Presenting by : Dr Mahammad Anas

Guided by :Dr Arshad Hussain

 PART-1

 Introduction
1.Controversies in Etiology of malocclusion
2. Extraction versus Non-extraction.
3. Timing of Orthodontic Treatment
4.Root resorption related to orthodontic treatment
5.Frenectomy for correction of midline diastema

2
 PART-2
1.Orthodontic treatment and temporomandibular disorders
2.0.018” vs 0.022”
3.Self ligating brackets
4.Extraction vs arch expansion
5.Orthodontic materials
6.Functional appliances
7.Aligner vs fixe
Conclusion and References

3
  A ‘Controversy’ features an active and honest difference of
Opinion where as an ‘Orthodontic controversy’ proves to be
different

 They never die, they never fade away; they are immortal

Adarshika Yadavet al.Few controversies in orthodontics -Evidence based studies. Indian Journal of
Orthodontics and Dentofacial Research, July-September 2018;4(3):129-137

4
 It has traditionally been a specialty in which opinions of
leaders were important, to a point that professional groups
coalesced around a strong leader.

 Angle, Begg, Tweed societies still exist where “disagreements

are the rule rather than exception”

5
Tongue-thrust as etiologic factor
Third molars – A dilemma! or is it?

6
•Placement of tongue-tip forward
between incisors during swallowing

•Tongue thrust is a defined as a

condition in which the tongue makes
contact with any teeth anterior to the
molars during swallowing.

7
Laboratory studies indicate that individuals who place the
tongue tip forward when they swallow have more tongue force
against teeth than those who keep tongue tip back

Tongue pressure against the teeth during a typical swallow is < 1

second.

A typical individual swallows about 800 times in a day, while

awake, but has only a few swallows / hour while asleep.

Proffit W R.Lingual pressure patterns in the transition from tongue thrust to adult
swallowing.Arch Oral Biol.1972;17:555-563.

8
Tongue –thrust is primarily seen in 2 circumstances:

 In young children with normal occlusion – transitional stage in

normal physiologic maturation.

 In individuals of any age with displaced anterior teeth – adaptive.

 Hence it is more a “Result” than a “cause”

 However tongue posture is more important.

 Light pressure for more duration  change in tooth position.

9
 Third molars are usually considered
as vestigial ,which may be
responsible for mutilated dentition.

 The role that mandibular third

molars play in lower anterior
crowding has provoked much
speculation in the dental literature.

Gupta S, Shukla P. The dilemma in label of cause and

effect: controversies in etiology of malocclusion.
International Journal of Science & Healthcare
Research. 2020; 5(1): 42-48.
10
 The differing views ranged between extremes, and can be
expressed in two different statements:

 a)Third molars should be removed even on a prophylactic

basis, because they are frequently associated with future
orthodontic and periodontal complications as well as other
pathologic conditions.

 b)There is no scientific evidence of a cause and effect

relationship between the presence of third molars and
orthodontic and periodontal problems.

11
 Pressure from behind theory states that late crowding occurs at
about the time third molars erupt.

But whether this pressure results from:

1. Developing 3rd molar.
2. Physiologic mesial movement / drift.
3. Anterior component of force derived
from forces of occlusion on mesially
inclined teeth.

Is not sure

12
 Bergstorm and Jensen (1961) concluded more crowding in the
quadrant with 3rd molar present than in the quadrant with the
third molar missing.

 Vego (1962) concluded arch perimeter decrease was less

noticeable in persons without lower 3rd molars with greater
degree of crowding in the group with third molar

Bergstrom K, Jensen R. Responsibility of the third molar for secondary crowding, Swedish
Dental Journal; 1961; 54:111-24.16.

Vego L: A longitudinal study of mandibular arch perimeter.Angle Orthod; 1962; 32:187-92.

13
 Bishara et.al (1989 and 1996) studied changes in lower incisor
that occur with time in untreated populations between 12 and
25 years and again at 45 years and found that :

 Increase in tooth size arch length discrepancy with age.

 There was a consistent decrease in arch length with age.

 Changes of 2.7mm in males 3.5mm in females were attributed

to a consistent decrease in arch length that occurred with age

Bishara SE, Treder TE, Damon P, and Olsen M:

Changes in the denta arches and dentition between 25
and 45 years of age.Angle Orthod;1996; 66:417-22.

