from a cervical neck
strap or a high-pull headgear. Cervical facebows are commercially
available in different sizes to suit variable arch lengths (Fig. 50.5).
FIGURE 50.5 Facebows.

(A) Parts of a Kloehn facebow. (B) Facebow with longer. (C) Short
outer bow.
The standard bow has its inner bow without any built-in stops. It
requires that stops to be created by making bayonet bends at
appropriate positions after it has been tried in the mouth. Molar stops
can also be soldered type or through ‘U’ loops mesial to first molars.
Standard facebows are usually available in mini, medium and maxi or
large size.
Facebow with stop loops

These facebows have built-in loops on the inner bow at various
distances on arch length. The facebow is ready to use after a selection
from stock but would need a large inventory to be maintained. The
outer facebow is bent to hold the hole in the neck strap/headgears
safety module. The ends are bent and covered with soft plastic caps to
minimise irritation or injuries associated with sharp ends of the bow
wire.
The neck pads and high-pull headgears are available either with
hooks or safety modules. If safety modules are not used, extraoral
elastics are recommended for the application of force. The extraoral
latex elastics are available in variable force values and sizes.
The use of extraoral elastics with Kloehn type of facebow has been
discarded due to risk of injuries associated with facebow. In modern
practice, the safety modules with metal clips are recommended as
they minimise a few risks of the injuries especially those associated
with recoil, where the appliance is actively pulled; or as a result of
accidental disengagement, particularly during sleep.11 The locking
facebows that offer safety against accidental pull are described later in
the chapter.
Facebow can be used in conjunction with a cervical pull neck strap
or a high-pull headgear (Figs. 50.6A–B and 50.7A–B).
FIGURE 50.6 Kloehn headgear components.
(A) Neck pad. (B) Safety modules.
FIGURE 50.7 Two types of head gear with calibrated force
modules.
(A) Cervical pull. (B, C) High pull headgear connected to facebow.
Clinical management Kloehn facebow

The inner bow fits into the round headgear tube on the maxillary first
molar bands. Conventionally, a double buccal tube is welded and
soldered on to the maxillary first molar bands, and the round tube is
housed as much gingival as permissible by the clinical crown height.
The purpose is to place the tube high and therefore the application of
force close to the centre of resistance of the first molar.13
The tubes are double checked for quality of welding and
additionally soldered to prevent any breakages. The molar bands
should be absolutely well fitting, cemented with great care after due
polishing and cleaning of molars such that no chances are left for the
band failure or tube breakages.
The centre of resistance of the maxillary molars lies somewhat near
the trifurcation of the roots (Fig. 50.8A). When the maxillary arch is
banded with archwire in place, the centre of rotation of the arch lies
somewhat between First and second premolars (Fig. 50.8B). The centre
of resistance of the skeleton of the maxilla lies just below the
zygomatic buttress (Fig. 50.8C).
FIGURE 50.8 Centre of resistance.
(A) Maxillary molar tooth. (B) Banded maxillary arch. (C) Maxilla.
A bow of the proper size is selected from the stock using dental
study models as a guide and tried in the mouth. The inner bow stops
against molar tubes are so adjusted that a space of 4–6 mm is kept
between the bow and incisors. The free ends of the inner bow are bent
inwards to prevent unwanted rotation of the first molars.
The inner bow is expanded, to 8–10 mm larger than the distance
between first molar tubes, and made parallel to the occlusal plane. The
expanded bow helps to widen the maxillary dentoalveolar arch, gain
in arch length and relief of crowding. The mandibular arch
correspondingly grows into an expanded maxillary arch (Fig. 50.9).
FIGURE 50.9 Cervical headgear and the placement of the molar

tube.
The inner bow is expanded 10 mm larger than the distance between
the first maxillary molar tubes and is parallel to the occlusal plane. The
arrows indicate the expansion of the inner bow.
The outer facebow has two long arms which remain on either side
of the face, extending to the tragus of the ear well beyond the first
molars. The rigid outer bow is maintained at an elevation of about 15
degrees (10–20 degrees) to the inner bow/horizontal plane to prevent
excessive distal tipping and extrusion of the molar teeth (Fig. 50.10).11
FIGURE 50.10 Cephalograms showing inclination of inner and

outer facebow. Source: Reproduced with permission from Lima Filho
RM.12
Force levels and wear schedule

Safety modules are available in three force levels (Table 50.2). Force of
450–500 g is used from cervical gear safety module to the outer bow.
The force is measured with a heavy duty force gauge.
Table 50.2
Safety modules: force values.

Sl. No Force grade Force value (g)
1 Light 450
2 Medium 600
3 Heavy/strong 750
The cervical headgear is recommended to be worn 12–14 h/day, in

the evening and at night. The patient is followed up at regular
intervals of 6–8 weeks. He/she is reviewed for the followings:
Any difficulties with the use of an appliance or accidental injuries.
Any history of appliance not in place on awakening or appliance
coming out during sleep. Loosening of bands or tubes.
Review of his/her diary on wear schedule.
Review signs of use of the appliance: intraoral clinical examination
about soreness and distal movement of teeth.
Signs of use on the elastic band and the neck strap.
With regular wear and good patient cooperation, it usually takes
about 12 months to achieve class I molar relation (Fig. 50.11). There is
a simultaneous improvement in overjet. This phase of orthopaedic
correction is followed by fully bonded fixed mechanotherapy if so
required.
FIGURE 50.11 A case treated with Kloehn headgear.
(A) At pre-treatment. (B) Progress models are showing correction of
molar relationship. Source: Reproduced with permission from Lima
Filho RM.14
With this protocol in practice, an excellent control over the occlusal,

palatal and mandibular planes is achieved with little, if any, adverse
effect on the vertical dimension, while accomplishing the intended
improvement in anteroposterior dimensions.9
Age of treatment
Kloehn facebow is indicated in growing children with maxillary
prognathism, or where mesial molar movement has occurred. The
facebow is indicated in early mixed dentition when permanent
maxillary first molars have erupted and can be banded. Lima Filho et
al.14 recommended the onset of treatment in the late mixed dentition
or beginning of the permanent dentition based on the belief that it
often coincides with the facial growth spurt. It may also have the
advantage of continuing the treatment with full-banded fixed
appliance, following completion of 12 months of the first phase. The
cervical traction is continued during/or till the end of active treatment
to prevent relapse and enhance anchorage for maxillary anterior
retraction/overjet correction.
Fig. 50.12A–D depicts a young girl treated for class II malocclusion
with high pull headgear. No further treatment was needed.
FIGURE 50.12 A young girl presented with superior protrusion
and class II malocclusion.
She has well-aligned upper and lower arches. She was treated with
high pull head gear and Klohen facebow attached to the first molars.
(B) Tremendous cooperation by the patient in using high pull headgear.
Note the direction and level of our facebow. The outer facebow is
passing through the centre of rotation of the maxilla. (C) Cephalometric
changes. Note a marked reduction in proclination of maxillary incisor
and skeletal relationship. The SN–GoGn plane remained unchanged.
(D) Posttreatment. Rapid correction in her profile and occlusion lead
to creation of a balanced profile and class I skeleton and dental
relationship. Major changes were observed in the correction of
maxillary incisor and ANB. The maxillo-mandibular relations in vertical
plane remained unaltered.
Asymmetric dental movement of the maxillary molars
In relation to the asymmetric distal movement of the molars, many
approaches have been used. A short outer facebow is used on the side
where less distal movement is required and large outer bow on the
side where greater distal movement of the molar is desired. An active
transpalatal arch on the side of the greater movement, when used in
conjunction with a normal facebow, is the best choice for producing
asymmetric distal force.
The headgear forces act by neutralising the mesial force on the
opposite molar, thus controlling the rotational movement and
optimising the distal force on the desired side.15
Effects of facebow
Cervical head gear affects dental/craniofacial structures in sagittal,
vertical and transverse dimensions. Following 12–18 months of
treatment, there is a reduction in maxillary protrusion, while
mandible continues to grow normally. The distalising effect on
maxillary molars causes them to erupt backwards and downward,
thus inhibiting the lowering of the posterior region of the maxilla,
while anterior region continues to move downward. There is a
downward tipping of the palatal plane at the anterior nasal spine
(ANS). This causes rotation of the palatal plane and slight increase in
SN-PP angle. The inferior descent or extrusion of upper molars is
essentially prevented by the forces of occlusion from the masticatory
muscles. The transverse width of the maxilla improves by the
expanded inner bow, which facilitates a forward displacement of the
mandible and hence, improvement in the facial convexity. The
expanded inner bow also widens the nasal cavity along with
maxillary arch.1,16,17
The maxillary protrusion is reduced while the sagittal position of
the mandible improves, which is measured as a reduction in angle
ANB. The improvement in craniofacial skeletal and dental profile is
sustained during the period of fixed appliance therapy and post
retention period (Fig. 50.13).14
FIGURE 50.13 Long-term effects of Kloehn facebow.
Regional cephalometric superimposition following treatment of ages 10
years (pretreatment), 12 years (posttreatment) and 27 years (follow-
up). Source: Reproduced with permission from Lima Filho RM.12
Children with class II malocclusion may have a narrower oro- and

hypo pharyngeal spaces than the controls. The Kloehn headgear
treatment can increase the nasal width and retropalatal airway space
to some degree, but rest of the upper airways remain unaffected.18
Unwanted side effects of Kloehn headgear can result from the use
of this method of treatment in high angle cases, where molar extrusion
and distal tipping may be significant. This coupled with unfavourable
growth of mandible and clockwise rotation may bring about an
undesirable outcome. The success of the treatment is fully compliance
dependent.
Long-term effects19,20
The long-term effects of early headgear treatment on 8-year follow-up
have shown a significant reduction in non-extraction treatment as
compared to controls. The appliance inhibits the growth of the maxilla
and results in wider and longer arches. Its main effect on maxilla is on
the orientation of the maxillary plane. The maxillary arch expansion
achieved during early headgear treatment results in a corresponding
wide lower arch as an adaptation to maxillary arch. The arch
expansion has been found to be maintained during long-term follow-
up.
Use of Kloehn facebow to correct maxillary protrusion in

high angle cases21–23
While cervical pull headgear may be an appliance of choice to restrain
maxilla and maxillary dentition in children with normal or low
mandibular plane angle subjects, the subjects with vertical growth
tendency may show a clockwise rotation of the mandible due to the
wedging effect caused by extrusion of the marginal ridge of the
maxillary first molars.
Use of facebow with high-pull headgear has been shown to modify
maxillary vertical growth and even produce a slight clockwise
rotation of the palatal plane when used directly on molars or with a
splint design. The maxillary molars are distalised and their vertical
position is maintained by high pull headgear therapy. High-pull
headgear treatment consistently improves sagittal skeletal
relationships, but not the vertical skeletal relationships.
A slight clockwise rotation of the palatal plane should be expected
when the forces are directed through the posterior maxilla. The
maxillary anterior plane is displaced inferiorly.
The response can be unpredictable regarding vertical effects with
cervical or high pull headgear in combination with fixed appliance
therapy. The changes in vertical skeletal relationships demonstrate
wide variation, both during treatment and retention.
Dentoalveolar changes brought about by cervical versus high pull
head gear appliances may not be able to make a predictable difference
in vertical skeletal patterns of growing patients.
Risks associated with the use of facebow and safety of extraoral
appliances have been of concern and more so after the appearance of
several reports of grievous injury that has afflicted eye, leading to
blindness in many cases. Since the first report by American
Association Risks and Safety Protocol of Orthodontists in 1975,24
many more reports continue to appear in the dental, medical and
ophthalmic literature.25–35 Of the 11 eye-cases reported, 10 (91%) of
these have the visual acuity (VA) limited to hand movement
perception or less.30 Consequent to endophthalmitis of the injured
eye, sympathetic ophthalmitis develops on the unaffected eye which
also needs immediate medical care. Serious, devastating outcome
from accidental injuries to eye calls for particular attention of the
orthodontists, patients/parents and ophthalmic surgeons who need to
be aware of this ‘not so common’ but a serious accident associated
with headgear use.35
In 1994, the results of a survey of facebow injuries of the
orthodontic societies and dental schools in 23 European countries
recorded nine serious injuries to the eye and surrounding soft tissue.36
In another facebow injury survey of orthodontic practitioners in the
United Kingdom and Eire 33 injuries were reported. These included
22 intraoral and 13 extraoral, 57% occurring with molar bands, 43%
with removable appliances and the majority occurring at night.37
This calls for adaptation of policy on the use of the appliance system
of proven safety standards and use of alternate appliances, for
patients and parents not willing for this mode of therapy even after
due information has been provided. The information on required
steps to adhere for a safe use of face bow and possible risks associated
with accidental injuries should be part of informed consent wherever
this treatment is being provided, so that both the patient and parents
are involved in the decision process as to its use.
How the facebow injury is caused?19–32
1. Most injuries are afflicted due to unintentional disengagement

of facebow from molar tubes while the bow is still attached to
the cervical neck strap or headgear elastic device. The elastic
traction can cause facebow to recoil, and propel to hit the
patients’ face, head or neck region.
2. The greatest incidence of disengagement of the facebow occurs
at night while the patient is asleep.32 This detachment of the
facebow at night would obviously compromise the
effectiveness of the treatment.
3. Another major cause of injury with a similar mode of action
has been reported to occur accidentally while either trying to
remove or place the facebow in the molar tubes or because of
incorrect use.
4. Accidental disengagement of the facebow can happen during
sports. Deliberate pulling of a standard facebow used with
elasticated extraoral traction by another child is known.
5. Disengagement of facebow can also occur due to the failure of
tube welding or tearing-off of the molar band.
Events following an eye injury

Most facebow injuries occur at night during sleep and often cause
little pain at the outset, which results in a delay in seeking immediate
medical attention. The sharp ends of the facebow, which remain
embedded in human saliva carry a mixed variety of oral
microorganisms, including gram-negative bacilli and Streptococcus
viridans.33–35 The eyeball is also an excellent culture medium and
when it becomes infected it is very difficult to control.24 The delay
allows the infection to proceed unchecked for a considerable period.24
The wounds contaminated by oral bacteria are difficult to treat,
resulting in impaired vision or even loss of the eye.27,28,35
Another serious consequence can be sympathetic ophthalmitis.
When one eye is injured, there is a risk to the other eye from a process
called sympathetic ophthalmitis, resulting in reduced field of
vision.29,35
Safety options for headgear and neck gear
1. Safety module. A variety of safety neck straps and anti-recoil

headgear have been developed by the orthodontic
suppliers.38–40 The safety modules have a built-in self-releasing
mechanism in these devices to prevent or reduce the catapult
effect encountered in the recoil injuries. The modules have the
required capabilities of generating therapeutic force (range
from 450–600 g to 750 g) and retaining the facebow in place,
without recurrent nuisance release, but can be manually
released when tested at the chair-side. The self-releasing
extraoral traction systems can reduce the catapult effect to
approximately 10 mm for the head cap and 25 mm for the neck
strap, but cannot be relied upon for sure to keep the facebow
in place at night.40 To retain the facebow from coming out of
buccal tubes, a locking mechanism has been developed.40
2. Plastic neck straps. Stiff plastic neck straps for cervical
headgear use have been offered as a simple safety device;
however, the stiff nature of this device makes it unsuitable as a
reliable method of retaining the facebow within the tube
housing when fitted around the neck.40
3. Shielded facebows. Shielding the ends of the intraoral bow can
reduce its shrapnel penetration effect but does not improve
either self-retentive capability40 or infective potential since it
remains embedded in the oral cavity full of oral
microorganisms.
4. Locking mechanisms. Should the safety release come off, the
facebow should have some kind of mechanism to retain it in
place. Locking mechanisms have been developed although
they do offer some difficulties in fitting and removing the bow
from the buccal tubes. Nitom 2* orthodontic locking-face has
been developed and tested by Samuels and colleagues.40–46
The Nitom locking facebow has bilateral locking catches which
resist light to medium displacing forces (Figs. 50.14 and 50.15).
FIGURE 50.14 Hamill safety facebow.
FIGURE 50.15 Nitom locking facebow.

Ortho-Care (UK) Ltd. 5 Oxford Place, Bradford, West Yorkshire
England BD3 0EF.
Safety guidelines
Safety guidelines and instructions for safe use of Kloehn headgear and
other extraoral hooks.40,41
Patient and parents should be demonstrated the correct method of
fitting and removing the headgear and facebow. The instruction
should be well explained to the patient and parents with detail and
emphasis. Following written instructions should be issued:
1. How to correctly place the facebow? The facebow is gently
fitted into the tubes on both sides and checked for stability.
The outer bow hook is thereafter engaged in the correct hole of
headgear safety module, on one side first and while holding
the bow with one hand, the other side of the module is
engaged. The whole idea is not to let elastic force to recoil and
propel the bow to cause injury.
2. How to remove your facebow? When removing headgear and
bow, always first disengage the facebow from the safety
module on both the sides. One hand can be used to hold the
bow, not to let it slip or disengage while removing the neck or
headgear.
3. If your headgear/or cervical strap comes off at night or you
have any problem, you should stop wearing and should
contact your orthodontist.
4. All extraoral appliances are not to be worn during any sports
or play or when you are with kids who can be unpredictable
or rowdy who may try to pull the bow. If that happens, you
must hold the bow till you are free.
5. In the rare and unlikely event of any injury or suspected injury
to eye, medical attention should be sought immediately.
Ophthalmologists should be aware of blinding potential of
even trivial and minor ocular injury by orthodontic headgear
and are advised to undertake immediate therapeutic
intervention one step ahead compared with ocular injuries
from other foreign bodies.
6. During each appointment, bring the facebow and headgear
with you. The orthodontist must make a check for proper
wearing and removal for any loose bands or tubes.
Key Point
Class II division 1 malocclusion has several forms of presentation the
one close to class I and other of extreme type of jaw dysplasia. In
between two extremes a huge variety of class II pattern exists which
has sagittal, vertical and transverse deviations of skeletal forms and
dental variations. The forward, growing maxilla can be intercepted
during mixed dentition utilising orthopaedic forces in right direction
and amount with Kloehn facebow bow. This modality of treatment
was once very popular, especially in the USA. The appliance is
effective in growing children during mixed dentition stage, however,
requires patient compliance. The use of these appliances necessities
that adequate safety measures are adhered to since serious eye injuries
have been reported to occur. The increase in case reports of such
injuries require the need for increasing awareness of orthodontists
and ophthalmologists to the blinding potential of even trivial and
minor ocular injury by orthodontic headgear. Other therapeutic
interventions of growing class II malocclusion are discussed in
subsequent chapters.
References
1. Varrela J. Early developmental traits in class II
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Dec; Review. PubMed PMID: 10066120.
2. Baccetti T, Franchi L, McNamara Jr JA, Tollaro I.
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15. SSqueff LR, Ruellas AC, Penedo ND, Elias CN,
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19741175.
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correction in children [dissertation]. Finland: Institute
of Dentistry University of Helsinki; 2010.
21. Antonarakis GS, Kiliaridis S. Treating class II
malocclusion in children vertical skeletal effects of
high-pull or low-pull headgear during
comprehensive orthodontic treatment and retention.
Orthod Craniofac Res. 2015;18(2):86–95: Epub 2014 Dec
29. PubMed PMID: 25545335.
22. Jacob HB, Buschang PH, dos Santos-Pinto A. Class II
malocclusion treatment using high-pull headgear
with a splint: a systematic review. Dental Press J
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23916449.
23. Barton JJ. High-pull headgear versus cervical traction:
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24. Editorial, AAO, issues special bulletin on extraoral
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25. Seel D. extraoral hazards of extraoral traction. Br J
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26. Preliminary results of headgear survey. The Bulletin
1982 1;2.[AAO Bulletin].
27. Holland GN, Wallace DA, Mondino BJ, Cole SH,
Ryan SJ. Severe ocular injuries from orthodontic
headgear. Arch Ophthalmol. 1985;103(5):649–651: May;
28. Holland GN, Wallace DA, Mordino BJ, Cole SH, Ryan
SJ. Severe ocular injuries from orthodontic headgear.
J Clin Orthod. 1985;19:819–825.
29. Booth-Mason S, Birnie D. Penetrating eye injury from
orthodontic headgear—a case report. Eur J Orthod.
1988;10(2):111–114: May; PubMed PMID: 3164677.
30. Béry A. Les accidents dus aux forces extra-orales. Rev
Orthop Dento Fac. 1992;26:137–141.
31. De Leo D, Bertele G. Lesioneocularepenetrante da
trazioneextraoraleortodontica. Minerva Medicolegale.
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32. Chaushu G, Chaushu S, Weinberger T. Infraorbital
abscess from orthodontic headgear. Am J Orthod
Dentofac Orthop. 1997;112(4):364–366: Oct; PubMed
PMID: 9345147.
33. Zamir E, Hemo Y, Zauberman H. Traumatic
Streptococcus viridans endophthalmitis after
penetrating ocular injury from orthodontic headgear.
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Jul–Aug; PubMed PMID: 10442733.
34. Blum-Hareuveni T, Rehany U, Rumelt S. Blinding
endophthalmitis from orthodontic headgear. N Engl J
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15616219.
35. Blum-Hareuveni T, Rehany U, Rumelt S. Devastating
endophthalmitis following penetrating ocular injury
during night sleep from orthodontic headgear: case
report and literature review. Graefes Arch Clin Exp
Ophthalmol. 2006;244(2):253–258: Epub 2005 Jul 6.Feb;
36. Samuels RH, Jones ML. Orthodontic facebow injuries
and safety equipment. Eur J Orthod.
1994;16(5):385–394: Oct; PubMed PMID: 7805812.
37. Samuels RH, Willner F, Knox J, Jones ML. A national
survey of orthodontic facebow injuries in the UK and
Eire. Br J Orthod. 1996;23(1):11–20: Feb; PubMed
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38. Postlethwaite K. The range and effectiveness of safety
headgear products. Eur J Orthod. 1989;11(3):228–234:
39. Stafford GD, Caputo AA, Turley PK. Characteristics
of headgear release mechanisms: safety implications.
Angle Orthod. 1998;68(4):319–326: Aug; PubMed
PMID: 9709832.
40. Samuels RH, Brezniak N. Orthodontic facebows:
safety issues and current management. J Orthod.
2002;29(2):101–107: Jun; PubMed PMID: 12114458.
41. Samuels RH, Evans SM, Wigglesworth SW. Safety
catch for a Kloehn facebow. J Clin Orthod.
1993;27(3):138–141: Mar; PubMed PMID: 8496352.
42. Samuels RH. A review of orthodontic face-bow
injuries and safety equipment. Am J Orthod Dentofac
Orthop. 1996;110(3):269–272: Sep; Review. PubMed
PMID: 8814027.
43. Samuels RHA, Miotti FA. Safety equipment to
prevent orthodontic facebow injuries. Rivista Italiana
di Odontoiatria Infantile. 1997;2:53–60.
44. Samuels RH. A new locking facebow. J Clin Orthod.
1997;31(1):24–27: Jan; PubMed PMID: 10356496.
45. Samuels RHA, O’Neill J, Gillot P. Utilisation des
dispositifsdesécurité des forces extraoral: unemise à
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1999;33:191–208.
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locking orthodontic facebow. Am J Orthod Dentofac
10715094.
CHAPTER 51
Evolution of functional
appliances and treatment with
one piece removable appliances
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Functional appliance and jaw orthopaedics
Dentofacial orthopaedics
Norman Kingsley 1879 bite plate
Evolution of removable functional appliance
Philosophy
Indications of activator
Bite registration for activator appliance
Trimming the activator
Clinical management and treatment follow-up
Retention protocol
Treatment changes with activator
Balters’ bionator
Balters’ concept on the aetiology of class II malocclusion
Rationale of appliance design
Bionator for class II
Bionator for class III has following features
Bionator for class I open bite or shield appliance
Indications of class II bionator
Objectives of treatment in class II division 1
malocclusions
Bite registration for bionator II
Clinical protocol
Frankel appliance
Frankel’s philosophy
Case selection and indications of FR II appliance
Bite construction
Construction of FR appliance
Clinical protocol on the use of Frankel appliance and
step-by-step advancement
Retention after Frankel appliance
FR-3 appliance
Relative indications of activator/bionator/Frankel appliance
Key Points
Introduction
Most young patients who report for an orthodontic consultation with
complaints of ‘buck teeth’ are likely to have a superior protrusion
and/or a retrognathic lower jaw. These patients classified as skeletal
and dental class II are considered for early treatment for improvement
in sagittal jaw relations and harmonisation through a process of
growth modulation of dentofacial structures. Though the process
appears to be simple, it requires a detailed clinical evaluation, case
selection, designing a comprehensive treatment plan and forecast of
remaining growth for prediction of prognosis. This field of
orthodontic therapy has emerged as the science of functional jaw
orthopaedics.
Functional appliance and jaw orthopaedics

The term Functional Appliance refers to a variety of removable
appliances designed to alter the arrangement of various muscle
groups that influence the function and position of the mandible to
transmit forces to the dentition and basal bone. Typically, these
muscular forces are generated by altering the mandibular position
sagittally and vertically resulting in orthodontic or orthopaedic
changes.1
The original concept of functional jaw orthopaedics essentially
encompasses growth modulation for the correction of mandibular
retrognathia, that is skeletal class II malocclusion not by active forces
of the appliance but by the forces generated by the muscles when the
mandible is held forward. The functional forces indirectly produce
growth modulation and bring about changes in jaw bones and hence
the term Functional Jaw Orthopaedics. The term has now been
applied to any device that is used to displace and hold the mandible
which includes a variety of removable and fixed functional
appliances.
Dentofacial orthopaedics
It involves a variety of treatment modalities that are adapted to create
a harmony and balance of the teeth-bearing facial skeleton either
through growth enhancement of the mandible, growth restraint on the
maxilla, or a combination of both. It also includes restraining the
excessive growth of the mandible in skeletal class III situations,
protraction of the maxillary complex and procedures such as rapid
maxillary expansion that brings about transverse changes in the
maxillary skeletal base. These therapeutic modalities include the use
of orthopaedic forces of 450 g or more in combination with functional
growth stimulation and orthodontic forces to affect skeletal and dental
alterations.
Norman Kingsley 1879 bite plate

Growing the short mandible to match the upper jaw dates back to
1879 when Norman Kingsley described a bite plate ‘to change or jump
the bite in the case of excessively retreating lower jaw’ in patients who
exhibited excessive over-jet and retrognathic mandibles. The term
Jumping the Bite originally described the concept of getting the
mandible to hold into a favourable occlusal position and inducing it to
stay there.2 This treatment was often utilised after expansion of the
arches but often did not prove successful due to the mandible’s
tendency to revert to its original position (Fig. 51.1A–B). ‘The fault of
the old Kingsley appliance was the tendency, even with the bite guide,
for all the teeth to return’.3
FIGURE 51.1 (A) An anterior bite plate that helps open the bite can
also help to posture the mandible forward. This is the simplest form of
functional appliance. (B) Concept of jumping the bite was given by
Kingsley whereby mandible was held forward and not allowed to revert
back. (C) To prevent the mandible slipping back, Andresen added
lingual acrylic extensions in anterior and (D) buccal regions to support
the mandible in forward posture.
Pierre Robin (1902) Pierre Robin, a French stomatologist, used a

modified bite plate extending all along the lingual surfaces of lower
gums in new-born children with micrognathia syndrome to influence
muscle activity to prevent glossoptosis in early 1902.4
Evolution of removable functional appliance

Viggo Andresen (1909) found his daughter’s left-over lingering
problem of class II relation after fixed orthodontic treatment got
corrected with a modified bite jumping type of appliance, in which he
added a horseshoe-shaped lingual flange. He aimed to guide the
mandible forward by 3–4 mm in occlusion and correct the tendency
for a deep bite. These observations and clinical results were the
fortuitous introductions of functional appliance in orthodontics.
The concept of addition of lingual extensions to bite jumping plate
was eventually crystallised into an appliance called the ‘activator’
(Fig. 51.1C–D).
Viggo Andresen (1910) used this appliance in many other patients
successfully after correction of his daughter’s occlusion to class I. In
1910, he gave a report on a new upper retention appliance. He
continued to use this appliance as a prophylactic tool for young
patients and modified retainer to the appliance, using a wax bite to
advance the mandible in the forward position.
Andresen and Häupl activator (1936) Andresen in collaboration
with Karl Häupl published a book, Funktionskieferorthopädie,
philosophy of treatment with the use of the activator, which he called
the ‘Norwegian system’.2 He called it ‘muscle and circulation
activators’ (Figs 51.2 and 51.3). The book was later published in
several editions in 1939, 1942, 1945 and the 5th edition in 1953 after
the death of Andresen, edited by Häupl and Petrik.5,6
FIGURE 51.2 Activator in the mouth showing its relationship with

maxillary incisors, mandibular incisors and buccal teeth.
Note inclines are created to facilitate mesial and occlusal eruption of
mandibular molars while maxillary molars should be tipped distally.
Arrows indicate the direction of dental eruption.
FIGURE 51.3 Monoblock or Andresen and Häupl activator.
Arrows point the direction of eruption guidance.
The use of an activator appliance became widespread in Europe and

its philosophy so influenced the profession that ‘… functional jaw
orthopaedics became a profession of faith, religion, besides which no
other opinion was tolerated’.7
Bimler appliance (1949) during those years, several modifications
of the appliance and new concepts were introduced. These included
cutting the bulk of acrylic, a rise in bite height, and incorporation of
wire and spring components to initiate dental corrections. The whole
idea was to create an appliance which is more comfortable and more
efficient in treating malocclusion. Hans Bimler (1949) a German
orthodontist incorporated elastic force into an orthopaedic appliance
which he called ‘Gebissformer’ by a German name. Later he also
called it an ‘adapter’. However, this appliance is known by its
inventor as the ‘Bimler appliance’.8,9
Wilhelm Balters (1950) modified the activator by removing its bulk
from the palate and substituted it with a coffin spring. He advocated
three designs of bionator for class I, II and III malocclusions (Figs
51.4–51.7).10,11
Leopold Petrik (1953) introduced an activator having a large
interocclusal thickness to increase the vertical dimensions of the bite.
Hugo Stockfisch (1953) An innovative modification of activator
was introduced by Hugo Stockfisch in 1953. The new appliance,
which he termed Kinetor, consisted of two movable plates connected
by wires, the buccinator loops. These loops kept the dental arches free
from the abnormal pressure of cheek muscles. An unusual feature of
the kinetor was the elastic tubes between the two plates that acted not
only as shock absorbers but also as a means of broadening and
optimising orofacial muscle pressures.11
With the incorporation of an additional mechanism of force, the
original philosophy of activator mechanism was getting modified.
With the publication of Functional Orthopaedics for the Masticatory
System in 1952 by Eschler, the concept of amalgamation of
combination of muscle stimuli together with forces created by
inherent elastic elements were starting to get accepted by the
profession.12
Rolf Frankel (1957) recognised that the stability of treatment could
occur only if the structural and functional deviations of the muscular
system are corrected. Frankel designed the function regulator (FR,
1957), making the oral vestibule the operational basis for his
treatment. The appliance was designated as FR-1, FR-2 and FR-3, for
treating class I, II and III malocclusions.13,14
Martin Schwarz (1956) modified the single block activator into
split-plates upper and lower halves. The idea was to take advantage of
the orthopaedic correction of activator and active forces on teeth.15
Schwarz double plate eventually got crystallised to the popular twin
block appliance.
William C. Clark (1977) Dr Willian Clark of Fife, Scotland
developed, used and promoted twin block appliance treatment.16,17
Later William Clark introduced bite blocks that can be inserted into
the specially designed tubes welded onto molars bands called ‘fixed
twin block’.18
Functional orthopaedic magnetic appliance (FOMA) 1989 by
Vardimon. An innovative addition to the armamentarium on FA was
functional orthopaedic magnetic appliance (FOMA) II introduced in
1989 by Alexander D. Vardimon and colleagues. FOMA II is an active
appliance that directs its inherent magnetic forces to the jaws and
thereby constrains the lower jaw in an advanced posture. Later in the
subsequent year, an appliance was developed for the treatment of
class III malocclusions that exhibit mid face sagittal deficiency with or
without mandibular excess.19,20
The clinicians and scientist in late 20th century and beginning of the
21st century focused research on evaluation of the true benefits of the
functional appliances, and the relationship of treatment outcome with
facial morphology. Functional jaw orthopedics is now an accepted
mode of therapy in growing children with class II malocclusion.
The functional appliances can be broadly grouped into those which
are tooth born or others which are retained in the mouth with major
support from oral cavity with little or no support from the teeth, so-
called tissue born. Most appliances use both teeth and oral tissues for
their support and hence it is difficult to precisely put any appliance in
the category of tissue support alone, though Frankel functional
regulator is often called ‘tissue born appliance’.
The appliances can also be grouped by mode of action on muscles—
active or passive—which are synonymous with myodynamic or
myotatic type of appliance.
With twin blocks having proved their usefulness in day-to-day
clinical practice it may be worth grouping the appliances into either
monoblock (one-piece) type or twin block (two pieces) type.
The appliances can also be grouped as removable and fixed type
though fixed type appliances are not truly the functional appliance in
nature.
• Removable functional appliances

■ Activator and its modifications
■ Balters’ bionator
■ Frankel functional regulator
■ Twin block appliance
• Fixed functional appliances
■ Rigid functional appliances
■ Flexible functional appliances
■ Hybrid functional appliances
Philosophy
The ‘activator’ is a loose fitting appliance, which holds the mandible
forward due to the extended lingual flanges coming from the
maxillary plate as a single piece appliance made of heat cure acrylic.
The only wire component is a labial bow.
Indications of activator
Activator is indicated in growing young children for the correction of
class II malocclusion, which is mainly due to the smaller mandible.
This appliance is a loose device worn at night. Being a loose fitting
appliance, it drops in the mouth during sleep. Consequently, the
mandible responds for closure to hold it in place. The muscles of the
face and stomatognathic system are thus activated and hence the
name Áctivator.
The appliance is worn at night time and brings about sagittal
correction of the molar relationship and bite opening. The resultant
changes induced are mainly dentoalveolar. These changes are
accompanied by marked changes in facial features and correction of
abnormal habits. ‘… the activator should be used only as a passive
apparatus, that is, it should not produce any power but only receive
and further transport power from the functional milieu to the teeth’.21
Loose passive appliance would shake and jolt the teeth and
periodontal tissue thereby causing remodelling of the tissue, only
source being ‘muscular forces’. These muscular forces are capable of
growth remodelling and create favourable tooth movements. ‘The
activators activate the appropriate muscles while the muscles, in turn,
activate the appliances’.22
This philosophy was later modified with a recommendation on the
recording of the bite with greater vertical activation beyond freeway
space and the addition of other components of wires to induce further
teeth movements. A high pull face-bow, attached to the activator is
indicated in patients with an increase in vertical dimensions of the
face. The combined headgear activator therapy provides greater
cumulative skeletal benefits than a single appliance alone.
Bite registration for activator appliance

The steps involve making of upper and lower impressions with deep
flanges. The bite is recorded by asking the patient to bring the
mandible forward and biting on a horseshoe-shaped wax roll softened
in a wax bath.
The activator bite is recorded ‘within the freeway space’. The
sagittal forward positioning is 4–5 mm. The bite with upper and lower
models is transferred to a hinge articulator. A labial bow of 0.8 mm (20
gauge) wire is constructed. A conventional or traditional activator has
large lingual flanges extending up to the distal of first or second
molars. The upper labial bow is constructed from canine to canine.
The lower incisors are free and do not have any acrylic cap on them.
However, there is a trend to cap lower incisors now, which prevents
labial tipping of lower incisors. Appliance wax-up is done, which is
followed by routine dewax and acrylisation in heat cure acrylic.
Trimming the activator

The most critical aspect of activator finishing is the trimming of the
inclined planes of the bite block. The inclined planes are trimmed with
extreme caution and care, to induce buccal and distal tooth movement
of the maxillary buccal teeth and enhance mesial and occlusal
movement of mandibular buccal teeth.
Trimming is done with sharp TC pear shape bur on a slow speed to
avoid heating the acrylic. The patient is asked to bite on acrylic inter-
occlusal bite block. The distal cusp positions of maxillary buccal teeth
and mesial cusp positions of the mandibular buccal teeth are marked
with a metal marker. The trimming is done for each tooth and checked
in the mouth. It is a tedious and time-consuming process which can be
a test of patience both for the orthodontist and the patient. At the
completion of trimming, the inter-occlusal block of acrylic resembles a
honeycomb appearance. The trimmed activator has inclines and space
created for the upper buccal segment of teeth to distalise, while buccal
teeth in the mandibular arch provided inclines and space to erupt
vertically and mesially. The distal positioning of the maxillary teeth
and mesial migration of mandibular teeth and their forward position
leads to correction of class II molar relation to class I. Palatal acrylic on
maxillary anterior teeth is trimmed to induce intrusion, while
mandibular incisors are nowadays capped to prevent their undue
flaring (Figs 51.2 and 51.3A–B).
Clinical management and treatment follow-up

The patient is motivated for its use, and those who wear the
appliance, have responded favourably showing improvement in
aberrant perioral muscle behaviour by optimising lip seal and a
definite control on tongue thrust. The sagittal correction gradually
shows up settling the occlusion in class I molar relation. The treatment
duration may vary from 18 months to longer.
Further trimming of inclined planes are required to settle the buccal
teeth in good inter-cuspation.
Retention protocol
The traditional view about retention after activator treatment was that
no retention might be required since the appliance works through
modification of muscle function. However, this is not the case, since
occlusal changes take a longer time to settle. The current thinking is to
finish the case with fixed orthodontic appliance, the second phase of
the comprehensive orthodontic therapy and retention with bite plate
having an incline to keep the mandible in a forward posture.
Treatment changes with activator

The activator treatment seems to inhibit maxillary growth, move the
maxillary incisors and molars distally, and move the mandibular
incisors and molars mesially. Mandibular growth appeared not to be
affected by activator treatment. Most treatment effects are of
dentoalveolar in nature. The cooperation is a critical determinant of
successful treatment, and the activator treatment is effective in the late
mixed than early stages of occlusion development.23
Balters’ bionator
The generic term, Bionator describes a ‘family’ of tooth borne
appliances that produce a forward positioning of the mandible in
association with variable effects in the vertical plane, that is open,
close or maintain the bite. Wilhelm Balters modified the activator by
removing the bulk of palatal acrylic plate and replaced it with a coffin
spring, which is expected to serve a stimulus to reposition the
abnormally positioned tongue in mandibular retrognathia. He
designed an extended labial bow in the buccal region to isolate teeth
and arches from harmful effects of perioral muscles and thereby
enhance the transverse growth of the arches. He advocated three
designs of bionator for class I, II, and III malocclusions.10–24
Balters’ concept on the aetiology of class II

malocclusion
Wilhelm Balters has a unique perception to the aetiology of
malocclusion. In his opinion class II malocclusion results from the
backwards (dorsal) position of the tongue that disturbs the cervical
region and impedes respiratory function, causing faulty swallowing
patterns and mouth breathing. According to Balters, the equilibrium
between the tongue and circumoral muscles is responsible for the
shape of the dental arches and proper intercuspation and that
providing the tongue with adequate functional space is of utmost
importance. A class II malocclusion is due to lack of transverse
development as a consequence of weakness of the tongue in
comparison with buccinator mechanism while a class III malocclusion
is caused due to forward position of the tongue (Fig. 51.4).
FIGURE 51.4 Wilhelm Balters’ hypothesised that class II
malocclusions are a result of a backward (dorsal) position of the
tongue.
A disturbed equilibrium between the tongue and circumoral muscles
lead to malocclusion.
Rationale of appliance design

The bionator prevents external and internal muscle forces from
exerting undesirable and restrictive effects on the dentition and
supporting structures. Balters believed that primarily the role of the
tongue was the decisive factor. Therefore, one of the main objectives
of treatment in class II division 1 malocclusions is to bring the tongue
forward. The principle of treatment with bionator is not to activate the
muscles but to modulate muscle activity, thereby enhancing the
normal development of the inherent growth pattern, eliminating
abnormal and potentially deforming environmental forces. The labial
bow which is extended to the buccal vestibules on both the sides is
expected to isolate dental arches from abnormal perioral pressure, and
let the tongue exert a moulding pressure, coffin spring being the
stimulus.
Bionator for class II

The components of the appliance for class II
1. Coffin spring is made up of 1.25 mm (16 gauge/0.045 in.) spring
hard wire. The shape of the spring is either diamond or pear
shaped with distal end closed.
2. A modified labial bow with buccinator loops is fabricated with
0.9 mm (19 gauge/0.036 in.) spring hard wire. The basic
bionator for class II has a labial bow which runs over incisal
third of the maxillary anterior teeth up to the middle of the
canine. The bent is set diagonally downwards somewhat 2 mm
away from gingival margins of the posterior teeth, making a
buccal loop in the region of the mesiobuccal cusp of the
mandibular first molar. From this point on, it is bent back
along the upper teeth with its free end engaged in occlusion
bite block distal to maxillary canine. The recommended height
of the loop between the two wires of the buccinator loop
should be 1 cm in order to shield off and avoid the
interposition of the cheek.
3. The lower incisors receive incisal capping to prevent labial
tipping (Figs. 51.5 and 51.6A–B).
FIGURE 51.5 (A–B) Balters’ bionator.

FIGURE 51.6 Balters’ bionator for class II malocclusion.
Bionator for class III has following features

1. The coffin spring is open in the distal aspect.
2. The labial bow is designed to allow protraction of maxillary
anterior teeth and retroclination of mandibular incisors. The
labial bow touches incisal third of the mandibular incisor,
extends into mandibular first molars and from there, back over
the upper molars its free end finishes between the maxillary
canines and the first premolars, where it is bent into the
occlusal bite block (Fig. 51.7A–B).
FIGURE 51.7 Balters’ bionator for class III malocclusion.

In the reverse appliance, the labial bow only contacts the lower front
teeth; it is then led distally up to the centre of the first molars and from
there, back over the upper molars. Between the canines and the first
premolars in the upper jaw, the labial bow is bent orally into the
retention. The shape of the coffin spring is opposite to the shape in the
base and shield appliance. In the anterior region, the acrylic base of the
reverse appliance is vertically elongated to influence the upper incisors
labially, as with an inclined plane. This bite plane serves as protrusion
element for the anterior maxillary teeth.
Bionator for class I open bite or shield

appliance
1. The purpose is to allow both upper and lower front teeth to
slightly retrocline with pressure of the lips while they are not
influenced by the tongue. The palatal-lingual acrylic shield of
the appliance keeps the tongue away and at the same time
relief is provided for retroclination of both maxillary and
mandibular incisors in dento-alveolar area on palate and
lingual side.
2. The labial bow is similar to class II type but vertically lies
somewhat in the middle of anterior open bite, therefore not in
contact with either upper or lower incisors (Fig. 51.8).
FIGURE 51.8 Balters’ bionator for class I open bite.

The shield appliance has a similar labial bow as the base appliance.
Because of the open bite, for example, in patients with tongue
dysfunction, the labial wire is located in the middle between the upper
and lower incisors. This bow hinders the introduction of the lower lip
between the arches. The acrylic base of the shield appliance is closed
in the front but it should not contact the incisors or the dento-alveolar
margin so that the open bite can close. This area can be blocked out
with wax before the application of the acrylic, or be trimmed free after
its finishing.
Indications of class II bionator
Treatment with bionator should be undertaken in class II division 1
cases of mild to moderate discrepancy where the dental arches are
well aligned, and the mandible is held in a posterior position. The
maxillary crowns are often tipped labially.10
Objectives of treatment in class II division 1

malocclusions
Treatment with bionator is highly dependent upon patient
compliance, especially with regard to exercising because his treatment
approach included postural exercises, gymnastics and dietary control.
Balters’ treatment objective to establish a muscular equilibrium
between the tongue and the ‘outer neuromuscular envelope’ are
summarised as follows:
1. Accomplish lip closure and bring the tongue back into contact
with the soft palate.
2. Enlarge the oral space and to train its function.
3. Bring the incisors into an edge-to-edge relationship.
4. Forward posture of the mandible that would enlarge the oral
space.
5. Continuously posturing of the mandible forward also enlarges
the respiratory pathways and enhances deglutition.
Bite registration for bionator II11

Bionator bite is recorded with the mandible positioned anteriorly with
incisors in an edge-to-edge relationship. This provides maximum
functional space for the tongue. The forward posturing of the
mandible enlarges the oral space, bringing the dorsum of the tongue
into contact with the soft palate and thus helps to accomplish lip
closure. Construction bite in bionator cannot make allowances for
growth direction by variations in the vertical opening as the mandible
is postured forward. The bite cannot be opened and must be recorded
in edge-to-edge incisor relationship (Fig. 51.9).
FIGURE 51.9 The class II bionator appliance in mouth fabricated

with the construction bite recorded with minimal vertical opening
in edge-to-edge bite.
Balters considered that a high bite could impair tongue function

which could lead to tongue thrust habit. In case the over-jet is too
large, to allow an edge to edge bite, a step-by-step protraction
procedure is followed.
Clinical protocol
The patient is suggested to wear the appliance all the times except
during meals. Most patients adapt well with speech while the
appliance is in place. There is no particular pattern of trimming of
inter-occlusal block described, however, in our experience we start
trimming the bite block when the bite opening is achieved, and
mandible is held in class I occlusion without the appliance. The bite
block is trimmed to make allowance for the eruption of mandibular
first molars followed by premolars to level the curve of Spee. Once the
proper inter-digitation is established, we recommend the same
appliance as a retainer for at least 1 year.
A case treated with bionator is given in Fig. 51.10.
FIGURE 51.10 Case SU, 13 years old female treated with Bionator
therapy followed by a phase of fixed appliance. (A) Pre treatment
profile and occlusion, (B) Bionator, (C) Occlusion after Bionator
therapy, (D) Occlusion after fixed appliance. (E) post treatment profile
and occlusion, (A’) pre treatment cephalogram (B’) After Bionator
therapy, (C’) post treatment cephalogram.
Frankel appliance
Rolf Frankel based his treatment philosophy on the concept that
adequate soft tissue function and environment regulates the growth of
the hard tissues. Frankel appliance serves to regulate abnormal
muscle function of the circum- and peri-oral capsule, and enhances
transverse width in class II cases and eliminates the restrictive effect
on the mandible, permitting normal displacement of the mandible and
spontaneous development of the orofacial tissues. The maxillary arch
develops in transverse dimensions more so in premolar and molar
regions. A wider maxillary arch allows mandible to posture and grow
forward.
The main components of Frankel appliance are vestibular shields
which act directly by stretching the circumoral muscles, thereby,
increasing the transverse growth of the maxilla. Frankel appliance was
therefore classified primarily as a tissue-born passive appliance.
The Frankel functional regulator was designed for treatment of
three types classes of developing malocclusion.25
The traditional grouping of FR appliance was in four groups as
under (Boxes 51.1 and 51.2):
Box 51.1 Types of functional regulators (FR)
FR-1 Class I and Class II, Division 1

FR-2 Class II, Division 2
FR-3 Class III
FR-4 Open bite/Bimax
Box 51.2 Order of grouping of types of functional

regulator
FR-2 Class II, Division 1 and Class II, Division 2: some open bite
FR-3 Class III
FR-4 Some open bites
FR-1 Some open bites : Class I
However, currently FR appliances are as follows:
Frankel’s philosophy26–27
The Frankel functional regulator is designed to be a muscular exercise
device. The appliance is designed to stretch circumoral muscles, and
hence stimulate the transverse growth of the maxilla, train the
suspensory muscles of the mandible, in particular, the protractor
group.
This training of protractors of the mandible is expected to influence
a more forward posture of the mandible to be initiated in a very
careful and stepwise manner, without disturbing the condyle–fossa
relationship. The lingual shields of the Frankel appliance do not
support the mandible in the advanced position as determined by the
construction bite. They generate a proprioceptive response that
repositions the mandible in a forward posture. Frankel believed that
stability of treatment outcome could be expected to occur only if the
structural and functional deviations of the muscular capsule can be
corrected. The FR appliance aids in the maturation, training, and
‘reprogramming’ of the orofacial neuromuscular behaviour.
The mandibular base development is significantly stimulated with
the sagittal stepwise advancement of FR II. The original position of the
condyle in the fossa is not disturbed, which is in contrast to a situation
where single activation of the functional appliance is given. ‘Thus in
contrast to most other removable appliances, and certainly all fixed
appliances, which place forces directly on the hard tissues, treatment
with functional regulator is focused primarily on the spatial
inadequacy of circumoral capsule as a major factor in restricting the
displacement of the mandible and the maxilla, and thus its
enlargement. Therefore, early intervention with the FR appliance
offers an opportunity to eliminate this restrictive effect permitting
normal displacement of the teeth and the facial bones’ (Fig. 51.11A–
D).10
FIGURE 51.11 Frankel appliances FR II.
(A) Frontal view. (B) Aerial view. (C) Aerial view seated on maxillary
cast. (D) Aerial view seated on mandibular cast.
Case selection and indications of FR II

appliance
A significant component of maxillary growth is over by 8 years of age
during early mixed dentition, therefore children who are 7-year-old or
younger are considered good candidates for FR II therapy. FR II
appliance is indicated for growing children who have a receding chin,
rolled lower lip, and a very prominent mentalis muscle, and a narrow
maxilla, with minimal crowding. As the maxilla grows in width with
FR II therapy, mild anterior crowding resolves spontaneously.
Bite construction26
In order to maximise skeletal benefits Frankel proposed taking the
initial construction bite with only 2–3 mm of mandibular
advancement. This is not more than what the protractor muscles are
able to keep the mandible in a forward position. When a construction
bite was taken with the mandible advanced 6–7 mm, the post-
treatment results showed dentoalveolar changes with Frankel
appliance, such as maxillary incisor retraction and lower incisor
proclination, which are undesirable.
Construction of FR appliance29
Impression taking for FR
The working models for FR II are prepared in dental stone plaster
from alginate impressions. The impressions for FR should not be
taken with regular over extended orthodontic impression trays. These
orthodontic trays tend to stretch the soft tissue and hence accurate
recording of the depth of the vestibules is marred.
For the purpose of FR appliance impressions are made deep into the
vestibular sulcus and lower anterior lingual region. McNamara and
Huge suggest either fabrication of custom tray for individual use or
thermal sensitive acrylic tray. The models should have at least 5 mm
of lateral extension from the base of vestibule. Accurate recording of
the vestibule’s depth and alveolus is required for making the
vestibular shields.
Preparation of working models and mounting

A well-fabricated Frankel appliance has overextension of the buccal
shields into the vestibules and also of the lower lip pads. Preparation
of working model involves extending the buccal vestibular sulcus to
about 4–5 mm in the region of canine eminence. The vestibule in the
mandible is carved with a pear-shaped bur and a plaster knife. The
extension of the lower labial relief is usually 12 mm below the lower
gingival margin. The models are well trimmed and with wax bite in
place, are mounted on a fixed articulator for wire bending and
acrylisation of the shields. Due care should be taken to check the
midlines or any discrepancy that may have arisen due to distortion of
the wax bite.
Wax relief for arch expansion

Wax relief is given in the area of buccal pads which would eventually
provide space for the lateral expansion of the arches. Pink modelling
wax is used to pad the teeth and vestibule in the thickness of 3 mm in
maxillary alveolar region and 0.5 mm in mandibular alveolar region.
Wire fabrication for labial and lingual pads

Wire components of lingual and labial pads are first fabricated for
acrylisation of these two pads first. The mandibular lingual support
wire is made from 0.51 in. SS wire which crosses over to buccal sides
between two deciduous molars. Lower lingual springs are made from
0.028 in. SS wire and the three-piece labial components on mandibular
labial model are made with 0.036 in. wires. The labial wire can also be
made as one piece assembly extending both sides from the midline.
Following completion of this part of wire framework the labial and
lingual pads are acrylised, finished and polished. The assembly is
placed back on the mounted models and checked for precision on
wire and pads and if any distortions have occurred during
manipulation these are corrected.
Maxillary wire fabrication and acrylisation of buccal

shields
A maxillary palatal wire that gives the appliance a unity on both sides
of shields and supports it on first molars through the occlusal
extensions is made from 0.040 in. SS wire. The upper lingual wire is
fabricated with 0.036 in. SS wire, right and left canine extensions from
0.032 in. and labial wire again 0.036 in. wire. The upper and lower
models are stabilised on articulator which is also checked for its
stability of parts. The wax bite is removed and the remaining buccal
shields of the appliance are then fabricated with cold cure acrylic and
finally cured under steam pressure.
Trimming, finishing and evaluation of appliance and

delivery
The FR appliance should be clean, smooth all around with no sharp
edges or pimples. The vestibular borders should be smooth and
should have enough thickness not to injure the vestibules. The
appliance is finished and polished in usual manner. Due care should
be taken, so that wire frameworks are not distorted.
Clinical protocol on the use of Frankel

appliance and step-by-step advancement 28,30
Clinical observations suggest that during sleep hours the suspending
muscles relax, the mandible drops inferiorly and slides backward.
Thus, the maxillary incisors could come into active contact with the
upper labial bow. The mandibular incisors are likely to contact the
lingual shields or wires attached to it. This is likely to happen when a
construction bite is made with 6–7 mm of advancement.
In FR II, step-by-step advancement is desired. The initial
construction bite is taken with the mandible advanced forward by 2–3
mm only. The second advancement of 1–2 mm is done in 4–6 months,
and third advancement is done in next 3–4 months to full cusp class I
relationship. In about 8–12 months of full-time wear of appliance,
sagittal discrepancy is corrected and mandible should not be retruded
clinically.
The stepwise forward progression of the postural position of the
mandible is possible by cutting the buccal shields and moving the
remaining segment of the appliance forward.
Retention after Frankel appliance

There is no general consensus on the mode of retention after
functional appliance therapy, since it is believed that following
establishment with proper inter-cuspation and skeletal adaptations
relapse is minimised. Clinicians suggest night-time wear of some kind
of device to hold the mandible forward.
FR-III appliance
FR-III is indicated in growing patients of mandibular prognathism in
association with maxillary hypoplasia. As the malocclusion dictates
the appliance design, it is in contrast to that of class II. The appliance
has two vestibular shields, two upper labial pads, one protrusion bow,
one lower labial bow and occlusal rests. The models require special
attention in the upper lip area. A deeper vestibule is carved here and
this is for wax relief since two lip pads are provided in here.
Relative indications of
activator/bionator/Frankel appliance
The clinicians are often in dilemma as to which appliance should be
used and how the bite recording is different for each of the appliances.
In general a functional appliance is indicated in a growing child
with class II malocclusion with aberrant oral functions.
a. Activator by virtue of its bulk of acrylic held in the inter-

occlusal space allows correction of the molar relationship from
class II to class I by mesial and supra migration of the
mandibular buccal segment and distal movement of the
maxillary buccal segment. Hence it leads to increase in facial
height and therefore should be avoided in children in vertical
face types. It is also mandatory that a child should have no
physical-nasal obstruction.
The bite is recorded within free-way space.
b. The bionator is effective only in mild class II situations and bite
recording is done at edge-to-edge bite.
c. The Frankel appliance is considered true muscle regulator as it
is expected to help to grow the development of the narrow
maxilla to normal width and thereby should be indicated early
during childhood (before 7 years).
FR II appliance works best during deciduous dentition stage or

early mixed dentition when incisors and maxillary molars are about to
erupt or erupting.
FR II appliance is not indicated in late mixed dentition stage. The
bite recording for the FR II is within free-way space and gradually
enhanced which is expected to provide enhanced skeletal growth with
little or no contribution in class II correction by dental changes.
The management of class II malocclusion in growing children with
versatile twin block appliance in given in a separate chapter.
Key Points
The concept of functional appliance which emerged from Europe from
accidental and empirical observations has now evolved as a definite
therapeutic option based on scientific research and longterm clinical
observations. The choice of appliance and method of recording the
bite are fundamental to treatment outcome.
The choice of appliance to some extent is governed by the
experience of the operator in handling and managing the appliance.
References
1. Bishara SE, Ziaja RR. Functional appliances: a review.
Mar; Review. PubMed PMID:2646914.
2. Wahl N. Orthodontics in 3 millennia Chapter 9
functional appliances tomidcentury. Am J Orthod
PMID: 16769503.
3. Hawley CA. The principles and art of retention.
Trans Eur Orthod Soc. 1922-;1923:5–14.
4. Robin P. Observation surunnouvelappareil de
redressement. Rev Stomatol. 1902;9(3):561–590: Cited
from: Hoffstein V. Review of oral appliances for
treatment of sleep-disordered breathing. Sleep
Breath. 2007 Mar;11(1):1–22. Review. PubMed PMID:
5. Schmuth GP. Milestones in the development and
practical application of functional appliances. Am J
Orthod. 1983;84(1):48–53: Review. PubMed PMID:
6346890.
6. Andresen V, Häupl K, and Petrik L. Funktions-
Kieferorthopädie. ed. 5. Johann Ambrosius Barth,
Barth, München; 1953 cited from Wieslander L,
Lagerström L. The effect of activator treatment on
class II malocclusions. Am J Orthod 1979 Jan; 75(1):20–
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7. Hotz RP. The changing pattern of European
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8. Bimler HP. Die elastischen Gebi B former Zahnaztl
Welt Schmuth GP. Milestones in the development
and practical application of functional appliances.
Am J Orthod. 1949;84(1):499–503: 1983, 48-53 Jul;
9. Bimler HP. Interviews Dr. H.P. Bimler on functional
appliances. J Clin Orthod. 1983;17(1):39–49: Jan;
10. Eirew HL. The bionator. Br J Orthod. 1981;8(1):33–36:
11. Melo ACM, dos Santos Pinto A, da Rosa Martins JC,
Martins LP, Sakima MT. Orthopedic and orthodontic
components of class II division 1 malocclusion
correction with Balters bionator. World J Orthod.
2003;4:237–242.
12. Eschler J. Die funktionelle Orthopadie des
Kausystems Munchen 1952 Carl Hanser. Cited from
Schmuth GP Milestones in the development and
Orthod. 1983;84(1):48–53: Jul; Review. PubMed PMID:
6346890.
13. McNamara Jr JA. Rolf Fränkel 1908-2001 (in
memoriam). Am J Orthod Dentofacial Orthop.
2002;121:238–239.
14. McNamara Jr JA, Huge SA. The Fränkel appliance
(FR-2): model preparation and appliance
construction. Am J Orthod. 1981;80(5):478–495: Nov;
15. Schwarz AM. Grundsatzlichesuberdiehentigen
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16. Clark WJ. The twin block technique a functional
orthopedic appliance system. Am J Orthod Dentofacial
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18. Clark WJ. New horizons in orthodontics & dentofacial
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CHAPTER 52
Treatment approaches with twin
block appliance
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Development of twin block
Clark philosophy
Advantages of twin block functional appliance over one-
piece appliance
Indications and case selection
Poor responders to FA therapy
Functional analysis
Examination of temporomandibular joint
Examination of tongue
Respiration
Evaluation of speech
Visual treatment objective (VTO)
Chronological age
Peak height velocity
Dental age
Skeletal age
Cephalometric evaluation and analysis
The extent of horizontal advancement
The extent of the vertical opening
Midline considerations
Bite recording according to Clark
Appliance design and construction
Angulation of inclined planes
Optimal thickness of bite blocks
Clinical management
Pre-functional phase
Functional phase
Support phase
Retention phase
Treatment effects of removable functional appliance
One phase versus two phase treatment
Retention
Twin block in deciduous dentition
Twin block traction technique
Treatment of anterior open bite and vertical growth
pattern
Twin block appliance in class II div 2 and class III
malocclusion
Fixed twin block
Key Points
Introduction
The twin block appliance is a two-piece functional appliance.1,2 The
two plates design was a significant change in the existing designs of
the functional appliances, all of them being one piece. The second
significant change was wearing time of 24 h from part-time wear of
one-piece appliances. The twin block is a smart modification of
Schwartz double plate and the split activator.
Twin block is fundamentally a pair of upper and lower plates,
which has occlusal bite blocks that interlock the mandible in a forward
posture and yet permit functional mandibular movements. It is a
widely accepted and popular removable functional appliance. The
invention of William Clark (Fig. 52.1) of Kirkcaldy, Fife, Scotland was
probably known to Europe, much before in percolated North America
and rest of the world.1 The appliance has been extensively used and
researched since his article appeared in the American Journal of
Orthodontics in 1988.2
FIGURE 52.1 William Clark developed the twin block technique in
1977 in his practice in Kirkcaldy, Fife, Scotland.
Conventional design of a twin block appliance is shown in Fig. 52.2

FIGURE 52.2 Twin block appliance.
Development of twin block

The twin blocks were initially designed to hold the mandible forward
to relieve upper lip pressure in a case of re-implanted avulsed tooth in
the maxilla. One of Clark’s colleague’s son reported to his practice
with luxation of the right upper central incisor. The tooth was re-
implanted and held with temporary splinting. After 6 months, he
noticed that tooth became partially stable, but there was significant
bone loss around the tooth. The patient had class II division 1 pattern
of occlusion with a lip trap and over-jet of 9 mm. Clark wanted to
design an appliance by which he could relieve the pressure of upper
lip on an upper incisor. He innovated an acrylic device with two
plates, the upper and a lower, inclined at 90°. While closing mouth,
the patient had to posture the mandible forward and close teeth
following the guidance of the inclined planes with an inter-incisal
clearance of 2 mm. After 6 months, he observed mandible got
sagittally advanced and molar relation became class I with a reduction
of over-jet to 4 mm. That was the beginning of a new concept of the
two-piece functional appliance.3 Subsequently; Clark used this device
for the correction of developing class II malocclusion in patients with
small mandible and continued to improve the design based on his
clinical experience with patients.
Clark philosophy3
The occlusal inclined plane is the fundamental functional mechanism
of natural dentition (Fig. 52.3). The cuspal inclines planes play an
important part in determining the relationship of teeth as they erupt
into occlusion. When the mandible occludes in a distal relationship to
the maxilla, the occlusal forces acting on mandibular teeth in normal
function have a distal component of force that is unfavourable to
normal forward mandibular development. The inclined planes
formed by cusps of upper and lower teeth represent a
servomechanism that locks the mandible in a distally occluding
functional position.3
FIGURE 52.3 (A) Occlusal incline plane is a functional mechanism of

natural dentition. (B) Twin block modifies the occlusal inclines and uses
the functional forces of occlusion to correct the malocclusion. The
mandible is guided forward by occlusal inclined planes. Functional
forces from occlusion promote mandibular adaptation in a forward
position and overall changes in the neuromuscular pattern around the
oral cavity and face.
Twin block appliance achieves rapid functional correction of
malocclusion by transmission of favourable occlusal forces to occlusal
inclined planes that cover the posterior teeth. The forces of occlusion
are used as a functional mechanism to correct the malocclusion. The
fixed occlusal inclined plane has been used to alter the distribution of
occlusal forces.3
Advantages of twin block functional appliance

over one-piece appliance
‘Twin blocks are designed to be comfortable, aesthetic and efficient.
By addressing these requirements, twin blocks satisfy both the patient
and the operator as one of the most “patient friendly” of all the
functional appliances’ 4.
1. The appliance is designed for full-time wear and hence is

expected to bring about faster adaptation of neuromuscular
system along with skeletal and dental changes.
2. The twin block appliance is less obstructive on speech and
other oral functions compared to the one-piece functional
appliances.
3. Since the appliance is worn full time and allows mandibular
movements, the functional inclines serve like natural dentition.
4. Tooth movements in individual arches can be accomplished
simultaneously when the sagittal jaw correction is in progress.
For example, a ‘Z’ spring can be added for lingually paced
tooth, or labial bow can be activated for the correction of the
spaced dentition.
5. The appliance eliminates the need for the pre-functional phase
of orthopaedic treatment. A midline screw is incorporated in
the upper appliance. The expansion of the maxillary arch is
accomplished while sagittal correction is in progress.
6. The vertical eruption of posterior teeth can be easily controlled
with twin blocks. In severe deep bite cases, lower molars can
be allowed to erupt vertically while in open bite tendency or
vertical growers molar eruption can be controlled.
7. Twin block can be used in conjunction with Kloehn face-bow if
required.
8. The appliance can be used simultaneously with a partial or
full-fixed appliance.
9. The appliance can be modified to suit the needs of the
transitional dentition. The appliance can be effectively used
during early mixed, late or in permanent dentition.
10. Rapid correction permits its use when patients report late for
treatment with little growth remaining.
11. Reverse twin blocks have been designed for the interception of
class III malocclusion.
12. The appliance has been modified and successfully used for the
treatment of class II division 2 malocclusions.
13. The construction of appliance does not require special
laboratory procedures or expensive equipment for its
fabrication. The appliance design is simple and hence cost
effective.
14. Can be cemented with glass ionomer cement in patients with
poor cooperation.
15. Literature is full of successful case reports and several short-
term and long-term studies on the effects of twin block
appliance on skeletal and dental changes.
Indications and case selection

Functional appliance treatment is indicated in growing patients with
class II division 1 malocclusion or less often class II division 2
malocclusions. Functional appliances are also considered for
correction of class III malocclusion, especially those due to the
functional forward shift of the mandible (Fig. 52.4A–B).
FIGURE 52.4 Case selection and VTO.
(A) A favourable case for FA therapy. Note retrognathic profile (left),
which becomes orthognathic, indicating positive VTO. Case selection
and VTO. (B) An unfavourable case for FA therapy. Class II, Case KS,
10 years/female, vertical grower case not suitable for FA. Large FMA,
IMPA and a significant maxillary protrusion with negative VTO.
Class II malocclusion
Patients having following features of occlusion/malocclusion are
considered suitable for FA:
Growing children preferably just before the pubertal growth spurt
1. Normal physical and mental growth, normal weight and
height/age
2. A child free from systemic diseases which may affect
skeletal/dental/neuromuscular behaviour and response
3. A cooperative patient
4. Normal eruption of teeth according to age
5. Square face with average or low mandibular plane angle
6. Dental and skeletal class II malocclusion, class II molar and/or
canine relationship
7. Normal or retrognathic maxilla with a small mandible
8. Maxillary dentoalveolar protrusion with a small mandible
9. Upright mandibular incisors on basal bone or those with mild
proclination
10. Deep curve of Spee, supra-erupted mandibular incisors or
infra-occlusion of the mandibular molars
11. Deep bite
12. Large over-jet contributed by a small/retrognathic mandible
13. Narrow maxilla may show a transverse deficiency. Maxillary
arch with minimal crowding of not more than 4 mm could be
resolved with arch alignment and maxillary expansion
14. Aligned anterior teeth or minimal crowding in the mandibular
arch
15. Subjects with low caries risk and good oral hygiene practice.
A case of class II malocclusion who responded favourably to

treatment is depicted in Fig. 52.5 and Box 52.1.
FIGURE 52.5 Case study treatment with twin block.
(A) Pre-treatment. Case AJ, 10 years old young boy with normal mid
face, proclined maxillary incisors with spacing and convex profi le due
to retrognathic mandible. He has well aligned upper and lower arches
with full cusp class II molar and canine relations on both the sides. The
lower incisors are upright and he is an average grower. (B) Profile and
occlusion after 16 months of twinblock appliance therapy. The
maxillary is wide and parabolic in shape, the buccal occlusion in class I
relationship. A buccal open bite will be normalised with the eruption of
lower buccal segment facilitated by sequential trimming of the upper
block. (C) Following completion of fixed appliance therapy. The
facial and skeletal profile is orthognathic. The occlusion has all the
features of normal occlusion. (D) Follow-up after 2 years of
completion of therapy. Excellent maintenance of the treatment results
is evident. (E) Lateral cephalograms showing growth and treatment
changes. a. Pretreatment; b. post-functional (8 months); c.
immediately post-debond; d. follow-up. Note the improved inter incisal
angle and sagittal jaw relations. The improvement to orthognathic
skeletal profile is also maintained (F) Lateral cephalometric
superimpositions. I, Pre- and post-twin block therapy. II, Post-
treatment superimposition. Note growth of the upper face, nose, middle
and lower face. The upper incisors are stable nearly in pre-treatment
position. The mandible is positioned forward and so are the lower
incisors. III, Follow-up indicates further growth of the nose and face.
The orthognathic skeletal profile and dental relations are maintained.
Source: Originally published in Journal of Indian Orthodontic Society,
Vol. 49, No. 4Sppl Copyright 2015 © Indian Orthodontic Society. All
rights reserved. Reproduced with the permission of the copyright
holders and the publishers, SAGE Publications India Pvt. Ltd, New
Delhi.
Box 52.1 Cephalometric comparative table
showing skeletal and dental changes of vertical
twin block appliance. The net changes are more
evident for sagittal advancement of the mandible
(decreased ANB angle. Angle of convexity),
retroclination of upper incisor, mild proclination
of lower incisor, marked changes in position of
the upper and lower lip.
Poor responders to FA therapy

1. Patients who have poor oral hygiene and are at higher risks of
caries should undergo optimisation of dental health before
they can be considered for functional appliance therapy.
2. Diseases of the skeletal system and neuromuscular
disturbances contraindicate treatment with a functional
appliance.
3. Children with a poor record of performance in school,
stubborn, with psychological problems and those on drugs for
attention deficient hyperactive disease (ADHD), are less likely
to wear the appliance which can result in failure or poor
treatment outcome.
4. A half cusp class II molar relationship that is purely dental in
nature, often due to a mesial migration of the upper molar(s)
into extraction space of second deciduous molar should be
considered for maxillary molar distalisation.
5. Patients with a very narrow maxilla, long face, and vertical
growth pattern, associated or superimposed with deleterious
oral habits such as oral breathing are not considered
favourable for treatment with removable functional appliance
alone. These patients may require additional orthopaedic
manipulation of growing maxilla with either Kloehn head-gear
or with maxillary splint appliance.
6. Children with gross skeletal anomalies and extreme vertical
growers may be better treated with surgical orthodontics.
Contraindication of functional therapy
1. Vertical growth pattern with a high mandibular angle

2. Bimaxillary dental protrusion
3. Severe tongue thrust
4. Limited growth response, the late grower
5. Neurological or bone pathology
Twin block and other removable functional appliances are indicated
in young patients who have not yet reached peak height velocity or
pubertal growth spurt. In general, the pubertal growth spurt in girls
occur around 10–14 years and about 12–16 years in boys. This is the
time of active growth including that of the facial skeleton.
Correction of class II treatment with a functional appliance is
expected to produce more favourable skeletal effects in children
treated just before peak height velocity compared to those during or
slightly after the onset of the puberty.21 During or after the completion
of puberty, growth potential of the mandible is limited and therefore,
treatment benefits could be limited to dental changes.
A detailed history and record of gain in physical height of the child,
and in girl’s history on the age of onset of menstruation cycle provides
a reasonable clue to pubertal growth status. Clinical observations on
absence/appearance of secondary sex characters also provide a
reasonable clue to the initiation of puberty.
Since dental eruption correlates poorly with skeletal and physical
development, stage of dental development alone should not be the
sole consideration in case selection for treatment with a functional
appliance Table 52.1.
Table 52.1
Case selection and treatment planning in class II division 1 cases for functional
appliance treatment
Trait Favourable conditions for FA therapy
Malocclusion: Growing patients with class II division 1 malocclusion due to retrognathic or
Dental and skeletal small mandible and normal maxilla
features
Physical status Normal physical growth and development (height and weight for age) and
free from systemic disease
VTO Positive VTO
Growth spurt and Young patients not yet reached PHV or pubertal growth spurt. Pubertal
PHV growth spurt in girls is seen around 10–14 years and about 12–16 years in
boys
Skeletal The peak in mandibular growth occurs between CVMI II and CVMI III
maturation/CVMI
stage
MPA/FMA Average to low mandibular plane angle is suitable, vertical growth pattern
patients are unsuitable
Jarabak’s ratio Good posterior facial height/decreased or normal lower anterior face height
IMPA Normal IMPA. Mild proclination cases can be included with extra caution on
provision for control of IMPA
FA, Functional appliance; VTO, visual treatment objective; PHV, peak height velocity; CVMI,
cervical vertebra maturation index; FMA, Frankfort mandibular plane angle; MPA, mandibular
plane angle; IMPA, incisor mandibular plane angle
Functional analysis5
Multiple assessments are necessary to analyse mastication,
respiration, speech, posture and the status of each component
involved in accomplishing the functional activity. These include:
• Determination of postural rest position of the mandible and

interposed freeway space or interocclusal clearance
• Examination of temporomandibular joint function and
dysfunction and condylar movement in performing the
stomatognathic system’s task
• Assessment of the functional status of lips, cheek and tongue.
Determination of postural rest position of the mandible and

interposed freeway space or inter-occlusal clearance is obtained in
natural head position (NHP) (Fig. 52.6A–B). The postural rest position
of the mandible can be obtained in one or combination of the
following techniques.
• Phonetic exercise repeat 5–10 times, word Mississippi

• Command method-lick the lips and swallow
• Non-command method-careful observation of the patient
• Combination of the above.
FIGURE 52.6 Vertical dimensions of face.
(A) At rest. (B) Vertical dimension at occlusion.
The patient is made to feel relaxed, to lick the lips, swallow and
then hold still. At this stage, sub-mental muscles are evaluated, a lack
of any activity is indicative of a relaxed state. It is pertinent that the
orthodontist makes an individual effort to create the office ambience,
conducive to a stress-free working which let the child feel relaxed and
attain a position of the rest position of the mandible. The postural rest
position is measured with a pair of callipers as the anterior face height
at two reference points from soft tissue nasion to menton.
The path of the closure of the mandible should be evaluated from
the postural rest position to the centric occlusion. A particular
attention is given to locate any functional interferences leading to
distal positioning, common cause being a palatally erupting or
position of the maxillary lateral incisor. The occlusion is evaluated for
over-jet and overbite. A deep bite, associated with the curve of Spee
and supraerupted mandibular incisors and reduced lower anterior
face height is better managed with a functional appliance; whereas
children with deep bite with a gummy smile and long face are not
suitable for FA treatment. Occlusion should be evaluated for any
lateral cross-bite due to functional interferences. Should the dental
midline coincide in the rest position and become shifted on closure in
occlusion, interference during closure should be suspected, identified
and corrected. A distinction should be made on midline shift of
skeletal aetiology which may contraindicate FA therapy.
Examination of temporomandibular joint

Detailed TMJ analysis is an integral part of the clinical assessment in
orthodontics and it is more so relevant in reference to functional
appliance therapy. TMJ examination should include evaluation of
function and dysfunction and condylar movement in performing the
functions of the stomatognathic system.
Examination of tongue
Tongue functions and posture should be assessed to determine their
role in malocclusion. Abnormal swallowing habit and posture of
tongue both are critical to the cause of malocclusion.6–10 Moyers,8 and
Woodside9 illustrated the possible role of the nasal and pharyngeal
blockade and compensatory tongue posture in malocclusion. A flat,
low lying, anteriorly postured tongue leads to development of class III
malocclusion. Abnormal the tongue posture is considered more
significant than merely the function.10
Respiration
Child should be assessed for symptoms of recurrent throat infection;
allergies, deviated nasal septum and history of snoring. Frank nasal
obstruction or sleep disordered breathing (SDB) is common in
children. The bulky oral appliance may not be tolerated by the child.
Airway assessment can be done clinically by seeing an enlargement of
tonsils and radiographically upper airway and lower pharyngeal
airway can be assessed on a lateral cephalogram. In habitual mouth
breathing with little respiratory resistance, functional therapy is
indicated which also improves the lip seal. Physical obstruction to
nasal breathing because of excessive adenoid tissue, allergies,
deviated nasal septum, enlarged turbinates or such conditions
necessitate ENT consultation and management prior to the institution
of bulky functional appliance in the mouth. Clark’s twin block is not a
contraindication in most instances, since it does not impede breathing.
Evaluation of speech
Evaluation of speech is the integral component of orthodontic clinical
evaluation and should be performed to assess how much overjet has
contributed to the production of sounds due to lack of lip seal and
expected benefits following successful therapy should be explained to
the child and parents.
Visual treatment objective (VTO)

A case that is otherwise suitable for functional appliance therapy for
malocclusion type and severity, age and skeletal maturation is
evaluated for expected treatment outcome by performing a clinical
endeavour of VTO. A diligent evaluation of the naso-labial angle,
mental sulcus, lip trap, and facial heights is necessary. In particular,
lower anterior face height is evaluated in reference to total face height.
Reduced lower anterior face height and lip traps with near normal
naso-labial angle are conducive to a positive VTO. The child is asked
to bring the lower jaw forward in a state of normal or near normal
overjet to evaluate improvement in facial profile. A case with normal
maxilla and small mandible may show instant improvement in facial
profile.
In the position of VTO, transverse, sagittal and vertical relations of
dental arches are evaluated. Overjet is measured. Clinical judgement
is made on severity of protrusion/pro-clination of maxillary anterior
teeth and the subsequent position they may occupy after their
retraction. The maxillary arch is often narrow, and when the mandible
is postured forward in class I molar relationship, maxillary canines
often fall in a situation of cross-bite. Such a situation calls for
expansion of maxillary arch either in a separate phase of pre-
functional therapy or provision should be made in the appliance itself.
With regards to vertical relations on arches, greater is the depth of
bite, more of inter-occlusal space is created in the position of VTO.
The quantum of vertical tooth movements of buccal segment needed
to flatten the curve of Spee can be judged in the position of VTO.
A positive VTO is considered with instant improvement in facial
profile, with chin and maxilla in alignment with upper face leading to
an orthognathic profile. Upper lip strain and naso-labial angle should
be near normal or less than normal but not acute which will be
suggestive of the dental protrusion. In the absence of spacing in the
maxillary dentition acute naso-labial angle is indicative of poor
prognosis. The mild protrusion can be accommodated with maxillary
expansion (Fig. 52.4A).
A negative VTO will show a poor profile, increased lower face
height with poor proportion to upper face height and significant lip
strain and acute naso-labial angle (Fig. 52.4B).
Assessment of skeletal growth and development is not only important
in orthodontic diagnosis and treatment planning but also is an
accurate indicator of the general body development and maturation.
Various methods have been proposed for assessment of skeletal
maturity. These include:11–13
1. Chronological age
2. Peak height velocity (PHV)
3. Dental age
4. Hand-wrist radiographs
5. Cervical vertebral maturation index (CVMI).
Chronological age
Chronological age is the age of the subject in years from the time of
birth. It has been proposed that under normal circumstances, the
skeletal age would be within 10% of the chronological age.14
However, the same does not hold true for the people who are early or
late maturing, or in obese individuals.14 Chronological age is
suggestive of the status of maturation and not a true indicator of
skeletal age.
Peak height velocity

Removable FAs are indicated in young patients who are yet to reach
peak height velocity (PHV) or pubertal growth spurt. This subject is
given in detail in the chapter on growth (Chapter 9).
Dental age
Dental age of a subject is determined by observing the stage of dental
development and comparing it to known population standards. The
following points are used for the assessment of dental age:
1. Number of erupted and un-erupted teeth

2. Stage of dentition (deciduous, mixed and permanent)
3. Stage of crown formation of developing teeth
4. Stage of root formation of all erupted teeth.
Schour and Massler15 were amongst the first to discover that tooth
mineralisation was a constant ongoing process and provided one of
the earliest reliable dental maturity index. Since then, many authors
have proposed different indices, the notable being: Demirjian et al.,16
Nolla,17 Prahl-Andersen and van der Linden.18
Two major approaches to assess dental maturation and its
association with skeletal maturity include mapping with standard
atlas and scoring system of dental development.
• The atlas approach was used by Nolla,17 Schour and Massler,15

Andersen18 and Moorrees.19 This approach requires
comparison of the radiographs of jaws where morphologically
different stages of tooth mineralisation is compared with
standard tables, figures, charts or radiographs in the form of
an atlas.
• Techniques using the scoring system include those of
Demirjian16 and Haavikko.20 These techniques require the use
of jaw radiographs. However, they restrict the number of teeth
included for analysis. The teeth selected are assessed for the
crown and root development, and the result is interpreted into
the dental age by the use of tables provided by the respective
authors. Most scoring systems are complicated and not so
reliable; however, among these, the system proposed by
Demirjian16 (Fig. 52.7) is the easiest and considered accurate.21
Demirjian dental maturity has lead to the creation of a ‘dental
maturity scaling system’ valid for universal use.22
FIGURE 52.7 Dental maturation stages of permanent teeth.
Despite all the efforts, attempts to relate dental age to skeletal

maturation have met with only limited success, and dental age indices
are not considered valid indicators of skeletal maturation. Precise
information in relation to the timing of the onset of the growth spurt
may not be provided by these indices.23 They are, however, more
accurate than skeletal age, for the estimation of chronological age. This
is because chronic systemic disturbances like undernutrition and
hormonal imbalances have more effect on the bone metabolism than
dental development.24 The effort has been directed to ascertain the
significance of the second molar in the prediction of the skeletal
maturation.25 The dental development has significant variation among
different ethnic groups, races and is affected by a host of
environmental influences and therefore no more used as a reliable
indicator of skeletal maturity.
Skeletal age
Hand–wrist radiographic methods
These are the most commonly used methods for the assessment of the
skeletal age in the medical clinics.26
Many methods have been described, including the Greulich–Pyle
method,27 and the Tanner–Whitehouse method.29 A few investigators
have correlated facial growth maturation with skeletal growth using
skeletal maturity indicators significant being Fishman,26 Hagg–
Taranger29 and Singer.30 Greulich–Pyle method and the Tanner–
Whitehouse methods are most used methods in medical practice.
Greulich–Pyle method27 was developed in Cleveland in the 1930s
based on the hand-wrist radiographs of 1000 white children of ‘above
average economic and educational status with no systemic
disturbances’. This method involves comparison of the hand–wrist
radiograph of the left hand of subject to the standard age-specific
hand–wrist radiographs of the Greulich–Pyle atlas. The radiograph in
the atlas, which most closely resembles the radiograph of the subject,
determines the skeletal age. Through this method, both qualitative
and quantitative observations can be made,4,31 and it is still the most
commonly followed and universally accepted method for skeletal age
estimation. However, the method has the following shortcomings:
1. Since the original radiographs are based on a single

population, the radiographic series may not be applied
uniformly to all populations.
2. There may be significant inter-observer variations when
comparing the subject radiograph to standards given in the
atlas.
3. The radiographs in the atlas vertebrae were not taken at
standard intervals (some are 6 months apart while some are 14
months apart), exhibiting large standard error.
4. Some children do not follow the same sequence of appearance
of wrist bones as the majority, which may lead to false results.
Tanner–Whitehouse (TW2) method28 uses modern computerised

mathematical procedures28 and adds precision to the Greulich–Pyle
method. The same standards are used for both boys and girls. It is
based on the identification of 20 predefined landmarks on 20 bones in
the hand–wrist radiographs. For each patient, the various landmarks
are identified, and a specific letter code is given to each. Each code is
later assorted into one of the eight categories as specified by the
authors and the data is converted into numeric scores by the method
given in the Tanner–Whitehouse atlas. The scores can be added to get
the skeletal age in years and months. The advantage of this method is
that it takes into account the individual variation in the formation of
each bone and the method is accurate for prediction of bone age up to
0.1 year.4
Apart from these analyses, one may evaluate growth and
calcification of specific bones of the hand and wrist to relate skeletal
maturation to the pubertal growth curve. These include the onset of
calcification of the adductor sesamoid, calcification of the hook of the
hamate, and staging of the middle phalanges of the third finger.32,33
Newer methods are focused on the use of MRI for assessment of
bone age through hand–wrist MRI.34
With respect to facial growth and its association with skeletal
growth in general, Fishman (1982) correlated and provided 11 stages
of skeletal maturation on hand–wrist radiographs.26 To an
orthodontist appearance and development of adductor, sesamoid
seems most relevant (Figs 52.8.1 and 52.8.2). The onset of ossification
of the sesamoid takes place at the time of adolescent growth spurt in
stature height begins. The duration of later coincides with sesamoid
development (Fig. 52.9).
FIGURE 52.8.1 Hand–wrist radiograph showing the various
parameters which are considered for assessment for skeletal age.
FIGURE 52.8.2 Radiographic identification of skeletal maturity
indicators.
(A) Epiphysis equal in the width of the diaphysis. (B) Appearance of
adductor sesamoid of the thumb. (C) Capping of epiphysis. (D) Fusion
of epiphysis. Source: Based on the concept of Fishman.
FIGURE 52.9 Scheme for observation of hand–wrist radiographs
for assessment of skeletal age. Source: Based on the concept of
Fishman LS.
Cervical vertebral maturation index

In 1972, Lamparski35 analysed the size and shape changes in the
bodies of the five cervical vertebrae from C2 to C6. They found that
cervical vertebrae, as seen on routine lateral cephalograms, were as
statistically and clinically reliable in assessing skeletal age as the
hand–wrist technique. Since then, cervical vertebral maturation
indices have been put forth by Hassel and Farman36 and McNamara
and coworkers.37–39
Cervical vertebral maturation has been found to be accurate in
assessment of the skeletal age; its accuracy was approaching that of
hand–wrist radiographs.40 In the current scenario, cervical vertebral
maturation is being increasingly used for the assessment of skeletal
maturation status replacing the hand–wrist radiographs, especially in
orthodontics.
The method suggested by Baccetti et al. 39 involves evaluation of the
morphology of the three cervical vertebrae (C2, C3 and C4) by visual
inspection on a lateral cephalogram. The vertebrae are analysed for
the following two sets of variables:
1. Presence or absence of a concavity at the lower border of the

body of the vertebrae C2, C3 and C4
2. The overall shape of the body of C3 and C4:
• Trapezoid
• Rectangular horizontal
• Squared
• Rectangular vertical.
In addition, the cephalometric analysis may be used for tracing the

morphology of the vertebra more accurately (Figs 52.10 and 52.11).
FIGURE 52.10 A diagrammatic representation of various stages

of cervical vertebra maturation. Source: Based on the concept of
Baccetti T.40
FIGURE 52.11 Radiographs showing stages of cervical vertebra
maturation from CS1 to CS6.
For details refer to the text.
Stages of cervical vertebral maturation can be summarised as

follows.39
1. Cervical stage 1 (CS1)

• Lower borders of all the three vertebrae (C2–C4) are
flat.
• Bodies of both C3 and C4 are trapezoid in shape.
• Peak in mandibular growth will occur, on an average,
2 years after this stage.
• Concavity is present at the lower border of C2.
• Bodies of both C3 and C4 are still trapezoid in shape.
Peak in mandibular growth will occur 1 year after
this stage (average).
• Concavities at the lower borders of both C2 and C3
are present. Bodies of C3 and C4 are either a
trapezoid or rectangular horizontal in shape.
• Peak in mandibular growth will occur within 1 year
of this stage.
• Concavities at the lower borders of C2, C3 and C4 are
present.
• The bodies of C3 and C4 are rectangular horizontal in
shape.
• The peak in mandibular growth has occurred within 1
or 2 years before this stage.
still present.
• At least one of the bodies of C3 and C4 is square-
shaped. If not square, the body of the other cervical
vertebra still is rectangular horizontal.
• The peak in mandibular growth has ended at least 1
year before this stage.
evident.
• At least one of the bodies of C3 and C4 is rectangular
vertical in shape. If not rectangular vertical, the body
of the other cervical vertebra is square-shaped.
• The peak in mandibular growth has ended at least 2
years before this stage.
Based on a systematic review of 29 complete articles, Cericato et

al.41 concluded that the Cervical Vertebral Maturation Index appears
to be a valid, reliable, and reproducible method for skeletal
maturation assessment and may substitute the analysis of hand–wrist
radiograph in orthodontic treatment planning. In general visual
assessment of the CVM stages is accurate and repeatable to a
satisfactory level. About one in three cases remain misclassified;
disagreement is generally limited to one stage and is mostly seen in
stages 4 and 5.42 However, there are different views and observations
on the use of CVM stages and its relations with the peak mandibular
growth.42–45
Codes for CVMI 2017: Perenetti et al.46 sugessted the use of a range of
combinations of concavities and shapes to assign CVM stage. They
utilised the method of Bacceti et al.39 with minor modifications and
used combination 5-letter code to define each case.
These abbreviations were described for defining different CVM
stages (Table 52.2 and Fig. 52.12).
Table 52.2
Code used for CVM staging

Code Abbreviation
F Flat
C Concave
T Trapezoidal
H Rectangular horizontal
S Square
V Rectangular vertical
FIGURE 52.12 Annual cervical vertebral maturation with

corresponding tracings of subjects 153 (boy, upper rows) and 079
(girl, lower rows).
CS, Cervical stage; F, flat; C, concave; T, trapezoidal; H, rectangular
horizontal; S, square; V, rectangular vertical. Actual ages were
generally within 3 months. Note that for subject 079, CS2 at 11 years is
close to CS3. Source: Perinetti G1, Bianchet A2, Franchi L3,
ContardoL. Cervical vertebral maturation: An objective and transparent
code staging system applied to a 6-year longitudinal investigation. Am
J Orthod Dentofacial Orthop 2017;151(5):898–906.41
The overall CVM changes are consistent with previous reports. In

addition, there are exceptional cases, which do not fall in any of the
categories (Fig. 52.13). The prevalence of exceptional cases was
infrequent, however, it is most often found on the CS4 followed by
CS3, which requires more comprehensive staging instructions. They
suggested that the variability in duration of the CS2 to CS4 might
require other methods of growth indicator such as standing height or
the middle phalanx maturation method.47
FIGURE 52.13 Examples of four exception cases of CVM with
corresponding tracings.
C, concave; F, Flat; H, rectangular horizontal; S, square; T, trapezoidal;
V, rectangular vertical. Source: Perinetti G, Bianchet A, Franchi L,
Contardo L. Cervical vertebral maturation: An objective and transparent
code staging system applied to a 6-year longitudinal investigation. Am
J Orthod Dentofacial Orthop 2017;151(5):898–906.41
• Besides a detailed medical, personal and dental history and
routine essential diagnostic records, a few additional
diagnostic records are needed for a patient under
consideration for a functional appliance therapy.
• Young patients are asked to keep a record of their weight and
height on a monthly basis to know if there is a sudden
increase in height, which signifies peak height velocity (PHV).
• The clinical photographs should include profile photographs
of the face, while mandible is held in a forward posture to
record improvement expected from the treatment. Such an act
of examination is called VTO. This picture with improved
profile when shown to patient and parents serves a useful
motivational tool.
• The dental impressions should be poured in duplicate, the first
sets of models are required for transfer of recorded bite and
serve as working models, the second set being the records.
• The lateral cephalogram should consider a clear exposure of
the cervical vertebra. This may necessitate minor adjustments
in head/film orientation not to miss the due exposure of the
vertebral column.
• Hand–wrist radiographs may not be required for assessment
of skeletal age since CVMI has nearly replaced the use of
hand–wrist radiographs.
• Children exhibiting posterior cross-bite or a narrow maxillary
base, or one with facial asymmetry should undergo PA
cephalogram.
• Those exhibiting a limitation of jaw movements/click or
inability to bring mandible in a forward posture equally on
both sides would need to be assessed for TMJ pathology. A
detailed clinical assessment of TMJ is must for such patients.
The patients suspected with TMJ pathology should be further
investigated with tomograms of TMJ.
• The registration of the rest position of the mandible and
evaluation of centric relation becomes significantly important
for patients showing discrepancy due to deformity or
functional shift of the mandible.
• Children with mouth breathing habits or those with a history
of recurrent throat infections, nasal allergies or snoring should
undergo a consultation with an ENT specialist.
Cephalometric evaluation and analysis

A cephalogram should be visually evaluated before undertaking its
comprehensive analysis. It is possible to make a judgement on the
severity of sagittal discrepancy, more so the chin in profile,
dentoalveolar protrusion of the maxillary teeth, the pattern of facial
growth, position of mandibular incisors and growth rotation of
mandible and inclination of the palatal plane on a diligent visual
inspection of a lateral cephalogram.
Ramus and condyle area

The lateral cephalogram should also be visually evaluated for width,
shape and height of ramus, the morphology of condyle head and its
inclination.
A broad ramus with good vertical height and close gonial angle are
the skeletal features, which exhibit a large ratio of posterior face
height to anterior face height. These patients have a low mandibular
plane angle. Such facial patterns permit and accommodate supra-
eruption of mandibular buccal segment required for bite opening and
correction of sagittal jaw discrepancy. These skeletal features are
suitable for functional appliance therapy.
A thin, short ramus with large gonial angle is more often associated
with vertical growth pattern and is not a suitable pattern for
functional appliance therapy. In addition evaluation of relation of the
occlusal plane with the palatal plane and the mandibular plane is
significant for treatment planning. A high posterior inclination of the
occlusion plane is unfavourable while a high anterior occlusal plane
indicates that possible supra-eruption of the molars can be
accommodated to flatten the deep curve of Spee.
Maxilla and palatal plane inclination

The relative inclination of the maxilla with cranial base effects the
show of maxillary incisors; this plane can be altered with dentofacial
orthopaedics, which then should become a part of a total plan of the
treatment. A downward posterior tilt of the palatal plane is suggestive
of extrusion of molars. In such cases, eruption of the mandibular
posterior teeth is contraindicated for they may further cause
backwards rotation of the mandible and worsening of the profile.
Nasopharyngeal passage
Cephalogram should be visually evaluated for the patency of
nasopharyngeal airway, the presence of adenoids and if required, the
suitable analysis should be performed.
The very purpose of cephalometric analysis for a case of FA is focused
on obtaining information on the nature and severity of skeletal and
dental dysplasia contributing to class II skeletal relationships and
dental malocclusion. The analysis includes the following:
1. Cranial base variables

2. Face height variables
3. Anteroposterior variables
4. Mandibular variables
5. Variables of mid face
6. Dental variables
7. Soft-tissue variables.
Cephalometric variables of high significance about functional

appliance include measurements of cranial base length (S-N or Ba-N)
and length of the maxilla and mandible and facial heights. It is
important to know mid facial and mandibular length as suggested by
McNamara analysis (Fig. 52.14, Table 52.3).48 The norm of effective
mandibular length measured at Co–Gn is 114.0 mm (SD ±4.3) and
effective mid-facial length Co–A is 85.0 mm (SD ±4.8).
FIGURE 52.14 The cephalometric landmarks and definitions by

McNamara.
S indicates sella (the centre of sellaturcica); N, nasion (the most
anterior limit of suture nasofrontalis); Ba, basion (the posterior inferior
point on the occipital bone at the anterior margin of the foramen
magnum); ANS, anterior nasal spine (the apex of the anterior nasal
spine); A, subspinale (the most posterior point on the concave anterior
border of the maxillary alveolar process); Pg, pogonion (the most
anterior point on the mandibular symphysis); Gn, anatomical gnathion
(the most anteroinferior point of the mandibular symphysis); cGn,
constructed gnathion (the intersection of the facial plane and the
mandibular plane; facial plane is the line from the nasion to the
pogonion); Me, menton (the lowermost point on the shadow of the
mandibular symphysis); Go, gonion (the most outward point on the
angle formed by the junction of the ramus and body of the mandible on
its posterior, inferior aspect); Co, condylion (the most posterior point on
the outline of the mandibular condyle); P, porion (the superior aspect of
the external auditory meatus); Or, orbit (the lower border of the orbit of
the eye); PTM, pterygomaxillary fissure (the most posterosuperior
aspect of the pterygomaxillary fissure).
Table 52.3
Cephalometric landmarks and reference planes used by McNamara

Landmarks Variable Definition
Maxilla to cranial base

1. NA- Nasion A vertical line is constructed perpendicular to the Frankfort
perpendicular perpendicular to horizontal and extended inferiorly from the nasion. The
point A perpendicular distance is measured from point A to the nasion
perpendicular
2. SNA The angle between the SN and NA lines
Mandible to maxilla
3. Co-Gn Effective A line is measured from the condylion to the anatomic
mandibular length gnathion
4. Co-A Effective midface A line is measured from the condylion to point A
length
5. MXMD-DF Maxillomandibular Effective mandibular length minus effective midface length
differences
6. ANS-Me Lower anterior face A line is measured from the anterior nasal spine to the menton
height
7. MD-P Mandibular plane The angle between the anatomic Frankfort plane and the
angle mandibular plane, gonion-menton
8. FA-A Facial axis angle A line is constructed from the basion to the nasion (Ba-N) A
second line (the facial axis) is constructed from the
posterosuperior aspect of the pterygomaxillary fissure (PTM)
to the constructed gnathion (the intersection of the facial plane
and the mandibular plane). The facial axis angle is the angle
between the Ba-N and the facial axis
Mandible to cranial base
9. Pg-N Pogonion to nasion The perpendicular distance is measured from the pogonion to
perpendicular the nasion perpendicular
Dentition
10. Ui-A Upper incisor to A perpendicular is constructed parallel to the nasion
point A perpendicular through point A. The perpendicular distance is
measured from the most anterior surface of the upper incisor
to the point A perpendicular
11. Li-APg Lower incisor to A- The distance is measured from the facial surface of the lower
pogonion line incisor to the A-pogonion line
Also refer to chapter 76
The cranial base, articular angle and gonial angles (N-S-Ar, S-Ar-
GO and Ar-Go-Me) are evaluated to know the rotation of the
mandible. The upper gonial angle (N-Go-Ar) and lower gonial angle
(N-Go-Me) are measured to evaluate their relative contribution to the
gonial angle, which represents ramus and corpus of the mandible
respectively.
Information on a growth trend, that is horizontal/vertical is
obtained from angles MP-FH plane, MP-SN plane and palatal plane to
SN plane angle. The ratio of vertical facial proportions, that is upper
anterior facial height to total anterior face height, and anterior to
posterior face heights (Jarabak’s ratio) are important parameters in
decision making process in the case selection. Normal or good
Jarabak’s ratio suggests the good development of the vertical ramus
and a horizontal pattern of the facial growth, favourable for FA
therapy.
In addition to commonly used sagittal discrepancy indicators, that
is angle ANB, sagittal maxilla mandibular relationship should be
reconfirmed with other variables which include WITS appraisal, A–B
plane angle and beta angle. Among dental variables, a careful
assessment of dentoalveolar protrusion and relationship of
mandibular incisors to basal plane (IMPA) are of great importance.
A summary analysis of a case would require a deep and detailed
analysis of skeletal and dental dysplasia and such parameters that
would help select the case for FA for better prognosis (Table 52.3).
Cephalometric features of a suitable case for functional

appliance
Sagittal.
1. A case with large anteroposterior discrepancy (ANB angle) due

to retro positioning and/or short mandible.
2. A horizontal growth trend of the face, FMPA/SN-Go-GN
normal or less than normal (25 or ≤32°).
3. Good posterior facial height/decreased or normal lower
anterior face height that in turn, is reflected as a favourable
Jarabak’s ratio.
4. Gonial angle normal or small.
5. Normal or small Y-axis/facial axis.
6. Parameters suggesting posterior position of gonion and small
mandibular length for a given age.
7. The lower incisors are upright or only slightly inclined on the
mandible, i.e. normal or decreased IMPA.
The philosophy of functional appliance is based on jumping the bite
by holding the mandible in a forward position. The extent to which
mandible should be brought forward and how much it should be
brought downward in the vertical direction is still a matter of debate.
The extent of horizontal advancement

In general two concepts of bite-recording are in vogue. While a few
clinicians, favour recording the bite in mandible postured forward
edge-to-edge bite or just short of it, (one step advancement) others
favour advancement of the mandible in two or three increments (step
wise advancement). Essentially, the quantum of sagittal skeletal
discrepancy, dental overjet and patient’s ability to bring the mandible
forward would influence the extent of sagittal advancement.
The optimal forward movement of the mandible for construction
bite is usually half of the individual’s maximum range of the
protraction of the mandible. The bite should not be painful or cause
discomfort on sagittal activation. The extent of sagittal activation is
largely governed by the amount of over-jet and the degree of the
upper incisor pro-clination and their possible retraction during
treatment. The maximum forward movement of the mandible up to 10
mm can be managed with a single activation. Activation must not
exceed 70% of the total protrusive path to remain within physiological
limits of movement of the mandible. However, if over-jet is very large
such as 14 mm or more, the mandible is advanced in a stepwise
manner more often in two stages.4
If forward posturing of the mandible causes a cross-bite relation in
the maxillary canine region as in a case of dental impediment or very
narrow maxillary arches, the bite should be advanced so far that the
canines are opposing each other’s cusp tip to cusp tip. Further
mandibular posturing should not be done until the maxillary arch is
expanded to prevent buccal-cross-bite. The extent of forward
positioning is also related to the amount of bite opening. Twin block
design has a unique ability to perform simultaneous sagittal activation
and maxillary expansion.
The extent of the vertical opening

The bite is often recorded beyond the freeway space. Separation of
buccal segments on the construction bite by approximately 2 mm
more than the individuals resting position is considered optimal.
When mandible is opened beyond the rest position, condyles move
downward and slightly forward thus the need for further sagittal
advancement to a required sagittal position is less than estimated. It is
essential that before bite recording is initiated, ‘rest position of the
mandible’ is ascertained. Face height is then measured in the position
of rest and in occlusion to estimate freeway space.
Rolf Frankel likes to record the bite within limits of freeway space.
The philosophy of activator also suggested recording the bite within
the limits of freeway space. However, most activator appliances are
now made as splint activator to be used with high pull headgear the
indication for the same being the vertical craniofacial pattern.
Therefore, for the bite block effect on the appliance, bite is recorded
beyond freeway space.
The extent of vertical opening is dependent upon the nature of
malocclusion and craniofacial growth trend. If the forward
positioning of the mandible is 10 mm or 7–8 mm, the vertical opening
must be slight to moderate, that is 2–4 mm so as not to overstretch the
muscles. If the forward positioning is not more than 3–5 mm, the
vertical opening could be more up to 4–6 mm. Greater vertical and
less sagittal activation is recorded in vertical growth type while
normal/horizontal growers receive more horizontal activation.
Patients with vertical growth pattern have weak elevators of the
mandible and are therefore unable to maintain the forward
mandibular posture consistently. These patients require prevention of
supra-eruption of the molars, with a little anterior positioning of the
mandible, change in inclination of the maxillary base and some dental
compensation is possible.
Midline considerations
Non-incident midlines may have varied aetiology that needs to be
ascertained to determine its possible impact on recording the bite.
Midline shift can occur due to pure dental causes such as
asymmetrical loss of deciduous canines or functional shifts. Dental
midline shift should not be corrected in the bite registration.
If the midline shift is observed in centric occlusion, while they
coincide in the rest position the prognosis is good. However, if there is
a persistence of midline shift in the rest position, they are usually due
to the asymmetrical growth of the mandible and may not always
respond favourably.
Midline changes due to skeletal reasons should be deeply looked
and investigated for any underlying pathology. Minor deviations of
midline due to a skeletal lateral translation of the mandible can be
corrected during recording the bite.
Bite registration in class II division 1 open bite/vertical growth. Patients
with vertical growth trend and anterior open bite would require that
mandibular forward position is small as they need greater vertical
separation. The bite is recorded with 4 mm separation in the incisor
region. The buccal bite blocks are not to be trimmed to create
impaction effect on molars to prevent their vertical eruption.
Bite registration in class II division II type situations. In clinical
situations of smaller over-jet but full cusp class II molar relationship,
the mandibular forward posture to correct it to class I molar
relationship would result in a reverse over-jet. The bite can be
recorded in this situation while a provision is made in the appliance to
procline the retroclined maxillary incisors. In situations with severe
deep bite such as class II division 2, bite may be recorded in edge-to-
edge position, and later second activation of bite blocks is done
following proclination of severally retroclined maxillary incisor teeth
that would permit more mandibular advancement.
Bite recording according to Clark

Dr Clark recommends the use of Project Bite Gauge for the bite
recording. (Fig. 52.15 A–E).
FIGURE 52.15 Steps in recording the bite with bite gauge.

(A) Bite gauge with 2 mm incisal separation. (B) Bite gauge is tested in
the mouth with mandible having brought forward to the extent of the
lower incisor in an edge-to-edge bite. The lower groove is used as a
reference to advance the mandible for recording the bite. (C) Modelling
wax is softened and wrapped around bite gauge fork. (D) Bite gauge
with wax is transferred in the mouth. (E) The bite is recorded by
advancing the mandible with lower incisors being brought forward in
pre-decided groove. The wax is allowed to harden. The wax bite can
also be recorded with modelling wax without bite gauge. The wax bite
is thoroughly washed air-dried with three-way syringe and transferred
to working models. The extent of sagittal and vertical advancement can
be measured with a ruler on the study models as shown in Fig. 52.17.
Dr Clark suggested up to 10 mm or less of sagittal advancement of

the mandible while recording the bite. In most instances, 10 mm or a
close value is often the maximum limit to which a child can tolerate
the advancement without muscle strain and pain. The sagittal
advancement should not exceed 70% of the maximum protrusive limit
of the mandible. The vertical opening is suggested to be 1–2 mm in the
first molar region, which is equivalent to 4–5 mm in premolar region.
Inter-occlusal clearance can be increased for severe deep bite cases.
Any functional midline discrepancies are corrected at the stage of bite
registration. In severe deep bite cases, edge-to-edge incisor
relationship with an inter-incisal clearance of 2 mm in protrusive bite
is recorded.
Procedure of bite registration49
Armamentarium (Fig. 52.16)
• Modelling wax
• Hot water bath
• Lecron carver
• Vernier calliper
• Bow divider
• Wax knife
• Wax carver
• Scissors
• BP blade and holder
• Two sets freshly prepared working and study model
• Hot and cold water.
FIGURE 52.16 Armamentarium required for recording the bite for

a functional appliance.
Hot water bath for softening the wax. Wax sheet, wax spatula, Lecron,
working models vernier callipers, bow divider and ruler, scissors, BP
blade and holder.
Reference line should be marked on the study model to assess

vertical and sagittal advancement. Predetermined sagittal and vertical
advancement should be checked on study models (Fig. 52.17).
Simultaneously reference mark should be placed on patient’s nose
and chin to assess vertical dimension of face, at rest and occlusion.
Patient mandible should be guided in the desired position repeatedly
so that he can achieve the same position while bite registration. Again,
vertical dimensions of the face from previous reference points should
be checked and noted.
FIGURE 52.17 Measuring the extent of vertical and sagittal

activation.
(A) Working models are marked bilaterally for registering molar position
in upper and lower arch. Two horizontal reference lines are marked
parallel to model bases. (B–C) These reference lines are used to
measure the extent of the vertical opening in the buccal segment by
transferring a wax bite on them. Horizontal activation is measured as
the distance on marked lines on first molars. The vertical height of the
recorded bite can be calculated as a difference in heights measured
between two horizontal lines marked on bases (seen as above) with
teeth in occlusion with and without a wax bite.
The modelling wax is gently heated, rolled to a thickness of 4–6

mm, to the buccolingual width of lower molars. It is shaped to follow
the curve of the lower arch extending up to last erupted molars. The
preheated wax bite roll is kept in the mouth on lower arch and child is
asked and guided to bite in pre-estimated horizontal and vertical
activation of the mandible. Wax bite is removed from the patient’s
mouth, chilled, washed and placed on the working models, over
extensions are trimmed, again placed in the patient mouth, and inter-
canine width is assessed (Fig. 52.15).
The bite after rechecking for desired horizontal and vertical
activations is washed under the running tap water and transferred to
dental models for reconfirming the desired occlusion and activation.
The models are then transferred to a hinge articulator. The wire
bending is completed and the appliance can be fabricated with either
heat cure or self-cure or heat cure acrylic, finished and cleaned for
delivery.
Appliance design and construction49,51
The twin block appliance constitutes an upper and a lower removable
appliance made in acrylic. It has a definite wire framework design.
The appliance is prepared on good quality working models prepared
from alginate impressions. The bite for the functional appliance is
recorded in class I occlusion and transferred to models, which are
articulated.
The upper appliance is usually retained with a long labial bow
extending distally to first premolars. The main retentive components
for the upper appliance are two arrowhead clasps on first molars. The
appliance can also be prepared without labial bow should there be no
need for retraction of the maxillary incisors.
Clark modified arrowhead clasp to a coiled tube for housing the
inner face-bow. However, simultaneous use of Kloehn’s face-bow is
rarely required. The coiled tube is now substituted with soldered
round tube on the buccal horizontal arm of the arrowhead clasp if so
required. Additional retention can be obtained with ball end hooks or
clasps, and are essential if the labial bow is not used. According to
Clark, the labial bow is seldom needed. A parallel maxillary
expansion screw is a major component of the upper appliance.
The mandibular appliance is retained with ball end clasps mesial to
canines, which are virtually invisible in the mouth. Delta clasps are
used on first premolars. The delta clasps are superior to Adams’
clasps because they do not open with repeated insertion and their
removal requires few adjustments, hence the chance of breakage due
to metal fatigue because of multiple adjustments are minimised. The
delta claps can be used on molars and premolars. In mixed dentition,
mandibular first premolars/deciduous first molar can be used for
retention with arrowhead clasps. Bite blocks cover the occlusal
surfaces from the second premolar to second premolars. The inclines
of the occlusal blocks meet at 70° in the first premolar region.
Angulation of inclined planes3
• During evolution of the appliance bite angulation of the blocks
varied from 45–90°
• The very first appliance was constructed with bite blocks
articulating at 90° Significant posterior open bite was
experienced in 30% of patients
• Bite blocks with 45° angle apply equal downward and forward
component of force to lower dentition. The mandible will
often drop back due to over inclination.
• Bite blocks with 70° angulation apply a more horizontal
component of force
Optimal thickness of bite blocks49

In clinical practice comfort zone for inter-gingival height for adult
patient is generally 17–19 mm. If inter-gingival height varies
significantly from the comfort zone, patients are at greater risk of
developing TMJ dysfunction. Other disadvantages of thick bite blocks
are:
1. Appliances are uncomfortable and cannot be worn full time.

2. Patients cannot incise or chew food making as it is impossible
to eat with the appliances in the mouth.
3. Speech is badly affected by large blocks that obstruct the
tongue.
4. Facial height is excessive with large blocks.
5. It is not possible to close the lips comfortably.
6. Patients are embarrassed when wearing the appliances at
school.
7. Lower molars are not free to erupt.
8. A large posterior open bite develops during treatment, which
may lead to an unsupported temporomandibular joint later.
Clinical management
Treatment sequence with twin block can be organised in following
phases
• Pre-functional phase
• Functional phase
• Active phase
• Supportive phase
• Retentive phase
• Follow-up.
Pre-functional phase
The objectives of the pre-functional phase are:
1. To create a transverse expansion of the maxillary arch to

accommodate the lower arch when the mandible is held in a
forward position of normal overjet.
2. To optimise alignment of the teeth that does not allow
unhindered sagittal forward relocation of the mandible. A
crowded maxillary arch or palatally inclined/a displaced
anterior tooth may hinder the sagittal advancement of the
mandible and hence prevent proper recording of the bite (Fig.
52.18). This may necessitate treatment with a removable
appliance or a short phase of fixed appliance therapy before
the institution of functional appliance insertion. Patients with
class II division 2 malocclusions require that retroclined
maxillary incisors are aligned to allow forward posture of the
mandible.
FIGURE 52.18 Retroclined or palatally placed maxillary incisor
hinders forward mandibular posture required for bite recording.
Such a situation would require a short phase of therapy to align the
maxillary left central incisor. Case RD, 14 years/male, his retroclined
left maxillary incisor was aligned with a Z spring.
Such situations can be resolved with a short course of a removable

appliance therapy or partially bonded fixed appliance treatment,
extending for a few months. In other situations, the maxillary arch is
often narrow, and when the mandible is postured forward in class I
molar relationship, canines often fall into a situation of transverse
cross-bite. Such a situation calls for expansion of maxillary arch either
in a separate phase of pre-functional therapy or provision should be
made for expansion in the twin block appliance.
Functional phase3 (Box 52.2)

a) Active phase
b) Supportive phase
c) Retentive phase
Box 52.2 Kharbanda protocol for records and
treatment follow-up with functional appliance
Records and Case Selection

• Patient counselling, history, and consent for treatment
Ear, nose, and throat (ENT) evaluation in case of adenoids, mouth breathing habit or
breathing problem
Duplicate set of models in dental stone
Intra- and extraoral photographs
Lateral cephalogram
Panoramic radiograph
Other X-rays if required such as IOPA/occlusal X-ray/PA cephalogram
Treatment Planning
• Case discussion
Functional appliance selection and tentative planning of fixed mechano therapy
Retention planning
Working model impression
Wax bite registration
Appliance fabrication
Functional Phase
• Appliance delivery and instructions
Follow-up and Review

• First review 24 h
• Second review 1 week, start activation of maxillary expansion screw
• Third review 4–6 weeks
• Follow-up, review and trimming, adjustment every 6–8 weeks
Second Activation (Twin block)

• Second activation in case of large overjet after 6 months
Supportive Phase
At 9 months, start supportive stage for phase II FA therapy or shift to fixed appliance
Stage records at the end of FA therapy or before fixed appliance
Study models with wax bite of the stage occlusion in dental stone
Intra- and extraoral photographs/and existing occlusion in wax bite
Lateral cephalogram
Review the treatment planning
• Follow-up with fixed appliance for settlement of occlusion and maintenance of class I
relationship with reverse bite plane and or class II elastics/bionator appliance
• Pre-finish records to evaluate root alignment and anterior torque lateral cephalogram
• Post-treatment records
Study models in dental stone
Intra- and extraoral photographs
Retention and follow-up

• Retention appliance delivery and Instruction
• First follow-up 24 h
• Second follow-up 1 month
• Follow-up every 3 months for 1 year
• Follow-up every 6 months for next 1 year
Active phase (6–9months)

During the active phase of therapy, the objectives are arch
development, attainment of sagittal correction and opening the bite.
First Visit: The appliance is issued after a full adjustment and a
thorough checkup for any sharps, acrylic pimples, clearance of
premolars undercuts and relief to lingual fraenum.
• The patient should be encouraged to wear appliance all the

time including meals except for hygiene purpose
• The lingual flange of appliance should be relieved slightly
lingual to lower incisors to avoid gingival irritation
• First few days speech will be affected, but will steadily
improve and should return to normal within a week
• Check initial activation and confirm that patient bites
consistently on the inclined plane
• Initial overjet should be recorded and checked at every visit to
monitor progress.
First visit E (EXTRA): At AIIMS, we like to recall the patient in 24–

48 h to review wearing difficulties and pain in TMJ. In our experience,
the first 2 days are critical and a child should be encouraged to
continue wearing the appliance after which time, he is usually fine.
Second Visit: Clark suggested review in 10 days to 2-weeks’ time.
By now child is comfortable in wearing the appliance and should have
started eating major meals with the appliance on. If the patient is
failing to posture forward consistently, the clinician should consider
reducing activation by trimming inclined planes.
At this stage maxillary expansion in initiated with two turns/week
(0.5 mm/week).
The deep bite correction is initiated by trimming the upper block
occlusodistally to relieve lower molar 1 mm clear of occlusion.
Third Visit: It is usually scheduled between 4–6 weeks. The facial
muscle and profile now shows progress towards balance.
The appliance retention is checked. Labial bow should be out of
contact with upper incisors.
A check is also made for maxillary expansion and its effect on the
dental arch. The palatal acrylic lingual to maxillary incisors should be
relieved by 2 mm or allow palatal movement of the proclined incisors.
Further relief is provided on the maxillary bite block to allow
eruption of the lower molars.
Fourth Visit (12–14 weeks): By this time the child is happy with the
appliance because his profile is much improved, and he can masticate
and live with the appliance. He is better with appliance and
uncomfortable without it due to neuromuscular adaptations and
relocation of the condyle. His occlusion is better and any attempt to
push back the mandible in pre-treatment occlusion becomes painful.
This is called the pterygoid reflex. At this stage, further trimming of
the maxillary bite block is continued to allow inter-digitation of the
molars in class I occlusion relationship.
Pterygoid response
As soon as the appliance is placed in the mouth, the neuromuscular
balance is altered, and in another few weeks, the mandible tries to
adapt to a new position decided by the inclines of the functional
appliance. At this stage, the newly acquired position is more
convenient, and effort to move the mandible back to its original
position is painful. In clinical terms, these observations are called
‘pterygoid response’, which is the outcome of neuromuscular and TMJ
adaptation occurring at histological level.52 Absence of pterygoid
response indicates ineffectiveness of the appliance in bringing about
growth modification.
Subsequent follow-up every 8–12 weeks may require trimming of
the blocks in an orderly manner (Fig. 52.19). By 6–12 months, a full
sagittal correction is usually achieved.
FIGURE 52.19 Maxillary bite block contacts the mandibular

molars on insertion of the upper and lower appliances.
(A) The maxillary bite block is trimmed usually after a few weeks of
adaptation to the appliance. The trimming is done on the occlusal
surface in a gradual manner to allow eruption of mandibular molars. (B)
Trimming is done not to disturb acrylic inclines in first premolar area.
(C) The acrylic in the regions of inclines near premolars is the last one
to be trimmed once buccal molars are established in class I inter-
cuspation.
In our experience at AIIMS, 9 months is the average time taken for

full sagittal correction.
Progressive advancement of the mandible can be done when the
over-jet is large by adding a block of cold cure acrylic to maxillary
inclines (Fig. 52.20).
FIGURE 52.20 Progressive advancement of mandible by adding

cold cure acrylic to upper occlusal inclined plane during
supportive phase.
Management of deep bite

Trimming the occlusal block of the upper appliance to encourage
the eruption of lower molars in a step wise manner facilitates bite
opening. In addition active intrusion of maxillary incisors is achieved
during the finishing phase of fixed appliance therapy with intrusion
arch to create a harmony with lip line during smile and at rest.
Support phase
Subsequent to sagittal correction, support phase is initiated. The
maxillary appliance is trimmed of the bite block, its expansion area is
sealed with cold cure acrylic and an anterior locking mechanism is
created for the mandible, which sustains the class I relationship (Fig.
52.21). During this period, the premolars erupt to level the curve of
Spee, and neuromuscular adaptation continues. To maintain the
corrected vertical dimension, a flat vertical stop of acrylic extends
forward from inclined plane to engage lower incisors (Fig. 52.19A–C).
FIGURE 52.21 Support phase of therapy with a modified Hawley

appliance having a reverse incline, this phase of therapy helps to
establish premolars in class I occlusion.
(A) Occlusal view of the modified bite plane. (B) Reverse incline plane
engages lower incisors which retain mandible in a forward position
while molars should inter-digitate in class I occlusion. (C) Premolars
erupt into occlusion. Proper inter-cuspation of the buccal segment is
critical to the maintenance of treatment outcome.
Successful cases treated with twin block appliance are depicted in
Figs 52.22A–D, 52.23A–C and 52.24A–D.
FIGURE 52.22 Treatment with twin block—A case study. A case
of class II division I malocclusion treated with twin block
appliance. (A) Pre-treatment.
Case SB, 11.5 years boy with slightly convex profile due to a small
chin. He has well aligned upper and lower arches with full cusp class II
molar and canine relations on the right side and half cusp molar and
canine relation on the left side. Case SB is a suitable case for
functional appliance therapy with normal maxilla and retrusive
mandible. (B) Effects of twin block on occlusion. (A) With appliance.
(B) After 3 months of active treatment, the molars and canines are in
class I relationship. There is a buccal openbite due to the effect of the
acrylic bite block. At this stage trimming of the upper bite block is
initiated on the occlusal side to allow eruption of lower molars. (C)
Occlusion is settling down. After 6 months. (D) After 12 months. (E)
After 18 months. (C) Case SB post twin block appliance treatment.
Note a significant improvement in profile and lip seal. The upper and
lower molars are in super class I relationship with normal over-jet and
overbite. There is a significant improvement in skeletal profile as seen
on the cephalogram. (D) Lateral cephalograms showing growth and
treatment changes. (A) Pretreatment; (B) post-functional (8 months);
(C) immediately post-debond; (D) follow-up. (E) Improved profile
following Twinblock therapy; (F) Successfully treated with Twinblock
therapy (A) Pre-treatment; (B) post-treatment.
FIGURE 52.23 Treatment with twin block—A case study of a
vertical grower. (A) Pre-treatment.
A case of class II division I malocclusion with vertical growth trend
treated with the twin block appliance. (B) Post-twin block. The bite
recording for twin block was carefully planned for more vertical and
smaller sagittal activation. Following 12 months of twin block therapy
there is a significant improvement in facial profile and lip seal. The
maxillary arch is wide and parabolic, the protrusion is significantly
improved, the mandible is positioned downwards, the overjet is normal.
Small buccal openbite will be corrected by achieving a proper inter-
cuspation with fixed appliance therapy. (C) Post-treatment. A marked
improvement in facial profile and lip seal is evident. The occlusion is
well settled in class I molar and canine relationship. The maxillary
dental proclination is corrected. There is forward position of the
mandible with excellent control on incisor mandibular plane angle.
Case N, 11 years growing female with a vertical growth pattern,
proclination of the maxillary incisors and class II pattern of the face,
craniofacial skeleton and occlusion. The palatal plane in inclined
downward in the molar region which suggests a vertical growth trend.
FIGURE 52.24 Treatment with twin block case study of bilateral
maxillary lateral incisors and lower premolar extractions.
(A) Case SR, 14-year-old male patient with a convex profile, prominent
upper front teeth, lip incompetence at rest, a lower lip trap and crowded
upper and lower arches. The lateral incisors are palatally placed which
locked the mandible in disto-occlusion. (B) With a twin block appliance,
the lateral incisors were extracted and mandible was sagittally
advanced. (C) Post-treatment photographs show significant
improvement. In the profile, lip seal and smile. The occlusion is well
settled in a class I molar and canine relationship. The crowding in lower
incisor is relieved by extraction of the lower first premolar. (D) Lateral
cephalograms are showing growth and treatment changes. (A) Pre-
treatment; (B) post-functional (8 months); (C) immediately post-debond;
(D) follow-up. Source: Reproduced with permission from Dave HR,
Samrit VD, Kharbanda OP. The extraction of maxillary lateral incisors
for the treatment of a Class II crowded malocclusion: a case report.
AustOrthod J. 2015 May; 31(1): 107–15.
Retention phase
A good buccal segment occlusion is the cornerstone of stability. The
appliance can be gradually reduced to night time wear. Early
appliance removal results in a subnormal growth of the posterior
condyle. Increasing the duration of mandibular advancement secures
normal levels of mandibular growth in the post-treatment period.53
Treatment effects of removable
functional appliance
The effects of twin block on developing occlusion, dentoalveolar
structures, maxillo mandibular skeleton soft tissues of the face and
oro-nasal spaces have been studied mostly using lateral
cephalograms, and recently CBCT. In general, the twin block
appliance causes a forward placement of the mandible and retrusive
effect on maxillary dentition and dentoalveolar structures. The
maxillary expansion leads to arch development and provides space
for the retraction of the maxillary anterior teeth and resolution of the
minor crowding. There is an increase in mandibular incisor
proclination and reduction in maxillary incisor proclination. The
overjet correction is contributed by a sagittal shift of the mandible and
dental corrections. The ANB angle improves with sagittal correction.
Twin block appliance also produces some mandibular counter
clockwise rotation due to action of the bite blocks and hence
improvement in the Jarabak’s ratio.54
In general, there is an improvement in lip seal, leading to improved
nasal respiration and overall improvement in facial aesthetics and
self-esteem of the child. There are controversies whether the long-term
effects of the functional appliance can lead to an increase in the length
of the mandible. The randomised controlled trials on the effectiveness
of early orthodontic treatment with the twin block appliance by
O’Brien et al. showed a substantial reduction in the over-jets of
children with class II malocclusion, which is mainly due to
dentoalveolar change, with a small element of favourable skeletal
change.55
Systematic review and meta-analysis by Koretsi et al. (2015)56 on
treatment effects of removable functional appliances in patients
showed that the skeletal changes were more pronounced with the
twin block appliance than the other removable appliance. It showed a
decrease in the ANB angle (−1.960/ year, 95% CI; 0.2.58 to −1.330/year)
and minimal increase in SNB angle (1.190/year 95% CI; 0.76–
1.610/year) compared to the untreated controlled group with the twin
block appliance therapy. Another meta-analysis by Ehsani et al.
(2015)57 evaluated the short-term treatment effects produced by the
twin block appliance. The dentoalveolar changes, increase in
mandibular length (Co-Gn) and forward movement of the mandible
(SNB) was a consistent feature.
Siara-Olds et al.58 evaluated the long term dentoalveolar changes of
functional appliances. Among the appliance evaluated twin block
group showed stable skeletal changes. In addition, twin block showed
the best vertical control and as well as flaring effect on the lower
incisors. Wadhawan and Kharbanda et al. reported that the condyle-
glenoid fossa (C–GF) complex forwardly relocated following 28
months of twin block appliance therapy, which seems to be one of the
mechanisms of action of functional appliances. The initial changes in
the internal anatomic structural arrangement within the
temporomandibular joint (TMJ) complex normalises to its pre-
treatment position at the completion of fixed phase of therapy.59
Twin block therapy leads to several beneficial effects on oro-nasal-
pharyngeal spaces. These include a significant enlargement in the
oropharynx and hypo pharynx as well as a more elliptic transverse
shape in the oropharynx. The hyoid bone moves to an anterior
position after twin block treatment.60 There is a significant increase in
all pharyngeal airway parameters in the subjects treated with twin-
block appliance for 8 months.61 The 3D analysis of twin block
appliance on mandible and cranial structures showed that it increases
condylar volume, mandibular length, and inter-condylar distance by
stimulating growth of condyle in an upward and backward direction,
decreases the saddle angle, ANB angle and facial convexity by
remodelling of the glenoid fossa and forward position of the mandible
(Table 52.4).62–63
Table 52.4
Effects of twin block appliance
One phase versus two phase treatment
Literature is full of discussion concerning the age of starting the
functional appliance therapy.
The functional appliance treatment should be started before
adolescence in the early permanent dentition followed by a phase of
fixed appliance therapy (one phase of combined functional therapy
followed by fixed appliance therapy) or early in mixed dentition,
which requires a phase of maintenance till the eruption of all
permanent teeth to institute fixed appliance therapy. Two phase
treatment started before adolescence in the mixed dentition might not
be more clinically effective than one phase treatment started during
adolescence in the early permanent dentition. Early treatment also
appears to be less efficient, in that it produces no reduction in the
average time in fixed appliance during the second stage of treatment,
and it did not decrease the proportion of complex treatments
involving extractions or orthognathic surgery.64
Early treatment can benefit by helping the children to get rid of
teasing in school, by reducing proneness of maxillary anterior teeth to
trauma and control of aberrant oral habits. However, in other
situations, it may be seen as undue prolonged treatment, which in
many instances causes premature termination of treatment. This can
be attributed to patient/parent ‘burn out’.65
Retention
A ‘long-term retention’ is the key to maintain treatment results after
functional appliance therapy. A device that can hold the mandible in
achieved occlusion is acceptable; however, its unwanted effects on
incisor proclination should be under scrutiny. Growth trend of face,
residual mandibular growth and late mandibular growth influence
retention protocol. It is a good idea to continue retention past puberty,
that is attainment of adulthood. All other factors contributing to good
retention including good inter-cuspation, a balanced, functional
occlusion, and periodontal health are significantly important for the
maintenance of occlusion after orthodontic treatment and equally so
after functional appliance therapy.
Clark stated, ‘functional retention is recommended following
functional therapy’.4 A removable appliance with the reverse inclined
plane is recommended to be worn.
The appliance used in the active phase can be continued to be worn.
In our experience at All India Institute of Medical Sciences (AIIMS),
New Delhi, India, where we have treated cases with large overjet,
relapse tends to occur on mandible getting back, yet the overjet is
maintained at the expense of proclination of mandibular incisors.
Therefore, we tended to think of greater support for the mandible by
using bionator appliance during support and retention to which the
patients adapt very well. The appliance is used for a period of one
year or more.
Twin block in deciduous dentition
Design and construction varies to attain retention using C clasp for
retention on deciduous molars. In addition, a functional retainer can
be given during support phase (b/w transition from mixed to
permanent dentition).
Twin block traction technique

In a situation of an inadequate response to functional correction, the
addition of orthopaedic traction force can be considered in the
following conditions. Clark modified the cervical face bow by
addition of an extra-hook in the midline and named it concorde face
bow.
1. Severe max protrusion

2. Unfavourable growth pattern
3. Adult patient.
Concorde face bow (Fig. 52.25) is used to:
1. Apply inter-maxillary and extraoral traction

2. Restrict maxillary growth
3. Encourage mandibular growth.
FIGURE 52.25 Concorde face bow is used to assist in holding the
mandible forward.
Concorde face bow is a modified cervical face bow with addition of an
arm in the midline.
Treatment of anterior open bite and vertical

growth pattern
It involves consideration of the degree of skeletal and soft tissue
imbalance and direction of facial growth. A thicker wax bite with an
inter-incisal clearance of 4 mm and a lesser amount of the sagittal
advancement is used.
Palatal spinner can be added to control tongue thrust. A labial bow
is usually added to retract upper incisor if they have been significantly
proclined by tongue and lip action. In addition certain modifications
are needed to manage malocclusion in vertical growing patients.
These are:
Avoid over eruption of second molar behind appliance for which
occlusal rest can be added even before their eruption.
Avoid trimming the block and only a progressive activation is
recommended.
Intraoral elastics should be used should there be a tendency for an
anterior open bite.
Management of crowding can be done either by arch development
before functional therapy or combination therapy by twin block and
fixed appliance.
Twin block appliance in class II div 2 and class

III malocclusion
Class II division 2 patients require progressive sagittal development. A
combined transverse and sagittal development is achieved with three
way screw.
Twin-block appliance for Class III malocclusion can be modified by
reversing the incline and recording the bite by holding the mandible as distal
as possible. Pseudo class III patients show an instantaneous favourable
response. Early treatment during deciduous dentition or early mixed
dentition is preferred.
The bite registration is performed with teeth in-close to the position
of maximum retrusion, leaving sufficient clearance between upper
and lower buccal segment (Figs 52.26).
FIGURE 52.26 Reverse twin block.
Fixed twin block

It was designed so that treatment effects are ensured by patient
compliance. Fixed twin blocks use the preformed component as an
effective guidance mechanism for mandibular advancement. The
system can combine with conventional fixed appliance or a
TransForce lingual appliance for arch development.
Three distinct objectives include
a. Interceptive treatment and arch development
b. Mandibular advancement with fixed twin block
c. Detailing of occlusion with fixed appliance.
Development of fixed twin block

Dr Clark continued to develop and evolve the design of twin block for
efficacy and different clinical situations of malocclusion including
patient’s cooperation. He initiated the concept of twin block early in
1990s. However, it was around 2008 that first preformed block was
created which could be used as an attachment to molar bends using a
blade attachment inserted into a lingual sheath. It was challenging to
fit blocks correctly as an attachment to the molar band which was a
major limiting factor.
By 2010 new version attempted to eliminate attachment to the molar
band.
Upper and lower blocks are bonded directly to the teeth. The blocks
are designed to cover the lingual and occlusal surfaces of the teeth,
leaving the buccal surfaces clear for attachment of bonded brackets.
The upper block covers the second premolar and extends distally to
the second molar region. The lower block covers the premolars with
lingual extensions on canine and first molar.
By 2014, the ultimate solution to fixed twin block was found. Buccal
extensions are added to preformed blocks to improve stability and
retention. The blocks fit over the teeth and are filled with Triad®
(visible light cure material by Dentsply-Sirona) material for an
accurate fit. The technique is similar to temporary crown and bridge
and may be used as a direct or indirect technique after first checking
the fit of blocks on a working model (Fig. 52.27).
FIGURE 52.27 Components of fixed twin block appliance.
(A–B) Preformed blocks have buccal, lingual extensions. (C–F) Blocks
bonded with fixed appliance treatment.
Preformed occlusal blocks cover the lingual, occlusal, buccal

surfaces of upper and lower teeth; they will be available in three sizes
—large, small and medium.
Key Points
Class II malocclusion caused by developing mandibular
retrognathism in growing children can be successfully managed by
functional jaw orthopaedics. Though FA therapy emerged as a major
therapeutic modality in Europe, its concepts were accepted rather late
in America. Functional jaw orthopaedics involves correction of
imbalances caused by a disproportionate growth of jaws and
normalisation of abnormal functions of and around orofacial
apparatus by altering the muscle activities and functions such as
swallowing and respiration. Success with this mode of treatment is
influenced by a multitude of factors which include severity and nature
of the problem, the biological growth potential of the individual,
appliance selection, operator’s experience and expertise, and patient’s
cooperation.
Although research studies have questioned the efficacy of
functional appliance treatment, their clinical performance has been the
reason for their continued and expanding popularity. The case
selection, appliance design, rigorous follow-up and favourable growth
are key factors that determine the success of functional appliance
therapy. Long-term maintenance necessitates a well-finished
occlusion achieved during the second phase of fixed appliance
therapy. A rigorous long-term follow-up is necessary.
AIIMS protocol for records and treatment follow-up with twin
block appliance has helped thousands of patients in public hospital to
get low cost yet effective treatment of the class II malocclusion.
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randomized controlled trial. Eur J Orthod.
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56. Koretsi V, Zymperdikas VF, Papageorgiou SN,
Papadopoulos MA. Treatment effects of removable
functional appliances in patients with class II
Eur J Orthod. 2015;37(4):418–434: Aug Epub 2014 Nov
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Epub2014 Jul 22. Review. PubMed PMID: 25052373.
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CHAPTER 53
Interception and treatment of
mandibular retrusion with non-
compliant fixed functional
appliances
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Historical perspectives
Advantages of FFA over other functional appliance
Contraindications
Herbst appliance
Herbst system of appliance
Herbst type I
Herbst type II
Herbst type IV
Bite registration for the Herbst appliance
Bonded/cemented type splint Herbst appliance
Clinical manipulation
Cephalometric skeletal and dental changes with Herbst
appliance treatment
Herbst appliance for non-surgical treatment during early-
and late adulthood
Mandibular anterior repositioning appliance (MARA)
Mandibular protraction appliance (MPA)
Short-term cephalometric skeletal and dental changes
with MPA
Flexible fixed functional appliance (FFFA)
Jasper Jumper
Klapper super spring
Adjustable bite corrector
Eureka spring
Twin force bite corrector
Forsus™ appliance
Key Points
Introduction
The previous chapters have described the treatment of class II
malocclusion in growing patients with a retrusive mandible. The main
therapeutic approach involved forward repositioning of the mandible
and restraining the maxillary dentoalveolar and skeletal protrusion
with removable appliances or Kloehn headgear or a combination of
the functional appliance with headgear.
Successful treatment with these modalities of treatment relies
heavily on patient compliance in wearing the removable appliance
and/or headgear. Therefore, in noncompliant patients, alternate
treatment strategies of functional appliance have been devised. These
devices are broadly grouped as ‘fixed functional appliance’ (FFA).
Fixed functional appliances are often used in combination with full
banded fixed appliance.
Although first fixed appliance was used as early as 1905 by Emil
Herbst,1 the popularity of fixed functional appliances in clinical
applications has only been established in the last three decades. These
appliances are now used in both compliant and noncompliant patients
for their enhanced effectiveness in the sagittal correction of
malocclusion in a relatively short duration.
Most FFAs are variations of a telescopic mechanism. The FFA is
attached bilaterally on the maxillary molars on their distal end and
mesially on the mandibular arch to hold it in a forward posture.
The FFA has gone through evolutionary transition in design and
uses from its first version of rigid telescoping system (rigid fixed
functional appliance), that is Herbst appliance, followed by flexible
versions (flexible fixed functional appliance) to more recent appliance
systems which are relatively flexible, yet rigid enough (hybrid type) to
sustain forward mandibular position. The mesial ends of the most
fixed functional appliances receive anchorage from mandibular
dentition. Hence it is difficult to control unwanted dental effects. FFAs
with numerous modifications are available in the market; however,
they can be broadly grouped into three types (Table 53.1).
Table 53.1
Classification of fixed functional appliances (FFA)

Rigid fixed functional Hybrid fixed functional
Flexible fixed functional appliances
appliances appliances
Herbst appliance and its Jasper Jumper 12 Eureka spring 22, 23
modifications1, 2 Eureka Spring Inc.
Mandibular anterior Adjustable bite corrector 14 Twin force bite
repositioning appliance Ortho Plus Inc. corrector24
(MARA, 1991)3, 4 Ortho Organizers
Mandibular protraction Klapper Super spring15 ORTHO Forsus 25 3M Unitek
appliance (MPA) Design Orthodontics
(Filho, 1995, 1997, 1998,
2001)5– 7
Magnetic telescopic device, The Scandee Tubular Jumper (Saga Sabbagh Universal
Ritto appliance (Ritto, 1999)8– Dental AS, Kongsvinger, Norway)9 Spring2 (SUS2),
11 Dentauram, Germany26
Biopedic appliance, The The Flex Developer (LPI Ormco,
Biopedic (GAC International Ludwig PittermannGesmbH, Maria
Inc., Islandia, NY)9 Anzbach, Austria)16
Functional Mandibular Amoric Torsion Coils17
Advancer (FMA) by Kinzinger
et al.12
The Bite Fixer (Ormco, Orange, CA)18
The ABC (OrthoPlus Inc., Santa Rosa,
CA)19
The SUPERspring II (ORTHOdesign,
Lake Forest, IL)20
The Churro Jumper 21
Most recent modification of the FFA is the one with its mesial end
connected to temporary anchorage device that is placed in the body of
the mandible. It is called implant supported FFA. The implant or plate
supported FFA derive the anchorage from mandible hence the
unwanted dental changes are minimised or eliminated altogether. The
FFA have several advantages over movable functional appliance.
Advantages of FFA over other functional

appliance
1. FFAs have the advantage of generating continuous stimuli for
mandibular growth without any interruption.
2. FFA is relatively smaller; therefore, permit better adaptation to
functions like mastication, swallowing, speech and respiration.
3. Fixed functional appliances treat class II malocclusion
successfully in a shorter time span with reduced need for
patient cooperation.
4. Their greatest advantage seems to be for those patients who
report for orthodontic treatment at the fag end of the facial
growth. Fixed functional appliances being 24-h wear
appliances produce a rapid sagittal correction taking
maximum benefits from short span of remaining skeletal
growth. This seems to be the most appropriate indication of
FFA besides non-compliant patient.
Contraindications
The FFAs are in general contraindicated in patients with vertical
growth pattern, anterior open bite and where lower incisors are
proclined. Most appliances cause proclination of the mandibular
incisors, which may not be desirable in subjects with large IMPA.
Patients with susceptible root resorption are also not good candidates
for extra loading of forces generated from FFA.
Rigid fixed functional appliances (RFFA) are attached distally to the
maxillary molars or the upper arch and are expected to hold the
mandible in the postural forward position through a rigid mechanism,
which is attached to the lower arch. Once the appliance is fitted in
patient’s mouth, he/she cannot close the teeth in centric relation. These
appliances are truly noncompliant. Herbst appliance was the first such
appliance to be introduced in orthodontic practice.1 However, its
numerous modifications and similarities are now available in the
market, which are designed to maximise the patient comfort and
minimise breakages, a common problem with these attachments.
Herbst appliance
The Herbst appliance was first described by Emil Herbst in 1905 at the
Berlin Dental Congress. After that very little was written on this
appliance until the end of the 1970s when Hans Pancherz2
reintroduced, researched and propagated this appliance. He continues
to publish research on its efficacy and long-term effects.27–32 Although
the appliance was introduced as a functional appliance to be used in
pubertal growth; its efficacy in adult patients has recently been
reported.33
Herbst system of appliance34

The Herbst appliance is used on either side of the dental arches. Each
appliance consists of a tube and a plunger. Each axle holds the tube in
place with the help of a screw. The plunger is attached to the
mandibular premolars/arch in a similar manner. The length of the
plunger determines the amount of forward posture of the mandible.
The axles are soldered either on to the molar bands or steel crowns.
Modifications with the system of attachment of axles/screws have
evolved the appliance from type I to types II and IV.
Herbst type I
It is characterised by a fixing system to the crowns or bands (Fig.
53.1A–B) or to the wire framework (splint design, Fig. 53.1C) through
the use of screws. This is the most commonly used design of the
Herbst appliance. It is necessary to solder the axles to the molar bands
or crowns, and then fix the tubes and plungers with the screws.
Herbst appliance does not permit lateral jaw movements. It is
extremely difficult to place the right and left axles in alignment, which
makes them susceptible to breakages. Breakages are common in
Herbst appliance.
FIGURE 53.1 Herbst appliance.
(A) Components of type I Herbst appliance. (B) Banded Herbst
appliance. (C) Splint Herbst appliance. (D) Components of type IV
Herbst appliance.
Herbst type II
It has a system that permits its fitting directly on to the archwires
through the use of special screw locks. The rigid appliance, which is
fixed on relatively less rigid archwires, has several drawbacks. It
causes difficulties in lateral movements of the jaw and stress fracture
of the archwires is common.
Herbst type IV
It was designed to permit greater flexibility of the mandibular
movements through a ball and socket system. The screw is replaced
with a special locking clasp. The main disadvantage was loosening
and breakage of the locking clasp (Fig. 53.1D).
Variations on the Herbst appliance and similar systems, utilising
ball attachments have appeared, in an attempt to:
1. Improve patient comfort and acceptance.

2. Minimise clinical problems such as solder failure and
breakages.
3. Reduce the frequency of emergency appointments.
4. Allow good lateral mandibular movements.
5. Allow easy application in splints for correction in mixed
dentition.
Herbst type appliances include:
1. The cantilevered bite Jumper (Ormco 1717 West Collins

Avenue, Orange, CA 92867).
2. MALU Herbst appliance (SAGA Dental Supply A/S, post-box
216, Kongsviner, Norway).
3. Flip-Lock Herbst appliance (TP Orthodontics, Inc., 100 Center
Plaza, LaPorte, IN 46350).
4. The magnetic telescopic device8,9 (Ritto, 1997, 1999).
Bite registration for the Herbst appliance

There is no universal agreement as to the ‘ideal’ amount of forward
position of the mandible for bite recording. Most clinicians agree on
end-to-end incisor bite registration in patients with an overjet of
approximately 7 mm or less. If the overjet is greater than 7 mm, a bite
registration that represents half of the overjet distance is obtained for
initial appliance fabrication, and then the Herbst appliance is
reactivated every 2–3 months in increments of 2–3 mm until an end-
to-end incisal relationship is achieved.
Bonded/cemented type splint Herbst

appliance35,36
Herbst appliance is supplied in a pack which consists of a pair of tube
sleeves and plunger which fit together. There are four axles and
corresponding screws, one set for each quadrant. To distinguish the
right side of the tube from the left side, place it in position buccal to
crown on the maxillary first molar. Correct tube at its mesial end is
directed slightly inwards (Fig. 53.1C). Pancherz used soldered axles
on the maxillary first molars and mandibular first premolar bands, but
that is always not possible especially in mixed dentition. Alternatively
a splint design with acrylic coverage over several teeth has been
suggested. The acrylic cap over the lower incisors helps in limiting the
amount of proclination of the incisors during treatment.
The wax bite is transferred to the working models. The wire
framework on upper and lower working models is done similar to the
one shown by Howe and later described by McNamara.37,38
Wire framework on maxillary arch

Wire framework is comprised of a main support SS wire of 18 gauge
or 0.045 in. diameter which extends from the buccal portion of the
posterior teeth; crosses over to the palatal aspect at the level of mesial
surface of the first bicuspid and then continues as a closely adapting
framework along the lingual surface of the bicuspids, and molars. A
transpalatal wire with an omega loop facing distally is adapted from
palatal surface of one molar on to the other. The pivots are located in
the region of the buccal surface of maxillary first molars.
Wire framework on mandibular arch

The wire assembly consists of buccal and lingual support wires, which
are later soldered together. The lingual support wire extends as a
continuous wire along the lingual surface of the lower anteriors. It is
then soldered to the buccal support wire. The pivots are located in the
region of the buccal surface of the lower first premolars.
Soldering
The next step involves soldering the various wire components. An
ample amount of solder is flown at the points where Herbst axles are
to be attached. The axles are soldered just above the region of disto-
buccal cusp of maxillary molars and on mesio-buccal surface of the
mandibular first premolars. This makes inter-maxillary axle span to be
longer and more comfortable. The axles must be soldered parallel to
each other. The tubes are then placed on the maxillary axle on either
side and retained with the screws. Each plunger is inserted inside the
tube and checked for free sliding while opening and closing of
articulator. Incorrectly placed axle should be identified and soldered
correctly.
The upper and lower models are held in position of correct bite. The
tube and plunger are placed riding over each other in the position of
eyelet over the pivots. The correct lengths of tube and plunger are
marked and cut with metal cutting saw and ends are smoothed. The
cut pieces of the tubes are retained for use as rings for future
activations of the appliance.
Acrylisation of the appliance

The plunger and tube assembly is removed from the casts. The study
models are soaked in water and separating medium is applied. The
wire framework is secured on casts by means of a sticky wax.
Acrylisation with cold cure acrylic is done using salt–pepper method.
The thickness of the occlusal covering is about half the vertical inter-
molar gap in the maxillary arch. In the mandibular arch, the acrylic
extends from molar to molar; covering the middle third of the anterior
teeth and following the gingival contour of the posterior teeth. The
appliance is left for curing in warm water. The appliance undergoes a
trimming and finishing more so at gingival borders and all acrylic
surfaces except those in contact with teeth surfaces. Escape holes for
the cement are drilled on the occlusal part of the appliance
framework.
Fitting the appliance

After trimming and polishing, these splints are placed on articulated
casts and checked for any occlusal interference. The splints are then
placed in the patient’s mouth, fixing the tubes and plungers in their
respective places. The following points are checked:
• The amount of forward positioning produced by the tube.

