Journal of Orthodontics, Vol.

38, 2011, 134–143

INVITATION Northcroft Lecture: How has the

TO SUBMIT
spectrum of orthodontics changed over
the past decades?
Birte Melsen
Aarhus University, Denmark

Three aspects have had a significant impact on orthodontics during the last few decades: the appliances being used, the
anchorage being used and finally the distribution of patients being treated.
Firstly, the marketing of appliances is increasingly leading the orthodontist to outsource important aspects of treatment such
as wirebending and bracket positioning. Brackets and wires are being presented as the solution to all problems and
metaphysical terms such as ‘intelligent design,’ ‘working brackets’ and ‘intelligent wires’ are dominating advertising and
reducing the impact of evidence-based treatment approaches.
Secondly, the introduction of skeletal anchorage has potentially widened the spectrum of orthodontics, allowing for
treatments that could not be done with conventional appliances. Biomechanical knowledge is, however, mandatory if we agree
that the system should not be abused.
Thirdly, the orthodontic population comprises an increasing number of adult patients, many of whom are characterized by a
degenerated dentition. The treatment of these patients requires a thorough knowledge not only of biomechanics but also of the
reaction of the periodontal tissues to various types of loading. They can be treated only with custom-made appliances adapting
the force systems and magnitude to the patient-specific treatment goal.
In summary, the orthodontic world is being split between ‘appliance-driven fast-food orthodontics’ where the results to a large
extent are dependent on both growth and function and ‘orthodontist-driven’ ‘slow-food’ treatments attempting to push the
limits of the possible in relation to complicated problems and reversal of degeneration in adult patients. The latter treatments
are performed with individualized appliances adapting the force system to the patient. This paper will attempt to summarize
the bearing of these factors on present orthodontics.
Key words: Adult orthodontics, brackets, skeletal anchorage, prescription, straight wire

Introduction Finally, bending wire was undertaken in order to

Three aspects within clinical orthodontics have changed
over the last few decades; these include the materials
being used, the anchorage being used and the type of
patients being treated.
Orthodontists have traditionally been wire benders.
There are several reasons for bending wire. One is to lower
the force level. With stainless steel and chrome cobalt wires,
the activation range was low and the load deflection rate
was large, so that the only way of lowering the force level
was to reduce the wire dimension or to include more wire.
This was achieved with bends (Figure 1).
A second reason for bending was to generate the final
adjustments in all three planes of space. As the early fixed
appliance brackets did not have any first, second and third
order pre-adjustments, bends were added to the archwire
in order to obtain satisfactory finishing.
generate a specific force system. The force system generated
by a straight wire is determined by the mutual relationship
between the brackets and the wire, and can be changed by
adding different configurations to the wire. Adding loops
or bends to the wire will change the force system delivered
to the active and the reactive units1–3 (Figure 2).
With the introduction of the new alloys, bending for
the sake of lowering the force became less important
and, with the newer generation of superelastic wires,
even superfluous4–6. The development of the pre-
adjusted edgewise bracket, with the prescription deter-
mined by the doctors, made the second indication for
the bending unnecessary as well.7 There is, however, a
lack of consensus both between different clinicians,
regarding the appropriate prescription and between
different companies in the approach to be chosen to
obtain the desirable result8.

Address for correspondence: Birte Melsen, Department of

Orthodontics, School of Dentistry, Aarhus University, Vennelyst
Boulevard 9 DK - 8000, Aarhuc C, Denmark.
Email: birte.melsen@odontologi.au.dk
# 2011 British Orthodontic Society DOI 10.1179/14653121141362
 JO June 2011 Invitation to Submit Northcroft lecture 135

Figure 1 Example of loops introduced to lower the load deflection

rate when performing vertical correction in the upper arch

Figure 4 A working bracket. Is it moving teeth faster?

