American Journal of ORTHODONTICS

and DENTOFACIAL ORTHOPEDICS

Founded in 1915 Volume 113 Number 3 March 1998

Copyright © 1998 by the American Association of Orthodontists

ORIGINAL ARTICLE

Perioral forces and dental changes resulting from

mandibular lip bumper treatment

Scot O’Donnell, DDS,a Ram S. Nanda, DDS, MS, PhD,b and Joydeep Ghosh, BDS, MSc
Oklahoma City, Okla.

This prospective study compares pretreatment and posttreatment forces produced by a lip bumper
on the mandibular first molars and determines the dental effects of this appliance after 1 year of
treatment. Twenty-five patients, ages 10 to 17 years, received fixed 0.045-inch passive stainless
steel lip bumpers positioned at the level of the gingival margin, 2 mm from the labial surface of the
teeth as the only form of treatment in the mandibular arch. At the end of 1 year, cephalometric
radiographs and dental casts were taken, and lower lip forces remeasured during rest, speech, and
swallowing. Lip force measurements were performed using specially designed strain gauges
mounted bilaterally in the lip bumper tubes. Measurements of lip forces made before and after
treatment were compared to explore the changes, if any, due to muscle adaptation to the
appliance. Dental changes were measured from casts and cephalometric radiographs. Correlation
analyses were performed to determine whether a relationship existed between initial force levels
and resulting tooth movement. Pretreatment and posttreatment forces did not demonstrate a
statistically significant difference. On the other hand, measurement of the dental casts revealed a
significant increase in arch length caused by incisor proclination and protrusion, combined with
molar distalization. The arch width significantly increased at the canines, first and second
premolars, and first molars. The amount of force exerted by the lower lip on the molars was not
correlated to the degree of tooth movement recorded in this sample. (Am J Orthod Dentofacial
Orthop 1998;113:247-55.)