14
 Shanley and Leo et.al. in 1962divided subjects into three
groups-bilaterally impacted, erupted and congenitally absent
mandibular third molars and he found no significant
difference between the means of the crowding measurements
and angulation measurements in the three groups indicating
that mandibular third molars exert little influence on crowding
or procumbency of mandibular anterior teeth

S h a n l e y S L: The Influence of Mandibular Third Molars on Mandibular Anterio:

Teeth: J. Orthdontics, October 1962

15
  Kaplan 1974 concluded that presence of 3rd molar does not
produce a greater degree of lower anterior crowding or
rotational relapse after cessation of retention therefore the
theory that third molars exert pressure on the teeth mesial to
them could not be substantiated

Kaplan RG. Mandibular third molars and post-retention crowding.Am J Ortho1974; 66:441-30.

16
 First school of thought-These long term studies indicated that
the incidence as well as the severity of mandibular incisor
crowding increased during adolescents and adulthood in both
the normal untreated individuals as well as orthodontic treated
patients, after all retention is discontinued.

17
 Second School of thought-The influence of the third molars on
the alignment of the anterior dentition may be controversial,
but there is no evidence to incriminate these teeth as being the
only or even the major etiologic factor in the post-treatment
changes in incisor alignment

 Suggests relationship between these two phenomena is that

they occur at approximately the same stage of development
i.e. in adolescence and early adulthood.

18
 “To extract or not to extract” was one of the early debates that
clouded orthodontic world ever since its beginning.”

Extraction vs Non Extraction Controversy:A Review. Journal of Dental & Oro-facial Research
Vol.14Issue 01Jan.2018

19
 Provide space to align remaining teeth in crowding.

 Allow teeth to move for camouflaging skeletal

malocclusion- Cl-II/Cl-III

20
 Celsus and Pierre Fauchard- Extraction of deciduous teeth

 Hunter-1771- Opposed extarction of permanent teeth

 Delabarre -1818,-He said, “It is much easier to extract teeth

than to determine if it is absolutely necessary

 Isaac B.- delivered a lecture in New York against extractions,

stating that extractions caused “A loss of an important organ”

21
 Initially, Edward Hartley Angle believed that extraction of
teeth was necessary to solve orthodontic treatment problems.

 Angle’s book, “Treatment of Malocclusion of the Teeth and

Fractures of the Maxillae-Angle System” sixth edition, was
published in 1900

 Contains an enormous amount of material and case reports in

which the extraction of teeth was involved. Angle advocated
extraction to improve facial appearance

22
 Rousseau, a philosopher, believed that many of the ills of the
modern man owed to the environment we now live in.

 He emphasized on the perfectibility of man. Consequently,

from an orthodontic viewpoint, a perfect occlusion could
never be achieved by extracting teeth.

 This became an article of faith for Angle and the early

orthodontists, that every person had the prospective to attain
an ideal relationship of all thirty two natural teeth, and
therefore extraction for orthodontic purposes was never
needed

23
 Early 1900- Wolffs Law.

 Angle was impressed by the discovery that the architecture of

bone responds to the stresses placed on that part of the
skeleton and thereby reasoned that, forces transmitted to the
teeth would cause bone to grow around, if teeth were placed in
a proper occlusion

 He described his edgewise appliance as a ‘bone growing

appliance

24
 Any relapse observed in any of his treated cases was
considered to be a result of inadequate occlusion.

 So accordingly, his treatment for every patient involved

expansion of the dental arches and elastics as needed to bring
the teeth into occlusion, and extraction was not necessary for
stability of result or esthetics

25
 Ideal facial esthetics would result when the
teeth are placed in ideal occlusion.

 He believed this can be achieved when the

dental arches are expanded so that all the
teeth were in ideal occlusion.

26
 Argued that although the
arches could always be
expanded so that the teeth
could be placed in
alignment, neither esthetics
nor stability would be
satisfactory in the long term
for many patients

27
 The controversy culminated in a widely publicized debate
between Angle’s student Dewey and Case in the dental
literature of 1920’s.

 Angle followers won : Extraction disappeared

- The Extraction debate of 1911 by case, Dewey and Case. Discussion of case: The question of
extraction in orthodontia. AJO 50: 751,1964

28
Charles Tweed

Re-treated the relapse cases with

extraction; previously treated with non-
extraction methodology, & found
occlusion to be much more stable.

