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Seminars in Orthodontics
EDITOR
P. Lionel Sadowsky, DMD, BDS, DipOrth, MDent
Professor and Chairman
Department of Orthodontics
University of Alabama
1919 Seventh Avenue South
Birmingham, AL 35294
Seminars in Orthodontics (ISSN 1073-8746) is Copyright © 1995 by W.B. Saunders Company.

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A Division of Harcourt Brace & Company
EDITOR
P. Lionel Sadowsky, DMD, BBS, DipOrth, MDent
EDITORIAL BOARD
Richard G. Alexander, Arlington, TX Robert N. Moore, Morgantown, WV
Rolf G. Behrents, Memphis, TN Ravindra Nanda, Farmington, CT
Samir E. Bishara, Iowa City, IA Perry M. Opin, Milford, CT
Larry M. Bramble, Cypress, CA Sheldon Peck, Newton, MA
John S. Casko, Iowa City, IA William R. Proffit, Chapel Hill, NC
Harry L. Dougherty, Van Nuys, CA Cyril Sadowsky, Chicago, IL
T.M. Graber, Evanston, IL David M. Sarver, Birmingham, AL
Robert J. Isaacson, Richmond, VA William J. Thompson, Bradenton, FL
Alexander Jacobson, Birmingham, AL James L. Vaden, Cookeville, TN
Lysle E. Johnston, Jr., Ann Arbor, MI Robert L. Vanarsdall, Jr., Philadelphia, PA
Gregory J. King, Gainesville, FL Katherine Vig, Columbus, OH
Vincent G. Kokich, Tacoma, WA
INTERNATIONAL
Zeev Abraham, Herzliya, Israel C.B. Preston, Johannesburg, South Africa
Roberto Justus, Mexico City, Mexico Bjorn U. Zachrisson, Oslo, Norway
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VOL 1, NO 1 MARCH 1995
Biomechanics and Appliance Design

Robert J. Isaacson, DDS, MSB, PhD
Guest Editor
CONTENTS
Introduction
P. Lionel Sadowsky
Preface
Robert J. Isaacson
The Ground Rules for Arch Wire Design 3

Robert J. Isaacson, Steven J. Lindauer, and Moshe Davidovitch
One-Couple Orthodontic Appliance Systems 12

Steven J. Lindauer and Robert J. Isaacson
Two-Couple Orthodontic Appliance Systems: Utility Arches 25

Moshe Davidovitch and Joe Rebellato
Two-Couple Orthodontic Appliance Systems: Torquing Arches 31

Robert J. Isaacson and Joe Rebellato
Two-Couple Orthodontic Appliance Systems: Activation in the

Transverse Dimension 37
Joe Rebellato
Two-Couple Orthodontic Appliance Systems: Transpalatal Arches 44

Joe Rebellato
Creative Arch Wires and Clinical Conclusion 55

Robert J. Isaacson
Responses of 3-Dimensional Wires to Vertical V-Bends: Comparisons with

Existing 2-Dimensional Data in the Lateral View 57
Robert J. Isaacson, Steven J. Lindauer, and Paul Conley
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will publish
Volume 1, Number 2, June 1995

RELEVANCE OF FACIAL ESTHETICS
TO ORTHODONTICS
Sheldon Peck, DDS, MScD
Volume 1, Number 3, September 1995

EARLY ORTHODONTIC TREATMENT
Gregory J. King, DMD, DMSc
Volume 1, Number 4, December 1995

TEMPOROMANDIBULAR JOINT
DYSFUNCTION
Daniel M. Laskin, DDS, MS
Volume 2, Number 1, March 1996

ORTHODONTICS/PERIODONTICS
Bjorn U. Zachrisson, DDS
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VOL 1, NO 1 MARCH 1995
Introduction
The evolution of orthodontics is proceeding of Seminars in Orthodontics will be the equivalent
at an accelerated rate. We are now able to of a mini-symposium on the topic. Efforts will
offer our patients treatment possibilities and be made to separate scientifically based infor-
outcomes that were not available in the recent mation from anecdotal opinion.
past. We are also in an era of rapidly increasing Topics already scheduled for publication in
new scientific data. The rate of technological Seminars in Orthodontics include "Biomechanics
advancement and sophistication is unprece- and Appliance Design," guest editor Robert J.
dented. Equipment and materials that are Isaacson; "The Relevance of Facial Esthetics to
available for our use are also undergoing Orthodontics," guest editor Sheldon Peck;
change and improvement. "Early Treatment of Malocclusion," guest edi-
All of these developments impact directly tor Gregory J. King; "Temporomandibular
on the clinical orthodontist as diagnostic pro- Joint Dysfunction," guest editor Daniel M.
cedures, treatment modalities, and expected Laskin; and "Orthodontics/Periodontics,"
outcomes are evolving and improving. The ex- guest editor Bjorn U. Zachrisson. Each journal
pectations of our patients are also greater. The issue will contain articles written by knowl-
rate at which new information is becoming edgeable contributing authors.
available and the resultant changes in patient We are very pleased with this innovative ad-
management that follow place an increasing dition to the orthodontic literature and also
burden on the clinical orthodontist who is at- with the enthusiastic acceptance of the many
tempting to keep abreast of all of these inno- recognized experts who have agreed to serve
vations. A noted academician, teacher, and cli- on our Editorial Board. Their expertise will
nician recently stated, "Information is the coin guarantee the ongoing excellence of Seminars
of the realm." in Orthodontics. We believe that Seminars in Orth-
The goal of Seminars in Orthodontics will be to odontics will enhance the readers' information
synthesize and correlate new information into database and provide in a user friendly format
an easily readable and digestible format. Semi- essential information for the clinical orthodon-
nars in Orthodontics, which will be published tist, the academician, and the student of orth-
quarterly, will focus on one topic in each issue. odontics.
Knowledgeable authors will contribute articles
containing current pertinent information on
the selected topic. In this manner a single topic P. Lionel Sadowsky, DMD, BDS,
will be addressed in-depth from various au- DipOrth, MDent
thors' perspectives in a single issue. Each issue Editor
Seminars in Orthodontics, Vol 1, No 1 (March), 1995: p 1

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Preface
Welcome to Seminars in Orthodontics. Our orthodontic treatment. It is not easy, it does
Editor, Lionel Sadowsky, has committedrequire work, but the rewards are wonderful.
each issue of this journal to a focused look at In today's information age, it is not enough to
the state-of-the-art in a selected area of orth- know how to make the bends. Nor is it enough
odontic interest. Based on a universal interest to expect them to be built into the appliance by
in orthodontic appliances, this entire inaugural the manufacturer. The subtleties of today's
issue is devoted to the application of physical preprogrammed appliances demand an aware-
science principles to arch wire mechanics. This ness of the relative magnitudes and directions
information can improve most clinicians' orth- of all of the forces, couples, and moments in-
odontic outcomes and greatly increase your evitably created by the arch wires you insert.
satisfaction in patient care. With this concept in use, clinical orthodon-
Orthodontics has long been interested in tics acquires a new level of pleasure and satis-
arch wires to create forces. The literature is faction. What used to be idiopathic unwanted
replete with studies of heavy forces, light tooth movements during treatment are recog-
forces, intermittent forces, differential forces, nized as reciprocals and force systems to be
etc. However, these are all statements about anticipated and managed before they mani-
the biological responses to single forces. The fest. Rote clinical techniques need not be fol-
force systems that create the mechanics in lowed as some sort of art form. Maximally ef-
biomechanics should properly be based on the fective force systems can be created readily to
well-developed and mature physical science of achieve predictable goals that were formerly
mechanics. With only a small number of nota- difficult to accomplish, required unpredictable
ble exceptions, however, orthodontics has patient cooperation or were unreachable.
commonly neglected or ignored this area. The focus here is on only one specific aspect
Orthodontists generally seem to be comfort- of orthodontic arch wires, the application of
able using isolated forces. However, the time-honored physical science principles to
unique capabilities of the edgewise appliance arch wire design. This issue shows the physical
reside in its abilities to create couples in three science principles providing the theoretical ba-
dimensions and the concept of a couple is in- sis for the arch wire designs proposed. This
frequently addressed in the analysis of orth- issue will also show applications of these same
odontic techniques. Moreover, the reciprocal arch wire designs documented by empirical ev-
of a couple, or its equilibrium, is rarely men- idence of their clinical use. Arrows are shown
tioned, not intuitive and certainly not com- to represent both the desired as well as the
monly understood. One major goal of this is- undesired forces that are unavoidably present.
sue is to make apparent the application of cou- Because every arch wire design must have
ples and their equilibriums to orthodontic its basis in Newtonian physics, analysis and un-
appliances. derstanding of these fundamentals will permit
As your guest editor, I can identify with this. comparison of all existing and proposed arch
For most of my professional career I was also wires using the same criterion standard. The
ignorant in this area. I had taught clinically goal is to elevate the standard of care so that all
oriented orthodontics for decades, put in the arch wire designs are analyzed following the
same arch wire bends as most people, and had teachings of the only totally correct guru—the
the same limitations and problems as most peo- physical science principles manifested in the
ple. mechanics of physics and engineering statics.
The discovery of how to use couples, mo-
ments, and equilibriums in arch wires changed Acknowledgment
my orthodontic world. There is no one more The guest editor acknowledges the computer graphics of
evangelical than a convert and I am that. If you Carol Wilkins, Wilkins Enterprises, Inc, 19900 Harris
are willing to invest the time and energy nec- Drive, Sutherland, VA 23885.
essary to understand forces, couples, mo-
ments, and their equilibriums, you will experi- Robert J. Isaacson, DDS, MSD, PhD
ence a new excitement and pleasure in clinical Guest Editor
Seminars in Orthodontics, Vol 1, No 1 (March), 1995: p 2

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The Ground Rules for Arch Wire Design

Robert J. Isaacson, Steven J. Lindauer, and Moshe Davidovitch
All force systems applied to a tooth are composed of either single forces
and/or couples. The application of a force through the center of resistance of
a tooth will result in translation of the tooth. The application of a force to act
at points other than through the center of resistance of a tooth will produce
different tendencies for rotation. Tooth rotation resulting from the applica-
tion of a force always creates a simultaneous tendency to move the center
of resistance of a tooth in the direction the force is acting. In contrast, the
location of a couple on a tooth is irrelevant to the resulting tooth movement.
A couple can never move the center of resistance, and with a couple the
center of rotation and the center of resistance will always be coincident. The
equilibrium forces, associated with a moment of a couple, also are single-
point forces and can produce different tooth movements depending on
where they are applied. All tooth movement must be either translation and/
or rotation as defined at the tooth's center of resistance.
Copyright © 1995 by W.B. Saunders Company
The principles of physical science that con- center of mass. The analogous point for an in
trol tooth movement are best adapted to vivo tooth is referred to as the center of resis-
orthodontic procedures using some basic, well- tance (CRes) (Fig 1). Any force acting through
established concepts.1-4 the tooth's center of resistance causes the tooth
to translate.
Center of Resistance Tooth Movements
Imagine a tooth as a motionless free body in When an arch wire applies a force to displace a
space. Any force directed through the tooth's tooth, the tooth can respond with only trans-
center of mass would cause the entire tooth to lation, rotation, or a combination of these two
move in the direction of the applied force. A movements. Translation requires that all
force acting through the center of mass results points on the tooth move the same amount in
in a movement where all points on the tooth the same direction. Rotation requires that no
move the same amount in the same direction. two points on the tooth move the same amount
This type of tooth movement is termed trans- in the same direction. The tendency to rotate is
lation or bodily movement in orthodontics. called a moment.
The in vivo tooth is not a free body because The generic term rotation is used with more
it is restrained from movement by its attach- specific orthodontic application: first-order ro-
ments to the supporting tissues. Therefore, the tation or rotation around a long axis of a tooth,
point at which all resistance to displacement which is referred to as rotation in orthodon-
may be thought of as concentrated is not at its tics; second-order rotation or rotation around
a faciolingual axis of a tooth, which is referred
to as tip in orthodontics; and third-order rota-
From the Department of Orthodontics, School of Dentistry,
Medical College of Virginia, Virginia Commonwealth University,
tion or rotation around a mesiodistal axis of a
Richmond, VA. tooth, which is referred to as torque in orth-
Address reprint requests to Robert J. Isaacson, DMD, MSD, odontics.
PhD, Department of Orthodontics, School of Dentistry, Medical
College of Virginia, Virginia Commonwealth University, PO Box Force Systems
980566, Richmond, VA 23298-0566.
Copyright © 1995 by W.B. Saunders Company The force systems of arch wires are analyzed in
1073-8746/95/0101 -0001 $5.00/0 terms of fundamental building blocks. These
Seminars in Orthodontics, Vol 1, No 1 (March), 1995: pp 3-11

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Isaacson, Lindauer, and Davidovitch
Figure 1. A force acting through the center of re-

sistance will cause all points on the tooth to move the
same amount in that same direction. This is termed Figure 3. Tooth rotation resulting from a force not
translation and is possible in any direction. acting through the CRes viewed as the simultaneous
process of tooth translation that moves the CRes in
building blocks are either single-point forces the direction of the force and, tooth rotation around
and/or pairs of equal and opposite noncollin- the CRe,
ear forces called couples.
The rotational tendency, or moment, pro-
The Single-Point Force duced by a force not acting through the CRes, is
expressed as the moment of the force, MF (Fig
A single-point force applied to a tooth has both 5). The magnitude of the MF is measured as
a magnitude and a direction. When a single the magnitude of the force (F) multiplied by
force is directed through the CRes, the tooth the perpendicular distance (d) between the line
feels a tendency to translate or to displace all of the force and the center of resistance (MF =
points on the tooth the same amount in the F • d). In orthodontic applications, it is conven-
same direction as the applied force (Fig 1). tional to express the units of a MF in terms of
Only forces are capable of moving the CRes of the force multiplied by a distance, eg, g • mm.5
a tooth. The use of g • mm to express moments is an
Commonly, a single-point force cannot be orthodontic convention. Grams are units of
applied to act directly through the CRes and mass and not properly used to express forces.
must be applied at the bracket. When a force Forces are properly expressed as Newtons.
does not act through the CRes of a tooth, the The conversion factors are: 1 g = .00981 N or
tooth rotates (Fig 2). This rotation can be de- 1 N - 101.937 g.
scribed two different ways. From one perspec-
tive, the CRes moves in the direction of the line A Couple
of the force, whereas the tooth simultaneously An arch wire may also send a signal to the pe-
rotates around the CRes (Fig 3). Alternately, riodontium for tooth movement via a pair of
the tooth movement resulting from these two
simultaneous events is kinematically described
by an instantaneous center of rotation which is
never at the CRes (Fig 4). Center of Rotation
Center of Resistance
Figure 4. Tooth rotation from a kinematic perspec-

tive describes rotation from time 1 to time 2 as
Figure 2. A single force applied at the bracket and movement around a center of rotation. The actual
not at the center of resistance will cause rotation of tooth movement clearly does not occur by move-
the tooth. Examples are shown of two possible force ment of points on the tooth along arcs of concentric
directions. circles around a center of rotation.
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Ground Rules
Figure 5. A tooth that receives a force not acting

through the CRes feels a moment or tendency to
rotate. The magnitude of this moment is measured
as the magnitude of the force times the perpendic-
ular distance from the line of the force to the CRes
and is expressed in force • distance units, MF =
F • d. First, second, and third-order rotations are
shown.
Figure 6. Moment of a couple resulting in first- and
equal and opposite noncollinear forces, second-order rotations. The two forces of the cou-
termed a couple. The force system of a couple ple on each bracket are located equidistant from the
is the sum of the force systems of the two equal CRes. The CRes and the center of rotation will be
coincident. Mc = F • d.
and opposite single forces that comprise the
couple.
Alone, each force of a couple would move counterclockwise rotation, the remainder is a
the CRes in the direction of the force as de- moment in a counterclockwise direction ex-
scribed for the single-point force. Because the actly as if the couple were positioned with the
two forces are equal and opposite, each force two forces equidistant from the CRes similar to
tends to move the CRes in an equal and oppo- those shown in Figure 6. Therefore, when a
site direction. Therefore, no movement of the couple is applied to a bracket, the resulting
CRes can ever result from the application of a tooth rotation is unaffected by the location of
couple to a tooth, no matter where the couple the bracket on the tooth or what torque is built
is applied on the tooth. into the bracket. The tooth can only respond to
Alone, each force of the couple also tends to a couple with rotation around its CRes.
rotate the tooth as described for the single- The rotational tendency produced by a cou-
point force. When the lines of force of each of
the two forces of the couple are located equi-
distant from the CRes both forces of the couple
tend to rotate the tooth in the same direction
around the CRes (Fig 6).
Even when the lines of force of the two
forces of the couple are not located equidistant
from the CRes, they still produce exactly the
same tendency for rotation of the tooth. In
Figure 7, a third-order couple is located at a
bracket with the line of force of each of the
forces of the couple acting at different dis-
tances from the CRes. The force nearest the
CRes produces a smaller moment or tendency
for rotation in a clockwise direction because
the force is multiplied by a smaller perpendic-
ular distance to the CRes. The force located Mr = F'd
further from the CRes produces a larger mo-
ment or tendency for rotation in an opposite
counterclockwise direction because the force is Figure 7. Moment of a couple resulting in a third-
order rotation where the two forces of the couple
multiplied by a larger perpendicular distance are not located equidistant from the CRes. No matter
to the CRes. When the moment for clockwise where the couple is located on the tooth, the CRes is
rotation is subtracted from the moment for always coincident with the center of rotation.
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pie is also referred to as a moment, the mo- site to the moment created by the associated
ment of the couple, Mc. The magnitude of the equilibrium forces at the attached ends of the
Mc is equal to the sum of the moments of the arch wire. This is equilibrium. Because the to-
two equal and opposite single forces that com- tal force system present during equilibrium is
prise the couple. Therefore, the magnitude of difficult to visualize and not intuitive, compo-
the Mc equals the magnitude of one of the nent parts can be overlooked and produce un-
forces of the couple multiplied by the distance wanted clinical tooth movements.
between the two forces of the couple (Figs 6 Equilibrium must exist for all first, second,
and 7). and third order rotations derived from a mo-
The uniqueness of the edgewise appliance ment of a couple, Mc. For example, a first-
arises from its ability to generate couples in order couple, created at a molar bracket by
three planes. No matter where a bracket is activating an arch wire as shown in Figure 8,
placed on a tooth, a couple applied at that tends to rotate the molar in a clockwise direc-
bracket can only cause the tooth to feel a tention. When the arch wire is deformed to create
dency to rotate around its center of resistance. this first-order couple at the bracket, the strain
A couple alone cannot cause the center of re- created in the wire results in an equal and op-
sistance to move in any direction and the cen- posite tendency to rotate the attached ends of
ter of rotation and the center of resistance will the wire in a counterclockwise direction,
always be coincident. F2 • d2. Equilibrium requires that the clockwise
moment of the couple at the bracket, (Fx • dj),
be equal and opposite to the counterclockwise
Equilibrium moment at the ends of the wire, (F2 • d2). Fig-
Newton's third law requires that for every ac- ure 9 shows an example of a couple creating
tion there be an equal and opposite reaction. second-order rotations at a molar bracket with
This is easy to visualize for single-point forces its associated equilibrium.
when a given wire is pressed against an iden- The equilibrium forces associated with a Mc
tical wire and both wires deform equally in op- also are single-point forces and, depending on
posite directions. When the wires are of un- where they are applied, can produce a MF. Al-
equal resistance, the weaker wire will deform though the location of the force at a bracket
more, but both wires will still be pushing with cannot be varied greatly, in a one-couple sys-
equal and opposite magnitudes of force. Equi- tem, ie, where only one end of the arch wire
librium requires that the sum of the forces act- engages a bracket to form a couple, the attach-
ing in any plane equal zero. ment of the other end of the wire is a point
Equilibrium also requires that the sum of
the moments in any plane equal zero. When an
arch wire engages a bracket to create a couple
at that bracket, the tooth feels a tendency for
rotation around its CRes. The couple at the
bracket is activated by bending or twisting the
arch wire between the bracket and the next
attachment of the arch wire. This creates strain
in the wire to either move the bracket or the
other end of the wire until the wire is again
passive.6"9
Equilibrium consists of a balance. Although
the couple created at the bracket results in a
moment in one direction, the forces at the ends Figure 8. A V-bend creating a positive first-order
of the activated arch wire represent another moment, Fx • dlf at the molar. Clockwise rotations
are positive by convention. Equilibrium requires
couple with a moment in an opposite direction. that a negative counterclockwise moment, F2 • d2,
The magnitude of the moment created by the be present and that the sum of FL • dx + F2 • d2
couple at the bracket must be equal and oppo- = 0.
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Ground Rules
Rotation occurs when a single force does not

act through the CRes and the tooth feels a MF
(Fig 2). With a MF the CRes is displaced in the
same direction as the line of force similar to
translation, and the tooth also feels a simulta-
neous tendency for rotation around the CRes
(Fig 3). Rotation also occurs when a couple is
applied to a bracket and the tooth feels a Mc
(Figs 6 and 7). A Mc is not capable of moving
the CRes.
+ F2«d2 = 0 A typical clinical example is a single, distally
+ ^ =o directed force acting at the bracket of a tooth
on a continuous arch wire as shown in Figure
Figure 9. A V-bend creating a positive clockwise sec- 10. This force results in a MF tending to move
ond-order moment Y1 - dx, at the molar. Equilib- the CRes in the direction of the force and also
rium requires that a negative counterclockwise mo- to rotate the tooth around its CRes. To coun-
ment, F2 • d2, be present and that the sum of Fx • dx teract this tendency of the tooth to tip in a
+ F2 ' d2 = 0. The associated equilibrium forces act
at the bracket and not through the CRes in all planes clockwise direction, the edgewise bracket is de-
resulting in a MF for third-order rotations for both signed to engage a second-order couple to ro-
teeth. tate the tooth in the opposite counterclockwise
direction. A perfect balance between the ten-
attachment that can be varied to act either dency of the MF to rotate the tooth in a clock-
through the CRes of a tooth or away from the wise direction and the tendency of the Mc to
CRes producing a MF. Unlike the Mc, the MF in rotate the tooth in a counterclockwise direction
a one-couple system can be increased or de- would produce tooth translation. In applied
creased just by relocating the site of force ap- orthodontic terminology, this relationship is
plication to change the distance between the expressed as a ratio of the Mc to the F that
line of the force and the CRes. The MF is not produces the MF, or the moment to force ratio,
intrinsic to the arch wire. M/F.5
It is useful to remember that the equilib- For example, in Figure 10, distal canine
rium of a Mc is intrinsic to the wire as the wire translation is desired and a force of 100 g is
is deformed to activate the couple at the applied 10 mm coronal to the center of resis-
bracket. The strain created in the wire by this tance. This will tend to move the center of re-
bending or twisting is the source of the associ- sistance distally in the direction of the force
ated equilibrium felt at the attached ends of
the wire.
Mc = Fd
Force Systems and Tooth Movements
Arch wire bends, no matter how complex, send
a message to the tooth consisting of a single Fjt d OF
force applied at some specific point and/or a
couple with no specific point of application.
The tooth can respond only with translatory MF = F*d = 100 g -10 mm = 1000 g-mm
and/or rotational movements.
Translation occurs only when a force is Figure 10. Canine retraction with a 100 g force act-
present. An isolated and single force, acting ing 10 mm coronal to the CRes creates a positive MF
of 1,000 g • mm. The edgewise appliance engages a
through the CRes, can translate a tooth without second-order couple at the bracket that must create
rotation, but only in the direction of the line of a negative 1,000 g • mm Mc to avoid distal crown
the force (Fig 1). tipping.
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vector. Because the force is not acting through ment created by the couple is possible by plac-
the center of resistance, a tendency for distal ing one end of an arch wire over, but not in,
crown tip or MF will also be present. The mo- the bracket slot where it is to be inserted. Place
ment or tendency to rotate in this direction is the other end of the wire at the location where
quantitated at 100 g • 10 mm = 1,000 g • mm. it will be tied as a single-point contact. When
When the wire is seated in an edgewise the wire crosses the bracket at an angle, the
bracket, a tendency to rotate the tooth in the bracket may be visualized as rotating to the
opposite direction is provided by a Mc created wire and this is the direction of the moment
by a second-order couple at the bracket. If the that will be created (Figs 8 and 9). Knowing the
bracket is 4-mm long, an arch wire would have direction of the moment at the bracket permits
to exert 250 g at each end of the bracket to identification of the direction of the forces in
create the necessary Mc of 1,000 g • mm in the the associated equilibrium.
opposite direction. If this could be achieved, all The magnitude of the forces and moments
tendencies for rotation would be eliminated in a one-couple system can be estimated clini-
and the net tooth movement would be transla- cally by measuring the force required to de-
tion in the direction of the applied force. form the wire for the tie at the point contact.
This force multiplied by the distance between
the bracket and the point attachment of the
Clinical Applications arch wire equals a moment which is equal and
In discussing the use of these basic principles opposite in direction to the Mc at the bracket.
with orthodontic appliances and tooth move- To estimate the magnitude of each of the
ments, it is important to remember that all ex- forces of the couple at the bracket, divide the
amples are analyzed under static conditions. magnitude of this moment by the length of the
To attempt to understand appliances in terms bracket.
of the changing conditions that are created as
tooth movement proceeds is the more complex Two Brackets and Two Couples
field of dynamics. When the free end of the arch wire in a one-
bracket system is not used as a point contact,
One Bracket and One Couple and instead is inserted into a second bracket, a
The simplest arrangement of an orthodontic two-couple system is usually created. For pur-
force system involving a couple is an arch wire poses of establishing the direction of the asso-
developing a single couple at one bracket. Ex- ciated equilibrium forces, the two-bracket sys-
amples of this type of system discussed in this tem can be considered as the sum of two suc-
issue are segmented springs, anterior intrusion cessive one-bracket systems. In this issue, we
arches, and anterior extrusion arches. will discuss torquing arches, upside-down
In a single-bracket system, one end of the torquing arches, utility arches, upside-down
arch wire is inserted into a bracket with an ac- utility arches, transverse activations, some seg-
tivation bend usually located close to this mented springs, and transpalatal lingual arches
bracket. The other end of the wire is displaced as examples of systems in which both ends of
and tied somewhere as a single-point contact the wire are inserted into brackets.
(Figs 8 and 9). When the activated wire is tied A two-bracket system usually creates cou-
at the point contact, the arch wire engages the ples and tendencies for rotation at each of the
bracket and two equal and opposite forces two brackets. With a two-bracket system, when
form the couple at the bracket. This couple the wire is placed over the slots of the two
produces a Mc or tendency to rotate the tooth brackets where it will be inserted, the angle of
around its CRes. entry of the wire vis-a-vis each bracket slot is
When a couple creates a Mc at a single not necessarily an accurate estimate of the di-
bracket, it is important to know the direction of rection of the Mc at both brackets. This differ-
the moment at the bracket to know the direc- ence from a one bracket, one-couple system is
tion of the forces of the associated equilibrium. related to the properties of the wire when cer-
With a one bracket, one-couple system, a use- tain specific relationships exist between the two
ful clinical estimate of the direction of the mo- brackets. These specific relationships are dis-
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Ground Rules
cussed in detail in the introduction to the sec- B

tion on three-dimensional (3-D) wires.
With a two-bracket system, when the wire is
placed over the slots of the two brackets where
it will be inserted, the angle of entry of the wire
at each bracket slot does show which bracket
has the larger angle of entry and, therefore,
the larger moment. This is important because,
irrespective of the direction of the moment at
the second bracket, the larger moment will dic-
tate the direction of the associated net equilib-
rium forces acting at each bracket. The older
commonly practiced rule of placing one end of
an arch wire in a bracket and using the position
of the other end of the wire as an indicator of
the direction of the resulting forces has many
important exceptions (Fig 11).
In a two-bracket system the forces of the
equilibrium associated with the moment at
each bracket always act at both brackets. Con-
sider a wire to be inserted into two successive
brackets on tooth A and B. The Mc resulting
from the insertion of the wire into the bracket
at tooth A will have associated equilibrium
forces acting on tooth A as well as tooth B.
These are labelled F2 in Figure 12A. The Mc At tooth B, Mc = F3-d3J|r^
the associated equilibrium = F4*d4
resulting from the insertion of the wire into
the bracket at tooth B will also have associated
equilibrium forces acting on both teeth A and
B. These are labelled F4 in Figure 12B. The
combined actions of the Mc at tooth A and the
Mc at tooth B are shown in Figure 12C. Be-
cause the V bend produces equal and opposite
False I
Total system for 2 couples with a V bend

Figure 12. Forces and moments present in a two-
bracket, two-couple system. (A) The Mc, FL • d1?
| False I False and its associated equilibrium, F2, • d2, resulting
from the engagement of the arch wire in tooth A.
Figure 11. Errors that will be made if the direction (B) The equal and opposite Mc, F3 • d3, and the
of the force systems in an two-couple system are associated equilibrium, F4 • d4, resulting from the
attempted to be read by placing one end of the wire engagement of the arch wire in tooth B. (C) Shows
in one bracket and noting the position of the other the total system effect on the two teeth which is a
end of the wire. combination of the separate effects shown in A
and B.
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10 Isaacson, Lindauer, and Davidovitch
couples at teeth A and B, the associated equi- determine the direction of the associated equi-
librium forces are equal and opposite and can- librium forces. At each tooth, the magnitude of
cel each other out at both teeth. the equilibrium force associated with the larger
Mc at each tooth will be modified by the equi-
Two Brackets—Two Equal and librium forces associated with the smaller Mc.
Oppositely Directed Couples Each bracket will feel the net difference (Fig
When the Mc at each of two successive brack- 13). The magnitude and direction of the equi-
ets are equal and opposite, their associated librium forces associated with the smaller Mc
equilibrium forces at each bracket are also are proportional to the magnitude and direc-
equal and opposite and function to cancel each tion of the smaller Mc. This moment will vary
other out (Fig 12). This is sometimes referred depending on whether the wire is two-
to as a symmetrical V-bend and it is assumed dimensional (2-D) or 3-D and where the
that it is placed equidistant between two collin- V-bend is located along the wire. The details of
ear brackets. A symmetrical V is used when this question are discussed in the section on
equal and opposite moments are desired at two 3-D.
successive teeth and the forces of the equilib- This wire configuration is referred to as an
rium associated with each moment are not asymmetrical V or off-center bend, but it is not
wanted. a question of where the V is located. The crit-
For a symmetrical V-bend to develop equal ical factor is the resulting orientation of the
and opposite couples at two brackets, it is nec- wire to each bracket slot. This angle of entry
essary that the brackets are collinear with the determines the larger moment created and,
bracket slots in alignment with each other. Be-
cause malocclusions commonly show asymmet-
rically positioned or noncollinear brackets on
the teeth, equal and opposite moments at two
successive brackets often will not result from a
V-bend placed equidistant between two brack-
ets. The important point is not the location of
the V-bend. It is the creation of equal and op-
posite moments at the two successive brackets.
Equal and opposite moments are accomplished
by adjusting the angle of entry of the arch wire
until it is equal and opposite when the wire is
placed over the two bracket slots before inser-
tion.
Two Brackets—Two Unequal Oppositely
Directed Couples
For clinical purposes, the effect of unequal and
oppositely directed couples at two successive
brackets may be thought of as the algebraic
sum of the two single-bracket systems present. Figure 13. Two-bracket, two-couple system with an
The relative magnitude of the moments at two asymmetrical V-bend in the arch wire. This shows
successive teeth is approximated clinically by which moment is larger and the direction of its as-
sociated equilibrium forces, information that can be
examining the wire passively placed over the determined clinically. The larger moment at tooth
two bracket slots. The bracket with the larger A determines the direction of the associated equi-
angle of entry and, therefore the larger Mc, librium forces. The smaller oppositely directed mo-
will have a greater tendency to rotate than the ment at tooth B has smaller associated equilibrium
bracket with the smaller Mc. forces that function to modify the larger equilib-
rium forces associated with tooth A. The direction
When the directions of the Mc at two suc- of the smaller moment at tooth B and its associated
cessive brackets are unequal and in opposite equilibrium forces are not discernable clinically and
directions, the larger of the two moments will are not shown.
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Ground Rules 11
rium forces at both brackets are also in the

same direction. Each tooth will feel the net re-
sult or the sum of the forces present (Fig 14).
This configuration of a wire is sometimes
referred to as a step bend. A step bend is ba-
sically two V-bends creating moments in the
same direction. When the wire is passively
placed over two adjacent brackets, the effects
of a step bend are created when the angle of
entry of the wire into the bracket is in the same
direction at both teeth (Fig 14). In contrast to
V-bends, step bends have no important
changes in the magnitude of the moment or
the associated equilibrium forces created when
the location of the step is moved mesiodistally
between two brackets.10
References
1. Marcotte MR (Ed). Mechanics in orthodontics. In:
Biomechanics in Orthodontics. Philadelphia, PA: BC
Figure 14. Two-bracket, two-couple system with a Decker, 1990:1-21.
step bend in the wire. Because both moments are in 2. Mulligan TF. Common sense mechanics. Phoenix,
the same direction, the associated equilibrium forces CSM, 2122 East Kaler Drive, 1982.
are also in the same direction and, therefore, in- 3. Smith RJ, Burstone CJ. Mechanics of tooth move-
creased at each tooth. ment. Am J Orthod 1984;85:294-307.
4. Thurow RC. Engineering in dentofacial orthopedics.
In: Edgewise Orthodontics. St Louis, MO: CV Mosby,
therefore, the direction of the equilibrium 1982:1-72.
forces present. 5. Burstone CJ, Baldwin JJ, Lawless DT. The application
of continuous forces to orthodontics. Angle Orthod
Two Brackets—Two Same
6. Demange C. Equilibrium situations in bend force sys-
Direction Couples
tems. Am J Orthod Dentofacial Orthop 1990;98:333-
The remaining possibility for a two-couple sys- 339.
tem is two couples with the moments of both 7. Isaacson RJ, Lindauer SJ, Rubenstein LK. Activating a
2x4 appliance. Angle Orthod 1993;63: 17-24.
couples acting in the same direction. The di- 8. Rony F, Kleinert W, Melsen B, et al. Force system
rection and relative magnitude of the moment developed by V bends in an elastic orthodontic wire.
present at each tooth is determined by the cou- Am J Orthod Dentofacial Orthop 1989;96:295-301.
ple created at each bracket which is related to 9. Isaacson RJ, Lindauer SJ, Rubenstein LK. Moments
the angle of entry of the arch wire into the slot with the edgewise appliance-incisor torque control.
Am J Orthod Dentofacial Orthop 1993; 103:428-438.
at that bracket. 10. Burstone CJ, Koenig HA. Creative wire bending-the
When the Mc at two successive brackets are force system from step and V bends. Am J Orthod
in the same direction, their associated equilib- Dentofacial Orthop 1988;93:59-67.
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One-Couple Orthodontic Appliance Systems

Steven J. Lindauer and Robert J. Isaacson
One-couple orthodontic appliances are capable of applying well-defined

forces and couples to effect controlled tooth movement during treatment.
There are two sites of attachment: one in which the appliance is inserted
into a bracket or tube where both a couple and force is generated, and one
at which the appliance is tied as a point contact where only a force is pro-
duced. Using relatively simple designs, powerful biomechanical force sys-
tems that are easy to discern clinically can be applied to move teeth accord-
ing to a prescribed plan. Several one-couple appliances are described to
move individual or groups of teeth in all three dimensions. A complete
biomechanical analysis of each appliance is presented and clinical reports
follow each description.
Theorthodontic appliances capable of proof tooth movement, but also a decreased need
ducing the most well-defined and dra- for appliance reactivation and the ability to lo-
matic tooth movements are often those that are calize unwanted side effects. The large range
the most simple biomechanically. Appliances of activation of these wires means that tooth
with long interbracket spans between two movement will proceed even without frequent
points of attachment have low load deflection monitoring and appliance adjustment. For this
rates and deliver relatively constant forces and reason, it is especially important for the prac-
moments as the teeth move toward their de- titioner to understand and accurately predict
sired locations.1'2 Moreover, in two-tooth sys- the tooth movements expected to occur. Un-
tems where the appliance is engaged in the wanted reactive effects can often be minimized
bracket of only one tooth and tied as a point or negated by applying independent intraarch,
contact to the other tooth, the force system cre- interarch, or extraoral mechanisms.
ated is statically determinate,3 meaning that
the forces and moments that the wire will ap-
ply to the teeth are easy to discern clinically. Canine Extrusion Springs
This makes tooth movements more predict-
able. A couple is created only at the tooth in A two-tooth system with a one-couple appli-
which the wire is engaged but forces exist at ance in place is depicted in Figure 1. In this
both attachment sites acting in opposite direc- example, a cantilever or long-arm wire is in-
tions because the appliance is in static equilib- serted into the molar auxiliary tube and bent
rium.4 so it is passive occlusal to a partially erupted
The advantages of one-couple orthodontic canine (Fig 1A). As the wire is activated by ty-
appliances include not only high predictability ing it to the canine attachment, a second-order
couple is created in the molar tube tending to
tip the molar in a crown-mesial/root-distal di-
From the Department of Orthodontics, School of Dentistry, rection. This activation applies an extrusive
Richmond, VA.
force to the canine and an intrusive force to
This work was supported in part by the Medical College of the molar.
Virginia Orthodontic Education & Research Foundation. The activated wire shown in Figure 1B is in
Address reprint requests to Steven J. Lindauer, DMD, MDSc, static equilibrium; the sum of the forces and
Department of Orthodontics, School of Dentistry, Medical College moments applied to it are equal to zero. This
of Virginia, Virginia Commonwealth University, PO Box
980566, Richmond, VA 23298-0566.
condition must be met for any orthodontic ap-
Copyright © 1995 by W.B. Saunders Company pliance.4,5 The two forces applied by the wire,
1073-874619510101 -0002$5.00/0 extrusive at the canine and intrusive at the mo-
12 Seminars in Orthodontics, Vol 1, No 1 (March), 1995: pp 12-24

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One-Couple Systems 13
Case AV (Fig 2) illustrates how a one-couple

appliance can be used effectively to avoid the
unwanted side effects from extruding high fa-
cial canines in a patient with an anterior open
bite tendency. If a continuous wire were used
to aid eruption of the canines in this patient,
the intrusive side effect would be expected to
result in incisor intrusion and anterior open
bite. By using a cantilever wire from the molar
auxiliary tube to extrude the canine, however,
no forces are transmitted to the incisors di-
rectly. The tendency for the molars to tip for-
ward and intrude is minimized by joining them
together with a transpalatal arch and engaging
an arch wire into the adjacent teeth.
One of the effects from applying an extru-
sive force to the bracket of a high facial canine
is that a third-order moment is created by the
force on the canine that tends to tip the canine
crown lingually and root facially as the canine
extrudes.6 This is because the extrusive force
acts facial to the center of resistance of the ca-
nine. It is difficult, if not impossible, to avoid
the tipping by directing the extrusive force
through the canine center of resistance. In
cases where the effect of the moment of the
force is expected to be especially pronounced,
such as when extensive amounts of extrusion
are necessary, it may be preferable to actually
insert the auxiliary wire into the canine bracket
rather than tying it as a point contact. The wire
can then be activated to apply lingual root
torque to the canine to provide third-order
control during extrusion. The side effect of
Figure 1. Canine extrusion spring. (A) In its passive this is labial root torque on the molar.
state, the spring is inserted into the molar auxiliary
tube and its anterior end is occlusal to the canine to Once the auxiliary spring is inserted into the
be extruded. (B) Activating the spring by tying it to brackets at two attachment sites it is technically
the canine generates a couple to tip the molar in a no longer a one-couple system and the forces
crown-mesial/root-distal direction, an intrusive and moments it produces are not statically de-
force to the molar, and an extrusive force to the terminate. In the case of extruding and con-
trolling root torque on a high canine, both sec-
lar, are equal in magnitude and opposite in ond-order (tip) and third-order (torque) acti-
direction, making their sum equal to zero. Be- vations are applied. Once the decision is made
cause the two forces are not collinear, however, to engage the wire in both the molar and ca-
they create an overall tendency for rotation. nine brackets, care must be taken to ensure
This rotational tendency or moment is equal in that a significant second-order activation is not
magnitude, but opposite in direction, to the present at the canine bracket but that all or
couple created in the molar tube that makes it most of the second-order couple is applied at
tip mesiodistally. Therefore the sum of the the molar. If a second-order couple is intro-
moments acting on the wire as a whole is also duced at the canine, the vertical forces associ-
zero and the conditions for equilibrium are sat- ated with the appliance may be adversely af-
isfied. fected. For example, a distal-crown/mesial-root
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14 Lindauer and Isaacson
Figure 2. Case AV: Canine extrusion springs are used bilaterally to erupt high facial canines in a patient with
minimal pretreatment overbite. (A and B) Right and left views of the patient's pretreatment occlusion
showing partially-erupted, high facial canines. (C and D) Canine extrusion springs fabricated of 0.016" X
0.022" titanium molybdenum alloy (TMA) wire are inserted into the molar auxiliary tubes and are passively
occlusal to the canines to which they will be tied. An 0.016" stainless steel wire stabilizes the rest of the arch
and a passive 0.032" transpalatal arch (not shown) further stabilizes the molars. (E and F) After canine
extrusion is completed, they are included into the continuous arch wire for final detailing and finishing.
couple at the canine would tend to intrude the A third-order activation was placed into the
canine and extrude the molar, thus partially or wire to torque the canine root lingually and
wholly negating the canine extrusive force. If crown facially to counteract the moment cre-
the spring is properly activated initially to ex- ated by the extrusive force. No second-order
trude the canine and provide lingual root activation was placed at the canine bracket to
torque, the appliance should be monitored and avoid significantly affecting the extrusive force
adjusted regularly to maintain the desired associated with the second-order couple at the
force system as the teeth move. molar tube.
Case CC (Fig 3) is an example of a situation Similar to extrusion of high facial canines,
where substantial canine extrusion is required. one-couple appliances can be designed to ef-
In this patient, the extrusive auxiliary spring fect the eruption of palatally impacted canines.
was inserted directly into the canine bracket so Figure 4A shows an exposed palatally im-
that third-order control could be maintained. pacted canine to be extruded using a wire ex-
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Figure 3. Case CC: A canine extrusion spring may be inserted directly into the canine bracket if extensive
vertical movement is required. (A and B) Frontal and lateral views showing a canine extrusion spring of
0.016" X 0.022" TMA wire extending from the molar auxiliary tube into a high facial canine bracket. A
second-order couple to tip the molar crown-mesial/root-distal provides the vertical force to extrude the
canine. A third-order couple to counteract the moment of the extrusive force helps control canine crown-
lingual/root-facial torque without affecting the extrusive force. (C and D) After several months of active
treatment, the canine has been extruded to the level of the occlusal plane.
tending from the molar auxiliary tube. The When activated by tying it to the canine attach-
wire is contoured so that, when tied to the ca- ment, a first-order couple is developed in the
nine attachment, it will be passively away from molar tube tending to rotate the molar mesio-
the palatal tissue. From the lateral view, acti- lingually (Fig 5B). Once again, this movement
vation of the wire by tying it to the canine but- is minimized if a transpalatal arch is in place.
ton produces a second-order couple at the mo- The forces exerted by the appliance in the oc-
lar that tips the molar in a crown-mesial/root- clusal plane are directed facially at the canine
distal direction. This basic force system is the and lingually at the molar.
same as that created by activating a wire to ex- Case GB (Fig 6) shows how a one-couple
trude the high facial canine shown in Figure 1. appliance extending from the molar auxiliary
Observed from the frontal view, however, it is tube can be used effectively to extrude a pala-
apparent that a third-order couple is also pro- tal canine and move it facially. By transferring
duced in the molar tube to torque the molar in the side effects of these movements to the first
a crown-lingual/root-facial direction as the molars, local intrusion and lingual movement
wire is activated (Fig 4B). If undesirable, the of teeth adjacent to the canine site are avoided.
unwanted molar side effect can be minimized Placement of a passive transpalatal arch helps
using a passive transpalatal arch. The wire is to stabilize the molars and minimize side ef-
extrusive to the impacted canine and intrusive fects from the canine auxiliary spring.
to the molar. These forces are associated with
both the second- and third-order couples gen-
erated at the molar attachment. Midline Springs
The occlusal view in Figure 5 shows how the Similar to moving a palatal canine facially, a
appliance in Figure 4 can also be activated to spring can be designed to help shift anterior
move a palatal canine facially. The wire is bent teeth laterally to the left or right when midline
to be facial to the palatal canine (Fig 5A). corrections are necessary as shown in Figure 7.
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Figure 5. Occlusal view of a spring designed to

move a palatally impacted canine facially. (A) Pas-
sive spring is facial to the canine. (B) Activation of
the spring creates a couple at the molar to rotate it
mesiolingually, a lingual force at the molar, and a
facial force at the canine.
place to minimize any unwanted molar move-

Figure 4. Frontal view of a spring designed to ex- ments. The forces will be directed laterally at
trude a palatally impacted canine. (A) Passive spring the incisors and lingually at the molar.
extends from the molar auxiliary tube and crosses to
the lingual through the canine site. The anterior Case JM (Fig 8) illustrates how an auxiliary
end is occlusal to the canine. (B) Activation of the midline spring can be used to help in correct-
spring by tying it to the impacted canine creates a ing a midline discrepancy. In this case, the
third-order couple at the molar, an intrusive force maxillary midline was moved to the right to
at the molar, and an extrusive force at the canine. coordinate it with the mandibular arch. Ade-
quate anterior overjet on the patient's left side
A wire extending from the appropriate molar was already present before the midline was
auxiliary tube is bent to move the midline to corrected. Midline discrepancies are often
the right or left. A small hook bent into the symptoms of more serious skeletal or dental
spring allows it to be crimped over an existing asymmetries. Midline springs should not on
arch wire or segment, or it may be tied to the their own be expected to resolve such complex
arch wire or individual teeth. Passively, the asymmetries. In the context of a comprehen-
spring is lateral to the incisors in the direction sive treatment plan, however, they can often
in which incisor movement is desired (Fig 7A). serve as a useful adjunct to, or substitute for,
As the wire is activated, a second-order couple other methods of midline correction. These
is developed in the molar to rotate it mesiolin- may include anterior interarch elastics or
gually (Fig 7B). The force system is similar to skewed arch wires that are often associated
the occlusal view activation of the palatal ca- with undesirable side effects that are difficult
nine spring shown in Figure 5. Once again, it is to control. A prerequisite for aligning midlines
often desirable to have a transpalatal arch in in any orthodontic patient is symmetric poste-
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Figure 6. Case GB: A canine extrusion spring is used to extrude an exposed, palatally impacted canine and
move it laterally. (A, B, and C) An 0.016" x 0.022" TMA spring is shown in its passive state from the frontal,
occlusal, and lateral aspects before attaching it to a button bonded to a palatally impacted canine. (D, E, and
F) After two visits, the palatal canine has extruded significantly and moved to the facial. There are no side
effects evident in teeth adjacent to the canine site. The canine spring remains active.
rior segments to allow for attainment of Class I in Figure 9A. When the wire is activated by
canine relationships bilaterally. pulling the anterior portion incisally and tying
it at the level of the incisor brackets, a second-
Anterior Intrusion Arches order couple is produced at the molar to tip it
crown-distal/root-mesial (Fig 9B). An intrusive
Probably the best known example of a one- force is present at the point of anterior attach-
couple appliance for effecting well-defined ment and an extrusive force of equal magni-
tooth movement is the intrusive base arch as tude exists at the molar.
described by Burstone in 1977.3 A full arch To produce predictable tooth movement, it
wire is inserted into the right and left molar is important that the intrusion arch not be in-
auxiliary tubes and bent so that the anterior serted directly into any brackets other than the
portion lies apical to the incisor teeth as shown molar. This ensures that a couple is created
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only at the molar so that the force system re-

mains determinate. A separate, stabilizing arch
wire or segment is usually inserted into the
brackets of the incisor teeth so they can main-
tain their positions relative to each other as
they intrude. The effectiveness of the intrusive
base arch is shown by Case JD (Fig 10). In this
patient, an intrusion arch was used to apply an
intrusive force at the maxillary incisors to
achieve correction of a deep anterior overbite.
Intrusion of maxillary incisors can be helpful
in reducing an excessive amount of tooth
showing below the upper lip.3,7 If a deep over-
bite is present and reducing this lip to tooth
relationship is undesirable, the intrusion arch
may be used in the mandibular dentition to
intrude lower incisors.
The extrusive force present at the molars
may or may not result in actual molar extru-
sion clinically depending on the magnitude of
the force itself and the influence of occlusal
forces. In some cases, molar extrusion, if it oc-
curs, may be beneficial for helping to reduce
Figure 7. Occlusal view of an anterior midline
spring designed to shift the maxillary midline to the excess overbite. In other patients, it may be
patient's right. (A) The passive spring extends from desirable to counteract the extrusive compo-
the molar auxiliary tube and has an anterior hook nent of the anterior intrusion arch with a high-
that will be attached over the arch wire. (B) Activa- pull headgear to the molars. Because the ex-
tion of the spring creates a couple at the molar to trusive force is acting facial to the molar center
rotate it mesiolingually, a lingual force at the molar,
and a facial force at the point of anterior attach- of resistance, there is also a tendency for the
ment. molar crowns to tip lingually as a result of the
moment of that force. This movement can be
Figure 8. Case JM: A midline spring is used to help

move the maxillary midline to the patient's right to
better coordinate the upper and lower dental
arches. (A) Frontal view showing midline discrep-
ancy between the maxillary and mandibular teeth.
The midline spring is in place on the patient's right
maxillary arch. (B) Lateral view showing the 0.016"
x 0.022" TMA midline spring extending from the
molar auxiliary tube and hooked over the 0.016"
nickel titanium maxillary arch wire mesial to the ca-
nine. The spring is activated to the patient's right, producing a couple that will tend to rotate the right molar
mesiolingually. (C) After one visit, the maxillary midline has moved noticeably to the patient's right.
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tude of this tendency can be decreased sub-

stantially or even eliminated (Fig 11B).
Another method for reducing the tendency
of the anterior segment to flare during intru-
sion is to cinch or tie back the arch to prevent
the incisor crowns from moving forward.3'8 By
fixing the arch length in this way, both the ten-
dencies for the molar crowns to move distally
and for the incisor crowns to move facially are
restricted. However, the magnitude of the cou-
ple produced at the molars and the magnitude
of the moment created by the force at the in-
cisors are not affected. Because the crowns of
the molars and incisors cannot move away
from each other, these tendencies for rotation
are expressed primarily as mesial root move-
ment at the molar and lingual root movement
at the incisor as shown in Figure 12.
The choice of point of force application and
the decision of whether or not to fix arch
length by cinching the arch wire can dramati-
cally affect the clinical outcome of treatment
with an intrusive base arch. A decision not to
cinch the intrusion arch allows arch length to
increase during this phase of treatment (Fig
13). If the anterior portion of the intru-
sion arch is tied to direct the intrusive force
through the center of resistance of the anterior
Figure 9. Anterior intrusion arch. (A) The passive segment, then arch length will increase only by
arch extends from the molar auxiliary tube and the the molar crowns tipping distally. If the arch is
anterior portion is apical to the incisor brackets. A
passive segment is shown engaged in the incisor tied more anteriorly, then the incisor crowns
brackets. (B) Activation by tying the intrusion arch will also tip anteriorly. However, if the arch
to the anterior segment creates a second-order cou- length is fixed by cinching the arch wire, then
ple at the molar to tip it crown-distal/root-mesial, an the molar crown is no longer free to tip distally
extrusive force at the molar, and an intrusive force
anteriorly. unless the entire arch moves with it. It is more
likely that the molar roots will move mesially.
Allowing molar tip-back to occur by not
prevented by placing a transpalatal arch wire cinching or tying back a maxillary intrusion
to stabilize the molars. arch is especially appropriate in cases where
Considerable variation in incisor angulation Class II correction is necessary. The couple
change can be expected during treatment us- causes the molar crown to tip distally toward a
ing an intrusion arch depending on the chosen more Class I relationship with the mandibular
point of force application anteriorly.3'8 The molar. Because this tendency results only from
wire itself cannot produce a couple at the inci- the couple and not from an actual distally di-
sors because it is not inserted directly into their rected force, however, it is necessary to apply
brackets.9 By applying the intrusive force an- an independent force system to upright the
terior to the center of resistance of the incisor molar roots if distal translation of the molar is
segment, however, a moment can be created desired. A headgear with a distally directed
tending to torque the incisor in a crown-facial/ force applied apical to the molar center of re-
root-lingual direction (Fig 11 A). If the intru- sistance can be used to achieve the appropriate
sion arch is tied more posteriorly, the magni- total force system. If the maxillary premolars
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Figure 10. Case JD: An anterior intrusion arch is used to intrude maxillary incisors. (A and B) Pretreatment
photographs showing a deep anterior overbite from the frontal and lateral aspects. (C & D) After 2 months
of treatment with an anterior intrusion arch, substantial overbite correction has occurred. In this patient, an
0.016" x 0.022" stainless steel wire with a helix of IVz turns was tied to an anterior segment to intrude the
maxillary incisors.
are not engaged in the arch wire, they may of the point of force application can be used
drift distally as the molar crown tips back. advantageously during treatment. By leaving
Case BB (Fig 14) illustrates how the decision the maxillary intrusion arch uncinched and
of whether or not to fix arch length and choice choosing a point of force application anterior
Figure 11. Location of the point of force application

can dramatically affect incisor tooth movement dur-
ing intrusion. (A) Applying the intrusive force an-
terior to the center of resistance results in a ten-
dency for the incisors to torque in a crown-facial/ Figure 12. Intrusion arch with arch length fixed by
root-lingual direction. (B) Applying the force cinching. The molar tip can only be expressed by
through the incisors' center of resistance causes the roots moving mesially. Incisor torque can only
straight intrusion. be expressed by the roots moving lingually.
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crowns). In addition, freedom for the molar

crown to tip distally helped in improving the
molar classification and allowed the premolars
to drift toward a more Class I relationship on
their own.
The anterior intrusion arch may also be
used during space closure to provide the force
system necessary to prevent the anterior and
posterior teeth from tipping excessively into
the extraction site. The molar couple counter-
acts the tendency for the posterior teeth to tip
mesially as a Class I force is applied occlusal to
the center of resistance. At the incisors, the
intrusion arch is tied as far anteriorly as possi-
ble to apply an intrusive force anterior to the
center of resistance to oppose the tendency for
the anterior teeth to tip distally during space
closure (Fig 15). This approach can be used in
Figure 13. Intrusion arch uncinched with arch the maxillary, mandibular, or both arches de-
length free to increase. The molar tip can be ex-
pressed by crown-distal/root-mesial movement. In- pending on the individual situation.
cisor torque can be expressed by crown-facial/root- The couple at the molar resulting from
lingual movement. placement of an anterior intrusion arch will be
greater in magnitude than the moment created
to the center of resistance of the incisors, arch by the intrusive force acting anterior to the in-
length increased quickly and dramatically both cisors. This is because the magnitude of the
by molar tip back and incisor flaring. Overbite couple acting at the molar is equal to one of the
reduction was achieved by a combination of vertical forces multiplied by the distance be-
actual intrusion (of the center of resistance) tween the forces. The moment acting anteri-
and relative intrusion (caused by flaring of the orly is equal only to the intrusive force times
Figure 14. Case BB: Proper case selection and acti-

vation for an uncinched anterior intrusion arch. (A)
Pretreatment lateral view showing deep anterior
overbite, upright maxillary incisors, anterior crowd-
ing, and Class II end-on premolars and canine. (B)
After treatment with a maxillary intrusion arch tied
anterior to the center of resistance of the anterior
teeth, the overbite is improved as a result of both
actual and relative intrusion. The arch length was
not fixed and the molar crown tipped distally into a
super-Class I occlusion, allowing the premolars to
drift passively toward a Class I relationship. (C)
Mid-treatment occlusal view showing the increased
arch length provided by the intrusion arch. Tip-
back of the molar crowns has afforded space for the
premolars to drift distally, whereas flaring of the
incisors allowed for alignment of the canines.
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the perpendicular distance between the vector

of that force and the center of resistance of the
anterior teeth. The significance is that molar
anchorage is enhanced when an intrusive arch
is used during space closure; the moment to
force ratio posteriorly is greater than it is an-
teriorly.10'11 Therefore, in Class II cases, it is
advantageous to use the intrusion arch during
space closure in the maxillary arch because the
intrusion arch can help to increase maxillary
molar anchorage. Mandibular molar anchor-
age can be increased, if desired, by using in-
trusive mechanics in the mandibular arch dur-
ing space closure.
Anterior Extrusion Arches

The appliance to deliver the force system re-
quired to achieve incisor extrusion can be de-
signed merely by inverting the anterior intru-
sion arch wire and inserting it into the molar
auxiliary tubes upside-down. In this case, the Figure 16. Anterior extrusion arch. (A) The passive
anterior portion of the wire will be incisal to arch extends from the molar auxiliary tube and the
the anterior teeth to be extruded as shown in anterior portion is incisal to the incisor brackets. A
passive segment is shown engaged in the incisor
Figure 16A. Activating the wire by tying it at brackets. (B) Activation by tying the intrusion arch
the level of the incisor brackets creates a couple to the anterior segment creates a second-order cou-
at the molar tube to tip the molar in a crown- ple at the molar to tip it crown-mesial/root-distal, an
mesial/root-distal direction (Fig 16B). An ex- intrusive force at the molar, and an extrusive force
trusive force is delivered anteriorly and an in- anteriorly. This is exactly opposite to the force sys-
tem delivered by the anterior intrusion arch (shown
trusive force posteriorly, similar to the canine inside the box).
extrusion spring (Fig 1). This force system is
exactly opposite to the one delivered by the
intrusive base arch. tain the relationships of the anterior teeth rel-
As with the intrusion arch, the force system ative to each other. The extrusion arch is tied
produced by an anterior extrusion arch is over this wire and, as with its intrusive coun-
more predictable when the wire is not inserted terpart, its effect can be modified by varying
directly into the incisor brackets. A stabilizing the location of attachment as shown in Figure
arch wire or segment is usually placed to main- 17. More anterior placement will locate the ex-
trusive force anterior to the center of resis-
tance of the incisors, thus creating a moment
that will tend to upright them (Fig 17A). By
tying the extrusion arch more posteriorly, ex-
trusion of the anterior teeth can be accom-
plished with less tendency for uprighting to
occur (Fig 17B).
Figure 15. Intrusion arch used during space clo- In contrast to the intrusive base arch, which
sure. An 0.016" x 0.022" stainless steel anterior in- has the potential to increase available arch
trusion arch with iVs helices provides an intrusive length if left uncinched, the extrusive base
force anterior to the incisor center of resistance, an arch is likely to reduce arch space availability as
extrusive force at the molar, and a couple to keep
the molar upright during space closure. The space tooth movement occurs. The reason for this is
closing force is provided by a nickel titanium coil that the couple acting at the molar tends to tip
spring. the molar crown forward, whereas the mo-
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ward if the whole arch wire moves forward (or

if the arch wire bows significantly). The stop
also minimizes the potential for the incisor
crowns to tip lingually because the wire is no
longer free to slide back through the molar
tube.
Case SR (Fig 18) illustrates anterior open
bite closure using an extrusive base arch. For
this patient, the decision was made to increase
overbite dentally by extruding the maxillary
anterior teeth. The extrusive force was di-
rected anterior to the center of resistance of
the incisors and the teeth were permitted to
upright as they extruded. The uprighting that
Figure 17. Location of the point of force application occurred also helped to reduce the amount of
can affect incisor tooth movement during extrusion. open bite present. The molars were stabilized
(A) Applying the extrusive force anterior to the cen- with a passive transpalatal arch and mesial
ter of resistance results in a tendency for the incisors crown tipping was minimized using a separate,
to torque in a crown-lingual/root-facial direction.
(B) Applying the force through the incisors' center continuous arch wire inserted into the premo-
of resistance causes straight extrusion. lar brackets.
ment created by the anterior extrusive force Conclusion

(usually placed anterior to the incisor center of
resistance) tends to torque the anterior teeth All one-couple appliance systems have the
lingually. The potential to lose available arch same basic features in common. At one end,
length can be reduced by placing a mesial stop usually the molar, the wire is inserted into a
in the arch wire at the first molar. With a me- bracket or tube. At the other end, the wire is
sial stop in place, the molar can only tip for- tied to an individual tooth or over another arch
Figure 18. Case SR: Anterior extrusion arches. (A and B) Frontal and lateral views showing maxillary and
mandibular anterior extrusion arches in place to correct an anterior open bite. 0.016" X 0.022" stainless steel
archwires with 1 Vs helices extend from the auxiliary tubes of the first molars and are tied as point contacts
at the lateral incisors. 0.016" X 0.022" nickel titanium wires are used to maintain relative intraarch dental
relationships as the anterior teeth extrude. (C and D) Two months later, anterior extrusion is complete. The
patient also wore posterior vertical box elastics to help improve overbite in the premolar and canine areas.
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wire or segment. Because the wire is not in- adapted to perform numerous functions. Ca-
serted into a bracket anteriorly, a point contact nine extrusion, midline movement, anterior
is made, and only a force (not a couple) can be intrusion, and anterior extrusion have been
applied at this attachment site. At the molar, previously discussed, but movements of any in-
where the wire is inserted into a bracket, both dividual tooth or group of teeth can be accom-
a force and couple are generated by the acti- plished in any plane. The actions of such ap-
vated appliance. The force exerted on the pliances are highly predictable and any un-
bracket will be equal in magnitude, but oppo- wanted side effects can be localized and easily
site in direction, to the force produced anteri- monitored during treatment. The simplicity
orly where the wire is tied as a point contact. and flexibility afforded by one-couple orth-
The couple created at the molar bracket will odontic appliance systems make them an at-
always produce a tendency for that tooth (or tractive choice in clinical situations where max-
segment of teeth, if several are rigidly joined imal control of tooth movement is desired.
together) to rotate around its center of resis-
tance. However, the force will act at the
bracket, tending to displace the entire tooth or References
segment. In addition, because the force is 1. Burstone CJ, Baldwin JJ, Lawless DT. The application
rarely directed through the center of resis- of continuous forces to orthodontics. Angle Orthod
tance, it will also cause the tooth to rotate, tip,
and/or torque. The effects of unfavorable mo- 2. Burstone CJ. Rationale of the segmented arch. Am J
ments and forces exerted on the molar can be Orthod 1962;48:805-822.
3. Burstone CJ. Deep overbite correction by intrusion.
controlled using independent force systems AmJ Orthod 1977;72:l-22.
such as a headgear, elastics, or a transpalatal 4. Burstone CJ, Koenig HA. Force systems from an ideal
arch wire. arch. AmJ Orthod 1974;65:270-289.
The force exerted at the anterior attach- 5. Mulligan TF. Common sense mechanics. 3. Static
ment site of a one-couple appliance will always equilibrium. J Clin Orthod 1979;13:762-766.
tend to move that tooth or segment in the di- 6. Smith RJ, Burstone CJ. Mechanics of tooth move-
ment. AmJ Orthod 1984;85:294-307.
rection of the force. If the force is not through
7. Burstone CJ. Lip posture and its significance in treat-
the center of resistance, then a tendency for ment planning. AmJ Orthod 1967;53:262-284.
rotation will also be created. The direction and 8. Isaacson RJ, Lindauer SJ, Rubenstein LK. Moments
magnitude of this rotational tendency can be with the edgewise appliance: Incisor torque control.
modified by changing the site of ligation. Ty- AmJ Orthod Dentofacial Orthop 1993;103:428-438.
ing the wire further away from the center of 9. Isaacson RJ, Lindauer SJ, Rubenstein LK. Activating a
resistance will produce more of a tendency for 2x4 appliance. Angle Orthod 1 993 ;63: 17-24.
10. Burstone CJ. The segmented arch approach to space
rotation, whereas moving it closer will decrease closure. AmJ Orthod 1982;82:361-378.
the rotational tendency. 11. Kusy RP, Tulloch JFC. Analysis of moment/force ra-
By applying the basic laws of equilibrium, tios in the mechanics of tooth movement. Am J
one-couple appliances can be designed and Orthod Dentofacial Orthop 1986;90: 127-131.
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Two-Couple Orthodontic Appliance Systems

Utility Arches: A Two-Couple
Intrusion Arch
Moshe Davidovitch and Joe Rebellato
The utility arch is a two-couple intrusion arch wire used for control of an-
terior deep overbite. It is similar to a one-couple intrusion arch in that it is
commonly made with rectangular wire, attached to the teeth only at the
molars and the incisors and is activated for incisor intrusion by a molar tip
back bend. It differs from a one-couple intrusion arch by the insertion of the
incisor segment into the incisor brackets. This results in a fixed point of
application of the intrusion force anterior to the incisors and, therefore,
incisor rotation by the moment of the force. In addition, insertion of the
rectangular wire into the incisor brackets usually creates a third-order cou-
ple for incisor rotation. Depending on how it is used, the moment of this
couple may be activated in either direction and the resulting associated
equilibrium forces will either supplement or reduce the vertical equilibrium
forces created by the activation bends at the molars.
he utility arch, as popularized by Rick- The relative contributions of incisor intru-

T etts,1'2 has been recommended for the res-
olution of a variety of clinical conditions.3 Per-
sion, increased incisor inclination and poste-
rior tooth extrusion in reducing OB should be
haps the most frequent application has been determined through differential treatment
for leveling the Curve of Spee and reduction planning and not dictated by the limitations of
of overbite (OB) through incisor intrusion. a specific mechanotherapy.4 The relative con-
Overbite, defined as the amount of vertical tributions of incisor intrusion and molar/
overlap of the mandibular incisor by the max- premolar extrusion in OB reduction has re-
illary incisor, is resolved clinically by one or a ceived attention regarding the stability of OB
combination of three different mechanisms. correction.5"8 Case reports based on cephalo-
Although the goal often is intrusion of incisors, metric analysis of utility arch OB reduction,
actual intrusion only occurs when it can be ob- have reported 1 to 5.5 mm of incisor intrusion,
served that the center of resistance (CRes) of with a stability rate of 75% to 100% claimed for
the incisors has been intruded. Alternatively, these clinical outcomes.9'10 Given these types
incisor OB can also be reduced through both of responses, it is of great interest to analyze
increased incisor inclination or mandibular au- this appliance from a biomechanical stand-
torotation resulting from posterior tooth ex- point to better understand its capabilities.
trusion without compensatory vertical growth The utility arch is usually fabricated from a
of the condyle. continuous rectangular stainless steel arch wire
inserted into the edgewise brackets on the in-
From the Department of Orthodontics, School of Dentistry, cisors and the maxillary or mandibular molars.
Medical College of Virginia, Virginia Commonwealth University, As a matter of convenience and comfort it is
Richmond, VA. stepped in a gingival direction between the in-
Address reprint requests to Moshe Davidovitch, DDS, MMSc, cisors and molars to bypass the buccal occlu-
Department of Orthodontics, School of Dentistry, Medical College
of Virginia, Virginia Commonwealth University, PO Box
sion (Fig 1). Avoiding engagement of the pre-
980566, Richmond, VA 23298-0566. molars and canines results in improved load
Copyright © 1995 by W.B. Saunders Company deflection properties because of the length of
1073-8746I95I0101-0003$5.00IO free wire existing between the segments at
Seminars in Orthodontics, Vol I, No 1 (March), 1995: pp 25-30 25

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26 Davidovitch and Rebellato
the point selected for the tie. This choice dic-

tates whether or not rotation is to be present
during incisor intrusion.
A second important difference between the
intrusion arch and the utility arch lies in the
nature of their attachment at the incisors. A
Figure 1. Schematic illustration of an uncinched utility arch, by inserting directly into the inci-
utility arch engaged in the incisor brackets. The ac-
tivation and potential tooth movements resulting sor brackets, will usually create a third-order
cannot be completely ascertained from an arch wire couple at the incisors and a two-couple system.
inserted into the brackets. As the third-order couple is knowingly or un-
knowingly activated, equilibrium forces are
each end of the appliance. This compensates created. The equilibrium forces associated
for the relatively stiff nature of the arch wire with the Mc at the molar, originally created for
and permits the delivery of a more physiologic incisor intrusion, will be modified by the equi-
level of force over a longer period of time. The librium forces associated with the Mc at the
stepping of the appliance away from the occlusal incisor. This will increase or decrease the in-
plane in the buccal segment also reduces the risk trusive force at the incisor depending on the
of deformation during mastication. The utility direction of the couple created at the incisor.
arch is activated for incisor intrusion by placing The direction of the couple at the incisor is not
tip-back bends mesial to the molar tubes. always clinically apparent resulting in less pre-
The continuous rectangular arch and the dictable force systems that may impede desir-
activation bends mesial to the molars give this able outcomes. In contrast, a one-couple intru-
appliance an appearance similar to that of the sion arch is tied as a point contact and acts as a
intrusion arch previously described. Both arch single force. Therefore, an intrusion arch is a
wires use a tip back bend at the molars to cre- one-couple system that can be accurately mea-
ate a vertical intrusive force at the incisors. sured and controlled clinically.
However, fundamental biomechanical differ- To appreciate the clinical process of incisor
ences do exist between these two arch wires in intrusion by a utility arch, it is helpful to ex-
their use and, as a result, in their mode of ac- amine the components of the system (Fig 2).
tion and treatment outcomes. The incisor teeth planned for orthodontic in-
One important difference lies in the loca- trusion must be thought of as one large multi-
tion of the line of vertical force created for rooted tooth. Because these teeth are coli-
incisor intrusion. If this line of force passes gated they will react as a single tooth forming a
directly through the CRes of the incisors, the mono-unit where independent movement of
teeth will be translated as they intrude. If the individual incisors is not possible. In a lower
line of force passes facially to the CRes, a ten- arch the CRes of this "tooth" lies in the anterior
dency for incisor rotation will be created as the portion of the floor of the mouth lingual to the
CRes intrudes. The strength of this tendency roots of the central incisors. To actually in-
for rotation will be directly related to the per- trude this segment (or any tooth/teeth) without
pendicular distance between the line of the rotation, an apically directed force through the
force and the CRes of the incisors. The utility CRes is necessary.
arch is inserted directly into the edgewise slots The molar teeth also have their own CRes.
of the incisor brackets and, therefore, the line With both intrusion and utility arches the distal
of force is dictated by the location of the incisor tip bends create a large Mc at the molar which
brackets. Because the brackets of the incisors can only produce rotation around the CRes. In
will almost always be facial to the CRes, the line addition, the equilibrium forces associated
of force of the utility arch will also be facial to with the Mc include an extrusive force at the
the CRes, with a tendency present for crown molar. Because the sum total of any force sys-
facial/root lingual rotation. In contrast, a one- tem must satisfy Newton's Third Law of Mo-
couple intrusion arch is attached at the incisor tion when viewed in each plane of space, the
region as a point contact that allows the line of first, second, and third-order movements must
force to be varied according to the location of also apply to the biomechanical system im-
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Utility Arches 27
sial to the molar tube creating an asymmetric V

activation. When the utility arch is inserted
into the molar tubes alone, the anterior por-
tion of the wire will lie gingival to the incisors
in the vestibule. To engage the incisor brackets
the anterior portion is deflected to the occlusal
(Fig 3). This action will generate a couple at
each molar with a moment for crown distal/
root mesial rotation. The associated vertical
equilibrium forces will be extrusive at the mo-
lars and intrusive at the incisors (Fig 4).
The activation bend mesial to the molars re-
sults in the largest moment at these teeth. It is
the larger moment that determines the direc-
tion of the associated equilibrium forces acting
on the attached ends of the arch wire. Because
the utility arch is inserted directly into the in-
cisor brackets, the intrusive force is usually la-
bial to the CRes and will cause, in addition to
intrusion of the CRes, a MF or tendency for the
incisors to rotate crown facial/root lingual.
In addition, insertion of the utility arch into
the incisor brackets will usually result in the
creation of a third-order couple at these brack-
ets. The equilibrium force associated with the
larger Mc at the molar will still result in equal
and opposite intrusive forces at the incisor and
extrusive forces at the molar. However, the
Figure 2. (A) Estimated location of the CRES of the equilibrium forces associated with the smaller
mandibular incisor segment in the sagittal plane. (B)
Estimated location of the CRES of the mandibular Mc at the incisors will either reduce or increase
incisor segment in the transverse plane. the magnitude of these forces, depending on
the direction and magnitude of the Mc created
at the incisors. The direction of the Mc at the
posed on each molar. With either an intrusion
arch or a utility arch, the molars are subjected
to extrusive forces applied at the molar tubes
lateral to the CRes. In the sagittal plane or lat-
eral view this force passes through the CRes of
the molar and can only result in vertical tooth
movements. However, in the frontal or coronal
plane, the vertical force is located lateral to the
CRes of the molars resulting in a MF or ten-
dency for crown lingual/root facial molar rota-
tion. It is important to comprehend the three
dimensional (3-D) nature of orthodontic bio-
mechanics.
Figure 3. A utility arch fabricated of .016" x .022"

Component Parts of the Utility Arch stainless steel wire. An activation bend has been
placed mesial to the molar tubes and the wire is
For clinical predictability, it is useful to begin inserted into the molar tubes. The wire is activated
with a passive arch wire. The passive utility by elevating the anterior segment and inserting it
arch is activated by placing a tip-back bend me- into the incisor brackets.
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as the moment at the molars. Therefore, the

equilibrium forces associated with the mo-
ments at both teeth are in the same direction
and are additive. This increases the magnitude
of the intrusive force at the incisors. This is
analogous to placing a step bend between the
molars and the incisors (Fig 5).
Performing the converse operation by plac-
ing a crown facial/root lingual bend in the in-
cisor segment of the arch wire mimics more
closely a symmetrical V-bend. Recall that sym-
metrical V-bends generate opposite moments
with associated equilibrium forces acting in op-
posite directions. Therefore, the net incisor in-
Figure 4. The force system generated by engage-
ment of the utility arch at the incisors and molars. trusive force derived from the equilibrium as-
The box shows the greatest angle of entry and the sociated with the Mc at the molar is reduced by
larger moment at the molar dictating the direction the equilibrium force associated with the Mc at
of the associated equilibrium forces. The equilib- the incisor (Fig 6). When the crown facial/root
rium forces associated with the Mc at the incisor lingual moment at the incisor equals the mo-
modify the equilibrium forces associated with the
Mc at the molar. Mc is the couple created in the ment for distal tip at the molar, no vertical
incisor segment. The direction of the Mc at the in- equilibrium forces remain at the molar or in-
cisor segment can be clockwise or counterclockwise. cisor.
The direction and magnitude of the moment cre- In a two-couple utility arch system the load
ated at the incisor brackets are related to the bend- required to bring the incisor segment of the
ing and torsion associated with insertion of the rect-
angular wire in the incisor brackets. The direction wire to the incisor brackets does not accurately
of the Mc cannot be accurately known clinically and reflect the intrusive load acting at the incisor
is important because its equilibrium forces modify teeth. The magnitude of the intrusive force
the intrusive force at the incisor. (See the article on present at the incisors is not only derived from
3-D mechanics.) the equilibrium associated with the molar acti-
incisors cannot accurately be determined clin-
ically. It is related to the location of the activa-
tion bend and the properties of the wire (See
the introduction to the article on 3-D mechan-
ics for details).
Thus the incisors are subjected to two sep-
arate possible forces for rotation and changes
in inclination. The line of the intrusive force
facially to the CRes creates a MF that will almost
always result in a tendency for crown facial/
root lingual rotation. The site of location of
this force cannot be altered with a utility arch.
In addition, the third-order couple at the inci-
sors creates a Mc that can be positive or nega-
tive in direction depending on the direction of
the couple at the incisor brackets. The direc- Figure 5. Schematic illustration of an uncinched
tion of the third-order couple at the incisors utility arch with a V-bend for crown lingual/root
can be assured by introducing a twist or torque facial rotation in the incisor segment (labial root
into the incisor segment of the utility arch. torque). The second-order couple at the molar and
If a twist or torque for crown lingual/root the third-order couple at the incisor are in the same
direction and the associated equilibrium forces act-
facial rotation is introduced into the incisor ing at both teeth are additive. The intrusive forces at
segment of the utility arch, a moment is cre- the incisor are doubled, and the incisor proclination
ated at the incisor acting in the same direction will be reduced.
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Utility Arches 29
Figure 7. An activated utility arch inserted in the

brackets at the incisors and molars. The arch has
been cinched introducing a new force system acting
Figure 6. Schematic illustration of an uncinched in a mesial direction at the molar and a lingual di-
utility arch with a V-bend for crown facial/root lin- rection at the incisor. The new force system does not
gual rotation in the incisor segment. The couple at act through the CRes at either location which creates
the molar and the couple at the incisors are in op- a new MF at both teeth. The molar and incisor will
posite directions. Therefore, their equilibrium have a combination of the MF from the cinch and
forces are also in opposite directions reducing the the Mc from the utility arch present.
vertical forces acting at the molars and incisors.
molar is restrained from distal crown rotation
vation bend. The magnitude of the intrusive by a cinch, the molar root will continue to ro-
force at the incisor is the net force derived tate mesially with a distal force against the
from a combination of the equilibrium associ- cinch. This will result in the CRes of the molar
ated with both the Mc at the molar and the moving mesially also. The distal force of the
equilibrium associated with the Mc at the inci- crown at the cinch is transmitted through the
sor. arch wire as a lingual force at the incisor brack-
Placement of third-order couples at the in- ets which restrains the incisor crown from fa-
cisors has a second effect on overbite correc- cial movement. Because the intrusive force at
tion. Apart from the magnitude of the intru- the incisor continues to act facial to the incisor
sive force present, the Mc at the incisor brack- CRes, the result is an increased incisor inclina-
ets affects overbite reduction by changes in the tion, but the increased inclination is all accom-
inclination of the teeth. If an increased intru- plished by lingual root movement. The CRes of
sive force is sought, and crown lingual/root fa- the incisor moves both intrusively and lin-
cial rotation is placed in the utility arch, the gually. This action is the same for both cinched
decreased incisor inclination will also tend to utility arches and cinched intrusion arches.
deepen the bite. If a lesser force is desired and The major difference is the utility arch needs
crown facial/root lingual rotation is applied, a to be tied back to control incisor inclination. In
tendency for more overbite reduction will oc- contrast, the one-couple intrusion arch can be
cur by increased incisor inclination. In con- tied back if desired, but does not require a
trast, a one-couple intrusion arch controls in- cinch because the incisor inclination can be
cisor inclination simply by the point of the controlled by the point of application of the
force application. The intrusive force can be incisor tie.
increased or decreased without necessarily af- Fabricating the utility arch from round
fecting the incisor inclination. rather than rectangular wire has been sug-
The inseparable side effect of changes in gested as a method of negating the third-order
incisor inclination associated with the utility couple created at the incisor brackets. A round
arch intrusion seems to be controlled by cinch- wire lacks the capacity to create third-order
ing or tying back the utility arch. However, re- couples and the result is a one-couple system
straining arch perimeter by cinching back will identical to an intrusion arch tied at the incisor
add a new horizontal force system (Fig 7). brackets. However, with a round wire utility
When the larger second-order couple at the arch the apically directed force for incisor in-
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trusion continues to be facial to the incisor CRes References

at the incisor brackets and results in a MF that
cannot be controlled as it can be with an intru- 1. Ricketts RM. Bioprogressive therapy as an answer to
sion arch. In addition, a round wire offers no orthodontic needs. Part II. Am J Orthod 1976;70:
third-order resistance to the extrusive force 241-268.
acting laterally to the CRes of the molar and its 2. Rickets RM, Bench RW, Gugino CF, et al. Bioprogres-
sive Therapy. Book 1. Denver, CO: Rocky Mountain
associated tendency toward crown lingual/root Orthodontics, 1979:93-126.
facial molar rotation. 3. Brehm W, Carapezza LJ. Space age pedodontics: The
Purposefully left out of this discussion is the use of the utility arch wire appliance. J Pedodont
effect of the second-order movement of the 1987;ll:201-229.
molars on incisor position when arch length is 4. Burstone CR. Deep overbite correction by intrusion.
restricted (ie, the reverse row-boat effect). The Am J Orthod 1977;72:l-22.
extent to which a distal molar tip effects incisor 5. Schudy FF. The control of vertical overbite in clinical
inclination is another factor which may or may orthodontics. Angle Orthod 1968;38:19-39.
not influence the system. Furthermore, the im- 6. Otto RL, Anholm JM, Engel GA. A comparative anal-
ysis of intrusion of incisor teeth achieved in adults and
pact of tip back bends on molar position with children according to facial type. Am J Orthod 1980;
regard to anchorage considerations has not 77:437-446.
been documented. Lacking clinical data and 7. Abdel-Kader HM. Clinical crown length and reduc-
any scientific formula for the predictability of tion in overjet, overbite, and dental height with orth-
this as a treatment modality weakens argu- odontic treatment. Am J Orthod 1986;89:246-250.
ments (eg, setting up anchorage as in Tweed 8. Arvystas MG. Non-extraction treatment of severe
mechanics) for this mechanism. Orthodontic Class II, division 2 malocclusions. Am J Orthod Den-
tofacial Orthop 1991;99:74-84.
tools should be chosen on the basis of the bio-
9. Engel G, Cornforth G, Damerell JM, et al. Treatment
logical responses (not an exact science yet) to of deep bite cases. Am J Orthod 1980;77:1-13.
their biomechanical properties (a much more 10. Dake ML, Sinclair PM. A comparison of the Ricketts
exact science), rather than anecdotal reports of and Tweed-type arch leveling techniques. Am J
success (failures are rarely described). Orthod Dentofacial Orthop 1989;95:72-78.
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Two-Couple Orthodontic Appliance

Systems: Torquing Arches
Robert J. Isaacson and Joe Rebellato
Twists placed in an arch wire between incisor brackets are often used in an
attempt to obtain root torque. This is only partially effective because of the
equal and opposite reciprocals acting on the adjacent teeth. Alternatively, a
V-bend in a torquing arch, inserted at only the molar and incisor brackets,
may use the bending properties of the arch wire to create dissimilar mo-
ments in a two-bracket system. If the greater moment is present at the
incisors, all of the incisors are rotated en masse in the same direction, with
the associated equal and opposite vertical equilibrium forces directed at the
incisors and molars. The lesser moment at the molar also usually has equi-
librium forces that may reduce or supplement vertical forces at the molar
and incisor depending on the magnitude and direction of the moment
present. If the arch wire is unrestrained the resulting tooth movement
shows rotation of the incisors around the CRes and movement of the CRes in
the direction of the vertical equilibrium force present. The alternative use of
a single force to rotate incisor crowns facially results in a reciprocal distal
force at the posterior teeth and rotation of the incisors with a center of
rotation apical to the CRes.
Third-order rotations are often referred to vent rotation around the C Res leading to
as torque because they are usually created greater root movement than crown movement.
by a twist in an arch wire at localized points
between edgewise brackets.1"3 When an arch
wire activated for torque is seated in two adja- The Torquing Arch
cent brackets, torsion is created in the wire
producing equal and opposite third-order cou- It is possible to avoid placing equal and oppo-
ples at the two brackets (Fig 1). Thus, an acti- site reciprocals on adjacent teeth while torqu-
vation to gain clockwise rotation on one tooth ing incisors by treating the incisors collectively
is accompanied by an equal and opposite ten- as one big tooth.5'6 The torquing arch is de-
dency for counterclockwise rotation on the ad- signed to place simultaneous, same-directional
jacent tooth.4 In an unconstrained system the third-order couples on one or more incisors
crowns would move apart in a faciolingual di- while treating all of these teeth as one big tooth
rection, but constraints from the arch wire pre- and one big bracket.6 The second bracket in
this two-couple system is at the molar. The de-
sirable low load deflection rate properties of a
From the Department of Orthodontics, School of Dentistry,
torquing arch are gained by the long span re-
Richmond, VA. sulting from inserting the arch wire into the
This work was supported in part by the Medical College of incisor and molar brackets, but not into the
Virginia Orthodontic Education &f Research Foundation. canine or premolar brackets as shown in Fig-
Address reprint requests to Robert J. Isaacson, DDS, MSD, ure 2.
College of Virginia, Virginia Commonwealth University, PO Box
Seating an arch wire at two successive brack-
980566, Richmond, VA 23298-0566. ets creates a two-bracket system that usually
Copyright © 1995 by W.B. Saunders Company creates couples and tendencies for rotation at
1073-8746I95I0101-0004$5.00IO both of the brackets. With a two-bracket system
Seminars in Orthodontics, Vol 1, No 1 (March), 1995: pp 31-36 31
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32 Isaacson and Rebellato
t
M = F-d Figure 2. A torquing arch treats the incisor brackets
as one large bracket and is inserted additionally only
into the molar tube. This represents a two-couple
system with the greater moment present at the in-
cisor that will determine the associated vertical equi-
Figure 1. A third-order couple creating a moment librium forces shown at the molar and incisor. The
for faciolingual rotation. The moment is equal to moment at the molar can be in the same or opposite
the force multiplied by the distance between the two direction.
forces of the couple and this distance is limited to
the depth of the bracket slot.
equivalent to using an intrusion utility arch and
a torquing arch simultaneously. When the Mc
it is possible clinically only to determine which at each of two successive brackets are equal and
bracket has the larger moment. When the wire opposite, their associated equilibrium forces at
is placed over the slots of the two brackets, the each bracket are also equal and opposite and
bracket slot with the greater angle of entry of function to cancel each other out. When the
the wire does show the bracket with the larger Mc at each of two successive brackets are un-
moment. The larger moment will dictate the equal and opposite, the larger of the two mo-
direction of the associated net equilibrium ments will determine the direction of the asso-
forces acting at each bracket.7"10 ciated equilibrium forces. The magnitude of
With a two-bracket system, when the wire is the equilibrium force associated with the larger
placed over the slots of both brackets where it Mc will be modified by the equilibrium forces
will be inserted, the angle of entry of the wire
at each bracket slot is not necessarily a reason-
able estimate of the direction of the Mc at the
bracket with the smaller angle of entry. When
the same arch wire is inserted into a one
bracket, one-couple system or a two bracket,
two-couple system, differences do exist that
are related to the properties of the wire when
some specific relationships exist between the
two brackets. (See article on 3-D for details.)
The V-bend in a torquing arch is placed
near the incisor to create the greater moment
at the incisors (Figs 2 and 3). In the case of
crown facial/root lingual incisor rotation, the
associated equilibrium forces are extrusive at Figure 3. A .016" x .022" torquing arch inserted
the incisor and intrusive at the molar. into the molar tubes on a model in an .018" system.
The vertical equilibrium forces at the molar The V-bend does not require a helix when using
TMA wire which is more comfortable for the pa-
and the incisor are decreased if the moments at tient. The anterior segment of the wire lies gingival
the molar tube and the incisor bracket are in to the incisors, but the vertical force at the incisor is
opposite directions (Fig 4). This would be extrusive.
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Torquing Arches 33
and a torquing arch simultaneously. When the

Mc at two successive brackets are in the same
direction, their associated equilibrium forces at
both brackets are also in the same direction.
Each tooth will feel the net result or the sum of
the forces present. This configuration of a wire
is sometimes referred to as a step bend and is
basically two V-bends creating moments in the
same direction.
To rotate incisors around the CRes and ad-
vance incisor crowns, the torquing arch wire
must be free to slide through the molar tube.
Figure 4. A two-couple system with a torquing arch In a two-couple system, if the wire is free to
bend at the incisor and an intrusion arch bend at the slide in the molar tube, the incisors will rotate
molar. When the moments at the molar and the
incisor are equal and opposite, the associated equi- around their CRes and the CRes will extrude in
librium force are equal and opposite and function to the direction of the vertical equilibrium force
cancel each other and no vertical forces are present. similar to the molar with an uncinched intru-
This is a symmetrical V-bend with rotations only sion arch in a one-couple system. When the
present. If the moments are in opposite directions
and unequal, the larger moment will prevail and will wire is cinched at the molar, a new force system
dictate the direction of the associated equilibrium is added and the incisor crown is restrained
forces. from advancing. The center of rotation of the
incisor will more nearly approximate the
bracket, only incisor lingual root torque will
associated with the smaller Mc at each tooth.
occur and the CRes will extrude in the direction
Each bracket will feel the net difference. The
of the vertical equilibrium force, as well as
magnitude and direction of the equilibrium
move lingually in the direction of the force re-
forces associated with the smaller Mc will vary
sulting from the cinch (Fig 6). This new force is
depending on the wire configuration and the
derived from the facial crown rotation being
location of the V-bend along the wire.
resisted by the cinched arch wire with a result-
The vertical equilibrium forces at the molar
ing equal and opposite lingual force at the in-
and the incisor are enhanced if the moments at
cisor and mesial force at the molar cinch, the
the molar tube and the incisor bracket are in
row-boat effect.
the same direction (Fig 5). This would be
When third-order couples for crown facial/
equivalent to using an extrusion utility type arch
root lingual movement are applied to all of the
incisor brackets, the facial crown movement
t
Figure 5. A two-couple system with a torquing arch
bend at the incisor and an extrusion arch bend at Figure 6. A torquing arch as shown in Figure 2, but
the molar. When the moments are in the same di- with the arch wire cinched. The cinch introduces a
rection, the associated equilibrium forces are addi- new horizontal force system that prevents the inci-
tive. This is a step bend with increased vertical sor crown from rotating forward and puts a mesial
forces present. force on the molar bracket.
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appears clinically to manifest more rapidly of torquing arch mechanics. This extrusion of
than the lingual root movement. This is be- the CRes does function to increase dental over-
cause the incisal edge is further away from the bite. However, the rotation of the incisors
CRes than the root apex and, for any given around their CRes will move the incisal edge
number of degrees of rotation, the incisal edge away from the occlusal plane even more rap-
will move a greater linear distance than the idly usually resulting in a reduction in clinical
root apex. The apparent rapidity of incisor overbite. The amount of overbite reduction is
crown advancement with rotation around the a function of the initial inclination of the inci-
CRes makes the torquing arch a valuable tool sor, ie, the more facially inclined the incisor is
for anterior crossbite correction. at the start of treatment, the more clinical bite
When a torquing arch is left in place for opening will occur with each degree of rota-
several months, some incisor second-order ro- tion.
tations also occur and the roots will diverge When incisor crossbite correction by a
distally. This is a function of the torsion in a torquing arch wire results in insufficient over-
3-D wire and can be corrected with a normal bite or open bite, a one-couple extrusion arch
continuous arch wire as soon as the torquing or upside-down intrusion arch is very effective
arch is removed. for closing the open bite. This requires an-
Figure 7 shows an example of the advance- other month or two of treatment time.
ment of maxillary incisor crowns using an If, instead of a one-couple system, the ex-
uncinched torquing arch. This was a true an- trusion arch wire is inserted into the incisor
terior crossbite as evidenced by the absence of brackets, it becomes a two-couple system. Un-
any anterior shift of the mandible. der these conditions, the functions of the
In the case of the patient in Figure 7, the torquing arch and the extrusion arch can be
anterior crossbite was corrected in 3 months combined in the same wire as shown in Figure
using an uncinched torquing arch wire. Fol- 5. The anterior bend gives the rotation of the
lowing incisor correction, the arch wire was torquing arch and the bend at the molar gives
cinched for three additional months in an ef- the rotation of the extrusion arch. Because the
fort to use the rowboat effect to improve the moments created at the molar and the incisor
maxillary molar Class III relationship. The lat- are in the same direction, the wire functions
ter effort was not successful as judged by the like a step bend and the equilibrium forces are
unchanged buccal segment relationship and additive.
the Class III remained dentally compensated. Another very effective application of the
The total treatment time was 6 months. torquing arch is shown by the patient in Figure
The CRes of the incisors of the patient in 8. Premature loss of mandibular primary ca-
Figure 7 was extruded, but the incisor overbite nines resulted in lingual tipping of the lower
did not significantly increase. This is a com- incisors creating a large overjet and increased
mon clinical occurrence and the usual outcome overbite. Because the patient showed excessive
Figure 7. Treatment of a dental Class III with acceptable facial esthetics. (A) Centric relations at the time
treatment was started. (B) After 6 months of treatment. An uncinched torquing arch was placed for 3 months
that rotated the incisors around their CRes and out of crossbite. At that point the arch was cinched to attempt
to improve the Class III posterior dental relationship that had no demonstrable effect in three additional
months.
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Torquing Arches 35
Figure 8. A phase I treatment. (A,C,E) Pretreatment records showing lower primary canines missing, sig-
nificant lower arch perimeter deficiency and deep overbite to the palate with an end on molar relationship.
(B,D,F) Records following upper uncinched intrusion arch and lower torquing arch treatment. The overbite
is reduced, Class I molars are present and the lower arch perimeter has been restored for eruption of the
remaining permanent teeth. This type of correction is commonly accomplished in less than 1 year of
treatment. A lower lingual holding arch is required.
lip-to-tooth, an upper intrusion arch was used root lingual direction. The arch wire was not
concurrently with a lower torquing arch. cinched because the molars were to tip distally
The upper intrusion arch was used to im- to achieve a Class I molar relationship.
prove lip-to-tooth esthetics and to contribute to When rotating mandibular incisors in a
overbite correction. It was tied distal to the lat- crown facial/root lingual direction as shown in
eral incisors to reduce the potential for a MF Figure 8, an important difference between a
further rotating the incisors in a crown facial/ torquing arch and a single force (such as an
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open coil spring) is the absence of any recip- rate, a short range, and exert equal and oppo-
rocal distal force on the molars with the use of site moments on adjacent teeth. In contrast, a
the torquing arch. In addition, the incisor torquing arch uses more of the bending prop-
tooth movement resulting from a couple is dif- erties of the arch wire to create same direction
ferent from that resulting from a force. With third-order couples at the brackets of incisor
an uncinched lower torquing arch, the lower teeth. Asymmetrical V bends can be placed
incisors rotate around the CRes and the CRes near the incisor brackets so as to create mo-
extrudes in the direction of the vertical associ- ments that are not equal and opposite at the
ated equilibrium force. With a force derived incisors and molars. Bends are far more easily
from an open coil, the resulting tooth move- visualized and measured than are torsional ac-
ment will be a rotation around a more apically tivations.
located point with the CRes moving anteriorly. A torquing arch simultaneously advances
This creates a greater chance for a force to one or more incisor crowns without the distally
move roots through the buccal plate or soft directed reciprocal force associated with sin-
tissue dehiscence than might occur with a gle-force systems such as coils. In addition, a
torquing arch and incisor rotation around the torquing arch results in incisor rotation
CRCS- around the CRes with extrusion of the CRes in
The torquing arch was extrusive to the CRes the direction of the associated equilibrium
of the lower incisors, but the overbite did not force. A single force, such as a coil spring, ro-
increase because of the crown facial/root lin- tates the incisors around a point apical to the
gual incisor rotation in the lower arch and the CRes and the CRes moves anteriorly in the di-
incisor intrusion that occurred in the upper rection of the single force.
arch from the intrusion arch. The result was
that good overbite and overjet, good lower
arch perimeter and Class I molar relations References
were established in about 1 year of total treat-
ment. A lingual arch was placed to hold the 1. Rauch ED. Torque and its application to orthodontics.
Am J Orthod 1959;45:817-830.
now sufficient lower arch perimeter and min-
2. Schrody DW. A mechanical evaluation of buccal seg-
imal Phase 2 treatment is anticipated. ment reaction to edgewise torque. Angle Orthod
As with the intrusion arch, there are occa- 1974;44:120-126.
sions to invert the torquing arch for use as an 3. Strang RHW. A Textbook of Orthodontia (ed 3). Phil-
upside-down torquing arch. For example, lin- adelphia: Lea & Febiger, 1950:439-460.
gually positioned maxillary lateral incisors may 4. Isaacson RJ, Lindauer SJ, Rubenstein LK. Moments
have been previously corrected by tipping with the edgewise appliance-incisor torque control.
Am J Orthod Dentofacial Orthop 1992; 103:428-438.
crowns facially and the root apices may still be 5. Burstone CJ. Rationale of the segmented arch. Am J
positioned palatally. An inverted torquing Orthod 1962;48:805-822.
arch, engaging only the brackets on these two 6. Burstone CJ. The mechanics of the segmented arch
lateral incisors, will provide a crown lingual/ techniques. Angle Orthod 1966;36:99-120.
root facial moment. The associated equilib- 7. Smith RJ, Burstone CJ. Mechanics of tooth move-
rium forces will be intrusive at the incisor and ment. Am J Orthod 1984;85:294-307.
extrusive at the molar. 8. Yoshikawa DK. Biomechanical principles of tooth
movement. Dent Clin North Am 1981;25:19-26.
9. Mulligan TF. Common sense mechanics. Phoenix:
Summary CSM, 2122 East Kaler Drive, 1982.
10. Demange C. Equilibrium situations in bend force sys-
Third-order rotations, activated by inter- tems. Am J Orthod Dentofacial Orthop 1990;98:333-
bracket wire twists, have a high load deflection 339.
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Systems: Activations in the
Transverse Dimension
Joe Rebellato
Partially bracketed arch wires can be activated in the transverse dimension

to produce first-order rotations of the molars and constriction or expansion
of intermolar width. A 2 x 6 arch wire is ideal for such activations because of
the minimal side effects to the anterior teeth. As with other two-couple
orthodontic appliance systems, symmetrical V-bends, asymmetrical
V-bends and step bends are used to generate moments of the couples
whose associated equilibrium forces can be used to produce desired tooth
movement.
A 2 x 6 arch wire is a partially bracketed,

two-couple appliance system that can be
activated in the transverse dimension, result-
Symmetrical V-bends, asymmetrical
V-bends and step bends are the three basic cate-
gories of wire bends used in producing couples
ing in first-order rotations of the molars and in a two-bracket orthodontic appliance system.
constriction or expansion of intermolar width, These principles apply to a 2 x 6 arch wire
with minimal side effects to the anterior teeth because it is a two-couple system.3 A rectangu-
and premolars. Although wire bends in other lar wire is used and, in this case, bends are
dimensions are certainly possible, this section made in the transverse (occlusal plane) dimen-
will deal exclusively with couples, moments of sion to generate couples at the molar and ca-
the couples (Mcs) and their associated equilib- nine brackets. The resultant Mcs are for first-
rium forces generated in the occlusal plane. order rotations and their associated equilib-
Partially bracketed appliance systems such rium forces are transversely oriented in the
as the torquing arch and the utility arch1'2 (di- occlusal plane. Because of the fact that the
agrammatically represented as two-bracket sys- transverse force systems are applied coronally
tems) have the advantage of long wire spans to the CRes, a third-order rotation is always cre-
resulting in low load deflection rate properties ated. Some molar third-order control is inher-
and a wide range of activeness. The long span ent because of the edgewise nature of the arch
facilitates a more accurate placement of bends wire but, if more torque control is required,
in the wire to create dissimilar couples, that is, the transpalatal arch may be a better choice.
couples whose associated equilibrium forces However, if the molar bands are not equipped
will not cancel each other out. Although the with lingual sheaths, the 2x6 arch wire is still
associated equilibrium forces can be the source a good option.
of clinical surprises if not properly under- The 2x6 arch wire can be used in a fully
stood, they can be harnessed in long span ap- bracketed dentition by placing convenience
pliances to produce desired tooth movement. bends to bypass the premolar brackets. These
bends should remain passive as the appliance is
From the Department of Orthodontics, School of Dentistry, inserted and will not contribute toward the
Medical College of Virginia, Virginia Commonwealth University, generation of couples or forces by the active
Richmond, VA. appliance.
Address reprint requests to Joe Rebellato, DDS, Department of Transverse activations can be placed in a 2
Orthodontics, School of Dentistry, Medical College of Virginia,
x 2 or 2 x 4 orthodontic appliance system.
Virginia Commonwealth University, PO Box 980566, Rich-
mond, VA 23298-0566. However, the best feature of the 2x6 arch
Copyright © 7995 W.B. Saunders Company wire is the ability to control molar first-order
1073-8746I95I0101-0005$5.00/0 rotations and intermolar width with minimal

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38 Joe Rebellato
side effects to the anterior teeth. This is be-

cause the 2x6 arch wire has an anterior seg-
ment of six teeth that can be visualized as one
large tooth.4'5 The reduced wire flexibility in
the short interbracket distances between the
anterior teeth tends to keep the canines from
moving independently of the segment. There-
fore, the orthodontic effects of the 2x6 arch
wire involve predominantly molar movement.
This is particularly true if identical bends are
placed bilaterally on the 2x6 arch wire be-
cause equal and opposite Mcs and/or forces on
the left and right canine will tend to cancel out
if the anterior segment is visualized as one
large tooth. Clinically, some side effects to the
canines can still be observed because the wire
in the anterior segment retains some flexibility
despite the short interbracket distances.
The 2x6 arch wire systems discussed in
this section will assume the canine and molar
bracket slots are collinear, and the wire be-
tween is a straight segment before activation.
Each activation of the 2x6 arch wire will in-
volve identical and bilateral bends, and the sys- Figure 1. Placing a 2 x 6 arch wire with a symmet-
tem will be analyzed according to the princi- rical V-bend over the brackets in which it will be
inserted will reveal opposite but equal angles of wire
ples of static mechanics. Although forces entry at the two brackets.
present in two-bracket systems are statically in-
determinate,6 clinical analysis is still possible to when the 2x6 arch wire is inserted (Fig 2).
determine the larger moment present and, The left and right canine will both feel D-out
therefore, the direction of the net associated moments of the couples but these will tend to
equilibrium forces present in the wire at time cancel each other out if we visualize the ante-
point zero (ie, before the teeth begin to move). rior segment as one large tooth. Because the
equilibrium forces associated with the Mcs at
Symmetrical V-Bends the canines and molars also cancel each other
out, only molar M-out rotations remain.
When a 2 x 6 arch wire with a symmetrical
V-bend is placed over the canine and molar Clinical Uses
bracket slots, equal but inverse angles of wire This activation of the 2x6 appliance is useful
entry are observed (Fig 1). The Mcs at both when bilateral M-out rotations of the molars
brackets will also be equal in magnitude but are desired without expansion of intermolar
opposite in direction. Their associated equilib- width (as measured at the CRes). The CRes of
rium forces will cancel each other out and both maxillary molars has been postulated to be lin-
teeth will only feel a tendency to rotate around gual to the central fossa from an occlusal
their centers of resistance (CRes) in opposite standpoint and, because of the rhomboidal
directions. shape of molar crowns, arch perimeter is in-
creased and molar M-out rotations help to-
Molar Mesial-Out Rotations ward the correction of Class II malocclusions.7
Bilateral toe-in bends made approximately
halfway between the canine and molar brack- Molar Mesial-In Rotations
ets will result in molar mesial-out (M-out) cou- Bilateral toe-out bends made approximately
ples and canine distal-out (D-out) couples halfway between the canines and molars will
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Transverse Arch Wire Activations 39
Mc
Figure 3. Bilateral toe-outs located halfway between

