Biomechanics Nanda PDF

CONTENTS
I. Principles of Biomechanics
Ra vindra Nanda alld Andrew Kuhlberg
2. Orthodontic Treatment Planning 23

Stephen 1. Lindauer
3. Improving Arch Mechanics Through Surface Chemistry 50

R. P Kusy, C. R. Saunders. and 1. Q. Whitley
4. Current Status of Magnetic Forces in Orthodontics 65

T. M. Graber
5. Biomechanical Aspects of Class n Mechanics with Special

Emphasis on Deep Bite Correction as Part of the
Treatment Goal 86
L R. Dermaul and C. De Pau w
6. Canine Impaction: Diagnosis, Treatment Planning,

and Clinical Management 99
8havtlO Shroff
7. The Role of Headgear in Class II Dental and Skeletal

Corrections 109
Raymmld E. Siatkowski
8. Biomechanics of Class II Correction 143

Bha vlla SllIvf! and Rm1itulra Nalldo
9. Biomechanical Basis of Extraction Space Closure 156

Ra vindra Nwuit, alld AI/drew Kuhlberg
xv
xvi CONTENTS
10. Biomechanical Considerations in Sliding Mechanics 188

Ram S. Nanda and Joydeep Ghosh
11. Clinical Considerations in Extraction Therapy 218

Thoma s F. Mulligan
12. Modified Lingual Lever Arm Technique: Biomechanical

Considerations 229
Hans· Peter Bam/eon
13. Contemporary Management of Class II Malocclusions:

Fact and Fiction in Class n Correction 246
Charles 1. Bllrstone
14. An Approach to Nonextraction Treatment of Class II

Malocclusions 257
Anthony A. Giannelly, John Bet/dar, Victor S. Dietz,
and James Koglin
15. The Herbst Appliance: A Powerful Class U Corrector 265

Hans Pancherz
16. Treatment of Class II Backward Rotating Malocclusions 28 1

Uoyd E. Pearsoll
17. Management of Severely Compromised Orthodontic Patients 294

Birle MeIse"
Index 321
CHAPTER
1
Principles of Biomechanics
Ravindra Nanda • Andrew Kuh lberg
INTRODUCTIO N
Orthodontic tooth movement results from the application of forces to teeth. These
fo rces are produced by the appl iances (wires, brackets, elastics. etc.) inserted and acti-
vated by the cl inici an . The teeth and thei r associated support structures respond to
these forces with a complex biologic reaction that ul timmcly results in tooth move-
ment through bone. The cell s of the periodontiu m. which respond to the app lied
forces. arc unaware of the bracket design. wire shape, or alloy- their activity is based
solely on the stresses and strains occurring in their environment. In order to achieve a
precise biologic response. one would have to apply precise sti mul i. mcchunical or
otherwise. The complex ity and vari abili ty associated with biologic:! 1 systems encour-
ages cl inic:!1 precision in the appli cation of any stimulus. Minim izing or elimin:!ting
the unknown factors related to the delivery of treatme nt can reduce the variability in
treatment response. Knowledge of the mechani cal principles governi ng forces is nec-
essary fo r the control of orthodontic treatment.
The bas is of orthodontic treatment lies in the clinical application of biomechan i-
cal concepts. Mechanics is the discipline that describes the effect of forces on bod ies;
biomechanics rcrcrs to the science of mechanics in relation to bio logic systems.
Onhodontic treatment applics forces to the leeth. The forces are gencrated by a vari-
ety of orthodontic :lppliances An analogy is the use of pharmaceutical agents in medi-
cine. Medications are used to achieve a specific biologic response aimed al resolving
or relieving a patient 's problems or symptoms. Judicious prescription of medications
requires an undersl:!nding of the mechanisms of action of Ihe therapeutic agents in
order 10 obtain the desired clin ical results. Orthodontists depend on a similar :!ppl ica-
tion of mechanical force systems for treatment success.
The duration of orthodontic trealment still approaches two years, arguably because
1
2 CHAPTER 1
Principles of Bio mechanics
of the time it lakes to correct the side effects that are genermed during the treatment. If
biomechan ical principles are applied (0 mechanotherapy, not only may treatment time
be reduced, but one could also develop more individualized treatment plans for achiev-
in g more predictable results. The proper application of biomechanical principles
increases treatment effici ency through improved planning and delivery of care.
MECHANICAL CONCEPTS IN ORTHODONTICS
An understanding of several fundamental mechanical concepts is necessary in order

to understand the clinical relevance of biomechanics to orthodontics.
The first concept is eenfer of re~;isfllllee. All objects have a center of mass. The
center of mass is the point through which an applied force must pass fo r a free object
to move li nearly without any rotation ; in other words, the center of mass is an object's
"balance point." Figure I- IA depicts the center of mass of a generic free body. A
tooth within a periodontal support system is not a free body because it is restrained by
the periodontium . The center of resistance is analogous to the center of mass for
restrai ned bodies. The center of resistance is the equi valent "balance poin t" for
restrained bodies. Figures 1- 18. C. and D show the approximate location of a center
of resistance for a single tooth . Notice that the cenler of resistance can be described in
each plane of space. Single teeth, units of leeth, complete dental arches, and the jaws
themselves each have cenler(s) of resistance. Figure 1- 2 shows the approximate cen-
ter(s) of resistance for a two-tooth segment and for a maxi lla.
The center of resistance of a tooth is dependent on the root length and morphol-
ogy, the number of roots, and the level of alveolar bone support. The exact location of
the center of resistance for a tooth is not easi ly identified; however, analytical studies
have determined thm the center of resistance for single-rooted teeth with normal alve-
olar bone levels is about one-fourth to one-third the distance from the cementoenamel
junction (CEJ) to the root apex. U3-42 The center of resistance of facial bones (i.e., the
maxilla), entire arches of teeth, or segments of teeth may also be cstimated. 21 Experi-
mental and analytical studies report the center of resistance for a maxilla to be slightly
inferior to Orbitale for the maxilla and distal (0 the latentl incisor roots for intrusive
movements of maxillary anterior teeth."1.42
A B
c D
Figure 1-1 . The center of resistance. A, The cen-
ter of mass of a free body. B. C. and D. The cen·
ter of resistance of a single tooth. B is the frontal
view, C is the ocdusal view. and D is the mesial Figu re 1-2. A. The center of resistance for a two-tooth segment. B.
view. The center of resistance for a max illa.
CHAPTER 1 3
Figure 1-3. The location of the center of resistance depends

on the alveolar bone height and root length. A. The location
of the center of resistance with alveolar bone loss. B. The
center of resistance with a shortened root.
A B
Allhough its prec ise location is typically unknown, it is important to have a con·
ceptual awareness of the center of resistance of a tooth (or teeth) when selecting and
activating an orthodontic appliance. The relationship of the force system acting on the
tooth to the center of resi stance detennines the type of tooth movement expressed.
Thi s relationship is discussed in more detail later in the chapter.
It is the "pplication of a force that results in orthodontic tooth movement. Forces
are the actions applied to bodies. A force is equal to mass times acceleration (F = rna).
Its units are Newtons or gram· millimeterslsecond 2• Grams are often substituted for
Newtons in clinical orthodontics because the contribution of acceler.llion (mls 2) to the
magnitude of the force is clinically irrelevant. A force is a vector. and is defined by the
characteristics of vectors.37 Vector quantities are characterized by having both magni-
tude and direction (Fig. 1-4). The magnitude of the vector represents its size. Direction
is described by the vector's line of action. sense. and point of origin (or point of appli-
cation). Orthodontic forces are obtained in a variety of ways. The denection of wires,
acti vation of springs, and elastics are common means o f producing orthodontic forces.
Muhiple vectors can be combined through vector addition (Fig. 1- 5). Since vec-
tors have both magnilUde and direction. simple addition o f vector quantities arithmeti-
cally is impossible. The sum o f two or more vectors is tenned the resu/wtl(. Vectors
may be added by placing the origin of one vector at the head of another while main-
tain ing the vectors' lines of action (in both length and direction). The resultant vector
is found by connecting the origin of the fi rst vector to the head of the fi nal vector.
Quantitative delenninalion resultants requires lrigonometric calculations.
Line of Action
Figure 1-4. A force vector. Force vectors are characterized
by magnitude. line of action. point of origin, and sense.
Origin! SenseI
Point of application Direction
Figure 1-5. Vector addition. The sum of two or more vectors is

the resultant. It is found by connecti ng the vectors ~head-to Resultant
tail " while maintaining the length and direction of the line of
action.
Force 2
Resultant Force = Force 1 + Force 2

4 CHAPTER 1
Princi ples of Biomechanics
Vertical
Component Figure 1-6. Vector components. A vector can be
analyzed by its components along reference axes.
Horizontal
Component
Vectors can also be resolved into components. Decomposition of a force into

components along x, y. and " axes can aid in vector addition (Fig. 1-6). Clinically. the
determin ation of the horizonta l, vertical, and transverse componen ts o f a force
improves the understanding of the direction of tooth movement that might be
expected. Agai n, trigonometry must be applied to calculate the values of the vector
components.
Orthodontic forces are most commonly applied at the crown of a tooth. There-
fore. the application of the force is generally not through the center of resistance of
the tooth . Forces not aCling through the center of resistance do not solely produce lin-
ear motion. The moment oj the Jorce results in some rotational movement (Fig. I~7).
The moment of the force is the tendency for a force to produce rotation. It is d.£lcr-
mined by multiplying the magnitude of the force QY the perpendicular distance of the
line of action to the center of resistance. Its direction is found by following the line of
action around the center of resistance loward the point of origin. The units of mea-
surement of moments is in gram mill imeters (newton millimeters). The moment of a
force is often unrecognized in clinical onhodontics. Awareness of the moment of a
force is needed to develop effective and effici ent appliance designs.)?
Note Ihal two variables detennine the magnitude of the moment of a force-Ihe
magnitude of the force and the distance (Fig. 1- 8). Either one can be effecti vely
manipulated by the clinician to achieve the desired force systems.
Another method of achiev ing rotational movements is through the mOil/em oj (j
couple (Fig. 1- 9). A couple is two parallel forces of equal magnitude acting in oppo-
si te directions and separated by a distance. The magn itude of:1 couple is calcu lated by
multiplying the mugnitude o f force(s) by the distance between them; the units are also
in gram millimeters. The direction of the rotation is determined by following the
direction of cilher force around the center of resistance to the origin of the opposi te
force. Couples result in pure rotati onal movemen t about the center of resistance
regardless o/where tile COlllJle is apIJ/ied all the object (Fig. 1- 10). Couples arc often
-- Figure 1-7. The moment of a force . A force that does not

pass through the center of resistance produces a rotational
movement as welt as linear movement.
CHAPTER 1 5
Figure 1-8. Clinical examples of moments of a

force. A. A mesial force at th e molar bracket cre-
ates a moment tending to rota te the t ooth
" mesial-in." B. An expansion force on a molar
creates a moment tipping the crown buccally. C.
An intrusive force at the molar bracket creates a
moment tipping the crown buccaJly. B
referred to as the applied moment in onhodontics. Torque is a common synonym of

moment (both moments of forces and of coup les). Torque is erroneously descri bed in
degrees by many o rthodonti sts. The degrees o f wire bend ing or the angulation of
bracket slot design are methods to produce moments- i.e .• they describe the shape of
the wire or bracket. The appropriate units for the appli ed ~qu e is gram millimeters
(force x distance). It is the description of the moments that more accurately describes
the rotational components of a force system and appliance design,31
A
...
00
B
50g-ri~
-
Smm 400 g-mm
50 9
Figure 1- 10. Clinical examples of couples. A. Engaging
Fi gure 1-9. The moment of a cou pl e. A couple produces a wire in an angulated bracket. B, Engaging a rectan-
pure rotation about th e cen ter of resistance. gular (edgewise) w ire in a bracket slot.
6 CHAPTER 1
EQUIVALENT FORCE SYSTEMS
The application of forces or couples (moments, torque) usually occurs at the bracket.
Wires, elastics, and springs are attached to the looth at the bracket. A useful method for
predicting the type of tooth movement that will occur with the appliance activation is
to detennine the equivalemforce system at the tooth's center of resistance. This analy-
sis replaces the applied force system from the wires, elastics. and/or springs at the
bracket with its equivalent at the center of resistance. The force system at the center of
resistance detennines the type of tooth movement. A pure force at the center of resis-
tance results in linear movement (no rotation). while a pure couple results in rotation.v
Determining the force system at the center of resistance is a simple procedure (Fig .
..::» I - II). First. forces arc replaced at the center of resistance. The force vcctor is simply
moved to the center of resistance, maintaining its magnitude and direction. The force at
the bracket also generates a moment of a force: this moment is equal to the magnitude
of the force multiplied by the distance of the point of application to the center of resis-
tance. Second. the moment of the force is also placed at the center of resistance. Third.
the applied moment is replaced at the center of resistance. Finally, Ihe moment of the
force and the applied mOlllent are added to detennine the net moment. The resulting
force system describes the expected tooth movement. By detenn ining the equivalent
force systems, it becomes apparent that achieving desired and predictable tooth move-
ments requires an awareness of both applied forces and moments.
TYPES OF TOOTH MOVEMENT
Tooth movement can be described in many wuys. The potentially infinite variety of
movements can be categorized into basic types. These basic types are llm:>.ing, transla-
tion root movement, and r lation. Each type of basic movement is the result of varia-
lion of the applied moment and force (either by magnitude or point of application).
The relationship between the applied force system and the type of movement can be
described by the moment-to -force ratio. The M/ F ratio of the a pplied force and
moment determine~ the type of movement or the center of rotation.lo. 12. 21. 37- 39.41.42
Tipping
Tipping is tooth movement with greater movement of the crown of the tooth than of
the root. The center of rotation of the motion is apical to the center of resistance. Tip-
ping can be further classified on the basis of the location of the center of rotation into
uncontrolled and controlled tipping. Uncontrolled tipping includes tipping with a cen-
ter of rotation between the center of resi stance and the apex. Controlled tipping is tip-
ping with the center of rotation at the root apex.
""" Figure 1- 11 . The equivalent force sys-
""-
. 10mm
'" . tem at a tooth's center of resistance. A,
The fme system applied at the bracket.
B, The force system at the center of
resistan~. The force system at the cen·
ter of resistance describes the expected
tooth movement.
----- ---------------------------------
CHAPTER 1 7
Uncontrolled Tipping
A hori zontal force at the level of a bracket will cause movements of the root apex and
crown in opposite d irecti ons. This is the simplest type of tooth mo ve ment, but it is
often undesirable. Figure J- I2A shows an inci sor w ith good axial inclinatio n thai
needs retraction. If a simple fo rce such as chain e lastics, intra-arch cJ..a stics, or coil
springs is used on a light ro und w ire, the root apex will move forward.
Figure 1- I2B shows a typical stress pattern generated by uncontrolled lipping.
The stresses are nonuniform, and maximum stresses arc c reated at the root apex a nd
crown. The MIF ratio for this type of tooth movement is 0: I to approximately 5: I
(Note: MIF ratios are for average root lengths and 100% alveolar bone he ight.)1.31 -
,. In certain circumstances, uncontrolled tipping can be useful . such as with Class ! l,
Division. 2 and Class m patients where the excessively upright incisors often need flaring. •
Controlled Tipp ing

Controlled tipping is a very desirable type of tooth movement. It is achieved by an
application of a force to move the crown, as do ne in uncontrolled tipping, and applica-
tion of a mo me nt to "control" or ma intain the position of the root apex. Figure 1- 13A
shows that in an o ptima l controlled tipping situatio n the center of rotatio n of the tooth
is at the root apex. An M/F ratio of 7: I is generally necessary for controlled tipping.
Figure 1- 138 shows the pattern of stresses produced in the periodontal ligame nt for
this type of tooth movement. The stress at the root apex is minimal, which helps to maintain
the integrity of the apex, and the concentration of stresses at the celVical area allows time ly
tooth movement. I .)7 In patients with protrusive maxillary incisors, the root apex is often in a
gcxxl position and does not need movement. 'The only major movement is of the crown.
Translation
The translation type of tooth moveme nt is also known as " bodily movement." Trans-
latio n of a tooth takes place when the root apex and crown move the same distance
and in the same ho rizontal direction. The center of rotatio n is at infinity.
Figure l- 14A shows para lle l movement o r translation of the an inc isor. A ho ri-
zontal force applied at the center of resistance of a tooth will result in thi s movement.
However, the brac ket where the force applicatio n takes place is at a distance from the
center of resistance. This force alone applied at the bracket will not result in transla-
tion. To achieve tra nslation at the level of the bracket. a couple and a fo rce afe
required that are eq uivalent to the force system through the center of resistance of the
A B A B
Figure 1- 12. Uncontrolk-d tipping. A, Uncon- Figure 1- 13 . Controlled tipping. A, Con-

trolled tipping produced by a single force (no trolk-d tipping with the center of rotation at
applied moment). 8, The stress pattern in the the root apex. B, The stress pattern in tht
periodontal ligament. Notice the root apex periodontal ligament with controlled tipping.
moves in th e opposite direction f rom the The stresses are the greatest at the cervical
movement of the crown. margin.
8 CHAPTER 1
figure 1-14. Translation. A, Translational or bodily tooth

movement. B. The stress pattern in the periodontal liga·
ment with translation. Uniform stresses occur through'
out the penodontalligament.
A B
tooth. An MIF ratio of 10:1 typically produces translation. Figure 1- 148 shows that
thi s type of tooth movement produces uniform stresses in the periodontium. I.]?
Root Movement
Root movement is achieved by keeping the crown of a tooth stationary and applying a
moment and force to move on ly the root. The center of rotation of the tooth is at the
incisal edge or bracket. Root movement requires a large moment. The M/F ratio
shou ld be at or above 12: I to achieve optimal movement.]?
Figure 1- 15A and B shows the stress distribution in the periodontium wi th this
type of tooth movement. Stress levels in the apex area require significant bone resorp-
tion in this area for toolh movement to take place. This concentration of stresses often
requires undermining resorption . which causes a significant slow-down in the move-
ment of the root. This slower pace of root movement can be used advantageously to
augment anchorage.
Root movement in orthodontic treatment is commonly used to "torque" upri ght
incisors, to correct cuspid roots .Ifter ex tr:lction space closure. and to upright mesially
tipped posterior teeth.
It is important to keep the crowns sliltionary by ligating them with adjacent teeth
to prevent their movement in the opposite direction. For !i!!sual rOOI movement of the
incisors. often the anteriorly directed force is large and may cause a "row-boat" effect
6r bringing even the posterior teeth forw:lrd. To prevent this. it is adviSable to use a
headgear or a force in the distal direction.
Rotation
Pure rotation of a tooth requires a couple. No net force acts at the center of resi stance,
so only rotation occurs. Clini cally, this moveme nt is most commonly needed for
movement as viewed from the occlusal perspecti ve. Figure 1- 16 shows an example of
rotation.
Figure 1-15. Root movement. A. Root movement

with the cen ter of rotation at the incisal edge. B, The
st~s pattern in the periodontal ligament with root
movement. The stresses are the greatest at the apex.
A B
CHAPTER 1 9
fi8ure 1-16. Rotabon. Pure rotation OCCurs around a tooth's cen·

ter of resistance .
STATIC EQUILIBRIUM
Static equilibrium is a valuable application of Newton's laws of motion to the analysis

of the force system delivered by an orthodontic appliance)· IJ. 31 Newton's laws under-
lie some of the funda mental concepts of mechanics. TIle three laws are as follows:
I. The law of illertill: Every body continues in its state of rest or unifonn motion
in a straight line unless it is compelled to change by the force s impressed on it.
2. The I(lW of acceleratioll: The change in motion is proportional to the motive
force impressed and is made in the direction of the straight li ne in which the
force is impressed.
3. The law of (lcliOll alld reaction: To every :lction there is alway s opposing and
equal reaction.
To understand the application of these laws to orthodontics, consider what is hap-
pening when a wire is inserted into poorly aligned brackets. The wire must be
deflected or activated in order to be tied into the brackets. Once the wire is inserted,
both the first and third laws of motion arc apparent. First. the wire and the teeth are at
rest; the wire is not moving, and neither arc the teeth (although the periodontal struc-
tures feel a stress that will elici t the biologic reactions necessary for tooth movement).
Thus, the law of inenia is demonstrated. Simi larly, the third law. the law of action and
reaction, is demonstruted. The deflected wire is applying a force to the teeth, and the
teeth are applying an equal and opposite force on the wire. With the "active" (on the
teeth) and "reactive" (on the wire) forces being equal and opposite. no net force is
acting and the resting state is maintained.
A more important application of the luw of uction and reaction is through the con-
cept of static equilibrium. Stalic equilibrium implies thut. ut any poim within a body. the
sum of the forces und moments acting on u body is zero: i.e .. if no net forces or
moments are acting on the body, the body remains at rest (static). The "body" may be
defined as the wire or spring and all (he tccth 10 which the wire or spring is attached.
Statics is a field of mechanics Ihat examines the aClion of forces acting on bodies aI rest.
Applying the fundamental s of SIalic equ il ibrium to the analysis of the force sys-
tem produced by orthodontic appliances aids in predicting tooth response to tooth
movement. The analysis o f equilibrium can be staled in equation form :
I Hori zontal force s = 0
I Vertical forces = 0
L Transverse forces =0
and.
I Momen ts (horizontul axis) = 0
I Momems (verticul axis) =0
L Moments (lransverse ax is) =0
This formulation is most easily demonstrated in an example of a cantilever-type
orthodontic appliance. 2.4 .26.:l6 A schematic diugram of the intrusion arch depicts the
10 CH APTER 1
Figure 1- 17. A schematic diagram of an

intrusion arch. A. The passive form: the
intrusion arch inserted in th e molar tube
A bu t not engaging t he incisor(s). B. Th e
intrusion arch activated by tyin g it to the
an terior segment.
buccal view of the appliance. Figure 1- 17A shows the intrusion arch inserted into the
molar tube. but not tied to the incisors; B shows the appliance tied to the incisors. The
wire is inserted into the auxiliary lube of the molar and tied to an anterior segment
(overlaid) such that it is not inserted into the incisor bracket slot.
As previously stated, the sum of the forces must equal zero. 1lIerefore, the vertica1
intrusive forces acting on the incisors must be opposed by vertical extrusive forces act-
ing on the molar. For the vertical forces, the stale of equilibrium is readily seen. The
vertical force s also establish a couple (they are equal and opposite, non--co-linear
forces) . Figure 1- 18 shows the vertical forces. The moment of this couple must be
opposed by another moment cq uaJ in magni tude acting in the opposite direction. This
moment is found acting at the molar. The wire produces a couple acting on the molar
tube. This moment's direction compels the molar to tip the crown distally (Fig. 1- 18B).
The magnitude of the moment is equal to the distance between the points of attachment
and the vertical force.
Figure 1- 19 shows another cl inical situation thai allows further examination into
the detennination of the equi librium state of an appliance. Two incisors are tipped
toward onc another; the crowns conlact near the incisal edge. but the axiaJ inclination
of the incisors is poor, with excessive root divergence. This situation may arise with
initial closure of a midline diastema. For the purpose of demonstration, assume that
the incisors are equally tipped mesially and that the brac kets are accurately posi-
Figure 1- 18. Force system from an intrusion

arch in equilibriu m. The vertical forces (blue)
H
are "balanced by the tipback moment (red)
acting on the molar.
CHAPTER 1 11
A B
Figure 1- 1'. Diastema closure by mesial tipping of the irlCisors. A, The crowns
contact but there is e)(cess.ive divergence of the roots . 8, The force system for
uprighting the incisors; the forces and moments are equiva~n t in magnitude,
opposite in direction.
tioned. To upright the incisors, equal and opposite moments ure needed . The brackets
are "figure-8" tied to hold the interbracket distance, and a strai ght wire is inserted.
The resu lting force system is shown in Figure 1- 198. The fi gure-8 tie produces a
small horizontal force on each incisor. These force s act in opposi te direcl"ions (pulling
each crown toward the other) and in the same line of aCli on; thus, the rules of equi lib-
rium are satisfied. The wire produces moments acting on each tooth. In thi s example,
the momenls are equal in magnitude and opposi te in direction (the moments acting on
both teeth tend to move the roots mesially).
The examples just given demonslrate simple examples of how to determine an
appliance's equilibrium state. The application of unequal moments results in more
complex force systems, as may occur with bracket malalignment (in any plane), the
placement of eccentric " V"_bends.8.9. 20 gable bends, or the use of auxiliary space clo-
sure springs. Whenever the applied moments are unequal in magnitude, "additional"
forces must be present to oppose moment difference. In many cases these "additional"
forces are vertical in direction (extrus ive/intrusive). The vertical forces could resu lt in
extrusive tooth movements (deepening of the overbite or eruption of posterior teeth
and an increase in the lower fa cial height/vertical dimens ion) or chan ge in the
occlusal plane. Determination of the complete force system in equilibrium aids in the
recognition of these side effects.
Being aware of the force system produced by an orthodontic appliance in equi lib-
rium aids in the pred ict ion of the response to trealmcnt. Both the desired, beneficial
movements of the teeth can be foreseen along with potential neg:lt ive side effects.
Prior knowledge of any mechanical side effects makes possible compen sation before
these effects occur. It must be understood that the forces and moments found when
determining an appliance's equilibrium stale must ex ist. The eliminat ion of any com-
ponent of the force system would re..o;ult in either unopposed forces or moments. Then
the appliance or the teeth would obey Newton's second law (the law of acceleration)
and accelerate out of the mouth. These side effects cannot be eli minated! They should
be dealt wi th through altemative designs or additional appliances (Le., use of a head-
gear) in order to negate or minimize side effects.
MATERIAL CONSIDERATIONS
Arcliwires, springs, and elastics are the primary means of gencmling forces for orthodon-
tic treatment. The wires and springs are fabricated from a myriad of alloys.s Stainless
steel, long the standard material, has been joined by nickel -titanium alloys, II titanium-
molybdenum alloys,7 and a variety of other alloys as orthodontic wires. Understanding the
basic material characteristics becomes essential for selecting wires for use in trcatmenl. 18
The mechanical characteristics of a material are detcnnined by several factors. Intrinsic
12 CHAPTER 1
Elel tic: linil

-
lMima", Tensile
Figure 1-20. Stress-strain diagram

for an orthodontic wire. See the text
for further description of the mater-
ia! characteristics demonstrated.
Strain/Deflection
properties arc inherent qualities of the wire. These properties are detcnnined by the material
composition at a molecular or crystalline level. Variation of intrinsic properties alters the
nature of the alloy itself. Extrinsic properties are macroscopic features of the material. such
as wire diameter or length. These features can Ix: detennined by the clinician.
The fundamental characteristics describing material s properties are depicted by a
stress-slm in or load-de neclion c urve (Fig. 1- 20). A few key features of the load-
dencction curve express the clinical char.Icteristics of a wire.
lllc stress-strain diagram relates the load or force (stress) exerted on a material 10 the
distortion (strain) of thai material. Two areas of the curve can Ix: described: the clastic
region and the plastic region. The elastic region is the linear portion of the curve. Deforma-
tion o f the material in this region is tcmpomry-i.c., the material will return to its original
shape with removal o f the stress (10..')(1). Distortion of the materiallx:yond the elastic mllge
results in pcnnanem defonnation of the material-i.e., the material changes shape. Ortho-
dontic wires and springs are generally used in the elastic region for tooth movement.
The modulus of elasticity is the slope of the clastic region of the stress-strain
c urve. It represents stiffness or nexibility of a wire. Stress-strain is an intrinsic prop-
erty of the alloy; in other word s, the modulus of e lasticity is an inherent qua lity o f the
a lloy. The clinical analog to the modulus is the load-dcflection rate of a wire. The
load-denection rate depends on both the intrinsic properties of the wire and the extri n-
sic properties (diametcr, length, loading condition. etc.).
A nexible wire would demonstrate .. natter curve (low modu lus) in the e lastic
range, whe reas a stifT wire would have a steep curve (high modulus). The lower the
modulus, the less force per unit denection, meaning a more flexible wire. Conversely.
stiffer wires demonstrate a higher modulus with a greater force per unit denecti on.
The elastic limit , ulso called the proportional limit or yield strength, is the point at
which any greater force will produce permanent dcfonnation in a wire. Technically it
is a difficult point to measure precisely. For prac tical purposes, the yie ld streng th is
identified. the point where 0. 1% of dcfonnation is measured. Beyond the elastic limit
is the plastic range. Distortion or denection of a wire beyond the clastic limit is neces-
sary to place a bend in a wire.
The amount of denection in a wire up to the c lastic limil represents a wire's e/a.s-
tic rallge. This characteristic is clinically useful because it detcnnines the allowable
amount of activation of a wire or spring. Wires with g reater elastic range.<i can be acti-
vated further than wires with lesser ranges.
The ultimate tensile strength of the wire is the peak of the curve (in the plastic
range). It is the maximum stress of force a mmerial cun wi lhstand. Dcnection beyond
the ultimate tensile streng th shows a weakening of the material. If a wire is defl ccted
far enough, the fai lure point is reached and the wire breaks. The ex tent to which the
material will return to its original shape after the removal of the load is the material's
spring back (un less the failure point is reached).
CHAPTER 1 13
Each of the characteristics o f a stress-strain curve described arc determined by

intrinsic properties of the material. The cli nically important load-deflcction curve for an
individual wire is detennined by both the intri nsic and extrinsic conditions. Wire diame-
ter, length, and loading condilion all affect the load-defl cction characteristics of a wire.
For tooth movement, the elastic characteri stics of a wire are most relevant . Generall y,
decreasing wire dimneter results in reduced load-deflection mtes. increasing the span of
the wire tends 10 decrease the load-defl ection rate. Increasing the length of the wire by
increasing the interbracket distance is a common method for gai ning an increased mnge
of acti vation as well as a decreased load-defl ection rate. Lower load-defl ection rates are
typically associated with greater force constancy over the activation range.
CONSIDERATIONS IN APPLIANCE DESIGN
Ideal orthodontic care achieves specific, indi viduali zed . predetermined treatment
objectives. Thrcc major components of treatment are ( I) diag n osis~ i de nli fyi n g a
patient'S specific problems needing treatment, (2) trcatment planning-establishing
treatment goals that identify precise objectives for treatment outcome, (3) deliveri ng
treatment- the course of action (treatment) selected that addresses the plltienl 's prob-
lems directed toward meeting the individualized goals. These components imply that
different patients requirc different treatments; i.c., onc appl iance design (bmckcI pre-
scription, archwire sequence, etc.), will not be capablc of solving all patients' prob-
lems. Applying the concepts of biomechanics to the selection and design of orthodon-
tic appliances improves the precision of treatment) No bracket design or prescription
can automatically deli ver indi viduali zed trcatrnent objecti ves. Only the orthodontist
can control the specific characteristics of the force system used in treatment.
SPECIFIC CONSIDERATIONS
Force 1II(l8l1itllde is the " li ghtness" or "heavi ness" o f the force. Ideal treatment
requires forces to be within an appropri ate ran ge to eli cit an efficient bi olog ic
response wi thout detrimental side effects. Freq uently. the term "optimal fo rce" is
used. An optimal force is the lightest force that will move a tooth to a desired posi tion
in the shortcst possible time and with no iatrogenic effects. Unfollunately, an accurate
measure of an optimal force eludes determination.32 Force magnitudes as lillie as 2 g
have been shown to produce tooth movement;13 whereas forces fro m headgear and
onhopcdic appliances often exceed 500 g. Klochn 19 recommended a force of 500 g
for cervical headgear in the late 1940s.
Force COl/stailey is the consistency of the applied force over the range of activa-
tion of the appli;mce. For tooth movemcnts over largc di stances, the continuity of the
force levels throughout is often desired. Force constancy can be obtained by reducing
the 101ld-defl ection rate in one or more of the fo llowing four ways: ( I) reducing the
cross-section of a wire. (2) increasing the intcrbracket d istance, (3) incorporming
loops in the wire, and (4) using memory alloys.
Reducing the Cross-Section of a Wire

Reduci ng the cross-section of a wire is commonly used 10 improve force constancy
and to reduce the load-defl ection rate. The advantage of using small-diameter wires is
that flexibility eases ligation into the brackets, especially at the earlier stages of the
treatment when teeth arc mulaligned . However, the smaller the cross-section of the
wire, the lcss control expressed on a tooth in three planes of space.
A large cross-secti on wirc provides beller bracket engagement and control in
14 CHAPTER 1
tooth positioning. bUI al lhe same lime the load-deflection rate and magnitude of force
gcnerated may be too high. Higher cross-sections and rectangular (edgewise) wires
permit greater expression of the three-dimensi onal control designed into modem
brackets. But as stiffness increases, the range of activation decreases as the load-
deflection rate increases. This provides excellent control in the final stages of treat-
ment when small . detail ed tooth movements are necessary. Large-dimension wires
can also be used 10 anchor units in early stages of treatment.
Increasing the Interbracket Distance

Large interattachment distance reduces the load-deflection rate and helps deliver con-
stant force magnitude. providing a better directional control of the tooth movement.
The wire length results in greater wire fl exibility. Many bracket and aux iliary spring
designs integrate increased interbracket distances 10 achieve improved force con -
stancy. A practical application of the principle of large interbracket distance is to
bypass the teeth or tooth in need of a major tooth movement using a simple spring or
a cantilever from an auxiliary lube on the first molar (Fig. 1- 21 ).
Incorporating Loops in the Wire

Prior to the introduction of memory alloys. one o f the most com mon methods to
reduce the load-deflection rate was to incorporate loops into the appliance system.
Most of the loops used in orthodontics are simple loops, which onl y increase the wire
material, thereby reducing the load-defl ection rate. However, for a biomechanical1 y
sound appliance system, it is important to understand the loop design to effectively
reduce the load-defl ection rate and wire deformat ion. Wilh a carefully designed loop
shape and by placing more wire in the area of loop defomlation , the loop efficiency
can be increased.
Use of Memory Alloys

One o f the most sign ificant advances in the practice of clinical onhodontics over the
last 15 years has been lhe introduction of memory alloys such as nickel titanium to
e ffecti vely reduce the load-defl ection rate. 11 Now. large-dimension memory all oy
wires can be used much earlier in the treatment for bener tooth motion control. The
nickel-titanium wire has a significantly lower modulus of elasticity than the stainless
steel wires. A reducti on in the modulus of e lasticity tran slates into an almost I: I
reduction in the load-defl ection o f the archwire.
The magnitude of the moment and its constancy should also be considered. Con-
trol of both force and moment magnitudes establi shes the MIF ratio. As discussed
previously, the MJF ratio determines the type o f tooth movement. A pure force
applied at the tooth crown or bracket produces an "uncontrolled" tipping. resulting in
the crown and apex moving in opposite directions. The application of a pure moment
(couple) rotates a tooth about its center of resistance. A combined moment and force
must be simultaneously applied to gain other types of tooth movement. In many clini-
cal situations, the moment is produced by the wire-bracket combination, whereas the
force is obtained from elastics or springs.16
The distribution of the force throughout the periodontal ligament detennines the
type and rate of tooth movement. The number of teeth upon which the force is
exerted, the force (and moment) magnitudes. and the M/F mtio detemli ne the type
and rate of tooth movement.
The point oj Jorce alJplicarioll is a very imponant. yet often overlooked. funda-
mental consideration in appliance design. The point of force deli very and the direc-
tion of force re lative to the cemer of resistance of the tooth have a significan t effect
CHAPTE R 1 15
f igure 1- 21 . A clinical eKample of using of increased Interbracket

distance in appliance design. A. B, C, Intraoral views of an adult
patient snowing deep overbite and Class II molar relation. The pos-
terior occlusal plane and incisor level have significant discrepancy.
D, E, F. Intraoral view showing segmental T-Ioops to close the maK-
illary edraction site. The T-loops have horizontal and vertical forces,
with anterior and posterior moments built in prior to insertion in the
mouth. This precalibrated T-loop spring with a large "interattach-
menl" distance is capable of delivering predktable tooth move-
ment. The lower arch has an intrusiofl wire, but here it is used to
upright the molars by simply tying the cuspids into the anterior seg-
ment and by increasing Ihe intrusive force that delivers a larger
moment on the molars 10 help them upright.
Illustration continued on fol/owlng page
,J
n
,I
e
i·
e
,.
is
lC
a·
c·
CI
16 CHAPTER 1
FIgure 1- 21 . (Continued) G. H, I, The patien t at the end of the

treatment with good overbite, corrected ocdusal plane, and good
buccal interdigitation.
on the type of tooth movement. Forces acting at a distance from the center of resis-
tance generate moments of the force, potentially producing unwanted tooth ntove-
ments.
Several simple examples ill ustrate the concept . Figure 1-22 shows four different
inclinati ons of the central incisors. Ln (A). the incisor has the ideal incli nat ion. In (8),
it is upright In (C), it is signifi cantly narcd, and in (D ) it is lingually incl ined. In all
four examples. the same vertical intrusive force is applied to the incisors. Figu res
1- 224, /1, and C show that the farther the line of force is labial to the center of resis-
tance, the larger the moment, which would bring the root lingually and the crown
buccally. Thus, in this example. although the force direction and amount are similar.
the type of tooth respon se would be quite different.
Conve rse ly, Figure 1- 22D shows that a vertical intrusive force appl ied to a
severely linguall y tipped incisor would have the opposite moment as compared to the
moments shown in A, n, and C. The force direction would furth er lingually tip the
incisor instead of improving it since the line of force is lingual to the cenler of resis-
tance of the incisors.
An example of an appli ance using these princi ples in ils design is the intrusion
arch. An intrusion arch is an auxiliary appliance for incisor intrusion and/or molar tip-
back. The basic design and force system are shown in Figure 1- 23 (same as Fig.
1- 18). The intrusion arch is ligated to an anterior segment. It exerts a vertical force
through a "poi nt attachment" to the anterior leelh . The large inlerbracket dislance
increases the mnge of activation. thereby red uci ng the force magn itude while increas-
ing the fo rce constancy. The point of fo rce application can be varied depending on the
axial inclination of the incisors (Figs. 1- 24 and 1- 25).The simple. two-tooth design
allows measurement o f the force magni tude. T he tipback moment actin g on the
CHAPTER 1 17
o
Figure 1- 22. The effect of axial inclination and loca-
tion of the point of force application on tooth move-
ment. An intrusive force on an incisor with W normal
axial Inclination, (8) uptight irl(isor, (0 flared incisor,
(0) 6ngually inclined inCisor. Figure 1- 23. Force system from an in trusion arch.
Figure 1- 24. A clinical example of an intrusion arch. A, Anterior intra-

oral View of a patient with deep overbite. B, Anterior view showing
intrusion arch ligated to an anterior segment that unites all four maxil-
lary incisors into one unit. Note tha i the point of force application
(location of ligation) is between the central incisors, anterior to the
se8ment's center of resistance. C Same patient. anterior view with
deep overbite correction.
18 CHAPTER 1
Figure 1-25. An example of a three·piece intrusion arch . The point of force application is closer to the anterior segmen t's cen ter of resis ·
tance. A, B, Initial intraoral frontal view and right buccal view. C, D, The three-pie<e intrusion arch; note the location of the I'IooIc distal to
the lateral incisors. E, F, Final frontal and right buccal Views.
CHAPTER 1 19
Fllure 1-26. A canblever for canine extrusion. A. B, C, Intraoral

views of a patient with a retained primary cuspid and retained pe1"-
manent cuspid. D, E. f. Intraoral vi~ with upper end banded and
bonded. Note that the cuspid is bypassed and a cantilever from the
molar is used to erupt and guide the cuspid in to a proper angula-
tion With the arch.
Illustration continued on following page
20 CHAPTER 1
Figure 1-26. (Con tinued) G. H, I, Intraoral views at the end of the

treatment with the retained cuspid successfully placed into the arch,
molars equals the force times the interbracket distance. This basic appliance is typical
of all cantilever-type designs. Figure 1- 26 shows a cantilever design for extrusion of
an impacted maxillary canine.
Biomechanical considerations are also useful in the comparison of cervical versus
occipital (high-pu ll) hcadgcar. Figure 1- 27A. B. C, and f) are diagrams of cervical
and high-pull headgears. TIle line of action of the force produced by a cervical head-
gear lies inferior to the center of resi stance of the molar and/or maxilla (Fig. l- 27A).
Thus, a moment of the force is produced, tending to tip the crowns di stally
(Fig. 1- 278). Further. the force vcctorcan be decomposed into horizontal and vertical
components. The vertical component is ext rusive (inferiorly directed) and the hori-
zontal force is distal (posteriorly directed).
Simi larly, Figures l- 27C and f) show the force of an occipital headgear. As
shown, the line of action passes through the estimated ce nter of resistance (Fig .
1-27 0. Therefore, no moment of the force is produced . Figure 1-27D shows that the
vertical and horizontal components of the force ure distal (posteriorly directed) and
intrusive (superiorly directcd).
Although both appliances are headg~lrs. their biomechanical, characteristics are
quite different. Depending on the particular requ irements of a patient's treatment,
either of these appliance designs can be selected.
Summary
Biomechanical principles explain the Illcchani sm(s) of action of onhodontic appli-
ances. They are of fundam ental importance to understanding orthodontic treatment.
CHAPTER 1 21
B
figure 1-27. CefVkal and occipital (high-pull)
Iltadgear. A, The force produced by a cerv ical
~eadgear. B, The tipback moment (red) and
force componen ts (blue) of this cerv ical head-
gear. C. The force produced by an occipi tal
Iltadgear. D, The components of force of this
ocdpital headgear.
Cognitive application of biomechani eal concepts in the delivery of onhodontic care

can be beneficial in achiev ing efficient and effcrti ve treatment.
REFERENCES
I. And<!rscn K. Mortensen HT. Pederse n E. Melsen B: Dctenl1ination of s tre~s levels and profiles in the
periodontal li gamen t by means of a n improved three-dimension finile element model for various
types of ortllOdon ti e and Imtuml force sys tems. J Biorncd Eng 13(4):293-303. 199 I.
2. Andersen K. Pedersen E. Melse n B: Material parameters and stress profiles within the periodontal
ligament. Am J Orthod Den tofacial Orthop 99(5):427--440. 1991.
3. BUlStOl1e CJ: The mechanics of the segmented arch tcchniques. Angle Drthod 36(2):99- 120. 1966.
4. BUISIOI1e CJ: Deep overbi te com:ction by intrus ion. Am J Orthod 72( I): 1- 22. 1977.
5. BulStone CJ: Variable-modu lus orthodontics. Am J Orthod 80( I): 1-1 6. 1981.
6. Burstooe CJ: The segmented approach to space closure. Am J Orthod 82(5):36 1-378. 1982.
7. Burslone 0. Goldberg AJ: Bela tilanium: A new orthodontic alloy. Am J Orthod 77(2): 12 1- 132. 1980.
8. Burstone 0. Koenig HA: Creat ive wire bending-the force system from step aoo V bends. Am J
Orthod Dcntofacial Orthop 93( 1):59-.{)7. 1988.
9. Burstone CJ. Koenig HA: Force systems from lhe ideal arch. Am J Orthod 65(3):270-289. 1974.
10. Burstone O. Pryputniewicz RJ : l'lo logrnphic determinat ion of cen ters of rotation produced by onho--
OOntic rorces. Am J Orthod 77(4):396-409. 1980.
II. Burstone CJ, Qin B. Morton J Y: Chinese N iTi wire-a new orthodontic alloy. Am J Ort hod
87(6):44$--452. 1985.
12. Chri~tinnsen RL. I~urstone CJ : Centers of rotation within the periodontal ~pace. Am J Drlhod
55(4):353-...369. 1969.
11 Dc:mnnge C: Equilibrium situa tion s in bend force systems. Am J Orlhod Dcntofacial Drthop
98(4):333-339. 1990.
14. Dcnnaut LR. Vundcn Buleke MM: Evaluation of intrusive mechanics of the type "segmented arc h"
22 CHAPTER 1
on macerated human skull using the la~r re nection technique and holographic interferometry. Am J
O"hOO 89(3):25 1- 26]. 1986.
15. Fau lkn er MG. Fuc hhube r P. l'labe rs tock D. M lod u e how~ ki A: A parametrk sll.ld y o f the
force/momem syste ms produced by T-loop retraction spring~. J Biomech 22(6-7):6]7-647. 1989.
16. Issacson Rl. Lindauer SJ. Rubenstein LK : Mome nts ,,·ith edgewise appli:lI1ce: Incisor torque control.
Am J O"hOO Dentofacia l Onho p 103(5): 428-438. 1993.
17. Jacobson A: A key to the understandi ng of extrnoral forces. Am J OnhOO 75(4):361 - 386. 19 79.
18. Kapila S. Saehdeva R: Mechanical propen ies and clin ical applications of o"hodontic wires. Am J
Onhod Dcntofacial Onhop96( 2):IOO- I09. 1989.
19. Klo.:hn S1: Gu idin g a lveolar growth and cn.lplion of teedl to redllce treat me nt time alld produce a
more balanced de nture and face. Angle O"hod 17: 10-33. 1947.
20 . Koe ni g HA. Vanderby R. Solonche D1. Bu rslonc 0: Force sys te ms from on hodontic app1iance.~: An
analytical and experimental co mpari son. 1 l1i omech Eng 102 (4):294- 300. 1980.
2 1. Ku sy RP, and Tulloch JFe: Analysis of moment/force ra tio in the mechan ics of tooth movement.
Amer J Onhod Dentofac Onhop 90:127- 13 1. 1986.
22. Melsen B. FO(is V. Bllrstone CJ : Veni cal force co n s id cration~ in ditl"crcntial space closure. J Clin
O"hOO 24(1 1):678-683. 19'JO.
23. Melscn B. Fotis v, Bu rstone C1: Venical force co nsiderat ions in difTeremia l space closure. J C lin
O"hod 24( II ):678-683, 1990.
24. Melsen B: Adult orthodontics: Factors differentiuting the selectio n o f biomechanics in growin g and
adult individuals. Int J Adult O"hod Onhognat h Surg 3(3): 167- 177, 19!!8.
25. Na nda R: Biomechan ica l and clinical eOllsider.lt ion~ of a modified protraction headgear. Am J Onhod
78(2):125- 139,1 980.
26. Nanda R: The different ial diagnosis and treatme nt o f excessl\'e overbite. III Nanda R (ed): Sympo-
s ium on Orthodont ie~. [)cntal Cli nics of No"h Ame rica. 198 1, pp. 69-84.
27. Nanda K Goldin B: Bioll)echanieal approaches to the study of al terat ions of facial morphology. Am J
Onhod 78(2):2 13- 226.1980.
28. Nager! H. Burstone O . Becke r B. Ku be in-Mcs.<iC nbu rg 0 : Cemers o f rotatioo with transver.;e forces:
An experimental study. Am 1 Onhod De ntof:lCial Onhop 99(4): 3]7- 345. 1991.
29. Nikolai RJ : On opti mum o rt hodontic force theory as applied to ca nine retractio n. Arn J Onhod
68(3):290-302. 1975.
30. Pederse n E. Andersen K. McI <;en B: Too h di~pl acemen t ana lY7.ed 00 human autopsy material by
means of a strain gauge tcr ho ique. EurJ Onhod 13( I ):65-74. 1991.
3 1. Pryputn iewicl. RJ. Bun;tonc 0 : The effcrt of time alld force magnitude ()II o"hodontic tooth move-
ment. J Dent Res 58(8): 1754-1764. 1979.
32. Quinn RS , Yoshi kawa OK: A reassessmen t of force magnitUde in onhodontics. Am1 Onhod 88(]):
252- 260, 1985.
33. Roben s WW. Chacker FM, Bllrstone A: Segmental approac h to m:lodibular molar upright ing. Am 1
0"hod81(3): 177- 184.1982.
34. Rom oo DA. Burstone 0: Tip-back mec hanics. Am J Onhod 72(4):4 14--421. 1977.
35. Ronay F. Kl e in en W. Melscn B, Burstone CJ : Poree sys te m deve loped by V bends in ~n elastic onho-
Jomic wire. Am 1 Orthod Den tofacial Ort ho p 96(4):295- 301 . 1989. lPublished erra tum :lppcars in
Am J Onhod Den!Of;l(; ial Onhop 98(1): 19A, 1990.1
36. Shroff B. Lindauer S1. Bu rstone O . Leiss JB : SegmClIled approach to si multaneous intn.lsion and
space closure: Biomec ha nics of the three-piece intrusion arc h. Am J Onhod Dentofac ial Orthop
107(2): 136- 143. 1995.
37. Smit h RJ . BUTStOlle (J: Mcrhanic s of tOOl h movement. Am 1 Orthod 85:29+.-307. 1984.
38. Tanne K, Koenig HA. Bursto ne CJ: Moment to force ratios and the center of rotat ion. Am 1 On hod
Dentofacial Onhop 94(5): 426-43 1. 1988.
39. Tanne K. Nagataki T, Inoue Y. Sakuda M. Bu rstone CJ: Patterns of in itia l tooth displaceme nts assoc i-
at e d wi th vari o us root le ngt hs a nd alveo lar bone h eigh t ~ . Am 1 Orthod Oe nto facial Orthop
100( 1):66-71. 1991.
40. Tanne K. Sakuda M. Bu rstone CJ: Three-d imensional fin ite ele ment analysis for stress in the peri_
odontal tissue by onhodomic forces, Am 1 Onhod Dento faci al Onhop 92(6):499-505. 1987.
4 1. Vanden Bulcke MM. Bursto ne CJ. S:lchdeva Re. l)cnnaut LR: Locat ion of centers o f resistance for
anterior teeth during rctrdction using the laser reflect ion technique. A ll) J Onhod Dentofacial Onhop
91 (5):]75-384, 1987.
42. Vanden Buleke MM, Dcnna llt LR. SachdcV3 RC, I1Ul"StOlle CJ: The center o f resistance o f anterior
teeth dllring intn.l~ ion using the la,er rencction t.:chnique and ho lographi c interfe rometry. Am 1
Onhod Dentofacial Onhop 90(30):2 11 - 220. 1986.
43. Wei nstein S: Minimal forces in tooth movement. Am1 Onhod 53( 12):88 1-903, 1967.
44. Wood \1G: Th e mechanics of lower incisor i ntm~ i on: Experime nts in nongrowin g baboons. Am J
Onhod Demofacial On hop 93(3): 186- 195. 1988.
45. Yoshikawa DK: Biomec hani<:31 princ ipl es of tooth rllove rne nt. In Nanda R (cd ): Symposium on
Orthodonti<:s. Dental C lin ics of No rth America. 1981, pp. 19- 26.
CHAPTER
2
Orthodontic Treatment Planning
Steven J. Lindauer
A
dv;mccs in diagnostic technology, appliance design innovations, and expan-
sion of practices to include morc diverse patient populatio ns have trans-
formed the face of orthodontics over Ihe past several years. These changes
afford grealer opportunities to provide morc well -conceived, effic ient, and cus-
tomized care, but also heighten the challenge of designing a treatment plan appropri-
ate for each indi vidual patie nt. More than ever, individualized planning is an integral
part of orthodontic treatment designed to provide optim al results with maximal
patient and provider satis fac tio n.
Diagnosti c capabilities in orthodontics have improved dramati cally in parallel
with advances in computer technology.t.2 Digital cephalometry, both radiographic and
sonic, al lows practi tioners to have access 10 extensive meas urements des igned to
reveal an individual patient 's subtle deviations from average values. The technology
10 allow three-dimensional analysis of facial soft tissue and skeletal characteristics is
already available; it is only a mailer of lime before this material will also be adapted
for routine clinical use.] The added infonnation afforded by new electron ic tools may
serve to enhance the clinical impression and encourage a reevaluation of previously
drawn conclusions:' Thorough clinical examination of facial appearance and occlusal
relationships, however, remains an essential comiX'nen\ of the diagnostic process.
The mechanical process of orthodontic treatment has been eascd considerably by
the already routine use of preadjusled bonded appliances and the development of new
wire compositions. These devices can be applied more quickly and will remain active
for longer periods of time than their predecessors. In addition, a wide range of func-
tional, extraoral. and magnetic appliances, as well as viable surgical options, are
available. They can be used as a supplement to, or in some cases as a substitute for.
conventional fixed appliance therapy.
Advances in diagnosis and treatment of malocclusion have hclped to widen the
spectrum of patients receiving orthodontic care. More adults are seeking treatment,
23
24 CHAPTER 2
Orthodontic Treatment Plan ning
and practices have grown to also incl ude more younger children in early or intercep-
li ve the rapy. ~
Accurate diagnosis is a key clement in the design of any successful treatment
plan . More infomlation about patients' characteristics helps improve d iagnostic capa·
bilities but also requires more complex processes of interpret.. tion. The greater range
and effecti veness of modem appliance systems onl y serve to emphasize the necessity
for well ·conceived plann ing based on a refin ed understanding of the mechanics
in volved; poorl y thought out appli ance activations can cause periods of ineffi cient
{rea{men( { The d{verslty or patients invofved in modem practice situations demands
Ocxibi\ity on the part of the practitioner to devise customized plans to suit the needs
of speci fic patiems. Emphasis on development of an indi vidualized pl an formul ated to
achieve the best possible result for a given patient will help shorten lhe duration of
therapy and improve the treatment outcome.
Treatment planning in difficult situations is best accom pli shed method ically.
resisting the temptation to devise a mechanic.. l strategy until the precise goals of ther·
apy are understood (Fig. 2- 1). The first step is to decide broadly what is to be accom·
plished by treatment and establish general facial. skelelal. and dental goals. Various
options, including surgical possibilities or ex traction patterns. can be tentati vely
expl ored. Th e spec ific ske letal and/or tooth movements that will be requi red to
achieve the general treatment goals can then be examined within the context of the
options availabl e. This may necessitate reevaluating the likelihood of achieving par·
ticular goals by employing certain strategies. After appropriate adjustments have been
made. a specific, seq uenced mechanics plan can be devised to achieve the skelewl and
dental movements desired. Before actual therapy begins. a time schedule should be
form ulated by which progress can be monitored to ensure that appropriate progress is
being made through critical treatment stages.
Treatment Planning for

Class II Malocclusions
Establishing Genera t Tr eatment Goa ts
- • Facial
• Ske le tal
• De ni al
• Fu nctional
I
'"
••
•" E~pJo rin gGener al Treatm ent Oplions
• Surgical vs. No n-Surgical Figure 2-1 . logical sequence for treat-
~ • En raction vs. Non-Extraction ment planning in patients with Class II
•
" , malocdusions.
Definin g Specifi c Treatmen t GoaJ~

- I De finin g Tooth Moveme nts
• De fining Skeletal Move ments
I
Sequencing Trcat nlcnt
• Treatment Mecha nics
,
( Assessing Trcatment rrogress )
CHAPTER 2 25
ESTABLISHING GENERAL GOALS
Once diagnostic infonnation has been gathered and sy nthesized into a coherent
description of ~h e patient's facial, skeletal, dental, and functional characteristics,
the goals of orthodontic treatment can be determined. For the Class II patient, gen·
eral goals may range from improvi ng the patient 's fac ial profi le by increasing
mandibular prognathis m to eliminating dental crowding and establishing a Class I
canine relationship without affecting the pati en t's soft tissue appearance. Goals
established at this earl y stage should be non specific and should not depend on the
treatment mechanism to be used. As a more definitive plan begins to take shape,
precise goal s ca n be defined and treatme nt options can be more thoroughly
explored. Arrivi ng at goals that are limited by a specific treatment mechani sm or
appliance will dimini sh the scope of solutions avail able for so lving the ort hodontic
problems of individual patients.
Several factors s hou ld be co nsi dered when establi shin g ge neral treatment
goals. Data co llec ted during the clinical examination and s uppl ementary diag-
nostic tests prov ide a bas is for the patient 's C lass II occlusa l relatio ns hip . Cer-
tain fun ctio nal c riteria need to be met by the e nd of treatment for every pati ent :
some in dividuals may also require additional fun cti ona l goals to be attained.
Esthetic considerat ion s are important for determinin g a plan that wi ll meet
both the patient' S and the practitione r's de mand s. In additio n, the degree of
stabi lity expected after treatment is completed must also be conside red when
establi shing the goals o f treatment. Every patient will require the practit ioner
to weigh and balance these conside rations when determi nin g the s pec ific aims
of care. It is not always possible o r necessary for the ideal to be met for each
of these factors.
USING DIAGNOSTIC INFORMATION
An often helpful starting point for establi shing treatment goals is a reexploration of
the diagnostic information. The clinical examination reveals what the patient desires
to gain from trelllment, and this can not be ignored during the planning process. For
Class 11 patients. thi s may be as simple as closing a maxillary midline diastema or
correcting mild anterior crowding. These considerations may seem trivial to a practi-
tioner facing an excessive overjet caused by severe mandibular retrognathism, but the
treatme nt and its process wi ll not be successful unless attention is given to the
patient's priorities. This is also true for young patients whose primary motivation may
seem to be linked to parental expectations.7
Determination of ske letal versus dental et io logy may pl aya role in setting
treatment goals. Most ofte n, the C lass II condi tion is a combination of both fac-
tors, but those wi th skeleta l in volvement are more likely to require plans wi th
skeletal goals. If the patien t has been diagnosed to have a ma locclusion in con-
junction with skeletal di screpancies and the goals are all dental in nature, then a
reeva luation o f both the diagnosis and the aims o f treatment is warranted . This
is not to say that dental compromi ses fo r skeletal problems cannot be attained
successfull y, but only that the dec ision to achieve correction in thi s manner
shou ld be a de liberat e rath er th an inad verte nt one. Skeletal in volveme nt in
Class II patien ts is most often in an an terior-posteri or direction, but may al so
involve transverse and/or vert ical components. Fai lure to consider vert ical di s-
crepancies can lead to mid -treatment setbacks that may prolong treatment time
and compromi se outcome.
26 CHAPTER 2
Function al Goals
Functional considerations probably cOl1lribute to the most controversial assortment of
goals set by practitioners for orthodontic patients. Certain basic, funct ional occlusal
criteria need to be met for orthodontic treatment to be considered successful. Conclu-
sive proof that a Class I occlusion with proper excursive guidance will lead to
improved dental and temporomandibular joint health, however, has been elusive. s
Under normal circumstances, given that the teeth are well proportioned, such occl u-
sion will lead to conditions of max imum intercuspation, optimum esthetics, and per-
haps even heightened stability.9 However, the fun ctional implications remai n unclear.
Class 11 patients with open bites or severe overjets may benefi t functionally by attain-
ing normal overbite and overjet rclationships.lo,ll Establishment of ideal occ lusal rela-
tionships for oral functional benefits. however, should be approached rationally and
within the context of attaining other treatment goals. There are circumstances in
which conven tional functional considerations may be sacrificed to achieve better
esthetics or more stable results (Fig. 2- 2).
Another level of fun ctional criteria exists in the soft tissue relat ionships to the
teeth. Aside fro m the possible intraoral functional benefits of attai ni ng ideal occlu-
sion, the ability of the patient to ach ieve ad"'quate lip closure should also be con sid-
ercd. 12.13 Class 11 patients may present with abnonnal lip posture because of excessive
overjet, bimaxill ary protrusion, or excessive vertical skeletal development. In rela-
ti vely severe cases, treatment may be intended to correct the dental relationship with
the goal of attaining more normal lip function.
Esthetic Goals
The esthetic benefi ts of orthodontic treatment arc probably the easiest to define and
the most universally accepted by both patients and practitioners. 1"-16 They are, how-
ever, the most commonly understated and the most dillicult to measure quantitatively.
Studies have shown that attractive individuals are more likcly to achicve success in
the form of academic and career accomplishmclUs. '7- 19 The role that orthodontic
treatment may play in helping indi viduals attain improvement in this :lrea should not
be undcrstated, nor should it be underemphasi7..ed in the treatmcnt planning process.
Movement of teeth can most obviously affect f..cial esthetics through anterior
tooth alignment to achieve an attractive smjle (Fig. 2-3). Even with significant over-
jet remaining, Class 1.1 paticnts with previously malaligned maxillary incisors will be
Figure 2-2 . Trad itional functional goals of orthodontic trea tmen t may sometimes be sacrifICed to achieve better esthetics and stability.
In this patient. a posterior crossbite was maintained in order to avoid worsening a pretreatment anterior open bite tendency. A, Pretreat-
ment malocclusion. 8, Posttreatment resu lt.
CHAPTER 2 27
Orthodontic Treatment Plann ing
Figure 2-3. AnteriOr tooth alignment can help improve overall

facial appearance. A and B, Pretreatment photographs showing
an terior tooth malalignmenl. C and D, Orthodontic alignment
improves the patient's appearance when smiling.
pleased when these teeth appear aligned. Another common esthetic goal may be to
correct the position of maxillary incisors that show excessively below the upper lip at
rest. These patients often also show abnonnal amounts of gingiva when smiling.20•2 •
Whether or not such conditions should be corrected dentally by intrusion or by surgi-
cal impaction of the maxilla depends on many factors, including eti ology and extent
of the problem, desire by the patient to have the situation changed, amount of overbite
present, and vertical position of the posterior teeth.
Lip fullness can also be affected by anterior tooth posi ti on. The dependence of lip
28 CHAPTER 2
position on the relative protrusion or retrusion of the an terior teeth is one of the rea-
sons cited for reluct:lIlce to extract teeth for orthodontic purposes. 22 .23 Increases in
nose and chin size 'Ire likely to outpace increases in soft tissue lip thickness over time,
thus making lips appear more retrusive even without treatmentP More anterior place-
ment of the teeth during orthodontic treatment can lead to increased lip support with
more fullness of the lip profile relative to the nose and chin and increased show of
vermi llion .2~.26 The act ual effect of orthodontic extractions on lip profile, however,
remain s controversiaP2.27.28 Appearance of the lips and their reaction to positional
changes of the teeth vary among individuals. Changes during treatment may be due as
much to patient-specific characteristics of the lips themselves as to the magnitude of
anlerior tooth retraction.2.'i
Stabi lity Considerati ons

Another factor inOuenci ng choice of treatment goals is the predicted stability of tooth
positjons. The traditional belief that extractions are warranted in cases where denial
crowding exists for achievement of lifetime stability has been challenged repeat -
edly.29--32 Movement of teeth into positions in which they will cause muscle or soft tis-
sue pressure imbalances is considered to be unstable unless appropriate adaptation
can occur.29 Precise definition of the position where such imbalances occur, however,
has not been accomplished. One confounding factor is the apparent changes in bal-
ance that occur naturally over timc.30·H.)4 Data suggest that performance of extrac-
tions does not necessari ly guarantee long-tenn stabili ty.35-J9 This does not mean, how-
ever, that no nextract io n therapy is always appropriate because re lapse can be
expected to occur regardless of treatment. Both extraction and nonextraction treat-
ment modalities may result in variable stabi lity based on the severity of the maloccl u-
sion, initial tooth irregularity, length of retention , ex ten t that fun ctional force s are
modified by treatment, and other as yet undefined characteristics of individual
patients. More in fonnation regardi ng stability of orthodontic treatment is required and
must be based on specific patient as we ll as treatment characteristics. Until the time
such data become available, practitioners need to make rational and indi vidualized
choices based on the scientific information currently accessible.
GENERAL TREATMENT OPTIONS

It is tempting to formulate a treatment plan instinctively based on a quick impression
o f whether or not extractions are necessary. If treatment is to be tailored to indi vidual
patient needs, then a great amount of fl exi bility is required in form ulati ng the plan.
One way of maintaining fl exibi lity is to resist the impu lse to decide on a course of
treat ment before examining all of the rational possibilities. Several option s should be
logicall y and progressively explored before settling on one main choice for presenta-
tion to the patient.
As each potential option is surveyed. the way in which it fits wi th the general
goals of treatment is evaluated. For example, if one goal of treatment is to reduce
mild mandibular crowdi ng, a first premolar extraction pattern may be considered. In a
Class 11 patient. thi s wi ll also necessitate extraction of maxillary teeth , and a Class I
canine relationship wi ll need to be establ ished . Assuming that this is possible mechan-
ically. the plan remains viable. If another goal of treatment is 10 maintain or increase
lip procumbancy, however. the space provided by extracting two premolars may be
excessive and result in overretraction of mandibular lecth. It may be possible to use
most of the space for protracting posterior mandibular leeth, using only a small part of
it for alleviating the crowding. This could require complicated and/or prolonged treat-
CHAPTER 2 29
ment efforts. An alternative may be to flare mandibu lar incisors to {lcquire space. This
approach may achieve the desired esthetic result but require a more involved retention
plan or cause periodontal concerns. In many cases, no single plan will easily ac hieve
all of the goals esta blished , a nd the final c hoice will be diffe re nt for indi vidual
patients.
Surgical versus Nonsurgical Decision Making

One place to start the deci sion-making process is at the surgical versus nonsurgical
treatment choice. Several factors should be considered when making thi s decision.
Diagnostic information has defin ed whether or not there is a skeletal component to
the malocclusion. For C lass II palienlS, this usuall y means maxill:u'Y protrus ion andlor
mandibular retru sion. but venical or transverse skeletal discrepancies may also be
preseO!. Neither the presence nor the absence of a skeletal contribution to the maloc-
clusion will define a path of treatment, but this infonnation will help in reaching a
decision based on othe r factors.
The func ti onal goal of most, but not all , orthodonti c treatments w ill at least
requi re establishing a Class I canine relationsh ip with well-aligned teeth not in cross-
bite . If thi s will not be poss ible without surgical assista nce. the n a surg ical plan
should remain under conside ration. Surgery. however, wi ll not be a necessity for all
such pat ients since compromised functional results are acceptable under many cir-
cumstances.
Esthetic goals arc probably the most common reason for selliing on a surgical
option. A patie nt with severe facial convex ity or excessive lower facial height may
benefit substantially rrom skeletal corrections not possible through orthodontic tooth
movement 1IIone.40.41 For pati ents desiring dramatic facial changes, it may even be
necessary to worsen the Class II occl usal relationship or anterior vertical di screpancy
to achieve the maximum benefit rrom such a procedure: 42 •43 In other cases, orthodon-
tic treatment of a Class 11 maloccl usion may create an esthetic problem, and surgery is
an option to prevent this occurrence. One example might be a nongrowing patient
with an already obtuse nasolabial angle but otherwise acceptable facia l esthetics. Ir
the on ly orthodontic solution incl udes ex traction of maxillary teeth to reduce the
overjet and establi sh C lass I canines, the n runher reduction of maxillary lip protrusion
can be expected . To avoid thi s outcome, a mandibular advancement procedure can be
considered to correct the Class II relationship without adversely affecting the upper
lip (Fig. 2-4).
Stability is anothe r conside ration in deciding between surgical a nd nonsurgical
alternati ves. The comparative stability of surgical versus non surgic:ll correction of
Class 11 malocclusions with or without accompanying vertical di scre pancies, however,
has not been fi nnly established scientifically.44 Greate r relapse has been noted follow-
ing large versus small surgical movemenlS just as more relapse can be expected when
orth<XIontic compensations for skeletal discrepancies are greater.4S-48 For vertical cor-
rections. surgical impaction or the maxilla to allow mandibular autorotation to correct
an anterior open bite has been considered to be more stable than extruding anterior
teeth,49 but othe rs claim that re liable nonsurgical correction is possible.»-'s2 Indis-
putable answers arc diffic ult to find becau se individu als and the treatments they
receive vary widely and are usually not directly comparabl e. Scientific research ofle n
igoores the circumstances peculiar to individual patients and the treatments performed;
patients are more orten studied in te nns of the surgical procedure they receive rather
than by specific objective morphologic, diagnostic, or treatment criteri a.
The amount of growth remai ning for a given patient may playa rol e in deciding
whether or not surgery should be considered and. if so, when surgery should occur. In
a growing indi vidual. there are many more nonsurgical options available for achiev-
30 CHAPTER 2
Filure l~. Possible worsening

of an already obtuse nasolabial
angle can be avoided by opting
for an orthognathic !;Urgical solu-
tion to a Class II problem. In thiS
patient. mandibular advance-
ment surgery was performed in
order to avoid e)(cessive flatten-
ing of the upper lip th at may
have resulted from differential
retraction of maJoCillary indsofs. A.
Pretreatment profile showing
ob tu se nasolabial ang le and
increased facial conve)(ity. B.
Facial profile after orthodontics
and BSSO mandibular advance-
ment with an accompanying
advancement genklPasty.
ing functional occlusion_Certain treatment mechanics. headgear, or functional appli-

ances may be chosen to correct a Class II relalionship. For adu lt patients, these
options may not be possible or may prove to be more difficult to implement success-
fully. depending on the severity of the problem.
Surgery perfonned before most growth is complete remains a controversial issue.
Some believe that surgery should not be attempted until patients have had the opportu-
nity to fully express their own potentials. It is unlikely, however, that a patient with a
severely retrognathic mandible and unfavorable growth pattern will suddenly grow nor-
mally and catch up. On the other hand, some fairly severe Class II patients can achieve
nomml occlusal relationships with a combination of favorable growth and well-planned
intervention. Surgical correction at an early age for the purpose of creating a more nor-
mal environment to promote favorable growth is logical in theory but remains unsup-
ported by scientific evidence.S) Studies suggest that growth patterns themselves are not
substantially improved by surgical correction of the relationships between the compo-
nent bony structures, though the result is potentiaUy different for each indi vidual. ~>-"
If a surgical option seems to fulfil l any of the previously detennined goals of treat-
ment better than a nonsurgical plan, then it may be the route of choice. In some cases. the
decision will be clear. For example, if a growing patient presents with an end-on Class U
occlusal relationship, with a nonnal or slightly retrognathic facial profile and adequate or
full lip protIllsion, then surgery is probably not the best treatment since good results can
be ach ieved dentally or through growth modification. Conversely. if a nongrowing
patient with a full-step Class U occlusion of skeletal origin and a severely retrognathic
profile presents with a desire to have a more prominent chin. then surgery needs to be
considered seriously. Many patients. unfortunately, fall between these extremes, and the
correct decision is not always apparent. It is often necessary to explore fu lly the best sur-
gical and nonsurgical options, weighing the advantages and dis.advantages of each. The
patient's attitude and previous experiences will also playa role, and the ultimate choice
needs to be a consensual one based on all of the infommlion avai lable.
Extraction versus Nonextraction Decision Making