He supported his theory by

Cephalometrics

29
 Extraction reintroduced widely

 Raymond Begg popularized

“Begg” appliance for extraction
treatment.

 This was further strengthened by

Prof. Stockard’s experiments which
showed that malocclusion could be
inherited

30
 Instability of non extraction results due to Arch length
collapse in particularly,

1. Lower anterior crowding

2. Reversion to original class II malocclusions
and procumbencies.

31
 Revival of non-extraction philosophy.

◦ Premolar extraction does not guarantee stability of tooth

alignment.
Little, Wallen and Riedel – 1981 AJO.
MC Reynolds and Little – 1991 Angle Orthod
◦ Lower anterior crowding recurred post retention

◦ Deep bites recurred more readily in all 4 extraction cases

Little RM, Wallen TR, Riedel RA. Stability and relapse of mandibular anterior alignment–first
premolar extraction cases treated by traditional edgewise orthodontics. 1998;1981:1–15.

McReynolds DC, Little RM. Mandibular second premolar extraction—postretention

evaluation of stability and relapse. Angle Orthod. 1991;61(2):133–44.

32
“If result not stable either way, why sacrifice teeth
at all”.
vs
“If extraction cases are unstable, non-extraction
would be worse”

33
 Changing views of esthetics : Fuller profile than
orthodontic profile

 Change from banding to bonding and introduction of

functional appliances.

34
 The ill-famous litigation – Witzig and Spahl (1980)

Premolar extraction causes distalization of mandible

posteriorly, displacement of condyle resulted in perforation of
articular disc  TMD.

35
 Management of Non extraction treatment has improved

1. Issue of growth and our ability to influence it

2. Reduction of caries thereby maintaining arch length.

(Mixed dentition treatment)

36
 Early intervention:
 Use of ‘E’ space.
 Space regainers with space maintainers.
 Arch expansion.
 Use of functional appliances
 Bonded attachments rather than banded ones.

37
 Adult:

 Molar distalization.
 Inter-proximal reduction.
 Arch expansion.
 Surgery for skeletal discrepancies.

38
 For Class I crowding / Protrusion:

 Arch length discrepancy < 4mm with no vertical discrepancy:

non-extraction.

 Arch length discrepancy = 5-9mm

Non-extraction : Transverse expansion of premolar segment.
Extraction : Any pattern of extract depending on hard and soft
tissues.

 Arch length discrepancy > 10mm :Extraction

39
 Identifying guidelines for the extraction vs non-extraction
decision in orthodontic treatment is a complex task.

 The option to treat with extraction or non-extraction should be

made objectively for each case based on strong evidence with
equal attention on the soft tissue paradigm.

40
 EARLY
VS
LATE TREATMENT

41
1. Superior facial esthetics
2. Greater ability to modify the growth process
3. Fewer extractions
4. Reduction in difficulty of subsequent therapy
5. Consistent and predictable elimination of phase II treatment
6. Reduction in the fracture potential of protruding maxillary incisors
7. Eliminate, if not reduce the need for future jaw surgery
8.Greater stability
9.Psychological benifits
One-stage versus two-stage treatment: Are two really necessary?
Bowman, S.Jay.American Journal of Orthodontics and Dentofacial Orthopedics, Volume 113, Issue 1,
111 - 116

42
1.Longer overall treatment time
2. Loss of compliance
3. Greater risk due to prolonged treatment such as root
resorption, white spot lesion, bone loss, caries
4. Increased cost
5. Dilacerations of roots
6. Impaction of maxillary canines by premature uprighting of
the roots of lateral incisors
7. Impaction of maxillary second molars

43
1. Growth modification
a. Headgears
b. Functional appliances
c. Face mask
d. Chin cap

2. Arch length discrepancy

a. Serial extraction
b. Arch expansion
c. Preservation of arch length

44
45
 It was a prospective long term study.
 It had an almost ideal research design.
 Conducted by Drs. Camilla Tulloch and William Profitt
 All subjects were children with overjet of 7mm

46
 There was no difference between the groups with regard to
ANB angle either at the start or after phase II of treatment.

 No difference in the quality of dental occlusion between the

children who had early treatment and those who did not.

 There was approximately the same distribution of success and

failure with and without early treatment

47
 Early treatment did not reduce the number of children needing
extraction of premolars or other teeth during phase II of
treatment.