Figure 2 Example of how the application of a rectangular loop
can change the force system delivered to a tooth
The third indication for wirebending, namely, to alter
the distribution of forces from that determined by the
angle between bracket and wire, the geometry is,
however, still relevant1–3,9–14 (Figure 3).
Along with the development of new materials, the
marketing and the competition between different manu-
facturing companies have become more evident and the
language used is less scientific. Brackets are claimed to
‘work’ (Figure 4) and wire to ‘think’ (Figure 5) and some
products are even claimed to ‘speed’ up the biological
response because they are self-ligating (Figure 6). The
claims have further been focused on all the things
orthodontists would not have to do if they just bought
the correct product. Outsourcing has entered the ortho-
dontic market and there is no end to what the orthodontist
needs to no longer do; wire bending is one of them.
The sequence of individualized clear aligners or of
custom-made preformed arches is offered to the ortho-
dontist and often supported by public marketing
advertisement.15–20 These concepts may be helpful for
the treatment of certain categories of patients in solving
some problems, but they cannot in any way be
considered to replace the manual skill of the orthodon-
tist and do not make the biological and mechanical
understanding upon which the profession is built super-
fluous. The outsourcing of bonding through an indirect
set-up undertaken by a laboratory, can facilitate the

Figure 3 The influence of the interbracket position of a ‘V’ bend. The force systems (forces and moments) generated are indicated by
arrows. Note how a minor displacement can alter the distribution and direction of forces and moments completely
 136 Melsen
Figure 5 An intelligent wire. Where does the brain tissue come from?
finishing of a treatment (Figure 7),21,22 but cannot replace
the custom-made appliances needed to accomplish a
specific goal. The prescribed sequence of wires do not
necessarily deliver the force system needed to correct a
specific problem and although levelling may be achieved,
the inclination of the final occlusal plane is still determined
by the initial relationship between the brackets following
the laws of the so-called geometries.9,23–25 Once a straight
wire is inserted, the control of the occlusal plane is lost and
it is not in the hands of the orthodontist to determine
whether a deep bite is corrected by intrusion of anterior
teeth or extrusion of buccal segments (Figure 8).
The standardization of appliances narrows the ortho-
dontic possibilities for prediction of a treatment result. It
is thus not possible to determine whether an expansion
performed with self-ligating brackets and a prescribed
wire sequence will lead to transversal or sagittal expan-
sion, in other words, wider or longer arches26 (Figure 9).
Figure 6 A self ligating bracket. Is the bow important? Where is
the evidence?
Invitation to Submit JO June 2011
Figure 7 Tray for indirect bonding acquired from a company
The limitations related to the straight wire approach
clearly influences orthodontic outcomes. Comparison of
visualization treatment objectives with the obtained results
is rare and continuous preformed arches of increasing
dimension and stiffness combined with variable intermax-
illary appliances as adjuncts are dominant in most teaching
programmes.27–29 New bracket systems are promoted as
the solution to all problems and supported by ample
marketing material, such as morphing, illustrating how the
laws of equilibrium can easily be overlooked.30 An
increasing outsourcing of skills to both auxiliary clinical
personnel and extra-clinical companies has also character-
ized the last decennia. The efficacy and the productivity of
the doctors have without doubt increased with this ‘fast-
food’ approach, but some problems can only be solved by
the application of custom-made appliances, a force system
generated by wirebending.1,9,31
The second significant factor that has had an influence
on orthodontics over the past decennia, and also
contributed to a widening of the orthodontic possibilities,
is clearly the introduction of skeletal anchorage.32–34 This
makes it possible to both differentiate the anchorage as
desired and make problems with compliance obsolete.
The classical concept of anchorage has been built on the
principle that more teeth will provide anchorage for the
Figure 8 Skewing of an occlusal plane resulting from an indiscri-
minant leveling
 JO June 2011 Invitation to Submit
Figure 9 Digital models on which the arch width and length are indicated. With permission from Agger 2009. Reproduced with
permission from Anne Agger Mortensen
displacement of fewer teeth. This has, however, no
biological support, since only a few gram can displace a
tooth.35 Consequently, lack of sufficient anchorage has led
to the introduction of numerous anchorage approaches,
such as extraoral anchorage systems, intermaxillary forces,
either elastics or bite jumping devices, or intramaxillary
non-compliant anchorage systems.32,36
The development of skeletal anchorage has made a
significant change. Skeletal anchorage systems originate
from two sources: dental implants or the surgical world.
The application of skeletal anchorage was first introduced
when dental implants, which were meant to be part of a
reconstruction, were used as anchorage for the existing
teeth in the optimal position for the later reconstruction.
Later, the small, specifically designed implants were used
as anchorage either in the palate,37,38 or in the retromolar
region,39,40 allowing for treatment that would otherwise
not have been possible or as a replacement for other types
of anchorage, often replacing extraoral anchorage, there-
by avoiding compliance problems.
Since 1997, the concept of skeletal anchorage has been
dominated by mini-implants deriving from the surgical
screws.41,42 These are machine polished and the majority
can be inserted without predrilling as they are self-cutting.
Figure 10 Drawing illustrating the characteristics of the Aarhus
mini-implant. Reproduced with permission from Giorgio Fiorelli
Northcroft lecture 137
A large and still growing number of temporary anchorage
devices have been introduced.43 Is a screw, a screw, a screw?
Of course not! Anyone from the building trade will tell you
that particular screws are meant for particular purposes.
Several parameters have to be taken into consideration. In
relation to the intra-osseous part, the diameter, the pitch
(defined both by the depth and cut being symmetrical or
asymmetrical) and the tip must be optimized with respect
to the material, in this case bone. This has been done by
many of the manufacturers of surgical screws, including
MediconH, which produces the Aarhus mini-implants.
The transmucosal part should be smooth, in order to
minimize plaque accumulation and should have a diameter
larger than the intra-osseous part, making it possible to
sense the collar reaching the periosteum when inserting the
‘screw’ manually. The extramucosal part, the head, can
have one point contact allowing only for usage as direct
anchorage with a tube allowing for two-dimensional
Figure 11 X-ray of a patient following removal of two min-implants.
These mini-implants are of a type that requires pre-drilling and obviously
the surgeon who inserted the ‘‘screws’’ did not notice that they had pene-
trated the roots. This would not be the case if the ‘‘screws‘‘ were inserted
manually without predrilling
 138 Melsen Invitation to Submit JO June 2011