• The plunger is not excessively long such that it impinges on
the buccal mucosa.
• Occlusal interferences, if, any should be adjusted before
cementation.
The splints are cemented in patient’s mouth with glass ionomer

cement after a course of polishing and proper isolation. The plungers
are inserted, and screws are tightened. Excessive length of plungers or
tubes is adjusted prior to cementation.
Clinical manipulation
Herbst appliance is not a comfortable appliance to experience since
once fitted; the patient is unable to bring the mandible in centric
occlusion. For the first few days, signs of muscle pain in and around
over-jaw muscles and around TMJ do appear. There are also
difficulties due to altered speech and mastication.
The appliance will produce rapid changes in occlusion within 3–6
months, showing correction of class II malocclusion to class I
occlusion. Signs of maxillary molar distalisation which is termed as
Headgear Effect can also be visualised clinically. After 6–9 months, the
appliance is removed and the second phase of treatment is started
with fixed appliance therapy. The purpose of this phase is to retain the
buccal occlusion and detailing posterior occlusion.
Cephalometric skeletal and dental changes

with Herbst appliance treatment
Herbst appliance has been found to have a minimal or an insignificant
restraining effect on maxillary growth. However, it has a significant
effect on the maxillary molar causing it to drive and tilt distally. The
head gear effect on the maxillary molars is a by-product of the fixed
functional appliance anchored to the molars.
Mandibular growth: The main therapeutic effect of Herbst appliance
is an enhancement of the sagittal mandibular growth, while vertical
growth is unaffected by this treatment. Pancherz2 reported that with
the banded Herbst appliance, the sagittal molar correction was
contributed by skeletal and dental changes. The contribution of
skeletal changes were 43% and the remaining 57% due to
dentoalveolar changes.
Overjet: The overjet correction was 56% due to skeletal changes and
44% due to dentoalveolar changes. Dentoalveolar changes include
lower incisor proclination and maxillary molar distalisation and an
intrusion. These changes are similar to those produced by high pull
headgear.28
Bite opening: Vertically, the overbite is reduced. This occurs by an
intrusion of lower incisors and an enhanced eruption of lower molars.
Effects on craniofacial skeleton: Short-term cephalometric changes
produced by splint design Herbst appliance in growing subjects have
shown that correction of molar relation was mainly due to forward
mandible positioning, some forward shift of lower molar and distal
shift of upper molars. Appliance therapy results in an increase in
mandibular length, reduction in ANB angle and increase in anterior
facial height.39 Studies have documented significant increases in
mandibular length compared to untreated controls that ranged an
average 2.0 mm for a 6-month period for the banded appliance and 3.0
mm for 1-year treatment period for the acrylic splint Herbst appliance.
During the post-treatment period, most of the mandibular
morphological changes revert to normal, and no long-term influence
of Herbst treatment on mandibular growth can be verified. Its effects
on maxilla are similar to that of a high pull headgear.
Herbst treatment is especially indicated in the permanent dentition
at or just after the pubertal peak of growth so that a good occlusion
and inter-digitation can be achieved.40–43 Long-term effects of Herbst
treatment on TMJ has been investigated in clinical and MRI studies
without any adverse findings. On the contrary, Herbst appliance
could prove useful in patients with anterior disc displacement.44,45
A systematic review,46 reported that splint type of Herbst appliance
in treating adolescents, produces significant improvement in class II
division I malocclusion and changes in the facial skeleton. The use of
the splint type Herbst appliance in treating adolescents with class II
division 1 malocclusion resulted in increased anteroposterior length of
the mandible, increased vertical height of the ramus, increase in lower
facial height, mandibular incisor proclination, mesial movement of
lower molars, and distal movement of upper molars. The appliance
caused a significant decrease in the inter-maxillary discrepancy,
improvements of overjet and overbite. The appliance does not
produce significant changes on the upper incisors. The upper molars
are significantly more retruded, (1.5–5.4 mm) slightly intruded, and
retroclined 5.6° after treatment.
Herbst appliance for non-surgical treatment

during early- and late adulthood
Herbst appliance with fixed multi-bracket therapy can be successfully
used as an alternate appliance combination for nonsurgical, non-
extraction treatment of class II division I subjects in early and late
adulthood. Ruf and Pancherz47 in subjects ranging from 15.7 to 44.4
years (mean 21.4 years) found successful outcome in the short-term
investigation. Class II correction was achieved by both skeletal and
dental changes. Overjet correction occurred mainly by dental changes
(13% skeletal and 87% dental). Similarly molar correction occurred by
22% skeletal and 78% dental changes.
Mandibular anterior repositioning
appliance (MARA)
Mandibular anterior repositioning appliance or MARA is a
miniaturised rigid fixed functional appliance primarily attached to
upper first molars on either side. The main part of the appliance
consists of cams made from 0.060 in. square wire that are fitted into
0.062 in. tubes attached to upper first molars. Each lower first molar
has a 0.059 in. arm placed perpendicular to its buccal surface that
interferes with upper cam, so adjusted to guide the mandible into
class I occlusion. The MARA appliance was a joint creation by
Douglas Toll of Germany and Jim Eckhart from the USA. The MARA
appliance is mostly indicated when most of the permanent teeth are
about to erupt or are in late mixed dentition (Fig. 53.2).
FIGURE 53.2 The mandibular anterior repositioning appliance

(MARA).
Mandibular protraction appliance
(MPA)
Mandibular protraction appliance (MPA) has evolved over a series of
modifications from the version I to IV.5–7 This rigid appliance is
simple, cost-effective and can be prepared in-house in the dental
laboratory. The appliance is used in conjunction with the multi-
bracket appliance and attached distally to the maxillary molar tube
and mesially on to the mandibular arch distal to the canine bracket.
The appliance brings rapid mandibular forward repositioning and yet
allows considerable lateral movements of the mandible.
Appliance is fabricated using 0.045 in. SS tube and 0.036 in. rigid SS
wire. The tube and wire function is similar to Herbst appliance. The
tube is attached to the maxillary first molar tube with a lock pin that is
attached to auxiliary tube soldered on main tube. The plunger or
mandibular rod is made of 0.036 in. SS wire. The mandibular rods are
attached to the lower archwire (0.019 X 0.025 in. SS wire) at the
circular inter-maxillary loops which are located in the middle of the
inter-bracket distance of mandibular canine and first premolar. The
inter-maxillary hooks are bent in occluso-gingival direction (Fig.
53.3A–B). Since the appliance is made in orthodontist’s lab, nearly
chair side, the distance of the mandibular rod is adjusted in mouth
according to patient’s ease of mandibular protraction and amount of
mouth opening. Its fabrication is simple, requires minimal
armamentarium and is a cost-effective appliance. The appliance has
also been proved clinically effective.
FIGURE 53.3 MPA IV appliance.
(A) Mandibular rod and tube of MPA IV appliance. (B) MPA IV
appliance in place in mouth.
Short-term cephalometric skeletal and dental

changes with MPA
In a study on samples of actively growing patients treated with MPA
IV for a period of 6 months, a significant reduction in overjet, overbite
and a significant improvement in the facial skeletal profile was noted.
Class II correction is contributed by a combination of skeletal changes
(57.24%) and dental changes (42.76%). Mandibular length is increased
to an average of 2.0 mm. Overjet correction is primarily due to
proclination of the lower incisors, lingual tipping of upper incisors
and skeletal changes in the mandible. An uprighting and distalisation
of the upper molars also contributed to the molar correction. The most
unwanted effect is flaring of lower incisors which may be detrimental
to the periodontal health if there is proclination of incisors/preexisting
large IMPA before treatment.48
Flexible fixed functional appliance
(FFFA)
Jasper Jumper
The introduction of Jasper Jumper,12,13 a spring-loaded device covered
with vinyl coated tubing and provision of an attachments to upper
molar tube and to the lower archwire in the canine premolar region
was a great change from traditional rigid Herbst appliance. The main
advantage of FFFA JJ are attributed to its flexibility that allows the
patient to close in centric relation and perform lateral movements with
ease. JJ is used in combination with fixed appliance therapy. It is
known to cause a rapid correction of class II relations, with a major
contribution from dental changes. It causes a significant increase in
IMPA which is not desired (Fig. 53.4A–B).
FIGURE 53.4 Jasper Jumper.
(A) Components of Jasper Jumper. (B) Jasper Jumper in mouth.
The mechanical drawbacks of Jasper Jumper appliance are frequent

fractures and fatigue in springs. With the new fatigue resistance
springs, this problem has been resolved to a great extent. After the
introduction of the concept of flexible functional JJ appliance other
similar flexible fixed functional appliances were introduced.
Klapper super spring15

It is an auxiliary consisting of a multi-flex nickel–titanium spring
introduced by Lewis Klapper in 1997. The spring is attached to the
maxillary first molar into specially designed molar tube and to the
mandibular archwire. The appliance can be used both in extraction
and non-extraction cases. The springs are paired with left and right
side (Fig. 53.5).
FIGURE 53.5 Klapper spring activated in mouth.
Adjustable bite corrector

Adjustable bite corrector or ABC appliance was introduced by R.P.
West in 1995. It is similar to Herbst appliance in terms of treatment
effects. Its parts include universal left and right appliance with
adjustable lengths and stretchable springs.14
These are intended for a continuous force that is lighter and yet keeps
the mandible forward. These appliances utilise the telescoping
mechanism for support and a high quality fatigue resistant
unbreakable coil spring to deliver constant force to keep the mandible
forward in an uninterrupted manner. Different hybrid fixed
functional-appliances (HFFA) are listed:
1. Eureka spring (Eureka Spring Inc.) is made up of teles-coping

mechanism and it has a spring inside the plunger.17
2. Twin force bite corrector (Ortho Organizers) has a double joint
telescopic system.18
3. Forsus (3M Unitek Orthodontics) delivers force from
unbreakable coil spring.25
Most hybrid fixed functional appliances have a rigid body that is

supported by a spring loaded device that permits the child to bite in
centric occlusion. It produces a continuous force of 150–200 g.
Eureka spring
It was introduced by DeVincenzo in 1997.16 This appliance is designed
for use with fully bonded fixed appliance with heavy archwires in
place. The upper molars are required to be stabilised with a
transpalatal bar. The appliance has a piston and plunger assembly
loaded with spring which is available in two force ranges, 150 and 210
g. The force of the spring is linear throughout the length of the ram
thrust and is 16.6 g for every millimetre of ram compression. This
appliance is now available with a quick lock system for attachment
and release on the mandibular archwire just distal to canine.
The appliance is effective in class II correction which occurs almost
entirely by dentoalveolar movement contributed by maxillary and
mandibular dentitions without changing or without increasing the
vertical dimension.49
Twin force bite corrector

Twin force bite corrector (Ortho Organizers) has dual force modules
which are enclosed in a metal cylinder. It is fixed on the mandibular
archwire through an attachment device using special square screws
for a secure fit. The appliance is relatively small, smooth and hygienic.
Forsus™ appliance
Forsus appliance (3M Unitek) is also designed for use with fixed
appliance. It is supplied as pre-fabricated ready to ligate kit of five
different lengths of 25, 29, 32, 35 and 38 mm. The appropriate length is
selected by asking the patient to bring his/her mandible forward in
class I molar relation and measuring the distance from the distal of the
maxillary molar tube to the distal of the canine bracket with a
disposable ruler provided with the kit (Fig. 53.6).
FIGURE 53.6 Components of Forsus Fatigue Resistant device
and size selection process using disposable ruler.
(A, B) L-spring module. (C) Push rods. (D) Split crimps. (E, F)
Measurement gauge.
The appliance is usually inserted after the upper and lower arches
have been aligned for minor crowding and a rigid steel archwires in
both jaws are in situ, which is particularly essential for the lower arch
since the mesial end of the appliance is fixed on the archwire distal to
canine bracket. The maxillary end is hooked to the buccal tubes (Figs.
53.7A–H and 53.8). The lower arch is supported with a lower lingual
arch which reinforces the anchorage as a single unit. A transpalatal
arch is provided on the upper first molars to prevent their buccal
flaring due to a distalisation force. Two cases treated with full fixed
appliance and fixed functional appliance (Forsus) is depicted in Figs.
53.9A–C and 53.10A–D.
FIGURE 53.7 Installation and activation of Forsus Fatigue
Resistant device.
(A) L-pin inserted into the spring module. The ball should be positioned
buccally. (B) L-pin inserted into a headgear tube from distal to mesial.
(C) 1–2 mm of clearance between the distal end of the buccal tube and
the universal spring eyelet should be given. Turn the L-pin up and over
the headgear tube. (D) Place push rod distal to the selected position.
(E) Crimp push rod. (F) Place elastomeric ligature with guard under the
archwire on the bracket of the tooth mesial to the push road to prevent
contact. (G) Activated appliance. (H) Split crimps for reactivation.
FIGURE 53.8 (A) Overactivation. (B) Correct activation.
FIGURE 53.9 (A) Case J, 14-year-old female in postpubertal stage
(CS5) with convex profile due to a small chin. The upper and lower
arch are well aligned with end-on molar and class II canine relations on
both sides. The upper and lower incisors are proclined and there is a
spacing in the upper arch. This is a suitable case for fixed functional
appliance therapy with normal maxilla and a retrusive mandible. (B) A
case of class II treatment with fully bonded fixed appliance and Forsus.
(A) After levelling and alignment. (B) With Forsus appliance in situ. (C)
After correction. (D) Pre-finish. (C) Case J, post-treatment. A significant
improvement in profile and lip seal is noticeable. The molar and canine
are in class I relationship. The cephalogram shows significant
improvement in skeletal profile with mild lower incisor proclination.
FIGURE 53.10A Case J, 16-year-old male in postpubertal stage
(CS5) with convex profile due to a small chin. Crowding in upper and
lower arch with end-on molar and class II canine relations on both
sides and the upper and lower incisors are proclined.
FIGURE 53.10B A case of class II treatment with fully bonded fixed
appliance and Forsus. The dentoalveolar correction required extraction
of upper and lower first premolars. (A) Segmental canine retraction with
NiTi coil spring. (B) Incisor retraction with continuous T loop. (C) After
incisor retraction. Note the class II molar relation with increased overjet.
(D) With Forsus appliance in situ. (E) After correction.
FIGURE 53.10C Post-treatment: The significant improvement in
profile and lip seal. The molar and the canine are in class I relationship.
The cephalogram shows significant improvement in skeletal profile with
a mild lower incisor proclination.
FIGURE 53.10D Lateral cephalograms showing growth and treatment
changes. (A) Pre-treatment; (B) postfixed appliance; (C) immediately
post-debond; (D) follow-up. Note the significant improvement in skeletal
profile with improved soft tissue relation.
AIIMS protocol for records and treatment follow up with fixed

functional appliance is given in Box 53.1.
Box 53.1 Kharbanda protocol for records and

treatment follow-up with fixed functional
appliance
Records and case selection
• Patient counselling, history and consent for treatment

• Ear, nose and throat (ENT) evaluation in case of adenoids, mouth
breathing habit or breathing problem
• Study models in dental stone
• Intra- and extraoral photographs
• Lateral cephalogram
• Panoramic radiograph
• Other X-rays if required such as IOPA/occlusal X-ray/PA
cephalogram
Treatment planning
• Case discussion
• Planning fixed mechanotherapy—whether extraction or non-
extraction planning based on the dental relationship
• Virtual 2D simulation of fixed mechanotherapy and fixed
functional appliance using cephalometric software
• Retention planning
First phase: fixed appliance
• Full banded appliance therapy

• Upper transpalatal arch
• Lower translingual arch
• Second molar banding in critical anchorage cases
• Decompensation of dentoalveolar inclinations
• Aligning the upper and lower arch to 0.019 in. × 0.025 in.
SS wire
• Upper labial crown torque and lower lingual crown
torque to prevent retroclination and proclination of
upper and lower incisors, respectively
• Stage photographs
• Stage lateral cephalogram
• Stage models
Second phase
• Appliance delivery and instructions
Follow-up and review
• First review 24 h
• Second review 1 week
• Followed by review at 4 weeks interval
Third phase
• Removal of fixed functional appliance after 6 months

• Stage records at the end of FFA therapy
• Review for finishing and settling
• Pre-finish records to evaluate root alignment and anterior torque
• Lateral cephalogram
• Panoramic radiograph
• Debonding
Retention and follow-up
• Retention appliance delivery and instructions

• First follow-up 24 h
• Second follow-up 1 month
• Follow-up every 3 months for 1 year
• Follow-up every 6 months for next 1 year
In a study conducted in AIIMS,50 we found rapid correction of class

II relationship with this appliance, in some cases within 12 weeks.50
Cephalometric findings of a group of seven patients showed that
during 6 months of therapy there was a marked improvement in the
profile, overjet and overbite. However, there was a slight increase in
the IMPA to the mean of 4.57 ± 1.06°. The Ar-Pg length showed an
increase of 2.0 ± 0.81 mm. The statistically significant changes
included an increase in mandibular length, improvement in ANB and
flaring of IMPA.
EMG studies on muscle adaptation using this appliance have
shown that on an immediate insertion of the appliance EMG activity
of anterior temporalis and masseter muscles significantly reduced
during swallowing of saliva and maximal voluntary clenching, which
gradually returned to pre-treatment levels at the end of 6 months.
Although class II correction occurs in 3 months, such appliance should
be given for at least 6 months for allowing adequate neuromuscular
adaptations to occur for long-term stability of the result.51
Perinetti et al.52 2015 reviewed the literature to assess the skeletal and
dentoalveolar effects of fixed functional appliances, alone or in
combination with multi-bracket appliances on class II malocclusion in
pubertal and postpubertal patients. The overall total mandibular
length changes were 2.22 mm and 0.44 mm for the pubertal and
postpubertal patients, respectively. The subgroup analysis for the total
mandibular length revealed a statistically significant greater effect for
the pubertal patients as compared to the postpubertal patients for the
functional treatment alone but not for the comprehensive treatment.
Overall supplementary total mandibular elongations as mean (95%
CI) were 1.95 mm (1.47–2.44) and 2.22 mm (1.63–2.82) among pubertal
patients and −1.73 mm (–2.60 to –0.86) and 0.44 mm (–0.78 to 1.66)
among postpubertal patients, for the functional and comprehensive
treatments, respectively. They also noted that the FFA is effective in
treating class II malocclusion with skeletal effects when performed
during the pubertal growth phase. However, the skeletal correction
alone is not accountable for the overall correction, which also includes
the dentoalveolar changes. Another meta-analysis by Zymperdikas et
al. (2016) showed that the FFAs are effective in treatment of class II
malocclusion with small stimulation of mandibular growth, small
inhibition of maxillary growth, and with more pronounced
dentoalveolar and soft tissue changes.53
Ishaq et al. evaluated the skeletal mandibular changes (horizontal
and vertical) in circum-pubertal patients with FFA and multi-bracket
appliance compared with untreated patients through the meta-
analysis.54 The FFA seems to have no significant positional or
dimensional skeletal effects on the mandible. However, the
dimensional skeletal effects are slightly greater in the pubertal
subgroup than in the post-pubertal subgroup, which was not
statistically significant. Similarly, the vertical dimension also showed
insignificant changes. Bock et al. reported the good stability of Herbst
appliance without clinically relevant changes in mean of 58 months of
post-treatment period.55
Recently, AdvanSync class II molar-to-molar appliance has been
introduced for the correction of skeletal class II malocclusion. It takes
anchorage from upper and lower first molars (Fig. 53.11).
FIGURE 53.11 AdvanSync class II molar-to-molar appliance for

skeletal class II correction.
A major unwanted effect of FFA is flaring of the lower incisors, which
limits the skeletal effects of the appliance. Although various
conventional methods have been used such as, lingual crown torque
in lower anterior teeth, second molar banding, and lower lingual arch,
the efficiency of these methods are still questionable. The mini-
screw/plate supported FFA appliance have been introduced recently
to overcome these shortcomings of conventional methods. Aslan et
al.56 used a Forsus appliance combined with a mini screw for the
sagittal correction of class II patients. The authors found that the
mandibular incisors proclined insignificantly (L1/MP 3.61°) in the
mini screw supported Forsus appliance compared to the conventional
Forsus (L1/MP 9.29°). Similarly, Unal et al. reported that overjet
correction of −5.11 mm was found to be mainly by skeletal changes,
which is approximately 74% (A-VRL, −1.16 mm and Pog-VRL, 2.62
mm) and remaining 26% is accounted for the dentoalveolar changes.57
Key Points
The fixed functional appliances have a definite role in the
management of class II malocclusion caused by mandibular deficiency
especially in noncompliant patients and in patients who report late for
treatment with pubertal spurt on or during its last phase when little
growth is remaining. Most of the appliances (exception of bonded
splint Herbst) are used with fully bonded fixed appliance. All
appliances receive their anchorage from mandibular archwire and
maxillary molar(s). A variety of rigid tubes and pistons, combined
with springs and methods of attachment have been described and
developed by the clinicians and manufacturers.
The bone plate supported/TAD supported FFA are recent
developments which have enhanced clinical efficacy in terms of
skeletal growth and minimal effect on incisor -inclination.
Fixed functional appliances when used in conjunction with fully
bonded fixed appliance greatly facilitate correction of class II skeletal
pattern to class I relationship in a short duration of 3–6 months. The
improvement is mostly contributed by dental changes that include
headgear like effect on maxilla and distalisation of the first molar,
mesialisation of mandibular first molars, and proclination of
mandibular incisors accompanied with forward posture. The extent of
significant sagittal growth with FFA therapy is still a matter of debate.
The most critical aspect of handling FFA is to control lateral flaring
of maxillary molars and proclination of mandibular incisors. Careful
handling of the appliance to minimise -unwanted effects in carefully
selected cases can bring about appreciable clinical benefits. Fixed
functional appliances when used judiciously are of definite
therapeutic advantage.
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CHAPTER 54
Mode of action of functional
appliances
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Effects on dentofacial skeleton
Effects on oral volume and respiratory passages
Condyle glenoid fossa complex (CGF) remodelling and
neuromuscular adaptations
Experimental studies on animals
Role of lateral pterygoid in enhancing the growth of the
condyle
Observations from studies on muscles of mastication in
the treatment of class II malocclusion
Condyle adaptation based on growth relativity hypothesis
Molecular and genetic control on CGF remodelling
Can the mandible be grown longer than it’s pre-determined
genetic potential?
Key Points
Introduction
Since the very beginning of the fortuitous invention of so-called ‘bite
jumping’, functional appliances (FA) have been continuously
modified and researched.
FAs work on the following premises:
1. They help in furthering the growth of jaw bones and thereby

correct malocclusion when the mandible is small or
retrognathic or positioned backwards.
2. FAs stimulate and regulate perioral muscles and muscles of the
stomatognathic system thus creating a favourable environment
for the growth of facial bones and dentition.
3. The FA brings about orthopaedic changes in the facial skeleton,
a philosophy which was founded by Andresen and Häupl
(1936), called functional jaw orthopaedics.1,2
4. The temporomandibular joint of young individuals can adapt
to new positions acquired by the mandible when it is held by
bite jumping appliance in a forward position.
5. Functional appliances induce skeletal growth modi-fications
when used during periods of active growth of a child before or
during occurrence of puberty or peak height velocity (PHV).3,4
Effects on dentofacial skeleton
Short-term and long-term clinical and cephalometric investigations
have been done on groups of class II division 1 patients treated with a
variety of functional appliances. A few prospective studies including
randomised control trials have also been reported.
In general, the clinical and research studies, based on successfully
treated groups have exhibited significant clinical improvement in
facial profile, reduction of overjet and normalisation of occlusion.
It is postulated that in patients with class II division 1 malocclusion,
the inclines of teeth in malocclusion hold the mandible in a distal
position under the cranium. The jumping of bite unlocks the mandible
which helps it to grow unhindered and thereby improves the patient’s
profile and occlusion.
Therefore the effects of functional appliance therapy are a
combination of the forward posture of the mandible and growth
modification of the growing mandible. The dentofacial changes can be
grouped as skeletal, dentoalveolar and dental (Fig. 54.1). These
changes are summarised in Box 54.1.
FIGURE 54.1 The skeletal and dental changes with functional
appliance therapy.
The pre- and post-treatment lateral cephalogram tracings are
superimposed at SN plane, registration at S. Black: pre-treatment, red:
post-treatment.
Box 54.1 Dentofacial changes of functional

appliances
Skeletal changes
1. Optimisation of mandibular growth and forward placement of

the mandible.
2. Enhanced growth at the head of condyles.
3. Deflection in ramal form and reduction in gonial angle.
4. Remodelling of CGF complex followed by relocation.
5. Redirection/Restraining vertical and sagittal growth of the
maxilla.
6. An increase in lower anterior face height and overall
improvement in the ratio of total anterior to posterior face
height.
Dentoalveolar changes
1. Mandibular dentoalveolar vertical development and change in

inclination of the occlusal plane.
2. Reduction in the proclination of maxillary anterior teeth and
remodelling of the alveolus.
3. Transverse development of the maxilla and arch expansion.
Dental changes
1. The mesial and vertical eruption of mandibular molars.

2. Flattening the deep curve of Spee and alteration of the
functional occlusion plane.
3. Labial tipping of mandibular incisors.
4. Inhibition of mesial migration of maxillary molars.
5. Distal tipping of maxillary buccal teeth.
6. Retroclination of maxillary incisors.
The condyle glenoid fossa complex undergoes remodelling. (Fig.

54.2). The ratio of the contribution of skeletal versus dental changes
varied with the type of appliance used, the method of bite recording,
compliance, elimination or persistence of aberrant environmental
factors, age and sex of the patient, duration of treatment, remaining
growth and individual’s biologic/physiologic response to therapy.
FIGURE 54.2 Effect of FA therapy on CGF complex.

Schematic representation showing condyle glenoid fossa complex
remodelling. Source: Reproduced with permission from Meikle.12
Quantum of increase in the ‘length’ of the mandible remains the

most controversial and debated aspect of functional appliance
therapy, and so is the long-term adaptation of condyle glenoid fossa
complex in the acquired functional position. The question ‘can
mandible be altered beyond its genetic potential’ has remained in
discussion ever since the existence of functional appliance therapy.
Prospective human studies

Orthodontic literature has witnessed studies in human testing, the
efficacy of Andresen activator, Frankel appliance, bionator, Herbst
and most recent being twin block appliance.5–11 These studies have
provided greater insight and a high level of evidence on benefits of
functional appliance therapy (Table 54.1).
1. Small but statistically significant differences in mandibular

length have been reported by a majority of these studies.
2. Functional appliances such as the Herbst and twin block based
on jumping the bite are more effective at modifying
mandibular growth than passive appliances such as Andresen
activator and its variants.12
Table 54.1
Randomised clinical trials of class II treatment: effects
on mandibular growth
a Mean difference between experimental and control groups. NS, not significant; all other
differences and small but statistically significant.
bMean annualised change (mm/yr). In the Pancherz (1982) study, the treatment time was 6
months.
Reproduced with permission from Meikle MC. Remodelling the

dentofacial skeleton: the biological basis of orthodontics and
dentofacial orthopedics. J Dent Res 2007;86(1):12–24.
All clinical studies have inherent limitations where some

anatomical, physiological and other biological confounders are
difficult to control in the population groups. Use of cephalometrics as
the most appropriate valid tool to measure the effects of FA is also
questionable.
Effects on oral volume and respiratory

passages
Current thinking on the effectiveness of the functional appliance is not
limited to the measurement of the enhanced length of the mandible
alone on 2D cephalograms. Current thinking on benefits of FA include
improvement in the overall volume of the oral cavity that is housing
the dentition, oral structures such as the position of the tongue and
soft tissue draped around face.13–15
‘The anterior positioning of the mandible may also have been a
secondary response to alteration in oral volume caused by appliance
and the subsequent alteration in tongue posture’.15
Forward mandible placement is also being viewed as an
improvement in the lip seal and improved pattern of breathing.
Following insertion of sagittal repositioning appliance, the mandible
is lowered to facilitate improved airway and altering tongue position.
‘As adaptive functional changes occurred, the tongue, as well as the
mandible, may have been positioned inferiorly, not only to establish a
more, efficient functional position for mandibular movements but also
to maintain an adequate oral volume for lingual function’.15 Many
patients with mild to moderate sleep apnoea do benefit with
functional appliance therapy. More evidence on these benefits of
functional appliance therapy is being reported in the literature.
Condyle glenoid fossa complex (CGF)
remodelling and neuromuscular
adaptations
Experimental studies on animals
Histological and histochemical studies on condyle and CGF have been
conducted following forced mandibular propulsion by experimental
studies in rats,16 rabbits,17 sheep,18,19 pigs20 and non-human
primates.15,21–23
Breitner was first to report histological evidence of extended effects
of orthodontic treatment in mandible and remodelling of the condyle,
and glenoid fossa in experimental animals.24–26 Other
investigators27,28 have reported similar trends in the enhanced activity
of condylar cartilage. Some of these studies were supported with
serial cephalometric and EMG recordings.15,21
In growing animals, forward displacement of the mandible initiates
compensatory adaptive changes at the condylar head marked by its
enhanced growth and change in the direction of growth.15 The facial
skeletal adaptations occur through a composite of adaptations in the
mandible, condyle, glenoid fossa and naso-maxillary complex to a
new altered position of the mandible. The extent and direction of
growth of the mandible are altered while horizontal and vertical
displacement of the maxillary complex is affected.15 Experimental
protrusions in Rhesus monkeys also showed an increase in
chondrogenic activity at the head of mandibular condyle.29 A
temporarily increase in proliferative activity in the mandibular
condyle in rabbit, changes in the thickness of the pre-chondroblastic
and chondroblastic layers, were the most marked changes in the
superior part of the condyle after propulsion.17 In a long-term follow-
up experimental study on Rhesus monkeys, McNamara and Bryan
(1987)21 have shown that an overall increase in mandibular length by
an average of 5–6 mm at the end of 144 weeks occurred in infants and
juvenile monkeys.
Histological and cephalometric evidence on enhanced mandibular
growth and CGF adaptation in postural forward position paved the
way for the use of the functional appliance in clinical practice beyond
the boundaries of Europe. Once it was said, that the final length of a
mammalian mandible cannot be increased orthopedically or
orthodontically beyond a genetically pre-determined value is
unfounded.21 It is pertinent to note that most adaptive changes of CGF
were reported in young growing animals (Figs. 54.3–54.6).
FIGURE 54.3 The temporomandibular joint region of a 2-week

experimental animal Macaca mulatta whose mandible was held
forward with gold cast splint.
Note the increased thickness of the condylar cartilage and the
proliferation of bone along the posterior border of the ramus. (Sagittal
section. Hematoxylin and eosin stain. Magnification, ×5). Source:
Reproduced with permission from McNamara.27
FIGURE 54.4 Condylar cartilages in a 2-week experimental
Macaca mulatta.
Note the increased proliferation of the cells in the pre-chondroblastic
and chondroblastic zones. (Sagittal section. Hematoxylin and eosin
stain. Magnification, ×40). Source: Reproduced with permission from
McNamara.27
FIGURE 54.5 Temporomandibular joint regions in a 12-week

experimental Macaca mulatta.
A slight amount of increased proliferation along the posterior border of
the condyle is still evident in this animal. (Sagittal section. Hematoxylin
and eosin stain. Magnification, ×5). Source: Reproduced with
permission from McNamara.27
FIGURE 54.6 The temporomandiburar joint region of the 24-week

experimental animal.
Although the overall thickness of the condylar cartilage is not different
from that of the control animals; there is an apparent increase in the
number of cells in the pre-chondroblastic zone. This observation has
been verified by radio autographic analysis. (Sagittal section.
Hematoxylin and eosin stain. Magnification, ×40). Source: Reproduced
with permission from McNamara.27
Voudouris et al. (2003)23,30 have provided further evidence to the

above observations. All six non-human primates who received fixed
functional appliances developed large super class I malocclusion. The
adaptations were the result of many factors including posterior
movement of the maxilla and the maxillary teeth, an increased
horizontal component of condylar growth, and anterior displacement
of the mandible and the mandibular teeth. The glenoid fossa in
experimental animals showed growth modification in an inferior and
anterior direction while there was a restriction of the downward and
backwards growth of the fossa observed in the control subjects.
Differences in the area and the maximum thickness of new bone
formation in the glenoid fossa and condylar growth were statistically
significant.
Neuromuscular adaptations
The insertion of a functional appliance causes an alteration in
exteroceptive and proprioceptive stimuli from the orofacial area. The
existing functional pattern of the neuromuscular system gets modified
and reorganised.
‘This change in functional pattern altered the orofacial environment
in such a way that tissue structural adaptations resulted and an
anatomical balance was eventually restored. As this occurred,
neuromuscular compensation correspondingly declined and
functionally more efficient patterns were developed’.15
The muscles of mastication, supra-hyoid and in and around oral
cavity including tongue and soft tissues that drape the face are forced
to assume new positions. The suprahyoid group of muscles are
shortened while muscles of mastication used in elevation of the
mandible are stretched. The muscles that have been elongated within
physiologic limits would try to re-establish a functional harmony by a
continuation of following mechanism: 21
1. By elongation of muscle fibres themselves.

2. The occurrence of changed muscular dimensions due to
displacement and rotation of bony elements.
3. Migration of muscle attachments along bony surfaces.
4. Establishment of new neuromuscular feedback mechanism.
Role of lateral pterygoid in enhancing the

growth of the condyle
Petrovic and coworkers27,28 have demonstrated that the increased
activity of the lateral pterygoid muscle was associated with enhanced
condylar growth response. These observations were also supported by
the classical experiments conducted by McNamara15 (1973) and other
investigators who reported an initial decrease in the activity of lateral
pterygoid muscle from 6 to18 weeks following insertion of
mandibular propulsion appliance.
Experimental studies by James A. McNamara, Jr15 were carried out
on 64 Macaca mulatta Rhesus monkeys and involved a period of 26
weeks (13 weeks observation and 13 weeks experimental). The
monkeys were in different age groups: infant (I), juvenile with
complete deciduous dentition (II), an adolescent with full permanent
dentition (III), and adults (group IV). The monkeys received gold cast
intraoral appliances, which served to prompt all occlusal functions in
2 mm forward position and similar vertical displacement. The study
involved serial cephalometric data, taken at the beginning of the
control period, beginning of the experimental period and at the
conclusion of the experiment. EMG studies of temporalis, orbicularis
oris, supra-hyoid muscles and the superior head of the lateral
pterygoid muscle were taken at the monthly interval during
observation. During the experimental period, EMG was recorded just
before cementation of an appliance, at the cementation of the
appliance and after 1 h. After that eight records were made at
succeeding intervals of 6 h, 1 day, 4 days, 1 week, 2 weeks, 4 weeks, 8
weeks and during the 12th week. Histological studies of the
temporomandibular joint of sacrificed animals were also obtained.
The findings suggested that changes in the maxillo-mandibular
relationship were the outcome of adaptations that occurred
throughout the craniofacial complex. The histological studies have
shown that anteroposterior alteration in the molar relationship was
seen in 10 of 12 experimental monkeys. ‘Mandibular adaptation was
primarily skeletal in nature in the young animals, while compensatory
movements of the dentition became more significant with increased
maturation. The primary effect of the experimental conditions on the
middle face was on the extent and vector of growth of the skeletal
components of the maxillary arch. This occurred at all age levels’. The
mandibular condyles in juvenile animals showed an average increase
in growth by 51% higher in increment compared to controls.
The superior head of lateral pterygoid appears to be principle
muscle to function as forwarding positioner of the mandible which is
evident by enhanced EMG activity. At the end of the experiment,
EMG activity is less, reduced or normalised.15
Authors have further reported that the increase in lateral pterygoid
activity associated with a forward positioning of the lower jaw. This
new functional pattern first appeared in association with such phasic
activities as swallowing and then during such tonic functions as
maintenance of mandibular postural position. However, as the
experiment progressed, there was a gradual return towards pre-
appliance levels of muscle activity. This gradual change in the level of
muscle activity was correlated in time with the skeletal and dental
adaptations observed in same animals.15
However, animal studies carried out at the University of Toronto
with chronically embedded implants have shown that lateral
pterygoid muscle (LPM) activity remains depressed for 18 weeks
following insertion of functional appliance device.31 Sessle et al.32
have demonstrated that with two types of functional appliances to
induce mandibular protrusion, the activity of superior and inferior
heads of the lateral pterygoid, anterior digastric and superior masseter
muscles remain significantly decreased up to 6 weeks and then
gradually returned to normal recorded through chronically implanted
electrodes.
Observations from studies on muscles of

mastication in the treatment of class II
malocclusion
Traditionally EMG studies have been used to measure electrical
potential of muscles of mastication which indirectly reflect the muscle
activity. EMG studies have been carried out mostly to record activity
of anterior temporalis, masseter and digastric muscle following
insertion of a variety of functional appliances.33–46
Literature reveals EMG studies on class II patients treated with an
activator, bionator, Herbst appliance and twin block appliance. The
findings from above studies reveal that EMG activity of anterior
temporalis and masseter muscles are decreased immediately
following the insertion of a functional appliance. As the time progress,
gradually the new pattern of occlusal contacts is established which is
evident by normalisation of EMG pattern in about 3 months’ time.
Thereafter, EMG activity shows higher values compared to pre-
treatment values at 6 months and maintained after that or normalised
(Fig. 54.7). The insertion of twin block results in an increase in the
vertical dimension of occlusion and so the masseter muscle initially
elongates which shows reduced thickness measured with
ultrasonography or MRI; however, it then gradually normalises to
original dimensions at 6 months or takes even longer (Fig. 54.8).
FIGURE 54.7 EMG adaptations with twin block appliance.

(A) Representative sections of EMG during postural position of the
mandible without twin block. (B) Representative sections of EMG
during postural position of the mandible with twin block. (A and B)
Tracings 1, 2, 3 and 4 represent raw EMGs and 5, 6, 7 and 8 are
integrated EMGs. Source: Reproduced with permission from
Aggarwal.42
FIGURE 54.8 Effects of twin block FA therapy on masseter
muscle.
Forces of twin block therapy on the masseter muscle cross-sectional
area (MCSA) and muscle volume (MV) measured with MRI over 18
months of an observation period. Note that CSA and MV reduced up to
3 months (T1) at a significant level (P < 0.05) after that gradually
normalised.46
Controversies concerning the increased activity of lateral pterygoid

muscle
1. The anatomical evidence of association of superior head of

LPM with intra-articular disk and head of the condyle has
been debated.48 LPM is found to be attached to the outer
border of the fibrous capsule.
2. There are reports on the increased activity of the superior head
of the lateral pterygoid muscle on EMG recordings and
contradictory reports on reduced EMG activity with
chronically implanted electrodes.
3. The increased activity of LPM following protraction of the
mandible is not expected since new position shortens the
length of LPM and increased hyperactivity from shortened
muscle is not expected.
4. Experimental studies by Voudouris et al.23,30 have reported
CGF remodelling in laboratory animals at the condyle and the
glenoid fossa which correlated with decreased postural
electromyography activity during the experimental period.
‘Results from permanently implanted electromyographic
sensors demonstrated that lateral pterygoid muscle
hyperactivity was not associated with condyle glenoid fossa
growth modification with functional appliances. Other factors,
such as reciprocal stretch forces and subsequent transduction
along the fibrocartilage between the displaced condyle and
fossa, might play a more significant role in new bone
formation’.
CGF complex has been extensively studied with cephalograms,
orthopantomograms, tomograms and bone scintigraphy using
radiologic markers like 99mTc-methylene diphosphonate (MDP), and
CT scanning in patients undergoing functional appliance therapy.47–56
Recent studies evaluating the effect of the functional appliance
therapy on CGF remodelling using MRI have documented both
internal and external rearrangements of the CGF that are caused by
the utilisation of these appliances.57
The condyle initially assumes an anterior position during the FA
therapy which alters its internal relations with articular disk and CGF
complex. This position when maintained during stabilisation period
relocates CGF in a relatively anterior position which enables
normalisation of condyle–fossa relations and internal arrangements
with disk and soft tissues. The appearance of notching at the anterior
aspect and rounding of the postero-superior surface of the condylar
head after functional appliance treatment (6 months) resumes to pre-
treatment contours during stabilisation (Fig. 54.9). Thus, it is evident
that FA treatment does not cause long regenerative or degenerative
changes; in the CGF complex during the study period instead it
inhibits the natural posterior inferior growth of the CGF complex and
causes it to relocate in a more anterior position in the cranium.
FIGURE 54.9 Internal and external rearrangements of the CGF
consequent to FA therapy.
Sequential sagittal oblique views of the TMJ (right side) of case SB
showing MRI changes in the condylar head morphology at the three
stages of treatment. (A) Pre-treatment anatomy of the condyle and the
TMJ complex. Arrows indicate (i) the prominent notch on the anterior
surface and (ii) the flat contour on the posterosuperior surface of the
condylar head. (B) Changes in condylar head morphology. (C) The
TMJ after functional appliance therapy (6 months). Source:
Reproduced with permission from Wadhawan et al.57
A possible growth modulation of the condylar cartilage leading to

increased ramus height and the overall length of the mandible, and an
anterior relocation of the whole CGF complex, all of which may
contribute to correction of the class II discrepancy. The internal
arrangement of the disc and its orientation with CGF complex is
disturbed with a forward posturing of the condyle, however, it
eventually normalises after settlement of the occlusion and CGF in the
new location.
Condyle adaptation based on growth
relativity hypothesis
Voudouris and Kuftinec58 hypothesised that when condyle is
displaced from condylar fossa, extrinsic signals are derived from
tissues surrounding it which serve as a stimulus to the fibrocartilage
on the head of the condyle to undergo growth modification. His
hypothesis laid the foundation for ‘growth relativity theory’. It refers
to growth that is relative to displaced condyles from actively
relocating fossae. The theory supports that enhanced condylar growth
is a result of some additional condylar signals following growth of
soft tissues.
Based on growth relativity theory it is postulated that condylar
growth seems to be more of the outcome for decreased postural and
functional activities. The CGF modification that occurs consequent to
growth modification with mandibular propulsar appliance is the
result of a combination of factors, stimulus to which is derived from
the extrinsic stimulus in the following sequence (Figs 54.10 and
54.11):58
1. Displacement of the mandible from temporal fossa.

2. Viscoelastic tissue extension forces to the condyle through
several attachments.
3. By transduction of forces radiating beneath the fibrocartilage of
the glenoid fossa and condyle or ‘turning on the light switch’
over fibrocartilage (Fig. 54.12).
FIGURE 54.10 Condyle adaptation based on growth relativity
hypothesis.
Significant anatomic differences between the condyle of the mandible
and the epiphysis of long bones may permit greater modification of the
condyle. The unique layer of fibrocartilage covering the condyle is
absent in the epiphysis. In addition, compared with epiphyseal
chondrocytes, condylar pre-chondroblasts are not surrounded by an
inter-cellular matrix to isolate them from local factors. The chondrocytes
are further oriented in a multidirectional fashion suitable for changes in
growth direction in comparison to the columnar arrangement of the
epiphyseal chondrocytes. Source: Reproduced with permission from
Voudouris.58 *Reasonable
FIGURE 54.11 Illustration of a 3/4 anterior-lateral perspective of
the forces on the advanced condyle and glenoid fossa through
their respective soft tissue attachments that change their growth
directions.
They are part of at least six viscoelastic lines of communication
including synovial fluid and the fibrous capsule that have been found to
connect directly and indirectly with the inter-facing fibro-cartilaginous
layer of the condyle. The sixth attachment to the condyle is specifically
through the more diagonally oriented posterior and middle fibres of the
fibrous capsule overlaying and communicating not only with the
condyles but also with the retrodiscal–articular disc complex. Source:
Reproduced with permission from Voudouris.58
FIGURE 54.12 Light bulb analogues of condylar growth and
retention.
When the growing condyle is continuously advanced, it lights up like a
light bulb on a dimmer switch. When the condyle is released from the
anterior displacement the reactivated muscle activity dims the light bulb
and returns it close to normal growth activity. In the boxed area, the
upper open coil shows the potential of the anterior digastric muscle and
other per mandibular connective tissues to reactivate and return the
condyle back into the fossa once the advancement is released. Source:
Reproduced with permission from Voudouris.58
The glenoid fossa which locates itself in postero-inferior direction

during growth is restrained by the viscoelastic tissues to relocate itself
in anterior and inferior direction thereby maintaining a relationship
with active condyle which is undergoing growth modification. The
foundation of growth relativity is based on following three main
foundations, as explained in the CGF modification:
1. The displacement affects fibrocartilage lining in the glenoid

fossa to induce bone formation.
2. This is followed by the stretch of non-viscoelastic tissues. Non-
viscoelastic tissues include all non-calcified tissues and not just
the muscles, specifically; viscoelasticity addresses the viscosity
and flow of the synovial fluids, the elasticity of the retro discal
tissues, the fibrous capsule including LPM, perimysium, TMJ
tendons and ligaments, other soft tissues and body-fluids.
3. The third one is the new bone formation, some distance from
the actual retrodiscal attachment in the fossa.
4. Consequent to mandibular advancement, there is an influx of
nutrients and other biodynamic factors into fibrocartilage from
engorged blood vessels of the stretched retrodiscal tissues.
Activation in joint fluid dynamics is altered whereby TMJ
works like a pump which permits a greater flow of blood in
CGF region (Fig. 54.13). It can be summed up that in young
growing subjects reciprocal forces of the viscoelastic tissues
between fossa and the condyle can change CGF growth
direction by switching on the ‘bulb’ at fibrocartilage.
FIGURE 54.13 Biodynamic factors involved in CGF growth
modification during orthopaedic mandibular advancement in
treatment and retention.
Metabolic action describes the pump-like influx and expulsion of
nutrients and other chemicals from the engorged blood vessels of the
proliferating retro-discal tissues (dark blue region) extending between
the condyle and the fossa. This biodynamic action (light blue circle)
occurs in the retro-discal tissues and fibrocartilage during condylar
displacement. The expulsion of these accumulated metabolites occurs
during reseating of the protracted condyle and is clinically evident as
relapse of the previously observed condition. Source: Reproduced with
permission from Voudouris.58
Molecular and genetic control on CGF
remodelling
Contemporary research is being focused on cellular and molecular
biology and genetic alterations in cells in condylar cartilage.59 These
cells respond to strain or viscoelasticity or such unknown stimuli that
send signals to generate the differentiation of mesenchymal cells in
the articular layer of cartilage into chondrocytes, which proliferate
and then progressively mature into hypertrophic cells. The expression
of regulatory growth factors, which govern and control phenotypic
conversions of chondrocytes during chondrogenesis, increase during
adaptive remodelling to enhance the transition from chondrogenesis
into osteogenesis, a process in which hypertrophic chondrocytes and
matrices degrade and are replaced by bone. This is followed by
increased neovascularisation, which brings in osteoblasts that finally
result in new bone formation beneath the degraded cartilage.60 Most
of such observations have been derived from experimental studies on
rats.
1. The expression of IGF-1, FGF-2, and their receptors (IGF-1r,

FGFr1, 2, 3) show enhanced expression, which might partly
underlie changes in proliferative activity of condylar cartilage
after alteration in mandibular posture.61
2. Increased neovascularisation, indicated by increased
expression of vascular endothelial growth factor (VEGF)
preceded the new bone formation.62
3. Higher levels of parathyroid hormone-related protein (PTHrP)
expression have been seen to coincide with the slowing of
chondrocyte hypertrophy.63 It was, therefore, suggested that
mandibular advancement promotes mesenchymal cell
differentiation and trigger PTHrP expression, which retarded
their further maturation to allow for more growth.
4. A significantly increased expression of type X collagen was
observed when the mandible was set forward,64 which
provided an easily resorbed fabric for the deposition of bone
matrix and regulated the calcification process during
endochondral ossification.65,66
5. A substantial increase in Sox9 expression during mandibular
protrusion was seen which has been correlated with an
increase of newly formed bone.67
6. Higher levels of Indian Hedgehog (Ihh) expressions have been
reported in condylar cartilage under propulsion. Ihh is an
important cell mediator that conveys mechanical signals
resulting from condylar repositioning to the mesenchymal
cells, which, in turn, initiates a chain reaction towards eventual
endochondral ossification.68 In another experimental study Ihh
embryos, TMJ development was severely compromised.69
Can the mandible be grown longer than
it’s pre-determined genetic potential?
The well-said and believed premise that mandible cannot be grown
any larger than genetically pre-determined length is mainly based on
genetic pre-dominance, control after the birth. A few short-term
clinical studies have shown effectiveness in the correction of a class II
relationship and enhanced growth of the mandible; these findings are
further supported by studies in experimental animals such as non-
human primates, rabbits and rats exhibiting an enhanced growth
response of condylar cartilage to functional forward shift in young
growing animals. With current technology and tools that are being
used to measure a true gain in the length of the mandible in humans
with a functional appliance remains debatable.
Key Points
The process of adaptations, following functional forward placement of
the mandible, involves the whole of the craniofacial complex skeletal
system, soft tissues around oral cavity and face and possibly oro-nasal
spaces. Clinically it is perceived as an improvement in skeletal and
dental relations. The actual mechanism of enhanced growth and
adaptations is more complex, occurring at cellular and or biochemical
level. Newer research at the molecular level has provided some
insight into the process of enhanced cellular growth and genetic
alterations in the cells in condylar cartilage. However, much more
information is awaited on precise control of growth changes which
once known could prove useful insight to the clinicians in the
manipulation of jaw growth to the best of advantage for the patients
with a smaller jaw.
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CHAPTER 55
Dentofacial orthopaedics for class
II malocclusion with vertical
maxillary excess
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Rationale of combined therapy
Case selection
Contraindications
Appliance concept and desired effects
Maxilla
Mandible
Bite recording
Appliance design
Acrylic components
Metal framework
High-pull headgear
Clinical management of the appliance
Application of extraoral force
Wearing schedule and follow-up
Second phase of therapy
Treatment effects
van Beek activator
Appliance design and bite recording
Wearing schedule
Treatment effects
Key Points
Introduction
The malocclusion with vertical maxillary excess is a category of
skeletal class II malocclusions, exhibiting an excessive gummy smile
and a long face. These patients have a vertical growth pattern of the
face with greater contribution from mid face.
The patients with VME show features of maxillary vertical and
maxillary descent in the buccal region also. Consequently, the palatal
plane on cephalogram shows an upward tilt in the region of the
anterior nasal spine but inclined downward in the molar region.
The mandible is retrognathic, with a thin recessive chin. The growth
of the ramus is inadequate, there is an open gonial angle leading to
backward growth rotation and increase in anterior face height.
These vertical grower patients with unique skeletal pattern are
likely to benefit by a therapy which in addition to encouraging sagittal
mandibular advancement can also restrain the vertical descent of the
buccal segments of the maxilla thereby allowing mandible and the
chin to rotate towards maxilla This cumulative benefit leads to
improvement in the facial skeleton and soft tissue profile.1–3
Rationale of combined therapy

The conventional functional activator therapy in class II growing
patients bring about significant dentoalveolar changes in the mandible
and maxilla.4,5 Together with distal inclinations of maxillary buccal
teeth, the mesial and vertical eruption of mandibular buccal teeth
combined with anterior displacement of the mandible, sagittal
correction in maxilla–mandibular relations is achieved. The activator
treatment in addition to restraining the sagittal growth of the maxilla
is also known to increase posterior maxillary vertical height. Activator
treatments also cause the maxilla and mandible to rotate in a
downward and backward direction.
The maxillary growth can be restrained effectively with cervical
headgear but not without side effects which are not -desirable in high
angle cases. Most of the orthodontic mechano-therapies are extrusive.
Particularly when the vertical chain of muscles is weak, the
masticatory forces are unable to counter such extrusive forces which
cause an opening of the mandibular plane angle. With each millimetre
of extrusion of the molars, the mandibular plane angle opens by 2.5°
which can have harmful effects on chin profile.
Therefore, a high-pull facebow attached to the activator or such an
appliance is expected to provide greater cumulative skeletal growth
adaptation than when treated with an activator or headgear appliance
alone. Class II division 1 malocclusion correction in high angle cases is
desired using high-pull headgear-activator combination therapy to
produce restriction of forward maxillary growth, inhibition of the
mesial and vertical displacement of the maxillary teeth, simultaneous
improvement of the buccal occlusion and condyle glenoid fossa
remodelling.
The main purpose of the headgear attached to the activator is to
enhance the effectiveness of the sagittal correction by -inhibiting
vertical growth of the maxilla, restraining the growth of the maxilla in
the sagittal direction which helps in autorotation of the mandible. This
phenomenon not only eliminates the ill effects associated with
extrusion of molars but also benefits by encouraging further forward
mandibular posture and an upward rotation.1–3,6,7
Case selection1,3,6,8
The application of an activator headgear set-up is therefore indicated
if a skeletal class II malocclusion is present in growing subjects in
which an anterior movement of the chin prominence is desirable and
at least some posteriorly directed maxillary dentoalveolar reaction is
acceptable. High angle cases with moderate vertical excess are of a
particular domain of this combination therapy (Fig. 55.1).1,3,6
FIGURE 55.1 1 A case of vertical growing class II malocclusion.
Case NS, age: 10 years class II division I malocclusion, maxillary
protrusion, vertical grower, with large overjet. (A) Pre-treatment profile.
(B) Pre-treatment cephalogram shows vertical growth pattern. (C–D)
Pre-treatment occlusion showing class II molars with large overjet. 2.
Activator headgear therapy. Case NS 10 years/female treated with
combined activator headgear therapy followed by a course of fixed
appliance. (A) With appliance. (B) Activator and facebow appliance. 3.
Treatment effects of activator headgear therapy. Profile, occlusion
and cephalometric changes after more than a year of combined
activator headgear therapy. (A) Profile. (B) Cephalogram shows
improved inclination of the palatal plane and sagittal relations. (C–D)
Class I molar and canine relations and normal overjet. She now
requires a phase of fixed appliance therapy for detailing of occlusion. 4.
Profile and occlusion at the completion of fixed phase of
orthodontic therapy. (A) Note a significant improvement in profile and
lip seal. (B) Cephalogram shows improved inclination of the palatal
plane and sagittal skeletal relations. (C–D) The upper and lower molars
are in super class I relationship with normal overjet and overbite. 5.
Lateral cephalograms showing growth and treatment changes. (A)
Pre-treatment; (B) a year of combined activator headgear; (C)
immediately post-debond. Note: the palatal plane angulation, it has
been rotated clockwise after a year of combined activator headgear
therapy. Also there is an improvement in incisor angulation and lip seal.
Dental class II situations with a skeletal class I profile should not be

treated with this appliance therapy.
The activator headgear is also well suited for retention of a
corrected class II. When used for retention purposes, the construction
bite is modified so, only a minor advancement of the mandible is
combined with the opening.1
The activator–headgear combination can be used for class II
corrections in the deciduous, mixed or permanent dentition. The best
developmental stage for this kind of treatment is the early mixed
dentition; when all incisors have erupted and the deciduous teeth are
still firm enough to provide good anchorage.
Contraindications
1. Class II horizontal growers and dental class II situations with a
skeletal class I profile should not be treated with this appliance
therapy.
2. Patients with a hypodivergent skeletal patterns such as class II
division 2 and of the ‘Deckbiss’ type with severe vertical
deficiencies.
3. An unfavourable period for starting activator–headgear
treatment is when the deciduous teeth in the buccal segment
are loose or most of them are lost.
Appliance concept and desired effects
The problems of vertical control of maxilla have been overcome in
part by the utilisation of high-pull vectors of extraoral traction with
Kloehn type of facebow. However, it has remained a challenging task
to produce an acceptable profile for the patients who have a divergent
face at the chin. The headgear when used alone can transfer distally
directed headgear forces from the maxilla via dentition to the
mandible which might prevent its forward relocation.
A combined activator–headgear therapy has been described by
Ullrich Teuscher (1978).6 He advocated the use of a high-pull
headgear with the activator to counteract the undesired maxillary side
effect of headgear alone. His therapy is also called headgear–activator
Teuscher appliance (HATA).9 The objectives of combined activator
headgear therapy are:6
Maxilla
1. Inhibition of the maxillary sagittal and vertical growth vectors
of the dentoalveolar process and dentition.
2. Restraint on the maxillary basal structures counter to the line of
development.
3. Restrain of maxillary dentition.
Mandible
1. Unlocking the occlusion.
2. Selective vertical management of mandibular molar eruption.
3. Stimulation and redirection of condylar growth.
4. Inducing a less backward and more downward remodelling
pattern of the glenoid fossae.
Bite recording
Before the activator headgear therapy is instituted in children with a
narrow maxilla, these children can receive a short phase of maxillary
expansion with W-appliance or rapid maxillary expansion.
For recording the bite, a set of working models is prepared with
alginate impressions with careful observations to check accurate
reproduction of occlusal surfaces, palatal area, and lower lingual
flange area.
The bite is recorded with a moderate vertical displacement of the
mandible slightly beyond freeway space and anterior displacement
not exceeding 6 mm. In patients with large overjet, two step
activations are performed.
A horseshoe-shaped wax rim is prepared on lower working models
that do not distally extend beyond the last erupted tooth. The
recorded bite should be rechecked in the patient’s mouth before it is
mounted on an articulator.
A greater vertical component of the bite is considered for vertically
growing children.
Appliance design
In 1978, Teuscher6 presented a preliminary report on an activator
design of a palatal bar, lower lip pads, and -torque-control auxiliaries
for the upper incisors. Lip pads are not used now (Fig. 55.2).
FIGURE 55.2 Teuscher appliance.

(A–B) Note the correct labiolingual position of torquing spurs and height
in relation to gingival margin. (C) Location of headgear tubes. Original
Teuscher appliance design also incorporated two mandibular labial lip
pads (not used now).
The appliance parts are: (1) acrylic components, (2) metal
framework and headgear tubes, (3) facebow and (4) high-pull
headgear.
Acrylic components
The appliance is constructed as palate free of acrylic activator. The
upper part of the appliance provides anchorage in the maxillary arch
with coverage on all occlusal and incisal surfaces of the teeth.
Laterally, the acrylic is extended to thebuccal cusps. In the buccal
segment from the mesial of the canine, the acrylic is extended towards
the palatal vault. The acrylic extends laterally to the buccal cusps
while it covers the labial surfaces of the incisor and canines by about 2
mm.
In the mandibular arch, the appliance on the lingual side is -
extended down as far as the floor of the mouth permits. The acrylic is
extended to the buccal cusps of the posterior teeth with all teeth
touching the appliance on their lingual and buccal surfaces. The
canines and incisors are covered labially also by about 2–3 mm of
acrylic to secure good anchorage. Any undercuts, if present, are partly
blocked before constructing the appliance. Adequate relief is provided
to lingual frenum. The lingual acrylic over the lower incisors must
extend to the gingival level, and the occlusal details of the lower
buccal segments must be retained where possible.
The acrylic base has to cover one-third of the lower incisors, and the
upper incisors should be covered on the palatal side up to one half
and on the labial side only upto the incisal edges.
Metal framework
The metal components of the appliance are: (1) torque springs of
maxillary incisors, (2) coffin spring and (3) activator–headgear tubes.
Torque springs
With the activator–headgear assembly, the applied forces are
transmitted eccentrically from the acrylic covering the occlusal and
incisal portions of the teeth. The bodily control over the incisors is
lacking due to which incisor crowns tend to tip palatally because of
the posteriorly directed component of the force vector. To counteract
this tendency of the crowns, torquing springs are fabricated from 0.5–
0.6 mm (23 gauge/ 0.022 in. approximately) resilient stainless steel
wire. The torquing springs provide palatal root tipping forces to the
upper incisors. The springs at their gingival end contact the upper
incisors, placed 1–2 mm short of the gingival margin. These are bent
to provide a point contact at their gingival end, while rest of the
springs remain out of contact of the clinical crown. Their free ends are
retained in the inter-incisal wax block.
For the torquing springs to be effective, it is essential that the incisal
acrylic extension well secures the incisors, particularly on the palatal
side, otherwise, the activated torquing springs can easily cause palatal
tipping of the crown rather than that of the root.
If torque-control of the upper incisors is not critical, the torquing
springs are substituted with a standard labial wire of 0.8 mm SS
spring hard wire with U-loops in the canine region. The acrylic
extensions for the front teeth should be the same. However, this
arrangement should be used only in mild class II cases, requiring a
short treatment period as this provides axial control of the incisors of
much lesser degree than with torquing auxiliaries.
Coffin spring
The palatal bar is made of 1.2 mm SS (0.045 in.) spring hard wire. The
coffin spring is made in a pear shape with its closed end -being placed
towards soft palate.
Activator headgear tubes

The specially designed headgear tubes have extensions which can
hold them in the occlusal bite blocks of the acrylic. The tubes are
placed parallel to the maxillary occlusal plane, between upper and
lower teeth in the region of the deciduous molars. Vertically these are
placed closer to maxillary occlusal surfaces, thus providing a free
acrylic surface for trimming for eruption of lower molars. Tubes on
both sides should be parallel to each other for gentle insertion or
removal of the inner bow without any problems. This should be
checked in the wax bite with facebow before the appliance is cured.
Facebow
A Kloehn facebow is used with high-pull headgear.
High-pull headgear
The high-pull headgear with self-release safety modules is
recommended.
Clinical management of the
appliance1,3,6,8
The appliance should be checked in mouth on each arch for precise
fitting and uniform pressure on all teeth in each arch. The occlusal
surfaces of the appliances should be checked for cleaner details.
Pimples if any should be taken care to allow a comfortable fit on either
arch individually. The torquing springs/labial bow and coffin bow are
also checked for fit.
Application of extraoral force

Determining the centre of resistance. According to Teuscher (1986)10 and
Stockli and Teuscher (1994)1 the centre of -resistance (CRes) of
nasomaxillary complex corresponds to a point just below the
zygomatico-maxillary buttress and that of the maxillary dental arch
lies somewhat between roots of upper premolars. By directing the
extraoral force between -respective centres of resistance, differential
reaction patterns of maxilla and or dentition are observed (Fig. 55.3A–
B).
FIGURE 55.3 (A) Centre of resistance of nasomaxillary complex. (B)
The intersection of the action lines defines the centre of resistance. A
horizontal (HT) and high-pull (HPT) force application induces
translation of the maxilla.
There are differing research studies on the exact location of the

centre of resistance of the nasomaxillary complex.11,12 FEM studies
concluded that the centre of resistance of nasomaxillary complex lies
on posterosuperior ridge of the pterygomaxillary fissure. Billiet et al.13
used holography to study the centre of resistance of nasomaxillary
complex and dentition with extraoral traction using a model on
macerated skull. They concluded that pure translation of
nasomaxillary complex and dentition occurred when force vector
passed by in the area of the key ridge. Their study could not
differentiate a distinction between the centre of resistance of
nasomaxillary complex and upper dentition.
After the appliance is seated and adjusted for good fit, a facebow of
appropriate size is selected. The inner bow is -adjusted and checked
for correct placement. It should follow the buccal contours of the arch
without touching them and vertically lie between lip embrasures. The
centre of the maxilla and dental arch are marked on the patient’s face
as suggested by Teuscher, with a water-soluble colour pencil that can
be easily wiped clean with wet cotton.
Stockli and Teuscher recommended outer arm of the face-bow to be
extended far enough posteriorly that their ends correspond in the
frontal plane to the distal cusps of the first permanent molars. The
vector of force passes in nearby key ridge somewhat vertically
between the centre of resistance of the dentition and nasomaxillary
complex. The facebow is connected to high-pull headgear and
checked for desired force levels and the stability of the appliance.
Force levels. In cases with full mixed dentition, force in the range of
300–400 g is used. It rarely exceeds 1lb on each side. However in
situations of mixed dentition during exfoliations of buccal teeth, a
lower force levels in the range of 150–200 g is recommended.
The appliance, when connected to extraoral traction at desired
force, should be stable in open mouth position. The unstable appliance
in the mouth may disengage from occlusal surfaces of the maxillary
teeth either at anterior or at its distal ends.
If disengagement of the appliance occurs in the incisor area while
opening the mouth, it indicates that the force vector is placed too far
posteriorly. Whether the vertical pressure is the same in front as in the
rear of the arm can be checked manually by slightly disengaging the
appliance with a scaler, first in the front and then in the molar region
or by analogously pulling on the mandibular wings of the activator.
If the posterior part of the activator becomes disengaged, it
indicates the force vector is passing too far anteriorly of the appliance.
Either the direction of the force vector must be adjusted by
appropriate bending of the outer arm or the torquing springs must be
activated accordingly (Fig. 55.4I,II,III).
FIGURE 55.4 Effects of headgear and bite height on

nasomaxillary complex, dentition and attached musculature.
(I) Inter-maxillary force initiated by the bite registration; a combined
action of the retractors and elevators of the mandible. The arrows
represent force vectors. (1) The horizontal portion of the musculus
temporalis. (2) Suprahyoid musculature. (3) Musculus masseter and
musculus pterygoideus medialis. (A) Addition of vectors 1, 2 and 3.
Vector A affects maxillary dentition and the midfacial complex. A
reciprocal vector to A exerts a force on the mandibular dentition. D,
Assumed position of the centre of resistance of the maxillary dentition.
M, assumed position of the centre of resistance of the maxilla. Note
that the path of A is below D and M. (II) Addition of inter-maxillary
forces generated by the musculature and of extraoral forces, both
acting on the nasomaxillary complex. A, same vector as in I. B,
extraoral force vector. C, addition of vectors A and B. (C) Acts on the
maxillary dentition and on the midfacial complex. Note that the path of
C runs between D and M. As in I a force vector reciprocal to vector A
acts on the mandibular dentition. (III) Influence of a high bite
registration on the inter-maxillary force vector A determined by the
musculature. In comparison with the analogous I, the following
differences can thus be observed: the greater height of the bite
registration leads to slight elongation of arrow 3; the path of A is
steeper and shows greater eccentricity in relation to D and M. Source:
Reproduced with permission from Teuscher.6
A rotational effect on the occlusal plane can be built-in the

appliance system by allowing differential force on the anterior or
posterior part of the occlusal bite block. Such as for buccal intrusion
little disengagement of the appliance in the anterior region or reverse
of that can be managed by altering the force direction (Fig. 55.5).
FIGURE 55.5 Intraoral stability of the activator headgear

combination.
(A) Red arrow: extraoral force vector; the appliance remains stable in
situ. Blue arrow: extraoral force vector which destabilises the appliance
by transmission of an anterior rotating moment on the activator (blue
semicircle). (B) The de-stabilising moment (blue semicircle) is
counteracted by a posterior rotating moment (red semicircle) on the
activator initiated by action of the torque control auxiliaries; the
appliance remains stable. Source: Reproduced with permission from
Teuscher.6
Wearing schedule and follow-up

For the first few days, 12-h wear schedule daytime is recommended.
Thereafter slowly it is increased including night time wear. If possible,
a 14-h schedule should be attempted initially. Later depending upon
the treatment response and the problems to be solved, the wearing
time should be reduced to 10–12 h.
First visit. The first visit after appliance delivery is scheduled after 1
or 2 weeks. During this period, the patient gets adapted to the
appliance, without major problems in majority of cases; however,
issues related to discomfort, irritation or difficulties in appliance use
should be carefully looked into and appropriately solved. If indicated,
light pressure with torquing springs should be initiated and
corresponding adjustments of the extraoral force vectors may be
required to ensure the stability of the appliance.14
Follow-up visits. One may expect a quicker treatment response than
in cases using the activator alone. Changes in inter-digitation and
overjet overbite relationships should be measured. ‘Patients are often
encouraged by the reduction in upper incisor display, produced as the
upper incisors are depressed relative to the upper lip. While this can
be a positive motivating factor we should be cautious in our
optimism, as there is often a compensatory lengthening of the lower
incisors. This effect can result in the upper incisors being moved up
beyond the control of the lower lip, the converse effect to that
produced by the activator in the vertically growing patients’.3
The checks are made every 6 weeks or so and if no activations are
necessary and cooperation is good, the recall visits can be scheduled
at 8 weeks intervals
Assess progress of treatment from centric relation. Appropriate
biomechanical modifications must be made. The possible need to
promote additional lower molar eruption should also be appraised.
When class II correction is fully achieved and the attained class I
relationship has corresponded to the centric relation for several
months, then the wearing time is reduced step by step, initially to
every other night and later to twice a week.
Second phase of therapy

It is carried out at the stage of late mixed dentition or establishment of
the permanent dentition often with the full fixed appliance. During
this phase, the class II correction is maintained with the use of long
class II elastics. Cases treated with AHG are shown in Figs 55.1 and
55.6.
FIGURE 55.6 1 Treatment with activator headgear therapy.
Case DS, 13 years boy with a convex profile, vertical growth pattern,
increased overjet and spacing in upper arch. (A) Pre-treatment profile.
(B) Pre-treatment cephalogram shows vertical growth pattern. (C–D)
Pre-treatment occlusion showing class II molars with large overjet and
spacing on the upper anterior teeth. 2. Treatment with activator
headgear therapy. Case DS, 13 years/male treated with combined
activator headgear therapy followed by a course of a fixed appliance.
(A) With appliance. (B) After 11 months of AHG therapy. 3. Treatment
with activator headgear therapy. Case DS, 13 years male treated
with combined activator headgear therapy followed by a course of the
fixed appliance. (A) With appliance. (B) After 11 months of AHG
therapy. (C) Finishing with a fixed appliance. 4. Case DS, 13 years
male treated with combined activator headgear therapy followed by a
course of the fixed appliance. Post-treatment photographs show an
improved profile, smile, incisor and molar relations. 5. Case DS, 13
years male treated with combined activator headgear therapy followed
by a course of the fixed appliance. (A) Pre-treatment, (B) post-
treatment photographs. Note the improvement in face and lip
competency. 6. Case DS, 13 years male treated with combined
activator headgear therapy followed by a course of the fixed appliance.
(A) Pre-treatment lateral cephalogram. (B) Post-debond cephalogram
is showing changes in occlusion and dentofacial skeleton occurred due
to growth modification.
Treatment effects15,18
Recent studies have compared the additional benefits of AHG
treatment when compared to an activator. Using a control group of
matched untreated patients, treatment outcome with two types were
found successful in treating skeletal class II malocclusion. The results
revealed that both the activator and the activator–headgear
combination significantly encouraged mandibular growth. The
restraining effect on the maxilla remains questionable. The
mandibular incisors were more controlled in the activator–headgear
combination group. Although the intensity of headgear effect on
maxilla remains in dispute in the sense of wide variations in response,
there is a general consensus that there is a reduction of maxillary
prognathism in patients treated with a regimen of combined
activator–headgear therapy.
Recently, a study19 cited other long-term benefits of this therapy on
an improvement of the pharyngeal space. Activator–headgear therapy
was found to increase pharyngeal airway dimensions, such as the
smallest distance between the tongue and the posterior pharyngeal
wall or the pharyngeal area which was maintained long-term, up to 22
years on average in a study reported by Teuscher’s group.
In contrast to several reports of success with AHG, a study which
followed a group of patients treated with HGAs for 5 years,20 reported
that one out of six subjects experienced a relapse of the treated class II
malocclusion.
The effects of Headgear–Activator Teuscher Appliance (HATA) on
the skeletal and soft tissue components in the correction of class II
malocclusion was evaluated by Singh et al. The results showed
anteroposterior restraint of the maxilla, improvements in the
mandible maintaining facial height and lip changes. Also there were
no gender differences in the effect of HATA.21
van Beek activator22,23
It differs from previously known activators in its design and facebow.
The design of van Beek activator overcomes some of the issues which
are fully resolved or unwanted side effects of the HATA. There is a
poor control of the maxillary incisors, possible proclination of the
lower incisors and possibly a limited intrusive effect on molars due to
small vertical displacement of the mandible in recording the bite.
These limitations have been overcome by the following
modifications (Fig. 55.7).
FIGURE 55.7 van Beek activator appliance.
Appliance design and bite recording

1. The construction bite is taken with moderate protrusion of the
mandible or in a protruded edge-to-edge position of the
incisors, which is about 7 mm of protraction.
2. van Beek recommends a fairly high occlusal bite of about 6–8
mm in the molar area.
3. No labial bow or torquing springs are used. Instead, this
activator uses full coverage of the labial surfaces of the
maxillary anterior teeth by acrylic.
4. Mandibular incisors and the alveolar process are relieved from
the acrylic on the lingual side.
5. The labial surfaces of the mandibular incisors are covered in
the acrylic to hold the teeth.
6. No headgear tubes are used to attach the facebow. Instead the
bows are incorporated bilaterally in the acrylic in the anterior
part of the activator and are short for the attachment of a high-
pull headgear force.
7. The point of extraoral force application is at the level of the
maxillary canines.
8. The outer parts of the bows are normally inclined upwards
relative to the occlusal plane.
9. However, the bows are kept parallel to the occlusal plane to
have vertical control on the maxilla and buccal teeth. This
effect is greatly desired in vertical growth pattern.
Reports from several studies have indicated that torquing spring

used in HATA have limited ability in providing effective torque-
control of incisors. The van Beek activator is effective in decreasing
overbite mainly due to an intrusion of the incisors.24
The cases with anterior skeletal open bite tendency, the intrusion of
molars can be attempted by the application of gutta-percha to the
activator over their occlusal surfaces in the molar region. This may
lead to intrusion of the molars and/or distraction in the
temporomandibular joints that promotes additional condylar growth.
Both of these mechanisms would enhance autorotation of the
mandible and prevent the open bite.25
Wearing schedule
The prescribed wear time of 12 h per day is considered essential for an
effective outcome, however, it is a difficult target to achieve.
Al-Kurwi et al. used a built-in microsensor (TheraMon; MC
Technology, Hargelsberg, Austria) (2017) studied the use of
monitoring sensor to investigate the association -between objective
wear times, overjet changes, and duration of treatment with van Beek
activators.26 They found a significant overjet reduction with the van
Beek activator with a daily wear time of 8 h or more in at least 5
months. The level of compliance is strong throughout the treatment
period and no patient achieved the prescribed wear time of 12 h per
day.
Treatment effects
The skeletal sagittal correction is attributed to forward mandibular
changes with insignificant skeletal maxillary reaction. The dental
changes include moderate proclination of the mandibular incisors and
moderate retroclination of the maxillary incisors with varying level of
intrusion of the maxillary incisors.25
When compared to Herren activator and activator–-headgear
combination, the skeletal effects were similar with all three activator
types. The retroclination of the maxillary incisors is smaller with the
van Beek activator than with the other -activator types. Similarly, the
mandibular incisors and vertical control of the maxillary incisors is
better than with the Herren activator.
Key Points
Treatment of growing class II malocclusion with the vertical growth
pattern is difficult and requires additional efforts to control the
vertical descent of the maxillary buccal segment and nasomaxillary
complex. The effective use of orthopaedic forces on maxilla require a
comprehensive diagnosis of the case including its aetiology, accurate
appliance design and flawless implementation. A thorough
understanding of the orthopaedic forces, their relationship with
nasomaxillary complex, effects on occlusion plane and possible
complications is a must. The most important contributor to the
successful outcome of the whole therapeutic endeavour is the patient
him/herself, whose cooperation in adherence to the protocol of wear
and follow-up treatment is a must for the success. His/Her motivation
and support should be gathered in every possible way. The
termination of this part of therapy should follow detailing and
finishing the occlusion with fixed appliance therapy and adequate
retention.
References
1. Stockli PW, Teuscher JM. Combined activator
headgear orthopedics. In: Graber TM, Vanarsdall RL,
Swain, eds. Orthodontics: current principles and
techniques. St Louis: Mosby; 1994.
2. Nielsen IL. Guiding occlusal development with
functional appliances. Aust Orthod J.
1996;14(3):133–142: Oct; PubMed PMID:9528411.
3. Heath JR. Maxillary control with functional
appliances: some clinical observations. Aust Orthod J.
1985;9(2):219–225: Oct; PubMed PMID:3870082.
4. Vargervik K, Harvold EP. Response to activator
treatment in class II malocclusions. Am J Orthod.
1985;88(3):242–251: Sep; PubMed PMID: 3862347.
5. Wieslander L, Lagerström L. The effect of activator
treatment on class II malocclusions. Am J Orthod.
1979;75(1):20–26: Jan; PubMed PMID: 283692.
6. Teuscher U. A growth-related concept for skeletal
class II treatment. Am J Orthod. 1978;74(3):258–275:
7. Teuscher U. Class II treatment. Guidelines for class II
treatment with the activator-headgear combination.
Schweiz Monatsschr Zahnmed. 1987;97(5):614–617:
German, PubMed PMID: 3473665.
8. Bertelè G, Leoci T, Stella F, Pisano C. Functional
therapy of class II division 1. Comparison of three
activators: Andresen, Fränkel and Teuscher. Minerva
Stomatol. 1999;48(4):115–123: Italian, Apr; PubMed
PMID: 10431533.
9. Singh GD, Thind BS. Effects of the headgear-activator
Teuscher appliance in the treatment of class II
division 1 malocclusion: a geometric morphometric
study. Orthod Craniofac Res. 2003;6(2):88–95: May;
10. Teuscher U. An appraisal of growth and reaction to
extraoral anchorage. Simulation of orthodontic-
orthopedic results. Am J Orthod. 1986;89(2):113–121:
11. Tanne K, Matsubara S, Sakuda M. Stress distributions
in the maxillary complex from orthopedic headgear
forces. Angle Orthod. 1993;63(2):111–118: Summer;
12. Tanne K, Matsubara S, Sakuda M. Location of the
centre of resistance for the nasomaxillary complex
studied in a three-dimensional finite element model.
Br J Orthod. 1995;22(3):227–232: Aug; PubMed PMID:
7577871.
13. Billiet T, de Pauw G, Dermaut L. Location of the
centre of resistance of the upper dentition and the
nasomaxillary complex an experimental study. Eur J
Orthod. 2001;23(3):263–273: Jun; PubMed
PMID:11471269.
14. Aelbers C, Dermaut L. Incisor torque by means of a
modified Teuscher activator three case reports. J
Orofac Orthop. 1998;59(3):171–177: English, German.
15. Türkkahraman H, Sayin MO. Effects of activator and
activator headgear treatment: comparison with
untreated Class II subjects. Eur J Orthod.
2006;28(1):27–34: Feb; Epub 2005 Aug 10. PubMed
PMID: 16093256.
16. Oztürk Y, Tankuter N. Class II: a comparison of
activator and activator headgear combination
appliances. Eur J Orthod. 1994;16(2):149–157: Apr;
17. Nielsen IL, Lagerström LO. Individual response to
treatments using Teuscher activator. Tandlaegebladet.
1991;95(18):882–891: Danish, Dec; PubMed PMID:
1817383.
18. Mars¸an G. Effects of activator and high-pull
headgear combination therapy: skeletal,
dentoalveolar, and soft tissue profile changes. Eur J
17488997.
19. Hänggi MP, Teuscher UM, Roos M, Peltomäki TA.
Long-term changes in pharyngeal airway dimensions
following activator-headgear and fixed appliance
treatment. Eur J Orthod. 2008;30(6):598–605: Dec Epub
2008 Oct 28. PubMed PMID: 18974068.
20. Lehman R, Romuli A, Bakker V. Five-year treatment
results with a headgear-activator combination. Eur J
3061833.
21. Singh GD, Thind BS. Effects of the headgear-activator
Teuscher appliance in the treatment of class II
division 1 malocclusion: a geometric morphometric
study. Orthod Craniofac Res. 2003;6(2):88–95: May;
22. van Beek H. Overjet correction by a combined
headgear and activator. Eur J Orthod.
1982;4(4):279–290: Nov; PubMed PMID: 6959820.
23. van Beek H. Combination headgear-activator. J Clin
Orthod. 1984;18(3):185–189: Mar; PubMed PMID:
6595262.
24. Uçüncü N, Türk T, Carels C. Comparison of modified
Teuscher and van Beek functional appliance
therapies in high-angle cases. J Orofac Orthop.
2001;62(3):224–237: May; English, German. PubMed
PMID: 11417206.
25. Altenburger E, Ingervall B. The initial effects of the
treatment of class II, division 1 malocclusions with
the van Beek activator compared with the effects of
the Herren activator and an activator-headgear
combination. Eur J Orthod. 1998;20(4):389–397: Aug;
26. Al-Kurwi AS, Bos A, Kuitert RB. Overjet reduction in
relation to wear time with the van Beek activator
combined with a microsensor. Am J Orthod
PMID: 28153156.
CHAPTER 56
Management of class II
malocclusion with fixed
appliance
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Class II treatment options
Combination with orthognathic surgery
Treatment sequence
Phase I
Phase II retraction of maxillary anterior teeth and class II
molar correction
Phase III finishing and detailing
Occlusion and profile after extraction treatment
Factors affecting soft tissue profile outcome
Key Points
Introduction
Class II malocclusion is the most common reason for seeking
orthodontic treatment, though it is second in the frequency
distribution, among three classes of malocclusion, class I malocclusion
being the most common and class III being the least.
The objectives of treatment of class II malocclusion in non-growing
or young adults with no or little mandibular growth are to correct
dental sagittal relationships, reduce dentoalveolar protrusion of
maxilla and correct deep bite. Adults with class II division 1
malocclusion are treated with fixed appliance alone or in combination
with orthognathic surgery. The severity and nature of the dysplasia
are critical deciding factors in the choice of treatment. Fixed appliance
orthodontic treatment is aimed at and results in the following:
1. The retraction of the proclined dentoalveolar maxillary anterior

segment to normalise overjet. Normalisation of the incisor
position brings about improvement in the mid-face convexity,
reduction in the acuteness of the naso-labial angle,
improvement in upper lip posture and elimination of the
lower lip trap.
2. Overall, orthodontic treatment results in a significant
improvement in the facial profile which is mainly limited to
the mid-face below the nose. In such patients, the sagittal
position of the chin remains largely unaffected (Fig. 56.1).
3. Goals of orthodontic treatment in class II malocclusion are
aimed at a functionally balanced occlusion (not necessarily a
class I occlusion relationship) and improvement of the soft
tissue profile while maxillo-mandibular skeletal base
relationship remains unaltered. Orthodontic treatment in
adults is therefore synonymous with camouflage treatment.
4. The dental–molar relationship is aimed at class I molar and
canine, relations when treatment is instituted with the
extraction of all first premolars or a combination of both upper
first and lower second premolars. Cases treated with
extraction of upper first premolars only are finished in class II
full cusp molar relations while class I canine, normal overjet
and overbite are attained.
FIGURE 56.1 A case of class II division 1 malocclusion treated
with fixed appliance.
(A) Pre-treatment, (B) post-treatment, (C) follow-up.
Class II treatment options
Non-growing patients with a maxillary protrusion and/or combined
mandibular deficiency can be treated with one of the following three
options.
Camouflage treatment without any extractions is indicated in mild
cases where arch length discrepancy is minimum, and the upper and
lower dental arches can accommodate the full complement of teeth
without any adverse effects on -facial profile. The overjet is correctable
with dental movements alone (Fig. 56.1). Treatment options include
intraoral molar distalisation, correction of molar rotations and an
increase in arch perimeter with maxillary dentoalveolar expansion.
Mild class II correction can also be achieved with either class II
elastics or fixed functional appliance (FFA).
In certain clinical situations with large overjet, class II full cusp molar
relation and minimal crowding of the lower arch, camouflage
treatment may be possible with the extraction of first premolars in the
upper arch only and thereby maintaining the class II molar relations
(Box 56.1).
Box 56.1 Indications of first premolar extraction

in the upper arch only2
1. The extraction of upper premolars is often chosen as an

alternative to orthognathic surgery for non-growing class II
patients with significant overjet.
2. In class II cases in which there has been a failure of attempted
headgear or functional appliance treatment to achieve class I
canine relationships.
3. A large overjet especially if the patient has full upper lips.
4. A relative mandibular deficiency.
5. Lower arch with minimal or no crowding.
6. Maximum anchorage required for orthodontic camouflage.
It has now been accepted that the occlusion obtained from upper-
premolar extractions for orthodontic camouflage in class II
mandibular deficiency patient is stable.1
Mild to moderate class II patients may be treated with -extractions
of all first premolars or a combination of upper first and lower second
premolars. The camouflage treatment is often the treatment of choice
where a discrepancy exists -between total tooth material and arch
length.
Tooth of choice for extraction

First premolars are most frequently extracted teeth in the maxillary
arch to create space relief of crowding and correction of the superior
protrusion. Cases requiring minimal anterior retraction can be
considered for extraction of second premolars or second molars where
the whole of the maxillary dental arch is distalised (Fig. 56.2).
FIGURE 56.2 (A) Case NS, 17 year female. Pre-treatment records
shows class II molar relations, severe crowding in upper arch, mild
crowding in lower arch. (B) Camouflage approach to treatment of a
case of class II division 1 malocclusion with fixed appliance therapy.
The case was treated with extraction of upper first premolars only to
correct crowding in the maxillary arch, thereby finishing the case in
class II molar and class I canine relationship. Note the improvement in
post-treatment profile and occlusion. (C) Case NS, 2 years follow-up
shows stable results. (D) Case NS, lateral cephalograms showing
growth and treatment changes. (A) Pretreatment; (B) immediately post-
debond; (C) 2 years follow-up.
In the lower arch, the tooth of choice for extraction are of either first
or second premolar. The justification rationale for either first or
second premolars extraction is greatly influenced by the nature of
malocclusion, the goals of occlusion and biomechanics being
considered. Extractions of first premolars are indicated in crowding in
the anterior segment, deep curve of Spee due to supra-eruption of
anterior teeth and marked proclination of lower incisors. In such
patients, molars may be in a half cusp to full cusp class II sagittal
relationship (Fig. 56.3).
FIGURE 56.3 (A) Case HS, 14 year old female patient with class II
bimax malocclusion, convex facial profile, forwardly placed upper front
teeth and potentially competent lips. (B) Case HS, post debond
photographs show improved profile, nasolabial angle, class I molar and
canine relation. (C) Follow-up photographs shows stable results after 6
months. (D) Cephalometric comparison pre-treatment and immediate
post-treatment radiographs.
Second premolar extraction in the mandibular arch is preferred over

first premolars in full cusp class II molar relationship where no/little
space will be needed for correction of malocclusion in the anterior
segment, and a majority of -extraction space is utilised for mesial
movement of the lower first molars. Second premolar extraction site is
next to the first molar which offers greater and faster mesial
movement of the lower first molar. However, the second premolar
extraction in the lower arch accordingly limits the scope of correction
of the anterior crowding and correction of severe proclination of the
lower incisors.
The maxillary first premolars only

Based on the cephalometric outcome of cases treated with upper
premolars only, Scott and Jernigan3 suggested that ‘maxillary first
premolar extraction for orthodontic camouflage may be a viable
treatment option, especially if the patient has full upper lips and only
a relative mandibular deficiency’. As a result, extraction of only
maxillary premolars with the goal of finishing with functional class II
molars and class I canines is a viable functional compromise.
Combination with orthognathic surgery

Dolichocephalic patients who exhibit crowding and protrusive lower
incisors, steep angle of the occlusal plane and proneness for clockwise
mandibular rotation are not good patients for orthodontic treatment
alone. These patients have a poor prognosis in terms of improvement
in the soft tissue profile and stability of occlusion. Such vertical
growers and more severe forms of class II division I malocclusion are
considered for orthognathic surgery.
Surgical treatment consists of mandibular advancement, superior
repositioning of the maxilla, or a combination. Mandibular deficiency
alone is the problem in about two-thirds of skeletal class II surgical
patients; while only one-third require maxillary surgery, either alone
(15%) or combined with mandibular surgery (20%).
Severe forms of skeletal retrognathia of mandible alone are treated
with mandibular advancement using bilateral sagittal split osteotomy
—BSSO (see Chapters 76, 68). Although -orthognathic surgery may be
the treatment of choice, it may not be a most preferred treatment
option due to several reasons, such as patients’ reluctance, the
presence of medical conditions, non-availability of expert teams, cost
of the treatment and other such logistics.
Treatment sequence
The treatment sequence for an extraction case of class II malocclusion
is as follows. Following the routine protocol of -records, treatment
planning and full mouth banding/bonding, active orthodontic
treatment is initiated.
Anchorage control in class II division 1 cases should be planned
based on severity and nature of superior protrusion. In patients with
upper premolar extractions, anchorage in the maxillary arch is
reinforced with the second molar banding or lately mini screws have
been used successfully.
Phase I
1. Levelling and alignment begin with the objectives to correct the
intra-arch vertical tooth positions, the axial inclination of each
tooth and to attain a good arch form. During this phase
occasionally but with great caution, light force class II elastics
can be used to prevent flaring of the upper incisors and
simultaneous mesial movement of the lower buccal segment.
2. In maxillary arch anchorage, conservation methods such as
transpalatal arch (TPA), second molar banding, and archwires
with molar stops are used to prevent loss of arch length.
Maxillary anchorage is further conserved with the use of curve
of the Spee and figure of 8 ligature ties between second
premolars and molar teeth.
3. In the lower arch, if the treatment objectives require mesial
migration of molars, molar stops are not bent in the archwires.
4. During this phase, bite opening mechanics are instituted. A
gentle reverse curve of Spee in the lower arch keeps the
mandibular molars upright and helps to flatten the curve of
Spee resulting in bite opening.
Phase II retraction of maxillary anterior teeth
and class II molar correction
Retraction of the upper anterior teeth can be achieved either in one
stage called en masse retraction or two stages, the first canine
retraction followed by incisor retraction. In maximum discrepancy
cases, two-stage retraction is one of the methods of conserving the
anchorage. The tooth-size arch-length discrepancy, anchorage
requirements and nature of craniofacial pattern would govern the
choice of one or two stage retraction.
1. Maxillary canine retraction is performed on a rigid SS base

wire of 0.019 × 0.025 in. dimensions. Intra-arch mechanics
using 150 g NiTi coil spring is activated on canine power arms
distally anchored at maxillary first molars on either side. The
rate of canine retraction is about 0.9 mm/month. It takes about
8 months to complete the canine retraction.
Inter-arch mechanics involve the use of class II elastics, a sliding
hook or a jig which is placed against a piece of open coil spring
mesial to the canine bracket. Need for canine retraction in the
lower arch is usually minimal to the extent to achieve a class I
canine relationship.
2. Upper incisor retraction is done with the frictionless
mechanism in an asymmetrical T-loop. It can be supported
with class II elastics. In some situations, class II elastics alone
can be a mechanics of choice for upper anterior retraction.
Care should be taken to ensure sufficient torque in the anterior
segment to prevent palatal dumping during this phase of
therapy.
3. The lower arch becomes an anchorage unit where a class II
space-closing mechanics is used to retract the anterior segment
and simultaneously move the lower molars forward. Intra-
arch forces are generated from a closing loop in the lower arch,
and mesial vector of the class II elastics helps burn the
anchorage. This phase of therapy lasts for 8–10 months. By the
end of this phase, the following treatment objectives should
have been achieved:
a. Normal overjet overbite.
b. Extraction space closure in both the arches.
c. Class I sagittal relations (full cusp class II molar
relationship in upper premolar extraction cases).
d. A normal labiolingual inclination of the maxillary
anterior segment.
Class II elastics
The class II elastics are used to generate a force system that enables a
forward position of the mandibular dentition and helps to close
extraction spaces created by the extraction of first or second bicuspids.
The objectives and treatment effects of class II elastics are different in
non-extraction or an extraction situation.
1. In a non-extraction situation, the main objectives are correction

of class II sagittal dental relationships by helping the mandible
to posture forward.
2. In extraction situation, the main objectives are to enhance
lower mesial molar movement or burn the anchorage.
3. Class II anchorage is also utilised to influence maxillary
segment: (1) for maxillary canine retraction and (2) for en
masse retraction of the maxillary anterior segment.
4. Roth recommends the use of ‘short’ elastics attached to the
lower second premolars could simultaneously level the curve
of Spee, correct the anteroposterior inter-maxillary relationship
and promote good inter-cuspation.4
5. Short class II elastics are also used in the finishing stages of
treatment for resolving the CR–CO discrepancy and settling of
occlusion.5
6. Class II elastics are used to prevent unwanted labial flaring of
maxillary incisors when full-size wires are used to create
effective palatal root torque.
Classically, the use of class II elastics is advocated when levelling
and alignment are complete, and the patient is on upper and lowers
rigid steel wires. Sufficient bite opening should be accomplished
before class II elastics are employed. The base wires are usually of
0.019 × 0.025-in. diameter when 0.022-in. slot system is in use. Most
orthodontists recommend class II elastics from the power arm of the
maxillary cuspids to hook on the mandibular first molars or hook
distal to lateral incisor (Fig. 56.4A–B). Traditionally edgewise systems
used a soldered inter-maxillary hook between the maxillary lateral
incisor and the maxillary canine at V-bend.
FIGURE 56.4 (A) Class II elastics. (B) Class II elastics are engaged
horizontally at soldered inter-maxillary hook at V-bend. (C–E)
Mechanical characteristics of class II elastics vary with placement of
hooks. (C) Vectors of class II elastics engaged from mandibular first
molar to the maxillary canine in an extraction case. (D) In a non-
extradition situation. (E) In a non-extraction situation when engaged at
mandibular second molars.
Force vectors of class II elastics6

Class II elastics generate two major force vectors on lower -molars: the
horizontal vector that brings the mandible/dentition forward and a
vertical vector component which tends to -extrude the anchor molars
with similar effects on another end, i.e. extrusion and distal movement
of the incisor segment. Class II inter-maxillary traction from the distal
of the mandibular first molar to the maxillary canine results in a
horizontal vector of 96% and a vertical vector of 27% (Fig. 56.4C–E).
The greater is the distance between two points of engagement of the
class II elastics greater is the horizontal vector, and lesser is the
vertical vector. For example, the distance can be increased by more
anterior application of the -inter-maxillary hook on the upper arch
such as at V-bend as described above or placing it more distally in the
lower arch, that is second molar (Fig. 56.4D).
The effects on the maxillary anterior dentition are that of lingual
tipping of incisors and extrusion. In non-extraction treatment, the
maxillary arch is stabilised as a single unit. The forces of class II
elastics can be effectively used to distalise the maxillary dental arch. In
mandibular arch, the effects are that of extrusion and mesial
movement which may transfer its -effects on mandibular incisors
resulting in their proclination.
In order to keep the lower molars upright, it is necessary that the
molar tube should have built-in provision for the distal tip (mesial end
of the tube is tilted mesio-gingivally) or alternatively, a mild second-
order bend is incorporated in the archwire mesial to the buccal tube
on either side. In classical Tweed’s technique, mild second-order
bends or anchorage preparation was employed to harness mandibular
anchorage.
In situations of non-extraction treatment, the lower arch is made as
one unit by a figure of 8 ligature tie extending from the molar on one
side to that of another side. The lower archwire should have a precise
arch length, with the molar stops on either side or it is gently cinched
back. The lower incisor segment of the wire should receive a gentle
labial root torque (5°) to counteract the flaring of incisors caused by
class II elastics.
In extraction situations where a significant mesial movement of the
lower first molars is required to burn the anchorage, a figure of 8
ligature tie is limited to the canine from one side to the canine on
another side. The archwire is made in a similar manner as mentioned
previously except it should not have molar stops. The tip back bends
should be placed just distal to second premolar brackets to allow
unobstructed mesial slide of the terminal molars.
The maxillary archwire is modified to minimise the extrusion and
distal tipping of the maxillary incisor segment. The maxillary incisors
should receive extra-palatal torque to counter lingual tipping vectors
of class II elastics. The extrusive effect is minimised by a second-order
effect and accentuated curve of Spee in the maxillary arch.
To minimise the extrusive effect on lower molars and maxillary
anterior segment long class II elastics are used. The effects can also be
minimised by short periods of elastic wear/day. Another careful
consideration is to keep a watch on alteration of the occlusion plane,
which tends to tip low on the front resulting in backward rotation of
the mandible. Patients with high mandibular plane angle tend to
show more extrusion than those with low MPA, who can
accommodate some extrusion of lower molars for bite opening.
Inter-maxillary class II elastics of moderate force levels (6
ounces/150 g) are used on either side. The medium strength elastics of
3/16, 4/16 and 5/l6 in. sizes are used most often. It is a good idea to
visually estimate the distance between two points of elastic
application in the mouth and select a size which is one-third of the
distance or select elastic that can be stretched up to three times of its
lumen size. The force is measured by Dontrix gauge. The patient is
instructed to wear elastics 24 h/day. Elastics should be changed every
12 h. As with most of the forces used in orthodontics, class II elastics
must be worn consistently. Intermittent wear will not -accomplish
success.
Fixed functional appliance when used with caution and force
control can substitute class II elastics to mechanically place the
mandible forward and help in correction of dental and to some extent
skeletal relationship.7 The class II elastics, when used in non-
extraction therapy in Begg’s technique, bring about major
dentoalveolar changes.8 The effects of class II elastics may extend
beyond dentoalveolar structures as far as naso-frontal suture.9
Phase III finishing and detailing
The mechanics towards the end of treatment are directed to fine-tune
individual tooth positions and good inter-arch relations. The clinician
should aim to finish the occlusion to Andrews six keys of occlusion. In
addition, we also aim at a functionally stable occlusion with no
interferences during the functional mandibular movements.
1. A class II malocclusion may necessitate the use of short class II

elastics to achieve good inter-digitation of the buccal segment.
2. Class II elastics can adversely affect lower incisors, which may
get labially proclined and therefore limit full retraction and
space closure in the maxillary arch. A careful watch to
maintain their correct labio-lingual inclination and
incorporation of the critical amount of labial root torque in
archwire may help to keep them upright on the basal bone.
Full size rectangular wires with additional torque and tip may
be required in the lower arch if the individual case demands
so.
The clinical observations while finishing, are reconfirmed on a

lateral cephalogram and the panoramic view X-ray. While
cephalogram is used to evaluate the torque of anterior teeth, OPG is
used to evaluate mesio-distal tip of the teeth. Dental study models are
prepared during the finishing phase to check arch form, tooth
contacts, marginal ridge relations and rotations.
Occlusion and profile after extraction
treatment
Several studies are available in the literature comparing treatment
changes and profile evaluation in cases treated with and without
extraction approach. There is a considerable debate regarding the
unsatisfactory outcome on the facial profile of cases treated with
extractions.
Recent studies have shown that case selection and growth
considerations are the important factors to be taken into consideration
and if suitable cases are treated with -extraction or non-extraction; the
treatment outcomes are comparable. On long-term, profile changes
associated with successfully treated extraction and non-extraction
class II division I malocclusions are stable, and most patients are
satisfied with the outcome. In reference to orthodontics vis à vis
surgery combined with orthodontics, Zierhut et al. evaluated 31
adults who had been treated with orthodontics alone for class II
malocclusions.10 The patients were recalled at least 5 years -post-
treatment to evaluate cephalometric variables and -occlusal stability
and also their satisfaction with treatment outcomes. The patients’
perceptions of outcomes were highly positive in both the orthodontic
and the surgical groups. The orthodontics only (camouflage) patients
reported fewer functional or TMJ problems than did the surgery
patients and had similar reports of overall satisfaction with treatment,
but -patients who had their mandibles advanced were significantly
more positive about their dentofacial images.
Effects of all first premolar extraction on facial profile are known.
Extraction treatment essentially attempts to normalise overjet by
retracting maxillary incisors to match lower -anterior teeth that are
housed on a deficient mandible. Many patients have ended in dished-
in profiles where nose becomes prominent with ageing. This has led
many orthodontists to attempt class II division I camouflage treatment
without -extractions. In other situations where mandibular deficiency
is relatively small, a maxillary protrusion can be corrected with
maxillary first premolars extraction for orthodontic camouflage. It is a
viable treatment option, especially if the patient has full -upper lips.3
Factors affecting soft tissue profile
outcome
It seems that the lips may be affected by anteroposterior tooth
movements, but the degree to which this occurs is likely to be
variable. Following factors have a considerable influence:
1. Pre-treatment lip thickness

2. Vertical and anteroposterior facial patterns
3. Individual variations in the growth of the nose and chin
4. The direction of overall facial growth
5. Final angulations of the upper and lower incisors
6. Treatment mechanics used.
Nevenka and Woods have summarised how the upper lip is likely
to behave with incisor retraction.11 ‘When pulling all this together, it
seems that the lips may be affected by anteroposterior tooth
movements, but the degree to which this occurs is likely to be
variable, depending on the treatment mechanics used, the various
extraction or non-extraction decisions, the final angulations of the
upper and lower incisors, the pre-treatment lip thickness, and the
underlying vertical and anteroposterior facial patterns. Furthermore,
individual variations in the growth of the nose and chin and the
direction of overall facial growth make it difficult, if not impossible, to
accurately predict changes in the naso-labial angle and lip curve
depths from previously published averages and ratio’.
Orthodontic treatment involving the extractions of only two upper
premolars is likely to result in a wide range of variation in the lip and
upper incisor behaviour. The pre-existing soft tissue morphology is
likely to be the greatest determinant of lip behaviour. In the light of
these findings, one should perhaps accept that the upper lip curve and
naso-labial angle are more likely to be negatively affected during
upper premolar extraction treatment in patients presenting with thin
pre-treatment upper lips, increased pre-treatment naso-labial angles,
expected vertical mandibular growth direction, or of limited
continued pubertal growth potential. In subjects with thick lips, and
marginal mandibular deficiency, where a dentoalveolar protrusion is
limited to maxillary teeth, upper first premolar extraction is the only
good option. Case selection is the key to an optimum outcome for
extraction treatment including only upper first premolars cases.
Key Points
Class II division I malocclusion in non-growing children or adults can
be treated with the extraction of upper premolars only, or extraction
of all first premolars and alternatively extraction of upper first
premolars and lower premolars. The nature and severity of class II
division 1 malocclusion and objectives of orthodontic treatment
greatly influence extraction decision. The camouflage orthodontic
treatment is aimed to bring about an improvement of the facial profile
and dental relations only, skeletal imbalance remaining unaltered. A
subgroup of class II patients may require additional procedures, such
as genioplasty for chin augmentation or mandibular advancement
surgery alone or in combination with maxillary surgery. Each case of
class II malocclusion requires a different line of action which should
be thoughtfully planned before the treatment is initiated.
References
1. Mihalik CA, Proffit WR, Phillips C. Long-term
follow-up of class II adults treated with orthodontic
camouflage: a comparison with orthognathic surgery
outcomes. Am J Orthod Dentofacial Orthop.
2003;123(3):266–278: Mar; PubMed PMID: 12637899;
2. Bokas J, Collett T. Effect of upper premolar
extractions on the position of the upper lip. Aust
Orthod J. 2006;22(1):31–37: May; PubMed PMID:
16792243.
3. Scott Conley R, Jernigan C. Soft tissue changes after
upper premolar extraction in class II camouflage
therapy. Angle Orthod. 2006;76(1):59–65: Jan; PubMed
PMID: 16448270.
4. Roth RH. Treatment mechanics for the straight wire
appliance. In: Graber TM, Swain BF, eds. Orthodontic
current principles and techniques. St. Louis: Mosby;
1985.
5. www.alexanderdiscipline.com.
6. Philippe J. Mechanical analysis of class II elastics. J
Clin Orthod. 1995;29(6):367–372: Jun; PubMed PMID:
8617860.
7. Jones G, Buschang PH, Kim KB, Oliver DR. Class II
non-extraction patients treated with the Forsus
Fatigue Resistant Device versus intermaxillary
elastics. Angle Orthod. 2008;78(2):332–338: Mar;
8. Reddy P, Kharbanda OP, Duggal R, Parkash H.
Skeletal and dental changes with nonextraction Begg
mechanotherapy in patients with class II division 1
malocclusion. Am J Orthod Dentofacial Orthop.
2000;118(6):641–648: Dec; PubMed PMID: 11113799.
9. Dermaut LR, Beerden L. The effects of class II elastic
force on a dry skull measured by holographic
interferometry. Am J Orthod. 1981;79(3):296–304: Mar;
10. Zierhut EC, Joondeph DR, Artun J, Little RM. Long-
term profile changes associated with successfully
treated extraction and nonextraction class II division
1 malocclusions. Angle Orthod. 2000;70(3):208–219:
11. Tadic N, Woods MG. Incisal and soft tissue effects of
maxillary premolar extraction in class II treatment.
Angle Orthod. 2007;77(5):808–816: Sep; PubMed
PMID: 17685775.
CHAPTER 57
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Facial features
Dental features
Class II division 2 subtypes
Cephalometric features
Aetiology
Mixed dentition treatment
Key Points
Introduction
Class II division 2 malocclusion is a distinct category of class II
malocclusion with unique features of retroclined incisors and a strong
pattern of familial inheritance. The subjects with class II division 2
malocclusion have round/square face, and cranio-facial features of
horizontal growth and distinct dental features, which are unique and
differentiate it from all other types of malocclusion to the extent to be
categorised as a syndrome.1
The ‘division 2 (of class II) is characterised specifically also by distal
occlusion of the teeth in both lateral halves of the lower dental arch,
indicated by the mesio-distal relations of the first permanent molars,
associated with retrusion instead of protrusion of the upper incisors’,
wrote E.H. Angle2 in 1907. The deep bite is due to the infra-occlusion
of the molars. ‘The molars have failed to erupt to their normal length,
allowing the lower incisors to come in contact with the vault of the
maxillary arch, while the cutting edges of the upper incisors pass
beyond the gingival margins of the lowers’.
There is a wide range of severity of class II division 2 malocclusions,
some exhibiting minimal characteristics of the classification, with only
dental manifestations of this malocclusion.
Facial features
Facial features of class II division 2 face include; a square/round
pleasing face, prominent chin, deep labio-mental sulcus, hyperactive
lower lip, a high lower lip line, thin upper lip, small gonial angle and
horizontal type of face. The masseter and temporalis muscles are
wide, and these subjects have a high biting force. The lips are usually
thin and there is a lack of vertical development of the face below the
nose (Fig. 57.1).
FIGURE 57.1 Profile of a class II division 2 boy.

A square or a round face, backwardly held mandible with a thick chin
button and thin lips.
Dental features
Dental features include a class II molar and canine relationship, deep
traumatic bite, retroclined upper four incisors or retroclined central
incisors with a labial inclination of the laterals and supra-erupted,
upright lower incisors. The tooth size may be small, and upper
incisors may have increased collum angle between the crown and the
root (Fig. 57.2). The incisors are relatively thin with small tubercles.
Class II division 2 incisors have a shorter root, a longer crown, and
axial bending of the incisor, in addition to a reduced labio-palatal
thickness.3
FIGURE 57.2 Occlusion of class II division 2 malocclusion.

(A) There is a deep traumatic bite, retroclined maxillary central incisors,
proclined laterals and crowding in the mandibular arch. (B) The collum
angle can be measured as an internal angle between the long axis of
crown and long axis of root. It may exhibit as an increased collum angle
when measured as external angle.
The maxillary incisors in class II division 2 malocclusions are about

12° more vertical than those in normal occlusion. The mandibular
incisors are upright in a class II division 2 malocclusion, but to a lesser
extent than the upper incisors. Not only the upper and lower incisors
are more recumbent, they are also more retrusive. The maxillary arch
is often wide in the posterior region and crowded in the anterior
region. However, there is a transverse underdevelopment of the
mandible from canine to canine probably a factor responsible for
mandibular incisor compression and crowding. Consequently, these
types of malocclusion are associated with severe deep bite (Fig. 57.2).4
Class II division 2 subtypes

1. Based on freeway space
There are two subtypes of class II, division 2 malocclusions,
a. such as the type in which the patient has excessive
freeway space with a lack of posterior alveolar
development and anterior alveolar overgrowth and
b. that in which the patient has normal freeway space.
2. Based on dental features.
van der Linden described three types of class II div 2 patterns based
on the alignment of incisors and canines. (Figs. 57.3, 57.4, 57.5).5
1. Type A: All the four maxillary incisors are palatally tipped, and
the maxillary canines are well aligned.
2. Type B: The maxillary central incisors are palatally tipped, and
the lateral incisors are labially tipped.
3. Type C: All the four maxillary incisors are palatally tipped, and
the maxillary canines are buccally-placed.
FIGURE 57.3 Class II division 2 type A.
The four maxillary permanent incisors are tipped palatally, and the
maxillary canines are well aligned in the dental arch.
FIGURE 57.4 Class II division 2 type B.
The maxillary central permanent incisors are palatally tipped, and the
lateral incisors are labially tipped.
FIGURE 57.5 Class II division 2 type C.
The four maxillary permanent incisors are tipped palatally, and the
canines are buccally located.
Cephalometric features6
The anterior cranial base lengths and sagittal position of the maxilla
are normal relative to class I and class II division 1 malocclusions,
while class II division 2 malocclusions have a shorter or normal
mandibular length with its sagittal position retruded, the chin being
prominent and lower posterior facial height definitely increased.
The mandibular growth vector is horizontally oriented, with a flat
mandibular plane, giving the appearance of a hypo-divergent facial
pattern. The gonial angle is acute. The lower incisors have a normal
inclination relative to the mandibular plane but are retroclined
relative to the facial plane. The inter-incisal angle is large and overbite
is deep due to infra occlusion of the molars. There is an extreme
skeletal mandibular counter-clockwise rotation rather than
dentoalveolar over eruption.
Aetiology
The class II division 2 pattern is known to have a strong familial
occurrence. Peck and Peck called it a heritable entity of small teeth in
well-developed jaws.1 According to their findings, the pattern of
strong vertical posterior development of the mandible with upward
and forward rotation and skeletal-facial hypo-divergence
anteroposteriorly, smaller mesio-distal tooth diameters for the
maxillary and mandibular incisors are characteristic pattern of
heritable skeletal and tooth-size features in class II division 2
malocclusion. These findings indicate the presence of strong genetic
influences in the formation of Angle’s class II division 2 overbite
discrepancies.
Ruf and Pancherz have reported a pair of monozygotic twins
showing malocclusion discordance with a class II division 1
malocclusion in one and division 2 in another child. Based on this
report, they have hypothesised that heredity is not the sole
aetiological factor of class II division 2 malocclusion,7 as normally one
would expect similar occlusion in monozygotic twins.
In a patient with a hypo-divergent facial pattern, redundant lips, and
a flat mandibular plane angle, the deep overbite could be corrected
and facial aesthetics improved by increasing the lower facial height,
correcting lip redundancy, or increasing facial convexity. Molars’
extrusion in growing patients will increase the lower anterior facial
height and allow favourable mandibular growth. The stability is fairly
good in the growing subjects. However, molar extrusion is not
recommended for adult patients, because the stability is highly
questionable.
A strong muscular pattern may not permit the bite opening with the
vertical increase of the buccal segment in adult patients. The shape
features of maxillary central incisors with decreased collum angle
could precipitate the development of a deep overbite in class II
division 2 malocclusions and may limit the amount of palatal root
torque during fixed appliance therapy. The narrow mandibular arch
in the anterior region limits the relief of crowding and plan of
retention should include a long term fixed rigid lingual retainer (Figs.
57.6–57.8).
FIGURE 57.6 1. Treatment of class II division 2 malocclusion.
(A) A case of class II division 2 malocclusions treated with two-phase
therapy. Fixed appliance to align arches, create overjet and open the
bite duration 14 months. Fixed functional appliance therapy (MPA IV)
for another 9 months resulted in unlocking the mandible to class I molar
and canine relation. Finishing and detailing is continued with a fixed
appliance to settle the occlusion prior to debonding. 2. Case of class II
division 2 malocclusions treated with two-phase therapy. (A) Pre-
treatment. (B) Post-treatment.
FIGURE 57.7 (A) In type B, the maxillary central permanent incisors
are palatally tipped, and the lateral incisors are labially tipped. (B)
Depicts correction of retroclined central incisor and proclined lateral
incisor using upper removable appliance with Z spring. (C) After the
correction of incisor relation. Note the forward movement of mandible
and correction of molar relation.
FIGURE 57.8 A Two-phase treatment of an adult of class II
division 2 malocclusion.
Pre-treatment records show type B class II division 2 pattern. (A) After
levelling and alignment. The molars are in end-on relation. (B) With
Forsus™ appliance for the sagittal advancement of the mandible. (C)
After correction. Post-treatment. Improved profile and smile, class I
buccal occlusion with normal overjet and overbite. Lateral
cephalograms showing treatment changes. (A) Pre-treatment; (B) After
levelling and alignment (8 months); (C) immediately post-debond.
Mixed dentition treatment

Mixed-dentition treatment of class II division 2 malocclusions with
deep traumatic bite should be planned with the objectives to take the
advantage of dental eruption, leeway space, alveolar growth, and
anteroposterior maxillary/mandibular growth.
‘The logical sequencing of early treatment is to resolve functional
problems and the arch-length discrepancies, to achieve vertical
correction, and finally, to achieve overjet correction’.8
‘The basic treatment format followed in the treatment of class II
division 2 malocclusions is the relief of maxillary crowding, the
development of maxillary arch length for incisor root torque,
alignment, crown advancement, and proper torque of the maxillary
incisors. Once the maxillary incisors are placed in proper labiolingual
inclination in the medullary bone, then maxillary intrusion can be
accomplished. It is pertinent that the roots of maxillary incisors lie in
the medullary bone, away from the thick labial cortex. At this point, a
class II division 1 malocclusion is achieved. The next step is an
intrusion of the mandibular incisors and canines. Alignment of the
buccal segments is achieved with distalisation of the maxillary buccal
dentition for correction of the class II malocclusion. Finally,
consolidation of the maxillary incisors, bucco-lingual coordination,
and finishing are achieved’.8,9
Buccal segment normalisation may include a phase of a fixed
functional appliance. In other situations, treatment may be started
with an upper removable appliance (URA) for bite opening and to
procline retroclined incisors with palatally placed Z springs. This
allows unlocking of retro-positioned mandible, leading to its forward
placement either with catch-up growth alone or helped with class II
elastics. The treatment with fixed appliance includes a phase of
alignment, and forward positioning of the mandible with a fixed
functional appliance. Class II correction was achieved with custom
made mandibular protraction appliance (MPA IV). Fig. 57.6 depicts
sequence of treatment with this approach.
Reduction of inter-incisal angle and establishment of guidance
between the maxillary and mandibular incisors is important for the
stability to be achieved in overbite correction. Muscular forces and
growth both have a role to play in the successful treatment of the class
II division 2 malocclusions. In adult patients, vertical development of
the buccal segments cannot be expected and the stability of bite
opening is questionable. Hypo-divergent facial types like class II
division 2 with a deficiency in anterior facial height usually present
problems in the maintenance of permanent overbite correction. It has
been reported that deep bite cases in which lower face height is
increased during treatment, exhibited less relapse than cases in which
little or no increase occurred during treatment. However, in patients
where overbite correction was accomplished during their respective
growth periods and those in whom vertical growth continued after
retention seemed to maintain this correction many years out of
retention.
Key points
Class II division 2 malocclusion is a distinct category of malocclusion.
A non-extraction approach works well in most instances in growing
children; however, those with severe crowding in the lower arch may
need extraction treatment.
References
1. Peck S, Peck L, Kataja M. Class II division 2
malocclusion: a heritable pattern of small teeth in
well-developed jaws. Angle Orthod. 1998;68(1):9–20:
2. Angle EH. Treatment of malocclusion of the teeth
and fractures of the maxillae. 7 Philadelphia: SS
White Manufacturing Co; 1907: 50-52.
3. McIntyre GT, Millett DT. Crown-root shape of the
permanent maxillary central incisor. Angle Orthod.
2003;73(6):710–715: Dec; PubMed PMID: 14719737.
4. Walkow TM, Peck S. Dental arch width in class II
division 2 deep-bite malocclusion. Am J Orthod
PMID: 12490871.
5. Linden van der. Development of the dentition.
Chicago: Quintessence Publishing Co. Inc; 1983.
6. Brezniak N, Arad A, Heller M, Dinbar A, Dinte A,
Wasserstein A. Pathognomonic cephalometric
characteristics of Angle class II division 2
malocclusion. Angle Orthod. 2002;72(3):251–257: Jun;
7. Ruf S, Pancherz H. Class II division 2 malocclusion:
genetics or environment? A case report of
monozygotic twins. Angle Orthod. 1999;69(4):321–324:
8. Arvystas MG. Reaction treatment of severe class II
division 2 malocclusions. Part 1. Am J Orthod
PMID: 2353681.
9. Arvystas MG. Nonextraction treatment of severe
class II, division 2 malocclusions Part 2. Am J Orthod
PMID: 1986530.
SECTION XII
Class III malocclusion
Chapter 58: Class III malocclusion in growing children

Chapter 59: Orthodontic treatment of borderline class III
malocclusion
CHAPTER 58
Class III malocclusion in growing
children
MA Darendeliler
O.P. Kharbanda
S. Karthik
CHAPTER OUTLINE
Introduction
Prevalence of skeletal class III malocclusion
Genetics
Environmental factors
Systemic factors
Epigenetic aetiology
Dental features
Functional examination
Management
Interception of malocclusion
Rationale for early treatment of developing class III
malocclusion
Management of pseudo class III malocclusion
Historical review of chin cup appliance
Functional appliances to correct class III malocclusion
Historical review
Appliance design and manipulation
Biomechanics of maxillary protraction
Skeletal and dental effects of facemask therapy
Treatment timing of protraction facemask therapy
Maxillary protraction and rapid palatal expansion
Retention
Stability and prognosis of maxillary protraction therapy
Bone anchored maxillary protraction (BAMP)
Maxillary protraction using skeletally anchored facemask
Maxillary protraction using skeletally anchored
intermaxillary elastics
Clinical recommendations
Micro-implant supported maxillary protraction
Hybrid Hyrax expander-facemask
Key Points
Introduction
Edward H. Angle in 1899 described class III malocclusion as
‘abnormal relation of the jaws, all the lower teeth occluded mesial to
the normal width of one bicuspid or even more in extreme cases’.1
With the advent of cephalometric radiography Angle’s classification
was extended to include abnormal skeletal jaw relationship where
class III malocclusion may exhibit a small maxilla, or prognathic
mandible or a combination (Fig. 58.1).
FIGURE 58.1 Remains of Al Qusais (1500–1200 BC).

This skeleton shows midface hypoplasia combined with mandibular
prognathism.
Jean Delaire, a French orthodontist, who worked extensively on the

growth of maxilla, class III malocclusion and its interception named
this condition as ‘syndrome prognathique mandibulaire’.2
The clinical presentation of class III malocclusion has a broad
spectrum, ranging from an edge-to-edge bite to a large negative
overjet, with extreme variations of underlying skeletal jaw bases, and
great diversity of craniofacial forms. The class III facial forms are
usually associated with a deformity extending deep into the cranial
structures. The soft tissue profile may show compensation in milder
forms of class III malocclusion with profile appearing as orthognathic
to mild concave. The facial profile would be truly concave in severe
forms of mandibular prognathism. The unbalanced skeletal growth of
the face, disturbance in functional occlusion and unique facial pattern
could lead to enormous psychosocial problems in patients suffering
from this deformity. Many young patients may be ignorant of the
deformity while others may seek treatment affected by the adverse
impact on their quality of life (Fig. 58.2A–B).
FIGURE 58.2 (A) Anterior cross-bite in deciduous dentition and

mesial step, the first indicator of a developing class III malocclusion. (B)
Anterior cross-bite in permanent anterior teeth and mesial step,
indicators of developing class III malocclusion.
Prevalence of skeletal class III
malocclusion
A systematic review reported a significant variation in prevalence of
skeletal class III malocclusion across various geographic regions and
ethnic groups (Table 58.1). Chinese and Malaysian groups show
higher mean prevalence rate of 15.69% and 16.59%, respectively.3 The
estimates of anterior cross-bite in Japanese population are 2.3% to
13%, and edge-to-edge relationships are 2.7%–7.4%. If the frequency
of occurrence of these two manifestations is combined, it can be
observed that a substantial percentage of the Japanese population
have characteristics of class III malocclusion.4 There has been an
increased prevalence rate reported in Middle Eastern countries
ranging from 1.3% to 15.2%. European countries demonstrate a
prevalence rate of 2%–6%. Indian population show a relatively lower
prevalence rate in comparison with the other racial groups.3
Table 58.1
Prevalence of class III malocclusion in different geographical areas

Author Population Prevalence rate
Hardy DK et al. (2012)3 Chinese 15.69%
Hardy DK et al. (2012)3 Malaysian 16.59%
Miyajima K et al. (1997)4 Japanese Anterior cross-bite—2.3% to 13%
Edge-to-edge bite—2.7% to 7.4%
Hardy DK et al. (2012)3 Middle eastern 1.3%–15.2%
Hardy DK et al. (2012)3 Europeans 2%–6%
Kharbanda et al. (1995)5 Indians North Indians—2.5%–3.4%
Singh SP et al. (2015)6 South Indians—2.1%–4.1%
Kelly JE et al. (1977)7 Caucasians European American—0.8%
African American—1.2%
The prevalence of class III malocclusion in the North Indian

population was reported to be 2.5% (Leh, age group of 10–18 years)6
and 3.4% (Delhi, age group of 10–13 years).5 In South Indian
population it was reported to be 2.1% (Karnataka, age group of 13–17
years)8 and 4.1% (Kerala, age group of 10–12 years).9 The prevalence
rate among the European American and African American
populations are estimated to be 0.8% and 1.2%, respectively in a 12–17
year age group population.7 Despite a lower prevalence of class III
malocclusion in Caucasian population, it has been reported that
approximately one-third of patients undergoing orthognathic surgery
present with this type of malocclusion.10 The importance of early
identification and possible orthopaedic correction should not be
overlooked.
The aetiology of class III malocclusion is complex and wide-ranging
and so is its spectrum of the craniofacial pattern. It can be broadly
grouped into genetic, environmental and gene-environment
interactions (Table 58.2).
Table 58.2

Genetic factors Environmental local factors
Both monogenic (commonly autosomal- Skeletal Dental Functional
dominant with incomplete penetrance) Maxillary Ectopic Macroglossia
and polygenic mode of inheritance transverse eruption of the and abnormal
discrepancy maxillary tongue position
central incisors Nasal
Early loss of obstruction
the deciduous Mouth
molars breathing
Neuromuscular
condition
Growth is affected by both genetic and environmental interaction producing a class III
phenotype. Mandibular prognathism is mainly genetic in nature and maxillary retrognathism is
the result of midface deficiency which is mainly environmental.
Genetics
It has been known for many years that the mandibular prognathism
has a significant familial trait. A well-known example of familial
inheritance pattern is the Hapsburg family, where 33 of the 40 family
members showed mandibular prognathism.11 Various genetic models
have been described, and it is assumed to have a multifactorial and
polygenic trait of transmission.12–14 However, monogenic
transmission by autosomal dominant inheritance with incomplete
penetrance has also been reported.15 A genetic study conducted
among parents of 24 children affected by severe class III pattern
showed that one-third of the group had a parent who presented with
the same malocclusion and one-sixth had an affected sibling. Similar
to the heritability of class III malocclusion, inheritance of the long face
pattern was also found between family members.12
Environmental factors
The local epigenetic factors include macroglossia, mouth-breathing
and enlarged tonsils (Fig. 58.3) leading to a forward shift of mandible
in response to functional demands.16,17 Normal development of
maxilla results not only from the movements of its constituent skeletal
units and structural remodelling but also from the development of the
anterolateral region which in turn depends upon the orofacial
functions.18 Excessive mandibular growth is also thought to result
from the forward mandibular posture, leading to condylar distraction
and growth.19 It should be noted that the natural head position
(relationship of head to the exact vertical) affects the cranial base
orientation. Raised natural head position produced class III effect and
it is related to degree of maxillary retrognathism. Although the
mandibular prognathism is related with natural head position, the
severity of prognathism is augmented by closing or opening rotation
of mandible which in turn is closely associated with natural head
posture (relationship of head to the cervical column).20
FIGURE 58.3 A young boy (A) with class III molar and canine
relations (B–D), has enlarged tonsils (E), obliterating oro-nasal
passages. The clinical examination shows an edge-to-edge bite (F),
however, he tends to occlude teeth in a most convenient way resulting
in a forward positioning of the mandible and deviation towards the right
side. Lateral cephalogram shows class III skeletal pattern with large
mandible (G) and small maxilla. PA cephalogram (H) shows a
discrepancy in the transverse widths of the maxilla and mandible
exhibiting bilateral cross-bite in the buccal region.
Systemic factors
The systemic factors include hormonal disturbances, syndromes
associated with premature synostosis of the cranial sutures restricting
maxillary growth. Apert’s and Crouzon syndrome are the common
examples.
Maxillary retrognathism is also seen in operated patients with cleft
lip and palate due to the scarring effect caused by surgical repair that
interferes with anteroposterior, transverse and vertical development
of maxilla.
Epigenetic aetiology
Class III malocclusion develops as a result of multiple factors that
interact during the morphogenetic growth period of the mandible. It
is likely that the skeletal morphology of the dentofacial complex is
dependent upon susceptibility genes involved in gene–environment
interactions resulting in a class III phenotype.14 However, it is
postulated that class III malocclusion due to mandibular prognathism
is mainly genetic in nature, whereas those associated with maxillary
hypoplasia is a result of environmental induction, which may also
include restraining effect of an inherited prognathic mandible
inhibiting maxillary forward growth (Fig. 58.4).21
FIGURE 58.4 Representation of gene-environmental interaction.

Mandibular growth is induced by both genetic and environmental
mechanisms, which interact with each other to produce the class III
phenotype. Source: Reproduced with permission from: Xue F, Wong
RW, Rabie AB. Genes, genetics, and Class III malocclusion. Orthod
Craniofac Res 2010;13(2):69–74.14
Class III malocclusion does not exist in a single form, but instead it is a
result of the various combination of skeletal and dentoalveolar
components, each responsible for the compound nature of this trait.
Ellis and McNamara found a combination of maxillary retrusion and
mandibular protrusion to be the most common skeletal relationship
(30%), followed by maxillary retrusion (19.5%) and mandibular
protrusion only (19.2%).22 However, studies have reported that
mandible is the strongest contributor to the skeletal manifestation of
class III malocclusion (45.2%, 49%11, 47.4%).23,24 It is further noted
that mandibular prognathism is mainly due to the positional
deviation of the mandible relative to the cranial base, whereas
maxillary retrognathism is primarily caused by inadequate length.25
There is a compensatory backwards rotation of the mandible, which
appears necessary to coordinate the occlusion relative to the small
maxilla.26 Different morphological studies on subjects with class III
malocclusion illustrate several common features like a short cranial
base with an acute saddle angle, a retrusive maxilla, a protrusive
mandible, proclined maxillary incisors and retroclined mandiular
incisors.27,28 Four different class III facial profiles have been described
(Fig. 58.5).29
FIGURE 58.5 Four different types of class III facial skeletal
profiles.
(A) Normal maxilla and mandibular prognathism. (B) Maxillary retrusion
and normal mandible. (C) Normal maxilla and mandible. (D) Maxillary
retrusion and mandibular prognathism. N, Nasion; FH, Frankfurt
horizontal plane; A, Point A; Pog, Pogonion. Source: based on Ngan P,
Hägg U, Yiu C, Merwin D, Wei SH. Soft tissue and dentoskeletal profile
changes associated with maxillary expansion and protraction headgear
treatment. Am J Orthod Dentofacial Orthop 1996;109(1):38–49 Jan,
Erratum in: Am J Orthod Dentofacial Orthop 1996 Apr;109(4):459.29
A new classification of class III malocclusion was proposed based

on cephalometric data and facial photographs of 120 subjects
belonging to Korean ethnicity. The patients were classified into three
categories as follows.30
Type A is true mandibular prognathism, which means that the
maxilla is normal, but the mandible is overgrown.
Type B is characteristic of the overgrown maxilla and mandible with
anterior cross-bite.
Type C indicates a hypo-plastic maxilla with anterior cross-bite.
Multivariate analyses such as discriminant analyses, principal
component analyses (PCA) and cluster analyses are being performed
to identify different phenotypic subgroups specific to the
population.31,32 These cluster analysis of different phenotypes can
guide in treatment planning and the evaluation of treatment effects
and find its application in genetic studies.
Ethnicity: Heterogeneity in craniofacial morphology between various
ethnic groups has been reported and is most likely determined by
genetic factors. Chinese subjects exhibit a shorter anterior cranial base,
a larger posterior cranial base, a smaller gonial angle, and an
increased mandibular length compared to Caucasians.32 Korean
population show a smaller anterior cranial base and midface
dimensions, exacerbated by a large and less favourable mandibular
morphology when compared with European–American children.
European–American children exhibit less flattening of the cranial base
and early closure of spheno-occipital synchondrosis resulting in less
apparent class III facial morphology.33 Japanese tend to have
maxillary skeletal retrusion, large posterior cranial base length and
increased lower anterior facial height whereas Americans show
mandibular prognathism, large anterior cranial base length and large
facial depth.26
Gender differences exist during craniofacial growth due to variations
in concentration of sex hormone particularly during the pubertal
growth spurt. A high testosterone/oestrogen ratio in puberty causes a
lateral growth of mandible and chin and the lengthening of the lower
face.34 Male subjects with class III malocclusion present with
significantly larger linear dimensions of the maxilla, mandible, and
anterior facial heights when compared with female subjects during the
circum-pubertal and post-pubertal periods.35 Sexual dimorphism was
also reported in growth pattern. The face of class III females show a
tendency for development in a more horizontal direction compared to
class III males, who show a more vertical direction of facial growth.36
A systematic way to diagnose class III malocclusion helps in
identifying the aetiology and critical factors that have to be considered
to formulate a treatment plan (Box 58.1).
• Extraoral features: Facial evaluation requires analysis of the

overall profile, chin position, maxillary and mandibular
position to differentiate between maxillary retrognathism,
mandibular prognathism or combination of both.37
• Profile evaluation: Skeletal class III patients with midface
deficiency present with a straight to concave profile.
Parameters on profile photographs can also aid as a diagnostic
tool. A soft tissue A’N’B’ angle of 6° is the critical value below
which it implies a skeletal class III malocclusion.38 Reduced
lower anterior facial height suggests over closure or forward
closure of mandible, which is evident in pseudo class III
malocclusion (Fig. 58.6).
• Chin position: The position of the chin relative to the nose and
upper face are evaluated by blocking out the upper and lower
lips. The position of the chin is also evaluated from a vertical
line extending from soft tissue nasion. It is important to
remember that facial convexity decreases as the patient
matures.
• Maxillary position: Lower lip and chin are blocked out to
accentuate the midface. There should be a convexity to the
shadow extending from the inferior border of the orbit,
through the alar base of the nose, down to the corner of the
mouth. A straight vertical shadow indicates a midface
deficiency. Upper lip length and upper lip support are
evaluated which gives an indication of midface deficiency.
The relationship of anterior cheek mass to the anterior corneal
plane has been used as an indicator of bony support along the
malar eminence.39
• Mandibular position: The presence, amount and direction of any
mandibular shift are significant in determining whether the
class III malocclusion is due to the maxilla or mandible. In
cases displaying a significant anterior mandibular shift, the
same facial evaluation should be performed with the
mandible in centric relation (Fig. 58.6).
• Facial asymmetry is frequently seen in patients with class III
deformity. It is often associated with posterior cross-bites. A
posterior cross-bite can be a consequence of constriction of
maxilla or merely the result of lower jaw deviation. Posterior
cross-bite with jaw deviation is usually accompanied by an
asymmetry of the shape of the TMJ and should be ruled out.
Box 58.1 Critical factors in diagnosis of growing

class III malocclusion
1. Cause of sagittal discrepancy

a. Skeletal, dentoalveolar or combination
2. If skeletal discrepancy is present
a. Maxillary retrognathism, mandibular prognathism,
combination
3. Associated vertical discrepancy
a. High angle or low angle
4. Associated transverse discrepancy
a. Maxillary or mandibular skeletal base or combination
b. Skeletal, dentoalveolar or combination
5. Severity of the deformity
a. Mild, moderate or severe
b. Presence/absence of functional shift
6. Underlying hereditary component
a. Family history of anterior cross-bite or class III
malocclusion
7. Remaining growth potential of maxillary and mandibular
component
a. Age and prediction of amount and direction of growth
FIGURE 58.6 (A) A patient with class III skeletal deformity exhibiting
exaggerated severity due to the habitual forward mandibular shift. (B)
When the mandible is guided into a centric relationship, an end-to-end
incisor relationship is present and represents the true skeletal base
relationship.
Orthopantomograph can be used to evaluate the symmetry of the

condyles. It is observed that in class III deformity, lower jaw presents
with more asymmetry than the upper jaw and left-sided facial
laterality occur more often than the right-sided deviation.40
Traditionally the combined use of posteroanterior, lateral, and sub-
mento vertex views for 3D evaluation of the maxillo-mandibular
structures are advocated. CBCT offers a great value in 3D evaluation
and substitute for the multiple x-rays. 3D photographs taken in a
natural head position allow for more precise measurement and
analysis of facial soft tissues.
Dental features
Patient presents with class III molar relation with or without negative
overjet. If a positive overjet or end-to-end incisor relationship is
found, together with retroclined mandibular incisors, a compensated
class III malocclusion is suspected. The diagnostic criteria of at least
two incisors in cross-bite or edge-to-edge with each other and a mean
canine mesiocclusion of at least a half-cusp width correlate relatively
higher with true class III sagittal molar relationship.41 If a negative
overjet is present, then the functional examination is performed to rule
out pseudo class III malocclusion.
The presence of a dental anterior cross-bite is not necessarily
indicative of an underlying skeletal class III problem. This anterior
dental relationship may be the result of a pre-maxillary dentoalveolar
deficiency or a functional problem where occlusal interferences create
an anterior shift of the mandible during closure. Upon elimination of
these interferences, which are mainly due to maxillary incisor
retroclination, the maxilla and mandible return to a normal class I
relationship. However, should it be left unattended a functional class
III malocclusion is likely to develop into a skeletal malocclusion.
Diagnostic characteristics of pseudo class III malocclusion were
identified in southern Chinese population after comparing 36 subjects
with pseudo class III malocclusion and 31 subjects with class I
malocclusion (Box 58.2).42 A diagnostic scheme was proposed to
differentiate between true and pseudo class III (Fig. 58.7).43
Box 58.2 Diagnostic criteria of pseudo class III

malocclusion
• Class III molar and canine relationships at habitual occlusion and

class I relationship at centric relation
• Decreased midface length
• Forward position of the mandible with normal mandibular length
and horizontal growth tendency
• Retroclined upper incisors and normal lower incisors
FIGURE 58.7 Diagnostic scheme to differentiate between true

and pseudo class III malocclusion.
CO, Centric occlusion; CR, centric relation.
Intermaxillary relations, as well as maxillary and mandibular incisors
contributing to class III malocclusion, can be confirmed using
cephalometric evaluation. However, during the diagnosis of class III
malocclusion in growing patients, cephalometric values can only
provide the relative contributions of skeletal and dental components
to the malocclusion, and neither jaw may be identified as the obvious
contributing factor to a class III malocclusion particularly in a young
child. Because of this variability, other factors, such as the overall
facial profile, chin position, maxillary position and mandibular
functional shift should also be considered.29 The important
cephalometric parameters to evaluate class III malocclusion are
represented (Fig. 58.8). In cases of class III malocclusion associated
with anterior functional shift two lateral cephalograms should be
taken, that is one at centric occlusion and another at centric relation
position as shown in Fig. 58.6. The rotational component and sliding
component are evaluated using these lateral cephalograms.
FIGURE 58.8 Linear and angular cephalometric parameters used

in the diagnosis of class III malocclusion.
Class III growth pattern is established early in life even before the pre-
pubertal stage. The class III discrepancy worsen with age and do not
essentially start in the later part of life.25,44 Due to the uncertainty of
the long-term stability of treated skeletal class III malocclusion, it is
important to identify potential predictors of class III growth pattern. If
prediction could be made before treatment, then the type and timing
of orthopaedic treatment could be modified, and the patient could be
informed regarding the future need for orthognathic surgery. The
positive family history and hereditary nature of malocclusion are good
indicators for potential severe class III patterns.
Growth prediction is difficult due to the greater individuality and
variation in craniofacial growth. Several attempts to predict growth
have been reported viz Ricketts’ arcial method, computerised growth
prediction and Johnston’s forecast grid.45,46
Bjork identified the seven structural signs of extreme mandibular
growth rotation related to the inclination of the condylar head, the
curvature of the mandibular canal, the shape of the lower border of
the mandible, the width of the symphysis, the interincisal angle, the
inter-molar angle, and the anterior lower face height.47 Later, the use
of symphyseal morphology to predict the direction of mandibular
growth was proposed. Mandibles that grew in an anterior direction
were associated with reduced height, increased depth, a small ratio
(height/depth), and a large angle of the symphysis. Symphysis
dimensions may continue to change until adulthood with male
subjects having a greater and later occurring change compared with
female subjects.48
Schulhof et al. calculated the sum of the deviations of molar
relationship, cranial deflection, porion location, and ramus position
from the norm with the Rocky mountain data system. If the sum of
deviations is greater than 4, it indicates increased mandibular
growth.49 With time, various cephalometric parameters were
introduced for the quantitative assessment of mandibular growth.
Franchi et al. used three variables that included inclination of the
condylar head, maxillary-mandibular vertical relationship (MP-PP)
and mandibular inter-molar width.50 Ghiz et al. used four variables
namely the position of condyle to cranial base, ramal length,
mandibular length, and gonial angle that can predict successful
outcomes with 95% degree of accuracy. However, these variables can
only predict unsuccessful outcomes with a 70% accuracy.51
Musich proposed the growth treatment response vector (GTRV)
analysis to predict the excessive mandibular growth after early
orthopaedic treatment.52 Ngan detailed the use of a growth treatment
response vector to predict whether patients who have had early
protraction facemask therapy in the mixed dentition will require
either a second phase of orthodontic camouflage or orthognathic
surgery. He suggested the use of serial cephalometric radiographs of
patients taken a few years (3–4 years) apart after facemask treatment.
GTRV analysis consists of the ratio of horizontal growth changes of
the maxilla to the horizontal growth changes of mandible measured
along the occlusal plane. The mean GTRV ratio for the successful
group was 0.49 ± 0.14 with a range of 0.33–0.88 and represented a
group that can be successfully camouflaged with orthodontic
treatment. The mean GTRV ratio for the unsuccessful group was 0.22
± 0.10 with a range of 0.06–0.38. The GTRV ratio below 0.38 should be
warned of the need for future orthognathic surgery (Fig. 58.9).53
FIGURE 58.9 Growth prediction of class III Malocclusion using
GTRV method as described by Ngan et al.53
A systematic review that analysed 38 different predictors of

treatment outcome (35 cephalometric parameters and 3 derived from
study casts) concluded that gonial angle was identified most
frequently combined with other predictors among the different
studies. The possibility of existence of universal predictor and
accurate prediction of the treatment outcome of class III malocclusion
is questionable.54
Management
1. Interception of the problem through dentofacial orthopaedics:
1.1. Appliances to restrain growth of the mandible
a. Chin cup with headgear
1.2. Appliances primarily directed for orthopaedic
effect on maxilla
b. Protraction facemask
1.3. Appliances that affect both the jaws by altering
growth
c. Functional appliances:
- Frankel FR III
- Reverse twin block
- Class III bionator
2. Camouflage treatment
3. Orthognathic surgery
Interception of malocclusion
Until the 1970s, treatment of class III malocclusions was mainly
directed towards the surgical correction of maxilla or mandible or
both. It was believed that these malocclusions were beyond the
boundaries of orthodontic and orthopaedic treatment.
Compared to the more convex class II profile favoured in the 1960s
and 1970s, fuller profiles have become more desirable in the
contemporary society. This change in perception has a significant
influence on orthodontic and orthognathic surgery treatment
objectives in the management of class II and III cases. As such, both
orthodontics and oral surgery specialities now prefer to bring the
maxilla forward in class III cases, and the mandible forward in class II
cases respectively, rather than create a retrusive profile.
Recent studies, however, have shown significant benefits of early
treatment in class III maxillary deficient patients with the use of
protraction headgear.55–57 In contrast, the long-term outcome of chin
cup therapy for mandibular prognathism was found to be
unsatisfactory.58,59
Rationale for early treatment of developing

class III malocclusion
The goals of early class III treatment are43
1. To prevent progressive, irreversible soft tissue and hard tissue

changes like abnormal wear of lower incisor, thinning of lower
anterior alveolar bone
2. To improve skeletal discrepancies and provide favourable
environment for future growth
3. To improve occlusal function, eliminate CR–CO discrepancy
and avoid adverse growth potential
4. To simplify phase II comprehensive treatment and minimise
the need for orthognathic surgery
5. To provide more pleasing facial aesthetics, thus improving the
psychosocial development of the child.
A recent multi-centric RCT study reported that early class III

protraction facemask treatment reduces the need for orthognathic
surgery from two-thirds (control group) to one-third (facemask
treated group) and early protraction facemask treatment does not
seem to confer a clinically significant psychosocial benefit.60
Turpin outlined the positive and negative factors that decide the
need to intercept a developing class III (Table 58.3). Early treatment
should be considered in patients who present with positive factors
and treatment can be delayed in patients showing negative factors.61
However, patients instituted with early treatment should be made
aware of the fact that surgery is the potential final treatment option
and may be required at a later date due to an unpredictable growth
pattern or relapse of early intervention.
Table 58.3
Factors to be considered to intercept class III malocclusion

Positive factors Negative factors
Good facial aesthetics Poor facial aesthetics
Mild skeletal disharmony Severe skeletal disharmony
Negative history of familial prognathism Established familial pattern
Presence of functional shift Absence of functional shift
CR–CO discrepancy No CR–CO discrepancy
Convergent facial types Divergent facial types
Symmetrical condylar growth Asymmetrical condylar growth
Good cooperation Poor cooperation
Management of pseudo class III malocclusion

Pseudo class III malocclusion is associated with anterior cross-bite as a
result of mandibular displacement. This functional shift of the
mandible accentuates the degree of the class III deformity. The
primary objective in such cases is to eliminate the functional shift. By
eliminating the CR–CO discrepancy, the negative forces on maxilla
are reduced. Earlier the forward positioning of the mandible is
corrected; the better will be the growth of both the maxilla and the
mandible.
Treatment is aimed at correcting the premature occlusal contacts,
that is usually the anterior dental cross-bite which can present in both
deciduous and permanent dentition. Intraoral appliances used to
correct non-skeletal cross-bites include:
• Catalan’s appliance (lower inclined bite plane) and tongue

blade
• Removable appliance using Z spring or expansion screw
exerting labial force on maxillary incisors
• Lingual arch with finger spring
• Fixed appliances in maxilla, most commonly 2 × 4 appliances.
In some cases, due to the premature contact, the patient deviates the
mandible in a forward posture to obtain a convenient occlusal bite.
This condition, if left untreated during growth period, could lead to
permanent alteration in the path of closure, facial asymmetry and
skeletal class III malocclusion. Removable functional appliances can
be used to redirect the altered path of closure. These appliances
provide proprioceptive stimuli that restrict the forward growth of
mandible and simultaneously assist in normalising the path of closure
and lateral deviation of the mandible. One such appliance is
Karwetsky modified U bow activator, which has a delicate influence
on the dentition and TMJ. There are three types of modification of this
appliance that are used in different clinical situations (Figs 58.10A–D).
FIGURE 58.10 (A) A young boy with functional forward and left shift
of the mandible resulting in anterior cross-bite and midline shift to the
left side. (B) Karwetsky U loop activator appliance. (C) The bite was
recorded in centric relation and Karwetsky U loop activator appliance
was given which rapidly corrected the cross-bite and centre line shift.
(D) Post-treatment photographs and radiographs. Pre- and post-
treatment cephalometric values are shown in the box.
Historical review of chin cup appliance

Attempts to restrain mandibular growth in patients exhibiting
mandibular prognathism date back to the beginning of orthodontics.
The first chin cup was used in 1802 by Cellier to correct jaw
dislocations. One year later Joseph Fox used chin cup in an attempt to
correct mandibular protrusion. Kingsley and Farrar used appliances
to restrain mandibular growth that resembles modern chin cup. The
early failure of treatment with the chin cup appliance was due to the
use of low force values that could not influence the condylar growth.
The lack of a clinical concept of growth guidance led to the use of
intermaxillary elastics to correct the skeletal class III malocclusion. In
early 1950s the conceptual change of the use of orthopaedic forces in
the range of 400–800 g reintroduced the chin cup appliance.62
Clinical aspects of chin cup therapy

Chin cup is advised in growing patients having true skeletal class III
malocclusion who lack maxillary recession, associated with acute
cranial base angle. Chin cup therapy is attempted when orthognathic
surgery is not an option.63 It can also be used along with upper
removable appliance to procline maxillary incisors where substantial
overbite can be achieved and mild to moderate skeletal discrepancy
can be camouflaged.64 Chin cup is also used to attain functional
occlusion after the first phase of treatment for growing class III
patients.65
The chin cup appliance can be used as occipital pull for patients
with mandibular protrusion, and in non-dolichofacial patients,
whereas high pull or combination of occipital and high pull chin cup
can be used in dolichofacial patients exhibiting steep mandibular
plane and excessive anterior facial height (Fig. 58.11A). The occipital
pull chin cup appliance is available in two forms. The soft chin cup
consists of a padded band extending coronally and a soft cup on the
chin with an elastic traction band connecting both components. In this
type the position of the head cap determines the direction of the force.
The hard chin cup type consists of padded bands extending coronally
and cervically and a hard chin cup anchoring on chin. These are
connected using a Hickman type headgear (force guide) placed in
front of the ear. The hard cup can be custom made for achieving a
better fit of appliance. The direction of the force is adjustable
according to the placement of the elastics between the chin cup and
the Hickman type force guide.
FIGURE 58.11 Various appliances to intercept the developing
(A) Chin cup appliance. (B) Frankel functional regulator III appliance.
(C) Reverse twin block appliance. (D) Class III bionator appliance.
Evidence suggests that the morphologic pattern of the prognathic

face with excessive forward mandibular growth is most likely to es-
tablish early in life. Hence the treatment of mandibular protrusion is
more successful when it is started in the primary or early mixed
dentition stage. The treatment time varies from 1 year to as long as 4
years, depending on the severity of the malocclusion.63,66 Gender
should be considered since females mature earlier than males. The
light-force (125–250 g) does not produce significant orthopaedic
change in the mandible.67 The suggested force at the centre of the chin
cup ranges from 300–600 g/side for 12–14 h/day. It is recommended to
be worn particularly during sleep to avoid injury to the inter-articular
disk. Otherwise, there is a higher risk of dislocating the disc at the
joint if worn during functional activity like speech and
mastication.63,66
Biomechanics of chin cup therapy

The mechanism by which chin cup treatment acts on growing
mandible have always remained controversial. Following mechanisms
are reported in the literature.68
1. Re-direction of mandibular growth at the chin

2. Backwards repositioning of the mandible
3. Retardation of mandibular growth at the condyle
4. Remodelling of mandibular morphology at the gonial angle
and symphysis
5. Concomitant remodelling at TMJ.
There are two main approaches to the occipital pull chin cup
therapy according to the direction of force against the mandible. In the
first approach, the force is aimed directly at the condylar area to
impede mandibular growth. In the second approach, the force is
aimed below the condyle to produce a clockwise rotation of the
mandible causing a decrease of the prominence of the chin exchanged
with an increase of the anterior facial height.17
The FEM studies showed that the force vector passing through the
condylar head induced little or no stress with clockwise rotation of the
mandible to produce favourable changes for most class III patients
with neutral or anterior growth rotation. The force vectors passing
through the coronoid process or anterior to coronoid process
produced higher stress levels and induced displacements in the
counter clockwise direction that might be favourable mainly for open
bite patients with no class III tendency.69
Treatment effects
Short-term application of occipital pull-chin cup result in a significant
decrease in SNB angle leading to an improvement in ANB angle
values. This seems to be contributed by a clockwise rotation of
mandible and to some extent restriction/redirection of the mandibular
growth. There is an increase in lower anterior facial height due to the
clockwise mandibular rotation. The closure of the gonial angle is
widely reported in the literature due to remodelling effects making it
more obtuse. Dental effects include upper incisor protrusion and
lower incisor retrusion resulting in increased overjet.70–72 Soft tissue
changes accompany the underlying skeletal and dentoalveolar tissue
changes. Significant reductions in the facial convexity angle and lower
lip inclination, causes improvement in the soft tissue facial profile.72,73
A short-term study has shown no adverse effects on pharyn-geal
airway passage, which is expected to reduce with a backward and
downward rotation of mandible.74 Long-term treatment, with chin
cup resulted in a significant inhibition of the vertical growth of the
ramus and body length of the mandible, remodelling of mandible and
TMJ, closure of the gonial angle. There are no changes observed in the
maxilla and the cranial base with use of chin cup appliance.75
Effects of chin cup therapy on TMJ

Chin cup therapy is most frequently cited as a cause of
temporomandibular disorder (TMD). It is claimed that the retracting
force on TMJ directed from the chin to the condyle may cause internal
derangement of the TMJ. Stresses from the chin cup radiate in a
postero-superior direction and get concentrated at the neck of the
condyle, which is most responsive to orthopaedic forces on the
mandible. The condylar head angle (angle between the condyle and
collum) is shown to decrease due to the forward bending of condylar
head.76,77 The expected upward and backwards movement of the
condyle is opposed by the horizontal portion of the
temporomandibular ligament that acts as a ‘safety belt’ mechanism. A
recent systematic review concluded that despite the craniofacial
adaptations induced by chin cup in patients with class III
malocclusion, it does not constitute a risk factor for the development
of TMD. There may be other factors that should be taken into
consideration. Age related peak (20 and 45 years of age) in occurrence
of TMD is reported particularly in females due to emotional factors
and stressful lifestyle.78
Stability of chin cup therapy

The soft tissue shows general improvement in the facial profile, along
with accompanying skeletal and dentoalveolar changes, but with an
uncertain long-term stability.72 Animal studies have shown that there
is a decrease in the activity of pre-chondroblastic layer of the condylar
cartilage resulting in a decreased bone formation at the condyle. It
was suspected that the release of compressive forces before growth
completion, stimulated condylar growth.65,68 This shows that the
mandible attempts to recover the size that was originally determined
morpho-genetically until the growth terminates.
The pre-treatment facial and skeletal profile, severity of
anteroposterior jaw discrepancy, type of mandibular rotation and
displacement and degree of forward growth of the mandible
determine treatment stability. A steeper mandibular plane, occlusal
plane, a more vertical profile and obtuse gonial angle contributing to
vertical characteristics of the facial profile were observed in the
relapse group.79–81
Clinical recommendation
Chin cup should be advocated only after proper diagnosis and after
assessing the desirable force of action. The growth status along with
pattern and compliance of the patient should be considered. It is
advisable to continue the chin cup therapy until growth is complete.
Temporomandibular joint function should be assessed before and
during active treatment. The remaining mandibular growth may lead
to a skeletal class III relations, which could necessitate orthognathic
surgery.
Current thoughts on chin cup therapy are controversial and in general it is
considered ineffective in long-term and is no longer considered a primary
treatment modality in the interception of the growing mandible.
Functional appliances to correct class III

malocclusion
Functional appliances are used in both orthopaedic and orthodontic
correction of class III malocclusion. The effects of functional
appliances in class III corrections are primarily dentoalveolar. An
ideal case for a functional appliance is the one having a mild to
moderate skeletal class III relationship, average to reduced anterior
facial height, pseudo class III with a functional shift of mandible, and
minimal incisor compensation. A functional appliance is also used as
a retention appliance following facemask therapy during the growing
stage (Fig. 58.11A–D).
Frankel functional regulator III appliance
Indications
The functional regulator type III (FR III) by Rolf Frankel appliance is
indicated in growing patients particularly during the late deciduous
or early mixed dentition stage (CS 1 in skeletal maturation). The
patients with mild maxillary deficiency and/or mandibular forward
shift, who are willing to wear the appliance for a long time, are
expected to benefit from it.
FR III design
The FR III appliance is composed of wire and acrylic, with four acrylic
parts. Two upper labial pads are positioned in the labial vestibule
above the maxillary incisors, which are used to eliminate the
restrictive pressure of the upper lip on the under developed maxilla.
Two vestibular shields extend from the depth of the mandibular
vestibule to the height of the maxillary vestibule that stimulates labial
alveolar bone apposition by stretching the adjacent periosteum. The
vestibular shields are placed approximately 2 mm away from the
alveolar buccal plates of the maxilla that eliminate the restrictive
forces created by the buccinators and the associated facial muscles and
fitted as closely to the alveolar process of the mandible as possible to
hold or redirect growth posteriorly (Fig. 58.11B).82
Bite recording
The wax bite is recorded with the mandible gently guided posteriorly
to the centric relation position. It is necessary to allow 1–2 mm of
interocclusal space in the molar region to accommodate occlusal rests
and crossover wire. In cases with an anterior open bite, only 1 mm of
vertical bite-opening in the posterior region is necessary.82
Treatment effects
FR III appliance is reported to cause a decrease in SNB and increase in
ANB angle along with dental effects like linguoversion of the
mandibular incisors. The downward and backwards rotation of the
mandible is largely attributed to the correction of class III
malocclusion. Long-term studies showed a significant change in
maxillary size and position with modification in mandibular
morphology, closure at the gonial angle and associated closure of the
mandibular plane angle.83 The forward displacement of the maxillary
complex has not been shown consistently in literature. This was
further supported by the systematic review which concluded that FR
III appliance restricts mandibular growth and weak evidence against
the forward movement of maxilla.84
Reverse twin block appliance
William Clark described a modification of twin block appliance for
correction of skeletal class III malocclusion in which the lower block
occludes distal to the upper block. The proposed mode of action of the
class III twin block is that the reverse angulation of blocks harnesses
the occlusal forces to advance the maxilla and maxillary dentition
while using the mandible as an anchorage and restricting its
development (Fig. 58.11C).85
Bite recording
A construction bite is recorded with mandible in maximum retrusive
position leaving sufficient clearance between the posterior teeth for
the occlusal bite blocks (Fig. 58.11D). Two mm interincisal clearance is
given for this purpose. In patients with reduced lower anterior facial
height, the bite is recorded with 4 mm interincisal clearance. The
appliance is constructed with heat cure acrylic with Adams’ clasps
placed on first molars and interproximal ball-ended claps for
retention. The upper and lower inclined bite planes are at 70° to the
occlusal plane configured in reverse of the conventional twin block. A
midline expansion screw can be incorporated into the upper
component in case of a constricted upper arch and to permit arch
coordination. An alternative design uses a three-way expansion screw
to combine transverse and sagittal expansion. Opening the screw
applies a distal force on upper molars which are resisted by occlusion
of the lower bite blocks on the reverse inclined planes. Therefore, the
net effect of opening the screws is a forward driving force on the
upper dental arch. A lower labial bow can be incorporated to control
the position of the lower anterior segment. The addition of acrylic to
the inclined planes may be necessary to increase the forces over the
maxilla and mandible to establish a positive overjet. Lip pads may be
added to support the upper lip to enhance the forward movement of
the upper labial segment, an action similar to that of the Frankel III
appliance.85,86
Treatment effects
The primary effect of the RTB appliance appears to be dentoalveolar.
Analysis of cases following full time wear of RTB appliance for 6
months showed proclination of the maxillary incisors and
retroclination of the mandibular incisors, downward and backward
mandibular rotation with a concomitant increase in lower facial height
and a relative reduction of mandibular prognathism.87 Comparison
between protraction facemask and RTB therapy revealed RTB
appliance-induced the greater dentoalveolar changes. When
compared with untreated controls, RTB was found to exert no skeletal
effects on maxilla.88
Historical review
The use of protraction facemask was first described in 1875 by
Potpeschnigg.89 In 1944, Oppenheim reported that when the growth
of the mandible was uncontrollable it was possible to bring the
maxilla forward to compensate for mandibular overgrowth.90 Haas
(1970) demonstrated a forward and downward movement of maxilla
as a result of palatal expansion.91 In 1971, Delaire revived the interest
in maxillary protraction and designed an appliance that had
incorporated chin cup, forehead support and an inter-labial bow with
spurs for attachment of elastics.92 This concept was then utilised by
Petit (1983) by using heavier forces and reduced the treatment time.93
In 1987, McNamara used a bonded expansion appliance with acrylic
coverage in conjunction with facemask appliance (Fig. 58.12).94
FIGURE 58.12 Types of facemask appliance.
(A) Delaire’s facemask. (B) Petit facemask.
Experimental studies on primates demonstrated that the application

of an orthopaedic force to the maxilla caused its separation from the
pterygoid plates and the maxilla was repositioned anteriorly as a
result of sutural modification. It was also observed that force variables
play an important role in attainment of desired change in the position
of mid-facial bones.95–97
Appliance design and manipulation

There are many varieties of maxillary protraction appliances that
differ in the biomechanics of force application and the area of
anchorage reinforcement (Table 58.4).
• Delaire’s facemask consists of two pads that take anchorage

from forehead and chin region. The pads are connected by a
square metal framework that is adjustable. An adjustable
anterior wire with hooks is also connected to the framework
to accommodate a downward and forward pull on the maxilla
with elastics (Fig. 58.12A).98
• Petit facemask consists of two pads that contact the soft tissue
in the forehead and chin regions. The pads are connected by a
midline framework made of stainless steel and in the centre of
the midline framework is a cross-bar that has attachments for
engaging elastics (Fig. 58.12 B).93
• Duane Grummons claimed that reverse pull headgear might
have harmful effects on the TMJ and supported
disengagement of the mandible during maxillary protraction.
He introduced a new appliance that uses the zygomatic region
as an anchorage unit for maxillary protraction and consists of
a forehead support, two sub-orbital pads and a metal frame.99
Table 58.4
Different types of maxillary protraction appliances

Anchorage area Types of facemask appliance
1. Forehead and chin Delaire facemask
Petit facemask
Turley facemask
Tubinger modification
Nanda protraction head gear
Maxillary modified protraction headgear
2. Forehead and zygomatic region Grummons facemask
3. Top of head and chin Hickham reverse pull headgear
4. Chin Mini maxillary protraction device
Nanda introduced a modified protraction headgear face bow which

is a combination of the facemask appliance and a modified headgear
that is used instead of intraoral elastics.100 Some authors prefer using
a custom-made appliance which is durable, comfortable, aesthetic,
better patient cooperation because it is made individually for each
patient. For example, Turley modification37 and maxillary modified
protraction headgear, for use in class III patients with maxillary
hypoplasia and anterior open bite tendency.101 Other modifications
include Tubinger model which consists of para-nasal rod for patient
comfort,102 Hickham reverse pull headgear that uses the top of head
and chin for anchorage,103 a mini maxillary protraction device where
only the chin is used as an extraoral anchorage unit.104
Intra-oral components consist of a maxillary splint which is either
banded or bonded to the dental arch. A banded design with a wire
framework extending around maxillary arch from the first molar on
one side to the first molar on other side was in use for quite some
time. However, it has limited use in deciduous and mixed dentition.
In contrast, a bonded protraction and expander may be used at any
stage of the dentition and during the late mixed phase where there is
adequate root length of deciduous molars and canines to provide the
necessary anchorage. The bonded appliance design is also
recommended for use in the permanent dentition because of its
practicality in both the clinic and laboratory. The need for the
placement and removal of separation elastics, band adaptation and
transferal, precision wire bending and soldering is eliminated. The
design of the appliance is extremely critical; the acrylic component of
the plate should cover the crowns of the teeth, leaving only 1 mm of
clearance at the gingival margins along the buccal and palatal aspects.
This ensures a maximum surface area for retention and sufficient
clearance at the gingival margins to allow maintenance of a good oral
hygiene. The acrylic extensions should have a chamfer finish to
minimise food retention. Acrylic occlusal coverage does not need to be
more than 1–2 mm in thickness, and holes should be drilled into it to
allow excessive cement to escape. With the introduction of
contemporary glass ionomer cement, the retention of bonded
expanders has improved significantly, and there is no longer a need to
use composite or acrylic-based materials that require acid-etching
procedures (Fig. 58.15).
Studies have shown that irrespective of the type of anchorage, that
is either banded or bonded appliance, the maxillary expansion and
protraction was accompanied by a significant expansion of maxillary
arch, vertical displacement of the maxilla, increase in lower face
height, vertical eruption and mesialisation of posterior molars.105
Biomechanics of maxillary protraction

Studies in non-human primates have shown that protraction forces
applied through facemask produce a significant tension in the circum-
maxillary sutures resulting in bone formation at the cartilaginous
suture area and anterior displacement of the maxillary complex.96,97
The sutures associated with maximum stress with protraction force
are the spheno-zygomatic, followed by the zygomatico-maxillary and
the zygomatico-temporal sutures. High stresses after maxillary
protraction with expansion are found mainly in the naso-maxillary,
fronto-nasal and fronto-maxillary sutures and superior part of the
pterygomaxillary region. These high stresses generated after maxillary
protraction with expansion are responsible for disrupting the circum-
maxillary sutural system and presumably facilitating the orthopaedic
effect of the facemask.106 It has been shown that by varying the force
magnitude, direction and point of application of force, the amount
and direction of maxillary rotation can be controlled (Fig. 58.13).107
1. The direction of force: The importance of directing the line of

protraction force through the centre of resistance of the maxilla
to allow translatory movement has been suggested.
Holographic interferometry on dried skulls has located the
centre of resistance of the maxilla on a line passing through the
distal contact of the maxillary first molar, perpendicular to the
functional occlusal plane and half the distance between the
latter and the inferior border of the orbit.107 This point is
coincident with the line of force at the level of 15 mm above
and directed 20–30° below the occlusal plane. To minimise the
counter-clockwise rotation produced by the protraction forces,
the point of force application should be at the canine
region.108,109 Varying the direction and point of force
application could control the amount of maxillary rotation and
translation. Experimental studies have shown that protraction
force parallel to occlusal plane and 5 mm above the palatal
plane or 15 mm above the occlusal plane produce a
combination of parallel forward movement and a very slight
anterior rotation (upward) of the maxilla. The forces at the
level of maxillary arch produce forward movement and
anterior rotation (upward) of maxilla. The lower the point of
application, the greater the magnitude of the resultant upward
rotation of maxilla. Protraction forces caused constriction of
the anterior maxilla. Protraction along with palatal expansion
is recommended to compensate for this constriction. Hence,
the vertical facial height of individual patient should be taken
into consideration while selecting the force direction and
intraoral site of force application.109–111
2. Optimal force and time of wear of appliance: According to the
recent systematic review112 that included 14 published articles,
the force magnitude ranging from 180 to 800 g per side were
used in force vector direction between 20 and 30° below the
occlusal plane or parallel to the occlusal plane, and a duration
ranging from 10 to 24 h of use per day. This systematic review
concludes:
FIGURE 58.13 (A) Conventional facemask appliance representing
level, location and direction of force in relation to plane of occlusion. (B)
Delaire facemask in situ.
If the optimal force is the smallest force that produces the greatest
amount of skeletal movement with the least amount of dental
movement, then it is more efficient to use 300–400 g of force. It
produces, a similar effect as that provided by greater forces, without
the biological wear and tear caused by greater forces.
With 16 h of use, there was more significant maxillary protraction
with minimal dental effects, which is similar when using the
appliance for 24 h. Hence it is suggested that the facemask should be
used 14–16 h a day (Box 58.4).
Skeletal and dental effects of facemask
therapy
Positive skeletal and dental changes have been demonstrated with the
use of the protraction facemask for class III correction. The short-term
changes are summarised as under: (Box 58.3)
Box 58.3 Short-term effects of facemask therapy
• Forward displacement of maxilla

• Counter-clockwise rotation of maxilla
• Downward and backward rotation of mandible
• Restriction on growth of mandible
• Increased anterior facial height
• Proclination of maxillary incisors
• Extrusion and forward movement of maxillary molars
• Retroclination of lower incisors
• Forward movement of upper lip and retrusion of lower lip
• Increase in facial convexity due to protrusion of upper lip and
downward movement of soft tissue chin
Cephalometric studies have shown an increase in SNA angle,

decrease in SNB angle with an overall improvement in ANB angle and
WITS appraisal. A prospective clinical trial was conducted in Chinese
children with a mean age of 8.4 ± 1.8 years to determine cephalometric
and occlusal changes following maxillary protraction with
expansion.108,113 Patients were observed for 6 months before
commencement of treatment, to evaluate skeletal and dental changes
due to growth. During a mean treatment time of 8 ± 3 months, the
maxilla moved forward by an average of 2.1 mm and the overjet
increased by 5.5 mm. These changes were found to be stable at 2 years
post-treatment, with positive overjet maintained in 90% of patients.
During this period, a continued forward movement of the maxilla
occurred at a greater rate than controls, possibly due to increased
sutural activity at the posterior aspect of the maxilla and the presence
of an overbite. Maxillary incisors continued to procline to compensate
for differential maxillo-mandibular growth in the treatment group,
while mandibular incisors continued to retrocline in the control group
due to a negative overjet. Change in palatal plane orientation was
transient, but the occlusal plane continued to rotate upward due to
molar extrusion and maxillary incisor proclination.113 During the 4-
year observation period, 15 of the 20 patients maintained a positive
overjet or edge-to-edge relationship. Both skeletal and dental changes
were similar to the controls between the second and fourth years after
treatment.108
A forward and downward movement of the maxillary complex and
the backwards and downward movement of the mandible contributes
to treatment outcome. A greater amount of forward displacement of
the maxilla was obtained when protraction was carried out in
conjunction with a rapid expansion appliance; the average sagittal
skeletal correction of the maxilla was 2.0 mm with maxillary
expansion and only 0.9 mm without expansion. This has been
attributed to the mobilisation of the maxillary sutures leading to an
increased response to mesially directed extraoral forces.114
A prospective three dimensional cephalometric analysis was
performed on twenty growing children in the age group of 7–13 years
who were treated with RME/ facemask therapy for an average period
of 6.37 ± 2 months. It showed a significant increase in the
anteroposterior dimension of maxilla when measured mid-sagittally
from ANS to PNS (mean: 1.12 mm) and bilaterally from the right and
left tuberosity posteriorly to ANS anteriorly (mean: 2.03 mm). There
was a significant displacement of maxilla as shown by increased
distance between right and left zygomatico-maxillary suture and Sella
(mean: 2.2 mm) and counter clockwise rotation of palatal plane (−1.2°).
There was also an increase in transverse maxillary dimension as
shown by an increase in inter jugular distance (2.8 mm) which can be
attributed to the skeletal effects of RME. Mandibular skeletal changes
showed a significant clockwise rotation (SNB: −2.3°, FMA: 2.2°) and an
overall increase in lower anterior facial height (ANS-Me: 2.2 mm). The
overjet correction also occurred due to dentoalveolar compensation
along with alveolar bone thinning on the labial surface of maxillary
incisors and lingual surface of lower incisors.115
Effects of facemask therapy on soft tissue