 Early treatment did not reduce the eventual need for

orthognathic surgery.

 There was little influence on the time duration that both

groups spent wearing fixed appliances.

48
 Early treatment did reduce severity of class II malocclusion.

 Overjet decrease in the treated groups whether the appliance

was a headgear restricting the maxilla or a functional one
positioning the mandible forward.

 Still doubt whether early treatment is better or not as long as

treatment is provided at some point in time.

49
The only result is now people refer to it as appropriate
treatment time

Early vs late depends upon type of malocclusion, treatment

response and view point of orthodontic practitioner
Class III needed early interception,in early mixed dentition
Class II can be treated with FFD in one phase by utilizing
pubertal growth

50
ROOT RESORPTION
RELATED TO
ORTHODONTIC
TREATMENT

51
 Bates (1856) – 1st to
discuss root resorption of
permanent teeth.

 Ottolengui (1914) –
related root resorption to
orthodontic treatment

52
1)Alveolar bone density

 Becks,Tager,Reitan found Root resorption is greater in

dense bone.

53
 The use of fixed appliances is more damaging to the
roots

 Ketcham claimed that normal function is disturbed by

the splinting effect of orthodontic fixed appliances
over a long period that can cause root resorption.

Linge BO, Linge L. Apical root resorption in upper anterior teeth.

Eur J Orthod 1983;5:173-83.

54
 It is often stated that the light wire Begg technique
causes less root resorption than edgewise

Remmelnick HJ. The effect of anteroposterior incisor repositioning on the root and
cortical plate: a follow-up study. J Clin Orthod 1984;18:42-9.

55
 The stress distribution along the roots during bodily
movement is less than the stress concentration at the
apex resulting from tipping.

 Therefore risk of root resorption due to bodily

movement should be less than that of tipping.

 Reitan K. Biomechanical principles and reactions. In: Graber TM, Swain BF.
Orthodontics current principles and techniques. St. Louis: CV Mosby,
1985:101-92.

56
 Harry and Sims found the distribution of resorbed
lacunae was directly related to the amount of stress on
the root surface. They concluded that higher stress
causes more root resorption.

 According to Schwartz, applied force exceeding the

optimal level of 20 to 26 gm/cm2 causes periodontal
ischemia, which can lead to root resorption.

57
 The pause in treatment with intermittent forces allows
the resorbed cementum to heal and prevents further
resorption.

Oppenheim A. Human tissue response to orthodontic intervention of short and long

duration. Am J Orthod 1942;28:263-301.

58
 Orthodontic treatment should begin as early as possible
since there is less root resorption in developing roots and
young patients show better muscular adaptation to
occlusal changes.

Rosenberg HN. An evaluation of the incidence and amount of apical root resorption and
dilaceration occurring in orthodontically treated teeth, having incompletely formed
roots at the beginning of Begg treatment. AM J ORTHOD 1972;61:524-5.

59
 There is currently considerable controversy about whether
labial frenectomy is indicated in all cases of maxillary midline
diastema

 The blanch-test, whitening of the tissue between the incisors

when the upper lip is everted, has been considered to be
diagnostic for determining whether the maxillary labial
frenum is involved

Wheeler B, Carrico CK, Shroff B, Brickhouse T, Laskin DM. Management of the Maxillary
Diastema by Various Dental Specialties. J Oral Maxillofac Surg. 2018;76(4):709‐715

60
61
 The timing of when a maxillary labial frenectomy to address a
midline diastema should be done is also controversial.
 Many base the timing for a planned frenectomy on whether
eruption of the permanent maxillary canines has occurred
 There may be a role for frenectomy before canine eruption in
cases where a large diastema makes spontaneous closure
questionable
 Another indication for removal of the maxillary frenum prior
to orthodontic closure is when the frenum is so large that it
potentially prohibits orthodontic space closure

62
 A systematic review of the literature has shown a tendency of
orthodontists to suggest post-treatment frenectomy.
 Arguments for this approach are supported by the theory that
the orthodontic forces may cause the frenum to remodel
 When this occurs it is thought to increase turnover of the
transseptal peridodontal ligament fibers, with the newly
developed fibers increasing incisor stability. However, there
are no controlled studies to support this theory

Delli K, Livas C, Sculean A, Katsaros C, Bornstein MM. Facts and myths regarding
the maxillary midline frenum and its treatment: a systematic review of the literature.
Quintessence Int. 2013; 44(2):177-87

63
 Orthodontic Treatment
and
Temporomandibular Joint
Disorders

64
 The attention of the orthodontic community regarding TMD
however was heightened in the late 1980s after litigation
involving the allegations that orthodontic treatment was
the cause of TMD in orthodontic patients.

