January 2023 . Volume 16 .

Number 1

The FR BCPPm: A novel, hybrid function regulator

Root resorption: Why we all need to get informed consent
Aligner orthodontics: A literature review
January 2023 Orthodontic Update 3

INSIDE THIS ISSUE

5 COMMENT 33 ORTHODONTICS
Artificial Intelligence: is it going to change everything? Aligner orthodontics: a literature review
PJ Sandler
N Gogna, M Irving and K Nandhra
7 GUEST EDITORIAL Objective: To highlight the various aspects of clear aligner
Working for a dental corporate body therapy, including patient compliance, clinical effectiveness, social
P Cornish interactions and iatrogenic effects.
Enhanced CPD DO C
10 ORTHODONTICS
The FR BCPPm: a novel, hybrid function regulator 41 ORTHODONTICS
RAC Chate Non-surgical management of a traumatic mid-palatal suture
Objective: Readers should gain a clear understanding of the diastasis by novel use of an orthodontic appliance
appliance’s various components in order to be able to replicate its S Duggal, F Jenkins, S Littlewood and I Siddique
laboratory prescription, as well as an insight into how the appliance Objective: The reader should understand that it is possible to use
can modify the growth of a prominent premaxilla. a rapid maxillary expansion orthodontic appliance in reverse to
Enhanced CPD DO C close a midline fracture, and how a patient’s age and anatomical
development may affect treatment options.
20 ORTHODONTICS Enhanced CPD DO C
Root resorption: why we all need to get informed consent
F Roshanray, C Sandler and PJ Sandler 46 ORTHODONTICS
Objective: To understand the rationale behind getting an informed Early removal of supernumeraries to close a midline diastema:
consent prior to orthodontic treatment, informing of the risk of
a case report
root resorption.
Enhanced CPD DO C L Brooks, K Smorthit, J Sandler
Objective: The reader should be able to list the main causes of a
28 ORTHODONTICS midline diastema, the complications caused by a supernumerary
An overview of light-curing within orthodontics tooth and the optimal time to refer for orthodontic assessment.
L Monaghan and R Needham Enhanced CPD DO C
Objective: The reader should understand the different types of
light-cure unit and the principles behind their effective use. They 51 TRICKS OF THE TRADE
should be able to recognize when bond failure has occurred Ten simple steps to PVS impression success
owing to defective equipment, and know how to confirm this with RM Conville
appropriate testing.
Enhanced CPD DO C 54 CPD QUESTIONS

EDITORIAL DIRECTOR Nerina Hendrickse Alison Murray

Professor Jonathan Sandler GDP Consultant Orthodontist
Consultant Orthodontist Winchester Royal Derby Hospital
Chesterfield and Hants Derby
North Derbyshire Royal Hospital
Calow, Chesterfield, Derbyshire Professor Anthony J Ireland Andrew Shelton
Consultant Orthodontist Consultant Orthodontist
EXECUTIVE EDITOR Division of Child Dental Health Orthodontic Department
Fiona Creagh Bristol Dental Hospital and School Montagu Hospital
Lower Maudlin Street Mexborough
EDITORIAL BOARD Bristol
Professor FJ Trevor Burke
Birmingham Dental Hospital and School Lynda Kirk
of Dentistry Orthodontic Therapist
5 Mill Pool Way, Edgbaston, Royal Derby Hospital
Birmingham Uttoxeter New Road, Derby

CPD in Orthodontic Update in partnership with Cover Picture: ‘Plastic will be the main ingredient of all
our grandchildren’s recipes’ Anthony T Hincks. Picture
courtesy of Catherine Brierley, Chesterfield Royal Hospital

OU ISSN 1756-6401
January 2023
Authors' Information
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before writing an article. The opinions expressed in
this publication are those of the authors and are not
necessarily those of the editorial staff or the members
of the Editorial Board.
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Orthodontic Update 5
Comment
Jonathan Sandler
Artificial Intelligence: is it going to change everything?
Recently my son introduced me to Chat GPT (https://chat.openai.com/chat). The claim is that this
software will lead to a technological revolution on the scale of the industrial revolution, for the
benefit of humanity. Time will tell whether it lives up to its laudable aims.
The software is already being used to assist students ‘in the know’ to write essays (in any style
imaginable), and to write ‘reflections’ on particular situations. I urge you all to check it out, and
put in your own questions to the system to witness the incredibly short time in which reasonably
credible answers are constructed.
Below I list a couple of computer-generated answers to simple orthodontic questions namely:
‘list the benefits of orthodontic photography’ and ‘how does a twin block work?’ The answers
were generated almost instantaneously.
„ ‘Orthodontic photography is an important tool in the practice of orthodontics, as it allows the
orthodontist to document the patient’s dental and facial characteristics, assess the progress
of treatment, and communicate with other dental professionals. Orthodontic photographs
can be taken at various stages of treatment and can help the orthodontist plan and execute
a treatment plan, as well as track the patient’s progress. They can also be used for patient
education and to communicate with other dental professionals, such as the patient’s dentist
or oral surgeon. Overall, orthodontic photography helps ensure the best possible outcome
for the patient and helps the orthodontist provide high-quality care.’
„ ‘A twin block appliance is a type of orthodontic appliance that is designed to correct an
overjet, which is a condition in which the upper front teeth protrude significantly beyond the
lower front teeth. It consists of two acrylic blocks that are attached to the upper and lower
dental arches, and it works by applying pressure to the upper and lower dental arches in
opposite directions in order to bring the upper and lower teeth into a more aligned position.
If a twin block appliance fails to reduce a patient’s overjet, it could be due to a number of
reasons. One possibility is that the appliance was not worn consistently or as prescribed by
the orthodontist. For the twin block appliance to be effective, it is important that the patient
wears it as directed, which typically includes wearing it for at least 22 hours per day. If the
appliance is not worn consistently or as prescribed, it may not have the opportunity to exert
the necessary pressure on the teeth to bring them into a more aligned position.
Another possibility is that the twin block appliance was not fitted properly. It is important
that the appliance be fitted correctly in order for it to work effectively. If the appliance is not
fitted properly, it may not apply the necessary pressure to the teeth to bring them into a
more aligned position.
A third possibility is that the patient’s overjet was too severe for the twin block appliance
to effectively correct. In some cases, an overjet may be so severe that it requires more
extensive treatment, such as orthodontic braces or surgery, to correct. In these cases, the twin
block appliance may not be sufficient to effectively reduce the overjet.
In conclusion, there are a number of reasons why a twin block appliance may fail to
reduce a patient’s overjet. It is important to work closely with an orthodontist to determine
the most appropriate treatment plan for correcting an overjet, and to follow the prescribed
treatment plan consistently in order to achieve the best possible results.’
I’m sure most of you will agree that the answers are pretty convincing and would certainly
appear to be doing much of the ‘heavy lifting’ of devising a viewpoint on a particular issue.
Everybody having answers, to every question about everything available, literally at the touch
of a button, will, in a short period of time, reveal the as yet ‘unknown unknowns’. Let’s hope none
of these seriously conflicts with the laudable aims of this project.
All articles published in Orthodontic Update are subject to review by specialist referees in the appropriate dental disciplines.
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January 2023
Guest Editorial
Paul Cornish
Working for a Dental
Corporate Body
This article relates my experience of selling my orthodontic
practice to a dental corporate body. It includes the advantages and
disadvantages of the sale, and my advice and recommendations to
anybody who is considering such a move. Some decisions made by
the dental corporate body did have an indirect impact upon clinical
practice. The objective of the article is to highlight the advantages
and pitfalls of selling an orthodontic practice and how to attempt to
mitigate against the latter as much as possible.
I jointly opened my orthodontic practice on the first of October
2000 with my colleague, Dr Stephen Duffy. It was in an ideal
location on the first floor of a premises in North Leeds. In a newly
built shopping centre, with extensive parking and ideally located
for easy access by private and public transport, the landlords had
earmarked a large first floor area for use as a general medical
practice. The premises were vacant, and we approached the
landlords with a view to leasing them for a 20-year period. It already
had planning permission for both dental and medical use, so it was
a relatively quick process to convert and equip the practice.
Over a period of 16 weeks the practice was completed and
ready to open. It consisted of an open plan area that contained
six clinical units and two side surgeries, each one a single clinical
unit. An office, X-ray room, laboratory, practice coordinator office,
shower, toilets and baby changing facilities, staff room with kitchen,
reception area and a storage system for 5000 sets of study models
completed the picture.
The practice thrived and over the next 5 years became an
extremely busy mixed NHS and private practice. At that time all
practices were free to accept as many patients who requested NHS
treatment as they desired. With the introduction of the new NHS
orthodontic contract of 2006, this situation changed overnight. For
the first time, a contract was in place that limited NHS orthodontic
treatment to existing providers, and a contract value was placed
on the practice. Our contract value was high and we were the main
Paul Cornish, BDS, MSc, DOrth RCS (Eng), MOrth RCS(Eng), FDSRCS (Eng), Retired Orthodontist and previous co-owner of Orthosolutions,
Leeds. Email: lizandpaulcornish@btopenworld.com
Orthodontic Update 7
provider of treatment in Leeds. In 2009, we were approached by
Integrated Dental Holdings (IDH). They wished to buy the practice
and after protracted negotiation we agreed terms and the sale
was completed.
A new practice owner
Thankfully IDH proved to be a thoroughly ‘benign’ owner. Clearly,
they had much experience of buying successful dental practices
and took an extremely ‘hands off’ approach to their new acquisition.
This was a mutually agreeable situation because we were left to
effectively run the practice exactly as before. While IDH obviously
wanted to maximize profit, they trusted us, as the people who
had made the practice successful, to continue to work in the same
vein. We had complete clinical freedom, could use a laboratory
of our choice and use any of the recognized orthodontic supply
companies. That is not to say that there were absolutely no issues,
but no more than one might expect from a reasonable owner. We
continued in this extremely agreeable way for many years and both
parties were happy with the arrangement.
Things were about to change. IDH then sold all their practices,
and the new owners decided on a major rebrand. That alone would
have been absolutely fine, but along with the rebrand came a new
management team that were of an entirely different mindset to
IDH. Their view seemed to be that the clinicians who had made the
practice so successful for many years, would now be bypassed when
clinical decisions were to be made. That materially affected the
character and mindset of all working within the practice, as well as
the clinical profile of the practice.
A good example was the decision to expand the range
of services offered, and to this end it was proposed that an
implantologist and an endodontist should be employed. The
clinician’s office was converted, at great expense, to a new surgery
for the implantologist and we were exhorted to persuade patients
8 Orthodontic Update January 2023

to use this services. It did not occur to the management that sure you sell it to the best of the dental corporate bodies (DCBs).
only a very small number of adult patients actually required the I strongly recommend that you do your research and track down
services of an implantologist and that the GDPs who referred their people who have already sold to your prospective buyer. There are
patients for orthodontic treatment may not take too kindly to many DCBs out there and I have heard some quite alarming reports
their patients being offered ‘other services’ at another practice. To about several of them.
nobody’s great surprise, and despite our frequent warnings, this When negotiating the sale, it is human nature to concentrate
departure from the status quo produced absolutely no patients solely on the sale price. While this is extremely important, it is also
at all for the implantology service. Not one! It was then implied
vital to try to future proof non-financial aspects of the sale. For
by the management that this lack of patients was because the
example, with hindsight, I would have inserted a clause that the
clinicians and ancillary staff had not been sufficiently enthusiastic
practice would remain an entirely specialist orthodontic practice,
about the new service on offer. It did not occur to them that that
was not actually our role. We were orthodontic specialists who had unless both parties agree to a variation of the contract.
the best interests of our patients first and foremost in our minds, It has to be said that there are a number of good things about
not salespeople. working for a DCB after selling your practice. Aside from the
Sadly, more and more clinical and non-clinical decisions were obvious financial rewards, the laborious parts of owning a practice
made in the practice that negatively impacted upon the morale disappear immediately. The relentless paperwork and regulatory
of the staff. As a result, morale plummeted and staff began to hurdles that increased year on year, almost drove me to despair.
leave. New replacement staff were rapidly employed, but often left Instead of coming home after a long and exhausting day and
quickly, leaving us chronically understaffed for a long period of reluctantly disappearing into your office for a couple of hours you
time. The ‘management team’ seemed utterly oblivious about what can just collapse on the sofa, put your feet up and watch Eggheads
the ingredients were for a successful practice, and simply ignored (other general knowledge quizzes are available).
legitimate, frequent complaints. In football parlance, they had ‘lost There are however disadvantages too. When I owned my
the dressing room.’ practice, I was entirely responsible for the acts and omissions of my
The final straw for me was when the study model filing system staff, as well as having to maintain the high standards expected of
was removed, without any consultation whatsoever, and the all any professional person. Any failings would have made me liable
of the patients’ orthodontic models were transferred to a distant
to a GDC hearing. Inexplicably, the same standards do not seem to
practice in Barnsley, over 30 miles away. This included the models
apply to the owners of DCBs. I have highlighted above the casual
of patients under current treatment, so there was a potential
attitude of the management regarding the need to maintain
clinical negligence issue. The models were literally dumped there,
in the most haphazard way imaginable, and despite my written excellent record keeping. I am sure that they would not have
protests, I was fobbed off with ‘that they were stored correctly, and been as cavalier if they were held accountable in the same way as
they were of course immediately retrievable.’ practice owners. This is something that needs addressing so that
I felt I had no choice but to resign and worked my requisite patients are protected from the failings of the less scrupulous DCBs.
6 months’ notice period. In my resignation letter I detailed the Finally, it is 13 years since I sold to IDH. There have been
many reasons for leaving, including the medico-legal implications dramatic changes since then regarding profitability within the DCB
for both the practice and for myself, but did not even receive world. Although it has been said many times in the past, by a large
a reply. My final day of work was the 1st October 2019, exactly number of experienced clinicians, I am another one who cannot
19 years after the initial practice opening. really see a healthy future for NHS Orthodontics. l know many
The practice finally closed in June 2022, having lost the clinicians who, having worked for the NHS, are now fully private,
NHS contract. and I don’t know any who regret this transition. I foresee many
DCBs struggling to survive in the future. If I were in my fifties now
Lessons learned and still working, with the benefit of the retrospectoscope, I think it
So, what have I learned from my experience? The most important extremely unlikely that I would sell my practice to a DCB. After all,
thing to realize is that you can only sell your practice once, so make nobody looks after a baby better than its parent.

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10 Orthodontics January 2023

Enhanced CPD DO C

Rob AC Chate

The FR BCPPm:
A Novel, Hybrid
Function Regulator
Abstract: The design features of a novel, hybrid function regulator, the FR BCPPm, are presented to facilitate the construction of other
such appliances that may be used in the treatment of juveniles with a prominent premaxilla associated with a bilateral cleft lip and palate
and mandibular retrusion. As an essential prerequisite to facilitate secondary alveolar bone grafting, how it may be used and the results
that can be achieved are documented in a single case.
CPD/Clinical Relevance: To illustrate the design features of a novel function regulator in detail, which may be used to correct a prominent
premaxilla in a patient with bilateral cleft lip and palate.
Ortho Update 2023; 16: 10–18

The correction of a bilateral cleft’s
prominent pre-maxilla is a challenging
clinical problem, but a recent case report
has illustrated a successful outcome after
a decade of treatment with a novel, hybrid
functional appliance, namely the Function
Regulator, for use in juveniles with
mandibular retrusion, a bilateral cleft and
a prominent premaxilla (the FR BCPPm),
together with a nocturnal high-pull
headgear, a quad helix (QH) appliance,
followed by a stabilizing transpalatal arch
(TPA) and a subsequent period of post-
functional, pre-adjusted fixed appliances.1
Over half a century ago, Fränkel
first described the design, construction
and clinical management of his various
function regulators for the correction
of Class I, Class II division 1 and Class III
malocclusions,2–5 which others have since
either expanded on, or modified.6–14
The aims of this article are therefore
to describe in detail the design features
of one further, new variant of function
regulator, namely the FR BCPPm, so that
it may be replicated for use in other
patients with bilateral cleft lip and palate
and a prominent premaxilla, and through
a single case, to document its effects
on the growth and development of the
teeth, face and the premaxilla.
Case report
BS was born with a bilateral cleft lip and
palate, which was repaired surgically
with lip closure at 5 months and hard
and soft palate closure at 8 months. By
the age of 7 years, the presence of severe
mandibular retrognathia, a prominent
premaxilla with incompetent lips, palatal
lower lip trapping and a pronounced
Class II division 1 malocclusion in the
early mixed dentition stage was evident
(Figure 1).
The surgeons on the multidisciplinary
cleft team were also concerned about the
very large separations and displacements
between the gingival and alveolar tissues
on either side of both clefts, in relation to
how these would prevent achieving full
soft-tissue coverage after the insertion
of alveolar bone grafts (ABGs), which
would otherwise compromise their post-
operative integration and consolidation.
As such, with only 2 years left before the
patient would reach the youngest age at
which an ABG could be inserted, there
was a sense of urgency to correct the
18.5-mm overjet, the 12-mm increased
overbite, the 12-mm wide alveolar gaps,
the bilateral crossbites and the 6-mm
vertical steps between the posterior and
anterior aspects of the maxillary occlusal
plane (Figure 2).
Consideration was therefore given as
to which appliance could be used during
the deciduous and early mixed dentition
stages and a function regulator of Fränkel
was selected. This was because, unlike
tooth-borne activators, the acrylic parts of