Ex traction versus nonex traction choices can also prove difficult in many circum-
stances . Contributin g fac tors in the decision-making process include not on ly the
CHAPTER 2 31
amount of intra·arch crowding present but also the predicted effect of treatment on lip
protrusion, the amount of overbite present, the patient's periodontal condition, and
whether or not there are missing or compromised teeth. Additionally, the severity of
the C lass II re lationship and w hether it will be corrected dentally. surgicall y. or
through growth modifi cation will play important ro les. Treatment time may be
affected by the choice. usually being lengthened when extractions are pcrfonned.S6
Depending on the situation. however, treatment duration may :Ictually be longer if a
nonextraction route is selected.
Evaluation of the amount of intra·arch crowding is a good place to begin assessing
the need for extraction as a mode for achieving orthodontic correction. The accepted
limits of relieving dental crowding without performing extractions have been driven
upward recently with a trend toward finding nonextraction solutions to orthodontic
problems.23 Because every patient varies morphologically and functional1y. there is no
defined UI110u nl of crowding that automatically warrants extraction therapy. For any
given patient. however. the more pre·existing crowding. the more likely thaI extrac-
lions will be pcrfonned to gai n the space necessary for aligning the remaining teeth.
This infomlalion is often most usefully procured by examining the mandibular arch,
which is also common ly the more crowded. Arch expansion or flaring of the teeth is an
alternative method for increasing available space. Approximately I mm of arch dr·
curnference is gained by flaring the incisors I mm. Arch width increases are also possi-
ble but the space yielded is smaller for any given amount of expansion.s7 By detennin-
ing how much space is required, the amount of expansion or flaring necessary can be
approximated. If the p..1lient can tolerate such changes fu nctionally, esthetically, and in
temlS of stability, then nonextraction treatment is a possi bility.
Another choice for avoiding extractions in cases where intra-arch crowding is pre-
sent may be by proximal reduction or air rotor stripping of teeth.58 This is a process by
which selected teeth are reduced in width in order to gain small amounts of space for
alignment. In cases of moderate to severe crowding, substantial numbers of teeth will
have to be reduced. The process requires patience and must be performed properly in
order to avoid compromising individual teeth or affecting the quality of occlusion Ihat
can be allained after alignment is complete. Additionally. unless a tooth size di screp-
ancy exists prior to treatment, tooth size reduction will have to be accompli shed
equally in both arches if normal interarch dental relationships are to be attainable.
Diagnostic information regarding the existing position s and angulations of the
anterior teeth is available from the cephalometric film and may influence an ex trac-
tion versus nonextraction decision. Once again, there are no fixed measureme nts at
which a case becomes clearly extraction or not. Teeth that are flared or anteriorly
positioned and accompanied by significant amounts of intra-arch crowding. more
strongly suggest an ex traction decision. Upright or retruded teeth with mild crowding
may be successfully and more easily aligned without extractions. dcpending on the
other conditions present.
In cases in which dental compensation instead of surgery will be used to mask a
skeletal discrepancy, extractions may be necessary to allow establi shment of a Class I
canine relationship regardless of the crowding or lack o f crowding present. Most
obviously, reduction of overjet in a nongrowing. full y Class II patient may be accom·
plished by extracting maxillary premolars and retracting the canines until they are '
Class I (Fig. 2-SA). Lower teeth may also be extracted in such a patient. but the space
created must then all be used for protraction of mandibular posterior teeth since the
mandibular can ines cannot be retracted at all (Fig. 2-S/J). If the mandibu lar canines
do move posteriorly during treatment in such a patient. then the maxillary canine can
never attain a Class I relationship, since it would then have to be moved back further
than the entire maxillary extraction site. Thi s mean s thm for full Class II adult patients
wilh significant lower anterior crowding, mandibular premolar ex tractions will not
32 CHAPTER 2
\--- Il-{l-{I'-I"
/
Figure 2-5. E~ traction options for treatment of a fu lly
Class II patient. A, Ma~illary premolars only are
e~tracted allowing for reduction of the overjet by maxi-
mum retraction of the anterior teeth. Molars remain
Class II, but maxillary canines are retracted to a Class I
position. B, Both ma~illary and mandibular first premo-
lars are e~tracted . Maximum retraction of the maxillary
an terior teeth is stitl necessary, but all of the mandibular
edraction space must be used for protraction of the
posterior teeth. Both molars and canines must achieve a
Class I relationship.
J
A B
provide any space for relief of crowding because the mandibular canines cannot be
moved distally. In these patients. reconsideration of a surgical option may be neces-
sary. As an alternative. extraction of one mandibu lar incisor may provide the space
req uired for tooth alignmcnt, while maxillary premol ar extracti ons allow establish-
ment of Class I canines (Fig. 2-6). An anterior tooth size discrepancy will then ex ist,
leaving the patient with excess overjet an~ overbite, which may be compensated
for by anterior maxillary tooth proximal reduction.
The funct ional goals of achiev ing a Class I occlusal relationsh ip with nomlal
overbite and overjet can also affect the ex tr.lctionlnonex tr.lction decision based on the
amount of overbite present before treatment begins. In patients with deep overbite.
upri ght incisors. and a convergent skeletal profil e. success may be facilitated by
choosing a nonextraction modality despite the presence of moderate crowding. This
process will aid the mechanics of overbi te correction significantly. If otherwi se com-
patible with treatment gools. a nonextraclion route will promote substantial reduction
of overbite consequent to changes in anterior tooth inclination . ~ Alternati vely, retrac-
tion of already upri ght teeth into extraction sites will require even greater movement
of the roots in order to obtain normal tooth angulations after treatment. In such
patients. significant amounts of true intrusion will be necessary to achieve overbite
control.
For patients with open bi te tendencies, extmctions may be indicated, especiall y if
the anterior teeth are already proclined. Some uprighting of these teeth during retrac-
tion can be permitted and will help to increase overbite. When treating such patients
without extractions, it may be difficu lt to achieve nomlal amounts of overbite because
CHAPTER 2 33
Fil"'''' 2-6. One rIOnsurgicaJ option for a Class II patient wi th significant mandibular crowding migh t be extraction of two
maxdlary premolars and one mandibular incisor. A and B, Pretreatmen t photographs snowing Class II ocdusioo with mandibular
crowding present. C and D, Posttreatment photographs after extraction of maxillary premolars and one lower indsor.
of the inclination of the anterior teeth and associated acute interincisal angle. Even if
incisal contacts are eventually establi shed, anterior guidance during protrusive excur-
sions may not be possible. __
Periodontal status, most notably the width and thi ckness of attached gingiva on
mandibular anterior teeth, may cause some hesitation in proceeding with what would
otherwise be a nonexlraction treatment plan (Fig. 2-7A and 8 ). Pos itioning the incisor
or canine crowns more labially in a patient already showing signs of recession, or
with deficient or thin ging ival tissue, is likely to cause progression of this condition.60
One option in such a compromised patient might be to reconsider extraction therapy.
It is advisable to seek ex pert opinion and infonn the patient of the risks of proceeding
regardless of the route chosen. In some cases a gingival graft procedure may be per-
fonned prior to treatment to increase or augment the amount of attached gingiva on
suspect leeth (Fig. 2-7C). Alternati vely, such a procedure may be planned for some
time duri ng or after treatment if deemed necessary allhat time.
Extractions may also be indicated if the teeth are SO protrusive that the patient
cannot achieve adequate lip seal during swallowing or if a large interlabial gap is pre-
sent at rest. In patients with substantial overjet. this may be a diffic ult problem to
diagnose since the lower lip oft en gets trapped in the overjet. Sometimes lip compe-
tency is attai ned after overjet reduction even without extractions. Increased lip length
with growth may also improve thi s situation if the height of the lower face does not
increase concomitantly.24.61
Short of surgery, orthodontic treatment exerts its most obvious effect on racial
34 CHAPTER 2
Figure 2-7. Class II patient with signifICant mandibular

crowding and minimal attached gingiva in the lower ante-
rior region . A and B, Pretreatment photographs. C, A free
gingival graft procedure was performed to increase
amounts of attached gingiva in anticipation of nooelCtrac-
tion orthodontic therapy.
soft tissue esthetics by affecting lip position. Though protrusive or retrusive move-
ments of the anterior teeth do not always result in an identical amount of lip move-
ment. the relat ive trends are in the same direction.:B.27.2S Soft tissue characteristics of
the lips, especiall y their thickness. affect the changes seen durin~menl.6261 Thin-
ner, incompetent lips respond more dramatically to changes in incisor position than
do thicker. already competent lips. If a goal of treatment is to decrease lip protrusion
and minor crowding is present, then a nonextraction treatment plan will not be help-
ful. Conversely. increased lip procu mbancy will generall y result from a nonextraction
plan provided some crowding is present and the final incisor position is anteri or to its
original position. Increased lip support may also result from extraction treatment if
the amount of crowdi ng exceeds the space used for relieving it.
The nasolabial angle is, of course. dependent on bOlh the base of the nose and the
upper lip projection. If a patient has an overly obtuse angle, it is likely to be undesir-
able to retract the lip furt her. Since resolution of a Class II relationship is often
accompli shed by intervening in the maxillary arch. a patient with this characteristic
poses difficult treatment chall enges. Growth modification, through headgear or func-
tional appliances. will upply distally directed forces on the max illary demition and the
max illa itself. both tending to reduce maxillary lip support. Any pattern of extraction
leading to differential retraction of maxillary anterior teeth would 6e undesirable in
this situation. Surgery offers a solution to this dilemma, but may not be a viable
option. Depending on individual circumstances, creative solutions may be available.
More often, however. some compromise will need to be reachcd with the hope thill
maxillary lip position will not be too adversely affectcd.
In patien ts wi th mi ss ing or compromised permanent leeth . the decision of
CHAPTER 2 35
whether to replace or restore them or close the space as if it were an extract ion site
depends on the individual circumstance. Generally, this situation should be planned as
if the tooth were prescnl and intact and the goals based on the existence ofa full com-
plement of teeth (Fig. 2- 8). If the decision is not clearly toward a nonextraction plan.
then elTorts should be made 10 use the siTe of the missing or severely compromised
tooth as an ex lraction space. This will usually also necessitate extracting at least the
contralateral tooth to achieve symmetry.
Figure 2- 8 . Treatment planning lor patients with missing or

compromised teeth should initially be planned as if all teeth were
present. F()( this patient. the decision was made to replace the
three missing teeth prosthetically and build up the peg-shape<!
lateral Incisor. A and 8, Pretreatment photographS showing the
patien t with a re tru sive lip profile and th ree missing lateral
incisors. C and 0, Near the end of treatment after opening space
for replacemen t of the missing teeth and build up of the ma.ICiI-
lary peg-shaped lateral indsor.
36 CHAPTER 2
O rthodontic Treatment Planning
Ln the case of a missing maxillary lateral incisor. the possibility of can ine substi-
tution can be evaluated both on the appearance and location of the canines. The
choice of whether to substitute canines in such circumstances wi ll vary somewhat
among practitioners depending on the individual's esthetic evaluation and predicted
viabi lity of replacement options. For Class 11 patients, canine substitution is usually a
workable alternative to tooth replacement. independent of whether or not teeth need
to be extracted in the mandible to alleviate crowding. The cani nes will. however. need
to be reshaped both lingual1y and facial1y to achieve normal occlusal contacts and
acceptable contours. This may be most easily done early in treatment so that the teeth
will fit properly as treatment progresscs.M
If pennanent mandibular second premolars are missing, the situation again will
vary among individual patients. If it would otherwise be unadvisable 10 extract teeth
because of esthetic considerations of lip support. then the remaining primary tooth
can be left in place for as long as possible or a space maintained in which to insen a
replacement. When mandibular primary second molars are preserved, however. a
tooth size discrepancy will exist that may comprom ise the buccal occlusion. II is
important in such cases that the goal of Class I c:mines be kept in mind. The molar
occl usion, because of the large mandibu lar primary tooth, wil1 then remain somewhat
Class U.
Stability is a commonly cited reason for extf'dcti ng teeth to relieve crowding.)~ If
expan sion of the dental arches. either labial1y or buccal1y. is the solution chosen in
lieu of eXlf'dctions. then it is logical that lip or cheek pressures wi l1 tend to push the
teeth inward as the bal ance of forces that mai ntained the teeth in their original posi-
tions is upset. Alternati vely, unless adequate crowding exists, extractions will posi tion
the teeth more linguall y. presumabl y infringing on tongue space and adversely affect-
ing stability. Teeth are like ly to continue to move lingually over..-tit"t'lC. however,
whether or not extractions are perfonned.65 The specific effect of an extf'dction versus
nonextraction decision on long-tenn stabi lity remain s unclear. Scientific studi es of
large patient samples show a tendency toward relapse in both ex traclion and nonex·
traction groups.J',36.65.66 Conversely. several series of patients have demonstrated that
high degrees of stability are attai nable for both treatment routes.27.l1.32.66.67
The factors leading to long+tenn stability are not likely to rcst solely on an extrac-
tion versus nonextraction decision. Cenainly, there are many changes that accompany
onhodontic reposition ing of the teeth. Adaptation of the lip. cheek. and tongue to new
tooth locations is only one pan of the transfonnation that occurs. Functional changes
that may accompany overjet reduction. or opening of a deep bite, also need to be con-
sidered. Elasticity of periodontal tissues has been implicated as a contributing factor
in the return of tooth irregularity. and the supracrestal fiberotomy procedure has been
advocated to limit this tendency.68 It has also been suggested that the mode of treat-
ment employed may affect long-tenn outcome.lJ9 More research is needed to identify
th e man y factors in vo lved and relate them both to treat ment and posttreatment
changes as determined for indi vidual patients.
DEFINING SPECIFIC GOALS
Specifi c goal s are the detailed skeletal and/or tooth movements that will be required
to achieve the general goals defi ned previously. For example. if a general goal was to
reduce facial convexity and a surgical opt ion ex ists for the patient. speci fi c goals
would include detenninalion of the direction and magnitude of the skeletal move-
ments required to achieve the desired profile change and the specific tooth positions
that would need to be altained. For an extraction case, specific goals would define the
relative amounts of anterior and posterior tooth movement needed so that anchorage
CHAPTER 2 37
requirements could be adequate ly pla nned . Depending o n the pre ference o f the practi-
tioner, specific goals can be bro ad, s uc h as " a necess ity fo r maxi mum pos te rior
anchorage," or more exact to include precise calculations of the mag nitudes of bony
and de nial movements to be accomplished.
Treatment Planning Tools
When defi ning specific goals, it may be helpful to make use o f adjuncti ve devices to
beller visual ize the e lTect of treatment o n the patient. This is especially true in surgical
cases, where the plan can be recorded for use by the onhooo ntist and the surgeon to
help coordi nate treatment pl anning between the two. In less involved cases. it may be
sufficient to me ntll il y visuali ze treatme nt goals in o rde r to map o ut the plllnned
sequence oft rcatlllent mechani cs rcquired.
Visual Treatment Prediction

The Visual Treatment Objective (YTO), or lateral predictio n tracing, may be used to
define both the surgical and genera l tooth moveme nts required to achieve the desired
facial goals. Traditio nally, thi s has been accomplished manually usi ng a pretreatment
lateral cephalometric trac ing of the patient. but mo re recently suc h predictions can be
accomplished on a compute r screen.70•11 For a no ngrowing, no nsurgical patient, the
vro wi ll re nect o nly the tooth movements to be allained onhoooliticully alo ng with
the expected conseque nt c hanges in the patient's lip profile. In the simplest case o f an
adult patien! with no crowd ing , e nd-on Class II mo lars. and :1 5-mm overje t, the yro
would show the original condition drawn initia lly. If treatme nt were to incl ude extrac-
tion of maxillary premo lars. the superimposed final o utcome would sho w protractio n
of the maxillary mo lar to full C lass II , retraction of the max illary incisors to norma l
o\'e~cl , and a small b:lc kward rotation of the upper lip (Fig, 2-9). No changes would
be eX]:MXted in the mandibul ar arch.
In a growing patient, the YTO can be used to re n ect the expected skeletal and
soft tissue changes that may occur during treatme nt. Care mUSt be taken. of course. in
interpreting such growth predic ti ons since few pati ents actuall y grow according to
oreffige values. As long as II compUler is HOI predicting [jle amounts or d lrectluns o j'
growth. the astute d iagnostician can mooify average values and directio ns to ren ect
abnormal growth patterns, or even intentionally ove r- o r underestimate amo unts of
growth to depict a worst-case scenario. At best, such a predicti o n is still o nly a g uess
Firunl 1-9. lateral prediction tracing mowing pretreat.

mtnt condition (solid lines) and predicted posttreatmen t
changes III tooth and lip positions (dotted lines) after
tKtraction of two maxillary premolars.
.
1j .') '.'.
-
CHAPTER 2 37
requirements could be adequately planned. Depend ing on the preference of the practi-
tioner, specific goa ls can be broad, such as "a necessity for maximum posterior
anchorage," or more exact to include precise calculations of the magnitudes of bony
and dental movements 10 be accomplished.
Treatment Planning Tools

When defining specific goals, it may be helpful to make use of adjunctive devices to
beller visualize the effcct of trcmment on the patient. This is especiall y true in surgical
cases. where the plan can be recorded for use by the orthodontist and the surgeon to
help coordinate trealment planning between the two. In less involved cases, it may be
sufficient to mentally visualize treatment goals in order to map out the planned
sequence of treatment mechanics required.
Visual Treatment Predidion

The Visual Treatment Objective (VTO), or lateral prediction tracing, may be used to
define both the surgical and general tooth movements required 10 achieve the desired
focial goals. Traditionally, this has been accomplished manually using a pretreatment
lateral cephalometric tracing of the patient. but more recently such predictions can be
accomplished on a computer screen.W.l l For a nongrowing, nonsurgical patient. the
VTO will reflect only the tooth movements to be attained orthodontically along with
the expected consequent changes in the patient 's lip profile. In the simplest case of an
adult patienl wi th no crowding, end-on Class II molars, and a 5-mm overjet, the VTO
would show the original condition drawn initially. If treatment were to include extrac-
tion of maxillary premolars, the superimposed fina l outcome wou ld show protraction ~
of the maxillary molar to full C lass II , retraction of the maxillary incisors to nonnal
overjet. and a small backward rotation of the upper lip (Fig. 2- 9). No changes would
be expected in the mandibular arch.
In a growing patient. the VTO can be used to reflect the expected skeletal and
soft tissue changes that may occur during treatment. Care must be taken. of course, in
interpreting such growth predictions since few patients actually grow according to
average values. As long as a computer is not predicti ng the amounts or directions of
growth, the astute diagnostician can modify average values and directions to reflect
abnonnal growth pallems, or even intentionally over- or underestimate amounts of
growth to depict a worst-case scenario. At best, such a prediction is still only a guess
F'l(Ure 1-9. lateral prediction trad ng showing pretreat-

ment condition (solid lines) and predicted posttreatment
changes in tooth and lip positions (dotted lines) after
extraction of two maxillary premolars.
.
1j :
. J
i '.
,.'
38 C HAPTER 2
si nce individual variations are known to be qui te large. n It is important. especially

whcn actually diagmmming growth predictions. that thc potential inaccuracy of the
process be recognized during the subseque nt treatment planning stages.
T he VTO is virtually essential to surgical treatment planning. There are two ways
in which the VTO can be used to help in the surgical treatme nt planning process. The
most goal-oricnted mc thod is to first superimpose the postsurgical bony positions
over the original tmcing to achieve the desired facial outcome (Fig. 2-IM). For a sin-
gle jaw mandibular adv:mcement. the mandible would be moved forward along the
occlusal plane until the desired position is reached to altain maximum facial esthetics.
The teeth will then appear in a new malocclusion. Usi ng the new relationship, one can
define the presurgical orthodontic movellle nt s lhat will be req uired to achieve this
desired surgical result (Fig. 2-108). If these tooth movements are not possible, then
surgical compromises or adjunctive procedures. such as an accompanying maxillary
impaction or supplemental advancement genioplasty. will be necessary.
The alternate method for using the VTO for surgical treatme nt planning would be
to first define the presurgical orthooontic changes and then perfonn the surgery to fit
the new malocclusion into normal overbite a nd overjet. Using the example above.
suppose the choice were made to maximize the amount of mandibular advancement
by extracting mandibu lar premolars and clos ing the space orthodontically. The
expected presurgical tooth movements are superimposed on the original tracing, in
this case reflecting retraction o f mandibu la r a nterior tee th and protraction of the
mandibular molars (Fig. 2- IOC). Assuming that the max illary teeth remain stationary,/
the new mandible. showing accomplishment of presurgical orthodontics. is moved
... '
A B c
Figure l-10. Two methods for using surgical treatment planning prediction trac·
ings. A. Method 1. Step 1: Surgical movemen ts are defined (dotted lines), display·
Ing the malocclusion as it would exist if I he desired surgery were already per·
formed. This method emphasizes the orthodontic tooth movements that must be
achieved to facilitate optimal surgical results. B, Method 1, Step 2: Orthodontic
movements (dotted lines) are determined to achieve the desired final occlusion (in
this case, Class III molars and Class I canines). C, Method 2, Step 1: Orthodontic
movements are defined (dotted lines), displaying the malocdusion as it is predicted
to exist before surgery is performed. This method emphasizes the surgical move-
ments that must be achieved to facilitate orthodontic correction. 0, Surgical move -
ments are determined to achieve the desired final occlusion (in this case, Class III
molars and Class I canines). Both methods should result in the same predicted out·
come.
D
CHAPTER 2 39
along the occlusal plane until Class IIJ molars and ideal overbite and overjet are
reached (Fig. 2-100). If this is not possible, then refinement of orthodontic move-
ments. such as intrusion of incisors, may be needed. At this point, the expected surgi-
cal result can be assessed and modifications made if deemed necessary. If the new
profile. for example, is now too prognathic, then the pla n can be restructured without
mandibular extractions or with both maxillary and mandibular extr'J.ctions.
Either method of surgical treatment prediction is somewh:lI of trial and error pro-
cedure. Both can be very helpful for visualizing treatment results and for exploring
various surgical options. It is important, however, to keep focused on the logic
involved in the planning process rather than on the mechanics of creating tracings. It
is easy to miscalculate along the way or to diagram results that are impossible to
achieve. When the plan is completed. it is worth the effort to go back and make sure
that the final results are the product o f a logical and practical approach to the problem.
Visual treatment predictions arc useful both fo r calcu lating lhe amounts of move-
ment required to achieve treatment goals and for explaining to patients expected treat-
ment outcomes. Modern video imaging. by which a digitally stored image of the
patient may be altered to depict the posttreatment prediction, can also be used for thi s
purpose (Fig. 2- 11). Computerized photographs, however, can be so reali stic as to
imply a guaranteed outcome that may not be :lchievable. Whi le they can be a power·
ful communication tool, the admonition that the likeness is only a rough predic tion /
must accompany any presentation to the patient.
The Occlusogram
Similar to the VTO or lateral prediction tracing, the occlusogram can be used to
define the specific tooth movements required to attain alignment within and between
arches to achieve treatment goals. For the occl usogram, photographic or photostatic
copies are made of the maxillary and mandibular study models pamUel to the occlusal
plane (Fig. 2- 12). Tracings of the teeth of both arches can be superimposed on each
other to match the occlusion using index marks carved in the models and transferred
to the tracings. Anticipated movements of the teeth can then be simulated to deter-
mine the positioning needed to attain correction of the malocclusion in concert with
treatment goals.
In the case of a Class II patie nt with severe mandibular crowding, a four premolar
extraction plan might be anticipated. If the treatment goal is to maintain mandibular
incisor position and arch form whi le treating to {he current max illary midline. the
chosen midline can be transferred to the tracing of the mandibular arch. Using the
predetennined arch form drawn through the tooth contact poi nts, measure ments cor-
fl,ur. 1-11. Oigital video imago

in! ~ used in this case to compare
the prelleatment patient pro file
(left) wllh that predicted to result
from a mandibular advancemen t
jlfOCedure (right).
40 CHAPTER 2
••
Figure 2-12. Ocdusograms can be used to determine the

tooth movements required to correct a malocdusion. Full-sized
tracings of the occlusal surfaces of the teeth are made using pho-
tographic co pies of study models.
t
t
responding to the widths of the mandibu lar teeth are marked off from the treatment
midline. Omitting the extracted teeth, the posttreatment mandibu lar molar positions
can be predicted, as can the required maxi llary molar position that must be Class I to
achi eve nonnal occl usion . For this exampl e, max imum maxillary molar anchorage
would be needed and the extent of anterior or even posterior movement of the maxi1 ~
lary molar could be detennined. It is al so possible to include the extent of anticipated
relative anterior growth or surgical movement of the mandible relative to the maxilla
by sliding the mandibul ar lracing forward the predicted amount.
The occlusogram is especiall y useful for predicting occlusal relationships in lieu
of a study cast wax-up when tooth size discrepancies exist or when unconventional
ex tract ion patterns arc planned. For example, if a mandibular incisor extraction is
anticipated, the remaining teeth can be arranged on the tracing and matched to the
predicted positions of the maxillary teeth after treatment. Thi s will demonstrate the
amount of excess overjet that will remain aft er Class I canines are establi shed.
Defining Specific Tooth Movement Requirements

Even when not using treatment planning tools such as lateral prediction traci ngs or
occlusograms, it is valuable to note the specific tooth movement requirements neces-
sary to achieve the desired goals. By using properly trimmed study models. it is often
possible to estimate thc anchorage requirements of both arches and detennine the
amount o f vertical movement of anterior or posterior teeth that will be necessary to
achieve a nonnal overbite relationship.
In both extraction and nonextraction situations. the max ill ary and mandibular
arches can be artificially di vided into anterior and posterior segments for the purposes
of defining specific tooth movement goals. The amount of movement requ ired of e:lch
segment in all three dimen sions shou ld be considered. Visuali zat ion is genera lly
CHAPTER 2 41
slmightforward in bilaterally symmetric situations, but may become more complex

when asymmetries are present. An occlusogram is particularly useful in asymmetric
cases to de termine the relative differences in tooth movement requ ired between the
right and lefl pos terior segments.
For a nonCX fraCfion treatment plan, the mandibular posterior teefh are probably
tKH planned to undergo significant amounfS of anterior-posterior movement. If may be
possible to slighdy move or tip the lower molar crown dislafiy to increase arch fength .
bot it is unlikely that this will yield more than one or two millime ters of space per
side for relieving crowding. Crowded tccth are more likely to be aligned by widening
the arch or flaring the mandibular anterior teeth forward , depending on the goals set
for a panicular patient. In cases with pretreatment spacing, the plan may be to protract
posterior or retract anterior teeth . PrOlraction of mandibular molars will help 10 cor-
rect the Class II relationship while maintaining as much lip support as possible. This
may also lead to a more stable result since the ante rior teeth will not be retracted and
infri nge on the tongue space.
Vertical movement of mandibular teeth can be used to help correct ante rior over-
bite relationships. Extrusion of posterior teeth, if maintained after treatment , will helP-
decrease overbite. Thi s will be accomplished, however, by rotating the ma ndibl e
open. thus increasing the lower face height and possibly worsening the Class II rela-
tionship. In cases whe re this is undesirable or predicted to be unstable. relati ve or
absolute intrusion of mandibular and/or maxillary ante rior teeth may be more practi-
cal. Relative intrusion of ma ndibular incisors can be accompli shed by flaring these
teeth forward when relieving crowding or leveling a deep c urve of Spee. Absolute
intrusion without Oaring, on the other hand, can be achieved by applying a n apically
directed foree through the center of resistance of the anterior segment (Fig. 2- 13).
Absolute extrusion of ante rior teeth to increase anterior overbite. by contrast, can be
perfonned by applying a coronally directed foree .
In extmction cases, protraction of mandibular posterior tccth will aid in C lass U
correction, but at the expense of taking space that could otherwise be used for relief
of anterior croWding. Use of extmction space can be titrated to allow enough retrac-
ficure 2-13. Both relative and absolute intrusion of

anttrior teeth may be used to correct a deep overbite.
A, By allowing anterior teet h to fl are forward. the
indsaI edges relatively intrude and also increase arch
Ief1gth. 8, By directing an intrusive force through the
center of resistance of anterior teeth, absolute intru-
Sion may be used to correct a deep overbite wi thout
llanng teeth forward or increasing arch length.
A B
42 CHAPTER 2
lion of anterior teeth 10 achieve facial esthetic and stability goals while protracting the
molars to a more Chlss I relationship. If most of the space is required for relieving
crowding, then Class U correction will need to come fro m mani pulation of the maxil-
lary arch, growth modification, or orthognath ic surgery.
Distal movement of maxillary posterior teeth to achieve Class II correction can
be accomplished using variou s appliances, most of which requ ire some degree of
pati ent compliance. Depending on the magnitude of movement required and the
amount of mandi bular growth occurring simultaneously. this process can be lengthy.
Distal tipping of maxillary posterior tooth crowns will occur more readily than trans-
lation or posterior root movement. With any type of distal movement, the new posi-
lions o f the posterior teeth will need to be mai ntained as the anterior leeth are
retracted into the newl y created spaces.
Deep overbite correction in the maxillary arch of Class II patients may often be
accomplished by true incisor intrusion. This is especially helpful in patients present-
ing with increased max illary incisor show relati ve to the upper lip. The apically
directed force can be applied anterior, through, or posterior to the center of resistance
of the anterior seg ment depending on the accompanying toot h angulation change
desired.13•74 More anleriorly placed forces will result in more rapid overbite-oorrection
because the teeth will also flare forward and relatively intrude. This mayor may not
be desirable depending on the original angu lation of these teeth and the goals of treat-
ment.
Arch width changes in the maxilla are most often planned to correct crossbites.
More recently. they have also been advocated to aid in relieving crowding. Whether
skeletally or dentall y accomplished. expans ion does result in a modest increase in
arch circumference.~7.7S These changes. if held for adequate periods of time. may also
be accompanied by minor mandibul ar arch width in crcases.1~·76
[n extraction cases, titration of maxillary space closure between anterior and pos-
terior tooth movement is critical to achieving a Class I canine result. If accompanied
by mandibular extractions. the anchorage requirements of both arches must be consid-
ered during planning so that anchorage conservation can begin when space closure is
initiated. In Class n palients where mandibular extractions are intended to be used to
relieve mandibular anterior crowding, max illary anchorage often must be max imized.
Auxi li ary appliances such as headgear may be used in conjunction with well-planned
intra-arch mechanics. Class II elastics will help in max illary anterior tooth retraction,
but at the expense of mandibular molar protraction. While this may help achieve a
Class I molar relationsh ip, it wi ll also minimize the use o f mandibular extraction
space for allev iating anterior crowding. When maxillary anterior teeth arc upright at
the start of treatment, additional maxillary posterior anchorage may be lost while per-
forming root correction of the anterior segment. n
Asymmetric cases pose more challenges during the diagnostic workup and treat-
ment planning stages. A decision must be made concemi ng whether to treat the asym-
metry in the maxilla, mandible. or both arches. Asymmetric goals are most easily met
if asymmetric extractions can be perfonned (Fig. 2- 14). If a maxillary dental asym-
metry exists. special consideration shou ld be given to predicting movement of the
midline before extractions are planned. Mandibular :lsymmetric extractions in Class II
patients will usually necessitate bilateral maxillary extmctions with treatment to Class
I molars on the mandibular ex traction side and Class II molars on the other. This is
done to maintain max illary symmetry while establishing a Class I canine relationship
bilaterall y. Extractions, if planned, should be designed so that treatment mechanics
can subsequentl y proceed symmetricall y.
Asymmetric extractions may not be feas ibl e if the circum stances warrant a
nonextraction approach because of soft tissue esthetic concerns. In other silUations,
bilateral mandibular extractions may be necessary for relieving severe crowding. For
CHAPTER 2 43
Fi, ul'lll 2- 14. Asymmetric extractions may be performed to allow use of symmetric mechanics to correct an asymmetric Class II occlu·
sion. A, 8, and C, Pretreatment photographs showing a Class n occlusion on the patient's left and a Class I occlusion on the right. D, E,
and F, Posttreatment results after extraction of maxillary and mandibular first premolars on the Class I side and only a maxillary first pre-
molar on the Class II side.
these cases, asymmetri c mechan ics may be necessary to achieve a symmetrical result.
Possibi lities may incl ude asymmetrically acti ve transpalatal or lingual archwires,
asymmetric headgear, and/or un il ateral elastics. Each alternative is likely to cause
unwunted biomechanical side effects that will have to be overcome by additional
mechunics or accepted as a compro mise in the treatment result . Undesirable tooth
movements can often be minimized by increasing the size of anchorage units appro-
pri ately. Successful resolution of asymmetrical problems can be accompl ished when a
44 CHAPTER 2
O rthodontic Treatment Plann ing
proper diagnosis is followed by in-de pth planning based on well -established ortho-
dontic biomechanical principles.
Reassessing Treatm ent Options and General Goals

After formul ating specific goals, it may be necessary to reconsider the treatment
options chosen previously. Often thi s process of reappraisi ng options occurs simuha-
neously wi th determinati on of specific goals. The tooth movements necessary 10
achieve general goa.ls may not be poss ible given the nonsurgical or nonextraction
route considered. In other cases, the ri sk and expense of surgery may no longer
appear justifi ed, or eXlr'J.ctions may not achieve the desired resu lt.
The most dramatic change of pl ans would be from a nonsurgical route to a surgi-
cal one. Most often this would occur because of an initial miscalcu lation in maximum
anchomge situations. An example might be the full-c usp Class II adu lt patient with
mandi bular crowding orig inall y plan ned for four premolar ex tractions. This plan
could crcate unreasonable maxillary posterior anchorage requirements, and surgery _
might be a more reasonable alternative. The opposite change, from surgical to nonsur-
gical pl ans, might occur in a case where surgery had been planned originally because
of esthetic concerns but, after planning, the magn itude of the ant ici pated surgical
improvement turned out to be minimal. One alternative might be to consider more
extens ive orthodontics to worsen the maloccl usion and max imize the surgery. This
treatment, however, which might include extracting mandibul ar teeth to maximize a
mandi bu lar advancement, could raise esthetic or stabi lity concerns in itself. An ortho-
dontic compromi se not incl uding surgery might be appropriate.
Chunges between ex traction and nonextraction options occur most often because
all of the goals are not attai nable by either route. An original plan for extractions to
relieve mandibular crowding can be changed to a nonextraction plan in order to avoid
an un acceptable lip profil e with the knowledge that fi xed retention may be necessary
to maintain stability. In another patient, a nonextraction choice may require large
amounts of cooperation and complex asymmetric mechanics, so extractions may be
opted for in order to expedite treatment.
In cases where no single choice seems to fulfill all of the goals, the advantages
and disadvantages of each option need to be weighed against one another. Frequent ly
this wi ll mean discardi ng or modifying some of the original. general lreatment goals.
Providing perfect occl us ion with a facia lly esthetic result that will be stable forever is
not always possible. Patients will presem with different morpho logical features. levels
of interest. cooperation, and expectations. Differem goals may be more important for
different patients or practitioners. The least importam may need to be sacri ficed if all
cannot be met by reasonable means. The extent of intervention necessary. considered
along with the potential for improvement afforded by any particular lreatment alterna-
tive. as well as the patient 's attitude. will help in detennining the best option for each
individual patient.
SEQUENCING TREATMENT
A sequenced mechanics plan can be formulated once the specific tooth movement
goals have been established. If treatments arc indi viduali zed for patients. recordi ng
the steps to be fo llowed during therapy is essential so that all of the work that went
into the treatment planning process is not wasted. Otherwise, it will be necessary to
rediagnose and plan the ease at every patient visi t.
Every case will present new opportunities for innovation in mechanics design and
for economizing treatment steps. For some patients. the mechanics used for accom-
- ----- -- --- -
CHAPTER 2 45
B
Figu re l - 15. Mechanics used to achieve one goal may aid in solving other problems. A, In this case, the intrusive base arch placed in
th e molar au~il i ary tube helps to correct e~ce5sjve overbite in the anterior while providing a tip -back moment at the molar to help main-
tain posterior anchorage during space closure. 8, The intrusive force at the incisors is accompanied by a tip-back moment that can be
used to aid in preserving molar anchorage.
plishing one particular goal will also aid in the correction of another problem (Fig.
2- 15A). In other cases, each goal will have 10 be confronted separately and held
through the next step in (he sequence. Devising a logical progression of treatment
before beginning will avoid the necessity for reversing directions during therapy and
will simplify patient visits.
In most cases requiring max.illary expansion. eXjXlnsion is the first treatment step.
and it is usually earried out independently from other therapy. During the retention
period for expansion. however. other aspects of treatment may be initiated . The
expansion appliance itself is very rigid and may be used to stabilize the molars as
anchorage for other tooth movements. If this is not convenient. the appliance can be
replaced with a more versatile transpalatal arch that can itself be activated symmetri -
cally or asymmetrica lly to rotate mo lars. provide rOOI torque. or tip the molars
mesially or distally. while retaining expansion.
If molar correction is to be accomplished through the use of headgear or other
functional appliances. it is also usually begun early in treatment and may continue
through other phases of fixed therapy. Headgear tubes can be designed to allow
mesial-buccal rotation of molars as they arc moved di stally, but it is often desirable to
first rotate them actively using a transpalatal archwire if this is a goa\.
Especially in nonextraction cases. molar occlusion can be completely establi shed
before fu lly bonding the remaining teeth . If the conditions arc favorabl e. it may be
advantageous to begin maxillary anterior overbite correction at the same time. Intru-
sive mechanics to the maxillary inci sors will be accompanied by an extrusive force on
the posterior teeth along with a moment that will tip the molar crown di stally (Fig.
2- 158). This moment can be used to aid in classifi cation of the molar at this early
stage, though headgear may still be needed to effect distal root movement. If the pre-
molars are not yet bonded. their crowns may spontaneously move distally as the
molars lip back. or they ean be actively retracted later in treatment.
Similarl y. asymmetries may be most easily corrected before full bonding is
accomplished. depending on the mechanism chosen. If an asymmetric headgear or
transpalatal or lingual archwire is to be used to effect asymmetric mechanics. it is best
to accomplish significant correction before bonding the remaining teeth. If elastics are
to be used in order to accomplish correction in bolh the maxillary and mandibu lar
arches. then intrJ.-arch alignment will need to be established beforehand.
General intra-arch alignment may proceed mOSl efficiently and without complica-
lion if severely displaced teelh are omitted from the initial aligning wire. In the most
46 CH APTER 2
Figure l-16. Long-arm, canti lever wires may be l.l sed to extrl.ld e individual teeth to minimi~e side effects on adjacent teeth ,
A. A wire extending from the molar auxiliary tl.lbe is used to extrl.lde a high canine without causing intrusive side effects in the
anterior region. B. After extrusion is compjeted.
obvious example, a patient with Hn open bite tendency and high buccal canines will
experience the unwanted side effect of furth er inci sor intrusion if the canines are
included during alignment. In a case such as this, it is best to first rigidly join the
remaining teeth, using them as anchorage to extrude the canines, or to perform canine
extrusion using long-arm. cantilevered wires extending from the molar auxiliary tubes
(Fig. 2- 16). The canine ex trusion can even be accomplished before bonding adjacent
teeth if cantilevers arc used and the molars are rigidly fi xed using a transpalatal arch.
Once initial alignment has been accomplished, the next step is usually overbite
correction. If a deep overbite exists and the mandibular incisors cannot be bonded,
then either flaring or intrusion of the maxillary anterior teeth must be accomplished or
a bite plate inserted before proceeding with mandibular arch treatment Overbite cor-
rection must precede complete closure of extraction spaces to ensure proper occlusal
relationship of canines CHn be accomplished. In some cases, intrusion of maxillary
teeth can be performed while space closure is occurring by applying an intrusive force
along with the force of retraction (Fig. 2- ISA).
Space closure can be effected using any of a number of mechanisms, all of which
work by applying a force to the respective leeth . Mechanics can be planned to titrate
space closure according to the tooth move ment goal s previously determined. Addi-
tional anchorage can be gained by utili zing auxi liary or extraoral appliances and by
varying moment to force ratios between the anterior and posterior segments.77•78
After spaces are closed and full intercuspation is established, it may be necessary
to undergo a rool correction phase to ensure proper parallelism of roolS at the extrac-
tion site or area of space closure. This is especially true in cases in which anchorage
requirements are demanding and teet h have been tipped, rather than translated, 10
avoid taxing anchorage. The necessity for root correction may become apparent by
the presence of a lateral or anterior open bite or by the appearance of upright incisors,
In other cases, a panoramic or oblique mdiogmph may be helpFul for assessing root
parallelism. Finishing or final detailing may also help in establishing good root dis-
persion.
During the process of fonnu lllling a detailed mechanics plan , it is helpful to visu-
alize what the occlusion will be at each patient visit or at the end of each stage of
treatment. In this way, the entire treatment process is worked through from start to
finish. This will help to avoid any seriou s omissions from the initial treatment plan.
Alternative backup plans can be devi sed in case anti cipated growth changes do not
occur or iF patient cooperation is less than optimal.
CHAPTER 2 47
O rthodontic Treatment Plann ing
Evaluating Treatment Progress

Having a general time frame in mind by which certain specilic lreaonent goals are
expected to be met is helpfu l for maintaining control of progress throughout therapy.
Especially for palients in whom growth or cooperation is expected, detecting defici ent
progress is important. If reevaluation of the success of headgear wear, for example. is
set specifically at six months after its initiation, proble ms can be detected earl y and
corrected. In some cases, if certain goals are not met within the specilied time. treat-
ment direction can be altered promptly to avoid unnecessary delays. Without definite
goals, such decisions may be deferred visit after visit until a signilicant extension of
overall treatment time is needed.
Similar guidelines apply to other aspects of treatme nt as well. Despite careful
planning, treatment docs not always proceed as intended. Thi s may be because of an
initial misdiagnosi s or because of an overestimation of the ability to fulfill a nchorage
requirements. Changes in treatme nt direction. if needed, should be made carefull y but
decisively and promptly. PatienlS are usually more recepti ve to such alterations if the
possibilities arc defined at the start of treatme nt, but even unexpected revisions are
accepted if they can be expl ained rationally.
Pl anning o f treatment is the most important step toward a ttain ing successful
onhodonlie results. The process may appear time consuming, but compensation will
come in Ihe form of improved patie nt care that proceeds smoothly and efficiently. The
objective of a good treatment plan is to complete the decision-making process before
therapy is initiated. This reduces the necessity for spending large amounts of chairside
time deciding how treatment should progress, thus lessening the chance that a hasty
decision will hamper advancement of piltient care. Frequent reevaluation of progress
will help to intercept and reverse setbacks as they appear rather than allowing them to
escalate into difficult problems. The overall result is increased praclice organization
and a higher level of satisfac tion both for practitioners and the patients they treat.
REFERENCES
l. Sakuda M, Tanne K, et al: Integrated informatio n· processing system in clinical orthodontics: An
approach with use of a computer networit system. Am 1 Orthod Dentofae Orthop 10 1:2 10-220. 1992.
2. lsaucson RJ , Li ndauer SJ, Strauss RA : Computers and cephalometrics. Alpha Omegan 84:37-40.
1991.
3. Moss Jp. Coombes AM. Linney A D. Campos J: Methods of three-d imensional ana tysis of ~Iiellls
with asymmetry of the face. Proc Finn Dent Soc 87: t 39- 149. 199 1,
4. JocOOson A: Planning for orthognat hic surgery-Art or science? IIlI 1 Adult Orthod Orthognath Surg
5:211-224, 1990.
5. Gottlieb EL, Nelson AH, Voge ls OS: 1991 l CO onhodontic practice st udy. I. TreTKIs. 1 Clin Orthod
25:67 1-678, t99 t.
6. Isaacson RJ, Lindauer S1. Rubenstein L K: Act ivat ing a 2)( 4 appliance. Angle Orthod 63: 17-24.
1993.
7. Von Fl'lIunhofer l A. Allen OJ . el al: t"Jlient empowerment:'f1le young patient, Am J Onhod Dcntofac
Onhop 103:365-367. 1993.
8. Greene CS; Onhodomics and It mporomulldibular diwrden. Oem elin Nonh Alii 32:519--538. 1988.
9. Harris EF, Behrents RG ; Illtrinsic stability of Class I motar re latio nship: A lo ngi tudinal st ud y of
untreated cases. Am J Onhod Dentofac Onhop 94:63-67. t988.
10. Lubi t BC: The relationship of malocclusion and faul ty speec h articulation. J Oral Moo 22:47-55.
t967.
II. Laine T: Malocclusion traits and articulatory componcllls of speec h. Eur J Onhod 14:302-309. 1992.
11. Burs«me CJ: Up posture and its significance in treatment ptanning , Am J Orthod 53:262-284. 1967.
t3. Fotis V, Melsen B, Williams S: Posttreatment changes of skeletal morphology follOWing treatment
aimed al restriCtion of mllllil1ary growth. Am J Orthod 88:288-2% . 1985.
14. Breece GL, Niebcrg LG: Mot ivat ions for adutt orthodontic treatme nt. J C lin Orl hod 20: 166--171,
1986.
48 CHAPTER 2
15. McK iernan EXF. Mc Kiernan F. Jones ML: Psychological profiles and Ill()ti ves of adults seeking
onhodontic lR:atmenl. Int J Adult Onhod Onhognath S urg 7: 187- 198, 1992.
16. Shaw WC, Rccs G. Dawe M, C harles C R: The influe nce of dentofacial a ppearance on the social
attractiveness of young adults. Am J Orthod 87:2 1-26, 1985.
17. Adams GR: Physical a1tracth·eness research: Toward a developmental social psychoklgy of beauty.
Human De\'elopment 20:217- 239. 1977.
18. Shaw we llte influence of children's dentofacial appeat:lnce on their social attrncti veness as judged
by peers and lay adults. Am J Orthod 79:399-415. 1981 .
19. Rosenthal R. Jacobsen C F: Pygmal ion in the Classroom: Teacher Expectations and Pupils' Intellec-
tual Development. New York: Holt. Rinehan and Winston. 1968, pp. 3-3 1.
20. Schendel SA. Eisenfeld J, Bell WH, Epker \IN. Mishe1evich DJ: 1be long face syndrome: Venical
maxillary excess. Am J Orthod 70:398-408. 1976.
Peck S. Peck L . Kataja M: 1be gi ngival smile line. Ang le Orthod 62:9 1- 100. 1992.
~. Drobocky OB, Smith RJ : Changes in facial profile durin g onhodontic lreatrncm with extrnetion of
fOUf first premolars. Am J Onhod Dcmofac Onhop 95:220-230, 1989.
23. O'Co nn or BMP: Contemporary trend s in onhodon ti c prac tice: A nationa l survey. Am J OnhOO
Dcnlofae Onhop 103: 163- 170. 1993.
24. Nanda RS , Meng H. Kapi la S, Goorhui s J: Growth changes in the soft lissue facial profile. Angle
~
Orthod60:177-190. I990.
~. Yogosawa F: Predic ting sof11i ss ue profile changes co ncurrent wilh orthodontic treatment. Angle
Orthod60:I99--206,I 990.
2,(l. Perkins RA. Slaley RN: Change in li p vennill ion height during orthodontic treatment. Am J Orthod
Dcntofac Orthop 103: 147- 154. 1993.
27. Paquelle DE, Beatt ie JR. Johnslon LE: A long· term comparison of no nextractio n and premolar
e xtrac tion edge wise therapy in "borde rl ine·' C lass \I pa tie nts. Am J Onhod Dentofac Orthop
\02: 1- 14.1992.
28. Young TM. Smith RJ: Effects of orthodontics on the facial profile: A comparison of changes duri ng
nOilCxtraction and four premolar ex trnct ion treatments. Am J Orthod Dcmofac Orthop 103:452-458,
1993.
29. Frlint..:el R. Muller M, Falck F: The upri ghting effect of the Fr'Jnt..:el a ppliance on the mandibular
canines and premolar.! d uring eruptio n. Am J Onhod Dcmofac Ortoop 92: 109-11 6, 1987.
30. Nanda RS, Nanda SK: Consideralions of den l0facial growth in long·term retemion and stability: Is
active retention needed? Am J Onhod Dentofac Orthop 10 1:297-302. 1992.
3 1. Hime DL, Owen A H: Slabili ty of the aT(:h.exp;1nsion effects of Frlint..:eI app liance therapy. Am J
Orthod Dcntofac Ortoop 98:437-445, 1990.
32. Glen n G. Sinclair PM. Alexander RG : Nonextraction onhodontic therapy: Posttrealment demal and
skeletal stabil ity. Am J Onhod Denl0fac Orthop 92:32 1-328, 1987.
33. LillIe RM , Riede l RA. Artun J: An ev ulualion of changes in mandibular anlerior alig nment from 1010
20 years postrelention. Am J Orthod Dentonlc Orthop 93:423-428. 1988.
34. Parker WS: Rc1enti on- Relaine(1; may be forever. Am J Orthod Dcntofac Orthop 95:505- 5 13, 1989.
35. Lin le RM, Wallen TR. Riedel RA: Stabi li ty and re l11pse of mandibu lar anterior ali gnment- Fi rst pre-
molar extrac tion cases treated by traditional edgewise orthodontics. Am J Orthod 80:349- 365. 198 1.
36. Sado wsky C, Sakols El: Long-tcrnl asscsSlncnt of o nhodo nti c relapse. Am J Orthod 82:456-463,
1982.
37. Uhde MD. Sadowsky C, B<:Go le EA: Long· tenn stability of denIal re lationships aftcr orthodontic
treatmcnt. Angle Orthod 53:240-252, 1983.
38. S hie lds TE, Little RM . C hapt..:o MK: Stabil ity and re lapse of mandibular anterio r alignmen l: A
cephalometric appraisal of first-premolar--e~ tract ion cases treated by trndi tional edgewise orthodon-
ties. Am J Onhod 87:27-38. 1985.
39. Little RM: Stability and relapse of dental areh al ig nment. Bri t J Orthod 17:235-24 1. 1990.
40. Sinclair PM: Orthodontic consideration in adul l surgical orthodontic uses. DenIal Clin North Amer
32:509-528. 1988.
4 1. Mc Neil RW, West RA: Severe mandibular ft'trognuthism: Orthodontic versus surgical onhodontic
treatmen l.Am J Onhod 72:176- 182. 1977.
42. Jacobs JD, Sinclair PM: Principles of onhodontie mechan ics in orthognathic surgery cases. Am J
Onhod 84:399-407. 1983.
43. Worms FW. Isaacson RJ. Speidel TM : Surgical orthodontic treatnlCnt planning: Profile anal ysis and
mandibu lar surgery. An gle Orthod 46: 1- 25. 1976.
44. Cassidy DW. Herbosa EG, Rotst..:off KS. Johnston LE: A comparison of surgery and orthodont ics in
··borderl ine" adu lts wilh C lass II. Di vision I ma locclusions. Am J Orthod Dentofac Orthop
104:455-470,1993.
45. Ki erl MJ, Nanda RS, Cu rrie r GF: A 3-ycar eval umion of skelelal stabilit y of man dibular adv ancement
with rigid fixal ion. J Oral Mux illof11e Surg 48:5117- 592, 1990.
CHA PTER 2 49
46. Law JH. Rotskoff KS. Smith RJ: Stability foUowing OOlllbincd maxillary and mandibular osteotomies
treated with rigid fiution. J Oral Maxillofac Surg 47: 128- 136. 1989.
47. Proffit WR. Phillips C. Tulloch JFC. Med land PH: Surgical versus orthodontic correction of skeletal
Class II malocclusion in adolescents: Effects and iudications. Int J Adul t Onhod Onhognath Surg
7:209-220.1992.
48. Lake SL. McNeill RW, lillie RM, West RA: Surgicnl tnandibulur advancement: A cephalometric
analysis of Ireatmem re~ponse. Am J Orthod 110:376-394. 1981.
49. Epke r BN. Fish LC: Su rgica l-Ort hodon tic correction of open -bite deformi ty. Am J Orthod
71:278-299,1977.
50. Kim YH: Anterior opcnbi te and its treatment with multiloop edgewise arch wire. Angle Orthod
57:290-32 1. 1987.
51. Dellinger EL: A clinical assessmen t of the act ive vertica l corrector-A nonsurgical alternative for
skeletal open bite treatme nt. Am J Orthod 89:428-436. 1986.
52. Barbre RE. Sinclair PM: A cephalometric evaluation of anterior opcnbite correc tion wit h the mag-
TM:tic active vertical oorrector. Angle Onhod 61 :93-102. 1991.
53. Washburn MC, Schendel SA, Epker BN: Superior repositioning of the maxilla during growth. J Oral
Maxil lofl«: Surg 40: 142- 149. 1982.
54. Huang es. Ros,~ RB: Surgical advancement of the re trognathic mandible in growing children. Am J
Onhod 82:89- 103. 1982.
55. Vig KWL, Tu rvey TA: Surgical correction of vertic~l maxillary excess during ado lescence. lnt J
Adult Orthod Orthognath Surg 4: 11 9- 128.
56. Vig PS. Weintraub JA, Browll C. Kowalski CJ: The duration of orthodontic treatment with and with-
out extracti ons: A pilot study of live <;elected practices. Am J Onhod Dentofac Orthop 97:45- 5 1.
1990.
57. Gennane N. Lindauer SJ. Rubenstein LK. Revere HI. Isaacson RJ: Increase in an:h peri meter due to
onhodonticexpansion. Am J Onhod Dentofac Orthop 100:421-427. 1991 .
58. Sheridan JJ: Air-rotor stripping. J e lin OrthOO 19:43-59, 1985.
59. EJx:rharl BB. Kuftinec MM. Baker 1M : The rclationship between bite depth and incisor angular
change. Angle Onhod 60:55-58, 1990.
60. Artun J. Krogstod 0: Periodontal SWIUS of mandibular incisors following excessive proclination. Am
J Onllod Dentofac Orlhop 91:225-232. 1987.
6 1. Geneoov JS. Sinclair PM. Dechow PC: Development of the IlOSC aod soft ti ssue profile. Angle Orthod
60: 191 - 198,1990.
62. Denis KL, Speidel TM: Co mparison of three methods of profile chunge prediction in the adult ortho-
dontic patient. Am J Orlhod Dcntofac Orthop 92:396-402. 1987.
63. Holdaway RA: A sofHis.~ue cephalometric ana lysis and its use in orthodontic treatment planning.
Pan I. Am J Onhod 84:1- 28. 1983.
64. Zachrisson BU, Mjtir IA: Remodeling of teelh by grinding. Am J Orthod 68:545-553. 1975.
65. Rossouw PE. l>reston cn. Lombard 0. Trutcr JW: A longi tudinal eval uation of the anterior border of
the dentition. Am J Orthod Dentofac Onhop 104:146- 152, 1993.
66. Linle RM, Riedel RA. Slein A: Mandibular urc h length increa'-C during the mixcd dentition: Postro-
tention evaluation of stability and relapse. Am J Onhod De ntofac Onhop 97:393-404. 1990.
67. Cetlin NM. Ten Hexwe A: Nonex tmction treatment. J elin Onhod 17:396-413. 1983.
68. Edwards JG: A long-Iertll prospective evaluation of the circumferential supracrestal liberotomy in
alleviating orthodontic re lapse. Am J Orthod Dentofac Orthop 93:380-387. 1988.
69. Dake ML, Sinclair PM: A eomparison of the Ricketts and Tweed-type arch !e\'eli ng techniques. Am J
Onhod DemonIC Orthop 95:72-78. 1989.
70. Sarver DM, Johnston MW: Video imaging: Techniques for superimposition of cephnlometric radiog-
raplly aud profile images. lnt J Adult Onhod Onhognath Surg 5:24 1- 248. 1990.
7 1. Sarver DM: Videoi maging: The pro!! and oons. Angle Orthod 63: 167-170, 1993.
72. Buschang PH , Tanguay R. laPalme L. Demirjian A: Mandibulur growth prediction: Mean growth
increments vcrsus mathematical models. Eur J Orthod 12:290-296. 1990.
73. BUTStone CJ: Deep overbite ootTrCtion by intrusion. Am J Orthod 72: 1-22. 1977.
74. Isaacson RJ . Lindauer SJ. Rubenstein LK: MonlCnl~ wi th the edgewise appliance: Incisor torque oon-
trol. Am J OnhOO Dentofac Onhop 103:428-438. 1993.
75. Adkins MD. Nanda RS. Currier GF: Arch perinlCter changes on rapid palatal e.l pansion. Am J Orthod
Dentofac Orthop 97:194- 199, 1990.
76. Gryson JA: Changes in mandibular interdental distance concurrent wi th rnpid maxillary expansion.
Ang le Orthod47: 186-1 92.1977.
77. BUTStone 0 : The mechanics of the segmented an:h techniques. Angle Orthod 36:99- 120. 1966.
78. Bur.;tonc 0 : TIle segmented arch npprooch to space closure. Am J Onhod 82:36 1-378. 1982.
CHAPTER
5
Biomechanical Aspects of Class II
Mechanics with Special Emphasis
on Deep Bite Correction as a Part
of the Treatment Goal
L. R. Dermaut • G. De Pauw
DIAGNOSI S OF THE DENTAL DEEP BITE
he deep bite can oc defined by the amount and percentage of overlap of the
T lower inci sors by the upper incisors. The overbite may be calculated as a per-
centage of the clin ical crown he ight of o ne of the mandibular cemral incisors.
At the age of 5 to 6 years this percentage varies between 36.5 and 39.2. In adults it
remains a lmost unchanged. varying betwee n 37.9 and 40.7%. Fleming showed thaI
between 9 and 12 years of age the overbite usuall y is increasi ng, whereas in the
period between age 12 a nd :ldullhood it is decrc:ls ing. ' No sex differences were noted.
Moreover, the amount of vcnicaJ overbite is closely associated with some craniofacial
dimensions. The study also determined thaI ramu s length was one of the most impor-
tant dimensions associated with the amount of overbite. Evidence indicated that the
reduction in the overbite after 12 years of age may be due to growth of the ramus of
the mandible. According to a study of Moorrees in 19592 it is not always easy to pre-
dict the evolution of a dental deep bite during growth in a particular patient (Fi g.
5-1). The overbite increases in some children. whereas in others the overbite changes
are erratic.
The amount of dental overbite is not always associmcd with a particular growth
pauem. Teeth tend to erupt until their spontaneous eruption is disturbed by an inter-
fering factor: for example. thumbsucking or tongue interposi tion may prevent teeth
from erupting until they reach the occl usal plane. In cases ~ f severe Class 11 , Divi sion
I maloccl usions lower incisors may erupt until they reach the pal alai vau lt . If an
antagonist is mi ssing, furth er eruption of a tooth may occur, leading to occlusal inter-
86
CHAPTER 5 87
Biomechanical Aspects of Class II Mechanics
ferences during nonnal jaw movements, wh ich may cause TMJ. complaints. "No
genes for bones" may also refer to alveolar growth referring to "continuous eruption."
THERAPY
Correction of a dental overbite can be achieved mainly by ex trus ion of molars, intru-
sion of incisors. or a combination of both movements.
Bile open ing in patients with a venical growth pattern should be accomplished by
means of il/lr/l5iOll of illcisors. The deep bite correction in these patients by means of
extrusion of molars may worsen their facial outlook. Most of these patients already
have lip incompetence and an increased lower anterior facial height. Also in adults.
where bite opening is aimed for, intrusion of inci sors should be our first choi ce.
Increasing the lower anterior facial height by extrusion of molars may not always be a
stable situat ion in adult patients.
[n a study of six adult patients, Carlsson 3 investigated the effect of a temporary
increase in the venical dimension of occlusion by inserting splints and increasing the
venical dimension beyond the original rest-face height. He concluded that a moderate
increase in the vertical dimension did not seem to be a hazardous procedure. provided
that occlusal stabi lity was established. This conclusion refers only to his finding that the
interocclusal dist'ancc remained greater than at the star1 of the experiment. (Fig. 5-2).
MALES
( -Lo..b-x:::....t.~
iJ---~~~~~~~
, ,. " '18 , ••
FEMALES
FEMALES
A
, ,. •••
B
Fi gure 5-1. longitudinal record5 of overbite in males and females who at 16 to 18 years have (AJ 0 to 'h and (8) 'h to ' I.< over1ap-
ping of the crown of the mandibular central incisors by the ma~il l ary incisor.
//Iustration continued on following page
88 CHAPTER 5
Biomechanlcal Aspects of Class II Mechanics
0 "'U"
I
'---\ \ \~ -
•
-
" ,
'" >< .-- 10· 11
~••••
•••
FEMALES
0
\
"" ""- ~ .
./
""" ~
" ,
c
Figure 5- 1. (Continued) Longitudinal fe1:ords of overbite in males and females who at 16 to 18 years
have (C) 2/.0 to complete overlapping of the crown of the mandibular centraJ incisors by the maxillary
incisor. (A-C from Moorrees CFA: The Dentition of a Growing Child. Cambridge, MA: Harvard Univer·
sity Press, 1959.)
Ln a study of 20 patients with advanced periodontal breakdown combined with

ex tensive tooth loss, the anterior fac ial height increased by 2 to 6 mm by means of
fi xed bridges.4 The authors found during fo llow-up that the anterior fac ial height did
not change in some patients, whereas in others it decreased sl ightly. indicati ng an
intrusion of the abutment teeth. They concluded that the original fac ial height was
never reached. It should be emphasized that those patients had extensive tooth loss
before fi xed bridgework was insellcd. resu lting in a "collapsed bite" and loss of verti-
cal dimension.
In 1982, Dahl and Krogstad 5 looked for the effect of a partial bite-raising splint
on the occlusal facial height. They found that the effect of the splint was one of intru-
sion of the upper and lower front teeth and eruption of the molars in all patients. This
study again seems to indicate indirectly that venical forces act on the incisors in an
effort to counteract the effect o f increasing fac ial height . However, a pennanent
increase of the facial height of 1.47 mm was found after ten months.
In a study of 14 rhesus monkeys, McNamara investigated the hi stologic and
cephalometric responses to increased venical dimension in the mature face.~ Cephalo-
metric examination of the postrctention animals revealed a return of the posterior den-
CHAPTER 5 89
MM
6
5
~
------"\ \ ,
4 ,,
. ,,
FIgure 5-2. Mean changes in morphologic and resbng-
,, ,
face height in si x subjects while increasing the vertical
dimension of occlusion. (From Carlsson GE, Ingerval! e,
3 ,..' 0
Kocak G: Effect of increasing vertical dimension on the
masticatory system in subjects with natural teeth, J Pros-
2
thet Dent 41(3):284-289, 1979.)
1
!!l 0 MORPHOLOGIC fACE HEIGHT

o ~ REST fACE HEIGHT •
INSERTION Of BITE RAIS ING SPLINTS
REMOVAL Of BITE RA tSING SPLINTS
tition to pretreatment height. Muscle stretching in nongrowing patients by means of

extrusion of molars ,\Od clockwise rotation results in a situation that does not always
seem to remain stable.
Corrcction of vertical max illary deficiency in adults can be achieved by midface
augmenuuion (Lefort I) with interpositional bone grafts. However, the t.reatment
resu lts demonstrate considerable relapse, varying from 0 to 100%. with one study
showing a 3 1% rate and another a 20 to 70% rate. 7 ,s Rctapse was most often observed
during the first six month s. and there W<lS no significant corre lati on between the
amount o f surgical dis placement and the percentage o f relapse. Stretching of the
mandibular elevator musculature is supposed to be responsible for th is skelelal insta-
bility. Thi s stretching may cause resorption of the bone graft. T he importance of the
forces created by muscle stretching has been shown in differenl studies. The use of
bite-opening appli ances (without surgery) may cause anterior and superior displ ace-
ment of the maxilla as well as intrusion of the mandibular molars.
Different methods have been proposed to counteract this muscle force and to sta-
bilize the surgica ll y di sp laced maxilla: coronoi deeto my and ptery gomasseter-
myotomy)~ Stein mann pin,S intraoral screw,10 muscle adaptation with bite-opening
appliances before surgery, ll rigid internal fixa tion,I2. 13 and the use of hydroxyapatite
blocs. 12
Compared to impaction osteotomy. augmentati on maxillary surgery was found 10
be less swble, indieming that elongation of the lower anterior face is not an easy goal
to achieve. [n adu lt patients where periodontal disease has caused loss of bony sup-
port, intrusion of incisors, in an attempt to correct a dental deep bite. might be a valu-
able treatment goal. Melsen 14 showed thai intrusion may lead to gain in bony support
and gingival attachment. In C lass II, Division 2 malocclusions the high lip line may
cause retroinclinalion of the upper incisors.1$ Van der Linden suggests changing the
vertical level of the li p line in an attempt to achieve a more stable result after treat-
ment. Changing the level of the lip line might be obtained most effecti vely by intru-
sion of the upper incisors. An important and sometimes limiting faclOr in these
patients might be the position of the apex of the upper incisors with respect to the
90 CHAPTER 5
Biomecha nkal Aspects of Class II Mecha nics
nasal floor. When there is avai lable vertical space wi thin the alveolar process. these
patients may benefit from upper incisor intrusion.
According to Burstone. 16 six principles must be considered in case of incisor or
canine intrusion:
I. The use of optimal magnitude of force and the constant delivery of this fo rce
with low·load deflections.
2. The use of the si ngle·point contact in the anterior region.
3. The careful selection of the point of force application with respect to the center
of resistance of the teeth to be intruded.
4. Selecti ve intrusion based on anterior loolh geometry.
5. Control over Ihe reactive unit by fonna tion of a posterior anchorage unit.
6. Inhibiti on of eruption of the posterior teeth and avoidance of undesirable eruJr
tive mechanics.
In growing patients where a clockwise rotation of the mandibl e is desirable.
extrusion of molars may be the treatment of choice to correct a deep bite. This can be
achieved by means of a bite pl ate, leaving the molars free to erupt. This effect can
also be achieved by means of a cervical headgear. The more the outer bow anns are
angulated upward, the more extrusion can be expected. Moreover. the length of the
outer bow arms as well as their inclination may define the amount of tipping of the
upper fi rst molar. A1though Class [] elastics may cause extrusion of the upper incisors.
they also attempt to overerupt lower molars. The use of an anchorage bend in the
upper jaw as well as in the lower jaw in combination with Class II elastics may cause
overeruption of the mol ars and may help to correct a dental deep bite. Nanda warns
agai nst the use of a reverse curve of Spee when edgewise appliances are used: there is
lack of control o f this wire in the edgewise brackets. causing undesirable changes in
the axial inclination o f the buccal teeth and flarin g of the ind sors.17 Extrusion of
molars might be fortified by means of clastics. whi ch attempt to overcrupt the molars
in both the upper and lower jaws (Fig. 5-3). To obtain this goal, the use of box elas·
tics may also be helpful.
FACTORS AFFECTING RELAPSE OF DEEP BITE CORRECTION
In a study of 26 patients, Berg'S found re lapse of 18.8% of the achieved deep bite cor·
rection . He also found more relapse of the deep bite in Class II . Di vision 2 cases.
Hellekant and L1.gerstrom l9 reported a relapse of the denIal deep bite in 19% of the
cases he investigated (n = 20). Simons and Joondephw found that proclination of the
incisors during orthodontic treatment may cause rel:lpse of the corrected deep bite in
the postretention period. They also fou nd that clockwise rotation of the occlusal plane
during treatmelll will go back toward its original cant. thereby causing relapse of the
dental deep bite. Contrary to other authors21 - 23 who foun d more deep bite relapse in
extraction cases, Simons and Joondeph.Was well as Berg l8 and Hellekant and Lager·
strom, 19 could nOl find any difference between extraction and nOllexlraction cases in
this regard.
McAIpinc 24 found that relapse o f the deep bite was correlated with the interin·
cisal angle and the lower anterior facial height. In case an interindsal angle of 125 to
135 0 was establi shed , the chances of stable correction of a dental deep bite were
found to be highest. Brachycephalic patients showed morc relapse of the dental deep
bite than others.
Gordon 2S found that intrusion of lower incisors in an auempt to correct a dental
deep bite was prone to relapse in 33% of the cases.
-------
CHAPTER 5 91
figure S-3. Check elastics according to Hocevar. (From Hocevar; Ort hodontic
force sys tems: Technical re finements for increased efficiency. Am J Orthod
81:1-1 1,1982, Fig. B .)
Ball nnd Hunt concluded lhat relapse of the overbite is primaril y due to continued
lower inci sor eruption , retroclination of these leeth, and forward rotation o f the
mandible with continued growth.26
A lthough Be nch and co-workers27 reponed that intrusion of lower incisors was
much morc diffic ult in patie nts with a narrow symphysis and casier in brachycephalic
patie nts. 0 11028 found that neither age nor facial type was statistically related to the
amount of incisor intrusion. He also concluded that more e xte mal root changes during
treatme nt arc observed for adulls than for growing children.
Burzin and Nanda 29 studied the stability of incisor intrusion in 26 patients 2.32
years post-treatment. The incisors were intruded an average of 2.30 mm and relapse
was only 0. 15 mm. The study concluded that the overbite correction by intrusion is a
stable procedure.
In conclusion, c hanging the lower ante rior facial height in adu lt patie nts due to
extrusion of molars is not a n advisable clinical procedure. According to some authors,
intrusion of lower incisors may not be the ideal treatment with respect to stability.
Some claim that the establishment of an appropriate inte rincisal angle is advisable in
an attempt to prevent deep bite relapse.
BIOMECHANICS
Prior to intrusion of a tooth , the localization of the cente r of resistance of that particu-
Inr tooth is ve ry important. As described in Chapte r I, when a force passes through
the cente r of resistance of a free body, the body translates without any tipping. This
principle also holds true for intrusion of teeth. The farther away the point of force
application with respect to the cente r of resistance of a tooth. the greate r the rotational
mome nt (Fig. 5-4). The poss ibilities of flarin g out of the upper a nterior teeth is more ,
likely 10 occur in Class II , Di vision I than in Class II , Di vision 2 malocclusions.30.31
Forintrusion of upper incisors, Melsen and associates30 and Nanda 17 suggest attaching
the intrusive nrc h to a sectional archwire (connecting the four upper incisors) distally
to the late rnl incisors. They suppose the cente r of resistance of the upper front teeth to
be situated at this a nteroposte rior level.
Intrusion Mechanics
Vande n Bulcke and associates J2 evaluated the intrusion mechanics of the segmented
arch on a macernted human skull using the laser reflection technique a nd hologmphic
interfe rome try. In a previous part of this study metal splints were used to hold the
anterior teeth ri gid to minimize individual tooth moveme nts. The number of teeth. the
poi nt of fo rce appli cation. and the magnitude of forces were the variables to be inves-
tigated. Forces we re applied directly to the splint to simulate the appli cation of an
intrusive fo rce system as suggested in the segmented arch technique according to
Burstone. 16 The objective of thi s part of thc study was to determine the location of the
92 CHAPTER 5
Fi gure 5-4. The possibilities of flaring out of

the upper anterior teeth is more likely to occur
in Class II, Division 1 than in Class II, Division
.- 2 malocdusions.
cen ter of resistance for different rigid units of the anterior maxillary dentition when
intrusive force s are applied to them.
[n a second part of the study Vanden Bulcke compared the location of the centers
of resistance determined with the splint experiment to the use of ~ec ti ona l archwires
in the upper frontal areas.J2
A first conclusion was that the number of teeth involved in a sectional arch to be
intruded was very important. Practicall y speaking, two, four, or six teeth can be
involved in a sectional wire. It appears from the experiment that the more elements
that are incorporated into the sectiional wires. the bener the control on the vertical
movement of the front unit. When only two elements were incorporated into the sec-
tional wire, control over the di splacements were not as good, especially when the
intrusive forces were applied more distall y. When four or six elements were included
CRs
r •
Figure 6-5. A V· bend positioned at the center of resistance of

the system will only cause tipping of both teeth. CR, = center
of resistance of the system . {Oemange: Equilibrium situations
in bend force systems. Am J Orthod 98:333-339. 1990J
•
CHAPTER 5 93
Biomechan ical Aspects of Class II Mechanics
a CRs
b •
Figure 5-6. The rotational moment (M) of the whole

system is the sum of both moments C1 and C2. This
effect has been visualized by the force vectors X and Y
acting on both teeth T1 and T2. (From Demange C:
Equilibrium si tua t ions in bend force syst ems. Am ,
Orthod 98:333-339.1990.)
c
d C1
C-12
•
""M
~
in the sectional wire, the results became reliable and symmetric. There was, however,
in both systems a great difference in the location of the center of resistance in the
front unit. Moreover, sectional arch wires were not found to immobilize teeth with
respect to each other. CCllain cli nici ans suggest the application of intrusive forces dis-
tal to the lateral incisors 10 avoid tipping of the incisors. This point of force applica-
tion is on ly partly corroborated by the experiments on the use of sectional wires
involving four front teeth. When one has decided to usc sectional wires that include
four or six clements, traction forces applied between the central incisors, or between
the central and lateral incisors, will be evenly spread over the teeth and will then react
94 CHAPTER 5
Biomechanlcal Aspects of Class " Mechanics
a CRs
•
b • • •
Figure 5-7. Biomechanical representation of an exchange bend

system in the Begs technique. (From Demange C: Equilibrium si t-
uations in bend force systems. AM J Orthod 98:333-339, 1990.)
c • •
d •
• •
as one unit. Still , a tendency to labial inclination must be laken into account. Thi s can
be intercepted. however. by the application of lighl intermax illary elastics or by bend-
ing the intrusion arch distally behind the molar tube.
The most important conclusions are the foll owing:
I. For an anlerior segment comprising two central incisors. the center of resis-
tance was located on a projection line parallel 10 the midsagittal plane on a
point situated on the distal half of the canines.
2. For an anterior segment that included the four incisors, the center of resistance
was silUated on a projection line perpendicular to the occlusal plane between
the can ines and the first prcmol:lrs.
3. For a rigid anterior segment that included the six anterior teeth. the center of
resistance was situated on a projection line perpendicu lar 10 the occlusal plane
distal 10 the first premolar.
4. The center of resistance of the anterior segment s incorporating two or four
CHAPTER 5 95
Biomechanical Aspects of Class 1/ Mechanics
T\ T1
a
W- CR S
•
1 0
CIG
b • • •
o
c • •
Figure 5-S. Siomechanicai representation of the utility

arch system according to Ricketts. (From Demange C:
Equilibrium situations in bend fo rc e systems. Am J d •
Orthod 98:333-339,1990.)
anterior teeth were within approximately 2 mm o f each other. However, inclu-

sion of the can ines in the anterior segment resu lted in the center of resistance
moving distally by approximately 1 premolar width (7 mm). This effect may
have been the result of the resistance of bony structures at the level of the
canines.
96 CHAPTER 5
5. No appreciable shift in the location of the centers of resistance of the various

segments studied was detected as varying magnitudes of intrusive force were
applied.
Whereas these studies referred onl y to the localization of the centers of resistance
in an anteroposterior direction, in a third pan of the study the venical level was deter-
mined as well.
This study was carried out on two skulls. The displ acement characteristics of the
dentition in both skulls were different. The results indicated, however, that the center
of resistance (for a given force system) shifted apically with the incorporation of a
greater number of teeth into an anteri or segment. Thi s phenomenon was observed in
both of the skulls tested.
Control of Reaction Forces Exerted by Intrusion Arches