Ngan attributed the forward movement of the maxilla with a
corresponding increase (50%–79%) in the soft tissues of the upper lip.
He also attributed the movement of the mandible to a reduction (71%–
81%) in the soft tissues of the lower lip.29 The facemask therapy also
tends to reduce the concavity of the profile by a forward movement of
the upper lip, backwards repositioning of the soft tissue pogonion and
slight inhibition of anterior migration of the lower lip. The effects of
this treatment were found to be more marked in the upper lip area.116
Effects of facemask therapy on airway

The cephalometric studies revealed that RME and protraction
facemask therapy showed improvement in nasopharyngeal airway
but not the oro-pharyngeal dimensions in the short term.117 A
prospective three dimensional study carried out on nine patient
revealed that RME and maxillary protraction does not have any
significant effect on the size of the nasopharyngeal airway. However,
there was a significant decrease in oro-pharyngeal volume in the short
term. It was concluded that the structural narrowing of pharynx due
to backwards rotation of mandible could be the reason for a
significant reduction in oro-pharyngeal volume.118 These results were
supported by another short-term 3D study which reported that
RME/FM treatment inhibited the normal increase in the volume of the
pharynx when compared with a control group.119 It was also shown
that there was a significant increase in the maxillary sinus volume.
Another prospective study on evaluation of changes in maxillary air
sinus volume following RME/FM treatment in 12 patients using 3D
CBCT has shown that there was an increase in volume and depth of
both the maxillary sinuses. However, it is to be noted that these
changes may be due to the general somatic growth that occurred
during the treatment period which needs to be differentiated from the
effects of protraction therapy.120
Effects of facemask therapy on TMJ

A mathematical model showed that 70%–75% of the orthopaedic
forces used to protract maxilla is transmitted to the TMJ.121 Studies
have revealed that facemask therapy resulted in bone remodelling of
glenoid fossa causing an upward and backwards displacement of the
condyle.122,123 It has been demonstrated that the reciprocal force from
maxillary protraction was transmitted to the TMJ, but this did not
have an increase in muscle pain or activity. Therefore, protraction
facemask treatment does not have any untoward effect on the TMJ.124
There is no evidence to the theoretical risk of a reciprocal downward
and backward force at the chin during the protraction facemask
treatment.125
Treatment timing of protraction facemask

therapy
1. Facemask therapy should be started at an early age for more
orthopedic changes.56, 126, 127
In a study on three groups treated with facemask, a significant
difference existed between three different age groups of class
III children: 4–7, 7–10 and 10–14 years, treated with expan-sion
and facemask therapy. The greatest amount of maxillary
change was observed in the 4–7 year age group, with forward
movement on an average of 4.31 mm.56
2. It is recommended that the tim-ing of facemask therapy should
correspond to the eruption of the maxillary permanent central
incisors and permanent first molars. This ensures a maximum
vertical overlap of the permanent upper and lower central
incisors at the end of facial mask treatment which is critical in
maintaining the corrected class III malocclusion during the
transition to the permanent dentition. The permanent
maxillary first molars provide better anchorage for
conventional bonded Hyrax assisted maxillary
protraction.94,108
3. Early class III protraction facemask treatment reduces the need
for orthognathic surgery from two-thirds (control group) to
one-third (protraction group).60
4. According to a recent systematic review there is a moderate
evidence to show that treatment at 7–12 years of age with a
facemask resulted in posi-tive improvements in both skeletal
and dental changes in the short term (Fig. 58.14).128
FIGURE 58.14 (i) Class III malocclusion in deciduous dentition
successfully treated with facemask therapy. (A) Pre-treatment
occlusion, (B) RME cemented in place. Note hooks soldered to wire
framework embedded in acrylic. The child wearing a Petit facemask,
(C) After correction with facemask, (D) During retention. (ii) Profile and
cephalometric changes of the patient. (A) Pre-treatment. (B) Post-
treatment stage. (C) One-year follow-up stage.
Maxillary protraction and rapid palatal

expansion
Maxillary expansion has been used concomitantly with maxillary
protraction therapy (Box 58.4). It is hypothesised that protraction of
maxilla along with expansion leads to disarticulation of the maxilla
and more forward displacement of maxilla than with protraction
alone. Haas reported that maxillary expansion alone often causes the
maxilla to advance and drop vertically rotating the mandible
downward and backward.91 A maxillary expansion with bonded
Hyrax appliance causes a spontaneous improvement of the class III
tendency to class I.129 Other effects of rapid maxillary expansion along
with maxillary protraction therapy include:130
• Increase in transverse dimension of maxilla to correct posterior

cross-bite
• Increase in maxillary arch length
• Splinting of the maxillary dentition
• Compensate for anterior constriction during protraction
therapy
• Backwards and downward rotation of the mandible and
increase in lower face height.
Box 58.4 Conventional expansion protocol

Hyrax maxillary expander
• Activation schedule: one quarter turn twice daily

• Rate of expansion: 0.25 mm per turn (0.5 mm/day)
• Time period: 8–10 days. In case of arch constriction expansion is
continued until palatal cusps of the maxillary posterior teeth
approximate the buccal cusps of the mandibular posterior teeth
• Follow up visits—Immediately after expansion schedule is
completed
A meta-analysis of 14 published studies concluded that there were

no distinct differences between treatments, with or without palatal
expansion, except for maxillary incisor angulation, which increased
2.81° in the non-expansion treatment group and an average duration
of treatment was longer in the non-expansion group.131 Other
systematic reviews reported that the amount of protraction of the
midface was not affected by preliminary rapid palatal
expansion.132,133 So the use of rapid palatal expansion should be
primarily determined by dentoalveolar abnormalities in the transverse
dimension (Fig. 58.15).134
FIGURE 58.15 Bonded Hyrax appliance.
(A and B). Before expansion, (C and D). After expansion. Clinically
evident midline diastema and opening of mid palatal suture seen in the
maxillary occlusal X-ray.
Fig. 58.16i–v describes a case treated with rapid maxillary

expansion, and facemask therapy followed by reverse hybrid bionator
and finished with fixed appliance. The protocol used for expansion
and maxillary protraction is described in Box 58.5.
FIGURE 58.16 (i) Class III malocclusion in mixed dentition stage
successfully treated with facemask therapy. (A and B). Pre-treatment
records. (ii) (A and C) After expansion protocol for 8 days. (B) Patient
wearing Delaire’s facemask. (D and E) After correction with facemask.
(F and G) During retention using bionator and chin cup appliance. (H)
Fixed appliance treatment for occlusal settling. (iii) (A and B) Two
dimensional & Three-dimensional changes with maxillary protraction.
(C) Steiner’s superimposition on cranial base. (D) Ricketts’ 5-point
superimposition method showing regional skeletal and dental changes.
(iv) Post-treatment records after fixed appliance therapy showing well
settled occlusion. Pre-, mid- (after maxillary protraction) and post-
treatment (after debonding) cephalometric values are shown in the box.
(v) (A) Pre-treatment extraoral and intraoral photographs. (B) One-year
follow-up extraoral and intraoral photographs.
Box 58.5 Conventional bonded RME/and facemask
protocol
Expansion is confirmed clinically and in maxillary occlusal X-ray.
Maxillary protraction is started immediately after expansion.
Delaire facemask
• Force application: 400–450 g/side measured using Dontrix gauge

or Correx gauge.
• Sequence of elastics wear: Extraoral elastics of increasing strength
are used. Initially 3/8”, 8 oz elastics for 1–2 weeks (training
elastics) followed by 1/2”, 14 oz or 5/16”, 14 oz elastics generating
400–450 g of force.
• Direction of force: 15 mm above and 20–30° below occlusal plane
• Schedule of facemask wear: 14 h/day
• Duration of treatment: Achievement of positive overjet, clinically
apparent class I skeletal relationship and dental class I or class II
molar relation. Overcorrection is recommended.
• Retention protocol: The same bonded RME appliance can be used
as removable retainer for a week until a removable functional
appliance is fabricated. Simultaneously a chin cup appliance
(night time wear) can be used if required until the cessation of
mandibular growth followed by fixed appliance to settle the
occlusion.
• Caution: Elastics could be crossed over to prevent catching or
interference with the corners of the lips.
Maxillary protraction with Alt-RAMEC

Liou developed the Alt-RAMEC protocol that mimicked distraction
osteogenesis, resulting in effective disarticulation without over
expanding the dental arch. It can be used both in cleft and non-cleft
patients. He used a special double hinged expander (Fig. 58.17) which
was placed such that the centre of rotation can be located near the
maxillary tuberosity, thereby enhancing the forward movement of the
maxilla. The Hyrax expander can also be used instead of special hinge
screw. However, double-hinged expander has been revealed superior
to the other types of expander for anterior displacement (Fig. 58.18).
The Alt-RAMEC protocol requires maxillary expansion 1 mm per day
for 7 days followed by constriction of maxilla by 1 mm per day for
another 7 days. This cycle was repeated for 7–9 weeks, and then the
maxilla was protracted using either fixed intraoral ®-Ti maxillary
protraction spring or conventional facemask with extraoral elastics
(Box 58.6). The ®-Ti maxillary protraction spring causes upward tilting
of palatal plane and downward rotation of mandible resulting in bite
opening. Hence it is contraindicated in patients with high mandibular
plane angle or anterior open bite. It has been shown that for growing
patients with cleft lip and palate the amount of maxillary protraction
was 5.8 ± 2.3 mm in 3 months (2 months of Alt-RAMEC followed by
one month of protraction) by using ®-Ti maxillary protraction spring
and results were stable after 2 years.135,136 Studies have shown that
Alt-RAMEC with facemask therapy results in a more forward
movement of maxilla than the normal RME facemask protocol
alone.137–139 It is not necessary to wait for maxillary protraction until
completion of the Alt-RAMEC procedure. Facemask treatment can be
started simultaneously along with expansion protocol.140 It was
reported; however, that the Alt-RAMEC group was less compliant
than the rapid maxillary expansion group.141
FIGURE 58.17 (A and B) Double-hinged expander, (C and D).
Intraoral ®-Ti maxillary protraction spring. Source: Reproduced with
permission from: Liou E. Interview. Rev Dent Press Ortodon Ortop
Facial 2009;14:27–37.142
FIGURE 58.18 Illustration of the postulated maxillary
displacement after rapid maxillary expansion.
(A) The maxilla before expansion. (B) Posterior displacement of the
maxilla after expansion by a Hyrax expander. (C) Anterior displacement
of the maxilla after expansion by a Hyrax expander. (D) Anterior
displacement of the maxilla after expansion by a double-hinged
expander. Source: Reproduced with permission from: Liou E. Interview.
Rev Dent Press Ortodon Ortop Facial 2009;14:27–37.142
Box 58.6 Alt-RAMEC protocol

A special double-hinged expansion screw/Hyrax expander
• Activation schedule: Two quarter turn twice daily (two turns in

the morning and two turns in the evening)
• Rate of expansion: 0.25 mm per turn (1 mm/day)
• Time period: Open the screw by 1 mm/day during the first week
and close it by 1 mm/day the following week. The alternating
opening and closing is repeated for 7–9 consecutive weeks
• Follow-up visits—Weekly visits. The width of expander
measured during every visit to ensure proper activation and
deactivation procedure performed
Retention
After the active treatment is finished with protraction appliance, it is
vital to maintain the outcome either with class III bionator or a
Frankel FR III. In addition, normalisation of orofacial functions should
be ensured. This includes removal of tonsils and adenoids when they
are the cause of low tongue posture or cause of continued mouth
breathing.
Stability and prognosis of maxillary

protraction therapy
If maxillary protraction is started early, there is significant time
remaining between end of facemask therapy and cessation of pubertal
growth. This raises a concern regarding the duration of retention
period and stability of treatment. A systematic review reported that
75% of the subjects treated with facemasks had successful outcomes at
a follow-up observation 5 years after the end of orthopaedic
treatment.143 A success rate of 81.8% after 10 years follow-up period in
female patients was documented following RME and facemask
therapy.144 So the major factor that determines the long-term success
is not the response of the maxilla to forward traction but the amount
and direction of mandibular growth.145
The other indicators of unfavourable long-term outcome
include.51,146–148
• Forward positioning of the mandible relative to the cranial

base
• Increased posterior face height (long mandibular ramus)
• Acute cranial base angle
• Steep mandibular plane
• Increased length of the mandibular body and increased gonial
angle.
Overcorrection of the overjet and molar relationship is

recommended to anticipate for subsequent horizontal mandibular
growth108 which can be in part sustained with fixed appliance. Hence
it is recommended to start fixed appliance treatment immediately
after protraction therapy at the pubertal or post-pubertal stage in
patients with severe sagittal mandibular growth tendency.
Bone anchored maxillary protraction
(BAMP)
Conventional facemask appliance utilize the intraoral tooth borne
device for point of force application with a source of anchorage being
fore head and chin which results in undesirable dentoalveolar effects
like maxillary molar mesialisation and extrusion along with
proclination of maxillary incisors. Avoiding tooth borne appliances
and use of a rigid and stable anchorage will eliminate these
undesirable dental effects and improve the skeletal effects. For
effective correction and minimal camouflage effects of the skeletal
problem, the total orthopaedic force has to be transferred to the
circum-maxillary sutures.149 Some attempts were made in the past
that used stable anchorage sources like deliberately ankylosed
deciduous canines,150 osseo-integrated implants in the zygomatic
buttress,151 a titanium lag screw placed in the processes
pterygoideus152 and onplant on the palatal bone.153 Over recent years
the thorough understanding of the biomechanics of force system with
temporary anchorage devices and bone anchors has increased its use
in maxillary protraction. The results of a meta-analysis on the
skeletally anchored maxillary protraction show a substantial maxillary
protraction without dental compensation when compared with
conventional facemask protraction therapy.154
Maxillary protraction using skeletally

anchored facemask
Kircelli and Pektas published preliminary reports on the use of a rigid
skeletal anchor attached to the lateral nasal wall of maxilla along with
Delaire’s facemask. They demonstrated maxillary advancement of 4.8
mm at point A and midface advancement (orbitale) of 3.3 mm.155 The
BAMP protocol produce significantly larger maxillary advancement
compared to facemask. The mandibular sagittal changes were similar
whereas vertical changes were better controlled than the conventional
RME/ FM therapy.149,156–158 Morphometric analysis following BAMP
protocol revealed significant favourable deformations of both the
maxillary and the mandibular structures (Fig. 58.19).159
FIGURE 58.19 (A) Lateral cephalogram showing force direction with

bone anchored maxillary protraction. (B) Panoramic radiograph
showing miniplates positioning in the lateral nasal walls of the maxilla
on both sides of the apertura piriformis. Source: Reproduced with
permission from: Kircelli BH, Pektas ZO. Midfacial protraction with
skeletally anchored facemask therapy: a novel approach and
preliminary results. Am J Orthod Dentofacial Orthop 2008;133(3):440–
9.155
Maxillary protraction using skeletally

anchored intermaxillary elastics
De Clerk et al. proposed a system that utilises miniplate anchorage
(Bollard modified miniplates) and intermaxillary elastics extending
between miniplates anchored in the infra-zygomatic and symphyseal
region. This technique is advantageous over the conventional
facemask appliance because of better acceptance by the patient. It is
observed that the better clinical results are obtained with light bone-
anchored intermaxillary traction than with a heavy extraoral force.
The treatment effects include forward movement of maxilla along
with translation of the midface as a whole.160,161 Skeletally anchored
facemasks with miniplates placed at the zygomatic buttress show
more opening rotation of the mandible and lingual inclination of the
mandibular incisor whereas patients treated with class III
intermaxillary elastics extending from infra-zygomatic miniplates in
the maxilla to symphyseal miniplates in the mandible were more
effective in controlling the vertical changes and retroclination of the
mandibular incisors (Box 58.7; Fig. 58.20).162
Box 58.7 BAMP using class III intermaxillary

elastics protocol
Surgical protocol
• Small muco-periosteal flaps are elevated

• Modified Bollard miniplates are used
• Site of placement: In maxilla, miniplate is positioned just in front
of and parallel to the infra-zygomatic crest area and secured
using three screws. In the mandible, the miniplate is fixed
between the lateral incisor and the canine using two screws
• The extensions of the plates perforated the attached gingiva near
the muco-gingival junction
Loading protocol
• Miniplates are loaded three weeks after surgery

• Initial force of class III elastics should be about 150 g on each side
later increased to 200 g after 1 month of traction, and finally 250 g
after 3 months.
• The patients are instructed to wear the elastics 24 h/day
• A removable bite plate can be used to eliminate occlusal
interferences in the incisor area, if present
FIGURE 58.20 (A–B) Lateral cephalogram (Reproduced from Elnagar
et al.161) and dry skull model showing miniplates placed on the
infrazygomatic crest of the maxillary buttress and between the lower
lateral incisor and canine in the symphyseal region. Source:
Reproduced with permission from: Hino CT, Cevidanes LH, Nguyen
TT, De Clerck HJ, Franchi L, McNamara Jr JA. Three-dimensional
analysis of maxillary changes associated with facemask and rapid
maxillary expansion compared with bone anchored maxillary
protraction. Am J Orthod Dentofacial Orthop 2013;144(5):705–14.158
Clinical recommendations
Bone anchored maxillary protraction is indicated in patients having
severe maxillary retrusion and exhibiting increased vertical growth
tendency which might worsen by using tooth borne appliances.161 It
can be used in growing skeletal class III patients lacking anchorage
teeth for the facemask, that is congenitally missing teeth or the
absence of posterior deciduous teeth in the mixed dentition stage.149
The potential application of this technique is in the patients with cleft
lip and palate where there is a tendency for vertical growth pattern
and multiple missing teeth.163
It is used more successfully in the late mixed or early permanent
dentition, particularly after eruption of mandibular canine to avoid
root damage and also when bone quality and quantity are enough for
the stability of bone plates and screw. The best stability of the skeletal
anchorage system is obtained in children above 11 years old.160 The
high forces may exceed the maximal resistance of the external cortical
plate of the infra-zygomatic crest and lead to bone loss and loosening
of the screws. So, use of forces higher than 200 g is not
recommended.164 It is suggested that miniplates should be placed in
infra-zygomatic crest area in patients requiring more advancement in
the middle part of the zygomatico-maxillary complex and placed in
the lateral nasal wall area in patients who need more advancement in
the para-nasal area and the lower part of zygomatico-maxillary
complex.165 Kim et al. recommend the use of palatal plates that
showed larger amounts of forward displacement and wider
distribution of stresses over the maxillofacial structures than with
buccally placed miniplates and conventional appliances.166 Clinical
indication for different techniques and anchorage site of miniplates
should be considered carefully.
Micro-implant supported maxillary
protraction
Although there are many advantages of bone anchored maxillary
protraction, the surgical procedure involved in placement and
removing miniplates is the major disadvantage of this technique. It
also carries a risk of infection and may cause root damage during
insertion.167 Micro-implant associated rapid palatal expander
(MARPE) is simple modification in which the palatal expansion screw
is anchored to the underlying basal bone with the use of palatal
implants. FEM study demonstrated that when MARPE is used, the
expansion force is concentrated near the mid palatal suture and the
point of force application is closer to maxillary fulcrum of rotation, as
well as the centre of resistance. This approach reduces bone bending,
eliminates dental tipping and thus proves to be beneficial in patients
having vertical growth tendency.168 Further, the insertion of micro-
implant in palate decreases the risk of root damage. There is decrease
in the rate of failure of these implants when placed in palatal region
due to superior bone quality and attached keratinised mucosa. These
appliances can be used for patients with missing deciduous teeth or
premolars with underdeveloped roots where there is less scope for the
use of tooth borne devices.169
Hybrid Hyrax expander-facemask

Wilmes et al. introduced a hybrid Hyrax expander-facemask
combination to improve the orthopaedic effects. Hybrid Hyrax
expander is attached to the basal bone with two orthodontic mini-
implants in the anterior palate and an attachment to the first molars.
Hooks near the canines are welded or soldered to the buccal sides of
the molar bands for the application of orthopaedic protraction
forces.169 The hybrid Hyrax-FM combination is found to be effective
for orthopaedic treatment in growing class III patients in the short
term. The maxillary skeletal expander disarticulates all circum-
maxillary sutures and impacts all structures surrounding the maxilla.
When a maxillary skeletal expander is combined with a facemask the
amount of maxillary protraction is much greater than with the
conventional approach. The recent development of the novel, N2
mini-implant which is short in length (3-mm diameter, 2-mm length
and tapered shape) the risk of damaging anatomic structures during
placement is reduced.170 A FEM study of these implants show that by
varying the location of implants and vector of class III mechanics,
clinicians can alter the magnitude of forward, downward and
rotational movement of the maxilla. Hence it is advantageous over
miniplates, in that the location of micro-implants and direction of
force can be customised (Fig. 58.21).171
FIGURE 58.21 (A) Illustration of the modified hybrid Hyrax device with
rigid sectional wire for maxillary protraction Hyrax device, (B) Molar
bands fitted to the second deciduous molars and hybrid Hyrax
assembly soldered to the bands, (C) Lateral cephalogram showing
biomechanics of maxillary protraction using hybrid Hyrax facemask
combination. Source: Reproduced with permission from: Nienkemper
M, Wilmes B, Pauls A, Drescher D. Maxillary protraction using a hybrid
hyrax facemask combination. Prog Orthod 2013;14:5.172
In mild cases, extraction or non-extraction camouflage treatment is
sometimes appropriate. The orthodontic treatment is undertaken with
full fixed appliance with the objectives to give a normal overjet and
possibly a normal buccal occlusion too. However, crowding in the
arches and tooth size arch size discrepancy may necessitate
extractions in one or both the arches. The camouflage treatment is
discussed in detail in the next chapter.
Combined orthodontic and surgical procedures are undertaken in
suitable cases when growth is complete. The details are given in the
chapter on surgical management of skeletal malocclusion.
Key Points
The interception of class III malocclusion poses complex challenges
regarding prognosis. The severity of the problem, its associated
hereditary component and growth potential have a significant bearing
upon the timing of treatment and the type of appliance to be used in
growing class III patients. Severity is assessed during the evaluation of
the components of the class III malocclusion at the differential
diagnosis stage. A mandibular prognathism signifies a more severe
form of class III than a maxillary hypoplasia because of the potentially
favourable response of the maxilla to growth modification therapy in
comparison to the poor response of the mandible to growth
modification.
A mandibular problem may be mild, but if associated with a
hereditary component, growth modification treatments such as chin
cup, class III bionator, a facemask or any combination are not likely to
be successful. However, exceptions are made for temporary correction
of inter-arch dental problems and orthopaedic corrections aimed at
giving some self-confidence to the patient and/or to eliminate any
existing or potential psychosocial disturbance. These types of class III
malocclusions can be managed with camouflage only in mild cases. A
majority of such cases may need orthognathic surgery, which is
performed after cessation of growth. Early treatment involving
maxillary skeletal and combined dental corrections seems to reduce
the need for extensive orthognathic surgery.
Younger the patient, greater is the sagittal skeletal effect of
treatment on the maxilla. Severity should be judged based on the
growth potential of the patient. A mild class III discrepancy in late
adolescence and a severe discrepancy in the age group of 6–8 years
old may seem to have similar potential for correction if the aetiology is
primarily due to maxillary deficiency. However, the patient should
always be made aware of the risk of relapse and possible need for
surgical treatment. Bone anchored devices such as skeletal anchorage
system and minscrew supported intermaxillary traction is likely to be
used more in future.
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CHAPTER 59
Orthodontic treatment of
borderline class III malocclusion
Gauri Vichare
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Ethnic correlates of class III malocclusion
Clinical features of a class III face
Extraoral features
Intraoral features
Classification of Class III malocclusion by Delaire
Growth considerations in treatment of class III patients
Pseudo versus true class III malocclusion
Cephalometric findings in borderline class III
malocclusion
Rationale of class III camouflage
Good cases for camouflage treatment
Class III cases which are not good for camouflage
treatment
Non-extraction approach
Extraction approach
Retention protocol
Key Points
Introduction
Class III borderline cases pose diagnostic and therapeutic challenges
for decision making, on timings and approach to treatment. Should
they be treated with orthodontics alone or orthodontics combined
with orthognathic surgery is perhaps the most controversial yet
crucial decision to be arrived at. Often, there is a difference of opinion
among peer groups to choose a mode of therapy based on the nature
and characteristics of the severity of the problem. A wide range of
skeletal dysplasias can be camouflaged with tooth movement without
deleterious effects to the periodontium. However, the bottom line is
optimum aesthetics and stability of the treatment outcome. This
chapter outlines the diagnostic and treatment consideration in the
management of such borderline class III malocclusion cases.
Ethnic correlates of class III malocclusion

The prevalence of class III malocclusion is higher in South Asian
countries such as Korea, Japan, Taiwan, South China and Thailand
compared to America, Europe and the Indian subcontinent. 1
Therefore, in South Asian countries a significant proportion of
patients seeking orthodontic treatment belong to class III variety
compared to class II variety in Europe and North America. Among
30% orthodontic patients in Japan and 20% in China, constitute class
III malocclusion.2,3
The incidence of malocclusion among Korean students at Yonsei
University was: Class I—61.6%, Class II—12.2% and Class III—16.7%.
Moreover, of those were presenting to the Department of
Orthodontics, Yonsei University, Dental Hospital; 27%–31% were
Class I, 28–30% were Class II and 38%–40% were Class III patients.4,5
Consequently, a larger number of clinical and research studies have
appeared in literature from countries with high prevalence of class III
malocclusion (in English and native languages). These clinical and
research studies have provided substantial evidence and a road map
to treatment strategies for interceptive, camouflage and surgical
treatment options of class III malocclusion (Fig. 59.1).
FIGURE 59.1 Showing distributions of types of class III among

Caucasian and Asians.
Based on ANB angle. Source of data Baik.22
Class III malocclusion is mostly described as supernormal class I or
frank mesial–molar relationship accompanied by an incisor edge-to-
edge bite or a negative overjet. The visible abnormal sagittal
relationship is only a minuscule expression of the complex maxillary
and mandibular deviations in sagittal, vertical and transverse
dimensions, and deeply seated disturbed skeletal proportions and
altered relationship with the cranium. 6 The abnormalities extend
deep into the cranial base, particularly anterior and middle cranial
fossa and frontal sinus. In class III malocclusions, there is often
underdevelopment of the frontal sinuses and the frontomaxillary
articulation may be located more posteriorly. There is a poor
development of ‘exo-peri-face,’ that is soft tissues around the face. 7
Poor muscle functions lead to compromised chewing, a low tongue
posture and reduced airway functions. 8
Clinical features of a class III face (Fig.
59.2A–B)
Extraoral features
On extraoral clinical examination, class III subjects present:>
1. A concave face, deficient maxilla and/or prominent chin

2. Malar deficiency resulting into a flat midface
3. Increased lower anterior face height
4. Anatomically large lower lip length.
FIGURE 59.2 Three cases with varying pattern of skeletal class III
malocclusion.
(A) A young girl with skeletal class III malocclusion showing anterior
cross-bite of incisors only. Cephalogram shows relatively more severe
form of mandibular prognathism that is clinically seen in occlusion. (B)
In this case although intraoral malocclusion appears similar to A, this
patient has some component of maxillary retrusion and some functional
shift of the mandible.
Intraoral features
1. Zero or negative overjet
2. Narrow maxillary arch with crowding
3. Unilateral or bilateral posterior cross-bite
4. Proclined maxillary incisors
5. Retroclined mandibular incisors
6. A wide lower arch buccal segment showing compensations to
accommodate narrow maxillary arch
7. Low tongue posture
8. A flat curve of Spee.
Traditionally, based on the sagital discrepancy, class III malocclusion
has been grouped into four basic combinations (Fig. 59.3):
1. Prognathic mandible, maxilla normally positioned

2. Retrognathic maxilla, mandible normally positioned
3. Maxilla and mandible normally positioned
4. Retrognathic maxilla, prognathic mandible.
FIGURE 59.3 Four common categories of skeletal class III pattern

according to Jacobson et al.
(A) Maxilla within the normal range of prognathism, mandible beyond
the normal range. (B) Maxilla below normal range of prognathism,
mandible within the normal range. (C) Maxilla and mandible within
normal range of prognathism. (D) Maxilla below normal range of
prognathism, mandible beyond normal range of prognathism (A and B).
Ellis and McNamara 9 calculated that 243 possible combinations of

jaw relations could exist, taking into account the height of the face and
following five factors:>
1. Position of the maxilla

2. Position of the mandible
3. Maxillary alveolus
4. Mandibular alveolus
5. Vertical development.
From the sample of 302 class III subjects, Ellis and McNamara could
identify 69 varieties of facial patterns.
Classification of class III malocclusion
by Delaire
Jean Delaire 7 based on a sample of 172 records of class III subjects,
taking into account maxillary-mandibular anomalies into sagittal
plane only, grouped these into nine discrete types:
1. Maxillary retrusion with mandibular retrusion

2. Maxilla normally positioned with mandibular protrusion
3. Maxillary protrusion with mandibular protrusion
4. Maxillary retrusion with the mandible normally positioned
5. Maxilla and mandible normally positioned
6. Maxillary retrusion with mandibular protrusion
7. Maxilla normally positioned with mandibular retrusion
8. Maxillary protrusion with mandible normally positioned
9. Maxillary protrusion with mandibular retrusion.
A class III malocclusion, therefore, can exist with mandible normal

or even smaller. 6
Li et al. did a morphometric analysis using procrustes
superimposition of 472 class III patients to group according to
different craniofacial morphology and relationship to treatment
options. This resulted in 14 subgroups with special characters. 10
A class III malocclusion pattern is also contributed by other
components such as protrusion and retrusion of the teeth; the
orientation and height of the maxilla; the length and orientation of the
ramus and body of the mandible and the mandibular angle; the
cranial base flexure and vault; and the neck.11,12
Studies have indicated that relative anterior position of the glenoid
fossa, in class III subjects, is a possible diagnostic anatomic feature of
class III malocclusion associated with mandibular protrusion. 13
Others have reported a rather short anterior cranial base and reduced
cranial base angle, an important feature of class III malocclusion.7,11,12
Cephalometric studies have traditionally been used to assess the
craniofacial morphology, as well as the growth of such subjects. This
two-dimensional (2D) radiographic tool has several limitations, and
fail to provide an accurate characterisation of morphological
variations that occur in all dimensions of space during the growth of
complex structures like face and cranium.
Lately, researchers used morphometric techniques to distinguish
characterisation of morphological differences between class III and
class I subjects. Using procrustes analysis, thin-plate spline analysis,
finite element analysis and graphic display geometric configurations
of class III and class I children, 14 researchers found that greatest
differences in class III morphology occurred in the posterior cranial
base region, which consists of horizontal compression, vertical
expansion and size contraction. The sphenoid region displayed
expansion, while the anterior regions showed shearing and local
increases in size.
The shape of the cranial base differs in subjects with class III
malocclusion compared to those with normal class I configuration,
due in part to deficient ortho-cephalisation, or failure of the cranial
base to flatten during development. Further, they showed that
reduction in size or alteration in the shape of the anterior cranial base
(ACB) might cause a retrognathic midfacial profile associated with
class III malocclusions (Fig. 59.4).15,16
FIGURE 59.4 Showing cranial base morphology of skeletal class

III assessed on procrustes, thin-plate spline and FEM analysis.
Thirteen craniofacial landmarks, (A) used in this study superimposed
on a cephalographic tracing of a class I profile. The geometry used for
the procrustes, thin-plate spline, and FEM analyses, (B) as well as the
linear, (C) and angular, (D) measurements used in the bivariate and
multivariate analysis are superimposed on tracings of class III subjects.
Fmn: Frontonasomaxillary suture, GI: Glabella (most prominent point
on the frontal bone), Pc: Posterior clinoid process (most superior point
on the clinoid process), Nb: Tip of nasal bone, Se: Sphenoidale
(intersection of the greater wings of thesphenoid and the anterior
cranial base), Ts: Tuberculum sellae (most anterior point of sella
turcica) Source: Reproduced with permission from Singh et al.14
Our face, virtually without exception, is the composite of a great

many regional ‘imbalances’. 17 Individuals with class III malocclusion
are brachycephalic; they have more upright basicranial floor and a
closed flexure angle, which decreases the effective anteroposterior
dimension of the middle cranial fossa. The result is a more posterior
placement of maxilla and shorter horizontal length of the
nasomaxillary complex. Because the basicranium is wider but less
elongated, the middle and anterior cranial fossa are correspondingly
foreshortened. The composite result is relative retrusion of
nasomaxillary complex and more forward placement of mandible.
This leads to prognathic mandible and class III molar relationship.
Growth considerations in treatment of
class III patients
It is suggested that the class III skeletal pattern is apparent much early
in the postnatal life by the age of 6–8, years or before.17–21 The
excessive lower anterior facial height, dentoalveolar compensations,
maxillary retrusion and mandibular prognathism, were evident in the
class III sample as early as 5 years of age. 22 Several growth studies
have indicated that the class III pattern worsens with age. 23, 24 It is
important to know that:
1. Growing class III individuals show increased amounts of

growth of the lower jaw and deficient growth of upper jaw
including zygoma and nasomaxillary complex.
2. There is a sexual dimorphism in the growth of class III subjects.
25, 26
3. In females, maximum changes for facial characteristics occurs

between average ages of 11 and 12 years but continue after the
age of 15 years, and beyond 17 years in contrast to class I
subjects when growth is essentially ceased. 26 The peak
mandibular growth corresponded with stage CS3 through CS4
in cervical vertebral maturation. 27
4. In male subjects, peak mandibular growth, occurred between
12.8- and 14-years which correspond to CS3–CS4 of cervical
vertebrae maturation. The increase in mandibular length
continues at a significant rate from CS4–CS5 and CS5–CS6,
which is the age beyond normal maturation. 27
5. The duration of peak interval of growth is longer by 6 months
in both male and female class III subjects than in individuals
with normal occlusion who present with an average of CS3–
CS4 interval of 1 year. 27
Aforementioned findings have a direct bearing on treatment
planning, camouflage orthodontic treatment, the timing of the
evaluation of stability of treatment protocols and surgical age of the
patient (Fig. 59.5).
FIGURE 59.5 Average differences between cervical vertebral

maturation (CVM) stages for mandibular length in class III females
and males.
Cross-sectional study. Source: Reproduced with permission from
Baccetti. 23
Rabie et al. described borderline patients as ‘those patients who were
similar in the characteristics on which the orthodontic/surgical
decision appeared to have been based’. 2 Their observations are based
on the study by Cassidy on class II division 1 cases. 28 In day-to-day
clinical practice, we often encounter patients where it becomes
difficult to straight away take a treatment decision for orthognathic
surgery, or there is a difference of opinion among a peer group to
choose a therapy based on the mild nature of the problem.
Pseudo versus true class III malocclusion

A class III malocclusion could result from premature contacts in
occlusion leading to an anterior shift of the mandible causing a
pseudo or functional class III. Functional class III or pseudo class III
malocclusion if left untreated would lead to a skeletal class III
malocclusion. A pseudo class III exhibits discrepancy in occlusion at
centric relation (CR) and centric occlusion (CO) with the path of the
closure of mandible. In a true class III patient, the profile will be
concave and prognathic in CO and at CR, whereas in pseudo class III,
the profile could be a straight line in CR and prognathic or concave in
CO. Path of the closure of the mandible will be upward and forward
in case of pseudo class III malocclusion because of the anterior shift of
mandible.
Cephalometric findings in borderline class III

malocclusion
These vary greatly according to type and nature, the severity of the
problem and age of the patient. A lateral cephalogram is helpful in the
evaluation of the severity of the relationship and existing dental
compensations both in maxilla and mandible. PA (posteroanterior)
view is particularly useful when there is a facial asymmetry. The PA
view cephalogram is useful to measure the extent of maxillary arch
constriction, the width of the large mandible and transverse
discrepancy including midline shift and deviations. It also provides a
useful supplement to clinical examination on the buccal/lingual
compensation of maxillary and mandibular posterior teeth, which
should help to outline possible limits of orthodontic tooth movements.
Clinicians and researchers have tried to work out cephalometric
guidelines to decide the treatment modalities for class III patients to
know if the patient is suitable for camouflage or orthognathic surgery.
Rabie et al. suggested that the Holdaway angle can be a reliable guide
in determining the treatment modality for patients who represent
borderline class III surgical cases. 2 They used several variables,
discriminant analysis of which showed that for the measurement of
the profile, the Holdaway angle was the most crucial variable to
classify patients. The threshold value was 12°, which meant that if one
patient had a Holdaway angle of greater than 12°, he/she would most
likely be treated successfully by orthodontics (Fig. 59.6).
FIGURE 59.6 Holdaway’s H-line angle is formed by the
intersection of soft tissue nasion–soft tissue pogonion line and a
line tangent to the chin point (Pog’) and the upper lip (Ls).
Holdaway angle can be a reliable guide in determining the treatment
modality for patients who represent borderline class III surgical cases.
If a patient had a Holdaway angle of greater than 12°, he/she would
most likely be successfully treated by orthodontics.
Ricketts 29 described eight major characteristics of surgical class III:
1. Open basion-nasion from Frankfort horizontal (FH)—average

27°
2. Closed Xi axis—average 15°
3. Obtuse central mandibular core—corpus condyle axis
4. Long condyle neck
5. Long corpus
6. Short porion distance from pterygoid vertical
7. Short anterior cranial length on basion–nasion
8. Concave profile.
According to him, the first three are weighed heavily in early

prognosis for surgical cases.
The extreme diversity of craniofacial patterns seen with class III
patients offers diagnostic and therapeutic dilemmas. The growth of
the mandible is often prolonged beyond adolescence, the amount and
intensity of which cannot be predicted with any accuracy.
Above considerations further contribute to the dilemma of the
clinician, for the unpredictable response, often with a sense of
uncertainty of outcome, as well as sustainability of the treatment
results achieved. 27 The relapse of orthodontic/orthopaedic treatment
in class III malocclusion is frequent, up to 50%. 30
Essentially there have been two philosophical approaches to
therapeutic inventions to class III malocclusion. First, wait for major
growth to be completed and intervene according to the severity of
deformity; or second, intervene early with dento-facial orthopaedics
followed by aggressive orthodontic compensations in selective cases.
Philosophy of institution, choice and experience of operator and
patient has often influenced treatment decisions.
There are some class III cases, where skeletal deformity is mild to
moderate and orthodontic non-surgical treatment can correct the
dental malocclusion without having an adverse effect on the soft
tissues of the face. Such treatment approach where the underlying
skeletal deformity is left untreated but teeth are moved to such
positions to create an acceptable occlusion without violating the
norms of aesthetics and stability is categorised as ‘camouflage
treatment’. These class III patients have often passed their pubertal
growth spurt, having had their major component of growth
completed, and have more of a horizontal rather than vertical face
type. Such camouflage treatment has also been instituted in cases with
mild open bite.31,32
Rationale of class III camouflage

Growth
The complexity of genetic variation in the growth, the morphology of
face, and lack of absolute precision of research tools on growth
forecast, uncertainty persists to accurately predict changing intricate
relations, and treatment response of craniofacial complex. One can
assume that each of class III-patient may have features unique to it
and its unique growth pattern. Therefore, two similar looking cases
and in similar age may respond differently to same treatment
approach. Class III skeletal discrepancies do not get resolved
completely during growth period by growth modification. They
require treatment by the non-surgical orthodontic approach in
permanent dentition stage after the major growth is over.
Limitation of tooth movement

In class III malocclusion, dental compensations mask the severity of
the underlying skeletal dysplasia. While planning the treatment by
camouflage approach, the pre-treatment dental compensations are
required to be enhanced which might result in unfavourable sequelae
such as the labio-gingival recession in mandibular incisors and root
resorption of maxillary incisors. Extensive labial movement of
maxillary incisors would move roots in proximity to the palatal
cortical plate. Retraction and lingual tipping of lower incisors may
reduce lip prominence which could increase in undesired chin
prominence. 22 Excessive proclination of maxillary incisor and lingual
tipping of mandibular incisors could result in roots too close to palatal
and labial alveolus which could compromise periodontal health (Fig.
59.7A–B).
FIGURE 59.7 (A) Consequences of proclined maxillary incisors

beyond the alveolar limits leading to maxillary incisor root resorption.
(B) Excessive mandibular incisor retroclination leading to root
prominence and resorption of labial cortical plate.
Psychology, treatment cost and relapse

The camouflage treatment should consider patients’ willingness,
motivation and expectation from this kind of treatment. The patients
should be aware of the economics of such treatment and expected
limited benefits. They should be educated on the limitations of
camouflage approach and should be made aware of the possible,
surgical treatment options. Therefore, case selection for camouflage
treatment should be based on 360° reviews of nature of the problem,
aetiological factors, psychology, the cost of treatment and prognosis
considerations.
Good cases for camouflage treatment
1. A class III case with mild to moderate severity
2. Subjects who have passed the active growth period for
orthopaedic treatment of maxillary protraction and chin cup
therapy
3. The absence of skeletal facial asymmetry
4. Hypo-divergent class III pattern
5. Lack of posterior cross-bite or mild posterior cross-bite
6. The presence of good alveolar bone support in mandible
anterior symphysis and maxilla to accommodate mandibular
anterior retroclination/maxillary anterior proclination
7. Good oral hygiene and periodontal health with no
fenestrations in the anterior region
8. Patients with limited expectations in the improvement of their
profile
9. Patients who accept camouflage treatment modality with an
understanding of a possible future surgery.
Class III cases which are not good for

camouflage treatment
1. The acute naso-labial angle which indicates that further
proclinations of maxillary anterior teeth could worsen the
profile
2. Limited possibilities of further retroclination of mandibular
incisor due to pre-existing dental compensations and further
limitations posed by the limited availability of bone at
symphysis
3. Large negative overjet
4. Large tongue
5. Class III malocclusion of familial or genetic aetiology: These
patients are not good candidates for their potential for
continued growth and therefore greater relapse tendency
6. Ethnicity and race: A proportion of class III patients among
Koreans, South China and Taiwan exhibit maxillary protrusion
with mandibular prognathism, the latter being more
pronounced. Any efforts to correct negative overjet would lead
to bi-dental/bi-maxillary protrusion. 22
7. Those with significant skeletal facial asymmetry and jaw
deviations 33
8. Open gonial angle, open bite and vertical growers
9. Patients with high expectations regarding the improvement of
chin and profile: These patients are looking for a significant
improvement in their profile, where orthognathic surgery may
be a better option to choose.
Diagnostic and therapeutic approach to a case of class III

malocclusion is outlined in Flowchart 59.1.
FLOWCHART 59.1 Diagnostic and therapeutic approach to class

III patients.
Essentially two approaches are used once a case is selected for
treatment with camouflage:
1. Non-extraction approach
2. Extraction approach
Non-extraction approach
This approach is used when skeletal dentoalveolar arches in each jaw
are sufficient to accommodate total tooth substance. Clinical situations
that do not warrant significant tooth movement for compensations,
like minor crowding in the maxillary arch can be resolved with arch
expansion and incisor proclination. Mandibular arch may be free from
any crowding that may allow retroclination of the lower incisors.
Should this type and amount of tooth movements allow, the negative
overjet to be corrected, non-extraction approach is used.
The lower buccal segment can be distally tipped with multi-loop
edgewise archwire (MEAW) technique (Fig. 59.8). Class III elastics can
be used to enhance retroclination of the lower arch and forward
movement of the maxillary arch. An important consideration, of
course, would be to watch for anterior limits of tooth movement at the
maxillary alveolar process. Extrusion of maxillary molars associated
with class III elastics also requires careful monitoring. In certain
situations reduction of the tooth material in the mandibular arch can
be considered with proximal re-contouring. Class III elastics tend to
cause flattening of occlusal plane (Fig. 59.9).
1. The MEAW technique. This technique was introduced by Kim

in 1987 and has been successfully applied for treatment of
severe open bite malocclusions (Fig. 59.8). 31 The form of the
MEAW is primarily that of an ideal edgewise archwire with
the addition of boot loops. 34 According to Yang et al., the
vertical loop component serves as a break between the teeth,
gives flexibility to the archwire, and allows horizontal control
of the tooth positions. The use of MEAW requires completion
of all levelling and alignment, and constant use of vertical
elastics on the anterior teeth. It was originally prescribed for
brackets with 0.018-in. slots and 0.016 × 0.022-in. archwires,
allowing more flexibility for intrusive forces. Effects of MEAW
on posterior open bite after orthopaedic treatment in a class III
patient are depicted in Fig. 59.10.
2. Use of distalisation of lower arch using anchorage derived
from mini implants. The TADs have proved useful in
providing anchorage required to distalise the whole
mandibular arch including second molars. However, presence
of third molars will have to be evaluated and if need be, it may
require surgical extraction (Figs. 59.11 and 59.12). 35
FIGURE 59.8 Multiloop edgewise archwire design (MEAW).
FIGURE 59.9 Effects of class III elastics on dentition and

occlusion plane.
(A) Class III elastics of force value of 200–300 g are used. (B) The
anterior component of force causes lingual tipping of anteriors and
slight change in the cant of occlusal plane shown with >blue arrow.
FIGURE 59.10 (A) Buccal open bite following orthopaedic treatment

of class III case. (B) Multiloop edgewise wire in upper and lower arch.
(C) Occlusion 6 weeks later. The buccal open bite is considerably
reduced.
FIGURE 59.11 Distalisation of mandibular arch using skeletal
anchorage.
Use of class III elastics in open bite cases is contraindicated because
of extrusive effect on maxillary molars.
FIGURE 59.12 An 18-year-old girl having mild class III [ANB
(–)1°], anterior open bite, treated using camouflage approach with
mandibular third molar extractions and distalisation of the lower
arch.
The appliance used was 0.018 in. slot MBT prescription. Mini screws
were placed between mandibular first and second molars. Initially this
skeletal anchorage was used for molar intrusion to correct the open
bite and later for mandibular arch distalisation to correct the class III
relationship. In retention phase, the upper Hawley’s retainer with
posterior bite plane was used. (A–C) Pre-treatment profile and
occlusion. (D–E) Treatment in progress. (F–H) Post-treatment profile,
cephalometric changes and occlusion.
Extraction approach
The decision of extraction of tooth/teeth assumes critical significance
in view of its irreversible nature of the procedure. Extraction decision
should be executed only after due considerations of the goals of
occlusion which vary considerably in class III malocclusion. Therefore,
extraction pattern varies considerably from case to case.
The space resolution should be primarily based on incisor position.
Once the incisor position is planned then consideration should be
given for crowding resolution. In class III malocclusion there is
already chin prominence, and if the lower anterior teeth are retracted
after extraction in lower arch, it would influence the lower lip
position, further increasing the prominence of the chin.
Extractions are planned only for relieving the crowding and for
correction of negative overjet and overbite. The limits for upper/lower
incisor movements to compensate for camouflage treatment in class III
malocclusion can be 120° to SN plane and 80° to mandibular plane
respectively. 36
Depending on the requirement of the case, the extraction choices
could be (Fig. 59.13):
1. Mandibular incisor
2. Upper second and lower first bicuspids
3. Only lower first bicuspids
4. Mandibular second molars.
FIGURE 59.13 Ultimate occlusal relationship in class III patients
following different extraction patterns.
Mandibular incisor extraction in class III malocclusion is the tooth

choice in situations where crowding is not large or when there is a
situation of Bolton discrepancy. 33 The only disadvantage could be of
upper/lower midline mismatch and the need for a long-term rigid
lingual retainer since the mandibular arch with three incisors has a
tendency for lingual collapse.
Upper second premolars and lower first premolars are considered
for extraction to resolve large mandibular crowding and induce
significant tipping of the mandibular arch. The maxillary arch which
has lesser crowding, is deemed for second premolar extraction.
Lower bicuspids only are extracted when upper arch is well aligned
or can be well aligned with the dental expansion of the arches, but
lower arch needs significant space to resolve crowding and lingual
tipping of the mandibular incisors. The post-treatment occlusion will
have the lower first molars antagonist with maxillary first and second
premolars, resulting in maxillary second molar being unopposed if
mandibular third molars are absent or have not erupted in occlusion.
Lower second molars are extracted to cause significant distalisation
of the entire lower dental arch. The lower dental arch can be distalised
either with cervical headgear or anchorage derived from intraoral
implants.
According to Mora et al., second molar extraction in class III cases
has following advantages: 37
1. Reduction in quantity and duration of the therapy with fixed

appliances 38
2. Rapid eruption of the third molar 39
3. Aiding in the prevention of late incisor crowding38,40
4. Facilitating the distal movement of the first molar and anterior
dentition when the overjet has to be corrected
5. Less residual spaces left at the end of the orthodontic
treatment38,41
6. Reduction of probability of relapse due to greater stability gave
the inter-cuspation between the bicuspids 38
7. Maintenance of the facial aesthetics38,42
8. Avoiding complications of the surgical removal of impacted
third molars. 38
A case treated with extraction of upper first premolars and lower
incisor extraction is depicted in Fig. 59.14A–B.
FIGURE 59.14 Asymmetrical extraction treatment approach to
(A) A 20-year-old female having high angle class III malocclusion
[FMA-32°, ANB (–)2° and wits (–)7 mm] with combination of maxillary
hypoplasia and mandibular prognathism. She was treated with
camouflage approach by extraction of upper second bicuspids and
lower single incisor. The appliance used was 0.018 in. slot mini uni-
twin. After completion of orthodontic treatment lower lingual bonded
retainer and upper Hawley’s retainer were used. Asymmetrical
extraction treatment approach to class III malocclusion. (B) Post-
treatment profile and occlusion. There is significant improvement in
facial profile. OPG radiograph showing lower midline shift which is
unavoidable with a single lower incisor extraction.
Retention protocol
The retention protocol after the camouflage treatment of class III
malocclusion does not vary from any other retention regime for other
malocclusions as the camouflage treatment is carried out after the
major active growth is over. However, it is a good idea to be vigilant
for any significant change occurring, since class III patients are known
to grow for number of years beyond the attainment of adulthood
compared to their class I counterparts. The upper removable Hawley
retainer and the lower lingual fixed retainer are effective in retaining
the dental corrections.
Implications of latent mandibular growth and the maturational
changes should also be kept in mind when the camouflage treatment
is done in early permanent dentition years. The remaining growth
may cause a reduction in angle of convexity, worsen apical base
relationships, and aggravate compensatory labiolingual angulation of
maxillary and mandibular incisors. A restriction of the mandibular
denture may be produced in the process, resulting in uprighting of the
mandibular incisors. The buccal segments may tend toward more
class III molar relationship. Usually, the occlusal plane flattens, the
mandibular plane decreases in relation to the Frankfort horizontal
plane (FHP), and often the overbite is reduced.
Continued night-time wear of chin cup along with the use of FR
III/reverse twin block appliance well beyond 16 years in girls and 18
years in boys is recommended in all class III patients who have
undergone growth modification or camouflage treatment.
Key Points
Significant dental and soft-tissue changes can be expected in class III
patients treated with camouflage orthodontic treatment. A wide range
of skeletal dysplasias can be camouflaged with tooth movement
without deleterious effects to the periodontium. Case selection which
includes severity of the deformity and remaining growth are the most
significant considerations that influence treatment outcome and
stability of results of camouflage treatment.
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SECTION XIII
Newer trends in orthodontics
Chapter 60: Temporary anchorage devices

Chapter 61: Surgically facilitated rapid tooth movement (SF-
RTM)
Chapter 62: Orthodontic considerations of inter-disciplinary
treatment
Chapter 63: Evidence-based orthodontics
CHAPTER 60
Temporary anchorage devices
O.P. Kharbanda
Vilas Samrit
CHAPTER OUTLINE
Introduction
Types of anchorage devices
Materials
Design and parts
Safe zones for MSI
Loading of implant
Miniscrew removal
Biomechanical considerations in a miniscrew anchorage
system
Risks and complications with the use of MSIs
Complications during removal
Patient-related factors
Miniscrew implant related
Technique related
Key Points
Introduction
Orthodontic anchorage provided by teeth and conventional methods
are often insufficient, more so in the management of severe and
complex malocclusion. Alternate anchorage systems are required to
enhance the quality of treatment outcome and induce tooth
movements, such as the intrusion of the molars and vertical control on
the buccal segments. Dental implants are considered immobile in bone
and hence could serve as a source of absolute anchorage. The dental
implants although proved to be excellent anchorage source, could not
gain popularity among orthodontists for their very quality of
osseointegration, which makes their removal difficult if not
impossible after they have served the term of their purpose.
The invention of non-osseointegrated, temporary anchorage devices
(TAD) a relatively new armamentarium, is considered a game changer
in the orthodontic clinical practice. TADS have become popular in
short time, and this subject is now the latest clinical and research fad
in orthodontics. The field is exciting for the possibilities of new
inventions in temporary anchorage devices and for the clinical
potential they have to offer.1–3
The evolution of orthodontic implants is closely linked to the
development of dental implants and orthognathic fixation methods.
Later, modifications of these techniques were unified with basic
biological and biomechanical principles of osseointegration.
The very first attempt to use an implant as a stable device for
orthodontic anchorage was made by Gainsforth and Higley (1945).4
They inserted Vitallium screws into a dog’s ramus for the purpose of
distalising a maxillary canine.4 Per Ingvar Branemark introduced the
concept of osseointegration and the use of titanium implants for
replacing teeth in the mid-1960s.5,6 Creekmore and Eklund (1983)
inserted surgical Vitallium bone-screw just below the anterior nasal
spine for deep bite correction.7 Maxillary central incisors were
intruded 6 mm in 1 year of treatment by this method.7 Similar
outcome was achieved for the intrusion of lower incisor teeth by
Kanomi (1997) by using surgical titanium bone screw in 4 months of
treatment. He implanted mini-bone-screw of 1.2 mm diameter and 6
mm long in the alveolar bone between the root apices of mandibular
incisors and did intrusion of the mandibular incisors.8 Over the past
few years, success with several types of implants has been reported,
and presently these devices are termed TADs (Box 60.1).
Box 60.1 Historical landmarks in development

and use of miniscrew implants
Researcher Year Contribution
Gainsforth 1945 Studied effectiveness of Vitallium screws and stainless steel wires in the
and Higley4 mandibles of dogs to retract the maxillary canines
*
Branemark 1964, Worked on the concept of osseointegration and use of titanium implants to
and co- 1969 replace missing teeth
workers5, 6
Linkow9 1969 First reported a patient treatment with the use of osseointegrated implants for
both restorative and orthodontic purposes
Creekmore 1983 Used surgical Vitallium bone-screw just below the anterior nasal spine to treat
and deep overbite and it was the first clinical report on the use of temporary
Eklund7 * anchorage devices
Roberts et 1984 Corroborated the findings of Branemark in an extensive study of titanium
al.10 implants in rabbits
Turley et 1988 Reported successful use of similar endosseous implants in dogs as anchorage
al.11 for the application of variety of orthodontic and orthopaedic forces
Wehrbein 1990s Developed palatal implants called the ‘Straumann Orthosystem,’ which was
and specially designed for orthodontic anchorage
colleagues12
Block and 1995 Described the use of implant coated on one side with hydroxyapatite that was
Hoffman13 placed against palatal bone and used for anchorage
Kanomi8 1997 First reported the clinical use of mini-implants for orthodontic anchorage. He
implanted mini-bone-screw of 1.2 mm diameter and 6 mm length in the
alveolar bone between root apices of mandibular incisors and did intrusion of
mandibular incisors
* Landmark events
TAD is a device that is temporarily fixed to the bone for enhancing
orthodontic anchorage either by supporting the teeth of the reactive
unit (indirect anchorage) or by obviating the need for the reactive unit
altogether (direct anchorage), which is subsequently removed after
use.14
Types of anchorage devices

The implantable anchorage devices can be grouped as osseointegrated
or mechanical/non-osseointegrated. These can also, be grouped based
on types of anchorage device used on the following bases:
(1) Endosseous implants15
These osseointegrated implants are modified forms of conventional
dental implants. These are placed in the palate, retromolar area and
the area of absent or missing teeth. Osseointegrated implants can
withstand more force than mechanically retentive implants, but they
have drawbacks like a waiting period before loading, limitation in the
area of placement because of their relatively large size, cost, extensive
surgical procedure required in the placement and difficulty in
removal. Such implants were earlier used in the palate for intraoral
molar distalisation.
(2) Surgical miniplates16,17
Modified or even conventional L- or T-shaped surgical titanium
miniplates are used with an intraoral extension to anchor the
orthodontic force. These are placed in the region of a thick cortex
similar to the zygomatic region, and the buccal cortex of the mandible.
Skeletal anchorage system has been successfully used for en masse
distalisation of the lower arch in class III cases. In maxillary dentition,
these have been used for the intrusion of the buccal segment in open
bite cases and for en masse molar distalisation.
Surgical miniplates offer perfect anchorage, but involve more
extensive surgical procedure, the presence of considerable
postoperative swelling, and discomfort to the patient, and thus
require surgical removal again.
(3) Miniscrew implants (MSIs) (Fig. 60.1)
FIGURE 60.1 Miniscrew implant (MSI).

Most MSIs are 4–12 mm in length and 1.2–2.7 mm in diameter.
Mechanically retentive MSIs can provide anchorage in orthodontics

for a short duration. MSIs are commercially available in the screw
diameter range of 1.2–2.7 mm and length varying from 4 to 12 mm.
Because of their tiny diameter, these are highly versatile in their site of
placement. The most common site for their placement is the inter-
radicular bone between the teeth. MSIs are grouped as absolute
anchorage units, although they might slightly tilt or move after
loading.
MSIs can be broadly grouped based on their composition, shape,
head type, the technique of placement and the site of placement (Box
60.2).
Box 60.2 Classification of MSIs
1. Based on composition
a. Biotolerant
– Stainless steel
– Chromium cobalt alloy
b. Bioinert
– Titanium
– Carbon
c. Bioactive
– Vetaroceramic
– Apatite hydroxide
– Ceramic oxidised aluminium
d. Bioresorbable
– Polylactide
2. Based on the site of placement
a. Buccal
b. Palatal
3. Based on technique of placement
a. Self-drilling
b. Tapping
4. Based on shape
a. Cylindrical
b. Tapered
c. Combination
5. Based on size
a. Length 4–12 mm (small, medium, large)
b. Diameter 1.15–2.5 mm (small, medium, large)
6. Based on head type
a. Small head type
b. Long head type
c. Circle head type
d. Fixation head type
e. Bracket head type
f. Hook head type
g. Combination of tube slot and hook
h. Interchangeable head type
Materials
The materials used for implants can be grouped into four categories:
1. Bio-tolerant. Stainless steel, chromium–cobalt alloy

2. Bioinert. Titanium and carbon
3. Bioactive. Vitroceramic apatite hydroxide and ceramic oxidised
aluminium
4. Bioresorbable. Polylactide.
Design and parts

Conventional MSIs are made of bioinert pure titanium or titanium
alloy or titanium-coated stainless steel. Among these, the medical
grade titanium alloy is the most commonly used material for its
known biocompatibility. Grade V medical titanium which is an alloy
of titanium, aluminium and vanadium; Ti6Al4V is the material of
choice. It offers biocompatibility and strength which is higher as
compared with commercially pure (CP) titanium. The high strength of
MSI is desired so that it can withstand insertion torque and stresses of
orthodontic loading. Although the orthodontic mechanism rarely uses
more than 300 g force, MSIs are designed to withstand up to 500 g
force.
MSIs are designed to be mechanically retained in the bone because
they should not osseointegrate for the ease of subsequent removal
following completion of their use.
They should be preferably self-drilling to make the MSI placement
procedure simple. The design provides provision for attachment of
orthodontic spring or auxiliary or bracket head to receive an archwire.
A conventional MSI has following parts:
1. Head. It is the portion exposed in the oral cavity. It provides

attachments for springs and elastics. It has a screwdriver slot
or a particular design/shape to engage the miniscrew driver
for implant placement. A solid head with a screwdriver slot is
recommended for easy insertion and removal.
a. For orthodontic attachments, a hole through head
and button is suitable. A bracket head is preferred
by many clinicians.
b. Bracket head designs with slots are also used in
some cases for direct wire engagement or indirect
anchorage.
c. A two-component MSI provides a separate screw
and a head portion with different neck lengths
which are screwed together after placement in the
bone. Such a design offers the flexibility of
interchangeable heads with different designs to
fulfil needs of biomechanics. This model has been
suggested to have reduced risk of fracture at the
neck.
2. Neck. Screw neck/trans-mucosal portion is the portion that
passes through the mucosa. The neck connects MSI with the
head, remains in contact with oral mucosa or gingival
attachment. The emergence profile from bone to mucosa is
often equal to the maximum outer diameter of the screw.
Different neck lengths are available for variable mucosal
thickness by some manufacturers while most of the others
offer a uniform length. The surface of the neck portion should
be smooth and well-polished to facilitate contact with mucosa
and discourage plaque accumulation around the neck. The
junction of MSI with mucosa is critical since most MSI failures
begin with peri-implant inflammation at this site.
3. Screw. It is the part of the MSI that embeds into the cortical and
medullary bone to provide retention. The thread of screw
around shank or main body of the MSI has the cutting edge
that facilitates insertion. The depth of the cutting edge and its
angle has a considerable influence on the stresses generated
during insertion and hence the amount of insertion torque
required to insert the MSI. The MSIs are either cylindrical or
tapered in shape. They are designed as self-drilling and self-
tapping types. Self- drilling implants have a sharp apex and
cutting edges, and therefore do not require a pilot drill for
insertion.
Miniscrew length and diameter

Commercially available MSI size ranges in length of 4–12 mm and
diameter of 1.2–2.7 mm. The length of an MSI is defined as the length
of the threaded body and not the length of the entire screw. Total
screw length is determined by the screw, neck and head length.
The major diameter of the MSI is the maximum diameter
determined by the outer diameter of the threads and is referred to as
diameter in day-to-day clinical practice. The minor diameter relates to
the inner (core or shaft) diameter, which usually ranges from 0.2 to 1.6
mm (Fig. 60.2).
FIGURE 60.2 MSI parts.
(A) MSI length. (B) Outer and inner diameters and pitch. (C) Symmetric
thread design. (D) Asymmetric thread design.
Thread design
Thread design and nature of its cutting edge (smooth or sharp)
determine the speed of insertion and stresses caused during insertion
of the MSI. The pitch is the distance between the two threads. When
the threads are spaced far apart, the MSI has a high pitch; conversely,
when the threads are close together the MSI is low pitched. The pitch
of the screw decides the rate of insertion. A screw with a large pitch
gets inserted at a faster rate. Some designs incorporate a flute at the
insertion tip of the miniscrew. A flute is a longitudinal groove in the
threaded portion of a screw which functions for cutting through the
bone and clearing the bone dust produced during insertion.
A self-drilling MSI is one that does not require a pilot hole and has
either a sharp tapered apex to allow placement or a notch in the tip to
drill through the cortex.18
Self-tapping MSIs can create their threads as they advance. There
are two different types of self-tapping designs: thread-forming and
thread-cutting. The thread-forming design compresses the bone
around the thread as the MSI advances. The thread-cutting design has
either a notch at the tip parallel to the long axis or a sharpened thread
that cuts threads into the bone as the MSI is inserted. All MSIs are self-
tapping.18
Extensive research is in progress so as to how the thread design
factors influence the primary stability of the miniscrew and nature of
biological response they generate, which would impact the ultimate
stability of the miniscrew. Commonly used terms concerning MSI are
depicted in Box 60.3.
Box 60.3 Commonly used terms in reference to

MSIs
Screw The length of an MSI is defined as the length of the threaded body and not the length of
length the entire screw (Fig. 60.2A). MSI lengths range from 4.0 to 12.0 mm
Major The major diameter is the maximum diameter determined by the outer diameter of the
diameter threads. The diameter of MSIs range from 1.2 to 2.7 mm
Minor The minor diameter refers to the inner (or core) diameter
diameter
Self- A self-drilling MSI is one that does not require a pilot hole and has either a sharp,
drilling tapered apex to allow placement, or a notch in the tip to drill through the cortex
screw
Self- Self-tapping MSI can create their threads as they advance. All MSIs are self-tapping.
tapping There are two different types of self-tapping designs: thread-forming and thread-
screw cutting. The thread-forming design compresses the bone around the thread as the
miniscrew advances. The thread-cutting design has either a notch at the tip parallel to
the long axis or a sharpened thread that actually cuts threads into the bone as the MSI
is inserted
Thread The thread depth is half the difference between the major and minor diameter
depth
Leading The leading angle is closest to the miniscrew tip and comes into bone contact first upon
angle insertion
Trailing The trailing angle is closest to the MSI head and is the last to contact during placement
angle
Thread It is often defined as asymmetric or symmetric. The symmetric thread design is V
design shaped, with leading and trailing angles that are congruent (Fig. 60.2C). An asymmetric
or buttress thread is the one with a leading angle (towards the tip), that is, at 45° to the
long axis of the shaft and a trailing angle (towards the head), that is, 90° to the long axis
of the shaft (Fig. 60.2D)
Pitch The pitch is the distance between the threads (Fig. 60.2B). When the threads are spaced
far apart, the miniscrew is high pitched; conversely, when the threads are close
together, the miniscrew is low pitched
Flute A flute is a longitudinal groove in the threaded portion of a screw used for cutting and
clearing bone chips
Primary Primary stability refers to the lack of miniscrew movement at the time of initial
stability placement. This type of stability is considered critical in orthodontics because it allows
for immediate loading
Secondary Bone regeneration and remodelling following implant placement results in an increase
stability in stability referred to as secondary stability. Primary and secondary stabilities are
related, in that poor primary stability has a detrimental effect on subsequent secondary
stability
Indications for the use of temporary anchorage devices
1. Absolute anchorage in maximum retraction requirements, such

as high-angle bimaxillary protrusion cases.
2. For patients who fail to cooperate with the use of headgears,
the TAD offers a viable option.
3. In a case of missing teeth, for example, first molars, MSIs can
provide anchorage as well as help manage the space
judiciously, which can avoid any further therapeutic
extractions.
4. To achieve difficult tooth movements such as anterior/
posterior intrusion, en masse distalisation of upper and lower
arches, molar uprighting and molar distalisation.
5. In adjunctive adult orthodontics for complex tooth movements.
6. Implants are even used for attaching orthopaedic forces to jaws
when there is a lack of anchorage units. For example, implants
for attaching facemask or mandibular protraction appliance.
7. Correction midline asymmetry and cant of occlusion.
Limitations of use of temporary anchorage device
1. Orthodontic implants are not indicated in the patients having

systemic problems that affect bone metabolism and in
medically compromising conditions.
2. Patients who are younger than 12 years who have not yet
completed skeletal growth should not receive implants. If
unavoidable, they should have palatal MSIs placed away from
the midline suture in the paramedian region.19
3. Miniscrews are contraindicated in heavy smokers and patients
with bone metabolic disorders.20
4. MSI should not be placed in the area of bone remodelling such
as a healing socket or near a deciduous tooth.
5. Thin cortical bone limits the use of MSIs. Because MSIs are
mechanically retained, loosening of the screw can develop as a
result of thin cortical bone, if thinner than 0.5 mm and also if
the density of trabecular bone is low.
6. Clinician’s skill. A clinician should be trained to place the MSI
at different locations in the mouth. Lack of skill often
contributes to MSI failure.
7. Ethical issues. Enthusiastic use of an invasive procedure like
miniscrew anchorage should be avoided. Miniscrew implant
should be considered based on a definite indication and be
considering high benefits and low risk.
Safe zones for MSI
Primary considerations in choosing the site of the MSI include the
desired biomechanical advantage required, cortical bone thickness,
inter-radicular bone volume and proximity of vital structures, such as
neurovascular bundle, inferior alveolar canal, mental foramen,
palatine foramen and vessels in the palate to the implant site (Fig.
60.3).21
1. Posterior region.22,23 Most frequently used MSI sites are buccal

inter-radicular bone in the maxilla and mandible in the molar–
premolar area. In the maxilla and mandible, the MSI can be
safely placed between the roots of the second premolar and
first molar, and between first molar and second molar through
the buccal cortical plate.
FIGURE 60.3 Safe zones for miniscrews.
(A) Safe and danger zones based on the mesiodistal distance in the
maxilla and mandible. (B) Safe and danger zones based on the
buccopalatal distance in the maxilla and buccolingual distance in the
mandible. The red areas indicate danger zones, and the green, blue,
yellow and orange areas indicate the safe zones. (Source: Purmal K,
Alam MK, Pohchi A, Abdul Razak NH. 3D mapping of safe and danger
zones in the maxilla and mandible for the placement of intermaxillary
fixation screws. PLoS One. 2013 Dec 19;8(12):e84202.)
In the palate, the optimal site is inter-radicular space between the

first and the second premolars, second premolar and first molar, and
first and second molars. The more apical the site, the safer is the
placement.
MSIs inserted in the posterior palatal slope should be placed
mesially to the second molar to avoid damage to the greater palatine
artery and the palatine nerve exiting at the greater palatine foramen.24
2. Anterior region.22 Optimal site in the maxillary anterior teeth
lies between central and lateral incisors at an approximate
distance of 6 mm above cementoenamel junction (CEJ) on the
labial cortical plate. One MSI, each can be placed on either side
of the centre line between the central and lateral incisors. A
single MSI can also be inserted in the maxilla in the midline
just below the anterior nasal spine. In the mandible, the
excellent anterior site lies at inter radicular bone between the
lateral incisor and canine.
For the anterior palate, MSI length is determined by the bone depth,
which can be assessed on a lateral cephalogram. The anteroposterior
location and inclination of the MSI are planned to optimise the
available bone. MSIs can also be inserted in para-median positions in
the palate, usually 6–9 mm posterior to the incisive foramen and 3–6
mm laterally.25
3. Other locations. These are retromolar, infra-zygomatic,

maxillary tuberosity areas and mandibular symphysis (Fig.
60.4).
FIGURE 60.4 Various sites for miniscrew placement.
(A) Buccal sites on maxilla. (B) Palatal sites on maxilla. (C) Buccal sites
on mandible.
1. Case selection, informed consent and records. The patient’s
medical history and assessment of the suitability of the patient
to undergo the additional procedure of miniscrew placement
are of great significance. It is imperative that the oral cavity of
the patient be free from gingival inflammation and periodontal
disease. He/she should have enough motivation and aptitude
to put the extra effort that is required to maintain a plaque-free
mouth, especially around the miniscrew. In addition to routine
orthodontic records, intraoral radiographs of the proposed
miniscrew site(s) are obtained to assess the inter radicular
bone width, any evidence of crestal bone loss, the length of the
roots and their mesio distal angulation (Fig. 60.5).26 The
patient and his/her parents should be fully explained about the
procedure to be undertaken and the course of events including
possible complications associated with this mode of therapy.
Informed consent should always be obtained. Any concerns
about the quality of bone on routine X-rays, medical history or
history of such medication which can influence bone
metabolism calls for an assessment of bone density. Bone
density values can be obtained as site specific through CT scan
or cone beam computed tomography (CBCT). It has been
suggested that D4 and D5 bone types are not good for
implants.27
2. Miniscrew selection. Selection of MSI size is governed by the
anatomical limits of its placement and intended biomechanics.
While the selection of miniscrew diameter depends on the
availability of inter radicular bone, mini screw length depends
on the buccolingual/bucco palatal dimensions of alveolus or
nasopalatal thickness of palate. Longer implants are used in
the retromolar area while regular sizes suffice for buccal inter
radicular bone in maxilla and mandible. Implants of smaller
length but larger diameter are more suitable for the anterior
palate.
We have most often used 1.4–1.5 mm diameter MSI and 7–8 mm
length in the maxilla and mandible into the buccal inter
radicular bone of the maxillary second premolar and first
molar for en masse retraction of anterior teeth in premolar
extraction cases. For intraoral molar distalisation, we found
1.4–1.6 mm diameter screws in the length of 8 mm are suitable
between the roots of first and second premolars. Other
important considerations of miniscrew selection are:
a. A miniscrew intended to be placed between roots
should be narrow enough to get accommodated and
should have at least 1 mm bone around its
maximum diameter.
b. For insertion into trabecular bone such as in the
retro-molar area in the mandible, a longer screw is
selected. Miniscrew of 2 mm diameter, 10 mm
length or longer are appropriate.
c. Miniscrew implants of 1.2–1.3 mm diameter can
withstand as much as 500 g of force, although most
orthodontic applications need forces of less than 300
g. A larger diameter (1.4–1.6 mm) miniscrew can be
used, if there is enough space between the roots,
and greater force is needed.
d. If the inventory permits, the MSI of the proper neck
height appropriate to the mucosal thickness at the
implant site should be used.
3. Surgical procedure. MSI placement is a short, appearing
simple, but a high precision invasive procedure, which needs
to be performed with high diligence. The procedure should
strictly follow the asepsis in the operatory including the use of
all disposables. The armamentarium is arranged on a sterile
tray.
FIGURE 60.5 AIIMS Universal connector for indirect MSI
anchorage.
(A) Miniscrew placed interdentally for the purpose of indirect
enhancement of orthodontic anchorage in an adult male with severe
arch length discrepancy. (B) A successful miniscrew is centred in the
thin interdental septum bone. (C) Miniscrew head being connected to
the maxillary first molar through a specially designed wire. (D) The
bracket head is coated with light cure composite to prevent irritation to
cheek mucosa.
In certain situations, miniscrew placement guide can be fabricated

on a recent plaster model. A variety of miniscrew guide devices has
been developed which can be helpful but are not always sensitive to
the accurate placement of the miniscrew. Lately, clinicians have used
3D CBCT, and customised surgical guide fabricated using
stereolithographic techniques. This method appears to harness
precision to the placement of orthodontic self-drilling MSIs adjacent to
the dental roots and maxillary sinuses.28,29
Following an accurate clinical assessment and observations on a
recently taken intraoral periapical X-ray, the location and angulation
of the self-drilling screw are is predetermined. The patient is also
advised to start with 250 mg amoxicillin or suitable antibiotic on the
night before the surgery, and those who seem to be less tolerant of
pain can be given a safe pain killer 1 hr before surgery. The mouth is
thoroughly cleaned of any material alba or plaque especially around
miniscrew placement zone. The patient is asked to rinse with 10 ml of
0.12% chlorhexidine gluconate mouthwash for 1 min. The procedure
can be done under 15% topical anaesthesia; however, we have found
much comfort with infiltration of 0.5 ml of local anaesthesia. The
patient is made to feel relaxed and allayed of anxiety before MSI
insertion is initiated. Once the location of the MSI is marked, the
process of the MSI insertion is initiated with preselected MSI. For self-
tapping non-self-drilling types of screw, a dent is made on the cortical
bone first with 0.9 mm round bur at 300–500 rpm under copious saline
irrigation. Irrigation helps to dissipate heat generated by drilling,
which can be detrimental to the success of the miniscrew. Miniscrew
is then carefully driven at the predetermined site at the desired angle
using appropriate driver. A buccal screw in the premolar-molar area
is placed between roots of teeth at an angulation of 45–60° to the long
axes of the teeth in the maxilla. The insertion angulation is lowered to
10–30° in the posterior mandible. The miniscrew location is checked
on an intraoral periapical (IOPA) radiograph taken immediately on
completion of the procedure.
Immediate postoperative phase would require strict maintenance of
oral hygiene, restrictions on hard food to avoid damage to miniscrew
and a course of antibiotics. The pain killers can be taken as and when
required.
Further follow-up after a week should include a careful review of
any unusual signs of inflammation, and a clinical review of the
mobility of the implant. Miniscrews that are likely to fail would show
up inflammation around the neck and mobility within first few days.
The patient is instructed to do brushing around MSI with a soft brush
after every meal. Chlorhexidine mouthwash (0.12%, 10 ml) should be
used for a minimum of two times a day. The patient should be
educated to keep a watch on the MSI that becomes mobile or in the
case of pain, should report to his orthodontist immediately.
Loading of implant
There is a general consensus that MSIs are not expected to be
osseointegrated, and provide anchorage due to their mechanical
locking in the bone. Therefore most clinicians suggest immediate
loading of the MSIs with light forces. However, in our practice, we
prefer a cooling period of about 2–3 weeks before an MSI is loaded—
Dr Kharbanda’s protocol.26 Drilling the MSI (self-tapping or self-
drilling) results in bone compression, stresses and microfractures of
bone being drilled resulting in bone trauma and collection of bone
debris and release of inflammatory mediators.
Studies at the Department of Orthodontics, AIIMS, focus on the
stability and peri-implant inflammation measured through the peri
miniscrew crevicular implant fluid (PMICF). The analyses revealed
the presence of inflammatory markers in PMICF within 1 hr and 24
hrs of MSI insertion and on loading.30–32 The inflammatory markers
gradually decrease towards the baseline over 3 weeks period. Dr
Kharbanda’s protocol, therefore, follows a delayed loading after three
weeks.
We prefer indirect loading protocol for the treatment of maximum
anchorage cases specially bimaxillary protrusion and severe class II
cases (Fig. 60.6). This protocol necessities use of triple buccal tube on
maxillary molars and double tube on mandibular molars. An auxiliary
wire framework, ‘AIIMS Universal Connector’ is fabricated in 0.017 ×
0.025 in. stainless steel wire, which connects the molar at its auxiliary
tube and the bracket head of the MSI. The MSIs are indirectly loaded,
for en masse retraction of the anterior teeth using conventional sliding
mechanism (Figs 60.7 and 60.8). The connector is so fabricated that it is
passively fitted in slots on the MSI or the connected molar without
exerting any force at both the ends. The patient is followed every 6–8
weeks. Once the extraction spaces are closed, the MSIs along with
connector is removed, and finishing is carried out in the usual
manner.
FIGURE 60.6 A schematic diagram of Dr Kharbanda protocol for
MSI anchorage.
FIGURE 60.7 Steps in the fabrication of AIIMS universal

connector.
(A) MSI inserted into the buccal interradicular bone between the
second premolar and first molar. (B) 0.017 × 0.025 in. stainless steel
wire is bent gingivally immediately mesial to the molar auxiliary tube so
that the free end passes distal to MSI head, is touching it. (C) A point is
marked on the wire at the level of the MSI slot. (D) A bend is given in
the wire at the marked point so that now the wire is paralleled to the
MSI slot. (E, F) Now the torque in the horizontal segments of the wire is
so adjusted that the wire framework can be passively seated in
position.
FIGURE 60.8 Indirect anchorage with miniscrews.
En masse retraction using Sentalloy closed coil spring attached
between gingivally soldered hook on archwire and miniscrew reinforced
molar.
Miniscrew removal
Miniscrew can be removed under topical anaesthesia with the
instrument used for driving, that is MSI driver with a firm yet slow
anticlockwise motion, followed by anticlockwise turns by holding the
head with tweezers or a similar instrument. Miniscrew wound does
not require sutures or post-removal dressings or systemic antibiotics
or pain killers. The wound is seen to heal spontaneously with mucosa
covering the site in 3–5 days (Fig. 60.9).
FIGURE 60.9 Miniscrew removal is a rather simple, painless and

uneventful procedure.
Miniscrews are unscrewed and picked up with tweezers. The wound is
dressed with sterile gauze impregnated with iodine solution. Oozing of
blood, if any, stops spontaneously. The wound healing and
epithelialisation occurs in 5–7 days.

Most clinicians use direct loading of the miniscrew implants.
However, in cases where en masse retraction is carried out by direct
loading, MSIs on both sides of the jaw should be placed at the same
height or location. This may not be possible in all cases because of
varying level of the mucogingival junction and differences in bone
height, thereby leading to the transverse cant of the occlusal plane. In
such cases, indirect loading can serve the purpose. The anchorage
control with indirect loading is comparable with direct loading
method, and it is suggested that in clinical situations when directly
loaded MSIs are not preferable, indirectly loaded MSIs can be
considered as a robust option.33
According to recent FEM studies, direct loading can overload the
MSIs and the peri-implant bone, sometimes, leading to MSI
failure.34,35 Indirect loading technique allows the clinician to vary the
position of MSI at a preferable location in the jaw. At the same time,
good biomechanical control of the teeth can be obtained by applying
conventional orthodontic mechanics.
Biomechanical considerations in a
miniscrew anchorage system
1. Enhanced anchorage by reinforcing the molars
MSIs offer absolute anchorage for en masse retraction of the
anterior segment into extraction spaces without anchorage loss.36,37
Miniscrews can be used either for direct application of force or with
conventional mechanics by reinforcing the existing anchorage, such as
molars or premolars. In cases that are intended and planned for
reinforcement of molars, it is advisable to use the triple buccal tube on
first molars. We followed a protocol of initial levelling and alignment
of the arches to prepare them for en masse retraction of the anterior
segment(s). At this stage, a 0.019 × 0.025-in. arch base wire is seated
which is flat in the posterior segment with mild lingual root torque for
incisors. A hook is soldered between lateral incisor and canine, or a
power arm is crimped at this position.
Insertion of rectangular wire follows a cooling period of 3–4 weeks
by which time active root movements are complete, and bone
inflammation is at minimal. We place bracket head type miniscrew
(1.5 mm diameter and 8 mm length) in the interdental bone between
the second premolar and first molar within the limits of attached
gingiva which is up to about 4–6 mm higher from the gingival crest.
Following 2–3 weeks of the healing period, the MSI is integrated to
maxillary first molar auxiliary tubes with a custom-made assembly in
0.017 × 0.025-in. wire.
The en masse retraction is initiated with 200 g nickel–titanium
closed coil spring activated from molar tube to power arm in the
lateral incisor canine region. Monthly follow-up would only require
checking the stability of the miniscrew, the motivation of the patient
to maintain hygiene especially around the miniscrews and need for
enhancement of anterior lingual torque. The extraction space usually
diminishes at the rate of 1 mm per month with entire premolar
extraction sites getting closed in about eight months’ time.
An extended gingival arm of such a connecting assembly of the MSI
with a molar tube, has been recently named molar-stabilising power
arm (MSPA).38 MSPA is expected to stabilise the molar in three planes
of space and allows the retraction force to be directed apically,
towards the centre of resistance of the posterior segment. It also
provides a posterior and a superior vector of force required for the
intrusion of anterior teeth.
Case 1 and Case 2 are excellent examples of successful treatment
with indirect MSI derived anchorage and conventional biomechanics.
2. Absolute anchorage with direct force application
Miniscrew can be used for direct application of force through a
variety of methods such as closed coil spring and power chain. For en
masse retraction of the anterior segment in extraction cases, a
retraction force is applied from the screw head in the posterior region
to the power arm distal to the canine bracket on a continuous
archwire (Fig. 60.10, Case 3):
FIGURE 60.10 Direct anchorage technique.
(A) En masse retraction of anterior teeth with miniscrew. The vectors
involved in sliding mechanics; (B) in the sagittal plane. Moment created
in the miniscrew driven sliding mechanics is around the miniscrew as
the centre of resistance.
a. Retraction mechanics
The preferred MSI location to achieve the proper force vector,
directed towards the centre of resistance of the posterior teeth is
between the roots of the second premolar and first molar or the first
and second molars.39 This may be a difficult location for the MSI
because the attached gingiva is limited in the molar region;40
however, to achieve mechanical advantage, MSIs must be placed
higher in the vestibule which is covered with loose mucosa. This
location although offers risks of higher failure due to peri-implant
inflammation associated with free mucosa, mechanical considerations
may over-weight the disadvantage provided by the location.
CASE 1 MH, a case of class II division 1 malocclusion treated
with MSI supported anchorage in upper arch
An 18-year old adult male patient reported with the chief complaint of
forwardly placed upper front teeth. He had class II division 1
malocclusion, full cusp class II molar relation and class II canine
relation on both sides with an overjet of 12 mm, a deep traumatic
overbite and mild incisor crowding in the lower arch.
It was planned to camouflage the problem by treating the case with
upper first premolars extraction using fixed mechanotherapy in a
maximum anchorage protocol. The patient was unwilling for the
surgical option. The maxillary molar band on both sides received a
triple buccal tube. A Roth set up 0.022 in. slot appliance was placed;
levelling and alignment could be achieved in 5 months.
The upper first premolars were extracted, and then the patient was
ready for en masse retraction of anterior teeth. At this stage, he
received one MSI on each side in the interradicular bone between the
first molar and second premolar in the maxillary arch. MSI was
connected to the maxillary first molar tube using 0.017 x 0.025 in.
stainless steel connector. En masse anterior retraction was started by
using Sentalloy closed coil spring, attached between the hook of the
molar tube and soldered hook on 0.019 x 0.025 in. stainless steel
archwire between lateral incisor and canine. Retraction force of 200 g
was applied. After 8 months and 2 weeks of en masse retraction,
spaces were closed.
The detailing and finishing the occlusion was carried out in the next few
months. Treatment with complete utilisation of extraction spaces
resulted in significant improvement in profile and normalisation of
overjet.
CASE 2 Case of bidental protrusion
SM, a case of class I malocclusion with bidental protrusion treated with
MSI supported indirect anchorage.
A 19-year-old adult female patient (case SM) reported with the chief
complaint of forwardly placed upper front teeth and excessive incisal
show on smiling. She had an orthognathic facial profile with potentially
competent lips and perioral procumbency due to proclined teeth. The
nasolabial angle was decreased, and mentolabial sulcus obliterated.
The smile was non-consonant, commissural and 100% incisal show on
smiling. She had Angle’s class I molar relation on the left side and end
on molar relation on the right side with a bidental protrusion in both the
jaws. It was planned to treat this case by extracting upper and lower
first premolars, and retraction of anterior teeth as a maximum
anchorage case with MSI reinforced anchorage and allowing some
mesial movement of lower right first molar to attain class I relation.
Treatment progress: A Roth set up 0.022 in. slot appliance was placed;
levelling and alignment were achieved in 4 months. Extraction of upper
first premolars was carried out. At this stage, she received four MSIs,
one each between first molar-second premolar interradicular area.
MSIs were connected to respective tubes of the first molars using
0.017 · 0.025 in. stainless steel connector. En masse anterior retraction
was initiated using Sentalloy closed coil spring, attached between hook
of the molar tube and soldered hook on 0.019 · 0.025 in. stainless steel
archwire between lateral incisor and canine. Retraction force of 200 g
was applied. After 8 months of en masse retraction, spaces were
closed.
Next few months were spent in detailing and finishing the occlusion.
The upper lip strain was significantly relieved, and there was a
significant enhancement in facial profile and smile.
CASE 3 Adult bi-maxillary protrusion treated with MSI derived
direct anchorage
Case SK. A case of class I malocclusion with bidental protrusion
treated with direct anchorage from MSIs.
A 17-year-old female patient reported with the chief complaint of
excessive display of anterior teeth on smiling. She had an orthognathic
facial profile with potentially competent lips and perioral procumbency.
The nasolabial angle was decreased and mentolabial sulcus
obliterated. The smile was non-consonant, commissural and 100%
incisal show on smiling. She had Angle’s class I molar relation
bilaterally with a bidental protrusion in both the jaws. It was decided to
treat this case as a maximum anchorage case by extracting upper and
lower first premolars utilising absolute anchorage from MSIs.
Treatment progress: A Roth set up 0.022 in. slot appliance was placed.
After 5 months, levelling and alignment was achieved till 0.019 × 0.025
in. stainless steel wires in both the arches. After extracting all first
premolars, four MSIs, one each between first molar-second premolar
interradicular area were placed. After a cooling period of 3 weeks,
retraction force of 200 g was applied by NiTi closed coil springs
connecting the MSIs to soldered hook on 0.019 × 0.025 in. stainless
steel wire archwire between lateral incisor and canine. After 13 months
of en masse retraction, spaces were closed.
Next few months were spent in detailing and finishing the occlusion.
There was significant enhancement in facial profile and smile.
En masse retraction mechanics with MSI needs to be modified from

conventional en masse mechanism to get the benefit of treatment
duration and desired moments of the teeth. When continuous arch
sliding mechanics are used with MSI anchorage, undesirable
biomechanical side effects are possible in all three planes of space.41,42
The vectors involved in sliding mechanics with conventional
mechanics differ from those in MSI.
i. In a sagittal plane. Moments created in the conventional sliding
mechanics are around the posterior and anterior segments when using
arches with accentuated curve of Spee or reverse curve of Spee or
asymmetrical V-bend. Moment created in the miniscrew-driven
sliding mechanics is around the MSI as the centre of resistance.
Therefore, a plain wire devoid of curve of Spee or bends is
recommended to avoid posterior open bite.43
ii. In an occlusal plane. In contrast to the conventional mechanics,
miniscrew anchorage system causes distal-in movement in the
posterior region. Thus, the molar toe-in often incorporated in
conventional sliding archwire is eliminated with miniscrew appliance
design.
iii. In a frontal plane. The level of the miniscrew site should be
predetermined at same heights on either side of the arch. MSIs placed
at different levels on the two sides of the same arch cause
rotation/canting of the occlusal plane.
Construction of the line of force.44 When using miniscrew
anchorage for en masse movement the archwire design should vary
according to the following clinical situations (Fig. 60.11).
FIGURE 60.11 Construction of the line of force.
(A) Controlled tipping of teeth. For controlled tipping, short hooks are
attached on the archwire, and the line of force is below the centre of
resistance. Thus, the resultant tooth movement is expected to be
tipping of incisors. (B) Bodily retraction of the anterior segment. For
bodily retraction of anterior, lever arms are extended from the main
arch, and the line of force becomes closer to the centre of resistance.
Additional torque on the archwire is required for the maintenance of the
proper moment/force ratio in the force system. (C) Root movement of
anterior teeth. For root movement, retraction force is reduced to the
minimum level, and the moment is increased by torquing the anterior
archwire. A light, constant force from the miniscrew helps maintain the
position of incisor torque during root torquing.
1. Situation A. In cases with severe proclination of anterior teeth,

controlled tipping of the teeth being retracted is desired. Here, the line
of force from an implant to retraction hook/power arm should pass
below the centre of resistance of the anterior segment which lies 6 mm
above the crest of the alveolar crest inter-dentally between the canine
and the lateral incisor.
2. Situation B. When bodily retraction of the anterior segment is
needed, the power arm height is so designed that the force vector
passes through the centre of resistance of the anterior segment. The
vestibular depth may limit the length of the power arm. In such
situations, it may be desired to incorporate slight lingual root torque
in the anterior segment.
3. Situation C. If root movement of the anterior teeth is to be carried
out, the power arm should be as high as possible to pass above the
centre of resistance of the anterior teeth. However, frequently this is
not possible due to anatomic limitations. Increased lingual root torque
in the anterior segment of the archwire will help to carry out the
desired movement.
b. Vertical tooth displacement
The intrusion of anterior teeth is carried out in deep bite cases while
intrusion of posterior is performed either for prosthetic purpose or in
vertical growers. Conventional intrusion mechanics cause reciprocal
effect, that is, extrusion of anchor teeth which are often the molars.
The miniscrew anchorage system allows direct application of precise
force systems from MSI to the target tooth or segment, producing
efficient intrusion and a possibility of intrusion of the buccal segment
(Fig. 60.12).
FIGURE 60.12 (A) Anterior intrusion, either single or double
miniscrew a system can be utilised according to the amount of intrusion
needed. Since the line of force is labial, torque has to be incorporated
for it to pass through the centre of resistance of the incisors. (B1,B2)
Posterior intrusion. The force should be balanced buccolingually and
mesiodistally during an active intrusion.
MSI can also be used for extrusion of the single/group of teeth, such
as a highly placed canine; teeth intruded following trauma or other
situations of aberrant tooth positions.
i. Anterior intrusion. Either two or single miniscrew system can be
used according to the amount of intrusion needed. Because the line of
force is labial, labial root torque has to be incorporated into the
intrusive force vector to pass through the centre of resistance of the
incisors.
ii. Buccal segment intrusion. The centre of resistance of the molar
for intrusion is the centre of the occlusal table (for upper molar it is
slightly palatal) and passes through the furcation area in the frontal
and sagittal view. It is recommended to use two MSIs in the mesial
and the distal interdental areas with one placed buccally and the other
lingually. Additional MSIs can be used for correction of tipping and in
cases of severe extrusion.
For bilateral intrusion of molars, a transpalatal system with a
miniscrew placed in the centre of the palate is recommended. Because
the force direction in such system is apical as well as palatal, it is
necessary to either apply a buccal crown torque to the molars or to use
expanded transpalatal arch or additional MSIs in he buccal region.
c. Space closure in the buccal segment and uprighting of the molars
Space closure in the molar region may one of the objectives of the
orthodontic plan, either in cases of missing premolars or where
closure of extraction space is needed to eliminate prosthesis. Such
situations are often encountered in the lower arch. The principles of
biomechanics would involve the use of a miniscrew as anchorage
somewhere in the premolar molar area and mesialisation of the molar
with a segmental or continuous arch mechanism.
Mesially impacted second molar(s) frequently need to be uprighted.
Conventional orthodontic methods of uprighting mandibular molars
involve preparation of an anchorage tooth or segment. Multiple
appliances are usually needed, and unwanted movement of the
anchorage unit can occur.
MSI anchorage can make difficult movements of the second or third
molars possible with greater predictability. In situations of mild-
moderate mesial tipping, an assembly of a miniscrew placed mesial to
the tipped tooth used as an anchorage for the distally directed force.
In cases of severe tipping, it is difficult to bond the molar on the
buccal aspect. A miniscrew distal to the tipped molar has to be used
for anchorage, that is the insertion site will be retromolar pad area or
the tuberosity area. These areas have thick soft tissue coverage over
the bone, so a screw of extra length is required. Impacted third molars
encountered in the path of uprighting of the second molars may be
required to be extracted (Box 60.4; Fig. 60.13).43
Box 60.4 Biomechanics of conventional versus

miniscrew retraction mechanics
Conventional retraction
Miniscrew retraction mechanics
mechanics
Curve of Spee/gable bend to Anchorage is derived from miniscrew; therefore, flat wire is
enhance anchorage and avoid deep recommended otherwise posterior open bite would result
bite
Molar toe-in to avoid distal out Avoid molar toe-in as it leads to distal-in
rotation
Two moments are created for the The entire arch acts as a single unit with a moment created
anterior and the posterior segments around the miniscrew at the centre of rotation
FIGURE 60.13 Uprighting the molars.
(A) Mild mesial tipping: in cases of mild mesial tipping, an assembly of
miniscrew placed mesially and open coil spring with distally directed
force can be used. (B) Moderately tipped molars: for moderately tipped
molars, mesially placed miniscrew with use of open coil spring for
unlocking the molar followed by use of uprighting spring is
recommended. (C) Severe tipping: in cases of severe tipping it is
difficult to bond the molar on the buccal aspect. A miniscrew distal to
the tipped molar has to be utilised for anchorage, that is the insertion
site will be retromolar pad area or the tuberosity area. These areas
have more soft tissue coverage, so a screw of sufficient length is
selected (at least 8 mm). It may require extraction of the third molar.
Risks and complications with the use
of MSIs25
Use of MSIs is an invasive procedure and not free from specific risks
inherent in their placement and use (Fig. 60.14). Both the clinician and
the patient must clearly understand the potential risks, and unwanted
effects of miniscrew assisted therapy. Complications associated with
the use of MSI can also arise during and after orthodontic loading
about stability and patient safety:
1. Trauma to the periodontal ligament or the dental root.

2. Potential complications of root injury. These include loss of
tooth vitality, osteosclerosis and dentoalveolar ankylosis.
Trauma to the outer dental root without pulpal involvement
will most likely not influence the prognosis of the tooth.
3. MSI slippage. The clinician might fail to fully engage cortical
bone during placement and inadvertently slide the MSI under
the mucosal tissue along the periosteum. High-risk regions for
MSI slippage include sloped bony planes in alveolar mucosa
such as zygomatic buttress, retromolar pad, buccal cortical
shelf, and the maxillary buccal exostosis, if present.
4. Nerve involvement. Nerve injury can occur during placement
of miniscrews in the maxillary palatal slope, the mandibular
buccal dentoalveolus and the retromolar region. Most minor
nerve injuries do not cause a complete tear and are transient in
nature.
5. Subcutaneous emphysema. Emphysema is the condition in
which air penetrates the skin or submucosa, resulting in soft
tissue distention. The clinician should be alert for
subcutaneous emphysema during miniscrew placement
through the loose alveolar tissue of the retromolar, mandibular
posterior buccal and the maxillary zygomatic regions.
6. Nasal and maxillary sinus perforation. Perforation of the nasal
sinus and the maxillary sinuses can occur during MSI
placement in the maxillary incisor, maxillary posterior
dentoalveolar and zygomatic regions. A posterior atrophic
maxilla often seen in adults is a major risk factor for sinus
perforation.
7. MSI bending, fracture and torsional stress. Increased torsional
stress during placement can lead to implant bending or
fracture, under orthodontic loading.
8. Implant failure. Stability of the orthodontic miniscrew
throughout treatment depends on bone density, the health of
peri-implant soft tissues, miniscrew design, surgical technique
and force load. MSI failure should be critically evaluated for its
aetiology before placing a new MSI.
9. MSI migration. Orthodontic miniscrews can remain clinically
stable but not stationary under orthodontic loading.
10. Soft tissue complications. These include:
a. Oral ulceration
b. Soft tissue coverage of the MSI head and auxiliary
c. Soft tissue inflammation, infection, and peri-
implantitis can occur after MSI placement.
FIGURE 60.14 Complications of using MSIs.
(A) The implant is driven into the periodontal ligament space. The
implant was unstable due to Hammock ligament effect. (B) Peri-implant
inflammation related to implant placement mobile mucosa. (C) Implant
drove close to the molar root. Attempts to immediately remove the
implant by unscrewing resulted in its fracture at the neck. (D) The
implant was removed in pieces with surgical exposure of the site.
Inflammation of the peri-implant soft tissue has been associated

with increased failure rates.37
Complications during removal

1. The miniscrew head could fracture from the neck of the shaft
during removal.
2. Partial osseointegration: Although orthodontic miniscrews
achieve stationary anchorage primarily through mechanical
retention, they can achieve partial osseointegration, increasing
the difficulty of their removal.
A miniscrew is considered to be a failure when it shows mobility
either immediately or few days after its placement in the bone. This is
called a failure of primary stability.
Implant failure can also occur after loading when it may show
mobility of a degree which is not suitable for orthodontic anchorage.
Several authors have reported failure rate ranging from 5% to 20%.
With increasing experience, the failure rate of miniscrews can be
reduced to around 5%, basically by improving the handling procedure
and avoiding skeletal anchorage in situations where the risk is
significant.45
The contributors to success are many and can be broadly grouped
into host related, implant related to a technique including experience
of the operator.
Factors affecting the success of orthodontic miniscrew implants are:
Patient-related factors
1. Age. Most authors found more failures in young patients
compared with adult patients, although it is not possible to
explain the reasons.36,42,44,46,47
2. Sex. Baek et al. 48 and Lim et al.49 reported more success rate in
females than in males. However, Chen et al.27 and Miyawaki et
al.50 found no difference between males and females. No
definite sex association can be predicted.27,40,48,51
3. Recipient jaw. Most studies report higher success rate in
maxilla than the mandible which has been attributed to greater
bone cell death occurring during implant insertion owing to
the thick cortical bone of the mandible.40,49,52,53
4. Attached gingiva versus alveolar mucosa. A high success rate
of about 90% has been reported for miniscrews inserted in the
attached gingiva. Risk of failure of miniscrew surrounded by
nonkeratinised mucosa has been reported to be higher than
that for miniscrews surrounded by keratinised mucosa.40,49,53
5. Bone quantity. Deguchi et al.54 found the inter-radicular
distance between the second premolar and first molar to be
2.9–3 mm in the maxilla and 2.9–3.1 mm in mandible at 5–8
mm level. Poggio et al.23 found that in the inter-radicular space
between the first maxillary molar and the second premolar, the
greatest amount of mesiodistal bone was located between 5
and 8 mm from the alveolar crest. To maximise the cortical
bone anchorage in buccal segments, the miniscrews should be
placed more than 4 mm apically from the alveolar crest, close
to the mucogingival junction.
6. Bone quality. The thick cortical bone in the posterior mandible
and the high bone density (D1) makes it prone to cell necrosis
possibly from over-heating during drilling. More failure in D3
and D4 bone has been reported compared with D1 and D2
bone.27,40
7. Oral hygiene. Inflammation around implants has been found
as a relative risk factor for failure. Low success rate has been
reported in implants with surrounding inflammation than in
implants without inflammation. MSI losses associated with
peri-implant inflammation occur due to mechanical irritation
and food impaction caused by orthodontic appliances.40,50,55
Miniscrew implant related

1. Length. Maximum insertion and removal torque values are
directly related to length; 7–8 mm miniscrew implants are
suitable in inter-radicular areas.
2. Diameter. The success rate of miniscrew implants is
significantly related to the diameter of implants. MSIs of
diameter 1.2–2 mm are acceptable. A larger diameter can
efficiently reinforce the initial stability of the miniscrew. Also,
the stress generated in and around the miniscrew the implant
can be reduced by increasing the diameter.56,57 However, the
proximity of the roots at the MSI site limits the maximum
diameter in clinical use.
3. Shape. Tapered miniscrew implants have a higher success rate,
but at the same time they have a higher insertion torque
values, which may result in an increased risk of microfractures
of bone.49
4. Pitch. It has been suggested that the pitch is clinically more
important than major diameter because that is limited by the
bone site and space available.57 Pitch is not limited by
available space and its effect on primary stability has been
noted.
5. Thread depth. Shallow threads are typically used for cortical
bone, and deep threads are used for cancellous bone.57 Greater
depth is thought to provide more holding power because of an
increased bone volume between the threads and increased
bone to screw contact.59
A greater thread depth would be recommended for orthodontic
applications to maximise resistance to the displacement under
force loads.60,61
6. Thread design. The thread is designed to facilitate placement,
prevent loosening, offer strength, and withstand axial loads.58
Carano et al.62 found that the asymmetric threads have a
geometry that facilitates insertion while obstructing removal.
7. Surface treatment. Orthodontic miniscrew implants are not
meant for osseointegration. These are mechanically retained
and should be easily removed once their purpose is over.
However, surface-treated miniscrew implants provide
osseointegration and therefore enhanced retention than the
machined miniscrew implants.63,64
Technique related
1. Incision vs. no incision. Miniscrew implant placement is
usually preferred without giving an incision. With the incision
technique, chances of failure are high and also more time is
required for the soft tissue to heal before loading, thus,
increasing the treatment time.
2. Insertion angle. Placement at 90° is the most retentive insertion
angle.65 However, to minimise the root contact, and to take
advantage of maximum cortical contact, implants are obliquely
placed. Very oblique placement angle (30°) results in reduced
stability of loaded miniscrew implants;66,67 45–60° insertion
angle to the long axis of the tooth is therefore recommended.
3. The onset of loading. Clinical studies have shown that the
onset of loading does not affect the success of miniscrew
implant treatment. Since the initial stability of miniscrew
implant is purely mechanical, and studies have shown that
immediately loaded implants are successful. The studies and
clinical protocol developed by Dr Kharbanada recommends a
cooling period of three weeks before implant loading. Their
protocol is based on the research on levels of inflammatory
biomarkers in PMICF which are high on insertion and
gradually decline over three weeks.50,52,68–70
4. The amount of loading. Miniscrew implants generally tolerate
500 g force without failure. The orthodontic force required for
various tooth movements hardly exceeds 300 g.
Key Points
TADs have revolutionised orthodontic treatment by decreasing the
anchorage loss, changing the extraction choices, bringing about the
possibilities of difficult tooth movements and providing better
orthodontic treatment for some borderline orthognathic surgical
patients.
TAD is not a solution to all the anchorage-related issues in
orthodontics. TADs should be used for difficult tooth movements
such as an intrusion of molars, molar distalisation, in cases where
anchorage is compromised due to missing teeth and in the adult
patients. If used injudiciously, it may create an extra burden to the
patient and doctor without any added advantage.
Most of the limitations in implants are resolvable with a careful
patient selection, skill and proper planning of the procedure. This
system of anchorage is now proven mode of orthodontic device. A
judicious use of TADs can be a boon to treat certain cases of
malocclusion. The use of TAD has certainly helped us in treating a
number of borderline orthognathic bimaxillary protrusion cases to be
treated well with orthodontics alone.
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11343020.
CHAPTER 61
Surgically facilitated rapid tooth
movement (SF-RTM)
Priyanka Sethi Kumar
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Biological basis of SF-RTM
Techniques of alveolar surgery
Piezocision-assisted orthodontics
Micro-osteo-perforations (MOP)
Corticision
Corticotomy facilitated orthodontic treatment (CFOT)
Selective alveolar decortication (SAD)
Periodontally accelerated osteogenic orthodontics
(PAOO)/accelerated osteogenic orthodontics
(AOO)/Wilckodontics
Osteotomy facilitated orthodontic treatment (OFOT)
Inter-dental/periodontal distraction osteogenesis
Dentoalveolar distraction osteogenesis
Mono-cortical tooth dislocation and ligament distraction
(MTDLD)
Surgery first
Key Points
Introduction
Attempts to modify bone growth, both in terms of amount and
direction have been made since antiquity.1 Initially, orthodontists
generally limited their mission to simply move the teeth, allowing the
alveolar bone to remodel naturally, ignoring the alveolar topography.2
However, in the 21st century, orthodontists are forced to widen their
horizon of treatment because more and more adult patients are
seeking treatment.3 Limitations in traditional orthodontic techniques
and the duration of therapy often create barriers to the patient’s
willingness to accept orthodontic therapy.4 Therefore, an inter-
disciplinary approach to treatment in conjunction with the principles
of tissue engineering2 and regenerative surgery which allow
manipulation of alveolar bone for rapid tooth movement has evolved.
Thus, identifying and harnessing the cellular regulators of tooth
movement which is safe for the health of the tissues are essential, if we
have to shorten the orthodontic treatment time. Both periodontal and
orthodontic specialities have merged directly into the field of surgical
dentofacial orthopaedics to produce biologically sophisticated,
optimal and -predictable response of the alveolar bone to enhance
tooth movement. Collectively, they represent variable methods, which
we -denote as peri--orthodontic surgery.2 To create biologically
optimal and predictable tooth movement an understating of
periodontal tissues and their response to force combined with and
surgically induced inflammation is required. Many surgical
techniques have been used over the years which in general, are called
peri-orthodontic surgery.2 Surgically facilitated orthodontic
techniques using corticotomies and single or multiple tooth
osteotomies to enhance orthodontic movements are gaining
widespread popularity.4 These clinical methods provide promising
concepts which empower orthodontist to enable better treatment for
complex dentofacial problems in relatively shorter duration. Such
techniques have significantly reduced side effects like root resorption
and relapse, therefore resulting in more stable outcomes.5
Historical perspective (Table 61.1)
Surgical intervention to affect the alveolar bone and speed tooth
movement has been used in various forms for more than a hundred
years. The concept of corticotomy was described in the dental
literature as early as 1892.6 Farrar was the first to report the use of his
‘positive system,’ a specialised screw to retract the canine into the first
premolar extraction space.7 In 1959, Kole first described the use of
corticotomies in the acceleration of orthodontic tooth movement.8 At
the turn of the 20th century, Codivilla9 performed the first limb
lengthening using external skeletal traction after an oblique osteotomy
of the femur. However, it was Ilizarov,10 a Russian orthopaedic
surgeon, who developed a single stage procedure to lengthen long
bones and subsequently developed and popularised distraction
osteogenesis. In 1973, Snyder11 first described Ilizarov’s technique to
extend a surgical osteotomy of the canine model. McCarthy et al.12
were among the pioneers who used the principles of distraction
osteogenesis in the craniofacial skeleton. In 1998, Liou and Huang13
introduced the concept of distraction osteogenesis in tooth movement.
However, it was Ferguson and Wilcko14 who affirmed that by moving
teeth through a surgical healing site, tensional stress on the teeth act in
a synergistic manner with the growth factors and redefine local bone
mass. They called it periodontally accelerated osteogenic orthodontics
(PAOO) or accelerated osteogenic orthodontics (AAO), or more
popularly it is called Wilckodontics (WO).14 Haluk Iseri et al.15
developed a concept of rapid movement of the canines in the
dentoalveolar segment in conformity with the principles of distraction
osteogenesis. Other techniques have been evolved to accelerate tooth
movement. Piezocision-assisted orthodontics16 is a minimally invasive
sophisticated surgical system which enhances bone inflammation
thereby speeding orthodontic tooth movement. Alikhani et al.
introduced micro-osteo-perforations (MOP) in the alveolar bone to
stimulate the expression of inflammatory mediators to increase the
rate of tooth movement.17 The terminology used to denote the process
of rapid orthodontic movement are listed in Table 61.2. A new
classification of surgically facilitated orthodontic treatment is given in
Flowchart 61.1.
FLOWCHART 61.1 Surgically facilitated orthodontic tooth movement

(SFOTM).
Table 61.1
Significant events in the development of dental distraction

Year Author and contribution
1876 — Concept of corticotomy was introduced
1892 Farrar Designed a specialised screw to retract the canine into the first
premolar extraction space
1959 Kole First introduced decortication facilitated orthodontics
1905 Codivilla First performed limb lengthening by using external skeletal traction
1907 Angle Developed a retraction screw to distalise the canine
1951 Ilizarov Significant contribution in developing and popularising distraction
osteogenesis of long bones
1973 Snyder Performed mandibular lengthening by gradual distraction in a canine
model
1992 McCarthy First performed lengthening of the human mandible by gradual
distraction
1998 Eric Liou Periodontal ligament distraction/inter-dental distraction/dental
distraction
2000 Ferguson and Periodontally accelerated osteogenic orthodontics/accelerated
Wilcko osteogenic orthodontics/Wilckodontics
2000 HalukIseri Dentoalveolar distraction osteogenesis
2006 Ferguson Selective alveolar decortication
2009 Serge Dibart Piezocision-assisted orthodontics
2012 Alikhani & Micro-osteo-perforation (MOP)
Michelle Y. Chou
Table 61.2
Common terms and their definitions used in surgically
facilitated rapid tooth movement (SF-RTM)
Biological basis of SF-RTM
The alveolus is comprised of lamellar bone configured into cortical
plates (compacta) and trabecular bone (spongiosa). In a steady
biological state, bone apposition and mineralisation are balanced. It
takes much less time to remodel trabecular bone than cortical bone
because of the difference in surface–volume ratio.14
Rapid tooth movement following surgery could be corticotomy
facilitated in which only the cortical bone is cut, and the medullary
bone is intact, or osteotomy facilitated where both the cortical and
medullary bone are cut to create a new bone segment.4
Following corticotomy, the alveolus becomes temporarily
demineralised chiefly due to the release of rich deposits of calcium
from the spongiosa by significantly enhanced osteoclastic activity.
This phenomenon is called alveolar osteopenia. It is followed by the
deposition of new bone, osteoid and is -supplemented with a bone
graft.14 Healing and remodelling are natural biological responses
following injury and surgery to both hard and soft tissues.
The processes associated with corticotomies are similar to processes
related to normal fracture healing and include a -reactive, reparative
and a remodelling phase (Fig. 61.1).18 In the reactive phase which lasts
for approximately 2 weeks, there is constriction of blood vessels to
mitigate -bleeding, followed by hematoma or blood clot -formation.18
The cells within the hematoma then die as do some of the -adjacent
cells19,20 and a loose aggregate of cells is formed, made up of
fibroblasts, intercellular materials and other -supporting cells
interspersed with small blood vessels -forming the -granulation
tissue.21 During the reparative phase, periosteal cells close to the
injury site, as well as fibroblasts within the granulation tissue develop
into chondroblasts and form hyaline cartilage. The periosteal cells
distal to the injury site develop into -osteoblasts and form -woven
bone.20 These -processes result in a mass of hyaline cartilage and -
woven bone called the -callus.22 The hyaline cartilage and woven bone
are then -replaced by lamellar bone as the tissue becomes -
mineralised. The -duration between callus formation and
mineralisation lasts 1–4 months.23 The remodelling phase involves
bone remodelling into a functionally competent -mature lamellar bone
which takes 1–4 years. Harold Frost24 observed a -direct correlation
between the degree of -injury and -intensity of physiological healing
response. The greater the insult, the more accelerated and intense is
the regional healing -response. He called it -regional acceleratory
phenomena (RAP). When a tooth moves through a healing surgical
site, the tensional stress on the teeth acts in a synergistic manner with
growth factors to redefine -local bone mass.2 Decortication liberates
marrow cells, stimulates neovascularisation and exposes -endogenous
mesenchymal cells to growth factors.2 Thus, a therapeutically induced
micro-strain is introduced into the bone. This mechanical tension is
directly transferred to the nuclear -cytoskeleton, which brings about
conformational changes in the nuclear DNA and alters the
cytoskeletal shape and protein synthesis.14 This induces osteo-
induction. -Mechanical signals are converted into biochemical events
via osteocyte-canaliculi syncytium.25 Thus, by using the concept of
tissue engineering, we get a newly engineered bone mass (Fig. 61.2A–
C).2 The RAP effect of a corticotomy has a finite period of bone
activation which peaks 1–2 months after corticomy and extends up to
2–4 months.5,18,26 This -suggests that effects in humans may be limited
to 2–3 months -during which 4–6 mm of tooth movement might be
expected to occur. Hence one can say that tooth movement is doubled
throughout the duration of RAP.
FIGURE 61.1 The three phases of healing. Source: Reproduced
with permission Buschang HP, Phillip MC, Ruso S. Accelerating tooth
movement with corticotomies: is it possible and desirable? Semin
Orthod 2012;18:286–294.
FIGURE 61.2 (A) Diagrammatic comparison of steady state versus
RAP induced bone resorption with hypertrophied osteocytes and
increased number of osteoclasts. (B) Shows cutting cone and
secondary osteon formation. (C) 3D diagram is showing osteocytic
osteolysis within the lamellar bone and illustrating a cutting cone
formation and formation of a secondary osteon. Source: Reproduced
with permission from Prof. Donald J Ferguson, European University
College, Dubai Healthcare City, UAE.
In osteotomy facilitated rapid tooth movement, a reparative callus is

formed between the edges of two bones which are split by an
osteotomy. The initial formation of callus is followed by an
application of distraction force which gradually pulls the bone
segment apart.27
This places the callus under tension, aligning the inter--segment gap
tissue parallel to the direction of distraction. Tension stress in the
gradually stretched tissues produces -alterations at cellular and
subcellular levels which in turn stimulates -differentiation of
mesenchymal cells into -osteoblasts.28 The tension also enhances the
formation of capillaries and -therefore enhanced bone formation.
Techniques of alveolar surgery
Piezocision-assisted orthodontics
Piezocision-assisted orthodontics is a minimally invasive surgical
procedure aimed to accelerate orthodontic tooth movement.16
Technique-Piezocision is performed one week after the placement
of an orthodontic appliance using a piezoelectric knife.16 A small
vertical incision is made buccally and inter proximally.29,30 This mid-
level incision will allow for the insertion of the piezoelectric knife.16
The tip of the piezotome is then inserted in the gingival openings
previously made, and a 3 mm deep piezoelectric corticomy is done
passing the cortical layer to reach the medullary bone to get the full
effect of the RAP16 (Fig. 61.3). In the areas with thin or no gingiva
(recessions) or with thin or no cortical bone (dehiscence and
fenestrations) hard and/or soft tissue, grafts can be added via a
tunnelling procedure.16 The patient is then seen every week or every
two weeks after surgery to change aligners or activate wires to take
advantage of the temporary demineralisation phase created by
Piezocision.16 This results in faster tooth movement and early
completion of treatment.
FIGURE 61.3 After the buccal interproximal gingival incision, the
piezotome is inserted to a depth of approximately 3 mm to do the
decortication that will start RAP. Source: Reproduced with permission
Dibert S, Keser E, Nelson D. Piezocision-assisted orthodontics:past,
present and future. Semin Orthod 2015;21:170–175.
Mechanism of action
When bone is injured using a piezoelectric knife, subsequent healing
process at the site of injury is dynamic and faster. This process is
called RAP.23,24 There is a localised surge in osteoclastic and
osteoblastic activities which result in decreased bone density and
increased bone turnover. In the alveolar bone, the RAP is
characterised, at a cellular level, by increased activation of the basic
multicellular units (BMUs), thereby increasing the remodelling space.
At the tissue level, the RAP is characterised by the production of
woven bone, with the typical unorganised pattern, that will be
reorganised into a lamellar bone at a later stage. The use of piezotome
at specific vibration frequency appeared to induce a more extensive
and diffuse demineralisation. This could be due to the additive effect
of the osteocytes response to micro-vibrations.16 Once the bone has
demineralised following bur corticotomy, there is a 3–4 month
window period to move teeth rapidly through the demineralised bone
matrix before the alveolar bone remineralises.31 Also, Piezocision can
be repeated more than once in the same area(s) to re-activate the RAP
after 5–6 months and keep the area demineralised (depending on the
difficulty of the movements being performed and the morphology of
the patient’s bone).
Clinical applications
Piezocision can be used in generalised, localised or sequential
manner.16
• Generalised: If the correction of the malocclusion requires

movement of multiple teeth in both maxilla and mandible at
the same time.
• Localised: If the correction of the malocclusion affects only one
part of the dentition or one arch.
• Sequential: If the correction of the malocclusion requires a
‘staged’ approach, where selected areas or segments of the
arch are being de-mineralised at different times during
orthodontic treatment to help achieve specific results.32
The indications/case selection and contra indications are given in

Box 61.1.
Box 61.1 Indications and contraindications of

piezocision 1 6
Indications
• Class I malocclusion with moderate or severe crowding

• Certain class II malocclusion
• Certain dental class III malocclusion
• Correction of the deep bite
• Correction of open bite
• Distalisation of molars
• Can be used with clear aligners
• Correction of mucogingival defects occurring during orthodontic
treatment
Contraindications16
• Medically compromised patients

• Patients taking drugs modifying the bone morphology
• Any bone pathology
• Non-compliant patient
• Patients with pacemaker
Advantages16
• Rapid tooth movement leading to shorter treatment time.

• Provides multidisciplinary care.
• Piezocision creates differential anchorage. It can be done
selectively around the teeth that are going to be moved, and
the anchorage value of these teeth can be lowered. Therefore,
the need for additional anchorage devices can be eliminated
by designing the alveolar decortication according to the
desired tooth movements.
• Creates ‘pliable’ bone via localised alteration of the
mineralisation/demineralisation process in various parts of the
mouth.
Micro-osteo-perforations (MOP)
MOP accelerates tooth movement based on the natural inflammatory
response of the body to physical trauma.33 It is based on the
philosophy that controlled -micro-trauma in the form of MOP would
amplify the -expression of inflammatory markers during orthodontic
treatment. The amplified response will accelerate bone resorption and
cause enhanced tooth movement.34
Mechanism of action
Application of orthodontic force causes compression and tension in
the periodontal ligament (PDL).33 Compression and tension
immediately deform and constrict blood vessels and damage cells in
the PDL. The initial aseptic, acute inflammatory response is marked
by a flood of chemokines and -cytokines from localised cells such as
osteoblasts, fibroblasts and endothelial cells.33
Many of these cytokines are pro-inflammatory and sustain the
inflammatory response by recruiting inflammatory cells and
osteoclast precursors from the PDLs extravascular space.33 Infiltrating
inflammatory cells maintain high chemokine and cytokine levels to
support osteoclast precursor differentiation into multinucleated giant
cells that perform the time consuming process of resorbing alveolar
bone needed to move teeth.33 Thus, the magnitude of cytokine release
that can be induced by orthodontic forces has an upper limit, and
consequently, the osteoclast activity initiated by orthodontic forces
has a ‘biological saturation point’.34 Increasing the force magnitude
does not overcome this limitation. While the application of
orthodontic force beyond the saturation point does not elevate the
expression and activation of inflammatory mediators beyond certain
levels,35 adding MOP to the area of tooth movement increases the
level of inflammatory mediators.36 This response is accompanied by a
significant increase in the osteoclast number, bone resorption and
localised -osteopenia around all adjacent teeth, which could explain
the increase in the rate of tooth movement.34
Clinical applications
• MOP can be selectively applied to target areas to enhance

tooth movement in one region while preventing anchorage
loss in another as treatment dictates. It decreases bone density
around the target teeth while bone density around the anchor
unit remains unchanged. Thus it helps in establishing
‘biological anchorage’.34
• It can facilitate root movement. By activating osteoclasts and
decreasing the bone density, MOP can decrease the stress on
the root during movement and therefore decrease the
possibility of root resorption.34
• It is very useful when a tooth is moved into an edentulous
space where the alveolar bone is dense with a narrow ridge.33
• MOPs should be considered during the segmental intrusion,
during which there is a possibility of root re-sorption due to
high stress area around the root apex.33
• Micro-osteo-perforation generated cortical drift-alveolar
cortical bone sets the physical and physiological limits of
orthodontic tooth movement. The cortical bone remodelling is
a slow process. Therefore, it would be beneficial for
orthodontists to manipulate these boundary conditions by
increasing bone formation at the surface of cortical bone.
Application of MOP in the opposite direction of orthodontic
tooth movement can stimulate osteoclasts that will decrease
the bone density of cortical bone and stimulate osteoblast
activity in the direction of movement.35
Contraindications16
• Medically compromised patients with compromised immune

systems.
• Patients taking drugs which modify the bone morphology like
bisphosphonates and long term corticosteroids.4
• Patients with bone pathology.
• Non-compliant patient.
Advantages34
• Minimally invasive and safe procedure to accelerate tooth
movement.
• More conservative than corticotomy and Piezocision.
• Can be repeated as a need to maximise the biological response
to orthodontic force.
• Allows bone remodelling in areas of deficient ridge.
• Less possibility of root resorption. One main reason for EARR
is high stresses that produce a cell-free zone when a tooth is
pushed towards dense bone.36 In these areas, osteoclasts are
recruited from the surrounding PDL and endosteal surfaces.
The continued presence of osteoclasts, rather than the number
of osteoclasts, causes EARR. MOP’s significantly increases the
number of osteoclasts on the adjacent endosteal bone surface
and not in the PDL34 thus reducing the possibility of root
resorption.
Corticision
‘Corticision’ was introduced as a supplemental dento alveolar surgery
in orthodontic therapy to achieve -accelerated tooth movement with
minimal surgical intervention. In this technique, a reinforced scalpel is
used as a thin chisel to separate the interproximal cortices through a
transmucosal -approach without reflecting a flap.37
Technique of corticision
The surgical blade is inserted in the interproximal bone -parallel to the
occlusal plane 5 mm apical from the tip of the papilla. The blade is
tapped with a mallet to a depth of -approximately 8 mm. Then the
angle of the blade is changed to about 45° apically and the blade is
tapped to a depth of 10–12 mm. The blade is replaced after 4–5 slices.
The goal is to cut the cancellous bone between the roots to 50%–75% of
the root length. The mobility of the teeth is tested by forcibly trying to
move them slightly. Orthodontic forces are applied immediately. The
patient is seen every two weeks, and the teeth are forcibly mobilised
to induce -minor trauma to extend the effect. This is a minimally
invasive -technique to induce accelerated tooth movement by
stimulating osteoblasts and bending alveolar bone that has been
surgically separated.38
Corticotomy facilitated orthodontic
treatment (CFOT)
The technique in the corticotomy facilitated orthodontic treatment
involves selective decortications of the alveolar bone in the area of
desired tooth movement. They primarily focus on weakening the
cortical bone–tooth interface. Some techniques suggest buccal and
lingual corticotomies followed by bone grafting to facilitate bone
expansion.39 The corticotomies appear to supercharge traditional
orthodontic treatment by inducing a state of increased turnover and
transient osteopenia, followed by a faster rate of orthodontic tooth
movement (Fig. 61.4). Corticotomy -facilitated orthodontic treatment
(CFOT) can be a broadly grouped into (1) selective alveolar
decortication (SAD) and (2) periodontally accelerated osteogenic
orthodontics (PAOO) which is also termed as accelerated osteogenic -
orthodontics (AOO). This technique is popularly known as
Wilckodontics.
FIGURE 61.4 The process by which corticotomies bring about

faster tooth movements. Source: Reproduced with permission
Buschang HP, Phillip MC, Ruso S. Accelerating tooth movement with
corticotomies: is it possible and desirable? Semin Orthod 2012;18:286–
94.
Indications/case selection
1. Adult patients who were requiring shorter treatment time.

2. Patients requiring high anchorage control.
3. Bimaxillary protrusion.
4. Patients with alveolar bone volume deficiency.4
5. Dentoalveolar discrepancies such as severe crowding.4
6. Corticotomy assisted expansion (CAE) is an effective technique
to treat maxillary transverse deficiency in adults.3
Contraindications
1. Patients with active periodontal disease or gingival recession.3

2. Bimaxillary protrusion accompanied with a gummy smile.3
3. Severe class III skeletal dysplasia.5
4. Medically compromised patients with uncontrolled diabetes
mellitus and compromised immune systems.4
5. Patients taking medications that alter bone metabolism like
bisphosphonates, nonsteroidal anti-inflammatory drugs
(NSAIDs) and on long-term corticosteroids.4
6. Non-compliant patient.
Selective alveolar decortication (SAD)

This technique is performed under local anaesthesia as a -routine
outpatient procedure. A full thickness -mucoperiosteal flap is
carefully reflected beyond the apices of the teeth to -allow adequate
decortication.40 Selective circumscribing -corticotomy cuts are
performed both labially and -lingually around the teeth to be
moved.40 This elicits the regional -acceleratory -phenomena (RAP).
Flaps are then repositioned and sutured into place.
Periodontally accelerated osteogenic

orthodontics (PAOO)/accelerated osteogenic
orthodontics (AOO)/Wilckodontics
This technique is a combination of selective alveolar decortications in
a linear or punctate pattern supplemented with a bone graft.2 It is
performed under local anaesthesia as an outpatient procedure. A full
thickness mucoperiosteal flap is reflected labially and lingually using
sulcular releasing incisions.3 The flap should be carefully reflected
beyond the apices of the teeth to avoid damaging the neurovascular
complex(es) exiting the alveolus and to allow adequate decortication
around the apices. Selective alveolar decortication is performed in the
form of lines and cuts up to 0.5 mm in depth over all the teeth that are
to be moved.3 Then an adequate bio-absorbable bone graft -material is
spread over the injured bone. This bone graft provides lateral alveolar
augmentation and has growth factors and bone morphogenic protein
(BMP) substance. Flaps are then repositioned and sutured into place.
Sutures should be left in place for a minimum of 2 weeks, and tooth
movement should be started 1 or 2 weeks after surgery (Fig. 61.5).3
FIGURE 61.5 Decortication pattern in PAOO.

Appliance activation
PAOO technique is a selective decortication facilitated -orthodontic
procedure with alveolar decortication.39-41 The surgery for PAOO is
performed during the week, following banding and bracketing.5 Both
the techniques advocated a healing period of 1 or 2 weeks before the
orthodontic -movement is started.3 The archwires are advanced
rapidly with adjustments being made at 2-week intervals. This -results
in rapid tooth movement at a rate, 3–4 times greater than normal -
orthodontic movement.5,39 The length of orthodontic treatment time is
reduced significantly from 2 to 2.5 years to -almost 6 months.5 An
evidence-based analysis of PAOO have shown the results to be quite
stable 10 years into retention.5
Advantages
1. Faster tooth movement results in shorter treatment duration

and therefore reduces patient burnout.5
2. Increases the envelope of tooth movement. There is a two- to
three-fold increase in the distance that the teeth can be moved5
as compared to traditional orthodontics.5
3. Enhanced post-orthodontic stability due to loss of tissue
memory from high tissue turnover of the periodontium, as
well as increased thickness of the alveolar cortices from the
augmentation grafting.39
4. Repairs pre-existing alveolar dehiscence by increasing the post-
treatment alveolar volume and covers the vital root surfaces.5
5. Reduces root resorption.5
6. Facilitates eruption of impacted teeth.3
7. Alleviates the need for extraction in some patients, through
bone extension.2
8. Reduced appliance adjustment pain.2
9. Usually performed as an outpatient procedure. Therefore the
risk of nosocomial infection is minimised.2
Disadvantages
1. Invasive procedure.
2. Dependent upon patient compliance for timely appliance
activation.
3. The procedure is technique sensitive, and a lot is dependent
upon the expertise of the surgeon.
4. Temporary postoperative oedema.2
5. Recession and loss of attached gingiva.3
6. Subcutaneous haematoma of the face.3
Potential complications
1. Infection
2. Devitalisation
3. Ankylosis.
Stability of PAOO
PAOO demonstrates an enhanced stability of orthodontic treatment
outcomes.42,43 Augmentation bone grafting of PAOO increases the
alveolus size and expands the soft tissue envelope gradually with
much less constraint from the craniofacial muscles. Also, there is an
increased tissue turnover and memory loss that results in undesirable
relapse type changes24 with increased thickness of cortical bone.5
Osteotomy facilitated orthodontic
treatment (OFOT)
During the past decade, rapid canine distalisation through distraction
osteogenesis has gained considerable importance because it
significantly reduces the treatment duration. Dental distraction is
brought about by using a dental distractor and can be of two types as
discussed below:
Inter-dental/periodontal distraction
osteogenesis
The canine is distalised by distracting the periodontal ligament just
like the mid palatal suture in the rapid palatal expansion with a
distraction device. When a distraction force is applied, it induces rapid
tooth movement, thereby simultaneously stretching the periodontal
ligament (PDL) on the mesial side. This enhances the cellular response
of the PDL. There are osteoid deposition and alveolar bone
mineralisation, -arranging the newly formed bony trabeculae parallel
to the path of tooth movement.13,44,45 With inter-dental/periodontal
ligament distraction osteogenesis, the upper canines can be -retracted
into the first premolar extraction spaces in about 3 weeks with a
minimal loss of anchorage and little or no root resorption.13,44,45
Dentoalveolar distraction osteogenesis

In this technique, the canine is distalised as a dentoalveolar or bone
transport segment in 8–14 days.15 Osteotomies surrounding the canine
are made to achieve rapid movement of the canine in the
dentoalveolar segment, in compliance with principles of distraction
osteogenesis. Distraction forces are applied after a latency period of 3–
7 days. This duration -allows callus formation, upon which osteoid
formation and bone mineralisation happen subsequently.15
Indications/case selection
1. Patients requiring canine retraction and first premolar

extraction.
2. Severe dentoalveolar bimaxillary protrusion.
3. Class II division 1 malocclusion with a maxillary dentoalveolar
protrusion.
4. Anterior crowding with high anchorage requirement.
5. Dental distraction works best if the teeth are in the alveolus
and are upright or mesio-axially inclined.
6. Patients with periodontal problems.
7. For alignment of ankylosed teeth.
8. Root shortening and malformations.
Contraindications for dental distraction
1. Patients with mutilated dentition.

2. Patients with debilitating diseases. However, this is not an
absolute contraindication. The patients need to be evaluated
on the type and severity of disease and its possible impact
during and after distraction.
3. Patients who are unwilling to comply with the distraction
schedule are not ideal candidates for this procedure.
4. Dental distraction is not indicated for patients with complex
behavioural problems and known psychological disorders.
Design of intraoral dental distraction (DD) appliance

The dental distractor is an intraoral, custom-made, tooth-borne
distractor cast in high-grade stainless steel. It is directly attached to
the teeth, thereby transmitting distraction forces to the bone via the
PDL (Fig. 61.6).
FIGURE 61.6 Dental distractor.
DD appliance comprises of the following parts
1. Anterior segment. Comprises of a retention arm soldered to the

canine band.
2. Posterior segment. Comprises of a retention arm soldered to
the first molar band.
3. Sliding rod. Connects the anterior and posterior segments. The
anterior portion slides distally on it.
4. Distraction screw. Placed parallel to a sliding rod, which can be
activated using a custom-made key or a wrench. The top of the
screw is rectangular in shape and should be located as anterior
as possible at an angle of 45° to the occlusal plane without
contacting the lingual surface of mandibular anterior teeth to
facilitate patient activation of the screw with a wrench. The
length of the screw is adjusted according to the distance
between the distal point of the canine and the mesial point of
the first molar.46 Preferably, a 13-mm screw should be used,
which has enough length for stability after activation
opening.47
Biomechanical considerations
The success of dental distraction is dependent upon a variety of
biological and biomechanical factors. The orientation of the distraction
device relative to the anatomic axis of the bone segment, occlusal
plane and desired direction of distraction must be considered. Most
dental distraction devices are -designed to be unidirectional. They
should be robust and placed deep in the vestibule to allow the force
vectors to pass close to the centre of resistance of the tooth. This
enables minimal tipping and more of bodily tooth movement. Since
the distractors are placed buccally in the arch relative to the centre of
resistance, their position results in distal rotation48 and some degrees
of buccal proclination of the canines. Distally moving canines
experience average distal tipping of 15–20°.13,41,48 Initial greater crown
movement than root movement slows down the stretching of
neurovascular bundle -entering the pulp and thereby reduces the risk
of endodontic complications such as pulpal irritation and necrosis.49
The technique of dental distraction

Relevant records required for complete diagnosis and planning are
prepared in a usual manner. In addition, IOPAs of the canines to be
distracted and the first molars are made to evaluate root forms,
availability of bone and exclusion of any pathology.
Clinical phase: Clinical phase is comprised of pre-surgical, surgical
and post-surgical phases.
1. Pre-surgical phase. It involves banding of the maxillary canines

and first molars and taking impressions with bands in the
mouth. Once the bands are made, they are transferred to the
model, and the distraction device is soldered to the bands. The
distractor is properly polished and then tried in the patient’s
mouth for fit and comfort.
2. Surgical phase. Surgical procedure for periodontal/inter-dental
distraction. The surgical procedure is performed under local
anaesthesia as a routine outpatient procedure by an oral
surgeon.13,44,48 The first premolars are extracted, and the inter-
septal bone distal to the canine is undermined and thinned to
1–2 mm. As the roots of the premolars are shorter than the
canine roots, the premolar sockets are extended to the same
depths as those of the canines using a round carbide bur. This
surgical step is performed carefully with the aid of trans-
operative radiographs to avoid damaging the canine root. Two
vertical grooves are made on the mesio-lingual and mesio-
buccal line angles of the extraction socket. The vertical
osteotomies are then connected with an oblique osteotomy at
the base of the socket, creating a U-shaped groove. The
objective of these osteotomies is to weaken the inter-septal
bone and allow the canine to move bodily. The wound is
thoroughly irrigated with saline and sutured (Fig. 61.7A–K).
Lately, Ribeiro et al.47 (2011) suggested a modified surgical
approach for inter-dental distraction (ID). After premolar
extraction, before starting to deepen the alveolus, a 1.5-cm
crescent shaped incision is made in the alveolar mucosa above
the root of the first premolar. The periosteum is removed, and
the buccal bone plate is exposed. From this opening, one can
directly observe the deepening of the socket, as described
above. By increasing this opening in the apical direction, one
can also accomplish through it, under direct vision, a
horizontal corticotomy above the apex of the canine without
risks (Fig. 61.8A–C).
Dentoalveolar distraction (DAD): A horizontal mucosal incision is
made parallel to the gingival margin of the canine and the
premolar beyond the depth of the vestibule. The flap is
elevated. Cortical holes are made using a small, round, carbide
bur around the root of the canine, curving apically to pass 3–5
mm from the apex. These holes are then connected around the
canine root using a thin, straight fissure bur. The first premolar
is extracted, and a round bur is used to remove bone present
distal to canine including the buccal cortical plate and
cancellous bone, leaving the palatal cortical plate intact.15 The
wound is thoroughly irrigated and sutured.
3. Post-surgical phase. The bands holding the distraction device
are cemented to the canine and first molar and after the
adhesive is set the appliance can be activated immediately or
after a period of latency. The activation is continued as per the
recommended protocol until the canine contacts the mesial
surface of the second premolar.13,44,48 Literature is not
conclusive on the timings of initiation of activation.13,45,48
While several clinicians like to start distractor activation
immediately after surgery, others recommend it after a latency
period of 3–7 days.
a. In inter-dental/periodontal distraction, the
distractors are activated one complete turn, that is
360° split into two sittings in a day. Twice with 8 h
between activations.
b. In dentoalveolar distraction, the distractors are left
in the mouth for a latency period of 3 days after
which activation is started. It is activated 180° twice
a day till the distal surface of the canine comes in
contact with the mesial surface of the premolar.
FIGURE 61.7 Technique of periodontal distraction.
(A) After extraction of the premolar. (B) Equalising socket depth for the
canine. (C) Reduction of inter-dental bone. (D) Vertical grooves made
at the mesio-lingual and mesio-buccal line angles technique of
periodontal distraction. (E) The implant drill and surgical burs used in
the procedure. (F–I) The procedure for use of implant drill before
socket widening is initiated. (J) Location of implant bur is confirmed in
the socket on IOPA radiograph. (K) Similarly, the location of the bur in
the socket is evaluated on an IOPA radiograph.
FIGURE 61.8 Modified surgical approaches for inter-dental

distraction.
(A) Buccal access. (B) Deepening of alveolus being undertaken under
direct visualisation. (C) Horizontal corticotomy is being performed
through buccal access.
Treatment progress, follow-up and records

Periapical radiographs of the canines and first molars are made on a
weekly review until completion of the canine -retraction, followed by
a monthly interval for 3 months. The films are evaluated for the
changes in the periodontal ligaments, alveolar bone deposition and
resorption, and root resorption of the canines and first molars during
the canine distraction.13
Pulp vitality is evaluated and recorded for the distracted -canines
and first molars with an electronic pulp tester.
The rate of tooth movement. The tooth movement is -rather rapid more
so at crown level. Average time taken to -distract -canines in inter-
dental/periodontal distraction is 17–22 days.49 The rapid stretching of
the PDL instantly accelerates the periodontal cellular response in
contrast to an initial -delay seen during conventional orthodontic
therapy.15 The native inter-septal bone distal to the canine is bent and
brought into the extraction socket (transport). It closely follows the
canine distraction and eventually contacts the inter-septal bone mesial
to the second molar (docking).13
In dentoalveolar distraction, the canine is distalised in 8–14 days.15
Neither the buccal nor the apical bone through the extraction site, nor
the palatal cortical plate interferes with the movement of the canine-
dentoalveolar segment during the distraction procedure.15 Also, the
traction forces in distraction are interrupted which do not cause as
much of a decrease in cellular activity in the compression zone.50 This
-allows tooth movement to initiate, 1–2 weeks earlier than seen with
continuous forces.51
Type of tooth movement. Distal displacement of the canine into the
extraction space is a combination of tipping and translation in both the
techniques.15,49 In inter-dental distraction, some tipping may occur,
possibly because of resistance offered by the inter-septal bone adjacent
to the apex of the -canine.48 Therefore, the distraction device should be
located close to the centre of resistance of the canine to enable bodily
movement (Fig. 61.9).44
FIGURE 61.9 Dental distraction appliance.

A case of canine distraction. (A) Indigenous canine distraction prepared
from a mandibular expansion screw. (B) The distractor is cemented.
(C) The first premolar is extracted. (D) Canine retraction completed in 1
week. Source: Courtesy, Dr. RS Wats, Army Dental Corps (ADC).
Anchorage loss dental distraction devices when used judiciously

and activated as per the protocol, should not induce anchorage loss in
sagittal and vertical dimensions. When a tooth is subjected to an
orthodontic force, there is a lag -period of 2–3 weeks before tooth
movement occurs, which has been attributed to the formation of a
hyalinised zone in the periodontal ligament. The aim of dental
distraction is to complete the retraction of the canines during this
period only before the first molars can move mesially.52–54 Forces–
acting more than 3 weeks can result in loss of anchorage as the canine
and the anchor unit move towards each other after the lag period.15,49
There are not many reports of pulp injury and vitality loss, tooth
discolouration or root resorption associated with this mode of therapy
although the forces are high.15,49 Root -resorption has been linked to
the duration of applied force than the magnitude of the force.55 The
amount of root resorption is also less in alveolar bone with loose bony
trabeculae.56 After tooth extraction, healing tissue fills the extraction
socket which becomes resistant and compact in about 3 months. If the
canine is not retracted across the first premolar socket in the first 3
weeks, the rate of tooth movement slows, the likelihood of external
root resorption increases and the anchor unit may move mesially.49
Therefore, the best way to minimise root resorption during distraction
is to complete canine distraction within 3 weeks and begin overjet
reduction before the canine sockets get filled with healing bone.15,56
However, while retracting the incisors varying degrees of -
anchorage loss has been noted, not to mention the -increased tendency
of the canines to migrate back into the distraction site. The latter may
result from forces produced by the stretched trans-septal fibres,
following distalisation.57 Therefore the period of consolidation or
stabilisation is increased which delays the initiation of fixed appliance
therapy and -incisor retraction. The increased duration of distractor
wear in the patient further accentuates the problems related to oral -
hygiene, speech, mucosal irritation and appearance. Therefore, a
simple appliance, which stabilises the canine after distraction, can be
used for the immediate retraction of incisors.58
Advantages
Rapid canine retraction through dental distraction has the following
advantages over the conventional method of canine retraction (Fig.
61.9):
1. Rapid retraction of the canine leading to shorter treatment

time.
2. Minimal loss of anchorage in the sagittal and vertical
directions.
3. Rapid retraction of the anterior teeth as the bone is fibrous
distal to the lateral incisors leading to further decrease in the
treatment time.
4. Elimination of the need for additional anchorage support.
Disadvantages
The drawbacks of dental distraction over the conventional technique
are (Fig. 61.9):
1. Invasive procedure.
2. Patient discomfort associated with the bulk of the distractor.
3. Difficulty in maintaining oral hygiene.
4. Constant monitoring of the patient during the distraction
period demanding excellent patient compliance.
5. Reactivation of the distractor device.
6. Technique sensitivity and a need for expertise.
Potential complications
Although dental distraction is a promising technique and has a high
potential, it could have the following complications:
1. Excessive distal tipping of crown compared to the conventional

techniques.
2. A non-compliant patient may result in treatment failure.
3. Tooth discolouration/symptoms of pulpal irritation.
4. Loss of tooth vitality.
5. Root resorption.
6. Ankylosis.
7. Infection may hinder osteogenesis.
Mono-cortical tooth dislocation and
ligament distraction (MTDLD)
MTDLD was developed by Vercellotti et al.59 to maximise the rapidity
of dental movement and prevent damage to the periodontal ligament.
During this procedure, a microsurgical corticotomy is done around
each tooth. Then buccal mono--cortical tooth dislocation is done
followed by palatal ligament distraction and application of
biomechanical force.
Advantages59
• A reduction in treatment duration by 60%–70%

• Simple and easy to perform
• Low incidence of complications.
Surgery first
Nagasaka et al.60 proposed the performance of ‘surgery first’ without
orthodontic preparation, followed by a regular postoperative dental
alignment. The postoperative orthodontic mechanics leads to
accelerated orthodontic tooth movement due to the increase in
osteoclastic activity and metabolic changes in the dentoalveolar region
caused by orthognathic surgery. The orthognathic surgery triggers 3
to 4 months of higher osteoclastic activity and metabolic changes in
the dentoalveolar region postoperatively, which possibly accelerates
postoperative orthodontic tooth movement.61
Advantages62
1. The patient’s chief complaint, dental function and facial

aesthetics are achieved and improved at the beginning of
treatment.
2. The entire treatment period is shortened to 1 to 1.5 years or less
depending on the complexity of the orthodontic treatment.
3. The phenomenon of postoperative accelerated orthodontic
tooth movement reduces the difficulty and treatment time of
orthodontic management in the surgery-first approach.
Key Points
Surgically facilitated rapid tooth movement addresses various
dentoalveolar and alveolo-skeletal discrepancies using corticotomies,
inter-dental osteotomies, dental and dentoalveolar distraction and
active orthodontics.
These techniques are promising, especially for adult -patients
because they help in overcoming many of the current limitations of
orthodontic therapy, such as long duration, a potential for periodontal
complications and limited envelope of tooth movement. All these
techniques are -osteo-inductive and have significantly changed the
way many orthodontists diagnose and treat complex malocclusions.
As with many new treatment concepts, the learning curve is steep.
Therefore the expertise of those involved and a team approach is the
essence of success. Future refinements of the appliance design may
help achieve better dental distraction. Long-term follow-up of a large
number of cases is desired to understand the real benefits of this
approach and stability of treatment.
There is a clear need to investigate in depth the molecular
mechanisms underlying accelerated orthodontic tooth movement to
elucidate the key factors that make the procedure more effective with
fewer side effects, shortest times and lowest cost to the patients. New
knowledge in this field will empower us to revolutionise orthodontic
therapy and its practice in the future.
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CHAPTER 62
Orthodontic considerations of
inter-disciplinary treatment
Parul Taneja
Lokesh Suri
CHAPTER OUTLINE
Introduction
Objectives of inter-disciplinary treatment
Diagnostic set-up
Realistic treatment objectives
Pre-restorative/pre-orthodontic periodontal status
Conditions commonly treated with inter-disciplinary care
Missing teeth/space management
Malformed teeth
Fractured teeth
Gingival discrepancies
Open gingival embrasures
Communication
Key Points
Introduction
In the recent times, the awareness about the benefits of a healthy and
aesthetically pleasing dentition has significantly increased. Our
knowledge of dental diseases and methods available to restore the
mutilated dentition has also leapt exponentially. Over the past two
decades, there has been a paradigm shift in the approach to treatment
planning for dental patients. The practice of dentistry is changing
from a single specialist or general dentist treating the patient to that of
a team approach. This team approach enables the utilisation of skills
and expertise of clinicians of different specialities. This joint care of a
patient’s dental needs is defined as inter-disciplinary treatment.
Inter-disciplinary approach is imperative for patients with
mutilated dentition. It is also invaluable for adult patients. The
mutilated dentition is observed in patients who have had dental
disease(s) and often did not receive any form of preventive or
interceptive therapy. As a result, their teeth are often malposed,
periodontally compromised, extensively worn or abraded and poorly
restored. Patients with congenital defects also benefit from inter-
disciplinary care as it idealises the dentition to an aesthetically and
functionally acceptable result.
Objectives of inter-disciplinary
treatment
The objectives of inter-disciplinary treatment are to:
• Idealise and streamline therapy

• Avoid unnecessary procedures
• Decrease treatment time
• Boost individual team members’ result
• Improve prognosis
• Enhance professional relationships
• Increase satisfaction of both patient and doctor.
Diagnostic set-up
The diagnostic set-up (Fig. 62.1A–B) is a fully waxed arrangement of
the patient’s dentition that includes prescribed orthodontic tooth
movements, tooth restorations and replacements for the missing teeth.
This set-up provides a three-dimensional visualisation of the patient’s
dentition on completion of treatment.1 It also helps the specialists to
visualise possible treatment plans. Subsequently, it serves as a
blueprint for the proposed treatment plan and an excellent tool for
communication among them. The set-up is also used as an
educational tool for the patient.
FIGURE 62.1 Inter-disciplinary approach for mutilated dentition.
(A) Pre-treatment photographs of a patient with mutilated dentition. (B)
The diagnostic set-up.
Realistic treatment objectives

Realistic and achievable treatment goals are determined after careful
consideration of aesthetics, function and occlusion. It is important that
the team members recognise the cases or dentitions where an ideal
outcome cannot be achieved. The two issues of paramount concern for
the patient are the duration of treatment and fee. They cannot be
ignored. Therefore, the realistic objectives of a case are set after the
various possibilities of the treatment are explored, their limitations
recognised, the financial and time limitations expressed by the patient
are considered.
Pre-restorative/pre-orthodontic
periodontal status
A healthy periodontium is a foundation for a stable dentition,2
therefore, the success of any inter-disciplinary treatment is dependent
upon sound periodontal treatment planning. The first phase of
treatment always involves a thorough periodontal work up. The
initial therapy is directed towards the control of aetiologic factors such
as plaque, sub-gingival calculus and occlusal trauma.2–6 A re-
evaluation is made in 3 months to evaluate the prognosis of
individual teeth. After initial therapy, the patient is assessed for tissue
response to determine whether the periodontium is stable enough to
proceed with restorative and/or orthodontic treatment. Areas of
minimally attached gingiva are evaluated and grafted before initiating
any restorative or orthodontic treatment. From an orthodontic
standpoint, teeth that are to be proclined are at a greater risk of
gingival recession.7,8 In addition, teeth with prominent roots are at a
higher risk of recession through mechanical and toothbrush trauma.2
An individualised periodontal maintenance regimen is determined for
the patient at the re-evaluation visit, maintained during treatment and
in the subsequent phase.
Conditions commonly treated with
inter-disciplinary care
Inter-disciplinary care can be discussed under the following
categories:
1. Missing teeth/space management

a. Tooth agenesis
b. Extracted teeth
2. Malformed teeth
a. Single malformed tooth
b. Multiple malformed teeth
3. Fractured teeth
4. Gingival discrepancies
a. Anterior aesthetic zone
b. Vertical maxillary excess or deficiency
Missing teeth/space management

Tooth agenesis
Mandibular second premolars rank highest as the most common
congenitally missing tooth followed by the maxillary lateral incisor,
except the third molars.9 In cases where the mandibular second
premolars are missing and the primary second molars are present, it is
often possible to maintain the latter for a long term. If they are
submerged due to ankylosis, they can be restored to the functional
occlusal plane with restorations such as occlusal composites. If the
adjacent teeth have drifted and tipped over the occlusal level of the
primary molar—orthodontic treatment may be necessary to reposition
those teeth with subsequent restorative care.10
During orthodontic treatment, the size of the deciduous molar often
needs to be reduced at interproximal surfaces to obtain optimal
occlusion. Reduction of mesiodistal dimensions of a deciduous tooth
is required to match with the succedaneous tooth of smaller
dimensions (Fig. 62.2A–D). In skeletally immature patients, ankylosed
teeth may have to be extracted to avoid the restriction leading to a
vertical growth of the alveolus.11 In such cases, careful space
management is necessary for future treatment options.
FIGURE 62.2 (A and B) Photographs showing the occlusal and the

left buccal view of a patient with retained and submerged mandibular
left primary molar. Note the lateral open bite. (C) View of the left buccal
occlusion after orthodontic treatment. Note the reduction in mesiodistal
width of the primary molar. (D) Restored primary molar using an onlay.
The patients who have a congenitally missing lateral incisor seek

treatment in the dental office at a relatively young age. This is because
the spacing is associated with the maxillary anterior aesthetic zone
(Fig. 62.3A–B). These cases may often have maxillary canines erupting
in the space for the maxillary lateral incisors. Occasionally, canine
impactions may also occur. The presence of the lateral incisor is a
guide to the direction of eruption for the permanent canines.
Impactions and ectopic eruption of the canine may occur due to lack
of eruption guidance.12,13
FIGURE 62.3 (A) Frontal view of the dentition. (B) Panoramic
radiograph of a patient with congenitally missing maxillary lateral
incisors. Note the mesially erupting permanent canines in the position
of the maxillary lateral incisors.
Two common treatment options for the treatment of congenitally

missing lateral incisors include:
• Space opening for restorative replacement of the missing

lateral
• Space closure.
Orthodontic space closure. The choice of treatment depends upon

the occlusion of the patient and the remaining general growth of the
patient. If the canine is to be substituted for the lateral incisor, it is
reshaped for aesthetics. It may require slight extrusion in order to
bring the gingival margin incisal to that of the central incisor. This
helps in establishing an ideal gingival aesthetic relationship between
the central incisor and the canine in the lateral incisor site. This is
especially important for a patient with a high smile line. Often the
shade of the canine is much darker than the adjacent incisors if so it
may have to be either bleached or veneered to match the shade.14
Space maintenance and rehabilitation. If a decision to open space
for the missing lateral incisor is made and the canine is unerupted, the
canine is allowed to erupt mesially into the lateral incisor spot to
develop the alveolar bone with tooth eruption. Once the canine has
erupted, the orthodontist can distalise the canine into class I
relationship with the opposing canine. The alveolar bone that
develops in this manner can often be maintained during the growth
years until definitive restorative care is feasible. The decision
regarding space requirement for the subsequent replacement of the
lateral incisor is made by the dentist. The ideal restoration for missing
teeth is an implant.15 Prior to the removal of appliances, the
restorative dentist should review the progress of treatment to make
sure that adequate space has been created. Space should be evaluated
between the roots and at the level of the crowns to ensure successful
implant placement. The root uprighting in the region of the missing
tooth can be monitored with a periapical radiograph using the long
cone technique. The implant is placed when the vertical growth of the
patient is complete. This is usually around 14–15 years of age in girls
and 16–17 years of age in boys. The changes in growth are monitored
by taking serial cephalometric radiographs at least a year apart.11
They serve as a reliable guide to evaluate the progress and determine
the appropriate stage for implant placement. A Maryland bridge or a
pontic on a retainer can serve as an interim prosthesis until the
completion of growth.15
Extracted teeth
Dental caries, periodontal disease and traumas are the most common
causes of tooth loss. Sometimes treatment is not sought for these lost
teeth by the patients for extended periods of time. This lack of
restorative care alters the equilibrium of the dentition. It leads to
shifting and tipping of the individual dental units, changes the cant of
the occlusal plane and creates functional shifts. It is possible to treat
these situations by restorative means alone; however, it is not ideal.
Tipped teeth can be included into the design of the prosthesis such as
telescopic crowns, a ring clasp or a reverse action clasp for a
removable partial prosthesis,16 endodontic treatment and crowns for
supra-erupted teeth, etc. The tipped teeth, however, are not the best
abutments for either a fixed or a removable prosthesis because the
occlusal forces are not directed along the long axis of the tipped teeth.
Besides, they often have three-walled periodontal bony defects on the
side of the tip.3,17 Orthodontics is also used to intrude supra-erupted
teeth and re-establish the correct occlusal plane.18 Such procedures
may simplify the restorative treatment.
The current standard of care involves orthodontic treatment along
with restorative treatment. The correct axial inclination of tipped teeth
is established by orthodontics (Fig. 62.4A–B). This improves the
periodontal prognosis and long-term maintenance of the tooth. It also
improves access to the restorative dentist to idealise the subsequent
fixed or removable prosthesis. It ensures achievement of ideal
interproximal embrasure form.
FIGURE 62.4 (A) Pre-treatment intraoral photographs of a patient

with a mutilated dentition showing deep bite, missing mandibular left
second premolar and first molar, space between the mandibular right
first and second premolars. Lingual occlusal view is showing
congenitally missing mandibular incisor. (B) Post-treatment
photographs showing an uprighted mandibular left second molar,
improved anterior overbite and space gained.
Sometimes the need for restorative care can be eliminated by

orthodontic space closure. An example of this is the frequently
missing first permanent molar that was lost early in life and the
second molar erupted mesially tipped into the space of the permanent
first molar. The ultimate possibility to close the space orthodontically
depends on the general occlusion, crowding and the available
anchorage.
Malformed teeth
Local or single malformed teeth
One of the most common malformations observed is the peg-shaped
maxillary lateral incisor (Fig. 62.5A). The patient often presents with
aesthetic discrepancies of the anterior region including uneven space
distribution and a midline deviation.19 The size and shape of the
malformed tooth need restorative care, but prior to any restorative
care, space distribution has to be established. If sufficient space exists,
a composite restoration or a ceramic veneer may be done to establish
ideal results. However, in most patients, both the space distribution
and occlusion are not ideal for restorative treatment. Space has to be
matched to the size of the contralateral incisor. The bite also has to be
corrected to an ideal overbite and overjet by orthodontic means (Fig.
62.5B). Adult case with spacing in upper anterior region treated with
fixed orthodontic appliance followed by restorative treatment is
shown in Fig. 62.6A.
FIGURE 62.5 (A) Pre-treatment intraoral photographs of a patient

showing peg-shaped and malformed incisors. (B) Orthodontically
aligned dentition with composite veneers on maxillary anterior teeth.
FIGURE 62.6 (A) Case RB, 39 years adult patient with deep bite,
microdontic lateral incisor, the spacing in upper arch and mesially
tipped upper central incisors. Fixed orthodontic treatment for
redistribution of space in upper arch for aesthetic composite restoration
and contact points build-up, bite opening and correction of upper
incisor tip was planned. (B) Case RB, after 18 months of fixed
orthodontic treatment, the space in upper arch is redistributed between
mesial and distal side of upper lateral incisors for the aesthetic
restorative procedure and upper central incisor tip is corrected. (C)
Case RB, post de-bond photographs show aesthetic composite
restoration of upper lateral incisors to proportionate the tooth size and
to provide contact point, hence improved smile.
Space management is easily accomplished with fixed orthodontic

appliances. Removable appliances are capable of affecting tipping
movements only and thus are of limited use. The removable
appliances are also incapable of idealising the axial inclination of the
teeth. In addition to space management, treatment to idealise the
overbite and overjet is essential to achieve an ideal restorative
outcome. If a deep bite is present, the composite restoration or the
veneer may not last long. It is likely to fracture frequently. Bite
opening mechanics with intrusion and/or extrusion can be employed
to idealise the vertical dimension of the tooth and subsequently, the
patient can proceed with restorative care. If a full coverage restoration
is planned, the overjet can be selectively increased by 0.5–0.75 mm on
the peg lateral to minimise lingual reduction.1 This can also help the
restorative dentist in minimising tooth reduction of an already
malformed tooth. The overbite is kept minimal when veneers are
planned in the restorative treatment.
Multiple malformed teeth

Generalised malformations of teeth can present a major challenge to
achieve an ideal treatment outcome. Though such malformations are
relatively uncommon, treatment of such aberrations require a
thorough understanding of the nature of the problem. Such patients
may occasionally have other systemic issues that need to be addressed
in the treatment planning. The role of the orthodontist in such cases is
to facilitate any subsequent restorative care. Bite opening is usually
necessary to increase the vertical dimension and can be achieved with
orthodontic treatment. If the condition is diagnosed early in life then
the development and eruption of the malformed teeth can be followed
by the orthodontist and the paediatric dentist. Such teeth often have
deviations in eruption pattern. If the malformation is severe, the teeth
may be extracted. The timing of extraction and issues of space
maintenance needs to be under the care of an orthodontist or
paediatric dentist to ensure the viability of future restorative options.
Fractured teeth
Fractured teeth above the gingival margins can be treated
restoratively with a cast or a pre-fabricated post. A coronal restoration
is then placed to re-establish ideal contours and aesthetics. A fracture
below the gingival margin encroaches on the ‘biological width’
creating significant restorative challenges.2 Besides fractures when a
carious lesion extends below the gingival margin, the biological width
may also be violated. In some situations, if the level of the fracture is
substantially below the gingival margin, the tooth cannot be restored.
So the tooth may be extracted and then subsequently replaced with a
fixed or removable restoration.
In other cases, the fractured tooth can be restored by making the
portion below the gingival margin amenable to restorative care with
either periodontal or orthodontic means. Periodontal surgery can
reposition the gingival margin to an appropriate level to expose the
sound tooth structure and allow for the restorative dentist to proceed
with the tooth restoration.20 Alternatively, orthodontic extrusion may
be considered to bring the root portion to the appropriate level for
subsequent restorative care. Both procedures aim to establish the
restorative margin on sound tooth structure without violating the
biological width.
Before deciding between periodontal surgery versus forced
orthodontic extrusion of a tooth fractured below the gingival margin,
it is necessary to assess the following parameters:
1. Root length. As the length of the root portion within the bone
has a direct bearing on the final crown/root (C/R) ratio, the
final C/R ratio needs to be established before initiating the
therapy. Anything greater than a 1:1 C/R ratio is considered to
have a poor prognosis for long-term maintenance.21
2. Root shape and form. A tapered or conical root fragment has a
much smaller root surface area than a broader or a wide root.
A tapered root shape may predispose a tooth to chronic
mobility after restoration.
3. Gingival sulcus depth. It is also important to evaluate the
periodontal health prior to making any decision regarding
orthodontic treatment or periodontal surgery.2
4. Aesthetics. In the anterior zone, the relative position of the
gingival margin has a critical role in the overall aesthetics of
the patient. Periodontal surgery or orthodontic treatment may
either improve or negate the aesthetics if the gingival margins
are positioned unevenly. In addition, if the tooth is non-
salvage, a surgical extraction necessary in the anterior region
may result in a defect in the alveolar ridge. In such a situation,
orthodontic extrusion leading to extraction would prevent the
development of a defect in the alveolar bone. This enables
creating a site for future implant placement or enhanced
aesthetics as it would not develop a defect in the alveolar bone.
In the patient with a high smile line, it is especially important
to rectify aesthetic defects.1,11,14
Gingival discrepancies
The relative level of the gingival margins of the six maxillary anterior
teeth has a significant influence on the aesthetic appearance.
Characteristics that contribute to ideal gingival form include:
1. Height of gingival margins. In the aesthetic zone, the gingival

margins of the maxillary central incisors are even, the lateral
incisors even with each other but about 0.5 mm coronal to that
of the central incisors and the gingival margins of the canines
about 0.5–1.0 mm apical to those of the maxillary lateral
incisors.
2. The contour of labial gingival margins. It is usually even with
the greatest height slightly distal to the centre of the tooth.
3. Papilla form and embrasure form. The height of the papilla is
usually halfway between the incisal edges.
Combined orthodontic and periodontal procedures can be used to

establish the proper levels of the gingival margins. A sulcular depth of
greater than 1 mm may necessitate gingival surgery to create more
ideal gingival health and architecture. In other cases, orthodontics
may help in the establishment of ideal gingival architecture. Intrusion
or extrusion of teeth allows for the movement of gingival margin in
the direction of the orthodontic movement. Accordingly, abraded
teeth may have to be intruded or extruded relative to each other to
correct gingival height discrepancies in the anterior aesthetic zone
(Fig. 62.7A–B).
FIGURE 62.7 (A) Frontal view of dentition showing poor anterior

aesthetics due to gingival margin discrepancies. Fractured and over
erupted maxillary left central incisors. (B) Restored maxillary left incisor
using orthodontic intrusion and composite bonding.
Open gingival embrasures

The presence of a papilla between the anterior teeth is a key aesthetic
factor in any individual.22 The lack of a papilla leads to an open
gingival embrasure or a black triangle between the teeth. These are
extremely unsightly and difficult to resolve with periodontal therapy.
Black triangles are present due to one of the three factors:
1. Tooth shape
2. Root angulation
3. Periodontal bone loss.
Periodontal regenerative therapy can be attempted to re-establish

inter-dental papilla, but it does not have great success.2 The problem
can be tackled by orthodontic correction of root angulation and
reshaping of interproximal areas of teeth with conical crowns.
Subsequent space closure often helps to close open gingival
embrasures.
Communication
Communication is key in the success of inter-disciplinary treatment.
In most situations, the patient’s general dentist is responsible for the
orchestration of the whole treatment. The general dentist is usually
assisted by an office manager or a treatment coordinator who ensures
that appointments are sequenced as dictated by the different
specialists involved in the case.
The wide range and complexity of problems that these patients
present with, necessitate a highly organised method of
communication among the team members. This allows each member
to voice opinions and presents the pros and cons of a suggested
option. Communication can happen by several means—electronic or
verbal, but team conferences and meetings in person are usually the
most effective. Such meetings can be scheduled at regular intervals to
discuss treatment progress of patients.
Key Points
This chapter has described conditions that frequently warrant inter-
disciplinary dental treatment. It is crucial that the orthodontist and the
restorative dentist establish treatment objectives that are realistic and
meet the needs of the patient. Constant interaction and
communication amongst practitioners and the patient are keys to the
success of the inter-disciplinary treatment.
References
1. Kokich VG, Spear FM. Guidelines for managing the
orthodontic-restorative patient. Semin Orthod.
1997;3(1):3–20: Mar; PubMed PMID: 9206469.
2. Newman MG, Takei H, Kiokkevold PR. In: Carranza
FA, editor. Carranza’s clinical periodontology.
3. Geron S. Managing the orthodontic treatment of
patients with advanced periodontal disease: the
lingual appliance. World J Orthod. 2004;5(4):324–331:
Winter; PubMed PMID: 15633379.
4. Laino A, Melsen B. Orthodontic treatment of a
patient with multidisciplinary problems. Am J Orthod
Dentofac Orthop. 1997;111(2):141–148: Feb; PubMed
PMID: 9057613.
5. Machuca G, Martínez F, Machuca C, Bullón P. A
combination of orthodontic, periodontal, and
prosthodontic treatment in a case of advanced
malocclusion. Int J Periodontics Restorative Dent.
2003;23(5):499–505: Oct; PubMed PMID: 14620124.
6. Norton LA. Periodontal considerations in
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7. Yared KF, Zenobio EG, Pacheco W. Periodontal
status of mandibular central incisors after
orthodontic proclination in adults. Am J Orthod
Dentofac Orthop. 2006;130(1):6: Jul; e1-8. PubMed
PMID: 16849063.
8. Djeu G, Hayes C, Zawaideh S. Correlation between
mandibular central incisor proclination and gingival
recession during fixed appliance therapy. Angle
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Dec; Review. PubMed PMID: 17190296.
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Congenital tooth anomalies and malocclusions: a
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impaction of the maxillary canine. Br J Orthod.
1989;16(1):9–16: Feb; PubMed PMID: 2923851.
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1997;18(12):1225–1231: Dec; quiz 1232. PubMed
PMID: 9656846.
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16. Carr AB, McGivney GP, Brown DT. McCracken’s
removable partial prosthodontics. St Louis: Mosby;
2004.
17. Mathews DP, Kokich VG. Managing treatment for the
orthodontic patient with periodontal problems.
Semin Orthod. 1997;3(1):21–38: Mar; PubMed PMID:
9206470.
18. Yao CC, Wu CB, Wu HY, Kok SH, Chang HF, Chen
YJ. Intrusion of the over erupted upper left first and
second molars by mini-implants with partial-fixed
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19. Counihan D. The orthodontic restorative
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2001;120(2):116–123: Aug; PubMed PMID: 11500652.
CHAPTER 63
Evidence-based orthodontics
N.G. Toshniwal
CHAPTER OUTLINE
Introduction
Why practice evidence-based orthodontics (EBO)?
Why teach evidence-based orthodontics?
A historical perspective of evidence-based orthodontics
Case-control study
Cohort study
Systematic reviews
Main steps of systematic review
Randomised controlled trials
Meta-analysis as a tool for the evidence-based practice
(EBP)
EBO practice steps
GRADE transitional tool
Cochrane
Evidence-based clinical practice in orthodontics
The treatment of class II malocclusion—an evidence to
make a decision
Class III malocclusion—the evidence on diagnosis and
treatment
Extraction and non-extraction approach: the evidence
Evidence-based use of orthodontic TADs
Orthodontics and temporomandibular joint disorders
(TMD): an evidence-based approach
Orthodontic retention and stability: EBO guidelines
The use of CBCT in clinical orthodontics
Evidence-based conclusions in orthognathic surgery
Accuracy and reliability of digital models: SR and MA
Accelerated orthodontic tooth movement: an evidence-
based guidelines
Evidence-based guidelines for orthodontically induced
inflammatory root resorption (OIIRR)
Obstructive sleep apnoea (OSA)
Key Points
Introduction
A huge amount of health care information has become available on
the touch of a button, revolutionised by the digital and the web world
since the end of the 20th century. This situation of an abundance of
literature, some of which may have components of BIAS or
contradiction, has created a serious a challenge in the minds of
clinicians, who are trying to make informed decisions for their
patients about the relative effectiveness of the various treatment
options.
The lack of systematic assessment of the literature led to delays in
the incorporation of better treatment as less effective, less efficient and
even harmful intervention(s) continued to be recommended. (1) In
response to this problem, medical experts pioneered an evidence-
based approach to clinical practice. Evidence-based medicine (EBM)1
has been defined by Rosenberg as the process of ‘Systematically
finding, appraising and using contemporary research as the basis for
clinical practice’. This definition can be applied to dentistry and its
specialities including orthodontics.
A recent article in the Journal of American Dental Association, Ismail
and Bader2 defined evidence-based dentistry (EBD) as ‘An unbiased
approach to oral healthcare that follows a process of systematically
collecting and analysing scientific evidence with the objective of
gaining use full decision-making information with minimal bias’.
Evidence-based orthodontics is an unbiased approach to orthodontic
care like EBD.2
Why practice evidence-based orthodontics

(EBO)?
Simply because of we, as health care professionals, owe it to our
patients to provide the currently best care available1 (Fig. 63.1).
FIGURE 63.1 Components of expertise in evidence-based clinical
decision.
Why teach evidence-based orthodontics?