Rob AC Chate, BDS, DDOrth RCPS(Glasg), MOrth RCS(Eng), M Surg Dent RCS(Ed), FDTF(Ed), FDS RCS(Ed), Retired Consultant Orthodontist,
Essex County Hospital, Colchester and The Royal London Dental Hospital
Email: chate@btinternet.com
January 2023
a d
e
b
f
g
c (iv) establishing a normal incisor occlusion;
h so minimize the prospects of either
Figure 1. (a–h) Extra-oral and intra-oral views the patient at age 7. (Figure 1 d–h reproduced by kind
permission of SAGE Publications Inc.)1
a function regulator remain on the outside
of the dental arch, and its component parts
become active, not by being in contact
with the teeth and alveolar processes, but
by standing away from them.4 It is therefore
irrelevant if not all of the permanent
teeth are present for appliance retention
or for tooth movements to be effected,
because the modus operandi of a function
regulator is to stretch and hold away the
soft tissues from the teeth, in order to allow
myofunctional forces to exert their effects
on them, instead.3,5
a
b
To this end, a new functional appliance
was created, the FR BCPPm, which was a
hybridized amalgamation of Fränkel’s FR I
and FR III function regulators, together with
two novel additions; namely a clear acrylic
bulb embedded in an upper labial bow that
encapsulated the premaxillary incisors and
extra-oral traction (EOT) tubes that were
incorporated in the buccal shields of the
appliance (Figure 3).
The FR BCPPm was designed to realize
the clinical objectives of (i) approximating
the opposing cleft alveolar margins
Orthodontics 11
Figure 2. (a) The 12-mm wide alveolar gaps.
(b) The maxillary occlusal plane’s 6-mm
vertical steps.
towards each other; (ii) levelling up the
anterior to the posterior aspects of the
maxillary occlusal plane; (iii) correcting the
bilateral crossbites through the expansion
of the lesser segments of the cleft maxilla;
and (v) creating an anterior oral seal.
The first three of these clinical
objectives were to facilitate achieving
complete, tension-free, mucoperiosteal
flap coverage of the future ABGs and
inadequate peri-operative soft-tissue cover
and/or post-operative wound breakdowns,
either of which could jeopardize the
success of the bone grafts.
The design features of
the FR BCPPm
The aspects of the FR BCPPm that are
drawn from the FR I appliance include
the upper labial bow; the lower incisor
cingulum wires; the lower labial sulcus
acrylic pads and the lower anterior lingual
shield of acrylic (both of which are jointly
constructed to effect forward mandibular
protrusion); the cross-over hanger
wires that pass from the lingual shield
and connect it to the acrylic vestibular
shields; and the vestibular flanges that
are extended in order to project into the
alveolar sulci with generous lateral relief of
the upper buccal segments (Figure 3a–e).
Those that are derived from the FR III
appliance are the transpalatal arch, which
12 Orthodontics January 2023

a a a

Figure 4. Maxillary occlusal views of the quad Figure 5. Schematic profile line diagrams
helix (a) pre-expansion and (b) post-expansion. of (a) the prominent premaxilla and (b) the
(c) Stabilizing Goshgarian TPA. required mandibular protrusion, premaxillary
vertical intrusion + horizontal restraint
and the preferential eruption of the upper
posterior teeth.
e passes distal to the upper terminal molars
from one vestibular shield into the other
on the opposite side, as well as the lower
molar occlusal stops (Figure 3e,f ). Modus operandi of the
The two novel components of the clear FR BCPPm in realizing the
acrylic cup that encapsulates the premaxilla
clinical objectives
and its incisor teeth, together with the
The approximation of the opposing cleft
buccal shields’ EOT tubes are illustrated in
alveolar margins and the levelling of the
Figure 3a–c.
maxillary occlusal plane are achieved
f As part of the treatment with the
through both the vertical intrusion and
FR BCPPm, a QH appliance is used
horizontal restraint of the premaxillary
concomitantly to expand the upper
incisors, together with the unopposed
arch,15,16 followed by a stabilizing, soldered
eruption of the maxillary posterior teeth
Goshgarian-type TPA17–19 that remains in situ
(Figure 5).
until the insertion and consolidation of the
The premaxilla acrylic cup is designed
alveolar bone grafts (Figure 4).
to restrain the downward and forward
Table I lists both the wire dimensions,
development of the premaxillary incisors
and the origins of the appliances’
Figure 3. Views of the FR BCPPm: (a) Right (Figure 6), while the buccal shield EOT
various wire components that are used,
lateral; (b) frontal; (c) left lateral; (d) lower tubes facilitate the insertion of a Kloehn
although these can be seen to vary
antero-lingual; (e) upper occlusal; and (f) facebow and the use of an occipital, high-
lower occlusal.
slightly, depending on which source is
pull headgear at night that supplements
referenced.7,9,10,12,14,16–19
January 2023
Figure 6. Schematic profile line diagram of
the FR BCPPm.
Figure 7. Schematic profile line diagram of the
FR BCPPm with a facebow attached.
Figure 8. An FR BCPPm with a Kloehn facebow
attached to the vestibular shields’ EOT tubes.
Figure 9. Occlusal view of the FR BCPPm on the
work model, showing the lateral relief for the
upper buccal segments and the transpalatal
arch that passes distal to the terminal molars, on
which is cemented a TPA.
the acrylic cup’s intrusive action
(Figures 7 and 8).
Posteriorly, the unopposed eruption
of the maxillary molars is promoted by
the positioning of the interconnecting
Wire components
Upper labial bow
Lower labial pad wires
Lower incisor cingulum wires
Lower lingual hangar wires
Vestibular shields’ transpalatal wire
Lower molar occlusal stops
Quad helix
Transpalatal arch
Table 1. The origins and dimensions of the wire components of the FR BCPPm, the quad helix and
transpalatal arch appliances. FR: function regulator of Fränkel; QH: quad helix; TPA: transpalatal arch.
vestibular shields’ transpalatal arch, which,
rather than passing over the mesial
marginal ridges of the upper terminal
molars, instead passes distal to them
(Figure 3e). In conjunction, the lower molar
stops facilitate the unopposed eruption of
the upper posterior teeth by obstructing
the vertical eruption of the mandibular
terminal molars (Figure 3d,f ).
In the correction of Class II division 1
malocclusions with a function regulator, in
order to avoid creating bilateral crossbites
as the mandibular dentition develops
forwards, generous lateral relief of the
maxillary buccal dentition is incorporated
in the design of an FR I, usually around
3 mm on each side,9 with the upper
peripheries of the acrylic vestibular shields
also extended to purportedly stretch and
thereby stimulate the adjacent peri-oral
musculature. In this way, unopposed
tongue pressure expands the maxillary
dental arch,2–5 and, as a consequence of
the peri-oral musculature tension, it is
claimed that osteogenic activity in the area
of muscle insertion is elicited,3,4,6 which
purportedly facilitates the expansion that
is required to avoid the development
of a buccal crossbite, and to relieve any
crowding as treatment to advance the
mandibular dentition progresses.2–5
However, in situations with a surgically
repaired cleft palate, this feature of
the function regulator that would
normally produce upper arch expansion
is ineffective. This is because of the
inelastic mid-palatal scar tissue and, as a
consequence, concomitant active dental
expansion must be undertaken using a
QH appliance while the FR BCPPm is being
worn instead, which is then subsequently
stabilized by a Goshgarian TPA (Figure 4).
With the design of the FR BCPPm, the
traditional FR I function regulator vestibular
shields’ lateral relief for the upper buccal
Orthodontics 13
Dimensions Origins
(mm)
0.9 FR I
0.9 FR I
0.7 FR I
1.25 FR I
1.0 FR III
1.0 FR III
0.9 Bio-progressive therapy
0.9 Goshgarian TPA
segments provides clearance into which
the upper canines and posterior teeth can
be expanded (Figure 3e), while the FR III’s
transpalatal arch, which passes distal to the
upper terminal molars, also avoids physical
contact and/or interference with either
the QH or the TPA, which are cemented by
bands onto the maxillary first permanent
molars (Figure 9).
In order to establish a normal incisor
occlusion, a clinical construction bite must
be taken with approximately 4.0–6.0 mm
of mandibular advancement, which will
usually result in an incisor edge-to-edge
occlusion.9 For more severe Class II cases,
the mandible needs to be re-advanced
approximately 6 months later, either by
constructing a new function regulator,9 or
by advancing the lower labial and lingual
acrylic pads downwards and forwards as
a unit,13 across the split vestibular shields
that may be pre-emptively incorporated
in the appliance’s initial design
and construction.4,5
It is the co-related anterior positioning
of the lower labial lip pads and the
lingual shield in a function regulator that
encourages the adoption of a protruded
mandibular position, and it is this that
effects the Class II incisor correction.
Fränkel emphasized that the difference
between his function regulator and tooth-
borne activator functional appliances
was that rather than producing a Class II
traction effect on the upper and lower
dentitions,4 whenever the mandible tries to
fall back into its habitual distal position, the
lingual acrylic shield produces a reaction
by making contact with the mucosa at the
lingual surfaces of the alveolar process,3
and thereby through feed-back, the lateral
pterygoid muscles are activated to protract
the mandible and so purportedly stimulate
compensatory growth of the condylar
cartilage, instead.4,5
14 Orthodontics
a a
b b
c c
c
Figure 10. (a–c) Intra-oral views of the FR BCPPm
being worn. (Reproduced by kind permission of
SAGE Publications Inc.)1
Figure 11. An occipital, high-pull headgear worn
with the FR BCPPm.
In reality though, while the lower
incisor cingulum wires are designed to
prevent only lower incisor extrusion during
treatment as a means of reducing a deep
overbite,9 they do result in lower incisor
proclination,20,21 which is why an appliance
a
Figure 12. (a–c) Intra-oral views of the over-
expanded upper buccal segments.
modification has been previously described
to try to limit this.8
For similar reasons, the FR II was created
with an additional wire palatal to the upper
incisors,9 in order to counter the FR 1 upper
labial bow’s tendency to retrocline the
upper incisors during treatment.20,21
However, in those Class II cases with
proclined maxillary incisors, retroclination
by the upper labial bow is desirable, but
in the case of the FR BCPPm, its primary
role is to provide a means of connecting
the premaxillary acrylic cup to the body of
the appliance.
In order to establish an anterior oral
seal, the lower labial sulcus acrylic pads
act to: (i) inhibit the aberrant vertical
contraction of the mentalis muscles;9
(ii) prevent the lower lip from curling
outwards, erecting it to contact the upper
lip, instead;5 and (iii) flatten the pronounced
labio-mental sulcus.9
However, it is suggested that to
effectively establish an anterior oral seal,
the use of lip-seal training exercises in
conjunction with the lower labial pads is
also essential.4,5,9
However, if these acrylic pads are
not constructed to fit into the depth of
the lower labial sulcus,9,20 or if they are
subsequently advanced just horizontally
forwards from the depth of the lower labial
sulcus, rather than being advanced both
downwards and forwards when further
protrusive activation is required,13 this
can result in lower incisor proclination.
This is because the pads then push
against orbicularis oris, which creates a
January 2023
Figure 13. (a–d) Intra-oral views of the
stabilizing maxillary arch bar that was modified
from a Kloehn facebow.
lower lip bumper effect that leaves the
tongue pressure against the lower incisors
unopposed, thereby resulting in their
unwanted proclination. In addition, the
desired restrictive effect of the lower labial
acrylic pads on the aberrant mentalis
muscle activity is also lost,20 which
consequently compromises the ultimate
establishment of competent lips.9
Clinical deployment and
standard regimen of wear of
the FR BCPPm
At the age of 7 years, BS was supplied with,
and instructed to wear, his FR BCPPm for
only 2 hours per day for the first fortnight,
thereafter progressing to additional night-
time wear for a month, followed by a
gradual advance to full-time wear at his
own pace (excluding sports and eating), as
previously recommended (Figure 10).3,6
After 7 months, he reached full-time
wear of the FR BCPPm and 6 months later,
at the age of 8.5 years, the nocturnal wear
of an occipital-pull headgear was initiated
(Figure 11).
Note should be made in the illustration
that only a single headgear safety product
was used, namely a snap-away safety clip,
January 2023
a a
Figure 14. The pre-functional appliance: (a)
lateral cephalogram and (b) tracing.
because at the time of its application in
the early 1990s, the selection of just one
of any such safety products per headgear
prescription was standard practice.22 It was
not until well after the cessation of this
patient’s treatment that the use of two
separate, independent headgear safety
products became the established norm.23
In relation to the number of scheduled
appointments that are required to
monitor progress with the FR BCPPm,
although function regulators have no wire
components that need to be reactivated,
the lower lingual acrylic shields and
the vestibular-extended buccal shields
require frequent and regular reviews.
This is because as the mandible tries to
fall back into its habitual distal position,
the lower lingual shield stimulates a
protrusive reaction by making contact
with the mucosa at the lingual surfaces of
the alveolar process.3 If the shield’s acrylic
does not remain well below the gingival
margins of the lower anterior teeth
throughout, there is a risk of irritation and
stripping of the lingual gingiva.9
Orthodontics 15
a
Figure 15. The post-functional appliance: (a)
lateral cephalogram and (b) tracing.
Figure 16. The (a) craniofacial, (b) maxillary
and (c) mandibular regional cephalometric
For the same reasons, the differentiation
superimposition tracings after the first 2 years
between areas of mucosal erythema
of treatment.
associated with the pressure exerted by the
vertically extended vestibular shields and
overt traumatic ulcerations also requires
close attention.6 After the consolidation of his grafts
The patient wore his FR BCPPm full
and the removal of his arch bar and TPA, a
time, and after 2 years, he was supplied
new FR BCPPm was supplied. It was worn
with a QH to correct his crossbites.
only at night from the age of 11 until all of
Figure 12 shows the over-expansion that
his permanent teeth had erupted at age
was achieved 6 months later. Unfortunately,
13, after which he commenced a second
7 months after his first TPA was inserted,
stage of treatment with non-extraction
one of the soldered joints failed and
the crossbites relapsed. It took a further fixed appliances.1
8 months for another QH to recover the
situation, after which a new TPA was fitted The effect of the FR BCPPm
and wear of the FR BCPPm was temporarily
suspended while a stabilizing maxillary
on the growth of the
arch bar to immobilize the maxillary cleft dentition and jaws
segments was applied,24 just prior to his Plain film lateral cephalograms were taken
admission for the insertion of the ABGs at the start of his treatment (Figure 14), at
(Figure 13). the end of his functional appliance phase
16 Orthodontics
a a
b
b
c (Figure 17). In the maxilla, the upper
c as a consequence of the QH and the
Figure 17. The (a) craniofacial, (b) maxillary
and (c) mandibular regional cephalometric
superimposition tracings after the second 2 years
of treatment.
(Figure 15) and biennially in between. These
radiographs were then electronically digitized
in order to generate computerized lateral
cephalometric evaluations and tracings.
For the regional maxillary and mandibular
outlines, the radiographs were hand-
traced, instead. For all of the craniofacial
cephalometric superimpositions, registrations
were made on the sella-nasion line at sella,
while the regional superimpositions were
made using Björk’s mandibular and maxillary
stable structures.25,26
Figure 18. The (a) craniofacial, (b) maxillary
and (c) mandibular regional cephalometric
superimposition tracings after 2 years of
nocturnal retention.
Figure 16 shows how in the first 2 years
of full-time wear of the FR BCPPm and its
nocturnal headgear, the downward and
forward growth of the premaxilla was
restrained and a forward and rather more
downward development of the mandible
was realized. In the maxilla, the upper
molars erupted more than the incisors and
these latter teeth retroclined noticeably.
In the mandible, the lower first permanent
molars erupted into the mouth and the
lower incisors uprighted labially.
January 2023
Figure 19. The craniofacial cephalometric
superimposition tracing at the end of 6 years of
functional appliance treatment.
After the second 2 years of full-time
wear, the growth of the premaxilla
continued to be restrained and the
mandibular pattern of growth became
equally downward and forward
molars were tipped distally (perhaps
TPA that were used during this stage of
the treatment) and the upper incisors
appeared to be bodily retracted. In the
mandible, there was minimal change
in the position of either the molars or
the incisors.
In the 2-year period when the
FR BCPPm was then only worn at night
while awaiting eruption of the permanent
dentition, Figure 18 shows that the
downward and forward restraint on the
premaxilla continued, the palatal plane
rotated slightly downwards at the back
and the growth of the mandible was
predominantly horizontal. In the maxilla,
the upper molars moved forwards, back
to their initial, pre-QH expansion and the
TPA retained anteroposterior positions,
and the upper incisors retroclined a
little further. In the mandible, the lower
molar crowns moved slightly forwards,
with greater forward translation and
anticlockwise rotation of their roots, while
the lower incisors moved slightly lingually.
The total effect that the FR BCPPm
had on the teeth and facial skeleton
during the entire 6-year period of its
use may be seen in the cephalometric
superimposition of Figure 19, while
Figure 20 illustrates the clinical outcome
at the end of the functional appliance
treatment, namely a Class II division 2
malocclusion with retroclined upper
January 2023
a d
e prominent premaxillae.
f degree of premaxillary protrusion should
b
g
h at The Royal London and Whipps Cross
c
Figure 20. The (a–c) extra- and (d–h) intra-oral
views at the end of the functional appliance
treatment. (Figure 20 d–h reproduced by kind
permission of SAGE Publications Inc.)1
incisors, a 13.5-mm reduction in the original
overjet, a 2-mm reduction in the increased,
complete overbite, a bilateral Angle’s Class
I molar relationship, consolidated alveolar
bone grafts and the development of lower-
arch crowding.
From this point, the patient progressed
to a second stage of non-extraction fixed-
appliance treatment, in order to complete
the correction of his residual malocclusion.1
Orthodontics 17
Summary
The design features of the FR BCPPm are
presented which, in conjunction with other
detailed publications on the laboratory
construction of function regulators,7,9,12,14
may be used to replicate this novel, hybrid
Fränkel functional appliance for use in
other patients with bilateral cleft-related
From this single case, for an FR BCPPm
and its corollary QH to be able to restrain
the premaxilla, reduce the alveolar
gaps, correct the crossbites and level
the maxillary occlusal plane prior to the
insertion of ABGs, clinicians treating
other bilateral cleft patients with a similar
allow a lead-in time of 2–3 years ahead of
the age when it is estimated the patient
will be developmentally ready for their
bone grafts.
Acknowledgements
My thanks to Ray Sinclair of the
Department of Medical Photography,
Colchester Hospital University Foundation
NHS Trust, for many of the slide
illustrations; to Daren Fitchew of The Slide
Converter, Shoeburyness, Essex, for the
digitization of all the clinical slides; to
Wayne Hallum, of Sheffield Orthodontic
Laboratories Ltd, for the laser scanned
e-study models and the laboratory support;
to Rakhee Talati, consultant orthodontist
Hospitals, for granting access to her
OPAL cephalometric digitizing system
and to Ciarán Devine for providing the
support in generating some of the latter
cephalometric superimpostions.
Compliance with Ethical Standards
Conflict of Interest: The authors declare that
they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
References
1. Chate RA. Correction of a prominent
premaxilla in a juvenile with a
bilateral cleft lip and palate using a
novel, hybrid function regulator, the
FR-BCPPm, followed by preadjusted
fixed appliances: a 20-year follow-up. J
Orthod 2022; 49: 426–440. https://doi.
org/10.1177/14653125221079635
2. Fränkel R. The theoretical concept
underlying the treatment with function
correctors. Rep Congr Eur Orthod Soc 1966;
42: 233–254.
3. Fränkel R. The treatment of Class II, division
1 malocclusion with functional correctors.
Am J Orthod 1969; 55: 265–275. https://doi.
18 Orthodontics January 2023

