MEAW (Multi-Loop Edgewise Archwire)

Multi-loop
Edgewise
Archwire
Kim Jeong- II
Orthodontic treatment with MEAW W
/,n Well Publishing

Multi-loop Edgewise Archwire
Kim Jeong-Il
~no««
Multi-loop
Edgewise
Archwire
Kim Jeong- II
Orthodontic treatment with MEAW W
/,n Well Publishing

Jara
Copyright O 2016 WELL Publishing
142-070.22, Samyang-r 118 gil, Gangbuk-gu, Seoul, Korea

T. 82.2. 907.2872 F, 82. 2. 907.2873
E. bkc905@hanmail.net
H www.well.pub.net
This book was originally published in Korea under the title of;
MAW Multi-loop Edgewise Arehwire:Oh dotic treatment with ME
AW
Kim Jeong-I, DDS, PhD
ISBN, 978.-89.97113-39.2 93510
All rights reserved No pant of this book may be reproduced in

any form without permission in writing from the publisher
A damaged book is exchanged at WELL Publishing.
Printed in Korea
••••
•
•
•
De Kim Young-Ho
This book is dedicated to the late Professor Kim Young-Ho

He introduced me to the ME
AW concept and inspired me
to do research and practice with passion as an orthodontist
5
FOREWORD
.
·..·····················:::::::::::::::::::,:""""""""'"'·······················································
. . . . . .. .. .. .
lt has been over 30 years since I started practicing as an orthodontist. Although it took a little
while for me to absorb and understand the concept of orthodontics, I still believe I am
insufficiently trained and have a long way to go. Since I started practicing, I have encountered a
number of orthodontic methods and applied such methods in clinic. However, I have been always
concerned about what the best solution and analysis would be. About 25 years ago I met the
deceased Professor Kim Young-Ho, which was a turning point in my career. He enabled me to
apply the ME AW technique to my orthodontic approaches and raised the awareness of the some of
the most important aspects of daily orthodontic clinical practice which were used to be ignored up
to that time. This has further modified my personal views of patients.
MEAW, first designed by the deceased Dr. Kim, was initially used to treat the open bite cases
only, but is now regularly applied to all kinds of malocclusion cases. In other words, MEAW had
once been regarded as a tool that could only be applied to the open bite patients or, only as a
finishing wire that could be used at the finishing stage of treatment. Nevertheless, in contemporary
AW on
orthodontics, many orthodontists as well as the general practitioners now frequently use ME
a daily basis to treat all sorts of malocclusion cases. Despite this popularity, the textbook that
formally teaches the MEAW technique has never been published in Korea. Also, the books that
were published in Japan were restricted to the non-extraction treatment method only and they did
not faithfully refleet the original concepts by Dr. Kim. As you can figure out from the book title,
this book is distinguished from the books published so far about MEAW. In this book, non-
extraction and premolar extraction cases are explained step by step according to the original
« orthodontic philosophy and treatment methods founded by the late Dr. Kim.
•
• The most important issue in orthodontic treatment is the exact understanding of malocclusion
and the diagnosis and treatment plan. Malocclusion itself cannot be treated without understanding
its specific problems and treatment strategy. Most orthodontists are aware of the usefulness of
MEAW technique, but it is notable that the ME AW technique brings about a meaningful result
only when accurate diagnosis and proper treatment are all accomplished.
6• ·------------------------�----------
••••
This book consists of three pants: Pant I Orthodontic Diagnosis, Pant II Orthodontic
Treatment, and Pant III Clinical Cases.
Pant l is based on the late Professor Kim's diagnosis method, which provided us with the
guidance about what the orthodontists should consider before the treatment. This part focuses on
causes and problems of each malocclusion. Instead of making a diagnosis just based on the visible
problems, I believe that the identification of hidden factors is crucial, as they can further provide •
•
the orthodontists with a wide range of diagnosis and treatment methods. Therefore, in this book,
the importance of cephalometric radiographic analysis, model analysis and facial aesthetic analysis
•
is emphasized. Additionally, it proposes the orthodontic differential diagnosis methods, which can
further be used both for the extraction and for the non-extraction treatments. In particular, in the
extraction treatment chapter, it explores the indications of the extraction of maxillary second
molars, the extraction of maxillary and mandibular first premolars, the extraction of maxillary first
premolars and mandibular second premolars, the extraction of incisors and the extraction of first
molars.
In pant II, the basic principles of MEAW are explained, and the use of MEAW in various
malocclusion cases is demonstrated with abundant photographs and diagrams. The details of each
procedure -brackets, bracket positioning, leveling and alignment, space closure, finishing, and
retention- are carefully explained with the answers to common concerns that frequently arise in
practicing orthodontics. However, it should be acknowledged that the methods introduced in this
book are not the eventual solution, and the further variables may arise in each different real clinical
case
In pant Ill, five different cases are explained. Case I deals with the extraction of four first
premolars, Case 2 deals with the extraction of maxillary first premolars and mandibular second
premolars, Case } explains a non-extraction treatment in Class l malocclusion and Case 4 explains
a non-extraction treatment in Class Ill malocclusion. Case S deals with the midline deviation
treatment
Again, the author would like to acknowledge that these are not the eventual solutions. l
believe that there is no absolute solution in orthodontics and the role of an orthodontist is to seek to
find a better solution for each different case. I believe that the orthodontists should never stop
learning and researching, driven by professionalism as well as by the sympathy toward his or her
patients. I would bike to remind you to regard the cases presented in this book, as an indication
only, and try to develop their own treatment method. I hope this book encourages you to think
differently when treating the common problems that you may encounter in your daily orthodontic
practices.
roe@woo+ 7
About the Author
Kim Jeong-II DDS, PhD

E mail. immeaw@gmail.com
Dr Kim Jeong-Al, DDS, PhD, currently serves as Chair in the Department of Orthodontics af
Kooalldam dental hospital in Incheon, South Korea. He is also appointed as Clinical Professor in the
Department of Orthodontics at Graduate School of Clinical Dentistry, Korea University, in Seoul, South
Korea, He is also Visiting Professor in the Department of Orthodontics at Dalian Medical University in
Dalian, China
After graduating from Dental School at Seoul National University in 1987, he completed the
orthodontic residency at Seoul National University Dental Hospital in 1990. He acquired his PhD in the
Department of Orthodontic and Dentofaeial Orthopedics at the Kanagawa Dental College in Yokosuka,
Japan, in 2006.
Dr. Kim was instructed to the ME

AW concept in orthodontics by the late Professor Kim Young-
Ho, who first invented MEAW, when he took the 2-year long MEAW course from 1993 10 1994 in
Seoul. Since then, Dr. Kim has been a clinical instructor of MEAW society and adjunet Professor at
Seoul National University. He had completed the TMJ and Occlusion related courses taught by
•
• Professor Rudolf Slavicek and Professor Sadao Sato from 2000 to 2001 in Austria, Japan and Boston.
• His specialty lies in the malocclusion treatment in consideration of TMJ function, and the main
treatment approach he advocates for this purpose is the control of occlusal plane.
8
••••
••••
•
•
•
De Kim Young-lo and Dr Km Jeong-l. 20O4
<Philosophy of Orthodontic Treatment>
The most important aspect in orthodontic treatment is accurate diagnosis and treatment planning. By
correcting the causes of malocclusion based on a comprehensive understanding of the skeletal and dental
patterns of each patient, an individualized orthodontic treatment planning should be made thoroughly.
Skeletal and denture patterns should be analyzed for accurate diagnosis. Based on accurate diagnosis,
simple but effective treatment method can be applied with the minimum need of wire bending, causing
the least discomfort to the patients. An orthodontist should be able to practice without any stress, but with
less need of orthodontic surgery or tooth extraction, as best as he or she can
Professional Memberships:
In addition to serving as an educational instructor for the Korean Academy of Orthodontics, Dr. Kim is
a board member of the Korean Academy of Orthodontics, a regular member of Korean Academy of
Stomatognathic Function and Occlusion, and an honorary president of Korea Institute for Malocclusion
Study (K1IMS)
Publications
Kim, JI.420l5). Practical Clinical Orthodontics. fart Orthodotie Treatment. 'ot Seod A'oer Well Publishing
Kim A. (209). Practical Clinical Ortlode ties. Orthodotie Dieng is. ot Seoul. Aorear. Well Publishing
at Orthodontics. Ortholotie Treatment with A4EA ot4 Seoul
Kim AI. (02. Practical Clinic 'oner. Well Publishing
9
ACKNOWLEDGEMENT
First of all, I would like to express my special gratitude to my permanent teacher and mentor, the
late Professor, Kim Young-Ho, for introducing me to the ME
AW concept in orthodontics. I was deeply
influenced by his passion as an orthodontist as well as by his professional expertise
I also would like to express my special thanks to Professor Sadao Sato, who has inspired me to do
research and practice with passion in orthodontics.
have realized how difficult it is to write a book on orthodontics in English as a nor-native English
speaker. I would like to express a tremendous degree of appreciation to all those who have made this
English publication possible. Without the help from these people, this book could not have been
published. I would like to first thank Lee Chang-Bong, my close friend, Professor of English and
Linguistics at the Catholic University of Korea, and three training dentists in Kooalldam Hospital, Dr.
Yoo So-Young, Dr. Park Sang-Eun, and Dr. Seo Won-Chae, who worked as a team to finalize the
English translation based on the first English draft. I must express my deep gratitude to Kim Sung-Kue,
my second son, and Dr. Kim Ye-Jin, who produced the first draft version of English text. My special
thanks should go to Dr. Son Eun-Jeong and Kim Jung-Hoon for their help in collecting and organizing
the data and to DT Kim Jeong-Min, the chief executive officer of Credent Laboratory, as well, for
providing the necessary equipment. Last but not least, I would like to thank Mr. Bong Gi-Chul,
President of Well Publishing for kindly agreeing to publish and to edit my book
•
• l would like to point out that some of the content in this book could be controversial and there can
• even be objections from some readers. I take this as a natural and healthy situation in the field of
orthodontics. I strongly believe that without disagreement and ongoing dialogue, we cannot continue
our path to excellence in orthodontics. All the shortcomings and errors in this book are mine
10 ••••
CONTENTS
oooo"""":::toss::;III........+.08888808000000000000..,
. . . . . . . .. . . .. . . . .. .. .•
6
PART I ORTHODONTIC DIAGNOSIS 17
Chapter 1 _ CAUSES OF ORTHODONTIC TREATMENT FAILURE.......------... 18
1. Pabems ····-----······------·····-··-··············---···· ... ..... .. _ . -··· ·······-··----····· 20

2Relationship between Orthodontist and PabenL ... • . . .. .. ···-·············---··----····· 20
3. Orthodontists....ooooooo-- ..•.......... ···-··-·······----········-···········-··· 22
Chapter 2_CAUSES OF MALOCCLUSION ..o...38
Chapter 3 _SKELETAL PATTERN ANALYSIS....om.....92
1. Vertic:al Atlalysis ·-··--······-·······················-··· ·····--·- 96

2. Horizonl!II Analysis---······----····························· -· . . . . . . .. . 100
3. Combination Factor (CF) ·-··-······· ·- ·----·················--------···· 105
4. Extraction index (El). . . --·· ...•.. ··---··· ·····--········-···········-··-------···· 113
5. Classification of Sl<elelal Pallem. ···--··········--····-·············-····-··-··-·---··----··- 114
Chapter 4_DENTURE PATTERN ANALYSIS.coo....122
1. Dentlnl Pattern Allalysis----········-··-·-·······--··----··· . .. • •............. 124

2. Ocd M Plairllt ··················-·······························-· -· -·· -·············-····- 126
3. Cha-,ges dOcd'SIII Plat1a ·········-····-················ .... •.•·• ••.••.•.•.•.•.•.•.•.•. ···-······-····· 135
corers « 11
Chapter5_ORTHODONTIC DIAGNOSIS .......---.-----.......158
1. Onhocbllic Dlflereolial Diagoosls .. ··- -··.. ····--- .. _ .... ·····- ... ·- .• --- . 160
2. � Treatment Melhod .•. ·-----··-··--······-··· ·············-- • ·--········· ·-- • 170
f)4Methods of none-etraction treatment
-----------""
3. £traction Treatment .......... . ···- -···. -· 193
1) Thi-d molarexlJlidlon_. __ ·--------··- -· -··--·-··-··-·- 19'
?t4go.a/y 9$e000 00la4 et7a4001... a...196
3)Pmmolar --·· --·-· -·· -·· ----·----·---·------""

Aeiteeeth oooooooooooooooooooooooooooooooooo
fstnoiletoooooooooooooooooooooooooooooooooooooooooooooo4
PART II ORTHODONTIC TREATMENT 259
Chapter 6 _ BRACKET SYSTEM AND BRACKET POSITIONING ...........260

1. Brackel System....... . . _ 262
1)8'adollsyslilln---··-------------·---··-·--"'
important 0onsierations tor bra.et$el0ho ..
4)packet selection for premolar era90010a0$ .coo coo.28.8

2 Posi1x::-w'lg ..•.. ····- - _ .. __ 290
l)Aconle b<llcbl ilil\j -·· _ -·-- -·---· ---·· -··--·-··-··-· 290
2Bracket positioning for individual teeth.oooooooooo36
)8rakt positioninginvaiou$0a$oooo6
• Chapter T_LEVELING AND ALIGNMENT.......346
•
• I . Basic Orthodontic Terms ·-······· .. -- .. ---··-·· .. -· _ .. _ _ __ .. _ . 348
1tevean8oooooooooooooooooooooooooooooooooooooooooooooooooooooooooob
Sirnplelevelingan1strategicievegoooooo30
R
[Cote. ._
2 Strategic Bordng.. . . .•. ·- . . ·······---···· ················-··-· 355
l)Dlfinilion ---- ----------- >M
·----··-··-·---------·--------"'
Cone6ooooooooooooooooooooooooooooooooooooooooooooooooo.,@Ge
3.Archwires for Leveling and Alignment. •• ooooooo..381 d

•
4. Strategic Leveling and Allgl11.ei '··········---··-····-··---·-··-····-········-···············-······ 385
1) Slrau,g,eslor ,..,.,..,_--■.. ----· -·-----·---- _ ao,
strategies foe premolar etrabon treatment 396
1. Space Closing Method ···············-·········--------··--···········----··-··-·····-··---····- 404

3a 0ethos0090e0.oooooooooooooooooooooooooooooooooooooooo
2) Spaoo dosrog llll!lr,d ·-·· --- -···-·-· -----·-· �,
2. Space Closing Art:hwire .•.•.•.•.•.•.•.•.•.• .•.•.•.•.• • • ·····-············· • ···-· -··············· •.• 425
3. Anchorage ··············-··········-···----··----------····-···---------·········-------· ·- 429
4.Retrusive Control in Clinical Cl.1hi.o...111CS..- •. ·······----··-·····-······-----····-·········-- 436
5. � FabricabDn for Space Closure ····-·······---------·······---------············· 445
Chapter 9_FIN ISH I N G ··-········-···-··-···-··-···-··-··-··-··-··-··-··-··-··-··-···-···-··-···- <1-66
1. Finishing Art:hwire •.• • • •. • .•.• • • • • •• __ --· • • • •.•.• •.• • • •• • • ···-- • ·- ••• 468
2. Multi-loop Edgewise Art:hwire (MEAW) .• •.•.• • • --· • • • •.•.• • •. • •• • • • •.•.•.•.•.•.•. 469
1Compositional basic lorn of4Me4..4.69
functions&mechanics oft4eAl_...47
3)instruments and materials for MEAW oo.,4
4) Fabrication of MEAW
------------------'''
fist,$e0ondaethis.oner beneieAWoo-ooooooo..48
6Coe1pet6feA/,oooooooooooooooooooooooooooooooooooooooooooooooooood9
core@rs « 13
3.Prescription of MEAW • ·····-· ···········-··-······----··--··--·············-··. ·- ..... 492
4. Basic Adjustment of MEAW ······-··· • . •• ·-·------------··--···--------·········· 500
5 Elastc'I-, MEAW ··-··-······················· •••. --· .• -·········-···········------·····--··-··· 507
6. Finishing Methods for Special Conditions......oooooooooooooooooooooooooooooooooo....519
f)EA/aligtrentlo fie 0onreion.o...519
expansion&chines in44£A/oooooo ..el

3)44£AW adjustments in the case of peg lateralis 52S
7. Orthodontic Nofrrllal Ocdi ISDl ·------······· .•... ·············-··------··-···---------· 526
Chapter 10 __RETAINERS ..........ooooooooooo.......542
1. General Types of Retainer . ......

2. Retainer for a Patient with Maxillary Anterior Crowding.oooooooooo....545
3. Retainer for a Patient with Mandibular Anterior Crowding .-oooooooooooooo.....546
4. Retainer fora Patient with Class l Malocclusion. ~oooooooooooooooooooooo..548
5. Retainer for a Patient with Class ll Malocclusion... ooooooooooooooooooooooooooo....55
6. Retainer for a Pabent With Deep Be ···----- . . . . ·-··-··-·········· 554
7Retainer for a Paben! with Open Bol& •. ·-··------········-·· • •• •• • • ·-··- • ·-··--······ 555
8. Retainer for a Patient with Posterior Cross Bite.. . . .ooooooooo....55l
9. Retainer for a Paben! Wilh Space·----············· ... ·········-··-······----··-··---··--· 559
PART Ill CLINICAL CASES 565
Chapter 11 _ A CASE OF THE MAXILLARY

AND MANDIBULAR FIRST PREMOLAR EXTRACTION........... 566
1. Case Sl.mlTIIIIY·········-···· ··-··-··-····---------················ ••.••.•.••. 568

• 2 Pre-treatment records •.•...•.•.•..•.•.•.• •·••••• ·-··---. ·····-------·····-··-----····-······ 568
• 3. Diagnosis and treatment plarring. ······-··. ·-- •• - . ··-··---····--·····---------······ 571

• 4. Treatment pocedi lre9 ······-·············--··-················ •••.••.• ·······-··-··------·--··-····· sn
5. Posl-treatment records·······------··--------················ ······--·· .. ·-···········-----· 578
+ corers
Chapter 12 _A CASE OF THE MAXILLARY FIRST PREMOLAR
AND MANDIBULAR SECOND PREMOLAR EXTRACTION............ 584
1. Ca5e $Ul1"fflilly ..... , • • • • •.• .. •.•.•. . ..... - .•.•.• ·-····················· .. ···························- 586
2. Pre-treatmen\rec0fds.......... • • .. .. . 586
•
3. Diagnosis and treatment plarri,g . ··-· ··--············· 589 •
4. Treatment pocecll"8S ··································--------·············--··---···········-······-- 590 •
5. Pos!-trealmenl rec0fds ·-······-··-····-·········-····----···-··············· 594
Chapter 13 _A NON-EXTRACTION TREATMENT CASE

IN CLASS Il MALOCCLUSION.....oooooooooooooooooooooooooooooooooooooooooo...600
1. Ca5e so..mma,y ·-····· 602

2. Pnl-tr8a1ment rec0fds -- -- .. ··-··········· ··--··-·····-····---··-- 602
3. Diagnosis and treatment plarring - ·---····- .. -·-········ .. 606
4 Treatment poeedure$ - - - - 607
5. Pos!.trealmenl rec0fds . . . . . . .. __ 610
Chapter 14_A NON-EXTRACTION TREATMENT CASE

IN CLASS Ill MALOCCLUSION.....coo.....616
1. Case summary.... . .. , ······-···········- ·-············· 618

2. Pre-treatment records.... ... --·· . .• . - 618
3. Diagnosis and lrealmenl plarri,g -·· ,. . •• ·---· - .. 622
4. Treatment pocedo lf9S .• -.... ••.•. .•. .•.•.•.•.•.• •.•.• • • • •.• • •••••••••••••• .. 622
5.Post-treatment records ······•·•· .. •···•·•···•·· , 626
Chapter 15 _ A NON-EXTRACTION TREATMENT CASE OF MIOLINE DEVIATION.... 634
1. Case surrrnary. . -- .. ········· .. -··--- _. 636

2. Pre-treatment records - _. 636
3. Diagnosis and treatmen1 plarri,g •·•·•·•·•· •···· . . . 639
4. Treatment pocedo n,s --············· 640
5.Post-treatment records.................................................. . . .•.... 643
corers «« 15
PARTI
ORTHODONTIC DIAGNOSIS
••••
. .
. . . . .. .
...........
Chapter 1_
CAUSES OF
ORTHODONTIC
TREATMENT FAILURE
There are a number of factors that can negatively impaet the finishing procedures of an orthodontic
treatment and its stability, The main causes can be categorized under the following:
) Patients,
2)Relationship between orthodontist and patient,
3) Orthodontists.
D Patients
The majority of orthodontic treatment failures have been caused by a lack of patient compliance.
)Cases where patients fail to visit their clinic on a regular basis.

2)Cases where patients do not wear their orthodontic appliance
)Cases where patients do not use the elastics.
4)Cases where patients have poor oral hygiene.
�
Relationship between Orthodontist and Patient
To obtain the best orthodontic treatment results, it is essential to maintain a good relationship
• between an orthodontist and patient
• Depending on the state of the relationship, the effectiveness and outcome of the orthodontic
• treatment may vary, If they sustain a positive relationship, the orthodontic treatment becomes more
effective and leads to a more positive outcome. In contrast, if they have a negative relationship, the
procedure tends to become far more complicated.
If they have a poor relationship, the orthodontist may focus only on the process of teeth alignment
On the other hand, an orthodontist with a good doctor-patient relationship will have greater
sympathy towards his/her patient who is suffering from malocclusion. Subsequently, they will
••••
••••
listen more carefully to the complaints of the patients, and/or the parents of patients, and come up
with the best treatment procedures
To conclude, keeping a positive orthodontist-patient relationship will prevent problems arising
from the lack of understanding between them and lead to better patient compliance. It is essential
her patients based not only on their teeth alignment but also on
for an orthodontist to diagnose his
•
chief complaints and the type of malocclusion that they are suffering from. In the case of any
•
potentially unsatisfactory results, an orthodontist should try to always provide sufficient •
information to his/her patients, which enlightens them about the limitations of the orthodontic
treatment.
0-lnical
Tlps: limitations of orthodontic treatment
1. Periodontal ligament cells are the main cause of tooth movement. The ankylosis
teeth, which are missing a periodontal ligament, will soon face a restriction in
movement
2. Tooth movement frequently occurs within the alveolar bone (Fig. 1-1)
1)in particular, when patients have a thin cortical bone in the anterior alveolar
area, there may be root resorption as well as dehisence and/or fenestration
on the buccal surface
2) The skeletal structure (retruded chin and prominent mandibular angle also
commonly known as square jaw) cannot be rectified by an orthodontic
treatment
3)Usually, the antero-posterior and vertical movements are made
simultaneously.
►►►►►
f
Fig.1.f Radiographs that demonstrate a variety of premaxilla and symphysis thicknesses

A. Patient who has thin premaxilla
B. Patient who has thin symphysis
CA diagram that shows a thin premaxilla or symphysis
D. Patient who has thick premaxilla
E. Patient who has thick symphysis.
F.A diagram that shows a thick premaxilla or symphysis.
� Orthodontists
•
• Orthodontist must make an evidence-based orthodontic diagnosis and treatment plan. If a diagnosis
• is made based on the practitioner's personal convenience, it may lead to an inaccurate diagnosis. In
addition, this may pose some difficulties in the finishing procedures, consequently leading to an
unaesthetic facial profile or temporomandibular joint disorder.
Even monozrygotie twins do not have identical dentition, facial profiles and skeletal patterns (Fig
1-2). For this reason, it is important to understand the patients' individual problems and make an
accurate diagnosis, followed by a logical treatment plan, To do so, an orthodontist must carefully
••••
••••
analyze the patient's skeletal pattern, denture pattern, personal physiological factors and facial
type. The majority of orthodontists pay too much attention to their patients' current conditions
when diagnosing (Fig. 1-3). As a result, they often fail to notice the real causes of anterior
crowding, protrusion of maxillary anterior teeth, mandibular prognathism, anterior open bite, deep
bite and midline deviation. Instead of focusing on the visible problems, it is far more important to
•
examine the real causes of malocclusion when treating patients. If orthodontists understand the
•
main causes, it will then minimize the risk of treatment failure and a need for extraction and •
orthognathie surgery treatment
Treatment failure may be caused by the following reasons:

) Diagnosis Problems,
2) Treatment Problems,
3) Retention Problems.
Fig. 1-2Facial and intraoral photographs and radiographs of mono2zygotic twins

A. Facial and intraoral photographs and radio0graphs of older sister
»» Fe. 1-2 (cont fact
ana""""""ohs ad morons ot mnonoyootc
B.Facial and intraoral photographs and radiographs of younger sister,
Athough they are twins, dissimilar skeletal patterns, facial profiles and denture patterns are observed
•
•
•
• •••
••••
•
•
•
Fig. 13Avariety of malocclusion

It is crucial to understand various patterns of malocclusion. anterior crowding, protrusion of maxillary
anterior teeth, mandibular prognathismn, anterior open bite, deep bite and midline deviation
A. Anterior crowding. B Class l malocclusion. C. Class Ill malocclusion
D. Open bite. E Deep bite. f AMiline deviation
b Diagnosis Problems (Fig. 1-4)
Lack of uniformity in diagnosis methods, insufficient understanding of skeletal patterns, and

limited understanding of denture patterns are often regarded as the causes of treatment failure. In
particular, the limited understanding of antero-posterior analysis and vertical analysis of skeletal
patterns can cause inaccurate analysis results. In denture pattern analysis, result-based analysis can
also lead to errors
Fig. 1+4A variety of orthodontic diagnosis methods
•
•
•
A Pre.treatment facial and intraoral photographs
• •••
••••
Fig. 14 (continued) A variety of orthodontic diagnosis methods
•
•
•
B. Post-treatment facial and intraoral photographs
wdaalysis FA A PA
dealt ) 25 65 90
Present() 24 47 109
Desired( ) 25 66 90
Correction factor in0degrees 19
Correction factor(men ten/252 15
DiopaoyMente art)(rnmn f
Curve of soee rel 2
Total arch length need(rd 18
tr case
.. 15
Total net tolong era0hon 3
C Tweed analysis even after the extraction of the premolars, there is an insufficient amount of space
Fig.1.d (continued) A variety of orthodontic diagnosis methods
Steine etereo 0om Loach • .
82 83
3%AN8
80
2
78
5
Discrepancy
Expansion '
$ND 76077 75
U1 to 4 1 Curve o Soee 2
U to NA 22 Rei at0L 16
L1to N8 4 12
L1to N8 25 38 Relocation LS 0
to N8 not blishef 0 Lfspaoe 0
&L1to 24
A 131 ' 105 intern ary •
sr 4 16 Dtraction 15 5
GoGn to $N 32 30
Total net 15 28
Arch length
'
D. Steiner analysis; more space is needed with the use of headgear after the premolar extraction
CHARTING THE ANCHORAGE PROBLEM • .

1 Depth of curve of Spee i mm(J 2
2MM die0rep800y()0r9000e (+)in lower arC' f
3.MM to uprigt T SUBTRACT GOAL FROM PROBLEM AND MALY 2 6
4 Aid Line2and Line 3, Divide by 6 tor molar anchorage loss whe retracing 3/3(4 3
5ANB change f/men per degree tor regular anchorage (
mm per degree or aor an0orage(l
R
45
•
3
6 4Mandibular plane8' hie(11,8" lo(41) (Now see directions A
7Use palatal bar (+1)used at0at 000yr 1
8 Deley era8onot 4[4untd ready to retract upper anteriors (+1)
9traction values (See Direction B") 15 ' 3
10 See Direction C' 17 28
1 See Direction D f
12Ue Cassi elastics (+1) per month tor number ot months NET
gore4negative (See note 1below •
13Llse high-pull headgear (+1)per six months 64 10-12h0rs de. Wee
2
(see chapter onh gr Number 12 pl Mrber 13 shod 0el ET
war trd motors tortore with distal tie ot7laetf
• Net.0he6eke8l8
E.Level Anchorage System analysis after premolar extraction, the patients must use Class Ill
elastics for 9 months and headgear for one year.
[t}Captor'Ca of Oodons Poet are

••••
••••
Fig. 1-4 (continued) A variety of orthodontic diagnosis methods
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F. MEAW analysis and the intraoral photographs of treatment procedure: After examining the ME AW
analysis and the values of ODI, AD and CF, the maxillary first premolars and mandibular second
premolars were extracted. in this case, neither the mini-implant nor extra-oral appliance was used
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�
Treatment Problems
Treatment failure may also occur from the enforced use of extraction treatment arising from a lack
of understanding of proper non-extraction treatment methods. In the case of premolar extraction
treatments, the SWA bracket is (especially on maxillary anterior teeth) highly effective
Typically, in the case of non-extraction treatments, the $WA bracket can aggravate the labioversion
of maxillary anterior teeth, which will subsequently increase the likelihood of using an extraction
treatment. Also, the tendency to conduct treatments without correcting the mesial angulation of
posterior teeth has been gradually increasing among orthodontists. If these factors are not taken
into account (especially when there is a severe curve of Spee), labioversion of mandibular anterior
teeth may also occur to increase the possibility of premolar extraction treatment
The relevant factors are as following:

(I)Limited understanding of orthodontic bracket (Fig. I-5),
(2) Failure of terminal molar adjustment (Fig. 1-6),
(3) Failure of severe curve of Spee adjustment (Fig. 1-7),
(4) Failure of severe curve of Wilson (Fig. 1-7),
(5)Limitations in non-extraction treatment approach (Fig. I-8)
.,, HH K
•
Fig.1-5Limited understanding
of orthodontic bracket
A Tooth movement patterns
A when the standard bracket
z 2 2 2 is used (black line)
• B. Tooth movement patterns

when the SWA bracket is
used (red line)
C. Comparisons between the
• standard bracket and the SWA
• bracket when compared
• 8 with standard bracket (black
line), the SWA bracket(red
line) has a greater crown
lingual torque and mesial
angulation
Cl
[f»Cort_Ca of Orthodontic feet far

••••
••••
•
•
•
Fig.1.6Failure of terminal molar adjustment

lf terminal molars are ignored, anterior teeth are likely to face the labial torque. Although the mandibular
extraction space is closed, it still has the Class ll canine relationship
A. Simple leveling
B. Case of simple leveling treatment
Fig.1.7.Failure of severe curve of Spee and curve of Wilson adjustment
A +8 C
I
• •
•
• Fig. 1.8Limitations in nor-extraction treatment approach
• However, because of simple leveling and open coil springs, labioversion of the maxillary anterior teeth
may be aggravated when the $WA bracket is placed on every tooth
A. Tooth movement patterns of the standard bracket (black line) and the SWA bracket (red line)
8 Standard bracket + archwire with crown lingual torque + open coil springs
C. SWA bracket + preformed archwire + open coil springs
• •••
••••
�
Retainer Problems
After receiving treatment, all patients are advised to wear a retainer to maximize their treatment
results and to diminish the factors of malocclusion risk. The required retainer may vary depending
•
on the type of malocclusion; the individualized retainer appliance must be appropriately used •
based on each malocclusion case •
• To minimize treatment failures, the followings are important
When treating malocclusion, it is essential to understand the concept of malocclusion itself. In

other words, orthodontists must identify the problems arising from each malocclusion and
make an accurate treatment plan for a successful treatment result. To do this, orthodontists
must always consider and understand the invisible as well as the visible problems.
When treating malocclusion, it is essential to identify the causes, to eliminate the etiological
factors, and to establish treatment methods.
For example, in the case of the visible Class I molar relationship, the final diagnosis can vary
after careful consideration of the skeletal pattern. In Class II skeletal pattern, it is
understandable to have a Class ll molar relationship, or even a Class I molar relationship,
depending on the posterior movement of maxillary molar or the anterior movement of
mandibular molar. However, in this case, if only the molar relationship is taken into account,
further problems may arise (Fig. 1-9)
Therefore, for a successful or positive treatment result, instead of a routine extraction treatment
method or a routine treatment planning. an individualized treatment must be performed.
Fig.1.9 Skeletal pattern and molar relationship.
A. Photographs of a patient who has Class ll skeletal pattern and Class I molar relationship.
•
•
•
• •••
••••
Fig. 1-9 (continued) Skeletal pattern and molar relationship
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relationship relationship
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upper molars), Class l molar relationship may be observed in Class ll skeletal pattern. As a result, there
is a change in posterior occlusal plane
B-1.Class ll skeletal pattern and Class ll molar relationship.
B-2. Class ll skeletal pattern and Class I molar relationship
Char'Ca of Oroo Teet fare L'

REFERENCES
f. Andrews LF, Straight wire, the concept and appliance, San Diego: LA Wells 1986
2. AndrewsLF, The six keys to normal occlusion, Am J Orthod 62.296-309, 1972
3. Ament GW, and McLaughlin RP,Facial and Dental Planning tor Orthodontists and Oral Surgeons
Mosby, 2004
4. Beckwith FR Ackerman R.J, Cobb CAM, and Tira DE. An evaluation of factors affecting duration of
orthodontic treatment. Am J Orthod Dentofaial Orthop 115439-47, 1999.
5. Bishara SE, Hoppens BJ, Jakobsen JR, Kohout,F. Jet al. Changes in the molar relationship between
the deciduous and permanent dentitions: a longitudinal study. Amn J Orthod Dentofacial Orth0p 93.19-
28, 1988
6. Blake M, and Bibby K. Retention and stability: A reviews of the literature. Am J Orthod Dentofac
0rthop 114.299-306, 1998
7. Burstone CJ. Lip posture and its significance in treatment planning. An J Orth0d 53.262, 1967
8. Creekmore TD. Inhibition or stimulation of the vertical growth of the facial complex. its significance to
treatment. Angle Orthod 37285-97, 1967.
9. Daskalogiannakis J, and Ammann, A. Glossary of orthodontic terms, Quint¢ ssence, 2000.
10. Dougherty HL The effect of mechanical forces upon the mandibular buccal segments during
orthodontic treatment. Am J Orthod 54.29-49, 1968.
f. Epker BN an O' Ryann F,Determinants of Class ll dentofacial morphology I A bi0mechanical
theory. In McNamara JA Jr (ed). The effect of surgical intervention on craniolacial growth. Monograph
No. 12, Craniofacial Growth Series. Ann Arbor. Center for Human Growth and Development,
University of Michigan, 1982.169-205
12 Fields HW, and Proffit WR Facial pattern differences in long faced children and adults. Amn J Orhod
85.217-23, 1984.
13. Fushima K, Kitamura Y, Mita H, et al. Significance of the cant of occlusal plane in Class [I division f
malocclusion. Europ J Orthodont 18.27-40, 1996.
14. Giannelly A One-phase versus two-phase treatment. Am J Orth0d 108-556-559, 1995.
15 Graber TM, Rakosi T, and Petrovic AG. Dentofacial Orthopedics with functional appliance, 2nd
• edition, Mosby, 1997.
• 16 Kim JI, AKimoto S, Shinj H, and Sato S. Importance of vertical dimension and cant of occlusal plane in
• craniofacial development. int J Stomatol Occlusion Med 2114-121,2009
17 Kim JI. Practical Clinical Orthodontics. vol1, Orthodontic treatment with EAW. Well publishing Inc,
2012
18 Kim JI. Practical Clinical Orthodontics. vol 2. Orthodontic Diagnosis. Well publishing Inc, 201.3.
19 Kim JI. Practical Clinical Orthodontics vol3. Early orthodontic treatment. Welt publishing Inc, 2015
••••
••••
20. Kim YH and Vietas JJ. Anteropostenior Dysplasia indicator. An adjunct to cephalometric differential
diagnosis. Am J Orto. 73-619-633. 1978
21. Kim YH. A Comparative cephalometnic study on Class It Division 1 non-extraction and extraction
cases. Angle Orthod. 49.77-84. 1979. •
22. Kim YH Common undesirable side effects of straight archwire technic. int J MEAW185-104, 1994 •
23. Kim YH. Overbite Depth indicator with particular reference to anterior open bite. Am J Orthod. 65586. •
611. 1974
24. Lobb WK. Craniofacial morphology and occlusal variation in monozygous and diygous twins. Angle
0rthod 57-219-233, 1987.
25. McNamara JA Jr, and Brudon WL. Orthodontics and Dentofacial Orthopedics. Needham Press, 2001.
26. Merrifield LL Dimensions of the denture: back to the basics. Am J Orthod Dentolac Orthop 106535-
542, 1994.
27 Moyers RE. Handbook of orthodontics. Chicago: Year-book Medical Publisher,1 988.
28. Nahoum HI, Horowitz SL, and Benedicto EA. Varieties of anterior openbite. Amn J Orth0d 61486.92
1972
29. Proffit WR. Contemporary orthodontics, St Louis CV Mosby company, 1986.
30. Ricketts RM. The influence of orthodontic treatment on facial growth and development. Amn J Orhod
30.103-31, 1960.
31. Root TL.Level anchorage system. Koonija Publishing inc, 1994
32 Sato S. Alteration of occlusal plane due to posterior discrepancy related the development of
malocclusion-Introduction of denture frare analysis. Bulletin of Kanagawa Dental College 15 115-
123, 1987
33. Sat0 S. Orthodontic therapy with multiloop edgewise archwire (Il). Shinhung international Inc, 2006
34. Steiner CC. Cephalometrios for you and me. Am J Orthod 39.729-755, 1953
35. Steiner CC. Cephalometrios in clinical practice. Angle Orthod 29.8-29. 1959.
36. Steiner CC The use of cephalometrics as an aid to planning and assessing orthodontic treatment
Report of a case. Am J Orth0d 46.721-735, 1960
37 Tweed CH. Clinical orthodontics, Mosby, St.Louis, 1966
38. Tweed CH. The Frankfort-mandibular incisor angle (FLA) in orthodontic diagnosis, treatment
planning, and prognosis. Am J 0rod 32175-230, 1946.
39. Tweed CH. The Frankfort-mandibular plane angle in orthodontic diagnosis, classification, treatment
planning, and prognosis. Angle Orthod 24121-169, 1954
40. Vaden JL, Dale JG, and Klontz HK. The Tweed Merrifield edgewise appliance. In Graber TM,
Vanarsdall RL, Vig KWL, editors. Orthodontics current principles and techniques, 4th edition, Elsevier
Mosby. 2005.
••••
········· ········
.. . . .
··········
Chapter 2_
CAUSES OF
MALOCCLUSION
D Skeletal Factors (Fig. 2-1)
I) Antero-posterior skeletal relationship: This relationship shows antero-posterior relationship

between maxilla and mandible. A relatively good antero-posterior relationship is known as a
skeletal Class I relationship. In the case of maxillary protrusion or mandibular retrusion, this is
regarded as skeletal Class I relationship. In a reverse case, this is regarded as skeletal Class Ill
relationship. Here, it is important to note that the antero-posterior skeletal relationship may not
be in line with first molar relationship
2) Vertical skeletal relationship: This relationship shows the vertical relationship between maxilla
and mandible. The vertical relationship, which indicates the excessive anterior dimension and
the shortage of posterior dimension, is known as open bite or high angle skeletal pattemn. In
contrast, the excessive posterior dimension and the shortage of anterior dimension is called
deep bite or low angle skeletal patter. In this case, the vertical relationship and the anterior
teeth relationship may also not be in line with each other.
3) Posterior vertical dimension (Fig. 2-2. As shown in Fig. 2-2, this indicates the height of the
posterior region between maxilla and mandible. It is possible to divide the cases into two
categories: (I) sufficient posterior vertical dimension, and (2) insufficient posterior vertical
dimension. The posterior vertical dimension is measured by the length of the perpendicular line
from PNS (posterior nasal spine) to mandibular plane (usually about 43mm). Even if the CF
(combination factor) value is equal, a clear distinction must be made between the case where
there is small posterior vertical dimension and the case where there is large posterior vertical
dimension.
4) Differences between left and right posterior vertical dimension (Fig. 2-3 The patients who
suffer from midline deviation and facial asymmetry are also likely to have different left and
right posterior vertical dimensions with different ramus heights and inclinations. Therefore, it
is essential to measure and evaluate these values.
• = To sum up, vertical relationship can exert a significant influence on the antero-posterior
•
• relationship, as well as the transverse problems.
• •••
••••
.. , A.2
•
•
•
Fig.21 Skeletal factors
A. Antero-posterior skeletal
relationship
A-1. Class Il
A-2. Class l
A-3. Class Ill
B Vertical skeletal relationship

B-1. High angle skeletal
pattern
B2Low angle skeletal
pattern
.•
A.•
C
A s
r"-------�
Fig.22Posterior vertical dimension (Pyp

A. Assessment method of posterior vertical dimension take a perpendicular line frgen NS t0 mandibular
plane
B. Cephalometric radiograph of a patient with sufficient posterior vertical dimension
C. Cephalometnic radiograph of a patient with insufficient posterior vertical dimension
he2Ca of .coo0co «
Fig.23 The difference between left and night side of posterior vertical dimension
A.Acase where there is no difference between the left and night posterior vertical dimension
B Acase where there is a difference between the left and night posterior vertical dimension
� Dental Factors
'9 Number of teeth
Abnormalities in the number of teeth can be caused by either congenital missing teeth or
supernumerary teeth
) Congenital missing teeth can cause a variety of malocclusion problems. The most common
sites are as follows
(I) Mandibular second premolar,
(2) Mandibular anterior teeth (one or two),
• (3) Maxillary second premolar,

• (4)Maxillary lateral incisor.
•
2) Supernumerary teeth Depending on the positions of supernumerary teeth, they can cause a
variety of problems. If a supernumerary tooth is located between the maxillary central incisors,
it is closely related to diastema. In contrast, if supernumerary teeth are placed at the molar and
premolar sites, they have a relatively low correlation with malocclusion
[»cer2_Ca of ole ion

••••
••••
Fig. 24 Congenital missing teeth
A. Missing one mandibular second premolar
•
•
•
B. Missing one mandibular incisor
B.1»
82%
C Missing maxillary second premolars
Cf
c-2»
Fig.24 (continued) Congenital missing teeth
D 4Missing maxillary lateral incisors
• Ee.Multiple missing teeth
Ceo2Ca of.loo0.on
••••
••••
•
•
•
Fig. 2- Supernumerary teeth

A. Between the maxillary central incisors A1 mnpacted supernumerary tooth
A-2 Erupted supernumerary tooth
B. Elsewhere. B-1. Mallary lateral incisor region
B2 4Mandibular canine region
B.3 Para.molar or supernumerary tooth
•• 45
�
Size of teeth
1) Tooth size (Fig. 2-6)
ln general, there is a low correlation between the mesio-distal width of crown and malocclusion
For Koreans, the average mesio-distal width of maxillary central incisor is 8.5mm (male 8.55mm
(±045), female 8.I9mm (0.44)). Here, the size of the maxillary central incisor tends to have a
high correlation with the size of other teeth In particular, when it is larger than the average size
(over 9.0mm), it is highly likely that the rest of the teeth are much larger too. In this case,
crowding may arise from the discrepancy between the tooth size and jaw size. This means that if
the tooth size is relatively smaller than the jaw size, space will be ensured
Fig.26 Tooth size.

A Case where there is a normal size (maxillary central incisor width is 8.6men)
B. Case where there is a larger size (maxillary central incisor width is 9.5mm)
C. Case where there is a smaller size (maxillary central incisor width is 7.5mm).
2) Tooth size discrepancy (Fig. 2-7)

•
•
• By comparing the discrepaney between the maxillary and mandibular tooth size, it is possible to
check whether there is occlusion, overbite, and overjet after the orthodontic treatment. This can be
done by measuring the sum of the mesio-distal width of six mandibular anterior teeth and
comparing them with the sum of the mesio-distal width of six maxillary anterior teeth. The
equation is (sum of mandibular 6/ sum of maxillary 6) x 100. This value is known as the ABR
(Anterior Bolton Ratio). The value is usually 77.2%(±1.65).
• •••
••••
•
•
•
Fig.27Tooth size discrepancy (ABR 79.3%)
(1)In cases where ABR is higher than 77.2% (Fig. 2-8), the following can
occur:
a. Mandibular anterior crowding,

b. Maxillary anterior space: when there is a small maxillary lateral incisor,
e. Shallow overbite and overjet.
In addition, as the patterns of malocclusion unfold, the following can occur.

a) In the case of Class I malocclusion; maxillary anterior space or mandibular anterior
crowding can be observed
b) In the case of Class II malocclusion: Mesial angulation of the maxillary canine can
cause Class Il canine relationship. This will aggravate the problem of Class IE
malocclusion.
e) In the case of Class Ill malocclusion: Shallow overbite and overjet can cause a forward
movement of the mandible. This can also aggravate the problem of anterior cross bite.
Coe?_Ca of Mocco «
Fig.28 Tooth size discrepancy (ABR > 77.2%).
A.Class I malocclusion maxillary anterior space or mandibular anterior crowding ca be observed
B.Class ll malocclusion the mesial angulation of maxillary canine can cause Class ll canine relationship,
which can aggravate the problem of Class ll malocclusion
C Class Ill malocclusion: shallow overbite and overjet can cause a forward movement of mandible
which can aggravate the problem of anterior cross bite
(2) In cases where ABR is lower than 77.2% (Fig. 2-9), the following can
occur:
a. Maxillary anterior crowding,

b. Mandibular anterior space,
e. Excessive overbite and overjet.
•
•
•
Fig. 29Tooth size discrepancy (ABR «772%
••••
••••
�
Shape of Teeth
1) Abnormalities in tooth morphology (Fig. 2-10)
•
Abnormal tooth morphology can also cause malocclusion. More specifically, when there is an
•
abnormal maxillary lateral incisor, or when the mandibular second premolars or the mandibular •
fusion teeth show a morphological problem, a variety of problems may occur during the final stage
of treatment or even during the retention period
Fig. 2-10 Abnormalities in

tooth morphology
A Abnormal crown morphology
of the maolary lateral in0is0rs
B. Mandibular fusion teeth
C. Abnormal crown morphology
of the mandibular second
premolars
Cap2_Ca of Micco « @
2) Shovel teeth (Fig. 2-11)
The shape of maxillary anterior lingual surface is diverse, Amongst Asians, it is common to have
prominent marginal ridge at the anterior lingual surface. This is known as shovel teeth, and since it
is difficult to establish a correct overbite and overjet, it may cause an opposing mandibular anterior
teeth crowding, labioversion of maxillary anterior teeth, and the detachment of fixed retainer.
• Fig.244Tooth morphology
• A. Lingual surface of normal anterior teeth
• B. Shovel tooth.
C. Maxillary incisor and lateral incisor with different labio-lingual thickness
D Diagram of maxillary and mandibular anterior crowding when there is a shovel tooth
D-1. Diagram of a normal lingual surface of anterior teeth
D2. Diagram of shovel teeth During treatment or in the final stage of treatment,
it is necessary to grind the lingual surfaces of the maxillary anterior teeth
••••
••••
3) Crown shape (Fig. 2-12)
Anterior tooth morphology has an influence on aesthetics. When the face is seen from a frontal
view, the crown shape is observed. In general, these are square, triangular, barrel or ovoid shapes.
In the case of triangular shapes, black triangles are highly likely to appear, while in the case of
•
barrel shapes, space can be identified around the incisal edge after treatment.
•
•
Fig.212Crown shape
A. Square shape
B. Ovoid shape.
C. Barrel shape
D. Triangular shape
Chge2Ca of Moccio ««]

'b Position of teeth (Ideal arch form or first-order bends)
1) Mesial rotation and/or positional deviation of molars (Fig. 2-13)
The buccal surfaces of the maxillary left and right first molars must be parallel to one another. If
there is a decrease in dental arch length, buccal cusps will mesially rotate on the axis of the palatal
root of the maxillary first molar. As a result, this movement will shorten the dental arch length and
mesially rotate the entire lateral teeth. However, by correcting the mesially rotated maxillary first
molar in the parallel direction, it is possible to I) gain space and 2) correct the dental arch shape.
Fig.213Position of teeth
•
•
•
G]
A.Case where there is a parallel rotation of maxillary first molars
8 Case where there is a mesial rotation of maxillary first molars.
C Mesial rotation vs parallel rotation mesially rotated teeth can gain
space trough parallel rotation
• •••
••••
Fig.2-13(continued) Position of teeth
•
•
D» •
r»
D.Case where there is no positional deviation
E.Case where there is positional deviation of maxillary first molar
F Case where there is positional deviation of mandibular first molar
9inical
Tips: Positional deviation
Measure the distances from the end of the diagnostic model to the mesio-bucccal
cusp of the first molar and compare the ones between the left and right $le.
Caci2_Ca of .eccl ««[

2) Transpalatal width (TPW) (Fig. 2-14)
Maxillary transpalatal width. This indicates the shortest distance from the left-to-right palatal
gingival margin of the maxillary first molars. 35.3mm is the average distance for European-
Americans (Moyers et al., 1976), but if this is less than 3Imm after the maxillary first molar
eruption, the teeth may not reach normal size, as explained in Table 2-14 C (Moyers et al,, I976)
In this case, because of an insufficient transverse growth of the dental arch, the dental arch itself is
expected to be protruded and be in a tapered arch form. Therefore, it is extremely important to
expand the maxillary first molar area and modify the dental arch form
Fig.2441Pw(teanspalatal width).
C
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A Tw measuring method
B. 1PW value change according to growth (Moyers et al., 1976)
C.Longitudinal changes according to various TPW (Moyers et al,, 1976)
D. Transition of arch form based on the changes in 1PW
on
[» Choir? Ca of Malo
••••
••••
Fig. 214 (continue@dy 1pw (Transpalatal width).
•
•
•
E Facial and intraoral photographs of a patient with sma Pw(29.2mm)
e \ - I
F.Facial and intraoral photographs of a patient with normal TPW (35.5men)
Cho2 Ca of Melecio « Do
3) Inter-canine width (1CW) (Fig. 2-15)
The inter-canine width indicates the distance from one side of the maxillary canine cusp tip to the
other. If the inter-canine width is small, the width between mandibular canines tends to be small,
too. This small width may then cause anterior crowding and restrict the mandibular forward
movement. As a result, Class II malocclusion may occur
Fig.215lter-canine Width (Cw)
34.07mm
U:
±190
25.,87mm
L:
±180
75.7%
(Chang et al., 1991)
A. Measuring method of inter-canine with and its normal value
•
•
•
B. Facial and intraoral photographs of a patient with small ICW (30nm).
- ••••
••••
Fig.215(continued) inter-canine Width (ICW).
•
•
•
C. Facial and intraoral photographs of a patient with normal 1CW (35.5mm)
4) Symmetry of maxillary canines (Fig. 2-16)
The position of maxillary canines must maintain their bilateral symmetry. If a maxillary canine is
asymmetrically located, mandibular shift or tooth movement may occur to achieve its canine
guidance
5) Positional deviation can be caused by prolonged retention of primary

teeth or premature exfoliation
In order to establish proper occlusion, maxillary and mandibular dentition must be arranged
without crowding. However, if occlusion is not proper, it may cause attrition, tooth displacement or
mandibular displacement.
Chat2Ca of Mocco «[
It is extremely important to check the changes in tooth position, especially when there are (Fig. 2-
17)
(D positional deviation caused by premature exfoliation, and
( positional deviation caused by prolonged retention of primary teeth
Fig.216 Symmetry of maxillary canines
A.Case where the maxillary canines are symmetrically positioned
•
•
•
B.Case where the maxillary canines are not symmetrically positioned
• •••
••••
fig.217Case where there are a variety of tooth malpositions
•
•
•
A Case with premature efoliation of primary teeth premature efoliation of the maxillary second primary
molars has caused 1) a space deficiency problem in the maxillary second premolars, and 2) anterior
cross bite.
B. Case with prolonged retention of a primary tooth. prolonged retention of a mandibular night primary
canine has caused 1) mandibular anterior crowding. 2) midline deviation, and 3) edge-to-edge bite
�
Mesio-distal angulation of teeth (tip-back bends or second-order bends)
In general, the main causes of open bite are extrusion of posterior teeth and intrusion of anterior
teeth. In contrast, the main causes of deep bite are intrusion of posterior teeth and extrusion of
anterior teeth. Here, depending on the vertical position of anterior and posterior teeth,
malocclusion may occur (Fig. 2-18).
Fig. 218 Vertical position of

teeth
A. Open bite and extrusion of
posterior teeth
8. Open bite and intrusion of
anterior teeth
C. Deep bite and intrusion of
posterior teeth
D. Deep bite and extrusion of
anterior teeth
•
•
•
''L-------------------"
••••
••••
Kim et al, (2009) argued that over-eruption of mandibular posterior teeth is apparent in Class IE
malocclusion in the early stages of mixed dentition periods (Hellman dental age IlIB). They also
argued that there might be an over-eruption of maxillary posterior teeth in Class Ill malocclusion
in the completion stage of permanent dentition. Their findings show that in Class II malocclusion,
steep posterior occlusal plane (POP) is apparent, while in Class Ill malocclusion, flat POP is
•
apparent. Additionally, they observed that in Class II malocclusion, there is insufficient posterior
•
vertical dimension, and in Class Ill malocclusion, there is sufficient posterior vertical dimension. •
The posterior occlusal plane (POP) is a line that connects the cusp tip of mandibular second
premolar to the disto-buccal cusp tip of the mandibular second molar. It is important to note here
that a posterior occlusal plane may vary depending on the vertical position of teeth and the mesio-
distal angulation of teeth.
The following demonstrates the factors which may influence the POP in the sagittal plane:
(I) Vertical height difference in posterior teeth (Fig. 2-19),