III a final part of the study carried OUI at the University of Ghent, the interaction
between the reaction forces and stabilization systems during intrusion of the anterior
teeth was studied as well as its effect on the posterior unit. The success of orthodontic
treatment often depends on the control of reaction forces. In most cases reaction
forces are undesirable. and specific measures must be taken to intercept and neutralize
their effects. This is also the case during intrusion of anterior leeth. The reaction
forces generated by the anterior unit during intrusion must be neutralized by the pos-
terior units. When only the first molars in the posterior unit are affected, the reaction
forces will cause extrusion and distal tipping. Palatal tipping might be expected as
wel\.
These displacements have to be avoided for two reasons: first . due to loss of
anchorage the intrusive forces will be partl y dissipaled. Moreover, extrusion and dis-
tal tipping of the molars have a bile-opening effect that results in a lengthening of the
face and a clockwise rotation o f the mandible. These side effects must be controlled.
especially where the intrusion is carried out on patients with a skeletal open bite. Dif-
ferent methods can be used to reinforce the posterior unit. A palatal bar together with
sectional s and the application of:l high-pull headgear nonnall y prevent these sidc
effects.
The experiments have shown that palatal tipping of the first molars (created by
an intrusion arch) is small and less than expected, even with an intrusive loading of
2()() g. The influence of the headgear is predominant and induces important buccal
tipping of the first molars: it even overcompensates the palatal tipping brought about
by the intrusive arch (as long as the intrusive fo rces are not too strong). The insertion
of a transpalatal bar in the molar tube made it possible to intcrceptthe greater part of
the reaction forces.
Considering thaI in clin ical trealment heudgear forces of more than 4()() g are
applied. we should realize that the buccal component of the tmction force is not negli-
g ible and that the lranspalatal bar on ly partially neutralizes this effect. The most
important side effect of an activated intrusion urch is di stal tipping of the fi rst molars.
Because the direction of the axis of rotation is pamllel to the transpalatal bar, it is no
wonder that the introduction of the laller has very little effect on the movement. Only
the mesial component of the headgear force counteracts this reaction to some extent.
For mesiodistal stabilization of the posterior unit , the best result is obtained by the use
of sectionals connecting the second premolars and the first pennanent molars. The
experi ment confinned that the best combination intercepting all reaction forces on the
posterior unit is obtained by maximum anchorage: the use of sectionais, the inscrtion
of a transpalataJ bar between the first molars. and the application of a high-pull head-
gear. However. some distal tipping of the first molar still occurs. The shortening of
--------
CHAPTER 5 97
Blomechanical Aspects of Class II Mechanics
the outer bows of the headgear could be considered in this respect. According to
Melsen,l4 e ruption of molars as a react ive force to intrusion of anterior upper incisors
can be controlled by a bile plate covering the occlusal surfaces of the molars and pre-
molars. She believes that high-pull hedgear therapy is not a must to control the veni -
cal reaction force s of an intrusive arch.
Apical Root Reso rption and Intrusive Tooth

Movements
Dcnnaut and DeMunc k 33 studi ed the relation between isolated intrusion :lnd rool
resorption in the upper anterior teeth. Two radiographs were taken. one before the
intrusion (but after alignment) and one after Ihe intru sion. Thus, Ihe observed resorp-
tion was limited to the resorption that occurred during the ac ti ve intrusion period.
The central lind lateral inci sors of the same quadrant were adjusted on a si ngle intra-
oral radiographic film in orde r to limit the patie nt 's exposure to radiation. In this
study a precise long cone radiographi c tec hnique was used.3 4 It was found thaI dur-
ing orthodontic intrus ion resorption of the upper incisors was obvious. No difference
in resorption could be found between the cenlral and lateral incisors. However, the re
were marked d iffere nces among the incisors in the same pati e nt. The relation
between root length before and after treatment indicated a mean root resorption of
18%. When the study by Unge and Linge3~ was compared with this study, the fi nd-
ing was that intrusion seemed to cause more resorption than overall orthodontic
treatment. In thi s study no relati on cou ld be established between the amounl of api -
cat resorption and the position of the apex in relation to the nasal fl oor. Moreover.
the re was no s ignifi can t correlati on between the amount of roOI resorption and
achievable intrusion (R = 0.03 for both incisors togethe r).
Costopou los and Nanda 36 in a study on the effect of intrusion on rOOI le ngth
showed that over a 4-month period of intrusion, root resorption was 0.6 mm versus
0.2 mmfor conlrols. The amount of resorption was not found to be correlated with the
amount of intrus ion.
SUMMARY
Correction of deep overbite needs a carefu l di agnosis and treatment planning. Intru-
sion of incisors is ideal for a palient with a long vertical face and incompetent lips.
Proper application of intrusion mechanics is essential to achieve results with minimal
side effects.
REFERENCES
I. Flem ing liB: Investigation of the vertical overbite during the eruption of the pennanent dentit ion.
AngleOrthod 3 1:53-62.1961.
2. Moorrees C FA: The den tition of the growing child. A lo ngitud inal study of dental devel opmen t
between 3 and 18 years of age. Cambridge. MA : Harvard University Press, 1959.
3. Carlsson GE. Ingervall B. Kocak G: Effect of increasi ng vertical dimension 011 the InlLSticatory sylilem
in subjects wi th natura l teeth. J Prosthct Delli 41 (3):284-289. t979.
4, DeBoever JA, Adriaens PA, Seynhacve TM : tnfluence of bite raising 011 abutment teeth with reduced
periodontal support. A cli nical and radiographic follow·up study. 111 : J, Ishikawa et al., cds. Recent
Advances in Clinical Periodontology. Elsivie r Science. It V., 1988. 287- 290.
5. Dahl BL. Krogstad 0 : The effcct of a partial bite-raising splint on the inclination of upper and lower
front teeth. Acta OdontoI Scand 41 :31 1~314. 1981
6. McNamara. HA: Histologic and ce phalometric responses to increased vertica l dimension in the
mattJre face. IADR Abstract no. 372, p, 369, 1974.
•
98 CHAPTER 5
J. Bell WHo s..::heidemann GB: Correction of verti cal maxillary deficiency: Stabili ty and soft tissue
changes. J Oral Surg 39:666-670. 1981.
8. Wolford LM. Hilliard ""W: The surgical.oohodontic correction of vertical dentofocial anomalies. J
Oral Surg 39:883. 198 1.
9. Dann JJ . Crump P. Rigenbcrg QM: Venical maxillary deficiency with cleidocranial dysplasia. Diag~
noslie findings and surgical.oohodontic correction. Am J Orthod 78(5):564-574. 1980.
10. Wessberg GA. Epker BN: Surgical inferior repos itioning of the max illa: Treatment oonsiderntions and
comprehensive management. Orol Surg. Om] Moo. Oml Pathol 52(4):349- 356, 198 1.
11 . Carlson OS. Schneidennan ED: Cephalometric anal ysis of adaptations after lengthe ning of the mas-
seter muscle in adult rhesus monkeys. Mococa Mulalta. Arch Om] BioI 28(7):627-637. 1983.
12. Wardrop RW. Wolford LM: Maxillary st~bili t y following downgrnft and/or advancement procedures
with stabilization using rigid fixation and porous block hydroxypatite implants. J Oml Maxillof,lc
Surg 47:336-342, 1989.
13. Ell is E, Carlson OS, Frydenlund S: Stability of rnidface augmentati on: An experimental study of mus-
culoskeletal interaction an d fixation mcthod ~. J Om] Maxillofac Surg 47: I 062-1068. 1989.
I,!. Melsen B: Intrusion of incisors in adult patients with marginal bone loss. Am J On hod 96(3):232-241,
1989.
15. Van ocr Linden A'GM : GehlUts~roei en ge luutso rlhopcdi e. Alphen aan den Rkjn. Stalleu & Tholen
b.v., 1981.
16. Burstone CR: Deep overbi te correClion by intrusion, Aln J Onhod 72(1): 1-22. 1977.
1]. Nanda R: The differential diagnosis and treatrnem of excessi\'e overbite. Dent Clin North Am
25(1):69-84.1981.
18. Berg R: Stabi lity of deep overbitel:orrection. Eur J Onhod 5:L75-83. 1983.
19. Hellekant M. Lagerstrom L. Gleerup A: Overbite and O\'erjet t:orrection in a Class II. di vision I sam-
ple treated with Edgewise therapy. Eur J Orthod 11:9 I- I06. 1989.
10. Simons ME. Joondeph DR : Change in overbi te: A ten-year postretention study. Am J Orthod
64(4):349-367, 1973.
2 1. Ha.'iegawa M: The roentgenoccpha lon"ICtric stud y of the re lapse behavior of O\'crjet and overbi te and
its fal:lors. J Jpn Orthod Soc 42: 1-23. 1983.
22. Cole I-IJ: Cenain resu lts of ex tract ion in tl"IC treatment of malocclusion, Angle Onhod 18: 103-1 13.
1948.
23. Hernandez JL: Mandibular bil:anine width relative to overbile. Am J Onhod 56:455-467. 1969.
24. MI:Alpine JE: A comparison of overbite re l3JlSC to age. interincisal angle and lower foct height in
Class II dccpbite cases. M~ster's thesis. Lorna Linda Universi ty. 1976.
25. Gordon JB: Lower incisor intrusion in low mandibular plane angle. deep overbite cases. Master's the-
sis. UCLA. 1977.
26. Ball JV, Hunt NP: TIle effect of Andresen. Harvold and BI:SS trea tment on overbite and molar erup-
tion. Eur J Onhod 13:53-58. 199 1.
27. Bench R. Gugino C, ]'Iilgl:rs J: B io-progrl:~sive therapy. P~n 7. J Clin Onhod 12: 192:207, 1978.
28. Ono RL. Anholm JM. Engel, GA: A I:omparmive amtly~is of intrusion of incisor tel:th ach ieved in
adu lts and children al:cordin g to facialtypc. Am J Ort hod 77(4):437-446. 1980.
29. Burlin J. Nanda R: The stability of decp overbite correc tion. In: Nanda R. BUl"Stone CJ. cds. Retention
and stability. Philadelphia: W.B . Sounders. 1993.
30. Melsen B. Agerback N. Eriksen J. et al: New al\achmcntthrough pcriodont~1 treatment and orthodon-
til: intrusion. Am J Onhod 94(2):104- 11 6. 1988.
31. Demange C: Equilibrium situations in bend force systems. Am J Orthod 98:333-339. 1990.
32. Vanden Bulcke MM. DermaUl LR, Sachtleva RCL. et al: The I:enter of resistance of anterior tccth duro
ing int rusion usi ng the laS(:r renectioll tec hnique aud holog raph ic inte rferometry. Am J Orthod
90(3):21 1-220. 1986.
33. Dennaut LR. DeMunck A: Apil:al root resorption of upper incisors I:aused by intrusive tooth move-
ment: A radiographiC study. Am J Orthod 90(4):321 - 326. 1986.
34. Van de I>oel ACM. Ouinkerkc AS H: Waarom long-cone techniek? Ned Tijdsch r Tandheelk
82: 188- 194,1975.
35. Linge 80. Linge J: Apical root resorption in upper anterior tccth. Eur J Orhod 5: 173-183. 1983.
36. Costopoulos G. Nanda R:An evaluation of root resorption incident 10 orthodontic introsion, Am J
Orthod. in press.
CHAPTER
6
Canine Impaction: Diagnosis,
Treatment Planning, and Clinical
Management
Bhavna Shroff
I
-----.
CHAPTER
6
Canine Impaction: Diagnosis,
Treatment Planning, and Clinical
Management
Bhavna Shroff
realmenl of orthodontic patie nts involves the managemellt of a constantly
T changing occlusion from the early mi xed dentition to the permanent dentition.
In the majority of patients, an uneventful transition from mi xed to pennanen!
dentition occurs without tooth impaction or I:lck of tooth eruption. However, in 2% of
orthodontic patients, canine impaction occurs as a result of a dcvi:uion from the nor-
mal seque nce of de nial deve lopment I Undiagnosed and/or unlrcated impacted teeth
may result in the development of malocclusion or may cause pathology in adjacent
teeth. It is therefore important for the orthooontist 10 be able to di agnose and system-
atically manage clinically unerupted or impac ted teeth.
Diagnosis, trealment planning, a nd cl inical manageme nt of impacted canines are
discussed here with e mphasis on the biomechanical analysis. Appliances designed to
eru pt impacted canines are described along with treatment sequencing.
DIAGNOSIS
Normal Development of the Dentit ion

The normal seque nce of e ruption of the permane nt dentition has been well docu-
mented, and the nonnal pathway of eruption of canines has been determinedP The
maxillary canine is initiall y located high in the maxillary bone at the age of 3 and pre-
sents a mesially and lingually directed c rown.l Signifi calll intrabony migration brings
the crown of the canine into close contact with the di stal aspect of the root of the lat-
eral incisors . As a result of the pressure exerted by the c rown of the canine against the
roots of the lateral incisors. the four maxill ary incisors are !lared and displ ay a charac-
teristic and normal inci sor arrangeme nt known as the " ugly duc kl ing" stage. 2 The
si multaneous uprighting and eruption of the canine normally results in a spontaneous
99
100 CHAPTER 6
Canine Impaction: Diagnosis, Treatment Planning, and Clinical Management
ciosi ng of the midline spaces. The pennanent maxillary canines erupt at the dental
age of 12.4
Deviation from this sequence of nonnal development may result in impaction of
the canine. The maxill ary canine is the second most frequently impacted tooth, and
the frequency of im paction of maxillary cani nes is fi fty times greater than that of
mandibul ar c anin es. ~ The reported frequency of palatal versus buccal impacti on
varies from rales of 2: I to as high as 12: 1.fH! Palatally impacted canines do Ilot oft en
erupt spontaneously and may require surgical exposure and orthodontic extrusion.
There is, however, controversy concerning the potential of labially impacted cani nes
to erupt spontaneously in a labial cctopic position.
Etiology of Canine Impaction

The etio logy of canine impacti on has been div ided int o primary and secondary
causes,3·9 Among primary causes are the rate o f root resorption of the dec iduous
teeth . trauma to the pri mary tooth bud. d isturbance in toot h eruption sequence.
availabi lity of space in the arch. rotation o f tooth buds, premature root closure, and
canine eruption into the cieft area in cleft palate patient s. The secondary causes
include abnormal mu scle pressure, febrile disease, endocrine di sturbances, and vit -
amin D defici ency.
Clinical Evaluation
A careful clinical evaluation of patients presenting with imp:lcted canines is impor-
tant for an accurate di agnosis and proper treatment planning. Ex traoral examination
of the patient helps assess facial form and sy mmetry. The precise relationship of the
max ill ary dental midline with respect to the fac ial midline shou ld be recorded. In
cases of unil atera ll y im pacted canines, maxi llary midli ne shi fts arc com monl y
observed on the side o f the impaction. It is important to d iffe rentiate a dental mid-
line discrepancy from a true apical base midline discrepancy.l0 A fron tal cephalo-
metric radiograph may assist in detenn ining the origin of the midl ine shift and help
establi sh the presence of an apical base midli ne discrepancy. The centric relation
and centric occlusion pos iti ons should also be carefull y recorded. Midline di screp-
ancies resulting from a fun ctional shift must be differenti ated from dental or apical
base midline di screpancies. The stage of deve lopment of the den tition must be
determined in order to di fferenti ate between an unerupted canine that will most
probabl y erupt on time and an unerupted canine that is delayed in its eruption.
Delayed eruption of the permanent canine after the age of 14 years strongly sug-
gests th at the tooth may be impacted.9 Retention of the deci duous canine past the
normal age of ex foliati on is al so a sign for impacti on.9
The overjet/overbite re lationship should be delennined, and an evaluation of the
arch fonn and symmetry should be done cl inically and on the models. Spacing of the
maxillary anterior teeth with or without a mid line shift is often observed in the pres-
ence of bil aterally impacted maxi llary canines. Di stal tipping of the incisors away
from the midline is an indication of prox imity of the cani ne crown to the lateral
incisor root. In the absence of a retained primary canine, the space between the lateral
incisor and the first premolar may be reduced because of mi grati on of adjacent teeth .
The soft ti ssue examination incl udes palpation of the maxill ary vestibule and
palate. The right and left sides are compared in cases of unilateral impaction. Soft ti s-
sue palpation allows the clinician to evaluate elevations of the soft tissue of the palate
or the labial mucosa and assess the presence of the canines if they are not deeply
impacted in OOne. Radiographic examination confi nns {he clinical diagnosis and indi-
cates the precise location of these teeth.
- ---- - - ---- - -
CHAPTER 6 101
Cani ne Impaction: Diagnosis. Treatment Plann ing. and Clinical M anagement
Radiographic Evaluation
Radiographic eV:lluat ion of the dentition is an excelle nt tool in the diagnosis and
locali zation of impacted can ines. Pe riapical radi ographic film s of unerupted/impacted
maxillary permanent canines arc useful in determining the presence of foot resorption
of teeth adjacent to canines. A number of radiographic methods are available to the
clinician to evaluate the position of impacted canines. The use of two or more radi-
ographic techniques which ex plore di fferent planes of space for a more accu rate
assessment of the position of the canine is recommended. Periapical radiographic
film s have traditio nally been used to assess thc position o f impacted teeth. Whe n
usi ng the tube-shi ft tcchnique, o r C lark's rule, two peri apical radiographs o f the same
tooth are taken with different ho ri zontal JXlsi ti ons of the tube head. If the impacted
tooth moves in thc same direction as the lUbe head, the tooth is consi dered to be lin-
gually positioned. If thc movement of the tooth is in the opposi te direction , the tooth
is conside red to be buccally positio ned. I I The angu latio n of the x-ray tube can also be
varied verticall y by approxi mately 20" when taking two successive periapical films.
In this case. the buccal object moves in a direction opposite the source of radiatio n
(buccal-object rule).9 Pe riapical radiographs are also useful in assessing the presence
of root resorption of the adjacenttccth, lhe ir periodonta l status, and root proxi mity.
To detennine the bucco-ling ual pos ition o f impacted canines, occlusal rad io-
graphs are usually ta ken. Occl usal radiographs give a good indication of the horizon-
tal orientation of the canine and the positio n of the crown and apex relati ve to othe r
teeth. One problem encountered in evaluating these radiographs is the JXlssible super-
imposition of the canine o n adjacent teeth. Panorami c radiographs arc oft en taken
during routine clini cal exami natio n, and their diagnostic value in paticnts presenting
with impacted canincs has been explored but is still controversial. !2 Althoug h it is
clear that the panoramic radiograph will give on ly limited infonnmion about the
bucco-lingual positio ning of the tooth, it has been recently documented that the rela-
tionship of the canine c usp tip to the dista l half o f thc root of the lateral incisor may
be a good predic tor fo r palatal impactio n.!3 The avai lability o f fronta l and la teral
cephalo metric film s for Ollhodontic palie nts makes these radiographs attmctive for
diagnostic purposes. The frontal cephalometri c mdiograph assists in evaluating the
bucco-lingual JXlsition of the canine as well as its bucco-li ngual axial inclination. Thi s
information helps in the assessme nt of the severity of the impaction and is imponant
for treatment planning and identification of the force system necessary to correct the
malocclusion. Also. the frontal cephalometric radiograph he lps to determine the rela-
tionshi p of the canine to the incisors. The lateral cepha lo metric radiograph is used to
eval uate the mesiodistal incli nation of the can ine a nd the vertical distance the canine
must be e rupted to be a lig ned in the arch. This information is c ritical for proper treat-
ment planning a nd applia nce desig n.
TREATMENT PLANNING
The timing of intervention is critical and is based on a careful assessment of the stage
of development of the dentition. The precise diag nosis will lead to the development of
a prioritized problem list and we ll-defined treatmcnt objectives. S urgical exposure of
the II.! to ~ of the crown of the canine is ofte n indicated in order to place an attach-
ment on the crown of the tooth. Generally, an o nhodontic attachment is bonded to the
crown of the canine a nd replaced with a conventio nal o rthodo ntic bracket o nce the
entire crown of the c;mine is erupted. The surgical tcchnique selected will depend o n
the vCllical position of the canine and the amount of surrounding gi ngiva. For labially
placed canines, gi ngivectomy is usually indicated whe n the tip of the impacted canine
102 CHAPTER 6
Canine Im pact ion: Diagnosis, Treatment Plann ing, and Cli nical Management
is near or coronal to the cemento-enamel junction (CEJ ) of the adjacent lateral incisor
and a wide zone of attached gingiva is present. 15 If there is not sufficient attached gin-
giva. an apically positioned flap shou ld be performed. This techn ique is usually used
for canines located apically 10 the CEJ of the adjacent teeth.l4
The flap/closed eruption technique is indicated when the tooth is very high in the
vestibule near the nasal spine. 14 For palatally placed canines, surgical uncovering of
the tooth is indicated as soon as enough space has been created in the arch for the
tooth's eruption.
Careful sequencing of the different stages of treatment must be done to efficiently
erupt the canine and bring it into place in the arch. It is usually helpful to obtain good
buccal occlusion and open up sufficient space for the canine to erupt into before
active extrusion of the canine is initiated. An adequate anchorage unit will then be
available to erupt the canine with fewer undesirable side effects.
BIOMECHANICAl ANALYSIS
M ethods Used to Erupt Impacted Canines and

Associated Undesi rable Side Effects
Placing a Straight Wire in a High Buccal Canine or a Palatal Canine. Eruption

o f high buccal canines has been achieved using a number of different techniques.
Chain elastics or clastic threads are used to deliver a single erupting force to the
canine and are attached directly to a main archwire that bypasses the canine. These
techniques introduce significant side effects. such as tipping of the adjacent teeth if
the main archwire is defl ected, and provide only poor control of the movement of the
can ine. This appliance design also has a high load deflection rate due to the rapid
decay of the force delivered by the elastic and the necessity of using a very rigid arch-
wire to avoid deflection.
The placement of a continuous wire into the bracket of a high buccal canine is
made possible by incorporating loops into a stainless steel wire (0.0 16 stai nless steel.
for example) or by using a multi strand wire to decrease the load deflection rate.
Superelastic wires are able to withstand great deflections without significant pcnna-
nent defonnation and can be placed directly into the bracket of a high, unerupted buc-
cal canine. Careful analysis of the force system between the brackets of the canine,
premolar. and lateral incisor shows that the eruption of the canine is achieved with
significant and predictable side effects on the adjacent teeth (Fig. 6--IA).14 Tipping
forward of the premolars and tipping back of the lateral incisors are observed simulta-
neously with their intrusion. creating an open bite in the cani ne region. A vertical
elast ic. often used co ncurrently to avoid the bite opening in the canine region,
requ ires good patient cooperation (Fig. 6- 18).
One approach to limiting these side effects is the use of a heavy stabilizi ng arch-
wire that bypasses the canine and an overlaid superelastic wire to erupt the canine.
The canine bypass archwire is used to connect the teeth on the arch and forms a rigid
stabi li zing anchorage unit. Canine bypasses are stepped out to the buccal in order to
avoid any interferences with the erupting canine. Superelastic wire is overlaid on the
main archwire and tied directly into the bracket of the canine, as in Figure 6-28 . By
using a canine bypass archwire. it is possible to distribute the undesired forces and
moments to a larger number of teeth and therefore minimize the cli nical side effects.
Palatally impacted canines have traditionally been moved into the arch with elas-
tic chains or elastic threads extending from the canine to the main buccal archwire. A
palatally impacted canine needs movement in two directions. An eruptive force is
104 CHAPTER 6
Canine Impaction: Diagnosis. Treatment Plann ing. and Clinical Management
Figure 6-3. Schematic representation of the maxillary arch form.

force system generated when a palatally positioned canine is moved
buccally using an elastic traction to a buccal archwire that may
deform .
J
/
Figure 6-4. Clinical example of a palatal canine erupted on

overlaid superelastic archwire. A rigid canine bypass archwire
is used to control the undesirable side effects on the anchor-
age unit.
Figure 6-5. Force system necessary to erupt a high Figure 6-6. Desired force system to erupt a
buccal canine. high buccal canine at equilibrium.
is a single extrusive force applied to the canine (Fig. 6-5). To achieve this force sys-
tem, a single force is applied to the canine using a cantilcver. The posterior teeth
experience a tip-forward moment and an intrusive force as the canine extrudes (Fig.
6-6). From a fronta l aspect, the canine tips linguall y as it erupts because the extrusive
force is applied buccal to its center o f resistance (Fig. 6-7A ). Simi larly, the posterior
teeth will tend to tip buccally (Fig. 6-78).
Appliance Design. Lever rums or cantilevers are useful in the delivery of a single extru-
sive force to the canine, and a poin! contact force "pplication assures that no momen! is
CH APTER 6 105
Canine Impaction: Diagnosi s. Treatment Planning. and Clinical Management
Figure 6-7 . Schematic representation of

the side effects associated with canine
eruption: A, the canine tips lingually as it
erupts; B, the molar tips buccally.
B L
B l
A B
produced at the bracket. Cantilevers made of 0.017 x 0.025 inch memory alloy wire
(T.M.A. wire, ORMCO Corp.• Glendora, California) are extended from the auxil iary
tube of the first pcnnanent molar and attached to the bracket of the canine with a liga-
ture wire. The wire is not placed directly into the bracket in order to obtain a point con-
tact of force application (Fig. 6-8). A force of 25 g to 30 g is necessary to extrude the
can ine. The anehorJ.ge unit feels a tip-forward moment and an intrusive force. The
anchorage unit can include the posterior teeth or can be extended to the entire arch. In
this case, a heavy stainless steel archwire (0.019 x 0.025 inch) stepped buccal to the
canine to :lVoid interference is utilized. When only the posterior teeth are used for
anchorage, a buccal segment (0.019 x 0.025 inch stainless steel) is placed into the poste-
rior tccth on the side of the arch with the unerupted cuspid. The flallening of the poste-
rior occlusal plane resulting from the tip-forward momen\ on that side is carefully moni-
tored and controll ed at every appointment. When canines are unerupted bilaterally.
headgear can be used to control the flattening of the posterior occlusal plane. nle use of
a canine bypass archwire allows the undesirable side effects to be distributed to a larger
number of teeth, minimizing their clinical effects. This approach is therefore recom-
mended in most cases. Palatal arches can also be used for stabili zation of the buccal seg-
ments. The lingual tipping of the canine as it erupts helps to correct its labiolinguaJ posi-
tion and is therefore desi rable.
Figure 6-8. Clinical example of a high buccal canine erupted with a cantilever extending
from the molar auxiliary tube. A. The cantilever is activated; B, the cantilever is in place and
the canine is erupted .
106 CHAPTER 6
Canine Impaction: Diagnosis, Treatment Planning, and Clinical Management
Palatal Canines
, Desired Force System. When canines are impacted palatally, they need to be erupted
and moved buccally. The application of an erupti ve force on the canine is associated
at equilibrium with an intrusive force and a tip-forward moment on the posterior
teeth, as described previously. In the transverse plane, as the canine erupts it has a ten-
dency to be displaced lingually, and the posterior teeth move buccally because the
vertical forces experienced by the canine and the posterior teeth are applied buccal to
their centers of resistance. The buccal tipping of the canine is obtained by applying a
single buccal force to the bracket. As the canine moves buccally, the molar tips lin-
gually and simultaneously rotates mesial-in (Fi g. 6--9).
Appliance Design. Cantil evers extending from the buccal aspect of posterior teeth
have been advocated to erupt palatally impacted canines. Jacoby5 described the bal-
lista spring, a 0.014, 0.016, or 0.01 8 inch round stainless steel wire that engages both
the headgear and edgewi se buccal tubes of the maxillary first molar in order to avoid
any rotation of the wire. The anchorage unit includes a transpalatal arch connecting
the first molars and premolars on both sides of the arch. A simpler design uses a can-
tilever extending from the auxiliary tube of the fi rst molar crossing the occlusal sur-
face and attaching to the canine, as shown in Figure 6- 10. Initially, an extrusive force
is applied to the can ine. and a buccal acti vation can be added as soon as the canine is
adequately extruded. The anchorage unit includes a transpalatal arch to stabilize the
posterior segments and a canine bypass archwire made of 0.01 9 x 0.025 inch stainless
steel extending to all the teeth in the arch. This helps to control any mesiolingual rota-
tions of the anchorage unit.
Figure 6-9. Force system necessary to move a

palatal canine buccally at equilibrium .
Figure 6-10. Clinical example of a

palatally impacted canine erupted with a
cantilever extending from the auxiliary
tube of the molar.
CHAPTER 6 107
Canine Impaction: Diagnosis, Treatment Planning. and Clinical Management
Figure 6-11. Palatally impacted canine erupted with a cantilever extending from a soldered
tube on the palatal arch. A. Cantilever activated; B, cantilever tied in place.
Figure 6-12. Example of bi late ral palatally

impacted canine erupted with a buccal cantilever
and a palatal cantilever, respectively.
When canines arc impacted very high in the palate and access is difficull from the
buccal, cantilevers ex te nding from the palatal arch can be used. Cantilevers made of
0.017 x 0.025 inch SS or me mory alloy are e ngaged in tubes soldered to a 0.036 inch
stainless steel palatal arch or directly welded on a palatal arch (Fig. 6-IIA and B).
They are used primarily to extrude the canines and are replaced with a buccal can-
tilever as soon as the canines are adequately extruded.
Cantilevers extcnding from the buccal aspect of posterior teeth or from the palatal
arch may be used simultaneously when indicated (Fig. 6-12). A canine bypass arch-
wire is extended to all the tccth in the arch for anchorage, and the cantilevers are tied
with a ligature wire to the canine attachment to assure a point contact force applica-
tion.
SUMMARY
The orthodontic manageme nt of buccally une rupted and palatally impacted canines is
challengi ng and represents a significant number of the cases treated in orlhodontic
practices. Carefu l diagnosis is critical to the adequate timing of treatment and possible
surgical intervention . The development of treatment and mechanics plans must be
based on the careful analysis of the clinical situation and identification of the correct
force system necessary to obtain the desired tooth movement. Appliance design is
developed according to the treatment objcctives and the desired force system.
108 CH APTER 6
Canine Impaction: Diagnosis. Treatment Planning. and Clinical Management
REFERENCES
, I. Bass T: Observalio n on lhe d isplaced uppo!r canine 1000h. Dental Practitioner 18:25, 1967.
2. Broadbe nt BH: Ontogenic development of occlusion. Angle Onhod 69(4):371 -387, 1976.
3. M oye~ RE: Handbook of Onhodontics, 2nd ed. Ch icago: Year Book Medical Pu blishe~ Inc, 1963,
pp.83-88.
4. Proffit WR with Field HW: Contemporary Onhodontics, 2nd ed. SI. Louis. MO: Mosby Yearbook
Inc, 1993. pp. 56-86.
5. Jacoby H: 11te " Ba ttista Spri ng" syste m for imp;aeled teeth. Am J Onhod 75(2): 143- 151, 1979.
6. Jacoby H: The e tiology of maxillary canine imp;actions. Am J Orthod 84(2): 125-132, 1983.
7. Gali lis R. Joho J- P: Parodonte marg inal de canines sup(!rieures inc luM:s: Evaluation suite a dilTt:ren tdi
methodes d'accb c h irurg ical e t de syst~me ort hodontique. Rev Mens Suisse d'ooont o-stom3 tol
88:1249-1261. 1978.
8. Fourn ier A. Turcolle 1. Bernard C: Onhodontic considemtions in the lre~tmcnt of maxillary impacted
canines. Am 1 On hod 8! :236-239, 1982.
9.- Bi shara SE, Kommcr DD, McNeil M it ct al: Management of impacted canines. Am J Ort hod
I I :223-24 1. 1941.
!9- Nanda Ii, Margolis MJ : Trca tme nt strategics for mid line discrepancies. Scminars in Orthodont ics
2:84-89, 1996.
II. Ewan GE: Loc at ing impacted cusp ids using the shift lcdmiqllc. Am J Onhoo 41:926-929, 1955.
12. Ericson S, Ku ro l1: R3d iographic examination of ectopically erupting m3xillary ca nines. Am , Onhod
9 1:483-492.1 987.
13. Lindauer SJ. Rubens tein L K, Hang WM, ct al: Canine impaction identified early with panora lnic
rad iographs. ' ADA 123:91. 1992.
14. Kokich VG. Mathews DP: Surgical and orthodontic management of impacted teeth. Dental C linics of
Nonh America 37:2,1993.
15. Smith RJ. B u~tooc CJ: Meehanics ofloolh mo\·enlCllI.A II1 J Onhod 8.5(4):294-307. 1984.
CHAPTER
,
7
The Role of Headgear in Class II
Dental and Skeletal Corrections
Raymond Siatkowski
here is no q uestion that headgear forces need to be used in conjunctio n with all
T conte mporary mec hanothe rapy modaliti es for the highest quality and most sta-
ble correctio n of Class II maJocclusions. Thi s chapter is devoted to ex plaining
and justi fyi ng the above statemenl.
PREVALENCE AND TREATMENT INDICATIONS,

MODALITIES, AND GOALS
The prevale nce of vari ous occl usio ns in adolescents in the Un ited Slates is shown in
Table 7- 1 from the most comprehe nsive study of this subject. Although Class U rela-
tionships comprise nearly o ne third of lhe occlusio ns in U.S. adolescents, most o rtho-
dontic practitioners in lhe United Stales have Class II patients as a majority of their
practices. Practices located in areas in which no no rthodontiS1S arc treating substantial
numbers of o rthcxlontic p<lti ents have up 10 80% of their practices treating Class 1\
maloccl usio ns. It is commo n experi ence to li nd that the majo rity of C lass II pat ients
being treuted by orthcxlontists involve a deep overbite as pa rt of the presenting con-
stellation of sympto ms.
Ind ications fo r Class II Treatm e nt

The indicati o ns for Class [I deep overbi te treut me nt are de lineated in Figure 7- 1.
Most of those ind icat io ns a lso apply to C lass 11 malocclu sio ns witho ut deep over-
bites. Treatment o f C lass II malocclusions resul ts in the su bstant ial improvemen t
in patient esthetics, speci fi cally in a lleviating convex profi les and smile li nes that
109
110 CHAPTER 7
The Role of Headgear in Class II Dental and Skeletal Corrections
,
Table 7-1. Prevalence (Ages 12-17)
Class I 53.5
Class II 31.5
Class II I 13.8
Ove~et 7+ mm 8.0
Overbite 6+ mm 10.3
Openbite 2+ mm 2.3
Severe crowding 32.5
Posterior crossbite 3.0
3+ teeth
From McLain JB, Proffitt WR: Oral health statu s in the United States:
Prevalence of malocclu sions. J Dent Ed 49:391, 1985
exhibit excessive tooth structure or gingival ex posure. In treating deep overbite

patients. practitioners have the clinical impression that once the deep overbite is
corrected, the mandible is free to fully express it s horizontal growth component.
That impression is particularly strong when treating C lass II , Division 2 patients.
Correction of Class II malocclus ions often has concurren t prevention of long-term
periodontal damage, panicularly when there is trau matic occl usion from the lower
incisors into palatal tissue. bu t al so in patie nt s without ante rior lip seals with
mouth breathing. Correct ion o f Class II maloccl usions often results in occlusal
fu nctional improvement , especi:tll y in deep bite patients with excessive anterior
guidance. Correction of Class II malocclusions in patients with severe overjets
allows them to achi eve sealed lips durin g swallowi ng. and in many patients is
accompanied by spontaneous reversal of tongue-thrust swallowing patterns, espe-
ciall y in those in earl y adolescence at the end o f treatment. Another indication for
correction of Class II malocclusions is to achieve contact between the incisors in
cen tric relation. Thi s is 11 major indication for treating these patients in the late
mixed dentition because 90% o f maxi ll ary incisor traumatic tooth fractures occur
in patients with severe overjet in thi s age group. Speech can be improved fo r these
patients as well. Such improvement s arc limited to correction of lisping the frica-
tive sounds "S" and "Z."
• Esthetics
Profile
Smile
• Freeing growth inhibition of the mandible
Class II, Division II
• Prev9fllion olloog· term periodontal damage
Lower incisors into palatal tissue
• Occlusal functional improvements
Anterior guidance excessive
• To achieve lip seal
• To achieve maxillaryfmandibular incisor contact
Impact load distribution in tra uma
• Speech Improvements
Fricatives
Figure 7- 1. Indications for Class II deep overbite treatment.

CHAPTER 7 111
The Role of Headgear In Class II Dental and Skeletal Corrections
Treatment Modalities
Many possibilities are available for treating Class /I skeletal and/or dental relation.
ships. Most approaches use several methods because the various combinations have
varying probabilities for long·term stability of the Class n corrections achieved. [n no
particular order, the treatment possibilities are:
I. Inhi bit maxi llary growth.
2. Redirect maxi llary growth.
3. Move the maxilla distally.
4. Stimu late mandibu lar growth.
5. Allow nonnal growth to ex press clini call y by removing dentoalveolar com-
pensations.
6. Steepen occlusal plane.
7. Translate maxill ary posteriors distally.
8. Tip maxillary posteriors distally.
9. Retract maxillary anterior teeth after (7), (8), or extractions.
10. Protract mandibu lar posterior teeth after ex tmctions.
I I. Hinge the mandible.
a. Clockwi se.'" opened (lower face height increases. and Class II apical base
di fference worsens).
b. Counterclockwise,'" closed (lower face height decreases, and Class JJ apical
base diffe rence im proves).
The treatment modalities available for stable correction of Class II maloccl usions
are outlined in Figure 7-2. Again, most of the concepts presented in the fi gure are not
confi ned to deep overbi te Class II malocclusions. Spec ific treatment mechanics
referred to are covered later in this chapter or in other chapters in this text. Speci fi c
plans for individual patients fall into four major categories: growing patients. non.
growi ng patients, horizontal discrepancies, and vcrt ical disc repanc ies. as shown in
Figure 7-2.
Treatment Goals
There arc two primary trealment goals fo r the stable correct ion of Class /I maloccl u-
sions. The fi rst goal is to fl atten the occlusal plane during treatment. The second goal
• Growing pati ents

Class II relationship (horizontal discrepancy)
Use mechanisms and mechanics that take advantage
of differenti al growth
II crowdi ng dictates extraction treatment. use
differential mechanics
Deep overbite (vertical discrepancy)
Intrude anterior's
Erupt posteriors
Combination 01 posterior eruption and anterior Intrusion
• Nongrowing patients (little or no growth expected)

Class II relationship
Orthognathic surgery
Uniarch eXl ractions
Differential mechanics if crowding dictates elClraction in both arches
Deep overbite
OI1hognath ic surgery
Intrusion of anteriors (posterior elltrusion invariably relapses)
Figure 7-1 . Treatment modalities for Class II deep overbites.

112 CHAPTER 7
• The Role of Headgear in Class II Dental and Skeletal Corrections
i s to hinge the mandible closed during treatment. Both goal s contribUie to OVCl1rcat-
me n! of Class II relationships and the refore contribute to the stability of the fi nal
treatment result.
Occlusal Plane Control. A crit ical trealment goal in C lass II correction is 10 nallen
the canl of the occlusal plane. Occlusal planes should nOI be steepened whe n these
patienlS arc treated because steepened occlusal planes surely relapse. Relapse of any
natte ncd occlusal plane is IOward C lass III buccal segment relationships. This is
desirable overtreatment. Relapse o f any steepened occlusal plane is toward Class II
buccal segment relationships. This is hardly desi rable treatment. Many appliances are
promoted to the profession that steepen the cant of the occlusal plane during Class n
correction. A large number of these approaches produce rapid correction of the Class
II occlusal relationships by rapidl y steepening the occlusal plane (Fig. 7-3 ). Unfortu-
nately, clinical experience has shown that mpid changes secured by short-te rm simple
mechanics tend to reverse spontaneously. Among the studies that have shown the
untoward effects of steepening the occlu sal plane in C lass II treatment is a particu-
larly well-controlled one by Douglas. 1 In thi s study pati ents who had C lass II inter-
max illary forces appli ed by tied-in coil springs (patient cooperation was therefore not
an issue) had cephalometric radi ographs just before application of the Class D springs
and just at the end of spring application. Even though all patients had occipital head-
gear forces, the Class II intermaxillary springs steepened the occlusal plane in all of
them. At the e nd of retention, all patients had occlusal pl anes that returned to the orig-
inal cant (prior to appl ication of intermaxillary spring forces) but at different levels.
Therefore, there is a large risk of C lass 11 correction relapse in treatment modalities
that use such approaches. Other modalities used in C lass 11 treatment s ignificantly
steepen the cant of the occlusal plane. If one uses a headgear whose force is occlusal
to the center of resistance of the arch. such as a cervical headgear without a raised
outer bow, the cant of the occlusal plane is steepened. Using appliances that distract
the condyles---either fi xed or removable- when not used in conjunction with occi pi-
tal headgear steepens the cant of the occl usal pl ane, as Tcuscher2 has shown so well .
If onc looks at patient treatment reports in the literature that have superimposed
cephalometric tracings. one invariabl y sees steepening of occl usal plane cant when
these appliances are used in treatment without occ ipital headgear. Such appliances
have another relapse factor when they arc used for Class II correction : the creation of
dual bites. When the condyle is di splaced forward. one can have fibrou s connective
ti ssue proliferating in the poslCri or joint space. The mandible cannot be retruded, even
Figure 7-3 . Class II molar corredion achieved via

steepening the cant of the ocdusal plane.
CHAPTER 7 113
Table 7-2 . Comparison of Herbst and Cervical Headgear Treatment Results

Insignificant Significant
Stable Relapse Relapse
Herbst 31 % 36% 33%
Cervical HG 69% 18% 13%
with the patient under general anesthesia. The skeletal Class U correction appears to
be complete and stable. However, a signifi c<llu percentage of these patients have grad-
ual resorption of the proliferated fi brous connective tissue within six months after
anterior traction is removed, and the condyle reseats in the glenoid fossa. With the
condyle returned to its position in the fossa, some, if not all , o f the Class 1I skeletal
correction revens. 3
Fid letl studied 84 grow ing patients whose Class II correction was achieved using
extraoral fo rce in the form of cervical headgear. Complete records included records
frolll 8.5 to 32.8 years out of retention with a mean of 14.0 years. J oo n de ph 's~ sum-
mary of Fidler's data in comparison to the data of Pancherz6 is shown in Table 7-2.
Relapse in the cervical headgear patients can be attributed to steepened occlusal
planes as well as to clockwise rotation of the mand ible during thi s treatment. Rever-
sion of steepened occl usal planes toward their original cants produce relapse of Class
IJ interocclusal relationships. The 13% significant relapse rate with cervical headgear
reported by Fidl er can be reduced to in signifi cant levels with a more appropriate
choice of the direction of extraoTal force, avoid ing the steepening o f the occl usal
plane, as will be discussed later.
M andibular Hinging. The second primary goal in treating Class \I malocclusions

is to hinge the mandibl e closed. Counterclockw ise mandibular rotat ion improves A-B
discrepancies . Hinging the mandible open worsens A-B discrepancies. as shown in
Figure 7-4 in exaggerated fo nn. Ir the indi vidual Class " patient has a counterclock-
wise growth tendency, as do the majority of patienls, any cloc kwise hinging of the
mandi ble during treatment tends to relapse. The mandibular plane returns toward or
FiBura 7-4_ Effect of hinging the mandible open.

114 CHAPTER 7
beyond its original cant (but at a different level). This was shown by Douglas,1 amo ng
others. If the individua l patient has a clockwise mandibular growth pattern, o nc would
not want to hinge the mandible open for esthetic reasons: the increase in venicai
dimension is usually unacceptable in these patie nts. Again. if the patient has a C lass []
apical base relationshi p, that relationship is worsened when the mandible is hinged
open. A corollary 10 these statements is that for treatment results to be Slable, for
patie nts with flat mandibular planes and deep overbites onc either keeps the same
face, correcting the deep overbite wholly by an terior intrusion. or performs onhog-
nalhic surgery. The heavy vertical occ lusal forces generated by the bulky vertical
musculature in these patients invariably reintrudes posterior teeth extruded concomi-
tant with any mechanotherapy thaI inc reases lower face heigh!.
BIOMECHANICS
The force systems (see Fig. 7- 10) a headgear is capable of delivering arc simple. A
headgear can deliver o nly a net single, simple force. A force is a vector quantity, hav-
ing both a magnitude and a direction. It has a poim of application. in addition, it has a
line of action. A basic property of a force 7• 1Q is that its effect on a rigid body is the
, same as if il is applied anywhere on its line of actio n (see Figs. 7-5 and 7...{j). To
dete mline the effect of the headgear force that is being applied, one merely needs to
examine the line of action of the force (after the headgear strap is attached 10 the outer
bow) w ith respect to the body to which the headgear force is being applied--e.g .•
tooth, arch, or max illa. Figure 7- 7 shows an occi pita l pull headgear in place. Figure
7-8 de mo nstrates thar the strap's pull- the force 's li ne of ac tion-is well above the
center of resislance of the max illary fi rst molar (the patienl has a 0.016 inch stainless
steel intrusion arch in place: the headgear force is being directed o nly to the maxillary
first molars). At the maxi llary first molar's center of resistance, the headgear force
• .J....-- --~=~~~-------- Uneofsclion
r
Point of application
Figure 7-5 . F01'ce.
50,
Fipre 7-6. Equivalent forces: along same line of action.

•
CHAPTER 7 115
Fi,ure 7- 7. A< OCcipital-pull headgear. B, Facebow typically

used with occipital pull.
system has a di stal componCnl, an apically directed vertica l component , and a large
rOOI-distal moment. The reader interested in further elucidation of thi s method is
referred to the excellent paper by Contasli. ll
If one uses a combination headgear, the situation becomes somewhat compli -
cated. One has to apply vector addition in this situation. Vector addition is accom-
plished by resolving the force along its line of action into its components along the
hori zontal and venical axes, as shown in Figure 7- 9. An example o f doing so is
shown for Class II elastic force to the maxillary arch in Figure 7- 10. Figure 7- 11
shows vector :Iddilion of two forces. This addition is accomplished by adding the hor-
izontal components o f each force to fi nd the net horizontal component o f the resultant
force and by adding the vertical components of each force, then adding them to find
the net vertical component of the resu ltant force. Figure 7- 12 shows parallelogram
addition of combi nation headgear force components.
Force Constancy
An overview of the biologic activity that results in tooth movement after a force sys-
tem is applied is shown in Figure 7-13. It is well known that the rate of tooth move-
ment is a function of the stress in the periodontal li gament: a schematic is shown in
Figure 7- 14. However, it is not known whether a constant force system produces
more mpid tooth movement than an intcrmittent force system. Ccrtainly clinical expe-
Filure 7-8. A. Occipital-pull headgear. close-up view. 8. Occipital-pull headgear. intraoral view.
116 CHAPTER 7
................................
Fi,ure 7-9 . Re solving a force inlo ils
components along axes of interest.
Fsine
~~----------------------~-------+x
F cos e
Resoille Class II elastic F into its H and V components relatille to occlusal plane:
Fh
-
!::::~ OP
I
o
o
o
o
10°
Fh = 90 cos 10° = 90(0.985) '" 88.6 9
FII .. 90 sin 10· " 90(0.174)" 15.69
I •••••••••••••••••••• FII
90, One-sixth of the applied force is extrusille
The patient now opens her mouth 10 mm:
Fh
Fh = 104 cos 21 ° '" 104(0.934) '" 97.1 9

o
o Fil a 104 sin 21° '" 104(0.358) = 37.3 9
o
I • • • • • • _. __ • • • • • • • • • • • FII
104 ,
Over one-third 01 the applied force is extrusive
Figure 7-10. Example of resolving a force into its components.
y y y
--- ...... j
••
Figure 7-11 . Vector addition.
CHA PTER 7 11 7
Figure 1-12. Vector addition of occipital

and cervicall'leadgear forcrs.
The force systems applied to teeth exist in quasistatic

equilibrium with their investing tissues.
Applied force system
!
POL stress distribution
Figure 1-13. Overview of tooth movement. ! triggers
Bone remodeling processes
Force levels change
Moment levels change
MlF may change
!
Tooth displacement
L !
Some deactivation 01 the wire's
applied force system (but the wire
always remains in equilibrium)
Necrotic ct\anges
in PDt..
AlUre 1-14. Rate of tooth movement as a func· ~

/
tion of stress in the periOdontal ~gament resulting ...
from an applied force system . (From Quinn RS,
Yoshikawa 0+( : A re~t of fOfce magnitude
in orthodontics. Am J Orthod 88(3):252-260,
1985.)
\
Stress
opt
Threshold (vory low)
CHAPTER 7 139
prospecti ve studies using di fferent mechanotherapy approaches. John ston has shown
that the results of tremment are similar both qu:mtitutively and quali tatively, although
individual cases, of course, can show remarkable changes (t hose pmienls wi th phe-
nomenal inherent hori zontal mandibular growth that expresses).
For patients requiring anterior intrusion. the recommended force levels are shown
in Figure 7- 39. These values are lower than those originall y proposed by Burstone28
and arc based upon the work of Demlaut 29•30 and long-tenn cl inical experience. The
author has seen no radiographic evidence of apical root resorption (or stunting of root
apexes in young patients with incomplete root formation) when these force values are
used for intrusion.
The results that are reliably achi eved in skeletal Class II patients in the late
mi xed dentition are shown in Figure 7-40. The figure shows the results after the first
phase of treatment. Phase I appliances consisted of a mandibular li ngual arch, pas-
sive and resting upon the mandi bular incisor cingula, maxillary fi rst molar bands.
brackets on maxillary incisors. and occipital pull headgear with short and high outer
bow at the level of 12 hours each night. Because of the severe fl ari ng of the maxi l-
lary incisors. very light clastic wear was instituted each night at the beginning of
treatment (when only the headgear was worn) to lip those incisors lingually. After
2 1n months, an intrusion arch (Fig. 7-4 1) was placed. Thi s archwire remained in
place until the e nd of phase I of treatme nt 8 11'2 mo nths later. At that time, the
mandibul ar lingual arch was left in place. and a max ill ary Hawley retainer was
placed awaiting fu ll eruption of the permanent dentition. Thi s was followed by a
short phase 2 for fi nal alignment. Phase 2 was followed by the usual 2 years of reten-
tion. using the reg im en outlin ed above. In mi xed dentiti o n pati ent s usin g thi s
approach. if the Class II and overjet correction had not been completed at the time
intru sion had been completed, the intrusion arch would have been deactivated to
hold the corrected incisor vertical level. the outer bow lowered slightly. and a cervi-
cal strap added so that the resultant headgear force would pass through the max il la's
center of res istance.
The approach used with thi s class of patients is a relatively short phase I treat-
ment during which Class II malrelationships are corrected as well as overjet and deep
overbite, if needed. There is a period of retention until the full pennanent dentition, at
which time a short course of full appliance therapy is instituted. Following phase 2,
the nonnal retention regimen is inSliruled.
Suggested Force Values
Intrusion Per Tooth To/a/(m/) Hsadgea'

..!l.!... 10-15 9 2()-3Q 9 Occipital-
Figure 7-39. Recommended intru-
sion !()fee values.
12 11 2 t 4C>-<lO g
antarior to CRES
~ 15-25 9 25-50 9 t
""""i"f1 5-10 9 10-20 9 Cervical-
anterior to CRES
'"2"1T21
3]"3
t
15-25 9
20-40 9
t
2>-00 9
118 CH ....PTER 7
rience indicates that intennillent fo rces can be very effi cient indeed. Witness, for
example, the effecti veness of finger- and thumb-sucking habits in moving teeth and
bone in patients with these aberrant habits. Clinical experience demonstrates that
headgear wear need not be 24 hours a day to be effective. Depending upon the results
required, intennittent wear at the level of 12 to 14 hours per night-sometimes as
much as 16 hours per night and tit times as lillie as 10 hours per night-is sufficient to
achieve specific treatment goals.
Center of Resistance
It is well accepted now that one must know the approx imate location of a body's cen-
ter of resistance in order to choose the applied force system to affect the tooth, seg-
ment, arch, or skeletal movement des ired in treatment mechanics. Experimental deter-
mination of res istan ce ce nte rs beg:ln in th e earl y 1970s at the Universit y of
Connecticut. 12 This initial work used double-exposed laser holography (Fig. 7- 15) to
measure load-displacement characteri stics of a ten-times scale model of a maxillary
central incisor root (Figs. 7- 16 and 7- 17) to generate data for finite element simula-
tion and for calculation of its center of resistance. The results of that initial work indi-
cated that the resistance center of a maxi llury central incisor is approximutely 0.25 the
distance from the marginal ridge to the root apex, u di stance far less apical than was
thought at the time (and that continues to be repeuted in much of the current li tera-
ture). More recently, there has been activi ty at several academic centers applying vari-
ous experimental and fi nite element techniques to determine the locations of centers
of rcsistance.n- 18 Tanne'sl6 work confi nns the origi nal projection for a central incisor,
placing the center of resistance at a location 0 .24 limes the distance from the marginal
ridge to the root apex. A corrected version of his results is shown in Figure 7- 18.
These results are verified by a previous cl inical study"20 which demonstrated that the
CW Holography System Schematic Diagram
He . N& Laser ,,-- Variable Segmented
[=~~~~~~;~:t::::::==",,~'r~:':m~. ~;:".
Front _ fl
. :'---...; .. ~
./ Mirror
Front Surface
Surface UI
Mirror
/
Spa'j a~
F~t&r
Spatial
_ } Filte!"
Fl&ferlll1C& _
Boam
v&rticaJly Mounted
I em Calibration
Scale on Movable
Moom
Figure 7-15. E.perlmentat configuration.

CHAPTER 7 119
,
1. 1"ooIh"BoK
2 . Val18ble Weighl
3. Air SuspensIon Table
". PeriOdOntal Ugamem Simulating SiIkxlne
5. DerlI8I Stone
6. Pre<:IaIon SuppoIting Rod (4 places)
7. Preellion Localing Plale
6. Tighlenk\g Scr_ (" places)
9. I()): idealized Tooth (Root) Model G :::'- - "
10. Compenaaling Weigh!
I I . Mleroposl1loner
12. FIIctIonIHs Pulley (3 placel)
Fi8ure 7- 16. Schematic of tooth model.
location of the resistance center for a central incisor at 0.24 times the distance cor·
rectly predicts the center of rotation for lingual uprightin g of incisors due to late
growth changes in indi vidual subjects longitudinally. The results of all the studies are
summari zed in Figure 7- 19 and Table 7-3. These new values can explain cl ini cal side
effects heretofore attributed to other causes (cf. Melsen21 ).
CLINICAL APPLICATIONS OF HEADGEAR FORCE
There are four mai n uses of headgear force in contemporary treatment of Class II
malocclusions:
1. Anchorage control.
2. Tooth movement.
3. Onhopcdic changes.
4. Controlli ng the cant of the occlusal plane.
Anchorage Control
In Class II extraction treatment, headgear force can playa major role in ensuring that
buccal segmenttecth do not move mesially when anteriors are retracted. It can form a
major component of differential mechanics for Class n correction.
120 CHAPTER 7
Figure 7-17. A, Horizontal force being applied via a proving ring. B, Photograph of
double-exposed hologram with typical fringe pattern due to an intrusive force.
In a more general sense, headgear force is used to control the side effects of intra-
oral mechanics. Intraoral mechanics orten result in eruption of teeth. An erupti ve
force appl ied to a molar is shown in Figure 7-20A. Such side effects arc seldom
des ired. The side effect force tends to extrude the molar. and the moment of the
force--expressed at the center of resistance of the tooth-produces a root-buccal,
crown-lingual moment, tending to tip the molar crown into lingual crossbite. Apply-
ing an occipital headgear force. whose line of action is shown in Figure 7- 20B. pro-
duces a vertical intrusive component of force that negates the vertical extrusive force
of the side effect even though the headgear force is not upplicd continuously. This
vertical forc e is usually of a much higher force level than the force of the side effect.
Note that the line of action is determined aft er the headgear strap has been applied to
the outer bow. and the outer bow has denected to its resting position. Inner and outer
bows can be any shape. convolution. and length. One needs only to see the angle and
CHAPTER 7 1 21
y ... 9.6 il'l mm

(C ROT -C RES '" 9.6)
,, 30
,,
r
,l~
C ROT al Apex (conlro11ed tipping)
T ,
~
13.0 C IIOT for M . 0 (pi.lra F at bnlc;kel)
l C~ ~
j /
CFW;)T al ± - (UlIJ1sla lion)
- - --- --- -- ,,----- -----------------

10
(-~ lIpping1
-fl.)--.....-"""i
. ,,
' .5 ,
-25 -20 - 15 ~ , -<
j , -M
-) ,,
' .0
i C~T at bracket / ,, 5
" " 20 25
, (mm)
.M.
,
---
(lingual
root movemenl) ,,
,. , , C~, Resuttil'lg
-"
-"
M L
"
Y
- 9.6
-0.0 "
APEX ., CO<1troiled
Tipping
-9.6 ,. • Translation
,
- 20 - 11.3 Bracket • Lil'lQual Root
M~"
Figure 7-18. Tanne's results '~orrected.
level of the fin al line of action after the strap forces have been applied to know
exactly the force of the headgear system.
Assuming one has a a cooperative patient, the headgear can also be used to main-
tain first molar widths and, therefore, buccal segment widths from any buccolingual
side effect forces from intraoral mechanics. Thi s approach can be used in lieu of a
transpalatal arch in cooperati ve patients when the headgear force is req uired for other
reasons.
Tooth Movement
In Class II patients. if onc adjusts the level of the outer bow such that a horizontal
force is produced that passes through the center of resistancc of the maxillary fi rst
molar, nnd the patient wears the headgear at a level of 14 hours each night consis-
tently, clinical experience shows thai the fi rst molars will move distally 2 mm in 24
months without tipping. The author prefers not to use di stal tipping forces to achieve
di stal movement becuuse of the high localized stress levels at the marginal ridge and
at Ihe root apices. Finite clement studies have shown thai the stress levels at the peri-
odontal ligament-bone and tooth interfaces arc beyond acceptable physiologic limits
even when tipping force s are very light. IS If the line of action of headgear force is
adjusted so that there is a vertical component tending 10 intrude the molar. as shown
in Figure 7- 208, the heudgear force tends to prevent extrusion from intraoral side
effects. If, however, the line of action of headgear force has an ex trusive vertical com-
ponent, the molar will extrude, independent of the individual patient 's skeletal pat-
tern, unless there is a large intrusion force from the arch wire on the molar. Th is situa-
tion is not usual in intraoral mechanics.
122 CHAPTER 7
MomenVForce tor Translation
/
1
Maxillary Maxillary Maxillary
Central
Incisor
Lateral
Incisor Tfl Canine
17.0
1.-
13.0
~- 1
-t~ .f.
-
1 "'--"/"\ 9.'
4 .2
i
9.7
1I
T ~)+
59" loOP: MIF = 8.2
~
4-
9.0
35
--'-
63G to OP: M!F = 7.7
10.0
~,,/ •
79~
1
4'5
to OP: M!F = 9.4
Maxillary Mandibular Mandibular -t~---~~~4''-

First
Mol"
Central
Incisor
First
Premolar
1
8.5 \ f
-I
'.5 t ~J-
14.0
83.5 to OP: MIF = 8.4

G
71 ° to OP: M/F = 7.6
l v
87.8 to OP: M!F .. 8.6
Q
Mandibular
First
Molar
t
7.5
(7, 4•
•
t
t _I
'.5
14:0/1U
8O.5 G to OP: M!F . 8.4
Figure 7-19. Location of centers of resistance for individual teeth.
Orthopedic Changes
If the headgear force is applied through the center of resistance of the maxilla, which
has been determined to lie at the apical level between the maxi llary premolars,22 and if
a preadolescent patient wears the headgear at least 12 hours each night (at least 14
hours each night for adolescent patients), the forward component of maxillary growth
is redirected. Tracings of patients in nearly 20 years of solo fu ll-time private practice
using cephalometric radiographs with constant magnification typically show the
responsc given in Figure 7- 228. Occasionally, especially in patients who wear the
CHAPTER 7 123
•
Table 7-3. Moment/Force Ratios Required for Translation
Tooth Bracket·Center of Inclination to M / F for
Resistance Distance (mm) Occlusal Plane (0) Translation (mm)
M 1 9.6 59.0 8.2

A 7.7
2 8.6 63 .0
X
I 3 9.7 7B.6 9.4
L B6.1 8.6
4 8.6
L
A 5 8.6 BB.B 8 .6
R 8.5 B3.5 8.4
y 6
7 7.6 92 .2 7.6
M 8.0 71.0 7.6

A 71.0 8.4
2 8 .9
N
0 3 10 .3 84.0 10.2
I 8.6 B7.B 8.6
4
8
U 5 8.6 84 .2 8 .6
L 80.5 8.4
6 8.5
A
R 7 7.6 68.6 7.1
M / F FOR T NSLATION
21 12 8.0 8.8 653 356
8.8 6543 3456
8.6 76543 34567
321 123 8.4 8.5 65 56
8.2 765 567
21 12 8.0 9.1 653 356
9.0 6543 3456
8.6 76543 34567
321 123 8.8 8.5 65 56
8.2 765 567
Reprinted with permIssion from Siatkowski RE ~ system analysis of V-bend sliding mechanics. J C~n Ofthod
28(9) ;543, Table 2. 1994
headgear at the level of 16 hours a night, the redirection is in a posterior direction. One
should note that the lotal magnitude of growth has not changed, only its direction.
Controlling the Cant of the Occlusal Plane

A major use of headgear force is to control the cant of the occl usal pl ane. Specifically
in Class II patients, headgear force is used to fl atten the occlu sal plane for reasons of
posttreatment stability. Examples of this use are presented later in the chapter.
124 ~ CHAPTER 7
~
'.......••••.....••
'. '.
.,..
' . '.
'. '. ' . ,•
'. '. '
'"
F F F
(side elfact)
A B
Figure 7- 20. A. Vertical force on molar tube, a side effect from intraoral mechanics. B, Vertical component of occipital headgear force
Ilegates elrtrusive intraOtal fOtee side effect.
Applications
Seq/lemial Steps for Applying Headgear Forces. Seven sequential steps may be used
in logical sequence to design the headgear force system for any onhodonlic applica-
tion:
I. First, determine the center of resistance of the body to which the headgear
force is being appli ed, whether tooth or segmen t or arch or maxill a (Fig,
7- 23).
2, Then determine the force system through the center o f resistance thai will pro-
duce the changes desired. One thinks of the force and moment at the center of
resistance:
a. Horizontally (A-P).
A, F, It"
,,, "
................. •• ...,
• ••••• •
F,
A B
Figure 7- 21. A. Horizontal compo nent through the molar's center of resistance can produce distal transla.
tion. B, J·Hook headgear force, applied to malrillary archwire to produce anterior intru sion and flattening of the
maxillary occlusal pl ane (not recommended).
CH APTER 7 125
Orthopedic Changes
........ ~
NL ... '
•NL
Expected Change of ANSChange

A B ANS with Growth Achieved
Figure 7-22. A. Force through center of resistance of the maxilla, B, Typical red irection of maxiliMY growth at ANS as seen on cranial base
superimpositions.
Determine the Location of the CAES:
"-.J \
I
• Tooth
\
1"- ~
/
V (J\ (\
Figure 7-23 . Center of resistance for an
individual molar, segment, or the maxilla.
• Segment
II /
-';
)
I~ ~ )
,~
.~~
~I
Maxilla
\J
j
126 C HAPTER 7
Example: Steepen QP, Erupt, and Prevent Mesial Movement
4000 glmm
..... --
't:~~;;"''''_:;. '\ \..ine o~ "·
L_...!:'=~'==='I'=20=~mSmi==::~:::::::::OO"""""
.....c ...... ..
•
Equivalent Force System althe CRES
Figu re 7-l4. Example of a commooly used (although not recommended) force system: cervical headgear with
low outer bow. Headgear force is shaded. The eqUivalent force system at the center of resistance is in black. The
same coding is used in all figures that follow.
b. Vertically.
c. Cant of occlusal plane.
d. How far from the center of resistance should the force be applied? In other
words, how important is the magnitude of the moment compared to the
magnitude of the force?
As an example (Fig. 7-24), suppose one would actually want to steepen an occlusal
plane, erupt the un it. and prevent mesial movement of the unit. Schematically, the unit
could be ei ther a tooth, segment, arch, or maxilla. A cervical headgear with a low
outer bow generates a large moment about the center of resistance that will tend to
steepen the occlusal plane. The vertical component of the headgear force acting at the
resistance center will erupt the unit. The distal component will tip the unit distally.
3. Mentally mark the cente r of resistance on the patient's check.
4. Choose the type of pull :
a. High pull (occipital).
b. Cervical.
c. A combination of (a) and (b).
d . Interlandi. One has more options for force direction with thi s appliance, but
because it is not fail-safe, "snap-a-way," it is not recommended.
5. Bend the outer bow angulation and adjust its length to deliver the desired line
of action after the strap force is applied. Examples of thi s step are given later.
6. Choose the applied headgear force magnitude:
a. In rotating the unit- that is, using a large moment in comparison to the
<lppl ied force through the center of resistance----one shou ld use low strap
forces to avoid high local stress in the periodontal ligament (150-200 g per
side).
CHAPTER 7 127
b. If the line of action of the headgear force passes close to or through the
unit's center of resistance, 400 to 500 g per side can be used.
7. Monitor for changes as treatment proceeds. Adjust the force line of action and
force magnitude as necessary.
An example of occipital headgear use to control the occlusal plane and prevent
side effects from maxillary incisor intrusion is given in Fi gure 7-25. The headgear
force is applied well away from the molar's center of resistance to generate a large
counterclockwise moment, negating the clockwise moment from the intrusion arch.
The outer bow is bent high and is cut short to provide the desired line of action. If
using a 0.016 inch stainless steel intrusion arch, 60 g will be generated at the midline
if the wire is activated 90" just mesial to the fi rst molar tubes when a single helix is
placed in that position. The author routinely places such an intrusion arch with 45° of
initial activation and then adds another 45 " intraorally with a Tweed-loop plier at the
patient's next visit. If the patient has a maximum anchorage Class U maloccl usion,
the angulation of the outer bow can be lowered and the headgear force increased to
400 to 500 g per side. The result will be a larger horizomal distal component of force.
The higher force with a line of action closer 10 the tooth 's center of resistance will
result in the same counterclockwise momelll as in the previous example.
One should never see molars tipped back or the anterior face bow level dropping,
with the outer bow adjusted such that the line of action is wel l above the center of
resistance. If such tipping (or anterior face bow dropping) is observed, the outer bow
can be adjusted to a higher angulation.
Designs
There are two main possible designs for applying headgear forces, as illustrated in Fig-
ure 7-26: One can hook a J-hook headgear to the arch wire. This approach is limited in
lhat one is restricted to one point of force applic:ltion (wherever one can nook the J-
hook). In addition, the li ne of action must pass through the hook itself. A far more flex-
ible approach is 10 place the headgear in a tube on a jX>slerior tooth. Having an inner
bow and outer bow allows adjustment of the length and angulation of the outer bow to
provide many possible points of anachment and lines of action. There can be many
Figure 7-15. Occipital-pull h~adg~ar althe level of 12 hours per night (10 hours per nighl lor consci·
entious adults) to control side effects from maxillary incisor Intrusion via a base arch.
128 CHAPTER 7
t . J-Hook onto An:;hwire 2. Facebow to Tube on a Posterior Tooth

Angulation and Ieogttl adjustment of outer bow allows
___
•••
__
.~
_.'.';~. ~=,~__.
many possible points of anadlment and lines 01 acti on:
. ~
Steepens
Eruptive
OP
_________ . .- - . RanenSOP Adjust outer bow angulation

~
•
Intrusive
Limited to one point of force application (the hook)

Line of action must pass through the hook
Figure 7-26. Possible headgear designs.
directions of force , ond therefore mony different M/F ratios opplied. This design is
more comfonable for patients to wear, and archwires are not prone to fraclUre.
Examples
Maxillary Headgear
Cen,jcal PI/II. Figure 7-27 illustrates, usi ng the same schematic diagram and coding
as in previous exmnples, three possibilities for applying cervical pull to a maxi llary
uniL The example at the top of the figure has the outer bow low. The equ ivalent force
system at the unit's center of resistance has an extrusive component, a di stal compo-
nent, and a large moment that tends to steepen the occ lusal plane. As mentioned
before, such a force system is rarely. if ever. desired. The middle example shows the
outer bow adjusted such that the headgear force line of action passes through the
unit's center of resistance. The equi valent force system at the unit's center of resis-
tance has an ex trusive and distal component and no momen!. The example at the bot-
tom shows the outer bow of the cervical headgear adjusted high such that the head-
gear force li ne of act ion passes distaito the unit's center of resistance, The outer bow
wou ld have to be long to allow this configurati on. The equi valent force system at the
unit's center of res istance has a large extrusive component, a distal force component.
and a moment that tends to nanen the occlusal plane. This configuration can be used
for Class II growing patients with deep overbites and adequate freeway space when
overbite correction is planned for via posterior extrusion.
CHAPTER 7 129
The Role of Headgear In Class II Dental and Skeletal Correction s
/
......... 1•
y•
Figure 7-27. Cervical-pull headgear e~amples ,
Occipital Pull. Figure 7-28 gives schematic illustrations of headgear incorporating

occipital pull . The figure at the top shows occipital pull wi th the shon outcr bow
angulated hi gh to create the headgear force line of action that is far anterior to the
unit's center of resiSlance. This results in a force system at the unit's center of resis·
wnce with a moment that tends to flatten the occlusal plane and distal and intrusive
force components.
The second figure from the top shows an occipital pull (with the outer bow
longer) such that the headgear force 's line of action passes through thc unit' s center of
resist:mcc. There is no moment generated about the center of resi stancc and therefore
no change in the cant of the occl usal plane. In trusive and di stal components of the
force are acting.
The third figure from the top i[[ustrates a combination of occipital and cervical
pu[[ to a shon outer bow angu lated upward such that thc net force 's line of action
passes through the center of rcsistance. Again, thcre is no moment acting to change
the cant o f the occlusal plane, and there is a pure distal forc e passing through the cen·
ter of resistance. This configuration is typical for redirecting maxil lary horizontal
growth in Class 11 patients and/or to move maxillary molars distally via translation.
When force is applied to a headgear with inner and outer bows, one side effcct is buc·
cal expansion component of forces, which act bilaterally. Thi s side effect is o ft en
helpful in Class U malocclusions because it is often necessary to expand the postcri-
ors to maintain proper intercuspmion as the buccal segment Class II interrelationship
is corrected. If such ex pansio n is not necessary, it can be prevented by usin g a
tf'..lnspal mal arch.
The bottom figure illustrates an occipital pull with a long outer bow. The equi va-
lent force system at the unit 's center of resistance has a moment that tends to steepen
the occlu sal plane and a force with intrusive and distal components. Such a system
might be necessary for Class U open bite patients.
130 CHAPTER 7
Fi gure 7-28. Examples of headgear incOf1)O(ating ocdpital pull.
It is often necessary to correct mesial-in rotation of first molars during Class n

correction. This can be accompli shed by an active transpalatal arch (TPA) or by
adj usting the angle of insertion of the inner bow ends into the headgear tube to effect
rotational change. mesial -out and di stal-in , in the transverse plane of space while
effecting desired changes in the sagittal plane.
Asymmetric Headgear. Right versus left asymmetries in molar relationships can be

corrected by using transpalatal or lingual arches to correct asymmetric molar axial incli-
nations. The same mechanisms can be used to correct asymmetric molar rotations. How-
ever. if the buccal occlusion is asymmetric. e.g.. Class J on one side and Class J] on the
other side. without asymmetries either in molar axial inclinations or in rotations. then it is
most logical to achieve the correction with asymmetric headgear.U24 Distal forces exist
on both sides. bUl they are three times greater on the long outer bow side than on the
soort outer bow side (Fig 7-29). Lateral forces. directed toward the short outer bow side,
exist with this headgear. One must therefore watch for crossbite development. It is usu-
ally best to stop using this mechanism if crossbile development begins to occur.
CLINICAL EXAMPLES
Four main categories of treatment types are presented here. Keeping in mind the fo l-
lowing: "It is human nature to pick out the slUnning successes of a method and to
overl ook the day in, day out losses that grind you down 10 the bone" (William eck-
hardt!.'! ), the author has chosen cases that represent fairly typical and reliable results
achi eved throughout his years of practi ce.
C HAPTE R 7 131
Typical Measurements'
Headgear Force (F)