org/10.1016/0002-9416(69)90106-7
4. Fränkel R. Decrowding during eruption
under the screening influence of
vestibular shields. Am J Orthod 1974; 65:
372–406. https://doi.org/10.1016/0002-
9416(74)90271-1
5. Fränkel R. A functional approach to orofacial
orthopaedics. Br J Orthod 1980; 7: 41–51.
https://doi.org/10.1179/bjo.7.1.41
6. Eirew HL, McDowell F, Phillips JG. The
function regulator of Fränkel: clinical
management. Br J Orthod 1976; 3: 67–70.
https://doi.org/10.1179/bjo.3.2.67
7. Graber TM, Neumann B. The Fränkel
appliance (the function corrector). In:
Removable Orthodontic Appliances.
Philadelphia, PA, USA: WB Saunders, 1977.
8. Eirew HL, McDowell F, Phillips JG. The
Fraenkel appliance – avoidance of lower
incisor proclination. Br J Orthod 1981;
8: 189–191. https://doi.org/10.1179/
bjo.8.4.189
9. McNamara JA Jr, Huge SA. The Fränkel
appliance (FR-2): model preparation and
appliance construction. Am J Orthod 1981;
80: 478–495. https://doi.org/10.1016/0002-
9416(81)90244-x
10. McNamara JA Jr. JCO interviews Dr James A
McNamara, Jr on the Frankel appliance. Part
1 – Biological basis and appliance design. J
Clin Orthod 1982; 16: 320–337.
11. McNamara JA Jr. JCO/interviews Dr James A
McNamara, Jr on the Frankel appliance. Part
2 – Clinical management. J Clin Orthod 1982;
16: 390–407.
12. McNamara JA Jr, Huge SA. The functional
regulator (FR-3) of Fränkel. Am J
Orthod 1985; 88: 409–424. https://doi.
org/10.1016/0002-9416(85)90068-5
13. Chate RA. Angulation of the crossover wires
for advancement of the FR-2 appliance. J
Clin Orthod 1986; 20: 43–45.
14. Orton HS. Functional Appliances in
Orthodontic Treatment: An Atlas of Clinical
Prescriptions and Laboratory Construction.
London: Quintessence, 1990.
15. Brandt S, Ricketts RM. Interview: Dr Robert
M Ricketts on growth prediction. 2. J Clin
Orthod 1975; 9: 340–362.
16. Birnie DJ, McNamara TG. The quadhelix
appliance. Br J Orthod 1980; 7: 115–120.
https://doi.org/10.1179/bjo.7.3.115
17. Goshgarian RA. Orthodontic palatal arch
wires. United States Government Patent
Office, 1972.
18. Baldini G, Luder HU. Influence of arch shape
on the transverse effects of transpalatal
arches of the Goshgarian type during
application of buccal root torque. Am J
Orthod 1982; 81: 202–208. https://doi.
org/10.1016/0002-9416(82)90053-7
19. Kharche A, Durkar S, Kawale P et al.
Transpalatal arch: an overview of literature. J
Adv Med Dent Scie Res 2019: 7: 26–32.
20. McNamara JA Jr, Bookstein FL, Shaughnessy
TG. Skeletal and dental changes
following functional regulator therapy
on class II patients. Am J Orthod 1985; 88:
91–110. https://doi.org/10.1016/0002-
9416(85)90233-7
21. Kerr WJ, TenHave TR, McNamara JA Jr. A
comparison of skeletal and dental changes
produced by function regulators (FR-2
and FR-3). Eur J Orthod 1989; 11: 235–242.
https://doi.org/10.1093/oxfordjournals.ejo.
a035991
22. Postlethwaite KM. Safety headgear
products. Br J Orthod 1990; 17: 329–331.
https://doi.org/10.1179/bjo.17.4.329
23. British Orthodontic Society. The use of
headgear and facebows. Advice Sheet 8.
2001.
24. Chate RA, Clarke JE. A modified Kloehn
bow for cranio-maxillary fixation. Br J Oral
Maxillofac Surg 1992; 30: 348. https://doi.
org/10.1016/0266-4356(92)90191-k
25. Björk A. Prediction of mandibular
growth rotation. Am J Orthod 1969; 55:
585–599. https://doi.org/10.1016/0002-
9416(69)90036-0
26. Björk A, Skieller V. Growth of the
maxilla in three dimensions as revealed
radiographically by the implant method.
Br J Orthod 1977; 4: 53–64. https://doi.
org/10.1179/bjo.4.2.53

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20 Orthodontics January 2023

Enhanced CPD DO C

Fatemeh Roshanray Cara Sandler PJ Sandler

Root Resorption:
Why we all need to get
Informed Consent
Abstract: Severe root resorption is a rare, but serious, complication of orthodontic treatment, which can affect the long-term prognosis
of the teeth affected. This case presents a young, healthy patient with severe root resorption affecting nearly all of her dentition. It was
an incidental finding by her GDP 8 months after completion of her orthodontic treatment. The article aims to raise awareness about the
importance of obtaining a valid consent at the start of each orthodontic treatment, and highlight the possible risk factors associated with
severe root resorption, diagnostic methods, and interventions to prevent or manage it when it occurs.
CPD/Clinical Relevance: Although developing severe root resorption as a result of orthodontic treatment is relatively uncommon, the
consequences are serious. This article highlights the importance of identifying high-risk orthodontic patients, where possible, and
obtaining valid, informed consent prior to every course of orthodontic treatment.
Ortho Update 2023; 16: 20–25

Orthodontically induced inflammatory
root resorption (OIIRR) is a term used
to describe the iatrogenic damage
caused to the roots of teeth as a result of
orthodontic treatment, leading to root
shortening. It is also known as external
apical root resorption (EARR).1,2 Root
resorption (RR) was first attributed to
orthodontics by Ottolengui in 1914.3
Orthodontics uses the body’s own natural
inflammatory process to allow movement
of the dentition into the desired position.
OIIRR occurs when osteoclastic activity
exceeds the reparative capacity of the root
cementum.4,5 Orthodontically induced
EARR (OIEARR)6,7 is associated with both
patient-related factors, such as gender,
age, genetics, medical history, abnormal
root morphology, previously root-filled
or traumatized teeth, and also several
treatment-related risk factors, such
as magnitude, direction and duration
of orthodontic forces and types of
appliances used.2,5,8,9
Radiographic and histological
findings claim 73% and 90% of patients,
respectively, experience OIEARR following
orthodontic treatment.2 In order for
OIEARR to be classified as severe, more
than 4 mm or one-third of the entire root
length has to be resorbed, which in one
study has been shown to affect nearly 15%
of orthodontic patients.5 Other studies
suggest only 1–5% of orthodontically
moved teeth are severely affected.2,7
Maxillary followed by mandibular incisors
are the most commonly affected teeth,2
with maxillary incisors having a mean
resorption of 0.49 mm,9 which, from a
clinical point of view, is insignificant.
Emphasis is placed on assessing the
potential for root resorption and, where
possible, preventing this irreversible
and destructive process because of its
serious threat to the longevity of the
teeth involved and to the treatment
outcomes.2,9 Despite the high prevalence
of OIEARR, there is no high-quality
evidence to create definitive guidelines
to manage this problem, or to advise
best methods for prevention or indicate
the prognosis of the resorbed teeth
with regards to their periodontal status,
mobility and viability.7
Diagnosis of OIEARR is predominantly
carried out through radiographic imaging,
since patients often have no clinical signs,
except in very severe cases where mobility
is present. Two-dimensional imaging, such
as peri-apical and panoramic radiographs,
is the most commonly used method of
detecting OIEARR. Three-dimensional
methods, such as cone beam computed
tomography (CBCT) are, however,
becoming an increasingly popular method
of assessing RR.8,9

Fatemeh Roshanray, 5th BDS, University of Sheffield. Cara Sandler, BDS, MFDS RCPS (Glas), PGCert ClinEd, Community Dental Officer.
PJ Sandler, BDS(Hons), MSc, PhD, MOrthRCS, FDSRCPS, Consultant Orthodontist, Chesterfield Royal Hospital.
Email: fatemeh.ray@gmail.com
January 2023
a c
e
b
Case report
A 12-year-old female presented in May
2016, in the permanent dentition, with
a Class 3 skeletal pattern due to a mild
maxillary hypoplasia, and a Class 3 incisor
relationship and a retained upper right
deciduous canine (Figure 1).
The pre-treatment OPT, with the
benefit of hindsight, perhaps showed
some slight root shortening of the lower
first molars and the upper left first molar;
however, a quick scan of the radiograph
would have probably concluded that
there were reasonable root lengths and
good bone levels, wisdom teeth present,
and little else of note. The pre-treatment
cephalogram confirmed a slight maxillary
hypoplasia, but again nothing else
of note.
The patient underwent a routine
course of orthodontic treatment involving
extraction of lower second premolars
to facilitate camouflage of the Class 3
malocclusion, expansion of the maxillary
dentition with a quadhelix, upper and
lower fixed appliances and intra-oral
elastics. The treatment time was slightly
f
Figure 1. (a–g) Pre-treatment extra- and intra-oral photographs. (h) Pre-treatment
panoramic radiograph.
longer than average, at 36 months.
Despite this, there was no indication
to take further radiographs, as spaces
had largely been closed, the teeth were
aligned well and the patient and her
parents were all delighted with the result
achieved (Figure 2).
At 8 months following debond, the
patient’s general dental practitioner (GDP)
saw her as an emergency. The patient
reported that she had been fighting with
her brother 3 weeks previously, and was
now complaining of a painful, slightly
loose upper left central incisor. She also
felt that several of her lower teeth were
mobile after the collision. Although
the patient had been provided with
Orthodontics 21
removable retainers, she admitted to her
dentist she had not been wearing them.
Radiographs taken by the GDP
indicated significant root resorption
of her upper left central incisor and
affecting several of her upper and lower
front teeth. She was then referred to
the Charles Clifford Dental Hospital for
specialist endodontic advice.
While awaiting this appointment,
the specialist practitioner who had
provided the treatment reviewed the
patient, discussed root resorption
and its long-term management, and
fitted both upper and lower bonded
retainers, and also remade the vacuum-
formed retainers.
22 Orthodontics
a d
e regular monitoring. She was reassured
b required 2 or 3 years later to determine
f
c whether CBCT under-9 or overestimates8
g
Figure 2. (a–g) Post-treatment extra- and intra-oral photographs.
The specialist restorative opinion
from the dental hospital noted that
while the UL1 had grade 1–2 mobility,
the other incisors had grade 1 mobility,
and none of the teeth was tender
to percussion. All of the teeth gave
a positive response to electric pulp
testing, with the exception of the UL1;
however, this tooth was responding
to cold stimuli. Radiographs taken at
the Charles Clifford dental hospital
were suggestive of external surface
resorption involving all incisors
(Figure 3).
It was decided that no further
investigations or treatment were required
for any of the teeth. The UL1 did not
require endodontic treatment at this
stage,, but needed to be monitored in
the future.
When the patient was seen at their
local hospital, a CBCT scan was taken so
the exact extent of the root resorption
was fully documented (Figure 4). The
consultant orthodontist explained to
the patient and parents that this was an
extreme presentation of root resorption,
which they had been warned about at the
January 2023
start of treatment. It was explained that
it was unusual to see this extent of root
damage, but that everything possible
had been done to maintain the health
of the teeth in the short to medium
term by placing bonded retainers as
well as providing removable retainers.
The retention protocol was discussed in
detail to ensure that the parents and the
patient understood the importance of
that the hospital, together with the
restorative department of the local
dental hospital, would do their utmost to
maximize dental health in the long term.
Another set of detailed images,
involving a repeat CBCT, would be
whether the root resorption had
progressed. The findings could then
be discussed with the patient and
her parents.
Discussion
2D imaging exposes patients to a lower
dose of radiation and is more widely
available, while 3D methods produce
more specific, less magnified and
distorted images that allow assessment
of all aspects of the roots.8,9 This is,
however, at a cost of 15–140 times higher
radiation exposure dose to the patient.8
Although controversy exists around
the amount of OIIRR compared to 2D
methods, the difference is probably not
clinically significant. The risk-to-benefit
ratio must be weighed by the clinician
on a patient-to-patient basis.8 Biological
markers, such as inflammatory, bone
remodelling and dentine matrix protein
markers in saliva or gingival crevicular
fluid, are potentially the diagnostic tools
of the future that could be used for early
and safer diagnosis of OIIRR; however,
further research is required prior to their
widespread clinical use.10
Early detection, wherever possible, is
important in the management of severe
OIIRR because discontinuation of the
orthodontic force on the teeth may cease
the resorptive process of the roots.5,11 In
very severe cases where the teeth have
become mobile, splinting might also
be indicated12 to enhance their long-
term prognosis.
According to a Cochrane review,
there is little evidence to recommend
particular interventions for the
management of OIIRR.12 However, a
more recent randomized controlled
trial concluded that daily application of
January 2023 Orthodontics 23

a c a

b
b

low-intensity pulsed ultrasound during

orthodontic treatment decreased OIIRR
while also enhancing tooth movement.13
There is no conclusive data to show
that interventions, such as ultrasound
or low-level laser therapy, actually
improve OIIRR.14
British Orthodontic Society
guidelines for the use of radiographs
in clinical orthodontics indicate that
obtaining intra-oral radiographs during
orthodontic treatment to assess OIEARR
is only justified when there is clinical
evidence of excessive mobility, loss
of vitality, abnormal delay in tooth
movement, extended treatment periods
or repeated treatments. Routine end-of-
treatment radiographs to check for RR
are, therefore, not recommended.15
In order to minimize the effects
of OIEARR, the risk level of patients
should be individually assessed, as
part of obtaining the valid consent. It
is important to identify the patient-
related risk factors prior to commencing
orthodontic treatment; therefore,
thorough history-taking is essential.
Age and gender are two factors that are
suggested to influence OIEARR, although
one systematic review suggested that
resorption occurs irrespective of the
c
Figure 3. (a–d) Peri-apical films from the dental
hospital.
patient’s age and gender.7 Other risk
factors have been suggested to impact
how different individuals experience
OIEARR; however, there is a low level of
evidence to support these findings.7 This
list includes patients with pre-treatment
trauma to their teeth, endodontically
treated teeth, abnormal root length/
shape (pointed, pipette, dilacerated),
agenesis, previous orthodontic
treatment, increased overjet/overbite
and corrected impacted canines.2,7
Systemic illnesses (asthma) and some
medications (steroids, NSAIDs, thyroxine
and systemic fluoride) can also impact
the development of OIEARR.16,17 Patients
taking bisphosphonates have shown
milder root resorption and a slower rate
of orthodontic tooth movement.18
It is therefore important that
patients with these risk factors are
Figure 4. (a–c) CBCT images to fully document
the extent of the root resorption.
identified early, by obtaining a thorough
medical history and performing a
careful examination following which,
if deemed vulnerable, are informed of
their higher risk of developing OIEARR
prior to the treatment. This might also
be an indication for them to have more
frequent follow-up appointments
focusing on the signs of increased
tooth mobility, and mid-treatment and
possibly post-treatment radiographs
could be justified to monitor
their condition.
24 Orthodontics
Figure 5. Patient information leaflet from the BOS
According to the General Dental
Council standards, valid consent must
incorporate all the consequences
and risks involved with a proposed
treatment.19 It is therefore important to
know the risk level of each treatment
prescribed to relay this information to
the patient, so that they can then make
an informed decision.
Specific orthodontic mechano-
therapies have been suggested to have
variable effects on the development or
prevention of OIEARR; however, there is
only a low level of evidence to support
them.5 It has been clearly established
that there is a positive correlation
between the application of orthodontic
forces and the incidence, as well as
the extent, of EARR.5 The probability of
developing OIEARR also increases with
continuous, rather than intermittent,
application of forces, in addition to
longer treatment durations.2,5,20 The
former believed to be due to a lack of
recovery time, preventing the dental
tissues from healing following the
inflammatory process.5 It is generally
accepted that resorption of the roots
will cease, and the reparative process
will begin once the orthodontic forces
have been discontinued. The use of
both intrusive and heavy forces have
been linked to an increased incidence
of OIEARR. Compression on periodontal
ligaments, rather than tension, appears
to contribute to EARR, which is why
intrusion of dentition, especially
the incisors, imposes a greater risk
than extrusion.2,5 A Cochrane review
concluded that there is insufficient
evidence to suggest a favoured archwire
type in terms of preventing OIEARR.21
The sequence of archwires used, the
bracket slot size22 and the choice of
ligation system have also been shown to
have no significant effect on the amount
of OIEARR.2,5,7 When teeth are extracted
as part of an orthodontic treatment
plan, the risk of OIEARR has been shown
to increase, which is probably linked to
January 2023
longer treatment times.7,8,20 Comparing
clear aligners and pre-adjusted edgewise
appliances, research shows that neither
cause a clinically significant EARR in the
maxillary incisors.9
The uncertainty around the efficacy
of preventive measures or relative
importance of exacerbating factors in
relation to OIIRR, brings into question
the validity of the consent taken at the
beginning of each orthodontic episode.
It also highlights the need for further
research in this area to increase the
quality of the guidance for the clinicians
to follow.
The patient information leaflet
outlining orthodontic treatment risks
by the British Orthodontic Society
(Figure 5) notes that any brace work
can lead to root-related changes in
the teeth. These root changes are
commonly seen, and are usually minor
and clinically insignificant, although
these changes can occasionally be
severe. It is, of course, essential that
January 2023
these discussions have been had with
each and every potential orthodontic
patient, and that written information
is given to them to peruse in their own
time before committing to a course
of treatment.
Conclusions
„ The orthodontist should be able
to identify some patients at
high risk for resorption, and this
is why a thorough history and
clinical examination is essential in
obtaining valid informed consent.
„ A thorough review of the literature,
however, shows that there is no
clear line separating high-risk from
low-risk patients.
„ If resorption risk is thought to be
high, measures should be taken to
minimize the damage to the teeth.
„ All patients should be warned of
the risks, and should sign to confirm
they have understood the warnings.
„ If extensive root resorption occurs,
all measures should be taken
to minimize further damage
and maximize the prognosis for
the teeth.
„ In the event of root resorption, the
patients and their parents should
be fully informed of the situation
and should be told the prognosis
for the dentition in the medium and
long term.
Compliance with Ethical Standards
Conflict of Interest: The authors declare
that they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
References
1. Killiany DM. Root resorption caused
by orthodontic treatment: an
evidence-based review of literature.
Semin Orthod 1999; 5: 128–133.
https://doi.org/10.1016/s1073-
8746(99)80032-2
2. Weltman B, Vig KW, Fields HW et
al. Root resorption associated with
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systematic review. Am J Orthod
Dentofacial Orthop 2010; 137:
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ajodo.2009.06.021
3. Ottolengui R. The physiological and
pathological resorption of tooth
roots. Dent Items Interes. 1914; 36.
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Grant PD et al. Orthodontic
mechanotherapies and their
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ajodo.2018.10.015
6. Walker SL, Tieu LD, Flores-Mir C.
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796–802. https://doi.org/10.1093/ejo/
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7. Sondeijker CFW, Lamberts AA,
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8. Samandara A, Papageorgiou
SN, Ioannidou-Marathiotou I et
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14. Michelogiannakis D, Al-Shammery D,
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17. Haugland L, Kristensen KD, Lie SA,
Vandevska-Radunovic V. The effect
of biologic factors and adjunctive
therapies on orthodontically induced
inflammatory root resorption: a
systematic review and meta-analysis.
Eur J Orthod 2018; 40: 326–336.
https://doi.org/10.1093/ejo/cjy003
18. Zymperdikas VF, Yavropoulou MP,
Kaklamanos EG, Papadopoulos MA.
Effects of systematic bisphosphonate
use in patients under orthodontic
treatment: a systematic review. Eur J
Orthod 2020; 42: 60–71. https://doi.
org/10.1093/ejo/cjz021
19. General Dental Council. Standards for
the Dental Team. 2013.
20. Jiang RP, McDonald JP, Fu MK.
Root resorption before and after
orthodontic treatment: a clinical
study of contributory factors. Eur J
Orthod 2010; 32: 693–697. https://
doi.org/10.1093/ejo/cjp165
21. Wang Y, Liu C, Jian F et al. Initial
arch wires used in orthodontic
treatment with fixed appliances.
Cochrane Database Syst Rev 2018
Jul 31;7(7):CD007859. https://doi.
org/10.1002/14651858.CD007859.
pub4.
22. El-Angbawi AM, Yassir YA, McIntyre
GT, Revie GF, Bearn DR. A randomized
clinical trial of the effectiveness
of 0.018-inch and 0.022-inch slot
orthodontic bracket systems: part 3
– biological side-effects of treatment.
Eur J Orthod 2019; 41: 154–164.
https://doi.org/10.1093/ejo/cjy039
26 Advertorial
Align Technology announces Invisalign® with
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January 2023
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References
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4 being “strongly agree”. Data on file at Align
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3. Data on file at Align Technology, as of February 2017
4. Data on file at Align Technology, as of September 27, iTero digital scanning system, please
2021. visit www.itero.com
5. Data on file at Align Technology, as of September 27,
2021 For additional information about exocad
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between upper and lower wings for 1,976 cases of
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precision wings produced between May 1, 2021 www.exocad.com
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© 2022 Align Technology, Inc. Align, Invisalign, and iTero, among others, are trademarks of Align Technology Inc. A009765 Rev A
28 Orthodontics January 2023