(2) Different mesio-distal angulation of posterior teeth (Fig. 2-20).
0 \)
- -
•
-· .. --------·
•
n n
�,�
6
L
• ]'
Fig.219 Over-eruption and occlusal plane
A. Extrusion of maxillary posterior teeth and changes in occlusal plane counter-clockwise
(CCW) rotation of occlursal pane or flattening of occlusal plane
B. Extrusion of mandibular posterior teeth and changes in occlusal plane: clockwise (CW)
rotation of occlusal plane or steepening of occlusal plane
Chace2Ca of Moccio « []
'0 e
D n,
• a
Cass Ill
C•L _: _J O.c_ __,
Fig. 2-20 Posterior occlusal plane (pop)

A Poe the line that connects the cusp tip of the mandibular second premolar to the disto-
buccal cusp tip of the mandibular second molar.
B. Over-eruption of mandibular posterior teeth and changes in posterior occlusal plane
C. Mesially-tilted mandibular posterior teeth and changes in posterior occlusal plane
D Correlation between posterior occlusal plane and malocclusion
Vnlcal
Tips: Posterior discrepancy (Sato et al., 1991) (Fig. 2-21)
• Disharmony of anterior teeth is called anterior discrepancy, whereas disharmony of
• posterior teeth is called posterior discrepancy. Posterior discrepancy frequently

• occurs when there is insufficient vertical dimension of the posterior area, which can
cause the mesial angulation of teeth or over-eruption. in this case, there may be
some changes in the posterior teeth or anterior teeth, and skeletal problems can
occur, too
►►►►►
G» cote?_Ca of eon
••••
••••
•
•
•
'-L _, ••·L _,
Fig.224Posterior discrepancy
A. Anterior discrepancy and posterior discrepancy
• Posterior discrepancy may Cause mesial angulation or over-eruption of teeth
A steep posterior occlusal plane is one of the characteristics of Class II malocclusion. It is formed
either from a relative over-eruption in mandibular posterior teeth (when compared with the
maxillary posterior teeth) or from the mesial angulation of mandibular posterior teeth (Fig. 2-22)
In contrast, a flat posterior occlusal plane is one of the characteristics of Class Ill malocclusion,
and is formed either from a relative over-eruption in maxillary posterior teeth (when compared
with the mandibular posterior teeth) or from the uprighted condition of mandibular posterior teeth
Fig.222Characteristics of Class Ii malocclusion

A To compensate for Class ll malocclusion, there may be decrease in vertical dimension of
posterior teeth
B. Differences in posterior occlusal plane are observed in different skeletal patterns. in Class ll
malocclusion, steep posterior occlusal plane can be observed, while in Class Ill
malocclusion, flat posterior occlusal plane is commonly observed (Kim et al., 20O9')
Ca?Ca o - .. 63
Steep POP (Fig. 2-23)
[n Class Il malocclusion, the majority of patients who have steep occlusal plane may also
have the mesially angulated posterior teeth, showing a severe curve of Spee. Also, when
the patients have midline deviation, I different vertical heights of left and right posterior
teeth, and 2) different angulations of left and right mandibular posterior teeth are evident.
In other words, the affected side is likely to have more mesially tilted mandibular posterior
teeth and a severe curve of Spee (Fig. 2-24)
During the transition of deciduous to permanent dentition, it is essential to check the

changes in movement of first-, second-, and third-order bends in the following cases:
Premature loss of deciduous teeth (Fig. 2-25),

Premature extraction of permanent teeth (Fig. 2-26),
Congenital missing teeth (Fig. 2-27),
Ankylosis (Fig. 2-28),
Abnormally eruptive teeth (Fig. 2-29),
Dental caries (Fig. 2-30),
Improper dental restorations (Fig. 2-30),
Delayed eruption of permanent teeth (Fig. 2-31),
Prolonged retention and abnormal resorption of deciduous teeth
•
•
•
- ••••
••••
+8
U·�------� .
,-
I
1 •
•I
•
•
•
a f
ge $ee
Q]
» Fig. 2-23 Steep POP
A. Diagram of steep POP (Fushima et al, 1996)
B. Class l malocclusion and over-erupted mandibular posterior teeth (Kim et al, 2009)
C.Mesial angulation of mandibular posterior teeth
D.A patient with steep POP the upper occlusal plane angle is 11.7 and the POP angle is 18.3
E Severe curve of Spee or anterior open bite
E.1.Case of severe curve of Spee (POP angle 22.3)
E2.Case of anterior open bite (pop angle 22.4)
f protruded lips that have been caused by retruded mandible
G.Temporomandibular joint disorder (Fushima et al., 1996)
Cc2_Co of ecco « D'

Fig. 224 Difference between the left and night posterior occlursal plane of a patient who has midline
deviation
Table Ooclu. ple erenoe between shied$.ea

0on.shift.eds.de of etie i mend.el lee.al
op et male 00(eh
'iii 0ecol
Pe
so
Me SD Mean $0
Derenoe
d
16 1136+412 1049 +366 086
4% -4
Sr
6
10.35+436
18,06 ± 12.28
20.30 ± 12.13
51
963±41
13.81 +585
15.22+528
072
4.24
dl er0ntonoose4see006
A. The relationship between midline deviation and posterior occlusal plane (Sato et
• al., 2006)
• Difference between the left and night posterior occlusal plane in a panoramic
• radiograph
• C. The relationship between posterior vertical dimension and midie deviation
[[»» Cott?_Ca oleo uo

••••
••••
Fig. 224 (continued) Difference between the left and night posterior occlusal plane of a patient who
has midline deviation
•
•
•
D. Miline deviation in the model

E. The relationship between differences in pop and midline deviation Different tooth angulation and
posterior occlursal plane may also imply the differences between the left and night posterior vertical
dimension These are often regarded as the causes of midline deviation. The above diagram has a
severe curve of Spee on the night hand side and the midline deviates to the night
Fig. 225 Case where a difference in mesio-distal
angulation of teeth is observed due to premature loss
of deciduous teeth
Because of mesial angulation of mandibular left
posterior teeth and lack of maxillary fight canine
space, the mandibular midline has moved to the left
•
•
• Fig. 226 Case where a difference in mesio-distal
angulation is observed due to premature extraction of
permanent teeth
As the mandibular night first molar was lost prematurely,
a difference between the left and the night occlusal
plane is observed
- ••••
••••
•
•
•
Fig. 227Case where congenital missing teeth have

caused the difference in mesio-distal angulation.
Case where maxillary night first and second premolars,
maxillary left second premolar, and bilateral
mandibular second premolars are missing. Mandible
deviates to the night due to a difference in mesial
angulation between the left and night first molar
Fig. 2-28 Case where ankylosis has caused a

mesio-distal angulation of teeth
The mandibular left second premolar is missing wth
ankylosis of primary second molar, and the mandibular
left molars are mesially tilted Although there is no
midline deviation, the left occlusion is unstable
69
8»
Fig.229Case where ectopic eruption of permanent

teeth has caused a difference in vertical position and
mesio-distal angulation of teeth
Over-eruption and mesial angulation of primary
second molars are observed due to ectopic eruption of
maxillary and mandibular first molars
A. Ectopic eruption of maxillary first molar.
B. Ectopic eruption of mandibular first mnolar
•
• Fig. 2-30 Case where dental caries and improper
• dental restorations have caused a difference in mesic-

distal angulation of teeth
Dental caries are observed on the mandibular night
primary second molar, and mnesial angulation is also
observed in the mandibular night first molar
••••
••••
•
•
•
Fig. 2.34Cases where delayed eruption of permanent teeth has caused a difference in mesio-distal
angulation of teeth
A Difference is observed in the eruption rate between the left and night molar as the maxillary night first
molar has not yet erupted, mandibular midline deviates to the night
Over-eruption of the maxillary second molar over-eruption of the maxillary night second molar has
moved the mandibular midline to the left
7
4Q Labio-lingual or bucco-lingual inclination of teeth
(torque or third-order bends)
Abnormal labio-lingual or bucco-lingual inclination of teeth restricts mandibular movement and

causes a variety of malocclusion. A severe lingual inclination of maxillary anterior teeth restricts
the forward movement of the mandible and causes Class ll malocclusion or deep bite. According
to Sato et al. (2006), midline deviation can aggravate the buccal crown inclination of maxillary
posterior teeth on the affected side, and the lingual crown inclination of maxillary posterior teeth
on the unaffected side
It is extremely important to check the following factors.
1) Anterior teeth inclination
(I) Maxillary anterior region (Fig. 2-32),

(2) Maxillary canine area (Fig. 2-33).
Fig. 232 Crown inclination

of maxillary anterior teeth
A. Proclination of maxillary
anterior teeth
B. Normal inclination of
maollary anterior teeth
C. Retroclination of mallary
• •• anterior teeth
•
•
• •••
••••
•
•
•
fig. 2.33\Various cases that show different torques of maxillary canines

A Case where the maxillary canine torque is normal
Cases where there is a severe palatal inclination
B.1 Normal maxillary inter-canine with (34 6mm)
B2. Small maxillary inter-canine width (32.0mm)
C. Acase where there is a difference in torque between the maxillary left ad night canine due to a severe
lingual crown torque of the maxillary night canine, the mandibular midis has deviated to the left
DA case where there isa difference in vertical height between the ma00lay canines. due lo severe
extrusion ad lingual crown torque of the maollary night canine, the mandibular midlie has deviated
to the left
• 73
2) Inclination of posterior teeth (Fig. 2-34)
• Fig. 234 Various cases that show different torques of posterior teeth
A. Normal torque of maxillary and mandibular posterior teeth
• B. Severe lingual crown inclination of mandibular posterior teeth
•
e Choir?Ca o son
••••
••••
3) Differences in torque between the left and right side
+ •
•
• 'pt
·�
' . -V ,
•
... 4
- '
t '
-
l 1
'
.l
g#,
'
l
'
. ... '
[W
Fig.2-35 Torque differences in posterior teeth

I
A. Midline deviation and torque differences in posterior teeth
• Diagram The maxillary posterior teeth on the affected side have a buccal crown inclination and the
maxillary posterior teeth on the unaffected side have a lingual crown inclination On the other hand, a
lingual crown inclination is observed in the mandibular posterior teeth on the affected side, while a
buccal crown inclination is observed in the mandibular posterior teeth on the unaffected side
Therefore, in order to orrect the midine deviation, torque adjustment of posterior teeth should be
made accurately
Chat?Co of Mocco « 7
onical Tips: Anterior component of force
Molars tend to move forward during our life time There are a few factors that can
influence their movement. These factors consist of the following
1) Morphology and angulation of teeth,
2) Occlusal force and muscle strength,

3) Trans-septal fibers
Due to the factors above, teeth have a tendency of mesial angulation as we
get older. In particular, if the molars are already mesially tilted, they may De
even more mesially angulated over a period of time. At the same time, the
Opposing teeth may also be mesially tilted, and the current condition of molar
occlusion is likely to persist. Also, the existing crowding on the maxillary and
mandibular anterior arch may be aggravated as we get older, in which case a
proper treatment is needed.
►►►►►
�lnicol
Tlps: Points to check when a patient has a midline deviation
(Fig. 2-36)
1. First-order bends symmetry in the maxillary canines and the arch form, and the
posterior cross bite

2 Second-order bends: differences in vertical position, mesio-distal angulation and
curve of Spee.
• 3 Third-order bends: torque differences in the maxillary canines and posterior teeth
• + Vertical, antero-posterior and transverse relationships are correlated with one
• another (Fig.2-37). bpp
[»»Co?Ca ot Mo on
••••
••••
•
•
•
Fig. 2.36 Points to check when a patient has a midline deviation

A Millie deviation
Fluet-order bends symmetry in the maxillary canines and the arch form
C. Second-order bends: differences in vertical position and mesio-distal angulation,
D Third-order bends: torque differences in posterior teeth
Fig.237Fuest-, second- and

[.] third-order bends
Depending on the vertical
position and angulation of
\ posterior teeth, antero-
[.-[:] posterior and transverse

relationship may also change
Although the molar shows a
Class l relationship, a Class I
canine relations.hip is observed
due to the mesial angulation of
the mandibular night posterior
teeth
A Correlation of vertical,antero-
posterior and transverse
relationship
B. Acase with a midline
deviation
Cow?Ca of Moccio « 77
� Environmental Factors
) Habitual mouth opening (Fig. 2-38 Patients should keep their mouth closed without any tension
on their chins when resting. Malocclusions such as dolicho-facial face, retruded chin and
bimaxillary protrusion are observed amongst the patients with habitual mouth opening. Since
patients close their mouth with a mentalis muscle action, they have short maxillary lips, and show
a reverse curve of smile are. Therefore, a careful examination of these factors must be made
Fig. 2-38 Lip seal

A. Hypertonic lip B. Normal lip seal C.Lip incompetency
2) Harmful (Bad) oral habits: Finger-sucking and nail biting are the pernicious habits that can
change the arch form and the facial profile. In particular, after the eruption of permanent teeth,
a finger-sucking habit is likely to lead to lip biting and may cause large overjet and an
unaesthetic facial profile (Fig. 2-39)
•
•
•
Fig. 2-39 Harmful oral habit Photographs of a patient whose finger-sucking habit has led to lip sucking
••••
••••
) Tongue thrusting habit: When the tongue is resting or during swallowing, a constant force is
applied to the mandibular dentition, and there can occur a variety of malocclusion such as open
bite, anterior cross bite or posterior cross bite (Fig. 2-40).
•
•
•
Fig. 240 Tongue thrusting.

A. Active tongue thrusting A case of open bite due to tongue thrusting. Due to active tongue thrusting,
the relapse possibility is relatively high, even after an orthodontic treatment in this case, the occlusion
of molars and premolars is fine, but the labiversion of maxillary anterior teeth, the diverse occlusal
planes between the anterior and postenior region, and the root resorption of maoollary anterior teeth
are typically observed (Kim et al., 1987)
B.Passive tongue thrusting. A case where the existing open bite provokes the passive tongue thrusting
in order to lose the anterior region. in this case, if the anterior relationship is corrected after an
orthodontic treatment, the tongue thrusting habit is improved naturally
4) Tongue position: the resting position of the tongue is assessed through the vertical position
(tongue position) and the antero-posterior position (tongue posture)(Fig. 241)
(l) Vertical position (tongue position): In general, the tongue is located 2- mm away from the
palatal plane If it is located on the maxillary alveolar bone, this is known as the middle
position. This is closely related to unilateral posterior cross bite, If it is located on the
occlusal plane, this is called the low position. This is closely related to the bilateral
posterior cross bite
(2)Antero-posterior position (tongue posture): anterior tongue posture is closely related to
bialveolar protrusion or mandibular prognathism
•
•
•
Fig. 24f Tongue position
A. Measuring method of tongue position
H. 2-3mm below the palatal plane,
Mathe masag_""Poe teyet (closey related to unatera posteoor cross bite)
Lat the occlusal (closely related to bilateral posterior cross bite)
B. Apatient whose tongue is located upward
C. Apatient whose tongue is positioned at the maxillary alveolar bone level
DA patient whose tongue is at the occlusal plane level
EApatient whose tongue is in the forward position
• •••
••••
Vlnlcol
Tips: Transitional open bite
Transitional open bite is a temporary phenomenon that occurs due to the different
eruption time between the maxillary and mandibular incisor,
•
•
5) Otolaryngological problems: Mouth breathing may cause cranial extension and mandibular •
downward movement; thereby leading to dolicho-facial face, bimaxillary protrusion, retruded
chin or mandibular prognathism.
(Nose problems: the problems include the hypertrophy of nasal turbinate, deviation of nasal
septum and allergic rhinitis (Fig. 2-42)
Fig. 242 Problems in nasal septum

A.A patient with normal nasal septum.
A patient with nasal septum deviation
B1 Pre-surgical radiograph
B2 Post-surgical radiograph
B.2»
Chair?Ca. of Mocco «
(2Hypertrophic adenoids: This can be examined by the distance from PNS to posterior
pharyngeal wall. According to McNamara (200), if the distance is less than 5mm, it is
regarded as hypertrophi adenoids. In general, hypertrophic adenoids are closely related to
the inhibition of growth in the anterior craniofacial region (Fig. 2-43).
Fig. 243 Hypertrophic
I el
f
adenoids
A. Measuring method of
adenoids
B.A patient with small
6
adenoids
4 nu C.Apatient with medium size
adenoids
I' D.A patient with large
adenoids
u
8
t,
t
, A l
'
4 t
-.
-
tl 'a I@'
{ ,
•
• • - At
'
•
$ f
w;
l
•
e, :rs..-
• •••
••••
(3)Hypertrophi tonsils: In cephalometric radiographs, this is marked as a radiopaque mass

located below the soft palate. This hypertrophy is closely related to posterior growth, and
can increase the risk of mandibular prognathism (Fig. 2.44). In particular, when the patient
is already suffering from ear, nose and throat (ENT) problems, he/she is likely to have
Class ll open bite or Class Ill open bite. Therefore, when treating this type of malocclusion,
it is crucial to examine the ENT problems (Fig. 2-45).
•
Fig.244 +Hypertrophic tonsils

A. Measuring method of tonsils
B.A patient who has small
tonsils
CA patient who has medium
size tonsils
D.A patient who has large tonsils
Fig.24 ENT'problems
A. A case of Class Ill malocclusion with ENT problems (hypertrophic adenoids and tonsils)
•
•
•
• •••
••••
Fig. 245 (continued) ENT problems.
•
•
•
..}
B. Acase of Class ll malocclusion with ENT problems (ypertrophic adenoids and tonsils).
aw?_Ca of Maiocco ['

6) Functional shift Due to premature contact (especially on the primary canines), the mandible
can be forwardly or laterally deviated. In this case, the grinding of primary canines or the
expansion of maxillary dental arch may be needed (Fig. 2-46).
• • • • • 8-2 8.3
\
\ �
;! . ' y
n
% �
r
�
,
% !I
Fig. 246 Functional shift

• A. Class ll malocclusion and functional shift
A-1. Diagram of maximum intercuspal occlusion
• A2. Skeletal Class Ill malocclusion
• A.3. Functional Class Ill malocclusion
B. Class Il malocclusion and functional shift
Bf.Diagram of maximum intercuspal occlusion
B-2. Skeletal Class ll malocclusion
B-3. Functional Class ll malocclusion
C Midline deviation and functional shift
Cf intraoral photographs of maximum intercuspal occlusion
C-2 intraoral photograph of an intentional mandibular shift in
order to match the maxillary and mandibular midines
••••
••••
A summary of causes for malocclusion.

I. Skeletal, dental and environmental factors are all closely related (Fig. 2-47).
=Differences in vertical relationship will cause antero-posterior and transverse problems.
2. Skeletal malocclusion may be caused by the following dental factors (Fig. 2-48)
=In Class II malocclusion, there is insufficient posterior vertical dimension and steep
•
posterior occlusal plane. In contrast, in the case of Class Ill malocclusion, there is
•
sufficient posterior vertical dimension and flat posterior occlusal plane. •
3. Skeletal malocclusion can be treated by adjusting the following dental factors (Fig. 2-49)
=For Class l malocclusion treatment, it is necessary to increase the posterior vertical
dimension by flattening the posterior occlusal plane
In contrast, in the case of Class Ill malocclusion, it is necessary to correct anterior cross
bite and simultaneously steepen the posterior occlusal plane. This means that the antero-
posterior relationship can be improved through a vertical adjustment.
Dental Environmental
00gin 0ngn
A] lL
Fig.247Factors that cause malocclusion
A. Relationship in the skeletal, dental and environmental factors
8 Correlation in the vertical, antero-posterior and transverse relationships
Chell teeney
[oerences in OP (occlusei plane)] ]seapooescn ee] be

by correcting 0entail prober.s
Fig. 248 Skeletal problems may arise Fig. 2-49 Skeletal problems can be
from dental problems. treated by correcting dental problems
Chor?_Ca o Mocco « [7
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•
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• •••
••••
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diagnosis. Am J Orth0d 113.619-633, 1978.
38. Kim YH. A comparative cephalometnic study of lass II, Division Nonextraction and Extraction cases
Angle Ort0d 4977-84, 1979
39. Kim YH. Anterior open.bite and its treatment with Multiloop Edgewise Archwire. Angle Orthod 57290-
321, 1987.
40. Kim YH. Caulfield Zoe, Chung WN, and Chang YI. Overbite Depth indicator, Anteroposterior
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41. Kim YH. Aberrant growth of the mandible and its effect on the occlusion. int J MEAW6.5-22, 1999
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44, Linder-Aronson S. Adenoijs. Their effect on mode of breathing and nasal airflow and their relationship
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51 Moyers RE. Handbook of orthodontics. Chicago:. Year-book Medical Publisher,1988
52 Muller Tp, IN, Petersen AC, and Blayney JR. A survery of congenitally missing permanent teeth. J
Am Dent Assoc 81/101-107, 1970
53 Miyashita K. Contemporary cephalometric radiography. Tokyo, Quintessence, 1996.
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55 Nanda SK. Patterns of vertical growth in the face. Am J Orhod Dentofacial Orth0p 93:103-16, 1988
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58 Proffit WR. Contemporary orthodontics. St Louis: CV Mosby company, 1986.
59 Proffit WR, and Mason RM My0functional therapy for tongue thrusting: background and
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60 Proffit WR. Lingual pressure patterns in the transition from tongue thrust to adult swallowing. Arch Oral
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0rthop 118.624-628, 2000.
• 63 Rhee SH et al. Tooth size and arch parameters of normal occlusion in a large Korean sample. Korean
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••
••••
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Ca0r?_Ca of Mloorion [[
••••
.. .. . . . . . .. .. .. . .
. .. .. .. . .. . . . . . .. .
. . . . .. . . . . . .
. .
Chapter 3 _
SKELETAL PATTERN
ANALYSIS
In the early stages of orthodontic treatment -leveling and alignment- different occlusal patterns and
various molar relationships are typically observed. For example, open bite may be closed or its
normal over bite could change to an anterior open bite during treatment. In this process, a Class I
relationship can always change to either a Class ll or Class III relationship. For this reason, it is
important to bear in mind that the treatment outcomes may not always turn out as expected
Fig.3-1Case with equal ANB values but different APD! values

Although SNA and SNS values are equal, these two cases may have different skeletal
patterns. They have different APDI values. Case A (Class ll division 1)is 75.5 and Case B
(Class I) is 80°
A ANB value (6) shows Class l skeletal pattern and APDl value (75.5) also shows Class
skeletal pattern
B. ANB value (6) shows Class ll skeletal pattern but Appl value (80°) shows Class l skeletal
pattern
Although they have the same ANB values, different skeletal patterns can be discovered.
Fig. 3-I shows two patients with the equal values in ANB (6) but different values in APDI. Here,
it is important to note that there is a big difference in the treatment method between someone who
is diagnosed as having Class II malocclusion (ANB-=6) and someone who is diagnosed as having
• Class I malocclusion. This is because, although they both have Class I molar relationship, the
• treatment methods can be different depending on their hidden skeletal pattern conditions
• In the case of Class I malocclusion, a choice can be made to extract the upper and lower first
premolars as a treatment option. In the case of Class ll malocclusion, it is important to consider the
dynamic conditions of Class II malocclusion because the extraction of the upper and lower first
premolars can cause more problems, such as overbite deepening and deterioration of Class Il
relationship. For this reason, to treat Class II malocclusion, only the upper first premolars should
be extracted, or both the upper first premolars and the lower second premolars should be extracted.
••••
••••
• ROC (receiver operating characteristic) Analysis (Fig. 3-2)
1) Sensitivity. TP/TP4FN
This is a type of diagnosis method that can be used to confirm a malocclusion case. [f%
patient is initially diagnosed as having Class ll malocclusion, the sensitivity method can be
•
used to confirm the Class II malocclusion. Thie is similar to a medical case where a patient
•
who is diagnosed as having pneumonia is confirmed as having pneumonia by some method •
2) Specificity: TN/FP+ TN
Tis is a type of diagnosis method that can be used to confirm a non-malocclusion case, If
a patient is initially diagnosed as not having Class II malocclusion, the specifcity method
can be used to confirm the non-Class ll malocclusion. This is similar to a medical case
where a patient who is diagnosed as not having pneumonia is confirmed as not having
pneumoma by some method
Wardlaw et al. (I992) analyzed all the analysis methods of anterior open bite by using the
ROC method. Their research result shows that Overbite Depth Indicator (ODD) is one of
the most useful methods when assessing anterior open bite. Similarly, Han et al, (1998)
analyzed all the analysis methods of Class ll and Class Ill malocclusion by using the ROC
method, and argued that Antero-posterior Dysplasia Indicator (APD) is the best analysis
method when assessing Class Il and Class III malocclusion.
II
lI
---
eesenoeot Dee Gr Condi-on
leg Class4 skeletal pattern
05
Present Absent Total
Test result oeve 1p p 1P+F
leg AN Negate N IN N+ IN
•• angel Total 19+#N p+IN
Fig.3-2R0C Method
Cc_Sr % Ayo «g
D Vertical Analysis
Most of the vertical analysis methods used so far measures the angles between the mandibular
lower border and I) SN line, 2) FH line, 3) palatal plane and 9) occlusal plane. As the picture
below shows, there are some limitations only when these angles are used to assess the vertical
relationship (Fig. 3-3)
,
1
'\
� % ,. \
mi
-
30 fee0D%
• eDo
2 • , Ge
,,
t.d
'
''
',''
''
' tad(
G2east
0era
- 2
1.• ,, ,'
,'
,, ''
''
''
'
/
-
gt4so
2nrad
0en4a
-
0466($%
''
04+30$ts6
,,
' $ ,, /
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$$69862668871 47$0848$0$6$6
•
• Fig. 3.3 Vertical analysis method
• A. Mandibular plane angles
• B. Differential diagnosis.
Bf.FMA frequency distribution of Group 2 and Group 4. A close overlap is observed in the
distribution pattern between the two groups
B2. 0DI frequency distribution of Group 2 and Group 4. A lear separation is observed in the
distribution pattern between the two groups. Only 1520% is overlapped
[»Cgtr3_let Pon eye

••••
••••
Overbite Depth Indicator (0DI) (Table. 3-1)
According to Kim (1974), in Class ll malocclusion there is a relatively higher deep bite
frequency than in Class Ill malocclusion. In Class Ill malocclusion, there is a relatively lower
deep bite but higher open bite frequency. Considering this frequency difference, they believed
•
that the vertical relationship could change under the influence of antero-posterior relationship •
Kim (1974) added the AB line to the list of evaluation factors and assessed it with the •
mandibular lower border. Then, they also added the value of the palatal plane angle and named
it Overbite Depth Indicator (0DD. Palatal plane angle indicates the angle between palatal plane
and FH tine and it is measured from FH fine, [f it is anterior-superiorly sloped, its value is
negative(-) but if it is anterior-inferiorly sloped, its value is positive(+)(Fig. 3-4). Here, if the
palatal plane is parallel with the FH line, the ODI will be the angle between the AB line and
the mandibular lower border. In general, this is 74_5 in average and shows little variation by
race (Table. 3-2)
Table, 3f Depth of anterior over bite and correlation coefficient of other measured values of 50Q
malocclusion patients
A. Distribution of 500 patients. B. Anterior overbite and correlation coefficient of
other measured values
le �
»ia
[ Ma
2Nitrii plane
[3new
4NSio
95.0
905
46 0 4
86.9 no 312101
77g 680 356
265 90 576 031
5
536 34 40 60
Class
- '- -
Pai enorpione 450 28 40 565
»l g No ' /
No le No
1/2
•
No
6 00i anbr pin
'Goel angle
29.0 183 65 410 01
1900 125.9 105.0 6.29 0
2 yrs 9mos 46 214 108 4f 20 4 0 00 8faoomanor pone 830 676 525 436 0a494
3 yrs9roe 134 3l 126 514 28 2 16 98 96.0 752 565 63 0557
1048%04+6 99 985 740 537 731 0588
• 122mos
Total
• 16.3 f 45 0 00 0 83
21% 430 245 490 28 56 12 24
toad
a?no6or oerote dept
1810 1280 100 10.40
n10 35 no243
0 2968
1 000
(Kn, 1974
Table. 3-2 Overbite Depth indicator (0DI)
N Me $.0 Sooroe
---
Car
.
Chinese
' 119
-
50
745
728
60r
52
Young4,Kn
Peeing unversiy
lap8nee
-
46 7234
-
482 Kora egen
Korean 190 7195 52 Su,Parke
Chor Si or oh
Fig.34 Overbite depth indicator (0DI).
AB plane to mandibular plane angle plus
or minus palatal plane to H plane angle
Palatal plane angle: if the palatal plane is
sloped anteriorinferiorly,it has a positive
value(). and if the palatal plane is sloped
anterior-superiorly, it has a negative
value(-)
If the 0DI value is less than 65.5,there is an open bite tendency, and if it is over 77.7,there
is a deep bite tendency. This is also used to find out whether the causes of vertical problems
are from the maxilla or from the mandible. If the palatal plane angle is less than .4,there is a
problem in the maxilla, and the mesial angulation of maxillary posterior teeth gets aggravated.
On the other hand, if the mandibular plane angle is over 30 there is a problem in the
mandible, and the mesial angulation of mandibular posterior teeth becomes aggravated (Fig.
3-5)
•
•
• 8»
Fig.35 Causes of vertical disharmony.

A When there is problem in the mandible
8 When there is a problem in the maxilla
••••
••••
The ODI value can be used to assess the following (Fig. 3-6):
)Patients can be classified into the following groups: skeletal open bite (50's or 60' s in 0DI),
open bite tendency (around 70's in ODD), deep bite tendency (far above 70's in 0DI),
and skeletal deep bite (over 80 in 0DI)
2Patients with open bite tendency or open bite tend to have a weak masticatory force, so
•
there is a greater risk of tooth extrusion.
•
3)Patients with deep bite tendeney or deep bite tend to have a strong masticatory force, so •
the risk of tooth extrusion is not high and tooth movement rarely occurs
4)When a patient has a high OD] value, he/she has a greater tendency of anterior crowding
and deep bite. To achieve stable anterior teeth alignment, the anterior vertical
relationship must be adjusted. If there is an excessive ODl value, bites are highly likely
to get deeper, so an extra-careful examination is required in this case.
5)Patients who have a low OD] value show relatively faster tooth movement.
The tooth movement speed of the posterior teeth can be different in the maxillary and
mandibular area, even in the case of the same patient.
For example, the bigger the mandibular plane angle is, the bigger the mesial angulation
of the mandibular posterior teeth becomes, and the mandibular tooth movement becomes
faster. Meanwhile, if the palatal plane is anterior-superiorly sloped, the mesial angulation
of the maxillary posterior teeth becomes worse, and as a result, the anterior component
of force increases. Therefore, the tooth movement speed of the maxillary
0o
be 06 •
•
Fig. 3-6 Clinical significance of 0DI
• ee0
• 0
• • •
•
eb -,
'
0o
Cele3_Si Po y « g@
H Horizontal Analysis
The ANB angle plays a crucial role in analyzing the antero-posterior skeletal pattern. However,
this angle has some weak points in that its value may change depending on the vertical and
horizontal position of nasion point (Na). Furthermore, the same ANB angle may still vary
according to the vertical height of its measuring points A and B(Fig. 3-7)
4
•
\
• al
8
CL
Fig.3.7 Problems of ANB angle.
A. Horizontal position of nasion
B.Vertical position of nasion
C. Vertical position of A and B
Antero-posterior Dysplasia Indicator (APDI) (Table. 3-3)
According to Kim and Vietas (1978), APDl can be calculated from the equation: facial angle
t AB plane angle t Palatal plane angle (Fig. 3.-8). First, the antero-posterior position of
mandible can be assessed through the facial angle. AB plane angle is marked with a(+) sign, if
the point A is posteriorly located from the facial angle or with a (-) sign, if it is anteriorly
•
• located. When the palatal plane is anterior-superiorly located on the basis of the FH fine, the
• palatal plane angle is marked with a (-) sign, whereas if it is located anterior-inferiorly, the
angle is marked with a (+) sign. For Westerners, the average value is 81.47 (± 3.79), while
the average values of Koreans, Japanese and Chinese are listed in table 3-4. If this angle is
above 8s,there is a Class IHI malocclusion tendency. When this is below 77,there is a Class
ll malocclusion tendency (Fig. 3.-9)
1ff»»Corle %er y
••••
••••
Table. 3.3The correlation coefficient between molar displacement and variables
1 Moler displacement 1,000

2.Facial angle 0Downs) 0184
3, Convey [Downs') 0434
4 AB plane Downs')angle 0566
5 SNA 0116 •
6 $N8 0.321 •
7AN8
8ptonHplane angle
0496
0.159
•
944Pt4plane angle 0168
10Palettomandiboder plane angle 0 069
11, Oonial angle 0.155
12.Ya6is angle 0009
13, Wits appraisal -0.6039
14, APO 0643
» Fig.3-8APDI
• Facial angle AB plane angle pp angle
AB plane angle (Downs' AB plane angle)
When point B is posteriorly located from
point A,its value is negative (-) but when it is
anteriorly located, its value is positive(+)
Palatal plane angle when the palatal plane
is anterior-inferiorly sloped, its value is
positive (+) but when it is anterior-superiorly
sloped, its value is negative(-)
Table. 3-4 ADI
N Me $.0 Soro
Ca 102 81.3 379 Young H.Kn
Coese
' s0 81 10 404 Peeing 0nor9y
Japanese 4.6 80.61 3.82 Koyama,90
Ko4e& 90 81 04 436
00¥
•
•
n • Fig. 3-9Clinical significance of Appl
• • • 90
•
C
•
•
'' '
-·
I
00¥
The APD value can be used to assess the following

)We can classify the cases into five different categories: A) Class II malocclusion, B)
Class II malocclusion tendency, C) Class I malocclusion, D) Class Ill malocclusion
tendency, and E) Class III malocclusion
2)When the patients have a high APDI value, they may have a Class Ill malocclusion
tendency,
3)When the patients have a low APD value, they may have a Class ll malocclusion
tendency.
4)A4PDI value can affect the post-treatment stability. When the APD! value is close to its
average, a positive or stable outcome is highly likely. In other words, if the APD] value
is slightly over 70° nd then becomes around 80 After treatment, it means there is an
improvement in the anterior-posterior relationship, thereby making it possible to expect
a stable outcome. However, if the APD] value still fails to reach 8@' _there would still be
• a possibility of Class Il malocclusion tendency. This means that there is a greater

• possibility of recurrence after treatment.
•
If the three angles of APDl are calculated geometrically, it will coincide with the angle
between the palatal plane and AB plane (Fig. 3-10)
1fe Cotes_Si Pr oyi

••••
••••
4-
•
•
•
18o+rte+dreg
Fig. 3-10 ADI

Facial angle ± AB plane angle PP angle = Palatal plane to AB plane angle
AB-maxillomandibular Triangle (Fig. 3-11)
Ts is a triangular shape that consists of the palatal plane, mandibular plane and AB plane.
Here, the angle between the palatal plane and AB plane indicates APDI, and the angle between
mandibular plane and AB plane indicates 0DI. The sum of these two angles is known as the
combination factor (CF)y. Here, the equation for CF is 180'- palato-mandibular plane angle"
Palatal plane is the line between the measuring points of ANS Ad PNS. When there is a severe
variation on the measuring point ANS, the posterior alar cartilage (PAC) can be used as an
alternative
Mandibular plane is the line that connects the measuring points Go and Me. If there is an
excessive antegonial notch, take the center of the line that conneets the mandibular lower
border to the deepest antegonial notch, and then connect the center to Me This final line is
regarded as the mandibular plane (Fig. 3-12). This method can minimize errors when assessing
the arrangement of upper and lower dentition in the triangle. To sum up, this implies that the
function of the dentition is very much dependent upon the shape of the triangle.
In general, the skeletal patter is marked as follows 74.5/ 81.4/ 155.9. Here, 74.5 is the ODL
value, 81.4 is the APDI value, and 155.9 is the CF value. If the CF value is over 155, it is
regarded as high CF, and if it is lower than 150, it is regarded as low CF.
Cao3_Si Pe oy « 1f
Fig.31f AB-maxillomandibular triangle
A. AB-maxillomandibular triangle
B. Various cases of AB-maxllomandibular triangle
B-1 Class I malocclusion
B-2Class It malocclusion.
B-3.Class Ill malocclusion
•
•
•
Fig. 3-12Palatal plane and mandibular plane
A. Adjustment of palatal plane
B. Adjustment of mandibular plane
C. Different condition of palatal plane
D. Different condition of mandibular plane
1fd»»coec3_So Pe y
••••
••••
�
Combination Factor (CF)
Kim et al, (1979) carried out an experiment on two groups of Class II division I malocclusion
•
patients. One was treated with a non-extraction treatment and the other with an extraction •
treatment. After the experiment, they discovered that the group of patients treated with the •
extraction treatment had relatively lower ODl and APD! values (Fig. 3-13).
Afterwards, they regarded the sum of 0DI and APD! values as the Combination Factor (CF)
Combination Factor (CF) = ODI + APD
=7
118
80
» Fig. 3.13 Summary of 0DI and APDI

0 78
�-
0 13010
values in Class ll division 1 non-extraction
and extraction cases
' 76
1n8
These two groups have clear disparity in
74
0DI an A9DI values. In the non-
4r54
extraction group, the ODl value was 80.3
R 16r104M and the APDl value was 75.6, while in the
c extraction group, the ODI value was 74.2
74 76 78 80 82 and the Appl value was 73.7. (Kim et al,
APpL 1979)
er3_$% Pe oy « 1[
CF has the following meanings:
) The skeletal patterns are classified by considering OD APD/ CF altogether
(p)When assessing skeletal patterns with open bite tendency or deep bite tendency, assess
it by considering CF and ODI together instead of solely focusing on OD
(2)0Dl itself can be influenced by the APDI value, so it is crucial to analyze its value by
making a comparison with CF
(3) Skeletal patters can be classified as follows (Table 3.-5, Fig. 3-14
Class I high angle,
2Class I low angle,
Class II high angle,
@Class II low angle,
Class III high angle,
@Class II low angle.
Table. 3- Classification of skeletal patterns

App 00¥ CF
Class t high angle 78«e6 «655 «150
Class t low angle 78««86 77 »155
Class n high angle e7 « 150
0es It low angle e »166
Class I high angle »85 e 155
Cass I low angle »85 » 160
•
•
•
Fig. 3-14 Combination factor
1[»Cw3l Pen
••••
••••
2) CF value remains steady during treatment and growth process.

(I)In the high angle case, it will remain as the high angle. In the low angle case, it will
maintain its low angle
(2) After the treatment of a high angle case, it is highly unlikely that this would transform
into the low angle case.
•
G3)Fig. 3-15. Bj6rk (1968)' study
•
•
3) CF shows a growing patter of a patient (Fig. 3-16)
A low CF value indicates the patient's vertical growth tendency, while a high CF value
indicates the patient's horizontal growth tendency
' '\
[8] B
[INT
» Fig. 3-1 8j6rk (1968)'s study.

A. Changes in CF value from the normal
angle case
B. Changes in CF value from the high
angle case
C.Changes in CF value from the low
angle case
C»
[ HE,
•
•
•
Fig.3.16 Combination Factor.
A. Open bite. OD/ APD/ CF + 64, 1/79.0/ 142.
B. Open bite tendency OD/ APD/ CF = 72.0/ 78.0/ 150.0
C. Normal bite. ODI/ APDI/ CF = 75.6/ 83.2/ 158.8
D. Deep bite tendency OD/ APD CF = 80.5/ 83.5/ 164.0
E. Deep bite. OD/ APO CF + 89.5/825/ 172.0
••••
••••
4) CF value shows the speed of tooth movement (Fig. 3-17).

(I)The speed of tooth movement is inversely proportional to the CF value
(2)When the CF value is high, it means that the tooth movement is slow, When this value
is low, it means that the tooth movement is fast.
()In the case of a deep bite, it is difficult to move the teeth because of the powerful bite
•
force •
•
• 6
es..
��
A •
a
••
+ u
C
C»
•
Fig.3.417 Combination F actor (Epler and O'Ryann, 1981)

A Lateral and frontal views of muscles
B. Direction and size of muscle movement and skeletal pattern
C. Shape of mandibular bone and skeletal pattern.
a3_Si Py f@
5) CF indicates the skeletal volume of teeth arrangement (Fig. 3-18).
()When the CF value is high, it means that teeth can be appropriately arranged by a non-
extraction treatment, but when the CF value is low, it means that an extraction treatment
is required (Fig. 3-19)
(2)The treatment plan can also vary depending on the size of teeth. If tooth size is small,
despite a small skeletal volume, appropriate arrangement is possible without extraction.
(3)If the CF value is high but an extraction treatment is applied, or if the CF value is low
but a non-extraction treatment is applied, a variety of problems can arise as a
consequence (Fig. 3-20,21)
Fig. 3-18 Combination factor

A High angle (red line) and
low angle (blue line).
B. Radiograph of high angle
and low angle
B-1.Padiograph of low angle
B-2. PRadograph of high angle
•
•
• Fig. 3.19 The relationship between CF and
extraction or nor-extra.con treatment
1[e Chor3Soi Pr oy
••••
••••
• Problems in premolar extraction when the CF value is above 155 (Fig. 3-20)
I. Aggravation of deep bite,

2 Mandibular anterior crowding,
3. Relapse of extraction space,
•
4 Higher risk of recurrence. •
•
Fig. 320 Problems in premolar extraction when the CF value is above 155
A.Pee-treatment lateral profile (ODl/ A9D CF are 80/ 81.5/ 161) and intraoral photograph
B Post-treatment lateral profile (ODl/ APD/ CF are 78.5/ 84.5/ 163) and intraoral photograph
Chace3Si Pe or « 1
Problems in non-extraction treatment when the CF value is below 150
(Fig. 3-21)
• Bite opening that is difficult to control

2. Difficulties in completing the occlusion inside the dental arch
3. Higher risk of recurrence
Fig. 3-21 Problems in nor-extraction treatment when the CF value is below 150
A. Pre.treatment lateral profile (OD/ ADU/ CF are 63/ 83.5/ 146.5) and intraoral photograph
B. Post-treatment lateral profile (OD/ APD CF are 63.5/ 83/ 146.5) and intraoral photograph
•
•
•
1[Chair3Slti Pt Aoay
• •••
••••
!J Extraction Index (El) (Fig. 3-22)
Extraction Index (EI) = ODI + APDI + (IA-130)/5 -(LP-EL)

•
•
I This is the value that refleets the degrees of maxilla-mandibular anterior protrusion and its •
aesthetic lip protrusion in CF
2) Maxilla-mandibular protrusion is marked as (lIA-130)/ 5. For example, if ILA is 115,mark it
as (115-130)/5= -3. Ifit is 135,it will be (135-130)/5= +1.
3) Lip protrusion indicates the upper and lower lip protrusion to the aesthetic line, and is often
written in mm. [f it is protruded, a negative value is used and if it is retruded, a positive value
is used. For example, if the upper lip is +3mm protruded and the lower lip is +2mm protruded,
mark it as (3+2.5. However, if the upper lip is -2mm retruded and the lower lip is + Imm
protruded, mark it as -(-2+1I.
'9,lnical
Tips
1. Etraction index is valuable and effective only in the case of Class I relationship
when the APDI value is around 80.
2.CF.EI if itis above 10, there is a greater possibility of carrying out a premolar
extraction treatment (Fig. 3-22 A)
3. CF-EL fit is below 10, a non-extraction treatment is possible (Fig. 3-22 B)
4. In the case of Class Il and Class Ill, Extraction index must be used cautiously
(Fig. 3-23)
►►►►►►
re.Resews
$$1-
1
"�-------------�" ··�--------------�
Fig. 322£traction index
•
Cow_Si e « 1
·•
Fig.3-23 Extraction Index (EI)

A. Class I malocclusion. B. Class Ii malocclusion C. Class HI malocclusion.
0DI . 64.2 0DI 86.0 0DI 57.6
APDI! 79.3 A9DI 71.f APDI 96.1
CF 143.5 CF 157.1 CF 153.7
EI 137.0 El 143.0 El 159.4
@ Classification of Skeletal Pattern
"b Class I high angle (Fig. 3-24 A)
f) This indicates patients who have skeletal patterns with an APD] value above 78 and below 85,
and with a CF value below 150, Most of the orthodontic patients belong to this category.
2) The patients have a normal antero-posterior relationship of maxillo-mandibular bone but due
to the reduction of posterior vertical dimension, they have the steep mandibular plane or
•
• retrognathie mandible. They also have the antero-superiorly sloped palatal plane with a
• negative value.
3) Due to retrognathi mandible, the patients may have a protrusive profile or crowding.
4) The patients have a normal upper occlusal plane (UOP) and a steep posterior occlusal plane
(POP)y. This indicates a case of mandibular retrusion that has been caused by limited
mandibular adaptation due to over-eruption of the maxillary posterior teeth
114de Cao3_Sll Pa oar

••••
••••
5) The characteristics of malocclusion.

(Protrusive profile,
(2) Anterior crowding,
(3)Excessive overjet,
(4) Anterior open bite
•
•
•
lo Class I low angle (Fig. 3-24 B)
) This indicates patients who have skeletal patterns with an APD value above 78 and below 85,
and with a CF value over 155, They have a normal antero-posterior relationship of maxillo-
mandibular bone, but there is a difference in the vertical relationship.
2) Except the cases of deep overbite and bialveolar protrusion, the patients usually have a fine
skeletal pattern and show a relatively aesthetically satisfying profile. The majority of
complaints by patients come from dental problems such as anterior crowding or protrusion.
3) The patients have a normal upper occlusal plane (UOP) and a normal posterior occlusal plane
(POP). This indicates a case of good mandibular adaptation after the eruption of maxillary
posterior teeth
4) The characteristics of malocclusion
(I Anterior crowding: the CF value is high with a large interincisal angle (ILA),
(2 Protrusion: the CF value is high with a small interincisal angle (IA)
Fig. 3-24 Class I high angle and Class l low angle.

A. Class Ihigt angle. OD/ APD CF=63.8/ 84.3/ 148.1
B. Class I low angle. OD/ APD/ CF±775/82.4/ 159.9
Cha¢3St P «1[
.._,
Class II high angle (Fig. 3-25 A)
) This indicates patients who have skeletal patterns with an APD! value below 77, and with a CF
value below I50, They show vertical discrepancies as well as upper and lower antero-posterior
differences. Most of them show a retrognathice growth pattern of the mandible because the
posterior growth has been more developed than the anterior growth due to the extrusion of
maxillary posterior teeth
2) In this case, the patients have a steep POP and show a steep mandibular plane and a long
LAFH due to the lack of posterior vertical dimension. Here, the LOP ean be normal
(1Anterior open bite,
(Protrusion: excessive overjet,
() Anterior crowding
._,
Class II low angle (Fig. 3-25 B)
I) This indicates patients who have skeletal patterns with an APD value below 77, and with a CF
value over 155, They have a Class ll antero-posterior relationship, but a favorable vertical
position of mandible
2) Most of the patients show a significant anterior growth of mandible due to the extrusion of the
maxillary posterior teeth, and they also show a sufficient posterior vertical dimension and an
excessive growth patter of the maxilla. In this case, the POP is flat and the mandibular plane
shows a flat pattern, too This is a case where the mandibular position is normal but the maxilla
is anteriorly positioned
) The patients have either a normal or steep UOP due to the over-eruption of maxillary anterior
• teeth with a normal POP
• 4) The characteristics of malocclusion.