‘To prepare our student with lifelong learning skills, so that they
continue to evaluate and use information for patients’1 (Fig. 63.2). An
orthodontist, like all health care providers, wants to know three things
about the treatment he or she is providing which are as follows
(Fig. 63.3):
1. Effectiveness (how well it works, i.e. how effective it is in

dealing with the patient’s problems, taking into account
possible negative side effects);
2. efficiency (how cost-effective it is, with cost in its broader sense
to include time and effort for the provider and impact on the
patient); and
3. predictability (the amount of variation in patient response).3
FIGURE 63.2 Right approach in evidence-based orthodontics
(EBO).
FIGURE 63.3 Three components of EBO.
A historical perspective of evidence-
based orthodontics4
The methods involved in creating, synthesising and disseminating the
knowledge which a dentist depends on when examining and treating
their patients have evolved through years.. In the first stage of this
evolution, the dental knowledge base was unwritten; dentists learned
from their experiences in treating patients and disseminated their
knowledge one-on-one through the apprenticeship system.
The second stage began approximately three centuries ago.
Learning was still experiential, but the appearance of texts and
journals permitted both syntheses of knowledge based on the
experiences of others and widespread dissemination of this
accumulated knowledge.
The third primary stage of the evolution of the dental knowledge
base began gradually at the dawn of the last century as the knowledge
generated through experimentation began to replace that based on
personal experience. Synthesis also evolved as literature reviews
became prevalent.
Nearly a century later, the dental knowledge base has begun a
fourth major stage in its evolution. The hallmark of this stage is the
systematic review (SR). SRs are a recent development in dentistry,
with the first SR of a clinical dental topic appearing in 19895
(Table 63.1).
Table 63.1
Differences between narrative and systematic reviews

Narrative review Systematic review
Clinical question Often several general Focused question following PICO
question addressed
Search for primary articles Not comprehensive or not Comprehensive search of multiple
reported sources
Select primary articles Not reported or selective Explicit inclusion/exclusion criteria
inclusion
Quality assessment of Not systematic or not Assessment of methodological quality of
primary articles reported included articles
Summary of results of Qualitative, non systematic Systematic qualitative or quantitative
primary articles summary (meta-analysis)
In dentistry, the methodology of conducting and critiquing SR has

been embraced by the American Dental Association (ADA), which has
devoted considerable resources to the development and promotion of
evidence-based dentistry during the past decade.6 ADA’s efforts has
resulted in translating and disseminating the evidence to help
practitioners incorporate evidence-based approach in their clinical
practice in collaboration with the centre for evidence-based dentistry
(CEBD). The ADA supports the vision of the centre of EBD through
the website and Journal of the American Dental Association (JADA),
which publishes critical summaries from a wide range of ADA
reviewers. The reviewers critique and summarise SRs in dentistry and
oral health. The ADA and the Cochrane Collaboration works together
to provide latest and best research information about evidence-based
care to the practitioners and health care providers.7,8
Evidence scientists have prioritised each type of evidence according to
the importance and weight, it is accorded during decision making. At
the low end of hierarchy lies expert opinion and at the high end lie
high quality meta-analysis (MA), SRs and randomised control trial
(RCT) with a very low bias.
Expert’s opinion9,10 is the clinician’s opinion about the diagnosis
and treatment planning of the desired case based on his knowledge
(which may or may not be updated) and clinical experience (which
may be adequate or inadequate) (Figs 63.4 and 63.5). While
considering the same does not always mean false, but it may or may
not be applicable for a large number of patients in relation to cost
versus benefits.
FIGURE 63.4 Evidence of clinical effectiveness: a hierarchy of

quality of evidence of the various study designs (in descending
order).
FIGURE 63.5 Evidence of clinical effectiveness: a hierarchy of
quality. Source: Proffit WR. Evidence and clinical decisions: asking the
right questions to obtain clinically useful answers. Semin Orthod
2013;19(3):130–6.3
SR and MA studies represent the latest wave of innovations that are

changing the way in which information is gathered, summarised and
distributed for use by clinicians.
The hallmark of evidence-based practitioners is that for particular
clinical decisions, they know the strength of the evidence and
therefore the degree of uncertainty. Traditionally, none of the dental
schools, medical schools and postgraduate program have taught these
skills. EBO practitioners must know how to search the literature
efficiently to obtain the best available evidence bearing on their
question, to evaluate the strength of the methods of the studies they
find, and to extract the clinical message, apply it back to the patient
and store it for retrieval when faced with similar patients in the future.
Case report: It is brief, objective report of a clinical characteristic or
a report on outcome from a group of clinical subjects.
The case selection may vary from individual to individual as
regards to clinical characteristics and procedural variations in relation
to the cost, time and benefit (selection bias). Also, as there is no control
group, the comparative outcome is difficult to obtain. These may be
considered as a limitation of case reports and case series.
Longitudinal and cross-sectional studies (incidence prevalence
studies): They are a type of case series report in which the entire
population is well defined and then uniformly surveyed regarding
parameter in the research question.
A cross-sectional study is an observational study and the
investigator has no control over the exposure of interest (e.g. type of
malocclusion). It includes identifying a defined population, or a
representative subset, at a particular point time, measuring a range of
variable on an individual basis and at the same time measuring the
outcome of interest that analyses data from a population, or a
representative subset, at a specific point in time, that is cross-sectional
data.
Case-control study
The case-control is a type of epidemiological observational study. An
observational study is a study in which subjects are not randomised to
the exposed or unexposed groups, rather the subjects are observed in
order to determine both their exposure and their outcome status and
the exposure status is thus not determined by the researcher. The
study proceeds backwards from effect to cause, and it uses a control
or comparison group to support or refute an inference.
Cohort study
A cohort study is an observational study where the sample (A Cohort)
is a group of people who share defining/common characteristics such
as the same types of malocclusion. The sample (A Cohort) is identified
before the appearance of the disease under the investigation (e.g.
developing malocclusion). These cohorts are observed over a period
to find out the frequency of disease (malocclusions) among them. The
study proceeds forward from aetiology of malocclusion (cause) to
effects of orthodontic treatment (effect).
Systematic reviews
Systematic reviews are aimed to collect and assimilate high quality
evidence for the effects of the intervention, in a systemic, transparent
and unbiased manner.
The collected information may be combined qualitatively or
quantitatively. Quantitative analysis may produce a more precise
estimate of efficiency and safety of therapy. Additionally, systematic
reviews may reconcile misunderstanding and existing controversies
regarding therapies and expose knowledge gaps and unanswered
questions, which may be addressed in future trails.
Reviews (Fig. 63.6) (i.e. research of literature on specific topics the
published and unpublished literature) can be divided into two types:
• Narrative reviews
• Systematic reviews.
FIGURE 63.6 Two major category of reviews. Concept based on

Pandis N, Randomized clinical trials (RCTs) and systematic reviews
(SRs) in the context of EBO, Semin Orthod 2013;19(3):142–57.10
In narrative reviews, no systemic and transparent methods were

adapted for research of studies and data synthesis. This gap gave way
to SRs (Table 63.1).
Main steps of systematic review
The validity of SR results is closely associated with the transparent
and disciplined methodology for their results to be trusted. The main
steps when conducting a SR are as follows (Fig. 63.7).
FIGURE 63.7 Main steps of systematic reviews. Source: Pandis N,
Randomized clinical trials (RCTs) and systematic reviews (SRs) in the
context of EBO, Semin Orthod 2013 (September);19(3):142–57.10
The desired research question should be in Patient, Intervention,

Comparison and Outcome (PICO) format. The studies related to a
similar research question are identified having similar material and
methods through Pub Med, Embase, and similar data base(s). The
relevant studies are selected for an SR after considering selection bias
(selective study inclusion) and publication bias (studies with
significant results are more likely to be published than studies with
non-significant results). The data from these studies is assessed for
quality synthesis, and the relevant interpretation is drawn.
Qualitative synthesis from SRs is known as ‘Narrative Synthesis’
while quantitative synthesis from SRs is known as ‘Meta-analysis’.
The potential benefits of developing and adopting SRs and MAs are
the reporting guidelines (Fig. 63.8).
FIGURE 63.8 Benefits of reporting guidelines. Source: Pandis N,
The important guidelines are accurate study design, data

abstraction and synthesis with quality assessment. The procedure
should be accurate, consistent, complete, transparent and should be
related to patient care and health-care policies.
Randomised controlled trials

RCT is a pre-planned experiment that aims to assess the effect or
benefits of at least one treatment modality in humans. RCT uses a
controlled group and randomisation to assign participants to
treatment arms and aims to create similar treatment groups in all
respects except the intervention.
The use of the control group is important as it allows separation of
actual treatment effects from changes that may occur due to natural
improvement, biased patient selection, and/or biased patient
responses. RCTs provide valid results if they are free of/or have
reduced bias.
During RCTs appraisal the following questions are important
1. What is the research question?

2. Can the result be trusted?
3. What are the results of the trial?
4. How can the result/conclusion be applied?
The above four questions have several components that should be

considered when appraising the report.
The components constitute the participant, intervention (treatment),
comparators (control group) and the outcome measure along with
validity and methodology of results with an appropriate evidence-
based conclusion.
Meta-analysis as a tool for the evidence-

based practice (EBP)
The term Meta-analysis (MA) was first proposed in 1976 by Glass, a
psychologist. MA involves statistical steps that integrate the result of
several independent studies considered to be combinable. An MA is a
study of the studies, said Kassiver (Glossary at Cochrane
Collaboration). By combining the data from individual studies, an MA
increases the overall sample size, which in turn, raises the statistical
power of the analysis as well as the precision for estimating the
treatment effects (Box 63.1).
Box 63.1 Purpose of meta-analysis

To summarise a large and complex amount of literature on a
‘research question,’ thereby resolving conflicting reports.
To clarify or qualifying the strength and weaknesses of various
studies on a specific research field.
To avoid the time and expense of conducting a clinical trial.
To increase the statistical power of the analysis by combining
data from many small studies.
Because the ‘data’ used for MAs are derived from original studies
published in the scientific journal, the quality of the MAs depends
heavily on the quality of these studies. They statistically combine the
result of several studies into a single outcome measure (Box 63.2).
Box 63.2 Strengths and limitations of meta-

analysis
S.No. Strengths Limitations
1 It permits quantitative synthesis of the Errors in the classification in the studies or in
literature that addresses specific research calculating the effective sizes because of the
areas. complicated coding system used.
It is possible to reach a stronger Some studies do not provide all the necessary
conclusion because more studies can be information required for analysis.
analysed objectively with specific
statistical method.
2 It is very helpful in examining with lack of A further weakness of MAs can arise from
evidence in a specific research field situations when the available studies for a
providing insight into new direction for particular research area are few or they are of
research. low quality.
3 Heterogeneous data from studies could limit
the interpretations.
Although the quantity of MA in orthodontics is still low, their

number is continually increasing over the last few years. The MAs
with orthodontic related subjects conducted so far provided only
limited evidence, mainly due to methodological inconsistencies and
the low number of original studies appropriate to be included in the
analysis.
EBO practice steps (Fig. 63.9)
Stratus10 has outlined the steps for EBO as follows
1. Ask clinical questions that may be answered using good

quality clinical research.
2. Search and locate the best evidence that will answer the
question of interest. For treatment effectiveness, if available,
identify high-quality SRs and RCTs.
3. Appraise the evidence regarding its validity, impact, and
applicability in your particular setting.
4. Combine best research evidence with clinical expertise and
with the patient’s biology, preferences and setting.
5. To continually improve and streamline the EBO process, assess
the successful and effective implementation of the previous
four steps.
FIGURE 63.9 Steps during EBO practice. Source: Pandis N,
The establishment of the evidence-based approach resulted in rapid

changes in the health care system and education of students and
residents in the health-care professions. A paradigm shift has
occurred from the paternalistic choice of a treatment intervention by
doctors for their trusting patients to a partnership in which the doctor
and patient make choices together to determine the best treatment. It
was, therefore, incumbent to the health care provider to have
knowledge of the best available evidence pertaining to the risks, costs,
benefits, burden and the probability of success for various treatment
options.
The orthodontists focus for clinical decision making should be on
treatment protocols and strategies that are proven to be both
efficacious and safe. To facilitate evidence-based decision making, a
plethora of guidelines have been developed that aim at improving
research methodology, reporting, appraisal, synthesis and translation
of scientific evidence into the clinical practice. Among the guidelines
pertinent to orthodontics are following:
• Consolidated Standard of Reporting Trials (CONSORT)11

• Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA)12
• Strengthening the Reporting of Observational Studies in
Epidemiology (STROBE)13
• Meta-analyses of Observation Studies in Epidemiology
(MOOSE)14
• Standards of Reporting of Diagnostic Accuracy (STARD)15
• Assessment of Multiple Systematic Reviews (AMSTAR)16
• Strength of Recommendation Taxonomy (SORT)5
• Cochrane17,18
CONSORT (Consolidated Standard of Reporting Trials)11

statement is used worldwide to improve the reporting of RCTs.
Kenneth Schulz19 and colleagues describe the latest version,
CONSORT 2010, which updates the reporting guideline based on new
methodological evidence and accumulating experience.
PRISMA. Devid Moher et al.20 in 2015 described these reporting
guidelines which consisted of a 17 item checklist intended to facilitate
the preparation and reporting of a robust protocol for the SR. The
main aim is to improve the quality of the SR protocol. The checklist
summarises aggregate data from study particularly the evaluation of
the effects of an intervention. Reporting and publishing protocol is an
important step in increasing the transparency of the research process
and reliability of published papers.
AMSTAR. Shea BJ et al.16 (2007) developed this measurement tool
to access the methodological quality of SR. The tool has 11 item
questionnaire that is used to assess the methodological quality of SR.
It takes into consideration empirical evidence and expert consensus.
MOOSE. It mainly consists of hypothesis generation, abstract
selection, data collection from various sources (live database to
register, a list of citations, etc.), like living documents of the Cochrane
data base, Cochrane Clinical register and list of citations The study
selection results and discussion guidelines are established with
relative strengths and weakness.
The proposed checklist contains specifications for reporting of
meta-analyses of observational studies in epidemiology, including
background, search strategy, methods, results, discussion and
conclusion. Use of the checklist should improve the usefulness of
meta-analyses for authors, reviewers, editors, readers and decision
makers.
SORT. Developed by Antovio et al.21 (2015) discusses the use of
levels of evidence in the overall assessment of the quality of the body
of evidence.
STARD. Patrick et al.22 in 2003 developed a checklist of 25 items
and flow diagrams to improve the reporting of quality studies on
diagnostic accuracy. It aims to facilitate the use, understanding and
dissemination of the relevant evidence through a quality checklist.
STROBE. Initially designed in 2008, mainly to address three main
study designs and analytical epidemiology: cohort, case control and
cross sectional study. The sole intention is to provide guidance on
how to report observational results.
These guidelines were developed and are continuously updated by
evidence-based expert teams. The need to communicate current
research findings of the highest level more effectively is becoming
imperative in influencing dental practice in the 21st century. Hence a
translation tool has been designed entitled ‘Grade Translation Tool’
(Grading of Recommendation, Assessment, Development and
Evaluation). It helps for the translation of scientific evidence into
clinical practice.
GRADE transitional tool

Determinants of the strength of recommendation according to Grade:
Grade approach postulates that clinical practice guidelines should
consider not only the quality of the available evidence but also the
values and preferences of patients, its safety and its cost (Fig. 63.10).
FIGURE 63.10 Grade transition tool. Source: Pandis N, Rinchuse

DJ, Rinchuse DJ, Noble J. Introduction to evidence-based clinical
practice. In: Miles PG, Rinchuse DJ, Rinchuse DJ, editors. Evidence-
based clinical orthodontics. Quientissence Publishing Co. Inc.; 2012.
The GRADE process

After defining the clinical question in PICO (i.e. Patient, Intervention,
Comparison and Outcome) one needs to identify the important
outcome including harms and costs. After balancing the same, search
and identify the best available evidence for the clinical question. Based
on relative importance, the outcome can be classified as critical,
important but non-critical or non-important. After grading each
outcome across the studies and quality of evidence, recommendations
(strong or weak) are made by considering benefits and harms and
patient values and preferences (Fig. 63.11).
FIGURE 63.11 The GRADE process for assessing the evidence
from SRs and making recommendations. Source: Pandis N.
context of evidence-based orthodontics (EBO). Semin Orthod
2013;19(3):142–57.
Critical appraisal
Reading journal articles can be time consuming, and in our busy lives,
we need to be able to identify those papers which are worth reading
and disregard those that will add little to our knowledge or impact on
our clinical practice. Critical appraisal is the process of assessing and
interpreting evidence by systematically considering its valid results
and relevance to your work (Critical Appraisal Skill Programme
(CASP), 1997).5
It is possible for critical appraisal skills to be learnt by all members
of the orthodontic team including those with no clinical training or
prior knowledge of research methods. SRs aim to synthesise high
quality evidence to determine the efficiency and safety of
interventions more accurately to resolve controversies and uncertainty
surrounding treatment modalities and to facilitate the development of
clinical practice guidelines. High-quality RCTs are an integral part of
SRs and allow us to be confident about the review results.
Cochrane
Cochrane data base (www.Cochrane.org) is named in honour of
Archie Cochrane (1909–88), a British medical researcher who
contributed greatly to the development of epidemiology as a science.
Cochrane prepares, maintains, updates and promotes SRs. Since its
inception in 1993, over 15,000 contributors from over 100 countries
have been involved with Cochrane, making it the largest organisation
related to this type of work.
Cochrane Collaboration is an international non-profit and an
independent organisation with its primary function to produce and to
disseminate the highest quality of SRs in health care services. The
main aim is to reduce the over increasing volume of both published
and unpublished research literature on a specific topic into
manageable, unbiased, quality assessed portions.
Cochrane Oral Health Group (COHG)23 is one of the 50 such review
groups. COHG was established in 1994 in the United States by Alexia
Antczak Bouckoms.24 The editorial base for the COHG was
transferred to the School of Dentistry, the University of Manchester,
UK in 1996 with Professor Bill Shaw and Helen Worthington as
coordinating editors. Funding for core staff at the editorial base is
provided by the United Kingdom’s Department of Health: The
Collaboration as a whole relies entirely on grants and donations and
does not accept conflicted funding.
Over the last 20 years, the COHG has evolved as an extremely
productive international network of health care practitioners, decision
makers, researchers and consumers. The aim of the group is primarily
to produce SRs of RCTs focusing on prevention, treatment and
rehabilitation of oral, dental and craniofacial diseases and disorders.
Many of these reviews are undertaken by highly motivated
volunteers, keen to find ‘the answer’ to a research question of great
clinical relevance. Reviewers are supported throughout the process by
the editorial team who can provide clinical, statistical, methodological
and technical advice as required.23
The COHG aims to have a transparent, rigorous editorial process
that ensures all registered review titles, protocols and completed
reviews.23 The managing editor for the COHG is responsible for
coordinating the whole process. The key elements of which involve
title registration, a justification for the chosen topic, and details of
review team including their experience in research methodology.
Cochrane reviews are ‘LIVING DOCUMENTS’ that are updated at
regular intervals. Typically, this could be every 2 years but may
depend upon the volume and clinical relevance of the emerging
research.
In addition to the production of SRs and MA, the COHG is
responsible for maintaining a trial register of reports of controlled
clinical trials (CCTS) and RCTs related to the oral health. The content
of the register is the product of comprehensive electronic searching
and hand searching, identifying both published and unpublished
reports of trials. The number of reports currently listed in the register
is approaching 25,000 making the register a highly valuable resource
for all these wishings to identify RCTs/CCTs of oral health.
New records added to the trial register are updated quarterly to
CENTRAL, a database of clinical trials also published in the Cochrane
Library.5
Databases included in the Cochrane Library are:
• Cochrane Database of Systematic Reviews (CDSR)
• Database of Abstracts of Reviews of Effects (DARE)
• Cochrane Central Register of Controlled Trials (CENTRAL)
• Cochrane Methodology Register (CMR)
• Health Technology Assessment Database (HTA)
• NHS Economic Evaluation Database (NHSEED).
The oral health group currently has 108 reviews and 98 protocols
published in the Cochrane Library (www.org.cochrane.org/).
Cochrane Oral Health Group collaboration in India

The South Asian Cochrane Network was formed in 2005 to raise
awareness about the Cochrane Collaboration and evidence-based
practice in South Asia, support review authors and contributors from
countries within the region, promote access to the Cochrane Library
and advocate high-quality research in South Asia. The growth of
activity in India has been dramatic, that with authors of Cochrane
reviews and protocols—from just 19 (with 11 authors) in 2000 to 126
(with 78 authors) in 2007. Increasing the uptake of relevant and
reliable evidence in healthcare decisions in India and the South Asian
region forms the core of the network’s strategic plan. The continued
growth of contributors from India and South Asia will help ensure
that decisions regarding healthcare are informed by reliable and
relevant evidence.
Centre for Dental Education and Research (CDER) at All India
Institute of Medical Sciences (AIIMS), New Delhi has been designated
as a global alliance partner for Cochrane Collaboration international
network (for India) under the leadership of Professor O.P.
Kharabanda. CDER is the centre of excellence in dental and
orthodontic research since last three decades.
Evidence-based clinical practice in
orthodontics
The treatment of class II malocclusion—an
evidence to make a decision
• Early orthodontic treatment of class II malocclusion reduces
the chance of incisal trauma and helps in improving the self-
esteem of the child.25
• The provision of early orthodontic treatment with either
functional appliances or headgear does not achieve the aims
of reducing treatment time, reducing extractions, and
improving skeletal pattern when compared to single-phase
treatment in adolescence.26
• While there may be some beneficial effect on a child’s self-
esteem, there are no significant differences ultimately in self-
esteem between those children who have received two phases
of treatment and those treated in one phase in adolescence.27
• EBO has confirmed that class II division 2 should be
considered as an ‘orthodontic emergency’. It should be treated
as early as diagnosed and detected to prevent trapping of
lower jaw and accentuation of the deep bite.28
• Maxillary expansion in the absence of posterior cross-bite is
not recommended to alleviate moderate to severe crowding
and to correct class II malocclusion.29
• Two-phase treatment undoubtedly involves more
appointments, increased duration of overall treatment with all
the associated risks, and increased cost to the health-care
system or the individual.30
When we consider functional appliance treatment there appears
to be some orthodontic growth modification from the use of a
functional appliance, but the majority of the change is
dentoalveolar. The use of headgear also provides limited
skeletal change, and the greatest effect is dentoalveolar, with
‘distal’ molar movement of up to 2 mm. Importantly, on an
average, this is not sufficient to correct a full-cusp class II molar
relationship.31
• It appears that with all functional appliance treatment, the
average failure rate is about 20%. This should be considered
when this treatment is offered to a patient, and it should be
explained to the parents and the patients that only four out of
five of these treatments will succeed. Unfortunately, there is
no comparable data for headgear noncompliance.32
• When we consider patient values, it is fair to suggest that
patients prefer fixed functional appliances as opposed to the
removable functional appliances. Furthermore, the
cooperation rate with fixed appliance appears to be greater.
These appliances are, however, significantly more expensive,
and cost should be considered in our discussions with patients
and parents.33,34
• Use of skeletal anchorage for skeletal class II correction is
recommended for maximum simultaneous skeletal and dental
correction as a time saving approach.35,36
• A recent SR and MA (2016) for assessment of treatment effects
of functional appliances have concluded that there is minimal
stimulation of mandibular growth, a minimal restriction of
maxillary growth and maximum dentoalveolar and soft tissue
adaptations. A slightly greater skeletal dimensional effect was
observed in the pubertal group than in post pubertal group
when treated with fixed functional appliances.30, 37
Class III malocclusion—the evidence on

diagnosis and treatment
• The six element of orofacial harmony can be used as an
effective diagnostic tool to discern the underlying dental and
skeletal components of a class III malocclusion.38
• Protraction facemask therapy can be used in the treatment of
class III malocclusion with a maxillary deficiency in both the
sagittal and vertical dimensions. The optimal time to address
a class III malocclusion is at the time of the initial eruption of
the maxillary incisors.39
• To date, there is no agreement in the literature as to whether
chin cup therapy can inhibit the growth of the mandible. The
efficacy of chin cup treatment remains unclear. The efficacy of
chin cup treatment has been reversed as the growth pattern
continued. Several studies reported a tendency to return to the
original growth pattern after the chin cup was discontinued.40
• Depending on the treatment goals specified after accurate
diagnostic analysis of the dental and/or skeletal components,
class III malocclusions may be effectively treated with
appropriate early/adult phase treatment using orthopaedic,
extraction, non-extraction, nonsurgical and surgical
approaches.41
• Pre-surgical orthodontics should decompensate the position of
teeth within their respective jaws. Surgical repositioning of the
jaws to the optimal location will result in facial harmony.38
Extraction and non-extraction approach: the

evidence
A recent SR by Filho et al.42 concluded that both early and late
extraction had a similar effect on correction of crowding. Early
treatment had two favourable secondary outcomes that are less
relapse and reduced active treatment time V/S late treatment.43
EBO proved that en-masse retraction is more efficient than two-step
retraction as it reduces treatment duration and risk of root resorption.
Anchorage value remains same for both. Temporary skeletal
anchorage device should be preferred in maximum anchorage
extraction cases (Fig. 63.12). EBO has confirmed the use of transpalatal
arch (TPA) to maintain the transverse width and to have control over
the molar rotation.44
FIGURE 63.12 A comparative evaluation of anchorage loss with

transpalatal arch (TPA), headgear (HG) and temporary anchorage
device (TAD).
In cases of class II/class III camouflage, it has been concluded that

the treatment with two premolars extractions achieved a better
occlusal success rate and stability than treatment with all premolar
extraction.45
Mechanotherapy for space closure (Fig. 63.13)

Nickel Titanium springs allow a potentially longer appointment
interval with possibly slightly more rapid space closure than an elastic
chain in the cases with premolars extraction. Appointments
scheduling efficiency can be improved by phasing appointment
intervals based on the properties of the materials used, the mechanics
applied, and the expected biologic response of the patient rather than
using a fixed appointment interval approach.
FIGURE 63.13 The rate of tooth movement (mm/month) with
three modes of therapy.
(A) Power chain. (B) Active ligature. (C) NiTi coil spring.
In non-extraction treatment approaches, molar distalisation should

be attempted only when molar has migrated mesially because of
premature extraction/exfoliation of ‘E’. It is more applicable to half
unit cases than to full unit cases. Intraoral distalising appliances are
more effective than extraoral headgear.45
In the absence of valid reasons for early intervention, the non-
extraction treatment of class II malocclusions can be more efficiently
treated in one phase in early adolescence.45
‘E’ space preservation

A more conservative non-extraction approach for resolution of
crowding is arch length preservation by use of E-space. With proper
management of E-space in the late mixed dentition (at roughly 10½
years of age), approximately 76% of class I and class II malocclusions
with good facial balance and 4–5 mm of crowding can be resolved
without extraction. At that time, the orthodontist can decide whether
non-extraction or extraction is preferred. The treatment can be
completed in one phase within a responsible time frame. Currently,
this protocol has the most evidence to support its utility.
Evidence-based use of orthodontic TADs

TADs can be used as a vehicle to obtain absolute anchorage without
the need of patient’s compliance with a minimum intervention. They
are simple to use, cost effective and predictable clinical tool.46
Orthodontics and temporomandibular joint

disorders (TMD): an evidence-based approach
TMD is a collective term embracing some clinical problems that
involve the masticatory musculature and the TMJ’s. TMD are of a
multi-factorial aetiology. The historic dental based model has been
gradually replaced by a biologic medical model used in the treatment
of other chronic musculoskeletal disorders.47
The contemporary bio-psychosocial approach to TMD management
focuses on the integration of biologic, clinical and behavioural factors
that may ultimately account for the onset, maintenance and remission
of TMD. Genetics, endocrinology, behavioural risk conferring factors,
psychosocial traits and mental states appear to be the variables
currently being researched and receiving the most attention.48,49
Orthodontics does not cause or cure TMD. The canine protected
functional occlusion has not been demonstrated to be optional for all
patients.50, 51
Orthodontic retention and stability: EBO

guidelines
It is essential to establish an ‘individualised retention protocol’.52 The
most predictable and cost effective way to ensure the stability of
orthodontic treatment is probably a life time retainer wear. The
patients (even minor children) and the parents should sign both pre-
and post-treatment retention agreement.
The following are the conclusions from the SR and MA on the topic
of retention in orthodontics.
• Retention should be for a lifetime.

• It appears that half time (night only) wear of removable
retainers may be as good as full time wear.53, 54
• High-quality orthodontic results may not be related to post-
treatment stability.55
• Bonding retainers require periodic monitoring, necessary to
detect breakage, relapse, decalcification and caries.
• Pre-treatment mandibular inter-canine and inter-molar width
should be maintained.56
• Prophylactic extraction of third molars to prevent late lower
arch crowding is not evidence-based recommended
approach.57
The use of CBCT in clinical orthodontics

The SEDENTEXCT consortium evidence-based guidelines on the use
of CBCT in dental and maxillofacial radiology were developed in
2012. Ten of these guidelines concern orthodontic applications. The
orthodontic guidelines as described in the original SEDENTEXCT
report published in 2012 are quoted below:58
I. All CBCT examination must be justified on an individual basis

by demonstrating that the potential benefits to the patients
outweigh the potential risks. CBCT examinations should
potentially add new information to aid the patient’s
management. A record of the justification process must be
maintained for each patient.
II. CBCT should not be selected unless a history and clinical
examination have been performed. Routine or screening
imaging is an unacceptable practice.
III. CBCT may be indicated for the localised assessment of an
impacted tooth (including consideration of resorption of an
adjacent tooth) where the current imaging method of choice is
multi-slice computed tomography (MSCT) or where lower
dose conventional dental radiography fails to provide the
information required. The use of CBCT units offering only
large volumes (craniofacial CBCT) requires very careful
justification and is discouraged.
IV. Where the current imaging method of choice for the
assessment of cleft palate patients is MSCT, CBCT may be
preferred if the radiation dose is lower. The smallest volume
size compatible with the situation should be selected to reduce
the radiation dose.
V. CBCT is not normally indicated for planning the placement of
temporary anchorage devices in orthodontics.
VI. Large volume CBCT should not be used routinely for
VII. For complex cases of skeletal abnormality, particularly those
requiring combined orthodontic/surgical management, large
volume CBCT may be justified in planning the definitive
procedure, particularly where MSCT is the current imaging
method of choice.
VIII. Limited volume, high-resolution CBCT may be indicated in
selected cases of suspected or established inflammatory root
resorption or internal resorption, where three-dimensional
information is likely to alter the management or prognosis of
the tooth.
IX. CBCT may be indicated for pre-surgical assessment of an un-
erupted tooth in selected cases where conventional
radiographs fail to provide the information required.
X. CBCT is indicated where bone information is required, in
orthognathic surgery planning, for obtaining three-
dimensional data sets of the craniofacial skeleton.
XI. However, more research is needed to elucidate the efficacy
and cost effectiveness of the use of CBCT for orthodontic
purposes.
Evidence-based conclusions in orthognathic

surgery59,60
A recent SR of literature in orthognathic surgery60 (2016) has
summarised the evidence-based guidelines for Surgical Class II/Class
III Corrections with special emphasis on ‘Surgery First Protocol’.
As regards to skeletal class II correction in adults, surgical
mandibular advancement with rigid fixation, less than 6 mm is very
reliable and stable procedure. Patients with high mandibular plane
angle are more prone to relapse (30%). Distraction osteogenesis is
advantageous over Bilateral Sagittal Split Osteotomy (BSSO) in
patients requiring greater than 7 mm advancement with normal/low
mandibular plane angle.
EBO has confirmed that patients with low mandibular plane angle
have increased vertical relapse where patients with high mandibular
plane angle have increased horizontal relapse. Mandibular
advancement that maintains and increases the mandibular plane
angle appears to be a relatively stable procedure. Maxillary setback
and setup at Lefort I and II level are recommended, reliable, and a safe
approach in an individual having vertical and horizontal maxillary
excess after growth cessation. Advancement genioplasty is the
simplest and safest minor surgical procedure which helps in restoring
lower facial balance (Holdaway’s ratio) in moderate class II situations
with a deficient growth of lower jaw.
As regard to class III correction, EBO confirmed that mandibular set
back through BSSO appeared to be stable whereas maxillary
advancement exhibit the good stability without inferior movement of
the maxilla. Reduction genioplasty is again simplest and safest minor
surgical procedure to reduce chin prominence in moderate skeletal
class III situation with mandibular prognathism.
Two jaw surgeries are recommended approach in bi-jaw
craniofacial defects. The use of full face CBCT is recommended in
three-dimensional craniofacial defects in adults demanding complex
surgical procedures with a virtual setup.
A current concept of surgery first protocol in orthognathic surgery
is highly accepted treatment paradigm. Advantages of the same
include a significant reduction in total treatment time, high level of
patient and orthodontic satisfaction; immediate improvement in facial
profile, and effective orthodontic decompensation.
Accuracy and reliability of digital models: SR
and MA
A current SR (2016) on ‘Diagnostic accuracy and measurement
sensitivity of digital models for orthodontic purposes’ has concluded
that digital models are as reliable as traditional plaster models with
high accuracy, reliability and reproducibility. Regarding cost, time,
and space required, digital models could be considered the new gold
standard in current practice.61
In a recent SR (2016) on ‘Validity and reliability of intraoral
scanners compared to conventional gypsum models measurements’
had indicated that inter- and intra-arch measurements obtained on
digital models produced from intraoral scans appeared to be reliable
and accurate in comparison to those from conventional impressions.
Digital models produced by intraoral scanner eliminate the need of
impressions making procedure saving time and cost. Thus ‘Digital
Intraoral Scan’ is a reliable and accurate procedure.62
Accelerated orthodontic tooth movement: an

evidence-based guidelines5,63,64
Despite the low friction of self-ligating brackets in vitro, evidence has
revealed that they do not perform faster alignment or space closure
than conventional brackets in vivo.
The effect of Low-Level Laser Therapy (LLLT) on accelerating
orthodontic tooth movement is still controversial experimentally and
clinically.
Surgically assisted accelerated tooth movement is currently the
most effective technique experimentally and clinically. It includes
rapid canine distraction, selective alveolar decortication, corticision,
piezocision and piezopuncture.
The sub-mucosal injection of plasma-rich protein (PRP) accelerates
the original rate of the orthodontic alignment and needs further
research.
Alveolar bone density and baseline bone metabolism in situ are the
predetermining factors for the rate of orthodontic tooth alignment.
Evidence-based guidelines for orthodontically

induced inflammatory root resorption (OIIRR)
There is evidence that comprehensive orthodontic treatment causes an
increase in the incidence and severity of root resorption. Increased
force magnitude and treatment time are particularly harmful.65
There is no evidence that archwire sequencing, bracket prescription
and self-ligating brackets (low friction) affect OIRR. There is little
evidence that a previous history of trauma or unusual tooth
morphology play a role in increased OIIRR. There is some evidence
that a 2–3 months treatment pause will decrease further root
resorption and allow root cementum to get repaired. Genetic
predisposing and systematic factors need to be assessed.66
Micro-CT analysis is the current gold standard for the quantification
of root resorption. The use of Low Intensity Pulsed Ultrasound
(LIPUS) minimises root resorption by acoustic pressure waves. Daily
application of LIPUS for 20 min per day for 4 weeks significantly
reduced the severity of OIRR.67
Obstructive sleep apnoea (OSA)68

OSA and obstructive sleep apnoea syndrome (OSAS) are subsets of
sleep disordered breathing (SDB). Awareness about the OSA and its
consequences amongst the general public as well as the primary care
physicians across India is poor. This necessitated the development of
the Indian Initiative on Obstructive Sleep Apnoea (INOSA) guidelines
under the auspices of Department of Health Research, Ministry of
Health and Family Welfare, and Government of India.68 Oral
appliances are indicated for use in patients with mild to moderate
OSA who prefer oral appliances to positive airway pressure (PAP), or
who do not respond to PAP or who fail treatment attempts with PAP
or behavioural measures. Surgical treatment is recommended in
patients who have failed or are intolerant to PAP therapy.68
Key Points
Orthodontists and students in the subject need to be sensitised to be
critical and understand the quality of research, value of RCTs and
levels of evidence.
University departments clearly have a significant role in educating
today’s students to become critical, selective practitioners of
tomorrow. Likewise, universities will have an ongoing role in
developing and coordinating research.
There is no doubt that the Cochrane and its protocols for
synthesising and disseminating quality—controlled summaries of best
evidence can play a significant role in promoting EBO care.
Orthodontists are well presented in the Cochrane oral health group
and there is already a cadre of experienced orthodontic reviewers. The
challenge for orthodontics is that a major step change is required to
increase the scale and quality of clinical trials and to increase the
profession’s collective will to become truly evidence based.
Lasting partnerships between academic researchers and networks
of practitioners in the real world are now essential to achieve
appropriate studies that will yield conclusions that can be generalised
to everyday circumstances. Journals can raise the quality and
reporting of trials by insisting on adherence to CONSORT checklists.
The real responsibility for promoting and faster research should fall
on the profession as a whole led by its national and international
representative bodies.
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SECTION XIV
Impactions and transpositions
Chapter 64: Orthodontic aspects of impacted anterior teeth

Chapter 65: Transposition of teeth
Chapter 66: Auto-transplantation of teeth in orthodontic practice
CHAPTER 64
Orthodontic aspects of impacted
anterior teeth
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Maxillary canine
Central incisor
Mandibular canine
Incisor impaction
Canine impaction
Palatal versus labial impaction
Development and eruption of maxillary canine
Aetiology of palatally displaced maxillary canine
impaction (PDC)
Aetiology of labial canine impaction
Maxillary central incisor
Maxillary canine
Palpation for canine(s)
Radiological examination
Peri-apical radiographs (IOPA)
Buccal versus palatal impaction
The orthopantogram
Occlusal X-ray
Technique modification
Lateral view cephalogram and PA skull or PA
cephalogram
Computed tomography (MDCT)/CBCT
CBCT and its applications in diagnosis and management
of dental impaction
Treatment considerations for impacted teeth
Observation
Maxillary canine
Sector classification
Orthodontic guidance/intervention
Extraction of a retained deciduous tooth
Removal of physical barrier
Surgically assisted orthodontic guidance
Welcome preparation
Surgical exposure and attachment to the impacted tooth
Orthodontic guidance to eruption
Surgical auto-transplantation
Key Points
Introduction
Impaction of a tooth is retardation or halt in the normal process of
eruption. An impacted tooth other than third molar is usually
required to be aligned if not otherwise possible for the reasons of arch
length deficiency, pathological conditions or for its location that does
not allow alignment in the arch. Timely diagnosis and appropriate
interventions lead to better treatment outcome and minimise the need
for complex treatment modalities.
The impaction of a tooth can be defined in several expressions.
Following are a few definitions of impacted tooth:
• According to Kuftinec and Shapira, impaction is a condition in

which a tooth is embedded in the alveolus so that its eruption
is impeded and it is locked in position by bone or by adjacent
teeth.1
• In the current perspective, an impacted tooth is one ‘whose
eruption is considerably delayed, and for which there is
clinical or radiographic evidence that further eruption may
not take place’.2
• In simple words, an impacted tooth is the one that fails to
erupt into a normal functional position past its root formation,
which may be attributable to physical impedance (other tooth
or surrounding soft or hard tissue), ankylosis, a systemic
cause or primary failure of eruption.
• A canine is considered as being impacted if it is interrupted
after complete root development or if the contralateral tooth is
erupted for at least 6 months with complete root formation.3
The canine is the most commonly impacted tooth after the maxillary
third molars. This chapter henceforth has been written keeping the
maxillary canine in mind although it would consider principles of
diagnosis and management to all types of impacted teeth excluding
third molars in general (Fig. 64.1A–B).
FIGURE 64.1A (A–C) Bilaterally retained deciduous canines in an

adult female. She remained unaware of impacted canines till she
reported for orthodontic consultation to treat her dental protrusion. Note
a bulge on either side of the palate due to bilateral palatally impacted
maxillary canines.
FIGURE 64.1B Case HG, 10-years-old growing girl.
(A and B) Missing upper central incisors, constricted maxillary arch with
bilateral cross-bite. (C) Panoramic radiograph shows unerupted upper
incisor with delayed dental eruption status. (D and E) CBCT MPR view
shows the palatal position of left upper central incisor the eruption
being impeded with the presence of supernumerary teeth.
In clinical practice, after the third molar, the maxillary canine is the
most frequently impacted tooth in the dental arch. The teeth involved
with impaction or delayed eruption in -decreasing order of frequency
can be listed as maxillary canines, second premolars, maxillary central
incisors and mandibular cuspids (Box 64.1).
Box 64.1 Teeth in order of frequency of

occurrence of impaction
Maxillary and mandibular third molars Most frequent
Maxillary cuspids
2nd premolars
Maxillary central incisors
Mandibular cuspids
2nd molars
Lateral incisors
1st premolars
Least Frequent
Maxillary canine
Its impaction prevalence has been reported in the range 0.8%–2.8%.4–6
A high incidence of maxillary canine impaction has been reported in
the Turkish population to the rate of 3.29%.7 The lowest incidence has
been reported in the Japanese population.8
Central incisor
The frequency of maxillary incisor impaction ranges from 0.06% to
0.2%.4
Mandibular canine
Its impaction is less frequent, and the incidence has been -reported to
be 20 times lower than that for maxillary canines.9 The incidence of
mandibular canine impaction is 0.35%.6 In Turkish population, the
incidence was 0.44%.7 Migration of a tooth across the midline is even
less frequent but not rare. At least 157 cases of mandibular canine
transmigration have been published.10–16
Teeth can get impacted due to various causes. Broadly speaking,
aetiology of impacted teeth can be grouped into systemic causes and
localised causes (Flowchart 64.1).
FLOWCHART 64.1 Aetiology of tooth impaction.
Generalised causes. These include endocrine deficiencies, febrile

diseases, irradiation and association of impaction with syndromes
affecting multiple systems. Syndromes in which multiple impactions
may be found include cleidocranial dysostosis, Gardner syndrome,
hypophosphatasia and Yunis--Varon syndrome.17,18
Localised causes. These include tooth size arch length discrepancies,
prolonged retention or early loss of the deciduous teeth, abnormal
position of the tooth bud, the presence of an alveolar cleft, ankylosis, a
cystic or neoplastic transformation of the follicle of the unerupted
tooth, dilaceration of the root, iatrogenic origin and idiopathic
condition with no apparent cause.
In clinical practice, following systemic conditions are seen
associated with delayed eruption/impaction.
• Hypothyroidism
• Hypopituitarism
• Cleidocranial dysostosis.
Incisor impaction
The aetiology of incisor impaction can be divided into -obstructive
causes and traumatic causes. Obstructive causes include
supernumerary teeth, odontome, and ectopic -position of tooth bud
and soft tissue fibrosis.
The traumatic causes include dilacerations, an arrest of root
development and acute trauma leading to intrusive luxation. The
most common cause of delayed eruption of the maxillary incisors is a
fibrous barrier and cause of impaction is supernumerary tooth (teeth)
in the pre-maxillary region. A retained deciduous tooth or root may
lead to the eruption of an incisor in palatal location or cause its
impaction. Lack of space in the arch length is the common cause to all
types of impactions.
Canine impaction
Before discussing the aetiology of maxillary canine impaction, it is
pertinent to consider:
1. The path of eruption of the maxillary canine: Aberrant path of

eruption is the most important aetiologic factor in canine
impaction.
2. Palatally and buccally impacted canines are entirely different
entities in terms of their aetiology, prevalence and risk factors.
Palatal versus labial impaction

Majority of the canine impactions are palatal (85%) and only 15% are
labial.19 Unilateral impaction is much more common than bilateral
impaction. It has been -reported that only 8% of canine impactions are
bilateral (Box 64.2).20
Race distribution. Maxillary canine impactions occur five times
more often in Caucasians than in Asians.21 The majority of
canines are impacted palatally among Caucasians and buccally
among Asians.1
Sex distribution. Gender may play a role because maxillary canine
impactions occur twice as often in females than in males in
ratio 2.3:1.6
Box 64.2 Impacted canines
Percentage
Incidence 0.8–2.8
Palatal:buccal 85:15
Bilateral:unilateral 8:92
F:M ratio 2.3:1
Left:right 5:2
Maxilla:mandible 20:1
Development and eruption of maxillary canine

The maxillary canine shows a wide-spectrum of eruption
abnormalities probably because of its long path of eruption and being
the last anterior tooth to erupt in the arch. It may be pertinent to track
the path of eruption of the maxillary -canine, which will help
understand why maxillary canine is so frequently impacted.
The permanent maxillary canine calcification begins approximately
at 12 months of age between the first deciduous molar roots. As the
first deciduous molar erupts, it allows development of first premolar
between its roots. So, at this stage, permanent canine occupy a higher
position than both, the first premolar and deciduous first molar. Now,
as the deciduous teeth approach towards occlusal plane, the crypts of
permanent incisor and canine migrate forward in jaws at a greater rate
compared to deciduous teeth. At 7 years age, the canine crown is
mesial to its predecessor roots with a vertical overlap of
approximatively 3mm.
The canine migrates buccally from its lingual position during its
developmental stages. But sometimes, due to the failure of this
transition, it may become impacted and remain palatally placed. With
growth, size of the sub nasal area increases, which allows the
maxillary canines to move downward, forward and laterally away
from root ends of lateral incisor. In the ugly duckling stage between 8
to 12 years of age, due to insufficient space at the apical base, lateral
incisor is unable to attain a more erect alignment in young adulthood
until canine approaches its place in the arch. In the final phase of
eruption, canines force these teeth to become upright while making
their way between lateral incisors and first premolar (Fig. 64.2A–C).
FIGURE 64.2 (A–C) Developing canine and its course from the first
year of life through 9 years of age.
The positional changes of canine between 8 and 10 years of age

need careful observation for detection of potential impaction. During
this stage of development, the canine normally migrates buccally from
a position lingual to the root apex of its deciduous precursor;
however, some canines do not make this transition from the palatal to
the buccal side of the dental arch and remain palatally placed. With
growth leading to sufficient increase in the size of the sub-nasal area,
the maxillary canine normally moves downward, forward and
laterally away from the root end of the lateral incisor. Between 8 and
12 years of age, in the ‘ugly duckling’ stage, there is insufficient space
at the apical base to permit the axis of the lateral incisor to shift into
the more erect alignment of young adulthood until the canine
approaches its place in the dental arch. In the final phase of the
eruption, canines drive their way between the lateral incisors and first
premolars, forcing these teeth to become upright. Most authors agree
that the maxillary canine follows a longer, and more tortuous path of
eruption than any other tooth, but the length of this eruption path and
the magnitude and timing of the changes in direction do not seem to
have been quantified. Coulter and Richardson22 have observed that in the
three planes of space, maxillary canines travel almost 22 mm from their
position at the age of 5 years to their position at 15 years.
Aetiology of palatally displaced maxillary

canine impaction (PDC)
Although there has been considerable controversy, regarding the
exact aetiologic factors associated with palatally impacted canines,
two main schools of thought have emerged.
Environmental aetiology. This school of thought was primarily
supported by Becker and co-workers.23 They believed that local
factors including a long path of eruption of canine were primarily
responsible for the palatal displacement of the tooth. Becker was a
believer of the ‘guidance theory of eruption’. The ‘guidance theory’
proposes that palatal canine displacement is a result of local
predisposing causes including congenitally missing lateral incisors,
supernumerary teeth, odontomes, transposition of teeth and other
mechanical determinants that interfere with the path of eruption of
the canine. As maxillary canines develop high in the maxilla, these are
among the last teeth to develop and travel a long path; they are
particularly prone to environmental influences, which may disturb
their eruption path. These factors increase the potential risk of
impaction of the tooth.
Genetic theory. Peck and Peck and co-workers promoted this
school of thought.24 They believed that genetic causes were significant
determinants of the palatal canine impaction. This theory is supported
by the fact that palatally impacted maxillary cuspids often present
with other dental abnormalities, including alteration in the tooth size,
shape, number and structure, which are linked genetically. Several
abnormalities are believed to have a common hereditary link,
manifested as a developmental disturbance during the embryonic
growth. Upto 33% of patients with palatally impacted cuspids have
congenitally missing teeth, four to nine times more frequent than that
of the general population.24 Studies also show that upto 64.7% of
patients with -palatally impacted cuspids have small, peg-shaped or
missing lateral incisors.25 In patients with congenitally absent
maxillary lateral incisors, the co--occurrence of palatally -impacted
canines is 2.4 times that of the general population.26 However, it
remains uncertain whether the anomalous lateral incisor is a local
causal factor for palatally displaced canines (PDCs) or an associated
genetic developmental influence.27 The role of the lateral incisor root
is considered critical for the normal eruption of the maxillary canine.
It seems that a missing or microdontic lateral incisor fails to guide the
canine, which dives into the palate. Whether the anomalous lateral
incisor and palatal maxillary impaction are co-variables or a primary
aetiologic factor, still needs to be confirmed.28 Palatally impacted
maxillary canines are also associated with anomalies such as enamel
hypoplasia, infra-occluded primary molars and aplastic second -
bicuspids.27
The current concept is that PDC is a result of both environmental
influences and the genetic predisposition.
Aetiology of labial canine impaction
While palatally impacted canines are much related to either genetic
predisposition or the lack of guidance to the erupting tooth, the labial
canine impaction has a different aetiology. It is more often seen in
crowded dentitions. Studies have proved that the crowding of arches
is the main aetiologic factor in this type of impaction. It has been
reported that up to 83% of arches with a labial displacement of
maxillary canines are associated with arch length deficiency.
Thilander and Jakobsson29 found that dental crowding usually
displaced the canine in a labial direction but rarely caused an
impaction.
It is surprising that while labial impactions are common in crowded
dentitions, the palatal type of impaction is more often associated with
spaced arches.
The diagnosis of an impacted tooth is essentially a clinical -decision
made after complete evaluation of the case records. The following
points are important to consider before diagnosing the tooth as being
impacted.
A visual examination should include a careful observation of the
dental eruption status of a child vis-à-vis chronological age. It is of
utmost importance to realise that to consider a tooth as impacted; one
must correlate the dental age, not the skeletal or the chronological age,
with the developmental/eruption status of the tooth concerned. Root
formation as seen on radiographs is a reliable method for assessing
the dental age. In addition, the sequence of tooth eruption is a far
more important parameter than the time of tooth eruption. For
example, a delayed maturing child may be 15 years old, but his
canines may not have erupted: this does not mean that they are
impacted. Until the time their root formation is not beyond the level
expected at time of tooth eruption, the tooth cannot be called
impacted. It will be more logical to evaluate the sequence of tooth
eruption in such a case.
The dentition should be charted and all the missing tooth/teeth
should be recorded with a measure of crowding or spacing. The area
of the missing tooth should be inspected for any obvious bulge of soft
tissue. In addition, the adjacent teeth need special attention for any
abnormal inclination, which may suggest impingement on its root by
the impacted tooth. A note should be made of the available arch
length, size of teeth, any indications of bulge or discolouration of oral
-mucosa, any malformations and loss of arch length.
Maxillary central incisor

Although impaction of a permanent tooth is rarely diagnosed during
the mixed dentition stage, an impacted central incisor is usually
diagnosed accurately when there is a delay in the eruption of the
tooth. A retained deciduous tooth or a bulge or thick fibrous gingival
tissue at the eruption site or indication of a mesiodens or
supernumerary tooth should alert the clinician to suspect abnormality
and investigate further. Many patients with impacted maxillary
central incisors are referred to orthodontists by general practitioners
or paediatric dentists due to parental concern about the possible
impaction of an incisor in the early mixed dentition even though its
occurrence is less frequent.30
Maxillary canine
An absence of canine bulge in the buccal sulcus by the age of 10 years,
over retained primary cuspids, delayed eruption of their permanent
successor and asymmetry in the exfoliation and the eruption of the
right and left canines7 are are indicative of possible impacted
maxillary canines. The palate and labial vestibule should be carefully
examined for any bulge associated with an impaction.
Primary cuspids that are retained beyond the age of 13 years and
have no significant mobility strongly indicate displacement and
impaction of permanent canines.19,31 The maxillary canine is
considered late in its eruption sequence if it has not emerged by the
age of 12.3 years in females and 13.1 years in males. However, the
correlation between chronological and dental eruption is not strong
and overall dental development and the eruption of teeth in the arches
must be considered when investigating delayed canine eruption.
A detailed clinical examination of the permanent lateral incisors is
important when looking for signs of canine -impaction. The lateral
incisor should be looked for its abnormal position of angulation
and/or rotation. The maxillary lateral incisor may be tipped distally,
inclined labially and/or rotated. Abnormal distally tipped crowns of
lateral incisors might be pressured by the crown of a mesially
displaced -canine against the distal aspect of the lateral incisor root,
which could be an early indicator of a canine impaction. A labially
inclined lateral incisor could be the result of a displaced canine lying
on the labial aspect of the lateral incisor root.
The excessive or unusual mobility of the maxillary permanent
lateral incisor could be the result of root resorption caused by a
displaced canine. Shapira and Kuftinec19 have reported a frequency of
12.5% for ectopically erupting maxillary canines causing some degree
of incisor root resorption.
Palpation for canine(s)

Palpation of the buccal and lingual mucosa, using the index fingers, is
an excellent way to locate the bulge and hence the site of the impacted
tooth. The index finger with its pulp facing the vestibular -mucosa
should be used. A gentle palpation of the buccal alveolus, deep into
vestibule extending from midline of the maxilla to the premolar molar
region helps to locate unerupted tooth. On palatal side, palpation is
extended in the pre-maxillary -palatal region towards the root apices
of maxillary incisors and back in the premolar region. Some clinicians
like to conduct palpation of palatal and buccal sides simultaneously
using index fingers of both the hands. In case of bilateral impaction, it
is common to find a variation in the position of the impacted tooth on
either side.
The maxillary canines can be clinically palpable in the buccal
vestibule, 1–1.5 years before they emerge, and the absence of the
canine bulge after the age of 10 years is a good indication that the
tooth is displaced from its normal position, suggesting that ectopic
eruption or impaction of the concerned tooth may be expected.
However, in younger patients, asymmetries and differences in
bilateral palpation could be due to differences in the rate of eruption,
and such cases should be kept under observation. In general, in
patients above 10 years or so, showing asymmetry of the bulge among
the right and left side should raise suspicion of a possible impaction.
Radiological examination
The commonly used X-rays include an OPG of maxilla and mandible,
occlusal view and IOPA films. Apart from these a lateral cephalogram
also provides useful information. In case, initial X-rays or OPG
indicates need for 3D evaluation of impacted tooth for its location and
its relationship with other dental structures, a CBCT may be advised.
In clinical situation of suspicion of complicated or multiple impaction,
a CBCT may be indicated. In these situations dental X rays/OPG are
avoided. However the indication and case selection for CBCT should
follow ALARA guidelines (Figs 64.3–64.5, 64.6A–B).
FIGURE 64.3 Radiological investigations for an impacted tooth.

IOPA films provide useful information on the location of impacted tooth
and its relationship with neighbouring teeth. Note supernumerary teeth
causing impaction of maxillary canine. (A) In a young child while canine
root is not yet fully formed. (B) Shows horizontal canine impaction in an
adult. (C) The occlusal view was suggestive of canine palatal impaction
which has caused rotation of lateral incisor. (D) OPG provides an
overview of dentition and impacted teeth. ‘X’ denotes impacted canine.
A retained deciduous canine can be seen.
FIGURE 64.4 Clark’s method of buccolingual location of an
impacted object.
Two IOPA X-rays are made while keeping the film in the same location,
but X-ray tube is moved either mesially or distally. An object closer to
the X-ray film that is palatal will appear to move in the same direction
as the X-ray beam while the opposite is true for a buccal object. (A)
Palatal impacted canine moved distally with distal movement of X-ray.
(B) Buccal impacted canine moved mesially with distal movement of X-
ray.
FIGURE 64.5 Position of head and X-ray tube for the occlusal views
of (A) maxilla and (B) mandible.
Peri-apical radiographs (IOPA)
Intra-oral X-rays are usually the first X-rays to be requested, are the
simplest and the most informative films.32 They are most useful to
assess the vertical and anteroposterior position of the impacted tooth
in the alveolus. The IOPA reveals significant information like the
extent of root completion, the presence and the size of the dental
follicle, any crown or root resorption, the root pattern and integrity,
presence of any hard tissue obstruction and its description and the
presence of cysts/pathologies in the affected region. Apart from that,
they offer superior -image clarity and excellent image detail (Fig.
64.3A–B).
For greater radiographic detail of maxillary arch and mandibular
anterior segment in an IOPA film, the beam should be angulated 20–
55° to occlusal plane.33 Here one must be careful not to try to measure
the length of the tooth from the film because the beam is so angulated
as to give the maximum details about the impacted tooth and not to
control the distortion of length of the tooth. For mandibular posterior
region, the beam should be kept parallel to the -occlusal plane.
Buccal versus palatal impaction

To locate the buccolingual position of an impacted tooth, it is
recommended to take two consecutive IOPA X-rays with Clarks ‘tube
shift method’ using a long cone tube. A conventional IOPA X-ray of
the canine region impacted tooth is made. Subsequently, the second X-
ray is made with the tube shifted to the distal position. With the
availability of the digital images, -instant diagnosis can be made based
on the principle of SLOB, which is ‘same side lingual opposite side buccal’.
If the image of the tooth moves on the side of tube shift, the tooth is
likely to be lingual since it is likely to be closer to the film (Fig. 64.4A–
B).
The orthopantogram
OPG X-ray provides a good overview of the status of dentition,
eruption pattern, root formation and pattern of the roots. The modern
digital OPG X-rays have good contrast and brightness with minimal
magnification in the central trough. The digital images can be
manipulated on screen and careful observations can be made on
zoomed images to see the relationship of the impacted tooth/teeth
with roots of neighbouring teeth and the path of eruption (Fig. 64.6A).
Some OPG software have the the option of the creation of a pseudo-
3D image using advanced function which can assist in somewhat
better location of the impaction in relation to its neighbouring dental
and skeletal structures.
FIGURE 64.6A Impacted right mandibular canine.
This young girl who reported for protrusion of upper front teeth was
discovered to have a retained right mandibular deciduous canine. (A)
OPG showing impacted right canine in the mandible. (B) Lateral
cephalogram is helpful in locating the distance of the tooth from the
occlusal plane and labiolingual position. (C) 3D CT is showing slice
locations from left to right. (D) From buccal to lingual CT. (E) Shows
labiolingual position of the impacted canine. (F) Panoramic view, slice
number 6 shows the relationship of impacted canine with incisor roots.
Occlusal X-ray
Occlusal X-ray of the maxilla provides an excellent view for
evaluating relationship of the impacted tooth in relation to the midline
of jaw and roots of the lateral incisors (Fig. 64.3C).
Technique modification
Maxillary arch
For the occlusal view in the maxillary arch, the anterior teeth are
recorded on the film with a tube angulation of 60°, while for the
posterior region a true occlusal view is desired. Herein the beam is
angulated 110° to the occlusal plane and the film is exposed from just
behind the vertex of the skull. Although the clarity of this view is not
so good and there is a risk of increased radiation exposure, yet the
advantage is that one can establish the exact labiolingual position of
the impacted tooth in the palate (Fig. 64.5A).
Mandibular arch
For the mandibular arch, a true occlusal view is usually required (in a
true occlusal view teeth should be seen upright on the X-ray that is the
crown superimposing on the roots). For the anterior region, this is
achieved by asking the patient to tilt the head back and establishing
the X-ray tube at an angulation of 110° to horizontal. For the posterior
region, the tube angulation should be kept at 90° to horizontal +15°
mesial shift to compensate for the natural mesial tipping of the teeth33
(Fig. 64.5B).
Lateral view cephalogram and PA skull or PA

cephalogram
The lateral cephalogram depicts the distance of the crown tip of the
impacted canine tooth from the occlusal plane and also angulation of
the canine in relation to a vertical plane. This information is of
prognostic significance. Similarly, a horizontally impacted incisor will
be accurately seen on a lateral cephalogram for its relationship with
the palate and vertical position from an occlusal plane.
The PA view of the skull or a PA cephalogram provides useful
information on the long axis and the inclination of the tooth in relation
to midsagittal reference (MSR) plane. The crown of a normally
erupting canine should lie slightly mesially inclined and below the
level of root apex of the lateral incisor and the lateral border of the
nasal cavity. The cuspid root lies buccal to the lateral border of the
nasal cavity.
Computed tomography (MDCT)/CBCT

It has been used in the past to precisely locate the position of the
impacted tooth in bone and its relations with the adjacent structures.34
MDCT scan offers accurate position, inclination and orientation of the
impacted tooth, its relationship with the adjacent structures in three
dimensions of space. However, due to high cost and exceptionally
high radiation doses routine use of MDCT for diagnosis of an
impacted tooth could not be justified. Therefore MDCT could be only
indicated for use in patients in whom there was a suspected
displacement of the long axis of the tooth due to an abnormal
orientation of the root apex, the presence of root resorption35 or cases
where the exact location of the -impacted tooth and its prognosis (and
that of adjacent teeth) could not be ascertained by the use of routine
radiographs.
CBCT and its applications in diagnosis and

management of dental impaction
The cone beam computed tomography has to some extent resolved
the issue of high radiation dose compared to MDCT upto some extent.
CBCT with its advanced software functions on 3D reconstruction
provides a virtual reality view of the impacted tooth/teeth and its
relationship with adjacent teeth and bone. CBCT is a useful
investigation in orthodontic diagnosis in cases of impacted teeth (Fig.
64.6A–I). CBCT scan overcomes the limitations of 2D imaging and
high radiation dose delivery of CT imaging. The 3D CBCT image of
impacted teeth is useful in determining the buccolingual position and
angulation, as well as the proximity of impacted teeth to the roots of
the adjacent teeth and degree of resorption if any. These features assist
in planning the surgical and orthodontic tooth movement to avoid the
root resorption of the adjacent teeth roots.
FIGURE 64.6B (G) CBCT helps reconstruct virtual reality models of

structures which are of great diagnostic help. (H and I) Special
software’s function can render bone burn-out and provide virtual reality
insight to visualise the impacted tooth with neighbouring structures.
Advanced capabilities of 3D software assist better visualisation

through volume rendered mode or multi-planar view, which provides
a better view of the impacted tooth position and the status of the
adjacent tooth structures. A systematic review by -Eslami et al.
assessed the comparisons between CBCT and conventional
radiography in the localisation of maxillary impacted canines. The
CBCT scans are more accurate than the conventional methods.
However, the evidence showed that the CBCT image is not the first
line of imaging modality for impacted maxillary canine evaluation.
The CBCT should be performed, the first and only radiological
investigation if clinical examination suggests an unusual location or
unexpected complications. In other situations, the CBCT is the last
investigation to be performed should initial X-ray suggest that
additional conventional radiography will fail to provide the requisite
information.36
Treatment considerations for impacted
teeth
Treatment of impacted teeth can be described under the following
headings:37
1. Observation
2. Orthodontics guidance/intervention
3. Relocation of an impacted tooth
4. Extraction.
Observation
It includes a watchful observation on developing dentition and all
those incidents and factors, which have a potential to prevent normal
eruption of a tooth:
• In incisor region, history of trauma and premature loss of

deciduous incisors, fibrosis in the area of prematurely lost
tooth or a retained tooth.
• In the canine area, loss of arch length due to premature loss of
deciduous molars and mesial migration of first permanent
molars and other such factors that need therapeutic attention.
• Presence of physical barrier such as supernumerary tooth,
odontome, missing lateral incisors, or microdontic maxillary
laterals.
• Lack of a bulge or position of bulge at an unusual place such
as distal to premolars and incisors or a bulge in palate should
make the clinician suspicious of abnormal path of tooth
eruption.
Maxillary canine
When to suspect a maxillary canine impaction (Box 64.3).
Box 64.3 Nine indicators of canine impaction
1. Lack of bulge in the buccal vestibule after 10 years of age

2. Presence of bulge in the palate
3. Contralateral canine has erupted and there has been a gap of more than 6 months since its
eruption
4. The deciduous canine is retained with no mobility
5. There is severe crowding in the arch
6. The maxillary laterals are missing or tendency for small laterals especially if there is a family
history
7. There is a general tendency for small teeth and delayed eruption of teeth
8. Unusual rotation of the maxillary lateral incisor in coexistance to unerupted canine
9. Mobility of the maxillary lateral incisor in coexistence with unerupted canine
The following points should be kept in mind when observing a

patient for a possible canine impaction.
1. Radiographic examination of erupting canines is useful for

prediction of canine impaction only for children between 10
and 15 years of age because it has been shown that
radiographic examination before the age of 10 does not
provide a reliable basis for prognosis of a future unfavourable
eruption path of the maxillary canines.
2. A spontaneous correction of palatally placed canines up to the
age of 10 years has been shown to be highly probable.
One common and highly relevant classification for the prediction of

chance of future canine impaction and its correction by early
intervention was proposed by Ericson and Kurol38 and it was later
modified by Lindauer.3 This classification is known as the sector
classification.
Sector classification
Ericson and Kurol38 found that the more mesially located the crown,
the lesser the likelihood of eruption after deciduous -extraction.
Lindauer et al.3 used Ericson and Kurol38 model for predicting
eruption after deciduous canine extraction (Box 64.4). Lindauer’s
method used the location of the cusp tip of the canine in question and
its relationship to the adjacent lateral incisor. He determined the
probability for impaction based on the canine cusp tip location in one
of the four sectors. Lindauer et al.39 reported that this method
identifies up to 78% of the canines that are destined to become
impacted, all of which have cusp tips located in sectors II, III and IV
(Fig. 64.7).
Box 64.4 Sector classification for impaction of

canine (Fig. 64.7)
Sector I. Represents area distal to a line tangent to distal heights of contour of lateral
incisor crown and root
Sector II. Is mesial to sector I, but distal to the bisector of lateral incisor’s long axis
Sector III. Is mesial to sector II, but distal to mesial heights of contour of lateral incisor
crown and root
Sector IV. Includes all areas mesial to sector III
FIGURE 64.7 Sector classification of canine impaction.
The four sectors are based on relationship of the developing canine tip
and its relationship with neighbouring lateral incisor.
It is to be clarified here that the sector classification was proposed to

be able to predict the possible chances of spontaneous eruption of
canine or correction of its position after removal of deciduous canines.
It does not directly reflect the prognosis of surgical methods and
orthodontic guidance to make the canine erupt.
Another method of predicting the chances of canine impaction is
based on calculating the angulation of the canine on an OPG or a
lateral cephalogram.31,38 Powers and Short31 also looked at angulation
as a predictor and found that if the tooth is angled more than 31° to
the midline, its chances of eruption after deciduous extraction are
decreased. Its prognostic value over sector classification is not yet
ascertained (Fig. 64.8).
FIGURE 64.8 Angulation of maxillary canine to the midline on
OPG.
If the tooth is angled more than 31° to the midline, its chances of
eruption after deciduous extraction is decreased.
Alqerban et al. used CBCT images to predict the maxillary -canine

impactions. They concluded that the canine angulation to the lateral
incisor on the coronal view, the canine cusp tip to the occlusal plane
on the sagittal view, and the canine crown position are the strongest
predictors of canine impaction using the CBCT radiographs.40
Orthodontic guidance/intervention
Intervention for the relocation of the impacted tooth (orthodontic
surgical guidance of tooth) involves one or more of the following
aspects of treatment:
Extraction of retained deciduous canine or incisor.
1. Removal of the physical barrier to the path of eruption such as

a supernumerary tooth, odontome, fibrous bands of mucosa or
non-pathological sack around the tooth crown.
2. Creation of sufficient space in the arch for the tooth to erupt.
3. Orthodontic guidance.
Extraction of a retained deciduous tooth

When to extract a retained deciduous tooth is a difficult clinical
decision as it is not yet clear whether a retained deciduous tooth is
responsible for impaction or vice versa. The primary canine is
recommended for extraction in children of 10–13 age group, in
situations of aberrant eruption or failure of eruption of the maxillary
canine. The deciduous tooth should also be extracted:
a. When the contralateral deciduous tooth has shed, and the

canine bulge is absent.
b. The deciduous tooth root shows atypical root resorption or no
resorption.
c. The permanent canine appears in an aberrant location.
In clinical situations when contralateral deciduous tooth has shed

and there is a clinical absence of bulge, the IOPA X-ray shows atypical
root resorption or no resorption or the permanent canine appears
aberrant in position, the deciduous tooth should be extracted.
Currently, the most common preventive treatment for dealing with
this quandary is to extract the deciduous canine with the hope that the
permanent canine resolves its unfavourable position. Two studies
have reported good success with this treatment, finding favourable
eruption to occur 78%37 of the time and 62%31 of the time, with the
latter study finding an improved -canine position in an additional 19%
of patients. In 78% of palatally erupting canines, a normal path of the
eruption was established within 12 months of the removal of the
primary canine.38 Clinical experience has shown that in a vast
majority of cases, extraction of deciduous tooth improves the
possibilities of eruption or at least alters the eruption path to a more
favourable position, which later improves the prognosis if surgical
orthodontic guidance is needed.
A major predictor of success is the relationship of tip of the
permanent canine crown with the roots of lateral incisors: those distal
to lateral incisors have better chances of successful eruption than
which are more mesially positioned.38 Studies have reported that 91%
of ectopically erupting canines came into proper occlusion if the
canine crown was distal to the distal half of the lateral incisor at the
time of removal of the deciduous canine.39 If, however, the crown was
mesial to the midline of the lateral incisor root, spontaneous eruption
occurred in only 64% of cases.
The second treatment option is to wait until the permanent canine’s
impaction is determined to be imminent and then surgically expose
and bond the tooth or teeth in question for active orthodontic
guidance.
Although success rates for both treatment modes are good, it is
desirable to have the ability to predict maxillary canine impaction.
Early detection and prevention of impaction by deciduous extraction
would decrease the patient’s need for oral surgery and simplify
Removal of physical barrier

Mesiodens are often found in incisor region and are a frequent cause
of delayed/abnormal eruption and/or impaction of maxillary incisors.
Literature is full of reports, where a timely and careful removal of the
mesiodens has allowed the eruption of the impacted incisors.
Supernumerary teeth like structures resembling -odontome may
occasionally be seen in maxillary canine region and may be a cause for
canine impaction (Fig. 64.3A–B).
Early detection of such physical barrier and their surgical removal
without disturbing the crowns/periodontium of the roots of the
developing tooth results in their spontaneous eruption. If the tooth
roots are fully formed and 1 year has passed, such cases would
require removal of physical barrier and orthodontic relocation (Fig.
64.9).
FIGURE 64.9 Twin mesiodens and impacted maxillary central
incisors.
(A) Pre-treatment model shows unerupted maxillary central incisors.
(B) Surgically exposed incisors bonded with brackets for orthodontic
eruption guidance. (C) Supernumerary teeth removed only after
bonding procedure is completed to control moisture due to bleeding.
(D) Elastomeric thread tied to the incisor brackets is passed through
the line of incision which is at the gingival crest, the site of the eruption
of teeth. (E) The elastomeric thread is gently activated over archwire.
(F) Alignment with light forces using round wires. (G and H) Fully
erupted incisors. This patient was later treated for class II malocclusion.
(A’) Occlusal X-ray maxilla showed supernumerary teeth which caused
the physical barrier to the eruption. (C’) Extracted twin supernumerary
teeth.
Other physical barriers include a fibrous gingiva or non-

pathological large sack around erupting crown, removal of which
results in spontaneous eruption.
It can be described under:
1. Surgically assisted orthodontic guidance

2. Surgical auto-transplantation.
Surgically assisted orthodontic guidance

Surgically assisted orthodontic guidance is performed when a definite
diagnosis of impaction has been made, and all possibilities of its
natural eruption have exhausted. Surgically -assisted orthodontic
guidance of eruption is usually considered after completion of the root
apex.41 However, in authors experience in cases of gross aberrant
location of the permanent tooth an early surgical intervention and
guidance of eruption is helpful. Several other factors determine the
possibilities of such an intervention, most important being availability
of the space for the proper alignment of the impacted tooth in
question and orthodontic treatment plan.
In certain situations where treatment of malocclusion necessitates
extraction of all first premolars, surgical relocation versus extraction
of the impacted tooth should be carefully weighed against the
extraction of the premolars.
Kharbanda Protocol of Orthodontic Surgical guidance is as
follows:
Welcome preparation
This includes:
• Creation of sufficient space in the arch by orthodontic means

for the impacted tooth in question to be aligned in the arch. In
certain situations, space may have to be created by derotation
of buccal teeth, labial proclination of incisors (within the
permissible limit of soft tissue profile) or by distally driving a
mesially migrated first molar.
Alignment of rotated teeth, specially those in the vicinity of an
impacted tooth should be considered with careful radiological
assessment of proximity of the impacted tooth to root apices.
While in some situations, derotation may be possible before
surgical interventions, in other situations rotation of the
erupted neighbouring tooth may have to be maintained until
the impacted tooth is moved away from the tooth roots.
• The arch should be bonded and prepared to house a heavy
steel wire such as 0.017 × 0.025 in. for anchorage. Hooks are
either attached or soldered to the wire to provide traction to
the impacted tooth. The author would usually complete
bonding and banding the arch(s), align the teeth, if not
contraindicated for the proximity of roots with impacted
tooth, and place a rigid wire such as an edgewise 0.017 × 0.025
in. wire with multiple soldered hooks for placement of
traction. Multiple hooks are handy in altering the direction of
orthodontic guidance and eliminates need for change of
archwire.
Surgical exposure and attachment to the

impacted tooth
Over the years, experience with different flap designs and assessment
of the periodontal health of the treated cases has led to define the
certain principles on exposure of impacted tooth (Box 64.5).
Box 64.5 List of Armamentarium used in

surgically assisted orthodontic bonding
procedure by OP Kharbanda at AIIMS, New
Delhi
Orthodontic Armamentarium Surgical instruments
1. Orthodontic instruments 1. Local anaesthesia set-up
a. Ligature wire 2. BP blade No. 11 and 15 with
b. Ligature cutter handle
c. Tucker 3. Periosteal elevators
d. Push scaler two pieces 4. Austin tissue retractor
2. Orthodontic attachments 5. Tissue forceps
a. Lower incisor bracket with NiTi coil spring attached 6. Surgical handpiece with saline
b. Lower incisor bracket with power chain attached irrigation system
c. Lower incisor bracket with ligature wire attachment with 7. Needle holders
eyelets for force application 8. Suture cutting scissors
3. Others 9. Hemostat
a. Kilroy spring 10. Silk sutures
b. Active labial archwire 11. Suction
4. Orthodontic bonding materials and instruments 12. Sterile gauge
a. Etchant 13. Universal curettage instrument
b. Primer 14. Push scaler, works like a micro-
c. Composite chisel
d. Light cure
e. Bonding tweezers
f. Low intensity air
Preservation of the band of attached gingiva is critical for the

maintenance of the periodontal health of a tooth. Hence, the flap
should be so designed that it preserves the band of attached gingiva
and the tooth is guided to erupt through its natural site of eruption.
In other circumstances, when a tooth cuts through oral mucosa,
attached gingiva is made available either by apically repositioning the
flap, a laterally repositioned pedicle graft or a free gingival graft.
Labial impaction. In an effort to guide the tooth to erupt at its
natural site, a large full thickness periodontal flap along with
mucoperiosteum is raised. The tooth is located through a very careful
chiselling of the alveolar bone, based on earlier radiological
assessment and palpation of maxillary bone. The bone is carefully
removed preferably towards the crown tip. Efforts are made not to
uncover cememto enamel junction or disturb periodontal fibres. Great
care is taken not to disturb the neighbouring teeth. Once the tooth
crown is exposed sufficiently for an -attachment, we recommend
bonding an attachment, with direct bonding orthodontic agent. It is
important to consider well-fitting contour of the bonding attachment
on to the tooth surface. The bonding attachment should preferably be
the one with low profile and minimal labiolingual thickness to
prevent tearing of flap and buttonholing.
The most critical aspect of the bonding an attachment procedure is
the maintenance of a moisture free environment for a successful
bonding. Author has used tiny pieces of gauze soaked in local
anaesthesia with adrenaline, pushed into space between tooth and
bone created by removal of tooth follicle with a micro-chisel such as
sharp push scaler. A watchful assistant maintains moisture free tooth
surface with a powerful suction and continuous gentle flow of
compressed air (oil and moisture free) over the tooth crown surface.
The advent of preprimed brackets and moisture insensitive primers
have considerably reduced the failure of bonding on impacted teeth.
The force of traction is directed towards the centre of the crest of the
alveolar ridge. For palatal impactions, the author has ligated nickel–
titanium spring directly on to the attachment, which is guided out at
the line of the incision and activated before the palatal flap is
repositioned.
Case report 1. Case NG, 8-years-old boy with missing permanent
maxillary right incisor. He had a harmonious profile and permanent
first molars in a class I relationship without any tooth size/arch length
discrepancy. The right lateral incisor was tipped mesially into the
space of the missing central incisor. The MDCT scan sowed
horizontally impacted tooth at the level of the nasal floor in the
anteroposterior direction. The tooth was rotated 90° along its axis,
with the palatal surface facing to the right. The guided eruption of
incisor was planned. The treatment steps are shown in Fig. 64.10.
FIGURE 64.10A Pre-treatment photos.
(A) Unaesthetic smile due to missing central incisor. (B–E) Impacted
permanent maxillary right central incisor seen as a bulge in the labial
vestibule. (F) Orthopantomogram showing an impacted and rotated
right central incisor. “Copyright ©2015 American Academy of Pediatric
Dentistry and reproduced with their permission.”
FIGURE 64.10B (A) Computed tomography image showing a
severely rotated and horizontally impacted right central incisor. (B and
C) Computed tomography image sections are showing the precise
location and position of the impacted tooth. Dilaceration of the root is
evident in section 24 of the computed tomography image. “Copyright
©2015 American Academy of Pediatric Dentistry and reproduced with
their permission.”
FIGURE 64.10C Dr Kharbanda’s technique.
Treatment progress: (A and A’) surgical exposure and bonding of
attachments with nickel titanium closed coil springs. (B and B’) Nickel
titanium coil springs instantly activated, with greater activation on the
palatal side for intrabony rotation and orthodontic eruption guidance.
(C) Placement of 0.014 in. nickel titanium archwire for final alignment.
(D) After alignment of the impacted incisor. (E and E’) Radiographs
before debonding. “Copyright ©2015 American Academy of Pediatric
Dentistry and reproduced with their permission.”
FIGURE 64.10D Occlusion immediately after debonding.
“Copyright ©2015 American Academy of Pediatric Dentistry and
reproduced with their permission.”
FIGURE 64.10E Occlusion at 2 years post-treatment. “Copyright

©2015 American Academy of Pediatric Dentistry and reproduced with
their permission.”
For labial maxillary canine impaction and incisors, -authors have
used an elastomeric chain with success. In literature, -authors have
recommended use of gold chain and braided ligature wire. Use of
dead soft wire around neck of a tooth requires considerable removal
of bone and is often associated with complications. Its use has been
discarded now.
Palatal impaction open technique. Palatal open exposure involves
cutting through a window of full thickness mucoperiosteal flap at the
site of the crown of the impacted tooth. The buttonhole or window is
packed with a non-absorbable dressing to prevent epithelisation. Once
uncovered, the impacted tooth tends to migrate towards the oral
cavity. The open window permits a dry area and access for a bracket
attachment for active traction force. The direction of traction is
intended for a vertical eruption of canine away from the roots of
incisors.
Closed technique. In the closed technique, the surgical access to the
impacted tooth is obtained and a suitable attachment bonded (many
clinicians used gold chain attachment) on the impacted tooth. An exit
hole in the flap near the traction device (chain/traction braided
ligature wire/power chain) allows crossing through into the oral
cavity. The flap is sutured back. In authors experience, it is a traumatic
and less predictable method. He prefers to exit the traction device at
the incisal crest, the usual site of the incision for the flap. The author
prefers to bond a pre-ligated 100 g. NiTi closed coil spring which is
pulled out and tied to a hook which offers the desired direction of pull
suitable for the orthodontic guidance.
Alternatively, Balsita spring provides efficient biomechanics when
activated from lingual tubes on first molars. Once canine is
sufficiently visible, a bonded attachment is replaced with a bracket at
the crowns labial surface. The canine can be now aligned in the arch
with a fixed appliance, continuous superelastic wires or piggyback
wires. Each case will require different planning for the angulation and
location of the impacted tooth.
Case report 2: Bilateral impacted palatal canines in an adult female.
An adult female reported in orthodontic clinic for -irregular teeth,
unaware of her retained deciduous -canines and bilateral impacted
maxillary canines in the palate (Fig. 64.11A–B). She had class II
division 2 malocclusion and there was insufficient space to align
impacted canines. Treatment included fixed mechanotherapy for
derotation of upper premolars and slight labial proclination of the
central incisors and alignment of arches. Welcome preparation
included a major orthodontic treatment of arch alignment, space gain
and opening of the deep bite prior to surgical exposure and
orthodontic relocation of the palatally impacted canines.
FIGURE 64.11A Management of palatally impacted maxillary

canines.
(A) Pre-treatment intraoral photo of an adult female who presented
class II division 2 malocclusion, retained bilateral deciduous canines
and palatally impacted canines. (B) Palatally impacted canines were
slightly palpable on the palate. Note a bulge on the right palate. (C)
Occlusal radiograph shows the proximity of canines to palatal roots of
lateral incisors. Note rotation of maxillary laterals.
FIGURE 64.11B (D) A major concern in treatment planning hovered
around guarded prognosis for orthodontic guidance and lack of space
to accommodate canines. Treatment began with derotations of
premolars and molars and some proclination of maxillary central
incisors. (E) The surgical procedure performed under LA. Exposure
under LA. Extraction of deciduous canines was delayed until bonding is
completed. Canines gently exposed. One lingual button each bonded
on available tooth crown area (lingual surface in this case). (F) 100 g
NiTi spring gently ligated with ligature wire. (G) Deciduous canines are
extracted. The NiTi springs are activated on base archwire. Suturing
completed. (H) Note healed palate and active springs. The canines are
visible in oral cavity having pierced through the mucosa. (I) Canines
are moving towards the arch. (J) The buccal surface of crowns
exposed with a full thickness flap raised at gingival crest which is
sutured at an appropriate height of gingiva of canine in relation to
lateral incisor(s). (K) Finished occlusion in class I molar anatomical and
functional relationship.
The surgical procedure was carried out under local anaesthesia and
a full thickness palatal flap was raised through gingival crest from
mesial of the second premolar to the second premolar of the other
side. Both canines received a direct bonded lingual button on their
palatal surfaces. On each canine, a NiTi closed coil spring (100 g) was
ligated on the button with soft-ligature wire. The flap was sutured
with NiTi spring gently activated attached to the archwire. The
direction of pull for the right canine was mainly labial, while the left
canine was distal and labial. The deciduous canines were removed at
this stage. Treatment with NiTi coil spring resulted in a significant
movement of canines to the level of the gingival crest. However, the
crowns were covered with gingivae, which required surgical
repositioning. Further treatment with fixed appliance resulted in
successful correction of class II division 2 malocclusion, a normal
contour of gingiva of erupted canines. The periodontal health of the
case was acceptable.
Case report 3: In a similar fashion mandibular canine impaction has
been aligned in occlusion using NiTi coil spring (Fig. 64.12).
FIGURE 64.12A Case of mandibular canine impaction.
Pre-treatment. Case RS, pre-treatment records show subject with late
mixed dentition with an almost horizontal position of left lower canine
teeth, which may have less chance to erupt into the oral cavity due to
its position and direction.
FIGURE 64.12B (A, B, C) After levelling and alignment of the lower
arch, guided eruption of left lower canine was attempted. The eruptive
force is applied through the NiTi coil spring attachment.
FIGURE 64.12C Alignment of lower left canine into arch.

Orthodontic guidance to eruption
This aspect of orthodontics for impacted tooth varies considerably
from case to case. The description of three clinical case reports of
incisor and canine impaction provide an overview of the principles
involved in orthodontic guidance of a impacted tooth (teeth).
Case report 4 (Fig. 64.9A–J): A 9-year-old boy was referred by a
general dental practitioner for non-eruption of both -permanent
maxillary central incisors. Earlier attempt by the dentist to remove
fibrous bands did not help. Occlusal X-ray revealed the presence of
two supernumerary teeth, thereby creating a physical barrier in the
eruption pathway. An envelop flap was used to locate incisors and the
twin supernumerary teeth which were housed lingual to each of the
central incisor. These supernumerary teeth were carefully removed
and incisors were bonded with edgewise brackets. Elastomeric
ligatures were tied around brackets, which hang out of the incision
site at the gingival crest. The molars and lateral incisors were banded
and gentle traction was applied through the elastomeric thread. The
incisors erupted through the gingival crest and were aligned into
occlusion with light orthodontic wires.23 The eruption of incisors at
the gingival crest resulted in physiologically contoured gingiva and
normal epithelial -attachment. Total -duration of treatment was 11
months. This boy developed class II malocclusion later and was
treated with twin block functional appliance that resulted in class I
molar and canine relation and normal overjet.
Case report 5: A 16-year-old female patient reported with
complaints of spacing in her upper anterior teeth. The right maxillary
lateral incisor was microdontic with a short root, and the maxillary
dental midline was shifted to the right side with diastema in the
midline. The right maxillary canine was impacted and the upper right
first molar was mesially migrated. The buccal teeth were in good
inter-cuspation with the left first molars in class I and right first
molars in full unit class II relationship. The tooth size arch length
discrepancy of 7 mm was in the upper arch and 2 mm in the lower
arch. The overjet was 4.0 mm, and the deep anterior bite was 7.0 mm.
The microdontic lateral incisor was extracted and substituted with
the canine, followed by crown modification and reshaping to make
the canine resemble the morphology of a lateral incisor (Fig. 64.13).
FIGURE 64.13A A case of palatal impacted canine, brought in

alignment with closed flap followed by Kilroy Spring (somewhat
resembles ‘Kilroy Was Here’ graffiti of the 1940s).
Case GC, pre-treatment facial and intraoral photographs shows
orthognathic profile, microdontic right upper lateral incisor and
impacted right upper canine. Source: Reproduced with permission from
Minotra R, Samrit VD, Kharbanda OP. Substitution of the microdontic
lateral incisor with the palatally impacted canine: A case report. J World
Fed Orthod, 2015; 4(2): 85–91.
FIGURE 64.13B (A) Surgically exposed right maxillary canine with
bonded lingual attachment. (B) Two weeks after surgery with activated
Kilroy Spring in situ. (C) Labial traction of the canine in lateral incisor
space with NiTi closed coil spring.
FIGURE 64.13C Post-treatment photographs show aligned right

canine in the arch and reshaping to mimic a lateral incisor.
Note the occlusion with good intercuspation full class II molar
relationship on the right side and a full class I molar relationship on the
left side.
FIGURE 64.13D Five years follow-up shows stable occlusion and

good gingival health.
Surgical auto-transplantation
It may be considered where relocation is not possible either due to an
extremely unusual position of tooth or anatomy of a canine root. The
auto-transplantation should be part of a total treatment plan only
when space closure with missing canine is clinically impossible with
known orthodontic mechanotherapy. However, the prognosis of a
transplanted tooth is unpredictable.42,43
There are clinical situations when a deciduous tooth may be
intentionally retained as a substitute for the permanent successor,
particularly if its root is well formed with no signs of resorption.
These clinical situations include an unfavourably impacted tooth,
which has a poor prognosis for the eruption. Due to its aberrant
location or root morphology, it may not be possible to attempt its
surgically assisted orthodontic eruption. Other factors that may
warrant impacted tooth not to be attempted for eruption guidance are
the general health of the child, underlying systemic disease, financial
and other logistic reasons for not seeking orthodontic treatment.
Extraction of an impacted tooth may be the treatment of choice where
there is no or insufficient space for its accommodation in the arch or it
is not possible to relocate the tooth by current known methods of
treatment. Patient’s general condition/unwillingness for treatment or
lack of expertise or logical support may indicate extraction,
particularly when impacted tooth is associated with pathology or
likely to cause damage to adjacent structures.
Key Points
Management of impacted teeth requires a holistic -approach to
treatment of malocclusion. It also necessitates that prognosis is to be
evaluated beforehand after thorough diagnosis. The 3D CBCT has
greatly enhanced the ability to correctly locate the impacted tooth and
its relationship with neighbouring teeth and bone. However CBCT
should be judiciously used to avoid unwanted radiation exposure.
The other factors that govern the prognosis of impacted teeth are oral
hygiene, status of oral health, -existing malocclusion and patient’s
willingness to undergo treatment including socioeconomic
considerations.
The availability of an expert clinician trained in surgical
management of impacted teeth is a key determinant for successful
outcome. All impacted teeth are not required to be aligned in the arch.
The approach to orthodontic guidance should factor in the benefits
versus inputs.
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CHAPTER 65
Transposition of teeth
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Complete transposition
Incomplete transposition
Prevalence
Maxillary arch
Mandibular arch
Aetiology
Interceptive treatment
Definitive treatment
Correction of a transposition
Management of complete transpositions in the maxillary arch
Maxillary canine–premolar transposition
Canine–lateral incisor transposition
Central incisor–lateral incisor transposition
Management of complete transposition in mandibular arch
Key Points
Introduction
Rarely, a tooth may migrate to occupy the position of another tooth in
an arch. This phenomenon of site substitution by two neighbouring
teeth is termed as Dental Transposition. Although in clinical practice
aberrant eruption of a tooth is common, a true tooth transposition is
where the crown and the root of two teeth are completely substituted
for each other in the arch.
More specifically, tooth transposition is defined as the positional
interchange of two neighbouring teeth and especially of their roots, or
the development or -eruption of a tooth in a position normally
occupied by a non--neighbouring tooth.1
The transposition of a tooth can be complete or incomplete.
Complete transposition
When both the crown and the entire root of the involved teeth
exchange places in the dental arch it is called complete transposition
(Fig. 65.1).
FIGURE 65.1 Complete canine–first premolar transposition in
right maxillary arch.
Incomplete transposition
Only the tooth crowns are transposed, although the root apices
remain in their relatively normal positions.2
Prevalence
Transposition of teeth is a rare phenomenon, with the -average
prevalence of 0.33%.3 The prevalence of transposition in various
ethnic groups is found to be 0.38% in Turkey, 0.40% in India, 1.4% in -
Nigeria, 0.09% in Greece and 0.13% in Germany.4–8
Maxillary arch
The occurrence of tooth transposition in maxilla is higher than in the
mandible. The unilateral occurrence of tooth transposition is more
frequent than the bilateral. The transposition of the maxillary canine
with the maxillary first premolar is the commonest. Other
transpositions include maxillary canine to lateral incisor, canine to
central incisor site, canine to the first molar site, and lateral to central
incisor.9 The lower density of the maxillary bone may enhance the
incidence of tooth transposition as well as a variety of types of
transposition in the maxilla.
Mandibular arch
Transposition in the mandibular arch is rare, the commonest among
them being a canine to lateral incisor transposition where the bone is
more porous than in the posterior area.10 The mandibular canine also
shows a tendency to migrate across the midline to the other side.11,12
Common transpositions are summarised in Table 65.1.
Table 65.1
Common transpositions
Maxillary Mandibular
Canine and first premolar Canine and lateral incisor
Canine and lateral incisor Transmigration of canine
Canine to central incisor site
Canine to first molar site
Lateral and central incisor
Aetiology
Apart from the genetic basis for tooth transposition, specific local
factors such as disturbances of normal eruption path of the permanent
teeth or trauma, early loss of a deciduous tooth may create a
developmental disharmony in the dental arch, and, at times, tooth
transposition.
1. The maxillary canine transposition may be the outcome of

either inherently displaced tooth germs, early loss of teeth due
to trauma or decay, or retained primary teeth. Its familial
occurrence has been well documented in the literature.
2. Mandibular canine transpositions are often associated with
retained deciduous canines, and some of them show bilateral
occurrence, which suggests a possible polygenic influence.
According to Howard,13 erupting mandibular canines with an axial

inclination of more than 25° to the mid--sagittal plane in the mandible
were likely to be displaced, while those that lay between 30° and 50°
had a tendency to migrate across the midline, and those with a more
than 50° inclination had a very high chance of crossing the midline.
A thorough and diligent diagnosis and thoughtful treatment planning
are critical while dealing with the management of transposed teeth
(Table 65.2). If the child reports with completely erupted transposed
teeth, the treatment -options may be limited. However critical
decisions may -require when a patient reports at an age when the
teeth are still in their formative stages, and the transposition of teeth
seems a definite possibility. Under such circumstances, one needs to
evaluate the benefits and risks associated with early versus late
intervention.
Table 65.2
Summary table of management considerations
Source14: Ngan DC, Kharbanda OP, Darendeliler MA. Considerations

in the management of transposed teeth. Aust Orthod J 2004; 20(1):41–
50.
Interceptive treatment
Early interceptive treatment would involve extraction of a primary
tooth5 with the hope that it might improve the path of eruption of the
potentially transposed tooth. But this is a possibility only if the root
apex of the tooth in question is at its normal site.
Definitive treatment
Ngan et al.14 have outlined definitive treatment possibilities of
transpositions that revolve around three treatment options:
1. Correcting the transposed order of the teeth

2. Maintaining the transposed order of the teeth
3. Extraction of one of the offending teeth.
Correction of a transposition
Correcting transposed teeth to their correct order of -sequence in the
arch may seem to be the best treatment -option. -However, correction
of a teeth transposition may be difficult to implement in many clinical
situations due to the complexity of biomechanics and/or the
limitations posed by the labiopalatal/lingual thickness of the alveolar
bone. One must recognise that correction of transposition would
require moving the roots of two transposed teeth in opposite
directions, roots of which should cross over each other through the
alveolar bone. The greatest challenge is posed by the buccolingual
thickness of alveolar bone which can support only one tooth. Hence,
in an attempt to achieve the ideal goal, orthodontic treatment duration
is prolonged, and one may end up jeopardising the periodontal
support of two teeth. In such situations, it may well be prudent to
maintain the order of transposition and modify the treatment
accordingly.
Surgical substitution with auto-transplantation may only be
considered if all other treatment options cannot be implemented or
have been exhausted.
Maintaining a transposition
Maintenance of the order of transposition and camouflage of the
transposed teeth to their respective anatomy and contours is a simpler
option. Camouflage may involve instituting changes in the gingival
contour, the crown height, the labiolingual thickness, incisal edge
form, proximal contacts, tooth colour and modification of the
functional occlusion. Most of the work is usually required in re-
contouring and restoring them with appropriate restorative material
to match the anatomy of the teeth they are replacing, and some form
of periodontal surgery to improve the gingival contour. For example,
the maintenance of the central incisor to lateral incisor transposition
would require a crown by a prosthodontist on the lateral incisor to the
size and shape of central incisor to achieve the desired aesthetics (Figs
65.2A, B and 49.1.7A–C).
FIGURE 65.2 Case report.
(A) This 13-year 7-month-old girl had a good facial profile, class I
dental malocclusion on class I skeletal base. Her left maxillary canine
was transposed with the first premolar, and corresponding deciduous
canine was retained. The maxillary canine had a dilacerated root, while
the first premolar had smaller and a slender root. Treatment progress:
The transposed canine was accommodated in the arch following
mesialisation of the premolar into the space created by the extraction of
the deciduous canine. The upper and lower arches were aligned using
fully bonded fixed appliance therapy. A 0.022-in. slot pre-adjusted
edgewise appliance was used, swapping the canine and first premolar
brackets. The premolar bracket was also bonded slightly distogingivally
to mesially rotate the premolar and increase buccal root torque. The
transposed canine and premolar were modified to fulfil aesthetic and
functional needs. The distal slope of maxillary canine was shortened to
resemble a premolar. A composite restoration of the first premolar at
the incisal edge to improve appearance was done later. (B) (A) A
young boy with impacted and transposed left upper canine. (B) After
fixed orthodontic treatment. The transposition was maintained and the
transposed canines and premolars were modified. Refer Fig. 49.1.7A–
C. Source: Reproduced with permission from Ngan DC, Kharbanda
OP, Darendeliler MA. Considerations in the management of transposed
teeth. Aust Orthod J 2004;20(1):41–50.14
Extraction of an offending tooth

Extraction of the transposed tooth is an alternative to an -extraction of
the tooth that has erupted in its normal position if the treatment plan
requires so.
Management of complete
transpositions in the maxillary arch
Maxillary canine–premolar transposition
It can be managed with rather a simple approach to this complex
problem. Orthodontic considerations include -canine tip and torque to
be incorporated on a premolar -using the canine bracket. Premolar
crown would need to be -reshaped for the distal slope of the incisal
edge and for the shortening of the lingual cusp. Crown-lengthening
periodontal surgery may be done to improve smile line if the
aesthetics require so.
Canine–lateral incisor transposition

Maintenance of maxillary canine–lateral incisor transposition requires
significant modification of orthodontic and restorative procedures. A
maxillary canine is modified to the contour of lateral incisor before
bonding with a lateral incisor bracket. The lateral incisor requires
major modifications of tooth anatomy with aesthetic material to
resemble a canine.
Central incisor–lateral incisor transposition

Such cases require intervention by a prosthodontist to build a central
incisor crown on the lateral incisor. Endodontic treatment and
periodontal surgery may be required as the case maybe.
Management of complete transposition
in mandibular arch (Fig. 65.3)
In cases of mandibular canine and lateral incisor transposition, the
gingival health of the canine is often -compromised due to a thin
labial alveolar bone in the lateral incisor area and the increased height
of gingiva. The transposed mandibular lateral incisor does not -
require aesthetic modifications due to its invisibility while smiling.
The canine needs to be suitably modified on its incisal edge and its
labiolingual thickness for optimum functional incisal guidance.
FIGURE 65.3 Lateral incisor–canine transposition in right

mandibular arch.
Arrow points to the transposed canine.
Mandibular canines tend to transmigrate to another side, the body

of the mandible, crossing the mid-symphyseal line and may remain
asymptomatic for several years before they are accidentally
detected.11,12 Such aberrant positioned teeth require their surgical
removal. Rarely they may cause pathological root resorption of the
adjacent teeth and -develop cyst or other pathological conditions.
Key Points
In deciding the most appropriate treatment option, the clinician must
consider the feasibility of the treatment plan, the duration of
treatment, chances of damage to the supporting alveolar bone,
periodontal tissues and the tooth root, aesthetic outcome, patient
motivation, adjunctive restorative and periodontal intervention, and
the final occlusal relationships. When these -aspects of transposition
management are duly considered, optimal treatment outcomes can be
expected and obtained.
References
1. Peck L, Peck S, Attia Y. Maxillary canine-first
premolar transposition, associated dental anomalies
and genetic basis. Angle Orthod. 1993;63(2):99–109:
Summer; discussion 110. Review. PubMed PMID:
8498708.
2. Shapira Y, Kuftinec MM. Tooth transpositions—a
review of the literature and treatment considerations.
Angle Orthod. 1989;59(4):271–276: Winter; Review.
3. Papadopoulos MA, Chatzoudi M, Kaklamanos EG.
Prevalence of tooth transposition: a meta-analysis.
Angle Orthod. 2010;80(2):275–285: Mar; PubMed
PMID: 19905852.
4. Yilmaz HH, Türkkahraman H, Sayin MO. Prevalence
of tooth transpositions and associated dental
anomalies in a Turkish population. Dentomaxillofac
Radiol. 2005;34(1):32–35: Jan; PubMed PMID:
15709103.
5. Chattopadhyay A, Srinivas K. Transposition of teeth
and genetic etiology. Angle Orthod.
1996;66(2):147–152: PubMed PMID: 8712493.
6. Onyeaso CO, Oneyeaso AO. Occlusal/dental
anomalies found in a random sample of Nigerian
schoolchildren. Oral Health Prev Dent.
2006;4(3):181–186: PubMed PMID: 16961026.
7. Hatzoudi M, Papadopoulos MA. Prevalence of tooth
transposition in Greek population. Hell Orthod Rev.
2006;9:11–22.
8. Dahl T. The transposition of teeth. Zahn Mund
Kieferheilkd Zentralbl. 1976;64:267–270: [in German].
9. Peck S, Peck L. Classification of maxillary tooth
transpositions. Am J Orthod Dentofac Orthop.
1995;107(5):505–517: May; Review. PubMed PMID:
7733060.
10. Shapira Y, Kuftinec MM. Orthodontic management of
mandibular canine-incisor transposition. Am J
6573140.
11. Kharbanda OP, Choudhury AR. Extreme
transmigration of mandibular cuspid: report of two
cases. J Clin Pediatr Dent. 1994;18(4):307–308:
Summer; PubMed PMID: 7811662.
12. Joshi MR. Transmigrant mandibular canines: a record
of 28 cases and a retrospective review of the
literature. Angle Orthod. 2001;71(1):12–22: Feb;
13. Howard RD. The anomalous mandibular canine. Br J
1065380.
14. Ngan DC, Kharbanda OP, Darendeliler MA.
Considerations in the management of transposed
teeth. Aust Orthod J. 2004;20(1):41–50: May; PubMed
PMID: 15233586.
CHAPTER 66
Auto-transplantation of teeth in
Rajiv Balachandran
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Case selection
Root-canal treatment
Orthodontic tooth movement of auto-transplanted teeth
Auto-transplantation versus osseointegrated dental implants
Key Points
Introduction
Transplantation refers to the transfer of tissue or organ from one site
to another.1 Auto-transplantation of teeth involves the surgical
transplantation of a tooth or teeth from one site in the mouth to
another site in the same mouth of an individual. The procedure of
auto-transplantation has been practised for many years to restore the
missing teeth or replace the teeth with a poor prognosis, with the
varying degree of success. However, recent long-term reports of its
success in orthodontic patients have generated significant interest,
more so in young subjects with congenitally missing teeth or, in
situations of traumatic avulsion. The auto-transplanted tooth is
considered a better substitute compared to an implant for its
biological behaviour of dental hard tissues and periodontal apparatus.
An auto-transplanted tooth undergoes physiological attrition and life-
long mesial migration, a biological necessity with ageing, which is
missing in an implant supported tooth. The auto-transplanted teeth
have a capacity for preservation of the alveolar ridge. Andreasen et al.
reported survival rates of more than 90% in a comprehensive study.2
The observation period and survival has been found to be 1–25
years mean of 10 years by Schwartz et al.3 and a no changes on 13
years and 9 months follow up in Japanese adult women by
Watanabe.4
Fong reported the first dental auto-transplantation in 1953.5 Since then
various surgical techniques and protocols have been introduced in the
literature.6,7 With clinicians working to create a standardised protocol
and attempting to report success on long term follow up, auto-
transplantation is gaining much attention as an alternative to the
implant prosthesis for the missing or teeth with poor prognosis.3,4
The indications for auto-transplantation of teeth includes8–10
1. Impacted or ectopic teeth

2. Premature and traumatic tooth loss especially in younger age
3. Congenitally missing teeth
4. Replacement of teeth with poor prognosis and developmental
dental anomalies.
Auto-transplantation of the impacted and ectopic erupted teeth may

be an alternative and faster treatment option for the patients who do
not want longer orthodontic treatment. This may be true in a case of
adult patients, who refuses to undergo orthodontic treatment or the
situation where the conventional orthodontic treatment procedure
alone will not be sufficient.
At the same time, auto-transplantation may also be useful in
premature or traumatic loss of teeth especially in younger patients.
Zachrisson reported that the maxillary incisors, which are the most
frequently involved teeth in trauma, can be replaced with premolars
(mandibular second premolar) in a young patient with avulsed front
teeth.11
The most common teeth used for auto-transplantation are
premolars, canines, incisors and third molars. Premolars, especially
the mandibular second premolars, are preferable for the maxillary
incisor region due to their morphology, size and single root canal.
Table 66.1 shows few indications for the auto-transplantation.
Table 66.1
Indications for auto-transplantation

S. Clinical condition Donor teeth
No
1. Impacted or ectopic teeth Extracted impacted or ectopic teeth
2. Premature and/or traumatic tooth loss/congenitally 1. Mandibular second premolar is
missing teeth preferable
• Maxillary incisors 2. Supernumerary incisors
3. Premature and/or traumatic tooth loss/congenitally • Third molars
missing teeth
• First and second molars
Contraindications:
1. Cardiac diseases
2. Poor oral hygiene
3. Poor self-motivation
4. An insufficient width of the alveolar bone (buccopalatal or
buccolingual).
Case selection
Proper case selection is the first and significant step in the success of
auto-transplantation. The following factors should be considered
while selecting the patients; absence of any systemic disorders, good
oral hygiene, regular dental checkup and patients with a history of
compliance. Above all the patient should have the suitable donor and
recipient site for transplantation.
The recipient site requirements are:
1. Adequate space
2. Adequate bone support both mesiodistally and buccolingually
3. No pathology or local inflammation.
The fair amount of alveolar bone all around the recipient space with
attached keratinised gingiva is essential for stabilisation of
transplanted teeth. If the mesiodistal space available for
transplantation tooth is less, a space-regaining procedure should be
carried out by orthodontic means.
The donor teeth requirements are10,12
1. Teeth with open apex are preferable, but with closed root, apex
can be considered.
2. Vital and intact periodontal ligament.
3. Atraumatic extraction of donor tooth. A tooth with abnormal
root morphology is contraindicated.
The developmental stage of root development is very critical for

success of the auto-transplantation. Studies show that the success rate
is high when the root development of the donor tooth is one-half to
two-thirds.11
The surgical steps can be summarised as follows:
1. Clinical evaluation of the donor and recipient site.

2. Preoperative radiographic evaluation of donor’s tooth and the
recipient site.
3. Surgical procedure: The surgical procedure involves extraction
of tooth, preparation of recipient site, extraction of the donor
tooth. It is advised to give antibiotic prophylaxis prior to the
surgical procedure.
The timing of extraction is more critical for the success of

transplantation. First, the recipient site is prepared to receive the tooth
(or teeth), little large size than the donor tooth is preferred. The donor
tooth is extracted carefully, and care should be taken to preserve the
entire periodontal ligament as much as possible. The donor tooth has
to be tried on the prepared recipient site with gentle pressure to check
whether it fits the socket passively. Changing the orientation to 90°
may help in fitting when the initial trial is a mismatch. If further
preparation of recipient site is required, then the donor tooth is
returned to the original socket to reduce the amount of out of socket
duration for the tooth. The donor tooth need to be placed with the
same biological width as the naturally erupted teeth. Next, the donor
tooth is secured in the position with sutures. The tighter and closer
adaptation between the flap and the donor tooth is more important for
the success of transplanted teeth.
Root-canal treatment
The root-canal treatment (RCT) of transplanted tooth is carried out
once the tooth is stable and prior to removal of the splint. In
developing transplanted teeth, pulp healing and apical closure can be
expected. The radiographs are taken every 3 months to monitor any
resorption or apical infection or apical closure. If any pulp pathology
is detected, the RCT has to be initiated immediately. However, RCT is
necessary for a fully developed donor tooth because healing of the
pulp cannot be expected after apical closure.13
Orthodontic tooth movement of auto-
transplanted teeth
The potential for orthodontic tooth movement of auto-transplanted
tooth provides a greater advantage over the implant prosthesis.
Paulsen et al.14 suggested orthodontic tooth movement 3–6 months
after transplantation, after periodontal healing but before total pulp
canal obliteration. Mensink et al.15 evaluated the success and survival
rate of premolar auto-transplantation and reported that 98% of
transplanted premolars are successfully aligned using orthodontic
forces. The orthodontic movement of these transplanted teeth had
been initiated 3 months after the procedure. It is advised to initiate
orthodontic treatment after 3–6 months. Cases successfully treated
with auto-transplantation followed by orthodontic treatment are
depicted in Figs 66.1–66.3.
FIGURE 66.1 Pre-treatment and post-treatment intraoral

photographs and panoramic radiographs of 10-year-old girl with
lower right first premolar transplanted to position of the maxillary
left central incisor.
(A and D) Upper left central and lateral incisors were both malformed
as a result of a previous trauma. After transplantation, (B) premolar
was reshaped to incisor morphology by a composite build-up;
orthodontic treatment was performed to close extraction spaces and
align the transplanted tooth. (C and E) Intraoral photograph and
panoramic radiograph 7 years after transplantation. Source:
Czochrowska EM, Stenvik A, Album B, Zachrisson BU. Auto-
transplantation of premolars to replace maxillary incisors: a comparison
with natural incisors. Am J Orthod Dentofacial Orthop 2000
Dec;118(6):592–600.
FIGURE 66.2 (A) Intraoral photographs of 11-year-old boy with two

lower first premolars transplanted to the anterior maxilla because of
traumatic loss of four maxillary incisors. (B) After the orthodontic
closure of the remaining spaces, auto-transplanted teeth and canines
in lateral incisor positions were reshaped to incisor morphology by
composite build-ups.
FIGURE 66.3 Intraoral photograph of the initial result (A) when an

accidentally lost maxillary right central incisor had been replaced with a
premolar transplant and then restored with a composite build-up. (B)
Because of an unsatisfactory aesthetic result, orthodontic treatment
was performed to level the gingival margins; composite restoration was
substituted with a porcelain veneer crown.
Auto-transplantation versus
osseointegrated dental implants
One of the significant difference between an auto-transplantated tooth
versus a dental implant lies in that the transplanted tooth can be
repositioned orthodontically, which is not possible with a dental
implant. Auto-transplantation contributes significantly to the oral
rehabilitation of younger subjects with missing teeth or who require
orthodontic treatment. As the growth is not complete in this age
group, the use of dental implants may lead to infra-occlusion of an
implant following osseointegration leading to poor aesthetics and
disturbance in occlusion. The auto-transplantation may be considered
as a viable alternative in these situations (Table 66.2).
Table 66.2
Auto-transplantation versus implant in orthodontic patients

Auto-transplanted teeth Dental implant
Patient age Patients with younger age with After the completion of physical growth
open apex teeth are preferable
Cost Free available from donor Heavy cost of implant and prosthesis
Surgical Two sites in the mouth One site
procedure
Prosthesis Needs aesthetic modifications Requires major prosthesis
procedure and restoration
Mesial Behaves like a natural tooth Infra occlusion with age
migration
Periodontal Same as natural periodontium Not as natural dentition. Can under go peri-
health implantitis
Alveolar Has the capacity for Does not have the capacity for preservation of the
ridge preservation of the alveolar alveolar ridge
ridge
Aesthetics A normal gingival contour can A normal gingival contour is problematic,
be obtained especially when two implants are adjacent to each
other
Orthodontic Orthodontic teeth movement is Not possible. Can be used as an absolute anchorage
treatment possible
Plakwicz16 have reported an interesting case with 9 years follow up

with missing maxillary lateral incisors. The right missing lateral
incisor site received auto-transplantation of maxillary third molar and
on the left side an implant prosthesis (Fig. 66.4). On long-term follow-
up it was observed that both treatment modalities provided functional
and aesthetic treatment outcome following aesthetic restorations of a
transplanted tooth and prosthetic restoration of the implant. The
periodontal assessment showed that the tissues around the implant
were showing progressive signs of recession. The status of the
periodontal tissues around the transplanted tooth did not differ from
those of natural teeth (Figs 66.5 and 66.6).
FIGURE 66.4 (A, B, C) Pre-treatment intraoral photos and study

model. (D) Pre-treatment OPG is suggestive of congenital absence of
maxillary laterals. The developing maxillary third molar with single
conical root was considered for auto-transplantation. Reproduced with
permission. Source: Plakwicz P, Fudalej P, Czochrowska EM.
Transplant vs implant in a patient with agenesis of both maxillary lateral
incisors: a 9-year follow-up. Am J Orthod Dentofacial Orthop 2016
May;149(5):751–6.
FIGURE 66.5 (A, B) Occlusion after orthodontic treatment in
preparation of space for the auto transplantation and implant. (C)
Intraoral photograph after orthodontic treatment showing the
transplanted third molar at the position of the maxillary right lateral
incisor (before restorative treatment) and the dental implant at the
position of the maxillary left lateral incisor. Reproduced with
permission. Source: Plakwicz P, Fudalej P, Czochrowska EM.
Transplant vs implant in a patient with agenesis of both maxillary lateral
incisors: a 9-year follow-up. Am J Orthod Dentofacial Orthop 2016
May;149(5):751–6.
FIGURE 66.6 (A) Intraoral photograph taken 5 years after surgery.
The transplanted third molar has a composite buildup to reshape it to
the morphology of the maxillary right lateral incisor. (B) Clinical
photograph 9 years after treatment. The transplanted third molar was
reshaped to lateral incisor morphology with a porcelain crown. Normal
soft periodontal tissues are present at the transplanted tooth. The
greyish colour is visible through the soft tissues above the implant
crown at the position of the maxillary left lateral incisor. (C) Intraoral
radiographs of the transplanted third molar at the position of the
maxillary right lateral incisor and the implant at the position of the
maxillary left lateral incisor (9 years after treatment).
Various authors evaluated the long-term survival rate of auto-
transplanted teeth. A systematic review conducted by Machado et
al.17 found that the survival rates ranged from 75.3% to 91%. Chung et
al.18 assessed clinical outcomes of auto-transplanted teeth with
complete root formation and found that 1- and 5-years survival rate of
98.0% and 90.5%, respectively. Another one systematic review and
meta-analysis by Atala-Acevedo et al.19 reported a success rate of 89%
and a survival rate of 98%, based exclusively on auto-transplanted
teeth with an open apex.
The possible complications are:
1. Root resorption (external and internal)

2. Ankylosis
3. Attachment loss.
Factors affecting success are:
1. Atraumatic procedure
2. The development of the root
3. Adequate fixation
4. Periodontal healing.
Key Points
The auto-transplantation is a viable alternative for the oral
rehabilitation in a clinical situation like missing teeth in younger
patients.
Its potential to adapt to the growth changes and possible
orthodontic tooth movement, relatively low cost compared to
osseointegrated implants and high success rate makes the auto-
transplantation a better treatment option, especially for younger
children. However, this procedure requires careful case selection,
professional skill and patient compliance.
References
1. Northway WM, Konigsberg S. Autogenic tooth
transplantation: the state of the art. Am J Orthod.
6986782.
2. Andreasen JO, Paulsen HU, Yu Z, Ahlquist R, Bayer
T, Schwartz O. A long-term study of 370
autotransplanted premolars. Part I. Surgical
procedures and standardized techniques for
monitoring healing. Eur J Orthod. 1990;12(1):3–13:
3. Schwartz O, Bergmann P, Klausen B. Resorption of
autotransplanted human teeth: a retrospective study
of 291 transplantations over a period of 25 years. Int
Endod J. 1985;18(2):119–131: Apr; PubMed PMID:
3858238.
4. Watanabe Y, Mohri T, Yoshida R, Yamaki M, Saito I.
Orthodontic treatment combined with tooth
transplantation for an adult patient with a missing
mandibular first molar: long-term follow-up. Am J
Orthod Dentofac Orthop. 2014;145(Suppl. 4):S114–S124:
5. Fong CC. Transplantation of the third molar. Oral
Surg Oral Med Oral Pathol. 1953;6(8):917–926: Aug;
6. Slagsvold O, Bjercke B. Auto-transplantation of
premolars with partly formed roots: a radiographic
study of root growth. Am J Orthod.
1974;66(4):355–366: Oct; PubMed PMID: 4529559.
7. Lapatki BG, Klatt A, Schulte-Mönting J, Jonas IE.
Dentofacial parameters explaining variability in
retroclination of the maxillary central incisors. J
Orofac Orthop. 2007;68(2):109–123: Mar; English,
German. PubMed PMID: 17372709.
8. Sagne S, Thilander B. Transalveolar transplantation
of maxillary canines: a critical evaluation of a clinical
procedure. Acta Odontol Scand. 1997;55(1):1–8: Jan;
9. Thomas S, Turner SR, Sandy JR. Auto-
transplantation of teeth: is there a role? Br J Orthod.
9884778.
10. Nimčenko T, Omerca G, Varinauskas V, Bramanti E,
Signorino F, Cicciù M. Tooth auto-transplantation as
an alternative treatment option: a literature review.
Dent Res J. 2013;10(1):1–6: Jan; PubMed PMID:
11. Zachrisson BU. Planning esthetic treatment after
avulsion of maxillary incisors. J Am Dent Assoc.
2008;139(11):1484–1490: Nov; PubMed PMID:
18978386.
12. Roden RD, Yanosky MR. Auto-transplantation: the
vital option for replacement of missing anterior teeth
in the developing dentition. Semin Orthod.
2013;19(1):13–23: Mar.
13. Andreasen JO. Analysis of pathogenesis and
topography of replacement root resorption
(ankylosis) after replantation of mature permanent
incisors in monkeys. Swed Dent J. 1980;4(6):231–240:
14. Paulsen HU, Andreasen JO, Schwartz O. Pulp and
periodontal healing, root development and root
resorption subsequent to transplantation and
orthodontic rotation: a long-term study of
autotransplanted premolars. Am J Orthod Dentofac
Orthop. 1995;108(6):630–640: Dec; PubMed PMID:
7503041.
15. Mensink G, van Merkesteyn R. Auto-transplantation
of premolars. Br Dent J. 2010;208(3):109–111: Feb 13.
16. Plakwicz P, Fudalej P, Czochrowska EM. Transplant
vs implant in a patient with agenesis of both
maxillary lateral incisors: a 9-year follow-up. Am J
Orthod Dentofac Orthop. 2016;149(5):751–756: May;
17. Machado LA, do Nascimento RR, Ferreira DM,
Mattos CT, Vilella OV. Long-term prognosis of tooth
auto-transplantation: a systematic review and meta-
analysis. Int J Oral Maxillofac Surg.
2016;45(5):610–617: May; Epub 2015 Dec 13. Review.
18. Chung WC, Tu YK, Lin YH, Lu HK. Outcomes of
autotransplanted teeth with complete root formation:
a systematic review and meta-analysis. J Clin
Periodontol. 2014;41(4):412–423: Apr; Epub 2014 Feb
19. Atala-Acevedo C, Abarca J, Martínez-Zapata MJ, Díaz
J, Olate S, Zaror C. Success rate of auto-
transplantation of teeth with an open apex:
systematic review and meta-analysis. J Oral
Maxillofac Surg. 2017;75(1):35–50: Jan; Epub 2016 Sep
SECTION XV
Surgical aspects of orthodontic
treatment
Chapter 67: Ortho-surgical management of skeletal

malocclusions
Chapter 68: Maxillomandibular distraction osteogenesis for
orthodontist
CHAPTER 67
Ortho-surgical management of
skeletal malocclusions
O.P. Kharbanda
M. Ali Darendeliler
CHAPTER OUTLINE
Introduction
Motivational factors involved in seeking orthognathic surgery
Aesthetics
Functional problems
Case selection for orthognathic surgery
Indications
Unsuitable cases for orthognathic surgery
Extraoral examination
Cephalometric and computer-based prediction technology
Role of digital cephalometric and video imaging in
treatment planning
3D models
Special considerations during surgical treatment planning
Social history and patients’ expectations including
psychological assessment
Importance of age in orthognathic surgery
Tissue considerations related factors
Steps involved in an orthognathic surgery procedure
Pre-orthodontic preparatory phase
Pre-surgical orthodontic treatment phase
Surgical phase
Post-surgical orthodontic phase
Surgery first approach
Retention and follow-up after orthognathic surgery
Complications following orthognathic procedures
Dissatisfaction with outcome
Complications and risks associated with orthognathic
surgical procedures
Complications unique to Le Fort surgery of maxilla
Bilateral sagittal split osteotomy of the mandible
Osseous genioplasty
Key Points
Introduction
The rehabilitation, attainment and maintenance of a well--functioning
masticatory apparatus in adult patients having dentofacial deformity
would require the involvement of a number of dental specialists.
Although the adult patient may seek dental treatment for simple
reasons like discomfort, pain or aesthetics, an accurate diagnosis may
reveal a need for more extensive treatment. The need for
comprehensive treatment is far greater now with the increase in life
expectancy, better health care and higher social standards. It is the
duty of the clinician to offer contemporary treatment options of
existing malocclusion and deformity to the patient, who may or may
not choose a treatment based on his personal/financial/social or other
unknown reasons.
Subjects with severe malocclusion due to underlying facial skeleton
disproportions cannot be treated with orthodontics alone. They have
an inherent imbalance of craniofacial structures regarding facial
heights, widths and anteroposterior dimensions in varying degree of
severity and a variety of combinations. The deformity may extend
deep into the orbital, zygomatic and cranial structures. Facial
disproportions may manifest as centre line problems or facial
asymmetry.
Surgical procedures which are undertaken to improve the facial
profile and aesthetics, are primarily focused on the correction of
disproportions of underlying jaws (GnathosGreek) and their
alignment (OrthosGreek). These are collectively grouped as
orthognathic surgery. The surgical procedures may be -undertaken on
either of the jaws (one jaw) or both the jaws (bimaxillary)
independently or in addition to surgery of the craniofacial structures
that may include the orbits, zygoma and the cranium.
While minor skeletal problems can be treated with orthodontic
camouflage, more severe forms of malocclusion and facial
disproportions need surgical correction. In the opinion of 28
orthodontists who independently evaluated 30 sets of pre-treatment
dental models, they perceived that a positive overjet greater than 8
mm, a negative overjet of –4 mm or greater, and a transverse
discrepancy larger than 3 mm were not orthodontically treatable.1
Historically, surgery on the mandible preceded that of the maxilla.
Hullihen was the first to perform osteotomy surgery on the lower jaw
to treat deformity caused by a burn.2 Vilray Blair for the first time
performed an osteotomy of the mandibular body for the correction of
prognathism in 1887, which was later called St Louis operation.
Subsequently, Blair reported mandibular body osteotomy in 1906 and
horizontal osteotomy of the ramus, with the external approach in
1907.3 The contemporary orthognathic surgery has much to owe to the
contribution of H. L. Obwegeser who introduced intraoral bilateral
sagittal split osteotomy (1942 first description published, 1957).4 The
BSSO technique was further modified by Dal Pont.5 BSSO with its
modifications is a widely accepted procedure on the mandible.
Cheever, as early as 1864, was the first to do down--fracture of the
maxilla to resect a nasopharyngeal mass in two -patients. Wassmund
reported his initial attempt to perform a maxillary osteotomy.
Wassmund employed orthopaedic traction postoperatively to position
the maxilla and did not surgically -mobilise the maxilla.6 Obwegeser
who fully -mobilised the maxilla in a single step brought it into the
predicted position. The technique to move the maxilla in three
dimensions of space emerged as revolutionary, as the sagittal split
osteotomy in the mandible. The primary concern was the preservation
of the vascularity to prevent necrosis of the maxilla, which by then
had been thoroughly researched. It is now well understood that intact
palatal and maxillary soft tissue pedicles attached to the osteotomised
segments preserve the vascularity, allow healing and minimise the
risk of tissue necrosis. In the 1960s, Obwegeser started to perform
maxillary surgery and described a large series of cases treated with Le
Fort I osteotomy. Obwegeser also reported simultaneous
repositioning of the maxilla and the mandible in 1970.7
The success of bimaxillary surgery has enabled correction of severe
deformities of the face. The technological and biomaterial inventions
lead to the development of the rigid internal fixation, mini plates and
bioresorbable rigid fixation devices. The orthodontic diagnosis and
treatment planning has considerably improved with knowledge of
growth and newer imaging devices that enabled 3D virtual planning,
visualisation of pre- and post-surgical orthodontics and prediction of
the profile. Also, quality care in anaesthesia and postoperative patient
care have together synergised to the -advancement in orthognathic
surgery resulting in minimal complications and quality outcome.
Distraction osteogenesis with multiple vector control -devices is the
most recent advancement in this field. These -developments have
already influenced treatment planning and therapy in skeletal
deformities.
Before the 1960s, orthognathic surgery was performed without
orthodontic treatment or sometimes surgery was planned after
orthodontic treatment was over or in a few situations, orthodontic
treatment was considered only after surgery.
Horowitz,8 in 1969, emphasised the importance of orthodontics in
this field and integrated it with the orthognathic surgery. In the
current scenario, a team approach is desired from the very beginning.
In this ‘team approach’, oral surgeon and orthodontist complement
each other and take up their unique roles, where assessment, planning
and execution are done in a coordinated manner with each specialist
doing their specialist jobs after interactive discussion and approval
and review and modify if the need be. Here, however, one needs to
realise that not all orthodontists are experienced and involved in the
field of surgical orthodontics, and same holds good for the oral
surgeons too.
Motivational factors involved in
seeking orthognathic surgery
Aesthetics
The aesthetic impairments may alter the psychological well-being of a
subject with a facial deformity and create perceptions of negative self-
image and social well-being. Many psychosocial studies have shown
cosmetic motivation as the primary reason for seeking orthognathic
surgery. However, it may vary across sociocultural groups. Type of
malocclusion and associated functional problems may have a direct
bearing on aesthetics and motivation for the treatment. It has been -
reported that patients with class III deformity rated themselves less
attractive than class II patients. After the surgery, they felt
significantly more improvement in attractiveness/self-confidence
compared to class II patients.9 A large proportion of these class III
patients suffer from aesthetic and functional problems -related to their
appearance before treatment, and aesthetic improvement was the
major driving force for their decision to seek treatment.
Functional problems
The functional problems are often associated with severe jaw
deformities but rarely the main reason for seeking orthognathic
surgery. Following are the functional reasons for seeking orthognathic
surgery:
1. Problems of articulation of speech. These problems are

common in patients with anterior open bite and severe deep
bite.10
2. TMJ problems especially in class III patients.
3. Periodontal and gingival health such as in traumatic deep bite.
4. Obstructive sleep apnoea (OSA).11
5. Compromised masticatory efficiency due to a decreased
number of functional occlusal contacts.
6. Tumour resection of the jaws.12
Case selection for orthognathic
surgery
Indications
1. Many of the deformities are developmental aberrations of the
facial structures that may have a familial trend. These subjects,
who have otherwise normal health may have a varying degree
of aesthetic and functional impairments.
2. Some of the patients reporting for surgery are those, who are
not satisfied with the outcome of orthodontic treatment aimed
to camouflage their facial skeletal problems.
3. Subjects exhibiting skeletal class III malocclusion with or
without mid face hypoplasia.
4. Subjects with severe class II skeletal malocclusion that cannot
be corrected with orthodontics alone.
5. Long face syndrome and vertical maxillary excess.
6. Facial asymmetry.
7. Orthognathic surgery is required for cleft palate patients who
have small maxilla consequent to the growth inhibitory effects
of scarring caused by the surgery of the lip and palate.
8. Children who have acquired jaw deformity due to the
ankylosis of the TMJ (unilateral or bilateral).
9. Post-traumatic jaw deformities due to malunited fractures.
10. Orthognathic surgery is indicated in patients with obstructive
sleep aponea to enlarge the oral space and therefore prevent
the tongue from falling back during sleep.
11. Orthognathic surgery may also be needed to correct
deformities due to the tumours of the condyle such as
unilateral condylar hyperplasia.
12. Other groups of orthognathic patients constitute children born
with craniofacial deformities.
Unsuitable cases for orthognathic surgery
1. Orthognathic surgery is not indicated for the patients with
mandibular prognathism due to tumours of the endocrine
glands and endocrine disorders such as acromegaly.
2. The psychological state of the patient is an important
consideration before taking a case for the orthognathic
surgery. The adults with complex behavioural problems and
known psychological disorders may have to be carefully
evaluated for their mental fitness to undergo surgery.
3. Patients with medical conditions are not an absolute
contraindication. However, they need to be assessed on the
kind and severity of the disease and its possible impact during
or after surgery.
Often, patients with malocclusion first report to an orthodontist, who
may seek advice and consultation with the oral surgeon for detailed
assessment of the case for a prospective surgical patient.
A potential patient for the orthognathic surgery should get a
thorough examination and assessment of all aspects such as medical,
dental, social, psychological and financial, besides the evaluation of
the clinical problem and investigations required.
The important steps are:
1. Medical and dental history

2. Extraoral examination
3. Intraoral examination
4. Diagnostic records
5. Possible VTOs and predictions/mock surgery
6. Reassessment in joint sessions, with an oral surgeon.
Evaluation of the face. It constitutes an assessment of the following

parameters:
• Vertical proportions
• Sagittal problems
• Transverse problems
• Symmetry of the face/midline deviations
• Nose and its impact on the overall facial profile.
The following parameters need to be assessed:
• Amount of overjet and overbite

• Sagittal relations of the molar, canine and occlusal contacts
• Posterior cross-bite and width of the maxilla
• The width of the mandible
• Inclinations of the anterior teeth
• Inclinations of the posterior teeth
• Crowding/spacing
• Curve of Spee.
Evaluation of the oral hygiene status, periodontal health, missing or

extracted teeth and need for maintenance of -general dental health are
also assessed. Possible need for the restorative work and optimisation
of oral health is a -pre-requisite before considering a case for
Extraoral examination
Evaluation of the face (Fig. 67.1A–C)
It includes visual observation and palpation of the facial structures
and prominence of the bony contours, muscle thickness and quality of
the soft tissue. A thorough clinical examination of the face is
conducted to evaluate and assess overall profile and shape of the face.
The type of face shape (long and thin, broad and short) and the
location of the skeletal problems that are of lower jaw alone, upper
jaw, an upper jaw with mid-face, or a combination of lower face and
mid-face are assessed.
FIGURE 67.1 Examination of the facial proportions.
(A and B) Face as analysed in vertical proportions. (C) Face in
transverse proportions.
The severity of the problem is assessed in anteroposterior, vertical

and transverse dimensions in a totality of face and for each jaw
separately including the nose. Facial asymmetry and skeletal midline
deviations are also evaluated. The assessment is done with regards to
soft tissue function, especially smile and speech.
• Assessment of facial proportions and discrepancy in three
dimensions of space.
• Zygoma and forehead, orbits, the width of the face, and
proportions.
• Evaluation of the soft tissue of the face, its thickness and
muscle mass.
• Nose and forehead: nose width of alar bases.
• Lip thickness, muscle mass and behaviour at rest, during
smile, speech and swallowing.
• Incisor show, gingival show at rest and during posed smile
and spontaneous smile.
• Nasolabial angle, lip height and contour.
• Inter-labial gap, lip seal, strain on mentalis muscle and depth
of the mental sulcus.
• Shape and thickness of chin and its overlying tissue.
• Type of face that is a horizontal or vertical type, ramus height,
gonial angle, chin position, chin thickness, chin shape.
• Any facial asymmetry or chin deviations during the closure, in
centric occlusion or at rest of the mandible.
• TMJ evaluation for its health and possible impact of surgery
Examination of the upper face

It is an essential and critical part of the evaluation process. It is
important to measure the height of the upper face (from nasal bridge
to the base of nose) and to know the cant (inclination) of the palatal
plane.
Examination of the lower face

It includes an assessment of the ramus height and anterior lower facial
height. The ratio of posterior to anterior facial heights is an important
consideration both clinically and cephalometrically.
For example, a subject with a large gonial angle, increased lower
anterior face height and smaller posterior face height would need a
different approach to surgical planning in contrast to the patient who
has a wide ramus body, acute gonial angle, increased height of the
posterior face and decreased lower face height.
The anterior open bite may be limited to the vertical excess of the
lower jaw or both the jaws. Subjects with long face syndrome have a
long narrow face with an excessive height of the maxilla and increased
visibility of the gingiva and teeth (gummy smile), anterior open bite
and increased lower anterior facial height.
In the frontal view, the face is divided into five equal -segments by
vertical lines. The mid-segment is formed -between two vertical
planes passing at the inner canthus of the eyes. In a well-balanced
face, these planes should pass through the base of the alae of the nose.
The next lateral segments are formed on either side of the plane
passing at the inner canthus of the eyes and the plane passing through
the outer canthus of the eyes. This outer plane usually should be -
coincident with the gonial angle. The outer two-fifth segments
essentially represent ears, and their widths may have to be improved
by the plastic surgeon if the ears are disproportionate with the rest of
the face. The width of the mouth normally should be equal to the
inter-pupillary distance.
Nose
Nose morphology can be a major contributing factor to an unaesthetic
appearance of the face. In a well-balanced face, the nasal width at alar
base is equal to the inter-canthal distance. A detailed examination of
the nose includes evaluation of the columella, nasal tip and the nasal
dorsum.
The shape of the nose and width of the nasal base is an important
consideration and surgeon has to evaluate and predict the influence of
the orthognathic surgery procedure on the alar base width and nasal
tip. For example, a forward movement of the maxilla aimed to correct
negative overjet would result in widening of the nasal base. This
problem should be evaluated and addressed before or during the
surgery.
Symmetry of the face

It is evaluated at an imaginary mid-sagittal plane. If facial asymmetry
is suspected, it should be confirmed with the analysis of a PA
cephalogram. The facial asymmetry may vary from slight deviation of
chin during functional closure in centric occlusion to a gross
asymmetry of the mandible and face. -Developmental facial
asymmetry can be seen in children who have been treated for
ankylosis of the TMJ or malunited fractures of the condyle or ear
infections involving TMJ. The other causes could be pathological for
example condylar hyperplasia. Facial asymmetry can be seen in
congenital face defects such as hemifacial microsomia (HFM) or
unilateral cleft lip and palate.
Evaluation of speech and indulgence of the speech therapist is
required in subjects having nasality of voice, cleft lip and palate
patients and those with articulation problems.
Examination of the oral cavity volume and size of the tongue makes
an important aspect of the clinical examination. Evaluation of the size
of the tongue is of particular significance in skeletal class III patients.
A setback surgery can pose volume constraints in accommodating a
large size tongue. Tongue size reduction procedure may need to be
included in the plan in such clinical situations.
Complete detailed records for orthognathic surgery include:
1. Facial photographs—profile views, and 45° at rest and in the

smile.
2. Study models with wax bite recorded in centric occlusion and
centric relation.
3. Lateral cephalogram and PA cephalogram are required in
almost all cases of class III malocclusion and vertical excess
patients to assess transverse problems.
4. Orthopantomograph and intraoral periapical radiographs that
are required to assess the interseptal bone available for making
surgical cuts. Oral surgeons like to assess the thickness of the
bone available and its density apical to root apices for the
surgical cuts.
5. Additional records include a CBCT scan. (For a detailed
description see Chapter 13.)
6. 3D facial photos such as 3dMD are optional however a great
tool for 3D virtual planning and prediction of post treatment
profile.
Cephalometric and computer-based
prediction technology
A variety of cephalometric analyses is available to ascertain the
location of the dysplasia and its severity. The lateral cephalometric
radiographs prediction technology should be considered with its
limitations of a 2D image of the 3D skeleton. PA cephalogram is a
useful adjunct especially in cases of -facial asymmetry. Analysis of PA
cephalogram provides useful -information on midline deviations and
transverse discrepancies of the maxilla and mandible. Cephalogram
tracings can be superimposed on Bolton standard tracings which
provide an instant graphics display of the site and severity of the
problems and the possible amount of correction required to achieve
an average profile.
Role of digital cephalometric and video

imaging in treatment planning
Before the advent of possibilities of direct digital image -acquisition of
the skeleton and its on-screen manipulation through the computer,
hand-drawn cephalometric tracings were used to predict and assess
the post-treatment profile following repositioning of the maxilla and
mandible by cutting the tracing template(s). Hence, treatment
planning in terms of the amount of movement of the jaws, location of
the -surgical cuts, and rotation of the osteotomised segments, its
execution and the possible outcome could be predicted. The
cephalometric tracings supported with the model mock surgery adds
to the transverse and vertical model of the -occlusion and dental
bases.
The current cephalometric analysis systems are supported by
powerful software functions that allow possibilities of ‘on screen’
digital image acquisition either directly from a digital cephalostat or
through a scanner and ‘on screen cephalometric analysis’ and storage
of data. The process is quick and -accurate for the landmarks
digitised. The digital photographic images, taken in a standardised
manner are calibrated and -superimposed on the digital cephalogram
image. The software functions facilitate ‘on screen mock surgery’,
movements of the skeleton segments and morphing the soft tissue
profile consequent to the surgery. The soft tissue changes of the
patient are predicted and morphed based on the data provided from
the research studies. Dynamic smile analysis is done through video
imaging techniques.13,14
The predicted image enhances communication with the patient who
can visualise the outcome of the surgery, and boosts his /her
confidence. However, these systems have limitations of accuracy
whereby, the actual surgical outcome may vary. Computer
predictions may have ethical and legal implications.
3D models
3D models with CBCT and digital reconstructions are other technical
advancements in this field. Herein, the digital CT images obtained
through cone beam computed tomography (CBCT) are used for the
reconstruction of patient’s skeleton and soft tissue. CBCT offers the
distinct advantage of much lower radiation doses than what
conventional MDCT offers. It provides a real life view of the bony
structures and therefore allows surgical treatment planning in detail
(Fig. 67.2). The bone thickness and relations with anatomical
structures such as neurovascular canal and teeth roots can also be
visualised. Stereolithography models can be generated using CT data
whereby a surgeon can plan a mock surgery.
FIGURE 67.2 Jaws and dentition as seen in 3D volumetric
reconstruction with CT.
Stereophotogrammetry is a technique that estimates the 3D
coordinates of an object using multiple photographic images taken
from different positions, front and side, for example, that have similar
points in each camera’s field of view (FOV).
It can capture the object (a patient’s face) in ∼ 1.5 ms to generate a
highly precise digital 3D model of the human anatomy. It is likely that
3D surface images will soon replace traditional 2D photographs. 3D
surface imaging has a wide range of clinical and research applications
in surgery, orthodontics, anthropometry, treatment planning and
assessment of outcome. The greatest advantage is that of its non-
invasive nature ultra short (∼1.5 ms) capture speed which is virtually
instantaneous and especially suited for imaging young, restless
children. The images offer possibilities of analysis and landmark on
patient’s surface data. It is easy to calculate and compare several
parameters such as linear, angular and complex surface distances,
ratio, areas and volumes. With 3dMD, it is possible to obtain surface
data from cross-sectional views on any plane or intersecting plane.
The images are of high quality, can be exported for use such as cross-
consultations through telemedicine. The image allows simulation and
-superimposition with radiological images such as 3D CBCT (Fig.
67.3).15
FIGURE 67.3 3dMD is a noninvasive technique, which permits 3D
model of soft tissues of the face.
A summary of clinical features and important cephalometric

features of skeletal jaw anomalies are compiled in Table 67.1.
Special considerations during surgical
treatment planning
Social history and patients’ expectations
including psychological assessment
Psychological profiling constitutes an important aspect of treatment
planning because, case preparation, surgical treatment and post-
surgical management require considerable time, effort and cost.
Hence, it is relevant to assess the psychological state and the
perception of the patient towards treatment at the beginning of the
consultation. This may involve psychological evaluation or sometimes
psychiatric assessment for depression and paranoid behaviour.16
Two types of motivations have been described for patients seeking
orthognathic surgical treatment:
1. External
2. Internal
Persons with long-standing inner feelings about deficiencies in

one’s appearance and negative self-image would be internally self-
motivated and are likely to be more satisfied after the surgery.
Whereas persons with external motivation, such as requirements in
career or the pressure from the spouse/partner to look better or
different, may not be good candidates for surgery.17 A few patients
are those whose internal motivation is activated from social,
professional or career needs.
Importance of age in orthognathic surgery

Orthognathic surgery should be delayed till adulthood so that the
skeletal growth is completed and the deformity is fully -expressed.
The mandible grows till late in adulthood, more so in subjects with
true mandibular prognathism, the mandible may continue to increase
well beyond the average age range. Sexual dimorphism in skeletal and
somatic maturation should be kept in mind. Earliest recommended
age for the orthognathic surgery in females is 14.9 and 16.5 years in
males.18
It is also important to highlight that the age at which surgery is to
be performed is also influenced by the type of -deformity to be
corrected.
• Surgical intervention in skeletal class III patients may have to

be delayed until completion of the mandibular growth which
may be as late as 22–24 years in males while much early in
females.
• Mandibular deficiency patients may need to undergo surgery
early before the growth is complete.
• Maxillary vertical excess patients can also have surgery before
growth is complete.
Tissue considerations related factors

Hard tissue considerations. There are three crucial hard tissue
considerations, which are affected significantly by growth and hence
are indirectly influenced by the age of the individual. These are:
1. Active growth and maturation of the skeletal tissues of the

craniofacial skeleton.
2. Late mandibular skeletal growth.
3. Third molars: extraction before, during or after the surgery or
no extraction.
Soft tissue considerations. The growth of the soft tissue of the face
should be evaluated and correlated with age to analyse the current
situation and possibly predict the soft tissue changes in lips, nose and
chin during maturity.
Age 13–16. The growth of the nose, in particular, has a greater
impact on the overall profile and outcome of the -orthognathic
surgery. Boys show a greater growth at the tip of the nose that is nasal
prominence, increases significantly compared to the girls between
ages 13 and 16 years.19
Age 18–42. Between ages 18 and 42 years in men, nose -increases in
size in all dimensions. The profile straightens with lips becoming
retrusive, with a decrease in upper lip thickness and increased lower
lip thickness. There is an increased soft tissue thickness at pogonion.
Among women, changes are different from men in the similar age
group. The profile does not become straighter, and the lips do not
become more retrusive. The nose increases in size in all dimensions.
There is a -decreased soft tissue thickness at pogonion. For men, most
of the hard tissue changes have occurred in 25 years, whereas soft
tissue changes in nose, lips and chin occur much after the age of 25
years. For females, both hard and soft tissue changes are more after 25
years old than before.20
Age 45–83. Behrents21 documented age changes between ages 17
and 83 years on the Bolton-Brush Growth Study sample. The
significant changes were an increase in nasal droop or nasal
prominence and nasal tip that moved more inferiorly. The lips became
less prominent and tended to be located -inferiorly thereby covering
the incisor show or decreasing visibility during a smile. These
considerations have a bearing on the amount of incisor visibility to be
planned at the time of maxillary surgery.
Steps involved in an orthognathic
surgery procedure
1. Pre-orthodontic preparatory phase
2. Pre-surgical orthodontic treatment phase
3. Surgical phase
4. Post-surgical orthodontic phase
5. Prosthodontic treatment phase, rehabilitation of occlusion and
aesthetic dentistry
6. Follow-up and retention.
Pre-orthodontic preparatory phase

Integrated orthodontics with orthognathic surgery has the following
objectives:
• Assessment of a case with the objectives to assess the patient’s

realistic expectations of skeletal, dental, soft tissue and others
related to chewing, speech, pain in TMJ.
• Assess the type and severity of the problems and plan the
treatment based on analysis of records, mock surgery and
cephalometric tracings (templates analysis or cephalometric
prediction software).
• A major component in the analysis would involve assessment
of the dental compensations in the malocclusion and how the
deformity would express when dental decompensations are
completed, and the teeth would have attained their normal
positions on their respective skeletal bases.
• Prediction of the post-surgical occlusion and its stability.
• Possible interceptive interventions such as facemask therapy
and their potential benefits in growing subjects.
Pre-surgical orthodontic treatment phase
Pre-surgical orthodontics
It involves the steps and procedures for correction of dental
malocclusion and is governed by the type of malocclusion. The basic
idea is to decompensate the tooth positions and inclinations which
have adapted themselves over time to compensate for the limitations
on function imposed by the malocclusion.
Appliance selection
The orthodontic appliances function to prepare the teeth -
orthodontically, and to stabilise the maxilla and mandible at the time
of surgery. It behoves the treating orthodontist to ensure that the
appliance selected for the case will withstand the surgical orthodontic
procedure in its entirety. A contemporary pre-adjusted appliance that
enables the placement of rigid rectangular wires prior to surgery is
essential. The minimal requirement would be to band the most distal
molar tooth, and excellent bonding to eliminate bond failure during
the surgical phase. In general, it is better to avoid ceramic brackets as
they are brittle and prone to fracture, and brackets with poor torque
control such as Begg appliance.
Extraction patterns for decompensation

Skeletal class II cases often have dental compensation present prior to
treatment. The lower incisors are often proclined by the dentoalveolar
apparatus in an attempt to adapt to the underlying class II skeletal
discrepancy. If surgeries were to proceed with proclined lower
incisors, the permissible mandibular advancement would be restricted
by the amount of overjet, which may be less than required for a
desired and an acceptable profile change. Often in skeletal II cases
either lower first bicuspids can be removed to retract and upright the
lower anterior teeth and allow for greater skeletal movement
(finishing class III molar), or lower first and upper second bicuspids
can be extracted to accomplish a class I molar finish.
The inverse of class II would apply to the skeletal class III case, with
the extraction of lower second and upper first bicuspids to finish to
class I molar relationship (Figs 67.4 and 67.5). The skeletal class III
patients show dental compensations through retroclined mandibular
incisors and -proclined maxillary incisors to compensate for the
skeletal discrepancy. The pre-surgical orthodontics would involve
placing the teeth to their normal inclinations resulting in increase in -
an reverse over jet.
FIGURE 67.4 Pre-surgical orthodontics for skeletal class II

patients.
(A) A class II skeletal malocclusion presents with proclined upper and
lower incisors on a smaller mandible. Pre-surgical orthodontics for
class II patients would require a decompensation of the incisors that
may involve correct labiolingual placement of the maxillary and
mandibular incisors. (B) After pre-surgical orthodontics. The over jet is
increased following upright placement of mandibular incisors. (C) Over
jet permits forward movement of the mandible with lengthening
procedure resulting in class I molar and normal over jet. After
FIGURE 67.5 Pre-surgical orthodontics for skeletal class III
patients.
(A) Class III skeletal malocclusion presents with proclined upper
incisors and retroclined lowers. (B) Pre-surgical orthodontics for class
III patients would require a decompensation of the incisors that may
involve correct labiolingual placement of the maxillary and mandibular
incisors. The negative over jet has increased after pre-surgical
orthodontics. (C) After orthognathic surgery. Negative over jet permits
distal movement of the mandible with shortening procedure resulting in
class I molar and normal overjet.
Orthognathic surgical procedures for common facial skeletal

problems are summarised in Table 67.2.
Table 67.2
Surgical treatment options for skeletal jaw discrepancy

Affected
Problem Procedure(s)
side
Mandibular deficiency Bilateral Sagittal split osteotomy with advancement
Mandibular excess Bilateral Sagittal split osteotomy with a setback
Horizontal chin deficiency Advancement genioplasty
Bimaxillary protrusion Pre-maxillary osteotomy such as Wassmund
operation in the maxilla
Segmental osteotomy of the anterior mandible
Maxillary protrusion Pre-maxillary osteotomy such as Wassmund
operation in the maxilla
Excess vertical growth of the maxilla Le Fort I procedure with maxillary impaction
Maxillary horizontal deficiency Le Fort I procedure with maxillary advancement
Class III with vertical maxillary Bilateral Le Fort I procedure with maxillary
deficiency and mandibular excess advancement, inferior positioning with bone
grafting
Sagittal split osteotomy with a setback
Class III with vertical maxillary Bilateral Le Fort I procedure with maxillary impaction
excess and mandibular excess Sagittal split osteotomy with a setback
Mandibular deficiency with high Bilateral Le Fort I procedure with maxillary impaction
mandibular plane angle Sagittal split osteotomy, mandibular
advancement
Asymmetry of the face Differential Le Fort procedure of the maxilla
Sagittal split osteotomy and
rotation/genioplasty with rotation
Maxillary deficiency
In a case of maxillary deficiency alone with normal mandible, the
maxilla may be deficient in arch width and length leading to
crowding of teeth. The dental compensations that may have taken
place are mainly in the form of proclination of maxillary anterior teeth
in an attempt to maintain normal overjet. The lower anterior teeth
may have supra-erupted due to loss of contact with upper anterior
teeth while the posterior teeth may be lingually dumped to maintain
contact with the upper posteriors.
• The pre-surgical orthodontics is aimed to provide well-aligned

and levelled arches with sufficient arch width and
decompensation of the abnormal inclinations of the upper and
lower teeth.
• Surgically assisted transverse maxillary expansion may be
required in cases with severe transverse deficiency of the
maxilla.
• First or second premolar extractions may be necessary in cases
of severe crowding of the arch.
• Patients with cleft lip and palate pose additional problems of
malformed and missing teeth.
The objective of orthodontic space closure for missing tooth, most

often the lateral incisor, may have to be attained during the pre-
surgical orthodontic phase itself. Supernumerary teeth and impacted
canines which are of common occurrence in cleft palate patients
should also be evaluated and treated accordingly prior to
Vertical maxillary excess (VME)
Anterior vertical maxillary excess may exhibit itself as an excessive
gingival display with normal overjet and overbite or more extreme
variation of the narrow maxilla, excessive display of dentoalveolar
structures and anterior open bite associated with a large mandibular
plane angle and large gonial angle. These subjects have an excess of
anterior facial height, downward rotations of the posterior maxilla,
and short -ramus. Jointly these features are more appropriately
termed as long face syndrome. Management of anterior vertical
maxillary -excess primarily involves corrective surgical procedure on
maxilla alone or bimaxillary procedure.
Vertical excess of maxilla can be aptly treated by Le Fort -osteotomy
of the maxilla and taking a slice of the bone beyond root apices at the
nasal septum, and walls of sinus, lateral to the pyriform aperture. The
maxilla is moved -upward in a favourable rotation (more upward in
the posterior region, if so required) thereby resulting in an
anticlockwise rotation of mandible, improvement in face profile and
of class II relation to some extent. A patient with a long face syndrome
-requires additional surgery of the mandible to reduce the high
mandibular plane angle. The maxillary surgical intrusion is combined
with ramus lengthening and rotation of the body of the mandible (Fig.
67.6). The vertical height of the chin is reduced by inferior border
osteotomy.
FIGURE 67.6 (A) Class II skeletal malocclusion presenting with
increased lower anterior face height and dental open bite. (B) A case is
treated with Le Fort I osteotomy and posterior impaction or clockwise
rotation of the maxilla, which helps rotate the mandible in the
anticlockwise direction, thereby improvement in the sagittal and vertical
relationship.
With the introduction of temporary anchorage devices (TAD) and

skeletal anchorage system (SAS), the intrusion of the upper posterior
segments has become a reality and may eliminate Le Fort I posterior
impaction, in cases particularly when sagittal repositioning of the
maxilla can be avoided. However, long-term stability of this approach
is yet to be evaluated.
Mild to moderate vertical maxillary excess may be associated with or
without superior protrusion and normal overbite. The pre-surgical
orthodontic procedures should not be aimed at the intrusion of
maxillary incisors.
The patients with a long face syndrome who may have -excessive
supra-eruption of lower incisors and crowding would require
levelling and alignment and extractions of -selected premolars (first or
second bicuspids) to prevent flaring of lower incisors. In some
situations, the supra-erupted mandibular incisors may need a
segmental osteotomy of the mandible to level the curve of Spee in the
mandibular arch.
Skeletal class II patients show dental compensations by excessive
lower incisor proclination. Orthodontic objectives are aimed at the
upright lower incisors on the mandibular base. Subjects with
crowding and space deficiency may need extractions of premolars in
lower arch alone or both upper and lower arches. At the end of the
pre-surgical orthodontic phase, dental arches should be well aligned,
both upper and lower teeth should be brought to normal positions
and -inclination. Upper and lower dental arch shapes and dimensions
should also match. Maxillary arch may need expansion to -
accommodate a retrusive mandible when brought forward to a
normal overjet. BSSO is a frequently employed single jaw procedure
for the correction of mandibular retrognathism. Horizontal chin
deficiency is compensated with additional surgery of sliding
genioplasty if required.
Borderline case concept

It has been beautifully summarised by Musich.22 -Borderline cases in
terms of orthognathic surgery, are essentially surgical–non-surgical
cases in terms of either severity of the problem or one jaw or two jaw
osteotomy. Such cases require -review and re-review to decide to do
or not to do surgery. For example, an adult class II with moderate -
maxillary excess and mandibular deficiency may be better treated
with orthodontic camouflage considering the cost-benefit -ratio of the
treatment.
Another example of a borderline case in terms of orthognathic
surgery could be a surgical class II case with some maxillary vertical
excess which may be considered for surgery on the lower jaw alone,
leaving mild maxillary excess if the surgical risks are greater as
compared to gains.
Levelling the maxillary and mandibular arches

Pre-surgical orthodontics also aims to minimise the amount of post-
surgical orthodontic treatment. The decision to level arches before or
after surgery depends upon the vertical dimensions of the patient and
can influence the post surgery duration of orthodontic treatment for
finishing and detailing. When there is a deep curve of Spee in the
lower arch, the decision to level by intruding incisors or extruding
molars is based upon the patients’ facial height. For a short face,
extrusion of molars is preferred, such that the chin moves downward
at surgery. Therefore, if a patient has a short face and a retrusive
mandible, this will obviate the -advancement. The surgical splint will,
therefore, be thicker posteriorly. Post-surgical levelling occurs rapidly
by the use of elastics on a lighter archwire in the lower arch.
Caution—as the deep curve of Spee is levelled, the lower incisors
will procline if there is no spacing within the arch. This should be
taken into account when deciding upon the surgical movement.
If the facial height is normal, then lower incisors are -intruded so
that facial proportions will be preserved at surgery. Levelling is done
prior to surgery.
In the maxilla, when segmental surgery in indicated, the arch
should not be levelled with a continuous wire prior to surgery.
Levelling should only be done within each segment, that is right and
left buccal segments and an anterior segment. The segments are
levelled during surgery.
The post-treatment occlusion is aimed to have the upper incisor on
the pre-determined vertical position and parallel to the facial axis, and
the lower incisor in the middle of the symphysis. Once the optimum
incisor position has been obtained in the vertical and sagittal plane,
any remaining spaces within the arches are closed by losing
anchorage. Lateral head films can be useful when the case is halfway
through space closure to ensure that the incisor position is correct
prior to the loss of the anchorage.
Joint evaluation after pre-surgical orthodontics prior to surgery:
• Ideal alignment of arches within respective jaws is a pre-

requisite to most of the orthognathic surgeries. This makes
accurate correction of the skeletal discrepancy possible, not
only in the anteroposterior and transverse direction, but also
vertically.
• Full records are made which include, dental study models,
cephalograms and clinical photographs. A joint assessment
with oral surgeon is planned to reassess the occlusion and
plan in detail. Particular attention is given to look for possible
interferences on tooth cusps if that may interfere with correct
positioning of the osteotomised parts.
A mock model surgery or virtual surgery can again be attempted at

this stage to view the final outcome of the occlusion and the extent of
surgical movement required.
The cephalometric template can be used to predict the type and
extent of the surgical change needed concerning horizontal and
vertical planes, orientation and rotation of the bony segments.
Transverse movement cannot be visualised on the -lateral
cephalograms. While it is possible to predict the -skeletal changes
with close accuracy, soft tissue changes vary -considerably. Different
parts of the soft tissue respond -differently to the same skeletal jaw
movement. For example, with a -mandibular setback, while bony chin
responds in the ratio of 100%, the lower lip responds by close to 60%.
Pre-surgical archwires. The pre-surgical archwires should be rigid
rectangular wires such as SS 0.019 × 0.025 in. to provide maximum
possible control during the surgical procedure. The wires should be
placed at least 4 weeks before the surgery. The wires should have
become passive at the time of impressions for the surgical splint. This
will avoid dental movements that could prevent the surgical splints
from fitting correctly. All modules are replaced with SS ligature quick
ties. Inter-maxillary hooks are placed at various sites on the archwire
to be used for inter-maxillary fixation following surgery.
The archwires themselves can be posted with multiple hooks by
soldering or using crimpable hooks. These hooks are utilised by the
surgeons to place inter-maxillary fixation and enable correct
positioning of the maxilla and -mandible.
At this stage, a face bow recording of the centric relation is
performed. An occlusal splint is prepared on a predicted position
agreed by the surgeon which helps as a guide to reposition the
osteotomised segments. The splint permits precise tooth movements
and finishing the occlusion postoperatively.
Surgical phase
During surgery, an orthodontist may be expected to be available in
the operation theatre while the occlusal wafer splint is being
positioned. The orthodontist primarily guards the -occlusion, before
rigid fixation is performed by a surgeon. -Occasionally, the wafer
splint may need to be modified in cases where expected, and planned
movements of the osteotomised segments are not possible to achieve.
The most commonly employed osteotomies are:
• Mandible. Bilateral sagittal split osteotomy

• Midface. Le Fort I osteotomy
• Horizontal osteotomy of the symphysis of the chin: reduction
or advancement.
Each case, based on its problems and expected outcomes, may

require single jaw or both jaw surgeries, with or without genioplasty.
More complex problems, such as facial asymmetry, may require
complex surgical planning such as alteration of the transverse plane,
correction of the ramus height and change in the midline. Individual
modifications to the above mentioned three basic surgeries would
then be required as per the need.
Bilateral sagittal split osteotomy

Bilateral sagittal split osteotomy (BSSO) of the mandible is a good
option for the reduction in mandibular length in skeletal class III as
well as mandibular advancement, in skeletal class II adult patients
(Figs 67.7 and 67.8). Representative case of a skeletal class III and
skeletal class II are presented through series of photographs which are
labelled for an explanation.
• A representative case of skeletal class III malocclusion treated
with a BSSO with a reduction in length of the mandible is
depicted in Figs 67.9.1–67.9.5. This patient also underwent a
Le Fort I procedure on the maxilla.
• A representative case of skeletal class II malocclusion treated
with BSSO for the advancement of the mandible is presented
through Figs 67.10.1–67.10.5.
FIGURE 67.7 Bilateral sagittal split osteotomy (BSSO).