65
 In the 1980’s articles in various journals and trade magazines
suggested that orthodontic treatment might play a role in
initiating temperomandibular disorder.

 On the other hand it was also claimed that orthodontic

treatment might be effective in alleviating the signs and
symptoms of TMD.

66
 The benefits of orthodontic treatment in the management of
Temperomandibular Disorder is questionable, since the
occlusion is considered as having a limited role in the cause of
TMD.

 But the potential detrimental effects of orthodontic treatment

on TMJ has captured the attention of orthodontic community.

67
 Some of the examples of Orthodontic treatment which can lead to
Temperomandibular Disorders are:

• Effect of headgear and/or class II elastics in correction of Class II malocclusions

with deep interlocking cusps.
• Effect of Cross elastics to correct the midline
• Effect of Reverse Headgear or Class III Elastics for Correction of Class III
malocclusion

William E. Wyatt. Preventing adverse effects on TMJ through orthodontic treatment . AJO
1987; 91: 493 –499

68
 By the headgear force, as the
maxillary dentition is moved
backward the muscles of
mastication will attempt to retract
the mandible when the patient
closes into maximum
intercuspation.
 This compensating movement by
the mandible can put distal
pressure on the condyles and
conceivably cause an anterior
dislocation of the disk.

69
2) Effect of Cross elastics to correct the midline

 The cross elastics have a little effect on TMJ.

 As the jaw is pulled to one side, distal pressure is put

only on one condyle

 If it creates a TMJ problem then elastics should be

worn only during morning

70
 This again can put distal pressure on the mandible.

 If there is a developing problem, treatment is limited to morning

time as muscle tension or tone, positions the mandible forward

71
Prevalence of signs and symptoms of TMD in

Orthodontically Untreated population

 Numerous epidemiologic studies have shown a significant
prevalence, with an average of 32% reporting at least one
symptom of TMD and an average of 55% demonstrating at
least one clinical sign.

 Several investigators have noted that signs and symptoms of

TMD generally increase in frequency and severity in the
second decade of life.

-Williamson EH. Temporomandibular dysfunction in pretreatment adolescent patients. AM J

ORTHOD 1977;72:429-33.

72
 Does Orthodontic treatment lead
to a greater incidence of TMD ?

 Two of the first major investigations sponsored by the

National Institute of Health revealed no statistically significant
differences between the treated and untreated groups & the
assumption made by some authors that orthodontic treatment
can prevent symptoms of mandibular dysfunction is
disproven.

-Sadowsky C, BeGole EA. Long-term status of temporomandibular joint function and functional
occlusion after orthodontic treatment. AM J ORTHOD 1980;78:201-12.

-Sadowsky C, Polson AM. Temporomandibular disorders and functional occlusion after orthodontic
treatment: results of two long-term studies. AM J ORTHOD 1984;86:386-90.

73
 Another study of the long term effects of orthodontic
treatment stated that comprehensive orthodontic
treatment can be under taken without fear of creating
TMD problems.

- Larsson E, Ronnerman A. Mandibular dysfunction symptoms in orthodontically treated

patients ten years after the completion of treatment. Eur J Orthod 1981;3:89-94.

74
 Does the type of appliance (e.g. fixed functional or
orthodontic vs orthopedic) make a difference ?

 In the major longitudinal study conducted by Dibbets et al

consisting of 171 patients, 75 of whom were treated by Begg
mechanotherapy, 65 were treated by activator and 30 patients
were treated with chin cups, revealed that at the end of
treatment, fixed appliance group had a higher percentage of
objective symptoms than did the functional group, but no
differences existed at the 20 year follow up evaluation.

75
 Does the removal of teeth as part of an
orthodontic protocol lead to a greater incidence of
TMD ?

 Articles and tests have strongly associated the extraction of

premolars with the occurrence of TMD in orthodontic
patients.

 But clinical studies that have dealt with this issue have not
shown relationship between premolar extraction and TMD.

76
 Sadowsky et al studied 160 patients and reported that joint
sounds were evident before and after treatment in 87
extraction patients and 73 non extraction orthodontic patients.