• (p)Protrusion: excessive overjet,
(2 Anterior crowding.
() Deep bite
Class II high angle has the characteristics of normal UOP and steep POP, while Class II low angle
has the characteristics of normal (or steep) LOP and normal POP
1[Choir3Soi Pt oy
••••
••••
•
•
•
Fig. 3-25 Class I high angle and Class ll low angle.

n this Class ll high angle case (A),
the patient has a normal OD value (74.2). However, since he has a
low CF value (148.7), he should be regarded as a high angle patient, and an appropriate treatment
method must be applied accordingly. If an appropriate treatment method is not applied, the posterior
downward rotation of the mandible wt be aggravated and other unexpected consequences may occur.
A. Class Il high angle. ODI/ APD/ CF=74.2/74.5/ 148.7
B. Class ll low angle. OD APD/ CF=81.4/ 77.3/ 158.7
�
Class Ill high angle (Fig. 3-26 A)
I) This indicates patients who have skeletal patterns with an APD! value above 85, and with a CF
value below 155, They show a Class Ill antero-posterior relationship, but a vertically posterior
downward rotation of the mandible. They have a prognathic mandible as a result of the
posterior downward rotation of the mandible due to the extrusion of maxillary posterior teeth
Therefore, they show a normal or steep mandibular plane
2) In this case, the patients have a steep Pop They have a normal or flat UOP and show an over
eruption of maxillary posterior teeth. However, they show a lack of posterior vertical
dimension and a long anterior facial height.
) Linguoversion of mandibular anterior teeth and labioversion of maxillary anterior teeth can
occur for dental compensation
(I Mandibular prognathism and long facial profile: Class Ill anterior crossbite
(2) Anterior crowding.
Coe Si Pon oy T
�
Class Ill low angle (Fig. 3-26 B)
p) This indicates patients who have skeletal patterns with an APD value above 85, and with a CF
value above 160, They show a Class Ill antero-posterior relationship, but a favorable vertical
position of mandible Tis is a case where both the anterior and the posterior growth have
occurred due to the extrusion of maxillary posterior teeth
2) In this case, the palatal plane angle has a positive value (+) with an anterior downward slope,
showing a lack of anterior vertical dimension. Here, due to the extrusion of the maxillary
posterior teeth, the mandible shows an over-closure condition with flat mandibular plane
3) In spite of the Class Ill malocclusion, mandibular anterior teeth show normal inclination or
labioversion
4) The patients have a normal or flat UOP and POP
(1Mandibular prognathism: anterior cross bite,
(2) Anterior crowding
Class Ill high angle has the characteristics of flat UOP and steep POP, while Class IHI low angle
has the characteristics of flat UOP and POP
•
•
•
Fig.3.26 Class Ill high angle and Class tit low angle.
in the case of Class Ill low angle (8), the patient has a low ODl value (62.8) showing open bite. However,
this patient should be regarded as having a low angle case because he has a high CF value (159.4)
A. Class Int high angle OD/ APD/ CF=53.9/ 93/ 146.9
B. Class Ill low angle. OD/ APD/ CF +62.8/ 96.6/ 159.4
11»Chol3 Si P Aoay
••••
••••
�uote
from Professor Kim Young-Ho
When you build a house, the most important factor is the detailsof (bun.gin
•
•
•
REFERENCES
f Ackerman JAL, and Proffit WR The characteristics of malocclusion a modem approach to classification
and diagnosis. Am J Orthod 56.443-454, 1969
2. Angle EH The treatment of malocclusion of the teeth and fractures of the maxillae. 6th ed.
Philadelphia. SS White, 1900.
3 Angle EH The treatment of malocclusion of the teeth and fractures of the maxillae. 7th ed
Philadelphia SS White, 1907.
4. Arnett Gw, and Bergman RT.Facial keys to orthodontic diagnosis and treatment planning, Part it. Am
J 0rthod Dentofacial Orthop 103.395-411, 1993
5. Bishara SE, and Jakobsen JR. Changes in overbite and face height from 5 to 4 years of age in normal
subjects. Angle Orthod 68.209-16, 1998
6. Bjork A, and Skieller V. Facial development and tooth eruption: An implant study at the age of puberty.
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8. Bjork A. Prediction of mandibular growth rotation. Am J Orthod 55,585-599, 1969.
9. Broadbent BH. The face of normal children. Angle Orthod7 183-233, 1937.
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1f. Chang Yi, and Moon SC. Cephalometric evaluation of the antenior open bite treatment. Amn J Orthod
Dentolacial Orth0p 115.29-38, 1999
12. Chung WN, and Kim YH. A comparative study of means and standard deviations of 0DI, ADI, and
combination factor in various malocclusions. Korean J Orth0d 22-779831, 1992
13 Daskalogiannakis J, and Amenann, A Glossary of orthodontic terms, Quintessence, 2000
14. Downs WB. Analysis of the dentofacial profile. Angle Orth0d 195626.191-212, 1956
15. Downs wWB. Variation in facial relationships Their significance in treatment and prognosis. Am J
Orth0d. 34.812-840, 1948.
16. Downs WB. The role of cehalometrics in orthodontic case analysis and diagnosis. Am 4 0rod 38
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17. Enlow DH, and Hans MG. Essentials of Facial Growth. Philadelphia WB Saunders 1996.
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18. Epker BN, an O'Ryann F,Determinants of Class fl dentofacial morphology I. A biomechanical
theory. in McNamara JA Jr (ed). The effect of surgical intervention on craniofacial growth. Monograph
No. 12, Craniofacial Growth Series. Ann Arbor Center for Human Growth and Development,
University of Michigan, 1982.169-205
19. Fields HW, and Proffit WR. Facial pattern differences in long faced children and adults. Am J Orthod
85-217.23. 1984.
20. Freudenthaler JW, Celer AG, and Schneider B. Overbite depth and anteroposterior dysplasia
indicators The relationship between occlusal and skeletal patterns using the receiver operating
characteristic (ROC) analysis. Eur J Orth0d 22-75-83, 2000.
21 FushimaK, OdairaY, Saito N, Tsurumi F, and Sat0 S. Dental asymmetry in facial asymmetry. Bulletin
of Kanagawa Dental College. 26.15-21, 1998
22. Graber TM, Rakosi T, and Petrovic AG. Dentofacial Orthopedics with functional appliance, 2nd
edition, Mosby, 1997.
23. Han UK, and Kin YH Determination of Class l and Class II skeletal patterns: Receiver operating
characteristic (ROC) analysis on various cephalometric measurements. Am J Orthod Dentofaial
0rthop 113.538-545, 1998
24 Han UK, and Kim YH. Determination of Class l and Class III skeletal patterns Receiver operating
characteristic(ROC) analysis on various cephalometric measurements. Am J Orthod Dentofacial
Orthop 113.538-545, 1998
25 Kim JI, Akimnoto S, Shinji H, and Sato S. importance of vertical dimension and cant of occlusal plane in
craniofacial development. Int J Stomatol Occlusion Med2114121,2009.
26 Kim JI. Practical Clinical Orthodontics. Vol1 Orthodontic treatment with MEA\W,Well publishing Inc, 2012
27 Kim JI. Practical Clinical Orthodontics. Vol 2. Orthodontic Diagnosis. Well publishing Inc, 2013
28 Kim JI. Practical Clinical Orthodontics. Vol3. Early orthodontic treatment. Well publishing Inc, 2015.
29 Kim YH and Vietas 4J. Anteropostenior dysplasia indicator. An adjunct to cephalometric differential
diagnosis. Am J Orth6d 113619-633, 1978
30 Kim YH, Caulfield Zoe, Chung WN, and Chang YI. Overbite Depth Indicator, Anteroposterior
Dysplasia Indicator, Combination Factor, and Extraction index. Int J MEAW 1/11-32, 1994
31. Kim YH. A comparative cephalometric study of class ti, Division1 Nonetraction and Extraction cases
Angle Orth0d 49-7784, 1979
32 Kim yH Aberrant growth of the mandible and its effect on the occlusion. Int J4EAW65-22, 1999
33 Kim yH Antenior open bite and its treatment with Muttiloop Edgewise Archwire. Angle Orthod 57290-
321, 1987
• 34 Kim YH. Overbite depth indicator (0DI) with particular reference to anterior open-bite. Amn J Orthod
• 65.586-611, 1974
• 35 Linder-Aronson S. Adenoids. Their effect on mode of breathing and nasal airflow and their relationship
to characteristics of the facial skeleton and dentition. Acta Otolaryngol Sand(Suppl 265), 1970.
36 Margolis H. Basic facial pattern and its application in clinical orthodontics. Am J Orthod Oral Surg
33.631641, 1947
37. McNamara JA Jr, and Brudon WL Orthodontics and Dentofacial Orthopedics. Needham Press, 2001.
38. McNamara JA Jr. A method of cephalometnic evaluation. Amn J Orthod 86.449.469, 1984
39. Merrifield LL, Klontz HA, and Vaden JL Differential diagnostic analysis systems. AmnJ Orth0d.
1[fe Cote3_Sear Pe oy
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40. Merrifield LL. Differential diagnosis with total space analysis. J Charles H Tweed Int Found 6.10, 1978
41. Merrifield LL. Differential diagnosis. Semin Orthod 2241, 1996.
42. Merrifield LL The dimensions of the denture back to basics. Am J Orthod Dentofaciat Orthop
106.535, 1994
43. Merrifield LL The profile line as an aid in critically evaluating facial es.thetics. Am J Orthod 11.804, 1966
44. Miyashita K. Contemporary cephalometric radiography. Tokyo, Quintessence, 1996.
45. Moyers RE Handbook of orthodontics. Chicago: Year-book Medical Publisher,1988. 6
46. Nanda R Bi0mechanics and Esthetic strategies in clinical orthodontics, Elsevier Saunders, 2005.
47. Nanda SK. Growth patterns in subjects with long and short faces. Am J Orthod Dentolacial Orthop a
98-247-58, 1990
48. Nanda SK. Patterns of vertical growth in the face. Am J Orthod Dentofacial Orthop 93.103-16, 1988.
49. Proffit WR Contemporary orthodontics. St Louis CV Mosby company, 1986
50. Po#ft WR fields HW, and Noxon WL Oclusal force in normal and long face adults. J Dent Res
62.566-571, 1983.
51. Proffit WR, and Fields HW. Occlusal forces in normal and long face children. J Dent Res 62-571-574,
1983.
52. Richardson A Skeletal factors in anterior open-bite and deep overbite. Am J Orthod 56-114.127,1969
53. Ricketts RW, Bench RW, Gugino CF, Hilgers 4J, and Schulhof RJ. Bioprogressive Therapy. Denver
Rocky Mountain Orthodontics 1979
54. Riedel RA. An analysis of dentofacial relationships. Amn J Orth0d 43-103-119, 1957
55. Sato S. A treatment approach to malocclusion under the consideration of craniofacial dynamics
(unpublished book). 1991
56. Sato S. Orthodontic therapy with multiloop edgewise arch wire (Il). Shinhung international Inc, 2006.
57. Sass0uni V, and Nanda S. Analysis of dentofacial vertical proportions. Am J Orth0d 50.801-823, 1964
58. Sassouni V. A classification of skeletal types. Am J Orth0d 55-109-123, 1969.
59. Schudy FF_The rotation of the mandible resulting from growth its implications in orthodontic
treatment Angle Orthod 35.36-50, 1965
60. Schudy FF,Vertical growth versus anteroposterior growth as related to function and treatment, Angle
Orthod 34.75.-93, 1964
61. Slaviek, RR. The Masticatory Organ. Gamma Dental Edition. 2002
62. Steiner CC. Cephalometrios for you and me. Am J Ort0d 39.729-755, 1953
63. Steiner CC. Cephalometrios in clinical practice. Angle Orthod 29.8-29. 1959.
64. Steiner CC. The use of cephalometrics as an aid to planning and assessing orthodontic treatment
Report of a case. Am J Orth0d 46721-735, 1960
65. Tweed CH. Clinical orthodontics. Vol1 and 2. St Louis. Mosby, 1966
66. Tweed CH. The Frankfort mandibular incisor angle (FMIA) in orthodontic diagnosis, treatment
planning and prognosis. Am J Orthod Oral Sung 24.121, 1954.
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RL Vig KWL, editors. Orthodontics current principles and techniques, 4th edition, Elsevier Mosby. 2005.
68. Wardlaw DW, Smith RJ, Hertweck DW, and Hiebolt CF. Cephalometics of anterior open bite A
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Ca3$% P oyi « 1[[

••••
. . . . .. .. .. .. . . . . . .
. . . . . . . . . . . . . . . . . . .. -- ...
. . . . . . . .. . . .
Chapter 4_
DENTURE PATTERN
ANALYSIS
D Denture Pattern Analysis
In orthodontic diagnosis, a dental analysis can be conducted by measuring the inter-incisal angle,
inclination of maxillary and mandibular anterior teeth, and occlusal plane.
I) Inter-incisal angle (IIA) (Fig. 4-1) This is the angle between the maxillary and mandibular
incisors' tooth axes. Its normal value is generally I30' However, if it is less than 120', it
means that there are protruded maxillo-mandibular anterior teeth; therefore, there is a
greater possibility of extracting premolars. In particular, if the value is below 110', the
possibility of extracting premolars increases, but if the value is around 115,g non-
extraction approach is also possible. The decision can be made by considering the skeletal
pattern factors and other dental factors of individual patients
Fig. 4-1 Inter-incisal angle

(A)
A Diagram.
B. When the inter-incisal angle
has a normal value (128.4)
C When the inter-incisal angle
has a low value (112.6)
D. When the inter-incisal angle
has a high value (143.9°)
•
•
•
2) Maxillary anterior tooth inclination (Fig. 4-2 Maxillary anterior tooth inclination is
marked as the angle between the axis of maxillary anterior tooth and FH plane or occlusal
plane. The angle with the FH plane is, in general, IH4 However, if it is over 120',it means
••••
••••
that there is a labioversion of maxillary anterior teeth. Also, the angle with the occlusal
plane is approximately SS, but if there is a labioversion of maxillary anterior teeth, this
problem can be addressed with a premolar extraction treatment method or through the use
of Class II elastics.
•
•
•
Fig. 4.2 The inclination and position of
maxillary anterior teeth
D inclination. U1 to FH, U1 to NA
( Vertical height U1 to lip line (mm)
(Antero-posterior position: U1 to NA
(mm).
3) Mandibular anterior tooth inclination (Fig. 4-3: Mandibular anterior tooth inclination is
marked as the angle between the axis of mandibular anterior tooth and mandibular plane. In
general, its normal value is 90 This angle refleets the different patterns of dental
compensation, according to skeletal patterns. In the case of Class II malocclusion,
mandibular anterior teeth show labioversion, while in the case of Class Ill malocclusion,
mandibular anterior teeth show linguoversion.
In particular, if the value is lower than 83, it is one of the most important factors that
determine the need of surgical treatment for Class Ill patients.
Fig. 4.3 The inclination and position of

mandibular anterior teeth
(9inclination L1 to mandibular plane LT
to A-Pog. L1 to NB
2 Vertical height L1 to lip line (mm)
(Anter-posterior position L1 to A-Pog
ctr4Detore Pm oy 1[_
4) Occlusal plane inclination (Fig. 4.-4). This is the angle between the bisected occlusal plane
(the center of the maxillo-mandiblular incisal tips and the center of maxillo-mandiblular
first molars) and FH plane. Its normal value is I0'. This angle changes as patients grow,
and it tends to get flattened with posterior growth
Fig. 4-4 0clusal plane inclination

A. Bisected occlusal plane: the line that connects the cusp tips of mall-mandibular first molar
to the center of the maxilla-mandibular incisal edges
B. Functional oclusal plane the line that connects the occlusal surface of the mandibular fest
molar to the cusp tip of the mandibular first premolar.
� Occlusal Plane
In previous orthodontic diagnosis approaches, a dental analysis was usually conducted by

measuring on a dental model. In a lateral cephalogram, inter-incisal angle, mandibular and
maxillary anterior teeth positions, and occlusal planes were measured and assessed. This kind of
occlusal plane is assessed, based mainly on Downs' bisected occlusal plane.
•
• As for dental patterns, it is more desirable to assess the occlusal plane that tefleets the occlusal
• condition of the maxillo-mandibular teeth. To be precise, the occlusal plane does not have a flat
straight form but a curved shape. When the occlusal plane is viewed from the sagittal plane, curve
of Spee is observed, and when seen from the frontal plane, curve of Wilson is observed (Fig. 4-5).
When assessing the curve of Spee, the occlusal plane must be assessed from the perspectives of
level, cant and curvature. Level is the distance from UI to the lip line, cant is an inclination of
upper occlusal plane, and curvature is an inclination of posterior occlusal plane
1[6»»co4boor Poon y
••••
••••
These occlusal planes have the following meanings.
Ny
•
€ �
¥
•
•
A
Fig.4.5 0lusal plane

.
A.Curve of Spee B. Curve of Wilson
�
The meaning of occlusal plane
I) Masticatory efficiency (Fig. 4-6: If the occlusal plane has a curved shape rather than a straight
shape, the contact areas of maxillo-mandibular teeth become large, and therefore leads to
greater masticatory efficiency
Fig. 46 0clusal plane and masticatory efficiency

A. Flat OCClus.al plane
B. Curved occlusal plane
Car4Orte y + ]
2) Disclusion (Fig. 4-7): If there is a severe curved shape, the forward and lateral movements of
mandibular teeth will increase the risk of premature contact.
B-
Fig. 4-7 Occlusal plane and posterior disclusion (Fushima et al.,1996)

A. The relationship between posterior occlusal plane and the sagttal condylar guidance
B-1. Posterior disclusion in flat occlusal plane
B.2 Posterior disclusion in curved occlusal plane.
3) Mandibular position (Fig. 4.8) According to Kim et al. (2009), a steep occlusal plane (UOP
and POP)y increases the possibility of posterior positioning of mandible. In contrast, a flat
occlusal plane increases the possibility of anterior positioning of mandible
B
Cuss II Cs 1It
•
•
•
• -
Fig. 4.8 Occlusal plane and mandible position (Kim et al., 2009)
A. Correlation between POP and skeletal pattern
B. Class malocclusion steep pop
C Class Iii malocclusion fat POP
• •••
••••
4) Aesthetics (Fig. 4-9): Cases with a steep occlusal plane (UOP and POP)y show a protrusive
profile due to the posterior positioning of mandible. In contrast, cases with a flat occlusal plane
show a mandibular prognathism due to the anterior positioning of mandible. Additionally, even
when maxillary anterior teeth are extruded, there may still be a gummy smile and a protrusive
facial profile due to mandibular retrusion and the steep upper occlusal plane (UOP')
•
•
•
Fig.4.90oelusal plane and anterior aesthetics
A The position of maxillary anterior teeth and anterior

aesthetics (Cozzani, 2000').
C Normal maxillary anterior teeth

5 Denture pattern (Fig. 4-10): despite a similar skeletal pattern and intraoral manifestation,
denture patterns can still be different.
•
•
•
Fig.4-10A variety of ooclusal panes
A. A variety of occlusal planes A variety of occlusal planes in Class I, Il and Ill
malocclusion subclasses (Naretto et al, 20O9)
B.A variety of occlusal planes in Class ll malocclusion
8-1 Steep 00P (17.9)
8-2. Normal 0OP (72) and POP (122)
B-3. Normal UOP (11.1) and steep POP (18.4)
[»»Cir4Deur %en y
••••
••••
�
Evaluation factors of occlusal plane
I) Level(Fig. 4-IH: This is the straight distance from UI to the lip line. If the maxillary anterior
teeth are located lower than the lip line, it is marked as positive (+), but if they are located
higher than the lip line, it is marked as negative (-). In general, when the UI incisor tip is mm
•
inferiorly away from the lip line, it is considered as normal. In particular, if it is over Smrn, the •
intrusion of maxillary anterior teeth may be required. •
Fig.4.1f occlusal plane level

A. Vertical height of U1.
B. Avariety of cases
B.1. Normal maxillary anterior teeth (3.0mm).
B-2. Extruded maxillary anterior teeth (10.5mm)
B-3 Intruded maxillary anterior teeth (-20mmn)
2) Cant(Fig. 4-12): This is the angle between UOP (upper occlusal plane) and FH Line
Here, UOP is a line that connects the tips of maxillary incisors to the center of the maxillary
first molar. In general, its normal value is 1p% can be divided into two cases (I) a normal
UOP, and (2) a steep UOP (above 15°)
Fig. 4-12 0cclusal plane cant
A UOP (Upper Occlusal Plane)
Char4Dente Pe oei « [
Fig. 4-12 (continued) Occlusal plane Cant
B-1 Normal U0P (12.7) 8-2 Steep U0P (16.0') 8-3. Flat u0P (4.9°)
C.Case showing normal UOP

(10)
D.Case showing steep U0

(15.8)
•
•
•
13[»Cote4bet Pm oy
••••
••••
3) Curvature (Fig. 4-13y: This is the angle between the posterior occlusal plane (POP) and FH plane.
Here, the POP is a line that connects the cusp tip of mandibular second premolar to the distal
cusp tip of mandibular second molar. In the case of Class I malocclusion, its value is lower
than 13, If the value is higher than I5,it is called a steep POP (Fig. 4.14). This type of steep
POP is closely related to mandibular retrusion, typically showing Class ll malocclusion. In
contrast, a flat POP is closely related to Class IHI malocclusion. «
•
Fig.4-13 0clusal plane curvature
A. Posterior Occlus.al Plane (POP)
B-1. Normal Poe
(t.7)
B-2 Steep POP
(18.9)
8-3.Flat POP(g')
C.Case showing normal po9 (10.4)
+
car4De Po oy « [
Fig.4-13(continued) Oclusal plane curvature
D.Case showing steep pop (15)
E Poe and skeletal malocclusion
A +8
•
•
•
Fig.4.14 Steep POP
A Relatively over-erupted mandibular posterior teeth
B. Excessive mesial angulation of mandibular posterior teeth
de Choir4Dt Pen or
••••
••••
� Changes of Occlusal Plane
'9 Change patterns of occlusal plane

•
•
•
In normal growth cases, as the mandible and occlusal plane both rotate in a counter-clockwise
(CCW) direction, the SN-MP angle decreases (Schudy, 1963)
D Normal growth (Fig. 4-15)

(Case of orthodontic treatment (Fig. 4-16).
Case of onthognathic surgery (Fig. 4-17)
e 4.0 M rr-As(ron
•
•'
6.AS
4th
IM.7±A4
#J
44
ts
.t
t#
1AT
ft4
,_--- - _,-
�
•• SJ±A
1l4% A#
±4
t#4$
t.st#
t" 44
A44
#AT 6.#44
6.#4#
±1
34
1 .4$
�- .... - .. , .............-1
4
" I#4 44
�
Fig.4.1s Normal growth (Sato et al., 1994)
Fig.416Case of orthodontic treatment

c
0
®
U
8 0
8
U
• U
''
r'
Fig.4.417Case of orthogathic surgery (Wolford et al., 1993)
I) During orthodontic treatment, a l change in occlusal plane can bring about a change of
0.5mm in dental occlusion (Fig. 4-18)
2) Changes in occlusal plane should be different depending on the type of malocclusion.
()in the case of a skeletal patter with an open bite tendency, it is desirable for the occlusal
plane to rotate in a counter-clockwise direction, but in the case of a skeletal pattern with a
deep bite tendency, a clockwise rotation is desirable
(2)Also, in the case of a skeletal patter with a Class ll open bite tendency, it is desirable for
the occlusal plane to rotate in a counter-clockwise direction, but in the case of a skeletal
pattern with a Class Ill deep bite tendency, a clockwise rotation is desirable
•
•
• tee000a
le5e ot.on)
64 P
(outer hot.cl
Fig. 4.18 Relationship between changes in occlusal plane

and occlusion.
A change in occlusal plane can bring about a change of
0.5mm in dental occlusion (Braun and Legan,1997)
6»» cwt4Denture Pen oy

••••
••••
48 Steepening/Clockwise rotation vs Flattening/Counter-clockwise

rotation
1) Maintaining the occlusal plane (Fig. 4-19)

•
This is an orthodontic treatment that aligns the anterior teeth while maintaining the posterior •
occlusion as much as possible. Diagnosis and treatment planning can be made relatively easily, but •
some unexpected changes in the occlusal plane can occur during treatment, which can cause some
difficulties and complications, For this reason, this method is applied only to limited cases of
malocclusion, such as cases with an acceptable posterior relationship and flat curve of Spee.
0 Pe
r0 -
IV\ V
WI i� V 2
Fig. 4.19Maintaining occlusal plane.
2) Changes in occlusal plane
Most orthodontic patients have antero-posterior as well as vertical and transverse problems, $0 a
comprehensive assessment must be made. Maintaining the posterior occlusal plane can help
treatment, but in cases of Class ll and IHI malocclusion, there may be a need for changes in the
posterior occlusal plane
(I) Steepening/ Clockwise (CW) rotation (Fig. 4-20 A: This is when the occlusal plane rotates
in a clockwise direction, as the picture below shows. This change commonly occurs due to
the use of Class ll elastics. Here, the mandible is more posteriorly positioned and, as a
result, mandibular anterior teeth show a labioversion. For this neason, during the treatment
of Class I and II malocclusion cases, occlusal conditions and aesthetics are highly likely to
get worse. Even when a non-extraction treatment method is applied, the need for premolar
extraction increases. However, in the case of Class Ill malocclusion, a positive outcome can
be expected due to the posterior movement of mandible
Ca4Dr Poe ey 7
(2) Flattening/ Counter-clockwise (CCW) rotation (Fig. 4-20 By: This is when the occlusal
plane rotates in a counter-clockwise direction, as the picture below shows. This change
commonly occurs due to the use of class [l elastics. Here, the mandible is more anteriorly
positioned and, as a result, mandibular anterior teeth show a linguoversion.
For this reason, during the treatment of Class l and ll malocclusion cases, non-extraction
treatment approaches are not only possible but also can be applied easily. However, in the
case of Class [lf malocclusion, there may be a negative outcome due to the anterior
movement of mandible
a
» Fig. 4-20Changes in
bolus.al plane
A Steepening of occlusal
plane and clockwise
rotation there is a
backward and downward
rotation of mandible,
linguoversion of maxillary
antenior teeth, and
labioversion of mandibular
anterior teeth
ml B. Flattening of occlusal plane
and counter-cocowrsee
rotation there is a forward
rotation of mandible
labioversion of maxillary
anterior teeth, and
Bl linguoversion of
C Flattening of posterior
• 00Clos.al plane. 0Outer-
• cloclowise rotation of
• posterior oclusal plane

(POP)
j
13[»e woe4bet Pt oy
••••
••••
-..
Changes in occlusal plane with orthodontic appliances
The common orthodontic appliances and their effects are as follows:
•
1) Extra-oral appliances •
•
(I Headgear
D High pull headgear (Fig. 4-21 A)
2Cervical pull headgear (Fig. 4-21 B)
J-hook type - High pull headgear.
(2)Face mask (Fig. 4.-22)
ri
/f
1
Cl
Fig.421Head gear
A. Diagram of higt-pull headgear. intrusion and distal movement of maxillary posterior teeth,
and steepening of upper occlusal plane (UOP)
• Diagram of straight-pull headgear. distal movement of maxillary posterior teeth
C Diagram of cervical headgear extrusion and distal movement of maxillary posterior teeth
and flattering of upper occlusal plane (UOP')
D. Apatient with a cervical headgear on
Cc4bu Posy + g
Fig. 422Face mask.
A. Diagram of face mask: forward movement of maxilla, and the extrusion and forward
movement of the maxillary first molar
B. Apatient with a face mask on
2) Removable appliances
(I Anterior bite plate (ABP)(Fig. 4-23)

(2) Posterior bite block (PBB)(Fig. 4-24)
(3) Functional appliance (Fig. 4.-25)
•
•
• Fig. 423 Anterior bite plate
A. Anterior bite plate
B With an anterior bite plate on
C Force mechanisms after putting the anterior bite plate on the maxilla due to the extrusion of
mandibular molars and the intrusion of mandibular anterior teeth, the mandibular occlusal plane
rotates in a clockwise direction
••••
••••
•
•
•
Fig. 4-24 Posterior bite block
A. Posterior bite block
• Watha posterior bite block on
C force mechanisms after putting the posterior bite block on the
mandible due to the intrusion of mandibular molars and the
extrusion of mandibular anterior teeth, mandibular occlursal plane
rotates in a counter-loclwise direction
Fig.42 Functional appliance

A. Twin block appliance (TB).
8 Watha twin block appliance on
C Force mechanisms after putting the twin block appliance on both
arches. The molar freeway space is created by the forward
movement of the mandible There may be an increase in
posterior vertical dirnension due to the extrusion and uprighting
of the maxillary and mandibular posterior teeth
Coot4Dt Peno [
3) Fixed appliance
(D) Transpalatal arch (TPA (Fig. 4-26)

(2) Intrusion arch (double archwire (DAW) and utility archwire)(Fig. 4.27)
() MEAW (Fig. 4-28)
Fig.4.26 Transpalatal arch (TPA)

A. Transpalatal arch
B.With a transpalatal arch on
C Force mechanisms after putting the transpalatal arch on the
maxilla by placing the omega loop on the maxilla in the mesial
direction, it can prevent the extrusion of maxillary posterior teeth,
causing an intrusive effect (Cetlin and Hoeve, 1983)
Bl +8-2
•
• Fig.4.27Double archwire (DAW).
• Due to the intrusion of maxillary anterior teeth and the extrusion of
maxillary posterior teeth, the maxillary occlursal plane rotates in a
counter-clockwise direction For this treatment, neither the
transpalatal arch nor the high pull headgear are put on the maxillary
posterior teeth
A. Double archwire
8 Wth a double arcwire on
C. Force mechanisms after putting a double archwire on the maxilla
1Le Chapter4Dote Pon Aoay

••••
••••
Fig.4.28 MEAW
A MEAW •
B Watha MEAW on
•
C. Force mechanisms after
putting the MEAW on the arch •
Tip back activation tniggers
intrusion and labioversion
of anterior teeth
4) Inter-maxillary elastics
(D)Class I elastics (Fig. 4-29)

(2) Class II elastics (Fig. 4-30)
(3) Class Ill elastics (Fig. 4-31)
(4) Anterior vertical elastics (AVE(Fig. 4-32)
(5)Long elastics (Fig. 4-33)
(6) Short elastics (Fig. 4-34)
Fig. 4.29 Class l elastics

since the same fore is applied
on the intra-arch, no changes
are made on the occlusal plane
Corte Poor [
Fig. 4.30 Class ll elastics
A. Ideal archwire and long Class ll elastics Force vector triggers the extrusion
and forward movement of mandibular posterior teeth and the extrusion and
backward movement of maxillary anterior teeth as welt The occlusal plane
rotates in a clockwise direction
B. MEAW and short Class ll elastics: Class ll elastics nigger the backward
movement of maxillary anterior teeth and the entire maxillary dentition, and the
forward movement of mandibular dentition as wet The force mechanisms of
ME AW and short Class ll elastics cause an intrusion and forward movement of
mandibular posterior teeth, and the extrusion and forward movement of
mandibular premolars as well. This means that the occlusal plane rotates in a
coos+se recton so me moo-ma"""""""rae en sot se antero-
posteriorly and vertically improved by controlling the extrusion of mandibular
posterior teeth
Fig. 4.34Class Ill elastics

• A. Ideal archwire and long Class ll elastics Force vector triggers the extrusion
and forward movement of maxillary posterior teeth and the extrusion and
• backward movement of mandibular anterior teeth as wet As a result, this can
• facilitate a counter-clockwise rotation of the occlusal plane
B. MEAW and short Class Ill elastics: Class ll elastics trigger the backward
movement of mandibular anterior teeth and the entire ma0bular dentition, a0
the forward movement of maxillary dentition as welt The force mechanisms of
MEAWand short Class Ill elastics cause an intrusion and forward movement of
maxillary posterior teeth, and an extrusion and forward movement of maxillary
premolars as well This means that the occlusal plane rotates in a counter-
clockwise direction, but the maolo-raibular dental arch can still be antero-
posteriorly and vertically improved by controlling the extrusion of maxillary
posterior teeth
d»chaste4 bee P%
••••
••••
•
•
•
Fig.4.32 Anterior vertical elastics (AVE)
Tip back activation triggers an intrusion and labioversion of anterior teeth, and an
intrusion and distal angulation of posterior teeth as welt The use 0of 3/16 602
elastics on anterior teeth causes an extrusion and linguoversion of maxillo-
mandibular anterior teeth as well as an intrusion and distal movement of mnaxdllo-
mandibular posterior teeth
+8
Fig. 4-33Long elastics.

A Long Class ll elastics due to an extrusion of mandibular posterior and
maxillary anterior teeth, the oclusal plane rotates in a clockwise direction
B.Long Class Ill elastics due to an extrusion of maxillary posterior teeth and
mandibular anterior teeth, the occlusal plane rotates in a counter-clockwise
direction
Cow4Or Pon or «[
B
Fig. 4.34 Short elastics

A Short Class ll elastics: The oclusal plane rotates in a clockwise direction, but
the extrusion of mandibular premolars and maxillary anterior teeth still occurs
Depending on the type of main archwire used, the intrusion of mandibular
posterior teeth can also 0Cur.
B. Short Class Ill elastics: The occlusal plane rotates in a counter-clockwise
direction but the extrusion of maxillary premolars and mandibular anterior
teeth still occurs. Depending on the type of main archwire used, the intrusion
of maxillary posterior teeth can also 0Cur
5) Mini-implant (Fig. 4-35)
Fig.43 Mini-implant
A mini-implant can be used to close the extraction space
and to control the occlusal plane. Different orthodontic
forces can be applied depending on the positions of the
mini
-implants (Park, 2001)
•
•
•
1f»or4Denture Pon y
••••
••••
'b Methods of changing the occlusal plane
There are four methods of changing the occlusal plane, which require different orthodontic
appliances. These are as follows:
•
•
I) Counter-clockwise rotation of upper occlusal plane (UOP extrusion of maxillary posterior •
teeth and intrusion of maxillary anterior teeth (Fig. 4-36)
(I)Extrusion of maxillary posterior teeth

Cervical headgear.
(2Anterior bite plate (ABP)
(Class Ill elastics.
Face mask
Intrusion arch (double archwire and utility arch)
(2)Intrusion of maxillary anterior teeth

QDHigh pull headgear -J hook.
(Intrusion arch (double archwire and utility arch).
MEAW.
(Mini-implant
A
·• Extrusion of upper molars intrusion of upper incisors
1 Cervical headgear 1_4hook -high put headgear
2Anterior bite plate 2intrusion arch
3Class II elastics
(double rchire and utility arch)
4aoemask
3,MEAW
5 intrusion arch
(double arcure and utty arch) 4Mini-implant
Fig. 4.36 Counter-clockwise rotation of upper occlusal plane (U0OP')

A. Fattening of upper occlusal plane (U0P)
B. Extrusion of maxillary posterior teeth
C. Intrusion of maxillary anterior teeth
Char4De Pe oey h
2) Counter-clockwise rotation of lower occlusal plane (L0Py intrusion of mandibular posterior
teeth and extrusion of mandibular anterior teeth (Fig. 4-37).
(intrusion of mandibular posterior teeth

(Cervical headgear
(MEAW.
Posterior bite block (PBB)
(0Mini-implant
(2)Extrusion of mandibular anterior teeth

(Class III elastics
2Posterior bite block (PBB)
·• Intrusion of lower molars Extrusion of lower incisors
1,Cervical hea09gear 1, Class Ill elastics
2.MEAW 2.Posterior bite block

3,Posterior bite block
4 Mi-implant
Fig.4.37 Counter-clockwise rotation of lower ooclusal plane (LOP')

A. Flattening of lower occlusal plane (LOP)
B. Intrusion of mandibular posterior teeth
C Extrusion of mandibular anterior teeth
•
•
•
• •••
••••
3) Clockwise rotation of upper occlusal plane (UOPy intrusion of maxillary posterior teeth and
extrusion of maxillary anterior teeth (Fig, 4-38).
(I)intrusion of maxillary posterior teeth

(2High pull headgear.
•
(2MEAW.
•
(Posterior bite block (PBB) •
@0Transpalatal arch (TPA).
( Mini-implant.
(2Extrusion of maxillary anterior teeth

2Cervical headgear
Q2Class II elastics.
·• Intrusion of upper molars Extrusion of upper incisors
1,Mgh pull headgear

1_Cervical pull headgear
2ME£AW
3Posterior bite block
4 Transpalatal arch
Fig. 4-38 Clockwise rotation of upper occlusal plane (U0')

A. Steepening of upper occlusal plane (UOP')
B. Intrusion of maxillary posterior teeth
C. Extrusion of maxillary anterior teeth
Char4Ore oei 4d
4) Clockwise rotation of lower occlusal plane (LOP extrusion of mandibular posterior teeth and
intrusion of mandibular anterior teeth (Fig. 4.39)
(/)Extrusion of mandibular posterior teeth

Class II elastics.
(2Anterior bite plate (ABP)
Intrusion arch (double archwire and utility arch).
(2Intrusion of mandibular anterior teeth

(Intrusion arch (double archwire and utility arch)
2Anterior bite plate (ABP)
MEAW.
@0Class II elastics.
(Mini-implant
A",
r'1ttsion of lower molars Intrusion of lower incisors
1_Class II elastics 1_intrusion arch
2.Anterior bite plate (double archire and utility arch)

2Anterior bite plate
3 intrusion arch
3.MEAW
(double arch#ire and utty arch) 4Class pl elastics
5 Mi-implant
Fig. 4-39 Clockwise rotation of lower occlusal plane (LOP)

A. Steepening of lower occlusal plane (LOP')
B Extrusion of mandibular posterior teeth
C Intrusion of mandibular anterior teeth
•
•
•
1[f»»co4bur Pen y
••••
••••
�
Correlation between the changes of occlusal plane and extraction
(Fig. 4-40)
The changes in occlusal plane are closely related to the extraction of mandibular first or second
•
premolars. In the case of an extraction of the mandibular first premolars, it is difficult to upright
•
the mandibular posterior dentition (second premolars and first and second molars) after the space •
closure. For these reasons, to treat the cases of flat curve of Spee and normal posterior occlusal
plane, an extraction of the mandibular first premolars is possible. However, to treat severe curve of
Spee and steep posterior occlusal plane, a non-extraction method is desirable. If an extraction
method is inevitable, the extraction of the mandibular second premolars is recommended rather
than the extraction of the first premolars.
For an effective orthodontic treatment, the skeletal patterns of a patient must be first analyzed
accurately, and based on this analysis his or her dental patterns must be evaluated. If a non-
extraction treatment method is difficult to be applied, then an extraction treatment method becomes
inevitable. In this case, it is desirable to decide which tooth to extract after considering whether the
occlusal plane should be maintained or changed. Only after all of this is done should a decision on
the proper orthodontic force be made
Fig.4.49 Correlation between the premolar extraction and changes of occlusal plane
l the case of mandibular first premolar extraction, positive outcomes are typically accompanied by the
anterior growth and uprighting of mandibular posterior teeth (Refer to Fig. A-1). However, when treating
adult patients, there occurs only an anterior teeth movement without the changes in mandibular posterior
teeth (Refer to Fig. A-2). In contrast, in the case of mandibular second premolar extraction, both the
forward movement and uprighting of mandibular posterior teeth occur, as demonstrated in Fig. B
A Changes in occlusal plane after the mandibular first premolar extraction
.Changes in occlusal plane after the mandibular second premolar extraction
Chair4Dot Pt oy 1[
The assessment procedures of an individualized orthodontic treatment
I. Evaluate the aesthetic conditions of the patient.

2. Analyze the skeletal patters of the patient.
3. Examine whether changes can be made on the skeletal patters. To treat growing patients,
changes on the skeletal patterns are possible. In the case of a high CF, a desirable skeletal
change is probable, but in the case of a low CF, a desirable change is less likely. As for
adult patients, changes in skeletal patterns are impossible
4. Analyze the denture patters of the patient. Check to see whether a non-extraction treatment
method or an extraction treatment method is required.
I)Positional changes in the maxillary anterior teeth.
2)Changes in the upper occlusal plane
3)If you decide to change the posterior occlusal plane, you must check the possibility of
tooth movement
5. Solve the chief complaints (CC) of the patient
6. Fully understand the correlation between skeletal and denture patterns
Fig.44f
Individualized orthodontic treatment
•
•
•
1G2»cwt4Detore Pm oy ••••
••••
Olnlcat
Tips: Making decisions an the position of the occlusal plane.
1, Decide the position of maxillary anterior teeth
1) Vertical position make sure that the distance from U1 to the lip is 3mm and
the lower lip line is placed on the incisal third of maxillary anterior teeth
•
2) Inclination the angle from U1 to FH should be set close to 114 s much as •
possible. •
2. Decide the position of mandibular anterior teeth make sure that the overjet and
overbite are approximately 3mm apart
3. Decide the position of occlusal plane
f) in general, the occlusal plane passes by the stomion, incisal tip of mandibular
anterior teeth and the Xi point
2) Form a perpendicular angle from the posterior occlusal plane to the AB plane
as best as possible.
4. Decide the position of molars form a perpendicular angle from the poste ior ooclusal
plane to the molars (especially the mandibular molars) as best.as os.$le
Olnlcal
Tips: Changes in occlusal plane
1. First, choose which tooth to extract from various options
1) Examine how the occlusal plane will change after the extraction
2) in order to make the finishing procedure simple and easy, make the molar
relationship as the cusp-to-cusp relationship. In other words, it is important not
to make a full cusp Class Il molar relationship. Try to make a Class l canine
relationship as best as possible
2. Treat each patient by considering whether the occlusal plane should be changed
or maintained
) Occlusal plane rotates in a counter-clockwise direction
2) Oclusal plane rotates in a clockwise direction
►►►►►►
Choir4Orte P Aoay «« 1[[d
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[d» Chor4Dure Pee Aoay

••••
••••
23. Downs WB: The role of cehalometrics in orthodontic case analysis and diagnosis. Am J Orthod
38.162-183, 1952
24. Enlow DH, and Hans MG. Essentials of Facial Growth. Philadelphia WB Saunders; 1996.
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•
posterior occlusal plane in Class It division 1 malocclusion European Journal of Orthodontics 1827-
•
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28. Hara;abakis NB, and Sifakakis I8. The effect of cervical headgear on patients with high or low
mandibular plane angles and the myth" of posterior mandibular rotation. Am J Orthod Dentofacial
0rthop 126./310-317, 2004.
29. Huynh T, Kennedy DB, Jo0ndeph DR et al. Treatment response and stability of slow maxillary
expansion using Haas, hyrax and quad-helix appliances. Amn J Orthod Dentofacial Orthop 136.331-
339, 2009.
30. Hwang DH, Akimoto S, and Sato S. Olusal plane and mandibular posture in the hyperdivergent type
of malocclusion in mixed dentition subjects. Bull Kanogawa Dent Coll 30.87-92, 2002
31. lngervall B, Gollner P, Gebauer U, et al. A clinical investigation of the correction of unilateral molar
crossbite with a transpalatal arch. Am J Orthod Dentofacial Orth0p 107418-425, 1995
32. lscan HN, and Saris0y L. Comparison of the effects of passive posterior bite -blocks with different
construction bites on the craniofacial and dentoalveolar structures. Am J Orthod Dentolac Orthop
112171-178, 1997.
33. lshi H, Morita S, TakeuchoY, and Nakamura. Treatment effect of combined masollary protraction and
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34. Kim JH, MC Viana, TM Graber, FF Oeneraza, and EA BeGolie. The effectiven s of protraction face
mask therapy. A meta-analysis. Am J Orthod Dentofac Orthop 115675-685, 1999.
35. Kim JI, Akimoto S, Shinjj H, and Sato S. importance of vertical dimension and cant of occlusal plane in
craniolacial dev lopmnent. int 4 Stomatol Occlusion Med 2114.121,2009.
36. Kim JI. Practical Clinical Orthodontics. Vol 1, Orthodontic treatment with ME AW Well publishing inc,
2012
37. Kim JI. Practical Clinical Orthodontics. Vol 2. Orthodontic Diagnosis. Well publishing in, 2013
38. Kim JI. Practical Clinical Orthodontics. Vol3. Early orthodontic treatment. Well publishing Inc, 2015.
49. Kim YH and Vietas 4J. Anteroposterior dysplasia indicator. An adjunct to cephalometic differential
diagnosis. Am J Orth0 113619-633, 1978
40. Kim YH, Caulfield Zoe, Chung wN, and Chang YI. Overbite Depth Indicator, Anteroposterior
Dysplasia Indicator, Combination F actor, and Extraction index. Int J MEAW 1.11-32, 1994
41. Kim YH, and Han UK. The Versatility and Effectiveness of the Muttiloop Edgewise Arch»ire(4EA) in
Treatment of Various Malocclusions. World J Orthod 2208-218, 2001.
Ce«be.re y Go
42. Kim YH. A comparative cephalometric study of class II, Division 1 Nonetraction and Extraction cases
Angle Orth0d 49-77-84, 1979
43. Kim YH. Anterior openbite and its treatment with Mutiloop Edgewise Archwire. Angle Orthod 57290-
321, 1987
44, Kim YH. Antenior openbite and its treatment with Multiloop Edgewise Arch.Wire. Angle Orthod 57290-
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45. Kim YH. Overbite depth indicator(0DI) with particular reference to anterior open-bite. Am J Orthod
65.586-611, 1974.
46. Kim YH Treatment of anterior openbite and deep overbite malocclusions with Multiloop Edgewise
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47 Kloehn SJ. Evaluation of cervical anchorage force in treatment Angle Orthod 3191.104, 1961.
48. Lagerstrom LO, Nielsen IL, Lee R, Isaacson RL. Dental and skeletal contributions to occlusal
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49. McNamara JA Jr, and Brudon WL Orthodontics and Dentofaciat Orthopedics. Needham Press, 2001
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55. Moyers RE.Handbook of orthodontics. Chicago:. Year-book Medical Publisher,1988.
56. Nanda R Biomechanics and Esthetic strategies in clinical orthodontics, Elsevier Saunders, 2005.
57 Naretto et al.. Occlusal plane related to skeletal pattern in mixed dentition stage; a descriptive
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• 65.321-326, 1995.
• 60. 0'Grad pw_McNamara JA Jr, Bacceti T, et al. A long-term evaluation of the mandibular Schwarz
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63. Richardson ER Atlas of craniofacial growth in Americans of African Descent, center of Human Growth
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96»cwer4boor fern oy • •••

••••
64. Ricketts RW, Bench RW, Gugino CF, Hilgers 4J, and Schuthof RA. Bioprogressive Therapy. Denver.
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&5. Riedel RA. An analysis of dentofacial relationships. Amn J Orth0d 43.103-119, 1957
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68. Sato S, and Suzuki Y, Relationship between the development of skeletal mesio-occlusion and •
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Cece4be.re Pe y 1G7
••••
......-::::::err:regs;;u;ii
. -- ..... . . .. .. . . ........
. . . . . . . . .. . .. . . . . . . . . .. .. ..
. . . . . .. . .
Chapter 5
ORTHODONTIC
DIAGNOSIS
D Orthodontic Differential Diagnosis
After the introduction of fixed orthodontic appliances, there are growing concerns regarding the
treatment method. The orthodontist should make a final decision on whether to exercise an
extraction or non-extraction treatment method.
When making this decision, the following data must be carefully analyzed:
L. Aesthetic analysis, 2. Cephalometric analysis, 3. Model analysis.
The procedures of orthodontic differential diagnosis are as follows (Table. S-1)

a. First, analyze the aestheties of the patient (Fig. 5-I)
ln Class II malocclusion, move the mandible at its forward position, and in Class Ill
malocclusion, place the mandible at its posterior position. However, if there is a midline
deviation, reconcile the midline and then analyze the facial profile (Fig. 5-2). From this, there
can be two types of outcomes: I) acceptable facial profile, and 2) unacceptable facial profile_ [f
the profile is acceptable, a non-extraction treatment can be conducted appropriately based on
the size of crowding. However, if the profile is still unaesthetic, an extraction treatment or a
surgery-combined orthodontic treatment is advised (Fig. 5-3).
Table. Sf Orthodontic differential diagnosis
1, Aesthetic A0oeol.ab Poor

2CF Mot gt Low Low Ho Low
3Non-ctraion Possible D#ficul Possible Diel
approach
1)v0
2 0P
3) Space gaining
bx, Method Non-Et Ext Nooe-Dt Et Ext Et
• ••
•
•
Fig..4 Aesthetic assessment

A. Profile view of a patient with Class ll malocclusion
B. Profile view of a patient with Class Ill malocclusion
C Front view of a patient who has midine deviation
1Gc»» ors_Oroon Ono

••••
••••
Fig.52Profile and front assessment of edge-to-edge occlusion
•
•
•
A. A patient with Class I malocclusion.

A-1 Facial and intraoral photographs of maximum bite
A.2 Facial and Intraoral photographs after moving the mandible forward
Cc$_Orinoco0ti bro « 1@[

Fig.S2 (continued) Profile and front assessment of edge-to-edge occlusion
•
•
•
B.A patient with Class Ill malocclusion
B-1.Facial and intraoral photographs of maximum bite
B-2. Facial and intraoral photographs after moving the mandible in a backward direction for edge-to-
edge bite.
1[»tors_Orocotic boo
••••
••••
fig.2(ontimueed Profile and front assessment of edge-to-edge occlusion
•
•
•
C.A patient who has midline deviation

C1.Facial and intraoral photographs of maximum bite
Cc2Facial and intraoral photographs after moving the mandible and matching the midlives
cars_0eo0etc Do « 1@
A.2
hose
Nora/hetoe
0rhodontical
rectal
eatable
Fig.5.3Profile and front assessment of edge-to-edge occlusion

A1 A patient with Class I malocclusion assessment of profile view when the mandible is moved in a
forward direction
A2. Maxillary protrusion
A.3. Long lower anterior facial height (LAFH)
.f A patient with Class Ill malocclusion. assessment of profile view when the mandible is moved in a
backward direction
B2 Mandibular prognathism
B-3. Long lower anterior facial height (LAFH)
C-1. A patient who has midline deviation assessment of front view when the midline is correctly
matched
C2,3.Lip canting.
•
•
1[4»»Cotes0octoric Do
••••
••••
b. Examine the value of CF, If it is over 155, a non-extraction treatment can be used, but if it is
below 150, an extraction treatment may be required (Fig. S-4)
•
•
•
Fig.5-d Combination factor (CF)assessment.

A. An explanatory diagram of 0DI/ ADI/ CF ACF is over 155. a non-extraction treatment can be used
B. Profile, intraoral photograph, and cephalometric radiograph of Class ll low angle
(OD APD/ CF = 80/ 77/ 157)
C. Profile, intraoral photograph, and cephalometnic radiograph of Class l high age
(OD/ APD CF + 71/73.5/ 144.5)
0aces 0eoclot Doro 1[[

e. Check whether a non-extraction treatment approach is possible
a) Check the possibility of space preservation (Fig. 5S-5). Depending on the size difference
between primary teeth and permanent teeth, maxillo-mandibular crowding of mixed
dentition can be treated through the use of Leeway space. In these cases, Kim et al.
(2009) pointed out that Class II malocclusion is closely related to the over-eruption of
mandibular molars in the early mixed dentition period. In addition, Class Ill
malocclusion is closely related to the over-eruption of maxillary first molars in the early
permanent dentition period.Therefore, in non-extraction Class II malocclusion cases, it
is advised to use a lingual arch on the mandible, whereas in non-extraction Class Ill
malocclusion cases, the transpalatal arch (TPA) should be used on the maxilla for
desirable outcomes.
b)Check whether space can be gained or not (Table. 5-2)
(a) Gain space by solving the mesial rotation.
(b) Gain space by expanding the dental arch laterally.
(e) Gain space by distally moving the molar.
(d) Gain space through stripping
(e) Gain space through the labioversion of incisors
e) Changes in occlusal plane (Fig. 5-7):
(a)If the occlusal plane is rotating in a counter-clockwise direction in Class I and IL
malocclusion, a non- extraction treatment is possible.
(b)If the occlusal plane is rotating in a clockwise direction in Class Ill malocclusion, a
non-extraction treatment is possible.
d)Changes in vertical dimension: When there is insufficient vertical dimension, there will
also be a change in teeth inclination(often, an increase in vertical dimension).This
implies that a non-extraction treatment method is possible (Fig. 5.8)
[f the space cannot gained through this method, some tooth should be extracted.
The thinking process of orthodontic differential diagnosis is as follows (Fig. 5-9):
(I)Should I adopt a non-extraction treatment method or an extraction treatment method?
•
• (2)1f decide to do an extraction treatment, should I extract the anterior teeth or the
• posterior teeth?
(3) Should I extract the first premolars or the second premolars?
(4)f there are abnormal anterior and posterior teeth, which one should I extract?
[[»» Choirs_Orthodontic Dono

••••
••••
•
•
•
Fig.5-Arch length preservation.