250 g1side
LEFT D istal Force

375g (75%)
RIG HT Distal Force

125 9 (25%)
Latera l Force
60 g (12%)
' Data from Hershey HG. at al: Unilateral face-bows:

A Ihooretical and laboralory analysis. Am J Ofthod
79:229-249.1981,
Figure 7-29. Asymmetric ~adgear forces. (From Haack DC. Weinstein S: Tke me<hanics of centric and e<centric cefVical
traction. Am J Orthod 44(5):346.1958)
1, Nonextraction Class II Headgea r Treatment in the Permanent Dentition

at Peak Growth
[n thi s category of patients (Fig. 7-30), a combination of occipital and cervical pull
with the facebow's short outer bow angulated occi pitally is used from the beginning
of treatment to direct a distal force at or above the center of resistance of the max ill a.
If the mandibul ar arch is well ali gned, a mandibu lar lingual arch is pl aced to maintai n
alignment and, primarily, mandibular incisor ven ical level by having the passive lin-
gual arch rest on the cingula o f the mandibular incisors. If the mandibular teeth are
not well aligned, bonded brackets are placed as required. The recommended general-
ized mechanics plan is as follows:
I. Intrude max illary canines, if needed .
2. Intrude maxillary incisors, if needed for esthetics.
3. Perform other ali gnment corrections while continuin g the Combi headgear
force system at the level of 14 hours each night while holding the corrected
levels of the max illary anteriors.
For the patient shown in Figure 7-30, the appliances used were a mandi bular
lingual arch, maxill ary first molar bands, and maxi ll ary incisor brackets. The
required incisor intrusion was accomplished in fi ve months, after which a passive
max illary archwire was placed while continuing combination headgear wear at the
level of 14 hours a ni gh t through the remainder of treatment. After incisor intru-
sion was completed, buccal segment teeth erupted into the intermaxil lary growth
space that ex pressed itse lf du ring the treatment. There was no mandibu lar hingi ng,
and the occ lu sal pl ane was flattened. For relenti on, th e lin gual arch was rece-
mented, and a maxi llary Hawley retainer was placed to be worn full time for six
months, fo llowed by sleep-time wear for 18 months. Headgear wear is /l ot rou-
tinely continued as part of the retention plan .
2. Class II Treatment Involving Extractions in the Permanent Dentition

If Ihe arch peri meter is so inadequale in both arches thaI extractions are necessary,
differential mechanics can be applied with combin ation headgear wear for a full Class
132 CHAPTER 7
The Role of Headgear in Class /I Dental and Skeletal Corrections
1(.1-
8
Figure 7-30. None~traction Class II cClfTection via Combi head-

gear at peak growth VelOCity. A, Cephalometric superimpositions.
A B. Selected cephalometric changes.
II corrcction. Asymmetric mechanics are facilitated by asymmetric extractions, i.e.,

maxill ary first premolars and mandibu lar second premolars. Four fi rst prcmolars were
extractcd for the patient shown in Figure 7-3 1. A gencrali zed mechanics plan for such
patients is as follows: (I) If the maxillary canines are not fully erupted, extractions
can be perfonncd at the beginning of treatment. Otherwise it is recommended to delay
extractions if possible unti l deep overbite correction has been completed, if such cor-
rection is planned by genuine intrusion. (2) Arter incisor intrusion has been com-
pleted, using a mandibular lingual arch to maintain lower incisor level if those teeth
arc not bracketed at the beginning of treatment, the extractions are then perfonned
and differential mechanics applied. i.e., rctr.lct ion of maxillary anteriors and protr.lC-
lion of mandjbular posteriors. Combination headgear wear is continued throughout
treatment to enhance max illary posterior anchorage (at the level of 12 hours a night).
If growth redirection of the maxilla is required. the level of wear requested is at least
14 hours each night. The advantage of this approach is that usually one has excellent
headgear cooperation at the beginning of treatment (when the patients are most enthu-
siastic). The use of headgear is critical during intrusion mechanics to negate the molar
root-mesial, crown-distal side-effect moment from anterior intrusion.
For the patient shown in Figure 7- 31. the occlusal plane was flattened, although
there was some hingi ng open of the mandible during treatment. Retention was the
routine previously stated. For deep overbite pati ents requi ring intrusion- if intrusion
is the first step in treatment- prior to extractions and differential space closure the
CH APTE R 7 133
o
Figu,.. 1- 31 . Class II correction via Combi headgear and differential me<hanics with edractions in both arches in the permanent den-
tition. A. Buccal ocdusion at beginning of treatment. B, Buccal occlusion at end of retention. C, Cephalometric superimpositions. D.
Selected cephalometric changes.
vertical level of the corrected incisors needs to be held during space closure. This is
accomplishcd by using a passive archwire that is placed in the fi rst molar auxiliary
tube. stcpped gi ngivally around the buccal segment teeth, then stepped occlusally into
the incisor brackets (Fig, 7-32A). Buccal segment space closure can proceed by what~
ever mechanics are most appropriate using the main lUbe of the fi rst molar for buccal
tooth archwire placement.
Conversely, if incisor intrusion is perfonned following differential space closure,
134 CHAPTER 7
an archwire is placed through all buccal teeth, stepp::d gingivally around the incisors,
and the intrusion arch placed in the first molar auxi liary lube (Fig. 7- 32B). With this
approach, because the incisors do not have brackets while canine retraction is under
way, the patient is warned that incisor spaces will open. (One wi ll also see some
incisor retraction. by tipping, due to transseptal fibers during canine retraction.)
If mandibular incisors aneVor canines (always separately) need to be inlruded for
a patient with a deep mandibular curve of Spec (with good max illary incisor smile
esthetics), the author uses a two-wire setup as in Figure 7-32B. The intrusion force is
kept very low (20 g or less at the midline), and intrusion proceeds very s lowly (1/4 to
1.1. mm/month). T he posterior vertical force and counterclockwi se moment have small
enough magnitudes to be dissipated among the posterior teeth without untoward side
effects. The fru strations with side effects from reverse curve of Spee archwire for so-
called leveling, so well elucidated by McDowell ,31 are avoided. (The concl usion that
one wait unt il growth is completed before attempting deep overbite correction may be
justified for reverse curve of Spec "mechanics," but certainl y not when using intru-
sion mechanics.) In contradistinction 10 other methods of leve ling, intrusion mechan-
ics have the ad vantages of not fl aring mandibular anleriors, nol increasing arch
perimeter requirements,32 and not changing buccal ax ial inclinations (which usually
begin fine in thi s situation), and they do not create molar open bites.
3. Adult Class II Camouflage Treatment

Occasionally one is faced wi th a malocclusion that one would prefer to treat surgi-
call y, but the patient refuses surgical intervention. The author is willing to perform
uniarch extraction camouflage treatment for these patients, with wamings given as to
the less-than-desirable profile treatment outcome, utili zing prediction tracings. The
patient shown in Figure 7-33 is such a case. The on ly appli ance in the lower arch was
a lingual arch between second premolars with premolar segment wires in place to pre-
vent li rst premolar eruption into the maxill ary extraction sites. In the maxillary arch,
bands were placed on the lirst molars and brackets on the second premolars and
canines. Combinati on headgear wear was instituted at the level of 12 hours per night
and continued unti l the linishing stage of treatment. The patient was then referred for
extraction of impacted third molars and maxillary firs t premolars. Two months of pre-
liminary bmcket alignment were fo llowed by 61,.5: months of maxillary canine retrac-
tion. At that time, brackets were placed on the maxillary incisors, and maxi ll ary
incisor intru sion was accomplished in 5 months. The maxi llary incisors were then
retracted, a process that required 5 Y.:. months. Headgear was stopped, and 5 months of
fini shing followed.
lncisor retraction was accomplished using a 0.0 16 x 0.022 inch archwirc with ver-
Fi gure 7-32. A. Intrusion accomplished prior to extractions. B< Intrusion after space dosure.
----- --~~~. - -.
CH APTER 7 135
tical loops fonned j ust distal to the Imeral incisors (Fig. 7-34). The vertical legs arc 8
mm in height. and the helices have a diameter of 3.5 mm. T his is the wire used in
0.018 x 0.025 inch brackets. Activalion is I mm every fi ve weeks. The archwire is
fonned from stainless steel straight wire, with the addition of an anterior lingual rool
torque. Inherent MIF muo from such a configuration can be mUlhemalicall y derived
from Castigliano's theorem. The equation for the deri ved MIF ratio, derived by the
author and D.C. Haack, is shown in Figure 7-35. The advantages in usi ng Cas-
tigliano's theorem in deriving such an equation is that the loop design can be optimized
based on the dimensions of the loop. For a praclicalloop height of 8 mm, the equation
predicts MIF ratios shown in Figure 7-36. For a vertical height of 8 mm. a loop diame-
8.'
8.L.
ill,·"',. D
+.
Figure 7- 33. Class II camouflage treatment in an adult. Maxillary
first premolar extractions. A, Buccal occlusion at beginning of treat·
ment. 8, Buccal occlusion at end of retention. C, Cephalometric
~
C ______________-J superimpositions. D, Selected cep halometric changes.
136 CHAPTER 7
ter of 3.5 mm with one helix at the apex is chosen. One can also use Castigliano's theo-
rem to derive the load-deflection rate. This was done by Haack in 1963, as shown in
Figure 7- 37 for 0.0 16 X 0.022 inch stain less steel wire. If one is using 0.022 inch
brackets, it is necessary to use two helixes at the apex to obtain an identical load-
deflection rate, as shown in Figure 7- 38 for 0.018 X 0.025 inch stainless steel wire.
Activation would be I mm at each 5-wcck visit. If the archwire were reactivated more
frequently or if the reactivation were greater than I mm every 5 weeks, the lingual TOOt
movement moment could nOI express fully. and net lranslation of incisors would nol
ensue. Should this occur inadvertently, the archwire can be left in place after space clo-
sure to act as a lingual root-torquing archwire; better yet would be an anterior root
spring 10 more quickly achicve lingual root movement.
The MJF ratio inherent with Ihi s loop is barely al the range that would produce
controlled tipping. This is the reason for placing the add itional lingual rootlorque in
the inci sor segment of the wire. Such lingual 'root torque and the placement of the
loop just distal to the laLCral incisor do tend to produce an extrusive force on the ante-
rioTS, which tends to express itself as maxillary occlusal plane steepening because of
the inherent vertical stiffness of the archwire (even with the vertical loop in place). [f
occlusal plane steepening is noted during treatment monitoring, the outer bow of the
headgear can be raised and the cervical strap discontinued to generate a maxillary
occlusal plane fl attening moment.
4. Mixed Dentition Class II Treatment

There has been a gradually developing consensus among practitioners thai beginning
treatment in the lale mixed dentition is ideal for IUOSI Class 11 patients. This has cer-
tainly been the author's experience. Even though one is not treating at peak growth
Figure 7-34. Incisor retraction archwire.
F~
Figure 7- 35 . M / F for vertical loop w ith
/ by Siatkowski RE,
apical h eli xes. (Derived
Haack DC, 1991 )
M \e M
M H2 + HRNIt + 2R2
T " 2H + NR It 12 F(2H + NR It)
CHAPTER 7 137
10 STO H .. 8mrn
n = l loop
9 D = 3.Smm
6
E ..;,'..::.:~:
§.
~I~
5 . -..--- ---
4
H. loop HT (mm) . •
(0 " 3.5, Loop '" 1)
3
O. Loop ClAM . (mm) . - -- . .
2 (H = 8,Loop ;; 1)
n. No. of LOOPS . ". . .•

(H = 8, 0 = 3.5mm)
0 10 12 14 16
4 6 6
I I I I
0 2 3 4
I I
0 2
Figure 7-36. M / F for vertical loop with apical helixes: graphical data.
500 H. Loop HT (mm) . •

(0 = 3.5 mm, LOOPS .. 1)
D. Loop ClAM. (mm) • - - - ....

400
STO H",Bmm (M ::8, LOOPS . 1)
n = 1loop
~ D.,3.5mm n. No. 01 LOOPS . '. •
~
300 (H = 8, Oa 3.5mm)
.~
~ RELATIVE INFLUENCE
= H ~ N>:>D
~ 200
.s .016 x .022
100 e __
&.
---- -- ...
....... . .
------
.......... . .
2 4 6 6 10
o 2 3 4
Figure 7-37. Load-deflection rate for vertical loop with apical helix in 0 ,016 x 0.022 irlCh
stainless steel wire.
138 CHAPTER 7
The Role of Headgear in Class /I Dental and Skeletal Corrections
600
H. Loop HT. (mm) . •
500 O. loop OIAM (mm) . - -- ..
n. No. 01LOOPS • ...... •
• 400
'""
~
STO H =8mm
300 n = 2 loops
~
O = 4mm
~
~
~ 200
e. RELATIVE INflUENCE
H >N> O
100
.. ..
------•...
• ~ ..::.:.:.."'" ... .0 18" x .025"
0
0 2 4 6 8 10
I I I I
0 2 2 3 4
o 2
Figure 7-38. Load·deflection rate for vertical loop with apical helixes in 0.018 )( 0.025 inch stainless
sl eel wire.
velocity. there seems to be a growth-freeing effect when treatment is instituted at this

age, resulting in two relatively short phases of treatment.
At this age. patients are moti vated to cooperate and have developed sufficient
dexterity to deal with all of the appli ances. One feel s bener about correcting severe
ovetjets to avoid the sequelae of lr.Juma to maxi llary incisors in this age group. There
does seem to be a net shorter duration of active treatment most commonly experi-
enced. In the fi rst phase of treatment, correction of the Class 1.1 relationship, overjet,
and any deep overbite is planned. The author plans on a maxi mum duration of 18
months for phase I treatment, whether or not full correction is achieved. Ln the ovcr-
whelming majority of cases, the treatment is accompli shed in far less time than 18
months. o rten within 9 months. A max illary Hawley retai ner is placed, without head-
gear wear, betwcen phases, and a short course of phase 2 treatment for any tOOlh and
axial inclination ali gnment corrections is instituted when ull permanent teeth mesial to
the fi rst molars have erupted . Phase 2 is carried out until second molars are erupted
and aligned.
Tulloch.26 in her thorough review of all orthodontic Class II growth literature.
concludes that orthodontic treatment influences on the growth of Class II patients
remains insufficiently known. Clinical evidence from the approach used herein argues
otherwise, although the mechanotherapy may just be allowing nonnal mandibular
growth to occur. Certain ly, as shown by Johnston ,27 there is little to choose between
various mechanotherapies on the net effect o f annual mand ibular growth. If growth is
stimulated, it seems to be done so eq ua ll y by headgear mechanotherapy and
approaches using condylar di stract ion. There is an obvious need for randomized
CHAPTER 7 139
prospective studies using different mechanotherapy approaches. John ston has shown
that the results of trealment are similar both qU:lOtitutively and qualitati vely, although
indi vidual cases, of course, can show remarkable changes (those patients with phe-
nomenal inherent hori zontal mandibular growth that ex presses).
For patients requiring anterior intrusion. the recommended force levels are shown
in Fi gure 7-39. These values are lower than those originally proposed by Burstone28
and are based upon the work of Demlaut 29•30 and long-tenn cl inical experience. The
author has seen no radiographic evidence of apical root resorption (or stunting of root
apexes in young patients with incomplete root formation) when these force values are
used for intrusion.
The results that are reliably achi eved in skeletal Class II pati ents in the late
mi xed dentition are shown in Figure 7-40. The fi gure shows the results after the first
phase of treatment. Phase I appliances consisted of a mandibular lingual arch, pas-
sive and resting upon the mandibular incisor ci ngula, maxillary first molar bands.
brackets on maxillary incisors. and occipital pull headgear with short and high outer
bow at the level of 12 hours each night. Because of the severe fl aring of the max il-
lary incisors. very light clastic wear was instituted each night aI the beginning of
treatment (when only the headgear was worn) to lip those incisors lingually. After
2 1n months, an intrusion arch (Fig. 7-4 1) was placed. Thi s archwire remained in
place until the e nd o f phase I of treatme n! 8 11'2 mo nths later. At that time, the
mandibular lingual arch was left in pl ace, and a maxillary Hawley retainer was
placed awaiting full eruption o f the permanent dentition. Thi s was foll owed by a
short phase 2 for fi nal alignment. Phase 2 was followed by the usual 2 years of reten-
tio n. usin g the reg imen outlin ed above. In mixed dentiti o n pati ents usin g thi s
approach. if the Class II and overjet correction had not been completed at the time
intru sion had been completed, the intrusion arch would have been deactivated to
hold the corrected incisor vertical level. the outer bow lowered slightly, and a cervi-
cal strap added so that the resultant headgear force would pass through the max ill a's
center of res istance.
The approach used with thi s class of patients is a relati vel y short phase I treat-
men! during which Class II malrelationships are corrected as well as overjet and deep
overbite. if needed. There is a period of retention until the full pennanent dentition, at
which time a short course of full appliance therapy is instituted. Following phase 2.
the nonnal retention regimen is inSliruted.
Suggested Force Values
Intrusion Per Tooth Total (ml) Hsa<tgea'

2l..!... 10--15 9 2()-3() 9 Occipital-
anterior to CAES
Figure 7-39. Recommended intru-
sion f()fee values.
12 11 2 ) 4C>-<lO g
~ 15-25 9 25-50 9 )
""""i"f1 5-10 9 10--209 Cervical-
anterior to CAES
""2"1"T21 ) 20-40 9
)
3]"3 15-25 9 25-50 9
140 CH APTER 7
Figure 7-40. Nooextraction Class II correction in the mixed

dentition. A, Anterior view at beginning of treatment. B, Buc-
cal view at beginning of treatment. C, Buccal view at end of
phase 1. D, Cephalometric superimpositions-phase 1
changes. E, Seleded cephalometric changes during phase 1.
D E
Figure 7-41. 0 .016 inch intruSion arch with initial 45° activa-
tion. It is tied back with stainless steel liga ture wire looped
through the helixes to prevent inciSOl'" naring. Five weeks after
initial insertioo, the activatioo is increased another 45° to gen-
erate 60 g of intrusive force at the midline.
CHAPTER 7 141
The Ro le of Headgear in Class II Dental and Skeletal Corrections
SUMMARY
This chapler presented the rationale and j ustificat ion for combin ing headgear force
with Class II mechanotherapy. T he theoretical principles were illustrated wilh typical
patients from the author's practice.
REFERE NCES
I. Douglas JR: A seri al cepha lometric ev aluation of the dentofacial chan ge~ in patients treated with
C lass II imennaxillary forces. 1llt:s is. University of Wash ington . 1973.
2. Teuscher U: A growth-rela ted conce pt for skeletal Class II treatment. Am J OnhOO 74(3):258-275,
1978.
3. Woodside Oil, Panc hen: H, McNamara J: Dentofac ial orthopedics panel di sc ussion. Ortho 200 1,
Rescurch Tri a ng le Park, NC, Nov. 16. 199 I.
4. Fidler BC, et al : Long· te rm Mability of successfully treatcd Ang le Class II , Divis ion I mulocc lusions.
Thesis, Universi ty o f Wushington , 1992.
5. Joondep h DR : Prese ntcd a t thc [992 Annual Meet ing o f the Midwe ste rn Orthodo nti c Society.
Nashville, TN. Oct. 28.1 992.
6. Pa nc her!. H: TIIC nature o f Class II relapse aftcr Herbst appliafICe treatment: A cephalonlCtric long·
tenn inves tigatio n. Am J Onhod 100:220-233. 1991 .
7. Smith RJ, Bu rstOlIC CJ: Mec hanics of tooth movemem. Am J Orthod 85:294-307. 1984.
8. Marco tte MR: Biomechall ics in Onhodontics. Philadelphia: BC lX'C ker, 1990. Chap. I.
9. Norlo n LA, Bu rstOtlC CJ : 1llc !liology of TOOIh Movement. !loca Rmon. FL: C RC Press, 1989. Chap.
20.
10. Ni ko ta i·RJ: Bioe ngi neering Analysis o f Onhodootic Mechan ics. Philade lphia: Lea & Febiger. 1985.
~ Co n tast i G , Lega n HL: Biomecha n ic al guidelines for headgea r a ppl ica tion . J CJin Orthod
16:308-3 12,1 982.
12. Bowley WW, BurstOtlC CJ. Koenig HA. Siatkowski RE: Prediction of tooth displacement using laser
holography and fi ni te element techn ique. In Heron RE (ed ): BiostereonICtries 74. Falls Church, VA:
AnICrican Society o f Photogrammetry.]>p. 24 1- 273. 1974.
13. Vnnden Bulcke, MM , eI al: Local ion of the centcrs o f resiSlance for anterior teeth during retraction
usin g the laser reflection tochnique. Am J Onhod 91 :375- 384. 1987.
14. Tanne K, et al: Moment to fOfCe mtios and the center of Mation . Am J Orthod 94 :4 26-43 1, 1988.
15. Tanne K, et al: Three-dime ns ional fini te element analysis for stress in the periodo nta l ti ssue by orIho-
dontic fOfCeS. Am J Onhod 92:499- 505 , 1987.
16. Tanne K, et al: Biomec ha ni cal responses of teeth associated with different root le ngth s and alveolar
bone heigh ts: Ch;lnges of stress di stribution in the PDL. J Osaka Uni v Dent Sch 29: 17- 24. 1989.
17. Pederse n E, Andersen K, Gjcssing PE: Electronic deteml ina tion o f ce nt ers of rotlttion prOOm;ed by
orthodo nti c force systems. Eur J OnhOO [2:272-280. 1990.
18. Pederse n E, Andersen K, Me lsen B: Tooth displaccment ana lyzed o n human au to psy nlatcrial by
means of a stmi n gage tec hniqu e. Eur J Onhod 13:65--74. 199 1.
19. Dennaut LR, et al: Expe rime ntal dcterminalion of the center of res istance of the upper fi rst molar in a
macerated, dry human skull s ubmined to hori;wntal llCadgear trac tio n. Am J Orthod 90(1):29-36,
1986.
20. Sialkowsk i RE: Inc isor uprighting: Mechan ism for laiC secondary crowding in tlIC anterior segments
of the de ntnl arches. Am J Orthod 66:39 8--4 10. 1974.
2 1. Melse n n, Fo ti s V, Burs to ne CJ : Ve rti cal fo rces in di ffe re ntia l space clos ure. J Cl in O rthod
24{l1):678-683. 1990.
22. Tanne K. et al: ThTt.'C-dimensio nal model of the human craniofacial skeleto n: Me thod and prt'li minary
results using finite c lement al1lllys is. J Biomed Eng 10(3):246-252. 1988.
23. Haac k DC, We instei n S: T he mechan ics of cenlri e and eccentric cervical tract io n. Am J On hod
44(5):346-357, 19 58.
24. Hershey ~I G, Hougtllon CW, BUTSto ne CJ: Unilateml face-bows: A tht'Orctical and talx>rnlory analy-
s is. Am J Orthod 79(3):229-249, 1981.
25. Schwager JD: The Ne w Markel Wi7.ardS. New York: l iarper-. 1993.
26. Tulloch JFC, Med land W, Tuncay OC: Methods used to evaluate growth modification in Cl a.~s [I ma l-
occlusions. Am J Orthod 98(4):340-377, t990.
27. Johnston LE: A comparative annlysis of Class II treatme nts. In Vig PS. Rilme ns KA (eds): Science
and C lini cal Judgement in Orthodontics. Ann Arbor: University of Mic higan Cmniofocial Growth
Series. Mo nograph 11 19,1986.
142 CHAPTER 7
28. BUlStollC CJ : Deep overbite cOITCCIioo by intrusion. Am J Ol1hod 72(1): 1-22, 1911.
\12. DennaUl LR, Vanden Bu1cke MM: Eva luation of inl rusive mechanics of the type "segmental arch" on
a macerated human skull using the laser renection technique and holographic interferometry. Am J
Orthod 89:25 1-263, 1986.
30. Dennaut LR, DeMunck A: Apical fOO( resorption of upper incisors cau.'ied by intrusive tooth n}(l\'e-
ment: A radiographjc study. Am J Ol1hod 90(4):32 1- 326, 1986.
3 1. McDowell EH, Baker 1M : The skeletodcntal adaptatio ns in deep bite correction. Am J Orthod
100(4):310-375, 1991.
32. Woods M : A reas sess ment of space requirements for lower arch leve ling. J Cl in O rthod
20{1 1):770-778. 1986.
CHAPTER
8
Biomechanics of Class II Correction
Bhavna Shroff • Ravindra Nanda
ental Class II malocclusions often present with common clinical characteris-
D tics. including increased overjet and overbite of the anterior teet h. flared
incisors. molar rOlalian s. and altered molar axial inclinations. The successful
:orreclion of such malocclusions rel ics on an accurate diagnosis IC:lding \0 a precisely
;equenccd lreatment plan. A careful clinical anal ysis allows the orthodon tist to design
.he appropriate appliance system in order to achieve the treatment goals. The biomc-
;hanical analysis of the desired fo rce system is of utmost im portance during appliance
lesign to avoid undesirable side effects.
Thi s chapler reviews :1 number of strategies that will hel p ill Class II correctio n
luring orthodontic lherapy. Emphasis is on the correction o f rotated maxillary molars,
he simu ltaneous correction of increased overjet-overbite relationship during extrac-
ion or nonextraction therapy. and the use of tip-back mechan ics during Class n cor-
ection.
",OLAR ROTATION S
)iagnosis and Treatment Plann ing

lie collection of a database of information aftcr clinical exam ination is very helpfu l
l r diagnosis. Anal ysis of extraoral and intraoral pictures. models. and radiographic
tlms wi ll help confirm the clinical findings. The examination of the orthodontic mod-
Is is espec ially helpful in visual izing any molar rotations. These rotations may be
ilateral or unilateral, introducing in the latter situation some degree of asymmetry
etween the right and left buccal occlusions. The mesiobuccal cusp of the maxillary
lolars is positioned mesially when the molars are rotated along an axis li ngual to
leir central fossae. as shown in Figure 8- 1. which is easi ly observed on an occluso-
143
144 CHAPTER 8
Figure 8-1 , Occlusal view of a maxillary

arch. The first pe rmanent molars a re
ro tated mesial-in and con tribute to the
Class II dental malocclusion.
Figure 8-2_ Occlusal tracing of the maxillary and mandibu·

lar arches. On this occlusogram it is possi ble to visualile !hi!
mesial-in rotation of the maxillary permanent first molars and
the corrected position at the eild of treatment (dotted !rae.
ing).
gram (Fig. 8-2). The diagnosis of rotated maxillary molurs is very important for early
correction , which will subsequently lead to the establishment of a more normal occlu·
sion. It has been shown thm the absence of rotation of maxillary molars is highly
desirable in obtaining a Class I occlusion of the molars, premolars, and canines.1
When molars are rotated they occupy more space mesiodistally than they would in a
Class I occlusion. The result will be forward positioning of the maxillary dentition
relative to the mandibul ur dentition and will contribute to a Class II malocclusion.
The early diagnosis of rotations is critical in achieving correction of the malocclusion
and obtaining good intercuspatioll . It is very important for molar rotation to be cor-
rected at an carly phase of orthodontic therapy in order to establi sh symmetric proper
buccal occlusion. Such correction is a prerequisite to obtaining ideal ove ~et and
overbite relationships.
Strategy to Correct Bilateral Molar Rotations

Biomechanics. To correct bilaterally rotated molars (mesial-in. distal-out rotation),
two equal and opposite moments are applied 10 the molars, as shown in Figure 8-3.
CHAPTER B 145
Figure 8-3. Diagram of th~ maxillary arch with tht'

correct forc~ syst~m nec~ssary for th~ correction of
bilaterally mesial-in rotattd permal\ef1t first molars.
This force system can be precisely and predictably obtained with the judicious appli-
cation of biomechanical principles.2-3 Thi s approach will also allow excellent control
of tooth movement in the first, second, and third order. A simple con tinuous arch wire
is not desirable for this clinical situmion because it will produce an unknown force
system with undesirable side etTects.6
Clinical Apl)/icariQII. Two appliance designs are described here: the palatal arch and
headgear.
PAU.TALARCH. For optimum correction of bilateral maxillary molar rotations, a palatal

arch may be used. The palatal arch is bent to the patient's models and is insened pas-
sive in the mouth. This firsl step is very important in detennining the neutr'J.1 position .
Activations are subsequently put into the horizontal tabs of the palatal arch and a tri al
activation can be done. To correct bilaterally rotated molars, the hOfi1.Onlallabs of lhe
palatal arch arc bent equally on the right and left sides, as shown in Figure 8-4. Two
methods can be employed 10 check for equal activation. The first approach is to draw
the initial angu lmion of the horizontal tabs of the palatal arch on paper and then activa-
\\oo'!. 'Me \T\COil'0n\\e(\ \equa' and oppos·\tc moments). The amount of activation may be
checked subsequently by superi mposing the horizomal portions of the activated palatal
arch onto the initial drawing. The second approach is done intraorally. The palmal arch
is activated extraorally and placed imfaorally into the lingual attachment on one side.
The horizontal distance fro m the lingual attachment to the free end of the palatal arch
Figure 8-4. Diagram of th~ maxillary arch

showing the corr~cled position of the first
molars after correction (dotttd line) and the
blatffaJ activation in the palatal arch.
CHAPTER 8 145
Biomechanics of Class /I Correction
Fi,ure 8-3. Diagram of the maxillary arch with the

correct force system necessary for the correction of
bjlateraJly mesial· in rotated permanent fim molars.
This force syste m can be precisely and predictably obtained with the judicious appJi+
cation of biomechanical princ i p l es.2-~ This approach will also allow excellent control
of tooth movement in the first. second, and third order. A simple cominuous archwire
is not desirable for this clinical situation because it wi ll produce an unknown force
system with undesirable side effects.6
Clinical Applicalioll. Two appliance designs are described here: the palatal arch and
headgear.
PALATAL ARCH. For optimum correction of bilateral maxillary molar rotations, a palatal
arch may be used. The palatal arch is bent to the patie nt's models and is inserted pas+
sive in the mouth. Thi s first step is very important in dete mlining the neutral position.
Activations are subsequently put into the horizontal tabs of the palatal arch and a trial
acti vation can be done. To correct bi laterally rotated molars, the horizontal tabs of the
palatal arch are bent equally on the right and lefl sides, as shown in Figure 8-4. lWo
methods can be employed to c heck for equal activation. The fi rst approach is to draw
the initial angulation of the horizontal tabs of the palatal arch on paper and then activa+
lions are incorporated (eq ual and opposite moments). The amount of acti vation may be
checked subsequently by superimposing the horizontal portions of the aeti vated palatal
arch onto the initial dmwing. The second approach is done intraorally. The palatal arch
is activated extraorally and placed intraorally il1[o the lingual attachment on one side.
The horizontal distance from the lingual attachment to the free end of the palatal arch
Figure 8-4. Diagram of the maxillary arch

showing the corrected position of the first
molars after correction (dotted line) and the
bilateral activation in the palatal arch.
CHAPTER 8 145
Biomechan ics of Class II Correction
Fip ... 8-J. [)ia&ram of the maxillary arch with the

corrtct force system necessary for the correction of
bilteraly ~-in rotattd permanent first molars.
This force system can be precisely and predic tably obtained with the judicious appli-
cation of biomecha nical pri nciples. 2- j Th is approac h will also allow excelle nt control
of tooth movement in the first , second, and third order. A simple continuous archwire
is not desirable for this clinical situation because it will produce an unknown force
system with undesirable side effects.1>
Clinical Application. Two appliance designs are described he re: the palatal arch and
headgear.
PAI..ATAL ARCH. For optimum correction of bilateral maxillary molar rotations, a palatal
arch may be used. The palatal arch is bent to the patient 's models and is inserted pas-
sive in the mouth . This first step is very important in determining the ne utral position.
Activations arc subsequently put into the horizontal tabs of the palatal arch and a trial
activation can be done. To correct bilaterally rotated molars, the hori zontal tabs of the
palatal arch arc bent equally on the right and left sides, as shown in Figure 8-4. Two
methods can be employed to check for equal activation. The fi rst approach is to draw
the initi al angulation of the hori7..0ntal tabs of the palatal arch on paper and then acti va-
tions arc incorporated (equal and opposite moments) . The :lmount of activation may be
checked subsequently by superimposing the horizontal portion s of the activated palatal
arch onto the ini tial drawing. The second approach is done inlmorally. The palatal arch
is activated extraoml1 y a nd placed intraomlly into the lingual attachment on one side.
The horizontal distance from the lingual attachme nt to the free end of the palatal arch
Figure 8--4. Diagram of the maxillary a«:h

showing the corrected position of the first
CHAPTER B 145
Fi,u,. 8-3. Diagram of the maxillary arch wi th the

correct force system necessary for t he correction of
bilaterally mesial·in rotated permanent fi rst molars,
This force system can be precisely and predictably obtained with the judicious appli-
cation of biomechanical principles.2-5 Thi s approach will also allow excellent control
of tooth movement in the fi rst. second, and third order. A simple continuous arch wire
is not desirable for this clinical situation because it will produce an unknown force
system with undesirable side effects.6
Clinical AIJplicatioll. lWo appliance designs are described here: the palatal arch and
headgear.
PAUTAL ARCH. For optimum correction of bi lateral maxillary molar rowtions, a palatal
arch may be used. The palatal arch is bent to the patient'S models and is inserted pas-
sive in the mouth. This first step is very important in detemlining the neutral position.
Activations are subsequently put into the horizontal tabs of the palawl arch and a tri al
activation can be done. To correct bilaterally roWted molars, the horizontal tabs of the
palatal arch are bent equally on the right and left sides. as shown in Figure 8-4. Two
methods can be employed to check for equal acti vation . The fi rst approach is to draw
the initial angulation of the horizontal tabs of the palatal arch on paper and then activa-
tions are incorporated (equal and opposite moments). The amount of acti vation may be
checked subsequently by superimposing the horizontal portions of the activated palmal
arch onto the initial drawing. The second approach is done immorally. The paJawl arch
is acti vated extraorally and placed intraorally into the lingual attachment on one side.
The horizontal di stance from the lingual attachment to the free end of the paJataJ arch
Flcu,.. 8-4. Diagram of the maxillary arch

showing the corrected position of the fif'5 t
146 CHAPTER 8
Biomechanics of Class 11 Correction
Filure 8-5. Occlusal view show·

ing the maxillary arch. The palatal
arch is in place, and the correction
of the molar ro tat ions has been
successfully completed.
on the other side is then measured. The distance should be equal when thi s procedure
is repeated on the opposite side.~ After careful evaluation of the activation, the palatal
arch is tied in place with metal ligatures or elastomeric rings. No buccal archwires are
engaged in the molars in order to allow a frictionle ss and therefore more efficient cor-
rection of the rotation (Fig 8-5). After full correction of the molars, the palatal arch is
kept in place during the rest of the orthodontic treatment.
HEADGEAR. An alternate way to obtai n two equal and opposite moments to rotate
maxillary molars mesial -oul and distal-in is to use a high-pu ll headgear with an
occlusal insertion of the inner bow in vertical tubes. which are soldered on the buccal
a.~pcc IS of molar bands. From a biomechanical standpoint. this approach presents a
number of advantages: High-pu ll headgear has a vertical force component that helps
maintain the vertical dimension. The force of the hi gh-pull headgear is directed
through the cen ter of resistance of the maxill:try first molars. The distal force applied
through the buccal tube of the molars is buccal to the center of resistance and creates
a moment thut tends to rotate the molars mesia l-out (Fig. 8-6), Thi s approach may be
advanlageous if good patient cooperation with headgear wear can be achieved.
Strategies to Corred Unilateral Molar Rotation

Biomechanics. The correction of a unilateral mesial-i n and distal-out molar rotation
may be achieved with proper application of force and a moment. Figure 8- 7 shows a
rotated molar on the left side of the max illary arch. The desired force system on the
left molar is a clockwise moment. At equilibrium. the force system will also include
Filure 8-6. A, Diagram of the maxillary arch and force system applied by a high-pull headgear. B, Dia-
gram of the maxillary arch and equivalent force system at the center of resistance of the molars. The per-
manenMirst molars w ill feel a distal force and equal and opposite moments.
CHAPTER 8 147
horizontal forces (distal force on the right side and mesial force on the left side). As
the left molar rotates mesial-out distal -in and tips mesially on the left side of the arch.
the molar on the right side of the arch tips distally (Fig. 8-8). The effect of the mesial
force may be conlrOlied by the distal force o f a headgear.
Clinical ArJplicatioll. A palatal afch can be used to achieve unilateral molar rotat ion.
A unilateral activation is incorporated into the horizontal portion of the palatal arch.
and the opposite molar will feel a tip-back moment. If such side effects afe not desir-
able, it is necessary 10 place a 0.017 x 0.25 inch ss wire from the right max ill ary
molar to the left second premolar fOf anchorage purposes (Fig. 8-9). An alternative
approach is bilateral mesial -out activation of the palatal arch with the .017 x .025
stainless steel wire augmenting the anchorage side. 7 Once the unilateral molar correc-
tion is achieved. the palmal arch is bent passi ve to the new corrected position of the
molars, and buccal archwires can be extended passive to the derotated molar.
Figure 8-7. Diagram of tht! maxillary arch with

tht! forct! system necessary to correct a unilaterally
rotatt!<1 first permanent molar.
Figur. 8-8. Sagittal view of the forct! sys-

tem developed to rotate unilaterally a first
permanent molar.
Figur. 8-9. Diagrammatic re presen tation of the

appliance system used to derotate unilaterally a first
permanent maxillary molar.
148 CHAPTER B
SIMULTANEOUS OVERBITE CORRECTION AND SPACE CLOSURE
The correction of a deep o verbite in patients with flared incisors is clinically challeng.
ing and cannot be achieved adequate ly with conventional mechanics that involve the
use of continuous archwires. Often, uprighting flared incisors 10 better axial inclina-
tions lengthens the ir c rowns a nd deepens the overbite. In nonex traction cases ill
which flared incisors are associated with intra-arch spacings, full space closure can be
ac hieved only when the deep overbite is corrected. Therefore, for optimum trcattnell
results it is advantageous to simultaneously correct the dee p overbite and to achieve
space closure.
A number of mechanisms have been described to correct deep overbites. includ-
ing intrusion of the anterior teeth, extrusion of the posterior teeth, or a combination or
both. Leveling a mandibular curve of Spee by extrusion of the posterior teeth $I"'"".,
the occlusal plane and causes backward rotation of the mandible, which is undesirable
in many C lass II patients. This also results in an increase in lower facial height, which
w ill c ompromi se treUlme nt s tabil ity u nless the pa tient presents with a favorable
growth pattern. The use of a utility arch has also been advocated. The anterior part
this arch is engaged into the brac kets o f the anterior teeth, which can result in Ilann,.
Such an approach may be useful in some clinical si tuations but may not achieve
intrusion of the anterior teeth . Furthermore. in patients with flared incisors, a utility
arch w ill tend to worsen the incisors' ax ia l inclination.
True intrusion is obtained by applying a single intrusive force through the
of resistance of the anterior teeth (Fig. 8- 10).8,9
Biomechanics. The usc of a point contact of force application is very i'~~::i~'d:

order to obtain true intrusion. This allows the intrusive force to be directed I
center of resistance of the anterior teeth. For example. an intrusion arch can be
an anterior segment. The precise selection of the point of application of the
force with respect to the axial inclination of the incisors is cri tical and will deli"ibe
type of tooth movement. True intrusion is obtained when an intrusive force is
through the center of resistance of the anterior teeth. If the incisors are flared
intrusive force is applied at a distance anterior to the cente r of resistance. further
ing will occur (Fig. 8- 11 ). In Ihis case, the point of force application should be
placed distally in order 10 direct the intrusive force through the center of resistance
the anterior teeth (Fig. 8- 12). An appliance design that will allow a variable point
force application includes di stal extensions from the anterior segment and
right and left tip-back springs to deli ver the intrusive force 1o (Fig. 8- 13). It is
to redirect the intrusive force along the lo ng axis of the incisors (Fig. 8-14) and obi..
Figu re 8-10 . Diagram showi ng a single intrusive

through the center of resistance of the incisor in the
plane.
148 CHAPTER 8
8iomechanics of Class II Correction
SIMULTANEOUS OVERBITE CORRECTION AND SPACE CLOSURE
The correction of a deep overbite in patientS with Oared incisors is clinically challeng-
ing and cannot be achieved adequ:ltcly with conventional mechanics that involve the
use of continuous archwires. Often, uprighting fl ared incisors to better axial incl ina-
ti ons lengthens their crowns and deepens the overbi te. In no nex tracti on cases in
which Oared incisors are associated with intra-arch spacings, full space closure can be
achieved only when the deep overbite is corrected. Therefore, for optimum treatment
results it is advantageous to simultaneously correct the deep overbite and to achi eve
space closure.
A number of mechani sms have been descri bed to correct deep overbites, includ-
ing intrusion of the anterior teeth. extrusion of the posterior teeth, or a combination of
both. Leveling a mandibular curve of Spee by ex trusion of the posterior teeth steepens
the occlusal plane and causes backward rOlation of the mandible, which is undesirable
in many Class U patients. This also results in an increase in lower facia l height, which
will comprom ise treatment stabi lity un less the patient presen ts with a favorable
growth pattern. The use of a utility arch has also been advocated. The anterior part of
this arch is engaged into the brackets of the anterior teeth. which can result in Oaring.
Such an approach may be useful in some clinical situations but may not achieve true
intrusion of the anterior teeth. Funhennore. in patients with Oared incisors. a Ulility
arch will tend to worsen the incisors' ax ial inclination.
True intrusion is obtained by applying a single intrusive force through the center
of resistance of the anterior teeth (Fi g. 8- 10).11.9
Biomechanics. The use of a point contact of force appl ication is very impon ant in
order to obtain true intrusion. Thi s allows the intrusive force to be directed through the
center {If resistance of the anterior teeth . For example. an intrusion arch can be tied to
an anterior segment. The precise selection of the point of appli cation of the intrusive
force with respect to the axial incl ination of the incisors is critical and will define the
type of tooth movement. True intrusion is obtained when an intrusive force is applied
through the center of resistance of the anterior teeth. If the incisors are Oared and the
intrusive force is appli ed at a di stance anterior to the center of resistance. funher flar-
ing wilt occur (Fig. 8--- 11 ). In this case, the point of force appl ication should be dis-
placed distally in order to direct the intrusive force through the center of resistance of
the anterior teeth (Fig. 8--- 12). An appliance design that wilt attow a variable point of
force application includes distal ex tens ions fro m the anterior segment and separate
right and left lip-back springs to deli ver the intrusive force1o (Fig. 8--- 13). It is possible
10 redirect the intrusive force along the long axis o r the incisors (Fig. 8---14) and obtain
Figure 8-10. Diagram showing a single intrusive fOrte

through the center of resistance of the ir.cisor in the sagittal
plane.
CHAPTER 8 1 49
Figure 8-11. A, Diagram represen ting an intrusive force applied

at the bracket of a flared miulillary incisor. 8, The equivalent force
system at the center of resistance of the incisor.
a b
ficure 8-12 . A, Diagram showing the correct point of
oIIppIatioo of an in trusive force to obtain intrusioo in cases
ill which incisors are flared. 8, The point of application of Fipre 8-13 . Diagramma tiC representation of a three-piece
IIw ntMiYe force is displaced distally. The intrusive forte is base arch including an anterior segmen t with distal extension
Iherdort' through the center of resistance of the incisors. and bilateral tip-back springs.
-.
ftc\ire 8-14. A, Diagram showing an intrusive force
rfdlrected aloflg the long axis of the incisor using a
~I distal force . 8 , The intrusive force is displaced
Intrusion. This can be done by adding a small distal force. The intrusive force will be
displaced anteriorly close to the bracket of the lateral incisor.
It is also possible to redirect the intrus ive force distal to the center of resi stance of
the incisors and paralle l 10 their long axes. The intrusive force perpendicular to the
octlusal plane is di splaced d istally, and a sma ll horizontal force is used to red irect the
inuusive foree alo ng the lo ng axis of the incisors. In this case, the incisors will no t
only be intruded but will also be retracted because of the tip-back mo me nt felt by the
anterior leethl 1 (Figs. 8-15 and 8- 16).
The mag nitude of the intrusive force s is kept s mall 10 e nsure o ptimal ti ssue
response. It has been demonstrated that the use of heavier fo rces will nOI accelerate
mlrusion. 12• I) The horizontal force applied to redirect the intrusive force parallcl to the
long axis of inc isors is also of small magnitude. The relmction of the anterior teeth is
due 10 the tip-back moment generated by the res ulting force.1 4 - IS TIle anc horage unit
150 CHAPTER 8
,, ,,
,,
, ,,
,
Figure 8-15. Diagram showi ng an intrusive force redirected along a
parallel line 10 the long axis of Ihe incisors and displaced distally. The
incisors wil l not on ly intrude but will also tip back.
Figllre 8-16. Diagrammatic picture of a three·piece arch retrac·

tion assembly using a three-piect base arch and Class I tlastics.
or posterior teeth will feel 11 small mesial force, which will not compromise thc
anchorage requirement.
Treulmellf Planlling. The indications of Ihis Iype of mechanotherapy arc deep over·
bite, excessive overjet, and Class II occlusion. The specific treatment objectives
include deep overbite correction by maxillary incisor intrusion, inci sor retraction, and
Class 11 correction by first molar lip-back. The force system of thi s appliance (Fig.
8- 13) produces all of these movements simultaneously. Locating the estimated center
of resistance of the anterior teeth aids in correctly designing the appliance for delivery
of the desired force systcm. The location can be evaluated from a lateral cephalomet-
ric radiograph. The axial inclination of the incisors should also be evaluated. The
greater the flaring of the incisors. the more imponant it is to position the point of
force deli very through or distal to the center of resistance.
Clillical Applicatioll. Mol .. r rot..tions .. nd spacings in the dental arches are usually
addressed at the beginning of mechanotherapy. The advantage of such an approach
is thai molar position is corrected early, establishing a better posterior occlusion,
and teeth are consolidated in order to faci litate sy mmctric space closure. The palatal
arch used to correct molar rotations is made passive and is kept in place for control
of the molar position during treatment. Buccal segments of wires (0.0 17 x 0.025
inch) arc placed into the molars. premolars. and canines (if canines have been sepa-
rately retracted and included in the buccal segments). The three-piece intrusion arch
is then fabricated. The anterior segment can be made of 0.0 17 x 0.025 inch stainless
steel and extends distal to the latera l incisors. The intrusive force is delivered on
each side by a tip-back spring made of 0.017 x 0.025 inch TMA (ORMCO Corp.,
Glendora, California) alloy. The application of the point of force is precisely deter-
mined with respect to the center of resistance of the anterior leeth . A light Class I
, .. •. . . .. . . -
C HAPTER 8 151
force paralle l to the long axis of the incisors. Intrusion and retraction of the anterior
teeth are achieved s imultaneously.
Case Presentation
A female patient presented to the Onhodontic Clinic at the Uni versity of Connecticut
School of Dental Medicine for treatment. She presented with a symmetric face and
convex profile. At rest. the patient showed a 5 mm interlabial gap. The overjet was 5
mm . Moderate crowding of the maxillary and mandibular arches was present (Fig.
8- 17). The cephalometric analysi s demonstrated a skeletal C lass II relation ship with a
slight ly protrus ive max illa. The soft tissue profil e was sati sfactory. The treatment
objecl" ives foc used on the el imination of thc crowd ing wi th correction of the axial
inclination of the anterior teeth and establishment of a molar, premolar, and canine
Class I occlusion. The patient received a passive palatal arch and a passive lingual
arch. A three-piece intrusion arch was used to simultaneously intrude and consolidate
the anterior maxillary teeth (Fig. 8-18). The tip--back moment of the intrusion arch
helped in the establishment of Class I molar occlusion as well as reinforced the
anchorage during the space consolidation of anterior teeth (Fig. 8- 19).
OVERBITE CORRECTION AND BILATERAL TlP· BACK MECHANICS
In growi ng patients with Class II, Division 2 dent:!1 malocclus ions. mechanics used
for deep overbite correction may be advantageously used for C lass II correction of the
molars. Class II. Division 2 dental malocclusions often include the presence of a deep
overbite and maxillary first molars, with altered ax ial inclinations. Th is section dis-
cusses the clinical management of such malocclusions.
Clinical Examination and Treatment Planning

A detailed clinical examination is carefully done. and a complete set of records is
taken for further analysis. Extraoral and intraoral pictures are usually very helpful in
confirming clinicul observations. The model s are evaluated, and the axial inclinations
of the maxillary and mandibular molars are chccked with respect to th e natural
occlusal plane. Axial inclination of molars can aJ so be evaluated on a 45° right and
left cephalometric head films. Altered axial inclination of the molars may contribute
to the Class II malocclusion, not only of the molars, but also of the premolars and
canines. It is therefore critical to correct the axial inclination and the antcropostcrior
position of the molars to obtain a C lass I buccal correction. The axial inclination of
the max illary incisors is evaluated from a lateral cephalometric head film. and their
center of rcsistancc is esti mated. After carefu l diagnosis, a problem list is developed
and trcatment objectives are defi ned.
Biomechanics
As just discussed , true intru sion is obtained w hen an in trusive force is directed
through the center of resistance of the anterior teeth. The point of force application is
critical.8 A segmented approach is more favorable for achieving sim ultaneous intru-
~ion and tip back because it givcs the clinician a statically detenninate and predictable
force system. The tip-back moment is applied through tip-back springsl0 to allow the
molars to tip back freely. The point of force application is located through the csti-
mated ccnter of resistance of the anterior lecth. An anterior segment of wirc extcnding
distal to the bracket of the lateral incisors is used for this purpose. The appliance
152 CHAPTER 8
Figure 8-17. A-E, Pretreatment clinical photographs

of the patient's malocclusion.
design, shown in Figure 8-20, consists of two intrusion springs. Good control of the
molars' ax ial inclinations as well as their distal movement is achieved through the usc
of an occipital headgear. The outer bow of the headgear is bent above the estimated
center of resistance of the molars. Using such a biomechanical approach, the practi·
tioner can translale molars distally after adequate correction of their axial incl ination.
Clinical Application
After treatment planning, the appliance is carefully designed to achieve the treatment
objectives. A palatal arch. which can be passive or active. is placed between the right
and left molars. A passive anterior segment (usuall y 0.017 x 0.025 inch stainless
s\ee') is phccD 'm \nc cen\ra' 'mc'lsors anD may'oc extenDeD to tne htera) 'm6sors if
their level is acceptable with respcctto the central incisors. This anterior segment will
present exten sion s di stal to the latera l inci sors where the tip-back spring will be
hooked. Tip-back springs fabricated in 0.0 17 x 0.025 inch memory alloy are placed in
CHAPTER 8 153
Fig"'" 8-18. Segmental springs were used to intrude maxillary Incisors and to tip the molars distally to achieve a
good Class i molar re lationship. Tip-back of molars also created space to accommodate crowded teeth. A. Frontal view.
Band C, Right and left buccal views.
154 CHAPTER 8
Ficure 8-19. Completion of space dowre. A, lateral view of the face. 8, Frontailliew. C. and D, Right
and left buccal views.
the auxiliary molar tube and activated equally on the right and left sides in order to
avoid canting of the frontal occ lusal plane. The springs deli ver a total intrusive force
at the midline of 60 g. As the molars slart to tip back and move di stally, premolars and
molars will drift di stally under the infl uence of transseplal fi bers. It is possible to use
a metal ligature fi gure eighlto lie the premolar and the canine 10 the molar 10 help this
process. However, no segment of wire should be put through the premolars, canines,
Firure 8-20. Laterallliew of a three·piece intrusion arch with simultaneous retraction. A shows passive cantilever with
chain elastic. B depicts the activated appliance.
CHAPTER 8 155
and molars in order to allow Ihese teeth to drift distally individually. The axial incl ina-
tion of {he molars and {he overbite correction are carefull y monitored at each appoi nt-
mcnt, and reactivation of the lip-back spring is decided accordingly. The patient is
given an occ ipital high-pull headgear, which he lps with di stal movement of the
molars and the control of their axial inclinations duri ng orthodontic therapy.
SUMMARY
This chapter discusses treatment strategies to correct deep overbite. Class II molar
relationship. and simultaneous intrusion and retraction of anterior teeth. Careful diag-
nosis and {'reatmen t pl an ning are very imporlant for achievi ng optima l treatment
resul ts. The precise biomechanical analysis of fo rce systems and adequate appli ance
design are necessary for successful management of orthodontic treat ment.
REFERENCES
I. Andrews LF: 1be six keys to normal occlusion. Am J Or1hod 62:296-309. 1972.
2. Burstone CJ : Precision lingual arches. Active applications. J Clin Orthod 23(2): 101 - 109. 1989.
3. Burstone CJ: Mechanics of the segmented arch tec hnique. Angle Onhod 36(2):99- 120. 1966.
4. Naoda R: 1lIe differemia l diagnosis and treatmem of excessive overbite III Nanda R (cd): Symposium
on Orthodol1lics. Dental Clinics of North America. l'hiladelphia: WB Saunders Company. 198 1, pp.
69-84.
S. Burtin J, Naoda R: The stability of deep overbite com:ction. In Nanda R, Burstone CJ: Retention and
Stability in Orthodontics. Philadelphia: WB Saunders Com pan y. 1993. pp. 6 1- 79.
6. Burstone CJ . B31dwin JJ . Lawless DT: TIle application of continuous force to onhodontics. Anglc
Orthod 3 1:1- 14. 1961.
7. van Steenbergen E. Nanda R: Biomechanics of orthodontic correction of dental asymmctries. Am J
Orthod Dcntofncial Onhop 107(6):6 18...(;24. 1995 ..
S. Burstone CJ: Deep ovcrbite correction by intrusion. Am J 011hOO 72( I): 1- 22, 1977.
9, Smith RJ. BUTStone CJ : Mec hanics of tooth movcmcm. Am J 011hOO 8S(4):294-307. 1984.
10. Romeo DA, BUTStOne CJ: Tip· back mechanics. Am J Orthod 72(4):414-421, 1977.
II , Shroff B, Lindauer SJ, Burstone CJ, Leiss JB: Segmented approach to simultanC()us intrusion and
space closure: Biomechanics of the three-piece base arc h appl iance. Am J Orthod 107: 136-143. 1995.
12. Dd li nger EL: A histo logic und cephalome tri c investigation of premolar intrusion in the Macaca SfN'o
ciosa mo nk ey. Am J Orthod 53:325-355. 1967.
13. Rei tan K: Initial tissue be hav ior during apical roo t resorption. An gle Orthod 44(1 ):68--82, 1974.
14. Burs tone CJ. Koenig HA: Optimizi ng amcrior and canine retracti on. Am J Or1hod 70: 1- 20, 1976.
15. Burstone CJ: TIle ~gmented arch approach to spacc closure. Am J Orthod 82(5):361- 378.
CHAPTER
9
Biomechanical Basis of Extraction
Space Closure
Ravindra Nanda • Andrew Kuhlberg
here arc many techniques uti lized for orthodontic space closure. yet linle
T auention has been devoted 10 the biomechanical principles of space closure.

Most approaches to space closure describe the ';technical" featu res of the
appliance, such as the loop or spring shape, the wirelbrackct interaction, or the place-
ment and size of elastics. The techn ique for their use follows a cookbook approach
rathe r an analytical assessment of the specific needs of the individual patie nt. Further-
more. these trealment modalities are often associated with individual advocates for
whom a technique may be named. Thus, cl ini cians follow the guideli nes of their guru
rather than basing treatment on sound biomechanical principles.
Orthodontic space closure should be indi vidually tailored based on the diagnosis
and treatmcnt plan. The selection of any treatment, whether a technique, stage, spring,
or appliance design, should be based on the desired tooth movement. Consideration of
the force system produced by an orthodontic device aids in de te rmining the utility of
the device for correcting any specilic proble m.
This c hapter discusses various theoretical aspects of space closure and two meth-
ods to close ex traction sites based on biomechanical concepts. One approach e mploys
segmental springs and the other uses loops in a continuous archwire.
ANCHORAGE CLASSIFICATION
Anchorage is a common orthodontic concept, yet it is vaguely defined. Terms such as

"cri lical anchorage," " noncritical anc horage," or " burning anchorage" are often used
to describe the degree of diffi culty of space closure. Fundamentally, anchorage may
be defined as the amount of movement of the posterior teeth (molars. premolars) to
close the extraction space in order to achieve selected treatment goals. Therefore, the
anchorage needs of a n individual treatme nt plan could vary from absolutely no mesial
CHAPTER 9 157
Biomechanical Basis of Extraction Space Closure
movement of the molars/premolars permitted (or even distal movement of the molars
needed) to 100% of the space closure by mesial protraction of the posterior teeth.
Anchorage can be classified liS:
A Aile/wrage This category describes the critical maintenance of the posterior tooth
position. Seventy-five percent or more of the extraction space is needed for anterior
retraction (Fig. 9-IA).
B Allchorage Thi s category describes relati vely symmetric space closure with equal
movement of the posterior and anterior teeth to close the splice. This is often the least
difficult space closure problem (Fig. 9-18).
C Anchorage T his category describes "noncritical" anchorage. Seventy-fi ve percent

or more o f the space closure is achieved through mesial movement of the posterior
teeth. This could lIlso be considered to be "critical" :lnterior anchorage (Fig. 9- 1C).
This classification helps in the design of mechanics plans that are individualized for
specific patient needs. Figure 9-2 shows the extraction space divided into these das·
sifications.l.l·4
SINGLE CUSPID RETRACTION VERSUS EN-MASSE RETRACTION
Over the years, orthodontists have been made to believe that two-step space closure-
first cuspid retraction and then incisor retraction- is less detrimerHallo the anchorage
than en·masse retraction of all six anterior teeth. This may be true with some methods
of space closure, but it is n OI necessarily true in all instances. Adequately designed
appliances. based on the desired biomechanics. permit en-masse retraction of all six
anterior teeth in a single stllge. En-masse space closure can significan tly reduce treat-
ment duration. Separate canine retraction can be reserved for situalion s in which one
needs 10 alleviate anterior crowding. Upon achieving incisor alignment, en-masse clo-
sure completes the space closure.
SPACE CLOSURE-A BIOMECHANICAL PERSPECTIVE
The end result of space closure procedures should be upright. well-aligned teeth with
parallel roots. Thi s implies that the tooth movement will almost always require some
degree of bodily tooth movement or even root movement. Figure 9-3 demonstrates a
typical sagittal view of space closure treatment. In this case. the space closure is
shown as Group B anchomge, or symmetric space closure. The space is closed while
maintaining coincident occlusal planes and molar-premolar-canine foot parallclism.
The tooth movement from Figure 9-3A to Figure 9-38 requires translation of the
antcrior and posterior teeth. The force system necessary to achieve such movement
requires the application of equal and opposite forces and moments. Figure 9-4 repre-
sents the geneml force system needed for this movement. Si nce the moments and
forces are of equal magnitude and on ly opposite in direction , vertical force couples
would not be present; therefore, the biomechanical side effects (from this view)
would be negligible. The moment-to-force (MIF) ratios acting on the anterior and
158 CHAPTER 9
Biomechan ical Basis of Extraction Space Closure
Before Space Closu re
Group A Anchorage
(
Group B Anchorage
Group C Anchorage
FIgure 9-1. Classification of anchorage. Group A space closure is characterized by an terior retraction. Group B
space closure involves equivalent amounts of anterior retraction and posterior protraction. Group C space clo·
sure requires posteri or protraction (m aintenance of anterio r anchorage).
CHAPTER 9 159
Figure 9-2 . Classification of anchorage. Divid-

ing the total e.-traction space into quarters aids
in visualizing the anchorage classification. The
shaded areas represent the final position of the
interpro.-imal contact between the canine and
premolar. Group A space closure incl udes 100%
anterior re traction (no posterior anchorage loss)
to 75% anterior retractJon (25% of space clo-
sure from posterior anchorage movement).
Group B space closure includes more equal
amounts of anterior and posterior tooth move-
ment. Group C space closure includes 75% to -+--- Anterior
Retraction
100% posterior protraction.
Posterior
------+ Protraction
Posterior 114 '12 3/4 Anterior

(meSial surface of (dislal surface
2nd Premolar) 01 canine)
A Fi gl.! re 9-3_ Idealized objective of space closure. A, Before closure of

e.-traction space. B, Following space closure. the canine contacts the sec-
ond premolar. the roots are parallel, and the occlusal plane is level.
B
posterior teeth shou ld appr01c:i mate 101 1, the M/F ratio needed for bodily tooth move-
ment.
Space closure requiring precise anchorage control is more difficult. For Group A
anchorage. or critical posterior anchorage, the mesial forces acting on the poslerior
teeth must be minimized or neutrali7..ed. Figure 9-5 shows thi s type of space closure
along with the most desirable force system, with no forces or moments acting on the
posterior teeth. Unfortunately, the force system shown can be achieved onl y with non-
dental anchorage. According to Newton's third law, any forces acting on the anterior
tecth must be opposed by equal and opposite force s acting somcwhere else, typi cally
the posterior leeth , the head, or the neck (via fu ll-time headgear use). If intraoral
160 CHAPTER 9
Blomechanical Basis of Extraction Space Closure
fle,... ft 9-4. fOfce '>~'>tem {Of GrOI.l\l S '>\lace clo<,l.lre.