Figure 2. Bilateral toe-ins located halfway between
the molar and canine brackets are symmetrical V-
the molar and canine brackets are symmetrical V-
bends. M-in molar rotations will occur and although
bends. M-out rotations of the molars will be the pre-
not intuitively obvious, no molar expansion will oc-
dominant orthodontic effect in this case. cur.
result in a diametrically opposed situation to librium force acting at each bracket is zero be-
the one above with all couples, moments and cause the two Mcs are equal and opposite. As
forces reversed (Fig 3). The clinical result will the bend is located progressively closer to the
be bilateral molar mesial-in (M-in) rotations molar bracket, the magnitude of the net equi-
around their respective CRes.
librium forces increases as the Mc at the molar
Clinical Uses increases and the Mc at the canine decreases.
At one-third the length of the wire segment
Bilateral M-in rotations of the maxillary molars away from the molar, the angle of wire entry at
to decrease arch perimeter are often required the canine bracket becomes zero and no couple
in upper premolar extraction cases to compen- is generated 6 ; the only equilibrium forces
sate for small-sized maxillary second premo- present are those that are associated with the
lar s. Mc at the molar. As the bend is progressively
located closer to the molar bracket from this
Asymmetrical V Bends one-third point, the couple at the canine be-
gins to increase, but it is now in the same di-
When a 2 x 6 arch wire with an asymmetrical rection as the molar couple. The equilibrium
V-bend is placed over the canine and molar forces associated with the Mcs at the molar and
bracket slots, the larger angle of wire entry canine will be additive at this point. Therefore,
and, hence, the larger Mc is shown (Fig 4). locating the bends progressively closer to the
This will determine the direction but not the molar brackets will, in turn, lead to net associ-
magnitude of the net associated equilibrium ated equilibrium forces of greater magnitude.
forces acting at each bracket.8"10 The same conditions occur as the bend is
Once again, if the bend is located halfway located progressively closer to the canine
along the posterior wire segment between the bracket from the midpoint of the posterior
canine and molar brackets, then the net equi- wire segment. The magnitude of the net equi-
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40 Joe Rebellato
Figure 4. The larger angle of wire entry of a 2 x 6

arch wire with an asymmetrical V-bend can be de- Figure 5. Toe-in bends closer to the molar than the
termined by placing the wire over the brackets as canine brackets result primarily in molar expansion
shown. In this case, the larger Mc is at the molar and M-out molar rotations. The orientation of the
bracket. The equilibrium forces of the smaller Mc smaller Mc at the canine will determine whether its
will either enhance or attenuate the magnitude but, associated equilibrium forces will be additive or sub-
will not change the direction of, the net equilibrium tractive with those associated with the Mc at the mo-
forces acting at each bracket. lar.
librium forces increases, only this time, their with molar M-out rotations. Once again, it is
direction is determined by the orientation of important not to tie the 2x6 arch wire into
the Mcs at the canines. the premolar brackets. If the 2x6 arch wire is
tied into the premolar brackets, it becomes an
Molar Mesial-Out Rotations arch wire with a symmetrical V-bend if the toe-
in is located halfway between the premolar and
Bilateral toe-in bends placed closer to the mo- molar bracket (Fig 6). No expansion of inter-
lars than the canines will result in a greater molar width will occur in this case.
angle of wire entry at the molar bracket and,
consequently, a couple of greater magnitude at
the molar on insertion of the 2x6 arch wire Molar Mesial-In Rotations
(Fig 5). M-out Mcs at the molars and associated
equilibrium forces that will be facially directed Bilateral toe-out bends placed closer to the mo-
at the molar and lingually directed at the ca- lars will result in a reversal of the situation
nine will result. However, all bilateral forces above with all couples, moments and forces in
and/or couples at the canines, being equal and the opposite direction (Fig 7).
opposite, will tend to cancel out across the stiff
anterior arch wire segment. Clinical Uses
This activation of the 2x6 arch wire is useful
Clinical Uses when constriction of intermolar width is de-
This activation of the 2x6 arch wire is useful sired in addition to bilateral molar M-in rota-
when intermolar expansion is desired along tions.
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wire entry at the canine brackets and, therefore,

couples of larger magnitude at the canines on
insertion of the 2x6 arch wire (Fig 8). D-out
Mcs at the canines and associated equilibrium
forces that will be facially directed at the canines
and lingually directed at the molars will result.
The constrictive forces at the molars will be en-
hanced as the bend is moved progressively closer
to the canines. The molar brackets will have a
smaller Mc, the magnitude and direction of
which will depend on where the V-bend is lo-
cated along the wire. It is also possible that the
angle of entry of the wire is zero degrees at the
molar bracket on insertion of the 2x6 arch wire
and that only the equilibrium forces associated
with the Mcs at the canines are present. This
would occur only if the bend is placed one-third
Figure 6. Ligating the 2x6 arch wire into premolar of the length of the posterior wire segment away
brackets creates a symmetrical V-bend and molar from the canine bracket.
expansive forces are negated.
Clinical Uses
Molar Constriction This activation of the 2x6 arch wire allows for
Bilateral toe-ins placed closer to the canines constriction of intermolar width with minimal
than the molars will result in a greater angle of effects on molar first-order rotations.
Figure 7. Toe-out bends closer to the molar than

the canine brackets result primarily in molar con- Figure 8. Toe-in bends close to the canine brackets
striction and M-in rotations. The orientation of the result primarily in molar constriction with little or
smaller Mc at the canine will determine whether its no molar rotation. The smaller Mc at the molars will
associated equilibrium forces will be additive or sub- have associated equilibrium forces that will either
tractive with those associated with the Mc at the mo- slightly enhance or attenuate the net constrictive
lar. equilibrium forces at the molar brackets.
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42 Joe Rebellato
Molar Expansion
Bilateral toe-outs placed closer to the canines
will result in a reversal of the previous situation
with all couples, moments and forces in the
opposite direction (Fig 9).
Clinical Uses
This activation of the 2x6 arch wire allows for
expansion of intermolar width with minimal
changes in molar first-order rotations.
Step Bends
When a 2 x 6 arch wire with a step bend is
placed over the canine and molar bracket slots,
similarly oriented angles of entry are revealed.
Figure 9. Toe-out bends close to the canine brackets The Mcs at the canine and molar brackets will
result primarily in molar expansion with little or no both be in the same direction with respect to
molar rotation. The smaller Mc at the molars will each other and their associated equilibrium
either slightly enhance or attenuate the net expan- forces will always be additive (Fig 10). Locating
sive equilibrium forces at the molar brackets. the bends progressively closer to the brackets
will result in greater angles of wire entry at the
brackets and greater Mcs present on insertion.
This in turn, will lead to associated equilibrium
forces of greater magnitude.
M
Figure 10. A 2 x 6 arch wire with step bends will
have angles of wire entry and resultant couples that Figure 11. Toe-outs at the canines and toe-ins at the
are similarly oriented. The magnitudes of the Mcs molars result primarily in M-out molar rotations
do not have to be equal, but their associated equi- with enhanced expansive equilibrium forces at the
librium forces will always be additive. molars.
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Clinical Uses
when molar M-out rotations are required
along with greater molar expansive forces than
can be obtained with asymmetrical V-bends.
Step Bend for Molar Constriction

Bilateral toe-ins closer to the canines with toe-
outs closer to the molars results in a reverse of
the previous situation with couples, moments,
and forces in the opposite direction (Fig 12).
Clinical Uses
when molar M-in rotations are required along
with greater molar constrictive forces than can
be obtained with asymmetrical V-bends.
References
1. Ricketts RM. Bioprogressive therapy as an answer to
orthodontic needs. Part II. Am J Orthod 1976;70:
241-268.
2. Ricketts RM, Bench RW, Gugino CF, et al. Biopro-
Figure 12. Toe-ins at the canines and toe-outs at the gressive Therapy. Book 1. Denver, CO: Rocky Moun-
molars result primarily in M-in molar rotations with tain Orthodontics, 1979:93-126.
enhanced constrictive equilibrium forces at the mo- 3. Isaacson RJ, Lindauer SJ, Rubenstein LK. Activating a
lars. 2x4 appliance. Angle Orthod 1993;63:17-24.
4. Burstone CJ. Rationale of the segmented arch. Am J
Orthod 1962;48:805-822.
5. Burstone CJ. The mechanics of the segmented arch
Step Bend for Molar Expansion techniques. Angle Orthod 1966;3:99-120.
6. Burstone CJ, Koenig HA. Force systems from an ideal
arch. Am J Orthod 1974;65:270-289.
Bilateral toe-outs closer to the canines with toe- 7. Burstone CJ. Precision lingual arches—Active applica-
ins closer to the molars results in a step bend tions. J Clin Orthod 1989;23:101-109.
activation of the 2x6 arch wire and the ca- 8. Demange C. Equilibrium situations in bend force sys-
nines and molars will both feel M-out Mcs tems. Am J Orthod Dentofacial Orthop 1990;98:333-
339.
(Fig 11). Their associated equilibrium forces 9. Smith RJ, Burstone CJ. Mechanics of tooth move-
will both be facially directed at the molar ment. Am J Orthod 1984;85:294-307.
bracket and lingually directed at the canine 10. Yoshikawa DK. Biomechanical principles of tooth
bracket. movement. Dent Clin North Am 1981;25:19-26.
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Systems: Transpalatal Arches
Joe Rebellato
The transpalatal arch (TPA) can be activated to deliver a clinically useful

array of forces and couples to move and/or rotate maxillary molars in all
three planes of space. Changing the palatal arch form can produce expan-
sion or constriction of intermolar width and activation of the inserts of the
TPA will produce couples at the molar sheaths. Activations of the inserts to
generate couples is possible in all three planes of space in the form of
symmetrical V-bends, asymmetrical V-bends, and step bends. Although the
associated equilibrium forces of a couple can be the source of clinical sur-
prises, they can also be harnessed to produce favorable tooth movements.
Thetranspalatal arch (TPA) has tradition- be measured clinically and are therefore very
ally been used as a soldered, passive orth- predictable. Two-bracket systems where the
odontic appliance. Its many uses have included appliance is engaged in the brackets/sheaths of
molar anchorage, space maintenance, and re- both teeth have force systems that are statically
tention after rapid maxillary expansion. The indeterminate.3'4 This is to say that it is diffi-
removable TPA, also known as the Palatal cult to measure clinically the forces that are
Arch Bar or Transpalatal Lingual Arch, allows present in the wire. However, static analysis
for more versatile treatment applications than still provides a clinically useful prediction of
does its soldered counterpart.1'2 the direction and relative magnitude of the
The biomechanical understanding of the re- forces and moments present in the TPA sys-
movable TPA is complex because it is a two- tem at time point zero (ie, before the teeth be-
bracket system that is constrained at both ends. gin to move).
It is, in a way, cinched so that the wire can
move neither in nor out of the molar sheaths Forming a Passive TPA
on either side. Constraining forces that cannot
be intuitively predicted are introduced into the A set of models can be used as a guide in in-
system caused by the rigidity and fixed length directly forming the approximate shape of the
of the transpalatal wire. The addition of these TPA, or it may be fabricated directly from the
new forces may affect tooth movement in such patient's mouth. The TPA can either be made
a way as to alter the anticipated response of the from stainless steel round wire of proper
teeth. It is difficult to accurately account for all gauge to fit into the molar sheaths (Figs 1-3) or
of these forces so they will only be discussed in a preformed TPA may be chosen.
certain instances where they play a significant It is very important to always have the TPA
role in tooth movement. tied to some string or floss while holding it or
One-bracket systems deliver forces that can inserting it inside the mouth to prevent acci-
dental swallowing or aspiration of the appli-
From the Department of Orthodontics, School of Dentistry, ance.
Medical College of Virginia, Virginia Commonwealth University, The next step is to make the TPA passive,
Richmond, VA. ie, the TPA should effect no forces, couples, or
Address reprint requests to Joe Rebellato, DDS, Department of tooth movement once inserted. This can be
Orthodontics, School of Dentistry, Medical College of Virginia, done by placing an insert into one of the
Virginia Commonwealth University, PO Box 980566, Rich-
mond, VA 23298-0566.
sheaths and checking if the contralateral insert
Copyright © 1995 by W.B. Saunders Company lies adjacent to and parallel to its sheath. It is
1073-874619510101 -0006$5.00IO impossible to tell if a TPA is passive with both
44 Seminars in Orthodontics, Vol 1, No 1 (March), 1995: pp 44-54

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Transpalatal Arches 45
Figure 1. Fabrication of TPA on a model. The pal-

atal loop and tissue offset bends are modifications Figure 3. A final bend to tuck the end of the wire
that help in adjustments to prevent soft tissue im- out of the way is made. The fit of the TPA can be
pingement. checked on the model and the inserts can be ad-
justed to the approximate location and orientation
of the molar sheaths.
inserts placed into their sheaths simulta-
neously. Only one insert must be in a sheath at
any given point in time to determine if the sumed to be sufficient to keep the TPA from
TPA is passive. becoming dislodged between appointments.
All adjustments should be done outside the
mouth and to the side that was inserted to al- Activating the TPA
low the contralateral insert to lie adjacent and The same biomechanical principles apply to
parallel to its sheath. Once this is accom- activating the TPA as apply to all other orth-
plished, remove the first insert from its sheath, odontic appliances. Forces and couples can be
place the contralateral insert into its own generated by the TPA, resulting in moments
sheath and repeat the process. Again, adjust- of the couples and moments of the forces. Un-
ments should be made only on the side that derstanding the application of couples and
was just inserted. The process may have to be forces with the TPA is a little more complex
repeated several times to get a completely pas- because it is a constrained two-bracket system.
sive TPA. Generating forces to expand or constrict in-
It is important to secure the TPA into the termolar width can be easily done by widening
sheaths with elastomeric or steel ligatures be- or narrowing the palatal arch form of the TPA
fore dismissing the patient (Figs 4 to 8). The before insertion. Adjusting the palatal loop will
friction between the inserts of the TPA and the help to keep the TPA an appropriate distance
sheaths of the molars bands should not be as- from the palate.
Figure 2. Lingual arch (lingual lock) pliers are used

to form the inserts of the TPA. The inserts should
be made slightly longer than the molar sheaths if Figure 4. An elastic ligature can be hooked around
there is no gingival bar on the sheaths to help tie in the gingival bar of the molar sheath to help secure
the TPA. the TPA.
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46 Joe Rebellato
Figure 5. An elastic ligature can be hooked around

the end of the insert to secure the TPA if the molar Figure 7. A heavy wire ligature can be used instead
sheath does not have a bar. The insert of the TPA of an elastic ligature to secure the TPA in place.
must be made long enough at the time of fabrica-
tion.
and theoretically, a symmetrical V-bend (oppo-
site and equal angles of entry) should result in
Generating couples using a TPA can be ac- symmetrical tooth movement. Clinical diffi-
complished in one of three activation types: culty in obtaining a perfectly symmetrical
symmetrical V-bends, asymmetrical V-bends, V-bend and differences in biological response,
and step bends. The TPA creates V-bends or even between contralateral molars, will keep
step bends by activations of the inserts. This this from precisely occurring. However, fairly
creates the relative couples determined by the predictable molar movements should occur
angle of insertion just as V-bends and step with a symmetrical V-bend.
bends in an arch wire.
Symmetrical V-bends will create opposite
and equal couples whose associated equilib-
Bilateral Expansion/Constriction
rium forces will cancel out. Asymmetrical Expansion of intermolar distance can be easily
V-bends will create opposite but unequal cou- accomplished by widening the palatal arch
ples whose equilibrium forces will be subtrac- form of the TPA, thereby increasing the dis-
tive but not cancel each other out. Step bends tance between the inserts of the TPA. When
will create couples in the same direction whose placed into the molar sheaths, the TPA will
equilibrium forces will always be additive. deliver an expansive force that will be acting in
The TPA is acting upon two similar teeth a facial direction at a level occlusal to the cen-
Figure 6. The TPA fully secured with an elastic lig- Figure 8. The TPA fully secured with a wire liga-
ature. ture.
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ters of resistance (CRes) of the teeth (Fig 9).

The CRes will have a tendency to move facially
along a direction that is parallel to the line of
force acting on the teeth. The teeth will also
have a tendency to rotate around their CRes in
a crown-facial/root-lingual fashion. This
Figure 10. Bilateral constriction of intermolar
tendency to rotate caused by the moment width.
(g • mm) of the force, can be represented as a
mathematical product of the magnitude of the
expansive force (g) acting on the tooth mul- strained by the TPA, the CRot will be closer to
tiplied by the shortest perpendicular distance the sheath and some expansion may be neces-
(mm) from the force vector to the CRes of the sary to maintain intermolar width. No antero-
tooth it is acting on. Similar molar movements posterior movement of the CRes will occur be-
should occur bilaterally. The instantaneous cause the associated equilibrium forces (which
centers of rotation (CRot) will be apical to the in this case act in an anteroposterior direction)
CRes of the molars. are equal and opposite and will cancel each
Constriction of intermolar distance can be other out.
easily accomplished by narrowing the palatal
Clinical Uses
arch form of the TPA, thereby decreasing the
distance between the inserts of the TPA. Once M-Fa rotations are frequently required in non-
activated by inserting the TPA into the molar extraction treatments to gain arch perimeter.
sheaths, the CRes of the molars will tend to Because of the rhomboidal shape of molar
move lingually toward each other, and the crowns and the fact that the CRes has been pos-
teeth will have a tendency to rotate in a crown- tulated to be lingual to the central fossa (as
lingual/root-facial fashion (Fig 10). Once seen from an occlusal view), space may open
again, the instantaneous CRot will be apical to mesial to the molars giving the illusion that
the CRes of the molars, but the rotation will be both molars are moving distally.5 This molar
in the opposite direction to expansion. characteristic becomes an important factor in
The analysis of these force systems does not defining arch perimeter during first-order ro-
take into account the couple that may be gen- tations. M-Fa rotations are also useful during
erated between the insert of the TPA and the extraction treatment to counter the mesiolin-
molar sheath as the teeth begin to move. gual (M-Li) moments produced by the space
closing forces acting facial to the CRes of the
teeth.
Symmetrical V Bends Patients often also present with upper first
Bilateral First-Order Activations
(Mesiofacial Rotations)
First-order symmetrical activations of the in-
serts as shown in Figure 11 will result in equal
and opposite couples applied to the molars.
The tendency will be for each molar to rotate
around its CRes in a mesiofacial (M-Fa) direc-
tion. However, because arch width is con-
M
Figure 11. Bilateral toe-ins in the occlusal plane will

Figure 9. Bilateral expansion of intermolar width. produce bilateral mesiofacial rotations.
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48 Joe Rebellato
molars that are rotated M-Li and require M-Fa cies and to seat the molar cusps properly for a
rotations before initiating headgear therapy to Class II molar finish.
allow easier insertion of the inner bow into the
headgear tube. The removable TPA can easily Bilateral Second-Order Activations
do this, obviating the need for brackets and (Mesiodistal Tipping)
wires to rotate the molars M-Fa.
Second-order activations of the inserts as
shown in Figure 13 will result in a torsional
Bilateral First-Order Activations activation of the palatal wire when the inserts
(Mesiolingual Rotations) are placed into the molar sheaths. Equal and
opposite couples will be applied to the molars
First-order symmetrical activations of the in- in the sagittal plane. One molar will have a
serts as shown in Figure 12 will result in equal tendency to rotate clockwise and the other mo-
and opposite couples applied to the molars, lar will tend to rotate counterclockwise around
but this time the tendency is for mesiolingual their respective CRes.
(M-Li) rotations about the CRes of the molars. However, the palatal arch will introduce
The arch width is constrained by the TPA so constraining forces into the system and will
the CRot will be close to the sheath and some move the instantaneous CRot occlusally and
expansion may be necessary to maintain inter- closer to the molar sheaths (Fig 14). The molar
molar width. Once again, the equal and oppo- with the crown-distal/root-mesial couple will
site associated equilibrium forces cancel out undergo mesial root movement and the CRes
and no anteroposterior movement of the CRes will move mesially because the stiffness of the
will occur. This situation is similar to the bilat- palatal arch will prevent the crown from mov-
eral M-Fa rotations, except all forces, couples, ing distally. The contralateral molar with the
and moments are reversed. crown-mesial/root-distal couple will undergo
distal root movement and the CRes will move
Clinical Uses distally for similar reasons.
Bilateral M-Li molar rotations are often re- There are no associated equilibrium forces
quired in finishing cases of upper extractions
for camouflage of Class II malocclusions. The
M-Li molar rotation takes advantage of the
rhomboidal shape of the molar crown and the
location of the CRes to decrease arch perimeter.
This may help to close any remaining posterior
spaces that resulted from tooth size discrepan-
Figure 13. Activation of a TPA for second-order

mechanics. (A) A side view of a TPA with bilateral
second-order activations. (B) A toe-up of the insert
at the upper right first molar will produce a crown-
distal/root-mesial couple at the molar sheath. (C) A
toe-down of the insert at the upper left first molar
Figure 12. Bilateral toe-outs in the occlusal plane will produce a crown-mesial/root-distal couple at the
will produce bilateral mesiolingual rotations. molar sheath.
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Clinical Uses
This activation of the TPA is useful in the cor-
rection of a unilateral Class II dental malocclu-
sion. This works most effectively when no arch
wires are in place or may be used in combina-
tion with a headgear. The molar with the distal
root movement also has its CRes moving distally
and this will help toward correcting the Class
II molar relationship.
Bilateral Third-Order Activations (Facial

Root Torque)
Symmetrical third-order activations of the in-
serts as shown in Figure 15 will result in equal
and opposite couples applied to the molars in
the frontal plane. The associated equilibrium
forces will cancel out, and the tendency will be
for the molars to rotate around their CRes in a
crown-lingual/root-facial direction and for the
molar sheaths to come closer together.
However, the system is constrained and the
stiffness of the palatal arch will help to main-
tain the intersheath distance. The stiffness of
Figure 14. Constraint from the wire of the TPA will the wire imposes a facially directed force acting
prevent second-order rotations of the molars
around their respective CRes. In effect, mesial and at the molar sheaths and the CRes of the teeth
distal root torque of the molar roots will result. will move facially because of this force. The
instantaneous CRot are in this situation moved
occlusally and closer to the molar sheaths.
present in this case. One couple and its mo-
ment will be equal and opposite to the other Clinical Uses
couple and its moment and the whole system
When performing arch expansion using a
will be in equilibrium.6'7 Torsional activations
TPA, facial root torque activations can be in-
in wires create equal and opposite couples on
corporated along with the expansive compo-
the involved tooth pair. This is similar to third-
nent to simultaneously upright the roots as the
order torque activations in continuous arch
intermolar width increases (Fig 16). This third-
wires where the adjacent teeth will feel equal
and opposite torquing moments (see Torquing order torque may help control transverse re-
lapse and create better occlusal interdigitation
Arch section). It is the stiffness of the contin-
and fewer balancing interferences by upright-
uous arch wire that introduces constraining
ing the molar roots. A TPA can also be placed
forces and prevents the teeth from rotating
around their CRes, leading to greater root
movement than crown movement.
Equal and opposite activation of the inserts
is not required because with torsional activa-
tions, the angle of entry is always equal and
opposite between the two paired teeth creating
opposite couples of equal magnitude. Tor-
sional activations of arch wires are closely re-
lated to V-bends because of the fact that the Figure 15. Bilateral toe-ins in the frontal plane will
angles of entry are always equal and opposite. produce bilateral facial root torque.
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50 Joe Rebellato
sociated equilibrium force being applied at the

sheath that will tend to move the CRes of the
molar mesially. This mesially directed force,
acting lingual to the CRes of the tooth, will gen-
erate a moment of the force that will be addi-
tive to the M-Fa moment of the couple. Al-
though present, the magnitude of the moment
Figure 16. Bilateral toe-ins in the frontal plane of the force is very small and clinically negligi-
along with expansion in the palatal arch form will ble compared with the effects of the moment
result in an increase in intermolar width and molar of the couple. This is because the moment of
translation. the force is a product of two small factors; the
magnitude of the equilibrium force multiplied
after rapid maxillary expansion (RME) to not by the smallest perpendicular distance from
only retain the transverse molar width, but to the force vector to the CRes of the molar.
also upright the molars that may have tipped The equilibrium force acting on the contra-
out facially with the RME appliance. lateral molar will apply a distally directed force
at the sheath. The CRes will move distally in a
direction parallel to the vector of the line of
Asymmetrical V-Bends force acting on the tooth. The force is acting
Unilateral First-Order Activations lingual to the CRes of the molar and for reasons
(Mesiofacial Rotation) previously mentioned, the resultant moment
of the force is small and can be clinically dis-
First-order activation of only one insert as regarded.
shown in Figure 17 will produce a unilateral
couple and result in a M-Fa moment of the Clinical Uses
couple on that molar and an associated equi-
librium force on the other molar. The associ- A unilateral first-order activation of the TPA
ated equilibrium forces will be in anteroposte- resulting in a unilateral M-Fa moment of the
rior direction. These equilibrium forces will be couple is useful in the correction of a unilateral
felt by the teeth at their point of application by Class II dental malocclusion. This works most
the TPA, ie, at the sheaths. effectively when no other arch wires are in
The molar with the large M-Fa moment of place. A headgear can be used to keep the
the couple will also feel a mesially directed as- M-Fa rotation of the molar from fully express-
ing itself.
To minimize the side effect of the molar
M-Fa rotation, the TPA can be used with a
full-bonded/banded appliance system (Fig 18).
This allows the molar moving distally to slide
back along the wire while at the same time the
arch wire minimizes the M-Fa rotation of the
other molar as the wire would have to bend or
the whole arch would have to skew over to al-
low the M-Fa rotation to express itself.
Unilateral First-Order Activations

(Mesiolingual Rotation)
First-order activation of only one insert as
Figute 17. A unilateral toe-in in the occlusal plane couple and result in a M-Li moment of the
will produce a M-Fa moment on one molar and an- couple on that molar and an associated equi-
teroposterior equilibrium forces. librium force on the other molar. This is sim-
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sheath and lingual to the CRes of the molar.

The CRes of the molar will tend to move me-
sially from the force and the small moment of
the force that is generated can be disregarded.
Clinical Uses
A unilateral first-order activation of the TPA
resulting in a unilateral M-Li moment of the
couple is ideal when the situation requires loss
of molar anchorage on one side. Again, the
side effect of molar rotation is minimized in a
full-bonded/banded appliance system. The
molar moving mesially slides forward along
the wire while the arch wire minimizes the
M-Li rotation of the other molar as the wire
Figure 18. A unilaterally-activated TPA has moved
the upper left buccal segment distally. The insert would have to bend or the whole arch would
with the toe-in is in its sheath to show the degree of have to skew over to allow the M-Li rotation to
activation of the appliance. Note the floss to prevent express itself. Although there is a tendency for
accidental swallowing or aspiration of the TPA. the molar with the M-Li moment to move dis-
tally, Class III elastics can be used to counter-
ilar to the previously discussed TPA except act this movement.
that all moments and forces are reversed.
The associated equilibrium forces will be in Unilateral Second-Order Activations
an anteroposterior direction. A distally di-
rected equilibrium force will be acting on the A second-order activation of only one insert
molar with the M-Li moment of the couple and will result in a torsional activation of the palatal
the CRes will have a tendency to move distally. wire when the inserts are placed into the molar
This distally directed force is acting lingual to sheaths. Equal and opposite couples will be ap-
the CRes of the molar but the resultant moment plied to the molars in the sagittal plane because
of the force is small and can be disregarded. with torsional activations, the angle of entry is
The contralateral molar will feel a mesially always equal and opposite between the two
directed equilibrium force that is acting at the paired teeth. It is therefore impossible to cre-
ate asymmetrical torsional activations because
the paired teeth will always feel opposite cou-
ples of equal magnitude.
Unilateral Third-Order Activations

(Facial Root Torque)
A third-order activation of only one insert as
couple and result in a facial root torque mo-
ment of the couple on that molar and an asso-
ciated equilibrium force on the other molar.
This is similar to the first-order activations ex-
cept the moments in this case are oriented in
the frontal plane.
The associated equilibrium forces will be in
a vertical (intrusive-extrusive) direction. These
Figure 19. A unilateral toe-out in the occlusal plane equilibrium forces will be felt by the teeth at
will produce a M-Li moment on one molar and an- their point of application. The molar with the
teroposterior equilibrium forces. large facial root torque moment will also feel
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52 Joe Rebellato
facially because of the expansive force, and the

moment of the force will tend to make the
tooth rotate in a crown-facial/root-lingual di-
rection.
Once the molar is tipped out of crossbite,
the expansive component to the TPA can be
inactivated. The insert bends are reversed so
that the molar that was tipped out of crossbite
Figure 20. A unilateral toe-in in the frontal plane will now be undergoing facial root torque to
will produce a facial root torque moment on one upright the roots. The molar that previously
molar and intrusive-extrusive equilibrium forces. had the large moment of the couple with the
intrusive equilibrium force now has the extru-
an intrusively directed equilibrium force ap- sive equilibrium force acting at its sheath.
plied at the sheath and the CRes will have a
tendency to intrude in a direction parallel to Step Bends
the intrusive force vector. The small moment
of the force generated by this lingually posi- The previous asymmetrical V-bend examples
tioned force may be clinically disregarded. have described a unilateral couple and its mo-
The contralateral molar will have an extru- ment on one molar, and no couple (angle of
sive equilibrium force acting at the sheath and entry = zero degrees) on the other molar. In-
lingual to the CRes of the tooth. The CRes of the creasing the angle of entry of the insert on the
molar will have a tendency to extrude in a di- couple side increases the magnitude of the mo-
rection parallel to the force vector. There will ment felt by that molar and concomitantly, the
also be a moment of the force generated, but magnitude of the associated equilibrium forces
once again it is not clinically relevant. felt by both molars. However, this creates a
very high angle of entry of the insert at one
Clinical Uses sheath and may make insertion of the appli-
ance difficult or possibly painful to the patient.
The differential moments in the above TPA
Step bends are essentially two-bracket sys-
can be used in conjunction with expansion in
tems that have couples at the brackets that are
the TPA's palatal wire to correct unilateral
always in the same direction. The associated
crossbites (Fig 21). The facial root torque gen-
equilibrium forces will also be additive and so,
erated on one molar can be used as anchorage
step bends can be an efficient way of increasing
to prevent expansion of the molar crown on
the magnitude of the equilibrium forces with-
one side, although the CRes will still have a ten-
out greatly increasing the angle of entry at a
dency to move facially. The CRes of the molar
sheath.
in crossbite will also have a tendency to move
First-Order Step Bend Activations

First-order step bend activations of the inserts
as shown in Figure 22 combines the two pre-
vious unilateral first-order activations (Figs 17
I and 19). The step bend generates couples on

the molars that are in the same direction and
so, the associated moments that make up the
Figure 21. A unilateral toe-in in the frontal plane equilibrium will both be in the opposite direc-
along with expansion in the palatal arch form will tion. The associated equilibrium forces will be
result in a facial translation of the molar with the
moment of the couple and a facial tipping out of the additive and the forces will be felt by the mo-
molar in crossbite. Note that more crown movement lars at their point of application, ie, at the
has occurred with the molar that is tipping facially. sheaths.
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n
Figure 23. A toe-in of one insert and a toe-out of
the other in the frontal plane will produce moments
of the couple that are both in the same direction
with intrusive-extrusive forces that are additive.
and so, the CRes of the molars will tend to move

in an apico-occlusal direction. The CRes of the
Figure 22. A toe-in of one insert and a toe-out of molar with the facial root torque moment will
the other in the occlusal plane will produce mo-
ments of the couple that are both in the same direc- tend to intrude, and the CRes of the molar with
tion with anteroposterior equilibrium forces that are the lingual root torque moment will have a ten-
additive. dency to extrude. The moments of these asso-
ciated equilibrium forces are present, but are
Additionally, the moments of the force will clinically insignificant.
be additive to the moments of the couple in
this situation. This is because of the lingual po- Clinical Uses
sition of the sheaths on the molar bands. Al-
though the equilibrium forces are greater than This step band activation of the TPA, if com-
in the asymmetrical V-bend examples, the mo- bined with expansion in the TPA's palatal wire,
ments of the force can still be disregarded. is useful in correcting unilateral crossbites (Fig
Once again, this is because the moments of the 24). This application is similar to the one dis-
force are very small compared with the mo- cussed in the unilateral third-order activations
ments of the couple. section, except the additional crown-buccal/
root-lingual couple helps to quickly get the mo-
Clinical Uses lar crown out of crossbite.
This step bend activation of the TPA is useful As with the unilateral third-order activation
in the correction of a unilateral Class II dental TPA, the expansive component can be inacti-
malocclusion where a distally directed force of vated once the molar is out of crossbite. The
greater magnitude is required. As previously inserts are now adjusted so that the molar that
mentioned, arch wires or headgears are useful was brought out of crossbite will now be un-
in minimizing the side effect of molar rotation.
Third-Order Step Bend Activations

Step bend activations of the inserts (Fig 23)
combines the previously discussed unilateral
facial root torque TPA with a unilateral lingual
root torque TPA (not previously discussed be-
cause of lack of clinical application). The cou-
ples generated are in the same direction and Figure 24. A step-bend activation of the inserts in
so, the associated equilibrium forces will be ad- the frontal plane along with expansion in the palatal
arch form will result in translation of the molar with
ditive. the facial root torque couple. The contralateral mo-
The equilibrium forces are acting in a ver- lar will tip out facially from the expansive force and
tical rather than an anteroposterior direction the lingual root torque couple.
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54 Joe Rebellato
dergoing facial root torque to upright the tions with the appliance, even if only a few of
roots. The angle of entry of the other insert is the possible activations are routinely used.
now adjusted to zero degrees or passive entry
and this molar will now have the extrusive References
equilibrium force acting on it. 1. Burstone CJ, Manhartsberger C. Precision lingual
arches-Passive applications. J Clin Orthod 1988;22:
444-451.
2. Burstone CJ. Precision lingual arches-Active applica-
Conclusion tions. J Clin Orthod 1989;23:101-109.
3. Burstone CJ, Koenig HA. Precision adjustment of the
Several clinical applications of the removable transpalatal lingual arch: Computer arch form prede-
TPA have been presented. This section is not termination. Am J Orthod 1981 ;79:115-133.
complete with regard to all the possible uses 4. Burstone CJ, Koenig HA. Force systems from an ideal
arch. Am J Orthod 1974;65:270-289.
and activations of this appliance. Unilateral lin- 5. Mulligan TF. Common sense mechanics. Phoenix,
gual root torque activations and bilateral lin- CSM, 2122 East Kaler Drive, 1982.
gual root torque activations have not been dis- 6. Isaacson RJ, Lindauer SJ, Rubenstein LK. Moments
cussed because of their lack of clinical applica- with the edgewise appliance: Incisor torque control.
tion but are nonetheless possible to obtain. As Am J Orthod Dentofacial Orthop 1993; 103:428-438.
7. Nikolai RJ (Ed). Delivery of torque by the orthodontic
with any other orthodontic appliance, under- appliance, In: Bioengineering analysis of orthodontic
standing the basic biomechanics leads to un- mechanics. Philadelphia, PA: Lea & Febiger, 1985:
derstanding the full range of treatment op- 272-321.
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Creative Arch Wires and

Clinical Conclusion
Robert J. Isaacson
When two successive couples are present, the absolute value of the moment
at each bracket cannot be clinically determined. The larger moment can be
identified, however, and this will show the direction of the associated equi-
librium forces. If the couples at two adjacent brackets produce moments in
opposite directions, the associated equilibrium forces are also in opposite
directions. The net equilibrium force present at each bracket is in the direc-
tion of the equilibrium force associated with the larger moment, but the
magnitude of the force is reduced by the oppositely directed equilibrium
force associated with the lesser moment. If the couples at two adjacent
brackets produce moments in the same direction, their associated equilib-
rium forces are also in the same direction and the net equilibrium force
present at each bracket is the sum of the equilibrium force associated with
each moment.
Theunique characteristic of the edgewise it is attached. This will create equal and oppo-
appliance is its 3-dimensional ability to cre- site tendencies for rotation at these teeth with
ate moments using couples. The orthodontic the associated equilibrium forces canceled out.
clinical application of the moment of a couple In Figure 1 the bracket-to-wire relationship
requires an understanding of the equilibrium at B and C shows angles in opposite directions
of the moment of a couple. This subject is at two brackets, but the angle is greater at the
rarely mentioned in the orthodontic literature. molar. Therefore, the direction of the moment
We prefer to use one-couple systems be- at the molar determines the direction of the
cause they are statically determinate—the associated equilibrium forces. These forces are
forces present can be measured clinically. only modified by the direction and magnitude
Two-couple systems are statically indetermi- of any lesser moment at the incisor.
nate—the complete force system present can In Figure 1 the converse is present at D and
not be measured clinically, but the larger mo- E and the greater moment is created at the
ment and the direction of its associated equi- incisor. The direction of this moment now
librium can be established clinically. dominates and its direction will determine the
Figure 1 shows the finite variety of wire direction of the associated equilibrium forces.
bracket relationships possible in a two-couple Figure 2 shows ways the equilibrium forces
system with one V-bend. Wire A creates equal associated with the moments in a two-couple
and opposite moments at the two teeth where system with two V-bends impact on each other.
If the effects shown at B and D in Figure 1 are
From the Department of Orthodontics, School of Dentistry, combined into one arch wire, the net result is a
Medical College of Virginia, Virginia Commonwealth University, symmetrical V-bend with equal and opposite
Richmond, VA. moments and equilibrium forces that are can-
Address reprint requests to Robert J. Isaacson, DDS, MSD, celed out. This is equivalent to using simulta-
PhD, Department of Orthodontics, School of Dentistry, Medical neously a utility arch and a torquing arch. The
College of Virginia, Virginia Commonwealth University, PO Box
980566, Richmond, VA 23298-0566. same effect is created when the effects of C
Copyright © 1995 by W.B. Saunders Company and E in Figure 1 are used simultaneously.
1073-8746I95I0101-0007$5.00IO Equal and opposite moments are created

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56 Robert J. Isaacson
Figure 2. The two-couple bracket-wire relationships

at the lesser bracket may be assured by amplifying
the direction of the moments at this bracket. If the
bracket wire relationships are clearly in opposite di-
rections (as in B-D and C-E) the equilibrium force
Figure 1. The qualitative wire-bracket relationships associated with the larger moment are progressively
possible in a two-couple system with one V-bend. In reduced until the angles are equal and opposite and
A the angle formed by the wire and the bracket is the associated equilibrium forces are canceled out.
equal and opposite at the two teeth. The associated This is a progression from an asymmetrical V to a
equilibrium forces are also equal and opposite symmetrical V. When the bracket-wire relationships
thereby canceling each other out. B has the larger are in the same direction (as in C-D and B-E) the
wire-bracket angle at the molar creating a larger equilibrium forces associated with the moments at
moment and larger associated equilibrium forces. It both brackets are additive up to the point of being
is possible clinically to know only the direction of the doubled. This is a step bend.
larger moment and the direction of its associated
equilibrium forces. C shows the same relationships
as B only in the opposite direction. D and E show forces are additive. This is a very useful pro-
the larger wire-bracket slot angle at the incisor cedure and can produce strong extrusive
showing the direction of the moment at the incisor forces at the incisor. Similarly, when the effects
and the direction of its associated equilibrium of B and E in Figure 1 are combined, it is
forces.
equivalent to adding heavy facial root torque
to a utility arch and the incisor instrusion force
which cancel out the associated equilibrium is increased.
forces. All systems reported in the past and all sys-
Figure 2 also shows the effects of creating tems that will be reported in the future will use
moments in the same direction or step bends at these principles. The orthodontists who un-
the two brackets. For example, if the effects of derstand and identify them will have better
C and D in Figure 1 are two moments in the control of their treatments and greater effi-
same direction, the associated equilibrium ciency in treatment.
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Responses of 3-Dimensional Arch Wires to

Veiîcal V-Bends: Comparisons with
Existing 2-Dimensional Data in the
Lateral View
Robert J. Isaacson, StevenJ. Lindauer, and Paul Conley
The mechanics of V-bends in orthodontic arch wires have been described

almost exclusively in terms of bending forces in two-dimensional (2-D) sin-
gle plane terms. When a rectangular arch wire enters a third dimension, a
more complex wire deformation pattern develops from both torsion and
bending during the activation of the V-bends. The necessity for a rectangular
three-dimensional (3-D) arch wire to undergo torsion during activation re-
sults in a greater resistance to deformation at those points in the wire where
the torsion is greatest. This is especially apparent with 2x2 long span arch
wires. This study used finite element analysis to model the force systems
produced by activation of V-bends in 3-D arch wires. In both 2-D and 3-D
data, greater moments are present as any V-bend is moved toward either
adjacent bracket. In 3-D systems, however, a V-bend at the molar produces
significantly less moment and associated equilibrium forces than the same
V-bend located the same distance from the incisor. Moreover, the reversal of
the direction of the moments at either bracket does not occur when the
V-bend location is two thirds of the distance toward that tooth as reported
with 2-D studies.
rthodontic arch wire mechanics have been When a segment of wire is passively ori-
O described almost exclusively in two-
dimensional (2-D), single plane terms. These
ented over the slots of two adjacent brackets,
the angular relationship between the wire and
reports describe either a 2-D length of wire the slot at each bracket has been reported to be
with a V-bend creating couples at collinear ad- an estimate of the relative magnitude of the
jacent brackets1"6 or a length of straight wire moment that will be created at each bracket.5'7
creating couples at noncollinear adjacent This is important because the larger moment
brackets.7 will determine the direction of the associated
equilibrium forces when the wire is engaged.
When the angular relationships are equal and
opposite, equal and opposite moments are pre-
From the Department of Orthodontics, School of Dentistry, sumably created.
Richmond, VA; and the Department of Mechanical Engineering,
In 1988, Burstone and Koenig1 quantitated
University of Virginia, Charlottesville, VA. the effects of locating a vertical V-bend pro-
This work was supported in part by the Medical College of gressively further from the interbracket mid-
Virginia Orthodontic Education & Research Foundation point of collinear bracket slots in a 2-D system.
Address reprint requests to RobertJ. Isaacson, DDS, MSD, As the V-bend was moved off center and away
College of Virginia, Virginia Commonwealth University, P.O.
from one of the brackets, the moment at this
Box 980566, Richmond, VA 23298-0566 bracket decreased. When the V-bend was
Copyright © 1995 by W.B. Saunders Company moved to a point where it was located twice as
1073-8746/95/0101-0008$5.00/0 far from one bracket as the other, the moment
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58 Isaacson, Lindauer, and Conley
at the more distant bracket decreased to zero.

Further movement of the V-bend away from
the more distant bracket resulted in a reversal
of the direction of the moment at that bracket
with the moments at both brackets now acting
in the same direction. They suggested clinical
applications of this 2-D data extrapolated into
three-dimensional (3-D) arch wires. In 1992
Nasiopoulos et al4 cited this 2-D work and re-
ported the clinical treatment of Class II mal-
occlusions using V-bends in 3-D arch wires in-
serted in brackets only on the molars and the
incisors ( 2 x 4 appliances).
Ronay et al6 also noted the reversal of direc-
tion of the moment at the bracket located more
than two thirds of the distance from a V-bend
in a 2-D system. They constructed graphs to
predict the force systems from a V-bend lo-
cated anywhere between two brackets. Incisal View Distal View
All of these reports have addressed the use Figure 1. Right maxillary molar and right central
of arch wires from a 2-D perspective. Arch incisor. Positive forces on all teeth are defined by
wires are often used clinically with insertion in maxillary molar position where: FX1 = a force on
only the two molar tubes and the brackets on the molar in the mesial direction; FYi = a force on
either two or four incisors (2 x 2 or 2 x 4 the molar in the lingual direction; and FZ1 = a force
on the molar in the apical direction. A couple cre-
appliances). An arch wire in this configuration ating a moment for rotation around FX1 is MX1;
is 3-D and a V-bend placed in a 3-D wire will around FYi is M Y i, and around FZ1 is MZ1. With the
cause torsion and bending to occur when it is global coordinate system, forces and moments at the
inserted into the brackets. The response of incisor are defined in the same directions as the mo-
wire to torsion differs from its response to lar. Therefore, a positive force on the incisor
equaled: FX2 = a force on the incisor in the facial
bending. Therefore, we hypothesize that the direction; FY2 = a force on the incisor in the mesial
effects produced by a 3-D rectangular wire direction; and FZ2 = a force on the incisor in the
with a single vertical V-bend will produce mo- apical direction. A couple creating a moment for
ments and forces different from those re- rotation around FX2 is MX2; around FY2 is M Y2 ; and
ported for the same bend in a 2-D system. around FZ2 is MZ2.
Methods and Materials lingual direction and FZ1 a force on the molar
in the apical direction (Fig 1).
A finite element analysis was used in this study Force systems were applied at the molar
to simulate an arch wire inserted in the brack- tube and the incisor bracket by simulating a
ets of only the maxillary molars and central 0.017" x 0.025" rectangular stainless steel arch
incisors (a 2 x 2 appliance). Arch wire symme- wire with single vertical V-bends introduced at
try was assumed and only the right half of the various locations along the arch wire. Because
arch wire was modelled. The molar was re- a clinician intends for this arch wire configu-
ferred to as tooth 1 and the incisor as tooth 2. ration to create a second-order rotation at the
The description of all couples and forces molar, M Y i, and a third-order rotation at the
present was based on a global x, y, z coordinate incisor, MY2, this report is limited to a descrip-
system referenced to the maxillary molar. tion of these moments and their associated
Thus, forces on both the molar and the incisor equilibriums, Fzl and FZ2.
were defined by the maxillary molar position A rectangular 3-D arch wire, as described
where FXi was a force on the molar in the me- herein, will also produce moments around the
sial direction, FYi a force on the molar in the x and z axes with associated equilibrium forces
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3-D Arch Wires 59
also present in the y and z directions at both tained by applied rotations of the molar and
the molar and incisor. These moments and incisor bracket nodes.
forces will be the subject of a subsequent re- A dental arch 35 mm in length and 23 mm
port. The data reported herein is limited to the in half-width was used. Arch form was defined
moments created around the y axis at the mo- by fixing molar, incisor, and intermediate
lar, MY1, and the incisor, M Y2 , and the total points and allowing the spline function to
vertical force present at the molar, FZ1, and the smooth the curve. The wire was 0.017" x
incisor, FZ2. 0.025" stainless steel with a single vertical V-
Existing reports in the literature define the bend with the apex of the V-bend 5-mm high
location of a vertical V-bend using an a/L ratio relative to the flat plane of the original arch
where a is the distance from the midpoint of wire.
the molar bracket to the apex of the vertical To define wire behavior within its elastic
bend, and L is the total interbracket distance, range the Poisson's ratio and the elastic mod-
all measured in a 2-D projection. A 3-D arch ulus are necessary. The Poisson's ratio de-
wire form cannot be described accurately in scribes the amount of transverse strain per unit
this lateral, 2-D view. In this study the location of longitudinal strain in a material; the stan-
of the V-bend was defined by an a/L ratio dard value for austenitic stainless steel (0.33)
where a is the distance from the midpoint of was used. The values for elastic modulus and
the molar bracket to the vertical bend as pro- yield strength vary in the literature depending
jected on and measured along the perimeter of on the testing methods, wire geometry, heat
the arch wire. L is the total interbracket dis- treatment, and yielding criteria; an average of
tance from the midpoint of the molar tube to the values reported for elastic modulus (27 x
the midpoint of the incisor bracket as mea- 106 psi) and yield strength (250 x 103 psi) were
sured along the arch wire perimeter. used. For this study, a fully elastic range of
The arch wire actions were modelled using wire activation was assumed.
the finite-element method that visualizes the
3-D wire as a series of smaller straight elements
termed beams. Each beam develops forces and
Results
moments along its length, and the junction of The clinical use of a 2 x 2 arch wire with a V-
each successive beam with another is termed a bend usually is intended to obtain second-
node. To identify the forces applied to the mo- order rotations at the molar, M Y1 , and/or
lars and incisors, the nodes of particular inter- third-order rotations at the incisor, MY2. Fig-
est were at the molar and the incisor brackets. ure 2 shows the curves depicting the values for
The model was tested with a progressively in- MY1 and MY2 as the V-bend is located at dif-
creasing number of nodes until the new data ferent sites along the arch wire perimeter.
did not vary by more than 1 % from that of the As hypothesized, the curves for MY1 and
previous test. This occurred when about 40 MY2 in this 3-D system are not symmetrical nor
beams were used to model one half of the arch centered around a neutral point at an a/L ratio
wire. Three translational and three rotational of 0.5 as reported for 2-D systems.1"7 Figure 2
degrees of freedom were determined at each shows an equal and opposite moment present
node. The ANSYS finite element software at the molar and the incisor with a neutral
package (Swanson Analysis Systems, Inc, point located at an a/L ratio of approximately
Houston, PA) was used. 0.45.
The finite element method requires that the As the a/L ratio is decreased by progres-
model be constrained by establishing boundary sively moving the V-bend toward the molar,
conditions. In this study the wire was re- the magnitude of the positive moment at the
strained from movement in all directions at the molar also progressively increases and the
incisor and allowed to move only in the x or magnitude of the negative moment at the in-
mesiodistal direction at the molar. The wire cisor progressively decreases. In contrast to the
was restrained from rotations in all directions 2-D system, the moment at the incisor does not
at both teeth to simulate a full-sized rectangu- reach zero and reverse its direction until the V-
lar arch wire. Activation of the wire was ob- bend reaches an a/L ratio of about 0.14.
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Figure 2. Moments at the

molar tube for second-
order rotation, M Y i, and
at the incisor bracket for
third-order rotation, MY2,
resulting from a single V-
bend at various locations
along the perimeter of an
arch wire. Positive mo-
ments are clockwise in di-
rection and negative mo-
ments are counterclock-
wise in direction. To find
the moments present for
Y2 any given V-bend, select a
V-bend location along the
horizontal coordinate and
read the moments present
0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 at the incisor and molar on
Molar
V-Bend Location Incisor the vertical coordinate. A
typical utility arch with the
V-bend at a/L 0.15 shows a positive moment of 3,100 g • mm at the molar and a negative moment of 50
g • mm at the incisor. A typical torquing arch with the V-bend at a/L of 0.85 shows a negative moment of
1,400 g • mm at the molar and a negative moment of 2,900 g • mm at the incisor.
Figure 2 also shows the effects of V-bends Figure 3 shows the changes in the magni-
located closer to the incisor. As the V-bend is tude of the vertical associated equilibrium
moved toward the incisor, the positive moment forces present at the molar, FZ1, and at the
at the molar, M Y1 , decreases and the negative incisor, FZ2 as the V-bend is progressively
moment at the incisor, M Y2 , increases. When moved along the perimeter of the arch wire. At
the a/L ratio reaches about 0.63, the MY1 value the neutral point a/L of 0.45 the moments at
reaches zero which is very close to the value the molar and the incisor are equal and oppo-
reported in 2-D systems. As the V-bend is site and, therefore, the associated equilibrium
moved further toward the incisor, the moment forces are equal and opposite and cancel each
at the molar reverses direction and the MY1 other out. This is represented in Fig 3 where
and MY2 values are both increasingly negative. the two force curves cross at zero at a/L 0.45.
Figure 3. Vertical forces at

the molar tube, FZ1, and
the incisor bracket, F Z2 ,
resulting from the equilib-
rium associated with the
moments created at these
teeth by a V-bend at vari-
ous sites along the perim-
eter of an arch wire. These
vertical forces are positive
0.4 0.5 0.6 0.7 0.8 0.9 in the apical direction and
Incisor negative in the occlusal di-
V-Bend Location rection.
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3-D Arch Wires 61
Discussion moment will be generated at the bracket

nearer to the V-bend. For example, in Figure 2
Past studies of the forces and moments devel- a/L ratios between 0.45 and 0.5 all have V-
oped by wires with a V-bend creating couples bends nearer the molar, but a greater moment
at two adjacent brackets have all been based on is present at the incisor bracket. The charac-
2-D analyses.1"7 A wire with a V-bend between teristics of a 3-D wire must be considered when
two adjacent brackets in a 2-D system develops attempting to estimate which bracket will have
second-order couples at both brackets (except the greater moment following wire engage-
when the V-bend is placed at a point on the ment and, therefore, in which direction the as-
arch wire twice as far from one bracket as the sociated equilibrium forces will act.
other). As long as the wire in the two bracket In addition to the greater torsion produced
system activates couples in a single plane, these in the anterior portion of a 3-D arch wire, dif-
data are valid. ferences clearly exist in how data are reported
A vertical V-bend located halfway along the for 2-D and 3-D systems. Projecting a 3-D arch
perimeter (a/L = 0.5) between the molar tube wire onto a 2-D lateral view is not valid. An a/L
and the incisor bracket in a 2-D system creates of 0.5 does not locate the halfway point of the
equal and opposite anterior and posterior mo- perimeter of a 3-D wire when the wire is pro-
ments. A vertical V-bend located halfway along jected in a 2-D lateral view. A preferable de-
the perimeter (a/L = 0.5) of a 3-D rectangular scription for the location of the V-bend is con-
arch wire does not create equal and opposite tinued use of the a/L measure, but redefining
anterior and posterior moments. The major the a and L values in terms of arch wire pe-
difference between V-bends placed in 2-D and rimeter as opposed to the use of 2-D projec-
a 3-D models is that 2-D wires undergo only tions.
bending during activation. A 3-D rectangular Because the 2x2 arch wire is commonly
arch wire undergoes torsion in addition to used as a utility arch or as a torquing arch, it is
bending during activation. The torsion devel- useful to compare the actual relationships of
oped during the activation of a 3-D rectangu- MYi and MY2 in an asymmetrical 3-D system as
lar arch wire is progressively greater as the opposed to the previous symmetrical 2-D data.
V-bend is located more anteriorly along the arch
wire. The torsion represents additional resis-
tance to deformation in the anterior leg and,
The Utility Arch
consequently, the neutral point where the mo- An example of the second-order molar rota-
ments are equal and opposite becomes located tion, MYI, and tne third-order incisor rotation,
more posteriorly in a 3-D model. MY2, developed by a typical 2x2 utility arch is
In a 2-D system, the moment created at any shown in Figure 2. If a V-bend for a utility arch
bracket is reversed in direction when that wire is placed at an a/L of 0.15, the moments
bracket is more than twice as far from a V-bend present at the molar and the incisor are also
as the collinear adjacent bracket. This reversal shown in Figure 2. The equilibrium forces as-
is a function of the bending properties of the sociated with each of these moments contrib-
wire. These properties cause the wire to re- utes to the forces shown in Figure 3.
verse its direction of curvature on insertion Figure 2 shows that a moment of 3,100
into the bracket after the length of the wire on g • mm for crown distal/root mesial rotation is
one side of the V exceeds twice that of the present at the molar and a moment of negative
length of the wire on the other side of the V.1 50 g • mm for crown facial/root lingual rota-
The presence of torsion alters the location tion is present at the incisor. The moment for
along the arch wire perimeter where the rotation at the molar, M Y1 , and the moment
V-bend will result in a reversal of the direction of for rotation at the incisor, M Y2 , are both asso-
the moment (Fig 2). Wire bending practices ciated with vertical equilibrium forces that con-
based on data from 2-D systems clearly do not tribute to FZ1 at the molar and FZ2 at the inci-
produce identical effects when used with a 3-D sor.
system. In this two-couple system the equilibrium
Ii is also not always true that the greater associated with the positive moment for crown
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distal/root mesial rotation at the molar requires at the molar and extrusive at the incisor. The
associated equilibrium forces that are extrusive equilibrium forces associated with the larger
at the molar and intrusive at the incisor. The same direction negative moment for crown fa-
equilibrium forces associated with the smaller cial/root lingual rotation at the incisor also re-
oppositely directed negative moment for quires equilibrium forces that are intrusive at
crown facial/root lingual rotation at the incisor the molar and extrusive at the incisor. The
requires equilibrium forces that are intrusive combination of these forces at both the molar
at the molar and extrusive at the incisor. The and the incisor contributes to the value of
combination of these extrusive and intrusive about 120 gm of intrusive force, FZ1, at the
forces at both the molar and the incisor con- molar and 120 gm of extrusive force, FZ2, at
tributes to the value of about 90 gm of extru- the incisor shown in Figure 3.
sive force, FZ1, at the molar and 90 gm of in- Increasing the negative MY at either the mo-
trusive force, FZ2, at the incisor shown in Fig- lar or the incisor will increase the magnitude of
ure 3. both the extrusive force at the incisor and the
Increasing the positive MY at either the mo- intrusive force at the molar. For example, the
lar or the incisor will increase the magnitude of addition of lingual root torque at the incisor
both the intrusive force at the incisor and the and/or mesial root torque at the molar will
extrusive force at the molar. For example, the both increase both the extrusive force at the
addition of facial root torque at the incisor will incisor and the intrusive force at the molar.
increase both the intrusive force at the incisor It is clear from these data that a torquing
and the extrusive force at the molar. Con- arch and a utility arch are not mirror images of
versely, the addition of lingual root torque at each other.5 This is true even when the V-bend
the incisor (a negative change in MY) will de- is placed equally as far from the incisor in the
crease both the intrusive force at the incisor torquing arch as it is from the molar in the
and the extrusive force at the rnolar. utility arch. The asymmetry of these data is
caused by the 3-D properties of the arch wire
and the important role of both torsion and
The Torquing Arch bending in the activation of a vertical V-bend.
An example of the second-order molar rota-
tion, M Y i, and the third-order incisor rotation,
M Y2 , developed by a typical 2x2 torquing Conclusions
arch may also be read from Figure 2. If a V- The data developed by this two-couple 3-D
bend for a torquing arch wire is placed at an model, while significantly different from the
a/L of 0.85, the moments present at the molar data developed by previous two-couple 2-D
and the incisor may be seen. The equilibrium models, does not radically modify the clinical
forces associated with each of these moments use of arch wires. It does provide a better un-
both contribute to the forces shown in Fig- derstanding and an ability to anticipate tooth
ure 3. movements seen when using two-couple sys-
Figure 2 shows that a negative moment of tems with V-bends creating major differences
1,400 g • mm for crown mesial/root distal rota- in the magnitude of the moments at the two
tion is present at the molar and a negative mo- brackets.
ment of 2,900 g • mm for crown facial/root lin- It is clear that torsion is an increasingly sig-
gual rotation is present at the incisor. The mo- nificant factor as the V-bend is placed more
ment for rotation at the molar, M Y i, and the anteriorly. This results in a utility arch produc-
moment for rotation at the incisor, M Y2 , are ing somewhat different force systems than a
both associated with vertical equilibrium forces similarly activated torquing arch.
that contribute to, FZ1 at the molar and FZ2 at This 3-D model does validate the technique
the incisor. of placing the wire for a two-couple system
In this two-couple system the equilibrium passively over the brackets where it will be in-
associated with the negative moment for crown serted to determine the bracket with the larger
mesial/root distal rotation at the molar requires moment and, therefore, the direction of the
associated equilibrium forces that are intrusive associated equilibrium forces. These data
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3-D Arch Wires 63
clearly show the impossibility of measuring the 2. Mulligan TF. Common sense mechanics. Phoenix,
magnitude of the equilibrium forces present in GSM, 2122 East Kaler Drive, 1982.
a two-couple system by using a force gauge to 3. Isaacson RJ, Lindauer SJ, Rubenstein LK. Moments
with the edgewise appliance-incisor torque control.
displace the wire to a bracket while the wire is Am J Orthod Dentofacial Orthop 1993;103:428-438.
inserted in the second bracket. This measure- 4. Nasiopoulos AT, Taft L, Greenberg SN. A cephalo-
ment is reliable in a one-couple system, but in metric study of class II, div 1 treatment using differ-
a two-couple system only the direction and not ential torque mechanics. Am J Orthod Dentofacial
the net magnitude of the forces can be clini- Orthop 1992;101:276-280.
cally assessed with existing techniques. 5. Isaacson RJ, Lindauer SJ, Rubenstein LK. Activating a
2x4 appliance. Angle Orthod 1993;63:17-24.
6. Rony F, Kleinert W, Melsen B, et al. Force system
References developed by V bends in an elastic orthodontic wire.
1. Burstone CJ, Koenig HA. Creative wire bending—the Am J Orthod Dentofacial Orthop 1989;96:295-301.
force system for step and V bends. Am J Orthod Den- 7. Burstone CJ, Koenig HA. Force systems from an ideal
tofacial Orthop 1988;93:59-67. arch. Am J Orthod 1974;65:270-289.
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There are three million

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to the tune of "If I Can Dream"
(Original words and music by W, Earl Brown)
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This space contributed as a public service.
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it makes sense to follow these guidelines for healthy living! Eat plenty of fruits and vegetables
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HOME
Vol 1, No2
Seminars in
P. Lionel Sadowsky, DMD

Editor
The Relevance of Facial

Esthetics to Orthodontics
Guest Editor

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EDITOR

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VOL 1, NO 2 JUNE 1995
The Relevance of Facial Esthetics to Orthodontics

Guest Editor
CONTENTS
Introduction 65
Sheldon Peck
Facial Soft Tissue Harmony and Growth in Orthodontic Treatment 67

Ram S. Nanda and Joydeep Ghosh
Orthodontic Applications of Psychological and Perceptual Studies of

Facial Esthetics 82
Donald B. Giddon
The Use of Three-Dimensional Techniques in Facial Esthetics 94

J.P. Moss, A.D. Linney, and M.N. Lowey
Selected Aspects of the Art and Science of Facial Esthetics 105

Sheldon Peck and Leena Peck
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EDITOR
EDITORIAL BOARD
John S. Casko, Iowa City, I A William R. Proffit, Chapel Hill, NC
INTERNATIONAL
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VOL 1, NO 2 JUNE 1995
Introduction
As a beauty I'm not a great star, article by Drs. Moss, Linney, and Lowey is a
There are others more handsome by far; fine example of orthodontics beginning to
But my face I don't mind it benefit from newly developed methods of elec-
Because I'm behind it— tronic imaging. The future surely will offer
'Tis the folks out in front that I jar. further, exciting opportunities for technologi-
—from Limeratomy cal transfer in this field.
by Anthony H. Euwer (1877 - after 1942) In their contribution to this issue, Drs.
Nanda and Ghosh offer data on the physical
onsiderations of facial esthetics always
C have been an inseparable part of the prin-
ciples and practice of orthodontics. The early
nature of facial harmony in growing and post-
growth samples. Some of the quantitative rela-
tionships they uncover between hard-tissue
orthodontists applied an artistic ideal of dental and soft-tissue structures are less predictable in
occlusion as their model in correcting irregu- the individual than orthodontists may have
larities of the teeth and jaws in young, growing wished. Their longitudinal research on facial
patients. It therefore was natural for them to changes in adults illuminates a subject that has
strive for artistic harmony and esthetic im- received too little attention in the past.
provement of the face also. Over the years, Dentist-psychologist Donald Giddon has
clinical concepts of facial esthetics have gradu- spent a good part of his multidisciplinary ca-
ally shifted from the application of personal or reer studying facial effects and affects. Dr.
traditional tastes to the use of quantitative soft- Giddon's article conveys a cornucopia of im-
tissue diagnostic evaluations. Orthodontists portant findings relevant to the concepts of fa-
have generally led the way in the quantitative cial attractiveness and the observer's percep-
analysis of the soft-tissue facial architecture, tion or self-perception. These are matters that
developing norms and longitudinal data im- touch deeply the interests and well-being of
portant equally to maxillofacial and plastic sur- many patients, so we must update our psycho-
geons and to clinicians in prosthetic dentistry. logical expertise to remain patient-centered cli-
Apart from the continuing attention re- nicians.
ceived from clinical medicine, the face is now In the last article of this issue, Dr. Leena
attracting serious study from diverse profes- Peck and I broadly explore the historical and
sions and is even becoming "big business." Psy- cultural foundations of esthetic concepts as ap-
chologists, anthropologists, and computer en- plied to the face. Scientific advances in under-
gineers are doing some ingenious work in the standing facial esthetic judgments are dis-
field of facial recognition.1"6 Using techniques cussed. Then interesting results from our an-
of digital imaging, they are identifying critical thropometric and cephalometric studies of the
contours, patterns, and measurements of hu- lips, teeth, and jaws are shared with special em-
man faces and are uncovering some of the un- phasis on the nature and esthetics of the smile
derlying mechanisms in the cerebral process- line.
ing of visual information. Much of this re- One positive outcome from the focused col-
search is providing essential elements for the lection of articles in this issue of Seminars in
development of automatic face-processing Orthodontics should be increased objective un-
computer systems with broad applications in derstanding and some professional accord re-
communications, legal and security matters, garding facial esthetics. Nonetheless, disagree-
and forensics, to name a few areas. The laser- ments are to be expected in a field that will
scanning techniques creatively applied in the always have subjective elements. At a personal
Seminars in Orthodontics, Vol 1, No 2 (June), 1995: pp 65-66 65

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66 Sheldon Peck
level, esthetics invites taste and differences of jectivity and state-of-the-art information, esthet-
opinion. ics will be used as the word form of preference.
For example, the word itself has provoked
disagreement: should (Aesthetics properly be- Sheldon Peck, DOS, MScD
gin with an "a" or an "e"? The term is derived Guest Editor
from aisthesis, the Greek word for "perception"
or "sensation." Surprisingly, the application of
this word to the study of beauty was not a References
Greek idea, but rather the creation of an 18th 1. Burton AM, Bruce V, Bench N. What's the difference
century German philosopher, Alexander between men and women? Evidence from facial mea-
Baumgarten.7 He coined the word "aesthetica" surement. Perception 1993;22:153-176.
for a scholarly treatise, written in Latin, ex- 2. Ekman P, Friesen WV. Facial action coding system: A
technique for the measurement of facial movement.
ploring the harmonious nature of poetry. Palo Alto, CA: Consulting Psychologists, 1978.
Baumgarten's "aesthetica" entered the English 3. Catterick T. Facial measurements as an aid to recog-
lexicon in the mid-18th century as aesthetics, a nition. Forensic Sci Int 1992;56:23-27.
neologism with the Latinized "ae" digraph re- 4. Vezjak M, Stephancic M. An anthropological model
maining affixed to the Greek word stem. Mod- for automatic recognition of the male human face.
Ann Hum Biol 1994;21:363-380.
ern scientific and technical usage has settled on 5. Pollack A. Japanese put a human face on computers.
esthetics, discarding the silent "a" from its be- New York Times, 28 Jun 1994:C1 (col.l).
ginning, the same as has been done for simi- 6. Bruce V, Cowey A, Ellis AW, Perrett DI, editors. Pro-
larly hybridized words, such as aetiology and cessing the facial image. Phil Trans Royal Soc Lond B
aether. Nevertheless, Baumgarten's Latinized 1992;335:1-128.
7. Baumgarten AG. Mediationes philosophicae de non-
spelling continues to be favored by those writ- nullis ad poema pertinentibus, 1735. In: Aschenbren-
ing in the humanities, and by the British. In ner K, Holther WB, translators. Reflections on poetry.
the four articles that follow, each aimed at ob- Berkeley, CA: University of California, 1954.
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Facial Soft Tissue Harmony and Growth in

Orthodontic Treatment
Ram S. Nanda and Joy deep Ghosh
The introduction of cephalometric radiography in orthodontic diagnosis in-

advertently shifted the specialty's attention from the facial soft tissues to
the skeletal structures. It has been shown that rigid adherence to the hard
tissue norms results in neither facial balance and harmony nor long-term
retention. The purpose of this article is to refocus the attention of the orth-
odontist on the consideration of harmonized facial structures as a primary
goal of treatment. Balancing the position of the lips in relation to the nose
and chin has a direct relationship with esthetic preference. Growth studies
have clearly shown that dynamic changes in dental, skeletal, and facial in-
tegument occur over the entire period of active growth and even into the
decades past the age of 20 years. Esthetic standards, therefore, must be
different for children and for adults. Treatment results should be projected
to when the patient is well into adulthood. Facial types also need to be
considered because long-face and short-face individuals have different
growth and maturational patterns. The compensatory nature of soft-tissue
growth in these individuals should be noted. Caution must be exercised in
using mean data from growth studies and applying them to all individuals at
all ages, because of the wide variation among individuals in all races and
both sexes.
The question of facial balance and harmony glance however, will show that the incisor teeth
in orthodontics has engaged the profes- of "Old Glory" protrude too much to be in
sion from its earliest beginnings to the present harmony with Apollo's facial profile (Fig 1).
time. Norman Kingsley1 devoted a special Case3 used facial masks of his patients to
chapter on the balance and harmony of facial orient their dentition and correct the irregu-
contours and their relationship to dental and larity of teeth. Later Simon4 advanced his
skeletal structures. He recognized the infinite method of diagnosing in three planes of space
variety of human countenance and equally in- based on facial lines. Hellman5 also studied fa-
finite diversity in the form of the jaws, but em- cial features and presented means and stan-
phasized that the attractiveness of facial fea- dard deviations of certain elements of facial
tures is dependent on harmonious relation- characteristics.
ships of the dentition and the facial Application of radiography to study facial
configuration. Edward H. Angle2 accepted the features was first recorded by Carrea6 who
face of Apollo Belvedere and the dentition adapted soft lead wire to the facial profile and
based on the skull of "Old Glory" as ideal stan- took radiographs to study facial prognathism.
dards for the orthodontic profession. A casual Further standardization of cephalometric radi-
ography and the application of this tool in
studying the growth and development of den-
tal and skeletal tissues focused the profession's
From the Department of Orthodontics, University of Oklaho- attention on the balance and harmony of the
ma College of Dentistry, Oklahoma City, OK. dental and skeletal structures. Charles H.
Address correspondence to Ram S. Nanda, DDS, MS, PhD, Tweed,7 noting failures in both the achieve-
Professor and Chair, Department of Orthodontics, College of
Dentistry, 1001 S.L. Young Blvd, Oklahoma City, OK 73190.
ment of esthetic facial lines and the lack of re-
Copyright © 1995 by W.B. Saunders Company tention of treated occlusions, said that, to have
1073-874619510102-0002$5.00/0
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68 Nanda and Ghosh
cialty placed more emphasis on dentoskeletal

balance than on total facial characteristics. One
may conjecture that the majority of orthodon-
tists follow the erroneous assumption that, if
dental and skeletal structures were in balance,
the facial lines would automatically follow suit.
Several investigators11"16 have noted that the
thickness of the facial integument varies and
may not be dependent on the dentoskeletal
structures.In addition, a proportionate change
or improvement in the soft tissue profile does
not necessarily accompany extensive dentition
changes;13 hence, we cannot rely entirely on a
dentoskeletal analysis for information on soft
tissue profile changes that occurred during
orthodontic treatment.
Figure 2 shows the cephalometric radio-
graphs and tracings of two individuals, both
women, aged 20 years and 26 years. Whereas
both have a Class I occlusion with a normal
facial skeleton, one shows a soft-tissue chin
thickness of 12 mm, versus the 23 mm of chin
thickness in the other individual. Although the
hard-tissue measurements are more or less
similar, the facial esthetics are different. In
such situations, rigid adherence to hard-tissue
norms could result in poor facial balance. To
illustrate the incongruity in our profession,
Figure 3 shows two examples of patients who
were successfully treated for their dentitions
with fairly stable results and yet poor enough
facial esthetics that the patients were seeking
retreatment.
Assessment of a Balanced Facial Profile

In traditional orthodontic practice, not much
can be done to the denture bases. Only den-
toalveolar changes are possible, and the effects
may be limited to lip position and posture.
Figure 1. The profile of Apollo Belvedere and the Therefore, it is mandatory that the orthodon-
dentition of "Old Glory." tist understand clearly the necessary correction
of the nose-lip-chin relationship of a given pa-
tient before making critical decisions relating
balanced faces, the anterior limits of the teeth to extraction versus nonextraction procedures
have to be determined by the position of the for the correction of malocclusions. As ob-
mandibular incisor relative to the mandibular served in the two examples in Figure 3, ad-
plane and the Frankfort mandibular incisor verse effects on the facial profile can accom-
angle. Cephalometric analyses conducted by pany extraction procedures. Rigidly adhering
Margolis,8 Downs,9 and Steiner,10 among oth- to a nonextraction philosophy can also have
ers, provided detailed dental and skeletal rela- undesirable results with protrusive facial pro-
tionships but offered only a passing reference files.
to soft-tissue facial balance. As a result, the spe- Recent advances in orthognathic surgery
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Facial Harmony and Growth in Treatment 69
Figure 2. Cephalometric radiographs of two women depicting the variability of the soft tissue chin thickness.
The individual on the left (age 20 years) has a soft tissue chin thickness of 12 mm, whereas the individual on
the right (age 26 years) has a soft tissue chin thickness of 23 mm.
have greatly increased the ability of the orth- sons with poor facial esthetics had convex
odontist, in cooperation with the maxillofacial faces. Foster19 used six groups of professionals
surgeon, to balance the nose, lip, and chin re- and lay persons to evaluate male and female
lationships. It is the belief of the authors that faces at ages 8, 12, and 16 years, and in adult-
the quality of facial esthetics benefits from har- hood. His results showed that there was a gen-
monized dental and skeletal relationships, but eral agreement between the groups as to the
it does not entirely depend on them. Most cli- age and sex of the full-face silhouette profiles.
nicians can relate to an ideal or beautiful face, All groups related full profiles to the women
but there are as many variations of this hypo- and to the younger ages and straight profiles
thetical norm as there are individuals. Ideal to men and to older age groups.
concepts of beauty differ not only based on In recognition of the confusion that seems
race and sex, but also from one individual to to exist over standards and norms for the hu-
the next. An individual's appearance is the re- man face, a study was conducted in the orth-
sult of form plus the influence of personality odontic department at the University of Okla-
traits. The evaluation of facial esthetics is sub- homa in which an effort was made to develop
jective for the lay person, and includes factors an ideal facial profile for white people without
such as balance and harmony of the constitu- any distractions.20 The objective of the study
ent parts, symmetry and proportions, color, was to develop a series of facial profiles based
and hairstyle. As far as possible, extraneous on an ideal constructed profile for evaluation
influencing factors should be eliminated, and by members of the dental profession. By vary-
the decision-making process should be struc- ing the size of the lips, nose, chin, angle of
tured on objective principles. facial convexity, and facial angle, it was hoped
Riedel17 traced the soft-tissue outline from to assess the combinations most acceptable, as
the cephalometric radiographs of 24 children well as those least desirable. On the basis of the
and asked 72 orthodontists to rate them as data available in the literature on average
good, fair, or poor. He found that there was thickness of the soft-tissue integument and its
greater agreement on poor profiles than on relationship to the underlying skeleton, an
those that were considered good. Cox and Van ideal skeletal and soft-tissue facial profile was
der Linden18 compared the esthetic standards constructed.
of 10 orthodontists and 10 lay persons. After Six series of profiles varying from the ideal
grading full-head silhouettes for good facial were then generated, three series to a page.
balance in grades from best to worst, it was Each series consisted of seven profiles.
concluded that the cephalometric radiographic Though pages 1 and 2 were for male profiles
analysis did not show statistically different and pages 3 and 4 depicted female profiles, the
evaluations between the two groups. The per- constructions were identical for both sexes to
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70 Nanda and Ghosh
Figure 3. Facial profile and intraoral frontal photographs of two orthodontically treated patients several
years postretention. Both show fairly stable orthodontic results but unsatisfactory profiles.
test if the examiners would accommodate and that the chin size was increased by 6 mm on all
identify sex differences. The first series of proof them.
files on page 1 of the Profile Survey Instru- On page 2 of the questionnaire (Fig 5), the
ment (Fig 4) showed lips that were protruded first series was based on the ideal normal con-
or retruded in 2-mm increments from the structed profile in position number 4. The
originally constructed profile, which was the changes made in the soft-tissue facial angle
middle (fourth) in the series. The second series were graded in increments of ±1.5°. The sec-
of profiles were the same as those made for the ond series varied the soft tissue convexity of
first series except that the size of the nose had the normal profile. The soft tissue point-A po-
been increased by 6 mm on all of the profiles. sition was moved to change the angle of con-
The third series again used the profiles convexity in increments of 3°. The third series was
structed for the first series with the exception a combination of both series one and two in
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YOUNG ADULT WHITE MALE YOUNG ADULT WHITE MALE

Please subjectively rank order each row of seven Please subjectively rank order each row of seven
Young Adult White Male profiles. Young Adult White Male profiles.
\\\\\\\ \rn\\
Each profile should have a number (1-7) assigned. No *•«. Each profile should have a number (1 - 7) assigned. No «
Number 1 would be your favorite. Number 1 would be your favorite.
Number 7 would be your least favorite. Number 7 would be your least favorite.
ROW1
ROW 2
mm
D D D D D G D a a a a a a a
mm mm
D a a D a a D a a D a a a D
ROW 3
D D D D D D D n D D a a a a
Figure 4. Androgynous profile relative to lip Figure 5. Changes in facial angle and angle of con-
changes (row 1), lip changes plus 6 mm nose in- vexity, separately and combined to produce differ-
crease (row 2), and lip changes plus 6 mm chin in- ent facial types. All profiles show static facial vertical
crease, along with static forehead contour and static dimension, static nose size, and forehead contour.
facial vertical dimension. (Reprinted with permis- (Reprinted with permission from Czarnecki ST,
sion from Czarnecki ST, Nanda RS, Currier GF. Nanda RS, Currier GF. Perceptions of a balanced
Perceptions of a balanced facial profile. Am J Dent- facial profile. Am J Dentofac Orthop 1993; 104:180-
ofacOrthop 1993;104:180-187.) 187.)
which both the changes in facial angle and an- ticulate on what they favored least than on
gle of convexity were incorporated. what they favored most. The profile with the
The survey instrument was graded by 545 most retrusive lips and a large chin (Fig 4, row
professionals who were asked to rank, in order 3, number 1) was considered to be the worst by
from 1 to 7, the most-favored to least-favored 62% of the participants. A slightly more pro-
profile in each series for both men and women. nounced chin (Fig 5, row 1, number 5) was
It was noted that for both men and women, the favored for the men, when compared with the
nose and chin configurations preferred were choice for women. Overall, a preference for a
close to the constructed normal or slightly straighter profile was shown for both men and
larger. In the men, comparatively retruded lip women (Fig 5, row 2, number 3).
contours were preferred. The least-favored This study showed that the judgment of
positions of nose and lips were the most pro- both lip protrusion and lip retrusion were de-
truded (Fig 4, row 1, number 7), whereas the pendent on the positions of the chin and the
least-favored chin contours were the most nose. More lip protrusion was acceptable for
retrusive for both men and women. Seventy- both male and female profiles when either a
five percent of the participants were more ar- large nose or a large chin was present. How-
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72 Nanda and Ghosh
ever, three times more lip protrusion was al- from 22 years 10 months to 32 years 4 months)
lowed with a large chin than with a large nose. with Class I occlusions and esthetically pleasing
This finding is highly significant because it has and balanced faces were selected from dental
a major impact on the consideration of treat- and dental hygiene students. For the selection
ment plans. It was also found that a straighter of the sample, a subjective evaluation of facial
profile with a more prominent chin was more esthetics was performed individually by three
the preference for men than for women. Also, orthodontic professionals. Soft tissue land-
more lip protrusion was permissible for marks were digitized directly from the subjects'
women than for men. With a relatively larger faces.
nose and chin, a more protrusive dentition and The digitization and measurement error
fuller lips are more acceptable for harmoniz- was determined by redigitizing the profile and
ing the face. In such "borderline cases" (extrac- frontal landmarks on 10 men and 10 women
tion versus nonextraction), the clinician should randomly selected from the sample. The initial
favor a nonextraction orthodontic treatment and repeated measurements were compared
approach. In any type of treatment philoso- using a paired t test, and the difference was
phy, the harmony of facial features and esthet- found to be insignificant (P < .05) for 35 of the
ics is of paramount importance. Although sub- 36 measurements evaluated in the profile view.
jective, the clinician must be able to differenti- Only one measurement, superior sulcus depth,
ate "normal" (acceptable) from "abnormal" had a statistically significant difference (P <
(unacceptable). .05). There was no significant difference in the
Ricketts21 has suggested the use of an es- 13 measurements in the frontal view.
thetic (E) plane for the evaluation of the rela- The means and standard deviation values
tionship of nose, lips, and chin. Our research for the measurements in the lateral analysis are
has confirmed that, with variations in the size reported in Table 1 and those for the frontal
of the nose and/or chin, the position of the lips analysis are in Table 2. A close comparison was
can be varied to harmonize facial relationships. found between most measurements obtained
A recent report by Hsu22 on comparative anal- from the video imaging system and similar
ysis of various soft-tissue facial planes to judge measurements obtained from previous radio-
balance in the facial profile reaffirmed that, in graph cephalometric studies.12'15'16'24 Thus fa-
any such consideration, the nose, lips, and chin cial imaging systems had the advantage of pro-
relationship must be included. viding reliable and repeatable soft-tissue mea-
surements, as well as comparability with the
Facial Video Imaging soft-tissue values derived from radiograph
The recent advances in facial video imaging cephalometric studies. Considering the profile
techniques with the use of the DigiGraph ma- alone, however, is not enough because it is only
chine (Dolphin Imaging Systems, Valencia, a two-dimensional outline of the face. Powell
CA) have made it possible to get superimposi- and Rayson25 noted that the overall appear-
tions of skeletal and facial images. The cut- ance of a face cannot be reliably assessed from
and-paste procedures used to provide a visual the profile outline alone. The orthodontist can
treatment objective have resulted in improved analyze the face in all three dimensions using
feedback to the patient as well as to collaborat- this imaging system without risking the haz-
ing clinicians. Because of the increasing de- ards of ionizing radiation. The importance of
mand for adult orthodontic and orthognathic conventional radiograph cephalometrics re-
surgical procedures for the correction of se- mains paramount; however, imaging systems
vere dentofacial disharmonies, a study of bal- may provide a valuable adjunct to orthodontic
anced young adult faces was conducted using a diagnosis and treatment planning.
facial video imaging technique to evaluate the
relationships of various soft-tissue measure-
ments in both video-imaged profile and frontal Growth of the Soft Tissues of the Face
views.23 Twenty-five white men (mean age of and Long-term Changes in the Profile
26 years 9 months; range from 21 years 6 The balance of the facial structures is affected
months to 36 years 1 month) and 25 white by both orthodontic treatment and growth. It
women (mean age of 25 years 6 months; range is essential that the clinician understand the
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Table 1. Mean and Standard Deviation Values for 36 Soft Tissue Lateral Measurements in Young Adult
White Men and Women
Female (n = 25) M ale (n = 25)
Number Variables Mean SD Mean SD
Sagittal: (A) Linear (mm)
1. Upper lip to esthetic plane -4.59 2.49 -6.03 1.87
2. Lower lip to esthetic plane -2.30 2.27 -3.95 2.01
3. Superior sulcus depth 3.24 1.39 2.92 1.49
4. Upper lip thickness at A-point 11.30 2.30 13.38 2.42
5. Upper lip thickness at Ver. Border 10.23 2.21 12.68 2.29
6. Soft tissue chin thickness 6.43 1.72 8.53 2.00
7. Nasal prominence 12.30 2.78 13.93 3.30
8. Tragus— N' 92.08 4.17 98.94 4.90
9. Tragus— Prn 112.74 4.89 122.21 4.19
10. Tragus—Ls 106.22 4.31 115.85 4.62
11, Tragus—Li 110.79 4.45 120.33 4.71
12. Tragus—Sto 103.36 4.31 113.28 4.22
13. Tragus— Pog' 118.56 4.18 132.08 5.23
Sagittal: (B) Angular (degrees)
1. Soft tissue convexity 164.74 4.29 165.74 4.94
2. Angle of total facial convexity 132.12 4.14 132.81 4.73
3. Upper lip Z angle 81.62 5.00 83.92 4.93
4. Lower lip Z angle 80.04 7.07 84.14 5.90
5. Nasolabial angle 102.78 14.01 108.15 13.18
6. Mentolabial angle 128.79 13.42 129.21 11.59
7. Nasofrontal angle 143.58 6.42 140.99 9.03
8. Nasofacial angle 29.68 2.85 30.06 3.70
9. Lower Face-Throat angle 105.70 8.10 112.12 7.88
10. N' -Tragus—Prn angle 23.88 1.94 22.35 2.10
11. Prn-Tragus-LS angle 14.10 1.50 14.98 1.71
12. Ls-Tragus-Li angle 7.78 1.60 6.43 1.62
13. Ls-Tragus-Sto angle 3.20 1.19 2.40 0.93
14. Li-Tragus-Pog' angle 12.44 1.15 12.49 1.55
15. N' -Tragus- Pog' angle 54.99 2.84 53.85 3.80
Vertical: Linear (mm)
1. Ratio mid to lower face (N-SN/SN-Me %) 77.41 7.12 71.36 6.26
2. Upper lip length 20.96 1.86 23.49 2.60
3. Lower lip length 42.25 2.69 47.90 2.97
4. Ratio of upper to lower lip length 49.66 4.24 49.20 6.41
5. Interlabial space 2.06 1.33 2.01 1.19
6. Mid-face height 49.74 2.85 51.49 3.11
7. Upper incisor exposure on smiling 8.93 2.26 8.42 2.47
8. Gingival exposure on smiling -1.31 2.31 -2.70 2.26
Reprinted with permission from Nanda et al.23
amount and the direction of growth expected ments. Longitudinal lateral head cephalo-
in the facial structures in addition to the effects grams of 40 white individuals, 17 men and 23
of treatment. The development of the soft- women, were selected from the records of the
tissue profile is a result of complex changes Child Research Council in Denver.28 The fol-
within the hard and soft tissue structures of the lowing criteria were used for selection of the
face. Previous studies on the growth changes in subjects:
the facial integument11'12'24'26 have either used
reference planes that themselves were subject 1. No previous orthodontic treatment per-
to change or used cross-sectional or mixed lon- formed.
gitudinal data. An investigation15 was per- 2. Class I or end-to-end molar relationship
formed to measure soft tissue growth changes with a normal overbite and overjet at the
with reference to the pterygomaxillary vertical age of 7 or 8 years; Class I molar relation-
(PMV) plane drawn from the sphenoethmoi- ship with normal overbite and overjet at 17
dal point (SE) to the pterygomaxillary (ptm) or 18 years of age.
point. This reference plane has been suggested 3. A relaxed lip posture with the teeth in oc-
to be relatively more stable for measure- clusion on all of the radiographs.
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74 Nanda and Ghosh
Table 2. Mean and Standard Deviation Values for 2 Dental and 13 Soft Tissue Frontal Measurements in
Young Adult White Men and Women
Female (n = 25) Male (n = 25)
Number Variables (mm) Mean SD Mean SD
Soft Tissue—Transverse
1. Interpupillary width 61.45 3.64 65.11 4.44
2. Nasal width 34.85 8.41 36.08 2.36
3. Width of commissure 47.04 2.80 50.44 3.09
4. S. T. Bi-zygomatic width 117.36 5.43 121.93 5.50
5. Bi-Gonial width 107.12 4.53 119.64 6.42
Distances to the Facial Midline (N'-Sn)
1. N'-SN line— Me' 0.15 2.67 0.63 2.98
2. N'-SN line— Nasal tip -0.25 0.96 -0.30 1.39
3. N'-SN line—A arch midline 0.89 2.09 1.42 1.95
4. N'-SN line—B arch midline 0.69 1.94 1.11 2.66
5. N'-SN line— AG 53.38 2.77 59.36 4.39
6. N'-SN line—GA 53.90 3.65 60.58 4.33
7. N'-SN line—Po'-right 67.62 2.57 70.91 4.09
8. N'-SN line— Po'-left 69.49 3.88 73.18 3.22
Reprinted with permission from Nanda et al.2
4. Six or more radiographs per individual, dis- in female subjects and 63% in male subjects.
tributed fairly evenly through ages 7 to 18 Similar to nose height, nose depth also showed
years. Each radiograph was taken at yearly a significant increase at age 17 in males. The
intervals and was included only if it showed soft-tissue height and depth of the nose ap-
the soft tissue profile in repose without any pears to be still growing at 18 years of age in
strain. Case records with large age gaps be- males. However, the skeletal base to the nose
tween the serial radiographs were omitted. measurement from the prn' measurement to
For each subject, the radiographs taken at 7 the PMV completed its growth by 17 years in
or 18 years of age had to be available. both the males and females.
Lip length and thickness are important ele-
All of the cephalometric radiographs were ments of the facial profile. Lip position is af-
traced, and the landmarks were digitized on a fected by the placement and inclination of the
computer to provide hard tissue as well as soft maxillary and mandibular incisors and hence is
tissue measurements. Most of the landmarks responsive to orthodontic treatment. It was sig-
were located according to the definitions pro- nificant that the average increase in upper and
vided by Riolo et al, Chaconas et al,26 and lower lip length in males was more than twice
Legan et al.30 that of females. Figure 6 gives the total incre-
The vertical dimension of the nose in- ments in the size of various measurements in
creased until 18 years of age. Whereas about millimeters from age 7 to 18 years. Whereas
80% of the upper nose height, measured by a the mean aggregate increase in upper and
method earlier described,15 had been com- lower lip lengths in the male subjects was 6.9
pleted for both sexes at age 7 and only a small mm, in the female subjects it was only 2.7 mm.
sex difference in its ultimate size was recorded, It is obvious from the small growth changes in
the lower nose height at age 7 was 90% com- the female upper and lower lip lengths that a
plete for the female group compared with 67% protruding dentition at 7 years will not change
for the male group at age 7. The male subjects much relative to the lips during growth. The
showed larger increments in growth of the treatment of choice, if so indicated, may re-
lower nose height at 17 years. It was apparent quire extraction of first premolars. However,
from the data that the upper nose height in- with growth in the lip lengths of the males,
creased three times more than the lower nose some accommodations are possible.
height, thereby maintaining a ratio of upper Small changes in the upper-lip length and
nose height to lower nose height of 3:1. prediction equations suggesting a linear rela-
Nose depth (projected pronasale [prn'] - tionship indicate a probability that those with a
pronasale) was 70% complete at 7 years of age short upper lip at 7 years will continue to have
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PMV
Pm
Figure 6. The total incre-

ments of the size of vari-
ous measurements in mil-
limeters for male and fe-
male subjects age 7 to 18
years (Reprinted with per-
mission from Nanda et
al.15)
a short upper lip even at age 18 years. The growth in the facial skeleton. The forward
impact of this finding on treatment planning is growth of the facial skeleton also varies, with
significant because the excessive display of up- more growth occurring in the mandibular re-
per gingiva, if present, should be corrected gion than in the maxillary region.31 The dif-
early to establish a more favorable tooth to lip ferential growth changes in the soft and hard
relationship. tissues determine the final form of the face
Lip thickness at points A and B increased and hence the relationship of the facial fea-
more than at the vermilion borders. The in- tures.
crease in lower lip thickness at vermilion bor- Most of the soft tissue growth changes at the
der was very small for the females. These nose, lips, and chin suggest sexual dimor-
changes lead to thicker, longer lips for the phism. Males had greater increases over a
males. The lips of males increased approxi- larger time span than females (Fig 6). Table 3
mately 7 mm in length and therefore accom- summarizes the observations made on all the
modate more protrusion of incisors than do measurements in terms of percentage of
the lips of females. growth completed at 7 years and the attain-
The esthetic-plane relationship to the lips is ment of adult size. In most of the measure-
exceedingly complex; the E-plane records only ments, females had attained their adult size at
the resultant growth in the regions of nose, 15 years, whereas in males, several measure-
lips, and chin. This growth is not just that of ments appeared to be increasing even at 18
the soft-tissue drape but also the translation years of age. The period of study covered only
forward of the entire facial profile caused by 7 to 18 years, and therefore the adult size of
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76 Nanda and Ghosh
Table 3. Attainment of Adult Size for the Various Soft Tissue Variables and Three Skeletal
Base Measurements
Growth Growth Ending Growth Completed Growth
Completed at or Before Past 15 and Continuing
at 7 Years (% 15 Years Before 18 Years at 18 Years
Variable Male Female Male Female Male Female Male Female
Upper nose height 80 82 X X