Enhanced CPD DO C

Liam Monaghan Richard Needham

An Overview of
Light-curing within
Orthodontics
Abstract: The use of light to initiate bonding reactions has become an integral part of orthodontic practice. Different technologies
are available to cure dental composite, each with advantages and drawbacks. The efficacy of light-curing is affected by a range of
factors and it is important for orthodontists to understand these concepts, alongside common problems with light-cure units, to aid
in troubleshooting. Periodic testing of light-curing equipment can help to identify defective units that can potentially contribute to
bond failure.
CPD/Clinical Relevance: An understanding basic materials science in relation to dental light-curing technology is important in allowing
orthodontists to maintain safe and effective equipment. The choice of light-curing equipment and method of use can influence bond
strength and, therefore, treatment success.
Ortho Update 2023; 16: 28–31

Historically, fixed orthodontic that orthodontists have come to rely History

appliances were retained through
circumferential bands chemically
bonded to enamel with a luting
cement. In the 1960s, enamel
conditioning with acid was shown to
facilitate effective micromechanical
bonding with resin composite,1 which
has since become the most widely
used method of retaining orthodontic
appliances. Devices which exploit light
to initiate such bonding reactions have
become a key piece of equipment
in any orthodontic clinic. Dental
light-curing units (or more precisely:
‘powered polymerization activators’2)
have evolved from the early use of UV
light to a wide range of units, using
a variety of light sources to produce
visible light. Such developments have
resulted in safer, more efficient curing
on daily.
The importance of light-curing in
relation to the clinical effectiveness of
bracket bonding is often overlooked in
favour of other important factors, such
as the bonding material, bracket surface
structure and the technique sensitivity of
the bonding process. It is important for
clinicians to have a working knowledge
of different types of light-curing unit, in
addition to the light-curing process itself,
because this allows dentists to identify
potential problems that may lead to an
increased bond failure rate.
This article aims to provide a
summary of the use of light-curing units
(LCUs) within orthodontics. Some of the
common causes of light-cure unit failure
are highlighted, and guidance on how
such failures can be identified is provided.
The earliest LCUs in dentistry used an
ultraviolet (UV) light source to initiate
the bonding reaction. One of the main
drawbacks of using UV light occurs
because dental composites contain
UV-attenuating filler particles that
limit the depth of cure and result in
a longer curing time.3 By the 1980s,
further concerns relating to the safety
of prolonged exposure to UV radiation
ushered in LCUs, which used the visible
light spectrum. Quartz–tungsten halogen
(QTH) LCUs where the first of this kind
and combined halogen bulbs with a
filter to produce the blue light used to
initiate the bonding reaction. QTH units
had to be large enough to accommodate
cooling fans, and the halogen bulbs
were subject to degradation over time.

Liam Monaghan, BDS, MFDS RCS Ed, MOrth RCS Eng; StR Orthodontics, University Dental Hospital, Manchester. Richard Needham, BDS,
MFDS RCS Ed, MJDF RCS Eng, MSc (Pros), MSc (Ortho), MOrth RCS Eng, FDS Orth RCS Eng, Consultant Orthodontist, University Dental
Hospital Manchester.
email: liam.monaghan@mft.nhs.uk
January 2023
Figure 1. A battery-powered LED light-cure unit
stored in a charging station.
By the late 1990s, blue light emitting
diodes were emerging as a potential
new technology that was able to deliver
sufficient irradiance to cure dental
composite while overcoming some of
the drawbacks of QTH technology.4 LED
and QTH LCUs remain the mainstay of
units used by dentists today. However,
attempts to reduce curing time have
been made through the development
of LCUs that use argon laser or plasma
arc technology. Argon lasers and
plasma arc units have been shown to
be effective with shorter curing times
than conventional units;5,6 however, they
are not commonly used and remain
prohibitively expensive.
Which light-cure unit
should I choose?
Quartz–tungsten halogen
While there has been a rise popularity
of LED light-curing technology, QTH
curing units remain on the market
despite having a number of perceived
disadvantages. Perhaps the most
significant drawback relates to the
energy output of QTH units which, while
emitting visible light, also generate
a great amount of heat. This heat
necessitates the incorporation of cooling
fans into the design of QTH units, adding
bulk and impeding ergonomics. The
lifespan of a halogen lamp has been
shown to be as low as 50 hours, with
significant degradation of the light
output occurring over that time.7 The
financial impact of these shortcomings
over time must be factored into the
overall cost of using a QTH unit.
Light emitting diodes
Limitations of early LED units were
that they had a lower radiant output
and emitted a narrow spectrum of
light when compared to QTH units.
However, advances in LED technology
have resulted in more powerful LED
chips (with a greater radiant output)
and the use of multiple LEDs producing
different wavelengths within the same
unit to give a spectrum similar to that
of QTH units.8 LED units are energy
efficient, allowing the production of
lightweight, battery-powered units that
are easy to use and can be conveniently
stored (Figure 1). When considering
the longer-term costs of these units, a
lifespan of >100,000 hours, with little
degradation, can make them a reliable
and economical choice.
Clinical effectiveness of different LCU types
When reviewing the evidence base for
the effectiveness of light-curing units,
it is important to consider that the
specific orthodontic application of LCUs
presents issues relating to the external
validity of research that examines the
effectiveness of LCUs in dentistry more
generally. Orthodontic bonding poses
specific challenges. While curing depth
and aesthetics are less of a concern than
when placing composite restorations,
there is often the added obstacle of an
opaque metal bracket base that impedes
the transmission of light. Bond strength
is a further unique consideration because
this must be sufficient to retain an
appliance for the duration of treatment
while allowing the removal of brackets
without enamel damage at debond.
Within orthodontics, the duration
of curing and incidence of bracket
failure could be considered the most
important outcomes when evaluating
LCU effectiveness.
In vitro research has demonstrated no
significant difference in bond strength
between QTH and LED light-cure units
Orthodontics 29
when each is used for 20 seconds9.
Furthermore, LED units have been
shown to achieve comparable bond
strengths when used for shorter
durations than QTH units10 with LED
units requiring 50% less time to achieve
a similar degree of hardness when
curing orthodontic resin compared to
a QTH device.11 It must, however, be
recognized that much of the research
investigating curing duration has been
lab based with inherent disadvantages
relating to the external validity
of results.
Many in vivo studies have looked at
the relationship between bracket bond
failures and LCU type. A meta-analysis
from a systematic review comparing
QTH and LED units failed to detect a
statistically significant difference in
bracket debond rate.12 Therefore, factors
such as cost and ease of use may be
more important when considering
which type of unit to use.
The use of light-curing units
Direction of the beam
The unique nature of orthodontic
bonding requires modifications to
the use of LCUs relative to other
areas of dentistry. Visible light-
curing of orthodontic composite by
transillumination through dental hard
tissue is a technique, which proponents
claim, allows clinicians to successfully
cure thin layers of composite hidden
behind opaque metal bracket bases.
Evidence surrounding the efficacy
of this technique remains equivocal.
The technique was first demonstrated
as effective in vitro in the 1970s,13
further in vivo studies concluded that,
while transillumination resulted in
a reduced degree of polymerization
when compared to direct illumination,
complete curing may not be necessary
for an adequate bond.14,15 More recent
research has suggested that similar
bond strengths can be achieved though
small increases in curing duration if
using a transillumination technique.16
It is generally recommended that the
light-cure tip is positioned as close as
possible and parallel to the surface
of the resin composite being cured.17
Difficulties can be encountered when
an assistant is tasked with using the LCU
when seated to the side of the patient
without a clear view of the bracket. The
tip should be stabilized, with sufficient
attention paid to prevent the LCU from
drifting from the target tooth.
30 Orthodontics
Figure 2. The tip for an LED light-cure unit stored
in a protective central sterilization cage.
Figure 3. Use of a Bluephase Meter II (Ivoclar
Vivadent, Schaan, Liechenstein), a type of hand
held radiometer.
Curing duration versus irradiance
Curing duration and the irradiance
of light are two further factors that
influence bond strength. The advent
of higher intensity LED units has raised
the possibility of reducing the amount
of time spent curing composite while
achieving satisfactory bond failure
rates. A randomized controlled trial
comparing a high intensity (3200 mW/
cm2) LED used for 6 seconds and a
lower intensity (1200 mW/cm2) LED
used for 20 seconds showed no
significant difference in the percentage
of bracket bond failures.18 Such
reductions in the duration of curing
may seem small at the level of an
individual bracket; however, when
considered in the context of bonding
the entire dentition, even marginal
gains can result in significant time
saved. Resin-composite manufacturers
state recommended light exposure
times, and these should be followed by
the operator.17
While increasing the irradiance of
a unit may improve curing efficacy,
caution must be used as the increased
heat generated can have adverse
effects on pulpal health. A lab-based
study established that LED LCUs were
unlikely to cause a critical change
in pulp temperature of 5.5oC and
described LED units as having less of an
QTH
Fragile
Bulky
High maintenance
Heat is generated
Table 1. A comparison of QTH and LED units.
impact on pulp temperature than QTH
units.19 However, the LED LCU tested had
a power intensity of only 400 mW/cm2,
which is significantly lower than the
3200 mW/cm2 described in the previous
comparison of LED units. Practitioners
should be aware of the risk of iatrogenic
thermal trauma to pulp tissue, and are
advised to air-cool the tooth when
undertaking longer exposures or using
high-energy units.17
Cleaning and sterilization
When choosing an LCU, consideration
must be paid to local infection control
policies and how any device would fit
with such guidelines. Many LCUs are
now cordless, battery-powered devices
charged from a docking station that
can be kept away from the immediate
clinical area. Interchangeable tips
are available that can be removed
and sterilized between patients. It is
important to note that the design of
light-cure tip (in particular its diameter)
can have an influence on irradiance and,
therefore, curing ability.20 Consideration
should be given for tips designed for the
curing of orthodontic resin composite.
Plastic sheaths are available to reduce
contamination of the LCU during use.
While such barriers reduce the intensity
of light from a curing unit,21,22 especially
if an excess of plastic is gathered around
the tip, any reduction in irradiance is
thought not to be clinically significant
if barriers are applied as per the
manufacturer’s instructions.
Common problems with
light-cure units
Damage to light-cure tips
Deterioration of the light-cure tip can
occur for several reasons, and well-used
tips may appear clouded or slightly
opaque after repeated cycles in an
autoclave. Similarly, tips may become
scratched during transportation to
sterilization facilities, or if improperly
stored alongside metal instruments.
Individual housing cages, with a clip to
securely fasten the removable tip, help
January 2023
LED
Less heat generated
Superior life expectancy
Lightweight
Easy storage
to reduce wear and tear and can be a
worthwhile investment (Figure 2).
Failure of power supply
As with any wireless device, the
rechargeable battery within an
LCU will deteriorate over time.
Furthermore, damage to the base of
the unit or the docking system can
result in a failure of the unit to charge.
Replacement batteries and docking
systems are available from suppliers.
LED failure
Failure of the light emitting diode is
an uncommon cause of LCU failure.
LED units have a much greater
lifespan than QTH devices, and other
LCU components, such as the battery,
are likely to fail long before the LED.
Testing of light-cure units
Visible inspection
It is good practice to regularly inspect
the light-cure tip for signs of damage
or for the residue of composite resin
which can adhere to the tip surface if
a protective barrier is not used.
Measurement of irradiance
The output of LCUs should be
regularly measured using the same
device to give a reliable comparison
of readings. Any device which fails
to meet the manufacturers guideline
values should be investigated
further and disposed of or repaired,
as necessary.
Different types of light-meter
are available to test LCUs, ranging
from lab-based radiometers (held in
laboratories for research purposes)
to smaller and more affordable
hand-held units (Figure 3). Despite
having good reliability, the majority
of hand-held radiometers have less
validity than laboratory-grade power-
meters with significant differences in
output measurements when devices
are compared.23
For this reason, it is recommended
that, rather than placing emphasis
January 2023
on the absolute measure of irradiance,
clinicians should use hand-held
radiometers to measure changes in
irradiance over time.
Chairside curing of composite
Using an LCU to cure a sample of
orthodontic composite at the chairside
can act as a crude assessment of how
well an LCU is functioning. However,
testing the surface hardness of resin
composite with a sharp instrument
is not a valid assessment of curing
depth.17
Conclusion
For a specialty that relies so heavily
on light-cured resin composite for
the bonding of appliances, LCUs are
an often-overlooked factor when
considering possible reasons for bond
failure. There are a plethora of LCUs on
the market and modern LED units have
a number of advantages over older
QTH technology. Curing technique,
in addition to the physical properties
of LCUs, can have an impact on bond
efficacy and care should be taken to
consistently use the correct bonding
technique. Clinicians should be aware
of the common causes of failure or
damage to LCUs and the periodic audit
of LCU irradiance can help to identify
poorly performing units before they
begin to have a clinically significant
effect on bonding.
Compliance with Ethical Standards
Conflict of Interest: The authors declare
that they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
References
1. Buonocore MG, Matsui A, Gwinnett AJ.
Penetration of resin dental materials
into enamel surfaces with reference
to bonding. Arch Oral Biol 1968; 13:
61–70. https://doi.org/10.1016/0003-
9969(68)90037-x
2. International Organization
for Standardization (ISO). ISO
10650:2018. Available at: www.iso.
org/standard/73302.html (accessed
September 2022).
3. Lee HL, Orlowski JA, Rogers BJ. A
comparison of ultraviolet-curing and
self-curing polymers in preventive,
restorative and orthodontic dentistry.
Int Dent J 1976; 26: 134–151.
4. Mills RW, Jandt KD, Ashworth SH.
Dental composite depth of cure with
halogen and blue light emitting
diode technology. Br Dent J 1999; 186:
388–391. https://doi.org/10.1038/
sj.bdj.4800120
5. Elaut J, Wehrbein H. The effects of
argon laser curing of a resin adhesive
on bracket retention and enamel
decalcification: a prospective clinical
trial. Eur J Orthod 2004; 26: 553–560.
https://doi.org/10.1093/ejo/26.5.553
6. Cobb DS, Dederich DN, Gardner TV.
In vitro temperature change at the
dentin/pulpal interface by using
conventional visible light versus
argon laser. Lasers Surg Med 2000; 26:
386–397. https://doi.org/10.1002/
(sici)1096-9101(2000)26:4<386::aid-
lsm7>3.0.co;2-c
7. Mills RW, Uhl A, Jandt KD. Optical
power outputs, spectra and dental
composite depths of cure, obtained
with blue light emitting diode
(LED) and halogen light curing
units (LCUs). Br Dent J 2002; 193:
459–463; discussion 455. https://doi.
org/10.1038/sj.bdj.4801597
8. Shortall AC, Price RB, MacKenzie L,
Burke FJ. Guidelines for the selection,
use, and maintenance of LED light-
curing units - Part 1. Br Dent J 2016;
221: 453–460. https://doi.org/10.1038/
sj.bdj.2016.772
9. Bishara SE, Ajlouni R, Oonsombat C.
Evaluation of a new curing light on the
shear bond strength of orthodontic
brackets. Angle Orthod 2003; 73: 431–
435.
10. Lamper T, Steinhäuser-Andresen S,
Huth KC et al. Does a reduction of
polymerization time and bonding
steps affect the bond strength of
brackets? Clin Oral Investig 2012; 16:
665–671. https://doi.org/10.1007/
s00784-011-0540-0
11. Cerveira GP, Berthold TB, Souto AA
et al. Degree of conversion and
hardness of an orthodontic resin
cured with a light-emitting diode and
a quartz-tungsten-halogen light. Eur
J Orthod 2010; 32: 83–86. https://doi.
org/10.1093/ejo/cjp048
12. Fleming PS, Eliades T, Katsaros C,
Pandis N. Curing lights for orthodontic
bonding: a systematic review and
meta-analysis. Am J Orthod Dentofacial
Orthop 2013; 143: S92–103. https://
doi.org/10.1016/j.ajodo.2012.07.018
13. Tavas MA, Watts DC. Bonding
of orthodontic brackets by
transillumination of a light activated
composite: an in vitro study. Br J
Orthod 1979; 6: 207–208. https://doi.
org/10.1179/bjo.6.4.207
14. Cheng L, Ferguson JW, Jones P,
Wilson HJ. An investigation of the
polymerization of orthodontic
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of tooth tissue. Br J Orthod 1989; 16:
183–188. https://doi.org/10.1179/
bjo.16.3.183
Orthodontics 31
15. King L, Smith RT, Wendt SL, Behrents
RG. Bond strengths of lingual
orthodontic brackets bonded with
light-cured composite resins cured
by transillumination. Am J Orthod
Dentofacial Orthop 1987; 91: 312–315.
https://doi.org/10.1016/0889-
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16. Oesterle LJ, Shellhart WC. Bracket
bond strength with transillumination
of a light-activated orthodontic
adhesive. Angle Orthod 2001; 71:
307–311. https://doi.org/10.1043/0003-
3219(2001)0712.0.CO;2
17. Watts DC. Let there be more light! Dent
Mater 2015; 31: 315–316. https://doi.
org/10.1016/j.dental.2015.03.001
18. Ward JD, Wolf BJ, Leite LP, Zhou J.
Clinical effect of reducing curing times
with high-intensity LED lights. Angle
Orthod 2015; 85: 1064–1069. https://
doi.org/10.2319/080714-556.1
19. Malkoç S, Uysal T, Uşümez S et al.
In-vitro assessment of temperature
rise in the pulp during orthodontic
bonding. Am J Orthod Dentofacial
Orthop 2010; 137: 379–383. https://doi.
org/10.1016/j.ajodo.2008.02.028
20. Nitta K. Effect of light guide tip
diameter of LED-light curing unit
on polymerization of light-cured
composites. Dent Mater 2005; 21:
217–223. https://doi.org/10.1016/j.
dental.2004.03.008
21. Hodson NA, Dunne SM, Pankhurst CL.
The effect of infection-control barriers
on the light intensity of light-cure units
and depth of cure of composite. Prim
Dent Care 2005; 12: 61–67. https://doi.
org/10.1308/1355761053695149
22. Soares CJ, Braga SSL, Ribeiro MTH, Price
RB. Effect of infection control barriers
on the light output from a multi-peak
light curing unit. J Dent 2020; 103:
103503. https://doi.org/10.1016/j.
jdent.2020.103503
23. Shimokawa CA, Harlow JE, Turbino
ML, Price RB. Ability of four dental
radiometers to measure the light
output from nine curing lights. J
Dent 2016; 54: 48–55. https://doi.
org/10.1016/j.jdent.2016.08.010
CPD ANSWERS
OCTOBER 2022
1. B 5. D
2. C 6. B
3. D 7. D
4. A
 +
Superior integration.
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Improved integration, a faster, simplified workflow, and higher case
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January 2023 Orthodontics 33