Translation of the anterior and posterior teeth is Figure 9-5. The ideal force system for Group A space
required to achieve ideal space closure. An M/F ratio closure. For perfect maintenance of the posterior
appro~lmatln8 10/1 is needed for translation. anchorage, no forces should act on the posterior teeth;
only a force system resulting in anterior translation is
desired , This force system cannot exist unless all the
anchorage units are ellf/aOfai Of in the opposite arch.
Figure ~. Alternative approaches to obtaining Group A anchorage

through varying the magnitude of force acting on either the anterior or
posterior teeth. The solid arrow represents the forces and moments
generated by the archwirelretraction device (i.e., archwire and elastic
chain). In A, the broken arrow repr-esents an additional force acting on
A the anterior teeth (i.e., Class II elastics or J·hook headgear). In B, the
broken arrow represents the force from a headgear acting on the pos.
terior teeth. In both cases the change in the force magnitude results in
a lower M/F ratio on the anterior teeth and an increased M/F ratio on
the posterior teeth,
anchorage is used. the forces and moments mIlS! be present on ( he posterior teeth. To
obtain differential tooth movement (i.e .. anchorage control) biomechanical strategies
mus t be incorporated into the appliance des ign. Figure 9- 6 shows two possible
approaches for this strategy.
As Figure 9-6 demonstrates. the distal force on the anterior teeth must allow
maximum potential for tooth movement wh ile the mesial force on the posterior teeth
must be minimized or counterJ.cted. With consideration to the force system required
for such movement, Group A anchorage requires a relative increase in the posterior
MIF ratio (reducing F results in a hi gher MIF) and/or a decrease in the anterior MIF
ratio (increasing F results in a lower M/F ratio). Within a single intra-arch appliance.
the mesio-distal forces must be eq ual (rules of static equilibrium); thus the forces can
be increased or decreased onl y by utilizing extraoral appliances or the opposite dental
arch. This is the general effect of headgears or intermaxillary clastics (Class 1.1 clas-
tics). The use of headgear or intermaxillary elastics is dependent on good patient com-
CHAPTER 9 161
Figtlte ~7. A biome<:hanical strategy for

Group A space dosure using differential
moments. The posterior (beta) moment
is increased relative to the anterior
(alpha) moment. The moment differen-
tial reduces the M/F ratio on the anterior
teeth while Increasing the M/F ratio on
the posterior teeth. Vertical forces occur
due to the difference in the alpha and
beta moments. intrusive to the anterior
teeth. extrusive to the posterior teeth.
pliance and is not without other side effects. Class U elastics also result in forces act-
ing on the mandibular teeth and exert a vertical (extrusive) force on the anterior teeth.
Either of these side effect s may be detrimental to the outcome of the treatment.
The strategy fo r Group A space closure suggests another approach. as dia-
gramed in Figure 9-7. The key feature is the differential M/F ratio. The scheme
described above and in Figure 9--6 obtained a difference in the anterior and poste-
rior MIF ratios by varying the force through the use of headgear andlor intennaxi l-
lary elaSlics. The moments can also be varied . Figure 9-7 depicts the application'
of a higher moment on (he posterior compared to the applied momen t on the ante-
rior teeth. Increasing the posterior moment while decreasing the anterior moment
would result in an equi valent change in the M/ F ratios. Increasing the moment on
the posterior teeth increases the MIF ratio and decreasing the moment on the ante-
rior teeth decreases the M/F ratio; the force (F) on the anterior and posterior teeth
is equal. Additionally, increasing the posterior MIF ratio encourages rOOI move-
ment (M/F - 12JI ) while decreasing the anterior MIF ratio causes a tipping type of
tOOlh movement (M/F - 711 ). If the posterior moment were large enough, the MIF
ratio would approach infinity, consistent with the application of a pure couple on
the posterior teeth. That couple would result in rotational tooth movement around
the center of the resistance of the anchor unit, moving the crow ns distall y (poten-
tially increasing the size of the extraction space). Furthermore. the clinical expres-
sion of tipping tooth movements regularly occurs more quickly than root move-
ment, so Ihat the anterior teeth retract distally into [he space before any mesial
molar movement is seen.
Differential moments are not without side effects. The unequnl moments must be
"balanced" by a third moment or couple. This couple is a pair of vertical forces. intru-
sive to the anterior teeth and extrusive to the posterior: Figure 9- 7 illustpte.<; these
forces. The magnitude of these vertical forces is dependent on the differen/;e between
the anterior and posterior moments and on the distance between the anterior and pos+
terior teeth . No mailer what {he strategy, some biomechanical side effccts will result.
The proper selection of appliance design depends on the compar,uive risks or benefits
of those side effects.
The difficu lty of Group C anchorage mirrors that of Group A anchorage. The dif-
ference is that the anterior tecth become the effective "anchor unit." Therefore, the
anterior moment is of greater magnitude and the vertical force side effect is an extru-
sive force on the anterior teeth .
From the perspective of the biomechanical force system, analyzing any space clo-
sure technique increases awareness of potential side effects or unwanted tooth move-
ments. Selecting the mechanics best suited to obtaining the planned goals improves
both the efficiency of treatment and the probabi lity of successful results.I -7.13.14.17
162 CHAPTER 9
Biomecnan lcal Basis of Extraction Space Closure
DETERMINANTS OF SPACE CLOSURE

Treatment planning in orthodontics involves far more than deciding extraction versus
nonextraction. Many considerations related to the diagnosis and treatment plan deter-
mine the need for the extraction of teeth as an adjunct to orthodontic treatment. Sim-
plistic approaches to treatment planning such as extraction versus nonextmction fa il
to consider the individual patient's problems. interests, and welfare.
Numerous factors must be considered when determining the need for extraction
of teeth for orthodontic treatment. Along with the fo llowing factors. the minimum
considerations must include est hetics. the geneml health of the teeth, and the patienrs
chief complaint.
Many details of the diagnosis and treatment objectives de termine the tooth move-
ment required during space closure. Included among these factors are:
[. Amount of crowding.
2. Anchorage.
3. Axial inclination of canines a nd incisors.
4. Midline discrepancies and left/right symmetry.
5. Vertical dime nsion.
i . Amount a/Crowding Extractions are usually done to relieve dental crowding. In

cases of severe crowd ing. anchorage control becomes very important. Maintenance of
anchorage while creating,JPace for incisor alignme nt is necessary in order to meet the
treatment objectives. I
2. Anchorage Anchorage classification a nd the concept of differential anchorage are

very important (described earlier in this c hapter). Using the same mechanics for dif-
fere nt anchorage needs limits the abi li ty to reach goal-oriented results. Traditional
anchorage reinforceme nt methods (headgear. increasing the number of teeth in the
anchor unit, lip bumpers. or palatal arches) may be su itabl e. However. if the concepts
of biomechanics arc applied to anchorage control, more predictable resullS with mini-
mal patient cooperation may be achieved.
Control of the molar pos ition is an obvious necessity in space closure. Inadver-
tent anchorage loss can prevent correction of antero-posterior malocclusions (Class
11/111 ). This can be especially important in extraction space closure associated with
Class II correction. Mesial movement of the maxillary posterior teeth may make it
very difficult to obtain correction of the malocclusion. Utilizing a fo rce system deter-
mined appliance design can improve the ch'lIlces for success.
3. Axial il/clilla/ioll of Canine.f and Incisors The same force and/or moment applied
to a tooth or a group of teeth with different axial inclinations will result in different
types of tooth movements. The ax ial inclination of the teeth is an important consider-
ation in the type of tooth movement needed during space closure. Figure 9-8A-C
show the effect of'l single force acting on teeth at different ax ial inclinations. In these
examples, the root would move mesially, opposite to the desired direction of move-
ment. Figure 9- 9A- C show the relative force system required to retract and upright
these Iceth. 14
4. Midline DiscrelJallcies alld Left/Right Symmetry Midline discrepancies with or

without an asymmetric left and right occlusal relationship should be correctcd as early
as poss ib le in treatment. Eliminating asymmetries early in treatment allows the
remainder of the therapy to be completed symmetrically (Le., the left and right sides
CHAPTER 9 163
A
A
B
B
c
Figure 9-8. The effect of a single, distal force
on teeth with different axial inclinations. A, The c
tooth is tipped d istally ; a simple distal force
would result in further tipping, w ith the roo t Figure 9-9. Th e force systems needed for
moving more mesially. B, A single force on an retraction of the teeth in Figure 9-7. A, Root
upright tooth also results in tipping and the root movement is needed to upright this tooth. An
moving mesially. C, A single force acting on a M/F ratio of approximately 12/1 is needed .
mesially tipped tooth will resufi in an uprighting B, Translation requires an M/F rallo of 10/1 .
tooth movement; however, this simple force C, Controlled or apical tipping occurs with an
system does not control the root position. M/F ratio of about 7/1 .
rece ive the same mechanics). Asymmetric forces on the len and right sidcs could
result in unilalcral vertical [orces, skewing o f the dental arch(es), or asymmetric
anchorage loss. Completing as much of the treatment as possible using symmetric
mechanics minimi 1..es the potential impact of any of these side effects.
5. Venic(l/ DimensiOIl Attention to venical forces is essential for the control of verti-
cal dimension in space closure. Undesired vertical extru sive forces on the posterior
teeth may result in increased lower facial height, increased interlabial gap. and exces-
sive gi ngival di splay ("gummy" smil es). The vertical forces associatcd with Class II
elastics may res ult in these problems. Understanding the vertical forces associated
with differential space closure prepares the orthodontist to deal with these difficulties.
164 CHAPTER 9
Biomechanical Basis of Ext raction Space Closure
SPACE CLOSURE-CONSIDERATIONS FOR ANCHORAGE

CONTROL AND DIFFERENTIAL TOOTH MOVEMENT
Bi ologic Variabl es
Ultimately, it is the biologic response to thc orthodontic force system that resu lts in
tooth movement. The mechanical sti mul us that the appliances exert on the teeth
induces physiologic activity that promotes bone resorption andlor deposi tion and the
resulting tooth movement. The force system acting on the teeth produces a stress in
the periodontiu m (the structures of the PDL "feel" a level of force per uni t area). The
stresses wi thin the PDL strain or distort the cells, fibers, and other structures. The bio-
logic response is due to the stress/strain characteristics in the periodontium.
O/Himai force is the idea that there is a force level which will promote the most
efficient treatment response withou t untoward side effects (i.e., rool resorption).
Unfortunately, lilt le is really known about what constitutes an optimal force level.
Quinn and Yoshikawa" discussed hypothetical model s characterizi ng optimal force.
One model views the relal'ionship between tooth movement and force magnitude as
linear. The greater the force, the greater the tooth movement. An alternative model
represents the relationshi p as a threshold. The tooth movement response varies with
force magnitude to threshold. Once the threshold is reached, tooth movement occurs
at a constant rate regardless of any increases in force levels.
Ideall y, the force magnitudes produced by orthodontic devices could be accu-
rately measured and prescribed based on indiv idual, speci fi c treatment objectives.
The levels of force magn itude generated have been reported on very few appliance
design s. Since ideal force levels needed for different types of tooth movements are
unknown, descriptions of specific force magnitudes are of limited value. However,
knowledge of the force levels applied to teeth via the appliance is at least a step in the
direction of understanding optimal forces. 1o, l s.16.L8
Size of An chorage Units

A popular approach to improving anchorage is to increase the number of tccth in the
anchorJge unit. Increasi ng the number of teeth disperses the load over a greater root
su rface area. This decreases the strain or distortion of the periodontal structures
within the anchorage unit. -
A fundamenlll i presu mpt ion is that the rate of tooth movement varies with the
force or load such that increasing the force magnitude results in an increased rate of
tooth movement. The rate o f tooth movement may vary with fo rce only up to a
threshold level. Once the threshol d fo rce magn itude is reached, tooth movement
occurs. Since the true relationship between force levels and the rate of tooth move-
ment is unknown, thi s approach to anchorage control should be used with caut ion.
Differential Force Systems-Variable M oments and Forces

The force system of an orthodontic appli ance detennines the type of tooth movement
expressed. The forces act in all three planes of space (first. second , or third order).
Most space closure concems arc second order, or the sagittal view. The components
of any force system (Fig. 9-10) in this view are: l -8
Alpha Momelll This is the moment acting on the anterior teeth (often tenned ante-
rior torque).
Beta Momelll Thi s is the momcnt acting on the posterior teeth. Tip-back bends
placed mesial to the molars produce an increased beta moment.
CHAPTE R 9 165
Figure 9-10. Components of the space clo-

sure force system. Forces and moments acting
on the anterior are shown by broken arrows.
Forces and moments acting on the posterior
shown by saiki arrows. The alpha moment is
shown smaller in magnitude than the beta
moment: thus the vertJcaJ forces are intrusive
on the anterior and extrusive on the posterior.
I! the alpha moment were greater than the
beta, th e vertical forces would be in the
opposite direction.
......'.
HoriZOllwl Forces These are the mesio-distal forces ,lcting on the teeth. The distal
forces acting on the anterior teeth always equal the mesial forces acting on the poste-
rior teeth.
Vertical Force.f These are intrusive-extrusive forces acting on the anterior or poste-
rior teeth. These forces generally result from unequal alpha and bela moments. When
the bct~l moment is greater than the alpha moment. an intrusive force acts on the ante-
rior teeth while extrusive forces act on the posterior teeth. When the alpha moment is
greater than the beta moment, extrusive forces act on thc anterior teeth while intrusive
forces act on the posterior teeth, The magnitude of the vertical forces is dependent on
the difference between the moments and the intcrbracket distance. Higher forces are
associated with decreased interbracket distances (for eq ui valent alpha-beta moment
differences).
SEGMENTAL EN-MASSE EXTRACTION SPACE CLOSURE

The segmented arch technique, as developed by Burstone,l-4 utilizes T-loop space clo-
sure springs for anterior retraction, symmetric space closure, or posterior protraction.
The segmental T-loap as described by Burstone and his colleagues :It the UniversilY
ofConneclicut is one of the more versati le space closure devices ~l va il ab l e.1 3. 1 7
One of the underlying principles of a segmented ,lpprooch is to treat Ihe anterior
and posterior uni ts as if they were each one large toolh. Each segment should be pre-
pared for sp:lce closure with the placement of large rectangular wires in the bracket
slots. The left and right buccal segments are connected with a tr.tnspalatal arch or lin-
gual arch, creating II si ngle large posterior unit.
The configurOilion for the basic T-loop spring is shown in Figure 9- IIA and B.
Thi s design uses .017 x .025"' TMA wire. Figure 9- IIA is a T-loop without preactiva-
tion bends. Figure 9-IIB shows thc loop shape before insenion. 11
General Concepts for Segmented T-loop Use

Understanding an appliance desig n requires recognition of the l)(ls.~ ive form of a
spring and its activation. Figure 9- 118 demonstrates thc passive form of the T-loop.
There are no forces or moments acting on the spring in thi s state. The activation of
the spring requires the application of forces and moments to engage the spring in the
brackets or tubes. The spring exerts a force system on the teeth in its act ive form.
166 CHAPTER 9
Bfomechanical Basis of Extraction Space Closure
An essential concept in understanding the use ofT-loops for space closure is the
nelllrai posirioll. l-4 The neutral posi tion is found by applying the acti vation moments
to the spring without any horizontal forces. In other words, the anlerior and posterior
extensions of the spring are "twisted" to bring each level 10 its respective attachment
on the occlusal plane. In this position the spring has zero horizontal force . The hori-
1..ontal force is produced by pulling the ''T' open from thi s position. The activation of
the spring is always considered with respect to the neutral position, and this can be
evaluated only by the application of the activation momenls. When the proper preacti -
vat ion bends are placed, the spring is designed such that the spring forms a "T' in the
neutral position. Simply observing the shape of the spring in its inserted position does
not indicate the spring activation. Figure 9-12A shows a T-loop inserted passively
into the auxiliary molar tube, B demonstrates the neutral position of this spring. and C
depicts the fu ll activation and insertion of the spring.
Differential anchomge is obtained by the application of unequal alpha and beta
moments. The higher moment is applied to the anchorage teeth. The differential
moments are obtained by applyi ng the concept of the off-cemer V-bend. An off-center
V-bend in a wire results in unequal moments. The closer the V-bend to a tooth or set
of teeth, the higher the applied moment. A simplistic model for envisioning this force
system is to consider the length of wire from the position of the V-hcnd apex to the
brackets. The closer the V-apex is to a bracket. the shorter the wire; the further the
distance of the V-apex to the bracket. the longer the wire. A shorter wire has a higher
bending moment than a longer wire. Therefore. a higher moment acts on the bracket
closer to the V-bend than the more distant bracket. 12• 17
The segmented T-loop approximates a "V" shape. Centering the T-loop equally
between the anteror and posterior lUbes produces equal and opposi te moments. Posi-
tioning the loop slightly off center relative to the anterior and posterior tubes gener-
ates unequal moments. The spring is posi tioned closer to the anchorage teeth. Clini-
cally, the spring usually needs to be I to 2 mm closer to one side than to the other to
obtain a momenl difTerenlial. 17
Subtle changes in the position of the V-bend can result in significant changes in
the moment magn itudes, especially wi th small interbracket distances. One advantage
of the segmented T-loop is the use of a larger interbracket distance, reducing the rela-
tive effect of minor errors in spring position. For instance, a I mm error is a smaller
proportion of a 20 mm interbracket distance than a 10 mill interbracket distance.
The T-loop described here is designed for an activation of up to 6 mm. At a full 6
mm activation, tooth movement occurs in three phases-/ippi/Ig. Irami/arion, and mor
movement (Fig. 9- 13). For a symmetric, centered spring, the initial force system
applies a MIF ratio of about 6/1 to the teeth. This results in tipping movement of the
anterior and posterior teeth into the space. With about 2 mm of deactivation or space
closure (spring activation = 4 mm), the M/F ratio increases toward lOll. resulting in
bodily tooth movement or translation. With one to two more mi llimeters of space clo-
sure (spri ng activation = 2-3 mm), the MJF ralio increases to 1211 and higher. 'The
high M/F ralio results in root movement. In typical clinical application, the spring
does not need reactivation until all three phases of tooth movement have been
expressed. I""
Symmetric Space Closure-Group B Anchorage
Group B anchorage is the simplest form of space closure. The requirements for space
closure include equal tran slation of the anterior and posterior segments into the
extraction space. Equal and opposite momen ts and forces are indi cated. AT- loop
spring centered between the anterior (can ine) and posterior (molar) attachments pro-
duces this force system. The center position of the spring can be found by:
CHAPTER 9 167
Biome<ha nical Basis of Extraction Space Closure
___'_~_y~_5_:"'_~____
5~
BETA ALPHA BETA ALPHA
Posterior Anterior Posterior Anterior
A B
Figure 9-11. Spring design of .017 x .025~ TMA segmented T. loops. A is th e standard form, w ithout the
preactivation bends. B is the preactivatiOll lonn of the spring. This spring is designed to produce equal
and opposite alpha and beta moments during space closu re when in a centered position.
Figure 9-12 . The segmented .017 x .025 H
TMA T-loop. A, TI'Ie T-loop passively inserted

into the au~iliary tube on the first molar. B,
The neu tral po5luon of the T-loop; the clini-
cian app lies activa ti on moments on the
spring, which aligns the spong to the level of
the ocdusal plane. No horizontal forces act
on the spring in thiS posi tion. C, Full insertion
of the T-Ioop spong into the vertical tube on
the canine or anterior wire segment.
AI'. f\
(\
V
ri
,
l "",;)
B
------
Di stance = Inle rbraeket Di stance - Activation

2
=
where di stance the leng th of the anterior and posterior ann s (distance from the cen-
ter of the T-loop to either the anterior or posterior tubc(s)),
interbracket distance = the distance between the molar and canine brackets. and
aCli valio n = the millime te rs of activation of the spring (usually 6 mm).
168 CHAPTER 9
With the use of a vert ical tube at the canine, a 90" gingival bend at the calculated dis-
tance cases placement and mon itori ng throughout space closure. If the can ine bracket
docs not have a vertical tube, crimpable "cross-tubes" may be attached to the anterior
segment. To insert the T-loop place the spring in the auxilary molar lUbe (Fig. 9- 12A).
Then the 90 0 bend is inserted into the canine tube. The distal end is pulled back until
the distal ann is the desired length. which results in the desired activation (usually 6
mm). Figure 9- 12C depicts the proper appearance.
At 6 mm activation, the spring delivers an M/F ratio of about 611 with 11 horiZOIl-
tal force of approximate ly 320-340 g. The horizontal force di ssipates at a rate of
about 60 g/rnm. The too th movement is expected to follow the phases described
above- tipping, translation , and root movement (Fig. 9- 13A-C).
Space closure should be monitored periodically. To check the remaining acliva-
ti on, the spring is removed from the canine lUbe and the remaining acti vation at the
neutral position is meas ured. The activation equals the distance"'the gingival bend
must be pulled mesially to be inserted inlO the canine tube. The passive spring form
shou ld also be eval uated si nce distortions in the spring shape will alter the force
system.
The progress of the space closure is assessed by observing the amount of remain-
ing space, the ax ial inclinations of the anterior a nd poste rior segments, a nd the
occlusal rela tionsh ip. During the ti pping phase the anterior and posterior occlusal
planes angle toward one another due to Ihe segments' tipped axial inclinations. This
;mgulation corrects during the root move ment. When the occl usal planes regain paral-
lelism, spring reacti vation is indicated (Fig.9- 13C). The amount of reactivation of the
spring should be based on the space closure requ ire ments at that time.
Figure 9-14A-S shows an example of a patient treated with Group B anchorage
space closure. Figure 9- 15 A- M also shows a clinical example of space closure with
T-loops. Figure 9-15C shows the use of Class III clastics with the T-loop for Group C
space closure.
Maximum Posterior Anchorage-Group A Space Closure

The biomec hani cal paradigm for this sp:lce closure problem is to increase the poste-
rior MIF ratio (beta M/F ratio) relati ve to the anterior MIF ratio (alpha MIF ratio).
Utilizing the V-bend princi ple, the T-loop is positioned closer to the posterior attach-
ment or the molar tube (Fig. 9- 16). It is not necessary to Ix very far off center to
obtain an adequate moment differential , with most cases requ iring on ly 1- 2 mm otT-
centering.
Activate the spring 4 mIU for Group A space closure. This reduces the horizontal
force without adversely affecting the mome m difference. The force system acting on
the ante rior segme nt favors tipping tooth movement. The moment difference remains
as the space closes and the spring deactivates. T'he spring must be reactivated when 2
mm or less of activation remain.
Because the beta moment is greater than the alpha moment. II vertical intrusive
force acts on the anterior segment. This intrusive force mlly exaggerate the tipping
tendency and the steepening of the anterior occlusal plane. Likewi se, the increast.'<I
beta moment may steepen the posterior occlusa l plane. Maintaining an adequate hori-
zontal force helps reduce Ihese effects. The posterior occlusal plane can also be con-
trolled with the usc of II high-pull headgear.
It is likely that a root correct ion stage will be required following Group A space
closure. The nature of the root correction needed will depend on the specific needs of
CHAPTER 9 169
Figure g....n. Phases of tooth movement with

segmented T. loop space closu re. A, Tipping,
B, translatioo, C, root movement. The spring
needs reactivation only after root movement
has beeen obtained.
the case. En-masse anterior and posterior root correcti on, anterior root correction, or
separate canine root correction are common possibilities.
Fi gures 9- 17A- P and 9- ISA-S show two examples or Group A space closure.
Maximum Anterior Anchorage-Group C Space Closure

Posterior protraction is the most difficult space closure procedure. The biomechan ical
pri nci ple reverses the approac h to Group A space closure. T he alpha (anterio r)
moment is increased relative to the beta (posterior) moment. T he primary side effect
is an extrusive rorce acting on the anterior teeth. The difficulty results rrom this extru-
sive force, thus deepening the overbite.
In Group C space closure with a segmented T-loop. the spring is positioned closer
to the :mterior segment. It is important thai the anterior wire segment achieve ru ll -
bracket engagement: otherwise, the play within the brackets reduces the effectiveness
of the moment di ffe rential. One or two millimeters closer to the anterior teeth is typi-
call y all that is necessary.
Space closure can be expected to proceed with mesial tipping of the buccal seg-
ment. To reduce the hori zontal forces, an acti vation of 4 mm is recommended. The
spring should be reacti vated llpprox imately every 2 mm.
The maj or side effects to monitor are loss of anterior anchoruge and anterior
extrusion. Intermax ill ary clastics can aid the anchorage conlroJ. For mandibular molar
170 CHAPTER 9
Figure 90-14. Patient M.D. A-F, This patient exhibits a signifi·

cant crowding in the anterior region, crossbile of maxillary lat-
erals, and a Class I malocdusion among other problems. Four
first bicuspids were e.tracted. The anchorage was determined
10 be of 8 type since indsors needed minimal retraction.
CHAPTi R9 1 71
Figure 9- 14. (Continued) G-K. Ma.ii-

lary space is completely cI~d after the
use of the T-Ioop. J and K. The segmen-
tal uprighting springs for en-masse cor-
rection of the roots of anterior teeth. The
lowe!" arch still shows some spaces at the
extraction si tes. L-M. A 8-type T-loop
positioned symmetrically to dose the
remaining extraction spaces.
lIIustJation continued on following page
172 CHAPTER 9
Fi gure 9-14. (Continued) N-S, The patient at the end of the treatment.
Figure 9-15. Patient J.F. A- F, The start of B-anchorage space
closure with a T-loop with equal alpha and beta moments.
The objective was to achieve a cuspid Class I and molar Class
II occlusion. When th e cuspids have achieved Ctass I relation -
sh ip, the T-loop with the equal moments can be positioned
near the cuspid for the protraction of the posterior teeth; or
as shown in G, Class III elastics can be used for a short period
to increase the protractive force of the T-loop.
IIIIJ~tration continued on following page
173
174 CHAPTER 9
Figure 9-15. (Continued) H-M. The patient at the end of the

treatment.
CHAPTER 9 175
Fi gure 9·16. T·loop positioned off center for

Group A space closure. A, The force sys tem
for Group A space closure, with greater beta
moment th an alpha moment. Note that there
are vertical forces in co nj unction with a
moment difference. B. The length of the beta
"arm" is shorter (by about 2 mm) than the
length of the alpha "arm." The activation of
th e spring Is 4 mm . C, Th e fully inserted
spring for Group A space dosure.
• •
B '"""
".
protraction, C lass II elasti cs from the mandibular first molar to the maxillary canine
further increase the fo rce Oil the lower buccal segment. As shown in Fi gure 9- l4G.
Class III clast ics aid in protracting upper buccal segments.3.4.17 Altemativcly. protrac-
ti on headgear may be used to the upper buccal segments. although compliance may
be questionable.
Contro l of Mechani cal Sid e Effects During Space Closure

The discussion SO far has focused on the second-order force system and tooth move-
ment. However, recogn ition of the three-dimensional nature of the force system is
critical to effi cient. predictable treatment.
From the occlusal view (the firs t order), the major side effect during space clo-
sure is the rotalion o f the molars and/or canines. Figure 9- 19 shows the occl usal view
of a maxillary arch. The horizontal forces act buceally to the centers of resistance on
the molar and canine. Thus. there is a moment of the force tending to rotate the fi rst
molar mesial-in and the canine distal-in.
Control of the molar rotation may be easily accompl ished with a palatal or lin-
gual arch. Rigidly joining the molars bilaterally negates the rotational effect. This is
shown in Figure 9- 20.
d
176 CHAPTER 9
Figure 9- 17. Patient E.T. This patient is an example of A

anchorage. A-F, Extraoral and intraoral photographs at the start
of treatment. The overjet was 6.0 mm and molars were fu ll
cusp Class II . A decision was made to extract the upper first
bicuspids and no treatment of the lower arch. Since the molars
were already Class II, the treatment objectives induded retrac-
tion of the anterior teeth inlo the extraction space with minimal
anterior displacement of molars.
l/Iu5iration continued on foJ/owing page
CHAPTER 9 177
Figure 9-17. (Contmued) G-J. The start of the anterior retraction with the T-loop. The preactivation bends of this T-Ioop indude
a small alpha angulation and a large beta angulation since the loop is positioned anteriorly. This loop can also be placed near the
motar, but then alpha and beta angulations should be equat, as noted in the tellt. Note that anterior and buccal stabilizing seg-
ments and a palatal arch are placed prior to the start of the retraction.
lIIustratJon continued on following page
178 CHAPTER 9
Figure 9-17. (Continued) K-P, The fadal and intraoral views at the elld of treatment. The anchorage is completely maintained aM
maximal retraction of the anterior teeth is obtained with only one reactivation of the T-Ioop over a 7-month period. No root correc-
tion was done at the end of the space closure. Finishing was done with the use of rectangular archwires.
CHAPTER 9 179
f i gure 9-18. PatJent S.R. A-F. This patien t IS an elfample of A anchorage but wi th a
significant amount of overbite and maxillary anterior crowding. The molars are full
cusp Class II occlusion. The treatment decision was to elf tract malfiliary first bicuspids.
The treatmen t objectives included intrusion of upper inosors and maximal retraction
of upper anterior teeth and no significan t treatment of the mandibular arch .
Illustration con tinued on following page
Figure 9-18. (Continued) G-J, An incisor bypass wire to retract cuspids with the T-Ioops just enough to align the incisors and pre·
pare for the en·masse retraction of the anterior teeth. This procedure maintains the incisor position without flaring of the incisors
before retraction. K-N, Consolidation of anterior teeth into one unit for en-masse retraction with the T-Ioop. This retraction was
accomplished with both a "composite T_loop· s l of .01lr TMA welded to a .017 x .025" TMA posterior section. Joining diHerent
diameter wires is used to obtain the desired moment diHerential rather than utilizing spring positioning. The alpha M/F at the start
of retraction is 7/1 and the be taM/F is 12/1.
180 lIIusuation continued on following page
CHAPTER 9 181
Biom echanical Basis of Extraction Space Closure
figure 9-18. (Continued) 0-5. The finished intraoral views.

PriOr to the complete space closure. a one-piece intrusion arch
was used to intrude maxillary inclSOl"S for 3 mon ths and then
the space closure was resumed. Note the occlus.al plane and
axial inclinations of the maxillary tee th. The lower arch was
treated for 6 months before the patient was debanded.
R()(alion o f the canines can be control led through a variety of tcchniqucs. For en-masse
space closure. a rigid anterior segment reduces the rotalion:11 tendency. A canine bypass. an
anterior segment connccting the canines but bypassing the incisors. is useful for separate
canine rotation. A third technique is to incorporate "anlirolal io n" bends inlO the spring
design (Fig. 9-2 1). Viewing a spring from the occlusal. one sees thai this involvcs creating
a V-bend geometry in the spring shape. The apex of the V would lXlinl buccally. This
design adds a mesial-in mo ment to the canines and a mesial-oul rotation to the first molars:'
With asymmet ric space closure_ vertical forces are produced. These fo rces may
produce undesirable intrus ive o r extrusive looth movements. These vert ical fo rces
may also produce unwanted third-order (buccal -lingual) side effects. Fig ure 9- 22
shows the e ffect of vertical fo rces on a molar a nd canine from the third order.
Palatal or ling ual arches he lp control the thi rd-order side e ffects o n the molar
182 CHAPTER 9
Biomechanica l Basis of Extraction Space Closure
Figure 9-19. First-order side effects seen

with extraction space closure. The ITleSIai
and distal forces (blue) produce rotation
(red) of the canine and molar. The canine
tends to rotate mesial-out while the molar
tends to rotate mesial-in . Fig ure 9-20. The transpalatal arch
for control of molar rotations.
(Fig. 9- 23). A round wire without third-order control is ineffecti ve for this application
(i.e .• a round TPA wire); otherwise, a wide variety of of lingual designs work. 4
The third-order control of the canine is primari ly a concern with Group A space
closure (Fig. 9-22D-F). The intrusive force on the canine will tend 10 tip the crown
buccally. This tends to increase the overjet at the canine and/or increase the interea-
nine distance. Thi s may be of particular concern when maxillary cani nes erupt buccal
and superior to the occlusal plane (so-called hi gh canines). The intrusive side effect
retards the eruption to the occlu sal plane. Buccal lipping moves the teelh away from
the arch form. Both of these movements arc opposite to the desired direction of move-
ment. Alternative appl iance design s arc indicated . Possible treatmen t approaches
include the use of intermaxill:lry elastics to aid in canine efuption or a symmetric.
centered T-loop spring with concurrent headgear anchorage control.
Appliance designs can be innovative: giving considemtion to the force system simply
prepares the clinician to deal with these difficulties. Dctennination of the static force system
in equilibrium identifies potential difficulties, and creative thinking aids in resolving them.
CONTINUOUS ARCH T-LOOP SPACE CLOSURE
Segmental T-loop space closure principles can also be applied to space closure on a
continuous arch. The force system is nol as well defined as with segmenlal T-springs,
F1sure 9-21 . First-order view of a T-loop

sprins with a V-bend incorporated lor rota-
tional con trol. Figure 9-15 shows the rota·
tional side effect of the distal force on the
cani ne, shown here in shaded red. The V-
bend produces a cou nterrotation (mesial-
in/distal-out) on the canine when th e wire is
inserted into the canine bracket. The rota·
tional effect of the V-bend is shown in red.
This rotational control also aids in reducing
the mesial-In side effect on the molar. A
uanspalataJ arch (Fig. 9-1 n further stabilizes
the buccal segments.
CHAPTER 9 183
Biomecllanlcal Basis of Extraction Space Closure
Figure 9- 22 . Third -ord er side effects

from space closure. A. Vertical forces act -
ing on the molar secondary to unequal
moments used for Group A space closure:
the beta moment is greater th an t he
alpha moment. An e)(truSive force occurs
at the bracket. 8, The equivalent force
system at the cen ter of resistance of the
molar; the e)(trusiYe force at the bracket
resuhs in a moment rotating the molar in
a crown lingual direct ion . C, The pre-
dicted tooth movement from this force.
A B c
0, The vertical forces acting on the canine
~\
secondary to unequal moments used for
Group A space closu re. E, The "equiva-
lent fo rce system" at th e center of reSis- \1
I! )..:
tance of the ca nine; th e intrusive force at
i@t\t
~
th e bracket results in a moment rotating
th e ca nine in a crown bu ccal directio n. F,
~~
The pred icted tooth movement from th is
force .
..~
D E F
bUI care ful usc of alpha and bela moments he lps to achieve compamble results. espe-
cially for Band C anchorage problems. For Group A anchor:lge C'ISCS, high-pull head-
gear is necessary to control {he posterior tooth position.
T-loops, one on each s ide, are made d istal to the c uspids lIsing a prefo nncd arch-
wire (.017 x .025" TMA or .016 x .022" stain less stee l wi re). The acti vation s
described a re inte nded fo r TMA wires; fo r stainless steel wires the :le li vatiOIlS c an be
reduced by 50 percent.
As shown in Fig ure 9-24A, T-loops are made 6-7 mm hig h a nd 10 mm wide and
arc positio ned dista l to the cuspids. Desired alpha and bela mo me nts arc placed ante-
A
5E
FIgure 9-23. The Iranspalatal arch for the control of third-order side effects.
The TPA must have third-order cOfl trol, i.e., rectangular (square) wire.
B
- 5c -
Figure 9-24. T-loops in continuous archwire for space closure. A, T-loop shape in
continuous archwire. B, Placemen t 01 preactivat ion bends for alpha and beta
momen ts. C, Archwire insertion w ith activation f or space closure,
c
¢
184 CHAPTER 9
rior and posterior to the T-loop vertical legs (Fig. 9- 24 IJ ). Recommended octa activa-
tion ror A. B. and C anchorages arc 40°.30°. and 20° respectively.
After the acti vations are placed. the loop shou ld be opened approximately 2 mm
before insertion into the mouth. If this is 1I0t dOlle. the vertical legs of the T-loop will
be overlapped in the neutral position.
The wire is inserted into the molar auxiliary tube and ligated to the anterior teeth.
If the T-loops are not passive. atl adjustments should be made outside the mouth. It is
advisable to connect the buccal segments with a palatal or lingual arch. With this con-
figuration. the beta end of the T-loop bypasses premolar brackets and is not inserted
into any posterior brackets except the molar tube. For TMA arches. the T-loop can be
activated 3 mm distal to the molar tube. It delivers a force ill the range of 250-300 g.
If no lingual arch is used. the buccal segments should be carefully monitored for
mesial -in rotation of the molars. Figure 9-25A- M shows an example of space closure
with continuous T-loops.
The patient should be monitored once a month. but no further activations are nec-
essary for 2-3 months. This allows for root correction as well as space closure to
occur. Too frequent reactivation of the T-loop cuuses an excessive tipping with lillI e
root correction.
Co ntro l of t he Side Effects

An optimal loop design for space closure allows the clinician to predict and possibly
prevent side effects. The following arc common side effects of space closure using
continuous arch T-loops and their possible solutions:
I. Side Effect: Tipping of Ihe anterior :Illd posterior segments into the extraction
site.
Correction: Increase the alpha and beta moments.
2. Side Effect: Flaring of the ante rior teeth .
CorrectiOlI: Reduce the alpha moment or increase distal activation.
3. Side Effect: Mesial-in rotation of the buccal segments.
Correction: Mesial-out rotation in archwire. palatal arch. or lingual arch.
4. Side Effect: Excessive lingual tipping of anterior teeth .
Correction: Inc rease the alpha moment.
EVALUATING THE COMPLETION OF SPACE CLOSURE
In many cases. the successful outcome of treatme nt depends on the successful execu-
tion of one's space closure objectives. Yet closure of the extraction space alone is not
an adequate cri te rion for favorable results. There are several observations that need
evaluation. First. the anchorage maintenance must be evaluated. For most cases. the
antero-posterior correction (Class I occlusion. overjet) occurs during space closure.
Second. the occlusal planes o f the anterior and posterior teeth must be evaluated in
both denial arches. Third. the axial inclinations of the teeth must be evaluated. The
occlusal planes a nd the axial inclination arc related. Root divergence is likely to be
associated with noncoincidentul occlm••\\ planes. Ahem;.\tivc\y. the foots may be par·
allel. but there may be a step relationship between the occl usal planes. Finally. the
rOlations of the teeth shou ld be assessed. I>art icular attention should be given to prob-
lematic rotations of the first molar (mesial-in) and the canine (mesial-out). Based on
the diagnostic observations notcd aftcr space c1o~ure. additional treatment mechanics
may be initiated.
-
CHAPTER 9 185
Figure 9-25. Pa tient N.D. A-F, An adult patient with significant crowding in th e upper and lower jaws. In the maxillary arch, firo!
bicuspids wefe extracted and in the lower arch 5eCood bicuspids due to the poor prognosis of their longevity.
lIIus/ratJon continued on followmg page
186 CHAPTER 9
Figure 9-25. (Con tinued) G-I, Space closure in tile upper

arch with continuous arch T~loops . The anterior j><lrt of
the archwire is ligated into the brackets and po!>teriorly
the wire is inserted directly into the molar auxiliary tube.
The wire had equal alpha and beta moments. J-M, The
patient at the end of treatment. No headgear was used
and root correction of anterior teeth was needed for 3
months prior 10 the finishing wires.
CHAPTER 9 187
REFERENCES
I. BurstOlle CJ: Rat iona le of the segmented arch. Am J Onhod 48:805-822, 1962.
2. Du rstor.e CJ: The mechanies of tile segmented arch techniques. Angle Onhod 36:99-120, 1966.
3. Bu rsto ne CJ: The segme nted arc h approach to space closure. Am J Onhod 82:361- 378. 1982.
4. Bu rstone CJ, l'lanley KJ: Modem Edgewise M echanic~ Segmented Areh Tcchnique. Fannington: Uni-
\'ersity o f Connocticut Health Ce nter. 1985.
5. Burstone 0 , Koenig HA: Optimizing anterior and canine retractio n. Am J Onhod 70( 1): 1- 19. 1976.
6. Faulke r MG. Fuchsh ubcr P. Haberstoek D. Mioduchows ki A : A par.lluetric study of the forcelmome nt
syMems produced by T. loop retraction spri ngs. 1 Biomechanics 22:637-647. 1989.
7. Manhansberger C, Monon lY. Bu rstone CJ: Space closure in adult pat ients using the segmented areh
tcchnique. An gleOnhod 59:205-2 10, 1989.
8. Kusy RP. Tulloch IF: Ana lysis of moment/force ratios in the mechanics of toot h movement. Am J
Onhod lXn tofac Orthopcd 90: 127- 131, 1986.
9. Marcone MR : Prediction of onhodontic tOOlh movement. Am J Onhod 69:5 11 - 523. 1976.
10. Nik ol ai RJ : O n optimum onhodontic force th eory as app li ed to ca nin e re tr~ cti on . Am J Orlhod
68:290-302. 1975.
II . Quinn RS. Yo shi kawa DK : A reassessment of force ma gnitu de in orth o donti cs. Am J OrtllOd
88:252- 260, 1985.
12. Bursto(lC CJ, Koe nig HA: Creative wire bending- ll1e force syste m from step and V· bends. Am J
Orthod lXntofac Onhopcd 93:59-67. 1988.
13. 5achdcva RC: A study of fo rce sys tems produced by TM A T- luop ret raction spr in gs. Maste r' s thesis.
Universi ty of Connecticut School of Dental Medi c inc, 1985.
14. Smith R1. Burstonc 0 : Ml."i;:han ics of tooth mo\'emen t. Am J Onhod 85:294- 307. 1984.
15. Tanr.e K. Koe nig !-lA. BurstOlic CJ: Moment to force ratios and the ce nter o f TOIation . Am J Onhod
94:426-43 1.1988.
16. Hixon E!-l, Aasen TO. Arango J. Clark RA, Kloistenllan R. Miller 55. Odom WM; On force and tooth
lnO\'cme lll. Am J Orthod 57:476-488, 1970.
17. Kuhlberg, AJ: Force systems from T·loop OI1hodolllic SJXk."C closure springs. Ma~ler's thesis, Uni ver.
si ty o f Connecticut School of De ntal Med ici ne. 1992.
18. Nanda R, Gold in 0 : Biomechan ica l approaches to Ihe sltJd y o f alterations o r facia l morphology. Amer
J Orthod 78:2 13-226. 1980.
CHAPTER
10
Biomechanical Considerations in
Sliding Mechanics
Ram S. Nanda • Joydeep Ghosh
INTRODUCTION
Orthodontic tooth movement during space closure is achieved through two lypeS of
mechanics. The fi rst type. seg mentnl or sectional mechanics, in volves closing loops
fabricated ei ther in a full or sectional archwirc. 1- j The teeth move through activation
of the wire loop, which can be designed to provide a low load-denection rate and con-
trolled moment-force fmio. The second type, sliding mechanics, involves either mov-
in g the brackets along an archwirc (Fig. IO- IA ) or sliding the archwire through
brackets and tubes (Fig. 10-1/J).1.2·~·6 One of the main differentiating factors between
the two types of mechanics pertain s to frict ion. Si nce sectional mechanics do not
involvc friction, it is also call ed the friclio/l-free or friclionless technique. On the
other hand, friction play s a significant role in sliding space closure: therefore, the
namefriclioll mechallic~' is often associatcd with it (Fig. 10--2).
MOMENTS AND FORCES WITH SLIDING SPACE CLOSURE
In any type of tooth movement. knowledge of two factors is critical: type of force sys-
tc m required to produce a given cente r of rotation and force magnitudes that are opti-
mal for tooth movement. Many authors1- 1~ have studied thc location of the ceOle r of
resist.mce. The site of the cente r of resistance of a tooth is detennincd by the suppon-
ing stress resisting tissues, i.e., the alveolar bone.1 periodontal ligament, and gi ngival
tissue. s It is also determined by the form. length, and number of roots of the t oo th .'~-13
Burstone and Pryputniewicz9 studied the center of resi stancc using laser holography
and reported that the center of resistance of the incisor was at a point onc-third of the
distance from the alveolar crest to the apex of the root. Pcdcrscn et aLI4 studicd the
ce nter of resistance on an cxperime rllal model and showed that it was 6.4 mm
188
CHAPTE R 10 189
Biomechanical Con si derations in Sliding Mechanics
Figure 10-1 . Two types of sliding mechanics: A. M ov ement of brackets along an archwire. B. Movement of
the archwire through brackets.
~ R etraction
FOK e
TIPPING ROTATION
Fi' ll r. 10-2 . The amount of wire extending distal to the morar

tube is an indicator of tooth mO\lemenl and palient adherence to
instructions 00 erastlc wear.
Mom,"'
Figure 10-3. A. Tipping and rotational moments produ ced by a hori ·

zon tal retraction force applied at th e canine bracket . B . Th e anti tip and
E~ Fo rce
antirotation moment-force condition s necessary for bodily movement. ®

(38.6%) and 3.6 (28.6%) mm apical to the cervical line of rhe mandibular fi rst molar
and premolar. respectively. Yamaguchi el al. 15 conducted an in vitro bench study to
estimate the center o f resistance of the maxillary canine ,Hld the mandibu lar first
mol:.r teeth . They foun d that the center of resistance was approx imately 35% and
32% of the length of the root measured apically from the cervical margin for the max-
illary canine and mandibular firs t molar. respectivel y. The point of force application
and archwire si1..cs had signifi cant effects on the location o f the center of rotmion.
As discussed in C hapter I. a single force acting through the center of resistance
of a tooth effccts pure translation of the tooth. In most instances. however. it is not
practical to place a force through the center of resistance because of anatomic limita-
tions in the oral cavity. To overcome th is problem. a force system must be placed on
the crown of the tooth at the bracket in such a manner that a moment is cre;Lted which
is equal in magnitude and opposite in di rection to the moment resulting from the force
acting at the bracket (Fig. 10-3). In sliding mechanics. however. the ort hodont ist does
not need to apply such a balanci ng moment. T he crow n of the canine will tip distally
unlil lhe diagonally opposite edges of the bracket slot contact and bind with the arch-
190 CHAPTER 10
Biomechanical Considerations in Slidi ng Mechanics
wire. The wire then produces a couple to upright the root (Fig. 10-4). The magnitude
of the moment is detennincd by the width of the bracket as well as characteristics of
the wire such as alloy, size, and shape. The alternating sequence of crown tipping fol·
lowed by the root uprighting occurs until all the space is closed.
THE ROLE OF FRICTION IN SLIDING MECHANICS
Over the years. there have been several theories regarding the relation between ortho-
dontic forces and tooth movement y>-n Schwartz IS pro(X>sed that orthodontic forces
should not exceed capillary blood pressure in the periodontal ligament. Storey and
Smith l9 developed the concept of optimal force :IS the minimum val ue of force that
res ult s in the maximum rate o f toot h movement, within the limits of biologic
response. However. the realization of the opt imal force value for movement of indi-
vidual teeth has been elusive. Quinn and Yoshikawa 22 conducted a critical review of
the theories relating orthodontic force and tooth movement and concluded that the
rate of tooth movement increnses with incre:lse in force up to a point, after which
increased forces do not result in nn appreciable increase in tooth movement. They
stated that there is an optimal range of forces within which max imum tooth move·
ment is achieved.
When sliding mechanics are used. friction occurs at the bracket-wire interface.
Some of the applied force is therefore dissipated as friction, and the remainder is
transferred to supporting structures of the tooth to mediate tooth movement. There-
fore, max imum biological tissue response occurs only when the applied force is of
sufficient magnitude to adequately overcome friction and lie within the optimum
range of forces necessary for movelllcnt of the tooth.
Frictional Resistance
Friction is a function of the relati ve roughness of two surfaces in contact. It is the
force that resists the movement of one surface past another and acts in a direction
opposite the direction of movemcnt. When two surfaces in contact slide or tend to
slide against each other, two components of total force arise. One of these is the fric·
tional component, which is parallel in direction to the intended or actual sl iding
motion and opposes the mOl'ion (Fig. I0-4A ). The other component, known as the
normal force , is perpendi cular to one or both contacting surfaces. During canine
retraction, the relationship of the bracket to the wire changes at different stages of
treatment (Fig. 10-411). Therefore, the magnitude and direction of the associ'Lted fric-
tional and nonnal components of contact forces will also vary with time. Once move-
ment has been initiated, fri ction does not depend on the surface :lreas in contact or on
the velocity of their relative motion.
Friction can be described by the coefficient of friction, which is a constant and is
related to the surface characteristics of the material. The coefficient of friction can be
described mathematically as the frictional force that resists motion. divided by the
nonnal force that acts perpendicular to the two contacting surfaces. There are two
coeffi cients of friction for a material. One is the coeffi cient of SIalic friction, which
renecLS the force necessary to initiate movement. and the other is the coefficient of
kinetic friction. which renects the force necessary to perpetuate this motion. It takes
more force to initiate motion than to perpetuate it.
Variables Affecting Frictional Resistance Du ring Tooth Movement

A large number of variables exist that cml directly or indirectly contribute to the fric·
tional force levels between the bmcket and the wire. They are listed as follows:
CHAPTER 10 191
Biomechanical Considerations in Sliding Mechanics
Figur. 10-4. Sequence of canine movement during

rttraction with sliding mechania. A. The normal compo -
--
Movt_nl
nent of force (N) and the frictional resistance to move-

ment (f). 8, The bracket tips until the diagonally oppo_
w.e come~ of the bracket contact the wire. C The wire
deflects produce a couple to upright the tooth.
A. PHYS ICA.L
I. Archwire.
a. Mate ria l2J-JO
b. Cross-sectional shape/size!3-27.JI.Jl
c. SurfitCe (ex(u~ff
d. Stiffness
2. Ligation of archwire to bracket
a. Lilbatll«: Wl(e.~24.J I -n.J6...l8
b. Elastomerics 2A.l J- 33.J6-l8
c. Method of ligation: method of tying, bracket designs to limil force of lig-
mion. self-ligating brackets39-41
3. Bracket
a.MmeriaJ2J,28
b.Manufacturing process: cast o r si nte red stai nless stcel42
c.Slot width and depth 23.24.26,27.30.J3
d.Design of brac ket : single or twin
c.First-orde r bend (in-out)
f.Second-order bend (ungulatio n)24.Z7.J1.32.43
g. Third-orde r bend (to rque)
4. Orthodontic appliance
a. Interbradet distance24
b. Level of brac ket SIOls between adjacent tceUt l
c. Forces applied for relractiOltJ·44
B. BIOLOG ICA.L
I . Saliva2l.29.3J.4.s
2. Plaque
3. Acquired pellicle
4. CorrosionJ2
With so many variables affecting the frictional force, it is difficult to accurate ly
detcnninc them in a clinical situation . The problem is further complicated by the wide
array of bmckets. wires, and li gatures avai lable that provide a mullitude of combina-
192 CHAPTER 10
lions for use during various stages of onhodontic treatment. No longer do orthodon-
lists solely utilize the traditional stainless steel wires, brackets, and ligatures. Today,
the use of wires of al loys such as cobalt-chromium (Co-Cr), nickel-titanium (N iTi), or
Jl-litanium (Jl-TI) during different phases of treat ment and both 0.0 18 inch and 0.022
inch bracket slots are commonplace. No one study has considered the effects of all
these factors together. Table 10-1 lists the variables that have been considered in
major studies on friction in onhodontic systems. Primaril y, four experimental meth-
ods have been utilized in these studies:
1. Simulmed fool1l movemel1l: Most of the studies within the orthodontic litera-
ture have carefully siTllul:lled different clinical conditions between bracket and
archwire to measure sliding frictional resistance.
2. Sutface rouglme.u: Some studi es have quantified the surface roughness of var-
ious bracket and archwire material s. The most common method of estimating
roughness was by spec ular refl ectance, which involves determination of the
amount of light that is reflected back from a surface. A very smooth surface
reflects much of the light shone on it in a narrow pattern, while a rough sur-
face scatters the li ght and reflects it back in a more dispersed pattern.
3. Contact fl{w': Coefficients of fri ction have also been evaluated using ortho-
dontic wire held between two parallel plates (contact flats) made of material
si milar to that used in onhodontic brackets, such as stai nless steel, polycrys-
tall ine alumina. or teflon . Various level s of nonnal force were appl ied on the
plates and the wire pu lled through them to measure the friction genemted.
4. Descriptive sflldies: These h:lVe involved discussion of the fri ctional resistance
of bmckets and wires based on cli nical experience and anecdotal information.
Effect of Bracket Material and Design on Kinetic Friction

Orthodontists today have a multitude of options when il comes to selecting a bmcket.
In the edgewise design itself. there are choices in slot size, bmcket width, number of
wings, prescri ption in preadj usted designs, li gation capabilities, and bracket material.
The most popular bracket materiul remains stain less steel; however, conventional cast
stainless steel has met its competitor in the si ntered variety. The technology of sinter-
ing, the process of fusing indi vidual panic les together after compacting them under
heat and press ure. allows each individual bracket to be premolded in a smooth
streamli ned manner. Th e stainl ess stee l particles are compressed in a contoured,
smooth. rounded shape, <IS opposed to the o lder cast ing procedure in wh ich the
milling or cutting processes left sharp angular brackets that were bulky and rough.
Newer alloys, such as titanium, arc also being tested in the quest for the material of
minimal fric tion and ultimate strength . For the aesthetically oriented clinician and
patient. ceramic brac k~t s, which are available in the monocrystall ine and polycrys-
lalli ne fonns. have provided an alternative. Al so available are plastic brackets, with
and without ceramic reinforcement and metal slot inserts. To understand Ihe effects of
bracket material on friction in sliding mechanics. a series of in vestigations have been
conducted at the department of orthodontics, University of Oklahoma College of
Dentistry.23.26.JSAIA2
Conventional cast stainless steel, sintered stai nless steel, cemmic. and plastic
bmckets were tested for fricl ion with seveml combinations of stainless steel, Co-Cr,
NiTi . and P-li wires in various cross-sectional sizes. Narrow single (0.050 inch),
medium twin (0.1 30 inch). and wide twin (0. 180 inch) edgewise brackets of zero
torque and zero angulation in both the 0.01 8 and 0.022 inch slot sizes were used. The
wires were subjected 10 equal amounts of tension. The bracket movement along the
wi re was implemented by an Instron uni versal testing machine (l nstron Corp., Can-
Table 10-1 . The Variables That Have Been Considered in Major Studies on Friction In Orthodontic Sliding Systems
Author/ year ligation Saliva Slot Bracket Wire Bracket Wire Surface Applied Angulation Interbrack.
Size Width Material Material Size/ Rough Load Width
Shape
Buck et aI. 19634 ) , , , ,
Andreasen and Quevedo 197()l1 , , , , ;
Echols 19750tfi , , I
Creekmore 1976.7 , , I
Greenber and Kus 1979'8 ,
Feene et al. 197949 ,
Rile et al. 197932 , , ,
Frank and Nikolai 198Q24 , , , , , ,
Peterson et al. 1982 27 , , , ,
Stannard et al. 198629 , , , ,
Garneretal .198@5 , ,
8aker et al. 198745 , ,
Ku~and Whitlev-198S50 ,
Ku~et al. 198834 , , ,
Drescher et aI. 19893) , , , , ,
Kus and Whitle 19895' ,
Tid 198930 , , , , , ,
Awolkar et aI. 199()2) , , , ,
Sewer 199()l9 , , ,
Ka ila et al. 199()2ii , , , , ,
Kus and Whitle 199()5l , , , ,
K~and Whitle 199()lS , , , ,
Pratten et aI. 199()28 , , ,
Bednar et aI. 1991 5} , , , ,
Ireland et aI. 1991 S. , , , , ,
Kus 1991 ~
Ku~et al. 1991 56 , , , , ,
Prososki et al. 1991 57 , ,
Tanne et al. 1991S8 , , ,
Omana et al. 199259 , , , , ,
Keith et al. 199460 , , ,
09ata 199141 , , , , ,
Saunders and Kusv1994 61 , , , ,
Shiva u'a and Ber er 199440 , , , ,
Tanne et al. 199462 , , ,
Tse~is et al. 199463 , , ,
..
~
II) Vaughan et al. 199542 , , ,
194 CHAPTER 10
Biomechanlcal Considerations in Sliding Mechanics
,
erosshead
I~
in
movable arm of
"'ffe frame CO ? 1o<te loadong
.<m I comp'es s"'" ce ll
eal,tlfaled Spf '''9
..
t--- ,
w"~
e ~cl frame 10 !>Old
Wk oa ll bearong
. ;L1.
w" e speC 'men
compreSSIOII tell
,.I
I I (
x • Y recCWder
Figure 10-5. A. Testing machine, bracket-wire assembly, and force-measuring equipment. B, Greater detail of the area
enclosed by the dashed line in A. (From Kapila 5, Angolkar PV, Duncanson MG Jr, Nanda RS. Evaluation of friction
between edgewise stainless stee l brackets and orthodontic wire s of four alloys. Am J Orthod Dentofac Orthop
98:117-126,1990.)
ton, MA) (Fig. 10--5). The mean values of frictional forces prcx:luced by the conven-
tional stainless steel, sintered stainless steel, and ceramic brackets and the statistical
fi ndings are reported in Table 10--2 for the 0.018 inch bracket slot and Table 10--3 for
the 0.022 inch slot.
Stainless Steel Brackets

Upon initiation of movement by the Instron machine, there was a rapid increase in the
recorded force as the applied force attempted to overcome stalic friction before move-
ment commenced. Once bracket movement had been initiated, subsequent displace-
ment of the bracket relative to the wire required smaller forces. However, during the
entire length of each run, undulations in the magnitude of forces required to overcome
friction were noted. These force variations generally occurred wi thin a narrow range
of values and probably resulted from the second-order movement of the bracket rela-
ti ve to the wire permitted by the experimental design. Similarly, in vivo factors such
as occlusion, mastication , wire resilience, and tooth movement may alter the second-
order bracket-wire relationship as the bracket moves in relation to the wire. 24
The mean frictio nal forces with the conventional cast stainless steel brackets
ranged between 40 and 336 g. The levels of frictional forces observed in 0.018 inch
conventional cast stainless steel brackets ranged from 49 g with 0.01 6 inch SS wires
in narrow single brackets to 336 g with 0.017 x 0.025 inch P-Ti wi res in wide twin
brackets. Simi larl y, for 0.022 inch stain less steel brackets, frictional fo rces ranged
from 40 g with O.Q\8 inch SS wires in narrow brackets to 222 g with 0.019 x 0.025
inch NiTi wires in wide brackets. Several stainless steel bracket-wire combinations
generated low levels of frict ional forces, less than 1\0 g. Within medium twin brack-
ets, 0.016 inch SS and Co-Cr wires, 0.016 x 0.0 16 inch Co-Cr and NiTi wires in
0.0 18 inch brackets, as well as 0.016 inch and 0,018 inch Co-Cr and SS wires, 0.0 16
CHAPTER 1 0 195
Blomechanlcal Considerations In Slid ing Mechanics
Table 10-2. Comparison of Mean Frictional Forces Produced by Conventional Stainless Steel (Ormco Corp.),
Sintered Stainless Steel (Mi ni-Taurus, Rocky Mountain Orthodontics; Miniature Twin, Unitek Corp.), and Ceramic
Brackets (Gem , Ormco Corp ) fo r the 0 018 Inch Bracket Slot
Wire Size Wire Frictional Force
(i nch) Alloy Kapila et al. Vaughan et al. Angolkar et a!.
Stainless Steel Sintered Mini-Taurus Si ntered Mi niature Twin Ceram ic
Mean g (SO) Mean g (SO) Meang (SO) Mean g (SO)
0 .016 SS 88.8 (33 .8) 81.4 (25.0) 60.3 (25.9) 123.0 (32.7)
Co-Cr 66.4 (27.4) 54 .8 (24.0) 45.8 (25.7) 88.4 (12.0)
8-TI 176.9 (34.0) 875 (24.6) 110.6 (42.8) 217.9 (21.2)
Ni-li 159.0 (19.4) 825 (215) 74.3 (38.8) 221 .9 (29.8)
0.016 x 0.016 Co-Cr 99.1 (145) 63.1 (23.7) 79.0 (26.8) 163.1 (22.7)
Ni-li 109.2 (23.7) 90.5 (28.0) 156.6 (51.6) 237.7 (29.4)
0 .016 x 0.022 SS 163.0 (35.7) 76.7 (26.0) 74.2 (25.7) 150.0 (20.4)
Co-Cr 141.4 (27 .6) 102.4 (42.2) 83.0 (27.4) 159.3 (2 1.3)
B-li 234.9 (68.0) 138.1 (36.1) 116.6 (52.6) 240.9 (35.9)
Ni-li 192.1 (42.3) 84.7 (29.2) 82.3 (465) 228.8 (23 .8)
0 .017xO.D17 SS 163.4 (34. 1) 104 .8 (20.8) SO., (26.4) 148.0 (20.2)
B-li 179.3 (38.3) 141 .2 (56.0) 11 7. 1 (29.0) 217.9 (3B.4)
0 .017 x 0.025 SS 175.4 (38.3) 110.4 (29.4) 82.1 (35.0) 250.3 (50.6)
Co-Cr 165.1 (24.8) 123.8 (33. 1) 93 .0 (40.0) 267 .0 (17.5)
B-li 2745 (49.7) 1335 (41.6) 144.9 (41 .0) 405.1 (101 .1)
Ni-li 225.2 (41.3) 55.9 (15.1) 57.9 (27.7) 182 .1 (19.2)
From Kaplla S. Angolk ar PV, Duncanson MG Jr, Nanda RS. Evaluation of friction between edgeWise stainless steel brackets and orthodontic
wires of four alloys. Am J Orthod Dentofac Orthop 98:117-126, 1990. Vaughan Jl. Duncanson MG Jr. Nanda RS, Currier GF. Relative
kinetic frictional forces between sintered stainless steel brackets and orthodontiC wi res. Am J Orthod Den tofac Orthop 107:20-27. 1995,
Angolkar PV, Kapil a S. Duncanson MG Jr. Nanda RS. Evaluation of friction between ceramic brackets and orthodontic wires of four alloys.
Am J Orthod Dentofac Orthop 98:499-506. 1990.
x 0.016 inch Nili wires, and 0.017 x 0.017 inch SS wires in 0.022 inch brackets gen-
erated relaLively small amounts of fri ction. Similarly. in wide brackets, 0.016 inch SS
wires in 0.018 inch brackets, and 0.016 inch. 0.016 x 0.016 inch, 0.016 x 0.022 inch,
and O.ot8 inch Co-Cr wires, as well as 0.016 inch and 0.017 x 0.017 inch SS wires,
produced low fri ctional forces.
The incorporation of additional design features in brackets can also reduce fric-
tion significantly.41 Bumps on the bracket slot walls and fl oor, which reduce the sur-
face contact with the wircs, hclp reduce the fri ction in the bracket-wire interface. li p-
edge brackets (TP Orthodontics, LaPorte, IN) have a design in which 20° wedges are
cut out of the bracket slot o n diagonally opposite comers, These brackets were
designed largely for the practitioners of the Begg technique, where teeth are first
tipped and later uprighted with auxiliary springs. With this bracket design, when a
tooth lips on retraction, the binding of the wire at the edges of the bracket is greatly
minimized and fri clional resistance is reduced. However, friction produced by thi s
bracket cannot be compared on the same plane with those of conventional edgewise
brackets, which are designed to seek bodily movement as far as possible.
Sintered Stainless Steel Brackets

The kineLic fricLional forces for two commercially available sintered stain less steel
brackets are also given in Tables 10-2 and 10-3. 42 In brackets with the 0.0 18 inch
slot, the frictional forces ranged from 45.8 g with 0.016 inch Co-Cr wires to 156.6 g
with 0.0 16 x 0.0 16 inch Nili wires. However. in brackets with 0.022 inch slots, the
196 CHAPTER 10
Table 10-3. Comparison of Mean Frictional Forces Produced by Conventional Stainless Steel (Ormco Corp.),
Sintered Stainless Steel (Mini -Taurus, Rocky Mountain Orthodontics; Miniature Twin, Unitek Corp.), and Ceramic
Brackets (Gem , Ormco Co rp) for the 0 022 Inch Bracket Slot
Wire Size Wire Frictional Force
(i nch) Alloy Kapila et aL Vaughan et al. Angolkar et al.
Stainless Steel Si ntered Mini -Taurus Sintered Miniature Twin Ceramic
Meang (50) Mean g (SO) Mean g (50) Mean g (SO)
0.016 55 100.6 (20.1) 54.4 (17.6) 58.5 (33.5) 119.0 (34.4)
Co-Cr 93.8 (26.8) 36.0 (27.9) 38.0 (19.6) 136.1 (40.8)
8-Ti 117.7 (21.0) 78.7 (29.8) BO.4 (25.1) 169.6 (31.5)
Ni-Ti 126.8 (16.7) 61.6 (26.5) 73.1 (17.0) 160.2 (23.4)
0.016 )( 0.016 Co-Cr 120.5 (19.4) 58.3 (24.6) 1043 (38.5) 163.9 (58.2)
Ni-Ti 100.7 (13.7) 96.0 (26.5) 40.8 (12.7) 207.0 (27.7)
0.016)( 0 .022 55 129.8 (20.6) 94.2 (39.3) 51.5 (18.2) 202.6 (303)
Co-Cr 146.8 (15.8) 75.7 (B.2) 68.2 (26.0) 2 12.4 (64.4)
8-li 165.8 (19.2) 108.8 (31.4) 114.0 (44.6) 308.4 (58.0)
Ni-Ti 153.2 (17.8) 68.7 (26.0) 74.3 (25.0) 226.4 (25.8)
0.017 )( 0.017 55 99.2 (19.2) 49.2 (7.5) 54 .1 (37.6) 170.3 (253)
B-li 136.5 (34.9) 75.5 (28.5) 95.1 (32.8) 251.0 (49.8)
0.017 )( 0 .025 55 115.4 (18.7) 68.8 (28.5) 63 .6 (18.1) 237.6 (555)
Co-Cr 176.3 (235) 79.6 (34.7) 57.1 (39.0) 231.9 (423)
B-li 215.3 (24.2) 112.1 (55.6) 1683 (44.3) 364.1 (58.3)
Ni-li 177.7 (31.7) 85.5 (27.8) 102.3 (43.1) 282.4 (40.0)
0.018 55 84.9 (13.9) 64.4 (36.0) 30. 1 (9.4) 135.6 (33 .0)
Co-Cr 101 .3 (27.0) 55.4 (20.5) 44 .1 (17.0) 159.0 (39.6)
8-Ti 112.9 (19.8) 1335 (38.6) 139.0 (28.8) 206.9 (225)
Ni-li 162 .1 (29.5) 113.7 (33.5) 132.1 (26.7) 204.9 (27.9)
0.018 )( 0.025 55 150.1 (35.0) 60.1 (20.2) 64.5 {37.5} 240.5 (51.7)
Co-Cr 194.5 (36.4) 50.4 (1 6.8) 45.8 (21.9) 220.3 (40.5)
Ni·li 138.8 (27. 1) 68.1 (27.5) 66.3 (38.3) 227.3 (63.7)
0 .019)( 0 .025 S5 193.3 (28.9) 61.6 (28.1) 71.1 (2 1.2) 265.2 (40.9)
Co-Cr 192.2 (2 1.1 ) 81.1 (36.0) 62.0 (36.8) 253.5 (88.8)
B-TI 154.8 (33.2) 98.9 (58.9) 95.4 (51.1) 399.4 (69.7)
Ni-Ti 155.7 (18.0) 59.2 (20.2) 117.1 (35.3) 283.1 (93.7)
From Kaplla S. Angolkar N, Duncanson MG Jr. Nanda RS. Evaluation of fndion between edgewise stainless steel brackets and orthodontic
wires of four alloys. Am J Orthod Dentofac Orthop 98:1 1 7~ 126. 1990. Vaughan JL. Duncanson MG Jr. Nanda RS, Currier GF. Relative
kinetic frictional forces between sintered stainless steel brackets and orthodontic wires. Am J Orthod Den tofac Orthop 107:20-27. 1995.
Angolkar PV, Kapila S. Duncanson MG Jr. Nanda RS. Evaluation of friction between ceram ic brackets and orthodontic wires of four alloys.
Am J Orthod Dentofac Orthop 98:499-506. 1990.
observed range of fri ctional forces was between 30. 1 g with O.O IS inch 5S wire and
16S.3 g wi th 0.0 17 x 0.025 inch ~-Ti wire.
For most wire sizes, the sintered stainless steel brackets produced significantly
lower friction than cast stainless steel brackets, For the 0.018 inch slot size, the fric-
tion of the sinlered Mini -Tauru s stainless steel bracket was 38% less than the friction
of the cast bracket, whereas the friction of the sintered Mini-1\vin bmcket was 41 %
less than the fri ction of the cast bracket. For the 0.022 inch slot size, the friction of
sintered sta inless steel brackets was approximately 44% less than the friction of cast
stainless steel brackets. This difference in frictional forces between the two bracket
materials may be attributed to the smoother surface texture of the si ntercd stai nless
steel material. There was no significant difference in the mean fric tional force level
between the two manufacturers of the sintcred brackets with the single exception of
the 0.0 17 x 0.0 17 inch wire size in the 0.0 IS inch slot.
CHAPTER 10 197
Ceramic Brackets
With cemmic brackcts, most of the wire sizc and ulloy combinations with both 0.01 8
and 0 .022 inch slot sizes dcmonstrated significantly higher frictional forces lhan with
stainless steel brackets (Tablcs 10-2 and 10-3).23 In brackets with the 0.DI8 inch slot.
frictional forces ranged fTOm 88.4 g for 0.0 16 inch Co-Cr wires to 405. 1 g for 0.017 x
0.025 inch ~-1i wires. However. in brackets with 0.022 inch slots, the observed range of
frictional forces wa<; between 119.0 g for 0.0 16 inch SS wire and 399.4 g for 0.017 x
0.025 inch ~-Ti wire. Thi s difference in friction between stainl ess steel and ceramic
brackets may be attributed to characteristics of the ceramic bracket material or slot sur-
face texture. Highly magnified views have revealed numerous genemlized small inden-
tations in the cemmic bracket slot. while the stainless stccl bracket appeared relati vely
smooth. Single crystal ceramic brackets are derived from large si ngle crystals of alu-
mina, which arc milled into the desired shape and dimensions by ultr..tSOnic cutting, di a·
mond cUlling. or a combinati on of the two techniques. 64 This procedure is difficult and
may ex pl ain the granular and pitted surface of the ceramic brackets seen in the scanning
electron micrographs. Polycrystulline ceramic bmckets have also been observed under
the scanning eleclron microscope to possess very rough surfaces, which actually scribed
grooves into the arc hwire. s9 Laser s pecular re n ec tance and scannin g e lec tro n
microscopy have been used to illustrate the general appearance and quantitati ve magni -
tude of roughnesses for single crystal sapphi re and polycl)'staJlinc alumina brackets. 61
The monocrystalline alumina brackets were observed to be smoother than polycrys-
taUine ones, but their fri ctional characteristics were comparable.
The combination o f mewl archwires and ceramic brackets produce high magni-
tudes of fri ctional force; there fore. greater force is needed to move teeth with ceramic
brackets compared to stainless steel brackets in sliding mechanics. Si nce ceramic
brackets on anterior teeth arc often used in combination with stainless steel bmckets
and tubes on the premolar and molar teeth. retracting canines along an archwire may
result in greater loss of anchorage because of the hi gher frictional force associated
with ceramic than steel brackets. Greater caution in preserving anchorage must be
exerted in such situations.
Zirconia Brackets
Besides high friction, ceramic brackets have very low fracture resistance. Due to
their brittle nature, even thc smallest surface crack or flaw can propagate rapidly
through the material. Zirconi a brackets have been offered as an alternati ve to the
ceramic bmckcts si nce surface hardcning treatments to increase fracture toughness are
available for zi rconium oxide. However, the frictional coe fficie nts of the zirconia
brackets were found to be greater than or equal to those of the polycrystalline alumina
brackets in both the dry and the wet states.60 Surfa ce changes consisting of wire
debri s and surface damage in the zirconia brackets aft er sliding of the archwircs were
also observed.
Plastic Brackets
In an attempt to create an esthetic bracket with lower frictional resistance and easier
debonding features than the ceramics, a variety of new, ceramic-reinforced plastic
brackets with or without metal slot inserts have been introduced . The results from a
study on fri ctional forces generated among four pl astic. one monocrystalline ceramic,
one polycrystalline cemmic. and onc metal bracket and selected wire alloy/size com-
binations are presented in Table 10-4 for the O.QI 8 inch bracket slot and Table 10-5
for the 0.022 inch bmcket 510t.38 The levels o f frictional force observed in the present
198 CHAPTER 10
Blomechanical Considerations in Sliding Mechanics
Table 10-4. Comparison of M ean Frictional Forces Generated by One M etal (55-1, Unitek Miniature Twin),
One Polycrystalfine Ceramic (PC-1, RMO Signature), and Four Plastic Brackets (SP-1, Ormco Spirit; El-1, GAC
Elan·, IM -1 , GAC Image·, 51-1 , American Sikon) for the 0 018 Inch Slot Size
Brackel Wire
Stainless Steel Alloy p-Titanium Alloy Nickel-Titanium Alloy
0.016 Inch 0.016 x 0.022 Inch 0.016 Inch 0.016 x 0.022 Inch 0.016 Inch 0.016 x 0.022 Inch
SNK Mean SO SNI< Mean SO SNI< Mean SO 5NI< Mean SO SNI< Mean SO SNI< Mean SO
A. Elastomeric ligation
55-1 8 74.17 17.61 8 95.17 28.4 A 152.21 47.n e 136.43 33.53 8 137.85 26.75 A 151 27.9
PC·1 A 75.78 13.32 A 100.9 31.9 8 112.34 19.59 8 149.19 2851 0 89.96 13 .49 8 143.4 23 .5
5p· l F 49.87 10.18 E 73 .85 15 e 107.98 1652 0 129.44 16.46 8 138.62 4157 e 1315 17.7
EL-l e 6553 14.17 0 83.06 14.9 8e 110.93 20.37 E 98.86 15.28 A 151 .09 29.09 E 114.1 11
IM-1 E 55.14 10.43 8 97.86 30.9 E 82.25 25.81 F 82.36 17.34 e 132.54 26.9 1 F 109.6 14.4
51-1 0 58.63 10.84 e 87.64 18.5 0 90.02 21.34 A 163.59 66.45 e 132 .18 4552 0 127.2 15.6
B. Steel ligation
55· 1 A 90.8 42.38 8 104.6 46.2 0 100.44 64.DB E 8452 37.47 8 136.47 88.63 8 175.8 142
PC- 1 8 78.03 33.65 e 97.28 70.3 8 185.85 121 .1 e 139.37 80.29 8 141 .1 107.2 E 87.69 34.5
5P-1 0 51 .3 15.82 0 59.17 31.3 A 199.21 58.76 A 222 .31 1085 A 207.82 73.11 A 186.6 76.8
El-l 0 48.81 19.08 0 59.15 26.6 e 138.14 SO.1 8 171.56 n.42 0 88.82 58.04 e 129.7 43
IM-l 0 48.81 22.1 0 58.87 24.2 e 133.03 33.87 0 106.72 50.6 e 104.04 42 .2 0 109.5 26.2
51-1 e 60.23 25.38 A 136.8 71 E 90.3 19.73 e 142.42 46.96 e 108.17 35.22 E 93 .68 61.7
From Bazakldou E. Evaluation of frictional resistance of esthetic brackets. Masters thesIS, Umverslty of Oklahoma, 1995.
investigation for the om 8 inch slot bracket rangcd from 49.87 g with the plastic
Spirit bracket-0.016 inch SS wire-clastomeric li gation combination to 222 .3 1 g with
the plastic Spirit bracket-0.0 16 x 0.022 inch P-Ti wire-slCel li gation. Similarly, the
levels of fri ctional force observed with the 0.022 inch slot bracket mnged from 31.35
g with the stainless steel bracket 0.017 x 0.025 inch SS wire-steel ligation combina-
lion to 270.6 g with the polycrystaUine ceramic bracket-O.OIS inch Nili wire-sleel
li gation combinalion. There was a stati stically signi ficant difference in the mean
kinetic fri ctional force produced by the stainless steel, ceramic, and each of the plastic
brackets.
In the 0.01 8 inch slol. the brackets could be ranked in order from highest to low-
est friction as stainless steel, polycrystalline ceramic, ceramic-reinforced composite
with mctal slot insert, and ccramic-reinforced composite without meta1 slot insert. In
the 0.022 inch slot. the brackets could be ranked in order from highest to lowest fric-
tion as polycrystalline ceramic, monocrystalline ceramic, ceramic-reinforced compos-
ite without metal slot insert, stainless steel, and ceramic-reinforced composite with
metal slot insert. The metal sleeve in the two composite brackets did not significantly
decrease friction relative 10 !.he brackets without the metal sia l. Several other studies
have also found that metal brackets are associated with lower levels of frictiona1 resis-
tance than ceramic or plastic brackets.211.)2.. 3S~~.63 When lightly ligated with steel
Table 1 ~5. Comparison of Mean Frictional Forces Generated by One Metal (55- 2, Un itek Miniature Twi n),
One Mo nocrystaJline Ceramic (MC-2, A-Company Starfire), One Polycrystalline Ceramic (PC-2, RMO Signature),
and Three Plastic Brackets (SP-2, Ormco Spirit; IM-2, GAC Image; 51-2, American Sileon) for the 0.022 Inc h Slot Size
Bracket Wire
Sta inless St eel Alloy ~- TItan ium Allo y Nicke l-TIta n ium Alloy
0.018 inch 0.017 x 0.025 inch 0.019 x 0.025 inch 0.018 inch 0.017 x 0.025 inch 0.01 9 x 0.025 inch 0.018 inch 0.017 x 0.025 inch 0.019 x 0.025 inch
SNK M@an SD SNK Mean SD SNK M@an SD SNK M@an SD SNK M@an SD SNK Mean SD SNK Mean SD SNK Mean SD NK M@an SD
A. Elasto meric Ligation
55-2 8 90.85 11.5 D 83.67 17.8 D 97.75 18.5 C 102.12 23 D 102.1 19.2 C 118.2 14.2 f 101.29 19.4 A 148.91 23.5 8 172.1 23.2
MC-2 8 92.24 16.2 8 101 16.8 A 121.3 30 8 109.7 16 8 130.7 24 8 147.5 32.2 C 144.59 22.4 AS 147.11 38.9 C 166.6 23.5
PC-2 A 114.8 24.8 A 143.6 51.9 8 114.1 22.8 A 147.D2 30.1 A 147.4 31.9 A 160.1 27.5 D 130.44 35.4 8 144.26 21.3 A 200 29.7
5P-2 D 66.07 14 E 78.37 12.2 f 83.51 11.2 D 90.68 14.8 E 85.79 15.8 C 118.2 26 A 158.43 36.4 C 121.33 18.7 C 166.1 26.3
IM-2 E 52.38 16.2 E 78.49 24.3 E 93.81 24.7 E 71 .1 14 E 82.99 19.9 D 99.94 14.1 E 108.45 17.1 E 102.98 13.4 E 144.3 20.8
51-2 C 78.n 15.7 C 91.82 21.8 C 110.1 27.3 D 92.5 14 C 127.2 33.2 C 118.3 10.9 8 148.06 28.3 D 117.8 21.8 D 161.4 30.4
B. Steel Ligation
55-2 C 42.01 18.2 f 31.35 20.4 f 38.75 31.5 C 139.42 60.1 C 124.5 82.6 C 144.2 85.8 C 127.75 38.1 8 131.67 85.4 D 136.2 123
MC-2 A 71.13 41 A 139.8 94.7 C 121 61.5 A 187.58 103 8 141.6 117 D 96.39 70.2 D 129.12 65.5 A 166.42 93 8e 149.2 91
P<-2 8 64.46 35.5 e 102.2 43.9 A 138.7 72.8 8 167.55 100 A 165.4 125 A 207.1 159 A 270.62 149 A 166.66 120 A 201.8 129
5P-2 C 42.14 9.75 D 74.47 39.7 E 44.53 22.4 D 94.08 43.7 C 123.1 60.9 8 159.8 44.2 8 91 .08 55.1 C 114.04 58.5 8 157.5 52
IM-l A 70.88 26.2 E 51.72 26.7 D 60.43 29.4 E n.7 41 .6 8 146.5 110 D 100.6 75.2 D 107.69 45.2 A 157.13 45.2 E 114.5 41.5
51-2 A 73.03 25.4 8 108.2 22.3 8 132.3 41 C 144.46 n.6 A 165.3 85.6 C 137.9 92.5 e 105.26 35.9 8 137.46 35.9 CD 141 .9 38.2
From Bazakidoo E. Eyaluation of frictional resistance of esthetic brackets. Master's thesis. University of Oklahoma, 1995.
......
~
200 CHAPTER 10
ligatures. the plastic brackets may also defonn slightly to squeeze the bracket slot.
thereby increasi ng fri ction.32
Effect of Bracket Width on Friction