Lower nose height 67 90 X X
Nose depth 63 70 X X
Nose skeletal base at pm'-PMV 85 90 X X
Upper nose inclination 87 90 X X
Lower nose inclination 92 89 X X
Upper lip length 88 95 X X
Lower lip length 78 91 X X
Upper lip thickness at A 73 76 X X
Upper lip thickness at LS 82 93 X X
Lower lip thickness at LI 85 89 X X
Lower lip thickness at B 80 85 X X
Sagittal length of mandible at B 75 84 X X
Chin thickness at Pgs 80 83 X X
Chin thickness at Pg 83 88 X X
Symphyseal thickness 92 95 X X
Skeletal base at Pg"-PMV 66 74 X X
Inclination of skeletal chin 44 27 X X
Inclination of chin integument 72 66 X X
23
i et al.
several of the male soft-tissue measurements edge of the potential changes that may occur in
could not be predicted. The percentage of adult facial structures and their magnitude
growth completed at each age relative to the could be a factor in the treatment of patients,
size of the variable at 18 years also showed dif- particularly late adolescents and young adults.
ferences in proportionate development of the An investigation was therefore undertaken to
various facial dimensions between males and evaluate growth changes of the adult face and
females. Sex differences in size of the soft tis- the impact of these changes on treatment plan-
sue measurements, suggest that the age at ning.4*
which orthodontic treatment is commenced This research used the longitudinal lateral
will be important, especially in patients requir- cephalometric radiographs of 47 subjects, 24
ing orthognathic surgery in conjunction with men, and 23 women, selected from a larger
orthodontic treatment. group of subjects who participated in the Child
Research Council Study in Denver. The radio-
graphs used were taken between the ages of 18
Growth of the Soft Tissues in Adults and 42 years. There were a minimum of three
cephalograms available during this age range.
The changes that occur in facial hard and soft They were selected on the basis of a relaxed lip
tissues must be taken into account in the adult posture with no soft-tissue distortion and with
as well as the adolescent patient because of the teeth in occlusion. The face exhibited near
continuing processes of growth and develop- normal profiles with no excessive protrusions
ment. Several studies that have documented or retrusions, and all occlusions had Class I or
longitudinally the growth changes in the hard end-to-end molar relationships. On the ceph-
tissues of the face and the soft tissues of alometric tracings, the measurements were
the face 11 ' 12 ' 15 ' 24 ' 26 ' 38 ' 39 show that these made relative to the pterygomaxillary vertical
changes occur predominantly before the age reference plane.
of 18 years but are not complete at that time. Figure 7 summarizes the overall mean
Further, the changes occurring at age 18 years changes that occurred in the male and female
and their relative rates indicate notable differ- face from the late teens through the early 40s.
ences between males and females.15 Knowl- Men had more increases in posterior face
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Figure 7. Mean growth

changes in male (M) and
female (F) faces between
the ages of 18 and 42
years. All changes are in
millimeters. (Reprinted
with permission from
Formby WA, Nanda RS,
Currier GF. Longitudinal
changes in the adult facial
profile. Am J Orthod
Dentofac Orthop 1994;
105:464-476.)
height than women, whereas the changes in changes, and an increase in chin soft-tissue
anterior face height were comparable between thickness, resulted in both lips appearing more
the sexes. This is consonant with the observa- retruded with age. The mean trends for men
tion made by Nanda28 that the sella-gonion indicated that the effects of chin growth
measurement showed significant increase in slightly outweighed nose changes in the male
length as the other facial measurements profile which resulted in a straightening of the
seemed to level off. The total increases in the profile. However, for the women, the upper
male samples in y-axis length, corpus length, lip and chin soft-tissue decreased in thickness,
and skeletal depth at pogonion indicated a sag- and the lower lip showed a small increase in
ittal increase in the mandible. This, taken to- thickness. Taken together with the minor man-
gether with a decrease in the mandibular plane dibular skeletal changes, the women did not
to sella-nasion angle, resulted in the male face have an effect of straightening the profile. In-
becoming more prognathic and having a stead, it became more convex as the changes at
straighter profile with age. The women had an the nose were greater than the changes at the
increase in ;y-axis length but registered only chin. In women, the reduction in thickness at
small increases in corpus length and skeletal the soft tissue chin may have been caused by
depth at pogonion with little change in man- the increase in the anterior face height and a
dibular plane angle. Both sexes had increased small increase in the mandibular plane angle
nose depth and nose length. Upper and lower causing slight stretching of the soft tissue over
lips of men decreased in thickness which, taken the chin. Both sexes had increased upper lip
with nose changes, sagittal skeletal mandibular length that reduced the incisor exposure by 1.0
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78 Nanda and Ghosh
mm. This difference probably helps to account

for the dental generalization that, as people
age, they show less teeth. However, the
changes in upper lip length on an individual
basis showed that the changes in the amount of
incisor exposure with age can vary greatly de-
pending on the individual. This increase in lip
length should be a consideration when treating
12 years
patients requiring surgical maxillary elevation. 18 years
In general, most changes in men occurred 30 years
between the ages of 18 and 24 years, whereas
most changes in women occurred between the
ages of 20 and 30 or more years. Male growth
occurring predominantly in early adulthood
was anticipated because studies have shown
that growth is not complete by age 18 years in
men, whereas female growth is more complete
by that time.6'7'14 Female changes occurring
mostly in more advanced adult age groups are
difficult to explain. It is possible that they may
be related to the childbearing and hormonal
changes that occur in women during this pe-
12 years
riod. 18 years
Figure 8 shows the superimpositions of 39 years
cephalometric radiograph tracings for two
male subjects who experienced notable growth
changes in their adult life. Male subject 1 had a
large increase in posterior face height (S-Go)
of 8.86 mm from age 18 to 30 years. Male sub-
ject 2, however, had the largest y-axis length Figure 8. Superimpositions along pterygomaxillary
(S-Gn) increase of 6.21 mm. His growth pat- vertical plane at sphenoethmoidal point for two
tern was mostly vertical from age 12 to 18 males to illustrate variations of late growth changes.
No. 1 experienced a large increase in posterior face
years, but was mostly sagittal in adulthood. height and y-axis length. No. 2 showed maximum
3>-axis length in the group, and his growth pattern
indicated a change from vertical to sagittal. Both
The Effects of Facial Type individuals show considerable growth in their facial
Our existing knowledge on the growth of the soft tissues beyond the age of 18 years, resulting in
a change of the profile. (Reprinted with permission
craniofacial complex is largely based on sam- from Formby WA, Nanda RS, Currier GF. Longi-
ples with a balanced craniofacial structure or tudinal changes in the adult facial profile. Am J
mixed variations. References have been made Orthod Dentofac Orthop 1994; 105:464-476.)
in the literature about the effect of facial pat-
tern on the growth potential of a person's fa- gitudinal sample taken of the subjects from 7
cial measurements.41"43 For example, those to 17 years of age.44
with long faces and high mandibular plane an- Thirty-two sets of lateral cephalometric ra-
gles will have a posterior rotation of the man- diographs taken from age 7 to 17 years were
dible with growth, versus those with short faces selected based on the percentage of lower an-
and low mandibular plane angles who are anterior facial height (ANS-Me) from the records
ticipated to have more sagittal growth. To ver- of the Child Research Council, Denver, CO.
ify the growth pattern and to quantify the in- The subjects who had the greatest extreme
tegumental changes in individuals with these values for this measurement were selected and
facial types, a study was conducted on individ- divided into four groups. There were eight
uals with a long lower anterior face height and male subjects each with short faces and long
a short lower anterior face height from a lon- faces, and eight female subjects each with short
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faces and long faces. The selection standards tinued growth of the lips in the men through
used in this study were the same as those used age 17 years, whereas the women showed small
in previous reports by Nanda.41"43 All subjects decreases after age 14 years. These findings
examined in this study were white and of are consistent with those of Burstone,11 Sub-
Northern European descent. No orthodontic telny,12 Chaconas and Bartroff,26 Kapila,45
treatment had been rendered and the radio- and Nanda et al.15 Whereas the changes in the
graphs were taken in a relaxed lip posture. thickness of the upper lip at labrale superius
Those subjects in whom the teeth were not in did not show any distinct pattern between the
occlusion or lip strain was evident were not in- long-face and short-face subjects, the relative
cluded. A lateral cephalometric radiograph growth in the lower lip thickness at labrale in-
taken at approximately 15 years of age for ferius was greater in the short-face subjects.
males and 13 years 6 months for females was When the mean growth changes were con-
used to classify the subject either as deep bite sidered, independent of gender, based on the
or open bite. Differentiation between open bite size of the dimension at age 7 years, the rela-
and deep bite was based on relative lower face tive growth increment in upper and lower lip
height (ANS-Me) taken as a percentage of lengths was greater in the long-face than it was
morphological face height (Na-Me). This ratio in the short-face subjects. The longer upper
was measured in the open bite sample as a and lower lips in the long-face groups could
mean of 60.65% for the male group and have been a compensatory mechanism for the
59.67% for the female group, whereas in the individuals to obtain a lip seal. Because shorter
deep bite sample it was 53.61% for the male facial patterns have a decreased vertical di-
group and 53.27% for the female group.41 mension, the length of the upper and lower
A significant trend toward sexual dimor- lips would not have to be as long for a seal to be
phism was evident for the lower anterior ver- produced. It could be argued that smaller lip
tical facial height and soft-tissue thickness at length in short-face subjects was caused by lip
point A. Trends were also noted for several closure, but that should lead to a greater gath-
other variables, including upper lip height, up- ering of lip tissue and an enhanced thickness.
per lip thickness, soft tissue thickness at point However, as shown by these data, the lip thick-
B, and pogonion thickness. In general, the ness of short-face subjects was less than that of
soft-tissue integument of the face in females those with long faces.
attained its adult size at age 15 years, at which For all chin measurements including the
time its growth leveled off. The growth curves thickness of tissue at point B and pogonion,
for males, however, showed continued growth significantly larger thickness was noted in the
even past the age of 17 years. As previously long vertical patterns. This may have been na-
discussed, Formby et al40 have shown that ture's way of compensating for the shorter
growth, particularly in males, continues past mandibular corpus length in an effort to mask
the end points of this study and into adult- the condition and provide a more normal fa-
hood. cial appearance. The converse was true for
The anterior nose depth was significantly subjects with the short patterns who showed a
larger in male and female subjects who had a thinner tissue drape.
short vertical pattern. For the upper lip thick- Although a considerable amount of variabil-
ness at point A, however, males with long verity was noted in individual growth patterns, the
tical patterns had the greatest thickness of tis- trends observed generally followed those of
sue from age 8 to 16 years. The relative the mean growth curves. Individuals whose
changes in the thickness of lips at points A and measurements were high at age 7 were ob-
B were noted to be similar in the two facial served to have high measurements even at age
patterns. Upper and lower lip thicknesses as 17. The trends for the individual growth
measured at labrale superius and labrale infe- curves observed in this study were similar to
rius showed a great deal of variability, as has those reported for skeletal measurements by
been reported previously. Unlike other re- Nanda.41"43 He noted that the females tended
ports,15'45'46 the males in this study did not to have their adolescent growth spurt earlier
have larger mean increment values than the than males and that the long facial patterns
females. However, there appeared to be con- expressed themselves in subjects before short
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80 Nanda and Ghosh
vertical patterns did. The soft tissues of the positioning the anterior teeth, changes in lip
perioral area closely followed this trend. This profile can be made to balance the profile.
may have clinical implications in that the indi- This concept has a direct impact on extraction
viduals with long faces may require therapeu- and nonextraction decisions in orthodontic
tic intervention at an earlier age than those treatment planning.
with short vertical patterns. Because females Knowledge gained in growth studies has
mature earlier than males, it would be benefi- clearly shown that dynamic changes in dental,
cial to conduct growth modification treatment skeletal, and facial integument do occur over
at an earlier age in females. This treatment the entire period of active growth and even
may consist of an attempt to restrict or redirect into the decades past the age of 20 years. All
the vertical growth of the maxilla in the long- these changes have to be kept in mind when
face individuals or may include some posteri- developing treatment plans for preadolescent
orly extrusive mechanics in the case of those patients with malocclusions. We can not look
with the short vertical patterns in an attempt to on normal as a static concept for a 13-year-old
reduce or redirect the growth of the dentofa- male or female individual but rather should
cial complex. In matters regarding the stability project our assessments to the time the patient
of the treated result, it is important to consider will be well into adulthood.
the pattern of an individual's vertical growth Facial types also need to be considered be-
and adapt the retention mechanics accord- cause long-face and short-face individuals have
ingly. Similar recommendations have also been different growth and maturational patterns.
made by Nanda and Nanda.46 The soft-tissue thicknesses and lip lengths,
It may be concluded from this study that the which are greater in the long-face individuals,
soft tissues attempt to compensate for ex- need to be noted. Furthermore, the fact that
tremes in an individual's vertical pattern. long-face individuals can be identified as early
Those individuals with short facial patterns as 7 years of age adds another dimension to the
have a thinner soft-tissue drape which may at- treatment planning for these patients.
tempt to mask the strong appearance of the The mean data on facial growth studies can-
mandible in profile. Conversely, those with not be rigidly applied to all individuals at all
long vertical patterns have a thicker integu- ages. Students of growth and development un-
mental profile that may be compensatory for derstand the presence of wide variation among
the lack of skeletal support. individuals of all races and both sexes. Clinical
judgment can never be replaced by any written
dogma based on mean numbers because the
Summary
mean measurements at best only indicate a
The traditional concepts in orthodontic diag- trend.
nosis have erred in focusing excessively on the
use of the dental and skeletal structures of the
craniofacial complex. Corrected malocclusions References
with acceptable long-term retention may not 1. Kingsley N. A Treatise on Oral Deformities as a
necessarily achieve overall facial balance and Branch of Mechanical Surgery. New York: Applegate,
harmony. This article makes a plea for the con- 1980:465-509.
sideration of harmonized facial structures as a 2. Angle EH. Treatment of malocclusion of the teeth.
primary goal of treatment. It has already been 7th ed. Philadelphia: S.S. White Dental Manufactur-
ing, 1907.
shown that adhering to the so-called dental 3. Case CS. The question of extraction in orthodontia.
norms did not provide greater advantages in Trans NDA, 1911.
long-term retention.47 4. Simon PW. On the necessity of gnathostatic diagnoses
Research into balancing aberrant profiles in orthodontic practice. Int J Orthod 1926; 12: 1102-
has indicated that the position of the lips is 1115.
5. Hellman M. Some facial features and their orthodon-
usually responsive to orthodontic treatment tic implications. Am J Orthod Oral Surg 1939;25:
and is, therefore, more critical in orthodontic 927-951.
diagnosis than the nose and chin, which can 6. Carrea GV.Les radiofacies a profile delinee en orth-
only be altered with orthognathic surgery. By odontometrie. Semaine Dent 1924;6:416-419.
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7. Tweed CH. Indications for the extraction of teeth in Atlas of Craniofacial Growth: Cephalometric Stan-
orthodontic procedure. Am J Orthod 1944;30:405- dards from the University School Growth Study.
428. Monograph No. 2, Craniofacial Growth Series, Center
8. Margolis HI. Standardized x-ray cephalographics. Am for Human Growth and Development, The Univer-
J Orthod Oral Surg 1940;26:725-740. sity of Michigan, 1974:14-21.
9. Downs WB. Variations in facial relationships: Their 30. Legan HL, Burstone CJ. Soft tissue Cephalometric
significance in treatment and prognosis. Am J Orthod analysis for orthodontic surgery. J Oral Surg
1948;34:812-840. 1980;38:744-751.
10. Steiner CC. Cephalometrics for you and me. Am J 31. Nanda RS, Ghosh J. Longitudinal changes in the sag-
Orthod 1953;39:729-755. ittal relationships of maxilla and mandible. Am J
11. Burstone CJ. The integumental contour and exten- Orthod 1993 (In press).
sion patterns. Angle Orthod 1959;29:93-104. 32. Broadbent BH. The face of the normal child. Angle
12. Subtelny JD. A longitudinal study of soft tissue facial Orthod 1937;7:183-208.
structures and their profile characteristics defined in 33. Brodie AG. On the growth pattern of the human head
relation to underlying skeletal structure. Am J Orthod from the third month to the eighth year of life. Am J
1959;45:481-507. Anat 1941;68:209-262.
13. Neger M. A quantitative method for the evaluation of 34. Brodie AG. Late growth changes in the human face.
the soft tissue facial profile. Am J Orthod 1959;45: Angle Orthod 1953;23:146-157.
738-751. 35. Lande MJ. Growth behavior of the human bony facial
14. Park Y, Burstone CJ. Soft-tissue profile—fallacies of profile as revealed by serial Cephalometric roentgen-
hard-tissue standards in treatment planning. Am J ology. Angle Orthod 1952;22:78-90.
Orthod Dentofac Orthop 1986;90:52-62. 36. Nanda RS. The rates of growth of several facial com-
15. Nanda RS, Meng H, Kapila S, et al. Growth changes in ponents from serial Cephalometric roentgenograms.
the soft tissue facial profile. Angle Orthod 1990; 60: Am J Orthod 1955;41:658-673.
177-190. 37. Nanda RS. Growth changes in skeletal facial profile
16. Zylinski CG, Nanda RS, Kapila S. Analysis of soft tis- and their significance in orthodontic diagnosis. Am J
sue facial profile in white males. Am J Orthod Dent- Orthod 1971;59:501-513.
ofacial Orthop 1992;101:514-518. 38. Pelton JW, Elsasser WA. Studies of dentofacial mor-
17. Riedel RA. Esthetics and its relation to orthodontic phology. IV. Profile changes among 6829 white indi-
therapy. Angle Orthod 1950;20:168-178. viduals according to age and sex. Angle Orthod
18. Cox NJ, Van der Linden FPGM. Facial harmony. Am 1955;25:199-207.
J Orthod 1971;60:175-184. 39. Mauchamp O, Sassouni V. Growth and prediction of
19. Foster EJ. Profile preferences among diversified the skeletal and soft-tissue profiles. Am J Orthop
groups. Angle Orthod 1973;43:34-40. 1973;64:83-94.
20. Czarnecki ST, Nanda RS, Currier GF. Perceptions of
40. Formby WA, Nanda RS, Currier GF. Longitudinal
a balanced facial profile. Am J Orthod Dentofacial
changes in the adult facial profile. Am J Orthod Dent-
Orthop 1993;104;180-187.
ofacial Orthop 1994; 105:464-476.
21. Ricketts RM. Planing treatment on the basis of facial
pattern and an estimate of its growth. Angle Orthod 41. Nanda SK. Patterns of vertical growth in the face. Am
J Orthod 1088;93:103-116.
1957;27:14-37.
22. Hsu BS. Comparisons of the five analytic reference 42. Nanda SK. Circumpubertal growth spurt related to
lines of the horizontal lip position: Their consistency vertical dysplasia. Angle Orthod 1989;59:113-122.
and sensitivity. Am J Orthod Dentofacial Orthop 43. Nanda SK. Growth patterns in subjects with long and
1993; 104:355-360. short faces. Am J Orthod Dentofac Orthop 1990;98:
23. Nanda RS, Ghosh J, Bazakidou E. A three- 247-258.
dimensional facial analysis using a video imaging sys- 44. Blanchette ME, Nanda RS, Currier GF, et al. A longi-
tem. Angle Orthod 1994 (Submitted for publication). tudinal Cephalometric study of the soft tissue profile
24. Bishara SE, Hession TJ, Peterson LC. Longitudinal of short and long face syndromes from 7 to 17 years.
soft tissue profile changes. Am J Orthod 1985;88; Am J Orthop Dentofacial Orthop 1993 (In press).
209-223. 45. Kapila S. Growth changes in lip profile from 7 to 18
25. Powell SJ, Rayson RK. The profile in facial aesthetics. years: A longitudinal Cephalometric study. Masters
Br J Orthod 1974;3:207-215. thesis. The University of Oklahoma Health Sciences
26. Chaconas SJ, Bartroff JD. Prediction of normal soft Center, 1986.
tissue facial changes. Angle Orthod 1975;45:12-25. 46. Nanda RS, Nanda SK. Considerations of dentofacial
27. Enlow DH, Kuroda T, Lewis AB. The morphological growth in long-term retention and stability: Is active
and morphogenetic basis for craniofacial form and retention needed? Am J Orthod Dentofacial Orthop
pattern. Angle Orthod 1971;41:161-188. 1992;101:297-302.
28. Nanda RS. Cephalometric study of the human face 47. Little RM, Wallen TR, Riedel RA. Stability and relapse
from serial roentgenograms. Ergebnisse der Anat- of mandibular anterior alignment—four premolar ex-
omic und Entwicklungs-Geschichte 1956;35:358-419. traction cases treated by traditional edgewise orth-
29. Riolo ML, Moyers RE, McNamara JA Jr, et al. An odontics. Am J Orthod 1991;80:349-365.
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Orthodontic Applications of Psychological

and Perceptual Studies of Facial Esthetics
Donald B. Giddon
Historically, orthodontists have not reconciled the paradox that their diag-
nostic and treatment decisions are based largely on objective morphological
considerations and their patients' decision-making centers on esthetic ex-
pectations and other subjective factors related to self-image and outcome.
Key to the unraveling of this discrepancy is a greater understanding of the
role of perception by self and others in orthodontic diagnosis and treatment.
Esthetics can be defined as relating to feeling, and perception can be defined
as the organization of environmental stimuli. Various physical, psychologi-
cal, and social factors that affect perceptual judgments are described and
related to the development and maintenance of self-image and/or concept.
The impact of these self and/or other perceptions of dentofacial attractive-
ness on motivation for seeking orthodontic care are discussed. New quan-
titative approaches to relate morphological changes to perception of facial
appearance are reported.
For the orthodontist, diagnosis and treat- Thanks to cephalometric and other anthropo-
ment planning are based primarily on de-metric measures and classification schemes,
viations from normative physical relationships the relationships among the anatomical com-
among dentition, bony support system, and ponents are easily described for the establish-
soft tissue drape. Physical and not mental ment of normative databases.4 Like physical
health is the primary focus. In contrast, 80% of scientists, orthodontists have had little regard
those adults (e.g., mothers) seeking orthodon- for what they cannot directly and objectively
tic care for themselves or their children are measure or experience with their visual, audi-
motivated by a desire to improve appearance tory, or tactile senses. Consistent with this ori-
regardless of structural or functional consider- entation, the indices of the need for orthodon-
ation.1 Until and unless physical attractiveness tic treatment before the 1970s, "Malalignment
becomes an issue, as in teasing and other forms Index of Massler and Frankel,"5 "Malalign-
of harassment, for example, children show lit- ment Index of Van Kirk and Pennell,"6
3
tle inclination to seek such care. "Handicapping Labiolingual Deviations In-
There are many reasons for this apparent dex" of Draker,7 and Grainger's "Treatment
paradox, the most important of which is dif- Priority Index,"8 relied almost entirely on
fering perceptions on the part of the doctor measurable deviation from an ideal occlusion,
and patient of the same objective information. as described by Angle.9 Not until the late 1960s
did orthodontists begin to acknowledge the
role of subjective factors such as perception of
From the Harvard School of Dental Medicine, Boston, MA; appearance or esthetic satisfaction in deter-
and the College of Dentistry, University of Illinois at Chicago. mining patient behavior. Before that time,
This research was supported by NIDR grant DE 10292 and they certainly understood esthetics but mostly
the American Association of Orthodontists. through the eyes of the clinician.2 Unfortu-
Address correspondence to Donald B. Giddon, DMD, PhD, nately, the now classic Health Belief Model of
Harvard School of Dental Medicine, 188 Longwood Ave, Boston,
MA 02115. Rosenstock and coworkers10'11 does not do jus-
Copyright © 1995 by W.B. Saunders Company tice to esthetic concern as a motivation for
1073-8746I95I0102-0004$5.00IO health care.
82 Seminars in Orthodontics, Vol 1, No 2 (June), 1995: pp 82-93

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Self/Other Perceptions in Orthodontics 83
Esthetics Physiological factors operate primarily at

the level of the nervous system. In addition to
Esthetics has been defined variously as the ap- the obvious involvement of the retina and vi-
preciation or the enjoyment of beauty.12 From sual pathways, there may in fact be higher-
a strict etymological point of view, esthetics, as order neurons in the cortex which respond se-
the application of the state of esthesia, has lectively to curves.16'17 Another example of
been considered to be the awareness of sensory higher CNS integration is the demonstration
stimulation and conversely is absence as anes- that individuals deprived of food or sex will
thesia. Over the centuries the concept of es- perceive ambiguous stimuli as food or sex ob-
thetics has grown to include emotional embel- jects.18 The literature is replete with the orga-
lishments, such as judgments of beauty and nization of affective/emotional or arousal re-
attractiveness, as well as the associated psycho- sponses to pleasurable stimuli,19 not the least
physiological patterns of arousal. For example, of which are facial expressions, which have be-
beauty as an esthetic experience has been de- come increasingly important to orthodon-
fined in terms of both stimulus and response tists.20 Johnston's recent work on recordings of
characteristics, or even operationally, as "that (esthetic) event-related potentials in the cortex
quality or combination of qualities which af- may provide further information on this im-
fords keen pleasure to the senses ... or which portant aspect.21
charms the intellectual or moral faculties."13 It Psychological factors can exert both positive
would seem that another word relating to and negative effects on perception. The effect
beauty (perhaps "cosmesis," to coin a term) of positive outcomes can be shown by such
might have avoided some semantic problems phenomena as perceiving loved ones as more
that followed. beautiful. Conversely, the adverse effects of
anxiety and depression on the perception of
Perception oneself and others has been noted by Cash and
others.22 Depressed individuals view them-
Perception has been defined as the process by selves more negatively than nondepressed in-
which patterns of environmental stimuli are dividuals despite the fact that there are no dif-
organized and interpreted. Considerable con- ferences between judgments of the same indi-
troversy exists over the origins of perception: viduals by others. Other factors such as reward
is it built up from sensory information by as- or punishment associated with learning, Ein-
sociative learning or, according to Gestalt psy- stellung, or readiness to respond can also influ-
chology, is it inherent in the organization of ence what one sees.15
the nervous system?14 Perception can be influ- A major contribution to this area was Rot-
enced by a variety of physical, physiological, ter's concept of locus of control.23 In essence,
psychological, and social factors. Classical when the outcome of an event is perceived to
physical factors associated with visual percep- be controlled by significant others, including
tion include stimulus attributes of color (hue, fate or chance, the individual believes the
saturation, brightness, etc), texture, and shape. events are externally controlled. Conversely,
For the gestaltists, the responses to more com- the belief that an event is contingent on one's
plex stimulus configurations, such as embed- own behavior or characteristics is deemed in-
ded patterns and figure-ground differentia- ternal locus of control.
tion, a type exemplified by the 1921 Rubin's A recognition of the relationship of person-
vase illusion, are important evidence for their ality variables to perceptual style was recog-
interpretation of perception. Whether one sees nized in 1972 by Witkin,24 who used the ori-
the figure or the ground is governed by the entation of a rod and frame to differentiate
relative frequency with which one is exposed to field-independent versus field-dependent per-
a particular pattern of stimulation from a sons, the former being more influenced by
physical arrangement, similar to the figure or their own body position than the visual field
ground. Perceptions thus reflect the probabil- and the latter more influenced by the visual
ities with which these patterns of stimulation field than by their own body position. Since his
occur in the environment.14'15 work, a plethora of research has emerged re-
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84 Donald B. Giddon
lating psychological and personality variables ural growth and aging to guide facial esthet-
of stress management and other dimensions of ics.32
health care behavior. Notable among these are What must have seemed like psychobabble
concepts of locus of control,23 self-efficacy,25 to orthodontists did not facilitate much agree-
or health belief,10 as summarized by Adler and ment about esthetic improvement. What was
Matthews.11 esthetically pleasing to some was displeasing to
The influence of social factors, ie, the ef- others.33 Furthermore, as Strieker noted in a
fects of group pressure on attitudes and per- state-of-the-art workshop, no current index
ception of individual members, was noted by was capable of predicting the degree of psy-
Asch.26 Using an experimental task of match- chosocial or functional handicap.34
ing lengths of lines to a given line, Asch found Subsequently, several studies have provided
the greater the individual's dependence on evidence that the perception of an individual
others, the less he or she will withstand group profile is more important to self-esteem and
pressure to modify his or her original percep- body image than the morphology. For exam-
tion. ple, Maxwell and Kiyak35 found that neither
body nor facial image self-perceptions was as-
sociated with cephalometric measures. It was
Inclusion of Dentofacial Attractiveness therefore no surprise that Bell et al36 con-
in Orthodontic Indices cluded that the profile is more relevant to pa-
tient motivation for orthodontic treatment. Re-
The recognition of the great importance of gardless, then, of clinically determined struc-
one's self-perception relative to others in addi- tural or functional deviation, it is the self-
tion to the standard orthodontic facial data led perception of oral function and appearance
to the rapid emergence in the late 1960s of a that seems to be the best predictor of the pa-
number of new orthodontic indices that in- tient's decision to undergo orthodontic and/or
cluded perceptions of attractiveness by self and surgical correction37'38 and subsequently de-
others. Thus, the Eastman Esthetic Index was termines the patient's posttreatment satisfac-
developed by Howitt and Strieker27 and was tion.39'40
validated by correlation with measures of chil- Bringing the pendulum of opinion back to
dren's self-esteem. Tedesco and Albino then center, Prahl-Anderson41 noted that motiva-
developed a dental-facial attractiveness rating tion for orthodontic treatment is a function of
(DFA)28'29 as the measure of a child's percep- three factors: objective signs, subjective symp-
tion of his or her occlusion. The most inclusive toms, and social sufficiency, the relative impor-
index, developed by Jenny, Cons, and Kohout tance of which varies according to the Zeitgeist.
in 1983,30 incorporated social and psychologi- Objective signs are deviations from an estab-
cal factors in addition to traditional measures lished norm, such as various indices of maloc-
of malocclusion. The Dental Aesthetic Index clusion; subjective symptoms include cognitive
(DAI)31 uses 10 derived occlusal traits to yield variables, such as recognition by the patient of
a score of severity of malocclusion and its ef- a problem requiring treatment; and social suf-
fect on appearance. The major difference ficiency involves recognition by society that the
from most previous indices was the inclusion patient's malocclusion creates a problem for
of the general public's esthetic rating of 200 the patient.
representative occlusal conditions found in a
population of 500,000 people.
The development of these indices created Self-Concept
considerable controversy by their suggestion Inculcation of society's values relative to one's
that the dentition was not a salient part of the perceived assets can have a major impact on
face except in cases of malocclusion. Peck and body image as a principal component of self-
Peck also provided some evidence challenging image and, ultimately, self-concept. Self-image
this changing emphasis, concluding that ortho- includes physical aspects of one's self com-
dontists should treat dentition and permit nat- bined with how one understands and weighs
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the perceptions of others. The more a person tients' motivations for seeking orthodontic care
is other-directed, or field-dependent, versus or surgical correction.
inner-directed, or similarly field-indepen-
dent,24 the greater the influence others have
on self-image; that is, how one thinks others Components of Attractiveness
see him or her is most important.26 All these Several authors have attempted to rank or clas-
terms can most easily be subsumed under "lo- sify faces on the basis of attractiveness, finding
cus of control" issues, as conceptualized by considerable agreement among judges in soci-
Rotter,23 ie, "Who's in charge?" and, "Are in- ety. Iliffe, for example, found surprising con-
ternal or external factors determining behav- sistency in ratings by 4,000 Britons, regardless
ior?" Consequently, the more one perceives of occupation or location, of 12 photographs
that one possesses an asset valued by society, of representative female faces 20 to 25 years of
whether physical, intellectual, or some other age published in the major London newspa-
measure of status, the more one will perceive per. Udry repeated the study in the United
oneself as valued. Self-concept then includes States with similar results for more than
the perceptions of self-efficacy25 or how one 100,000 Americans.60 Similar cross-cultural
views the ability to achieve goals, in addition to agreement has been reported by several inves-
self-image, including body image. tigators,61'62 who found such characteristics as
neoteny and average proportions to be attrac-
tive in at least five different cultures. Similar
Role of Attractiveness results were obtained with works of art instead
of faces,48 with judges from different back-
Perception of the appearance, particularly of grounds or dental esthetic sophistication; ie,
the face, by oneself and others, affects mental high concordance in judgments of facial attrac-
health and social behavior with significant im- tiveness across three groups of raters: ortho-
plications for educational and employment op- dontists, high school students, and graduate
portunities and mate selection.42"48 As noted students in art education.63'64 Similarly, Cross
by Patzer,49 there is in fact a hierarchy among and Cross found that adolescents do not differ
features in judging attractiveness, with the face significantly from adults in their ratings of at-
being the most important. Within the face, the tractiveness.65 Further evidence that beauty is
mouth and eyes are primary in these judg- not necessarily in the eyes of the beholder was
ments.49"52 Moreover, Secord and Backman recently noted by Johnston and Franklin,66
found that some dentofacial characteristics, who found that given 17 billion combinations
such as protrusion of maxillary teeth, corre- of facial features to choose from, essentially
lated negatively with attractiveness.53 the same face was generated by all subjects;
For evolutionary psychobiologists, symmet- that is, the inter-rater reliability was extremely
rical beauty and other aspects of physical ap- high.
pearance may serve as cues of reproductive There are of course methodological prob-
and sexual capacity for mate selection. Accord- lems with this kind of research, such as the
ing to the "good genes theory," people may representativeness of the stimulus faces42 and
also be genetically advantaged in physical and the influence of a number of characteristics of
intellectual abilities essential for survival in an those making judgments of attractiveness of
adverse society54; conversely, institutionalized others. For example, older persons tend to
criminals49 and mentally ill individuals55"57 downgrade youthful faces,60 whereas ex-
have been found to be less attractive than the tremely attractive and unattractive raters tend
average population. Whether right or wrong, to give lower attractiveness ratings than raters
the social consequences of what may be soci- of more average attractiveness.67 With so
ety's pernicious attitude are pervasive. How- much information on how the ultimate con-
ever, there is little doubt that concern for ap- sumer views appearance, particularly from the
pearance is a serious mental, as well as dental, media, cosmetic, and fashion industries,68'69 it
health issue,58 and as such it contributes to pa- is surprising that the providers and/or doctors
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86 Donald B. Giddon
do not routinely seek information on con- more likely than nondepressed patients to re-
r
sumer preferences. ^9
quest cosmetic surgery; that patients with hy-
Many authors have tried to identify physical pochondriasis and body dysmorphia seek out
features that can differentiate attractive from dentists, plastic surgeons, dermatologists, and
unattractive faces.4'40'48'49'61'62'66'70-73 For an other specialists who may alleviate their body
in-depth review of the history of esthetic con- image concerns. As pointed out by Macgreg-
siderations, see the article by Peck and Peck.48 or, often patients with the least severe devi-
ations are the most troublesome for the clini-
cians, particularly if there has been little or no
Morphometric Correlates of communication between doctor and patient.
Face Perception Imagined dysmorphia is in fact a related and
The precise relationship between morphology serious mental health problem.77 Thus, the cli-
and esthetics, however, has not been ade- nician must be constantly alert to exaggerated
quately defined. Only by inference from the concerns for appearance of the face and body.
data acquired by a variety of psychophysical Preoccupation with appearance can be both a
and related techniques can one get an indica- cause of or effect of psychopathology.
tion of the ideational representation or mental
image an individual has of his or her own face
or another's face or body. Unfortunately, cli- Psychobiological Significance of the
nicians do not always realize that it is this per- Orofacial Areas
ception and not the actual physical character- Part of the problem of doctor-patient commu-
istics to which the potential patient is respond- nications may well be caused by the failure of
ing, often with no ability to communicate his or the doctor to appreciate the significance of the
her cognitions, feelings, or expectations of orofacial stimulus to an individual patient and
treatment.45 Verbal responses themselves do the extreme distress that any adverse effect on
not provide sufficient information about the facial appearance can have. As noted by Gid-
patient's perceptions. don, the orofacial structures can be both a tar-
In contrast to the perception of simple get and a source of suffering.78 Galsworthy
changes in the frequency of light or sound en- had earlier stated, "One's eyes are what one is;
ergy emanating from inanimate objects de- one's mouth is what one becomes."79 The im-
scribed earlier, perception of the face is a com- portance of the mouth may be conceptualized
plex experience, being confounded by affec- as a hierarchy of needs into three sequential
tive and related physiological changes, as well levels, varying in biological and social signifi-
as behavioral responses toward the face as a cance: survival, socialization, and self-
stimulus object, such as avoidance behaviors of actualization.80 Thus, survival depends on the
increasing interpersonal distance or gaze aver- use of the mouth to satisfy such biological
sion.74'75 It is particularly difficult to deter- needs as thirst and hunger and survival of the
mine to what components of the face the ob- species. The organism can devote little effort
server is actually responding. Is he or she re- to socialization and subsequently self-
sponding to isolated components of the face or actualization until such basic needs are met.
to a relationship among them as part of a ge- Some affiliation with the opposite sex, how-
stalt-like configuration? ever, is essential to survival of the species as we
Unfortunately, there is no one-to-one rela- know it, as cooperation is to enhance accom-
tionship between physical aberrations and psy- plishment and self-esteem.
chological reactions to dysmorphia. Such dis- An aspect of socialization of particular rele-
crepancies may vary from patients with major vance for the orthodontist is the maturation of
craniofacial deformities requiring obvious in- the masticatory and speech apparatus to com-
tervention with little discernible evidence of municate with others by words and facial ex-
personal concern, to those with minimal phys- pression. In contrast with lower animals, the
ical deviation but great concern which ad- human being is able to use symbols effectively
versely affects their quality of life. Pruzinsky22 to express an aggressive idea rather than to
notes, for example, that depressed patients are bite or attack for this purpose. By virtue of an
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already-established primordial role as an in- would have been more appropriate. In re-
strument of aggression, the mouth becomes a sponse to Perrett, who recently found cross-
logical channel and, indeed, an acceptable tar- cultural preference for "non-average" or exag-
get of this aggression. The results of noxious, gerated facial features,61 Peck suggested that
nonmasticatory activities are seen in bruxism much of the preference could be accounted for
and clenching, with deleterious effects on the on the basis of features associated with youth-
teeth and the temporomandibular joint struc- fulness: foreshortened lower face, large eyes
tures. and forehead.82 These findings were also con-
The third and highest level of self-actual- sistent with Cunningham70 and Johnston and
ization or self-fulfillment is the need to fulfill Franklin's66 finding that male and female re-
one's potential, becoming everything one is ca- spondents preferred a female face determined
pable of becoming. Thus, the musician must anthropometrically4 to have features of a 13-
make music, the artist must paint, the poet year-old face even though they estimated the
must write. With specific relevance to the computer-evolved beautiful face to be 25 years
mouth, the actor must speak, the clarinetist of age. Langlois, Roggman, and Musselman,83
must play, the gourmet must eat, and the lover on the other hand, found that neither youth-
must kiss. fulness nor symmetry correlated with judg-
At the risk of being teleological, the most ments of attractiveness. Symmetry, however,
convincing argument for the significance of did improve the ratings of unattractive faces.
the orofacial areas is its biological substrate; If researchers can get into such semantic ha-
that is, the disproportionately large represen- rangues, it is no wonder that clinicians have
tation of the orofacial areas in the somatic, sen- problems choosing the correct word. Except
sory and motor systems of the cerebral cortex. for highly technical words that the patient
Given all the factors that can affect percep- would never use, the clinician assumes that the
tion in general and perception of the face in patient and the doctor are using the words in
particular, it seems most appropriate to at- the same way to describe the clinical situation
tempt to reconcile at least the objective (phys- or present expected treatment outcome. What
ical) with the subjective (perceptual) measures. is beautiful or attractive to the orthodontist or
Thus, a major research question has been to plastic surgeon based on experience and/or
determine the physical basis for the various training may or may not agree with what the
terms used in the judgment of attractiveness. A patient thinks is beautiful, attractive, or a sat-
continuing problem is difference in words that isfying clinical outcome.2 Finding the physical
are used in the task requirement; ie, "attrac- basis for words used in making judgments
tive," "acceptable," "tolerable," "pretty," "beau- about appearance will thus help both patients
tiful," "pleasing," "ugly," or "repulsive," as and clinicians communicate more precisely
used by Perrin,81 who surveyed students at the about proposed changes of various features.
University of Texas in 1921. Valentine first To avoid semantic confusion in our own re-
noted that whereas the responses of "beauty" search, the term "acceptable" was selected as
and "pleasingness" of 500 art students to works the generic description encompassing all the
of art were correlated, they were not identi- other superlatives; ie, all beautiful or pleasant
cal.12 Additionally, there is a continuous flurry faces would be considered acceptable; and all
of media and fashion research on the popular unpleasant, ugly, or unattractive faces would
connotations of beauty and attractiveness.68 be considered unacceptable. As will be shown,
Recent authors have generally ignored this research has been directed at determining
these possibilities, assuming their meanings to how much change in the physical units of one
be the same for all respondents. For example, feature by itself and/or in combination with
Johnston66 simply asked his panel of judges others must occur before the face, considered
(Js) to use a genetic algorithm program to con- as a gestalt or whole, is found acceptable or
struct the most beautiful face without establish- unacceptable. Ultimately, these perceptions
ing what Js meant by "beautiful." Perhaps the can be compared with a normative data bank
use of a semantic anchor point such as "attrac- specific to the physical and social characteris-
tive" at one end and "unattractive" at the other tics of a particular patient.
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88 Donald B. Giddon
Psychophysical Approaches to the ference in judgment among the respondent

Perception of Appearance groups.
Other studies by Giddon and colleagues87
Given some of the difficulties associated with have related the objective soft-tissue profile
trying to measure esthetic judgments, we at- (STP) dimensions to the perception of one's
tempted to begin where Wundt and Fechner own profile to elucidate psychosocial factors in
began in the late 19th century, ie, with the de- the motivation for orthodontic and/or orthog-
termination of absolute and differential nathic treatment. The subjects in these studies
thresholds in physical units for the quantita- were asked to simulate their own and ideal fa-
tion of perceptions of attractiveness.14 Using a cial profiles using moveable wooden pieces in
combination of psychophysics and bioassay for the shape of a jaw, nose, forehead, and other
relating objectively observed measurements to features. These measurements were then com-
subjective judgments as described by Giddon pared with their actual soft-tissue cephalomet-
and coworkers,84 tolerance for facial devia- ric measurements, yielding a measure of the
tions was quantitated by determining the per- accuracy of profile perception, as well as dif-
cent of acceptable and/or unacceptable reference from "ideal" among profiles for corre-
sponses to systematic variations in interocular lation with measures of anxiety or concern
distance and angulation of the mouth selected with physical appearance.
to simulate various degrees of hypertelorism Similar to the approach of Kiyak and her
and/or hypotelorism and mandibular asymme- colleagues,39 Lim88 used line drawings to com-
try.85'86 Five groups of 20 people each, varying pare the esthetic perceptions of Korean-
in familiarity and experience with craniofacial American men and women, and more recently
deviations (CFD), participated: parents and to document the influence of acculturation on
children with CFD, unaffected children under- the esthetic preferences of Korean-American
going ordinary dental treatment and their par- women in comparison with native-born Kore-
ents, and dental health professionals. They ans and white women.89'90
were asked to rate each of 10 randomly pre- Several problems were found to exist with
sented, systemicatically changed stimulus pho- previous approaches by our group as well as
tographs varying in interocular distance or an- the work of others. Most stimulus presenta-
gulation of the mouth and chin as either "actions have consisted of touched-up photos, car-
ceptable" or "unacceptable". For each physical icatures, or line drawings.59'85' ' As indi-
variation, the logit of the acceptable percent- cated by Alley,42 such representations are sub-
age and line of best fit were used to indicate ject to considerable distortion, and may be
acuteness of judgment and 50% thresholds; ie, significantly different from those obtained
the point in physical units above which 50% of with actual people, holograms, or very realistic
the respondents classified the objective stimu- photographs. Manipulation by the subject of
lus as acceptable and below which 50% consid- cardboard or wooden pieces, or even a stylus,
ered it unacceptable. is dependent on the subject's psychomotor
In response to changes in interocular disability, which varies considerably, as noted by
tance displayed in isolation in the upper one Giddon and associates.92
third of the children's faces, the professional It was essential therefore to improve on
groups, orthodontic patients, and parents were the methods of stimulus presentation. One
significantly more sensitive to changes in the possibility was to provide a continuously
separation in the eyes (greater slope, lower changing stimulus presentation of facial pro-
threshold) than were groups of CFD and nor- file features; for example, manipulation of
mal patients and their parents. When the dis- anterior-posterior (AP) position of the upper
tance was varied within the context of the lip, lower lip, mandible, bimaxillary relation-
whole face, however, the CFD group was the ships, and chin in sagittal and vertical dimen-
more acute in its judgments. The discrimi- sions.
nation of variations in the mouth and chin To reiterate, such a method would permit
was less acute than for the eyes, with little dif- us to determine how much physical change
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there must be in a particular feature before an treme distortions to create 44 transitional im-
acceptable, attractive, preferred, or beautiful ages. The results with the Morph program
face is rejected; or, conversely, how much were essentially identical to the original anima-
change in the shape or size of an unattractive tion of discrete distortions.95'96
feature must be present before it is rejected or Perhaps the most unusual application of this
no longer recognized. To accomplish these technology was performed by Kitay to deter-
tasks, user-friendly computer programs were mine how perceptual distortions related to mo-
developed for measuring subjective responses tivation for orthodontic treatment.97'98 She hy-
to manipulated changes in the dimensions of pothesized that adults seeking or undergoing
the STP. Software was developed to make dig- orthodontic therapy would be less tolerant of
itally modified images of gradations of change variations in their profile than nonorthodontic
in physical dimensions of the STP appear con- patients. These self-perceptions included a
tinuous, much like a flower blossoming in con- comparison of what the patients actually
tinuous slow motion. looked like, as well as what they wanted to look
Our studies validated this new simplified like or what was "most pleasing." To determine
computer method of animation by comparing their psychomotor ability to perform the re-
the responses to the animated feature distor- quested tasks, patients were also asked to re-
tions with the same distortions presented ran- produce the stationary position of a retruded
domly one at a time (ie, discretely) and show- mandible using the moving image. Orthodon-
ing the ability of the animation procedure to tic patients were more accurate than nonortho-
distinguish among posttreatment outcomes. dontic patients, and men were more accurate
Thus, digitized distortions of the chin, upper in reproducing the stationary image than were
lip, mandible, bimaxillary relationship, and the women, which may be related to mens' re-
lower face height were prepared from two portedly superior computer skills.99 In con-
male and two female faces representing Angle trast to the findings in an earlier study of Gid-
Class I, Class II Division 1, Class III, and Class don and others92 using a more primitive
I with microgenia. Judges rated each discrete method, all patients regardless of orthodontic
alteration as "acceptable" or "not acceptable" status or sex were very accurate in their ability
and gave each a rating from 1 to 6. They re- to identify their own profile with the moving
sponded to the AP and/or vertical movement image. The orthodontic patients also seemed
of each feature by depressing a button when to have less tolerance for changes in their own
the face became acceptable and releasing it faces. In response to features on a face other
when no longer acceptable. The details of the than their own, the orthodontic patients had a
procedure can be found in Giddon et al.93"95 significantly smaller range of acceptability than
For all these tasks, the percentage acceptable the nonorthodontic group, thus indirectly sup-
was plotted against distortions in millimeters. porting Kitay's hypothesis.
Consistent with clinical expectations of where An interesting application of this technique
the features should be positioned following was to compare the most pleasing distortion
treatment, highly significant differences were obtained on oneself with the midpoint of max-
found between the faces (Fig 1) Class II Divi- imal acceptance obtained by others who re-
sion 1, and Class I with microgenia. sponded to the same faces in previous experi-
Another study was performed to determine ments. In general, the four patients' (whose
if a more advanced "morphing" software faces were used in those other experiments)
(Morph, Windows version, Gryphon Software perceptions of what they thought they should
Corporation, San Diego, CA) provided results look like agreed with the two combined panels
similar to the animation method. In the origi- of 36 judges.
nal program, the preparation of discrete dis- The last experiment represented the first
tortions required approximately 15 hours per venture using the new Morph methodology
patient. The new program, basically a variation for variation of features in the full-face config-
of computer imaging, required less than 1 uration.100 The two unacceptable extremes
hour and used only key points from the ex- were created by drawing in lips according to
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90 Donald B. Giddon
Figure 1. Comparison of computer-generated photos of unaltered faces with preferred position for Class II
Division 1 and Class I with microgenia malocclusions. (A) Unaltered Class I with microgenia. (B) Facial
composite of midpoint acceptability. Upper lip, 0.2 mm; chin, 3.8 mm; mandible, 0.4 mm. (A) Unaltered
Class II, Division 1. (B) Facial composite of midpoint acceptability. Upper lip, -0.05 mm; chin, 2.3 mm;
mandible, 2.0 mm.
anthropometric guidelines4 from which the clinician need not be limited to an invariant
guidepoints were derived. The Morph pro- profile outcome, but can be more flexible dis-
gram was then used to generate the transi- cussing a range of acceptable outcomes of
tional images between the two extreme direc- treatment planning.
tions. The height of the lip was systemically
presented in random order as moving stimuli
in six representative faces. In general and con- Summary
sistent with the findings of other authors,4 In conclusion, the computer is not a new tool
judges preferred fuller lips. When corrected for the orthodontist.101 Effective treatment-
for differences in apparent image size, no sig- planning computer software programs (Pacific
nificant difference in preferred morphology Coast Software, Inc, Beverly Hills, CA) have
between the full face and isolated lower third been developed for orthodontists and maxillo-
was found. facial surgeons based on the relationships be-
By establishing a range in addition to a sin- tween anatomical variables with some recent
gle midpoint of acceptability, the animation advances in three-dimensional imaging.102
technique may be more sensitive and clinically There are no reliable and valid databases, how-
useful than discrete presentation for determin- ever, on the perception corresponding to these
ing perceptions of physical change. Thus, the physical measurements. From the author's
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perspective as a psychologist and dentist, orth- 15. Hochberg J. Perception. In: Kling JW, Riggs LA, ed-
odontists now have a major opportunity to im- itors. Experimental psychology, 3rd ed. NY: Holt,
Rinehart and Winston 1971:395-474.
prove treatment planning significantly by
16. Dobbins A, Zucker SW, Cynader MS. Endstopped
adapting new imaging technologies101 to bet- neurons in the visual cortex as a substrate for calcu-
ter integrate patient needs and esthetic percep- lating curvature. Nature 1987;329:483-441.
tions with the customary objective diagnostic 17. Hubel DH, Wiesel TN. Receptive fields and func-
data. tional architecture in two nonstriate visual areas (18
and 19) of the cat. J Neurophysiol 1965;28:229-289.
18. Murray HA. Explorations in Personality. NY: Ox-
Acknowledgments ford University Press, 1938:36-141.
19. Cacioppo JT, Petty RD, editors. Social psychophysi-
The authors thank Ian Clemens, Caroline Rains, and Nina ology: A sourcebook. NY: Guilford Press, 1983:51-
Anderson for their technical and bibliographic assistance 101.
in the preparation of this article. 20. Peck S, Peck L, Kataja M. The gingival smile line.
Angle Orthod 1992;62:99-100.
21. Johnston VS. [personal communication] August 20,
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92 Donald B. Giddon
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47. Peck H, Peck S. A concept of facial esthetics. Angle attractiveness: Quasi-experiments on the sociobiol-
Orthod 1970;40:284. ogy of female facial beauty. J Pers Soc Psychol
48. Peck S, Peck L. Facial realities and oral esthetics. In: 1986;50:925-935.
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28. Ann Arbor: Center for Human Growth and De- tractive, but very attractive faces are not average. Psy-
velopment, 1993. chol Sci 1991;2:123-125.
49. Patzer G. The physical attractiveness phenomena. 72. Langlois JH, Roggman LA. Attractive faces are only
NY: Plenum Press, 1985. average. Psychol Sci 1990;!:! 15-121.
50. Ellis HD. Introduction: Processes underlying face 73. Lucker GW. Esthetics and a quantitative analysis of
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ogy of face perception and facial expression. Hills- Namara J A Jr, editors. Psychological aspects of facial
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51. Friedman MP, Reed SK, Carterette EC. Feature sa- University of Michigan, 1981:49-80.
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Percept Psychophys 1971;10:47-50. cal appearance, stigma, and social behavior. Ontario
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53. Secord PF, Backman CW. Malocclusion and psycho- 75. Shaw W, Humphrey S, McLoughlin J, et al. The ef-
logical factors. J Am Dent Assoc 1959;59:931-938. fect of facial deformity on petitioning. Hum Rela-
54. Kodric-Brown A, Brown JH. Why the fittest are pret- tions 1981;33:659-671.
tiest. The Sciences, Sept/Oct 26-33, 1985. 76. Macgregor FC. Transformation and identity, the
55. Archer RP, Cash TF. Physical attractiveness and mal- face and plastic surgery. New York: Quadrangle/The
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Psychol 1985;3:170-180. 77. Phillips KA. Body dysmorphia disorder: The distress
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nuggets of truth or fool's gold? Psychol Today 1988; 1138-1149.
22:36-41. 78. Giddon DB. Psychophysiology of the oral cavity. J
57. Napoleon T, Chassin L, Young RD. A replication Dent Res 1966;45:1627-1636.
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79. Galsworthy J. Flowering wilderness, 1932, cpt 2. ancy between objective and subjective profile mea-
Cited in: Bartlett J. Familiar quotations. 13th ed. Lit- sures. Scand J Dent Res 1974;82:527-535.
tle, Brown, 838a, 1955. 93. Giddon DB, Sconzo R, Kinchen JA, et al. Quantita-
80. Maslow AH. Motivation and personality. 2nd ed. tive comparison of computerized discrete and ani-
New York: Harper & Row, 1970:35-58. mated profile preferences (manuscript submitted).
81. Perrin FAG. Physical attractiveness and repulsive- 94. Giddon DB, Sconzo R, Kinchen JA, et al. Psycho-
ness. J Exp Psychol 1921;4:203-217. physical comparison of computerized discrete and
82. Peck S. Beauty is youth, youth beauty? [letter] Sci animated profile preferences [abstract]. J Dent Res
News 1994; 146:115. 1994;73:368.
83. Langlois JH, Roggman LA, Musselman L. What is 95. Giddon DB, Bernier DL, Kinchen JA, et al. Compar-
average and what is not average about attractive ison of computer-animated programs for quantify-
faces? Psychol Sci 1994;5:214-220. ing facial profile preference [abstract]. J Dent Res
84. Giddon DB, Mosier M, Colton T, et al. Quantitative 1995; 74:140.
relationship between perceived and objective need 96. Bernier D. A comparison of two computer-animated
for health care. Dentistry as a model system. Public imaging programs in quantifying facial profile pref-
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87. Hershon LE, Giddon DB. Determinants of facial tion of computer animated profiles in orthodontic/
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88. Lim JY. Soft tissue cephalometric analysis and per- 99. Williams SW, Ogletree SM, Woodburn W, et al. Gen-
ceptual analysis of Korean Americans [Thesis]. Bos- der roles, computer attitudes, and dyadic computer
ton, MA: Harvard School of Dental Medicine, 1989. interaction performance in college students. Sex
89. Lim JY.. Self/other perception and cephalometric Roles 1993;29:515-521.
differences among Korean (K), Korean-American 100. Farzaneh S, Kinchen J, Evans CA, et al. Aesthetic
(KA) and Caucasian (C) females [Thesis]. Boston, judgment of variations in lip morphology. Am Cleft
MA: Harvard School of Dental Medicine, 1990. Pal-Craniofac Assoc Abstracts 1994:53.
90. Lim JY, Giddon DB. Self/other perception and facial 101. Walker R. Computer applications in orthodontics.
anthropometry in Korean (K), Korean-American In: Graber TM, Vanarsdall RL, editors. Orthodon-
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92. Giddon DB, Hershon LE, Lennartsson B. Discrep- stract]. J Oral Maxillofac Surg 1991:49(89)(suppl 1).
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The Use of Three-Dimensional Techniques

in Facial Esthetics
J.P. Moss, A.D. Linney, and M.N. Lowey
The three-dimensional nature of beautiful faces is analyzed and beauty is

investigated by means of optical-surface scanning. This noninvasive tech-
nique is described and illustrated and its value in the assessment of beauty
noted. Forty men and 40 women with a normal Class I skeletal pattern and
a Class I occlusion were scanned and an average face was obtained for each
group. The averages were compared with those derived from a group of 9
men and 15 women employed as professional models and the differences
were noted. A group of normal Asian teenagers were scanned to investigate
ethnic differences. The groups of professional models were further analyzed
to see whether they measured up to the "golden proportions" described by
the ancient Greeks. The groups did not fit the "golden proportions" and they
represented instead a range of malocclusion and a wide range of cephalo-
metric values.
First appearances tend to influence the One of the problems with assessing whether
opinion of those we meet, and our socialthe face is acceptable or beautiful is that when
interaction is heavily dependent on how we we view ourselves in the mirror we usually ob-
look to others. From cosmetics and hair styling serve only one aspect (the frontal view) of a
to orthodontics and plastic surgery, millions of three-dimensional (3D) problem. All the
dollars are spent on improving or making the records that we take to analyze whether a face
most of our faces. Patients with facial deformi- is acceptable or to analyze what we understand
ty such as cleft lip and palate have problems in by beauty are in two dimensions (2D) in the
coming to terms with their facial disfigure- form of photographs and radiographs or,
ment, which they try to hide or mask, and their more recently, in the form of video images.
ability to overcome the problem depends on Acceptability and beauty are probably two dif-
their attitude and personality and the help that ferent standards although the former may be
we can give them. One of the patients with a the first step toward the latter. David Hume,
treated facial deformity defined happiness as, the 18th century Scottish philosopher, said,
"when you can go around the supermarket "Beauty is in the mind of the beholder, each
without anyone staring at you." Frequently, mind perceives a different beauty." Although
the aim of our treatment is to achieve this for this may be true, the majority of people have
our patients, but the process is often difficult fixed ideas on what is beautiful, and these are
and fraught with problems. Until now, limited very much influenced by our environment,
ways were available to assess the problem and our racial background, and our upbringing.
therefore help with the situation. Nevertheless, although some aspects of the
judgments of facial beauty may be influenced
by culture or individual history, the general
geometric features of the face that give rise to
From the Royal London Hospital Medical School and the a perception of beauty may be universal.
Medical Physics and Bioengineering Department of University Examination of the faces of professional
College London, London, England. models from different cultures indicates that,
Address correspondence to J.P. Moss, BDS, PhD, FDSRCS, regardless of color and shape, these faces do
MOrthRCS, Royal London Hospital Medical School, Dental In-
stitute, New Road, Whitechapel, London El IBB, England. have a harmony of proportions that artists
Copyright © 1995 by W.B. Saunders Company over the centuries have struggled to elucidate.
1073-874619510102-0003$5.00IO The Greek sculptor Polykleitos suggested that
94 Seminars in Orthodontics, Vol 1, No 2 (June), 1995: pp 94-104

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Use of 3-D Techniques in Facial Esthetics 95
beauty is the commensurability of the parts, The hypothesis that averageness is attractive
and Galen also designed figures according to was tested by Langlois and Roggman7 using a
simple ratios. The Greeks applied ratios for computerized version of a technique devel-
the face, although theirs were usually unisex- oped by Galton in 1878, who superimposed
ual because they were more interested in hu- photographs of faces on one another to pro-
manity than with sexual dimorphism.1 The di- duce a composite face and found that this was
vine proportion or "golden section" originated more attractive than the individual faces that
in the Pythagorean theory of chosen numbers went into it. This finding was confirmed by
and was taken up by Plato as a mathematical Langlois and Roggman.7
relationship expressing universal harmony Biologists have identified two types of
and, as such, an ideal measure governing the beauty, the average of the population and that
relationship of the elements of the human composed of at least some features of the pop-
body.2 It is related to the Fibonacci series and ulation extremes. Perrett and coworkers 8
is expressed as 1/1.618 or roughly 5/8. In his tested this hypothesis by using composites of
drawings, Leonardo da Vinci used proportions either white or Japanese faces. They found
to harmonize the face. A drawing by Leonardo that the composite face was less attractive than
of the head of Isabella d'Este shows lines di- the individual attractive face. They make the
viding the face into golden sections. The point that averageness is not the only determi-
golden section is considered to be important nant of attractiveness. Their studies show that
esthetically as it occurs in many natural forms highly attractive faces are systematically differ-
such as flowers, shells, and snowflakes. Al- ent from the average. The similarity of attrac-
brecht Diirer sought harmonious proportions tive facial characteristics between two cultures
that would guarantee perfection, but had to was consistent with the claim that such charac-
admit that, "only God can know what beauty teristics are functionally significant.
is."3 The apparent importance of the 1:1.618 One of the great problems is the assessment
ratio in nature led Ricketts to postulate a divine of beauty. How can we measure and quantify
proportion for facial analysis.4 this elusive quality? Whatever techniques we
Despite some controversies regarding the use, they must be able to assess the face in 3D.
correct proportions, most people would agree The majority of the methods that have been
that balanced proportions and a harmonious used for the assessment of facial esthetics have
arrangement of the facial parts are necessary been 2D. Although these, including the re-
for facial beauty. Davis and Jahnke5 did, how- cently developed computer prediction pro-
ever, publish a refutation of the golden section grams, give an artistic representation of the ef-
as an ideal following experiments using simple fects of treatment on the face, none is accurate
geometric figures divided internally. Using in 3D. One of the problems in evaluating pa-
multiple tests, they identified preferences for tients with facial asymmetry is that 2D analysis
esthetic appeal of rectangles and squares and of such patients does not give a satisfactory pic-
found that subjects showed a strong prefer- ture of the underlying problem. Various meth-
ence for internal divisions in a unity ratio with ods have been suggested to overcome this
bilateral symmetry and no evidence of prefer- problem, such as stereophotogrammetry,9 but
ence for a ratio at or near to the golden section. this method is time-consuming and is not fully
Darwin suggested that beauty was a form of automated.
sexual selection for mating purposes; but this Attempts at 3D measurement of the face for
does not explain the beauty of the butterfly monitoring the growth of children with facial
whose sexual attraction is not beauty but scent. deformities usually use hazardous and invasive
Symons,6 an anthropologist following Darwin's techniques of ionizing radiation and metallic
hypothesis, proposed that beauty was average- implants to assess the growth of the skull. To-
ness because evolutionary theory operates day it is possible to obtain a 3D reconstruction
against the extremes of the population. Never- of the face using computed tomography (CT)
theless, beauty is seen to be important as it may or magnetic resonance imaging (MRI) scan-
indicate sexual maturity and is a means of ning, but these methods are expensive and are
emotional expressiveness. not very accurate unless the level of radiation
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96 Moss, Linney, and Lowey
exposure using the first method is increased or Class I skeletal jaw relationship and a Class I
the patient is kept in the equipment for a long occlusion. The optical scans of these patients
time. were averaged to give a composite average
None of these systems provides a readily an- male and female face. To obtain an average
alyzable, global description of change in the attractive face, a series of professional models
face. The 3D changes in the shape of the face from an agency were scanned. The male sam-
that occur during growth and with surgical in- ple consisted of 9 models, and the female sam-
tervention remain undetermined, either qual- ple consisted of 15 models. To estimate the
itatively or quantitatively except with the opti- effect of ethnicity, a group of Bangladeshi
cal scanner that can measure 60,000 points teenagers, comprising 19 men and 30 women,
across the face in 15 seconds.10'11 13 to 18 years of age, were scanned.
The reason for developing optical methods
of recording and visualizing the 3D surfaces of
the human body developed almost 15 years System for the 3D Measurement of
ago, when the question posed was whether the Face
computer graphics could be used to simulate
and predict facial surgery. At that time, the
The system for recording the facial surface is
outcome of reconstructive facial surgery was
shown diagrammatically in Figure 1. It is based
often unsatisfactory to the surgeons in terms of
on the principle of triangulation. When a
the anticipated postsurgical result and was also
fanned beam of laser light is projected onto the
disappointing for the patient. It was believed
surface of the face and viewed obliquely by a
that if a suitable means of acquiring the neces-
charged couple device (CCD) camera, it ap-
sary data on the human face could be found,
pears distorted, reflecting the shape of the sur-
computer graphics could be developed as the
face. An arrangement of mirrors allows the
means of visualizing and manipulating this in-
line to be viewed by the camera from two op-
formation.12
A system for acquiring 3D data on the facial
surface, setting up and producing algorithms
for the visualization and manipulation of this
data, was developed.13 This system, which has
undergone many revisions, is in regular clini-
cal use at the Royal London Hospital and Uni-
versity College Hospitals and in a number of
other hospitals in the United Kingdom and in
one plastic surgery center in Singapore. The
clinical material has extended to all parts of the
body, and the range of its applications now in-
cludes surgery, prosthetics, clinical growth
studies, studies of the results of treatment, fo-
rensic science, archeology, and psychology.
The quantification of the amount that an
attractive face differs from an average face can
now be undertaken using 3D techniques of fa-
cial measurement. The aim of this study was to Vid
establish the 3D coordinates of an average face
and compare this with the 3D coordinates of Video
attractive faces.
PC with Transputer
Graphics System
Sample
Figure 1. Schematic plan of UCL-MGI (University
The average facial dimensions were derived College London Medical Graphics Informatics) op-
from a group of 40 men and 40 women with a tical face scanner.
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posing directions. This was necessary to avoid simple method of removing a rare erroneous
the loss of signal, caused by the prominence of point, or for low-level editing to change the
the nose excluding parts of the facial surface. shape of the surface in the neighborhood rep-
A custom built printed circuit board prepro- resented by this data. In the most commonly
cesses the video signals from the camera. The used display mode, the data are presented as a
subject is rotated on a platform under com- rendered surface from any chosen viewpoint
puter control to achieve a scan over the surface with adjustable illumination. This rendered
of the face or body. The platform is usually image is produced in a few seconds (Fig 2).
rotated through 200°, taking 15 seconds to ac- To measure between points, a suitable view-
quire data on the facial surface. Both the speed point and illumination are selected to show
and extent of rotation may be varied to suit the most clearly the anatomical landmark or fea-
subject and purpose. Up to 256 profiles may be ture to be located. The selected points are then
recorded per scan and the angles at which marked by directing a cursor using a "mouse."
these are recorded may be programmed, al- A series of points may be marked, using dif-
lowing a maximum rate of acquisition over ar- ferent viewpoints and illumination, and the
eas such as the midline and the ears where the distance between any number of pairs of these
greatest detail is required. The surface detail computed (Fig 2). Computed dimensions on
and curvature may thus be matched to the res- the external (or in the case of volume data,
olution in this dimension. The data set col- internal), surfaces can be of two types: the
lected usually consists of between 40,000 and shortest distance between any two points or the
60,000 3D coordinates of points lying on the distance between them following a path over
anatomical surface. The accuracy and repeat- the surface. Marks placed on a rendered facial
ability of measurements both on inanimate ob- surface are illustrated in Figure 2. These have
jects and the face has been fully investigated been used as sets of distance measurements to
and has a precision better than 0.5 mm.10 characterize facial asymmetry for the assess-
ment of surgical treatment of this condition.15
Visualization Techniques
and Technology Registration of Two Surfaces
Computer graphics algorithms and the appli-
cation software tools have been developed The change in faces as the result of growth or
along with the optical scanning system. The treatment can be shown in 3D by use of the
hardware used to produce the graphics con- registration program. This is useful for moni-
sists of PC-hosted Transputer boards, taking toring the growth of normal individuals and
advantage of the speed that may be realized by
parallel processing. 14 The choice of PC-
compatible equipment as a host allows access to
a wide range of available word processors,
spreadsheets, databases, and desk-top publish-
ing software at little extra cost. The systems are
integrated with our optical scanning system to
produce immediate images of the data col-
lected. They also produce image data in a
tagged image file format (TIFF), allowing pa-
tient notes containing the images to be pro-
duced on a laser printer.
The optical scanner data may be presented
on the graphics screen in several ways. Raw
profile data may be displayed as individual
points measured along the profile. The posi-
tion of each point may be selected, and the Figure 2. A facial surface scan with marked points
point edited to a new position. This provides a and two lines joining three of the points.
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abnormal development caused by deficiencies

of growth, tumors, or accidents. For all of
these conditions, special methods are required
so that different data sets may be registered in
some way, and the surface differences or
changes may be displayed in a way that can be
rapidly interpreted.
To meet this need, programs have been
written that allow the registration of surfaces
in 3D. The two surfaces to be registered are
displayed side-by-side on the graphics screen
and a set of homologous landmarks are
marked using the PC mouse and directed cur-
sor. For the face, 10 landmarks are used and
Figure 3. The average male model face (A) with a
the location of landmarks is greatly assisted by face one standard deviation from the average (B).
a simultaneous display of the vertical and hor-
izontal sections of the facial surface through
the point at which the cursor is located. This Esthetic Standards
allows the maxima and minima of curvature to To ascertain what is average, a series of pa-
be accurately located. A part of the face that tients consisting of 40 men and 40 women with
has not changed must be used for registration normal occlusions were recorded. The scans
purposes and for this purpose the eyes and were then processed to give an average normal
forehead are included as these show least male face and an average normal female face
change in treatment and growth. Once appro- (Fig 4). The differences between the two nor-
priate landmarks have been located, the differ- mal faces was then shown using registration of
ences in the registered surfaces are color- the two scans. It was shown that the normal
coded and displayed. These differences are male face was wider and longer than the fe-
the radial distances from a computed common male face and that the nose, chin, and lips were
axis of the two surfaces and are displayed on more prominent. However, the eyes and
each of the registered images. Positive differ- cheeks were more prominent in women. The
ences are colored in warm colors (yellow to brow ridges were more marked in men and
deep red) and the negative differences in cold there was also a larger standard deviation of
colors (green to deep purple). Each color rep- facial measurements in the men (Fig 3).
resents a 2-mm difference in the surfaces.16'17 The next question studied was, "Is the av-
erage face beautiful?" For this purpose the
groups of professional models were used. Each
Averaging had been selected by their model agency peers
as having a beautiful or handsome face. A se-
Averaging involves the registration and scaling ries of scans of these individuals were averaged
of a set of faces and the resampling of the face to give an esthetic standard for male and fe-
surfaces onto a coordinate grid where the co- male models (Figs 5 and 6). These average
ordinates of corresponding points may be av- scans represented the appearances of the most
eraged. For this purpose 15 points are marked attractive faces. Detailed comparisons showed
across the face, 5 on the forehead, 5 across the that the faces of the female models were not as
eyes, and 5 over the lower part of the face. wide as the average face and that the lips and
Each of the scans has 15 points placed on the chins were more prominent than the average
surface and then each scan is superimposed patients. The nose was also wider across the
over the previous scan and the coordinates av- alar bases (Fig 7). Fuller faces were obviously
eraged. In this way, an average facial form can more attractive than flatter faces. The male
be obtained and the program also allows a one models had more prominent angles to the jaws
standard deviation facial form to be shown and therefore tended to be wider across the
(Fig 3). face than the average face. The nose, lips, and
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Figure 4. (A) The average female (left) and male faces from a European sample, anterior view. (B) The
average female (left) and male faces, lateral view illustrating the three dimensional nature of the image-scan.
chin were more prominent and the alar bases were compared to test whether their propor-
were wider (Fig 8). It was also interesting to tional measurements matched the "Golden
note that a considerable number of the models proportion" described by the ancient Greeks
had slight facial asymmetry with the left side and popularized in orthodontics and surgery
shorter than the right. as the divine proportion by Ricketts.4 Propor-
It was noted that the difference between the tional measurements of this esthetic group did
average male and female models is more strik- not match the Golden proportion (Table 1).
ing than the difference between the normal The absolute measurements of eye width,
average counterparts. This observation re- mouth width, nose width, and length seemed
garding the sample of photographic models to be distributed in a narrow range in contrast
raises the question as to whether a polarization to cephalometric radiographic measurements
of the sexes is relevant to the issue of beauty. taken of the same individuals who showed a
wide range of variation (Tables 2 and 3).
Examination of the dental occlusions of
Golden Proportions these individuals also showed that the com-
A number of direct facial measurements taken plete range of occlusion from Class III to Class
from the laser scans of the professional models II Division 1 could be found in individuals se-
Figure 5. The average female (A) and male (B) Figure 6. The average female (left) and male (right)
model faces, anterior view. model faces, lateral view.
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Table 2. Means and Standard Deviations for the

Facial Measurements of the Esthetic Sample of
Professional Models
Mean (mm) SD
Female
Right eye width 32.0 4.8
Left eye width 32.8 1.4
Nose width 34.0 1.6
Mouth width 48.5 2.5
Nose length 40.2 2.4
Tip to subnasale 17.5 1.9
Philtrum 12.1 1.5
Upper lip thickness 8.8 1.3
Lower lip thickness 9.5 1.1
Lip to soft tissue B point 8.9 1.9
Soft tissue B to menton 16.8 2.2
Male
Right eye width 34.6 3.1
Figure 7. The average face of women, normal sam- Left eye width 34.5 1.5
Nose width 39.0 2.0
ple (A) compared with professional models (B). Mouth width 49.0 2.3
Nose length 70.8 3.1
Tip to subnasale 18.1 1.4
Philtrum 11.3 3.4
Upper lip thickness 9.6 1.6
Lower lip thickness 10.1 2.4
Lip to soft tissue B point 9.4 2.1
Soft tissue B to menton 16.7 2.0
lected solely on the basis of facial esthetics. De-

spite the mixture of malocclusions, the soft-
tissue profiles of the professional models were
uniformly acceptable (Fig 9) and the arrange-
ments of their teeth were good.
To study the effect of ethnicity on esthetic
standards, an examination of the faces of the
Bangladeshi group of normal teenagers was
Figure 8. The average face of men, normal sample Table 3. Range of Cephalometric Measurements
(A) compared with professional models (B). for Esthetic Sample of Professional Models
Minimum Maximum
SNA 77 91 degrees
SNB 75 93 degrees
Table 1. The Proportions of Various Facial ANB -3 6 degrees
Measurements of the Esthetic Sample of MM 10 34 degrees
Professional Models Compared with the U I/PAL 97 128 degrees
"Golden Proportion" LI/MAN 82 103 degrees
OB 2 7 mm
Female oj 2 8 mm
Nose width/mouth width 1 .147 UFH 46 60 mm
Nose width/nose length 1 .206 LFH 60 79 mm
Right eye/mouth width 1 .513 PFH 28 42mm
Left eye/mouth width 1 .479
Male Abbreviations: SNA, Sella Nasion Point A angle; SNB,
Nose width/mouth width 1 .258 Sella Nasion Point B angle; ANB, Point A Nasion Point B
Nose width/nose length 1 .816 angle; MM, Maxillary Mandibular Planes angle; UI/PAL,
Right eye/mouth width 1 .417 Upper incisor to palatal plane angle; LI/MAN, Lower in-
Left eye/mouth width 1 .424 cisor to mandibular plane angle; OB, Overbite; OJ, Over-
Golden proportion 1 .618 jet; UFH, Upper face height; LFH, Lower face height;
PFH, Posterior face height.
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Figure 9. Four representative lateral cephalograms showing the variation in dental occlusion present in a
sample of professional models. (A) Class I, (B) Class II/l, (C) Class III and (D) model with proclined lower
incisors.
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Figure 10. (A) The anterior view of the European sample average female face (left) and the average of the
Asian female group (right). (B) The lateral view of the European sample average female face (left) and the
average of the Asian female group (right).
undertaken (Figs 10 and 11). This illustrated region of the nose, although the noses were
that the Bangladeshi faces were narrower, the comparable in width.
noses were wider across the alar bases by 3 to 5
mm, and the eyes and lower lips were more
prominent than the European normal group Discussion
by 3 to 5 mm. The noses of the European
group were more prominent and the upper lip The wide variety of malocclusions in the group
was also slightly more prominent than the of professional models poses the question,
Asian group. However, the comparisons of the "What is the importance of teeth to beauty?" It
Asian group with the professional models was Solomon, the wise king of Israel, who
showed that the lips were not as prominent summed up the value of teeth to beauty. He
and that the faces were less prominent in the said, "Your teeth are like a flock of sheep come
Figure 11. (A) The anterior view of the European sample average male face (left) and the average of the
Asian male group (right). (B) The lateral view of the European sample average male face (left) and the
average of the Asian male group (right).
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up from the washing; each has its twin, not one ciency of the growth can be quantitatively as-
is alone." He emphasized the value of color sessed.
and symmetry of the teeth as being an impor- Because we live in a multi-ethnic society, it is
tant part of beauty. Peck and Peck17 have also important to have norms for various groups.
emphasized the value of teeth in beauty and Figure 10 shows the average for a group of
have described the importance of the position Asian women and Figure 11 shows the average
of the teeth to the smile line. for a group of Asian men. There are consid-
Although the teeth have great value both in erable differences between these groups and
support of the soft tissues and their intrinsic the European averages which illustrate that,
value of color and symmetry, the group of pro- when assessing the results of treatment, the
fessional models from the model agency dis- norms must be tailored as closely as possible to
played a wide variety of malocclusion and a the individual.
wide variation in cephalometric values for the
various angles measured (Table 3). It was also
interesting to note that a considerable number References
of the models had facial asymmetry with the
left side shorter than the right. A similar left- 1. Galen C, De Placititis Hippocratis et Platonius V. In:
sided facial asymmetry has been noted in the Pollitt JJ, editor. The art of Greece, 1400-31, BC.
Sources and documents in the history of art series.
statue of Venus de Milo at the Louvre Mu- Englewood Cliffs, NJ: Prentice Hall, 1965.
seum. Perhaps, as Francis Bacon said, "There 2. Wood J. Aesthetics and orthodontics. Dental Practitio-
is no beauty that hath not some strangeness in ner 1969;19(7):247-258.
the proportion." 3. Olds C. Facial beauty in western art. In: McNamara,
Although the ideal man is often looked JA, editor. Esthetics and the treatment of facial form,
vol. 28. Craniofacial Growth Series, 1993:7-25.
upon as being like Apollo and the ideal woman 4. Ricketts RM. Divine proportion in facial esthetics. Clin
like Venus, Angle18 based his ideas of esthetics PlastSurg 1982:401.
on the Apollo Belvedere and on the concept 5. Davis ST, Jahnke JC. Unity and the golden section:
that proper dental occlusion required a com- rules for esthetic choice? American Journal of Psy-
plete dentition. However, it is well known that chology 1991;104(2):257-277.
6. Symons D. The evolution of human sexuality. Oxford
he would not have been able to achieve the flat University Press, 1979.
profile of the lower face with his expansion 7. Langlois JH, Roggman LA. Attractive faces are only
techniques. Case,19 his antagonist who believed average. Psychol Sci 1990;1:115-121.
in the extraction of teeth to improve the pro- 8. Perrett DI, May KA, Yoshikawa S. Facial shape and
file and obtain a stable result, said that the pro- judgements of female attractiveness. Nature 1994;
368:239-242.
file needed to be adjusted to the different 9. Burke PH, Banks P, Beard LFH, et al. Stereophoto-
types of physiognomies that present for treat- graphic measurement of change in facial soft tissue
ment. Even Angle later admitted that beauty, morphology following surgery. British Journal of
balance, and harmony were not limited to one Oral Surgery 1983;21:237-245.
facial type.20 10. Moss JP, Linney AD, Grindrod SR, et al. Laser screen-
ing system for the measurement of facial surface mor-
These esthetic averages have been used by phology. Optics and Lasers in Engineering Journal
clinicians as a norm to compare the results of 1989;10:179-190.
their treatments and have been used in surgi- 11. Coombes AM, Moss JP, Linney AD, et al. A mathe-
cal cases to assess the results of treatment fol- matical method for the comparison of three-
lowing the retention period.16 dimensional changes in the facial surface. European
Journal of Orthodontics 1991;13:95-110.
They are also useful for assessing the 12. Moss JP, Linney AD, Grindrod SR, et al. "Three-
amount of growth failure in patients with cra- dimensional visualization of the face and skull using
niofacial microsomia. In this condition, there is computerized tomography and laser scanning tech-
a failure of growth of one or both sides of the niques." European Journal of Orthodontics 1987;
face, resulting in gross facial deformity. 15 9:247-253.
13. Moss JP, Grindrod SR, Linney AD, et al. "A computer
Comparison with the growth of a normal indi- system for the interactive planning and prediction of
vidual at the same age is possible by registering maxillo-facial surgery." Am J Orthod Dentofacial Or-
the scans of the patient with the norm for that thop 1988;94:469-475.
age. In this way, the exact amount of the defi- 14. Tan AC, Richards R, Linney AD. 3D medical graph-
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ics—using the T800 transputer. Developments in us- 17. Peck S, Peck L. Facial realities and oral esthetics. In:
ing OCCAM. OUG-8. Proceedings of the 8th OC- McNamara J A, editor. Esthetics and the treatment of
CAM User Group Technical Meeting (Publ. IOS, Am- facial form, vol 28. Craniofacial Growth Series. Ann
sterdam), 1988:83-89. Arbor: University of Michigan, 1993:77-113.
15. Moss JP, Linney AD, James DR. Three dimensional 18. Angle EH. The treatment of malocclusion of the teeth
analysis and treatment of patients with Hemifacial mi- and fractures of the maxillae. Philadelphia: SS White
crosomia. Transactions of Nederlandse Vereniging Co, 6th edition, 1900.
Voor Orthodontische Studie, pp 261-275, 1990. 19. Case CS. Some principles governing the development
16. Moss JP, McCance AM, Fright WR, et al. A three di- of facial contours in the practice of orthodontia. Co-
mensional soft tissue analysis of fifteen Class II/l pa- lumbia Dental Congress 1893;2:727.
tients following bimaxillary surgery. Am J Orthod 20. Angle EH. The treatment of malocclusion of the
Dentofacial Orthop 1994; 105:430-437. teeth. Philadelphia: S.S. White Co, 7th edition, 1907.
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Selected Aspects of the Art and Science of

Facial Esthetics
Sheldon Peck and Leena Peck
The historical aspects of facial esthetics and its role in orthodontic teachings
and practice are traced to their origins in classical art. Related discussions
include the failure of "divine proportions/' the ascent of the Class II facies,
and the influence of 19th century pseudoscience. Today, the treatment of
facial form for a diverse society requires a tolerant sense of esthetic plural-
ism. Moreover, advances in neuroscience and psychology have extended
understanding of the biological basis of variation in facial expression and
judgment. The nature of oral esthetics was examined through quantitative
studies of the smile line. Significant sexual dimorphism was found, ie, the
gingival smile line (GSL) appears to be a female lineament and the low smile
line seems to be a male lineament. Further results indicated that the GSL is
associated with several facial characteristics, including anterior vertical
maxillary excess, and the muscular capacity to raise the upper lip signifi-
cantly higher than average on smiling. Other variables associated with GSL
are statistically significant increases in overjet, interlabial gap at rest, and
overbite. The gingival smile line is not necessarily objectionable esthetically
and it will normally diminish with age. However, the treatment of choice for
the GSL patient with an uncoached complaint is orthognathic surgery and
orthodontics.
The face is the key feature in the determi- beyond orthodontics and facial surgery are se-
nation of human physical attractiveness.1'2 riously studying the human face and the na-
Esthetic judgment of faces is enjoyably prac- ture of the observers' perceptions. The expan-
ticed by all humanity and everyone eventually sive growth in scholarly interest is evident in
becomes an "expert" in this pursuit. In earlier the publication record: 20 years ago, the scien-
times, artists, writers, and philosophers were tific periodical literature contained approxi-
often spellbound in their perceptions of facial mately five articles annually presenting re-
beauty. Some early devotees, the so-called search on physical attractiveness, including
physiognomists, even attempted to rationalize that of the face; now, the annual worldwide
a science of personality identification from the output on this subject is approximately 150 sci-
study of facial appearance.3"5 The pioneering entific publications.6
orthodontists of the 19th century seized on fa- This article is multidisciplinary, addressing
cial esthetic improvement as an intellectual several perspectives within the realm of facial
cornerstone of their ministrations, perhaps to esthetics. The esthetic interpretation of artistic
help place the fledgling art and science of representations of the face is presented from
tooth movement into a more worldly context. the viewpoint of clinical scientists with a de-
Today, scientists from numerous disciplines voted interest in art history. Enmeshed with
this specialized analysis of art is a critical his-
tory of esthetic concepts that have been used
From the Department of Orthodontics, Harvard School of by orthodontists. Next, recent developments in
Dental Medicine, Boston, MA. neuroscience and behavioral science are ex-
Address correspondence to Sheldon Peck, DDS, MScD, 1615
Beacon St, Newton, MA 02168.
plained for their facial esthetic importance. Fi-
Copyright © 1995 by W.B. Saunders Company nally, oral esthetics is studied in-depth by re-
1073-874619510102-0005$5.00/0 porting the results of objective investigations

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106 Peck and Peck
on the anatomical relativity of the lips, the

teeth, and the jaws, with special attention to the
nature of the smile line.
Facial Art: Tastes and Reality

Ancient Civilizations
Prehistoric man rarely delineated the features
of the human representations he carved in
stone or painted on rock. Artworks finally be-
came refined enough to depict likeness or re-
semblance in the ancient civilizations of Egypt,
China, and Greece. However, portraiture in
antiquity was often stylized and idealized to try
to improve on the common reality.7 Although
kings and deities were portrayed with some of
the ideal features of the times, portraits of
lesser people were more realistically rendered.
A brief selective history of facial portraiture in
Western civilization can illustrate esthetic tastes
and realities and the shadows in between.
Egyptian artists, beginning in the Old King-
dom dynasties (ca. 2600 to 2000 BC), used a
simplified grid system to draw figures to ideal
proportions.8 Several horizontal lines marked
the location of key points of the body from the
top of the head to the baseline. Lines repre-
senting the crown of the head, the hairline, Figure 1. Drawing of ancient Egyptian from a tomb
and the junction of the neck and shoulders ceiling dating from the New Kingdom (ca. 1500 BC)
guided the proportional construction of the and constructed using a proportional grid system
developed by the artists of the time. The head and
head. One vertical axial line, registered on the face were carefully composed on the squared grid to
ear position, divided the traditionally profiled meet canonical guidelines set down by the Egyptians
figure into two parts. for ideal proportions.
By the time of the Middle and New King-
doms, a squared grid composed of regularly artists drew and painted faces usually as part of
spaced horizontal and vertical lines was in use complete figures, so facial features were pre-
(Fig 1). An additional facial horizontal now ap- cisely proportioned yet lacking details, except
peared near the base of the nose, and many on larger works such as statuary. Their use of
verticals were added. The head usually was de- squared grids and exact proportions helped
picted within a grid block consisting of 12 the Egyptians toward their goal of deifying
squares. This squared grid system, perhaps the beauty and harmony. As Olds10 has stated, his-
oldest forerunner of the proportional mesh di- tory confirms that the Egyptian period "will
agram designed by Moorrees9 for cephalomet- not be the last time that beauty and divinity are
ric analysis, guided the ancient Egyptians in considered synonymous."
applying their canon of ideal proportions to Ancient Greece formalized the study of
the pictorial representation of the human fig- beauty as a learned pursuit and developed in-
ure. tricate formulas for constructing human and
The Egyptian proportional canon was mod- godly representations. The Greek philoso-
ified only slightly over the 3,000 years of Egyp- phers, notably Plato (427-347 BC) and Aristotle
tian civilization. Facial proportions were gen- (384-322 BC), questioned the intrinsic meaning
erally the same for representations of men and of beauty and studied the theory of beauty and
women throughout this period. The Egyptian the philosophy of taste.11 Interestingly, the
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Art and Science of Facial Esthetics 107
Greeks did not apply any particular word, like portion of which is concealed by a low hairline.
"esthetics," to describe these intellectual con- Also characteristic is a relatively straight sweep
cerns. It was only in the mid-18th century that from the forehead to the nose tip, allowing
the term "aesthetica" was coined by German only a faint concavity at the root of the nose.
scholar Alexander Baumgarten12 in a Latin The lower face is orthognathic in profile, usu-
treatise on the beauty of poetry, and soon af- ally displaying some retrusion around the lips.
terward the concept and the word were ap- Between the prominent chin and the rolled
plied broadly to the arts and nature. lower lip is a sharply angled mentolabial sul-
Two leading Greek sculptors of the 5th cen- cus.
tury BC, Polykleitos (ca. 450 to 420 BC) and
Phidias (ca. 500 to 432 BC), established strict
The Renaissance
canons and rules for ideal bodily proportions
and harmonious anatomic relationships. The Skipping over the dissipation of Grecian clas-
great artists of ancient Greece attempted to im- sicism in the Hellenistic period, and the less
plement these laws of beauty in their works. remarkable artistic achievements of the Ro-
Classical Greek art and architecture blossomed mans, who are remembered more as imitators
in the fifth and fourth centuries BC, a period than as creators, the next facial esthetic inspi-
now labelled the golden age of Greece. rations may be found in the Italian High Re-
The classic Greek face is oval, slightly taper- naissance of the 15th century. Leonardo da
ing toward the chin (Fig 2). Like the Egyptians, Vinci (1452 to 1519) typified the new integra-
the basic facial features of men and women tion of art and science, with his interminable
appear to be treated the same. In profile, the search for mathematical explanations of natu-
face exhibits a prominent forehead, a sizable ral phenomena. He was driven by a powerful
Figure 2. The facial esthetic ideals canonized by the ancient Greeks are embodied in this head of Aphrodite
(4th century BC, Greek). A flat, often concave, lower facial profile was characteristic for both female and male
representations. (Museum of Fine Arts, Boston, reprinted by permission)
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108 Peck and Peck
curiosity and imagination that left enduring progression that has fascinated mathemati-
artistic records. Leonardo studied the face cians and numerologists since the 13th cen-
from all angles to unlock some arithmetic mag- tury. It was first described in detail by the Ital-
ical formula for facial form and beauty, a pur- ian mathematician Leonardo Fibonacci, hence
suit that was predictably unsuccessful, judging its name, the Fibonacci series and Fibonacci
by today's scientific standards. His anatomical numbers.
sketches document these experiments and con- Ricketts14'15 attempted to introduce this
jectures. Many of his realistic ink drawings mathematical curiosity as a tautology on which
show geometric studies superimposed on to base facial analysis for orthodontics and sur-
heads and faces, depicting men whose aged gery. He believed that the esthetic propor-
faces often suggest the effects of severe tooth tional norms for facial structures (eg, the ratio
wear and multiple tooth loss (Fig 3). between forehead-to-eye and eye-to-menton
distances), as measured from photographs and
The Golden Section and cephalograms, were remarkably close to the 1:
Divine Proportions 1.618 divine proportion. Despite its contempo-
rary supporters, this method of establishing fa-
During the Renaissance, Leonardo da Vinci cial norms remains unproven scientifically and
and his contemporaries vainly searched for the reported proportions and philosophical
mathematical explanations of nature, includ- claims are highly suspect. One recent investi-
ing the human facial form. One of the meth- gation,16 in fact, tested the claim that divine
ods frequently referenced was the "golden sec- proportions are reflected in the sizing of har-
tion" or "divine proportion," a precise struc- moniously looking anterior teeth. Samples
tural ratio said to exist throughout nature and were measured and statistically analyzed. The
to have been observed by the ancients. The study found a "failure of the postulated [di-
Greeks, from the time of Pythagoras, Plato, vine] ratios to be supported by measure-
and Euclid, seem to be the earliest to have ments."16
identified the golden section within certain The search for exact laws of nature under-
geometric shapes and forms that, in their eyes, lying some of the sublime values of life, such as
possessed optimum visual harmony and pleas- harmony and beauty, has been a universal hu-
ing proportions.13 The proportion was based man motive. For example, early Buddhist so-
on the number 1.618, or its reciprocal 0.618, ciety in Japan independently developed a
the same numbers expressed in an arithmetic mathematical system of perfect proportionality
for worldly forms, only with different propor-
tions than those the early Europeans espoused.
The ancient Japanese proclaimed a ratio based
on the square root of 2 (V2 = 1.414) as the
esthetic canon of divine proportions. This con-
cept is now experiencing renewed popularity
in segments of Japanese society.17
Man's dream for a mathematical key to the
design of natural beauty seems then to have
produced at least two distinctly different an-
swers from two cultures, each with elaborate
dogma to back up its claims. Although Fibon-
acci numbers still hold fascination for mathe-
maticians, their application to facial esthetics
Figure 3. Detail of one of many anatomical draw- can hardly be convincing to bioscientists today.
ings by Leonardo da Vinci, who searched futilely for At this point in the late 20th century, the glo-
mathematical explanations of nature, including hu- rified concept of the golden section or divine
man facial form. Here, Leonardo studied facial
landmarks on an aged man for measurable patterns proportion as a perfectly commensurate math-
of proportionality. (Royal Library, Windsor Castle, ematical relationship expressed across nature,
reprinted with permission) whether set at 1:1.618, 1:1.414, or some other
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beguiling ratio, displays earmarks of pseudo- and, indirectly, overjet. The personal fork and
science, possessing doubtful value beyond its knife took the functions of holding and shear-
historical significance. ing food away from the incisors and placed
them on the table. Protrusive function, essen-
Ascent of Class II Facial Pattern tial to the holding and shearing process, swiftly
In the Renaissance, realism prevailed to the became outmoded, and deep overbite with its
extent that for the first time families of maloc- associated dentofacial warpage, the Class II
clusions were represented literally in sculpted pattern, have since proliferated.19
and painted portraits. Severe angle class II Furthermore, a relationship may exist be-
malocclusions with sagittal jaw discrepancies tween changes in the intensity of tooth wear
are particularly evident as a rather common and increased occurrence of the Class II dent-
mid-15th century facial trait among noble and ofacial pattern. Attrition of the teeth among
wealthy Italians (Fig 4). European populations appears to have abated
Some of the profound social changes gen- by the time of the Renaissance because of re-
erated during the Italian Renaissance may finements of diet.20 In theory, the longer, less-
have contributed to the increased expression worn incisors could have provoked the expres-
of class II distocclusion and its attendant over- sion of even deeper overbites and greater
bite among European populations. During this prevalences of Class II facies, a significant
period, the table fork was introduced in Italy, trend continuing to the present.
and it rapidly gained popularity as the Renais-
sance ascended in Europe. According to Brace Neoclassicism and the Evolution of the
and Mahler,18 the introduction of individual Orthodontic Ideal
table forks (as distinct from the serving uten- By the middle to late 17th century, classicism
sils) and the accompanying new eating style began to reemerge in European art and values.
may have had a devastating effect on overbite The return to Greek esthetic values was in full
Figure 4. Profile views (detail) of two realistic portrait busts from the mid-15th century by Italian sculptor
Desiderio da Settignano. The faces of the lady (A) and the little boy (B) both show signs of an underlying
Class II jaw discrepancy, a condition first finding wide expression among Europeans during the Renaissance.
(National Gallery of Art, Washington, reprinted by permission.)
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110 Peck and Peck
swing by the final third of the 18th century, ence reached the newly constituted United
largely because of the influence of one person, States, helped by the inclinations of American
Johann Joachim Winckelmann. Winckelmann intellectuals like Thomas Jefferson, James
was a brilliant and persuasive German art his- Fenimore Cooper, and Nathaniel Haw-
torian born in 1717. In 1755, he heralded the thorne.23 Neoclassicism and the Greek Revival
neoclassical movement with the publication of movement were ardently embraced by the
his essay, "Reflections on the Imitation of early 1800s because the newly independent
Greek Art," that changed the thinking in al- Americans held a widespread sentiment that
most all spheres of European society by the late they were the spiritual successors of ancient
1700s.21'22 He extolled the virtues of Greek es- Greece.
thetics, magnifying the achievements of the The Apollo Belvedere was one of the Greek
Greek artists to colossal dimensions. Winckel- works that Winckelmann admired most and
mann proclaimed that the classical Greek ideal, popularized (Fig 5).22 Today it is known as a
as expressed in the Apollo Belvedere sculpture rather mechanical Roman copy with no great
(Fig 5), possessed "a noble simplicity and quiet artistic distinction modeled after a lost Greek
grandeur," poetic words that had immediate sculpture from the 4th century BC. Since its
impact on a receptive public. The centerpiece discovery around 1500 near Rome, it has been
of his alluring dogma was the assertion, "The housed in the Belvedere courtyard of the Vat-
only way for us to become great or, if this be ican Museum. Winckelmann's enchantment
possible, inimitable, is to imitate the an- with the Greek esthetic ideal embodied in the
cients."21 Apollo Belvedere gave the mediocre statue far-
Within a few decades, Winckelmann's influ- reaching fame and tribute for more than a cen-
Figure 5. Views of the Apollo Belvedere (detail), Roman marble copy of a lost Greek sculpture from the 4th
century BC. From the 18th to the early 20th century, this statue was revered as a standard for Western esthetic
values. Today, it is considered a mediocre work of little artistic distinction. (Vatican Museum, Rome, re-
printed by permission.)
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tury and a half. This statue's declared reputa- them conform to it, wouldn't we necessarily all
tion for universal beauty significantly influ- be beautiful?
enced the facial esthetic taste of the early
orthodontists in 19th century America. Weurpel rejected Angle's simplistic, literal
Norman William Kingsley, born in 1829 in a comprehension of classical esthetics. Weurpel
farm community in northern New York State, counseled Angle to discard his one-standard
was one of the pioneers in the evolution of method for judging facial esthetics in the het-
dentofacial orthopedics. In his classic book, "A erogeneous population of the United States.
Treatise on Oral Deformities as a Branch of Angle later admitted that "beauty, balance,
Mechanical Surgery," published in 1880, he and harmony" were not limited to just one fa-
includes a chapter on "the aesthetics of den- cial type, like Apollo, but might be found in
tistry."24 An accomplished artist himself, many different facial types.26'27 However, he
Kingsley states his reverence for the ancient still held the Apollo type as the most estheti-
canon governing the construction of the ideal cally pleasing.
head or face. He cites the Apollo Belvedere as Angle incorporated another error in his
"a standard of male beauty" and a head of theory by assuming an association between his
Greek goddess Medusa (the Medusa Rondi- icon of facial esthetics, the Apollo Belvedere,
nini) as "the most remarkable female head I and his notion that proper occlusion of the
have ever seen," and he sketched both faces for dentition required a full complement of teeth
his book.24 Kingsley was a skilled dentist and "as Nature intended."26'27 He held vigorously
artist, but clearly he was no esthetician. He was to his bias against orthodontic tooth extraction,
simply caught up in the esthetic trend of his especially toward the end of his career.
times. Angle27 assessed the face of Apollo in very
Edward Hartley Angle, the acknowledged exacting terms: "The face is a study of symme-
"father" of orthodontics, was born in 1855 on a try and beauty of proportion. . . . Every fea-
farm in Bradford County, PA. Although his ture is in balance with every other feature and
greatest contributions in teaching, writing, and all the lines are wholly incompatible with mu-
inventing were made after the turn of the cen- tilation [charged synonym for extraction] or
tury, Angle remained in outlook thoroughly malocclusion." In this description of the
rooted in the 1800s until his death in 1930. Apollo Belvedere, Angle propagates the kind
In 1895, Angle moved from Minneapolis to of myth for which the late 19th century and
St. Louis and established a private orthodontic early 20th century are famous. It was an Amer-
practice. A prominently displayed object in his ican era that spawned much pseudoscience,
operatory was a bust of the Apollo Belvedere. when many untested beliefs were promoted as
By 1900, he had started the Angle School of facts or "laws."28
Orthodontia and he began a lifelong friend- In practice, Angle could rarely, if ever, have
ship with Edmund Weurpel, a distinguished achieved the flat, almost concave, lower facial
art professor at Washington University in St. profile of Apollo Belvedere. By opposing tooth
Louis. Wuerpel became Angle's mentor in the extraction in orthodontic treatment, Angle
fine arts. After Angle's death, Wuerpel25 re- and his strict followers usually had to expand
called a particular exchange between the two the dental arches to achieve tooth alignment.
soon after they met in 1900. Angle apparently As a result, the lower facial form would invari-
was deeply under the esthetic "spell" first cast ably appear plumper, strained, and more con-
by Winckelmann and embellished by Winckel- vex, just the opposite of the flat Apollo profile
mann's 19th century disciples. He seriously Angle espoused.
asked Wuerpel: Facial distortions more commonly are cre-
ated and tolerated in the world of art than the
Man has dreamed of beauty like that of the world of medicine.29'30 Ocular and mental dis-
[ancient] Greeks. All the world has acknowl- orders warping the vision of many famous art-
edged its supremacy. Therefore if [the ists are well documented.31 Such distortions
Greeks] worked under a law and we could ap- can become confusing when the viewer per-
ply that law to ... living being[s] and make ceives the art literally. For example, during the
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112 Peck and Peck
mid-to-late 1800s, the Pre-Raphaelite move- orthodontists and surgeons 100 years ago did
ment was active in England. A group of artists not adopt this distorted ideal as a goal in treat-
including Dante Gabriel Rossetti returned to ing patients.
early Italian traditions as a basis for their art. Calvin S. Case, an eminent orthodontist
In 1870, Rossetti drew a portrait of his par- from Chicago and a contemporary of Angle's,
amour, Jane Morris, using a photograph taken was a progressive man and a leading propo-
a few years earlier. The existence of the pho- nent of facial esthetic pluralism. In 1921, he
tograph provides a rare opportunity to com- pleaded that the "standard of beauty should
pare the real image with the image created by not be confined to a fixed idea of facial out-
the artist (Fig 6). In the drawing, Rossetti lines of classical art shown in that of Apollo
transformed Jane Morris's facial appearance Belvedere, but it should be one which may at
dramatically to conform to his classical notions times be adjusted ... to the different types of
of beauty: It was as if he performed an ad- Physiognomies which present for treat-
vancement genioplasty, collagen injections of ment."
the upper lip, a rhinoplasty, and a mid-facial Charles H. Tweed33 in 1944 finally cut the
reduction. Her Class I bimaxillary protrusion Gordian knot that Angle had so tightly tied.
has been revised to nearly a Class III facial Tweed, a student at the Angle School in the
profile. To the Pre-Raphaelite artists and their late 1920s, courageously abandoned Angle's
patrons, beauty tended to favor a Class III fa- stifling nonextraction dogma and obtained ex-
cial pattern, not a Class I pattern. Fortunately, cellent treatment results with extraction ther-
Figure 6. (A) Detail from "The Roseleaf," drawn in 1870 by Dante Gabriel Rossetti, a leading pre-Raphaelite
artist in Victorian England. Rossetti used a photograph (B) as his model for the drawing but also incorpo-
rated multiple facial transformations into the drawn image to conform to his neoclassical notions of beauty.
(Drawing, National Gallery of Canada, Ottawa; photograph, Victoria & Albert Museum, London, reprinted
by permission.)
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apy. He modified Angle's diagnostic equation

by linking facial esthetics to the need for ex-
traction. His diagnostic discriminator was the
new tool of cephalometrics, rather than man-
made "laws." Unfortunately, Tweed retained
Angle's ideal of a flat Apollo-like profile and
designed his new cephalometric standards to
fit this narrow esthetic model.
Today, Greek classicism has almost van-
ished from general awareness. Television,
films, and photography emphasize the visual
realities of the present, not the images from an
ancient past.
In 1970, the senior author first inquired
into the relevance of facial esthetics to orth-
odontics as coauthor with Harvey Peck in a Figure 7. Facial profiles of six beauty contest win-
ners and professional models from a sample of 52
study34 of the dentofacial patterns of 52 young young adults recognized by the general public as
adults who had been acclaimed by a segment of having very pleasing facial esthetics.33 The profiles,
the general public for their pleasing facial es- registered on the ear canal, show increasing facial
thetics. The sample consisted entirely of pro- fullness from left to right, with the subject on the
fessional models, beauty contest winners, and left demonstrating a flat Apollo-like profile, evi-
dence that a wide range of facial form is within the
performing stars noted for their facial attrac- public's concept of pleasing esthetics.
tiveness. The rare nature of the sample made
this study exceptional. Sagittal cephalograms digital imaging concluded that individuals are
of the subjects were analyzed using the Steiner, inclined to prefer neutral-looking, typical
Downs, and Margolis analyses. The results in- faces, those showing facial measurements "rep-
dicated that "the general public admires a resenting the mathematical average of faces"
fuller, more protrusive dentofacial pattern within the studied population.41'42
than customary cephalometric standards New work further challenges the view that
would like to permit."34 Facial profile photo- judgment of faces is largely an individualized
graphs of the subjects (Fig 7) confirmed the process, by pointing to an innately pro-
diversity of facial form falling within the gen- grammed skewed preference with regard to
eral public's concept of pleasing esthetics. This facial form. British and Japanese researchers
revealing study, coupled with others, helped found cross-cultural consistencies in a detailed
lead the orthodontic specialty to a realistically study of judgments of female facial attractive-
broadened range of acceptable facial esthetics ness.43 Their results emphasized the "non-
today, and to a more rational balance between average" nature of the preferred faces, reject-
extraction and nonextraction treatment. ing the concept that "attractiveness is average-
ness"41'42 and suggesting that directional
selection pressure may be operative in the evo-
New Scientific Findings Relevant to lution of the human face.
Facial Esthetics According to their study, the faces people
found most attractive were deliberately exag-
Facial Preferences and Youthfulness
gerated computer-generated images of the
The judgment of facial attractiveness has been full-face view, showing "higher cheek bones, a
thought generally to be the product of individ- thinner jaw and larger eyes" than the average
ual taste, shaped in part by cultural and pop- face.43 Unrecognized by the British and Japa-
ular trends, and influenced by racial and sex nese scientists, however, was the uncanny re-
differences in facial form.36"40 Recently, psy- semblance between their "optimally attractive"
chologists have critically questioned the com- faces and the soft-tissue facial pattern normally
mon belief that "beauty is in the eyes of the observed around puberty and during adoles-
beholder." Some of the results of studies using cence (ie, higher cheek mass and a shorter,
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114 Peck and Peck
less-developed lower face that would make the the left side.50 This functional asymmetry fa-
eyes appear larger in comparison to an average voring the left side of the face fixes neurobio-
adult face). This observation has supported a logical control of facial expression in the right
recent proposal associating human facial pref- cerebral hemisphere, the same brain location
erences with age-related features signaling as the centers for emotional perception and
youthfulness and, by extension, fertility, a face recognition common to human and non-
powerful evolutionary selection pressure.44 human primates.51
In effect, the circuitry of the human brain is Although the brain may receive the image
probably "wired" to recognize facial attractive- of facial symmetry as a very appealing visual-
ness from some of the subtle facial cues of ization, all evidence points to varying degrees
emerging sexual maturity, an evolution-based of asymmetry as the natural status of the hu-
behavioral strategy bound to promote the suc- man face both anatomically and functionally.
cess of the species. Today, culture, education,
and reproductive science are possibly under-
mining this primal esthetic attraction to youth- Oral Esthetics and the Smile Line
ful-looking faces. Yet the current evidence
seems compelling that all eyes tend to equate From the perspective of today's oral healthcare
the facial signs of youth with facial beauty. provider, esthetics can be divided into the fol-
lowing three relevant anatomical categories:
Facial Symmetry facial, oral, and dental. Oral esthetics, or the
Traditional understanding of facial symmetry esthetics of the mouth aperture, has been the
and asymmetry may benefit from the advances least studied. Yet the mouth and the perioral
in current research. Morphological symmetry tissues, the lips, are perhaps the most signifi-
refers to an equilibrium in size, form, and ar- cant sources for facial animation among hu-
rangement of anatomical features on opposite mans. Two mouth postures involving the up-
sides of a constructed median reference per and lower lips are easily reproducible and,
plane.34 Anatomical symmetry has always been thus, are eminently suitable for study: the lip
a goal in surgical and orthodontic revisions of position at rest and the lip position at maxi-
the face. mum smile, more commonly referred to as the
Recent evidence from human and nonhu- smile line.
man behavioral studies support the appeal of Although the smile is pivotal in the work of
symmetry throughout the animal kingdom. a dental generalist or specialist, it is a key ex-
Studies of flies, birds, and large mammals, in- pression in the social life of all human beings.
cluding man, have indicated that bodily sym- Almost invariably, when a person senses hap-
metry is a desirable trait, because it seems to be piness, pleasure, humor, or greetings, a smile
a crucial factor in mate selection and, ulti- develops. It is the mouth posture that most in-
mately, in species fitness.45"47 fluences a prospective patient to seek improve-
Nonetheless, in the evaluation of human ment and it is also the stage on which treat-
faces, asymmetry (usually at a subclinical level) ment success finds its most appreciative audi-
is the typical finding, even among those rated ence.
the most esthetically pleasing.48 From mathe- Our studies on lip-tooth-jaw relativity focus
matical analysis of the frontal view of the hu- primarily on the vertical dimension.52'53 In the
man skull, most asymmetries show less than a literature on lip position, only a fraction of
3% right-left difference, the threshold level at the studies have examined the vertical as-
which facial discrepancies become severe pects.29'54"71 Instead, most investigations have
enough to be recognized simply by soft-tissue, analyzed profile lip retraction, the horizontal
clinical observation.49 change in lip position concurrent with treat-
Furthermore, asymmetry seems to be a basic ment or growth.
characteristic of the face in animation. In mon- The first of two studies to be presented here
key studies, the left side of the face began to investigated lip postural variations in the ver-
display facial expressions earlier than the right tical dimension. Selected soft tissue, skeletal,
side and the magnitude of the physical facial and dental variables describing the vertical rel-
expression was rated as significantly greater on ativity of the lips, upper jaw, and teeth were
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measured and lip lineaments and sex differ- e. Interlabial gap, in rest position
ences were assessed. 2. Dental measurements, in millimeters
Tjan and colleagues62 performed a semi- a. Overbite
quantitative study of smile-line variations and b. Overjet
their data suggest evidence of sexual dimor- c. Clinical crown height of the upper in-
phism of smile lines in the vertical dimension. cisor
Full face photographs of men and women with 3. Sagittal cephalographic measurements
open smiles were analyzed with the intention a. SN - Mandibular plane, in degrees
of identifying features of smiles for help in de- b. SN - Palatal plane, in degrees
signing esthetic dental restorations. One part c. Palatal plane to upper-incisor edge, in
of their semiquantitative study divided the millimeters
smiles into the following three categories: a low
smile displaying less than 75% of the maxillary Linear measurements were taken using a
incisor crown height; an average smile showing stainless steel ruler graduated to half-
75% to 100% of the crown height; and a high millimeters and were recorded to the nearest
smile showing a contiguous band of maxillary millimeter. Angular measurements were re-
gingiva. Low smile lines were predominantly a corded to the nearest degree. In rest position
male characteristic (2.5 to 1, male to female) the upper and lower teeth were apart slightly,
and high smile lines were predominantly a fe- and at maximum smile the teeth usually were
male characteristic (2 to 1, female to male). lightly closed. To reach the maximum smile
The investigations that follow were per- position, each subject was coached and re-
formed to obtain more specific data on differ- quired to achieve the same lip configuration at
ences and variations in smile lines. least twice successively before any soft-tissue
measurements were taken. Following this pro-
Subjects and Methods cedure, most subjects easily attained a repro-
ducible maximum smile position.
The 88 subjects, private orthodontic patients The first measurement, upper-lip line at
who were either in treatment or on posttreat-
maximum smile (upper-lip smile line), was
ment observation, were North Americans of made on an imagined vertical axis along the
European descent with a mean age of 15.0 facial midline (Fig 8). A perpendicular tangent
years and a median age of 14.2 years. The sam- to the gingival margin of the upper central in-
ples (women, N = 46; men, N = 42) were cisors established the horizontal zero point.
composed of consecutively examined orth- When the border of the upper lip on smiling
odontic patients who had appointments on was superior to this zero point, the amount of
randomly chosen days. Most of the subjects gingival display in millimeters was signed pos-
were adolescents. No one in this study had pre- itively. When the upper-lip border on smiling
viously undergone maxillofacial surgery. was inferior to the zero point, a negative value
For each subject, data were compiled for 11 was recorded.
variables that describe soft-tissue lip position Upper-lip length was measured directly on
and other seemingly relevant dental and skel- the subject's face (Fig 9), with the subject's
etal vertical factors. Five frontal soft-tissue re- mandible in occlusal rest position. The alar
lationships (measured directly on the face), base of the nose was recorded at the soft-tissue
three dental dimensions (measured directly),
septum (subnasale), and a vertical measure-
and three sagittal cephalographic measurement was taken from this point to the inferior
ments were recorded: border of the upper lip.
1. Frontal soft-tissue measurements, in milli- The next two measurements record the dis-
meters tance between the inferior border of the upper
a. Upper-lip smile line lip and the incisal edge of the upper left cen-
b. Upper-lip length, in rest position tral incisor with the subject first in rest position
c. Upper lip to upper-incisor edge, in and then in a maximum smile (Fig 10). These
rest position measurements are not pertinent to this study,
d. Upper lip to upper-incisor edge, smil- but they hold importance in further work de-
ing scribed later in this article.
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116 Peck and Peck
from the mesioincisal corner of the maxillary

left central incisor to its opposing mandibular
tooth. Clinical crown height was recorded as a
millimetric vertical projection on the maxillary
left central incisor from the incisal edge to the
most superior point at the gingival margin.
Three skeletal factors were measured from
a pretreatment standardized sagittal cephalo-
metric film with each subject in centric occlu-
sion (Fig 11). A Margolis cephalostat was used.
The sella-nasion to mandibular plane relation-
ship (SN-MP) is an angular measurement often
used to describe facial vertical dimension and
specifically mandibular vertical development.
The sella-nasion to palatal plane (ANS-PNS)
relationship is an angular measurement (SN-
Figure 8. Measurement of upper-lip smile line. A
Pal) expressing the inclination of the maxilla
vertical axis graduated in millimeters is visualized relative to a cranial reference line. The third
along the soft-tissue facial midline. A perpendicular skeletal factor is a linear measurement of an-
tangent to the cervical margin of the upper central terior maxillary height: a perpendicular was
incisors defines the horizontal axis (zero). Smile constructed from the palatal plane to the in-
lines above the horizontal axis are given a positive
value, those below the axis, a negative value. For cisal edge of the maxillary central incisor.
example, the smile line represented in this figure Correlation matrices were computed from
measures +2 mm. the data on the male and female samples, sep-
arately and combined.
The interlabial gap is the vertical midline Measurement error was calculated using the
opening between the relaxed upper and lower double-determination method. Two linear
lips with the mandible at rest position. Upper- measurements and one angular measurement
to-lower lip seal at rest was recorded as zero. were retaken on 30 subjects by the same inves-
Three dental measurements were obtained tigator. The error analysis, calculating the dif-
from each subject: overbite, overjet, and clini- ferences between two determinations, the
cal crown height. Overbite (vertical overlap) mean difference, and the standard error for a
and overjet (horizontal overlap) were mea- single determination, was consistent with ex-
sured directly to the nearest half-millimeter pectations. More than two thirds of the second
Figure 10. Measuring the relationship between the