Over the last two decades, there has been

an increase in nonextraction treatment and the 1-3
popularity of two phase treatment is on the rise.4 In
this context, mandibular lip bumpers may be used as
a means of maintaining and gaining arch length,5-11
width,5-8,11-14 and perimeter.6,7,11,15
Tooth movement resulting from mandibular lip
bumper therapy has been quantified.5-8,11,16,17 Most
of these investigations have been retrospective6-8
and lack the control of a prospective study. Various
treatment lengths,5-8 records from multiple practi-
From the Department of Orthodontics, University of Oklahoma.
a
Graduate student.
b
Professor and Chairman.
c
Formerly Assistant professor.
Reprint requests to: Dr. Ram S. Nanda, Department of Orthodontics,
University of Oklahoma, PO Box 26901, 1001 S.L. Young Blvd., Oklahoma
City, OK 73190.
Copyright © 1998 by the American Association of Orthodontists.
0889-5406/98/$5.00 1 0 8/1/82229
tioners,7,8 small sample sizes,11,16,17 and patient ad-
herence issues make comparisons difficult. Patient
age,5,7,8 gender,5,7,8 eruption status of the second
molars,5,7,18 and treatment length6,7 have been inves-
tigated as possible causes for large variations of
individual response reported in clinical studies that
used this appliance. However, none of these factors
have shown any correlation to resultant tooth move-
ment.
The lip bumper has been described as a func-
tional appliance by several investigators.11,15,16,19 Lip
bumpers are typically positioned 2 to 5 mm from the
facial surface of the teeth, thereby altering the
equilibrium between the lips, cheeks, and tongue,
causing anterior and transverse movement of the
teeth with a resultant increase in arch circumfer-
ence. Lip forces are transmitted through this appli-
ance onto the molars maintaining their position or
causing distalization.
247
248 O’Donnell, Nanda, and Ghosh
It can be postulated that lip force may be the key
to determine which patients will exhibit the greatest
molar distalization with the lip bumper appliance. A
recent study by Soo and Moore16 measured lower lip
forces during treatment with mandibular lip
bumpers over an 8-month period. Several monthly
measurements were made, but their reports were
confined to comparison of lip pressure measure-
ments at pretreatment, 1-month, and 8-month
records. The lip bumper was adjusted so that the
shield was 4 to 5 mm anterior to the lower incisors
and approximated the depth of the vestibule. Lip
pressure was measured by means of pressure trans-
ducers mounted in an acrylic stent. The transducers,
however, did not project more than 2 mm from the
labial surface of the gingiva and were positioned at
the height of the interdental papilla in two locations,
the midline and the mandibular left canine. They
found a decrease in lip pressure after 8 months of
treatment and attributed this to adaptation of the
muscular response.
There is a large range of perioral pressures when
measured on the acrylic shield of the lip bumper.
However, this does not always translate into forces
exerted on the molars, because the lip and cheeks
exert pressures in varying directions on the lip
bumper and a part of the force may be absorbed by
the lip bumper itself. Therefore measuring the
forces at the molars may be a better indicator of the
effectiveness of the appliance. This is a prospective
study performed with the following objectives: (1) to
evaluate tooth movement after 1 year of lip bumper
treatment, (2) to record posttreatment forces ap-
plied by the lip bumper to the mandibular perma-
nent first molars and compare with pretreatment
measurements, and (3) to determine the relation-
ship between lip forces and tooth movement.
MATERIAL AND METHODS
The sample consisted of 25 patients (15 girls and 10
boys) with a mean age of 13 years, 1 month and a range
from 10 years, 6 months to 17 years, 4 months. These
patients were selected from the 38 who participated in an
earlier study on the forces produced by lip bumpers on
mandibular molars.20 The 25 patients were indicated for
lip bumper therapy with the criteria being a mild to
moderate arch length deficiency and a nonextraction
orthodontic treatment plan in the mandibular arch. All
patients received 12 months of lip bumper treatment with
no other appliances in the mandibular arch while regular
orthodontic treatment proceeded in the maxillary arch.
Treatment Phase
The lip bumpers were prefabricated and made of
0.045-inch stainless steel with adjustment loops mesial to
the mandibular first molars (American Orthodontics).
The appliances were positioned 2 mm anterior to the
American Journal of Orthodontics and Dentofacial Orthopedics
March 1998
mandibular incisors at the gingival margin and inserted
passively into the molar tubes. To reduce the need for
patient compliance, all lip bumpers were secured to the
first molar bands with an elastic or wire ligature. The lip
bumpers were advanced as needed during routine ortho-
dontic appointments (every 3 to 4 weeks) to maintain the
initial position. At the initiation, as well as on completion
of 12 months of treatment, a mandibular alginate impres-
sion, intraoral photographs, and a lateral cephalometric
radiograph were taken. Lip force measurement was sched-
uled on the same day that lip bumper treatment was
discontinued.
Force Measurement
The apparatus and technique used for force measure-
ment were described by Hodge.20 Molar force devices
(MFD), specially designed strain gauges, were placed into
the lip bumper tubes on the mandibular first molars. A
custom lip bumper was fabricated from 0.040-inch stain-
less steel wire, using the posttreatment cast as a guide.
This lip bumper was made to fit passively within the
conical receptacles of the gauges. Force measurements
were made with the lip bumper placed at the 2G position
(2 mm anterior to the incisors and 4 mm gingival to the
middle of the clinical crown). This approximated the
position at which the lip bumper was maintained during
treatment. A wire framework constructed from 0.017 3
0.022-inch stainless steel wire was embedded in a vacuum-
formed stent that fit over the mandibular incisors and was
used as a guide for accurate placement of the lip bumper
at the 2G position.
Measurements were taken with the patient seated up-
right in a firm chair with the head unsupported in a natural
position. Force measurements were recorded five times at
rest with the lips lightly touching, during speech (“phone,”
“church,” and “pop”), and swallowing 5 ml of water. The
signal received from the MFD was amplified and converted
from analog data to digital data (DaqBook/100, IO Tech,
Inc.). The digital voltage data were converted to gram
measurements with customized software that used a Gate-
way 2000 486 DX 66MHz microprocessor and CrystalScan
FS color monitor. Before testing each subject and perform-
ing a linear regression analysis, each MFD was calibrated
with gram weights of 0, 10, 50, 100, and 200.
Cephalometric Information
Landmarks from lateral cephalometric radiographs
were digitized on a Numonics Accugrid Digitizer (Model
3030BL, Numonics Corporation) with a software program
(Dentofacial Planner and Tools software version 5.32,
Dentofacial Software Inc.). Skeletal, dental, and soft
tissue measurements were made by using these land-
marks. Twenty-five cephalometric radiographs were ran-
domly selected, retraced by the same examiner, and
redigitized. It was found that no measurements were
significantly different at p , 0.05.
American Journal of Orthodontics and Dentofacial Orthopedics O’Donnell, Nanda, and Ghosh 249
Volume 113, No. 3