A. Transpalatal arch (TA) of maxillary arch
B. Lingual arch of mandibular arch
a
g"r,a
oseuo
ISM
scletl Ce f
0scletl Ce ll
d)
t tset cs sled Ce Ill
s
5
1%
'
L1 I
95-
liti
Sorge Er Ed d
III8
Fil
Sage
Fig.5.6 Alteration of vertical height of the maxillary and mandibular first molars (Kim et al., 20O9')
Skeletal Class ll malocclusion is closely related to the over-eruption of mandibular posterior teeth at the
beginning of Hellman dental age Ill8. Also, the skeletal Class Ill malocclusion is closely related to the
over-eruption of maxillary posterior teeth in the final stage of permanent dentition
CS_Oho6lei. Do « 1@
Fig. 5.7Changes in occlusal
plane
A. Class I, I malocclusion
The treatment direction
should be in the counter-
clockwise rotation of
occlursal plane
B. Class Ill malocclusion. The
treatment direction should
be in the clockwise rotation
of occlusal plane
•• �----------------�
Fig. 8 Changes in vertical

dimension
A Anterior and posterior
vertical dimension
B Anterior vertical dimension
(AVD)
B-1.Long anterior vertical
dimension
B2. Short anterior vertical
dimension
C. Posterior vertical dimension
• (PVD)
• Ct. Sufficient posterior
• vertical dimension
C-2 Insufficient posterior
vertical dimension
_., 7
t
16er ors_Ortodone Dino

••••
••••
1 Third molar extraction

) Third molar extraction
2)Mallary second molar extraction
2 Premolar extraction •
1)Maxillary and mandibular first premolar extraction •
2)4Mallary first premolar and mandibular second premolar extraction •
3)Maxillary premolar extraction only
4)Maxillary and mandibular second premolar extraction
5) Three premolar extraction
6)Unusual premolar extraction
7)Unilateral premolar extraction
3.Unusual extraction
1)4Mandibular anterior tooth extraction

2)Maxillary central incisor extraction
3)Maxillary lateral incisor extraction
4)Maxillary canine extraction
5)First molar extraction
Fig.5.9Various extraction options
Cows_0root bro +« 169

fl Non-Extraction Treatment Method
'b Methods of non-extraction treatment
Non-extraction treatment can be conducted by lateral expansion, molar distalization and forward
movement of anterior teeth. However, it is difficult to apply such methods systematically in actual
clinical cases. There is a tendency to rely mostly on reported cases of clinical diagnosis, which
leads to difficulties in actual diagnosis and treatment processes. The dogmas for non-extraction
treatment methods are as follows:
) Maxillary molars cannot make a posterior bodily movement. ln particular, such a movement
s impossible after eruption of the maxillary second molar.
2) The dental arch cannot be expanded in any direction in any circumstances.
3) The inter-canine width cannot be increased.
4) Te maximize post-treatment stability, the patient is advised to wear a retainer for a long
period of time
For these reasons, many orthodontists take extraction treatment approaches

Cetlin and Vanarsdall (2005) proposed the following guidelines for non-extraction treatment
methods:
When crowding is less than 8mm.

2) When there are mesially or lingually tilted molars (constricted dental arch).
) When there is no need for stability or aesthetics
• 4) When the patient is cooperative
• 5) When the patient is growing.

•
To take a non-extraction treatment approach, the patient must have a good facial profile. In the
case of slight protrusion, a non-extraction treatment is still applicable, if the crowding problem can
be solved by maintaining the position of anterior teeth. However, if there is a severe protrusion, the
extraction treatment approach is highly likely.
17[»cotes_Orocot Deno
••••
••••
Strategic leveling (Fig. 5-10 The shape of the dental arch can be modified through
uprighting the mesially tilted molars or de-rotating the mesially rotated molars. Strategic
leveling is necessary to get this result. Strategic leveling is a process of aligning the anterior
teeth first, and then uprighting or de-rotating the molars with no appliances attached to the
teeth in front of the terminal teeth in the early stages of treatment. As a result, it is possible
•
to minimize the labioversion of anterior teeth and secure the space that is required to solve •
the crowding problems by flattening the posterior occlusal plane. •
This is one of the most fundamental points in the MEAW treatment. This method makes it
possible to minimize the labioversion of anterior teeth and solve the crowding problems
while still maintaining the position of anterior teeth.
A A2
77/it
;
.4
•
:
:
: :;i
UN
ii' Fig. 510 Strategic leveling
and alignment
·• A. Strategic leveling.
B. Tight cinch back.
C Loose cinch back.
v- -,
Chor_OMoone Do TM
Method of non-extraction treatment.
L. Space gaining methods (Table. S-2)

I) Gain space through the parallel rotation of mesially rotated molars (Fig. 5-1H)
2) Gain space through the distal movement of posterior teeth (Fig. $-12-14)
3) Gain space through the lateral expansion (Fig. $-15-17).
4) Gain space through the stripping of proximal surface of teeth (Fig. 5.18)
$) Gain space through the labioversion of anterior teeth
Labioversion of anterior teeth is a common phenomenon that frequently occurs
during an orthodontic treatment. However, this kind of Labioversion of anterior teeth
may lead to an unaesthetic facial profile and thereby it increases the possibility of an
extraction treatment approach. Therefore, caution is needed
Table. 5.2 Space gaining methods.
Upper arch Lower arch
ecired ch length
Non-eraon tr80en
Molar rotation
2Transverse dimension
3Distal 0overent of molars
4 eproonotion
5 Avanoerent otin0iors
Arch length gain total
•
•
•
7»choirs_Orthodontic Dino
••••
••••
Fig, 5.1f Space gaining

through the parallel rotation of
mesially rotated molars.
Most of the maxillary first
molars mesially rotate on the
axis of palatal root and, thereby,
the dental arch shows the
tapered arch form. Via parallel •
rotation of the molars, space
can be gained.However, in
•
cases that show a parallel •
relation to the buccal surfaces
of the molars, it is extremely
difficult to gain space, an
therefore the extraction
treatment approach is highly
likely
AA parallel relation with the

buccal surfaces of the maolary
fest molars.
B. Amesial rotation of macollary
first molar.
6n
a 8
E
Fig. 5-12 Space gaining
trough a distal movement
A.A diagram of full cusp Class
l molar relationship: through'
the distal movement of molars,
it is possible to gain 6mm of
space per unilateral
•0 8 Distal movement of molars
Average tire Cepl 9rans Model though the use of mini-
hot 0 46months 396mm 48men Golgor et al plant
sore 906 distal tip AO0DO C. Distal movement of molars
(pron lo] 2007131 161 e1 through the use of pendulum
61 8 appliance
eddun 33mm
'
f
-
Ghosh et al DA comparison of the mini
8.36distal to A0ODO implant and pendulum
du4255em 1996110639-46 appliance approaches in the
- . 129 meseal ti
- . . papers
Fig.5.43Posterior available space (PAS)
A The distance from the distal surface of the mandibular second molar
to the anterior border of ramus
B. Cephalometric radiograph and panoramic view ofa patient who has
sufficient PAS.
C Cephalometric radio0graph and panoramic view ofa patient who has
insufficient PAS
•
•
•
17»hoper_Oroone Door
••••
••••
•
•
•
Fig.14 Normal curve of Spee and deep curve of Spee
ln the case of a normal curve of Spee, it is difficult to gain the space
needed to solve the crowding problermn The possibility of an extraction
treatment approach therefore increases
In contrast, in the case of deep curve of Spee. gaining Space is
possible by uprighting the mesially tilted molars, and the non-
extraction treatment approach therefore becomes possible Here, if the
CF value is low, the extrusion of the posterior teeth causes the
backward rotation of the mandible, and the extraction treatment
approach becomes highly likely. owever, if the CF value is high, even
with the extrusion of the posterior teeth, the backward rotation of the
mandible rarely occurs, so0a non-extraction treatment approach
becomes more likely
A.A model showing normal curve of Spee.
B. Amodel showing deep curve of Spee.
Fig.S.ts Space gaining through lateral expansion

Improvement of arch form the lateral expansion of posterior teeth (1men) increases the length
of arch perimeter (approximately 0.7men) (Adkins et al., 1990)
CS_oeo0ens Do 7f
Fig.5-16 Expansion appliances
A. Maxillary expansion appliances
A-1. Slow maxillary expansion (SME)
A-2. Rapid maxillary expansion (RME)
B. Mandibular expansion appliance: Schwarz appliance.
Fig. 517 Limitation of mandibular arch

expansion (Proffit et al, 2013
Increase in the mandibular inter-canine
width can negatively affect post-treatment
stability
'91nical
•
• Tips
• (D Active enlargement: actively expanding the mandibular dental arch
( Passive enlargement subtle and natural expansion of the maxillary dental arch
leads to an enlargement of the mandibular dental arch
►►►►►
1@»Cows_0rodeo0tic boo
••••
••••
Fig. 5.18 Space gaining

through reproximation
•
A. Square shape crown •
B. Ovoid shape crown
C. Barrel shape crown
•
D.Triangular shape: space
can be gained by reducing
the proximal surface
2. Changes in occlusal plane (Fig. 5-19)

A steep occlusal plane brings about the backward movement of mandible as well as the
labioversion of mandibular anterior teeth. This causes unaesthetic facial profile
Therefore a careful examination must be made when treating Class I and IH
malocclusion. On the other hand, a flattened occlusal plane can still cause the uprighting
of mandibular anterior teeth, as well as the forward movement of mandible. If this kind
of force is possible to apply during the treatment of Class I and Il malocclusion cases, a
non-extraction treatment approach is possible. In particular, during the ME
AW diagnosis
and treatment, it is possible to use the mechanic of flattening the steep occlusal plane
3. Changes in vertical dimension (Fig. $.20)

It is extremely difficult to adjust the vertical dimension in general dentistry and during
an orthodontic treatment_ The vertical dimension is closely related to the changes of
occlusal plane. If there is insufficient posterior vertical dimension, a steep posterior
occlusal plane is observed. Therefore, it is important to stabilize the vertical dimension
by adjusting the occlusal plane, This is one of the most important points to notice in
ME AW diagnosis and treatment
Coor 0eoo Ono TT

··�--------------" ··�--------------�
Fig.5-19Changes in occlusal plane
A. Flattening of occlusal plane desirable for Class land l malocclusion treatment
B. Steepening of occlusal plane desirable for Class Ill malocclusion treatment
[
Fig. 520 Changes in vertical dimension
A. By increasing the insufficient anterior vertical dimension, a nor-extraction treatment approach
becomes possible
B.By increasing the insufficient posterior vertical dimension, a non-extraction treatment approach
becomes possible
C When the anterior vertical dimension is long the patient already has an unaesthetic condition, so the
nor-extraction treatment alone cannot solve the problerns entirely
••••
••••
The thinking process for non-extraction treatment should be as follows (Fig. S-2:
I. Posterior cross bite or case where the transpalatal width (TPw) is less than 3Imm
(Fig. 5-15, 22: These indicate maxillary lateral expansion. There are usually two types
of maxillary expansion appliances, SME type and RME Type, which are reported to have
•
similar effects. The author usually adopts the SME type and rotates it two or three times •
a week. Per rotation, approximately 0.25mm of lateral expansion is made. However, for •
high angle cases (Fig. 5-23), the PBB type and SME appliances, which cover the
posterior occlusal surfaces, are recommended because the backward rotation of
mandible can occur due to the extrusion of palatal cusp of maxillary molars.
2. When more than 2mm of curve of Wilson is observed in the mandible (Fig. 5-24This
means a severe lingual inclination of mandibular posterior teeth. Here, the Schwarz
appliance, which has a screw that is applied on the mandibular anterior lingual surface,
should be used and rotated once or twice a week.
3. When there are excessive overjet and midline deviation (the cases that show an
acceptable facial profile in edge-to-edge bite): The twin block appliance is used to
induce a forward movement of mandibular teeth and, simultaneously, to match the
midlines (Fig. 5-25). Here, to expand the posterior teeth, a slow maxillary expansion
(SME) type can be used on the maxilla, and the Schwarz type on the mandible.
4. IfUI to lip line is greater than Smm (Fig. 5-26 When the upper occlusal plane is steep
(UOP is greater than 15), a double archwire (DAW) is used to intrude the maxillary
anterior teeth and to extrude the maxillary posterior teeth. This as a result flattens the
upper occlusal plane and a non-extraction treatment approach becomes possible
$, When there is a full cusp Class [l molar relationship: First, it is important to move the
maxillary posterior teeth distally (Fig. 5-27). To achieve this, a pendulum appliance
(when the maxillary second molars are not erupted), a mini-implant (when the maxillary
second molars are erupted), or the ME
AW (when there is anterior open bite with anterior
crowding) can be used.
Ctr_Orotor. Doro « 7Q
osenior 0ros bit Yes can$ion
1w « 3Imm Strate» leveling
No
es Schwan a0oanoe
Curve ol Wilson » 2 + Strategieveg
No
Ex $sve owerjet,acceptable la0al Ye win block
prole in edge toe0ge bite Strategic leveling
No
Yes
U1to lip» Sm, Steep 0P »15
Fig. 521 Thinking process
No
Yes for non-extraction treatment
Class ll molar re ship
Full Class IE
No
Mesia rotation Yes
Ach ton V-shape
No
Yes fepoornaion
Crown shape Triangular
-Statelevelg
[traction needed
I' t
J• l
•
'
''_"
Fig.522
Maolary expansion appliances
A. Comparison of effectivene s
between rapid and slow
expansion appliances there
is a difference during the
fist two weeks, but in 10
weeks, the result is almost
the same (Proffit, 1986)
• B Slow expansion appliance
• C. Rapid expansion appliances
•
1gr»»Cotes oeodon Deno

••••
••••
Fig.523Expansion appliance
in high angle cases •
A Changes that arise from the •
use of expansion appliance
A-1. Change in bucoo-lingual
•
inclination of molars
A-2 Changes in the mandible:
due to molar extrusion,
there may be a pos nio
rotation of the mandible
B peeventions
B-1. SME with PBB.
B2 Schwarz appliance with
PBB.
Fig.524 Mandibular expansion

appliance
A Indication of mandibular
expansion appliance more
than 2mm of mandibular
curve of Wilson
B. Schwarz appliance
C.Schwarz appliance with
9BB
Ccr$_oeo0enc Do « [
Fig.52 Twin block appliance
A. Photographs of twin block appliance
B. Intraoral photographs after putting twin block appanoe on
•
•
•
1g[»es_0ho6lo0ti. Do
••••
••••
» Fig. 5-26
Double archwire (0DAW). •
A Photographs of double •
rchwire appliance
B Mechanism of double
•
archwire appliance
C Intraoral photograph after
putting double archwire
appliance on
Fig.527Molar distalization
A. Full cusp Class It molar
relationship
B Pendulum appliance
C. Mini-implant
6. Triangular crown shape (Fig, 5-28: Through reproximation, the space required for
solving crowding problems can be gained. In particular, adults who have a triangular
crown shape are likely to suffer from black triangle after the premolar extraction.
Therefore, for the borderline group of extraction and non-extraction treatment, a non-
extraction treatment can be accomplished by choosing reproximation
-
r
. , -F';' 4
'
ade
.-•-
,....,.....,., . . ,..-- -
id
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'le' j
4
.• .
4
;+
• •·
� •h
4
t
4
•
..
l4
.
L.
«'
Fig.5.28 Reproxmation
A Pre.treatment intraoral photographs
B. Post-treatment intraoral photographs after reproximantion
7, Mesially rotated and angulated molars: Dental arch shape can be modified through
parallel rotation and by uprighting the mesially angulated posterior teeth. To achieve this,
•
• strategic leveling is required. Strategic leveling is the process of parallel rotation and
• uprighting of the molars after aligning the anterior teeth in the early stages of treatment.
This could, as a result, gain the space for crowding by minimizing the labioversion of
anterior teeth and flattening the posterior occlusal plane. Such an approach can help
maintaining the current position of anterior teeth and solving the problems of crowding.
This is the most basic aspect of MEAW treatment. In such treatment methods, other
appliances such as twin block and mini-implant can be used, too.
1[»»Corsoro6do0tic boo
••••
••••
[ndications of nor-extraction treatment.

I)Must have an acceptable facial profile.
2)Must have a high combination factor (CF>155)
3) Dental factors: a non-extraction treatment approach should be possible
4Environmental factors the patients must be able to close their mouth without any form
of tension (with proper lip competency).
onical
•
Tips: Nan-extraction and extraction treatment (fig. 5-29).
A. Non-extraction treatment must have an acceptable facial profile along with the
following conditions:
A1. Mesial rotation of molars
A.2. Deep curve of Spee.
A-3. Steep POP
B. Extraction treatment.
B.1.Parallel rotation of molars
B-2. Flat curve of Spee.
8-3. Flat POP pppppbp
Fig. 529 Clinical tips

A. Non-extraction treatment
B. Extraction treatment
Points to note during a non-extraction treatment.
L. Betts et al. (1995) argued that an excessive expansion of the maxillary arch can increase
the fenestration risk of the premolar and molar roots. They advised us not to make a
transverse tooth movement more than mm
The increase in the inter-canine width of mandible can be one of the main causes of
relapse. Therefore, in non-extraction treatment, it is important not to actively increase
the inter-canine width of mandible. Here, it is important to first treat the maxillary arch
and then attach the appliance on the mandibular arch after an increase in the inter-canine
width of maxilla. This is called a passive enlargement.
3. In cases of small teeth, it is better to perform a non-extraction treatment method.
Here are the problems that can arise in non-extraction treatment when the CF value is below
150:
I. Uncontrollable opening of the bite,
2 Difficulties in articulating the dentition,
3. Inevitable relapse of the occlusion.
Fig. 30 Anon-extraction treatment case when the CF value is below 150
•
•
•
A Pee-treatment facial and intraoral photographs
1g@»Cotes oodonit Dino

••••
••••
fig.5.30 (continued) A non-extraction treatment case when the CF value is below 150
•
•
•
C. Superimposition
D. Post-retention facial and intraoral photographs (2 years after the treatment')

...
Reproximation
The reduction of proximal sides of the teeth (Fig. S-31) is referred to as stripping, reproximation or
slenderizing. According to Boese (I980), there are two advantages of stripping:
I) Improves the contact stability through broad contact points, and
2) Increases the space availability around the mandibular anterior area.
+ r
� -
r
'
(
�
$
p l
" a
-
Fig.53f inter-proximal stripping
When using the reproximation method, Kokieh (2005) emphasizes that the following points must
be considered:
) Bolton ratio discrepancy,
2) Maxillo-mandibular anterior crown shape,
3) Width of maxillary anterior root,
4) Amount of interproximal enamel thickness in maxillary anterior crown,
5) Maxillo-mandibular anterior inclination,
• 6) Healthy mandibular anterior teeth,
• 7) Congenitally missing teeth,

• 8) Post-treatment stability.
If the mandibular anterior teeth size is greater than L.6mm compared to the maxillary anterior teeth
size, the following methods can be considered reproximation, the extraction of one mandibular
anterior tooth, or maxillary anterior restoration.
• •••
••••
Summary of indication
I) Stripping proximal surfaces:
(I)When there is a triangular crown shape.
(2)When there is a sufficient amount of interproximal enamel
(3)When the root width is narrow in the cervical area of the maxillary anterior teeth
•
2) Extraction of one mandibular anterior tooth: when Bolton discrepancy is greater than 2mm •
per unilateral •
3)Anterior restoration: when there is a maxillary peg lateralis.
In the finishing stage of treatment, when shallow overjet and overbite are observed after securing a
Class I canine relationship, reproximation should be conducted to solve the tooth size discrepancy
of anterior teeth
If there is a crowding problem in the mandibular anterior area, reproximation of mandibular
anterior teeth must be conducted. However, if there is no crowding problem, a restorative treatment
can be conducted after gaining the maxillary lateral incisor space.
When applying a reproximation treatment, the following points must be considered:

I) Amount of reproximation: According to Sheridan (1985), proximal portions of enamel can
be stripped up to 50%. This means that 8.9mm (0.5mm x 5+0.8mm4x2= 8.9mm) can be
stripped overall: 0,5mm in the anterior area and 0.8em in the posterior area
2) Dental caries and periodontal diseases When stripping the proximal surfaces, be cautious
about the occurrence of secondary caries. In particular, the patients who are still growing
tend to show secondary caries due to poor oral hygiene, so a reproximation method should
be adopted for adult patients only. Also, after a reduction of proximal surfaces, the roots
become very closely located to one another, which can cause periodontal problems.
3) Reproximation method (Fig. 5-32
Roh et al.(1999) pointed out that when stripping the enamel, it is possible to get the best
results by using separation strip with etchant, soft-Lex strip and pumice.
f linguoversion of lower incisors occurs after the extraction of the first premolars, with the
possibility of aggravating the black triangle, either a non-extraction treatment through
reproximation or extraction of the mandibular second premolars can be considered alternatively
(Fig. 5-32)
cs_Orotors bro 1g
ln general, the indications for reproximation are as follows (Fig. 5-33)
)Adult patient,
2) Triangular crown shape,
3) Black triangle
Fig. 5-32 Reproximation methods

%re
A Perforated diamond-coated
disk (Komet, grain size-<30a)
B. Sol-Lex XT die6k (2382F, 2382SF,

3M Unitel)
• C Ortho-Strips set (W&H Contra

• Angle WA67)
•
• •••
••••
Fig. 532 (continued) Reproximation methods
D. Super-Snap finishing and

polishing disk
•
•
•
E Smallest diamond point burs

and sand paper
-·--
tee
4
-
••
&-
finishing strips
cars_oeode Oro « @[
Fig. 5-32 (continued) PReproximation methods
G. Photographs of mandibular
antenor reprooraton treatment
G1.Pee-treatment intraoral
photographs
G2.Post-treatment intraoral
photographs
G-2»
Fig. 5-33
Triangular crown shape
A. Pre. and post-treatment
intra0oral photographs after
A extracting the maxillary and
mandibular fest premolars
severe black triangles are
observed between the
adjacent teeth
g pee.and post-treatment
intraoral photographs after
stnipping the proximal
• •• surfaces
• C.Pre. and post-treatment
• intraoral photographs after

extracting the maxillary first
premolars and mandibular
second premolars
1g[»»tors_oocoti bno
••••
••••
� "'Extraction Treatment
[f there are problems in the anterior area, it is better to extract the anterior teeth, and if there are
problems in the posterior area, it is better to extract the posterior teeth (Fig. 5.34). On the other hand
•
there are many cases in which the anterior problems look worse due to posterior problems. Most of •
these cases are caused by a steep mandibular plane or anterior-superiorly tilted palatal plane •
[f there are problems in the posterior area, an extraction treatment can be conducted in the
following ways:
) Third molar extraction; f there is a third molar and the force is applied in a forward
direction, the distal movement of the second molars becomes very difficult. Therefore, the
extraction of the third molar facilitates the uprighting and the distal movement of the
mesially angulated second molar.
2) Second molar extraction: If there is an eruption of the second molar, there may also be an
extrusion and mesial angulation of the first molar due to posterior discrepancy. Here, if the
condition of the maxillary third molar is satisfactory, it is possible to extract the maxillary
second molar(s), and then to upright and distally move the mesially angulated first molar
) First molar extraction: When closing the extraction space, there must be a mesial movement
of the roots of the posterior teeth. However, such tooth movements are difficult to achieve
Therefore, the extraction of the first molars must be carried out only in special
circumstances (for example, severe cavity cases or failure of endodontic treatment).
Fig. 534 Antenior discrepancy

and posterior discrepancy
A Anterior discrepancy and
posterior discrepancy
B When the CF value is low
There is a decrease in
posterior vertical nension
(At first, the posterior
teeth are affected
(9The greater the decrease
in posterior vertical
dimension, the more
affected anterior teeth
become
Coors_0toot bro « 1g
'b Third molar extraction
The distance from the distal surface of mandibular second molar to the anterior border of ramus is
referred to as the posterior available space (PAS), which is used to evaluate posterior discrepancy.
As shown in Fig. S-35, if the third molar is erupted, impacted, or missing, there are some important
factors to consider when moving the posterior teeth distally. First, if the third molar is erupted, it is
possible to move the tooth distally by taking advantage of the space created after the extraction.
However, if the third molar is missing, the distal movement of posterior teeth is restricted, and the
possibility of exercising premolar extraction increases. The distal movement of posterior teeth is
related to the distance from the anterior border of ramus to the terminal molar. If this distance is
sufficient, the distal movement is possible, but if not, the movement is restricted. Furthermore_, if
the CF value is high, the distal movement is possible, but if it is low, a backward rotation of the
mandible is likely to occur rather than a distal movement
• Indications of third molar extraction
I) Must have an acceptable facial profile

2) After extracting the erupted third molar, a distal movement of the entire dentition must be
possible. Most of these cases show high CF values.
) After the application of a non-extraction treatment, an cxtraction treatment can be applied in
the case of a relapse due to third molar eruption.
4) If there is a postenor discrepancy in relation to the third molar, an extraction treatment should
be applied.
• Fig.53 Posterior available space (PAS)

•
• A. Posterior available space
(PAS)
A1.PAS from a panoramic
view
A-2 PAS from a cephalometric
radio9rap
@»»Coors_Orthodontic bro
••••
••••
Fig. 53(continued) Posterior available space (PAS)
•
•
•
8 When third molars exist
B-1. Sufficient PAS
B-2 insufficient PAS
8-2
C When third molars are missing.

C-1. Sufficient PAS
C-2 insufficient PAS
'91nlcal
Tips: Posterior Available Space (PAS).
In general, the distal movement of a tooth is limited to 2-3mm away from the anterior
border of ramus. The distance from the anterior border of ramus to the distal surface
of mandibular second molar is called posterior available space (PAS). This can be
examined by both panoramic and cephalometric radiographs. If there is sufficient
space, the molar can move to the posterior direction, but if there is insufficient
space, the movement is almost impossible.
Here, space can be gained by extracting the third molar or premolars. However, if the
second or third molars have erupted, it is difficult to predict posterior space. In general,
the distance from the distal surface of first molar to the anterior border of ramus grows
1.5mm/side per year, up to the age of 14 for females and 16 for mold
cows_Ooton Do +« 19'
"b Maxillary second molar extraction
The conditions of third molars are quite diverse (Fig. 5-36).

If the shape, size and calcification of maxillary third molar are all in satisfactory conditions, the
maxillary second molar can be extracted in some cases of malocclusion patients. However, even if
the shape of the mandibular third molar is satisfactory, there is a possibility of orthodontic
retreatment, if the eruption direction is not favorable or if the eruption is late. For this reason,
caution is needed when extracting the mandibular second molar.
Chung and Kim (1992) compared non-extraction treatment cases with extraction cases of
maxillary second molars to treat Class ll malocclusion. It was reported that the anterior-posterior
relationship (APDP) is similar but the vertical relationships (0DH and CF) are different. In
maxillary second molar extraction treatment cases, the CF values were relatively low. In non-
extraction treatment cases, the OD/ APDI CF values were reported to be 79/ 74/ 153, and in
maxillary second molar extraction treatment cases, the values were reported to be 76/ 74/ 150
(Table. 5-3). According to Kim et al. (2005), in maxillary second molar extraction treatment cases,
the first molars showed over-eruption and mesial angulation, while maxillary second molars
showed distal angulation. This is similar to the cases of posterior discrepancy by Sato et al. (1991).
Fig.536 Third molar growth and development
,f
I
A The growth pattern of third
molars after extracting the
maxillary and mandibular
second molars
• Maxillary third molars are
• erupted at normal positions but
• mandibular third molars are

erupted at abnormal positions
Therefore, a retreatment is
needed
10@»» Cotes 0atolontic Do

••••
••••
Maxillary second molars should be extracted when the maxillary third molar crown begins to form;
that is, when root forming starts. When the first, second, and third molars show a stair structure due to
posterior discrepancy, it is an indication of second molar extraction, as shown in the figures below. The
best timing for the extraction is when the second molar is already erupted or about to erupt (Fig. S.37)
Fig.5.36 (continued) Third molar growth and development •

•
•
B. The growth pattern of maxillary
third molars
B-1.Erupted maxillary third
molars
B-2 Missing maxillary third
molars
B-3 Impacted maxillary third
molars
B-4. Small maxillary third
molars
C.The growth pattern of

mandibular third molars
C-1. Erupted mandibular third
molars
C-2Missing mandibular third
molars
C-3. impacted mandibular third
molars
C4. Smalt mandibular third
0nolars.
Table. 53 Comparison of the maxillary second molar extraction group and the non-extraction group in
Class I malocclusion
Class ll malocclusion treatment is determined by ODl
The lower the ODl value is, the greater the possibility of extracting second molars or premolars
Class f Cle l
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ge 1t7 121 18 207
00 7657 578 7927 5.50
A8p¥ 7417 34 7416 346
CF 150 74 6.23
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Fig.537Mallary second molar extraction
A.Posterior discrepancy (Sat0, 1991)
(D The distance from the maxillary first molar posterior area to NS is short
(The angle between the line that connects the maxillary first, second and third
molars to the maxillary oclusal plane is big
• (9 The axial angle between the maxillary second molar and the third molar ranges
• from 30' t0 45
• B. Normal third molars and posterior discrepancy. this is an indication of the maxillary
second molar extraction
B-1.Class ll malocclusion
B-2Class Il malocclusion.
C. Abnormal third molars and posterior discrepancy. this is a contra-indication of the
maxillary second molar extraction
@[»» cors_Orthodontic Deno

••••
••••
• Indications of maxillary second molar extraction
I) Aesthetics is good and the maxillary third molars are in good condition.
2) A moderate crowding: especially when there is no or moderate crowding in the mandible
3) Skeletal patterns: when the posterior vertical dimension is insufficient (generally the CF value
•
is lower than 150) •
4) When the mandible is under-developed (retrognathic mandible). •
5) Unusual reactions to Class II malocclusion treatment.
6) When there is a greater possibility of relapse after the non-extraction treatment of Class Il
malocclusion.
7) When the posterior teeth show a strong anterior component of force.
) When the second molars have severe caries or abnormal root shapes
9) Where there is a very limited space around the tuberosity.
• Contra-indications of maxillary second molar extraction
I) When the third molars are missing,

2) When the third molars are small or have abnormal shapes,
3) When the third molars have already erupted, a third molar extraction is recommended rather
than a second molar extraction,
4) Compared to the second molar, the angulation of the third molar is below 25
• The advantages of maxillary second molar extraction
I) A shorter treatment period,

2) Mechanical appliances are applied minimally, and tissue irritation could be minor,
3) Agreater possibility of uprighting the mesially tilted maxillary first molar,
4) The root lingual torque of anterior teeth decreases,
5) Asatisfactory aesthetic facial profile,
6) The possibility of impacted third molars decreases,
7) The possibility of relapse decreases,
8) More satisfactory proximal contact is expected in the premolar areas.
CS_Oooone Deno +« 19g

According to Quinn (1985$), after a second molar extraction, 75% of the third molars are successfully
erupted without causing any problems. Here, after the extraction of maxillary second molars, third
molars are likely to erupt at the second molar positions, but after the extraction of mandibular second
molars, an additional uprighting and repositioning of the mandibular third molars are likely to be
required. In the meantime, after the maxillary second molar extraction, there can be an over-eruption
of the mandibular second molars, so the occlusal conditions must be carefully analyzed
Maxillary second molar extraction can be done in following malocclusion cases (Fig. 5-38)
I.When a severe cavity on maxillary second molars increases the need for extraction treatment.
• When occlusal changes due to the over-eruption of maxillary second molars.
I)Deteriorate Class Ill malocclusion,
2)Aggravate midline deviation,
3)Cause scissor bite
3. An orthodontic treatment becomes highly effective when treating:
D)Class I or ll crowding.
2Class Ill maxillary crowding.
4. Post-treatment stability
I) Solving posterior discrepancy enhances stability,
2)Post-treatment stability after the Class ll malocclusion treatment: if the APp] value is
below 77 after the non-extraction treatment of (lass ll malocclusion, the second molar
must be extracted to enhance stability,
)Post-treatment stability after the Class Ill malocclusion treatment: if there is an extrusion
of the maxillary first molar due to the maxillary second molar, the maxillary second
molar should be extracted to enhance stability.
Fig.538 Maxillary second molar extraction
•
• A1
A. Class Ill maxillary crowding
A1 Pretreatment photographs
2o»»cos_oeoosons Deno
••••
••••
Fig.5-38 (continued) Maxillary second molar extraction.
•
•
A. Class ll maxillary crowding
•
A-2. Post-treatment
photographs.
A3. Post-retention
photographs after the
maxillary third molar
eruption
,_
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a !I,
l LT
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iv - •w
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- --
8-2+ �
B. Scissor bite in the maxillary second molar area
-1.Pre-treatment photographs
•
t
B2. Post-treatment photographs
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.._
Premolar extraction
Premolars are the teeth that are responsible for functioning the guidance and occlusal support (Fig.
5.39). Since the premolars are located at the center of dental arch, they are frequently extracted
during treatment. In particular, when there is an anterior protrusion or a severe crowding, the
extraction of first premolars becomes far simpler.
The general indications of first premolar extraction are as following.
Indications
) Crowding that is bigger than 12mm,

2) Protrusion, when the inter-incisal angle is less than 120',
3) Combination of two cases above.
However, the majority of orthodontic problems arise from the case where the inter-incisal angle is
less than 120°This includes the extraction of four maxillary and mandibular first premolars
•
•
•
Fig.5.39 The role of premolars (Slavicek, 2002)
Guidance and occlusal support
• •••
••••
The orthodontic problems that can arise from maxillary and

mandibular first premolar extraction (Fig. 5-40).
I) A severe deep bite may occur.

2) Itmay require a huge amount of torque adjustment when there is a retraction of anterior teeth
•
3) tis diffieult to achieve space closure and root parallelism at the extraction site, To successfully
•
close the space and obtain root parallelism, a number of complicated appliances can be •
utilized. However, it is important to bear in mind that such applications can lengthen the
treatment duration significantly.
4) As there is limited contact on the six anterior proximal teeth, spacing may frequently occur.
5) Since it is difficult to maintain proximal teeth contact in the extracted area, the closed space
may re-open.
6) Decrease in dental arch length and insufficient tongue space can cause imbalanced muscle
activity.
7) Adished-in face and an unnatural smile may appear.
8) After treatment, there may be a need for the third molar extraction method. Sometimes,
through such a treatment process, patients may lose up to eight teeth.
Fig.540 Problems of maxillary and mandibular first premolar extraction
AA patient who has deep bite

during the first premolar
extraction treat00l
(OD APO CF 80/ 85/ 165,
Class /low angle case,
mandibular plane angle 2
linter-incisal angle 141.5)
Chor_Ooton Oro o«[C

Fig. 540 (continued) Problems of maxillary and mandibular first premolar extraction
B. A patient who has open bite and an aggravated lateral facial profile during the first premolar extraction
treatment (OD/ APD/ CF 70/ 73/ 143. Class Il high angle, inter-incisal angle 107.9°)
• Problems that can arise from premolar extraction and high CF values
(over 155) (Fig. 5-41)
•
• I, Bite deepening,
• 2. Crowding of the mandibular anterior teeth,
3. Space opening in extraction site,
4. Inevitable relapse in occlusion.
l»» cos Oroone Deno

••••
••••
•
•
•
Fig.5.4fA patient after maxillary and mandibular first premolar extraction treatment
OD APDI CF: 70/ 94/ 164,
Class Ill low angle,
MPA. 60.8',
Inter-incisal angle (11A 173.4
1) Maxillary and mandibular first premolar extraction
Maxillary and mandibular first premolar extraction is used I) when there is a Class I skeletal and
canine relationship, and 2) when patients have a normal posterior occlusal plane and flat curve of
Spee, but are difficult to treat with a non-extraction approach (Fig. 5.42). Patients who come to the
clinic for the purpose of treating protrusion and crowding often suffers from malocclusion caused
by mandibular retrusion. Therefore, although there is a visible Class l canine relationship, its inner
skeletal pattern may be Class Il or III. This means that in order to compensate for the skeletal
disharmony, the maxillo-mandibular teeth angulation must be adjusted, and the assessment of the
posterior occlursal plane must be made to correct the angulation. If the posterior occlusal plane
angulation is underestimated, and only the extraction treatment is exercised to match the current
molar and canine relationship, unexpected consequence may arise. Therefore, to make an accurate
diagnosis with a correct treatment plan, a skeletal pattern analysis that focuses on ODl/ APDL/CF
and a denture pattern analysis, which is based on the Ul position and UOp.POP, must be carefully
done. Here, the treatment purpose of first premolar extraction should always be to maintain the
normal posterior occlusal plane and to close the extraction space
Fig.542 Maxillary and mandibular first premolar extraction
A Pe-treatment facial and intraoral photographs
-
-- - - -·. . -
--.. - -·..
•• ••
•• ••
•
••·
• 4
••
• •• ••
• 4.
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••
•• ••
4
• r •• ••
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A ••
•• ••
•• ,
8 Pre-treatment cephalomnetnic measurements
Doe»cos_orocontc bro
••••
••••
Fig. 542 (continued) Maxillary and mandibular first premolar extraction
•
•
•
C. Post-treatment facial and intraoral photographs
-- - -
-
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.. -·
-•• -·-- - ..
•• ••
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•• •••
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p pee.and post-treatment cephalometric measurements and superimposition
• Indications of maxillary and mandibular first premolar extraction.
I. Skeletal patter: Class I malocclusion.

2. Denture patter: 1)Class I molar relationship,
2)Normal posterior occlusal plane (POP),
)Normal overjet and overbite,
4) Flat curve of Spee,
5) lnter-inc isal angle (IA) less than 120',
6) Arch length discrepancy (ALD: in cases that cannot be treated
through a non-extraction treatment or when there is severe crowding
3. Facial profile: protrusion
2) Extraction of maxillary first and mandibular second premolars
Maxillary first and mandibular second premolar extraction is the type of extraction options used
frequently to treat Class I malocclusion. In Class II malocclusion, a mandibular second premolar
extraction is more effective than a mandibular first premolar extraction. The main purpose of
mandibular second premolar extraction is to move the mandibular first molars in a forward
direction and to cover the mandibular second premolar area. The treatment results, however, have
not been always consistent. These inconsistent outcomes have encouraged many orthodontists to
return to the mandibular first premolar extraction treatment method. Nevertheless, when this is
Fig.543 Maxillary first premolar and mandibular second premolar extraction
A. Pre-treatment facial and intra0oral photographs
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••••
••••
viewed from the perspective of occlusal plane control, the mandibular second premolar extraction
treatment can be far more useful and effective. This means that the maxillary first premolar Ad
mandibular second premolar extraction methods must be used when all the following conditions
•
are apparent: when there are a Class Il skeletal and molar relationship, a steep posterior occlusal
•
plane and deep curve of Spee, and when a non-extraction treatment approach is difficult (Fig. S- •
43). In this situation, the main purpose of the treatment is to flatten the steep posterior occlusal
plane and to close its extraction space.
Fig.5.43 (continued) Maxillary first premolar and mandibular second premolar extraction
C Post-treatment facial and intraoral photographs
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• Indications of maxillary first premolar and mandibular second premolar
extraction
I) Skeletal patter: Class I or Class II malocclusion.
2) Denture patter
(I)Steep posterior occlusal plane (POP)y,
(2)Class I or Class II molar relationship,
(Excessive or normal overjet,
(4)Deep curve of Spee,
(5) Inter-incisal angle (ILA: less than 120',
(6) Arch length discrepancy (ALD: when it cannot be treated through non-extraction
treatment or when there is severe crowding.
3) Facial profile: protrusion
• The advantages of second premolar extraction (Schudy, 1992)

I) Since the mesio-distal dimension of maxillary first premolar is greater than that of the
second premolar, a satisfactory occlusion can be obtained.
2) Since the maxillary first premolar has two long roots, it can resist the lateral force
3) Maxillary first premolar has a long buccal cusp, so it may appear more aesthetic
4) Maxillary first premolar has a long buccal cusp, so when there is a lateral movement,
posterior disocclusion becomes far simpler.
5) Throughout treatment, the buccal cusp of the maxillary first premolar is mesially located at
the mandibular first molar position, so permanent and stable occlusion can be achieved
6) Since the mandibular second premolar has greater mesio-distal dimension compared to the
mandibular first premolar, it is moved in a forward direction to obtain better occlusion
7) If the mandibular canine is distally angulated from the extraction space, its root can be
placed even closer to the labio-alveolar bone, and the crown can be lingullay angulated for
easier torque adjustment.
8) There is less need for canine movement, so a more stable dental arch can be formed.
•
•
• Rationale of second premolar extraction
I) Second premolar extraction prevents excessive lingual movement of the mandibular
anterior teeth
2) It constrains the intrusion of mandibular canine and mandibular anterior teeth
3) It prevents bite deepening after treatment.
4) It is more effective to extract the distally located teeth
2C»»Cows_ohooonte Ono
••••
••••
5) Since there is less need for mandibular canine movement, it becomes easier for mandibular
canines to maintain a correct axis
6) It would be far more effective to maintain the inter-canine width
7) Since the maxillaryfirst premolar is placed in in front of the mandibular first molar, an exact
antero-posterior relationship can be established.
•
8) More teeth can be preserved. •
9) Amore stable outcome can be achieved. •
[0) Treatment procedure becomes far simpler.
IH)Canine and first premolar relationship improves.
12)ltis easier to obtain the canine guidance occlusion.
Problems of second premolar extraction

I) [tis difficult to close the extraction space; therefore, there may be poor contact between the
mandibular first molar and first premolar.
2) There is a great possibility of experiencing gingival retraction around the mandibular first
molar site
3) Due to a short lingual cusp of mandibular first premolar, stable occlusion cannot be achieved.
4) When extracting the maxillary second premolars, the extraction space cannot be closed due
to the pneumatization of maxillary sinus.
• Comparison of maxillary and mandibular first premolar extraction (U44,

L44 extraction), and maxillary first premolar and mandibular second
premolar extraction (U44, L55 extraction) (Fig. 5-44 and Table. 5-4--6).
••
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Fig. 544 Comparison of maxillary and mandibular first premolar extraction (U44, L44 extraction). and
maxillary first premolar and mandibular second premolar extraction (U44,L55 extraction)
A Maxillary and mandibular first premolar extraction. A1. Adult patient
A-2. Growing patient
B. Maxillary first premolar and mandibular second premolar extraction (Adult patient)
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Fig. $.45 Forward movement of mandibular molar and changes in

0cclus.al plane.
By using Class I elastics, anterior and posterior teeth movement can
close the extracted space without changing the oclusal plane When a
mini-implant is set as an anchorage,a steep mandibular oclusal plane
can be formed after the space closure
A Teeth movement arising from Class !elastics
B Teeth movement when a mini-implant is used to close the spa0e
Ouote
from the late professor Kim Young-Ho
ere should be no malocclusion that you cannot treat
lt takes a keen sense of judgment to produce a successful result and
a satisfaction of accomplishment." l
Char0root Doro «« DJ
• Malocclusion treatment
I. Maintaining posterior occlusal plane.

I) When there is a normal posterior occlusal plane (Fig. 5-46A),
2) When there is a steep posterior occlusal plane (Fig. S-46B)
If there is tooth movement without changing the posterior occlusal plane, there will be
less risk of experiencing severe crown lingual inclination and extrusion of maxillary
anterior teeth in the normal posterior occlusal plane. However, when there is a steep
occlusal plane, there may be excessive extrusion and severe crown lingual torque in the
maxillary anterior teeth in the finishing stage of treatment, Therefore, anterior open bite
or deep curve of Spee in the mandible may inevitably remain even after the treatment.
Also, the majority of skeletal patterns is in Class II condition, but because of the
difference in molar angulation, a Class I molar relationship may appear as well, in which
case, the mandibular first premolars must be extracted. For this reason, if the patients are
diagnosed just on the basis of their current oral state and model, but not on their skeletal
pattern, further problems may arise.
•
•
•
.l Fig.546 Maintaining posterior occlusal plane
A Normal posterior occlusal plane
B. Steep posterior occlusal plane
[14»»cholers_0octortic Do
••••
••••
2. Changes in posterior occlusal plane

D)When there is a normal posterior occlusal plane (Fig. 5-474),
2)When there is a steep posterior occlusal plane (Fig. 5-47).
f the tooth movement is caused by the changes in the posterior occlusal plane, strategic
leveling can be highly effective in non-extraction treatment. In premolar extraction, the
•
uprighting and forward movement of molars are restricted, thereby making it •
undesirable to change the posterior occlusal plane. Nevertheless, when closing the space, •
along with the minimization of Lingual inclination of anterior teeth, the uprighting and
forward movement of the posterior teeth can be accomplished through the use of
mechanics. Here, if the MEAW technique is used in the finishing stage of treatment, the
process of uprighting can become much simpler.
When there is a normal posterior occlusal plane, extrusion and crown lingual torque of
maxillary anterior teeth can be minimized by uprighting and moving the posterior teeth
in a forward direction. [f there is a steep posterior occlusal plane, the force attempts to
flatten the occlusal plane, so the posterior teeth get uprighted, which minimize the
extrusion and crown lingual torque of maxillary anterior teeth. This becomes a crucial
treatment threshold when treating Class II malocclusion, so an exact differential
diagnosis between maxillary and mandibular first premolar extraction, and maxillary
first premolar and mandibular second premolar extraction must be made (Table. 5.7)
Fig.547Changes in posterior occlusal plane

A Normal posterior occlusal plane
B. Steep posterior ooclusal plane
Ccrs_Orocont Degro [1
Table, s.7 A differential diagnosis of maxillary and mandibular first premolar extraction vs maxillary
first premolar and mandibular second premolar extraction
Sleet.a pattern Molar relate Poe Curve ot Soe uD 4

Maooery and 0onouor
Class I Class Nona fed Severe e 120
rst preroiar era0or
Malay fest premolar an
mandibular $e000d premolar Cass 1 or I Clas t or it Steep Deep Sgt e120
0tr.aeon
3) Maxillary premolar extraction only
When only the maxillary premolar is extracted, the canine relationship becomes Class I, and its
molar relationship changes into the full cusp Class ll molar relationship after treatment.
Indications are as following:

I) Acase where there is excessive overjet and fult Class ll canine and molar relationship,
2) Acase where there is normal overjet and severe crowding on the maxillary arch
In this, there must be no or minor crowding on the mandibular arch (Fig. 5.48)
•
•
• Fig. 548 Maxillary premolar extraction only
A. A diagram of Class I canine relationship and Class ll molar relationship
B. Excessive overjet and Class ll canine relationship
C. Normal overjet and Class I molar relationship
[16»»Coors oeocdonti Deno

••••
••••
Merel et al. (2004) argued that when only the maxillary first premolar is extracted, there is a
more posterior rotation of mandible. This causes extrusion or lingual angulation of maxillary
anterior teeth. In other words, as no mandibular teeth are extracted, no changes are made on the
mandible
Nevertheless, it is important to note that depending on the skeletal patter, the mandible may
•
also posteriorly rotate. If this is the case, there must be extrusion and lingual inclination of
•
maxillary anterior teeth in order to finish the treatment (Fig. S.49). Therefore, it is advised that •
one should extract maxillary premolars only, if the CF value is high (over 155). If the CF value
is low (below 150), it is advised that one should extract both the maxillary first premolars and
mandibular second premolars.
Fig. 549 Maxillary premolar extraction only

A.Low CF
A.1 When mandibular third molars are not extracted
A.2When mandibular third molars are extracted
B. High CF
Ca0tr Oriol0ti boo [7

When only the maxillary premolars are extracted:
To form an appropriate overbite and overjet relationship, tooth movement such as the extrusion
and linguoversion of maxillary anterior teeth occurs inevitably (Fig. 5-50 A)
To minimize this, one should

(Form a deep curve of Spee through the extrusion of mandibular anterior teeth
2Form a flat curve of Spee by uprighting the mandibular posterior teeth (Fig. S-50 B)
Different teeth movement must, however, be made depending on the skeletal and denture
patterns
Fig. 5.50 Tooth movement when only maxillary premolars are

extracted.
A When the mandibular posterior occlusion is maintained, there
0curs severe extrusion and lingual inclination of maxillary anterior
teeth
B. When the mandibular posterior occlusion is upnighted, extrusion and
lingual inclination of maxillary anterior teeth can be minimized
•
• The indications of maxillary premolar extraction only are as follows:
• I. Skeletal pattem: Class I or II malocclusion, and high combination factor (CF)

2. Denture pattern.
Class ll molar (cusp-to-cusp or full cusp) relationship,
2)Mandibular arch when there is no or minor crowding.
• Aesthetics; protrusion or satisfactory facial profile.
• •••
••••
Differential diagnosis of maxillary second molar extraction and maxillary premolar extraction
only (Fig. 5-51).
In order to extract the maxillary second molars, the maxillary third molars and current
aesthetics rust be in good conditions with a noral inclination of mandibular anterior teeth,
minor crowding and flat curve of Spee. Nevertheless, in order to extract the maxillary
•
premolars only, there must be a protruded facial profile, with a normal inclination of •
mandibular anterior teeth, minor crowding and flat curve of Spee. This means that if there is •
labioversion of mandibular anterior teeth and deep curve of Spee, not the maxillary second
molar extraction method but the maxillary premolar extraction method should be performed.
Fig. 55f Maxillary premolar

extraction only vs maxillary
second molar extraction
A Maxillary premolar extraction
only
B.Maxillary second molar
extraction. acceptable third
molars and aesthetic
conditions
Differential diagnosis of maxillary first premolar and mandibular second premolar extraction,
and maxillary premolar extraction only (Fig. 5-52)
In order to extract the maxillary premolars only, there must be Class I canine and Class ll
molar relationship, but in order to extract the maxillary first premolars and mandibular second
premolars, there must be Class I canine and Class I molar relationship. Similarly, when there is
a need for extraction treatment -arising from overjet and high combination factor (CF) only
the maxillary premolars must be extracted. If the CF value is low, the maxillary first and
mandibular second premolars must all be removed
•
•
•
Fig. 52 Maxillary premolar extraction only vs maxillary first premolar and mandibular second
premolar extraction
A. Maxillary premolar extraction only
B. Maxillary first premolar and mandibular second premolar extraction
• •••
••••
Differential diagnosis of maxillary first premolar extraction and maxillary second premolar
extraction (Fig. 5-53)
In order to extract the maxillary premolars only, there should be full cusp Class II molar
relationship. However, if there is Class I molar relationship in the early stage of treatment, one
can only obtain the full cusp Class ll molar relationship by extracting maxillary second
•
premolars. Here, if there is crowding on the maxilla, the extraction of maxillary first premolars
•
will increase the possibility of using the elastics in later stages of treatment. If there is Class IE •
molar relationship in the early stages of treatment with excessive overjet, the maxillary first
premolars must be extracted to facilitate the retraction of maxillary anterior teeth
When extracting the maxillary premolar only, mandibular anterior teeth must also be retracted
at the same time. Therefore, depending on the amount of crowding and the shape of teeth, there
may be a need for an extraction of one mandibular anterior tooth or even a reproximation of
On the other hand, in the cases of maxillary premolar extraction only, posterior occlusion may
become unstable because of the mesial angulation of maxillary posterior teeth after space
closure. Therefore, to avoid such occurrences, an accurate orthodontic bracket selection and
bracket positioning must be made (Fig. 5-54)
Fig.5.53Maxillary first premolar extraction only vs maxillary second premolar extraction only
A. Maxillary first premolar extraction only.