Showing the location of the osteotomy cuts on the lateral and medial
surface of the mandible. (A and B) Mesial surface cuts are above
mandibular foramen to preserve the integrity of the neurovascular
bundle. (C) Cuts are made of minimal depth to permit a gentle split.
FIGURE 67.8 BSSO can be manipulated for reduction and
lengthening of the mandible.
(A) A local split of the mandible. (B) Sagittal split osteotomy of the
mandible, so as not to disturb neurovascular bundle entering
mandibular foramen. (C) BSSO can be used for the advancement of
the mandible. (D) For reduction in the length of the mandible.
FIGURE 67.9.1 Double jaw surgery for a severe case of skeletal

(A) Pre-treatment. (B) Post-surgical. (C) Post-treatment occlusion of a
case treated with BSSO and Le Fort I osteotomy.
FIGURE 67.9.2 A case of skeletal class III malocclusion treated
with BSSO, for a reduction in the length of the mandible and Le
Fort I osteotomy of the maxilla.
(A) Pre-treatment. (B) Post-treatment profile pictures.
FIGURE 67.9.3 (A) Pre-treatment lateral cephalogram. (B) At the

completion of pre-surgical orthodontics.
FIGURE 67.9.4 Facebow transfer and surgical splint.

Models are transferred to the articulator through facebow registration.
(A) An intermediate splint to dictate maxillary advancement. (B) A final
splint to dictate mandibular setback was prepared.
FIGURE 67.9.5 Pre, post and superimposition lateral

cephalograms of a case treated for skeletal class III malocclusion.
(A) Treatment planning included bimaxillary surgery. Le Fort I maxillary
advancement of 6.5 mm with 3.5 mm posterior impaction. The
mandible required 6.5 mm of sagittal setback through BSSO. (B) Post-
treatment. (C) Superimpositions on tracings. Note a significant
improvement in a sagittal skeletal relationship, occlusion and facial
profile. Source: Case credit Dr Deobra Harris, University of Sydney,
Australia.
FIGURE 67.10.1 Orthognathic surgery for skeletal class II
malocclusion.
A case RB, 15-years 11 months. Full cusp class II molar and canine
relations, deep bite, skeletal class II.
FIGURE 67.10.2 Case RB, 15-years 11 months, treated for the

advancement of the mandible.
FIGURE 67.10.3 Continued…
FIGURE 67.10.4 Continued…

FIGURE 67.10.5 (A) Cranial base superimposition. (B) Regional
superimposition.
FIGURE 67.10 A case of skeletal class II malocclusion treated
with a combined orthodontic-orthognathic approach. Source: Case
credit Dr Sivabalan Vasudavan, University of Sydney, Sydney,
Australia.
Le Fort maxilla
Fig. 67.11 depicts sites of osteotomy and repositioning of the maxilla
to correct midface deficiency. An adult patient with midface
deficiency treated with maxillary advancement is presented in Figs
67.12 and 67.13.
FIGURE 67.11 Dried human skull depicting site for the Le Fort I
osteotomy.
FIGURE 67.12 Surgery for mid-face deficiency.

Adult patient (DR) has a mid-face deficiency with a normal mandible.
He has been treated with maxillary advancement. Note change in mid
face, improvement in profile and nose upper lip relation. Source: Case
credit Dr Claude Mossaz.
FIGURE 67.13 Line drawings illustrate repositioning of the
maxilla to correct maxillary hypoplasia as in the case.
(A) Pre-treatment. (B) Post-treatment.
Bi-jaw surgery (BSSO mandible + Le Fort maxilla)

The severe cases of skeletal class III would need bi-jaw surgery (Fig.
67.14). A case of severe skeletal class III malocclusion was -treated
with bimaxillary surgery, is explained through pictures (Figs 67.15.1–
67.15.7).
FIGURE 67.14 Bi-maxillary surgery for long face syndrome.
(A) location of osteotomy sites and (B) its possible impact on the face
in a case with long face syndrome.
FIGURE 67.15.1 A journey of a severe skeletal class III patient.

A young boy with maxillary hypoplasia and class III malocclusion and
abnormal growth of the mandible continued to worsen with age.
FIGURE 67.15.2 Treated with Le Fort III osteotomy, BSSO and
orthodontics.
Significant improvement in profile and stable results 23 years
postoperative.
FIGURE 67.15.3 (A and B) Serial pre-treatment cephalograms depict

maxillary hypoplasia and abnormal growth of the mandible that
worsened with age.
FIGURE 67.15.4 (A and B) Pre-surgical radiograph showing sizeable

negative overjet. (C) Significant improvement in profile and stable
results 6 years post operatively.
FIGURE 67.15.5 (A–C) Pre-treatment occlusion, showing large

negative overjet, retroclination of lower incisors, a wide mandible and
dental compensations. (D–E) Pre-surgical orthodontics. (F–G) After
bimaxillary surgery. Orthodontic treatment in progress.
FIGURE 67.15.6 (A) Post-treatment occlusion at the age of 22 years.
(B) At 42 years 9 months 23 years postoperatively.
FIGURE 67.15 (1–6) Long-term follow-up of a child who
developed severe mandibular prognathism.Note significant
improvement in profile and stable results 23 years postoperative.
Source: Case courtesy Prof Jean-Pierre Joho, Switzerland. Surgery
was done by Prof JM Chausse.
Post-surgical orthodontic phase

The phase typically begins 6–8 weeks after surgery when a patient is
seen in the orthodontic office. At this stage, the patient would have
recovered from most of his facial oedema. The patient is assessed for
the removal of the surgical splint.
The patient is advised on jaw mobilisation exercises which are
increased progressively to acquire the full range of jaw motion. The
oral hygiene which gets deteriorated during splint phase would
require special attention for optimisation.
Finishing and detailing of the occlusion is started as soon as a
patient is comfortable with the mouth opening and free from pain.
This period lasts for about 6–8 months. During this time any
prosthodontic rehabilitation, if planned, can also be implemented.
Surgery first approach

The surgery first approach entails the orthognathic surgery precedes
the orthodontic treatment, whereas the -orthodontics-first approach
indicates that the orthodontic treatment precedes the orthognathic
surgery. The conventional approach is an orthodontics-first
approach.23 The conventional pre-surgical–orthodontic approach
followed by surgery and post surgical orthodontics encompasses a
prolonged treatment duration and temporary worsening of -facial
appearance. The surgery first approach (SFA) technique or ‘surgery
first-orthognathic-approach’ or ‘SFA involves rigid fixation’ followed
by rapid orthodontic treatment to take advantage of the regional
acceleratory phenomenon (RAP).23,24 Treatment time as short as 7
months have been reported in the literature and -bypassing pre-
surgical orthodontics results in an overall shortened treatment time
up to 1–1.5 years.24
Indications. The SFA can be used in those non-growing individuals
who have well-aligned arches and a flat to mild curve of Spee.
Although there is no contraindication on malocclusion type for the
SFA, class III skeletal malocclusion cases fulfill the most criteria of
case selection.23
• Well-aligned to mild crowding

• Flat to mild curve of Spee
• Normal to mild proclination/retroclination of incisors
• Minimal transverse discrepancy.
This approach is also indicated in cases in which decompensation is

needed.
A recent systematic review reported that class III malocclusion was
the most prevalent underlying malocclusion (84.7%) in patients who
were suitable and treated with surgery first approach. Total treatment
duration was shorter in surgery-first patients than in those treated
conven-tionally.25
Steps in surgery first approach23
1. Following complete records and discussion on the plan of the

surgery both the arches are bonded and banded, but no
archwires are placed.
2. The model surgery is performed as per the determined end
objectives of the occlusion or class I molar relations.
3. Following surgery the orthodontic treatment is initiated 1 week
to one month after surgery to take advantage of the regional
acceleratory phenomenon (RAP).
4. Orthodontic treatment involves de-compensation and
flattening of the curve of Spee.
Advantages of surgery first approach, according to Liou et al.23
1. Patient’s chief complaint, dental function, and facial aesthetics

are achieved and improved in the beginning of the treatment;
2. The entire treatment period is shortened to 1–1.5 years or less
depending on the complexity of orthodontic treatment; and
3. The phenomenon of postoperative accelerated orthodontic
tooth movement reduces the difficulty and treatment time of
orthodontic management in the SFA.
Apart from certain -advantages, problems of surgery first approach

are:
1. Predicting the final occlusion is the hardest challenge with SFA

due to multiple dental interferences
2. Cases requiring extractions are extraordinarily complicated to
plan while performing surgery-first
3. Any minor surgical error can compromise the final occlusion
4. The planning process highly time consuming
5. The increase in the number and complexity of osteotomy
procedures poses a greater risk to the patient.
Retention and follow-up after
orthognathic surgery
A specific protocol for the retention is designed which may be a
combination of fixed bonded retainers and removable appliances. A
definite monitoring plan is provided to the patient.
Most orthognathic surgery procedures are done with an -intraoral
approach. Hence, there are no problems of scar formation on the skin.
Scars are one of the major deterrents for surgical procedures.
Most of the orthognathic surgical patients are otherwise healthy.
Hence, choice of undertaking this procedure should also be weighed
concerning the benefits in proportions to inputs required including
the cost of entire treatment.
Complications following orthognathic
procedures3
Dissatisfaction with outcome
At times, the orthognathic surgery may go well, but the patient may
still feel unhappy with the results. Patients’ dissatisfaction is a
discouraging news for the orthognathic team. There could be many
reasons for patients dissatisfaction, some of which are:
1. Patient-related factors. Unrealistic expectations, external

motivating factors, unknown psychological problems.
2. Team-dependent factors. Lack of proper understanding of the
patients’ expectations, needs and psychology. Such a situation
could result from the hurried approach by the team during
patient evaluation or due to too poor pre-operative
preparation.
3. Poor communication. Poor doctor-patient inter-action or
personality conflict. Short-term patient dissatisfaction and
depression may be associated with pain and discomfort caused
by surgery, use of drugs and sedatives, and insufficient pre-
operative information about the immediate consequences of
the operation. Lack of family support may also be a
predisposing factor.
Complications and risks associated with

orthognathic surgical procedures
Complications related to procedures of orthodontic treatment,
anaesthesia or surgical procedures are given in Fig. 67.16.3 These are:
1. Postoperative infection
2. Bleeding
3. Malunion and nonunion
4. Soft tissue injuries
5. Unanticipated fractures
6. Malocclusion
7. Devitalisation of teeth
8. Relapse
9. Gingival recession and periodontal complications.
FIGURE 67.16 Frequency of complications associated with

orthognathic surgery. Source: Based on data from Panula K.
Correction of dentofacial deformities with orthognathic surgery;
outcome of treatment with special reference to costs, benefits and
risks. Academic Dissertation Faculty of Medicine, University of Oulu,
Oulu; 2003.
Complications unique to Le Fort surgery of

maxilla
1. Infraorbital nerve traction injury
2. Unanticipated fractures (pterygoid plate, sphenoid bone,
middle cranial fossa)
3. Damage to the internal maxillary artery and its branches
4. Avascular necrosis of the maxilla or a segment
5. Velopharyngeal insufficiency
6. Injury to nasolacrimal or Stenson’s duct
7. Maxillary sinusitis
8. Nasal septal deviation and buckling
9. Arteriovenous fistulas (carotid-cavernous sinus)
10. A widening of the nasal alar base.
Bilateral sagittal split osteotomy of the

mandible
1. Injury to the inferior alveolar nerve is the single most frequent
and significant complication of a sagittal split ramal osteotomy
2. Bleeding from the inferior alveolar artery or masseteric artery
3. Unanticipated fractures and unfavourable split
4. Avascular necrosis
5. Acute/progressive condylar resorption
6. Aggravation of asymptomatic TMJ disorders
7. Malpositioned proximal segment
8. Malocclusion
9. Relapse during correction of class II problems.
Osseous genioplasty
1. Injury to the mental nerve
2. Inferior mandibular border contour irregularity
3. Gingival recession
4. Relapse.
Key Points
Orthognathic surgery can be a rewarding experience for the patient,
the treating team of oral surgeon and the -orthodontist in carefully
and well-planned cases. The key to success is to be able to meet the
outcome expected by the patient following treatment. That is rather a
difficult task to assess, being governed by a number of variables such
as the psychological needs of the patient and understanding,
assessment of the deformity in the perspectives of soft tissue, skeletal
deformity and malocclusion.
The other most critical aspect of orthognathic surgery assessment is
to weigh the ratio of the inputs with rewards. Since most orthognathic
surgery patients are otherwise healthy only careful case selection,
flawless planning and seamless execution can avoid complications
and bring desired happiness both for the patient and orthognathic
surgery team.
References
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2. Hullihen SP. Case of elongation of the underjaw and
distortion of the face and neck, caused by a burn,
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3. Panula K. Correction of dentofacial deformities with
orthognathic surgery: outcome of treatment with
special reference to costs, benefits and risks
[Dissertation], University of Oulu, Oulu; 2003.
Available from: http://herkules.oulu.fi/issn03553221.
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CHAPTER 68
Maxillomandibular distraction
osteogenesis for orthodontist
Balakrishnan Jayan
Nanda Kishore Sahoo
Abhijeet Kadu
CHAPTER OUTLINE

Molecular mechanism during distraction osteogenesis
Distraction histiogenesis
Historical perspective and philosophy of maxillo-mandibular
Development of intraoral distractor
Development of rigid external distractor (RED)
Indications
Contraindications
Advantages of distraction osteogenesis over orthognathic
surgery
Disadvantages
Types of distractors based on design and location
Types of distractions based on a vector
Treatment planning
Orthodontic treatment protocol
Pre-distraction orthodontics
Orthodontic management during distraction and
consolidation
Retention after maxillary distraction
Post-distraction orthodontics
Maxillary transverse distraction osteogenesis
Rapid maxillary expansion (RME) is a form of DO
Indication for surgically assisted rapid maxillary
expansion (SARME)
Mandibular transverse distraction osteogenesis
Factors affecting distraction
The future of maxillomandibular distraction osteogenesis
Key Points
Distraction osteogenesis (DO) is a biologic process of the new bone
formation between vascularised margins of bone segments gradually
separated by incremental traction. The traction force generates tension
in the callus that connects the bone segments. The tension, in turn,
stimulates bone formation. Distraction force also creates tension in the
soft tissues, including muscles, fascia, tendons, ligaments, blood
vessels, nerves, mucosa, skin and gingiva, which initiate a sequence of
soft tissue changes and therefore DO is more appropriately termed as
distraction histiogenesis.
Sequential periods in DO (Fig. 68.1A–D):
1. Osteotomy
2. Latency
3. Distraction
4. Consolidation
5. Remodelling.
FIGURE 68.1 Schematic representation of the sequential phase
of distraction osteogenesis (DO) for mandibular corpus
lengthening.
(A) Osteotomy and placement of distractor. (B) End of distraction. (C
and D) Consolidation and Remodelling. At the end of 1 year, distracted
bone cannot be distinguished from origin bone.
Osteotomy. Surgical sectioning of the bone is called osteotomy.

Osteotomy for DO should be done by controlled microtrauma aiming
for maximum preservation of periosteum and endosteum. The
periosteum is the most viable structure for successful regeneration of
bone. Each bone surface that is being distracted must contain viable
osteocytes in the bony lacunae with an intact blood supply to initiate
and perpetuate the DO process.
Latency period. The histological sequence during the latency period
is similar to that seen during fracture healing. It is characterised by
inflammation and formation of soft callus. The initial clotting around
the osteotomised segments is converted into granulation tissue in
three days. The granulation tissue is marked by inflammatory tissue
and fibroblasts that would become more fibrous as the days progress
due to the presence of collagen and appearance of new capillaries. It is
at this early stage, the mesenchymal bone cells from the adjacent
medullary bone and periosteum are recruited. The collection of cells
and biological fluids around is also referred to as regenerate. If the
distraction of soft callus is not initiated, it will follow the usual
sequence of fracture healing that is hard callus formation followed by
calcification. Initial latency period -recommended is between 5 to 7
days. The distraction process is carried out at the rate of 1 mm/day.
The slower rate of 0.5 mm is recommended for transverse maxillary
distraction.
Distraction period. During DO, the usual process of fracture
healing is interrupted by the application of gradual traction to the soft
callus. A dynamic microenvironment is created which encourages
new tissue formation in the direction parallel to the vector of traction.
Mechanical tension is one of the primary factors responsible for
enhanced angiogenesis during natural growth and development. As
distraction begins, the fibres of the soft callus and the spindle shaped
fibroblasts like cells located between the collagen fibres become
oriented longitudinally along the axis of distraction. These cells form
collagen fibrils that are grouped into fibres at the distal and proximal
ends of the inter-fragmentary tissues. During the process of
distraction, there is increased and prolonged angiogenesis with the
proliferation of spindle shaped fibroblast like cells. These spindle
shaped cells are situated peripherally and throughout the vessels
producing more and more collagen parallel to distraction vector. The
collagen produced is type I and the bone that is formed is intra-
membranous. The cells are found to express osteocalcin, osteopontin
and alkaline phosphatase, indicating osteoblastic differentiation.
Application of tension through distraction on the regenerate
stimulates transdifferentiation of chondroblasts and fibroblasts into
the osteoblasts. The tension on the regenerate results in chondroblasts
to express type I collagen instead of type II collagen. Vascular growth
during distraction is tenfold compared to conventional repair.
Consolidation period. During this phase regenerate converts into
the bone by the process of primary mineralisation that begins at either
end of the fibrous central zone and advances to central part making a
bridge of immature bone across the distraction segments. Greater the
distance of distraction longer the duration of the consolidation phase.
The duration of the consolidation phase has been suggested as 3–8
weeks for children and 8–14 weeks for adults for the maxillofacial
skeleton. In general, the period of consolidation should be twice the
duration of the distraction phase.
Remodelling. The remodelling period is the time from the
application of full functional loading to the complete remodelling of
the newly formed bone. It takes a year or more before the structure of
newly formed hard tissue is comparable to that of the pre-existing
bone.
Molecular mechanism during distraction

osteogenesis
An understanding of molecular mechanism during DO has profound
clinical implications as it is a step towards understanding future
therapeutic intervention for acceleration of regenerate and
consolidation time. Bouletreau and coworkers have shown that some
several factors including cytokines and extracellular matrix proteins
are involved in the process of mineralisation of regenerate in
distraction gap.1 Messenger RNA and protein expressions of the
regulatory factors fluctuate at different stages of distraction. Therefore
one can infer that application of protein at the right time should
optimise the outcome. It is not only the chemical factor but also the
physical factors that may influence the results of DO. Electric and
ultrasound stimulation of the regenerate have been found to have
stimulatory effect on osteogenesis and the bone quality.2
Distraction histiogenesis
A unique aspect of DO technique is the fact that osseous regeneration
is followed by simultaneous stretching and adaptation of soft tissues,
tissue including blood vessels, nerve, ligaments, fascia, muscles, skin,
mucosa, cartilage and periosteum. This adaptation process of adjacent
soft tissues induced by tension generated during distraction is
referred to as distraction histiogenesis. Distraction histiogenesis is
found to share many features of embryonic growth, foetal growth and
neonatal limb development. The exact cellular and molecular
mechanisms of distraction histiogenesis are still not well understood.
The lesser tendency of relapse in DO as compared to conventional
orthognathic surgery is attributed to this phenomenon of distraction
histiogenesis.
Historical perspective and philosophy
of maxillo-mandibular distraction
osteogenesis
DO has revolutionised the management of severe maxillo-mandibular
deformities. However, the application of tensile and compressive
forces to the craniofacial skeleton is not new. An attempt of skeletal
traction was described as long ago as -460–377 BC during Hippocrates
era when traction on long bones was performed using rubber straps.3
In 18th- and 19th- century, mechanical forces were used to separate
the bones of maxilla at the mid-palatal suture.
Integration and amalgamation of various philosophies like extraoral
orthodontic appliances, orthodontic expansion with jack screws,
craniofacial osteotomies, skeletal fixation methods, limb lengthening
procedures and appropriate applications for use on face and jaws
have resulted in the evolution of contemporary craniofacial DO.
Although orthognathic surgery is now a well-established discipline,
it has several limitations in the management of severe deformities, in
particular in those situations where the volume and amount of bone
associated soft tissues are insufficient. In such cases, orthognathic
surgery produced less than optimum outcome with greater chances of
relapse. Inadequate bone contact, insufficient fixation, stability and
partial or total regression due to excessive muscle stretching were
often observed.
In 1905, Codivilla4 introduced a surgical procedure for lengthening
the lower limbs, but this procedure had a high number of
complications. The most path-breaking work in the field of DO is
acknowledged to Dr Gavril IIizarov (1951) of Russia. He developed
DO for limb lengthening based on the biology of bone and ability to
surround tissues to regenerate under tension. He performed
corticotomy that is a surgical bone division with maximum
preservation of the periosteum and the endosteum. His distraction
protocol utilised 5–7 days latency period, and the bone segments were
separated at the rate of 1 mm/day. Following distraction,
consolidation period is commenced, during which the tissue in the
distraction gap gets mineralised and remodelled.
Successful use of DO in the field of orthopaedics and the associated
development of armamentarium was noticed by maxillofacial
surgeons, and the experimentation on the craniofacial region began. A
miniaturised orthopaedic device was successfully used by J.G.
McCarthy et al.5 in four children (average age of 78 months) with
craniofacial anomalies. The amount of mandibular lengthening
ranged from 18 to 24 mm. Later, McCarthy’s group developed
multidirectional mandibular distractor, which enabled correction of
defects in all the three planes of space. Their team has continued to
report work related to distraction and is considered high esteem in
this field.6–11 Inspite of advances, patients were apprehensive about
the placement of extraoral distracter as these are socially inconvenient
and often resulted in permanent facial scars. This led to the evolution
of intraoral distraction devices.
Development of intraoral distractor

K. Wangerin in late 1990s developed the first intraoral titanium
mandibular distraction device. The device consisted of mini plates for
bone fixation connected by distraction cylinder. Intraoral devices
significantly improved mandibular distraction techniques. The main
advantages are an absence of extraoral scars and inconspicuous nature
of the device.12 Dessner and group demonstrated an intraoral, tooth
borne distractor for lengthening the mandible.13 They are available in
five different designs and are used as per the required clinical
situations. Commercially known as RODTM distractor. The designs
include tooth-born, bone-born and hybrid models. The RODTM
distractor can be utilised both for maxillary and mandibular
advancement. They are also available as pre-programmed devices and
have been reported to be successful.14
The distractor designs continued to be evolved with changes in size,
shape and modes of attachments and so on. Some manufacturers
developed -universal distraction systems that could be applied to -
different parts of the craniofacial skeleton, while others developed
specific devices based on anatomic locations. Most of the intraoral
distractor systems are unidirectional. Lately, 3D intraoral distractor
has been developed. Other developments in the hardware include
curvilinear, motorised and hydraulic distraction devices. The latter
two are characterised by remote activation, monitoring, and precise
directional control. Reports on successful intraoral distraction devices
for mandibular lengthening with reasonable successful outcome are
now available.15
Development of rigid external distractor (RED)

Rigid external distractor (RED) was first experimented on animal
models before its use in clinical practice. Rachmiel and coworkers in
late 1990s16–18 successfully performed mid face gradual advancement.
During same years, Polley, Figueroa and colleagues used RED, an
external fixed cranial halo to distract the mid face.19 They continued to
use, improve techniques and report the findings on patients with mid
face deficiency syndrome and cleft patients.20–24
Indications25–27
Mandibular distraction is used for the lengthening of the mandible
where due to loss of bone substance or unavailability of bone
contraindicates orthognathic surgery. In situations where a large
amount of bone lengthening is required, distraction is preferred
therapeutic modality over orthognathic surgery.
Maxillary distraction is required most often for mid face hypoplasia
that could be developmental or congenital. Maxillary advancement in
cases of operated cleft palate is a challenging job, and these patients
immensely benefit from mid face DO.28,29
Frequently attended congenital deformities where distraction
osteogenesis is preferred.
• Pierre-Robin syndrome. DO is required to prevent asphyxia

and for correction of the mandibular deficiency.
• Treacher-Collins syndrome and Goldenhar syndrome.
• Severely constricted mandible in children and adults.
• Congenital micrognathia (non-syndromic).
• Maxillary deficiency in operated cases of cleft lip and palate.
• Craniofacial microsomia-unilateral/bilateral.
• Mid face hypoplasia.
• Obstructive sleep apnoea (OSA) syndrome.
• Severely constricted maxilla in adults.
• Facial asymmetry.
Acquired conditions:
• Post-traumatic growth disturbance of the mandible,

commonest being mandibular hypoplasia due to TMJ
ankylosis (Fig. 68.2)
• Mal-union of fractures
• Atrophy of edentulous segments
• Oncologic mandibular osseous defects.
FIGURE 68.2 A case of bilateral TMJ ankylosis and OSA.

Pre-treatment profi le and cephalogram of a 30-year-old female, a case
of severe OSA. The OSA can be attributed to severe mandibular
hypoplasia with an inferiorly placed hyoid bone.
Miscellaneous:
• Rapid canine distraction

• Distraction for ankylosed teeth.
Contraindications
There are no absolute contraindications for mandibular distraction.
However, relative contraindications are as follows:
• Poor nutrition and lack of soft tissue

• Inadequate bone stock as in neonates
• Geriatric patients due to a decreased number of mesenchymal
stem cells
• Irradiated bone
• Osteoporotic bone
• Any systemic disease which affects bone metabolism or
contraindicates general anaesthesia (GA).
Advantages of distraction
osteogenesis over orthognathic
surgery
• Need for orthognathic surgery is minimised and so are the
complication associated with orthognathic surgery.
• The slow rate of bone elongation allows histiogenesis of the
associated soft tissues, and therefore possibilities of relapse
are minimised.
• A shorter hospital stay.
• Reduced postoperative pain and swelling.
• Increased stability. A gradual bone lengthening allows soft
tissue adaptation in form and function and therefore muscle
pull causing relapse in orthognathic surgery can be avoided in
distraction osteogenesis.
• A less likelihood of nerve injury.
• Reduced need for inter-maxillary fixation.
• Large maxillo-mandibular advancement is possible.
• No bone graft is required unlike conventional orthognathic
surgery thus eliminating donor site morbidity.
• The new bone formed via DO is more native and permits
orthodontic tooth movement.
• No need to extract teeth.
• A less likelihood of idiopathic condylar resorption.
• Allows complete bone sculpting that is changing the shape
and form of bones to maximise the 3D structural, functional
and aesthetic needs of the patient.
Disadvantages
• Poor 3D control on the segments with current distractors. The
3D distractors are being continuously modified for desired
results.
• Manipulation of healing corticotomy daily or several times a
day could give rise to pain.
• Difficult access for the orthodontist during distraction and
consolidation stages as the distractor could obscure the buccal
segments.
• Poor plaque control.
• Damage to TMJ due to incorrect vector orientation.
• Technique sensitive surgery.
• Equipment dependent operation.
• Need for second surgery to remove distraction devices.
Types of distractors based on site and use:
• Mandibular
• Mid face/maxillary
• Alveolar ridge distractor
• Bone transport
• Periodontal distractor
• Craniofacial.
Types of distractors based on design and

location
External distractors
Rigid external distractor (RED): It is used for mid face advancement
(Fig. 68.3A). It consists of a halo frame fixed to cranium with titanium
screws. A mid-sagittal rod with distraction cylinders is suspended
from the halo frame. The distraction is usually set at the level of the
centre of mass of the osteotomised maxilla. The osteotomised maxilla
is connected to the distraction cylinders with an intraoral splint and
stainless steel ligature wires. Titanium mini bone plates at the level of
the centre of resistance (CRes) of maxilla can be used in place of the
intraoral splint. The distraction cylinder is activated with the help of
Allen key provided by the manufacturer. Activation is performed in
the counterclockwise direction.
FIGURE 68.3 (A) Photo sequence showing rigid external distractor
(RED), its accessories and RED in situ. (a) Mid-sagital rod, (b) cranial
halo frame, (c) distractor rods and (d) Allen key (e) RED in situ. (B) a-e
showing external mandibular distractor and its placement.
Mandibular external distractor: They are placed using bone pins.

They are much easier to set and simpler to replace during distraction
if necessary or to remove at the completion of bone lengthening (Fig.
68.3B). The disadvantages of extraoral distractors include skin
scarring and poor acceptance by the patient. The external distractors
for the mandible have virtually have been replaced with intraoral
distractors. However, on the maxilla, external distraction devices like
the RED appliance have been greatly successful.
Internal distractors
They are placed either sub-mucosally (buried) or extra mucosal
(intraoral). They may be tooth-borne, bone-borne or hybrid. Internal
devices have a unique advantage of intraoral placement; they do not
produce facial scarring and hence do not have the negative
psychosocial impact of the external devices (Fig. 68.4).
FIGURE 68.4 Different types of internal distractors with
accessories.
(A) Horizontal distractor and Allen key for activating distraction cylinder.
(B) Alveolar distractor. (C) Vertical mandibular distractor. (D) Modular
internal distractor. (E) Vertical distraction of alveolus with alveolar
distractor in situ.
Mandibular intraoral distractor: The most commonly used

distraction device is the intraoral titanium mandibular distraction
devices (Fig. 68.5). The design varies for vertical and horizontal
distraction. These are implantable devices intended for single use
only. The device consists of mini plates which enable bone fixation
with mini-screws. The most important part of the distraction device is
the distraction cylinder. The distractor cylinder is activated with the
help of an Allen key provided by the manufacturer. The activation is
performed by counterclockwise turns. A complete rotation
corresponds to distraction of 0.5 mm
FIGURE 68.5 OPG is showing horizontal distractors for bilateral
corpus distraction in situ.
Note that the distractors on the left and right side are in the same
plane.
Modular internal distractors (MID): They are used for mid face
advancement, but they are not popular as they have poor vector
control. This design is a universally adaptable distractor made up of
adaptable titanium mesh plates and flexible activation cable (Fig.
68.4D).
Customised tooth–borne distractor: They can be developed and
fabricated by the orthodontist for maxillo--mandibular distraction in
the transverse plane. Unidirectional micro screws can be incorporated
into a custom -orthodontic appliance for the distraction of ankylosed
teeth or rapid canine distraction.
Alveolar distractor: These distractors are primarily used to increase
the height of the alveolar ridge (Fig. 68.4B). It is a contemporary pre-
prosthetic surgical procedure for correcting grossly resorbed
edentulous alveolar ridge. Dental implants can be optimally placed
after alveolar distraction.
Types of distractions based on a vector

Uniplanar and multiplanar devices: Uniplanar devices accomplish
the distraction in a single direction while multiplanar devices permit
distraction in more than one plane using separate distraction arms.
The type of deformity dictates the type of distractor. The uniplanar
device is appropriate if the skeletal deficiency is largely in a single
plane. However, for complex deformities which require distraction in
more than one plane, multiplanar device or separate distractors are
placed sequentially.
The distractors are available commercially, along with tools
required for their fixation and activation. An extraoral device is more
versatile. It can accomplish greater magnitude of distraction in
multiple planes and also permit changes in the vector of distraction as
it is being carried out. However, such a device is cumbersome and
leaves pin track scars on the skin. The intraoral appliance, in contrast,
is inconspicuous and does not interfere with day to day activities,
making the treatment more acceptable to the patient.
Once distraction becomes part of the treatment plan the surgeons and
orthodontists must plan for exact location of placement of the
distractor device. The surgical plan must include osteotomy design,
pre-, during and post-distraction orthodontics. Placement of intraoral
distractor requires making deep, and long vestibular incisions. The
distractors are positioned along the planned vector of distraction.
Template constructed on a standardised radiograph or
stereolithographic models can be a useful guide for device orientation
and osteotomy design.
Anaesthesia: Most of the distraction surgeries in contemporary
practice are performed under naso endotracheal general anaesthesia.
The patient also receives prophylactic antibiotics. At the completion of
consolidation phase, the distractor device should be preferably
removed under GA. However, many surgeons also perform the same
under local anaesthesia and sedation.
Osteotomy: Due care should be taken not to violate or disturb
underlying unerupted teeth, roots and neurovascular bundle. For
mandibular distraction, only corticotomy is performed initially. In
sagittal mandibular distraction, if osteotomy cuts are placed distal to
the last molar, posterior/a lateral open bite would be observed during
distraction. The osteotomy cuts mesial to the last molar can lead to an
anterior open bite. The orthodontist should plan appliance design and
treatment mechanics keeping surgeons plan in mind. Bilateral sagittal
split osteotomy can also be considered as osteotomy design for
sagittal mandibular distraction.
In a case of mid face advancement as in cleft-lip and palate cases; a
high-level Le Fort 1 osteotomy is preferred. In the case of transverse
maxillary deficiency, a low-level Le Fort 1 osteotomy with a mid-
palatal split is performed.
Monocortical screws are used for fixation of the distractor device.
The device is activated by 2–3 mm to verify the movement of the
segments at the completion of the osteotomy and as initial/trial
activation. A water tight closure of the surgical site is required to
minimise the chances of contamination and subsequent infection. In
case the distraction device requires the distraction port to be
externalised, the port must be placed in an easily accessible area.
Distraction Protocol: The latency period recommended ranges from
5 to 7 days. The distraction is carried out 1.0 mm/24 h. The amount of
bone movement is found to be less than the distance indicated on the
distractor device. Therefore, the surgeon and orthodontist should
monitor the patient’s progress clinically and radiologically.
Consolidation phase ranges from 8 to 14 weeks. The distractors are
removed only on radiological confirmation of cortical outline.
Orthodontic considerations30–32
Treatment planning
The following points are considered important while planning a case
for DO:
1. Records: Complete records (pre-, mid- and post-treatment) are

essential. The CBCT has virtually replaced the need for all
other X-rays. The decision to undertake CBCT should be
undertaken in consultation with the surgeon to avoid
duplication of the OPG, cephalogram and additional X-rays.
2. Treatment planning sessions: joint sessions between the
orthodontist and the team of surgeons are advisable.
3. When planning mandibular lengthening, nature and type of
advancement must be considered.
a. Unilateral versus bilateral
b. The vector of distraction: vertical versus horizontal
versus oblique
c. The site of distraction: corpus versus ramus.
4. Maxillary advancement in hypoplasia: sagittal, sagittal
combined with transverse.
5. Maxillary advancement in CLP patients: velopharyngeal
considerations/speech considerations are of paramount
importance.
Successful management of maxillo-mandibular deformities with

DO involves a team approach among surgeons and orthodontists.
Photo sequences vide (Figs 68.6 and 68.7) are examples of successful
management of cases of mandibular and maxillary deficiency with
DO. Orthodontist plays a crucial role in diagnosis and treatment
planning following a thorough clinical examination of the face and
oral structures. A diagnostic database consisting of study models,
photographs, lateral and PA cephalograms, OPGs or CT scan is
essential to treatment planning and evaluation of treatment results. A
3D virtual planning software can be immensely helpful in a joint
planning session to consider vectors of the distraction, effect on
occlusion and treatment outcome.
FIGURE 68.6 Distraction for mandibular lengthening.

(A) Pre-treatment. A 17-years-old male with skeletal class II division 2
malocclusion and associated intractable snoring. Treatment procedures
included pre-distraction orthodontics to decompensate the arches,
followed by mandibular distraction for corpus lengthening and post-
distraction orthodontics for settling of the occlusion. (B) Post-treatment.
Note significant increase in the mandible length which has resulted in
improvement of the facial profile. Snoring improved markedly.
FIGURE 68.7 Distraction in a case of the cleft maxilla.
A 15-year-old male; an operated case of UCLP with severe maxillary
deficiency treated by combined orthodontics and DO. (A and B) Pre-
treatment extraoral photographs depicting concave profile due to the
hypoplastic maxilla. Pre-treatment intraoral photographs are showing
reverse overjet of 5 mm. (B) Pre-distraction preparation involved
securing maxilla as one rigid unit with a metal reinforced acrylic splint.
(C) Maxillary distraction being carried out using Rigid External Device
(RED). (D) Distraction following consolidation phase was maintained
with reverse pull Petit facemask. (E) Post-treatment photographs are
showing marked improvement in profile and smile aesthetics, and post-
treatment intraoral photographs are showing well-settled occlusion with
optimised overjet and overbite. (F) Pre- and post-treatment lateral
cephalogram.
Orthodontic treatment protocol

• Pre-distraction orthodontics
• Orthodontics during the distraction and consolidation phase
• Post-distraction orthodontics
• Retention
Pre-distraction orthodontics
The maxillary and mandibular dental arches are prepared for DO by
levelling, alignment, decompensation and correction of the curve of
Spee. The teeth should be moved to such positions about the basal
bone so that a perfect maxillo-mandibular relationship is not
compromised by existing dental compensations.
The standard distraction orthodontic treatment protocol includes
appropriate transverse arch width coordination of both maxillary and
mandibular arches followed by placement of passive rectangular
archwires with hooks for engaging inter-arch elastics during and after
distraction.
Before DO, the orthodontist should jointly plan the objectives with
the surgeons to arrive at a consensus on the type and extent of
orthodontic tooth movement and desired vector(s) of DO. The
osteotomy design, distractor device orientation, masticatory muscles
influence, occlusal interferences and orthodontic forces during the
distraction and consolidation phases govern and affect the vectors of
distraction. In the case of DO in children and young adolescents,
future growth prediction and requisite overcorrection are
recommended. However, overcorrection should not have an adverse
psychosocial impact due to poor aesthetics.
In a case of mandibular corpus/ramus distraction, the occlusal
plane, mandibular plane and ramus plane (posterior border of ramus)
are of significant relevance in the planning. These planes are used as
guiding planes to orient the distractor device. If the device is placed
parallel to the ramus plane, it will result in an oblique distraction
vector. If greater sagittal advancement is desired, the distractor should
be put parallel to the occlusal plane. If the distractor device is placed
parallel to the mandibular plane, a clockwise rotation of the mandible
will result leading to an anterior open bite and an increase in the
lower anterior face height (Fig. 68.6). Vector planning will have a
profound effect on the treatment outcome. The vectors for mandibular
distraction and its impact are presented wide (Figs 68.8A–C and
68.9A–B).
FIGURE 68.8 Vector planning in mandibular corpus distraction.
(A) When the vector is planned parallel to the maxillary occlusal plane,
the mandible is distracted forward with no or minimal change in anterior
face height. (B) When the vector is planned bisecting the maxillary
occlusal plane and lower border of the mandible, it is distracted forward
and downwards with an increase in anterior face height and reduction
in a deep bite. (C) When the vector is planned parallel to the lower
border of the mandible; mandible is distracted forward and more
downwards with an increase in anterior face height and creation of
open bite.
FIGURE 68.9 Vector planning in ramus distraction.

(A) When vector is planned perpendicular to the occlusal plane, ramus
is distracted vertically downwards with the creation of a posterior open
bite. (B) When a vector is prepared oblique to occlusal plane and more
or less parallel to posterior the border of ramus, ramus is distracted
downward and forward with the creation of the posterior open bite.
Orthodontic management during distraction

and consolidation
Orthodontic management during distraction and consolidation is
aimed to direct, tooth bearing segments to their post distraction
positions. The increased metabolic response during the healing and
manipulation of the regenerating bone allows significantly large
skeletal and dental changes with orthodontic therapy. In mandibular
distraction, inter arch elastics during distraction and consolidation
phase influence the vector and are useful in remodelling the
regenerated bone and close the open bite created due to the
lengthening. Class II elastics result in the forward posturing of the
mandible, and the treating team may misinterpret it as a correction
due to DO. Therefore the measured amount of distraction should be
executed as planned. The vertical elastics are useful in closing both
posterior and anterior open bites. Unilateral mandibular distraction as
in cases of hemifacial microsomia can lead to posterior open bite on
the distraction side and cross-bite on the normal side. Expansion of
maxillary arch along with the use of inter-arch elastics can be used to
correct developing transverse and vertical discrepancies. Occlusal bite
blocks can be utilised during consolidation and -post-consolidation
phase for supra eruption of dentition to adjust the cant and open bite.
Mandibular widening can be done with a custom fabricated
distraction device made with a lingually placed Hyrax expansion
screw which is soldered to orthodontic bands on molars and
premolars on either side.33 Pre-distraction preparations should
consider incisor root divergence with a fixed orthodontic appliance in
the osteotomy site. This is to ensure adequate alveolar bone on both
sides for optimum periodontal health.33,34
Custom made rigid cast cap metallic splints/acrylic
splints/orthodontic appliances modified with face bow should be -
fabricated for maxillary and mid face distraction (Fig. 68.7). The
direction of maxillary advancement is determined by the vector of
applied traction, type of osteotomy cut, soft tissue resistance, the
strength of traction hooks and occlusal interferences. Ideally, the
distraction force should be directed through the CRes of the maxilla
which is approximately located between the apex of the premolars
and first molars below the zygomatic buttress. If the force is directed
below CRes of the maxilla, an open bite results. Light vertical elastics
from maxillary splint to lower arch would help in controlling
clockwise rotation of mandible and open bite. Better vector control has
been experienced by the authors when a three hole ‘L’ shaped mini
plate is fixed by mono cortical screws in the region of the pyriform
aperture. A twisted stainless wire is secured to the hole at the free end
of the plate, and the twisted wire in the form of the port is drawn out
of nostrils to engage the distraction cylinders of RED (Fig. 68.7C).
Retention after maxillary distraction

An orthodontic facemask/reverse pull headgear which delivers 250 g
of force with extraoral elastic engaged to hooks soldered at the canine-
premolar region on the maxillary splint should be prescribed during
retention phase for neuromuscular adaptation (Fig. 68.7). Class III
elastics are useful for enhanced neuromuscular adaptation.
Tooth-borne custom made banded Hyrax appliance can be used for
transverse distraction of maxilla in the adults. The same
appliance/distractor device can be used in adult cleft lip/plate cases
with posterior alveolar osteotomy. Custom made distractor with
unilateral expansion screw can be used to mobilise tooth segments
and close alveolar clefts.
Post-distraction orthodontics
It should be initiated following consolidation phase which is aimed at
finishing and settling the occlusion. Permanent bonded lingual
retainers should be considered along with functional appliances for
stability and retention.
Retention: Retention protocol is a crucial element in
maxillomandibular deficiencies treated with DO. In mandibular
deficiency cases, fixed bonded retainers for retention of corrected
dentition and functional appliances like twin block, bionator or
similar appliance with slight mandibular advancement to maintain
the soft tissue stretch can be considered. Forward maintenance
ensures a neuromuscular adaptation and minimal skeletal relapse.
Recently published systematic review on complications of
mandibular DO has reported 9.6% complications of permanent nature.
These permanent complications meant functionally and/or
psychosocially disabling and the ones which did not achieve the
stated goals leading to unsatisfactory results. Permanent
complications predominantly included anterior open bite and
relapse.35
In cases of maxillary deficiency due to operated cleft lip and palate,
permanent retainers like banded palatal arches along with reverse
pull headgear calibrated at 150 g of force for 12 months has been
found useful by the authors. Current evidence on correction of cleft
maxillary hypoplasia with DO as compared to orthognathic surgery
has concluded that the upper jaw was more stable in distraction group
5 years after surgery. Patients who had undergone maxillary
distraction were more satisfied with the treatment than orthognathic
surgery. However, no differences in speech and velopharyngeal
function have been concluded.36
Combined maxillomandibular DO: Mandibular distraction in
adults with hemifacial microsomia or facial asymmetry produces
good aesthetic results but leaves the patient with severe alteration in
the occlusion, requiring complex orthodontic treatment over a long
period. To avoid this problem, an incomplete Le Fort 1 osteotomy is
performed simultaneously (i.e. without pterygomaxillary disjunction
on the unaffected side) with mandibular ramal corticotomy. Inter-
maxillary fixation is placed postoperatively, and distraction is
initiated. In such cases requiring combined maxillomandibular DO,
arches should be levelled and aligned. Satisfactory functional and
anatomic occlusion should be achieved. Full sized rectangular
archwires with hooks are to be placed for inter maxillary fixation
postoperatively, during distraction period and consolidation phase.
This technique has the advantage of tilting or canting the facial
skeleton to correct the asymmetry of the face without disturbing
occlusion.
Maxillary transverse distraction
osteogenesis (Fig. 68.10A–C)
Rapid maxillary expansion (RME) is a form
of DO
RME is useful in correcting both class II and class III problems as well
as in resolving mild-to-moderate tooth size/arch perimeter
discrepancies. Procedures to correct a maxillary transverse deficiency
in adult individuals have conventionally been grouped into two
categories; segmenting the maxilla during a Le Fort 1 osteotomy to
reposition the individual segments in a widened transverse dimension
and surgically assisted rapid maxillary expansion (SARME).
Segmental osteotomy is reported to be unstable especially when more
than 8 mm expansion is desired.37
FIGURE 68.10 SARME in a young adult with severe maxillary

transverse discrepancy and anterior open bite.
(A) Pre-treatment intraoral photographs showing open bite and severe
maxillary transverse deficiency. (B) SARME executed with bonded
Hyrax appliance. An occlusal photograph is showing separation of
palatal shelves at midline. (C) Post-treatment intraoral photographs.
The open bite and cross-bite due to severe transverse discrepancy are
fully resolved.
Indication for surgically assisted rapid

maxillary expansion (SARME)38
• To increase the maxillary arch perimeter and to correct
posterior cross-bite.
• To widen the maxillary arch as a preliminary procedure, even
if further orthognathic surgery is planned.
• To provide space for a crowded maxillary dentition when
extractions are not indicated.
• To widen hypoplastic maxilla associated with clefts of the
palate.
• To reduce wide black buccal corridors when smiling.
• Alternate to failed orthopaedic maxillary expansion.
• Adult OSA patients with narrow maxillae and deep palatal
vault.
Clinical evaluation should include an evaluation of the buccolingual

inclination of the posterior teeth which gives a more accurate
distinction between dental and apical base skeletal maxillary
transverse deficiency. PA cephalograms are a reliable means to
identify and evaluate transverse skeletal discrepancies between the
maxilla and the mandible. Advances in imaging techniques have
added a new dimension to the evaluation of bone density and surgical
manipulation.
Hyrax appliance, either implant supported, banded or bonded is the
recommended expansion device to be used with SARME. Some bone-
borne distractors are now available commercially. The force is
generated by a jackscrew in all these appliances. The Hyrax has a
metal frame-work that is less irritating to the palatal mucosa and is
more hygienic. Expansive growth occurs in the direction of the force
applied, and the change is volumetric. The tooth-borne appliance
should be placed preoperatively, and the appliance key must be in the
operating room to allow intra-operative activation.
Mechanism of SARME: An ‘artificial suture’ is created by
performing a LeFort 1 osteotomy with mid-palatal osteotomy. A
hematoma forms around the fracture sites due to vascular disruption.
Once the clot has formed, a reorganisation process takes place as a
result of invading capillaries. By the fifth to seventh day after the
osteotomy, inflammatory granulation tissue of the initial soft callus is
converted into an organised fibrous connective zone, when the
traction can be started. The expansion schedule should be tailored,
depending on the symmetry of the bony fracture and the health of the
gingival attachments. The activation varies between 0.25 and 1 mm
per day. SARME is a predictable technique when followed with
surgical protocol and guidelines on expansion. Once traction stops,
ossification and concomitant remodelling occur, leaving a stable
increase of bone in the transverse dimension.
SARME has traditionally been reported to have low morbidity
especially when compared with other orthognathic surgical
procedures. A careful planning and execution of treatment are
necessary to ensure an acceptable outcome. A period of retention after
expansion varying from 2 to 12 months is needed. Most studies on
SARME have reported that the incidence of relapse is low.
Mandibular transverse distraction
osteogenesis (Fig. 68.11A–D)
DO holds great potential for correcting transverse mandibular
deficiencies. Mid-symphyseal distraction osteogenesis (MSDO) was
introduced by Guerrero et al. who showed that MSDO method,
provides an efficient surgical alternative to orthognathic surgery for
the treatment of transverse deficiencies.33,34 MSDO provides a good,
predictable treatment option for borderline patients when extractions
might compromise facial aesthetics. In combination with rapid
maxillary expansion, MSDO gives the orthodontist an approach to
widen both arches.
FIGURE 68.11 Mid-symphyseal distraction osteogenesis (MSDO)

carried out with a simple tooth-supported appliance in a patient
with a skeletal transverse mandibular discrepancy.
(A) Pre-treatment intraoral occlusal view. (B) Bonded tooth supported
expansion appliance used for distraction. (C) Mid-symphyseal
osteotomy. (D) Consolidation stage, note the space being created
between mandibular central incisors.
The ideal distraction device to be used for MSDO, whether bone-
supported or tooth-supported is controversial. Bone-borne expansion
devices have a greater potential for proportional movement than do
tooth-borne appliances but require a second surgical intervention to
remove them thereby substantially increasing the cost and time of the
treatment. Although tooth-supported distraction devices produce
greater dental than skeletal widening, the followup radiographs
showed transverse skeletal stability. In tooth-borne appliances the
expansion screw is similar to that used in the Hyrax device and is
positioned as far anteriorly as possible, to avoid tongue interference
and to facilitate its activation with a key. Creating a symphyseal
osteotomy associated with a pre-positioned expansion device is the
first step in MSDO.
The location and orientation of the distraction force are of
fundamental importance because they might influence the shape of
the distraction gap. Activation of the distraction device should start a
week after surgery which allows enough time for the callus to be
formed. This period is also crucial to prevent tooth loss and
periodontal defects that can occur if the distraction is started too soon.
Orthodontic tooth movement into the newly formed alveolar bone can
be started, after radiographic evidence of bone healing is seen.
Factors affecting distraction

Several factors have been found to influence the process of DO, and
they can be categorised into bone healing factors and distraction
factors.40 The factors are summarised in Box 68.1.
Box 68.1 Factors affecting distraction4 0

The future of maxillomandibular
DO has an enormous role as an alternative method of skeletal
correction in patients with severe maxillomandibular deformities. It is,
however, not the best substitute for established treatment procedures
like growth modification and orthognathic surgery, where these can
be best performed. With technological advancements, distraction
devices would become miniaturised and more sophisticated than
existing versions. Distraction surgery may also be teamed with
endoscopic techniques to allow the placement of devices with
minimal surgery. Bone morphogenetic proteins like BMP-2 are likely
to be used in the future to accelerate consolidation phase. Resorbable
distraction devices may be a dream in present times but could be a
reality in the near future. More research in the field of craniofacial DO
will validate unclear biological, craniofacial DO parameters and
elucidate molecular mechanism that mediates craniofacial DO.
Technological advances and understanding on bone healing will
continue to influence the design and protocols of distraction.
Key Points
DO has revolutionised the management of maxillomandibular
deformities. Rapid developments are taking place in this field.
Patients with severe deformities can be better managed with DO at a
much lower risk and complications than with orthognathic surgery
particularly when hard and soft tissues are deficient.
DO has replaced orthognathic surgery to some extent and has
indeed redefined the envelope of the discrepancy.
References
1. Bouletreau PJ, Warren SM, Longaker MT. The
molecular biology of distraction steogenesis. J
Craniomaxillofac Surg. 2002;30(1):1–11: Review.
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intensity pulsed ultrasound as a useful adjuvant
during distraction osteogenesis: a prospective,
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3. Thur A, Bagatin M. Distraction osteogenesis of the
bones of the face. Acta Stomat Croat. 2002;36:103–105.
4. Codivilla A. On the means of lengthening, in the
lower limbs, the muscles and tissues which are
shortened through deformity. Am J Orthop Surg.
1905;2:353–369.
5. McCarthy JG, Schreiber J, Karp N, Thorne CH,
Grayson BH. Lengthening the human mandible by
gradual distraction. Plast Reconstr Surg.
1992;89(1):1–8: Jan; discussion 9-10. PubMed PMID:
1727238.
6. Shetye PR, Boutros S, Grayson BH, McCarthy JG.
Midterm follow-up of midface distraction for
syndromic craniosynostosis: a clinical and
cephalometric study. Plast Reconstr Surg.
2007;120(6):1621–1632: Nov; PubMed PMID:
18040197.
7. Shetye PR, Grayson BH, Mackool RJ, McCarthy JG.
Long-term stability and growth following unilateral
mandibular distraction in growing children with
craniofacial microsomia. Plast Reconstr Surg.
2006;118(4):985–995: Sep 15; PubMed PMID:
16980861.
8. Mackool RJ, Grayson BH, McCarthy JG. Volumetric
assessment of the distracted human mandible. J
Craniofac Surg. 2004;15(5):745–750: Sep; discussion
751. PubMed PMID: 15346011.
9. McCarthy JG, Hopper RA, Hollier Jr LH, Peltomaki
T, Katzen T, Grayson BH. Molding of the regenerate
in mandibular distraction: clinical experience. Plast
Reconstr Surg. 2003;112(5):1239–1246: Oct; PubMed
PMID: 14504506.
10. Stelnicki EJ, Lin WY, Lee C, Grayson BH, McCarthy
JG. Long-term outcome study of bilateral mandibular
distraction: a comparison of Treacher Collins and
Nager syndromes to other types of micrognathia.
Plast Reconstr Surg. 2002;109(6):1819–1825: May;
discussion 1826-7. PubMed PMID: 11994578.
11. McCarthy JG, Stelnicki EJ, Mehrara BJ, Longaker MT.
Distraction osteogenesis of the craniofacial skeleton.
Plast Reconstr Surg. 2001;107(7):1812–1827: Jun;
12. Wangerin K. Distraction in mouth, jaw and facial
surgery. Mund Kiefer Gesichtschir. 2000;1(4
Suppl):S226–S236: May; Review. German. PubMed
PMID: 10938663.
13. Dessner S, Razdolsky Y, el-Bialy T. Surgical and
orthodontic considerations for distraction
osteogenesis with ROD appliances. Atlas Oral
Maxillofac Surg Clin North Am. 2001;9(1):111–139:
14. Dessner S, Razdolsky Y, El-Bialy T, Evans CA.
Mandibular lengthening using preprogrammed
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15. Trahar M, Sheffield R, Kawamoto H, Lee HF, Ting K.
Cephalometric evaluation of the craniofacial complex
in patients treated with an intraoral distraction
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Orthod Dentofac Orthop. 2003;124(6):639–650: Dec;
16. Rachmiel A, Potparic Z, Jackson IT, Sugihara T,
Clayman L, Topf JS, Forté RA. Midface advancement
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17. Rachmiel A, Levy M, Laufer D. Lengthening of the
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21. Figueroa AA, Polley JW. Management of severe cleft
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22. Figueroa AA, Polley JW, Ko EW. Maxillary
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23. Polley JW, Figueroa AA. Maxillary distraction
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24. Figueroa AA, Polley JW, Friede H, Ko EW. Long-term
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distraction osteogenesis using a rigid external
distraction device in cleft maxillary deformities. Plast
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1393-4. Review. PubMed PMID: 15509923.
25. Baur DA. Distraction osteogenensis of the mandible.
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27. Roy Chowdhury SK, Jayan B, Menon PS, Prasad
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28. Figueroa AA, Polley JW, Eilen K. Distraction
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30. Distraction osteogenesis: a new frontier in correcting
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Osteogenesis.pdf.
31. Hanson PR, Melugin MB. Orthodontic management
of the patient undergoing mandibular distraction
osteogenesis. Semin Orthod. 1999;5(1):25–34: Mar;
32. Hanson PR. Treatment planning and orthodontic
management of patients undergoing mandibular
distraction osteogenesis. In: Rudolph P, Dendill J,
Steln D, eds. Craniofacial distraction osteogenesis. 1st
ed. St. Louis: Mosby; 2001:156–167.
33. Guerrero CA, Bell WH, Contasti GI, Rodriguez AM.
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of mandibular distraction osteogenesis for
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36. Kloukos D, Fudalej P, Sequeira-Byron P, Katsaros C.
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SECTION XVI
Treatment of complex
malocclusions
Chapter 69: Malocclusion and asymmetries of the face

Chapter 70: Dental midline deviations
Chapter 71: Asymmetry of occlusion
Chapter 72: Cant of occlusal plane in transverse direction
Chapter 73: Asymmetries of the face
Chapter 74: Temporomandibular disorders and orthodontics
CHAPTER 69
Malocclusion and asymmetries of
the face
O.P. Kharbanda
CHAPTER OUTLINE

Aetiology
Evaluation of facial symmetry in three planes of space
Pitch
Roll
Yaw
Key Points
Absolute symmetry in biological specimens including human body
and face is rare. In other words, asymmetry is not an exception but is
of common occurrence. Asymmetry in biological organisms is
ubiquitous.1 Most structures that are perceived balanced and
symmetrical may have subtle asymmetry, which is usually not readily
discernable. Human face, dentition and craniofacial skeleton which
concern us as dentists and orthodontics are rarely symmetrical in
absolute terms. Slight facial asymmetry can be found in normal
individuals, even in those with aesthetically attractive faces. Right–left
differences do exist in nature where two bilateral congruent parts
present in an entity. Humans frequently experience functional, as well
as morphological asymmetries, for example, right-handedness is more
common (88%–92%) than left.2
Aetiology
Some of the asymmetries are embryonically or genetically determined
and encoded in the central nervous system.3 Preferential laterality for
some anomalies is striking, such as cleft lip, which occurs more
commonly on the left side. Left–right tooth crown size asymmetry,
evident by measurement, is also a normal state in the general
population.4
When facial asymmetry is part of skeletal malocclusion, there is a
decrease of NSP genes in the masseter muscle. It has been found that
NSP gene downregulation promotes the development of asymmetry.
Pitx2 expression differences also contribute to both skeletal and
muscle development in facial asymmetry.5
The photos of a balanced face and beautiful model created by collating
the mirror image of each of the two halves, right to the right and left
to left have resulted in faces different from each other and the
untouched. Three pictures thus created will appear as (1) untouched
apparently symmetrical, (2) symmetrical made from right halves of
the face and its mirror image and (3) symmetrical but different from
previous two made by left half of the face and its mirror image.6 Three
faces thus are dissimilar owing to the presence of a mild asymmetry in
the original picture (Fig. 69.1). Similarly, a dental arch form of so
called normal occlusion subject when compared from right half to the
left are rarely symmetrical in precise terms.7
FIGURE 69.1 Computerised images of a relatively symmetric face

reveal the extent of asymmetry in each of us.
(A) This image is the original photo of the patient. (B) This composite is
made up of the patient’s left side with a flipped mirror image
representing her right side. (C) This composite is similarly created with
two right sides. The effect demonstrates how each half of the patient’s
face is different. This can be an interesting way to begin the
conversation about asymmetries.
The point at which ‘normal’ asymmetry becomes ‘abnormal’ cannot

be easily defined for it is often determined by the clinician’s sense of
balance and patient’s sense of imbalance.3,8 According to the research
study by Beyer and Lindauer, generally speaking, a 2 mm (2.2 ± 1.5
mm) or greater deviation of the dental midline appears to be easily
detectable.8,9 However, in a recent study, Pinho concluded that
midline shifts became perceptible when equal to or greater than 1.0
mm for orthodontists and 3.0 mm for prostho-dontists; lay persons
saw no alteration.9,10
A systematic review on the subject concluded that on an average,
orthodontists were able to detect midline deviations greater than 2.2
mm. On the other hand, laypeople were able to detect only midline
deviations greater than 3 mm. Considering that either laypeople or
professionals would be part of our society, authors advised using the
most restricted limit of 2.2 mm as a boundary of acceptable midline
deviation.1,10 With respect to facial morphology, similar quantification
stands true with 4 mm of deviation being easily appreciable.11–13
Evaluation of facial symmetry in three
planes of space
Facial asymmetry is a complex morphological disorder and needs to
be evaluated in X, Y and Z-axis including cant of occlusal plane and
depth of curve of Spee. Three aeronautical rotational descriptors
(pitch, roll and yaw) are used here to supplement the planar terms
(anteroposterior, transverse and vertical) in describing the orientation
of the line of occlusion and the aesthetic line of the dentition13 (Fig.
69.2).
FIGURE 69.2 The face and its structures should be evaluated in

all three planes of space, i.e. sagittal, vertical and transverse.
A relatively new concept proposed by Ackerman, describing the spatial
orientation of dentofacial traits in a fashion similar to the aeroplane’s
movement. 3D analysis of orientation of the head, jaws and dentition is
incomplete without also considering three rotational axes of pitch, roll
and yaw in addition to planar terms anteroposterior, transverse and
vertical.
Pitch
The cant of occlusion in the sagittal plane, which makes the dentition
downward or upward displacement viewed along the aesthetic line, is
best described as translation (no tilt) or pitch upward or downward
anteriorly or posteriorly.
Roll
The Rotation of so called occlusal plane in a transverse plane or
aesthetic line of dentition around a horizontal axis, up or down on
right or left side, is best described as a roll. A fox plane used is
prosthetics can help visualise the roll left or right.
Yaw
When the entire dentition/jaw is asymmetric and rotated around an
axis presenting as asymmetry is described as yaw. A class III
malocclusion with posterior cross-bites, buccal on one and lingual on
the other is an example of yaw.
Asymmetries of the face and craniofacial region could be associated
with congenital malformations, developmental disorders of the facial
skeleton, pathological conditions of local/systemic origin and facial
trauma. These conditions related to the disfigurement of the face lead
to social, psychological and functional problems adversely affecting
the well-being of a person. Asymmetries of occlusion may cause an
undesirable aesthetics, the most common reason for seeking
treatment. Other functional problems are sub optimal mastication,
altered speech, obstructive sleep apnoea and temporomandibular joint
problems such as pain and clicking.
The interest in the prevalence of facial asymmetry is relatively new.
Researchers have used clinical examinations, study models and
photographs to evaluate the midline and dentofacial asymmetries.
The quantum of various types of facial asymmetries that include
midline deviations, asymmetry of occlusion, cant of occlusal plane
and facial asymmetry affecting maxillomandibular region are
tabulated in Table 69.1.
Table 69.1
Key Points
Asymmetry in a nature is a rule not an exception. However it is the
extent of asymmetry which is critical in terms of facial aesthetics. The
clinicians and lay persons have a different perception of noticing the
asymmetry.
References
1. Cohen Jr MM. Perspectives on the face. New York,
NY: Oxford University Press; 2006: p. 256-57.
2. Available from:
http://www.scientificamerican.com/article/why-are-
more-people-right/.
3. Bishara SE, Burkey PS, Kharouf JG. Dental and facial
asymmetries: a review. Angle Orthod.
1994;64(2):89–98.
4. Burke PH. Stereophotogrammetric measurement of
normal facial asymmetry in children. Hum Biol.
1971;43(4):536–548: PubMed PMID: 5148006.
5. Nicot R, Hottenstein M, Raoul G, Ferri J, Horton M,
Tobias JW, Barton E, Gelé P, Sciote JJ. Nodal pathway
genes are down-regulated in facial asymmetry. J
Craniofac Surg. 2014;25(6):e548–e555: PubMed PMID:
6. Thiesen G, Gribel BF, Freitas MP. Facial asymmetry:
a current review. Dental Press J Orthod.
2015;20(6):110–125: PubMed PMID: 26691977;
7. Scanavini PE, Paranhos LR, Torres FC, Vasconcelos
MHF, Jóias RP, Scanavini MA. Evaluation of the
dental arch asymmetry in natural normal occlusion
and class II malocclusion individuals. Dental Press J
Orthod. 2012;17(1):125–137.
8. Beyer JW, Lindauer SJ. Evaluation of dental midline
position. Semin Orthod. 1998;4(3):146–152: PubMed
PMID: 9807151.
9. Pinho S, Ciriaco C, Faber J, Lenza MA. Impact of
dental asymmetries on the perception of smile
esthetics. Am J Orthod Dentofacial Orthop.
2007;132(6):748–753: PubMed PMID: 18068592.
10. Janson G, Branco NC, Fernandes TM, Sathler R, Garib
D, Lauris JR. Influence of orthodontic treatment,
midline position, buccal corridor and smile arc on
smile attractiveness. Angle Orthod.
2011;81(1):153–161: PubMed PMID: 20936969.
11. van Keulen C, Martens G, Dermaut L. Unilateral
posterior crossbite and chin deviation: is there a
correlation? Eur J Orthod. 2004;26(3):283–288:
12. Masuoka N, Muramatsu A, Ariji Y, Nawa H, Goto S,
Ariji E. Discriminative thresholds of cephalometric
indexes in the subjective evaluation of facial
asymmetry. Am J Orthod Dentofacial Orthop.
2007;131(5):609–613: PubMed PMID: 15222713.
13. Ackerman JL, Proffit WR, Sarver DM, Ackerman MB,
Kean MR. Pitch, oll, and yaw: describing the spatial
orientation of dentofacial traits. Am J Orthod
PMID: 17346584.
14. Severt TR, Proffit WR. The prevalence of facial
asymmetry in the dentofacial deformities population
at the University of North Carolina. Int J Adult
Orthodon Orthognath Surg. 1997;12(3):171–176:
15. Sheats RD, McGorray SP, Musmar Q, Wheeler TT,
King GJ. Prevalence of orthodontic asymmetries.
9807150.
16. Haraguchi S, Iguchi Y, Takada K. Asymmetry of the
face in orthodontic patients. Angle Orthod.
2008;78(3):421–426.
urban Iranian population. An epidemiological study
of 11- to 14-year-old children. Eur J Orthod.
2009;31(5):477–484: PubMed PMID: 19477970.
18. Murshid ZA, Amin HE, Al-Nowaiser AM.
Distribution of certain types of occlusal anomalies
among Saudi Arabian adolescents in Jeddah city.
Community Dent Health. 2010;27(4):238–241: PubMed
PMID: 21473360.
19. Behbehani F, Roy R, Al-Jame B. Prevalence of
asymmetric molar and canine relationship. Eur J
Orthod. 2012 Dec;34(6):686–692: doi:
10.1093/ejo/cjr060. Epub 2011 Jul 7. PubMed PMID:
21742643.
20. Gribel BF, Thiesen G, Borges T, Freitas MPM.
Prevalence of mandibular asymmetry in skeletal class
I adult patients. J Research Dent. 2014;2(3):189–197.
21. Bhateja NK, Fida M, Shaikh A. Frequency of
dentofacial asymmetries: a cross-sectional study on
orthodontic patients. J Ayub Med Coll Abbottabad.
2014;26(2):129–133: PubMed PMID: 25603660.
22. Jain S, Jain V, Gupta A. Prevalence of midline shift in
orthodontic patients. Int J Curr Innov Res.
2015;1:287–290.
CHAPTER 70
Dental midline deviations
Prashanti Bollu
O.P. Kharbanda
CHAPTER OUTLINE
Midline deviations
Effects of an altered tip of the incisors on the midline
Reference planes
Prevalence of midline deviations
Clinical presentation of dental midline deviations
Aetiology of the dental midline shift
Management of dental midline shifts of purely dental origin
Retention protocol
Key Points
Midline deviations
Dental asymmetry or centre line deviations may be the outcome of
discrepancies in tooth dimensions or improper placement of dental
units within normal/symmetrical underlying jaw bones or be the
outcome of asymmetrical skeletal bases housing the dental units.
‘Centre line’ is the synonym for the midline, a term more often used
by British clinicians.
Dental midline or centre line is evaluated at the junction of contact
points of the mesial surface of the central incisors in each arch. It is the
centre point of the dental arch which marks the anterior limit and a
reference point that divides the arch into two parts. Midline symmetry
or deviations are recorded as coincident or non-coincident to face and
to each other (Fig. 70.1).
FIGURE 70.1 The dental midlines must coincide with facial

midlines.
Therefore, the dental midline is assessed in relation to the facial
midline. MSR is used as a reference plane to evaluate the deviations.
MSR is an imaginary line that divides the face into two halves.
The maxillary dental arch midline is expected to coincide with mid-

sagittal line of the face and midline of the maxilla. Accordingly,
mandibular dental midline is supposed to be placed in mid dental
arch of the mandibular symphysis and the face. Both maxillary and
mandibular midlines are expected to be coincident with each other
and to the midline of the face. The dental midlines are evaluated with
(1) teeth in occlusion and (2) on the opening of the mandible.
Dental midline shifts more than 2 mm are usually considered a matter
of concern, for these deviations compromise attractiveness of the face.
It was estimated that the probability of a layperson recording a less
favourable attractiveness score when there was a 2-mm discrepancy
between the dental and facial midlines was 56% (Fig. 70.2).
FIGURE 70.2 A perfect coincidence of maxillary and mandibular

midlines is desirable though rare.
Up to 1 mm of midline deviations is acceptable. Note slight shift of
maxillary midline to right in a girl following orthodontic treatment. The
occlusion is perfect with class I molar and canine relationship. Bold
white line: refers to MSR; red line: maxillary midline; yellow line:
mandibular midline.
Effects of an altered tip of the incisors on the

midline
Dental midline shifts may or may not be associated with alteration in
the mesiodistal inclination of the incisors. In certain situations, altered
angulations may compensate for underlying dentoalveolar or mild
forms of skeletal asymmetry. In other instances alteration in
angulations may reflect as a midline shift. A discrepancy of 10°
change in incisors angulations could compromise facial aesthetics and
are therefore considered unacceptable by the orthodontists.
Thomas et al. studied attractiveness scale as related to angulation of
the incisors. They reported that the mean acceptable midline
angulation for the male subject was 6.6±4.58° for the orthodontists and
10.7±6.28° for laypeople. For the female subject, the mean acceptable
threshold was 6.4±4.08° for orthodontists and 10.0±6.18° for laypeople
(P < .001). Discrepancies of 10° were unacceptable by 68% of
orthodontists and 41% of laypeople.2
Reference planes
1. Mid-sagittal reference (MSR) plane. Mid-sagittal reference
plane of the face/head is also called MSR plane. It corresponds
to a median plane that divides the body into two halves. It is
mainly constructed or follows the average of mid-sagittal
structures of the skull. MSR extends down from the head, in
natural head position (NHP) or when a subject is sitting
upright or standing vertically. The face is bisected by a mid-
sagittal vertical line running through the head, the centre of
nose, lips and chin. The pupils are equidistant to this line in
the horizontal plane, vertical to mid-sagittal line.
MSR plane can be visualised as an imaginary vertical, or plumb
line outside the face dropped at glabella.3 The plumb line also
bisects dorsum of the nasal tip equidistantly unless there is an
asymmetrical nose. In dental clinical settings MSR plane is
easily visualised with a piece of long floss or a ruler (Fig. 70.3).
2. Philtrum of the upper lip. Burstone suggested evaluation of
midline according to patient’s perspective. Most patients are
more concerned about their facial midline in reference to
upper lip or the corners of the mouth.4 Therefore, the centre of
the philtrum is a good guide to the placement of the maxillary
dental midline. The ‘V’ at the vermillion border forms a
suitable landmark that is much easily appreciated by
orthodontists and patients (Fig. 70.4). Arnett and Bergman
noted that the philtrum is usually a reliable midline structure
and can, in most instances, be used as the basis for midline
assessment.5 According to Miller, the maxillary midline is
situated exactly in the middle of the mouth (using the
philtrum as a guide) in approximately 70% of individuals, but
that the maxillary and mandibular midlines coincide in only
one-fourth of the population.6
3. Corners of mouth. Another guide for assessment of midline is
to look at the distance between the canine or first premolar
and the corner of the mouth. If the midline is properly
positioned, the patient will see the same amount of tooth
exposure on the right and left side. The patient is more apt to
look at soft-tissue guides, such as the philtrum and the corners
of the mouth, in evaluating the dental midline, than any
arbitrary string such as a plumb line or dental floss that is
placed in front of the face.
4. Mid palatal raphe. Maxillary dental midline in the arch is
evaluated as a part of symmetry. Mid palatine raphe and
incisive papillae used as reference points in cases of the normal
shape of the arch.7 Marking points usually determine the
maxillary model midline over the mid palatal suture, from the
incisive papilla to the most visible posterior landmark.
5. Symphysis of the mandible. Mandibular dental midline is
evaluated in reference to MSR and relation to symphysis of the
mandible (Fig. 70.5A).
6. The base of dentoalveolar structures. Midlines are evaluated on
their respective skeletal bases, that is maxillary and
mandibular bases at A point and B point respectively
(Fig. 70.5B).
7. Angulation of the incisors. A diligent appraisal of the dental
casts and clinical evaluation is performed to assess the axial
inclinations of the incisors which may either be contributing to
midline discrepancy or alternatively these may have inclined
in compensation to underlying dento-alveolar or apical base
discrepancy. Under these situations, a mental graphic picture
needs to be created for the positions of incisors by placing
them in a correct mesio-distal angulation (tip) and visualising
where the centres of the roots might be so located that a
perpendicular can be dropped to the occlusal plane.
FIGURE 70.3 Evaluation of midline shift in a clinical setting.
(A) Using a long piece of dental floss. (B) Using a ruler.
FIGURE 70.4 Patients perceive symmetry of dental midline in
relation to lips.
The ‘V’ at the vermillion border forms a suitable landmark for the dental
midline evaluation that is much easily appreciated by orthodontists and
patients. Source: Reproduced with permission from Burstone CJ.
Diagnosis and treatment planning of patients with asymmetries.Semin
Orthod. 1998 Sep;4(3):153–64.
FIGURE 70.5 (A) The dental and skeletal midlines are evaluated in
relation to MSR, which is constructed on a conventional PA
cephalogram. Incisor apical base discrepancy between upper and
lower arches. Arbitrary skeletal mid-sagittal plane passes through the
lower apical base midline. (B) Upper dental midline to the right of the
lower midline. Skeletal problem with apical base discrepancy. (C)
Upper midline to the right without an apical base discrepancy. Upper
incisors are tipped towards the right. (D) Dental midlines correspond.
Apical base discrepancy is masked by compensatory tipping of the
upper incisors to the left side. Source: Reproduced with permission
from Burstone CJ. Diagnosis and treatment planning of patients with
asymmetries. Semin Orthod. 1998 Sep;4(3):153–64.
Fig. 70.5C shows a midline discrepancy with the upper incisors to

the right of the lowers. By mentally uprighting the incisors to equalise
their axial inclinations, midlines would correspond, and a dental
midline discrepancy therefore exists. In contrast, in Fig. 70.5D, a
skeletal discrepancy is shown. Equalising axial inclinations would not
help the midline coincide. The midlines become further apart as the
teeth are uprighted. This is an example of a skeletal or apical base
discrepancy.
Once axial inclinations are corrected with simple orthodontic
mechanism, midline correction is easy to achieve. While in contrast to
a situation, where upper teeth have tipped to maintain a midline
correction to compensate for the underlying apical base asymmetry,
corrections of teeth angulations will aggravate the midline
discrepancy. Such patients would require a surgical approach to
correct apical base relations ship, which will simultaneously correct
the dental midlines as well.
Prevalence of midline deviations
(Tables 70.1, 70.2)
The presence of midline deviations in population surveys has been
reported to be close to 20%.8–10
Table 70.1
Prevalence of midline shift in children
Table 70.2
Prevalence of midline deviations orthodontic subjects
and with facial asymmetries
Midline deviations in orthodontic population and patients with

facial asymmetries are close to 60% in the range of 46% to as high as
78%.8,11,12
Maxillary midline deviations ranged from 21 to 39% with an
average of 30%.8,11,12 Midline deviations and asymmetries are more
common in mandible owing to its more extended period of growth,
which makes it susceptible to be influenced by environmental factors
affecting normal growth till adulthood. In the mandible, midline
deviations are reported in the range of 43%–67.5%.
Clinical presentation of dental midline
deviations
Jerrold and Lowenstein (1990) described following major possible
clinical situations on midline deviations.13
Group A: Local/dentoalveolar type of midline shift when the face is
symmetric, and there are no major skeletal deviations. Four clinical
situations can exist.
1. When maxillary midline is off to the right or left side

2. A clinical situation in which both maxillary and mandibular
midlines are coincident but both are off from the centre line of
the face in the same direction. Both have moved to the right or
left side.
3. A clinical situation when face, maxilla, mandible and maxillary
midlines are coincident however mandibular midline is off to
centre line or plumb line of the face. This clinical situation is
seen during the late mixed dentition stage. Unilateral loss of
deciduous canine in the lower arch can lead to a slight shift of
the incisors towards lost tooth side. Once detected, it is
advised to perform the extraction of deciduous canine of the
contralateral side which usually leads to spontaneous
correction of the midline.
4. While facial midline is correctly centred, the maxillary midline
and mandibular midlines are not in alignment due to the shift
of each of them in their respective jaws in a direction opposite
to each other. Say, when maxillary midline is shifted to the
right side the midline of the mandibular dental arch has
moved to left side, thus compounding the severity of the
problem.
Group B: Dental asymmetry comprises clinical situations of facial

asymmetry functional or true skeletal deviations. The dental midline
deviations may or may not be present. A major cause of such
asymmetries in otherwise normal faces involves a lateral functional
shift of the mandible.
1. The functional lateral shift of the mandible. A simple test

involves carefully observing a subject from the front. He is
gently asked to open the mouth. If the chin deviation
disappears on opening the mandible and reappears on closure
of the mandible to centric occlusion the cause is often lateral
shift due to premature contacts during closure in occlusion.
Here the mandible is rotated into a lateral eccentric posture,
usually as a result of functional interferences. The maxillary
midline is correct.
On gentle manipulation and guiding the mandible during closure
till the first point of dental contact is made, the face becomes
relatively symmetric, and the patient should be able to tolerate
this position for a short period without feeling the excessive
strain in the temporomandibular joint areas or the muscles of
mastication, a functional shift is suspected. However, if this
condition is not treated well, that is in time during early
growth, the deformity may become skeletal in nature.
2. Occasionally in a situation as described in above (1) the local
tilting or shifting of teeth may lead to maxillary and
mandibular midline coinciding while chin remains deviated.
3. Both maxillary and mandibular midlines are coincident but
deviated from midline of the face to the side of chin deviation.
4. The maxillary midline is off to opposite side to the mandible,
dental midline of which is deviated towards the deviated chin.
5. Both dental midlines are coincident, and yet both are off to one
side of the facial midline while the mandible is rotated to the
contra lateral side. Aetiologically, the upper and lower teeth
have shifted to one side as described, while the mandible has
reacted to the functional interferences or cross-bite, thus
assuming an eccentric posture.
6. The maxillary midline is off to one side, the mandibular
midline is coincident with the mid frontal plane, and yet the
mandible has rotated or deviated to the opposite side.
7. The maxillary midline is off to one side, chin is off to the same
side because of functional interferences, and the mandibular
midline is centred at the initiation of the treatment. In such
situations, the lower midline moves to the opposite side
following asymmetry correction.
8. This situation is similar to the previous one except that instead
of the mandibular midline being ‘centred’ at the initiation of
treatment, it is off to the opposite side of the maxillary midline.
Aetiology of the dental midline shift
(Figs 70.6–70.12 and Table 70.3)
1. During the development of dentition, several dental factors can
cause asymmetry of the dental arches and midline shift.
a. Side differences in the pattern of exfoliation. A
midline shift in the mandible is often seen with the
premature shedding of the deciduous canine
leading to shifting of midline to the same side.
b. Position and orientation of the developing
successor tooth buds in the eruptive phase, eruption
path ways. Eruption pathways can be disturbed due
to the physical obstruction such as a presence of a
supernumerary tooth.
c. Differences in the site of tooth emergence, the
sequence of eruption and position of the antagonist.
A premature loss of the deciduous molar leading to
drift of permanent molar teeth compromising arch
length leading to dental arch asymmetry including
midline shift.
d. Tooth rotations occur consequently to lack of space
in the arch or due to the physical obstruction caused
by root stumps of the deciduous teeth, retained
deciduous teeth or in association with
supernumerary teeth.
e. Transverse problems in the dental arch or its bases
leading to crowding of the anterior segment are
associated with midline shift. Need to accommodate
a full complement of teeth in the arch in a small
bony base can lead to crowding and midline
deviation.
f. If anterior crowding results in an infra-position of
canine or a palatally positioned lateral incisor on
one side, this leads to an upper midline shift
towards the crowded side.14
g. Missing teeth/partial hypodontia, microdontic teeth
leading to migration of adjacent teeth, a situation
often seen in missing maxillary lateral
incisors/missing second premolars/microdontic
laterals.
h. Deleterious oral habits, influencing facial
morphology.
i. Mandibular functional shift or deflective contacts
due to cross-bite.
j. The tooth-size discrepancy, unusually large teeth,
such as macrodontia.
2. Asymmetries can be congenital or developmental in origin
during growth/or acquired.
FIGURE 70.6 Common causes of dental midline shifts.

(A) Midline shift due to microdontic laterals. (B) Midline shift with
missing laterals; (C) midline shift associated with a mesiodens.
FIGURE 70.7 Midline shift with severe crowding in two cases.

Lower midline shifted towards canine displacement in severe crowded
case.
FIGURE 70.8 Midline shift with palatally placed lateral incisor.

FIGURE 70.9 Midline shift in a cleft patient.
FIGURE 70.10 Case of lower midline shift and asymmetrical

malocclusion associated with class II division 2 malocclusion.
The left mandibular lateral incisor is lingually displaced, leading to
shifting of lower midline to the left and class I molar relation on that
side. Molar relation and canine relationship on the right side remain
class II.
FIGURE 70.11 Midline shift due to premature functional contacts.
(A) Midline shift in centric occlusion; (B) maxillary and mandibular
midline coinciding during closure of mandible with first initial contact.
FIGURE 70.12 Midline shift due to periodontal migration.
Table 70.3
Aetiology of midline shift

Maxillary Clinical condition Outcome/Traits
1 Microdontic maxillary Maxillary midline shift to the side of the anomaly
lateral incisor/partial
anodontia
2 A palatal eruption of The maxillary dental midline shift to the affected side
maxillary lateral incisor
3 Impacted canine unilateral Midline shift
4 Supernumerary Can cause midline shift
tooth/dichotomy of incisor
5 Single incisor avulsion due Mesial migration of buccal segments into space of
to trauma avulsed tooth/tilting of teeth next to space
6 Unilateral retained Midline shift
deciduous canine
7 Premature loss of deciduous Mesial migration of buccal segment/permanent first
molars in Maxilla due to molar resulting in class II subdivision malocclusion
extensive caries
8 Missing mandibular incisor- Midline shift to the affected side
one or more
9 Mandible: Early loss of Mesial migration of permanent molar, lack of space for
deciduous molars due to erupting premolars. Unilateral/subdivision molar class
caries or iatrogenic III relation and midline shift to affected side
extractions
10 Functional shift of the Lower midline shift to the same side of the shift
mandible
11 Posterior unilateral cross- Results in functional mandibular displacement (FLMD)
bite towards cross-bite side
Functional mandibular displacement (FLMD)
Management of dental midline shifts of
purely dental origin
Midline deviations in subjects with the normal skeletal pattern with
no apparent asymmetry of face, skeleton and occlusion can be
corrected with orthodontic mechanics alone. Subjects in which
midline correction is required to correct migration of teeth in spaces
created by partial hypodontia or microdontic teeth will require one of
the following treatment plans to attain good proximal contacts:
1. Orthodontic space closure,

2. Prosthetic rehabilitation of the available space of a missing
tooth or teeth, and/or, and
3. Aesthetic restorations of the microdontic teeth to normal
dimensions.
The integrity of the arch and smooth gliding during functional

movements are the key to stability and minimise relapse.
Conversely, where there is a true apical base discrepancy, the
translatory mechanics become more challenging and is a limitation on
the amount of mesiodistal movement possible.4,15
Consequently, asymmetric anchorage loss is associated with
midline deviations which tend to appear during stages of finishing.
These clinical situations often require complex orthodontic mechanics
though the problem may initially appear simple.
The force systems used for dental midline correction
1. Simple cantilever mechanics for tipped incisors (Fig. 70.13A)

2. Simple cantilever mechanics for translation of incisors
(Fig. 70.13B)
3. Looped archwire mechanics for bodily movement
a. Looped mechanics with push force (Fig. 70.14A)
b. Looped mechanics with pull force (Fig. 70.14B)
c. Looped mechanics with a combination of pull and
push force (Fig. 70.14C)
d. Open coil spring (Fig. 70.14D)
4. Correction of midline with a simultaneous resolution of
crowding
5. Correction of midline with the transverse expansion of the
maxilla
6. Correction of midline with unilateral molar distalisation or
asymmetric extraction
FIGURE 70.13 Treatment of midline deviation in the mandible

with use of cantilever forces.
(A) Midline discrepancy caused by tipping of the lower incisors. A
simple force at the crowns of the teeth generated from molar without an
archwire will upright the incisors and achieve midline coincidence (A1).
And midline correction by tipping (A2). (B) Midline correction by
translation. (B1) An anterior wire with a loop extended apically to
approximate the centre of resistance of the incisor teeth to provide a
contact point for the force. (B2) A force applied through the centre of
resistance will produce a translation. The red dot represents the centre
of resistance. Source: Reproduced with permission from Kulberg AJ
Cantilever springs: force systems and clinical applications. Semin
Orthod 2001;7:150–9.
FIGURE 70.14 Treatment of midline deviation in the maxilla in a
continuous wire with a looped mechanism.
Migration of central incisors caused midline discrepancy to the opposite
side, across midline due to a missing contralateral lateral incisor. (A)
Pull force; (B) push force; (C) combination of pull and pushnforce; (D)
push coil spring.
1. Simple cantilever mechanics for tipped incisors.
When the incisors are tipped associated with ectopic eruptions or
the premature loss of primary teeth, a single force is needed to
upright the incisors and establish midline coincidence.
Cantilever mechanics may be a preferred option compared to a
full arch because of the inherent qualities it offers with minimal
side effects minimal friction compared to continuous arch
engaged to brackets of all the teeth in the arch.16
The point force generated from anchor tooth to the anterior teeth
is preferred before placing an aligning wire. The cantilever can
provide a pulling force to shift the midline. Each incisor needs
to be independently tipped to correct the midline. By tying the
brackets together in a figure of 8 and attaching the cantilever at
the level of the brackets, this simple tipping movement easily
corrects the midline discrepancy.
In contrast, the use of an archwire for alignment may up-right, tip
the teeth in their respective crown positions with significant
movement at their roots without obtaining the midline
correction. Therefore, when incisor crowns are tipped,
engagement of the continuous archwire for alignment and
levelling is postponed.16
2. Simple cantilever mechanics for translation of incisors.
In situations where midline correction is required by bodily
movement of the incisors (Fig. 70.15) cantilever mechanics
allows the point of force application to be varied, more
gingivally, close to the centre of resistance of the teeth required
to be moved. Translation movement of incisors is achieved by
extending a passive loop apically towards the centre of
resistance of the anterior teeth; the spring can be attached to
produce the force at the desired level.16
3. Looped archwire mechanics for bodily movement:13
a. Midline correction with a vertical loop mechanism:
Push mechanism. Multiple looped archwires are a
suitable mechanism for moving teeth in a
mesiodistal direction to correct drifting of anterior
teeth where the translation of teeth is a major
requirement.
The other option includes use of criss-cross
powerchains applied from upper right first molar
(UR6) to upper left lateral incisor (UL2). Powerchain
is applied in the opposite direction on the lower arch
(i.e. LL6 to LR2). This helps especially when
correction is minor 1–2 mm and canines are not
already in class I position.
Alternatively, midline elastics can be used for minor
corrections, especially when minor cant of occlusal
plane is also noted.
Case scenario: The right maxillary lateral incisor is
absent, left lateral incisor is microdontic and
maxillary centre line is shifted to the right side by
4 mm with spacing in the anterior region.
The molars and canines are in class I relationship. In
such or similar situations involving an anterior
segment following archwire design is suggested.
After levelling with super elastic wires, a vertical loop
with helix is prepared in 0.018 in. stainless steel, or
Blue Elgilloy wire between right maxillary canine and
distal of right central incisor say in this case. The loop
is so designed when activated would translate the
maxillary central incisors to opposite direction, that is
the left side. It is pertinent that the archwire should
be free to slide through the brackets and molar tube,
in the direction of tooth’s/teeth movement. If the
archwire is not free to slide in the tube, the push force
vectors will lead to labial tipping of the incisors. A
molar stop is desired on the side generating the push
force, say in this case right side.
b. Midline correction with a closed vertical loop: Pull
mechanics. In a similar situation as above, dental
movement in mesiodistal direction can also be
achieved using frictionless pull mechanics. This will
entail the following changes in above mentioned
appliance design.
A stop at distal bracket margin of the maxillary right-
central incisor.
A closed helix on left segment, with enough distance
from the mesial margin of the left canine bracket.
The closed vertical loop with helix is activated by 1–
2 mm with the gentle cinch to annealed distal end of
the wire at the left molar buccal tube.
c. Midline correction with vertical loops in a
combination of pull and push mechanics.
The open and closed vertical loops can be used in
combination to enhance dental movement with a
push from one side and pull force on another side.
For example: In the scenario below on an archwire
with open helix can be prepared between, right
maxillary canine and incisor which should serve to
push the teeth towards the centre and a closed helix
on opposite side between lateral incisor and canine.
The closed helix is activated by a pull/gentle cinch at
the distal end of the molar tube. A combination of
push force and pull force is likely to move the teeth in
the desired direction, towards the midline. The
vertical loops generate force close to the centre of
resistance of incisors and hence entail the bodily
movement.
Following archwire design considerations are
important.
• The height of vertical loops is so tailored to
be comfortably accommodated in the
vestibule.
• To ensure a free sliding movement, it is
pertinent to use stainless steel or Elgilloy
wires. Sufficient levelling should have been
achieved before activation of the loops. The
buccal segments are secured as a unit with
the figure of 8 ligatures from canine to
molar on either side.
Alternate of above methods is a use of compressed open
coil spring. The push force generated by the
compressed spring between the canine bracket and
the bracket of the tooth to be moved can help correct
midline. The mechanism can also be supplemented
with a pull force by using a power chain on the
contralateral side.
The stainless steel open coil spring can generate heavy
force. Hence the NiTi coil is preferred over stainless
steel spring.
Large dimension base wire, such as 0.020 in. stainless
steel is preferred to minimise tipping of teeth during
movement. The compressed open coil spring may
require reactivation by replacing it with a spring of
longer length, and it could be a constraint for patients
who are not able to make frequent visits for
treatment.
4. Correction of midline with a simultaneous resolution of
crowding.
The subjects with class I molar relationship with severe crowding
with no other skeletal or functional shift can be treated for
centre line correction with a concurrent resolution of crowding.
The resolution of crowding is achieved by choosing careful
biomechanics to create sufficient space for movement of
anterior teeth in the desired side of the arch. It is critical to
conserve the anchorage on the contralateral side of the centre
line shift.
Clinical scenario: The maxillary centre line is moved to the left
due to the palatal placement of the left maxillary lateral incisor
with canines being crowded as well. This clinical situation
would require following considerations in biomechanics; the
case being treated as extraction case of four first premolars.
The right side anchorage requirements are much greater
compared to the left where the left canine is likely to quickly
move into space created by extraction of the first premolar.
The anchorage requirements on the right side are greater because:
a. The right anterior segment requires a greater range
of tooth movement.
b. More dental units need to be moved, which include
the right canine, lateral and central incisors and left
incisor. Therefore it is pertinent to preserve the
anchorage. Any loss of molar anchorage on the right
side would be detrimental in achieving complete
correction of the midline.
5. Dental midline and transverse deficiency of maxilla (Fig.
70.15A)
The transverse deficiency of maxilla often clinically exhibits as
unilateral cross-bite leading to crowding in the anterior
segment and midline shift. The maxillary expansion and
resolution of anterior crowding lead to centre line correction
when carefully and diligently chosen biomechanics is utilised.
Following are necessary steps when performing RME with
simultaneous unilateral cross-bite and midline correction.
a. Rigid rapid maxillary expansion (RME), such as
HYRAX (Hygienic Rapid Maxillary Expander) with
occlusal coverage is the appliance of choice.
b. RME is usually performed at the rate of two turns
(0.25 mm) every 12 h for 1 week
c. The midline diastema is likely to appear at this
stage of expansion.
d. When a desirable expansion is achieved, expansion
screw can be fixed with either ligature wire or
sealed with light cure restorative composite.
e. During next 4–6 months of retention, the severity of
crowding is likely to lessen to some extent, as the
teeth migrate into diastema under the effect of
stretched trans-septal fibres.
f. To allow the tilted incisors to move towards midline
whereby preventing the opposite side from
migrating, a modified design of expander with
acrylic covering the one side of the anterior arch can
be made. The alternate strategy can be bonding the
selected teeth and retaining them with a figure of 8
ligature.
g. Active movement of teeth into midline diastema
should be avoided,17 therefore active teeth
movement with fixed appliance should be initiated
after 3–4 months of starting RME.
However, the incisors or non-crowded side can be held
with bonding a section of the arch.14
FIGURE 70.15A Dental midline and transverse deficiency of

maxilla.
(A) Bilateral constricted maxilla with upper midline shift; (B) type 1 RME
appliance in the mouth; (C) end of expansion; (D) correction of upper
midline shift at the end of the retention period. Source: Reproduced
with permission from Alcan T, Ceylanoğlu C. Upper midline correction
in conjunction with rapid maxillary expansion. Am J Orthod Dentofacial
Orthop. 2006 Nov;130(5):671–5.
FIGURE 70.15B (A) Bilateral constricted maxilla with upper midline
shift; (B) type 2 RME appliance in the mouth; (C) end of expansion; (D)
correction of the upper midline shift at the end of the retention period.
Source: Reproduced with permission from Alcan T, Ceylanoğlu C.
Upper midline correction in conjunction with rapid maxillary expansion.
Am J Orthod Dentofacial Orthop. 2006 Nov;130(5):671–5.
Retention protocol
There is no suggestion for specific retention protocol following
midline correction in the literature. Tight contacts, correct mesiodistal
angulations and freedom during functional movements are
fundamental to the maintenance of the integrity of the arch. In clinical
situations of missing teeth or microdontic lateral incisors, the required
prosthesis or restoration of crown anatomy to normal anatomic
dimensions with aesthetic restoration procedures should be achieved
at the time of debonding.
Key Points
Mild asymmetry is common in all biological specimens including face,
teeth and jaws. Dental asymmetry of midline shift of more than 2 mm
may require correction for aesthetic reasons or functional maintenance
of occlusion. The location of midline asymmetry requires a diligent
clinical examination and observations of occlusion and teeth positions.
The biomechanics of midline correction varies in each given situation
and should be tailored to meet the objectives of the treatment. All
midline deviations do not need to be corrected.
References
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CHAPTER 71
Asymmetry of occlusion
O.P. Kharbanda
CHAPTER OUTLINE
Definition and criteria of asymmetric occlusion

Development of asymmetries with dental arches
Ankylosis of primary molars
Ectopic eruptions of the maxillary permanent first molars
Partial hypodontia
Dental caries
Common traits of asymmetrical occlusion
Asymmetrical molar relationship
Asymmetrical canine relationship
Asymmetrical overjet
Clinical evaluation
Prevalence and features of asymmetrical occlusion
Class II asymmetric relations
Class III asymmetric relations
Features of asymmetric class II subdivision malocclusion
Management
Asymmetrical mechanics
Molar distalisation
Extraction of three first premolars
Unilateral maxillary first premolar extraction
Key Points
Definition and criteria of asymmetric
occlusion
Asymmetric occlusal relationships can result from an asymmetry
within a single arch or asymmetric skeletal relationships between the
maxilla and the mandible.1 People with normal occlusion can have
molar asymmetry greater than 1 mm in transverse and
anteroposterior directions (Fig. 71.1).2
FIGURE 71.1 A case of mild asymmetry of malocclusion.

There is a 2 mm midline shift of the mandible to the right, left side a
mild class III premolar and molar relationship, and mild class II molar
and canine on the right side.
The cause of asymmetries in the molar relationship can be

multivariate. In some patients, the problem originates with an
abnormal dental eruption, premature loss of primary teeth, or loss of
permanent teeth; however, in other patients, the origin may be
primarily skeletal in which an asymmetric maxilla or, more likely, an
asymmetric mandible is present.3
Development of asymmetries within
dental arches
Asymmetries within the maxillary or mandibular arch can produce
asymmetric occlusal relationships.1
Ankylosis of primary molars

Ankylosis of primary molars often seen in the mandibular arch causes
them to remain submerged below the line of occlusion of the adjacent
teeth. Continuing eruption of the adjacent permanent teeth lead them
to ‘tip’ over the crown of the ankylosed tooth, thereby causing loss of
arch length and asymmetric axial inclinations of the adjacent teeth
compared to those on the contralateral (unaffected) side of the arch.
This leads to an asymmetric molar occlusion. This space loss involves
the distal eruption of the permanent tooth anterior to the ankylosed
primary molar and a medial tip of the tooth distal to the submerged
tooth. The distal eruption of the teeth anterior to the ankylosed tooth
can result in a shift of the dental midline towards the affected side of
the arch, compounding the developing arch asymmetry and
producing asymmetric canine relationships.
Ectopic eruptions of the maxillary permanent

first molars
Maxillary first permanent molars are known for their aberrant
behaviour during the eruption, moving more mesially leading to
premature loss of the primary second molar tooth. Early loss of
second primary molar in maxillary arch results in loss of arch length
on the affected side, leading to class II molar relationship on the
affected side, and loss of arch length, which could lead to an
impaction of the second premolar tooth or crowding in the canine
region.
Partial hypodontia
Missing mandibular second premolars can be associated with retained
primary molar which can, in turn, cause asymmetric molar relation by
either preventing mesial movement of the erupting permanent molar
or allowing mesial tilting of adjacent permanent teeth in the event of
shedding (Fig. 71.2).
FIGURE 71.2 A case of lower midline shift and asymmetrical

malocclusion.
The retained right lower second deciduous molar associated with
missing successor premolar has created a shortage of arch length
leading to a slight shift of lower midline to left and mild crowding of the
left premolar. Molar relation and canine relationship on both the sides is
class I.
Dental caries
Dental caries is the most common cause of premature loss of the
deciduous molar. When space is not managed, the erupting
permanent maxillary molars move mesially leading to the
development of class II malocclusion. When it happens unilaterally,
the outcome is an asymmetric molar relationship. The mesial tilt of the
mandibular molar will cause class III relationship, and when it
happens on one side, it will lead to class III subdivision malocclusion.
Common traits of asymmetrical
occlusion
Asymmetric conditions of occlusion that can be possibly managed
with orthodontic treatment are:
1. Asymmetrical molar relationship

2. Asymmetrical canine relationship
3. Asymmetrical overjet
4. Asymmetrical overbite
Asymmetrical molar relationship

Class II subdivision (Fig. 71.3) and class III subdivision (Fig. 71.4)
malocclusions are an apt example of asymmetry of occlusion in the
anteroposterior direction. Rarely one may encounter a clinical
situation of class III molar relation on one side and class II molar
relation on another side. Asymmetrical buccal occlusion leads to
shifting of the midline and canine relationship (Fig. 71.5A–B).
FIGURE 71.3 Class II subdivision malocclusion.

FIGURE 71.4 Class III subdivision malocclusion.
FIGURE 71.5 Criteria of classification used to evaluate molar and
canine relationship for recording malocclusion.
Asymmetry of occlusion that has compensations with underlying

facial asymmetry of skeletal origin cannot be treated with orthodontic
therapy alone. In other situations of mild skeletal asymmetry of
occlusion may show compensations and any attempt to treat such
asymmetrical occlusion will compromise the aesthetics and occlusion.
Facial asymmetry itself might be concealed by dental compensations,
and if not correctly diagnosed, it tends to be revealed throughout
orthodontic treatment, thereby extending treatment time and
hindering outcomes.
Asymmetrical canine relationship (Fig. 71.5C–

D)
The asymmetrical canine relationship usually follows asymmetrical
molar relations or could be seen due to partial hypodontia, or
presence of severe crowding and dichotomy of teeth. The underlying
skeletal deformities affecting one side of jaw and chin deviations
contribute to unilateral mal-relationship of the canines in the sagittal
direction. It can be clinically expressed as unilateral class II or class III
or even worst class III on one side and class II on another side.
Asymmetrical overjet
Asymmetrical overjet is seen in patients with unilateral thumb
sucking, children with large unilateral cross-bite associated with
functional shift or with underlying skeletal anomalies. Mandible is
more frequently affected than the maxilla. Asymmetrical overjet
observed with class III malocclusion is often associated with a lateral
shift of the mandible which can be functional or caused by the
unilateral excessive growth of the condyle.
While asymmetrical overbite is unusual, it can exhibit as, one-sided
open bite.
Clinical evaluation
A detailed clinical and radiological evaluation of the case with
asymmetrical occlusion is fundamental to establish the nature and
severity of the problem. Clinical evaluation includes a thorough
observation of mesiodistal inclinations of the molars, teeth in the
buccal segment in the arch, their relationship to the apical bases and
underlying jaw bones and overall facial skeleton. A comprehensive 3D
evaluation with CBCT remains the gold standard (Fig. 71.6A–B) to
measure the exact location and severity of the asymmetry; however,
CBCT should only be, prescribed with caution keeping in view
Sedentexct guidelines on the use of CBCT.4 In the absence of CBCT,
routine OPG and PA cephalogram are of immense value in
differentiating the underlying structures in transverse and vertical
dimensions. These are described later in the chapter in association
with skeletal jaw asymmetries. Other non-radiation imaging
modalities include 3dMD and similar techniques that record face and
soft tissue structures may prove useful.
FIGURE 71.6 CBCT applications in facial asymmetry.
(A) Facial asymmetry as visualised on a volume-rendered CBCT
image. (B, C) Maxillary dental midline deviation caused by ‘Yaw’ of the
maxilla.
Prevalence and features of
asymmetrical occlusion
The prevalence of molar asymmetry in patients visiting orthodontic
clinic has been reported in the range of 22%–43%.5,6 There are only
two population-based studies related to occlusal asymmetry one from
Kuwait7 and other from Kathmandu, Nepal.8
Class II asymmetric relations

The total prevalence of an asymmetric molar relationship in Kuwaiti
children was 29.7%, which included 21.3% in class II, and 7.9% in class
III malocclusion. Among class II, half-step asymmetries were found in
18.9% and full-step asymmetries were prevalent in 2.4%.
Class III asymmetric relations

Among class III, 7.1% were as half-cusp class III, and 0.8% were full-
cusp class III. It is interesting that 0.4% subjects were a combination of
half-step class II on one side and a half-step class III on the other side.7
A study from Nepal has reported high distribution (16%) of class III
malocclusion in their sample population of high school students in
Kathmandu valley of which 45.5% were a subdivision. Class II
malocclusion was observed in 25% of the sample of which 2%
exhibited subdivision.8

The asymmetrical canine relationship usually corresponds to an
asymmetrical molar relation in the arches. It can be clinically
expressed as unilateral class II or class III or even worst class III on
one side and class II on another side. The cumulative prevalence of an
asymmetric canine relationship in Kuwaiti children was 41.4% with
only 4.2% of the cases falling in the moderate to the severe occlusal
asymmetry category. In the canine region, half-step asymmetries were
found in 33.4% as half-step class II and in 3.8% as half-step class III.
Full-step asymmetries were prevalent in 1.8% as class II, 1.2% as class
II and 1.0% as a combination of half-step class II one side and half-step
class III on the other.7
Features of asymmetric class II subdivision

malocclusion
Significant differences exist about dental arch and facial asymmetries
between Angle’s class II subdivision malocclusions, and persons
having normal occlusions. The main component of class II subdivision
malocclusion is dentoalveolar. It signifies a primarily distal
positioning of the first mandibular molar on the class II side and
secondarily mesial positioning of the first maxillary molar on the same
side.9,10 These findings have been further corroborated in a study by
Janson et al. (2001). The more frequent distal positioning of the
mandibular molars on the class II side, compared with the mesial
positioning of the maxillary molars on that side resulted in
mandibular dental midline deviation to the class II side more
frequently than the maxillary dental midline to the opposite side.11
Observations mentioned above based on lateral and PA
cephalometry, have been lately reconfirmed using CBCT. Sanders et
al. have found that the aetiology of class II subdivision malocclusions
is primarily due to an asymmetric mandible that is shorter and
positioned posteriorly on the class II side. A mesially positioned
maxillary molar and a distally positioned mandibular molar on the
class II side are minor contributing factors.12
Most class II subdivision malocclusion patients present the
mandibular dental midline displaced towards the class II side
associated to the maxillary dental midline coincident to the mid-
sagittal plane or with a mild deviation.10
Li J et al. (2015) further described that, in subdivision malocclusions,
functional deviation resulting in pseudo-asymmetry occurred in
nearly one-third subjects with class II subdivision malocclusion.13 This
variation is probably related to the disharmonious arch width
between maxillary and mandibular dental arches in the premolar
section. The origin of Angle class II subdivision malocclusion is
multifactorial, with dental, skeletal and functional factors included.
The functional deviation occurs, probably due to dental arch width
disharmony. An asymmetric position of the glenoid fossa may
account for most of the skeletal asymmetry. A recent study has also
shown that Angle’s class II, subdivision 2 subjects show a smaller
vertical amount of the centric slide compared to Angle’s class I and
class II, subdivision 1 malocclusion.14
Management
Asymmetries are among the most challenging clinical conditions in
orthodontics both from the point of a quantification and location of
the dysplasia and in arriving at proper mechanics. The goals of
treatment outcome should be based on patient’s perceptions of the
problem and orthodontic needs. The sex and growth status also
influence the choice of treatment.
A patient with asymmetrical occlusion needs careful evaluation of
occlusion, and functional mandibular movements, detailed
cephalometric and radiological evaluation. The dentition is examined
in all three lanes of space.
The maxillary and mandibular arches should be carefully evaluated
to assess the presence of a molar rotation. A mesial-in, that is mesio-
palatal rotation of a maxillary molar may appear as more class II
molar relationship should mesio lingual cusp remaining in the central
fossa of the mandible. A mild class II molar relationship will seem
more severe when associated with maxillary molar in a rotation.
Dental arch forms should be evaluated on the study models are
assessed for symmetry. Median palatal raphe and its projection on the
mandibular arch are used as reference landmarks however in cases
with facial skeletal deformities with severe unilateral cross-bite, MPR
may prove tricky reference plane. The study models can be
photocopied on occlusal view or scanned as 1:1 for evaluation. One
can use symmetry grid over the occlusal surface of the dental arch
(Fig. 71.7.1). The asymmetric occlusion segment should be evaluated
for excessive rotation of the teeth, unusual tip and buccolingual
position in the arch, such as a cross-bite or the excessive buccal-palatal
tip.
FIGURE 71.7.1 Use of symmeterograph.
Shroff and Siegel15 have recommended evaluation of rotation of the

molars by drawing a line along the mesial surface of the molar on
each side of the arch and observe the point of intersection of these two
lines (Fig 71.7.2A). If the right and left molars have the same amount
of rotation, these lines will intersect at the median raphe (Fig. 71.7.2B).
If the right molar is more rotated than the left molar, the lines will
intersect on the right side of the arch (Fig. 71.7.2C).
FIGURE 71.7.2 Assessment of molar rotation.

(A) Trace a line along the mesial surface of the molars on each side of
the arch. (B) If the molar rotation is bilateral and of equal amount, these
two lines will intersect at the median raphe. (C) If the molar rotation is
on one side only, these two lines will intersect on the side of the rotated
molar.
Similarly one needs to be diligent in an evaluation of the excessive

mesial tip of the molars or premolars which may be responsible for
the disturbed occlusal relationship. This can be readily done by
visualisation of the long axis of the segment about the plane of
occlusion (Fig. 71.8).
FIGURE 71.8 Assessment of tip of teeth in the buccal segment.
This can be readily done by visualisation of the long axis of the
segment in relation to the plane of occlusion.
The clinical evaluation of CR and CO discrepancy helps to evaluate

the cause of the disturbed occlusion. Also, the abnormal buccolingual
inclination of the teeth which may or may not be associated with
unilateral buccal cross-bite should be performed on PA cephalogram
(Fig. 71.9).
FIGURE 71.9 The buccolingual axial inclination of the molars.

This is evaluated on study models or PA cephalogram in relation to a
the horizontal line in the frontal plane connecting the right and left
molar. OP, Occlusal plane.
Once the location of the asymmetrical occlusion, teeth involved,

exact nature of the deviation and its severity are located, the plan of
treatment can be formulated with specific goals designed to correct
the asymmetry early during treatment.
Depending on the patient’s age and the severity of the condition, a
variety of orthodontic and orthopaedic options have been described in
the literature.
• Asymmetrical mechanics
■ Molar distalisation
• Asymmetrical extractions
• Asymmetrical orthopaedic appliance activation
• Surgical interventions
Asymmetrical mechanics
Most class II subdivision malocclusion patients present with
mandibular dental midline displaced towards class II side. In such
situations, maxillary dental midline is coincident with the mid-sagittal
plane or shows a mild deviation. Such a clinical situation depicting
mild asymmetry, asymmetrical mechanics and extractions tend to
yield good results.
Asymmetrical mechanics necessarily involves orthodontic non-
extraction treatment whereby heavy class II elastics are used on class
II side and light elastics on class I side. Similarly, the severity of tip
back bends in the maxillary archwire can be enhanced on class II
molar side. Mild class II sub-division malocclusion can be treated with
such mechanics by distal tipping of the maxillary molars and mesial
migration of the mandibular buccal segment resulting in bilateral class
I molar and canine relations. Indiscriminate use of class II elastics on
one side can lead to canting of the occlusal plane.
Molar distalisation (Fig. 71.10)
The correction of unilateral class II molar relation can be achieved by
intraoral molar distalisation. This mode of therapy is useful in
situations of unilateral loss of the arch length caused by mesial
migration of the maxillary first molar. Molar distalisation can be
achieved with intraoral non-compliance appliance which brings about
correction of class II half-cusp relationship to class I.
FIGURE 71.10 A case of unilateral molar distalisation.

Top row: Pre-treatment occlusion. Middle row (left): Shows molar
distalisation with a Jones Jig-type sectional assembly. Right side:
Shows occlusion settlement with a fixed appliance. Bottom row: Stable
occlusion at 15 years of follow-up. Note perfect interdigitation. A mild
midline deviation persists.
Extractions of teeth are a conventional orthodontic means of gaining
the space required to correct potential discrepancies such as crowding
and incisors proclination. However, in situations of existing facial
asymmetry, the extraction pattern may have to be alerted for
compensating existing facial asymmetry. In such situations, the
anchorage control needs to be carefully analysed, so the particular
identified teeth are extracted allowing dental movement and thus
correction.16
Extraction of three first premolars (Figs 71.11,

71.12, 71.13)
Asymmetric extractions in class II subdivision are a usual feature of a
treatment plan. Possible orthodontic treatment approaches include
extractions of three premolars when some retraction of the profile is
allowed. The extraction protocol of two maxillary premolars and one
mandibular premolar on the class I side results in a finished occlusion
with a bilateral class I canine relationship, while maintaining the
original unilateral class II molar relationship on one side.
FIGURE 71.11 Asymmetrical extractions.

Scheme of occlusion with two maxillary and asymmetrical side
mandibular first premolar, i.e. asymmetrical extractions in class II
subdivision malocclusions. This protocol when used with acceptable
maxillary midlines can result in predominantly class I space closure.
The final treatment outcome would be full-cusp class II molar on one
side and class I on another side.
FIGURE 71.12 Asymmetrical extractions.

(A–J) A case of class II subdivision malocclusion on the right side with
mild facial asymmetry with deviation of the mandible to the right.
Source: Reproduced with permission from: Thiesen G, Gribel BF,
Freitas MP. Facial asymmetry: a current review. Dental Press J Orthod
2015;20(6):110–25.
FIGURE 71.12A Corrective orthodontic treatment.
This patient was treated with three extractions (teeth numbers 14, 24
and 34). Extraction in the mandibular arch was recommended for
correction of lower dental midline coinciding with patient’s median
sagittal plane, in addition to correcting protrusion and crowding of
mandibular anterior teeth. Extractions in the maxillary arch were carried
out to correct protrusion, crowding and overjet. Lateral intraoral
photographs on the right side (A), in frontal view (B) and on the left side
(C).
FIGURE 71.12B Treatment outcome with asymmetric extraction
pattern.
(A–J) The protrusion, crowding are corrected. Lower midline is now
coinciding with patient’s median sagittal plane. The molar relationship
is now full-cusp class II with class I canine relation on the right side and
class I molar and canine on the left side.
FIGURE 71.13 Stable occlusion with asymmetric extractions in a
case of class II subdivision malocclusion.
Alternatively, such cases can be treated with extraction of all first

premolars (Figs 71.14, 71.15). This would require a use of class II
elastics more so on the side of the distal positioning of the mandibular
molar to finish in bilateral class I molar and canine relationship. Long
term stability of class II subdivision malocclusion treatment with three
or four premolar extractions is similar with four premolar
extractions.17
FIGURE 71.14 Symmetrical extraction.
The extraction of all first premolars would require the use of class II
elastics to mesialise mandibular first molar to class I relationship.
FIGURE 71.15 Stable occlusion with symmetric extractions, i.e.

all first premolars in a case of class II subdivision malocclusion.
Unilateral maxillary first premolar extraction
This plan of treatment works out well in cases where unilateral class II
molar relationship exists because of mesially migrated maxillary first
molar on one side leading to midline shift and crowding in the
maxillary canine/anterior region. In situations where maxillary molar
distalisation cannot be considered due to the age of the patient or
severity of the crowding, unilateral extraction of the maxillary first
premolar is the treatment of choice. The premolar extraction space is
utilised to finish class II molar relation on the extraction side with
class I intra arch mechanics. This approach will simultaneously correct
the midline.
Growing subjects with subdivision malocclusion can benefit from the
orthopaedic asymmetrical approach. One of the options is the use of
fixed functional appliance with greater activation on more severe class
II molar relation side. Achieving effective correction of asymmetry
using asymmetrical activation of orthodontic and orthopaedic
appliances might be considered an effortful procedure; however,
provided that basic biomechanical principals be followed the use of
asymmetrical resources becomes an ordinary and less intimidating
procedure.3,18
Orthodontic approach to class III malocclusion more so when it is
associated with facial asymmetry would have to be carefully
evaluated for prognostic outcome and stability of results, since most
class III malocclusion have complex underlying skeletal components,
variable shades of genetic aetiology and unpredictable remaining
growth.
Class III malocclusion leading to the mandibular dental midline
deviations may present with anterior teeth in an edge-to-edge or even
cross-bite relationship, with asymmetrical overjet. The option of one
mandibular premolar extraction on the class III side would allow for
primarily class I closure mechanics, and minimise inter-arch elastics.
A drawback to leaving buccal segments in a class III molar
relationship often results in unopposed maxillary second molars. If a
mandibular third molar is present on the class III side, it should be
retained to occlude with the upper second molar. If the third molar
has yet to erupt, a maxillary retention appliance should be designed to
prevent supra eruption of the upper second molar until the third
molar has erupted into occlusion.19
Class III subdivision malocclusion in subjects with a full component
of teeth, past pubertal growth spurt and one which does not have
significant skeletal dysmorphology can be considered for intra arch
lower molar distalisation with mini screw supported anchorage from
retro-molar region.20
Key Points
Asymmetric occlusion can present itself in a variety of spectrum and
severity. Although the above mentioned approaches are well accepted
in clinical practice each case of asymmetry should be carefully
assessed for prognosis before initiation of treatment with an
appliance. The apparent dental asymmetry of occlusion often has a
hidden skeletal component which should be assessed carefully before
attempting any orthodontic treatment.
References
1. Kronmiller JE. Development of asymmetries. Semin
9807149.
2. de Araujo TM, Wilhelm RS, Almeida MA. Skeletal
and dental arch asymmetries in individuals with
normal dental occlusions. Int J Adult Orthodon
Orthognath Surg. 1994;9(2):111–118: PubMed PMID:
7989812.
3. Burstone CJ. Diagnosis and treatment planning of
patients with asymmetries. Semin Orthod.
1998;4(3):153–164: Sep; PubMed PMID: 9807152.
4. SEDENTEXCT. Available from:
http://www.sedentexct.eu/.
Semin Orthod. 1998;4(3):138–145: Sep; PubMed PMID:
9807150.
2014;26(2):129–133: Apr-Jun; PubMed PMID:
25603660.
7. Behbehani F, Roy R, Al-Jame B. Prevalence of
asymmetric molar and canine relationship. Eur J
Orthod. 2012;34(6):686–692: Dec; Epub 2011 Jul 7.
8. Shrestha BK, Yadav R, Basel P. Prevalance of
malocclusion among high school students in
Kathmandu valley. Orthod J Nepal. 2012;2:1–5.
9. Azevedo AR, Janson G, Henriques JF, Freitas MR.
Evaluation of asymmetries between subjects with
class II subdivision and apparent facial asymmetry
and those with normal occlusion. Am J Orthod
PMID: 16527633.
10. Alavi DG, BeGole EA, Schneider BJ. Facial and dental
arch asymmetries in class II subdivision
1988;93(1):38–46: Jan; PubMed PMID: 3422120.
11. Janson GR, Metaxas A, Woodside DG, de Freitas MR,
Pinzan A. Three-dimensional evaluation of skeletal
and dental asymmetries in class II subdivision
malocclusions. Am J Orthod Dentofacial Orthop.
2001;119(4):406–418: Apr; PubMed PMID: 11298314.
12. Sanders DA, Rigali PH, Neace WP, Uribe F, Nanda R.
Skeletal and dental asymmetries in class II
subdivision malocclusions using cone beam
computed tomography. Am J Orthod Dentofacial
Orthop. 2010;138(5):542: Nov; e1-e20; discussion542-3.
13. Li J, He Y, Wang Y, Chen T, Xu Y, Xu X, Zeng H, Feng
J, Xiang Z, Xue C, Han X, Bai D. Dental, skeletal
asymmetries and functional characteristics in class II
subdivision malocclusions. J Oral Rehabil.
2015;42(8):588–599: Aug; Epub 2015 May 5. PubMed
PMID: 25944587.
14. Čimič S, Badel T, Šimunkovič SK, Pavičin IS, Ćatič A.
Centric slide in different Angle’s classes of occlusion.
Ann Anat. 2016;203:47–51: Jan; Epub 2015 Sep 30.
15. Shroff B, Siegel SM. Treatment of patients with
asymmetries using asymmetric mechanics. Semin
Orthod. 1998;4(3):165–179: Sep; Review. PubMed
PMID: 9807153.
16. Thiesen G, Gribel BF, Freitas MP. Facial asymmetry: a
current review. Dental Press J Orthod.
2015;20(6):110–125: Nov–Dec; Review. PubMed
PMC4686752.
17. Janson G, Araki J, Estelita S, Camardella LT. Stability
of class II subdivision malocclusion treatment with 3
and 4 premolar extractions. Prog Orthod.
2014;30(15):67: Dec; PubMed PMID:
25547371;PubMed Central PMCID: PMC4279037.
18. Lindauer SJ, Asymmetries:. diagnosis and treatment
(Editorial). Semin Orthod. 1998;4(3):133.
19. Rebellato J. Asymmetric extractions used in the
treatment of patients with asymmetries. Joe Rebellato
Semin Orthod. 1998;4:180–188.
20. Ma QL, Conley RS, Wu T, Li H. Asymmetric molar
distalization with miniscrews to correct a severe
unilateral class III malocclusion. Am J Orthod
CHAPTER 72
Cant of occlusal plane in
transverse direction
George Anka
O.P. Kharbanda
CHAPTER OUTLINE

Asymmetrical growth of the mandible
Facial asymmetry
Faulty biomechanics
Prevalence
Clinical evaluation
Frontal photographs
Reference planes
MDCT/CBCT
Management
Growing patients with mild cant
Selective intrusion/extrusion of anterior segment
Occlusal cant management supported by TAD
Biomechanics for the canted occlusal plane in the
maxilla
Mandibular arch
Occlusal cant management supported by SAS: a case
study
Key Points
Occlusal plane canting (OC) can occur in both anteroposterior and the
vertical plane. Any canting of occlusal plane in frontal plane affecting
smile aesthetics originates from the vertical plane. In contrast canting
of occlusal plane in frontal plane affecting smile aesthetics originates
from facial asymmetry and/or vertical position asymmetry of the right
and/or left quadrants of the dental arches. Cant of the occlusal plane
more commonly refers to change in the inclination of the occlusal
plane showing a tilt, when viewed from the front (Fig. 72.1).
FIGURE 72.1 An adult who reported asymmetrical show of teeth

during the smile.
A case with class II division 1 malocclusion with excellent soft tissue
compensation resulting in excellent facial profile with lips in resting
position. While smiling, she shows a cant of an occlusal plane on her
left side which extends from left central incisor to second molar teeth.
The left maxillary segment is in infraocclusion in reference to the
palatal plane and occlusal plane on another side.
Although changes in the inclination of the OP in the sagittal plane

are associated with growth and development, changes in the
inclination of the OP in the vertical plane result from asymmetric
growth of the craniofacial structures and lead to an asymmetric OP;
this is defined as OC.1
Many terms have been described to denote this feature of occlusion:
cant, canting, and maxillary cant. Recently Gateno et al. (2015)
described it as roll malrotation.1 van Steenbergen and Nanda
described these clinical features with the term ‘diverging occlusal
planes’.2
The ‘cant of an occlusal plane’ is evaluated in relation to a
horizontal transverse plane formed by a line connecting R–L pupils
when a subject is looking in front. A wooden spatula held between the
teeth (L–R) and its inclination can be visualised in relation to a
horizontal reference plane, most common being the inter-pupillary
line. A cant of more than 4° or above is considered clinically
appreciable.
It has been reported that the detection rate for both untrained and
trained observers surpassed 50% at 3° of occlusal canting. Cants
greater than 4° were detected 90% of the time by untrained observers
and 98% of the time by trained observers. Padwa et al. concluded that
4°, as the threshold at which occlusal cants are detected with greater
than 90% frequency and 3° is the threshold for greater than 50%
frequency.3
Occlusal cants of 0–3° are seen in normal occlusion subjects. The
cant up to 3° will not be noticeable, and occlusal canting of this
magnitude probably does not have detrimental effects on
postoperative outcome. Any efforts to alter this inclination of cant
with restorative or surgical procedures are not desired and may have
an adverse effect on TMJ.3
Asymmetrical growth of the mandible
The asymmetrical growth of the mandible is the primary driver of the
cant and or causation of facial asymmetry, the maxilla follows and
adapts mandible to maintain occlusal contacts between upper and
lower teeth. The consequence is cant of the occlusal plane. Mild cants
can be treated with orthodontics alone, however, if the cant is more
severe, surgical options are the choice of therapy.
Facial asymmetry
Occlusal cant is frequently observed in facial asymmetries, more so
when the growth of the mandible on one side is different from another
side. For example, trauma to TMJ and subsequent unilateral ankylosis
(Fig. 72.2) leading to arrest of the growth, with average growth
occurring on the contra-lateral side, the chin deviates to ipsilateral
side. There is a compensatory adaptation of the maxillary complex to
maintain occlusal contacts, which results in the cant of the occlusal
plane. The vertical growth of the face on the side of trauma is much
less thus exhibiting as cant of the occlusal plane.
FIGURE 72.2 Cant of occlusal plane in a subject with unilateral
ankylosis of the mandible.
This patient has undergone condylectomy of the left side. Note a
deviation of the chin on the affected side.
In contrast subjects with unilateral condylar hyperplasia (Fig. 72.3)

show excessive growth of the condyle and ramus on the affected side
leading to the cant of the occlusal plane. However, the cant direction
is reversed compared to that seen in TMJ ankylosis.
FIGURE 72.3 A case of occlusal plane in a subject with unilateral

condylar hyperplasia of the left side.
The chin has deviated to the right side with a tendency for a cross-bite
of the right buccal segment. The OPG showed an increased length of
the condyle and increased ramus height of the left side. There is an
obvious cant of the occlusal plane with a downward tilt on the left side.
Faulty biomechanics
Canting of the occlusal plane can occur due to the use of asymmetrical
biomechanics during orthodontic therapy, such as midline oblique
elastics, use of class II elastics on one side and class III on another side.
Prevalence
Most facial asymmetries more so those involving the vertical growth
of the mandible would exhibit cant of the occlusal plane. However,
the cant of an occlusal plane may be observed independently of any
significant clinically apparent facial asymmetry which may be first
noticed by the clinician on diligent examination or on PA
cephalometry evaluation. Severt et al. 1997 reported the clinically
apparent facial asymmetry affecting canting of the occlusal plane in
41% (vertical asymmetry) subjects.4 Although many studies are
available on traits of facial asymmetry, independent reporting of cant
of the occlusal plane has remained elusive.
Subjects with suspected or apparent asymmetry are evaluated
through a thorough clinical examination, frontal photographs,
posteroanterior (PA) cephalometry, OPG and 3D imaging techniques,
which include CBCT and non-radiation 3D imaging of the face such as
3dMD.
Clinical evaluation
Clinical evaluation on cant of the occlusal plane is performed with a
simple and yet reliable clinical method. By placing a wooden tongue
blade or ice cream stick across both sides of first molars/premolars,
while a patient is seated upright, his face at eye levels of the operator,
the left to right inclination of the spatula is evaluated in relation to an
imaginary line connecting the pupils. The relationship of the
transverse occlusal plane and inter pupillary line can be readily
appreciated (Fig. 72.4A). The detailed extraoral examination is
followed by an intraoral examination to record asymmetry in an
overbite, arch form, and levels of buccal occlusion.
FIGURE 72.4 A severe case of cant of occlusion plane in an

operated case of unilateral cleft lip and palate.
(A) Clinical evaluation of cant of occlusal plane. A wooden spatula/or a
steel ruler is held between the teeth (L–R) and its inclination can be
visualised in relation to a horizontal reference plane. A horizontal
reference plane is constructed by connecting right and left supraorbital
arches or inter-pupillary line. (B) Evaluation of cant of the occlusal
plane on a frontal facial photograph taken during a smile. A case of
occlusal plane cant in a subject with unilateral condylar hyperplasia of
the right side.The chin has deviated to the left side with a tendency for
a cross-bite of the left buccal segment. There is an obvious cant of the
occlusal plane with a downward tilt on the right side.
Frontal photographs
The evaluation of frontal facial photograph is a diagnostic tool used to
evaluate soft-tissue asymmetry and lip cant (Fig. 72.4B). A detailed
clinical and radiological evaluation of the TMJ is essential in such a
patient (Fig. 72.5).
FIGURE 72.5 Radiological evaluation of a patient with a cant of

the occlusal plane.
(A) The right side condyle is long and thin. (B) PA cephalogram is
showing mandibular deviation towards the left. (C) Technicium scan
shows a hot spot in the right condyle suggestive of active growth and
possibility of further growth and thereby worsening of the facial
asymmetry with age.
Posteroanterior (PA) radiography is necessary for the evaluation and
objective measurement of occlusal plane cant (Fig. 72.6). Analysis of
PA radiograph allows easy visual comparison of asymmetry. The
most commonly used asymmetry analyses are Grummons front
analysis (Fig. 72.6A) and simplified Grummons frontal asymmetry
analysis (Fig. 72.6B).5,6 These analyses demonstrate the parallelism
and asymmetry of facial points and planes according to a pre-
determined mid-sagittal reference plane. The frontal analysis is useful
in the quantitative evaluation of the right to the left asymmetry of the
facial structures. However, the effectiveness of PA radiographs maybe
compromised by head rotation or improper landmark identification,
therefore, a close technical supervision and adherence to protocol are
required during obtaining a PA cephalogram.
FIGURE 72.6 (A) Simplified Grummons analysis. Landmarks and

planes: Point CO right and left. Point Fr right and left. Point NC right
and left. Occlusal plane (OP) occlusal of the maxillary first molars on
either side. Points J–J′: width of the maxilla. Points Ag–Ag: width of the
mandible. Point menton: Me to evaluate asymmetry at the chin in
relation to MSR. A mid-sagittal reference (MSR) plane and a horizontal
reference plane are used for measuring facial asymmetry and cant of
occlusal plane according to simplified Grummons analysis. A mid-
sagittal reference plane (MSR) is drawn using the following landmarks:
i. Bisect crista galli (Cg) or nasion (Na). ii. Bisect anterior nasal spine
(ANS). iii. Extend beyond chin (Me). (B) Simplified Grummons’ analysis
involves evaluation of inclination of OP to the maxillary base, that is JJ
and deviation of chin and maxilla in relation to MSR plane. Any
discrepancy in vertical placement and transverse dimensions between
two halves of the maxilla and mandible can be graphically visualised.
Reference planes
The reference lines for determining the cant are as follows:
1. A true horizontal represented by a tangent to the normal

supraorbital rims
2. A vertical line is drawn through the crista galli and upper third
of the nasal septum representing mid-sagittal reference plane.
The tilt of the occlusal plane to the true horizontal plane is

measured as the angle of cant of the occlusal plane.
Research studies have confirmed that, in patients with facial
asymmetry in the frontal plane, the degrees of occlusal cant relative to
the true horizontal measured cephalometrically is equal to the linear
difference, in millimetres, between the vertical length of the right and
left sides of the maxilla.7 Therefore in a clinical situation, the
magnitude of occlusal cant can be measured by evaluating the medial
canthus-canine distance. In the patient ‘X’ (Fig. 72.7), the medial
canthus to right canine distance was 62 mm; the distance to the left
canine was 56 mm, for a total vertical discrepancy of 6 mm.The degree
of cant is determined with respect to the true horizontal plane. On this
PA cephalogram, the degree of canting of the occlusal plane was 6°,
and it was equal to the difference in vertical discrepancy as measured
clinically.
FIGURE 72.7 Measurement of occlusal cant in the maxilla.
(A) The magnitude of occlusal cant by measuring the degree of canting
relative to the true horizontal. The reference lines for determining the
cant are as follows: a true horizontal represented by a tangent to the
normal supraorbital rims (1) and a vertical line drawn through the crista
galli and upper third of the nasal septum (2). The degree of cant is
determined with respect to the true horizontal. On this PA
cephalogram, the degree of canting of the occlusal plane was 6°. (B)
The magnitude of occlusal cant can be measured by evaluating the
medial canthus-canine distance. In the patient above, the medial
canthus to right canine distance was 62 mm; the distance to the left
canine was 56 mm, for a total vertical discrepancy of 6 mm. Source:
Susarla SM, Dodson TB, Kaban LB. Measurement and interpretation of
a maxillary occlusal cant in the frontal plane. J Oral Maxillofac Surg
2008 Dec;66(12):2498–502. Reproduced with permission.
MDCT/CBCT
Three-dimensional computed tomography (CT) can provide
information for use in diagnosis and treatment planning (Fig. 72.8).8
Because of the complex 3D nature of facial asymmetry, CT scan can be
recommended in the evaluation of asymmetry cases that cannot be
assessed using conventional methods. CBCT could be a preferred
mode of diagnosis over MDCT owing to lower radiation doses.
FIGURE 72.8 Cant of occlusal plane as viewed on CBCT
volumetric image.
The cant is caused by roll malrotation of the maxilla.
Management
Growing patients with mild cant
In young patients, asymmetry of the occlusal plane caused by
infraocclusion of dental units in a buccal segment on one side can be
treated using the fixed bite plate. The fixed bite plane on molars is
used for the purpose of increasing the vertical dimension of occlusion
to relieve interferences. These can be managed with a fluoride
releasing ionomer cement blobs. These glass ionomer bite lifters can
be either on the maxillary or mandibular posterior teeth, selectively,
described by Grummons as a ‘turbo’. The turbo allows contralateral
teeth in infraocclusion to erupt to the level of transverse cant of the
occlusal plane.9,10
The correction of altered occlusal plane requires a complex
biomechanics in all the four buccal quadrants. While on one side
maxillary buccal segment requires intrusion of maxillary segment and
extrusion of the mandibular segment on other side reverse
movements are required to correct the transverse tilt of the occlusal
plane (Fig. 72.9).
FIGURE 72.9 The correction of altered occlusal plane.
Selective intrusion/extrusion of anterior

segment
van Steenbergen and Nanda2 suggested the use of vertical inter-arch
elastics to extrude the buccal segment on the side of the occlusal plane
that is farthest from the treatment occlusal plane. The inter-arch
multiple vertical elastics exert reciprocal extrusive forces on maxillary
and mandibular arches. This option works best when both upper and
lower occlusal planes are equally diverging, and the treatment plan
calls for extrusion. However, in the majority of the patients, the
problem is limited to either the upper or the lower arch, or isolated to
anterior or posterior segments.2
Asymmetrical intrusion of incisors followed by individual intrusion
of the of diverging occlusal planes
I. The selective intrusion of the anterior segment [Fig. 72.10 (1)]. A

canted maxillary anterior occlusal plane with asymmetrical
deep bite can be corrected with the intrusion of the extruded
teeth. One-piece intrusion arch of 0.017 × 0.025-in. titanium
molybdenum alloy (TMA) wire is used that is engaged with
molars as anchors. The teeth in anterior segment requiring
intrusion are selectively ligated. Light intrusive force level of
approximately 60 gm for four maxillary incisors and about 50
gm or less for four mandibular incisors has been
recommended.2 Extruded canines are taken care of as a stage II
at the completion of the incisor intrusion [Fig. 72.10 (2)]. A
simple cantilever (0.017 × 0.025-in. TMA) wire extending from
auxiliary molar tube exerting a light force of 20–25 gm can
effectually level the extruded canine2.
II. The selective extrusion of the anterior segment [Fig. 72.10 (3)].
Patients without deep overbite problem would require
extrusion of selected teeth. A unilateral cantilever arch
prepared with TMA wire of 0.017 × 0.025 in. with light
extrusive forces can be effectively used for the purpose. A light
force of approximately 30 gm is sufficient.2
FIGURE 72.10 Correction of cant with intrusion arch by selective
ligation of affected teeth.
(1) Intrusion arch with selective ligation of extruded teeth to level cant
of occlusal plane in the anterior segment. (A) TMA intrusion arch 0.017
× 0.025 in. comes from a molar auxiliary tube and is tied to one side of
the anterior segment (0.018 × 0.025-in. stainless steel) delivering
intrusive force on that side. (B) Activated intrusion arch, before ligation
on anterior segment. (C) Intrusion arch tied on one side only. (2) An
intrusion of the canine can be taken up separately. (A) Anterior view of
separate canine intrusion. 0.018 × 0.025-in. stainless steel arch wire
bypasses canine. A 0.017 × 0.025-in. TMA cantilever comes from the
molar auxiliary tube and is tied underneath canine bracket (point force
contact) delivering intrusive force. (B) Buccal view of separate canine
intrusion. Ideally, the wire should not be tied into bracket slot to deliver
force without moments. (C) Buccal view of separate canine intrusion.
(3) Extrusion arch with selective ligation to intrude teeth to level the
cant of occlusal plane in the anterior segment. (A) Diagrammatic
representation of unilateral extrusion of the canted anterior segment.
0.017 Å–0.025-in. TMA cantilever coming from an auxiliary tube of
molar is tied to one side of the anterior segment. (B) Patient with a
canted maxillary occlusal plane. (C) Correction of the canted occlusal
plane with cantilever hook tied on the affected side. Source:
Reproduced with permission from: van Steenbergen E, Nanda R.
Biomechanics of orthodontic correction of dental asymmetries. Am J
Orthod Dentofacial Orthop 1995;107(6):618–24.
Occlusal cant management supported by TAD
Temporary anchorages devices can be optimally utilised to support
orthodontic biomechanics for the purpose of selectively intrusion of
the maxillary segment on one side and mandibular teeth on another
side thereby allowing the cant to be corrected (Fig. 72.11).
FIGURE 72.11 TAD supported biomechanics employed for

selective intrusion of anterior segment. Source: Polat-Özsoy Ö,
Arman-Özçırpıcı A, Veziroğlu F, Çetinşahin A. Comparison of the
intrusive effects of miniscrews and utility arches. Am J Orthod
Dentofacial Orthop 2011 Apr;139(4):526–32. PubMed PMID:
21457864.
In general, TAD supported mechanics can decrease or increase the

vertical height of nearby alveolar bone, with a maximum of 3 mm
impaction potential, and 1–2 mm possible extrusion. Alveolar dental
impaction leads to counter clockwise rotation of 3°. Xun. et al.10
reported intrusion of the maxillary and mandibular molars of 1.8 and
1.2 mm, respectively, and a 2.3° counter clockwise mandibular
rotation.
The mandibular occlusal plane manoeuvring is comparatively less
effective compared to the maxilla. In the maxilla the intrusion control
is a possibility with possible biomechanics from palatal and buccal
side simultaneously. At present, we are able to intrude the
mandibular occlusal plane less than 2 mm. The skeletal anchorage
system (SAS) allows greater and more effective intrusion in both the
arches however the placement of SAS mini plates will require
additional surgical procedures.
Mechanics of selective intrusion and extrusion of the buccal alveolar
segments involves use of the TAD supported anchorage usually in
two stages. The maxillary TADs are used for intrusion and
mandibular TAD are used for intrusion of lower buccal teeth on
contralateral side. In the second stage, these TADS can be used to level
the arch by extrusion of the teeth from opposite arches. In the maxilla
intrusion mechanics can be applied simultaneously from two sides,
that is palatal and buccal and in the mandible, the only options are
buccal sites.
The orthodontic options work only with select cases however when
asymmetry is deeper beyond dentoalveolar structures surgical options
are unenviable.
Biomechanics for the canted occlusal plane in

the maxilla
With possibilities and ease of placement of miniscrew implants (MSI)
in labial or buccal and palatal region of maxilla selective intrusion of
the anterior segment and molars is a possibility. For intrusion of the
maxillary anterior segment, MSI(s) are placed at the most logistic
position in the buccal cortical bone between the incisors/canine and
first molar to take maximum advantage.
For molar intrusion, palatal placement of MIS is preferred. The
palate offers larger interdental space between the roots of the second
premolar and first molar. The palate is preferred site also because of
the large area of keratinised mucosa. Typically, bilateral TADs are
placed about 5–10 mm away from gingival margin between roots of
the second premolar and first molar. The transpalatal arch with hooks
is constructed with lingual arms that can be used for application of the
force module. Typically, a power chain through the hooks generates
the intrusion force. The force vectors can be modified for distal molar
movement and intrusion of the molars (Fig. 72.12).
FIGURE 72.12 Appliance design for intrusion of buccal segment

supported with palatal TAD and a modified palatal arch.
The cases requiring extrusion and distalisation, the length of the

hook can be so extended so that the sum of the force vector will go
upward. The force will extrude the molars as well as distalise the
posterior teeth. The extruded molars produce a wedge-like effect. The
distal driving and extrusion of the molars effect the correction of the
deep bite. A different force mechanic between left and right side can
be generated by a variable length of hooks between the two sides to
cause intrusion on one side and extrusion on the other side. The
smaller arm will cause intrusion, while the more extended arm is used
for molars’ extrusion.
The correction of cant of the occlusal plane by the intrusion or
extrusion involves all the four quadrants of the dentition, that is left
and right, upper and lower buccal segments. In addition, the anterior
segments also require the corresponding alteration to balance the
aesthetics. Although the condyle in the glenoid fossa maintains a
fluctuating relationship with synovial fluid and can endure forces and
adapt well within a specific amount of displacement in the vertical
dimension, as a rule, the orthodontic biomechanics should be directed
to influence all the four quadrants of dentition and aim for a
functionally balanced occlusion. The only exception can be if the new
location is less than 2 mm although the adaptation can be very
individual for each person. After the correction of occlusal plane, the
mandibular dentition and TMJ slowly adapt to the new position
which is primarily governed by the maxillary dentition. The
functional adaptations of TMJ take a long time. A functionally
balanced occlusion is the key to the health of the TMJ.11,12
Mandibular arch
Compared to the posterior teeth of the maxilla, the manipulation of
the lower molars can be difficult due to an insufficient alveolar bone
height which limits the intrusion of teeth in this region. Orthodontic
correction of cant of the occlusal plane by intrusion or intrusion of the
molars should be considered with these limitations in mind.
Once the intrusion of the maxillary buccal segment is achieved, the
mandibular segment will need extrusion. These movements can either
be achieved by the natural eruption of teeth or by active mechanics.
These movements of teeth can be achieved with biomechanics
supported by MIS. The intrusion can be achieved with direct force
arising from MIS to an individual tooth or a group of teeth. In such
situations, a segmental archwire is tied to the teeth being intruded.
Skeletal anchorage system (SAS) is more useful for the intrusion of
lower teeth.
The MSI-supported appliance design entails a lingual arch and
buccal hooks. The lingual arch maintains the intermolar width and
restrains untoward forces so that biomechanics used for their
intrusion/extrusion is effective. In most cases in the correction of
malocclusion, we must deal with the 3D movement of which the
biomechanic can be complicated. In cases where we can be sure that
the proper force can be generated to a safe performance, then the
lingual arch can be eliminated to lessen the amount of force and thus
will ease the manipulation of the appliances (Fig. 72.13A).
FIGURE 72.13A Biomechanics of MSI-supported molar

intrusion/extrusion.
The lingual arch (LA) plus extended arm: the blue arrows indicate the
possibilities of intrusion and extrusion forces from the MSI. The
distalisation arm is extended anterior and inferior to the MSI. The force
generated between distalisation arm and MSI using power chain leads
to en-masse movement of the mandibular arch.
Case study 1
A case of cant of occlusal plane and deviation of the chin to left side
causing asymmetry are depicted in Fig. 72.13B (1–3). The legends
explain step-by-step biomechanics of the management.11 Occlusal cant
management supported by SAS use of mini plates to intrude
maxillary segment and extrude mandibular segment.
FIGURE 72.13B Management of canted occlusal plane with TAD.
(1) Pre-treatment records of a 13 years 8 months old female with chief
complaints of crowding. She has upper left lateral incisor in linguo-
version leading to functional deviation of the mandible to the left
leading to asymmetric mandibular body growth. The malocclusion has
a significant tilt of the occlusal plane which is more evident on PA
cephalogram. (2) Palatal TADs and transpalatal arch in situ. The
mechanics was employed for control of the maxillary occlusal plane
with the TPA (transpalatal arch) and hooks, with the left buccal side
slightly intruded. (3) Post-treatment records show improved smile due
to correction of occlusal cant.
Case study 2
A case of cant of occlusal plane and crowding in the maxillary arch
(Fig. 72.13C).
FIGURE 72.13C (1) The chin and the mandibular midline have
deviated towards the right side. (2) The TAD palatal arch assembly for
the intrusion of right buccal segment and extrusion of the left buccal
segment. Note the length difference between right and left lingual arms
extended from the palatal miniscrew assembly. The shorter arm (right
side) is designed for intrusion and the more extended arm (left side) for
extrusion. (3) MEAW technique was used to balance the cant of
mandibular buccal segments to maintain the occlusal contact with the
changing maxillary occlusal plane. (4) Post-treatment photographs
show profile changes and normalisation of the occlusal cant. (5) Pre-
and post-treatment PA cephalogram. The orthodontics treatment
effects are limited to the dentoalveolar segments.
Occlusal cant management supported by SAS:
a case study
Use of mini plates to intrude maxillary segment and extrude
mandibular segment
The mini plates offer robust anchorage system when implanted
after due consideration of the health of soft tissues and bone. Farret
and Farret13 have reported the successful management of a 29-year-
old woman with class II malocclusion, pronounced midline deviation
and accentuated occlusal plane inclination caused by mandibular
deciduous molar ankylosis [Fig. 72.14 (1–8)]. The patient was treated
with a miniplate to provide anchorage in order to intrude maxillary
teeth and extrude mandibular teeth on one side, thus eliminating
asymmetry. Miniplate anchorage was also used to distalise molar to
correct class II malocclusion on the same side. Authors used miniplate
in the shape of a Y which was inserted in left zygomatic buttress. The
direct anchorage from Y plate was utilised for an effective intrusion of
the maxillary left teeth, with elastics connected to 0.019 × 0.025-in.
wire segments inserted into a tube and connected to a miniplate,
generating a force of 200 g on each side.
FIGURE 72.14 Use of Y plate skeletal anchorage system in an
adult with a cant of the occlusal plane.
(1) Pre-treatment 29-year-old woman with class II malocclusion,
pronounced midline deviation. (2) Pre-treatment intraoral records are
showing class II bilateral molar relations with missing left maxillary
lateral incisor and accentuated occlusal plane inclination caused by
mandibular deciduous molar ankylosis. (3) Pre-treatment records show
ankylosed second deciduous molar on the left side has caused tilting of
the neighbouring teeth. (4) The patient was treated with a miniplate
used to provide anchorage in order to intrude maxillary teeth and
extrude mandibular teeth on one side, thus eliminating asymmetry.
Class II molar relationship was corrected on the left side employing
distalisation, anchored in the miniplate as well. On the right side,
maxillary first premolar was extracted and the molar relationship was
kept in class II, while canines were moved to class I relationship. The
patient received implant-prosthetic rehabilitation for maxillary left lateral
incisor and mandibular left second premolar. (5) (A–B) Intraoral
mechanics employed to level cant of the occlusal plane. (C–D) After
maxillary right buccal segment intrusion elastics were employed to
extrude left maxillary buccal segment (E–G). (H–J) Occlusion after
mandibular extrusion and during finishing. (6) Post-treatment profile
and smile photographs show midline is symmetric and consonant
smile. The smile is commissural, class II was corrected, midlines were
matched and the canted occlusal plane was totally corrected, thereby
improving smile function and aesthetics. (7) Post-treatment results
show bilateral class I molar and canine relationship. Centre lines are
aligned. The missing left maxillary lateral and lower second premolar
have been substituted with implant prosthesis. (8) Post-treatment
panoramic radiograph, lateral cephalogram, cephalometric tracing, total
superimposition, maxillary superimposition and mandibular
superimposition. Source: Reproduced with permission from Farret MM
and Farret MM. Class II malocclusion with accentuated occlusal plane
inclination corrected with miniplate: a case report. Dental Press J
Orthod. 2016 Jun; 21(3):94–103.
Surgical options for the treatment of the canted occlusal plane usually
involve bijaw surgery both in maxilla and mandible. A comprehensive
description is given in part IV of the the chapter on facial
asymmetries.
Key Points
Transverse canting of occlusal plane is a clinical presentation of an
underlying complex structural deviation of asymmetry of maxillary-
mandibular complex, more so in vertical dimensions. The maxillary
cant represents an adaptation of the maxilla to unequal ramus heights.
When canting is limited to dentoalveolar structures and mild, it can be
effectively managed with orthodontic options.
Most facial asymmetries may have a component of cant of the
occlusal plane. Orthodontics options in such situations are limited or
contraindicated. Therefore a thorough clinical examination and
discussions with the surgeon and patient are necessary before any
attempt is made to correct the cant of the occlusal plane.
References
1. Gateno J, Alfi D, Xia JJ, Teichgraeber JF. A geometric
classification of jaw deformities. J Oral Maxillofac
Surg. 2015;73(12 Suppl):S26–31: PubMed PMID:
2. van Steenbergen E, Nanda R. Biomechanics of
orthodontic correction of dental asymmetries. Am J
3. Padwa BL, Kaiser MO, Kaban LB. Occlusal cant in
the frontal plane as a reflection of facial asymmetry. J
Oral Maxillofac Surg. 1997;55(8):811–816: discussion
817. PubMed PMID: 9251608.
frontal asymmetry analysis. J Clin Orthod.
1987;21(7):448–465: PubMed PMID: 3476493.
6. Grummons D. Facial asymmetry and frontal analysis.
Clin Impr. 1998;8(3):2–9: Published by ORMCO.
7. Susarla SM, Dodson TB, Kaban LB. Measurement
and interpretation of a maxillary occlusal cant in the
frontal plane. J Oral Maxillofac Surg.
2008;66(12):2498–2502: PubMed PMID: 19022130.
8. Park SH, Yu HS, Kim KD, Lee KJ, Baik HS. A
proposal for a new analysis of craniofacial
morphology by 3-dimensional computed
2006;129(5): 600 e23-34 May; PubMed PMID:
16679198.
9. Grummons D. Frontal facial asymmetry information
presented at the AAO meeting, Las Vegas, May 2006.
10. Xun C, Zeng X, Wang X. Microscrew anchorage in
skeletal anterior open-bite treatment. Angle Orthod.
2007;77(1):47–56: PubMed PMID: 7029531.
11. Kuroda S, Tanimoto K, Izawa T, Fujihara S, Koolstra
JH, Tanaka E. Biomechanical and biochemical
characteristics of the mandibular condylar cartilage.
Osteoarthritis Cartilage. 2009;17(11):1408–1415.
12. Okeson JP. Management of temporomandibular
disorders and occlusion. 6th ed. St. Loius, MO:
Elsevier; 1985: p. 2-8.
13. Farret MM, Farret MM. Class II malocclusion with
accentuated occlusal plane. inclination corrected with
miniplate: a case report. Dental Press J Orthod.
2016;21(3):94–103: PubMed PMID: 27409658; PubMed
CHAPTER 73
Asymmetries of the face
Mithran Goonewardene
O.P. Kharbanda
CHAPTER OUTLINE

Chin: the hallmark of facial symmetry
Cranial base facial asymmetry
Unilateral TMJ sounds and facial asymmetry
Airway and facial asymmetry
Muscular asymmetry
Functional asymmetry of the face
Prevalence
Structural classification by Reyneke
TML classification
Geometric classification
Classification based on ramus length and chin deviation
Aetiology
Radiographs
3D evaluation
Management strategy
Key Points
Asymmetry of the craniofacial skeleton is a complex morphological
variation resulting from variable etiological factors and interplay
growth disturbance. It is often masked by the compensating growth of
the facial bones, adaptive response to respiration and other functional
needs of the stomatognathic system, soft tissue compensation and
alteration in head posture. Facial symmetry has functional and
aesthetic implications. The facial asymmetry could involve skeletal of
the craniofacial region affecting occlusion, muscular or affecting soft
tissues of the face. Orthodontists deal with facial asymmetry of
skeleton and occlusion. A patient presenting with facial deformities of
asymmetry may have camouflaged the appearance by alterations in
hair do, cosmetic procedures and head posture.
Treatment of facial asymmetry varies from no treatment to
complicated craniofacial surgery depending upon the severity of the
problem, social and aesthetic concerns, compromised functions of the
stomatognathic system and additional morbidity. Besides
orthognathic surgery, additional procedures are often needed to mask
soft tissue asymmetry. These include fat grafts and Botox injections.
Chin: the hallmark of facial symmetry

Facial symmetry is first evaluated with chin point or menton, the
hallmark of facial asymmetry (Fig. 73.1).1 Facial asymmetry has been
perceived to be clinically relevant when chin/menton deviation is by 4
mm or menton deviations of 4.28 and more2,3 (Table 73.1).
FIGURE 73.1 Chin: the hallmark of facial symmetry. Facial symmetry
is first evaluated with chin point or menton. Facial asymmetry has been
perceived to be clinically relevant when chin/menton deviation is by 4
mm or menton deviations of 4.28 and more.
Table 73.1
Major causes of facial asymmetry4,15–21
Haraguchi et al.4 considered subjects with a deviation of more than
2 mm from the facial midline associated with any of the four
landmarks (ANS, U1, L1 and Me) as asymmetric when measured on a
posteroanterior (P–A) cephalogram. Subjective evaluation of the facial
asymmetry can be hindered by soft tissue compensation, such as the
masseter muscle. Therefore, in contrast, subjects who exhibit no
asymmetry in skeletal measurements but are subjectively judged as
needing treatment should be accounted for soft tissue laterality.
Cranial base facial asymmetry
Computed tomography studies of craniofacial morphology in subjects
with facial asymmetry revealed that even though facial asymmetry is
accompanied by various degrees of cranial base asymmetry, severity
of cranial base is not dominant in determining the severity of facial
imbalance. The compensatory growth of maxilla facial region may
camouflage the cranial base asymmetry.5
Unilateral TMJ sounds and facial asymmetry

Asymmetry in the development of the mandible, glenoid fossa and
the presence of unilateral TMJ sounds are a possible indicator of facial
asymmetry even when the dominant side is the affected one, and
there have been mechanisms compensating for it.6 Unilateral TMJ
sounds when present can be associated with asymmetries of the
glenoid fossa, mandibular and maxillary structures that derive from
differences in size and inclination with the mandibular ramus being
the most affected structure. The absences of TMJ sounds, however, do
not rule out absence of facial asymmetry.
Airway and facial asymmetry

Asymmetry of the craniofacial skeleton also affects upper airway
structures and their function. It has been reported that
underdevelopment side of the nostril and nasal fossa are narrow
while para-nasal sinuses are frequently larger.7
Muscular asymmetry
In major facial asymmetries, soft tissue drape over the skeletal
deformities is similarly affected. In certain clinical situations, soft
tissue compensations may mask the severity of the conditions. Facial
asymmetries limited to soft tissue are rare though hypertrophy of the
masseter muscle, neurofibromatosis and traumatic injuries affecting
soft tissue may be more prominent and limited to soft tissues of the
face.
Functional asymmetry of the face

Facial asymmetry with an isolated functional component can be seen
as chin deviation in centric occlusion, while on opening the mandible
the facial mid line and chin line coincide (Fig. 73.2). This clinical
situation is often seen during mixed or early permanent stage of
dentition development and could be caused by deflection of the
mandible on closure due to premature contacts such as incisor cross-
bite or unilateral posterior cross-bite. In certain situations, the
deflection in the path of closure may lead to aberrant development of
the facial structures leading to skeletal deformity.
FIGURE 73.2 Functional asymmetry of the face. Facial asymmetry

with an isolated functional component can be seen as chin deviation in
centric occlusion, while on opening the mandible the facial midline and
chin line coincides.
Functional jaw deviations could result from excessive mandibular
growth as seen in skeletal class III subjects where incisors
interferences may cause jaw deviation to either side.
It is pertinent to mention here that not two facial asymmetries are
the same with each having a unique variation of morphological and
functional variations.
Prevalence
Among early studies, Severt and Proffit reported that in 1460 patients
at the University of North Carolina, 34% of individuals were found
with a facial asymmetry, with a deviation of the chin being the most
remarkable feature. Deviation of the chin was present in 74% of
asymmetrical patients.8 In a study in Brazil among 171 patients
requiring orthognathic surgery, a prevalence of asymmetries was
32%.9
With the 3D studies now available, data suggests a higher
prevalence of facial asymmetries than reported on examination. X-ray
investigations with CBCT measurements have recorded higher values
compared to clinical evaluation.
In general, the mandible shows a greater prevalence of asymmetry.
In a CBCT study of 250 skeletal class, I subject with CBCT, a high
prevalence of asymmetry was noted in subjects with class I occlusion.
The deviation of gnathion (Gn) to mid-sagittal plane (MSP) of less
than 2 mm asymmetry was seen in 56.4%, up to 2−5 mm in 34% and <
5 mm was seen in 9.6% of sample.10
Facial asymmetry does affect the craniofacial skeleton in any/all the
three planes of space. However, it is most easily assessed in the full-
face or frontal view. Several classification systems have been devised
to assist in the management of facial asymmetry (Boxes 73.1–73.2,
Table 73.2).
Box 73.1 The categorisation of facial asymmetry

by Reyneke (1997)
Type Asymmetry caused by asymmetry of the symphysis of the mandible.
I The maxilla and the body of the mandible are symmetric with the dental midlines in the
centre of the face.
Type Facial asymmetry in which the discrepancy is primarily in the body, ramus or condyle of the
II mandible. The maxillary dental midline coincides with the facial midline and the
mandibular dental midline coincide with the symphysial midline.
Type Asymmetry in which the maxillary midline is still coincident to the facial midline, but the
III mandibular midline is asymmetric to the maxillary midline and the symphysis is still more
asymmetric to the mandible.
Type Facial asymmetry, in which the discrepancy involves the maxilla, mandible and the
IV symphysis. The maxillary midline is asymmetric to the facial midline while the body of the
mandible to the maxillary midline is further asymmetric (mandibular midline is
asymmetric), and the mandibular symphysis is asymmetric to the body of the mandible.
Type Depicts facial asymmetry caused by a cant in the occlusal plane while the maxillary and
C: mandibular dental midlines and symphysis\coincide.
Type C can be superimposed on type I, type II, type III, and type IV to create subtypes IC, IIC,
IIIC, and IVC.
Box 73.2 TML classification: in this system

transverse hard tissue asymmetry was defined as
distance of MSR from gonion (DG) greater than
2.0 mm
Table 73.2
Jaw deformity nomenclature

Attribute Aspect Terms
Size Too big Hyperplasia, macrognathia, macrogenia
Too small Hypoplasia, micrognathia, microgenia
Position Anteroposterior Prognathism, retrognathism Laterognathia
Transverse Excessive downward displacement, institution download
Vertical displacement
Orientation Malrotation
Shape Distortion
Completeness Agenesis, cleft, defect
Symmetry Object Asymmetry
Alignment Asymmetric alignment
Source: Gateno J, Alfi D, Xia James J, Teichgraeber John F A Geometric

Classification of Jaw Deformities. J Oral Maxillofac Surg.
2015;73:S26−S31.
Structural classification by Reyneke

Reyneke et al. in 1997 suggested that once growth of the facial
complex is completed, clinical presentation of the facial asymmetry
has overriding consideration in the management irrespective of their
aetiology. In other words, correction of the maxillo-mandibular bony
complex does not differ appreciably for etiologically different
asymmetries with similar clinical presentations when growth is not a
contributing factor.11 Based on his observations and practice, he
suggested a simple and a practical classification that addresses the
aesthetic and the structural discrepancy of maxillo-mandibular
asymmetry irrespective of cause Fig. 73.3.
FIGURE 73.3 Facial asymmetry.
Structural classifications by Reyneke.11
TML classification (Fig. 73.4)

TML classification has been proposed by Kim and his group in 2014. It
involves a categorisation of deviation with Transverse asymmetry (T),
Maxillary cant (M), and Lip cant (L).12 Though efficacy of the
classification is now being evaluated, the authors believe that
analysing such patients’ facial asymmetry with the new classification
system presented in this study and employing surgical methods
appropriate for each case would help to achieve a more harmonious
aesthetic outcome. In this system, transverse hard tissue asymmetry
was defined as deviations greater than 2.0 mm.
FIGURE 73.4 TML classification.
It involves categorisation of deviation with Transverse asymmetry (T),
Maxillary cant (M), and Lip cant (L). (A) Reference landmarks and lines
of the soft tissue (R: right, L: left). EC: external canthus; Pm: midpoint
of pupil; SG: soft tissue gonion; UStm: upper stomion; LC: lip
commissure; SMm: soft tissue mandibular midline point. (B) Reference
landmarks and lines of the hard tissue (R: right, L: left). M: molar point;
Mm: menton point; G: gonion; Lo: latero-orbitale; CG: crista galli; ANS:
anterior nasal spine. Source: Reproduced with permission from Kim JY,
Jung HD, Jung YS, Hwang CJ, Park HS. A simple classification of
facial asymmetry by TML system. J Craniomaxillofac Surg 2014
Jun;42(4):313-20. (C) Classification of facial asymmetry according to
the combination of menton deviation and transverse asymmetry (T-
group). (D) Subclassification of transverse asymmetry (T-group)
according to direction of angle prominence in soft vs. hard tissue. (E)
Classification of asymmetry according to the combination of menton
deviation and maxillary canting (M-group). (F) Classification of
asymmetry according to the combination of soft tissue menton
deviation and lip canting (L-group).
Geometric classification
Gateno et al. (2015) proposed a geometric classification of jaw
deformities.13 They grouped jaw deformities according to (1) size (2)
position (3) orientation (4) shape (5) completeness and (6) symmetry.
Classification based on ramus length and chin

deviation (Fig. 73.5)
Hwang14 have proposed a simple classification based on menton
deviation and ramus length. Facial asymmetry is classified into four
groups: RM (Ramus Menton), M (Menton), RA (Ramus Angle), and B
(Bulkiness).These groups are based on menton deviation and ramal
length differences on frontal cephalograms. This classification allows
the clinician to determine the cause of a given asymmetry and to
formulate a proper treatment strategy of facial asymmetry patient.
FIGURE 73.5 Classification based on Ramus length and chin
deviation.
Facial asymmetry is classified into four groups: RM (Ramus Menton),
M (Menton), RA (Ramus Angle), and B (Bulkiness).
Aetiology
The morphological asymmetry of face usually involves maxilla,
mandible and extend deep into sphenoid bone and cranial base in
other instances. Morphology of asymmetrical face has an embryonic
and developmental origin, affecting facial development during early
embryogenesis. In other instances the facial asymmetry could be
acquired due to pathological conditions such as neoplasia of condyle
or consequent to facial trauma (Fig. 72.2), poorly united fractures (Fig.
73.6) of the facial bones or condyle. In the literature, a number of
causal factors have been highlighted in the development of facial
asymmetries.
FIGURE 73.6 Facial asymmetry consequent to malunited facial

fracture.
Causes of facial asymmetry can be grouped into three main

categories: (I) congenital, of prenatal origin; (II) acquired, resulting
from injury or pathological conditions of the jaws and facial tissues
and (III) developmental, arising during development and of unknown
aetiology.
• Clinical examination
■ Facial photos (Fig. 73.7)/3D facial photos 3dMD
■ Functional examination
• Radiographs
■ PA cephalogram
■ OPG
■ Submentovertex view
• MDCT/CBCT
■ Virtual 3D set up and 3D printing models
FIGURE 73.7 Evaluation of facial asymmetry using photographs.