Enhanced CPD DO C

Nikhil Gogna Murray Irving and Kieran Nandhra

Aligner Orthodontics:
A Literature Review
Abstract: Many studies have been undertaken to understand the limitations and benefits of aligners, including systematic reviews with
meta-analyses. However, there are very few comprehensive reviews of the current evidence. This literature review provides an up-to-
date summary of various aspects of clear aligner therapy, including patient compliance, clinical effectiveness, social interactions and
iatrogenic effects.
CPD/Clinical Relevance: Clear aligners are a popular choice and the article provides an up-to-date summary of various aspects of clear
aligner therapy.
Ortho Update 2023; 16: 33–38

Clear aligners are an aesthetic alternative
to fixed appliances and have come a long
way since their conception as a ‘tooth
positioner,’ in the 1940s. In 1946, Kesling
stated that a series of these positioners
could be used to achieve more ambitious
tooth movements when used as an adjunct
to conventional treatment.1 Many aligner
systems were created, but often their
scope was limited and required clinicians
to take multiple impressions throughout
the course of treatment. In 1999, Align
technology introduced Invisalign, which
used computer aided manufacturing and
design principles to mitigate the need for
multiple impressions.2 This encouraged
more clinicians to engage with this mode
of orthodontics, thus resulting in its
increase in popularity. Currently, Invisalign
and other major clear aligner systems can
use specific force delivery via composite
precision attachments, generating force
vectors to permit a range of specific
tooth movements. Once thought to
be limited to tipping only, aligners
have developed into a system that can
attempt most movements achieved with
fixed appliances.
Many studies have been undertaken to
understand the limitations and benefits of
aligners, including systematic reviews with
meta-analyses. However, there are very
few comprehensive reviews of the current
evidence. This literature review provides
an up-to-date summary of various aspects
of clear aligner therapy, including patient
compliance, clinical effectiveness, social
interactions and iatrogenic effects.
Patient-related factors
Oral hygiene
The accumulation of dental plaque is
the major factor that leads to gingival
inflammation and periodontal disease.
This is of particular concern in orthodontic
treatment owing to appliances hindering
oral hygiene. Appliances have differing
levels of effect on plaque build-up, but
there are few studies that directly compare
clear aligners to fixed appliances.
Chhibber et al carried out a prospective
randomized clinical trial over 18 months
that compared oral hygiene at regular
intervals with clear aligners and pre-
adjusted edgewise fixed appliances with
both self-ligated brackets and elastomeric
ligated brackets.3 The study measured
effects using three different indices:
„ Plaque accumulation;
„ Gingival colour and consistency;
„ Papillary bleeding.
They found that there was no significant
difference in the oral hygiene levels among
the different orthodontic appliances after
18 months.
Zhao et al monitored 25 adult patients
wearing clear aligners over 6 months
and found that there were no significant
differences in the oral microbiome before
and after treatment.4 They also found
that participants had reduced plaque,
increased daily brushing frequency and
lower sugar intake post orthodontic
treatment. It is important to note that this
study had a limited sample size with a
majority of females and lacked any long-
term observation.
Periodontal effects
It is well documented that, as well as oral
hygiene, periodontal health can be affected
by orthodontic appliances, and so it is
imperative to assess a patient’s periodontal
status prior to offering orthodontic