Table I. Means, standard deviations and differences between pre- and posttreatment forces in grams during the various functions

Function Side Pretreatment Posttreatment Difference p value

Rest Left 14.37 6 7.09 12.24 6 7.06 22.13 0.3206

Right 12.39 6 6.92 13.18 6 8.37 0.79 0.7325
“Church” Left 15.30 6 8.70 16.37 6 8.09 1.06 0.4282
Right 13.23 6 8.74 17.08 6 9.26 3.86 0.0446
“Pop” Left 20.93 6 10.42 20.68 6 10.56 20.25 0.9334
Right 18.62 6 10.25 21.19 6 9.25 2.57 0.3631
“Phone” Left 24.20 6 11.22 25.96 6 8.50 1.76 0.4721
Right 22.45 6 11.98 26.01 6 7.11 3.56 0.1323
Swallow Left 36.32 6 14.63 32.98 6 12.85 23.35 0.9627
Right 33.76 6 15.65 33.94 6 13.82 0.18 0.8301

The p values reflect the statistical significance of the differences between the two measurements.

Dental Cast Measurement statistical significance for either pretreatment or

The points on pretreatment and posttreatment man-
dibular casts to be measured were marked with a sharp
lead pencil to facilitate identification. Measurements for
arch width, length, perimeter, and incisor irregularity were
made with an electronic caliper (Mitutoyo Model no.
500-351), accurate to 0.01 mm. Arch widths were mea-
sured between the cusp tips of the canines and occlusal
landmarks for the premolars and molars. Arch length was
measured as the shortest distance between the mesial
contact points of the central incisors to a line connecting
the mesial contact points of the permanent first molars.
Arch perimeter was measured as the sum of the distances
measured on both sides of the arch from the mesial
contact point of the permanent first molar to the distal of
the lateral incisor, then from the distal of the lateral
incisor to the mesial contact point of the central incisors.
Error of measurement from the dental casts was similarly
assessed and revealed no statistically significant difference
in any of the measurements at p , 0.05.
Pretreatment and posttreatment forces were com-
pared with repeated measures analyses of variance. All
dental and skeletal changes were evaluated with paired t
tests, whereas Pearson’s correlation analysis was used to
evaluate the relationship between tooth movement, force,
and patient age.
RESULTS
Comparison of Pretreatment and Posttreatment
Forces
Pretreatment and posttreatment forces on the
lip bumper measured at the mandibular permanent
first molars during various functions are presented
in Table I. Resting forces before treatment were
14.37 6 7.09 gm on the left side and 12.39 6 6.92 gm
on the right. Resting forces after treatment were
12.24 6 7.06 gm on the left and 13.18 6 8.37 gm on
the right. The difference between pretreatment and
posttreatment forces was not statistically significant.
Lip force measurements were higher during speech
and swallowing movements.
Right and left force values did not demonstrate
posttreatment forces. The right and left values were
averaged for each function and are presented in
Fig. 1. The combined force value for all functions,
i.e., rest, speech, and swallowing measured 21.16 6
13.07 gm before treatment and 21.96 6 11.83 gm
after 1 year of treatment.
There was a significant difference between the
forces for various functions (p , 0.05) at both time
intervals, with the exception of the pretreatment
forces when speaking the word “church” and the
pretreatment resting force.
Tooth Movement
The means, standard deviations, and range of
changes in mandibular dental cast measurements
are given in Table II and Fig. 2. Mean increases in
arch length and perimeter were found to be 1.25 and
4.18 mm, respectively (p , 0.001). Intercanine
width, measured from the cusp tips, increased an
average of 1.65 mm (p , 0.001). Arch width also
increased at the first premolars 2.46 mm and at the
second premolars 2.27 mm, both of which were
statistically significant at p , 0.001. Intermolar
width measured at the first molars showed a statis-
tically significant increase of 1.21 mm (p , 0.05), but
an increase of 0.39 mm at the second molars was not
statistically significant. Incisor irregularity was sig-
nificantly reduced (p , 0.001) by the amount of 1.38
mm.
The mean changes in dental cephalometric mea-
surements are shown in Table III and illustrated in
Fig. 3. In 22 patients (88%), the mandibular incisors
tipped anteriorly with the maximum increase being
14.10°. The mean increase for all patients was
4.38° and was highly significant p , 0.001. The
mandibular incisors protruded an average of 0.90
mm that was significant at p , 0.001. Nineteen
patients (76%) demonstrated anterior movement of
the incisors and only six (22%) either showed no
250 O’Donnell, Nanda, and Ghosh American Journal of Orthodontics and Dentofacial Orthopedics
March 1998