The special views required. The facial asymmetry is much more
appreciated in submental view.
Clinical examination should be focused on an overall balance of the
face when the patient is relaxed and also during talking and walking.
Detailed clinical history is required to arrive at the diagnosis and
elicit the aetiology of the facial asymmetry. Also of significant
relevance is to record the status of physical growth and skeletal
maturation of the subject.
The face is examined for hard and soft tissue asymmetry in upper
third, mid face and lower third of the face. The clinical exanimation is
perceived in transverse dimensions, differences in vertical heights
from right to left, the angulations of the lower border of the mandible,
the cant of occlusal plane, the zygoma and mid face are looked for
asymmetry/deviations. For example difference in vertical height of
commissures of the oral cavity and cant of occlusal plane is suggestive
of differential skeletal heights of the mid face.
The skeleton asymmetry can be in part marked by soft tissue
compensations. The soft-tissue features can also be quantified by
measuring frontal facial photographs. Patients with a chief complaint
of facial asymmetry visit the clinic after seeing their images in the
mirror or photographs of themselves. Furthermore, photographs are
easy to take, feasible, inexpensive and provide an instant review.
Chin deviation, body inclination difference, gonial angle difference,
and lip canting should be carefully examined since these are
significant variables to differentiate asymmetry from normal subjects.
Chin deviation seems to be the most influencing factor in assessing
facial asymmetry more so in the lower third of the face. Asymmetry of
the lower third of the face, the mandibular area, tends to be perceived
more than asymmetry in the upper or middle third of the face.22
Examination of the face in function is performed by careful
observation during the smile, speech and chewing movements. The
cant of occlusion plane and asymmetrical vertical positioning of
maxillary teeth (R–L) can be greatly appreciated when the patient is
asked to smile. Lip canting can be associated with mandibular
asymmetry as well as maxillary height differences and occlusal plane
canting. At the resting position, lip canting (deviated labial
commissure or alar base) on one side often indicates vertical skeletal
asymmetry. The lip commissural angulations and lip posture is better
evaluated in function of smile and blowing.
The functional examination also involves the range of mouth
opening, deviation of chin during mouth opening, movements of the
condyle at TMJ, any crepitus and sounds indicating TMJ pathology,
condylar growth and associated pathologies. The functional jaw
movements can also be recorded through videography for repeated
observations
Head tilting might slightly correct a deviated chin. Asymmetric
patients tend to posture their heads with a tilt to compensate for a
deviated menton. The more asymmetric the patient, the more his head
is likely to be lean.
It has been observed that when a discrepancy is found between
skeletal measurements and a subjective evaluation, the influence of
soft tissue structures should be considered with regard to facial
asymmetry.23 In brief, the face and facial skeleton are examined for
three major orientation described earlier, that is ROLL, PITCH and
YAW independently and in totality.
While there is no substitute for a detailed and vigilant examination
of facial asymmetry, the transverse deviations of the face is often
measured on well captured front photographs and PA films in
reference to mid-sagittal, a plane to quantify the chin deviation.
Radiographs
Posterior–anterior cephalograms (Fig. 22.4). Posteroanterior (PA)
cephalogram has been traditionally used to discern the facial
deformity in the transverse plane. The deviation is measured in
transverse plane at several levels and discrepancy in left to right
halves in reference to a median reference plane.
Simplified Grummons Analysis

The PA analysis for facial asymmetry by Grummons et al. is discussed
in detail in the chapter on PA cephalometric analysis. Grummons
suggested a simplified frontal asymmetry analysis that involves the
following aspects of maxillo-mandibular and facial asymmetry.24,25
1. Frontal X-ray is placed as reversed, so it becomes an A–P view

—label the X-ray for left and right sides. Reversing the PA to
AP view is done so that the tracing will then match with the
patient on models, and photographs, and as they appear to
themselves. This will minimise confusion during analysis and
conversations with the patient and other clinicians.
2. Mid-sagittal reference plane (MSR) is drawn using following
landmarks
a. Bisect Crista Galli (Cg) or nasion (Na).
b. Bisect anterior nasal spine (ANS).
c. Extend beyond chin (Me).
MSR is constructed from the anatomic Crista Galli (Cg) vertically
through the anterior nasal spine (ANS) and extends inferiorly
beneath the chin (Me).
3. The maxillary incisors are located in relation to MSR. It is
important to check incisors clinically or on study models with
correct bite records, to confirm the upper-dental-to-skeletal
midline.
4. Mid-symphysis of the mandible is located and marked. This
helps to determine the deviation of the chin (Me) laterally from
the MSR. The deviation is measured in mm.
5. Drawing the occlusal plane (OP)—Grummons recommend the
use of a wire transversely across the palate to depict true
maxillary occlusal plane. He suggested that when taking the
frontal X-ray, position a 50–60 mm length of 0.014-in. wire at
the mesio-occlusal of the maxillary first molars and have the
patient bite down. Be careful with sharp ends to avoid injury.
The wire will be visible in as radiopaque marker in PA X-ray,
which serves as a guide for tracing to identify the true
maxillary molar occlusal plane.
6. The right and left sides of a patient’s landmarks are compared
to detect skeletal and dental asymmetry. After skeletal and
dental landmarks have been marked, and perpendiculars are
drawn laterally/transversely, assess relationships between
skeletal and dental references.
a. Points J–J’: width of the maxilla
b. Points AG–GA: width of the mandible
c. Point menton: Me
Observing down the MSR line, one can easily compare the inter-
section of the right and left references at the point where they intersect
the MSR that helps to visualise and quantify asymmetries. This
contributes to answering followings:
1. The difference between left to right side in maxillary width.

2. The degree of cant of the occlusal plane.
3. Chin deviation from MSR, measured in mm.
4. Relationship of upper dentition mid line with the skeletal
midline. If not coincident the amount of deviation is measured.
5. Upper and lower midlines alignment.
Effect of head posture on width measurements

Width measurements from frontal-view cephalograms are most
sensitive to minor movements in head posture and therefore should
be used with caution and should be supplemented with clinical
evaluation. Combined errors in point identification and geometric
error may be large enough to influence the diagnosis of facial
asymmetry. One has to clearly understand that asymmetry recorded
in an individual should be regarded as relative to a reference point or
line that may be asymmetrically positioned. This is obvious in the
cases of severe asymmetries, where every structure in the craniofacial
skeleton may to some extent be distorted and thus asymmetrically
positioned.26 Therefore the accuracy of head positioning while
recording PA cephalogram is a prerequisite for the diagnosis of facial
asymmetry measurements.11
OPG in facial asymmetry (Fig. 73.8)

Panoramic view X-ray of the maxilla and mandible X-ray offers useful
information in a subject with facial asymmetry. In cases with gross
facial asymmetry, visual examination of panoramic film reveals a
discrepancy in the length of the body and ramus heights on either side
of the structures, shape and size of the condyle, the length of the neck
and its inclination, presence of anti-gonial notch and other similar
features suggestive of asymmetrical growth of the mandible.
FIGURE 73.8 Evaluation of facial asymmetry OPG.

RH: Ramus height; CH: condylar height; X and Y: the most lateral
points of the condyle and the ramus are marked X and Y on the left and
right sides. A line: The lines (ramus tangent) are drawn passing
through X and Y. Z point: To the A lines (the ramus tangent from the
most superior points of the condylar images), perpendicular B lines are
drawn, and the intersection point is called Z point. The distances
between X and Y and between Z and Y were measured and registered
as ramus height (RH) and condylar height (CH).
Caution is required in interpreting the absolute measurements on

OPG films since magnification and distortion are inherent
components of the OPGs, and these vary with the machine to machine
and also influenced by the accuracy of the patient’s positioning.
Therefore correct patient positioning is critical to minimise the errors
of distortion and magnification. Manufacturer’s magnification values
should also be considered. It has been reported that vertical variables
were magnified by 18%–21%, with the greatest magnification in the
anterior region.27
Habets method of facial asymmetry on OPG

Habets et al. (1988)28 introduced a method to determine asymmetries
between the condyles of the mandible: a comparison of vertical
heights of the mandibular right and left condyles and rami. In this
method, panoramic radiographs are scanned with a magnification of
100% or digital OPG are calibrated for 100 sizes. The outlines of each
condyle and the ascending ramus of both sides on the panoramic
radiographs are traced. These can be either traced on tracing paper on
analogue films or contours can be determined on digital images with
cephalometric software.
The most lateral points of the condyle and the ramus are marked X
and Y on the left and right sides. The lines (ramus tangent) are drawn
passing through X and Y (A line). To the ‘A lines’ (the ramus tangent)
from the most superior points of the condylar images, perpendicular B
lines are drawn, and the intersection point is called Z points.
The distances between X and Z are measured and recorded as
condylar height (CH). Similarly, the distances between X and Y and
between Z and Y were measured and registered as ramus height (RH)
and condylar plus ramus height (CH–RH).
The asymmetry indexes of the condyle, the ramus, and the condyle
plus ramus can be calculated following asymmetry index (AI):
This method has been used for diagnosis in temporomandibular

disorder patients and to determine condylar asymmetries in various
malocclusions, such as class II and III and various skeletal patterns.
Sangam and Sanli have suggested measurements of condylar height
and ramus height and their comparison from right to left.29
Sub-mento-vertex view (Fig. 73.9)

Sub-mento-vertex projection is more useful for excellent visualisation
of the cranial base structures that allow the use of the anatomical
reference points over the cranial base to determine the mediosagittal
axis.30 Despite its inherent benefits, it’s used much less in the clinical
practice than those described previously.
FIGURE 73.9 Evaluation of facial asymmetry.
Submentovertex view.
3D evaluation (Fig. 73.10)

The CBCT allows for the reduction of many limitations extracted from
conventional radiography, which is OPG and cephalograms. CBCT
also eliminates the need for any other X-rays, that is OPG,
cephalograms and intraoral X-rays.31
FIGURE 73.10 3D cephalometrics.
Facial asymmetry as evaluated on CBCT.
The clinical examination of the face can be supplemented with

3dMD (Fig. 73.11). The 3D real time soft tissue images are
superimposed on 3D CBCT volume rendered images. A complete
picture allows quick evaluation of ‘virtual face’ and measurements. It
is possible to have virtual treatment planning and precisely do the
surgical planning and evaluate the effect of surgical movements
associated with different, treatment options and visualise the effect on
soft tissue. The rapid prototype 3D printing has further allowed
clinicians to make more precise treatment planning and design
customised plates for surgery.
FIGURE 73.11 (A, B) Evaluation of facial asymmetry using non
radiation 3D imaging such as facial 3dMD. Source: Patel A, Islam SM,
Murray K, Goonewardene MS. Facial asymmetry assessment in adults
using three-dimensional surface imaging. Prog Orthod 2015;16:36.
Management strategy
• Mild asymmetry with no other pathologies in growing
children [Fig. 73.12.1–73.12.2)]
• Mild asymmetry of the face with malocclusion treated with
orthodontics alone
• Mild asymmetry of the face with mild malocclusion treated
with minor surgical procedures such as sliding genioplasty
with or without orthodontics
• Severe asymmetry treated with a combination of orthodontics
and orthognathic surgery (Fig. 73.13, Box 73.4).
FIGURE 73.12.1 Management of facial asymmetry in a growing
individual.
Class II growing patient with mandibular deficiency. Presence of mild
facial asymmetry with deviation of the chin to the left. Initial extraoral
(A, B and C) and intraoral photographs (D, E, F, G and H), as well as
profile, panoramic and carpal radiographs (I, J and K). Source:
Reproduced with permission from Thiesen G, Gribel BF, Freitas MP.
Facial asymmetry: a current review. Dental Press J Orthod 2015 Nov–
Dec;20(6):110–25.
FIGURE 73.12.2 (A) Telescopic mechanism of the Herbst appliance
in place. Asymmetrical mandibular advancement was aimed at
correcting skeletal occlusal and facial asymmetry. Lateral intraoral
photographs on the right side, (B) in frontal view and (C) on the left
side. (C) Treatment outcomes for the patient presented after the
second phase of treatment conducted with a full fixed orthodontic
appliance. Final extraoral (A, B and C) and intraoral (D, E, F, G and H)
photographs. Profile and panoramic radiographs (I and J). Source:
Thiesen G, Gribel BF, Freitas MP. Facial asymmetry: a current review.
Dental Press J Orthod 2015 Nov-Dec; 20(6):110–25.
FIGURE 73.13 Management of facial asymmetry in a patient with
unilateral condylar hyperplasia.
(A) A mature patient with asymmetry evinced with lateral deviation of
the chin, in addition to vertical difference in leveling between lip
commissures and inclination of the occlusal plane in frontal view. Initial
extraoral (A, B and C) and intraoral photographs (D, E, F, G and H), as
well as profile, posterior-anterior and panoramic radiographs (I, J and
K). Source: Thiesen G, Gribel BF, Freitas MP. Facial asymmetry: a
current review. Dental Press J Orthod 2015 Nov–Dec;20(6):110–25.
(B) Final extraoral (A, B, C and D) and intraoral (E, F, G, H and I)
photographs. Profile, posterior-anterior and panoramic radiographs (J,
K and L). (C) CBCT scans with soft tissues overlapping hard tissues.
(D) Tomographic superimposition evincing changes before and after
surgical correction of facial asymmetry (A, B and C). Surgical maxillary
advancement of 4 mm was carried out, in addition to 1.5-mm impaction
in the anterior region, 2-mm asymmetrical impaction in the posterior
region on the right side and 2.5-mm asymmetrical impaction in the
posterior region on the left side. The mandible was rotated for
asymmetry correction.
Box 73.3 Table-plan of surgical treatment

according to proposed classification of facial
asymmetry
Reyneke (1997) has given a summary Table on the treatment plan of

facial asymmetry according to his classification.11
Facial asymmetries offer a diagnostic and therapeutic challenge. In
this part of the world, the asymmetries are often associated with TMJ
ankylosis and hence offer additional challenge due to lack of sufficient
hard and soft tissues.
The correction of facial asymmetries may remain unpartially
resolved even when it is achieved using an orthodontic-surgical
approach. Because after the intervention, the asymmetrical growth of
soft tissues occurring throughout the years is not usually corrected by
surgery and therefore influencing ultimate treatment outcome.
Furthermore, some asymmetrical craniofacial regions cannot be
corrected using conventional surgical techniques. Therefore it is
pertinent that the patient should be informed of the possible
limitations of orthognathic surgery.32
Key Points
Facial asymmetries require a comprehensive plan of action. The
mandible is more often at fault and hallmark of the treatment plan.
Diligent clinical evaluation and assessment of chin position
deviation and soft tissue compensation are integrated with a 3D
evaluation to arrive at a comprehensive diagnosis.
Further, 3D virtual treatment planning is an invaluable tool to
determine an appropriate, customised surgical treatment plan for the
patient and to predict an accurate outcome.
Additional soft tissue procedures are often necessary to resolve soft
tissue related asymmetry.
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the mandible in unilateral posterior crossbite and the
adaptation of the temporomandibular joints: a pilot
study. Eur J Orthod. 1999;21(2):155–166: Apr; PubMed
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21. Ishizaki K, Suzuki K, Mito T, Tanaka EM, Sato S.
Morphologic, functional, and occlusal
characterization of mandibular lateral displacement
2010;137(4): Apr, 454.e1-9; discussion 454-5, PubMed
PMID: 20362898.
22. Lee MS, Chung DH, Lee JW, Cha KS. Assessing soft-
tissue characteristics of facial asymmetry with
photographs. Am J Orthod Dentofacial Orthop.
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23. Masuoka N, Momoi Y, Ariji Y, Nawa H, Muramatsu
A, Goto S, Ariji E. Can cephalometric indices and
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asymmetry? Angle Orthod. 2005;75(4):651–655: Jul;
frontal asymmetry analysis. J Clin. Orthod.
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25. Grummons D. Facial asymmetry and frontal analysis
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PMC4686752.
CHAPTER 74
Temporomandibular disorders
and orthodontics
Sanjivan Kandasamy
Charles S Greene
Donald J Rinchuse
CHAPTER OUTLINE
Introduction
What are TMDs?
Historical relationships between orthodontists and TMDs
Management of TMD signs and symptoms
Examination
Treatment
Patient self-directed care and education
Key Points
Introduction
Orthodontists primarily deal with treating patients with both skeletal
and dental malocclusions, with the aim of achieving more ideal
occlusal and skeletal relationships whilst maintaining or improving
the overall facial soft tissue balance. Ideally, all of this should be done
without disrupting the temporomandibular joints (TMJs).
Like general dentists, orthodontists will inevitably encounter some
patients exhibiting temporomandibular disorder (TMD) signs and
symptoms in their practices who may require some form of
management. Some of these patients may be referred to the
orthodontist’s practice for TMD treatment, while others may develop
TMD problems during or after orthodontic treatment. Some TMD
signs and symptoms may be present or may develop in orthodontic
patients, but it is critical to be aware that not all of these
signs/symptoms need to be treated. Therefore, it is important to
adequately examine, document, diagnose, inform and manage these
patients when indicated.
The topic of TMD management can be quite complex and multi-
layered. One of the main purposes of this chapter is to present an
evidence based approach to TMD management that practicing
orthodontists can utilise. Based on currently accepted scientific
evidence, emphasis is focused on conservative treatment for the vast
majority of TMD conditions, especially during the early and acute
stages. In addition, since orthodontic procedures are not generally
indicated as treatment modalities for TMD patients, this chapter will
not include any discussion about those approaches. In order to
introduce the reader to the clinical management of such patients, we
will begin with a discussion of current concepts about these disorders.
We will review the historical relationship between the orthodontic
profession and the TMD community. We will also discuss the issues
related to occlusion and malocclusion, condyle position, and
orthodontics as they might relate to TMD. Functional occlusion and
the role of articulators in orthodontics will also be addressed. For a
thorough, detailed and highly referenced overview on every major
topic pertaining to TMD and orthodontics, we would recommend
readers to look at our textbook, TMD and orthodontics: a clinical guide
for the orthodontist.1
What are TMDs?
TMDs comprise a group of neuromuscular skeletal conditions that
involve the TMJs, the masticatory muscles and associated tissues. A
recent systematic review of TMD prevalence in the general population
which included only studies that used the Research Diagnostic
Criteria for TMD (RDC/TMD) reported a prevalence of up to 16% for
disc disorders, up to 13% for masticatory muscle pain and up to 9%
for TMJ pain disorders.2 Only 3.6%–7% of individuals who had signs
and/or symptoms of TMD were estimated to be in need of treatment.3
TMDs are essentially divided into joint/disk disorders and
masticatory muscle disorders. The masticatory muscle disorders
include muscle pain, inflammation, contracture, hypertrophy,
neoplasms and movement disorders. TMJ disorders include joint pain,
inflammation, degeneration, neoplasms, disc displacements, hypo-
mobility, hyper-mobility, congenital or developmental disorders and
fractures.4–6 Given the difficulties associated with defining the
etiologies of most TMD conditions, contemporary TMD diagnoses and
treatments are based on addressing the symptoms rather than the
cause; this is an approach that generally requires little attention to
individual etiologic factors. Similar to the treatments of other
musculo-skeletal disorders, management is typically palliative and
symptomatic, primarily targeted at decreasing pain, decreasing
loading on the muscles and joints, and facilitating the restoration of
function and quality of life of patients. TMD treatments in most cases
should be conservative, reversible and based on scientific evidence.7
TMD signs and symptoms can develop in any individual at any
time. In many cases, these can be transient phenomena like a sore jaw
muscle, a painful joint following a minor trauma, or limited opening
after a dental appointment. Also, many patients observed during a
screening exam may have a painless TMJ click or an odd opening and
closing pattern, but these do not typically reach a level of being a
clinical case of TMD. When actual TMD problems do arise, the
patients are often in their mid to late teens, or they are young adults
and middle-aged adults, rather than children and the elderly.
Prevalence of TMDs in women is twice more common than in men.3
Based on these facts, the likelihood of an average orthodontic patient
developing signs or symptoms before, during or after treatment is
likely. It has been shown that over the long term most cases of TMD
pain and dysfunction generally tend to lessen.8,9 This however does
not obviate an orthodontist’s professional obligation to recognise
TMD problems when they do arise, to inform and educate those
patients about the conservative treatment protocols, and if needed to
either engage in the treatment or to effect the necessary referral to an
appropriate specialist to manage the patient’s TMD. It should be
mentioned that the research literature has shown that orthodontic
treatment is TMD neutral if properly performed; in other words, it
generally neither causes nor cures TMD. This is further discussed later
in this chapter.
Historical relationships between
orthodontists and TMDs
The relationship between orthodontics and TMD is one that has been
fraught with controversy and debate for over half a century. Many
believe that orthodontically changing the positions of the teeth and
jaws will significantly affect the relationship of the condyles within
the fossae either unfavourably or favourably. The main controversy is
centred around whether achieving a particular occlusal outcome
and/or an ideal condyle position via various elaborate technical and
labour intensive means will either resolve a pre-existing TMD or
prevent TMD from occurring in the future. Much of this chapter will
concentrate on dealing with the various controversies associated with
TMD and orthodontics.
The first discussion of a TMJ disorder came from Dr James Costen,
an otolaryngologist who described a syndrome named after himself
that included 11 symptoms related to the TMJs and the ears.10,11 The
cause was believed to be over closure of the mandible as a result of the
loss of dental vertical dimension subsequent to tooth loss. Costen’s
syndrome included symptoms such as TMJ sounds, pain in and
around the jaw, limited mandibular opening, and myofacial
tenderness/pain, as well as ear symptoms such as vertigo, tinnitus,
pain and impaired hearing. The close anatomical proximity of the TMJ
to the external auditory meatus and related structures was believed to
contribute to the ear symptoms. Several years later, Costen’s
syndrome was ultimately found to be fallacious from an anatomical
viewpoint.12,13 Even though Costen’s etiologic proposals were
disproved, they formed an initial framework for a variety of dentally-
based theories of TMD aetiology. This initiated great interest,
awareness and involvement of dentists to begin assessing and treating
these problems. Dentists were now TMJ sensitised and therefore
stimulated to look more closely at occlusion as the major causative
factor in TMDs.
It was not until the early 1970s that Dr Ronald H. Roth introduced
gnathologic concepts to orthodontics.14–18 Roth believed that
orthodontic treatment was similar to prosthodontics/restorative
dentistry such as full-mouth rehabilitation, with the difference since
the orthodontists moved teeth instead of restoring them. Consistent
with the traditional gnathologic view, Roth believed that
discrepancies of the occlusion and improper condyle position would
cause TMD.14–18 He believed that orthodontists were obliged to attain
gnathologically optimal functional, occlusal and condyle
relationships. The gnathologic goals were to:
• Establish a canine-protected (mutually-protected) occlusion;

• Restoratively and/or orthodontically establish a maximal inter-
cuspal occlusal relationship with a now anterior-superior
centric relation condyle position; and
• Analyse the discrepancy between a patient’s occlusion and
centric relation position after obtaining a particular centric bite
registration (power-bite), followed by the articulator
mounting of the patient’s dental casts.
It was believed that patients would be predisposed to TMD if these

gnathologic objectives were not achieved with orthodontic treatment.
However, the gnathologic/orthodontic view as promoted by Roth and
his associates was not evidence-based, and the scientific evidence
accumulated over the years has contradicted much, if not all, of it.
The orthodontic community went into a tailspin following the
infamous landmark 1987 Brimm versus Malloy19 court case in the
United States. This case resulted in an unfavourable judgment against
a Michigan orthodontist for purportedly causing TMD in a 16-year-
old female by performing orthodontic treatment involving the
extraction of maxillary first premolar teeth and wearing headgear. The
allegation was that this orthodontic treatment resulted in the over
retraction of the upper incisors, leading to the distal displacement of
the mandible, internal derangements and pain. Even without
adequate scientific evidence to support such an argument, the jury
still awarded the plaintiff US $850,000 at the initial court trial. This
unfortunate outcome forced the orthodontic profession to properly
examine the relationship between orthodontic treatment and TMD in
order to provide much needed evidence based information in
response to the anecdotal claims being made. Many important
research investigations have since been conducted by the orthodontic
establishment as a direct reaction to the Brimm case. These studies, as
well as others following, have helped the profession to clarify the
relationship between orthodontics (and orthodontists) and TMD.
We have come a long way since 1987. Today, according to the
evidence based literature, orthodontic treatment in general has not
been found to cause TMD.20–26 Therefore, it can be described as TMD
‘neutral’, because in general, it neither causes nor cures (or mitigates)
TMD. Furthermore, orthodontic treatment does not prevent the
development of TMD in patients who have malocclusions, so
advocating orthodontic treatment to mitigate the risk of TMD
developing in the future is unfounded. It has also been shown that the
utilisation of any specific type of orthodontic treatment, or appliance,
such as headgear, inter-arch elastics, chin cup, or whether extractions
are performed, has not been shown to predispose patients to any
increased risk for developing TMD.20–36
The concept of centric relation (CR) has been a component of many
occlusal theories for more than a century. The term centric relation
refers to the relationship of the mandibular condyles to the glenoid
fossae. Over the last six decades the definition, as well as the concept
of CR has changed within the prosthodontic community from a
retruded, posterior, and for the most part, superior condyle position
to an anterior–superior condyle position.37 Even though the position
of human condyles did not change physiologically over the last six
decades, the aim of these revised definitions was always to describe
CR as a biologically sound position.
Gnathologists believe that centric occlusion (CO) or maximum
inter-cuspation (MI) should be co-incident with a specific CR position.
These clinicians also believe that the presence of a CR–MI discrepancy
is the reason for patients developing signs and symptoms of TMDs.
To identify a CR–MI discrepancy, orthodontic gnathologists use a
specific centric relation bite registration called the Roth Power centric
bite. Based on this information they then carry out orthodontic or
prosthodontic treatment to establish coincidence between CO and an
anterior-superior centric relation condyle position. However,
Kandasamy et al.38 in 2013 demonstrated via an MRI study that
irrespective of the centric bite registration used, including the Roth
Power Bite Registration, clinicians cannot accurately and predictably
position condyles into specific locations in the glenoid fossae.
Further, the evidence suggests that there is a range of acceptable
condylar positions for the population at large. Each individual has
his/her own unique condylar position which is more commonly
located in the anterior to mid fossa regions than the retruded CR
positions, but individuals with healthy TMJs can even have a retruded
condylar position.36,39,40 There is no specific optimal 3D
position/location of the TMJ condyles in the glenoid fossa.41 It may be,
however, that a mid- to anterior position may be best for most
individuals. The original position of the condyles while the teeth are
in centric occlusion should be used as a sound physiologic guide to
base treatment upon. Any procedure that deviates or positions the
condyles away from a position they naturally and physiologically
occupy may potentially be harmful to the patient in the long term.
The term Functional Occlusion refers to the contact relationship of the
upper and lower teeth within the functional range of mandibular
movement. It is believed by gnathologists and occlusionists that the
optimal functional occlusion for all dental patients, including
orthodontically treated patients, is canine protected occlusion (CPO).
CPO refers to contact occurring only at the canine teeth on the
working side, with no occlusal contact(s) on the non-working
(balancing) side during lateral or side to side mandibular movements.
This occurs when only the canine teeth on the working side, discludes
the entire dentition on laterotrusive movements out of centric
occlusion. It is believed by some that failure to establish CPO during
orthodontic treatment will predispose patients to TMD, as well as
orthodontic relapse.14–16,18,42
However, trying to establish CPO as the optimal functional
occlusion for orthodontic patients is not supported by the evidence.43
Such a practice fails to recognise the importance of each person’s
unique stomatognathic and neuromuscular functional status. People
rarely actually function in the extreme lateral side to side border
movements during any of their functional activities such as
mastication and swallowing. Even in para-function, a person would
typically move the mandible forward, or forward and to the side, not
directly side-to-side.44,45 It would appear that the most important
functional occlusal movements are those closest to centric occlusion.
It should be obvious that no one single type of functional occlusion
predominates in nature.46 In addition, it is important to be cognisant
of the fact that even if a particular functional occlusion is achieved, it
will not necessarily be stable or retained over the patient’s lifetime.
Regardless of what type of functional occlusion is achieved, over time
it will typically evolve into group function followed by balanced
occlusion as a result of tooth attrition, changes in the oral
environment, demands on the dentition with growth and aging, para-
function, and occlusal settling; all of these normal biological changes
will affect the vertical level and position of the canines.
The use of articulators in dentistry is well documented. In
orthodontics, articulators have been primarily used in conjunction
with orthognathic surgical procedures to at least maintain a certain
vertical dimension, while laboratory procedures are being performed.
However, given the accuracy, efficiency, detail, visualisation and
greater diagnostic information that comes with 3D imaging and
virtual planning today, mounting dental casts in cases involving
orthodontics associated with orthognathic surgical procedures is no
longer necessary to achieve the goals of that treatment protocol.
It was Dr Ronald Roth in the early 1970s who believed that the
routine mounting of dental casts on articulators would aid the
orthodontist in detecting CR–MI discrepancies and diagnosing 3D
condylar (CR) discrepancies.14–18 By introducing his personal
philosophy to the orthodontic profession with articulator mounting,
Roth believed that he could produce superior outcomes by seating the
condyles in a more ideal position. He proposed that orthodontic
treatments should be based around this condylar position of centric
relation. He and other gnathologic orthodontists believed that this
would either cure an existing TMD or prevent the development of
TMD in the future. According to these clinicians, routine articulator
mountings with the appropriate centric bite registration will improve
the orthodontic diagnosis (Angle’s classification) in 18.7%–40.9% of
cases.47,48
As discussed previously, the contemporary model of TMD
diagnosis and treatment has moved away from the mechanical dental-
based model, which involved a detailed analysis of occlusion and
condyle position (CR) and has now embraced a medical and bio-
psychosocial model. Given this paradigm shift, there is no need to
concentrate on the mechanics of bite registration or articulator
mounting, nor should we be focusing on the minutia of occlusion and
condyle position in relation to TMD. However, regardless of this
paradigm shift, there is still a proportion of the dental profession that
believes in these outdated concepts. However, as discussed
previously, there are many issues with this philosophy. Firstly, the
evidence-based data supports the view that clinicians are not able to
estimate the position and location of patients’ condyles via certain bite
registrations taken chairside.38 So if one takes an inaccurate bite
registration and then mounts dental casts on a crude instrument such
as an articulator which poorly reflects the dynamics of the masticatory
apparatus including the TMJs the whole process becomes futile.
Further, the evidence is clear that there is no terminal hinge axis in
humans that corresponds to what articulators are based on. Posselt’s
concept of the terminal hinge axis relied on the notion that condyles
only rotate and do not translate within the initial 20 mm of opening.49
In 1995 however Lindauer50 demonstrated that the condyles actually
rotate and translate instantaneously within the very first millimetres
of opening and closing. In addition, recent evidence has shown that
the face-bow transfer used in the mounting process on an articulator is
not valid.51
Therefore, given the evidence based literature available today, there
is no justification for the routine mounting of models on articulators
or for condylar positioning in orthodontics; this is true for the general
practice of orthodontics as well as the proposed association with TMD
prevention or treatment.
Management of TMD signs and
symptoms
Examination
A basic TMJ examination is a necessary part of any initial overall
evaluation of the orthodontic patient. The primary purpose of an
examination is to ascertain the condition of the joint and masticatory
apparatus as a baseline and identify if there are any TMD issues
present prior to embarking on any orthodontic treatment. The same
basic examination can also be applied to the orthodontic patient
during or after treatment. Although a detailed discussion of a
thorough TMJ examination is beyond the scope of this chapter, a basic
screening questionnaire and a list of procedures for a clinical TMJ
examination are presented in Boxes 74.1 and 74.2. It is important to be
aware that normal constitutes a range, so considerable variation
among individuals should be expected. Painless TMJ clicking,
crepitus, deviated opening, tenderness in certain areas, or non-
progressive limited jaw opening should simply be regarded as
imperfections that do not reach the threshold of being significant
clinical problems. It is also important to realise that the patient’s self-
report and description of his/her TMD complaint may be as
important, if not more important, than the orthodontist’s clinical
evaluation.
Box 74.1 Basic screening questionnaire
1. Do you have difficulty and/or pain when opening your mouth?

2. Does your jaw get stuck or locked when you move it?
3. Do you have difficulty and/or pain when you talk, chew, sing,
eat?
4. Do your jaw joints make any noises?
5. Do you have pain in or around your ears, side of the head or
cheeks?
6. Does your bite feel unusual or not come together properly?
7. Do you experience headaches?
8. Have you experienced any recent trauma to your face, head,
neck, jaws or teeth?
9. Have you been treated in the past for any problems with your
jaw joint or bite?
Box 74.2 Basic procedures for a TMJ clinical

examination
1. Measure range of motion of the mandible on opening and to the

right and left
2. Palpate for any pre-auricular TMJ tenderness
3. Palpate for any clicking and/or crepitus
4. Palpate for any tenderness in the masseter and temporalis
muscles
5. Examine for any excessive occlusal wear or fremitus, and soft-
tissue ridging or lateral tongue scalloping
6. Inspect the symmetry and alignment of the face, tissues, jaws,
and dental arches
The key to an adequate screening exam is to identify situations

where there is dysfunction and pain associated with the TMJs. If there
is pain, it is important to resolve or at least manage the pain prior to
embarking on orthodontic treatment. If the patient is in the midst of
treatment, it usually will be necessary to stop certain aspects of active
orthodontic treatment, such as inter-arch elastics or fixed functional
appliances, and manage the pain.
Treatment
If the examination process described above leads to a presumptive
diagnosis of TMD, the orthodontist has two choices: Treat the patient
in the office, or refer to an appropriate oral medicine or orofacial pain
colleague. The two key clinical features of most TMDs are pain and
dysfunction, and these are the major reason most people seek
professional care. Dysfunction is usually a consequence of the pain
rather than its cause; therefore, primary attention should be directed
at relieving the pain. When an orthodontist decides to provide a
patient with basic TMD treatment, it is critical that the clinical
approach to management of pain and dysfunction is supported by
current science and evidence.52–54
TMD treatments are now based on a bio-psychosocial model rather
than the historical, dental-based model i.e., TMD management has
moved away from treatments related to conventional dentistry
involving altering the occlusion and realigning jaw relationships to
treatments based on the biomedical and psychosocial sciences. The
contemporary bio-psychosocial model attempts to integrate the host
of biologic, clinical and behavioural factors that may account for the
onset, maintenance and remission of TMD.55 The factors that are
receiving the most attention and research in the understanding of
TMD today are genetics (vulnerabilities related to pain), imaging of
the pain-involved brain, endocrinology, behavioural risk factors,
sexual dimorphism, psychosocial traits and states, and co-morbid pain
conditions.56,57
There are conservative and reversible TMD treatments that
orthodontists can provide for patients. In most cases, the specific
cause of the TMD cannot be ascertained prior to treatment. Therefore,
the treatments provided will be palliative pain-relieving measures.
These include patient self-directed care, physical therapies, cognitive-
behavioural therapies, biofeedback, pharmacologic agents and oral
occlusal appliances. It should be mentioned again that orthodontic
treatment generally does not cause or cure TMD. Nevertheless,
orthodontists get many referrals from their dental colleagues to treat
and correct a malocclusion in order to treat/cure a patient’s TMD. This
is an inappropriate referral based on the evidence.
Patient self-directed care and
education
Patients experiencing TMD-related pain and dysfunction are
frequently anxious about what is happening to them. Once a
preliminary diagnosis of some type of TMD has been established, it is
important for the orthodontist to reduce that anxiety by
communication with the patient. It is important to remember that
long-term studies have shown that 80%–90% of these patients can
expect good short-term results with little or no long-term problems
after conservative orthopedic therapy to reduce pain and restore
normal function.58,59 Even for the very few patients who require
actual treatment procedures inside the joint, there are simpler and less
invasive measures available today such as arthrocentesis or
arthroscopy rather than the traditional open-joint surgical operations.
With regard to TMD management, it is important to reassure
patients that very positive treatment outcomes often will result when
appropriate conservative measures are taken. Some studies have
reported that patients informed of this prognosis sometimes get better
without any professional treatment simply because they were relieved
by the explanation, went home and let some time pass.58
Patient self-directed care for TMD includes actions that the patient can
take to limit jaw function and para-functional activities. Patients
should limit or stop such activities chewing gum, yawning, yelling,
singing, cheer-leading, and so on. They can support their mandible to
limit opening when yawning, and they should avoid unnecessary
clicking maneuvers. For acute symptoms, which include limited
mandibular opening, patients should be advised to temporarily
change their diet as follows: eat soft foods, avoid hard or chewy foods,
avoid wide opening during meals, and grind or finely chop meats and
other tough foods.
Also, TMD patients should be advised to relax their jaws and keep
their teeth apart. Patients should be informed about the relationship
between musculoskeletal pain, stress and tension and instructed about
relaxation procedures that can be practiced at home.60 In more
complex cases, professional help in this area may be required from
psychologists or stress management specialists. Home physical
therapy procedures that can be implemented include ice for acute
pain and heat for more chronic pain, as well as self-massage.
Finally, non-prescription medications, such as acetaminophen or
non-steroidal anti-inflammatory drugs (NSAIDs) can be taken
continuously around the clock for 2–4 weeks to facilitate breaking the
cycle of pain and inflammation. NSAIDs should always be taken with
stomach acid-prevention products. Other medications requiring a
prescription are beyond the scope of this chapter.
Psychological and behavioural factors play a significant role in the
onset or continuance of TMD symptoms. A patient’s state of mind or
personality trait and how an individual deals with TMD pain can be
influenced by factors such as depression, anxiety, catastrophising,
fixation, poor coping skills, life stressors, stress-reactivity, parasomnia
and oral para-functions. This can lead to somatosensory amplification,
a tendency for the individual to perceive a given somatic sensation as
intense, noxious and disturbing; and hyper-vigilance, which is an
increased awareness of the difference between the perceived sensation
versus what is expected as ‘normal’, with an increased attention
focused on weak sensations. This in turn can lead to a worsening of
the pain disorder and a transition to chronicity. It is critical to consider
these factors when managing TMD patients, but they do not
necessarily need to be referred to a professional psychologist. A
simpler method of intervention referred to as Cognitive Behavioural
Therapy (CBT) can be used by all types of medical providers.
Recognising that an individual’s thoughts, feelings and resultant
actions are interconnected, CBT facilitate increasing the patient’s
awareness about the mind-body connection through education about
stress management and the body’s reaction to stress. Studies have
shown that compliant patients can be taught about identifying
negative thoughts, relaxation techniques, use of distraction and
pleasant activity scheduling, cognitive restructuring, self-instructional
training, and various maintenance skills. Some patients however may
need professional counselling, which may involve the use of hypnosis,
biofeedback and guided imagery training. See our textbook for more
detailed information regarding psychological considerations in the
aetiology of various TMD conditions and in the management of TMD
patients.
Dentists and orthodontists generally prescribe and use splints for the
management of bruxism and for the treatment of TMD patients.
Splints have been around for over seven decades, and certainly many
thousands of patients have been helped by their use. However, the
potential for serious negative outcomes is very high for splints,
because they can produce irreversible occlusal and jaw position
changes, altered vertical dimension and major dentoalveolar
discrepancies. This often occurs when they are designed improperly
and worn full time for extended periods, leading to the
aforementioned sequelae.
In general, the oral appliance of choice is a simple full-arch flat
plane or stabilising splint, where there is even contact with all teeth
when the patient bites into it as well as in slight lateral and forward-
backward movements. There should be no attempt to incorporate any
particular type of functional occlusion. Any splint design or protocol
that repositions the mandible or does not provide contact for all the
teeth is not recommended. According to the contemporary evidence,
splint therapy is recommended as a temporary orthopaedic modality,
with the primary therapeutic goals being relaxation of muscles,
reduction of oral habits, altering joint loading and general relief of
symptoms.61–63
Oral splints should not cause irreversible occlusal changes or
alterations of TMJ relationships to occur. At worst, a patient’s failure
to respond positively to splint therapy should be the only downside
risk. The conservative viewpoint involves avoidance of any protocols
involving full time wearing of splints. With rare exceptions, the
proper protocol for an oral appliance is night-time usage only, so that
normal occlusal relationships can be maintained in the daytime. If
prolonged splint wear is required to control bruxism or to treat
recurrent symptoms, then careful and regular monitoring is required
to ensure no irreversible changes occur.
Informed consent for orthodontic treatment is a necessary
requirement prior to the commencement of any treatment. Part of
obtaining informed consent for orthodontic treatment is obtaining
informed consent from the patient (parent/guardian) in relation to
orthodontics and TMD. Various orthodontic organisations around the
world, such as the American Association of Orthodontics have a
section in their recommended informed consent document(s) on the
current and evidence-based view on the topic of orthodontics and
TMD. Along with a thorough informed consent process, every
orthodontist should also keep meticulous records for every patient.
This includes all records pertaining to the patient’s evaluation,
diagnosis, treatment plan, informed consent, treatment rendered,
radiographs, models, photos, as well as all communications with the
patient, relevant third parties and third party payers. From a legal
perspective, these records serve to protect the legal interests of all
related parties including the orthodontist. Clear and thorough record
keeping is not only a good risk management strategy but it also
strengthens and enhances the doctor–patient relationship.
Key Points
• TMDs are neuromuscular skeletal conditions, which may be
encountered before, during, and/or after orthodontic treatment.
• TMD diagnosis and management has evolved from a historical
dental-based model to a bio-psychosocial model based on the
biomedical and psychosocial sciences.
• The majority of TMDs can be managed with conservative and
reversible treatments, most of which are based on solid scientific
evidence.
• TMD treatments are typically palliative and symptomatic, with
the objective of reducing pain and improving jaw function.
• Orthodontists should always make detailed notes and take
thorough records including digital photos, casts and radiographs.
• Orthodontists should provide adequate TMD informed consent
and make appropriate TMD patient referrals when indicated.
• Orthodontic treatment is considered TMD ‘neutral’ in that it
generally neither causes nor cures TMD.
• Orthodontic treatment does not prevent the development of TMD
in patients who have malocclusions; so advocating orthodontic
treatment to mitigate the risk of TMD developing in the future is
unfounded.
• There is not one functional occlusion type or jaw relation position
that is optimal for all orthodontic patients.
• Based on the current evidence, the use of articulators as a
diagnostic ‘tool’ in orthodontics is a futile exercise and not based
on science.
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SECTION XVII
Expanding role of orthodontist
and inter-disciplinary care
Chapter 75: Inter-disciplinary management of cleft lip and palate

Chapter 76: Orthodontist’s roles in upper airway sleep disorders
CHAPTER 75
Inter-disciplinary management of
cleft lip and palate
O.P. Kharbanda
Nitika Monga
CHAPTER OUTLINE
Introduction
Epidemiology of CL ± P
Abbreviation of cleft types
Cleft of the lip and primary palate
Cleft of the secondary palate
Cleft soft palate only (CPO)
Submucous cleft palate (SMCP)
Aetiology of CLP
Familial affiliation
Environmental causes
Epigenetic factors/gene environment interactions
Risk of recurrence
Sex ratio
Laterality of CLP
Kernahan ‘Striped-Y’ classification
ACPA classification
LAHSHAL classification
Indian classification
Nagpur classification
AIIMS classification
Primary team or core team
Issues with cleft care
Immediately on birth
First few weeks
First few months
Feeding appliance
Latham appliance
Presurgical nasoalveolar moulding (PNAM)
Dynamic presurgical nasoalveolar remodelling (DPNR)
Controversy to conclusion
Presurgical orthopedics for protruding premaxilla
Oslo protocol
Obturators
Record taking in cleft patients
Orthodontic management
Indices for cleft
Orthodontic intervention during deciduous dentition
Orthodontic intervention during early mixed dentition
Alveolar bone graft
Comprehensive orthodontic treatment
Key Points
Introduction
Cleft of the lip and/or the palate (CL ± P) is a congenital birth defect,
which is characterised by complete or partial clefting of the lip and/or
the palate. The severity of clefting may vary from the trace of notching
of the upper lip to complete non-fusion of the lip, primary palate and
secondary palate.
Facial clefts are seen due to non-fusion of the facial process. The
cleft of the lip, palate and face may be seen as an isolated birth defect,
non-syndromic cleft or as a part of a syndrome with multiple
congenital anomalies later referred to as ‘syndromic clefts’.1
Epidemiology of CL ± P
The cleft lip and palate anomaly constitutes nearly one-third of all
congenital malformations, thus making the most conservative
incidence of this anomaly as 1.6 per 1000 live births excluding those
associated with syndromes. Robert, Kallen and Harris (1996)2 pooled
the data from five birth registries from California, Sweden and France
to study the prevalence of CLP anomaly. From their pooled data, they
calculated the incidence of CLP as 1.57/1000.
The incidence of this anomaly is reported to be highest in Afghans3
as 4.9 and lowest in Negroid population, 0.4 per 1000 live births.4
According to rough estimates, about 30,000 children afflicted with
CLP anomaly are born every year in India.5 Although organised
epidemiological surveys to evaluate the incidence of CLP in India are
yet to be carried out, more than two dozen studies have been done on
newborns in the past three decades for evaluating the
incidence/prevalence of congenital malformations in them (including
cleft lip and palate). From these reports, the pooled incidence for cleft
lip and palate is estimated to be 1.2 per 1000 births and 0.46 per 1000
for cleft palate alone.6 A recent study conducted in south India
reported the incidence of cleft lip and palate as 1.15 and that of the
isolated cleft palate as 0.08 per 1000.7 The incidence of CL ± P anomaly
in AIIMS New Delhi Hospital births has been calculated as 1.4 per
1000 live births for CL ± P and 0.3 per 1000 live births for isolated CP.8
Abbreviation of cleft types

The cleft of the lip is denoted by CL, and cleft of the lip with the
alveolus is denoted by CLA. The complete cleft extending from a
unilateral cleft lip and primary palate passing through the mid-palatal
suture to the soft tissue uvula is conveniently denoted as the unilateral
complete cleft of the lip and palate (UCLP). The one with a bilateral
cleft of lip and premaxilla, which extends down to the bifid uvula is
denoted as bilateral complete cleft of the lip and palate (BCLP) (Fig.
75.1).
FIGURE 75.1 Types of clefts.
(A) Microform of cleft lip. (B) Cleft of the lip (CL). (C) Cleft of lip and
alveolus (CLA). (D) Unilateral complete cleft of lip and palate (UCLP).
(E) Bilateral complete cleft of lip and palate (BCLP). (F) Cleft of palate
only (CPO) isolated cleft palate is limited to soft palate and uvula (ISO–
CP) Source: Courtesy Prof RK Khazanchi, former Head, Division of
Plastic Surgery, AIIMS.
A wide range of severity of the cleft may be observed, and the

affected site may be interrupted by soft bridges (skin or mucosa)
and/or bony bridges, corresponding to the diagnosis of an incomplete
cleft. This may occur in either unilateral or bilateral CLP. Cleft lip and
palate can be grouped as (1) typical/atypical orofacial clefts and (2)
syndromic or non-syndromic clefts. This chapter focuses on
management of non-syndromic clefts.
The facial skeleton, connective tissue of the face and all the dental
tissues except enamel are derived from the ectomesenchyme tissues,
which are derived from the embryonal neural crest cells (NCC). The
NCC migrates into the facial region during facial morphogenesis. The
enamel is ectodermal in origin. The muscles and vascular
endothelium are mesodermal in origin.9 During the early stages, in
the development of the face, the medial nasal processes of either side
merge with each other to form the inter-maxillary segment which
constitutes the philtrum of the upper lip and the area of palate called
primary palate bounded by two lines from incisive foramen to the
alveolar bone between lateral incisor and canine on either side. The
lateral parts of the upper lip are formed by the fusion of the medial
nasal process (MNP) with the maxillary process. The palate is formed
by the fusion of the two palatal shelves of the maxilla, which fuse with
each other as well as the premaxillary segment as they acquire their
final position. Also, see Chapter 8.
Cleft of the lip and primary palate

The cleft of the upper lip results most commonly from the non-fusion
of the maxillary process with the median nasal process (MNP) during
the early stages of the morphogenesis of the face. Failure of merging
between the median nasal and maxillary processes at the 5th week of
embryonic development results in the cleft of the lip, which usually
occurs at the junction of the central and lateral parts of the upper lip
on either side. The clinical expression of the cleft may vary from a
slight notching on the lip to a more severe cleft extending up to
incisive foramen.
The cleft may be unilateral or bilateral. A bilateral cleft of the lip
and alveolus separates the philtrum of the upper lip on both sides and
premaxilla from the rest of the maxillary arch. If the cleft extends deep
into the primary palate, it results in the cleft of the alveolus also. The
clefts anterior to the incisive foramen are grouped as cleft of the
primary palate. Occasionally, the clefts of the lip and alveolus may
have bands of soft tissue bridging across the two sides called
Simonart’s bands.
Cleft of the secondary palate

Cleft of the secondary palate develops due to lack of fusion of the
right and left palatine shelves. These palatine shelves develop from
the neural crest cells, which make the maxillary process. The palatine
shelves are formed vertically downwards on the 45th day at the side
of the tongue. These shelves elevate to become horizontal in position
above the dorsum of the tongue and migrate towards each other as
the tongue descends accompanied by the growth of the mandible.
Fusion of palatal shelves begins anteriorly at the 8th week and
proceeds backwards. Fusion of palatine processes continues till
12/17th week of IU life.
When the fusion of the palatal shelves is impaired along with the
failure of fusion of medial nasal and maxillary processes, the cleft of
the lip is extended further down to the secondary palate forming the
cleft lip and palate anomaly. Cleft of the palate alone is formed due to
the partial or total lack of fusion of palatal shelves. It can occur in a
number of ways:
1. Defective growth of the palatal shelves

2. Delayed or total failure of the shelves to elevate and attain a
horizontal position
3. Lack of contact between shelves
4. Post-fusion rupture of shelves
5. Failure of mesenchyme consolidation
Many cellular and molecular events are involved in the fusion of the
two palatine shelves in the midline. These events are trans-
differentiation of the epithelial cells into the mesenchymal cells (EMT)
or mesenchymal cells into the epithelial cells (MET). Programmed cell
death (PCD) of the epithelial cells around the palatal shelves and its
timings are critical for the fusion of palatal shelves as any disturbance
would lead to the failure of the union of the shelves and hence the
formation of the cleft palate.
Midline fusion events are critical for the normal embryonic
development of the face, and any disturbance there of has serious
implications developmentally.10 The timing of the PCD is also
responsible for the concurrent presence of supernumerary
teeth/hypodontia in CLP patients.11
Cleft soft palate only (CPO)

Cleft of the palate alone (CPO) is considered as a separate entity and
appears to be under the high genetic influence. It is also an
embryologically and aetiologically different entity from the cleft lip
and palate. The cleft of the palate alone is more common in females
which have been hypothesised to be linked with a week’s delay of
hard palate closure and therefore a prolonged sensitive embryonic
period.12 The cleft may vary in expression of severity from a very mild
notching on the tip of the uvula to a cleft extending the soft palate
alone or into the secondary hard palate up to the incisive foramen.
Isolated cleft of the soft palate is usually associated with Pierre
Robin malformation and has a distinct U shape while most of the
clefts in the palate make a V-shaped notch.
Submucous cleft palate (SMCP)

Submucous clefts are clinically invisible and present on the palate as
bony defects but are covered with oral mucosa. Submucous cleft
palate (SMCP) is a subgroup of cleft palate that presents as (1) bifid
uvula, (2) translucent zone in the soft palate and (3) bony notch in the
posterior edge of the hard palate.
A submucous cleft of the palate may only occur in the hard palate,
or as a submucous cleft of the soft palate alone. The cleft involving the
bony palate at posterior nasal spine appears as a V-shaped notch on
occlusal X-ray. Careful clinical observations may reveal a blue triangle
anteriorly in continuation of the cleft of the soft palate, which
represents a bony defect underneath the mucosa. Submucous cleft
should be looked for when no other apparent cause of the hypernasal
speech could be identified.13
The clefts of the lip, palate and face can be grouped as non-syndromic
and syndromic forms.
The non-syndromic cleft affected individuals have no other physical
or developmental anomalies though they may show subnormal
growth or other parameters of physical development. It has been
suggested that about 70% of cases of CL/P and 50% of CPO are non-
syndromic.14
The syndromic cleft may appear as a part of multiple congenital
anomalies (MCA). In multiple congenital anomaly syndromes, cleft
patients can be further grouped into:
1. Monogenic syndrome
2. Chromosomal aberrations
3. Part of an association, or part of a complex of multiple
congenital anomalies of unknown aetiology
4. Teratogenic syndromes
More than 350 syndromes are known to have associated cleft lip
and palate.
Aetiology of CLP
The exact aetiology of cleft lip and palate is obscure because of its
heterogeneous presentation. Many cases are sporadic while others are
familial in occurrence.
Familial affiliation
The familial association is greater for cleft of the soft palate alone with
its preponderance for an increased incidence in females.
Cephalometric studies on normal parents of the cleft lip and palate
patients have suggested that a distinct craniofacial pattern exists in
normal parents of cleft patients which include short facial heights and
wider nasal widths.15 Many children born with cleft lip and palate
without any positive family history would have genetic predisposition
which may have been aggravated by the presence of an
environmental insult resulting in a phenotype cleft. Gene
environment interactions are being greatly investigated in reference to
the aetiology of CLP anomalies.
Environmental causes
Among the environmental causes, anti-abortifacient drugs, anti-
emetics, phenytoin, excessive alcohol and smoking have been linked
to congenital defects including cleft lip and palate. Cleft has also been
produced in albino mice in animal experiments after administration of
hydroxyl progesterone.16
Nutrition seems to play a significant role. Micronutrient and folic
acid deficiencies have been linked to the formation of neural tube
defects (NTD). The role of folic acid in the prevention of cleft lip and
palate has been under investigation for some time now. Some studies
show a positive correlation while others have found no beneficial
effects. Lately, the most interesting results that strongly support use of
a high dose of folic acid in the prevention of non-syndromic clefts are
those of Czeizel and his colleagues who have shown dose dependent
benefits of folic acid supplementation in the reduction of occurrence of
cleft palate anomaly. They reported that low physiologic doses of folic
acid (0.8 mg/d) did not show any preventive effect on the first
occurrence of isolated CL/P and CP.17,18 However, the general
evaluation of congenital anomalies in this study indicated a reduction
of non-syndromic clefts after the use of high doses of folic acid (3–9
mg/d) in the early post-conception period.19,20
Epigenetic factors/gene environment

interactions
The current research is more focused on gene-environment
interaction. Studies of twins have shown a lack of 100% concordance
in monozygotic twins, which is an indication that genetic events alone
are not responsible for the clefting phenotype. Concordance in
monozygotic (MZ) twins ranges between 40 and 60% and is 5% in
dizygotic twins. Greatly increased MZ concordance does strongly
support a major genetic component.
Research on association and location of genes has been in progress
in humans and also in knock-out mice. A number of gene loci, which
have been linked and researched in relation to CLP anomalies have
been summarised by Murray.21
With the invention and practical applications of 3D imaging to
prenatal ultrasound, diagnostics of cleft anomalies seem to be an
exciting field. It is possible to locate cleft of the lip as early as 15 weeks
and, with an experienced ultrasound radiologist, the cleft of the palate
too.22
Risk of recurrence
According to Tolarova et al.23 ‘genetic factors’, that is, genes
participating in the aetiology of non-syndromic orofacial clefts are
passed to the next generation, thus creating an increased risk for such
anomaly in offspring(s). The risk of recurrence also differs with
respect to the proportion of genetic and non-genetic factors. In CL/P,
the hypothetical 4-threshold model corresponds closely with the
differences in the risk of recurrence.
From a clinical point of view, two factors are most important when
evaluating the risk of recurrence for CL/P—the sex of the individuals
(i.e. patient and individual at risk) and the severity of the effect in the
patient (i.e. unilateral vs. bilateral).
The lowest recurrence risk for CL/P is for the subcategory of male
patients with a unilateral cleft, within this category, for sisters of
males with a unilateral cleft and daughters of fathers with a unilateral
CL/P.
The highest risk of recurrence of CL/P is for the subcategory of
female patients affected with a bilateral CL/P.
The risk of recurrence for CP seems to be influenced only by sex.
The risk is highest for daughters of fathers affected with a CP and
lowest for sons of mothers affected with a CP.23
Sex ratio
A number of studies conducted all over the world show that the males
are affected more than females for cleft lip and palate anomaly.
However, there is no definite sex predilection for the isolated cleft of
the palate while some suggest a high incidence in females.24–27
Laterality of CLP
In general for the unilateral clefts (cleft of lip and alveolus, cleft lip
alveolus and palate), there is a tendency for the left side
predisposition. However, when the cleft of the lip alone is involved,
there is no definite trend towards right or the left side. Studies carried
out in Delhi16 observed a high preponderance of left sided cleft in the
ratio of R:L = 1:1.5.
Ritchie was first to present the classification for congenital CLP in
1922. The classification is based on the alveolar process. This was
neither an anatomical nor an embryological classification.28 Brophy in
1923 gave a classification including 16 distinct morphological forms of
cleft palate with/without cleft lip based on an understanding of
anatomy, but it was overly complex and impractical.29,30
Veau in 1931 greatly simplified Brophy’s classification of palatal
clefts, which consisted of four morphological forms (Fig. 75.2). The
main drawback of Veau’s classification was that it did not include
cleft of the lip and alveolus. The Veau classification became very
popular and still in use for its simplicity, though it is incomplete,
embryologically not sound and surgically not applicable.31 Fogh-
Andersen in 1942 gave classification from an embryological
perspective using incisive foramen, rather than alveolar process.32
FIGURE 75.2 Classification of Veau (1931).
Group I – cleft of the soft palate, Group II – cleft of the soft and hard
palate, Group III – unilateral complete cleft of the alveolus, hard and
soft palate, Group IV – bilateral complete cleft of the alveolus, hard and
soft palate.
In 1958 Kernahan and Stark advocated a cleft classification system

based on developmental anatomy rather than morphology alone.
Kernahan and Stark proposed three groups:
1. Clefts of structures anterior to the incisive foramen

2. Clefts of structures posterior to the incisive foramen
3. Clefts affecting structures anterior and posterior to the incisive
foramen.33
Kernahan ‘Striped-Y’ classification

Kernahan proposed ‘Striped-Y’ classification (Fig. 75.3A) in 1971,
using nine boxes with nasopalatine foramen as the central point.34 It
was further modified by Elsahy, Millard and Friedman et al.35–37 (Fig.
75.3B,C,D). The modified Kernahan’s ‘Y’ classification represents the
cleft deformity precisely as it exists and is very versatile. This
classification is a diagrammatic or symbolic representation of the cleft
deformity and used for documentation or charting effectively.
FIGURE 75.3 A) Kernahan ‘Striped -Y’ classification. (B) Millard
modification of Kernahan ‘Striped-Y’ classification. (C) Elsahy
modification of Kernahan ‘Striped-Y’ classification. (D) Friedman
modification of Kernahan ‘Striped-Y’ classification.
The only disadvantage of this classification lies in the fact that it is

difficult to use for verbal communication or description in the text
format and for computer archiving. Kernahan’s striped-Y has served
as the predominant classification system used in daily clinical
practice.34
ACPA classification
The American Cleft Palate-Craniofacial Association (ACPA)
classification was introduced in 1962 by Harkins et al. It was based on
anatomic segmentation into the prepalate and the palate permitting
separation into four major categories of orofacial clefts (Table 75.1).
Table 75.1
American Cleft Palate–Craniofacial Association (ACPA) classification

1 Clefts of the prepalate (cleft of lip and embryologic primary palate)
1. Cleft lip (cheiloschisis)
2. Cleft alveolus (alveoloschisis)
3. Cleft lip, alveolus and primary palate (cheiloalveoloschisis)
2 Clefts of the palate (cleft of the embryologic secondary palate)
1. Cleft of the hard palate (uranoschisis)
2. Cleft of the soft palate (staphyloschisis or veloschisis)
3. Cleft of the hard and soft palate (uranostaphyloschisis)
3 Clefts of the prepalate and palate (alveolocheilopalatoschisis)
4 Facial clefts other than prepalatal and palatal
1. Cleft of the mandibular process
2. Naso-ocular clefts
3. Oro-ocular clefts
4. Oroaural clefts
ACPA classification covers all types of clefts including clefts of the

prepalate, clefts of the palate, clefts of both prepalate and palate and
facial clefts. It is the first descriptive classification but extensive and
difficult to remember therefore did not gain popularity.38
LAHSHAL classification
Kriens (1989) proposed LAHSHAL, an abbreviated documentation
system (Fig. 75.4). The laterality (right or left side) of each anatomical
area (apart from the soft palate) can thereby be recorded. The
completeness of the cleft may also be recorded with incomplete clefts
represented by lowercase letters and uppercase letters representing a
complete cleft.
FIGURE 75.4 LAHSHAL documentation system for cleft lip and

palate
(Kriens, 1989).
Later, it was modified to LAHSAL on the recommendation of Royal

College of Surgeons UK in 2005 to exclude the second ‘H’. This
modification excluded the possibility of classifying bilateral clefts of
the hard palate especially in cases where one palatal shelf rather than
both fail to fuse with the nasal septum. This was a simplified version
of Kernahan’s ‘Y’ classification and had similar shortcomings and
limitations.39 The major advantage of the LAHSHAL classification is
that it allows for the description and recording of every typical non-
syndromic orofacial cleft precisely and briefly. This classification
provided the advantage of recording both the degree of completeness
as well as the laterality of cleft defect, which was lacking in the
previous classifications.
Indian classification
C. Balakrishnan in 1975 described 12 types of possible cleft
deformities (Table 75.2).
Table 75.2
Indian classification as presented by Prof Balakrishnan (1975)

Cleft type Original abbreviation
Cleft Lip Gp1
Cleft palate Gp2
Cleft lip, alveolus and palate Gp3
Right R
Left L
Midline M
Alveolus A
Additional abbreviations
Partial P
Submucosal S
Simonart’s band Sb
Microform micro
This classification has both the anatomical and the embryological

basis. Incisive foramen is the demarcation between primary and
secondary palate. All elements of the primary palate, that is, lip,
alveolus, anterior palate and nose are repaired together as a single
entity, hence grouped as Gp1.
The elements of the secondary palate, that is, hard and soft palate
and uvula are repaired together, hence grouped together as Gp 2.
This grouping system follows the clinical severity of the cleft. CL is
considered simple when it is mainly aesthetic deformity, CP resulting
in functional problems considered more severe, and CLP is
considered most severe in functional as well as aesthetic concerns.
This way the grouping has been done in increasing order of severity
from 1 to 3.
The Indian classification scores over other classifications because it
is descriptive and also has an abbreviation form. These abbreviations
can be used for coding of cleft. Indian classification is simple, easy to
communicate, easy to write in an abbreviated format, and it is also
possible to code it. It is very convenient for data retrieval from the
computer archive.40
Nagpur classification41
The Nagpur classification derives its name as it was first formulated at
Plastic & Maxillofacial Surgery Department at Government Medical
College, at Nagpur, the first Plastic Surgery Department in India
established by Professor C. Balakrishnan. It is a simplified version of
his original classification and is routinely followed by the plastic
surgeons of India (Table 75.3).
Table 75.3
Nagpur classification
Group I Cleft of lip
Group I(A) Cleft of the lip with a cleft of the alveolus
Group II Cleft of palate alone
Group II(S) Submucous cleft of the palate
Group III Cleft of lip and palate
The side of the cleft was mentioned as (R) for the right, (L) for left and (RL) for bilateral
AIIMS classification
Combined Cleft Palate Clinic at Centre for Dental Education and
Research at All India Institute of Medical Sciences, New Delhi, peruse
following cleft abbreviations to represent various cleft deformities
(Table 75.4).
Table 75.4
Cleft abbreviations used in CDER, AIIMS

CL Cleft lip
CLA Cleft of lip and alveolus
CP Cleft of palate
UCLP Unilateral cleft of lip and palate
BCLP Bilateral cleft of lip and palate
The side of cleft is mentioned as (R) for the right, (L) for left
This classification is simple, time saving and yet descriptive of the

location and extent of the cleft.42
The pioneer work for the formulation of a dedicated interdisciplinary
team for the treatment of cleft patients exclusively was done by an
orthodontist, Dr Herbert K. Cooper in Lancaster, Pennsylvania, USA.
In 1938 he established a team of specialists for the management of
CLP patients, popularly known as Lancaster CLP team. His core team
constituted of an orthodontist, a prosthodontist, a surgeon and a
speech correctionist. This team composition stands relevant in current
scenario and serves as a foundation for the cleft and craniofacial teams
all over the world.43
The care of cleft lip and palate patients require a number of
specialists including psychologists and social workers to provide a
comprehensive treatment from birth to adulthood. Counselling with a
clinical geneticist is needed for the adult treated cleft patients when
they want to become parents and would like to be informed on the
risk of recurrence in their offsprings.
A treatment course of a cleft patient and approach is based on the
consultation among the specialists involved with the cleft care.
However, during different stages of the physical and social
development of the cleft patient, the role of one specialist may be
more significant than the other. During early days, immediately after
birth the feeding specialist, neonatologist, orthodontist and the cleft
surgeon take the lead role. After the first year, issues with hearing,
middle ear infections and speech therapy are more relevant and
important issues to be resolved. Similarly, later during the late mixed
dentition stage orthodontist would need greater indulgence and at
adulthood, plastic surgeons would play a key role in the correction of
secondary deformities of lip and nose. A prosthodontist may be
required to rehabilitate missing teeth and for aesthetic treatment of
the dentition (Flowchart 75.1).
FLOWCHART 75.1 Key (inner circle) and supporting
professionals (outer most box) of an inter-disciplinary cleft team.
Primary team or core team

• The cleft surgeon/plastic surgeon undertakes the primary and
secondary repair.
• The speech therapist monitors speech from 9 months onwards
and institutes measures for normal development of the
speech.
• The audiologist quantifies and locates the cause of hearing
problems.
• The orthodontist monitors dental development, occlusion,
skeletal problems and institutes interceptive therapy,
dentofacial orthopaedics and prepares for secondary alveolar
bone graft.
• Orthodontist’s expertise in cephalometry and craniofacial
growth uniquely qualifies him or her to monitor craniofacial
growth, dental development and treatment results.
• Oral surgeon. Secondary alveolar bone graft and orthognathic
surgery if required.
• Plastic surgeon. Correction of nose deformity, secondary
deformities of lip and scar revision.
The entire team would also include the following specialists whose
role is significant and would be critical by requirement:
• A specialist cleft nurse who can monitor the neonates during

the early days after birth and give feeding advice.
• Clinical geneticist to resolve the genetic basis of the cleft and
advice on recurrence risk.
• Paediatric dentist/dentist to maintain and monitor dental
health and oral hygiene.
• ENT surgeon/audiologist to take care of recurrent ear
infections, insert grommets and hearing tests.
The team care can be more efficiently provided at cleft care units or
cleft care centres where all the concerned specialists can meet, discuss
and plan implementation strategy. There are a few fundamental
principles that should be followed in a cleft team.
1. Regardless of the type of oral cleft, an inter-disciplinary team

of specialists should provide the care (and not the multi-
disciplinary team). The interdisciplinary approach requires
that the treatment approaches are based on mutual
consultations and discussions.43–45
2. There should be a team leader or coordinator that facilitates the
function and efficiency of the team and ensures coordinated
care to the patients. In many centres around the world, it is the
orthodontist who likes to see patients through his dental
development and monitor facial skeletal growth.43
3. Treatment plan at any stage should be discussed and
implemented based on team recommendations.
4. The principal role of the inter-disciplinary team should be to
provide integrated case management to assure quality and
continuity of patient care and long-term follow-ups.45
5. Parents should be provided with written and audiovisual
material on feeding and all aspects of care and management of
the child with the cleft and craniofacial deformity.
An inter-disciplinary coordinated team approach with defined

treatment protocols have shown better treatment outcomes and
reduced the overall burden of care for the child and parents.45
A cleft child should receive treatment with the concerned specialist
at correct age, which is critical for the successful treatment outcome
(Flowchart 75.2).
FLOWCHART 75.2 Schedule and timing protocol of cleft care.
Issues with cleft care

The CLP anomaly is a congenital defect, which affects the face, the
most visible part. Hence, it comes as a shock to the parents when they
see their cleft child for the first time. This initial shock may then turn
into anger, frustration, grief and guilt. Hence, it becomes essential to
counsel the parents at the time of birth of the child affected with this
deformity. Apart from the psychological issues, feeding is an
important consideration because a cleft child cannot suckle effectively
and breastfeeding may become impossible.
Immediately on birth
Feeding and psychological problems are the major issues. The
following specialists are required to evaluate the child:
• Neonatologist, paediatrician
• Feeding specialist nurse
• Clinical psychologist
• Clinical geneticist to assess for syndromic associations.
Newborn children with clefts present the risk of aspiration and

airway obstruction, which may lead to acute asphyxia in children with
small mandibles like in Pierre Robin syndrome. Such cases may
require tracheostomy at birth.
First few weeks

• Recurrent chest and throat infections: care by the neonatologist
and paediatrician.
First few months

• Primary surgery of lip and anterior palate: done by a cleft
surgeon who could be an oral surgeon/plastic
surgeon/paediatric surgeon.
Feeding appliance
Feeding in a normal child involves two mechanisms: one is sucking
and another is swallowing. In cleft patients, due to abnormal
musculature attachment, there is an inability to cre-ate negative
intraoral pressure, and hence, the sucking mecha-nism is disturbed
while the swallowing is normal. The feeding appliance or feeding
obturator is intended to block the continuity of the oral cavity with the
nasal cavity. It creates a rigid platform towards which the baby can
press the nipple and extract the milk. Initially, it was believed that the
feeding obturator creates intraoral negative pressure by the sucking
act. However, Choi in 1991 contraindicated this fact in his study in
which he intended to measure the intraoral pressure created by
feeding plate.46 However, the literature provides sufficient evidence
on the effectiveness of the feed-ing plate as it provides an artificial
palate against which the infant can suck. It facilitates feeding and also
reduces the time span required for feeding, prevents nasal
regurgitation and incidence of choking. It prevents abnormal
positioning of the tongue into the cleft palate and therefore prevents
widening of the cleft, assists in speech development, provides the
max-illary cross arch stability and prevents arch collapse after the
surgical closure of the lip.47–50 Feeding plates are problematic for
difficulties in their use, the cost of making appliances, travel and
associated burden. The practice has been substituted more or less by
proper feed-ing advice (Fig. 75.5A–D). Nevertheless in certain
situations with large clefts feeding plates are useful (Fig. 75.5E–G).51
FIGURE 75.5 Feeding a cleft baby.
(A) A soft squeeze bottle with a wide cut to let the milk drip slowly
without child making effort (suction) is desired. (B) Use small feeds.
Place the nipple in intact palate while holding the baby at 45°. Frequent
burping should be done. (C) Feeding position for a cleft patient. (D)
Indian household Paladi is a good utensil to feed a cleft baby. It is easy
to clean and readily available. (E) Newborn with a severe form of cleft
lip and palate extending to the right face. (F, G) Feeding appliance for
the cleft patients is required for the severe forms where other feeding
devices cannot work. (Parts C, D: Courtesy Prof AK Deorari,
Neonatology Unit, AIIMS, New Delhi).
Presurgical orthopaedics was pioneered and introduced by McNeil in
the 1950s.52 He advocated that the neonatal maxillary orthopaedics
could control and modify the postnatal development of the maxilla by
stimulating the growth of the soft tissues overlying the hard palate.
The original philosophy of McNeil was to reduce the displacement of
the alveolar segments and create a butt joint between the alveolar
segments in the cleft region. The idea was to create a normal arch
form by actively moulding the alveolar segments using a series of
plates.
Propagator of presurgical orthopaedics also believed that the
patient is benefited from this therapy, as it would facilitate the
creation of a good functioning palate, normalise tongue position and
help in speech development. Presurgical orthopaedics is also expected
to improve the symmetry of nose and cleft maxilla and
psychologically boost the patient and the parents as the patients get
continued supervision. Some even believed that this procedure would
reduce the frequency of middle ear disease and help in weight gain.
The presurgical orthopaedic plates have been found to be
ineffective considering their hypothesised benefits in long-term
studies. The concept of presurgical orthopaedics is not being practised
in many of the European centres and being abandoned by others. The
long-term prospective Euro-cleft studies have shown better outcome
in those centres that did not practice presurgical orthopaedics.51
In the late 1950s in Europe support for primary bone grafting to
stabilise the effects of presurgical orthopaedics gained tremendous
popularity. For about a decade, Kernahan and Rosenstein procedure
was followed in which a passive appliance was used to mould
alveolar segments to produce a butt joint prior to lip surgery followed
by subperiosteal onlay rib graft.53 In 1977 Berkowitz concluded that
the primary bone grafting was detrimental to midfacial growth
leading to abandoning of primary bone grafting.54
Latham appliance
Georgiade and Latham55 (1976) introduced a pin-retained, active
appliance to retract the premaxilla and expand the posterior segments
simultaneously. The appliance mechanically manipulates the
maxillary segments into close approximation. Along with lip
adhesion, the gingivoperiosteoplasty (GPP) provides stabilisation of
the maxillary segments and reconstruction of the nasal floor.55,56 The
advantages include a fixed appliance which provides quick results in
2.5–3 weeks. The appliance is inserted just 4 weeks before lip surgery.
The main disadvantage lies in the need of additional surgery for its
placement under general anaesthesia (Fig. 75.6).57
FIGURE 75.6 Georgiade and Latham Appliance design for PNAM.
By turning the green clockwise, the maxillary arches expand. Turning
the blue knob counterclockwise will retract the premaxillary segment.
Berkowitz et al.58 reported a longitudinal study in unilateral and

bilateral cleft lip and palate treated with the Latham device and found
a higher frequency of anterior and posterior cross-bite in the
presurgical orthopaedics group. Though it was debated that the
results obtained by Berkowitz might be the result of GPP procedure
rather than presurgical orthopaedics.
Hotz plate: Hotz in 1987 described the use of a passive orthopaedic
to slowly align the cleft segments by grinding away the acrylic in
specific areas. The primary aim was to take advantage of natural
development potential and not to facilitate surgery or to stimulate
growth as recommended by McNeil. Therefore, after a lip operation at
the age of 6 months, palate repair was postponed until 5 years of age
to allow growth through intrinsic growth potential.46
Presurgical nasoalveolar moulding (PNAM)

Conventional approach and appliances for presurgical orthopaedics in
cleft children focused on correcting the alveolar cleft until 1993 when
Grayson et al.59 described a technique to correct the alveolus, lip and
nose simultaneously. The concept is based on the findings by
Matsuo60 who recognised alar cartilage exhibits the same elasticity as
auricular cartilage in the early neonate. The presence of high levels of
hyaluronic acid in the newborn inhibits the linking of the cartilage
intercellular matrix and correlates with increased levels of maternal
oestrogen during the first days of life, giving neonate tissues elastic
properties at the time of delivery. Grayson adapted nasal stent, from
Matsuo method, to extend from the anterior flange of an intraoral
moulding plate to skilfully apply force to shape the nasal cartilage.59,60
Presurgical nasoalveolar moulding (PNAM) appliance. PNAM
appliance is a palatal plate that is constructed on an infant’s maxillary
cast prepared on an accurate impression (Figs 75.7). The device
consists of an acrylic bulb (nasal stent) attached to the maxillary plate
with a rigid wire. The bulb lifts the nasal dome and moulds the shape
of the nostril and soft tissue of the cleft region. The construction of the
nasal stent is delayed until the cleft of the alveolus is reduced to 5–6
mm. A retentive arm is part of the plate which is attached at 45° near
the cleft lip region. A small opening of 6–8 mm is provided in the
plate to maintain the patency of the airway in case the plate gets
dislodged posteriorly and chokes the airway. Typically, PNAM is
initiated within the 1st week after birth and needs to be modified and
activated on a weekly basis.61,62
FIGURE 75.7 Presurgical nasoalveolar moulding (PNAM)
appliance.
(A) Oral plate with retention arm for alveolar moulding. (B) PNAM
appliance with a nasal wire stent. (C) Angulation of the retention arm.
(D) The position of the nasal stent inside the nostril. (E–F) Two cases
of UCLP who underwent presurgical nasoalveolar moulding (PNAM)
followed by lip surgery. (G) A case of BCLP. PNAM helps in several
ways. Not only it serves as a feeding appliance; its primary benefits are
a better surgical outcome of lip repair. A modified surgical approach is
required along with the PNAM for good results. It involves
gingivoperiosteoplasty for alveolus interdomal stitches or postoperative
nasal conformer for the maintenance of the corrected nasal cartilage
position. Source: Courtesy Dr Ajay Bajaj, JCD Dental College, Sirsa
and Prof Krishna. Shyama Rao, Mangalore.
Alveolar moulding is done via active moulding and passive growth

guidance. Active moulding is done by over buildup of the soft acrylic
on the labial flange and at the same time removal of the hard acrylic
on the lingual side allowing the movement of the larger segment into
the desired space and reverse is done for lateral or smaller segment.
Passive growth guidance involves guidance of the alveolar segment
growth on the medial aspect along the labial flange so that alveolus
grows inside the cleft space and fills it. The appliance is used for 4–6
months and alveolar moulding is finished before primary closure of
lip.63 In bilateral cleft lip and palate cases two retention arms and two
nasal acrylic pelottes lift the nasal area simultaneously, retracting the
premaxilla. Non-surgical columella lengthening is done by a tape
adhered to the prolabium and stretching downwards to engage the
retention arm with elastics. This vertical pull provides a counter
stretch to the upward force applied to the nasal tip of the nasal stent
and helps to lengthen the columella and the small prolabium.
Advantages of PNAM
The benefits of using this presurgical technique have been
documented.64
Use of this labour intensive therapy benefits by decreasing the cleft
side alar curvature increases the length of the columella, makes the
prolabium more visible by retracting the premaxilla and thereby
improves the aesthetic outcome of the surgery.
Singh et al.65 in a prospective longitudinal study of 10 patients, with
unilateral cleft lip and palate, evaluated three-dimensional changes in
nasal morphology with nasoalveolar moulding (NAM) using
stereophotogrammetry technique. Using NAM for 112 days, bilateral
nasal symmetry in patients with unilateral cleft lip and palate was
improved before surgical repair.
Dynamic presurgical nasoalveolar remodelling

(DPNR)
DPNR has been introduced by Bennun and Figueroa in 2006 (Fig.
75.8). The principle behind this procedure is the redirection and
transmission of the forces generated during suction and swallowing
through a nasal dynamic component to produce remodelling effects
on the nasal structures, and by stimulating labial muscle contraction
thereby enhancing lip function. This intraoral appliance consists of
two components: (1) a conventional acrylic intraoral plate and (2) a
dynamic nasal bumper attached to the vestibular flange of the
intraoral plate.66 The DPNR technique does not rely on the relatively
static force exerted by the orthopaedic plate held in place using tape
or adhesives as in NAM. Bennun further studied the long-term effects
of DPNR appliance and found that this appliance resulted in
remodelling and repositioning the deformed nasal cartilage with
improved nasal aesthetics and stabilised the effects by avoiding
memory cartilage fixation. It is comfortable to the patients, required
simplified adjustments during follow-up, significantly reducing the
consultation time and frequent appointments.67
FIGURE 75.8 Dynamic presurgical nasoalveolar remodelling

(DPNR).
Controversy to conclusion
Santiago and Grayson et al.68 reported that clefts who underwent
presurgical infant alveolar moulding and gingivoperiosteoplasty
(GPP) by a single surgeon from 1985 to 1988, 60% did not need a
secondary alveolar bone graft in the mixed dentition. This helped in
the saving of cost of about $2999 per patient.69
However, the long-term benefits of PNAM are still elusive. In a
meta-analysis, Papadopoulos et al.,70 reported that except for the
increase in maxillary arch form, presurgical infant orthopaedic
treatment has no beneficial effect on cleft lip and palate patients. A
literature review by Abott71 reported some evidence for improvement
of nasal outcomes in the unilateral cleft lip, cleft palate via
nasoalveolar moulding. A systematic review conducted by Uzel et
al.72 in 2011 documents no long-term positive effects on treatment
outcomes in patients with cleft lip and palate when treated by
presurgical infant orthopaedic appliances.
Further in author’s view and experience at his centre, though
presurgical nasoalveolar moulding seems beneficial to surgeons in
facilitating primary lip surgery. However, in a public hospital, many
patients are unable to cope up with the cost and logistics required for
the patient and parents for visiting the hospital during the early days
of child life.
Presurgical orthopedics for protruding

premaxilla
Newborn children with BCLP present with a protruding premaxilla.
The premaxilla may be protruding as well off centre with significant
gaps. It is a usual practice to push it back and towards the centre line
to facilitate the primary closure of the cleft lip. Adhesive lip strap and
similar appliances have been in vogue for ages. The posteriorly placed
premaxilla may show greater growth inhibition compared to those
where the premaxilla is not pushed back by presurgical orthopaedic
appliances (Fig. 75.7A–G).
A cleft neonate poses great difficulties in making impressions of the
oral cavity. There is an associated risk of causing asphyxia due to
excess of alginate and possibilities of introducing infection. It is
imperative that strict infection control measures be practised. An
orthodontist can make an alginate impression under general
anaesthesia with a throat pack in place in the operation theatre prior
to surgery. The impression should be made with an aseptic technique
with all instruments in use being properly sterilised. If an available
stock tray for a newborn does not fit well, the impression should be
recorded with a thermoplastic material held against the tissues with
the index and middle fingers. Care should be taken not to burn the
mucosa as a child is under anaesthesia. A plaster model is produced
from which a custom tray is constructed of acrylic. The final maxillary
impression is taken using an irreversible hydrocolloid with the child
in an upright position. While Dr Hubner, a paediatric dentist, prefers
to make an impression under GA, the majority of the orthodontists
can manage an impression without it in the cradle itself.73,74
Disturbance of the functional equilibrium due to abnormal insertion
and function of the nasolabial and soft palatal musculature in cleft lip
and cleft palate results in the skeletal and soft tissue anomalies on the
two sides of the cleft (Fig. 75.9).
FIGURE 75.9 Nasolabial surface anatomical characteristics of
unilateral cleft lip and palate.
(A) On frontal view. (B) On submental view.
Cleft palate
There are two main differences in the anatomy of the cleft and non-
cleft soft palate. First, the anterior aponeurosis is absent in the cleft
palate. Second, the anterior third of the cleft velum contains
longitudinal muscle fibres of palatopharyngeus and levator. These
fibres insert into the posterior rim of the hard palate and into the
medial edges of the bony cleft of hard palate75,76 (Fig. 75.10 A, B).
FIGURE 75.10 Anatomy of the cleft lip and palate.

(A) Normal anatomy: the levator veli palatini muscle can be seen
forming a sling across the soft palate; the tensor veli palatini is shown
coming around the hamulus to fuse with the levator. (B) Cleft palate:
The muscles are seen running more or less parallel with the cleft
margin. (C) Circumoral muscle attachments in cleft lip and palate. (D)
Blood supply to the circumoral region in cleft lip and palate.
Normally, the levator muscle forms a transverse sling across the
posterior half of the soft palate, and contraction of which causes
elevation and retraction of velum for a normal velopharyngeal
closure. The absence of transverse sling of muscles in a cleft situation
results in ineffective contraction and inability to close the palate
against the posterior pharyngeal wall leading to velopharyngeal
insufficiency (VPI). VPI is associated with air escape and so the
nasality of speech. The oronasal fistula also contributes to the nasality
of speech if it is not closed with palatal surgery. The sole and unique
function of tensor veli palatini muscle is to open the eustachian tube.77
Aberrant levator positioning, as well as an abnormal fusion with the
tendon of the tensor veli palatini muscle, impairs the function of the
tensor contributing to cleft otopathology.76
Cleft lip
In unilateral complete cleft lip, the muscles of the superior and middle
rings of the anterior facial muscle chain (constrictor nares, the levator
muscles of the upper lip and the nose and the oblique and horizontal
heads of orbicularis oris and the incisive muscle) on the cleft side
cannot cross the cleft. Therefore they run along the edges of the cleft,
turning upward towards the line of the nasal alar wing on the lateral
side and to the base of the columella on the medial side and insert into
the anterior border of the nasal septum on either side of the anterior
nasal spine where they unite with the muscles from the opposite side.
The muscles on the philtrum side of the cleft are hypoplastic and do
not extend up to the edge of the cleft as on the lateral side (Fig.
75.10C).
On the non-cleft side, the muscles have normal insertions; however,
the pull which they exert is not opposed which results in ipsilateral
displacement and deformity.29 On the cleft side the constrictor nares
muscle pulls the lateral crus inferiorly and anteriorly due to its
abnormal attachment and the medial crus is pulled down by the
muscles on the non-cleft side. This produces an overall flattening of
the cartilage in relation to the opposite side with distention and
distortion of the two crura. There is no cartilaginous hypoplasia. The
anterior margin of the septal cartilage is pulled towards the non-cleft
side by the muscle fibres.78,79
The main branch of the superior labial artery follows a similar
pattern by running along the edges of the cleft turning upward
parallel with the course of the muscular bundles and being stronger
and forming a denser network on the lateral side then on the philtrum
side (Fig. 75.10D).80,81
In the complete bilateral cleft, the anatomy and course of muscles
and the arterial network of the lateral segments of the lip is similar to
that in a unilateral cleft. On the contrary, the prolabium is composed
of dense connective tissue with no muscle insertion and with a rich
vascular network from the septal and columellar arteries.
In unilateral incomplete clefts, the muscles do not cross the cleft
unless the bridge is one-third of the height of the lip. On the contrary,
in an incomplete bilateral cleft, the bridges are well occupied with
muscle fibres, which penetrate from the lateral sides to the medial part
of the lip where they open like a fan. The central part of lip, though
partially isolated by the cleft and originally without any muscle fibres,
directly absorbs the necessary tissue from the lateral richly
vascularised and muscular parts.
The blood supply demonstrated a similar pattern with weak arterial
branches in bridges of unilateral incomplete cleft and considerably
stronger arterial branches in bilateral clefts.78
Various surgical protocols with regard to the timings of surgery and
type of operations for cleft lip and palate repair are in practice.
Technique and time of surgery that is best for the child have always
been a matter of controversy among surgeons. However, there is a
consensus that the primary closure of the lip is undertaken at the age
of 3 months or 10 weeks when the child is fit to undergo general
anaesthesia. The secondary/remaining palate is closed at the age
between 12 and 18 months.
The main objectives of the primary surgery are:
• To provide good aesthetics of the lip, prolabium and columella

with a functioning lip which can provide a good lip seal. A
good lip seal is essential for phonation, articulation and for
optimal balance of muscular forces in the orofacial region. The
scar should be minimally visible.
• The palate surgery should provide well-functioning uvula that
can provide a velopharyngeal seal during the functions of
speech, swallowing and phonation.
• The surgery should be aimed to generate an intact functioning
palate, free of any fistula.
• The surgery and scarring should not adversely affect the
dentition and growth of the maxilla.
Following two techniques have been popular with the surgeons
for the primary closure of lip:
• Tennison’s triangular flap procedure.
• Millard’s rotation flap (Fig. 75.11).
FIGURE 75.11 (1) Millard’s rotation flap for lip repair. (A) Incision
lines, (B) after rotation and suturing. (2) A newborn with UCLP
operated with Millard’s rotation flap. (A) Pre-operative and (B)
Postoperative. (Courtesy Prof RK Khazanchi, former Head, Division of
Plastic Surgery, AIIMS, New Delhi)
Oslo protocol
A protocol for the management of cleft patients in 1948 was
established with the following key elements.
1. No presurgical orthopaedics.
2. Closure of cleft lip in infancy combined with a one-layer vomer
flap for the closure of the nasal floor in the region of the
alveolus and hard palate at the same operation.
3. Closure of the remaining posterior palatal cleft in early
childhood by a von Langenbeck palatoplasty.
4. Secondary operations when required in consensus with all
team members with the ultimate aim of final rehabilitation of
patient by 18–20 years of age.
5. All surgical operations should be done as conservatively as
possible with no unnecessary harm to the hard or soft palate
(Fig. 75.12).82,83
FIGURE 75.12 Modifications in surgical technique and timing in

Oslo.
Lip repair
In BCLP patients lip closure is being done in two stages. Since 1961
Millard’ lip repair was adopted due to its advantage of optimal
muscle alignment.82,83
Primary lip repair was originally performed at 6 months, which is
now at 3 months (10 weeks) or rule of 10 has been in practice when
the baby is fit to withstand the risks of surgical procedures like
anaesthesia, blood loss, aspiration and so on. Also, the face grows
considerably after birth, making a fastidious repair easier.84
Closure of palate
In the Oslo Protocol, the anterior part of the palate is closed
simultaneously with the lip with a single-layer vomerplasty so as to
obtain a good closure. The rationale behind this procedure is that if
only the lip is closed at the first operation leaving the anterior part of
palate, the pressure of the lip muscle will narrow the gap between the
alveolar processes leaving little room to prepare the flaps necessary
for a reliable closure later on with a greater risk of developing an
oronasal fistula. Closure of hard and soft palate is done by von
Langenbeck procedure.
The timing of palatal closure is reduced from 3 to 4 years to 18
months as the chances of achieving normal velopharyngeal function is
better when the entire palate is closed before the most active phase of
speech development, which starts at 1 1/2–2 years of age.
Closure of the soft palate and reconstruction of the levator muscle
sling will provide as far as possible the anatomical basis necessary for
normal oronasal physiology; it will improve eustachian tube function
and reduce the incidence of otitis media along with psychological
benefits to the parents of cleft child.83
Secondary surgeries
Secondary alveolar bone grafting (SABG) of the primary palate is
done as a standard procedure following the principles of Boyne and
Sands, the pioneers in SABG.
Cleft palate patients with persistent velopharyngeal incompetence
are treated with a superiorly based pharyngeal flap before the start of
school if possible. The majority of children with BCLP are offered a
columella lengthening and a sulco-plasty at 5–6 years of age to
improve lip seal and aesthetics.
Rhinoplasty is done if required in the teenage period.83
Bilateral cleft lip and palate

‘Bilateral CLP cases also do not receive any presurgical orthopaedics’.
This approach provides least restraint on the maxillary
anteroposterior growth. Lip closure is done first on the wider cleft
side at about 3 months of age. Straight line closure is done on the skin
and mucosa without the suturing of the orbicularis oris in the midline.
The tension of lip closure centralises the premaxilla and then the other
side of the lip is closed at 4 months of age. Vomerine flaps from right
and left sides are used to close the anterior palate, which is done at the
age of 8–12 months using von Langenbeck technique. This provides a
well-aligned anterior palate and fully closed palate without any fistula
remaining.
Lip revision and columella lengthening are done at the age of 3
years. The objectives are to provide a nice philtrum and slight
narrowing of the alar bases.
The Oslo CLP team does not practice presurgical orthopaedics and
orthodontic treatment in the deciduous dentition. Minor corrections of
incisor tooth positions, anterior cross-bite and transverse segmental
cross-bites are corrected with fixed appliances only if necessary.
Secondary alveolar bone grafting is a standard protocol since 1977,
followed by a period of observation until definitive orthodontics can
be undertaken in the early permanent dentition. Nocturnal protraction
headgear is used to support anchorage during the period of active
space closure in cases where it is required.82 Current Oslo Protocol is
shown in Box 75.1.
Box 75.1 Current Oslo Protocol
• Unilateral clefts of the lip are closed at the age of 3 months by

Millard’s technique.
• Bilateral complete clefts are closed in two stages with an interval
of 4–6 weeks between the operations. The widest cleft in a child
with BCLP is closed first and the other side is closed 4–6 weeks
later.
• The anterior part of the palate is closed simultaneously with the
lip by means of a single layer vomerplasty.
• Clefts of the secondary palate are closed at the age of 12–18
months with a von Langenbeck procedure with reconstruction of
the levator muscle sling.
• The patients are reviewed at the age of 3–4 years when plans are
made for further treatment. Functional and cosmetic
imperfections are corrected as far as possible before school age.83
Children with a cleft of palate usually have associated speech and
language disorders. Speech has been recognised as one of the main
outcomes of cleft surgeries. The speech and language pathologist has
the primary role in the evaluation of speech and velopharyngeal
function in cleft patients. An assessment by the speech therapist is
required as early as 9 months of age. Development of speech and
language is a complicated process and takes place in different stages
(Fig. 75.13).85,86 The first 2 years of a cleft child are crucial for speech
development; moreover, it is the same time when the primary
surgeries for the cleft repair are undertaken.
FIGURE 75.13 Diagrammatic illustration of the oronasal seal.
(A) Normal. (B) Air escape in VPI causing nasality of voice. (C)
Production of speech requires well-functioning oronasal structures.
Children with delayed development of the speech may have

receptive language problems that arise because of the collection of
fluid in the middle ear. Hearing loss may also occur in these patients
due to ossicular malformations and/or improper ventilation of the
middle ear because of abnormal functioning of the eustachian tube.86
ENT evaluation and audiometry are essential investigations in CLP
patients.
The physiological integrity of the structures involved in speech and
optimal coordination of neurosensory-motorfunctions is essential for
the development of normal speech.36 The proper functioning of the
palate is an essential component in the articulation of speech.
The age of palatal repair influences the optimum development of
speech.86,87 The age of palate repair varies among different treatment
protocols in different countries and hospitals. The current trend is to
have the palate repair around 12–18 months to support speech
development by providing intact and functioning palate. In general,
the speech problems are more severe if the surgery is delayed.87–90
Clinically, an operated cleft palate child usually presents with a
short palate and/or decreased mobility of soft palate due to scarring
and the presence of an oronasal fistula. The post-surgery cleft
anatomy and function contribute to causing velopharyngeal
insufficiency, hypernasality, a nasal escape of air, misarticulation and
poor intelligibility of speech.87,90 If the lip seal is inadequate due to the
decreased mobility of the lip, enhancing the lip competence with a
simple sulcoplasty may help in speech improvement.
The speech assessment tool consists of a perceptual evaluation of
articulation characteristics, resonance, nasal emission, nasal
turbulence, grimace, phonation and intelligibility. It also includes the
cold mirror test, nasometry and a myofunctional examination.91
Obturators
Acrylic obturators help to ascertain the cause of nasality and also
serve as devices, which prevent the escape of fluids to the nasal
cavity.90 Temporary obturators prevent the escape of air through the
oronasal fistula. The modified obturator-called speech bulb appliances
are useful in cases where a palatal lift, alternatively soft palate closure,
is needed to improve the velopharyngeal seal.
The closure of oronasal fistula can be accomplished by secondary
bone graft in the cleft and fistula region at about 7–10 years of age.
Pharyngoplasty and palate lengthening procedures are performed
to maintain velopharyngeal seal by the plastic surgeons in
consultation with the speech therapist. Speech therapist and
audiologist are an integral part of the cleft team. Most children require
speech therapy guidance following surgery.
Record taking in cleft patients
Clinical records should be taken for individual patients to allow
treatment planning, monitoring treatment progress and treatment
evaluation. Further, it helps in comparison of treatment outcomes and
therefore plays an indispensable role in improving the overall quality
of care.
The case history of the patient should be recorded at the initial visit
and should include the following details of cleft patient:
1. The demographic details with unique id assigned to each

patient
2. Family history and psychosocial assessment
3. Antenatal history of the mother
4. Medical history including history of surgeries
5. Dental and orthodontic history
6. Examination of cleft to be done by the plastic surgeon or
general surgeon
7. ENT assessment
8. Speech assessment
9. Genetic assessment via pedigree chart
10. Orthodontic evaluation and complete records.
The photographs of the cleft patient should include extraoral and

intraoral views. The extraoral basic views should include frontal view,
right and left lateral view, inferior (columellar) view, three-quarter
facial (oblique) view. Dynamic views include smiling and whistling in
the cooperative older patient. These views will give an idea of the
functioning of the circum-oral musculature. Video recording will be
better for assessing circum-oral movement but this will also need to be
standardised and cannot be used routinely at present (Fig. 75.14).92
FIGURE 75.14 Cleft lip and palate photographic protocol (A).
Additional optional views (B). Cleft photography protocol. Facial
and optional intraoral views.
General Principle’s governing record taking and timings of

minimum records were discussed and formulated at the WHO. The
timing of minimal radiograph protocol so as to reduce the radiation
exposure of the cleft patient has been shown in Tables 75.5–75.7.93
Table 75.5
Timing of minimum records
a Only in cases with cleft of the alveolus as well as cleft lip.
b If hard palate is closed.
Table 75.6
Timing of minimum records for secondary alveolar bone grafting (SABG)

Timing Intraoral X-ray Photographs
Just before bone graft ✓ ✓
6 months after graft ✓
After canine fully erupted ✓ ✓
Table 75.7
Timing of minimum records for pharyngoplasty and
orthognathic surgery
The specific applications of CBCT in cleft patients are related to 3D
evaluation of alveolar bone defect, position and structural anomalies
of teeth and skeletal malocclusion associated with CLP (Fig. 75.15).
However, the CBCT imaging should be used based on the individual
basis with clinical justification, not as a routine investigation.
American Academy of Oral and Maxillofacial Radiology recommends
small (≤10 cm) or medium (≥10 to ≤15 cm) FoV for the evaluation of
CLP and associated dental and skeletal anomalies. The large field of
view (FoV) (≥15 cm) imaging may be used for orthognathic surgical
planning.94
FIGURE 75.15 CBCT volumetric image helps to locate bone

defects and relationship of teeth roots in the vicinity.
Orthodontic management
Each cleft patient has his phenotype and is affected by iatrogenic
effects of surgery.
The operated patients of the cleft lip and palate show:
1. Reduced growth of the maxilla in all the three dimensions of

space that is, anteroposterior length, height and width.
2. The unwanted effects of cleft surgery are highly variable. The
severity of the congenital birth defect and protocol of surgery
does affect the treatment outcome.
3. In developing countries such as India, all cleft children do not
get timely and proper intervention by the cleft surgeons due to
several factors, including lack of access to the cleft team. Many
operated patients are seen with incomplete, badly repaired
clefts and large fistulas. Many of the patients undergo multiple
surgeries for the correction of the fistula that further hampers
the maxillary growth. The outcome is severe maxillary
hypoplasia and skeletal class III malocclusion.
4. Unoperated children with cleft maxilla are occasionally
encountered. While their speech and aesthetics are severely
affected, the growth of the maxilla in all the three dimensions
of space seems to be normal (Fig. 75.16).
FIGURE 75.16 Unoperated UCLP.
Case TR 12 years. Unoperated cleft subjects have a potential for
normal maxillary growth.
Indices for cleft

To categorise the complexity of malocclusion in patients with cleft lip
and palate and the purpose of choosing a treatment option several
indices have been used. Among these, GOSLON yardstick was the
first introduced by Michael Mars and Olav Bergland in 1987.
The indices allow results to be scrutinised and the overall quality of
care to be improved.
The cleft surgery outcome indices on dental models are usually
performed on children with UCLP at either 5, or 10–12 years of age.
The commonly used indices used in cleft patients are enlisted as
under:
1. GOSLON yardstick
2. 5-yr-old’s index
3. Huddart Bodenham system
4. Modified Huddart Bodenham system
5. EUROCRAN.
GOSLON Yardstick. GOSLON index categorises the dental
relationships into five ratings based on the severity of malocclusion
deduced from anteroposterior assessment, vertical assessment and
transverse assessment (Box 75.2).
Box 75.2 GOSLON ratings
• GOSLON 1 – Excellent
• GOSLON 2 – Good
• GOSLON 3 – Fair
• GOSLON 4 – Poor
• GOSLON 5 – Very poor
Based on reference study models, the index is applied in three

stages:
Stage 1: Anteroposterior assessment – This is considered to be the
most important clinical feature for the rating in the GOSLON index
and is examined first. Class II div 1 malocclusion or positive overjet is
considered most favourable for orthodontic correction and is ranked
group 1, while severe class III incisor relation is considered to be least
favourable and is placed in group 5. Edge-to-edge bite is classified as
group 3 and negative overjet of 1–2 mm as group 4 and negative
overjet of 3–4 mm is classified as either group 5 depending on dento
alveolar inclination. Further dentoalveolar compensation in reverse
overjet cases is considered unfavourable. For example, if the reverse
overjet is 3–4 mm, it indicates that the case might belong to group 4. If
the dentoalveolar compensation is present with marked proclination
of maxillary incisors and retroclination of mandibular incisors, it
indicates that the overjet underestimates the severity, and it should be
ranked in higher category that is group 5. On the contrary, if the
inclination of incisors over exaggerates the severity then lower
category, that is, group 3 is allocated. This holds true for all the
groups.
Stage 2: Vertical assessment – Deep overbite is considered
favourable, and open bite is unfavourable. Vertical features do not
indicate a modification of the provisional category charted earlier
based on anteroposterior assessment except in borderline cases. For
example, a case placed at the borderline between group 3 and 4 on
anteroposterior assessment, but with a deep overbite is ranked into
group 3 while a case provisionally diagnosed as group 3 but with
open bite will be transferred to group 4 at this stage.
Stage 3: Transverse assessment – Canine cross-bite is considered to
be more difficult to treat rather than molar cross-bite. Further, the
degree of transverse arch constriction is more crucial than the number
of teeth in cross-bite. A normal transverse relationship or cross-bite
that can be treated orthodontically does not require a change of group.
Marked narrowing of the maxillary arch with bilateral cross-bite could
indicate a more severe or higher category for a case already at the
upper limits of the lower group (Fig. 75.17).
FIGURE 75.17 Goslon index.
Representative models Group1–5.
Based on the GOSLON index rating, the treatment of the child is

decided as follows (Box 75.3).
Box 75.3 GOSLON index

Groups 1 and 2: Require simple orthodontic treatment or no
treatment at all.
Group 3: Malocclusion requires complex orthodontic treatment but
good result can be anticipated.
Group 4: Malocclusion being at the limits of orthodontic treatment
without orthognathic surgery to correct skeletal malrelations and if
facial growth is unfavourable, orthognathic surgery is required.
Group 5: Requires orthognathic surgery.
The main advantage of GOSLON index is that it is simple to use as

an outcome measure of primary UCLP surgery.95 This index is limited
to be used in UCLP children with late mixed and early permanent
dentition only. This is the major limitation of this index.
5-year-olds’ (5YO) index was developed by Atack et al. in 199796 to
overcome the shortcomings of the GOSLON Yardstick; this index is
applied at 5 years of age that is in the primary dentition in UCLP
patients. It categorises the dental relationships into 5 groups ranging
from 1 to 5 with the outcome measure ranging from excellent to very
poor based on overjet, incisor inclination, cross-bite, open bite,
maxillary arch shape and palatal vault anatomy96,97 (Table 75.8).
Table 75.8
General features of study models in the 5-years-olds’ index

Predicted long-
Group General features
term outcome
1. Positive overjet with average inclined or retroclined incisors Excellent
No cross-bites/open bites
Good maxillary arch shape and palatal vault anatomy
2. Positive overjet with average inclined or proclined incisors Good
Unilateral cross-bite/cross-bite tendency ± Open bite tendency
around the cleft site
3. Edge-to-edge bite with average inclined or proclined incisors; or Fair
reverse overjet with retroclined incisors
Unilateral cross-bite ± Open bite tendency around the cleft site
4. Reverse overjet with average inclined or proclined incisors Poor
Unilateral cross-bite ± Bilateral cross-bite tendency ± Open bite
tendency around the cleft site
5. Reverse overjet with proclined incisors Very poor
Bilateral cross-bite
Poor maxillary arch form and palatal vault anatomy
Huddart Bodenham system – The original Huddart Bodenham

scoring system was developed in 1972. This system was devised
subsequent to evaluation of two other categorical indices, which were
devised by Pruzansky and Aduss, and Matthews et al., both of which
assess the presence and degree of cross-bite, both anteriorly and
posteriorly. This index scores each maxillary tooth and its opposing
tooth based on the presence and degree of cross-bite. These scores are
then summed to deduce one overall score. It has five categories for
scoring incisors ranging from + 1 to −3 and three categories for scoring
canines and molars ranging from 0 to −2. This system is used for the
assessment of treatment outcomes in patients with UCLP in
deciduous dentition or below 6 years (Fig. 75.18).98
FIGURE 75.18 The Huddart/Bodenham system.

(A) Segmental divisions of the maxillary arch. (B) Incisor scoring. (C)
Canine scoring. (D) Molar scoring.
The modified Huddart/Bodenham index – The Huddart/Bodenham
system was designed for use in the primary dentition, and it was,
therefore, necessary to modify it for use in the mixed dentition. This
was undertaken by scoring premolars in the same way as primary
molars. At the age of 6 years and after that, the first permanent molars
if present, or the midpoint of the maxillary alveolar ridge were scored
similarly as in original Huddart/Bodenham index ensuing maximum
range of score from −22 to +2. In theory, this allows for finer
discrimination between results and also provides a more objective
final score. This can be applied to either of the groups. It is the most
reliable and objective primary surgery outcome measure but the most
time-consuming index to use.99–101
EUROCRAN index developed by the participants of the
EUROCRAN project (2000–2004) – This scores palatal morphology, as
well as the dental arch relationship and a score, is assigned for each
component from a 3-point and 4-point scale, respectively. Variants of
this index have been developed for application on either the 5- or 9-
year age group. Thus the EUROCRAN yardstick is a modification of
the GOSLON yardstick and 5-year-old index, and it is again designed
to assess surgical outcomes in patients with UCLP.102
Orthodontic intervention during deciduous

dentition
The present concept in the orthodontic management of cleft lip and
palate patient is of minimal intervention during various phases of
development of dentition and occlusion. In deciduous dentition, the
dental irregularities are usually minor, and orthodontic treatment
does not offer long lasting benefits. Moreover, the correction of
malocclusion in the deciduous dentition does not ensure eruption of
permanent teeth in normal occlusion.
Maxillary arch collapse and posterior cross-bite can be identified
during deciduous dentition stage itself. However, the maxillary
expansion is usually deferred until the transitional dentition period
and undertaken after the eruption of the first molars and permanent
incisors. The maxillary expansion may also precede maxillary alveolar
bone grafting. This approach reduces treatment time and enhances
therapeutic efficiency and patient cooperation. Correction of anterior
cross-bite and anteroposterior dysplasia is usually undertaken
simultaneously. A multi-band fixed approach is preferred over the
removable appliance.
Orthodontic intervention during early mixed

dentition
Children with cleft lip and palate have several dental anomalies,
which include microdontic teeth, missing lateral or central incisors
and supernumerary teeth in the cleft region. The teeth in the incisor
region also show an aberrant path of eruption. During early mixed
dentition any retroclination or anterior cross-bite is corrected with the
objectives to allow normal growth of the maxilla. The rotated teeth
that are not in cross-bite may or may not be interfered with, especially
if bone support is not enough. In such conditions, one is always posed
with the danger of tipping the root of the tooth into the cleft area thus
risking its vitality. Anterior cross-bite or edge-to-edge bite causing a
functional shift of the mandible can be relieved either by selective
grinding or orthodontic treatment as the case may require.
Patients with minimal anteroposterior inter-maxillary skeletal
malrelation are usually treated with protraction headgear for
maxillary advancement. However, the protraction appliance demands
cooperation from the patients, which may be a constraint in many
children.
Alveolar bone graft

• Alveolar bone grafting (ABG) is aimed at providing a bony
bridge to the cleft in the alveolus area.
• Primary ABG is usually done between the first few days of life
and 2.5 years of age.
• Early secondary ABG is done between the ages of 2 and 5
years old.
• Secondary alveolar bone grafting is carried out between the
ages of 6 and 13 years.
• Late ABG is done after 13 years of age.
• The alveolar bone graft may be done along with the Le Fort 1
osteotomy procedure which is called tertiary alveolar bone
graft (TABG).103
Primary alveolar bone grafting

Primary alveolar bone grafting (PABG) and early secondary alveolar
bone grafting are not in practice now because of the burden and risks
of additional surgery required to harvest the bone from the donor site
at a relatively young age. Additionally, the surgical procedures
themselves are not without deleterious effects, not only on the maxilla
but also on the donor site. It has been documented in the literature
that such surgeries also result in increased growth disturbances of
maxilla.104,105
In some centres, the primary bone graft is still followed and is done
with a wedge-shaped piece of the rib bone.
Secondary alveolar bone grafting

Boyne and Sands introduced secondary alveolar bone grafting (SABG)
technique in 1972, and it has greatly influenced the cleft lip and palate
treatment approach around the world. This technique is aimed to
bridge the cleft segment with grafted cancellous bone, harvested from
the iliac crest.106 Norwegians were the first to adopt, practise and
report findings of SABG.107 Grafted cancellous bone fills in the
residual alveolar cleft and is anatomically joined to the adjacent bone,
becoming indistinguishable in radiographic images after an average
period of 3 months. This structural incorporation has been
histologically proved in young Rhesus monkeys. It seems to occur
more rapidly in younger patients.108
Merits of secondary alveolar bone graft
Prior to the era of secondary alveolar bone graft, the teeth in the area
of the bony cleft used to be sacrificed due to non-availability of the
bony support. The orthodontic closure of the space was not possible,
and hence the prosthodontic rehabilitation was the only option. The
secondary alveolar bone graft has now minimised the need for
prosthodontic rehabilitation. It has several other benefits:
• Elimination of bony clefts and thereby encouraging a normal

eruption of lateral incisor and canine through cancellous bone.
The most important benefit of secondary bone grafting is that
the newly grafted bone acts as the alveolar bone, allowing for
spontaneous migration of the erupting canine towards the
alveolar ridge and for the creation of a functional
periodontium around the tooth.
• Orthodontic closure of cleft space becomes possible thus
minimising the need for prosthodontic rehabilitation of the
missing teeth in the cleft area.
• In case lateral incisor is missing, and a decision is made to
maintain the space, the grafted bone provides an excellent site
for the prosthetic implant placement.
• SABG helps in the closure of oronasal fistulas.
• The stabilisation of maxillary segments, which is helpful
during the orthognathic surgery.
• Provides structural support to the alar base and improvement
in aesthetics.
Timing of SABG surgery

SABG is done at an age when the growth inhibition effects of the
surgery on maxilla are minimised, and it can help the maxillary canine
or lateral incisor to erupt normally through the cancellous bone. After
the age of 9 years, maxillary growth is minimal. Secondary bone
grafting is done during the mixed dentition stage after the eruption of
permanent incisors but before the eruption of permanent canines. The
timing of bone graft is based on the root formation and eruption
pattern of the maxillary lateral incisor and maxillary canine. In case
insufficient bone is available in the cleft area for the lateral incisors to
erupt, bone graft can be done around 7 years of age.
Assessment for secondary alveolar bone graft

SABG requires careful clinical and radiological assessment. Clinical
evaluation involves recognition of the presence of any fistula,
symptomatic or asymptomatic, that may require simultaneous
closure. A clinically asymptomatic fistula may become apparent
following pre-bone graft expansion. Teeth in the vicinity of the cleft
area need to be assessed. All retained deciduous teeth, supernumerary
teeth and rudimentary teeth at the cleft area are usually extracted
before the bone graft.
Radiological assessment includes a full set of radiographs. The
intraoral periapical (IOPA) radiographs, supplemented with occlusal
radiographs are usually sufficient. The 3D evaluation of the bony
defects with CBCT has greatly enhanced diagnostic possibilities by
offering a virtual evaluation of the defects.
Pre-bone graft orthodontics

The pre-graft orthodontic treatment contributes to better access of site
for the surgeon at the time of the grafting procedure and helps to
expand the cleft to the normal size of the maxilla.
The maxillary arch expansion is usually performed preparatory to
secondary alveolar bone graft. The quad helix appliance is the
appliance of choice for expansion of the collapsed maxilla (Figs 75.19
and 75.20). The advantages are controlled force, need for relatively
less patient cooperation and ability to derotate the molars.
Orthopaedic expansion during the mixed dentition to reposition the
palatal segments can also be undertaken. However, we prefer a slow
and gentle arch expansion and alignment of the dental arches. Trihelix
appliance is useful in V-shaped arches. Occasionally, some patients
are subjected to maxillary protraction in addition to the expansion to
correct maxillary anteroposterior deficiencies.
FIGURE 75.19 Wire framework maxillary dentoalveolar expansion
appliances.
(1) A Quad helix appliance. (A) Collapsed maxillary arch. (B) Quad
helix appliance in situ. (C, D) After dentoalveolar expansion. (2) Tri-
helix expander is the appliance of choice for anterior collapse. (A)
Collapsed maxillary arch in UCLP patient. (B) Tri-helix appliance in situ.
(C, D) After dentoalveolar expansion.
FIGURE 75.20 (1) NiTi palatal expander. (2) NiTi palatal expander for
alignment of collapsed maxillary dental arches seen in operated UCLP
patients. (A) Collapsed maxillary arch. (B) NiTi palatal expander in situ.
(C) After dentoalveolar expansion.
The secondary alveolar bone graft helps obturate the oronasal

fistula, improves speech and allows the canine to spontaneously erupt
through the graft thereby reducing the need for prosthetic
replacement.106,109,110
Surgical technique
Two surgeons work simultaneously, one on the donor site and other
at the host site. The technique of SABG involves an incision around
the margin of the cleft alveolus. Full thickness mucoperiosteal flap is
raised to allow space for bone graft. The gingival mucoperiosteal flap
is the most recommended method of bone graft coverage because the
attached gingiva covering the bone provides an excellent cuff around
the tooth, which then erupts through it. The iliac bone graft is
harvested, packed in the cleft alveolus space. This flap is then sutured
to ensure a complete seal. Occasionally, there is a lack of soft tissue
coverage of the graft, which increases the risk of failure of the graft.
Surgeons at AIIMS have undertaken alveolar bone graft with
simultaneous lip revision and closure of the oronasal/labionasal
fistula. This technique was developed for the patients who had a large
oronasal fistula, incomplete repair of the lip without any nasal lining
and improper lip repair (Fig. 75.21). UCLP case treated with SABG
and orthodontic treatment is shown in Figs 75.22 and 75.23.
FIGURE 75.21 One stage lip, fistula repair and secondary

alveolar bone graft procedure.
(A) Approach to the fistula from lip and palate. (B) Nasal and oral floor
repair. (C) Harvested bone graft in place. (D) Lip closure, palate
closure.
FIGURE 75.22 (A) Case VM, UCLP right side. Arches are aligned and
secondary alveolar bone grafting was planned. Pre-treatment lip profile
and IOPAs show rudimentary left maxillary lateral incisor present next
to the alveolar cleft. Early secondary bone graft for a lateral incisor.
(B) The IOPA radiographs show successful secondary alveolar bone
grafting. (C) Post debond photographs show improved smile and
occlusion. The occlusal and IOPA radiographs show the stable alveolar
bone grafting. (D) Five years post debond photographs show stable
occlusion and bone graft.
FIGURE 75.23 Treatment results after SABG with lip revision in a

young female with BCLP.
(A) Pre-treatment occlusal radiographs show an extensive bone defect
on the left side, rotated central incisor, missing left lateral incisor,
erupting canines. (B) Following pre-bone graft orthodontics. (C)
Following lip revision and bone graft. (D) Follow-up during retention
phase.
Post-bone graft follow-up
It requires retention of the expansion either by a fully bonded
appliance or by reinserting a passive expansion appliance. The post-
bone graft period is essentially a wait for the permanent canine to
erupt through the grafted cancellous bone, which gets incorporated
into the surrounding alveolar bone. Literature documents that 70% of
the canines spontaneously erupt through the grafted bone.
Occasionally, however, the canine need some type of extra biological
stimuli to facilitate their eruption. The possibility of surgical
procedures, with or without subsequent orthodontic intervention,
which aims to stimulate eruption of teeth through the grafted area
needs to be considered when the canine does not show any signs of its
movement towards the occlusal table. These procedures include
surgical exposure of the canines, and orthodontic traction.
Bergland and co-workers108 have given an index to evaluate the
success of the grafted bone based on the height of the interdental
septum on IOPA X-ray films (Fig. 75.24; Box 75.4).
FIGURE 75.24 Bergland index.

The success of SABG is evaluated on IOPA radiographs. (A) Normal
bone height up to the inter-dental crest. (B) 75% of the normal. (C)
Less than 75%. (D) No bony bridge.
Box 75.4 Bergland index
Type I – normal
Type II – 75% of the normal bone height
Type III – less than 75%
Type IV – no bony ridge.
Comprehensive orthodontic treatment

Two to three years after the secondary bone grafting, when the
permanent canines have erupted, comprehensive orthodontic
treatment can be started. The case is assessed for orthodontic
treatment and, alternatively, orthodontic treatment combined with
orthognathic surgery (Fig. 75.25).
FIGURE 75.25 Comprehensive orthodontics and rehabilitation of
edentulous space with a conventional partial denture.
(A) Young girl with UCLP has anterior and bilateral posterior cross-bite.
(B) Comprehensive orthodontics to camouflage anterior cross-bite,
expansion and alignment of the posterior arches. She also underwent
lip revision and SABG to close the oronasal fistula. (C, C′) Her canine
has been moved distally to the healthy bone as a substitute for the
missing first premolar. A large bone defect limits option to place
implants or fixed prosthesis. (D) A removable partial denture (RPD)
also serves as a retention appliance. (D′) A pleasing outcome.
The severity of the negative overjet and deficiency of the maxillary

skeleton are major deciding factors on orthodontic treatment alone or
a combined orthodontic and surgical approach. GOSLON index is a
reliable indicator of the complexity of treatment need in the
evaluation of such cases.
The orthodontic treatment is accomplished by using fixed
appliances. Twin bracket edgewise or a pre-adjusted appliance system
for three-dimensional control on the teeth works well. With the wire
sequence from highly flexible to rigid wires in a progressive approach
with simultaneous expansion and/or chin cup therapy, dental
malpositions are corrected and arches are well aligned to a good arch
form.
If the lateral incisor is present and viable in a cleft region, every
attempt should be made to preserve it. In patients with missing lateral
incisors, a decision should be made regarding whether the patient
needs space closure or space is to be maintained for prosthetic
rehabilitation. Long-term evaluation in non-cleft patients has
demonstrated the superiority of orthodontic closure over the
restorative treatment with regard to oral health. Moreover, a multi-
unit prosthetic bridge is undesirable in young patients for a number of
reasons. In all patients with missing lateral incisors in whom space
closure seems to be possible, every effort is made to move the canine
and buccal teeth mesially (Fig. 75.26A–C).
FIGURE 75.26 Comprehensive orthodontics and rehabilitation of
secondary deformity in a case of BCLP.
(A) Case R, with BCLP, mobile premaxilla, a large alveolar cleft
bilateral cross-bite in canine and premolar region. (B) Maxillary arch
collapse have been corrected, and upper and lower arches are aligned.
Due to the large size of the alveolar cleft, the removable partial denture
was planned. (C) After lip revision and completion of the orthodontic
treatment, the missing teeth have been provided with a temporary
prosthesis.
In most patients, the contemporary orthodontic treatment is

completed by the age of 15 years, and a retainer is placed. In patients
in whom space closure is not possible because of aplasia or class III
occlusion, prosthetic management should be considered. Rigid palatal
retainers such as those with wire framework soldered on molar bands
are considered better options to maintain arch alignment and
expansion.
Patients with large basal maxillomandibular jaw discrepancies with
unfavourable growth pattern (GOSLON 4,5) require combined
orthodontic and orthognathic surgical treatment to achieve good
aesthetics and stable dental occlusion. These patients would need Le
Fort osteotomy of the maxilla to bring the small and retro-positioned
maxilla forward, alone or in combination with BSSO on the mandible
for the reduction of the mandibular length. Orthognathic surgery of
cleft palate patients presents with considerable difficulties as
compared to the non-cleft subjects. Most complications are related to
an inadequate blood supply, scarring from previous surgeries and a
split maxilla. Common complications are the infection of the soft
tissues, bone necrosis, loss of teeth and delayed healing. Patients with
palatal clefts who undergo orthognathic surgery are also at risk of
worsening velopharyngeal insufficiency due to the forward
movement of the soft palate along with the maxillary advancement.
This may, in turn, lead to increased hypernasality of the voice after
such surgeries. Therefore, a pre-operative evaluation by the speech
pathologist is always required, and the patient must be duly informed
about the possible speech alterations before surgery. Distraction
osteogenesis is a viable option for consideration.
The application of DO technique for expansion and protraction of the
cleft maxilla is gradually catching up. DO is a superior alternative to
orthognathic surgery. The orthodontist helps to create a rigid wire
framework on the maxilla which provides suitable attachment for the
application of traction force through rigid extraoral fixation device
(RED). DO is surgically less invasive compared to orthognathic
surgery. The benefits of DO also lie in its efficacy to correct a large
negative overjet. Distracting the maxilla also minimises the chances of
relapse. The danger with worsening of velopharyngeal problems is
virtually non-existent if the procedure is done properly.
The ultimate goal of treatment for the patient with cleft lip and palate
is rehabilitation that results in normal functions and excellent
aesthetics without the use of prosthesis.111,112
The prosthetic needs of each patient vary; these include a single
tooth or multiple tooth replacements and cosmetic restorations. A
patient in whom space closure by orthodontics is not possible,
prosthetic replacement of the missing teeth is required. The final
design of the fixed prosthesis is determined on the basis of original
malocclusion, the cleft space, hard tissue of the abutment teeth, their
periodontal status, aesthetics and the need for replacement of other
teeth.
Malformed and abnormal shaped central and lateral incisor is a
common feature in cleft patients. Such malformed and discoloured
teeth are successfully treated with laminates and porcelain crowns.
In cleft lip and palate patients with severe maxillary retrusion and
collapse of the upper arch, the orthognathic surgical approach may
not be feasible. Such patients require overlay prosthesis for the
correction of horizontal and vertical growth deficiencies of the
midface and rhinoplasty.
The challenge of treatment and burden of care of cleft lip and palate is
huge and long. The cleft care involves multiple disciplines, time and
cost. The only way to eliminate the occurrence of CLP is to know its
exact aetiology which has so far remained elusive to the scientists and
researchers. The current focus of research is to be able to locate genes
involved and the nutrition factors that are responsible for the
aetiology of the cleft.
The 3D imaging is also likely to be used for scanning the cleft
mouth and fabrication of appliances using 3D printing technology.
The 2D clinical photograph will be replaced with non-radiation 3D
imaging of face; their current use is limited to research.113–115
The scientists have successfully evolved the use of bone substitutes
to fill in the bone defect. Although bone morphogenetic protein 4
(BMP 4) has been in use for some time, a more practical and
economical alternative is needed. The 3D CBCT scans could be
manipulated for the creation of bioabsorbable scaffolds of the cleft
defect which can be filled with bone substitutes and growth factors as
a substitute to iliac bone graft.
Key Points
Treatment of a child affected with cleft lip and palate begins from the
day he is born. Psychological counselling of the parent and a full team
assessment of the affected child are important to provide quality care
to the patient and to start holistic treatment planning.
Although the treatment involves a multispecialty approach, the role
of one specialist may appear more important at certain stages of
treatment than others. The primary repair of lip and palate is done by
a plastic surgeon.
The speech is evaluated during the first year after the primary
surgery because this is a critical time for speech development and a
child may need guidance and evaluation. Follow-up is done by an
orthodontist to assess the development of occlusion and the need for
bone grafting. Secondary surgeries to improve speech like palatal
lengthening procedures or pharyngoplasty are also planned as
required.
During the mixed dentition stage, the role of orthodontist becomes
significantly important as he prepares the maxilla for secondary
alveolar bone graft. An oral surgeon in consultation with the
orthodontist decides the timings of bone grafting. After 15 years of
age, the needs for prosthetic rehabilitation and orthognathic surgery
are assessed.
In some countries, the high cost of rehabilitating the child with a
cleft is borne or at least supported by the state. The high cost of
treatment in part can be reduced with rationalisation and timely
treatment. The need for establishing combined cleft palate clinics
involving specialists is the need of the hour in many countries.
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PMC3977868.
CHAPTER 76
Orthodontist’s roles in upper
airway sleep disorders
Balakrishnan Jayan
Abhijeet Kadu
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Epidemiology
Normal sleep
Abnormal sleep
Anatomical variations in the upper airway
Craniofacial morphology of decreased airway space
Snoring
Sleep apnoea
Symptoms of OSA
Investigations
MADs with set/recorded mandibular advancement
Tongue retaining device (TRD)
Tongue repositioning manoeuvre with oral shields
Titratable mandibular advancement devices (MADs)
Therapeutic benefits of MAD
Fabrication of a MAD
Limitations of MAD
Sleep bruxism
Upper airway resistance syndrome (UARS)
Upper airway sleep disorders in children
Predisposing factors
Prevention and management
Key Points
Introduction
Human beings spend approximately one-third of their lives sleeping
and this is recognised as having an important physiological role. Sleep
disorders of the upper airway result from any condition or disease
that causes partial or complete obstruction of airway when the patient
assumes a supine position and goes to sleep. Sleep disruption caused
by breathing disorders are potentially life threatening and therefore
an important global health issue.
Common upper airway sleep disorders are:
• Snoring
• Obstructive sleep apnoea (OSA)
• Sleep bruxism
• Upper airway resistance syndrome (UARS).
Sleep disorders, particularly untreated obstructive sleep apnoea

(OSA) has been linked to deteriorating systemic health and known as
a risk and possible causative factor in developing of systemic
hypertension,1–3 depression, stroke,4 angina5 and cardiac
dysrhythmias.6 OSA, when left untreated, can be associated with
motor vehicle accidents,7 poor work performance in the office or work
place and therefore, also makes a person prone to occupational
accidents and reduced quality of life.8,9 This constellation of issues
adversely affects patients on their personal, social and professional
levels.
Comprehensive management of upper airway sleep disorders
requires an interdisciplinary approach. The orthodontist can play a
significant role in the team approach to the management of mild to
moderate OSA. He can help the sleep physician to analyse the
craniofacial anatomy of upper airway, design and fabrication of oral
appliance for mandibular advancement, institute orthodontic
treatment during maxillomandibular advancement by orthognathic
surgery or distraction osteogenesis. An orthodontist can diagnose,
plan and treat mandibular deficiency in growing children by
appropriate functional appliance therapy and thereby prevent
established OSA in children and prevent potential OSA in adults. An
orthodontist can help growing children by predicting potential sleep
apnoea and instituting the right course of treatment.
Epidemiology
Snoring: Prevalence of snoring increase with age and approximately
25% of all men and 5%–10% of all women snore. Recent population
surveys have found a strong correlation between snoring and daytime
sleepiness.10 The estimated prevalence of sleep disordered breathing
(SDB) in urban Indian men was 19.5% (AHI of 5 or more) and 7.5%
(SDB with hypersomnolence) which is striking and may have major
public health implication in a developing country like India.11 It is
considered that prevalence of sleep related disorders has a significant
correlation with obesity.
OSA: Prevalence studies in western countries estimate that 4% of
middle-aged men and 2% of middle-aged women in the general
population would meet the minimum criteria for sleep apnoea
syndrome.12 Wisconsin sleep cohort study, a population based study
of middle-aged adults, estimated 24% of men and 9% women as
having sleep disordered breathing based on AHI (apnoea–hypopnoea
index) criteria of five or more and have reported daytime
hypersomnolence.13
Sleep bruxism is reported in 5%–8% of the general adult population
with no significant gender difference.
Normal sleep
Sleep is not a homogenous state and is divided into two states: (1)
non-rapid eye movement (NREM) sleep and (2) rapid eye movement
(REM) sleep. These stages can be distinguished by
electrophysiological criteria using electroencephalogram. In REM
sleep, the brain activity is similar to a state of wakefulness. NREM
sleep is divided into four stages. Stages 3 and 4 represent a deeper
level of sleep and are required to refresh the brain. REM and NREM
sleep alternate cyclically through the night at intervals of 90–120 min.
In a normal sleep, a person would progress from wakefulness to
NREM sleep state to REM sleep state. Overall sleep at night comprises
of 75%–80% NREM and 20%–25% REM sleep. Recently the sleep
staging has been revised and is as follows:14
• Stage W (Wakefulness)
• Stage N1 (NREM1)
• Stage N2 (NREM 2)
• Stage N3 (replaces NREM stages 3 and 4)
• Stage R (REM)
The salient features and EEG recording associated with sleep stages
are presented in Box 76.1. The minimum amount of sleep that is
required for healthy living is 7–9 h. The number of hours of sleep that
is considered to be optimal varies with age. Infants and young
children require 12–14 h, preadolescents require 10–11 h, teenagers or
young adolescents 8–10 h, and adults 7–9 h.
Box 76.1 Sleep stages
Sleep stage Salient features EEG recording

Wakefulness
Stage N1 • 2%–5% of sleep time
• Drowsy or light sleep
stage
• Can be awakened easily
• Sudden muscle
contraction
• Brainwave activity from
rhythmic alpha waves to
mixed waves
• Can be aroused but more
stimulus required than N1
• Reduction in heart rate
and body temperature
• EEG will show K
complexes and sleep
spindles

• Slow wave sleep, deep
sleep or restorative sleep
• Highest threshold for
awakening
REM stage R • 20%–25% sleep time

• Each recurring REM is
longer than the prior
period
• Increased heart rate,
respiration, blood
pressure and jerky eye
movements
• EEG characterised by saw
toothed wavy form,
similar to wakefulness
The ventilatory activity of respiratory muscles including the

musculature of the upper airway is reduced in sleep. This results in a
fall in ventilation and increase in resistance of upper airway leading to
increasing CO2 saturation. Ventilatory activity in sleep is stimulated
by chemical drive from hypoxia and hypercapnia. During
wakefulness, the behavioural drive also stimulates ventilatory
activity. During REM sleep, there is generalised inhibition of skeletal
muscles including intercostals, accessory and pharyngeal dilators.
Thus, ventilation during REM is virtually dependent on
diaphragmatic function, and upper airway function is more
precarious than during NREM. Sleep is a time of vulnerability for the
respiratory system. The resistance of the system is increased, and at
the same time, both chemical and mechanical sensors are depressed.
Considerable individual variation exists in the threshold for arousal in
response to chemical and mechanical/behavioural drive. This
variation in responsiveness may be a significant risk factor for OSA.15
Abnormal sleep
Pathophysiologic mechanism of snoring and OSA although fully not
understood can be explained by either the obstacle theory or the
Bernoulli theory.16
According to the obstacle theory, an increased negative pressure
during inspiration retracts the structures of the pharynx and makes
them vibrate in the airflow to produce snore and possible obstruction
in OSA.
The Bernoulli theory assumes that according to the principle of
Bernoulli (1738), the velocity of streaming air is higher and the
pressure lower at a constriction of a tube compared with a larger part.
This may cause inward suction of the pharyngeal structures in a
constricted area and causes snoring by the vibration of wall structures.
Anatomical variations in the upper airway

Upper airway is a non-rigid structure, which includes hypo pharynx,
oropharynx, velopharynx and naso pharynx (Fig. 76.1A). During
inspiration, the air pressure in the upper airway space becomes sub-
atmospheric caused by diaphragm attempting to pull air through the
airway and the walls of the airway resisting this airflow. The negative
pressure tends to cause a change in shape of the airway, which is
resisted by the activity of tensor veli palatini and the genioglossus
muscles. In an OSA patient, there is a reduction in the activity of these
muscles that results in decreased airway space.17
FIGURE 76.1 (A) Functional anatomy of the normal airway during

sleep. (B) Anatomy of the airway during OSA.
The man is the only mammal other than English Bulldog that
experience OSA. OSA in humans has often been hypothesised as an
anatomic illness caused by evolutionary changes. Natural selection,
during the process of evolution, is believed to have resulted in
bipedalism along with the migration of splanchnocranium (face)
under and behind the neurocranium for locomotion and binocular
vision and laryngeal descent with shortening of the palate for
enabling the development of voice and speech. These adaptive
changes when compared to other primates are considered the
anatomic basis of OSA in humans.18
Craniofacial morphology of decreased airway

space
Craniofacial anomalies seen in OSA patients include retrognathic
mandible, maxilla or both and thereby compromising on the upper
airway volume.
1. Cases with an apparent mandibular deficiency or functional
retrusion, the tongue is placed posteriorly resulting in
obstruction in the airway (Fig. 76.1B).
Patients with long face syndrome are found to be more
susceptible to OSA19 and so with mandibular
deficiency/retrusion. Such patients may be associated with
craniofacial syndromes like Pierre Robin, Treacher–Collins, and
mandibular deficiencies, related to temporomandibular joint
(TMJ) ankylosis.
In dolichocephalism, there is a tendency towards mandibular
retrusion and a convex profile; these cases have chances of
developing sleep disordered breathing. These subjects exhibit
an increase in lower anterior face height and steep mandibular
plane angle. High arch palate and narrow maxilla have been
observed in children with upper airway sleep disorders.
2. Maxillary deficiency can cause an approximation of the soft
palate with the posterior pharyngeal wall, thus reducing the
airway. Other common causes of obstruction include adenoids,
enlarged tonsils, deviated nasal septum, postnasal space
tumours, retropharyngeal mass and short neck (Fig. 76.2).
Posterior and inferior placement of Hyoid bone can also be a
contributory factor.20
3. Obesity can compromise airway space, hence makes a subject
susceptible to breathing disorder.
4. Environmental factors like localised polyneuropathy could
affect the small fibres of the soft palate.21 Untreated
longstanding gastroesophageal reflux can progressively scar
the soft palate and surrounding tissues. The scarring caused
can decrease the size of the upper airway and thus proneness
to OSA.
FIGURE 76.2 Possible anatomical locations and factors
contributing to a compromised airway and OSA.
Based on the cephalometric and morphometric analyses, patients

with upper airway sleep disorders can be grouped into:
1. Non-obese with craniofacial abnormalities

Retroposed mandible, narrow posterior airway space, enlarged
tongue and soft palate, inferior positioned hyoid bone and retro
positioned maxilla are considered significant risk factors for
sleep apnoea in non-obese individuals.22–25
2. Obese with craniofacial abnormalities as above.
3. Obese with normal craniofacial anatomy where bone structures
are well-placed. These patients have truncal obesity and
enlarged neck circumference.
Snoring
Snoring is a common sleep disorder, which is not only a widespread
acoustical phenomenon but also indicates a serious and potentially life
threatening health problem. It occurs as a result of the base of the
tongue or soft palate or both approximating the posterior wall of the
pharynx. The obstruction happens when a patient falls asleep or
assumes a supine position when oro-pharyngeal musculature is
relaxed leading to decreased airflow. Consequently, the patient
attempts to increase the speed of airflow to maintain the required
oxygen saturation. The increased airflow velocity results in vibration
of the soft tissue which causes the sound of snoring.15,16,26 Other
causes include obesity, adenoids and enlarged tonsils. A proper
diagnosis based on polysomnogram would be required in cases with
intractable snoring before instituting treatment.
Sleep apnoea
Apnoea is defined as cessation of airflow during sleep, which lasts for
at least 10 s with oxygen desaturation of more than 3% and/or
associated with arousal.
Hypopnea is defined as a reduction in amplitude of airflow of
greater than 50% of baseline measurement, for at least 10 s with
accompanying oxygen desaturation of at least 3% and/or associated
with arousal. These apneic/hypopnoea spells last for 10–30 s.
Obstructive sleep apnoea (OSA) refers to the occurrence of at least
five apnoeas or hypopnoeas per sleep hour (AHI > 5/h), resulting in
sleep fragmentation and decreased oxygen saturation.
Sleep apnoea is classified as central, obstructive and mixed sleep
apnoea.13,27
• In central sleep apnoea, the respiratory muscles do not attempt

to breath as a result of central nervous system disorder.
Orthodontists have no role in these cases.
• Obstructive sleep apnoea (OSA) syndrome is a sleep disorder,
which is characterised by repetitive obstruction of the upper
airway during sleep, resulting in episodic hypoxemia and
arousal. In OSA, the respiratory muscles attempt to breathe
but are characterised by repetitive episodes of complete or
partial upper airway obstruction leading to diminished or
absence of airflow to the lungs (Fig. 76.1).
Sleep physicians may refer these cases to the orthodontist for
craniofacial and upper airway evaluation with lateral cephalogram
and fabrication of suitable oral appliances.
• Mixed sleep apnoea. A patient with a combination of central

and OSA is said to have mixed apnoea. Oral appliance alone
can not address mixed apnoea effectively.
All cases of OSA elicit snoring, but all snoring cases need not have
OSA.
Symptoms of OSA
• Common symptoms include loud snoring, excessive daytime
sleepiness, and feeling of choking, restless sleep, unrefreshing
sleep, and change in personality and nocturia.
• Less common symptoms are morning headaches, enuresis,
reduced libido, nocturnal sweating, nocturnal cough,
symptomatic oesophageal reflux and a worried spouse.
Such patients may report with associated fatal disorders such as

hypertension, heart failure, night time cardiac dysrhythmia,
myocardial infarction and ischaemic stroke.28
A patient may often report to his physician with the symptoms
associated with the sleep disorder and or with associated systemic
diseases. Physicians may like to refer such patients to sleep physician,
which is a fast emerging superspeciality of medicine.
Case details should be recorded in a sleep disordered breathing
examination form which should include body mass index (BMI), neck
size, alcohol consumption and sedative usage details, sleep position,
frequency and intensity of snoring and a subjective assessment on
Epworth sleepiness scale (Box 76.2).
Box 76.2 Epworth sleepiness scale
Epworth sleepiness scale A list of eight social

circumstances with the
likelihood that the
person will fall asleep
rated on a 4 point scale
How likely are you to doze off or fall asleep in the following 1. Sitting and reading
situations, in contrast to this refers to your usual way of life in 2. Watching TV
recent times. Even if you have not done some of these things 3. Sitting, inactive in public
recently, try to work out how they would have affected you (e.g. theatre or meeting)
0 = Would never dose 4. As a passenger in a car for
1 = Slight chance of dosing an hour without a break
2 = Moderate chance of dosing 5. Laying down to rest in the
3 = High chance of dosing afternoon when
Total score circumstances permit
6. Sitting and talking to
someone
7. Sitting quietly after lunch
without alcohol
8. In a car, while stopped for a
few minutes in traffic
Interpretation
1. Score <10 = normal
2. Score >12 = signify sleep disorder
3. Maximum score 24 = definite OSA
Treatment modalities of OSA are aimed to increase life expectancy,

reduction in disease severity and improve the quality of life.
Comprehensive management of upper airway sleep disorders
requires an interdisciplinary approach. The management team
comprises of:
• Sleep physician or pulmonologist

• Oto-rhino-laryngologist
• Psychiatrist
• Neurologist
• Orthodontist
• Maxillofacial surgeon
• Prosthodontist
• Radiologist
• Nutritionist
• Bariatric surgeon
• Sleep and dental lab technician.
An orthodontist should evaluate for tongue size, air space

evaluation between soft palate and tongue using Malampatti
scores/airway grading (Fig. 76.3), tonsillar grading (Fig. 76.4).
Periodontal and soft tissue examination, TMJ evaluation, arch size,
maximum protrusive movement and clearance between central
incisors at full mouth opening.
FIGURE 76.3 Mallampati scores.