Nikhil Gogna, BDS (Hons), MFDS RCS (Glasg), DClinDent, MOrth (Eng), FDS (Eng), Specialist Orthodontist, Quayside Orthodontics,
Carmarthen, Wales. Murray Irving, BDS, MFDS RCS (Eng), Restorative DCT, Cardiff. Kieran Nandhra, BDS, MFDS RCS (Eng), OMFS DCT,
Bedfordshire NHS Trust. Email: dr.nikhilgogna@hotmail.com
34 Orthodontics
treatment. With the removable nature of
clear aligners, this prompts questions on
whether they have an advantage over
conventional fixed braces concerning their
effects on the periodontium.
Rossini et al carried out a systematic
review of five studies and concluded that
clear aligners were not only a clinically safe
option for the periodontium, but fared
better than fixed appliances.5 This may be
due to their removability, thus allowing
for better oral hygiene measures. Four
out of the five studies, however, were not
randomized and most had methodological
issues, such as bias, confounding variables
and lack of blinding. Two papers concluded
that clear aligners had superior periodontal
outcomes regarding probing pocket depths
and plaque and gingival indices. Again the
level of evidence was only moderate.6,7
A recent prospective study8 suggested
that as long as sufficient oral hygiene
instructions were provided to patients,
the type of orthodontic appliance had no
effect on periodontal health, which is in
accordance with other recent literature.3
Nonetheless, there were limitations to this
study including baseline characteristics, such
as smoking not being recorded, follow-up
was only 3 months, and there was significant
heterogeneity in the ages between groups
(mean age difference of 14.1 years).
Enamel demineralization
A common issue with orthodontic
appliances, fixed or removable, is enamel
demineralization. White spot lesions lead
to poorer aesthetic outcomes, patient
dissatisfaction and unwanted long-term
colour discrepancy, some of which do not
resolve over time.9 Comparing enamel
demineralization after clear aligner
therapy with fixed appliances has become
increasingly more important given the
burgeoning increase in aligner therapy in
our cosmetic-driven populations.
Buschang et al studied white spot
lesions in both fixed appliances and
clear aligner therapy using 450 cases
(244 on clear aligner therapy and 206
on fixed appliance therapy). A reported
incidence of 25.7% was found with fixed
appliances, while clear aligner therapy
was shown to have an incidence of 1.2%.10
According to the study, this was largely
linked to differences in oral hygiene and
plaque control. It has been established
previously that there is a close correlation
between poor oral hygiene and white
spot lesions.11,12 Poor pre-treatment oral
hygiene doubles the risk of developing
lesions, while worsening of oral hygiene
during treatment has been shown to triple
the risk.13 Clear aligner therapy, although
making it easier to clean effectively, does
not completely mitigate the chances of
developing white spot lesions. Lack of
analysis via quantitative light fluorescence
(QLF) and differences in treatment time
between the two groups could have
confounded these results.
A prospective randomized clinical
control trial by Albhaisi et al used QLF to
evaluate enamel demineralization during
fixed appliance and clear aligner therapy.
In total, 113 patients were examined, of
whom 49 were deemed suitable. Like
Buschang,10 Albhaisi et al concluded that
fixed appliance therapy resulted in a higher
incidence of white spot lesions.14 Analysis
of the white spot lesions found that clear
aligner therapy, although having a lower
incidence and less mineral loss, resulted in
significantly wider lesions when compared
to fixed appliances.14 Conversely, fixed
appliances encouraged deeper white spot
lesions with more mineral loss. This can be
accounted for by the fact that clear aligners
use attachments that take up a significant
area on the tooth surface. Additionally,
saliva flow is reduced when aligners are
worn resulting in decreased ability to
buffer acids and provide minerals to tip
the balance in favour of remineralization.11
As stated by Albhaisi et al, the study was
limited by its duration (3 months) and most
participants were female, and therefore
does not allow for a comprehensive
gender-based comparison.
Quite clearly there is need for a
comparison of fixed appliances and clear
aligners and incidence of white spot
lesions with QLF, but it is evident that oral
hygiene pre-treatment and mid-course
significantly correlates to the formation of
such demineralization.
Tooth movement
Mesial crown tip
Distal crown tip
Buccal crown tip
Lingual crown tip
Intrusion
Extrusion
Mesial rotation
Distal rotation
Torquing
Table 1. Percentage accuracy of tooth movements.16,18 *The accuracy of torquing did not compare the
maxilla versus mandible.
January 2023
Aligner clinical effectiveness
The recent surge in popularity of clear
aligners has led to widespread use in both
adults and children. Evidence on what they
can accurately and predictably achieve is
still in its early stages. One online survey
found that 45% of orthodontists believed
that aligners limit orthodontic treatment
outcomes, whereas only 5% of general
dentists thought the same,15 highlighting
a disparity within the profession over
whether clear aligners can produce high-
quality results.
Tooth movements
A prospective clinical study by Haouili et
al followed up Kravitz et al’s study, which
assessed movements of all teeth using
Invisalign, and found the overall mean
accuracy of tooth movement to be 50%.16,17
Although far from ideal, this is a clinical
improvement from the previous 41%.17
Haouili et al measured all movements
apart from torquing, as radiographs
would have been required to assess root
movement.16 The most accurate movement
was buccal-lingual crown tip (56%) and
the least was rotation (46%). Jiang et al
used radiographs to measure accuracy of
torquing movements and found them to be
worse than rotations (Table 1).18 Intrusion
was found to be challenging, and results
suggested that Invisalign favours bite
closure over bite opening, thus these cases
may benefit from the ‘hybrid’ approach of
Invisalign in the maxillary arch and fixed
appliances in the mandibular. The study
was limited because it used ClinCheck
digital models to assess accuracy. However,
ClinCheck does not necessarily represent
the actual clinical end result, but is merely
a cartoon of a computer-generated model
representing a desired result.
Percentage accuracy (%)
Maxilla Mandible
52.7 48.8
53.4 53.4
57.6 57.6
55.2 54.3
44.4 47.7
45.9 45.9
49 45
45.6 42.5
35.21*
January 2023
ClinCheck accuracy
ClinCheck, developed by Align Technology,
is the algorithmic software in which
treatment plans and prediction of tooth
movement are conveyed to the clinician.
The accuracy of this software and actual
outcomes have been studied by many
clinicians with varying outcomes. Sheridan
reported 70–80% of patients treated with
aligners required some form of refinement
or mid-course adjustment.19
Kravitz et al17 showed discrepancies
between predictions of tooth movement
and outcomes following clear aligner
therapy. Overall, no significant difference
was found between mandibular and
maxillary movement accuracy between
teeth of the same type.17 This study did not
evaluate posterior teeth, unlike the study by
Robertson et al,20 and only mild cases were
used with few bodily movements exceeding
2 mm. Additionally, overcorrections were not
accounted for and confounding factors, such
as age, periodontal condition, bone density
and root morphology, were not mitigated.
Charalampakis et al and Grünheid et
al had similar conclusions on accuracy
of movement when compared to
predictions.21,22 Robertson et al20 also agreed
that rotational movements were inaccurate,
demonstrating statistical differences
between predicted and achieved tooth
movements. They found that posterior
tooth movements and anterior extrusion
predictions were the most inaccurate.20
Many of the studies carried out were
retrospective and of non-extraction cases.
A difficulty in assessing the accuracy of
specific tooth movement with ClinCheck
is that with aligners, teeth are moved
in a compound manner and so specific
movements are hard to analyse and
compare. On the other hand, prospective
studies16,17 provide good evidence that
predictions of tooth movement with
ClinCheck have improved significantly
in recent times, but refinement is
often needed to compensate for lack
of predictability of tooth movement.
Another pertinent observation described
was that the ClinCheck software fails to
show roots of teeth and root movement
and does not accurately reflect the
patient’s final outcome.23 Clinicians should
understand that ClinCheck predictions
are not extremely accurate, but are simply
estimations of where teeth are likely to
move to. It is clear from the literature that
aligner therapy does require refinement
most of the time; however, the severity of
the malocclusion, as well as other factors
outlined, determines how much refinement
is needed.
Aligner wear
A recent randomized clinical trial evaluated
aligner wear protocol and its effect on
treatment outcomes in mild malocclusions.
They compared 7-, 10- and 14-day wear
patterns and observed statistically significant
improvements in the 14-day group for
maxillary posterior teeth, which suggests
that for complex posterior segment
movements, 14-day wear may be beneficial.24
The study found no clinically significant
differences in achieved tooth positions.
However, that the mean treatment duration
for the 7-day group was 4 months faster
than the 14-day group, which is clinically
significant.
Aligner attachments
Attachments can be a useful adjunct for clear
aligner treatment and with the more recent
development of optimised attachments,
which are engineered to provide a bespoke
force to a tooth, improvements in the
accuracy of tooth movements would be
expected. Karras et al compared the use of
conventional and optimised attachments.
They found that there were no clinical
differences in accuracy of tooth movement
between conventional and optimised
attachments.25 This was a retrospective study
with significant heterogeneity in ages of
patients and did not cover the use of elastics
or use of attachments in more complex cases.
Aligners and teleorthodontics
One retrospective study evaluated the
treatment outcomes of Invisalign in
conjunction with Dental Monitoring, a form
of teleorthodontics that allows patients
to digitally scan their mouth from home
using their smartphone and grants the
orthodontist remote access to review
progress.26 The study found no differences
in treatment duration, emergency visits,
number of refinements or number of
refinement aligners. The Dental Monitoring
group had a mean of 3.52 fewer visits
than the control group and therefore
this may be a useful tool to help increase
patient satisfaction.
Patient discomfort and
social interactions
Pain
Pain is a common patient factor in
orthodontics, which is subjective in nature
and depends on a range of factors, such as
age, sex, pain threshold, stress levels and
cultural differences.27 There are few studies,
however, directly comparing pain levels
in clear aligners and fixed appliances. One
systematic review compared the treatment
Orthodontics 35
modalities in mild malocclusion cases
and found that there were no significant
differences in pain levels after 3 months, but
clear aligners performed better in the first
few days.28 There were significant limitations
in the review, including heterogeneity
in study types, lack of randomization of
studies analysed, presence of potential
financial bias, insufficient descriptions of
types of malocclusions with which patients
presented and lack of reporting on the use
of analgesics. Analgesia can significantly
reduce pain levels and most certainly would
affect results: the fixed appliance group had
a higher pain medication intake, which may
underestimate the level of pain experienced.
Social perception
One study looked at anxiety and oral health-
related quality of life in relation to pain
during orthodontic treatment and found
patients with clear aligners experienced
lower anxiety and pain, and a higher quality
of life.29 Reasons behind this could be that
clear aligners decrease social anxiety and as
pain and anxiety positively correlate with
one another, decreased anxiety could lead
to less pain. Additionally, it was suggested
that patients undergoing clear aligner
treatment were more confident in treatment
progression and outcome because 3D
visuals could be viewed on the aligner
software, which could decrease anxiety
regarding treatment.
Speech
A randomized clinical trial found speech was
only affected immediately after insertion of
clear aligners, but there were no differences
after 30 days between aligners and fixed
appliances. Therefore, they concluded
temporary changes of speech would be
most likely to occur in the first month, but
the oral and peri-oral musculature tends to
adapt quickly to the changes, regardless of
the appliance.30
Iatrogenic effects and relapse
Root resorption
Root resorption is the permanent loss of
the cementum and dentine at the apical
region of the root structure via osteoclastic
activity, either through physiological or
pathological phenomena. This occurrence
is multifactorial, and apical root resorption
(ARR) secondary to orthodontic treatment
is a common unwanted complication,
classified as pathological (inflammatory) in
origin.31,32 There have been many studies
in this area, with conflicting results mainly
being due to contrasting study designs.33
A systematic review by Ghandi et al
36 Orthodontics
Area Quality of evidence Research findings
No significant differences in plaque
and bleeding levels in clear aligners
One randomized clinical trial and fixed appliances overall, but
Oral hygiene and one prospective cohort slightly better oral hygiene in the
study early stages of treatment in the clear
aligner group
Significantly better plaque and
bleeding indices, probing depths
and biofilm mass in clear aligners,
RCTs and systematic reviews
Periodontal however the level of evidence for
present, but more recent RCTs
effects this is moderate and more recent
required
studies must be carried out to
support these findings
Fixed appliance showed greater
incidence of deep and narrow WSLs.
Enamel Prospective randomized Less WSLs were found in CAT but
demineralization clinical trials reviewed WSLs were wider and shallower
Systematic reviews dominate Similar mean root resorption
this area of research, however between CAT and PEAs. CAT showed
Root resorption marginally less ARR associated with
further RCTs are required to
(ARR) UR2 according to Ghandi et al.
provide more information to
compare PEAs and CAT
Pain: systematic reviews Overall, no significant differences
present; significant limitations in pain between clear aligners and
fixed appliances, however the use
Patient related of analgesia was not documented.
interests: pain, Speech: RCT
Lower anxiety in the clear aligner
speech and social group, which may affect pain levels.
perceptions There are no significant differences
Social perception: cohort in speech between the different
studies orthodontic treatments
Accuracy of tooth movement has
increased overall, but rotations and
torquing are still inaccurate.
No clinically significant differences
in achieved tooth positions in 7-, 10-
and 14-day wear protocols
Different attachment types showed
no clinical differences. Predicted
Only one randomized control values were significantly higher than
Clinical achieved values. Use of elastics was
trial, majority of papers were
effectiveness not covered
retrospective.
The use of Dental Monitoring
in conjunction with Invisalign
showed no differences in duration,
emergency visits, number
of refinements or number of
refinement aligners, but found a
mean of 3.52 less visits in the DM
group
Table 2. Summary of results.
January 2023
Clinical significance
Clear aligners may allow for better oral
hygiene at the start of treatment, but
there is no overall clinical difference
between the orthodontic treatment
modalities
Clear aligners may be beneficial
for patients with a compromised
periodontium
WSLs are heavily attributed to poor oral
hygiene, CAT allows patients to uphold
good hygiene but as a result of patient
factors CAT does not mitigate the
presence of WSLs completely
There is no clinically significant
difference between PEAs and CATs with
regards to ARR
There is no clinical difference in pain
levels between clear aligners and fixed
appliances, however anxiety levels
have been shown to be better in clear
aligner patients, which can affect pain
perception. There are no clinically
relevant differences regarding speech
Overcorrection may still be required to
achieve desired tooth positions
7-day wear protocol has been shown to
be 4 months faster than 14-day wear
Conventional and optimised
attachments are equally as effective
in class 1 malocclusions. Interproximal
reduction or spacing does not affect
results
No differences in treatment duration
using Dental Monitoring in conjunction
with Invisalign, but may reduce number
of visits.
January 2023
Prospective and retrospective
ClinCheck
studies with additional follow
accuracy
up
Systematic reviews studied a
Relapse and single reliable cohort study
stability only, further studies are
required
Table 2. Summary of results (continued).
compared external apical root resorption
of clear aligner therapy (CAT) and fixed pre-
adjusted edgewise appliances (PEA) in non-
extraction cases. The review looked at 16
studies, 12 of which were retrospective and
four were prospective studies. Following a
random effect meta-analysis and subgroup
comparison, it was found that there was no
clinical significance between clear aligner
therapy and fixed pre-adjusted edgewise
appliances because both resulted in similar
mean root resorption of less than 1 mm. The
average ARR of central and lateral incisors
was found to be 0.4 9mm when using either
PEA or CAT, whereby CAT resulted in an
average of 0.44 mm of ARR and PEA resulted
in 0.52 mm. The only statistical significance
found between the two methods was
the ARR of the upper right lateral incisor
(0.74 mm with PEA and 0.36 mm with CAT);
however, given the minimal difference
and confounding factors, this was deemed
clinically insignificant. Furthermore, these
data cannot be extrapolated to extraction
cases and are open to selection bias, with
no randomized controlled trials satisfying
the inclusion criteria.34
Aman et al collated data from 160
patients using clear aligner therapy. This
study also found minimal root resorption
associated with comprehensive clear aligner
therapy techniques when comparing pre-
and post-treatment CBCT scans. Mean
ARR of central incisors and lateral incisors
was found to be 0.49 ± 0.57 mm and
0.53 ± 0.59 mm, respectively. However,
this too, did not include many extraction
cases, assessed maxillary incisors
Accuracy of ClinCheck has improved
with time but there is still a limit to
its ability to predict accurately, even
for movements which have been
shown to be the most predictable.
More evidence is required to assess
this accuracy for extraction cases as
well as assessment of movements in
the posterior regions
CAT was shown to have quicker
relapse times than fixed appliances.
However, more studies are required
to provide evidence in order to draw
this conclusion
only, and provided no control against
fixed appliances.33
Further studies investigating the
incidence and severity of root resorption
with clear aligner therapy, compared to
fixed appliances (both self-ligating and
ligated systems) should be carried out to
mitigate confounding factors. Further, high-
quality studies and randomized controlled
trials may elucidate which therapy
definitively causes less root resorption.
However, clinically, there seems to be no
major significance. Both techniques may
lead to ARR, but when used correctly, the
changes to root resorption are usually less
than 1 mm and so of little clinical concern.
Relapse and stability
Relapse following orthodontic treatment
has been described both in terms of
short-term relapse following orthodontic
treatment and long term as part of
maturation.35 There is currently very little
evidence comparing fixed appliances to
clear aligners. According to Zheng et al,36
only one study37 sufficiently studied the
differences in stability between the two
methods. Patients treated by Invisalign
were shown to have relapsed more
than those treated with conventional
fixed appliances, following a similar
retention protocol.36,37
Force magnitude was also a point
of contention. Fixed appliances provide
measured forces onto teeth to allow for
optimal movement without tissue damage.
Owing to the design of aligners, force
magnitude cannot be measured accurately
and so, tooth movement is considered
Orthodontics 37
Clinicians should be aware that
predictions are simply estimations of
likely tooth movement and some form
of correction will be necessary when
utilising CAT.
It is important that patients wear
retainers indefinitely and follow
retention research protocol
to be distance- rather than force-based.36
The lack of evidence around force
magnitude is a potential area that needs
further investigation.
Overall, more studies are required
to provide evidence on the differences
in stability between aligner therapy and
fixed appliances.
Conclusions
Clear aligners have been an available
orthodontic treatment option for many
years and are rapidly increasing in
popularity. There is still a shortage of
high-quality evidence concerning the
treatment modality. Most of the evidence
is retrospective and thus, the conclusions
drawn are questionable (Table 2). To
accurately assess the risks and benefits
of aligner therapy, more randomized
controlled trials are required.
Clear aligners have no clinically
significant differences with fixed appliances
regarding oral hygiene, apical root
resorption and speech. There are, however,
studies to suggest that clear aligners
may benefit patients with compromised
periodontal health and induce lower pain
levels compared to their fixed counterparts.
Higher-quality studies are needed to
support these conclusions.
The literature indicates that ClinCheck
accuracy has improved, but only to 50%.
It is important for clinicians to use it only
as a guide, and to build in overcorrection,
particularly for movements such as
torquing and rotations.
There are differences between fixed
38 Orthodontics
appliances and clear aligner therapy in
terms of relapse and stability, suggesting
faster relapse in clear aligner therapy cases.
Further research would help to identify why
this is the case.
Aligner education should be introduced
into orthodontic specialty training
programmes to inspire further research,
as well as to ensure newly qualified
orthodontists are comfortable and
confident with aligner orthodontics.
Compliance with Ethical Standards
Conflict of Interest: The authors declare that
they have no conflict of interest.
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clinical study evaluating the efficacy of tooth
movement with Invisalign. Am J Orthod
Dentofacial Orthop 2009; 135: 27–35. https://
doi.org/10.1016/j.ajodo.2007.05.018
18. Jiang T, Jiang YN, Chu FT et al. A cone-beam
computed tomographic study evaluating
the efficacy of incisor movement with clear
aligners: assessment of incisor pure tipping,
controlled tipping, translation, and torque.
Am J Orthod Dentofacial Orthop 2021;
159: 635–643. https://doi.org/10.1016/j.
ajodo.2019.11.025
19. Sheridan JJ. The Readers’ Corner. 2. What
percentage of your patients are being treated
with Invisalign appliances? J Clin Orthod 2004;
38: 544–545.
20. Robertson L, Kaur H, Fagundes NCF et al.
Effectiveness of clear aligner therapy for
orthodontic treatment: a systematic review.
Orthod Craniofac Res 2020; 23: 133–142.
https://doi.org/10.1111/ocr.12353
21. Charalampakis O, Iliadi A, Ueno H et al.
Accuracy of clear aligners: A retrospective
study of patients who needed refinement. Am
J Orthod Dentofacial Orthop 2018; 154: 47–54.
https://doi.org/10.1016/j.ajodo.2017.11.028
22. Grünheid T, Loh C, Larson BE. How accurate
is Invisalign in nonextraction cases? Are
predicted tooth positions achieved? Angle
Orthod 2017; 87: 809–815. https://doi.
org/10.2319/022717-147.1
23. Buschang PH, Ross M, Shaw SG et al.
Predicted and actual end-of-treatment
occlusion produced with aligner therapy.
Angle Orthod 2015; 85: 723–727. https://doi.
org/10.2319/043014-311.1
24. Al-Nadawi M, Kravitz ND, Hansa I et al. Effect
of clear aligner wear protocol on the efficacy
of tooth movement. Angle Orthod 2021; 91:
157–163. https://doi.org/10.2319/071520-
630.1
25. Karras T, Singh M, Karkazis E et al. Efficacy
of Invisalign attachments: a retrospective
study. Am J Orthod Dentofacial Orthop 2021;
160: 250–258. https://doi.org/10.1016/j.
ajodo.2020.04.028
January 2023
26. Hansa I, Katyal V, Ferguson DJ, Vaid N.
Outcomes of clear aligner treatment with and
without dental monitoring: a retrospective
cohort study. Am J Orthod Dentofacial Orthop
2021; 159: 453–459. https://doi.org/10.1016/j.
ajodo.2020.02.010
27. Bergius M, Kiliaridis S, Berggren U. Pain in
orthodontics. A review and discussion of the
literature. J Orofac Orthop 2000; 61: 125–137.
English, German. https://doi.org/10.1007/
BF01300354
28. Cardoso PC, Espinosa DG, Mecenas P et al.
Pain level between clear aligners and fixed
appliances: a systematic review. Prog Orthod
2020; 21: 3. https://doi.org/10.1186/s40510-
019-0303-z
29. Gao M, Yan X, Zhao R et al. Comparison of
pain perception, anxiety, and impacts on oral
health-related quality of life between patients
receiving clear aligners and fixed appliances
during the initial stage of orthodontic
treatment. Eur J Orthod 2021; 43: 353–359.
https://doi.org/10.1093/ejo/cjaa037
30. Damasceno Melo PE, Bocato JR, de Castro
Ferreira Conti AC et al. Effects of orthodontic
treatment with aligners and fixed appliances
on speech. Angle Orthod 2021; 91: 711–717.
https://doi.org/10.2319/110620-917.1
31. Topkara A, Karaman AI, Kau CH. Apical root
resorption caused by orthodontic forces: a
brief review and a long-term observation. Eur
J Dent 2012; 6: 445–453.
32. Dindaroğlu F, Doğan S. Root Resorption
in orthodontics. Turk J Orthod 2016;
29: 103–108. https://doi.org/10.5152/
TurkJOrthod.2016.16021
33. Aman C, Azevedo B, Bednar E et al. Apical
root resorption during orthodontic treatment
with clear aligners: a retrospective study
using cone-beam computed tomography.
Am J Orthod Dentofacial Orthop 2018;
153: 842–851. https://doi.org/10.1016/j.
ajodo.2017.10.026
34. Gandhi V, Mehta S, Gauthier M et al.
Comparison of external apical root resorption
with clear aligners and pre-adjusted
edgewise appliances in non-extraction
cases: a systematic review and meta-analysis.
Eur J Orthod 2021; 43: 15–24. https://doi.
org/10.1093/ejo/cjaa013
35. Ireland AJ McDonald F. The Orthodontic
Patient: Treatment and Biomechanics. New
York: Oxford University Press, 2003.
36. Zheng M, Liu R, Ni Z, Yu Z. Efficiency,
effectiveness and treatment stability of clear
aligners: a systematic review and meta-
analysis. Orthod Craniofac Res 2017; 20:
127–133. https://doi.org/10.1111/ocr.12177
37. Kuncio D, Maganzini A, Shelton C, Freeman
K. Invisalign and traditional orthodontic
treatment postretention outcomes compared
using the American Board of Orthodontics
objective grading system. Angle Orthod 2007;
77: 864–869. https://doi.org/10.2319/100106-
398.1
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January 2023 Orthodontics 41

Enhanced CPD DO C

Simone Duggal Fiona Jenkins, Simon Littlewood and Ibraz Siddique

Non-surgical Management
of a Traumatic Mid-palatal
Suture Diastasis
by Novel use of an
Orthodontic Appliance
Abstract: Sutures are formed during embryonic development at the sites of approximation of the membranous bones of the craniofacial
skeleton. They afford major sites of bone expansion during postnatal craniofacial growth, and also influence facial fracture patterns
through offering a path of least resistance to force. There are some studies that have shown that the mid-palatal suture (MPS) fuses
at 11–13 years and 14–16 years in females and males, respectively. This means that during childhood, the suture is open; thus force
applied to the palate at this time tends to split the bone in the midline between the two unfused palatal shelves. The understanding of
this biological process allows orthodontists to correct transverse growth discrepancies of the maxilla. Various appliances, including the
hyrax appliance, can be used to allow rapid maxillary expansion (RME) by expanding the suture. Paradoxically, the same appliance can
be used to allow rapid maxillary contraction (RMC) by contracting the suture. This method of application using a hyrax appliance is rare.
We present a case report where this method of application allowed closure of a traumatic mid-palatal suture diastasis, correction of a
traumatic transverse discrepancy of the maxilla and avoided an invasive surgical intervention in a 15-year-old male.
CPD/Clinical Relevance: This article highlights the importance of considering a patient’s age and anatomical development when exploring
treatment options. It is prudent to take advantage of this to enhance the natural biological healing process.
Ortho Update 2023; 16: 41–44

Traumatic midface injuries can occasionally
result in fractures of the hard palate. These
fractures may occur as isolated injuries,
but are more commonly associated with
comminuted midfacial fractures.1 Even so,
they are usually found in fewer than 10% of
patients with mid-face fractures, although
some isolated studies report a much higher
incidence.2 Owing to their low incidence, „ I: anterior;
they are often overlooked, causing „ II: posterolateral alveolar;
post-operative malocclusion in trauma „ III: sagittal;
patients, resulting in potentially avoidable
„ IV: parasagittal;
extensive surgical, orthodontic and/or
restorative treatment to manage residual „ V: para-alveolar;
malocclusion.3 Palatal fracture patterns can „ VI: complex; and
be classified as follows: „ VII: transverse.4