The effect of bracket width on fri ction has been controversial. Some studies have
found that altering bracket width made no difference in friclion. 27,31 whereas others
have found that frictional resistance increased as bracket width increased. 24,26,41 On
the other hand. frictional resistance has also been reponed to decrease with increase
in bracket width.30,)),S3.$9 Frank and Nikolai24 related the greater friction with wider
brackets to the fact that binding occurs frequentl y with wider brackets at smaller
degrees of second-order angulation than with narrow bracket s, To the contrary,
Drescher et al..33 Bednar et al.,53 and Om,lOa et al.j9 suggested th:u with a narrow
bracket, the tooth could tip considerably before binding occurred, and that once bind-
ing did occur, it was of a severe nature and resisted further sliding of the archwire.
Kapila et al.26 and Ogata et al. 41 suggested that with a wider bracket the elastomeric
li gature used was stretched more than wit h a narrower bracket , which exerted a
greater normal fo rce on the wire. Kapila et al. 26 reponed that the medium twin brack-
ets in the 0,018 inch slot s i ~e were associated with about one and one-hal f times as
mueh fri ction as narrow single brackets. and wide twin brackets produced almost
twice as much fri ction as narrow brackets. Medium twin and wide twin 0.022 inch
brackets demonstrated no statistical difference in levels of fric tion. However, these
brackets were associated with more friction than narrow single 0.022 inch brackets.
Bracket width is also closely related to interbracket distance. The narrower the
bracket. the greater the length of the interbracket wire, and therefore the greater the
fl exibility of the wire. Bracket width may therefore have an indirect effect on frict ion
si nce an increase in interbracket wire span decreases wire stiffness and results in a
greater chance of binding with the more flexible wi re. In addition, narrow brackets
have the disadvantage of less rotational and tipping control due to the smaller section
of the archwire engaged within the bracket slot.
Effect of Orthodontic Archwires on Kinetic Friction

Wire Alloy
The role of wire alloy in the frictional characteristics of sliding mechanics has been
extensively studied. Table 10-6 lists the major studies conducted and their findings on
the effcct of wiTC alloy on friction. It is evident from the table that most studies have
found stainless steel wires to be associated wi th the least amount of friction and beta
titanium with the most. A greater magnitude and more frequent variation in frictional
forces per unit distance of bracket travel have also been noticed with NiTi and P-Ti
wires than with S5 or Co-Cr wires.26 Frank and Nikolai24 found that stainless steel
wires had less fri ction than nickel titanium at nonb inding angulations, but as the
angulation increased and binding was presellt. the reverse was true.
Specular refl ectance studies have shown that S5 wires have the smoothest sur-
face. followed by Co-Cr. P-Ti, and iTi wires in order of increasing surface rough-
ness.34 In addition to their relatively high surface roughness. P-Ti wires may fonn
microwelds with stain less steel brackets in dry conditions. funher increasing the fric-
tional forces. Kusy and WhitleylS investigated the correlation between surface rough-
ness and frictional chanacterislics of various wire materials. They found that stainless
steel demonstrated the smoothest surface and had the lowest coefficient of frict ion,
With nickel titanium and p-titanium, however, there was no correlation between sur-
face roughness and coefficient of friction. Since p-titanium had the most fri ction but
was not the roughcst. Kusy and Whitley concluded that one cannot use surface rough-
CHAPTER 10 201
Bio mechanical Considerations In Slid ing Mechanics
Table 10-6. Major Studies Investigating the Effect of Wire Alloy on Friction in Orthodontic Sliding Systems.
The Alloys Have Been Ranked from 1 through 4, 1 Being Least Friction and 4 Being Most Friction
Author/Year Wire Alloy
Stainless Steel Cobalt-Chromium Nicke l-TJtanium ~-Titanium
Frank and Nikolai 198()2~ 1 if nonbinding 3 2 if nonbi nding None

2 if binding 1 if binding
Peterson et al. 198227 Equal if nonbinding None Equal if nonbinding None
2 if binding 1 if binding
Stannard et al. 198629 2 4 3 1
Garmer et al. 198@5 None 2 3
Kusy et al. 198834 2 Titanal4 3
Yellow: blue E@Jo.Y Nltinal5
Kusy and Whitley 1989!1 ' 3 2 4
Tidy 1989JO None 2 3
Drescher et aJ. 1989)3 1 2 3 4
Kapila et al. 199()2' 1 2 3 4
Kusy and Whitley 199()52 1 2 3 4
Pratten et al. 199()l8 None 2 None
Angolkar et aJ. 199()23 2 3 4
KusyetaI.1991 ~ 2 3 4
Irelandetal.1991 !5-! 1 None 2 None
Omana et al. 199259 Equal None Equal None
Vaughan et al. 199542 2 3 4
ness as an indicator of the fric tional c harJ.cteristics in sliding mechanics. Prososki et

al.,'? using a profilome tcr to assess surface rough ness. also found no correlation
between surface roughness and coefficients of fri ctio n. Although stainless steel had
the smoothest surface. it had hi gher friction than cobalt chromium wires. Only p-tita-
nium was associated with more friction.
One possible solution to the high coefficient of friction of P-tit<mium and nickel tita-
nium wires is ion implantation, an area that is currently being investigated. Gas ions
(nitrogen and oxygen) arc implanted into the wire surface. resulting in a surface that is
cxltCmely hanJ. Ion implantation produces no interface between the coating and the wire
that could lead to delamination. as with conventional coating processes; neither does it
alter the dimensions of the wire. BUfStone and Farlin-Nia demonstrated that ion-implanted
~titanium wires produced about the same level of fri ction as stainless steel wires.M
Berger39 studied friction produced by a 0.0175 inch braided archwire (wildcat) in
a 0.022 slot and found vel)' high friction level s, 1.5 times compared to om8 inch
round stainless steel wire with elastomcric li gat ion and over 5 limes with stain less
steel ligation. Thc braided wire also demonstrated a very erratic flow chan for the
friction plot. An attempt to decrease the friction by applying a coating of teflon to the
archwire has also been made. However, th is approach has met with liule success.66
Wire Size
Several studies h.we found an increase in wire size to be associated with increased
bracket-wire fri c tion .23-21.J l.32.39.41.42.-M.5J.S4.58 In general. rectangular wires produce
f
202 CHAPTER 10
more friction than round wires (Tables 10-2 and 10-3). However, this mighl nOI hold
true for bracket-wire angulations that result in binding.24 At nonbinding angulmions,
the contact area between the bracket and archwire is the important factor in friction,
and one wou ld therefore expect more friction with the rectangular wire. At greater
angulation of the bracket. the determining factor is the jX>int at which the wire con-
tacts the edge of the bracket. With round wi res. the bracket slot can "bite" into the
wire at one point, causing an indentation in the wire. However, with a rectangular
wire, the force is distributed over a larger area, i.e .• the entire faciolingual dimension
of the wire. resulting in less pressure and. therefore. less resistance to movement. This
can account for the finding by Frank and Nikolai24 that an 0.020 inch wire was associ-
ated with more friction than the 0.017 x 0.025 inch wire.
Role of Wire Stiffness and Clearance

Mechanically speaking, orthodontic wires are clastic beams supported at either one or
both ends. A force applied on such an e lastic beam cau ses a deflection, which is
reversible within the elastic limit of the malerial. The slope of the elastic portion of the
force-deflection curve is proportional to the stiffness of the wire. Stiffer wires are less
springy lUld deflect less for a given force. Changing the diameter or the cross-section of
the wire greatly changes the stiffness. Doubling the diameter of a round wire supported at
one end resullS in the stiffness increasing by a factor of 16. with strength increasing eight
times and range decreasing by half. Doubling the diameter of an archwire supported
between two bracket<; would also increase the sti ffness as a fourth power function.
The length of the beam also affeclS its stiffness. Doubling the length of a can-
tilever beam decreases stiffness by a factor of eight. During canine retraction in a pre-
molar extraction case, the increased imerbracket span of the unsupported wire over
the extraction site decreases the stiffness of the wire. The retraction force therefore
has a greater chance of deflecting the wire. resulting in buckling. To prevent such
defl ections of the wire thai may increase friction and chances of bracket binding. the
diameter of the wire should be increased to compensate for the decrease in stiffness
when the interbracket span is greater than normal. Yet another reason for not using
'i'lexib\e, sma\\-si-z.e arc"wil es t\unl'l~ ~\\t\\f\~ caf\\f\e teUac\\t)f\ i.'So \na\ {\e:,:.i.b\e arch-
wires can deflect as the canine crown tips distally, which could result in incisor extru-
sion (Fig. 10-6). This situation can be exacerbated with the use of preadjusted canine
brackets with a built-in distal root angulation.
For rectangular wires. stiffn ess is also dependent on the cross-sectional dimen-
sion in the direction of bending. In other words, a 0.017 x 0.022 inch wire placed
edgewise is more springy in the vertical dimension than when placed flatwise. as in
filUre 1()..6. An undesirable side

eHect of incisor extrusion resulting
from canine tipping during sliding
retraction on a flexible arch wire.
CHAPTER 10 203
the ribbon arch appliance. Drescher ct al.33 stated that the venical dimension of the
wire was an imponant factor in frictional resistance. When a tooth tips during retrac-
tion. it will eventually contact the archwire and defonn it. The di rection of defonna-
lion of a 0.0 16 x 0.022 inch wire is in the direction of the cross-sectional height. i.e..
the 0.01 6 inch side. They found that 0.016 inch and 0.016 x 0.022 inch wires gener-
ated signi fica ntly lower frictional forces than 0 .01 8 x 0.025 inch wires.
The stiffness of a beam is also affected by the nature of its end suppons. A can-
tilever beam is less stiff than a beam supponed at both ends. Rigid ly supponing a
beam at both ends increases stiffness four times. During sliding space closure, the
wire should therefore be tied into the supporting brackets tightly to increase sti ffness.
In other words. during canine retraction, the premolar and lateral incisor brackets
should be lied tightly to the archwire. Thi s will not only increase the stiffness of the
archwire but will also increase fri cti on in the premolar brackct, minimi zing anchorage
loss.
An adequate clearance should be provided between the bracket and lhe wire to
prevent binding. The clearance or play in the second order, i.e., tipping. depends on a
combi nation of slot size. bracket width , and archwire size. Third-order play for rec-
tangular wires in an 0.01 8 inch slot ranges between 16.7° for the 0 .0 16 x 0.01 6 inch
wire to 4.5° for the 0.0 17 x 0.025 inch wireP For the 0.022 inch slot, third-order pl ay
ranges between 27.40 for the 0.016 x 0.022 inch wire to 2° for the 0.02 15 x 0.028
wire. Since rectangular wires produce significantly highcr friction than round wires,
the authors recommend the use of 0.0 18 inch wires in the 0.022 inch slot during space
closure and canine retraction. The round wire results in less fri clion, and the 0.01 8
inch diameter provides adequate stiffness, reducing the buckling tendency of the wire.
Effect of Second-Order Deflection on Friction

Frictional forces detennined in vitro by keeping a fi xed second-order bracket-wire
denection system are not likely to be representative of in vivo dynamic changes in
wire-bracket relationships. The clinical situation often requires leveling of deflections
in a series of bracketed teeth , not j ust a single bracket. Second-order defl ections of the
wire between brackets held in series can have significant effects on bracket-wire fri c-
ti on. Several studies have fo und thai increasing the angul ation between bracket and
wi re produced greater friclion.24.27,3Q,3 1.4 1.53,63 Frank and Nikolai 24 found that fri ctional
resistance increased in a nonlinear manner with increased bracket angulation.
Ogata et al. 41 used an apparatus to hold four brackets in series and tested seven
bracket types. three of which were designed to limit the force of ligation. The brackets
were offset. deflecting the wire in increments of 0.25 mm. The mean kinetic fri Clional
forces generuted by all 0.018 x 0.025 inch brackets are given in Table 10-7. whereas
those for lhe 0.022 x 0.028 inch brackets arc given in Table 10-8. As second-order
deflection increased. fri ctional resislance was noted to increase for every bracket-wire
combinatio n eva luated. Fri ctional increases appeared in two phases ; with lower
defl ections. a smooth sliding phase appeared in which friction increased in approxi-
mately a linear manner. As the defl ection increased funher, a binding phase occurred
in which friction increased at a much greater mte and was not necessaril y linear. The
poi nt at wh ich this binding occurred was different for each bracket-wire combination
but generally occurred between 0 .75 and 1.00 mm of second-order deflection. There-
fore. in the clinical management of the patient requiring maximum anchorage protec-
lion. complete leveling o f an arch prior to using sliding mechanics is imperative. Lev-
cling will red uce the force req uired for retraction of the teeth because the fri ctional
resistance will be decreased . However. the reader must be cautioned thaI the leveling
and ali gning phase of treatment may cause flarin g of the anterior teeth as an adverse
side effect. oft en more so with preadjusted appliances.
204 CHAPHR 10
Biomechanical Considerations in Sl id ing Mechanics
Table 10-7. Effect of Second-Order Def lections on Friction. M ean and Stand ard Deviation Values for Friction
for Three Cast Stainless Steel Brackets (A-018, American Friction Free; G-018, GAC Shoulder; 0-018, Ormco
Mini Diamond) and Three Sintered Stainless Steel Brackets (R-S-018, RMO Mini-Taurus; RS-S-018, RMO Mini-
Taurus Synergy; U -S-018, Unitek Mini Tw in) for the 0 .018 Inch Slot Size Are Provided for Six Deflections
Between 0 and 1.0 mm .
0.018 x 0.025 Inch Bracket s
Wi re
Shape
0.016 2.• 5.0

O.oomm 16 x 22 142.5 44 .•
17 x 25 188.5 33.7 622.5 184.5 49.5 610.5 75.9 68.7 58.1
0.016 151.6 26.0 237.0 41.4 432.0 24.2 469.6" 57.1 55.3 19.0
0.25 mm 16 x 22 559.5 29.8 754.0 31.9 925.0 49.9 965.0 55.4 39.5 20.6
17 x 25 766.5 45.0 1,238.5 117.6 1,237.0 102.1 762.5 83.5 215.0 108.7
0.016 361 .4 40.0 4805 50.2 648.5 35.7 678.2 74.6 222.8 36.7
ftfx .?.? 1,.?.20.0 611.1 l, !ilH.5 1,579.5 115...1 617.0 68.2
17 x25 1,530.5 38.4 2,323.5 98.1 1,821.0 142.7 1,586.5 174.9 920.3 204.2
0.016 558.6 56.5 767.5 55.3 854.0 36.0 874.6 95.1 407.0 53 .2 934.0
0.75 mm 16 x 22 1,976.5 74.0 2,430.0 77.0 2,001 .0 107.5 2,223 .0 156.0 1,497.0 186.6 1,624.0
17 x 25 2,451.0 293.3 4,441.5 66.0 2,386.0 137.0 2,486.0 283.7 1,744.5 328.6 2,512.0
0.016 789.6 83.5 955 64.1 104.7 5%.8 60.4

1.00 mm 16 x 22 3,463.5 94.7
17 x 25 6,685.0
:and
'~I"~d~0.25
;'~M~"~t~h~
.t :t~h':'~';W~'~'~~~~~. All other interactions~~::~~m~'.~"~
mm of second·order
, ~~~~~~~:;~~::~~~~~~
were significant at p <O.OS.
Effect of ligation Technique on Fricti on

Elastomeric Modules versus Stainless Steel Ligatures
The normal force exerted by the ligature has a significant innuence in determining the
frictional resistance developed within an orthodontic system. This force has been esti -
mated to be between 50 and 300 g24.31.33.36 and up to 735 g in onc study.37 Elastomeric
modules are adverse ly affected by the oral environment,70 demonstrate stress relax-
ation with time,11 and ex hibit great indi vidual variation in propcnies. n On the other
hand, stainless steel ligatures can be tied either too light or too loose, depending on
(he technique and nceds of the clinician.
Edwards et al .37 conducted a study to compare the effect o f four ligation tech·
niques, i.e., elastomeric modu les tied conventionally and in a figure 8 pattern , stain·
less stccl ligatures. and tenon-coated ligatures. on the static fri ctional resistance of
stainless steel brackets and arch wires. Elastome ric ligatures tied in a fig ure 8 pattcrn
wcre responsible for signi fi cantly greater mean static fri ctional forces than any other
ligation techn ique. There were no significant differences between the frictional resis-
tances offered by the conventionally tied elastomeric modules and stainless steel liga-
tures. TeOon-co.:'1ted ligatures produced the lowest mean slatic frictional forces under
both testing conditions. confirming the results of Spiller et al. 7J Bazakidou 'll also
Table 1o-B. Effect of Second-Order Deflections on Friction. Mean and Standard Deviation Values for Friction for Three Cast
Stainless Steel Brackets (A-018, American Friction Free; G-018, GAe Shoulder; 0-018, Ormco Mini Diamond), Three Sintered
Stainless Steel Brackets (R-S-018, RMO Mini· Taurus; RS-S-018, RMO Mini-Taurus Synergy; U-S-018, Unitek Mi ni Twin), and One
Combination Bracket with a Modified Edgewise Slot (TP-022) TP Tip- Edge) for the 0.022 Inch Slot Size Are Provided for Six
Deflections Between 0 and 1.0 mm .
Wire
Shape
iize Mean SO Mean SO Mean SO Mean SO
13.9 481.0 44.2 4635 53.5
16.4 7325 25.6 680.0 51.3 0.0 0.0 646.5 87.5 574.5 29.0
0.00 mm 17 x 25 I 1925 12.3 I 205.0 15.8 7475 25.6 645.0 30.4 0.0 0.0 705.5 20.5 732 .0 58.9
25.8 549.0 51.3 361 .5 42.4 0.0· 0.0 436.5 16.2 362.0 37.3
30.0 700.0 76.6 0.0 0.0 803.0 49.1 6125 24.5
7375 351
0.016 91.0· 7.7 1175 17.4 529.0 46.9 487.0 58.7 0.0· 0.0 430.0 31.6 326.5 265
16 x 22 195.0 13 .1 282.5 10.1 842.0 35.3 734.0 48.9 6.5 4.1 7145 57.6 607.0 18.0
0.25 mm I 17 x 25 213.0 7.5 441.5 27.6 868.0 31.7 733.0 40.6 11.0 5.7 SOB.O 39.2 7615 49.4
0.018 117.5 9.2 177.5 28.5 605.0 49.6 408.5 40.6 15· 3.4 498.5 17.8 442 .0 69.8
18 x25 266.5 28.2 515.0 10.0 1,131.0 94A 852.0 122.7 12.0 5.9 895.0 69.5 814.5 24.9
19 x 26 356.0 58.6 592.5 25.0 1,830.0 36.1 1,044.0 55.6 30.5 18.2 993.5 97.3 799.5 29.9
0.016 113.5 6.7 247.5 14.2 665.0 52.3 550.0 64.8 29.0 12.4 384.5 27.8 383 .0 25.4
16 x 22 291.0 23.5 653.0 22.0 1,355.0 45.3 905.0 44.0 1515 24.8 1,061.5 99A 657.0 23.6
O.50mm I 17x25 409.0 11 .0 1,017.5 55.8 1,468.0 45.0 1,032.0 68.2 254.5 28.9 1,063.0 75.2 806.5 21.2
0.D18 185.0 9.1 403.0 23.9 830.5 64.4 596.5 23.7 97.5 8.2 620.5 33.0 480.5 54.7
18 x 25 589.0 56.4 1,221.5 32.1 1,616.0 121.3 1,621.5 272.1 234.0 21 .1 1,136.5 BOA 1,009.5 73.4
9 x26 997.0 183 .8 1,3805 73.2 2,499.5 54.4 1,889.0 136.0 373.0 62.7 1,432.0 104.2 1:0
0.016 236.5 14.2 398.5 18.3 824.5 58.0 713.5 79.1 110.5 23.7 734.0 36.5 450.0 34.8
16 x 22 786.0 86.0 1,190.0 48.0 1.934.0 74.1 1,336.0 87.5 459.0 41.6 1,280.0 78.3 857.5 29.8
0.75 mm I 17 x 25 1,067.5 54.0 1.929.0 60.7 1,990.5 89.2 1,609.0 98.3 755.5 32.3 1,546.0 160.2 %2.0 43.1
0.018 475.0 16.3 710.5 29.4 1,081.5 87.2 873.0 58.9 313.5 53.8 787.0 35.3 527.0 45.8
18 x 25 1,383.0 50.5 2,224.5 75.9 2,741.0 182.6 2.532.4 468.9 866.0 51.2 1,815.5 190.9 1,276.0 nJ
9 x26 1,600.5 117.5 3,051.5 64.9 3,468.5 61.7 2,680.0 224.0 1,217.5 146.9 2,247.0 171.3 1.5
0.016 442.0 10.3 590.5 18.9 975.5 67.9 869.0 85.2 241.5 24.3 858.0 40.9 471.5 31.2
16 x 22 1,534.0 117.9 1,728.0 69.3 2,524.5 695 1,854.0 120.9 1.027.0 116.7 1,973.5 72.5 1,031.5 50.1
1.00 mm I 17 x 25 1,831.5 94.8 2,629.0 74.8 2,797.5 185.7 2,229.5 128.4 1,486.0 109.5 2,295.0 196.8 1,104.0 64.5
0.018 776.5 23.6 972.5 36.2 1,299.0 89.1 1,091.5 38.0 632.5 74.5 1,060.5 36.5 584.0 48.2
18 x25 2,065.0 82.9 4,377.0 59.0 3,668.5 125.5 3,249.5 679.7 1,658.5 175.3 2,587.0 262.6 1,434.0 69.4
19 x 26 2,694.0 192.6 5,488.5 50J 5,907.5 56.1 3,408.0 263.7 2,171.5 259.3 3,107.5 193.9 1,981.5 53.4
...
0
I
· Indlcates that there was not a Significant difference (p < 0.05) between the means of thiS speCifiC bracket-Wire combmatlon across 0.00 and 0.25 mm of sec-
'" ond-order deflection. All other interactions were significant at p < 0.05.
206 CHAPTER 10
Blomechanlcal Considerations in Sliding Mechanics
found no difference in friction between eiastomeri c modules and stainless steel liga-
tion. However. usi ng preformed steel ligatures with a twi st-mate pl ier (GAC, Central
Islip. NY), she found the variability to be almost 2.5 times more than with elastomeric
ligat ion.
Bracket Designs Limiting the Force of Ligation

Three brackets. American Friction Free bracket (American Orthodontics. Sheboygan,
Wn, GAC Shoulder bracket (GAC. Central Is lip. NY). and the RMO Synergy bracket
(RMO Inc .• Denver. CO). were introduced to restrict the amount of force placed on
the wire by the ligature. These bracketS generated lower mean frictional forces at sec-
ond-order deflection s of 0.00 and 0.25 mm than conventionally ligated bracketS. 41
The design of the Synergy bracket. for example, includes s ix wings. three on each
side of the bracket slot. The lateral wings may be included in ligation for correction of
rotation of teeth, but only {he center wings may be li gated during sliding mechanics to
reduce the force of li gation. In addition, other design features such as bumps on the
bracket wall s and bracket fl oor, which reduce the su rface area in contact with {he
wires along with mesial and distal fl ares of the bracket box, have helped reduce fric-
lion and binding.
Self-Ligating Brackets
Orthodontic brackets are now available that possess the feature of self-ligation with a
highly resilient spring clip. 1llc potenti al for reduced friction as well as chair time for
self-ligating brackets has been touted since the introduction of the fi rst edgewise self-
li gati ng brnckel, the Ru sse ll Lock.74.7s A comparison between the SPEED bracket
(Strite Industries Lid. , C ambridge, Ontario, Canada) and a stai nless steel bracket
revealed that friclion with the self-ligating bracket was between 12% and 23% that of
the stainless steel bracket. irrespective of wire shape and ligation technique.l9 This
cou ld explain the claims that the SPEED system is a faster treatme nt modality.76 Shi va-
puj a and Berger40 found that three commercially available self-ligating brackets (Edge-
lock, Ormco Corp., Glendora, CA; SPEED, Ind ustries Ltd .• Cambridge, Ontario,
Canada; Activa. "A" Co .. San Diego, CA) produced significantly lower levels of fric-
tion than metal or ceramic brackets tied with either elastorneric or metal ligatures.
Effect of Saliva on Kinetic Friction

It has been suggested that sali va or a saliva substitute serves as an excellent lubricant
in the sliding of the bracket along the wire. Baker et 011..45 using an arti fic ial saliva
substitute. found a 15% to 19% reduction in friclion. Kusyet al. 56 found that sali va
could have lubricous as well as adhesive behav ior, depending on which arch wire-
bracket combination was under consideration. The stainless steel wires showed an
adhesive behavior with saJiva and a resultant increase in the coefficient of fri ction in
the wet state. The kinetic coefficients of friction of the P-Ti arch wires in the wet state,
on lhe other hand, were 50% of the values in the dry state. When s liding through
stainless sleel bracketS. the titanium-rich oxide layer in P-T! archwires breaks down,
reacts, adheres, and breaks away, resulting in a "stick-slip" phenomenon. With alu-
mina brackets, the rough slot surface removes layers of the soft wire materiaJ. They
hypothesized that sali va probably acts by preventing solid-to-solid contact. Therefore.
especially in the adult patient, a history of xerostomia or reduced salivary flow, oral
radiation therapy, or anticholinergic medication should be noted as possible factors in
varyi ng the force levels necessary to move teeth.
CHAPTER 10 207
CLINICAL SIGNIFICANCE OF FRICTION
An appreciation of the magnitude of friction is crucia l fo r the orthodontist who

employs sliding mechanics during treatment. With the best of wire-bracket combina-
tions, at le;lst40 g of friction must be included in the force applied to the tooth to ini-
tiate movement. High levels of bracket-wire fric tion may result in binding of the
bracket accompanied by linle or no tooth movement. Furthermore, binding of an ante-
rior tooth under retr:lction may lead to a "tent-pegging" effect. with the applied force
being optimal for movement of posterior teeth instead. th us resulting in a loss of
anchorage. The ideal situation is one in which no friction exists between bmcket and
wire. Si nce this docs not occur in sliding mechanics. the orthodonti st must be aware
of the magnitude of friction in the appliance system. Friction can then be compen-
sated for in the appli ed force, and it is hoped that the optimal force value can be
achieved.
Based upon the infonnation gathered from studies on friction, several points of
cli nical sign ificance can be identified. New bracket designs and manufacturing tech-
niques have been introduced to reduce the amount of friction generated between the
wire and the bracket slot. Bracket designs that restrict the force of li gation also
decrease friction. Since simcrcd brackets reduce friction by about 40%, such a bracket
manufacturing process is advantageous. For clinicians who use esthetic or tooth-col-
ored brackets such as ceramic or plastic bmckcts, it is importam to know the level of
friction generated by these bmckets before initiating tooth movement. The selection
of various wire shapes and sizes will also allow the clinician to regu late the amount of
frict ion. For the least amount of friction, a small diameter round wire, such as 0.016
inch stainless steel, would be the best choice for both leveling of an arch and retrac-
tion of teeth. If overall torque control is required. however, a rectangular wire such as
0.0 16 x 0.022 inch in an 0.018 inch slot or 0.0 19 x 0.025 inch wire in an 0.022 inch
slot may be a good cli nical selection. Addition of torque in the posterior segment of
the arch wire would also help preserve posterior anchorage. The archwire can also be
thinned down in the region distal to the canine so as to further facilitate movement.
Care must be taken not to overreduce the wire dimensions. which could decrease the
strength of the wire.
Complete leveling of the arch is an important factor in reducing fri ction during
tooth movement. Deflections or second-order discrepancies of as little as 0.5 mm
between brackets can signifi cantly increase friction. If retraction of teeth is done on a
rectangular wire, it may be prudcnt to first achieve torque control or third-order align-
ment, then drop back to a smallcr rcctangular wire si7..e and initiate sliding mechanics.
This could prevent the edges of the rectangular wire from binding into the bracket slot
and inhibiting movement.
The newer wire alloys, such as nickel-titanium or beta-titan ium, produce more
friction than the traditional stainless stecl or cobalt-chromium wires. The beta-tita-
nium wires may form microwelds with the bracket slots and cause binding between
the wire and the bm.ckel. With the recent advances in metallurgy, design and manufac-
turing processes, and the resultant improvements in the orthodont ic appliance, the
clinician has beller control of the mechanics.
RETRACTION FORCE
Effect of Point of Application of Force

Mesial or di stal tipping of the bracket is dependent upon the location of force applica-
tion relative to the center of resistance8- 14 and the biological resistance of a tooth to
208 CHAPTER 10
movemenL1.I ~·30 Tipping of the bracket produces pressure at the contact area between
the bracket and the archwire with a resu ltant increase in frictional resistance.l IJ 2.77
DrescherTI found that frictiona l resistance decreased by applying an uprighting spring
during archwire guided tooth movement. Yamaguchi el al.78 conducted an in vitro
study to investigate the relationship between the point o f application of retmction
force and Ihe ::\mount of retarding force when sliding a bmcket along a wire. Wide,
medium, and narrow twin standard cdgewise stainless steel brackets (Tomy Intema-
tional Inc .. Japan) for the om 8 inch slot size were bonded onto the center of the
metal mesh plate and a 0.0474 inch wire was soldered to the mesh plate to represent
the long axis (Fig. 10--7A). Three retraction hooks were soldered to the bracket-long
axis assembly: hook number 1 was soldered to the mesh plate perpendicular to the
long axis at the level of the bracket slot (point I). hook 2 was placed at 3.9 mm (point
2). and hook 3 was at 5.6 mm (point 3) fro m the center of the bracket on the long
ax is. Another hook, to simulate an estimated center of resistance. was soldered on the
long axis at 9.0 mm from the center of the bracket. The measurements for placement
of these hooks were obtained from a previous study done to detennine the center of
resistance of the canine during retraction in a typodont setup. From the 9.0 mm hook,
three weights of 100 g, 200 g, and 400 g were attached to simulate the retardi ng
forces of the tooth to movement. An 0.016 x 0.0[6 inc h stainless steel wire (Hi-T.
3M-Unitek, U.S.A.), 20 mm in length, was held in a vertical position between two
arms of a wire-holding device under 2.0 kg of tension (Fig. 10-78). The bmcket was
engaged in this wire wi th elastomeric ligatures and a retraction wire (0.0257 inch
diameter) was attached between the crosshead of the testing machine (lnstron 6022.
0-016.D-016-!nch
s..inl<H SIftIWIM Rotanbng weif;h .. 01
lOOg. ZOOs ond 400 g
Figure 10-7. The experimental set-up to investigate the relationsh ip

between the magnitude of the retraction force and frictional resistance,
resistance to tooth movement, and varying points of application of
retraction force. A, Three retraction hooks were soldered on the long
1.11 ,
\ 1 movement
axis. Weights of 100 g, 200 g, and 400 g were suspended from the cen-
ter of resistance . B, The bracket was retracted at each of the three hooks
along a stainless steel wire (0.016 x 0 .016 inch) supported between two
arms under 2 kg tension. (Modified from Yamaguchi et aI.78J
I~-
1
I.... I EITiiiO
,..ble
®
CHAPTER 10 209
InSIl'On Corp .. Canton. MA) and a retraction hook on the long axis. The long axis wire
was maimained perpendicular to the retraction wire. The effects of three variables on
the retraction force were studied: ( I) appljcation of force at poinlS 1,2. and 3: (2)
retarding forces of 100 g. 200 g, and 400 g at the center of resistance; and (3) wide.
medium, and narrow twi n bracket wid ths. The retraction wire was fi xed to the
cross head, wh ich was advanced at a rate of 0.0 1 mm per second for a distance of 2.0
mm, and the load cell reading was continuously recorded on graph paper.
For all brackets. the force of retraction at points I and 2 was observed to increase
with an increase in the retarding force (Fig. 10-8). This was due to the fact that with
the larger retarding force of 400 g. the long axis tipped inferiorly. resu lting in
increased pressure at the contact point between the bracket and wire. The retraction
force. therefore. had to be greater in order to overcome this resistance to movement.
This finding is supported by Tidy30 and Drescher et al P On the other hand. the retrac-
tion force decreased with an increased retarding force when retraction force was
placed more apically at point 3. With a 100 g weight, the long axis tipped superi orly
by retraction at point 3, once again resulting in increased pressure at the contact
points. With the 400 g weight, the long axis remained horizontal, resulting in less
pressure at the contact area between the archwire and the brackets and therefore less
retraction force.
Bracket width also played a role in the amount of retraction force. In this study,
the narrow twin bracket produced signi fi cantly hi gher retracting force by retraction at
point 1 with 200 g and 400 g weighlS. With thi s combinatjon of the retarding force
and the l oc~lI i on of force application. the long axis lipped inferiorly. resu lling in
increased pressure between the bracket and the wire. These findings are simil:lr to
those of Kamiyama et al. 79 Thus, the pressure acting on the contact area between the
bracket and wire is a major factor in generating the frictional resistance to the sliding
movement of a tooth . The amount of retarding force and the resistance force induced
by the ligation technique. wire size. and bracket width strongly innuence this pres-
o tOO g w~ight
500 ~ 200 g welgh t
o 4OOgwC'ight
~• 400
"
!9
~
oJ:"
c
.£
~
t
'"
o
Point 1 Point 2 Point 3 Point 1 Point 2 Point 3 Poin t t !,oint 2 Point 3
Wide Twin Bracket Medium Twin Bracket Narrow Twin Bracket
Figure 10-8. Effect of force application at points 1. 2. and 3 and retarding force of 100 g. 200 g. and
400 g on the retraction force. The retraction force increased with an increase in the retarding force for
retraction at points 1 and 2. However. the retraction force decreased with an increase in the retarding
force for retraction at point 3. (Modified from Yamaguchi et a1. 7II )
210 CHAPTER 10
Biomechanlcal Considerations in Sliding Mechanics
sure. In this study, weights provided a constant resislance to tooth movement. In a

clinical situation, however, the resistance force is not constan! and increases during
tooth movement in vivo. Therefore. one must also consider the elasticity and vis-
coelasticity of the periodontal ligament and alveolar bone. 8O.81 The poi n! of applica-
(ion of force is another important factor to be considered in sliding mechanics. The
farther away the retraction force is applied frolll the center of rotation, the greater the
moment ann, and the greater the chance of tipping and binding. Hence several manu-
facturers provide extensions of different lengths on the canine brackets, called "power
anns," to reduce the effective rotational momeni (Fig. 10-9).
Methods of Force Application

Elastics and Efastomeric Chains
Rubber elastics, nylon-covered latex threads, elastomeric chains, and eJaslomcric
modules are extensively used in orthodontics for apply ing forces for canine rClraction ,
space closure, rotational correction, and'intra-arch tooth movemenl. Class 11 inter-
maxillary traction from the distal of the mandibular first molar to the mesial of the
maxillary canine results in a horizontal vector of 96% and a vertical vector of 27%.82
In other words, if an elastic is stretched to apply 100 g of force on a maxillary canine
bracket. the effective distal force will be onl y 96 g. In situations where fou r premolars
have been ex tracted and the space closed. the same Class n elastic, now stretched
over a shorter span. has a horizontal vector of 93% but a signifi cantly increased verti-
cal vector of 37%. On the other hand. Class II clastics that are stretched over a longer
distance from the distal of the mandibular second molar to the mesial of the maxillary
canine have a horizontal effect of 98% and a smaller vertical vector of 20%. There-
fore, to get the greatest distal effect of Class II elastics with the smaller collateral ver-
tical vector, elastics should be applit.'<i from the farthest distal point, i.e., the distal of
the mandi bular second molar. The same concepts apply to Class III elastics, only in
the opposite direction.
The elastomeric chain s are made from synthetic rubber polymers, which are
capable of large elastic deformation s due to their pattems of folded or kinked molecu-
lar chai ns at rest. When extended, they unfold in an ordered linear fashion. Exposure
to ozone and ultraviolet light break down the unsaturated double bonds at the molecu-
lar level and result in a decrease of tensile strength and flexibility. Manufacturers.
therefore, add antioxidants and antiozonates to retard these effects. In the oral cavity,
elastics absorb water and sal iva, which cause a breakdown of the intemal bonds and
pennanent defonnation of the material. In addition. the elastics swell and stain due to
the filling of the voids in the rubber matrix by fluid s and bacterial debris. These lead
Fllur. 1 0-9. ~Power arm~ on the canine bracket that

allows for the retraction force to be applied doser to the
cen ter of rotation of the tooth. thus minimizing the rota·
tional moment and the binding of the bracket to the arch·
wire.
CHAPTER 10 211
Biomechanical Considerations In Sliding Mechanics
to a loss in force delivered to the tooth. To minimize such side effects, orthodontists
recommend that patients change their elastics twice daily, but thi s requires faithful
patient adherence. Elastomeric chains gained in popularity because they were more in
the control of the clinician. They too experience a rapid loss of force as a result of
stress relaxation.
Force Degradafiotl of Elastics and Elastomeric Chaitls Andreasen and Bishara83

compared the stress relaxation behavior of Alastiks modu les (Unitek Corp., Mon-
rovia, CAl and latex elastics and found 74% loss of force with Alastiks after 24 hours,
whereas the latex elastics lost only 42%. They recommended an initial extension of
the chai n to four times the desired force level to c~pensate for the force loss.
Bishara and Andrcasen S4 observed changes in force exerted by rubber clastics and
plastic Alastiks used for Class II and Class m mechanics during a three-wcck period.
The avcrage decay was less for rubber elastics (10%) than for plastic Alasliks (45 %)
after one hour. The drop in force level at the end of 24 hours on average was 17% for
rubber elastics and 54% for plastic Alastiks. This study also observed that plastic
Alastiks taken from the same batch and stretched under the same conditions had
greater variability in their force when compared with rubber elast ics. Hershey and
Reynolds8!l compared three commercially available elastomeric chains and found a
60% loss after four weeks. Fifty percent of the loss in force was after the very first
day. Wongn found between 50% and 75% force loss after the first 24 hours when the
chains were stored in water at 37 0 C. He also found a considerablc variation in the ini-
tial force delivcry of chains from different manufacturers. Young and Sandrik86 stud-
ied the ex tension of plastic modules at various forces for loading and unloading.
Upon unloading, the modules did nOi return to zero extension and a permanent defor-
mation resulted. The difference between the loading and unloading curves, termed
hysteresis, was significant.
Elastomeric chains extended and stored in vivo have a significantl y greater loss
in force than when stored in air.70 Kuster et al.S? found thai chains stored in air and
extended to 82% and 115% of the original length had maintaincd 70% to 75% of their
initial force level after 4 weeks, as compared to chains placed in vivo at approxi-
mately 100% ex ten sion that retained 43% to 52% of their initial force level. Lu et al. 88
found that the greater the initial force and the submerged time (37 0 C water), the more
the force decay. After 3 weeks, the percentages of force remaining were between 49%
for the RMO Energy chain (med ium) at 40 mm, 43% for the American Orthodontic
Clear chai n (short). and 35% for the American Orthodontic gray (short) chai n. The
effects of salivary enzymes, mastication, oral hygiene, and temperature may all influ-
ence the degradation rates in vjvo. Ferriter et a1. 89 investigated the effect of pH of
plaque (4.95) and sali va (7.26) on elastomeric chains and found that chains subjected
to the more basic solution exhibited significantly more force decay over the 4 week
testing period.
Short filament chains generally provide higher initial force levels and retain a
higher percemage of the remaining force than long filament chains.1lO.91 The newer.
colored elastomeric chains have also been compared with the standard gray chain.
and results indicate that coloring of the elastomeric chains has lillie effect on the ini-
tial force delivery characteristics.93
Bell94 recommended extension o f elastics to three times their length to obtain the
desired fo rce leve l. On the o ther hand , for elastomeric chains, Hershey and
Reynolds85 recommended using a force gauge when extending them to arri ve at the
desired force level. Rapidly extending the elastomeric chains resulted in greater initial
force level s than those slowly stretched, but more force loss after I week. 9S Kovatch
et al. 9S therefore recommended slowl y stretching plastic modules to positi on to
decrease the rate of stress relaxation. Prestretching the elastomeric materials in ai r
212 CHAPTER 10
8iomechanical Considerations in Sliding Mechanics
prior to engaging onto the brackets in vivo resulted in a smaller percentage of force
decay.12.86
Sonis et al. 96 compared in vivo canine retraction by using two elastomcric chains
and a nylon-covered latex thread and found no significant difference in tooth move-
ment between the prodUClS. They empirically fou nd the elastomeric aux iliaries to be
,
more hygienic and to require less chair time in their application than the thread.
Coil Springs
Coil springs have provided an alternative to the use of the clastic products. Coil
springs were introduced for orthodontic tooth movement in 1931. Arnold and Cun-
ningham91 described the use of a compressed coi l spring made of 0.0 10 inch SS
White wire coiled to 0.040 inch diameter. They advocated activating the spring 2 \0 3
mOl but not greater than 3 mm, with the next adjustment not occurring umil six weeks
latcr or until no amou nt of activation remains. Variables thaI affect the force levcls
produced by coil springs include the alloy. wire size, lumen size, pitch angle of the
coils, length of the spring, and amount of activation of the spring. Bell94 found that as
the size of the lumen of a spring was incrcased, lighter forces were required to dis-
place it. Also. the larger the wire, the greater was its tendency to resist displacement.
He slated that if the greatest amount of force is desired, the largest-size wire with a
small lumen shou ld be selected. being cautious to avoid friction between the spring
and the archwirc. Springs with larger lumen sizes and snwller wire sizcs are indicated
for orthodonti c use because of their more constant force production.9II.99
Boshart et al. HXJ compared the load-deflection rates of 10 mm lengths for a vari-
ety of open and closed coil springs made of HiT stai nless steel and cobalt-chromium
(Elgiloy). They found that wire size had the greatest effcct upon the spring rate, fol-
lowed by the pitch angle. The lumen size (0.030 or 0.032 inch) had a very small effect
upon the spring rate. The pitch angle of the HiT open coil springs was 7.5 0 higher
compared to springs made of cobalt-chromi um. As the pilch angle increases, the num-
ocr of coils per unit length decreases. The smaller the number of coil s in the spring,
the more the space between coils and therefore the greater the activation that can be
achieved. Alloy composition illustrated that Eigiloy load-defl ection rates averaged
5% greater than HiT. When the Elgi loy is heat-treated the stiffness increases 13%.
The advent of the Japanese nickel-titanium archwires led (0 the introduction of
the nickel -titanium coil springs. Miura et al. lO l studied the differences between the
Japanese nickel-titanium open and closed coi led springs and the stain less steel coil
springs. The closed coil springs made of stainless steel showed a linear relationship
between load and deflection. The nickel-titanium springs, however, demonstrated a
superelaslic effect. with a constant load for a large range of deflection. Miura et al.
also indicated thOlt the open coil spring delivers a relatively more constant load value
in the superelastic region than the closed coil spring. Thus, a more desirable continu-
ous force can be obmined from the open coil spring than from the closed coil spring.
In 1992. Angolkar et al. I02 examined the force degradation over time for closed
coil springs made of stainl ess steel , cobalt-chromium, and nickel-titanium alloys
when stored in a salivary substitute at 370 C and extended distance such that the ini-
tial force was in the range or 150 to 160 g. They divided their specimens into two
groups. Group I had four types of springs (one stainless steel, one cobalt-chromium.
and two different nickel-titanium springs) with dimensions of 12 mm in length and
0.010 x 0.030 inches in diameter. Group Tl had three types of springs (one stainless
steel, one cobalt-chromium, and one nickel-titanium) with dimensions of 6 mm in
lcngth and 0.010 x 0.036 inches in diameter. All springs in both groups showed force
loss over time, with the major force loss occurring in the first 24 hours for most
springs (Fig. 10-10). With a lumen size of 0.030 inch. the percentage of force loss
214 CHAPTER 10
consider bracket material, size and design, and wi re alloy, size and shape, as well as
tooth sire and resistance fact~rs. The multitude of possible appliance combinations in
sliding systems poses a serious challenge in producing a rorce system that is optimal
for tooth movement. Mechanical as well as biologic factors must be considered in
produci ng the appliance best suited for the patient. The level of force systems must
lake into account the fri ctional force levels in order to successfull y achieve the treat-
ment objectives.
REFERENCES
I. Farmn t so: An evaluation of di ffere nt methods of can ine retracti on. Br J Onhod 4:5-- 15. 1917.
2. Ziegler P, Ingervall B: A clinical study o f maxillary canine retraction with a retractiOll spri ng and
with s lid ing mechanics. Am J Orthod 95:95-99, 1989.
3. Bur:;tone CJ, Koen ig HA: Optimizi ng anterior and canine retraction. Am J Orthod 70: 1- 19, 1976.
4. ChllConas S}, Caputo AA, Hayas hi RK : Effects of wire, loop configuration an d gabli ng o n can ine
retraction springs. Am J Orthod 65:58-66, 1974.
5. Staggers l A. Gennane N: C linical considcrntions in the use: o f retrnction mechanics. J C lin Orthod
25:364-369, 1991.
6. Huffman OJ , Way DC: A cl inical evaluation of tooth move ment along arc hwires of two d ifferen t
sizes. Am J Onhod 83:453-459, 1983.
7. Bridges T. King G, Mohan1lllCd A: The effect of age on tooth moveme nt and mineral dens ity in the
alveo lar t i ssue.~ in the rat. Am J Orthod 93:245-250. 1988.
8. Yettra m AL, Wri ght KWJ . Housto n WJB : Ce nter o f rotati on of a maxill ary ce ntral incisor under
orthodontic load ing. Br J Orthod 4:23-27. 1977.
9. Burstone CJ, Pryput niewic7. RJ: Ho lographic determ ination of centers o f rotat io n produced by
orthodontic forces. Am J Orthod 77:396-409. 1980.
10. Bu rstone CJ : Ce nter of res istance of the human mand ibu lar molurs. J Dent Res 60:5 15. 198 1.
II. Fortin JM: Trans lation of prcmoillfll in the dog by controlli ng the moment-to-force nll io on the
crown. Am J Orthod 59:541-55 1, 1971.
12. N ikolai RJ: Periodontal ligament reaction and displacement of a ma)(ilIary celllral incisor subjected
to transverse crow n lo ading. J Biomec h 7:93-99, 1974.
13. Pryputniewicz RJ, BurslOoe 0: 1be effect of ti me and force magn itude on orthodontic tooth move-
ment. J Dent Res 58: 1754- 1764, 1979.
14. Pederson E, Anderson K, Gjcssing PE: Electronic detennination o f center of resistance produced by
o rthodontic force sys te m. Euro Onhod Soc 12:272- 280, 1990.
IS. Yamaguchi K, Nanda RS: Considerations in slid ing tooth movement along an arch wire. l. 1'ypodont
work. too Orthod Jnl 1993 (acccpled for publication).
16. Sandstedl C: Einige beitrage zur theorie der zahnreguberu ng. Nordisk Tandlakare. lidsskrisl 4,
1904.
17. Oppenheim A : Tissue changes, paI1icul arly of the bone, incident to tooth movement. Tr. Bur Onhod
Soc. 8: 11 , 19 11.
18. Schwartz AM: Tissue changes inc ident 10 orthodontic looth movement. [nt J Orthod 18:33 1-352,
1932.
19. Storey E. Smith R: Force in orthodontics and its relat iOllIO tooh movement. Aust De nt J 56: 11-18.
1952.
20. Rei ta n K: Some factors de te nnining the eval uat io n o f fo rces in o rt hodo ntic s. Am J O rthod
43:32-45, 1957.
2 1. Boester CH, Johnsto n LE: A cli nical investigation of the concepts of differenti al and opti mal force
in eanine retraction. Angle Orthod 44: 113- 119, t 974.
22. Quin n RB , Yosh ikawa DK : A reassessment of force magnitude in orthodontics. Am J Orthod
88:252-260. 1985.
23. A ngolkar PV. Kapil a S, Dunca nson MG Jr, Nallda RS: Evalum ion of fricti on between ceramic
brnckets and onhodOlltie wires of four alloys. Am J Onhod Dentofac Onhop 98:499-506, 1990.
24. Frank CA, Ni ko la i RJ: A comparative study of frictiona l res istances between orthodont ic bracket
and arch wire. Am J Onhod 78:593-609, 1980.
25. Gamer LD. All al WW, Moore BK: A comparison of frictional forces du ri ng si mu lated canine retrac-
tion o f a continuous edgewise: arch wire. Am J Orthod DenlOfac Orthop 90: 199-203. 1986.
26. Kapila S. Angolkar PV. Du ncanson MG Jr. Na nda RS: Evaluatio n o f frict ion between edgewise
stainl ess steel brac kets and ort hodon tic wires of fou r a lloys. Am J Ort hod Den torac On ho p
98: 11 7- 126. 1990.
CHAPTER 10 215
,
Biomechanical Considerations in Slidi ng Mechanics
27. Peterson L. Spencer R. Andreasen GF: Com parison of frictional resistance o f Nitinol and stainless
steel wires in Edgew ise brackets. Quinl lnter Digest 13:563-571, 1982.
28. Prallen DH. Popti K, Ge nnane N. Gunsolley J: Frictional resistance of ceramic and stainless steel
orthodontic bracket5. Am J Orthod Denlofac Orthop 98:398-403, 1990.
29. Stannard JG, Gau JM, Hanna M: COlnparative friction of o nhodon tic wires under dry and wet con-
d itions. Am J Orthod 89:485-49 1,1 9 86.
30. Tid y OC. Frictional forces in fixed appl iances. Am J Orthod Dentofac Ortoop 96:249-254. 1989.
31. Andreasen G F, Q uevedo FR: Evaluation of frictional forces in the 0.022 x 0.028 edgewise bracket
in vitro. J Biomech 3: 15 1- 160, 1970.
32. Riley JL, Garrell SG, Moon PC: Frictional forces o f ligated plastic and metal edgew ise brackets. J
Dent Res 58:A2 1, 1979.
33. Drescher D. Bourquel C, Schumacher H: Fric tional forces between bracket and arch wire. Am J
Orthod Dentofac Orthop 96:249-254. 1989.
34. Kusy RP. Whitley JQ. May hew MJ, Buckthal JE: Sulface Il)Ugh ncss of Or1hodontic archwires via
laser spectroscopy. Angle Ort hod 58:33-45, 1988.
35. Ku sy R I~ Whitley JQ: Effects of surface Il)Ughness on the cocfficients o f fri ctio n in model onho-
do ntic syste ms. J Bio mech 9:9 13-925. 1990.
36. Pop li K. Prnlle n D, Germane N. Gunsolley J: Frictional resistance of ceramic a nd stain less stee l
orthodonti c brackets. J Dcnt Res 68:275 (A 74 7), 1989.
37. Edwards GD. D(lvies EH. Jo nes S P: TIle ex vivo effect of li gat ion technique o n the static fricti onal
res istance of stai nl ess steel bracke ts and archwires. Br J Orthod 22: 145-153, 1995.
38. Bazaki dou E: Evaluati on of frict ional resis tance o f esthetic brac kets. Mas ter's thes is. Universi ty of
Oklahoma. 1995.
39. Berger JL: The infl ue nce of the S PEED bracke t's self- li gating de.~ign on force leve ls in tooth ,nove-
ment: A comparati ve in vitro study. Am J Onhod De ntofac Orthop 97:2 19-228. 1990.
40. Shivapuja PK. Berger J: A comparative study of con ventiona l ligation and se lf-ligation brac ket sys-
tems. Am J Ortho p Den tofac: Orthop 106:472-480. 1994.
41 . Ogata RH. Duncanson MG J r. Naoda RS, Currier G F. Sinha PK: Frictional resistances in stain less
steel bracket-wire: combinalions with e ffects o f vertical deflections. Am J Orthod Den tofac: Orthop
1994 (accepted for publication).
42. Vaughan JL, Dunca nson MG Jr. Nanda RS. Currier GF: Re lati ve kinctic frictiona l forces between
s inte red stai nless stee l brackets and o rthodontic wires. Am J Orthod Dcntofac Orthop 107:20-27.
I99S.
43. Buck TE. Scott JE, Morrison WE: A stud y o f the dislribution o f force in cuspid retraction utilizi ng a
coil spring. Master 'S thesis. Uni versity ofTexa.~, 1963.
44. Stoner M: Force control in clinical practice. Am J Orthod 46: 163-186, 1960.
45. Baker KL. Nieberg LG, We imer AD, Hanna M : Fricti onal changes in force values caused by sali va
substi tut ion. Am J Orthod Den tonte Orthop 91 :3 16-320. 1987.
46. Echols PM : Elastic ligat ures: Binding forces and a nchorage ta~at ion . (Abstract.) Am J Orthod
67: 2 19-220, 1975.
47. Creekmore TO: The im]XJ na nce of interbracket width in orthodontic tooth moveme nt. J C lin O rthod
10:530-534. 1976.
48. G ree nbe rg A R, Ku sy RP: A s urvey o f s pec ia lty coa ti ngs for orth odo nti c wi res. J De nt Res
58:98(A23). 1979.
49. Fec ney F, Morton J. Burston.:: C: The effect of bracket width o n brac ket-wire fri ctio n. Crnn Biology
Abstrncts 3S9, 1979.
SO. KUsy RP, Whi tley JQ: Effect of surface roughness on fricti Ollal coefficients of arch wires. J Dent
Res 67: A 1986. 1988.
5 1. Kusy RP, Whitley JQ: Effects o f sliding veloc ity o n the coefficients of friction in a model orthodon·
tic syste m. Dental Materials, .5:235-240. 1989.
52. Kusy RP, Whi tley JQ: Coefficients of fric tio n for arch wires in stai nless stccl and polyerystalline
a lumina bracket s lots. I. The d ry state. Am J Onhod Dentofac Orthop 98:300-3 12, 1990.
53. Bednar JR , Groendeman GW. Sandrik Jl; A comparative stooy of frictional forces between ortho-
dontk brac kets and arch wires. Am J Orthod DentofacOrthop 100:5 13-522. 199 1.
54. lreland AJ , Sherri ff M. McDona ld F: Effect o f bracket and wire composi tion on frictional forces.
EurJ Orthod 13:322-328, 199 1.
55. Kusy RP: Ceramic brackets. Ang le Orthod 61:29 1- 29 2.199 1.
56. Kusy RP, Whitley JQ, Prew itt MJ: Comparison of the frictional coefficients for selected arch wi re
bracket slol combinations in the dry a nd wet states. Angle Orthod 61 :293-302. 199 1.
57. Prososki RP, Bagby MD. Erickson LC: Static frictional force and surface roughness of nickel-tita-
n ium arch wires. Am J Orthod Den to fac Orthop 100:34 1-348. 199 1.
58. Tanne K, Matsubara S. Shibaguchi T. Sakuda M : Wire fri ctio n from ceramic brackets during simu-
lated canin e retraction. Angle Orthod 6 1:285-290, 1991 .
CHAPTER
11
Clinical Considerations in
Extraction Therapy
Thomas F. Mulligan
any different appliances and techniques are used in extraction therapy.
M Likewise, many di agnostic procedures are used to determine which teeth

should be removed. However, there has never been uniformity of opinion
regarding the ideal appliance or universal agreement on lhe removal of specific teeth,
a nd it is highly likely that this will be the case for years to comc. Yet the laws of equi-
librium t--4 allow us to apply princ iples when engag ing in different types of tooth
movement during extraction therapy. Recognizing and understanding the forces and
moments invol ved creates a common language from which one can deri ve treatment
deci sions as they pertain to the mechanics of tooth movemenL Memory wiress- 7 and
creative loop design offer the orthodontist exciting approaches to tooth movement,
but in actuality tecth can also be moved readily with relatively inexpensive and loop-
free archwires. Different types of tooth movements from wires without loops require
an understanding of the moments and forces and a proper location of the bends.s
It is the purpose of this chapter to present considerations in the application of the
forces and moments involved in extraction therapy regardless of the appliance used or
the teeth removed. The orthodontist may use these applications during treatment with-
out agreeing with the orthodontic community on the appliance to be used or the
extraction decision. For the sake of communicarion and simplicity, it is assumed that
thc individual is using a continuous archwirc without loops.
BIOMECHANICAL CONSIDERATIONS IN BENDING

LOOP-FREE ARCHWIRES
11lc intent of this chapter is 1I0t to suggest that the orthodontist should refrain from using
loops. Rather, the purpose is to offer an alternative that permits interpretation of the
actual forces and moments present and therefore predictability of the tooth movemenL
First. a comparison of a standard bracket slot with an angulated slot is in order 10
218
i 2§
CHAPTER 11 219
Clinical Considerations in Extraction Therapy
appreciate the angular relationships a nd their acti vation of the arch wire. When an
archwire is engaged into the brac ket slots, there must always be at least one angular
relationship in orde r for tooth movement to occur. Figure 11 - 1 illustrates that whe ther
the slots are aligned and the wire bent or the slots are angulated and the wire stmight,
the wirelbracke t a ngles are ide ntical. tn the s ituation in which the wire is stmight and
the slots are angulated. one might cons ide r this to re present a ease w ith prescription
bracke ts. the inte ntional canting of brac ket slO1s during placeme nt on the crowns, or
the :lIlgles that can result from various tooth pos itions in a malocclusion regardless of
the plane of space. A fter noticing that both s ituations result in the same angular rela-
tionships a nd the refore the same force syste ms. one can ta ke further comfort in know-
ing tha t regardless of the s lot size or interbracket di stance. the relati ve values will
remain unchangcd. There are many possibl e a ngular relationships, which have been
thoroughly di scussed in the literature.4 .8 The conside rations offe red here are intended
for the clin ically orie nted orthodontist who is interested in developing a n approach
whe re by suc h force syste ms can be applied on a regular basis and in a reasonable and
orderly manner. In order to accompli sh the latter. one must accept certain conditions.
First. from a purely scientific point a two-brac ket system is the ideal. The re are appli-
an ce syste ms in o rthodonti cs spec ifi call y deve lo ped to ta ke adva ntage o f th is
concept. IO Generall y spea kin g, howeve r, man y orthodonti sts lack the skill s a nd
knowledge to appl y such concepts in daily practice. The reali ty therefore is to com-
promise the "ideal" and still utili ze the benefits of the applied mechanics. Because the
typical orthodontist is in volved with a multitude o f teeth whcther the appliance con-
sists of a partial or full strap-up, it is suggested that the a ngular relationships between
the wire and brac ke t be attained by means of intraoral activation with Tweed Loop
pliers. These acti vations are djscussed more thoroughly later.
As a practical m;me r, the bracketed teeth immediately adjacent to the bend will be
conside red as undergoing what will be referred to as the Primary Response. These
bends are not pl:lced during the bracke t alignment phase because the malocclusion at
this stage produces wi re/bracket angles that automatically result in given force sys-
tems. 11 T hese fo rce syste ms may not be altogether desirable, but as an orthodontist
becomes more knowledgeable and experie nced with the concepts involved in using
wirelbracket angles for the production of specific force systems, it will becoille possible
to avoid or utilize the force sysLCms that take place during the bracket ali gnillent phase.
In the meantime intraoral aCli vation should be considered following basic bracket align-
me nt. Primary Responsc refers to the initial tooth move me nt that takes place. knowing
that in lime othe r responses may follow that are not desirable. These late r responses.
referred to as Secondary Responses, are avoided or at least kept to a minimum by elimi -
nating bends following completion of the Primary Response. Again. it is emphasized
Filure 11-1. Straight slots and angulated

wire can produce fon::e systems identical to
stralght wire and angulated slots.
220 CHAPTER 11
Clinical Considerations In Extraction Therapy
that the force systems discussed technically apply to a two-bracket system. but for the
sake of daily clinical use in a practical manner, an acceptable compromise is offered. In
order to clarify Primary versus Secondary Response. refer to Figure 11 -2. Hcre one can
see that gable bends- Ialer referred to as center bends- have been placed into the
extraction sites for root ali gnment. Effective moments are created at the brackets on
each side of the bend. These equal and opposite moments are used to produce root
alignment. If thc wire were allowed to continue to act followi ng root alignment. (){her
undesirable responses would begin to take place. These Secondary Responses would
consist of excessive movement of the apexes toward each other as well as eventual flar-
ing of the lower incisors. A reverse curve of S)X!e in the same arch would produce equal
and opposite moments at each end of the arch, resu lting in immediate flarin g of the
incisors. One might in very general tenns consider a cominuous archwire with these
gable bends to be somewhat like a reverse curve of Spec in the lower arch with response
initially limited to the brackets adjacent to the bends. In other words, immediate and
favorab le response to equal and opposite moments can be deri ved whi le avoiding the
side effects that tend to be delayed until the Primary Response is achieved. The bends
are then removed. In summary. if a specific bend is placed, forces and moments can be
produced that will have their primary effects on the teeth adjacent to the bend while
other effects are either eliminated or kept to a minimum. 12 Removal of the bend follow-
ing the Primary Response eliminates the adverse responses.
Although four wirclbracket angles are discussed, only two of them are usually
necessary. Actually. there are many more angles that can be formed, but those under
discussion have the advantage o f deli vering the forces and moments necessary while
permitting the orthodontist to create them inlraorally with considerable ease. All four
of these angles, which can be created intraorall y with l\veed Loop pl iers (Fig. 11 -3),
are show n in Fi gures 11 -4 through 11 - 7. The fi gures illustrate both the aligned
bracket slots and the prescription- slots, Because both produce the same force systems.
only me aligned slots are demonstrated in the utilization o f intraoral activation to
form specifi c wirclbmcket angles and their characteristic force systems.
Figure 11 - 2. Locating a cen ter bend between

the ca nine and second premolar wi ll produce a
Primary Response in these teeth. In this case the
response is root alignment.
Figure 11-3. Tweed Loop pliers ca n produce

consistent angular bends during intraoral activa-
tion.
CHAPTER 11 221
Clinical Con siderations in Extraction Therapy
Figure 11-5 . A n off·center bend located at th e "one·

Figure 11-4. The center bend is located at the midpoint third" position on the interbracket span,
between two brackets.
Figure 11-6. An off·center bend located at the

bracket-beyond the "one-third" position in a can- Figure 11 - 7 . Two off-center bends located at each
tileyer, bracket, but on opposite sides.
Figure 11-8 . The center bend produces equal and opposite

moments.
10
Figure 11-9. An off-center bend located at the "one-third" pos;_
tion produces a moment at the bracket closest to the bend and
equal and opposite forces at each bracket. This represents a can-
tileyer system,
222 CHAPTER 11
,,
Fil ure 11-10. An off-center bend located at

10 i0
the bracket-beyond the "one· third" position-
produces unequal moments in the same direction Filure 11-11 . Two off·center bends (step) pro·
and forces larger than those in the cantilever. ducing equal moments in the same direction and
the largest magnitude of force in the four
wire/bracket relationships presented.
The force systems associated with each wirclbracket angle are illustrated in Fig-
ures 11-8 through I I- I I. Why these different force systems exist in a loop-free wire
is not discussed here because the lite rature offers a scientific basis for each.4.8 How-
ever. it should be noted that whenever the moments arc not equal and opposite, forces
are introduced in order to comply with requirements for static equilibrium. Whe never
one moment is different in magnitude than the othe r, a net mome nt will occur that is
balanced by forces which creale a couple or pure moment in the opposi te direction. It
is this couple that keeps the teeth in equ ilibrium . As an orthodontist, olle does not
have to make the effort to comply with the requirements for equilibri um. This is done
whe n activation takes place by e ngaging the wire into the bracket slots. However, an
understanding of fo rces produced is essential in order 10 avoid or control side effects.
Figures 11 - 8 through II - II show that each wirelbracket angle produces specific
moveme nts. Figure 11-8 ilJustnttcs equal and opposite moments and is therefore an
effecti ve method to parallcl roots in extraction cases. Figure 11-9 may be used to treat
various problems associated with extraction treatment, incl uding the control of molar
position and the buccal-lingual positioning of the central grooves. s This canti lever is
also excellent for intrusive movcments because it is characterized by a single force at
one bracket. Figure 11 - 10 illustrates an effective method to initime cuspid retraction
with good anchorage control since roth brackets produce initial moments in the same
direction. Finally, Figure II - II shows a familiar technique for anchorage preparation
used in treatment that combines tip-back bends with anterior labial root torque. But this
particu\ar wire/bracket re\alionship produces the greatest magnitude of force due to
moments in the same direction that require a balanci ng couple. These larger forces pro-
duce the couplc necessary in compliance with the requirements of equilibrium. This
wirelbracket relationship should be used with caution in the venical plane of space
because it could result in the need for high-pull headgear and paticnt coopenllion.
RETRACTION AND PROTRACTION OF TEETH
A lthough this discussion penains to various aspects of extrac tion treatme nt, topics
such as initial bracket alignment, overbi te correction, and crossbite correction are not
CHAPTER 11 223
discussed, even though they arc part of extraction mechanics. Rather. thi s discussion
focuses o n space closure. Space closure of any kind first needs a dctcnnin:llion of the
anchorage requirements. I] Do we need to maximize retraction? Do we need to maxi-
mize prolr.lclion? How much of each do we need? Patient needs will dClemline which
wirelbrackct angle is c hosen. For example. leI us look at a specific insta nce represent-
ing cuspid retraction . Which wirelbracket relationship would best serve for desired
tooth movement? Figures 11 --8 through II - II show the available choices. In a full y
bonded case, the interbrackct di stances are qu ite small . Notice in Fi gures 11 -8
through t I- II that various degrees of anchorage are available depending on the "dif-
ferential" between the moments. Center bend (Fig. 11 - 8), with the momems equal
and opposite, would not have an effeclive reciprocal anchorage. If a canine retraction
case is begun with the off-center bend seen in Fi gure II - 10, movement will be initi-
ated with moments acting in the same direction, thus providing better initial anchor-
age. Admittedly, since the interbracket distances are qui te small , there is not a great
deal of di frerence from the force system produced with a center bend because just a
small amount of ca nin e movement quickl y alters th e force syste m sin ce the
wirelbracket angle quickly changes. The greater the di stance the bend can be placed
from the center, the greater the difference in the magnitude of the moment s at the
brackets adjacent to the bend. Ironically, thi s means that when more anchorage is
desired than can be obtained in a ful1 strap-up with the usc of an ofT-center bend, this
increase in anchorage can be better obtained by actually avoiding the pl acement of
brackets on the second premolars (Fig. 11 - 12), assuming a first premolar extraction
case. This allows further distal displacement of the bend from a centered position.
resulting in a greater differential between the moments. The largest moment occurs at
the bracket or tube located closer to the bend. Si nce the placement of the bend j ust
mesial to the molar tube instead of mesial 10 the second premolar bracket results in a
greater difference between the moments, it actually enhances anchorage. It should be
noted that when the bend is in the cenler, the moments are equal and opposite, but a
slightly ofT-centered position bend will create a difference in the magn itude of the
moments. As the distance of th is bend is increased from the center, the differemial
continues to increase, and thus the reason for not always bonding every tooth . This
approach mi ght seem quite contrary to what many indi vidual s have been taught, but
experience will prove its effecti veness.
Figures 11 - 13 through 11 - 16 il1ustrate the changing force systems during retrac-
tion of canines with chain elastics on a continuous archwire. These fi gures do not
renect precise angles but show the changes in the force systems as space is closed.
Duri ng canine retraction. because the location of the bend is di stal to the one-third
position (i n reference to interbracket di stance), two moments arc produced that act in
Figure 11 _12. Increasing the wire span by not bracketing the premolars creates a greater ~ d ifferen
lial" in moments w ith an off-cen ter bend located at the molar tube.
1
224 CHAPTER 11
10 i
Figure 1 1-1 3. Initial fo rce Figu re 11 - 14. Force sys- Figure 11 -15 . Force sys- Figure 11 - 16. Force sys-
system during canine re trac· tem following some canine tem prior to final space clo- tem following space clo-
tion. retraction. sure, sure. (Technically, these
moments are unequal due
to the angulat ed canine
bracket.)
the same direction , although they arc not of equal magnitude. This results in maximum
anchorage at the time retraction is initiated. As the canine is slowly retracted, although
the bend remains in its original posi tion. it now lies closer to the center because the
canine bracket is moving toward the bend (Fig. 11- 17). As long as the power chain
used for canine rclruction is not ovcmctivaled. the larger momcnt holds (he anchor
tooth in an upright position. If the bend is just mesial to the second premolar bracket.
the second premolar is held in an upright position. If the second premolar is not brack-
eted <and the bend is therefore located mesial 10 the molar lube, the molar is held in an
upright position (Fig. 11- 18). In either case. the canine lips and moves toward the
bend. If the second premolar is not bracketed, the cani ne tipping is somewhat greater
as a result of the greater difference in the magnitude of the moments present on the
canine and molar. As canine retraction takes pl ace, the smaller canine moment gradu-
Figure 11 - 17. Canine retraction with premolars

bracketed. Note the small interbracket distance.
Figu re 11-18. Canine retraction with premol.ar

bracket absent on one side. An off-center bend at
the molar tube will produce more effective
anchorage than an off-center bend on the oppo-
site side mesial to the second premolar bracket.
11 CHAPTER 11 2 25
Figure l' -1 9. A, A center bend and two off-

center bends produdng the same force system. B,
--
A center bend following canine retractioo with the
second premolar bracketed. The bend is located
mesial to the second premolar bracket. C, Two
off' center bends follOWing canine retraction with-
out brackets 0f'I the second premolar. The bend
distal to the canine bracket is added after space
closure Is completed.
B
•
=
=
ally disappears, and with further movement a small moment reappears on the canine,
but in the opposite direction. Thus anchorage diminishes as canine retraction takes
place. The force system is undergoing constant change and gives us maximal anchor-
age when it is nceded most and diminishes as the space is closed. Throughout space
closure, the largest moment continues to be present on the anchor side of the ex traclion
site. The bracket or tube closest to the bend contains the larger moment.
226 CHAPTER 11
Clinical Cons iderations in Extraction Therapy
Finally, when the space is closed and therefore anchorage is no longer a requi rement,
a center bend relationship occurs. Thi s takes place just as a pmient is ready for alignment
of the roots. If a second premolar bracket is not present (Fig. 11- 18), completed space
closure cannot result in a center bend relationship because the origi.nal off-centcr ~
placed mesial to the molar tube still exists as an off-center bend. Intrdoral activation of
the wire just distal 10 the canine bracket creates the equi valent of a cenlCr bend because
an off-ccnter bend mesial to the molar tube and another just distal to the cani ne bracket
each produces opposite angles and therefore opposite moments (Fig. 11 - 19).
The concept of root alignment using two off-center bends also has other benefits.
If first premolars arc removed while second deciduous molars are still present (Fig.
11 -20). canine rctmction can sti ll be accomplished with the off-center bend placed
mesial to the molar tube and an additional bend placed distal to the canine bracket fol-
lowing space closure. Thi s second bend, again. is pl aced to provide equal and oppo-
site angles (Fig. 11- 19). As stated earlier, two off-center bends can be placed in this
manncr to producc the same foree system as a center bend would- that is, equal and
opposite moments. Likewise, should a second prcmolar bracket fall off during a busy
schcdule or at the end of a busy day (Fi g. 11 - 18), the original o ff-center bend mesial
to the second premolar can be removed and another off-center bend placed just mesial
to the molar tube. Then. following space closure, a bend can again be placed diswl to
the canine brackelto provide equal and opposite moments for rOOI alignment.
Followi ng cani ne retraclion, anterior alignment is accompli shed. If there remai ns
the need for anterior retraction, it must be dctennined how much tipping versus bodily
movement is required . If only tipping is required. a loop-free archwire. as shown in Fig-
ure 11- 21 , may be used. The curvature at the distal of the wire will provide antirota-
Filure 11 - 20. canine retraction prior 10 eruption of second premolars.
Filure 11-21 . loop·free wi re containing a
I curve of Spee and posterior curvature for control

of molar rotation.
CHAPTER 11 227
~
J
Figure 11 -ll. MIDCiliary archwire and anterior brackets removed while cusps are S!ated.
lional moments on the molars during space closure wh ile the curve of Spec in the arch·
wire will tend to controilipping by pnxlucing a center of rotation ncar the apices of the
anterior teeth. A power chain elastic will provide the force for space closure. but it is
imperati ve that there be no critical anchorage requirements. If the relmetion of the ante·
nor teeth requires considerable anchorage, an archwire that comes out of the molar lube
and bypasses the teeth in the buccal segment, gingival to the brackets. and then insened
inlo the incisor bmc kels, can be utilized. This bypass is necessary only when teeth in the
buccal segment :Hoe bmckeled. The bypass creates the equivalent of a 2 x 4 appliance
and perm its the development of posterior anchorage by creating a relatively large
moment at the molar through the use of a curve of Spee in round wire. The curve in the
wire pennits the wire to slide through the molar tubes during anterior retrdCtion of teeth
while at the same time avoiding any torque in the incisor bmckcl'i. Because both tip-
b..'lck bends and c urves. as described, pnxluce differential torque in partial stmp-ups.
they provide anchorage whi le retracting a nterior teeth. It shou ld be noted that this
results in tipping of the incisors. [n patients needing incisor root torque. care is needed
in application of moments because they tend to fl are incisor crowns and slrain posterior
anchorage. The result may be loss of the Class I correction previously obtained. A solu-
tion is 10 place an equal and opposite moment at the other e nd of the archwire.
It is known from experience that crown moveme nt tends to precede root move-
me nt. and the refore teeth will move forward if on ly anterior lingual root torque is
placed into a rectangular wire. But if an equal amount of torque is placed in the poste-
rior, providing a moment in the opposite direction. the Class I correction wi ll be main-
tained as a result of anterior and posterior teeth being unable to move in opposite direc-
tions. Thi s assumes. of course. that the wire is tied back at the molar tubes. Whe n
crown movcme nt is prevented in one direction. the moment present resu lts in root
movement in the opposite direction. Thus, during anterior lingual root movement
mesial root movement is pnxluced at the same time in the posterior while preserving a
Class I relationship. It is advisable to remove all wires on patienLI; periodically during
treatment (Fig. 11-22). This results in seating all cusps prior to appliance removal.
Protraction is really nothing more than retraction in reverse. In patients with miss-
ing second premolars. to protrnct the molars a loop-free wire would be used as usual.
but the off-center"bend would be located just distal to the first premolar bracket in order
to provide the larger moment in this area. The molar now contains the smaller moment
and wi ll tip forward during closure. just as the canine lipped back when it contained the
smaller momc nt. Everything that was discussed during canine retraction remains the
same except that the force system is ''turned around." The bend is always placed against
the bracket of the tooth whose movement we wish to minimize. resulting in the smallest
moment being localed on the opposite tooth. The tooth with the smallest moment under-
•
118 CH APTER 11
----.;?
goes the tipping. and the lrnnsitional force system (Figs. 11 - 13 through 11 - 16) results
in a gradual loss of anchorage followed by alignment of the roots when spaces arc
finally closed. In the fin al analysis, an understanding of retraction mechanics and
anchorage considerations leads to a like understanding of protraction mechanics.
SUMMARY
Extraction treatment involves many aspects of mechanics. Because space closure is
invol ved in four premolar extractions, upper first premolar extractions. unilateral pre-
molar extractions, lower incisor ex tractions, etc., a discussion of force systems related
to various wirelbracket angles enables the operator to recogn ize that decisions must
be made concerning the location of bends withi n an archwire. The bends discussed
are capable of producing entirely different force systems during space closure, and the
opportunity exists fo r each person to make a selection based on anchorage require-
ments. Additional effort is not needed to create one angu lar relationshi p versus
another. but to do so requires knowledge thm rewards the operator and patient in
many different ways. He:ldgear and elastics may be minimized or even eliminated.
The use of loop-free wires with predetennined bends enables the operator to have a
better sense of what forces and momeniS are taking place at the initiation of retraction
or protraction and the changes Ihat are beginning to take place as a result of tooth
movement. Tooth movement docs not alter the absolute posi tion of the bend that has
been placed into the arch wire, but its position is changed relative to the inlerbracket
span as a result of changmg loolh position. With this in mind, we can properly locate
a bend at the iniliation of space closure and monitor the new force systems that take
place as the bracket moves "toward Ihe bend." It has been shown thai force systems
can be produced that aCI favo rably throughout the entire process of space closure.
REFERENCES
I, Mu11igan TF: Common Sense Mt.'Chanic.~ , Phocni~. A7.: C5M. 1982.
2. Isaacson RJ. Lindauer 5J. Rubenstein LK: Moments with the edgewise appliance: Incisor torque oon·
trol. Amer J Orthod Dcntofac Onhop 103(5):428-438, 1993.
3. Nikolai RJ: Bioengineering Analysis of Onhodontie Mechanics. Philadelphia: Lea & Febiger, [985,
pp.56-69.
4, Burstone CJ. Koeni g HA: Force systems from an ideal arch. Amer J Orthod 65:270-289. 1974.
5. Burstone CJ, Goldberg AJ: Beta titanium: A new onhodontic alloy, Arner J Orthod 7:2,121-132.
1980.
6, DurslOne. CJ. Sai Q. Monon JY; Chinese NiTi wiro-A new onhodontic alloy. Arner J Onhod
87(6):445-453, 1985.
7. Nelson K, SUTStQflC CJ, Goldberg AJ: OpIimaJ welding of beta titanium onhodootic wires. Amer J
Orthod92:213-2 19,1987.
8 . Surstone CJ. Koenig HA: Creative wire bending-The force system from Slep and V bends. Arner I
Onhod Dentofac Ortbop 93:59-67. 1988,
9. Ronay F. Kleinert MW. Melsen B. HurMone CJ: Force system developed by V bends in an elastic
onhodontic wire. Amer J Onhod Dentofac Orthop 96(4):295-301. 1989.
10. Surstone CJ:"The rationale of the segmented arch. Amer J Onhod 48:(11 }805-82 1. 1962.
IJ . Marcone MR: Preliminary brackel alignmenl. In Biomechanics in Onhodontics. Toronto: B.C.
Decker. 1990. pp. 45-83.
12. Mulligan TF: Common Sense MC(;hanics (office course).
13. Isaacson RJ . Lindauer 5J, Rubenstein LK: AClivating a 2 x 4 appliaocc. Angle Onhod 63( I): 17-24.
1993.
CHAPTER
12
Modified Lingual lever Arm
Technique: Biomechanical
Considerations
Hans-Peter Bantleon
n treatment with fixed appli ances, the bracket serves as a means of applying a
I force or a moment to a tooth. The center of resistance (e res ) of a tooth, however. is

typically located 10 mm apical to the bracket.\'2 If the line of action of an applied
force does not pass through C~. the force will produce rotation} The moment of a
force is equal to the magnitude of the force muhiplied by the perpendicu lar distance
fro m its line of action to Crcs (M = fx d). Fo r example, a single ho rizonta l force acting
at the brac ket is equivalcnI to a force of the same directio n and magnitude at C...,. com-
bined with a moment producing tooth rotation. The crown moves in the direction of
the force. whereas the root moves in the opposite direction (Fig. 12- 1).
In many patients translation is the desired tooth movement to keep stress levels in
the periodontal ligament ncarly uniform and low."'!! Burstone developed fri ctionless
springs that deliver counte mlOmenlS as they work oul. These countemlome nts should
be of the same magnitude as the tipping moments in order to achieve pure bodily
tooth movement.6
Another approach is to combine two forces acting at some distance to Cres ' If the
line of action of the resultant forcc passcs through Crei • translation is achicved. If the
two forces are parallel, the moments of these two forces at Cre> have to cancel each
othe r out- i.c. , the moments have 10 be of the same magnitude but of opposite direc-
tions. The magnitude of the resul!nnl force, then, is the sum of the two s ingle forces.
One of these two forces can easil y be applied at the level of the crown of the tooth,
but the other has to be applied at the level of the rOOt apex. This can be achieved only
with extension arms, or so-called lever arms.
The lever ann principle can be demonSifated by the force systc m of the widely
known uprighting spring. An upright ing spring made of 0.017 x 0.025 inc h stainless
steel wire wi th two and a half helixes and 20 mm length acting on a lower molar is
loaded with a weigh! of 20 g. The force syste m is registe red by means of an electronic
measuring device (Fig. 12-2). A vellical force of20 g and a moment of 400 gmm act-
229
230 CHAPTER 12
Modified lingual Lever Arm Technique: Biomechanlcal Considerations
Figure 12- 1. A single fOfce of 200 g applied

at the bracke t (sys tem 1) is equivalent to a
.- force of 200 g and a moment of 20Cl0 gmm

(2000 gmm= 200 g force x 10 mm of distance)
at the center of resistance (system 2). Thus, the
center of rotation is just slightly apical to the
center of resistance.
ing at the tube was measured. The molar wi ll be extruded by the vertical force and
uprighted by the moment. In the anterior region of the lever arm the teeth wil l be
intruded.
Influenced by the method of Fontenelle, who applied molded metal splints with
lever arms.' a lingual lever ann system consists of an 0.032 inch stainless steel spring
wire soldered to a bond ing pad .s A hook is bent in the wire 20 mm from the pad, and
the lever arm is adapted to the palatal vaul t. Usually a small offset bend is placed into
the wire at the gingival margin. The lever arm is then bonded to the lingual surface of
the tooth at the level of the bracket.
Concise, * together with Scotchbond U I, was used as the adhesive system. Load-
ing o f the lever anns is possible as soon as 15 minutes after bonding because Scotch-
bond I accelerates the curing o f Concise. Measurements showed that the mean shear-
ing force 15 minutes after placement of the p:td is 19.3 N/mm2 (± 2.2 N/ mm 2 SO).
76% of the fi nal shear bond strength .
The tip of the lever aml is located at approximately the apex of the tooth. Viewed
from the buccaL the distance between the hook of the lever arm and Cm; equal s the
distance between the buccal bracket and C.n. The moments of the two equal forces
acti ng at the tip of the lever arm and the brac ket cancel each ot her out, resulting in a
force being the sum of the two single fo rces. This force is located at the level of Cft:S
(F;g. 12-3).
"'Conci se. 3M Co mpan y, 51. Paul. Minnesota.