The assessment is made by asking the patient to open the mouth with
tongue protruding fully: Score I: soft palate, uvula and the pharyngeal
wall is fully visible. Score II: the pharyngeal wall is slightly visible, and
space between uvula and tongue is reduced. Score III: The uvula is
partially obscured by the tongue and pharyngeal wall not visible at all.
Score IV: uvula and part of soft palate obscured and pharyngeal wall
not visible at all. Mallampati score is a means of determining airway
patency. The score is a predictor for determining the severity of sleep
apnoea. A patient with a score of III or IV is at a higher risk of
developing OSA.
FIGURE 76.4 Tonsil grading scale.

(A) Grade O; (B) Grade I; (C) Grade II; (D) Grade III; (E) Grade IV
(kissing tonsils). In Grade III and IV the airway is severely
compromised.
Investigations
1. Polysomnogram (PSG) is considered the gold standard test for
diagnosis of OSA (Fig. 76.5).
The test involves the overnight recording of sleep, breathing
pattern and oxygenation. The study records analysis of
apnoea, oxygen saturation, body position, change in heart rate,
snoring, desaturation relations and sleep staging. The
recordings include electroencephalography (EEG),
electrooculography (EOG), electromyography (EMG) and
electrocardiography (ECG).
PSG provides the apnoea–hypopnoea index (AHI) scores, which
are an estimation of apnoeic–hypopnoeic episodes per hour of
sleep. Also, respiratory effort related arousals (RERA) could be
evaluated using a full PSG, which helps to calculate the
respiratory disturbance index (RDI). Based on the AHI scores.
OSA is grouped into four categories:
a. Normal (AHI < 5)
b. Mild OSA (AHI 5–15)
c. Moderate OSA (AHI 16–30)
d. Severe OSA (AHI > 30)
Based on recorded channels and data analysed sleep studies have
been classified into four levels. PSG in the sleep lab remains
the gold standard although there is increasing acceptance for a
home sleep study or portable sleep study these days. Different
levels of sleep study are as follows:
– Level 1: Gold standard, attended PSG and
intervention are possible.
– Level 2: Unattended full PSG, same parameters as
level 1 and intervention are not possible.
– Level 3: A cardio-respiratory study with only four
parameters namely airflow, SpO2, respiratory effort
and EEG.
– Level 4: Only one or two parameters namely airflow
and SpO2.
2. Dynamic MRI and CT scans (Fig. 76.6) are useful imaging aids
to investigate upper airway in snoring and sleep apnoea
patients.29–31
3. Lateral cephalogram though a 2D radiograph is helpful in the
examination of upper airway, craniofacial and soft tissue
analysis (Table 76.1). The lateral cephalogram should be
standardised and recorded at end expiration and not at
deglutition because upper airway calibration is affected by
respiratory cycle.
The most important cephalometric measurements include
posterior airway space, the length of the soft palate and
distance of hyoid measurement perpendicular to the
mandibular plane.24,32,33 A comprehensive airway analysis
with respect to the upper airway, hyoid position, soft palate
and tongue would indeed be handy for diagnosis and
treatment planning (Table 76.1). A recent systematic review
and meta-analysis of cephalometric studies with respect to
craniofacial and upper airway morphology in OSA patients has
concluded that: ’There is strong evidence for reduced
pharyngeal airway space, inferiorly placed hyoid bone and
increased lower anterior face height in OSA patients than
controls’. Cephalometric analyses have been found to be a
valuable tool to understand the anatomic basis of the aetiology
of OSA, which would be helpful for planning appropriate
intervention.34
4. Recently acoustic pharyngometer has been introduced in
clinical practice for orthodontists and otorhinolaryngologist
for evaluation of oro-pharyngeal airway. Acoustic
pharyngometry is a non-invasive procedure based on acoustic
reflection technology, similar to the ship’s sonar.35 Sound
waves are projected down the airway and reflected back out in
such a way that pharyngometer software can analyse and
quantify changes in the airway cross-sectional area. It allows
users to quickly and easily measure a patient’s pharyngeal
airway size and patency from the oropharyngeal junction to
the glottis. The accuracy and reproducibility of the acoustic
reflexion technique in measuring airway dimensions have
been validated.36 The technique has also demonstrated
excellent agreement between glottis area measurements of the
pharyngeal cross-sectional area measured acoustically as
compared to those obtained through computed tomography
(CT).36 Eccovision acoustic pharyngometer of sleep group
solutions is a proprietary article, which has been in clinical use
so far. The procedure involves making the patient rest and
acclimatise for 15–20 min. The patient is asked to be seated on
a straight back chair. The patient should be informed of the
nature of the test and the clicking noise that will be emanating
from the wave tube during the procedure. Proper positioning
of the mouthpiece (tongue under, teeth touching and lips
around) and proper execution of breathing trials (slow exhale,
with external compression of the nose) should be
demonstrated to the patient. The positioning should be
checked before each trial. Patients are to be instructed to avoid
nasal breathing as the opening of velopharyngeal space during
the nasal breathing increases the calculated volume. The
patients should be asked to pronounce ‘oooh’ in the
mouthpiece of pharyngometer without actually producing the
sound with the nostrils closed and should also be instructed to
look forward at a fixed point during the test (Fig. 76.7). The
mean airway volume, mean area and the mean airway would
be recorded in minutes. A phonogram of a patient is depicted
in Fig. 76.8.
FIGURE 76.5 A patient undergoing polysomnography (PSG)—
overnight sleep study.
FIGURE 76.6 CT scan of an 18-year-old patient with bilateral TMJ
ankylosis and severe OSA.
Characteristic features to be noted are severe mandibular hypoplasia,
collapsed upper airway due to tongue being placed posteriorly and
hyoid being placed downwards and far away from the lower border of
the mandible.
Table 76.1
Simple cephalometric analysis for upper airway

No Parameter Description Value mean
1. NAS Measured from PNS to the upper pharyngeal wall 25.9 + 2.6 mm
along palatal plane (M); 24.1 + 2.3
mm (F)
2. MAS/VAS A horizontal distance from the tip of the soft palate to 9.9 + 2.8 mm
pharyngeal wall (M); 9.9 + 2.4
mm (F)
3. PAS/oropharyngeal Horizontal distance from the posterior margin of the 10.1 + 3.1 mm
airway space tongue to pharyngeal wall measured on the Go-B line (M); 10.0 + 2.8
mm (F)
4. HAS Minimum horizontal distance in the hypopharyngeal 18.7 + 2.6 mm
area measured from point V (intersection of tongue (M); 16.5 + 3.1
and epiglottis) mm (F)
5. Hyoid distance The perpendicular distance from the mandibular 15 mm
(MP-H) plane (Go-Gn) to the anterior superior aspect of the
hyoid
6. Hyoid angle The angle from the mandibular plane (Go-Gn) to the 25.42 + 7.48
superior aspect of the hyoid
7. Hyoid, C3 The perpendicular distance from H to the line joining H point should
vertebrae and inferior-anterior tip of cervical third vertebrae (C3) to be on or above
menton menton the line
relationship
8. Length of soft PNS to tip of soft palate 34.3 + 3.9 mm
palate (M); 30.6 + 3.7
mm (F)
9. Soft palate Maximum thickness of soft palate measured 10.1 + 1.4 mm
thickness perpendicular to PNS–P line (M); 8.9 + 1.2
mm (F)
10. Length of tongue Measured from vallecula (V) to tip of tongue (T) 72.0 + 4.1 mm
(VT) (M); 64.8 + 4 mm
(F)
11. Height of the Measured as the perpendicular distance from H to VT 36.9 + 3.9 mm
tongue line (H—the highest point on the superior part of the (M); 32.9+ 3.9
tongue) mm (F)
NAS, nasopharyngeal airway space; MAS, Middle airway space; VAS, velopharyngeal airway
space; PAS, posterior airway space; HAS, Hypopharyngeal airway space; PNS, posterior
nasal spine; P, Tip of the soft palate.
FIGURE 76.7 Acoustic pharyngometry set up.
FIGURE 76.8 Phonogram generated by acoustic pharyngometry

of a 58-year-old male patient of OSA.
The X-axis is depicting airway distance calculated in cm from the tip of
the incisors and Y-axis depicting area in cm2. The oropharyngeal
junction is approximately 8–10 cm on X-axis.
The management protocol includes behavioural modifications;

sleep position change and weight control by modification in life style.
Definite modalities include continuous positive air pressure, surgery
to enlarge upper airway and orthognathic surgery for bringing the
mandible and maxilla forward. Oral appliances are useful in mild to
moderate OSA. Complete dentures for edentulous patients help
restore face height and better control on the lower jaw thereby helping
in normal breathing.
1. Behaviour modification. They include body weight control, sleep

position changes, stopping of sedatives/alcohol.
a. Increase in weight results in the loss in diameter of
the upper airway because fat deposits accumulate in
the walls around pharynx. Obese patients should be
encouraged to lose weight and attempt to reach BMI
of 25 or close to it.
b. Patients may be asked to lie on their side and place
a pillow behind them so that they cannot roll on to
their back to a supine position during sleep.
Another alternative is to sew a tennis ball in the
centre of the back of pyjamas to serve the same
purpose.
c. The elimination of alcohol and sedatives at least 3 h
before sleep has been recommended because of the
depressant effect of the drugs on the central nervous
system (CNS).
2. Continuous positive airway pressure (CPAP). It continues to be a
logical method for treating the symptoms of OSA in adults and
children37 (Fig. 76.9). This involves continuously pumping
room air under pressure through a sealed gauge or nose mask,
which passes through the upper airway to the lungs. However
CPAP suffers from poor patient compliance because of
portability problems, pump noise, dryness of airway and mask
discomfort (Fig. 76.9).38 Patients, who are unable to be
compliant with a nasal mask due to claustrophobia,
headaches, mask leaks, eye irritation and sinusitis, may benefit
by using oral mask ventilation with oral positive air pressure
(OPAP). OPAP delivered through an oral appliance is a
treatment alternative to nasal CPAP.
3. Surgical procedures: Many surgical procedures have been
practised to increase and stabilise the upper airway calibre.
These include maxillomandibular advancement, palato-uvulo-
pharyngoplasty, laser assisted uvulopalatoplasty, hyoid
suspension, genioglossus advancement, tongue-based
suspension sutures and midline glossectomy.
Maxillomandibular advancement is done by orthognathic
surgical procedure or by distraction osteogenesis.39–43 In these
situations, the orthodontist should follow the same protocol as
described in chapters on orthognathic surgery and distraction
osteogenesis. In worst situations, tracheostomy may be needed.
4. Oral appliances: Consensus and evidence based Indian initiative
on OSA Guidelines in 2014 have endorsed the use of oral
appliances in non apnoeic snoring, mild and moderate OSA.44
Oral appliances are also to be considered in those severe OSA
patients who are not amenable to CPAP therapy.
FIGURE 76.9 A 52-year-old female with severe OSA being treated

with continuous positive airway pressure (CPAP).
Most of the oral appliances work by placing the mandible forward

and thus increasing the space between the posterior pharyngeal wall
and tongue. Such an appliance was first described by Pierre Robin in
190245 to hold the lower jaw forward and hence prevent the
swallowing of the tongue and death due to asphyxia in a case of
Pierre Robin syndrome. The appliance holds the mandible in a
forward position, thereby minimising the posterior movement of the
tongue. It can also be achieved with tongue retaining device (TRD).46
An influential review of oral appliance therapy for OSA (1995)
accompanied by a practice parameter of the American Sleep Disorders
Association, signalled the entry of dentistry into mainstream sleep
medicine.47 Adjustable mandibular advancing oral appliances became
the predominant form of dental therapy for sleep disordered
breathing in the 1990s.
Controlled studies during the late 1990s indicate the effectiveness
and greater patient’s preference for oral appliances compared with
CPAP in mild and moderate OSA.37,48–53
Update on Clinical Practice Guidelines for management for
treatment of OSA and snoring with oral appliance therapy published
was in 2015 by a seven member task force commissioned by American
Academy of Sleep Medicine (AASM) and American Academy of
Dental Sleep Medicine (AADSM).54
The AASM and AADSM board of directors approved the final
guideline recommendations.
Recommendations:
1. We recommend that sleep physicians prescribe oral appliances,

rather than no therapy, for adult patients who request
treatment of primary snoring (without obstructive sleep
apnoea). (STANDARD)
2. When oral appliance therapy is prescribed by a sleep physician
for an adult patient with obstructive sleep apnoea, we suggest
that a qualified dentist use a custom, titratable appliance over
non-custom oral devices. (GUIDELINE)
3. We recommend that sleep physicians consider prescription of
oral appliances, rather than no treatment, for adult patients
with obstructive sleep apnoea who are intolerant of CPAP
therapy or prefer alternate therapy. (STANDARD)
4. We suggest that qualified dentists provide oversight— rather
than no follow-up—of oral appliance therapy in adult patients
with obstructive sleep apnoea, to survey for dental-related side
effects or occlusal changes and reduce their incidence.
(GUIDELINE)
5. We suggest that sleep physicians conduct follow-up sleep
testing to improve or confirm treatment efficacy, rather than
conduct follow-up without sleep testing, for patients fitted
with oral appliances. (GUIDELINE)
6. We suggest that sleep physicians and qualified dentists instruct
adult patients treated with oral appliances for obstructive
sleep apnoea to return for periodic office visits— as opposed to
no follow-up—with a qualified dentist and a sleep physician.
(GUIDELINE)
The effects of mandibular advancement on upper airway

anatomical relationship are:55
• Elevates the base of the tongue

• Tenses the palatoglossus muscle and pulls the soft palate
forward
• Decompress tissues around the pharynx and allows the
pharynx to expand
• Helps stabilise the lateral pharyngeal wall by applying tension
to pharynx mandibular raphe, which is coupled to pharyngeal
constrictors
• Splays the tonsillar arches formed by palatoglossus and
palatopharyngeal muscles, which lead to further stabilisation
of the lateral pharyngeal wall.
Once the patient gets used to the prescribed oral appliance and
reports improvement subjectively, that is, a decrease/cessation of
snoring, reduced daytime sleepiness; the patient must be subjected to
PSG with oral appliance in-situ for the objective assessment to
evaluate the therapeutic efficacy of the treatment.
Mandibular advancement device (MAD) can be one with fixed
mandibular advancement or titratable/adjustable mandibular
advancement appliances.
MADs with set/recorded mandibular

advancement
• A simple splint (Fig. 76.10)
• Activator
• Bionator
• Karwetzky activator (Fig. 76.11)
• Removable Herbst appliance
• Twin block
FIGURE 76.10 Mandibular advancement splint.

It is a simple maxillomandibular splint, which helps in keeping the
mandible in a pre-recorded protrusive position.
FIGURE 76.11 (A) Karwetzky activator is a tooth-and-tissue-borne
activator which is divided along the occlusal plane and joined by two
SS 19-gauge U-loops in the lingual acrylic area of first molars. (B) In
mouth: this design permits lateral and vertical jaw movements during
sleep.
All these appliances are made with the mandible in a requisite

protrusive position. Karwetzky activator is one of the most widely
used mandibular advancement devices in the management of OSA.
Karwetzky activator is a tooth and tissue borne activator, which is
split along the occlusal plane and joined by two U loops made of 0.9
mm stainless steel wire in the lingual acrylic area of first molars. This
design permits lateral and vertical jaw movements during sleep. This
appliance can be easily made in an orthodontic laboratory. Fig. 76.11A
and B depict an example of a 52-year-old female patient with severe
OSA who switched over from CPAP therapy to oral appliance therapy
(Karwetzky activator). In this case, AHI decreased from 43.6 to 17.9
(Fig. 76.12).
FIGURE 76.12 PSG findings before and after oral appliance
therapy.
(A) A 52-year-old female patient recorded AHI-43.6, AI-10. She was
given Karwetzky activator with 70% protrusive positioning of the
mandible. (B) PSG with a oral appliance in situ recorded a decrease in
AHI to 17.9 and AI to 0.
Tongue retaining device (TRD)

Cartwright in 1982 described TRD.56 The appliance consists of hollow
bulb attached to trays that fit over maxillary or mandibular teeth or
edentulous ridges. The patient projects the tip of the tongue into the
hollow bulb and the appliances are retained by suction.
The research on this design has lead to the improvisation of TRD
and the development of tongue stabilising device (TSD) or aveoTSD.
The aveoTSD is made of soft medical silicone for comfort. It works by
holding the tongue forward by gentle suction, preventing it from
falling back against the back of the throat and thus keeping the airway
open during sleep. AveoTSD does not attach to the teeth; it is more of
a vestibular appliance. This appliance has been found effective in
snoring and OSA.
Tongue repositioning manoeuvre with oral

shields
Engelke et al. have demonstrated the benefits of tongue repositioning
manoeuvre with the help of membrane funnel oral shields in the
management of snoring (Fig. 76.13).16 The appliance is an
improvisation of oral screens by attaching a funnel anteriorly, which
is covered by a membrane. The membrane funnel oral shields enable
the patient to form negative intraoral pressure during and after
deglutition and thus continuously train a tongue position at hard
palate with close tongue velum contact which is needed for posterior
mouth closure. This concept has been found to be effective in the
training of nasal breathing, oral rest position and nocturnal assistance
of mouth closure.
FIGURE 76.13 Membrane funnel oral shield.
Titratable mandibular advancement devices

(MADs) (Figs. 76.14 and 76.15)
Titratable MADs are preferred for their inbuilt system by which
mandibular protraction can be titrated or sequentially advanced in the
sagittal plane until the acceptable level of subjective improvement
occurs.26 Titratable mandibular advancement helps in slowly
repositioning the mandible either anteriorly or posteriorly using the
adjustable mechanism until successful results are achieved with a
minimum possible protrusive position. Cephalograms can be
recorded with titratable mandibular advancement devices in situ for
evaluating the impact of the appliance on upper airway and hyoid
position(Fig. 76.16A and B).
FIGURE 76.14 MDSA.

Medical Dental Sleep Appliance (MDSA) is a titratable mandibular
advancement device.
FIGURE 76.15 Lateral cephalogram showing increased airway

space after 6 months of MDSA therapy.
FIGURE 76.16 (A) Lateral cephalogram of a female OSA patient aged
50 years at end expiration. Note increased hyoid distance and reduced
upper airway parameters. (B) Lateral cephalogram of the same patient
at end expiration with 60% of maximum mandibular advancement. Note
the reduction in hyoid distance and improvement in upper airway
parameters.
A unique oral appliance named oral/nasal airway system has not

only the feature of adjustable mandibular repositioning but also nasal
dilators. Dental and ENT divisions of FDA have approved the
appliance. The appliance has been found to be effective in the
management of snoring, OSA and UARS. It is designed in such a way
that it addresses the upper airway resistance in the nasal region and
blockage in the throat region. It also has an optional lingual tongue
positioner (Fig. 76.17A–C).
FIGURE 76.17 OASYS appliance.
(A) Labial view and (B) lingual view. (C) OASYS appliance in situ. The
appliance is characterised by mandibular advancement mechanism,
nasal dilators for dilating external nares and tongue positioners to
facilitate anterior repositioning of the tongue.
Therapeutic benefits of MAD

In a recent investigation, Thornton adjustable positioner (TAP), which
is a titratable mandibular protrusive appliance was examined for
initial effect in PSG diagnosed patients with OSA.50,57 A predictable
AHI based improvement was achieved.55
The authors also found the higher acceptance than with the
Karwetzky activator. A recent study has proven the initial efficiency
of Karwetzky activator in the management of mild, moderate and
severe OSA.58 However, it is unclear whether oral appliance treatment
can be recommended as a lifelong option.58
Edentulous patients when restored with their vertical face height
with full dentures may restore normal breathing. A significant
reduction in AHI scores has been noticed with the use of dentures
while sleeping.59,60
The therapeutic MAD with CPAP is a very important area of
research in sleep medicine. The comparison of the two methods is
summarised in Box 76.3.
Box 76.3 Comparison of CPAP and MAD
CPAP MAD
How it works Uses air pressure through a tube and a mask Physically moves the lower jaw
worn over the nose or mouth to force air forward, repositions the
through the obstruction structures forming the airway to
open the obstruction
Reimbursement Yes, through medical insurance Yes, through medical insurance
Travel Difficult, stored in large case. Must travel with Easy, can be stored in a small
appropriate electrical cords and adapters. retainer case and carried in a
Typically have to take as carry-on baggage as purse or briefcase
the machine is not durable
Can open No Yes
mouth, talk or
drink while
wearing
Requires Yes No
electricity
Comfort May be uncomfortable, can also cause skin 91% of patients report that
discomfort MAD are comfortable
Makes noise Yes No
Despite discrepancies in efficacy (AHI reduction) between CPAP

and oral appliances, randomised trials show similar improvement in
health outcomes between treatments in terms of sleepiness, quality of
life (QOL) and blood pressure (BP).61 There is enough robust evidence
supporting the efficacy of oral appliances for improving PSG indices
and modifying the health risks associated with OSA similar to the
impact of CPAP. There are a few unresolved issues in management of
sleep disordered breathing/OSA with OAs, such as influences of
appliance design, titration procedures and prediction of treatment
outcome.62
Fabrication of a MAD
1. Oral hygiene and optimisation of dental health. Oral
appliances are often prescribed for middle-aged and older
adults, so dental treatment should be completed before
delivering an oral appliance. This is because oral appliances
are tooth-tissue-borne and can dislodge loose restorations and
worsen periodontally compromised mobile teeth.
2. Steps followed for appliance fabrication include impression
making with sodium alginate impression material and
preparation of two sets of plaster models. Set one is used for
the preparation of appliance while the 2nd set is used as
diagnostic records.
3. Bite recording can be done with modelling wax, articulation of
models with recorded bite and appliance fabrication with heat
cure acrylic. During bite recording, mandibular advancement
should not exceed 70% of maximum protrusive movement13
and 7–8 mm of vertical opening. Bite recording can also be
done conveniently with a device called George bite gauge,
which allows indexing of anterior teeth and uses bite fork
along with a scale to determine the amount of vertical opening
and advancement (Fig. 76.18A–C).63
Recently a three components airway metrics Jigs based bite
recording system has been introduced. It has a snoring
screening component and 15 mandibular position indicators.
The Jigs helps to identify that in which vertical and sagittal
mandibular position the snoring sound is completely
eliminated or grossly minimised. This is done by asking the
patient to simulate snoring and do the same with various jigs in
situ. The subjective feedback can be integrated with
pharyngometer, which will also give the objective appraisal of
the dimensional airway change. Once the Jig is selected, it can
be integrated with a bite fork for bite recording.
Bite recording for custom made titratable MAD is the most crucial
step. Some important points for successful bite recording are:
a. Most important factor for the success of oral
appliance therapy.
b. Ask the patient to bite in centric occlusion and mark
midlines.
c. Move the mandible straight forward (deviation may
cause TMD).
d. Leverage pharygometer and plastic jigs for
ascertaining an ideal position.
e. Most common: 6 mm vertical and 4 mm protrusion.
f. Remember 6–8 mm of vertical opening required for
appliance fabrication (dual laminate).
g. Phonetic bite recording is also found to be useful.
This is done by repeating64 and fabricating the
appliance to thus predetermined vertical and sagittal
position.
4. The models with bite are transferred on to semi-adjustable
articulator. The appliance can be fabricated in thermoplastic or
acrylic material. Most modern dental laboratories make
devices with thermoplastic materials, which are more
comfortable for patients. Titanium Halstrom hinges and
modified unidirectional expansion screws are used for the
incremental advancement of the mandible. Contemporary
titratable/adjustable mandibular advancement device like the
TAP is a two split system with titrating assembly in the upper
and rod or plate in the lower Figs. 76.14 and 76.15). The splint
bases are vacuum formed with a thermoplastic hard-soft
composite material (Dura soft 2.5 mm). Maintaining the
recorded vertical height on the articulator, accurate placement
of titrating assembly on the upper base and rod/plate on lower
base is the key to successful fabrication of these appliances.
FIGURE 76.18 Bite gauge developed by Peter T. George.
(A–B) This device accurately measures the protrusion. The bite is
recorded either with bite registration paste or polyvinyl siloxane putty.
(C) A recorded bite is transferred into the working models, which are
then articulated for appliance fabrication.
There are several oral appliances for snoring and OSA, many of
which are approved by the Food and Drug Administration, USA. The
basic philosophy of these appliances is either to posture the mandible
forward, protrude the tongue and hold it in a cup with the help of
suction or by lifting the soft palate. They vary in terms of design and
biomaterial. Box 76.4 lists a few of the popular FDA (USA) approved
oral appliances other than the ones already described for snoring and
OSA with their brief description.
Box 76.4 Some of the FDA (USA) approved oral

appliances for snoring and OSA
Appliance Brief description
Elastic The primary treatment mechanism of opening the bite and gently moving the
mandibular mandible forward is achieved with the use of interchangeable elastic straps that
advancement offer varying degree of mandibular advancement. Hand plastic trays are pressure
appliance formed to the patient’s models and utilise the undercut areas of the teeth for
(EMA) retention
Klearway Fully adjustable oral appliance fabricated by thermo active acrylic resin. The
appliance is pliable for easy insertion and confirms securely to the dentition for an
excellent fit. Small increments of forward jaw movement are initiated by the patient
under the direction of the doctor. The appliance does not encroach on the tongue
space
OASYS (oral This appliance was the first appliance to be approved by Dental and ENT division
nasal airway of FDA. This appliance is indicated for snoring and OSA. It enables forward
system) mandibular posturing and also has a nasal dilator for reduction of nasal resistance
and improved nasal breathing
Adjustable This is one of the few appliances, which can be constructed on the chairside. It is a
TheraSnore boil and bite appliance. It is available in three different sizes based on the most
commonly used impression trays. The lingual fin on the lower tray guides the
mandible to forward posture
SOMNOMED Is a mandibular advancement splint. It consists of upper and lower dental plates
with unique patented fin coupling component, which allows normal mouth
opening and closing. Each device is custom made to doctor’s specification
providing a comfortable fit
Adjustable The appliance fits over all maxillary and mandibular teeth and is made of a special
PM acrylic material (Bruxeze) that softens in hot water to provide a combination of
positioner comfort, strength and retention. Expansion screws are located on the right and left
buccal areas to allow maximum space for the tongue and easy anterior positioning
of the mandible to achieve optimal effectiveness
OPAP (oral Is an oral appliance, which incorporates an airway and mandibular position in its
positive air design and function. It allows delivery of positive air pressure through the mouth.
pressure) Indicated for patients with nasal allergies, headaches, claustrophobia, eye irritation
and sinusitis
NAPA Can be constructed in a dental laboratory with heat cure acrylic and is tooth
(nocturnal retained by Adams clasps. An anterior positioned ’breathing beak’ allows for oral
airway breathing when necessary. The mandible is held firmly in position to prevent any
patency jaw movement during use and thus is non-adjustable
appliance)
Although, CPAP is considered as the gold standard for treatment of

OSA, the Oral appliances (OAs) have certain inherent advantages. Box
76.4 depicts a comparison of CPAP and MADs.
Limitations of MAD
Although oral appliance therapy is very popular and widely used, it
has a few limitations.26,65 These limitations are:
• Uncertainty to reliably predict treatment outcome.

• Apparent need for acclimatisation period to attain maximum
efficacy of treatment.
• Uncertainty about the selection of maximum ‘dosage’ of
mandibular advancement required to control OSA in
individual patients.
• Uncertainty about the influence of appliance design on
treatment outcome and adverse effects.
• Potential long-term complications of therapy with respect to
TMJ and occlusion.
Sleep bruxism
Sleep bruxism (SB) is an oral parafunctional activity that occurs when
the individual is asleep. According to the American Academy of
Sleep, SB is a parasomnia, which is an undesirable physical
phenomenon, which occurs during sleep; however, the condition does
not affect sleep and wakefulness.66
The pathophysiology of this condition is not clear. It has been
classified as primary (idiopathic) and secondary (iatrogenic forms).
The secondary forms are associated with neurological, psychiatric,
OSA or with administration and withdrawal of drugs.
Management includes behavioural and stress management, lifestyle
changes and oral hard acrylic splints to protect the teeth from
grinding.66 The patient goes back to sleep after arousal and the cycle
continues. Patients with sleep bruxism and OSA are treated in the
same way as OSA.
Upper airway resistance syndrome (UARS)

The term Upper Airway Resistance Syndrome (UARS) present with
excessive daytime sleepiness subjectively and objectively but without
apnoeic or hypopneic episodes.64 Patients usually wake up to the
sound of own snoring. Sleep is fragmented. However, there is a
preservation of airflow and oxygenation. An investigation of upper
airway collapsibility during sleep showed that changes in pharyngeal
properties of UARS subjects are between those of OSA patients and
normal controls. PSG normally shows snoring with marked
paradoxical breathing movements or repetitive arousals. CPAP and
oral appliances are the treatment of choice in UARS.
Upper airway sleep disorders in children

Children with upper airway sleep disorders have loud snoring. Sleep
disorders have a profound effect on a child’s health, and the sequel
can range from learning disability to sudden unexpected death at
night during sleep. A child like an adult could suffer from OSA,
central or mixed type. Snoring is a characteristic of OSA in children,
but others may present with pauses and snorts.
Common symptoms include restless sleep, morning headaches,
frequent waking up, enuresis, nightmares, thirst and tremors.
Daytime symptoms include sleepiness, hyperactivity, attention span
problems, poor school performance and behavioural abnormalities.67
Predisposing factors
A significant component of craniofacial development occurs within
the first 4 years of life with a major growth of craniofacial region by
puberty. Environmental factors that contribute to oral breathing
predisposes a child to sleep disorder including OSA. This can also
affect the head posture (Fig. 76.19A and B) A pre-existing abnormal
anatomy can influence upper airway, and environmental factors can
adversely influence craniofacial growth and hence aggravate the
features contributory to unhindered normal breathing pattern. It can
be inferred that morphometric features that put adults at risk of OSA
or sleep disordered breathing were probably present at the age of
12.68,69
1. Breastfeeding is important for the proper development of

dental arches and proper alignment of teeth (Fig. 76.20A).69,70
The tongue contributes to the developmental shaping of the
palate during its motion across the palate while swallowing
(Fig. 76.20B). Use of bottle nipple or pacifier can interfere with
proper contact of the tongue and its force distribution on the
palate (Fig. 76.21A). A vacuum created by strong sucking
actions can also increase the height of the palate (Fig.
76.21B).69,70 Proper swallowing pattern and maturation is seen
in breast fed children and is crucial for optimum craniofacial
development. A tongue thrust is likely to develop in bottle fed
children. A tongue thrust and narrowing/deepening of the
palate are one of the main contributing factors of malocclusion
that put an individual at risk of OSA/SDB. The above is also
true for the excessive use of pacifiers, thumb sucking, blanket
sucking and arm sucking.
2. Frequent upper airway infections, sinusitis, otitis media,
tonsillitis and enlarged adenoids are common symptoms
associated with mouth breathing. It has been stated that mouth
breathing as an ongoing pattern may be a sign of impending
sleep apnoea.69,71 Harvold et al. concluded from non-human
primate studies that any factor lowering the posture/position
of mandible would promote additional tooth eruption and
thereby cause an increase in lower anterior facial height.72,73
Mouth breathers tend to develop an abnormal head posture to
facilitate breathing. It is of paramount importance for an
orthodontist to keep a close eye on environmental risk factors
that may be contributory to nasal obstruction and head posture
in children. In children with sleep related breathing disorders,
head neck postural adaptations can be recognised.74 The
adaptations such as craniocervical extension and forward head
posture help to maintain the patency of the compromised
airway.
3. Malformations of underdeveloped maxilla and mandible can
also result in upper airway obstruction during sleep. Children
with bilateral TMJ ankylosis may present with OSA and
malnutrition.
4. Syndromes that affect craniofacial morphology like Pierre
Robin, Crouzons, Aperts and Treacher–Collins often present
with OSA.
5. The orthodontic therapeutic procedures that compromise
upper airway are:
a. Use of headgear may predispose children to sleep
apnoea when used in conjunction with other
conditions such as mandibular retrognathia, large
tonsils or history of upper airway infections.75
b. Removal of four bicuspids for orthodontic therapy
can reduce the tongue space, alter tongue posture
and reduce posterior airway space76,77 (Fig. 76.22).
FIGURE 76.19 Craniocervical posture.

(A) Normal craniocervical posture. (B) Craniocervical extension and
forward head posture. This is observed in patients with upper airway as
a mechanism of postural adaptation. This tendency is noticed in
children with adenoids and OSA.
FIGURE 76.20 Breastfeeding and oral cavity.
(A) While breastfeeding the nipple of the breast adapts to the shape of
the mouth. The peristaltic motion of the tongue during breastfeeding
presses the breast up against the palate. This stimulus is vital for
optimising the development of palate. (B) The position and action of the
tongue during breastfeeding. The action of the tongue is one of the key
stimuli for mandibular growth and maxillary arch development.
FIGURE 76.21 Bottle feeding and oral muscle behaviour.
(A) Bottle feeding can separate the epiglottis soft palate approximation,
elevates the soft palate, drives the tongue back and alters the action of
the tongue. (B) Demonstrating action of pacifier/bottle nipple. The
mouth has to adjust to any object in the mouth other than the breast.
The unnatural forces can impact the position of teeth and shape of the
palate.
FIGURE 76.22 Detrimental effects of first premolar extractions on

the upper airway.
The oral cavity volume is reduced, and thereby the tongue adopts a
more posterior posture, compromising the airway.
Prevention and management

1. Promote breastfeeding. Important preventive strategies include
advocating breastfeeding.
2. Facilitate nasal breathing. Management strategies are aimed at
the controlling of aggravating factors such as frequent
infections in the throat, and if required, surgical options are
needed to facilitate nasal breathing such
tonsillectomy/adenoidectomy. Nasal CPAP is effective as a
transient measure in situations of severe OSA in children, but
compliance is poor.78
Chronic mouth breathing is considered an impending sign of
SDB. So interceptive treatment using myofunctional appliances
and orthodontic treatment to enable lip competency and
promote mouth breathing should be the prime treatment goal.
Nasal breathing is crucial to optimum health and well-being
due to the following reasons:
a. Air breathed through the nose is of a different
composition than through the mouth.
b. Nitric oxide is free radical, a key component of
human health. It is produced in nasal sinuses,
secreted through nasal passages and inhaled
through the nose.
c. Nitric oxide prevents bacterial growth, improves the
ability to absorb oxygen, vasodilator, brain
transmitter, increases oxygen transport throughout
the body and is vital to body organs.
3. Develop oral volume with the functional appliance. Although
monoblock was prescribed in newborns with Pierre Robin
syndrome to prevent asphyxia,45 the merit of functional
appliances to improve breathing by enhancing posterior
airway space is often not factored. Improvement in upper
airway and breathing has been reported after functional
appliance therapy.79 Therefore prescription of functional jaw
orthopaedic appliances should also be viewed in the light of
benefiting breathing and improving upper airway. Functional
appliances aimed at advancing the mandible are effective and
have little side effects when compared to that of adults. Herbst
appliance has been found to be quite effective.80 Modified
monoblock has also been reported to be an effective
appliance.81
A randomised control trial reported of 7-year-old children with
OSA observed a mean reduction in AHI of 7.1 ± 4.6 to 2.6 ± 2.2
whereas no reduction was noticed in control group.82 Positive
outcomes were demonstrated in retrognathic adolescents with
SDB in the absence of tonsillar hypertrophy. AHI was
effectively normalised with orthopaedic correction of
mandibular deficiency.83
4. Treatment of narrow maxilla. It has been found that patients with
compromised upper airway who had narrow maxilla and
underwent palatal expansion, either with an appliance or
surgically showed a significant improvements in the number
of respiratory events that occurred following the expansion.84
There is mounting evidence from anthropological studies that
pre-historic skulls had a wide palate and large posterior nasal
aperture. The broad width between the pterygoid plates
resulted in a wide entry into the soft tissue portion of the
airway. In the studies conducted on skulls after the 1940s, show
that on an average they have a high palate and narrow arch
resulting in a smaller posterior nasal aperture.85 This can be
attributed to widespread use of bottle feeding, pacifier and
digit sucking which cause adverse effects on the craniofacial
development. Considering the above connection, it would be
pertinent for orthodontists to envisage transverse deficiency of
maxilla and deepening of the palate and therefore the scope to
prescribe palatal expansion as a preventive measure for OSA
and SDB.
Recent studies have shown that RME has a positive effect on
children with snoring and OSA. By changing the anatomic
structure, RME brings a functional improvement.
5. Mandibular advancement/lengthening with surgery/distraction.
Mandibular advancement with distraction osteogenesis has
been shown to be quite effective in resolving OSA in children
with mandibular retrognathia syndromes.44,86,87
6. Consider the impact of extractions on tongue space. Tongue posture
and oral space are key variables to be considered for fixed
orthodontic treatment with bicuspid extractions. Dr William
Hang, one of the strongest advocates of bioblock orthotropics
has recommended optimising oral posture as the core
philosophy of dento facial orthopaedics.78 He has attributed
bicuspid extractions for orthodontic treatment as the cause in
some cases of OSA. The reopening of extraction spaces in these
cases had helped resolve OSA.70 Good aesthetics should never
be achieved for patients undergoing orthodontic treatment at
the expense of diminishing capacity of the upper airway.88 So
proactive research to correlate the impact of bicuspid
extractions for orthodontic treatment on airway merits
consideration.
Key Points
Dentists entry into the management of upper airway sleep disorders
has led to the development of a new speciality, that is, dental sleep
medicine. This speciality involves oral appliance therapy for OSA and
snoring, maxillomandibular advancement surgeries to increase upper
airway volume, cephalometric studies for airway evaluation and most
important of all; prevention of sleep disordered breathing in children
by maxillary expansion, functional appliances, adeno-tonsillectomy,
advocating breastfeeding and oral habit breaking therapy.
Dentists trained in dental sleep medicine, orthodontists and
maxillofacial surgeons are recognised members of the
interdisciplinary team to manage upper airway sleep disorders.
The dental students and orthodontists should familiarise
themselves with the necessary knowledge of upper airway sleep
disorders. They should interact with sleep physicians to contribute
effectively in managing the affected patients. Indications, efficacy and
use of dental appliances have been summarised in OSA guidelines
report.44
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expansion. Sleep. 1998;21(8):831–835: PubMed PMID:
9871945.
85. Barsh LI. The origin of pharyngeal obstruction during
sleep. Sleep Breath. 1999;3(1):17–22: PubMed PMID:
11898099.
86. Smith K, Hamish M. Paediatric sleep apnoea treated
with distraction osteogenesis. In: Rudolph P, Dendill
J, Stein D, eds. Craniofacial distraction osteogenisis.
1st ed. St. Louis: Mosby; 2001:213–224.
87. Roychowdhury SK, Jayan B, Menon PS, Prasad
BNBM, Ravishankar K. Management of obstructive
sleep apnoea and non apnoeic snoring with maxillo-
mandibular distraction osteogenesis. Indian J Sleep
Med. 2007;2(3):101–108.
88. Cobo Plana J, de Carlos Villafranca F, Macías
Escalada E. Orthodontics and the upper airway.
Orthod Fr. 2004;75(1):31–37: PubMed PMID:
15301356.
SECTION XVIII
Steps in conclusion of orthodontic
therapy

appliance Phase III: finishing and detailing
Chapter 78: Deband, debracketing and delivery of retention
appliance
Chapter 79: Post-orthodontic care and management of white
spot lesions
Chapter 80: Maintenance of the outcome results, retention and
relapse
CHAPTER 77
contemporary fixed appliance
Phase III: finishing and detailing
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Goals of orthodontic treatment
Pre-finish assessment
Clinical examination of face
Study models and wax bite
Lateral cephalogram
Orthopantomogram
Steps in attaining goals for finishing and detailing of occlusion
Finishing wires
Standard edgewise system
Settling the occlusion
Use of light round wires
Use of laced vertical elastics
Passive utility arch
Use of specially fabricated tooth positioner
Tooth-size discrepancies
American Board of Orthodontics—objective grading system
Assessment criteria
Tooth alignment
Marginal ridges
Buccolingual inclinations
Occlusal relationship
Occlusal contacts
Overjet
Inter-proximal contacts
Root angulation
European Board of Orthodontics
Post-orthodontic occlusion scheme for extraction treatment and
complex malocclusion situations
Characteristics of occlusion in four premolar extraction
cases
Extraction of maxillary first premolars and mandibular
second premolars
Class I occlusion with missing maxillary laterals
Critical issues of clinical relevance on maxillary canine
substitution for a lateral incisor
Occlusion with missing one lower incisor or treatment
with extraction of a mandibular incisor
Occlusion following extraction of maxillary first premolar
only: therapeutic class II occlusion
Therapeutic class III occlusion following extraction of
mandibular first premolars
Key Points
Introduction
The final phase of orthodontic treatment involves finishing and
detailing of occlusion to achieve normal occlusion, optimum aesthetics
and functional harmony of the stomatognathic system.
Often goals of orthodontic treatment and biomechanical strategies
to achieve these objectives have been generalised. However, it is
pertinent to regard each person and his/her occlusion a unique
biological entity, which necessitates that the goals should be
individualised. ‘I don’t think all cases should be finished in the same
way’, said Dr Bjorn Zachrisson.1 Many of the subjects have their
treatment when they are teenagers or young adults. Their craniofacial
skeleton, particularly the mandible, continues to grow past puberty,
which can alter the orthodontic treatment outcome some time beyond
expectations.
A ‘textbook occlusion’ though desired cannot be the objective for all
clinical situations. It may not be possible to attain an ‘ideal occlusion’
in complex malocclusion cases, especially those with poor periodontal
health and mutilated dentition.
Goals of orthodontic treatment

At the finish of orthodontic treatment, it is imperative that the
outlined goals of orthodontic treatment be attained. These can be
broadly categorised into five major groups:
1. Normal occlusion in centric relation

2. Normal functional movements
3. Optimum facial and dental aesthetics
4. Healthy TMJ in harmony with occlusion
5. Good periodontal health.
Pre-finish assessment
Proper finishing of orthodontic cases can be evaluated by a systematic
approach, which when adopted routinely in practice may provide the
orthodontist with the checklist to conduct a self-assessment of his/her
work and hopefully, with it, opportunities to improve continuously. If
one does not implement systematic clinical protocols, one risks
providing patients with incomplete or even unsatisfactory treatment
outcomes.2
During the final phase of treatment, inaccuracies of bracket
placement and improper bends in archwires become ostensibly
evident. There may be discrepancies in occlusogingival heights, tip(s)
of teeth and inadequate torque. Discrepancies in the improper
positioning of teeth hamper complete space closure and attainment of
proper occlusion. Consequently, the aesthetics is compromised, and
the functional movements of the jaw may have undue interferences,
which in turn could adversely affect the health of TMJ. Therefore prior
to debonding, the final phase of the orthodontic treatment should
involve an organised and diligent clinical evaluation, review of the
stage dental models, a panoramic radiograph and a lateral
cephalogram.
Clinical examination of face

Clinical examination of the face includes evaluation of the profile and
smile at rest and in a dynamic state. Assessment of profile includes
nasolabial angle, chin prominence, lip relations at rest and relation of
lips to anterior teeth.
Clinical assessment of occlusion in functional movements of the
mandible is performed to evaluate any interferences during the lateral
and forward glide of the mandible. While the patient is made to feel
relaxed and asked to perform gentle glide of the mandible forward
with teeth in occlusion. A smooth glide with uniform contacts are
expected with functional surfaces of upper and lower anterior teeth.
The labial-incisal surfaces of the mandibular incisors should smoothly
glide against the lingual surfaces of the maxillary incisors with
uniform pressure (exhibiting no premature contacts) without any
deflection. Any errors in occluso-gingival discrepancy in bracket
placement or errors in tip causing premature contacts should be taken
care at this stage either by repositioning the brackets or appropriate
bends in the wires.
During lateral right and left movements of the mandible a gentle
lateral slide on canines in expected. During the lateral jaw movement
there should be complete disocclusion of the buccal teeth. The
hanging lingual cusp of the maxillary molar is often an interference.
The hanging lingual cusps and buccal interference are caused by a
narrow upper arch or inadequate buccal root torque or a combination
of thereof. The interference in lateral movement, therefore, should be
corrected with appropriate buccal root torque and coordination of the
upper and lower arch forms.
Following records are prepared and evaluated (Fig. 77.1):
1. A set of upper and lower working/study models and a wax bite

2. Lateral cephalogram and OPG (Fig. 77.1F, K)
3. Clinical photos of posed and spontaneous smile (Fig. 77.1D).
FIGURE 77.1 Pre-finish evaluation of a case with records to
attaining a finished occlusion.
(A) Case VS, 20/M. (A, B) Pre-treatment photographs and occlusion.
The patient underwent treatment with standard edgewise fixed
appliance after extraction of all first premolars. (C) Pre-treatment lateral
cephalogram with U1-SN of 124.4° and inter-incisal angle of 110.9°. (D,
E) After space consolidation. Clinical examination in profile and
intraoral photos exhibit under-torqued maxillary front teeth. (F) Lateral
cephalogram after space consolidation with U1-SN decreased to 94.4°,
and inter-incisal angle increased to 139.4° resulting in under-torqued
maxillary anterior teeth. (G, H) After finishing and detailing. Note
sufficient torquing has been achieved, which has improved anterior
relations and profile. (I) Post-treatment lateral cephalogram with U1-SN
increased to 103.5°, and inter-incisal angle decreased to 129° restoring
proper lip to tooth relation. (J) Pre-treatment OPG. (K)
Orthopantomogram after space consolidation demonstrating mesial
angulation of maxillary left lateral incisor. (L). Post-treatment
orthopantomogram showing corrected mesiodistal angulation of
maxillary left lateral incisor and fixed spiral space retainer bonded in
both arches. (M–Q) Pre-treatment occlusion. (R–V) Post-treatment
occlusion. Note flexible spiral wire (FSW) in upper and lower arches.
Study models and wax bite

Upper and lower models are used to outline and record discrepancies
from normal deviations so that suitable measures can be taken to
achieve normal occlusion. Study models are registered with a wax bite
and mounted on a semi-adjustable articulator. The mounted study
models are the most useful reference for comparison with pre-
treatment models to evaluate improvement in existing malocclusion,
unwanted effects of orthodontic therapy. The pre-finish study models
serve as a reference to outline the desired occlusion and plan the
retention appliance.
Lateral cephalogram
Lateral cephalogram is assessed for the thickness of cortical bone
around maxillary/mandibular anterior teeth and position of tooth
roots, which should be placed centred in the alveolus process. The
inclination of the long axis of maxillary central incisor to SN plane
serves as a guide to labiolingual inclination and hence the torque. A
low angle (<110°) suggests a need for further palatal root torque to be
incorporated (Fig. 77.1F). A pre-debond stage cephalogram is also
useful for evaluation of remaining growth, which will affect further
treatment strategies on finishing and suggest any alterations in the
retention schedule.
Orthopantomogram
OPG is the most useful guide for evaluating the mesiodistal tip of the
teeth and relationship of roots of teeth with those of neighbouring
teeth. Based on the OPG evaluation, compensating bends are placed in
the archwire to ensure that the desired root and crown tip should be
attained. OPG X-ray can also offer an overview of periodontal status
to mark the teeth for further IOPA X-rays for detailed periodontal
examination (Fig. 77.1 K, L). The pre-treatment and post-treatment
occlusion of a case, are exhibited in Fig. 77.1 M–V.
Steps in attaining goals for finishing
and detailing of occlusion
Finishing wires
The pre-adjusted appliance system is capable of placing the teeth
according to its predetermined prescription, while needs of an
individual or the nature of malocclusion may substantially differ from
its inbuilt prescription. The use of the pre-adjusted appliance is based
on the premise of complete expression of the prescription, which can
be attained only on insertion of full-size wires. In day-to-day
orthodontic practice, full-size wires are rarely used; therefore, the total
potential of a pre-adjusted appliance in achieving final tooth positions
remains underutilised (Fig. 77.2). The placement of full-size wires and
expression of tip, torque and alignment of arches in achieving correct
occlusion is predetermined by the accurate positioning of the brackets
and tubes. It is practically impossible to place all the brackets free
from error. These bracket positioning errors become apparent during
finishing stage and reflect in a variety of forms of less than ideal
occlusion. Hence, a selective bracket repositioning may be required,
which should be undertaken before finishing wires are inserted.
FIGURE 77.2 There is a loss of torque during space closure and -
retraction of anterior teeth.
Rectangular wires are manufactured by drawing round wires by rolling;
therefore the edges of the wires are round, which accounts for the
interplay between the bracket slot and the best-fit wire. (A) The figure
demonstrates torque loss with different sizes of wire in 0.022 × 0.028
in. slot. (B). The actual loss of torque is double of the play between the
wire and the bracket slot. Manufacturers tend to make the bracket slot
slightly larger and the wire slightly smaller than the size, resulting in
greater torque loss than the calculated value when exact -dimensions
are used. Source: Schwaninger B. Evaluation of the straight archwire
concept. Am J Orthod 1978;74(2):188–96.
Standard edgewise system

In a standard edgewise appliance system, Tweed suggested that a
long V-bend should be incorporated at a mid--incisor point to prevent
the mesial tipping of the roots during overjet reduction. Following
final space closure, required torque is attained by incorporation of
active root torque in the anterior portion. Integration of palatal root/-
buccal crown torque during retraction causes loss of tip; it is called the
wagon wheel effect (Fig. 77.3). Finishing wires of 0.0215 × 0.0275 in.
are fabricated with an artistic positioning bend between two maxillary
central incisors and one each on both sides between central and lateral
incisors. In the mandibular arch, similar bends of much less intensity
are required (Figs 77.4 and 77.5).
FIGURE 77.3 Wagon wheel effect.

The anterior teeth and their roots in an arch are placed like seen in (A).
When buccal crown torque is incorporated in the wire, the roots of
anterior teeth tend to converge towards the centre like spokes of a
wheel (B). It has been often called a wagon wheel effect.
FIGURE 77.4 Marking for artistic bends.
(A) Long V-bend placed between central incisors. (B) A second artistic
bend is incorporated between central and lateral incisors with arrows
depicting the direction of the bend. (C) A third artistic bend being
placed between lateral incisor and canine. (D) Finished wire. (E)
Finishing archwire with artistic bends and V-bend.
FIGURE 77.5 The incorporation of torque.

(A) For buccal torque, the wire torque is incorporated in the incisal
direction. (B) For palatal torque, the wire torque is incorporated in a
gingival direction. (C) When no torquing is desired, the wire should be
parallel to bracket slot. (D) In case of torquing single tooth, torque is
incorporated in part of the archwire.
Settling the occlusion
The purpose of this stage is to bring all teeth into a stable occlusal
relationship before brackets are removed. There are five ways to settle
the occlusion:
1. Use of light round wires

2. Laced vertical elastics
3. Passive utility arch
4. Use of specially fabricated tooth positioner
5. Altering teeth size to correct tooth size discrepancy.
Use of light round wires

Using light round wires replacing rectangular wires was the original
method for settling recommended by Tweed in the 1940s. According
to him, these light wires must have ‘first and second order bends’ of
intensity used in rectangular wires which are not a necessity with the
pre-adjusted appliance system. These light archwires would quickly
settle the teeth into final occlusion and should remain in place for only
a few weeks at most. The light wires have inherent disadvantage of
loss of precise control of arch form. Therefore a careful watch on
occlusion is required. The patient is recommended to chew sugar-free
gum, which helps to settle the occlusion in maximum inter-cuspation
while the teeth try to occupy positions in the alveolar bone. Vertical
elastics should be used in the buccal segment as and when needed.
Use of laced vertical elastics

Laced vertical elastics were in practice around Tweed era; however,
later this technique was modified by removal of the posterior part of
the rectangular archwire while leaving a segment of the rectangular
archwire in a canine-to-canine or premolar-to-premolar region.
Elastics for settling are placed around tubes and brackets. A typical
arrangement is to use light 0.25 in. elastics with class II or class III
pattern depending upon the type of correction desired. The rubber
bands can also be used in a configuration of M or W or a fashion that
will appear suitable to bring in maximum inter-cuspation (Fig. 77.6A).
These elastics should not remain in place for more than 2 weeks. This
technique is contraindicated in patients with major rotations or
posterior cross-bites, for it does not offer good control on posterior
teeth. The rubber bands can also be used for mild anterior open bite
closure in a box pattern (Fig. 77.6B, C).
FIGURE 77.6 The settling bands.

(A) Light elastics for settling are laced around tubes and brackets
usually for 2 weeks. The arrangement of lacing the elastics varies from
case to case. Finishing elastics in a case with open bite. (B) Anterior
vertical elastics with class II pull. (C) With class III pull.
Passive utility arch

A passive utility arch fabricated in 0.016 × 0.018 in. stainless steel wire
is tied in bracket slots of incisors. Passive arches help to maintain
overbite and arch length, while premolars are kept free to settle in
occlusion with inter-digitation.
Use of specially fabricated tooth positioner

An alternative to segmental elastics or light round archwires for
settling is a rubber or plastic tooth positioner. The tooth positioner is a
custom-made resilient mouthpiece, which is a useful adjunct to
quickly ‘sock in’ the unsettled occlusion. The resilient positioners are
made from upper and lower impressions, and a wax bite is recorded
in centric occlusion. A face bow record in centric relation is required.
The models are transferred on an articulator in centric relation. The
teeth on upper and lower models are selectively split into several
segments to be seated in best occlusion. The positioners are made in
this new ‘set-up’ occlusion.
On debond appointment, the soft tooth positioner is issued with
instructions of 24 h wear. In 2 weeks’ time, the occlusion is usually
settled, showing improved occlusion, and the patient is ready for new
retainers, which are made from freshly made impressions. Tooth
positioners have been found effective in improving the occlusal finish,
but the effects are independent of an increase in occlusal contacts.
Positioners primarily help to achieve first-order alignment by tipping
teeth into an improved inter-cuspation.3
Tooth-size discrepancies
The tooth-size discrepancy may be corrected either by reducing tooth
mass in one arch with inter-proximal enamel reduction (usually lower
incisors) or by an addition of tooth mass with a restorative material in
the opposing arch. It is more common to find an excess tooth
substance in the lower arch. If the Bolton analysis confirms excess, it is
advisable to carry out inter-proximal stripping in the lower anterior
region in the initial stages of treatment. As the finishing stage is
approached, the relative tooth mass in the upper anterior segment is
evaluated, and inter-proximal reduction is carried out if necessary.
The tooth size discrepancy may be overcome with suitable aesthetic
restoration of microdontic maxillary lateral incisor(s).
Standard errors in occlusion seen during or at a finish of anterior
retraction are tabulated in Table 77.1. Plausible reasons and solutions
are classified side by side (Figs 77.7–77.11).
Table 77.1
Common errors in occlusion seen at final space closure
and suggested solutions for finishing and detailing
FIGURE 77.7 Unilateral class II elastics.
A case with class II molar relationship on the left side and class I on the
right: unilateral class II elastic for a short duration will bring about
desired corrections.
FIGURE 77.8 Mild midline and molar relation correction with

elastics.
In this case, the left side buccal occlusion is mild class II and right side
less than perfect class I, resulting in a mild midline shift. Greater force
on left side class II component, double class II elastics on the left side
and single class II elastic on the right side is expected to bring desired
corrections.
FIGURE 77.9 Class III subdivision buccal segment.
An arrangement of elastics for a class I dental relationship on the left
side and class III on the right: single class III elastic is worn on the right
side for a short duration.
FIGURE 77.10 An arrangement of elastics for the correction of

class II molar relationship on the left side and class III on the right.
FIGURE 77.11 Oblique for midline discrepancy, primarily in

anterior segment.
The purpose of finishing and detailing of occlusion is to provide
quality treatment outcome to the yardsticks and guidelines developed
by the expert groups.
American Board of Orthodontics (ABO) devised an ‘objective
grading system’ of evaluation of post-treatment models and
panoramic radiographs to assess the quality of treatment and the final
finish of occlusion.4–6 European Board of Orthodontics (EBO) has also
defined the goals of occlusion.7
American Board of Orthodontics—
objective grading system
American Board of Orthodontics (ABO) grading system is based on
the objective assessment system of the orthodontic records has
evolved over the years since the first field test in 1995. The second
field test conducted in 1996, the third field test in 1997 and the fourth
field test was conducted in 1998. The outcome saw the refinement of
the measuring and calibration process of examiners to establish the
validity or cutoff for passing this portion of the clinical examination.
In 1999, the ABO decided to initiate the use of Model Grading System
for examiners officially. The same grading system is used by
examinees to self-assess the outcome of the case and select cases that
are suitable for them to successfully pass the examination process
because the examining directors will use the same system.
ABO guidelines
The ABO gauge is used to measure discrepancies on a numerical scale
as low as 0.5 mm for each of the variable (Fig. 77.12).5 A sum of score
represents the total deviation from ideal occlusion. Higher the score
more are the discrepancies. In general, a case report that scores 30 or
more points will generally not be considered to pass that portion of
the clinical examination although several other criteria of records/case
treatments were included in the overall assessment (Fig. 77.13).
FIGURE 77.12 ABO measuring gauge.
(A) This portion of the gauge is in 1 mm increment and is used to
measure discrepancies in alignment, overjet, occlusal contact, inter-
proximal contact and occlusal relationships. (B) This portion of the
discrepancies in mandibular posterior buccolingual inclination. (C) This
portion of the gauge has steps measuring 1 mm in height and is used
to determine discrepancies in marginal ridges. (D) This portion of the
discrepancies in maxillary posterior buccolingual inclination. Note: Third
molars are not scored unless they substitute for the second molars.
FIGURE 77.13 Case AK, 17 years/female, class I type 1
malocclusion.
(A) Pre-treatment records, ABO discrepancy score 17. (B) Post-
treatment records, ABO objective grading score = 365 points.
Assessment criteria
The eight criteria assessed to attain normal occlusion and qualities of
treatment outcome are summarised.
Tooth alignment
The incisal edges of anterior teeth, mesiobuccal and distobuccal cusps
of mandibular posterior teeth and central fossae of maxillary posterior
teeth should be well aligned.
Anterior region. The incisal edges and lingual surfaces of the
maxillary anterior teeth and the incisal edges and labioincisal surfaces
of the mandibular anterior teeth were chosen as the guide to assess
anterior alignment. In the anterior maxillary and mandibular regions,
proper alignment is characterised by coordination of alignment of the
incisal edges and lingual incisal surfaces of the maxillary incisors and
canines and the incisal edges and labial incisal surfaces of the
mandibular incisors and canines.
Posterior region. In the maxillary posterior region, the mesiodistal
central groove of the premolars and molars is used to assess the
adequacy of alignment. In the maxillary arch, the central grooves
(mesiodistal) should all be in the same plane or alignment.
In the mandibular arch, the buccal cusps of the premolars and
molars are used to assess proper alignment. In the mandibular
posterior quadrants, the mesiobuccal and distobuccal cusps of the
molars and premolars should be in the same mesiodistal alignment.
Marginal ridges
The marginal ridges of adjacent teeth should be at the same vertical
level or within 0.5 mm of the same level. Marginal ridges help
establish proper occlusion. Radiographically, the cementoenamel
junction (CEJ) should be at the same relative height, resulting in a flat
bone level between adjacent teeth.
Buccolingual inclinations
There should not be a significant difference between the buccal and
lingual cusps of maxillary and mandibular—premolars and molars
with all cusps within 1 mm of straight edge. This arrangement will
eliminate any cuspal interferences and help establish an excellent
interdigitation.
Occlusal relationship
The mesiobuccal cusp of maxillary first molar must coincide within 1
mm of the buccal groove of the mandibular first molar and buccal
cusps of maxillary molars and premolars, and the canines must align
within 1 mm of the inter-proximal embrasures of mandibular
posterior teeth.
Occlusal contacts
Occlusal contacts are measured to assess the adequacy of the posterior
occlusion. Maximum inter-cuspation should be established between
the buccal cusps of the mandibular posterior teeth and lingual cusps
of the maxillary posterior teeth. Each functional cusp should be in
contact with the opposing arch.
Overjet
In the anterior region, the mandibular incisal edges should be in
contact with the lingual surfaces of the maxillary anterior teeth. In the
posterior region, the mandibular buccal cusps and maxillary lingual
cusps are used to determine proper position within the fossae of the
opposing arch.
Inter-proximal contacts
All of the maxillary and mandibular teeth should be in tight contact
with one another, as viewed from the occlusal surfaces.
Root angulation
Root angulation can be assessed using panoramic radiographs. The
roots of the maxillary and mandibular teeth should be parallel to one
another and oriented perpendicular to the occlusal plane.
This objective grading system for assessing the final occlusal results
of orthodontic treatment has helped in the assessment of highest
standards of clinical excellence in final ABO examinations and
development of quality graduate education progrmmes.6
European Board of Orthodontics7
EBO suggests evaluation of occlusion be conducted on the study
models taken within 4 weeks of debonding labelled as RED and 1 year
after treatment cast labelled as GREEN. EBO guidelines on
evaluations are more realistic; to quote, ‘the board promotes, as a
general rule, that the final occlusion should be as precise as is
appropriate for the case in question’.7 The board encourages to
evaluate models according to the ‘six keys to normal occlusion’ given
by Andrews in 1972.
Post-orthodontic occlusion scheme for
extraction treatment and complex
malocclusion situations
It should be remembered that ideal ‘textbook’ occlusion is not always

a viable treatment objective in complex and difficult cases. Extreme
variations in morphology of the jaw bases, crowns and the roots of the
teeth may lead to occlusal variations that are acceptable. On the other
hand, changing tooth morphology is a common orthodontic procedure
to improve functional occlusal fit and stability.7
The choice of tooth/teeth to be extracted and affected arch (es) is

governed by several factors, which include nature of malocclusion,
arch length discrepancy, Bolton’s ratio, teeth affected by dental caries,
the presence of non-vital teeth, underlying skeleton pattern and soft
tissue profile.
Characteristics of occlusion in four premolar

extraction cases
Class I, type I, class I bimaxillary protrusion and class II
division 1
The extraction space achieved following premolar extraction in both
the arches is utilised for arch alignment in subjects with crowding of
the teeth. In children with a bimaxillary protrusion, the extraction
space is primarily utilised for the normalisation of proclined teeth.
In class II division 1, malocclusion part of lower premolar extraction
space is used for mesialisation of molar for correction of molar
relationship to class I. The maxillary second premolars are usually
smaller than the first premolars and the less convex on the mesial
surface. Therefore the contact area of the distal surface of the canine
with that of mesial surface of the second premolars will be less than
ideal.
Extraction of maxillary first premolars and

mandibular second premolars
Such an approach is required in class II cases, where a substantial
reduction in the overjet is needed for the retraction of the maxillary
anterior teeth. The lower second premolar extraction space provides
scope for the greater mesial movement of the lower first molars,
which enable correction of class II to class I molar relationships. The
second premolar extraction is preferred, where space requirement in
the lower anterior segment is small. This approach is standard in the
treatment of class II division 1 dental malocclusion.
Class I occlusion with missing maxillary

laterals
Two approaches have been employed to treat cases with missing
maxillary lateral incisors. In children with a normal profile and class I
occlusion, arch alignment is achieved with a class I molar and canine
relation and regaining the space for the prosthetic replacement of the
lateral incisors with a partial denture or a fixed prosthesis or a
prosthesis supported on implants.
In other situations where the nature of malocclusion needs
space/extractions, the space(s) made available by the missing teeth are
utilised to align the teeth and correct the proclination, while in the
lower arch first premolars are extracted as usual. Post-orthodontic
occlusion in such a case would house maxillary canines having
substituted the lateral incisors, with first premolars as canines. Thus
the need for a prosthetic replacement of the congenitally missing
tooth/teeth is eliminated.
Such an option would require aesthetic camouflage of the
substituted teeth. Reshaping and beautiful composite work of the
labial surface, cusp tip, proximal surfaces and incisal edges of the
canine are required to mimic a lateral incisor. The maxillary first
premolar, which would then substitute the maxillary canine, needs to
be accordingly reshaped to establish functional contact with the distal
slope of the mandibular canine. The reshaping of the mesiobuccal
slope of the premolar and reduction of the lingual cusp is required.
The matter has been a serious point of discussion whether space
should be substituted with a prosthesis or closed orthodontically.
Although orthodontic treatment is completed when patients are
young, the decision to substitute the missing tooth with a prosthesis
should be based on goals of optimum oral health in natural dentition
for the remaining span of life.
Critical issues of clinical relevance on

maxillary canine substitution for a lateral
incisor
Canine is a large tooth for its labiolingual, mesiodistal and
occlusogingival (crown height) dimensions. The tooth has greater
dimensions of the root, which are difficult to be accommodated in the
maxillary lateral incisor alveolus.
The tooth is morphologically dissimilar with that of lateral incisor
more so at its incisal edge.
Canines are usually darker in the shade compared to lateral incisor,
especially at the neck.
Thick cingulum of the maxillary canine may interfere with that of
the incisal edges of lower incisors.
Accordingly, in such an occlusal arrangement, the first premolar(s)
is required to substitute the canine. This tooth is relatively diminutive
compared to a maxillary canine.
With the availability of high-quality, sophisticated restorative
material and techniques such as porcelain laminates and hybrid
composites, optimum aesthetics can be achieved by mimicking the
substituted teeth. Therefore orthodontic space closure is preferred
over the prosthesis.
Zachrisson et al. have summarised the combined
orthodontic/restorative techniques.8 This technology can include the
following:
1. Careful correction of the crown torque of mesially relocated

canines to mirror the optimal lateral incisor crown torque,
along with providing optimal torque and rotation for the
mesially moved premolars.
2. Intentional bleaching or a porcelain veneer to transform any
yellowish or dark canines into an optimal lateral incisor shade.
3. Individualised extrusion and intrusion during the mesial
movement of the canine and the first premolar, respectively, to
obtain an optimum level for the marginal gingival contours of
the anterior teeth.
4. The first premolar tooth can receive a porcelain veneer or a
composite camouflage to compensate the need for a tooth with
larger dimensions.
5. Minor surgical procedures for localised clinical crown
lengthening.
6. Clinicians should evaluate and eventually restore the central
incisors because, in many patients with lateral agenesis, the
central incisors are small.10
Widening and lengthening the incisors could allow patients to more

optimally display their dentition during speech and smiling.
This approach applies not only to canine substitution cases, but also
when spaces are opened, and the missing lateral incisors are replaced
with restorations.
Kokich et al.9 have highlighted the issue of replacement of the
missing tooth with single tooth implant, though several other
restorative options are available such as resin-bonded bridge. They
feel conservation of tooth structure is the main advantage of such an
approach, whereby the primary role of orthodontists would be to
provide coronal and apical spacing necessary for the prosthesis.
Occlusion with missing one lower incisor or
treatment with extraction of a mandibular
incisor
A mandibular incisor may be congenitally missing or may have a poor
prognosis for orthodontic treatment due to periodontal reasons. Other
appropriate indications of such a choice are mild-to-moderate class III
malocclusion, an edge-to-edge anterior occlusion or anterior cross-
bite, with mild anterior mandibular tooth size excess and minimal
open bite tendencies.11 The completed post-orthodontic occlusion
would have a non-coincident midline with a more than normal overjet
remaining. Clinicians should also be careful to avoid gingival
recession, open inter-proximal gingival embrasures and a tendency
for an increased overbite.11 The anterior mandibular arch may be
slightly narrow compared to the maxillary arch. It is imperative that a
rigid lower lingual retainer is provided for a long term.
Occlusion following extraction of maxillary

first premolar only: therapeutic class II
occlusion
While deviating from the traditional view on a prerequisite of class I
molar relationship, a functional yet stable class II malocclusion is now
an acceptable option. The proclination of the maxillary arch in a class
II malocclusion can be treated with the extraction of the upper
premolars only if the lower arch is well aligned, and lower incisors are
not too much proclined. This would result in a normal overjet and
overbite, class I canine and class II relationship of maxillary second
premolars and molars. The mesiobuccal cusp of the maxillary first
molar articulates in the embrasure between the mandibular first molar
and second premolar with the distobuccal cusp of the maxillary first
molar articulating with the mesiobuccal groove of the mandibular first
molar (Fig. 77.14). Slight mesiolingual rotation of the maxillary first
molar helps to achieve good inter-digitation.12
FIGURE 77.14 Finishing class II buccal occlusion.
Case NS, 18-years female, treated for blocked out maxillary canines by
extraction of first premolars only. Buccal occlusion features class II
molar relations and class I canine relationship.
Although, the severity of malocclusion is usually smaller in patients

treated with upper first premolar extraction, it brings about a greater
change in profile than the four premolar extraction approach. Such an
approach seems to provide a better occlusal success rate than that
with four premolar extractions. The final overbites, remaining overjet
and canine relations were seen in better relationship with this
approach.13
Therapeutic class III occlusion following

extraction of mandibular first premolars
Mild forms of class III malocclusion may be associated with mild
crowding/hypoplasia of maxillary dentoalveolar segment. Such
patients may be treated with non-extraction treatment in the upper
arch, whereby arch expansion and proclination are the norms while
mandibular anterior teeth are retroclined to maintain normal overjet.
Zachrisson suggested that in class III cases, we can rotate maxillary
molars and bicuspids in a mesial direction. In other situations, the
lower anterior segment is distalised after extraction of first premolars.
Other situations for a finish in class III occlusion are the patients
with congenitally missing teeth in the mandible and patients in whom
teeth in only the mandibular arch are required to be extracted. With
this type of inter-cuspation, proper aesthetic and functional aspects
must be observed.14,15
FIGURE 77.15 Finishing in class III occlusion.
A case of severe crowding in the mandibular arch and negative overjet
treaded with the extraction of first premolars in the lower arch only.
Note normal overjet and class III molar which are stable.
Key Points
The goals of the orthodontic treatment are to achieve a functionally
normal occlusion, which is stable and selfsustaining in harmony with
the underlying skeletal facial structures and creates a balanced,
pleasing soft tissue profi le of a person. Another dimension of
functionally normal occlusion involves its harmony with the
neuromuscular system and TMJ functions. The occlusion and soft
tissues should also be in harmony with the functions of the
stomatognathic system, including speech and smile. A healthy
periodontium and a caries free environment are a pre-requisite to the
maintenance of optimum oral health and a well-functioning occlusion.
References
1. Zachrisson BU. JCO/interviews Dr. Bjorn U.
Zachrisson on excellence in finishing. Part 1. J Clin
2. Gottlieb EL. Grading your orthodontic treatment
results. J Clin Orthod. 1975;9(3):155–161: PubMed
PMID: 1054698.
3. Park Y, Hartsfield JK, Katona TR, Eugene Roberts W.
Tooth positioner effects on occlusal contacts and
treatment outcomes. Angle Orthod.
2008;78(6):1050–1056: doi: 10.2319/070307-307.1
4. Objective Grading System. Available from:
http://americanboardortho.com/about/articles/Objective
GradingSystem1998.pdf.
5. Casko JS, Vaden JL, Kokich VG, Damone J, James
RD, Cangialosi TJ, et al. Objective grading system for
dental casts and panoramic radiographs. American
Board of Orthodontics. Am J Orthod Dentofacial
6. James RD. Objective cast and panoramic radiograph
grading system. Am J Orthod Dentofacial Orthop.
2002;122(5):450: PubMed PMID: 12439470.
7. European Board of Orthodontics. Available from:
http://www.eoseurope.org/ebo/ebo.
8. Zachrisson BU, Rosa M, Toreskog S. Congenitally
missing maxillary lateral incisors: canine substitution
point. Am J Orthod Dentofacial Orthop. 2011;139(4.):
doi: 10.1016/j.ajodo.2011.02.003 434, 436, 438 passim.
9. Kokich Jr VO, Kinzer GA, Janakievski J. Congenitally
missing maxillary lateral incisors: restorative
replacement counterpoint. Am J Orthod Dentofacial
Orthop. 2011;139(4):435: doi:
10.1016/j.ajodo.2011.02.004 435, 437 439 passim.
10. Olivadoti A, Doldo T, Treccani M. Morpho-
dimensional analysis of the maxillary central incisor
clinical crown in cases of congenitally missing upper
lateral incisors. Prog Orthod. 2009;10(1): 12–L19
English, Italian. PubMed PMID: 19506742.
11. Zhylich D, Suri S. Mandibular incisor extraction: a
systematic review of an uncommon extraction choice
in orthodontic treatment. J Orthod.
2011;38(3):185–195: doi: 10.1179/14653121141452 quiz
12. Nangia A, Darendeliler MA. Finishing occlusion in
class II or class III molar relation: therapeutic class II
and III. Aust Orthod J. 2001;17(2):89–94: PubMed
PMID: 11862871.
13. Janson G, Janson M, Nakamura A, de Freitas MR,
Henriques JF, Pinzan A. Influence of cephalometric
characteristics on the occlusal success rate of class II
malocclusions treated with 2- and 4-premolar
extraction protocols. Am J Orthod Dentofacial Orthop.
2008;133(6):861–868: doi: 10.1016/j.ajodo.2006.04.045
14. Farret MM, Farret MM, Farret AM. Strategies to finish
orthodontic treatment with a class III molar
relationship: three patient reports. World J Orthod.
2009;10(4):323–333: Winter. PubMed PMID: 20072750.
15. Schneider-Moser U, Moser L, Bennett J. Atypical
treatment of class II malocclusion with space closure
only in the lower arch. Prog Orthod.
16276428.
CHAPTER 78
Deband, debracketing and
delivery of retention appliance
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Case review and preparation: scheduling the
appointments
Debanding of molar bands
Debonding/debracketing bonded appliances
Advanced techniques
Electrothermal debracketing (ETD) technique
Impulse-generated debonding procedure
Laser-assisted debracketing
Er: YAG laser
Post-debonding agents to facilitate debonding
Rationale and use of adhesive removal and polishing
armamentarium
Steps in adhesive removal and polishing
Key Points
Introduction
The removal of orthodontic appliance is a moment of great
significance for all those involved in the long process of treatment.
Debonding occupies particular significance for the patient and his/her
parents as they are looking forward to the final treatment outcome,
and for the orthodontist who is awaiting appreciation for his/her hard
work and sense of pride for the provision of care.
The removal of an appliance is only a phase of transition to the
second and equally important phase of therapy called ‘retention’.
Debanding and debonding procedures require a longer clinical
appointment and a strict unfailing schedule of delivery of the
retention appliances and a close follow-up after that.
Case review and preparation: scheduling the

appointments
Debonding appointments are organised to ensure availability of
required laboratory support for making or delivery of retention
appliance in stipulated time and availability of patient for the issue of
retention appliance, not to miss it. A typical schedule is discussed in
Appointment I
The decision to debond the appliance is arrived at after a detailed
review of finishing and detailing. At this stage, retention plan and
type of retention appliance to be issued should have been envisaged.
Accordingly, upper and lower alginate impressions are made. The
lower impression is made to fabricate flexible spiral wire or rigid
retainer. Hence, accurate recording of lingual/occlusal surfaces of the
lower arch is a pre-requisite. The upper impression should be made
after removing the archwire. A retainer in the maxilla is fabricated
from dental models after scrapping brackets and tubes with the help
of sharp scalpel while study models are wet. The maxillary Hawley-
or Begg-type circumferential retainer is made on these study models.
The retention appliance should be ready for issue on the day of
debonding.
The alternate protocol involves making a lower sectional impression
of the anterior segment for fabrication of the flexible wire retainer in
the laboratory.
Appointment II
The lower flexible or rigid wire retainer is bonded first prior to any
debond procedure. This step ensures lower retention in place. The
maxillary appliance is debonded next and the retention appliance is
issued.
The alternate protocol involves making upper impression after
complete debond. Two models are prepared. The first one is used for
creating a thermoplastic transparent retainer which is issued within
2 h of debond. The second model is used for the fabrication of Hawley
retainer which is issued 1–2 weeks later.
Debanding of molar bands, debonding of the bonded appliance and
accessories, and removal of residual adhesive and cement are done.
This is followed by a final clean up of all tooth surfaces and polishing
of teeth.
A review of oral health should involve the recording of gingival
health with complete periodontal assessment, bone loss, any new
carious lesions, secondary caries and white spot lesions. Oral cavity
and dentition are critically examined for aesthetic dentistry
procedures for improvement of tooth morphology, restoration of
fractured enamel edges, aesthetic restoration of small-sized teeth for
the creation of contact points and restoration/rehabilitation of missing
or carious teeth. The patient is given instructions on oral hygiene and
referral for review with his/her general dentist. Treatment of stains
and hypoplastic lesions is planned. The upper and lower retention
appliances are issued.
Appointment III
It is organised within a week to review the patient on compliance with
retention schedule, settling of occlusion and final review of occlusion
for a preparation of post-treatment records. A set of upper and lower
study impressions are made for preparations of post-treatment study
models. Clinical photographs of the face and a set of intraoral
photographs are shot. Post-treatment records include lateral
cephalogram and panoramic view radiographs of maxilla and
mandible.
The author suggests clinical photographs and intraoral photographs
within the first week of debonding which entail sufficient time for
gingival bleeding and inflammation to settle down and any residual
adhesive/molar band cement and stains left on tooth surfaces become
apparent. The patient undergoes the second round of clean up and
polishing, before clinical photography. European Board of
Orthodontics suggests that post-treatment models can be prepared
within 4 weeks of debonding to be labelled as RED.1
Debond procedures are not free from risks such as pain, damage to
tooth cusps on molars and enamel cracks on anterior teeth. Other risks
are related to accidental swallowing or aspiration of brackets or
composite flakes, broken and chipped parts of porcelain brackets, and
inhalation of dust arising from porcelain/composite/cement. Injuries
to gingival, oral mucosa and periodontium can occur due to careless
handling of debonding instruments. Most of the mechanical debond
procedures can be undertaken with archwires remaining in the
brackets. However, electrothermal debracketing (ETD) and removal of
porcelain brackets can only be undertaken with archwires out of a
mouth. All instruments should be properly sterilised.
Debanding of molar bands

The procedure is carried out with molar debanding pliers. The patient
is explained about the possibility of severe pressure on the tooth, and
he/she should remain calm while molar band lifts out of the tooth.
Molars should be examined for possible restorations, which might get
damaged and/or careless handling may cause fracture of the crown,
especially if a tooth has undergone root canal treatment or restored
with a crown.
The sharp and short end of the pliers is engaged under the buccal
gingival band margin in the mandible, (palatal gingival band margin
in the maxilla) of the molar band while the long end of the pliers is
placed on the occlusal table in the centre of the tooth. The pliers are
held firmly, pressed gently to break cement/band bond, to slowly lift
off the molar band. The process is repeated on the other side. The long
beak of pliers should always be padded with a safe rubber cap to
minimise chances of enamel fracture (Fig. 78.1A–C).
FIGURE 78.1 (A) Band remover with a plastic tip. (B) The short and
sharp end engaged under the palatal gingival band margin in the
maxilla. (C) The short and sharp end engaged under the buccal
gingival band margin in the mandible.
In case the entire debond/deband process is planned with wires in

place, it is a good idea to loosen the molars band and leave them till
other brackets are debonded. Entire arch with brackets is afterwards
removed along with molar bands. The molar bands are secured to the
main archwire by turning the distal ends of the archwire before
debonding is started. Following completion of loosening of molar
bands, debonding process on remaining teeth is undertaken.
Debonding/debracketing bonded appliances

Most orthodontic appliance brackets and accessories are made from
stainless steel, which does not pose significant problems on
debonding. Porcelain brackets, on the other hand, are hard and brittle
therefore require high shearing forces for their removal. Alternate
methods have been therefore proposed for debonding of porcelain
brackets.
Following clinical steps are involved in debonding:
1. Removal of bonded brackets tubes and accessories from tooth

surfaces.
2. Removal of residual adhesive.
3. Polishing of tooth surfaces.
4. Treatment of stains and white spot lesions.
Debracketing can be performed in any of the methods discussed in
Conventional mechanical methods
Debracketing metal brackets
1. Squeezing brackets to create composite failure with

debonding pliers. The mechanical methods require squeezing
the mesial and distal wings of the bracket with debracketing
instrument thereby distorting the bracket base, causing a bond
failure at the bracket mesh and adhesive interface. This
method is effective for removal of stainless steel brackets but
leaves them distorted, unsuitable for recycling or reuse. This
process cannot be effectively used when an edgewise full-size
wire is in place (Fig. 78.2A–C) for this does not allow the
bracket slot to squeeze.
2. Shearing force at composite bracket interface with a sharp-
bladed instrument. The other mechanical method is to
squeeze the bracket at its base, in occluso gingival direction,
and peel off the bracket. This method utilises use of sharp-
edged debonding pliers or a ligature cutter, the sharp blades of
which are engaged on each side of the bracket at the junction
of bracket base on composite–enamel interface. A careful
placement of sharp edges of pliers holding them at the precise
locations in a firm grip is required. The squeezing force is then
applied which causes enamel composite adhesive failure, and
the bracket is peeled off from the tooth surface. The tooth is
supported with fingers of another hand at the occlusal or
incisal end. The squeeze force is applied from palm grip
without any other movement at wrist or elbow, to avoid
transmitting jiggling force on the tooth.
This method can cause damage to enamel surface due to rubbing
of sharp ends of pliers and site of failure being adhesive to
enamel interface (Fig. 78.3A–C).
3. The lift-off debonding instrument (LODIa). It is a specially
designed instrument to be used for debonding of winged
brackets. It has a wire loop that engages beneath a tie-wing
and applies a shear force when the handles are squeezed. The
feet of the instrument rest on occlusal/gingival to the bracket
on the labial tooth surface of the tooth crown. For the removal
of orthodontic brackets, lift-off instrument is better accepted
by patients compared to the ligature cutting pliers. Patients
report two times lower pain compared to ligature cutters, but
the amount of remaining adhesive on the teeth is same.2
Pithon et al. investigated the level of discomfort reported by
patients during the removal of orthodontic metallic brackets
performed with four different debonding instruments. The
lower level of pain and discomfort was reported when metallic
brackets were removed with the LODI and the use of a straight
cutter plier caused the highest pain and discomfort scores
during debonding.3
4. Ultrasonic debracketing. Ultrasonic KJS and KJC tips to be
used with Cavitron 2002 ultrasonic unit (Dentsply
International) were designed for removal of bonded Maryland
bridges. The same technique has been inducted for
debracketing of the orthodontic appliance. The KJS instrument
tip is used at high power to create a purchase point within the
adhesive between the bracket base and the enamel surface.4,5
In this technique, the brackets are debonded with a decreased
chance of enamel damage, a decreased likelihood of bracket
failure and the ability for the removal of the residual adhesive
with the same instrument after debracketing.6 The
disadvantages of the ultrasonic technique include a
significantly increased debonding time, excessive wear of the
expensive ultrasonic tips, the need to apply moderate force
levels which could create some discomfort to sensitive teeth,
and the potential for soft tissue injury by a careless operator.
There is a need for a water spray to reduce the heat build-up
which minimises the possibilities of pulpal damage. As the
ultrasonic method is effective but time consuming, its use
might be indicated when a ceramic bracket fractures, while the
conventional bracket removal method was being used and
part of it remains attached to the tooth.7
FIGURE 78.2 (A) Debonding pliers for anterior teeth. (B) Debonding
pliers for premolars. (C) Debonding by squeezing the twin bracket
mesiodistally thus causing distortion of the bracket, which facilitates
debonding.
FIGURE 78.3 (A) Ligature cutter as debonding plier. (B) Ligature

cutter being used to create shearing forces by holding the sharp edges
of pliers at composite bracket interface. (C) Debonding pliers to create
shearing forces by holding the sharp edges of pliers at composite
bracket interface.
Debracketing of porcelain brackets

Most ceramic brackets are made of either polycrystalline alumina,
single-crystal alumina, or zirconium. Polycrystalline brackets with
metal slots are also commercially available. The porcelain brackets
pose significant problems with their removal due to their physical
properties, which are much different from stainless steel.8
• Porcelain brackets are harder than SS brackets (nine times or

more).
• Porcelain brackets have higher tensile strength compared to SS
brackets. Monocrystalline brackets have higher strength than
polycrystalline ceramic brackets.
• They have low fracture toughness. Therefore, they easily break
on the application of force for debonding.
• Ceramic brackets exhibit a high bracket bond strength, which
necessitates the use of high forces to remove brackets, which is
higher than mean linear tensile strength of enamel (14.5 MPa).
Therefore, debonding of porcelain brackets is associated with a high

risk of damage to tooth enamel.
Mechanical debonding of porcelain brackets. Ceramic bracket
specific debonding pliers are recommended by the manufacturers of
porcelain brackets. Manufacturers supply and recommend pliers
specially designed to work with their brand of brackets. It is
important to follow the manufacturer’s guidelines specific to their
product regarding debonding.
For example, 3M Unitek has patented a debonding slot and ‘stress
concentrator’ located on the base of their Clarity brackets. The
manufacturer recommends debonding pliers 900–850 for Clarity
brackets.9 The debonding slot concentrates stress at this point, causing
the bracket to collapse under gentle pressure from Howe or Weingart
pliers (Fig. 78.4A–B).
FIGURE 78.4 (A) Weingart pliers. (B) Debonding ceramic brackets by
squeezing the bracket mesiodistally.
This technique allows debonding in a similar method to metal

brackets, with most of the residual adhesive remaining on the enamel
surface.10 Their guidelines for debonding are as follows:
• The archwire is removed.

• It is recommended to remove all composite adhesive around
the base of brackets to be debonded especially on mesial and
distal sides.
• The debonding pliers are placed against mesial and distal
sides in such a manner that edges of the instrument are
symmetrically positioned against the labial surface of the
bracket.
• The pliers are pressed to squeeze the bracket till it collapses.
• Once collapsed, it is presumed that bond failure has occurred.
Rock the bracket gently to remove it from tooth.
• The pliers’ beak may carry tiny pieces of ceramic brackets.
Clean it or wipe it before using it on another bracket, to ensure
even contacts and force distribution.
Bracket removal with Weingart or Howe pliers

The bracket is held at slots mesially and distally between jaws of
pliers, gently squeezed which deforms the slot and peels off the
bracket. Rock it gently to remove the bracket.
Problems associated with debracketing of porcelain brackets.5,11
The high bonding strength of porcelain brackets with enamel
necessitates the use of high shear stress when mechanical methods of
bracket removal are used. The hard and brittle porcelain brackets have
little scope for deformation under the squeeze pressure of the
debonding pliers causing their fracture with little or no possibility of
bracket/adhesive failure. If the enamel adhesive failure occurs, it can
cause damage to enamel surface, which may crack, get chipped off or
delaminate along with bracket.
Fracture of ceramic bracket during debonding is not uncommon
leaving its base attached to the enamel surface leading to great
difficulty in its removal from enamel surface. The only option
available is the use of a high-speed diamond bur. This process is time
consuming and unpleasant for the patient. Grinding of ceramic
materials over the tooth surface generates considerable heat with a
potential for pulpal damage. Therefore, the use of only fresh high-
speed diamond grinding stone with coolant spray is recommended.
During grinding, large ceramic fragments may pop-up which pose the
risk of aspiration of the radiolucent material by the patient and
produce ceramic dust that has been associated with skin and eye
irritation.5,11
Therefore, techniques and methods have been evolved whereby
debracketing of ceramic brackets can be performed without damage to
enamel surface. They are discussed in the following sections.
Advanced techniques
Electrothermal debracketing (ETD)
technique
It is a technique of bracket removal by gently heating of the adhesive
composite under the bracket base which may lead to its thermal
softening thereby facilitating a gentle peel off from the tooth surface.
The handheld, cordless battery operated instrument has a blade which
fits into the slot and transfers the heat rising temperature up to 130 °C
or close. The bracket is firmly held by a thumb-activated lock-on arm
of the ETD unit. The bracket can be gently lifted from the enamel
surface without distortion of the bracket or excessive force to the
underlying enamel.12,13
This method has been developed to eliminate a risk of enamel
cracks/enamel surface damage associated with high stresses generated
by purely mechanical methods of debracketing.
Risks of ETD
A major risk with the use of ETD involves pulpal necrosis and injury
of soft tissue with the heated instrument. Dental pulp is shown to
tolerate a rise in temperature of 1.8 °C without any adverse effects;
however, where the temperature is raised to 5.5 °C, 15% of tested teeth
are found to have pulpal necrosis.14 Sheridan et al. reported that all
ETD procedures elicited pulpal wall temperatures that were
significantly below the primate baseline. When water spray was used
in conjunction with ETD, the mean ultimate increase in pulpal wall
temperature was below 1 °C.
Histological observations on pulp after ETD showed up some
cellular modifications, which corresponded to the placement of the
extraction forceps. There was no evidence of cellular pathosis or
modification due to ETD.12,13 ETD can cause slight inflammation and
odontoblastic disruption in pulp.15
Removal of metal brackets on porcelain veneers through
electrothermal debonding can produce and elevate temperature
beyond the threshold of irreversible pulpal damage (5.5 °C) in 46% of
cases while it is safe for pulp for removal of porcelain brackets on
porcelain veneers.16
The temperature required to cause thermal softening of the
adhesive for a successful debond varies with different bonding agents
based on their composition. Greater the filler content higher the
temperature required. There is an inverse exponential relationship
between debonding temperature and load needed to cause
debracketing. While room-temperature debonding showed failure at
the bracket/resin interface with evidence of cohesive enamel fracture,
ETD procedures caused a shift of bond failure at tooth/resin interface
with no evidence of overt enamel fracture.17
ETD for porcelain brackets

It is a safe and acceptable mode of debracketing technique suitable for
the porcelain brackets. Dovgan et al. reported that monocrystalline
sapphire brackets bonded with Bis-GMA composite resin could be
removed from an average of 2.1 s. The bracket failure was usually at
the bracket/composite interface.15
ETD provides predictable debonding to ceramic brackets with no
veneer damage. However, removal of metal brackets through
electrothermal debonding can produce ceramic damage in 13% of
cases.16
Impulse-generated debonding procedure

Recently, Knosel et al. tested the alternative debonding technique
using air pressure impulse devices, commonly used for crown
removal in prosthodontics.18 The CoronaFlex was used by positioning
its toggle parallel to the adhesive–enamel interface. By pulling the
trigger, a piston with a weight of 2.5 g was impelled by an air pressure
of 2.2 bars along the shaft on the toggle, thereby releasing a short
impact pulse of 3000 N for 10 ms. This short yet powerful impulse
removed the adhesion to release the bracket. Impulse air pressure is a
good alternative to conventional debonding methods by bracket
removal pliers and LODI. The adhesion failure is usually at the
bracket–adhesive interface, thereby avoiding enamel damage.
Laser-assisted debracketing
The use of Er: YAG and CO2 lasers for debonding ceramic brackets
have been tested in many studies. Laser energy can degrade the
adhesive resin as a result of the effects of heat transmitted to bonding
adhesive, which may undergo either of the following processes:
1. Thermal softening
2. Thermal ablation
3. Photoablation.
The heat produced by laser beam exposure is localised as the

debracketing tool is essentially ‘cold’.19 The method can be used for
the removal of various types of ceramic brackets, regardless of their
design. The laser-aided debonding technique significantly reduces the
residual debonding force, therefore risks of enamel damage and the
incidence of bracket fracture associated with pure mechanical
methods of debracketing.
Er: YAG laser

Polycrystalline ceramic brackets exposed with Er: YAG laser at 4.2 W
for 9 s required lowered shear bond strengths of 9.52 MPa compared
with that of a conventional method 20.75 MPa. Laser exposure also
caused failure at bracket composite interface. The exposure creates
bond failure through thermal softening of the adhesive.20 For
debonding of ceramic brackets, 300–450 mJ of laser energy would be
safe and efficient for monocrystalline brackets and about 450 mJ for
polycrystalline brackets.21 One laser beam pulse each can be applied
at two points for one bracket. Er: YAG laser is considered safe for
greatest average temperature change was 3.78 °C on the enamel
beneath the bracket and 0.9 °C on the pulp chamber when used in
laser energy range up to 600 mJ.21
Porcelain brackets, when exposed to a CO2 laser beam of 14 W for
2 s, lowered the average torque force necessary to break the adhesive
between the polycrystalline ceramic brackets and the tooth by a factor
of 25. The brackets were removed in one piece. The average torque
force needed to debond monocrystalline brackets was lowered by a
factor of 5.2 when illuminated with a laser setting of 7 W.18 The
temperature of cross-sectioned enamel increases by about 200 °C
under CO2 laser irradiation with a relatively high output (5 and 6 W),
while the temperature increases by about 100–150 °C under laser
irradiation with low output (3 and 4 W). The hardness and elastic
modulus of enamel are not affected by CO2 laser irradiation. CO2 laser
debonding may not cause iatrogenic damage to enamel.22
The advantage of the laser-aided bracket-removal technique include
little force required for debonding and therefore the risk of enamel
damage is greatly reduced. The technique is well accepted by the
patient. The brackets are gently lifted in one piece, therefore,
complications associated with the removal of fragments of porcelain
remnants are eliminated.
Post-debonding agents to facilitate debonding

It has been suggested that the derivatives of chemical agents—
peppermint oil should be applied around the bracket base before
mechanical debonding. A chemical agent can help to facilitate easier
mechanical debonding without causing damage to the enamel surface.
Post-debonding agent (GAC International Inc.) and P-de-A
(Oradent Ltd.) are available in the market, both of which are
derivative of peppermint oil. It neither produces any significant effect
on the surface micro-hardness of orthodontic resins nor softens the
resin matrix but allows easier debonding of orthodontic appliances.23
A 60-s application of peppermint oil facilitated ceramic bracket
removal and promoted failure at the adhesive–enamel interface,
without damaging the tooth surface.24
The purpose of final cleanup procedure is to restore treated enamel
close to normal enamel, which has not carried the brunt of etching and
bonding. Even with the best possible techniques and currently
available polishing kits, it is not possible to restore post debond
enamel for its finish and lustre to pre-treatment normal.
Any instrumentation carried out on enamel surface removes some
amount of enamel. Polishing with rubber cup alone abrades 5 µm of
enamel surface while bristle cup brush for 10–15 s per tooth abrades
10 µm of enamel surface. Removal of residual resins may cause
enamel loss ranging from 26.1 to 31.8 µm for unfilled resin and from
29.5 to 41.2 µm for filled resin, depending on the instrument used for
prophylaxis and debonding. Enamel loss with high-speed carbide bur
is more (19.2 µm) than with a low-speed (11.3 µm).24 Studies have
confirmed greater loss of enamel occurred with high-speed tungsten
carbide bur or the ultrasonic scaler and least with the slow-speed
tungsten carbide bur or the debonding pliers.26,27
Little removal of an outermost layer of enamel is not so harmful by
recent views on tooth surface dynamics because the thickness of
enamel is in the range of 1000–2000 µm. Remineralisation of enamel
after polishing and completion of all dental procedures is around 1–
2 µm a year which fill up micro-level defects of enamel surface
rendering it smooth.28
Rationale and use of adhesive removal and

polishing armamentarium
Tungsten carbide burs of 8–30 flutes have been suggested for the
removal of adhesive. Using 30-fluted tungsten carbide bur appeared
to be the most efficient method of removing highly filled resin after
debonding, and it produced the least amount of scars.29 A final
cleanup and polishing generally include a multi-step use of fine and
superfine tungsten carbide burs (TCB), and an aluminium oxide
coated abrasive discs in order of finer particle size. This is usually
followed by polishing with slurry paste.
It has been reported that a combination of 12- and 30-flute tungsten
carbide bur at high speed with a water coolant, provide fast and
efficient and residual adhesive removal. However, Ulusoy based on
SEM studies reported that the enamel surface showed enamel scars,
which need to be finished by other polishing techniques.30
Steps in adhesive removal and polishing

Precautions to be observed before initiating cleanup
procedures
Following procedures should be observed before initiating cleanup
procedures:
• Use of surgical mask is mandatory to avoid inhalation of

aerosol or dust generated during adhesive removal.
• Eye protection glasses must be worn by the operator, assistant
and the patient to protect against ejected particles.
• All instruments must be inspected for the integrity of cutting
surfaces such as flutes. Burs with worn out and any broken
flutes must be discarded.
• The rotator instrument should be used according to the speed
recommended by the manufacturer.
• Bur should be used in a gentle feather touch-moving motion to
avoid localised heating.
• It goes without saying that all instruments including burs
should be cleaned and sterilised by the directions of the
manufacturer.
Steps of clean up procedure
1. Gross cement flakes can be easily removed with the help of

ultrasonic scaler tips. At this stage, patient also undergoes a
gross oral hygiene process to remove any tartar that becomes
visible after removal of molar bands and debracketing.
Residual adhesives are not easily distinguishable from
adjacent enamel for their colour similarity especially when
they are wet with saliva. Therefore, teeth should be isolated
with cotton rolls and gently air dried to locate the remaining
residue. Remove large scrapes of the adhesive with bond-
removing pliers or with a scaler but within the adhesive
without rubbing the sharp instrument on the enamel surface.
This procedure should be done only if a large quantity of
adhesive is visibly remaining but with great caution.
2. Dr Bowmen31 recommends a combination of two types of TC
burs followed by polishing with green superfine stones which
have been specially developed as a kit for post-debond care
(Fig. 78.5A–B).
a. A round-end, tapered 12-blade TC bur is used for
removing cement and orthodontic bonding
adhesives on teeth at a speed of 25000–30000 rpm
after debracketing and debanding. Gross removal of
adhesive is preferred with 12-flute TC bur.
b. This is followed by the use of a long, flame-shaped
30-blade carbide bur to remove last remnants of
adhesive and produce a smooth finishing after gross
adhesive removal.
3. This is followed by polishing with green superfine stones at the
same high speed.
4. Final polishing is performed with a slurry of pumice paste and
good quality rubber cup brush under sufficient wet conditions
to prevent overheating.
FIGURE 78.5 (A) Boxed kit. (B) Set of three burs critical to adhesive
removal. Adhesive removal kit recommended by Dr Bowmen. This set
consists of: (i) red carbide, a gross adhesive removal bur. (ii) White
finishing carbide, a 30-fluted finishing bur. (iii) One polisher, a green
polishing point
A recent study found one-step diamond micro-polishers developed

for polishing resin composite and compomer restorative materials
produced enamel surface as smooth as natural enamel.30 Using micro
polishers alone is a time consuming process, therefore their use is
recommended after gross adhesive removal with of TC burs of 12 and
30 flutes. The PoGo (Dentsply International) disposable single-use
discs are used with increasing light pressure to slowly produce a
highly polished surface. Each disc is diamond-impregnated, urethane
dimethacrylate-mounted on plastic, latch-type, slow-speed hand piece
mandrel.32
Key Points
Deband procedures should be performed with as much clinical
diligence as the process of bonding. A complete understanding of the
composition of adhesive used, depth of etching, setting reaction, the
bracket material, that is steel/porcelain (mono- or polycrystalline), any
use of silane coupling agents in bonding and all such factors that
influence bond strength should be taken into consideration when
choosing the debonding technique and instruments.
Other clinical factors of great significance are periodontal status of
the teeth, history of endodontic treatment and restorations. The
debonding technique and procedure require careful handling of
brackets to minimise discomfort and the pain associated with this
procedure.
Careless handling of dental tissue may lead to chipped cusps of
molars and loss of enamel. The teeth, which are endodontically
treated and carry larger restorations, are at greater risk of damage.
Once debonding is completed, process of a removal of residual
adhesive, cleanup and polishing of teeth is undertaken with the same
diligence to avoid surface enamel loss.
Final cleanup and polishing is a technique-sensitive operation,
which should be effectively and efficiently performed with
instruments specially designed for the purpose. The armamentarium
of finishing and polishing should follow the manufacturer’s
instructions of their use. All efforts should be directed to get a finish
as close to natural enamel as possible but without iatrogenic damage
to the dental hard and soft tissues.
Care of the dental hard tissues to facilitate remineralisation of white
spot lesions and optimisation of gingival health should be the next
step at the completion of debonding.
References
1. EBO European Board of Orthodontics. Available
from: http://www.eoseurope.org/ebo/ebo.
2. Normando TS, Calçada FS, Ursi WJ, Normando D.
Patients’ report of discomfort and pain during
debonding of orthodontic brackets: a comparative
study of two methods. World J Orthod.
2010;11(4):e29–34: PubMed PMID: 21490985.
3. Pithon MM, Santos Fonseca Figueiredo D, Oliveira
DD, CoqueiroRda S. What is the best method for
debonding metallic brackets from the patient’s perspective?
Prog Orthod. 2015;16:17: PubMed PMID: 26081783;
4. Krell KV, Courey JM, Bishara SE. Orthodontic
bracket removal using conventional and ultrasonic
debonding techniques, enamel loss, and time
requirements. Am J Orthod Dentofacial Orthop.
1993;103(3):258–266: PubMed PMID: 8456784.
5. Bishara SE, Trulove TS. Comparisons of different
debonding techniques for ceramic brackets: an in
vitro study Part I. Background and methods. Am J
6. Bishara SE, Trulove TS. Comparisons of different
debonding techniques for ceramic brackets: an in
vitro study Part II. Findings and clinical implications.
7. Russell JS. Aesthetic orthodontic brackets. J Orthod.
2005;32(2):146–163: PubMed PMID: 15994990.
8. Tehranchi A, Fekrazad R, Zafar M, Eslami B, Kalhori
KA, Gutknecht N. Evaluation of the effects of CO2
laser on debonding of orthodontics porcelain
brackets vs. the conventional method. Lasers Med Sci.
2011;26(5):563–567: PubMed PMID: 20725757.
9. Unitek™ Debonding Instrument. Available from:
http://multimedia.3m.com/mws/media/340996O/unitek-
debonding-instrument-technique-guide.pdf?
&aEVuQEcuZgVs6EVs6E666666--. Accessed on
11/06/2018.
10. Bishara SE, Olsen ME, VonWald L, Jakobsen JR.
Comparison of the debonding characteristics of two
innovative ceramic bracket designs. Am J Orthod
Dentofacial Orthop. 1999;116(1):86–92: PubMed PMID:
10393585.
11. Winchester L. Methods of debonding ceramic
brackets. Br J Orthod. 1992;19(3):233–237: PubMed
PMID: 1390580.
12. Sheridan JJ, Brawley G, Hastings J. Electrothermal
debracketing. Part I. An invitro study. Am J Orthod.
1986;89(1):21–27: PubMed PMID: 3510550.
13. Sheridan JJ, Brawley G, Hastings J. Electrothermal
debracketing. Part II. Anin vivo study. Am J Orthod.
1986;89(2):141–145: PubMed PMID: 3511716.
14. Zach L, Cohen G. Pulp response to externally applied
heat. Oral Surg Oral Med Oral Pathol. 1965;19:515–530:
15. Dovgan JS, Walton RE, Bishara SE. Electrothermal
debracketing: patient acceptance and effects on the
dental pulp. Am J Orthod Dentofacial Orthop.
1995;108(3):249–255: PubMed PMID: 7661140.
16. Lee-Knight CT, Wylie SG, Major PW, Glover KE,
Grace M. Mechanical and electrothermal debonding:
effect on ceramic veneers and dental pulp. Am J
17. Rueggeberg FA, Lockwood P. Thermal debracketing
of orthodontic resins. Am J Orthod Dentofacial Orthop.
1990;98(1):56–65: PubMed PMID: 2194390.
18. Knösel M, Mattysek S, Jung K, Sadat-Khonsari R,
Kubein-Meesenburg D, Bauss O, Ziebolz D. Impulse
debracketing compared to conventional debonding.
20677952.
19. Strobl K, Bahns TL, Willham L, Bishara SE, Stwalley
WC. Laser-aided debonding of orthodontic ceramic
brackets. Am J Orthod Dentofacial Orthop.
1992;101(2):152–158: PubMed PMID: 1531397.
20. Oztoprak MO, Nalbantgil D, Erdem AS, Tozlu M,
Arun T. Debonding of ceramic brackets by a new
scanning laser method. Am J Orthod Dentofacial
20691361.
21. Suh CH, Chang NY, Chae JM, Cho JH, Kim SC, Kang
KH. Efficiency of ceramic bracket debonding with
the Er:YAG laser. Korean J Orthod. 2009;39(4):213–224.
22. Iijima M, Yasuda Y, Muguruma T, Mizoguchi I.
Effects of CO(2) laser debondingof a ceramic bracket
on the mechanical properties of enamel. Angle
Orthod. 2010;80(6):1029–1035: PubMed PMID:
20677951.
23. Larmour CJ, Chadwick RG. Effects of a commercial
orthodontic debonding agent upon the surface
microhardness of two orthodontic bonding resins. J
Dent. 1995;23(1):37–40: PubMed PMID: 7876414.
24. Waldren M. An introduction into the fracture
toughness of a light cured orthodontic adhesive
[Thesis]. J Orthod. 2005;32(2):146–163: London:
University of London; 1991. Cited from: Russell JS.
Aesthetic orthodontic brackets Jun Review. PubMed
PMID: 15994990.
25. Pus MD, Way DC. Enamel loss due to orthodontic
bonding with filled and unfilled resins using various
clean-up techniques. Am J Orthod. 1980;77(3):269–283:
26. Hosein I, Sherriff M, Ireland AJ. Enamel loss during
bonding, debonding, and cleanup with use of a self-
etching primer. Am J Orthod Dentofacial Orthop.
2004;126(6):717–724: PubMed PMID: 15592221.
27. Ireland AJ, Hosein I, Sherriff M. Enamel loss at bond-
up, debond and clean-up following the use of a
conventional light-cured composite and a resin-
modified glass polyalkenoate cement. Eur J Orthod.
2005;27(4):413–419: PubMed PMID: 16043478.
28. Vinay P, Chandrashekhar BS. Debonding of
orthodontic brackets-a clinical tip 1. Available from:
http://www.aedj.in/.
29. Campbell PM. Enamel surfaces after orthodontic
bracket debonding. Angle Orthod. 1995;65(2):103–110:
30. Ulusoy C. Comparison of finishing and polishing
systems for residual resin removal after debonding. J
Appl Oral Sci. 2009;17(3):209–215: PubMed Central
PMCID:PMC4399534.
31. Orthodontic Adhesive Removal Set by Dr. S. Jay
Bowman. Available at:
https://www.kalamazooorthodontics.com/wp-
content/uploads/2017/05/AXIS-FLYER-LS-7585-TS-
copy-1.pdf. Accessed on 11/06/2018.
32. The PoGo (Dentsply International). Available at:
http://dentsply.co.in/products/restorative/finishing-
polishing/pogo. Accessed on 11/06/2018.
a 3M Unitek, USA
CHAPTER 79
Post-orthodontic care and
management of white spot
lesions
Sridevi Padmanabhan
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Prevention of white spot lesions and the role of fluoride
Nanotechnology in the control of biofilms
Key Points
Introduction
The completion of orthodontic treatment is an event much anticipated
by the patient and the orthodontist. The presence of unexpected white
lesions on the teeth can mar this otherwise happy occasion.
Additional scars on hard tissues can be seen as staining of the tooth
surfaces, excessive abrasion or marks caused by the inadvertent
removal of adhesive, enamel cracks and pencil marks placed during
bonding.
Orthodontic scars are the residual effects of orthodontic appliances
left behind on the teeth and periodontium. White spot lesions (WSL)
are frequently seen lesions caused by decalcification of enamel as a
consequence of multiband or bonded appliances. The WSL has been
defined as ‘subsurface enamel porosity from carious demineralisation’
that presents itself as ‘a milky white opacity when located on smooth
surfaces’1 (Fig. 79.1).
FIGURE 79.1 Visible scars of orthodontic treatment.

Note decalcification on incisal edges and labial surfaces of the anterior
teeth. Also, note the lead pencil marks used as guides for correct
placement of the brackets during bonding. Lead pencils or any such
staining marks should be avoided.
WSLs appear white because of reduced enamel mineral content

leading to increased permeability of enamel causing backscatter of
light by dentin. The difference in the refractive index between
decalcified and adjacent healthy enamel defines the white spot lesion.
They need to be differentiated from idiopathic white opacities of the
enamel and fluorosis.
The prevalence of WSLs in orthodontic patients is reportedly varied.2
It is reported that at least 50% of orthodontic patients develop at least
one or more lesions during orthodontic treatment.3,4 Using
conventional visual methods of detection, the prevalence of at least
one white spot lesion in orthodontic patients was 49.6% compared to
24% in an untreated control group.3 The use of advanced techniques
such as light induced fluorescence (QLF) shows that a significantly
larger percentage of patients are affected.5
Though there is an increased prevalence in both vestibular and
lingual surfaces, distribution is more in the cervical and middle 1/3rds
of the crowns particularly in the maxillary and mandibular molars,
maxillary lateral incisors and mandibular lateral incisors and canines
(Fig. 79.2).4 Lesions are also larger in maxillary central and lateral
incisors particularly in the gingival third. Distogingival quadrants are
more affected than the mucogingival quadrants.6
FIGURE 79.2 Orthodontic appliance and poor oral hygiene.

Such a situation is alarmingly predisposing the teeth to decalcification
and formation of white spot lesions.
The vulnerability of the orthodontic patient to WSLs is linked to the
plaque harbouring nature of the orthodontic appliances. With
multiband appliance in the mouth, not only is the volume of plaque
increased along with cariogenic bacteria but the pH of plaque is also
reduced.7,8
The biofilm which surrounds the tooth/teeth is a dynamic entity
which is in a state of equilibrium with the enamel and oral fluids.9 The
salivary pellicle is adherent in nature and tends to attract cariogenic
bacteria. Streptococcus mutans are the first to colonise the plaque. The
mucilaginous pellicle, which demonstrates increased adherence
attracts other free floating bacteria from saliva. The cariogenic
microorganisms in the presence of fermentable carbohydrates
produce organic acids that lower the pH in the plaque thereby causing
a diffusion of calcium and phosphate ions from the enamel through
the pellicle and into the plaque fluid. This process continues as the pH
of plaque further decreases.
When the pH of oral fluids increases to the normal, calcium and
phosphate ions in the saliva are transmitted through the pellicle into
the enamel following the laws of chemical equilibrium and causing
remineralisation.10
With progressive colonisation in the biofilm, the composition of the
microflora shifts to gm −ve bacteria, increasing the susceptibility of the
orthodontic patient not merely to decalcification but also to gingivitis
and progressive periodontal disease.
A white spot lesion is characterised by enamel surface softening
which involves preferential removal of the interprismatic substance
with mineral loss maximum at the enamel surface. The subsurface
lesion is marked by dissolution in the deeper part of the enamel. The
lesion is covered by a porous but mineral-rich layer.
Development of white spots has been reported to occur within
4 weeks.11 The demineralised enamel is more susceptible to taking up
the stain and appears unsightly. If not controlled in the initial stages, it
could lead to further cavitation, which cannot be reversed.
White spot lesions should be recorded before the initiation of
orthodontic treatment and should be an integral part of intraoral
clinical examination protocol. The WSL should again be evaluated
immediately after the completion of the treatment and debond. A
simple index was proposed by Gorelick et al.12 (1982) (Fig. 79.3). The
index can be used in four zones around the bracket13 (Fig. 79.4).
Clinically, visual detection is quite satisfactorily performed by the
discerning clinician and has significant validity as this is what would
also be visible to the patient. Also, some clinical studies have used
photography to record the lesions. Scientific literature shows the use
of optical non-fluorescent and optical fluorescent methods to detect
WSLs. In particular, quantitative light-induced fluorescence (QLF) has
proved to be a reliable method, which allows early detection and also
evaluation of mineral loss and change in the size of the lesions over
time.14
FIGURE 79.3 A simple index used for WSL.

FIGURE 79.4 Modified index to assess the WSL in four zones.
Prevention of white spot lesions and
the role of fluoride
Maintenance of good oral hygiene is paramount in the orthodontic
patient. Also, fluoride is a key contributor to WSL prevention. The
preventive effect of fluoride was thought to be due to the
incorporation of fluoride ions in tooth structure. It is now known that
the presence of fluoride ions in the fluid phase of caries (the biofilm)
goes a long way in prevention of demineralisation and contribution to
the process of remineralisation.
Application of topical fluoride leads to a reservoir of CaF2 in
plaque, which acts as a source of fluoride ions for release when there
is a carious attack.15 However, the protective effects of fluoride
become questionable in a situation of a lowered pH because of poor
maintenance of hygiene. Arnberg16 demonstrated different pH of
plaque at various sites in the oral cavity. The Ph of the plaque in the
area of upper incisors was the lowest, which could be attributed to
poor salivary clearance. The concentration of fluoride is low in such
conditions demonstrating a direct relationship between pH and
fluoride efficacy. The effect of fluoride is presumably neutralised at
pH below 4.5 owing to a reduced concentration of both fluorapatite
and hydroxyapatite in the plaque. Thus patient cooperation in the
maintenance of oral hygiene is therefore critical to the effectiveness of
fluoride.
Toothpaste contains fluorides in various forms such as sodium
fluoride, monofluorophosphate, stannous fluoride or amine fluoride.
A dose of at least more than 0.1% fluoride is recommended for
orthodontic patients. However, a few studies have shown that
toothpaste alone is inadequate17 for effective prevention. It is
recommended that all orthodontic patients should use additional
fluoride mouthwash in the concentration of 0.05% NaF in addition to
using a fluoridated toothpaste.18
For patients who are at high risk of WSL and those uncooperative in
the maintenance of oral hygiene, additional use of professional
application of fluoride varnishes is recommended. The varnish should
be applied at each appointment. Fluoride varnish has shown
therapeutic benefits even in the presence of plaque.18 Other additional
options of fluoride delivery are fluoride incorporated into chewing
gums and elastomeric ligatures. A slow-release fluoride device, which
is incorporated in beads for attachment to orthodontic appliances, has
been used though with variable results and unconfirmed effects.19
A recent systematic review showed that fluoride incorporated into
material used to lute brackets or cover bonding surfaces, significantly
reduced the risk of WSLs. Fluoride in the luting material or varnish
was considerably more effective than the sealant used.20 The use of
glass ionomers or resin-modified glass ionomer (RMGIC) should be
considered in patients with a high risk of WSLs as these seem to have
an advantage over conventional composites in this regard.
The use of antimicrobials alone or in addition to fluoride is another
attempt to modify the biofilm. One potent antimicrobial agent is
chlorhexidine which is a positively charged molecule that binds to
negatively charged sites on bacterial cell walls. Chlorhexidine can
damage microbial cell walls within 20 s and can then permeate the cell
and attack the cytoplasmic membrane leading to cell death. Though
chlorhexidine is effective in bacterial control for 48 h post use, its
effect on the reduction of white spot lesions is questionable.21 An
additional disadvantage of chlorhexidine is its tendency to stain
composite and glass ionomer. In general, antibiotics and
antimicrobials though capable of suppressing caries infection can
never eliminate it and need to be given long term for useful results.
Probiotics which are live microbial feed consumed in the diet or
applied locally in dentifrices have proved to be effective against
cariogenic bacteria in orthodontic patients.22 Long-term studies,
however, are required to determine their effectiveness in reducing
white spot lesions.
Bioactive glass ceramic materials composed of calcium,
phosphorous, sodium and silica have claimed to remineralise the
WSLs. One such material is NovaMin® (Innovation.GSK.com) which
contains calcium sodium phosphosilicate. The product is
commercially available as toothpaste. The calcium sodium
phosphosilicate particles coming in contact with oral fluids release
calcium and phosphate ions. Their Na ions are exchanged with
hydrogen cations which allow calcium and phosphate ions to be
released. A calcium phosphate layer is formed which then crystallises
into hydroxycarbonate apatite which is similar to the mineral in
enamel and dentin, and this results in enamel remineralisation. The
bioactive glass paste also increases the pH thereby inhibiting bacterial
flora. A recent study found that using a NovaMin powered toothpaste
not only reduced the streptococcus mutans concentration in
orthodontic patients but also reduced the incidence of white spot
lesions.23
Xylitol, a polyol carbohydrate, is not metabolised by S. mutans and
is, therefore, noncariogenic. When incorporated in chewing gum, it
has demonstrated an increase in stimulated saliva with increased
concentrations of phosphates and calcium than non-stimulated
saliva.24 The methods of control early WSL during orthodontic
treatment and their prevention are provided in Boxes 79.1 and 79.2).
Box 79.1 Control of early WSL during orthodontic

treatment
• Fluoride varnish (during visits)

• Chlorhexidine alone or in association with fluoride mouth wash
• Dentifrices, lozenges and probiotic foods
• Xylitol chewing gum
• Casein phosphopeptide amorphous calcium phosphate (CPP-
ACP)
Box 79.2 Prevention of WSLs
• Maintenance of good oral hygiene

• Fluoride toothpaste (Conc. more than 1%)
• Fluoride mouthwash (.05% NaF)
• Dentifrices, lozenges and probiotic foods
• Xylitol chewing gum
• NovaMin tooth paste
• Use of fluoride releasing orthodontic adhesive
Nanotechnology in the control of
biofilms
Nanoparticles present a greater surface to volume ratio (per unit
mass) and thus interact better with microbial membranes and provide
a considerably larger surface area for antimicrobial activity.25
Nanocomposites and nanoionomers have been lately introduced.
Nanocomposites have a comparable bond strength to conventional
counterparts but have the additional advantage of better aesthetics,
smoother finish and possibly reduced plaque adherence.
Nanoparticles of Ag, ZnO2 and zirconium-silica complexes
incorporated into resins have demonstrated an inhibitory effect on the
microflora.25 A recent study comparing Filtek supreme plus universal
and conventional composite in orthodontic patients confirmed the
Streptococcus mutans concentration was less in the former.26
Nanocoatings on archwires and other orthodontic appliances are an
emerging area of interest, and in this regard, one material which has
evinced enormous interest is Titanium dioxide (TiO2). TiO2, when
exposed to ultraviolet light in the presence of an aqueous medium,
undergoes oxidation and reduction reactions to form hydroxyl
radicals, which decompose organic compounds. While several in-vitro
studies have evaluated its usefulness in controlling biofilms, its use in
clinical conditions is still to be demonstrated.27 One area of concern is
its potential lack of biocompatibility, and a recent study has shown
that the anatase phase of TiO2 is less toxic and as effective as
compared to other phases giving a direction to their future use.28
Orthodontic treatment indisputably does bring about some change in
colour and structure of the enamel due to the physicochemical process
involved in bonding and debonding. The enamel surface is altered
during etching and resin tag formation, damage during debonding
and clean up procedures. Further, the enamel changes colour due to
external reasons such as absorption of food, other colouring agents
and corrosion products from bracket bases. It discolours intrinsically
due to change in the adhesive resin entrapped in the resin tags.
Enamel cleanup is a critical phase as all resin needs to be removed
and this is believed to be about 50 µm but with minimal damage to
enamel. Excessive removal of enamel leads to the fluoride rich
superficial enamel being removed leaving enamel prisms open and
susceptible to caries. Most of the abrasives used are harder than
enamel and remove enamel aggressively and leave behind a rough
surface.
A recent systematic review compared several methods of enamel
cleanup and concluded that tungsten carbide burs in a contra-angle
hand piece are the most efficient in resin removal and cause less
damage than Arkansas stones, green stones, diamond burs, steel burs
and lasers. As they leave a rough surface behind, they should be
followed up by multi-step Sof-lex discs and pumice slurry.29
Stainbuster burs are composite finishing burs, which also can be used
for polishing the enamel surface after composite clean-up.30
The orthodontist in addition to attempting prevention of white spot
lesions also has to grapple with the treatment of these white spot
lesions.
Management of WSL. Management would depend on the severity
of the white spot lesions. Gorelick and co-workers3 classified white
spot lesions as:
1. No white spot formation

2. Slight white spot formation (thin rim)
3. Excessive white spot formation (thicker bands) (Fig. 79.5)
4. White spot formation with cavitations (Fig. 79.6).
FIGURE 79.5 Moderate white spot lesions (WSL) on canines and

premolars in the maxillary arch.
FIGURE 79.6 Severe forms of white spot lesions (WSL) leading to

cavitation.
Remineralisation—milder forms of white spot lesions are likely to
become less noticeable over a period of a year or so because of the
natural remineralisation that takes place due to the calcium and
phosphates and other trace elements present in the saliva. Though the
use of a high concentration of fluorides arrests the caries process,
Ogaard and co-workers have cautioned against this as this arrests
both demineralisation and remineralisation by surface
hypermineralisation.31 Instead, they advocate natural remineralisation
as this results in better repair and a less visible lesion. If high doses of
fluoride are used locally, the arrested lesion stays the same size and
frequently becomes stained. Natural remineralisation and low dose
fluoride as in toothpaste and mouthwashes seem to be a cost-effective
and practical solution for smaller lesions.
Casein phosphopeptide-amorphous calcium phosphate (CPP-
ACP), a product of milk casein. has demonstrated effective
remineralisation due to its absorption through the enamel surface. The
freely available calcium and phosphate ions move out of the CPP-ACP
into the enamel rods and reform as apatite crystals.32 CPP-ACP, which
is delivered as mousse, a topical cream, chewing gum, mouth rinses
and sugar-free lozenges, has shown some promise although a recent
systematic review regards its success with caution.33
Vital tooth bleaching with hydrogen peroxide or carbamide
peroxide increases the whiteness of the surrounding enamel to match
that of the WSL, thus camouflaging the WSL without affecting its size
or depth. Bleaching is a non-invasive procedure that patients are
happy to adopt as it lightens the shade of the teeth.19
Microabrasion is a technique, which involves using a slurry of
pumice or silicon carbide particles and hydrochloric acid to create
surface dissolution of enamel and is effective in removing superficial
stains or defects which do not exceed 0.2–0.3 mm in depth.
Resin infiltration is a relatively new technique, which is based on
the porous nature of demineralised enamel to allow a low-viscosity
resin to permeate into the enamel matrix and fill in the voids
previously filled with air or water. Resin infiltration produces a
refractory index comparable to healthy enamel, and early studies have
shown that this provides an immediate improvement in the
appearance of the lesion.33 Icon (DMG America, Englewood, NJ, USA)
is currently the only product in the market that uses this approach.
Restorations. Patients with cavitated lesions or more severe WSL
who have already attempted more conservative aesthetic treatments
without significant improvement may have to resort to restorations
(Box 79.3).
Box 79.3 Managment of WSLs after orthodontic

treatment
Mild Moderate to severe
Natural remineralisation Bleaching
Low concentration fluorides Microabrasion
Xylitol chewing gum Resin infiltration
CPP-ACP Restorations (direct or indirect)
Key Points
WSL pose a significant challenge to excellence in clinical orthodontics
probably because WSLs are relegated to the background in the face of
more attention demanding clinical issues. A recent survey has shown
that orthodontists probably do not use all the evidence available to
them in the prevention of white spots during fixed appliance
treatment and thus guidelines have been advocated.34 Since then,
more research is available giving future direction in prevention and
clinical management of the white spot lesions.
References
1. Summitt JB, Robbins JW, Schwartz RS. Fundamentals
of operative dentistry: a contemporary approach.
Hanover Park: IL: Quintessence Publishing; 2006:2–4.
2. Willmot D. White spot lesions after orthodontic
treatment. Semin Orthod. 2008;14:209–219.
3. Gorelick L, Geiger AM, Gwinnett AJ. Incidence of
white spot formation afterbonding and banding. Am
J Orthod. 1982;81(2):93–98: PubMed PMID: 6758594.
4. Mizrahi E. Surface distribution of enamel opacities
following orthodontic treatment. Am J Orthod.
1983;84:323–331.
5. Boersma JG, van der Veen MH, Lagerweij MD,
Bokhout B, Prahl-Andersen B. Caries prevalence
measured with QLF after treatment with fixed
orthodontic appliances: influencing factors. Caries
Res. 2005;39(1):41–47: PubMed PMID: 15591733.
6. Willmot D. White spot lesions after orthodontic
treatment. Semin Orthod. 2008;14:209–219.
7. Chatterjee R, Kleinberg I. Effect of orthodontic band
placement on the chemical composition of human
incisor tooth plaque. Arch Oral Biol.
1979;24(2):97–100: PubMed PMID: 45361.
8. Gwinnett AJ, Ceen RF. Plaque distribution on
bonded brackets: a scanning microscope study. Am J
9. Zero DT. Dental caries process. Dent Clin North Am.
1999;43:635–664.
10. ten Cate JM, van Loveren C. Fluoride mechanisms.
Dent Clin North Am. 1999;43(4):713–742: vii. Review.
11. Ogaard B, Rølla G, Arends J. Orthodontic appliances
and enamel demineralization: Part 1. Lesion
development. Am J Orthod Dentofacial Orthop.
1988;94(1):68–73: PubMed PMID: 3164585.
12. Gorelick L, Geiger AM, Gwinnett AJ. Incidence of
white spot formation after bonding and banding. Am
J Orthod. 1982 Feb;81(2):93–98: PubMed PMID:
6758594.
13. Banks PA, Richmond S. Enamel sealants: a clinical
evaluation of their value during fixed appliance
therapy. Eur J Orthod. 1994 Feb;16(1):19–25: PubMed
PMID: 8181546.
14. Benson P. Evaluation of white spot lesions on teeth
with orthodontics brackets. Semin Ortho.
2008;14:200–208.
15. Ogaard B. Effects of fluoride on caries development
and progression in vivo. J Dent Res. 1990;69: Spec
No:813-9; discussion 820-3 Review. PubMed PMID:
2179345.
16. Arneberg P, Giertsen E, Emberland H, Ogaard B.
Intraoral variations in total plaque fluoride related to
plaque pH: a study in orthodontic patients. Caries
Res. 1997;31(6):451–456: Erratum in: Caries Res
1998;32(2):158. PubMed PMID: 9353585.
17. O’Reilly MM, Featherstone JD. Demineralization and
remineralization around orthodontic appliances: an
in vivo study. Am J Orthod Dentofacial Orthop.
1987;92(1):33–40: PubMed PMID: 3300270.
18. Benson PE, Parkin N, Millett DT, Dyer FE, Vine S,
Shah A. Fluorides for the prevention of white spots
on teeth during fixed brace treatment. Cochrane
Database Syst Rev. 2004;3: CD003809 Review. Update
in: Cochrane Database Syst Rev. 2013;12:CD003809.
19. Chambers C, Stewart S, Su B, Sandy J, Ireland A.
Prevention and treatment of demineralisation during
fixed appliance therapy: a review of current methods
and future applications. Br Dent J.
2013;215(10):505–511: doi: 10.1038/sj.bdj.2013.1094
Nov; Review. PubMed PMID: 24264666.
20. Nascimento PL, Fernandes MT, Figueiredo FE, Faria-
E-Silva AL. Fluoride-releasing materials to prevent
white spot lesions around orthodontic brackets: a
systematic review. Braz Dent J. 2016;27(1):101–107:
doi: 10.1590/0103-6440201600482 Jan-Feb; Review.
21. Ogaard B, Larsson E, Henriksson T, Birkhed D,
Bishara SE. Effects of combined application of
antimicrobial and fluoride varnishes in orthodontic
patients. Am J Orthod Dentofacial Orthop.
2001;120(1):28–35: Erratum in: Am J Orthod.
Dentofacial Orthop 2001 Sep;120(3):279. PubMed
PMID: 11455374.
22. Jose JE, Padmanabhan S, Chitharanjan AB. Systemic
consumption of probiotic curd and use of probiotic
toothpaste to reduce Streptococcus mutans in plaque
around orthodontic brackets. Am J Orthod Dentofacial
Orthop. 2013;144(1):67–72: doi:
10.1016/j.ajodo.2013.02.023 Jul; PubMed PMID:
23810047.
23. Priyadarshini G. Effect of novamin® containing
toothpaste on enamel remineralization and
streptococcus mutans population in orthodontic
patients. MDS dissertation submitted to Sri
Ramachandra University. 2014.
24. Isokangas P, Alanen P, Tiekso J, Makinen KK. Xylitol
chewing gum in caries prevention: a field study in
children. J Am Dent Assoc. 1988;117(2):315–320:
25. Uysal T, Yagci A, Uysal B, Akdogan G. Are nano-
composites and nano-ionomers suitable for
orthodontic bracket bonding. Eur J Orthod.
2010;32(1):78–82: doi: 10.1093/ejo/cjp012 Feb; Epub
2009 Apr 28. PubMed PMID: 19401356.
26. Deepti C. Comparative evaluation of streptococcus
mutans concentration in plaque around orthodontic
brackets bonded with conventional orthodontic
composite and nanocomposite- a randomized,
controlled trial. MDS dissertation submitted to Sri
Ramachandran University, Chennai. 2015.
27. Shah AG, Shetty PC, Ramachandra CS, Bhat NS,
Laxmikanth SM. In vitro assessment of photocatalytic
titanium oxide surface modified stainless steel
orthodontic brackets for anti adherent and
antibacterial properties against Lactobacillus
acidophilus. Angle Orthod. 2011;81(6):1028–1035: doi:
10.2319/021111-101.1 Nov; PubMed PMID: 22007663.
28. Baby RD, Subramaniam S, Arumugam I,
Padmanabhan S. Assessment of antibacterial and
cytotoxic effects of orthodontic stainless steel
brackets coated with different phases of titanium
oxide: an in-vitro study. Am J Orthod Dentofacial
Orthop. 2017;151(4):678–684: doi:
10.1016/j.ajodo.2016.09.014 Apr; PubMed PMID:
28364890.
29. Janiszewska-Olszowska J, Szatkiewicz T, Tomkowski
R, Tandecka K, Grocholewicz K. Effect of orthodontic
debonding and adhesive removal on the enamel –
current knowledge and future perspectives - a
systematic review. Med Sci Monit. 2014;20: doi:
10.12659/MSM. 890912 Oct 20; 1991-2001 Review.
PMC4211420.
30. Trakyali G, Ozdemir FI, Arun T. Enamel colour
changes at debonding and after finishing procedures
using five different adhesives. Eur J Orthod.
2009;31(4):397–401: doi: 10.1093/ejo/cjp023 Aug; Epub
2009 May 21. PubMed PMID: 19460855.
31. Ogaard B, Rølla G, Arends J, ten Cate JM.
Orthodontic appliances and enamel
demineralization: Part 2. Prevention and treatment of
lesions. Am J Orthod Dentofacial Orthop.
1988;94(2):123–128: PubMed PMID: 3165239.
32. Reynolds EC, Cai F, Shen P, Walker GD. Retention in
plaque and remineralization of lesions by various
forms of calcium in a mouth rinse or sugar-free
chewing gum. J Dent Res. 2003;82(3):206–211:
33. Sonesson M, Bergstrand F, Gizani S, Twetman S.
Management of post-orthodontic white spot lesions:
an updated systematic review. Eur J Orthod.
2017;39(2):116–121: doi: 10.1093/ejo/cjw023 Apr 1;
34. Derks A, Kuijpers-Jagtman AM, Frencken JE, Van’t
Hof MA, Katsaros C. Caries preventive measures
used in orthodontic practices: an evidence-based
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2007;132(2):165–170: PubMed PMID: 17693365.
CHAPTER 80
Maintenance of the outcome
results, retention and relapse
O.P. Kharbanda
CHAPTER OUTLINE
Introduction
Riedel’s nine rules of retention and relapse
Rule 1
Rule 2
Rule 3
Rule 4
Rule 5
Rule 6
Rule 7
Rule 8
Rule 9
Rule 10
Other factors influencing relapse and retention
1. Facial types, craniofacial growth and relapse
2. Late mandibular growth
3. Bolton tooth size discrepancy
4. Third molars and relapse
6. Sex, age and race
7. Systemic diseases
8. Lower anterior teeth position
Orthodontic factors
Retainer appliances
Tooth positioners
Hawley retainer
Advantages of fixed lingual retainers
Disadvantages
Active retainers
Retention protocol
Class I non-extraction case
Class I extraction case
Class II non-extraction case
Class II extraction case
Class III cases
Retention schedule
Adjunctive periodontal procedures for successful orthodontic
results
Circumferential fibrotomy
Maxillary frenectomy
Autogenous gingival grafts
What is new?
Current status of research and evidence affecting orthodontic
practice
Fixed lingual retainers some new facts
Which retainer is a better choice?
Can we enhance the bone quality to prevent relapse?
Key Points
Introduction
The real orthodontic challenge does not lie in the accomplishment of a
well-finished occlusion but to maintain the correction for years to
come. This phase of the orthodontic treatment is called retention, the
whole purpose being the prevention of relapse.
Relapse in orthodontics in very simple terms pertains to the
tendency of teeth to return to the original position during a post-
treatment phase. It is a much more comprehensive term, which
involves a return of correction of skeletal dysplasia, as well as the
dental malocclusion, returning towards the pre-treatment position.
Relapse has obvious implications on the facial profile, aesthetics and
function of occlusion.
Retention implies to the holding of teeth during post-orthodontic
phase in anatomical, functional and aesthetic positions. Essentially,
retention is an inseparable part of the treatment in the sense that,
without the retention phase, treatment is likely to be unsuccessful and
therefore incomplete. Therefore, planning the retention strategies start
at the beginning of the diagnosis, not when the treatment has ended.
Hellman1,2 said ‘Retention is not a separate problem in orthodontia
but is a continuation of what we are doing during treatment. A
complete result must be accomplished before retention is applied’.
Stability of the orthodontic outcome can only be achieved and
maintained once the factors influencing relapse are identified and
taken care of, right from the step of diagnosis, and throughout the
treatment.
Long-term studies of treated cases at the 10–20 years post-retention
period have shown that orthodontic results were potentially unstable
due to multiple reasons (Box 80.1).
Box 80.1 Reasons for the unstable orthodontic

outcome
1. Developmental changes in the dentition over time
2. Re-organisation of periodontal and gingival tissues
3. Neuromuscular adaptations to the new occlusion scheme
4. Continued growth after orthodontic treatment
5. Specific orthodontic tooth movements
6. Ageing and late growth of the mandible
7. Abnormal muscle behaviour or orofacial function
8. Developing third molars (?)
A retention phase following orthodontic treatment is required:
• To allow for periodontal and gingival reorganisation.

• To minimise changes in the orthodontic result due to
remaining growth.
• To permit neuromuscular adaptations to the corrected
occlusion.
• To maintain unstable tooth position if such positioning was
required for reasons of compromise or aesthetics.
Factors associated with relapse and retention are outlined in

Fig. 80.1.
FIGURE 80.1 Factors associated with stability of orthodontic
treatment outcome and relapse.
Riedel’s nine rules of retention and
relapse
Richard A. Riedel3 has outlined principles of relapse and retention as
‘Rules’ which were further discussed by George Hahn, R.H.W. Strang
and H.M. Lang. Twenty eight years later, Henry Kaplan4 (1988)
published an up-to-date review and scientific rationale of retention
and relapse. These two classical articles are perhaps the most
elaborate reviews on retention till today. Their observations hold true
to the test today. These are summarised as under:
Rule 1
Teeth that have been moved into or through bone by orthodontic
appliances often tend to return to their former positions. Hence
retention is an accepted fact and part of the orthodontic treatment,
which cannot be and should not be ignored. The retention programme
should be outlined from the very beginning during diagnosis and
treatment planning.
Rule 2
Arch form, particularly in the mandibular arch cannot be permanently
altered by appliance therapy, therefore, all efforts should be made to
preserve arch form presented by the original malocclusion.
There is often concern about maintenance of inter-canine and inter-
molar width of the mandibular arch.5,6 Much of relapse of lower
anterior crowding is being linked to collapse of the expanded lower
arch. A balance of muscular forces is inherent to the individual and
dictates the limits of the buccolingual position of teeth. The buccinator
mechanism involves a balance between the orbicularis oris of the lip,
buccinator of cheek outside being opposed by a muscular tongue from
within mouth. In some instances, the inter-canine width of more than
3 mm or more can be stable, where pre-treatment mandibular canines
had been considerably constricted or blocked lingually to the general
outline of the arch form.
The maxillary expansion can only be stable when carried out in a
narrow maxilla with an increase in width of the skeletal base before
the closure of the mid-palatal sutures.
According to Kaplan,4 teeth can be moved with success within the
area of tolerance where they will not be in conflict with the forces of
the closed stomatognathic system. When teeth are moved outside the
area of tolerance, relapse follows.
Rule 3
Elimination of cause of malocclusion will prevent recurrence.
The orthodontic diagnosis and planning must entail aetiology of the
malocclusion, and if the extraneous neuromuscular influences are
there in the form of deleterious habits or mouth breathing, it needs to
be eliminated for the results to be stable. The influencing factors that
bring the teeth back could arise from the musculature surrounding the
teeth, the apical base in which the teeth are housed or supracrestal
trans-septal periodontal fibres, attaching one tooth to the other.
Rule 4
Malocclusion should be overcorrected. A malocclusion is
overcorrected to make a provision for some degree of relapse, which
is unavoidable. Overcorrection is especially required for rotations and
deep overbite.
Rotational relapse has been linked to many factors: the stretching of
the supragingival fibres,7–9 discrepancies of tooth dimensions, altered
Peck and Peck ratio,10 late mandibular growth and third molars. There
is a general tendency for relapse of the deep bite.11,12 The different
malocclusion and traits of malocclusion have a variable tendency for
relapse. For example, the lower anterior segment alignment and
overbite are the most unstable occlusal features and tend to worsen
during the retention period.
Rule 5
Good occlusion is a major contributor to retention. Therefore an
orthodontist should attempt to achieve the best possible occlusion. In
other words, proper inter-digitation is the key to hold the teeth in
their correct positions.
The occlusion achieved, following orthodontic treatment, should
pertain to the principles of static and functional occlusion. The
traditional Angle’s concept of stability involved a full complement of
teeth in class I relationship. The extraction approach was later proved
to give stable results in the cases with tooth size jaw size discrepancy.
Charles H. Tweed suggested that upright mandibular incisors are a
pre-requisite for the stability of occlusion and aesthetics. Later, a
concept of functional occlusion and harmony with the neuromuscular
apparatus of the individual was included in the definition of normal
occlusion.
The class II malocclusion can be treated to normal overjet and
overbite while maintaining a class II relation if the lower arch permits
so. Such an occlusion may be stable and remain in harmony with the
neuromuscular apparatus.
A therapeutic class III occlusion may be a goal in cases where
extraction of the premolars is performed in the lower arch only.
Andrews13 concept of normal occlusion entails not only inter-arch
relations but also each tooth should occupy its correct labiolingual and
mesiodistal angulations (Fig. 80.2A–D).
FIGURE 80.2 Excellent finish of occlusion is a prelude to
minimising relapse.
Coordination of arch forms, normalisation of overjet and overbite, tight
proximal contacts and good inter-digitations are pre-requisite for
finished occlusion. These are, in turn, contributed by proper mesiodistal
crown angulations and labiolingual inclinations of teeth. (A) Improperly
inclined maxillary anterior crowns with insufficient torque result in all
upper contact points being mesial, leading to improper occlusion. (B)
The overlay shows how an institution of lingual root torque allowed
anterior crowns to be properly inclined in labiolingual inclination, the
contact points moved distally, allowing normal occlusion and thus
minimising relapse. (C) Insufficiently distally tipped teeth are the cause
of residual spacing. (D) When the buccal segment finished to proper
mesiodistal angulations occlusion is settled without spacing.
The current views on occlusion have broadened from merely static

anatomical intercuspation to the functional aspects of occlusion.14
A smooth functional forward guidance should be created so that the
lower anterior teeth smoothly glide to the protrusive position from a
centric occlusion position, when posterior teeth are in intercuspation,
the anterior teeth are separated by 0.005 in., thereby protecting the
anterior teeth from excessive forces. Similarly during anterior
guidance, typically the posteriors should not interfere for a smooth
disocclusion. Such a functional occlusion is a mutually protected
occlusion.
The lateral excursions are guided by the cuspid inclines without any
interference from posterior teeth or buccal (canine protected
occlusion) cusps both in working and balancing sides.
Rule 6
Bone and adjacent tissues must be allowed time to reorganise around
new tooth positions.
Orthodontic tooth movements happen in the bone with the
disruption of the periodontal ligament and the gingival fibre-network
complex. The period required for reorganisation of these fibres after
removal of the appliances is the retention phase.
A variety of periodontal and gingival ligaments, hold the teeth to
the bone, gingiva and each other. The classic group of periodontal
fibres are oblique, horizontal, alveolar crest, apical and inter-radicular
fibres, which attach the tooth to the bone and are responsible for
restriction of movement of teeth in the lateral, apical or occlusal
direction. Apart from this, the gingival ligament fibres are circular,
alveolar dental, dentogingival, dentoperiosteal and trans-septal fibres
(Fig. 80.3).
FIGURE 80.3 Periodontal fibres involved in relapse.
(A–D) The gingival fibre bundles remained displaced and stretched for
232 days while principal fibres readjust rapidly. Oxytalan fibres of an
elastic-like nature proliferate and get accumulated in the gingiva and
particularly in trans-septal fibres during mechanical stress and
orthodontic tooth movement. It has been hypothesised that the elastic
properties of oxytalan fibres might induce relapse. (E) Stretched supra-
alveolar fibres as observed during rotation. Experimental transsection
of these fibres, as indicated by stippled lines, did not cause any marked
difference in the degree of relapse, but there is little relapse tendency
following removal of the supra-alveolar structures. Over-correction
followed by retention will also result in stabilisation of the rotated tooth.
The periodontal ligament fibres are made of collagen type I and III.
The elastic system fibres consist of three different types oxytalan,
elaunin and elastic fibres.
The oxytalan fibres are distributed in periodontal ligament and in
gingiva, while elaunin and elastic fibres are present only in the
gingiva.15 The remodelling of collagen fibres takes around 4–6 months
according to histological evidence while the elastic fibres take about
1 year to remodel. Some evidence suggests that elastic fibres may take
up to 6 years to remodel. It is believed that the slow remodelling of
the supra-alveolar fibres of the gingival complex contribute to the
relapse of teeth after the orthodontic treatment, especially in the
rotated teeth.
The supracrestal fibres in general and trans-septal fibres, in
particular, have a lower rate of remodelling because these fibres insert
on both ends on the cementum of adjacent teeth, which is avascular
and fibre-ends in cementum are also mineralised. This is in contrast to
bone, which is highly vascular, and the fibre-ends in the bone are non-
mineralised.
Apart from maintaining the teeth with a full-time retention till the
time the fibres remodel, the orthodontist can opt for a simple surgical
procedure of supracrestal fiberotomy or pericision. This minor yet
useful procedure involves a severing of fibres present in supracrestal
region by an incision deep down to the alveolar bone encircling the
tooth crown in the gingival sulcus (Fig. 80.3E).16,17
Rule 7
Upright lower incisors are the key to stability. Charles H. Tweed18,19
considered the aesthetics and stability of occlusion from the
perspective of axial inclination of the lower incisors and their
relationship with the mandibular plane. He suggested that upright
mandibular incisors are pre-requisites for the optimum aesthetics and
stability of occlusion. The incisor inclination compensates for a
variable mandibular plane angle. In the horizontal growers, lower
incisors are proclined to provide an eccentric relation to the upper
incisors (relation between the long axis of upper and lower incisors).
On the contrary, in the vertical growers, a more stable relation would
be one with upright incisors so that the interincisal angle would be
obtuse (Tweed’s Analysis, Chapter 17).
Rule 8
Corrections carried out during growth are less likely to relapse.
Growing individuals show greater adaptations to the newly acquired
skeletal jaw positions. Early treatment is also preferred as sutures are
immature and are amenable to alterations. Therefore skeletal
maxillary expansion is stable when carried out before the fusion of
palatal suture around 8 years of age. The teeth and the periodontium
show faster adaptations, and so does the neuromuscular system
following orthodontic treatment. The results achieved should have
consideration for the remaining growth of the craniofacial skeleton
particularly the mandibular growth, which continues until late
adulthood.
Rule 9
The farther the teeth have been moved, less is the likelihood of
relapse. Real evidence supporting this belief is not available.
Logically, it can be presumed, those teeth that move far away from
their original environment would have less tendency for relapse
compared to those who are close to their former environment.
Rule 10
The years of experience and review of treated cases has shown that
there are additional multiple factors and variables which influence the
stability of occlusion. Many treated cases require permanent retaining
devices. These include median diastema, severe rotations and severe
crowding of lower incisors. Half of the total relapse takes place in the
first 2 years after retention. All occlusal traits relapse gradually over
time but remain stable 5 years post-retention except lower anterior
contact point displacement.20
In addition, the final detailing and finishing of occlusion should
conform to functional needs (Fig. 80.4), for orthodontic results to
sustain.
FIGURE 80.4 Finishing occlusion according to the concepts of
functional occlusion.
The incisal guidance, condylar guidance, eminence angle, interincisal
angle and torque of anterior teeth contribute to functional occlusion.
Occlusion should finish for a smooth slide from the centric occlusion
position to the protrusive position. The incisal guidance should be in
harmony with the condylar guidance. The interincisal angle is to some
extent, governed by the facial pattern. While low FMA subjects tend to
have an acute interincisal angle, the vertical growers with high FMA
generally should have a more obtuse interincisal angle for stability.
Torque in anterior teeth should be in harmony with the angle of
eminence.
Other factors influencing relapse and
retention
1. Facial types/craniofacial growth
4. Third molar position (?)
6. Sex, age, race
8. Lower anterior teeth position.
1. Facial types, craniofacial growth and

relapse
Three types of growth trends have been recognised by Charles H.
Tweed:
• In type A, both mandible and maxilla grow downward and

forward but at the same pace.
• In type B, both of them grow downward and forward, but
maxilla grows at a greater pace than mandible, resulting
mostly in vertical growth.
• In type C, the mandible grows at a greater pace than maxilla,
these are horizontal growers.
Active orthodontic treatment is likely to conclude during the age

group of 14–15 years, while anteroposterior and vertical growth does
not cease till 17–18 years, particularly in males. Sagittal growth
declines to adult level at 14–15 years in females, 16–17 years in males
and vertical growth declines to adult levels at 17–18 years in females
and early 20s in males. Transverse growth completes first, prior to the
adolescent growth spurts at 11–12 years in females and 13–14 years in
males.
In short face syndrome children, that is, those with a low
mandibular plane angle, management of deep bite is difficult due to
the presence of a strong chain of elevator muscles which tend to keep
the mandible in an anticlockwise rotation, thus worsening the bite.
Such children require longer retention with an anterior bite plane
touching the lower incisors and no separation of posteriors. Such an
appliance has to be worn until the maxillomandibular growth is
complete, that is, around 16 years in females and 18–20 years in males.
In contrast, in children with a dominant vertical growth pattern, an
over eruption of buccal segment teeth is expected, and the vertical
position of molars has to be retained with high pull headgear or
posterior bite blocks to prevent opening of the bite.
Growth modulations achieved with functional appliances need to
be maintained till the skeletal growth is complete. Retention using a
modified activator or bionator appliance has been reported effective in
maintaining class II correction.
In mild class III, a functional appliance like Frankel or a reverse
twin block positioner can be given as long as the correction required is
less than 3 mm. Chin cup for retention can only be given in average
growers as it tends to rotate the mandible downward and backwards.
Lower incisor position depends on the skeletal pattern of the patient
for stability. For hyperdivergent skeletal pattern patients, mandibular
incisors must have an overly upright position over the basal bone to
have a balanced face at the end of treatment.21 For a hypodivergent
skeletal pattern, mandibular incisors can be left in their pre-treatment
position or proclined position.22

The late mandibular growth continues especially in horizontal
growers (Type C) after adulthood and is thought to be responsible for
lower incisor crowding. As the mandible continues to grow
downward and forward, the bite deepens and lower incisors confined
by the upper incisors are bound to tip lingually in a crowded state.
The untreated lower incisors in adults show increased crowding with
age while inter-canine widths and arch lengths continue to decrease
with age (Fig. 80.5).23
FIGURE 80.5 Physiological mesial migration is a life-long

process and thought to be a contributory factor for relapse.
The integrity of the arch through tight proximal contacts is maintained
by the periodontium exerting a continuous force on the mandibular
dentition. This force is increased manifold during occlusal loading
which is considered a major contributor to the long-term appearance of
crowding of the mandibular anterior teeth.

Orthodontic treatment should compensate for any significant
variation in the ratio of the mesiodistal width of maxillary and
mandibular teeth. The key factor is to maintain tight proximal contacts
without any rotation or crowding and adequate overjet and overbite
to ensure the stability of occlusion. Deviation in the Bolton
discrepancy would not allow a good finish of occlusion, that is, overjet
and overbite with good functional contacts. Most often, the
discrepancy is in the form of mandibular tooth excess, which can be
balanced by judicious reduction of the proximal tooth surfaces of the
lower anterior teeth. The amount of proximal reduction on lower
incisors can be calculated by Peck and Peck analysis, which essentially
re-confirms the large mesiodistal width of incisors in proportion to
their labiolingual thickness.
In other situations, maxillary tooth material may be deficient as is
seen with smaller lateral incisors. Such cases would require proximal
composites or veneers on the teeth with smaller mesiolingual
dimensions.
The stable occlusion is the outcome of a balanced ratio of tooth
material of maxillary teeth to mandibular teeth. Any deviation would
result in inappropriate intercuspation and therefore the tendency for
relapse. Removal of teeth from the arch is a known method to achieve
the reduction of tooth material, which creates space for the resolution
of the crowding and reduction of the protrusion. The actual space
requirements may be less (say 3/4 or 1/2 the dimensions; however, the
orthodontist cannot do partial tooth sacrifice resulting in some
compromise with tooth size jaw size discrepency.24
Dr Williams said that inter-proximal reduction of lower anterior
teeth provides better inter-proximal contacts and therefore stable
position.24
4. Third molars and relapse

The role of erupting third molars in the causation of the relapse has
long been debated. Many clinicians recommended therapeutic
removal of the third molars following the completion of the
orthodontic treatment. Recent research has questioned the role of
third molars in the causation of the anterior crowding. The therapeutic
removal of third molars for prevention of relapse of lower anterior
crowding is not justified.25 Between the ages of 18 and 21 years, the
lower arch is stable in terms of tooth alignment and mesial drift,
regardless of third molar status or continuing mandibular growth.26
The integrity of the dentition is maintained by the healthy teeth that
are held in tight contacts with a healthy periodontium. A healthy
periodontium is a pre-requisite for the well functioning occlusion. The
presence of periodontal disease causes the forces of occlusion to act
adversely and therefore cause migration of the teeth. Occlusal trauma
was considered a significant contributor to periodontal migration.
However, research has proven that occlusal trauma alone would be
incapable of causing migration in the absence of disease of the
periodontium. In patients with previously treated severe periodontal
disease, permanent retention is advised. For those with minimal to
moderate disease, a more routine protocol can be used.
6. Sex, age and race

It is a well known fact that females are early maturers than males. The
mandibular growth in females may be completed by 13 years while
males continue to grow beyond 16 years. Hence age and sex are
essential considerations not only in terms of the prognosis of
orthodontic treatment but also for the relapse. Skeletal adaptations
occur better in younger age and hence the stability in the outcome.
The skeletal changes with functional appliances and with rapid
maxillary expansion are two good examples. When the periodontal
supporting tissues are normal, and no further occlusal settling is
required, there is no evidence to support any changes in retention
protocol for adult patients compared with adolescent patients, but for
growth considerations.
Some malocclusion types have racial predilections. For example,
class III is more common in Mongoloids and bimaxillary protrusion
with a large tongue and thick lips are more common in Africans and
some races in South India and Islanders of the subcontinent.
Accordingly, the bimaxillary patients treated with extractions of all
first premolars encroach upon the tongue space and therefore have
greater possibilities of relapse.
Systemic diseases that may affect bone turnover would cause an
adverse relapse. The common diseases that affect the bone turnovers
are hyperparathyroidism and disorders of the pituitary glad like
acromegaly. While in hyperparathyroidism the lamina dura may not
be directly affected, the jaw bones show area of bone formation and
resorption where the bone is replaced with multinucleated giant cells
contained in ‘brown nodes’. In acromegaly, the mandibular condyle
would show excessive growth and lengthening of the mandible,
therefore, causing relapse of the treatment outcome.
These diseases require the attention of the medical specialists.
8. Lower anterior teeth position

Ricketts recommended that for optimum position for lower incisor
stability, the incisal edge of the lower incisor should be placed on the
A-Po line or 1 mm in front of it.27
For better stability, the lower incisor apices should be positioned
distally to the crowns more than is generally considered appropriate,
and the apices of the lower lateral incisors must be more than those of
the central incisors. All four lower incisor apices must be in the same
labiolingual plane similarly, to the incisors, the apex of the lower
cuspid should be positioned distal to the crown but lower cuspid root
apex must also be positioned slightly buccal to the crown apex.24
Relapse following orthognathic surgery for the correction of the
skeletal dysplasia could be attributed to several factors. The outcome
of orthognathic surgery would be stable only when skeletal
movements are within the confines of neuromuscular adaptation. A
stable and functioning occlusion is mandatory for the success of the
orthognathic surgery. A pre-surgical orthodontic treatment followed
by post-surgical orthodontic phase is mandatory to achieve a good
occlusion. Disturbed occlusion is one of the key contributors to relapse
after orthognathic surgery.
Orthodontic factors
Removal of dental compensations
In class II cases, this would involve carefully chosen extractions of
second premolars in the upper arch and first premolars in the lower
arch. The idea is to offset orthodontic relapse in anteroposterior
direction rather than compound surgical relapse.
Corrections of tooth mass discrepancies

The intercuspation that is provided by the surgeon can only be stable
if no Bolton discrepancy is present. These have to be managed by
routine procedures like interproximal reduction or cosmetic
recontouring or prosthetic rehabilitation.
Correction of transverse discrepancies

In case the transverse discrepancy is over 4 mm in a patient over 16–
18 years (till the time the transverse growth is complete), the surgical
option of expansion should be used. The orthodontic expansion in
maxilla tends to produce an open bite due to overhanging cusps. The
transverse discrepancy which is addressed orthodontically or
surgically should be settled to a normal buccal overjet of posterior
teeth, good coordination of upper and lower arches and excellent
interdigitation.
Surgical factors
Surgical factors causing relapse include post surgical stretch of the soft
tissues, periosteum, muscles and the submucosal tissue. The soft
tissue stretch is greater with mandibular advancement surgery and
directly related to the length of advancement. The distraction
osteogenesis which allows simultaneous growth of the attached
tissues along with the lengthening of the mandible is considered an
option with less relapse.
One of the methods to minimise relapse is to slightly rotate the
mandible clockwise to minimally alter the position of Pogonion and
also to have a rigid fixation. Another precaution is to avoid the
distraction of condyle from the fossa in which case relapse is
inevitable.
Suprahyoid muscle pull plays a significant role in relapse when the
mandible is advanced. In such cases, suprahyoid myotomy is
recommended.
Children with repaired unilateral or bilateral cleft of the palate have
bony deficient maxilla in the midline and also in the alveolus
segments at the cleft sites. These children also have palatal scars. The
maxillary expansion in such cases is potentially unstable for the lack
of the bony structures in the midpalate and scarring of the palatal
tissue.
The dentoalveolar expansion is often carried out as pre-bone graft
orthodontics. The secondary alveolar bone graft integrates the split
maxilla/alveolus to one segment and therefore reduces the tendency
for transverse collapse.
Orthodontic alignment should achieve good intercuspation for the
maintenance of occlusion. Restoration of missing teeth with a
removable prosthesis, followed by fixed prosthesis, maintains the
integrity of the arch and expansion. A rigid fixed retainer with a rigid
wire components extending to the lingual of all teeth is recommended
to combat the relapse which is more so in transverse dimensions.
Retainer appliances
A retainer is an orthodontic appliance, which is given after debonding
the fixed appliance. A retainer is also issued at the completion of
active treatment with a functional or a removable appliance(s).
Retainers can be of the fixed type, which is bonded to the two or
more teeth often on the lingual surfaces of anterior teeth and rarely on
buccal surfaces of posterior teeth. These retainers are also referred to
as invisible retainers. Other invisible retainers could be transparent
removable retainers, which are colour less and therefore are relatively
invisible (Box 80.2).
Box 80.2 Types of retainers
Conventional removable retainers

Transparent vacuum formed retainer (VFR), tooth positioner
Hawley retainer
Circumferential retainers, for example, Begg retainer
Hawley retainer with bite plate
Hawley retainer with reverse bite plane
Flexible spiral wire (FSW) retainers in the maxillary arch
Preformed 3-3 bonded retainers
FSW retainer in the mandibular arch
Lower lingual arch as a retainer
Retainers after dentofacial orthopaedics
Functional appliances (class II and III)
Headgear
Chin cup
Active retainers
Spring aligners
Transparent vacuum-formed aligner
Functional appliances (class II and III malocclusion)
Headgear
Chin cup
The removable retainers can be removed by the patient and inserted

back. The retainers by their very nature are supposed to be passive
appliances which hold the teeth in their post-orthodontic positions. In
some instances, a retainer could be active for some duration and
subsequently modified as passive retainer.
While certain types of malocclusion may not require any retention
appliances, others need it for a much longer duration than the
conventional regime and these are known as permanent retainers.
These are vacuum formed plastic retainers (VFR) which can be issued
to the patient immediately after debonding. The appliance is prepared
from a transparent thermoplastic sheet of 2 mm thickness. The
appliance is nearly invisible, and allowance can be made for minor
corrections of derotation or space closure to be incorporated by
making necessary changes on the dental plaster model. This appliance
serves as a transitionary appliance until a laboratory fabricated
retainer is issued. This appliance does not allow for vertical settling of
occlusion (Fig. 80.6).
FIGURE 80.6 Vacuum-formed retainer.