Figure 9. Measurement of upper-lip length. With inferior border of the upper lip and the incisal edge
the mandible and lips in rest position, a vertical of the maxillary left central incisor. Two measure-
measurement is recorded from subnasale to the in- ments are recorded, at maximum smile (as shown)
ferior border of the upper lip. and in rest position.
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upper-lip smile line for males and females are

shown in Figure 12.
Significant sexual dimorphism was appar-
ent in smile-line extremes: high smile lines (ex-
posing ^1 mm of gingiva) appeared to be a
female lineament and low smile lines (covering
^2 mm of incisor crown) seemed to be a male
lineament. The proportion of females with
high smile lines was approximately twice that
of males (25 of 46 females [54%] versus 11 of
42 males [26%], X2 = 7.20, P < .01). The pro-
portion of males with low smile lines was ap-
Figure 11. Three skeletofacial measurements re- proximately twice that of females (14 of 42
corded, derived from sagittal cephalometric films: males [33%] versus 7 of 46 females [15%], x2
(1) SN-MP angle, (2) SN-palatal plane angle, (3) pal- = 3.97, P < .05).
atal plane to incisal edge distance. Comparisons of upper-lip length in rest po-
sition showed particularly significant differ-
measurements were identical to the first mea- ences. The mean vertical length of the upper
surements. lip of males was 2.2 mm greater than that of
females (P < .001).
Results and Discussion Similarly, the linear cephalometric measure-
ments of maxillary height showed a statistically
Means and standard deviations were derived significant male-female difference of 2.2 mm.
for all measured variables. Several statistically The anterior maxilla was long vertically for the
significant male-female differences in vertical male group than for the female group (P <
dentofacial measurements were elucidated. .001). In addition, maxillary height was mod-
Five of the eleven variables studied will be ex- erately correlated with upper-lip length (r =
amined (Table 1). 0.60, n = 88, P < .001).
The upper-lip smile line (or lip position on It was not surprising to find highly signifi-
smiling, relative to the gingival margin of max- cant male-female differences in upper-lip
illary central incisors) was 1.5 mm higher in length and maxillary height.55'68'72 These dif-
female subjects than in male subjects (P < .01). ferences are reflections of simple biological
The female sample averaged nearly a 1 mm scaling, with male samples sized uniformly
gingival smile line (high lip line), whereas the larger than age-equivalent female samples. In
male group showed a low lip line tendency of
nearly a millimeter. The statistically significant Number of Subjects
12
differences in frequency distribution of the
Males
10
Females
Table 1. Sex Differences in Vertical Dentofacial 8
Measurements
Measurement (mm) Sex N Mean SD t Test
Upper-lip smile F 46 0.7 2.1
line M 42 -0.8 2.4 3.14*
Upper-lip length, F 46 21.2 2.4
rest position M 42 23.4 2.5 4.19t
Interlabial gap, F 46 3.3 2.9 1.02,
rest position M 42 2.6 3.2 NS - 8 - 7 - 6 - 5 - 4 - 3 - 2 - 1 0 1 2 3 4 5 6 7 8
Maxillary height F 46 28.7 2.6 Upper-Lip Smile Line (mm)
M 42 30.9 2.8 3.94t
Clinical crown F 46 9.8 1.2 Figure 12. Frequency distribution of upper-lip
height M 42 10.6 1.1 3.17* smile lines (n = 46 female subjects, 42 males sub-
*P< .01. jects). High smile lines (1 mm or higher) were found
tP < .001. more frequently in females, and low smile lines (— 2
Abbreviation: NS, not significant. mm or lower), in males.
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118 Peck and Peck
this study, the sex differences and variabilities variation includes "gummy smile," "high lip
in lip length and maxillary height were very line," "short upper lip," and "full denture
similar, likely nullifying either factor's effect smile."
on the observed differences in upper-lip smile The GSL is often an associated feature of
line. The moderate positive association be- maxillary alveolar overdevelopment or vertical
tween upper lip length and maxillary height maxillary excess (VME). In 1974, Willmar77
derived from correlation analysis (r = 0.60) published the first report on this GSL-VME
tends to support this speculation. association in a monograph discussing the "id-
The interlabial gap measurement at rest was iopathic long face." Since then, other research-
slightly greater among females (3.3 mm) than ers in orthognathic surgery have studied lip
males (2.6 mm). This nonsignificant difference position in relation to skeletal discrepancies
is illuminated by comparing the numbers of and surgical treatment.78"84
persons with an interlabial gap of zero (those Given the general subjective concern among
who exhibited competent lip seal in rest posi- clinicians regarding the esthetics of the GSL,
tion): 26% of females (12 subjects); 50% of this particular dentolabial configuration was
males (21 subjects). The nearly 2:1 ratio of studied further. A study comparing anatomi-
males to females with competent lip seal at rest cal characteristics of a GSL sample with those
is statistically significant (chi-square = 5.36, P of a reference population was undertaken.
< .05).
The last variable to show a notable sex dif-
ference was clinical crown height. The male Gingival Smile Sample
subjects showed a statistically significant in-
crease in the clinical crown height of central A GSL sample was collected from private orth-
incisors over the female subjects (P < .01). Fur- odontic patients who were either in treatment
thermore, clinical crown height was negatively or in posttreatment observation. It was com-
correlated with the upper-lip smile line (r = posed of 27 North American subjects of Euro-
-0.38, n = 88, P < .001). Therefore, hypo- pean descent (11 men and 16 women) with
thetically, high smile lines may be associated very prominent gingival smiles, defined as 2
with short clinical crowns and low smile lines mm or more of maxillary gingiva exposed
may be associated with long crowns. above the left central incisor at maximum
smile.
It was difficult to accumulate the gingival
The Gingival Smile Line smile sample, particularly of male subjects, ap-
The sexual dimorphism in the upper-lip smile parently caused by the rarity of high smile lines
line marks this variable as a significant vertical among men. Therefore, for statistical testing
lineament of lip position. High smile lines can purposes, the GSL sample was formed by com-
be considered within the female norm, and low bining the male and female subjects. The male
smile lines can be considered within the male and female reference samples also were com-
norm. bined for this comparative study, yielding a to-
For some individuals, the high smile is char- tal reference sample of 88 subjects. However,
acterized at its fullest by the exposure of a con- for additional comparisons, the means and
tiguous band of gingiva superior to the maxil- standard deviations for the male and female
lary anterior teeth and often posterior teeth. components of both reference and GSL
This anatomical feature defines a gingival groups were computed separately. Because the
smile line (GSL) (Fig 13). In orthodontics and reference sample was constructed from an un-
surgery, the GSL traditionally provokes stron- selected pool of orthodontic patients, it is not
ger concern from clinicians than a low smile surprising that 26% of them showed GSL as
line, one that conceals the gingiva and part of defined above (8 men and 15 women).
the maxillary anterior teeth. Orthodontists and For each subject, data were compiled for 11
surgeons are conditioned to see a gingival variables associated with lip position and other
smile as esthetically undesirable.58'73"76 The dental and skeletal factors seemingly relevant
varied nomenclature for this anatomical smile to GSL.
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Figure 13. Two representative subjects, one man and one woman, from the GSL sample.
Results and Discussion smile-line measurement equaled 0.0, indicat-

ing the inferior border of the upper lip at max-
Means, standard deviations, and comparative imum smile was positioned exactly at the gin-
Student's J-test values for all the variables mea- gival margin of the upper incisor crown.
sured are reported in Tables 2 through 5. Upper-lip length in rest position showed no
The upper-lip smile line was positioned 3.4 difference between the selected GSL sample
mm higher on average for the GSL group than and the reference group. Both samples had an
for the reference group (Table 2). This sub- identical mean value of 22.3 mm for the up-
stantial difference between the samples was at- per-lip length at rest.
tributable to the selection bias for the GSL The finding of no significant difference be-
sample. With the male and female reference tween the mean upper-lip lengths of the GSL
groups combined into one sample, the mean and reference samples may appear counterin-
Table 2. Dentolabial Measurements for GSL and Reference Samples (in mm)
Measurement Sample AT Mean SD t-Test
Upper-lip smile line GSL 27 3.4 1.3
Reference 88 0.0 2.3 7.35*
Upper-lip length, rest position GSL 27 22.3 2.1 0.09,
Reference 88 22.3 2.7 NS
Interlabial gap, rest position GSL 27 6.2 2.8
Reference 88 3.0 3.1 4.91*
*P < .001.
Abbreviation: NS, not significant.
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120 Peck and Peck
Table 3. Upper-lip Elevation From Rest Position Further data on the interlabial gap for GSL
to Maximum Smiling Position (in mm) subjects were derived by analyzing the compo-
Sample N Mean SD t-Test sition of the reference group. Of the 88 sub-
1.8
jects, 36 displayed a GSL of 1 mm or more, and
Gingival smile 27 6.2
Reference 88 5.2 1.6 2.84* of these 36 GSLs in the reference sample, 31
(86%) exhibited lip separation in rest position
*P< .01.
and 5 (14%) attained lip seal (gap = 0). In
contrast, of the 55 reference subjects with lip
tuitive, but it is not surprising. Surgical pa- separation in rest position, 31 subjects (56%)
tients with vertical maxillary excess also are re- also displayed a GSL.
ported to have normal lip lengths.78 The clin- In a descriptive essay, Matthews85 proposes
ical notion that the upper lip would likely that an individual exhibiting an interlabial gap
measure shorter in a high smile line pattern is in rest position will also have a GSL. This as-
simply false. In a study of 70 GSL female sub- sumption is specious, according to the results
jects, Singer58 actually detected a significantly of the present study. The data showed GSL
longer upper lip for the gingival display group subjects exhibiting an interlabial gap in 86% to
when compared with a nondisplay sample. 93% of the instances, a remarkably high rela-
The present study also indicated slightly tive frequency. However, the converse, was not
longer mean lip lengths in the GSL group, af- true: only 56% of those with interlabial gaps
ter dividing the samples according to sex.53 had GSL, much less than a predictive level.
The mean upper-lip length of 22.3 mm de- Therefore, an interlabial gap or lip separation
rived for both samples in this study compares in rest position is logically an associated facial
favorably with Burstone's55 normative data. feature of the GSL, but contrary to Matthew's
The interlabial gap measurement at rest po- view, it cannot be considered predictive of the
sition averaged 6.2 mm for the GSL sample GSL phenomenon.
and 3.0 mm for the reference sample, a statis- A data transformation using two of the mea-
tically significant difference (P < .001). More sured variables produced an interesting result.
importantly, a remarkable difference between The absolute value of the difference between
the samples existed in the numbers of subjects the two "upper lip to incisal edge" measure-
exhibiting lip separation in rest position (inter- ments in rest position and at maximum smile
labial gap > 0): gingival smile sample, 93%; represents the vertical linear change in upper-
reference sample, 63%. This difference in lip- lip position in the formation of a smile. The
separation frequency between the two samples change in upper-lip position from rest position
was statistically significant (\2 = 7.47, P < .01). to maximum smile, ie, the amount of lip ele-
The likelihood ratio calculated from this data vation on smiling, was derived for each subject
is 5.5. The GSL subjects were 5.5 times more (Table 3). The GSL sample showed a greater
likely to exhibit an interlabial gap at rest than mean increment of lip elevation on smiling (6.2
the reference population. In addition, the up- mm) than did the reference sample (5.2 mm).
per-lip smile line was moderately correlated The upper lip of the GSL subjects showed a 1.0
with the interlabial gap (r = 0.46, n = 88, mm greater elevation superiorly from rest to
P < .001). maximum smile than did the reference group,
Table 4. Skeletal Measurements for GSL and Reference Samples

Measurement Sample N Mean SD t-Test
SN-MP, degrees GSL 27 35.7 7.2 0.62
SN-palatal plane, degrees GSL 27 6.8 4.4 0.63
Palatal plane to upper incisor, mm GSL 27 32.0 3.0 3.55*
Reference 88 29.7 2.9
*P< .001.
Abbreviation: NS, not significant.
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Table 5. Dental Measurements, GSL, and The smile is formed in two stages (Fig 14).
Reference Samples The first stage raises the upper lip to the na-
Measurement Sample N Mean SD t-Test solabial fold by contraction of the levator mus-
Overjet, mm GSL 27 4.8 1.7
cles originating in the fold and inserting at the
Reference 88 3.3 1.8 3.96* upper lip. The medial muscle bundles raise the
Overbite, mm GSL 27 3.8 2.7 lip at the anterior teeth and the lateral muscle
Reference 88 2.8 1.6 2.43f groups raise the lip at the posterior teeth. The
Clinical crown GSL 27 9.8 1.4 1.46
height, mm Reference 88 10.2 1.2 NS lip then meets resistance at the nasolabial fold
because of cheek fat. The second stage involves
*P < .001.
tP< .05. further raising superiorly of the lip and the
fold by three muscle groups: the levator labii
a statistically significant difference (P < .01). superior muscles of the upper lip, originating
This finding indicates that persons with GSLs at the infraorbital region; the zygomaticus ma-
have significantly more efficient lip-elevation jor muscles; and superior fibers of the bucci-
musculature than those with average lip lines. nator.
The facial muscular capacity to raise the upper Usually, the appearance of squinting accom-
lip on smiling an average of 1 extra millimeter, panies the final stage of smiling. It represents
or nearly 20% more than the reference group, the contraction of the periocular musculature
may be a key anatomical determinant in the (orbicularis oculi muscles) to support maxi-
genesis of the GSL. mum upper-lip elevation through the nasola-
From cadaver studies, Rubin and cowork- bial fold. Davidson, Ekman, and Friesen88'89
ers86'87 determined that the nasolabial fold was have shown recently that the squint accompa-
a key in the anatomic mechanism producing nying a maximum smile is a facial muscular
the open smile. They were particularly inter- trigger that activates the brain centers in the
ested in the muscular basis of the smile in sur- anterior temporal region regulating the pro-
gically reanimating patients with facial paraly- duction of pleasant emotions. So without this
sis. Based on Rubin's work, we can construct a final squinting action, a perceived smile of
theory linking the elevator muscles at the na- happiness is likely a false smile, joyless for the
solabial fold with the ability of some individu- person smiling.
als to project a gingival smile. In the sample comparisons for three skelet-
Figure 14. Stages in the genesis of a full smile. (A) Stage 0, rest position. (B) Stage 1, upper lip elevation to
the nasiolabial fold. (C) Stage 2, maximum upper lip and fold elevation by the levator labii superioris (LLS),
zygomaticus major (ZM), and superior fibers of the buccinator (B).
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122 Peck and Peck
Figure 15. Patient before (A) and after (B) Le Fort I osteotomy with orthodontic treatment to reduce vertical
maxillary excess and GSL.
ofacial dimensions (Table 4), the sella-nasion providing no reason to believe that mandibular
to mandibular plane angle (SN-MP) and the vertical development or palatal plane inclina-
sella-nasion to palatal plane angle (SN-PP) tion play significant roles in the GSL "equa-
both showed nonsignificant differences be- tion." Singer's work58 compared a GSL sample
tween the GSL sample and the reference with a non-GSL group (rather than an unse-
group. In contrast, the linear cephalometric lected reference sample), a difference in meth-
measurement of anterior maxillary height odology that is likely responsible for the exag-
(palatal plane to upper-incisor edge) showed gerated results.
mean values of 32.0 mm for the GSL sample One of the most important factors uncov-
and 29.7 mm for the reference sample, a ered in this investigation was the highly signif-
highly significant difference of 2.3 mm (P < icant difference (P < .001) in anterior maxil-
.001). In the reference sample, anterior max- lary height (palatal plane to upper-incisor
illary height correlated strongly with upper-lip edge) between the GSL sample and the refer-
length (r = 0.60, n = 88, P < .001), while in ence sample. The GSL sample, compared with
the gingival smile line sample, the correlation the reference sample, showed a mean vertical
was weak and nonsignificant (r = 0.29, n = 27, maxillary excess of 2.3 mm. The resultant up-
ns). per lip-incisor-jaw discrepancy is similar to that
Among the skeletal measurements re- reported in long-face syndrome: an excess dis-
corded, two cephalometric variables, SN-MP play of the anterior maxillary teeth and jaw
and SN-PP, showing statistically nonsignificant coupled with a normal upper-lip length.78 Fur-
results were found in a study by Singer58 to thermore, the GSL sample's mean anterior
have characteristic values associated with gin- maxillary height of 32.0 mm (SD = 3.0) is re-
gival display. In the present study, both vari- markably close to that reported by Isaacson
ables showed remarkably consistent mean val- and others90 for a combined-sex sample of un-
ues and variability in all sample comparisons, treated high mandibular plane subjects.
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The substantial difference in the correlation pected with a somewhat older sample. Vig and
coefficients for anterior maxillary height to Cohen60 investigated the vertical growth of the
upper-lip length between the reference sample lips using serial roentgenographic cephalome-
(r = 0.60) and the GSL sample (r = 0.29) may try. Among the variables in their study were
help explain a causal, proportional relation- upper-lip height (length) and lip separation
ship between vertical maxillary height and gin- (interlabial gap). The reported changes in both
gival display on smiling. Less than one-quarter soft-tissue variables between 15 to 20 years of
of the variability accounted for in the refer- age were very small and within the standard
ence-sample coefficient is explained in the errors.
GSL-sample coefficient. Lip length is relatively Nevertheless, evidence indicates that the
stable for both samples, so the major distur- GSL diminishes with age. Vig and Brundo59
bance in variability must be concentrated in the described a gradual drooping of lip position as
weaker field (the GSL sample) with the weaker an aging phenomenon. They collected five
variable (anterior vertical maxillary height). adult samples in different age categories to be-
Measurements of overbite and overjet yond 60 years. With the lips gently parted in
yielded statistically significant differences be- repose, the older adult samples in their study
tween the GSL sample and the reference sam- displayed progressively less maxillary incisor
ple (Table 5). The difference between the and more mandibular incisor than younger
mean overjets was 1.5 mm (P < .001) and the groups. In support of an age-related reduction
difference between the mean overbites was 1.0 in GSL frequency, the adult samples (between
mm (P = .05), with the GSL sample having the 20 and 30 years) of Tjan and coworkers62
larger value in both dimensions. All correla- showed less than one third the frequency of
tion coefficients derived for both variables GSL occurring than that observed in our study
against the upper-lip smile line variable were using orthodontic-aged samples (mean age =
very weakly positive, the strongest being be- 15.0 years). The sagging of the perioral soft
tween reference-sample overjet and upper-lip tissue with age is in part caused by the natural
smile line (r = 0.24, n = 88, P < .05). flattening, stretching, and decreased elasticity
The findings of statistically significant dif- of skin.91'92 Environmental and occupational
ferences between the GSL and reference factors, such as exposure to sunlight, can often
groups in overjet (P < .001) and overbite (P < accelerate these age-related facial changes.
.05) may have immediate clinical relevance for
orthodontists. In both variables, the GSL sam-
ple exhibited the larger values. Vig and Clinical Remarks
Brundo59 observe that individuals with mod-
erate to severe Class II malocclusions show ex- The GSL is not as objectionable as many clini-
ceptional resistance to the usual pattern of in- cians may imagine. It is prevalent in all popu-
creased lip coverage of the maxillary incisors lations. Gingival display is generally compati-
with age. If this clinical observation is scientif- ble with pleasing facial esthetics in the eyes of
ically valid,61 perhaps orthodontic reduction of the public; a sampling of fashion and beauty
overjet and, to a lesser extent, overbite can ef- magazines will show a remarkable number of
fectively moderate a GSL in a Class II condi- models of both sexes with gingival smiles. For
tion. example, in a recent Miss America pageant,
Although earlier data showed a sexual di- five of the 51 contestants had conspicuous
morphism in clinical crown height, suggesting GSLs and one of them was chosen as one of the
that this may be a factor in the formation of five finalists.
various smile-line patterns, the present data A specialist may validly ask why one per-
show clinical crown height differences are not son's GSL is seen as an unobtrusive facial fea-
statistically significant. ture, whereas another person's is viewed as un-
satisfactory. Probably other visual factors are
GSL and Facial Aging operative, such as the shape or size of the smile
Although the 115 subjects studied had a mean aperture and the extent to which the maxillary
age of 15.5 years, similar results would be ex- posterior gingiva is exposed at maximum
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124 Peck and Peck
smile. Isaacson93 has aptly called for some in- 5. Burr CW. Personality and physiognomy. Dent Cosmos
vestigative attention to the posterior GSL-VME 1935;77:556-560.
6. Patzer GL. Reality of physical attractiveness. J Esthet
esthetic relationship. Some differences of Dent 1994;6:35-38.
opinion may be found to be more a function of 7. Breckenridge JD. Likeness, a conceptual history of an-
observer bias than of actual oral form. As psy- cient portraiture. Evanston: Northwestern University
chologists have concluded, "We are still some Press, 1968.
way from understanding the nature of the vi- 8. Robins G. Proportion and style in ancient Egyptian
art. London: Thames and Hudson, 1994.
sual information which is encoded from faces
9. Moorrees CFA, van Venrooij ME, Lebret LML, et al.
to form the basis of the subtle discriminations New norms for the mesh diagram analysis. Am J
we are able to make from these complex pat- Orthod 1976;69:57-71.
terns."39 10. Olds C. Facial beauty in Western art. In: McNamara
In light of the findings from these studies, JA Jr, Editor. Esthetics and the treatment of facial
clinicians should perceive the GSL to be an ac- form, vol 28, Craniofacial Growth Series. Ann Arbor:
Center for Human Growth and Development, Uni-
ceptable anatomical variation and should re- versity of Michigan, 1993:7-25.
frain from conditioning patients to regard it as 11. Beardsley MC. Aesthetics from classical Greece to the
anomalous or undesirable. In fact, a moderate present. New York: Macmillan, 1966.
GSL is well within the normal range of lip- 12. Baumgarten AG. Meditationes philosophicae de non-
tooth-jaw variation, especially for women. nullis ad poema pertinentibus, 1735. In: Aschenbren-
However, should a patient deliver an un- ner K, Holther WB, translators. Reflections on poetry.
Berkeley: University of California Press, 1954.
coached complaint about a GSL several reme- 13. Huntley HE. The divine proportion: A study in math-
dial pathways exist at present. ematical beauty. New York: Dover Publications, 1970.
Orthodontics directed at intrusion of the 14. Ricketts RM. The biologic significance of the divine
maxillary anterior teeth with significant reduc- proportion and Fibonacci series. Am J Orthod
tions of overjet and overbite may succeed in 1982;81:351-370.
moderating a GSL in some cases. Yet, the most 15. Ricketts RM. Divine proportion in facial esthetics. Clin
Plast Surg 1982;9:401-422.
effective treatment would be to reduce the as- 16. Preston JD. The golden proportion revisited. J Esthet
sociated vertical maxillary excess with maxil- Dent 1993;5:247-251.
lary superior repositioning surgery (eg, Le 17. Nakajima E, Maeda T, Yanagisawa M. The Japanese
Fort I osteotomy) in conjunction with orth- sense of beauty and facial proportions. II. The beau-
odontics (Fig 15). This method does have lim- tiful face and the V2 rule. Quintessence Internal
1985;9:629-637.
itations: along with the vertical maxillary re- 18. Brace CL, Mahler PE. Post-Pleistocene changes in the
duction, the upper lip shortens by up to 50% human dentition. Am J Phys Anthropol 197l;34:191-
of the surgical skeletal intrusion.81"83 204.
19. Peck S, Peck H. Orthodontic aspects of dental anthro-
pology. Angle Orthod 1975;45:95-102.
Acknowledgments 20. Corruccini RS. Anthropological aspects of orofacial
and occlusal variations and anomalies. In: Kelley MA,
We acknowledge with thanks Dr. Matti Kataja of Tam- Larsen CS, editors. Advances in dental anthropology.
pere, Finland, for his contributed expertise in data man- New York: Wiley-Liss, 1991:295-323.
agement. The manuscript was improved measurably as a
21. Winckelmann JJ. Reflections on the imitation of
result of our conversations with Dr. Coenraad F. A. Moor-
Greek works in painting and sculpture, 1755, Heyer
rees. We are grateful to him.
E, Norton RC, translators, La Salle (IL): Open Court
Publishing, 1987;5:33.
22. Potts A. Flesh and the ideal. Winckelmann and the
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126 Peck and Peck
adults with normal occlusion. Angle Orthod 1992; pressure following orthognathic surgery. Am J
62:127-134. Orthod Dentofacial Orthop 1988;93:294-302.
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the soft tissue facial profile. Angle Orthod 1990; 180-182.
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diagnosis and treatment planning. Part I. Am J Angle Orthod 1991;61:267-276.
Orthod Dentofacial Orthop 1993; 103:299-312. 85. Matthews TG. The anatomy of a smile. J Prosth Dent
72. Riolo ML, Moyers RE, McNamara JA, et al. An atlas of 1978;39:128-134.
craniofacial growth, vol 2, Craniofacial Growth Series. 86. Rubin LR. The anatomy of a smile: Its importance in
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77. Willmar K. On Le Fort I osteotomy. Scand J Plast variation in vertical facial growth and associated vari-
Reconstr Surg 1974; 12:1-68. ation in skeletal and dental relations. Angle Orthod
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80. Phillips C, Proffit WR. Full face soft tissue response to aging in oral mucosa and skin. Boca Raton (FL):CRC
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81. Proffit WR, Phillips C. Adaptations in lip posture and Angle Orthod 1992;62:101-102.
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Vol 1, No 3 September 1995
Seminars in
ORTHODONTICS P. Lionel Sadowsky, DMD
Editor
Early Orthodontic Treatment

Gregory King, DMD, DMSc
Guest Editor

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Editor-in-Chief:
Patrick M. Lloyd, DOS, MS
Journal of
Prosthodontics
Official Journal of the American
College of Prosthodontists
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on every aspect of the specialty, including implant prosthodontics, dental prosthetics,
fixed and removable prosthodontics, geriatric dentistry, and craniomandibular
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management, and technology. Journal of Prosthodontics keeps you informed of
the latest advances in all areas of prosthodontics.
Several superb sections are included in each peer-reviewed issue. The Clinical
Research and Basic Research sections report the results of recent investigations
and work-in-progress. The Clinical Science section features reports of clinical or
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procedures and discuss the advantages and disadvantages of new techniques.
These articles provide comparisons with alternative methods. The Academics and
Education section presents articles on new approaches for particular instructional
problems and unique programs and teaching techniques. Finally, the Topics of
Interest section consists of articles, essays, and reviews on current prosthodontics
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In addition, the Journal is the first in the dental literature to provide structured
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VOL 1, NO 3 SEPTEMBER 1995
Early Orthodontic Treatment

Gregory King, DMD, DMSc
Guest Editor
CONTENTS
Introduction 127
Gregory King
The Randomized Clinical Trial as a Powerful Means for Understanding

Treatment Efficacy 128
Ceib Phillips and J.F. Camilla Tulloch
Decision Analysis to Optimize the Outcomes for Class II Division 1

Orthodontic Treatment 139
Peter S. Vig and Katherine Dryland Vig
Temporomandibular Disorders After Early Class II Treatment With Bionators

and Headgears: Results From a Randomized Controlled Trial 149
Stephen D. Keeling, Cynthia W. Garvan, Gregory J. King, Timothy T. Wheeler,
and Susan McGorray
Monitoring Growth During Orthodontic Treatment 165

Joseph G. Ghafari, Frances S. Shofer, Larry L. Laster, Diane L. Markowitz,
Susan Silverton, and Solomon H. Katz
Maxillary Adaptation to Expansion in the Mixed Dentition 176

Lawrence M. Spillane and James A. McNamara, Jr.
Leeway Space and the Resolution of Crowding in the Mixed Dentition 188
Anthony A. Gianelly
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will publish
Volume 1, Number 4, December 1995

TEMPOROMANDIBULAR JOINT
DYSFUNCTION
Daniel M. Laskin, DDS, MS
Volume 2, Number 1, March 1996

ORTHODONTICS/PERIODONTICS
Bjorn U. Zachrisson, DDS
Volume 2, Number 2, June 1996

MANAGEMENT OF COMPLEX
ORTHODONTIC PROBLEMS
Ravindra Nanda, BDS, MDS, PhD
Volume 2, Number 3, September 1996

CLEFT LIP AND PALATE
Christos C. Vlachos, DMD, DDS, MS
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VOL 1, NO 3 SEPTEMBER 1995
Introduction
This issue of Seminars in Orthodontics con- the uniqueness of orthodontics as a health care
tains six articles that focus on important service, and the appropriateness of limiting
issues in early orthodontic treatment. As one clinical orthodontics research to the use of only
might predict, there is no shortage of questions one design, despite its power.
regarding this topic. Many of these questions Preliminary results from two of the RCTs
are familiar. What are the best means to man- on early treatment are presented in the reports
age incipient crowding in the mixed dentition? by Keeling et al and Ghafari et al. The former
What is the impact of early treatment of mal- presents important new findings on the impact
occlusion on the signs and symptoms of tem- of early treatment on temporomandibular dis-
poromandibular disorders (TMD)? Can we use orders. This report confirms some ideas widely
more precise knowledge of somatic growth ac- held by clinicians today, but clearly does not
tivity to predict orthodontic outcomes? Noted confirm others. The latter report presents data
experts review each of these issues and present on the relationship between biochemical and
new data aimed at answering such queries. physical measures of somatic growth and out-
This issue of Seminars in Orthodontics also raises comes of early orthodontic treatment.
new questions regarding the best methods to The last two reports deal with the manage-
assess the outcomes of orthodontic treatment. ment of incipient crowding problems in the
The reader should find these articles ex- mixed dentition. One approach common today
tremely valuable because they address the im- involves expansion, a procedure that is widely
portant issue of how to best perform clinical believed to be stable when performed early.
orthodontic research, balancing scientific rigor Spillane and McNamara present important
with the unique nature of orthodontic treat- new data from the Ann Arbor Expansion
ment. Study that clearly confirms this idea. In the last
The randomized controlled trial (RCT) is report Gianelly discusses the other powerful
the accepted standard of proof in medical re- approach to managing incipient crowding, tak-
search today. In the first report, Phillips and ing advantage of the space gains available dur-
Tulloch describe this important research de- ing the transition from deciduous to perma-
sign with particular emphasis on the three on- nent dentitions.
going early treatment trials funded by the Na- In summary, this collection of reports on
tional Institute of Dental Research. The article early orthodontic treatment satisfies on several
not only provides a convenient summary of levels. It provides the reader with the insights
this method that promises to have a major im- of noted leaders in the field that can be used in
pact on the dental profession in the future, but clinical practice. It offers data obtained with
also provides a discussion of its attendant scientific rigor, and serves as a discussion of
strengths and weaknesses. the relative merits of future trends in clinical
In the second article, Vig and Vig provide a orthodontic research. Enjoy!
demonstration of decision analysis applied to
assessing the outcomes of early orthodontic
treatment. They also raise important questions Gregory King, DMD, DMSc
about the assessment of orthodontic outcomes, Guest Editor
Seminars in Orthodontics, Vol I, No 3 (September), 1995: p 127 127

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The Randomized Clinical Trial as a

Powerful Means for Understanding
Treatment Efficacy
Ceib Phillips and J.F. Camilla Tulloch
The comparison of technologies, ie, alternative ways to accomplish the

same aim, is inherently difficult. In orthodontics, technology covers a wide
spectrum of areas: variations in treatment approach, appliances, wires, di-
agnostic procedures, and patient management techniques. Clinical trial
methodology has been developed to minimize the effect of bias and to
provide more objective answers to questions of comparative efficacy and
benefits of particular treatments or procedures. The randomized controlled
clinical trial (RCT) is now generally considered the strongest research design
for the comparison of treatments. This report reviews four issues that
should be addressed in planning an RCT: defining the study cohort, select-
ing the treatment allocation technique, estimating sample size, and per-
forming the trial.
Copyright © 1995 by \N.B. Saunders Company
rthodontists have for decades attempted ating new health care technologies is related
O to understand facial growth and biome-
chanics to provide improved oral function and
both to the way in which new technologies are
introduced into clinical use and to the methods
facial/dental esthetics for patients. Technology used in assessing their usefulness.
in orthodontics covers a wide spectrum of ar- The comparison of technologies, or alterna-
eas: variations in treatment approach, appli- tive ways to accomplish the same aim, is inher-
ances, wires, diagnostic procedures, and pa- ently difficult. The differences in the treat-
tient management techniques. New development effects could be because of differences in
ments or modifications of existing methods are the patients being treated rather than real dif-
frequently based on theoretical constructs or ferences in the treatment's effects. Even if al-
empirical evidence without any clear underly- ternative treatments can be compared in the
ing mechanism, and are often introduced into same patient, the differences between those
clinical practice without any formal assessment treatments will still vary from one patient to
of their benefit or effectiveness. Many of these another. Until recently, comparisons in orth-
technologies have later been deemed ineffec- odontics have generally depended on case se-
tive, for example, the use of the chincap to ries or observational studies.1'2 In these series
prevent mandibular growth, Class II elastics to or studies, the investigator is a passive observer
advance the mandible, or myofunctional ther- of a technology (treatment) initiated for the
apy to close openbite. The difficulty in evalu- purpose of patient care, and has no control
over how the treatment is provided or to
whom. Because neither the treatment pro-
From the Department of Orthodontics, University of North
Carolina School of Dentistry, Chapel Hill, NC. vided nor the way patients are assigned to
Supported in part by National Institutes of Health, Bethesda, treatment is governed by any written protocol,
MD, Grant No. DE-08708. the treatment groups are likely to differ in
Address correspondence to Ceib Phillips, MPH, PhD, Re- some systematic way (either recognized or not)
search Professor, Department of Orthodontics, University of and so bias in the comparison of treatments is
North Carolina School of Dentistry, Chapel Hill, NC 27599-
7450.
also likely. Most often, convenience samples of
Copyright © 1995 by W.B. Saunders Company patients are selected for analysis only after
1073-8746/95/0103-0002$5.00/0 treatment has been started, or this may not oc-
128 Seminars in Orthodontics, Vol 1, No 3 (September), 1995: 128-138

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The Randomized Clinical Trial 129
Case Series / Observational Studies the questions of comparative efficacy and ben-
efit of particular treatments or procedures. A
TxA
TxB
•—
•—
Retrospective •it clinical trial is a "method of comparing the rel-
ative merits (and shortcomings) of two or more
TxA treatments tested in human subjects."5 In a
Retrospective I Prospective
clinical trial, the investigator is an active par-
•
ticipant in the treatment process because the
treatments being evaluated and the assignment
Prospective
of patients are controlled by a well-defined
protocol. A clinical trial is an experiment in the
sense that the alternative treatments are initi-
ated specifically for the purpose of evaluation.
Clinical Trial
The protocol makes explicit the objective of
the study, what treatments are to be applied
and how, when, and where, and to what kind
of patient.
Clinical trials are always prospective studies
(Fig 1), and can be classified as (1) uncon-
Randomized Clinical Trial
trolled, if there is no concurrent comparison
group although historical controls may be
used; (2) nonrandom controlled trial, if a con-
Assignment
current comparison group is used but patients'
Figure 1. Pictorial representation of comparative allocation to each group occurs by means of
clinical research designs illustrating whether a treat- some nonrandom process (eg, convenience or
ment protocol is used and the relationship of the clinical judgment); and (3) randomized con-
investigator to the initiation of treatment. The fig- trolled trial (RCT), if subjects are randomly al-
ure indicates the timing of the investigator's input located into treatment and control groups. In
with respect to the initiation of treatment.
an RCT, the control group may receive no
treatment (observation only or placebo) or the
cur until after treatment has been completed current standard treatment (active control).
(Fig 1). Although the serial nature of orth- Historical controls and nonrandomized con-
odontic records easily permits patients to be current controls have the disadvantage that
monitored from before to after the time of these groups are likely not to be comparable
treatment, case series and observational study with the treatment group because of genera-
designs are inherently susceptible to bias, par- tional differences in patients, differences in
ticularly those associated with selection and at- the definition and application of background
trition.3'4 Selection bias can result from the care, and/or the occurrence of variables that
ways in which individuals are selected for study may confound the results of treatment.
and includes differential diagnosis, disease se- The modern era of RCTs began in the early
verity, and referral of patients for particular 1950s with the evaluation of streptomycin in
treatments. Attrition bias may represent a loss patients with tuberculosis.6 The RCT is now
of patients to follow-up, or a failure of the generally considered the strongest research
treatment approach such that only those pa- design for the comparison of treatments. The
tients who experience some minimum of effect reasons are that the random assignment of pa-
complete the treatment and thus become po- tients to groups provides a basis for inference
tential study subjects. using population sampling methods and
makes it likely that the outcome differences
Clinical Trials can more safely be attributed to the treatment
and not to the selection biases inherent in
Clinical trial methodology has been developed other research designs. The assumption is that
to minimize the chance of these biases occur- the random allocation of patients to treatment
ring and to provide more objective answers to also randomly allocates important prognostic
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130 Phillips and Tulloch
factors (both known and unknown) thereby

making the treatment groups as similar as pos-
sible before the initiation of the treatment pro-
tocol. In a review of 50 clinical studies to eval-
uate growth modification in Class II malocclu-
sion, 76% of the studies reported using a Steps in Planning:
comparison group (untreated Class II patients • 1. Defining the study cohort
- a. Inclusion criteria
or an alternative appliance system), but ran- - b. Exclusion criteria
domization procedures were not used in any of • 2. Selecting the randomization technique
these studies.1 • 3. Defining the outcome(s)

• 4. Calculating sample size
When active treatments are compared it is
• 5. Assessing feasibility of study
interesting to note that the findings regarding • 6. Establishing a plan for the conduct of the trial
the relative effectiveness of the treatments, ie,
the clinical gain achieved by the "new" treat- Figure 2. Steps in planning a randomized clinical
ment as compared with that of the standard, trial of the efficacy of an orthodontic treatment or
procedure.
have been shown to be affected by the study
design itself. There have been many instances
in medical practice where treatments evaluated of North Carolina [UNC]), all assessing the ef-
in a poor research design have been widely en- fect of early orthodontic treatment on Class II
dorsed only to be found to be either ineffective patients.
or even harmful when evaluated in RCTs.7
One example of such an ineffective or harmful Defining the Study Cohort
treatment that was approved on the basis of
poorly designed research is the use of antiar- The objective and the primary research hy-
rhythmic drugs to suppress ventricular extra- pothesis of a clinical trial provide a basis for the
systoles in survivors of myocardial infarction.8 definition of the study cohort. For example, it
Findings from observational studies and un- is highly unlikely that the same criteria would
controlled and nonrandomized clinical trials, be used to select a cohort of patients to inves-
the weaker research designs, are generally as- tigate space closure rates along orthodontic
sociated with more positive conclusions re- arch wires, as would be used to select patients
garding a treatment's effectiveness and the to compare patient information procedures or
overall likelihood of success from a new treat- evaluate the benefits of early treatment. Even
ment is often reported as substantially greater within a single broad question, differences may
when such designs are used.9 There have been arise as to the framing of the study's objective,
some attempts to quantify the bias in clinical the selection criteria, and/or the screening pro-
gain attributable to the different research de- cedures used to enroll patients. The three on-
signs.10'11 Such estimation is difficult because going RCTs were all developed to address the
of differences in eligibility criteria, study pro-
tocols, outcome assessment, and differences in- SELECTION TREATMENT
CRITERIA EFFECT
herent in the study designs themselves. A
Several issues should be addressed in plan-
PATIENT
ning (Fig 2) and performing an RCT. The evo- AVAILABILITY
lution of a protocol should reflect the decisions

made at each step and act as a dynamic, inter- COST OF SAMPLE
active process (Fig 3) that requires close collab- ENROLLMENT SIZE
oration between the health professionals pro-

viding the treatment and the biostatistician. ATTRITION
Examples to illustrate the decisions made for
the issues discussed in this report will be drawn Figure 3. Planning an RCT should not happen se-
quentially but rather as an interactive process in a
from the protocols developed for three ongo- feedback loop. Decisions made for a given issue will
ing RCTs (at the University of Florida, the impact, and potentially modify, the assessments for
University of Pennsylvania, and the University other issues.
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same broad question of the effects of early

treatment. Within this broad concept, how-
ever, the decisions made by the research teams
at each institution differed. Figure 4 illustrates
the differences in the clinical examination se-
lection criteria used in the screening of pa-
tients at the three institutions.
Generalizability Comparability
Inclusion and exclusion criteria should be as
inclusive as is both practical and consistent with Figure 5. The conflict between increasing the ho-
the objectives of the study. They also should mogeneity of subjects to increase the clarity of the
facilitate recruitment of subjects and maximize findings and the subjects' comparability and increas-
ing the heterogeneity of subjects to increase the gen-
the generalizability of the study's findings. The eralizability.
inclusion criteria should ensure that subjects
have the condition being studied, could poten-
tially benefit from the intervention, and are pool to extend the findings to a wider and
willing and able to give informed consent. The more diverse patient base.12"14
exclusion criteria should eliminate subjects Three practical considerations affect the de-
who have contraindications to the study's pro- velopment of selection criteria. First, as the
cedures, are unlikely to comply with the pro- stringency of the selection criteria increases,
tocol or follow-up requirements, or for whom the numbers of available patients will decrease.
randomization would be unethical. The crite- For example, of the first 124 patients enrolled
ria should be broad enough that recruiting pain the UNC early-treatment trial on the basis of
tients will not present a challenge and the find- overjet measurements greater than 7 mm, only
ings will be generalizable to a relatively large 108 (87%) would have been eligible if the se-
and diverse target population. At the same lection criteria had also included a full unit
time, they should be stringent enough that pa- Class II molar relationship bilaterally, and
tients with characteristics that will produce only 92 (74%) if more than 10 mm of soft tis-
qualitatively different outcomes will be ex- sue A point to B point difference had also been
cluded. This dilemma is a "tug of war" (Fig 5) required.15
between increasing the homogeneity of the pa- Second, the available patient pool must be
tient pool to enhance the clarity of the findings sufficient to meet the sample size requirements
and increasing the heterogeneity of the patient of the trial. Often, an overly optimistic estimate
is made of the available patient pool. The esti-
mate of availability should, if possible, use the
exact same selection criteria proposed for the
trial. Even supposedly minor deviations in cri-
Decision Branches Clinical Exam Criteria teria can substantially alter the number of pa-
tients eligible when enrollment begins. At
UNC, a preliminary search for the early treat-
ment trial was made using the graduate orth-
odontic clinic database to assess the numbers of
patients who would likely meet the proposed
selection criteria. This search suggested that
Distocclusion
Fully erupted permanent 1st Molars
Bilateral Distocclusion
(no unilateral class II)
Overjet > 7mm
All incisors erupted
approximately one third of our clinic popula-
Not more than 3 permanent
cuspids or bicuspids erupted
Overjet > 3mm
Caucasian
2nd Molars not erupted
Caucasian
tion had "increased overjet." Unfortunately,
Positive overjet and overbite
3rd or 4th grade
overjet had been recorded in the database as
reverse, normal, moderate, and severe rather
Figure 4. Comparison of the clinical examination than as a millimeter measure. Shortly after the
selection criteria used in three RCTs designed to trial began, we became acutely aware that "se-
assess the effects of early orthodontic treatment.
Differences in the framing of a broad general con- vere" did not translate into an overjet of 7 mm
cept can result in differences in selection criteria, or greater. Announcements of the trial on tele-
screening procedures, and/or outcome assessment. vision and in the newspaper as well as requests
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of private practitioners to refer patients for Selecting the Treatment Allocation

screening became necessary to complete the Technique
patient recruitment. The effectiveness of re-
The major objective of a controlled clinical
cruitment methods like the media (television,
trial is to provide a precise and valid treatment
radio, and newspapers), neighborhood promo-
comparison. Randomization is the most com-
tion, direct mail, worksite promotion, or refer-
mon technique used for patient allocation.
ral by other clinicians depends on the objectives
However, even when selection criteria are well
of the trial but will be maximized by using mul-
defined, investigators have no control over the
tiple overlapping recruitment strategies.16'17
variation that will occur among patients within
The third consideration is the amount of
the inclusion criteria or over the variation in
resources required to identify and recruit pa-
characteristics not delineated in the selection
tients. The effort and costs of recruitment are
criteria. For example, although all patients in
often underestimated. Taking into account
the UNC had an overjet of 7 mm or greater,
only personnel costs and the material cost of
overjet ranged from 7 to 15 among the pa-
records, we estimated that the minimum cost
tients enrolled, and there was no way to control
of enrollment per child now active in the UNC
how many of these would have maxillary ex-
trial was $328. An estimated enrollment cost
cess or mandibular deficiency.
should be included in any budget. For the
In an RCT, the following sequence of events
UNC trial, a multistep screening was per-
usually occurs:
formed so that a patient's eligibility potential
could be assessed quickly and efficiently. Fig- 1. Patient requires treatment
ure 6 illustrates the number of patients 2. Patient is eligible for inclusion in the trial.
screened to meet the recruitment goal. The fi- 3. Patient consent is obtained.
nal intake of patients to the trial was approxi- 4. Patient is formally entered into the trial.
mately 10% of those screened, which was con- 5. Treatment assignment is obtained from the
siderably lower than had been projected. Many randomization list.
clinical trials do not meet their original recruit- 6. Baseline study forms are completed.
ment projections. It is essential that plans be 7. Treatment begins.
made for alternative methods/sources of pa-
tients, and that interim goals be established The motivation for randomly allocating pa-
and monitored. tients is twofold. First, randomization pro-
Overjet < 7
Too few/many teeth
Previous ortho
Figure 6. The numbers of

patients examined in the
multistep screening pro-
cess in the early treatment
trial at UNC to achieve the
recruitment goal of 192
patients.
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vides a basis for statistical inference, that is, for size could be set at 8 and randomization within
testing the statistical significance of differences each block would be restricted to produce an
in the outcome among the groups because allocation that would assign 4 patients to treat-
there is no systematic bias affecting the way in ment A and 4 to treatment B. At the end of the
which patients are assigned to treatment. Sec- trial, exactly 24 subjects would be assigned to
ond, although it is still no guarantee, random- each group.
ization offers the best chance of achieving However, equal group size does not neces-
equivalence across the treatment groups of all sarily insure a similar distribution in the treat-
factors that might confound or modify the ef- ment groups of baseline characteristics that are
fect of treatment.18 Alternative approaches, known, or believed, to affect treatment out-
such as matching on factors thought to be in- comes. In a stratified blocked randomization,
fluential (eg, gender, age, and severity of the subjects are classified before randomization on
condition), although theoretically possible, are one or more prognostic factors. Separate block
cumbersome, require large samples to achieve randomization lists are then prepared for each
matches, and ignore the important consider- subgroup (stratum). Blocked stratification
ation of pretreatment equivalence across fac- guards against imbalances between the groups
tors that are not even suspected of being im- resulting in the prognostic factor(s) being
portant.19 The balancing effect produced in a more evenly distributed within the treatment
randomized trial allows the differences in out- groups than might happen by chance alone.
come to be more safely attributed to differ- Stratification also facilitates subgroup analyses
ences in treatment rather than to differences within strata because the numbers of subjects
in the characteristics of the patient groups. with a given prognostic factor are more bal-
Simple randomization is equivalent to coin anced in the treatment groups. Because strat-
tossing if there are just two groups. This allo- ified randomization reduces the variation in
cation method does not depend on the pa- outcome that comes from chance dispropor-
tient's prognostic factors, on patient character- tions in the way the prognostic factor is distrib-
istics, or other patients' treatment assignments. uted in the groups, the power of the study is
However, in RCTs of small to moderate size generally increased. However, studies that use
(<300 subjects), simple randomization may re- stratified blocked randomization should not
sult in treatment imbalances either in the num- use more than a few important predictors.21
ber of subjects allocated to a given group or in Other allocation techniques, for example,
the distributions of potential confounders. In adaptive randomization or minimization, can
an RCT comparing two treatments with a total be selected if a large number of baseline vari-
of 50 patients, there is greater than a 5% ables need to be considered.22
chance that the number of patients allocated to Although stratified blocked randomization
each treatment will differ by at least 14, ie, 18 was used in all the ongoing trials of early orth-
in one group and 32 in the other, or an imbal- odontic treatment, the factors chosen for strat-
ance more extreme.20 Such an imbalance in ification differed. At UNC, patients' gender
the group sizes may result in a loss of sufficient was used; at the University of Florida, severity,
power to detect effects of clinical interest. need for preparatory procedures, mandibular
To overcome this problem, the technique of plane angle, and gender were considered; at
block randomization is commonly used. Block the University of Pennsylvania, skeletal age
randomization assures that the number of sub- (early v late) and severity of malocclusion (low
jects is closely balanced at periodic intervals v high) were selected as factors.
during recruitment and equal at the end of the
trial. A predetermined "block" size, usually a
multiple of the number of treatments, is estab- Estimating Sample Size
lished, and randomization of treatment occurs
within each block such that an equal number of Clinical trials require careful planning. Deter-
patients is allocated to each treatment group mining how many patients are to be included
within each block. In a study of 48 subjects in the trial requires close collaboration between
with two treatment groups (A and B), the block the clinical investigator(s) and the biostatisti-
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P c =0.65
nT= 56
0.9 n c =56
a = 0.05
0.8
- Probability of missing a 25%
increase in the proportion of
successes; R ~ 0.60 where P = proportion of success
c
in the control group
n = sample size for the
T
treatment group
0.5 n = sample size for the
control group
0.4
Figure 7. An operating - /- Probability of missing a 50%

increase in the proportion of
characteristic curve of p as / successes; B « 0.03
a function of the absolute
difference between two
proportions. 0.05
cian. The information required to estimate the a classic test of a two-tailed hypothesis compar-
sample size requires not only knowledge re- ing two proportions, in the null hypothesis
garding the size of a clinically important effect (Ho) "the proportion of 'successes' for the
of therapy but also an understanding of the treatment group (PT) is equal to the propor-
statistical concepts relating to type I and II er- tion of 'successes' in the control group (PC),"
rors, the structure of the outcome measure and in the alternative hypothesis (HI), "the
(nominal, ordinal, or continuous), and the sta- proportion of 'successes' in the two groups is
tistical analyses proposed. Although it is often not equal." However, we know that, even if the
difficult for clinicians to state what a clinically true proportion of successes is equal, observed
meaningful "difference" between treatments nonzero differences between the proportion of
(ie, a therapeutic effect) might be, knowledge successes in the groups will occur by chance
about the magnitude of the treatment effect because the treatment groups studied are only
considered clinically important is necessary to a subset of the population. The level of signif-
calculate an appropriate sample size. Many icance (a) is the rule, set using a "possible but
clinical trials are too small to provide reliable not probable"23 argument, for how small the
answers to the medical issues they seek to eval- probability associated with the observed differ-
uate. Analysis of 71 "negative" RCTs indicated ence between the proportion of successes in
that investigators often work with sample sizes the treatment groups must be to reject the null
too small to offer a reasonable chance of suc- hypothesis. If the null hypothesis is rejected,
cessfully rejecting the null hypothesis in favor there is a risk (a) that the observed difference
of the treatment, and 50 of these 71 trials car- occurred by chance and that the two true pro-
ried a 10% risk of missing a 50% therapeutic portions are equal. This false-positive error
improvement. 2S (made by rejecting Ho when in fact it is true) is
Often the difficulty in specifying the thera- called the type I error. If the decision based on
peutic effect arises from differences in opinion the probability associated with the observed
among clinicians and/or a lack of available data differences between the proportions is not to
on the outcome of choice as it is specified in the reject Ho, then the observed difference is "not
protocol. The simplest approach, for generat- statistically significant." But what if the true
ing discussion among trial investigators and as proportion of successes is not equal, and by
a preliminary determination of the feasibility chance the observed difference was not large
of a trial, is to focus attention on one specific enough to fit our rule for rejecting the null
dichotomous measure of patient response to hypothesis? If this happens, then a false nega-
treatment, such that each patient's outcome tive error, called a type II error, has been
can be classified as a "success" or a "failure." In made in not rejecting the null hypothesis,
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when in fact Ho is false. The probability of this of interest and the number of interim analyses
error occurring is called beta (P). planned. At UNC, the sample size determina-
Unfortunately, the probability of a type II tion was based on the average coefficient of
error is not one single value like the probability annualized change in the angle sella-nasion-
of a type I error. If the true difference be- pogonion (SNPg) obtained from nine growth
tween the proportions is not zero, then there is studies of treated and untreated Class II pa-
an infinity of values that such a difference can tients.24 Conservative significance and power
have, and for each difference value, there is a levels (.01 and .90, respectively) were chosen to
probability of a type II error when Ho is reflect the broad scope of the expected data
tested. In clinical trials, it is essential that the analysis. A doubling of the annualized change
difference value that represents a therapeutic (8 = 100%) was chosen as a clinically signifi-
effect and the ability to detect that difference cant difference in the mean value for any two
be considered. An operating characteristic of the three treatment groups (functional ap-
curve that depicts the entire curve of beta as a pliance, headgear, and observation only). The
function of the differences of interest can be sample size estimate was 40 patients in each of
used to guide discussions about the feasibility three treatment groups. At the University of
of the study. Figure 7 is an operating charac- Pennsylvania, adjusted standard errors for two
teristic curve for a hypothetical clinical trial primary outcomes, ANB and mandibular unit
with 56 patients in each group (alpha = .05) length, were obtained from a retrospective
and the proportion of "success" in the control study of children treated with a headgear or a
group is estimated at .65. For any value of dif- Frankel appliance. Using the pilot data, a sam-
ference on the horizontal scale that is of inter- ple size of 20 patients per treatment group,
est, the value of P (the probability of not re- with alpha set at .05, was sufficient to provide
jecting the null hypothesis) can be read from 99% power to detect a mean ANB difference
the vertical scale. This randomized controlled of 1.5 degrees and 80% power to detect a man-
trial would have a 3% likelihood of deciding in dibular unit length difference of 2.5 mm be-
favor of the null hypothesis when the differ- tween the two treatment groups (headgear and
ence in the proportion of success between the Frankel appliance).
two treatments was actually .30 (ie, a 50% in-
crease in the proportion of "successes" in the Performing the Trial
treatment group). However, if the clinical dif- Planning a trial also requires establishing pro-
ference of interest was a 25% increase in "suc- cedures for how the RCT will actually be per-
cess," then the likelihood of deciding in favor formed and strategies for making modifica-
of the null hypothesis would be 60% when the tions in the protocol as the trial proceeds (Ta-
difference was actually .15. In other words, the ble 1). The methods for collecting data are
power (1 - p) to detect the .15 difference in determined by the primary objective of the
the proportion of successes in the two groups, trial and the ability to obtain consistent results.
that is, the probability of avoiding the type II Details of the methods, including the physical
error, would only be 40%. If the beta values equipment, the sequencing during an exami-
for the differences of clinical interest are un- nation, and the duration of the examination,
acceptably high, other alternatives should be should be both standardized and kept uniform
considered, either increasing the acceptable al- throughout the trial. Both random and system-
pha and/or beta values, or allowing a larger atic error are likely to be reduced if only one
difference for discrimination. examiner is used in a clinical trial, although
Tables, graphs, and computer calculations more than one examiner is often necessary for
can be used to provide the minimum sample logistic reasons. The examiner(s) should un-
size. Sample size will depend on the level of the dergo a period of training before the trial be-
difference of clinical interest, the structure of gins. This training has two objectives: (1) to
the outcome measure, the proposed statistical insure uniform interpretation of the criteria
analysis, and the error sizes (alpha and beta) established for collecting records and data;
selected. The choice of Type I and II error and (2) to maximize the reproducibility of the
sizes will depend on the number of outcomes clinical findings among and between examin-
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Table 1. Issues Related to the Performance of a other important technique used in clinical tri-
Trial als to reduce bias is masking or blinding. There
Patient screening and recruitment are three levels at which masking can be used:
Monitoring that of the patient, the clinician, and the exam-
Alternate methods/strategies iner. Although it may not be possible to mask
Baseline/follow-up assessments
Measurement protocol participants at all three levels, the examiner
Standardization of examination should be masked whenever possible, and the
Physical equipment results of previous examinations or previous
Sequencing
Duration physical records should not be available before
Training randomization or during data collection.
Timing Because an RCT is protocol controlled, in-
Intra/inter examiner
Validity and reliability of measures vestigators should consider the unexpected as
Masking well as the conceivable problems (Table 1) that
Level: patient, investigator, examiner will occur during the trial and devise appro-
Effective management
Protocol modifications priate monitoring/preventive systems. No mat-
Proposal method ter how carefully a clinical trial is planned,
Decision process some patients will be lost from the study. Pa-
Implementation
Protocol errors/protocol violations/attrition tients may be "dropped" because of protocol
Prevention violations of the inclusion or exclusion criteria
Monitoring or patient compliance, protocol errors of mis-
Note. Methods to control, prevent, or monitor errors diagnosis or incorrect assignment, or patient
should be included in the protocol for the trial. attrition resulting from loss to follow-up or
missed examinations. Figure 8 illustrates the
ers. Quantitative estimates of the consistency attrition that occurred in the UNC trial. The
(reliability) between examiners and within a reasons for the loss of 17 patients after ran-
single examiner should be obtained before the domization but before the initiation of treat-
trial begins and be repeated during the course ment included protocol error (misdiagnosis),
of the trial, depending on the trial's length. patient refusal of randomization assignment,
The replication of calibrations and reliability and a protocol violation (patient had received
estimation helps to insure that no bias is intro- some orthodontic treatment before the proto-
duced during the data collection process. An- col treatment). Nine patients' protocol treat-
No Records
Figure 8. Patient attri-

tion in the early treat-
No Later Records Later Records ment trial at UNC.
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ment was discontinued for reasons including Table 2. Flow Chart of the Counts of Patients in
ethical concerns about the assigned treatment the Early-Treatment Trial at UNC
continuance, a protocol violation (incorrect ap- Population Number
pliance construction), and attrition. No. of patients screened 2,164
Although statistical analysis can be useful in No. of patients randomized 192
identifying any lack of baseline equivalence No. of ITT patients
(at least one data collection visit) 180
among the treatment groups that might result No. of efficacy analyzable patients
from patient attrition, special attention should (represents target population
be paid during the development of the proto- through adherence to protocol criteria) 166
col to mechanisms that will minimize loss of NOTE. For the UNC trial, n3/n2 = .94 and n4/n3 = .92.
patients from the trial. The attitude of clinic
staff toward patient complaints and the vigor-
to the number of patients randomized (n3/n2)
ous pursuit of patients who fail to keep study
should exceed 0.95, and that the ratio of the
appointments are important factors in reduc-
number of patients who complete the trial and
ing drop-out.25 Strategies that have been used
adhere to protocol to the number of ITT pa-
include reminding patients of forthcoming ap-
tients (n4/n3) should exceed 0.80. Study man-
pointments, assisting with transportation, min-
agement procedures should be implemented
imizing waiting times, sending newsletters,
to achieve these numerical criteria. If n3/n2 is
providing monetary reimbursement, provid-
less than 0.95, then a sensitivity analysis of the
ing continuity of care, involving family mem-
comparability of the ITT population and the
bers, and maintaining contact with patients'
efficacy analyzable population should be per-
primary care health professionals. Orr et al,26
formed.27
in a study of the patient and clinic factors pre-
dictive of missed visits and inactive status in a
multicenter clinical trial, found that the factors Conclusion
most strongly associated with incomplete fol-
low-up were those that could not have been This article has introduced just a few of the
identified before enrollment, including main issues that are of concern in a random-
changes in marital or employment status, mo- ized controlled clinical trial. The strength of an
tives for enrolling in the trial, and too little RCT for comparing the efficacy of treatments
time spent with the study clinician. is threefold: (1) the use °f methodologies to
Minimizing patient loss from a trial has be- control and/or eliminate biases from a variety
come particularly important since the principle of sources; (2) the collaboration of clinical in-
of intention-to-treat (ITT) has gained investigators and biostatisticians in the planning
creased acceptance by methodologists and reg- and performance of the trial; and (3) the ad-
ulatory agencies. Bias may be introduced if herence to previously agreed on protocols.
some patients who were randomized to treat- Certainly, there are circumstances that would
ment are excluded from the statistical analysis, prohibit the use of an RCT, but the RCT still
or if patients are not analyzed as though they remains the strongest method for comparing
belong to the treatment group originally in- the efficacy of treatments. The RCT is an un-
tended by the randomization procedure. Pa- usually reliable method for learning from ex-
tients should be carefully identified, as in perience. Its success comes from structuring
Table 2, before final statistical analyses are un- that experience so as to eliminate many of the
dertaken. For the UNC trial, the ITT popula- sources of ambiguity apparent in other re-
tion was defined as all patients who had been search designs.5
randomized and who previously had baseline
measures taken. The "efficacy analyzable" References
population represents the patient group of the
most clinical interest because these are the pa- 1. Tulloch JFC, Medland W, Tuncay OC. Methods used
to evaluate growth modification in Class II malocclu-
tients who had both baseline and end of phase sion. Am J Orthod Dentofacial Orthop 1990;98:340-
I measures. Gillings and Koch27 recommend 347.
that the ratio of the number of ITT patients, 2. Johnston LE, Paquette DE, Beattie JR, et al. The re-
those with at least one data collection visit, duction of susceptibility bias in retrospective compar-
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isons of alternative treatment strategies, in Vig KD, sessment of recruiting strategies. Control Clin Trials
Vig PS, eds. Clinical Research as the Basis of Clinical 1993;14:38S-51S.
Practice. Ann Arbor, MI, Center for Human Growth 17. Bjornson-Benson WM, Stibolt TB, Manske KA, et al.
and Development, University of Michigan, 1991; 155- Monitoring recruitment effectiveness and cost in a
178. clinical trial. Control Clin Trials 1993;14:52S-67S.
3. Sackett DL. Bias in analytic research. J Chron Dis 18. Ingelfinger JA, Mosteller F, Thibodeau LA, et al. Bio-
1979;32:51-63. statistics in Medicine. New York, NY, Macmillan Pub-
4. Hennekens CH, Buring JE. Epidemiology in Medi- lishing Co, 1987;245-261.
cine. Boston, MA, Little, Brown, 1987; pp 272-286. 19. Guyatt GH, Sackett DL, Cook DJ. Users' guide to the
5. Committee for Evaluating Medical Technologies in medical literature II. How to use an article about ther-
Clinical Use. Assessing Medical Technologies, Wash- apy or prevention A. Are the results valid? JAMA
ington, DC; National Academy Press, 1985; pp 70-79. 1993;270:2598-2601.
6. Streptomycin in Tuberculosis Trials Committee, Med- 20. Pocock SJ. Statistical aspects of clinical trial design.
ical Research Council. Streptomycin treatment of pul- The Statistician 1982;31:1-19.
monary tuberculosis: A Medical Research Council in- 21. Therneau TM. How many stratification factors are
vestigation. BMJ 1948;2:769-782. "too many" to use in a randomization plan? Control
7. Warren KS, Mostellar F. Doing more good than harm: Clin Trials 1993;14:98-108.
The evaluation of health care interventions. Ann N Y 22. Kalish LA, Begg CB. Treatment allocation methods in
AcadSci 1993; 703:1-43. clinical trials: A review. Stat Med 1985;4:129-144.
8. Passamani E. Clinical trials—Are they ethical? N Engl 23. Freiman JA, Chalmers TC, Smith H Jr, et al. The
J Med 1991 ;324:1589-1592. importance of beta, the type II error, and sample size
9. Wortman PM, Yeaton WH. Using research synthesis in the design and interpretation of the randomized
in medical technology assessment. Int J Technol As- controlled trial, In: Bailar JC III, Mosteller F, eds.
sess Health Care 1987;3:509-522. Medical Uses of Statistics. MA: NEJM Books, 1986, pp
10. Colditz GA, Miller JN, Mosteller F. How study design 289-304.
affects outcomes in comparisons of therapy I: Medi- 24. Mills JRE. Clinical control of craniofacial growth: A
cal. Stat Med 1989;8:441-454. skeptic's viewpoint, in McNamara JA, Ribbens KA,
Howe RP, editors. Clinical Alteration of the Growing
11. Miller JN, Colditz GA, Mosteller F. How study design
Face. Ann Arbor, MI, Center for Human Growth and
affects outcomes in comparisons of therapy II: Surgi-
Development, University of Michigan, 1983, pp 17-44
cal. Stat Med 1989;8:455-466.
25. Goldman JF, Holcomb R, Perry HM, et al. Can drop-
12. Rubins HB. From clinical trials to clinical practice: out and other noncompliance be minimized in a clin-
Generalizing from participant to patient. Control Clin ical trial? Report from the Veterans Administrative
Trials 1994; 15:7-10. [sic] National Heart, Lung, and Blood Institute Coop-
13. Davis CE. Generalizing from clinical trials. Control erative study on antihypertensive therapy: Mild hy-
Clin Trials 1994; 15:11-14. pertension. Control Clin Trials 1982;3:75-89.
14. Bailey KR. Generalizing the results of randomized 26. Orr PR, Blackhurst DW, Hawkins BS. Patient and
clinical trials. Control Clin Trials 1994; 15:15-23. clinic factors predictive of missed visits and inactive
15. Simon L, Lowe B, Phillips C, et al. Defining Class II status in a multicenter clinical trial. Control Clin Trials
malocclusion by cephalometric or clinical measures. J 1992;13:40-49.
Dent Res 1992;7l:27l (abstr). 27. Gillings D, Koch G. The application of the principle of
16. Connett JE, Bjornson-Benson, Daniels K. Recruit- intention-to-treat to the analysis of clinical trials. Drug
ment of participants in the lung health study II: As- InfoJ 1991;25:411-424.
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Decision Analysis to Optimize the

Outcomes for Class II Division 1
Peter S. Vig and Katherine Dryland Vig
Selection of the treatment method of choice in orthodontics is usually a

question of the clinician's personal preference and is generally based on
subjective criteria. Orthodontic treatment of malocclusions is unlike treat-
ment of a disease and hence terms such as success and failure are relative
and undefined. Ideally, both patients and providers should be able to arrive
at treatment decisions that have the greatest potential for optimum out-
comes at minimal cost and risks. This article applies the method of decision
analysis to demonstrate how policy choices between "one-stage" or "two-
stage" treatment of Class II Division 1 malocclusions for children between 11
and 14 years old can be based on objective criteria. A decision tree was
designed to yield the value of payoffs, or outcomes, at each of the possible
terminal nodes, and the probability of each payoff. Both positive (ie, im-
provement in malocclusion) and negative (ie, extraction of teeth and long
treatment duration) attributes of outcomes were considered, and numerical
values, or "utilities," were assigned to each outcome. For this model, one-
stage nonextraction treatment yields the highest probability of maximum
benefit. Further applications of decision analysis to resolve clinical uncer-
tainties in orthodontics are discussed.
The treatment of Class II malocclusion var-ical considerations involved in the application

ies depending on the age of the patient, of clinical research methods derived from
the experience and training of the clinician, medicine to evaluate the clinical management
the desires, concerns, and expectations of the of malocclusion. Because health services re-
patient, and other clinician- and patient- search methods have only recently been intro-
related variables. In an attempt to rationalize duced to orthodontics, there is an understand-
the treatment decisions, a methodological ap- able tendency to fit such existing methodology
proach to determine optimal clinical strategies to orthodontic issues, even if some of the study
is proposed. methods are not designed for the unique prob-
The ensuing discussion extends the theme lems of a service such as orthodontics, which
from the application of decision analysis to some dispute as even falling within the realm
some more general issues, such as the theoret- of health care. The facts that malocclusion is
not a disease, is not definable by a gold stan-
dard, is not a biologically abnormal state, and is
From the Center for Health Policy Studies, Section of Com-
not a condition with any unequivocally demon-
munity Dentistry, College of Dentistry, Ohio State University, Co-
lumbus, OH. strable health consequences, need to be taken
Supported by National Institutes of Health/National Institute into account when clinical study designs are
of Dental Research, Bethesda, MD, Grants No. DE 09883 and adopted. This is especially pertinent if the
DE 06881. rigor of the design, and, therefore, its value,
Address correspondence to Peter S. Vig, BDS, PhD, Section of
lies in the application of rigorous criteria that
Health Services Research, College of Dentistry, The Ohio State
University, 305 W 12th Ave, Columbus, OH 43210-1241. in medical models permit a systematic control
Copyright © 1995 by W.B. Saunders Company of methodological biases, but that in orthodon-
1073-8746I95I0103-0003$5.00IO tics do not actually exist.
Seminars in Orthodontics, Vol ly No 3 (September), 1995: 139-148 139

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140 Vig and Vig
A variety of alternative strategies exist for fits, and risks. Thus it recognizes and takes into
the treatment of Class II Division 1 malocclu- account the existence of trade-offs between
sions in growing children. Fundamental and positive and negative attributes of treatment.
mutually exclusive treatment decisions con- Before the use of the decision analysis ap-
cerning one-stage versus two-stage treatment proach, orthodontic treatments have generally
as well as extraction versus nonextraction ap- been compared according to a methodological
proaches are routinely made. These clinical paradigm that has so far failed to provide de-
choices are based entirely on operator prefer- finitive and generally accepted conclusions on
ences, which in turn are founded on cumula- any of the controversies regarding the relative
tive subjective clinical impressions and/or the superiority of any valid choices that confront
training of the practitioner. Although all con- orthodontists. This is probably why orthodon-
temporary treatment methods in widespread tic controversies have such long histories, and
use clearly work some of the time, it is so far continue to be recycled as each generation of
uncertain whether any approach provides pa- practitioners rediscovers alternatives, finds
tients with significantly better outcomes. Of new leaders, and seeks these authorities' reas-
equal importance for both providers and con- surance for the idiosyncratic views embodied
sumers is the relative predictability of degrees in the competing schools of thought, or philos-
of success and the relative risks of undesired ophies. Far from adding legitimacy to the doc-
attributes of both orthodontic treatment pro- trine embodied in these philosophies, such
cess and its sequelae or outcomes. misuse of the term merely reveals these ideas
The primary purposes of this article are to as belief systems or, at best, as quasi-codified
introduce the application of decision analytic creeds based on untested axioms. Only if we
modeling to orthodontics and to demonstrate are willing to accept that this is a problem can
the usefulness of this method in deciding be- progress be made toward a more satisfactory
tween mutually exclusive strategic options for state of affairs.
the treatment of Class II Division 1 malocclu- It is not suggested that past clinical research
sions. has failed to produce scientific evidence or
some useful information concerning the vari-
ous methods of skeletodental manipulation.
Clinical Decision Analysis We certainly have a large body of verifiable
The method of clinical decision analysis is spe- data on the feasibility and the general plausi-
cifically designed to enhance the odds in favor bility of many, if not all, of the competing clin-
of maximum yields, termed "payoffs," for clinical claims on which orthodontic beliefs rest.
ical strategies when the decisions are taken un- We know that certain biomechanical interven-
der some degree of uncertainty. It is essentially tions can and do produce measurable changes
an application of Bayesian logic and depends in the craniofacial complex. We know that
on the use of prior probabilities and the sub- measurable changes associated with and coin-
sequent probability revisions, when decisions cident to orthodontic-orthopedic force appli-
have chance elements intervening in the pro- cations may influence adaptations in teeth,
cess leading from decision to outcome. Deci- their supporting structures, the skeletal ele-
sion analysis is a statistical process that has ments, and even in the neuromuscular system
been used in economics as well as in medical of the craniofacial region. We are not entirely
applications. The mathematical principles are certain of the precise contributions of treat-
based on the manipulation of probabilities and ment as opposed to growth, maturation, and
the solution of problems, which entail a series aging, but we may safely assume that therapeu-
of contingent probabilities. The formal basis of tic interventions are capable of creating
this probabilistic analysis is rooted in Bayes' changes that are quantitatively greater than
theorem, which is more fully discussed else- those that may, on average, be expected to oc-
where.1 cur without orthodontic intervention. All of
Decision analysis also permits the specifica- this adds up to a degree of biological plausibil-
tion of outcomes with more than one attribute, ity that clinicians can use to support any ther-
and their comparison in terms of costs, bene- apeutic rationale. Such information helps
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Decision Analysis for Orthodontic Outcomes 141
more by providing credibility than by serving Much of the published literature is focused
as the underpinning of any reliable prediction on the comparison of specific dental or skeletal
of outcomes, either on an individual case by changes attributable to alternative treatments.
case basis, or as the argument in favor of one These studies at best can attest to the feasibility
strategy to the exclusion of another. of attaining certain changes that, in some com-
bination, contribute to morphological alter-
ations and so contribute to treatment effects.
Alternative Strategies To evaluate and compare the merits of com-
The methodological paradigm that so far has peting alternatives, it is necessary to establish a
proved to be less than enlightening in terms of valid basis for making such comparisons. Such
issues concerning effectiveness may be charac- a qualitative and quantitative comparison re-
terized as follows. Published comparisons be- quires that we identify measurable outcomes of
tween alternative orthodontic treatments gen- tangible benefit to patients. Therefore, these
erally report mean values and standard devia- attributes of treatment should reflect the utility
tions of some aspect of the effects of treatment. structure of consumers of orthodontics rather
Frequently the variables being compared are than be based primarily on diagnostic criteria
numerous and those that are selected for pub- of orthodontists. Although these may be help-
lication are chosen because they do reveal sta- ful to establish treatment plans and to monitor
tistically significant differences, rather than be- treatment progress, they may not in any way be
ing a priori determinants of a unique feature obvious measures of outcomes valued by pa-
of the condition or the essence of success in tients. Variables such as cephalometric angles
treatment. Examples of such variables are cra- or linear distances and changes in their values
nial base angle or lower face height. Both of relative to some arbitrary standards do not
these variables and others like them are con- concern patients, although they may show ele-
tinuous variables that characterize the entire ments of change over time to the clinicians.
human species, are not unique or pathogno-
monic attributes of a single disease or condi-
tion, and have a distribution that is sufficiently
Orthodontic Outcomes
normal as to preclude their use as diagnostic The distinction between variables that have
tests with clinically useful degrees of accuracy been used in the traditional approach to clini-
for positive or negative prediction. Despite cal research and those deemed useful for our
this, comparisons of treatments, and, there- present day concerns may be understood by
fore, conclusions, are based on such observed their utility for patients. The term "surrogate
measures, which then are tested for statistically endpoints" and its converse, "outcomes with
significant differences to arrive at some con- tangible patient benefits," have gained cur-
clusions regarding the relative merits of each rency in clinical research in medicine. For ex-
treatment. Such comparisons of average treat- ample, treatment aimed at reducing or curing
ment effect, even when a large number of vari- osteoporosis may be evaluated by methods that
ables are combined, do not provide generally determine the appearance of bone by assessing
useful information on the probability of density and thus calcification. Results of such
achieving a predetermined and unambigu- tests yield surrogate endpoints. If the purpose
ously defined treatment effect. Thus, they are of the treatment is to reduce the risk of frac-
limited in their usefulness for making proba- tures, then the outcome of tangible benefit is a
bilistic estimates that apply either to individual reduction in the incidence of fractures rather
patients or to the expected yield of alternative than the density of bone. Although the surro-
policies. Another shortcoming of the tradi- gate is a marker that can be correlated to some
tional decision making logic resides in the fail- extent with fractures, it is merely an estimate
ure to define attributes of outcomes that are and does not in and of itself produce the de-
both positive and negative. Without consider- sired effect in terms of patient benefit.
ing the undesired aspects of both process and The dental literature, especially that of
outcomes, it is impossible to determine what orthodontics, is replete with surrogate out-
trade-offs are implicit in any clinical decision. comes. One reason for this is that it is ex-
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142 Vig and Vig
tremely difficult to define tangible benefits at least take into consideration the following
accruing from orthodontic treatment. Com- factors:
monly used "surrogates" for deciding out-
(1) reduction in the severity of malocclusion,
comes of tangible benefit to consumers in-
(2) loss of healthy teeth as a part of the "orth-
clude cephalometric parameters or measurable
odontic burden" to the patient,
component features of malocclusion, such as
and (3) overall duration of treatment, which is
the millimeter magnitude of overjet or degree
another "cost" to both provider and
of crowding. Perhaps at this stage it is fair to
patient.
assume that patients who accept orthodontic
treatment do so because they expect to have Although we recognize that patient satisfac-
their teeth "straightened." In spite of all other tion and other considerations of a psychosocial
claims for orthodontically produced benefits nature also may be quite relevant, at this junc-
regarding predictable alterations in faces, the ture we confine our example of decision anal-
consequent enhancement of the quality of life, ysis to those variables for which we have reli-
the longevity of dentition, or the general able data.
health considerations, incontrovertible evi- A decision analysis model was developed us-
dence does not exist that all or any of these ing a commercially available software package
intangibles are realistic and predictable conse- (DATA 2.5.3, by TreeAge Software, Inc., Bos-
quences of orthodontics. Certainly no data to ton, MA) to construct our decision tree. This
the contrary exists, nor have suitable instru- program is also capable of testing the model
ments been devised to measure such potential for sensitivity (ie, the robustness of the model
benefits of orthodontics to date. for a range of values used in scaling utilities),
Therefore, the salient question is how do we as well as providing such information as the
define the attributes of treatment that would probability density of various payoffs at speci-
make one option better than the other? fied decision nodes.
"Which treatment is better?" is by no means a
clear or easily answered question. Materials and Methods
Given that displays of selected cases chosen This application of decision analysis was per-
for demonstrations of clinical competence may formed to compare the outcomes of treatment
include esthetically pleasing records docu- between one-stage and two-stage treatment of
menting before and after treatment status ob- Class II Division 1 malocclusion. Data were ob-
tained by all currently used techniques, this is tained from a sample of 500 Class II Division 1
clearly not a suitable basis for determining patients aged 11 through 14 years who were
which is best. Other equally unsatisfactory previously treated at the University of Pitts-
bases for comparison may be cited and be re- burgh's Orthodontic Department. A more
sponsible for the unresolved questions that comprehensive description of the entire study,
both providers and consumers may wish to of which this is a part, is provided elsewhere.2
know. However, in the real world not all cases The outcomes that were of interest and con-
are perfect and not all treatment plans work sidered to tangibly impact on patient benefit
out as planned. Therefore, is it of greater in- were (1) treatment duration in months, (2) loss
terest to see which treatment performed by a of teeth, ie, extraction or nonextraction, and
selected clinician, under the most favorable (3) the quality of the orthodontic result as as-
conditions, can produce the best result by any sessed by the percentage reduction in maloc-
single criterion, or which treatment in a real clusion severity using the Peer Assessment Rat-
world setting has the highest probability of ing (PAR) Index, to compare pretreatment
yielding the most benefit for the least cost and and posttreatment occlusions.3 This index has
inconvenience to both patient and provider? been validated for use in the United States,4
and has been recently applied as an objective
The Methodological Approach assessment of the effectiveness of Class II Di-
In general, we favor the "real world" compar- vision 1 treatment.0
ison, and consider that a fair and reasonable Thus, the payoff computed by the model at
comparison between treatment options should each terminal node (Fig 1) was the "orthodon-
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/ 0.16
Short ^rfcceptable ^
0.44 °^N 0.32
^Minimal
:3 0.52
Excellent
,,,,/- Acceptable ...

HH322r i<jj|350 = 350; P = 0.14
.44 \~— 0. ^" '
\Mlnlm
Figure 1. Decision tree

showing the structure of
the decision, probabilities
at the chance nodes (cir-
cles), and the payoffs at
the triangular terminal
nodes. The tree is "solved"
to define the optimum
pathways and their ex-
pected probabilities and
payoffs (ie, values of out-
comes). This model deter-
mines that the one-stage,
n o n e x t r a c t i o n choice
yields that highest ex-
pected values and pro-
vides the pathways' respec-
tive probabilities of attain-
<||170 = 170] ment.
tic value" of treatment, which was deemed to 100% to 90%, PAR reduction ("Excellent") Ar-
be the improvement in malocclusion as deter- bitrary Value = 500; 75% to 89%, PAR reduc-
mined by the percent reduction in PAR score, tion ("Acceptable") Arbitrary Value = 400;
which was in turn potentially diminished by and less than 75%, PAR reduction ("Minimal")
the extraction of permanent teeth and by the Arbitrary Value = 300.
duration of treatment if it was categorized as Values can also be arbitrarily assigned to the
"long." other intermediate variables, which in fact can
Relative frequency data and absolute values detract from the overall value of the desired
of the variables were obtained from the outcome, as follows: extraction Arbitrary
records of the treated cases. These served to Value = —50; nonextraction, Arbitrary Value
determine relative probabilities at the chance = 0; short duration treatment, Arbitrary
nodes of the model. Value = 0; and long duration treatment (>24
To calculate the "orthodontic values," we se- months), Arbitrary Value = —50.
lected the following cutoffs and utilities (ie, val- Treatment decisions made at the "decision
ues) for improvement of malocclusion severity: nodes" were one of the following: (1) do not
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144 Vig and Vig
treat; (2) treat using a one-stage approach; or One stage

(3) treat using a two-phase approach. The
treatment pathways were dichotomized for ex-
traction and nonextraction decisions. Relative • Two Stage
frequencies of treatment results (excellent, ac-
ceptable, and minimal) reflect the PAR scores
of the 500 cases.
The values at the terminal nodes repre-
sented by the triangular nodes at the end of
each possible pathway range from 120 to 500.
These numbers represent the minimum and
maximum payoffs in terms of orthodontic B
value for patients and are based on both posi-
tive and negative attributes of outcomes. The P Threshold Values:
values indicate the relative probability of the Excellent = 615
CD
specified payoff if the decision pathway is ad- >
hered to in practice.
The decision tree created by this process
was solved for optimum outcomes and for the
relative probability of each possible outcome.
Long Tx
Sensitivity analyses are also shown (Fig 2) for
the effect of varying utility scales on the deci-
sion analysis results. The probability distribu- Figure 2. Decision analytical models are susceptible
tion of payoff values for one-stage and two- to assumptions such as the assigned value of (A)
stage treatment strategies is also presented in "minimal," and (B) "excellent." The robustness of
Fig 3. the conclusions based on assigned values or utilities
here exemplified by the quality of orthodontic re-
sults "excellent" v ("minimal") may be tested for a
Results range of values of another variable shown here on
the x-axis. The sensitivity analysis shows that for the
A number of results are evident from inspect- entire range of observed values and a wide range of
ing the solved tree. Among the more interest- assigned values for "minimal" and "excellent" the
ing and possibly important ones are the follow- optimal strategy remains as defined by the decision
analysis model.
ing:
(1) The solved tree indicates that the optimum variably achieving complete reduction of mal-
treatment choice for 11 to 14-year-old chil- occlusion with any method is unwarranted,
dren with Class II Division 1 malocclusion and should not be the basis for comparing
is "one-stage" treatment. This give the best treatment methods. It would seem prudent to
chance of obtaining the highest positive recognize the probabilistic nature of orthodon-
value for the most patients. tic results.
(2) The relative probabilities of obtaining ex- (3) Figure 2a and 2b are examples of sensitiv-
cellent, acceptable, or minimal improve- ity analyses. These two examples show the
ment (0.16 v 0.32 v 0.52) show that com- robustness of the model for a wide range
parisons of orthodontic alternatives should of values arbitrarily assigned to the relative
not be based on the best that a particular values of both excellent and minimal im-
treatment can produce. In fact, the best or provements in terms of percentage reduc-
near perfect result (>90% reduction in tions in PAR scores.
malocclusion severity, as measured by (4) The cumulative probability distribution
PAR) is rather rare. (Fig 3) may be used to estimate the likeli-
This is seldom taken into consideration by hood of attaining a given value of the pay-
those interested in comparing alternative offs or, in this case, that the orthodontic
methods of treatment. The assumption of in- value of outcomes will be at least a certain
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0.9-
0.8-
0.7-
5V6-
I°' 5 -
•g 0.4-
Q. 0.3-
0.2-
0.1-
0.0-
110 150 190 230 270 310 350 390 430 470 510 70 110 150 190 230 270 310 350 390 430 470 510
Payoff Values Payoff Values
Figure 3. The program provides both individual probability distributions of expected payoff values (A) and
the cumulative probability distributions (B) of payoff values for the whole model. These are presented in the
form of histograms.
quantity, providing that the assumptions of The essentials of clinical research methodology
the model are correct. are now well accepted and qualitative criteria
do exist to judge the soundness of conclusions.
Discussion However, some fundamental and possibly
unique problems do exist in regard to orth-
The above example of decision analysis has odontic research. The lack of strict equivalence
used a scaling of values for the three attributes between "malocclusion" and "orthodontics" on
of treatment (quality, duration, and extrac- the one hand, with "disease" or a definable
tions), which was based on the opinion of 10 "condition" and "treatment" in the medical
orthodontists. It is entirely possible that a pop- sense, should not be treated merely as a minor
ulation of patients may have different values, inconvenience. It has been argued that orth-
and that the relative scores for the three levels odontics is no different from any other treat-
of orthodontic results, the extraction of teeth, ment. One argument 6 recently proposed is
and the long duration of treatment may there- that the gold standard for resolving clinical
fore differ from our arbitrarily assigned controversies in obstetrics is the randomized
scores. This in no way negates the decision clinical trial. As obstetrics deal with pregnancy,
analysis approach but merely recognizes the which like malocclusion is also not a disease, it
need for studies that directly assess the con- follows that the best way to study the effective-
sumers' value structures. Such studies, which ness of alternative orthodontic approaches is
are currently in progress, are essential if the also the randomized clinical trial. From this
ultimate goal of achieving agreement between one may also argue that the application of any-
patients' and providers' value systems is to be thing other than the presumptive gold stan-
attained. dard of clinical studies is to be avoided. This
This article is based on a presentation enti- line of logic is incorrect in both its premise and
tled "Problems With Clinical Trials When its conclusion. The argument fails to recognize
There Is No Disease," which was an oral con- that complications of pregnancy, whether iat-
tribution to the 1994 National Institute for rogenic or not, are not all that rare, and al-
Dental Research/International Association for though pregnancy in itself is not a disease, its
Dental Research (IADR)—sponsored sympo- natural course or its clinical management can
sium, "Clinical Trials in Orthodontics: Chal- produce unequivocally demonstrable morbid-
lenges in Design and Outcomes Assessment." ity or even mortality. This permits the anchor-
Selection of the original title was not intended ing of scales of outcomes at well-defined ex-
to be contentious or cute, but rather to stress a tremes, with tangibly different values at the ex-
generally ignored and somewhat inconvenient tremities of such scales so that patients risk
fact concerning orthodontic clinical research. aversion and values may be derived. Obstetri-
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146 Vig and Vig
cally pertinent outcomes may range from life method on orthodontic problems may result in
to death and tradeoffs can be critically signifi- the mixture of a strictly scientific procedural or
cant. Nothing in orthodontics comes even close experimental protocol with loose definitions of
to being analogous to such a condition. variables and the selection of variables princi-
At the two most recent I ADR (1994) and pally to fit the study design, rather than ad-
American Association for Dental Research dressing the most salient attributes of orth-
(1995) symposia, considerable discussion fo- odontic process or outcomes. In the final anal-
cused on methodological issues and, in partic- ysis, the results of even the most carefully
ular on whether randomized clinical trials were crafted of such research efforts could be pre-
essential, suitable for, or cost-effective, enough dictably disappointing. Therefore, it is possible
to address orthodontic controversies. Argu- that some medically valid clinical research
ments for and against the cost effectiveness of methods need to be applied, but with suitable
retrospective versus prospective studies were provisos appropriate to the unique nature of
made. It is a matter of some concern that per- orthodontics.
haps the strongest argument for randomized An example of an inherent pitfall in clinical
clinical trials in orthodontics is that the method orthodontics, one already discussed under the
is so well respected in areas quite remote from topic of surrogate outcomes, is the use of ceph-
our own that, therefore, it must, or at least alometric measures as variables to denote
ought to, be our method of choice also. treatment needs and goals, and hence as crite-
To date, little of this dialogue has reached ria for success in defining outcomes. Cephalo-
the published literature. There are clearly two metric features are measurable, generally rep-
opposing views being promulgated among resent continuous variables, and can be sub-
those working in clinical research in orthodon- jected to reliability testing. All of which makes
tics. The argument is important and timely. them very attractive and "suitable" in the sta-
Although raising this topic in the discussion of tistical framework of clinical research. The
this article may appear to represent a digres- problems deal not with the precision of such
sion, an awareness of the nature and the con- measures but rather with their interpretation
sequences of this debate should be publicized and external validity.
widely. It seems certain that the unresolved de- Malocclusion is not a disease nor an abnor-
bate regarding methodology is likely to have mal condition. No universally accepted gold
effects on both current and proposed research standard exists to serve as an unambiguous re-
in clinical orthodontics. That such work should search inclusion criterion, nor for specifying
be done and strongly encouraged is important. unequivocal treatment "need" or "success." In
The plea is for a moratorium on making human populations, acceptable ranges of both
definitive judgments as to the debate over pro- "normal" and "ideal" skeletodental configura-
spective versus retrospective methods, ran- tion and facial appearance exist, although
domized trials versus registries, and so forth, these are not uniform globally. They differ by
in orthodontic studies on treatment effective- demography, geography, and with changing
ness. As a profession, we have not yet clearly fashion, over time. Classification schemes for
defined, formulated, or prioritized the most malocclusion are topological in nature and do
important questions. We do not yet know the not correspond to disease progression or dif-
best approach to the quantification of the key ferentiable severity of conditions. Class II mo-
variables, and we can not yet begin to make lar relations are not inherently worse or better
comparisons between the cost effectiveness in than either Classes I or III, and a 4-mm overjet
terms of societal benefits of any research meth- is not twice as "bad" as one of 2 mm. Such
odology as it pertains to orthodontics. Perhaps orthodontic classification schemes have noth-
this is the time for encouraging projects of var- ing in common with, for example, the staging
ious types and for their subsequent evaluation schemes used to classify malignancies. These
in terms of their respective advantages. attributes of malocclusion and orthodontics se-
Randomized clinical trials are excellent tools verely limit both reliability and validity in clas-
but are not necessarily applicable to or appro- sification, as well as the establishment of mu-
priate for all clinical issues. Forcing this tually exclusive categories on which outcomes
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may be anchored. In malocclusion we deal with trials, and should also be capable of quantifi-
arbitrary cutoffs, which can operationally per- cation. The nature of the studies should per-
mit subdivision of a continuum, but that do not mit the maximum amount of generalizability
correspond with any health consequences that to the real world setting. Such outcomes
correlate with these nominal scales selected for should also be presented in terms of the prob-
descriptive purposes. abilities of their attainment under specific con-
Given such limitations inherent in the na- ditions. If these evaluations of effectiveness for
ture of, and virtually unique to, orthodontic various treatments are reliable and valid, such
clinical research, we should critically consider research should contribute to the elimination
if the canons of medical clinical research meth- of the less effective and costly treatments, in
odology are in their entirety appropriate for favor of those that work best.
orthodontics without some careful reconsider- In the long term, the type of information
ation of the purpose behind the methodology. that will be the most compelling will probably
The very essence of clinical research design come from population-based studies. The cur-
targets the issue of bias. Uncontrolled bias con- rent status may simply be evolving methodol-
tributes to erroneous conclusions, imprecise ogy and refining the questions that will ulti-
inferences, and a general lack of value of the mately be the focus of orthodontic clinical re-
research endeavor. Essential conditions for search.
controlling bias are as follows: the specification
of inclusion and exclusion criteria, which must
be explicit and rigid; outcomes and end-points Conclusions
that are unambiguous; and both dependent This article shows the application of decision
and independent variables that have to be pre- analysis as a method with the potential to re-
cise measures or categorically unique features solve some long-standing clinical uncertainties,
pertaining to the patient and the condition. especially as they pertain to the choice of treat-
These strictures virtually define scientific rigor ment for Class II Division 1 malocclusion in
in clinical epidemiology, but for the reasons children 11 to 14 years old.
stated above they cannot be entirely replicated Results indicate that given data from clinical
in orthodontic research. studies, it is possible to assess utilities to attri-
Many of those engaged in clinical research butes of outcome and to develop models that
in orthodontics recognize these problems at an allow for the inevitable tradeoffs that charac-
intellectual level. However, on the practical terize all clinical treatment.
level, there is a tendency to believe that if the Furthermore, the prediction of orthodontic
experimental design and protocols borrowed clinical outcomes may be systematically evalu-
from medicine are sufficiently rigorous, for ated and probabilities can be calculated for sin-
example, in a well-constructed randomized gle and multiple attribute outcomes at any
clinical trial, then these orthodontically condi- level of value from the best to the worst.
tioned imperfections in classification and the The method lends itself to systematic com-
less than precise definitions or validated fea- parisons between alternative clinical strategies
tures of process or outcome variables will all be and may also be adapted for use in quality as-
washed out and overcome by the strength of surance programs.
the method. This is somewhat analogous to ap-
plying a potent and highly effective remedy—
for the wrong illness. The method is great but References
the results may be disappointing. 1. Weinstein MC Fineberg HV. Clinical Decision Analy-
The results of clinical trials in particular and sis. Philadelphia, PA: Saunders, 1980.
health services research in general should in- 2. Vig KWL, Bennett ME, O'Brien K, et al. Orthodontic
form practitioners, and thereby yield treat- treatment: Outcome and effectiveness. In: Trotman
ments that provide the maximum in tangible CA, McNamara JA editors. Orthodontic Treatment:
Outcome and Effectiveness. Vol 30. Center for Hu-
benefits to patients while reducing costs and man Growth and Development, Craniofacial Growth
risks to the minimum. Outcomes should be ex- Series. Ann Arbor, MI: The University of Michigan,
pressed in terms that are comparable across 1995,pp 227-254
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148 Vig and Vig
3. Richmond S, Shaw WC, Stephens CD, et al. The PAR tiveness of Class II Division I treatment. Am J Orthod
index, reliability and validity. Eur J Orthod 1992; 14: 1995; 107:329-334.
125-139. 6. Sackett DL. Nine years later: A commentary on revis-
A ~ ^
4. DeGuzman i Bahiraei
L, r> u- • r^ D, \T-
Vig T7x*n
KWL, et al. j -ru r
The vah- * tm&g tne _Movers
. ' .. Symposium.
' Jl , . In:. Trotman
_ CA,' Mc-
XT
j . ri_r» A r» • ' • j r i Namara IA editors. Orthodontic Treatment. Out-
dation or the Peer Assessment Rating index tor mal- , T,rr _. . rt^ ^
, . . . j-rr- i A T come and Effectiveness, Vol 30. Center for Human
occlusion seventy and treatment difficulty. Am I „ , . _^ . r> . _ . . _ , 0
Ôrthod
u j 199D;
mn- IAT 1*70 ITC
107:172-176. ' Growth. and. Development,
, .;. _, Cramofacial
... . Growth
_ _,. . . Se-
nes. Ann Arbor, MI: I he University or Michigan,
5. O'Brien KD, Robbins R, Vig KWL, et al. The effec- 1995, pp 1-5.
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Temporomandibular Disorders After Early

Class II Treatment With Bionators and
Headgears: Results From a Randomized
Controlled Trial
Stephen D. Keeling, Cynthia W. Garvan, Gregory J. King,
Timothy T. Wheeler, and Susan McGorray
Symptoms and signs of temporomandibular disorders were assessed in chil-

dren enrolled in a randomized controlled trial of early treatment for Class II
malocclusion. Children (mean age of 9.8 years) were assigned to a treatment
protocol (bionator, n = 60; observation, n = 60; headgear/bite plane, n = 71)
using randomized block stratification. Temporomandibular joint (TMJ)
sounds, joint capsule pain to palpation, and muscle pain to palpation were
scored as binary responses (present/absent in a subject). Determinations
were made by blinded, calibrated examiners initially (DC1) and after a Class
I molar correction was achieved or 2 years had elapsed (DCS). Univariate
relationships among explanatory factors (group assignment, gender, age,
time interval between DC1 and DCS, Class II severity, mandibular plane
angle, preparatory treatment, whether Class I molar relation was achieved)
and binary responses were explored using Chi square tables and ANOVA
methods. Logistic regression modeled the relationship between binary re-
sponses and the explanatory variables. At DC1, the 3 groups were equiva-
lent in the explanatory variables (P > .05). Subjects with a TMJ sound, joint
pain, and/or muscle pain at follow-up were more likely those who had the
sign at baseline (P < .01). Early treatment with bionators and headgear/bite
planes did not place healthy children without these signs at risk for devel-
oping these signs. Only increasing age (for the development of sounds, P <
.04) and failure to achieve a Class I molar relation (for development of mus-
cle pain, P < .04) placed sign-free children at greater risk. Subjects with TMJ
pain at baseline were 7 times more likely to have pain at follow-up if they
had been treated with a headgear/bite plane or observed than if they had
been treated with a bionator (P = .007). We conclude that an immediate
benefit or risk for children receiving early Class II treatment with bionators
and headgear/bite planes with respect to temporomandibular joint function
does not exist with the prospect that Class II children with TMJ capsule pain
may benefit from bionator therapy.
From the Department of Orthodontics, University of Florida

The relationships between temporoman-
College of Dentistry, Gainesville, FL. dibular disorders (TMD), malocclusion,
Supported by the National Institute of Health/National Insti- and orthodontic treatment are not fully under-
tute of Dental Research, Bethesda, MD, Grant No. DE08715. stood. Although some suggest that orthodontic
Address correspondence to Stephen D. Keeling, DDS, MS, treatment may induce temporomandibular
Department of Orthodontics, College of Dentistry, University of
Florida, Box 100444, JHMHC, Gainesville, FL 32610-0444.
joint (TMJ) disorders,1"4 other data suggest
Copyright © 1995 by W.B. Saunders Company that orthodontic treatment of malocclusions
1073-8746/95/01 03 -0004$5.00/0 may actually prevent the development of dys-
Seminars in Orthodontics, Vol 1, No 3 (September), 1995: pp 149-165