"''''Scotchbond. 3M Com pany. SI. Paul , Minn esota.
Figure 12-2. An uprighting spring

is loaded with a weight of 20 g. The
measuring apparatus registers the
vertical force and the moment at the
level of the molar tube by means of a
force and a moment recorder.
CHAPTER 12 231
Modified Lingual lever Arm Technique: Blomechanical Considerations
Palatal view
- -
Figure 12-3. The moments of the forces
f
at the lever arm and the bracke t cancel
each other out, resulting in translation.
t - - I
EM . 0
Forces add up
Vie wed from the mesial. there is a small diffe r~ nce belween the distance fro m the
tip of the lever aml to the long ax is of the tooth and the distance from Ihe bonded
bracke t to thi s axis (Fi g. 12--4). This difference produces a sli ght rotation. which is
desirable if the tooth was rotated out distally before treatment.
Supcrelastic closed-coil springs or elastic c hains are used as the power source.
One is stretched buccal1 y between the brac kets of the tooth or segment to be moved
and the anc horage unit. and the other is stretched palatally from the lever arm to an
exte nsion solde red on the nanspalatal bar or. alte rnati vely, to another lever ann.
To de monstrate the force levels reached by superelastic springs, three types of
springs were tested with a special measuring device consisting of a load cell and a linear
measureme nt transducer.· 1be measurements were taken in a water bath at 37 DC.
The le ngth of the unused springs without eyelets was 4.25 mm. The spri ngs were
stretched 2. 12, 4.25. and 6. 5 mm to a n ex te nsion of 50%. 100%. and 150% of the pas-
sive le ngth . Ten specime ns of each brand we re tested and the results analyzed.
Fig ure 12-5 su mmari zes the results of the measure me nts o f the superelastic
closed-coil springs. The load defl ection rate of the springs used shows a clear devia-
tion from linearity. At a spring activation of 50%, 100%, and 150% almost the same
initial force is reac hed. and it is just slightly hi ghe r with increasing ac tivation. During
deacti vation, however. the graph is steeper with the small amount of activation. The
deacti vation graphs show a force plateau. which is more distinct for the springs that
we re initiall y activated than for the others.
Based on these findin gs the superelastic springs are overstretched to 10 to 15 mm
in the patient's mouth at body temperature.
*Scntnlloy red, yellow, and blue.
Mas/a/View
Figure 11-4. A slight rotation is produced because

the distance from the tip of the lever arm to the long
axis (d,) is greater than the distance from the bradet
to this axis (d1).
a_ b _ translation
ct.> ~ - slight rotation
,
232 CHAPTER 12
Modified lingual lever Arm Technique: Biomechanical Considerations
•
~
0
~
N
~
0 3
"
~
* N
0>
-
0
N
C ~
~
U
L
0
2 •
"- ~
.:
•: ~~I
•
g ••
-...
.;
t . '" 2 . 00 " . 10
Length In rnrn
15. "0 e.70 8 .00
,
0
0
0
""
.
-* "
0 2
N
0>
~
C
.~
~
~
U
0
•
-
L
0 .;
"-
0
•.;
• , • I •• ••
~. •• . ••
•
....
0
0 •••
B
,;
.00 .." 2.60 S."
Length In rnrn
6." 7 . 80
Filure 12-5. A and B, Deactivation graphs of SentaJloy red, yellow, and blue closed-
coi l springs. In each graph the highest force level Is reached with the Sentalloy red spring
and the lowest force level with the SentaHoy blue spring. The activation in A was 2.12, in
84.25.
CHAPTER 12 233
Modified Lingual lever Arm Technique: Biomechanical Considerations
c Length in mm
Figure 12-5. (Continued) C, Deviation graph of Sentalloy red, yellow, and blue
dosed-coil springs. The highest fOfce level 15 reached with the Sentalloy red spring
and the lowest force level with the Sentalloy blue spri ng. The activation in C was
6.5.
Because it is so easy to modify the force system with the lingual lever arm tech-
nique, the approach offers many possibi lities for cli nical application. The followin g
four case reports arc aimed at illustrating some of these possibi lities.
Case 1
The 38-year-old male pUlient presented with severe crowding in the lower fronL In
the upper arch the right lateral incisor was congenitall y mi ssing. Cephalometric
analysis revealed a long face with skeletal deficiency of the mandible (Fig. 12-6).
Since Ihe patient refused surgery. treatment objectives were a Class I relationship
on both sides. resolving of the arch length discrepancy. and vertical control during
space closure. The treatment plan was to extract both central incisors in the lower
arch and the first premolars on the left in the upper arch. By doing so. the lower
canines could be positioned as lateral incisors and the upper lefl canine brought into
Class I. Because the upper lateral incisor on the right was congenitally missing, the
ri ght canine could remain in its position adjacent to the central incisor, and extraction
on the right side was not necessary.
A palatal lever arm was bonded to the can ine for bodily retraction. An elastic
chain and a NiTi closed-coil spring were used as the power source (Fig. 12-7). In the
lower arch the space between the lateral incisors was closed by means of a centered
0.016 inch T·loop, and the posterior segments were uprightcd by inlruding the anle-
rior segment with slightly activated tip-back springs.
234 CHAPTER 12
Modified Lingual Lever Arm Technique: Blomechanical Considerations
Figure 12-6. A-E. Thirty-eigh t-year-ol d male patien t

before treatment.
o
CHA.PTER 12 235
Modified lingual Lever Arm Technique: Biomechanical Considerations
Figure 12-7. A-C. Belore and afte r space closure with ,

palatal lever arm. r
After 22 months treatment was completed with Class I dentition on the rieht side
and near-Class I dentition on the left side (Fig. 12- 8). A lingual retainer was bonded
in the lower arch as we ll as in the upper arch to stabilize the resul t.
Congenitall y missing upper lateral incisors arc a common orthodontic problem.
Space closure can be achieved by the mesial movement of the canines and by posi-
tioning them as lateral incisors, thus avoiding successive prosthodontic treatment.
Case 2
The next case is a male pati ent with bilateral cleft lip and pal ate who had been
referred just after birth (Fig. 12-9). One central and both lateral incisors were congen-
itally missing. When he was 10 years old, in his late mixed dentition (Fig. 12- 10), the
cen tral incisors were protruding. An insufficient bony support of the intermax ill a
became apparent during bone grafting surgery. Therefore. instead of bone grafting,
the complete premaxill a had to be removed (Fig. 12- 11 ). In order to gain new bone in
this area, the canines were bodily moved to the mesial by auaching palatal lever arms
to their crowns and by pulling them labially and lingually together with two elastic
chains (Fig. 12- 12). Figure 12- 13 shows the canines in the position of the central
incisors. A retaining plate maintains the space fo r the lateral inc isors until fi nal
prosthodontic treatment.
Case 3
A 33 Ih-year-old male patient presented with a severe midline shift of 7 mm, 5 mm to
the left in the upper arch and 2 mm to the right in the lower arch. The intraoral exami-
nation showed a unilateral crossbite on the right side; the upper left can ine was con-
gen itally missing: and the upper as well as the lower right first molar had already
236 CHAPTER 12
Fi,ure 12-8. A-E, Patient after treatmen t.

CH APTER 12 237
Modified Lingual Lever Arm Technique: Blomechanlcal Considerations
Figure 12-9. Patient with bilateral chello-

gnathopalatoschisis just after birth.
Figure 12- 10. Orthopantomogram at the age of 10.
Figure 12- 11 . Orth opantomogram after

complete removal of the premaxilla.
238 CHAPTER 12
Modified lingua/lever Arm Technique: Biomechanica/ Considerations
Figure 12-12 . Protraction of the

canines with palatal lever arms,
been extracted (Fig. 12- 14). Cephalomctric analysis revealed skelctal deficicncy of
the mandible. Since the patient refu sed surgery, treatment objectives were Class I den-
tal relationship on both sides. space opening for the len upper canine. and correction
of the crossbite as well as the midline shift.
in the initial treatment phase the molars were expanded with a Goshgarian-type
transpalatal bar. The premolars on the right side were retracted with a centered T-loop,
in which an antirotational moment had been bent in the anterior pan on ly. In the same
way the right canine was moved with a centered T-loop into Class I dental relation-
ship. An opened coil spring was placed between the upper central incisors. Lever
anns were bonded to the right canine and left incisor. By means of an elastic chain
between the lever anns and Class II elastics the midlinli was sh ifted to the right (Fig.
12-15). To intrude and upri ght the right second bicuspid which had been tipped 10
the buccal, an elastic chain was stretched between the transpalatal bar and a button
bonded to the lingual surface of the crown (Fig. 12- 16).
Treatment was completed after 3 years and 2 months with Class I on both sides,
space opening for the left canine. and complete correction of the midline in the upper
arch. Figure 12-17 shows the Class I dental relationship and tempomry bridges.
Case 4
This patient. with unilateral cleft lip and palate. had transposed left canine and the left
first premolar (Fig. 12-18). The treatment plan was to protract the bicuspid to avoid
its extmction. A palatal lever arm was attached to the lingual crown surface of the
bicuspid. An extension arm was soldered to the transpalatal bar, and a superclastic
closed-coil spri ng was stretched between the lever aml and a hook on an extension
arm soldered to the transpalatal bar (Fig. 12- 19). The force system was modified later
by using a horseshoe-shaped transpalatal arch (Fig. 12-20). The buccal eruption of
the canine resulted in a slight rotation of the premolar to the mesial. To rotate the
tooth further an elastic was stretched from a button on the buccal surface of the toolh
to a facebow with cut-away outer bows (Fig. 12- 21). After having achieved a rotation
of 900 the premolar had to be reshaped to resemble an inci sor. Both cusps were
slightly trimmed, and the gap between them was fi lled with composite (Fig. 12-22).
DISCUSSION
In recent years the percentage of adult patients receiving onhodontic treatment has
increased. Force systems that have been routinely applied to the adolescent should be
reevaluated and customized fo r the adult patient, who may have dimin ished alveolar
Filur. 12-13. A-f, Patient after mesial movement
of the canines. A retaining plale keeps the place for
the lateral incisors. The x·rays show that bone has
been moved with the canines to the mesial.
]39
240 CHAPTER 12
Modified Lingual lever Arm Technique: Biomechanical Considerations
Filure 12-14. A-f, Male patient, 33'h years old, wit h a

severe mid'i~ shift be fore treatment.
.......--------~------------- CHAPTER 1 2 241
Modified Lingual Lever Arm Technique: Biomechanical Considerations
Figure 12-15. A and e, By means of palatal lever arms and Class II elastics the midline was shifted to
the righ t
Figure 12- 16. Intrusion and uprighling of the right se<ond

premolar with an elastic chain stretched to the transpalatal bar.
suppon . As an example. if 3 mill o f alveolar bone is lost, the moment-Io-force ratio

(M/ F nllio) shou ld be inc reased by approx imate ly 20% to maintain translation .?
Altering the M/ F ratio is much easier in the lingual lever arm technique than with
calibrated springs because the moments and forces produced by a spring arc not capa-
blc of independe nt adjustme nts. The length of a levcr arm, on the other hund, can eas-
ily be varied, and if a higher M/F ratio is desired. the lingual lever ann may be com-
bined with a buccal extension ann .
Tanne et at. demonstrated by usc of the fi nite clement method that even a very
small difference in the MIF rat io produces cli nically signifi cant changes in the posi-
tion of the center of rotation. LO C li nicall y it is very difficult to determine accurately
the actual M/F ratio needed for translation. Therefore it is advisable to use a 0.016
inch round or a 0.016 x 0.022 inch rectangular stainless steel guiding wire for a con-
trolled tooth movement. Friction generated wi th stainless steel wires is lower than
with TMA or NiT. wires, and it is lower with round than with rectangular wires. I I .! 2
Because with the use of lingual lever arms the actual MfF ratio needed for translation
is already approx imated. the gu iding wire is on ly slight ly deformed. Thus, the fri ction
generated with the guiding wire is low.
242 CHAPTER 12
Filure 12-17. A-E, Patief1t after treatmeflt WI!t1 corrected midijne

shift.
CHAPTER 12 243
Modified lingual lever Arm Technique: 8iomechanical Considerations
..-
Fi,ur. 12-18. Status·X of the patient with
transposition of the !eh lJ~r canine and first
premolar.
Figure 12-19. Mesialilation of the bicuspid with lingual

lever arm and superelastic closed-coil spring.
Figure 12-20. Modification of the force system by usi ng a

horseshoe-shaped IranspaJatal arch.
Figure 12-21 . Rotation of the premolar with elastics.

244 CHAPTER 12
Modified Lingual Lever Arm Technique : Biomechanlcal Considerations
Figure 12- 22. A-C, Patient after treatment. The rotated

first premolar was reshaped as latera! incisor.
In nongrowi ng ind ividuals it is sometimes desirable to move teeth into an area in

which the alveolar process is not so weH developed. Therefore, the movement has to
be with d irect resorption, which is fo Howed by corresponding periosteal apposi-
tion.13•14 . Hyalinization must be avoided by applying only light continuous forces and
by tr.:mslating teeth.
Superelastic closed-coil springs allow the delivery of an almost continuous rela-
tively low force over a large range of deactivation if they are "overstretched" in the
patient's mouth al body temperature prior to application.
The lingual lever arm technique is useful in tTCati ng patients in need of sophisti-
cated mechanics.
CHAPTER 12 245
Modified Lingual Lever Arm Technique: Biomechanical Considerations
REFERENCES
l. Burstone CJ. Pryputnicwicz J: Hologra phic detennination of ce nt ers of rotation produced by ort ho-
dontic forces. Am J Orthod 77: 121 -132. 1980.
2. Tannc K, Koeni g HA. Burstone CJ: Moment to force ratios and the center of rotation. Am J Orthod
Dentofac Orthop 94:426-431. 1988.
1 Smith RJ. BurstoneCJ : Mccllanics of tooth movemem.Am J Orthod 85:294-307. 1984.
4. Aodcrscn KL. PedCfSCn EH. Melse n B: Material par:lmeters aod stress profiles within the pt:Tiodontal
ligamem. Am J Orthod Demofac Orthop 99:427..-440. 199 1.
.5. Tanne K. Sakuda M, Hurstone CJ: Three-()imensional fin ite element analysis for stress in the peri-
odontal tissue by orthodomic forces. Am J Orthod Dentofac Orthop 92:499-.505. 1987.
~. Burstone CJ: The segmented nreh npproaeh to space elOStlfe. Am J Orthod 82:361-378. 1982.
7. Fontenclle A: La conception parodonta1e du mouvemCIl1 demaire provoque: Evidence cliniques. Rev
Orthop Dentofac 1:37-59. 1982.
8. Kucher G. Weiland Fl. Ball11eon HP: Modified lingual lever arm tec hnique. JCO 27: [8- 22, 1993.
9. Braun S. Win zler 1, Johnson BE: An analysis of orthodontic force systcms applied to the dCll1ition
with diminished alveolar support. Eur 1 Orthod 15:73-77. 1993.
10. Tanne K, Koenig HA, Burstone CJ: Moment to force ratios and Ihe center of rolation. Am J Orthod
Demofac Orthop 94:426-431, 1988.
11. Fronk CA. Nikolai RJ: A cornparatl\'c slUdy of frictional re!iistnnce between orthodontic bracket and
arch wire. Am J Orthod 78:593-«l9. 1980.
12. Kapila S. Angolkar PV. Duncanson MG. Naoda RS: Evalu3lion of friction between edgewise stain·
less steel brJckets and orthodontic wires of fou r alloys. Am J Orthod Dentofac Orthop 98: 117- 126,
1990.
13, Wehrbein H. Ri e6 H. Meyer R. Schneider B. Diedrich P: Kl:Irperli chc Zahnbewegung in atrophierte
Kieferabsc hnil1C. Dtsc h Zahn!!rlll Z 45: 168-171, 1990.
14. Wehrbein H. Diedrich P: Parodontale Veriindcrungen nach orthodonlischcr Z'Ihnbewegung-eine rCI-
rospcklive histologische Studie ~Im McnschC!1. Fortschr Kicferorthop 53:203-2 1D. 1992.
248 CHAPTER 13
Contemporary Management of Class II Malocclusions: Fad and Fiction in Class II Correction
Figure 13-4. Longitudinal growth of untreated Figure 13-5. Longitudinal growth of untreated
subject -typical pattern show ing more mandibular subject. Note the counterclockwise rotation of
than maxillary growth. the mandible and greater mandibular growth
than normal.
Figure 13-6. In untreated nor·

mals, large valiation is found in
growt h incremen ts of the
mandible. (From Burslone CJ,
and Hickman J: Syllabus: Ortho-
dontic treatment planning. Indl'
ana University, 1969)
will drop straight down, moving neither forward nor backward. However, the varia·
tion is considerable (over 6.00 mm at three standard deviations). The clinician should
be very carefu l in interpreting tracings of hi s or her cases or of cases reported in the
literature. since a difference between an indi vidual patient and a standard does not
prove that orthopedic changes have occurred. It may mean that the patient is showing
normal variation that can be observed in any untreated sample.
If it is true that mandibles typicall y grow more horizontally than maxillas, does
that mean that Class li s are self-correcting? The answer is no. It would be very
unusual for a Class II to self-correct, although some cases have been reported. With
differential growth , the teeth compensate and mignlte, which explains why the occlu-
sion wi ll remain the same unless treatment is insti tuted. Usually, as the mandible
grows forward more than the maxilla. the maxi ll ary teeth compensate by moving
downward and forward. Intervention by Class II elastics, headgears. or functional
appliances will usually hold the maxillary teeth (keep them from displacing forward
while the mandible is growing).
The first key to correcting the Class II is to consider the growth potential of the
patient. As best as possible, the clinician is concerned with predicting where the child
is in respect to peak velocity (the child's developmental level) and the magnitude and
direction of growth. Figure 13-8 demonstrates that using a developmental age rather
than a chronologic age provides a more predi ctable measure of the growth increments
that might be anticipated during peak velocity. Standards based upon chronologic age
alone can be deceiving. Since some pat ients are earl y, average, or late maturers, when
CHAPTER 13 249
Contemporary Management of Class II Malocclusions: Fact and Fiction in Class II Correction
Figure 13-7. In untreated normals,

large variation is found in the dis·
placement of point A re lat ive to
nasIOn. (From Burstone CJ, Hickman J:
Syllabus: Orthodontic treatment plan-
ning. Indiana University, 1969.)
averaged the chronologie age growth curve lends to nallen and does not refl ect some
of the remarkable growth increments Ihat occur. particularly arou nd puberty.
Nonnal growth and its variations can explain a high percentage of the skeletal
changes that occur during the treatment of Class II cases. Is it possible beyond the nonnal
growth 10 enhance mandibular growth or retard maxillary growth and thereby proouce an
orthopedie change? A voluminous literature suggests that ,ml(ll/ changes arc possible
orthopedically, which could help us during treatment. However. over lime these orthope-
dic changes may be partially or completely lost if therapy docs not continue until the
time all growth has ceased. The patient shown in Figure 13-9 demonstmtes a mandible
that has moved forward considembly with growth during treatment while the maxilla has
not moved forward at all. How do we explain this change? Sincc the pattern is not typi-
cal, we could speculate that the maxilla was held back while the mandible was encour-
aged to grow, The reality is thm this patient was a Class I, where no headgears. clastics.
or functional appliances were used and that the changes represent the nonnul growth pat-
tern for that individual. If a maxilla has nOl grown forward typically or a mandible that
has grown more horiwntall y. one cannot make the statement that these changes are due
to treatment since they may be in the realm of nonnal variation in growth.
In short, growth considerations are perhaps the most important factors in planning
treatment for a Class U palient when one recogni zes that (he most dramatic changes in
the correct ion are probably attributable to growth and not tooth movement. Beyond the
patient's inherent growth it may be possible to proouce some small orthopedic effects
,. .- 32'Iro increase
.., Increments ol "'·PI! (malt)

- De..elopment&1
••• - Cllronologlcal
Figure 13-8. Growth incremen ts based on ,.