Fig. 1. Pretreatment and posttreatment forces produced by mandibular lip bumpers on

mandibular permanent first molars for various functions tested. Solid color represents
pretreatment values and diagonal lines reflect posttreatment values.

Table II. Dental cast changes after 1 year of lip bumper treatment

Mean
change Minimum Maximum
Measurement N (mm) SD (mm) (mm) p value

Arch length 25 1.25 1.01 20.10 4.20 0.0001

Arch width
3-3 21 1.65 1.30 20.04 6.03 0.0001
4-4 23 2.46 1.19 0.44 5.06 0.0001
5-5 19 2.27 1.19 20.66 4.33 0.0001
6-6 25 1.21 2.81 24.24 7.52 0.0411
7-7 15 0.39 1.09 22.37 1.83 0.1858
Arch perimeter 25 4.18 2.12 0.99 9.87 0.0001
Incisor irregularity 21 21.38 1.38 23.49 1.15 0.0001

movement or moved posteriorly, with the maximum
retrusion of 0.7 mm.
The first molars moved distally in 72% of the
sample (18 patients). The mean distal movement for
all patients, as measured from the mandibular sym-
physis, was 0.95 mm, which was significant at p ,
0.01. Of the sample, 20 patients (81%) exhibited
distal tipping of the first molars as measured to the
mandibular plane. The mean amount of distal tip-
ping at the first molar was 4.73° and 5.64° at the
second molar, both of which were highly significant
at p , 0.001.
To study the effect of the second molars on
molar distalization, the sample was divided based on
the presence of both right and left second molars
erupted at the initiation of treatment. There were 17
patients in this category and the remaining 8 pa-
tients had either one or no second molars clinically
present. There was no statistically significant differ-
ence found in linear or angular molar distalization
American Journal of Orthodontics and Dentofacial Orthopedics O’Donnell, Nanda, and Ghosh 251
Volume 113, No. 3

Fig. 2. Mean changes in mandibular arch widths and length after 1 year lip bumper treat-
ment.