Figure 12 Patient with agenesis of 4 second premolars. (a) Extraoral images before and after treatment demonstrating that it would be
undesirable to retract the anterior teeth. (b) Intraoral images demonstrating neutral occlusion and perfect incisal relationship. As an alternative to
the replacement of the missing teeth with 4 implants it was decided to displace the first and the second molars mesially against one mini-implant
between the first premolar and the canine in the lower arch. It was previewed to insert two mini-implants also in the upper arch, but it became
unnecessary as the upper molars followed the mesial displacement of the lower molars. (c, d) Status following treatment
 JO June 2011 Invitation to Submit Northcroft lecture 139

Figure 13 Patient suffering from severe extrusion of 21 as a consequence of local periodontal involvement. (a) Pre and post-treatment
extraoral images. (b) pre-treatment intraoral images. Note the increased length of the clinical crowns especially on 21. The first phase of
treatment was to intrude and retract the 21 with a 25 cN coilspring pulling to a power arm in an upwards posterior direction, the force
vector was close to the centre of resistance. (c). An .017x.025 TMA wire was adapted passively to the upper arch and bypassing 21 to
which an .016 stainless steel wire was inserted as overlay. This arch delivered a combined retraction and intrusion contributing to the
closure of the median diastema. Once the 21 had reached the level of 11 and 22 the three incisors were connected by a rectangular segment
for minor leveling. In the lower arch a proclination and intrusion of the incisors was produced by a Utility arch tied to the anterior
segment with rectangular loops for rotation and tipping of the canines. (d) Post treatment status. Note the shortening of the clinical crown
on 21. A cast retainer produced on the basis of an articulator mounting according to the principles of a Maryland bridge was bonded
lingually to the upper front teeth. In spite if the intrusion no clinical pocket could be detected

control or with a bracket-like head as the Aarhus implant.
This renders it possible to use the mini-implant as both
direct and indirect anchorages, in addition to the
displacement of the point of force application without
having to insert a second screw (Figure 10).
Skeletal anchorage not only replaces the need for
extraoral anchorage and reduces the need for patient
compliance, but could also be considered as a means by
which the spectrum of orthodontics can be widened. The
interest in and development of skeletal anchorage have
140 Melsen Invitation to Submit JO June 2011
 JO June 2011 Invitation to Submit Northcroft lecture 141