 They reported there is no increase in the risk of development

of joint sounds regardless of whether teeth were removed .

Sadowsky C, BeGole EA. Long-term status of temporomandibular joint function and

functional occlusion after orthodontic treatment.
AM J ORTHOD 1980;78:201-12.

77
 Steiner introduced the 0.457 mm × 0.711 mm (0.018-inch ×
0.028-inch) slot for stainless steel wires in lieu of the 0.559
mm × 0.711 mm (0.022-inch × 0.028-inch slot for gold alloy
wires.

 Original intention of 022 slot was not meant for sliding

mechanics, (as it is ideally suited) but it is for torque
movement control when 22 X 28 gold wires were used

78
018 vs 022 Slot

 With the advent of stainless steel wires, edgewise brackets

were redesigned from 022 to 018 slot.

79
018 vs 022 Slot:

 Role of Titanium arch wires became evident in alignment and

torque control in wider 022 slot by the characteristics like
higher range and resistance to permanent deformation.

 Even undersized stiffer wires are the alternate solution

80
 Detterline ,Isikbay ,Brizendine ,Kula (2010) determined if
there is a significant difference in the clinical outcomes of
cases treated with 0.018-inch brackets vs 0.022-inch brackets
according to the American Board of Orthodontics (ABO)
Objective Grading System (OGS).

DetterlineDA,IsikbaySC,BrizendineEJ,KulaKS: Clinical outcomes of 0.018-inch and

0.022-inch bracket slot using the ABO objective grading system.
AngleOrthod.2010;80(3):528-32.

81
 Treatment time and the ABO-OGS standards in
alignment/rotations, marginal ridges, buccolingual inclination,
overjet, occlusal relationships, occlusal contacts,
interproximal contacts, and root angulations were used to
compare clinical outcomes between a series of 828
consecutively completed orthodontic cases (2005-2008)
treated in a university graduate orthodontic clinic with 0.018-
inch-and 0.022-inch-slot brackets.

82
 There were statistically, but not clinically, significant
differences in treatment times and in total ABO-OGS scores in
favor of 0.018-inch brackets as compared with the 0.022-inch
brackets in a university graduate orthodontic clinic (2005-
2008)

 Understanding biomechanics is the matter; it is not the slot

dimension which in debate

83
 Latest Controversies in Orthodontics: From in
Vitro Data to in Vivo Evidence

Volume 16, Issue 4,Pages 243-302 (December 2010)

84
 Mechanics is divided into two branches:
 (1) Statics
 (2) Dynamics.

 Statics deals with bodies at rest (unaccelerated motion), and

dynamics deals with accelerated motion.

Critical Appraisal of in Vitro Steady-State Frictional Resistance Studies.

Samuel J. Burrow. Semin Orthod 2010;16:244-248

85
 In vitro laboratory studies designed to study friction are based
on the second branch of mechanics, i.e, dynamics, which is
based on accelerated motion

 Teeth have biological constraints that prevent immediate

motion, we need to consider the rigid-body model under
statics as the best model to predict tooth movement.

86
 The average movement per month in these in vitro studies is
very high, which puts it in the dynamic branch of mechanics

 Clinical tooth movement is in the static section of mechanics

 Use of the dynamic branch of mechanics to explain clinical

tooth movement is inappropriate and unscientific.

 Very little useful information, from a clinical perspective, can

be interpolated from these in vitro investigations.

87
 The main industry claims in favor of self ligating brackets and
in relation to treatment efficiency are the following:
 Self-ligating brackets reduce appointment duration
 Self-ligating brackets reduce treatment time.

 Questions that should be posed are:

 How do the aforementioned claims measure up with the
scientific evidence?
 Do self-ligating brackets deliver what they promise for the
patient and the clinician?
 Do they really outperform conventional brackets?

88
 Shivapuja and Berger: Found that clinically significant chair
time savings may be achieved using self-ligating brackets

 Turnbull and Birnie: Found that the Damon2 self-ligating

system had a significantly shorter mean archwire ligation time
for both placing and removing wires compared with the
conventional elastomeric system

 Ligation of an archwire was approximately twice as quick

with the self-ligating system.

89
 From the limited evidence it appears that self-ligating brackets
have the potential of reducing appointment duration with
favorable consequences for both patients and clinicians.