between the two groups. Further, no significant

correlation was found between either molar distal-
ization or incisor movement and patient age.
To investigate the relationship between various
cephalometric factors and molar distalization, the
sample was divided into three groups. The groups
were defined as follows: Group one patients (n 5 6)
had mesial molar movement, group two patients
(n 5 12) exhibited distal molar movement of 0 to 2
mm, and group three patients (n 5 7) showed distal
molar movement greater than 2 mm. There were no
statistically significant relationships between molar
movement and any of the following: lip thickness or
height, mandibular plane angle, age, overbite, or
overjet.
A similar test was conducted to identify factors
with significant relationships to incisor movement.
Patients were placed into three groups based on the
amount of incisor movement. Group one (n 5 3)
demonstrated retrusion of the mandibular incisors,
group two (n 5 20) showed proclination of the
mandibular incisors of 0° to 7.5°, and group three
(n 5 2) exhibited proclination exceeding 7.5°. No
cephalometric variable was found to be correlated
to incisor movement.
Relationship Between Tooth Movement and Force
Levels
To determine whether an association existed
between the amount of tooth movement after 1 year
of mandibular lip bumper treatment and the level of
force recorded at the mandibular permanent first
molars, Pearson’s correlation analysis was per-
formed. The degree of molar distalization, molar
tipping, arch length, and arch perimeter were eval-
uated with regard to right and left resting forces. No
significant relationship was found to exist between
tooth movement and resting force readings.
Fig. 3. Mean differences in cephalometric dental mea-
surements after 1 year of lip bumper treatment.
The sample of 25 patients was divided into three
groups based on their left and right combined force
levels (all functions combined). Group one (n 5 11)
contained all patients with a recorded force of 0 to
21 gm, group two (n 5 11) consisted of patients with
forces of 21 to 30 gm, and group three (n 5 3) had
forces greater than 30 gm. There was no statistically
significant difference found in molar distalization or
molar tipping between the groups.
DISCUSSION
Pretreatment and Posttreatment Forces
Pretreatment and posttreatment force levels
produced a consistent trend for the functions tested.
Rest had the lowest force level, followed by
“church,” “pop,” “phone,” and swallow. This would
reflect the increased muscular activity of the lip
during speech and deglutition. A large individual
variation in forces was evident in this study at both
pretreatment and posttreatment periods. This vari-
ation appears to be a common finding in studies that
have measured muscle activity and forces.16,21-24
252 O’Donnell, Nanda, and Ghosh
Table III. Changes in dental cephalometric measurements after 1 year of lip bumper treatment
Measurement Mean change
IMPA 4.38°**
L1 to NB 4.37°**
L1 to NB 0.90 mm*
1st molar angle 4.73°**
2nd molar angle 5.64°**
1st molar distance 0.95 mm*
Arch length to 1st molar 1.76 mm**
Arch length to 2nd molar 2.08 mm**
**p , 0.001, *p , 0.01.
There was no statistically significant difference
between pretreatment and posttreatment forces for
any function. This was a surprising finding, consid-
ering that the lip bumper was tied in place for 1 year
at one position and that past studies16,21 have indi-
cated that muscles adapt to changes in the local
environment. McNulty et al.21 examined the adapt-
ability of the upper lip to changes in incisor position
in five adults. An increase in forces was found after
inserting the appliance, but after 1 week of reten-
tion, the force approximated baseline levels. The
authors hypothesized that the muscles adapted to
the appliance but admitted that large intersubject
and intrasubject variation and small sample size
made interpretation of the data difficult.
Soo and Moore16 investigated muscle adaptation
in response to lip bumper treatment. Lip pressure at
the midline increased at 1 month and then de-
creased below baseline for both rest and speech at 8
months. The authors suggested that an adaptive
response to the new lip position had occurred.
However, the left side lip pressures during speech
did not demonstrate a significant change with time.
The conflicting results between midline and left side
forces could not be explained by the investigators.
Further, they did not measure the forces at the exact
position in which the lip bumper was maintained
during treatment. Thus the method, small sample
size (n 5 10), and inconsistent results cloud their
conclusions.
Muscle adaptation was not a finding of the
current study and may have clinical implications.
Repositioning of the appliance throughout treat-
ment may not be necessary to account for muscle