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150 Temporomandibular Disorders and Early Class II Treatment
function. 5-7 In contrast to these views, the clusal scheme does not increase risk of hav-
prevalence of signs and symptoms of mandib- ing TMD signs and symptoms.
ular dysfunction in subjects treated with either 7. No method of TMD prevention has been
functional or fixed appliances have been demonstrated.
found to be similar to those in untreated indi- 8. Simple treatments can alleviate severe TMD
viduals,8'9 suggesting neither a risk nor a ben- signs and symptoms in most patients.
efit.
Previous orthodontic research has exam- Similar conclusions have also been reached
ined the relation between signs and symptoms by others.10
of dysfunction and morphologic malocclusion; Most of these conclusions are not supported
from these epidemiological studies it is gener- by longitudinal data from well-designed stud-
ally acknowledged that the relationship be- ies, which examine mandibular dysfunction
tween temporomandibular disorders and oc- and various orthodontic treatments. 12 The
clusion, albeit significant, is neither simple, fre- purpose of this article is to present data that
would examine the immediate functional out-
quent, nor dramatic.10 It has recently been
shown in adults that, except for a few occlusal comes of early treatment of Class II malocclu-
conditions (skeletal open bite, overjets greater sions with headgears and bionators, when the
than 6 to 7 mm, centric slides between treatment was initiated during preadolescence
in the mixed dentition.
retruded contact and intercuspal position
greater than 4 mm, unilateral lingual cross-
bites, and 5 or more missing posterior teeth), Methods and Materials
there is a poor association between occlusal fac-
tors and temporomandibular disorders; oc- The experimental design is a prospective, lon-
clusal factors contribute only 10% to 20% to gitudinal randomized controlled trial (RCT) of
identifying TMD patients.11 early treatment of children with a Class II mal-
A consensus about the functional outcomes occlusion. This project began in March 1990
(risks/benefits) of specific treatments does not with the hiring of staff and the identification
emerge from the literature, largely because of and recruitment of subjects. The RCT contin-
the limitations of study design used to answer ues at the time of this writing.
questions about treatment outcomes. 12 ' 13
Subject Screening and Recruitment
However, despite these limitations, a new per-
ception has emerged. This is shown in the con- To identify Class II subjects suitable for entry,
clusions reached by McNararra, Seligman, and a total of 6,428 Alachua county school children
Okeson14 in an excellent review (with 110 ref- were examined in their own school during
erences), which examines the issues of occlu- years 1, 2, and 3. Of these, 1,207 children
sion, treatment, and temporomandibular dis- (18.8% of the screened children) were identi-
orders: fied as possible subjects, notified of the study,
and, along with a parent, invited to our re-
1. Signs and symptoms of TMD occur in search clinic for reexamination and recruit-
healthy individuals. ment.
2. These increase with age, particularly during
adolescence. Inclusion and Exclusion Criteria
3. Adolescent orthodontic treatment generally Children were targeted for inclusion if they
does not increase or decrease the odds of met the following criteria: presently attending
developing TMD later in life. the third or fourth grade in school; bilaterally
greater than or equal to 1/2 cusp Class II mo-
4. Extraction treatment does not increase risks
lars, or one side less than 1/2 cusp Class II, if
of TMD.
the other side is greater than 1/2 cusp Class II;
5. There are no differences in risk for TMD fully erupted permanent first molars; emer-
among different types of orthodontic me- gence of not more than 3 permanent cuspids
chanics. or bicuspids; and, positive overbite and over-
6. Not achieving a specific gnathologic oc- jet.
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Keeling, Garvan, King, et al 151
Subjects were excluded if they did not meet mandibular plane angle (SN/Mand Plane),
the following criteria: willingness to undergo measuring low (<30°), normal (30° to 40°), or
orthodontic treatment/observation for 2 years high (>40°); race, either black or non-black;
or less, followed by 6 months of retention/no and sex, in cases where the mandibular plane
retention, and an additional 6 months of fol- angle is greater than 40°.
low-up; willingness to be randomly assigned to Subjects were initially selected in blocks of
an observation, bionator, or headgear group six and randomized into the treatment proto-
and, if assigned to a treatment group, to be cols described. The procedure of waiting to as-
randomly assigned to a retention or no reten- sign subjects to groups only after a block had
tion group after treatment; good general been filled was modified in the third year after
health, free from systemic pathology/dysfunc- we recognized the slow entry rate and the
tion requiring continued supervision by a phy- many partially filled blocks. Subsequently, chil-
sician; an absence of active dental or periodon- dren (representing 23% of the total sample)
tal pathology; and willingness to sign informed were randomized to group from incompletely
consent. filled blocks.
Orthodontic Records Study Stages and Data Collection and
After obtaining informed consent, routine Treatment/Observation Appointments
orthodontic records were taken. These in-
cluded the following: a clinical examination; After being assigned to a treatment group and
medical and dental histories; maxillary and any preparatory treatment/observation, there
mandibular dental impressions; centric occlu- were three necessary stages for patients: Class
sion bite registration; lateral cephalometric, II early treatment, retention/non-retention,
panoramic, and hand-wrist radiographs; and and follow-up. Each subject passed through
facial and intraoral photographs. Stratification each stage with data collection (DC) occurring
was based on findings from the clinical exam- as indicated in Figure 1.
ination, dental cast, and lateral cephalometric Class II treatment/observation (Stage 2)
records. ended when two orthodontists independently
agreed within a three-month interval that at
least a bilateral Class I molar relation existed or
Randomization to Group 2 years had elapsed from the start of treat-
A stratified block randomization procedure ment. Stage 3 (retention/non-retention) and
was used to assign a treatment protocol to each
subject. Each subject had an equal likelihood of
assignment to observation, retention, or no re-
tention groups. In addition, for those subjects
assigned to either retention or no retention, it
was equally likely that they would be assigned
to either treatment with a headgear/maxillary
retainer with bite plane or treatment with a
bionator.
Strata were defined by: the severity of Class
II malocclusion, either mild (bilateral 1/2
cusp), moderate (one side > 1/2 cusp, but not
bilateral full cusp), or severe (bilateral full
cusp); the need for preparatory treatment/
observation because of the need for maxillary
incisor alignment to produce overjet equal to
or greater than the greater molar discrepancy
(only subjects assigned to treatment received
this, if necessary), posterior cross bite correc- Figure 1. Overall protocol for each subject in the
tion, incisor eruption, or habit cessation; the clinical trial.
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Stage 4 (follow-up) were fixed 6-month inter- orthodontists until the DC3 appointment, after
vals. active treatment, to avoid any possibility for
The headgear group received a cervical over-treatment in the non-retained subjects.
(mandibular plane angle [MPA] of ^40°) or This report describes functional outcomes
high-pull (MPA of >40°) headgear strap with at DC3 on all subjects with complete functional
the inner bow attached to maxillary first molar data at DC 1 and DC3 at the time of this report
bands. Each headgear subject also received a in this ongoing RCT. Reports on the effect of
maxillary acrylic bite plane with labial bow and retention and follow-up after early treatment
molar circumferential wires. The anterior bite will be made at the completion of the RCT.
ramp was adjusted to permit posterior erup-
tion in cases with deep overbites. Subjects with Scoring TMJ sound, TMJ Capsular Pain,
ideal overbites (1 to 2 mm) received a bite or Muscle Pain
plane without an anterior bite ramp. Subjects
were instructed to wear the acrylic retainer/bite A clinical assessment of signs was performed
plane full-time, removing it for eating, brush- by two examiners, blinded to subject symp-
ing, and contact sports; they were instructed to toms, treatment group status, and data collec-
wear the headgear at least 14 hours a day. tion time point. The assessments included:
Bionator subjects received a bionator to TMJ sounds, TMJ capsular pain in response to
maintain the bite, with occlusal stops for max- palpation, and masticatory muscle pain in re-
illary and mandibular teeth. The construction sponse to palpation.
bite was taken with the mandible advanced ap- TMJ sounds were determined bilaterally by
proximately 3 to 4 mm. Bionators were ad- lightly placing the index fingers over the joint
justed during treatment by removal of poste- and having the patient open and close several
rior acrylic to allow for eruption of mandibular times. TMJ sound was scored if both the ex-
posterior teeth to level the Curve of Spec and aminer and patient could feel or hear a TMJ
establish an ideal overbite. Incremental ad- sound during movement. The distinction be-
vancements of the mandible were made in tween clicking and crepitus was not considered
those subjects who needed more molar correc- for this report, and no attempt was made to
tion than that provided in the initial construc- describe the timing of the TMJ sound during
tion bite. These were performed at chairside the opening and closing cycle. TMJ pain in re-
by the addition of cold cure acrylic. Adjust- sponse to palpation was determined bilaterally
ments to the original bionator for the advance- with the index fingers during maximum open-
ment or posterior eruption were not made un- ing; the lateral, posterior, and superior capsu-
til 3 to 4 months of treatment had elapsed. lar areas were examined. Pain of the mastica-
Subjects were instructed to wear their bionator tory muscles was determined during bilateral
22 hours per day, with removal for eating, palpation with the index fingers at the follow-
brushing, and contact sports. ing masticatory muscle sites: the deep masseter
To control for proficiency bias, each child's inferior to the zygomatic arch, the extraoral
clinic appointments were rotated among the medial pterygoid mass medial to the angle of
four project orthodontists. Children in orth- the mandible, the anterior temporalis, the pos-
odontic appliances were scheduled with each terior temporalis, and the lateral pterygoid in-
clinician every month; children without orth- traorally. Pain was scored as present if palpa-
odontic appliances were scheduled once every tion elicited a palpebral reflex (a facial grimace
3 months. that included closure of the eyes), a withdrawal
All appliances were removed by the clinic response, or an unequivocal statement of pain
dental assistant (a dentist) at each data collec- ("that hurt me"). Equivocal responses, such as
tion appointment before the examiner could "It hurts a little," "I don't like it," "It bothers
obtain any data, and replaced, as necessary af- me," "It's uncomfortable," were scored as no
terwards, so that examiners could be blinded pain.
to treatment group and treatment stage. Re- One examiner performed all of the exami-
tention status was not revealed to the project nations at DC1 and less than 10% of the exams
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at DC3. The second examiner completed the tions: those subjects who were initially ob-
remaining examinations at DCS and beyond. served to show a positive response (sign
present), those who were initially observed to
Data Analysis show a negative response (sign absent), and
Reliability of signs of dysfunction. Reliability of those who were initially observed to show ei-
judging TMJ sounds, masticatory muscle pain, ther a positive or negative response. Consider-
and temporomandibular joint capsular pain ation of the two subsets of the total population
were evaluated by having five examiners, in- was motivated by a desire to investigate the fac-
cluding the two study examiners, indepen- tors that might explain improvement or devel-
dently examine 25 children. Data on TMJ opment of a sign of dysfunction at the follow-
sounds, muscle tenderness, and joint tender- up examination.
ness were examined by site, and also after col- Explanatory factors considered were the
lapsing all sites to reflect the presence or ab- following: sex, age of patient, group assign-
sence of a trait in an individual. Percentage of ment, whether or not pretreatment was re-
pair-wise agreement among pairs of examiners ceived, time between assessments, initial man-
and corresponding Kappa statistics10'16 were dibular plane angle, severity of the initial Class
determined for each site/side and by consider- II molar discrepancy, and whether or not the
ing presence/absence of signs in an individual. subject achieved bilateral Class I molars at the
Relationship among signs of dysfunction. To in- end of treatment or observation. Additionally,
vestigate the relationships among TMJ sounds, for the combined analysis of the total popula-
muscle pain, and joint pain, the binary (pres- tion, initial presence of the sign of dysfunction
ence or absence by subject) responses for each was considered an explanatory factor.
sign were examined, using the initial DC1 data Chi square tables were generated to explore
for 191 subjects. The data were fit using log- univariate relationships among categorical ex-
linear models for categorical data. 17 planatory factors and binary responses. 17
Equivalency of treatment and observation groups ANOVA methods were used to explore uni-
at baseline and between included and excluded sub- variate relationships among continuous ex-
jects. Baseline differences were explored be- planatory factors and the binary responses.18
tween treatment groups to examine initial ho- Logistic regression19 was used to model the
mogeneity of groups. Also, differences were relationship between a response variable and
examined in stratification variables and TMJ the explanatory variables in a multivariate set-
sound presence between those included in this ting. A stepwise procedure was used for vari-
analysis and those subjects, assigned to a able selection, with approximately equivalent
group, whose data were not included (drop- models considered for biological plausibility.
outs, those with an incomplete data set). Strat- The stepwise logistic regression algorithm al-
ification and screening data were available on lows factors to enter the model only if they can
all subjects. further explain the response variable in a sig-
\2 tables were generated to explore univari- nificant (P < .05) way. After a set of main ef-
ate relationships among categorical explana- fect variables was selected for the model, the
tory factors and binary responses for TMJ interactions of these variables were evaluated
sound, joint pain, and muscle pain. 17 ANOVA for possible inclusion in the model using the
methods were used to explore univariate rela- same criteria as the original variable selection.
tionships among continuous explanatory fac- Note that the significant factors in the logis-
tors and the binary responses.18 tic regression model are, in general, a subset of
Impact of treatment on signs of dysfunction. the significant factors identified in the univari-
Three binary (present/absent) responses were ate setting. The results of the univariate testing
considered in this analysis: TMJ sound, TMJ should not, however, be ignored. At the least,
joint pain, and muscle pain. Responses ob- these suggest trends which might be illumi-
served at DCS, the end of the early Class II nated by use of a larger sample or more re-
treatment or observation period, were mod- fined measurement techniques. Additionally,
eled according to inclusion in three popula- correlation between explanatory variables may
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affect their entry into the logistic model; if sim- Reliability of Scoring Signs of
ilar information is provided by two variables, the Dysfunction
addition of one to the model will usually suffice.
The reliability of TMJ sound, joint pain, and
muscle pain by location (Table 1) was poor
Results (median Kappas of -0.06, 0.08, 0.04, respec-
Sample Available for Analysis tively); reliability improved when these TMD
The report includes those subjects with TMD signs were scored as present/absent in a subject
data at DC1 and DCS at the time of this anal- (median Kappas of 0.22, 0.53, 0.56). Because
ysis. A total of 355 subjects, who had previ- of the poor reliability of scoring a sign by spe-
ously been screened by one of the project orth- cific location, the data in this report were col-
odontists in their school, gave informed con- lapsed in each subject at each time point and
sent for the study and had orthodontic records scored as either present or absent. The reliabil-
taken. Twenty-nine of these, after review of ity of the two study examiners (no. 3 and no. 5
orthodontic records, were judged by the proj- in the tables) is indicated and appears accept-
ect orthodontists not to be appropriate for enable when utilizing the latter method by cur-
try in the RCT because they did not meet in- rent standards.20 For the purposes of all fur-
clusion criteria. An additional eight withdrew ther analyses, a subject with 4 painful muscle
after orthodontic records were taken, prior to sites was considered similar to one with 1 or 10
data collection at DC1. These 35 subjects were painful sites, because our data indicate that the
never assigned to a treatment/observation examiners were more reliable when scoring
group. Thus, 320 subjects were stratified to a presence or absence by person rather than by
group, entered the RCT and had data collec- specific location.
tion at DC1. Forty-nine of these dropped out
before they reached DC3 (moved away, ex- Relationship Among Signs of
pense, lost interest). Thirty-nine subjects have Dysfunction
not reached DC3 at this writing and 41 are
missing TMD data at either DC1 or DC3. Based on log-linear model results, TMJ sounds
Thus, this report includes data on 191 subjects. were found to be independent of muscle and
Table 1. Reliability Among 5 Examiners of Determining Presence or Absence of a Sign of Dysfunction
By Site and By Subject in 25 Children
TMJ Sound (Yes/No) By Location (Right Side) TMJ Sound (Yes/No) By Person
Examiner 2 3 4 5 Examiner 2 3 4 5
1 .25 .60 -.12 .36 1 .43 .67 .26 .15
2 -.11 -.09 -.06 2 -.11 .25 -.09
3 -.11 .33 3 .09 .20
4 -.06 4 .25
TMJ Capsule Pain (Yes/No) By Location TMJ Capsule Pain (Yes/No) By Person
1 .09 .26 .08 .04 1 .39 .60 .25 .46
2 .07 .26 .30 2 .38 .67 .66
3 -.04 .17 3 .38 .76
4 .07 4 .69
Masticatory Muscle Pain (Yes/No) By Location Masticatory Muscle Pain (Yes/No) By Person
1 .06 NA .22 .01 1 .67 NA .61 .52
2 NA .01 .53 2 NA .34 .65
3 NA NA 3 NA NA
4 -.07 4 .33
Note. Pairwise Kappa statistics are shown, with 0 representing agreement no better than chance and 1 representing perfect
agreement. No value can be determined if an examiner scores no sign in any subject. The study examiners were no. 3 and
no. 5. Examiner no. 3 examined only 16 subjects in common with the other examiners.
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joint pain, while joint pain and muscle pain cle pain in 36.1%. The population was 62%
were positively associated (x2 for goodness of male. Twenty-nine percent of the population
fit = 3.52, 3 degrees of freedom (df). The odds had a mild (bilateral half cusp) Class II molar
that a subject displayed joint pain were 7.38 relation, 48.7% a moderate one (>half cusp,
times higher for a subject displaying muscle <full cusp), and 22%, severe (bilateral full
pain than for a subject who did not display cusp Class II or worse). Twenty-five percent
muscle pain. The relationships between the (24.6%) of the population was characterized by
three variables are displayed in Table 2. having a low mandibular plane angle, 68.6% a
normal mandibular plane angle, and 6.8% a
Equivalency of Included and Excluded high mandibular plane angle. Thirty-three
Subjects percent of the population received a form of
A comparison of the 191 subjects included in pretreatment (Stage 1 A, before Stage 2, see Fig
the TMD analysis and the 129 subjects not in- 1) orthodontics/observation.
cluded in the TMD sample (drop outs after At baseline, the bionator, headgear/bite
DC1, those not reaching DC3, and those active plane, and observation subjects did not differ
subjects missing either DC1 or DCS TMD data) in age, TMJ sound presence, TMJ capsular
is shown in Table 3. The subjects included in pain presence, muscle pain presence, gender,
this report did not differ at DC 1 (or at screen- Class II molar relation severity, or mandibular
ing) from those not included with respect to plane angle. The bionator and headgear
age, treatment group assignment, mandibular groups were more likely to have received pre-
plane angle, need for pretreatment, Class II treatment than the observation groups as the
severity, gender, or presence of a TMJ sound. observation subjects did not receive pretreat-
ment to reposition (align or flare) maxillary in-
Equivalency of Treatment Groups at cisors to make overjet equal to or greater than
Baseline (DC1) molar discrepancy.
Note that subjects in all groups received
The baseline characteristics of the bionator, "pretreatment" Stage 1A for habit cessation,
headgear/bite plane, and observation subjects posterior crossbite correction, and normal
included in this TMD analysis are presented in completion of incisor eruption, if needed.
Table 4. The average age of the population
was 9.8 (standard deviation [SD] 0.9) years.
TMJ sounds were present in 11.5% of the pop- Impact of Treatment on Signs of
ulation, TMJ capsular pain in 37.7%, and mus- Dysfunction
TMJ capsular pain to palpation. Subjects at the
Table 2. Relationship Between TMJ Sound, TMJ completion of the treatment/observation pe-
Capsular Pain, and Muscle Pain in Subjects at riod at DCS (Table 5) were significantly more
Baseline (DC1)
likely to have joint pain if they had joint pain
TMJ Sound initially at DC1 than if: (1) they did not have
No Yes x2 pain initially (38% v 21%, P = .013); (2) they
had been treated with a headgear or observed,
Muscle pain
No 112 10
versus being treated with a bionator (27% and
Yes 57 12 3.656 1 .056 38% vs. 17%, P = .028); (3) they had not re-
TMJ Sound ceived pretreatment versus having received
No Yes pretreatment (33% v 16%, P = .013); (4) they
Joint pain initially had a moderate to severe Class II mo-
No 107 12 0.637 1 .425 lar relation versus a mild Class II molar rela-
Yes 62 10 tion (32% v 16%, P - .026); and (5) if they
Joint Pain remained Class II rather than converted to a
No Yes Class I molar relation (33% v 19%, P = .032).
Muscle pain Thus, the prevalence of TMJ capsular pain
No 96 26 38.603 1 <.001 was lower following treatment/observation at
Yes 23 46
DC3 for subjects who had no pain at DC1, had
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Table 3. Initial Characteristics of Those Subjects in the TMD Sample (n = 191) and Those Not Included
(n = 129)
Explanatory No. Not Included No. Included
Variable Condition N(%) N(%) x2 P
TMJ sound
at screening No 115(89) 169 (89) 0.006 .939
Yes 14(11) 22(11)
Treatment group Bionator 46 (36) 60(31) 2.047 .359
Observation 45 (35) 60(31)
Headgear/biteplane 38 (29) 71(37)
Mandibular plane angle Low (<30) 32 (25) 47 (25) 0.006 .997
Normal (30-40) 88 (68) 131 (68)
High (>40) 9(7) 13(7)
Needed pretreatment No pretreatment 63 (49) 82 (43) 1.877 .171
Yes pretreatment 66(51) 109(57)
Class II molar severity Mild(l/2c) 27(21) 56 (29) 0.054 .973
Moderate 64 (50) 93 (49)
Severe (full c) 38 (29) 42 (22)
Sex Male 70 (54) 119(62) 2.285 .131
Female 59 (46) 72 (38)
Mean (SD) Mean (SD) T value
Age 9.66(1.01) 9.68 (0.88) -0.127 .899
been treated by a bionator, had pretreatment, Class II molar relation than for a subject clas-
were initially a mild one-half cusp Class II, and sified as having a mild Class II.
had been treated to a Class I molar relation- The odds of joint pain were 7 times more
ship. Presence of capsular pain was not influ- likely for a non-bionator wearer than for a
enced by mandibular plane angle, gender, age bionator wearer if both initially exhibited joint
at DC 1, or length of the interval between DC 1 pain (Table 6). There were no other factors
and DCS. related to the presence of pain at DC3 in those
Results of the logistic regression analysis in- subjects who initially had pain at DC1.
dicated the odds of joint tenderness were 2.3 In those subjects with no initial joint pain
times higher for a subject who had initial joint (Table 7), none of the factors examined in this
pain than for someone who did not, were 2.4 report placed the subject at increased risk for
times higher for a subject in the headgear or pain at DC3.
observation group than for a subject in the TMJ sound. The associations between ex-
bionator group, and 2.3 times higher for a sub- planatory factors and presence of joint sound
ject classified as having a moderate or severe in all subjects at DCS are presented in Table 8.
Table 4. Pretreatment Group Characteristics

Bionator Headgear Observation Total
Characteristic N = 60 N = 71 N = 60 F value P N = 191
Age (years) 9.80(1.10) 9.93 (0.82) 9.71(0.75) 1.010 0.365 9.82 (0.9)
x2 P N(%)
TMJ sound present 8(13) 10(14) 4(7) 2.778 0.249 22(11.5)
TMJ capsule pain present 24 (40) 26 (37) 22 (37) 0.198 0.906 72 (37.7)
Muscle pain present 22 (37) 24 (34) 23 (38) 0.300 0.861 69(36.1)
Gender (no. % male) 38 (63) 41 (58) 40 (67) 1.141 0.565 119(62.3)
Class II severity 2.060 0.725
Mild 18 (30) 22(31) 16 (27) 56 (29.3)
Moderate 26 (43) 34 (48) 33 (55) 93 (48.7)
Severe 16(27) 15(21) 11(18) 42 (22.0)
Mandibular plane angle 2.312 0.679
Low (<30) 12 (20) 20 (28) 15 (25) 47 (24.6)
Normal (30-40) 42 (70) 42 (66) 42 (70) 131 (68.6)
High (>40) 6(10) 4(6) 3(5) 13 (6.8)
Pretreatment (% yes) 27 (45) 31 (44) 5(8) 24.075 0.000 63 (33)
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Table 5. Modeling Presence of Joint Pain to Palpation Following Early Class II Treatment/Observation in
All Subjects (N = 191) at DCS
Explanatory No. (%) with Odds ratio
Variable Condition N pain at DC3 x2 P (confidence limits) P
Pretreatment No pain 119 25(21) 6.158 0.013 2.3 (1.2-4.4) 0.015

(DC1) pain Pain 72 27 (38)
Treatment Bionator 60 10(17) 7.120 0.028 2.4(1.1-5.4) 0.026
Group Headgear 71 19 (27) (bionator v others)
Observation 60 23 (38)
Mandibular Low (<30) 47 15 (32) 0.692 0.405
plane angle Normal or high ^30 144 37 (26)
Received No pretreatment 128 42 (33) 6.115 0.013
Pretreatment Pretreatment 63 10(16)
Class II molar Mild (1/2 c) 56 9(16) 4.975 0.026 2.3 (1.0-5.3) 0.024
severity Mod./severe (>l/2 c) 135 43 (32)
Sex Male 119 33 (28) 0.041 0.840
Female 72 19 (26)
Achieved No (Class II) 112 37 (33) 4.614 0.032
Class I molars Yes (Class I) 79 15(19)
No Pain at DC3 Pain at DC3 T value

N mean (SD) N mean (SD)
Age at DC 1
(year) 139 9.9 (0.9) 52 9.7 (0.8) 1.245 0.215
Time DC 1-3
(month) 139 23.9 (7.8) 52 23.9 (6.9) 0.035 0.972
A higher percentage of subjects with sounds at had a bilateral full cusp Class II molar relation
DC1 compared with those without sounds at at baseline (P = .05). The percentage of sub-
DC1 were found to have TMJ sound at DCS jects with TMJ sound at DCS did not differ
(41% v 9%, P < .001). In addition, subjects according to treatment group, mandibular
with sounds at DCS were older initially than plane angle, pretreatment condition, gender,
those without sounds at DCS (P = .049) and or whether or not a Class I molar relationship
Table 6. Modeling Presence of Joint Pain to Palpation Following Early Class II Treatment/Observation at
DCS for Those Subjects (N = 72) with Joint Pain Initially (DC1)
Variable Condition N pain at DC3 x2 P (confidence limits) Presence
Treatment Bionator 24 3(12) 9.958 0.007 7.0 (1.8-26.6) 0.0019

Group Headgear 26 12(46) (bionator v others)
Observation 22 12(55)
Mandibular Low (<30) 13 7(54) 1.809 0.179
plane angle Normal or high 5=30 59 20 (34)
Class II molar Mild (1/2 c) 19 4(21) 2.979 0.084
severity Moderate severe (>l/2 c) 53 23 (43)
Sex Male 45 19(42) 1.142 0.285
Female 27 8(30)
Achieved No (Class II) 39 18(46) 2.719 0.099
No Pain at DC3 Pain at DCS T value P

Age at DC 1
(year) 45 10.1 (0.9) 27 9.8 (0.7) 1.530 0.131
Time DC 1-3
(month) 45 22.2 (8.2) 27 22.5 (7.8) -0.122 0.904
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Table 7. Modeling Presence of Joint Pain to Palpation Following Early Class II Treatment/Observation at
DCS for Those Subjects (N = 119) With no Joint Pain Initially (DC1)
No variables entered
Treatment Bionator 36 7(19) 2.303 0.316 logistic regression model
Group Headgear 45 7(16)
Mandibular Low (<30) 34 8(24) 0.182 0.669
Class II molar Mild (1/2 c) 37 5(14) 1.818 0.178
severity Moderate/severe (>l/2 c) 82 20 (24)
Sex Male 74 14(19) 0.515 0.473
Female 45 1 1 (24)
No Pain at DC3 Pain atDC3 T value P

Age at DC 1
(year) 94 9.8 (0.9) 25 9.6 (0.8) 0.845 0.403
Time DC 1-3
(month) 94 24.7 (7.56) 25 25.4 (5.4) -0.507 0.614
had been achieved. The logistic regression were older at the start of the clinical trial (P =
analysis indicated that the odds of having a .016).
TMJ sound at DCS were 9 times higher for In that subset of subjects who had a joint
those who initially had a joint sound than for sound at DC1 (Table 9), none of the explana-
those who did not (P < .001). Also, subjects tory conditions examined in this report re-
were more likely to have a sound at DCS if they duced the risk of having a TMJ sound at DCS.
Table 8. Modeling Presence of Joint Sound Following Early Class II Treatment/Observation in all
Subjects (N = 191) at DCS
Variable Condition TV sound at DC3 x2 P (confidence limits) P
Pre treatment No sound 169 15(9) 18.180 <0.001 9.0(3.1-25.9) <0.001
(DC1) sound Sound 22 9(41)
Treatment Bionator 60 8(13) 0.077 0.962
Observation 60 7(12)
Mandibular Low (<30) 47 7(15) 0.308 0.579
plane angle Normal or high 5=30 144 17(12)
Received No pretext 128 19(15) 1.833 0.176
Class II molar Mild/moderate (<FC) 149 15(10) 3.850 0.050
severity Severe (bilateral FC) 42 9(21)
Sex Male 119 18(15) 1.884 0.170
Female 72 6(8)
No Sound at DC3 Sound at DC3 T value P

AgeatDCl (year) 167 9.8 (0.9) 24 10.2 (0.9) -1.984 0.049 1.9(1.1-3.2) 0.016
Time DC1-3 (month) 167 24.1 (7.5) 24 23.0 (7.6) 0.626 0.532
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Table 9. Modeling Presence of Joint Sound Following Early Class II Treatment/Observation at DCS for
those Subjects (N - 22) with Joint Sound Initially (DC1)
Variable Condition N sound at DC3 x2 P (confidence limits) P
No variables entered
Treatment Bionator 8 2(25) 2.764 0.251 logistic regression model
Group Headgear 10 4 (40)
Observation 4 3(75)
Mandibular Low (<30) 6 2 (33) 0.169 0.658
plane angle Normal or high 2^30 16 7(44)
Pretreatment Pretreatment 6 1 (17)
severity Severe (bilateral FC) 9 4 (44)
Sex Male 14 7(50) 1.316 0.251
Female 8 2(25)
Class I molars Yes (Class I) 6 1 (17)
No Sound at DCS Sound at DCS T value P

Age at DC1 (year) 13 9.6 (0.6) 9 9.8 (0.7) -1.019 0.320

Time DC1-3 (month) 13 25.2 (10.2) 9 25.1(5.4) 0.025 0.980
In the subset of subjects with no joint ble 11. Patients with muscle pain at DC 1 had a
sounds initially (Table 10), those subjects who higher prevalence of muscle pain at DCS than
were older initially were more likely to have those who had no pain at DC1 (59% v 34%, P
developed a sound by DCS (P = .029). None = .001). Subjects who had not received pre-
of the other factors examined increased the treatment had a higher percentage of muscle
risk for developing a TMJ sound. pain at DCS than those who had received pre-
Muscle pain to palpation. The percentages of treatment (48% v 32%, P = .028). Treatment/
subjects with muscle pain to palpation follow- observation assignment, mandible plane angle,
ing Class II early treatment/observation at DCS Class II molar seventy, gender, whether or not
by explanatory conditions are presented in Ta- Class I molars had been achieved during treat-
Table 10. Modeling Presence of Joint Sound Following Early Class II Treatment/Observation at DCS for
those Subjects (N = 169) with No Joint Initially (DC1)
Variable Condition N sound at DC3 x2 P (confidence limits) P
Treatment Bionator 52 6(12) 0.699 0.705

Observation 56 4(7)
Mandibular Low (<30) 41 5(12) 0.737 0.390
plane angle Normal or high 5^30 128 10(8)
Received No pretreatment 112 11(10) 0.367 0.545
severity Severe (bilateral, FC) 33 5(15)
Sex Male 105 11(10) 0.878 0.349
Female 64 4(6)
No Sound at DC3 Sound at DC3 T value P

Age at DC1 (year) 154 9.8 (0.9) 15 10.3 (0.9) -2.270 0.037 1.9(1.1-3.3) 0.029
Time DC1-3 (month) 154 25.0 (7.3) 15 21.8(8.6) 1.089 0.277
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Table 11. Modeling Presence of Muscle Pain to Palpation Following Early Class II
Treatment/Observation in all Subjects (N = 191) at DCS
Pretreatment No pain 122 41 (34) 11.987 0.001 2.9(1.6-5.3) <0.001

(DC1) pain Pain 69 41 (59)
Treatment Bionator 60 22 (37) 2.956 0.228
Mandibular Low (<30) 47 16 (34) 2.011 0.156
Pretreatment Pretreatment 63 20 (32)
Class II molar Mild (1/2 c) 56 22 (39) 0.430 0.521
Sex Male 119 47 (40) 1.521 0.217
Female 72 35 (49)
No Pain at DC3 Pain atDC3 T value P

Age at DC1
(year) 109 9.9(1.0) 82 9.8 (0.8) 0.964 0.337
Time DC 1-3
(month) 109 24.1(7.6) 82 23.6 (7.4) 0.443 0.658
ment, age at DC1, and length of the DC1 to In the subset of subjects with muscle pain at
DCS time interval were not associated with DC1 (Table 12), those who also had pain at
pain at DCS. The odds of exhibiting muscle DCS had a shorter time interval between DC 1
pain at DCS were 2.9 times higher for subjects and DCS than those patients with no pain at
initially observed to have had muscle pain than DCS (P = .035). The odds ratio data for this
for those without initial muscle pain (P < continuous measure can be interpreted to
.001). mean that a subject followed for 20 months
Treatment/Observation at DCS for those Subjects (N = 69) with Muscle Pain Initially (DC1)

Mandibular Low (<30) 14 5(36) 4.093 0.043
Pretreatment Yes pretreatment 17 9(53)
Class II molar Mild (1/2 c) 16 10 (62) 0.082 0.775
Sex Male 46 24 (52) 3.005 0.083
Female 23 17 (74)
No Pain at DC3 Pain at DC3 T value P

Age at DC1
(year) 28 9.7(1.0) 41 9.9 (0.8) -0.459 0.648
Time DC 1-3
(month) 28 25.5(7.0) 41 21.5(8.07) 2.157 0.035 0.9 (0.87-0.99) 0.039
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Keeling, Gaman, King, et al 161
(treated or not) was half as likely to have mus- data suggest a functional benefit for preado-
cle pain as one followed for 10 months if both lescent children immediately following treat-
initially displayed muscle pain. Additionally, ment for Class II Division 1 malocclusions.
subjects with a low mandibular plane angle This study also demonstrated that the col-
were less likely to have muscle pain at follow- lection of TMD data in children is made diffi-
up (P = .043) cult by the poor reliability of the measures. In-
Table 13 displays the results in that subset terjudge reliability of clinical signs of dysfunc-
of subjects with no muscle pain initially. As tion (TMJ sounds, TMJ capsular pain, and
seen, those subjects who remained Class II had muscle pain) when scored as present or absent
a higher prevalence of muscle pain at DC3 in children by specific site was poor. However,
than those patients who became Class I during interjudge reliability of clinical signs of dys-
treatment/observation (41% v 23%, P = .034). function improved when the data were col-
The odds of muscle pain at DC3 were about lapsed to reflect only presence or absence of a
half that for a subject achieving a bilateral trait (TMJ sound, TMJ capsular pain, and
Class I molar relation than for one who did muscle pain) in an individual. The poor reli-
not, if both initially displayed no muscle ten- ability of identifying signs of dysfunction by
derness (P = .034). specific site has been reported by others,21 and
calls into question the results of many previous
studies which considered individual sites, uti-
Discussion lized multiple examiners to collect data, and
The most general finding of this study is that did not report the reliability of the measures
those subjects with TMJ sounds, TMJ pain, reported. Interestingly, three of the examiners
and muscle pain after treatment or observation were clinicians who were providing care in the
were those who had the sign at baseline. These College's Facial Pain Center and routinely per-
data also show that, for preadolescent patients forming TMD evaluations; one was an orth-
without a TMJ sound, without muscle pain, odontist who had been collecting TMD data
and/or without TMJ capsular pain, there is no for 5 years in a prospective randomized trial of
immediate risk of patients developing these orthognathic surgery patients, and one was a
TMD signs from early treatment with bion- senior dental student who had been trained for
ators and headgears/bite planes. Further, these over a year by the orthodontist.
Treatment/Observation at DCS for those Subjects (N = 122) with no Muscle Pain Initially (DC1)
Explanatory No. (7c) with Odds ratio
Variable Condition N pain at DC 3 x2 P (confidence limits) P

Mandibular Low (<30) 33 1 1 (33) 0.002 0.969
Pretreatment Pretreatment 46 1 1 (24)
Class II molar Mild ( 1/2 c) 40 12 (30) 0.347 0.556
Sex Male 73 23 (32) 0.359 0.549
Female 49 18 (37)
Achieved No (Class II) 70 29(41) 4.503 0.034 0.4 (0.2-0.9) 0.034
No Pain at DC3 Pain at DC3 T value P

Age at DC1
(year) 81 9.9(1.0) 41 9.7 (0.8) 1.657 0.101
Time DC 1-3
(month) 81 23.7(7.8) 41 25.8 (6.2) -1.609 0.111
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These results from a randomized clinical follow-up if treated with a headgear/bite plane
trial of early Class II treatment in children con- or observed than if they had been treated with
firm many (but not all) conclusions that oth- a bionator. These data from children are in
ers10'14 have recently reached after extensive agreement with data from adults treated with
reviews of the orthodontic literature. For ex- mandibular repositioning appliances; a review
ample, these two-year longitudinal data re- of the literature recently concluded that adult
vealed that signs of TMD do occur in healthy anterior repositioning splint therapy appears
individuals not seeking treatment for a TMD to be superior to the flat-plane occlusal splint
condition and that some signs (specifically in eliminating palpatory tenderness of the
TMJ sounds in our sample) increased with age. TMJ.2° Although the headgear/bite plane sub-
Interestingly, because the risk for muscle pain jects with moderate to deep bites experienced
decreased with longer follow-up in children an anterior bite plane effect to open the bite,
without initial muscle pain (see Table 12), only the bionator subjects had anterior man-
these data do not support a generalized state- dibular positioning.
ment that prevalences of all signs increase with The data characterizing functional out-
age. comes of early Class II treatment using head-
These data also support the conclusion10'14 gears and bionators were obtained from a pro-
that orthodontic treatment with bionators and spectively designed randomized controlled
headgears in preadolescent children does not trial. In clinical medicine, the RCT is well rec-
increase the odds of developing TMD, at least ognized as the most rigorous test of treatment
in the short term, immediately following ces- effectiveness. 12 ' 26 However, these findings
sation of treatment. Appliance therapy in chil- need to be supported by data from similarly
dren without preexisting TMJ sounds, TMJ designed studies, before they become gener-
capsular pain, and/or muscle pain did not inally accepted. Further, these trends must be
crease the risk of developing these signs. Only examined in the longer term. We are near the
increasing age (for the development of sounds) point in the RCT where we can begin to exam-
and failure to achieve a Class I molar relation ine 6 month and 1 year posttreatment data.
(for development of muscle pain) placed sign- Plans for longer follow-up, an additional 3
free children at greater risk. This later finding years, are currently underway. The impact of
is provocative and suggests that establishing signs of dysfunction in children on later need
proper occlusion, at least Class I molars, may for treatment of a temporomandibular disor-
have an immediate functional benefit. This is der remains unclear, and can only be resolved
in contrast to the current consensus10'14 that with follow-up into adulthood.
not achieving a specific gnathologic occlusal Those enrolled in the study who were ex-
scheme does not increase the risk of having cluded from this report (drop outs, active cases
TMD signs. Rather, these data support the who are incomplete, and those with missing
opinions expressed by those who stress the im- data) did not differ in many important prog-
portance of obtaining ideal occlusion but lack nostic factors from those examined in this re-
direct supporting data.22"24 Interestingly, the port; this suggests that missing data occurred
subjects with a bilateral full cusp Class II molar randomly. Also, randomization and stratifica-
relation were more likely (2.3 X) to have TMJ tion yielded groups (bionator, headgear/bite
pain after treatment/follow-up observation plane, and control) which were equivalent in
than the less severe ones. factors that might have impacted the out-
The most surprising finding from this trial comes, including age, morphology (mandibu-
concerns the difference in outcome following lar plane angle), Class II molar severity, and
bionator therapy and headgear/bite plane gender. Randomization to groups is further
therapy in those subjects with pre-existing expected to equalize factors that might influ-
TMJ capsular pain and counters the prevailing ence treatment outcome but are not readily
consensus that there are no differences in risk identified by the experimenters; to point, a re-
for TMD among different types of orthodontic view of 145 articles examining treatment for
mechanics.14 Subjects with TMJ pain at base- myocardial infarction found 59.1% of nonran-
line were 7 times more likely to have pain at domized studies having at least one maldistrib-
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uted prognostic variable versus 14% of the gears/bite planes. Early treatment with
randomized studies.26 This suggests that bias bionators and headgear/bite planes did not
in treatment assignment (eg, using selected place healthy children without these signs at
controls or historical controls) could be more risk. Only increasing age (for the develop-
important in determining treatment outcome ment of sounds) and failure to achieve a
than the treatment itself. Randomization to Class I molar relation (for development of
treatment and control groups of subjects with muscle pain) placed sign-free children at
similar conditions was seldom done in orth- greater risk.
odontic clinical research before 1990,12 but 5. The risk for TMD differs by orthodontic
this is now changing.27 (An exception to this is mechanics/treatment techniques. Subjects
the report by Jacobsson in 1967, a seldom- with TMJ pain at baseline were seven times
referenced cephalometric study of early Class more likely to have pain at follow-up if they
II treatments.28) had been treated with a headgear/bite plane
Finally, these data reflect the outcome of the or observed than if they had been treated
original randomization; no subject was ex- with a bionator.
cluded from analysis because of poor (or no)
cooperation or for not having reached a treat-
ment goal. Thus, data describing outcomes in Acknowledgment
the bionator and headgear/bite plane groups We would like to express our appreciation to the dentists,
were obtained from both cooperative and non- orthodontists, and graduate students who collaborated
with us in screening more than 6,400 Alachua County, FL,
cooperative subjects whether or not the treat- school children and who aided us in the clinic: Drs Richard
ment was "successful." The effect of coopera- Hocevar, Janet Pappas, Michael Kania, Debra Sappington,
tion on functional outcomes of early treatment Sal Cabassa, Alan Ossi, Robert Bates, and Scott McCranels.
will be examined in a subsequent paper. Thanks are due to our data manager, Narinder Nangia,
and to the data entry personnel, Laurel Johnson, Elgyn
Reid, and Karen Owens. Special thanks are due to those
Conclusions who have served as our administrative staff, Sarah Gar-
rigues-Jones, Mary Seymour, and Marie Taylor, and to
These data obtained in a randomized con- our departmental secretaries, Kathy Cannon and Donna
Joiner. We also wish to thank assistant superintendent of
trolled trial of early treatment of Class II mal- schools, Dr Mel Lucas, and the teachers of Alachua
occlusion in preadolescent children with bion- County, FL, who granted us access to their school children
ators and headgear/bite plane appliances sup- during their busy days. Finally, none of this would have
port the following conclusions. been possible without the participation of the children and
their families, who continue to strongly support this proj-
1. Signs commonly associated with temporo- ect; our most sincere thanks to these special people.
mandibular disorders occur in healthy pre-
adolescent children not seeking treatment
for a TMD condition. References
2. Some signs (specifically, TMJ sounds in our 1. Ricketts RM. Clinical implications of the temporoman-
sample) increase with age. However, a gen- dibular joint. Am J Orthod 1966;52:416-439.
2. Franks AST. The dental health of patients presenting
eralized statement could not be supported, with temporomandibular joint dysfunction. Br J Oral
as the risk for muscle pain decreased with Surg 1967;5:157-166.
longer follow-up in children without initial 3. Roth RH. Temporomandibular pain-dysfunction and
muscle pain. occlusal relationships. Angle Orthod 1973;43:136-
3. Subjects with TMJ sounds, TMJ pain, and 153.
4. Berry DC, Watkinson AC. Mandibular dysfunction
muscle pain after treatment or 2 years of and incisor relationships. A theoretical explanation of
observation were more likely to be those the clicking joint. Br J Oral Surg 1978;44:74-77.
who had the sign at baseline. 5. Wigdorowicz-Makowerowa N, Grodzki C, Panek H,
4. In those subjects without a TMJ sound, Maslanka T, Plonka K, Palacha A. Epidemiologic
without muscle pain, and/or without TMJ studies on prevalence and etiology of functional dis-
turbances of the masticatory system. J Prosthet Dent
capsular pain, there was no risk of develop- 1979;41:76-82.
ing these TMD signs immediately after 6. Larsson E, Ronnerman A. Mandibular dysfunction
early treatment with bionators and head- symptoms in orthodontically treated patients ten years
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after the completion of treatment. Eur J Orthod 1981; 15. Cohen J. A coefficient of agreement for nominal
3:89-94. scales. Educ Psych Meas 1960;20:37-46.
7. Janson M, Hasund A. Functional problems in orth- 16. Cohen J. Weighted Kappa: Nominal scale agreement
odontic patients out of retention. Am J Orthod 1981; with provision for scaled disagreement or partial
3:173-179. credit. Psych Bull 1968;70:213-220.
8. Sadowsky C, Poison AM. Temporomandibular disor- 17. Agresti A. Categorical Data Analysis. New York: John
ders and functional occlusion after orthodontic treat- Wiley and Sons, Inc, 1990.
ment: Results of two long-term studies. Am J Orthod 18. SAS Institute. SAS/STAT User's Guide, Version 6. 4th
1984;86:386-390. ed. Gary, NC: SAS Institute, 1990:1-2.
9. Egermark-Eriksson I, Carlsson GE, Magnusson T, 19. Weisberg S. Applied Linear Regression. 2nd ed. New
Thilander B. A longitudinal study on malocclusion in York: John Wiley and Sons, Inc, 1985.
relation to signs and symptoms of cranio-mandibular 20. Landis JR, Koch GG. The measurement of observer
disorders in children and adolescents. Eur J Orthod agreement for categorical data. Biometrics 1977;33:
1990; 12:399-407. 159-174.
10. Behrents RG, White RA. TMJ research: Responsibility 21. Fricton JR, Schiffman LE. Reliability of a cranioman-
and risk. Am J Orthod Dentofac Orthop 1992; 101:1- dibular index. J Dent Res 1986;65:1359-1364.
3. 22. Williamson EH. Occlusion: Understanding or misun-
11. Pullinger AG, Seligman DA, Gornbein JA. A multiple derstanding. Angle Orthod 1976;46:86-93.
regression analysis of the risk and relative odds of 23. Aubrey RB. Occlusal objectives in orthodontic treat-
temporomandibular disorders as a function of com- ment. Am J Orthod 1978;74:162-175.
mon occlusal features. J Dent Res 1993;72:968-979. 24. Roth RH. Functional occlusion for the orthodontist.
12. Sackett DL. The science of the art of clinical manage- Part I. J Clin Orthod 1981; 15:32-41.
ment. In: Vig PS, Ribbens KR, editors. Science and 25. Zamburlini I, Austin D. Long-term results of appli-
Clinical Judgement in Orthodontics. Ann Arbor: The ance therapies in anterior disk displacement with re-
Center for Human Growth and Development, The duction: A review of the literature. J Craniomand
University of Michigan, 1986:237-251. Pract 1991;9(4):361-368.
13. Keeling SD, King GJ, Wheeler TT, McGorray S. Tim- 26. Chalmers TC, Celano P, Sacks HS, Smith H. Bias in
ing of Class II treatment: Rationale, methods, and treatment assignment in controlled clinical trials. N
early results of an ongoing randomized clinical trial. EnglJ Med 1983;309:1358-1361.
In: Trotman CA, McNamara JA, editors. Orthodontic 27. Trotman CA, McNamara JA. Orthodontic Treat-
Treatment: Outcome and Effectiveness. Monograph ment: Outcome and Effectiveness. Monograph 30,
30, Craniofacial Growth Series. Ann Arbor: Center Craniofacial Growth Series. Ann Arbor: Center for
for Human Growth and Development, University of Human Growth and Development, University of
Michigan, 1995:1-32. Michigan, 1995.
14. McNamara JA, Seligman DA, Okeson JP. Occlusion, 28. Jacobsson SO. Cephalometric evaluation of treatment
orthodontic treatment, and temporomandibular dis- effect on Class II, division 1 malocclusions. Am J
orders: A review. J Orofacial Pain 1995;9:73-90. Orthod 1967;53:446-456.
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Monitoring Growth During

Joseph G. Ghafari, Frances S. Shofer, Larry L. Laster,
Diane L. Markowitz, Susan Silverton, and Solomon H. Katz
The relationship between somatic growth and orthodontic treatment has

been limited to the evaluation of body height and skeletal age relative to
craniofacial development. The aim of this study was to evaluate the corre-
lation of anthropometric and biochemical measures of general growth with
facial and occlusal changes during the early treatment of Class II Division 1
malocclusion. Findings are reported from 46 children, ages 7.20 to 12.85
years (skeletal ages, 5.75 to 12.75 years), who are enrolled in a prospective
clinical trial. Body and knee heights were measured monthly, with a Holtain
stadiometer and a Knee Height Measuring Device, respectively. Every three
months, serum levels were measured of the hormone dehydroepiandroster-
one sulfate (DHEAS), an androgen associated with growth in midchildhood,
and osteocalcin, an indicator of bone turnover. Significant correlations ex-
isted between knee height and various occlusal measurements, but man-
dibular length was not significantly correlated with knee height and DHEAS
levels. Knee height correlated significantly (P < .05) with DHEAS and osteo-
calcin only in 46% and 37% of the children, respectively. The results indicate
that the evaluated biochemical measures, at the time intervals considered,
may not increase the accuracy of growth depiction by physical measures
alone (height and skeletal maturation).
raniofacial growth can be critical to the goal in defining this relationship is the ability
C timing of orthodontic therapy because
treatment outcome is thought to be related to
to predict craniofacial events on the basis of
somatic developments. This knowledge im-
concomitant developments in the craniofacial pacts on treatment decisions such as timing of
complex. Similarities and correlations have early treatment of malocclusions, orthognathic
been described between craniofacial and so- surgery, or orthodontic treatment during ad-
matic maturational patterns.1'2 The ultimate olescence. In many of these instances, the cli-
nician seeks to take advantage of potential fa-
cial growth, such as maximizing differential
From the Department of Orthodontics, School of Dental Med-
icine, the Department of Emergency Medicine, School of Medi- growth between the jaws during active periods
cine, the Section of Epidemiology, Department of Clinical Studies, of growth in the case of mandibular retro-
School of Veterinary Medicine, the Department of Oral Medicine, gnathism, or to avoid the deleterious effect of
School of Dental Medicine, and the Wilton Marion Krogman ongoing growth, as in the surgical setback of a
Center for Research in Child Growth and Development, the Uni- prognathic mandible after mandibular growth
versity of Pennsylvania, Philadelphia, PA; and the Department of
Geography and Anthropology, Rowan College of New Jersey, has ceased.
Glassboro, NJ. Craniofacial development has been com-
Supported by National Institute of Health, Bethesda, MD, pared mainly with general body height and in
Grant Nos. RO1-DE08722 and RR-00040. relation to skeletal maturation, evaluated with
Address correspondence to Joseph Ghafari, DMD, Department
hand-wrist radiographs.3"6 Recently, stages of
of Orthodontics, School of Dental Medicine, University of Penn-
sylvania, 4001 Spruce St, Philadelphia, PA 19104-6003. maturation of cervical vertebrae, described as
Copyright © 1995 by W.B. Saunders Company changes in shape on cephalometric x-rays,
1073-8746I95I0103-0005$5.00IO have been related to skeletal development.7
Seminars in Orthodontics, Vol 1, No 3 (September), 1995: pp 165-175 165

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166 Ghafari, Shofer, Laster, et al
Growth curves of the maxilla and mandible constitutional stimuli (eg, hormones) and envi-
have been related to body height curves and to ronmental stressors (eg, diet, trauma, habits)
each other.1'8'9 The facial bones undergo an during critical periods in their development.
adolescent growth spurt similar in pattern to These theories offer the basis for pursuing bio-
that of the body: facial growth peaks at the chemical correlates of skeletal growth.
same time or slightly later than the peak of The roles of the growth hormone, adrenal
maximum increments in height. 10 ' 11 Correla- steroids, gonadal hormones, and thyroid hor-
tions tend to be higher between body height mone have been the object of numerous inves-
and the mandible than between body height tigations to determine their roles in skeletal
and the maxilla. This discrepancy probably re- metabolism.17 The association between hor-
sults from the fact that growth of the sutures, monal levels and craniofacial growth is recog-
which is closely associated with maxillary nized mainly through the study of relation-
growth, ceases about 2 years before the com- ships between hormonal deficiencies or excess,
pletion of growth in mandibular length.2 and aberrant craniofacial growth. Such associ-
The predictors of timing of skeletal growth, ations are evaluated in clinical manifestations
assessed with hand-wrist radiographs, apply of craniofacial anomalies and remain the ob-
both to growth in height and facial develop- ject of current research. However, when deal-
ment, particularly mandibular growth.12 The ing with normally developing children, and
latter is relatively easier to measure on cepha- probably for lack of scientific data, clinical
lometric radiographs than is maxillary devel- practice does not include the evaluation of nor-
opment, because the mandible is a distinct skel- mally occurring biochemical events, and is lim-
etal unit, whereas the image of the maxilla is ited to assessing the physical measures related
not readily separated from adjacent bones, to these events, namely body height and skel-
and its assessment is usually reduced to that of etal maturation.
the size and position of the midline structure, Timing of early orthodontic treatment has
particularly the palate. In general terms, the been based on stages of skeletal maturation as
limitations of the cephalometric record should they relate to peak height velocity2 or to max-
be recognized, as superimposed three-dimen- imal treatment response.18 McNamara et al19
sional structures can affect the identification of reported a larger increase of mandibular
landmarks. 13 ' 14 length in children treated with the Frankel ap-
Several scientists described growth in terms pliance at ages estimated to be closer to pu-
of cellular and molecular changes and, more berty than at younger ages. Woodside20 corre-
specifically, biochemical events, rather than in lated activator treatment with growth curves of
terms of physical measures such as height and mandibular length. He concluded that success-
weight. 10 ' 16 For any organ, three distinct ful treatment is more likely to coincide with
growth phases are defined: a period of hyper- normal periods of active growth. Other inves-
plastic growth, characterized primarily by cell tigators related the effect of treatment with the
division and manifested biochemically by an Herbst appliance21'22 and with an activator-
increase in DNA; a period of simultaneous hy- type appliance associated with extraoral trac-
perplastic and hypertrophic growth, and a pe- tion 23 to longitudinal records of standing
riod of hypertrophic growth with an increase height. They concluded that the skeletal effect
in cell size (not number), measurable primarily of the appliances was more pronounced dur-
by an increase in weight and protein. Critical ing the peak height velocity periods than dur-
periods of development are times in the devel- ing the prepeak period. These findings are not
opment of an organ system that equate with surprising, but they are subject to a vast range
the intense hyperplastic growth phase and are of individual variation, and do not explain the
marked by the rapid synthesis and accretion of contribution of growth in prepubertal periods
protein.16 This critical period concept explains to successful early treatment nor the nature of
why the application of constitutional and envi- the relationship between therapy and growth.
ronmental stimuli to a developing system does It is logical, then, to relate growth status of
not always produce the same result. A number the body to that of the craniofacial complex in
of oral tissues, including maxillary and man- growing children, particularly in children un-
dibular bone, are susceptible or sensitive to dergoing orthodontic therapy that is pre-
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sumed to influence facial growth, or whose trial. They were assigned at random to treat-
success may be caused by concomitantly occur- ment with either the headgear (n = 24) or the
ring facial growth. However, the growth event Frankel appliance (Great Lakes Orthodontics
that has been most frequently analyzed, body Laboratory, Tonawanda, NY) (n = 22). Body
height, is examined biannually or annually. and knee heights were measured monthly,
Such intervals are large enough to miss indi- with a Holtain stadiometer and a Knee Height
vidual fluctuation in growth velocity. More fre- Measuring Device (Intersciences Development
quent assessment of growth events is needed. Associates, Inc., Philadelphia, PA), respec-
In an ongoing prospective clinical trial pre- tively. This device is designed to measure the
sented here, not only body height but also the length of the lower limb while the patient is
lower limb height, which is related to body seated in a chair: the knee rests in a brace
height but subject to smaller measurement er- placed just below the patella tuberosity, and
rors, were measured on a monthly basis. In the heel of the foot is placed in a similar brace
addition, the concentrations of biochemical so that the lower leg is immobilized and per-
substances in blood and saliva were investi- pendicular to the foot platform. Proper place-
gated. The aim of this study was to evaluate the ment causes the subject to have an angle of
correlation of anthropometric and biochemical about 85° between the lower limb and the
measures of general growth with facial and oc- thigh. A sliding measuring pad is brought in
clusal changes during the early treatment of contact with the knee at a constant pressure to
Class II Division 1 malocclusion by either the standardize tissue compression. The same ex-
headgear or the Frankel appliance. aminer measured body height twice, and knee
Retrospective studies in which treatment height four times. Molar and canine sagittal
with the Frankel appliance was compared with relationships, overjet, and intermolar and in-
other orthodontic treatment techniques, intercanine distances were measured from casts
volving the use of fixed appliances with or taken every 2 months, mounted on a SAM II
without headgear, showed overall similar articulator (Great Lakes Orthodontics Labora-
retrusive or stabilizing effects on the max- tory, Tonawanda, NY), using digital calipers
illa.24"26 No statistically significant difference accurate to 0.01mm.27'28
was observed in forward mandibular growth Every 3 months, serum levels were mea-
or in mandibular length between the Frankel- sured by radioimmunoassay of the hormone
treated or other groups. However, variation in dehydroepiandrosterone sulfate (DHEAS),
treatment response within groups was signifi- and an indicator of bone turnover, osteocalcin.
cant, underscoring the need to test treatment DHEAS is an androgen associated with growth
effects under conditions controlling for in midchildhood, the pubertal growth spurt,
growth status. Thus, the working hypothesis and possibly skeletal maturation. Osteocalcin is
underlying our investigation was that response a bone-specific, hydroxyapatite binding pro-
to early treatment of distoclusion is positively tein produced by osteoblasts during late stages
associated with growth and maturational activ- of differentiation. 29 Because a primary goal of
ity during the treatment period. A subsidiary the investigation was to gain the ability to de-
null hypothesis was that no significant associa- tect changes on a regular basis over time that
tions existed between growth, maturational, could be compared with recorded changes in
and hormonal/biochemical correlates of so- occlusal measurements, salivary levels of
matic growth and craniofacial growth. Prelim- DHEAS were measured on a monthly basis.
inary findings are reported on the relationship Stimulated (parotid) and unstimulated (whole)
between growth and treatment outcome, par- saliva specimens were collected, and a consid-
ticularly occlusal measures. erable number of pilot studies and experi-
ments were performed to detect the low levels
of DHEAS present in saliva (approximately
Materials and Methods 1,000 times lower than plasma levels).
Forty-six children, ages 7.20 to 12.85 years Adrenarche is an endocrine event of mid-
(skeletal ages, 5.75 to 12.75 years, as evaluated childhood that is characterized by the capacity
by the Greulich and Pyle3 method, 1959), met of the zona reticularis of the adrenal gland to
strict criteria for enrollment in the prospective secrete androgens. During childhood and
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early puberty, the adrenal gland is a major 1. Statistically significant increases of the max-
source of androgens in both sexes. Studies sug- illary intercanine distance in patients who
gested that adrenarche precipitates a develop- used the headgear, and the maxillary inter-
mental growth spurt at about ages 6 to 8 molar distance in those treated with the
years,30 but no corresponding precocious den- Frankel appliance.27
tal development.31 A clinically and statistically 2. Further improvement of the sagittal molar
significant association was reported between relationship in patients who used the head-
increased DHEAS serum levels and advanced gear, suggesting that restraining and/or dis-
skeletal age that is independent of the effects talizing forces on the maxillary molars are
of testosterone in circumpubertal males.32 more effective with the headgear than the
This finding, and the significant association, Frankel appliance.28 This preliminary con-
also independent of serum testosterone conclusion must be corroborated with cephalo-
centration, between DHEAS and height veloc- metric data.
ity in the early phases of the pubertal growth 3. Larger reduction of the overjet occurred in
spurt show a plausible mechanism accounting patients treated with the Frankel appliance,
for somatic and craniofacial growth variation possibly because this appliance exerted a
in children. distal force on the maxillary incisors.28 Con-
ceivably, the headgear would provide simi-
Statistical analysis lar results if combined with a similar force.
Intraclass correlation coefficients and errors of 4. Measurements of mandibular length
measurements were calculated for each of the (condylion-pogonion) in only a cohort of
parameters measured to assess examiner vari- the children were not statistically signifi-
ability of repeated measurements. For each pa- cantly different between those treated with
tient separately, linear correlation and regres- the headgear (5.69 ± 1.78 mm) and those
sion techniques were used to evaluate relation- treated with the Frankel appliance (6.18 ±
ships among and between growth measures, as 1.60 mm).
well as between growth measures and occlusal
parameters. For reasons related to the longitu- Measurements of growth
dinal nature of an investigation in which two
treatment approaches are being compared, For each patient, body and knee height veloc-
and that require withholding definitive analy- ities (millimeter increments per time) were
sis of the data until completion of treatment in evaluated by fitting linear, quadratic, and cubic
all subjects, only preliminary findings on a sub- functions. Individual parameter estimates for
set of cephalometric measurements are pre- each patient were then evaluated collectively.
sented. They pertain to the measurement of In this analysis, all three functions were statis-
mandibular length (condylion-pogonion). This tically significant, and the quadratic function
length was compared with growth measures best fit the data. However, individual velocity
using regression techniques. functions, calculated for each patient, were not
consistent. The data were then analyzed in the
following way. For each patient, a regression
Results analysis of change from baseline versus time
was performed for body and knee heights.
The investigated hypotheses and correspond-
The correlation coefficients were subsequently
ing findings to date are summarized as they
compared by a paired £-test. The mean coeffi-
relate to therapeutic differences between the
cients, across the patients, were high for both
headgear and functional appliance, measure-
body (r = .993) and knee (r = .995) heights,
ments of growth, and associations between
and were not statistically significantly different
treatment and growth.
(P = .08). The range was essentially similar for
knee height (.95 < r < .99) and for body height
Treatment Effects (.97 < r < .99).
The most significant findings included the fol- The errors of measurement for knee and
lowing: body heights were 0.35 mm and 0.94 mm, re-
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spectively, but the intraclass correlation coeffi-

cients for both knee and body heights were — Frankel
similar (.999). Since knee height measurement • •• Headgear
detected small changes on the order of 0.5

mm, similar in magnitude to changes in oc-
clusal relationships, and because this measure-
ment allowed precise evaluation of growth
within and between patients, occlusal parame-
ters were regressed against knee height.
Radioimmunoassay of the DHEAS serum
samples proceeded without problems because
high levels of the hormone are readily detect-
able. Interestingly, however, the salivary levels Knee Height Change (mm)
of DHEAS did not correlate well with the cor-

responding plasma levels. Therefore, the se-
rum levels were used to assess the relationship
between the hormone and knee height, as well
as between the hormone and treatment out-
comes. Differences between DHEAS levels for
boys and girls across time were statistically sig-
nificant (P = .04).
Associations Among and Between

Correlates of Somatic Growth and
Craniofacial Growth Knee Height Change (mm)
A correlation was found between growth in Figure 1. Changes from baseline of occlusal param-
knee height and occlusal records.28 Statistically eters were regressed on changes from baseline of
significant correlations (.56 < r < .98;.05 < P knee height. Regressions were calculated separately
< .0001) were observed between increases in for each subject. Each line illustrates the mean of all
occlusal measurements and knee height. individual correlations in the Frankel appliance and
Higher percentages of these correlations were headgear patient groups. Differences between
slopes and intercepts were compared between the
found in one or the other treatment group: two groups. (A) Difference between the slopes of
between knee height and maxillary intercanine mean regressions on knee height of maxillary inter-
distance in the headgear group (Fig. 1A), be- canine distance was statistically significant (P =
tween knee height and intermolar distances in .0008), reflecting the larger increase of the interca-
the Frankel appliance group (Fig. IB), and be- nine distance in the headgear group (x = 3.90, stan-
dard error (SE): 0.30 mm) than in the Frankel ap-
tween knee height and molar and canine sag- pliance group (x = 1.42, SE: 0.29 mm). (B) Differ-
ittal occlusions in the headgear group. ence between the intercepts of mean regressions on
Mandibular length was not found to be sig- knee height of maxillary intermolar distance (mea-
nificantly correlated with knee height and sured between the palatal cusps of the permanent
first molars) was statistically significant (P < .0001),
DHEAS levels, while knee height correlated reflecting the larger increase of the intermolar dis-
significantly (P < .05) with DHEAS (.64 <r< tance in the Frankel appliance group (x = 2.82, SE:
.93) and osteocalcin levels (.69 < r < .95) only 0.44 mm) than in the headgear group (x = 1.05, SE:
in 46% and 37% of the children, respectively. 0.42 mm).
Of the children (N = 21) in whom knee height
was correlated significantly with DHEAS, one and either DHEAS or osteocalcin levels was
third (only 9% or 1 of 11 of the girls, but 60% evaluated relative to skeletal age at baseline,
or 6 of 10 of the boys) also had knee height the averages of these correlations were higher
that was significantly correlated with osteocal- for DHEAS than those for osteocalcin at all
cin levels. When the distribution of individual ages before age 10 years (Table 1). The notable
correlation coefficients between knee height exception was for the female subjects whose
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Table 1. Correlation Coefficients Between Knee Height and Biochemical Measures

Mean (SD) of Correlations Between Knee Height and
Skeletal Age
at Baseline N DHEAS Osteocalcin
Females
7-8 4 0.83 (0.05) 0.49 (0.32)
8-9 6 0.36 (0.28) 0.74 (0.14)
9-10 6 0.82 (0.11) 0.43 (0.26)
9 0.49 (0.22) 0.63 (0.31)
Total 25* 0.59 (0.27) 0.59 (0.28)
Males
<7 5 0.79 (0.14) 0.58 (0.18)
7-8 3 0.74 (0.14) 0.59 (0.39)
8-9 2 0.86 (0.09) 0.60 (0.05)
9-10 8 0.67 (0.16) 0.58 (0.33)
>10 3 0.48 (0.18) 0.60 (0.45)
Total 21* 0.70 (0.18) 0.59 (0.28)
All 46 0.64 (0.24) 0.59 (0.28)

:
No statistically significant differences between mean correlations of males and females.
treatment started between ages 8 and 9 years, height and maxillary intercanine distance and
and whose correlations between DHEAS and molar and canine sagittal relationships in the
knee height were lower than those between os- headgear patient group, and intermolar dis-
teocalcin levels and knee height. Also for these tances in the Frankel appliance patient group,
girls, the mean correlation between knee suggest that development of the dental arch is
height and osteocalcin levels was higher than at related to growth in height and/or rate of tooth
the other age levels considered. movement.28 The contribution of differential
growth between the jaws, rather than only
tooth movement, to these correlations can only
Discussion be ascertained through the analysis of the
A significant contribution of this study is the cephalometric data. Nevertheless, the findings
measurement of small changes in knee height suggest that long-term investigations are
on a monthly basis on the order of 0.5 mm, needed of the association between the devel-
which were compared with occlusal measure- opment of the dental arches and both somatic
ments of the same order of magnitude. The and craniofacial growth in normal occlusions
error of measurement for body height (0.94 and malocclusions.
mm) was larger than the error for knee height The present study emphasizes the fact that,
(0.35 mm), but the intraclass correlation coef- in order to clarify the relationship between
ficients for both knee and body heights were growth and orthodontic treatment, frequent
identical (.9999). This finding would indicate documentation of both events is necessary.
more variation between patients in body height The bimonthly occlusal measurements proved
measurements than in knee height measure- to be a practical method to record orthodontic
ments. Thus, knee height is a more sensitive changes, particularly in view of the restriction
measurement than body height, as repeated on generating radiographic data at similar in-
measurements of knee height within and be- tervals. The correlation between growth in
tween patients would lead to more precise eval- knee height and increases in arch width (inter-
uation over time. Therefore, correlating change molar distance with the Frankel appliance, in-
in occlusal and/or cephalometric relations over tercanine distance with the headgear) indicates
time with knee height is recommended as a good that these appliances remove the restraining
model to evaluate the interaction between effect of cheek/lip muscles on the development
growth and orthodontic treatment effects. of arch width.
The significant correlations between knee The lack of significant correlation between
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mandibular length and growth measures may DHEAS was the ability to sample saliva at time
result from the small number of subjects in- points concomitant with monthly growth mea-
cluded in this analysis. A definitive conclusion surements and bimonthly occlusal records. An-
on this relationship should not be formulated other reason was that collecting saliva is a less
until the final data are computed. invasive procedure than venipuncture, and it is
Knee height correlated significantly with more readily acceptable to pediatric (and
DHEAS and osteocalcin levels in less than 50% adult) patients to donate saliva than blood
of the children, and with both DHEAS and specimens. The lack of significant correlation
osteocalcin levels in the same children 33% of between serum and salivary levels of DHEAS is
the time. This finding underscores the impor- in agreement with recent research findings by
tance of individual variation, which is illus- other investigators that salivary levels of con-
trated in Figure 2 where changes from baseline jugated steroids like DHEAS do not correlate
of knee height and DHEAS and osteocalcin well with blood levels.33 The findings on this
levels of two children are displayed. hormone did not yield any significant im-
One reason to evaluate salivary levels of provement in monitoring growth over the
B
25
.— KHMD . .KHMD
— -DHEAS — - DHEAS
E 15 g 15
5,0 X
Q
1
Q
0
10.3 10.5 10.7 10.9 11.1 11.3 11.5 11.7 11.9 9.8 10.2 10.4 10.6 10.8 11 11.2 11.4 11.6
Skeletal Age Skeletal Age
-•— -• Osteocalcin ~ ••- •• Osteocalcin
"56
10.3 10.5 10.7 10.9 11.1 11.3 11.5 11.7 ll.S 9.8 10 10.2 10.4 10.6 10.8 11 11.2 11.4 11.6
Skeletal Age Skeletal Age
Figure 2. Change from baseline in knee height (KHMD) versus change from baseline in serum DHEAS
(upper graph) and osteocalcin (lower graph) levels in two male patients (A and B) from the same age group.
Skeletal age was used to compute the start time, then adjusted by chronological time elapsed over the study.
Note the individual variations displayed in the graphs.
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measurement of knee height or estimation of the regular clinical setting. Ultimately, when all
skeletal maturation. This limitation may result the records, including annual cephalometric
from the fact that monthly measurements are data, are available, a prediction model of treat-
needed to detect the significant changes, or ment outcome of distoclusions in childhood
that the role of DHEAS in monitoring somatic can be explored that will include the combined
and craniofacial growth is restricted. As a sig- input of occlusal, cephalometric, growth, and
nificant longitudinal collection is available of compliance measures. Such a model will reflect
monthly salivary specimens on all patients in the effectiveness of orthodontic treatment
the study, testosterone and estradiol will be (headgear and Frankel appliance) relative to
tested as possible indicators of growth events. the characteristics of the child's malocclusion,
The association between these hormones and age, growth pattern, and compliance with
growth is well documented,34'30 and the sali- treatment.
vary levels of the two unconjugated steroids The majority of clinicians do not seek infor-
are readily measurable and correlate with their mation on general growth routinely, but
respective serum levels.33 mostly in instances where patients have severe
The difference in DHEAS levels between malocclusions (Angle Class II and Class III)
boys and girls apparently reflects reported associated with discrepancies between the jaws,
findings of gender differences related to the such as mandibular retrognathism or prog-
earlier maturation of girls than that of boys.1! nathism. In the usual clinical setting, growth
Interestingly, boys accounted for the majority evaluation is often limited to assessing skeletal
of the children who had statistically significant maturation (from hand-wrist radiographs),
correlations between knee height and both and/or observing the physical expression of the
DHEAS and osteocalcin levels. The existence adolescent growth spurt (eg, perceived in-
of a time-lag between the levels of DHEAS and crease in height and/or tracking development
osteocalcin as they relate to knee height should of height from the child's school record) or
be explored. Such a relationship is plausible sexual maturation (eg, onset of menarche in
considering the hypothesis that the hormone girls; facial hair or change of voice in boys).
DHEAS would contribute to stimulating This practice probably stems from the fact that
growth in height, while osteocalcin, an indica- the available knowledge of somatic growth,
tor of bone turnover, is an outcome measure while limited, helps the clinician situate pa-
reflecting that growth. A time-lag phenome- tients relative to their pubertal spurts. Since
non has been described for the effect of an- accurate prediction of an individual's growth is
other androgen, testosterone, on growth in not yet possible, locating the child's growth as
body height and the bone mineral content.36 either prepubertal, pubertal, or postpubertal
Testosterone is thought to be an initiator of the may be adequate for the clinician's purposes.
pubertal growth spurt and mineralization. Af- Indeed, this knowledge, although not predic-
ter the growth spurt, growth in height slows tive of the precise onset of growth spurts, is an
down while bone mineralization rises signifi- attempt at individualizing timing of treatment
cantly. Thus, further investigation is war- to take advantage of craniofacial growth
ranted of variable patterns of relationship changes during treatment. In this context, the
among and between the biochemical and phys- assessment of skeletal maturation and/or sec-
ical measures still under study. ondary sexual characteristics may provide the
necessary information for timing treatment be-
fore or after puberty. However, children may
Considerations for the Future pass through pubescence rapidly or slowly.
Despite probable opposition by many patients, Moreover, while most clinicians pay close at-
frequent venipuncture could become justified tention to adolescent growth, the significance
in research settings. If successful in determin- of growth in childhood may have an impact
ing the significant substances that may interact both on the timing and success of treatment of
with optimal timing and success of treatment, developing malocclusions.
collection of saliva on a monthly or bimonthly Other than timing treatment, prediction of
basis is a more accepted and practical way in craniofacial pattern is concerned with direc-
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tion and amount of growth. In the individual treatment, the relationship between skeletal
patient, the determination of the amount of and dental developments in investigating indi-
craniofacial growth in any given period of time vidual models of prediction will also require
is subject to error. Often, the present skeletal accurate definition. Our research protocol in-
pattern provides the basis for prognosticating cludes the exploration of such models. Demir-
general direction of growth and, in a related jian et al39 reported that dental development is
manner, broad expectation of the amount of not closely related to skeletal maturity or peak
growth. One would expect, for example, a hy- height velocity. They concluded that the mech-
perdivergent skeletal pattern to be associated anisms controlling dental development are in-
with a more vertical direction of mandibular dependent of somatic and/or sexual maturity.
growth, thus, with small horizontal increments The imperatives of dental development may
of growth. These forecasts are based on gen- require a timing of treatment independent of
eral trends that may prove detrimental to the the requirements of craniofacial growth. This
individual patient, whose craniofacial develop- potential discrepancy in the individual patient
ment may deviate significantly from average must be incorporated in the analysis of timing
tendencies. Consequently, the clinical rele- and efficacy of early treatment.
vance of monitoring growth during orthodon-
tic treatment does not only lie in evaluating the
interaction of growth with specific modalities
of treatment; it also extends to defining the
Conclusion
impact of developing further knowledge of so-
matic growth on predicting the individual Monitoring growth during orthodontic treat-
amount and direction of facial growth. There- ment has been limited to physical measures of
fore, such prediction models should be tested body height and skeletal maturation, and their
for levels of accuracy with and without any in- correlation with craniofacial growth. The rea-
put of somatic growth. sons for this limitation have been the difficulty
Prediction models have been explored that in identifying and collecting other biological
would make it possible to estimate an individ- data that may correlate with facial develop-
ual's mandibular growth curve from serial ment and the need for the concomitant fre-
measurements of stature.37 Presumably, such quent measures of growth correlates and pa-
models would be more successful as additional rameters of treatment outcome. The exposure
longitudinal data on skeletal (body height and/ of patients to multiple radiographs in short pe-
or bone age) and craniofacial parameters are riods of time is not acceptable, and venipunc-
incorporated in the model. Research eventu- ture on a routine basis in children is consid-
ally should yield appropriate information on ered an invasive procedure. Yet, individual
the contribution of growth to the success of variation requires the frequent collection of
treatment, but may not allow prediction of serial biological data, at least in these early in-
treatment timing and outcome beyond that vestigative stages. The results of our study in-
which is now available, until individual predic- dicate that the investigated biochemical mea-
tion models are developed and tested for ac- sures (DHEAS and osteocalcin), at the time-
curacy under conditions of normal growth intervals evaluated, may not increase the
and/or orthodontic treatment. accuracy of growth depiction by height mea-
Preliminary findings of our study indicate surements and skeletal maturation. This con-
that treatment in late childhood may be as ef- clusion does not imply, however, that biochem-
fective as that in midchildhood, thus more ical correlates of growth do not exist that
practical and cost effective, since it reduces the would allow adequate association with cranio-
total length of time a child has to be seen by an facial growth. Before any definitive conclusion
orthodontist. Timing of space management in is formulated, other substances must be inves-
developing malocclusions may be most critical tigated and further analysis of the available
before the loss of the mandibular primary sec- data is needed that would incorporate a cohort
ond molar,38 also in late childhood. If such of patients still undergoing treatment and not
concepts become the state-of-the-art of "early" included in this report.
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Acknowledgment Shaw JH, Sweeney EA, Cappuccino CC, et al, editors.

Textbook of Oral Biology. Philadelphia: Saunders,
We acknowledge the contributions of Drs Daniel Mala- 1978:319-342.
mud, Sheil Ahuja, and Shiv Kapoor in the analysis of bio- 17. Tashjian AH, Jr. Hormones affecting mineralized tis-
chemical substances, and of Mr James R. Coleman, Jr, BA, sue metabolism. In Shaw JH, Sweeney EA, Cappuc-
Mrs Laurie Strow, RDH, MEd, Mrs Clare R. Salamon, and cino CC, et al, editors. Textbook of Oral Biology. Phil-
Mrs Barbara Smith, in the conduct of this project. adelphia: Saunders, 1978:511-545.
18. Kopecky GR, Fishman LS. Timing of cervical head-
gear treatment based on skeletal maturation. Am J
References Orthod Dentofac Orthop 1993; 104:162-169.
1. Bambha JK. Longitudinal cephalometric roentgeno- 19. McNamara JA, Jr, Bookstein FL, Shaughnessy TD.
graphic study of face and cranium in relation to body Skeletal and dental changes following functional reg-
height. J Am Dent Assoc 1961;63:776-799. ulator therapy. Am J Orthod 1985;88:91-111.
2. Bjork A. Timing of interceptive orthodontic measures 20. Woodside DG. The Harvold-Woodside activator. In
based on stages of maturation. Trans Eur Orthod Soc Graber TM, Neumann B, editors. Removable Orth-
1972;611-674. odontic Appliances. Philadelphia: Saunders, 1984:
3. Greulich WW, Pyle SI. Radiographic atlas of skeletal 244-309.
development of the hand and wrist. (ed2) Stanford 21. Pancherz H, Hagg U. Dentofacial orthopedics in rela-
University Press, Stanford, CA, 1959. tion to somatic maturation. An analysis of 70 consec-
4. Tanner JM, Whitehouse RH, Marshall WA, et al. As- utive cases treated with the Herbst appliance. Am J
sessment of skeletal maturity and prediction of adult Orthod 1985;88:273-287.
height. TW2 method. London: Academic Press, 1975. 22. Hagg U, Pancherz H. Dentofacial orthopaedics in re-
5. Fishman LS: Chronological versus skeletal age, an lation to chronological age, growth period and skeletal
evaluation of craniofacial growth. Angle Orthod development. An analysis of 72 male patients with
1979;49:181-189. Class II, Division 1 malocclusion treated with the
6. Fishman LS: Radiographic evaluation of skeletal mat- Herbst appliance. Eur J Orthod 1988; 10:169-176.
uration: a clinically oriented method based on hand 23. Malmgren O, Omblus J, Hagg U, Pancherz H. Treat-
wrist films. Angle Orthod 1982;52:88-112. ment with an orthopedic appliance system in relation
7. Hassel B, Far man AG. Skeletal maturation evaluation to treatment intensity and growth periods. A study of
using cervical vertebrae. Am J Orthod Dentofac Or- initial effects. Am J Orthod 1987;91:143-151.
thop 1995; 107:58-66. 24. Creekmore T, Radney L. Frankel appliance therapy-
8. Baughan B, Demirjian A, Lesveque GY, Lapalme- orthopedic or orthodontic? Am J Orthod 1983;83:89-
Chaput L: The pattern of facial growth before and 108.
during puberty as shown by French-Canadian girls. 25. Gianelly AA, Arena S, Bernstein L. A comparison of
Ann Human Biol 1979;6:59-76. Class II treatment changes noted with the light wire,
9. Hunter CJ: The correlation of facial growth with body edgewise, and Frankel appliances. Am J Orthod 1984;
height and skeletal maturation at adolescence. Angle 86:269-276.
Orthod 1966;36:44-54.
26. Righellis EG. Treatment effects of Frankel, activator
10. Nanda RS: The rates of growth of several facial com-
and extraoral traction appliances. Angle Orthod
ponents measured from serial cephalometric roent-
1983;53:107-121.
genograms. Am J Orthod 1955;41:658-673.
11. Evans CA: Postnatal development of the Human Den- 27. Ghafari J, Jacobsson-Hunt U, Markowitz D, et al.
tition. In Shaw JH, Sweeney EA, Cappuccino CC, et Changes of arch width in the early treatment of Class
al. editors, Textbook of Oral Biology. Philadelphia: II, Division 1 malocclusions. Am J Orthod Dentofac
W.B. Saunders, 1978; 109-142. Orthop 1994; 106:496-502.
12. Silveira AM, Fishman LS, Subtelny JD, Kassebaum 28. Ghafari J, Jacobsson-Hunt U, Markowitz D, et al. Den-
DK: Facial growth during adolescence in early, aver- titional changes and somatic growth in the early treat-
age and late maturers. Angle Orthod 1992;62:185- ment of Class II, Division 1 Malocclusions. In McNa-
190. mara JA, Jr, editor. Orthodontic Treatment: Out-
13. Ghafari J, Jacobsson-Hunt U, Higgins-Barber K, et al: come and Effectiveness. The Craniofacial Growth
Identification of condylar anatomy affects the evalu- Series. Ann Arbor, MI: Center for Growth and De-
ation of mandibular growth. Guidelines for accurate velopment, 1995:139-161.
reporting and research. Am J Orthod Dentofac Or- 29. Lian JB, McKee MD, Todd AM, et al. Induction of
thop. In press. bone-related proteins, osteocalcin and osteopontin,
14. Baumrind S, Frantz RC: The reliability of head film and their matrix ultrastructural localization with de-
measurements. I. Landmark identification. Am J velopment of chondrocyte hypertrophy in vitro. J Cell
Orthod 1971 ;60:111-27. Biochem 1993;52:206-219.
15. Stevenson SK: Growth measurements and the biologic 30. Forest MG, DePeretti E, David M, et al. L'adrenarche
interpretation of mammalian growth. Nature 1962;916: joue-t-elle vraiment un role determinant dans le de-
1070-1074. veloppement pubertaire? Ann d'Endocrinol 1982;43:
16. De Paola DP: Biochemical aspects of development. In 465-495.
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31. Roberts MW, Lis H, Comite F, et al. Dental develop- 35. Zemel BS, Katz SH. The contribution of adrenal and
ment in precocious puberty. J Dent Res 1981;64: gonadal androgen to the growth in height of adoles-
1084-1086. cent males. Am J Phys Anthropo 1986;71:459-466.
32. Katz SH, Hediger ML, Zemel BS, et al. Adrenal an- 36. Krabbe S, Christiansen C, Rodbro P, Transbol I. Ef-
drogens, body fat, and advanced skeletal age in pu- fect of puberty on rates of bone growth and mineral-
berty: new evidence for the relations of adrenarche ization: with observations in male delayed puberty.
and gonadarche in males. Human Biol 1985;57:401- Arch Diseas Childhood 1979;54:950-953.
413.
37. Buschang PH, Demirjian A. Modeling longitudinal
33. Read GF. Status report on measurement of salivary
statural and mandibular growth simultaneously. J
estrogens and androgens. In Malamud D and Tabak
Dent Res 1993;72:366.
L, editors. Saliva as Diagnostic Fluid. New York, NY:
Annals of the New York Academy of Sciences 1994: 38. Gianelly AA. Crowding: timing of treatment. Angle
146-160. Orthod 1994;64:415-418.
34. Porcu E, Venturoli S, Fabbri R, Paradisi R, Longhi M, 39. Demirjian A, Buschang PH, Tanguay R, Patterson
Sganga E, Flamingni C. Skeletal maturation and hor- DK. Interrelationships among measures of somatic,
monal levels after the menarche. Arch Gynecol Obstet skeletal, dental, and sexual maturity. Am J Orthod
1994;255:43-46. 1985;88:433-438.
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Maxillary Adaptation to Expansion in

the Mixed Dentition
Lawrence M. Spillane and James A. McNamara,Jr.
This study presents the findings of 162 patients who underwent rapid max-
illary expansion during the early mixed dentition. Maxillary changes were
evaluated through the analysis of serial dental casts. Arch dimensions were
measured pre-expansion, immediately post-expansion, and at yearly inter-
vals until the eruption of the first premolars. The expansion was effected
with an acrylic rapid maxillary expansion appliance bonded to the posterior
teeth for 5 to 6 months. A simple retention protocol was used post-
expansion. The average increase in transpalatal width was 5 to 6 mm. Dur-
ing the post-expansion period, most of the arch width increases were main-
tained. For example, 90.5% of the original expansion at the first permanent
molars remained after the first year, with slightly less overall expansion
(80.4%) evident at the end of the observation period (2.4 years postexpan-
sion). Maxillary dental arches that initially were narrow tended to retain a
greater percentage of the achieved expansion than those with initially wider
arch dimensions. In addition, maxillae with initially more lingually-inclined
molars tended to retain more expansion than maxillae with initially more
facially-inclined molars. Palatal vault height decreased very slightly during
treatment, but returned to pretreatment values one year after expansion
and increased slightly during subsequent time intervals. The results of this
study indicate that the majority of increased arch dimensions in patients
produced by early orthopedic expansion of the maxilla are maintained at the
end of the transitional dentition.
ne frequently encountered problem in lescent patients depending upon the etiology

O clinical practice is a discrepancy between
patient tooth size and arch size, a relationship
of the crowding or protrusion problem.
During the last two decades, an increasing
that is manifested as dental protrusion or more number of younger patients have been re-
frequently as dental crowding. In the perma- ferred for orthodontic treatment. This change
nent dentition, discrepancies between tooth in referral pattern in part may be a reflection
size and arch size usually are treated in one of of the growing interest in prevention evident
three ways: extraction,1"4 interproximal reduc- within the general population, as well as the
tion,5"8 or arch expansion.9" These treat- result of a heightened awareness among dental
ments have been shown to be effective in ado- practitioners of the possibilities of orthodontic
and orthopedic treatments that can be used in
From Dr Spillane's private practice, Novi, MI; Department of young patients. Mixed dentition patients are
Orthodontics and Pediatric Dentistry, Center for Human Growth referred most frequently on the basis of con-
and Development, The University of Michigan, and Dr McNa- cerns about "crowding," as this potential prob-
mara's private practice, Ann Arbor, ML
Supported in part by grants from the American Association of lem is recognized easily by the family as well as
Orthodontists and the American Association of Orthodontists by dental and medical professionals.
Foundation, St Louis, MO.
Address correspondence to James A. McNamara, Jr., DDS,
PhD, Department of Orthodontics and Pediatric Dentistry, School Methods of Treatment in the
of Dentistry, University of Michigan, Ann Arbor, MI 48109- Mixed Dentition
1078.
Copyright © 1995 by W.B. Saunders Company The variety of treatment alternatives for man-
1073-8746I95I0103-0007$5.00IO aging a tooth-size/arch-size discrepancy in the
176 Seminars in Orthodontics, Vol 1, No 3 (September), 1995: pp 176-187

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mixed dentition is similar in many respects to Serial Extraction

those protocols used to correct this problem in
the permanent dentition. Comparable mixed In instances of more severe crowding, a logical
dentition treatment protocols include serial ex- diagnostic decision may be to extract teeth. Se-
traction and orthopedic expansion, with inter- rial extraction has been recognized as an ac-
proximal reduction typically being reserved ceptable method of treatment for over 60
for permanent dentition patients. In addition, years. This protocol began in Europe in the
space maintenance procedures also can be 1930s, and since then has been advocated by a
used to take advantage of the size differences number of clinicians, including Hotz, 19 ' 20
between the primary teeth and their successors Kjellgren,21 Dewel,22~24 and Dale.25'26 Ringen-
(ie, leeway space). berg27 stated in a critical review of serial ex-
traction protocols that these types of extraction
sequences should be used in those patients who
Space Management have a tooth-size/arch-size discrepancy of 7
mm or greater, while Proffit28 cites a predicted
A relatively simple, yet frequently overlooked, discrepancy of 10 mm or greater as an indica-
protocol that can be used for the patient with tion for serial extraction. In addition, Graber29
mixed dentition is space management, a treat- cautioned against using these protocols in pa-
ment scheme that includes the maintenance of tients with substantial skeletal discrepancies or
leeway space. Among others, Moyers and col- in those who have bialveolar protrusion or
leagues15 have shown that an average of 2.5 retrusion.
mm of space per side can be gained in the McNamara and Brudon17 stated that a pri-
mandibular arch, and about 2 mm per side in mary factor to consider when making a treat-
the maxillary arch, if permanent first molar ment decision concerning serial extraction is
position is maintained during the transition to the size of the individual permanent teeth. A
the permanent dentition. Gianelly16 hypothe- serial extraction protocol is indicated in in-
sizes that tooth-size discrepancies can be re- stances in which teeth are abnormally large
solved in 85% of all mixed dentition patients and the dimensions of the dental arches (eg,
using a non-extraction approach that includes the transpalatal width between the upper first
the placement of one or more holding arches molars) are within normal values. For exam-
in the late mixed dentition. ple, large tooth size can be determined by com-
Appliances used in space management in- paring the aggregate width of the upper or
clude lingual arches to stabilize either mandib- lower four permanent incisors (or both) of an
ular or maxillary molar positions during the individual patient to ethnic- and gender-
transition from the deciduous to the perma- matched standards.15'30 Large tooth size is an
nent dentition. A transpalatal arch17 also can indication for serial extraction rather than ex-
be used either as a passive appliance to main- pansion, because of the obvious difficulty in
tain the position of the upper molars or as an accommodating relatively oversized teeth
active appliance to rotate and torque these within averaged-sized dental arches. If nonex-
teeth, often improving the sagittal molar rela- traction treatment is attempted in these types
tionship in the process. It should be noted, of patients, unfavorable changes in facial pro-
however, that there is wide variation in tooth file may result and the treatment outcome may
size among patients,18 and that each patient be unstable.
must be evaluated radiographically to deter-
mine the relative size of the second deciduous Orthopedic Expansion
molars and their successors. In addition, if
space maintenance is to be used to resolve an An alternative approach to the treatment of
arch length discrepancy, the leeway space can- crowding in the mixed dentition is orthopedic
not be used to correct a disparity in interarch expansion. The cornerstone of this treatment
molar relationship (eg, by "slipping anchor- approach is rapid maxillary expansion (RME),
age"). an orthopedic procedure that has been shown
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178 Spillane and McNamara, Jr.
not only to separate the midpalatal suture, but 60 patients who wore the Haas-type expander
the circumzygomatic and circummaxillary su- and who previously had been studied by
tural systems as well.31 New bone is deposited Wertz. 12 A decrease in the vertical displace-
in the areas of expansion, so that the integrity ment of the maxilla was noted in the bonded
of the mid-palatal suture is usually reestab- appliance group. Sarver and Johnston46 sug-
lished within 3 to 6 months.10 In addition to gested that the inferior displacement of the
crossbite correction, the RME procedure can maxilla may be limited during treatment by the
increase maxillary arch perimeter, as has been forces placed on the dentition by the elevator
shown by Atkins and colleagues32 who re- musculature and by the forces associated with
ported that every millimeter of posterior ex- the stretch of other soft tissues. In the bonded
pansion produces about 0.7 mm of additional expander group, a slight superior movement
arch perimeter. The RME procedure either of the posterior aspect of the palatal plane also
can be used alone or in combination with ad- was noted, as was a downward and posterior
junctive treatments that produce orthodontic movement of the anterior aspect of the maxilla
tooth movement (eg, fixed appliances, lip at the anterior nasal spine.
bumpers, utility arches, Schwarz appliances). Mossaz-Joelson and Mossaz 47 compared
The RME procedure has a long history, dat- banded and bonded spring-loaded expanders
ing back to the middle of the last century, 33 as methods of slow maxillary expansion. Pa-
and has been accepted as a routine treatment tients had metallic implants placed in cranio-
modality for over 30 years.9"14'35"39 This ortho- facial structures before treatment. Lateral and
pedic treatment, however, generally was not posteroanterior cephalograms and serial den-
used routinely in mixed dentition patients un- tal casts were used to evaluate the treatment
til the development of bonding technology. results obtained in two groups of five juvenile
The acrylic splint expander, developed40"44 patients each. The researchers reported that
during the last 20 years, has become a rou- the relative amount of skeletal and dental
tine method of achieving maxillary arch ex- movements equaled results obtained with
pansion in primary and mixed dentition pa- rapid maxillary expansion. No statistically sig-
tients.17'45'46 nificant differences were found between
The acrylic splint expander not only affects banded and bonded appliances with regard to
the transverse dimension, but also can produce dental and skeletal expansion or relapse.
changes in the vertical and anteroposterior di-
mensions as well.17 The occlusal acrylic cover- Purpose
age, typically made from 3 mm-thick splint Although the RME procedure has been stud-
Biocryl (Great Lakes Orthodontic Products, ied extensively in adolescents and to a lesser
Tonawanda, NY), acts as a bite block to inhibit extent in adults and mixed dentition patients,
the eruption of the posterior teeth during the treatment effects produced by the bonded
treatment, thereby making possible the use of acrylic splint expansion appliances on the den-
this appliance in patients with increased lower tal arches of mixed dentition patients have not
anterior facial heights.17 The acrylic occlusal been investigated yet. The purpose of this
coverage also opens the bite anteriorly, facili- study, therefore, is to present initial data from
tating the correction of anterior crossbites. an on-going clinical investigation of the RME
Although there is extensive literature on the procedure in mixed dentition patients. The
treatment effects of the RME procedure, only current investigation quantifies the amount of
two studies have investigated the effects pro- maxillary expansion resulting from the RME
duced by the acrylic splint expander with pos- procedure and the changes in the maxilla at
terior occlusal coverage. Sarver and John- specific post-expansion intervals. The relation-
ston46 conducted a cephalometric study on ship between the stability of arch expansion
twenty patients, whose average age at the be- and initial arch width, age at start of treatment,
ginning of treatment was 10.8 years. The ef- gender, presence of initial posterior crossbite,
fects of acrylic-splint RME treatment for these amount of expansion, and length of retention
patients were compared to the findings from also will be considered.
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Patients and Methods Treatment Protocol

The RME protocol used on these patients is
Sample described in detail in McNamara and Bru-
don.17 The bonded acrylic splint expander was
A major focus of this initial investigation was activated one-quarter turn per day for 28 to 42
assembling the data base. For the present in- days until the appropriate amount of expan-
vestigation, all mixed dentition patients who sion had been achieved, as judged by the up-
had the RME procedure during a 5-year pe- per lingual cusps of the maxillary posterior
riod in the private practice of one of the au- teeth approximating the lower buccal cusps of
thors (J.A.M.) were potential participants in their antagonists. The appliance was left in
the study. All patients under consideration had place for 4 to 5 months following cessation of
tooth-size/arch-size discrepancies diagnosed in expansion to allow for the reorganization of
the early mixed dentition and were treated for the midpalatal and circummaxillary sutural
this problem, at least in part, by rapid maxil- systems. About half of the sample patients had
lary expansion. The parent sample consisted brackets placed on the upper four anterior
of 224 consecutively treated patients. teeth to achieve incisal alignment. Immediately
Well-defined exclusionary rules were ap- after appliance removal, an acrylic palatal re-
plied to the parent sample to establish a de- tainer with arrow clasps on either side of the
fined treatment group. No patients were ex- second deciduous molars was applied and
cluded from the study based on the success of worn by the patient for a minimum of 1 year.
treatment; however, patients became ineligible
for one or more of the following reasons:
unerupted maxillary first permanent molars Data Collection
before treatment (25 cases eliminated); not all
maxillary first and second deciduous molars Records are gathered prolectively48 on all par-
and deciduous canines present before treat- ticipants in the Ann Arbor Expansion Study,
ment (14 cases eliminated); absence of imme- an ongoing clinical investigation of the treat-
diate postexpansion records (20 cases elimi- ment effects produced by rapid maxillary ex-
nated); and distorted dental cast (3 cases elim- pansion in the mixed dentition. Accordingly,
inated). all subjects have records taken at specific treat-
The final treatment sample for this study ment intervals, regardless of the outcome of
ultimately consisted of 162 subjects (73 males treatment. Specifically, each patient has study
and 89 females) almost all of whom were white. models taken pretreatment, immediately post-
The average age of the subjects when pretreat- treatment, at 6-month intervals until the begin-
ment records were collected was 8 years 8 ning of the final phase of fixed appliance ther-
months (±16 months). Thirty-seven subjects apy, at the end of treatment, and then every 1
exhibited unilateral crossbites and six subjects, or 2 years thereafter. Cephalograms have been
bilateral posterior crossbites; the remaining (or will be) obtained before and after major
119 subjects had no posterior crossbites. phases of treatment (ie, Phase I, Phase II) and
None of the patients had orthodontic treat- at five years posttreatment as well.
ment in the maxillary arch prior to undergoing For the purpose of the present investiga-
RME treatment. Although it was anticipated tion, study models taken before expansion
that virtually all patients would have a final (T x ), immediately post-expansion (T2), one
phase of fixed-appliance therapy after the year postexpansion (T3), two years postexpan-
eruption of the permanent teeth, the interval sion (T4), and after the eruption of the first
considered in this investigation included the premolars (T5) were evaluated. According to
phase of treatment during which the expan- the study's exclusionary rules, all 162 subjects
sion appliance was worn and the subsequent had study models taken pre- and posttreat-
interval during the mixed dentition phase until ment. Because of the longitudinal nature of
the eruption of the first premolars was com- the overall study, however, there was a de-
pleted (2.4 years postexpansion). creasing number of subjects beginning at T3
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(124 subjects), T4 (94 subjects), and T5 (84 sub- Other Measures

jects). The average post-expansion time inter- Palatal height. Palatal height was measured
val of the T5 records was 2.4 years. as the distance from the functional occlusal
plane at the level of the maxillary first molars
to the palatal raphe.10
Measurement of Arch Dimensions Arch depth. Dental arch depth was measured
as the distance from a point between the cen-
Measurement of arch width, palatal height, tral incisors perpendicular to a tangent touch-
and palatal depth were obtained on the max- ing the mesial surfaces of the maxillary first
illary dental casts available for each series. Se- molars.10
rial maxillary dental casts were measured di-
rectly by one investigator (L.M.S.) who used a
digital caliper calibrated to 0.1 mm. Photo- Analysis of Subgroups
copying or digital imaging of the dental casts Postexpansion changes in arch width were an-
was not used. alyzed for subgroups of the treatment sample
to determine correlations between pretreat-
Transpalatal Width ment variables and postexpansion stability.
Initial arch width. The treated sample was di-
Transpalatal width was measured between the vided into "narrow" and "wide" subgroups to
deciduous canine/canines, first deciduous mo- determine if maxillae that were narrower at
lar/first premolar, second deciduous molar/ the beginning of treatment retained more ex-
second premolars, and the first permanent pansion than those that were wider initially.
molars. Dental cast data were not recorded for Patients with the 20 widest arches and the 20
teeth in the process of initial eruption and ex- narrowest arches were compared. The groups
foliation or for teeth that were severely tipped, were divided on the basis of initial transpalatal
rotated, or carious, for teeth that were ectopi- width between the maxillary first primary mo-
cally erupted, or for teeth that obviously were lars. This measure was chosen for two reasons.
distorted in the study model. Both lingual den- At T5 time, the first premolars were fully
tal and facial alveolar measures, as described erupted and were thought to be a reliable in-
by McDougall and co-workers,49 were ob- dicator of overall retained expansion because
tained. these teeth remained unerupted during the
Lingual measures. The distances between an- expansion procedure and thus were affected
timeres were measured from the cervical mar- only indirectly by the treatment. In addition,
gin of one tooth at the point of greatest con- the distance between the deciduous first molar/
vexity to the same point on its counterpart on first premolar appeared to be more sensitive to
the opposite side of the arch. When the dimen- changes in arch form than was the distance
sion between first permanent molars or second between the maxillary permanent first molars,
deciduous molars were measured, landmarks particularly in instances of tapered maxillary
at the junction point of the lingual groove and arches.
the gingival margin were used. Initial tooth inclination. In order to determine
Alveolar measures. The distances between the if lingually inclined buccal segments retain
facial alveolar processes overlying the first de- more expansion than those that were more fa-
ciduous molar/first premolars regions (ante- cially inclined, the treated sample was divided
rior alveolar measure) and the first permanent into subgroups, based on the difference be-
molar region (posterior alveolar measure) tween lingual dental and facial alveolar mea-
were determined by measuring reference sures at the level of the maxillary first perma-
points located 4.0 mm below the free gingival nent molar. A ratio of pretreatment, consisting
margin at approximately the same position of first molar lingual dental and facial alveolar
mesiodistally as were those points used to es- arch widths, was made. The 20 subjects with
tablish the lingual landmarks for the decidu- the highest ratio (lingually inclined teeth) were
ous first molars/first premolars and permanent compared with the 20 subjects with the small-
first molars.49 est ratio (facially inclined teeth).
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Other comparisons. Other factors were corre- ation for each dimension was calculated from
lated with the stability of the expansion, in- the double-determinations with the aid of
cluding age at start of treatment, gender, the Dahlberg's formula:
presence of an initial crossbite, the amount of
the expansion, and the length of time postex- SDe =
pansion. where d is the difference between each of the
50 replications and N is the number of sub-
Statistical Analysis jects. For the measures used here, the error
standard deviations were about 0.2 to 0.3 mm.
Groups were compared by completely ran-
domized £-tests, whereas the significance of
changes across time was determined by paired Results
£-tests. The association between pretreatment Treatment Effects Produced by RME
variables was evaluated by the Pearson prod-
uct-moment correlation. Multiple regression Arch Width
and correlation were employed to test the Significant increases (P < .001) in arch width
working hypothesis that the amount of stable were seen when preexpansion (T:) and postex-
molar expansion at T3, T4, and T5 times can be pansion (T2) measurements were compared
predicted from measures evaluated at Tx time. (Table 1). Mean transpalatal width increases at
Independent variables considered included T2 time ranged from 4.9 mm at the canines to
age at start of treatment, gender, pretreatment 6.0 mm at the first molars, indicating that
crossbite, amount of expansion obtained, and more expansion occurred posteriorly than an-
postexpansion time. For all tests of statistical teriorly. No sexual dimorphism was observed.
significance, the type I error rate was set at .05. A comparison of the differences between the
Given the present sample size, therefore, cor- lingual dental measures and the facial alveolar
relations of r = .7 or greater were considered measures indicated that the teeth anchoring
significant. the expander were moved bodily rather than
tipped (Table 1).
Error Study Palatal Height
Measurements were repeated on 50 randomly Palatal height remained relatively unchanged
selected sets of casts. The error standard devi- postexpansion (Table 2). The mean pretreat-
Table 1. Transpalatal Width Preexpansion (Tj) and Postexpansion (T2)