A1 Closing the extraction space through the backward movement of the maxillary anterior teeth
A2. Closing the extraction space through the forward movement of the maxillary posterior teeth
B.Maxillary second premolar extraction only.
cows0rotor bro «[]

Fig.553 (continued) Maxillary first premolar extraction only vs maollary second premolar extraction only
•
•
•
C. Maxillary second premolar extraction only
C-1. Pre-treatment intraoral photographs
C-2. Mid-treatment intraoral photographs
C3.Post-treatment intraoral photographs
• •••
••••
•
•
•
Fig. 554 Bracket positioning in cases of maxillary premolar extraction only.

A. Bracket positioning in cases of maxillary premolar extraction only
A1. Accurate bracket placement
A-2 Inaccurate bracket placement.
B. lntraoral photographs in cases of maxillary premolar extraction only.
4) Maxillary and mandibular second premolar extraction
When the anterior teeth are lingually inclined and the facial profile is concaved, the teeth may be
labially tilted during a non-extraction treatment. Post-treatment problems in stability and aesthetics
may occur. Here, if te first premolars are extracted, the anterior teeth are highly likely to be
further lingually tilted, and the facial profile is likely to become even more unaesthetic. Therefore,
if a non-extraction treatment approach is not probable, it is more desirable to extract the maxillary
and mandibular second premolars (Fig. 5-55).
Here, the main purpose of this treatment is to move the molars forward whilst minimizing the
lingual movement of anterior teeth. For this purpose, a SWA bracket is recommended for the
maxillary anterior teeth and a standard bracket for the mandibular anterior teeth. By providing the
crown labial torque on the anterior portion, the lingual movement of anterior teeth can be
minimized
CS0rooter Oro e«[

Orthodontic patients tend to show a difference in tooth size between the maxillary first premolar
and second premolar (Fig. S-56). If the maxillary second premolar is notably smaller than the first
premolar, the first premolar extraction can bring about the unaesthetic shape of gingival margin as
well as the opening of extraction site. Therefore, if the maxillary second premolars are small in
size, it is more desirable to extract the second premolars. Nonetheless, even if protrusion is the
main complaint, it is better to close the extraction site after extracting the maxillary second
premolars. Here, a mini-implant or a transpalatal arch on the maxilla can be additionally used to
reinforce the stability of anchorage
Fig.5Closing the space of missing maxillary and mandibular second premolars
A Pretreatment data
A.1. Pretreatment facial and intraoral photographs
A-2 Pre-treatment panoramic radio0graph
(1Four missing maxillary and mandibular second
premolars,
(2) Remains of second primary teeth,
• A2
(3) impacted maxillary left first premolar
[2d»cotes Orto6lotic Deno

••••
••••
Fig.555 (continued) Closing the space of missing maxillary and mandibular second premolars
•
Bf •
•
B. Post-treatment data
B-1 Post-treatment facial and intraoral photographs
B2 Post-treatment panoramic radiograph
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Fig.556 Maxillary second premolar extraction
A. The shape of maxillary

premolars and the gingival
margin of first molars.
At. Acceptable gingival
margr
A-2 Unaesthetic gingival
margin
B.Mallary second premolar
Bf. Pretreatment intra0oral

photographs
(1)Small maxillary second
premolar,
(2) Unaesthetic gingival
margin
B2Post-treatment intraoral
photographs
•
•
•
82+%
••••
••••
However, when closing the extracted space after a maxillary second premolar extraction, the
bucal-side tooth movement becomes easy, while the palatal-side tooth movement may get
difficult. As a result, this can increase the distance from the palatal cusp of the maxillary first
premolar to that of the first molar. To prevent this, lingual buttons should be attached to the lingual
side of first premolar and first molar, and the bucco-lingual surface should be closed (Fig. 5-57)
•
However, in the case of sinus pneumatization, caution is needed when extracting the maxillary •
second premolars •
Fig.5.57Problems in maxillary second premolar extraction

A Increase in distance from the palatal Cusp of the maxillary first premolar to that of the first molar
B. Space closure through the use of lingual buttons and energy chain
In Class IHI high angle malocclusion (Fig. 5.58), due to its insufficient posterior vertical
dimension, it is difficult to maintain the stability of occlusion when treating the mandible with a
non-extraction treatment method. Since this type of malocclusion has the lingually inclined
mandibular incisors, the maxillary and mandibular second premolars should be extracted to
facilitate the forward movement of molars. Then, the MEAW technique can be used to complete
the occlusion. Here, if the mandibular first premolars are extracted to overcome the problems of
Class Ill molar relationship, the lingually tilted mandibular anterior teeth will be even more
lingually tilted. In this, if Class Ill elastics are used, the mandibular anterior teeth will be further
lingually tilted. As a result, the extracted space is highly likely to relapse.
Even if a Class Ill molar relationship is observed, the extraction of maxillary second premolars and
mandibular first premolars is not recommended.
Cows oeocore Oro o«[T

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Fig. 58 Maxillary and mandibular second premolar extraction
A. Pretreatment facial and intraoral photographs
B. Post-treatment facial and intra0oral photographs
C.Comparison of pre- and post-treatment cephalometric measurements, and superimposition
2B»» cows_ooctortc beano

••••
••••
Differential diagnosis for the first premolar extraction and the second premolar extraction
(Table. 5-8).
•
Table. 5-8 Comparison of the first premolar extraction and the second premolar extraction
•
Skelet. patten Molar relate POP Ore of Spee AND A •
fest premolar eacon Cass l Cass I None fat Sever «120
Second premolar etraction Cass 1 or I Class 1 or . fed

Sot
0rSevere
<120
0r»130
The indications of maxillary and mandibular second premolar extractions are as follows:
L. Class I or Ill skeletal pattern,
2. When the inter-incisal angle is over 130',
3. The mandibular anterior teeth are lingually tilted,
4.The crowding problem on mandibular teeth is moderate or severe,
$. Class I or Ill molar relationship,
6.When the mandibular canines are distally angulated.
5) Extraction of three premolars (maxillary bilateral first premolars and
one mandibular unilateral premolar)
The indications of extraction of three premolars are as follows:

L. Class II sub-division,
2. Midline deviation,
3. Three mandibular incisors
In the case of Class II division I sub-division, midline deviation can cause Class I molar
relationship on the unaffected side, and Class II molar relationship on the affected side;
therefore, theoretically either three or four premolars can be extracted. When four premolars
are extracted, there may be limited improvements to problems in midline, canine and molar
relationships after the space closure. Furthermore, the canting of the occlusal plane or lip
canting can be aggravated even after treatment. Here, the extraction of three premolars can be
considered instead (Fig. 5-59)
•
•
•
Bl]Lb
Fig.559Class ll sub-division
A traction of three premolars
B. Extraction of four premolars
••••
••••
Method.
I. The extraction of maxillary bilateral first premolars and one mandibular premolar on
unaffected side (Class I molar relationship).
According to Janson et al. (2003), the problems of midline deviation can be improved more
successfully by extracting three premolars than by extracting four premolars. It is also
•
possible to expect a greater success rate in treatment. Here, the symmetry of the maxillary •
canine positions is important •
The indication of this extraction option is when maxillary canines are in a normal position,
and the mandible shows a lateral deviation due to a difference between the left and right
sides. Here, due to the severe curve of Spee, the premolar on the affected side is not
extracted; instead, one premolar on the unaffected side and the maxillary bilateral first
premolars should be extracted. Also, the mandibular molars on the non-extraction side
should be uprighted.
Indications of the extraction of three premolars (maxillary bilateral premolars and one
mandibular premolar) are as follows
I, Class II division l sub
division (when there is midline deviation),
2. Premolar extraction when there are three mandibular incisors (Fig. S-60).
In the case of three mandibular incisors, it is difficult to achieve an accurate occlusion either by
a non-extraction method or by the extraction of four premolars, If the premolars are extracted,
the condition of the occlusion should be assessed based on a set-up model, in which the two
maxillary premolars and one mandibular premolar are extracted as in the figure below. Here,
the mandibular first premolar takes over the role of the mandibular canine.
Chor_Oroot Ono3
fig.560 pemolar extraction when there are three mandibular incisors
A Pee-treatment intra0ral
photographs
B. Post-treatment intraoral
photographs. extraction of
thee premolars (two maxlary
first premolars and one
mandibular night second
premolar)
•• 6)Unusual premolar extraction

•
This is a process of extracting different premolars on the same arch This extraction method is
applied particularly when there is a need for premolar extraction
(I)Symmetry of the left and right maxillary canine teeth (Fig. 5-61)
(2) The maxillary midline and facial midline matches with each other (Fig. 5-62)
(3) Symmetry of the left and right maxillary first molars.
2[»» Corsorooort Deno

••••
••••
To satisfy the above criteria, different extraction options of maxillary premolars should be
considered. Also, in the mandible, a premolar extraction method or a non-extraction method can be
applied to gain a Class I canine relationship.
Fig.$6f Symmetry of maxillary canines

•
•
•
A. Maxillary canine symmetry.

A.f
A1 Maxillary canine symmetry and
molar symmetry.
A2Maxillary canine symmetry and
molar asymmetry
B. Mallary canine asymmetry

Bf #Maxillary canine asymmetry
and molar symmetry
B-2 Maxillary canine asymmetry
and molar asymmetry
C.Maxillary arch asymmetry.
cows_0rotor bro «[
Fig.5.62Maxillary midline, facial midiine and palatal miline
A When all three midines are matched
€7
B. Deviation in maxillary midline
•
•
• C Deviation in mandibular midline
• •••
••••
7) Unilateral extraction
lt is extremely rare to extract the unilateral premolar only. Many dentists tend to extract the
unilateral premolar to solve crowding problems in the ectopic erupted maxillary canine. However,
such an approach can aggravate the asymmetry of dental arch and cause a temporo-mandibular
•
joint disorder. Even in the problem of unilateral crowding, many different cases are observed. [f
•
the maxillary canines are asymmetrical, a unilateral premolar can be extracted to achieve the •
symmetry of maxillary canines (Fig. 5-63)
Fig.563 Asymmetry of maxillary canines

A. Intraoral photographs of dental arch form after the extraction of a
unilateral maxillary left second premolar (the maxillary night
second premolar is congenitally missing)
B. intraoral photographs of dental arch form after the extraction of
bilateral maxillary premolars
C. Intraoral photographs after a unilateral maxillary premolar is
extracted to achieve canine symm0er¥
Indications
I. Extraction of one maxillary unilateral premolar solely for the purpose of achieving the
maxillary canine symmetry.
2 Mandibular unilateral premolar extraction in full cusp Class Ill malocclusion: After the
extraction of the mandibular unilateral premolar, there are no opposing teeth in the maxillary
posterior area. For this reason, the maxillary terminal molar is highly likely to get over-
erupted, and the mandibular third molar should never be extracted in this kind of treatment.
[f the mandibular third molar is missing, different extraction options should be considered.
•
•
•
Fig. $.64 Problems arising from the unilateral mandibular premolar extraction there must be
interdigitation between the maxillary second molar and the mandibular third molar
8. Post-treatment intraoral pholographs
C Panoramic radiographs after the mandibular third molar eruption
[@»» cos_oo0cont Deno «.

••••
'b Anterior teeth extraction treatment
In general, the anterior tooth extraction treatment is not applied except for special circumstances
This is particularly because the extraction of anterior teeth should be decided in relation to the
•
premolar extraction by considering aesthetic factors
•
•
1) Extraction of one mandibular anterior tooth
Since the extraction of one mandibular anterior tooth can result in three incisors, further increasing
the buccal overjet between the maxillary and mandibular canine, it is not recommended even in the
case of severe crowding (Fig. 5.65). However, if there is a severe tooth size discrepancy between
the maxillary and mandibular anterior teeth, it is possible to extract one of the mandibular anterior
teeth. For example, if the anterior Bolton ratio(ABR) is large, it means that there is a big tooth size
discrepancy between the maxillary and mandibular anterior teeth, despite the Class I canine
relationship. This condition can aggravate mandibular anterior crowding or decrease overjet. Here,
the extraction of one mandibular anterior tooth, feproximation or the size-up restoration of
maxillary lateral incisor can be conducted.
I) Extraction of one mandibular anterior tooth: when the Bolton discrepancy is more than
2mm per unilateral.
2) Reproxmaton
(I) Triangular shape crown,
(2) Sufficient amount of interproximal enamel,
(3)When the root width is narrow in the cervical area of the maxillary anterior teeth
) Anterior tooth restoration: when peg lateralis is observed.
The extraction of one mandibular anterior tooth can be considered I) if there is a severe crowding
problem in the mandibular anterior teeth, 2) if there is a big discrepancy in the anterior Bolton ratio,
3)in the case of a normal overjet, and 4) depending on the shape of the crown (the triangular shape
of the anterior teeth is not an indication). However, the most challenging problem that can arise
from the extraction is black triangle. Therefore, if there is a need for extraction of one mandibular
anterior tooth, it must be notified to the patients in advance. The problem of black triangle can be
solved to some extent by reproximation, but the canine relationship can be aggravated after
reproximation in the case of Class l malocclusion. On the other hand, in the case of Class Ill
malocclusion, there can be improvement in the control of overjet and overbite (Fig. 5.66)
cir_Ooton Doro «[7

Fig.565 Occlusion in three mandibular incisors
A When there is good canine bucoal overjet
B. When there is excessive canine buccal overjet
•
• 8»
• Fig. 566 Things to consider in the extraction of one mandibular anterior tooth The black triangle
formed after the extraction of one mandibular anterior tooth should be treated by reproirnation. in the
case of Class Ill malocclusion, there are usually no further problems, but in the case of Class Il
malocclusion, excessive overjet can be formed if reproximnation is performed
A. Class Ill malocclusion
B. Class ll malocclusion
e»» tors Orodone Deno

••••
••••
2) Extraction of maxillary anterior teeth
When there are missing teeth in the maxillary anterior area, the following treatment methods must
be considered:
L. Space closure through orthodontic treatment,
•
2. Premolar auto-transplantation,
•
3. Prosthodontic treatment or implant after gaining the space •
Since the restoration treatment of the maxillary anterior teeth can cause an unaesthetic condition
after treatment, an extraction treatment approach is not desirable unless there is a serious
pathological, traumatic, or unaesthetic problem. If an extraction treatment is applied, full cusp
Class ll molar relationship (through a non-extraction treatment on the mandible) and Class I molar
relationship (through a premolar extraction treatment on the mandible) can be formed depending
on the occlusion patterns (Fig. 5-67). Here, caution is needed when extracting the mandibular
teeth. If the maxillary anterior teeth are missing, it is essential to restore the Class I relationship
through a forward movement of the posterior teeth, so it is desirable to extract the mandibular
second premolars (Fig. S-68).When the maxillary lateral incisor is missing and the maxillary
canine replaces the maxillary lateral incisor, the shape and color of the canine must be carefully
checked. If the color of the maxillary canine is too dark, caution is needed because an additional
restoration treatment is required. Also, since the maxillary premolar takes over the role of the
maxillary canine, it (maxillary first premolar) must have a long bucecal cusp (Fig. 5-69)
Fig.67 Occlusion after the extraction of maolary anterior teeth

A. Non-extraction on the mandible Class ll molar relationship
8 Premolar extraction on the mandible Class l molar relationship
Fig. 568 Mandibular premolar
extraction when maxillary
anterior teeth are extracted
A Diagram after a mandibular
premolar extraction
A1 Mandibular first
' a premolar extraction.
A-2. Mandibular second
premolar extraction
B. intraoral photographs after
extracting the mandibular
second premolar
Fig. 569 Considerations in

the extraction of the maxillary
anterior teeth
A When the maxillary canine
takes over the role of the
lateral incise
A.1.When the shape and
color of the maxillary
canine are good
A2When the shape and
color of the maxillary
canine are unaesthetic
• When the maxillary first
premolar takes over the
• role of the maollary canine
• B-f when the shape of the
• maxillary first premolar
is good
-2 When the shape of the
maxillary first premolar
is unaesthetic
••••
••••
�lnlcal
Tips: Considerations In the extraction of the maxillary
anterior teeth (Fig. 5-69).
A. Maxillary canine: B. Maxillary first premolar
(0 Shape, (0 Shape,
•
( Color, 2Mesio-distal angulation, •
(3 Mesio-distal angulation, (3Labio-lingual inclination •
@Labio-lingual inclination.
►►►►►
(1) Maxillary central incisor extraction
Czochrowska et al. (200.3) found out that when the maxillary central incisor space is closed,
most patients are satisfied with the treatment outcome
Here, when closing the space, the following must be carefully examined
I The size, length and shape of the maxillary lateral incisor;
2)Malocclusion patterns and occlusal relationship;
3)Relationship between crowding and space, etc;
4) Shape and color of the canine crown.
Particularly in the case of growing patients, a permanent prosthodontic treatment on the

missing maxillary incisor is difficult to apply. The space closure is desirable, if the size of the
lateral incisor is appropriate
[fa restorative treatment is applied to growing patients, their pulp would be exposed, and their
gingival shape can become unaesthetic due to the eruption of teeth. Therefore, a permanent
prosthodontic treatment can be considered only after they become adults. If the maxillary
lateral incisor has a small size, the space closure in this area is not desirable (Fig. $.70)
Fig.$.70 #Missing maxillary
central incisors
A Peosthodonti treatment after
maintaining the space
A1.Pre.treatment intraoral
photographs
A2. Post-treatment intraoral
photographs
B Space closure (maxillary
left central incisor)
Bf pee-treatment intraoral
photographs
B2Post-treatment intraoral
photographs
(2) Maxillary lateral incisor extraction
The majority of maxillary anterior tooth extraction falls under this category,
Nordquist and MeNeill (1975) and Robertsson and Mohlin (2000) argued that space closure is
better than a prosthodontic treatment in the lateral incisor area, not only to satisfy the patients
•
• but also for their periodontal health
• When the impacted canine causes a root resorption of the maxillary lateral incisor or when the
lateral incisor has a small size, an extraction treatment can be needed. Here, it is important to
consider the shape and color of the maxillary canine and the shape of the first premolar as well.
For example, if the maxillary canine is worn out or if the maxillary first premolar has a long
and sharp cusp, it is possible to expect a good treatment outcome, if the maxillary incisor is
extracted and the space is closed afterwards.
[[»»cotes oeooetc boo

••••
••••
The following considerations are needed in the extraction of the maxillary lateral incisor;
I)Bilateral symmetry: the lateral incisors have normal shape and size.
2)Bilateral symmetry: the lateral incisors have normal shape but small size.
3)Bilateral symmetry: the lateral incisors have peg lateralis.
4)Bilateral asymmetry: a peg lateralis and a normal size lateral incisor.
•
5)Bilateral asymmetry: a small-size lateral incisor and a normal-size lateral incisor.
•
•
Fig.5.7f Various sizes and shapes of maxillary lateral incisiors
A Maxillary lateral incisors in bilateral symmetry

A1. Normal shape and size
A-2. Normal shape but slightly smaller.
A.3. Peg lateralis
A4. Congenitally missing
Cages_0eooent Do «[do
Fig.$.7f (continued) Various sizes and shapes of the maxillary lateral incisors
B Maxillary lateral incisors in bilateral asymmetry.

B-1. Congenitally missing and normal shape and size
B2. Congenitally missing and slightly smaller
B-3. Congenitally missing and peg lateralis
B4. Normal shape and size, and peg lateralis
•
•
•
[»cholers_ooootic Deno
••••
••••
n the case of maxillary lateral incisor extraction, since the maxillary first premolar takes over
the role of the maxillary canine, the torque and crown angulation of the maxillary first
premolar should be adjusted (Fig. 5$-72)
. . • A2 • A»J •
•
' «
•
r
tr
�
r
aooy
0a
Pa $e
8006
00a
r
-
lb%.tee
nee o
nae
I
r
8
"
r
8
�
I
·• Fig.572Bracket selection and positioning for space closure after

extracting the maxillary lateral incisor
A. Mallary canine.
A-1. Vertical position: by considering the gingival margin of
central incisor, a modification of appearance must be made
after the extrusion
A-2Labio-lingual inclination: palatal surface reduction after
giving the crown labial torque of the lateral incisor to the
canine
A.3.Mesip-distal inclination crown mesial angulation after root
parallelism
B. Mallary first premolar vertical position
9,lnical
Tips: Considerations in bracket selection and posllionlng
after the maxillary lateral incisor extraction (Fig. 5-72).
A. Maxillary canine replaces maxillary lateral incisor,
(D Vertical height the gingival margin of maxillary canine should be closer to the
incisor edge than to the central incisor.
(2Mesio-distal angulation.
Labio-lingual inclination should have crown labial torque.
B. Maxillary first premolar replaces maxillary canine
( Vertical height
(Mesio-distal angulation must have crown mesial angulation
(Labio-lingual inclination
►►►►
(3) Maxillary canine extraction
Except for cases where the maxillary canine is difficult to tract because of its position, the
application of the maxillary canine extraction is not usually desirable. In the premolar
extraction case, it is always difficult to decide whether to extract the first premolar, the
impacted canine or the small-size maxillary lateral incisor (Fig. 5-73). In the case of growing
patients, auto-transplantation of the maxillary canine can be considered (Fig. S-74)
Fig.573A dilemma for orthodontists: whether to extract the first premolar, the impacted canine or the
small-size maxillary lateral incisor
A re-treatment intraoral photographs two mandibular incisors are observed, and an ectopic.ally erupted
night maxillary canine and an impacted left canine are observed
•
•
•
B. Pre.treatment panoramic radiograph
[[»»cows_0tool0tic b%no
••••
••••
•
•
•
Fig.573(continued) A dilemma for orthodontists whether to extract the first premolar, the impacted
canine or the small-size maxillary lateral incisor
C. Post-treatment intraoral photographs after the extraction of the maxillary night first premolar and the left
lateral incisor
D. Post-treatment panoramic radiograph
Chor$ oeolot Do [7
Fig.5.74\Maxillary canine auto-transplantation
A Pre.treatment intraoral photographs and panoramic radiograph. an impacted maxillary left canine
B Post-treatment intraoral photographs and panoramic radiogrph auto-transplantation of the impacted

maxillary left canine
4» tors_Orocort Dono
••••
••••
�
First molar extraction
Since the first molar is the biggest and the strongest tooth, an extraction treatment should not be
applied unless there is a failure in endodontic treatment or there is a severe cavity, Also, as it is
•
difficult to induce the forward movement of the second molar, space closure is difficult to be
•
achieved and as a consequence, the treatment can take longer; it can take at least 2 years and a half •
In the case of an extraction of the unilateral first molar, caution is needed because dental arch
asymmetry can occur. Here, a mini-implant is recormended to close the space; however, if
possible, the best approach is to carry out the bilateral extraction.
Indications of first molar extraction are as follows

a. Third molars in good condition,
b. First molar has a severe dental cavity,
c. High angle skeletal pattern,
d. Severe anterior crowding.
1) Maxillary first molar extraction
(/)Class ll malocclusion case with maxillary protrusion: the overjet problem should be solved by
a posterior movement of the anterior teeth through the extracted space of the first molar
(2)Class Ill malocclusion case with maxillary undergrowth the anterior crowding problem should
be solved through the extracted space of the first molar.
2) Mandibular first molar extraction
f there is a steep mandibular plane angle, it can be treated by the extraction of the mandibular first
molar. However, if the mandibular first molar is extracted, the overjet problem can be aggravated
due to the posterior movement of the mandibular anterior teeth. Here it is desirable to close the
space after the extraction of a maxillary tooth (usually the first premolar). As a result, a Class ll
molar relationship will be formed (Fig. $.75)
Fig.57 Mandibular first molar extraction
A Pee-treatment intraoral photographs and panoramic

radiograph
(9Severe cavity on the mandibular night first molar and
missing left first molar
2Mesially impacted mandibular night third molar
B. AMid-treatment intra0oral
photographs the extraction of
the mnaollary second
premolars and mandibular first
molars.
•
•
•
SL tors orooone Deno ••••

••••
Fig.$.75 (continued) Mandibular first molar extraction
•
•
•
C. Post-treatment intraoral photographs and panoramic

radiograph space closure in the mandibular first molar
site and uprighting of the mandibular night third molar
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72 Kolich VO Jr, Kyak HA, and Shapiro PA Comparing the perception of dentists and lay people to
altered dental esthetics. J Esthet Dent 11.311-324, 1999.
•
73Lee DK, and Kim JI.Personal communication, 2011,
•
74 Lehman R. A consideration of the advantages of second molar extraction on orthodontics. Europ J
•
0rthod 119-24, 1979
75. Liddle DW_Second molar extraction in orthodontic treatment. Amn 4 Orthod 72-599-161, 1977
76. Linder-Aronson S. Adenoids. Their effect on mode of breathing and nasal airflow and their
relationship to characteristics of the facial skeleton and dentition. Acta Otolaryngol Scand(Suppl
265), 1970
77Little RM, Riedel R, and Engs! ED. Serial extraction of first premolars-postretention evaluation of
stability and relapse. Angle Orthod 60.255-62, 1990
78. Little RM. Stability and relapse of dental arch alignment. Br J Orth0d 17-235-241, 1990.
79Luppapomlap S, and Johnston LE. The effects of premolar extraction: a long-term comparison of
outcomes in clear-cut' extraction and non-extraction Class l patients. Angle Orth0d 63257-272, 1993
80. McLaughlin RP, and Bennett JC The extraction-non extraction dilemma as it relates to TAD, Angle
Orthod 65:175-186, 1995
81. McNamara JA Jr, Sigler LM, Franchi L, et al. Changes in occlusal relationships in mixed dentition
patients treated with rapid maoilary expansion. Angle Orth0d 80.230-238, 2010.
82. McReynolds DC, and Little RM. Mandibular second premolar extraction-postretention evaluation of
stability and relapse. Angle Orthod 61.133-44, 1991.
83. Merrifield LL, Klontz HA, and Vaden JL. Differential diagnostic analysis systems. Am J Orthod
Dentofacial Orthop 106.641, 1994.
84. Merrifield LL. Differential diagnosis. Semin Orthod 2241, 1996.
85. Merrifield LL. Dimensions of the denture: back to the basis. Am J Orthod Dentoac Orthop 106.535-
542, 1994
0rthod 68.147-152, 1998
87. Moyers RE, Van der Linden FpGtM, and Riolo ML • Standards of human occlusal development
Monograph No. 5, Craniofacial Growth Series. Ann Arbor: Center for Human Growth and
Development, University of Michigan, 1976
88. Moyers RE.Handbook of orthodontics. Chicago: Year-book Medical Publisher,1 988
89. Nanda R. Biomechanics and Esthetic strategies in clinical orthodontics, Elsevier Saunders, 2005.
90. Nordquist, G.G, and McNea Rw.Orthodontic vs. restorative treatment of the congenitally absent lateral
incisor-long term periodontal and occlusal evaluation. Journal of peniodontology 46. 139-143, 1975
91. 0'Grad PW, McNamara JA Jr, Bacteti T, et al. A long-term evaluation of the mandibular Schwarz
appliance and the acrylic splint expander in early mixed dentition patients. An J Orthod Dentofacial
Orthop 130.202-213, 2006.
92. Ono K. Fujita A, Kaneko M, and Sato S. Orthodontic treatment of severe crowding malocclusion with
extraction of lower third and upper second molars. Bulletin of Kanagawa Dental College. 28 (2).99-
105, 2000
93. Parekh S, Fields HJW, Rosenstiel, et al. Attractiveness of variations in the smile arc and bu0cal
corridor space as judged by orthodontists and laymen. Angle Orthod 76.612-618, 2006.
94. Polat-O2soy O, Kiroelii BH, Arman-Ozcirpici A, et al. Pendulum appliances with 2 anchorage designs
conventional anchorage vs. bone anchorage. Am J Orthod Dentofacial Orth0p 133.339, e9-e17, 2008
95. Po#ft WR Contemporary orthodontics. St Louis. CV Mosby company, 1986.
96. Proffit WR, Fields HW, and Sarver DM. Contemporary orthodontics, 5th edition. Mosby, 2013
97. Quinn GW. Extraction of four second molars. Angle Orthod 55.59-69, 1985
98. Rhee SH, and Nahm DS. Triangular-shaped incisor crowns and crowding. Am J Orthod Dentofac
Orthop 118.624-628, 2000.
99. Richardson ME. Development of the lower third molar from ten to fifteen years, Angle Orth0d 43191.
193, 1973
100. Richardson ME. Late lower arch crowding: the aetiology reviewed. Dental Update 29.234-238, 2002
101 Ricketts RW, Bench RW, Gugino CF, Hilgers AJ, and Schulhof RJ. Bioprogressive Therapy. Denver.
Rocky Mountain Orthodontics; 1979.
102. Robb SI, Sadowski C, Schneider BJ, and BeGole EA Effectiveness and duration of orthodontic
treatment in adults and adolescents. Am J Orthod Dentofacial Orth0p 1143836, 1998.
103. Robertsson S, and Mohlin B. The congenitally missing upper lateral incisor. A retrospective study of
orthodontic space closure versus restorative treatment. Eur J Orth0d 22697-710,2000.
104. Row J, and Chun YS. A comparative study of roughness of enamel surface to various interdental
enamel stripping methods in vitro. Korea J Orth0d 29.483-490, 1999.
105. Sat0 S, Sakai H, Sugishita T, Matsumoto A, Kubota M, and Suzulg Y,Developmental alteration of the
in skeletal Class Ill malocclusion and its significance in orthodontic diagnosis
form of denture frame
and treatment MEAW Thec Res 1.33-46, 1994
106. Sato S, and Suzuki Y, Relationship between the development of skeletal mesio-occlusion and
• posterior tooth to denture base discrepancy-Its significance in the orthodontic reconstruction of
• skeletal class Ill malocclusion. Journal of Japanese Orthodontic Society 47-796810, 1988
• 107. Sato S, Takamoto K, Fushimha K, Akim0to S, and Suzuki Y, A new orthodontic approach to mandibular
lateral displacement malocclusion - Importance of occlusal plane reconstruction. Dentistry in Japan
25.81-85, 1989
108. Sat0 S, Takamoto K, and Suzuki Y, Posterior discrepancy and development of skeletal class Ill
malocclusion. Orthodontic Review Nov/Dec. 16-29, 1988
[56»» Corso0roone Deno

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••••
109. Sato S. A treatment approach to malocclusion under the consideration of craniofacial dynamics
(unpublished book). 1991.
110. Sato S. Case report Developmental characterization of skeletal Class l malocclusion. Angle Orthod
64105-112, 1994
111. Sat0 S. Orthodontic therapy with multiloop edgewise arch wire (Ii). Shinhung international line, 2006
112. Schuy FF. Cant of occlusal plane and axial inclinations of the teeth. Angle Orthod 33.69-82, 1963.
•
113. Schudy FF,The control of vertical overbite in clinical orthodontics. Angle Orthod 38.19-39, 1968
114. Schud FF. The rotation of the mandible resulting from growth its implications in orthodontic
•
treatment. Angle Orthod 35.36-50, 1965
115. Schudy FF, Vertical growth versus anteroposterior growth as related to function and treatment, Angle
0rthod 3475-93, 1964
116. Schudy FF The occlusal plane and the vertical dimension. D. Armstrong Co., Inc, 1992
117 Schwarz AM, and Gratzinger M. Removable orthodontic appliances. Philadelphia wB Saunders,
1966.
118. Sheridan 44. Air Rotor Stripping (ARS) Manual. New Odeans: Raintree Essix, 2005
119. Slavicek,R The Masticatory Organ. Gamma Dental Edition. 2002.
120. Subtelny JD, and Saluda M. Open-bite: diagnosis and treatment. Am J Orthod 50.337-58, 1964.
121. Suzuki S, Onodera K, Aoki S, and Sato S. Treatment of hyperdivergent type Class ll malocclusion
with dysfunction of craniomandibular system. Bulletin of Kanagawa Dental College, 29.89-98, 2001.
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Toronto: AAO Annual Session, 1993
123. Ten FV Alas of orthodontic appliances, Caravel, 1985
124. Tweed CH. Clinical orthodontics Vol1 and 2. St Louis.Mosby, 1966.
125. Tweed CH. indications for the extraction of teeth in orthodontic procedures. Am J Orthod Oral Surg
30.405, 1944
126. Vaden JL, Dale JG, and Klontz HK. The Tweed Merrifield edge wise appliance. in Graber TM, Vanarsdall
RL Vi KWL, editors. Orthodontics: current principles and techniques, 4th edition, Elsevier Mosby. 2005.
127. Vanarsdall RM. Diagnosis and treatment of transverse discrepancy, JV Mershon Memorial lecture. St
Louis: AAO Annual Session, 1992
128. Wiliams R, and Hosila FG. The effects of different extraction sites upon incisor retraction. Am J
Orth0d 69.388-410, 1976
129. Wilson HE. Long-term of observation on the extraction of second permanent molars. Trans Eur
Orthod. Soc. Pp 15-221, 1974
130. Wolford LM, Chemello PD, and Hillard FW. Oolusal plane alteration in orthognathic surgery. J Oral
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mode of breathing. Am J Orthod Dentofac Orthop 100.1-18, 1991.
PART II
ORTHODONTIC TREATMENT
••••
. . . . .. .. . . . . . . . . . . .
. . . .. . . . . . .. .. .
..........
Chapter 6_
BRACKET SYSTEM
AND BRACKET
POSITIONING
D Bracket System
'b Bracket system
1) Basic configuration and components (Fig. 6-1)
l
Fig.61Atypical bracket
A. Shape of a typical bracket
--
B. Names of the bracket parts.
a. Wire slot : This is a part of the bracket which the orthodontic archwire is inserted into. The
slot is made up of two sizes: .018" slot (018".025") or .022" slot (.022" x.,028").
b. Bonding base : This is a part of the bracket that comes in direct contact with a tooth
Here, to ensure strong bonding, two types of bracket bases are used: a bondable mesh type,
or a weldable type.
c. Bracket width: This is the distance between the mesial and distal sides of the bracket.
•
• Depending on the number of wings, brackets can be classified into two types: a single
• bracket, or a twin bracket.
d. Bracket height : This is the distance from the base of the bracket to its top. There are
three different bracket heights: low profile, standard profile, and high profile. Since a high
profile bracket can cause premature contact with the opposing tooth, a low profile bracket is
recommended.
• •••
••••
e. In-and-out : This is the distance from the bottom of the wire slot to the bonding base. In
order to form an ideal dental arch, different in-and-out values should be applied to the
bracket of each tooth - this is the fundamental base af swA appliance. Since the size,
thickness and shape of the teeth are different among various races (e.g. Asians or
Westerners), there can be various in-and-out options
•
•
f. Tie wing: This is the place where the bracket is ligated in order to ensure tight fit of the •
orthodontic archwire into the wire slot. The tips of these tie wings are usually curved
inward so that the bracket can be ligated more effectively with a ligature wire or an O-ring.
(1) Labial and lingual brackets (Fig. 6-2)
Brackets are categorized according to bonding areas. A labial bracket is attached to the labial
surface of a tooth, and a lingual bracket is bonded to the lingual surface of a tooth
Fig.6.2Labial and lingual brackets

These images show maxillary lingual brackets and mandibular labial brackets
(2) Edgewise brackets and Begg brackets (Fig. 6-3)
Brackets are classified into two different types: Edgewise and Begg brackets. In Edgewise
brackets, a rectangular wire is used to ensure three-dimensional movement of the teeth, while
in Begg brackets, a round wire is used to ensure tipping movement of the teeth
(3).018" slot and .022" slot (Fig. 6-4)
Brackets can be classified by their slot size: 018"(018"x..025") slot and .022" (.022".028") slot
For the ME
AW technique, brackets with 018" glots are recommended.
·I -l
• •
Fig.6.3 Edgewise bracket and Begg » Fig.64018 slot and 022 slot
bracket A. 018 .025 slot bracket
A. Edgewise bracket B. 022x.028 slot bracket
8. Begg bracket
(4) Single brackets and twin brackets (Fig. 6-5)
Brackets are also classified into two types based on the number of wings: single brackets and
twin brackets. The single bracket only has one wing, but the twin bracket has two wings. The
single bracket can increase the inter-bracket distance, but it can be difficult to control the
rotation of teeth. In contrast, in the case of a twin bracket, the control of the rotation of teeth
becomes easy, but the inter-bracket distance can be decreased. To solve these problems,
• strategic bonding is also needed along with the twin bracket
•
•
• •••
••••
•
•
•
8»Li"_d
Fig.65 Single brackets and twin brackets
A. Single brackets
B. Twin brackets
tater-bracket distance
(5) Metal brackets and aesthetic brackets (Fig. 6-6)
Brackets can be also classified by the type of material: metal brackets and aesthetic brackets
(plastic and ceramic brackets). Plastic brackets are advantageous for aesthetics, but
discoloration or wear-out can occur. Ceramic brackets can increase bonding strength, so they
can damage the teeth when are being removed
Fig.66 Metal brackets and ceramic brackets

A. Metal brackets
B. Ceramic brackets
erst sod sect Po.lo + Do[

(6) Standard brackets and SWA brackets (Fig. 6-7)
There are two types of brackets: standard brackets and straight wire appliance ($WA) brackets.
n-and-out, angulation, torque, and rotation are incorporated into $WA brackets, while none of
these are incorporated into standard brackets.
A
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Fig.6.7 Standard brackets and SwA brackets.

A. Standard bracket
B. SWA bracket
C.Various kinds of SWA brackets (Orthodontic Product Catalogue of American Orthodontic.s, 2011)
Goo» Cos_Sect yo hoot

••••
••••
(7) Ligation brackets and self-ligation brackets (Fig. 6-8)
Brackets can be further categorized by the type of required ligation: ligation brackets and self.
ligation brackets. For ligation brackets, O-rings or ligature wires are used, but for self-ligation
is used.
brackets, a built-in ligation clip
•
•
•
Fig.68Ligation brackets and self-ligation brackets

A. Metal ligation brackets
B. Ceramic ligation brackets
C. Metal self-ligation brackets
D. Ceramic self-ligation brackets
Cha¢rt ft Pe neg [@
2) Buccal tubes
Terminal molars should not be ligated with conventional brackets; small-sized equipment -single
buccal tubes with a slot size of 018"x 025". must be used. However, when a headgear is used to
treat the maxillary protrusion, a double buccal tube is used
The following tube types are commonly used:

A. Single buccal tube,
B. Single convertible bracket,
C. Double buccal tube
(1) Maxillary and mandibular second molars (Fig. 6-9)
Single buccal tubes are frequently used to treat the terminal molars. A hook should be placed
on the mesio-gingival side of the tooth
Fig.69 Single buccal tube for the maxillary and mandibular second molars
When used on the terminal molars, the hook is placed on the molar's mesio-gingival side to facilitate the
use of an elastic or energy chain Therefore, the same appliance should be used interchangeably on the
maxillary night side and on the mandibular left side. The same appliance should be used interchangeably
on the maxilary left gide and on the mandibular night side. The appliance in figure A is the tube that is
frequently used on the maxillary left molars or on the mandibular night molars
•
•
•
2D[»»coos_Sect id beet Po.cneg

••••
••••
(2) Maxillary first molars (Fig. 6-10)
( Wide bracket
This bracket is commonly used on the maxillary first molars when the appliance is
extended to the maxillary second molars.
•
•
Q2 Convertible bracket •
This bracket is used on the maxillary first molars before the appliance is extended to the
maxillary second molars. During treatment, if the appliance is extended to the maxillary
second molars, this bracket can be converted into a wide bracket by removing its cap
Double buccal tube

This type of bracket is used when there is a need for an extra-oral appliance. The 045"
tube is commonly used and is placed on the occlusal side of the tooth
• •
• •
"'-
�
0lr
-.t
- -�
�
..--
Fig.6-10 Orthodontic appliances on the maxillary first molars
(3) Mandibular first molars (Fig. 6-11)
( Wide bracket
This is the type of bracket that is frequently used on the mandibular first molars when the
appliance is extended to the mandibular second molars.
2 Single buccal tube

This tube is used on the terminal molars. If it has a hook, it must be placed on the mesio-
gingival side of molar. If the appliance is extended to the mandibular second molars, the
single buccal tube should be removed, and then a wide bracket and a single buccal tube can
be bonded to the first molar and to the second molar as well.
Fig.&.ff Orthodontic appianoes on mandibular first molars

A. Wide bracket
B. Single buccal tube.
•
•
•
[f»»tors_et Sy ho
••••
••••
�
Important considerations for bracket selection
1) Third-order bends (Fig. 6-12)
•
This refers to the labio-lingual or bucco-lingual inclination of a tooth. For each SWA appliance,
•
based on the treatment goal, crown labial inclination on the four maxillary anterior teeth, and •
crown lingual inclination on the maxillary canines, premolars, and molars are incorporated into the
brackets.
On the mandibular anterior teeth, zero-degree torque or crown lingual torque is incorporated into
the brackets, and on the mandibular canines, premolars and molars, crown lingual inclination is
Incorporated into the brackets
/0//%4-
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gr
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r
tr
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-t
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-tr
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\ V Ill/
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Fig.6412 Third-order bends
A. Crown inclination of each individual tooth (Andrews,1972)
s When the standard bracket is bonded to maxillary incisor and to a mandibular molar
C.When the SWA bracket is bonded to a maxillary incisor and to a mandibular molar
D.A comparison of inclination difference standard bracket (black line) and SWA bracket(red
line) on maxillary incisors and on mandibular molars
Choir6ct sod be Pe mg « D
(1) Class Ill malocclusion case
In general, when a SWA appliance is used, crown labial torque is incorporated into the
maxillary anterior teeth, and zero-degree torque or crown lingual torque is incorporated into
the mandibular anterior teeth. However, in the case of Class Ill malocclusion, due to the dento-
alveolar compensation, labial inclination of the maxillary anterior teeth and lingual inclination
of the mandibular anterior teeth are commonly observed. When treating such cases, the use of
a typical $WA appliance with Class Ill elastics can worsen these compensatory inclinations. In
the ME
AW technique, however, after using the zero-degree torque brackets on the maxillary
and mandibular anterior teeth, a positive treatment outcome can be expected by using I) the
maxillary ME AW that has crown lingual torque on the maxillary anterior teeth, 2) the
mandibular MEAW that has crown labial torque on the mandibular anterior teeth, and 3)Class
Ill elastics
Fig.6.13Class Ill malocclusion.

A. Characteristics of Class Ill malocclusion labial inclination of the maxillary incisors and lingual
inclination of the mandibular incisors
B. In Class Il malocclusion, there is a greater probability of using Class Ill elastics in the finishing stage
of treatment. in this case, an undesirable tooth movement can occur To solve this problem, it is
recommended to use an archwire that has crown lingual torque on the maxillary incisors, and an
archwire that has crown labial torque on the mandibular incisors
C.A comparison of tooth movement (inclination) Standard bracket (black line) and SWA bracket (red
line). When the SWA bracket is used, the crown an be more labially inclined than when the standard
• bracket is used.
•
•
D7[»Co6 beet Sys ad bet ocloning

••••
••••
(2) Non-extraction treatment case (Fig. 6-14)
In general, in the case of the $WA appliance, crown labial torque is incorporated into the
maxillary anterior teeth. Therefore, for a non-extraction treatment, labioversion of the
maxillary anterior teeth can be aggravated. However, in the MEAW treatment, labioversion of
•
the maxillary anterior teeth can be minimized and the space can be secured I) by using a •
standard bracket on the maxillary anterior teeth and 2) by effectively using the open coil •
springs on a rectangular archwire that already has crown lingual torque on the maxillary
anterior teeth
·•
Fig.61d Nor-extraction treatment

A. Standard bracket (black line) archwire with crown lingual torque + open oil springs
SWA bracket (red line) + preformed archwire with zero-degree torque + open coil springs
B.A comparison of tooth movement (inclination): standard bracket (black line) and SWA bracket (red
line) When the SWA bracket is used, the crown is more labially inclined than when the standard
bracket is used, thereby increasing the need of an extraction treatment
C Intra0oral photograph standard brackets + archwire with crown lingual torque open coil springs
(3) Maxillary canine inclination (Fig. 6-15,16)
There has always been controversy over the ideal inclination of the maxillary canine.
Appropriate inclination of the maxillary canine is important because the excessive lingual
inclination of the maxillary canine can cause retrusion of the mandible as well as
temporomandibular joint disorder (TMDy. In general, a bracket with zero-degree torque is used
on the maxillary canines in ME
AW
Fig.615Maxillary canine inclination

A. A comparison of tooth movement (inclination) standard bracket (black line) and SWA bracket (red
line'). When SWA bracket is used, the crown tends to have a greater lingual inclination than when a
standard bracket is used. Excessive crown lingual inclination of the maxillary canines has the effect of
reducing activation of the masticatory muscles, while increasing the risk of mandibular retrusion and
compression of mandibular Condie Therefore, a cautious approach is needed when a crown lingual
torque bracket is used on the maxillary canines
B. Comparison of condylar movement (Tarmali et al., 2001)
Bf Amaxillary canine with appropriate inclination
B2Amaxillary canine with excessive crown lingual inclination(10°)
•
•
•
fig.6.16Maxillary canine inclination

A. Pre-treatment intraoral photograph
B.Mid-treatment intraoral photograph
C Post-treatment intraoral photograph excessive lingual inclination of the mnaollary canines
[7+Chapter6Beet Sod Bet Pe o

• •••
••••
(4) Extraction treatment case (Fig. 6-17
In a $WA bracket, since there is 0 to 5 of crown lingual torque, mandibular anterior teeth
may be excessively inclined when closing the extraction site. In ME
AW, however, a zero-
degree torque bracket is recommended to prevent severe lingual inclination of the mandibular
anterior teeth.
•
••
•
Fig.6.47Extraction treatment.
A. In the case of a premolar extraction treatment, lingual inclination will inevitably occur (caused by the
retraction of the anterior teeth). In these cases, the use of a bracket with crown lingual torque on the
mandibular anterior teeth can aggravate the linguoversion
B.A comparison of tooth movement (inclination) standard bracket (black line) and SWA bracket (red
line). When a SA bracket is used, the crown shows greater linguoversion than when a standard
bracket is used
Corf6ot Sr.d beet Po.log « D7

(5) Class II malocclusion case (Fig. 6-18)
Unlike Class Ill malocclusion, in the case of Class II malocclusion, when a SWA bracket is
used (crown labial torque on the maxillary anterior teeth, and zero-degree troque or crown
lingual torque on the mandibular anterior teeth), similar results can be achieved as when a
standard bracket is used with the maxillary and mandibular MEAWs and Class II elastics
together
Fig.618Class ll malocclusion
A. Characteristics of Class ll malocclusion linguoversion of the maxillary anterior teeth and/or
labi0version of the mandibular a0eni0or teeth
B. In the finishing stages of Class ll malocclusion treatment, Class ll elastics are likely to be used. in this
case, an undesirable tooth movement may occur To solve this problem, crown labial torque ghoul be
applied on the maxillary anterior teeth and crown lingual torque should be applied on the mandibulg
anterior teeth
C. Comparison of tooth movement pattern standard brackets (black line) and SWA brackets (red line)
•
•
•
D7[»»cos_sect sod 8colt Po.orig

••••
••••
(6) Torque of posterior teeth (Fig. 6-19)
From premolars to second molars, there is a progressive increase in crown lingual inclination
both on the maxillary posterior teeth and on the mandibular posterior teeth. Especially in $WA
brackets, since the same torque is given to the maxillary first and second molars, the lingual
•
cusps of maxillary second molars are more likely to be extruded •
•
8»
.,._,,/\�� l
- --
c• U \ '
�
Fig.619 Torque of a posterior tooth

A. Progressive crown lingual inclination of molars (Andrews, 1972)
B Excessive crown lingual inclination of molars (Andrews, 1972)
C. Comparison of tooth movement pattern standard brackets (black line) and SWA brackets (red line)
When SWA bracket is used, there is greater crown lingual inclination than when a standard bracket
is used
Chor66ct Sid et Po.oneg [TT

(7) Torque differences between left and right posterior teeth (Fig. 6-20)
In the case of midline deviation, torque differences are typically observed between the left and
right posterior teeth. The affected maxillary molars relatively show crown buccal inclination,
while non.affected maxillary molars relatively show crown lingual inclination. In contrast, the
affected mandibular molars relatively show crown lingual inclination, while non-affected
mandibular molars relatively show crown buccal inclination (Fig. 6-20). Therefore, when
treating midline deviation, a torque control of the posterior teeth must be done
Fig. 620 Torque differences

between left and night posterior
Ar].
teeth
A. Torque differences in the
case of midline deviation
B. Comparison of pre- and
post-treatment intra0rail
photographs the changes
in inclination are observed
on the maxillary night
posterior teeth
Bf.Pre-treatment intraoral
photographs
82 Post-treatment intra0oral
photographs
82»
•
•
• •••
••••
2) Second-order bends (Fig. 6-21)
Second-order bends refers to the mesio-distal angulation of the crown long axis. This should be
placed so that the cervical area of the tooth is placed more in the distal direction than the incisal
edge is. Depending on the goal of the treatment, various SWA brackets can be used
•
•
•
$ 21$$
HH »
·• +G
I
l
' • '
r,
�
I ,_
RH
"
I\ D RH D
"
�
I 1 9 s I
Fig.621 Second-order bends
A. Mesio-distal angulation of each individual tooth (Andrews, 1972)
footh movement with standard brackets (black line)
C. Tooth movement with SWA brackets (red line)
D.Comparison of tooth movement pattern standard brackets (black line) and SWA brackets (red line)
When standard brackets are used, the process of uprighting can be made much easier
Ee When SWA brackets are used, due to crown mesial angulation, the possibility of premature molar
contact increases
F Tooth movement with standard brackets (black line)
G. Tooth movement with SWA brackets (red line)
H.Comparison of tooth movement pattern standard brackets (black line) an4 $WA packets (red line)
When standard brackets are used, the process of uprighting can be made much easier
Cars eot Sa sec e ow « D7

(1) Angulation problems (Fig. 6-22)
In using $WA brackets, which permit the crown mesial angulation in the molar and premolar
areas, there is an increasing possibility of occlusal interference with molars. During space
closure (in an extraction case), due to the mesial angulation of the crowns, the possibility of the
molars being mesially tilted increases more than the possibility of the posterior movement of
anterior teeth, Therefore, in ME AW, the bracket that restricts the mesial angulation of the
crowns should be used in order to upright the premolars and molars successfully.
-%
! ;
/!i)j '!'
;
'
"+ - -
R D D
�
D KY KN
-
' 'e
�
'\
\
�
·.
'
q,
i A\
I,
+
'
f
/
i • .
t
' \
\
\
\ \
·1
'
\
Fig. 6-22 Angulation problems