Figure 14 (a) Patient suffering from a progressive degeneration of his dentition. Two teeth (12 and 45) have been replaced by bridges
and the patient is now experiencing a gradual worsening of an anterior open bite. Intraoral images at the start of treatment. (b)The first
phase of treatment aimed to generate space for the displacement of the incisors. This was obtained by a distal displacement of the upper
canines. As anchorage the two mini-implants were inserted below the infrazygomatic crest. The mini-implants were additionally consolidated
to the side segments that were connected with a transpalatal bar. From the transpalatal bar extensions were used for a lingual tipping and
intrusion of the second molars. Once the canines had been distalised the left central incisor was tipped distally and intruded with a
.017x.025 TMA segment extending distally from the incisor and activated towards the mini-implant on the left side. (c) Having corrected
the left incisor the bridge replacing 12 was tipped and rotated mesially with an extension tied to the left consolidated side. (d) Having
rotated the bridge 21 is aligned with 11 with an .016 NiTi overlay wire extending from the bridge to the right canine. (e) A space closure
was done with Sentalloy coilsprings between power arms and the mini-implants. (f) Status at finishing

been exponential, but some of the skeletal anchorage
used in patients could, in the mildest sense, be
considered superfluous and some directly detrimental
(Figure 11).34,44–46 However, the impact of skeletal
anchorage has changed the treatment approach, making
the need to consider the equilibrium obsolete. With
skeletal anchorage, teeth can be moved without loading
of reactive units (the teeth that do not have to be moved)
and all teeth can be displaced in the same direction
(Figure 12). Also in relation to the correction of
asymmetries, mini-implants have changed the spectrum
of orthodontics.
The third aspect that has influenced orthodontics within
the past decennia is the type of patients presenting in the
orthodontist office.47,48 Whereas orthodontics was pri-
marily a treatment focusing on young, growing patients,
the number of adult patients seeking orthodontic treat-
ment is gradually increasing. Several explanations can be
found for this trend. Maintenance in the widest sense has
become important. Keeping young is a trend penetrating
the Western world today and maintaining teeth and a
pleasant smile is just one aspect of body language
expressing that the individual is taking care of her or
himself. The availability of adult orthodontics and the
increased level of information within the adult population
regarding treatment possibilities are certainly also con-
tributing. A large number of adult patients seek treatment
for minor imperfections and can without doubt be satisfied
with the abovementioned treatment approaches, especially
those focusing on local irregularities and minor or
moderate crowding.
However, a different category of adult patients is those
that need tooth movement as part of a larger
reconstruction, often involving insertion of dental
implants. The improved understanding of the biological
reaction related to orthodontic treatment has contrib-
uted to the development of treatment possibilities for
these patients, and the improved possibilities for post-
treatment reconstruction have probably also had an
impact (Figures 13 and 14).
Implants need bone. The orthodontic tooth movement
can generate bone and teeth can be moved ‘with’ or
‘through bone.’ The tissue reaction determining this
differentiation depends on the stress/strain distribution in

Figure 15 Patient exhibiting previous loss of all upper molars in the right side leaving no alveolar process behind. A lingual appliance
was used to generate a distal translation of the second premolar thereby building up sufficient alveolar process for a later insertion of an
implant or a bridge. Reproduced with permission from Dr Musilli Marino
 142 Melsen Invitation to Submit
the periodontium surrounding the loaded teeth. The
classical pressure–tension theory has to be abandoned.
Histological animal studies and finite element studies of
human autopsy material, as well as micro-CT imaging of
the periodontium, indicate that the direct resorption
described by Reitan49,50 was comparable to remodelling as
defined by Frost,51 and that the indirect resorption could be
perceived as a repair and removal of necrotic bone resulting
from the local ischaemia generated during loading.52–56
The displacement of teeth into edentulous areas or
outside the initially given envelope without loss of
attachment has demonstrated that teeth can be dis-
placed ‘with bone’ if the stress/strain distribution can be
controlled (Figure 15).
The shift of focus from hard to soft tissue profile
(‘face-driven orthodontics’) over the past decades has
opened the eyes of the orthodontist to the possibility of
reducing an increased overjet by labial displacements
of lower incisors, instead of the traditional retraction of
the upper incisors. When comparing attachment levels
before and after anterior displacement of lower incisors
ranging between 3.8 and 8.0 mm, it was found that the
displacement per se did not result in development of
dehiscence57 and a follow-up 13–19 years after treat-
ment confirmed that the deterioration was not exceed-
ing that of the age-related changes reported in the
literature.58–60
Conclusions
Developments within the world of orthodontics has led
to a separation between ‘appliance-driven’, ‘fast-food’
orthodontics, where the results are to a large extent
dependent upon both growth and function and ‘ortho-
dontist-driven’, ‘slow-food’ treatments attempting to
push the limits of the possible in relation to complicated
problems and reversal of degeneration in adult patients.
Whereas the first type of treatments tend to follow a
prescription, the latter treatments are performed with
individualized appliances adapting both force system
and magnitude to the patient.
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