 However, this modest time saving represents only a portion of

actual chair time during an orthodontic adjustment. Depending
upon the use of staff and flow of patients in the office, this
may or may not have an impact upon practice efficiency

90
91
 In conclusion, it appears from the available peer-reviewed
studies that there is no concrete evidence to support the notion
that self-ligating brackets effectively shorten treatment
duration, while in some cases where statistical significance
was reached the difference was clinically unimportant.

 However, the number of publications is currently limited, and

for some brackets systems there are no data available in the
literature, indicating the need for further comparative
evaluation of the various bracket systems.

92
 The current limited evidence does not support the notion that
self-ligating systems deliver faster space consolidation.

 Lower friction and faster tooth movement in vitro does not

necessarily result in faster tooth movement in the clinic due to
the fundamental differences between in vitro and in vivo
setups.

 To evaluate this appropriately requires additional research in

the form of randomized clinical trials.

93
 Most fluoride-containing materials that have been investigated
for their effectiveness in preventing enamel demineralization
during orthodontic treatment are bonding agents

 Addition of flouride to composite resin was done as early as

1960

 Later investigations failed to detect significant reductions in

the prevalence of demineralization between fluoridated and
nonfluoridated composites

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 The only way we can determine if a particular fluoride-
containing material does reduce demineralization in the
orthodontic patient, without any adverse side effects, such as
bond failures, is to study the material in the environment
within which it will be used and for the length of time that it
will be used for

 This will inevitably mean a randomized controlled trial

 In- vitro findings can seldom be compared to the in- vivo

studies

95
.

Soft tissue considerations Stability considerations

Lip separation – increases Limiting forces from cheeks

with tooth prominence. Fenestrations in Buccal
Thick, full lips – can afford cortical plate (> 3mm)
prominent incisors.
Size of nose and chin.
Lip strain i.e. lack of well
defined labiomental
sulcus.

96
“What are the spaces at the corners of smile from extraction
treatment?”
Witzig and Spahl 1987 and Dierkes 1987

If the inter canine width or arch form is maintained during

treatment, whether extraction or non extraction, the width of
the smile would be the same post treatment

No predictible relationship between extraction of premolars

and Esthetics of smile
Johnson and smith 1990

97
98
Since the inception of the idea of functional jaw orthopedics, it
has always been surrounded with numerous views regarding
its mode of action, the outcomes of such treatment, the
stability, the timing, the appliance and its effects on the
skeletal pattern.

99
 The influence of functional appliances on mandibular
growth is a controversial issue.

 The primary question is whether treatment with a

functional appliance can induce a clinically significant
increase in mandibular growth.

 Much of the work demonstrating the ability of

functional appliances to stimulate mandibular growth is
based on animal experimentation.

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 Effects on mandibular growth

2 Schools of thought

Increased mandibular Normal growth

growth
 Mc Namara evaluated the results obtained in his laboratory
and those of Petrovic and concluded that :

 Maximum of 5% - 15% increase in mandibular length can

be expected in experimental animals under controlled
laboratory conditions and during periods of active growth.

 Johnston, after renewing series of experimental studies,

concluded that condylar growth can be altered by
unloading or distracting the condyle

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 Stockli and Willert also reported an increase in the size of the
condylar head

 Rabie et al showed there was significant increase in both

vascularization and mandibular bone growth upon forward
mandibular positioning and highest amount of both were
expressed in posterior region of the condyle.

-The highest acceleration of vascularization preceded that of

new bone formation.

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 Whether these findings on animal models are applicable to
human beings during routine clinical treatment is debatable.

 Discrepancies between animal and human studies are expected

since animal experimentation frequently involves the use of
continuous forces.

 These types of forces usually are impractical and often

undesirable in most clinical situations; therefore treatment
results can be expected to be less dramatic and more variable.

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 The construction bite determines the sagittal and
vertical
displacements of the mandible and therefore the degree
and direction of appliance activation.

 The determination of a proper construction bite is

critical
for a functional appliance to succeed.

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 Andersen and Haupl increased the vertical dimension
between the molars by 3-4 mm.

 Appliance was loosely fitting appliance that would

induce “myotactic reflex” which would encourage the
patient to bite into the appliance.

 Too wide opening made compliance more difficult and

could produce a depressing force on the teeth, hardly
desirable in deep bite, class II malocclusions.