adaptation, however, adjustments will be required
to avoid incisor contact with the lip bumper as
arch length increases. Given that the appliance
was placed only 2 mm anterior to the incisors,
perhaps the biologic threshold for muscle adapta-
tion was not surpassed. One could also argue that
periodic adjustments of the bumper would main-
American Journal of Orthodontics and Dentofacial Orthopedics
March 1998
SD Minimum Maximum
4.18 24.30° 14.10°
4.43 25.90° 14.10°
1.08 20.70 mm 3.20 mm
4.97 22.30° 17.80°
5.53 23.20° 20.20°
1.63 22.50 mm 3.80 mm
1.52 21.20 mm 5.70 mm
1.23 20.30 mm 5.10 mm
tain the same level of force even if there were
muscular adaptations. Future studies should in-
vestigate muscular response to greater anterior
placement of the lip bumper, with and without
periodic adjustments.
No statistically significant differences in lip
forces were found between male and female sub-
jects. This is in agreement with previous studies that
examined perioral forces.20,22,25
No statistically significant difference in force
values between right and left sides was observed in
this study. Symmetry of perioral forces was reported
earlier by Lear and Moorrees.26
Tooth Movement
The current study used a wire lip bumper placed
in a passive state at identical positions in all 25
patients for a 1-year period and was secured to the
molar bands thereby eliminating issues of patient
adherence. In addition, the sample size (n 5 25) was
sufficient for statistical evaluation. The most signif-
icant changes in the mandibular arch with lip
bumper treatment include incisor proclination and
protrusion, molar distal tipping, increase in arch
widths at the premolars and the canine, and de-
crease in incisor irregularity. Collectively, these fac-
tors caused an increase in arch length and perime-
ter.
Labial movement of the mandibular incisors has
been cited in the literature.5-8,11,16 The lip bumper
serves to break the zone of muscular equilibrium
that allows tongue pressure to procline the incisors.
Our finding of mean proclination at 4.37° was
slightly higher than that reported by other
studies.5-8,16 This is surprising, because it has been
suggested that there is less incisor movement when
the lip bumper is positioned at a gingival level.12,13
At this position, the lower lip may curl over the
appliance and contact the mandibular incisors
thereby preventing their anterior movement. A pos-
sible reason for greater incisor proclination in the
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 113, No. 3
Fig. 4. Occlusal photographs of mandibular arch before and after lip bumper treatment.
current study may be related to the fixed nature of
the appliance.
The mean linear distal movement of the man-
dibular first molars (0.95 mm) was greater than that
reported by others with wire lip bumpers.5,7 A
significant portion of the distal movement in this
investigation was due to distal crown tipping (4.73°)
as found by others.6,18
When compared with studies that used shield lip
bumpers, the amount of molar distalization in this
study was slightly less. Mayfield18 reported 1.8 mm
of molar distalization when using a shield appliance,
and Nevant et al.8 found 1.51 mm of distal move-
ment. On the other hand, mesial molar movement
with wire lip bumper therapy was reported by
Nevant et al.8 and Werner et al.,6 0.02 and 0.55 mm,
respectively. In these studies, most of the patients
had second deciduous molars present and their loss
with ensuing leeway space, along with possible pa-
tient nonadherence, could have accounted for the
mesial movement. For clinicians intending to use lip
bumpers for molar distalization, it appears that
shield lip bumpers are most effective. However, oral
hygiene procedures are more difficult with the shield
in place, and if a wire bumper is to be used, then
securing it to the molar bands may yield results that
closely approximate those achieved with a shield.
The amount of distal tipping at the second molar
as an indirect effect of therapy has not been re-
ported. A slightly greater distal tipping at the second
molars when compared with the first molars was
demonstrated in this study. This may be explained
by the natural eruption process of the mandibular
permanent second molars. Before eruption, the
crowns of the permanent mandibular second molars
are directed mesially, but gradually begin to rotate
in a distal direction as the resorption of the anterior
border of the ramus creates room and the tooth
erupts.27 In addition, the eruption status of perma-
O’Donnell, Nanda, and Ghosh 253
nent second molars did not influence the amount of
first molar movement and is in agreement with the
findings of others.5,7,18
The mean arch width changes reported in this
investigation are consistent with the results of other
studies. The increase in intercanine width of 1.65