chronological age (red line) are poorer predic-
tors than those baSe1l on developmentaJ age
(blue line). Note that developmental age pre-
dicts more mandibular growth at puberty. 2.'
...,
,"
~ age
~~~~~~~~~~~~~
5.8 6 .8 7.8 8.8 9 .8 10.8 11.8 12.8 13.8 1• .8 15.8 16.8 17.8 18.8 HU 20.8
(years) -6 _7 -8 -6 - 'I -3 -2 -1 P .1 .2 +3 ." .S -+6
151 CHAPTER 13
Figure 13- 11 . Nance appliance attached to bicuspids to en h anc~

anchorage during molar distal movement. A. Space has opened, but
head films (8 and 0 show marked flaring of the upper incisors with
the appliance.
men! have been suggested. The most obvious one is to use a distal force with a spring,
magnet. or other mechani sm. The difficulty with the distal force is that an equal and
opposi te mesial force might flare the incisors-a common occurrence. Some clinicians
have suggested using a Nance-type appliance to rei nforce the anchorage on the anterior
segment (Fig. 13--11 ). It appears from the occlusal view that molars have been distal-
ized and that a large space has been opened both mesial and distal to the second bicus-
pid (Fig. 13- IIA). However. if we look at the head films before and after, we see that
there has been considerable fl aring of the maxi llary incisors (Fig. 13-I IB and G.
Although headgears and distal forces are often viewed as primary mechanisms
for distal movement, other possibilities may be useful that, at the same time, mini-
mize undesirable side effects. In Figure 13-12. a .032 x .032 inch stainless steel can-
tilever is placed in a hinge-cap bracket tube. A light Class n clast ic is run from a
lower arch. These mechanics can effecti vely tip back an upper molar and rotate the
mol ar mesial oul. Figure 13- 13 demon strates schematically that the light Class II
elastic is effective. not onl y becau se of its di stal force bu t becau se a very large
moment is produced tipping the molar distally. Bilaterally. the same effect can be
achieved with a large .045 inch steel archwire that fit s iOlO headgear tubes with a
Class II elast ic attached anteriorly. There is no question that a Class II elastic can flare
the lower arch , increase the vertical, and steepen the occlusal plane. Hence, the Class
II is used only for a short period of time; and because the molar lips back rapidly. only
a short period of Class U elastics wear is required. leading to negligible side effects.
Many Class U patients have deep overbite, so one may take advantage of si multa-
neously intmding incisors while posterior teeth are tipped back. Figure J 3- 14 shows a
three-piece tip-back mechanism. A rigid interior segment fi ts the four incisors that are
CHAPTER 13
Contemporary Management of Crass II Malocclusions: Fact and Fiction In Crass II Correction
Figure 13-12 . light Class 11 elas·

tic produces a large momen t to tip
back on upper molar, The light
force and short inteNal of use mini-
mizes the side effects on the lower
arch.
Figure 13-13 . Force sys tem from the appliance

snown in Figure 13-12.
Figure 13-14. Three-piece intrusion arch used for distal movement of molars. A. Passive tip-back spring. 8, Activated spring. The
moment tips back the molar. The hook slides along the anterior segment. The reciprocal effect is the intrusion of incisors.
254 CHAPTER 13
•
-t
,
>-\.
"
U ;t
B ~
Figure 13-15. Distal elastic has been added to change the direction of force so that intrusion occurs parallel to the long aJoClS of the
incisors. Pladng the hook distal to the cente r of resistance of the anterior segment produces incisor retraction. A. App liance; B, tradng show·
ing incisor intrusion and retraction .
to be intruded. A posterior tip-back spring produces a tip-back moment. tipping the

first molar di stally. Note that the spring is free to slide di stally on the posterior exten-
sion of the anterior segment. Transsep,al fibers or fi gure eight tics kccp the bicuspids
moving di stally along with the molar. Since individual tipping of teeth is required, no
archwire is placed in the buccal segment. By placing the intrusive hooks on the anle-
rior segment either anteriorly or posteriorly, one can either nare the inci sors or retract
them simultaneously during the tip back of the posterior teeth . The same type of
spring can be used 10 move the anterior teeth distally and simultaneously intrude them
(Fig. 13~ 1 5A). The three-piece intrusion arch has intruded and retracted the upper
inci sors (Fig. 13- 158 ). During treatment. the intrusive force was placed along the
long axis and through the center of resistance and later moved linguall y to produce
the lingual movement of the upper incisors.
If a patient has deep overbite and one can take advantage of intrusive forces, a
powerful mechanism presents itself for tipping molars distally. What does one do if
the molar has a normal axial inclination and one is not interested in producing a major
distal ti p? Small distal tipping at the end of treatment may be satisfactory if more
mandibular growth is yet to come. Later. the upper arch will be normally moving
Figure 13-16. The curved arrow shows the direction of

molar tipping. Occipital and cervical headgear force posi·
tions and directiOns (arrows) negate tipping moments and
lead to distal trans lation.
CHAPTER 13 25 5
Contemporary M anagement of Class II M aloccl usions: Fad and Fidlon in Class II Corredion
downward and forward, giving the upper molar the chance to correct its axial indi na·
lion while s fiJJ mmnwining:1 stable Cl.-iSS II correction. But SOllie patients may require
translati on of the upper molar di stally. To accomplish thi s, one could combine a ti p--
back mechanism as a three·piece intrusion arch with the use of headgear. Some of the
points of force application and di rection of headgear that would compensate for the
molar tipping are shown in Figure 13- 16. Why should one use an intrusion mccha·
,I nism with a headgear rather than just the headgear alone, since a properly positioned
headgear should be able to translate a molar distally? Of course, the answer lies with
patient cooperation. The tip· back mechani sm is always working, keeping the molar
distal, while the headgear is the backup mechanism used only for the root retraction.
A further benefit , of course. is that simultaneously the deep overbi te can be corrected.
In some Class n cases. max illary expansion may be required . either because o f
the crossbite or a narrow maxilla. Figure 13-17 shows that bilateral expansion will
not only ex pand widths but also can improve the C lass II occlusion . The reason is that
there are two components to expansion as measured to the line of occlusion of the
posterior segments. If the line of areh of the posterior segment is not parallel to the
midsagittal pl ane, there is both a buccal and a distal component. It is this distal com·
pOnent that is responsible for helping the correction of a C lass H.
MISCELLANEOUS FACTORS IN CLASS II CORRECTION

The successful correction of a C lass II patient is inti mately tied to proper verti cal con·
trol. In some patients with a large max illomandibular di screpancy and in which
growth is insuffic ient or inadequate. it is not desirable to rotate the mandible down·
ward and backward with improper mechanics. Although these mechanics may give
the illusion of successful deep overbite correction. they nevertheless make the di s·
crepancy worse because the mandible moves back into a worse Class II . Control of
the vertical dimension means control not onl y of the mandible but also of the occl usal
plane. It is not desirable in most patients to steepen this plane of occlusion, which
unfortunately is a typical side effcct of intermaxill ary elastics and improperl y directed
headgears.
The orthodontist should carefully observe the axial incl inations of the posterior
teeth. Most bracket systems are designed to produce average or typical mesiodistal
axial inclinations of the posterior teeth . In some C lass H patients. the bicuspids as
well as the molars may be tipped distally. A straight wire will move all of these teeth
forward. so that it may be best to angle the brackets to preserve these axial inclina·
tions. If one plans to correct the distal tip. mechanics other than a straight arch should
be used (Fig. 13- 18).
Most normal occlusions present a curve of Spee posterior to the fi rst molars.
Lower fi rst or second molars can be leaning forw ard and upper fi rst and second
molars leaning distally. Overfl attening the upper and lower arches can cause the
occlusion to move into an even worse Class IJ . In you nger patients. these axial incli·
nations should be recogni zed as a stage of development. and one should be panicu·
lad y careful not to eliminate too early the immature axial inclinations of erupting sec-
ond molars. Although some orthodontists like to flatten upper and lower arches to
he lp correct a deep overbite, this approach may not be desirable if it leads to an
increase in vertical dimension , mesial movement of the upper molars. and distal
movement of the lower molars-all resulting in increased Class n occlusion with loss
of vertical control. Selective intrusion of inci sors may be a better way to correct a
deep overbite and avoid these undesirable side effects.
Thi s chapter has described important theoretical considerations and rationales for
the correction of C lass LI malocclusions. It points out that a high percentage of correc·
256 CHAPTER 13
Contemporary Management of Class II Malocclusions: Fact and Fiction in Class 1/ Correction
Fillire 13-18 . Posterior ax ial inclinations shou ld be

carefully examined in some caSM. Maintenance of dis-
toangular axial indinations may be desirable.
tion is achieved in growing paticnts as the result of differential mandibular growth

between the maxilla nnd the mandible. Although added to this growth may be an
orthopedic effect. lhe major changes can most likely be explained by nonnal growth
variation. In addition, the diagnosis and treatment planning for distal movement of the
upper arch have been discussed. When ind icated. distal movement of posterior teeth
can be accompli shed with a number of mechanisms; some of them produce no distal
force whatsoever but rely on the reciprocal action between anterior intrusion and pos-
teri or lip back. There is an infinite variati on in lhe morphology and fun ction of Class
U patiems, so that lreat mem goals and biomechanics have to be tailored to indi vidual
pat ients. There is no single appliance that can meet all of these needs-hence, the
theme of desirable Class II correction is creati ve versatility.
REFERENCES
t . Bursto ne CJ: The integumental profile. " me r J Onhod 44: 1- 25, 1958.
2. BUTStone CJ: Process of maturation and growth predictio n. Amcr J Orthod 12:907-9 19. 1963.
3. Bu rs tone CJ: Lip posture a nd its sign ilicance in treaunent plan ning. Amer J Orthod 53:262- 332.
1967.
4. Bun;tone CJ. Hickman J: Syllabus: Onbodomic treatmem planning. Indiana University. 1969.
5. Hu ang JS. Bu rstonc CJ: The growth velocity prcdic1ion usi ng thc sa mpled. transfe r-function. Growth
45:105-1 13.19 77.
6. Burstone CJ: Ikep overbite correct ion by intrusion. Amer J Orthod 72(1): 1-22, 19]7.
7. Romeo DA. BUTStone CJ: Tip-back mechanics. Amcr J Onhod 72(4):4 14-421. 1977.
8. Robcrt~ WW Ill. ChackeT PM. Bu rstone CJ: A segme ntal approach 10 mandibular molar uprigh1ing.
Amcr J Orthod 8 1(3): 1 77~ I 84. 1982.
9. Smith RJ , Bursto ne CJ: Mechanics of tooth movement. Amer J Othod 85(4):294-307. 1984.
10. Bul"Stooc CJ : Precision li ngual arches-active npplications. J Oin Orlhod 23(2): 10 1- 109, 1989.
II . Shroff B, Li ndaucr SJ , BUTstone CJ. Leiss JB : Segmented approach to simultaneous intro~iOl1 and
space closure: Biomechanic.~ o f the three-piC<.'C base arch appli ance. Am J Onhod Iknto fac Orlhop
107:136- 143.1995.
CHAPTER
14
An Approach to Nonextradion
Treatment of Class II Malocclusions
Anthony A. Gianelly - John Bednar - Victor S. Dietz -James Koglin
onex traclion treatment of C lass II malocclusions can be accompl ished by
N ma ny treatme nt modali ties. One is 10 convert the C lass II molar relationship

to a C lass I by moving max illary molars distally in the initial stages of treat·
menl, followed by the sequential retrac tion of the premolars, canines, and incisors.
The inlcnt of th is chapter is to demonstrate this treatment protocol by means of the
Bidimensional technique. which emphasizes the use of Sentalloy· coils 1 to move the
maxill ary molars distally! and slid ing mechanics for all tooth movements, including
bod il y retraction of the incisors.
In this technique, .0 18 x .025 inch verticall y slotted brackets are placed on the
maxi ll ary and mand ibu lar central and lateral incisors (Fig. 14- 1). The brackets for the
maxi llary incisors are pretorqued and preangu lated (Roth prescription), while those in
the mandibular arch are standard brackets. All othe r attachments are .022 x .028 inch
with vertical slots in the canine and premolar brackets. Th is means that an .0 18 x .022
inch w ire can "fill" the incisor brac kets and be undersized in the canine, premolar.
a nd molar attac hments. For this reason, the wire can s lide through the poste rior
attachme nts.
When bodi ly retraction of the maxillary incisors is required, an 0 18 x .022 inch
wire, with hooks crimped on the wire between the lateral incisors and canines. is
inserted. and Sentalloy closed coils exerting 300 g of force are activated fro m the
molars to the hooks to retract the incisors by sliding the wire through the attachments
on the poste rior teeth (Fig. 14-2).
Anc horage control duri ng incisor re trac tion is gained by use of a gear and 150 g
Class II claslics placed on the maxillary canines.
Whe n Class II elastics are used, an .0 18 x .022 inc h wire with approxi mately 10
to 15 degrees of lingual crown torque and a reverse curve of Spee is inserted in the
lower arch. The lingmll crown torque is placed to control the amerior component of
" GAC Internationa l Inc. 257

258 CHAPTER 14
An Approach to Nonextractlon Treatment of Class II M alocclusions
·OIB .018
Figure 14-1 . Attachments: Incisor brackets
are .018 x .025 inch. Canine, premolar, and
molar attachments are .022 x .028 inch.
MOLARS INCISORS
BICUSPIDS
CU SPIDS
the Class 11 elastics, and the reverse curve of Spee serves to contain the extrusive
compone nts of the elastics and the lingual crown torque.
TECHNIQUE FOR DISTAL MOVEMENT OF MOLARS
The procedure for mov ing the maxillary molars distall y involves inserting an
.016 x .022 inch passive archwire and 100 g Sentalloy open coils. which are acti vated
10 mm against the molars2 (Fig. 14-3). To maintain anchorage. a fi xed Nance-type
a ppliance is cemented on the fi rst premolars. The appliance abuts the incisor segment
where a bite plate is constructed to open the bite approx imately I mm in the molar
region (Fig. 14- 3). Since the Sentalloy coils arc s uperelastic. one can expect an
approximate 100 g force over the 10 mm activation range; the system generally needs
no funher activation. I Molar movement occurs by means of sliding mechanics along
the .01 6 x .022 inch archwire. The r'J.te of movement should be al least I mm/month.
Anchorage loss will become ev ident as an increase in overjet. No effort is made
to support incisor anchorage unless the overjet increases by morc than 2 mm. Under
these conditions. 100 g Class " elastics are placed to maintain incisor position. As
indicated. the use of Class n clastics necessitates the insertion of an .01 8 x .022 inch
wire with 10 to 15 degrees of lingual crown torque and a reverse curve of Spec in the
mandibul ar arch.
Figure 14-l . Incisor retraction. A, .01 8 x .022 inch wire with elastic hooks between lateral incisors and canines and activated 300 8
Sentalloy coil. B, Retraction completed.
CHAPTER 14 ·259
An Approach to Nonextradion Treatment of Class II Malocclusions
Figure 14-:1. A, Modified Nance·type appliance cemented on the first premolars. B. 100 g Sentalloy open coi ls on an .016 x .022
inch wire activated against th e first molars.
The molars are moved distally to an overcorrccted Class I position- which is at

least 2 mm posterior to the nonnal Class I position. The overcorrection is necessary
because 2 mm of anchorage loss will most often occur as the premolars, canines, and
incisors are retracted by intra-arch mechanics. Overcorrection of molar position is one
of the most fundamental and most imponant aspects of this treatment strategy and
cannot be overemphasized because of the inevitable anterior movement of the molars
that wil l occur in the subsequent treatment procedures. The mesial molar movement
also helps in uprighting the molars, which tip somewhat even though they slide di s-
tally along an .01 6 x .022 inch arch wire.
As the molars are moved distally, the second premolars, which are not banded.
drift distally. Thi s is a fortunate and important occurrence because it reduces potential
anchorage strai n and treatment time during the premolar retraction phase.
The time necessary to move the molars to the overcorrected position usuall y is 4
to 9 months. For obvious reasons, less time is necessary (and anchorage loss is less)
when second molars have not erupted.
When the molars are in the overcorrected position , a number of options are avail-
able. One is to to maintain molar position with a hcudgear (generally hi gh pull for root
uprighting) or a removable appliance. The brackets ure aligned with a Nili wire und
100 g Class II elastics to control incisor posi tion during the alignment process. Follow-
ing alignment. an .016 x .022 inch wire with molar stops and hooks for Class 11 clastics
is inserted, and the premolurs and canines are sequentially retracted by sliding mechan·
ics wi th intra-arch Class I forces (Fig. 14-4). Often retraction involves only the fi rst
premolars and canines because the second premolars have drifted distally to the Class I
position. Anchorage is provided by the headgear and. when necessary, 150 g Class II
elastics. If Class II clastics are used, an .018 x .022 inch wire with 10 to 15 degrees of
lingual crown torque and a reverse curve of Spee is placed in the mandibular arch.
After the the can ines have been moved to the Class 1 posi tion, the inci sors are
retracted bodily with an .0 18 x .022 inch wire as outlined previou sly.
A second. more conservati ve option is to stabilize the molars in their new posi-
lion! for 01 leo,l ] /0 6 month; while upnghling the rools. The mechanics used (or sra-
bll/~llflim llfld roof a p<lssr"ve .0(6 x .azz inch archwire with stops at the
upngfrrirrg <Ill:
molars and a high-pull headgear. Class II elastics, exerting 100 g of force. can also be
~Jaced
, .
on the
.
.s~tJ
.
.:vch,vi.rr 10 r..nb.:mrr .wal:v _~
... ....-""'""'""-----,;,; ...-..- ........ - -, _
_ 4.1"kY".do.- . ?~
. . . . ....... .
CHAPTER 14 ·259
An Approach to Nonextraction Treatment of Class II Malocclusions
Figure 14-3. A, Modified Nance-type appliance cemented on the first premolars. B, 100 8 Sentalloy open coi ls on an .016 x ,022
inch wire activated against the first molars.
The molars are moved distally lo an overcorrectcd Class I position-which is at

least 2 mm posterior to the normal Class I position. The overcorrection is necessary
because 2 mm or anchorage loss will most often occur as the premolars, canines, and
incisors arc retracted by in tra·arch mechanics. Overcorrect ion or molar position is one
of the mosl fun damental and most important aspects of thi s treatment strategy and
cannot be overemphasized because of the inevitable anterior movement or the molars
that will occur in the subsequent treatment procedures, The mesial molar movement
also helps in uprighting the molars, which tip somewhat even though they slide dis·
tall y along an .016 x .022 inch archwire.
As the molars arc moved distall y, the second premolars, which are not banded ,
drift distally. Thi s is a fortunate and important occurrence because it reduces potential
anchorage strain and treatment time during the premolar retraction phase,
The time necessary to move the molars to the overcorrccted position usually is 4
to 9 months. For obvious reasons, less time is necessary (and anchorage loss is less)
when second molars have not erupted.
When the molars arc in the overcorrected position. a number or options arc avail-
able. One is to to maintain molar position with a headgear (generally high pu ll ror root
upri ghling) or a removable appliance. The brackets arc aligned with a Nili wire and
100 g Class II elastics to control incisor position during the alignment process. Follow·
ing alignment, an .0 16 x .022 inch wiTC with molar stops and hooks ror Class II clastics
is inserted, and the premolars and canines are sequentially retracted by sliding mechan-
ics with intra·arch Class I forces (Fig. 14-4). Often retraction involves only the first
premolars and canines because the second premolars have drifted distally to the Class I
posi tion. Anchorage is provided by the headgear and, when necessary, 150 g Class \I
elastics. If Class I( elaslics are used, an .018 x .022 inch wire with JO to 15 degrees or
lingual crown torque and a reverse curve of Spec is placed in the mandibular arch.
After the the can ines have been moved to the tlass I position, the incisors are
retracted bod ily with an .0 18 x .022 inch wire as outlined previously.
A second. more conservati ve option is to stabili ze the molars in their new posi-
tions ror at least 3 to 6 months while llprighting the roots. The mechanics used ror sta-
bilization and root uprighting are a passive .016 x .022 inch archwire with stops at the
mol:lrs and a high-pull headgear. Class 11 elastics, exerti ng 100 g or rorce. can also be
placed on the stopped archwire to enhance molar stabili zation. After the 3·to-6-
month stabilization period, bracket alignment and premolar, canine. and incisor
retnlction are done as described.
The difrerence between the two options is defined by ri sk, cooperation, and lime
of treatment. In the first option, the placement of a headgear and/or a removable
260 CHAPTER 14
An Approach to Nonextraction Treatment of Class II Maloccl usions
f iJure 14-4. Canine retraction by means of an ac1Jvated

150 g Sentalloy coil along an .016 x .022 inch wire with a
stop at the molar.
appl iance \0 control molar posili on is riskier because each appliance used to maintain
molar posi tion is controlled by the patient. As such, the approach should be used only
with very cooperative patients. The benefi t is that there is no hiatus in the treatment
sequence and total treatment ti me is usually less.
In the second option, risk of losi ng molar position is less because a stopped arch-
wire, which is not dependent on p<ltient cooperat ion, is inserled along with the head-
gear. In addition, the 3-to-6- month "rest" period mOly be important to help st<lbilize
the molars. as ev idenced by Andreasen's fi nding that molars which were moved dis-
tally relapsed up to 90% of the total distance when they were not maintained in their
new positions) With this more conservati ve approach, tre<ltment time is generally at
least 3 to 6 months longer.
Case Repo rt
The patient is a 25-year-old male with a Class II , Di vision 2 malocclusion and a
hypodivergent facial pallem (Fig. 14-5). Prior to treatment, the maxillary third molars
were removed. Aft er appli ance placement, including a modified Nance appl iance
cemented on the maxillary firs t premolars, an .0 16 x .022 inch passive arch wire was
inserted in the maxillary arch and 100 g Sentli lloy open coils were activated against
the max illary molars by means of Gu rin locks (Fig 14-6A- C) . To support anchorage,
uprighti ng springs made of .0 18 Auslmli an wire were placed in the vertical slots of
the fi rst premolar brackets (Fig. l4-SA and /1). In the lower arch, alignment was fol-
lowed by the placement of an .0 18 x .022 inch archwire.
The max illary molars were moved distall y to an overcorrected Class I position in
S to 6 months, and the second premol'lrs hud dri ft ed postcriorly 10 a cusp-ta-cusp rela-
tionship (Fig. 14-6A and 8). The Nance uppliance was then removed and repl aced
immedi ately with a removable appliance with fi nger spri ngs to move the second pre-
molars to the Class I position (Fig. 14-7). The Guri n locks were stopped against the
fi rst molars to maintain molar posi tion. Six to 8 weeks later, the second premolars
were Class I and were banded (Fig. 14-8), and a removable appliance was placed to
stabilize molar position. This was fo llowed by the banding of the fi rst premolars.
After bracket alignment, an .0 16 x .022 inch molar stopped wire, with hooks for Class
II e lastics, was in serted and the fir st pre molars and canines were seque nti ally
retracted with Class I forces as described previously. Anchorage was maintained with
150 g Class II elastics. As emphasized previously, in the lower arch, 10 to IS degrees
of lingual crown torque and 'l revcrse curve of Spee were placed in the .0 18 x .022
arch wire because Class 1.1 el.lst ics were used.
After canine retraction. an .0 18 x .022 archwire was inserted in the maxillary
arch and the incisors were retracted by means of Sentalloy coi ls exerting 300 g of
CHAPTER 14 261
An Approach to Nonextraciion Treatment of Class II M alocclusions
-"
Figure 14- 5. A-D, Pretreatment models.

and E, cephalograph illustrating a Class U,
Division 2 malocclusion and a hypodivergent
fadal pattem.
force (Fig. 14-9). Class II clastics ( 150 g) were placed on the canines for anchorage
control. At th is point, the molars. which were held in the overcorrccted position, were
allowed to move mesially as all spaces were closed. Figure 14- 10 illustrates the
resu lts of treatment, which lasted approximately lin years.
The strategy of treati ng Class II malocclusions by convening the molar relation-
ship to a Class I in the initial stages of treatment is dependent on the ability to move
the maxillary molars distally to an overcorrected Class I posi tion. Th is procedure is
not always simple. particu larly if the mechanotherapy to move the molars distally is
262 CHAPTER 14
An Approach to Nonextradion Treatment of Class II Malocclusions
Filure 14-{j:. A and 8, 100 g SentaJloy open coils activated

against the fi rst molars by means of Gunn locks. C. Cemented
modified Nance appliance. Note the second premolar drift.
Figure 14-7. Removable appliance with finger springs to

move the second prem olars distally.
Figure 14-8. The second premolars in Class I position and banded .

CHAPTER 14 263
An Approach to Nonextraction Treatment of Class It Malocclusions
Fi,ure 14-9. A and B, Incisor retraction. C, D, and E,

Incisof retraction completed.
totally dependent on patient cooperation. such as the use of a gear or an ACCO appli-
ance." With Sentalloy coi ls coupled with a modified Nance appl iance. the need for
patient cooperation is reduced. In the case report described. the molars were moved
distally without patient cooperation since the oveljet did not increase by more than 2
mm. This does not always occur. In the author's expe rience. man y patients will
requi re Class 11 clast ic support if the oveljel increase is 10 be kept to 2 mm. However.
elastics are generally not necessary for the II rst 3 to 4 months o f the dista1i1.ation pro-
cedure. Th is means that the cooperation necessary to move the molars distall y in most
patients involves the use of Class II elastics for 3 to 4 months. Since premolar. canine .
•md incisor retraction is relatively simple (as long as the molars have been moved to
an overcorrcctcd Class I position to compensate for the expected anchorage loss that
wil l occur during the retraction phase), successful nonextraction resolution of Class II
maloccl usions can routinely and reproducibly be accompli shed with thi s treatment
strategy.
264 CHAPTER 14
An Approach to Nonextraction Treatment of Class II Malocclusions
Figure 14-10. A-E. Posttreatment intraoral photos. and F,

cephalograph.
REFERENCES
l. Miura r. Mogi M. Ohura Y. Karibe M: Th..: super·elastic 1aP'lnese NiTi alloy for use ill onhodontics.
Pan 1lI . Studi<:s on Ih..: 1<lpancse NiTi <llloy coil springs. Am J Orthod Dcntofac Onhop 94:89-96.
1988.
2. Gianelly AA. Bednar 1. Dietz VS: Japanese NiTi coils used to move molars di'lally. Am J Orthud
Dcntofac Orthop 99:546--566, 1991.
3. Andreasen G. Naessag C: Experimental findings on mesial re lapse of maxillary first molars. Angle
Orthod 38:51-55.1%8.
4. Cetlin NM. Ten Hocve A: Non,,:xlraction treatment. J Clin Orthod 17:3%-413. 1983.
CHAPTER
15
The Herbst Appliance: A Powerful
Class II Corrector
Hans Pancherz
he Herbst appliancc l- 3 is a fixed bite jumpi ng device for the treatment of Class
T II malocclus io ns. It is comprised of a telescope mechanism attached to the

upper and lower denlilion. The mechanism keeps the mandible in a protruded
position throu g hou t trcatment. It a ll ows openin g and c losing movements of the
mandible as well as some lateral jaw movements (Fig. 15- 1). During the 15 years of
use of the Herbst appliance by the autho r its design has changed. In the early years a
simple anchorage system was utilized (Fig. 15- 2A). Now maxillary and mandibular
anchorage is increased by incorporating the front teeth (Fig. \ 5- 2/J).
Up 10 this date this autho r has uti lized the Herbst appliance in 150 cases. Seventy
of these eases were followed for 5 to 10 years posttreatment. The short- and long-tenn
treatment results, which are presented in this c hapter, are based o n analyses of these
patients.
EFFECTS OF THE HERBST APPLIANCE ON THE DENTOFACIAL

COMPLEX
In order to examine the treatment and early posttre:l1ment effects of the Herbst appli-
ance, 40 consecutive ly treated cases were analyzed during three observation periods:
the treatment period of 7 months (T), the fi rst posttreatment period of 6 months (PI).
and the second posttreatment period of 6 months (P2).4
In using a syste m of ana lysis with the occlusal plane as reference, a quantitative
evaluation of sagitta l, skeletal, and dental c hanges was made.s Thi s method makes il
possible to re late alterations in the occlusion to skeletal and dental components in the
maxilla and mandible separately as well as to compare the changes in the two jaws.
Thus, it can be ascertained how muc h ::J C lass II correctio n in the molar or incisor area
is due to maxillary and mandibu lar jaw base positio n changes and how much is due to
265
266 CHAPTER 15
The Herbst Appliance: A Powerful Class II Corrector
Figure 1S-1 . lhe Herbst appliance.
tooth movemer.lS in the two jaws. The results of the analysis are presented in Figure
15- 3.
During the treatment period (T) of 7 months, the saginal occlusal relationships
were nonnalized (overcorrected) in all subjccts. Overjet was reduced by an average of
6.9 mm , and the molar relationship was improved by an average of 6.3 mm. The
improvement in sagittal incisor and molar relationships resuhed from both skeletal
and dental changes (Fig. 15-3).
During the first posttreatment period (PI ) of 6 months. the occlusion settled in
the patients. Overjet recovcred (rel;'psed) with 2 mm and molar relation with 1.6 mm.
The occlusal changes were a result of maxi ll ary and mandibular tooth moyements.
The upper molars moved anteriorly and the lower molars and incisors moved posteri-
orly. Maxillary and mandibular growth were llpprox imatcly equal and thus did not
contribute to the occlusal changes observed (Fig. 15- 3).
During the second posttreatment period (P2) of 6 months, only minor occlusal
changes occurrcd. Overjet recovered furth er with 0.3 mm while the molar relation
was almost unchanged. Maxillary and mandibular tooth movements were small .
Figure 1S-2. A, The Herbst appliance with " Simple" anchorage. B, The Herbst appliance with "increased" anchorage.
CHAPTER 15 267
.3 '~O~":.o.1) T O verje t
6:9 • 2 .7 _ correCTion
Molar rel at ion

6"::3 • 1.5 - correction
Ove r jet
i:i 1
2,"0 • 1.2 _ .elapse
Mola r reiai ion

0.8 • 1. 2
1."6 • 1.2 - relepse
ci"j •.~O~.:.0 .1)

Over je t
0.3 : 0.8 - 'elapse
Molar rela l ion

0 .1 ! 09 _ lelapse
o Ove rj et
"'.6 ! 2.4 - correctIon
M ola r r ela l ion

4 .6 • 1.5 - correCTion
Figure 15-3. Skeletal and dental changes (mm) contributing to alterations in ove~et and sagittal molar
relationships In 40 Class II, Division 1 malocclusions treated with the Herbst appliance. Registrations
(mean, SO) during the treatment period en. posttreatment period 1 {PH. posttreatment period 2 (P2),
and total observation period (0). 'Indicates significance at the 5% level. " 'Indicates significance at tile
0.1% I~el .
Mandibular growth was 0.2 mm larger than max illary growth and thus counteracted
the negative effects of the dental changes (Fig. 15--3).
In order to examine the nature of Class U relapse after Herbst appliance treatment
on a long-term basis. a comparison was made between 15 relapse and 14 stable cases
5 to 10 years posttreatment. 6 Lateral head fi lms from before treatment. after treat-
ment, 6 months posttreatment, and 6 years posttreatment were analyzed.
The results revealed that posttreatment relapse in the overjet and sagittal molar
relationshi ps resulted mainl y fro m maxi llary and mandibu lar dental changes (Fig.
15-4). In particul ar. the maxi llary incisors and molars were moved significant ly
(I' <0.05) to a more anterior position in the relapse than in the stable group. In the
concl usion of the st udy it was hypothesized that the main causes of the Class II
268 CHAPTER 15
os O verj e t r.~.l aps e
,.• R>S 3.5

" "
" Mo la r
R>S
relap se
2.5
06
Figure 15-4. Mean differences between 14 stable (S) and 15 relapse (R) cases with respect to skeletal and
dental ch anges ;mm) contributi ng to al terations in overjet and sagittal molar relationships. Registrations
duri ng the periOd 5 to 10 years after Herbst treatment. ' Indicates significance at the 5 % level.
relapse were a persisting lip-tongue dysfunction habit and an unstable cuspal interdig-
itation after treatment.
EFFECTS OF THE HERBST APPLIANCE O N THE M ANDIBLE
In order to examine the short- and long-teml effects of Herbst treatment on mandibu-
lar growth and morphology, mouth-open lateral head fi lms from before treatment,
after treatment, and at the end o f growth (7 years posttreatment) were analyzeeJ.?
The subject cases were boys 10 to 13 years of age, all with a Class II , Division I
malocclusion. In the eval uation treatment period of 6 months, 30 Herbst cases were
compared to 20 untreated control cases. In the posttreatment evaluation period of 7
years, 12 Herbst cases were compared to 10 control cases.
Mandibular morphology was assessed on the mouth-open lateral head film s by
meas uring the jaw base length (c-pgn), the gonion angle (RUML), and the f3-angle
(Fig. 15- 5). By superimposin g the mandibular traci ngs fro m before and after the
examination period on the swble reference structures given by Bjork,S mandibular
growth changes at the lower and posterior borders of the mandible cou ld be ascer-
tained.
When the Herbst and control groups were compared the fo llowing changes were
observed du ring 6 months o f treat ment (Fig. 15- 6): Mandi bular bOIse length was
increased more in the Herbst group than in the control group. The gonion angle was
opened in the Herbst group while it was closed in the control group. The opposite was
the case fo r the p ~.. ngle. In the Herbst group the p-angle was closed while it was
opened in the control group.
The mand ibul ar morpholog ic ch .. nges could be ex pl ai ned by th e foll ow ing
growth processes (Fig. 15-7): Bone resorption at the posterior part of the mandibul ar
lower border and sagittal condylar growth were larger in the Herbst group than in the
control group. The amount of vertical condylar growth, on the other hand, was the
same in both groups.
When looking at the 7 years postlreatment changes the following were found
(Fig. 15- 8): In the Herbs! group the increase in mand ibul ar base length was less than
in the control group. The gon ion angle closed more in the Herbst group than in the
control group, whi le the I!-angle opened more in the Herbst than in the control group.
The changes in the <lngular and li near measurements could be explai ned by the
followi ng mandibular growth changes (Fig. 15- 9): S..gittal condylar growth was less
in the Herbst than in the control group. The growth changes at the posterior part of the
lower mandibular border were in the form of bone apposit ion in the Herbst cases and
bone resorption in the control cases. A possible explanation might be an increase in
masseter muscle function found in the Herbst cases after the appli ance was removed.9
CH APTER 15 269
The Herbst Applia nce: A Powerful Class II Corrector
FIgure 15-5. Linear and angular mea-

surements for the assessment of
mandibular morphology.
RL
Herbst> Control
Figure 15-6. Comparison between
12 Herbst and 10 control cases with
respect to mandibular morphologic
changes during 6 months of treat-
mentm.
Herbst +
C ontrol
Herbst
Control +
T
Herbst = Control
Herbst> Control
Herbst = Control
Herbst = Control Herbst > Control

FIgure 1>-7. Comparison of 12 Herbst and 10 control cases with respect to mandibular periostaJ and
condylar growth changes during 6 months of treatment (T).
270 CHAPTER 15
The Herbst Appliance: A Powerful Class II Corredor
Herbs t < Control
Figure 1S- 8. Comparison of 12 Herbst and 10 control

cases with respect to mandibular morphologic changes
during the posttreatment period of 7 years (Pl.
Herbst
Cont rol
Herbs t + +
Control +
p
Herbst = Control
Herbst < Control

Figure 1S-9. Comparison of Herbst and 10
control cases with respect to mandibular
periostal and condylar growth changes during
the posttreatment period of 7 years (Pl.
(- ) Herbst =Control
(+)
Herbst = Control Herbst +
Control -
When considerin g the total changes thai occurred d uring the treatment and
posttreatment period s. the following results were observcd (Fig. 15- 10): The
increase in mandibul ar base length was the same in the Herbst and control groups.
The goni on angle was closed at about thc same amount in the Herbst and control
cases. The f)-angle, on the other hand. was opened more in the Herbst than in the
control subjects.
The following growth changes cou ld be responsible for the differences in the
Herbst and control groups (Fig. 15- 11 ): Bone apposition at the posterior part of the
lower mandibular border was found in the Herbst group, while bone resorption was
seen in the control group. The difference in masseter muscle function found in the
two groups mi ght expl ain these findingsY
The conclusions were that marked mandibular morphologic changes occurred
during Herbst treatment. After treatment. however, these changes seemed to revert,
and on a long-term basis no influence of Herbst treatment on mandibular morphology
could be verified.
CHAPTER 15 271
o
Herbst; Control
Figure 15-10. Comparison of 12

Herbst and 10 con trol cases with
respect to mandibular morphologic
changes during the treatment and
posttreatment periods of 7.5 years
(0).
Herbst
Control
Herbst + +
Control +
EFFECTS OF THE HERBST APPLIANCE ON THE MAXilLA
The shon- and long-ternl effects of Herbst treatment on the maxillary complex were
analyzed in 45 Class 11. Di vision I cases. The patients were reinvestigated 5 to 10
years posureatmenl. 10
Max illary skeletal and dental changes were assessed on mouth-open lateral head
film s by using the occlusal line and the occlusal line perpendicular through sella as a
refercnce systcm. The radiographic analysis comprised the fo llowing examination
periods: The treatment period of 7 months (T- period), the fi rst posttreatment period
of 6 months (PI -period). the second posttre<ltment period of 5.5 years (P2- period),
and the 100ai observation period of 6.5 years (O-period). I
a Herbst =Control
Herbst = Control
(- ) Herbst = Control
\....L--r-- -V
( +)
Herbst =Control Herbst +
Control
Figure 1S-11 . Comparison of 12 Herbst and 10 control cases with respect to mandibular periostal and
condylar growth changes during the treatment and posttreatment periods of 7.5 years.
272 CHAPTER 15
Sagittal Maxillary Molar Position Changes (Fig. 15-12)

During the treatment period (T) of 7 months, the firs t molars were distalized by an
average of 2.1 mm during the exami nation period. The max imum distal movement
was 4.5 mm. In corresponding untreated Class II control subjects the molars moved
mesially by an average of 0.3 mm. The difference between the Herbst and control
groups was statistically signifi cant (1' <0.00 1). During the first posttreatment period
(PI ) of 6 months the molars moved mesially (relapse) by an average of 1. 1 mm. The
maximum mesial movement was 4 mm. During the second posttreatment period (P2)
of 5.5 years the molars moved further mesially by 1.6 mm. The maximum mesial
movement was 5.5 mm. During the total observation period (0) of 7 years the molars
moved mesially an average of 0.6 mm. which was 60% of that seen in the untreated
controls.
Ftgure 15-12. Sagittal ma~illary molar position changes (mean, SD) in 45 Herbst cases. Registrations
during four e~amination periods: treatment period (T), posttreatment period 1 (P1), posttreatment period
2 (P2), and total observation period (0).
Vertical Maxillary Molar Position Changes (Fig. 15-13)

During the treatment period (T) the firs t molars were intruded by an average of 0.7
mm, The maximum intrusive movement was 3.5 mm, In the unlreated Class II con-
trol group the molars extruded by an average of 0.4 mm. The difference between the
Herbst and control groups was statistically significant (I' <0.00 1). During the first
posttreatment period (PI ) the molars extruded (reJ:lpse) an average of 1.1 mm. The
max imum extrusive movement was 2.5 mm . During the second posttreatmem period
(Pl) the molars extruded further by an average of 3.5 mm. The maximum extrusive
movement was 7.5 mm. During the total observation period ( 0 ) extrusive molar
movements were seen in all subjects. On average the molars extruded by 3.9 mm.
which was comparable to that seen in the untreated controls.
Occlusal Plane Changes (Fig. 15-14)

During the treatment period (T) the occlusal plane tipped downward by un average of
2.0°. In the untreated Class II control group an upward tipping of the occlusal plane
1 CHAPTER 15 273
mm
)~
5
+ 3
2
;:;
;:;
;:;;:; DC ?-p ••
+
;:;
;:;
- 2
P, P, 0
0 Herbst
~ Control
Figure 15-13. Vertical maxillary molar position changes (mean, SO) in 45 Herbst cases. Registrations dur-
ing four e)(amination periods: treatment period m. posttreatment period 1 {PH, posttreatment period 2
(P2), and total observation period (0).
degrees
NSL
+ 2 NL
+ -
\ \
1 (j?[j
- 1
2
o Herbst
[0] Control
Figure 15-14. Maxillary occlusal plalle inclination changes (mean, SD) in 45 Herbst cases. Registrations
during four examination periods: treatment period m. posttreatement period 1 (P1), posttreatment
period 2 (P2), and total observation period (0).
by an average of 0.4° was recorded. The difference between the Herbst and control
groups was statistically significam (p <0.001), During the fi rst posurealment period
(PI ) the occl usal plane tipped upward (relapse) Ly an avemge o r 1. 1°. During the sec-
ond posttreatment period (P2) the occlusal plane tipped rurther upward. On avemge
the upward tipping was 1.5 °. During the total observation period (0) the occlusal
pl ane tipped upward by an average or 0.6 mOl. Thi s was about half that seen in the
untreated controls.
2 74 CHAPTER 15
Palatal Plane Changes (Fig. 15-15)

During the treatment period (T ) the palatal plane tipped downward by an average of
0.2°. In comparison wi th the untreated Class II control group no signi ficant differcnce
was seen. During the fi rst posllrcatmCIII period (PI ) the palatal plane tipped upward
by an average of 0.1 °, and during the second cxamination period ( P2) the palatal
plane lipped downward by an avcr..ge of 1.0°. When looking at the tOial observation
period (0) the palatal planc tipped downward by 1.1 0. This was about twice as much
tipping as in the untreated controls.
degrees
NSL ; " "_ __ ",,"1-_
+ 2
3
NC -\J1?
::;::-=~.---'-L
.-.-
Figure 15- 15. Palatal plane inclination
changes (mean, SO) in 45 Herbst cases. Reg·
(/ fJ istrations during four e ~ am i natiDn periods:

treatment period (T). posttreatment period 1
(P1). posttreatment period 2 (P2), and total
observation period (0).
T P, ~ 0
- 2
o Herbst
~ Control
Sagittal Maxillary Jaw Position Changes (Fig. 15-16)

During the lreatment period (T ) the maxilla grew forward by an avcrage of 0.4 mm. In
comparison with the untreated Class II control group no statistically significant differ-
ence was seen . During the fi rst posttreatment (PI) the maxilla grew forward by 0.8 mm.
During the second posttr~tment period (P2) the maxilla grew further forward by 2.4
mm. During the total observ:llion pcrioo the average amount of forward growth of the
maxilla was 3.6 mm, which was about half the rorward growth in the untreated control s.
mm
5 Figure 15-16. Sagittal ma~illary jaw base
+ 4 position changes (mean. SO) in 45 Herbst

cases. Registrations during four e~amination
periods: treatment period (T), posttreatment
3 period 1 (P1), posttreatmen t period 2 (P2),
and total observation period (0).
2
- 2
CHAPTER 15 275
The Herbst Appliance : A Powerful Class II Corrector
The conclusion was that the Herbst appliance exhibited a marked high-pull head-
gear effect on the maxillary complex. Especially pronounced was the distaliz.ing and
intrusive effect ('n the molars. The clinician should take advantage of this effect when
attackin g C lass II malocclus ions with maxillary c rowding and thus possibly avoid
extractions of pennane nt teeth. Without proper retention after acti ve treatment, however,
the effects of the Herbst appliance on the maxillary complex seemed to be telllfXJrary.
INDICATIONS FOR HERBST TREATMENT

Because the Herbst appliance is aimed at stimulating mandibular growth it is especially
useful in the tremment of Class II malocclusions with a retrognathic mandible. This is
true for both CI:1SS 11 , Division I as well as for Class 11 , Division 2 maloccl usions.
Basicall y, the same prerequi sites for successfu l treatment apply for the Herbst
appliance as for a removable fun ctional appliance (e.g., the acti vator. Frjnkel, biona-
tor). Unlike these appliances, the Herbst appliance can be used successfull y in the fol-
lowing instances:
Neglected Patients. Patients who have passed maximal pubenal growth may be too
old for removable functional appliances because treatment with these appliances is
extended over a long time period (2-3 years). Treatme nt w ith the He rbst appliance.
on the other ha nd. can be fi nished within 6 to 8 months, thus making it possible to use
the residual growth left in olde r patients.
Permanent Dentition. The Herbst appliance is most useful in the permanent denti -
tion. Tre:lI menl at this stage of dental development makes it possible to obtain a stable
cuspal interdigitation after therapy that wi ll counteract an occlusal relapse. Treatment
in the mixed dentition, on the other hand. will make it necessary to retai n the result
until the permanent teeth have eru pted and the occlusion is stabilized. Otherwise there
is risk of a n occlusal relapse.6
Mouth Breathers. Nasal ai rway obstructions will not interfere with the correct func-
tioning of the Herbst appliance.
UIICOOI)eral ive Patiems. The He rbst a pplia nce is fixed to the teeth and works 24
hours a day without patient assistance.
No RespOlue to Removable FUllctional Ap{Jliallces. Because removable functional

appliances arc used mainl y onl y part of the day, the impl ication is that in cenain
patients the threshold for adaptive condy lar growth c hanges will never be reached
(F;g.15- 17).
As a rule a Class U malocclusion cann(){ be treated to a perfect end result with the
Herbst appliance exlusively. Most cases will require a subsequent dental al ignment treat-
ment phase with a mullibrackcl nppliancc with or without extraction of teeth. But by stan-
ing treatment with the Herbst applinnce the sagittal jaw base relationship is normalized
and the Class II maloccl usion is transferred to a Class I malocclusion, thus making subse-
quent treatment with the multi bracket onhodontic appliance much easier (Fig. 15--18).
RETENTION AFTER HERBST TREATMENT

As explained earlier, a possible relapse after He rbst treatment will result from recov-
ering maxillary and mandibular tooth movements. A SWbl\ uspal interdi gitation after
276 CHAPTER 15
1 2 3 4
Figure 15-17. A 13-year-old boy with an Angle Class It, DivisiOn 1 malocclusion treated with the Herbst appliance. Before Herbst therapy
the child was treated unsuccessfully with an activator for two years. A, Before activator treatment. B. Before Herbst treatment (after 2 years
of activator treatment). C, Start of Herbst treatment. D, After 7 months of Herbst treatment when the appliance was removed. Nole the
overcorrecled sagittal dental arch relationships. E, Five years after Herbst treatment (3 l;lrs after retention).
\ Illustration continued on following page
CHAPTER 15 277
5 6 7
Figure 15-17. (Continued)

278 CHAPTER 15
1 2 3 4
Figure 15-18. A 12.year-old boy with an Angle Oass II, Division 1 malocclusion and severe crowding treated in two p~. A, Befort
treatrMnt. B, Start of Herbst treatment (orthopedic treatment phase), C, After 6 months of Herbst treatment when the appliance was
removtd. D, Multibrad::et appliance treatment with eKtraciioos of four first premolars (orthodontic treatment phase), E, 1'1.1: years after
multibracket appliance treatment.
CHAPTER 15 279
5 6 7
Figure 1S-18. (Continued)
(
J
280 CHAPTER 15
treatment will counteract an occlusal relapse. However, as trelltment generally ends

with teeth in overcorrected position, retention wi ll be necessary until the occlusion
has senled.
The Andresen type of activator is a most useful retention device after Herbst
treatment. The appliance holds the teeth in their new posilion and allows interocclusal
adjustments. FunhenllOre, the activator trains and lIccommodates the musculature to
the new mandibular position ach ieved by treatment.
SUMMARY
The Herbst appliance is most effective and powerful in the treatment of Class II mal-
occl usion s. The treatment method s hould not, however, be looked upon as a last
resort. Unfavorable growth, unstable occ luslIl conditions, and oral habits that persist
after treatment are potential ri sk factors for occluslli relapse.
REFERENCES
1. Herbst E: Dreissigjlihrige Erfahrungen mit dem Re tentionsschamier. Zahnlirzt t. Rund schau
43: 15 15-t 524. 1563-1568. 16 11 -16 16. 1934.
2. Pancherl H: Treatment of C lass II malocc lusions by jumping the bite with the Herbst appliance: A
cephalom etric investigation. Am J Orthodont 76:423--442. 1979.
3. Panchcrl H: 'The Herbst appliance-Its biologic effects and clinical use. Am J Orthodont 87: 1-20.
1985.
4. Pp.ncherz H, Hansen K: Occlusal c hanges during and after Herbst treatment: A cephalometric invcsti·
gat ion. Europ J Orthodont 8:215-228. 1986.
5. Panc herl H: The mechanism of Class II correction in Herbst appliance treatment. A ccphalometril;
investigation. Am J Orthodont 82: 1t)+...1 13. 1982.
6. Panchen H: TIM! MllIre of Class II re lapse: after Herbst appliance treatment. A cephalometric long-
tenn investigation. Arn J Orthodont Del1lofac Orthop 100;220--233. 1991.
7. Panchen H. LittOlaflll C: MOfllhologie und Lage des Untcrkiefers bci c1er Herbst-Behandlung. Eine
kcphal ornetri sc he Ana lyse dcr Veriimkrungcn bis zurn Wochstumsabschluss. In f Onhod u Kiefe r·
ortOOp 28:493-513. 1989.
8. Bjtirk. A: Prediction of mandibu lar growth rotat ion. Am J Orthodont55:585-599, 1969.
9. P:mcherl H. Anehus-Pancherz M: Muscle activity in Class II, Divisio n I malocclusions treated by
bite jumpil1g with the Herbst appliance. An electrom yogrnphic study. Am J Orthodont 78:32 1-]29.
1980.
10. P3ncher'.t H, Anehus-Pancherz M : The head-gear effec t of the Herbst appliance. A cephalometric
long-tenn study. Am J Orthodont Dcntofac OrtOOp 1992.
/
CHAPTER
16
Treatment of Class II Backward Rotating
Malocclusions
Lloyd E. Pearson
lass I] malocclusions is the most common Iype o f case that the orthodontist is
C called upon to treat. Bjork,! in 1969, divided Class II malocclusions into for-
ward and backward rOialors. He pointed oul that forward rotators are more
common and easier to treat. Backward rotators have some significant characteristics
thai make them much harder to trcat; for example, it is difficult to prevent opening the
bite and to prevent fu rther increases in the height of the lower face. Bjork described
hi s morphologic method of predicting growth rotation from a single cephalogram.
Thi s is helpfu l in treatment when deciding whether extrusive or intrusive forces arc
necessary o r when environmenta l factors must be changed. Typical mandibular
growth has the condyle growing upward wh ile curving forward with resorption on the
lower aspect of the gon ial angle and some apposition be low the symphysis. In 1969,
Bjork gave us seven structural signs for predicting forward or backward growth rota-
tions. Sk.ieller et al.,2 in 1984, digitized this sample and analyzed 44 morphologic vari-
ables. They found that of Bjork 's seven original signs, four of the variables when
combined gave the best prognostic estimate of 86 percent of mandibular growth rota-
tion. These four are:
I. Mandibular In clination. Thi s ex plaTned 60 percent of the growth rotation . It was
measured in three ways:
a. Index I: a proportion between posterior and anterior facial height.
b. Gonial angle measurement.
c. Inclination of the lower border.
2. Imenllolar Angle, In forw ard growth rotation, the premolars and the molars are
more vertical to each other, whereas in backward growth rotation these teeth
are more inclined.
3. The Slwpe oflhe Lower Border. The forward rotator has a concave lower border
contrasted by the convex, or notched, lower border of the backward rotator.
281
282 CHAPTER 16
Treatment of Class II Backward Rotating Malocclusions
4. /"clillutio" of Ihe SYI1lI)hy.fi.f. If the symphysis point s forward or anterior to

nasion, a backward rotational pattern is likely presen t. If it poinls behind
nasion, or posterior to nasion, il is an indication of forward rotation. Forward
rotators arc easy to predict. whereas backward rotators are more difficult. The
range in the condylar growth direction cou ld be as much as 45 percent. accord-
ing to Bjork.
Creekmore 3 gave us a usefu l tool in measuring the effective amount of condylar
growth. His technique describes the composite increment summation of condylar
growth, gonial fos sa changes, and positional chunges of the condyle and the fossa.
This is hel pful in comparing cases th .. t have been treated when significant growth has
occurred in the condy lar area.
Popovich4 has published some excellent information on templates. b..sed on the
Burlington growth study. that describes three different growth directions. A typical
pallern was labeled u "horizontal/venical growth pattern," the venical growth pattern
the "steep. or backward rotating p..1uem." and the horizontal growth pallem the "nat-
ter pattern." The templates show gnathion descending approximately 2 mm per year
in a typical pattern. In a steep case with large amounts of growth there is evcn more
lower facia l height increase.
Harvold 5 and McNamara6 hn ve matched lower facial height for age and sex. This
measurement usually increases I mm a year in untreated females, and approaches 2
mm a year in males, between the ages of 9 and 14 years.
Isaacson7 examined a number of variables and found only three factors that could
be considered morphologically causative in the low versus high mandibular plane
angle. The height of thc posterior/alveolar process is clearly the most imponant vari-
able when detenni ning high or low patterns. The three reliable factors they foun d
were:
I. The ramus height measurements.
2. The lower molar height, as measured to the mandibular plane.
3. The upper molar height, as measured to the palatal plane.
In 1984, De Smit and Dermaut8 did a study on soft tissue profile preferences. They
analyzed nine different types or profiles and concluded that taller profiles wcre the
least appreciated. Further, the correction of the skeletal Class II in the long race
appearance brings no obvious est hetic improvement. On the contrary, convelllional
Class II correction, function al and C lass II elastics. usually tend 10 increase the lower
anterior fac ial height and profiles could deteriorate.
Environmental factors that keep the teeth apan can cause lower facia l increases.
Success requires resolUlion of these factors. Inadequacy or airway: mouth breathing
particularly early in life: tongue thrusting ; and amelo-genesis imperrecta, where teeth
are sensitive and patients tend not \0 bring them together, arc all factors that can per-
mit elongation of the posterior teeth. Dual bites act much as a tongue-thrust habit,
keeping the teeth ap:.n . Also, pathology of the temporomandibular joint can be a fac-
tor. Palpebraltosi s, a condition in which the patient is unable to fully elevate the eye-
lids, can cause the head to be carried in'l b'lckwards position and consequently tends
to permit extrusion of the posterior teeth and an increase in lower facial height.9 - 13
Tre:lted orthodontic cases in which the vertical growth has not been well man-
aged may eventually need orthogllathic surgery to bring the face back into reasonable
balance (Fig. 17- 1). Many surgical procedures have been developed, including maxil-
lary impaction and venical reduction genioplasty, that help onhodontists and oral sur-
geons cope with these extreme cases. The difficult task for the practicing orthodontist
has been to allempt to guide or rechannel growth into a more horizontal direction in
CHAPTER 16 283
tJ;" \~'
~11-
:--- ' \.,'v:
Figure 16- 1. Patient 0 . 8 .: A
t reate d orthodontic case in
which the vertical factors have
not been well managed and DB 9
,, -11
orthognathlc surgery could be ___ _14-_6
5
utilized to bring the patient back
into reasonable balance. Notice
the chin has gone down and
back.
those patients ex hi biting excess vertical dimension. Besides controll ing environ men-
tal factors such as airway and longue habits, othe r treatment modal ities are requ ired.
Seven d iffere nt procedures thai have proved clinical ly useful may be considered
in the treatment of the backward rolators:
I. In the mi xed de ntition open-bite paticnt we cou ld intrude the upper lirst penna-
ne nt molars and the n remove the remaining deciduous teeth. penn ilting open-bite clo-
sure (Figs. 16-2 and 16-3). This requires occipital headgear with a transpalatal arch
to control the incl ination of the molars as they are intruded. Additionally. timing is
critical. Ideally, after the molars have bee n intruded perhaps 3 mm the deciduous teeth
arc re moved. the mandible is hinged closed. and the ante rior open bi te is subsequently
closed much as in a max illary impaction. The lower molars will ofte n tend to extrude
in th is type of situation unless mechanics are designed to control their eru ption (Fig.
16-4). Wayne Watson reported in 1972 that lower molar extrusion can rob the case of
any lower facia l height reduction.
The addition of a vertical pull -chin cup to the occi pital headgear and transpalutal
arch wou ld intrude the upper molars while preventi ng the e rupt ion of the lower
molars (Figs. 16-5 and 16--6). As the open bite cl oses the mandi ble hinges upward,
reducing the height of the lowe r face (Fig 16-7). .
Figure 16-2. Patient M.T.: A mixed dentition an terior open Figure 16-3. Patient M.T.: After intrusion of the maxillary
bite prior to intrusion of the maxillary first permanent first permanent molars and the extraction of the remaining
molars and the eK{raction of the remain ing deciduous deciduous teeth.
teeth.
284 CHAPTER 16
-4,- .. ~
~-' ~ ~
M T .1
_ g_11
___ . 10-11
Figure 16-4. Patient M.T.: Cephalo-
metric tracing illustrating maxillary
molar intrusion and closure o f the
open bite.
Figure 16-5. Patient illustrating vertical Fig ure 16-6. Patient illustrating vertical
pull-chin cup with force being applied as pull-ctiin cup strap with wider strap mater-
f ar anterio rly as possible. (Northwest ial to distribute the force. (Summit Ortho-
Orthodontics and Unitek) dontic Supply Co.)
2. A second method that has been found useful in extraction cases is to remove all
four fi rst premolars and use a vertical pull-chin cup with 16 ounces of force directed
anteriorly as fa r as possible approximately 12 hours a day (Figs. 16-8 and 16-9). This
can close the mandibular plane, reduce the lower facial height, and in selected cases
close anterior open bites (Fig. 16- 10). In a study of 20 cases, II females and 9 males,
approximately 4° of closure of the mandibular plane angle with an average treatment
ti me of nine months was reported. These were fairl y Sleep mandibular planes, averag-
ing 41 .9° Sella-Nasion to GO-GN. After the nine months of treatmentlhe mandibular
plane was reduced to 38°. There may be four possible mechanisms of action at work
here. The posterior teeth tend to move forward mesiall y; maxillary sutures are pres-
sure sensitive and some intrusion of the maxill a could occur; there is a slight change
in the shape of the condylar neck. with many lending to be curved more forward than
previously; and there is ret:lrdation of eruption of the posterior teeth.
Garlington and Loganl6 reported on cnucliation of second premolars and found
CHAPTER 16 285
Treatment of Class II Backward Rotati ng Malocclusions
Figure 16- 7 . Patient M.M.:

Cephalome tric tracing illustrating
intrusion of the maxillary molars,
closure of the an terior open bite.
and a 3 mm reduction in the lower
anterior facial height.
,n.· '"
'
. :
,
-,
. 5•
M. M. ~
- _ 10 - 10
• ••. -- 11 - .
Figure 16-8. Patient D.P.: Prior to the removal of four first Figure 16-9. Patient D.P.: After four first premolar extractions
premolars and before vertical pull-chin cu p therapy. and wearing the vertical pull·chin cup.
<
~
'v
47 ,, -, ,
3. ,
,, ,,
,: .2
• , D. p . $!
8, 10
60 10- 5
\\
Figure 16-10. Patient D,P.: Cephalometric tracing illustrating an 8° closure of the mandibular plane, closure of the open bite,
and a 2 mm reduction of the lower anterior facial height. Note the change in the shape of the mandible superimposed on inter-
nal structures.
•
286 CHAPTER 16
an e ight tenths of a degree mandibular plane closure with just the enucliution proce-
dures. DePalma l7 reponed on sleep cases lrcuted with venical pull-ch in cup therapy
and premolar extractions. He fou nd anterior facial heig ht decreased significantly. the
cranial base angle became more acme, and the gonial a ngle tended 10 decrease two or
three degrees. He cautioned the cliniciun not to lose Ihis closure during banded ortho-
dontics. It is wise 10 hold the reduction until growth ceases. These changes are very
fragi le.
3. The third method might be described as the use of mandibular bile blocks com-
bined with vertical pull-chin c up,n Mandibular bi le-block therapy, augmented with
venical pull-chin cup therapy, can produce a favomble holding of the vertical height
throughout the growth period, in tru sion of po ste ri o r teeth, the hinging of the
mandibular plane in a closed or counterclockwise directio n, and closure of anterior
open bites lS (Figs. 16--1 I throug h 16- 13). Mandibul:lr bite blocks can be made with
acrylic that is J to 2 mm thick in the lirsl molar area. It is useful to cement the appli-
ances for three or four week s to help patients get used to wearing them, and then
make them removable.
4. The use of magnetic bite blocks can be a ve ry fast-ac ting method and can
demonstrate some dramatic closures. Two difficulties arise with the use of an active
venical corrector. One is the extreme open ing often required by appliance design,
limiting the hours the patient will tolerate the appliance. The second difficulty is that
\~It 'It .\\!) \!)\\W. ~~~\ \\;\~~~. ~\ \~\~\~\ """t""'~\ ~\ \\\t I:\\~~~\"'\•. \\\~\ <.~ <.~'"
some temporomandibular joint strain. \t is possible to add an acrylic lip \0 the bite
block 10 prevent some of this lateral movement. The results reported illustrate some of
the most rapid open-bite closures. 19
5. InLrusive forces with fully banded appliances can be developed in a number of
ways. Occipital headgear has proved useful and gene rally seems effective in control -
ling the vertical dimension in the maxilla. Mandibular control appears 10 be more dif-
Figure 16- 11. Patient K.P. : An anterior

open-bite. narrow ma~ill a patient prior to
sutural expansion, mandibular bite block,
and' vertical pull-chin cup therapy.
Figure 16-12. Pa tient K.P.: An open-bite patien t

f ollowing trea t men t w it h sut u ral expansion.
mandibular bile block, vertical pull-chin cup, and
full appliances.
CHAPTER 16 287
Figure 16-13. Patient K.P. : Cephalo-

metric tracing illustrating a 6° closu re
of the mandibular plane and a 3 mm
reduction of the lower antenor facial
height prior to the placement of fixed
appliances,
fi cult to manage. The lower molar nonnally increases its height as measured to the
mandibu lar plane by about 1.5 mm over a two-year period. which is the approximate
treatment time in a growing child. The different methods thai have been advocated for
reducing extrusion of the mllndibular arch include II lower cerviclll headgear with a
very light force through the centcr of resistance, slid ing jigs with Class III elastics,
bite blocks, and vertical pu ll -chin cups. Modern-day Twced mechanics are also intru-
sive to the posteriors in many ways.
Several authors have reported on the aver.age lower molar height increase as mea-
sured from the mandibu lar plane. Unlreated conlrols have been reported with a 1.5
mOl lower molar height increase over a two-year period. 3•19.20 For nonextraction Ircal-
ment, C reekmore3 reported a 2.2 mm lower molar height increase. For nonexuaction.
anchorage preparation cases, Harry Dougherty21 reported a 2.6 mm lowe r mo lar
height increase in 1968. For cx tmction cases without rIny special attempt 10 intrude
lower posteriors, Pearson 22 reported a 3.2 mm increase in lower molar height. For
extraction cases with anchomge preparation, Harry Do ugherty reported a 3.5 mm
increase in lower molar height. Fi nally, fo r extraction cases wi th light lower cervical
headgear, Pearson reported a 1.9 mm lower molar height increase and a 1.5 mm
increase in extraction cases with sliding j igs to the lower molars.22
It is possible with certain patients to have a considerable increase in the lower
molar height, particu larly in patients with allergies, mouth breath ing, or backward
rotating growth patterns (Fig. 16- 14). A case is presented illustraling good max illary
control and a 10 mOl lower molar height increase. Thi s increase in lower molar height
can be devastating in the llntenor fllcial height and can give us as much as a 10 mm
increase instead of the 2 or 3 mm increase that can usually be expected in untreated
cases. It is insuffici ent tremment i'n some cases to have just good occipital headgear
wear and to lack control in the mandibular arch. In II typical orthodontic case the
lower molar height increases more than in the max ill a. Schudy2] reported that in nor-
mal growth there is more posterior vertical height increase in the maxi ll a than in the
mandible. although orthodontic treatment freque ntl y reverses this.
Clinicians in the past have advocated not treating backward rotating patients until
thei r growth is complete. and the n treating them as extraction cases. 1•23•24 T his is
based on the fac t that nongrowing patients tend not to have extrusion of the posterior
teeth wi th orthodontic treatment. T his can be excel lent advice if the cl inicilln is unllble
to control the vertical hei ght in the treatment or if the patient is not willing to cooper-
ate in weari ng some o f the appl iances necessary to control this height increase.
288 (HAPTfR 16
Treatment of Class II Backward Rotati ng M alocclusions
Figure 16-14. Patient D.N .:

Cephalometric tracing of a premo·
~1I· 2 lar extractioo case illustrating good
____ 15·0 vertical control and a Significant
increase in the lower molar height
,, and the downward movement of
,, the chin.
,,
Kuh n25 reported that I mm posterior extrusion can create 3 mm of anterior facial
height increase. Other people have debated this amount. but the point is that there is a
greater increase anteriorly than posteriorly.
In a 1986 study, 79 cases were analyzed to detennine whether or not a venical
pull -chin cup. in addition to an occipital headgear. would be a useful adjunct to con-
trol lower fa cial hcight. 26 These patients were divided into four different levels of
cooperation. They were both extraction and nonextraction cases. The excellem coop-
erators in the ex traction treatment group showed significantl y less molar extrusion
than the poor cooperators.
A number of suggeslions can be made for biomechanics for steep backward rotal-
ing patients. In the maxillary arch the upper second molar tube could be placed
occl usally to help achieve an intrusive force on that tooth ; the archwire could be
stepped up to intrude the second molar gingivally; buccal root torque on the upper
second molars could be helpful in preventing prematurities: and an occlusal curve in
the upper archwire can provide intrusion in the posterior pan of the arch to prevent
extrusive and balancing-type force interferences. Also, transpalatal arches on the
maxillary fi rst molars and occasionally maxillary second molars are useful for provid-
ing the correct inclination and avoiding interferences. Occipital headgear is useful.
When the maxilla requires sutural expansion an occl usal coverage bonded-type :Ippli-
ance lessens extrusion. as Sarver27 has reported . Extrusion during expansion may also
be minimized by uprighting the upper posterior teeth prior to the sutural expansion
wilh transpalatal arches. Generally, for maximum conlrol in these steep backward
rotating patients it is helpful to achieve nasal breathing; eli minate tongue habits; use a
vertica l pull -chin cup; and use nexible rectangular wires because they maintain a
sli ghtl y greater occlusal curve. prevent extrusion in the mid-portion of the arch. and
close extraction spaces slowly with light forces to produce less extrusion. II is best to
avoid elastics off terminal molars and to avo id in terarch clastics if possibl e. If
absol utely necessary. a shon Class II clastic could be utili zed that would pull from the
upper first molar forward to a Class IJ hook. then down to the distal of the lower first
premolar.
In the mandibular arch u~e of a light lower cervical headgear has been demon-
strated to be useful. A mandibular bite block: could help prevent extrusion of the lower
posteriors. and Class 111 clastics and sliding j igs have also proved useful. Placement
of the lower lingual arch after space closure can help prevent some extrusion. Band-
CHAPTER 16 189
ing of the mandibular second molars later in treatment can help prevent extrusion of
the mid· ponion o f the arch.
An imponant early treatment decision is surgery versus nonsurgery in a backward
rotator. The growth projection is an important factor. Class II backward rotators
would be best treated after growth has been completed if the case involves surgery.
The more extreme growth pattern obviously is more likely to require onhognathics.
The side effects o f our treatment mechanics have to be an alyzed very carefull y.
Younger patients really give us an advantage because we can utilize growth and lee-
way space, intrude posterior teeth, and remove deciduous teeth for hinging mandibles
closed. Psychological factors are important, and in some quite young children that
need major changes. relati vely early orthognathics may be required . The availability
of insurance is an important factor today. Some insurance programs eliminate orthog-
nathics, so that the onhodonti st is required to provide the best treatment possible with
nonsurgical, methods. Availability of a skillful surgeon is obviously imponant, and the
skill of the orthodonti st in handling this type of case is a major consideration. It is
important to look at the lower anterior facial height. Patients with an anterior nasal -
spine·memon measurement in excess of 75 mm (unless they are very tall) may benefit
a great deal from orthognathics. The height of the upper molar and the height of the
lower mo lar are significant factors, as is the amount of visi ble gingiva at rest and
upon smiling. Burstonelll has pointed out that the incisal edge of the upper incisors
should be about 3 mm below the upper lip. In nonsurgical treatment we have demon·
slraled intrusion up to 7 mm. Interlabial gap has also been noted by Burstone to be
around 2 to 3 mm. If it is very large it is an indication for intrusive forces or onhog-
nathics. A reverse max illary occlusal curve that would permit intrusion of the upper
anteriors is helpful when there is excess gingiva visible, but if the max illary molars
are also elongated. then it is more likely to become an orthognathic case. Environ-
mental factors contribute not only to the development but to the stability o f this type
of case, and it is an imponant consideration.
6. Ano ther use ful treatment modality is verti cal reducti on geni oplasty. One
advant:lge of thi s procedure is that it does not involve the temporomandibular joints.
and it can be done after nonsurgical treatment as an adjunct to bring the chin up and
forwurd , to improve facial bal ance, and to reduce the interlabi al gap. A verti cal reduc-
tion genioplasty I1li ght be more useful in patients with the correct amount of exposed
gingiva in the maxilla because it docs not provide maxillary anterior intrusion (Fi gs.
16- 15 through 16- 17).
7. A maxillary impaction , possibly together with <I vertical reduction genioplasty,
should also be considered. This can be a great benefit to patients with elongated upper
posterior teeth, elongated upper anterior teeth, a gummy smile. a tall lower face. and
an anterior max illa that can allow a large impaction. We reported intrusion up to 12
mm in the anterior region with a maxillary impaction (Figs. 16- 18 through 16-20).
Thi s can provide significant esthetic as we ll as fun ctional improvements fo r the
patients.
The rc <Ire li mits to what we can treat with orthodontics alone. In nonsurgical
cases we reported on intrusion o f the upper molars of approx imately 3 mm, up to 7
mm of upper anterior intrusion while concomitantly holding the mandibular molars
without any extrusion throughout the orthodontic treatment period (Fig. 16-2 1). The
lower facial hcight has been reduced nonsurgically up to 5 mm . Beyond this, cases
are very likely to require onhognathics. It is wise to prepare patients initi ally for pos-
sible orthognathics or a vertical reduction geniopl asty procedure following con ven-
tional orthodontic treatment .
The future holds exciting possibilities as differential ex tractions. better manage-
ment of environmental factors, and improved trelltment planning <lnd mechani cs ena-
gle us to give our patients even better results in thi s critical dimension.
290 CH APTER 16
Figure 16-15. Patient C.W.: Illustration of an f igure 16-16. Patient C.W. After a vertical reduc-
excessive lower facial height be fore treatment. bon genioplasty.
' .
c .w. ~
15-4
~ ____. 15- 8
,,
"6.
,,
,
,
.,
~lgure ~t-~J. ~~u@"t c.w.:C@po!lometf\c trncin% illustrating an 6 mm red uction in th e lower antenor
facial height.
CHAPTER 16 291
Figure 16-1 8. Patien t l.H ,: Prio r to extraction Figure 16-19. Patient L.H.: Following extraction
therapy, maxillary Impaction, and a vertical reduc· therapy. maxillary impaction, and a vertical reduc·
tion genioplasty. tion genioplasty.
=
--_ .... -
Zf
L. H . \!
33-2
42 •
30 •,, 36-2
,
,
,
/jl• ••
• ••
"
Figure 16-20. Patient l.H. : Cephalometric trad ng illustrating a 12 mm maxillary Impaction and a vertical
reduction advancement genioplasty.
292 CHAPTER 16
---
,• --•• A.s.9
,,• ,I'~, " ,, -10-6
•, ,, ······13-9
, , \' ,
,,,
Figure 16-21 . Patient A.S.: The patient was treated wi th four premolar eJctractions, fixed appliances, and
in trusive forces to the teeth . There was a 4 mm reduction in the lower anterior fada! height and a SOcJo.
sure of the mandibular plane angle and 7 mm intrusion of the maxillary incisors.
REFERENCES
I. Bjork A: Prediction of mandibular growth rotution. Am J Orthod 55:585- 599, 1969.
2. Skieller V. Bjurk A. Linde-Han se n T: Pred ict ion of mandibular growth rotat ion evaluated from a lon-
gitudinal implant sample. Am J Onhod 86:359- 370, 1984.
3. Creekmore TD: Inh ibitiun or stimulation of th e vertical growth of the facial complex; its significance
to treatment. Angl e Orthod 37:285-297. 1967.
4. Popovic h F. Thompson G: Cr.miofacial templates for orthodont ic ca.'\C analys is. Am 1 Orthod 71:406,
1977.
5. Harvo ld E: Morphoge netic response to activator treatment. Am J Orthod 60:478-490, 1971.
6. McNamara. J A Jr: Components of Class II malocclusion in children &-10 years of age. Angle Onhod
5 1:1 77, 198 1.
7. Isaacson JR. et al: Extre me variation in vertica l facial growth and associated variation in ske1elal and
dental re lations. Angle Onhod 4 1:219-229, 197 1.
8. De Smi l A, Dennall1 L: Soft tissue profile preference. Am J Onhod 86:67-73. 1984.
9. Li nder-Aronson S. Woodside D: TIle channe liUltion of upper and lower anterior face heights com-
pared 10 populalion slandards in males between age 6 and 20 years. Eor J Onhod 1:24--40. 1979.
10. McNamara JA Jr: Influence of respiratory p.1l1em on craniofacia l growlh. Angle Onhod 51 :269. 1981.
I I. Vi g P; Respiration, na.o;al airway, aud o nhodont ics: A review of current cl inical concepts and research.
New Vistas in Orthodontics. Ph iladelphia: Lea aud Febiger. 1985.
12. Weimen T: On airway obstruclion in onhodolllic practice. J Cli n Orthod 20:96- 104. 1986.
13. Woodside D. Under-Aronson S: Progressive increase in lower anterior face height and the use of pus-
tt:rior occlusal bite block in its man agement. Orthodol11ics: State of the Art, Essence of the Science.
51. Louis, Mosby, 1986.
14. Watson W: Acomputerizcd appntisal of thc hi gh-pull face bow. Am J Onhod 62:561-579, 1972.
CHAPTER 16 293
15. Pearson L: Vertical control in trcalnlCtH of paticnts ha ving backward rotational growth tcnde ncies.
Angl e Orthod 43: 132- 140. 1978.
16. Garlington M. Logllll L: Vertical c hange.~ in high mandibular plane cases following enuclilltioo of sec-
ond premollU'll. Angle Orthod 60:263-268. 1990.
17. DiPalma 0 ; A morphomet ric ~lUdy of onhopedic and fu nctional therapy for the hyperdiverge nt skele-
lal pallem. Master's thesis, Case Western Reserve Univers ity, May 1982.
18. Pearson L: Case report KP: Treatmen t of a severe open-bile excessive vertical pattern with an eclectie-
no nsurgical approach. Angle Orthod 6 1:7 1- 76. 1991.
19. Dellinger EL: Vertical Dimension Proble ms and Thei r Clinical Solutions. Chicago: 1985.
20. Richelts R: The influence of orthodont ic treatment on facin l growth and deve lopmen1. Angle Or1hod
30:103- 13 1. 1960.
2 1. Dougherty I-I: The effcct of mechanica l forces upon the mandibu lar buecal segmenL~ during orthodon-
tie treatmenl. Am J OrthOO 54:29-49. 1968.
22. Pear,;;on L: Venical control th rough use of mandibular posterior intrusive force s. Angle Onhod
43:194-200,1973.
23. Schudy F: Verti cal growth ver,;;us anteriopostcrior growth a.~ re latcd 10 function and trealmen1. Angle
Orthod 34:75-92. 1964.
24. Neilsen I: Vertical malocc lusions: Etiology. developmen1. diugnosis and some aspects of treatmcnt.
Angle OrthOO 6 1:247-260. 199 1.
25. Kuhn RJ : Control of anterior venical dimension and proper selection of extrllOra l llnchorage. Angle
OrthOO 38:340-349. 1958.
26. PcIlr,;;Qn L: Vertical control in fully banded orthodontic trealment. Angle Orthod 56:205-224. 1986.
27. Sarver D. Johnson M: Skeletal changes in vertical and anterior displacemcnt of the maxilla with
bonded rapid pallltal expansion appliances. Am J Orthod Dentofacilll Orthop 95:462-466. 1989.
28. Burstol'le C: Deep overbi te correctio n by intrusion . Am J Onhod 72: 1- 22. 1977.
CHAPTER
17
Management of Severely
Compromised Orthodontic Patients
Birte Melsen
he treatment objective for a severely compromi sed putient is to restore the
T health and function of the stomulognulhic system, Le .. to establish an estheti-

cally and functionall y sat isfac tory dentition surrounded by a hcuilhy periodon-
tium and in harmony wi th the soft tissues of the facc.
It was previously the rule more than the exception th.1t people ended their lives
without leeth, with or without dentures. depending on the nonn of the society. In the
Western world. however, it is becomi ng increasingly unacceptable to wear a remov-
able denture, l
With the reduction of caries as well as of periodontal disease, elderly patients are
retaining :10 increasing number of lCClh.2 In the United States. 59.5 % of 18- to 74-
year-olds in 1971 - 1974 had six or fewer teeth missing. By 1985- 1986, this fi gure had
incrc..sed to 80.6%. As the number of teeth in the mouth has increased, SO has the
divers ity of problems related to teeth . along with the spectrum of treatments avai lable
for the compromised dentition} Whereas periodontal treatment was previously lim-
ited to arresting the destructi ve process. modem treatment aims at reestablishing lost
periodontium through the principle of guided ti ssue regeneration .4-5
Lost teeth. which we re usuall y replaced by dentures or if fea sible by bridges,
are today often re pl aced by implants that can serve as bridge pillars as well as
replacement s of s ingle teeth. The combination of implant s and guided ti ssue
regeneration has fun her widened indication for implants. The height and width
requirements of the alveolar process ha ve been reduced as guided ti ssue rege nera-
tion. combined with imp lants, may restore the loss of alveolar process in both
he ig ht and width .6 - s The recent de ve lopment of th e usc of resorbable mem-
branes ll - 12 ha s further opened the potentia l for these treatm ent s. and it seems
likel y that biochemical compounds with osteogenic possibilities will also find
their usage as part of the treatmcnt. 13- IS
294
CHAPTER 17 295
Management of Severely Compromised Orthodontic Patients
Why Do Pati ents Become Compromi sed?

In spite of improved dental health, a large number of older patients suffer not only
from loss of teeth and/or periodonlium but also from the consequences of the gencral
dcterioration of tooth resistance. A change in the equ ilibrium that results from age-
rclated processes can Icad to spontaneous migration of the teeth. Such mi grations
result in the development o f so-called secondary malocclusions or aggravation of
al ready existing malocci usions.1The migration may lead to further periodontal break-
down because gingival impingement may develop through migration or due to tipping
and rotation of teeth, rendering the cleaning procedure more difficult. l 6-20 The migra-
tion may include elongation of teeth without an antagonist, and in the case of the
incisors of an increased overjet. Loss of one or more teeth in the posterior scgments
may lead to furthcr tipping and rotation into the cxtraction spaces and the devclop-
ment of traumati c occl usion, which enhances thc prog ression of periodontal di s-
cascs. 21
Interdi scipl i nary Treatment with and w ithout Orthodontics

The reestablishment of a well-balanced and well-functioning occl usion and articula-
tion in the vast majority of patients requires collaboration among many denlal special-
ties. 22~24 Perfect oral hygiene is a necessary precondition for a controlled tissue reac-
ti on during trea tm cnt. 25- 26 Prosthodo11lics may also be needed in remedying a
deteriorated dentition. The pati ent 's fun ctional SWtus with regard to muscles and
joints plays a dec isive ro le in considering th e other di sc iplines that should be
involved. Several disciplines are optional in some pntients and necessary in others-
for example, orthodontics and orthognathi c surgery.
The relationship betwecn the alveolar process in all three planes of space deter-
mines whether the establish mcnt of a well -functioning occlusion is possible through
reconstructional means in the widest sense alone, or whether orthodontics or even
orthognathic surgery is necdcd or recommended. In many patients the addi tion of
orthodontics will on ly changc or facilitate the reconstruction needed, whereas in other
patients orthodontics wi ll dramaticall y change the prognosis of the dentition. 27
Impl ants in Orthodonti cs : Alternatives or Compl ementary?

Clinically, implants are used as substitutcs for teeth with the purpose of facilitating an
acceptable reconstruction of a compromised dentition. The combination of gu ided tis-
sue.regeneration and implants has further widened the indication for implants and
reduced the need for orthodontic treatment. It may no longer be necessary to perfoml
orthodontics when an implant can be used to obtain the best possible distribution of
the remaining teeth with regard to conslruction of bridge work.
011 the tissue level, the orthodontic displacement of teeth offers. in addi tion to
effecting tooth movement within the alveolar process, the possibility of altering the
alveolar process in any di rection. Moving the teeth "w ith bone" by generating a tissue
rcaction, wh ere resorpti o n and formati o n nre co upl ed, as in the remode lin g
scquence,28 allows for the modeli ng of the alveolar process beyond the li mi ts of the
original borderlines. Although the exact nature of the events that transfer a mechani-
cal stimulus to the cellul ar reaction is still unknown in detail, it is evident that the first
reaction is demonstmlOO in the preosteoblast, or the "helper oSleoblast,"29 and that the
resorption leading to the tooth displacement is not displayed until later (Fig. 17- 1).
The formation of an increased bone density in the direction of the tooth movement
has recently been demonstrated, as has the ability to form dense bone ex tending into
the maxillary sinus.30-)2
296 C HAPTER 17
M echanical Stress
"~
I ST~ ~
~
~
}\
Cylo k ln..
" c l j~. I.d e~

\ \ 'Helper' o. l eo ble.l e
~
I ~STEP ,I ~et, l~
Cyloklnee
[STEP 31 / ICOliegen
Collegene e e
, TIMP
)
Co ll egene.e
\ Olle oblee'
,\:'Oklne
,Bone lo.mellon f 18 .0.pl1on
Olleo e l •• t
b
Figure 17-1. A, Hypothetical model of the sequence of events involved in mechanically indlKed remodeling activity. B, HYi>Othetical
model of how mechanical stress might lead 10 changes in either bone formation or bone resorption . Critical steps are (1) the cytokil'lfS pro·
duced locally by mechanically activated cells and their interaction with molecules such as Iranslonning growth factor II and fibroblast growth
factor; (2) the functional state 01 the available target osteoblasts. (I wish to thank Dr. Murray C. Meikle, London, for permission 10 reproduce
the two figu~ . )
The level o r the change in stre~s/strain di ~tri bution or the periodontal ligament
that is required 10 produce a coupled phenomenon leading to tooth movement with
bone remains unknown so rar. It is ev ident, however, that the tooth movement is
related to a concentration or rorce level. In the casc or tipping, it leads to an uncoup-
ling; Le., the tooth will be moved through bone and eventually outside the alveolar
process, resulting in dehisccnce. 3J..34
On the other hand. there is al so ample evide nce or the abi lity through orthodontic
tooth movement to di splace the alveolar process in alllhree dimensions, as well as 10
rebuild an atrophic alveolar process through the tooth movement into the area, pro-
vided the force system is well controlled.
The combination or implants and orthodontics has rurther improved the possibil-
ity ror an adequate treatment result ror the compromised patient. Implants have round
increasing use as stable anchorage for orthodontic tooth movement in partially eden-
tulous patients. Thus. tooth movement. which otherwise would be impossible due to
an unfortunate distribution of tccth, can be eflccted.3s-36 The clinical management of
the. severely compromi sed orthodontic palient starts with the workup or a proble m
list.
Problem list
Before planning an orthodontic treatmcnt, it is important to develop a complete prob-
lem list based on a thorough case hi story of the patient suppleme nted with the results
or clinical, radiographic, and othe r oplionul unalyses,31-38
The patient will orten present to the ramily dentist or the orthodontist with a sub-
jective problem li st or chier complaint. The patient' s perception or the proble m
reflects only the symptoms or a muc h more complex problem.
CHAPTER 17 297
When recording the case history. the dentist should focus on both the patient's
altitude to his or her problem and the patient's general medical history. With increas-
ing age medical problems are more freq uent. Most metabolic diseases and diseases
related to the immune response system, as well as regular medication. may playa role
when the dentist monitors the tissue reaction for the planned tooth displacement.
The objective problem list should, as in all orthodontic patients, include infonna-
tion on facial appearance; denml and periodontal status; function of the stomata-
gnathic system, including swallowing, breathing. chewing, and TMJ function. Denti-
tional anomalies, including deviation in eruption and position, should be noted, as
should deviation in occlusion. sagittally. vertically, and transversely. Based on a
cephalometric analysis. the skeletal relationship should be described. In individual
cases, additional examinations. such as special radiographic images. cr or MR scans.
or functional ayalysis. may be needed.
As soon as the problem li st is complete, the necessary interdi sciplinary contact
must be made and the problem li st discussed before presentation to the patient.
Patient's Attitude
The vast majority of patients belonging to the group of heavily compromised treat-
ments present complex problems due to loss and destruction of dentition related to
both disease andlor previous treatment. Many patients. such as those in the case
reports described later in this chapter. are not aware of the complexi ty of their prob-
lems. O thers have li ved with a so-called "patchwork" for a long period unti l finally
this is no longer possible, so that a large, multidisciplinary treatment approach is
needed if the patient is to avoid removable dentures.
The process of choosing a treatment goal is markedly innuenced by the patient 's
understanding of the problems and the various possible solutions. Due to the large
discrepancy between the subjcctive--the personal- and the objcctive-the true prob-
lem list- many patients feel tempted to leave the orthodontist's office before even
starting treatment. This can best be illuslraled in the example of Case I (see later).
It is therefore important that the patient be well informed, not only with regard to
the first part of treatment in volving periodontal and orthodontic treatment but also
with regard to the reconstruction process and the long-term maintenance.
With a heavily compromised dentition the ideal solution is never possible, but
any altemative treatment plan can be presented with its pros and cons. It is crucial to
present to the patient the solutions that can be obtained and the available resources.
The patient must be motivated to maintain perfect oral hygiene and the patient must
understand the time frame and cost for the reconstruction to be completed.
A satisfied patient is a patient who feels hi s or her expectations have been ful-
filled . A coordination of the IX>ssible treatment goal and the expectations should there-
fore be establ ished before starting treatment. The patient should reali7..e not only the
benefits but also the cost in the widest sense (money, cooperation. time) related to the
chosen treatment, alternative treatment, or no treatment.
Treatment Sequence
An interdisciplinary treatment always starts with treatment of acute problems: caries,
periodontal di sease, and endodontic treatment needed. Since most of the compro-
mised patients are aClUally expressing a low resistance. they should be considered as
risk patients. The tissue reaction generated by orthodontic forces in severely compro-
mised patient s is crucial. The range between the threshold level and the excessive
stress level is small. The recipient. i.e .• the area onto which the forces are transferred,
is reduced for such reasons as loss of teeth or loss of periodontium. In the case of
298 CHAPTER 17
periodontal breakdown. the patient. although at the present withoul active disease,
may demonstmte a reduced resistance 10 periodontal di sease. It should be k.ept in
mind, therefore. that the tissue reaction generated by orthodonti c forces basically
resembles that of an innammation, with increased concentration of prostaglandins.
Thus, the periodolltal status is not completely under control, and additional marginal
bone loss may occur. The loadi ng is also interacting with other forces related to an
unstable occlusion, with premature traumatic occlusions or overloading of one or
more teeth in addition to the eventual influence of parafunction.
The possibility of maintaining u healthy periodontium throughout treatment is
therefore a necessary precondition for the onhodontic treatment of the compromised
patient if the ri sk. for further damage is to be kept under control. This also implies that
pathologicully deepened pockets should be treated before initiming the onhodontic
treatment. The pockets should be reduced surgically through an apical displacement
of the gingiva if guided tissue regeneration cannot be applied. 11le fim slep in any
treutment is therefore to establish a healthy gingival status, and during that period to
evaluate the pat ient's cooperation and tissue response to the periodontultreatment.
Final Discussion of Treatment Goal

The patient's response to and cooperation during the periodontal treatment guides the
final discussion of the treatment goal. With a positive response and an interested
patient. a more demanding treatment can be recommended if the benefits of more
extensive treatment are obvious.
The key to the success of the extensive and often complex interdisciplinary treat-
ment is a concordance between the expectmions of the patient and the outcome of the
treatment. The subjecti ve need for on hodontics is basically related to esthetic consid-
erations. Patients' thresholds for acceptance of change in appearance vary a great
deal. innuenced to a great extent by the infonnation provided by the dentist and the
attitude of fami ly members.
An impon:mt step before initiating treatment of a heavily compromised patient is
to agree on a well-defined treatment goal both with the other dental practitioners and
with the patient. The patient must understand his or her role in obtai ning this goal. 39
The treatment goal, presented as a composite of a cephalogmm and an occlusogmm.
also defines the anticipated tooth displacements in three dimensions. since there is
only one correct force system for a given tooth movement.
Force System Needed-Active Unit

The force system can be described by the line of action and the magnitude of the
force with respect to the center o f res istance o f the tooth or group of teeth to be
moved. Knowing the necessary force system with respect to CR, the practitioner can
establish a replacement force system wi th respect to the bracket. All active unit force
systems deliver equal and opposite fo rces to the reactive (the anchorage unit). It is
therefore imponam to consider how the reactive unit can be kept stable. This subject
has been discussed in detail by Melsen} 1
Passive Unit Anchorage

The biomechanical setup thaI delivers the correct type and magn itude of force must
be established. It is crucial to respect the need for anchorage and to monitor the force
according to the reaction of the tissues. All force systems are in equilibrium, and if the
force s implici t in the eq uilibrium are not acceptable, special considemtion must be
CH APTER 17 299
given to anchorage. The best anchorage control is obtained by utili zing the patie nt's
sense of occlusion, as demonstrated in Case 4.3 1
Appliance Design
Optimizing treatme nt also means moving the teeth directly from the original position
to the onc defined by the treatment goal. This implies a minimum treatment time and
a minimum of iatrogenic damage. The appliance should therefore be designed to
deliver a force system as close to the ideal as possible. This is best done utilizing a
free body diagram, indicat ing forces and moments delivered to both the active and
reactive unit. A light, continuous. and constant force system should be applied. Bur-
stone, as early as the 1960s. described appliances for all types of tooth movements,
includin g canine ret raction, deep bite correction. space closure. and leve lin g. 40 -46
More imponant thun the appliance itself, however, is the principle "the force drives
ort hodontics" rathe r than the appliance. The same defined force system can be
achieved by a wide range of appliances, and the development of new alloys has also
facilitated the generation of desirable force systems; oft en on ly imagination sets the
limits. Recently. an interactive hypertex t com puter system has been developed41 that
enables the clinician to dcfine the desired tooth movement on the computer screcn.
The computer then displays the correct force system, and when the wire material has
been selected the computer can also assist in the appliance design. With force-driven
onhodontics the prognosis for the compromi sed pUli ent can be improved. Uncontrol-
lable force-deli very wire-driven onhodontics, which may function in growing chil -
dren, shou ld be avoided in the compromised patient.
CASE 1
A 35-year-old woman presented to her dentist with an ongoing recession of the labial
gingiva on the lower incisors (Fig. 17- 2). She reponed bruxi sm at night and frequent
morning headaches. The clinical examination showed that aU teeth, apnn from the
wisdom teeth, werc presen t and that there was a very high treatment experience.
There was no active caries present: the upper left lateral incisor had been endodonti-
cally treated and was extremely discolored. Due to the extreme deep bite the patient
had labial periodontal impingement on the lower incisors and linguall y on the upper
incisors. The labial impingement fa the lower inci sors had led to gi ng ival retraction
lingually to the upper incisors and to pocket fonnation with a depth of 5-6 mill on
both central incisors. Loss of attachment was also seen in relation to a de hi scence
buceally to the ri ght lower Jirst premolar. All other teeth exhibited on ly minor peri-
odontal problems wi th superficial periodontiti s.
The dentilion was funher characterized by several heavy abrasion facets. espe-
cially on the upper and lower incisors: local rotation and tipping of teeth; and a sli ght
crowdi ng in the upper and lower jaws.
The composi te analysis of the profil e tracing and the occJusogram revealed an
asymmetric arch shape, most pronounced in the lower jaw, where the arch was nat-
tened in the region of the right lower canine. The midline of the upper jaw corre-
sponded to the midline of the face, whereas the midline of the lower dentition was
displaced toward the left. Occlusally, there were also signs of asymmetry, with a distal
molar relalionship on the right side and neulml occlusion on the left. The occlusion
was further characterized by a deep bite and di socclusion in the right firs t premolar
region. From this examination il became obvious that the patient, who had presented
with a "single" periodontal problem, had to face a multidi sciplinary treatment plan.
300 CHAPTER 17
Fi,ure 17-2. Case 1. A, ExtraOfal photo of the patient befOfe treatment Her appearance is char·
acterized by a pronounced alveolar retrognathism. B, IntraOfal appearance. Deep bite with gingival
impingement, both lingual to the upper indsors, has resulted in deep pockets. C, Study cast before
treatment. Note the asymmetrit lower jaw. D, Three-dimensional treatment plan.
CHAPTER 17 301
Filure 17_2. Case 1. (Continued) E, Biomechanics of the

lower Jaw consisting of two lingual arches, one of which is tele-
scoped into the other, making it possible to generate a symmetric
lower arch by opening a space between 43 and 44. F, Treatment
analysis. G, Posttreatment: in traOf"a1 photo showing the correc.
tion of the deep bite. The gingival situation h<15 been improved
and a neutral canine relationship h<15 been established in spite of
a distal molar relationship on the right. Note that the dehiscence
region 44 has been treated by a mucogingival drafting.
F
302 CHAPTER 17
Figure 17-2. case 1. H, Satisfied patient after treatment.
The patient was not prepared for major treatment when she approached her den-
tist with the gingival recession. It was therefore important for her to understand the
relation between her symptoms and the many problems given in the objective lis1. A
three-dimensional treatment goal was defined on the basis of the composite secn in
Figure 17-2D, which also indicates that sufficient intrusion or proclination of the
maxillary incisors to solve the upper crowding would result in an overjet that could be
corrected only if the lower incisors were also proclincd considerably. Proclination
would also lead to opening space in the region of the lower right first premolar. With
this approach a symmetric lower arch cou ld be generated. From a periodontal point of
view it seemed risky to procline the four incisors, which already expressed marked
gingival recession. As a consequence of the patient's positive response to the peri-
odontal treatment, it was decided to attempt the trealment and to monitor the ti ssue
response carefully. The treatment would also result in a neutral canine relationship
bilaterally. and the midline would be corrected while maintaining the distal molar
relationship on one side.
Before starting trealment general conservative periodontal treatment was initi-
ated. Surgical intervention was necessary on the lingual to the upper incisors. In order
to prevent the lower incisors from traumatizing the healing, comJXlsite onlays on the
occlusal surfaces of the molars were used for a period while the intrusion was initi-
ated. The mucogingival graft related to the right lower first premolar was JXlstponed
to the end of the treaUTIenl. However. later experience has shown that it is advanta-
geous to do the graft before treatment because the remodeling of the soft tissue may
lead to a bener result cosmeticall y.
The treatment was initiated with intrusion of the upper incisors. Because brackets
could not be inserted in the lower jaw due to the deep bite, the treatment was initiated
lingually. Bands were fitted with sheaths for twO lingual arches. One served as
anchorage, and the other was divided into two cantilevers filting into a telescope sys-
tem with open coil springs used to procline the lower incisors. The system was
CHAPTER 17 30 3
adjusted so that the space opening would occur on the right side whereby the arch
fonn would become symmetric.
When the upper incisors had been sufficiently intruded, a labial appliance was fit -
ted for the lower jaw. and the treatment ended with correction of rotat ions and adjust-
ment of root inclination . At the conclusion of treatment a symmetric lower arch was
obtained. and the prosthodontist placed a bridge involving a third premolar in the
region of the right lower first premolar. The treatment time was 15 months. and the
side effects related to the treatment were negligible.
The patient was highly motivated throughou t treatment. It was importam for the
patient to understand the dynamics in the treatment and to feci that the team. in this
case the periodonti st. prosthodontist, and ort hodontist, agreed on the treatment goal.
Posttreatm ent Care

Following tremment the patient should understand the importance of biological main-
tenance. The responsibility for the stability of the treatment is left partly with the
patient, since only she or he is able to maintain the result. A full y balanced splint is
normally inserted at the end of treatment in addition to a canine-to-canine bonded
retainer in the lower jaw. These retainers are for a lifetime. The splint is used for
maintaining the mandible in the structural position during the reconstruction of the
oce/usion and is needed in most patients foll owing treatment. Further. the splint can
be used for regular control and is usually 'Ippreciated so much by patients. who feel
that they are fully relaxed at night, that it is used on a more regu lar basis. It also
serves the purpose of avoiding tmuma related to bruxism or parafunction.
e ASE 2
A second example of a patient presenting with what is percieved as a simple problem

is a 43-year-old man who was referred to the orthodontics department because he lost
a deciduous canine in an area in which the pemlanent canine was ectopic and was
later proved to be anchylotic (Fig. 17-3). The patient had seveTli I molars ex tracted
because of caries. Following extraction he experienced severe tipping and rotation of
the neighboring teeth, posterior inclination of the lower incisor segment. and deepen-
ing of the bite. [n relation to caries on visible teeth, he had received endodontic treat-
ment and a crown of very dubious quality. The direct reason for referral was, how-
ever, the ectopic canine.
The case history revealed experiences with different dentists-when he was
young mostly for extractions due to pain and when he was older for repair of at least
the visible caries. The patient. who is a teacher, also reported frequent headaches and
problems with the gingiva due to traumatic occlusion labially to the lower incisors.
His wife reported that he was a heavy bruxer. which was confinned by the presence
of pronounced abrasion facets. especially on the incisors.
His objecti ve problem list involved early extraction of the upper first and second
molars and left first and lower right second molars; ectopic eruption of the right upper
canine: mesial tipping; rotation of upper right and left and lower left third molars;
deep bite with gingival trauma; distal cani ne relationships on the left side; and disoc·
clusion related to left upper and lower first and second premolars. Ccphalomelrical1y,
it was shown that the deep bite was of skeletal origin. In order to release the impinge-
ment before orthodontic treatment. a splint was in serted in the lower jaw. The peri-
odontal preparation was then performed. Surgical intervention revealed that the
impacted canine was anchylosed, and for this reason it was removed. Uprighting of
the third molars was done with a root spring using the incisors as anchorage, thereby
304 CHAPTER 17
Figure 17_3. Case 2 . A. Edraoral appearance of a 48-year-old man suffering from ectopia 13 and loss of one
deciduous canine in the same region. B, Intraoral appearance characterized by the lack of canine on the left side, dis·
colored lateral, and extreme deep bite. C, Slight opening shows extreme abrasion facet. D and E, Study cast reveal-
ing 45· mesial tip of upper molars. 30· mesial, and lingual tip of lower molars.
CHAPTER 17 305
Fi",,.. 17-3. C.5. 2. (Continued) F, Profile tradng; note

the interincisal angle of appro~imate ly 180°. G, Periapical
status e~h ibit ing the anchylosed canine in the left upper
region with severe tipping into previous e~traction spaces.
H, The appliance used.
//Iust/alion con tinued on following page
30'
Ct
H
306 CHAPTER 17
Figure 17-3. Case 2. (Continued) I and 1, Following treatment a splint was placed in the upper Jaw to retain the
resul t and to maintain the mandibular position while the lower jaw was being treated. K and L. Study cast at the end
of treatment. The molar has been upnghted. the deep bite has been reasonably reduced, and the interincisaJ angle
has been established, M , Intraoral status following treatment w ith the satisfactory uprighting; the lingual bonded
wire is permanently retained .
CHAPTER 17 307
Figure 17-3. Case 1. (Continued) Nand 0, Intraoral appear-

ance aftef bonded bridges were established. Note the reduction
of the clinical crown height of 16. p. Superimposilioning of the
radiographs revealed this pronounced uprighting and the
improved interindsaJ angle. Q, Extraoral appearance character-
ized by a smoothening 01 the concave profile.
308 CHAPTER 17
Management of Severely Com prom ised O rthodontic Pat ients
reciprocally providing root torque to the incisors and upri ghting to the molars. The
bite opening was I mm- the maximum the patient could accept without inducing a
headache.
Following the treatment of the upper jaw, a splint was inserted as a retainer.
Uprighting of the lower molars for correction of the di socclusion was perfonned by
means of a root spring between the canine and the molars combined with a stabilizing
arch. Uprighting was also supported by asymmetric activation of the lower lingual arch.
The patient's si tuati on following orthodontic treatment was subjectively charac-
terized by the absence of headaches and a smoothening of the very concave profile.
The patient was referred back to his own dentist. who produced lhe necessary bridge-
work in the lower and upper jaws. The replacement of the esthetically compromised
crowns was postponed for economic reasons.
All his life th is patient had experienced dental problems, all of which had been
taken care of over very short periods-e.g .. extractions or a single crown. For the fi rst
time in hi s life he had to face a full treatment plan. and he therefore wanted a thor-
ough explanation of the pros and cons in terms o f short- and long-tenn solutions. On
the basi s of this information he was very pleased to accept the combined peri%rtho,
gnathologic. and prosthodontic treatment.
CASE 3
This patient was in the same category as the patient in Case 2 (Fig. 17-4). However,
she had had less experience with restorative dentistry. but because of caries. molars
and a single premolar had been removed on the left side. In add ition. extrusion of the
upper molars into the extraction space and heavy atrophy of the alveolar process had
taken place. The patient was referred to the orthodontics department with a request for
possible correction of the di soccJ usion in the molar region before extraction of the
right upper first molar and bridgework on the left side. The upper first left molar had
erupted panly out of the socket. As a result. the alveolar process was consequently
overdeveloped venically in thi s region, and the clini cal crown was elongated, leavi ng
about 3 mm of visible cementum.
A biomechanical system using the occlusion onto a ccmcnted splint as anchomge
was designed. and intrusion and protraction of the right upper second premolar and first
molar were initiated. The necessary force systcm was produced with aT-loop buccally
and a nickel-titanium coil spring lingually. Once the spaces were closed. panial upright-
ing by tipping was done with :1 cantilever. agai n using the spl int as anchorage. Follow-
ing a space closure and uprighting. fini shing by means of a fu ll on hodontic appliance
was perfonned. and the paticnt was referred for bridgework. The disocdusion, which
was her original subjecti ve problem. was corrected as pan of the IOtal treatment.
In some patients imponant factors pointing to the need for onhodontic treatment
become evident only following the periodontal treatment. In the case of horizontal
bone loss and severely deepened pocket s, the periodontal surgery will inevitabl y
result in lengthened clinical crowns, and the increased overjet may thereby become
even more evident. Selecti ve ciongmion of the lateral incisors is also a common find -
ing, and it may be the reason the patient finally seeks treatment.
CASE 4
A 44-year-old woman had also al ways suffered from a slightly increased overjet, and
the gradual augmentation of it had not become noticeable to her until she changed
dentists and was advised that her periodontal conditi on was severe (Fig. 17- 5).
CHAPTER 17 309
Fi,ure 17-4. Case 3. A-E, A 3a·year·old patient referred to

the Orthodontic Department for correction of the nonocdusion
(scissor bite) in the molar region. The patien t had previously
e.perienced e.traction of the first molars in both sides of the
lower taw and tne first premolar in the upper )aw_ Secondary to
the e.traction severe e.trusion of the upper molar had taken
place, and the lower molars were tilted mesially into a nonocdu-
sion. The alveolar process in the region of the extracted premolar
was completely atrophic, as was the alveolar process in the
extraction sides of the lower jaw. F, Drawing of tne desired force
system in the sagittal plane. It was desirable to attempt to intrude
and protract the right side segment in the upper jaw. The desired
force system is indicated on the drawing; the anchorage will be
occlusal forces to a bonded splint. G, The force system in th e
horizontal plane of space.
310 CHAPTER 17
Figure 17-4. Ca5e 3. (Continued) H and I, A cemen ted

splint was used as anchorage. The forces were produced by an
appliance consisting of a 50 g SentaJloy spring on the right ~e
and an .016 x .022 inch T-Ioop on the the left side, both mooi-
tore(j for a line of action of the force passing through the roots .
1, Aftef some time it was obviOus that the line of action was
too low and that a tipping had taken place into the extradion
space. K, Uprighting me(hanic5 was therefore inserted. This
consisted of a wire extending distally to the molar in addition to
a cantileve!" delivering an intrusive force to a point distal to the
center of resistance to the segment. l. At this point the treat·
ment of the lowe!" JC\w was Initiated with a traverse fme deliv-
ered from an E-arch. M, The expansioo was continued with a
telescope system between the canines. N, At the end of treat-
ment the splint was removed and a conventional appliance was
inserted.
CHAPTER 17 311
FiIU~ 17-4. Case 3. (Continued) 0 and P, The situation at the

end of the treatmenl Q-T, The situation after bridge construction.
U, A rad iograph ic image of the elongated tooth at the start of
treatment (compare with AJ. The bone level indicates abou t 30%
bone loss.
II/IJ~uation continued on following page
312 CHAPTER 17
Figure 17-4. Case 3 . (Continued) V, Radiographs following treatment. A root resorption is evklent on
the premolar, however. The bone level with respect to the molar is markedly improved. W, Superimposi-
tion of the pre- and posttreatment radiographs indicates that the molar has been moved forward about 8
mm and intruded 5 mm.
C HAPTE R 17 313
M anagement of Severely Compromised Orthodontic Patients
Figure 17-5. Case 4. A. A 42· year· old woman presented wi th a large overjet. B, The overjet was present when the patien t was
young, bu t has gradually increased. (-E, Intraoral view following a periodontal treatment, which was necessary to reduce the pockets.
The clinical crowns became considerab ly longer, and the patient's situation was acceptable. The ove~et was 15 mm, and there was no
occlusion in the premolar region on one side. A fu ll distal molar relationship was established.
Illustration con tinued on following page
314 CHAPTER 17
V"CO
Figure 17-5. Case 4 . (Continued) F, Tradng of the profile radio

ograph revealing a large overjet with a thin short upper lip. G,
Three· dimensional treatment plan. Dut' to the short upper lip it was
decided to avoid extraction. There seemed to be a forced bite plac.
ing the mandible dorsally in the last part of closure. It was therefore
anticipated that the mandible would slide forward approximately 2
mm . H, Cast stiff segment used as anchorage. I, The force system
for distal movement of the can ines was delivered by Sentalloy
springs lingually and labially. J, Rotation control was effected by a
labial appliance.
CHAPTER 17 315
,~
_ •• \ · 92
- 4 · 94
...
FI",re 17- 5. Case 4 . (Continued) K, Retraction of the incison with a homemade lingual appliance. L, Following major tooth move-
ments and correction of the crucial relatiooships treatment was finished with a conven tional appliance. M, Treatment analysis. The
rtsult coincided well with the VTO. N-P, Intraoral appearance following trea tment before reconstruction.
316 CHAPTER 17
Figure 17-5. Cue 4 . (Continued) 0-5, Extrao ral

appearance . T and U, As part 01 the retention a cast-
bonded splint was prepared lex the upper incisors.
CHAPTER 17 31 7
Management of Severely Compromised Orthodontic Pat ients
Following periodontal surgery the palient's interesl in her leelh was probably
increased, and she now noted Ihe elongation of the laterals in addition to the opening
of a diastema diSlal 10 the laternl on one side and to Ihe can ine on the other side. The
patient was suffering from a dual bite. by which she al so tried to avoid the disocclu-
sion. The dual bile had resulted in severe muscular tension.
The treatment goal was to maintain the molar relationsh ip and to retract and
intrude the canines and incisors. thereby reducing the overjet to a degree that incisal
contact would be possible. A treatment goal like this one represents a compromi se. It
was chosen in order to minimize the orthodontic treatment. thereby lessening the risk
of further attachment loss. The treatment was commenced with II very rigid anchorage
unit. and the canines were retracted by means of Sentalloy springs adapted labiaJiy
and lingually.
Follow ing retraction of the canine, the lingual wire was bonded to the incisors .
Upper incisors were retracted and intruded while the lower incisors were intruded and
proclined . The result was a compromise compared to the future development of the
patient without orthodontic treatment. Without treatment the inev itable result would
have been a further loss of teeth and very probably remov:lble dentures, since the
patient's skeletal di screpancies did not render it feasible to usc implants.
CONCLUSION
Should orthodontics be part of the treatment of compromised patients? Yes. bUi only
with cert:lin preconditions:
1. The periodontal status is healthy and under control.
2. There is agreement among the patient. the orthodontist. and other in volved
dental practitioners concerning the treatment goal and the postorthodonlic
maintenance.
3. The optimal force system is selected for development of the correct stress-
strain di stribution for the planned tooth displacement.
4. A differenti ation is made between the active and passive appliance. allowing
for the maximum anchorage control.
REFERENCES
I. Melsen 13: Orthodontic treatment of the degenerated dentition. In Carlson I)S (cd): Orthodontics in an
aging society. MOllograph 22. Cran iofacial Growth Series. Ann Arbor, MI : Center for 1·lu man Growth
and Developmcnt. University of Michigan.
2. Bun BA: Tooth loss. In Burt BA. Ekl und SA (cds.): Dentistry. Dental Practice. and the Communi ty.
Philadelphia: WI3 Saunders. 1992. pp. 83--99.
3. Lang NP. Nyman S: Implant and crown bridge therapy in the periodontally compromised patie nt.
Pcriodontology 2000 2. 1944.
4. Caton. JG. Greenstcin G: Factors related to periodontal regenerat ion. Pe riodontology 2000 1:9-- 15.
1993.
5. Kaning T. Nyman S. Gottlow J. Laurell L: Development of the biological concept of guided tissue
regenermion- ani mat mid human studies. Periodontology 2000 1:26-35. 1993.
6. Jovanovis SA. Spiekermann H. Richt er 8: Bone regeneration arou nd titanium dental impl ants in
dehisced dc!fecl si tes: A clinical study. In t J Oral Maxillofac Im pt 7:233-245. 1992.
7. Kenn ey EB. Jovanovis SA: Osteopromoti on as an adjunct \0 osseointegration. lnt J Prost hod
6:131 - 136.1993.
8. Nyman S. Lang NP. Buser D. Bragge r U: Bone regeneration adjacent to tilanium dental implants
using guided tissue rcgenemtion: A report of two cases. Int J Oml Maxillof:!c Impl 5: 9- 14. 1990.
9. Wac ht el HC. Langford A. Berni moulin J-P. Reichart P: Guided bo ne regcneration next loosseointe-
grated impla nts in humans. Int J Oral Maxillofac Impl 6: 127- 135. 199 1.

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CONTENTS

2. Orthodontic Treatment Planning 23

3. Improving Arch Mechanics Through Surface Chemistry 50

4. Current Status of Magnetic Forces in Orthodontics 65

5. Biomechanical Aspects of Class n Mechanics with Special

6. Canine Impaction: Diagnosis, Treatment Planning,

7. The Role of Headgear in Class II Dental and Skeletal

8. Biomechanics of Class II Correction 143

9. Biomechanical Basis of Extraction Space Closure 156

10. Biomechanical Considerations in Sliding Mechanics 188

11. Clinical Considerations in Extraction Therapy 218

12. Modified Lingual Lever Arm Technique: Biomechanical

13. Contemporary Management of Class II Malocclusions:

14. An Approach to Nonextraction Treatment of Class II

15. The Herbst Appliance: A Powerful Class U Corrector 265

16. Treatment of Class II Backward Rotating Malocclusions 28 1

17. Management of Severely Compromised Orthodontic Patients 294

MECHANICAL CONCEPTS IN ORTHODONTICS

An understanding of several fundamental mechanical concepts is necessary in order

Figure 1-3. The location of the center of resistance depends

Figure 1-5. Vector addition. The sum of two or more vectors is

Resultant Force = Force 1 + Force 2

Vectors can also be resolved into components. Decomposition of a force into

-- Figure 1-7. The moment of a force . A force that does not

Figure 1-8. Clinical examples of moments of a

referred to as the applied moment in onhodontics. Torque is a common synonym of

EQUIVALENT FORCE SYSTEMS

TYPES OF TOOTH MOVEMENT

""" Figure 1- 11 . The equivalent force sys-

Controlled Tipp ing

Figure 1- 12. Uncontrolk-d tipping. A, Uncon- Figure 1- 13 . Controlled tipping. A, Con-

figure 1-14. Translation. A, Translational or bodily tooth

Figure 1-15. Root movement. A. Root movement

fi8ure 1-16. Rotabon. Pure rotation OCCurs around a tooth's cen·

Static equilibrium is a valuable application of Newton's laws of motion to the analysis

Figure 1- 17. A schematic diagram of an

Figure 1- 18. Force system from an intrusion

Elel tic: linil

Figure 1-20. Stress-strain diagram

Each of the characteristics o f a stress-strain curve described arc determined by

CONSIDERATIONS IN APPLIANCE DESIGN

Reducing the Cross-Section of a Wire

Increasing the Interbracket Distance

Incorporating Loops in the Wire

Use of Memory Alloys

f igure 1- 21 . A clinical eKample of using of increased Interbracket

FIgure 1- 21 . (Continued) G. H, I, The patien t at the end of the

Figure 1- 24. A clinical example of an intrusion arch. A, Anterior intra-

Fllure 1-26. A canblever for canine extrusion. A. B, C, Intraoral

Figure 1-26. (Con tinued) G. H, I, Intraoral views at the end of the

Cognitive application of biomechani eal concepts in the delivery of onhodontic care

Treatment Planning for

Definin g Specifi c Treatmen t GoaJ~

ESTABLISHING GENERAL GOALS

USING DIAGNOSTIC INFORMATION

Figure 2-3. AnteriOr tooth alignment can help improve overall

Stabi lity Considerati ons

GENERAL TREATMENT OPTIONS

Surgical versus Nonsurgical Decision Making

Filure l~. Possible worsening

ing functional occlusion_Certain treatment mechanics. headgear, or functional appli-

Extraction versus Nonextraction Decision Making

Figure 2-7. Class II patient with signifICant mandibular