Mean SD Mininum Maximum
Time Distance N (mm) (mm) (mm) (mm)
T, 6-6 162 32.4 2.8 23.5 40.7
E-5 161 28.9 2.6 22.4 34.7
D-4 160 25.0 2.2 19.4 30.7
C-3 153 22.8 2.2 17.6 28.3
Posterior Alveolar 162 53.7 2.9 46.4 61.7
Anterior Alveolar 162 41.8 2.3 49.6 49.6
T2 6-6 162 38.3 2.8 29.2 45.6
E-5 159 34.5 2.3 28.4 42.0
D-4 157 30.6 2.1 25.2 36.9
C-3 148 27.6 2.1 21.1 32.4
Posterior Alveolar 162 59.9 2.9 51.8 66.7
Anterior Alveolar 162 47.2 2.4 41.3 52.8
T.-T, 6-6 162 6.0* 1.6 2.2 12.1
E-5 160 5.6* 1.8 1.3 13.3
D-4 157 5.7* 1.8 0.7 13.3
C-3 147 4.9* 1.9 0.3 11.4
Posterior Alveolar 162 6.2* 1.7 1.2 13.0
Anterior Alveolar 162 5.5* 1.8 1.3 12.3
*P < .001.
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ment (T\) palatal height of 17.6 mm, as mea-

sured at the level of the first permanent mo-
lars, decreased to 17.0 mm at the time of T2, a
small but statistically significant difference (P
< .001).
Palatal Depth
A very slight but significant (P < .05) decrease
in palatal depth was observed between pre-
treatment (29.5 mm) and postexpansion (29.2
mm) dental casts (Table 2).
LOCATION
Figure 1. The percentage of original expansion re-

Postexpansion Changes in maining at each posttreatment time period. T r l-
Arch Dimensions year post-expansion, T 2 -2-years post-expansion,
T3-eruption of upper first pre-molars. B-T3, ^-T4,
Arch Width S-T5.
Arch dimensions existing postexpansion (T2) Palatal Height

were given a value of 100%, representing the Palatal height, measured from the occlusal
total arch width present at the time of appli- plane at the level of the first molars, increased
ance removal. Arch width measures at later in- slightly during the postexpansion interval. The
tervals were expressed as percentages of the mean increase of 0.8 mm measured between
T2 (posttreatment) distances. the time of T2 and T3 indicated that palatal
Maxillary arch widths decreased during the vault height increased to pretreatment values
postexpansion period (Figure). For example, (17.6 mm). Palatal vault height continued to
at the level of the first permanent molar, increase, totaling 1.4 mm at T4 and 1.5 mm at
90.5% of transpalatal width was maintained af- T5 (Table 2).
ter 1 year, 85.8% after 2 years, and 80.4% at
the time of the eruption of the first premolar Arch Depth
(T5). A similar reduction was seen in the pre- Statistical comparisons of pretreatment and
molar and the canine regions. posttreatment measurements of arch depth in-
dicate that palatal depth did not change signif-
Table 2. Average Palatal Height and Palatal icantly after treatment (Table 2).
Depth
Mean SD Significant Analysis of Subgroups
Time N (mm) (mm) to Tj
Percentage of Expansion Retained versus
Palatal Initial Arch Width
height
T! 162 17.6 1.7 na As mentioned previously, "narrow" and "wide"
T2 162 17.0 2.0 t subgroups were identified, based on the pre-
T3 120 17.7 2.1 *
T4 90 18.3 2.1 t treatment arch width of the deciduous first
T5 84 18.4 2.1 t molars. The 20 subjects with the narrowest
Palatal maxillae and the 20 subjects with the widest
depth
T\ 162 29.5 2.2 na maxillae were compared. In the analysis of the
T2 162 29.2 2.3 * T5 values, there were significant differences
T3 119 29.4 2.2 ns between the groups in the percentage of ex-
T4 88 29.6 2.2 ns
T5 81 29.4 2.2 ns pansion retained (P < .05). For example, the
average percentage of expansion retained at
*P < .05.
+
P < .001. the first premolars for the Harrow arches was
Abbreviations: ns, not significant; na, not applicable. 85.2%, compared with 62.0% for the wide
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arches. Similar differences were observed in to predict future changes in any of the dental
other arch width measures. cast variables at any time point.
Percent of Expansion Retained versus
Initial Tooth Inclination Discussion
To determine if initial inclination of the pos- This investigation represents the first report
terior teeth was associated with the amount of from the Ann Arbor Expansion Study, an on-
stable expansion, the 20 subjects with the most going clinical trial of the treatment effects pro-
lingually inclined first molars were compared duced by rapid maxillary expansion in mixed
with the 20 subjects with the most facially in- dentition patients. Records were collected to
clined molars before treatment. Significant be- determine maxillary dental-arch changes oc-
tween-group differences were observed (P < curring after expansion and also during a de-
.05); the average percentage of arch expansion fined posttreatment interval.
retained at the T5 period was 96.3% and It should be noted that the amount of arch
75.6% for the first molar and first premolar, expansion produced by a given RME protocol
respectively, for the more lingually inclined is variable and is based on the goals of the cli-
group. In contrast, for the arches with initially nician. For example, Haas9"12 recommends
more facially inclined molars, the average per- opening the expander to the full extent of the
centage of retained expansion was 83.6% and screw (10.0 to 10.5 mm), thus maximizing in-
66.8% for the first molar and first premolar creases in arch width. In the current study, the
respectively. appliances were expanded more modestly—
only to the extent that the lingual surfaces of
the upper posterior teeth maintained contact
Correlations Between Study Variables and with the buccal cusps of the mandibular teeth.
Expansion Retained Thus, no buccal crossbite relationships were
To examine the effect of postexpansion time, present at the T2 time.
the percentage of stable first premolar expan-
sion was plotted as a function of time following
expansion treatment. The amount of recovery Transpalatal Width
after expansion did not increase as a factor of Substantial increases in transpalatal width oc-
time (r = .053). Width at the deciduous first curred as a result of rapid maxillary expan-
molar was analyzed to determine its effect on sion. The amount of expansion ranged from
the percentage of first premolar expansion re- 4.9 mm to 6.2 mm, as measured at lingual den-
tained at the time of T5. Initial arch width was tal and facial alveolar points (Table 1). The
a poor predictor of the stability of expansion (r maxillary first molars were present throughout
= — .168). When the amount of expansion at the observation period and, on average, dem-
the first premolar region was compared to the onstrated about 5 mm of residual expansion at
amount of subsequent relapse, only a weak the time of T5, 2.4 years after expansion. The
correlation was found (r = .468). In addition, net expansion retained at the first molars was 4
the amount of expansion during treatment in- to 10 times greater than would be expected
dicated essentially no association (r = .08) with without treatment. For example, the average
the amount of stable first premolar expansion. annual change in maxillary arch width from
Further comparisons were made to deter- ages 8 to 12 years in untreated individuals is
mine if the stability of the expansion is a func- 0.3-0.5 mm at the permanent first molars and
tion of age, gender, and presence of a pretreat- — 0.5 to 0.3 mm at the deciduous first molars/
ment crossbite. All multiple correlations exam- premolars.15'30
ined in this study were weak (r2 = .01—.21), Arch width at the end of the retention pe-
suggesting that the changes seen in dental cast riod averaged 72% to 91% of the treatment
dimensions were relatively independent of expansion (Fig 1), a 9% to 28% relapse/
these variables. Multiple regression analysis rebound during the posttreatment period.
failed to show any clinically significant linear The amount of rebound reported in this study
combinations of parameters that could be used is considerably less than that reported by pre-
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vious investigators. Stockfisch00 noted 40% to (Table 1), suggesting a bodily movement of the
50% of patients relapse in intermolar width, anchor teeth. This observation was verified in
whereas Linder-Aronson and Lindgren39 re- a subsequent study of some of the same pa-
ported patient relapse of 55% of the original tients used in this sample. Brust03 and Brust
expansion. Wertz13 reported a 30% decrease and McNamara 04 used a digital imaging sys-
in intermolar width, as compared to 20% for tem developed after the completion of the
the present investigation. Stable arch width in present study and noted that the average
the deciduous canines/canine region was 91% amount of tipping produced by the acrylic
of the original expansion in the current study, splint expander is about one degree, thereby
a relapse of 9%. This amount of relapse was indicating that the movement of the teeth an-
considerably less than the 77% relapse re- choring the acrylic splint expander is bodily in
ported by Linder-Aronson and Lindgren39 for nature.
the same region. Subjects with initially narrower maxillae
Although on average a loss of arch width tended to retain more expansion than initial
postexpansion was noted, many subjects expe- wider maxillae, as measured after the first pre-
rienced increases in arch width beyond initial molars erupted. Narrow maxillary arches re-
expansion values. These changes occurred in tained 85% of the original expansion, and
25% to 30% of the sample and may be related wider arches retained only 62% of the original
to increases in transpalatal width that occur expansion. Spillane and McNamara 00 showed
during normal growth.10'30 Wertz 13 observed that, in untreated subjects examined annually
increases in skeletal and dental widths follow- from ages 7 to 15 years, individuals with ini-
ing treatment, but only in the younger subjects tially narrow maxillae experienced greater
of his study. gains in arch width than did subjects with ini-
The effects of age and maturation on rapid tially wider maxillae. This observation may
maxillary expansion, as shown in the cephalo- corroborate, in part, the differences in residual
metric studies of Krebs0 Lo2 and Wertz and expansion between the "narrow" and "wide"
Dreskin,13 may help explain the differences in subgroups.
results between the present study of mixed
dentition patients and previous studies. These
Palatal Height
investigators showed similar dental width in-
creases during treatment for all age groups, During treatment in this study, palatal height
but significant skeletal changes only in decreased slightly as a result of rapid maxillary
younger individuals. Krebs02 concluded that, expansion. As described by Björk and
although skeletal expansion is influenced by Skieller,06 palatal height increases both by ver-
age, dental expansion is less dependent. In the tical development of the maxilla and by alveo-
present study, the average age of the subjects lar growth associated with the eruption of
(8.6 years) was significantly younger than the teeth. The average decrease of 1.7 mm in pal-
average age (13.5 years) of the subjects used by atal height observed in this study is contrasted
Timms.30 Subjects from the older age groups with normal annual increases in palatal vault
may have influenced the average buccal tip- height of 0.5 mm to 1.0 mm that occurs after
ping reported by Timms. The flexible appli- the eruption of the maxillary first molar and
ance design used by Timms in his treatment continues to increase through adolescence.10
undoubtedly contributed to the buccal tipping The slight decrease in palatal height observed
as well. in the present study may be due to a lateral
The appliance used in the present study was rotation of the two palatal segments around
rigid in design and remained bonded to the the mid-palatal suture, 31 ' 02 thereby causing the
posterior teeth for 5 to 6 months before appli- palatal vault to become more shallow.
ance removal (T2). The expansion observed Palatal height increased with time following
did not involve a buccal tipping of the anchor removal of the expansion appliance. One year
teeth, as has been reported by others. The fa- after treatment (T3), palatal height returned to
cial alveolar measures increased to a similar ex- pretreatment values, and two years following
tent, and so did the lingual dental measures expansion (T4) palatal height averaged 0.5 mm
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greater than pretreatment values. The in- atal vault height, and arch depth were evalu-
crease in palatal vault height during the obser- ated to quantify changes occurring during
vation period may be an indicator of continued treatment in addition to changes occurring
growth after rapid maxillary expansion. It during the posttreatment interval. The results
should be noted that, although palatal height of this study were as follows:
returned to pretreatment values, this increase
was less than the palatal vault changes ex- 1. Rapid maxillary expansion (RME) resulted
pected without treatment. Moyers et al15 rein a statistically significant increase in max-
ported that, over a 2-year period, the average illary arch width of about 5 to 6 mm, de-
palatal height increase in untreated subjects is pending on the region measured.
1.0 to 2.0 mm. The increase in palatal vault 2. Seventy-two to ninety-one percent of the
height in the present sample also was less than expansion remained at the time of eruption
that observed by Lebret,57 who reported a 2 of the maxillary first premolars.
mm gain 4 years after rapid maxillary expan- 3. Rapid maxillary expansion produced bodi-
sion therapy. ly, rather than tipping movement of the
Palatal vault height may be less than in un- posterior teeth.
treated individuals because of remodeling of 4. Initially narrower arches tended to retain
the palate or intrusion of the teeth during more expansion than initially wider arches.
treatment. Sarver and Johnston46 showed that 5. Maxillae with initially more lingually in-
the downward displacement of the maxilla clined molars tended to retain more expan-
may be minimized or negated using a bonded sion than maxillae with initially more fa-
acrylic expansion appliance. The method of cially inclined molars.
measurement used in the present study related 6. Palatal vault height decreased during treat-
the occlusal plane to the depth of the palatal ment but returned to pretreatment values 1
vault and, therefore, could not evaluate the year after expansion and increased slightly
relative contributions of maxillary rotation and thereafter.
dental intrusion. 7. Arch depth decreased slightly during treat-
ment and showed no statistically significant
Association of Variables change during the posttreatment interval.
8. The amount of residual expansion could
Associations between various parameters un- not be correlated with gender, age at start
der study were made in an attempt to predict of treatment, pretreatment crossbite, initial
individual percentages of stable expansion. arch width, or length of posttreatment in-
Multiple regression was used to investigate the terval.
possible effect of age, gender, initial crossbite,
initial arch width, amount of expansion ob- The results of this investigation, a major fo-
tained, and posttreatment time on the percent cus of which was the establishment of the data
of expansion retained. The values of r2 ob- base, are preliminary, and reflect only the ini-
tained ranged from .01 to .13 mm, suggesting tial findings of an ongoing clinical study. Sub-
that changes in dental arch dimensions were sequent reports will consider changes in arch
relatively independent of the variables studied. width, arch depth arch height, and arch perim-
eter evident before and after the anticipated
Summary and Conclusions final fixed appliance phase of treatment, and
during the retention and postretention peri-
The present investigation was a clinical study ods.
in which serial dental casts were gathered ev-
ery 6 months on 162 subjects treated with
rapid maxillary expansion during the mixed
Acknowledgment
dentition. Subjects were treated with an acrylic
splint appliance that was bonded to the maxil- We thank Dr Lysle E. Johnston, Jr., Dr Carroll-Ann Trot-
lary posterior teeth for approximately 5 man, and Dr Paul W. Reed for their editorial assistance
months. Changes in maxillary arch width, pal- during the preparation of this manuscript.
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adults with and without surgery. Angle Orthod 1987; 52. Krebs A. Rapid expansion of midpalatal suture by
75:245-263. fixed appliance. An implant study over a seven year
45. McNamara JA Jr. An orthopedic approach to the period. Trans Europ Orthod Soc, 1964;40:131-142.
treatment of Class III malocclusion in growing chil- 53. Brust EW. Arch dimensional changes concurrent with
dren. J Clin Orthod 1987;21:598-608. expansion in the mixed dentition. Unpublished Mas-
46. Sarver DM, Johnston MW. Skeletal changes in vertical ter's Thesis. Ann Arbor, MI: Department of Orth-
and anterior displacement of the maxilla with bonded odontics and Pediatric Dentistry, The University of
rapid palatal expansion appliances. Am J Orthod Michigan, 1992.
1989;95:462-466. 54. Brust EW, McNamara JA Jr. Arch dimensional
47. Mossaz-Joelson K, Mossaz CF. Slow maxillary expan- changes concurrent with expansion in mixed denti-
sion: a comparison between banded and bonded ap- tion patients. In: Trotman CA, McNamara JA Jr,
pliances. Europ J Orthod 1989;! 1:67-76. Orthodontic Treatment: Outcome and Effectiveness,
48. Feinstein A. Clinical Epidemiology: The Architecture Monograph 30, Craniofacial Growth Series. Ann Ar-
of Clinical Research., Philadelphia, PA: Saunders, bor, MI: Center for Human Growth and Develop-
1985:225-226. ment, The University of Michigan, 1995.
49. McDougall PD, McNamara JA Jr, Dierkes JM. Arch
width development in Class II patients treated with 55. Spillane LM, McNamara JA Jr. Arch width develop-
the Frankel appliance. Am J Orthod 1982;82:10-22. ment relative to initial transpalatal width. J Dent Res
50. Stockfisch H. Rapid expansion of the maxilla—success 1989;68:374.
and relapse. Trans Europ Orthod Soc, 1969;45:469- 56. Bjork A, Skieller V. Facial development and tooth
481. eruption: an implant study at the age of puberty. Am
51. Krebs A. Expansion of the midpalatal suture by means J Orthod 1976;62:339-383.
of metallic implants. Trans Europ Orthod Soc, 57. Lebret M: Changes in the palatal vault resulting from
1958;163-171. expansion. Angle Orthod 1965;35:97-105.
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Leeway Space and the Resolution of

Crowding in the Mixed Dentition
Anthony A. Gianelly
The leeway space provides adequate space to resolve crowding that is

present in the mixed dentition in the majority of individuals. This space can
be maintained by preserving arch length with a lingual arch as the primary
teeth begin to exfoliate, unless conditions such as the premature loss of a
primary canine require earlier intervention. A lip bumper can also be in-
serted after the eruption of the first premolars to preserve arch length.
rowding, which can be present in all classes Crowding was defined as a tooth-size/arch-size
C of malocclusions, is probably the most
common problem resolved by orthodontic
discrepancy and was determined by comparing
the mesiodistal diameters of the primary and
treatment. To align a crowded dentition, space permanent teeth to arch perimeter. When
is necessary. In the mixed dentition, one mech- teeth were absent, their size was estimated
anism for gaining space for alignment is to from their antimere, when present, or from
preserve the leeway space, which can be as data provided by Moyers et al.3
much as 4.3 mm.1 This generous space may be When the leeway space gain was included in
one reason why crowding in the mixed denti- the analysis, only 23 of the 100 individuals had
tion becomes less pronounced with the devel- insufficient space for alignment. In actuality,
opment of the permanent dentition. For exam- the leeway space represents the "E" space or
ple, Moorrees and Chada indicated that 1 to 2 the difference between the mesio-distal (m-d)
mm of crowding is a characteristic feature in diameter of the second primary molar and the
individuals who demonstrate normal align- second premolar because the combined m-d
ment in the permanent dentition.1 diameter of the primary canine and first molar
This observation raises a series of interest- (13.64 mm) is approximately equal to the com-
ing questions, such as what is the incidence of bined m-d diameter (13.85 mm) of the perma-
crowding in the mixed dentition, and how of- nent canine and first premolar.3 This simpli-
ten can the leeway space provide adequate fies the usual leeway space calculation.
space to resolve this crowding? (Since lower Thus, with the inclusion of the E space, 77
arch conditions dictate the strategy for maxil- of the 100 patients had adequate space in the
lary arch treatment, only the changes in the arch to accommodate an aligned dentition.
lower arch will be discussed.) (The size of unerupted permanent teeth was
To answer these questions, the mandibular derived from m-d diameter ratios of primary
models of 100 patients in the mixed dentition to corresponding permanent teeth as defined
stage of development were evaluated. In the by Moyers et al.3)
sample, crowding, which averaged 4.5 mm, In seven of the remaining 23 patients who
was present in 85 of the 100 individuals.2 would still exhibit a space deficit even after the
inclusion of the E space, the crowding did not
From the Department of Orthodontics, Boston University exceed 2 mm, indicating that 84 out of 100
School of Graduate Dentistry, Boston, MA. subjects would have no more than 2 mm of
Address correspondence to Anthony A. Gianelly, DMD, PhD, crowding by simply maintaining the E space.
MD, Professor and Chairman, Department of Orthodontics, Bos- Developmentally, there are three signs that
ton University School of Graduate Dentistry, 100 E Newton St,
Boston, MA 02118. are usually described to identify the potential
Copyright © 1995 by W.B. Saunders Company for crowding in the permanent dentition.4 The
1073-8746I95I0103-0006$5.00IO first is the lack of interdental spaces in the pri-
188 Seminars in Orthodontics, Vol 1, No 3 (September), 1995: pp 188-194

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Leeway Space and Crowding in the Mixed Dentition 189
mary dentition. This sign is not especially reli-

able since Baume showed that 9 of 16 individ-
uals with no interdental spaces in the primary
dentition did not exhibit crowding in the per-
manent dentition.5 The second sign is crowd-
ing of the permanent incisors in the mixed
dentition. The third sign is the premature loss
of a primary canine, presumably reflecting in-
adequate space for the eruption of the lateral
incisor. In crowded conditions, the erupting
lateral incisor "promotes" the resorption of the
root of the primary canine which then exfoli-
ates.
In the group of 100 patients, the most se-
vere crowding was most often associated with
the early loss of a primary canine.
Maintenance of the E Space

Two common appliances used to maintain the
E space are the lingual arch and the lip bum-
per.
Figure 1. (A) Models illustrating early loss of right
Lingual Arch primary canine, the removal of the left primary ca-
nine, and a lingual arch in place to maintain arch
Despite its widespread use, comparatively little length. (B) Lingual arch in place as permanent teeth
is known concerning the effect of lingual arch erupt. Space is available for all teeth.
placement on the dimensions of the lower
arch. In one of the few reported investigations stance, in a review article on space closure fol-
on this topic, Singer observed that both arch lowing the early loss of primary teeth, Owen
length and arch width were increased slightly indicated that most investigators found that
by approximately 0.5 mm.6 Although not a space closure in the lower arch is primarily due
clinically useful increase, this led him to state, to lingual movement of the lower incisor
"It can be seen that the appellation 'passive lin- teeth.7
gual arch' is a misnomer. Certain basic dental This raises a question: Why not consider a
changes were noted with the use of this appli- serial extraction protocol in patients who lose a
ance. A portion of the effect may be construed primary canine early, because exfoliation of
as active movement (distal repositioning of the the canine represents a space deficit and the
molars) although the reason remains obscure." most severe crowding was often noted in pa-
The results of Singer's study indicated that the tients who lost a primary canine early? This
lingual arch should readily maintain the E would avoid the routine insertion of a lingual
space. arch in these patients. An answer to this ques-
Timing of lingual arch placement. The lingual tion is that the prediction of impending crowd-
arch is used when a primary canine is lost pre- ing in the permanent dentition is difficult.5'8
maturely, disrupting the integrity of the dental For example, Sampson and Richards8 were
arch (Fig 1). The opposite primary canine is unable to predict incisor crowding from dental
then removed for purposes of symmetry and a arch parameters and pre-eruptive tooth posi-
lingual arch is inserted. The function of the tions because of unpredictable changes in den-
lingual arch at this stage is to prevent the lin- tal arch width and depth. They advised that,
gual movement (uprighting) of the incisors "Considering the great individual variation,
with consequent loss of arch length. For in- lack of reliable radiographic and dental arch
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190 Anthony A. Gianelly
parameters of crowding, and the unexpected cur if the lateral incisors moved lingually, fol-
tendency for many initially crowded cases to at lowed by the central incisor teeth.
least partially resolve the incisor and/or canine
crowding, extreme caution should be exercised Lip Bumper
in deciding which patients will truly benefit
from serial extraction or early space gaining The lip bumper is an effective appliance for
procedures." maintaining and/or increasing arch length (Fig
Another reason for not routinely endorsing 3). Any increase in arch length generally re-
serial extraction procedures when crowding flects both distal movement of the molars and
exists in the mixed dentition is the observation labial movement of the incisors.11'12 Also, most
by Ringenberg that there was no difference in of the changes induced by lip bumper treat-
treatment results obtained in a group of pa- ment occur within the first year.11 As an ex-
tients treated by means of serial extraction ample, Bergerson noted that a 1 mm increase
when compared with patients whose treatment in arch length can routinely be achieved in as
involved conventional premolar extractions.10 little as 3 months of full-time lip bumper use.12
Active treatment in the serial extraction group Arch width also increases with lip bumper
was approximately 6 months shorter. This in- treatment. 13 Cetlin and Ten Hoeve14 demon-
dicated that the extraction procedure can be strated a 2.5 mm increase in intercanine width
delayed with little consequence. and a 4 mm gain in interpremolar width. They
Accordingly, a recommended strategy is to emphasized that this arch width increase is an
maintain arch length until the first premolars important mechanism for gaining space for in-
erupt. At that time, a decision concerning ex- cisor alignment. Others have observed similar
traction can be made with more precision be- increases in arch width. 10
cause most developmental changes will have Nevant et al13 indicated that the type of lip
occurred, reducing the chance for error. bumper and the activation schedule can influ-
There are exceptions to this protocol. One is ence the changes in the mandibular arch ob-
the presence of a dehiscence on the labial as- tained with lip bumper therapy. They noted a
pect of a mandibular incisor tooth. Lingual larger increases in arch length and width when
movement of the incisor might be favorable a lip bumper with an acrylic shield was acti-
since lingual movement is associated with more vated every 4 to 5 weeks when compared with
periodontal support.9 A second exception is the changes observed with the use of a thinner
when erupting teeth are forced to erupt in an lip bumper which was activated every 2 to 3
area of non-keratinized gingiva. In this in- months. Thus, more frequent activation of a
stance, the periodontal support of the tooth lip bumper with a relatively thick labial shield
might be compromised due to the lack of ke- can enhance the changes in the dental arch.
ratinized tissue. The arch length and width changes produced
A lingual arch is also commonly used when by the lip bumper lead to an increase in arch
the lateral incisors erupt lingual to the central circumference which, in one study, averaged
incisors (Fig 2). The function of the appliance 4.1 mm. 11
is to prevent loss of arch length that could oc- Because both the length and width of the
lower dental arch can be increased by bumper
use, what are reasonable objectives of lip
bumper treatment? This is a difficult question
to answer because opinions differ concerning
the stability of expanded mandibular dental
arches. Nance 16 believed that excessive labial
movement of anterior teeth leads to eventual
relapse and possible tissue damage: "to line up
the teeth in an arch to normal contact point
relationships ... is downright easy provided
Figure 2. Pre- and post-lingual arch placement. one ignores the relationships of teeth to sup-
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Figure 3. (A) Lip bumper in place. (B) Adequate space is present to align the teeth. Arch length was
increased by 1 mm.
porting bones." His view reiterates the well- most gratifying. Not so for the other, the con-
known extraction/non-extraction controversy trol case. . . . The experiment was repeated,
between Edward Angle and Calvin Case. doubling the numbers and the results were
Angle, as referenced by Bernstein, repre- similar."20 Finally, a group of patients present-
sented the "new school" of dentistry which ing a discrepancy between the size of teeth and
stressed that normal occlusion could exist only basal bone were selected. They were first
when there was a full complement of teeth.17 treated by retention of all teeth. "These same
Angle also believed that basal bone growth patients were retreated after the removal of all
could be induced by functional forces so that first premolars. The mandibular incisors were
teeth that were moved to a new position would positioned over basal bone. The changes in fa-
be surrounded by newly-formed basal bone. cial esthetics were remarkable and the cases are
Thus, expansion was acceptable and extrac- now out of retention and free from any serious
tions never indicated. In disagreement, Case, relapse."19
who supported the views of the "rational Tweed also stated that when patients with
school," argued that "new bone cannot b? in- bimaxillary protrusions were treated by non
duced to grow beyond its inherent size and, extraction procedures, "the cases were finished
therefore, there are indications for extractions with the mandibular incisors either tipped or
in certain types of malocclusions".18 bodily displaced mesial from their normal po-
One of the more compelling tales of orth- sition. Facial aesthetics were bad and the dis-
odontic folklore is the conversion of Dr harmony of facial lines increased in direct re-
Charles Tweed from a "non-extractionist" to lation to the extent of mesial displacement of
an "extractionist." As he recalled, "I practiced the mandibular incisors from their normal po-
the philosophy of the full complement of teeth sition. Years of retention were futile, and, as a
diligently for six years. At the end of six and a rule, collapse of the mandibular arch in the
half years of orthodontic practice, I called 70% incisor region occurred . . . and irreparable
of the patients I had treated and classified the damage to hard and soft investing tissues par-
results into successes and failures. To my ticularly in the incisal and premolar areas, was
amazement, my successes were less than 20% the usual aftermath of such treatment."19
and my failures more than 80%."19 This brief review indicates that, historically,
Tweed then performed a series of trials the expanded lower dental arch was perceived
that, to this day, are unique. He noted, "In the to be unstable. Since there is confusion, one
beginning, two patients with similar occlusions approach to develop a sound strategy might be
were selected, both 13 years old. One was to evaluate comparative outcomes. For exam-
treated with the retention of teeth and the ple, is the stability of lower dental arches which
other had four first premolars removed before have been expanded in the mixed dentition
treatment. After treatment, the results were equal to or greater than the stability of dental
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arches which have not been expanded? This tigations indicates that the original arch di-
question has been addressed in one study. Lit- mensions are not easily changed. Therefore, a
tle et al compared the stability of mandibular prudent goal of lip bumper therapy may be to
dental arches that were expanded in the mixed gain no more than 1 mm of arch length and
dentition stage of development to resolve little arch width, producing only a 2 mm in-
crowding with the stability of arches that were crease in arch perimeter. If this 2 mm increase
not expanded.21 They found that lower arches in arch perimeter is applied to the 100 individ-
that underwent an increase of more than 1 mm uals previously described, space for alignment
in arch length (as measured from one molar to would be available in 84 of these individuals or
the mid point between the central incisors to in 84% of the study group.
the other molar) experienced more recrowd- Timing of lip bumper placement. The author's
ing when compared with the recrowding noted preference is to insert a lip bumper after the
when arches were not expanded. This obser- eruption of the first premolars, particularly
vation led the authors to recommend a nonex- since the primary goal of bumper placement is
pansion treatment protocol. to maintain the E space. If a decision is made to
Is the transverse expansion noted with lip increase arch length 1 mm, it can be readily
bumper treatment stable? Most emphasis has achieved as the second deciduous molars exfo-
been placed on the intercanine dimension be- liate and the second premolars erupt.
cause an increase in intercuspid width provides As discussed previously, one of the indica-
more space to correct crowding than other tions for earlier intervention is the premature
transverse changes. Specifically, one estimate is loss of a primary canine. The treatment entails
that 1 mm of intercanine expansion produces a the removal of the contralateral primary ca-
0.73 mm space that can be used for alignment, nine and the placement of a lingual arch.
whereas a 1 mm expansion at the level of the When the first premolar teeth are erupting, a
molars produces only a 0.25 mm increase in space analysis is performed. If space is ade-
space.22 quate for alignment, the lingual arch is left in
The vast majority of investigators who as- place until all premolars have erupted. Any
sessed the long-term stability of intercanine ex- necessary alignment is performed at this time.
pansion indicated that expansion of this zone is If there is a space deficit which does not exceed
inherently unstable.23"30 In a relevant study 2 mm, the lingual arch is removed when the
that emphasized stability of nonextraction first premolars are erupting and a lip bumper
treatment results, the intercanine width was in- inserted. If the shortage of space is greater
creased slightly in treatment from 25.4 mm to than 2 mm, extraction treatment may be the
26 mm. After retention, the intercanine width treatment of choice unless skeleto-dental con-
contracted to 25 mm. Arch length was not in- ditions contraindicate the extraction of teeth.
creased in this sample. At the start of treat- In the study sample, only 16 of the 100 pa-
ment, arch length was 60 mm, whereas imme- tients evaluated had crowding in excess of 2
diately after treatment, it was 60.2 mm. After mm.
retention, arch length was 58 mm, reflecting a Some might argue that earlier intervention
loss of 2 mm.31 could also provide the space necessary for
The inability to enlarge mandibular interca- these 16 patients. For example, one strategy is
nine width permanently is probably one of the to expand the maxilla (RPE) to gain space in
most documented post treatment changes. Al- the maxillary arch, and at the same time pro-
though most of the information for this con- voke spontaneous transverse expansion of the
clusion has been derived by evaluating records lower arch.32 Although there are too little data
of patients who were not treated "early" in the to assess the merits of this approach ade-
mixed dentition stage of development, it places quately, the results of two studies are not op-
the burden of proof to verify the stability of timistic. Sandstrom et al33 evaluated the
expansion of the intercanine width in the records of 28 patients whose maxillae were ex-
mixed dentition on those who propose this panded orthopedically and noted a 2 mm in-
treatment plan. crease in intercanine width which later con-
The findings of the above-mentioned inves- tracted to only 1.1 mm. Adkins et al34 observed
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that expansion of the lower arch following rapid would be apparent. This lack of correlation be-
palatal expansion did not exceed 0.8 mm. tween control groups may indicate that arch
If "passive" expansion of the lower arch width changes that occur in conditions with a
proves inadequate, there is the possibility of space deficit may be different from the
actively expanding the transverse dimension of changes noted when there is adequate space
the arch with an appliance such as a Schwartz for alignment.
plate.35 As Burstone36 indicated, the ability to Crowding can be easily resolved by nonex-
expand this apical base skeletally is limited traction treatment procedures, if desired, in at
since there is no suture. Therefore any expan- least 85% of all patients with modest treat-
sion is principally dental in nature. The avail- ment, which can be started in the late mixed
able data are sparse and equivocal concerning dentition. (One exception previously noted is
the ability to expand the lower arch with active the early loss of a primary canine, which re-
appliances such as the Schwartz plate. Lutz and quires earlier intervention.) The fate of the
Poulton37 expanded the transverse dimension other 15% of the patients is debatable. Should
of 13 patients in the primary dentition stage of these be "extraction" type patients (assuming
development and compared the changes to there are no skeletal contraindications), or
those observed in 12 control subjects. Expan- should they be treated earlier, to pursue a non-
sion was accomplished with removable appli- extraction approach more aggressively? One
ances in 11 patients and with fixed appliances view, shared by the author, is that extractions
in the remaining two patients. After a three- are the preferable route. A reason for this is
year retention period, the patients were fol- that long-term consequences of early interven-
lowed for another three years. At this time, (6 tion procedures, which are designed to avoid
years posttreatment) the intercanine dimen- extraction by producing active and/or passive
sion of the treated sample was not different expansion of the anterior part of mandibular
from the control group, indicating total re- dental arch (arch development), are not clear.
lapse of the treatment gain. The findings of Often, the focus is lateral expansion of the in-
this study are consistent with the many inves- tercanine dimension, because this procedure,
tigations, which concluded that expansion of as indicated, can readily provide space for
the intercanine dimension of the lower arch is alignment. In this context, arch development is
inherently unstable.23"30 contrary to the vast majority of available data,
Mclnaney et al38 used Crozat appliances to which document the instability of mandibular
expand the transverse dimension of the lower intercanine expansion.23"30 In addition, others
arch in 5-year-old and 6-year-old patients and who have discussed and demonstrated post-
retained the changes until all the primary teeth treatment stability have emphasized that the
exfoliated. The intercanine dimension was ex- mandibular intercanine dimension should not
panded approximately 5 mm. After retention be expanded during treatment.39'40
was discontinued, the arches remained stable. Thus, for those who prefer not to expand
In this study there were no control subjects the mandibular dental arch more than 1 mm, a
and data from other published sources were fundamental difference between extraction
used to represent the controls. As such, the and non-extraction resolution of crowding is
actual net expansion (treatment change/ the timing of treatment. Four to five millime-
growth change) was not reported. The net ex- ters of incisor crowding in the mixed dentition
pansion would depend on the control sample stage of development can usually be treated by
chosen for comparison. If the control sample nonextraction procedures whose goals include
were comparable to the control group identi- maintaining the E space. Extraction treatment
fied by Lutz and Poulton, in which the inter- is most often necessary to correct 4 to 5 mm of
canine width increased 4 to 5 mm,37 there crowding in the permanent dentition.
would be no net expansion. If, on the other
hand, the comparison involved the control
sample reported by Moorrees and Chada,1 in References
which the intercanine width increased only 2 1. Moorrees CFA, Chada JM. Available space for incisors
or more mm as the permanent incisors during dental development. A growth study based on
erupted, a net gain approximating 2 mm physiologic age. Angle Orthod 1965;35:12-22.
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2. Arnold S: Analysis of leeway space in the mixed den- sion. Am J Orthod Dentofacial Orthop 1991; 100:421-
tition. Thesis for certification. Boston, Boston Univer- 427.
sity, 1991. 23. Peak JD. Cuspid stability. Am J Orthod Dentofacial
3. Moyers RE, van der Linden FPGM, Riolo ML, et al. Orthop 1956:42:608-614.
Standards of Human Occlusal Development. Mono- 24. Bishara SE, Chada JM, Potter RB. Stability of interca-
graph #5 Craniofacial Growth Series. Ann Harbor, nine width, overbite and overjet correction. Am J
MI: Center of Human Development, The University Orthod Dentofacial Orthop 1973;63:588-595.
of Michigan, 1976. 25. Shapiro PA. Mandibular dental arch and dimension.
4. Gianelly AA. Diagnosis of incipient malocclusions. J Am J Orthod Dentofacial Orthop 1974;66:58-70.
Am Dent Assoc 1969;79:658-661. 26. Kuftinec MM. Effect of edgewise treatment and reten-
5. Baume L. Physiological tooth migration and its signif- tion of mandibular incisors. Am J Orthod Dentofacial
icance for the development of occlusion. Part III. The Orthop 1975:68:316-22.
biogenesis of the successional dentition. J Dent Res 27. El-Mangoury NH. Orthodontic relapse in subjects
1950,29:338-348. with varying degrees of anteroposterior and vertical
6. Singer J. The effect of the passive lingual arch on the dysplasia. Am J Orthod Dentofacial Orthop 1979;75:
lower denture. Angle Orthod 1974;44:146-155. 548-61.
7. Owen DG. The incidence and nature of space closure 28. Sondhi A, Cleall JF, BeGole EA. Dimensional changes
following the premature extraction of deciduous in the arches of orthodontically treated cases. Am J
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Orthop 1971;59:37-49. 29. Little RM, Wallen TR, Reidel RA. Stability and relapse
8. Sampson WS, Richards LC. Prediction of mandibular of mandibular anterior alignment-first premolar ex-
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47-63. 349-65.
9. Dorfman HS. Mucogingival changes resulting from 30. Uhde MD, Sadowsky C, BeGole EA. Long term stabil-
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10. Rigenberg AM. Influence of serial extraction on 31. Glenn G, Sinclair PM, Alexander RG. Nonextraction
growth and development of the maxilla and mandi- orthodontic therapy: Post treatment dental and skel-
ble. Am J Orthod Dentofacial Orthop 1967:53:47-58. etal stability. Am J Ortho Dentofacial Orthop 1987;
11. Osborn WS, Nanda RS, Currier GF. Mandibular arch 92:321-28.
perimeter changes with lip bumper treatment Am J 32. Haas A. Long term post treatment evaluation of rapid
Orthod Dentofacial Orthop 1991:99:527-532. palatal expansion. Angle Orthod 1980;50:189-217.
12. Bergerson EO. A cephalometric study of the clinical 33. Sandstrom RA, Klapper L, Papaconstantinou S. Ex-
use of the mandibular labial bumper. Am J Orthod pansion of the lower arch concurrent with rapid max-
Dentofacial Orthop 1972:61:578-602. illary expansion. Am J Orthod Dentofacial Orthop
13. Nevant CT, Buschang PH, Alexander RG, et al. Lip 1988:94:296-302.
bumper therapy for gaining arch length. Am J 34. Adkins MA, Nanda RS, Currier GF. Arch perimeter
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14. Cetlin, NM, Ten Hoeve A. Non extraction treatment. Dentofacial Orthop 1990;97:194-199.
J Clin Orthod 1983; 17:396-413. 35. McNamara JA Jr, Brudon WL. Orthodontic and or-
15. Moin K. Buccal shield for mandibular arch expansion. thopedic treatment in the mixed dentition. Ann Ar-
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16. Nance H. The limitations of orthodontic treatment. 36. Burstone CJ. Perspective on orthodontic stability. In:
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18. Case CS. The question of extraction in Orthodontics.
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crease in arch perimeter due to orthodontic expan- Saunders, 1993:115-134.
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BE LESS PRODUCTIVE
AT THE OFFICE.
C^x he office has always b>een are some simple ways you can brushing your teeth or
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r
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VOL 1, NO 4 DECEMBER 1995
Temporomandibular Joint Disorders: Facts and Fallacies

Daniel M. Laskin, DOS, MS
Guest Editor
CONTENTS
Introduction 195
Daniel M. Laskin
The Clinical Diagnosis of Temporomandibular Disorders in the

Orthodontic Patient 197
Daniel M. Laskin
Radiographic Diagnosis of Temporomandibular Disorders 207

D. Carl Dixon
Etiology of Temporomandibular Disorders 222

Charles S. Greene
Management of Masticatory Myofascial Pain 229

James R. Fricton
Management of Internal Derangements of the Temporomandibular Joint 244

Bruce Sanders
Implications of Temporomandibular Disorders for Facial Growth and

Orthodontic Treatment 258
Jos M.H. Dibbets and David S. Carlson
Annual Index 273

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VOL 1, NO 4 DECEMBER 1995
Introduction
Despite many years of basic and clinical re- provide. This is particularly true in the current
search in the field, there is still greatenvironment of cost containment. The rule
controversy regarding the management of that probably needs to be followed is that im-
temporomandibular disorders, and the dental aging should only be carried out when the ex-
literature is replete with diverse and often di- pected information will change the manner in
ametrically opposed viewpoints on how these which the patient is treated.
conditions should be treated. To attempt to In addition to accurate diagnosis, having an
bring clarity to all aspects of this problem in a understanding of the etiology of a condition is
brief monograph such as this is certainly not helpful in determining therapy. Whereas suc-
possible. Thus, the approach has been to pro- cessful treatment can still be achieved in some
vide sufficient basic information to enable the instances even though the cause of the prob-
readers to accurately distinguish the various lem is unknown, the chances of success are
temporomandibular disorders and to under- greatly improved when there is both an exact
stand what is known about their etiology, and diagnosis and a known etiology. It is unfortu-
then to show them how this information can be nate that the precise causes of most of the tem-
applied in a rational approach to therapy for poromandibular disorders are not understood,
the more commonly encountered conditions. because therapy then becomes based on the
Finally, the influence of the various temporo- particular theory of causation to which the cli-
mandibular disorders on orthodontic diagno- nician subscribes. By relying on those concepts
sis and treatment are discussed. with the most scientific support, however, the
The major challenge to the clinician dealing clinician is more likely to avoid the pitfalls of
with patients having temporomandibular dis- inappropriate treatment.
orders (TMD) is to distinguish between those Of the various conditions encountered in
suffering from masticatory myofascial pain the orthodontic patient, the two most com-
and dysfunction and those who have pathology mon are masticatory myofascial pain and dys-
in the temporomandibular joint. This is an im- function and the internal derangements of the
portant distinction because of the different temporomandibular joint. These conditions
therapeutic approaches that are required in are of particular concern, not only because
each instance. Much of the difficulty encoun- their presence may require modification in
tered by clinicians in successfully treating orthodontic treatment, but also because there
TMD patients is based on diagnostic inaccu- have been claims that they can be caused by
racy and, therefore, in this issue considerable such therapy. The discussions presented in this
emphasis has been placed on the proper rec- monograph provide a rational approach to the
ognition of the various temporomandibular general management of these conditions and
disorders. form the basis for the application of this infor-
Although many of the conditions involving mation to the orthodontic patient.
the temporomandibular joint and associated Because of the important role of the man-
structures can be diagnosed clinically, imaging dibular condyle in facial growth and develop-
is still essential in instances when this is not ment, an understanding of the relationships of
possible or when confirmation of the clinical temporomandibular disorders to mandibular
diagnosis is necessary. Faced with a variety of growth and facial form, and the effects of
imaging techniques, the clinician needs to de- these conditions on therapy, are of primary
cide when imaging should be used and the ac- concern to the orthodontist. Thus, a discussion
curacy of the information that the imaging will of the orthodontic implications of TMD has
Seminars in Orthodontics, Vol 1, No 4 (December), 1995: pp 195-196 195

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196 Introduction
been included. A careful review of the litera- clarifications. They have also attempted to dis-
ture on the subject confirms the opinion that tinguish between what is supported by scien-
most of these conditions are either present be- tific evidence and what merely represents
fore the initiation of orthodontic treatment or, opinion. However, it is clear that even among
if they develop during treatment, their occur- such a group of experts, there is not unanim-
rence is unrelated to what is being done. They ity. Nevertheless, there is sufficient informa-
also confirm that orthodontic treatment does tion provided to enable the readers to make
not increase the likelihood of developing a their own independent decisions. Only time,
temporomandibular disorder in later life. and continued research, will provide the defin-
There are still many fallacies that exist in itive answers.
regard to our understanding of the temporo-
mandibular disorders. In the various discus-
sions, the authors have attempted to identify Daniel M. Laskin, DBS, MS
these areas and to provide the appropriate Guest Editor
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The Clinical Diagnosis of

Temporomandibular Disorders in the
Orthodontic Patient
Daniel M. Laskin
Because many of the diseases and disorders that affect the temporoman-
dibular joint (TMJ) and associated masticatory muscles occur in the age
group of patients generally seen by the orthodontist, their recognition is of
great importance in planning and performing orthodontic therapy. This ar-
ticle discusses the diagnosis and clinical significance of the various condi-
tions that may be encountered. (Semin Orthod 1995; 1:197-206.)
The basis for the successful management of that this was a single disease entity continued
any temporomandibular disorder is the es- to permeate clinical practice.
tablishment of an accurate diagnosis. Without In 1969 Laskin4 challenged this concept
an accurate diagnosis, management of the con- when he proposed that within this heteroge-
dition becomes empirical rather than rational, nous population of patients there was a distinct
and the chance of successful treatment is group whose problem was related to the mas-
greatly diminished. Unfortunately, despite ticatory muscles rather than to the TMJ, and
many years of clinical investigation, there is suggested the name myofascial pain-dys-
still considerable confusion about the classifi- function (MPD) syndrome for this condition.
cation of disorders that involve the temporo- Although this concept brought some clarity
mandibular joint (TMJ) and associated struc- to the field, it was still not unusual to hear
tures. It is not that logical classifications have practitioners speak about TMJ patients and to
not been developed.1'2 The problem is that see the term used generically to describe pa-
one continues to see a failure of these classifi- tient populations in both clinical and research
cations being used as the basis for clinical man- studies.
agement, and patients with diverse problems In 1982, the American Dental Association
continue to be treated as if their pain and dys- sponsored a conference on the subject that re-
function were caused by a single disease. sulted in a recommendation that the umbrella
Historically, this diagnostic dilemma began term for the conditions involving the TMJ and
more than 60 years ago when Costen3 de- associated structures should be "temporoman-
scribed a series of signs and symptoms that he dibular disorders (TMD)," with subcategories
related to the TMJ and related structures, and encompassing masticatory muscle pain and
was ultimately named Costen's syndrome. Al- dysfunction (MPD) and the true pathology of
though the name changed over the years from the temporomandibular joint (TMJ disor-
Costen's syndrome to TMJ syndrome to cran- ders).5 However, despite the fact that this pro-
iomandibular syndrome, the underlying idea posed classification has had wide acceptance, it
has still not resolved the diagnostic dilemma.
Although most clinicians now speak of TMD
From the Department of Oral and Maxillofacial Surgery, and patients rather than TMJ patients, the treat-
MCV Temporomandibular Joint and Facial Pain Research Cen- ment used often has not changed to reflect the
ter, Medical College of Virginia, Virginia Commonwealth Uni- heterogeneity of the conditions involved.
versity, Richmond, VA. Moreover, there continues to be confusion in
Address correspondence to Daniel M. Laskin, DDS, MS, De- the literature; it is not easier to distinguish a
partment of Oral and Maxillofacial Surgery, Medical College of
Virginia, PO Box 980566, Richmond, VA 23298-0566. current group of TMD patients from a former
Copyright © 1995 by W.B. Saunders Company group of TMJ patients with respect to what
1073-8746I95I0104-0002$5.00IO their specific problem(s) might be.
Seminars in Orthodontics, Vol 1, No 4 (December), 1995: pp 197-206 197

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198 Diagnosis of TMD in Orthodontic Patients
This article provides a brief description of volves the TMJ and mandibular ramus, rarely
the various temporomandibular disorders so extending beyond the antegonial notch. There
that the clinician is able to establish an accurate are also associated abnormalities of the exter-
diagnosis on which to base rational therapy. nal, middle, and inner ear; the temporal bone;
Although many of these conditions are limited the parotid gland; the muscles of mastication;
only to the structures of the TMJ, others also and the facial nerve. Because of the absent or
involve adjacent structures. Moreover, in some hypoplastic condyle, the mandible deviates to
patients, the TMJ involvement can be part of a the affected side and the unaffected side is flat-
more generalized pattern of malformation. In tened and elongated. Associated with the skel-
all instances, when damage occurs to the etal deformity is a malocclusion which, along
condyle in a growing child, one can expect to with the facial deformity, becomes worse as
see secondary mandibular and facial defor- growth continues.
mity. Goldenhar's syndrome (oculoauriculovertebral dys-
ostosis). The facial asymmetry and malocclu-
sion observed in patients with this syndrome
Pathology of the are similar to that which occurs with hemifacial
Temporomandibular Joint microsomia. However, in addition there are fa-
The conditions that involve the TMJ are no cial skin tags, epibulbar dermoids, and verte-
different than those that involve other joints of bral anomalies. In approximately half the cases
the body. Thus, one may see congenital and there are also anomalies of the cardiovascular
developmental anomalies, acute traumatic in- and genitourinary systems, and in a small per-
juries, neoplasia, all of the various forms of centage of patients there is a cleft palate.
arthritis, and internal derangements of the Treacher Collins syndrome (mandibulofacial dys-
TMJ. Of the various conditions, those of great- ostosis). In comparison with the first and sec-
est interest to the orthodontist are the congen- ond arch syndrome and Goldenhar's syn-
ital and developmental disturbances, degener- drome, which are usually unilateral, Treacher
ative and rheumatoid arthritis, and derange- Collins syndrome usually presents as a sym-
ments of the intra-articular disc. Some of these metrical bilateral facial deformity character-
conditions are of concern because they can ized by a hypoplastic mandible, deficient malar
produce facial skeletal deformities and severe bones, low-set deformed ears, and an antimon-
malocclusions in the growing child, whereas goloid slant to the palpebral fissures. Although
others can cause pain and dysfunction in chil- joint function is generally normal, the condyles
dren as well as young adults. are usually small, the mandibular body and ra-
mus are short, and there is antegonial notching
Congenital Anomalies and a downward bowing of the lower border of
The various congenital anomalies that affect the mandible. Although the deformity is clas-
the region of the TMJ are a diagnostic as well sically symmetrical, asymmetrical cases have
as a therapeutic challenge to the orthodontist. been reported,8 and in such patients it may be
Although they may share some clinical fea- difficult to distinguish between Treacher Col-
tures, there are distinct differences that make lins syndrome and bilateral facial microsomia.
each uniquely different from the others.6 Hallerman-Streiff syndrome (oculomandibulodys-
Hemifacial microsomia (first and second arch syn- cephaly). The facial deformity in this syn-
drome, lateral facial dysplasia). This congenital drome resembles Treacher Collins syndrome
anomaly is characterized by hypoplasia but, in addition, one finds scaphocephaly, con-
or agenesis of the tissues in the region of the genital cataracts, and proportionate dwarfism.
first and second branchial arch. Although it The face is small in comparison to the skull,
is usually unilateral, bilateral cases have been the mandible is narrow, and the nose is
reported.7 The faces of the latter patients, beaked, leading to a bird-like facial appear-
however, are asymmetrical, a feature that gen- ance. The TMJ, which is located more anteri-
erally distinguishes them from patients with orly than normal, is hypoplastic and the
Treacher Collins syndrome. condyles are small or absent. Despite the ante-
The mandibular deformity generally in- riorly displaced joints, however, the underde-
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Daniel M. Laskin 199
velopment of the mandibular ramus and body eruption of the maxillary teeth and downward
results in a Class II malocclusion and often an growth of the maxillary alveolar process, as
anterior open bite. well as upward growth of the mandibular al-
veolar process in an attempt to maintain the
Developmental Anomalies occlusion. The latter often leads to a convex
Injury to the TMJ in the growing child by such appearance of the inferior mandibular border
conditions as trauma, infection, or irradiation on the affected side. This is in contrast to the
can also cause condylar hypoplasia, with antegonial notching observed with condylar
growth arrest or retardation and facial asym- hypoplasia.
metry similar to that observed with the congen- Radiographically the TMJ appears normal
ital hypoplasias. However, because of the later or there may be symmetrical enlargement of
onset, the morphological changes are usually the condyle and elongation of the mandibular
less severe, and the other syndromic phenom- neck.9 Because a chondroma or osteochon-
ena are not present. Condylar hyperplasia and droma of the condyle can produce signs and
mandibular overgrowth can also occur in some symptoms similar to unilateral condylar hyper-
individuals. However, unlike condylar hy- plasia, they must be ruled out in the differen-
poplasia, which is usually recognized at an tial diagnosis. The latter generally grow more
early age, condylar hyperplasia is usually not rapidly, causing quicker changes in facial sym-
recognized until the late teens or early 20s metry. Moreover, because of the rapid growth,
when condylar growth continues beyond the dental compensation may not occur and an
normal time. open bite develops. Another distinguishing
Condylar hypoplasia. Condylar hypoplasia characteristic is the fact that with a chondroma
produces a facial deformity on the affected or osteochondroma the condyle is asymmetri-
side characterized by a short and wide mandib- cally rather than symmetrically enlarged.
ular ramus, a short mandibular body, fullness
of the face, and deviation of the chin. On the The Arthritides
unaffected side the body of the mandible is All of the various forms of arthritis that can
elongated and the face is flat. Malocclusion de- affect the other joints of the body can also in-
velops from the mandibular deviation. When volve the TMJ. The commonest forms seen are
there is a bilateral growth arrest, there is usu- degenerative and rheumatoid arthritis. How-
ally a symmetrical underdevelopment of the ever, in some instances, infectious and trau-
mandible and a micrognathic appearance. matic arthritis, as well as the rarer types such as
Diagnosis is based on the history of a pro- psoriatic arthritis, ankylosing spondylitis, gout,
gressive facial asymmetry beginning during and pseudogout can be encountered.10
the growth period, generally associated with an Rheumatoid Arthritis. As many as 50% of pa-
injury; radiographic evidence of condylar un- tients with rheumatoid arthritis will show some
derdevelopment; and increased antegonial involvement of the TMJ.11'12 The degree of
notching.7 The last is important in helping to involvement may vary from transient episodes
distinguish condylar hypoplasia and growth of pain, swelling, and limited movement to se-
retardation from condylar hyperplasia and vere damage of the periarticular and articular
mandibular overgrowth. structures resulting in fibrous or bony ankylo-
Unilateral condylar hyperplasia. This disorder sis. The disease has a female to male predilec-
of unknown origin is characterized by persis- tion of approximately 3:1.12
tent or accelerated unilateral condylar growth The distribution of rheumatoid arthritis, in
at the time when growth should be diminishing comparison with that of degenerative arthritis,
or ended. The slowly progressive unilateral en- generally tends to be symmetrical. Moreover,
largement of the mandible causes a cross-bite whereas degenerative arthritis can be limited
malocclusion, facial asymmetry, and shifting of to only the TMJ, rheumatoid arthritis usually
the midpoint of the chin to the unaffected side. begins in the peripheral joints (wrists, elbows,
Concomitant with the increased downward ankles) and the clinical findings are more gen-
and forward growth of the mandible, which eralized (Table 1).
carries the teeth with it, there is compensatory Patients with involvement of the TMJ usu-
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Table 1. General Features of Rheumatoid Arthritis and Osteoarthritis

Rheumatoid Arthritis Osteoarthritis
Joint involvement Symmetric Asymmetric or symmetric

Joints usually involved Wrists, hands, elbows, ankles Hips, knees, spine, hands
Joint tenderness Usual None or mild
Morning stiffness >30 minutes <30 minutes
Hand joints commonly involved Proximal interphalangeal and Distal interphalangeal
metacarpophalangeal
Type of hand swelling Soft Bony hard
Sedimentation rate Usually elevated Normal
Rheumatoid factor Positive (70% to 80%) Negative
Anemia Hypochromic, normocytic None
Extra-articular findings May be present None
Radiographic findings Erosive changes Erosive and exophytic changes
Gender distribution Female 3:1 Equal
ally complain of a deep, dull, aching pain in and 3 years and the other between the ages of
the preauricular region that is exacerbated by 8 and 12 years.13
function, swelling of the preauricular tissues Juvenile rheumatoid arthritis is classified
during the acute phases, and progressive lim- into three subtypes: systemic (Still's disease),
itation of jaw movement. When severe destruc- polyarticular, and pauciarticular.13 Although
tion of the condyle occurs in the late stages, the the TMJ can be involved in any of these sub-
patient may develop a progressive Class II mal- types, it is most often affected by the polyartic-
occlusion and an anterior open bite caused by ular form. The clinical features include TMJ
loss of ramal height. The radiographic fea- pain, tenderness, and decreased range of mo-
tures of rheumatoid arthritis of the TMJ in- tion. Because the disease process destroys the
clude a loss of the intra-articular joint space, condylar growth site, a characteristic feature is
condylar destruction, and erosion of the glen- micrognathia and a Class II relationship, fre-
oid fossa.9 quently referred to as a birdface deformity.
When rheumatoid arthritis is suspected on The severity of this deformity is related to the
the basis of the clinical and radiographic find- age of onset of the disease and its duration.
ings, laboratory tests can be used to confirm Ankylosis is more common with juvenile rheu-
the diagnosis.13 The most commonly used test matoid arthritis than with the adult onset type.
is for rheumatoid factor, which is positive in up The radiographic findings with juvenile
to 80% of the patients. The erythrocyte sedi- rheumatoid arthritis resemble those observed
mentation test, although not specific for rheu- in adult disease. These include erosion of the
matoid arthritis, is positive in about 90% of articular surface of the condyle, flattening and
patients during the acute stages of the disease. erosion of the articular eminence, and loss of
Other tests for rheumatoid arthritis include the joint space.15 Because of the growth defi-
the presence of antinuclear antibodies, which ciency, there is micrognathia, increased ante-
are found in 15% to 50% of patients, and gonial notching, and frequently an anterior
HLA-DW5 and HLA-DR8, which are found in open bite. The laboratory findings are incon-
50% of rheumatoid patients. sistent and vary with the subtype. Rheumatoid
Although rheumatoid arthritis generally oc- factor is positive in 5% to 20% of patients,
curs in patients between 40 and 60 years of mostly those with the pauciarticular and poly-
age,12 there is also a juvenile form occurring in articular forms, and the antinuclear antibody
patients under 16 years of age. It is estimated test is positive mainly in patients with the pau-
that the number of children affected in the ciarticular form (60% to 88%).10
U n i t e d States ranges from 30,000 to Degenerative arthritis (degenerative joint disease,
250,000.14 Thus, such patients may occasion- Osteoarthritis 9 osteoarthrosis). Degenerative ar-
ally be encountered by the orthodontist. The thritis is the commonest disease affecting the
disease occurs predominately in girls, and has TMJ. Radiographic evidence has been noted in
two peaks of onset, one between the ages of 1 14% to 44% of asymptomatic persons16 and it
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has been noted histologically in 40% to 60% of dition is most frequently unilateral, although it
studied populations.17'18 However, only 8% to may become bilateral in the late stages, and
16% of the population have clinical symp- involvement of other joints is uncommon.
toms.19'20 The radiographic changes are similar in
Degenerative arthritis can occur in either a both the primary and secondary forms of de-
primary or secondary form.9 Primary disease generative joint disease.9 The earliest change is
is a gradually developing process, and is subchondral sclerosis. As the condition pro-
caused by the normal wear and tear to which gresses, there is condylar flattening and lip-
the joint is subjected. It usually occurs in per- ping, erosion, or osteophyte formation. Occa-
sons older than 50 years and the large weight- sionally, in the late stages, breakdown of the
bearing joints are most commonly involved. subchondral bone gives rise to a bone "cyst"
When the disease involves the hands, the most within the condyle. When the intra-articular
frequently affected joints are the distal inter- disc becomes involved, there will be narrowing
phalangeal joints, producing the characteristic of the joint space. The radiographic changes
enlargements known as Heberden's nodes. are generally more severe in the secondary
When the proximal interphalangeal joints are than in the primary form of degenerative joint
involved, the enlargements are called Bouch- disease. The distinguishing features between
ard's nodes. Primary degenerative disease of degenerative arthritis and rheumatoid arthritis
the TMJ is generally asymptomatic, although are described in Tables 1 and 2.
patients may occasionally complain of joint
stiffness, crepitation, and mild pain. It usually Internal Derangements
occurs bilaterally.
Secondary degenerative joint disease is ob- Internal derangement of the TMJ can be de-
served most often in persons between 20 years fined as an abnormal relationship between the
and 40 years of age, although it can occur dur- intra-articular disc and the condyle when the
ing the teens. It is caused by a speeding up of teeth are in occlusion. Originally this was con-
the degenerative process by trauma, persistent sidered to involve an anterior or anteromedial
parafunction, or increased stress on the joint displacement, with the posterior band forward
produced by loss of teeth or severe malocclu- of the 12 o'clock position. However, because it
sion. It is characterized by TMJ pain, joint ten- has now been shown that a forward position is
derness, limitation of mouth opening and, in not always associated with clinical signs or
the late stages, crepitation. When associated symptoms,21 a more logical definition would
with myofascial pain and dysfunction (MPD), be that an internal derangement is a condition
there is usually masticatory muscle tenderness characterized by either an abnormal anatomic
and the symptoms are more severe. In contrast disc-condyle relationship, or a normal relation-
to primary degenerative joint disease, the con- ship associated with disc immobility, that re-
Table 2. Distinguishing Clinical Features of Rheumatoid Arthritis and Osteoarthritis of the

Temporomandibular Joint
Rheumatoid Arthritis Osteoarthritis
Incidence 50% of patients 20% to 30% of patients

Location Usually bilateral Often unilateral
Signs Bilateral preauricular swelling and Occasional joint tenderness; mild to
tenderness; moderate to severe moderate jaw limitation; popping,
limitation of jaw movement; anterior clicking, or crepitant sounds; no
open bite and retrognathia in late occlusal or facial changes
stages
Symptoms Constant preauricular pain; joint Dull, aching preauricular pain,
stiffness; crepitant joint noises; exacerbated by function; popping,
progressive restriction of jaw motion clicking, or crepitant sounds; some
restriction of jaw motion
Radiographic changes Erosion of condyle and fossa; loss of Subchondral scerosis; condylar
joint space flattening; marginal lipping;
osteophyte formation
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suits in clinical symptoms of pain and/or dys-

function.
Internal derangements can be classified into
four stages. The earliest stage involves an in-
coordination phase, which is not associated
with joint pain or noise, and is only recognized
when patients are asked if their jaw joint moves
smoothly and they reply that they feel a slight
catching or binding sensation. In some patients
the incoordination phase is eventually followed
by the onset of limited mouth opening associ-
ated with adhesion of the disc to the fossa in a
relatively normal position (Fig 1). However, in
most patients the next stage is anterior or an-
teromedial displacement of the disc, which re-
turns to a normal relationship with the condyle
during the opening movement and is associ-
ated with a clicking or popping sound (Fig 2).
If the degree of disc displacement progresses, Figure 2. Diagram showing anterior displacement
reduction to a normal relationship on mouth of the intra-articular disc with reduction on opening
the mouth. A clicking or popping sound occurs as
opening does not occur, the patient's jaw is the disc returns to its normal position in relation to
locked, and opening is initially limited to 23 to the condyle. During closure the disc again becomes
25 mm (Fig 3). Because return of the disc to its anteriorly displaced, sometimes accompanied by a
normal relationship does not occur, this stage second sound (reciprocal click). (Modified with per-
is not characterized by joint clicking or pop- mission from McCarty W. Diagnosis and treatment
ping. If a separation or tear occurs at the point of internal derangements of the articular disc and
mandibular condyle. In: Solberg WK, Clark GT, ed-
of attachment of the retrodiscal tissue to the itors. Temporomandibular Joint Problems: Biologic
disc, however, crepitus may be heard as the Diagnosis and Treatment. Chicago IL: Quintes-
condyle rubs directly against the articular em- sence, 1980: 155).
inence.
Although most stages of internal derange- ages made at varying degrees of mouth open-
ment can be recognized by the clinical signs ing provide a series of static views of the
and symptoms, in instances when there is un- dynamic disc-condyle relationship. When the
certainty the disc can be visualized using mag- images are made in an anteroposterior direc-
netic resonance imaging (MRI). 22 Lateral im- tion, lateral or medial disc displacement can
also be observed. Although tears or separa-
tions in the disc-retrodiscal tissue junction can
sometimes be observed on MRI, arthrography
is the most reliable diagnostic method for this
purpose.
Considerable attention has been given in the
literature to the clinical significance of recip-
rocal clicking of the TMJ (Fig 2), with the im-
plication that it is a more serious situation than
Figure 1. Adhesion of the intra-articular disc caus-
ing limitation of mouth opening. (A) The disc is the mere presence of a click on opening of the
adherent to the articular eminence in a normal po- mouth. Actually, the same changes in the disc-
sition when the mouth is closed. (B) During mouth condyle relationship occur whether or not a
opening the disc does not move and this limits click is heard on mouth closure.23 In patients
condylar translation. Because the condyle only ro- whose TMJ clicks every time they open their
tates, opening is limited to 25 to 30 mm. (Reprinted
with permission from Kaplan AS, Assael LA. Tem- mouth, the disc has to slip off the condyle dur-
poromandibular Disorders: Diagnosis and Treat- ing mouth closure so that the process can re-
ment, Philadelphia, PA: Saunders, 1991). peat itself. The difference is that, in some pa-
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row signal in the condyle and condylar neck of

some patients with internal derangements has
led to the suggestion that such derangements
can cause avascular necrosis in TMJ. 25 ' 26
Based on the rich blood supply provided to the
condyloid process via the inferior alveolar ar-
tery, the periosteal vasculature, and the lateral
pterygoid muscle, however, it is unlikely that a
traumatic etiology can be implicated in these
cases. In fact, avascular necrosis has not been
shown to occur even when there are displaced
fractures of the condyloid process, whereas it is
a common occurrence with displaced subcapi-
tal and high transcervical femoral neck frac-
tures.
Fat emobolism has also been proposed as a
Figure 3. Diagram showing anterior displacement cause of vascular necrosis in the femur. The
of the intra-articular disc without reduction on at- source of these emboli has been postulated to
tempted mouth opening. The displaced disc acts as be either alcohol-related or high dose steroid-
a barrier and prevents full translation of the related fatty liver disease, or a coalescence of
condyle. (Modified with permission from McCarty
W. Diagnosis and treatment of internal derange- endogenous plasma lipoproteins.24 However,
ments of the articular disc articular disc and man- none of these conditions are common in the
dibular condyle. In: Solberg WK, Clark GT, editors. usual age group developing internal derange-
Temporomandibular Joint Problems: Biologic Di- ments of the TMJ.
agnosis and Treatment. Chicago, IL: Quintessence, It thus appears that if avascular necrosis
1980: 151).
does occur in the temporomandibular joint it is
a rare phenomenon. Although there may be
tients, the passage of the condyle over the pos- MRI changes observed in the condyloid pro-
terior band as the disc again slips forward cess that resemble avascular necrosis of the fe-
during closure is associated with a clicking mur, there is no histologic proof of such a sim-
sound, but in others it occurs silently and can ilarity, and it is probable that the decreased
only be detected by the slight jarring sensation marrow signal observed on MRI generally rep-
felt by palpation over the joint or the mandib- resents fibrosis or osteoporosis rather than an
ular angle. Thus, the presence or absence of avascular necrosis.27 Until better documenta-
reciprocal clicking does not seem to have any tion is provided of the presence of a true avas-
real clinical significance. cular necrosis in the condyle, therapy should
be directed solely toward management of the
Avascular Necrosis primary condition (internal derangement, de-
Avascular necrosis is the death of bone second- generative joint disease).
ary to the loss of its vascular supply. It was first
described in the femoral head, where it gener-
ally results from disruption of the blood supply
Myofascial Pain and Dysfunction
caused by a fracture of the femoral neck. How- It is now recognized that many of the patients
ever, it has also been claimed that nontrau- who, in the past, were diagnosed as having a
matic avascular necrosis of the femur can be TMJ disorder actually were suffering from
associated with systemic corticosteroid therapy, masticatory MPD. It is easy to understand how
excessive alcohol use, and sickle cell disease.24 such confusion could have occurred. In the
On MRI the normal strong signal caused by first place, the major symptoms (pain and dys-
the hydrogen-rich fat content of the marrow function) of many forms of TMJ pathology
decreases when avascular necrosis of the fe- and those of masticatory muscle involvement
mur occurs, and this allows early detection. are similar in character and location. Secondly,
The finding of a similarly decreased mar- patients with primary TMJ pathology fre-
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quently develop secondary muscle symptoms side of head that is generally interpreted by the
caused by protective splinting of the jaw. Fi- patient as a headache. Involvement of the lat-
nally, patients with long-standing MPD associ- eral pterygoid causes pain that feels like an
ated with chronic parafunctional habits, partic- earache and/or a pain behind the eye, whereas
ularly clenching, can develop secondary or- medial pterygoid involvement causes discom-
ganic changes in the TMJ. However, despite fort when swallowing, the feeling of a painful,
these overlapping phenomena; a recognition swollen gland beneath the angle of the mandi-
of the clinical signs and symptoms of MPD, ble, and a sensation of stuffiness or a full feel-
plus a careful analysis of the patient's history, ing in the ear.
should enable the clinician to make a correct The pain associated with MPD is usually
diagnosis of the primary problem. Generally constant, but it is often more severe on arising
this involves distinguishing MPD from second- in the morning or gradually worsens as the day
ary degenerative joint disease (Table 3) and progresses. It is generally exacerbated by man-
understanding its relationship to internal de- dibular function, especially chewing and exces-
rangements of the TMJ. Because these condi- sive talking. The pain also tends to become re-
tions occur most frequently in young women, a gional with time, and spreads to the cervical
major component of the orthodontists' patient region and later to the shoulders and back.
population, the clinician needs to be cognizant Masticatory muscle tenderness is another
of their presence before beginning treatment common finding in MPD patients,29 and its
and should be aware of the fact that their de- presence can be used to confirm the source of
velopment during therapy is usually coinciden- the pain in those muscles accessible to palpa-
tal. tion (masseter, temporalis, medial pterygoid).
The most common symptom of MPD is pain The most common sites of tenderness are near
of unilateral origin.29 In contrast to the pain the angle of the mandible, in the belly and an-
associated with joint disease, which is well lo- terosuperior aspect of the masseter, in the an-
calized, the pain of muscular origin is more terior temporal region, and over the temporal
diffuse, and patients are usually unable to crest on the anterior aspect of the coronoid
identify the specific site involved. When asked process.
to locate the source of the pain, they will gen- The third common symptom of MPD is lim-
erally place their hand on their face rather itation of mandibular movement.29 There is
than place a finger on the exact area. This is an inability to open the mouth as wide as usual
important distinguishing criterion between and the mandible deviates to the affected side
muscle and joint disorders. when opening is attempted. There is also re-
Although myofascial pain is poorly local- duced excursion to the unaffected side. The
ized, the patient's description of the character degree of limitation in mandibular movement
of the pain can help the clinician determine the is usually correlated with the severity of the
muscles that are involved. The masseter is the pain.
most frequently involved muscle, and the pa- Clicking or popping sounds in the TMJ are
tient usually refers to the pain as a jawache. another finding in some patients with MPD.
The temporalis, which is the next most com- Intermittent clicking or popping can accom-
monly involved muscle, produces pain on the pany the lateral pterygoid spasm that occurs in
Table 3. Distinguishing Features of Degenerative Arthritis and Myofascial Pain and Dysfunction
Degenerative Arthritis MPD
Type of pain Dull, aching, preauricular pain, Dull, aching, radiating pain, increased
increased with function with function
Localization of pain Well localized Poorly localized
Joint tenderness Always present Generally absent
Muscle tenderness Occasional (splinting) Always present
Limitation of mouth opening Mild to moderate Moderate to severe
Joint noise Frequent popping, clicking, or Occasional clicking or popping sounds
crepitant sounds
Radiographic TMJ changes Present Absent
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some of these patients, whereas the frictional pain, the main complaints are usually related
changes introduced by a chronic clenching to altered jaw function.
habit are the cause when the joint sounds are The differences in the history and clinical
persistent. The presence of joint sounds alone, and radiographic findings should help the cli-
however, is not sufficient to make a diagnosis nician distinguish TMJ pathology and MPD
of MPD.4'30 They must be accompanied by from the various nonarticular conditions that
pain and tenderness in the masticatory muscles produce relatively similar signs and symptoms.
that began before rather than after the onset Although it is not the purpose of this article to
of the clicking or popping, as would occur in discuss the specific differential diagnosis of
patients with a primary internal derangement these conditions, it is essential that one is fa-
and secondary muscle splinting. miliar with this information, which is readily
In addition to the three common symptoms available in the literature.
of diffuse pain, masticatory muscle tenderness,
and limited mouth opening, most patients with
primary MPD usually have an absence of clin- Conclusions
ical or radiographic evidence of pathological Although not all orthodontists may wish to be-
changes in the TMJ.4'30 These negative char- come directly involved in the treatment of pa-
acteristics are important in establishing the di- tients with MPD, they will encounter such pa-
agnosis because they help confirm that the pri- tients in their practice. It is therefore essential,
mary site of the problem is not in the articular when it is present, that they recognize the con-
structures. dition before beginning orthodontic treatment
so that patients will not consider it a conse-
quence of their therapy. The same is true for
Nonarticular Conditions Mimicking TMJ problems such as internal derangement
Temporomandibular Disorders or secondary degenerative joint disease. More-
over, when these conditions arise during orth-
Although an understanding of the signs and odontic treatment, the orthodontist must also
symptoms of the various temporomandibular realize that they are generally unrelated to
disorders should generally enable the clinician such therapy.29 However, they may require
to make an accurate diagnosis, it is still impor- modifications in treatment procedures that can
tant to be aware of the various nonarticular aggravate the situation. Finally, the orthodon-
conditions that also need to be considered in tist will play a major role in the management of
the initial differential diagnosis. There are a patients with malocclusions and facial asymme-
number of conditions besides TMJ pathology tries associated with congenital and develop-
and MPD that can cause similar symptoms of mental anomalies. Because the orthodontist
facial pain and mandibular dysfunction. Those may be the first doctor to see such patients, he
causing similar pain include pulpitis, pericoro- or she must not only be able to make the cor-
nitis, otitis, parotitis, maxillary sinusitis, tri- rect diagnosis, but also must understand the
geminal neuralgia, atypical facial neuralgia, chronology of the underlying growth distur-
temporal arteritis, Trotter's syndrome (naso- bances so that this can be integrated into the
pharyngeal carcinoma), and Eagle's syndrome. final treatment plan.
Conditions that can cause mandibular limita-
tion and dysfunction include chronic odonto-
genic infections, chronic nonodontogenic in- References
fections, myositis, myositis ossificans, posttrau- 1. McNeill C, editor. Craniomandibular Disorders—
matic or postsurgical scarring, neoplasia, Guidelines for Evaluation, Diagnosis, and Manage-
scleroderma, hysteria, extrapyramidal reac- ment. Chicago, IL: Quintessence, 1993.
tions produced by psychotropic drugs, and 2. Dworkin SF, LeResche L. Research diagnostic criteria
mechanical obstruction caused by posttrau- for temporomandibular disorders: Review, criteria
and specifications, critique. J Craniomandib Disord
matic depression of the zygomatic arch or os- Facial Oral Pain 1992;6:301-355.
teochondroma of the coronoid process. Al- 3. Costen JB. A syndrome of ear and sinus symptoms
though some of these conditions also cause dependent on disturbed function of the temporoman-
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dibular joint. Ann Otol Rhinol Laryngol 1934;43:1- 20. Mejersjo C. Therapeutic and prognostic consider-
15. ations in TMJ osteoarthroses: A literature review and
4. Laskin DM. Etiology of the pain-dysfunction syn- a long-term study of 11 subjects. J Craniomandib
drome. J Am Dent Assoc 1969;79:147-153. Pract 1987;5:70-78.
5. Laskin DM, Greenfield W, Gale E, et al, editors. The 21. Westesson P-L, Eriksson L, Kurita K. Reliability of a
President's Conference on the Examination, Diagno- negative clinical temporomandibular joint examina-
sis and Management of Temporomandibular Disor- tion: Prevalence of disk displacement in asymptomatic
ders. Chicago, IL: American Dental Association, temporomandibular joints. Oral Surg Oral Med Oral
1982. Pathol 1989;68:551-554.
6. Poswillo D, Robinson P. Congenital and developmen- 22. Westesson P-L. Diagnostic imaging of internal de-
tal anomalies. In: Sarnat BG, Laskin DM, editors. rangements of the temporomandibular joint. In: Cur-
The Temporomandibular Joint: A Biological Basis rent Controversies in Surgery of the Temporoman-
for Clinical Practice. Philadelphia, PA: Saunders, dibular Joint, Oral and Maxillofacial Surgery Clinics
1992:183-206. of North America. Philadelphia, PA: Saunders, 1994:
7. Ross RB. Lateral facial dysplasia (first and second 227-244.
branchial arch syndrome, hemifacial microsomia). 23. Laskin DM. Etiology and pathogenesis of internal de-
Birth Defects 1975;! 1:51-59. rangements of the temporomandibular joint. In: Cur-
8. Marsh JL. The skeletal anatomy of mandibulofacial rent Controversies in Surgery of the Temporoman-
dysostosis (Treacher Collins Syndrome). Plast Recon- dibular Joint, Oral and Maxillofacial Surgery Clinics
str Surg 1986;78:460-470. of North America. Philadelphia, PA: Saunders, 1994:
9. Laskin DM. Diagnosis of pathology of the temporo- 217-222.
mandibular joint—clinical and imaging perspectives. 24. Mehlhoff MA. The adult hip, In: Weinstein SL, Buck-
In: Imaging of the Paranasal Sinuses and Oromaxil- waiter JA, editors. Turek's Orthopaedics: Principles
lofacial Region, Radiologic Clinics of North America. and their Application. Philadelphia, PA: Lippincott,
Philadelphia, PA: Saunders, 1993:135-147. 1994:537-540.
10. Abubaker AO. Differential diagnosis of arthritis of the 25. Schellhas KP, Wilkes CH, Fritts HM, et al. MR of os-
temporomandibular joint. In: Medical Management teochondritis dissecans and avascular necrosis of the
of Temporomandibular Disorders, Oral and Maxillo- mandibular condyle. AmJ Roentgenol 1989;152:551-
facial Surgery Clinics of North America, Philadelphia, 560.
PA: Saunders, 1995:1-21. 26. Schellhas KP, Wilkes CH. Temporomandibular joint
11. Akerman S, Kopp S, Nilner M, et al. Relationship be- inflammation: Comparison of MR fast scanning with
tween clinical and radiologic findings of the temporo- Tl- and T2-weighted imaging techniques. Am J
mandibular joint in rheumatoid arthritis. Oral Surg Roentgenol 1989; 153:93-98.
Oral Med Oral Pathol 1988;66:639-643. 27. Westesson P-L. Diagnostic imaging of internal de-
12. Yelin E. Arthritis: The emulative impact of a common rangements of the temporomandibular joint. In: Cur-
chronic condition. Arthritis Rheum 1992;35:489-497. rent Controversies in Surgery for Internal Derange-
13. Katz WA. Diagnosis and Management of Rheumatic ments of the Temporomandibular Joint, Oral and
Diseases (ed 2). Philadelphia, PA: Lippincott, 1988. Maxillofacial Surgery Clinics of North America. Phil-
14. Gewanter HL, Roghmann KJ, Baum J. The preva- adelphia, PA: Lippincott, 1994:537-540.
lence of juvenile arthritis. Arthritis Rheum 1983;26: 28. Davidovitch M, Isaacson RJ. The role of orthodontics
599-603. in the treatment of temporomandibular disorders. In:
15. Taylor DB, Babyn P, Blaser S, et al. MRI evaluation of Medical Management of Temporomandibular Disor-
the temporomandibular joint in juvenile rheumatoid ders, Oral and Maxillofacial Surgery Clinics of North
arthritis. J Comput Assist Tomogr 1993; 17:449-454. America. Philadelphia, PA: Saunders, 1995:141-148.
16. Madsen B. Normal variations in anatomy, condylar 29. Greene CS, Lerman MD, Sutcher HD, et al. The TMJ
movements and arthrosis frequency of the temporo- pain-dysfunction syndrome: Heterogenicity of the pa-
mandibular joints. Acta Radiol 1966;4:273-281. tient population. J Am Dent Assoc 1969;79:1168-
17. Macalister A. A microscopic study of the human tem- 1172.
poromandibular joint. NZ Dent J 1954;50:161-169. 30. Laskin DM. Diagnosis and etiology of myofascial
18. Blackwood H. Arthritis of the mandibular joint. Br pain and dysfunction. In: Medical Management of
DentJ 1963;! 15:317-326. Temporomandibular Disorders, Oral and Maxillofa-
19. Toller P. Temporomandibular arthropathy. Proc R cial Surgery Clinics of North America. Philadelphia,
SocMed 1974;67:153-159. Pa: Saunders, 1995:73-78.
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Radiographic Diagnosis of
Temporomandibular Disorders
D. Carl Dixon
Although many of the disorders involving the temporomandibular joint and

associated structures can be diagnosed clinically on the basis of the history
and physical findings, there are others that require the use of various imag-
ing techniques to make an accurate diagnosis or to determine the extent of
involvement. To take maximum advantage of the benefits of these proce-
dures, however, it is not only important for the clinician to be able to select
the correct methods, but also to understand their limitations as well as their
capabilities. In this article the various techniques used for imaging the hard
and soft tissues of the temporomandibular joint are reviewed and recom-
mendations are made regarding their appropriate applications. (Semin
Orthod 1995;1:207-221.)
This is a US government work. There are no restrictions on its use.
The status of the temporomandibular joint diet its future occurrence; (2) Which specific
(TMJ) and associated musculature is not findings indicate the superiority of one treat-
only a concern when a patient is complaining ment over another; and (3) What findings may
of pain or dysfunction, but also at any time help predict the course and prognosis of the
treatment may affect loading and usage pat- disease with and without treatment.
terns. This is especially true at the initiation of A common method of quantifying detection
orthodontic treatment where it is difficult to probability compares the TMJ images of a
imagine that such manipulation of occlusal re- group of subjects known to have disease to
lationships would not alter demands on the those of a group known to be disease free. Ob-
system. This article will review the evidence viously, imaging findings should be positive in
that specific findings on imaging lead to diag- the diseased group and negative in the nondis-
noses that allow prediction of future disease eased group. The ratio of true positive test re-
onset or the course of the current disease. sults to the total number of diseased individu-
Without providing such information, the clin- als is called the sensitivity of the test (Table 1).
ical value of imaging is greatly reduced. If the test is positive in all diseased individuals,
The clinician must have several items of in- sensitivity is 1.00 or perfect. However, if only
formation to make an informed decision about five diseased individuals have positive tests, the
whether or not to order an imaging examina- sensitivity is 0.50 and the discriminative capac-
tion: (1) What the probability is that the imag- ity of the test is no better than tossing a coin.
ing examination will detect disease and its se- The ratio of true negative findings to the total
verity when it is present, or whether it can pre- number of individuals in the nondiseased
group is called specificity (Table 1). High sen-
sitivity without correspondingly acceptable
specificity is undesirable because low specificity
From the Wilford Hall Medical Center, Lackland Air Force
Base, San Antonio, TX.
is the result of excessive false positive diag-
Address correspondence to D. Carl Dixon, DDS, 11727 Mills- noses, which could lead to overtreatment of
way Drive, San Antonio, TX 78253. individuals not having disease. It is generally
The views expressed in this chapter are those of the author and considered that both sensitivity and specificity
do not reflect the official policy of the Department of Defense or
should be greater than 0.70 for a temporo-
other Departments of the United States Government.
This is a US government work. There are no restrictions on its mandibular disorder (TMD) imaging test to be
use. clinically useful. The less sensitive and specific
1073-8746I95I0104-0003$O.OOIO the test, the more likely that additional diag-
Seminars in Orthodontics, Vol l,No4 (December), 1995: pp 207-221 207
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208 Radiographic Diagnosis of TMDs
Table 1. Calculation of Sensitivity and Specificity Joint Anatomy Relative to Imaging

for a Diagnostic Test
Cases with disease Nondiseased
The diverse anatomy of the TMJ makes the
task of consistent, high-quality imaging de-
Positive test 8 (true positives) 4 (false positives) manding. Yale1 identified four markedly dif-
Negative test 2 (false negatives) 6 (true negatives)
ferent naturally occurring condyle morpholo-
gies, some of which might appear abnormal on
Total 10 10
imaging to the inexperienced eye. The medio-
true positives 8 lateral length of the condyle, averaging 20
SensitivityJ = r^ = 77: = 0.80 mm, prevents reproduction of the medial por-
total diseases 10
true negatives 6 tions of the joint on conventional, flat plane
Specificity
r J = • ^ r = 77: = 0.60 radiographs. Adjacent dense osseous struc-
total nondiseased 10
tures in and around the cranial base are easily
Note. True positives are subjects known to have the disease superimposed on the joint image, absorbing
in whom the diagnostic test was positive (correct diag- radiation and degrading image clarity.
noses). False negatives are those subjects known to have
the disease but tested negative (diagnostic errors). False
Perhaps the most technically demanding an-
positives are subjects known to be disease free but who atomic obstacle to overcome is the great vari-
tested positive (again, diagnostic errors). True negatives ability in angulation of the long axis of the
are subjects known to be disease free and tested negative
(correct diagnoses). condyle both in the horizontal and vertical
planes. Optimal imaging results require the
central X-ray beam to be aligned with the
nostic procedures will be required, resulting in condylar long axis. Not only is there wide vari-
additional cost and possibly invasiveness. ability in condylar long axis angulation be-
The accuracy of sensitivity/specificity data is tween individuals, as is illustrated in Figures 1
dependent on the absolute homogeneity of the and 2, but 75% of dry mandibles in a large
diseased and nondiseased test groups. Results collection had between-side variation in condy-
will obviously be invalid if a diseased patient is lar angulation of five degrees or more.1 A five
mistakenly assigned to the nondiseased group degree error in beam alignment can affect in-
or vice versa. This problem is overcome in terpretation of joint space width and degrade
many TMJ imaging studies by the use of au- diagnostic quality.
topsy joint specimens, in which the presence or Anatomic variability must be accommo-
absence of disease can be confirmed by direct dated in the radiographic technique when pos-
visual examination after imaging is performed.
In this case, the direct visual examination is
referred to as the gold standard to which the
imaging test in question is being compared. In
other situations where the use of autopsy spec-
imens is not feasible, another imaging tech-
nique, considered to be the present state of the
art, can be used as the gold standard.
Sensitivity/specificity data, when available,
will be used to compare imaging techniques
throughout this article. However, even though
an imaging technique may have acceptable
sensitivity/specificity, other factors such as cost,
invasiveness, side effects, and the impact of the
information gleaned on the treatment selec-
tion process (items [2] and [3] above) must be
considered in the decision to use it clinically. Figure 1. Variability of the condylar long axis in the
horizontal plane. For optimal diagnostic quality, the
Unfortunately, information addressing these X-ray beam should align with the condylar long
last two factors is in short supply (See Sum- axis, which varies between 30° as shown in projec-
mary and Implications at end of article). tion angle (A) to 0° as shown in projection angle (B).
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D. Carl Dixon 209
others allow individualizing the central X-ray

beam to each patient's anatomy.
B The standard transcranial projection is de-
-45" picted in Figure 3. The angulation in the ver-
tical plane avoids superimposing the dense
structures in the cranial base on the joint im-
age.4 The angulation in the horizontal plane,
not depicted in Figure 3, is set at 15°, which
positions the central beam parallel with the av-
Figure 2. Variability of the condylar axis in the ver- erage horizontal condylar angulation. How-
tical plane is even greater than that of the horizontal ever, condylar angulation is highly variable
plane, ranging from + 35° to —45°.
(Figs. 1 & 2 and the joint anatomy section), and
the standard technique is predisposed to er-
sible, and its potential image-altering effects rors if individual condylar angulation varies 5°
must be considered when diagnostic interpre- or more from the 15° average setting.5 The
tations are being made. corrected technique minimizes error by align-
ing the X-ray beam with the condylar axis in
the horizontal plane, the angulation of which is
Transcranial Radiographs measured on a submento-vertex radiograph
Transcranial radiography (TR) has been used (inferior-superior view, Figs 1 and 4).
extensively as a diagnostic aid for TMDs, The TR image represents a profile view of
partly caused by the technique's simplicity and the lateral third of the joint because the central
the wide availability of the required equip- and medial portions of the joint are projected
ment. Historically, transcranial radiographs inferiorly onto the condylar neck by the verti-
have been used to evaluate the status of joint cal angulation of the X-ray beam (Fig 3). This
hard tissue and the spatial relationship of the may be an advantage when looking for osseous
condyle to the fossa.2'3 lesions because they most often occur in the
The transcranial image. TR images can be lateral third of the joint. However, it must be
produced with standard dental X-ray units and kept in mind that lesions occurring in the cen-
relatively inexpensive head and film position- tral and medial portions will not be discernible
ing devices. Some head positioning devices on TR. It is possible to image the more medial
produce only the standard projection while portions of the joint with the transmaxillary
Cranial base Figure 3. Transcranial ra-

structures
diograph projection in the
vertical plane. The 20°
beam angulation in the
vertical plane minimizes
superimposition of dense
cranial base structures on
the joint image. Horizon-
tal plane angulation
should be individualized
for each patient (see text).
Note that in the resultant
radiograph, the medial
pole is projected onto the
condylar neck and the lat-
Projection of
eral pole is profiled in the
transcranial superior portion of the
radiograph condyle image.
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dysfunctional pain. However, sensitivity and

specificity analysis applied to his data does not
support this premise (Table 2). Subsequent
studies,8'9 found even poorer sensitivity and
specificity values (Table 2), whereas other
studies10'11 question the accuracy of TR depic-
tion of joint space, especially in the standard
view.
TR summary. TR is capable of producing ac-
curate, diagnostic images of osseous abnormal-
ities in the lateral third of the joint. Although
the equipment is relatively uncomplicated, the
corrected technique requires exacting atten-
tion to detail. The image of the joint spaces
may be distorted and the diagnostic meaning
has been questioned by the preponderance of
Figure 4. Submento-vertex or inferior-superior the literature. Perhaps the best use of TR is as
projection. The images of the condyles in the hori- a screening aid for osseous lesions in the lateral
zontal plane can be seen bisected by the angled lines
representing the condylar long axes. The straight third of the joint. Panoramic radiography, to
line drawn between the small opaque circles repre- be discussed later, may be a more cost and time
senting the ear rods of the head positioning device is efficient alternative.
a reference from which condylar angulation is mea-
sured. This measurement is then used to individu-
alize beam angulation in the horizontal plane in the Transmaxillary Radiography
corrected transcranial and tomographic techniques.
This technique provides a frontal view of the
TMJ, sometimes referred to as the transantral,
technique to be discussed later. The capacity of
transorbital, or infraorbital projection. The en-
TR to detect osseous lesions was found to be
tire mediolateral profile of the condyle is im-
comparable with tomography. 6 Omnell7 re-
aged, making this view a very useful supple-
ported the superiority of the corrected tech-
ment to a saggital view, such as the transcranial
nique over the standard technique in detecting
projection. Used together, the views provide a
osseous lesions.
three-dimensional perspective not possible
Posterior condylar positioning and TR. The di-
with either of the views alone. A disadvantage
agnostic significance of condyle position in the
of the transmaxillary view is its failure to por-
fossa has been the subject of much contro-
tray most of the fossa, which is hidden by the
versy. Weinberg2'3 strongly defended poste-
shadow of the eminence.
rior condyle position (Fig 5) as being associated
The technique, as described by Bean,12 in-
with, and the origin of, disc displacement and
volves positioning the film cassette, as dia-
grammed in Figure 6, perpendicular to a stan-
dard dental X-ray beam. The condyle should
be translated to the height of the eminence ei-
ther by opening the mouth or protruding the
mandible maximally. Failure to translate the
condyle properly will result in a degrading su-
perimposition of the eminence on the superior
condylar margin. A mouth prop may aid in
Figure 5. Representation of condylar position in the maintaining desired condyle positioning. The
fossa with teeth in centric occlusion. Joint A shows required beam angulations result in some dis-
the condyle centered in the fossa with the anterior tortion and magnification of the condylar im-
joint space (A) and the posterior joint space (P)
nearly equal. Joint B represents a posteriorly posi- age, although it seems to be of minor clinical
tioned condyle with the posterior joint space signif- importance in detecting osseous abnormali-
icantly smaller than the anterior joint space. ties. 12
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D. Carl Dixon 211
Figure 6. Transmaxillary radiograph projection ge-

ometry. The 40° angulation in the horizontal plane
(A) is required to avoid superimposition of the mas-
toid process on the joint image. The 10° angulation Figure 7. Tomography projection principle. Ob-
in the vertical plane (B) avoids superimposition of jects A and B appear on the film but their images
the hard palate and sphenoid bone. are blurred and unfocused due to the movement of
the beam as the X-ray tube, head, and film cassette
rotate. Objects in the tomographic plane experience
Transmaxillary summary. The transmaxillary minimal beam movement as they are located near
view compares well with other techniques in the center of rotation and accordingly appear more
detecting condylar lesions. Larheim6 found to- focused.
mography to be superior in detecting fossa le-
sions. However, in his study, some condylar
movement through objects away from the to-
lesions were detected on transmaxillary views
mographic plane and center of rotation pro-
that were not detected on tomography. Lar-
duces blurring and loss of focus. The degree of
heim suggests that the transmaxillary view
image blurring depends on the amplitude and
compliments the lateral view, giving a good
pattern of the beam and film movement, with
perspective of the entire joint comparable to
larger amplitudes of movement creating thin-
the more sophisticated and expensive tomog-
ner tomographic planes. Many dental tomo-
raphy.
graph machines use the linear or straight line
movement pattern. This is the least compli-
Tomography cated system, but the one-dimension; J move-
ment may produce streaking and dense objects
Tomography is a step up the technological so- outside the tomographic plane whose surfaces
phistication ladder compared with previously are parallel to the beam path movement, may
discussed plane film techniques. It is consid- degrade image sharpness. More complex
ered by many to be the standard for evaluating movement patterns, such as circular, ellipsoid,
the status of osseous joint structures. Tomog- or hypocycloidal (cloverleaf) found on newer
raphy evolved as a method to overcome unde- computer-controlled machines, minimize these
sirable superimpositions that are difficult to problems. A head positioning device is re-
eliminate in plane film radiography, for exam- quired for consistent results. The position of
ple, the cumbersome angulation required in the tomographic cut can be centered on any
the transmaxillary technique to avoid superim- desired point of interest (Fig 8). Central tomo-
posing the mastoid process on the joint image. graphic sections appear sharper and less dis-
Tomograph technology. The tomographic im- torted than medial and lateral sections and, in
age is generated by rotating the X-ray beam many cases, a technically correct transcranial
source and the film cassette in opposite direc- radiograph may be sharper and more accurate
tions around the area of interest (Fig 7). Ob- than its lateral cut tomographic counterpart.
jects near the center of rotation, called the to- As is the case of transcranial radiographs,
mographic plane, experience limited beam the corrected tomographic technique repro-
movement and appear focused, whereas beam duces joint spaces more accurately and has im-
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Lateral Central Medial
Condylar axis
Figure 9. Central cut TMJ tomogram. Note the

beaking or osteophyte formation. This probably
represents a healed stage because the contours are
relatively smooth and no resorptive processes are
Figure 8. Diagram representing tomographic evident.
planes through the lateral, central and medial por-
tions of the joint. Note that the tomographic planes
are perpendicular to the condylar axis as prescribed
by the corrected technique. tients with normal arthrograms had posteri-
orly positioned condyles on tomography. Bl-
aschke17 examined bilateral tomograms from
proved detection rates for osseous defects 25 asymptomatic subjects and found that, al-
compared with the standard tomographic though the average condylar position was in
technique.13 The standard technique specifies the center of the fossa, there was wide varia-
a 15° to 20° horizontal angle and the vertical tion of individual condylar positions, many of
angulation is usually zero degrees. In the cor- which were positioned posteriorly.
rected technique, horizontal angulation is in- Although tomography is the standard for
dividualized by measuring horizontal condylar detecting osseous lesions, small defects often
angulation on a submento-vertex radiograph are not detected. Conclaves18 imaged a series
(Fig 4) and the vertical angulation is measured of gradated holes in dry condyles and found
on an anteroposterior radiograph. The result- that holes less than 11 mm in diameter were
ing tomographic plane closely approximates detected only one-fourth of the time. Rohlin19
the true perpendicular to the condylar long imaged 44 autopsy specimens with corrected
axis (Fig 8). Just as in plane film imaging, the tomography and found a less than desirable
coronal or frontal perspective complements detection rate for moderately severe arthritic
the lateral sections and, if taken before the sag- lesions with soft tissue completely sloughed
gital views, provides a means of measuring ver- and bone exposed (Table 2). The detection
tical condylar angulation. rate for fossa lesions was poor.
The tomographic image. It is generally agreed Tomography summary. Tomography is gener-
that tomography, and specifically corrected to- ally accepted as being superior to plane film
mography, more accurately depicts joint radiography for assessing joint spaces and de-
spaces than the transcranial technique (see tecting osseous lesions, especially when frontal
Fig 9 for an example of tomography). How- as well as saggital views are taken. However,
ever, the relationship of condylar position to early arthritic changes on the condyle, and
disc displacement is not diagnostically defini- even more advanced changes in the fossa, are
tive (Table 2).14-16 Brand16 presented addi- not well detected. This may partially explain
tional evidence questioning the association be- why radiographic findings often correlate
tween posteriorly positioned condyles and disc poorly with clinical signs and symptoms, which
displacement when he found that 50% of pa- often peak early in the course of the disease.
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D. Carl Dixon 213
Panoramic Radiography
Panoramic radiography is closely related to to-
mography because in both techniques the
X-ray source and film cassette move in oppo-
site directions, with the area of interest near
the center of rotation. However, with pan-
oramic radiography the film also moves within
the film cassette. This film movement allows
variation in the position of the focus plane or
trough during the exposure, allowing the fo-
cus layer to follow the irregular curve of the
mandible and maxilla. The dimensions of the
focal trough vary from manufacturer to man-
ufacturer, some being more focused on the
TMJ than others.
The panoramic image. The quality and clarity
of the image depends in part on how well the Figure 10. Diagram of arthrography injection pro-
patient is positioned relative to the focal cedure with needle in place in lower joint compart-
trough and how closely the patient's jaw cur- ment. Anterior and posterior recesses are identi-
vature fits the image layer configuration. In fied.
general, image sharpness is typically less than
with technically correct plane film radiography, or fluoroscopy. The last method allows
phy. Larheim20 found panoramic radiography for monitoring of the needle during the injec-
to compare favorably to transcranial and trans- tion procedure, viewing of dynamic disc move-
pharyngeal radiography in detecting rheuma- ments, and visualizing contrast material mov-
toid arthritic lesions. ing through existing perforations. In many
Panoramic radiography summary. Considering cases of disc displacement with reduction on
its comparability to other imaging techniques mouth opening the dynamic movement of the
for detecting osseous abnormalities, cost effec- disc during displacement and reduction is dra-
tiveness, availability, and relatively low radia- matically evident and can be recorded on vid-
tion dose, the panoramic radiograph is a good eotape for later study.
choice for a screening view. Combined with a If the diagnosis cannot be made using fluo-
carefully conducted clinical examination and roscopy, saggital and possibly coronal view to-
history, the probability of overlooking a malig- mography, referred to as arthrotomography
nancy or life-threatening disease is low. How- when used with contrast medium in the joint,
ever, with this technique many early lesions may be required to provide high definition
will not be detected, and no information on views of the medial and lateral portions of the
joint soft tissue status will be provided. joint (Fig 11). Both the closed mouth and an
open mouth view, with the mandible past the
Arthrography opening click, are required to diagnose disc
displacement with reduction. The contrast me-
Arthrography is a technique used to highlight dium may also show joint space distention in
or outline joint structures by using a radi- the anterior, posterior, and/or lateral and me-
opaque contrast medium to enhance their im- dial recesses, a possible indication of a dis-
ages on plane or tomographic films. In the case placed disc or stretched attachments. An en-
of the TMJ, the contrast medium is injected larged anterior recess is indicative of an ante-
into the upper or lower joint space or both (Fig riorly directed disc displacement, whereas an
10). The disc then appears as a radiolucent enlarged anteromedial recess on the medial
mass against the background of contrast me- cut arthrotomogram may indicate a medially
dium on conventional radiographs, tomogra- directed displacement.
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vasive methods such as MRI have to a large