Simone Duggal, BDS, MFDS, RCSEd, DCT3 Oral and Maxillofacial Surgery, St Luke’s Hospital, Bradford Teaching Hospitals. Fiona Jenkins,
BDS MDentSci FDS(Orth) MFDS M.Orth RCS(Eng), Consultant in Orthodontics, St Luke’s Hospital, Bradford Teaching Hospitals.
Simon Littlewood, BDS MDSc FDS(Orth)RCPS MOrthRCS FDSRCSEng, Consultant in Orthodontics, St Luke’s Hospital. Ibraz Siddique,
Consultant in Oral and Maxillofacial Surgery, Bradford Teaching Hospitals. Email: simoneduggal1@gmail.com; fiona.jenkins@bthft.nhs.uk
42 Orthodontics
We present a case of a 15-year-old accident. He presented with a minimally
male who attended our emergency displaced Le Fort 2 facial fracture and a
department following a motorized bike Type III (sagittal) fracture of his palate.
The traumatic mid-palatal suture diastasis
resulted in an upper midline central
a incisor diastema and tendencies towards
a posterior scissor bite on the right hand
side, causing aesthetic and functional
challenges for management.
Surgical intervention would have
required arch bar reduction of the
fractured segments of the maxilla,
transpalatal rigid plate fixation of the
palate and post-operative intermaxillary
fixation to stabilize the occlusion. This
procedure under a general anaesthetic
would afford the benefits of a direct
reduction and fixation of the fracture.
However, the risks would include:
b periodontal damage to teeth; hardware
exposure or infection; oronasal
communication; palatal mucosa necrosis;
and the need for a secondary general
anaesthetic to remove arch bars and
the fixation plate to prevent maxillary
growth disturbance. To avoid surgical
intervention, a joint oral and maxillofacial
Figure 1. (a,b) Study models exhibiting the
midline diastema.
a c
b process allows orthodontists to correct
Figure 2. (a) CT head axial view exhibiting the mid-palatal suture diastases. (b) OPG demonstrating
the diastema between the UL1 and UR1. No dental trauma can be seen. (c) Upper standard occlusal
imaging where the diastema between the UL1 and UR1 is visible.
January 2023
surgical and orthodontic treatment
plan was agreed to consider a non-
surgical approach.
Maxillary expansion treatments have
been used for more than a century to
correct maxillary transverse deficiency.4
Rapid maxillary expansion (RME) is
an effective procedure that is able to
produce transverse skeletal effects on
the maxilla by opening the mid-palatal
suture.5 A Hyrax expander is a type of
tooth-bourne RME that makes use of
a special screw, HYRAX (hygenic rapid
expander). It is essentially a jackscrew
with an all-wire frame.6 The screws have
heavy gauge wire extensions that are
adapted to follow the palatal contours
and soldered to bands on premolar and
molar. Each quarter turn of the screw
produces approximately 0.2 mm of
lateral expansion.
The amount of skeletal or dento-
alveolar effect of the RME is directly
correlated with the stage of skeletal
maturation of the palatal suture. The
current evidence varies, in that some
studies show that mid-palatal suture
maturation could be observed as non-
mature even in adults.7–9 One study
evaluating the mid-palatal suture
maturation stages in adolescents and
young adults using cone-beam computed
tomography (CBCT), however, concluded
that fusion of the mid-palatal suture
was completed after the age of 11 years
in females and 14–17 years in males.
Overall, it has been concluded that there
is a significant variation in the timing of
skeletal maturation among individuals
as the palatal suture fuses. Generally
speaking, the expansion by opening of
the palatal suture progressively becomes
more difficult as patients grow older.10,11
The understanding of this biological
transverse growth discrepancies of the
maxilla. In the same way that the hyrax
appliance can be used to to achieve
rapid expansion, paradoxically, the
same appliance can be used to allow
rapid maxillary contraction (RMC) by
contracting the suture. For this reason,
owing to the patient’s skeletal immaturity,
a specialized ‘reverse hyrax’ device was
designed and constructed to enable RMC
of the maxilla.
Diagnosis and aetiology
A 15-year-old male sustained facial
injuries following a motorized bike
accident. No head and facial helmet
protection was worn during the impact.
January 2023
Following a primary survey, head and
cervical spinal injury was clinically and
radiologically excluded. The primary
patient complaint was the development
of an upper central incisor diastema and
malocclusion following the injury.
Comprehensive facial and intra-oral
examination revealed palatal bruising
following the course of the mid palatal
suture and tendencies towards scissor
biting posteriorly on the right side. The
patient had a Class 2 intermediate incisor
relationship, and there was a 1-mm upper
central incisor diastema that the patient
said he did not have before (Figure 1).
There were no specific traumatic dental
injuries with all teeth intact and immobile.
The patient had had no previous dental
treatment and was medically fit and well
with no allergies.
Computed tomography and plain
film radiography confirmed a minimally
displaced Le Fort II fracture and diastases
of the mid-palatal suture (Type III palatal
fracture) (Figure 2).
Treatment aims and plan
The primary treatment aims were to
reduce and stabilize the palatal fracture
to allow appropriate healing and also
re-establish occlusion in the correct
position. Initial management included
analgesia, antiseptic mouthwash,
soft diet and maxillary sinus pressure
control advice.
A joint orthodontic/oral and
maxillofacial surgery multidisciplinary
approach was undertaken. Clinical and
radiological exam, as well as dental study
cast and photographic analysis were used
to formulate the definitive treatment
plan: conservative management of the
Le Fort II fracture, transverse contraction
of the maxilla using a ‘reverse’ hyrax
appliance and stabilization of the post-
treatment occlusion.
A ‘reverse’ hyrax appliance was
constructed using the patient’s upper
dental study model cast. The laboratory
technician was instructed to construct
a conventional form of the appliance
with the key mechanism ‘reversed’. This
would allow for the appliance to contract
when the key is turned from anterior
to posterior. The patient was instructed
on how to turn the key mechanism. The
bonded RME appliance was fitted by the
orthodontic team with anchorage of the
upper premolars and molars (Figure 3).
It was cemented with a light-cured
glass ionomer cement (GC Fuji LC, GC
UK Ltd). The key was then turned once
(0.2-mm contraction). The patient was then
instructed to turn the key twice a day for 2
consecutive days (2 x 0.2 mm x 2 = 0.8-mm
contraction), all this with the aim of closing
the 1-mm diastema.
Treatment outcome and
follow up
On clinical review 7 days later, the
diastema had completely closed, with
the posterior transverse discrepancy
corrected with the scissor bite tendency
resolved (Figure 3). His incisor relationship
remained as before the accident. The
appliance remained in situ for a further
7 weeks to allow stabilization of the
occlusion and to splint the palate. A final
review was scheduled with both the
orthodontic and oral and maxillofacial
surgery team at week 8 to assess progress.
At this appointment the appliance was
removed. The palate had healed and
was stable with no remaining diastema
(Figure 3).
Discussion
Isolated palatal fractures are not
common and are usually associated with
concomitant midfacial fractures. Even
in these instances, the incidence is low
(around 10%).12 The most common causes
of injury are assault and road traffic
accidents. Clinical signs suggestive of
these fractures include palatal ecchymosis
in closed fractures, and lacerations of
the upper lip or the palatal mucosa, loss
of incisor teeth, occlusal disruption and
maxillary tooth diastasis.13
René Le Fort (30 March 1869–30
March 1951) reported that fracture lines
of the midface tend to travel through
the path of least resistance. The palatal
suture line is similar to the cranium
and forms a strong synostosis during
adolescence, with synostosis completion
between the ages of 11and 13 years in
females and 14 and 16 years in males
(although the start and the advance of
fusion of the MPS has been reported to
vary greatly with age and sex).14 Thus in
pre-adolescent patients any split would
tend to be in the midline; however,
these fractures are less common in
children owing to the elasticity of their
facial skeleton, delay in palatal suture
synostosis, and the significant amount
of force required to fracture the palate.15
It is this delay in the MPS synostosis that
makes management of a traumatic MPS
diastasis possible with an orthodontic
appliance alone.
Orthodontics 43
a
b
Figure 3. (a) Midline ecchymosis visible. (b) One
week of treatment with the Hyrax appliance. The
palatal split has been reduced.
Treatment of a palatal fracture is
planned and performed with the goal
of restoring the transverse width of the
palate, the anteroposterior projection
of the maxillary arch, and the patient’s
prior occlusion. Treatment options range
from orthodontic appliances, palatal
splinting, arch bars for maxillomandibular
fixation to internal fixation, with plates
and screws placed under the palate
mucosa and periosteum, together with
alveolar plating.16 Our patient did not
experience a true palatal fracture, but
instead a diastasis of the MPS suture.
This had not fully fused at the time of
the injury, giving it the potential to move
quickly and effectively under the correct
applied forces. Even so, the treatment
aims remain the same as in a true palatal
fracture with, in this case, the addition
of aesthetic benefit by closure of the
diastema between the UL1 and UR1,
as well as correction of the posterior
transverse malocclusion.
The hyrax is a screw type of appliance
that is traditionally used in orthodontic
appliances to expand the upper arch.
By turning the screw 1–2 times a day, a
rapid expansion force can be applied.
When the screw is turned 1–2 times a day,
the periodontal ligament on the buccal
surfaces of the teeth is compressed and
lateral force builds up bilaterally in the
posterior maxilla. The weakest point in a
young patient is the midline suture, and
44 Orthodontics
this is split open, causing expansion of
the maxilla. In this case, the hyrax screw
was mounted in reverse so that turning
the screw caused contraction of the
upper arch.
A combined orthodontic/oral and
maxillofacial surgery multidisciplinary
approach helped devise the treatment
plan. Knowledge of RME appliances,
MPS maturation and morphology were
used to create a hyrax appliance that
contracted the maxillary arch instead
of expanding it. The appliance was
designed such that the key was turned
in the opposite direction to usual, thus
contracting and, therefore, reducing the
diastasis. After 1 week of the appliance
being in situ, the diastema and posterior
scissors bite had been successfully
treated. The appliance was left in situ for
a total of 7 weeks for stabilization.
Management of these injuries is not
well documented due to low incidence.
However, in a study carried out in
2015, 13 patients underwent palatal
fracture management using a palatal
splint made from a rapid light-cure
resin, sometimes in conjunction with
intermaxillary fixation. It was deemed
successful and cost- effective. Other
documented treatments involve placing
a palatal splint, then physically reducing
palatal fractures by applying pressure
laterally on the two maxillary halves
while applying arch bars; however, there
has been no report on the effectiveness
of this method.10 Despite previous use
of orthodontic appliances in palatal
injuries, no cases of using a ‘reverse RME’
to treat a traumatic MPS diastasis have
been recorded.
In this case, allowing healing of
the bony segments in their current
positions with no intervention was
an option6. However, this would have
left the patient with a residual upper
central incisor diastema and occlusal
discrepancy, potentially resulting in in
the need for future restorative and/or
orthodontic treatment. Furthermore,
it would have left the patient unhappy
in terms of aesthetics. Palatal fractures
require rigid horizontal stability of the
dentition along with restoration of
midface projection and height.9 This case
demonstrates the possibility to achieve
this via non-invasive management.
The treatment carried out was reliant
on patient compliance; adapting to
the intra-oral device, maintenance of
oral hygiene and ensuring that correct
instructions regarding the key turns was
followed. It is also important to carry
our regular reviews, and imperative to
ensure succinct communication with the
lab in construction of the appliance for a
successful outcome.
Conclusion
In this case, a novel approach to reduction
of a traumatic mid-palatal fracture
was successfully employed, using an
orthodontic appliance. It is important to
think beyond the conventional approach
in managing traumatic facial fractures
and it is important that treatment
planning is approached analytically and
flexibly to bring a range of approaches to
problem-solving. Current knowledge of
well-known clinical practices, combined
with a multidisciplinary approach made it
possible to create a new and effective way
of treating this type of injury.
Learning points
„ It is possible to use a rapid maxillary
expansion orthodontic appliance in
reverse to close a midline fracture.
„ It is important to be aware of the
consequences of a traumatic mid-
palatal suture diastasis, including
restorative and orthodontic
implications.
„ Consider a patient’s age and
anatomical development because
this may affect treatment options.
Take advantage of this to enhance the
natural biological healing process.
„ Management of injuries in children
may differ from that of adults with the
same injury.
„ Use current clinical knowledge to
find innovative ways to treat facial
fractures, where appropriate.
References
1. Mehboob B, Khan M, Fahad Q. Pattern
and management of palatine bone
fractures. Pakistan Oral Dent J 2014; 34.
2. Narula K, Shetty S, Shenoy N, Srikant
N. Evaluation of the degree of fusion
of midpalatal suture at various stages
of cervical vertebrae maturation. APOS
Trends Orthod 2019; 9: 235–240.
3. Cienfuegos R, Sierra E, Ortiz B, Fernández
G. Treatment of palatal fractures by
osteosynthesis with 2.0-mm locking
plates as external fixator. Craniomaxillofac
Trauma Reconstr 2010; 3: 223–230. https://
doi.org/10.1055/s-0030-1268519
4. Manson PN, Shack RB, Leonard LG et
al. Sagittal fractures of the maxilla and
palate. Plast Reconstr Surg 1983; 72: 484–
489. https://doi.org/10.1097/00006534-
198310000-00011
5. Gala Z, Halsey JN, Kapadia K et al.
Pediatric palate fractures: an assessment
January 2023
of patterns and management at a level 1
trauma center. Craniomaxillofac Trauma
Reconstr 2021; 14: 23–28. https://doi.
org/10.1177/1943387520935013
6. Angelieri F, Cevidanes LH, Franchi L
et al. Midpalatal suture maturation:
classification method for individual
assessment before rapid maxillary
expansion. Am J Orthod Dentofacial
Orthop 2013; 144: 759–769. https://doi.
org/10.1016/j.ajodo.2013.04.022
7. Rimell F, Marentette LJ. Injuries of the
hard palate and the horizontal buttress
of the midface. Otolaryngol Head Neck
Surg 1993; 109: 499–505. https://doi.
org/10.1177/019459989310900319
8. Hoppe IC, Halsey JN, Ciminello FS et al. A
single-center review of palatal fractures:
etiology, patterns, concomitant injuries,
and management. Eplasty 2017; 17: e20.
9. Waldrop J, Dale EL, Halsey J, Sargent
LA. Palate fracture repair with light-
cured resin splint: technical note.
J Oral Maxillofac Surg 2015; 73:
1977–1980. https://doi.org/10.1016/j.
joms.2015.03.049
10. Carl-Peter Cornelius, Nils Gellrich, Søren
Hillerup, Kenji Kusumoto, Warren
Schubert. Closed treatment for
palatoalveolar fracture, complex injury.
AO Surgery Reference 2009. {AQ: FURTHER
DETAILS, PLEASE}
11. Liu S, Xu T, Zou W. Effects of rapid
maxillary expansion on the midpalatal
suture: a systematic review. Eur J
Orthod 2015; 37: 651–655. https://doi.
org/10.1093/ejo/cju100
12. Angelieri F, Cevidanes LH, Franchi L
et al. Midpalatal suture maturation:
classification method for individual
assessment before rapid maxillary
expansion. Am J Orthod Dentofacial
Orthop 2013; 144: 759–769. https://doi.
org/10.1016/j.ajodo.2013.04.022
13. Bishara SE, Staley RN. Maxillary
expansion: clinical implications. Am J
Orthod Dentofacial Orthop 1987; 91:
3–14. https://doi.org/10.1016/0889-
5406(87)90202-2
14. Persson M, Thilander B. Palatal
suture closure in man from 15 to 35
years of age. Am J Orthod 1977; 72:
42–52. https://doi.org/10.1016/0002-
9416(77)90123-3
15. Knaup B, Yildizhan F, Wehrbein H. Age-
related changes in the midpalatal suture.
A histomorphometric study. J Orofac
Orthop 2004; 65: 467–474. English,
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004-0415-y
16. Korbmacher H, Schilling A, Püschel K et
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microcomputed tomography analysis of
the human midpalatal suture. J Orofac
Orthop 2007; 68: 364–376. https://doi.
org/10.1007/s00056-007-0729-7
 CELEBRATING 30 YEARS
Thank you to all our valued customers for your loyal support during the last 30 years!

Proud to have remained an independent company since the start, TOC has grown into one of the leading suppliers of orthodontic
products in the UK. As experts in our field, and with a sales team who are orthodontic specialists, we offer the very latest products
and those designed to increase treatment efficiency and maximise results. Our comprehensive range of products incorporates a
variety of options for both private and NHS treatments suiting all price points. Plus, you can rely on our excellent stock levels held
in our Bristol warehouse ready for next day delivery to your practice.

y Brackets, bands & wires

“Having worked with TOC for a number of years and using a wide selection of their products,
y Bonding supplies I’ve found them to be one of the very best suppliers out there. TOC’s products are always of
y Aligner accessories an incredibly high standard and Orthodontics in my practices simply wouldn’t be possible
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longer than other brands. Many thanks to the whole team at TOC for their continued help
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46 Orthodontics January 2023

Enhanced CPD DO C

Laura Brooks Kelly Smorthit and Jonathan Sandler

Early Removal of
Supernumeraries to
Close a Midline Diastema:
A Case Report
Abstract: A midline diastema is a part of normal dental development, which, in the mixed dentition, is termed the ‘ugly duckling’ stage.
Supernumerary teeth, however, can also be a cause, with the most common type being a mesiodens. Supernumeraries can cause other
complications including delayed or failure of eruption of a permanent tooth, displacement of crowns, crowding, root resorption and cyst
formation. Treatment options for supernumeraries include immediate or delayed removal or active monitoring. This article advocates for
early diagnosis and treatment to reduce the need for future complex treatment.
CPD/Clinical Relevance: This case emphasizes the importance for clinicians to accurately and carefully diagnose the cause of a midline
diastema and the presence of supernumerary teeth early in development. Prompt orthodontic referral can reduce the need for later
complex surgical and orthodontic treatment.
Ortho Update 2023; 16: 46–49

A supernumerary tooth (ST) is ‘any
tooth or odontogenic structure that
is formed from tooth germ in excess
of usual number for any given region
of the dental arch.’1 They present as
single or multiple teeth, unilaterally or
bilaterally and can occur in both the
maxilla and mandible.2 They are more
prevalent in the maxilla by up to 10
times, and are more common in the
premaxillary region.3,4 The most common
type of ST is the mesiodens5 and they
are more prevalent among men than
women in a ratio of between 2:1 to
3.25:1.4,6 Prevalence in the deciduous
dentition is 0.3–0.8% and 1–3.5% in the
permanent dentition.4,7–9
The aetiology of ST is still unclear;
however, several theories have
been proposed:
„ Atavism: is a type of long distance
heredity and so, ST are a reversion to
an ancestral human dentition that
contained a greater number of teeth.10
„ Dichotomy: division of a tooth bud into
two teeth of equal size or one normal
and one dysmorphic tooth.2
„ Dental lamina hyperactivity: there is a
localized, independent and conditional
hyperactivity of remnant epithelial
cells of the dental lamina, which is
the most widely accepted reason.10 A
rudimentary form (teeth of abnormal
shape and smaller size) develop from
the proliferation of epithelial remnants
of the dental lamina and a supplemental
form (teeth of normal shape and size)
develop from the lingual extension of an
additional tooth bud.5
„ Genetic factors: there are multiple
reports to support the theory of a
familial tendency to ST with autosomal
dominant inheritance and a sex-linked
pattern being proposed.11 Mouse
models are being used to investigate
the role of different genes in tooth
development, including the regulation
of the number and development
of supernumeraries.12
„ Associated syndromes: ST are
associated with syndromes such as