A vacuum-formed plastic retainer, an excellent immediate post-debond
appliance. However, does not allow for vertical settling and should be
substituted with the proper retainer.
A study found that patients receiving VFRs seem to be significantly

more likely to be ‘very satisfied’ currently (50%) compared to those
with Hawley (35%) or permanently bonded (36%) retainers.28
Tooth positioners
Tooth positioners are prepared from the upper and lower study
models. These allow for the final occlusal adjustments to be made
through the soft positioners. The process of making a positioner is
more exacting. The teeth are cut and mounted on the plaster models
in an ideal occlusion setup. A positioner is prepared in a
thermoplastic soft material. The positioner helps the child patient
achieve minor tooth movements and final settling of the occlusion that
has been earlier set on the study models.
A positioner is essentially used as an aid to finishing, and to obtain
ideal occlusion and also to maintain the correction. This appliance is
bulky and patient cooperation can be poor.
Hawley retainer
Standard Hawley retainer typically utilises a cuspid-to-cuspid labial
bow with clasps and/or rests on molars, and acrylic body is covering
on the palate. Occlusal clearances present at the completion of
treatment may require slight design modifications with regards to
wire placement and clasp design. A Hawley retainer with an anterior
bite plane is advantageous in facilitating posterior occlusal settling
during the first few months of retention.
Demerits of Hawley type retainers include occlusal interferences
resulting from wires of retentive devices such as Adams clasp crossing
over the embrasure and interdental areas, interference from Adams
clasp, which does not allow occlusion contacts with the opposite arch.
Circumferential clasp such as clasp may partly resolve the issue where
contacts are tight and interferences are significant.
Also, in the first premolar extraction cases, the extraction space may
reopen from the wedging effect of the labial bow between the canine
and premolar (Fig. 80.7).
FIGURE 80.7 Hawley retention appliance.

(A) The distal margin of acrylic plate usually terminates distal to first
molars. The appliance should be thick enough to retain wire
components, yet not bulky, and well fitting into embrasures. Slight
anterior bite platform is needed for the cases who tend to have deep
bite relapse, such as those with low FMA, and class II division 2
malocclusion. The distal palatal border of acrylic is thinned to gently
merge with palatal mucosa. The labial bow is kept passive yet in gentle
contacts with labial surfaces of teeth. The retaining end of wires of
Adams and pin head should very closely adapt on occlusal marginal
ridges from buccal to the palate, not to interfere with opposite tooth
cusps. (B) The U loop of the labial bow should be checked for any
pressure or injury to gingiva.
Circumferential retainers/Begg’s retainer: Dr P.R. Begg used a

circumferential retainer which is made up of a single wrap around
labial bow extending from the distal of the right molar to the left
molar. Retention can be achieved through pin head between second
premolar and first molars. The wrap around wire distal to the second
molars eliminates potential occlusal interferences inherent to Adams
clasps and therefore allow vertical settling of the occlusion. It has the
additional advantage of maintenance of canine—second premolar in
tight contact at extraction cases (Fig. 80.8).
FIGURE 80.8 Mandibular and maxillary wrap around retainer or

Begg’s retainers.
(A–C) The appliance has an advantage in maintaining the integrity of
the arch and tight contacts, particularly in extraction cases. (D, E)
Upper and lower wrap around or Begg’s retainer in all first premolar
extraction cases.
Anterior bite plane can be incorporated into removable upper
retainers to intrude lower incisors and, therefore, control overbite
relapse (Fig. 80.9).
FIGURE 80.9 Maxillary Begg’s wrap around retention appliance

with bite platform in a non-extraction case.
Slight anterior bite platform is needed for cases with a tendency for
deep bite relapse. The bite platform can be given in a reverse incline.
Should there be a class II tendency or a remaining overjet, note first
order bends on the labial bow.
Posterior bite plane or acrylic extending on to the occlusal surfaces

of the buccal teeth. These may be used to intrude molars and therefore
control open bite relapse.
The bonded lingual retainers can be prepared from a variety of wires
types, diameter and composition. Besides SS rigid or flexible
multistrand wires lingual fixed retainer can also be prepared by fibre
resin composite (FRC) threads.
The flexible multi strand wire (FSW) is most commonly used wires
type for a lingual retainer. The proposed advantages of the use of
multistrand wire are that the irregular surface offers increased
mechanical retention for the composite without the need for the
placement of retentive loops29 and that the flexibility of the wire
allows physiologic movement of the teeth, even when several adjacent
teeth are bonded in a unit.30
The evolution of the fixed lingual retainers can be broadly classified
into three generations
• Fixed retainers made of blue Elgiloy of dimensions 0.032–

0.036 in. were introduced in 1944.
• During 1970, lower fixed retainers were soldered to either first
molar bands or canine bands. A 0.032 in. steel wire is chosen
for it provided sufficient rigidity.
• Since 1994, lingual fixed bondable retainers are made of 0.030–
0.032 in. stainless steel, wire, which is sandblasted with
aluminium oxide to improve micro-mechanical retention.
• Current orthodontic opinion recommends either the use of
0.0215 in. multi strand wire or 0.030–0.032 in. sandblasted
round stainless steel wire (Fig. 80.10).
FIGURE 80.10 Flexible spiral wire (FSW) retainer is often used in
the mandibular arch.
It can extend from canine to canine in non-extraction case like earlier.
The FSW usually extends between the mesial occlusal pit of the
second premolars on either side to prevent the extraction space to
open.
Advantages of fixed lingual retainers

1. Lingual retainers are invisible and permit effective retention
with the simultaneous individual movement of the teeth,
which is essential for the biological integrity and survival of
teeth.
2. This type of retainer keeps extraction spaces closed in adults,
maintains diastema closure and pontic or implant space.
3. Fixed retention is favourable in preventing relapse at 5 and
10 years post-retention.20
Disadvantages
1. Calculus and plaque deposition around retainer.
2. Maintenance of oral hygiene would need extra attention.
The bonded fixed retainers may extend from the canine on one side
to the other or premolar to premolar or even segmental on two or
more teeth. A relatively rigid large diameter multistrand wire, usually
0.032”, is bonded. A smaller diameter multistrand wire, usually 0.0175
or 0.0215 in., bonded to each tooth in the buccal segment can be used
in adults with periodontal problems.
Lee considered the following indications for placement of a bonded
canine-to-canine retainer:31
• Planned alteration in the lower intercanine width;

• After advancement of the lower incisors during active
treatment;
• After non-extraction treatment in mildly crowded cases;
• After correction of deep overbite.
The flexible wire retainer appears to have different indications for

clinical use.
Zachrisson listed the following:29
1. Closed median diastemas

2. Spaced anterior teeth
3. Adult cases with potential post-orthodontic tooth migration
4. Accidental loss of maxillary incisors, requiring closure and
retention of large anterior spaces
5. Space reopening, after mandibular incisor extractions
6. Severely rotated maxillary incisors
7. Palatally impacted canines.
The main indications for the canine-to-canine retainer are related to

alteration of the anteroposterior or lateral position of the lower labial
segment during treatment. Differential growth of mandible between
the age of 16 and 20, relapse is caused by lingual tipping of the central
and lateral incisors in response to the pattern of growth. In these
conditions, the retainer of choice is a canine-to-canine fixed retainer.
Bonded fixed retainers are now in common use for long-term
aesthetic retention. The failure rate ranging from 10.3 to 47.0%. The
failure rate is approximately twice as great in the maxilla as the
mandible, and this is most likely because of occlusal factors.
When placing maxillary retainers, care must be taken to ensure the
retainer is free from occlusal trauma to reduce the likelihood of
failure. The most common site of failure is at the wire/composite
interface. Placement of insufficient adhesive and material loss because
of abrasion are implicated in the detachment of the wire from the
surface of the composite. The use of increased bulk of composites or
materials of greater abrasion resistance may improve the longevity of
the retainer.32
Bonded fixed retainer may be waved fixed retainer or plain fixed
retainer. A meta-analysis was done to know the differences in the
gingival health and plaque index between wave fixed retainer and
plain fixed retainer. The results revealed no differences on plaque
index and calculus index between wave FR and plain FR.33
Any of the three wire types can be used for FSW retainers. These are
0.0215 in. five-stranded wire, 0.016 × 0.022 in. dead-soft eight-braided
wire, and 0.0195 in. dead-soft coaxial wire.34
Active retainers
They are used for realignment of irregular incisors or as functional
appliances to manage class II or class III relapse tendencies.
Tooth positioners
They are potentially active retainers as they cause finer tooth
movement to the pre-destined position. They are fabricated after the
teeth have been debonded, an impression taken and the teeth reset in
an ideal position on study models with 0.25 mm of tooth movement
possible. If more tooth movement is required, teeth must be set at
0.25 mm increments with a new appliance. The clear aligners are now
being increasingly used for short duration to achieve the perfect finish
of alignment or treat minor relapse occurring after completion of the
treatment (Fig. 80.6).
Anterior retention of skeletal correction

For retaining class II correction, an anterior locking plate during day
time and a night time wear of bionator are recommended. In children
with a tendency for an excessive vertical growth of the maxilla, a high
pull headgear with Kloehn face bow can be used.
Frankel III or reverse twin block are used for the maintenance of
class III treatment.
Spring Hawley retainer

It is used in correcting minor rotations of the anterior teeth. Before
fabrication of the spring retainer, it is essential that space is available
to accommodate the teeth needing an alignment. This appliance is not
designed to gain any arch width or length, or move teeth mesially or
distally. Some space can be gained by doing light interproximal
recontouring from cuspid to cuspid if enamel thickness and integrity
allows the same. One should be certain that these conditions are met
before beginning this phase of treatment. In fabricating this appliance,
the rotated teeth are set-up on the model in the corrected alignment.
When worn in the mouth the spring action of the labial and lingual
wire and acrylic components gently aligns the teeth. No adjustments
are necessary except to check that the labial and lingual acrylic on the
incisors are in proximity to each tooth’s surface. They should be
separated only by the labial/lingual width of the incisors when the
appliance is out of the mouth for inspection. A well cared spring
retainer, can be used as a final retainer if desired.
Retention protocol
Class I non-extraction case
In cases with anterior cross-bite of one or two teeth, no retention is
required as the lower arch retains the upper teeth relapse. However, if
there is an associated crowding a Hawley retainer may be required to
prevent the rotational relapse. In cases with severe crowding and
multiple rotations, it is a good idea to either retain with very well-
fitting Hawley retainer or Begg’s wrap around retainer. At AIIMS, we
prefer to provide bonded lingual retainer both in the upper as well
lower arches. In some cases especially in the mandibular arch, a
spring aligner is preferred to overcome a mild relapse.
The cause of relapse is often negligence in strictly wearing the
removable retainer or bond failure on one or more teeth of spiral wire
bonded retainers. Spring aligner is the appliance of choice as it is not
bulky and serves both as an active appliance to begin with and as a
retainer, once the correction has taken place.
Children with an expansion appliance for the buccal correction of
cross-bite would need longer retention and stronger appliance.
A child treated at the optimum age for the skeletal expansion of the
maxilla with rapid maxillary expansion (RME) is likely to be more
stable than a case where dental expansion has been achieved with
fixed orthodontic appliance alone. Each case of expansion needs to be
reviewed for its original shape of the arch, the amount of expansion
achieved, mode of expansion, post-orthodontic occlusion and
muscular pattern. In general, the better the cusp-to-fossa relationship
less is the likelihood of the relapse.
The teeth should be placed in the neutral zone of the muscular
forces where the lingual and buccal muscular forces are in balance
and in harmony. The aberrant muscular pattern must be modified for
prevention of relapse.
Class I extraction case

Malocclusion treated with extraction of all first premolars or second
premolars extractions are prone to relapse. Maintenance of proximal
contacts at extraction site is critical so are the contacts between all
teeth. Tight contacts are the outcome of a well-finished occlusion
which is influenced by the arch form, torque, marginal ridge relations
and mesiodistal inclinations of the teeth. The conventional Hawley’s
appliance usually poses problems of impingement of the wire
extending from U loop of the labial bow passing from the buccal side
of the embrasure of the extraction site into the palatal acrylic. This
may prevent the firm contact to be maintained or some time open up
the contact area between canine and second premolar. Therefore, in
such cases, it is advisable to use a wrap around Begg’s retainer, which
would help maintain tight contacts of the arch. Placement of flexible
spiral wire (FSW) bonded retainer on the lingual of the lower arch is
now a convention. However, in extraction cases, the FSW needs to be
extended to the mesial occlusal pits of the second premolars that help
to maintain proximal contacts at the extraction sites.
Class II non-extraction case

These would require similar retention appliances as for the class I
non-extraction cases. In class II cases, some additional measures may
have to be taken to maintain the class I molar relation which is often
accomplished with the forward placement of the mandible. The
maxillary Hawley or Begg’s wrap around retainer may be modified to
have an anterior bite plane to help maintain the anterior bite and a
forward slide of the mandible. At times, the anterior bite with a
provision to hold the lower incisors in the desired position is built in.
Class II extraction case

Class II extraction cases would need almost similar retention devices
as non-extraction but with care not to allow the extraction space to
open. High angle class II cases may need additional use of the night
time high pull headgear in growing children with aberrant vertical
growth trend. Class II cases treated with functional appliances may
require a night time bionator or a modified activator appliance so as to
maintain the class I correction.
Class III cases

Class III children treated with facemask therapy would need to
continue night time chin cup for a considerable period of time, till the
mandibular growth is complete.
We have used FR III and reverse twin block appliance as a retaining
device for young children immediately following protraction
facemask therapy.
Retention schedule
General principles that govern the retention schedule include a
minimum of 6 months of day and night wear of retention appliance,
which is usually extended up to 1 year as night time wears and
gradual weaning off for the next 6 months.
The children with severe rotations and crowding would need at
least 1 year of retention followed by a gradual withdrawal.
The fixed spiral wire bonded retainers on the lower arch may be left
beyond 1 year until such time that they come off by themselves if the
child can maintain a reasonably good oral hygiene. In adult patients
with periodontal mobility, permanent type of retainers would have to
be advised. The new tooth colour retainers can be left bonded for an
indefinite period.
Most important of all, retainers are delivered to the patient as soon
as the brackets are debonded, preferably removable retainers at first.
Some orthodontists would like to make the retainers from the
impressions made 1 week or so before the debond procedure is
undertaken. The upper removable and lower FSW are fabricated in
advance before debonding procedure is undertaken. The lower FSW
may be bonded first followed by debonding and issue of the
removable upper retainer. In children with median diastema in upper
arch, a FSW may have to be provided to prevent the diastema relapse.
The patient should be advised to wear the retainers 24 h, taking
them out only at brushing and while cleaning it thoroughly. The
patient should regularly visit, for a review of the retainers and any
possible relapse. After a few weeks, the occlusion is checked for
centric relation and centric occlusion, and for any interference in
eccentric relations during functional mandibular movements. Some
orthodontists prefer to bond the lingual retainers after the occlusion
has settled after about a few weeks of debonding.
As a rule of thumb, the retainer should be in place at least for the
same duration as the treatment time; however, age at the completion
of active treatment determines the duration. While orthodontic
treatment is rapid and more stable during adolescence, the retention is
continued till adulthood.
A classic regimen also is to wear the removable retainers full time
for half of the treatment time. Then divide the remainder of the
treatment time in two periods; the first period is for at home wear and
the second period is for night time wear; thereafter the retainers can
be maintained for night-time wear or can be weaned away by
alternate night wear until it is worn only to test for a good fit. If there
is any difficulty in the fit, then adjustment or at least night-time wear
be maintained.35
The cleft palate patients require a rigid retention framework to
prevent the collapse of the maxillary arch. These patients would
require prosthodontic rehabilitation such as the replacement of a
missing tooth, which should proceed early (Fig. 80.11).
FIGURE 80.11 Retention following expansion in operated cases

of CLP.
The retention is is somewhat tricky. The relapse occurs due to the
scars in the palate following surgery. A removable partial denture
(RPD) serves: (1) as a retainer, (2) as RPD and (3) as an obturator to
prevent nasal regurgitation from oronasal fistula.
The retention plan summarised by Kaplan4 is given in Boxes

80.3–80.6.
Box 80.3 Cases requiring minimal or no retaining
appliances
1. Blocked out canines in class I extraction cases without incisor

crowding.
2. Class I anterior cross-bite with sufficient degree of overbite.
3. Posterior crossbites with very steep cusps and no anterior
crowding.
4. Class II cases slightly over treated with Kloehn headgear to
restrict maxillary growth with sufficient arch length indicated
by mandibular anterior spacing and absolutely no mandibular
incisor rotations.
These patients should follow scheduled checks during the post-

treatment adolescent period for any possible spacing or unfavourable
growth changes or TMJ symptoms.
Box 80.4 Cases requiring indefinite retention
1. Class II division 2 deep bite cases.

2. Severe rotations with poor periodontal health.
3. Undue arch expansion treatment for aesthetic demands.
4. Patients with tongue thrust or uncontrolled muscular habits.
5. Adult patients.
6. Patients of maxillary expansion of collapsed arches due to scars
of surgery in patients with complete cleft lip and palate.*
*
Suggested and practised by O.P. Kharbanda
Box 80.5 Cases that require operative procedures

with indefinite retention
1. Tooth size discrepancies such as larger maxillary teeth may
result in an increased overbite.
2. Conversely, larger mandibular teeth will result in end-to-end
incisor relationships, maxillary spacing or buccal end-on
occlusion.
3. A vertical incisal relationship, will lead to deepening overbite
and should be retained.
4. Proximal recontouring of the mandibular incisor may resolve
the Bolton discrepancy if mandibular anterior tooth material is
in excess or vice versa for the maxillary teeth.
5. The microdontic tooth may require aesthetic build-ups with
tooth coloured restorative or laminates to resolve this problem.
6. Severe rotations would need circumferential supracrestal
fiberotomy (CSF) procedures.
7. Frenectomy may be needed to prevent relapse of the midline
diastema.
Box 80.6 Cases requiring special considerations

and/or renewal of removable retaining appliances
or acrylic on the labial bows
1. Late mandibular growth spurt and Tweed’s type C growers.

2. Post-treatment adolescent palatal changes.
3. To maintain torque and overbite correction.
Routine cases, extraction or non-extraction, should have to use

retention appliances—fixed or removable until the growth process has
slowed in late teens and early 20s.
Each case needs its own evaluation of retention plan and has its
own possible potential for relapse. The treating orthodontist has to
inform the patient the known statistics on reported relapse, which is
as high as 66%.
Adjunctive periodontal procedures for
successful orthodontic results
A healthy periodontium is essential for successful orthodontic
treatment. After the orthodontic correction of teeth, periodontal
procedures are useful in preventing relapse of certain types of tooth
irregularities and in maintaining healthy gingiva. The periodontal
procedures, which are often performed at the conclusion of active
orthodontic treatment, are:
1. Circumferential fibrotomy
2. Maxillary frenectomy
3. Autogenous gingival grafts
Circumferential fibrotomy
The orthodontic practitioners well recognise the propensity for relapse
of corrected rotated teeth. The more severe the original rotation,
greater will be the amount of rotational relapse. Supracrestal fibres are
suspected to be the main cause and if these fibres can be severed, the
relapse can be minimised. The surgical procedure consists of inserting
tip of the number 11 surgical blade into the depth of the gingival
sulcus, pushing it down towards alveolar crest and severing all
fibrous attachments surrounding the tooth just below the crest of the
alveolar bone. It is best performed after the correction of rotation prior
to removal of the appliance. In the presence of gingival inflammation,
procedure is postponed until inflammation has subsided. The efficacy
of this procedure has been found effective in alleviating pure
rotational relapse in a 12–14 years of post-treatment follow-up
study.36 The procedure is performed under local anaesthesia
(Fig. 80.3E).
Maxillary frenectomy
Abnormal maxillary fibrous frenum has been considered responsible
for the recurrent relapse following the closure of midline diastema.
The presence of abnormal frenum is diagnosed when the frenal
attachment closely approximates inter-dental margin and/or inserts
palatally to the incisors. The attachment is wider than usual at its
insertion point. Blanching of inter-dental and/or palatal tissue upon
stretching of upper lip and frenum confirms the cause. The presence
of an invagination of the inter-septal bone between the central incisors
on a periapical radiograph reconfirms a deep attachment of the
frenum.
Abnormal frenum should be excised after the space closure.
Removing frenum prior to space closure produces scar tissue
formation, which can slow down subsequent attempts at space
closure. Edwards37 recommends a three-stage procedure when
performing a frenectomy.
• The frenum is repositioned apically with denudation of the

alveolar bone.
• The trans-septal fibres are severed between the approximated
central incisors.
• The labial and/or palatal gingival papillae are recontoured in
cases of excessive tissue accumulation.
This procedure significantly increases the long-term stability of an

orthodontically closed maxillary midline diastema.37 Other authors
have also proposed frenectomy as an adjunct in retention procedures
for such a problem cases.38
Autogenous gingival grafts39,40

The free gingival graft procedure involves preparation of a recipient
site, done by supra-periosteal dissection to remove epithelium,
connective tissue and muscle fibres. A graft is harvested, traditionally
from the palate, and secured at the recipient site. It creates adequate
zones of attached gingiva, reduces the possibility of a future recession,
eliminates aberrant freni and enhances the health of the affected area.
This procedure is recommended prior to the commencement of
orthodontic treatment. Free connective tissue grafts are also done for
obtaining root coverage; when a recession is present.
What is new?
Memotain—a new CAD/CAM fabricated lingual retainer
Memotain is a wire made of custom-cut nickel-titanium—as an
alternative to multi-stranded lingual retainers.
Memotain is a CAD/CAM fabricated lingual retainer made of
0.014×0.014 in. rectangular nickel-titanium wire. The wire is highly
flexible, and custom cut to precisely adapt to the patient’s lingual
tooth anatomy. The name Memotain is a combination of ‘memory’
and ‘retainer’ because of the uniqueness of using nickel-titanium for
the lingual wire.
To place an order, the orthodontist can submit a polyvinylsiloxane
impression or an intraoral scan in STL format. Memotain is digitally
positioned to prevent occlusal interferences; therefore, if an
impression is taken for a maxillary retainer, the orthodontist should
also submit a mandibular impression with a bite registration.
Typically, the orthodontist will submit the scan with the braces still on
and bond the retainer before debonding; however, this is not possible
with lingual braces. The custom lingual wire and a silicone putty
transfer jig are mailed to the orthodontist in approximately 2 weeks.
Bonding the lingual retainer follows a traditional protocol of
prophylaxis, etchant, primer, and placement of luting agent.
Memotain offers numerous perceived advantages to traditional
multistranded lingual wires, including no need for wire measuring or
bending, individually optimised placement, greater accuracy of fit,
tighter interproximal adaptation, less tongue irritation, better
durability and resistance to microbial colonisation. Memotain’s tight
interproximal wrap is beneficial in common break-point areas, such as
the embrasure between the lateral incisor and the canine, or the step
between the canine and the premolar.41
Current status of research and
evidence affecting orthodontic practice
Fixed lingual retainers some new facts
The lingual retainers are the most commonly used and preferred
retainers by most orthodontists who also like to continue them as long
as possible. The concerns have been raised about their adverse effects
on periodontal health and effects of the oral environment on the
mechanical and elemental integrity of the wires used. The third main
question, which remains to be answered is related to the risk of failure
and associated factors.
There is often a debate about adverse effects related to their
presence in the mouth with hampered cleaning, leading to a greater
risk of periodontal diseases. A 5 years follow-up has shown that fixed
lingual retainers do not seem to increase the development of
mandibular gingival recession. However, the presence of FSW for
longer duration enhances increase calculus accumulation.42
A long-term study equivalent to 14 years of ageing in mouth
revealed that 0.022 in., seven-stranded wires, lingual retainer wire
(LRW) and Tru-Chrome (TCH), both from the same manufacturer
(Rocky Mountain Orthodontics, Denver, CO, USA) seemed to
maintain their mechanical and elemental integrity within a period of
14-year intraoral exposure. No measurable ionic release could be
identified. This study was limited to two products from the same
manufacturer hence may or not hold true for other brands.43
The risk of failure of fixed orthodontic retention protocols was
evaluated to guide the orthodontist to select the best protocol by the
evidence. This elaborative study included four selected studies for
assessing glass-fibre retainers. The glass fibre bond failures were from
11 to 71%. A large group of 20 studies evaluating multi-stranded
retainers reported failures ranging from 12 to 50%. The selection of the
best treatment protocol remains a subjective issue.44
However, another study demonstrated that a bonded retainer for
maintaining closure of a maxillary midline diastema could last an
average of 17 years or more, with a yearly 2% chance of breakage and
with no expected adverse effects on the periodontal health of the
maxillary central incisors.45
With the recent increasing use of vacuum formed retainers, the
clinicians would like to be informed of their effectiveness in the
prevention of relapse, patients’ acceptance, vis-a-vis efficacy and
effects of oral fluids.
Speech and vacuum formed retainers

The VFR is more acceptable by the patients in speech, appearance,
gingival irritation, swallowing, self-confidence and comfort. The
patients using Hawley retainer believed that their retainers were
significantly more durable than those in the vacuum formed retainer
group.46
The production of /I: /, /i: /, /f/, /h/, /s/ and /R/ sounds for the
Hawley retainer group and /i: /, /h/, /s/ and /R/ sounds for the
vacuum-formed retainer group showed severe speech impairment
according to acoustic analysis. A comparison of the Hawley retainer
group with the VFR group revealed that the performance of /i:/, /f/
and /s/ sounds were significantly different. Although sound distortion
could be found in both the Hawley retainer group and the VFR group,
changes in articulation were more obvious in the Hawley retainer
group.47
Cytotoxic implications of VFR

The bisphenol A is released in the mouth from the removable oral
appliance. The significant release of BA is highest in the vacuum-
formed retainer group, followed by Hawley retainers fabricated by
chemical cure; the lowest levels were found with Hawley retainers
fabricated by heat cure. Therefore it is concluded that a Hawley
retainer fabricated by heat cure is a favourable choice.48
Which retainer is a better choice?
Some relapse is unavoidable after fixed appliance therapy irrespective
of retainer choice, and this is minimal in most patients at 6 months
after debonding. Bonded retainers have a better ability to hold the
mandibular incisor alignment in the first 6 months after treatment
than do VFR.49
When three types of retainers were evaluated after 5 years or more
out of retention: (1) Removable VFR covering the palate and the
maxillary anterior teeth from canine-to-canine; (2) bonded canine-to-
canine retainer in the lower arch maxillary VFR combined with a
stripping of the lower anterior teeth; (3) Prefabricated positioner
covering all erupted teeth in the maxilla and the mandible. All
retention appliances were provided within 1 h of debonding. All the
three retention methods had achieved equally favourable clinical
results.50
Evaluate the effects of different retention strategies used to stabilise
the tooth position after orthodontic braces. Removable retainers
versus fixed retainers, different types of fixed retainers, various types
of removable retainers, and one study compared a combination of
upper thermoplastic and lower bonded versus upper thermoplastic
with lower adjunctive procedures versus positioner.9 According to
Littlewood, there is currently insufficient high-quality evidence
regarding the best type of retention or retention regimen, and so each
clinician’s approach will be affected by their personal, clinical
experience and expertise, and guided by their patients’ expectations
and circumstances.51
Can we enhance the bone quality to prevent

relapse?
A group of female albino rabbits supplemented with 15.4 mL/kg b.w.
Per day olive oil during an orthodontic retention period clinically
reduced orthodontic relapse on rabbit model. Histologically, olive oil
increased osteoblasts and osteocytes counts and the relative amount of
bone mineralisation of connective tissue layer forming alveolar bone
(AB) at the end of four weeks after the orthodontic retention period.52
Key Points
Retention plan is part of orthodontic diagnosis and planning, and
perhaps the most difficult part of the active orthodontic treatment.
Choice of retention appliance and retention protocol varies in each
patient, according to malocclusion, treatment mechanics used,
extraction pattern, craniofacial morphology, functional anatomy of
stomatognathic system and periodontal health besides systemic
health. Prevention of relapse is no less challenge than doing
While a definite protocol of retention is still elusive based on the
evidence, the choice of appliance seems to be subjective and a matter
of preference by the orthodontist. An FSW is safe and effective while
VFR are good for patients’ perspectives during the first 6 months.
Further research is required to enhance bone quality to prevent
relapse.
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Index
A
AAO, See American Association of Orthodontists (AAO)
ABO, See American board of orthodontics (ABO)
Accelerated osteogenic orthodontics (AOO), 963
N-Acetyl cysteine (NAC), 164
Achondroplasia, 172
Activator, 757
bite registration for, 757
clinical management, 758
indications of, 757
relative indications, 765
retention protocol, 758
treatment
changes, 758
follow-up, 758
trimming, 757
Active retainers, 1230
anterior retention of skeletal correction, 1231
spring hawley retainer, 1231
tooth positioners, 1230
Addison’s disease, 104
Adenoidectomy, 163
Adenoid facies, clinical features, 162
Adenotonsillectomy, 163
ADHD, See Attention deficit hyperactivity disorder (ADHD)
Adhesive composite, curing of, 499
bond failures, 500
adhesive-bracket bond failure, 500
adhesive-enamel bond failure, 500
light-cure, 499
light sources
argon laser, 499
halogen light, 499
light emitting diode (LED), 499
plasma arc light, 499
self-cure, 499
Adhesive remnant index (ARI), 500
Adjunctive periodontal procedures, 1233
autogenous gingival grafts, 1234
circumferential fibrotomy, 1233
maxillary frenectomy, 1233
Adolescent spurt, 135, 136
Adult mastication, 152
Adult seeking orthodontic treatment
clinical assessment, 192
AdvanSync class II molar-to-molar appliance, 826
Aesthetics, 978, 1022
in adult patients, 423
aesthetic component (AC of IOTN) index, 64
brackets, 453
erupted mesiodens causing poor, 37
improved, and enhanced self esteem, 36
optimum facial, and dental aesthetics, 1190
positioning bends, 645
wires, 470
optiflexTM wire, 471
plastic/teflon-coated NiTi, 471
Ageing
facial profile and nose changes, 149
and soft-tissue integument of face, 148
Ahmed, Dr Rafiuddin, 27
AJ Wilcock Wires, 465
diameters, 464
grades, 465
pulse straightened spools wires grade and size, 464
straightening processes, 465
pulse straightening, 465
spinner straightening, 465
Aligners and root resorption, 433
Alveolar bone, 696
response to orthodontic force, 512
Alveolar cleft, 987
American Association of Orthodontists (AAO), 14
American board of orthodontics (ABO), 1195
guidelines, 1195
measuring gauge, 1198
objective grading system, 1195
American dentistry, in mid-19th century, 10
American journal of dental science, 5
American journal of orthodontics, 767
Anchorage for fixed appliance, 564, 566
extraoral sources, 566
facemask, 566
headgear, 566, 567
factors affecting anchorage requirements, 567
classification of anchorage requirements, 567
craniofacial pattern, 567
friction, 568
nature of malocclusion, 567
type of tooth movement, 567
teeth as anchor unit, 564
angulation of tooth, 566
differential force, 565
reciprocal anchorage, 564
root length, 566
root ratings, 565
root shape, 566
root surface area, 565
stationary anchorage, 564
tooth form, 566
basal bone, 566
muscular anchorage, 566
periodontium, 566
Anchorage in orthodontics, defined, 563
Anchorage loss, 563, 733
mesial, 563
vertical and transverse, 563
Anchorage savers
treatment planning, 568
mini implants, 570
modified Nance button, 569
Nance palatal arch, 569
skeletal anchorage system, 570
translingual arch (TLA), 569
transpalatal arch (TPA), 568
utility arch, 570
vertical holding appliance (VHA), 570
Anchorage sources for removable appliance, 564
Andresen activator, 754, 755
Andresen, Viggo, 19
Andrews, Lawrence, 23
Angle, Edward H, 17
contribution, 11, 18
edgewise appliance, 16
model of ideal occlusion, 14
non-compliance functional Class II corrector, 14
Angle School of Orthodontia, 14
Angulation, 645
Ankylosis, 173, 964, 985, 987
bilateral TMJ ankylosis, and OSA, 1050
primary molars
unilateral ankylosis of mandible, 1099
Annealing, 461
Anterior
bite plates, 1228
cross-bite, 544
deciduous dentition, 539, 543
local causes, 540
mixed dentition, 539
retention, 544
therapeutic approach, 540
treatment of, 540
Anthropometrics, 233
AOO, See Accelerated osteogenic orthodontics (AOO)
Apert syndrome, 36, 172
Arch forms
Bonwill-Hawley, 472, 473
brader arches, 473
catenary curve, 473
cubic interpolatory spline, 474
ideal, 475
lingual, mushroom-shaped, 474
pentamorphic arch forms, using dental records, 473
primary forms
narrow/V arch form, 474
oval arch form, 474
U/square arch form, 474
Arch length, 532
analysis during mixed dentition, 201
combination method, 203
Nance’s analysis, 204
Staley and Kerber method, 203–204
non-radiographic method, 202
Moyer’s analysis, 202–203
Tanaka and Johnston method, 203
radiographic method, 201
advantage, 202
disadvantage, 202
factors influencing plan of a space maintainer, 532
rate of space loss, 532
management, 532
preservation, 532
Arch wire, 455, See also Orthodontic wires
ideal, properties, 462
preformed, 472
Argon laser, 499
ARI, See Adhesive remnant index (ARI)
Artificial neural network, 129
Asymmetric occlusion, 1085, 1090
common traits, 1086
canine relationship, 1086, 1088
clinical evaluation, 1088
CBCT applications in facial asymmetry, 1089
molar relationship, 1086, 1088
class III subdivision malocclusions, 1087
class II subdivision malocclusions, 1087
overbite, 1086
over jet, 1088
definition and criteria, 1085
mild asymmetry of malocclusion, 1086
development within dental arches, 1085
ankylosis of primary molars, 1085
dental caries, 1086
ectopic eruptions of maxillary permanent first molars, 1085
maxillary or mandibular, 1085
partial hypodontia, 1086
lower midline shift, and asymmetrical malocclusion, 1087
extractions, 1091–1093
three first premolars, 1091–1093
corrective orthodontic treatment, 1093
symmetrical extraction, 1095
treatment outcome, 1094
management, 1090
assessment of
molar rotation, 1091
tip of teeth in the buccal segment, 1091
buccolingual axial inclination of molars, 1091
symmeterograph, usage, 1090
molar distalisation, 1091, 1095, 1096
unilateral, 1092
option II uni-lateral maxillary first premolar, 1095
prevalence and features, 1088
asymmetric relations
canine, 1088
class II, 1088
class III, 1088
class II/subdivision malocclusion, 1088
subdivision malocclusion
class II, 1091
asymmetrical mechanics, 1091
class III, 1096
Attention deficit hyperactivity disorder (ADHD), 164
Austenitic stainless steels, 463
Autogenous gingival grafts, 1234
Automatic landmark detection, 398
cephalometric analysis, 398
Auto-transplantation of teeth, 24
Axial rotations, 607
B
Balters’ bionator, 758
bite registration for bionator II, 759
for class III malocclusion, 756
for class II malocclusion, 756
clinical protocol, 760
concept on aetiology of class II malocclusion, 758
for class I open bite/shield appliance, 759
for class II, 758
components of the appliance for class II, 758
for class III, features, 759
indications of class II bionator, 759
objectives of treatment
in class II division 1 malocclusions, 759
rationale of appliance design, 758
BAPA, See Bone anchored pendulum appliance (BAPA)
Basal cell naevus (Gorlin) syndrome, 173
Bauschinger effect, 461
Begg, P Raymond, 21
Begg’s retainer, 1229–1228, 1230
Bending art system (Orthomate), 475
Beta hypothesis, 157
Bilateral maxillary molar distalisation, 722
Bilateral sagittal split osteotomy (BSSO), 1033, 1034
Bimaxillary protrusion, 609
Biocompatibility, 464
BioForce wire, 470
with Ion Guard, reduction in friction, 470
Biomechanics, 657, See also MBT biomechanics
Biomedical imaging, 219
Bionator, See Balters’ bionator
Bioprogressive therapy, 445
Bite jumping, 827
appliance, 754
Bite plate, 409, 754
Bjork’s Method Index of Swedish National Board of Health
(SweNBH), 63
Blood vessel reorganisation, 513
Body proportions, at different ages, 134
Bolton-Brush Growth study, 234
Bolton tooth size discrepancy, 1225
Bonding agents, 487
advanced, 488
compomers, 488
evolution of bonding agents (generations), 487
hybrid bonding agents, 488
ideal, prerequisites of, 489
moisture insensitive primer (MIP), 488
nanocomposites, 488
self-etching primers (SEP), 488
one-step adhesives, 488
two-step adhesives, 488
Bonding orthodontic appliances, 485
advantages, 486
limitations, 486
Bonding techniques, 489
Bone anchored pendulum appliance (BAPA), 713
Bone as osseous connected cellular network (CCN), 129
Bone formation, mechanism, 119
endochondral ossification, 120
intra-membranous ossification, 120
Bone growth
basic concepts involved, 120
displacement, 120
growth centre, 120
growth field, 120
growth site, 120
ossification centre, 120
current views, 21st century, 130
Bone scan, indications, in orthodontics, 216
Bonwill-Hawley arch form, 472, 473
Borderline class III malocclusion cases, 917
borderline patient, 920
camouflage treatment, 922
rationale, 923
cephalometric findings, 922
Holdaway’s H-line angle, 922
diagnostic and therapeutic approach, 924
extraction approach, 925
asymmetrical extraction, 930
ultimate occlusal relationships, 929
limitation of tooth movement, 923
non-extraction approach, 924
buccal open bite, 926
case study, 927
distalisation of mandibular arch using skeletal anchorage, 926
effects of class III elastics, 925
Multiloop edgewise archwire design, 925, 926
psychology, treatment cost and relapse, 923
treatment approaches, 924
treatment considerations, 922
cases with varying pattern of, 919
categories of skeletal class III pattern, 920
classification, 918
clinical features of a class III face, 918
extraoral features, 918
intraoral features, 918
cranial base, 919
morphology, skeletal class III assessed on, 921
ethnic correlates of class III treatment, 917
among Caucasian and Asians, 918
glenoid fossa, 919
growth considerations in treatment, 920
maxillo-mandibular relationship, 918
nature of skeletal class III malocclusion, 917
pseudo vs. true, 921
Bracket, 449–450
angulation, 646
Holdaway’s method of placing, 446
based on their composition, classification of, 450
base of bondable brackets, 450
bracket positions on anterior and premolars, 556
bracket positioning errors, 560
body and slot, 450
body-base interface, 450
with built in torque and angulation, 647
customisation, 457
dynamic, 457
identification, 451
occlusogingival placement or bracket height, 557–559
positioning, 554
measuring aids, types of, 555
prebond evaluation, 554–555
pre-adjusted, 451
design features, 452
rotational position, 558–560
self-ligating, See Self-ligating brackets
slot angulations, 559–560
twin, 451
Brader arches, 473
Braided nickel-titanium rectangular wire, 470
Brittleness, 461
Bruxism, 164
aetiology, 164
childhood, 164
clinical features, 164
BSSO, See Bilateral sagittal split osteotomy (BSSO)
Buccal acting appliance, 720
Keles molar distaliser, 725
K loop molar distaliser, 722
sectional jig assembly, 720
Buccal and palatal appliance, 726
Buccal tubes, 555
inaccurate buccal tube placement in angulation, 556
inaccurate mesiodistal placement of the buccal tube, 557
occlusal view indicating
correct mesiodistal position of tube, 556
tube placement on a maxillary first molar, 556
Buccolingual inclinations, 1201
Building treatment
into appliance, 444
Holdaway’s method of placing brackets, 446
Ricketts bracket system, 446
into brackets, evolution of, 645
effect of standard edgewise brackets, 649
new approach to prevent rotations and tipping, 646
Pre-SWA era, 647
rotational effect, 648
shortcomings of edgewise appliance, 649
standard, edgewise bracket, 648
SWA and after, 1970, 647
Buonocore, 485
Burstone, Charles J, 22
C
CAD/CAM fabricated lingual retainer, 1234
CAD/CAM technology, 8
Calcium fluoride, 472
Camera
aperture, 224
settings, 224
basics, 219
close-up lenses, 220
depth of field, 225, 226
digital single lens reflector (DSLR) camera, 219
ISO or film speed, 225
JPEG format, 223
lenses, 220, 221
macro lens, 220
3 MP camera, 222
raw files, 223
shakes and image stabilisation, 227
SLR camera body, 220
working, 220
TIFF formats, 223
working distance, 220, 227
zoom lens, 220
Canalised growth, 116
Canine protected occlusion (CPO), 1119
Case, Calvin Suveril, 16, 19
Casein phosphopeptide-amorphous calcium phosphate (CPP-ACP),
1217
Catch-up growth, 116
Catenary curve, 473
CBCT, See Cone-beam Computed Tomography (CBCT)
CBCT scanners, 381
anode, rotating type of, 372
applications in orthodontics, 374, 376
airway, 378, 380
assessment of treatment outcomes, 378
3D colour maps, 381
craniofacial morphometrics, and cephalometry, 378
diagnostic assessments
MIP and multiple cross-sectional, 379
orthodontic treatment planning, 378
mirroring techniques, 380
TMJ assessment, 376
classification, based on patient positioning, 373, 374
sitting position, 373
standing position, 373
supine position, 373
complete or partial rotation of gantry, 372
fundamental principles, 371
image artefacts, 374
beam hardening, and proton starvation, 376
categorisation, 374
patient- based, 374
physics-based, 374
scanner- based, 374
imaging goals, and protocols, 378
limitations, 379
operational principles, 372
radiation safety, pertaining to, 380, 381
rotating type of anode, 372
CCD/CMOS sensors, 340
Cellular behaviour in sites of PDL tension, and compression, 512
Cemented hygienic rapid expansion (HYRAX) appliance, 693
Centre of resistance (CRes), 519, 520
Centre of rotation (CRot), 521
Centre V-bend, 523
Centric occlusion (CO), 1119
Centric relation (CR), 1119
Cephalocaudal gradient of growth, 133
Cephalogram, 234, 277, 311, 329
for complete obliteration of upper airway, 161
conventional, 234
definition, 234
errors of cephalometric landmark identification, 333
cephalometric landmark accuracy, 333
random, 333
systematic, 333
in cephalometric measurements, 334
during making, 331–332
during X-ray tracing, 332–333
features, 239
indications and uses, 239
location of anatomical structures, 240
patient positioning, 238
posteroanterior (PA), 239, 330
quality, 330
reference colours for stages of treatment, 311
soft tissue, features, 329
concentricity of ear rods, 329
overlap of side structures, 330
smooth curve of cervical spine, 329
teeth in centric occlusion, 330
unstrained lips, 330
quality lateral cephalogram, 330
submentovertex projection, 239
technique of taking, 238
tracings, 242–243
required, 311
types according to patient orientation, 238
unexpected findings, 241
Waters’ projection, 239
Cephalometric analysis, 234, 247 See also various entries starting as
cephalometric
fundamentals, 241
longitudinal cephalometric superimpositions, 311
for nasopharyngeal airway, 162
principles, 238
Sassouni, See Sassouni’s cephalometric analysis
soft tissue face of, 277, 278
Arnett’s soft tissue cephalometric analysis (STCA), 283, 285
dentoskeletal factors, 283
facial lengths, 283
harmony of parts, 283, 285
interjaw, 283, 285
intramandibular, 283, 285
orbit to jaw, 283, 285
total face, 283, 285
interrelated areas, 283
soft tissue components, 283
TVL projections, 283, 285
assessment sheet, 284
Bergman’s comprehensive analysis, 286, 287
cephalogram, 277
recording techniques, 277
chin prominence, 279
chin thickness, 279
general appraisal, 278
chin/neck region, 278
lower two-third of lower face, 278
middle one-third of face, 278
nasolabial angle, 278
upper one-third of face, 278
Holdaway’s analysis, 281
landmarks and plane, 281
measurements, 281–282
H angle, 281
inferior sulcus to the H line, 282
lower lip to H line, 282
nose prominence, 281
skeletal profile convexity, 281
soft tissue chin thickness, 281
soft tissue facial angle, 281
superior sulcus depth, 281
upper lip strain, 281
upper lip sulcus depth, 282
upper lip thickness, 281
horizontal nasal prominence, 279
inclination of nasal base, 282
Indian norms, 286
interlabial gap, 279
landmarks of soft tissue of face, 278
lower lip prominence, 279
mentocervical angle, 282, 283
Merrifield’s profile line: Z angle, 282
middle-third to lower-third ratio, 279
overview, 277
Ricketts’ E line, 282
schwarz analysis, 279, 280
Steiner’s S line, 280
submental neck angle, 283
subtenley analysis, 279, 280
upper lip prominence, 279
upper lip to lower lip height ratio, 279
three-dimensional, See Three-dimensional cephalometry
Cephalometric apparatus, 235
cassette, 237
components of equipment, 235
conventional, 236
fundamentals of head orientation, 236
superoinferior orientation, 237
grid, 237
head holder, 236
components, 236
Image receptor system, 237
intensifying screens, 237
radiographic apparatus, 237–238
radiographic film, 237
soft tissue shield, 237
Cephalometric landmarks, 241
dental landmarks, 245
landmarks on PA films, 245
landmarks on the cranial base, 243
landmarks on the mandible, 244
landmarks on the maxilla, 245
soft tissue landmarks on face, 245
soft tissue landmarks on front view of face, 246
upper airway cephalometric landmarks, 245
Cephalometric norms, 234, 241
floating norms, 241
for Indians, 241
Cephalometric radiology, 234
historical perspective, 234
Cephalometrics for orthognathic surgery (COGS), 22
Cephalometric superimpositions, 311
American Board of Orthodontics
superimposition requirements of, 322–323
anatomical anterior cranial base (ACB), 312
automatic superimpositions, 322
stages, 324
Bjork’s method of structural superimposition, 313, 314
3D superimposition, 325
CBCT images, 325–326
I-point and I-curve superimposition, 320–321
advantages, 321
lateral, 312
on cranial base structures, 312
cranial base superimposition, 313
De Costers method, 312
cranial base superimposition, 313
stable landmarks on cranial base, 312
stable landmarks on cranial base, 312
longitudinal, 311
methods of tracing and superimposition, 313
mandibular superimposition, 313, 315
maxillary superimposition, 315
sagittal position, 313
vertical, 313
regional superimpositions, 321
Ricketts five step method, 317
landmarks, 317
Basion (Ba), 317
Pm, 317
pterygoid point (Pt), 317
Xi point, 317
spheno-occipital synchondrosis (SOS), 312
stable landmarks, 312
superimposition and rationale, method, 318
positions, 318–319
superimposition of PA cephalogram, 322
superimposition on cranial planes, 316
Bolton plane, 316
tracings, 316
on FH plane, 317
on SE-N plane, 316
on SN planes, 316, 317
limitations, 316
Cephalometric variables
cranial base, 305
dental parameters, 304
anteroposterior position
of mandibular incisor in relation to mandible, 304
of maxillary incisor in relation to maxilla, cranial base, 304
interdental, 304
interpretation, 301
mandible, 302
maxilla
related parameters, 302
sagittal position and inclination, 302
purpose of analysis, 301
sagittal discrepancy, 302
ANB angle, 302
APDI for assessment of, 303
maxillo-mandibular relation, 302
MM bisector, 302
sagittal parameters, interchangeably for, 302
soft tissue, 304, 305
vertical face pattern, 304
facial height ratio (LAFH-TAFH), 304
position of Gn point, 304
Sn-GoGn parameter, 304
vertical maxilla mandibular relation with, 304
Ceramic brackets, 454
advantages/disadvantages, 454
with metal slot, 454
CFA therapy, See Contemporary fixed appliance (CFA) therapy
CFOT, See Corticotomy facilitated orthodontic treatment (CFOT)
Child for suspected deleterious habit(s), 189
clinical examination, 189
frenum, 190
intraoral examination, 190
soft tissues of oral cavity, examination of, 190
palate, 190
tongue, 190
Child with developing/established malocclusion, See also Malocclusion
clinical assessment
dentition and occlusion, 176
normal physical growth, 176
orthodontic evaluation during mixed dentition stage, 176
Circumferential
fibrotomy, 1233
retainers, 1228
Circumpubertal acceleration, 135
Class II division 2 malocclusion, 865, See also Class II malocclusion
aetiology, 870
cephalometric features, 870
features, 865
dental, 865
facial, 865
occlusion, 866
profile, 866
retention, 870
stability, 870
subtypes, 866
based on
dental features, 866
freeway space, 866
type A-C, 867–869, 873
treatment considerations, 870, 871
mixed dentition treatment, 870
two-phase treatment, 875
Class III borderline cases, See Borderline class III malocclusion cases
Class III malocclusion, 886
aetiology, 883
environmental factors, 883
epigenetic, 883
gene-environmental interaction, 885
genetics, 883
systemic factors, 883
Alt- RAMEC protocol, 912
appliance design and manipulation, 898
Delaire’s facemask, 898
facemask appliance, types of, 899
Duane Grummons, 898
intraoral components, 898
modified protraction headgear face bow, 898
Petit face mask, 898
appliances to intercept developing, 896
bone anchored maxillary protraction (BAMP), 905, 913
camouflage treatment, 913
categories and facial profiles, 885
cephalometric evaluation, 887
chin cup appliance, historical review of, 891
chin cup therapy
biomechanics of, 893
cephalometric values, 894
clinical aspects of, 891–893
effects on TMJ, 894
stability, 896
treatment effects, 893
clinical recommendation, 897
clinical recommendations, 911
components of, 883–885
dental features, 887
diagnosis of, 886
chin position, 886
critical factors in, 886
facial asymmetry, 887
mandibular position, 887
maxillary position, 886
profile evaluation, 886
early treatment of developing, rationale for, 891
goals of, 891
ethnicity, 885
functional appliances to correct, 897
Frankel functional regulator III appliance, 897
reverse twin block appliance, 897
functional examination, 887
gender differences, 885
geographical areas, prevalence of, 882
growing children, 881
hybrid hyrax expander-face mask, 913
modified hybrid hyrax device, 914
linear and angular cephalometric parameters used in diagnosis, 889
management, 889
interception of malocclusion, 889
of pseudo class III malocclusion, 891
maxillary protraction appliances, 898
historical review, 898
maxillary protraction, biomechanics of, 898
conventional facemask appliance, 900
direction of force, 899
optimal force and time of wear of appliance, 901
maxillary protraction using inter-maxillary elastics, 908
BAMP using protocol, 913
lateral cephalogram, 913
maxillary protraction using skeletally anchored facemask, 906
micro-implant supported maxillary protraction, 912
orthognathic surgery, 914
orthopantomograph, 887
prediction of class III skeletal growth, 887
growth treatment response vector (GTRV) determination, 890
pseudo class III malocclusion, diagnostic criteria of, 887
retention, 904
skeletal and dental effects of facemask therapy, 901
airway, 902
short term effects, 901
soft tissue, 901
TMJ, 902
skeletal, prevalence of, 882
stability and prognosis of maxillary protraction therapy, 905
treatment timing of protraction face mask therapy, 902
maxillary protraction and rapid palatal expansion, 902
maxillary protraction with Alt-RAMEC, 902
true and pseudo class III malocclusion, diagnostic scheme to
differentiate, 888
Class II malocclusion, 737, 738, 756
case treated with Kloehn headgear, 746
clinical findings, 737
deciduous and early mixed dentition, 737
occlusal and craniofacial characteristics, 738
findings during late mixed/permanent dentition stage, 739
clinicians perspective of, 742
clustering approach of phenotype characters, 740
principal components, 740
growing maxillary excess, treatment of, 743
clinical management Kloehn facebow, 744–746
components of facebow, 743
effects of facebow, 746–750
Kloehn facebow, indication and uses of, 743, See also Kloehn
facebow
headgear and neck gear, safety options for, 750
guidelines, 751
interception of developing, 742
nature of, 739
McNamara’s classification, 739
Moyers classification, 739–740
orthodontic interventions
during deciduous dentition, 742
maintenance of healthy primary dentition, 742
during early mixed dentition, 742
prevalence of, 738
superior protrusion and, 747
Wilhelm Balter’s hypothesis, 756
Class II malocclusion, with fixed appliance, 852
combination with orthognathic surgery, 853
extraction treatment, 853
camouflage approach to treatment, 854
indications of first premolar extraction
in upper arch only, 857
maxillary first premolars only, 853
tooth of choice for, 853
case study, 858
factors affecting soft tissue profile outcome, 863
management of, 851
objectives of treatment, 851
treatment aimed at results, 851
treatment sequence for extraction, 853
class II elastics, 860
force vectors of, 862–862
occlusion and profile after extraction treatment, 862–863
phase I, 853
bite opening mechanics, 857
conservation methods, 853
levelling and alignment, 853
mesial migration, 853
phase II
class II molar correction, 857
retraction of maxillary anterior teeth, 857
phase III
finishing and detailing, 862
Class II malocclusion, with vertical maxillary excess
appliance concept, and desired effects, 841
acrylic components, 841
appliance design, 841
bite recording, 841
mandible, 841
maxilla, 841
metal framework, 842
activator head gear tubes, 842
Coffin spring, 842
facebow, 842
high-pull head gear, 842
torque springs, 842
case selection, 838
contraindications, 841
nature of malocclusion, 838, 841
orthodontic mechano-therapies, 837
clinical management of appliance, 842
extraoral force, application of, 842–843
centre of resistance of nasomaxillary complex, 843
effects of headgear and bite height on, 844
intraoral stability, 844
second phase of therapy, 838, 845
wearing schedule and follow-up, 843
combined therapy, rationale of, 837–838
effectiveness of sagittal correction, 838
using high-pull headgear-activator, 838
treatment effects, 845, 848
van Beek activator, 848
bite recording, 848
wearing schedule, 849
Clear aligner appliance(s), 423
Clear aligner therapy, 425, 433
acceptability, 433
apply intermittent forces to, 433
discomfort, 433
mild crowding treated with, 424
and root resorption, 433
steps in, 425
Clear path System, 430
anterior cross-bite and class III treated with, 432
use of elastic button technique, 430
Clear path technology, 430
use IPR and dentoalveolar expansion, 431
Clear plastic aligners, 423, 424
mild crowding treated with, 424
Clear plastic retainers, 1227
Clear smile system, 428
crowding in both the arches treated with, 430
Cleft of lip and/or palate, management, 104, 1127
classification, 1131
American cleft palate-craniofacial association (ACPA), 1131, 1134
AIIMS, 1132, 1134
Indian, by Prof. C. Balakrishnan in, 1975, 1134
LAHSHAL, 1131, 1134
Nagpur, 1132, 1134
historical perspectives, 1131
Kernahan proposed ‘Striped -Y’, 1133
Veau (1931), 1132
developmental aspects, 1128
cleft of the lip and primary palate, 1128
cleft of the secondary palate, 1128
cleft palate only (CPO), 1130
submucous cleft palate (SMCP), 1130
distraction osteogenesis (DO), 1159
epigenetic factors/gene environment interactions, 1130
laterality, 1131
prenatal identification, 1130
risk of recurrence, 1131
sex ratio, 1131
inter-disciplinary team care, 1134, 1135
bilateral cleft lip and palate, 1144
controversy to conclusion, 1140
impression of a cleft child, 1141
issues with cleft care, 1135
feeding appliance, 1135, 1137
first few months, 1136
first few weeks, 1136
immediately on birth, 1136
OSLO protocol, 1144, 1145
closure of palate, 1144
lip repair, 1144
secondary surgeries, 1144
presurgical orthopaedics, 1136
latham appliance, 1138
presurgical naso alveolar moulding (PNAM), 1138, 1139
advantages, 1138
dynamic presurgical nasoalveolar remodelling (DPNR), 1141
prosthetic management, 1162
protruding premaxilla for, 1140
primary team or core team, 1134
schedule and timing protocol, 1136
orthodontic management, 1146
alveolar bone graft, 1153
post-bone graft follow-up, 1156
bergland index, 1160, 1161
treatment results after SABG, 1160
pre-bone graft, 1154, 1155
alignment of collapsed maxillary dental arches, 1156
wire framework maxillary dentoalveolar expansion
appliances, 1155
primary, 1154
secondary, 1154
assessment of, 1154
merits, 1154
surgical technique, 1154, 1157
UCLP case, 1156, 1158
timing of, 1154
comprehensive, 1157, 1161, 1162
indices for cleft, 1149
EUROCRAN, 1152
GOSLON, 1150, 1150–1151, 1152
Huddart/Bodenham system, 1152, 1153
modified, 1152
5-year-olds’ (5YO), 1152
orthodontic intervention during
deciduous dentition, 1152
early mixed dentition, 1153
unoperated UCLP, 1150
overview, 1127
abbreviation of cleft types, 1128, 1129
epidemiology, 1128
recent advances in the cleft care, 1163
speech in cleft patients, 1145
oronasal seal, 1145
palate obturator, 1146
surgical anatomy, 1141, 1142
cleft lip, 1142
primary surgery, 1143
cleft palate, 1141
naso-labial surface, 1141
syndromic and non-syndromic clefts, 1130
aetiology, 1130
familial affiliation, 1130
treatment steps and approach, 1146
record taking in patients, 1146, 1148, 1149
antenatal history of the mother, 1146
CBCT volumetric image, 1149
demographic details with unique id assigned to each patient,
1146
dental and orthodontic history, 1146
ENT assessment, 1146
examination of cleft to be done by plastic surgeon or general
surgeon, 1146
family history and psychosocial assessment, 1146
genetic assessment via pedigree chart, 1146
medical history including history of surgeries, 1146
orthodontic evaluation and complete records, 1146
photographic protocol, 1147
speech assessment, 1146
Cleft palate only (CPO), 1130
Cleidocranial dysostosis, 987
ClinCheck simulation, 432
CMOS/CCD sensors, 340
CO, See Centric occlusion (CO)
Coaxial wires, 465
diameters of, 466
Cobalt-chrome wires, 466
composition, 466
Co-Cr-Ni alloys wires, 466
general properties, 466
heat treatment, 466
COGS, See Cephalometrics for orthognathic surgery (COGS)
Coil springs, 455
closed, 456, 457
nickel-titanium (NiTi) open coil springs, 455, 456
Complex deformities, 36
common syndromes, affecting face, 36
Composite growth
and direction of displacement of maxilla, 139
Computed axial tomography (CT), 6
Computed radiography (CR), 340, 342
advantages, 345
chronology of image processing, 344
hardware components, 344
limitations, 345
phosphor screen cassette, 343
photostimulable phosphor cassettes
design characteristics of, 345
steps of using system, 344
Computer-aided designing (CAD), 441
Computer-aided manufacturing (CAM), 441
Computerised cephalometric analysis, 339–342
hardware, 341
software, 341, 343
software usage, 346
steps in analysis, 345–346
Computers, 222
Condylar cartilage, 139
Cone-beam computed tomography (CBCT), 353
applications for impacted canines in maxilla and mandible, 217
3D reconstruction of patient with
impacted left upper and left lower canines, 216
imaging, 387, 388, 388–389
indications of, 389
in orthodontics, 390
Connecticut new arch (CNA) wire, 469
Contemporary fixed appliance (CFA) therapy, 549
first interaction with patient, 549
information, 549
minimal/essential diagnostic records, 549
second consultation, 550
Continuous arch wires, 610
shape memory archwires, 610
Continuous positive airway pressure (CPAP), 1173, 1175
Copper NiTi alloy wires, 468
advantages over other NiTi alloys, 468
clinical applications, 461
types of, 461
Corrosion
effect of fluoride, 472
metal corrosion, 471
orthodontic alloys in mouth, 462
fatigue, 462
fretting, 462
galvanic, 462
intergranular, 462
pitting, 462
stress, 462
orthodontic metals resist, 472
wire, 472
factors promoting, 471
Corticotomy facilitated orthodontic treatment (CFOT), 963
Cost factor, 464
Couples, 520
first order (buccolingual) couple, 521
magnitude of the moment generated by, 521
root torque, 521
CPAP, See Continuous positive airway pressure (CPAP)
CPO, See Canine protected occlusion (CPO), See also Cleft palate only
(CPO)
CPP-ACP, See Casein phosphopeptide-amorphous calcium phosphate
(CPP-ACP)
CR, See Centric relation (CR), See also Computed radiography (CR)
Crack propagation, 461
Cranial fontanelles, and characteristics, 138
Craniofacial
anatomical structures, 391
3D landmarks, 391, 393, 397
definition of hard tissue, 393
image orientation, 391
MPR slices, 391, 392
pharyngeal airway, 395
soft tissue, 395
volume rendered images, facial skeleton, 391, 392, 396, 397
visualization, 391
development, 151
growth, 114, 130, 1224
skeleton, 233
Craniometer, 234
CRes, See Centre of resistance (CRes)
Cr-Ni alloys, 455
Crouzon’s syndrome, 36, 172
Crowding, severe, 35
maxillary and mandibular arches, 37
Crozat appliance, 421
Crozat, Dr George B, 11
Cryosurgery, 163
CT scanners
anode, rotating type of, 372
functioning difference from CBCT, comparison of, 372
fundamental principles, 371
types of, 371
Cubic interpolatory spline, 474
Cyclic fatigue, 461
Cyclohexylmethacrylate, 471
Cytoskeleton protein, 129
D
DAD, See Dentoalveolar distraction (DAD)
DALI programme, 475
3D bimetric distalising arch, 711
DCI, See Dental Council of India (DCI)
3D CT/ cone beam CT, 216
3D digital dental scanners, 354
common digital imaging technologies, 355
contact scanners, 354
non-contact scanners, 354
confocal laser scanning microscopy, 354
3D laser scanners, 354
interferometry, 354
photogrammetry, 354
structured light method, 354
Deband/debond procedures, 1206
case review and preparation, scheduling, 1205
appointment I, 1205
appointment II, 1205
appointment III, 1206
debanding molar bands, 1206
buccal gingival band margin in mandible, 1206
debonding/debracketing bonded appliances, 1207
conventional mechanical methods, 1207
debracketing metal brackets, 1207, 1208
debracketing porcelain brackets, 1208
Deglutition, 152, 158
Deleterious oral habits, 154
Dental aesthetic index (DAI), 63
Dental arch form, 472
Dental council of India (DCI), 27, 31
Dental drill, 5, 6
Dental education, 5
Dental electric drill, 6
Dental health component (DHC), 63
Dental journal, 5
Dental malalignments, 35
Dental midline deviations, 1073
clinical presentation, 1073
local/dento-alveolar type, 1073
definition and evaluation, 1071
maxillary and mandibular midlines, perfect coincidence, 1072
reference planes, 1072
angulation of the incisors, 1073
apical base discrepancy, 1073, 1074
base of dento-alveolar structures, 1073, 1074
corners of mouth, 1073
Mid palatal raphe, 1073
mid-sagittal reference (MSR), 1072
philtrum of the upper lip, 1072, 1073
symphysis of the mandible, 1073, 1074
dental midline or centre line, 1071
coincide with facial midlines, 1071
dental midline shifts, 1071
aetiology, 1076, 1079
class II division 2 malocclusion, 1078
cleft patient, 1077
common causes of, 1076
development of dentition, 1076
palatally placed lateral incisor, 1077
periodontal migration, 1079
premature functional contacts, 1078, 1079
severe crowding, 1077
management of, 1079
correction of midline with
simultaneous resolution of crowding, 1083
dental midline and transverse deficiency of, 1082, 1083
looped arch wire mechanics for, 1080, 1081
simple cantilever mechanics
for tipped incisors, 1080
for translation of incisors, 1080
evaluation, 1071
on opening of mandible, 1071
teeth in occlusion, 1071
maxillary dental arch midline, 1071
prevalence of, 1073–1075
Dental scanners, evolution of, 357
Dentistry, 4
before Christ, 4
middle ages, 4
landmark events, 7
as a science, 4
in 21st Century, 8
3D technology and CAD CAM, 8
in 19th Century, 5
bonding in, 6
branemark era, 6
high-speed, 6
in 20th Century, 6
MDCT and CBCT, 6
regenerative dentistry, 6
restorative materials, 6
Dentition examination, 191
Dentoalveolar distraction (DAD), 967
Dentoalveolar structures, 233
Dentofacial deformities, 3
Dentofacial orthopaedics, 3, 754
3D facial imaging systems, 351
3D medical imaging system, 351, 352, See also 4D imaging
Diaphysis, 121
Dichotomy of maxillary lateral incisors, 192
DICOM standard, See Digital Imaging and Communications in
Medicine (DICOM) standard
Digital CAD/CAM technology, 475
Digital cameras, 223
Digital cephalometry, 311, 334, 342
Digital images, 340
acquisition of, 340
direct digital image, 340
direct digitisation, 340
AutoCEPH©, 342
indirect digitisation, 341
calibration
and magnification correction of, 334
analogue films scanned, 334
using DPI in digital cephalogram, 335
using the metal scale, 335
image calibration metal scale, 336
Digital Imaging and Communications in Medicine (DICOM) standard,
341
Digital over conventional cephalometry, 340
advantages, 340
Digital photography, 221
Digital radiography, 342
advantages of, 340
Digital radiology image, 340
Digital single lens reflector (DSLR) camera, 219
Digital workflow, 349
contemporary digital office equipments and procedures, 349
comprehensible digital orthodontics, 350
contemporary clinical orthodontics, 350
terminology used in, 3D imaging, 351
treatment planning, and execution, 349
4D imaging, 352
Direct bonding technique, 489
amalgam and Co-Cr/Ni-Cr alloys, 494
armamentarium required for, 489
on enamel variant surfaces, 493
bonding on teeth with fluorosis, 493
impacted teeth, 493
nonvital teeth, 493
porcelain surfaces, 494
steps in procedure, 490–493
adhesive application and bracket positioning, 493
application of primer/coupling agents, 493
cleaning, 490
curing of adhesive, 493
drying the etched enamel, 492
enamel conditioning, 491
isolation of teeth for bonding, 490
removal of excess bonding material, 493
review of bonded attachments and wire ligation, 493
rinsing, 492
on unconventional tooth surfaces, 494
Direct digital radiography (ddR), 340, 342, 344
charged coupled device, 344
complementary metal oxide semiconductor (CMOS), 344
Disc operating systems (DOS), 339
Distalisation rate, 733
Distal jet appliance, 713
Distraction osteogenesis (DO), 1047, 1050, 1159
classification of distractors, based on, 1051
design and location, 1051
external distractors, 1051
mandibular external distractor, 1051
rigid external distractor (RED), 1051, 1052
internal distractors, 1051, 1053
alveolar distractor, 1051
customised tooth-borne distractor, 1051
mandibular intraoral distractor, 1051, 1054
modular internal distractors (MID), 1051
site and use, 1051
alveolar ridge distractor, 1051
bone transport, 1051
craniofacial, 1051
mandibular, 1051
midface/maxillary, 1051
periodontal distractor, 1051
vector, 1053
uniplanar and multiplanar devices, 1053
definition and biological basis, 1047
distraction histiogenesis, 1049
disadvantages, 1051
indications, 1050
bilateral TMJ ankylosis, and OSA, 1050
mandibular transverse, 1061
factors affecting distraction, 1061, 1062
mid-symphyseal distraction osteogenesis (MSDO), 1061, 1062
maxillary transverse, 1060
rapid maxillary expansion (RME), 1060, 1061
surgically assisted rapid maxillary expansion (SARME),
indication for, 1060, 1061
maxillo-mandibular, 1049, 1060
future of, 1061
historical perspective and philosophy of, 1049
development of intraoral distractor, 1049
development of rigid external distractor (RED), 1050
molecular mechanism, 1049
orthodontic considerations, 1054
management during distraction, and consolidation, 1056, 1058
post-distraction, 1058
pre-distraction, 1058
mandibular lengthening, 1055
vector planning, 1059
retention after maxillary distraction, 1058
cleft maxilla, 1056
treatment planning, 1054
treatment protocol, 1058
orthognathic surgery, advantages over, 1051
schematic representation of sequential phase, 1048
sequential periods, 1047
consolidation, 1048
distraction, 1048
latency, 1047
osteotomy, 1047
remodelling, 1048
surgical considerations, 1053
3D non-radiation imaging of face (3D-MD), 24
DO, See Distraction osteogenesis (DO)
Doctor of Dental Surgery (DDS) degree, 5
Donatello aligners, 431
indications, 431
limitations, 431
steps and treatment stages, 431
Downs’ analysis, 249
Adams and Vorhies polygon, 251
based on Caucasian subjects of age range, 249
basis of, 249
cephalometric norms, 251
denture pattern, 250–251
graphic presentation, 251
population groups, 252
skeletal pattern, 250
reference planes, and variables, 250
Downs, William, 249
Down syndrome, 36, 172, 173
3D printing, 24, 432
in dentistry, 8
3D skeletal imaging, 352
computed tomography (CT)
image reconstruction
3D rectangular voxels, 353
3D square isotropic voxels, 353
reconstruction matrix, 352, 353
movements of gantry, scanning image
rotation, 352
translation, 352
properties of, 353
vs. cone-beam computed tomography (CBCT), 354
2D to, 3D cephalometrics, 234
3D triad in orthodontics, 354
integration of CBCT data of face, 355
Dual flex archwires, 469
types, 469
Dual Flex-1, 469
Dual Flex-2, 470
Dual Flex-3, 470
Dumbbell elastic separator, 551
3D volumetric imaging, 387, See also 3D facial imaging systems
CBCT derived cephalogram
vs. conventional, 2D cephalogram, 388
2D cephalogram from, 3D data, 388
projection methods, 388
orthogonal, 388, 389
perspective projection, 390
type of, 388
hemifacial projection, 388, 389
maximum intensity projection (MIP), 388
ray-sum, 388
2D X-rays, 6
E
E-arch, 442–444
appliances, 687
Begg bracket and round tubes, 444
first edgewise appliance, 443
Lewis brackets, 445
pin and tube appliance, 442
Ribbon arch appliance, 443
standard edgewise weldable brackets, 445
EBT, See Elastic button technique (EBT)
ECM, See Extracellular matrix (ECM)
Elastic bands, 477
Elastic button technique (EBT), 430
Elastic chains (power chains), 481
environmental effects, 482
force degradation, 482
force delivery, 482
length of filament, 482
pre-stretching effects, 482
uses of, 482
Elastic limit, 461
Elastic material, 477
Elastic modules, 482
advantages, 482
disadvantages, 483
Elastic ring separators, 551
Elastic separators, 483
Elastic thread, 483
Elastomeric accessories, 481
Elastomeric separators, 551, 553
Electrocautery, 163
Electrothermal debracketing (ETD) technique, 1209
porcelain brackets, for, 1210
risks of, 1209
Elgiloy wires, 466
E models, 357, 360
advantages of, 358
3D surgical planning, and splint generation, 366
evaluation of treatment changes, 366
3D superimposition of digital models, 367
quantitative measurements, 362
cross-section measurements, 364
tooth width and arch length measurements, 363
virtual set-up, 364, 365
aligner fabrication, 365
steps in, 365
visual analysis of occlusion
and analysis of occlusal contact area, 363, 364
visual analysis of the occlusion, and analysis of occlusal contact
area
occlusal inspection, 364
coordinate system, 361
disadvantages of, 358
evolution of dental scanners, 357
orientation, 361
ABO method, 362
anterior orientation of maxillary model, 362
levelling the maxillary occlusal plane, 362
overview, 357
technologies to produce, 357
3D CT-based, 357
impression/model scanners, 357, 359
intraoral scanners, 359
commercially available systems, 358
virtual study models
tooth width and arch length measurements, 363
using Maestro three-dimensional (3D) scanner, 358
Enamel etching, 486
acid concentration and duration, 486
acid etching, alternatives to, 487
air abrasion, 487
crystal growth, 487
lasers, 487
crystal bonding technique
advantages of, 487
microscopic patterns, 487
SEM classification, 486
Enlarged tonsils, 161
Epigenetic
antithesis, 130
factors, 130
Epiphysis, 121
growth, 120
Epworth sleepiness scale, 1171
Erbium YAG laser, 6, 1210
polycrystalline ceramic brackets, 1210
Erupted mesiodens, 192
Eruption failure, 192
Essix appliance, 425, 426
ETD technique, See Electrothermal debracketing (ETD) technique
Ethnic stock, 67
Ethnic variations, 67
European board of orthodontics, 1201
Expansion of arch, 412
removable expansion appliance, 412
Exposure modes, 225
External apical RR with orthodontics, 516
Extracellular matrix (ECM), 505
Extraction decision, factors influencing, 688
important considerations, 688
F
FA, See Functional appliances (FA)
Facebows, 743, See also Kloehn facebow
Hamill safety facebow, 751
Nitom locking facebow, 751
Face examination, 176, 178
examination of face in profile, 177
bimaxillary protrusion, 179
concave profile, 179
convex profile, 178, 179
orthognathic profile, 179
straight profile, 179
facial profile, classification, 179
facial symmetry, 178
features of normal growth, 171
potential malocclusion, 171
overall shape of face
cephalic index, 176, 177
head classification, 178
facial index, 177
face classification, 179
Face in lateral profile, 180
examination of
nostrils, 181
size and shape, 181
zygoma or cheekbones, 181
Gonial angle, 180
nasolabial angle, 182
transverse facial proportions, 181
vertical dimensions, evaluation in, 180
vertical facial proportions in front profile, 181
Facial asymmetry, 173, 174, 1067
complex morphological disorder, 1067, 1069
aeronautical rotational descriptors, 1067
pitch, 1068
roll, 1069
yaw, 1069
computerised images of relatively symmetric face, 1068
congenital malformations, 1069
decrease of NSP genes, 1067
dentofacial asymmetries, prevalence of, 1069
developmental disorders, 1069
embryonically or genetically determined, 1067
cleft lip, 1067
face and its structures, evaluation in three planes of space
sagittal, vertical and transverse, 1068
functional and morphological, 1067
of occlusion, 1069
right-left differences, 1067
skeletal malocclusion, 1067, 1069
slight, 1067
systematic review, 1067
types of, 1069
affecting maxillomandibular region, 1069
cant of occlusal plane, 1069
midline deviations, 1069
occlusion, 1069
Facial deformities, 35
Facial dysplasia, 272
Facial photographs, 206
evaluation, 207
analysis of face heights, 207
frontal analysis, 207
central fifth of the face, 209
cephalometric, 209
medial fifth of the face, 209
outer fifths of the face, 209
profile, 209
lip-chin-throat angle, 209
neck-chin-angle, 209
skeletal pattern and profile, 209
high angle/low angle pattern, 210
typical pattern of class II division, 210
transverse relationships, 209
worms eye view, 209
extraoral, 206
intraoral, 207, 208
Facial photography, 229
frontal view, 229
oblique/three-quarter view, 229
profile view, 229
smile, 229
Facial symmetry, 1067, See also Facial asymmetry
computerised images, 1068
Facial triangle, 253
and clinical implications, 253–254
Frankfort mandibular incisor angle (FMIA), 253, 254
Frankfort mandibular plane angle (FMA), 253
norm for, 254
relationship with IMPA, 254
head plate correction, 254
incisor-mandibular plane angle (IMPA), 253, 254
prediction of, 255
Tweed’s analysis, 253
interpretations and comments, 255
planes and angles used in, 254
Tweed’s cephalometric norms, 255
Tweed’s norm for Indians and Asians, 254
Facial types, 1224
Familial gingival fibromatosis, 192
Fauchard, Pierre, 4, 5, 9, 441
FCA, See First class appliance (FCA)
Ferritic stainless steels, 463
FFA, See Fixed functional appliance (FFA)
FFFA, See Flexible fixed functional appliance (FFFA)
FH plane, See Frankfort horizontal (FH) plane
Fibre-reinforced composite (FRC), 409
Fibre resin composite (FRC) threads, 1228
Fibrosed gingivae, 192
Field of view, 373, 375
File formats, 223
Final cleanup, and polishing, 1210
adhesive removal and polishing
armamentarium, rationale and usage, 1211
tungsten carbide bur (TCB), 1211
Dr Bowmen, recommendation, 1211
steps in, 1211
precautions to be observed, 1211
Finishing occlusion, 1224
First class appliance (FCA), 726
treatment outcome, 726
Fixed appliance, contemporary, finishing and detailing, See also Fixed
functional appliance (FFA)
American board of orthodontics (ABO), 1195
guidelines, 1195
class I type 1 malocclusion, 1199
measuring gauge, 1198
objective grading system, 1195
assessment criteria, 1195
buccolingual inclinations, 1201
inter-proximal contacts, 1201
marginal ridges, 1201
occlusal contacts, 1201
occlusal relationship, 1201
overjet, 1201
root angulation, 1201
tooth alignment, 1195
European board of orthodontics, 1201
finishing and detailing of occlusion, steps in attaining goals, 1190
finishing wires, 1190
loss of torque during space closure and retraction of anterior
teeth, 1193
standard edgewise system, 1193
artistic bends, marking for, 1194
incorporation of torque, 1195
wagon wheel effect, 1193
orthodontic treatment, goals, 1190
good periodontal health, 1190
healthy TMJ in harmony with occlusion, 1190
normal functional movements, 1190
normal occlusion in centric relation, 1190
optimum facial and dental aesthetics, 1190
pre-finish assessment, 1190
clinical examination of face, 1190, 1191
lateral cephalogram, 1190, 1191
orthopantomogram, 1190, 1191
study models and wax bite, 1190
settling occlusion, 1193
laced vertical elastics, usage, 1194
settling bands, 1195
light round wires, usage, 1193
passive utility arch, 1194
specially fabricated tooth positioner, usage, 1194
tooth-size discrepancies, 1194
class III subdivision buccal segment, 1198
class II molar relationship on left side and class III on right,
arrangement of elastics for correction, 1198
common errors seen at final space closure, 1196
mild midline and molar relation, correction with elastics, 1198
oblique for midline discrepancy, primarily in anterior segment,
1198
unilateral class II elastics, 1197
Fixed functional appliance (FFA), 810, 853
advantages over other functional appliance, 810
classification, 810
effects of, 820, 823
implant supported, 823
modification, 810
protocol for records and treatment follow up with, 825
Fixed lingual retainer, 1228
advantages, 1229
disadvantages, 1230
failures, 498
new facts, 1234
using DuraLay resin transfer, 498
Fixed orthodontic appliance, components of, 449
active, 449
closed coil springs, 456
coil springs, 455
nickel-titanium (NiTi) open coil springs, 456
open coil springs, 455
orthodontic wires, 455
rubber elastics, elastomeric chains, 457
appliance and treatment customisation, 457
futuristic appliance design, 457
passive, 449
aesthetic brackets, 453
bracket, 449–450
based on their composition, classification of, 450
base of bondable brackets, 450
body and slot, 450
body-base interface, 450
customisation, 457
identification, 451
buccal tubes, 451, 452
ceramic brackets, 454
advantages/disadvantages, 454
with metal slot, 454
intraoral orthodontic accessories, 454
limitations of current bracket
and appliance systems, 457–457
lingual orthodontic appliances, 453
orthodontic bands, 454, 455
polycarbonate plastic brackets, 453
power arm, 451
pre-adjusted brackets, 451
design features, 452
self-ligating brackets, 453
advantages, 453
disadvantages, 453
twin brackets/Siamese brackets, 451
wings, 451
Flash light, 225
Flash synchronization, 225
Flexibility, 461
Flexible fixed functional appliance (FFFA), 815
adjustable bite corrector, 815
Jasper Jumper, 815
Klapper Super spring, 815, 816
Flexible multi strand wire (FSW), 1228, 1230
Floating norms, 305
combination of cephalometric variable, craniofacial pattern, 305
ANB angle, 305
correlation between sagittal and vertical parameters, 305
craniofacial pattern, cephalometric correlation for assessment, 306
floating norms step by step method, 306
using hypothetical norms, 307
harmony box, 306
Segner-Hasund harmony schema, 306
statistical correlation and linear regression with, 306
Fluoride-containing products, 472
Fluoride ions, 472
Force, 519
Foundation for orthodontic research (FOR), 263
Frankel appliance, 760
bite construction, 760
clinical protocol on use of, 764
construction of, 764
impression taking for, 764
maxillary wire fabrication and acrylisation of buccal shields, 764
trimming, finishing and evaluation of appliance, 764
Wax relief for arch expansion, 764
wire fabrication for labial and lingual pads, 764
working models and mounting, preparation of, 764
Frankel’s philosophy, 760
FR-III appliance, 764
FR II appliance, 763
case selection and indications, 760
construction of, 764
retention after, 764
step-by-step advancement, 764
Frankfort horizontal (FH) plane, 271
FRC, See Fibre-reinforced composite (FRC)
f-Stop, 224
Functional appliances (FA), 753, 827, See also Fixed functional
appliance (FFA)
classification of, 757
condyle adaptation based on, 833, 834
biodynamic factors involved in CGF growth modification, 835
illustration of a 3/4 anterior lateral perspective, 834
light bulb analogues of condylar growth and, 835
condyle glenoid fossa complex (CGF)
clinical evidence of CGF remodelling, 831
internal and external rearrangements of CGF consequent to,
833
remodelling and neuromuscular adaptations, 829
studies on animals, 829–830
dentofacial changes of, 828
dentofacial skeleton, effects on, 827, 828
effect of therapy on CGF complex, 828
effects on oral volume and respiratory passages, 829
mandible growth, 835
randomised clinical trials of class II treatment, 828
molecular and genetic control on CGF remodelling, 834–835
expression of IGF-1, FGF-2, 834
Ihh expressions, 835
neovascularisation, 834
PTHrP expression, 835
Sox9 expression, 835
type X collagen, 835
muscles of mastication
in treatment of class II malocclusion, 831
effects of twin block FA therapy on masseter muscle, 832
EMG adaptations with twin block appliance, 832
role of lateral pterygoid, 830
skeletal and dental changes with therapy, 828
work on premises, 827
Functional forces, 753
Functional jaw orthopaedics, 753
Functional matrix, 128
and molecular basis, 128
Functional occlusion, 659
essential features to achieve, 660
Functional orthopaedic magnetic appliance (FOMA), 757
G
Gap junctions, 129
Gardner syndrome, 987
Gastrointestinal disturbances, 164
Gene-environment interaction, 67
General body growth, 133
Genomic thesis, for growth and development, 129
Glenoid fossa, 688
Goldenhar syndrome, 36
Gross line ligature, 483
Growth, 113 See also specific entries
in adolescence and puberty, 135
body tissues, 135
craniofacial complex, 136
neurocranium, 136
viscerocranium, 137
cranium from birth to adulthood, 137
cranial base, 138, 139
cranial vault, 137
sphenooccipital synchondrosis, 139
curve for nose depth derived from, 149
hormone, 135
mandible, 141–143
modulations, 1224
nasomaxillary complex, 139
composite growth and direction of displacement of maxilla, 139
cranial base contribution, 139
growth at sutures, 139
role of the nasal septum, 140
surface remodelling and growth at alveolar process, 140
physical, 114
postnatal, 133
rotations, 143
backward, 145
effect of mandibular rotation on occlusion, 146
forward, 143
matrix versus intra-matrix, 145
sinuses, 140
skeletal, See Skeletal growth
soft tissue
integument of face, 146
of midface, 147–148
timing of, 134
trends and patterns, 143–143
Growth assessment, 212
cervical vertebrae maturation index (CVMI), 213
chronological age, 212
dental age, 213
facial growth spurts, 213
height for age, 113
height for weight, 113
methods of, 116
graphical data, general interpretations of, 117
height, graphical representation of, 117
mid-arm circumference, 113
peak growth velocity, 212
skeletal maturation, 212
weight for age, 113
Growth spurts
before and after birth, 135
pre-pubertal spurt, 135
stages, 136
Growth theories, 123
Brash’s remodelling theory (1930s), 123
discontinuities in occlusal relationships
and regulation of facial growth, 127
Enlow-Hunter growth equivalent theory, 126
functional matrix theory, 125
functional matrices, types of, 125–126
Petrovic’s servosystem theory (1970s), 127
Scott’s theory of cartilaginous growth dominance, 124
Servosystem theory, 128
Sicher’s theory of sutural growth dominance, 124
Growth treatment response vector (GTRV), 890
Growth velocity, 136
and face, 119
Gurin lock, 456
H
Hartley, Edward, 11
Hawley appliance, 408, 409
components, 409
active, 411
canine retraction spring, 412
labial or buccal tipping, 411
mesial/distal tipping of tooth, 411
palatal tipping, 411
springs, for for mesial/distal tipping, 412
Z cantilever spring, 411
passive, 409
retentive, 409
Adams’ clasp or double arrowhead clasp, 409
ball end hooks, pin head, 409
C-clasp, 409
delta clasp, 410
labial bow, 410–411
south end clasp, 410
wire dimensions used for, 410
Hawley retainer, 1227
Hawley retention appliance, 1228
Headgear-activator teuscher appliance (HATA), 848
Health-related quality of life (HRQoL), 35
Heat treatment, 461
Co-Cr-Ni alloy wires, 466
Helium-neon laser, 342
Hemifacial microsomia, 36, 172
Herbst appliance, 810, 811, 812
appliance fabrication, 811
acrylisation, 813
fitting the appliance, 813
soldering, 813
wire framework
on mandibular arch, 813
on maxillary arch, 811
bite registration for, 811
bonded/cemented type splint Herbst appliance, 811
cephalometric skeletal and dental changes
treatment with, 813–814
clinical manipulation, 813
Herbst type I, 811
Herbst type II, 811
Herbst type IV, 811
for non-surgical treatment
during early and late adulthood, 814
Hevea brasiliensis, 477
High tensile wires, 464
Human life cycle, 114
Hybrid fixed functional appliances, 815
Eureka spring, 816
Forsus™ appliance, 817–820
Forsus fatigue resistant device
components, 817
installation and activation, 818
twin bite force corrector, 817
Hydrofluoric acid (HFA), 494
Hyperthyroidism, 164
Hypodontia/missing teeth, 104
Hypophosphatasia, 987
Hypothetical model, for orthodontic treatment, 25
Hysteresis, 461
I
Iatrogenic effects
orthodontic force application and mechanics, 515
orthodontic mechanics, 514
resulting from failures to, 514
Impulse-generated debonding procedure, 1210
Indian Board of Orthodontics, 29
Indirect bonding technique, 494
armamentarium required, 494
steps in, 495–497
clinical stage step I, 495
clinical stage step II, 497
laboratory stage, 495
Indirect scanners (impression/model scanners), 359
CT based scanner, 360
maestro, 3D dental studio viewer, creation of virtual base, 361
desktop scanners, 360
Inflammatory responses, 513–514
Interceptive orthodontics, 531
goals of, 531
Inter-disciplinary treatment, 971, 972, 978
communication, 978–979
conditions commonly treated, 972
fractured teeth, 977
aesthetics, 978
gingival sulcus depth, 978
root length, 978
root shape and form, 978
gingival discrepancies, 978
contour of labial gingival margins, 978
height of gingival margins, 978
open gingival embrasures, 978
periodontal bone loss, 978
periodontal regenerative therapy, 978
root angulation, 978
tooth shape, 978
papilla form and embrasure form, 978
malformed teeth, 974
local or single, 974–976
multiple, 974
missing teeth/space management, 972
extracted teeth, 974
tooth agenesis, 972
orthodontic space closure, 974
space maintenance and rehabilitation, 974
objectives, 971
avoid unnecessary procedures, 971
boost individual team members’ result, 971
decrease treatment time, 971
diagnostic set-up, 971
mutilated dentition, 972
enhance professional relationships, 971
idealise and streamline therapy, 971
improve prognosis, 971
increase satisfaction of both patient and doctor, 971
realistic treatment, 971
overview, 971
pre-restorative/pre-orthodontic periodontal status, 972
Interpolation, 223
Interproximal reduction (IPR), 457
Interproximal tooth reduction (IPR), 425
Intraoral clinical examination, 191
Intraoral images, 225, 227
accessories for, 228
intraoral mirrors, 229
frontal, 227
lateral, 228
right and left buccal, 228
lower occlusal, 228
occlusal views/mirror views, 228
upper occlusal, 228
Intraoral orthodontic accessories, 454
ball-end hooks, 454
cleats, 454
lingual buttons, 454
vertical tubes and palatal tubes, 454
Intraoral scanners/direct scanners, 359
commercially available systems, 358
iTeroElement scanner system, 359
flowchart, steps of taking complete scan, 360
scanner sleeve, 359
Wand, 359
Invisalign system, 426
appliance
anatomy of crown, 427
indications, 426
class II subdivision treated with, 429
clear aligners
steps and treatment stages with, 427
ClinCheck interactive treatment planning system by Invisalign,
428
clinical management with Invisalign aligners, 427
collection of high-quality records, 427
interactive treatment planning, 427
smart force innovation, 426
smart stage innovation, 426
story of evolution of, 427
IPR gauge set, 709
IPR kit and instruments, 708
J
Jarabak’s ratio of anterior and posterior facial heights, 273
facial growth
according to ratio of, 274
rotations, 275
types of face pattern, in vertical plane, 273
hyperdivergents, 273, 274
hypodivergents, 274
neutrals, 273, 274
vertical facial heights, analysis of, 276
Jaw orthopaedics, 753
Jones Jig, 712
Journal of Indian Orthodontic Society (JIOS), 29
JPEG format, 223
K
Kanomi, Ryuzo, 24
K clear aligner, 430
anterior open bite case before and after treatment, 431
crowding, deep bite and retroclination case before and after
treatment, 430
K clear system, 428
indications, 429
limitations, 429
steps and treatment stages
of clear aligners, 428
Keles molar distaliser, 713, 725
Kesling separators, 551
Kesling set-up, 425
Klinefelter’s syndrome, 173
Kloehn facebow, 743, 744
centre of resistance, 745
age of treatment, 745, 747
case treated with Kloehn headgear, 746
centre of resistance, 745
cephalograms, 745
force levels and wear schedule, 744
safety modules, 746
components, 743
facebow with stop loops, 743
effects of facebow, 746
events following an eye injury, 750
long-term effects, 746, 750
usage to correct maxillary protrusion, 746
force levels, 744
indication and uses, 743
Kloehn headgear components, 744
wear schedule, 744
Kloehn headgear components, 744
K-loop, 724
assembly, 723
molar distaliser, 722
placing activation, 726
reactivating, 726
L
Laser-assisted debracketing, 1210
photoablation, 1210
thermal ablation, 1210
thermal softening, 1210
Late mandibular growth, 1225
Latex polymer, 477
LED, See Light emitting diode (LED)
Leeway space, 532
Lefoulon, Joachim, 10
Lewis developed winged brackets, 645
Lift-off debonding instrument (LODI), 1207
Ligature wires, 455
Light emitting diode (LED), 499
Lingual arch to preserve arch length, in mandible, 689
Lingual-bonded retainers, 497
advantages, 497
basic designs, 497
Lingual retainer wire (LRW), 1234
Linguoalveolar sounds, 104
Lips, 182
biting, 164–165
chin button, 183
incompetent, 183
labiomental sulcus, 183
lower, 182, 183
trap and deep labiomental sulcus, 183
redundancy, 182
smile position lip level, 182
upper, 182
LODI, See Lift-off debonding instrument (LODI)
Longitudinal cephalometric superimpositions, 311
Longitudinal growth studies, 234
Bolton-Brush Growth study, 234, 235
Burlington Growth study, 234, 235
other growth studies, 235
Loops, 612
closed vertical loop, 612
double horizontal loop, 612
double vertical loop, 612, 615
force system characteristics, 614
horizontal loop, 612
omega loop, 612, 615
vertical loop, 612
Lumen dimensions, 478
M
Macro lenses, 221
MADs, See Mandibular advancement devices (MADs)
Magnification, 227
Malocclusion, 35, See also Class III malocclusion, See also Class II
malocclusion
adverse consequences, 37
dental trauma, increased susceptibility to, 40
functional appliance, help to reduce, 40
severe deep bite causing trauma, 39
loss of tooth substance and function, 40
poor aesthetics, 37
proneness to dental diseases, 41
dental caries, 41
occlusal trauma, 41
periodontal disease, 41
stomatognathic system, alteration in functions of, 37
abnormal respiration, 39
articulation and quality of speech, 39
masticatory performance, 37
obstructive sleep apnoea, 39
snoring, 39
American Board of Orthodontics (ABO), 95
discrepancy index scoring sheet, 96
grading system, 95
measuring gauge, 97
anterior functional shift/pseudo class III, 193
articulation of speech, 104
assessment criteria, to normal occlusion
and treatment outcome, 88–98
classification, 68
Ackerman and Proffit’s classification, 81
strengths and limitations, 82
British incisor system classification, 80
historical review, 68–69
inter-arch malocclusions, 70
sagittal plane malocclusions, 70
vertical plane malocclusions, 70
intra-arch malocclusions, 69
Katz’s premolar classification (1992), 80–81
advantages, 80
disadvantages, 80
primary dentition, 82
flush terminal plane relationship, 82
sagittal plane, 70
Simon’s classification and canine law, 78
basis of, 79
incisor classification, 79
limitations of, 79
systems of, 70
Angle’s classes of malocclusion, 74–76
Angle’s concept of malocclusion, 70–74
Dewey’s modification, 77
ideal facial beauty, 74
Lischer’s modification, 76
modifications for class III malocclusion, 77
modifications of class I malocclusion, 77
skeletal classification, 78
Strang’s classification, 77
vertical plane malocclusions, 70
class I molar and canine relation, 67
cleft lip and palate, 104
in deciduous dentition, features of, 173
edge to edge incisor relation/negative overjet, 174
incisor liability, 175
Lee way space, 175
posterior cross-bite, 174
primate spaces, 173
dental aesthetic index (DAI), 87
limitations, 88
diagnostic classification index, 86
occlusal index (OI), 86
treatment need indices, 87
discrepancy index (DI), 95
epidemiological data
Angle’s classification and limitations, 51
qualitative methods, 52
Federation Dentaire Internationale (FDI), 52
World Health Organisation (WHO), 52
anteroposterior molar relationships, 53
buccal and lingual posterior cross-bite, 53
functional factors, 104
index for treatment standards (PAR) ruler, 91
index of complexity, outcome and need (ICON), 93
complexity grade and score range, 94
cut-off values, 94
improvement grade and score range, 95
protocol for occlusal trait scoring, 94
scoring protocols, 93
strengths of, 95
treatment need, 94–95
to assess treatment complexity, 94
to assess treatment outcome acceptability, 95
DHC ruler, 89
index of orthodontic treatment needs (IOTN), 88
aesthetic component, 88
dental health component, 88, 89
limitations, 88, 93
scoring protocols, 93
intra-arch dental alignment, 67
motivational factors in adults, 103
orthodontic therapy, limits of, 46
dentofacial orthopaedic treatment, 47
distraction osteogenesis, 49
anterior segment retraction, 48
orthodontic, orthopaedic and surgical movements, 46
orthodontics supported with implants
and skeletal anchorage system, 46
orthodontic treatment, 46
limits of tooth/jaw movement in the mandible, 48
limits of treatment in the maxilla, 47
orthodontic treatment, benefits of, 41, 45
critical appraisal, 45
improved aesthetics/enhanced self-image, 41, 44
oral functions, improved, 43
oral health benefits, 45
reduction in trauma to maxillary anterior teeth, 42
temporomandibular joint, health of, 45
orthodontic treatment needs, 61
in America, Brazil and Australia, 62
in Asia and Middle other countries, 63
Indian Children, 60, 64
Delhi, 61
in Scandinavia and Europe, 62
orthognathic surgery patients, 103
overjet, labial/buccal overlap, 68
peer assessment rating (PAR) index, 88
components, 89
index for treatment standards (PAR) ruler, 91
limitations, 93
normogram, 93
rules and conventions for recording, 92
personality traits affecting cooperation, 102
prevalence
ethnic trends in, 54
Africa, 57
America, 54, 55
Canada, 54, 55
China, 58
Columbian population, 55
European countries, 56
India, 60
Iran, 58
Mongoloid races, 58
Scandinavian population groups, 56
South America, 54
tribal population, 61
need for recording, 51
reasons for large variations, 53
psychological factors motivating patient, 100
gender, 101
parental perception, 101
patient’s personality traits, 102
peer pressure, 101
self-esteem, 101
self-perception, 100
severity of malocclusion, 100
social class, availability and affordability, 102
psychological implications, 99
adverse occupational outcomes, 100
low self-esteem and maladjustment, 99
quality of life and psychological stress, 100
restriction of social activities, 100
quantification of, 61
recognition of, 67
recording of, 85
handicapping malocclusion assessment, 87
qualitative methods, 85
quantitative methods, 86
signs before eruption of permanent incisors, 175
traumatic occlusion, 104
Malocclusion situations, complex
post-orthodontic occlusion, extraction treatment, 1201
mandibular first premolars
therapeutic class III, 1203
maxillary canine substitution for lateral incisor, 1202
maxillary first premolar
and mandibular second premolars, 1202
therapeutic class II occlusion, 1203
buccal, 1203
missing maxillary laterals, class I occlusion with, 1202
missing one lower incisor/treatment with, 1202
premolar extraction cases, 1201
class I, type I, class I bimaxillary protrusion and class II
division, 1, 1201
Mandible, 696
lingual arch to preserve arch length in, 689
Mandibular advancement devices (MADs), 1176–1178, 1181
Mandibular and maxillary wrap around retainer, 1229
Mandibular anterior repositioning appliance (MARA), 814
Mandibular dentition, 810
Mandibular hypoplasia, 114
Mandibular protraction appliance (MPA), 814, 815, 870
dental changes with, 814
short-term cephalometric skeletal, 814
Mandibular retrusion
implant supported FFA, 810
with non-compliant fixed functional appliances, 809
historical perspectives, 809
overview, 809
Martensitic stainless steels, 463
Mastication, 151
adult, 152
chewing stroke, 152
Material stiffness numbers (Ms), 470
Maxillary
anterior teeth, 696
arch expansion, 694
expansion and left molar derotation
with nickel-titanium maxillary expander, 701
expansion appliances, 702
frenectomy, 1233
posterior teeth, 696
skeletal effect, 695
Maximum intensity projection (MIP), 388
MBT appliance design, 661
changes introduced to SWA, 661
modified tip in maxillary and mandibular anterior segments, 661
modified torque
in mandibular posterior segment, 663
in maxillary and mandibular incisors, 662
in maxillary posterior segment, 663
torque options in maxillary and mandibular canine brackets, 663
MBT biomechanics, 663–665
anchorage control during stages of levelling and alignment, 665
canine lace back, 664
closing loop arches with standard edgewise appliance, 665
effect of initial archwires, 663
effects of cuspid bracket tip with cuspids in, 664
modification with elastic module, 666
overjet case, inadequate incisor torque, 666
second molar pick up in arch enhances bite opening effect, 665
space closure with light forces, 666
MDSA, See Medical dental snoring device (MDSA)
Mechanical forces, neural responses to, 513
Mechanotransduction, 128, 514
pathways, 129
electrical processes, 129
ionic and mechanical process, 128
Medical dental snoring device (MDSA), 1178
Memotain, 1234
Menarche, 136
Merchant, Dr. H. D, 29, 31
Metal-based separators, 551
Metal corrosion, 471
Metal orthodontic wires, 460
properties, 460
Metals used in orthodontics, 461
Metaphysis, 121
Micrognathia, 171
MID, See Modular internal distractors (MID)
Mid-sagittal reference (MSR), 1072
Mini growth spurts, 136
differentiation stage, 136
expansion stage, 136
Mini implant screw supported molar distalisation system (MISDS),
728
Miniscrew implants (MSIs), 936, 1104, 1105
biomechanical considerations, 943–954
classification, 937
design and parts, 937–939
direct vs. indirect loading, 942
loading of implant, 942
materials used for implants, 937
miniscrew placement protocol, 940–942
miniscrew removal, 942, 944
risks and complications, 953–956
safe zones for, 939
Mini screw supported distalisation system (MISDS), 727
MIP, See Maximum intensity projection (MIP)
MIS supported maxillary expansion appliance, 704
MIS-supported molar distalisation, 728–731
Mode of respiration, clinical assessment, 162
Modified Nance button, 569
Modular internal distractors (MID), 1051
Modulus of elasticity, 461
Molar bands, 552
Molar distalsiation, 711
maxillary molar distalisation, 732
modified sectional jig assembly, 720
noncompliance distalisation appliances, 732
Moments, 520
bodily movement, 522
clockwise (Cw) or counterclockwise (Ccw) direction, 520
to force ratio, 521
magnitude of, 520
root movement, 522
types of, 521
controlled tipping, 521
uncontrolled tipping, 521, 522
Mongolism, 104
Monitor resolution, 222
Monoblock, 755
Morphometrics, 307
cephalometric variables, 308
ANB angle, 308
GoGnSN angle, 308
Wits appraisal, 308
principle component analysis (PCA), 308
procustes analysis, 307
vs. conventional method, 307
procustes superimposition using, 308
Mouth breathing habit, 159–162
cephalometric analysis, 162
clinical features, 162
adenoid facies, 162
ENT perspective, 163
mode of respiration, clinical assessment of, 162
orthodontic implications, 163
pathophysiology following reduced nasal breathing, 161
rhinomanometric examination, 163
stretch theory, 162
MS, See Mutans streptococci (MS)
MSIs, See Miniscrew implants (MSIs)
MSR, See Mid-sagittal reference (MSR)
Multi-detector CT (MDCT) imaging
applications, 374
3D reconstruction, Pierre Robin syndrome patient, 377
PA cephalogram, 377
panoramic, and maximum intensity projection (MIP), 377
submentovertex view, 377
Multiflex wires, 466
diameters of, 466
Multiple loop archwires, 610–611
Multistrand wires, 465
Mushroom-shaped lingual arch forms, 474
cuspid to bicuspid offset, 474
lateral offset, 474
molar offset, 474
Mutans streptococci (MS), 415
N
Nail biting (NB), 164
aetiology, 164
complications, 164
management, 164
non-pharmacological, 164
pharmacological, 164
Nance palatal arch, 569
Nanda, Ram S, 23
Nanocoatings, 1216
Nanotechnology, in control of biofilms, 1216
Nasal cavity, 696
Nasal septal deviation (NSD), 696
National Electrical Manufacturers Association (NEMA), 341
Natural rubber, 477
NEMA, See National Electrical Manufacturers Association (NEMA)
Neovascularisation, 513
Neural responses, to mechanical forces, 513
Neurocranium, 136
Neuronal mass, 134
Newborn child’s face, 171
Nickel-free stainless steel, 469
Nickel-titanium wires, 467
austenitic active alloys, 467
limitations, 468
martensitic active alloys, 467
martensitic stabilised alloys, 467
useful properties of, 467
hysteresis, 468
NiTi-deflection curve, 467
superelasticity, 467
Nitinol wires, 467
Nitrogen ion implantation, 469
Non-extraction treatment, 687, 688, See also Serial extraction protocol
cases, 688
clinical and histological basis of maxillary expansion, 691
CBCT classification of mid-palate growth, 691
diagnosis of maxillary transverse deficiency and case selection, 689
expansion appliances, types of, 692
expansion of narrow maxilla, and arch development, 689
factors influencing extraction decision, 688
interproximal reduction, 688, 704
Bolton’s ratio, 706
caries susceptibility, 705
enamel thickness, 705
periodontal health, 705
indications, 705
overview, 704
peck and peck ratio, 706
precautions and complications, 706
prevention of relapse, 706
steps in, 706
with maxillary expansion, 688
with non-compliance molar distalisation, 711
clinical efficacy and anchorage loss, 733
historical review, 711–714
indications of intraoral molar distalisation, 714–715
molar distalisation biomechanics, 728–732
palatal acting appliance, 715–727
skeletal anchorage, 727–728
timings of molar distalisation, 732
methods to gain space to resolve limited crowding and protrusion,
688
mild crowding and transposition of left maxillary canine-premolar,
699
mini-implant attached rapid palatal expansion, 704
NiTi expander, 698
parallel expansion screw, 696
posteroanterior cephalogram, 691
preservation of leeway or ‘E’ space for resolution of crowding in
lower arch, 688
rapid maxillary expansion (RME), 693
adverse effects of, 696
contraindications for, 693
design of, 693–695
forces involved in, 696
indications for, 693
manipulation of, 695
structural and functional effects of, 695
maxillary skeletal effect, 695
nasal cavity, 696
rapid vs. slow expansion, 698, 704
retention and relapse, 698
retention schedule, 704
slow maxillary expansion, 696
study models, 690
evaluation of dental inclinations, arch widths and symmetry, 690
techniques of IPR, 707
air-rotor for reduction of interproximal enamel, 707
chemical mechanical method, 709
commercially available enamel reduction accessories, 707
diamond strips, 707
IPR gauge set, 709
IPR kit and instruments, 708
reduction of the interproximal enamel of buccal teeth for, 708
wire framework expander appliances, 697
quad helix/tri-helix appliance, 697
Non-nutritive sucking habits, 155
Non-orthodontic normal models, measurements of, 647
Non-radiation, 3D face scanning, 350
laser scanning, 351
stereophotogrammetry, 351
advantages, 351
3D photograph of face, 352
Non-radiation imaging techniques, 381–384
magnetic resonance imaging, 383
applications in orthodontics, 384
MMR views, 385
sagittal MRI, 384
T1-weighted axial section of head, 384
larmour frequency, 383
proton, tiny bar magnet, 383
single proton, external magnetic field in, 383
ultrasonography, 381
masseter muscle, thickness and AP diameter measurement, 383
Normal occlusion, See also Malocclusion
crown inclination, 652
crown tip or crown angulation, 650
flat to a slightly curved curve of Spee, 653
and goals of orthodontic treatment, 649–654
location of bracket area on the tooth surface, 654
mandibular arch measurements, 656
maxillary arch measurements, 655
molar relationship, 650
rotated molar, 653
Norman Kingsley, 1879 Bite plate, 754
NSD, See Nasal septal deviation (NSD)
NSP genes, 1067
O
OASIS, See Oral Aesthetic Subjective Impact Scale (OASIS)
Obstructive sleep apnoea (OSA), 1170, 1171
OC, See Occlusal cant (OC)
Occlusal cant (OC), 1097, 1098, 1101, 1105
aetiology, 1097
asymmetrical growth of the mandible, 1097
unilateral ankylosis of mandible, 1099
unilateral condylar hyperplasia of left side, 1099
faulty biomechanics, 1098
clinical presentation and diagnosis, 1098
evaluation, 1098
unilateral cleft lip and palate, operated case of, 1100
frontal photographs, 1100
TMJ, radiological evaluation, 1100
unilateral cleft lip and palate, 1100
posteroanterior cephalogram, 1101
introduction and definition, 1097
asymmetrical show of teeth during smile, 1098
management, 1097
biomechanics for canted occlusal plane in maxilla, 1104
appliance design for intrusion of buccal segment, 1104
case study, 1, 1097, 1106
case study, 2, 1106
growing patients with mild cant, 1102
correction of altered occlusal plane, 1102
mandibular arch, 1104
MSI-supported molar intrusion/extrusion, 1104, 1105
selective intrusion/extrusion of anterior segment, 1102
ligation of affected teeth, 1103
supported by
SAS, case study, 1097
Y plate skeletal anchorage system, 1110
TAD, 1097, 1103, 1104
prevalence, 1097
MDCT/CBCT, 1102
volumetric image, 1102
measurement in maxilla, 1101
true horizontal represented by a tangent to normal supraorbital
rims, 1100
vertical line is drawn through the crista galli and upper third of
nasal septum representing mid sagittal reference plane,
1101
Occlusal index (OI) scores, 408
Occlusal plane canting, 1097, See also Occlusal cant (OC)
Occlusion examination, 191
Oestrogen, 135
Off centre V-bend, 524, 525
intrusion arch, 526
molar uprighting spring, 525
OFOT, See Osteotomy facilitated orthodontic treatment (OFOT)
Oppenheim, Albin, 17, 19
Optiflex wires, 470
Oral Aesthetic Subjective Impact Scale (OASIS), 64
Oral breathing, 160
effect on developing face and occlusion, 160
Oral environment, 471
effects on orthodontic archwires and brackets, 471
metal corrosion, 471
Oral health, and periodontium
examination of, 190
Oral health-related quality of life (OHRQoL) scores, 35
Oral respiration, 160
Orofacial function, 151
Orofacial habits
deleterious, 154
prevalence of, 154, 155
relative distribution, 155
Orthodontic appliances See also other specific appliances
analysis of common force systems produced by, 523
application of principles and properties, 529
K-SIR archwire, 529, 530
off centre V-bend, 529
1-couple appliance, 525
efficient, to design, 519
equal and opposite forces, 523
ideal appliance, characteristics of, 529
patient treated with K-loop molar distalising appliance, 524
Orthodontic bands, 454, 455
Orthodontic bonding adhesives, 489
clinical performance, 489
handling properties, 489
Orthodontic diagnosis, 170
Orthodontic elastics
classification of, 478
extraoral elastics, 480
size and force values, 481
force decay, 481
heavy elastics, 480
instructions on wearing of, 480
intraoral elastics, 479
natural latex elastics, complications of use, 481
allergy to latex, 481
cytotoxicity, 481
missing rubber bands and bone loss, 481
safety modules, 480
size of elastics, 478
storage and dispensing of, 480
Orthodontic force, 459, 505, See also Functional forces, See also
Mechanical force
optimal, 505
pressure-tension hypothesis, 506
Orthodontic implications, 152
Orthodontic mechano-therapies, 837
Orthodontic metals resist corrosion, 472, See also Corrosion
Orthodontic records
additional, 196
and investigations, 196
diagnostic, essential or minimum, 196
minimum set of, 196
orthodontic study models, 196
parts of a study model, 196, 197
anatomic region, 196
artistic region, 196
pre-treatment study models, 197
progress/stage and post-treatment study models, 198
study models, evaluation of, 198
arch forms, 198
arch length, analysis for, 199
arch length deficiency, 201
arch length measuring, 200
arch length versus arch perimeter, 200
arch perimeter
measuring arch perimeter, 200
Korkhaus cast measurement instrument, 199
Korkhaus palatal index, 198
tooth size measuring, 201
total tooth material, 200
Orthodontics, 3 See also specific entries
during, 1930-40, 18
during, 1940-50, 19–20
during, 1950-60, 20
during, 1960-70, 21
during, 1970-80, 22
during, 1980-90, 23
during, 2000-18, 24
in Ancient times, 9
400 BC to 19th century, 12
beyond, 2020, 24
clinical assessment
of child with potential for malocclusion, 170
clinical examination and evaluation, 170
information, 170
diagnosis and treatment planning, 170
family history, 170
foundation of, 442
Angle era (20th century), 442
E-arch, 442–444
Begg bracket and round tubes, 444
first edgewise appliance, 443
Lewis brackets, 445
pin and tube appliance, 442
Ribbon arch appliance, 443
standard edgewise weldable brackets, 445
Pre-Angle era (19th century), 442
interpretation of diagnostic records
and investigations, 170
medical history, 170
in mid-19th century, 10–11
patient’s history, 170
pre-adjusted appliance and bonding, evolution of, 22
preventive, 531
goals of, 531
robotic, 24
speciality in India, historical perspective, 27
first MDS orthodontics course, 29
course curriculum, 29
formal dental education, 27
chronology, 28
Indian Orthodontic Society (IOS), 29
information on postgraduate programme, 12
postgraduate dental education, 27
21st century, 12
20th century, 12
in 17-18th century and European dominance, 9
Orthodontic tooth movement (OTM), 505
inflammation, 514
mechanosensing, 510
responses by various cells, 510
sequence of, 510
theories of, 506
bone bending theory, 507–508
fluid-dynamic theory, 508
pressure-tension hypothesis, 506–507
second messenger concept in orthodontics, 509
flowchart, 509
transduction, 510
in treatment with aligner, 432
Orthodontic treatment, active, steps in
alignment, 607–609
bent-in stop loop, 612
canine retraction loops and springs, 633
clinical applications, 631, 633
loop design, 634
loop position, 633
loop pre-activation, 633
continuous arch wires, 610
shape memory archwires, 610
deep bite and its maintenance, correction of, 615
Gjessing canine retraction spring, 630
activation, 631
clinical application, 631, 634
intrusion arch, 619
with anchorage derived from mini screw, 623
connecticut, 621, 630
continuous, 619, 629
three-piece, 620, 629
levelling, 607–609
of curve of spee, 616
bite plate, 616
reverse curve wires, 616
second order bends, 616
loops and helices, 612–614
closed vertical loop, 612
double horizontal loop, 612, 615
double vertical loop, 612, 615
horizontal loop, 612
omega loop, 612, 615
types of loops, 612
vertical loop, 612
maxillary and mandibular incisor intrusion, 616
intrusion arches, 617
intrusion with step-up bend, 616
Ricketts utility arch, 617, 625
parts of, 618, 623
multiple loop archwires, 610–611
Opus loop, 631, 634
activation, 632, 635
clinical application, 632, 635
retraction of incisors into extraction space, 634
asymmetrical ‘T’ archwire, 637, 642
Bull loop/double Keyhole loop, 637
continuous T-loop, 637
friction method, 634
base arch, 634
standard edgewise appliance, 635, 637
Kalra simultaneous intrusion and retraction archwire, 641, 642
monitoring space closure, 641
Mushroom loop space closing archwires, 639, 642
pre-adjusted appliance, 637
Ricketts incisor retraction technique, 638
vertical loop for space closure, 635, 638
Ricketts canine retraction spring, 628, 633
clinical application, 628
sectional arches, 610
sectional method/frictionless mechanism, 624
space closure, 623
canine retraction on continuous wire, 623
pull method, 624, 630, 631
push methods, 624, 630
two stage, 623
T-loop, 624
activation of, 626, 631
clinical applications, 626, 631
vertical and horizontal loop, combination of, 612
box loop, 612, 615
Orthodontic wires, 455, 459, 526 See also specific wires
archwire materials, 528
nickel-titanium alloy, 529
superelasticity, 529
stainless steel, 528
titanium-molybdenum, 529
basic properties, 526
diameter, 528
direction of loading, 528
formability, 528
friction, 528
length, 528
load-deflection, 527
load-deflection rate, 528
modulus of elasticity, 527
range or spring back, 528
resilience, 528
stiffness, 527
strain, 527
strength, 527
stress, 527
stress-strain curve, 527
evolution of, 463
metal composition, 464
properties, 464
Orthodontsoie, 3
Orthognathic surgery, 339
case selection, 1023
indications, 1023
unsuitable cases, 1023
cephalometric, and computer-based prediction technology, 1025
treatment planning, role in, 1026
3D models, 1026
jaws and dentition, 1026
skeletal class II, III malocclusion, 1028
stereophotogrammetry (3dMDTM), 1026, 1027
complications, 1043
bilateral sagittal split osteotomy of the mandible, 1044
dissatisfaction with outcome, 1043
frequency of, 1043
osseous genioplasty, 1044
risks associated with, 1044
unique to le fort surgery of maxilla, 1044
diagnostic records and investigations, 1025
history and clinical evaluation, 1023
examination of the lower face, 1025
nose, 1025
symmetry of the face, 1025
examination of the upper face, 1025
extraoral examination, 1024
evaluation of face, 1024
intraoral examination, 1023
motivational factors, 1022
aesthetics, 1022
functional problems, 1023
overview, 1021
pre-surgical orthodontic treatment, 1022
relapse in, 1226
steps involved in, 1029
post-surgical orthodontic phase, 1036
pre-orthodontic preparatory phase, 1029
pre-surgical orthodontic treatment phase, 1029
appliance selection, 1029
extraction patterns for decompensation, 1029
skeletal class II, and III patients, 1030
skeletal jaw discrepancy, 1031
levelling the maxillary and mandibular arches, 1032
maxillary deficiency, 1029
pre-surgical orthodontics, 1029
vertical maxillary excess (VME), 00067f0035, 1030
retention and follow-up after, 1043
surgery-first approach, 1036
surgical phase, 1033
bi-jaw surgery (BSSO mandible + le fort maxilla), 1033, 1040–
1040, 1042
bilateral sagittal split osteotomy, 1033, 1034, 1036–1038
le fort maxilla, 1038–1039
surgical treatment planning, considerations, 1026
importance of age in, 1027
social history and patients’ expectations
including psychological assessment, 1026
Orthopantomogram (OPG), 210–211
bony structures and symmetry, 211
dentition and associated structures, 212
OSA, See Obstructive sleep apnoea (OSA)
Ossification, 136
Osteoclasts, 512
Osteogenesis imperfecta, 173
Osteotomy facilitated orthodontic treatment (OFOT), 964
OTM, See Orthodontic tooth movement (OTM)
P
PACS, See Picture archiving and communication system (PACS)
Pain with orthodontic mechanotherapeutics, 515
Palatal acting appliance, 715
pendulum appliance, 712, 715
case treated by, 718
efficacy, 718
fabrication and insertion, 717
pendulum K, 718
pendulum X, 716, 719
Palatal components, 726
PAOO, See Periodontally accelerated osteogenic orthodontics (PAOO)
PDL, See Periodontal ligament (PDL)
Peak height velocity (PHV), 136, 827
Periodontal health, 1225
Periodontal ligament (PDL), 505, 962
Periodontally accelerated osteogenic orthodontics (PAOO), 963
decortication pattern, 964
Periodontium, 190, 432, 566, 917
Personality traits, 102
Phosphoric acid etched enamel, 485
Photomultiplier tube (PMT), 342
Photostimulable phosphor plate (PSP), 340, 342
Photostimulable phosphor screens, 345
PHV, See Peak height velocity (PHV)
Picture archiving and communication system (PACS), 344
Pierre Robin sequence, 36, 104, 171, 172
Plasma arc, 499
Plastic bite, 152
PMM, See Polymethyl methacrylate (PMM)
Polycarbonate plastic brackets, 453
Polymethyl methacrylate (PMM), 408
Poly rubber elastics, 481
Polysomnogram (PSG), 1172
Polyvinyl siloxane (PVS) material, 426
Post-debonding agents to facilitate debonding, 1210
Posterior bite plates, 1228
Posteroanterior cephalometric analysis, 295, 1098, 1100
evaluation of cephalogram, 290
features, 290
landmarks on, 290, 292
planes in, 290, 293
median sagittal reference (MSR), 290
frontal vertical proportions, 294
maxillomandibular differential value and ratio, 297
Ricketts’ analysis, 294–298
dental relations, 295, 296
dental to skeletal, 295, 297
internal structure, 296
jaw to cranium, 296, 298
norms, 295
skeletal relations, 295, 297
Grummons’ analysis, 293, 294
frontal vertical proportions, 292
horizontal planes, 292
linear asymmetry assessment, 293
mandibular morphology, 292
maxillomandibular comparison of asymmetry, 293
maxillomandibular relation, 293
volumetric comparison, 293, 294
head positioning, 289
frankfort horizontal plane (FHP), 289
limitations, of, 297
overview, 289
posteroanterior (PA) cephalogram, 289, 291
setup, 289
Postnatal growth, 133
phases, 133
Pre-adjusted appliance, 645, 659
limitations, 665
and modern orthodontics, 445
Andrews straight wire appliance, 445, 448
McLaughlin, Bennett and Trevisi MBT system, 448, 449
pre-adjusted appliance vis-a-vis standard edgewise appliance,
distinct features of, 447
Roth’s prescription, 448
tip edge bracket, 449
Premolar extraction, 688
Pre-pubertal acceleration, 135
Prevalence/incidence of impactions, 987
central incisor, 987
mandibular canine, 987
maxillary canine, 987
Primate spaces, 171
Printing resolution, 222
Program mode, 225
Proper aligning, 227
Prophylactic fluoride gels, 472
Proportional limit, 461
Protrusion, severe, 35
PSG, See Polysomnogram (PSG)
Pt, See Pterygoid point (Pt)
Pterygoid point (Pt), 317
Pubertal spurt, 135
Pulse straightening, 465
Q
QTH, See Quartz tungsten halogen light (QTH)
Quad helix appliance, 697
Quality of life (QoL), 35, 881
Quartz tungsten halogen light (QTH), 499
QwikStrip Interproximal Strips, 707
R
Radiation, 369
doses, from X-rays, 370
forms, 369
electromagnetic, 369
particulate, 369
guidelines, 381
orthodontic practice, in, 382
safety and protection, principles, 370
sources, 370
man-made, 370
natural radiation, 370
units of measurement, 370
Radiology, 369
basic concepts, and terminologies, 369
overview, 369
Rapid maxillary expansion (RME), 163, 1060, 1061
Rectangular bracket slot, 645
Rectangular wires, 462, See also Wire dimensions
RED, See Rigid external distractor (RED)
Relapse, 1224
age and sex as factors, 1226
bone quality to prevent, 1235
in cleft lip and palate, 1227
contributory factor, 1225
to minimising, 1222
orthodontic factors, 1226
in orthognathic surgery, 1226
periodontal fibres involved in, 1223
systemic diseases and, 1226
third molars and, 1225
Relative body composition in newborns and adults, 134
Removable appliances, 407
advantages, 408
appliance delivery
and activation, 413
active wire components, 414
anterior bite plane, 414
follow-up for activation, 414
guidelines, 415
methods of disinfection, 415
posterior bite plane, 414
avoidable complications, 421
bite plate, 409
class II division 2 malocclusion, 418, 419
clinical considerations, 412
clinical procedures, 413
correction of cross-bite of anterior teeth, 415
case report, 415
anterior proclination, 416
bite opening, 417
deep bite, 415
maxillary incisor, 415
space closure, 418
correction of ectopic canine, 420
Crozat appliance, 421
stage I and stage II, 421
disadvantages, 408
ectopic canine, correction of, 418
efficient, considerations for, 413
expansion of arch, 412
removable expansion appliance, 412
fixed appliance, integration with, 418
Hawley appliance, 409
components, 409
active, 411
passive, 409
retentive, 409
indications of, 408, 415
laboratory requisition
and appliance design, 413
limitations, 408
overactivated finger springs, 421
recent advances in, 407
treatment effectiveness, 408
occlusal index (OI) scores, 408
Removable functional appliance, evolution of, 754
Resin tags, 485
Resolution, 222
optical versus interpolation resolution, 222
Respiration, 153
upper airway obstruction, 154
Retainer
appliances, 1227
types of, 1227
vacuum formed plastic retainers (VFR), 1227
choice, evaluation for, 1235
Retention
appliance, 1205
delivery of, 1205
protocol, 1231
schedule, 1232–1233
Retraction of teeth, in buccal segment, 724
Retrognathia, 171
severe, 172
Rhinomanometric examination, 163
Ricketts’ analysis, 294–298, See also Ricketts’ cephalometric analysis
dental relations, 295, 296
denture midline, 295
intercanine width, 295
intermolar width, 295
molar relation left, 295
molar relation right, 295
dental to skeletal, 295, 297
denture-jaw midline, 296
lower molar to jaw left, 295
lower molar to jaw right, 295
occlusal plane tilt, 296
internal structure, 296
facial width, 296
nasal height, 296
nasal width, 296
jaw to cranium, 296, 298
skeletal relations, 295, 297
mandibular width, 295
maxillary width, 295
maxillomandibular midline, 295
maxillomandibular width left, 295
maxillomandibular width right, 295
Ricketts’ bracket system, 446
Ricketts’ cephalometric analysis, 263
basic reference planes, 264
cranial base, 265
facial axis, 265
horizontal reference plane, 264
occlusal plane, 265
vertical reference plane, 265
construction of Xi point according to, 264
dental landmarks, 264
norms at 9 years and growth changes, 265
skeletal landmarks, 263, 264
Ricketts’ 12-factor summary analysis, 265
measurements
to determine profile, 268–269
to locate chin in space, 265–267
facial axis angle, 266
facial depth angle, 266
lower facial height, 266
mandibular arc, 266
mandibular plane angle, 266
measurements to determine convexity, 266
to locate denture in face, 267–268
interincisal angle, 268
lower incisor protrusion, 267
mandibular incisor inclination, 267
upper molar position, 267
soft tissue evaluation, 269
Ricketts, Robert Murray, 22, 263, 339
Riedel’s nine rules of retention, and relapse, 1220–1224
Rigid external distractor (RED), 1051, 1052
Rigid fixed functional appliances, 810
Ring light, 226
RME, See Rapid maxillary expansion (RME)
Robotic technology, 24, 475
Rocky mountain data system (RMDS), 475
Roentgen, Wilhelm, 5
Rubber bands, 477
Rubber elastics, 477
S
Sachdeva, Rohit Lal, 25
SAD, See Selective alveolar decortication (SAD)
SARME, See Surgically assisted rapid maxillary expansion (SARME)
SAS, See Skeletal anchorage system (SAS)
Sassouni’s cephalometric analysis, 272
arcs, 273
planes, 272
anterior cranial base, 272
anterior cranial base plane or basal plane (OS), 272
mandibular base plane (OG), 272
occlusal plane (OP), 272
palatal plane (ON), 272
ramus plane (RX), 272
planes meet at point O, 273
relation of planes to common point, 273
Schwartz double plate, 767
Second order bends, 645
Sectional arches, 610
Selective alveolar decortication (SAD), 963
regional acceleratory phenomena (RAP), 963
Selective serotonin reuptake inhibitors (SSRI), 164
Self-esteem, 101
Self-etching primers (SEPs), 488
Self-ligating brackets, 681
active, 670
In-Ovation brackets, 672
SPEED™ appliance, 671–672
evidence on claims of, 681–684
studies related to
initial orthodontic alignment with, 683
pain and discomfort, 683
treatment duration and number of visits, 684
evolution of, 670, 671
Edgelok bracket, 670
Ideal requirements, 671
Mobil-lock bracket, 671
Russell attachment, 670
passive, 672
vs. conventional brackets, 677
biomechanical challenge, 677
dimpled NiTi initial aligning wire, 680
efficiency tips for self-ligating brackets, 681
bracket slots tipped toward extraction sites, 681–681
Oscar tubing on archwires during sliding, 682
lack of consolidation of anterior teeth with, 681
options for effective torque expression, 679
rotational control, 677–679
torque considerations, 678, 679
upper palatal torque and lower labial torque, 679
very quick initial alignment and levelling, 680
walking of archwire, 680
Self-ligation, 669, See also Self-ligating brackets
conventional ligation, limitations of, 670
Damon system, 673
ideal ligation system, properties of, 670
SmartClip appliance, 673–675
Sensitisation, 461
Sensor based remotely controlled orthodontics, 25
Sentalloy open coil springs, 456
Separation of teeth, 550
elastic/rubber-based separators, 551, 553
metal-based separators, 550
molar bands, 552
Serial extraction protocol, 537
benefits, 538
class II division, 2, 539
controversies with, 538
extreme facial types and serial extraction, 539
indications, 538
relative contraindications, 539
self-alignment/driftodontics, 539, 541
steps in serial extraction, 539
Dewel’s method, 539
Nance method, 539
Tweed’s method, 539
SFOTM, See Surgically facilitated orthodontic tooth movement
(SFOTM)
SF-RTM, See Surgically facilitated rapid tooth movement (SF-RTM)
Shape memory effects (SMEs), 471
Shape-memory polymers (SMP), 463, 471
Shutter speed, 224, 225
Siamese brackets, 451
Simon, Paul, 17, 19
Gnathostatic approach, 19
Simultaneous nasal and oral respiratory technique (SNORT), 163
Single lens reflector (SLR) camera, 220
Skeletal anchorage system (SAS), 1097, 1104, 1105
Skeletal growth, 120, 136
cortical drift, 121
Enlow’s V principle of growth, 122
Enlow’s counterpart principle of growth, 123
palatal remodelling, 122
ramus-to-corpus remodelling, 123
epiphyseal growth, 120
periosteal and endosteal growth, 120
remodelling, 121
sutural growth, 121
Skeletal malocclusions, ortho-surgical management, See Orthognathic
surgery
Smart stage innovation, 426
Smart track technology, 426
SMEs, See Shape memory effects (SMEs)
Smile, 183
arc, 185
arrangement of teeth, morphology and colour, 184
buccal corridors, 185
and arch form, 184
dynamics and orthodontic implications, 183
evaluation, 184
gingival display, 184
index, 185
Morley’s ratio, 185
nature of, 184
posed smile, 184
spontaneous smile, 184
transverse cant, of maxillary occlusal plane, 186
SMP, See Shape-memory polymers (SMP)
Sodium fluoride (NaF), 472
Soft SS wires, 455
Soft tissue comprehensive analysis (STCA), 285
Software, 222
for photograph editing, 222
Soldering, 464
brackets, 444
Somatic growth, factors affecting, 115
Space maintenance appliances, 533
active space maintainer, 533
bonded space maintainer, 533
disadvantages of, 532
distal shoe space maintainer, 533
lower lingual arch, 533
mandibular arch, 535, 536, 538
maxillary arch, 535–537
Nance button as space maintainer, 533
passive appliances, 533
potential benefits of, 532
removable partial denture, 533
space regaining appliance, 533
Speech, 154, 187
assessment of, 188
in relation to malocclusion and dental anomalies, 188
in cleft child, 189
dental alignment and, 189
lip seal, 189
tongue anomalies, 189
velopharyngeal seal, 189
and malocclusion, 188
relationship to speech sound production, 188
parts, 187
articulation, 187
language, 187
rhythm, 187
voice, 187
stages of development, 179
stages of development of, 154
Spinner straightening, 465
Square wires, 462
Stabilisation, 461
Stability, factors associated with, 1220
Stainless steel (SS) wire, 409, 463
properties, 464
biocompatibility, 464
low cost, 464
soldering, 464
stiffness, 464
Static equilibrium, 522–523
compressed coil spring exerting, 523
STCA, See Soft tissue comprehensive analysis (STCA)
Steiner, Cecil C, 257
Steiner’s analysis, 257
cephalometric norms, 261
choice of landmarks, rationale on, 257
ANB angle, 257, 260
interincisal angle, 258
NA and NB planes, 257
S-N plane, 257
composite analysis, 258
dental analysis, 258
interpretations and applications, 259
skeletal analysis, 258
S line, 259
Steiner chevrons, 259
plane used to define relationship, 260
Step bend, 526
Stereophotogrammetry, 214, 351
Stiffer wires, 466
Stiffness, 464
Straight-wire (SW) appliance, 22, 29, 445, 654
Andrew’s Prescription of, 448
auxiliary features, 657
compound contour of bracket base, 654
compound contour design, 660
effect of standard edgewise, pre-torqued and straight wire
brackets, 659
mid-sagittal plane, 659
midtransverse plane of the slot, stem, crown, 658
convenience features, 657, 660
Andrews extraction bracket series, 660
design features of fully programmed brackets, 657
features of, 654
Andrews’s plane and LA point, 658
slot features in midtransverse plane, 654
slot sitting features, 654
torque in base, 654, 660
Strain, 461
Stress, 461
Supercable wire, 470
Supernumerary teeth
clinical implications, 545
dichotomous right maxillary lateral incisor, 547
hypodontia, 546
management of, 546
mandibular second premolar, 546
in maxillary anterior region, 545
missing maxillary lateral incisors, 546
orthodontic aspects of, 545
supernumerary premolars, 546
supplemental tooth/dichotomy, 546
treatment options, 546, 548
Supplementary records
analysis and investigations, 213
cleft lip and palate, 214
congenital and chromosomal abnormalities, 214
congenital hyperplasia of the face, 214
facial asymmetry associated with ankylosis of the TMJ, 214
PA view cephalograms, 213
unilateral condylar hyperplasia, 214
Surgically assisted rapid maxillary expansion (SARME), 1060, 1061
Surgically facilitated orthodontic tooth movement (SFOTM), 959
Surgically facilitated rapid tooth movement (SF-RTM), 959
accelerated osteogenic orthodontics (AOO), 963
alveolar surgery, techniques of, 960
piezocision-assisted orthodontics, 960
after buccal interproximal gingival incision, 961
biological basis, 958, 961
surgically facilitated orthodontic tooth movement (SFOTM), 959
advantages, 961
piezocision, indications and contraindications of, 962
corticision, technique of, 963
corticotomy facilitated orthodontic treatment (CFOT), 963
indications/case selection, 963
corticotomy assisted expansion (CAE), 963
dental distraction development, significant events, 958
three phases of healing, 960
mechanism of action, 960
micro-osteo-perforations (MOP), 962
advantages, 962
mechanism of action, 962
periodontal ligament (PDL), 962
mono-cortical tooth dislocation and ligament distraction (MTDLD),
969
advantages, 969
osteotomy facilitated orthodontic treatment (OFOT), 964
biomechanical considerations, 965
dental distraction (DD)
advantages, 969
clinical phase, technique of, 965, 966
post-surgical, 967
pre-surgical, 966
surgical, 966, 967
disadvantages, 969
intraoral appliance, 968
comprises of following parts, 965
dental distractor, 965
design of, 965
potential complications, 969
treatment progress, follow-up and records
dentoalveolar, 965
indications/case selection, 965
inter-dental/periodontal, 965
treatment progress, follow-up and records, 967
anchorage loss, 968
tooth movement, rate of, 967
tooth movement, type of, 968
dental distraction appliance, 968
overview, 957
periodontally accelerated osteogenic orthodontics (PAOO), 963
advantages, 964
appliance activation, 964
decortication pattern, 964
disadvantages, 964
potential complications, 964
ankylosis, 964
devitalisation, 964
infection, 964
root resorption, 969
stability, 964
selective alveolar decortication (SAD), 963
regional acceleratory phenomena (RAP), 963
surgery first, 969
advantages, 969
wilckodontics, 963
Swallowing, 152
orthodontic implications, 153
stages of, 153
Symphysis, of mandible, 1074
Synchondrosis, 139
Syndromes
affecting face and jaws
associated with mandibular deficiency, 172
midfacial deficiency, 172
associated with mandibular prognathism, 173
prognathique mandibulaire, 881
Synthetic latex elastics, 477
Synthetic rubber elastics, 477
T
TADs, See Temporary anchorage devices (TADs)
TCB, See Tungsten carbide bur (TCB)
TCH, See Tru-Chrome (TCH)
Technetium 99m scan, 214
Temporary anchorage devices (TADs), 23, 935
classification, 935
definition, 935
historical perspective, 935, 936
types of devices, 936
endosseous implants, 936
miniscrew implants (MSIs), 936
biomechanical considerations, 943–954
classification, 937
design and parts, 937–939
direct vs. indirect loading, 942
loading of implant, 942
materials used for implants, 937
miniscrew placement protocol, 940–942
miniscrew removal, 942, 944
risks and complications, 953–956
safe zones for, 939
surgical miniplates, 936
Temporo-mandibular disorders (TMDs), 114, 688, 827, 1117, 1119
historical relationships, 1118
gnathologic goals, 1118
home care instructions, 1121
joint/disk disorders, 1117
masticatory muscle disorders, 1117
neuromuscular skeletal conditions, 1117
orthodontics, 1117, 1118, 1122
centric occlusion, 1119
centric relation, 1119
diagnosis, 1120
articulators for, 1119
functional occlusion, 1119
canine protected occlusion (CPO), 1119
gnathologic concepts, 1118
relationship with TMDs, 1118
treatment, 1118, 1119
informed consent, 1122
oral appliances (splints), 1122
psychological approaches, 1121
overview, 1117
patient self-directed care, 1121
education, 1121
signs and symptoms, 1118
management of, 1120
examination, 1120
treatment, 1121
Temporomandibular joint (TMJ), 173, See also Temporo-mandibular
disorders (TMDs)
ankylosis, 36
click, 186
crepitus, 187
functional examination, 186
joint sounds, 186
range of motion, 187
incisal opening, 187
lateral excursions, 187
mandibular deviation, 187
tenderness on palpation, 186
trauma and dislocation, 187
Testosterone, 135
Three-dimensional cephalometry, 390–390, 396, 398, 399
analysis, 398
angular cephalometric measurements, 399
automatic landmark detection and, 399
limitations, 401
dolphin imaging software, 400
linear cephalometric measurements, 398
ratio of cephalometric measurements, 399
reference planes, 396, 398
FH planes, 398, 400
evolution measurements, 390, 391
step-by-step procedure, 398
three-dimensional imaging
evolution from, 2D imaging, 387
Three-dimensional (3D) digital models, 357, See also E models
coordinate system, 361
virtual study models, 358
Three-dimensional imaging, See also Three-dimensional cephalometry
orofacial imaging, 384
brackets, computer-aided bracket design and, wire bending,
indirect bonding, 384
research and recent advances, 384
virtual models, 384
virtual orthodontic patient, 385
Three dimensional virtual orthognathic surgical planning, 401
Thumb sucking, 156
digit sucking, effects on oral structures, 156
interception of, 157
pathophysiology, 157
treatment, 158
types, 156
Tip edge bracket, 449
Titanium-molybdenum alloy (TMA), 1102
limitations, 469
wires, 463
Titanium-niobium-aluminium (Ti-Nb-Al) alloy, 469
shape memory alloy wires, 469
Titanium wires, 469
b-titanium wires, 468
composition, 468
general properties, 468
TLA, See Translingual arch (TLA)
TMDs, See Temporo-mandibular disorders (TMDs)
Tongue anomalies, 189
Tongue behaviour, 158
Tongue retaining device (TRD), 1177
Tongue thrusting habit, 158
causes of, 158
interception, 159
management, 160
tongue thrusting swallow
clinical features of, 159
complex, 159
retained infantile swallow, 159
simple, 159
diagnosis of, 159
treatment, 159
modalities, 159
types of, 158
Tooth impaction, 985
aetiology, 987
canine impaction, 988, 993
development and eruption of maxillary canine, 988
incisor impaction, 988
labial canine impaction, 989
palatally displaced maxillary canine impaction (PDC), 988–989
palatal vs. labial impaction, 988
computed tomography (MDCT)/CBCT, 994
applications in diagnosis and management, 994
definitions, 985
diagnosis, 990
buccal vs. palatal impaction, 992
maxillary canine, 990
maxillary central incisor, 990
occlusal X-ray, 992
orthopantogram, 992
palpation for canine(s), 990
peri-apical radiographs (IOPA), 991
radiological examination, 991
impacted tooth, extraction of, 1009
impacted tooth, relocation of, 998
surgical exposure
and attachment to impacted tooth, 998
closed technique, 999, 1004, 1005
labial impaction, 1000–998, 1003
orthodontic guidance, 997, 1007–1008
palatal impaction open technique, 999
surgically assisted, 998
lateral view cephalogram, 992
orthodontic guidance/intervention, 996
PA skull or PA cephalogram, 992
technique modification, 992
mandibular arch, 992
maxillary arch, 992
extraction of a retained deciduous tooth, 996
maxillary canine impaction, 995
indicators, 995
radiographic examination, 995
spontaneous correction, 995
observation on developing dentition, 995
physical barrier, removal of, 996
twin mesiodens and impacted maxillary central incisors, 997
sector classification, 995
angulation of maxillary canine, 996
for impaction of canine, 995
Tooth movement, phases of, 511–512
Tooth positioners, 1227
Tooth size-arch length
analysis
factors influencing estimation
curve of Spee, 205
incisor inclination and position, 204
discrepancy, 205
Carey’s analysis, 205
Tooth size ratio, 205
Bolton’s analysis, 205
Bolton’s ratio chart, 206
premise, 205
Royal London space analysis, 207
Tooth transposition, 1011
aetiology, 1012
canine-lateral incisor transposition, 1013
central incisor-lateral incisor transposition, 1015
complete canine-first premolar transposition, 1012
complete/incomplete, 1011
correction of a transposition, 1013
definitive treatment, 1013
extraction of offending tooth, 1013
interceptive treatment, 1012
lateral incisor-canine transposition, 1015
maintenance of order of transposition
and camouflage of transposed teeth, 1013
case report, 1014
management considerations, 1013
maxillary canine-premolar transposition, 1013
prevalence, 1011
mandibular arch, 1011, 1012
maxillary arch, 1011, 1012
Torque, 645
Translingual arch (TLA), 569
Transpalatal arch (TPA), 568
Transparent aligners, 407
Traumatic deep bite, 608
TRD, See Tongue retaining device (TRD)
Treacher collins syndrome, 36, 171, 172
Treatment plan, 550
with complete records, 550
demand on oral hygiene, 550
designing, 550
execution strategy, 550
first banding/bonding appointment, 550
objectives of orthodontic treatment, 550
planned treatment approach, 550
posttreatment outcome, 550
treatment outcome aimed at, 550
Tricyclic antidepressants (TCA), 164
Tru-Chrome (TCH), 1234
Tube thickness, 478
Tungsten carbide (TCB), 1211
Turbo wire, 470
Tweed, Charles H, 21, 572
analyse treatment records, 572
anchorage and goals of FMIA for large ANB, 584
anchorage conservation, 591
anchorage preparation, 592
first, second and third degree anchorage, 583
in mandibular arch, 576
in maxillary arch, 582
cephalometric analysis, 253, 572
clinical observations, 572
criticism, 572
diagnostic facial triangle, 572
in different classes of malocclusion, 573
directional forces from, 594
disheartened with his work, 571
extraction or non-extraction treatment, 574
facial triangle, development of, 572
finishing and detailing objectives, 594–598, 599
FMA and its relationship with IMPA, 574, 576
growth trends
of face, 574
treatment mechanics, and prognosis, 575
head plate correction/cephalogram correction, 574
incisor retraction, 593
maxillary and mandibular
canine retraction, 595
methodical and indispensable inclusion of second molar, 591
objectives of treatment, 576
occlusal plane maintenance, significance of, 588
practised edgewise appliance, 571
principles as applied to clinical practice at AIIMS, 598
canine retraction, 601
edgewise mechanics, 600
finishing and detailing, 601, 602
protocol on treatment planning, 600
second order bends, analysis of, 594
space closure, 591
stages of treatment, 588
anchorage saver be added, 590
bite opening mechanics, 589
control of its adverse effects on incisors, 589
levelling and alignment, 588
precautions to facilitate correct tooth movement, 590
treatment principles, 590
standard edgewise appliance, 578
Bonwill Hawley chart, 578
first order bends, 578, 580, 581
second order bends/up and down bends, 579, 581
importance of coordination in, 583
placement, 581
steps in fabrication, 581
treatment sequence with, 589
third order bends (torque), 584–586
total arch length discrepancy calculation by, 576
treatment mechanics and type C growth trend, 575
Twin block appliance, 767, 768
appliance design and construction, 790
angulation of inclined planes, 790
optimal thickness of bite blocks, 791
bite recording, fundamentals of, 788
bite recording according to Clark, 789
extent of
horizontal advancement, 788
vertical opening, 788
midline considerations, 788
cephalometric comparative table, 776
cephalometric evaluation and analysis, 786
features, 788
landmarks and definitions, 787
maxilla and palatal plane inclination, 786
nasopharyngeal passage, 786
ramus and condyle area, 786
Clark philosophy, 768
occlusal incline plane, 769
functional analysis, 777
vertical dimensions of face, 778
respiration, 778
temporomandibular joint, 778
tongue, 778
visual treatment objective, 778
case selection, 769
case study, 772
class II malocclusion, 769
and VTO, 770
functional phase, 792
active phase, 792
retention phase, 794
support phase, 794–802
indications, 769
pre-functional phase, 791
contraindication of functional therapy, 777
development of, 767
diagnostic records and analysis, 785
fixed twin-block, 805
components, 806
development of, 805
modification, 804
in class II div 2 and class III malocclusion, 805
reverse twin-block, 805
in deciduous dentition, 804
traction technique, 804
concorde face-bow, 805
treatment of anterior open bite and vertical growth pattern, 805
poor responders to therapy, 777
profile and occlusion after therapy, 772
removable functional appliance, treatment effects of, 794–798, 804
long-term retention, 804
case study, 799
one phase vs. two phase treatment, 798, 804
skeletal maturity indicators, 779
chronological age, 779
dental age, 779
peak height velocity, 779
skeletal age, 780
cervical vertebral maturation index, 781–785
hand-wrist radiographic methods, 780
twin block functional appliance vs. one-piece appliance, 769
Two-dimensional cephalometry, limitations, 387
Two-dimensional imaging, 370–371, See also Three-dimensional
imaging
assessment, 371
digital radiography, 371
3D imaging in medicine, and dentistry, 371
intraoral radiographs, 371
panoramic radiographs, 371
evolution, historical perspective, and limitations, 370
U
UCLP, See Unilateral cleft of lip and palate (UCLP)
Ultimate tensile strength, 461
Unfavourable root angulation, of mandibular canine, 609
Unilateral cleft of lip and palate (UCLP), 1128, 1150, 1152
Unilateral cross-bite, with mandibular shift, 544
aetiology, 544
early treatment, 544
maxillary expansion schedule, 545
Unstable orthodontic outcome, 1220
reasons for, 1220
Upper airway resistance syndrome (UARS), 1182
Upper airway sleep disorders, 1167, 1169–1171, 1182
in children, 1182
predisposing factors, 1182
bottle feeding and oral muscle behaviour, 1184
breastfeeding and oral cavity, 1183
craniocervical posture, 1182
first premolar extractions on the upper airway, detrimental
effects of, 1174
prevention and management, 1184
consider impact of extractions on tongue space, 1185
develop oral volume with the functional appliance, 1184
facilitate nasal breathing, 1184
mandibular advancement/lengthening with
surgery/distraction, 1185
promote breastfeeding, 1184
treatment of narrow maxilla, 1185
diagnosis and treatment protocols, 1171
Epworth sleepiness scale, 1171
investigations, 1172
acoustic pharyngometer, 1173, 1175
dynamic MRI and CT scans, 1173
lateral cephalogram, 1173, 1174
polysomnogram (PSG), 1172
mallampati scores, 1171
management protocol includes, 1173
behaviour modification, 1173
continuous positive airway pressure (CPAP), 1173, 1175
oral appliances, 1175
surgical procedures, 1175
mandibular advancement devices (MADs), 1176–1178, 1181
fabrication of, 1180
bite gauge, 1180
FDA (USA) approved oral appliances, 1181
limitations, 1181
set/recorded, 1176
karwetzky activator, 1176
removable herbst appliance, 1176, 1177
simple splint, 1176
therapeutic benefits, 1178
titratable, 1178, 1179
Medical Dental Sleep Appliance (MDSA), 1178
OASYS appliance, 1179
vs CPAP, 1180
sleep bruxism, 1182
tongue repositioning manoeuvre with oral shields, 1177
membrane funnel, 1177
tongue retaining device (TRD), 1177
tonsil grading scale, 1172
upper airway resistance syndrome (UARS), 1182
epidemiology, 1168
overview, 1167–1167
pathophysiology, 1168
abnormal sleep, 1169
anatomical variations, 1169
craniofacial morphology of decreased airway space, 1169
environmental factors, 1170
mandibular deficiency or functional retrusion, 1169
maxillary deficiency, 1169, 1170
obesity, 1169
normal sleep, 1168
non-rapid eye movement (NREM), 1168
rapid eye movement (REM), 1168
stages, 1168
N1 (NREM1), 1168
N2 (NREM 2), 1168
N3 (replaces NREM stages 3 and 4), 1168
W (wakefulness), 1168
sleep apnoea, 1170
central, 1170
central sleep apnoea, 1170
mixed, 1171
obstructive sleep apnoea (OSA), 1170
symptoms, 1171
snoring, 1170
Upper removable appliance (URA), 415, 696, 870
Utility arch, 570
V
Vacuum-formed retainer, 1228, 1234
cytotoxic implications, 1235
Van Beek activator, 848
bite recording, 848
wearing schedule, 849
Variable modulus orthodontics, 470
advantages, 461
Vertical analysis, of face, 271
analysis of vertical face heights and ratios, 272
anterior facial height, 271
evaluation of facial dysplasia, 272
Frankfort horizontal (FH) plane as reference, 271
lower face height, 271
Wylie and Johnson as pioneers, 271
Vertical growth rotations, signs of, 275
Vertical holding appliance (VHA), 570
Vertical maxillary excess (VME), 1030
VHA, See Vertical holding appliance (VHA)
Viscerocranium, 136
Visual treatment objectives (VTO), 339
VME, See Vertical maxillary excess (VME)
VTO, See Visual treatment objectives (VTO)
W
W arch, 697
Wells, Horace, 5
White balance, 223, 224
White spot lesions (WSL), 1213–1215, 1216
detection of, 1214
modified index, 1215
simple index, 1214
etiopathogenesis, 1213
nanotechnology in control of biofilms, 1216
nanocoatings, 1216
nanocomposites, 1216
nanoparticles, 1216
post-orthodontic care, 1216
casein phosphopeptide-amorphous calcium phosphate (CPP-
ACP), 1217
enamel cleanup, 1216
management, 1216, 1217
excessive white spot formation (thicker bands), 1216
no white spot formation, 1216
slight white spot formation (thin rim), 1216
white spot formation with cavitations, 1216
microabrasion, 1217
overview, 1213
remineralisation, 1216
resin infiltration, 1217
restorations, 1217
visible scars, 1214
vital tooth bleaching, 1217
prevalence and distribution, 1213
light induced fluorescence (QLF), 1213
orthodontic appliance and poor oral hygiene, 1214
prevention, 1214–1216
bioactive glass ceramic materials, 1215
probiotics, 1215
role of fluoride, 1214, 1215
xylitol, 1215
Wings, 451
Wire alloy composition, 459
Wire dimensions, 460
rectangular wire
modes of, 460
thickness (height) of, 460
width of, 460
round wires, 461
vis a vis wire properties, 465
Wires cross-section/types and material, 461, 462
WSL, See White spot lesions (WSL)
X
X-rays discovery, 5
Xylitol, 1215
Y
Yield strength, 461
Yunis-Varon syndrome, 987
Z
Zoom lens, 220

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Orthodontics: Diagnosis and

Management of Malocclusion and

Professor and Chief

Preface to the third edition

Section I: Historical aspects of orthodontics:

Chapter 1.1: History of dentistry and significant events that

The origin of the term Orthodontia

History of dentistry before Christ was born (BC)

The beginning of dentistry as a profession: early to middle ages

The development of dentistry as a science

Dentistry in 19th century

Dentistry in 20th Century

Dentistry in 21st Century

Chapter 1.2: History of orthodontics

Orthodontics in ancient times

Orthodontics in 17–18th century and European dominance

American dentistry and orthodontics in mid-19th century

Contribution of Edward Hartley Angle to the orthodontic

Orthodontics during 1960–70

Orthodontics during 1970–80: pre-adjusted appliances

Orthodontics during 1980–90: clinical success with twin block

Orthodontics during 2000–18

Orthodontics beyond 2020

Chapter 1.3: History of orthodontic speciality in India

History of formal dental education in India

Postgraduate dental education

The first MDS orthodontics course in India

Section II: Fundamentals of orthodontics

Chapter 2: Adverse consequences of malocclusion and benefits of

Adverse consequences of malocclusion

Benefits of orthodontic treatment

Limits of orthodontic therapy

Chapter 3: Epidemiology of malocclusion and orthodontic treatment

Need for recording malocclusion prevalence

Methods of recording malocclusion for epidemiological data

Reasons for large variations in malocclusion prevalence

Ethnic trends in malocclusion prevalence

Orthodontic treatment needs

Chapter 4: Classification and methods of recording malocclusion

Angle’s classes of malocclusion

Strang’s classification based on the body of mandible

Skeletal classification (Fig. 4.19 A–C)

Simon’s classification and canine law

Incisor classification (1964)

Katz’s premolar classification (1992)

Ackerman and Proffit’s classification (1969)

Classification in primary dentition (Baum 1959)

Chapter 5: Recording the severity of malocclusion: orthodontic indices

Qualitative methods of recording malocclusion

Quantitative methods of recording malocclusion

Diagnostic classification index

Handicapping malocclusion assessment record (HMAR)

Dental aesthetic index (DAI)

Index of orthodontic treatment needs (IOTN)

Index of complexity, outcome and need (ICON)

American Board of Orthodontics (ABO) grading system and

Chapter 6: Psychological implications of malocclusion and

Psychological implications of malocclusion

Psychological factors motivating patient to seek orthodontic

Motivational factors in adults

Orthognathic surgery patients

Cleft lip and palate

Malocclusion due to trauma