Posterior occlusion can be influenced by the mesio-distal angulation. FF or example, even in the
case of Class ll malocclusion, a Class I molar relationship can be maintained due to the mesial
angulation of the mandibular molars
•
•
•
EL»» cotes_scot sos d bee

••••
••••
(2) Occlusal plane problems (Fig. 6-23)
In the $WA system, the posterior occlusion of mesially angulated molars is maintained even
after the entire treatment procedure is finished. In contrast, in ME
AW, the mesial angulation of
molars is considered as one of the main contributing factors to malocclusion. Therefore, when
•
using ME
AW, it is essential to correct the mesial angulation of the molars. This means that the
•
treatment can be done by using standard brackets that have zero-degree angulation and by •
using strategic leveling and MEAW (tip-back bends).
;
'
i 8ZH
:
' '
1\1 f
r
:
"
�
KN
�
. f
+Hr
-
i
1\1
i
id �
i
"!'
\
\ ' \.
\
, tf
\
z +
'
t \
\
'
! t i i
' ' \
•
Class IE Class III
Fig. 6-23 00clusal plane problems

A The mesial angulation of posterior teeth can be evaluated from the posterior occlusal plane
An abnormal posterior oclus.al plane is considered to be one of the contributing factors to
malocclusion. Therefore, the posterior occlusal plane should be aggressively controlled and
corrected when treating malocclusion
B. Class ll malocclusion with a steep posterior occlusal plane (POP')
Class Ill malocclusion with a flat posterior occlusal plane (POP)
Cece66et Sod ecol Pe ow «« Dg]

(3) Vertical dimension problems (Fig. 6-24)
Differences in the vertical dimension between the left and right sides of dentition are caused by
the differences in occlusal planes. Therefore, when treating this type of malocclusion,
differences in the vertical dimension between the left and right sides can be treated by
improving the occlusal planes. To achieve this, the independent movement of each molar is
needed.
Fig. 624 Vertical dimension

problems
A. Tooth angulation and
occlursal plane differences
can lead to differences in
the posterior vertical
dimension, the main causes
of midine deviation
BA model for a patient who
has severe curve of Spee in
the night side with ridline
deviation to the night
'•
[e[»»cote6 see%t Sri d sect Po.cog

••••
••••
3) First-order bends (Fig. 6-25)
This refers to the arch form (when seen from the occlusal view) that has a natural curve on the
maxillary and mandibular anterior lingual surface on the lines that connect the fossa of the
maxillary posterior teeth, and on the lines that connect the cusp tips of the mandibular posterior
•
teeth. In order to achieve this in the SWA system, the thickness of the bracket must be pre-adjusted •
for appropriate alignment of the tooth without bending the wire •
Ar]]8r,
Fig. 625 Fist-order benae
A. Comparison of tooth movement pattern standard brackets (black line) an SWA brackets
(red line)
When a standard bracket (black line) is used, the labia movement of the maxillary lateral
mesia rotation of the maxillary first and second molars becomes easier than
incisors and the
when a SWA bracket (red line) is used
B. An ir-and-out is incorporated into the SWA bracket
(1) In-and-out
Since there is a difference in thickness among teeth, an in-and-out is incorporated into the
$WA bracket to compensate for the differences. In most cases, minimal wire bending is used,
but if severe thickness differences are observed, some form of wire bending may be required.
Chap6 bet Sr 8et Po.cooing e[

(2) Dental arch form (Fig. 6-26)
In general, there are three different arch forms: ovoid, tapered, and square. I $WA, the
arehwire that perfectly fits into the pre-existing arch shape is used to maintain a patient's
current arch form. However, in some cases, a correction of the arch form may be needed, in
which case, the stable arch form is known as the ovoid shape. To achieve this, the proper
selection of appliance as well as the appropriate adjustment of archwire is required
» Fig.6-26 Dental arch form

A. Square arch form (U-shape)
B. Ovoid arch form
C. Tapered arch form (V-shape)
(3) Passive centric line and active centric line (Fig. 6-27)
The passive centric line that connects the central fossa of the maxillary molars to the lingual
surfaces of the maxillary anterior teeth should match the active centric line that connects the
cusp tips of the mandibular molars to the edges of the mandibular anterior teeth
•
•
•
Set St an Soot ooneg

[[d»Chapter
••••
••••
•
•
•
Fig.627Passive centric line and active centric line
Centric stop : The position of mandible is determined by the inter-uspation of the

maxillary and mandibular teeth. When the teeth establish maximum inter-cuspation, the
contact points of the maxillary and mandibular teeth are known as centric stop
Passive centric : The centric stop of the maxillary teeth exists in the maxillary dental
arch. This is considered to be in a relatively fixed state because the maxilla is connected to
the cranium, while the mandible is in a movable state. Moreover, as this is considered to be
a passive contact point that accepts the functioning cusps of the mandibular teeth, it is
called passive centric
Active centric ; The centric stop of the mandibular teeth is an actively moving centric
when compared with the passive centric of the maxilla. Therefore, the centric stop of the
mandible is called active centric
The goal of an orthodontic treatment is to match these centric stops of the maxillary and
mandibular teeth perfectly. In a Class I malocclusion case, the passive centric stops of the
maxillary first and second premolars are located in the mesial marginal ridge.
4) KIMS bracket system (Fig. 6-28)
To sum up, a standard bracket should be used to overcome the problems of angulation and
inclination, while a SWA bracket should be used to minimize wire bending. The KIMS bracket has
the in-and-out incorporated inside to minimize wire bending. It is also possible to use preformed
archwires. However, since the second- and third-order bends are not incorporated into the KIMS
bracket, it becomes possible to perform a treatment based on the diagnosis. Furthermore, the KIMS
bracket is made up of a self-ligation type to minimize the patient's discomfort and to reduce chair-
time.
Fig.628 K1MS bracket system

A. KIMS bracket
B. Opened and closed view of a KIMS bracket clip
C.Stages by wire size.
Cf.Passive stage: tooth movement with weak frictional force
C2 interactive stage: combining the sliding mechanism with the torque control
C-3. Active stage: satisfactory control of torque and rotation
•
•
•
D[»»cwt6 boot Sood bees

••••
••••
O,cket
system should have the following characteristics:
It should be able to minimize wire bending.
2.It should be able to offer a unique mesio-distal angulation and torque to each
patient.
•
3.It should be able to provide weak force.
•
4. Only a minimal amount of orthodontic archwire must be used.l •
(1) KIMS bracket
The KIMS bracket has the following characteristics:

lt uses a 018" slot
It does not require basic wire bending as an in-and-out is already built into it
It can effectively use the preformed archwires.
@It uses the orthodontic archwires and transmits a weak force.
It can move teeth effectively without causing crown angulation or torque (crown
inclination) to the bracket
@It can move teeth effectively using MEAW
(2) Applications of KIMS brackets
It is possible to use the same KIMS bracket interchangeably on both maxillary central
nets.ors.
The same brackets can be used both on maxillary lateral incisors and on four mandibular
incisors interchangeably.
( The same brackets can be used interchangeably on the maxillary right and mandibular
left canines, and the maxillary left and mandibular right canines. The hook must be
placed on the distal side
@The same brackets can be used interchangeably on the maxillary and mandibular first
premolars. The same standard brackets can be used on the maxillary and mandibular
canines as well as on the first and second premolars.
The appliances on the maxillary and mandibular first and second molars can be used as
shown in Fig. 6.9,10 and IH.
Cade6_6et $ d see P ow «[g

"b Bracket selection for non-extraction cases
In nor-extraction cases, the standard edgewise brackets with 018" «lots are used. A single buccal
tube with 018" 025 «lot is used for the terminal (usually the second) molars, and a wide bracket
is used for the first molars
It should be able to prevent the labioversion of the maxillary incisors.
It should be able to prevent the labioversion of the mandibular incisors.
It should be able to control the curve of Spee.
It should be able to control the curve of Wilson.
It should be able to prevent the retrusion of the mandible that has been caused by excessive
crown lingual torque of the maxillary canines.
Use of standard brackets.
The terminal molars: use of a buccal tube.
b Bracket selection for premolar extraction cases (Fig. 6-29)
In premolar extraction cases, the Roth prescription brackets (.018" slot) are used only for the four
maxillary anterior teeth. It is recommended to use a bracket with +12 torque for the maxillary
central incisors and a bracket with +8 torque for the maxillary lateral incisors. In addition to using
a bracket with crown labial torque, it is possible to minimize the possibility of extrusion and
hinguoversion of the maxillary incisors in extraction cases by sing a combination loop with step
that has crown labial torque in the anterior region
For the remaining teeth, a standard edgewise bracket with a 018" slot is used. When treating the
terminal molars (usually the second molars), a single buccal tube with a 018" slot is used, and a
wide bracket is used for the first molars. In particular, when $ SWA appliance on the mandibular
premolars and molars is utilized, the lingual inclination of the molars can be aggravated during
•
• treatment due to the lingual inclination that is already built into the SWA appliance. Also, in
• extraction cases, curve of Wilson can be aggravated. Additionally, mesial angulation of the
mandibular molars can be aggravated through the use of an orthodontic appliance that has a mesial
angulation built into it. In some severe cases, there is a high possibility of premature contact
between the maxillary and mandibular terminal molars. Therefore, it is recommended to use the
standard appliances on all teeth except for the four maxillary anterior teeth
[[[»» capers_Sect sys odd set Po.long

••••
••••
4
•
•
Al Bl •
Fig. 629 Bracket selection in premolar extraction cases
Crown lingual inclination, which can occur during space closure, can be minimized by giving
additional crown labial torque to the wire
A. Standard bracket
8 SWA bracket
Linguoversion and extrusion of maxillary anterior teeth should be prevented.

Curve of Spee should be controlled.
Curve of Wilson should be controlled
Retrusion of the mandible caused by excessive crown lingual torque of the maxillary
canines should be prevented.
Choir6tee8.
•• 289
� Positioning
�
Accurate bracket positioning
1) Criteria for bracket positioning
When placing a bracket or a tube on a tooth, a three-dimensional assessment is essential:

(I) Vertical height,
(2) Mesio-distal position,
(3) Slot angulation
First, the crown is examined. If an imaginary line is drawn on the facial axis of a crown, it will be
a FACC (Facial Axis of Clinical Crown). The mid-point of this line is the FA point. In principle,
the bracket must be placed at this FA point (Fig. 6-30)
••L__ I
-�--=----
i]=--==----=-
•
0.5334
•
•
• 3 Fig. 6-30 FACC (Facial Axis of Clinical
Crown) and FA point
A The shape of clinical and anatomical
0rown
B. FACC ol maxillary teeth
.tr
C FACC of mandibular teeth
D FACC and FA point (Andrews,1986)
••••
••••
(1) Vertical height
This refers to the distance from the bracket slot to the cusp tip or incisal edge. By accurately
placing the brackets vertically, ideal occlusion as well as the appropriate relationship of
marginal ridge can be formed in the flat archwire (Fig. 6-39). %
•
Fig. 6.34 Things to consider
•
for bracket positioning
• Reference points
1 Long axis of the tooth
2 Facial airs of the clinical
crown,
3 iisal edge of incisor
and cusp tip of premolar
and molar,
4. Marginal ridge
relationship
5. Contact points,
6. Type of malocclusion
91nlc:al
Tips: Brocket positioning
1. Check the parallelism of the long axis of each tooth
2.Mark the FACC an FA points of each tooth
3.Mark the existence and the degree of marginal ridge discrepancy of the adjacent teeth
a) When there is no marginal ridge discrepancy:
(1) The height of the slot should be lined with the height of the adjacent teeth
ln this case, the brackets should be placed at the FA point.
b) When there is a marginal ridge discrepancy
(1)Amount of marginal ridge discrepancy = Expected distance between the
slots. In this case, the brackets should be placed at the FA point
(2) Amount of marginal ridge discrepancy + Expected distance between the
slots. In this case, the brackets should be placed at the FA point t mm.
4. lace the center of the slot at the mesio-distal center of the tooth
5. Place the slot perpendicularly to the long axis of the tooth. The wing of the bracket
must be parallel to the long axis of the tooth.
6. Make sure that the base of the bracket is in tight contact wth the 'tootsuc.
ad6t Se et Poon e«[@[

(Din general, the ideal bracket heights are as listed below
Maxilla S0mm(UI, 4.5mm(U2), 5.0mm (U3), 4.5mm(U4), 4.5mm(US),4.0mm(U6), 3.5mm (U7)
4.5mm(UI, 4.0mm (U2), 4.5mm (U3), 4.0mm (U4), 4.0mm(US, .5mm (U6), 3.0mm(U7)
Mandible 4.5mm(LI, 4.5mm (L2), 50mm (L), 4.5mm (LA, 4.5mm (LS), 4.0mm (L6), 4.0mm(L7)
4.0mm (LD, 4.0mm(L2), 4.5mm (L3, 4.0mm (LA), 4.0mm (LS), 3.5mm (L6), 3.5mm(L7)
The vertical height of a bracket is measured by a bracket positioning gauge. However,

depending on its assessment method, there may be a high possibility of making an error
(Fig. 6-32)
" -
) ca i.aid '.
�
» e
·, ,�,
t
T •
·w
f •. ..I '
Fig. 6.32 Bracket positioning gauge.
Instead of using a bracket positioning gauge, an eye.ball measurement must be used for accurate
bracket bonding. In this case, a positioning gauge must first be used to check the height, and then the FA
point should be marked. The bracket then should be bonded after careful consideration of its adjacent
teeth
A. A different position of bracket. depending on the angulation of its bracket positioning gauge.
B. Different types of bracket positioning gauges
•
•
•
['»ctr6 Bet rd Bot Poon

••••
••••
The following guidelines should always be considered when determining bracket height
(Fig. 6-33, Table. 6-1)-
a. The average aesthetic length of the upper central incisor is I0mm. The height of this
midline is known to be Sm. If the patient has shorter teeth, a slightly lower height -
•
4.5mm is also acceptable. In these cases, it is undesirable to place a bracket deeper
•
than 5mm •
b. If the bracket is bonded on a lateral incisor, it should be attached approximately
0.5mm closer to the incisal edge than the height of central incisor. Therefore, the ideal
height of the bracket on the lateral incisor would be 4.5mm (if the height of the
central incisor is 5.0mm) or 4.0mm (if the height of the central incisor is 4.5mm).
c. In general, the bracket on a maxillary canine must be bonded at the same height as the
central incisor
d. Brackets for maxillary first and second premolars are positioned at the same height.
Usually, for the second premolar, it is normal for the bracket to be placed 0.5mm closer
to the occlusal edge than the first premolar. However, due to the under-eruption of
second premolars and a step in the first molar, it is recommended to place the brackets
on the same height as the first premolar. This is 0.5mm closer in the occlusal direction
than the maxillary central incisors and canines are. Here in average, the distance of
premolar area is known to be either 4.0mm or 4.Sm away form the cusp tip
e. The bracket on a maxillary first molar should be placed 0.5mm closer to the occlusal
surface than a second premolar is, which is usually O.5mm deeper than the second molar
f. The height of a bracket on the four mandibular anterior teeth must, after considering
the contact with opposing teeth and crown length, be bonded on the height of 4.5mm
or 4.0mm. In this case, it is also important not to place the bracket deeper than its
center of crown
g. The bracket of a mandibular canine must be placed 0.5mm deeper than the one on the
h. The brackets of mandibular first premolars and second premolars must all be placed
at the same height. When treating a second premolar, it is normal to place the bracket
0.5mm closer to its occlusal surface. However, due to the under-eruption of second
premolars and step of first molars, it is recommended to place the brackets at the
same height. Additionally, it is better to place the bracket 0.Sm closer to the
occlusal surface than the mandibular canines are, which are approximately 4.5mm or
4.0mm away
i. The bracket of a mandibular first molar should be placed 0.5mm closer to the occlusal
surface than the second premolar, but attached at the same height as the second molar
Here, it is normal to place the second molar 0.5mm closer in the occlusal direction,
but if there is no difference in marginal ridges, it is recommended to bond the bracket
at the same height.
Table. 6.f Reference table of different

bracket heights
$ t
f
Centi Lee Carine
0or
6+05
50
n0er
x
45
05
50
fest
x
45
Second
Xx
45
-
fest
X05
40
Second
mo
X10
35
45 40 45 40 40 35 3.0
X X 8+05 x x-05 x05
'
I 40
45
40
45
4.5
50
40
45
40
45
35
40
35
40
Fig.633 Reference of brackets height

Bracket slots are bonded in reference to the
distance from the cusp tip of the first
premolar to ts Crown 0enter
•
•
•
• •••
••••
2 Cautions
a. These measurements have been determined according to observations made by dental
practitioners on properly erupted teeth. In the case of a short crown, adjustments may be
required. For example, after careful consideration of its marginal ridge relationship, the
vertical bracket height can be adjusted.
•
b. If possible, a consistent application of bracket height must be made in the same
•
dentition •
e. Marginal ridge relationship This is the most important criterion when considering
vertical height. The slot of a molar bracket or tube should be the same distance from the
imaginary line which connects the mesial and distal marginal rides. If the slot
positioning is inaccurately marked, anterior open bite or malocclusion may Occur.
d. In the case of an anterior open bite or deep bite, the bracket should be placed at the
center of crown. Here, since the main purpose of ME
AW treatment is to improve its
occlusal plane, excessive changes in bracket positioning is not recommended
e. If the mandibular molar bracket or tube comes into contaet with a maxillary molar,
unexpected problems such as, detachment of an appliance, or lingual inclination of
mandibular molars (and subsequent retrusion of the mandible) may occur. Therefore,
one must be extra careful in order not to permit the contact between brackets/tubes and
opposing teeth (Fig. 6-34)
Fig. 634 Problems of contact

between mandibular brackets
and maxillary teeth
f footh mobility and bracket
detachment
2 Lingual inclination of the
crown
8+ 3 Retrusion of the mandible
Cage6 et rd 8et Posco0g «[l

(3 Vertical positioning errors
This refers to an error in the vertical height. The majority of errors arising from bracket
positioning are related to this. If the bracket is placed too close to its occlusal surface, the
tooth will also be located lower than the occlusal plane, Reversely, if the bracket is
positioned too close to its gingival direction, tooth extrusion may occur (Fig. 6-35).
Therefore an accurate evaluation of the marginal ridge relationship must be made when
positioning the bracket.
A.f
Fig. 6.35 Vertical height of

brackets
A-1. Gingirvally-positioned
bracket
A.2Tooth movement that has
%..y
been caused by a
gingivally-placed bracket
B-1. Accurate bracket
postoning
R 8.2 Expected tooth
movement
•
•
•
• •••
••••
The following errors commonly occur (Fig. 6-6)

a. Inconsistencies in the marginal ridge of the posterior region,
b. Inconsistencies in the maxillary and mandibular incisal edges.
A.f +Bf •
•
' l •
''
'
K KY
�
K K o, 8
'-,-�------�-�
- •
r=-
-------,
1
+A.2
�L___-I
Fig. 636 Vertical positioning errors.
A. Tooth movement is caused by incorrectly placed brackets on the night incisors.
Tooth movement when the brackets are accurately bonded on the first premolar and second molar
that have the discrepancy of marginal ridge relationship
C. Bracket positioning and its adjustment on partially erupted teeth
f) The bracket is occlusally placed on the maxillary left second premolar
2)Post-treatment intraoral photograph
Te following errors commonly occur.

a. When treating partially erupted teeth, it is not compulsory to follow its strategic bonding
and to place a bracket on the tooth. [f there is a difference in vertical bracket height, an
archwire adjustment must be made in the finishing phases or the bracket should be re-
bonded into an ideal position after the leveling procedure
b. When treating a patient who has a crown fracture or attrition on the incisal edge or
occlusal surface, a bracket must be positioned after the occlusal adjustment. Here
however, if the patient is still growing or the amount of attrition is small, a bracket must
be positioned after the incisal edge adjustment.
297
On the other hand, when treating an adult, it is important to discuss what their main
purpose of the treatment is i.e. aesthetic prosthesis, occlusal adjustment, etc. A
discussion must be carried out whether to perform a prosthodontic treatment after
modifying the vertical height in the early stage of treatment, or whether to grind the
ncisal edges before bonding the brackets.
e. When the buccal cusp is too long and sharp, appliances must be bonded after a re-
shaping of the maxillary canine.
(2) Mesio-distal position
The bracket is positioned at the mesio-distal center of the crown (Fig. 6-37).
a. In the anterior dentition, the natural shape of the lingual surface can be maintained.
b. The line that connects the central fossa of the posterior dentition is natural and smooth.
c. In the occlusal view, the buccal surface of the maxillary first molars should be as parallel
as possible
# t
7
I
7
¢
t 'r
f
(Yr I
,
'
- ' -- '
' ,
I
• Fig.6.37Alesio-distal position
• At the incisor, canine and premolar area, the brackets should be positioned at the mesio-distal
• center of the crown, but at the molar area, the brackets should be positioned at the buccal
groove
••••
••••
2) Bracket positioning errors
(1) Horizontal positioning errors (Fig. 6-38, 39)
This refers to the positioning of a bracket that improves the mesio-distal position relative to the
•
long axis of crown. When a bracket is placed on its mesial position, the bonded tooth rotates in •
a distal direction, and if a bracket is placed on its distal position, the attached tooth rotates in a •
mesial direction. Here, the special considerations are as follows
Fig. 6-38 Horizontal positioning error on

the maxillary fight lateral incisor. The
bracket is positioned too far distally
A Fig. 639 Horizontal positioning error on

the mallary night lateral incisor
A The bracket is distally positioned
8. Tooth movement caused by a distally
positioned bracket
C Expected tooth movement mesial
» rotation of the tooth is induced by the
distally positioned bracket
C»
Cord8et Dant8t 299

(1 Mesial rotation and parallel rotation of the maxillary first molar
A mesially rotated maxillary first molar can cause a variety of problems, such as
exacerbation of Class ll molar relationship and crowding in the premolar area (Fig. 6.40).
1
B
1 ,. Fig. 6-40 Mesial rotation and parallel

rotation of the maxillary fest molar
A. A correctly placed bracket on the maoary
first molar the slot entrance is placed at
{:- {:- r the center of the mesio-bu0cal cusp
B.A bracket is distally placed on the
maollary first molar
$ I
$ 3 ,
C.Expected tooth movement. mesial
rotation of the tooth is induced by the
distally positioned bracket
(2 Crowding in the maxillary and mandibular anterior areas (Fig.6-41)

a. Between the central and lateral incisors: In the case of a mesially rotated lateral incisor,
crowding can be corrected by positioning the bracket more on its mesial direction than
the long axis of the tooth. However, if it is placed more in a distal direction, a correction
of the mesially rotated lateral incisor would be difficult to achieve
b. Between the lateral incisors and the canines: Most errors occur from the mesial rotation
of the canine. Therefore, it is important to place the bracket slightly more in a mesial
direction than the long axis of the canine crown
... ".
"
A
• ca
• ''
• ''
-·-
Fig.641 Maxillary incisors
A Accurately positioned bracket on the center of the tooth
B. The night side (red line) of the brackets is distally positioned
C Expected tooth movement mesial rotation of the tooth is induced by the distally positioned brackets
ff»cord_St yd sot Pooni

••••
••••
As a result, the bracket is placed closer to the mesio-distal center of the crown. In a Class ll
malocclusion case, in order to induce the distal rotation of maxillary premolars, the bracket
must be placed more towards the mesial direction. In Class Ill malocclusion, in order to
induce the mesial rotation of the maxillary premolar, the bracket must be placed more in
the distal direction. Here, however, the bracket should also be placed in the mesial
•
direction of the mandibular dentition to induce the distal movement of mandibular •
dentition (Fig. 6-42) •
A
·• +C
I (
€ ' "
LJ
Fig. 642 Bracket positioning in the case of Class ll and Class Ill malocclusion
A Brackets positioned at the mesio-distal center of the crown
B. In the case of Class fl malocclusion, the brackets on the maxillary premolars are bonded more in the
mesial direction to permit the distal rotation of the teeth and mesial rotation of the palatal Cusps
C In the case of Class Ill malocclusion, the brackets on the maxillary premolars can be placed more in a
distal direction to facilitate the mesial rotation of the teeth Here, the brackets on the mandibular
premolars must be positioned mote in the mesial direction to induce the distal rotation of the teeth
in this case, the brackets should not be bonded in the opposite direction
3 Bracket angulation in relation to the long axis of the tooth
The bracket slot must form a right angle with the long axis of the tooth. In order to achieve
this, the panoramic image must be referred to when positioning the bracket. In particular, in
the KIMS bracket, crown inclination is not included, so the following must be considered
in order, when positioning: long axis of the tooth, FACC, and then the incisal edge (in the
case of anterior teeth) (Fig. 6-43)
a. The bracket slot should form a right angle with the long axis of the tooth
b. The bracket slot should be perpendicular to the FACC
e. The bracket slot should be parallel to the incisal edge on the incisors, and the cusp
tips on the molars
d. When closing space, the crown is likely to be angulated towards the extraction site.
Therefore, the bracket slot must be placed more on the gingival side.
e. When only the maxillary premolars are extracted, the mesial sides of maxillary molar
brackets should be positioned towards the gingival side in order to obtain a proper
occlusion, and to further induce the anterior root movement.
f Artistic bends in the anterior dentition; In the case of four anterior teeth, the roots
should be parallel to each other not only for aesthetic purposes, but also to prevent the
close proximity of roots.
Fig.643 Bracket angulation on teeth

1.Long axis of the tooth
2Long axis of the clinical crown
3. Incisal edge of ncisors and cusp tips of
i
molars
4. Extraction site
•
•
•
• •••
••••
(2) Angulation errors (Fig. 6-44)
The bracket slot should be perpendicular to the long axis of the tooth. If not, the long axis of
the tooth will not be parallel to each other. Therefore, when treating the following cases,
special attention must be paid
•
•
8
•
K
Fig.644 Angulation errors

A. Mesial side of the gingovally-positioned bracket on the molar
B. Extrusion of mesio-buccal cusp on the molar
C. Expected tooth movement
(D Tooth adjacent to the extraction site (Fig. 6-45)

When closing the extraction site, a tilting of the adjacent teeth frequently occurs.
To compensate for this, the bracket wing must be bonded after tilting it to the gingiva side.
Here, the bracket should not be positioned in the opposite direction (i.e. towards the
occlusal area of the extraction site)
·•
Fig. 64 Bracket positioning of adjacent teeth around the extraction site

A Tooth movement with the ideal bracket position crowns tilt in a converse direction towards the
extraction site, while the roots tit in a diverse direction
footh movement when the bracket is gingivally-positioned towards the extraction site tooth movement
is accomplished through tooth uprighting and root movement
C Tooth movement when the bracket is occlusally positioned towards the extraction site roots tilt more
in a diverse direction
(2 Maxillary lateral incisor area (Fig. 6-46)
Due to the different shapes of the maxillary lateral incisors, the tooth axis may become
very close to its adjacent teeth. Therefore, when positioning the bracket, special attention
should be given to root parallelism
Ce
Fig.646 Bracket positioning in the maxillary lateral incisor area

A. Post-treatment intraoral photographs
8 Post-treatment panoramic radiography inadequate root angulation is observed
•
•
•
.the
C Mid-treatment intraoral photographs
bracket angulation that required adjustment
• •••
••••
(3) Thickness errors (Fig. 6-47)
When a bracket is not properly bonded, tooth rotation and subsequent crowding may Occur.
Therefore, the brackets must all be accurately attached on the tooth surfaces.
•
•
•
l
Fig.6.47 Thickness error
A Intraoral photographs tooth rotation is caused by a thickness error
B. Diagram of thickness error.
Corlee. std 8ct Potion «[f

3) Precise bracket positioning in clinical practice.
There are a couple of different bracket positioning methods that are used in the clinical field. These
are I) direct bonding procedures, where the practitioner bonds the bracket directly, and 2) indirect
bonding procedures, where the brackets are placed on a model and then transferred into a patient's
mouth using a template or a tray. Advantages of direet bonding procedures are that a bracket can
be bonded easily, eliminate the need for laboratory work and thereby lowering the cost. The main
disadvantage of direct bonding procedures is the increased difficulty (for the practitioner) of
precise bracket positioning. In the case of indirect bonding procedures, precise bonding can be
achieved, but is important to bear in mind that it is more expensive and there is a greater risk of
detachment. Each procedure has its own advantages and disadvantages. It is recommended to
perform direct bonding for visible procedures, and indirect bonding for lingual orthodontic
procedures (Fig. 6-48)
Fig. 648 Direct bonding system and indirect bonding system

A. Direct bonding system
B. indirect bonding system
(1) Necessary materials for direct bonding procedures (Fig. 6-49)

•
•
• There are different types of adhesives: mix type, no-mix type, and light curing type.
Nowadays, the light curing type is preferred. as it makes the adjustment procedure much easier
and has greater bond strength. The entire bracket base must be accurately attached onto the
labial surface of tooth. If not, the adhesive will be squeezed into the apex of the curvature,
forming a weak bond. Too much stress may be placed on this procedure, thereby increasing the
risk of bond failure. Here, the layer of adhesive between the bracket base and the tooth must be
••••
••••
e-
B
- -4 -f
•
•
•
Fig. 649 Materials for direct bonding system (DBS)
A. Bonding kit. ( Etchant, Bonding agent,
Bonding resin, @ Tweezers,
($ Timer, $ Brush,
7Plastic spatula, @ Dapper glass
B. Etchant, bonding agent, bonding resin, brush
(2) Direct bonding procedures (Fig. 6-50)
Oral prophylaxis
First, to maximize its boding effect, an oral prophylaxis must be completed perfectly. This
should be done with a pumice that is soaked in water, using a brush or a rubber cup. If a
paste that contains oil, glycerin, or fluoride is used, it will diminish the effect of acid
etching.
2 Moisture control
Salivary inflow can be blocked by a lip retractor, cotton roll, and gauze
3 Acid etching
37% phosphoric acid must be used to carry out etching for 20 seconds. Nowadays, the
etchant is spread via a syringe onto an area of the tooth surface that is slightly larger than
the bracket base. After 20 seconds, the tooth's surface is washed and dried. If it is properly
etched, it would show a white chalky surface.
Coor66et Si bet Po.oneg «[7

Primer
Apply a thin layer of primer onto the etched surface of tooth and the bracket's base.
S Resin and bonding paste

After holding the bracket with tweezers, bonding paste is added on top of the previously
applied primer.
6 Bonding
a. Placement
Tweezers must be used to place the bracket (now with bonding paste on it) onto the
labial tooth surface
b. Positioning
After positioning the bracket at the previously determined location, the tweezers must be
released. Then, a scaler or an explorer must be carefully used to adjust the bracket
position. Here, the vertical position of the bracket can be accurately adjusted through the
use of a bracket positioning gauge. The horizontal position, especially when there is a
premolar rotation, can be more effectively adjusted when it is checked from the occlusal
surface by using a dental mirror.
c. Fitting
Slight pressure must be applied to the bracket through the use of an explorer, a scaler, or
tweezers. This would then create a tight fit to the tooth surface, and this firm contact can
form a strong bond. Here, it is very important not to move the bracket until it is bonded
and placed correctly.
d. Removal of excess resin
Onee the resin is indurated, it cannot be removed through brushing or any form of
mechanical force_ Therefore, it should be removed gently before it hardens. This can be
done by sliding and pushing the resin outward with the help of an explorer or a scaler
• However, if the resin is hardened before removal, it must be removed through a tungsten
• carbide bur. The emoval process should be done with great care, especially in the
• gingival area.
Lght curing
lndurate by shooting a hight curing gun for about 20 seconds.
3f@»»Cots_ct Sys ad 8et Po.long

••••
••••
Fig. 650 Direct bonding procedures
•
•
•
A Pumice an Robinson brush

8. Oral prophylaxis
C. Water wash
D. Moisture control
E. Bonding kit
F. Acid etching
G After water wash
4 peener application apply the primer on the tooth surface
I. Abracket held by tweezers.
Cc6 beet sod set Po.icon « [f

Fig. 6-50 (continued) Direct bonding procedures
' hi
J. Primer application on the bracket base

K. Applying resin on the primered bracket a suitable amount of resin must be applied on the bracket base
L. Resin is evenly distributed on the bracket base
M. Bonding the bracket on the tooth
N The bracket is accurately positioned and fem pressure is applied
0. Correcting the bracket position, and removing the excess resin is accomplished by using an explorer
P. Accurate positioning and angulation of bracket is verified.
0.Light curing
•
•
•
[f»»cord 8root Swan Soot Pooneg

••••
••••
(3) Bracket bonding in special cases
D Bonding to porcelain (Fig. 6-51)

a. The gingiva and lips are protected using Koo-Dam (pulpdent) and cotton rolls.
b. Etching is done for 3 minutes, with 9.6% hydrofluoric acid
•
c. Using a cotton roll, the hydrofluoric acid is carefully wiped off
•
d. Water rinse •
e. Application of porcelain primer (Silane: wait I minute.
f Activation of solvent using air
g. Bonding primer is applied, and using the same method as on a natural tooth, the bracket
is bonded with bonding resin.
(2 Bonding to amalgam
a. Small amalgam filling with sound enamel surrounding.
a) Treat the surface with a sandblaster for 3 seconds.
b) Use 37% phosphoric acid to etch for IS seconds.
e) Similar to the case of natural tooth, the bonding agent is applied. The bracket is
bonded with bonding resin.
b. Large amalgam restoration

a) Treat the surface with a sandblaster for 3 seconds.
b) Apply Reliance metal primer and wait for 30 seconds.
e) Use air to activate the solvent
d) Similar to the case of natural tooth, the bonding agent is applied. The bracket is
bonded with bonding resin.
G
f 44$
--
6 .$4
Fig.6f Bracket bonding to porcelain

A. Application of hydrofluoric acid for 3 minutes
B. Removal of hydrofluoric acid by using a cotton roll
C Water wash.
D Application of porcelain primer, waiting 1 minute
E.Activation of solvent by air
f Bonding primer and bonding resin application (same procedure as ona natural tooth)
][e Cord Sot Sod Bet Po.tog

••••
••••
3 Bonding to gold
a. Onlay with sound enamel surrounding (Fig. 6-52)
a) Surface is treated with a sandblaster for seconds.
b) Etching is done for IS seconds, using 37% phosphoric acid.
e) Reliance metal primer is applied: wait 30 seconds.
•
d) Activate the solvent by air,
•
e) As on a natural tooth, the bonding agent is applied, and the bracket is bonded with •
bonding resin.
Fig.6.52 Bracket bonding to amalgam or gold inlay

A. Sandblasting
B. Acit etching
C. Check for rough and chalky surface
D. Metal primer
E Apply the Reliance metal primer and wait tor 30 seconds. Then activate the solvent by air
F Bracket bonding.
b. Gold crown restoration or Large BO inlay (Fig. 6-53)
a) Existing methods do not provide sufficient bonding strength and have a higher risk of
treatment failure. Therefore, if possible, band fabrication should be performed.
b) Surface is treated with a sandblaster for 3 seconds.
e) Either intermediate resin (All-Bond 2 Primer A and B) Or 4-META metal bonding
resin (Superbond C&B) should be applied
d) When applying the intermediate resin, the application should be done twice in 30
seconds. The solvent is then activated using air.
e) Similar to the case of natural tooth, apply the bonding agent and then bond the
bracket with bonding resin.
f) When applying 4-META metal bonding resin, there is no need to follow the
procedures hike in the case of natural tooth. Simply follow the manufacturer's
instructions/guidance.
·•
Fig.6.53 Bracket bonding

on the gold crown
A Sandblast the metal surface
• B Check for rough surface

C. Apply metal primer
• D Apply bonding agent (primer)
• and light-curing
E. Bond the bracket
14»Cord Bot Sea let Pe o

• •••
••••
Bonding to composite restoratives (Fig.6-54)

a. Reliance Plastic Conditioner is applied and then wait for I minute
b. Leave it under room temperature
e. Similar to the case of natural tooth, apply the bonding agent and then bond the bracket
with bonding resin
•
•
•
Fig.654 Reliance Plastic Conditioner.

..
Bracket positioning for Individual teeth
1) Maxillary central incisor (Fig. 6-55)
8»
Fig.6.55 Accurately positioned brackets on the maxillary central incisors

A. Frontal view. B Occlusal view.
(1) Mesio-distal relationship
The bracket is placed at the mesio-distal center of the crown
(2) Bracket angulation
( Make sure that the positions of bracket slots are perpendicular to the long axis of the tooth
(fthere is attrition on the incisal edge, the bracket proximal margin should be parallel to the
proximal margin of crown
•
•
• (3) Vertical relationship
(D Place the bracket at the center of crown.

As is clearly stated on the guideline, the bracket should be placed about S.0mm away from
the incisal edge.
(Ensure that there is no difference between the ineisal edge and the adjacent central incisor.
[@ Cort Soot Swea et Po.song

••••
••••
(4) Common errors (Fig. 6-56)
(D Height discrepancy between the central incisors: This commonly arises from the
discrepancy of the bracket heights. To prevent this, it is recommended to place the bracket
from the frontal view, while considering the incisal edge and gingival margin
•
(Mesio-distal positional error can cause crowding.
•
(9 Distortion of root parallelism between adjacent teeth •
Fig.656 Common errors in bracket positioning on maolary central incisors

A Height discrepancy between the central incisors caused by a bracket positioning error
B. Anterior crowding caused by a horizontal positioning error.
C. Distortion of root parallelism caused by a bracket angulation error on the maxillary night central incisor,
Coor6Sot Sy ad Sot Pe mg «]
2) Maxillary lateral incisor (Fig. 6-57)
Fig.6.67 Accurately positioned brackets on the maxillary lateral incisors

A. Frontal view. B Ooclusal view.
Place the bracket at the mesio-distal center of the crown

(When there is a need for overcorrection, place the bracket towards the mesial side.
(2) Angulation
(D Make sure that the positions of bracket slots are perpendicular to the long axis of the tooth
(lfthere is attrition on the incisal edge, the proximal margin of the bracket must be parallel to
the proximal margin of crown.
(3) Vertical relationship
•
• (D Place the bracket at the center of erown.
• Asis clearly stated on the guideline, the bracket must be placed about 4.5mm away from the
incisal edge
( There should be a difference of 0.5mm from the incisal edge to its central incisor.
1[»Cr6 Sect Syd let Poon

••••
••••
(4) Common errors (Fig. 6-58 A--D)
(DA distally located lateral incisor bracket. This complicates the correction of a mesially
rotated maxillary lateral incisor. Therefore, with the use of overcorrection, it is more
desirable to place the bracket slightly more in the mesial direction (when compared to the
•
long axis of the crown). If, however, it is diffieult to bond the bracket at its ideal position,
•
the tooth should first be moved in the distal direction, and then repositioned. •
More extruded maxillary lateral incisor when compared with the central incisor: Since the
bracket, which is placed on the maxillary lateral incisor, is located more in the gingival
direction, the tooth extrudes more than the central incisor. This, as a result, can cause an
unaesthetic appearance.
(9 sufficient root labial movement When moving the palatally positioned maxillary lateral
incisor towards its dental arch, not the root but the crown is likely to move. In this case, the
root of the lateral incisor must be moved sufficiently towards its labial side, To maximize its
scope of movement, the pre-adjusted bracket of the lateral incisor must be bonded upside
down, as this can allow the crown lingual torque effect on the bracket that has crown labial
torque. Then, L-loops must be applied on the mesial and distal sides and root labial torque
must be applied on the lateral incisor area to encourage the labial movement of root
However, this is a time-consuming treatment, which can take up to 6 months. Therefore,
such treatment methods must be carefully considered in the early bracket bonding stages,
not in the finishing stages of procedure
( Distortion of root parallelism between adjacent teeth Sometimes, the root of the lateral
incisor and the canine may become too closely located after the treatment. This is a
common phenomenon when an appliance is bonded on the basis of worn maxillary lateral
incisors. To prevent this, careful examination of the panoramic radiograph and the mesial
surface of crown must be made
Fig.68 Common errors in bracket positioning on maxillary lateral incisors
A Mesial rotation of tooth caused

by a distally positioned bracket
B. Ideal bracket positioning on
mesially rotated lateral incisors
C Tooth extrusion caused by a
gingivally-positioned bracket
•
•
•
D. Mesial tilting of the root caused by inaccurate bracket angulation

E. Unaesthetic maxillary night lateral incisor due to insufficient labial movement of root
E-1.Pre-treatment intraoral photographs
E-2Mi-treatment intraoral photographs
E-3. Post-treatment intraoral photographs.
• •••
••••
3) Maxillary canine
•
•
•
B»
Fig. 6-59 Accurately positioned bracket on the maxillary canines

A. Frontal view. B Ooelusal view
The bracket is placed at the mesio-distal center of the crown.
(2) Angulation
Make sure that the bracket slot is perpendicular to the long axis of the tooth.
(D Place the bracket at the center of crown.

As is clearly stated on the guideline, the bracket must be positioned about S.0mm away
from the cusp tip
( When there is a pointy cusp tip, the bracket should be appropriately positioned under the
consideration of the occlusal adjustment
(When there is attrition, the bracket should be placed slightly more towards the gingival side,
considering the re-contouring of maxillary canine.
Char6ct mt Set Polong Lal

(4) Common errors {Fig. 6-60)
(D Excessive distal positioning of the bracket on a maxillary canine:

There is a mesial rotation of maxillary canine to cause a step between the lateral incisor and
the canine. Therefore, it is more desirable to place the bracket more towards the mesial side
of the center of crown
(Excessively over-erupted maxillary came
(9 Distorted parallelism between the root and adjacent teeth
Unaesthetic mesio-distal inclination of the maxillary canine: In particular, in maxillary
premolar extraction cases, when the maxillary canine is moved more posteriorly, the crown
is highly likely to be positioned in the distal direction to cause (-) angulation. To prevent
this, either a bracket that is appropriately angulated should be used or the distal side of the
bracket should be placed more towards the gingival side.
Fig. 660 Common errors in

bracket positioning on
maxillary canines
A. Mesial rotation of tooth
caused by a distally
positioned bracket
B. Extrusion of the maollary
left canine caused by a
bracket positioning error
C. Under-eruption of the
maxillary night canine
caused by an 0cclusally-
B positioned bracket
D inadequate root angulation
of the maxillary left canine
caused by a bracket
angulation error
•
•
· ·""
0»
Decor6 Soot Sys ad beet otioog

••••
••••
4) Maxillary first premolar and second premolar (Fig. 6-61)
[ 1 •
•
•
»
Fig.661 Accurately positioned brackets on the maxillary premolars.
A Frontal view B. Oclusal view.
Place the brackets at the center of crown.
(2) Angulation
Place the bracket so that the slot forms a right angle with the long axis of the tooth
As is clearly stated on the guideline, the bracket must be placed about 4.5mm away from the
cusp tip.
Car6 et St bet Po.ion «[[

(D Differenee in vertical height: This occurs due mainly to the difference in the vertical heights
of the brackets between the canine, premolars, and the first molar. Here, an accurate bracket
positioning, as well as the marginal ridge relationship, is essential.
( sufficient mesio-distal rotation: The bracket should be placed at the mesio-distal center of
crown. In Class II malocclusion, mesially rotated premolars must be placed more on the
mesial side to implement the de-rotation. From such movements, the lingual cusp of the
premolar shifts more towards the mesial direction, rendering the future process -retrusive
control- more beneficial and easier
Distorted parallelism between the root and adjacent teeth.

bracket positioning on maxillary
premolars
A. Under-occlusion (between
the maxillary and mandibular
night premolars) caused by an
0ochusally positioned bracket
• lere, MAW6 used to erode
the tooth that has problems
B inadequate root angulation
of the maxillary left first
premolar caused by a boak.et
angulation error
C Distal rotation of the maollary
night first premolar caused by
am illy positioned bracket
[[d»cord_feet Syd 8cot Pocong

••••
••••
5) Maxillary first molar and second molar (Fig. 6-63)
•
•
•
Fig.663 Accurately positioned bracket on the maxillary molars

A. Frontal view B. Ooelusal view
The entrance of the bracket slot should be located at the center of the mesio-buccal cusp.
(2) Angulation
The bracket slot must be positioned to form a right angle with the long axis of the tooth
As is clearly stated on the guideline, the bracket should be positioned about 4.0mm (maxillary
first molar) or 3.5mm (maxillary second molar) away from the cusp tips.
Coors ct Sm sod eek Po oc «[[_

(D Differences in vertical height: An over-erupted maxillary first molar (when compared to a
maxillary premolar) causes problems. To prevent this, the bracket should be positioned with
the same difference as the difference between the marginal ridges of the maxillary first
molar and premolar. Also, as the second molar is likely to over-erupt, the bracket must be
accurately placed after careful consideration of its relationship with the first molar. The
bracket for the second molar should either be placed 0.5mm more towards its occlusal
direction, or at a similar level (when compared with the first molar and its bracket).
( lnsufficient mesial rotation This occurs when the bracket is positioned more on its distal
site than the mesio-distal center of crown. To prevent this, the entrance of a bracket slot or
buccal tube should be positioned at the center of the mesio-buccal cusp of the maxillary
molar. This is the very first step when making the buccal surfaces of the maxillary first
molars parallel to each other at its occlusal surface Here, to reinforce this, it is better to use
a bracket in which the rotation control has been already embedded.
( Over-eruption of the mesial part of a tooth This occurs when the bracket and the mesial
surface of a buccal tube are placed more in its gingival direction. Here, however, the mesial
pant of the band may be more gingivally placed due to anteriorly inclined molars, so great
caution is required when using a band

bracket positioning on mapolary
molars
A Under-occlusion caused by
a bracket positioning error
B. kMesial rotation of maxillary
• night first molar caused by a
• distally positioned bracket
•
[DD»»coirshot sod ecol Poto

••••
••••
6) Mandibular incisor (Fig. 6-65)
•
•
•
Fig.665 Accurately positioned brackets on mandibular incisors

A. Frontal view B. Occlusal view.
Place the bracket at the mesio-distal center of crown.
(2) Angulation
Make sure that the bracket slot is perpendicular to the long axis of the tooth
( Place the bracket at the center of crown

Asis clearly stated on the guideline, the bracket should be placed about 4.5mm away from
the incisal edge
(0Make sure that there is no difference in the incisal edge on the adjacent tooth
Chace6_et Sod sect Pe oc +«[[7

(D Height difference between the central and lateral incisors: This occurs because of a height
difference between the brackets on the four mandibular incisors.
When there is crowding in the mandibular anterior area, the bracket must be accurately
placed, under careful consideration of crowding and attrition.
Crowding caused by a mesio-distal positioning error.
fig.666 Common errors in bracket positioning on mandibular incisors

• A. Height discrepancy caused by a bracket positioning error
• A.1. 4Mid-treatment intraoral photographs
• A.2. Post-treatment intraoral photograph
B. Gingivally-positioned brackets on lower incisors
C.Crowding on mandibular left central incisor caused by a distally positioned bracket
••••
••••
7) Mandibular canine (Fig. 6-67)
•
•
•
4 Fig.667Accurately positioned brackets on mandibular canines

A. Frontal
view. B. Occlusal view
Place the bracket at the mesio-distal center of crown.
(2) Angulation
(D Place the bracket at the center of crown

(Asis clearly stated on the guideline, the bracket must be placed about S.0mm away from the
cusp tip.
(9 When there is a pointy cusp tip, the bracket should be appropriately positioned under
consideration of the occlusal adjustment.
When there is attrition, the bracket should be placed slightly more on its gingival side,
considering the re-contouring of mandibular canine
Cote66et Sod sec Pe ow [DSG

D Excessive mesial rotation of the mandibular canine due to the distal positioning of bracket:
Because of this, the mandibular canine rotates mesially to cause a step between the lateral
incisor and the canine, Therefore, it is more desirable to place the mandibular canine on its
mesial side away from the center of crown.
Over-erupted mandibular canine.
Unaesthetic mesio-distal inclination (or angulation) of the mandibular canine
• Fig. 668 Common errors in bracket positioning on mandibular

canines
A. Mesial rotation of tooth caused by a distally positioned bracket
B. Height discrepancy of mandibular left canine caused by an
0cClus.ally positioned bracket
C inaccurate root position of mandibular night canine caused by a
C bracket angulation error
Cord Sot So ecol Pe o

• •••
••••
8) Mandibular first and second premolar (Fig. 6-69)
•
•
•
Fig. 669 Accurately positioned brackets on mandibular premolars

A Frontal view. B Occlusal view.
Place the bracket at the center of the mesio-buccal cusp.
(2) Angulation
As is clearly stated on the guideline, the bracket must be placed about 4.mm away from the
cusp tip
(D Difference in vertical height.

Insufficient mesio-distal rotation
( Broken root parallelism with adjacent teeth
Fig.6.70 Common errors in bracket positioning on mandibular premolars

A. Infraocclusion caused by an occurs.ally positioned bracket
• Mesial rotation of the mandibular premolars caused by a distally positioned bracket
C inaccurate root angulation of mandibular left first premolar caused bya bracket angulation error.
•
•
•
[»»tors_Sect sod sect Po.orig

••••
••••
9) Mandibular first and second molar (Fig. 6-71)
•
•
•
A Frontal view
.B
Fig.671 Accurately positioned bracket and tube on mandibular molars
B. Occlusal view
Place the entrance of bracket slot at the center of the mesio-buccal cusp
(2) Angulation
As is clearly stated on the guideline, the bracket must be placed about 4.0mm (mandibular first
molar) or 3.5mm (mandibular second molar) away from the cusp tips
D Difference in vertical height.