extent replaced it.
Computed Tomography
Computed tomography (CT) is a technologi-
cally advanced form of tomography using
computerized storage of data from a series of
thin X-ray tomographic sections taken from
multiple directions. The exposures are re-
corded by an array of sensors positioned on
the opposite side of the rotating gantry from
the radiation source (Fig 12). The data are col-
Figure 11. Example of arthrotomogram, closed
mouth position. Note elongated anterior recess lected as a three-dimensional matrix of small
filled with contrast medium (white arrow) and volumes or voxels, each assigned a value cor-
dumb-bell shaped lucent mass (black arrows) ante- responding to the density of the tissue within.
rior to condyle representing anteriorly displaced These data can be reformatted to produce to-
disk. mographic-like sections in different planes, al-
Several well-conducted studies have as- though reconstruction of planes other than
sessed the validity of arthrography in diagnos- that of the original scan results in images that
ing disc displacement with and without reduc- are somewhat degraded.
tion. Sensitivity and specificity was more than Because CT uses X radiation just as in all
0.74 for anteriorly displaced discs21'22 (Table previously discussed radiographic techniques,
2). However, Liedberg22 found the sensitivity it is not well suited for differentiation between
for medially displaced discs to be 0.50, because soft tissue types. Density differences between
many joints with medially displaced discs did muscle, capsule connective tissue, and the disc
not show enlarged anteromedial recesses. He are relatively subtle under the normal CT op-
concluded that arthrographic diagnosis of me- erating mode, and not well differentiated.
dially displaced discs may not be reliable and Discs in normal position are often lost in the
recommended other diagnostic methods, pos- background of the immediately adjacent high
sibly MRI, for these types of displacements. A
more recent study,23 using only a small num-
ber of autopsy specimens, found dual joint
space, coronal perspective arthrotomography
to have greater sensitivity/specificity for medial
displacements than the lower joint space ar-
thrography used in the Liedberg22 study.
Arthrography summary. The adaptation of ar-
thrography to the TMJ was a crucial step in
our understanding of joint soft tissue dynamics
and aided in classification of internal joint de-
rangements. It remains the only imaging
method providing reliable information on per-
forations. However, there is some discomfort
for the patient associated with injecting the
contrast medium, and its presence in the joint
probably affects joint dynamics. Also, exten-
sive experience is required to obtain reliable
results because the method is technique sensi-
tive. As a result, clinical use of arthrography
has declined in the past few years and less in- Figure 12. Diagram of CT scanner.
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D. Carl Dixon 215
contrast condyle and fossa. Anteriorly dis- (Table 2).24'25 However, tomography should
placed discs usually appear as amorphous be considered for this purpose because it costs
masses anterior to the condyle when special much less and its validity is comparable with
computer enhancement techniques are used. that of CT. Probably the best use of CT is for
The sensitivity/specificity values from sev- diagnosing intraosseous lesions (Fig 13). More-
eral studies assessing accuracy of CT in detect- over, CT has a large area of coverage that is
ing disc displacement have varied considerably not only useful for diagnosing tumors in the
(Table 2).24'25 Westesson found poor specific- TMJ, which are very rare,26 but also in adja-
ity (0.50) caused by difficulty in differentiating cent anatomic regions.
between the insertion of the lateral pterygoid
muscle and a displaced disc.24 Other difficul-
ties encountered with CT include inability to
Magnetic Resonance Imaging
detail perforations and disc morphology, as Magnetic resonance imaging (MRI) has several
well as its relatively higher cost and radiation distinct advantages over previously discussed
dose. These factors have led to declining use of imaging techniques. Chief among these advan-
CT for soft tissue diagnosis. tages is the substitution of relatively harmless
Computed tomography summary. CT has good superconducting magnets and radio wave en-
validity for diagnosing osseous abnormalities ergy for the well known hazards of ionizing
Table 2. Sensitivity and Specificity Data From Pertinent TMJ Imaging Validity Studies
Diagnostic Finding Diagnostic of Gold Standard Sens Spec Reference
Condyles posterior in TMJ pain & dysfunction Clinical diagnosis of pain 0.58 0.64 Weinberg2'3
fossa on TR & dysfunction
Condyles posterior in TMJ pain & dysfunction Clinical diagnosis of pain 0.13 0.87 Bean8
fossa on TR & dysfunction
Condyles posterior in Disc displacement Arthrographic dx of disc 0.41 0.55 Dixon9
fossa on TR displacement
Condyles posterior in Disc displacement with Arthrographic dx of DD 0.61 0.61 Ronquillo14
fossa on Tomos reduction with reduction
Disc displacement without Arthrographic dx of DD 0.33 0.61
reduction without reduction
Condyles posterior in Disc displacement Arthrographic Dx of disc 0.30 0.65 Katzberg15
fossa on Tomos displacement
Detection of osseous Degenerative joint disease Direct visual exam of 0.61 0.73 Rohlin19
lesions by Tomos on condyle autopsy specimens
Degenerative joint disease 0.38 0.81
on fossa
Detection of DD by Anterior DD Direct visual exam of 0.84 0.74 Westesson21
arthrography autopsy specimens
Detection of DD by Lateral DD Direct visual exam of 0.45 1.0 Liedberg22
arthrography autopsy specimens
Detection of osseous Degenerative joint disease Detection of lesions by 1.0 0.94 Manzione34
lesions by CT tomography
Detection of osseous Degenerative joint disease Direct visual exam of 0.75 1.0 Westesson24
lesions by CT autopsy specimens
Detection of DD by CT Disc displacement Arthrographic dx of disc 0.96 1.0 Manzione25
displacement
Detection of DD by CT Disc displacement Direct visual exam of 0.86 0.50 Westesson24
autopsy specimens
Detection of osseous Degenerative joint disease Direct visual exam of 0.50 0.71 Tasaki27
lesions by MRI (saggital autopsy specimens
view)
Detection of osseous Degenerative joint disease Direct visual exam of 0.83 1.0 Katzberg28
lesions by MRI (frontal autopsy specimens
view)
Detection of DD by MRI Disc displacement Direct visual exam of 0.86 0.63 Tasaki59
(saggital view) autopsy specimens
Detection of DD by MRI Disc displacement Direct visual exam of 0.87 0.80 Katzberg28
(frontal view) autopsy specimens
Abbreviations: TR, transcranial radiography; DD, disk displacement; CT, computed tomography; MRI, magnetic reso-
nance imaging.
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trast and the low contrast soft tissue is often

lost in the background.
The MRI and disc displacement. Several studies
have assessed the validity of MRI in diagnosing
disc displacements.27'28 Sensitivity was gener-
ally more than 0.86 in all studies (Table 2).
However, if only the saggital view was consid-
ered, specificity was a less than desired 0.63,
apparently caused by a similar appearance of
the lateral capsule in healthy joints and discs
that were anteriorly displaced only in the lat-
eral portion of the joint. In a follow-up study
that included the coronal view, sensitivity im-
Figure 13. CT image of a benign condylar tumor; proved to 0.80. The coronal view is superior in
frontal perspective. demonstrating displacements that are primar-
ily medial or lateral, with little or no anterior
component. The prevalence of medial dis-
radiation used with all previous forms of im- placement is relatively high. Liedberg29 found
aging. a 33% occurrence of medial and a 4% occur-
Simplified description of MRI technology. Some rence of lateral displacement in an elderly pop-
of the polar hydrogen ions in tissue fluids (wa- ulation (autopsy material). Medial and lateral
ter) whose magnetic axes are normally ori- displacements may be difficult to diagnose on
ented randomly, align their axes when ex- saggital views. The three-dimensional com-
posed to the magnetic field produced by MRIs plexity of internal derangements requires both
superconducting magnets. Precession or wob- saggital and coronal examinations to insure re-
bling, similar to a toy top starting to wind liable diagnostic results. Figure 14 is an exam-
down, is induced in the aligned protons as they ple of a cine MRI of a joint with disc displace-
absorb energy from the electromagnetic waves ment with reduction.
(radio-like waves) sent from a transmitter that MRI and osseous lesions. MRI also has the po-
is rapidly switched on and off. When the trans- tential for detecting osseous lesions27'28 (Table
mitter is switched off, the protons give off the 2). Katzberg28 reported that a number of os-
energy they have absorbed, generating a signal seous abnormalities were visible on coronal
that can be received by coil antennae placed views that were not apparent on saggital views
over the area of the TMJs. The strength of the or, in some cases on tomography, reconfirm-
signal is proportional to the number of protons ing the value of the frontal perspective.
in a given area. The magnitude and location of MRI and joint effusion. Joint effusion or ex-
these signals, corresponding to proton (water) cessive fluid inside the capsule, presumably as-
density, are stored in the computer, which can sociated with inflammation, can be detected by
reconstruct cross-sectional images in most any MRI because of its high water (proton) con-
location or spatial plane. By manipulating the tent. Schellhas30 found MRI evidence of effu-
radio wave pulsing sequence, different tissues sion in 88 of 100 painful joints, although he
with varying amounts of water can be high- also noted a high occurrence of effusion in
lighted. For example in a "partial saturation contralateral asymptomatic joints. In a review
Tl weighted" pulse sequence, fat produces a of 379 cases of TMD imaged with MRI, West-
high return, free tissue fluid produces a low esson31 found approximately 30% of the im-
return, and muscle and connective tissue are aged joints to have effusions. However, many
intermediate in return. This pulse sequence painful joints did not have effusions. Increas-
typically best details disc position and mor- ing occurrence of effusion was reported with
phology. Note that in MRI the material of high more advanced stages of disc displacement.
contrast is soft tissue, which is not affected by The effect of effusion on the course of TMJ
nearby dense osseous structures that contain disease, however, is unclear and its presence,
less water. This is opposed to X radiation tech- as detected by MRI, is currently not helpful in
niques, where bone is the material of high con- selecting treatment.
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D. Carl Dixon 217
Figure 14. Cine MRI of a

joint with disc displace-
ment and reduction.
Views of incremental
opening steps beginning
with a closed mouth posi-
tion (A) and ending with a
maximum opened posi-
tion (F). Note increasing
amount of condylar trans-
lation in each view (A) to
(F). Also note disc, dark
mass designated by ar-
rows, anteriorly displaced
in (A) but gradually being
reduced (C), (D) and (E) to
a near normal relationship
to the condyle in (F).
MRI summary. MRI has the capacity to con- with several studies showing good sensitivity
trast soft tissues, to image complex disc dis- and specificity values for differentiating it
placements in multiple planes, and apparently from other femoral head abnormalities and
lacks health hazards, which gives it great po- from normal hips.34"36 Staging and classifica-
tential as a tool for research and longitudinal tion systems have been established using MRI
follow-up of joint disorders. High cost is its findings specific to hip AVN (ring and double
major drawback. Also, it must be kept in mind line sign). However, MRI findings in early dis-
that much work remains in relating MRI find- ease stages are not specific36 and Beltran34 rec-
ings to clinically meaningful diagnoses that aid ommends its early use in the diagnostic process
in treatment selection. Although MRI has been only in high-risk circumstances, such as pa-
available for several years, its technological so- tients with organ transplants, long-term ste-
phistication still outstrips our capacity to wisely roid use, chronic systemic diseases, or sickle
apply its findings clinically. cell anemia.
Unfortunately, diagnostic validity informa-
tion, of the quality that is available for the hips,
MRI and Avascular Necrosis of has not been developed for the TMJ. The
the Condyle pathophysiology of AVN in the hip is likely
Of interest to all clinicians is the recent puta- different from that in the TMJ because of its
tive association of disc displacement and distinctly different blood supplies, the hip hav-
condylar degeneration caused by avascular ne- ing significantly fewer supply arteries. As a re-
crosis, (AVN) and its diagnosis by MRI. Schell- sult, MRI depiction of AVN in the TMJ may
has,30'32'33 in a series of case reports, implied differ significantly from that of the hip. At this
that the prevalence of this condition is greater point, osteoporotic-like MRI signal returns
than previously thought, and treatments (orth- from the TMJ condyle should be considered
odontic and others) that may cause occlusal or nonspecific, and could result from a number
joint loading changes could exacerbate or of disorders including degenerative joint dis-
cause this disorder. ease, osteoporosis, stress fracture, or nonspe-
It is suggested that diagnosis and treatment cific marrow edema. Reliable studies have not
of AVN of the TMJ should be patterned after been accomplished associating MRI osteoporo-
data and experience gained from treatment of sis-like findings in the condyle with histopa-
this disorder in the femoral head of the hip thology of specific disease processes, nor is
joint. MRI is a key diagnostic tool for identify- there epidemiological evidence of increased
ing mid to late stage AVN in the femoral head, prevalence of such occurrences in specific pop-
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ulations or subgroups. Although such relation- adults aged 6 to 25 that found a 27% preva-
ships may be established in the future, it is lence of disc displacement. Displacements were
presently premature, at best, to suggest a cause identified in subjects as early as 6 years of
and effect relationship between any of the pre- age.41 Another longitudinal study by Magnus-
viously discussed factors. son44 found the signs of internal derangement
Even less information is available on the appear and disappear in children without
short-term and long-term natural outcome of treatment or intervention. These studies are
disease processes that may be associated with part of an increasing pool of evidence indicat-
MRI findings of osteoporosis and how curing the common occurrence of internal de-
rently available treatments might alter out- rangements in nearly all age groups, the great
come. The possibility that AVN is a distinct majority of which do not result in changes that
and relatively common affliction of the TMJ significantly alter structure, function, or life-
certainly deserves additional study. However, style. The common finding of internal de-
the prevalence of acquired anterior open bite rangement in asymptomatic subjects indicates
and severe retrognathia in the general popu- that factors other than the displacement itself
lation is relatively low compared with the high could be the source of symptoms in patients
prevalence of internal derangement, 20% in a with internal derangements. A short list of
survey of 403 non-TMD subjects,37 and longi- these other factors includes: neuroendocrine,
tudinal studies indicate benign outcomes for a psychophysiologic, osseous, vascular, and con-
very large majority of internal derangement nective tissue disorders. Imaging has no role in
and degenerative joint disease patients.38'39 establishing the relative contribution of these
Before current conservative treatments and factors to the overall clinical presentation.
practices are significantly altered, scientifically Normal disc position and morphology are
valid answers to the uncertainties of TMJ AVN obviously desirable, and are associated with
should be firmly in place. healthy joint surfaces and contours, whereas
joints with chronic disc displacement without
reduction often show osseous degenerative
Summary and Implications changes.45 However, it seems that a very large
Although imaging has contributed in a major proportion of the general population will, at
way to our understanding of joint disease, and some point in their lives, acquire degenerative
newer technologies such as MRI hold much joint changes. Pereira46 interviewed and exam-
potential for continued research, the applica- ined 19 terminal cancer patients and com-
bility of the findings to clinical situations leaves pared the history of their TMD symptoms with
much to be desired. Osseous changes resulting macroscopic examination of their TMJs at au-
from degenerative joint disease can be de- topsy. Only 9% of the joints had no morpho-
tected in their later stages by most imaging logical changes, whereas 53% had evidence of
techniques. Unfortunately, small, early degenerative joint disease, 39% had disc dis-
changes that are usually present during the placement, and 32% had perforations. How-
more symptomatic stages of the disease are not ever, none of the subjects ever sought treat-
well detected by current imaging techniques. ment and only one reported ever experiencing
This partially explains the poor correlation be- pain in the region of the joints.
tween many imaging findings and signs and Several other studies have failed to show
symptoms. Additionally, several MRI and ar- that signs and symptoms of TMDs are closely
thrography studies have identified internal associated with the presence of internal de-
derangements at a prevalence rate of up to rangements. Roberts,47"49 in a comprehensive
one-third in otherwise asymptomatic popula- study of 205 patients, found poor correlation
tions.40'41 Other studies have reported a high of arthrographically diagnosed disc position,
prevalence of disc displacement in the contra- whether normal or displaced, with a wide array
lateral asymptomatic joints of patients com- of clinical signs and symptoms including inten-
plaining of unilateral symptoms.42'43 Of par- sity of joint and muscle pain, muscle palpation
ticular interest to orthodontists is an MRI tenderness, and headache. Zaki50 in an MRI
study of 56 asymptomatic children and young study of 55 patients, found the only signs or
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D. Carl Dixon 219
symptoms associated with MRI findings of disc the information gleaned will play a salient role
displacement were maximum unassisted in the proposed treatment.
mouth opening and TMJ noise. In addition, The major problem with TMJ imaging is
Weissman51 found no significant correlation not its capacity to diagnose. Sensitivity and
between pretreatment MRI findings and sub- specificity data show that imaging, especially
sequent treatment outcome. MRI, has excellent diagnostic validity for cer-
Unfortunately, there is a paucity of longitu- tain diagnoses. The problem is a lack of studies
dinal studies relating presymptomatic phase tying these diagnoses to individual patients in
findings with later onset of disease and its ap- clinical settings where treatment decisions are
pearance on imaging as the disease progresses. being made. Until these studies are forthcom-
Such studies might allow identification of indi- ing, imaging will not play a pivotal role in day-
viduals with high potential to develop disease to-day patient treatment.
or those in whom it is likely to progress. Is-
berg,52 in a quasi-longitudinal study, arthro-
graphically imaged both joints of 50 patients References
with unilateral disc displacement symptoms 1. Yale SH, Allison BD, Hauptfuehrer JD. An epidemi-
and found that 60% had disc displacement ologic assessment of mandibular condyle morphology.
Oral Surg Oral Med Oral Pathol 1966;21:169-177.
without reduction in the asymptomatic joint. 2. Weinberg LA. Role of condylar position in TMJ dys-
These asymptomatic disc displacements were function-pain syndrome. J Prosthet Dent 1979;41:
followed for a period of 5 years, during which 636-642.
57% developed pain symptoms. In another 3. Weinberg LA. The role of stress, occlusion and
longitudinal study, Westesson53 followed the condyle position in TMJ dysfunction-pain. J Prosthet
Dent 1983;49:532-545.
course of 61 patients with initial arthrographic
4. Pala S. Condyle position: Determinants and radiolog-
diagnoses of disc displacement with reduction, ical analysis, In: Solberg WK, Clark GT, editors. Ab-
finding 20% of the joints progressed to closed normal Jaw Mechanics. Chicago, IL: Quintessence,
lock within 1 year. Cases that tended to prog- 1984:57
ress had, at initial examination, more pain on 5. Eckerdal O, Lundberg M. Periodic roentgenography
of the temporomandibular joint. Dentomaxillofac Ra-
function, increased frequency of catching, and diol 1975;4:4-11.
a deep anterior recess in the lower joint com- 6. Larheim A, Tveito L, Dale K, et al. Temporomandib-
partment. ular joint abnormalities in rheumatoid arthritis: Com-
There is minimal information that imaging parison of different radiographic methods. Acta Ra-
findings in asymptomatic subjects can be reli- diol(Diagn) 1981;22:703-707.
7. Omnell KA, Petersson A. Radiology of the temporo-
ably related to the future occurrence of pain, mandibular joint utilizing oblique lateral transcranial
dysfunction, or adverse skeletal changes. The projections. Odont Revy 1976;27:77-92.
available evidence indicates that the greatest 8. Bean LR, Thomas CA: Significance of condylar posi-
potential for disease progression is in those pa- tions in patients with temporomandibular disorders. J
tients who initially present with the highest Am Dent Assoc 1987; 114:76-77.
9. Dixon DC, Graham GS, Mayhew RB, et al: The valid-
level of symptoms, whereas asymptomatic or ity of radiography in diagnosing TMJ anterior disk
low symptom level patients do not tend to show displacement. J Am Dent Assoc 1984;108:615-618.
progression. At present knowledge levels, im- 10. Aquilino SA, Matteson SR, Hollan GA, et al. Evalua-
aging in the absence of definite signs and tion of condylar position from temporomandibular
symptoms in an attempt to predict the poten- joint radiographs. J Prosthet Dent 1985;53:88-96.
tial that a disorder will surface in the future 11. Kitamori H, Tagawa K, Yamada M. Effect of projec-
tion angle on the fossa-condylar relationship in ob-
cannot be justified. There is even less valid in- lique lateral transcranial radiography and lateral to-
formation on how treatments (eg, orthodontic, mography. Dent Radiol 1988;28:93-101.
bite appliances) might interact with this un- 12. Bean LR, Petersson A, Svensson A. The transmaxil-
quantified potential to precipitate or exacer- lary projection in temporomandibular joint radiogra-
bate symptoms. The use of imaging for these phy. Dentomaxillofac Radiol 1975;4:13-18.
purposes should be reserved for experimental 13. Heffez L, Jordan S, Rosenberg H. Accuracy of tem-
poromandibular joint space measurements using cor-
protocols. Before patients are exposed to the rected hypocycloidal tomography. J Oral Maxillofac
expense and possible side effects of an imaging Surg 1987;45:137-142.
procedure, there should be a high probability 14. Ronquillo HI, Guay J, Tallents RH. et al. Tomo-
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graphic analysis of mandibular condyle position as Tl- and T2-weighted imaging techniques. Am J
compared to arthrographic findings of the temporo- Roentgenol 1989; 153:93-98.
mandibular joint. J Orofacial Pain 1988;2:59-64. 31. Westesson P-L, Brooks SL. Temporomandibular
15. Katzberg RW, Keith DA, Ten Erick WR, et al. Internal joint: Relationship between MR evidence of effusion
derangements of the temporomandibular joint: An and the presence of pain and disk displacement. Am J
assessment of condylar position in centric occlusion. J Roentgenol 1992; 159:559-563.
Prosthet Dent 1983;49:250-254. 32. Schellhas KP, Pollei SR, Wilkes CH. Pediatric internal
16. Brand JW, Whinery JG, Anderson QN, et al. Condy- derangements of the temporomandibular joint: Effect
lar position as a predictor of temporomandibular joint on facial development. Am J Orthod Dentofac Or-
internal derangement. Oral Surg Oral Med Oral thop 1993;104:51-59.
Pathol 1989;67:469-476. 33. Schellhas KP, Piper MA, Omlie MR. Facial skeleton
17. Blaschke DD, Blaschke TI. Normal TMJ bony rela- remodeling due to temporomandibular joint degen-
tionships in centric occlusion. J Dent Res 1981;60:98- eration: An imaging study of 100 patients. Am J
104. Roentgenol 1990; 155:373-383.
18. Conclaves N, Miller AM, Yale SH, et al. Radiographic 34. Beltran J, Herman LJ, Burk JM, et al. Femoral head
evaluation of defects created in mandibular condyles. avascular necrosis: MR imaging with clinical-
Oral Surg Oral Med Oral Pathol 1974;38:479-489. pathologic and radionucleotide correlation. Radiology
19. Rohlin M, Ackerman S, Kopp S. Tomography as an 1988;166:215-220.
aid to detect macroscopic changes of the temporo- 35. Glickstein MF, Burk DL, Schiebler ML, et al. Avascu-
mandibular joint. Acta Odontol Scand 1986;44:131- lar necrosis versus other diseases of the hip: Sensitivity
140. of MR imaging. Radiology 1988;169:213-215.
20. Larheim A, Johannessen S, Tveito L. Abnormalities of 36. Turner DA, Templeton AC, Selzer PM, et al. Femoral
the temporomandibular joint in adults with rheumatic capital osteonecrosis: MR findings of diffuse marrow
disease. A comparison of panoramic, transcranial and abnormalities without focal lesions. Radiology 1989;
transpharyngeal radiography with tomography. Den- 171:135-140.
tomaxillofac Radiol 1988;17:109-113. 37. Lundh H, Westesson P-L. Clinical signs of temporo-
21. Westesson P-L, Bronstein SL. Temporomandibular mandibular joint internal derangement in adults. An
joint: Comparison of single- and double-contrast ar- epidemiologic study. Oral Surg Oral Med Oral Pathol
thrography. Radiology 1987; 164:65-70. 1991;72:637-641.
22. Liedberg J, Westesson P-L, Kurita K: Sideways and 38. de Leeuw R, Boering G, Stegenga B, et al. Clinical
rotational displacement of the temporomandibular signs of TMJ osteroarthrosis and internal derange-
joint disk. Diagnosis by arthrography and correlation ment 30 years after nonsurgical treatment. J Orofacial
to cryosectional morphology. Oral Surg Oral Med Pain 1994;8:18-24.
Oral Pathol 1990;69:757-763. 39. Rasmussen OC. Temporomandibular arthropathy.
23. Kurita K, Westesson, P-L, Tasaki M. Diagnosis of me- Int J Oral Surg 1983; 12:365-389.
dial temporomandibular joint disc displacement with 40. Kirkos LT, Ortendahl DA, Mark AS, et al. Magnetic
dual space anteroposterior arthrotomography. J Oral resonance imaging of the TMJ disc in asymptomatic
Maxillofac Surg 1992;50:618-620. volunteers. J Oral Maxillofac Surg 1987;45:852-854.
24. Westesson P-L, Katzberg RW, Tallents RH, et al. CT 41. Riberio R, Tallents R, Katzberg R, et al. TMJ struc-
and MR. of the temporomandibular joint: Compari- tural evaluation by MRI in asymptomatic children and
son with autopsy specimens. Am J Roentgenol 1987; young adult subjects. J Orofacial Pain 1995;9:98. (ab-
148:1165-1171. str 3).
25. Manzione JV, Katzberg RW, Brodsky GL, et al. Inter- 42. Kozeniauskas JJ, Ralph WJ. Bilateral arthrographic
nal derangements of the temporomandibular joint: evaluation of unilateral temporomandibular joint
Diagnosis by direct sagittal computed tomography. pain and dysfunction. J Prosthet Dent 1988;60:98-
Radiology 1984;150:111-115. 105.
26. Nwoku AL, Koch H. The temporomandibular joint: A 43. Ross JB. Arthrography of the temporomandibular
rare localization for bone tumors. J Maxillofac Surg joint, In: Clark GT, Solberg WK, editors. Perspectives
1974;2:113-119. in Temporomandibular Disorders, Chicago, IL:
27. Tasaki MM, Westesson P-L. Temporomandibular Quintessence, 1987.
joint: Diagnostic accuracy with sagittal and coronal 44. Magnusson T, Egermark-Eriksson I, Carlsson GE.
MR imaging. Radiology 1993; 186:723-729. Changes in subjective symptoms of craniomandibular
28. Katzberg RW, Westesson P-L, Talents RH, et al. Tem- disorders in children and adolescents during a ten-
poromandibular joint: MR assessment of rotational year period. J Oraofacial Pain 1993;7:76-82.
and sideways displacements. Radiology 1988; 169:741- 45. Westesson P-L. Rohlin M. Internal derangement re-
748. lated to osteoarthrosis in temporomandibular joint
29. Liedberg J, Westesson P-L. Sideways position of the autopsy specimens. Oral Surg Oral Med Oral Pathol.
temporomandibular joint disk: Coronal cryosection- 1984;57:l7-22.
ing of fresh autopsy specimens. Oral Surg Oral Med 46. Pereira FJ, Lundh H, Westesson P-L, et al. Clinical
Oral Pathol 1988;66:644-649. findings related to morphologic changes in TMJ au-
30. Schellhas KP, Wilkes CH. Temporomandibular joint topsy specimens. Oral Surg Oral Med Oral Path 1994;
inflammation: Comparison of MR fast scanning with 78:288-295.
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D. Carl Dixon 221
47. Roberts CA, Tallents RH, Katzberg RW, et al. Clinical MR findings and TMD signs and symptoms. J Dent
and arthrographic evaluation of temporomandibular Res 1993;72:191 (A 703).
joint sounds. Oral Surg Oral Med Oral Pathol 1986; 51. Weisman JL, Rudy TE, Curtin HD, et al. MR findings
62:373-376. and treatment outcome in TMD patients. J Dent Res
48. Roberts CA, Tallents RH, Katzberg RW, et al. Clinical 1993;72:192 (A 709).
and arthrographic evaluation of temporomandibular 52. Isberg A, Stenstrom B, Isacsson G. Frequency of bi-
joint pain. Oral Surg Oral Med Oral Pathol 1987;64: lateral temporomandibular joint disc displacement in
6-8. patients with unilateral symptoms: A 5-year follow-up
of the asymptomatic joint. A clinical and arthrotomo-
49. Roberts CA, Tallents RH, Katzberg RW, et al. Com- graphic study. Dentomaxillofacial Radiol 1991;20:73-
parison of arthrographic findings of the temporo- 76.
mandibular joint with palpation of the muscles of 53. Westesson P-L, Lundh H. Arthrographic and clinical
mastication. Oral Surg Oral Med Oral Pathol 1987; characteristics of patients with disk displacement who
64:275-277. progressed to closed lock during a 6-month period.
50. Zaki H, Rudy T, Weissman JL, et al. The association of Oral Surg Oral Med Oral Pathol 1989;67:654-657.
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Etiology of Temporomandibular Disorders

Charles S. Greene
This article discusses the subject of causation (etiology) as it has been ap-
plied to the field of temporomandibular disorders (TMD). These disorders
have been the focus of considerable disagreement about what constitutes
proper diagnosis and treatment, and it is clear that the main basis for these
controversies has been conflicting views about the etiology of the various
disorders. Many earlier theories emphasized dental morphological factors of
malocclusion, occlusal dysharmony, and bad mandibular alignment as being
primarily responsible for the development of TMD symptoms. Certain ver-
sions of these dental/skeletal concepts have long been a part of the belief
system of the orthodontic specialty, leading to some special orthodontic
protocols for managing TM disorders. Today, it is generally agreed that the
etiology of TM disorders includes a multifactorial combination of physical
and psychosocial factors, with some of them being either poorly understood
or difficult to assess. In most cases, there are no special occlusal or orth-
odontic factors to be considered, and therefore occlusion-changing proce-
dures are not generally required for successful treatment. This means that
contemporary orthodontists must face the same challenge as all their other
dental colleagues: to learn about modern concepts of diagnosis and treat-
ment for all types of orofacial pain patients, and then to use currently rec-
ommended protocols for pain management and musculoskeletal therapy for
those patients who have temporomandibular disorders. (Semin Orthod
1995:1:222-228.)
The etiology of temporomandibular (TM) occur.1 This obvious truism can hardly be dis-
disorders is a complex subject at best, but it puted, but in the real world we have to deter-
must be discussed to further our understand- mine when it can or cannot be applied to the
ing of these problems. Although the field is problems of each patient. There are many
only 60 years old, we already have observed a medical conditions that are poorly understood
number of major and minor shifts in thinking in terms of etiology; yet, clinicians can and do
about this subject. As might be expected, these treat them at some level below the ideal one of
conceptual shifts have had an enormous im- fully understanding the cause. In addition,
pact on the treatment of patients, while also there are some conditions in which the etiology
being a source of significant controversy among may be known but unchangeable. For exam-
clinicians. Before proceeding with this discus- ple, trauma often is a clear etiologic factor in
sion of past and present orthodontic concepts specific injury cases, but it cannot simply be
of TMD etiology, it is first necessary to con- undone. In other situations, the etiology seems
sider some general issues in the study of etio- to be multifactorial, but these types of disor-
logic relationships. ders generally are characterized by disagree-
The key to proper treatment of any disor- ment between experts as to what weight each
der is an understanding of what caused it to factor should be given.2 Indeed, the term
"multifactorial" often seems to be merely an
From the TMD Clinic, Northwestern University Dental intellectual cover-up for the term "idiopathic"
School, Department of Orthodontics. (etiology unknown).
Address correspondence to Charles S. Greene, DDS, 4709
Golf Road, Suite 1005, Skokie, IL 60076. Discussions about etiology have become
Copyright © 1995 by W.B. Saunders Company complicated in recent years by the introduction
1073-874619510104-0004$5.00/0 of new terminologies, often based on statistical
222 Seminars in Orthodontics, Vol l,No4 (December), 1995: pp 222-228

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Charles S. Greene 223
concepts. Although it is beyond the scope of hibiting factors, all of which lead to the on-
this article to discuss all of these, many readers set of symptoms.
will recognize the most common terms: corre- 3. Perpetuating factors. These include poor
lations, associations, risk factors, and odds ra- healing capacity, failure to control etiologic
tios. Despite the warnings that most investiga- factors, secondary gains from staying sick,
tors provide when writing about these issues, and negative effects from inappropriate
there is a tendency for some readers to over- treatments.
interpret certain data that infer an etiologic re-
lationship, but are far from proving it. Even Although this approach is both reasonable
the well-known relationship between smoking and practical, its limitations must be recog-
and lung cancer had to travel a long road from nized; at any given point in time, only some
being a positive correlation to becoming estab- of these etiologic factors can be identified,
lished as a major causative (etiologic) factor in whereas others may remain quite elusive. Of-
that disease; it was necessary to determine how ten such factors can be analyzed in groups of
the ingredients of tobacco smoke could actu- patients (by comparing them with normal pop-
ally cause lung cells to become cancerous, ulations), but they are difficult to identify in
which is a level of science that is much more individual patients.
complex than the assessment of risk. For clinicians who wish to provide the best
Some interesting ethical questions arise care possible, despite the lack of clear etiologic
from the study of so-called risk factors for var- findings, some important decisions must be
ious diseases. For example, if it is determined made. Should one wait for a more perfect eti-
that a certain morphological factor appears ologic picture to emerge from research, mean-
more often in an affected population (this is while providing only symptomatic care, or is it
properly described as an association), how far possible to do better than that? Although we
should we go with that knowledge? Is this fac- have an imperfect understanding of the etiol-
tor actually contributing to causation of the ogy of most TM disorders at this time, we have
problem, or is it merely a predictor of greater been able to develop some rational systems of
likelihood of getting the problem? Do we know treatment based on other data; namely, the
for sure that changing this morphology is ther- large body of data that has been produced
apeutic, or is it too late to reverse the condition from controlled studies of the clinical out-
by that approach because the damage is al- comes of many treatment approaches for the
ready done? Is there a risk-benefit ratio asso- various TM disorders.3"6 Other authors in this
ciated with changing morphology? Should we issue have presented the currently recom-
change it in children to prevent them from de- mended nonsurgical treatment protocols for
veloping the condition later in life? Should these disorders, based on the extensive litera-
asymptomatic adults routinely be screened ture dealing with this subject.
and/or treated for the potential risk attributed Any attempt to clarify the etiology and
to this factor? If these questions sound familiar treatment issues in regard to TM disorders
to orthodontic readers, it should not be sur- also must include a critical review of past ther-
prising. apeutic concepts in this field, many of which
One approach to the complexity of causal were based on faulty etiologic theories.7 In the
relationships is to subdivide possible etiological next section, several orthodontic versions of
factors into three categories: causation and cure for TMD that have had a
significant impact on the behavior of specialists
in this discipline will be considered.
1. Predisposing factors. These include a mix-
ture of morphological, physiological, psy-
chological, and environmental variables Special Orthodontic Concepts of
that heighten an individual's susceptibility TMD Etiology
to develop a certain problem.
The origins of orthodontic thinking about TM
2. Precipitating factors. These include vari- disorders can be traced to the writings of
ous combinations of trauma, stress, hyper- Thompson.8 His concept of posterior and su-
function, and possibly failure of natural in- perior displacement of the condyle greatly in-
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224 Etiology of TM Disorders
fluenced orthodontists when it first was pub- age between orthodontics and TM disorders
lished 40 years ago, and even today he and have come both from traditional orthodon-
others are still promoting this concept.9'10 Al- tists19 and from various nonspecialist dentists
though prosthodontists, in general, have who provide orthodontic treatment.20 These
claimed that most condyles in patients with practitioners often discuss matters in terms of
TMD are anterior to their proper centric rela- so-called functional jaw orthopedics (FJO), a
tion (and therefore need to be pushed back- concept that in many ways resembles the early
ward and upward), Thompson believed that concepts of posterior jaw displacement. With
most condyles needed to be brought down- the advent of functional orthopedic appli-
ward and forward. This viewpoint was based ances, many of these practitioners have made
on his analysis of tracings taken from cephalo- orthopedic mandibular advancement the cen-
metric radiographs in which the condyle could terpiece of their entire treatment philosophy,
not be observed in the closed position, so it had claiming that they are producing superior re-
to be traced on open-mouth views and trans- sults both orthodontically and in terms of TMJ
posed to the first radiograph. The treatment health.20'21 At the same time, they are criticiz-
concept that followed from this line of thinking conventional orthodontists for continuing
ing often was referred to as "freeing up a dis- to do such traditional procedures as premolar
talized (trapped) mandible," requiring among extractions, incisor retraction, and using vari-
other things anterior positioning of the upper ous headgear. None of this rhetoric has been
incisors. supported by findings from the scientific liter-
Subsequent developments in the orthodon- ature, but the debate has been a source of con-
tic view of TM disorders came from the radio- siderable bitterness both within the orthodon-
graphic studies performed by Ricketts,11 as tic profession and outside of it.
well as from a number of electromyographic In 1988, a review and analysis of this topic
studies performed by Perry,12 Jarabak,13 and entitled "Orthodontics and Temporomandib-
Moyers.14 These studies initially seemed to ular Disorders" was published,22 and a list of
show significant differences between normal 10 myths in this field was presented:
subjects and TMD patients, but further re-
search over the years has failed to support 1. People with certain types of untreated
these early findings.15 Even with the improved malocclusion (for example, Class II Divi-
sophistication of modern imaging and EMG sion 2, deep overbite, crossbite) are more
procedures, it has been found that neither ap- likely to develop TM disorders.
proach can be reliably used to separate TMD 2. People with excessive incisal guidance, or
patients from normal populations.16'17 people totally lacking incisal guidance
A more insidious development for orth- (open bite), are more likely to develop TM
odontists came when some of their own col- disorders.
leagues began attributing TM disorders to im- 3. People with gross maxillomandibular dis-
proper finishing of orthodontic cases18 and a harmonies are more likely to develop TM
lack of appreciation for "correct" concepts of disorders.
functional occlusion (eg, CO and CR must co- 4. Pretreatment radiographs of both TMJs
incide; no balancing interferences should be should be taken before starting orthodon-
present; anterior guidance must disclude the tic treatment. The position of each condyle
posterior teeth; and so forth). Despite consid- in its fossa should be assessed as good or
erable debate about this subject, it never was bad, and orthodontic treatment should be
shown scientifically that any "wrong" concepts directed at producing a good relationship
of occlusion or "improper" finishing by orth- at the end. ("Good" position usually was
odontists using diverse methods had produced defined as being a concentric placement of
any significant number of postorthodontic the condyle in the fossa).
TMD sufferers. Even today there still is no 5. Orthodontic treatment, when properly
agreement among orthodontists about any su- done, reduces the likelihood of subse-
perior methods of finishing cases. quently developing TM disorders.
More recent ideas about the presumed link- 6. Finishing orthodontic cases according to
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specific functional occlusion guidelines specific gnathologically ideal occlusion does

(eg, gnathologic principles) reduces the not result in TMD signs and symptoms.
likelihood of subsequently developing TM 7. No method of TM disorder prevention has
disorders. been demonstrated.
7. The use of certain traditional orthodontic 8. When more severe TMD signs and symp-
procedures and/or appliances may in- toms are present, simple treatments can al-
crease the likelihood of subsequently de- leviate them in most patients.
veloping TM disorders.
8. Adult patients who have some type of oc- In reaching these conclusions, the authors
clusal "disharmony" along with the pres- depended heavily on the large number of
ence of TMD symptoms will probably re- long-term prospective and retrospective stud-
quire some form of occlusal correction to ies performed by orthodontic and occlusion re-
get well and stay well. searchers throughout the world.24"26 In addi-
9. Retrusion of the mandible because of nat- tion, they incorporated the fine literature re-
views and analyses performed by both Swedish
ural causes or after treatment procedures
is a major factor in the etiology of TM dis- and American investigators27'28 that assessed
the relationships between all types of occlusal
orders.
variables and nearly all forms of TMD. Alto-
10. When the mandible is distalized, the artic-
gether, McNamara et al23 cited over 100 ref-
ular disc may slip off the front of the
erences in their article.
condyle.
None of these statements is correct accord- What Should Contemporary
ing to the current scientific literature. Most of Orthodontists Be Doing in Relation to
them simply represent the accumulated myth- TM Disorders?
ology of the orthodontic profession, handed
down from one generation to another. In an If orthodontists can accept the fact that there is
excellent review of this topic that was pre- no special orthodontic viewpoint required for
sented to an international conference spon- dealing with TMD patients, they can join their
sored by the National Institute of Dental Re- other dental colleagues in providing the best of
search (NIDR), McNamara, Seligman, and modern diagnosis and treatment for these pa-
Okeson23 listed eight conclusions that essen- tients. Intellectually, this process must begin by
tially refute all of the previous statements: shedding the beliefs of the past, especially
those etiologic concepts that have been either
1. Signs and symptoms of TMD occur in disproved or unsupported by scientific evi-
healthy individuals dence.7'22'23 For many orthodontists, the big-
2. Signs and symptoms of TMD increase with gest barrier to taking this step is that so many
age, particularly during adolescence. Thus, patients have apparently done well following
TMD that originates during [orthodontic] orthodontic treatment for TMD, but the same
treatment may not be related to the treat- can be said for prosthodontic treatment, oc-
ment. clusal equilibration, bite opening, condylar re-
3. Orthodontic treatment performed during positioning, and many other irreversible den-
adolescence generally does not increase or tal procedures that have not withstood the ret-
decrease the chances of developing TMD rospective scrutiny of scientific analysis. Most
later in life. authorities today agree that the high level of
4. The extraction of teeth as part of an orth- positive response in TMD patients treated by
odontic treatment plan does not increase these aggressive methods is due to the combi-
the risk of developing TMD. nation of a natural tendency to recover, pla-
5. There is no elevated risk for TMD associ- cebo effects, and ingredients from therapies
ated with any particular type of orthodontic that work successfully.3'4'29
mechanics. In many cases, TMD patients have under-
6. Although a stable occlusion is a reasonable gone a two-stage treatment protocol in which
orthodontic treatment goal, not achieving a Phase I provides symptom relief (with conser-
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vative and reversible modalities), and Phase II uted the pain to some type of malocclusion?
requires some permanent alteration of den- What should you do if one of your own pa-
toskeletal relationships.30 As is true of most tients develops symptoms of temporomandib-
treatment concepts, this approach is based on ular discomfort during your orthodontic treat-
some type of etiologic theory; in this con- ment? What kind of TMD screening should
cept, either the mandible is described as you do before starting treatment, especially in
being malpositioned, malaligned, or displaced, this age of medicolegal concerns? What if a
or the condyle is described as being in a former patient comes back some time later
wrong centric position or not centered in the with a TM disorder that another dentist has
fossa.10'18'31 All of this is said to be caused by blamed on your treatment? To deal with any of
some malrelationship of the upper and lower these situations, a contemporary orthodontist
teeth, either congenital or acquired.32 The must have a reasonable level of knowledge
orthodontic version of this treatment concept about modern concepts of TMD etiology, di-
for TM disorders often includes both an agnosis, and treatment.
orthodontic component and an orthognathic Although it is beyond the scope of this arti-
surgery component. Frequently, the Phase II cle to discuss all aspects of what should be
procedures are based on a particular type learned in this field, the following short list
of oral appliance (splint) that has been used may serve as a guideline to those who are in-
in Phase I to establish a "correct" jaw position, terested:
and indeed these types of appliances can
produce permanent dental and skeletal 1. Learn about the complexities of differential
changes.31'33'34 However, it has been found diagnosis of orofacial pain. Because there
through both retrospective and prospective are more than 150 varieties of headaches
studies that the Phase I treatments are what classified by the International Headache So-
really help TMD patients to improve, whereas ciety,39 a diagnosis of a TM disorder must
Phase II generally represents a mechanistic be segregated from a large number of other
"stabilization" of the mandible for patients who possibilities.
would not have needed it if their original jaw 2. Learn about the differences between acute
position had been maintained.4'35'36 There- and chronic pain. These distinctions be-
fore, the mere accumulation of "successfully come crucial in the management of TMD
treated" TMD cases is far from being sufficient patients, especially when they do not re-
proof of the conceptual validity of any partic- spond to initial therapy. In chronic pain sit-
ular etiologic theory or treatment philosophy. uations, psychological variables become
Another step that most practicing orth- even more important, and this is another
odontists will need to consider is rejection of subject that must be understood by all clini-
the false prophets and gurus within their cians.
own specialty. Many well-known orthodontic
authorities continue to defend the TMD/ 3. Learn about the musculoskeletal nature of
orthodontic positions of the past, a viewpoint TM disorders. These disorders are similar
that was clearly expressed in a recent editorial to most other joint, muscle, and disc disor-
in their major journal.37 It is somewhat ironic ders throughout the body, and an appreci-
that an entire issue of that same journal was ation of orthopedic principles is fundamen-
devoted to scientific studies and review articles tal to proper understanding of these prob-
about TM disorders and orthodontics which, lems.
in general, rejected most of that outdated 4. Learn how to treat patients with conserva-
thinking.38 tive and reversible modalities. Again, the in-
Even orthodontists who prefer not to treat formation gained from the general ortho-
patients with TM disorders will find them- pedic literature has been the foundation for
selves caught up in certain clinical dilemmas. development of modern treatment proto-
How should you deal with a patient who is re- cols for TMD.7 As in other areas of the
ferred by another dentist for treatment of oro- body, there has been a clear trend toward
facial pain, if that dentist already has attrib- more conservative management techniques,
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usually involving a considerable amount of for Clinical Practice (ed 4). Philadelphia, PA: Saun-
patient self-help participation. ders, 1992:298-315.
8. Thompson JR. Temporomandibular disorders: Diag-
The sources for all of this information are nosis and treatment. In: Sarnat BG, editor. The Tem-
poromandibular Joint (ed 2). Springfield, IL: Charles
many and varied, but a good place to start is by C Thomas, 1964:146-184.
reading several overview articles that summa- 9. Thompson JR. Abnormal function of the temporo-
rize the major diagnostic categories and the mandibular joints and muscles (Part 3). Am J Orthod
recommended treatment protocols for TM dis- Dentofac Orthop 1994; 105:224-240.
orders.40"43 In addition, the guidelines pub- 10. Weinberg LA. Role of condylar position in TMJ pain-
dysfunction syndrome. J Prosthet Dent 1979;41:636-
lished by the American Academy of Orofacial 643.
Pain36 have become recognized as the most 11. Ricketts RM. Roentgenography of the temporoman-
comprehensive and up-to-date summary of dibular joint. In: Sarnat BG, editors. The Temporo-
current diagnostic classifications and treat- mandibular Joint (ed 2). Springfield, IL: Charles C
ment protocols for the management of TMD Thomas, 1964:102-132.
12. Perry HT. Muscular changes associated with tempo-
patients. Some recent textbooks also provide a romandibular joint dysfunction. J Am Dent Assoc
great deal of information about contemporary 1957;54:644-653.
concepts of temporomandibular anatomy, 13. Jarabak JR. An electromyographic analysis of muscu-
physiology, normal function, and dysfunc- lar and temporomandibular joint disturbances due to
tion.44'46 imbalances in occlusion. Angle Orthod 1956; 26:170-
190.
In conclusion, the subject of etiology in the 14. Moyers RE. An electromyographic analysis of certain
field of temporomandibular disorders remains muscles involved in temporomandibular movement.
both controversial and incomplete, but this has Am J Orthod 1950;36:481-515.
not prevented our profession from making sig- 15. Lund JP, Widmer CG. An evaluation of the use of
nificant advances in the care of TMD patients. surface electromyography in the diagnosis, documen-
tation, and treatment of dental patients. J Cranio-
As more work is being performed on the study mandib Disord Facial Oral Pain 1989;3:125-137.
of etiologic factors, concerned dentists must 16. Pullinger AG, Solberg WK, Hollender L, et al. Tomo-
continue to provide the best possible care with graphic analysis of mandibular condyle position in di-
the lowest possible risk to relieve the pain and agnostic subgroups of temporomandibular disorders.
J Prosthet Dent 1986;55:723-729.
suffering of these patients35'41'42 and enable
17. Mohl ND, et al. Devices for the diagnosis and treat-
them to return to a more normal and comfort- ment of temporomandibular disorders. J Prosthet
able life. Dent 1990;63:Parts I, II, III (Feb, March, April).
18. Roth RH. Functional occlusion for the orthodontist. J
Clin Orthod, 1981;15:Parts I, II, III, IV.
References 19. Wyatt WE. Preventing adverse effects on the tempo-
romandibular joint through orthodontic treatment.
1. Laskin DM. Etiology of the pain-dysfunction syn- Am J Orthod 1987 ;91:493-499. (See also Rinchuse
drome. J Am Dent Assoc 1969;79:147-153. DJ, pp 500-506, for response to Wyatt.)
2. Clark GT. Etiologic theory and prevention of tempo- 20. Witzig JW, Yerkes IM. Functional jaw orthopedics:
romandibular disorders. Adv Dent Res 1991;5:60-66. Mastering more than technique. In: Gelb H, editor.
3. Mjersjo C, Carlsson GE. Long-term results of treat- Clinical Management of Head, Neck, and TMJ Pain
ment for temporomandibular pain-dysfunction. J and Dysfunction, (ed 2). Philadelphia, PA: Saunders,
ProsthetDent 1983;49:809-815. 1985:598-618.
4. Greene CS, Laskin DM. Long-term evaluation of 21. Stack BC. Orthodontic treatment methods. Parts I and
treatment for myofascial pain-dysfunction syndrome: II. Funct Orthod 1984;!:! 1-33.
A comparative analysis. J Am Dent Assoc 1983; 107: 22. Greene CS. Orthodontics and temporomandibular
235-238. disorders. Dent Clin North Am 1988;32:529-538.
5. Greene CS, Laskin DM. Long-term status of TMJ 23. McNamara JA, Seligman DA, Okeson JP. Occlusion,
clicking in patients with myofascial pain and dysfunc- orthodontic treatment, and temporomandibular dis-
tion. J Am Dent Assoc 1988;! 17:461-465. orders: A review. J Orofacial Pain 1995;9:73-90. Orig-
6. Magnusson T, Egermark-Eriksson I, Carlsson GE. inally presented to the NIDR International Workshop
Five-year longitudinal study of signs and symptoms of on the TMD's and Related Pain Conditions, April 17-
mandibular dysfunction in 119 young adults. J Cra- 20, 1994.
niomandib Pract 1986;4:338-344. 24. Dibbetts JMH, van der Weele L Th. Long-term effects
7. Greene CS. Temporomandibular disorders: The evo- of orthodontic treatment, including-extraction, on
lution of concepts. In: Sarnat BG, Laskin DM editors. signs and symptoms attributed to craniomandibular
The Temporomandibular Joint: A Biological Basis disorders. Eur J Orthod 1992; 14:16-20.
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25. Sadowsky C, Poison AM. Temporomandibular disor- itor. Temporomandibular Disorders: Guidelines for
ders and functional occlusion after orthodontic treat- Classification, Assessment, and Management. Chi-
ment. Am J Orthod 1984;86:386-390. cago, IL: Quintessence, 1993.
26. Egermark-Eriksson I, Carlsson GE, Magnuson T: A 37. Graber TM: Hardcore, softcore, or fringe? Am J
long-term epidemiologic study of the relationship be- Orthod Dentofac Orthop 1993; 103:556-559. (See re-
tween occlusal factors and mandibular dysfunction in sponse by Greene CS, pp 16A-17A.)
children and adolescents. J Dent Res 1987;66:67-7l. 38. American Journal of Orthodontics and Dentofacial
27. Droukas B, Lindee C, Carlsson GE. Occlusion and Orthopedics. Vol 101, Jan 1992.
mandibular dysfunction: A clinical study of patients 39. Classification and diagnostic criteria for headache dis-
referred for functional disturbances of the mastica- orders, cranial neuralgias, and facial pain. Presented
tory system. J Prosthet Dent 1985;53:402-406. by the Headache Classification Committee of the In-
28. Seligman DA, Pullinger AG. The role of functional ternational Headache Society, in Cephalgia, vol 8,
occlusal relationships in temporomandibular disor- Suppl 7, 1988.
ders: A review. J Craniomandib Disord Facial Oral 40. Clark GT, Seligman DA, Solberg WK, et al. Guidelines
Pain 1991;5:265-279. for the examination and diagnosis of temporoman-
29. Mohl ND, Ohrbach R. The dilemma of scientific dibular disorders. J Craniomandib Disord Facial Oral
knowledge versus clinical management of temporo- Pain 1989;3:7-14.
mandibular disorders. J Prosthet Dent 1994;67:113- 41. Clark GT, Seligman DA, Solberg WK, et al. Guidelines
120. for the treatment of temporomandibular disorders. J
30. Ramfjord SP, Ash MM. Occlusion, (ed 3). Philadel- Craniomandib Disord Facial Oral Pain 1990;4:80-88.
phia: Saunders, 1983. 42. McNeill C. Temporomandibular disorders: Guide-
31. Gelb H. editor. Clinical Management of Head, Neck, lines for diagnosis and management. Cal Dent Assn J
and TMJ Pain and Dysfunction. Philadelphia: Saun- 1991;19:15-26.
ders, 1977. 43. Truelove EL, Sommers EE, LeResche L, et al. Clinical
32. Dawson PE. Temporomandibular joint pain-dys- diagnostic criteria for temporomandibular disorders:
function problems can be solved. J Prosthet Dent New classification permits multiple diagnoses. J Am
1973;29:100-112. Dent Assoc 1992;123:47-54.
33. Tallents RH, et al. Occlusal restoration after orthope- 44. Sarnat BG, Laskin DM, editors. The Temporoman-
dic jaw repositioning. J Craniomandib Pract 1986;4: dibular Joint: A Biological Basis for Clinical Practice.
369. Philadelphia, PA: Saunders, 1992.
34. Okeson JP. Long-term treatment of disk-interference 45. Zarb GW, Carlsson GE, Sessle BJ, Mohl ND, editors.
disorders of the temporomandibular joint with ante- Temporomandibular Joint and Masticatory Muscle
rior repositioning occlusal splints. J Prosthet Dent Disorders. Copenhagen: Munksgaard Intl Publ Ltd,
1988;60:611-616. 1994.
35. Greene CS. Managing TMD patients: Initial therapy is 46. Okeson JP. Management of Temporomandibular Dis-
the key. J Am Dent Assoc 1992; 123:43-45. orders and Occlusion (ed 3). St Louis, MO: Mosby
36. American Academy of Orofacial Pain, McNeill C, ed- Year Book, 1993.
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Management of Masticatory Myofascial Pain

James R. Fricton
Masticatory myofascial pain is a relatively frequent occurrence in patients

seen by the orthodontist. Thus it is important to understand the manage-
ment of this condition. Treatment is generally directed toward the restora-
tion of a more physiological state in the muscles of mastication and involves
medications, appliances, various forms of behavioral modification, as well
as the use of muscle exercises and trigger point therapy. This article focuses
on the role of the latter modalities in the management of myofascial pain
and dysfunction. (Semin Orthod 1995; 1:229-243.)
yofascial pain (MFP) is a regional muscle taut band of skeletal muscle that is responsible
M pain disorder characterized by localized
muscle tenderness and pain. It is the most
for the pain in the zone of reference and, if
treated, will resolve the resultant pain.1'5"9 The
common cause of persistent regional pain such zone of reference is defined as the area of per-
as back pain, shoulder pain, tension-type head- ceived pain referred by the irritable trigger
aches, and facial pain. Two studies of pain point. It is usually located over the trigger
clinic populations have revealed that MFP was point but can spread from the trigger point to
cited as the most common cause of pain and a distant site (Fig 1). There are generally no
that it was responsible for 54.6% of a chronic neurological deficits associated with the disor-
head and neck pain population1 and 85% of a der unless a nerve entrapment syndrome, with
back pain population.2 In addition, Skootsky et weakness and diminished sensation, coincides
al3 studied myofascial pain in a general inter- with the muscle trigger points.8 Blood and
nal medicine practice and found that among urine studies are generally normal unless there
those patients that present with pain, 29.6% are changes caused by a concomitant disorder.
had myofascial pain as the cause. In an epide- Imaging studies, including radiographs and
miological study of orofacial pain in a young magnetic resonance imaging, do not show any
female general population (age 20 to 40 years) pathological changes in the muscle or connec-
using specific criteria, Schiffman et al4 found tive tissue.
that myofascial pain in the masticatory muscles Because of this lack of objective findings, as
occurred in about 50% of this population, with well as confusion about diagnostic criteria,
6% having symptoms severe enough to be MFP is often overlooked as a common cause of
comparable to patients seeking treatment. persistent pain.8'10"16 This article discusses the
The clinical characteristics of myofascial most recent information on diagnostic criteria,
pain include trigger points in muscle bands, clinical characteristics, and treatment strategies
pain in a specific zone of reference, occasional for myofascial pain.
associated symptoms, and the presence of con-
tributing factors (Table 1). A trigger point is Diagnostic Criteria
defined as a localized, deep tenderness in a
The development of diagnostic criteria is a
critical step in improving our understanding of
From the Department of Diagnostic and Surgical Sciences, MFP. Because MFP can occur in muscles
University of Minnesota School of Dentistry, Minneapolis, MN. throughout the body, the criteria need to be
Address correspondence to James R. Fricton, DDS, MS, broad enough to allow application to different
6-320 Moos Tower, Department of Diagnostic and Surgical Sci- regional muscle groups and to distinguish
ences, University of Minnesota School of Dentistry, Minneapolis,
MN 55455. MFP from systemic disorders affecting the
Copyright © 1995 by W.B. Saunders Company muscles, such as fibromyalgia. For each re-
1073-874619510104-0005$5.00IO gional MFP syndrome, such as headache, neck
Seminars in Orthodontics, Vol l,No 4 (December), 1995: pp 229-243 229

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230 James R. Fricton
Table 1. Clinical Characteristics of Myofascial Pain ability and validity were confirmed. Validity of
Trigger points in taut band of muscle the original MMFP diagnosis or the normal
Tenderness on palpation status of the subjects was determined based on
Consistent points of tenderness all relevant clinical data by another indepen-
Palpation alters pain locally or distally
Associated symptoms dent examiner different than the rater.
Otologic The results confirmed that the scope of ten-
Paresthesias derness (percentage of tender muscle sites) is
GI distress
Visual disturbances the most valid predictor of the presence of
Dermatographia MMFP. Other items, including pressure al-
Pain in zone of reference gometry to measure the absolute pressure pain
Constant dull ache
Fluctuates in intensity thresholds of the muscles, the twitch response,
Consistent patterns of referral and pain radiation on palpation were predic-
Alleviation with extinction of trigger point tive but not to the same extent as scope of ten-
Contributing factors
Traumatic and whiplash injuries derness. Items that showed no difference be-
Occupational and repetitive strain injuries tween the groups included taut muscle bands
Physical disorders and relative pain thresholds. Different cutoff
Parafunctional muscle tension-producing habits
Postural and repetitive strains levels of scope of tenderness were analyzed to
Disuse determine which level provided the best sensi-
Metabolic/nutritional tivity and specificity and it was found that 28%
Sleep disturbance
Psychosocial and emotional stressors best distinguished clinical cases from normal
subjects. However, this clinical population had
higher levels of tenderness than subjects with
pain, or orofacial pain, experts in the area MMFP in the general population and, thus, the
need to obtain a consensus on the definition of definition for general populations will show a
MFP and ensure construct validity of the clin- lower percentage of tender sites. In addition, it
ical items that are potentially used to diagnose is possible that the definition of myofascial
the condition. Studies also need to be accom- pain in other areas of the body may also have a
plished using discriminate analysis between different level of tenderness as the most accu-
various populations and disorders to deter- rate definition.
mine which items best predict MFP of each re-
gion. In establishing these diagnostic criteria,
Clinical Characteristics
care must be taken to minimize false positives
and false negatives so that the sensitivity and The major characteristics of myofascial pain
specificity are acceptable and repeatable by the include trigger points in muscles and local and
same and different investigators. Using this referred pain. However, MFP, particularly in
developmental process, diagnostic criteria for the head and neck, has numerous ancillary
the masticatory muscles have been developed findings and common associations with joint
and the disorder has been termed masticatory disorders and other pain disorders. In addi-
myofascial pain (MMFP). tion, despite trauma being the major initiating
Thirty-one patients with MMFP and 31 sub- factor, there are a multitude of other contrib-
jects who met the criteria for being normal uting factors that perpetuate the condition and
were each examined by a rater who was blind make it more difficult to treat (Table 1). Each
to their status.17 Measures included a muscle of these will be discussed, along with current
index of 44 extraoral, intraoral, and cervical knowledge of their prevalence.
muscle sites to assess the scope of tenderness in
the muscles involved in masticatory function; Trigger Points
pressure algometry to measure the absolute Trigger points are a 2 to 5 mm diameter point
and relative pressure pain thresholds of the of increased hypersensitivity in palpable bands
muscles; and determination of the presence of of skeletal muscle, tendons, and ligaments,
taut muscle bands, twitch response, and pain which have decreasing hypersensitivity as one
radiation on palpation. The techniques used palpates the band further away from the trig-
for examination were defined and their reli- ger point. The points may be active or latent.9
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Sternocleidomastoid Trapezius Splenius capitis
Posterior digastric Posterior temporalis Deep temporalis
Anterior temporalis Intermediate temporalis Superficial masseter
Deep masseter Lateral pterygoid Medial pterygoid
Figure 1. Trigger points with associated patterns of referral in the head and neck. • Primary pain referral;
D secondary pain referral; x, trigger area.
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Active trigger points are hypersensitive and points, there must be evidence that supports
display continuous pain in the zone of refer- the concept that the pain is related to and/or
ence, which can be altered with specific palpa- generated by the trigger point, particularly if it
tion. Latent trigger points display hypersensi- is distant from the trigger point. This evidence
tivity but no continuous pain. This localized primarily stems from clinical observation and
tenderness has been found to be a reliable in- needs to be studied more rigorously in well
dicator of the presence and severity of MFP controlled scientific studies. First, clinical ex-
with both manual palpation and pressure al- amination of trigger points shows that palpa-
gometers.18"20 However, the presence of taut tion of the active trigger points in accessible
bands appears to be a characteristic of skeletal muscles will alter the referred pain (usually in-
muscles in all subjects regardless of the pres- tensification). In addition, injection of a local
ence of MFP.17 anesthetic into the active trigger point will re-
Palpating the active trigger point with sus- duce or eliminate the referred pain and the
tained, deep, single-finger pressure on the taut tenderness.24"26 Treatment such as spray and
band will elicit an alteration of the pain (inten- stretch, exercises, or massage directed at the
sify or reduce) in the zone of reference (area of muscle with the trigger point will also predict-
pain complaint) or cause radiation of the pain ably reduce the referred pain.27 Other evi-
toward the zone of reference. This can occur dence to confirm the relationship includes the
immediately or be delayed a few seconds. The use of pressure algometry to show a positive
pattern of referral is both reproducible and correlation between both the scope of tender-
consistent with patterns in other patients with ness and the severity of pain.28 In addition, the
similar trigger points (Fig 1). This enables a change in scope of tenderness in response to
clinician to use the zone of reference as a guide treatment correlates positively with the change
to locate the trigger point for purposes of in symptom severity (r = .54).28
treatment.
The patient's behavioral reaction to this Ancillary Findings and Relationship with
firm palpation is a distinguishing characteristic Other Disorders
of MFP and is termed a "jump sign." This re- The affected muscles may also display an in-
action may include withdrawal of the head, creased fatigability, stiffness, subjective weak-
wrinkling of the face or forehead, or a verbal ness, pain on movement, and cause slightly re-
response such as, "That's it" or, "Oh, yes." The stricted range of motion that is unrelated to
"jump sign" should be distinguished from the joint restriction.1'6"9 The muscles are painful
"local twitch response," which can also occur when stretched, causing the patient to protect
with palpation. The latter response can be elic- the muscle through poor posture and sus-
ited by placing the muscle in moderate passive tained contraction.29 For example, a study of
tension and snapping the band containing the range of jaw motion in patients with MFP and
trigger point briskly with firm pressure from a no joint abnormalities showed a slightly dimin-
palpating finger moving perpendicularly ished range of motion (approximately 10%)
across it at its most tender point. This can pro- compared with normal subjects and pain on
duce a reproducible shortening of the muscle full range of motion. This is considerably less
band (visible in larger muscles) and associated limitation than was found with joint locking
electromyographic changes characteristic of caused by a TMJ internal derangement.17 This
the "local twitch response" described lat- restriction may perpetuate the trigger point
er.12'21"23 In locating an active trigger point, and cause other trigger points in the same
the "jump sign" should be elicited and, if pos- muscle and agonist muscles. As mentioned
sible, alteration of the patient's complaint by previously, this can result in multiple trigger
the palpation. points with overlapping areas of pain referral
and changes in pain patterns as different trig-
Local and Referred Pain ger points are inactivated.
In examining the basic concept of MFP, Although routine electromyographic
namely local and referred pain from trigger (EMG) studies show no significant abnormali-
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ties associated with trigger points, some spe- Table 2. Additional Signs, Symptoms, and
cialized EMG studies show differences.12'21"25 Disorders that Have Been Found with MFP of the
Head and Neck
A burst of electrical activity is found with nee-
dle insertion into the trigger point and not in N %
adjacent muscle fibers.30 In two experimental Neurological
EMG studies of trigger points, Simons23 and Tingling 45 27.4
Fricton et al21 found abnormal electrical activ- Numbness 43 26.2
Blurred vision 23 14.0
ity associated with the local muscle twitch re- Twitches 20 12.2
sponse when specifically snapping the tense Trembling 13 7.9
muscle band containing a myofascial trigger Excess lacrimation 12 7.3
Musculoskeletal
point. The consistency of soft tissues over the Fatigue 65 39.6
trigger points has been found to be more than Tension 60 36.6
over the adjacent muscle.31'32 Skin overlying Stiff joints 32 19.5
Swelling 20 12.2
trigger points in the masseter muscle seems to Otologic
be warmer as measured by infrared emis- Tinnitus 69 42.1
sion.33'34 Although each of these findings are, Ear pain 68 41.5
Dizziness 38 23.1
by and large, from solitary studies, they do Diminished hearing 29 17.7
provide preliminary evidence of a broad range
n - 164.
of objective characteristics that may prove im- Data from Fricton et al.1
portant in the diagnosis of MFP. Note. Additional signs such as excessive sweating, skin
Myofascial pain, particularly in the head flushing, muscle twitching, and swelling have also been
observed. The numerous otologic symptoms such as ear
and neck, is frequently overlooked as a diag- pain, tinnitus, diminished hearing, dizziness, vertigo, and
nosis because it is often accompanied by signs fullness in the ear have been reported despite negative
and symptoms in addition to pain, coincidental examinations of the ear.10<12'14'29'49-50 in addition, other
symptoms may include scratchy sensations, cutaneous hy-
pathological conditions, and behavioral and peresthesia, and tooth sensitivity.3°'31
psychosocial problems. Table 2 lists the per-
centage of patients with MFP who had other
specific neurological, musculoskeletal, and oto- patterns of pain referral, such as the trigger
logic signs and symptoms.1 These signs and points in the pectoralis major found with acute
symptoms may appear to mimic many other myocardial infarction.22
conditions, including arthritis, fibromyalgia, It is unclear whether MFP develops in re-
migraine headache, neuralgia, temporal arteri- sponse to other pathological conditions or co-
tis, causalgia, temporomandibular joint disor- incidentally. There is a common belief that
ders, spinal disc disease, and sinusitis, and muscle tenderness and pain are only a reaction
cause confusion in diagnosis. to these other disorders and do not represent
However, the characteristics of MFP also specific disorders by themselves. However,
appear to accompany many other pain disor- treatment of the concomitant disorder will re-
ders. For example, trigger points often de- duce the MFP in some cases and in other cases
velop in association with joint pathology such will not. It is possible that in associated cases,
as disc derangements, osteoarthritis, and sub- "muscle splinting" may occur as a central ner-
luxation.1'20 Table 3 lists the number of con- vous system response to a barrage of periph-
comitant diagnoses found in a study of 164
patients with head and neck MFP, with joint Table 3. Concomitant Diagnoses Found With
problems being most frequent at 42%. 1 MFP MFP of the Head and Jaw1
has also been reported to be found with sys-
Other diagnoses N %
temic or local infections of viral or bacterial
origin; with lupus erythematosus, scleroderma TMJ internal derangement 50 30.4
and rheumatoid arthritis; and along the seg- TMJ degenerative joint disease 19 11.6
Paroxysmal trigeminal neuralgia 4 2.4
mental distribution of nerve injury, nerve root Sinusitis 2 1.2
compression, or neuralgias. Moreover, pathol- Cluster headache 2 1.2
ogy of specific viscera has been associated with Total 46.8
the development of specific trigger points and Data from Fricton et al.1
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eral nociceptive input from other disorders concludes that they are two distinct conditions,
that cause pain, particularly in other parts of but which may have the same underlying
the motor system such as the joints. Reducing pathophysiology. The clinical significance of
this barrage of input may have an effect in distinguishing between them lies in the more
reducing the "splinting." In other cases, it is common centrally generated contributing fac-
possible that splinting of agonist muscles may tors in FM (sleep disorders, depression, and
stem from pain in a specific muscle contribut- stress) versus the more common regional con-
ing to regional tenderness and pain. If this tributing factors in MFP (trauma, posture, and
does occur, it may explain the common re- muscle tension habits), as well as the better
gional patterns that occur in myofascial pain prognosis in the treatment of MFP as com-
and why long-term success in treatment de- pared with FM.
pends on reducing trigger points in a specific
muscle. Contributing Factors
Many of the same characteristics of MFP are As with all chronic pain conditions, concomi-
also found in other muscle pain disorders such tant social, behavioral, and psychological dis-
as fibromyalgia, tension-type headaches, myo- turbances often precede or follow the develop-
sitis, and muscle spasm. Perhaps the most ment of MFP.37 Patients report psychological
pragmatic taxonomy related to differentiating symptoms such as frustration, anxiety, depres-
muscle pain disorders is in the Academy of sion, and anger when acute cases become
Orofacial Pain Guidelines for Diagnosis and chronic. Maladaptive behaviors such as pain
Management of Temporomandibular Disor- verbalization, poor sleep and dietary habits,
ders. In this classification, different muscle dis- lack of exercise, poor posture, bruxism, and
orders are descriptively defined by their char- other tension producing habits and medication
acteristics and classified as myofascial pain dependencies can also be observed when pain
(regional pain and localized tenderness), fibro- becomes prolonged. Each of these may com-
myalgia (widespread pain with tender points), plicate the clinical picture by perpetuating the
myositis (regional pain and diffuse tender- pain, preventing compliance with the treat-
ness), muscle spasm (brief painful contraction ment program, and causing self-perpetuating
with limited range of motion), contracture chronic pain cycles to develop. Although a
(longstanding limited range of motion), and number of factors can complicate identifica-
muscle splinting (regional pain and localized tion and management, IMPATH is a psycho-
tenderness accompanying a joint problem). metrically derived instrument that facilitates
Other terms used in the past for the broad assessment of the contributing factors.37
category of muscle pain syndromes such as fi- Parafunctional muscle tension-producing
brositis, myofascial pain dysfunction (MPD), habits, such as back bracing, neck tensing, and
myelogelosen, interstitial myofibrositis, muscu- teeth clenching, can be generated as a form of
lofascial pain dysfunction, TMJ dysfunction, tension release as well as a learned behavioral
nonarticular rheumatism, and myalgia are response. The relationship between stress and
poorly defined and confusing and, thus, MFP is difficult to assess because of the diffi-
should be avoided. culty in defining stress and the major method-
In most recent classifications, the regional ological problems that exist in studying stress.
pain found with MFP is distinguished from the Although no evidence suggests a direct causal
widespread muscular pain associated with fi- relationship between stress and myofascial
bromyalgia (FM). These two disorders have pain, some studies suggest that a correlation
many similar characteristics and may represent does exist between them. There is a higher
two ends of a continuous spectrum. For exam- than normal incidence of psychophysiologic
ple, as Simons35 notes, 16 of the 18 tender disorders such as migraine headaches, back-
point sites in FM lie at well-known trigger ache, neck pain, nervous asthma, and ulcers in
point sites. Many of the clinical characteristics patients with myofascial pain, which suggests
of FM, such as fatigue, morning stiffness, and similar etiologic factors.38'39 Also, higher than
sleep disorders, can also accompany MFP. normal levels of urinary catecholamines and
Bennett36 compares these two disorders and 17-hydroxysteroids, commonly associated with
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a high number of stressful events, were found ment of MFP using a wide variety of tech-
in a group of myofascial pain dysfunction syn- niques such as exercise, trigger point injec-
drome patients compared with controls.40 In tions, vapocoolant spray and stretch, intraoral
addition, stress management interventions fre- appliances, TENS, biofeedback, posture cor-
quently provide significant benefit for patients rection, tricylic antidepressants, analgesic and
with MFP. muscle relaxant medications, and addressing
Poor muscle health caused by a lack of ex- perpetuating factors.5"9'43'44 However, the dif-
ercise, muscle disuse, or poor posture has also ficulty in managing MFP lies in the critical
been suggested to predispose the muscle to the need to match the level of complexity of the
development of trigger points.41'42 They often management program with the complexity of
develop after muscles have been weakened the patient. Failure to address the entire prob-
through immobilization caused by, for exam- lem, including all involved muscles, concomi-
ple, the prolonged use of cervical collars or tant diagnoses, and contributing factors, may
extended bedrest. Postural discrepancies may lead to failure to resolve the pain and perpet-
also contribute to joint displacement and ab- uation of a chronic pain syndrome (Table 5).
normal functional patterns, and both can con- Although there are no controlled studies ex-
tribute to abnormal proprioceptive input and amining progression of chronic pain syn-
sustained muscle contraction. Poor posture dromes, results from clinical studies show that
caused by a unilateral short leg, small hemipel- many patients with MFP have seen multiple
vis, increased cervical or lumbar lordosis, non- clinicians and received numerous medications
compensated scoliosis, occlusal abnormalities, and various other singular treatments for years
and poor positioning of the head or tongue without having more than temporary improve-
have also been implicated.35 Table 4 lists com- ment. In one study of 164 MFP patients, the
mon postural problems found with myofascial mean duration of pain was 5.8 years for men
pain of the head and neck. and 6.9 years for women, with a mean of 4.5
past clinicians seen.1 In another study of 102
Table 4. Postural Problems of the Head and Neck consecutive TMJ and craniofacial pain pa-
in 164 Patients With MFP as Noted tients, which included 59.8% MFP patients, the
on Examination1 mean duration of pain was 6.0 years, with 28.8
n % previous treatment sessions, 5.1 previous doc-
tors, and 6.4 previous medications.1
Body
Poor sitting/standing posture 157 96.0
These and other studies of chronic pain
Forward head tilt 139 84.7 suggest that regardless of the pathogenesis of
Rounded shoulders 135 82.3 muscular pain, a major characteristic of some
Poor tongue position 111 67.7
Abnormal lordosis 76 46.3
Scoliosis 26 15.9
Leg length discrepancy 23 14.0
Table 5. The Problem List Associated With
Occlusion Patients With MFP Should Include the Symptoms,
Slide from retruded contact position to 140 85.5 the Diagnoses, and Contributing Factors
intercuspal contact position of > 1 mm
Symptoms
Unilateral occlusal prematurities in 113 68.9 Physical
intercuspal contact position Functional
Class II, Division 1 malocclusion 51 31.1 Emotional
Class III malocclusion 16 9.8 Diagnosis
Primary (responsible for the chief complaints)
Secondary (responsible for the associated symptoms
or aggravate the primary diagnosis)
Treatment of Masticatory Contributing factors (those factors that initiate,
Myofascial Pain perpetuate, or result from the disorders and in some
way may complicate management)
Myofascial pain can range from simple cases Emotional
Cognitive
with transient single muscle syndromes to com- Social
plex cases involving multiple muscles and Behavioral
many interrelating contributing factors. Many Physical
Environmental
investigators have found success in the treat-
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of these patients is the failure of traditional Table 6. Short and Long-term Goals in Treatment
approaches to resolve the problem. Each clini- of Myofascial Pain
cian confronted with a patient with MFP needs Short-term goals
to recognize and address the whole problem to Reduce pain
Restore muscles to normal length and achieve a full
maximize the potential for a successful out- range of joint motion
come. Strategies can differ depending on Restore muscles to normal posture
whether the condition is acute, simple, or com- Reduce sustained muscle activity
Long-term goals
plex (Fig 2). Acute cases can often be managed Restore normal lifestyle activities
with palliative care strategies designed to pro- Reduce contributing factors
tect the muscles and encourage healing (Table Regular stretching, postural, and conditioning
exercises
6). Simple cases with minimal behavioral and Proper use of muscles
psychosocial involvement can typically be man-
aged by a single clinician with home care, ex-
ercises, a stabilization appliance, and spray and therapy (Table 6). This is followed long-term
stretch. Complex patients can be most effec- with a regular muscle stretching, postural, and
tively managed within an interdisciplinary pain strengthening exercise program as well as con-
clinic setting that uses a team of clinicians to trol of the contributing factors. Each of these
address different aspects of the problem in a major interventions will be discussed in more
concerted fashion. This team approach often detail.
requires shifting the paradigms implicit in pa-
tient care and are listed in Table 7. Muscle Exercises
Regardless of the complexity, evaluation of The most useful techniques for muscle reha-
myofascial pain includes locating the trigger bilitation include muscle stretching, posture,
points and muscles involved as well as recog- and strengthening exercises. A home program
nition of all contributing factors. Management of active and passive muscle stretching exer-
of the syndrome follows with muscle exercises, cises will reduce the activity of trigger points,
bite appliances, therapy to the trigger points, whereas postural exercises will reduce the sus-
and reducing all contributing factors. The ceptibility to reactivation of trigger points by
short-term goal is to restore the muscles to nor- physical strain. Strengthening and condition-
mal length, posture, and achieve full range of ing exercises will improve circulation, strength,
joint motion with exercises and trigger point and durability of the muscles.
Evaluating the range of motion of muscles is
Acute Palliative Care the first step in prescribing a set of exercises to
treatment Exercises follow. For example, in the head and neck,
T Table 7. Shifting the Doctor/Patient Paradigms

Involves Each Member of the Team Following the
Simple Exercises
Same Concepts by Conveying the Same Messages
treatment with Splint in Their Dialogue with the Patient
single clinician Spray and stretch
Concept Statement
Behavioral Therapy
Self-responsibility You have more influence on
T Self-care
your problem than we do.
You will need to make daily
changes in order to
Exercises improve your condition.
Complex Splints Education We can teach you how to
treatment make the changes.
Trigger Point Injections Long-term change It will take at least 6 months
with a team Physical Therapy for the changes to have an
Psychosocial Management effect.
Strong doctor-patient We will support you as you
relationship make the changes.
Patient motivation Do you want to make the
Figure 2. Treatment triaging of patients with mas- changes?
ticatory myofascial pain.
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range of motion should be determined for the

jaw and neck at the initial evaluation. A limited
mouth opening will indicate if there are any
trigger points within the elevator muscles: tem-
poralis, masseter, and medial pterygoid. If
mandibular opening is measured as the inter-
incisal distance, the maximum range is gener-
ally between 42 and 60 mm or approximately
three knuckles' width (nondominant hand).
Mouth opening with trigger points in the mas-
seter will be between 30 mm and 40 mm or two
knuckles' width. If contracture of the mastica-
tory muscles is present, mouth opening can be
as little as 10 to 20 mm. Other causes of dimin-
ished mouth opening include structural disor-
ders of the temporomandibular joint such as
ankylosis, internal derangements, and gross
osteoarthritis.
Passive and active stretching of the muscles
will increase the opening to the normal range Figure 4. Neck stretching exercise. This exercise
as well as decrease the pain. Passive stretching can be performed gradually and gently six times
of the masticatory muscles during counter- daily for 1 minute each time. Precaution should be
stimulation of the trigger point can be accom- taken to avoid stretching when there is an acutely
plished through placing a properly trimmed, strained neck, severe cervical osteoarthritis with
nerve compression, recent surgery in the area or
sterile cork, tongue blades, or other object be- other structural cervical disorders.
tween the incisors while the spray and stretch
technique is accomplished. Active stretching at must be emphasized that rapid, jerky stretch-
home and in the office can be accomplished ing or overstretching should be avoided to re-
using the exercises noted in Figures 3 and 4. It duce potential injury to the muscle.
Postural exercises for MFP are designed to
teach the patient mental reminders to hold the
body in a balanced, relaxed position and to use
the body with positions that afford the best me-
chanical advantage. This includes patients with
static postural problems such as unilateral
short leg, small hemipelvis, occlusal discrepan-
cies, scoliosis, or functional postural habits
such as forward head, jaw thrust, shoulder
phone bracing, and lumbar lifting. In a study
of postural problems in 164 head and neck
MFP patients, Fricton and associates1 found
poor sitting/standing posture in 96%, forward
head position in 84.7%, rounded shoulders in
82.3%, lower tongue position in 67.7%, lordo-
sis in 46.3%, scoliosis in 15.9%, and leg length
Figure 3. Jaw stretching exercise. This exercise can discrepancy in 14.0%. In improving posture,
be performed gradually and gently six times daily specific skeletal conditions such as structural
for 1 minute each time. The mouth should be asymmetries or weakness of certain muscles
stretched slightly beyond the point of tightness and need to be considered. In the masticatory sys-
pain. Precaution should be taken to avoid over-
stretching when an acutely strained jaw or severe tem, the patient should be instructed to place
capsulitis of the temporomandibular joint are the tongue gently on the roof of the mouth
present. and keep the teeth slightly apart. In the cervi-
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cal spine, a forward or lateral head posture neous electrical nerve stimulation (TENS),
must be corrected by guiding the chin in and electroacupuncture, and direct current stimu-
the head vertex up. The shoulders will natu- lation provide electric currents to stimulate the
rally fall back if the thorax is positioned up and muscles and trigger points. Acupuncture and
back with proper lumbar support. Patients trigger point injections of local anesthetic, cor-
need to be instructed in proper posture for ticosteroids, or saline cause direct mechanical
each position, sitting, standing, and lying or chemical alteration of trigger points. How-
down, as well as in movements that are per- ever, the two most common techniques for
formed repetitively throughout the day such as treating a trigger point are the spray and
lifting or turning the head to the side. Sleeping stretch technique and trigger point injections.
on the side or back is particularly important With the spray and stretch technique, appli-
for patients who wake up with muscle soreness. cation of a vapocoolant spray such as fluo-
Improved posture is also facilitated by reg- rimethane over the muscle and simultaneous
ular physical conditioning. Patients need to be passive stretching can provide immediate re-
placed on a conditioning program to increase duction of pain, although lasting relief re-
aerobic capacity and strength. Aerobic pro- quires a full management program (Fig 5).8
grams, such as becoming involved in an exer- The technique involves directing a fine stream
cise class, regular running, walking, biking, or of fluorimethane from the finely calibrated
swimming will improve the comfort, endur- nozzle toward the skin directly overlying the
ance, and functional status of patients with trigger point in the muscle. A few sweeps of
MFP.9 the spray are first passed over the trigger point
Occlusal Appliances and zone of reference before adding sufficient
manual stretch to the muscle to elicit pain and
Occlusal appliance therapy can be effective
discomfort. The muscle is put on a progres-
alone or in combination with other treatments
sively increasing passive stretch while the jet
for MMFP. The full-arch stabilization appli-
stream of spray is directed at an acute angle
ance is the most common one used for MMFP.
This appliance, also termed a flat-plane, gna-
thologic, or full-coverage splint, is an appliance
that covers all of the mandibular or maxillary
teeth. It is designed to provide postural stabi-
lization and to protect the TMJ, muscles, and
teeth. The occlusal surface can be adjusted to
provide a stable jaw posture by creating single
contacts of all posterior teeth in centric relation
and centric occlusion. Anterior guidance is
provided by an incisal plane, and lateral guid-
ance is provided by a canine ramp. Complica-
tions that can occur with the use of any appli-
ance include caries, gingival inflammation,
mouth odors caused by poor oral hygiene, Figure 5. Spray and stretch procedure. The tech-
speech difficulties, and psychological depen- nique involves directing a fine stream of fluo-
rimethane from the finely calibrated nozzle toward
dence on the appliance. the skin directly overlying the muscle with the trig-
Trigger Point Therapy ger point. The muscle is put on a progressively in-
creasing passive stretch while the spray is directed at
There are many methods suggested for pro- an acute angle from 30 to 50 cm (1 to 1.5 feet) away.
viding repetitive stimulation to inactivate trig- This sequence can be repeated up to four times if
ger points. Massage, acupressure, and ultra- the clinician warms the muscle with his or her hand
sound provide noninvasive mechanical disrup- or warm moist packs to prevent overcooling after
tion to inactivate the trigger point. Moist heat ice each sequence. Precaution should be taken to avoid
frosting the skin, lowering the underlying skeletal
packs, fluorimethane, and diathermy provide muscle temperature, and overstretching to avoid ag-
skin and muscle temperature change as a form gravating the muscle pain. (Reprinted with permis-
of trigger point counterstimulation. Transcuta- sion from Travell and Simons, Ref 9)
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from 30 to 50 cm (1 to 1.5 feet) away. It is

applied in one direction from the trigger point
toward its reference zone in slow even sweeps
over adjacent parallel areas at a rate of about
10 cm per second. This sequence can be re-
peated up to four times if the clinician warms
the muscle with his or her hand or warm moist
packs to prevent overcooling after each se-
quence. Frosting the skin and excessive sweeps
should be avoided because they may lower the
underlying skeletal muscle temperature, which
tends to aggravate trigger points. The range of
passive and active motion can be tested before
and after spraying as an indication of respon-
siveness to therapy. Failure to reduce trigger
points with spray and stretch may be caused by
(1) inability to secure full muscle length be-
cause of bone or joint abnormalities, muscle
contracture, or the patient avoiding voluntary
relaxation; (2) incorrect spray technique; or (3)
failure to reduce perpetuating factors. If spray
and stretch fails with repeated trials, direct
needling with trigger point injections may be
effective.
Trigger point injections have also been
shown to reduce pain, increase range of mo-
tion, increase exercise tolerance, and increase
circulation in muscles.24"26 The pain relief may
last for the duration of the anesthetic to many
months, depending on the chronicity and se- Figure 6. Trigger point injection. The technique of
verity of the trigger points, and the degree of trigger point injection involves mechanical disrup-
reduction in perpetuating factors. Because the tion by precision needling of the exact point. Both
critical factor in relief seems to be the mechan- the intensity of the dull pain and a twitch response
ical disruption of the trigger point by the nee- are indicators of the accuracy of the injection. After
the initial needling and injection, the needle should
dle, precision in needling the exact point and be withdrawn from the muscle, but not the skin, and
the intensity of pain during needling appear to redirected to adjacent muscle bands. (Reprinted
be the major factors in trigger point inactiva- with permission from Travell and Simons, Ref 9)
tion22 (Fig 6). Trigger point injections with a
local anesthetic are generally more effective procaine (medium acting), without vasocon-
and comfortable than dry needling or injecting strictors, are suggested.
other substances such as saline, although acu-
puncture may be helpful for patients with
Behavioral Therapy to Control
chronic trigger points in multiple muscles. The
Contributing Factors
effect of needling can be complemented with
the use of local anesthetics in concentrations One of the common causes of failure in man-
less than those required for a nerve conduction aging MFP is the inability to recognize and sub-
block. This can markedly lengthen the relative sequently to control contributing factors that
refractory period of peripheral nerves and may perpetuate muscle restriction and tension.
limit the maximum frequency of impulse con- As noted previously, postural contributing fac-
duction. Local anesthetics can be chosen for tors, whether behavioral or biological, perpet-
their duration, safety, and versatility. Three uate trigger points if not corrected. In general,
percent chlorprocaine (short acting) and 5% a muscle is predisposed to developing prob-
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lems if it is held in sustained contraction in the "feedback" loop so that a patient can receive
normal position and, especially, if it is held in immediate information or feedback about the
an abnormally shortened position. Behavioral biological activity. When this information is
factors causing sustained muscle tension are available, individuals can voluntarily make
the most common contributing factors, and changes in functions that were previously
can involve habits such as tooth clenching and thought to be involuntary. For example, mus-
grinding, cradling a phone between the head cle tension in the jaw can be reduced on receiv-
and shoulder for hours each day, studying ing information about how postural changes
with the head forward for a long time, or gum- can reduce muscle activity.
chewing and other oral parafunctional habits. In some cases, patients may have significant
Correcting poor habits through education and psychosocial problems that accompany MMFP
long-term reinforcement is essential in pre- and may benefit from antidepressant or
venting a reduced trigger point from return- antianxiety medication, counseling, or psycho-
ing. Approaches to change maladaptive habits therapy with a mental health professional. A
and behaviors need to be addressed and pre- decision needs to be made before initiating
sented as an integral part of the overall treat- treatment regarding whether the psychological
ment program for all patients with MMFP and distress is the primary problem. If this is the
oral habits. case, treatment of the psychological problem is
Behavioral therapy strategies are commonly best accomplished first, as a problem separate
used to change habits. These include a range from the MMFP disorder. If it is not, simulta-
of techniques such as habit reversal, massed neous treatment of both the physical and the
practice, and over-correction. Although many psychosocial problems is best done by a team.
simple habits can be changed by making the
patient aware of them, changing persistent Team Management
habits requires a structured program that is Although each clinician may have limited suc-
facilitated by a clinician trained in behavioral cess in managing the "whole" patient alone, the
strategies. Patients should be aware that the assumption behind a team approach is that it is
habits will not change by themselves and that vital to address different aspects of the prob-
they are responsible for initiating and main- lem with different specialists to enhance the
taining the behavioral change. overall potential for success.11'45'46 Although
Habit change using a habit reversal tech- these programs provide a broader framework
nique can be accomplished by becoming more for treating the complex patient, they have
aware of the habit, knowing how to correct it added another dimension to the skills needed
(ie, what to do with the teeth and tongue), and by the clinician: those of working as part of a
knowing why it needs correction. When this coordinated team. Failure to adequately inte-
knowledge is combined with a commitment to grate care may result in poor communication,
conscientious monitoring, most habits will fragmented care, distrustful relationships, and
change. Progress with changing habits should eventually confusion and failure in manage-
be addressed at all appointments with the pa- ment. However, team coordination can be fa-
tient. The habits need to be addressed in this cilitated by a well-defined evaluation and man-
manner for more than 6 months for the agement system that clearly integrates team
change to be maintained long-term. members.
Supplemental behavioral strategies such as A prerequisite to a team approach is an in-
biofeedback may also be helpful. 43 " 45 Bio- clusive medical model and conceptual frame-
feedback is a structured therapy based on the work that places the physical, behavioral, and
theory that when an individual receives infor- psychosocial aspects of illness on an equal and
mation about a desired change, and is rein- integrated basis.47'48 With an inclusive theory
forced for making it, the change is more likely of human systems and their relationship to ill-
to occur. Generally, biofeedback training uses ness, a patient can be assessed as a whole per-
equipment to measure biological activity (eg, son by different clinicians from diverse back-
surface electromyography to measure muscle grounds. Although each clinician understands
activity). The equipment is designed with a a different part of the patient's problem, he or
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she can integrate them with other clinicians' mal function without the need for future
perspectives and see how each part is interre- health care. The patient first participates in an
lated in the whole patient. For example, a phy- educational session with each clinician to learn
sician or dentist will evaluate the physical find- about the diagnoses and contributing factors,
ings, a physical therapist will evaluate postural why it is necessary to change these factors, and
habits, and a psychologist will evaluate behav- how to do it. The dentist or physician is re-
ioral problems or social stressors. Each factor sponsible for establishing the physical diagno-
will become part of the problem list to be ad- sis, providing short-term medical or dental
dressed in the treatment plan. In the process, care, and monitoring medication and patient
the synergism of each factor in the etiology of progress. The psychologist or behavioral ther-
the disorder can become apparent to clinicians. apist is responsible for providing instruction
For example, social stressors can lead to anxi- about contributing factors; diagnosing, man-
ety, anxiety can lead to poor posture and mus- aging, or referring for primary psychological
cle tension, the poor posture and muscle ten- disturbances; and establishing a program to
sion can lead to a myofascial pain syndrome, support the patient and family in making
the pain contributes to more anxiety, and the changes. The physical therapist is responsible
cycle continues. Likewise, a reduction of each for providing support, instruction, and a man-
factor will work synergistically to improve the agement program on specifically assigned and
whole problem. Treatment of only one factor common contributing factors. Depending on
may improve the problem, but relief may be the therapist's background and the patient's
partial or temporary. Treatment of all factors needs, this person may also provide special
simultaneously can have a cumulative effect care such as physical therapy modalities or
that is greater than the effects of treating each occupational therapy. Each clinician is also
factor individually. responsible for establishing a trusting, sup-
The problem list for a patient with a specific porting relationship with the patient while
chronic illness includes both a physical diagno- reaffirming the self-care philosophy of the
sis and a list of contributing factors (Table 5). program, reinforcing change, and assuring
In establishing the problem list, the clinician compliance. The patient is viewed as responsi-
needs to determine if the patient is complex ble for making the changes (Table 6). The
and requires a team approach. Recommended team meets regularly to review current patient
criteria for determining complexity include progress and discuss new patients.
any one of the following: multiple diagnoses,
persistent pain longer than 6 months in dura-
tion, significant emotional problems (depres-
Summary
sion, anxiety), frequent use of health care ser- Myofascial pain (MFP) is a regional muscle
vices or medication, daily oral parafunctional pain disorder characterized by localized mus-
habits, and significant lifestyle disturbances. cle tenderness and pain. The affected muscles
The use of a screening instrument such as IM- may also display an increased fatigability, stiff-
PATH can readily elicit the degree of com- ness, subjective weakness, pain on movement,
plexity of a case at the initial evaluation.37 The and cause a slightly restricted range of motion
more complex the case, the greater the need that is unrelated to joint pathology. MFP is fre-
for a team approach. The decision to use a quently overlooked as a diagnosis because it is
team must be made at the time of evaluation often accompanied by signs and symptoms in
and not part way through a singular treatment addition to pain, coincidental pathological con-
plan that is failing. If a team is needed, the ditions, and behavioral and psychosocial prob-
broad understanding of the patient is then lems. As MFP persists, chronic pain character-
used to design a long-term management pro- istics often occur.
gram that both treats the physical condition Evaluation of myofascial pain includes locat-
and helps reduce the contributing factors. ing the trigger points and muscles involved as
The primary goals of the program include well as recognition of the contributing factors.
reducing the symptoms and their negative ef- Depending on the complexity of the case, man-
fects, while helping the patient return to nor- agement of the syndrome involves palliative
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care, appliance therapy, muscle exercises, ther- 13. Awad EA. Interstitial myofibrositis: Hypothesis of the
apy to the trigger points, and behavioral ther- mechanism. Arc Phys Med Rehabil. 1973;54:449-453.
14. Bengtsson A, Henriksson KG, Larsson J. Reduced
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and pathology. Arch Phys Med Rehabil 1987;68:122- cial pain-dysfunction syndrome using the biofeedback
125. principle.] Periodontol 1977;48:643-645.
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34. Berry DC, Yemm R. Variations in skin temperature of 1987;27:186-190.
the face in normal subjects and in patients with man- 45. Fricton J, Hathaway K, Bromaghim C. Interdiscipli-
dibular dysfunction. Br J Oral Surg 197l;8:242-247. nary management of patient with TMJ and craniofa-
35. Simons D. Muscular pain syndromes, in Myofascial cial pain: Characteristics and outcome. J Cranio Dis-
Pain and Fibromyalgia, Fricton J, Awad EA, editors. ord Facial Oral Pain 1987;!: 115-122.
Press: New York Raven 1990:1-43. 46. Ng K, Lorenz (editors). New approaches to treatment
36. Bennett R. Myofascial pain syndromes and the fibro- of chronic pain: A review of multidisciplinary pain
myalgia syndrome: A comparative analysis, In: Fric- clinics and pain centers. NIDA Research 36 Mono-
ton J, Awad EA, editors. Myofascial Pain and Fibro- graph Series. Washington, DC: US Government
myalgia. New York: Raven Press 1990:43-66. Printing Office, 1981.
37. Fricton JR, Nelson A, Monsein M. IMPATH: Micro- 47. Rodin J. Biopsychosocial aspects of self management,
computer assessment of behavioral and psychosocial In: Karoly P, Kanfer FH, editors. Self Management
factors in craniomandibular disorders. Cranio 1987; and Behavioral Change: From Theory to Practice,
5:372-381. New York: Pergamon, 1974.
38. Berry DC. Mandibular dysfunction pain and chronic
48. Schneider F, Kraly P. Conceptions of pain experience:
minor illness. Br Dental J 1969; 127:170-175.
The emergence of multidimensional models and their
39. Gold S, LiptonJ, MarbachJ, et al. Sites of psychophys-
implications for contemporary clinical practice. Clin
iological complaints in MPD patients: II. Areas re-
Psych Rev 1983;3:61-86.
mote from orofacial region. J Dent Res 1975;480:165
(A). 49. Bernstein JM, Mohl ND, Spiller H. Temporomandib-
40. Evaskus DS, Laskin DM. A biochemical measure of ular joint dysfunction masquerading as disease of ear,
stress in patients with myofascial pain-dysfunction nose, and throat. Transactions - Am Acad Opthalmol
syndrome. J Dent Res, 1972;51:1464-1466. Otolaryngol 1969;73:1208-1217.
41. Glyn JH. Rheumatic pains: Some concepts and hy- 50. Travell J. Temporomandibular joint pain referred
potheses. Proceedings of the R Soc Med 1971;64:354- from muscles of the head and neck. J Prosthet Dent
360. 1960;10:745-763.
42. Kendall HO, Kendall F, Boynton D. Posture and Pain. 51. Fricton JR, Kroening R. Practical differential diagno-
Huntington, Ny: Krieger, 1970:15-45. sis of chronic craniofacial pain. Oral Surg Oral Med,
43. Clarke NG, Kardachti BJ. The treatment of myofas- Oral Path 1982;54:628-634.
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Management of Internal Derangements of

the Temporomandibular Joint
Bruce Sanders
This article discusses the orthodontist's involvement in treating patients

with complex temporomandibular joint (TMJ) disorders. It includes a review
of the literature and information regarding classification, epidemiology, in-
cidence, and diagnosis of TMJ internal derangements. Controversies in
management discussed include the importance of disc position, the conse-
quences of not repositioning the disc, and the predictability of progression
of disease. Considerations regarding home care, medical care, and surgical
care are also presented. (Semin Orthod 1995; 1:244-257.)
rthodontists have a long and distinguished lationship between occlusal problems and TMJ
O history of treating complex malocclusions
and severe dentofacial deformities. In recent
disorders.10
years there seems to be an increasing aware-

ness that many orthodontic patients may have Classification of TMJ
coexisting temporomandibular joint (TMJ) Internal Derangements
disorders.1 Ochs et al2 have reviewed the liter-
ature correlating TMJ clicking with age, gen- Dolwick and Sanders11 have described internal
der, dental wear, unilateral posterior tooth derangement as any disturbance between the
contact in the retruded position,3 and poste- articulating components within the joint.
rior crossbite.4 Mohlin and Kopp5 performed However, the term has been adapted mainly
a study on the relationship between malocclu- for changes in the disc-condyle relationship.12
sion, occlusal interferences, and mandibular The disc is commonly displaced anteriorly or
pain and dysfunction. These investigators anteromedially.13 More rarely, posterior or lat-
found a high correlation between posterior eral displacement are encountered.14'15
crossbite and masticatory muscle soreness, Disc displacements generally have been
joint clicking, and other TMJ symptoms. classified as disc displacement with reduction
Perry6 and Upton et al7 have reported a high and disc displacement without reduction.
correlation between TMJ disorders and Class McNeill12 has described disc displacement with
II malocclusion. Patients with a deep bite have reduction as an interference with the disc-
a high incidence of TMJ complaints,8 and Ri- condyle relationship during the mandibular
olo4 reported that young patients with an an- translation associated with mouth opening and
terior open bite have a high incidence of TMJ closing. This results in clicking or intermittent
and muscle tenderness. Wisth9 reported that locking. Disc displacement without reduction is
patients with mandibular prognathism also often referred to as a closed lock because it is
may show significant TMJ symptoms. clinically accompanied by mandibular hypo-
Other studies, however, have shown no re- mobility caused by condylar blockade. The pa-
tient with acute closed lock typically has severe
pain as well as restriction of mandibular mo-
From the UCLA School of Dentistry, Los Angeles; Saint tion. The disc often becomes "fixed" or "stuck"
John's Hospital Center, Santa Monica, CA. to the articular eminence and fossa secondary
Address correspondence to Bruce Sanders, DDS, 1304 15th
Street, Suite 213, Santa Monica, CA 90404. to a "suction-cup"16 or a "vacuum effect".17
Copyright © 1995 by W.B. Saunders Company The presence and significance of adhesions
1073-8746I95I0104-0006$5.00IO in the upper compartment have been de-
244 Seminars in Orthodontics, Vol 1, No 4 (December), 1995: pp 244-257