Laura Brooks, BDS, MFDS, MSc (Dist), PGCert in Medical Education (Dist), Community Dental Officer, St Leonard’s Hospital, London.
Kelly Smorthit, MChD/BChD(Dist), MFDS(Edin), PGCert(Dist), Registrar in Orthodontics, Chesterfield and North Derbyshire Royal Hospital.
Jonathan Sandler, BDS(Hons), MSc, PhD, MOrthRCS, FDSRCPS, Consultant in Orthodontics, Chesterfield and North Derbyshire Royal
Hospital. Email: laura.brooks14@nhs.net
January 2023
a a
Figure 1. (a, b) A 6-year-old female patient
showing two midline supernumeraries causing
an extremely large midline diastema and rotated
upper central incisors.
cleidocranial dysplasia,13 Ehlers–Danlos
syndrome, 14 Gardner’s syndrome15 and
Marfan syndrome.16
ST can be classified according to their:
„ Morphology: conical, tuberculate,
supplemental, odontomes.
„ Location: mesiodens (between the two
central incisors), paramolar (palatal or
labial to a molar), distomolar (distally
to the third molar) and parapremolar
(palatal or labial to a premolar).
„ Position: buccal, palatal, transverse.
„ Orientation: vertical or normal,
horizontal, inverted.17
The presence of a ST can cause various
complications including:
„ Midline diastemas: often caused by an
unerupted or erupted mesiodens.
„ Delayed or failure of eruption of
a permanent tooth: often affects
the premaxillary region with a
tuberculate ST.
„ Displacement of the crowns of
adjacent teeth: mild rotation to
severe displacement.
„ Crowding: often caused by an erupted
or unerupted supplemental ST.
„ Root resorption: sometimes loss of
vitality of the adjacent tooth occurs.
„ Cyst formation: dentigerous cysts are
the common type.1,7,18
Thorough clinical and radiographic
examination is required to correctly
identify and locate an ST and any of the
complications above should alert the
clinician that an ST may be present. A
Orthodontics 47
vertical or horizontal parallax technique
using a combination of long cone peri-
apicals, or an upper standard occlusal
and a dental panoramic radiograph is
required. Where an ST is to be surgically
removed, and its location is in the region
of important anatomical structures, a small
FOV CBCT is justified.19 Treatment options
for ST include immediate or delayed
removal or, if no complications are present,
regular monitoring with no intervention.1,20
A diastema is a space greater than
0.5 mm between the proximal surfaces
of two adjacent central incisors.21 A
midline diastema in the mixed dentition
is often seen, and is labelled as the ‘ugly
duckling’ stage and is part of normal dental
development. Patients aged 6–8 years have
the highest prevalence of maxillary midline
diastemas, which usually reduces with age
following full eruption of lateral incisors
and canines.21
The following case illustrates the
benefits of early referral for an orthodontic Figure 2. (a) OPG and (b) peri-apical radiograph
showing the two supernumerary teeth at age
assessment of a midline diastema due to ST,
6 years.
and early interceptive treatment.
Case report
A 6-year old female patient was erupted and slightly palatally positioned
referred by the Community Dental (Figure 1). The upper central incisors were
Service to Chesterfield Royal Hospital partially erupted, rotated and positioned
orthodontic department for assessment lateral to the ST. An OPG and a peri-apical
of two asymptomatic upper midline radiograph were taken by the referring
supernumerary teeth, which were causing a clinician (Figure 2).
midline diastema. Medically the patient was The treatment plan involved
fit and well, took no regular medications extraction of the two ST under general
and had no known allergies. anaesthetic with the hope of spontaneous
Examination revealed a Class 1 skeletal improvement in the position of the two
pattern with an early mixed dentition. central incisors. Surgery was performed
Two upper midline supernumeraries were when the patient was 7.5 years old.
present, preventing the two central incisors Figure 3 shows spontaneous reduction
coming together. The upper right ST was of the midline diastema 6 months after
fully erupted and the upper left ST partially surgery, and Figure 4 illustrates complete
48 Orthodontics
a a
Figure 3. (a, b) Significant closure of the midline
diastema 6 months post-surgery.
a
b
Figure 4. (a, b) Complete closure of the midline
diastema at 10 years old.
closure of the midline diastema at 10 years
old. The patient continues to be reviewed
periodically to ensure correct eruption of
the upper canine teeth.
Discussion
A midline diastema can be caused by normal
dental development, a missing tooth, a peg-
shaped lateral, proclination of the upper
labial segment, a prominent midline frenum
or a midline supernumerary tooth, which
occurred in the case described above.22
Ethnic differences also exist, with the
prevalence of maxillary midline diastemas
greater in those of African origin than in
those of European or East Asian origin.23
January 2023
b
Figure 5. (a–c) An unerupted mesiodens causing rotation of the UR1.
Figure 6. (a) OPG showing horizontally impacted b
supplemental supernumerary extending from
UR1 to UR3. (b) CBCT axial view showing no
pathology related to the supernumerary.
Indications for removal of ST include
when eruption of the central incisor has
been delayed or displacement has occurred.
Other indications include associated
pathology, spontaneous eruption of the
ST, if active orthodontic alignment would
result in close proximity to the ST, or if the ST
compromised alveolar bone grafting in cleft with some clinicians advocating immediate
lip and palate patients.7 removal, while others favour a delayed
In the literature, optimal timing for approached. The advantages of immediate
surgical intervention remains controversial, removal following early diagnosis are
January 2023
avoidance of: space loss, midline shifts,
cyst formation and root resorption,
failure of correction of the displaced
teeth using the spontaneous eruptive
forces of adjacent teeth, and preventing
extensive future surgical and orthodontic
treatment.24 The disadvantages of early
removal include the possible risk of
loss of vitality and root malformations
of adjacent teeth, and the inability of
a young child to cope with a surgical
procedure.5 Because of these concerns,
some clinicians recommend delayed
intervention until root formation of
adjacent teeth is completed, around
10 years of age for an upper central
incisor.5 However, Omer et al state
that the optimal age for removal of
a maxillary ST is 6–7 years of age
after which more complications are
expected.1 This can be demonstrated
by the case described in Figure 5 where
a delayed approach has resulted in a
rotated UR1 due to the presence of an
unerupted mesiodens.
Occasionally ST are asymptomatic
and may be detected as a chance finding
during radiographic examination.
Such teeth can be actively monitored
if there is no associated pathology,
satisfactory eruption of related teeth,
no orthodontic treatment planned and
removal could risk loss of vitality of the
adjacent teeth.7 This decision was taken
in the case shown Figure 6. There are
no radiographic guidelines related to
the frequency of monitoring, but the
authors suggest every 2 years would be
reasonable. During active monitoring,
clinicians need to be aware of the risk
of development of late-forming ST,
especially in the lower premolar region
and which can occur after a patient
has previously developed anterior
maxillary ST.25
Conclusion
This case demonstrates the importance
for clinicians to accurately and carefully
diagnose the cause of a midline diastema,
which in this scenario was because of ST,
early in development. Timely orthodontic
referral allowed for optimal treatment,
reducing the need for later more complex
surgery and orthodontics.
Compliance with Ethical Standards
Conflict of Interest: The authors declare
that they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
References
1. Omer RS, Anthonappa RP, King NM.
Determination of the optimum time for
surgical removal of unerupted anterior
supernumerary teeth. Pediatr Dent
2010; 32: 14–20.
2. Rajab LD, Hamdan MA. Supernumerary
teeth: review of the literature and
a survey of 152 cases. Int J Paediatr
Dent 2002; 12: 244–254. https://doi.
org/10.1046/j.1365-263x.2002.00366.x.
3. Ata-Ali F, Ata-Ali J, Penarrocha-Oltra
D, Penarrocha-Diago M. Prevalence,
etiology, diagnosis, treatment and
complications of supernumerary teeth.
J Clin Exp Dent 2014; 6: e414–418.
https://doi.org/10.4317/jced.51499.
4. Arandi NZ, Abu-Ali A, Mustafa S.
Supernumerary teeth: a retrospective
cross-sectional study from Palestine.
Pesqui Bras Odontopediatria Clín Integr
2020; 20. https://doi.org/10.1590/
pboci.2020.029.
5. Primosch RE. Anterior supernumerary
teeth – assessment and surgical
intervention in children. Pediatr Dent
1981; 3: 204–215.
6. Anthonappa RP, Omer RS, King NM.
Characteristics of 283 supernumerary
teeth in southern Chinese children. Oral
Surg Oral Med Oral Pathol Oral Radiol
Endod 2008; 105: e48–54. https://doi.
org/10.1016/j.tripleo.2008.01.035.
7. Garvey MT, Barry HJ, Blake M.
Supernumerary teeth--an overview
of classification, diagnosis and
management. J Can Dent Assoc 1999;
65: 612–616.
8. Mahabob MN, Anbuselvan GJ, Kumar BS
et al. Prevalence rate of supernumerary
teeth among non-syndromic South
Indian population: an analysis. J Pharm
Bioallied Sci 2012; 4: S373–375. https://
doi.org/10.4103/0975-7406.100279.
9. Kumar DK, Gopal KS. An
epidemiological study on
supernumerary teeth: a survey on
5,000 people. J Clin Diagn Res 2013; 7:
1504–1507. https://doi.org/10.7860/
JCDR/2013/4373.3174.
10. Anthonappa RP, King NM, Rabie AB.
Aetiology of supernumerary teeth:
a literature review. Eur Arch Paediatr
Dent 2013; 14: 279–288. https://doi.
org/10.1007/s40368-013-0082-z.
11. Kawashima A, Nomura Y, Aoyagi Y,
Asada YJPDJ. Heredity may be one of
the etiologies of supernumerary teeth.
2006; 16: 115–117.
12. Fleming PS, Xavier GM, DiBiase
AT, Cobourne MT. Revisiting the
supernumerary: the epidemiological
and molecular basis of extra teeth. Br
Dent J 2010; 208: 25–30. https://doi.
org/10.1038/sj.bdj.2009.1177.
13. Lubinsky M, Kantaputra PN. Syndromes
with supernumerary teeth. Am J Med
Genet A 2016; 170: 2611–2616. https://
doi.org/10.1002/ajmg.a.37763.
Orthodontics 49
14. Melamed Y, Barkai G, Frydman
M. Multiple supernumerary teeth
(MSNT) and Ehlers-Danlos syndrome
(EDS): a case report. J Oral Pathol
Med 1994; 23: 88–91. https://doi.
org/10.1111/j.1600-0714.1994.tb00263.x.
15. Groden J, Thliveris A, Samowitz W et al.
Identification and characterization of
the familial adenomatous polyposis coli
gene. Cell 1991; 66: 589–600. https://doi.
org/10.1016/0092-8674(81)90021-0.
16. Mallineni SK, Jayaraman J, Yiu CK,
King NM. Concomitant occurrence
of hypohyperdontia in a patient with
Marfan syndrome: a review of the
literature and report of a case. J Investig
Clin Dent 2012; 3: 253–257. https://doi.
org/10.1111/j.2041-1626.2012.00148.x.
17. Mallineni SK. Supernumerary teeth:
review of the literature with recent
updates. Conference Papers in Science
2014; 2014: Article ID 764050. https://
doi.org/10.1155/2014/764050.
18. Proff P, Fanghanel J, Allegrini S, Jr. et
al. Problems of supernumerary teeth,
hyperdontia or dentes supernumerarii.
Ann Anat 2006; 188: 163–169. https://
doi.org/10.1016/j.aanat.2005.10.005.
19. Isaacson KG, Thom AR, Atack NE et al.
Guidelines for the use of radiography
in clinical orthdontics. 2015. Available
at: https://www.bos.org.uk/portals/0/
public/docs/general%20guidance/
orthodontic%20radiographs%20
2016%20-%202.pdf (accessed January
2023).
20. Hogstrom A, Andersson L. Complications
related to surgical removal of anterior
supernumerary teeth in children. ASDC J
Dent Child 1987; 54: 341–343.
21. McVay TJ, Latta GH, Jr. Incidence of the
maxillary midline diastema in adults. J
Prosthet Dent 1984; 52: 809–811. https://
doi.org/10.1016/s0022-3913(84)80009-8.
22. Kamath M, Arun AV. Midline diastema. Int
J Orthod Rehab 2016; 7: 101–104. https://
doi.org/10.4103/2349-5243.192532.
23. Lavelle CL. The distribution of
diastemas in different human
population samples. Scand J Dent
Res 1970; 78: 530–534. https://doi.
org/10.1111/j.1600-0722.1970.tb02106.x.
24. Russell KA, Folwarczna MA. Mesiodens
– diagnosis and management of a
common supernumerary tooth. J Can
Dent Assoc 2003; 69: 362–366.
25. Oliver G, Hamilton S, Read N, Atack N.
The continued development of multiple
supernumerary teeth: do they influence
orthodontic treatment? Orthodontic
Update 2021; 14: 125–133. https://doi.
org/10.12968/ortu.2021.14.3.125.
24 - 25 March 2023 • ExCeL London

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January 2023 Orthodontics 51

Tricks of the Trade:

Ten Simple Steps to PVS
Impression Success
The two-step putty and wash impression
technique with a spacer medium is
an important technique to master.
Many associate it primarily with fixed
prosthodontics. However, it has an
important role to play in many aspects
of orthodontic practice. This technique
can lead to more accurate stone
dies.1 This is extremely pertinent for
orthodontists involved in prescribing
and making orthodontic aligners
and custom-made fixed appliances
using impressions. Furthermore, this
technique is useful for cases where
palatal temporary anchorage devices are
being used. Additionally, this technique
can produce accurate models that
may be required for cases requiring
a multidisciplinary orthodontic–
restorative approach.
Compliance with Ethical Standards
Conflict of Interest: The authors declare
that they have no conflict of interest.
Reference
1. Nissan J, Laufer BZ, Brosh T, Assif D. Accuracy
of three polyvinyl siloxane putty-wash
impression techniques. J Prosthet Dent 2000;
83: 161–165. https://doi.org/10.1016/s0022-
3913(00)80007-4

Step 3. Use the impression tray as a template to cut out the correct sized
spacer. A lab bag is a more than suitable material if no spacer foil is available.
Step 1. Preparation is key, assemble all the equipment you need. This
includes: a lab bag, scissors, disposable mirror and scalpel, PVS heavy-
bodied silicone and light-bodied silicone.

Step 2. Line the impression tray with an impression tray adhesive. Step 4. Mix the heavy-bodied PVS material and place in impression tray.

Robert M Conville, BDS, MJDF (RCS Eng), PG Cert Med Ed, FHEA, MClinDent (Orth), MOrth (RCSEd), MRACDS (Orth), Specialty Registrar in
Orthodontics, Queens Medical Centre, Nottingham; Charles Clifford Dental Hospital, Sheffield. Steven Clark, BDS, MSc, FDS MOrth FDS
(Orth) (RCS Edin) M.Orth (RCS Eng), Consultant Orthodontist, Queens Medical Centre, Nottingham.
Email: robertconville@gmail.com
52 Orthodontics January 2023

Step 5. Place the spacer on top of the PVS material so that it covers the entire
arch and therefore will act as a barrier between the teeth and the material.

Step 8. Once set, remove the impression and inspect for any defects, air-
blows or drag marks.

Step 6. (a) Fully seat the impression and remove after a few seconds. While
the impression material is still not fully set use the side and end of the
mirror to smooth the inner lining of the impression with the spacer in situ.
(b) Then, gently remove the spacer material being careful not to distort the Step 9. Trim the impression of any unwanted excess material with the
material and continue to smooth the inner areas of the impression. This will scalpel.
remove any drag marks or uneven surfaces and make space for the light-
bodied material.

Step 7. Ensure the teeth are fully dried and isolated prior to commencing
with the next stage. Place the light-bodied silicone into both buccal sulcus
and the impression tray and fully seat the impression – this is the second
and final stage of the technique. Step 10. Repeat the same process for the opposing arch.
Reach for the stars
plan for your future
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54 Orthodontic Update January 2023

CPD
A.continuing education

Test your knowledge on the content of the articles published.

The following 7 questions relate to some of the articles carried this month. Only one answer is correct.

To receive CPD credit, answer the questions online at www.orthodontic-update.co.uk

Q1 CHATE 16: 10–18 Q5 GOGNA ET AL 16: 33–38

The Function Regulator for juveniles with a bilateral cleft Based on the literature, which movement appears to be the most
and a prominent premaxilla (the FR-BCPPm) is made from an challenging for aligners to correct?
amalgamation of: A. Intrusion.
A. An FR I and an FR II Function Regulator, with one additional B. Torquing.
novel component. C. Rotation.
B. An FR I and an FR III Function Regulator, with one additional D. Extrusion.
novel component.
C. An FR I and an FR II Function Regulator, with two additional
novel components.
D. An FR I and an FR III Function Regulator, with two additional
novel components.
Q6 BROOKS ET AL 16: 46–49

Which is the most widely accepted theory for a supernumerary

Q2 ROSHANRAY ET AL 16: 20–25 tooth developing?
A. Atavism.
British Orthodontic Society guidelines for the use of radiographs B. Dichotomy.
in clinical orthodontics indicate that obtaining intra-oral C. Dental lamina hyperactivity.
radiographs during orthodontic treatment to assess OIEARR is only D. Genetics.
justified when:
A. There is clinical evidence of excessive mobility.
B. Loss of vitality of a tooth.
C. Abnormal delay in tooth movement.
D. All of the above. Q7 BROOKS ET AL 16: 46–49

According to Omer et al, which is the optimal age for removal of a

Q3 ROSHANRAY ET AL 16: 20–25 maxillary supernumerary tooth?
A. 4–5 years.
Which patients are potentially at a greater risk of developing B. 6–7 years.
orthodontically induced inflammatory root resorption (OIIRR)? C. 8–9 years.
A. Patients with previous orthodontic treatment. D. 10–11 years.
B. Patients with abnormal root length/shape.
C. Patients with systemic illnesses such as asthma.
D. All of the above.

Q4 MONAGHAN AND NEEDHAM 16: 28–31

Which of the following is not a disadvantage of a quartz-tungsten

halogen light cure unit compared to an LED?
A. Generation of heat.
B. Bulkier unit.
C. Reduced life span.
D. Increased energy efficiency.

CPD in Orthodontic Update in partnership with DEADLINE FOR SUBMISSION: 12 APRIL 2023

ANSWERS FOR OCTOBER 2022 CPD ON PAGE 31

7 QUESTIONS REPRESENT 4 HOURS OF CPD

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