(Insufficient mesial rotation.
Over-eruption of the mesial part of a tooth
(Contact with maxillary teeth: If the bracket of a mandibular molar comes into contact with a
maxillary tooth, unexpected movement occurs. If it is left untreated, a lingual inclination of
mandibular tooth can occur.
•
•
•
Fig.6.72Common errors in bracket positioning on mandibular molars
A Linder-occlusion caused by a bracket positioning error
- ...J
B. Over-eruption of the mnesio-Ducal cusp of the mandibular left second molar caused by placing the
mesial side of the bracket more towards the gingival side
C. Mandibular bracket that comes into contact with a maxillary tooth if the bracket on the mandibular left
molar comes into contact with the maxillary first molar, the lingual inclination of the mandibular molar
can be aggravate
••••
••••
Accurately positioned brackets on a model (Fig. 6.73)
•
•
•
Fig.673 Accurately positioned brackets

.._,
Bracket positioning in various cases
(· Bracket positioning to secure the space for a maxillary lateral incisor (Fig. 6-
74, 75)
When gaining space for an implant at its missing lateral incisor site, the mesio-distal
distances between the adjacent roots, as well as the distance between the crowns, are
essential
To accomplish this successfully, the root of the maxillary central incisor needs to move
Bf
C
I
p -- u
9a/
Fig.6.74 Accurate bracket positioning to secure space for a maxillary lateral incisor implant
A1.Tooth movement during spa0¢ gaining for the maxillary lateral incisor
•
•
.f
A2 Sufficient amount of space is secured not for the root but for the crown. As a result, the
space is closed by adjacent roots
To prevent this, the mesial side of the canine bracket and the distal side of the incisor
bracket must be placed more towards the occlusal direction
• B-2 Expected tooth movement
C. Periapical radiograph showing a correct tooth movement
D. Bracket positioning for space closure of a missing lateral incisor opposite to the above
instructions
••••
••••
more towards its mesial direction. Also, the bracket angulation must be altered so that the
distal side of the bracket is placed more towards the incisal direction, and the mesial side is
located more towards the gingival direction. In contrast, in the case of maxillary canines,
the root needs to be placed more towards the distal direction. This means that the bracket
angulation should be altered so that the mesial side of the bracket is positioned more
•
towards the incisal direction, and the distal side is located more towards the gingival •
direction. Here, the vertical height of the bracket should remain consistent, and the •
horizontal relationship should be placed at the center of crown.
Fig.6.75 Accurate bracket positioning to secure the space for a maxillary lateral incisor
A. Changes in bracket positions on the maxillary night canine and the central incisor
B. Pre-treatment intraoral photographs
Post-treatment panoramic radiograpl
D. Intraoral photographs after the implant treatment
Corf ot beet Po.co0g «[d/

(2 Proper bracket positioning to gain space for a mandibular first premolar (in the
case of a missing mandibular second premolar) (Fig. 6-76)
When there is a missing mandibular second premolar, there must be a posterior movement
of the first premolar to secure the space for implant. Here, the root movement of the first
premolar and the canine is required. However, to accomplish the above movement, the
bracket angulation must be altered: the distal side of the first premolar bracket must be
placed in the gingival direction, and the mesial side, in the occlusal direction. On the other
hand, in the case of canine, its root should be moved more towards the mesial direction.
Here, to accomplish the above movement, the bracket angulation must also be altered: the
distal side of the canine bracket must be placed in the incisal direction, and the mesial side,
in the gingival direction. In this case, the vertical height of the bracket should also be
consistent, and the horizontal relationship must be placed at the center of crown.
Fig.6.76 Accurate bracket positioning to secure the $pace fora mandibular first premolar (in the case
0fa missing mandibular second premolar)
« .....
r
IOI ""
D KY
1v '
8
r-- "'
r-- 0
All •
. - • "
A Tooth movement when the mandibular first premolar is shifted distally distal crown angulation
and mesial root angulation
B To prevent this, the distal part of the first premolar bracket must be placed in the gingival
direction and the mesial pant, in the occlursal direction. In contrast, the distal part of the canine
bracket should be placed in the occlusal direction and the mesial pant, in the gingival direction
•
•
•
••••
••••
,,
Fig.6.76 (continued) Accurate bracket positioning to secure the space for a mandibular first
premolar (in the case of a missing mandibular second premolar).
•
•
•
C. Intraoral photographs
Cf Pretreatment intraoral photographs
C-2. Mid-treatment intraoral photographs
C-3. Post-treatment intra0ral photographs
C-4. Intraoral photograph after the implant treatment
D. Panoramic radiograph after the implant treatment
This is similar to bracket positioning in an extraction case ie the bracket sides that are lose to the
extraction space should be tilted more towards the gingival side for space closure and more towards the
occlusal side for space gaining
(3 Bracket positioning for the leveling of six maxillary anterior teeth which are
worn and extrusive (Fig. 6-77)
For adults, when leveling the six maxillary anterior teeth that are extruded due to attrition,
the leveling of the gingiva, rather than of the incisal edge, is important
In other words, the brackets must be at a position where the gingival margins of the central
incisors are parallel, and where the gingival margins of central incisor and canine are at the
same height. Here, the gingival margin of the maxillary lateral incisor must be placed more
towards the occlusal direction (when compared with the central incisor)
d
t
.a e?
, %
� •
•
-
Fig. 6.77 Bracket positioning for the leveling of the six maxillary anterior teeth which are worn and
• extrusive
• A1. Pre-treatment intraoral photograph. anterior space and unaesthetic gingival margin
• A2The width-height ratio of the maxillary central incisors is 8mm-8mm
A-3. Prosthodontic treatment after obtaining an aesthetic gingival margin
B-1. Bracket positioning after obtaining an aesthetic gingrval margin
B-2 Intraoral photograph after the completion of leveling
B-3. Intra@oral photograph after removing the orthodontic appliance
Cf Pre-treatment intraoral photograph
C2.Post-treatment intraoral photograph
C-3. Post-retention intraoral photograph (two years after the treatment)
[dd[Jr» Coor6Sect yd et Poon

••••
••••
@ Proper bracket positioning in the case of maxillary premolar extraction only

(Fig. 6-78-80)
In the case of maxillary premolar extraction only, if bracket positioning is completed in the
same way as in the maxillary and mandibular premolar extraction cases, there will be a
greater risk of unstable occlusion and terporomandibular joint disorder. Also, due to the
•
mesial tilting of maxillary molars, establishment of posterior occlusion cannot be made •
accurately and easily. Therefore, to prevent this, the mesial part of the bracket on the •
maxillary posterior teeth should be placed more towards the gingival direction. By doing
so, the mesial drifting of roots can be made to facilitate maximum intereuspation.
Fig.6.78 Proper bracket

positioning in the case of
maxillary premolar extraction
only
• A If the bracket is placed at
the normal position, mes+al
overent of postenor
fi59J +% teeth can cause unstable

occlusion
8. The bracket is accurately
positioned for stable
occlusion and desirable
tooth movement
- C. Standard brackets should
be used to facilitate the
mes.ial rotation of posterior
teeth
341
Fig.679 Proper bracket positioning in the case of maxillary premolar extraction only.
When only maxillary premolars are extracted, the occlusion of the left and night posterior area wilt differ
Arguably, this is due to the different angulation of maxillary first molars i.e. the normal bracket angulation
is enforced on the right fest molar, but the bracket on the left side is placed more towards the mesial side
and tilted towards the gingiva.±Here, the desirable occlusion is obtained only on the left side.
•
•
• Fig. 680 Proper bracket positioning in the case of maxillary premolar extraction only.
A.Case when only maxillary premolars are extracted the mesial side of the maxillary first molar bracket
is bonded more towards the gingival side
B Post-treatment intraoral photographs
••••
••••
REFERENCES
1. Adams DM, Powers JAM, and Asga K. Effects of brackets and ties on stiffness of an arch wire. Am J
0rtnod Dentofac Orth0op 91-131-136, 1987.
2 Aguirre MJ, King Gd, and Waldron JAM. Assessment of bracket placement and bonding strength when
comparing direct bonding to indirect bonding techniques. An J Orth0d 82.269, 1982 •
3. American Orthodontics. Orthodontic Product Catalog, 2011. •
4. Andrews LF, Straight wire, the concept and appliance, San Diego: LA Wells; 1986 •
5. Andrews LF. The six keys to normal occlusion. Am J Orthod 62(3).296, 1972
6. Andrews LF. The straight wire appliance explained and compared. J Ciin Orth0d 10(3)-174-195, 1976
7Andrews Lr The straight wire appliance onigin, controversy, commentary. J Ci Orth0d 10421-99114,
1976
8. Badawi HM, To0goo Rw, Carey JP, Heo, G. and Major, P.M. Torque expression of self-ligating
brackets. Am J Orthod Dentofacial Orth0, 133721-728, 2008
9. Begg R. Orthodontic theory and technique. 3rd ed. Philadelphia wB Saunders, 1977.
10. Bell WR A study of applied force as related to the use of elastics and coil springs. Angle Orthod
21.151-162, 1951
1f. Bennett JC, and McLaughlin Rp_Orthodontic management of the dentition with the preadjusted
appliance. Isis Medical Media, 1997
12. Bis.hara SE, and Andresen GF A comparison of time related forces between plastic alastics and latex
elastics. Angle Orth0d 40-.319-328, 1970
13. Boone GN. Archwires designed for individual patients. Angle Orthod 33.178-185, 1963.
4. Burrow SJ. Canine retraction rate with self-ligation brackets vs conventional edgewise brackets. Angle
Orth0d 80.438-445, 2010.
15. Burstone CJ, Bai Qin MS, and Morton JY, Chinese NTi wire:. A new orthodontic alloy. Am J Orthod
87445-452, 1985
16. Cozzani Giuseppe. Garden of Orthodontics. Quintessenoe. 2000
17 Daskalogiannakis J, and Ammann, A Glossary of orthodontic terms, Quintessence, 200O.
18. G&Hwire company. Orthodontic. Product Catalog. 8th edition.
19 Grauer D, and Pro#ft WR Accuracy in tooth positioning with fully customized lingual orthodontic
appliances. Am J Or1hod Dentofac Orthop 140.433-443, 2011
20. Gurgel J, kenr S, Powers JM, and LeCrone, V. Force-deflection properties of super-elastic nickel-
titanium archwires. Am J Orthod Dentolac Orth0p 120.378-382, 2001
21. Harraine NWT. Self-ligating brackets and treatment efficiency. Cin Orthod Res 4220-227,2001
22. Harraine NWT. Self-ligating brackets: where are we now? J Orthod, 30.262-273, 2003.
23. Iwasaki LR, et al. Clinical ligation forces and intraoral friction during sliding on a stainless steel
archwire. Am J Orthod Dentofacial Orthop 123.408-415, 2000.
24. Joondeph DR. graber TM, Vararsdall RL, Vig KWL, eds. Orthodontics Current Principle and
Techniques. Ed4. St Louise. Mosby, 2005
25. Joell SD, Leiss JB, and RekOw ED. Force degradation in elastomenic chains. Semin Orthod 3.189-
197, 1997
26. Khambay B, Millett D, and Mc Hugh S. Evaluation of methods of archwire ligation on frictional
resistance. Eur J Orth0d 26.327-332, 2004
27 Kim JI, Akimoto S, Shinjj H, and Sato S. Importance of vertical dimension and cant of occlusal plane in
craniofacial development. int J Stomato0l Occlusion Med 2114-121,2009
28. Kim JI. Practical Clinical Orthodontics. Vol 1, Orthodontic treatment with MEAW. Well publishing Inc,
2012
29. Kim JI. Practical Clinical Orthodontics, Vol 2. Orthodontic Diagnosis. Well publishing Inc, 2013
30. Kim JI. Practical Clinical Orthodontics. Vol3. Early orthodontic treatment. Well publishing Inc, 2015.
31. Maijer R, Smith DC. Time saving with self-ligating brackets. J Clin Orth0d 24.29-31, 1990.
32. McNamara JA Jr, and Brudon wL Orthodontics and Dentofacial Orthopedics. Needham Press, 2001.
33. Pandis N, Bourauel C, and Eliades T. Changes in the stiffness of the ligating mechanismn in retrived
active self-ligating brackets. Am J Orthod Dentofacial Orthop 132.834-837, 2007
34. Pandis N, Polychronopoulou A, and Eliades T. Active or passive self-ligating brackets? A randomized
controlled trial of comparative efficiency in resolving maollary anterior crowding in adole cents. Amn J
0rthod Dentofacial Orth0p 13712, 2010.
35. Pizzoni L, Raunholt G, and Melsen B. Frictional forces related to self
ligating brackets. Eur J Orthod
20.283-291, 1998
36. Proffit WR. Contemporary orthodontics. St Louis CV Mosby company, 1986.
37. Ricketts RW, Bench RW, Gugino CF, Hilgers 4J, and Schulhof RA. Bi0progressive Therapy. Denver.
Rocky Mountain Orthodontics 1979.
38. Roth RH. Functional occlusion for the orthodontist. J Cin Orthod 1541-4), 1981.
39. Sato S, AkKimoto S, Matsumoto A, Shirasu A, and Yoshida J. MEAW .Manual for the clinical
application of MEAW technique, 2002
40. Shivapuig PK, and Berger J, A comparative study of conventional ligation and self-ligation bracket
systems. Am J Orthod Dentofacial Orth0p 106.472-480, 1994
• 41 Stefanos S, Se0chi AG, Coby G, et al, Friction between various self-ligating brackets and archwire
• couples during sliding mechanics. Am J Orthod Dentofacial Orthop. 138.463-467, 2010
• 42 Strang RH. Highlights of sixty-four years in orthodontics. Angle Orthod 44, 1974.
43. Tamali et al. A pilot study on masticatory musoles ativitie durning grinding movements in occlusion
with different grinding areas on working side. Bulletin of Kanagawa Dental College. 29.26-27, 2001
44 Tent FV. Atlas of orthodontic appliances. Caravel, 1985
• •••
••••
45 Thomas RB et al. Force extension characteristics of orthodontic elastics. Amn J Ortho 72-296-302,
1977.
46. Thorstenson BS, and Kus Rp Comparison of resistance to sliding between different self-ligating
brackets with second order angulation in the dry and saliva states. Am J Orthod Dentofacial Orth0p
121472-782. 2002.
47. Tomy international inc. Tomy Orthodontic Product Catalog, vol. 4.0, 2009. •
48. Tweed CH. A philosophy of orthodontic treatment. Am J Orthod Oral Surg. 31.74, 1945
•
49. Tweed CH. Clinical orthodontics. Vol1 and 2. St Louis. Mosby, 1966.
•
50. Tweed CH. Report of cases treated with the edgewise arch mechanism. Angle Orth0d 2-236, 1932
51. Tweed CH. The application of the principles of the edgewise arch in the treatment of Class Il,
Division1, part I. Angle Orthod 6:198-208, 1936
52 Tweed CH. The application of the principles of the edgewise arch in the treatment of Class I,
Division1, part IL. Angle Orthod 6.255-257, 1936
53. Wrong AK. Orthodontic elastic materials. Angle Orthod 46.196-204, 1976
Corot mt Sot Po.orig «[d

••••
. . . . . . . . . . . .. -- ...
Chapter 7_
LEVELING AND
ALIGNMENT
D .Basic Orthodontic Terms
'9 Leveling and alignment
1) Leveling
This refers to an orthodontic treatment procedure for flattening the curve of Spee (along the
vertical plane) until the marginal ridges of all the teeth are positioned at the same level(Fig. 7-D).
\
0
NR
!" RH {s))
•
-
K V
,
H
f J
J
• ,. _
•
• Fig.7.4Leveling
A. Maxillary teeth leveling B. Mandibular teeth leveling
••••
••••
2) Alignment
This refers to an orthodontic treatment procedure that moves the teeth bucco-lingually (in the
horizontal plane) to form an ideal arch form.
•
(e
--'-
, ./\
1r
j
r
•
•
e ' F
'
-:l--'
)
8 �
1
-:l- t ¢
•
I < $ z 3 Fig.7.2Alignment
A. Maxillary teeth alignment
-t
B. Mandibular teeth alignment
@ ( + #
± ¢
r 'f
'
¢
r r
�
,' )
"
B•
''
el- ' '' -- ,' )
3) Ideal arch form
The teeth move on a continuous archwire while maintaining its ideal areh form (Fig. 7.3)
Fig.7.3The concept of ideal

arch form
Tooth movement ona continuous
archwire is a basis for both
extraction a0d 00r-el/aDion
treatment
Led Anet «&

�
Simple leveling vs strategic leveling
1) Simple leveling
Simple leveling refers to the process of bonding the brackets on all the mandibular teeth (even
including the terminal molars), If the terminal molars are included, the labioversion of mandibular
incisors would be aggravated due to the interactions of mandibular incisors and mandibular
molars. It is notable here that there will be no changes in the posterior occlusal plane, and that the
labioversion of incisors will get aggravated (Fig. 7-4),
' :
.. . ......
Fig. 7-4 Simple leveling.
f the brackets are bonded on every tooth excluding the terminal molar, labiversion of
anterior teeth will get aggravated
•
•
•
3c»» Corr_Ag a Moment

••••
••••
2) Strategic leveling
Tis refers to the process of aligning the eight or ten anterior teeth, and then uprighting the
terminal molars without bonding the brackets to the teeth that are located in front of the terminal
molars (mostly the second premolars and/or the first molars) in the mandible (Fig. 7-5). In this
•
case, a non-extraction treatment becomes possible because the space is gained when the mesially
•
tilted and rotated second molars are uprighted and de-rotated as the anterior teeth are used as an •
anchor. It is notable here that there will be some changes in the posterior occlusal plane and a
slight labioversion of the incisors
Al
-I . CA.>
e(
' 4' -'pp-
; ; 4
;-
-
7
-:}
;
r -
-:}
;
"-'
�
-z
Fig.7.5Strategic leveling.
-
$ -z• $
-
A. Strategic leveling refers to the process of aligning the eight or ten anterior teeth, and
then uprighting the terminal molars without bonding the brackets to the teeth in front of
the terminal molars (mostly the second premolars and/or the first molars) in the
mandible
B. An example of incorrect strategic leveling open coil springs (0CS) are first used on the
posterior teeth
C.An example of correct strategic leveling open coil springs (0CS) are first used on the
anterior teeth to align them
Ca'tog Alt «['

.._,
Cinch back bends (Fig. 7-6)
This is gingivally and/or mesially directed bends of archwire, which is distal to the terminal
attachments in an arch. The main purposes of these bends are to maintain the current position of
the archwire, to prevent the archwire from sliding to an anterior direction, and to protect the soft
tissue from being damaged. In particular, distal end bends can be used to prevent the excessive
labioversion of anterior teeth during leveling.
•
•
• Fig.7-6 Cinch back bends
A Cut the wire 3 mmn away from the distal end of buccal tube
Hold the wire with utility pliers ad bend it inward
C. Bend it gingivally again
D. Cinch back bends
E. Weingart utility pliers.
39a» corr_tog met • •••

••••
'b Tight cinch back & loose cinch back
After bonding the appliance strategically (strategic bonding), open coil springs (0CS) should be
appropriately applied to gain space at the crowded site. If the appliances are bonded to every tooth,
anterior teeth will be labially inclined due to the interaction of posterior and anterior teeth, and the
•
need for an extraction treatment will increase. Nevertheless, if ) strategic bonding is achieved, 2) •
the open coil springs (0CS) are used to solve crowding, and 3) the tight cinch back is conducted to •
remove any remaining extra distal archwire (behind the buccal tube), inter-canine expansion will
occur rather than labioversion of incisors. Here, if the brackets are not attached to the first
premolars, such an expansion could negatively influence the premolars (inducing the palatal
displacement or extrusion). Therefore, the lingually positioned lateral incisors are likely to move in
the anterior direction after the space opening. If the above procedures are successfully done, the six
anterior teeth can, as a result, be accurately aligned with minimal labioversion of incisors. Next,
the palatally positioned premolars should be aligned in the same way as mentioned above. Here, to
upright and de-rotate the mesially angulated and rotated second molars, the open coil springs
(0CS) should be applied to the first premolars and/or the first molars. In this case, the loose cinch
back should be conducted to make some extra room in the archwire after the buccal tube, This
entire treatment procedure makes it possible to solve crowding with minimum labioversion of
maxillary incisors. As a result, the possibility of nor-extraction treatment increases and this leads
to a change in arch form from a V-shape to an ovoid-shape.
1) Tight cinch back (Fig. 7-7 A)
(I) Ligate all the brackets

(2) With Weingart pliers, bend one end of the archwire in the mesio-gingival direction
() After pulling the opposite end of the archwire in the posterior direction, bend it in the mesio-
gingival direction.
(4) If the anterior archwire of the bucal tube comes off after pulling it in the posterior direction,
the cinch back must be done again in the mesio-gingival direction
The tight cinch back can solve crowding problems with minimum labioversion of anterior teeth
by modifying the dental arch form with little change to arch length. To achieve this, it is more
desirable to bond the appliances selectively to facilitate a strategic tooth movement instead of
bonding the appliances to all the teeth
2) Loose cinch back (Fig. 7-7 B)
(I) Ligate only one central incisor.

(2)Leave some extra wire at the end of the buccal tube and use Weingart pliers to do the cinch
back in the mesio-gingival direction. Then, apply the same method to the other side and do the
cinch back.
()) Ligate all the remaining teeth
If the cinch back is done properly in this way, the mesially rotated and angulated terminal
molars will get de-rotated and uprighted. To successfully achieve this, without bonding the
appliances to the teeth in front of the terminal molars, the eight or ten anterior teeth should be
aligned without any crowding.
Fig.7.7Tight cinch back and loose cinch back

A. Tight cinch back
)Ligate all the bonded teeth
2) Do the cinch back bends on one side, and do another inch back bends on the other side while
pulling it posteriorly.
+ Note that the wire should not be popped out when it is pulled posteriorly.
B.Loose cinch back
• 1Ligate only one antenior tooth and then do the cinch back bends on both ends of archwire
• 2)Ligate all the remaining teeth
•
• •••
••••
so Bonding
4b Definition
•
•
•
This is the process of bonding appliances strategically to meet their treatment objectives. In this
process, an appliance is only attached selectively, and is regarded as the second most important
factor after diagnosis and bracket positioning in MEAW concept. Such bonding methods can be
applied both in extraction cases and in non-extraction cases.
'b Purposes
(I) Efficient tooth movement.

(2) Increase the inter-bracket distance.
(3) Shorten the treatment period.
( Increase the possibility of non-extraction treatment
(5) Reduce the possibility of orthognathie surgery
't, Methods of application
(l)Fiest, the appliances should not be bonded to the teeth in front of the terminal molars. This
means that if an appliance is attached to the second molars, it should not be further bonded to
the first molars.
(2f possible, appliances should be bonded to both of the maxillary central incisors.
(3) If possible, the four maxillary and mandibular incisors should be aligned in advance.
(4) If there is a vertical discrepancy in the maxillary canine area, the appliances should be bonded
later. In this case, the appliances should be first attached to the four maxillary incisors and the
maxillary first premolars. However, if there is no vertical discrepancy in the maxillary canine
area, the appliances should be first bonded to the canines to gain space for the palatally
positioned lateral incisors (Fig. 7-9)
(5) In the case of mesially tilted premolars, brackets should not be attached to the teeth, that are
located in front of these premolars, for effective uprighting.
(6) In non-extraction cases, if there is a full cusp Class ll molar relationship, the maxillary first
molars should be moved posteriorly in advance. Here, different treatment methods may be
required depending on the eruption status of second molars. Before the eruption, a pendulum
appliance is recommended to be used, while after the eruption mini-implants are recommended
between the second premolars and the first molars. In this case, there must be sufficient molar
distalization to make a super Class I molar relationship
(7) In premolar extraction cases, the appliances should be attached first to maintain the Class I
canine and premolar relationship. This means that in the extraction cases of both maxillary and
mandibular first premolars, the maxillary canines should be moved posteriorly, and the
mandibular second premolars should be moved anteriorly. Here, it is very important not to
move the maxillary second premolars anteriorly in advance
Fig.78 Strategic leveling

A. During the early stages of
non-extraction treatment,
appliances should not be
bonded to the teeth in front
of the terminal molars
B. In extraction cases, if the
second molars are to be
bonded. then the first molars
should not be bonded
C.in extraction cases. the first
molars are to be bonded,
• the second premolars should
• be bonded during the early
• stages of treatment
56»» Chore ad egret ••••

••••
•
•
•
Fig.7-9 Strategic bonding

Conduct strategic bonding after careful consideration of the vertical discrepancy in the maxillary canine
are%8
A.If the maxillary canines are more gingivally positioned (than the adjacent first premolars), it is more
desirable to exclude the canines when bonding the appliances
fthe maxillary canines are positioned at the same level as the adjacent first premolars, it will be more
desirable to include the canines when bonding the appliances
cow_Awe neert +«Bo7

�
Considerations
(I) Utilization of open coil springs (0CS).

(2) Management of molar rotation
(3) Management of upper occlusal plane (UOP)
(4) Management of posterior occlusal plane (POP).
(5 Elimination of occlusal force.
1) Utilization of open coil springs (0CS)
(1) Purposes (Fig. 7-10)
( Space opening effect

a. ltis used to open the space of one tooth or two teeth
b. It has an effect of arch expansion.
2 Tooth uprighting effect

[tis used to upright the mesially tilted mandibular first premolars and molars.
A»» •
• Fig.7-40 Strategic bonding with the open coil springs (0CS)
• A. Opening the space for de-crowding
• B. Uprighting the mesially tilted teeth uprighting can be done successfully by using the open
coil springs (0CS) in the anterior area of the mesially tilted teeth
(2) Minimal archwire thickness: .016" stainless steel archwire
[58»» Cw Leg Monee

••••
••••
(3) Force generation by open coil springs (Fig. 7-11)
(D For activation, open coil springs must be inserted 30% Longer than the inter-bracket distance
( To gain the space of one tooth, the width of the open coil springs must be inserted as much
as the width of one bracket.
•
( After the insertion of open coil springs, make sure that slight compression is felt. •
•
'/
_.,.
&7#
A I
''L-----------�
Fig.7.44 Strategic utilization of open coil springs (0CS)
A. Open coil springs (0CS)
B. For activation, open coil springs must be inserted 30% longer than the inter-bracket distance
2) Management of molar rotation
The buccal surfaces of both first molars should be parallel to each other (Fig. 7-12). If maxillary
second molars (or first moalrs) are mesially rotated, and the appliances are attached to all the teeth,
the mesially rotated second molars can be de-rotated, or reversely, the labioversion of anterior teeth
can be aggravated. This side effect can be solved by using the open coil springs (0CS) to de-rotate
the mesially tilted molars, instead of attaching the appliances to the teeth in front of the terminal
molars. This is a type of strategic leveling and alignment that can correct the maxillary and
mandibular arch form (Fig. 7-13). If the arch form is in a V-shape (tapered), and the appliances are
attached to all the teeth, there is a limitation in tooth rotation because of the rotation in the brackets
and the toe-in bend in archwire. This means that it becomes far easier to secure the space and
change the arch form by de-rotating the terminal molars without attaching the appliances to the
teeth in front of the terminal molars in the early stages of treatment.
To treat the maxillary first molars that are already parallel to each other, a non-extraction treatment
can be done only through the expansion of maxillary arch or labioversion of incisors, which means
that there is a greater possibility of taking a premolar extraction treatment approach.
cc'greet e+Bo
ln this case, since the maxillary molars are already parallel to each other, it is important to maintain
the current position of the molars and to close the extraction space. On the other hand, in premolar
extraction cases with mesially rotated maxillary first molars, open coil springs (OS) should be
first used in the first molar area I) to recover the parallel relationship of maxillary second molars,
2)to de-rotate the maxillary first molars, and ) to secure space for extraction by using the energy
chain between the second molars and first molars (Fig. 7-14)
Fig. 7.412Management of molar rotation

The bu0cal surfaces of maxillary first molars should be parallel to each other
A. Parallelized first molars. B. Mesially rotated first molars
A
•
4'
F
."' 2{J
• 1 1
• -j t
<: 5
Fig.7-13 Molar rotation in nor-extraction cases
Though the parallel rotation of mesially rotated molars and the modification of arch form,
a nor-extraction treatment approach becomes possible
••••
••••
•
•
•
Ct]Cl
LL]
Fig. 7.4 Molar rotation in premolar extraction cases
A. Mesially rotated maxillary first molars the mesisal movement of molars becomes far easier
when closing the space
B. Parallelized maxillary first molars
When the open coil springs are inserted between the second molars and second premolars,
the mesially rotated first molars can be parallelized through the use of the energy chain
between the first and second molars
D After parallelizing the fest molars, the maxillary canines should be retracted from the first
molars
• Decrowding
Although there are various methods for de-crowding (multi-loop archwire, super-elastic
archwire, etc.), it is more desirable to gain space first by using the open coil springs, and then
to try to align the teeth effectively. Here, it is possible to gain space and minimize labioversion
of anterior teeth by using the aforementioned tight cinch back method. To successfully
accomplish this, a standard edgewise bracket should be bonded on the anterior teeth, and the
open coil springs should be inserted into the 016"x 02" stainless steel archwire with crown
lingual torque.
Te align the palatally positioned teeth, the following methods can be used:
D Elastic thread,
Ligature wire,
3L-loop,
Overlay archwire.
•
•
• Fig.7.41s Solutions for de-crowding
+ The teeth should be aligned after the space opening
The following methods can be used

A. Elastic thread,
B. Ligature wire,
C. Overlay archwire
D. L-loop
In the cases of A, B or C method, it is recommended to align the
teeth with the open coil springs (0CS) inserted.
[o»» Coe_Lt re
••••
••••
After the space is secured, the bracket or lingual button should first be attached to the palatally
positioned teeth, and then the teeth should be tracted by using the elastic thread or ligature wire
with the open coil springs (0CS) inserted. After the teeth are aligned to the extent of arch form,
the overlay archwire (014" NiTi) or 014" L-loop can be used for further alignment. If there is a
need for three dimensional control (first-, second-, and third-order bends), loop bending is highly
effective. Next, leveling anchwire can be used again to re-level and re-align the teeth (Fig. 7-16). «
•
Fig. 7-16 Alignment of palatally positioned teeth (maxillary lateral incisors)

A le the case of palatally positioned maxillary lateral incisors, even if they are aligned to the dental arch,
they look unaesthetic because of limited root movement
A-1. Pre-treatment photographs
A-2. Mid-treatment photographs after leveling and alignment. The maxilary left lateral incisor looks
unaesthetic
A-3. Post-treatment photographs
B Orthodontic treatment procedure.
B-1.L-loop treatment.
8.2The maxillary lateral incisor looks unaesthetic because of limited root movement
8.3. Tooth movement pattern after applying toot labial torque to the maxillary lateral incisor
c'Ag ad rt «LG
Unicoi
Tips: Alignment methods for palatally positioned maxillary
lateral incisors.
1. Bond the $WA (+8°) bracket on the maxillary lateral incisor in the reverse direction.
2. Bond the bracket slightly towards the gingival side (about 0.5mm).
3. Use the 016.022 torque control archwire to ensure root labial movement.
4. Keep the torque controlling wire for 6 months
5. If necessary, grind the incisal edges.
►►►►►
In premolar extraction cases with crowding problems, it is easy to solve the issue of crowding
by moving the tooth towards the extraction space in the early stages of treatment
However, in non-extraction cases, the teeth should be aligned based on the current positions of
maxillary and mandibular incisors, and to do this strategic leveling and alignment are essential
In particular, for non-extraction cases, a standard bracket (with zero-degree torque), open coil
springs, and 016"x 022" stainless steel archwire (with crown lingual torque) should all be
used to minimize the labioversion of maxillary and mandibular incisors (Fig. 7.17)
This is specifically important for non-surgical or non-extraction treatment approaches when
treating Class Ill malocclusion patients (who also have crowding on the maxillary anterior
teeth due to maxillary deficiency). In this case, due to the dental compensation of Class Ill
malocclusion, maxillary incisors show normal or even labial inclination, If there is a normal
inclination, this can be solved by a non-surgical or non-extraction treatment approach. Here
although there is crowding in the maxillary canines, excessive labioversion of anterior teeth is
not desirable when correcting the Class Ill relationship.
The treatment procedures are as follows (Fig. 7-18)

(D Strategic bonding: bonding the standard bracket with zero-degree torque.
016 stainless steel archwire with open coil springs (0CS) and tight cinch back.
• Activation of open coil springs (0cs).
• @0.016"x.022" stainless steel archwire (crown lingual torque) with open coil springs
• (0CS) and loose cinch back
Activation of open coil springs (0CS).
@.016" stainless steel archwire with open coil springs (0CS) (the anterior area) and tight
cinch back ( is repeated).
0 Bonding the appliances on the remaining teeth
[[ Cooteg ad Mt
••••
••••
•
•
•
Fig.7.47Crown lingual torque.

Standard bracket + archwire with crown lingual torque open 0oil
springs (0CS) due to the effects of the archwire with crown lingual
torque and open coil springs(0CS), the crown remains in the
Current position and the root moves to the labial direction
A. Standard bracket and SWA bracket
(Left -Standard bracket. Right - $WA bracket')
• Archwire with crown lingual torque
C. Open coil springs (0CS)
D. Intraoral photograph
V'nlcot
Tips: non-extraction treatment approach to crowding
Minimize the labioverison of anterior teeth
1, Bond the 018 slot standard edgewise bracket on the anterior teeth
2. Apply the 016.922 stainless steel archwire with crown lingual torque
(approximately.7)to the anterior part of archwire
3. Use the open coil springs (0CS) in the under-erupted or crowding areas
Expected results
By using an archwire with crown lingual torque and open coil springs (0CS),
the crown of anterior teeth can be successfully aligned from the current
antero-posterior position. Nevertheless, due to labial movement of the root,
the labioversion of anterior teeth can be minimized, and the space for de-
crowding can be secured )bbl)
gee' Lr ad rent «[o'

Fig. 7.18 Crown lingual torque application
A. Pre-treatment intraoral photograph insufficient space for canines and severe anterior cross bite
B. Use the posterior bite block (PB) in the mandible and open coil springs (0CS) on the maxillary
canines. Then do the tight cinch back at the end
C. Use the 016.022 stainless steel archwire with crown lingual torque and open coil springs (0CS)
D Remove the posterior bite block (PBS) and apply a resin cap on the mandibular second primary molar
E.Extract the primary molar. Then level and align the maxillary canines
F Finish the treatment by using the maxillary and mandibular MEAW$
G. Post-treatment intraoral photograph
4. Post-retention photograph (one year after the treatment).
or the details of orthodontic treatment procedure, refer to Chapter 14.a non-xtration treatment case
in Class Ill malocclusion (From Fig. 14.1 t0 Fig. 14.23)
•
•
• •••
••••
3) Management of upper occlusal plane (UOP)
The upper occlusal plane (UOP) represents the angle between the FH plane and the plane that
connects the incisal edge of the maxillary central incisors to the midpoint of maxillary first molars
on the occlusal surface. This value is approximately0' (Fig. 7.19)
•
When the upper occlusal plane (UOP) is normal, it is desirable to maintain its value in both
•
extraction and non-extraction cases. In particular, for premolar extraction cases, caution is needed •
to control the upper oclusal plane. If the appliance is extended to the distally tilted maxillary
second molars (for the purpose of anchorage reinforcement), the upper occlusal plane (OP)y will
become steeper. This means that it is not desirable to extend the appliance to the maxillary second
molars, and therefore it is better to extend the appliance only to the maxillary first molars and to
close the extraction space. In other words, the decision of whether to extend the appliance to the
maxillary first molars or to the maxillary second molars should be made during the diagnosis, and
caution is required not to make the upper occlusal plane (UOP) too steep (Fig. 7-20). When the
upper occlusal plane (UOP) is steep, it means that the maxillary incisors are extruded excessively
and/or the maxillary molars are intruded. Here, the vertical position of the maxillary incisors is
important, and this position can be determined by the distance from the UI to hip line (distance,
mm). In cases where the maxillary incisors are excessively extruded, a counter-clockwise rotation
of the upper occlusal plane (UOP) should be applied, which arises from the intrusion of maxillary
incisors and the extrusion of maxillary molars, to induce the forward rotation of mandible
Cc'Lg ad Me @7
Fig.7.419 Upper oclusal plane (u0)
A. Upper occlusal plane (UOP') a line connecting the incisal tip of the maxillary central incisors to the mid-
point of the maxillary first molars
tn the lateral ephalometric radiograph, it is marked as the angle between the FH plane and upper
occlusal plane (U0P). This value is generally 1gr
• B.Lateral cephalometric radiograph, intraoral photographs, and dental models of a patient who has normal
• upper occlusal plane (UO)
•
• •••
••••
Fig.7.19 (continued) Upper oclusal plane (UOP')
•
•
•
C.Lateral cephalometri radio0graph, intra@oral photographs, and dental models of a patient who has steep
upper occlusal plane (U0P)
ca0Agreer «BO9
l
'"L a ••�--------------�
Fig. 7-20 Precautions in extending the appliance to the maxillary second molar
A Extrusion of maxillary anterior teeth when the appliance is attached to the maxillary second
molar
B. If the appliance is bonded on the maxillary second molar, the steps must be applied on the
archwire (between the first molar and the second molar).
• Double archwire (DAW) appliance
Double archwire was first invented by Dr. Cetlin NM for the purpose of bodily retraction of the
maxillary incisors (without using an extra oral appliance). However, because the reaction of
incisor intrusion frequently caused the distal tilting or extrusion of a molar, it was not widely
used. Recently, its drawbacks have been minimized and have been used increasingly for the
purposes of intruding the maxillary incisors, extruding the maxillary molars, improving the
occlusal plane, and increasing the vertical dimension.
In particular, this appliance is now used in the early stages of treatment for disto-occlusion
cases with an over-erupted maxillary incisor or a steep upper occlusal plane (UOP). By altering
the positions of anterior sectional arch, labially or lingually inclined incisors are now
accurately adjusted. In other words, from the lateral view, if the hook is located more in the
anterior direction (in comparison to the center of rotation of anterior teeth), labial inclination is
likely to occur, while if the hook is located more in the posterior direction, lingual inclination
•
• is likely to occur. A double archwire (DAW) is used to treat growing patients, who have Class
• II malocclusion. The indication for using the double archwire here is that the distance from the
UI to lip line is 5mm or longer and the upper occlusal plane (UOP) is 15 or steeper (Fig. 7-
337(»»cw!Ag nee
••••
••••
21).By using this appliance, the maxillary incisor is intruded and the maxillary molar is
extruded to cause the changes in upper occlusal plane(UOPy; thereby there is no need to
reinforce the anchorage at the maxillary molars. However, if the high-pull headgear (HG) or
mini-implant is used to reinforce the anchorage, the molars will be intruded and the upper
occlusal plane (UOP) will get steeper, which would as a consequence, restrict the forward
•
movement of the mandible, •
In general, a double archwire (DAW) is used after the 2x4 appliance is used in the early mixed •
dentition period. It is composed of labial archwire (.016"x 022 " stainless steel archwire) in the
molar area and sectional archwire (016"x 022" stainless steel archwire) in the incisor area
There are hooks to be used to hang onto the main archwire at the end of the anterior sectional
archwire. By hanging these hooks onto the main archwire an intrusive force can be applied to
the maxillary incisors. Here, the exerted intrusive fonce is usually 60--80gm (for the four
maxillary incisors). The force system of a double archwire (DAW) changes the upper occlusal
plane (UOP) through the extrusion of molars and intrusion of incisors. The methods of
fabricating a double archwire (DAW) are shown in Fig. 7-22 and 23
•
1
l_
Fig. 7-21 Mechanics of double archwire (DAW)

A Double archwire (DAw mechanically causes the extrusion of maxillary molars and the
intrusion of incisors
B.Labial or lingual tipping of incisor is controlled by the hook position of the anterior archwire
Bf lfthe hooks are placed more in the anterior direction (than the center of rotation of
anterior teeth), the incisors will be labially angulated and intruded
B-2fthe hook position is in line with the center of rotation,an intrusive force is applied
B.3.If the hooks are placed more in the posterior direction (than the center of rotation of
anterior teeth), the incisors will be lingually angulated and intruded
Choir'Leg d rot « 37
Fig. 7-22Fabrication of double archwite (DAW).
A. Insert the center of 016 022 stainless steel archwire into the zero-degree slot of arch turret
Equally rotate the turret with the same amount of fore
C form the ovoid shape of the anterior arch after turreting
D.Mark the rid-point of anterior arch on the archwire
E. Bilaterally mark the mes+al contact points of the first molars on the archwire
•
•
•
f Hold the marked point with the round beak of Kim pliers and bend the archwire to form a heliox.
G.Move the round beak in the occlusal direction and bend the archwire with the rectangular beak until it
becomes parallel to the main arch form
H. The same method should be applied to the opposite side
I. Fabricated double archwire (DAW
••••
••••
Fig. 7.23 Fabrication of double archwire (DAW) for anterior sectional arch
•
•
•
A. Insert the midpoint of 016 022? stainless steel archwire into the zero-degree slot of turret
B. Rotate the turret
C. Mark the mid-point on the bent archwire.
D Mark the distal contact points of the bilateral lateral incisors
E. Bend it inward and form a hook

fabricated anterior archwire
G. Bend the distal end of the main archwire in the gingival direction until the force reaches 60--80gm
H. Photographs after placing the double archwire (DAW) frontal and lateral view
ca!Ag a rot337
4) Management of posterior occlusal plane (POP)
The posterior occlusal plane (POP) represents the angle between the FH plane and the line that
connects the cusp tip of mandibular second premolar to the disto-buccal cusp tip of mandibular
second molar (Fig. 7-24)
lt is divided into two cases: I) when the posterior occlusal plane (POP) is nomal (14 or less), and
2) when the posterior occlusal plane (POP) is steep (I5 or more). This is closely related to
mandible retrusion, If there are skeletal problems, such as Class l or Class Ill malocclusion, a
positive orthodontic treatment can be achieved by controlling the posterior occlusal plane (POP
(Fig.7-25
When the posterior occlusal plane (POP) is normal, it is more desirable to maintain the current
condition, and if an extraction treatment is required, the extraction of maxillary and mandibular
first premolars is recommended. In other words, it is more desirable to close extraction space while
maintaining the posterior occlusion.
Css II Cass I
··�--------------�
Fig.7-24 Posterior occlusal plane (Poe)
A. Posterior occlusal plane (po9 the angle between the FH plane and the line that connects
the cusp tip of mandibular second premolar to the disto-buccal cusp tip of mandibular
second molar
• B. Posterior occlusal plane (POP) tends to be sleep in Class ll malocclusion, and flat in Class
ll malocclusion.
•
•
7A»» coteer teeing d Anet

••••
••••
•
•
•
00I 63.9
APD1 81.0
CF 145.0
UOP6.1
U1 to lip 6.0mm
pop 15.0
» Fig.7.25 Flat POP vs Steep POP

A. Intraoral photograph, model and cephalometnic radiograph of a patient who has flat POP
• Intraoral photograph, model and cephalometnic radiograph of a patient who has steep POP
When there is severe curve of Spee in the mandible, the decision of whether to maintain or change
the posterior occlusal plane (POP) must be made carefully (Fig. 7-26). In particular, if the posterior
occlusal plane (POP) is steep, leveling should be done while flattening the posterior occlusal plane
(PoPy, Such an application is effective for both extraction and non-extraction treatment cases, and
it is regarded as one of the most important factors in the ME
AW concept.
Fig.7.-26 Deep curve of Spee.

A Deep curve of Spee
B. Maintaining the POP uring leveling (red dotted line).
C. Changing the POP during leveling (blue line)
In other words, if the posterior occlusal plane (pop) is steep, it must be rotated in the counter-
clockwise direction. This can be applied for both extraction and nor-extraction cases. In non-
extraction cases, as mentioned above, the mesially angulated terminal molars can be uprighted
through strategic leveling and alignment (Fig. 7-27). In contrast, in extraction cases, mandibular
second premolars should be extracted (not the first premolars), and it is recommended to upright
the mesially angulated mandibular first premolars at the very beginning. To successfully
open coil springs (OCS) in the mandibular canine
• accomplish this, it is recommended to use the
• area and to bond the appliance later

•
76»» Cow_Ag a Monee

••••
••••
•
• •c
..
•
u .. � HI 8
� , o,
4
a
0 ]
,
)
'
d
/ fv •
•
•
Fig.7-27 Changing the POP tor non-extraction treatment cases
A. Apply the open coil springs (0CS) in the canine area and then do the tight cinch back to upnight the
mesially angulated mandibular first premolars
B. Bond the brackets on the canines and level them after upnighing
C.Use the open coil springs (0CS) in the first molar and second premolar areas and do the loose cinch
back to upright and de-rotate the second molars Then, bond the brackets on the first molars and
second premolars before leveling them.
• ·• •C
42/ l
J �II
- /{J/l 8
p
,, "
42/ n]
)«,8
nl A
rr
u ..
Fig. 7.28 Changing the POP for premolar extraction treatment cases
A. Mandibular second premolar extraction
B. Apply the open coil springs (0CS) in the canine area and do the tight cinch back to upnight the
mesially angulated mandibular first premolars
C. Bond the brackets on the canines and level them after sufficient uprighting
D. Close the space
Ee. Bond the brackets on the second molars and level them
5) Elimination of occlusal force
(1)Purposes
D Due to contact among opposing teeth, bracket bonding becomes very difficult. For this
reason, it is necessary to eliminate the occlusal force
Byeliminating occlusal force, effective tooth movement becomes possible
(2) Problems that arise from the occlusion of opposing teeth and the
bracket (Fig. 7-29)
(D Increase in tooth mobility.

Severe crown lingual inclination of mandibular molars.
9 Aggravated mandibular curve of Wilson.
(Restricted forward growth of mandible
Fig. 7-29 Problems arising from the contact between mandibular

appliances and maxillary teeth
f increase in tooth mobility
2 Severe crown lingual inclination of mandibular posterior teeth
3.Aggravated mandibular curve of Wilson
4 Restricted forward growth of mandible this is aggravated more
in extraction cases
•• (3) Methods (Fig. 7-30)

•
( Do not bond the appliances in the early stages of treatment.
If possible, use the smallest bracket.
(9Use the resin build up
Use the anterior bite plate
5 Use the posterior bite block.
7g corr_tog mot
••••
••••
•
•
Fig. 7.30 Methods that can prevent the contact between bracket and tooth
•
1.If possible, use the smallest bracket
2. Do not bond the appliances in the early stages of treatment
3.If there is a mesially angulated tooth, upnight it first by strategic leveling, and then increase the vertical
dimension
4.Use the following appliances to move the teeth effectively without any occlusal force
A. Anterior bite plate (ABP),
B.Posterior bite block (PB8),
C Resin build up
(4) Anterior bite plate (ABP)
Design (Fig. 7-31 A)

Eneets
a. Intrusion and labial inclination of mandibular incisors.
b. Extrusion of mandibular molars
e. Mandibular occlusal plane: rotates in the clockwise direction.
- tis used when there is a deep bite with normal or lingual inclination of mandibular
incisors with a deep skeletal pattern (High CF> 155).
(5) Posterior bite block (PBB)
Design (Fig. 7-31 B)

Efeets
a. Extrusion and lingual inclination of mandibular incisors.
b. Intrusion of mandibular molars.
c. Mandibular occlusal plane: rotates in the counter-clockwise direction.
It is used when there is a deep bite with labial inclination of mandibular incisors with
an open bite skeletal pattern (low CF « 150)
Ce' Leng d net « 7

When these removable appliances are used, it is possible to achieve positive treatment results
after careful evaluation of skeletal and dental patterns of individual patients. Here, it is
important for patients to seal their lips consciously.
•
•
•
» Fig.7-31 Anterior bite plate (ABP') and posterior bite block (PB8)
A Anterior bite plate (ABP)
8 Posterior bite block (PBB)
C. Anterior leveling and alignment while using the mandibular posterior bite block (PBB)
D When these removable or functional appliances are used, it is important for patients to seal their lips
consciously
Be»» cwt_u not

••••
••••
�
Archwires for Leveling and Alignment
'9 Initial archwires

•
•
•
1) Purposes
This is used to trigger a minor tooth movement by provoking an osteoclastic response within the
bone
2) Requirements
(I) It should be sufficiently flexible.