mm is within the range (1.3 to 1.99 mm) of reported
increases for wire lip bumpers.5-8 Similarly, the
mean width increases at the first premolar (2.46
mm) and second premolar (2.27 mm) support the
findings of Osborn et al.7 who found 2.50 mm and
2.43 mm of expansion at the first and second pre-
molars, respectively, Nevant et al.8 who reported a
2.09 mm increase in transverse width at the first
premolars, and Grossen and Ingervall6 who mea-
sured the expansion to be 2.1 mm at the first
premolar and 2.2 mm at the second premolar. In this
research project, a mean of 1.21 mm of expansion
was found at the first molars, despite the fact that all
lip bumpers were maintained in a nonexpanded
state throughout treatment. However, the influence
of the buccal musculature may have been eliminated
by the adjustment loops that allowed buccal crown
tipping of the molar from the lateral pressures of the
tongue. Other investigators also report first molar
expansion.5-8 The 0.39 mm increase in second molar
arch width in this study was not statistically signifi-
cant and is of minor clinical importance.
The magnitude of dental changes was highly
variable between subjects. As reported previously,
patient age and eruption status of the second molars
were not correlated with tooth movement.5,7,8 Molar
distalization was not related to upper or lower lip
thickness or length, overbite, overjet, or the man-
dibular plane angle. Similarly, the degree of incisor
proclination was not correlated with lip thickness or
length, overbite, overjet, amount of pretreatment
crowding, or initial incisor to mandibular plane
angle. Clinically, the best results were achieved in
254 O’Donnell, Nanda, and Ghosh
patients in the transitional dentition. Three patients
(12%) in our sample had both deciduous second
molars present at the initiation of treatment. These
cases demonstrated the most dramatic results. The
occlusal views of one of these patients is shown in
Fig. 4. However, arch perimeter increases were not
greater than the mean for the entire sample. The lip
bumper was not more effective in gaining space in
these cases, but maintained leeway space thus max-
imizing space for the permanent dentition. There-
fore the ideal patient for lip bumper therapy is in the
mid to late transitional dentition.
There was no correlation between the amount of
molar movement and the initial force measured at
the mandibular first molars. This finding is sup-
ported by Mayfield.18 There was also no correlation
between force measurements and incisor, as well as
canine and premolar movements. It must be remem-
bered that force level is only one of many variables
that affect tooth movement.
There is a high variation among persons in the
threshold force level required to initiate movement.
A variety of factors, such as root shape and form,
bone density, health of the investing tissues, occlu-
sion, and a host of cellular and biochemical pro-
cesses play a role in this phenomenon.
Molar distalization and tipping are not the
main effects of lip bumper treatment. The labial
movement of the mandibular incisors combined
with increases in arch width account for the
majority of space gained by the use of lip
bumpers. Removal of the constraint of buccal
musculature in conjunction with the expansive
forces of the tongue appear to be the cause of
most dental changes. If placed far enough buccally
from the teeth, the lip bumper may also stretch
the mucoperiosteal attachments of the buccal
musculature and cause expansion—a Frankel
shield effect. Perhaps forces produced by the
tongue on the lingual surface of the mandibular
teeth would be more highly correlated with tooth
movement and a better indicator of tooth move-
ment. Bergersen17 offered tongue pressure as an
explanation for the amount and frequency of
incisor proclination during lip bumper treatment.
Osborn et at.7 also attributed the increase in arch
width and perimeter to tongue pressure. The
findings of other investigators have also suggested
that tongue pressures are greater than forces
produced by the buccal musculature.26-35
CONCLUSIONS
The following conclusions were made:
American Journal of Orthodontics and Dentofacial Orthopedics
March 1998
1. There was no statistical difference between pre-
treatment and posttreatment forces measured at
the mandibular permanent first molars with a lip
bumper. Muscular adaptation to the appliance did
not occur.
2. The main dental effects included incisor proclina-
tion and protrusion, molar distalization and tip-
ping, increases in arch widths, length, perimeter,
and a decrease in anterior crowding.
3. There was no correlation between initial lip force
and tooth movement.
4. Dental changes may be greater when the lip
bumper is not removable by the patient.
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