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Bruce Sanders 245
scribed by Sanders.16 These adhesions are ob- face of the temporal component and the artic-
served in patients with chronic closed clock ular disc or posterior attachment (Fig 1 A). The
that involves a nonreducing anterior disc dis- band-like adhesions represent fibrous bands
placement. Murakami and Segami18 support connecting the intersynovial structures, ex-
the use of diagnostic arthroscopy for deter- tending from the roof of the glenoid fossa to
mining the presence of intracapsular adhe- the disc and capsule (Fig IB). This condition is
sions. On the basis of diagnostic arthroscopy, observed both in the anterior and posterior sy-
they classified adhesions into three types; filmy novial recess, as well as in the medial capsular
adhesions, band-like adhesions, and pseudo- region. The third type, the pseudowall adhe-
wall adhesions. The filmy adhesions are de- sions, are commonly observed in the anterolat-
fined as a stickiness between the articular sur- eral aspect of the upper joint cavity (Fig 1C);
Figure 1. (A) Filmy adhesion on posterolateral aspect of the eminence. E = eminence; Al = lateral attach-
ment of the disc; arrows = adhesion. (B) Bandlike adhesion in the anterior recess. B = adhesion. (C)
Pseudowall in the anterior recess of the right TMJ. D = anteriorly displaced disc; P = pseudowall. (Re-
printed from Murakami K, Segami N: Intraarticular adhesions of the temporomandibular joint. In Clark G,
Sanders B, Bertolami C (eds): Advances in Diagnostic and Surgical Arthroscopy of the Temporomandibular
Joint. Philadelphia, WB Saunders, 1993.)
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246 Internal Derangements of the TMJ
Table 1. Incidence and Distribution of Each Type of Fibrous Adhesion

Number of
Internal Band- like Filmy TM/s* with
derangement adhesion Pseudowall adhesion adhesions
Click 2/6 0/6 2/6 2/6

Closed-lock 4/30 28/30 7/30 28/30
DJDt 6/23 20/23 12/23 23/23
DJD with closed-lock 3/9 7/9 9/9 9/9
Total 15/68 55/68 28/68 62/68
* Temporomandibular joint.
t Degenerative joint disease.
(Reprinted with permission from Murakami K-I, Segami N. Intraarticular Adhesions of the Temporomandibular Joint.
In: Clark GT, Sanders B, Bertolami CN (editors). Advances in Diagnostic and Surgical Arthroscopy of the Temporo-
mandibular Joint. Philadelphia: Saunders, 1993:17.)
therefore, distinguishing the real capsule from adhesions (41.2%, or 28 joints), and band-like
this structure is not easy. adhesions (22.1%, or 15 joints). Some joints
Murakami and Segami18 reported the over- had several types of adhesions. As one would
all incidence of intra-articular adhesions in 68 expect, adhesions were found more frequently
consecutive cases of internal derangement to in the more advanced cases of internal de-
be 91.2% (62 of the 68 joints examined dis- rangement and degenerative joint disease (Ta-
played some form of adhesion). Pseudowall ble 1).
adhesions were the predominant finding Wilkes19 has devised a staging classification
(80.9%, or 55 of 68 joints), followed by filmy for internal derangements based on the clini-
Table 2. Wilkes' Staging Classification for Internal Derangement of the TMJ

I. Early Stage
A. Clinical: no significant mechanical symptoms other than early opening reciprocal clicking; no pain or
limitation of motion
B. Radiologic: slight forward displacement, good anatomic contour of the disc, negative tomograms
C. Anatomic/pathologic: excellent anatomic form, slight anterior displacement, passive incoordination
demonstrable
II. Early/Intermediate Stage
A. Clinical: one or more episodes of pain, beginning major mechanical problems consisting of mid- to
late-opening loud clicking, transient catching and locking
B. Radiologic: slight forward displacement, beginning disc deformity of slight thickening of posterior edge,
negative tomograms
C. Anatomic/pathologic: anterior disc displacement, early anatomic disc deformity, good central articulating area
III. Intermediate Stage
A. Clinical: multiple episodes of pain, major mechanical symptoms consisting of locking (intermittent or fully
closed), restriction of motion, and difficulty with function
B. Radiologic: anterior disc displacement with significant deformity/prolapse of disc (increased thickening of
posterior edge), negative tomograms
C. Anatomic/pathologic: marked anatomic disc deformity with anterior displacement, no hard-tissue changes
IV. Intermediate/Late Stage
A. Clinical: slight increase in severity over intermediate stage
B. Radiologic: increase in severity over intermediate stage, positive tomograms showing early to moderate
degenerative changes—flattening of eminence, deformed condyle, sclerosis
C. Anatomic/pathologic: increase in severity over intermediate stage, hard-tissue degenerative remodeling of
both bearing surfaces (osteophytosis), multiple adhesions in anterior and posterior recesses, no perforation of
disc or attachments
V. Late Stage
A. Clinical: crepitus; scraping, grating, grinding symptoms; episodic or continuous pain; chronic restriction of
motion; difficulty with function
B. Radiologic: disc or attachment perforation, filling defects, gross anatomic deformity of disc and hard tissues,
positive tomograms with essentially degenerative arthritic changes
C. Anatomic/pathologic: gross degenerative changes of disc and hard tissues, perforation of posterior
attachment, multiple adhesions, osteophytosis, flattening of condyle and eminence, subcortical cystic formation
(Reprinted with permission from Bronstein S, Merrill B. Disorders of the TMJ. Oral and Maxillofacial. Surgery Clinics of
North America. Philadelphia: Saunders, 1989.)
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Bruce Sanders 247
Table 3. Bronstein and Merrill Arthroscopic Staging of Internal Joint Derangements Correlated with
Wilkes' Staging Classification
I. Early Stage
Roofing, 80 percent (closed position) to 100 percent (open or protrusive positions); incipient bilaminar zone
elongation; normal disc flexure at junction of discal eminence and superior lamina; normal synovium; incipient
loss of articular surface smoothness; normal superior compartment recesses and vascularity
II. Early/Intermediate
Roofing, 50 percent (closed) to 100 percent (open or protrusive); bilaminar elongation with decreased flexure;
early adhesive synovitis with beginning adhesion formation; slight lateroanterior capsular prolapse
III. Intermediate
Advanced bilaminar elongation with accordion-shaped redundancy and loss of flexure; prominent synovitis;
diminished lateral recess; advanced adhesion formations; anterior pseudowall formation in substage B.
Substage A: Roofing, 5 percent (closed) to <15 percent (open or protrusive); chondromalacia grades I-II
(softening, blistering, or furrowing)
Substage B: No roofing, more severe anterior recess changes, chondromalacia grades II-III (blistering,
furrowing, ulceration, fraying, fibrillation, surface rupture)
IV. Intermediate/Late
Increase over intermediate stage disease, hyalinization of posterior attachment; chondromalacia grades III-IV
(ulceration, fraying, furrowing, fibrillation, surface rupture, cratering, bone exposure)
V. Late Stage
Prominent fibrillations on articular surfaces, perforation, retrodiscal hyalinization, false-capsule formation
anteriorly, generalized adhesions, advanced synovitis; chondromalacia grade IV (cratering, bone exposure)
(Reprinted with permission from Bronstein S, Merrill B. Disorders of the TMJ. Oral and Maxillofacial Surgical Clinics of
North America. Philadelphia: Saunders, 1989.)
cal, radiological, and anatomic/pathological to reduce the muscle pain and tightness is to
findings (Table 2). This classification has been reduce emotional stress.26'27
widely used, and has been adapted by Bron-
stein and Merrill to develop an arthroscopic
classification correlated with the Wilkes staging
Controversies in the Management of
Internal Derangements
classification (Table 3).
Internal derangements of the TMJ are Although there is much information available
more common in certain types 01r patients. • 20
about the nature of TMJ internal derange-
21
These patients are typically young women ments, there is still great controversy about its
who are generally slender and have general- management. Much of this controversy in-
ized joint laxity.22 Often there is a familial his- volves a dispute over the importance of disc
tory (ie, mother and sisters) of having "jaw position. If the anteriorly displaced disc is not
joint clicking." repositioned, will the posterior attachment be-
TMJ clicking can start early in adoles- come compressed and perforated, leading to
cence.23 Intermittent locking and acute closed degenerative joint disease, or will the disc and
lock tend to appear in the later teens and early the posterior attachment successfully adapt by
twenties. Chronic closed lock and degenerative virtue of a fibrous response? Some clinicians
changes are commonly observed in the late believe that it is absolutely essential to reposi-
twenties and early thirties.24'25 Often a trau- tion the disc to avoid progression of the con-
matic episode (eg, injury to the chin, a long dition and deterioration of the TMJ.28 How-
dental appointment, severe clenching/ ever, investigators such as Scapino29 and Bibb
bruxism) can be a precipitating factor in caus- and Pullinger30 have shown joint adaptation in
ing a closed lock. cadaver specimens with displaced discs. Addi-
Muscular pain (myofascial pain and dys- tionally, Katzberg et al,31 in a magnetic reso-
function [MPD]) associated with clenching can nance imaging (MRI) study of 70 asymptom-
occur in any age group and in either gender, atic nonpatient subjects, found that 24% had
but is most commonly observed in young internal derangements of the TMJ. Similarly,
women. It is a stress-related condition. Unfor- Westesson et al32 did an arthrographic study of
tunately, it is often confused with TMJ intra- 40 asymptomatic nonpatient subjects and
capsular disease, and overtreatment is com- showed that 15% had internal derangements
mon. Aside from supportive care, the best way of the TMJ. These findings support the con-
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tention that joint motion may be more impor- Controversies over management of internal
tant than disc position. derangements come from the fact that there
There is a great deal of difficulty predicting are few outcome studies comparing "no treat-
in which patients TMJ disease will progress ment" versus "nonsurgical treatment" versus
and in whom it will go into remission. "surgical treatment." Additionally, there are
DeLeeuw et al33 did a study of clinical signs of few outcome studies comparing the various
TMJ osteoarthrosis and internal derange- surgical techniques. The literature shows little
ments 30 years after nonsurgical treatment evidence for using aggressive "prophylactic"
and showed a significant decrease in symptoms treatment to prevent the progression of TMJ
with only this form of therapy. Two to four disease. It is best to avoid complex, invasive
years after the initial treatment there was a procedures, be they nonsurgical or surgical,
stage of quiescence or a great decrease in that offer no advantage over no treatment or
symptoms, and in the following three decades simple, less invasive procedures. Thus, the ba-
minimal change occurred. These authors con- sic approach to the management of internal
cluded that with conservative treatment there derangements generally should involve home
was an improvement in masticatory function care (self care) and medical care (nonsurgical
and a reduction of pain. The patients felt "se- care). Surgery should be reserved for patients
cure about the nature of the disorder," and with closed lock and patients with painful click-
residual joint noises were of little or no con- ing that is unresponsive to treatment with non-
cern to them. surgical therapy for a period of 3 to 6 months.
Figure 2. The stages of arthrocentesis. (A) A ruler is placed from the tragus to the outer canthus of the eye.
The two marks represent the points of entrance into the superior compartment of the TMJ (see text). (B)
First needle inserted into the posterior point of entrance. (C) Second needle inserted into the anterior point
of entrance, allowing free flow of fluid. (D) The posterior needle is connected by tubing to the infusion bag
(not shown). (Reprinted with permission from Nitzan D. Arthrocentesis for management of severe closed
lock of the temporomandibular joint. Oral Maxillofac Surg Clin 1994;6:245-257.)
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Bruce Sanders 249
explained and shown on various models or by

using sketches or other educational devices.
The patient must understand that most inter-
nal derangements are episodic and can often
be treated very simply. Through proper edu-
cation, the patient will feel empowered and
more able to cope with the tasks involved in
home care. Reassuring rather than terrifying
the patient is the key to obtaining cooperation
and achieving a successful outcome.
Recommendations for jaw rest and soft diet
should be given. Use of booklets on diet and
dietary counseling is also helpful. Explaining
the relationship of emotional stress, worry, and
nervousness to muscular contracture and
tightness, and the subsequent effect of the lat-
ter on compression of the temporomandibular
joint must be explained. Attempts at stress re-
duction by patients are much more likely to be
successful when they understand the cause of
Figure 3. Proposed sequence of events in the cre-
ation and release of a vacuum between the TMJ disc their muscle/TMJ symptoms.
and fossa. (A) Normal TMJ, showing condyle, disc, The use of thermal applications, either heat
posterior attachment, eminence, and fossa. (B) Disc or cold, can be recommended, depending on
pressed flat against the slope of the eminence. (C) the situation. For example, in the acutely trau-
Vacuum effect (black area) produced by center of matized joint, ice applied to the region will be
disc's resumption of its biconcave shape while the
rims remain fastened to the fossa. (D) The pull of helpful. However, if there is considerable
the lateral pterygoid muscle on the condyle (anterior myofascial contracture and tightness adjacent
star) is reflexively inhibited because of pain gener- to the TMJ, moist heat will be more effective.
ated by the stretched capsule (posterior star). (E) Re- Pain from early, mild TMJ internal derange-
lease of vacuum by insertion of needle between disc ments can be managed with nonprescription
and fossa. (F) Re-formation of upper joint space and
initiation of free sliding motion of the disc after ar-
analgesics such as acetaminophen or ibu-
throcentesis. (Reprinted with permission from profen. Very often, with home care the painful
Nitzan D. Arthrocentesis for management of severe click that was such a concern for the patient
closed lock of the temporomandibular joint. Oral and doctor will become painless and the click-
Maxillofac Surg Clin 1994;6:245-257.) ing will be of little consequence. In such pa-
tients it is important to initiate routine follow-
Home Care (Self-Care) up and continued reassurance. However, if the
patient remains symptomatic, medical care
For patients with painful clicking of the TMJ, should be started.
home care begins with an extensive education-
al session. This may require more than one Medical Care (Nonsurgical Care)
appointment. It is essential that the clinician
explain in simple, straightforward terms, the There are a variety of medical (nonsurgical)
anatomy of the TMJ and the associated mus- modalities, including physical therapy, bite ap-
cular and skeletal structures. Additionally, a pliance therapy, and the use of prescription
simple explanation of the normal physiology medications such as muscle relaxants or non-
of the disc-condyle-fossa relationship is a re- steroidal anti-inflammatory medications, that
quirement. Discussing the general epidemiol- can be used.34 Additionally, trigger point in-
ogy and natural history of internal derange- jections, jaw manipulation, and psychological/
ments is also essential. Then, in very simple biofeedback treatments are acceptable nonsur-
terms, the pathological process (ie, clicking, in- gical modalities. However, complex dental,
termittent locking, or persistent closed lock) is prosthodontic and orthodontic treatments
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TMJ Closed-Lock
Surface Adhesion Stickiness
Figure 4. (A) Diagram of surface adhesions between the articular eminence and the disk. (B, C, and D) Lysis
of adhesions via superior compartment sweep. (D) Therapeutic lavage. (Reprinted from Sanders B, Buon-
cristiani RD. Surgical Arthroscopy. In: Sanders B, Murakami K-I, Clark GT, editors. Diagnostic and Surgical
Arthroscopy of the Temporomandibular joint. Philadelphia, Saunders, 1989.)
have questionable benefit in patients with in- pomobility and TMJ pain that is unresponsive
ternal derangements. to medical management, surgical methods may
Lundh et al35 investigated the treatment of be necessary to treat the disorder. If the TMJ is
TMJ pain and disc displacement without re- locked, whether painful or nonpainful, it
duction using a flat-plane occlusal appliance needs to be unlocked as soon as possible. Sur-
versus no treatment in a 12-month clinical trial gical care can be broadly classified into arthro-
involving 51 patients in whom the condition centesis, arthroscopy, and arthrotomy.
had been documented with arthrograms. They
were randomly divided into two groups, 25 pa- Arthrocentesis
tients being treated with a flat-plane occlusal
appliance and the other 26 patients serving as Arthrocentesis is an increasingly popular mo-
untreated controls. The investigators found dality for treatment of mandibular hypomobil-
that joint pain and muscle tenderness de- ity caused by closed lock (Figs 2 and 3). A great
creased more often in the nontreatment con- deal of work has been performed by Nitzan,
trols than in the treated group, thus indicating Dolwick, and Martinez36 showing the efficacy
that appliance therapy is not always the pan- of this procedure, and there are those who be-
acea for internal derangements that we had lieve that arthrocentesis can be substituted for
hoped it would be. arthroscopy in all cases. However, the latter
has not been substantiated by the prospective
treatment outcome study of Murakami and
Surgical Care
Segami37 in which they compared manipula-
When a patient has a persistent internal de- tion and appliance therapy to arthrocentesis or
rangement that involves severe mandibular hy- arthroscopy for treatment of TMJ closed lock.
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Bruce Sanders 251
Figure 5. (A and B) Prearthroscopy closed lock of left TMJ (C and D) One day postarthroscopy. Note the lack
of sutures and full oral opening. (Reprinted from Sanders B, Buoncristiani RD. Surgical Arthroscopy. In:
Sanders B, Murakami K-I, Clark GT, editors. Diagnostic and Surgical Arthroscopy of the Temporoman-
dibular Joint. Philadelphia, Saunders, 1989:95-114.)
The results showed a success rate of 55.6% of the disc, and arthroscopic lysis and lavage
with manipulation and appliance therapy, 70% would more effectively eliminate these adhe-
with arthrocentesis, and 91% with arthroscopy. sions, thus mobilizing the disc and eliminating
The authors concluded that 5 of the 6 arthro- the chronic closed lock.
centesis failures were associated with chronic
closed lock of 7 months or more. In these cases Arthroscopy
it is likely that intracapsular adhesions in the Arthroscopic lysis and lavage is the most widely
upper joint space prevented full mobilization used form of operative TMJ arthroscopy (Fig
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Figure 5. Continued. E and F, Note mandibular

stabilizing splint and excellent opening, G, The pa-
tient is asymptomatic (picture taken 2 years post-
operatively). Nonsurgical therapy done by Dr.
Duane Grummonds, Marina del Rey, CA. (Re-
printed from Sanders B, Murakami K-I, Clark
GT, editors. Diagnostic and Surgical Arthroscopy
of the Temporomandibular Joint. Philadelphia,
Saunders, 1989:95-114.)
4). Sanders38"40 has reported a high degree of throscopy is now recognized as the first-line
success with arthroscopic lysis and lavage in the outpatient surgery to eliminate painful chronic
treatment of painful TMJ hypomobility sec- hypomobility associated with persistent closed
ondary to closed lock and other investigators lock and degenerative joint disease associated
have confirmed these initial findings. Ar- with adhesive capsulitis. It is a conservative ap-
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Bruce Sanders 253
proach that can be performed on an outpatient Table 5. Relationship Between Patient Age and
basis. However, arthroscopic lysis and lavage Preoperative Diagnosis*
does not typically result in reduction of the an- Range in Age Internal Degenerative joint
teriorly displaced disc. Nevertheless, it does in- (years) derangements disease
crease disc mobility and dramatically improve 10-19 27 2
the clinical symptoms (Fig 5). 20-29 52 17
30-39 55 21
40-49 16 12
Long-Term Experience with Arthroscopic 50-59 5 5
Lysis and Lavage ^60 1 0
Totals 156 57
From the beginning of 1985 until the middle
* Age distribution of 213 patients as it relates to their di-
of 1989 Sanders and Buoncristiani 50 per- agnosis of either internal derangement or degenerative
formed 340 arthroscopic procedures on 213 joint disease.
patients who had painful TMJ hypomobility. (Reprinted with permission from Sanders B, Buoncristiani
R. A 5-year Experience with Arthroscopic Lysis and La-
The youngest patient was 10 years old and the vage for the Treatment of Painful Temporomandibular
oldest was 60 years old; the average age was 30 Joint Hypomobility. In: Advances in Diagnostic and Sur-
years (Table 4). There were 198 female pa- gical Arthroscopy of the Temporomandibular Joint. Phil-
adelphia: Saunders, 1993: p 32).
tients and 15 male patients. The average du-
ration of symptoms before the arthroscopic
procedure was 3 years and 2 months. There examinations and chart reviews. A successful
were 127 bilateral procedures and 86 unilat- result was characterized by increased mouth
eral procedures performed. Of the 340 arthro- opening, improved mandibular mobility and
scopic procedures, 34 were diagnostic only and function, and decreased pain and disability.
306 were therapeutic (ie, surgical or operative) Results were classified as excellent, good, or
as well. All 34 diagnostic arthroscopies were poor. An excellent result was defined as an in-
followed by immediate arthrotomies. Most of terincisal opening of 40 mm or greater (or an
these arthrotomies were performed on pa- opening three fingers in breadth) associated
tients who were younger than 40 years of age. with minimum or no pain, minimum dietary
The preoperative diagnosis in 156 of the 213 and functional restrictions, and no sense of dis-
patients (73%) was internal derangement with ability. A good result was defined as an open-
persistent closed lock and in 57 of the patients ing of 30 to 35 mm (or an opening of 2 and
(27%) it was degenerative joint disease (os- one-half fingers in breadth) causing minimum
teoarthritis) (Table 5). to moderate pain, moderate dietary and func-
A retrospective evaluation of these patients tional restrictions, and a minor sense of disabil-
was performed by means of periodic clinical ity. A poor result was characterized by an
Table 4. Relationship Between Patient Age and Table 6. Results of Arthroscopic Lysis and Lavage
Sex and the Average Duration of Symptoms* by Year*
Average duration Number of Number of Number of

Range of symptoms Number of excellent good good
in Age Male Female Year patients results (%) results (%) results (%)
(years) patients patients Years Months
1985 34 26 (76%) 4(12%) 4(12%)
10-19 2 27 2 7 1986 69 56(81%) 10(14%) 3 (4%)
20-29 5 65 2 4 1987 79 73 (92%) 3 (4%) 3 (4%)
30-39 6 69 4 0 1988 70 63 (90%) 6 (9%) 1 (1%)
40-49 2 26 3 8 1989 54 46 (85%) 5 (9%) 3 (6%)
50-59 0 10 4 2 Totals 306 264 (86%) 28 (9%) 14 (5%)
3*60 0 1 1 0
Totals 15 198 3 2 * Distribution of postoperative results (rated as excellent,
good or poor) by the year of surgery from 1985 to 1989.
(Reprinted with permission from Sanders B, Buoncristiani (Reprinted with permission from Sanders B, Buoncristiani
R. A 5-year Experience with Arthroscopic Lysis and La- R. A 5-year Experience with Arthroscopic Lysis and La-
vage for the Treatment of Painful Temporomandibular vage for the Temporomandibular Joint Hypomobility. In:
Joint Hypomobility. In: Advances in Diagnostic and Sur- Advances in Diagnostic and Surgical Arthroscopy of the
gical Arthroscopy of the Temporomandibular Joint. Phil- Temporomandibular Joint. Philadelphia: Saunders, 1993:
adelphia: Saunders, 1993:p 32.) p33.)
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Table 7. Results of Arthroscopic Lysis Table 9. Improvement in Opening Before and

and Lavage* After Arthroscopic Lysis and Lavage Following
Mandibular Sagittal Osteotomy (15 Patients)
Result Number of Patients (%)
Preoperative Postoperative Improvement
Excellent 10(71) Patient opening (mm) opening (mm) (mm)
Good 0(0)
Poor 4(29) 1 25 35 10
Total 14(100) 2 29 35 6
3 27 35 8
* Results of lysis and lavage in 14 patients who had arthro 4 39 41 2
scopically observed disc perforations. 5 39 42 3
(Reprinted with permission from Sanders B, Buoncristiani 6 23 35 12
R. A 5-year Experience with Arthroscopic Lysis and La- 7 16 34 18
vage for the Temporomandibular Joint Hypomobility. In: 8 30 40 10
Advances in Diagnostic and Surgical Arthroscopy of the 9 26 36 10
Temporomandibular Joint. Philadelphia: Saunders, 1993: 10 31 40 9
p33.) 11 26 38 12
12 20 35 15
13 22 38 16
opening of less than 30 mm (or an opening of 14 26 42 16
less than two fingers in breadth) causing sig- 15 23 37 14
nificant pain, significant dietary and functional (Reprinted with permission from Sanders B, Buoncristiani
restrictions, and a sense of major disability. R. A 5-year Experience with Arthroscopic Lysis and La-
One hundred ninety-two of the 221 joints vage for the Temporomandibular Joint Hypomobility. In:
Advances in Diagnostic and Surgical Arthroscopy of the
with closed-lock (86.9%) had an excellent re- Temporomandibular Joint. Philadelphia: Saunders, 1993:
sult, 9.5% had a good result, and 3.6% had a P 34.)
poor result following arthroscopic lysis and la-
vage. Seventy-two of the 85 joints with degen- throtomies with disc removal. One hundred
erative joint disease (84.7%) had an excellent percent of these procedures failed. Two joints
result, seven (8.2%) had a good result, and six were treated nonsurgically after failed arthros-
(7.1%) had a poor result (Fig 6). Yearly results copy, but continued to do poorly.
were also evaluated (Table 6). Seventeen of the joints undergoing arthros-
Fourteen of the 306 joints (4.5%) that un- copy had disc perforations. Three of the 17
derwent arthroscopic lysis and lavage did not joints underwent immediate arthrotomy and
improve. Factors that likely influenced failure discectomy; there were two excellent results
included uncontrolled bruxism (six joints), sys- and one good result. The other 14 joints with
temic arthritis (three joints), and previous ar- perforations were treated with arthroscopic ly-
throtomy (one joint). All six patients with un- sis and lavage. The arthroscopic results were
controlled bruxism had continuous physical relatively good and are presented in Table 7.
therapy and counselling to eliminate parafunc-
tional muscle activity. Four had subsequent ar- Arthroscopic Lysis and Lavage in the
Treatment of Painful Joint Hypomobility
Table 8. Arthroscopic Findings in 28 Painful After Mandibular Sagittal
Hypomobile Joints after Mandibular Ramus Osteotomy
Sagittal Osteotomy
TMJ internal derangement after mandibular
Finding Number of joints sagittal split ramus osteotomy resulting in pain
Displaced disc 26 and mandibular hypomobility has been re-
Morphologic changes 26 ported by several authors. Sanders and col-
Adhesions 26 leagues51 have reported the treatment of 15
Synovitis 20
Perforated or destroyed disc 6 female patients with this problem. Thirteen of
Eburnation 2 these patients had bilateral TMJ problems and
(Reprinted with permission from Sanders B, Buoncristiani two had unilateral joint problems. All patients
R. A 5-year Experience with Arthroscopic Lysis and La- had mandibular advancement for retrognathia
vage for the Temporomandibular Joint Hypomobility. In: and none had significant preoperative TMJ
Advances in Diagnostic and Surgical Arthroscopy of the
Temporomandibular Joint. Philadelphia: Saunders, 1993: symptoms. Postoperatively, all had preauricu-
P 34.) lar pain, mandibular hypomobility, and joint
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Bruce Sanders 255
Excellent (192 joints) Excellent (72 joints)
Poor (8 joints)
Poor (7 joints)
\
Good (21 joints) Good (6 joints)
Figure 6. Postoperative results of arthroscopic lysis and lavage (A) Treatment outcome in patients with a
preoperative diagnosis of internal derangement (221 joints). (B) Treatment outcome in patients with a
preoperative diagnosis of degenerative joint disease (85 joints). (Reprinted with permission from Clark G,
Sanders B, Bertolami C: Advances in Diagnostic and Surgical Arthroscopy of the Temporomandibular Joint.
Philadelphia, Saunders, 1993.)
crepitus. The arthroscopic findings are pre- Conclusions

sented in Table 8. The duration of symptoms
was from 5 months to 2 years 7 months, with Orthodontists commonly find themselves
an average of 1 year 3 months. treating patients with TMJ disorders. There-
Eight of 28 involved joints (29%) had evi- fore, it is essential to be familiar with the clas-
dence of closed-lock, 14 (50%) had closed-lock sification of various internal derangements
with early degenerative joint disease, and 6 and the natural progression of these disorders.
(21%) had advanced degenerative joint dis- Early stages may be treated effectively with
ease. The average opening before arthroscopy nonsurgical modalities. However, late stage
was 27 mm, with a range of 16 to 39 mm. All disease, including persistent, painful closed
15 patients (28 joints) underwent arthroscopic lock, may require surgical intervention that
lysis and lavage as an outpatient hospital pro- might involve arthroscopy or arthrotomy. A
cedure. There were no complications, and all team approach is suggested.
patients had postoperative physical therapy.
The range of clinical follow-up was from 6 References
months to 4 years. The average postarthro-
scopic interincisal opening was 38 mm, with a 1. Grummons D. Orthodontics for the TMJ/TMD pa-
range of 34 to 42 mm; the average improve- tient. Scottsdale, AZ: Wright Co, 1994.
2. Ochs M, La Bane J, Dolwick MF. The diagnosis and
ment of opening was 11 mm, with a range of 2 management of concomitant dentofacial deformity
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duction of pain in all of the patients. Orthognathic Surgery. Oral and Maxillofacial Sur-
gery Clinics of North America 1990;2:669-67l.
3. Engermark-Ericsson I, Ingerwall B, Carlsson G. The
Arthrotomy (Open Joint Surgery) dependence of mandibular function in children on
functional and morphologic malocclusion. Am J
Open joint surgery should be reserved for pa- Orthod 1983;83:187.
4. Riolo M, Brandt D, TenHaue T. Association between
tients who have very advanced disc deformity occlusal characteristics and signs and symptoms of
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conservative treatment such as arthrocentesis Orthod Dentofac Orthop 1987;92:467.
or arthroscopy has failed. Discectomy without 5. Mohlin B, Kopp S. A clinical study on the relationship
replacement is an effective procedure in such between malocclusion, occlusal interferences and
cases.52 Currently, there is little or no evidence mandibular pain and dysfunction. Swed Dent J 1978;
2:105.
supporting the need for disc replacement (ie, 6. Perry H. Relationship of the occlusion to temporo-
auricular cartilage, temporal fascia, or prosthe- mandibular joint dysfunction: A retrospective study. J
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7. Upton L, Scott R, Hay wood J. Major maxillomandib- 23. Egermark-Erisson I, Carlson G, Ingerwall B. Preva-
ular malrelations and temporomandibular joint pain- lence of mandibular dysfunction and orofacial
dysfunction. J Prosth Dent 1984;51:686. parafunction in 7-11 and 15 year old Swedish chil-
8. Williamson E. Temporomandibular dysfunction in dren. Eur J Orthod 1981 ;3:163-172.
pretreatment adolescence patients. Am J Orthod 24. Rasmussen O. Treatment of temporomandibular ar-
1977;72:429. thropathy. Scand J Dent Res 1981;89:64-68.
9. Wisth P. Mandibular function and dysfunction in pa- 25. Rasmussen O. Description of population and progress
tients with mandibular prognathism. Am J Orthod of symptoms in a longitudinal study of temporoman-
1984;85:193. dibular joint arthropathy. Scand J Dent Res 1981 ;89:
10. Stohler CS. Occusal therapy in the treatment of tem- 196-203.
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of Temporomandibular Disorders. Oral and Maxillo- ment for myofascial pain-dysfunction syndrome. A
facial Clinics of North America. Philadelphia, PA: comparative analysis. J Am Dent Assoc 1983; 107:235-
Saunders, 1995: 129-139. 238.
11. Dolwick MF, Sanders B. TMJ Internal Derangement 27. Rugh J. Behavioral therapy. In: Mohl N, Zarb G,
& Arthrosis: Surgical Atlas. St. Louis, Mosby, 1985. Carlsson G, et al, editors. A Textbook in Occlusion.
12. McNeill C. Temporomandibular Disorders: Guide- Chicago, IL: Quintessence, 1988:329-338.
lines for Classification, Assessment, and Management, 28. Hall HD, Nickerson J, McKenna S. Modified condy-
The American Acad of Orofacial Pain. Quintessence, lotomy for treatment of the painful temporomandib-
Chicago, IL: 1993. ular joint with a reducing disc. J Oral Maxillofacial
13. Isberg-Holm A, Westesson P-L. Movement of the disc Surg 1993;51:133-142.
and condyle in temporomandibular joints with click- 29. Scapino R. Histopathology associated with malposition
ing: An arthrographic and cineradiographic study on of the human temporomandibular joint disc. Oral
autopsy specimens. Acta Odontol Scand 1982;40:151- Surg Oral Med Oral Pathol 1983;55:382-397.
164. 30. Bibb C, Pullinger A. The histologic basis and clinical
14. Blankestijn J, Boering G. Posterior dislocation of the implications for temporomandibular joint adaptation.
temporomandibular disc. Int J Oral Surg 1985; 14: In: Clark G, Sanders B, Bertolami C, editors. Ad-
437-443. vances in Diagnostic and Surgical Arthroscopy of the
15. Liedberg J, Westesson P-L, Kurita K. Side-ways and Temporomandibular Joint. Philadelphia, PA: Saun-
rotational displacement of the temporomandibular ders, 1993:117-127.
joint disk: Diagnosis by arthrography and correlation 31. Katzberg R, Westesson P-L, et al. Abnormalities of the
to cryosectional morphology. Oral Surg Oral Med temporomandibular joint in asymptomatic subjects
Oral Path 1990;69:757-763. with attention to rotational and sideways disc displace-
16. Sanders B. Arthroscopy of the temporomandibular ment. Radiology 1992; 185:174.
joint: Treatment of internal derangement with persis- 32. Westesson P-L, Erickson L, Kurita K. Reliability of a
tent closed lock. Oral Surg Oral Med Oral Path 1986; negative clinical temporomandibular joint examina-
62:361. tions: Prevalence of disc displacement in asymptom-
17. Nitzan D, Dolwick MF. An alternative explanation for atic temporomandibular joints. Oral Surg Oral Med
the genesis of closed lock symptoms in the internal Oral Pathol 1989;68:551-554.
derangement process. J Oral Maxillofac Surg 1991; 33. deLeeuw R, Boering G, Stegenga B, et al. Clinical
49:810. signs of TMJ osteoarthrosis and internal derange-
18. Murakami K, Segami N. Intraarticular adhesions of ment 30 years after non-surgical treatment. J Orofa-
the temporomandibular adhesions of the temporo- cial Pain 1994;8:18-24.
mandibular joint. In: Clark G, Sanders B, Bertolami 34. Laskin DM (ed.). Medical Management of Temporo-
C, editors. Advances in Diagnostic and Surgical Ar- mandibular Disorders. Oral and Maxillofacial Surgery
throscopy of the Temporomandibular Joint. Philadel- Clinics of North America, Feb, 1995.
phia: Saunders, 1993. 35. Lundh H, Westesson P-L, Eriksson L, et al. Tempo-
19. Wilkes C. Internal derangement of the temporoman- romandibular joint disc displacement without reduc-
dibular joint: Pathological variations. Arch Otolaryn- tion. Treatment with flat occlusal splint vs. no treat-
gol Head Neck Surg 1989; 115:469-477. ment. Oral Surg Oral Med Oral Pathol 1991;73:655-
20. Solberg W. Epidemiological findings of importance to 658.
the management of temporomandibular joint disor- 36. Nitzan D, Dolwick MF, Martinez G. Temporomandib-
ders. In: Clark G, Solberg W, editors. Perspectives in ular joint arthrocentesis: A simplified treatment for
Temporomandibular Joint Disorders, Quintessence, severe limited mouth opening. J Oral Maxillofac Surg
Chicago, IL: 1987. 1991;48:1163.
21. Solberg W, Woo M, Houstan J. Prevalence of mandib- 37. Murakami K, Segami N. Manipulation and splint ther-
ular dysfunction in young adults. J Am Dent Assoc apy vs. arthrocentesis vs. arthroscopy for treatment of
1979;98:25-34. closed lock. Abstract presented at UCLA Interna-
22. Westling L, et al. Background factors in cranioman- tional Oral & Maxillofacial Surgery Symposium,
dibular disorders with special reference to general Maui, HI, December 1993.
joint hypermobility, parafunction and trauma. J Cran- 38. Sanders B. Arthroscopic surgery of the temporoman-
iomandib Disord Facial Oral Pain 1990;4:89-98. dibular joint: Treatment of internal derangement
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Bruce Sanders 257
with persistent closed lock. Oral Surg Oral Med Oral 48. Mosby E. Efficacy of temporomandibular joint ar-
Pathol 1986;62:361-372. throscopy: A retrospective study. J Oral Maxillofac
39. Sanders B, Buoncristiani R. Diagnostic and surgical Surg 1993;51:17-21.
arthroscopy of the temporomandibular joint: Clinical 49. Zeitler D, Porter B. A retrospective study comparing
experience with 137 procedures over a 2-year period. arthroscopic surgery with arthrotomy and disc repo-
J Craniomandib Disord Facial Oral Pain 1987; 1:202. sitioning. In: Clark G, Sanders B, Bertolami C, edi-
40. Sanders B. Discussion: Efficacy of temporomandibu- tors. Advances in Diagnostic and Surgical Arthros-
lar joint arthroscopy: A retrospective study. J Oral copy of the Temporomandibular Joint. Philadelphia,
Maxillofac Surg 1993;51:21. PA: Saunders, 1993:47-60.
41. Indresano T. Arthroscopic surgery of the temporo-
mandibular joint: Report of 64 patients with long- 50. Sanders B, Buoncristiani R. A 5-year experience with
term follow-up. J Oral Maxillofac Surg 1989;47:439. arthroscopic lysis and lavage for the treatment of
42. Montgomery M, Van Sickels J, Harms S, et al. Arthro- painful temporomandibular joint hypomobility. In:
scopic TMJ surgery: Effects on signs, symptoms, and Clark G, Sanders B, Bertolami C, editors. Advances in
disc position. J Oral Maxillofac Surg 1989;47:1263. Diagnostic and Surgical Arthroscopy of the temporo-
43. White D. Retrospective analysis of 100 consecutive mandibular Joint. Philadelphia, PA: Saunders, 1993:
surgical arthroscopies of the temporomandibular 31-34.
joint. J Oral Maxillofac Surg 1989;47:1014. 51. Sanders B, Kaminishi R, Buoncristiani R, et al. Ar-
44. Moses J, Poker I. TMJ arthroscopic surgery: An anal- throscopic surgery for treatment of temporomandib-
ysis of 237 patients. J Oral Maxillofac Surg 1989;47: ular joint hypomobility after mandibular sagittal oste-
790. otomy. Oral Surg Oral Med Oral Pathol 1990;69:539-
45. Moses J, Sartoris D, Glass R, et al. The effect of ar- 541.
throscopic surgical lysis and lavage of the superior
joint space on TMJ disc position and mobility. J Oral 52. Hall HD. The role of discectomy for treating internal
Maxillofac Surg 1989;47:674-678. derangement of the temporomandibular joint. In:
46. Nitzan D, Dolwick MF, Heft M. Arthroscopic lavage Laskin D, editor. Oral and Maxillofacial Surgery Clin-
and lysis of the temporomandibular joint: A change in ics of North America. Current Controversies in Sur-
perspective. J Oral Maxillofac Surg 1990;48:798-801. gery for Internal Derangement of the Temporoman-
47. Moore L. Arthroscopic surgery for the treatment of dibular Joint, 1994.
restrictive temporomandibular joint disease: A pro- 53. Eriksson L, Westesson P-L. The need for disc replace-
spective longitudinal study. In: Clark G, Sanders B, ment after discectomy. In: Laskin D, editor. Oral and
Bertolami C, editors. Advances in Diagnostic and Sur- Maxillofacial Surgery Clinics of North America. Cur-
gical Arthroscopy of the Temporomandibular Joint. rent Controversies in Surgery for Internal Derange-
Philadelphia, PA: Saunders, 1993:35-40. ments of the Temporomandibular Joint, 1994.
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Implications of Temporomandibular
Disorders for Facial Growth and
Jos M.H. Dibbets and David S. Carlson
The purpose of this article is to review the literature concerning the possible
associations between temporomandibular disorders (TMD), orthodontic
therapy, mandibular growth, and facial form. Consideration of the associa-
tion between TMD and orthodontic treatment leads to one conclusion: there
is no evidence that orthodontic treatment generally increases or decreases
the chances of developing TMD later in life. Still, our understanding of TMD
is not final, and the expanding diagnostic knowledge continues to call for
new longitudinal studies focusing on the developmental basis of temporo-
mandibular disorders. Little is known about the potential effect of TMD on
facial development. However, information relating to the normal develop-
ment, growth, and adaptation of the temporomandibular joint all tend to
emphasize the significant ontogenetic plasticity of the growth-related sec-
ondary cartilage associated with the TMJ, within the bounds of normal
function and histophysiology. With the exception of such diseases as juve-
nile rheumatoid arthritis and osteoarthritis, little is known about the influ-
ence of TM pathology or myofascial disorders on facial growth. Also, little is
known about the possible influence of disc interferences on facial growth.
However, the condyle is known to play a prominent role in normal mandib-
ular growth and, consequently, facial development. Thus, categories of TMD
that involve dysplasia of the condylar cartilage could be associated with
aberrant facial growth and form. (Semin Orthod 1995; 1:258-272.)
hree conceptual problems are most ap-

T parent when considering the orthodontic
implications of temporomandibular disorders
TMD. Therefore, the problem to be addressed
in this article must be formulated with care.
A second concern is the often-heard notion
(TMD). One is contained in the statement of that TMD is a "multifactorial disorder." This
the problem itself; ie, it is not possible at this proposition clearly emphasizes two related
time to actually test the statement that orth- points. First is the implicit assumption within
odontic treatment causes TMD. Even the most such a statement that TMD is a single, well-
comprehensive studies in this area at present characterized clinical problem; second, is the
do not generate cause-and-effect answers. At more explicit assumption that TMD has a po-
most, such studies can show or reject associa- tentially wide variety of efficient causes. Un-
tions between orthodontic treatment and fortunately, the concept of TMD as a multifac-
torial disorder has done little to enrich our
From the Department of Orthodontics, Philipps University,
thinking, and may even have constrained or
Marburg, Germany; and the Department ofBiomedical Sciences, inhibited proper understanding of the causes
Center for Craniofacial Research, Baylor College of Dentistry, and implications of TM disorders. Considered
Dallas, TX. broadly, signs and symptoms of disorders of
Supported in part by NIH-NIDR DE 08824 to DSC, the temporomandibular joint (TMJ), such as
Address correspondence to David S. Carlson, PhD, Depart-
ment ofBiomedical Sciences, Baylor College of Dentistry, PO Box
pain, limitation of jaw opening and excursion,
660677, Dallas, TX 75266-06677. inflammation, and degeneration, undoubtedly
Copyright © 1995 by W.B. Saunders Company have many potential and discrete causes. How-
1073-8746I95I0107-0007$5.00IO ever, this partial list of characteristics illustrates
258 Seminars in Orthodontics, Vol 1, No 4 (December), 1995: pp 258-272
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TMD, Facial Growth, and Orthodontic Treatment 259
the fact that it is unwarranted to consider consensus as to which signs and symptoms fa-
TMD as a single disorder, with a discrete and cilitate selective differential diagnosis. This of-
well-defined progression. Although recent ten leads to confusion and apparent disagree-
studies have introduced a variety of new diag- ment concerning the etiology of the disorder,
nostic procedures with promising sensitivity as well as the nature of the affected tissues.
and specificity, there exists no consensus as to Finally, TMD should be considered within the
which signs and symptoms facilitate selective broader context of growth and adaptive re-
differential diagnosis within the broad cate- sponses by cells and tissues comprising the
gory TMD. TMJ and masticatory system.
The notion that TMD is a single disorder In this article, we take the position that signs
precipitated by a wide variety of specific causes and symptoms as reported in the literature are
is especially unfruitful as it concerns the pos- indicators of an array of problems, collectively
sible effects of existing TM disorders on sub- referred to as TMD. Consideration of the im-
sequent growth and orthodontic/orthopedic plications that TMD may have for facial
treatment. For example, myofascial pain, in- growth and orthodontic treatment has three
ternal disc derangement, and osteoarthrosis parts. The first reviews the literature relating
each fit the broad classification of TMD; yet to the association between signs and symptoms
each is very different in terms of the target attributed to TMD and orthodontic treatment.
tissues that may be affected. Therefore, it must The second part focuses on TMJ growth.
be considered that each will most likely have Based on the assumption that TMD may be
different specific effects and implications for characterized by the presence of compromised
facial growth and for possible orthodontic tissues and dysfunction of the TMJ, this sec-
treatment. tion will provide a context and foundation for
A third problem relates to the age-related the third and final section, which explores the
expression of TMD in the general population, potential effect of specific TMDs on mandibu-
and in the specific clinical orthodontic popula- lar and facial growth and form.
tion. Most commonly, it is thought that TMD is
a disorder expressed uniquely in young to
middle-aged adults. However, signs and symp-
TMD and Orthodontic Treatment
toms of TMD do occur in children and adoles- Initial identification of a putative causal rela-
cents.1"3 Like all diseases and disorders, espe- tionship between occlusal factors and pain in
cially those associated with abnormal structure the region of the TMJ is generally attributed to
caused by growth and remodeling, certain Costen in 1934.6 Since that time, various types
manifestations of TMD must have a develop- of corrective therapy involving orthodontic/
mental basis.4'5 Essential issues that emerge orthopedic approaches and occlusal adjust-
from this assumption concern the specific fac- ment have been proposed to correct the mal-
tors predisposing to or leading up to TMD in occlusion and thereby to alleviate the signs and
subadults, the impact of TMD on facial growth symptoms of TMD.7"9 It was assumed gener-
and form, and the implications of this for orth- ally that structural or functional malocclusions
odontic treatment. cause TMD, and that normalization of the oc-
Potential confusion about the scope, causes, clusion by means of occlusal adjustment and
and characteristics of TMD, as well as its nat- orthodontics should correct the disorder.4"5
ural progression, gives rise to three caveats This concept tended to be embraced with some
that are essential to consider with respect to the enthusiasm by many orthodontists.8'10 How-
implications of TMD for facial growth prob- ever, this presents something of a dilemma.11
lems and for orthodontic treatment. First, If it is assumed that orthodontic treatment can
TMD is not a single disorder, but rather is a alleviate TMD via alteration of the way the
broad classification of a number of disorders teeth fit together and thereby influencing the
that may affect differentially a number of rel- position and function of the condyle-disc as-
atively independent tissues within the TMJ sembly, then it must also be accepted that orth-
and associated structures. Second, within the odontic treatment can cause TMD through the
broad classification of TMD, there exists no same general process.
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260 Dibbets and Carlson
Another interesting dichotomy concerning TMD and orthodontic treatment were pub-
the relationship between TMD and orthodon- lished very recently by Sadowsky14 and by Mc-
tic treatment has developed recently. Although Namara and colleagues.9 Sadowsky14 reviewed
it is more common to regard malocclusion as a 14 studies totaling 1,300 patients who had pre-
predisposing factor for TMD, recent publica- viously undergone orthodontic treatment. Mc-
tions by Schellhas and colleagues12 have re- Namara and coworkers9 provided an excellent
versed this causal relationship and proposed historical overview and reviewed data from
that TMD, and internal derangement of the more than 150 clinical studies covering several
disc specifically, is a causal factor leading to thousand subjects. Although different in
malocclusion, which then requires orthodontic scope, both reviews arrived at very similar
treatment because of abnormal facial growth overall conclusions based on their extensive
and form. However, the latter twist on the mal- consideration of the literature. According to
occlusion-TMD concept, which will be dis- Sadowsky, "the overwhelming evidence sup-
cussed in more detail later, is highly question- ports the conclusion that orthodontic treat-
able because of methodological problems. ment performed on children and adolescents
Several specific orthodontically related pro- is generally not a risk for the development of
cedures have been proposed to cause TMD. TMD years later." Similarly, McNamara and
Conventional wisdom led to the assumption 15 coworkers found no evidence for increased
years ago that extractions and/or orthodontic risk of TMD in orthodontic patients.
treatment procedures are responsible for the The review by McNamara and coworkers,9
initiation of TMD. Other putative causes in- also provides a more in-depth analysis of the
cluded such dichotomous interventions as dis- data from the literature concerning TMD as it
talization of the mandible caused by retraction relates to occlusal status, orthodontics in gen-
of the upper incisors, thereby "trapping" the eral, specific types of orthodontic treatment
condyle-disc assembly, and anterior protrusion (including extraction/nonextraction) and
of the mandible. All of the information pur- TMD, and orthodontic approaches designed
porting to support this assumption was simply for prevention of TMD. With respect to the
intuitive, anecdotal and, at best, retrospec- relationship between functional occlusal fac-
tive. 10 tors and TMD, McNamara and colleagues
Several years have elapsed between initia- evaluated 20 studies with a total of more than
tion and completion of well-designed longitu- 7,000 participating individuals from healthy
dinal studies on the interaction between orth- and patient populations. In light of apparently
odontic treatment and TMD, which are abso- conflicting conclusions and contentions from
lutely necessary to establish the relative validity these studies, their general conclusion was that
of this association. Since that time a number of it is more important to carefully examine the
publications have explored the possibility of a methodology used than the conclusions in each
significant relationship between TMD and of the individual studies. From the data, Mc-
orthodontic treatment using credible method- Namara and coworkers concluded further
ological approaches. However, at the same that, except for a few defined occlusal condi-
time through significant progress in diagnostic tions, such as anterior open bites, overjets
capabilities via such techniques as magnetic more than 6 mm, RCP-ICP slides over 4 mm,
resonance imaging of the joint and enhanced unilateral crossbites, and five or more missing
clinical procedures, for example, it became posterior teeth, there is relatively low risk of
clear that TMD should no longer be consid- occlusal factors being associated with TMD.
ered a discrete disorder.13 Because none of the None of the studies reviewed identified a
original unfavorable claims, as logical as they cause-effect relationship and all correlation co-
once seemed to be, can be upheld anymore efficients were very low (r < 0.3), explaining
today, it seems prudent not to speculate on as- less than 10% of the total variation.
sociations between orthodontics and TMD be- McNamara and colleagues9 also critically re-
fore clinical trials have been completed. viewed published data concerning the occur-
Two critical review articles dealing with the rence of signs and symptoms in studies totaling
evidence concerning the association between over 10,000 healthy individuals. They found
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that an average of 32% of this combined pop- and early postnatally (phase I), and diminishes
ulation exhibited at least one symptom, and in expression as development proceeds post-
55% showed at least one sign of TMD. More- natally through adolescence (phase II). The
over, they noted that the signs and symptoms second role of the mandibular condyle is di-
of TMD occur in healthy individuals, and the rected toward mandibular articulation and
number of signs and symptoms increase with load-bearing capabilities. Beginning in incipi-
age, particularly during adolescence. Because ent form, because the mandible may move
of these findings, they concluded that the oc- prenatally, the articular function gains pri-
currence of signs and symptoms during orth- macy as the growth function diminishes during
odontic treatment must be considered within phase II. With adulthood (phase III), condylar
the context of normal longitudinal changes. growth has essentially ceased, though remod-
Moreover, orthodontic treatment during ado- eling may continue throughout life, while ar-
lescence generally does not increase or de- ticular function continues.
crease the odds of developing TMD later in Essentially, the earlier growth function and
life. the later articular function can be considered
Considering the issue of orthodontic treat- as competing roles within the mandibular
ment more specifically, McNamara and col- condyle. Unlike typical growth cartilage, such
leagues concluded that it is not reasonable to as that found in synchondroses (ie, epiphyses
assume that TM disorders that originate or are and cranial base), the condylar cartilage must
first reported during treatment are necessarily be capable both of active growth and of with-
related to the treatment. They noted specifi- standing some degree of loading caused by the
cally that there is no scientific evidence to in- forces of mastication. Unfortunately, the tis-
dicate that extraction of teeth as part of an sues and histomorphology of the TMJ are not
orthodontic treatment plan increases the risk optimally suited for this purpose because they
of TMD. Nor is there evidence for elevated are derived from a specialization of perioste-
risk for TMD associated with any particular um and are characterized by a special type of
type of orthodontic mechanics. Although a sta- intramembranous skeletal formation. As a re-
ble occlusion is a reasonable orthodontic treat- sult, variations in articular function, especially
ment goal, not achieving a specific gnathologic during phases I and II of development, may
ideal occlusion does not result in TMD signs have important consequences for development
and symptoms. Finally, McNamara and co- of the mandible and, thus, for facial form. Fur-
workers also concluded that there is no evi- thermore, variations in mandibular function,
dence to indicate that orthodontic treatment trauma, and a history of disease may play a
can prevent TMD, although when more severe significant role in compromise of the tissues of
TMD signs and symptoms are present, simple the developing TMJ, and thus in disorders of
treatments usually can alleviate them in most the TMJ. However, the potential adaptive ca-
patients. pabilities of the TM tissues will undoubtedly
play a significant role in the avoidance and al-
leviation of TM disorders via normal processes
Normal Development of the TMJ of development and growth. Normal events
The TMJ provides the essential functional and conditions experienced by the TMJ dur-
connection between the cranium and the up- ing development and growth can be resolved
per and lower jaw. However, the primary func- effectively by the process of adaptation. How-
tion of the TMJ in general, and of the man- ever, pathology of the TMJ may occur if the
dibular condyle in particular, is not so simple, physiological bounds of normal adaptation are
and it changes during development. Consid- exceeded, caused by the nature of the pertur-
ered specifically, the primary roles of the man- bation, the capabilities of the tissues compris-
dibular condyle are twofold, and they may be ing the TMJ, or both.4'16'17
considered within three arbitrary phases of de- To effectively consider the potential associ-
velopment.15 The first primary role of the ation between TMD and facial growth and
mandibular condyle is directed toward growth, form it is necessary to understand the nature
which is most evident and important prenatally of the tissues comprising the TMJ, their rela-
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tionship to the normal growth process, and the skeletal tissues comprising both the mandibu-
manner in which they express themselves dur- lar condyle and the squamous portion of the
ing maturation. In the following section, the temporal bone arise from a specialized skele-
development and growth of the TMJ will be togenic membrane (ie, periosteum/perichon-
reviewed briefly, with emphasis on the growth- drium). Moreover, it is understood that growth
related tissues. of all skeletal tissues associated with the TMJ
takes places via osseous replacement of in-
tramembranously formed secondary cartilage,
Morphogenesis especially within the condyle, but also along
In human fetuses the condyle originates the subarticular surface of the squamous tem-
around 7 to 7.5 weeks of gestation as a con- poral bone.
densation of mesenchymal tissue separate Secondary Cartilage
from the developing intramembranous bone
of the mandible and squamous portion of the In part because of its atypical development and
temporal bone.18 By 16 to 17 weeks a fully cellular structure, the cartilage of the mandib-
formed joint is present.19 Interposed between ular condyle and articular eminence is desig-
the mandibular condyle and temporal articu- nated as a special form of periosteally/peri-
lation is the articular disc, which is derived chondrally derived hyaline cartilage, called
from the same mesenchymal mass as the lateral secondary cartilage.20'21 Although primary
pterygoid muscle. cartilage, which gives rise to the cartilaginous
template of the limbs and cranial base, forms
very early in development, secondary carti-
Histomorphology (Fig 1) lages develop considerably later, arising and
being maintained in areas where intramembra-
The nature of the various layers of tissue asso- nous bone is exposed to local intermittent bio-
ciated with the articular and growth-related mechanical stress. Modulation between the
skeletal tissues comprising the TMJ, and the chondroblastic and osteoblastic phenotype in
specific terms used to define them, have been response to altered local biomechanical cir-
the subject of considerable discussion (see cumstances is caused by the bipotential nature
Carlson17 for a more complete review). In gen- of the undifferentiated cells of the periosteal/
eral, it is appreciated that the growth-related perichondrial membranes.22"24
Figure 1. Photomicrographs of parasagittal sections of the left TMJ from a young rhesus monkey (Macaca
mulatto) demonstrating the histomorphology of the TMJ. (A) Low power overview of the TMJ. Note the
continuous nature of the periosteum (p) along the posterior border of the ramus as it splits to form the joint
capsule and articular disc (a), and then splits again to form the outer fibrous articular layers and inner
chondrogenic layers of the mandibular condyle and fossa (c). (B) Medium power view of the condylar
cartilage, articular disc, and articular eminence. (Modified with permission from Carlson DS. Growth of the
temporomandibular joint. In: Zarb et al, editors. Temporomandibular Joint and Masticatory Muscle Disor-
ders. Copenhagen, Denmark, Munksgaard. 1994.)
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Articular Layer and subadjacent secondary hyaline cartilage

At the sites of articulation between the condyle that is typically considerably thinner than that
and temporal bone within the TMJ, the outer, observed in the condyle. In contrast, the man-
fibrous layer of the bilaminar perichondrium dibular fossa, which is not heavily loaded dur-
thickens somewhat, enhancing its protective ing function, is comprised of lamellar bone
function. This fibrous connective tissue layer, overlayed by a periosteum, but there is no car-
which is continuous with the fibrous layer of tilage throughout postnatal development.
the periosteum along the neck of the mandible
and along the temporal bone, becomes known
Growth of the TMJ
as the articular layer. Although the articular
layer is analogous to an articular cartilage, be- Neonatal-Juvenile Period
cause it provides a similar articular function,
the TMJ does not have a true articular carti- Most of the major morphological changes as-
lage. sociated with growth of the TMJ are com-
pleted during the first decade of life. The neo-
Prechondroblastic Layer natal mandibular condyle is capped by a rela-
tively thick, highly vascularized, and very
Immediately deep to the articular layer is the
mitotically active secondary cartilage. In gen-
prechondroblastic or proliferative layer, which
eral, as the mandible is displaced downward
is an irregular layer of densely packed cells
and forward by the growing midface, the
continuous with the osteogenic layer of the
condylar cartilage grows actively via perichon-
periosteum. The prechondroblastic layer is the
drial deposition in a superior and posterosu-
preponderant site of mitotic activity in the
perior direction to maintain its articulation
condylar cartilage and squamous temporal re-
with the temporal component of the TMJ. The
gion, supplying cells for both the articular
anterior-inferior region of the condyle, the
layer and underlying cartilage or bone.25"28
condylar neck, and the bony medial and lateral
Chondroblastic Layer poles of the condyle tend to be resorptive.
During the first year of life the mandibular
On its deep surface, the flattened cells of the condyle becomes progressively less vascular-
deepest parts of the prechondroblastic layer ized and the entire growth cartilage layer be-
become larger and more ovoid shape, with a comes significantly thinner. By 6 months of
dense nucleus typical of chondrocytes,29 as age, there is up to a two-thirds reduction in the
they come to occupy the chondroblastic zone.24 thickness of the cartilage layer (to 0.50 mm) in
In growing individuals, the chondrocytes in humans, 30 primarily caused by reduction in
the deepest layers are considerably hyper- the zone of hypertrophy. The thickness of the
trophic, with characteristically large lacunae. growth cartilage remains constant from in-
fancy through adolescence. Also, by 6 months
Zone of Endochondral Ossification
of age there is a significant reduction in the
The deepest three to five cell layers are sur- number and size of vascular canals within the
rounded by a matrix that is mineralized. The condylar cartilage; those that persist do so in
last of these is in direct contact with the front the medial and posterior aspects of the
of invading vascular cells and osteoblasts in the condyle, where growth is most active. By 3
zone of endochondral ossification. years of age in humans, vascular canals are no
longer present.
Temporal Portion of the TMJ Growth of the articular surface of the tem-
The growth-related tissue overlying the crest poral bone is characterized by enlargement of
and posterior slope of the articular eminence, the articular eminence and postglenoid region,
with which the condyle articulates during the which becomes evident by around 8 months of
power stroke of mastication and incision, is age and continues through development of the
similar, although less luxuriant, to that cover- mixed dentition. The S-shaped curve that
ing the condyle. It also is characterized by a characterizes the temporal component of the
perichondrium with a thickened fibrous layer TMJ becomes evident during this period. By 6
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or 7 years of age the articular eminence may continued but progressive slowing of the
enlarge to 5 to 6 mm in height. At this point, growth of the TMJ. By age 10, the mandibular
compact osseous tissue and secondary osteons condyle is characterized by a maintenance of
are present within the articular eminence and the relatively thick articular tissue layer, pro-
postglenoid process. gressive reduction in the size of the entire
Also during the period of early mixed den- growth cartilage layer, and evidence of in-
tition the articular layer of the condyle be- creased mineralization in the deeper portion
comes thicker and the cartilage layer thins to of the hypertrophic zone. After age 13 to 15
approximately 0.3 mm in humans. The under- years, the cartilage layer decreases further in
lying bone trabeculae, although sparse, be- thickness; however, it is not necessarily lost al-
come progressively thicker and remain ori- together (Fig 2). The proliferative layer is
ented superiorly and posteriorly, toward the present through at least the age of 18.51 Hy-
direction of condylar growth. This pattern of pertrophic condylar cartilage, which is an in-
growth continues through the period of the dication of an actively growing condyle, has
late mixed dentition, approximately 7 to 12 been observed in autopsy specimens through-
years of age. out the second decade of life and, in some sub-
The articular disc remains highly vascular- jects, through age 30.32 By 19 to 27 years of
ized and rich in fibroblasts during the first few age, only islands of cartilage cells typically re-
years of life. After that time, the central part of main in the superior and anterior regions of
the disc becomes avascular and less cellular, the condyle.31'33
and the collagen fibers become oriented per- The onset of a cortical bone cap coalescing
pendicular to each other, anteroposteriorly the trabecular bone beneath the condylar car-
and mediolaterally. The periphery of the disc tilage becomes apparent by approximately 10
and, in particular, its most posterior region, to 12 years of age, and it becomes essentially
the so-called retrodiscal or bilaminar region, complete by 20 years of age.34 As documented
remain highly vascularized as well as being by Lubsen and coworkers32 and by Pullinger
characterized by the presence of nerve end- and colleagues,35 the bone cap increases in
ings. thickness from approximately 0.1 mm in im-
mature subjects, to 0.4 mm in young adults, to
Juvenile-Adolescent Period 0.6 mm in adults. With the formation of the
The second decade of life, especially toward bone cap, the tissue immediately deep to the
its latter half, is characterized primarily by prechondroblastic layer of the mandibular
Figure 2. High power view of a parasagittal view of the articular eminence (A) and condylar cartilage (B) of
a juvenile rhesus monkey. A, articular layer, comprised of the dense connective tissue specialization of the
outer, fibrous layer of periosteum. G, entire growth cartilage, which can be subdivided further into four
zones: prechondroblastic or proliferative zone (P); chondroblastic zone (C); zone of hypertrophy (//); and
zone of endochondral ossification (E). (Modified with permission from Carlson DS. Growth of the tempo-
romandibular joint. In: Zarb et al, editors. Temporomandibular Joint and Masticatory Muscle Disorders.
Copenhagen, Denmark, Munksgaard. 1994.)
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condyle and the articular eminence now be-

come fibrocartilage, characterized by less cell
number, more extracellular matrix, and a non-
hypertrophic appearance typical of hyaline
cartilage that is not actively growing.
Adulthood
The cartilage of the human TMJ is essentially
completely replaced by bone around the begin-
ning of the fourth decade of life. The articular
tissue remains relatively unchanged in appear-
ance throughout adulthood, although it may
undergo metaplastic transformation into fibro-
cartilage, depending on the biomechanical-
loading to which the joint was subjected. Deep
to the articular layer in the mandibular
condyle the fibrocartilage is typically partially
mineralized, at which time it is referred to as
chondroid-type bone (Fig 3). Within the min-
eralized, chondroid bone layer, islands of hya-
line cartilage may be found until relatively old
age. Once the bony cap is fully present, active
growth of the mandibular condyle has essen-
tially ceased, although progressive and regres-
sive remodeling may continue throughout life,
largely in response to the local biomechanical Figure 3. Photomicrographs of the crest of the ar-
environment. 15,17,36 ticular eminence (A) and mandibular condyle (B) of
a young adult rhesus monkey (M. mulatto}. Note: the
pronounced presence of collagenous fibers (cf) run-
TMD, Mandibular Growth, and ning between the articular tissue and the underlying
bone in the condyle and the extensive bone cap in
Facial Form both the articular eminence and the condyle. (Mod-
As discussed previously, the broad category of ified with permission from Carlson DS. Growth of
the temporomandibular joint. In: Zarb et al, editors.
TMD is characterized by a number of signs Temporomandibular Joint and Masticatory Muscle
and symptoms. Some of these, such as idio- Disorders. Copenhagen, Denmark, Munksgaard.
pathic joint and muscle pain (eg, myofascial 1994.)
pain) and limitation of jaw movement, might
be considered acute conditions of short-term,
transient, or episodic nature.11 Even if they oc- that could lead to compromise and even de-
cur in young individuals, there is no reason to struction of growth-related tissues within the
assume that such signs and symptoms are nec- TMJ.42 Notable in this category of TMD are
essarily indicative of an underlying disorder inflammatory diseases such as juvenile rheu-
that would have an adverse long-term effect on matoid arthritis (JRA), as well as condylar apla-
maxillofacial growth and form. Although sia or hyperplasia, psoriatic arthritis, ankylos-
there is a large amount of literature document- ing spondylitis, and neoplasms. Each of these
ing the association between muscle function serious disorders, although they can lead to
and facial form,37"40 there are no data to indi- significant unilateral and bilateral dysplasia of
cate a relationship between muscle dysfunction mandibular and facial growth, are fortunately
associated with TMD (eg, myofascial pain/ rare.43,44
dysfunction) and abnormal facial growth.41 The destructive impact of JRA and some
However, it is possible that some combina- other rare conditions on the mandibular
tion of similar signs and symptoms could indi- condyle has been well documented in the liter-
cate the presence of a more profound disorder ature.45"51 JRA, in particular, has been shown
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to have a significant effect on growth of the inflammatory expression of this disease.13 The
mandible and on overall facial form as a result prevalence of OA in samples referred for
of extreme compromise and even destruction TMD problems is estimated to run from 8%
of the cartilage of the growing mandibular to 18%.13 In addition, it has been documented
condyle. However, JRA has an estimated prev- that OA affects predominantly adults in the
alence in the general population of only 1 % or third or fourth decade, with a female to male
less.40 Moreover, when JRA and other signifi- ratio of 1 to 5 in the fifth to sixth decade.13'59
cant disorders that will affect growth of the There are very few reports on OA and its
TMJ do occur, the systemic manifestations relationship to facial growth.1'2'13'60"62 In fact,
rather than the dysfunction of the temporo- there is very little to be found on diagnostic
mandibular and mandibular dysplasia are criteria pertaining to OA of the TMJ and there
likely to be the precipitating problems for is no gold standard for QA.1'59'63"65 Crepita-
which the patients seek treatment.44 There- tion, for example, certainly is not an exclusive
fore, these disorders will not be discussed fur- sign of OA.66'67
ther in this article. However, a more common Only one study has provided estimates of
disorder, osteoarthrosis/osteoarthritis (OA), OA in a young orthodontic population.67 In a
that clearly has potential effects on growth of sample of 170 children referred for orthodon-
the TMJ, will be considered. tic treatment and followed longitudinally more
The second factor involved in the potential than 15 years with infracranial radiographs, a
effect of TMD on facial growth and form is the diagnosis equivalent to OA was made in 5% of
maturational status of the subject in whom the the individuals, as compared to 8% to 18% in a
disorder manifests itself. Obviously, the extent TMD population, according to Zarb and Carls-
to which facial form could be affected by TMD son.68 In seven of nine cases the diagnosis was
is dependent on both the duration of the dis- made at age 16 years or younger. The docu-
order and the amount of growth remaining to mentation for the two other cases was not suf-
be potentially expressed by the individual. ficient to exclude later development. Although
the literature predicts an increase of OA with
age, no new cases of OA were diagnosed
TMD and Growth of the TMJ through the end of the study, at an average age
Temporal Region of 26.5 years. Thus, it was concluded that OA
detected incidentally in the third decade of life
Quantitatively, the contribution of the tempo- could well be the exacerbation of an older,
ral part of the TM joint to the development of longer existing, osteoarthrotic process. At
the face is small and not thoroughly docu- present, a further 5 year follow-up is available
mented.52'53 There are only a few cephalomet- on 90 individuals from this study at an average
ric reports of horizontal and vertical positional age of 31.5 years, and no new cases of OA have
change of the fossa relative to the maxilla.54'55 been diagnosed.
There is some evidence that the shape of the There is considerable debate concerning the
glenoid fossa is associated with the growth of relationship between OA and mandibular
the mandible.56"58 However, the influence of growth. At the very least, OA within the TMJ is
TMD on the development of the articular em- typically associated with abnormal variations in
inence and its subsequent role on the develop- condylar remodeling. OA in a growing child,
ment of the face is not well known. as indicated by variation in condylar form,
could be indicative of a significant variation in
Mandibular Condyle the direction of mandibular growth. OA also is
In general, the disorder within the realm of associated with destruction of articular tissues
TMD that has the greatest potential affect on as well as increased remodeling and thickening
growth of the mandibular condyle, and conse- of the subarticular bone.6'8 As noted previ-
quently on the entire mandible, is OA. Tech- ously, the growing TMJ lacks a true articular
nically, osteoarthrosis is a noninflammatory cartilage and is characterized by the presence
degenerative disease of movable joints; os- of a highly adaptable secondary cartilage lo-
teoarthritis is a more severe and symptomatic cated deep to the fibrous articular tissue. Al-
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though the significance of this with respect to joint sounds show the poorest reliability of all
the growth and adaptive capabilities of the clinically relevant variables. Stohler concluded
TMJ is not fully understood, involvement of that advances in modern imaging technology
the subarticular cartilage will likely result in a have not enhanced our insights into the etiol-
severe compromise or cessation of condylar ogy of DID and therefore imaging is more
growth. likely to result in overemphasis of the mechan-
Although different in terms of etiology, the ical aspects of disc displacement. Specifically,
outcomes of OA and JRA, as they pertain to interventions aimed at the repair of the disc-
the TMJ, are similar. Both JRA and OA, espe- condyle complex have not been able to show
cially in their more severe form, are associated significant benefit.73 Disc interference disor-
with destruction of the articular tissue and ders, or internal derangements, relate to the
prechondroblastic layer of the mandibular disc-condyle assembly and, as such, may be ex-
condyle and temporal region. As a result, the pected to exert little or no influence on man-
mandible exhibits a severely impaired vertical dibular growth. As long as the mesenchymal
growth at the condyle. When the vertical covering of the condyle remains intact, the
growth of the condyle is impaired, the vertical growth potential of the condyle will be unaf-
cranial development of the entire ramus is fected.
blocked, perhaps with the exception of the Recently there has been considerable discus-
coronoid process.69'70 Thus, when OA and sion in the clinical literature concerning the
JRA arise during the period of active facial potential effect of internal disk derangement
growth, they may be expected to result in a (ID) on facial growth and form. According to
relatively short ramus, which in turn creates a Schellhas and coworkers,12 there is a causal re-
backward autorotation of the mandible, result- lationship between ID and abnormal growth of
ing in an anterior open bite. The facial profiles the facial skeleton, characterized primarily by
of patients with OA and JRA are almost mandibular retrognathia, mandibular asym-
identical and are indeed characterized by metry, and occlusal instability. Specifically,
backward rotation and a tendency to an open they proposed that, "Once a TMJ is internally
kjte 2,49,51,61,71,72 deranged, adaptive or degenerative osteocarti-
In 1994 it was concluded that there seems to laginous processes take place in the mandible,
be a typical face for individuals with OA, the temporal bone, and masticatory muscles ... In
distinction being a backward rotated and the growing facial skeleton, [this] either re-
adapted mandible.61 Mandibular morphology tards or arrests condylar growth, which results
and position were identical, but somewhat in decreased vertical dimension in the proxi-
more extreme, in adults relative to juveniles. mal mandibular segment(s) with ultimately
The diagnosis of OA in juveniles predicted an mandibular deficiency or asymmetry." In es-
adapted mandibular morphology and position sence, this postulate is an reiteration of Boer-
at adulthood; the diagnosis of OA in adults was ing's thesis,1 which led to the initiation in 1970
already associated with an adapted mandibular of the Groningen prospective longitudinal
morphology and position at adolescence. The study on TMD in growing children.2
latter finding is in agreement with the previous According to Schellhas and colleagues,12 the
conclusion 67 that OA of the mandibular primary factor leading to abnormally deficient
condyle can take place in early adolescence. mandibular growth in the presence of ID is
presumed to be compromise of the blood sup-
Articular Disc ply to the mandibular condyle, resulting in os-
In an excellent review on disc interference dis- teoarthritis, avascular necrosis (AVN), and re-
orders, Stohler73 emphasized the need for a gional osteoporosis. Schellhas and coworkers
better case definition to delineate the subset of put forward four arguments related to the re-
disc-interference disorders, or DID, from lationship of ID to mandibular and facial
other conditions affecting the TMJ. It appears growth. First, it was proposed that ID is
that many subjects without any complaints may present in a disproportionately large and pre-
exhibit a disc-condyle assembly similar to that viously unrecognized number of young pa-
observed in DID symptomatic subjects. Also, tients (approximately 90%) presenting with
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mandibular deficiency and facial asymmetry. interferences as an accompanying sign of

Second, it was postulated that ID is a primary condylar destruction rather than its cause.76'68
etiologic factor resulting in abnormalities of Simple mechanistic explanations like joint hy-
mandibular growth and facial form. Third, it permobility also have not stood the scientific
was proposed that orthodontics and ortho- test.77 As long as the mesenchymal covering of
gnathic surgery cause increased biomechanical the condyle remains undisturbed, no mecha-
loading of the TMJ, which cannot be tolerated nism can be theorized which, as a result of disc
by a compromised joint. As a result, fourth, interference disorders, induces developmental
". . . therapeutic endeavors such as orthodon- changes in the normal growth of the mandible.
tics and orthognathic surgery may either pro- Currently, the direct interaction between disc
voke or exacerbate mechanical and inflamma- interference disorders and the condition of
tory TMJ symptoms ..." condylar tissue is unknown at best.
Reaction to the concepts put forward by Although there are at present no postulates
Schellhas and coworkers concerning the rela- that connect disc interference disorders di-
tionship between ID and abnormal growth of rectly with different growth potentials of the
the mandible and facial skeleton has generally face, there is reason to explore the association
taken two forms. Those clinicians who con- between disc interference disorders and facial
sider TMD in general, and ID in particular, to form when signs and symptoms are taken as
be the dental equivalent of the Black Plague, indicators of growth patterns.3 The association
welcome every argument as a stimulus to fi- between disc interference disorders and facial
nally get the orthodontic specialty to "... pull morphology traditionally has been assessed by
its head out of the sand and realize what is comparing the prevalence of signs and symp-
happening in the real world."74 However, oth- toms in a group with characteristic orthodontic
ers find significant problems with several fea- anomalies such as deep bite, open bite, or cross
tures of Schellhas' concepts and methodology. bite with that of a reference population.78 A
For example, it is difficult to accept that one higher percentage of signs and symptoms in
and the same noxious influence, ie, orthodon- one of these a priori selected groups should be
tic treatment, is the principal cause for both interpreted as an association between TMD
provocation and exacerbation of TMD. This and facial morphology.
leaves unanswered the question of what pro- Only a few studies have reversed the ques-
voked the TMD in the first place, later to be- tion and explored facial morphology in groups
come exacerbated. selected on the basis of TMD criteria. Yet,
It has been stressed previously that mandib- there exists an essential difference between the
ular and facial growth will experience rela- two approaches. The first method establishes
tively little abnormal variation in direction and TMD signs and symptoms in groups selected
amount unless the condylar cartilage, and es- on the basis of morphological criteria. The al-
pecially the prechondroblastic layer, is signifi- ternate method seeks morphological charac-
cantly compromised or destroyed. OA, in par- teristics in groups selected on the basis of TMD
ticular, does have the potential for a significant criteria. Nesbitt and coworkers,79 in a retro-
effect on the condylar tissue that is capable of spective study, concluded that adults with TMJ
resulting in alteration of the direction and clicking had significantly deeper bites, greater
amount of condylar growth. Similarly, central overjets, and more severe Class II occlusal re-
to the notion that ID plays a significant causal lationships at age 14 to 16 years. Stringert and
role in abnormal mandibular and facial growth Worms,80 in a preliminary report, found a ten-
is the assumption that it results in OA, which in dency toward an increased horizontal discrep-
turn leads to AVN and regional osteoporosis.12 ancy in patients with functional alterations of
At one time, disc interferences were thought to the TMJ. Brand and colleagues81 reported dif-
form the first step in a dangerous cascade of ferences in skeletal patterns between 24
events eventually leading to osteoarthrosis of women with and 24 women without internal
the bony joint components.75 This postulate derangement confirmed by magnetic reso-
has never been proven and, on the contrary, it nance imaging (MRI). A comprehensive ceph-
seems much more compelling to consider disc alometric analysis made it evident that women
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with internal derangement had "normal" ver- Conclusions

tical skeletal relationships, but horizontally sig-
nificantly smaller mandibles and maxillae. Reviewing of the literature for evidence of
This finding must have puzzled the investiga- clinical implications of TMD on facial growth
tors, because they concluded in their last sen- and consequently for orthodontic treatment
tence that, "In general, no distinct relationship makes it clear that there still is much work to be
was found between the morphological features done. Many hypotheses have been brought
of the face and the internal derangements of forward, but over time many have failed scien-
the temporomandibular joints." It is difficult tific clinical evaluation. More studies are in
to see what mechanism possibly could explain progress. Statistically, an association has not
shorter sagittal dimensions in relation to disc been shown between signs and symptoms as-
interferences, but this difficulty does not jus- signed to TMD, on the one hand, and quality
tify rejection of the findings. orthodontic treatment on the other. As our un-
With a different sample, a different statisti- derstanding of TMD develops, new studies will
cal method, and different criteria, ie, palpated have to narrow down the targets of research.
clicking and crepitation in contrast to MRI- The potential adverse effects of TMD on
confirmed disc interference disorders, Dibbets facial growth have been explored in the liter-
and van der Weele82 found exactly the same ature. In cases of JRA, osteoarthrosis, and
results as Brand and coworkers.81 The same other similar conditions, an adverse effect on
set of horizontal variables in adult patients with mandibular development has been docu-
a palpated click or crepitation showed a signif- mented. It seems that impaired mandibular
icantly shorter dimension: articular to A point, growth in these patients necessarily results in
palate length, articulare to pogonion, and go- orthodontic treatment, rather than the re-
nion to pogonion. Notably, true vertical facial verse.
dimensions never differed significantly be- Another controversial issue is the interpre-
tween groups. tation of findings of an elevated prevalence of
Because the full documentation made more TMD in individuals selected on the basis of
than 14 years previously was available, it was facial morphology, eg, open bite. This ap-
possible to determine the facial dimensions of proach has led to speculation on the etiology of
these adults at a time when they were still chil- TMD. We propose an alternate research
dren. It appeared that the shorter horizontal method, by determining facial morphology in
dimensions that characterized adults with groups selected on TMD criteria. It appears
clicking joints were already significantly that disc interferences in adults are associated
shorter in their teenage faces, although the with a horizontally shorter facial depth. One
majority of the joints were not yet symptomatic study even found that these adults were al-
at that age. Faces tended to be "flat" 14 years ready horizontally shorter many years before
before clicking was palpated, thus indicating TMD was diagnosed.'Thus, when studying the
that characteristic horizontal facial differences implications of TMD for facial growth and for
preceded the emergence of signs by at least 14 orthodontic treatment, we have to look at chil-
years. This implies that not all TMD signs in dren before the need for treatment is estab-
adults can be regarded as being exclusively the lished. The etiology of TMD in this perspective
result of some etiologic factor operating after antedates orthodontic treatment.
the teenage period.
On the basis of these studies, signs of disc
interference disorders are related to horizontal References
deficits of the midface. Although the horizon-
tal deficit was already evident at an average age
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Author Index
Carlson, D.S., 258 Katz, S.H., 165 Peck, L., 105
Conley, P., 57 Keeling, S.D., 149 Peck, S., 65, 105
King, G., 127 Phillips, C., 128
Davidovitch, M., 3, 25 King, G.J., 149
Dibbetts, J.M.H., 258 Rebellato, J., 25, 31, 37, 44
Dixon, D.C., 207 Laskin, D.M., 195, 197
Laster, L.L., 165 Sadowsky, P.L., 1
Fricton, J.R., 229 Sanders, B., 244
Lindauer, S.J., 3, 12, 57
Linney, A.D., 94 Shofer, F.S., 165
Garvan, C.W., 149 Silverton, S., 165
Ghafari, J.G., 165 Lowey, M.N., 94
Spillane, L.M., 176
Ghosh,]., 67
Gianelly, A.A., 188 Markowitz, D.L., 165 Tulloch, J.F.C., 128
Giddon, D.B., 82 McGorray, S., 149
Greene, C.S., 222 McNamara, J.A., Jr., 176 Vig, K.D., 139
Moss, J.P., 94 Vig, P.S., 139
Isaacson, R.J., 2, 3, 12, 31,
55, 57 Nanda, R.S., 67 Wheeler, T.T., 149
Subject Index
Adhesions, types in TMJ, 244-245 Arthrocentesis, treatment, TMJ, 248, 250-251
Adults, growth of facial soft tissues, 76-78 Arthroscopy, treatment, TMJ, 251-255
Aging, and gingival smile line, 123 Arthrotomy, treatment, TMJ, 255
Ancient civilizations, facial art in, 106-107 Articular disc, and TMD, 267-269
Anterior extrusion arches Attractiveness
for incisor extrusion, 22-23 components of, 85-86
one-couple appliance to produce well- dentofacial, factors for, 84
defined tooth movement, 17-22 evolutionary and social role of, 85
Appearance, psychophysical approaches to see also Beauty and self-concept, 84-85
perception of, 88-90 Avascular necrosis
Appliance design, and biomechanics, 1-63 of condyle, MRI, 217-218
Arch, lingual, for resolution of crowding in in TMJ, 203
early mixed dentition, 188-194 AVN, see Avascular necrosis
Arch dimensions, and rapid maxillary expan-
sion, 176-187 Beauty, quantification of, 94-104; see also At-
Arch wire tractiveness
creative, 55-56 Behavioral therapy, for MMFP, 239-240
design, ground rules, 3-11 Biomechanics, and appliance design, 1-63
force systems, 3-6 Bionators, and headgear, results of random-
partially bracketed, first-order rotation of ized controlled clinical trial for treat-
molars with, 37-43 ment of class II malocculsion with, 149-
three-dimensional, responses to vertical V 164
bends, 57-63 Birdface deformity, 200
Arthography, imaging of TMJ, 213-214 Branchial arch, and congenital anomalies in
Arthritides, and TMJ, 199-201 TMJ, 198-199
Arthritis, degenerative, distinguishing features Bronstein and Merrill arthroscopic staging, in-
from myofascial pain, 204 ternal joint derangements, 247
Seminars in Orthodontics, Vol 1, No 4 (December), 1995: 273-279 273

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274 Subject Index
Canine extrusions springs, 12-15 Derangement, internal, of TMJ, 201-203

Canines, high facial, use of canine extrusion Development, normal, of TMJ, 261-265
spring, 12-15 Developmental anomalies, TMJ, 199
Chin DHEAS, see Dehydroepiandrosterone sulfate
contours and orthodontic treatment, 68-71 Diagnosis, accurate, for TMD, 197-206
growth patterns in adults, 79 DID, see Disc-interference disorders
Clicking, TMJ, home-care, 249 Disc derangements, relationship to myofascial
Clinical trial pain, 233
definition, 129-130 Disc displacement
randomized MRI diagnosis, 216
performance, 135-137 types in TMJ, 244-245
and understanding treatment efficacy, Disc-interference disorders, and TMD, 267-
128-138 269
randomized controlled Divine proportions, facial art, 108
issues for planning, 128-138
for temporomandibular disorders after
E space, maintenance of in crowding of early
early class II treatment with bionators
mixed dentition, 188-194
and headgears, 149-164
Embolism, fat, and vascular necrosis, 203
Cluster headache, relationship with myofascial
Equilibrium, for rotations, 6-7
pain, 233
Esthetic standards
Computed tomography, and imaging of TMJ,
orthodontic treatment and growth of facial
214-215
soft tissue, 67-81
Condylar hypolasia, 199
three-dimensional for face, 98-99
unilateral, 199
Esthetics, 83
Condyle
facial, 105-126
avascular necrosis, MRI of, 217-218
psychological and perceptual studies and
morphogenesis, 262
orthodontic applications, 82-93
Congenital anomalies, of TMJ, 198-199
Constriction, molars, 41-42 use of three-dimensional techniques, 94-
104
Costen's syndrome, 197. See also Cranioman-
oral, and smile line, 114-117
dibular syndrome
Couple, 4-6 orthodontic, history of, 110-113
Expansion
rotational tendency produced by, 5-6
Craniomandibular syndrome maxillary, and early mixed dentition, 176-
187
Crowding, and leeway space in early mixed
orthopedic, and early mixed dentition, 177-
dentition, 188-194; see Expansion
178
CT, see Computed tomography
Extraction, serial
in crowding of early mixed dentition, 188-
Decision analysis, for optimization of class II,
194
division 1 orthodontic treatment, 139-
serial, and early mixed dentition, 177
148
Decision tree, for optimization of orthodontic
treatment, 139-148 Fabrication, two-couple intrusion arches, 25-
Degenerative arthritis, and TMJ, 200-201 26
Degenerative joint disease, and TMJ, 200-201 Face
Dehydroepiandrosterone sulfate, correlation correlation of anthropomorphic and bio-
of measurements of with somatic and chemical measures with changes in dur-
facial growth, 165-175 ing early treatment, 165-175
Dentition, early mixed esthetic standards for three-dimensional
crowding and leeway space, 188-194 representation, 98-99
and rapid maxillary expansion, 176-187 golden proportions, three-dimensional, 99-
Dentofacial attractiveness, factors for, 84 102
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Subject Index 275
growth of soft tissues and long-term changes mandibular and facial, relationship of inter-
in profile, 72-76 ference disorders to, 267-268
growth of soft tissues in adults, 76-78 monitoring of during orthodontic treat-
long, and growth of facial soft tissues, 78-80 ment, 165-175
perception, morphometric correlates of, 86 TMJ, 263-265
short, and growth of facial soft tissues, 78-80 values for facial soft tissue lateral measure-
symmetry, 114 ments in young adults, 73-76
three-dimensional measurement of, 94-104 GSL, see Gingival smile line
values for soft tissue lateral measurements in
Hallerman-Streiff syndrome, 198-199
young adults, 73-76
Headgear, and bionators, results of random-
Facial art
ized controlled clinical trial for treat-
ancient civilizations, 106-107
neoclassicism, 109-113 ment of class II malocclusion with, 149-
164
renaissance, 107-109
Hemifacial microsomia, 198
Facial deformities, and congenital anomalies in
Histomorphology, of TMJ, 262-263
TMJ, 198-199
History, orthodontic esthetics, 110-113
Facial esthetics, 105-126
and orthodontics, 65-126 Imaging
psychological and perceptual studies and and joint anatomy, 208-209
orthodontic applications, 82-93 sensitivity/specificity data, 215
scientific findings relative to, 113-114 see also specific types
use of three-dimensional techniques, 94-104 Incisor
Facial form, relationship to TMD, 265 central and maxillary molars, responses of
Facial growth, implications of TMD for, 258- three-dimensional arch wires to vertical
272 V bends, 57-63
Facial pattern, class II, in Renaissance art, 109 and rotation with torquing arch, 62
Facial type, effects of, 78-80 and rotation with utility arch, 61-62
Fibromyalgia, as distinguished from myofas- crossbite correction, with torquing arches,
cial pain, 234 31-36
FM, see Fibromyalgia extrusion, use of anterior extrusion arches,
Force systems 22-23
arch wires, 3-6 intrusion, and overbite reduction, 25
and tooth movements, 7-8 rotation with torquing arches, 31-36
Forces, exerted by two-couple intrusion Infections, viral and bacterial, relationship
arches, 26 with myofascial pain, 233
Interference disorders, relationship to man-
Gingival smile line, 118-123 dibular and facial growth, 267-268
and aging, 123 Internal derangements
Golden proportions, face, and three-dimen- controversies in management, 247-255
sional measurements, 99-102 TMJ, management of, 244-257
Golden section, facial art, 108 Introduction
Goldenhar's syndrome, 198 biomechanics and appliance design, 1
Growth early orthodontic treatment, 127-194
anthropomorphic neasures, correlation with facial esthetics and orthodontics, 65-66
facial and occlusal changes during early temporomandibular disorders, 195-196
treatment, 165-175
Joint anatomy, and imaging, 208-209
biochemical correlations between somatic
Joint effusion, MRI diagnosis, 216
and facial, 169-170
Jump sign, distinguishing characteristic of
biochemical measures, correlation with facial
MFP, 232
and occlusal changes during early treat-
ment, 165-175 Leeway space, and crowding in early mixed
and effects of facial type, 78-80 dentition, 188-194
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276 Subject Index
Lingual arch, for resolution of crowding in first-order rotations with partially bracketed
early mixed dentition, 188-194 arch wires, 37-43
Lip bumper, for preservation of arch length, maxillary and central incisors, responses of
188-194 three-dimensional arch wires to vertical
Lips V bends, 57-63
growth patterns in adults, 79 movement or rotation with transpalatal
protrusion and retrusion, and orthodontic arches, 44-54
treatment, 68-71 and rotation with torquing arch, 62
Local pain, 232 and rotation with utility arch, 61-62
Lupus erythematosus, relationship with myo- mesial-in rotations, 38-39, 40-41
fascial pain, 233 mesial-out rotations, 38, 40
Moment, rotational tendency produced by a
Magnetic resonance imaging couple, 5-6
and avascular necrosis of condyle, 217-218 Morph methodology, visualizing facial changes
TMJ, 215-217 with computer, 89-90
Malocclusion Morphometric correlates, and face perception,
class II randomized controlled clinical trial 86
for treatment, 149-164 Mouth, esthetics of and smile line, 114-117
division 1, decision analysis for optimization MPD, see Masticatory muscle dysfunction
of orthodontic treatment for, 139-148 MPD, see Myofacial pain-dysfunction
and TMJ, which is causal factor?, 260 MRI, see Magnetic resonance imaging
Mandibular condyle Muscle exercises, treatment, MMFP, 235-238
growth of and TMD, 266-267 Muscle splinting, and myofascial pain, 233-234
see also Condyle Myofacial pain-dysfunction, 197
Mandibular growth, relationship to TMD, 265 Myofascial pain, 203-205
Mandibular movement, limitations, in MPD clinical characteristics, 229-230
patients, 204 as distinguished from fibromyalgia, 234
Mandibular sagittal ramus osteotomy, arthro- distinguishing features from degenerative
scopic lysis and lavage treatment, 254- arthritis, 204
255 jump sign as distinguishing characteristic,
Mandibulofacial dysostosis, 198 232
Masticatory muscle dysfunction, confusion management, 229-243
with TMJ disorder, 203-204 psychological, social, and behavioral factors,
Masticatory muscle tenderness, in MPD pa- 234-235
tients, 204 relationship with other disorders, 232-234
Masticatory myofascial pain team management, 240-241
behavioral therapy, 239-240 trigger points, 229, 230-232
management, 229-243
treatment, 235-241
Nose, growth patterns in adults, 79
treatment, occlusal appliances, 238
Nose-lip-chin relationship, and orthodontic
trigger point therapy, 238-239
treatment, 68-72
Maxillary expansion, rapid, and early mixed
dentition, 176-187
Midline springs, to shift anterior teeth laterally Occlusal appliances, treatment, MMFP, 238
for midline correction, 15-17 Occlusal factors, and TMJ pain, 259
MMFP, see Masticatory myofascial pain Oculoauriculovertebral dysostosis, 198
Molar expansion, step bend for, 43 Oculomandibulodyscephaly, 198-199
Molar/premolar extrusion, and overbite reduc- One-couple systems, 12-24
tion, 25 Optical-surface scanning, three-dimensional
Molars technique for determination of facial es-
bilateral expansion/constriction, 46-47 thetics, 94-104
constriction, 41-42 Oral esthetics, and smile line, 114-117
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Index
Subject Index 277
Orofacial areas, psychobiological significance, Paroxysmal trigeminal neuralgia, relationship

86-87 with myofascial pain, 233
Orthodontic appliance system Perception
single-bracket, 8 and facial esthetics, 82-93
two-couple, 44-54 psychological factors in, 83-84
one-couple, 12-24 Preface, 2
two-bracket, 8-11 Profile, facial
two-couple esthetics based on race, sex, and subjective
and activation in the transverse dimen- opinion, 68-72
sion, 37-43 long-term changes with growth of facial soft
torquing arches, 31-36 tissues, 72-76
two-couple intrusion arches, 25-30 and orthodontic treatment, 68-72
Orthodontic concepts, for TMD, 223-225 Profile Survey Instrument, 70, 71
Orthodontic esthetics, history of , 110-113 Psychobiology, significance of orofacial areas,
Orthodontic force systems, forces exerted by, 86-87
8-11 Psychology
Orthodontic patient, clinical diagnosis of tem- and facial esthetics, 82-93
poromandibular disorders, 197-206 studies regarding facial esthetics, 113-114
Orthodontic treatment
class II, division 1, decision analysis for op- Radiograph, transcranial, 209-210
timization, 139-148 Radiography
early, 127-194 diagnosis of temporomandibular disorders,
and harmony and growth of facial soft tis- 207-221
sue, 67-81 panoramic, 213
implications of TMD, 258-272 transmaxillary, 210-211
monitoring of growth during, 165-175 Randomized clinical trial, and understanding
use of randomized trial to understant effi- treatment efficacy, 128-138
cacy, 128-138 Rapid maxillary expansion, 176-187
Orthodontics, and facial esthetics, 65-126 Referred pain, 232
Osseous lesions, MRI diagnosis, 216 Renaissance
Osteoarthritis class II facial pattern in art of, 109
clinical features, 201 facial art in, 107-109
effect on growth of mandibular condyle, Rheumatoid arthritis
266-267 clinical features, 201
general features, 200 general features, 200
relationship with myofascial pain, 233 juvenile, 200
and TMJ, 200-201 relationship with myofascial pain, 233
Osteocalcin, correlation of measurements of and TMJ, 199-200
with somatic and facial growth, 165-175 RME, see Rapid maxillary expansion
Overbite Rotation
anterior deep, control with two-couple intru- equilibrium for, 6-7
sion arches, 25-30 first-order, of molars with partially brack-
correction, with torquing arches, 31-36 eted arch wires, 37-43
incisors, with torquing arches, 31-36
Pain maxillary molars and central incisors, and
local and referred, 232 utility arch, 61-62
masticatory myofascial, management of, mesiofacial
229-243 with asymmetrical V bends, 50
myofascial, 203-205 with symmetrical V bends, 47-48
Palatal height, and rapid maxillary expansion, mesiolingual
176-187 with asymmetrical V bends, 50-51
Panoramic radiography, 213 with symmetrical V bends, 48
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Index
278 Subject Index
third-order, 31 relationship to mandibular growth and facial

tooth movement, 3 form, 265-266
Rotational tendency, produced by a couple, and underlying more serious disorders, 265-
5-6 266
Temporomandibular disorders
determination of treatment, 225-227
Sample size, estimation for randomized clinical
etiology, 222-228
trial, 132-135
implications for facial growth and orthodon-
Scleroderma, relationship with myofascial
tic treatment, 258-272
pain, 233
nonarticular conditions that mimic, 205
Self-concept, and attractiveness, 84-85
orthodontic concepts, 223-225
Sensitivity/specificity data
radiographic diagnosis, 207-221
for comparison of diagnostic imaging for
Temporomandibular joint, 197
TMJ disorders, 208
and arthritis, 199-201
TMJ imaging validity studies, 215
avascular necrosis, 203
Sexual dimorphism
congenital anomalies, 198-199
and growth of facial soft tissues, 78-80
and developmental anomalies, 199
dimorphism, upper-lip smile, 118
disorder, confusion with masticatory muscle
Single point force, 4
dysfunction, 203-204
Single-bracket system, one couple, forces ex-
histomorphology, 262-263
erted by, 8
internal derangement of, 201-203
Single-point force, and center of resistance, 4
classification, 244-247
Sinusitis, relationship wtih myofascial pain,
management of internal derangement, 244-
233
257
Smile, upper-lip, sexual dimorphism of, 118
normal development, 261-265
Smile line
pathology, 198-203
gingival, 118-123
and aging, 123 randomized controlled clinical trial for treat-
and oral esthetics, 114-117 ment with bionators and headgear, 149-
164
Soft tissue, facial, harmony and growth in
surgical care, 250
orthodontic treatment, 67-81
Tip, rotation, 3
Space management, and early mixed denti-
tion, 177 Tipping, mesiodistal, with symmetrical V
bends, 48-49
Step bends
TMD, see Temporomandibular disorders
arch wire, 42-43
TMJ, see Temporomandibular joint
two-bracket systems, 52-53
Tomography, advantages in imaging TMJ,
Still's disease, 200
211-212
Stress, and myofascial pain, 235
Tooth
Study cohort, identification, for randomized
center of resistance, 3
clinical trial, 130-132
movement types, 3
Subluxation, relationship with myofascial pain,
Tooth movement
233
control of with orthodontic procedures, 3-11
Surgery, open joint, treatment of TMJ, 255
and force systems, 7-8
Symmetry, facial, 114
high predictability of one-couple orthodon-
tic appliances, 12
Temporal region, growth of and TMD, 266- Torque
267 facial root
Temporomandibular disease with asymmetrical V bends, 50-51
clinical diagnosis in orthodontic patient, with symmetrical V bends, 49-50
197-206 rotation, 3
and growth of TMJ, 266-269 third-order rotation, 31
<<
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Index
Subject Index 279
Torquing arches Two-couple systems

and rotation of incisors, 31-36 and activation in the transverse dimension,
and rotation of maxillary molars and central 37-43
incisors, 62 torquing arches, 31-36
TPA, see Transpalatal arch Transpalatal arches, 44-54
Transcranial radiography, 209-210
Translation, tooth movement, 3
Transmaxillary radiography, 210-211 Utility arch
Transpalatal arch, 44-54 and rotation of maxillary molar and central
activating, 45-46 incisor, 61-62
fabrication, 44-45 see Two-couple intrusion arches
Treacher Collins syndrome, 198
Treatment, selection of allocation technique V bends
for randomized clinical trial, 132-135 asymmetrical
Trigger point injection, treatment, MMFP, 239 in arch wires, 39-40
Trigger point therapy, treatment, MMFP, 238- for facial root torque, 50-51
239 for mesiofacial rotation, 50-52
Trigger points for mesiolingual rotation, 50-51
in myofascial pain, 229, 230-232 symmetrical
and poor muscle health, 235 in arch wires, 38
reducing activity with muscle exercises, 235- for facial root torque, 49-50
238 for mesiodistal tipping, 48-49
Two-bracket system for mesiofacial rotations, 47-48
two couples, forces exerted by, 8-10 for mesiolingual rotations, 48
two equal and oppositely directed couples, vertical, responses of three-dimensional arch
forces exerted by, 10 wires to, 57-63
two same direction couples, forces exerted Vapocoolant spray, and trigger point therapy,
by, 11 238-239
two unequal oppositely directed couples, Video imaging, facial, superimposition of skel-
forces exerted by, 10 etal and facial images, 72
Two-couple intrusion arches, 25-30
component parts, 27-30
fabrication, 25-26 Wilkes' Staging Classfication, internal de-
forces exerted, 26 rangement of TMJ, 246
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Vol 1, No 1 March 1995

W. B. Saunders Company • A Division of Harcourt Brace & Company

Seminars in Orthodontics (ISSN 1073-8746) is Copyright © 1995 by W.B. Saunders Company.

W.B. SAUNDERS COMPANY

Biomechanics and Appliance Design

The Ground Rules for Arch Wire Design 3

One-Couple Orthodontic Appliance Systems 12

Two-Couple Orthodontic Appliance Systems: Utility Arches 25

Two-Couple Orthodontic Appliance Systems: Torquing Arches 31

Two-Couple Orthodontic Appliance Systems: Activation in the

Two-Couple Orthodontic Appliance Systems: Transpalatal Arches 44

Creative Arch Wires and Clinical Conclusion 55

Responses of 3-Dimensional Wires to Vertical V-Bends: Comparisons with

Volume 1, Number 2, June 1995

Volume 1, Number 3, September 1995

Volume 1, Number 4, December 1995

Volume 2, Number 1, March 1996

Seminars in Orthodontics, Vol 1, No 1 (March), 1995: p 1

Seminars in Orthodontics, Vol 1, No 1 (March), 1995: p 2

The Ground Rules for Arch Wire Design

Seminars in Orthodontics, Vol 1, No 1 (March), 1995: pp 3-11

Isaacson, Lindauer, and Davidovitch

Figure 1. A force acting through the center of re-

Figure 4. Tooth rotation from a kinematic perspec-

Figure 5. A tooth that receives a force not acting

Isaacson, Lindauer, and Davidovitch

Rotation occurs when a single force does not

Isaacson, Lindauer, and Davidovitch

cussed in detail in the introduction to the sec- B

Total system for 2 couples with a V bend

10 Isaacson, Lindauer, and Davidovitch

rium forces at both brackets are also in the

One-Couple Orthodontic Appliance Systems

One-couple orthodontic appliances are capable of applying well-defined

12 Seminars in Orthodontics, Vol 1, No 1 (March), 1995: pp 12-24

Case AV (Fig 2) illustrates how a one-couple

14 Lindauer and Isaacson

16 Lindauer and Isaacson

Figure 5. Occlusal view of a spring designed to

place to minimize any unwanted molar move-

18 Lindauer and Isaacson

only at the molar so that the force system re-

Figure 8. Case JM: A midline spring is used to help

tude of this tendency can be decreased sub-

20 Lindauer and Isaacson

Figure 11. Location of the point of force application

crowns). In addition, freedom for the molar

Figure 14. Case BB: Proper case selection and acti-

22 Lindauer and Isaacson

the perpendicular distance between the vector

Anterior Extrusion Arches

ward if the whole arch wire moves forward (or

ment created by the anterior extrusive force Conclusion

24 Lindauer and Isaacson

Two-Couple Orthodontic Appliance Systems

he utility arch, as popularized by Rick- The relative contributions of incisor intru-

Seminars in Orthodontics, Vol I, No 1 (March), 1995: pp 25-30 25

26 Davidovitch and Rebellato

the point selected for the tie. This choice dic-

sial to the molar tube creating an asymmetric V

Figure 3. A utility arch fabricated of .016" x .022"

28 Davidovitch and Rebellato