468 Readers’ forum
October 2008
control group. Thus, the difference shows the real treat-
ment effect, and, in almost all clinical orthodontic re-
search, the treatment effect in relation to growth is of
interest. This was why it was so important to have an
untreated control group. The ethicality of using an un-
treated control group should, of course, always be thor-
oughly considered. The treatment of the control patients
was delayed by 12 months, and the risk of missing the best
time for treatment was small.
In addition, it was stated that the trial was ethically
approved by a committee that follows the guidelines of the
declaration of Helsinki.
Dr Hayes suggested that children with posterior crossbite
should be exposed to radiation—ie, anteroposterior radio-
graphic examination before treatment—to evaluate the tip-
ping of the posterior teeth. With respect to ethical consider-
ations, anteroposterior radiographic examinations of these
young patients seems questionable.
Considering the absence of overcorrection, Dr Hayes
used a citation by Haas from 1961 that refers to a study on
rapid expansion and midpalatal suture, but this is not of
interest in this context. In a forthcoming study, a long-term
follow-up on treatment stability will show whether the ab-
sence of overcorrection is “risky business.” Furthermore, in
this follow-up, it is planned to analyze whether the posterior
teeth have been pushed beyond their periodontal biologic
limit.
Dr Hayes claimed that “crossbite is not a diagnosis—it is
a symptom in search of a diagnosis.” We strongly believe that
crossbite is a generally accepted orthodontic diagnosis and
not only a symptom.
Sadly, it is obvious that Dr Hayes misunderstood the idea
of evidence-based evaluation, and his criticism of this meth-
odology is the same because he dismissed the main body of
evidence-based evaluations in odontology and medicine for
the last decade.
Sofia Petrén
Lars Bondemark
Malmö, Sweden
Am J Orthod Dentofacial Orthop 2008;134:467-8
0889-5406/$34.00
Copyright © 2008 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2008.08.008
REFERENCES
1. Petrén S, Bondemark L. Correction of unilateral posterior cross-
bite in the mixed dentition: a randomized controlled trial. Am J
Orthod Dentofacial Orthop 2008;133:790.e7-13.
2. Petrén S, Bondemark L, Söderfeldt B. A systematic review
concerning early orthodontic treatment of unilateral posterior
crossbite. Angle Orthod 2003;73:588-96.
3. Harrison JE, Ashby D. Orthodontic treatment for posterior cross-
bites (Cochrane Review). In: The Cochrane Library, Issue 4, 2000.
Oxford: Update Software.
4. Thilander B, Myrberg N. The prevalence of malocclusion in
Swedish schoolchildren. Scand J Res 1973;81:12-21.
American Journal of Orthodontics and Dentofacial Orthopedics
The friction concept must
acknowledge the biology of tooth
movement
When dealing with force management in orthodontic
tooth movement, 2 entities must not be confused: force and
pressure. Although we can ultimately control force and are
used to dealing with it, biologic processes ultimately deter-
mine tooth movement by bone resorption, and these are
triggered and modulated by the pressure exerted on the
periodontal ligament (PDL) (for review, see Krishnan and
Davidovitch1).
To consider this in more detail, 2 key aspects of orth-
odontic tooth movement must be taken into account: biome-
chanical and anatomic/biologic. For the former, the net force
exerted by an archwire on a tooth depends not only on the
type and dimension of the wire itself, but also on the degree
of wire bending and the friction in the slot. For the latter, the
anatomic/biologic aspect, the pressure (not the force) exerted
by the archwire on the PDL depends on the surface the force
is spread over, and thus on the differential root anatomy and
the type of movement (an intrusive movement will generate
greater PDL pressure, compared to that of bodily orthodontic
tooth movement). Moreover, the locations of the centers of
resistance, and the individual inflammatory responses are also
important and crucial determinants for the resultant move-
ment. Thus, optimal control of tooth movement must deal
with fine control of PDL pressure, which is still far from
optimal, and where the net force exerted by the archwire is
only 1 component.
Recently, much effort has been focused on the develop-
ment and testing of low-friction orthodontic systems; how-
ever, these studies should acknowledge that friction in the slot
ultimately has only a relatively minor role in the complex
determination of PDL pressure, which is impossible to
measure in vivo.
Although low-friction systems allow the use of lower-
intensity forces, this does not mean that the resultant PDL
pressure is always more biologically compatible with that
of a standard high-friction system with greater forces, as
has been implied. Therefore, control of effective PDL
pressure, which is the critical point, is an open issue
irrespective of the system used. Moreover, the locations of
the centers of resistance are also difficult to determine
precisely.
Nevertheless, low-friction systems can provide great
advances when levelling crowded dental arches with pre-
adjusted appliances. This requires the use of thin arches,
the force of which might be in the same order of magnitude
as that of the friction in the slots of standard systems.
Clinical studies have shown faster orthodontic tooth move-
ment in such cases, when a low-friction system was used.2
At the same time, when all teeth in an arch are engaged by
the wire, the differentiation of frictional forces at each
bracket becomes important in dictating the relative move-
ment of each tooth.3
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 134, Number 4
Therefore, the concepts of high and low friction can be
put together as a “differential” friction concept. With these
considerations, it becomes clear that the most efficient orth-
odontic system must provide differential friction over the
various stages of treatment and eventually in the same dental
arch at each stage, instead of being characterized as only
either high or low friction.
Finally, even if systems that allow differential friction are
valuable clinical tools, the most efficient orthodontic treat-
ments will come with the fine knowledge of the biology of
tooth movement.
Giuseppe Perinetti
Nocciano (PE), Italy
Readers’ forum 469
Am J Orthod Dentofacial Orthop 2008;134:468-9
0889-5406/$34.00
Copyright © 2008 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2008.08.007
REFERENCES
1. Krishnan V, Davidovitch Z. Cellular, molecular, and tissue-level
reactions to orthodontic force. Am J Orthod Dentofacial Orthop
2006;129:469.e1-32.
2. Baccetti T, Franchi L, Fortini A. Orthodontic treatment with
preadjusted appliances and low-friction ligatures: experimental
evidence and clinical observations. World J Orthod 2008;9:7-13.
3. Halazonetis DJ. Friction and anchorage loading. Am J Orthod
Dentofacial Orthop 2008;133:484-5.