 Grude and Frankel strongly support this construction

bite limit

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 Harvold increased the vertical dimension 9-11mm ; 5-6
mm beyond 4-5mm rest position.

Reason- vertical dimension normally increase during sleep

causing mandible to slip out of the appliance.

 Horizontal displacement of the mandible was also increased

beyond Class I molar relationship to an end to end incisor
relationship.

 The overextended activator, stretching the soft tissues like a

splint, induces no myotactic reflex activity but creates a
buildup of potential energy.

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 Herren over extended in a saggital plane, moving the
mandible anteriorly into an incisal cross bite relationship.

 According to Graber, if the forward positioning of the

mandible is 7-8mm, the vertical opening should be 2-4 mm.
and if the forward positioning is 3-5mm the vertical opening
should be 4-6 mm.

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 The term “jumping the bite” was introduced by Kingsley
regarding his maxillary plate.

 It refers to the advancment of the mandible to a class I

relationship during bite registration.

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 McNamara and Petrovic (1981)

Progressive activation method to bring the mandible

gradually forward :

- places less stress on the investing soft tissue matrix,

and
- reduces the undesirable dental effect while
maintaining the skeletal effect.

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 Anehas and Pancherz - multistep approach to be more
physiologically favourable in terms of muscular
response.

 Rabie et al investigated the number of replicating

mesenchymal cells to correlate it to the amount of bone
formation in the condyle during stepwise advancement
of the mandible Vs single step advancement.

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 Single step advancement Stepwise advancement

 the posterior region of the  Replicating cells are half in

condyle contains replicating number in response to the
cells twice in number initial advancement in the
stepwise group.
 Bone formation is double  Bone formation is also half

 Maximum level of bone  Second advancement recruits

formation reached in 30 days more mesenchymal cells
followed by decline to levels leading to more bone
equal natural growth formation.
between days 40 to 60.

112
 B C
A

Cellular changes in posterior region of condyle. (A) control group , B) 1 step advancement C) stepwise
advancement on day 7

Thus stepwise advancement of the mandible seems to be a

better option when compared to the maximal bite jumping.

 It is more comfortable and physiologically acceptable mode

of treatment for the patient.

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  The efficiency of maxillary canine retraction was compared
with the sliding mechanics (along a.016 x.022-in stainless
steel labial arch and nickel-titanium closed coil spring) and a
canine retraction spring.

 The patterns of tooth movement obtained with both of these

mechanics were measured 5 times each

Rhee JN, Chun YS, Row J. A comparison between friction and frictionless mechanics with a new
typodont simulation system. Am J Orthod Dentofacial Orthop. 2001;119(3):292‐299.
doi:10.1067/mod.2001.112452

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 Friction mechanics were superior to frictionless mechanics in terms
of rotational control and dimensional maintenance of the arch .

 Frictionless mechanics were shown to be more effective at reducing

tipping and extrusion

 However, the observed differences between the 2 methods were

relatively small in terms of their clinical significance, and no
differences were found in anchorage control

 In conclusion, this study indicated that friction and frictionless

mechanics perform similarly.

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 Aligner technology has developed greatly over past few years.

 Patients tended to prefer clear aligners over conventional

brackets because of the superior comfort and esthetics, while
the effectiveness of clear aligners was still controversial.

 Systematic Review: Ke Y, Zhu Y, Zhu M. A comparison of

treatment effectiveness between clear aligner and fixed
appliance therapies. BMC Oral Health. 2019;19(1):24.

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 The similar overall improvement in OGS scores indicated that both
clear aligners and braces were effective in treating malocclusion.
 Clear aligners had advantage in segmented movement of teeth and
shortening treatment duration.

 While braces were more effective in achieving great improvement,

producing adequate occlusal contacts, controlling teeth torque,
increasing transverse width and retention than aligners.

 Therefore, clinicians should consider the characteristics of these

two orthodontic appliances when making treatment decision.

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 From the outset, it important to draw a clear distinction between
controversies and orthodontic controversies.
 Scientific controversies, therefore, tend to come and go. The
fathers of our specialty were people of considerable scientific
achievement and sophistication. Like their medical colleagues,
they, too, disagreed on many basic questions. Orthodontic
controversies however, have proved to be different. They never
die, they never fade away; they are immortal.

 The only way to resolve these controversies is by moving on

from traditional “Opinion based Orthodontics” to “Evidence
based Orthodontics”

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