(2) Ht should be able to endure the occlusal force.
(3It should have a narrow diameter.
(4) The frictional force with the bracket should be weak
3) Archwires (Fig. 7-32)
A
••
-·-
E
A=
•••
•
--a
s.
Fig. 7-32 initial orthodontic archwires
A. 014 NTi 8. 015Co-ax
(I).04" NiTi. This is the first wire used right after bracket bonding. Since it has special shape
memorizing and super-elastic properties, this archwire can be inserted even into crowded teeth.
Nonetheless, due to this special super-elastic property, the gingival area behind the tube can be
damaged. Therefore, in order to minimize the patient's discomfort, the NiTi cinch back plier
should be used, or the cinch back must be done after applying the heat to the wires for
permanent deformation (Fig. 7-33)
Fig.7-33 Cinch back bends tor N,Ti wire

A Apply heat to the wire for permanent deformation Then, use the utility pliers to complete the cinch
back bends
B. NTi cinch back pliers
Ct Maxillary arch place the archwire behind the molar tube and bend it inward
C2 Mandibular arch. place the archwire behind the molar tube and bend it mesio-gingivally
ea»» toe'Leg Monee ••••

••••
(2)015" Co-ax: Due to its flexible properties, this archwire can be used in the early stages of
treatment. If this wire is used, unlike the NiTi wire, the cinch back can be performed within the
mouth without any application of heat. It is important to note that it can only be used after
bending (Fig. 7-34)
•
•
•
Fig.7.34 Co-ax archwire

A Method of shaping the Co-ax wire inan arch form
B. Bent archwire
91nicol
Tips: Initial orthodontic archwire.
f,There is no need to pay too much attention to the arch form
2. In the early stages of treatment, it is essential to minimize the patient's discomfort
3. Once the wire is ligated, place a finger night behind the terminal molars, and then
check the distal ends of the archwire. If any discomfort is detected even after the
cinch back, flowable resin must be used to relief the discomfort.
car Lg ad rent «[
-._
Leveling archwire
1) Purposes
(I This archwire is used to secure the alignment space by using the open coil springs (0CS) after
the use of initial archwires.
(2) This is the archwire that is used again for leveling and alignment after space closing
2) Archwire: .016" stainless steel archwire
() It is an archwire that is used along with the open coil springs (0CS) or energy chain to open or
close the space.
(2)ltis an archwire that is frequently used to close the space through the sliding mechanism.
(3 It is an archwire that is used again for leveling and alignment, after space closure and before
the finishing stages of treatment.
•
•
•
• •••
••••
B Strategic Leveling and Alignment
'b Strategies for non-extraction treatment

•
•
•
(I)If there is crowding, perform strategic bonding. The appliances should not be attached to the
teeth that are located in front of the terminal molars. When the appliances are extended to
second molars, the first molars should not be bonded, and when extended to first molars,
second premolars should not be bonded.
(2)A standard bracket with zero-degree torque is used.
(3) Use the open coil springs (0CS) to secure sufficient space
(4) In non-extraction cases, the labioversion of maxillary and mandibular anterior teeth should be
mimmized.
(5) When there is a tendency of labioversion, the torque adjustment of anterior teeth should be
conducted during the space opening.
(6) After aligning the eight or ten anterior teeth, space can be secured by uprighting and de-
rotating the terminal molars. Here, if the CF value is high, sufficient amount of space can be
secured, but if the CF value is low, the posterior vertical dimension (PVD) is insufficient, and
thereby the process of uprighting and de-rotating the terminal molars becomes very difficult.
Therefore, the need for extraction treatment increases
(7) De-rotate posterior teeth to successfully secure the space
(8) If there is severe protrusion caused by the insufficient anterior vertical dimension, the vertical
dimension should be increased first by using the twin block appliance Then, the teeth should
be aligned strategically. Here, the use of maxillary and mandibular arch expansion appliances
may be considered
cw'_tug rent e«Be

(9) First of all, if there is a full cusp Class ll molar relationship, it should be modified first to a
Class I relationship, and then the teeth should be aligned strategically
(D If the maxillary second molars are under-erupted, the pendulurn appliance should be used
first.
(lfthe maxillary second molars are erupted, the mini-implant should be used
(If there is a tendency of anterior open bite with anterior crowding, use the ME
AW fist
(l0) Conduct strategic leveling while doing the reproximation.
(I) Strategically align the teeth while intruding the maxillary anterior teeth
(12)If it is difficult to gain space through the aforementioned procedures, an extraction treatment
approach should be considered.
(D Methods of non-extraction treatment through the modification of maxillary arch form (Fig.
7-35)
(Methods of non-extraction treatment when there is severe curve of Spee in the mandible
(Fig. 7-36)
�lnical
Tips: Non-extraction.
The basic concept of non-extraction treatment is to move the teeth through strategic
leveling and alignment. In most cases, a non-extraction treatment approach
becomes possible by using strategic leveling and alignment. If additional appliances
(le. maxillary and mandibular expansion appliances) are used adjunctively before
strategic leveling, the non-extraction treatment becomes much easier and shortens
•
•
•
the treatment duration, too
►►►►►►
eo» cape_Lg green ••••

••••
Fig. 7.35 Nor-extraction treatment strategy to solve crowding
•
•
•
,, I>
s
t
)
@
A. Schematic figure of tooth movement
At. Pretreatment maxillary oclus.al view.
A.2 When there is no anterior crowding, bond the appliance to the eight anterior teeth and second
molars. When there is anterior crowding. bond the appliance to every tooth except the crowded teeth
and first molars.
A-3. Apply the open coil springs (0CS) to the crowded canines and do the tight chinch back. After
securing the space, bond the appliances to the canines.
A4.By using the open coil springs (0CS) and doing the loose cinch back on 016 stainless steel
archwire, the mesially rotated second molars can be de-rotated
A-. After bonding the appliances to maxillary first molars and leveling the teeth, the open coil springs are
used again in the premolar area to de-rotate the mesially rotated first molars
A6. Bond the appliances to second premolars and then align the teeth
A.7post-treatment maxillary occlusal view
Fig. 7.35 (continued) Non-extraction treatment strategy to solve crowding
B Intraoral photographs that demonstrate the entire process of non-

• extraction treatment of maxillary crowding
•
•
3e»» Corr tweg an Nome

••••
••••
•
•
8 •
.,
H 'aj)
¥ I
t
'
Fig. 7.36 Severe curve of Spee in the mandible: non-extraction treatment strategy
A Bond the appliances on the four mandibular incisors, first premolars, and second molars
B. Use the open coil springs (0CS) in the canine area, and then perform the tight cinch back to upnight
the mandibular first premolars, and to solve the problems of crowding and mesial angulation
C Bond the appliances on mandibular canines and then align the teeth
D This shows the alignment of eight anterior teeth
E. Alter the alignment of eight anterior teeth, the open coil springs (0CS) are used to upnight and de-
rotate the terminal molars.
f Bond the appliances on the rest of the teeth -first molars and second premolars- and align them
G. Diagram of the mandible after leveling and alignment.
H. Before and after the treatment
f these methods (strategic leveling and alignment) are used to align the teeth, the anterior teeth can
stay or move in the lingual direction due to the modification of dental arch form At the same time, the
anterior teeth will move in the anterior direction due to the correction of deep curve of Spee. Ag a
result, the final position of anterior teeth can be maintained during leveling and alignment
Co tr rent «Beg
1) Expansion appliances
If there is a posterior cross bite or a small transpalatal width (TPW) that is less than 3Imm (Fig. 7-
37),a maxillary expansion appliance can be used. Here, depending on the case, a rapid maxillary
expansion (RME) appliance or even a slow maxillary expansion (SME) appliance can be used. The
rapid maxillary expansion (RME) appliance is rotated once a day and this expands the maxilla by
0.25mm/rotation (it takes about 4 weeks). In contrast, the slow maxillary expansion (SME)
appliance is rotated two or three times a week and should be worn for 3 months (Fig. 7.38)
Fig.7.37Teanspalatal width (Pw)

A The distance between the gingival margins of mesic-palatal
Cusps of maxillary first molars (check the arrow)
B. Normal maxillary dental arch
C Narrow maxillary dental arch
D. Changes in arch form and arch perimeter due to transpalatal
width (TPW) modification
•
•
•
Fig.7-38
Mallary and mandibular
expansion appliances
••••
••••
By using these maxillary expansion appliances, we can gain the space in the central incisor area; as
a result, the nor-extraction treatment approach becomes possible, f there is severe lingual
inclination in the maxillary premolar area, the maxillary expansion appliances could be used again
to improve the tooth axis.
f there is severe lingual inclination in the mandibular molar area (lingual cusps are more than
•
2mm away from the line connecting the occlusal plane), the Schwarz appliance (mandibular •
expansion appliance) can be used to upright the molars, and should be rotated once or twice a •
week. When the mandible is retruded, the twin block appliance, which includes both maxillary and
mandibular expansion appliances, can be used to move the teeth (Fig. 7-39)
» Fig.7-39
Twin block appliance
2) Molar distalizalization
In the case of full cusp Class ll molar relationship, it is more effective to conduct strategic leveling
and alignment while using the following appliances (Fig. 7-40)
Fig. 740 Full cusp Class [f

molar relationship
A. Full cusp Class l molar
relationship
B Dental models of a patient
with full cusp Class Il molar
relationship
Cc'tlg net « [@
(1) Pendulum appliance (Fig. 7-41)
This is an appliance used to posteriorly distalize the maxillary molars without any patient
compliance. This appliance is advantageous for inducing distal movement of posterior teeth,
but has a side effeet of mesial tilting of first premolars. Therefore, in order to use this appliance
effectively, it is important to first change the molar relationship into a super Class I molar
relationship, and then perform strategic leveling and alignment of the mesially tilted first
premolars. This makes it possible to align the teeth while minimizing anterior protrusion. Here,
it is important to note that this appliance is particularly effective when there are non-erupted
maxillary second molars.
Fig.74f Pendulum appliance

lf strategic leveling and alignment are performed after the pendulum
appliance is attached, the teeth an be aligned even more
effectively without moving the anterior teeth forward
A. Photograph of pendulum appliance.
B ttraoral photographs of a patient with a pendulum appliance on
•
•
•
9a»» co_Ag id re
••••
••••
(2) Mini-implant (Fig. 7-42)
If the maxillary second molars are already erupted, the posterior teeth can be even more
distalized by using a mini-implant between the maxillary second premolars and the first
molars
•
•
•
Fig. 742 Mini-implant

Intraoral photographs after using the mini-implant
If strategic leveling and alignment are performed after using the mini-implant, the teeth can be aligned
without causing the proclination of anterior teeth
(3) MEAW (Fig. 7-43)
If crowding is mild with an anterior open bite, a modified offset archwire (40A\W) Gr AW
ME
can be used to close the open bite or to achieve the distahization and the intrusion of molars
simultaneously. In this case, patient cooperation is essential (in wearing elastics in the early
stages of treatment).
•
•
•
Fig.743 MEAW
Intraoral photographs of a patient with MEAW in the early stages of treatment
[Gd»» cote_urged Ant

••••
••••
3) eproximation and stripping (Fig. 7-44)
Adults who have a triangular-shaped crown are likely to suffer from black triangle. In borderline
extraction/non-extraction cases, the non-extraction treatment approach, along with reproximation,
is recommended more than the extraction treatment approach. Here, it is desirable to perform the
•
reproximation after the crowding problem is solved, but since de-crowding can cause an even more •
severe labioversion of anterior teeth, it will be more effective to gain the space only after •
performing the selective reproximation
Fig. 7-44 Reproximation

ff the reproximation is performed, followed by strategic leveling and alignment, it can minimize the
labioversion of anterior teeth and facilitate the successful alignment
4) Strategic leveling and alignment
While undertaking the aforementioned methods, brackets should not be bonded to the teeth that are
located in front of the terminal molars (usually first molars when the second molars are bonded'y
Anterior crowding can be successfully solved through strategic bonding, open coil springs and
tight cinch back. Here, de-rotation and uprighting should then be performed on terminal molars
after grouping the anterior teeth into one unit.
rt a net9'
�
Strategies for premolar extraction treatment (Fig. 7-45).
(I) The Roth type SWA(0I8" slot) is attached to the four maxillary incisors, and the zero-degree
standard edgewise appliance is attached to the remaining teeth.
(2) The orthodontic appliances on the mandible should never come into contact with the opposing
maxillary teeth
() Since it is essential to retract the maxillary canines after confirming its parallel relationship to
the maxillary first molars, the problems in such contact must be detected and overcome in the
early stages of leveling treatment.
(D Parallelized first molars: retract the maxillary canines from the first molars.
Mesially rotated first molars: First and foremost, the mesially rotated maxillary first molars
should be de-rotated This can be achieved by using the energy chain between the maxillary
second and first molars, and by using the open coil springs in the maxillary first molar area
(4) Since the maxillary extraction space should be closed while maintaining its upper occlusal
plane (UOPy, extending the appliance to maxillary second molars for the maximum retraction
of the maxillary anterior teeth should be cautiously performed in the early stages of treatment.
However, the mesially rotated maxillary first molars are an exception. In this case, the rotated
maxillary first molars should be de-rotated beforehand, by bonding an appliance to the
maxillary second molars
(5) The teeth should be moved so that the maxillary and mandibular canine relationship can form
or maintain a Class I relationship
Here, it is extremely important not to retract the mandibular canine in advance
(6) f there are maxillary and mandibular crowding, open coil springs should be used to solve
crowding problems.
(7) The space should be closed after uprighting the mesially angulated mandibular molars and
premolars. Here, if there is severe mesial angulation, a mandibular second premolar extraction
is recommended (more than the mandibular first premolar extraction). For this, the open coil
•
• springs should be used in the mandibular canine area to sufficiently upright the first premolars,
• and then the appliances should be bonded on the canines.
(8) In the case of mandibular first premolar extraction, space should be closed while maintaining
the premolar and molar occlusion
(9) The teeth should be aligned while maintaining its retrusive control, and then the space should
be closed afterwards (Refer to Chapter 8: Space closure)
2Ho Coit Argo rent

••••
••••
In premolar extraction cases, if the leveling is not sufficient or the leveling is done without
considering the upper occlusal plane (UOP), difficulties will arise in the next stage of space closing
and in the finishing stages of treatment
•
•
A
•
. .
- f
% $ "
n
•
'
8%°
Fig. 7.45Leveling and alignment in premolar extraction cases
A. Use the SWA brackets to treat the four maxillary anterior teeth
A-1 Standard brackets.
A.2. SWA brackets (recommended)
B. Establish the parallel relationship of maxillary first molars
C. Maintain the upper ooclusal plane (U0OP
D. Maintain the Class I canine relationship
E. Sufficiently upnight the mandibular posterior teeth
E.1.V-shaped arch form
E-2. Mesially angulated mandibular posterior teeth
E-3.By conducting strategic bonding and using the open coil springs in the first molar area, the
second molars can be successfully uprighted and de-rotated (mandibular fest premolar extraction
case)
cow u net«33@7
�
purposes of strategic leveling and alignment can be summarized
as follows:
1. Tooth movement must be in accordance with the diagnosis.
f) The extraction options and subsequent tooth movement may differ depending
on the diagnosis (whether to maintain or change the posterior occlusion)
2) The maxillary incisor position and upper occlusal plane (UOP) should be
established in the early stages of treatment, and tooth movement should be
done in accordance to the diagnosis.
2. In extraction cases, tooth movement should be done to make space closing
effective. To achieve this, the sufficient leveling of mandible curve of Spee and
the adjustment of upper occlusal plane (U0OP) are required
3 Tooth movement in the finishing stages of treatment: Tooth movement is done to
make the finishing procedures of treatment easier, This applies for both
extraction and non-extraction cases. In clinical cases, it is important to maintain a
Class I relationship betore the finishing stages of treatment, and it is not desirable
to exceed the cusp-to-cusp relationship. bl
•
•
•
39e»» cwten_Lg ad ere

••••
••••
REFERENCES
1. Adams DAM, et al, Effects of brackets and ties on stiffness of an arch wire. Am J Orthod Dentofacial
Orth0p 91.131-136, 1987
2 oooecurs an
3. Andrews LF Straight wire, the concept and appliance, San Diego: LA Wells 1986. •
4. Antonarakis GS, and Kiliaridis S. Maxillary molar distalization with non-compliance intramaxillary •
appliances in Class Il malocclusion. A systematic review. Angle Orthod 78.1133-1140, 2008 •
5. Badawii, et al. Three dimensional orthodontic force measurements. Am J Orthod Dentofacial Orthop
136.518-528, 2009
6. Begg PR, and Kesling PC. Begg Orthodontic Theory and Technique. Philadelphia WB Saunders,
1977
7. Begg RR. Orthodontic theory and technique. 3rd ed. Philadelphia wB Saunders, 1977.
8. Bennett JC, and McLaughlin RP Orthodontic management of the dentition with the preadjusted
appliance. Isis Medical Media, 1997
9. Burstone CJ, Qin B, and Melton JY. Chinese NTi wre - a new orthodontic alloy. Am J Orth0d 87\445-
452. 1985
10. Burstone DR. Deep bite correction by intrusion. Am J Orthod 72-1-22,1977.
11. Byloff FK, Darendelike MA, Clar E, and Darendeliler A Distal molar movement using the pendulum
appliance. Part pl, The effects of maxillary molars root uprighting bends. Angel Orthod 67261.270,
1997
12. Byloff FK_and Darendeliker MA Distal molar movement using the pendulum appliance. Part I, Clinical
and radiological evaluation. Angel Orthod 67.249-260, 1997
13. Cetlin NM, and Ten Hoeve A. Non-extraction treatment. J Cin Orth6d 17-396.413, 1983
14. Cobb NW Ill, Kula KS, Phillips C, and Proffit WR. Efficiency of multistrand steel, superelastic NrTi and
ion-implanted NTi arch wires for initial alignment. Cin Orthod Res 1.12-19, 1998
15. Cozani Giuseppe. Garten of Orthodontics. Quintessence. 2000
16. Dake ML, and Sinlair PM A comparison of the Ricketts and Tweed-type arch leveling techniques
Am J Orth0d 9572-78, 1989
17Daskalogiannakis J, and Ammann, A. Glossary of orthodontic terms, Quintessence, 2000
18. Drescher D, Boutrauel CHM, and Schumacher HA Frictional forces between bracket and archwire. Amr
J 0rthod Dentofacial Orth0p 96-397404, 1989.
19. Edwards JG. Soft tissue surgery lo alleviate orthodontic relapse. Dent Cin North Am 37205-225, 1993.
20. G&Hwire company. Orthodontic Product Catalog. 8th edition
21. Gelgor et al. Am J Orthod Dentofac Orthop 131.161 e1.-161.e8., 2007
22. Ghosh et al. Evaluation of an intraoral maxillary molar dis.talization technique. Am J Orthod Dentolac
Orth0p 110.639-646, 1996
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23. Graber TM, Rakosi T, and Petrovic AG. Dentofaciat Orthopedics with functional appliance, 2nd
edition, Mosby, 1997
24. Gunduz E, Schneider-Del Savio T, Kaucher G, Schneider B, and Banteleon HP Acceptance rate of
palatal implants A questionnaire stury. Am J Orthod Dentofacial Orthop 126.623-626, 2004.
25. Hilgers 4J. The pendulum appliance for Class I non-compliance therapy. J Cin Orthod 26.706-714,
1992.
26. Huynh T, Kennedy DB, Joondeph DR, et al. Treatment response and stability of slow maxillary
expansion using Haas, hyrax and quad-helix appliances. Am J Orthod Dentofacial Orth0p 136.331-
339, 2009
27 lgaacson RJ, Lindauer SJ, and Rubenstein LK. Activating a2 x 4 appliance. Angie Orthod 6317.24,
1993.
28. lsaka F, Suzuki Y, Hwang DH, Tuazon RR, and Sato S. Non-extraction therapy of Class it crowding
malocclusion with high mandibular plane angle. Bulletin of Kanagarwa Dental College. 28 (1)47.-54,
2000.
29. lscan HN, and Sarisoy L. Comparison of the effects of passive posterior bite-blocks with different
construction bites on the craniofacial and dentoalveolar structures. Amn J Ort.hod Dentofac Orthop
1121714178, 1997.
30 lwasaki LR, et al, Clinical ligation forces and intraoral friction during sliding on a stainless steel
archwire. Am J Orthod Dentofacial Orthop 123.408-415, 2000.
31. Jacobs SG. Localization of the unerupted maxillary canine: How to and when to. Am J Orthod
Dentofacial Orth0p 115.314-322, 1999
32 Jones ML, Staniford H, and Chan C. Comparison of superelastic Ni and multistanded stainless steel
wires in initial alignment. J Cin Orth0d 24.611-613, 1990
33 Joondeph DR, graber TM, Vararsdall RL, and Vig KWL, eds. Orthodontics Current Principle and
Techniques. Ed4. St Louise: Mosby, 2005.
34 Kapila S, and Sachdeva R. Mechanical properties and clinical applications of orthodontic wires. Am J
Orthod Dentofacial Orth0p 96.100-109, 1989
35. Ki JH, MC Viana, TM Graber FF Orneraza, and EA BeGolie The effectiveness of protraction face
mask therapy. A meta-analysis. Am 4 Orthod Dentolac Orthop 115675-685, 1999
36 Kim JI, Akimnoto S, Shinji H, and Sato S. importance of vertical dimension and cat of occlursal plane in
• craniolacial development int J Stomatol Occlusion Med2114.121,2009
• 37 Kim JI Practical Clinical Orthodontics. Vol1, Orthodontic treatment with MEAW. Well publishing inc,
• 2012
38 Kim JI. Practical Clinical Orthodontics. Vol 2. Orthodontic Diagnosis. Well publishing In, 2013.
39. Kim J. Practical Clinical Orthodontics. Vol3. Early orthodontic treatment Well publishing inc, 2015.
40 Kus RP. A review of contemporary archwires Their properties and characteristics. Angle Orthod
63-197-207, 1997
4 Marcott MR. Biomechanics in Orthodontics. St Louis.CV Mosby, 1990.
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42 McNamara JA Jr, and Brudon WL Orthodontics and Dentofacial Orthopedics. Needham Press, 2001.
43. Miura F, Mogi M, OhuraY, and Hamanaka H. The super-elastic property of the Japanese Ti alloy
wire for use in orthodtontics. Am J Orthod Dentofacial Orth0p 901-10 1986.
44. Nanda Ravindra. Biomechanics and Esthetic strategies in clinical orthodontics, Elsevier Saunders,
2005
45. Oliveira NL, Da Silveira AC, Kusnoto B, and Viana G.Three-dimensional assessrnent of morphologic
changes of the maxilla A comparison of 2 kinds of palatal expanders. Am J Orthod Dentofacial
Orth0p 126.354-362, 2004
46. Pandis N, and Bourauet CP, Nickel-titanium (NTi) archwires. The clinical significance of super
elasticity. Semin Ortho 16-249-257, 2010
47, Proffit WR Contemporary orthodontics. StLouis CV Mosby company, 1986
48. Rhee SH, and Nahm DS Triangular-shaped incisor crowns and crowding. Am J Orthod Dentolac
Orthop 118.624-628, 2000
49. Ricketts RW, Bench RW, Gugino CF, Hilgers 4J, and Schulhof RJ. Bioprogre ive Therapy. Denver.
Rocky Mountain Orthodontics, 1979
MD. Am J Orthod Dentolacial Orth0p 127-249-254, 2005.
51. Roth RH. Functional occlusion for the orthodontist. J Clin Orthod 1541-4), 1981.
52. Sandler JP, An attractive solution to unerupted teeth. Am J Orthod Dentofacial Orth0p 100.489-493,
1991
53. Sarver DM, and Johnston MW. Skeletal changes in vertical and anterior displacement of the maxilla
with bonded rapid palatal expansion appliances. Am J Orthod Dentolacial Orth0p 95.462-466, 1989
54. Scheffler NR patient and provider perceptions of skeletal anchorage in orthodontics. Ms Thesis,
University of Northo Carolina, 2005.
55. Schur fr The control of vertical overbite in clinical orthodontics. Angle Orthod 3819.39, 1968.
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1966
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physical properties. Eur J Orth0d 19.637646, 1997.
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61. Tweed CH. Clinical orthodontics. Vol1 and2. St Louis Mosby, 1966
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Caw' Lei Ant f[

••••
:::::::zzzrrrrresg;;
Chapter 8_
SPACE CLOSURE
D $pace Closing Method
'b Sliding method vs loop method
To close the space, two different methods can be used: the sliding method (frictional method) and
the loop method (frictionless method). The sliding method (frictional method) is used with elastics,
coil springs, etc., and facilitates tooth movement on the archwires. The loop method (frictionless
method)is used to move the teeth along with the archwire that has a loop(Fig. 8.1)
Fig.8-1Space closing method

1) Sliding method
2)Loop method
Advantages of the sliding method:

I Minimal wire bending
2) Effective sliding on the archwire,
) Reduced chair time
Disadvantages of the sliding method:

I) There is no clear indicator for the optimum amount of force necessary for tooth movement
Since there is friction between the bracket and the arehwire, the applied force should be
•
• greater than both the frictional and tooth-moving forces to cause tooth movement.
• 2In the early stages of treatment, if the elastic or spring force is excessively activated, tilting
may occur initially
) The recovery time required for successful uprighting may be insufficient.
4) Tooth movement does not occur when the archwire is damaged or deformed
• •••
••••
In clinical orthodontics, depending on the doctor's preference, various methods such as energy
chain, elastics, coil springs, etc., can be used to induce the sliding movement of teeth.
Advantages of the loop method:

)Depending on the extent of initial tilting, precise adjustments can be made regarding the size
of loop activation.
2)A sufficient recovery time for tooth uprighting is given to the patients during treatment. •
3) When there is only a minimum activation, the extraction space can be closed rapidly without
tipping the teeth
Disadvantages of the loop method:

I Time consuming due to wire bending
2) All the activation is lost once the loop comes into contact with the bracket, and as a result
the archwire must be made again.
) The initial activation force is strong.
4) The loop can cause some discomfort.
In ME AW, to induce effective tooth movement, an extraction space must be closed by a

combination of sliding and loop methods.
The conventional treatment procedures are as follows
First, retraet the maxillary canines. To do this, the sliding method should be used with the energy
chain, Next, align the six or eight mandibular anterior teeth, and the 018" shoe-hook or 016"
x02" ideal archwire with hook should be used to close the space. Then, the sliding method - the
elastics or energy chain - should be used, When retracting the four maxillary incisors, the loop
method should be used with the 016"x 022" combination loop with step to close the space (Fig.
8-2). In MEAW, the space closing is done differently case by case, but in most cases, the tooth
movement pattern should be the combination of the retraction of anterior teeth and the protraction
of posterior teeth, rather than the maximum retraction of maxillary and mandibular anterior teeth.
In other words, space closing in MEAW can be more efficiently done by the combination of
vertical and antero-posterior tooth movement, but not by relying solely on the antero-posterior
space closure. By doing so, the finishing procedure can be done more easily and can prevent bite
deepening, which frequently occurs when closing space. Also, if the molars are mesially angulated,
the ME
AW technique can solve such problems in the finishing stages of treatment by uprighting
and space closure with ME
AW
Fig. 8-2 Clinical method of space closure
Oergy
chain (Fig. 8-3)
1 lts function is closing space.
1) Through the individual tooth movement, a small amount of space can be closed
2)Caution is needed not to deform the arch form or not to reduce the arch length
2.Uses it on the archwire that has a minimum 016 (diameter.
3. In general, it loses 2/3 of its activation force in 48 hours
Fig.8.3Energy chain and tension

9age
A Energy chain (power chain)
B. Tension gauge.
C.250gm force is the optimum
force for the maxillary canine
retraction, Considering the
friction
•
•
•
►►
B C
£6»» tors So Coor

••••
••••
48 Space closing method
1) Maxillary canine retraction (Fig. 8-4)
•
•
•
Fig.8-4Maxillary canine retraction

A Tooth movement pattern with an ideal arch form on the continuous arc'wire
B. Canine retraction with energy chain,
C poblerns in the maxillary canine retraction on the continuous arc#wire
D. Canine retraction with open coil springs
(D The main archwire used for maxillary canine retraction is either 016" stainless steel archwire
or 016"x 022" stainless steel archwire.
The main archwire is not a segmented arehwire but a continuous archwire that creates an ideal
areh form. Here_, since the maxillary canine is retracted on the continuous archwire, the
maxillary incisors can be extruded to a certain extent.
( Retract the maxillary canines from the maxillary first molars by using the energy chain, The
maxillary canine should first be moved until a Class l canine relationship is formed The
required force for maxillary canine retraction is 250gm. This value includes the tooth
movement force as well as the frictional force
cows_So Coor + O
(9 When there is crowding in the maxillary and mandibular anterior teeth, the open coil springs
(0CS) should be used to align the crowded teeth after securing the extraction space. Here, even
though there is severe crowding in the mandibular anterior area, it is not desirable to retract the
mandibular canine first.
( For canine retraction, many orthodontists tend to extend the appliance to the maxillary second
molars for the purpose of maximum retraction of the maxillary anterior teeth. Here, the
angulation of the maxillary second molar, the upper occlusal plane, and the posterior occlusal
plane should all be considered. In other words, if the maxillary second molars are uprighted
with a normal upper occlusal plane and posterior occlusal plane, the canine retraction from the
maxillary second molars can be made without any difficulties. However, if the maxillary
second molars are distally tilted, it is more desirable to retract the canine from the maxillary
first molar because there is a greater possibility of extruding and lingually angulating the
maxillary incisors (Fig. 8-5)
• Fig.8-5Maxillary canine retraction considering the upper oclusal

• plane
• A. Distally angulated maxillary second molar
8 Problems in inserting the archwire to the distally tilted maxillary
second molar extrusion of the maxillary anterior teeth and
steepening of the upper oclusal plane
C. Space closure considering the upper occlusal plane
D intraoral photograph of maxillary canine retraction
0e» cors so too ••••

••••
(1) Class ll case (Fig. 8-6)
•
•
•
Fig.8-6Cases of premolar extraction in Class l malocclusion

A. Posterior movement of maxillary canine in Class ll malocclusion
B. Posterior movement of maxillary canine while using mandibular posterior bite block (PBB) in Class Il
malocclusion
C Mallary canine retraction while intruding maxillary incisors in Class ll malocclusion
D First, retract the maxillary canine by using the energy chain.

The retraction should be done sufficiently until a Class I canine relationship is formed.
(9 lfthere is contact between the mandibular teeth when retracting the maxillary canine, it is
more desirable to make the bite open. Here, when treating a patient who has a vertical
growth pattern with low combination factor (CF), the mandibular posterior bite block
(PBB) should be used when retracting the maxillary canine (Fig. 8-6B)
Q After the Class I canine relationship, even though there is a space in the canine distal area,
the combination loop with step should be used as a main archwire to close the space of four
maxillary anterior teeth. Then, the energy chain should be used to successfully retraet the
maxillary canine (Fig. 8-6€)
( When there is a normal overjet with more than 3 mm of space for premolar extraction, the
mandibular premolar or incisor extraction is required for mandibular incisor retraction,
However, if the space is 2mm or less, the mandibular incisors can be retracted with the use
of Class ll elastics to close the space. Here, it is important to note that this is an extraction
case of maxillary premolar only in Class ll malocclusion (Fig. 8-7).
•
Fig.8.7 An extraction case of maxillary premolar only in Class ll malocclusion

Close the space after extracting the maxillary premolars only. The canine key and overjet should be
analyzed, and a decision on mandibular premolar extraction should be made in consideration of the
remaining space and the extent of mandibular crowding
A.If there is mandibular crowding with more than 3mmn space of maxilla, there is high possibility of
extracting the mandibular premolars
B.lfthere is minor mandibular crowding with less than 2men space of maxilla, there is a high possibility of
• performing a nor-extraction treatment method
• C intraoral photographs
• C-1. re-treatment intraoral photographs
C-2 Intraoral photographs during the space closure after extracting the maxillary premolars only
C3. Post-treatment intraoral photographs
[»» ors soc Coo ••••

••••
(2) Class Ill malocclusion (Fig. 8-8)
D If there is maxillary anterior crowding, open coil springs should be used to move the
maxillary canines posteriorly and to secure space for the alignment of crowded teeth. Here,
a weak force should be applied, by using the energy chain, to retract the maxillary canine.
•
After this is done, the crowded teeth should all be aligned
•
When anon-surgical orthodontic treatment is used to treat Class Ill malocclusion, caution is •
needed because the lingual retraction of the maxillary incisors can lead to the excessive
lingual retraction of the mandibular incisors
To prevent this, the 016"x 02" ideal archwire with hook having a crown labial torque on
the anterior portion should be used to cause an en-masse retraction of the six maxillary
anterior teeth
Cr_So Coor ]
Fig.88 Premolar extraction in Class Ill malocclusion
A Pretreatment intraoral photographs
B Maxillary canine retraction using the open coil springs maxillary canine retraction while preventing the
• excessive linguoversion of maxillary incisors
C The case of a patient who refused to have surgical treatment; the mandibular second premolars are
extracted to achieve space closure and normal overjet
D. Finishing stages of Class Ill malocclusion treatment, using the MEAWs on the maxilla and mandible
E Post-treatment intraoral photographs
1[»»cotes$co Coore
••••
••••
Parallel rotation of maxillary first molar

Before the maxillary canine retraction, the buccal surfaces of maxillary first molars should
be parallel to each other (parallel rotation). Here, if they are already mesially rotated, it is
more important to de-rotate them first. To do this, the energy chain should be used with a
weak force between the first and second molars. after inserting the open coil springs into
•
the maxillary first molar area. Then, to retract the maxillary canine, it is recommended to •
extend the archwire just up to the maxillary first molar because if the second molar is •
engaged, the upper occlusal plane can become steeper (Fig. 8-9).
Fig.8-9Mesial rotation and

parallel rotation of the
maxillary first molars.
A. The maxillary first molars
should be parallelized
before the space closure
A-1 Parallelized maxillary
first molars
A-2. Mesially rotated maoary
first molars
B. fthe maxillary first and
second molars are mesially
rotated, the open coil
springs should be used in
the first molar area for the
parallel rotation of first and
second molars. Then, the
energy chain should be
used with a weak force
between the first and
second molars for the
parallelization of first
molars
C. After parallelizing the first
molars, the canines must
be retracted from the first
molars
rs_Soc Coor 1
(3) Factors to be checked in maxillary canine retraction
Patterns of tooth movement: Check to see whether the canine is retracted or the first molar
moves forward. In maxillary canine retraction, a space should be secured between the
lateral incisor and the canine, If this space is not secured, and instead the space is secured in
the maxillary first molar area, the posterior anchorage should be reinforced because this is
highly likely to be caused by the mesial angulation of maxillary first molars. Here, it is
important to note that it is more desirable to close the extraction space after placing the
mini-implant between the maxillary second premolars and the first molars
( Extrusion and linguoversion of the maxillary incisors: If the maxillary canine is retracted on
a continuous archwire, there is an inevitable risk of linguoversion and extrusion of
maxillary incisors. Therefore, when retracting the maxillary canine, it is better to move the
canines until a Class I canine relationship is formed. Do not attempt to trigger a full canine
movement from the maxillary canine to the second premolar. Instead, it is more desirable to
substitute the maxillary archwire with the combination loop with step to retract the
maxillary canine successfully.
( Bowing effeet (Fig. 8-10)
( Mesial rotation of the maxillary first molars: In canine retraction, the mesial movement of
maxillary first molars is permitted only to a certain extent. In order to maintain the position
of the maxillary first molar, the maxillary incisors must be retracted as much as possible
However, such movements can cause excessive extrusion, linguoversion and an unaesthetic
appearance, which can make the finishing stages of orthodontic treatment a lot more
complicated. Therefore, when starting the maxillary canine retraction, it should make sure
that the buccal surfaces of the first molars are parallelized.
•
•
•
1d»owes soc Co ••••

••••
•
•
•
Fig. 8-10 Bowing effect when closing the extraction space when
closing the space, the bowing appearance of the teeth adjacent to
the extraction site is apparent
2) Mandibular en-masse retraction
(1) Space closing method after the extraction of mandibular first premolars
(9 Severe proclination of the mandibular incisors (IMA>95) (Fig.8-11)

a. To upright the severely proclined mandibular incisors and to close the space,
the 018 archwire with shoe-hook, the energy chain, or elastics should be
used. Tooth movement occurs more frequently in the anterior area than in the
posterior area. Here, if a rectangular wire, instead of a round wire, is used,
there is a greater possibility of causing the anterior movement of posterior
teeth than the posterior movement of anterior teeth
b. When the mandibular incisors are fully uprighted alter the Class I canine
relationship is formed, a different wire -the 016.022" ideal archwire with
hook- should be used to move the posterior teeth forward
·•
•
215
->
'=======
I
E ks
Fig.&.44Soace closing after the mandibular first premolar extraction (in case of excessive labioversion
of mandibular incisors)
A. lfarectangular wire is used, there is a greater resistance between the slot and the wire; therefore, the
anterior movement of molars occurs more than the posterior movement of incisors
s When a round wire is used, there is a greater possibility of lingual movement of crowns therefore, the
posterior movement of incisors can 00Cur fore ears4l¥
C. Shoe-hook
D Intraoral photographs of shoe-hook
problems in closing the extraction space through the excessive posterior movement of mandibular
incisors
1. Excessive lingual inclination and extrusion of mandibular incisors,
2. Bite deepening and deep curve of Spee,
3. Class ll canine relationship
•
•
•
1[»»Cwrs Soc Clo

••••
••••
2 Normal position of mandibular incisors (IMPA<95) (Fig. 8-12)

a. Space closure is done by using the energy chain or elastics on the 016"x 022" ideal
archwire with hook. Here depending on the situation of each patient- +7_ +10, or
+13,a different amount of crown labial torque can be given to the mandibular incisors.
In general_.7 torque is applied to the posterior area of the mandibular canine, and the
•
hook is placed in between the mandibular lateral incisor and the canine •
b. If there is remaining space in the mandibular arch even after closing the maxillary space, •
which forms a Class I canine relationship, it is more desirable to use the 016"x 022"
ideal archwire with hook for space closure (Fig. 8.12 B). Here, caution is needed when
closing the space through further retraction of mandibular incisors, as a Class II canine
relationship may be formed to complicate the finishing procedure.
e. If the lingual inclination of mandibular incisors is to be avoided during space closure, it
is recommended to apply the crown labial torque to the anterior pant of mandibular
archwire
A B
• •
Fig. 8-12Space closing after the mandibular first premolar extraction (in case of normal inclination of
mandibular incisors)
A. When a round wire is used, the lingual movement of crown can be made more easily.This leads to a
greater possibility of posterior movement and inguoversion of incisors
s When a rectangular wire is used, there is a greater resistance between the slot and the wire.
Therefore, anterior movement of molars occurs more than the posterior movement of incisors, and the
extraction space can be closed to prevent aggravation of the existing incisor axis
C Archwire with crown labial torque in the lower anterior area
Ca Soc Co « T
(2)Space closing method after the extraction of mandibular second
premolars (Fig. 8-13)
(D This is a type of space closing method which is used after grouping the eight mandibular
anterior teeth as one unit.
(The extraction space of the mandibular second premolar is closed through the protraction of
posterior teeth and the retraction of anterior teeth
( To achieve this, the space is closed by using an energy chain or elastics on the 016"x 022"
ideal archwire with hook
There are different amounts of crown labial torque given to the mandibular incisors
depending on the situation of each patient; +7, +10'or +13. In general, -T torque is
applied to the posterior area of the mandibular canine, and the hook is placed in between the
mandibular lateral incisor and the canine.
Fig. 8-13 Space closing after extracting

the mandibular second premolars
lf the mandibular second premolar is
extracted, a rectangular wire must be used
to close the space in order to induce the
protraction of the posterior teeth (not the
retraction of the anterior teeth).
•
•
•
41[»»Cord Soot Clos

••••
••••
(3) Factors when closing the mandibular extraction space (Fig. 8-14)
(D Excessive lingual inclination and the retraction of mandibular incisors,
Bite deepening,
( Bowing effect,
•
(Excessive mesial angulation of mandibular molars •
•
The above phenomena occur mostly from space closing in the mandibular first premolar
extraction area with deep curve of Spee. Therefore, in making a diagnosis, it is necessary to
check the mnesial angulation of mandibular premolars and molars to determine the appropriate
extraction option and treatment mechanics. Also, if premolar and molar brackets have
excessive crown lingual torque, it can cause the lingual inclination of mandibular molars,
thereby restricting the forward movement of the mandible In particular, this problem is
aggravated due to the contact between the mandibular molar brackets and the maxillary teeth
[f the premolar is extracted despite an incomplete anterior leveling, the mandibular molars are
likely to be tilted forward during the space closure. This problem gets worse particularly when
the posterior occlusal plane is steep, Therefore, even after the extraction space is closed in this
way, mandibular retrusion, unaesthetic appearance, and undesirable Class ll relationship can
appear. This means that if the posterior occlusal plane is steep, it is better to extract the
mandibular second premolar rather than the mandibular first premolar. Here, it is important to
sufficiently upright the mandibular first premolars by using the open coil springs and the
MEAW
Table.8.f Guidelines for selection of mandibular space closing arcwire
Position of anterior teeth deal teeth movement

018" shoe-hook + Class l elastics roodinaton A) 96 Lingual movement ot incisors
--
Combination oop
016 022 ideal AW Class1,ll elastics Normal or rerooination MA (95 tenor moverent ofolees
Coors Sc Cr 1_
Fig.8-14 Check points when closing the mandibular space
A. Molar relationship: Class l with flat curve of Spee
B. FACC shows that the mesial angulation of the mandibular premolars and molars are apparent
C. Intraoral photographs after extracting the mandibular second premolar. excessive mesial angulation of
the first premolar and the first molar
D. Posterior movement of maxillary and mandibular canines
E lntraoral photographs of uprighted maxillary and mandibular canines For a desirable tooth movement,
the maxillary canine retraction should occur before the mandibular canine retraction. To achieve this,
the anterior movement of molars should occur before the posterior movement of canines and incisors
in the mandible
vhodsofpreventinglhebitcdeepet1ingduringlhefflC11'1dibularspocedosure
1. Make sure that severe curve of Spee is not formed.
• (1)Avoid the excessive lingual movement of mandibular incisors
• (2) Use the standard brackets in the mandibular incisor area

• 2.Make sure that severe curve of Wilson is not formed
(1)Avoid any oocdusal contact between the mandibular appliances and the maollary teeth
(2) Do not cause severe lingual tilting of mandibular molars.
(3)Use the standard brackets in the mandibular molar area
3. Close the space while maintaining the Class I canine relationship.
4. Move the teeth in the direction of maintaining the premolar ocluglen
►►►
[C»» Corso Core
••••
••••
[f bite deepening occurs during the mandibular space closure, it is important to stop the space
closing process and induce bite opening. In most cases, bite deepening occurs due to the
deformation of mandibular archwires. Therefore, if there is a tendency of bite deepening with
severe curve of Spee, the mandibular archwires should be carefully examined (Fig. 8-15)
•
•
•
t
Q
Fig.8.1s Bite deepening when closing the mandibular space

A. Bite deepening when closing the mandibular space
B Deformed mandibular archwire it is important to be wary of the
possibility of wire deformation in the case of unwanted severe
bite deepening.
C. Bite raising through the extrusion of premolars and the intrusion
of incisors and molars
D. Mandibular dentition after bite raising.
Cad Soc Co ++ [
Solutions for bite deepening.
Combination loop with gable bends and elastics: When closing the mandibular space,
bite raising can be achieved by giving the gable bends to the mandibular combination
loop, and by using the triangular elastics between the loop and the opposing teeth. By
doing so, the extraction space can be opened again. If the roots become parallelized to a
certain extent, the space should be closed again by activating the loop However, bite
deepening may not be improved despite using the combination loop. In this case, it is
important to check whether the combination loop is deformed or not. If the wire is
actually deformed, remove it and use MEAW to raise the bite.
(MEAW with tip-back bends and elastics: The effects and mechanisms of MEAW will be
explained in detail in the next chapter. If the tip-back bends are applied to the
mandibular ME AW, it will form the reverse curve. This triggers the extrusion of
premolars and the intrusion of incisors and molars, thereby raising the bite. Here, if the
triangular (I/4" 6oz) or short Class I elasties (3/16" 6oz) are used in between the loop
and the opposing teeth, the bite will be raised. The extraction space can be closed with
the use of an energy chain from the first molar to the first loop; however, the energy
chain should never be used on the mandibular second molar in such cases. By following
the procedures above, it is possible to achieve bite raising by uprighting the molars,
which are already mesially angulated with bite deepening.
Reverse MEAW with tip-back bends and elastics (Fig. 8-I6): Reverse MEAW makes
the direction of the loop posterior. This loop direction triggers the effects of molar
extrusion and incisor intrusion. It is highly effective when treating bite deepening with
molars that are vertically low positioned and mesially angulated.
•
•
•
Fig.8-16 Reverse ME AW wth tip-back bends and elastics
A. Pre-treatment intraoral photograph
B. Intraoral photograph after the space closure in the extraction case of the maxillary first and the
mandibular second premolars major problems such as deep curve of Spee and deep bite, etc
C. Post-treatment intraoral photograph
[2»»cos_Soc coo
••••
••••
3) Maxillary anterior teeth retraction (Fig. 8-17)
D Use the 016"x 022" stainless steel archwire to close the space of the four maxillary incisors
(The maxillary incisor torque can, depending on the anterior inclination, be divided into different
degrees: +7,+10',or +13°
•
( Apply Imm step between the maxillary lateral incisor and canine for the intrusion of four
•
maxillary incisors. •
Apply -T torque to the teeth behind the maxillary canine
5In the first visit, do not activate the loop before engaging the combination loop.
@In the following visits, activate the loop by moving the wires until the loop legs overlap with
each other, and by doing the cinch back. If the wires cannot be pulled in the forward direction,
it means that the cinch back has been done well
ln the next visit, check the deactivation and then re-activate
·•
+8-f
Fig.8.47 etraction of four maxillary incisors

A. Standard bracket and a wire with crown labial torque
B-1 swA bracket (crown labial torque) and a wire with crown labial torque
8.2Awire with crown labial torque for anterior teeth
8.3 Application of fmen step between the anterior and posterior parts of wire
Coors soc Coore s«4

(1) Factors to be checked in the retraction of four maxillary incisors.
(D Excessive linguoversion of maxillary incisors.

Excessive extrusion of maxillary incisors
To prevent the above

a. Use the SWA appliance that has crown labial torque on the four maxillary incisors.
b. The appliance should be carefully extended to the maxillary second molars. In doing so,
the upper occlusal plane must be checked and controlled.
c. Do not retract the canines excessively as they can come into contact with the second
premolars
d. Do not retract the canines by giving force directly from the maxillary mini-implant
e. To close the space of the four maxillary incisors, it is desirable to trigger the intrusion of
those teeth by applying the additional crown labial torque to the maxillary archwire, and
by providing Imm step between the lateral incisor and the canine (Fig. 8-18).
f. In the first month of treatment, keep the combination loop deactivated until the next visit.
When activating, slight activation is desirable, as excessive force may aggravate the
extrusion and linguoversion of incisors
Fig.8.18 Retraction of four maxillary
A Use the SwA brackets on the four

maxillary incisors
Space losing wth the consideration of
upper occlusal plane do not extend the
appliances to the second molars.
C. Avoid the ex )give retraction of maollary
Carmines
D Use the main archwire that has crown
labial torque in the anterior area
• Ee fmm step should be applied between
• the lateral incisor and the canine
[»» cotes Soc Coor

••••
••••
�
Space Closing Archwire
'9 Orthodontic archwire size

•
•
•
(I.016" stainless steel archwire,
(2).018" stainless steel archwire,
(3)016"x022 stainless steel archwire
�
Orthodontic archwire for space closure in the maxilla
(1).016 stainless steel archwire
(9This is an orthodontic archwire used to retract maxillary canines.

( The energy chain is used to close the space from the first molars to the maxillary canines.
(When there is a space within the four maxillary incisors, the energy chain must be used to
close the space, If there is no space, ligate the four incisors with the figure of 8 tie
Maintain the Class I canine relationship during space closure.
When there is a remaining space behind the canine even after the Class I canine
relationship, the main archwire must be replaced with the combination loop to facilitate the
canine retraction
(2) .016".022" stainless steel archwire (Combination loop with step)
(This is an orthodontic archwire used to retraet the four maxillary incisors.

(Apply the crown labial torque to the maxillary incisors.
(9 De-torque the maxillary canines to give the .7 clination to them.
/mm step is given for the intrusion of the four incisors.
First, apply only the intrusive force, and then perform the loop activation in the patient's
next visit.
@By doing so, the anterior and posterior teeth move to a similar extent and the extraction
space is closed as a result.
Cort So Coor [
"b Orthodontic archwire for space closure in the mandible
(1).018" stainless steel archwire (Shoe-hook)
(D This is an orthodontic archwire used for the retraction of the six or eight mandibular
incisors.
(Place the loop between the mandibular lateral incisors and the canines.
8 The archwire is used when there are severe proclined mandibular incisors.
( Space closure is done through a sliding mechanism, which uses the elastics or the energy
chain from the loop to the terminal teeth
$ The I/4" 6oz elastics must be used for the first molars, while the 5/16" 6oz elastics must be
used for the second molars
@By doing so, more retraction of the anterior teeth (when compared with the posterior teeth)
is made to close the extraction space.
When the mandibular incisors are severely retroelined (severe linguoversion), the 016"
02" ideal archwire must be used to close the space.
(2) .016".022" stainless steel archwire (ideal archwire with hook)
(D This is an orthodontic archwire used to close the posterior space of the six or eight
mandibular incisors
(Apply the crown labial torque to the mandibular anterior teeth
(9 De-torque the mandibular canines to give the .T inclination to them.
( Place the hook in between the mandibular lateral incisors and the canines
9A sliding mechanism, which uses elastics or energy chain, can be conducted to close the
space from the loop to the terminal teeth
@ The t4" 6oz elastics must be used for the first molars, while the 5/16" 6oz elastics must be
•
• used for the second molars
• By doing so, more protraction of the posterior teeth (when compared with the anterior teeth
s made to close the extraction space.
[Go» cwrs_So Coor

••••
••••
(3) .016".022" stainless steel archwire (Combination loop)
(D This is an orthodontic archwire used to close the posterior space of the six or eight
mandibular teeth
(Apply the crown labial torque to the mandibular incisors.
•
( De-torque the mandibular canines to give the .7 inclination to them.
•
Give a30 gable bends to the loop of anterior and posterior wires •
/tis used when there is minor curve of Spee.
4fthe teeth collapse toward the extraction space, the 3/16 6oz elastics can be used to close
the space between the maxillary canines and the mandibular loop
( By doing so, the space is closed with a similar amount of contribution from the anterior and
posterior teeth while maintaining the root parallelism.
�
Summary of space closure (Fig. 8-19)
Fig.8.49peooedures of space closure

(1) After leveling the maxillary and mandibular teeth, retract the maxillary
canines first.
The maxillary canines should be moved until a Class I canine relationship is achieved.
Only a certain amount of mandibular canine movement is required to solve anterior crowding.
Here, if there are any signs of Class ll eanine relationship, the mandibular canines should start
moving after the maxillary canines have moved.
(2) Extraction space closure in the mandible
( When there are severely proclined mandibular incisors, the 018" <hoe-hook must be used to
close the space. If the incisors are uprighted and lingually tilted during the procedure, the
archwire should be changed to the .016"x 022" ideal archwire with hook to complete space
closure
If the mandibular incisors are normally inclined, the 016"x 022" ideal archwire with hook
should be used to close the space
(3) Retraction of maxillary incisors (after the Class I canine relationship is

achieved)
Retract the canines after inserting the combination loop archwire in between the lateral incisors
and the canines
9-leveUng
after space closure
• f the appliances are extended to the maxillary and mandibular first molars and the
• space is closed, it is essential to extend the appliances to the mandibular second

• molars before the final stage of treatment. Here, it is important to consider the arch
form and move the teeth individually in the final stage.
DB»» cw So Coor
••••
••••
�
Anchorage
._, •
Minimum anchorage (Fig. 8-20) •
•
Fig.820 Minimum anchorage
This means closing more than 3/4 of the space by protracting the posterior teeth
The methods are as follows:
(/).016"x.022" ideal archwire with hook + Class I elastics (1/4" 6o or 5/16" 60, Fig. 8-21 A)
protraction of posterior teeth can be achieved more than the retraction of anterior teeth, if
the crown labial torque is applied to the anterior pant of archwire.
(2) Maxillary combination loop + mandibular MEAW + short Class Ill elastics (Fig. 8-21 By
In cases of maxillary premolar extraction only, the extraction space can be closed by using
the maxillary combination loop and Class Ill elastics to move the maxillary molars
forward. This is also a space closing method which is used when there is severe mandibular
curve of Spee and when maxillary incisors are protruded as well, Additionally, depending
on the canine relationship, this rnethod can be used again, if there is a lack of space for
mandibular incisors in closing the maxillary space. Here, if there is severe curve of Spee,
AW with tip- back bends and shot Class Ill elastics can be used to
the combination of ME
trigger the retraction of mandibular dentition and protraction of maxillary molars, thereby
raise occlusion eventually
cars_So Core [9
(3) Second premolar extraction (Fig. 8-21 C: when the second premolars are extracted,
posterior teeth can be protracted more than when the first premolars are extracted.
(4)Maxillary MEAW + mandibular combination loop + shont Class ll elastics: This is one of
the methods that is applicable in theory, but not commonly used in actual clinical cases.
I
oc== I
.. =
C•L __J
Fig. 821 Methods to obtain minimum anchorage

A. 016.022 ideal archwire with Class l elastics or power chain
B. Maxillary combination loop + mandibular MEAW + short Class Ill elastics
• C. Extraction of second premolars
•
•
• •••
••••
48 Maximum anchorage (Fig. 8-22)
This means closing I/4 of the space by protracting the posterior teeth This method is used most
frequently
•
•
e l
•
""
\) \ il "
''
'
'"• - '
Fig.822Maximum anchorage
In the maxillary dentition (Fig. 8-23)

(First, retract the maxillary canines only;
(2)Next, retract the four maxillary incisors by using the combination loop.
B
Fig. 8-23 Methods to obtain the maximum anchorage in the maxilla
A. Retract the maxillary canines first
Use the combination loop for the retraction of the four maxillary incises
Ce$ $%c Core + 4d]

In the mandibular dentition (Fig. 8.24)
(I)Close the space by using the 0I8" stainless steel archwire with shoe-hook + Class I elastics
(I/4" 6oz or 5/16" 602)
Fig. 824 Methods to obtain the maximum anchorage in the mandible

Use the round archwire (018" shoe-hook) for maximum retraction of the mandibular incisors
.._,
Moderate anchorage (Fig. 8-25)
This means closing more than I/4 and less than I/2 of space by protracting the posterior teeth.
Here, the 016"x 022" combination loop is frequently used (Fig. 8-26).
Fig. 8-25 Moderate anchorage
•
•
•
A
--- 8»
Fig.8-26 Methods to obtain moderate anchorage

A. Combination loop. B intraoral photograph of combination loop
••••
••••
"b Absolute anchorage (Fig. 8-27)
This is the process of space closure that is achieved by restricting the protraction of posterior teeth
The mini-implant is used for this process; however, if the mini-implant is used to solve a protrusive
•
profile, and only the anterior retraction is permitted with the posterior protraction restricted, the •
following problems may occur •
Fig.8.27 Absolute anchorage

A Retraction of anterior teeth by using the mini-implant
B.CD. Clinical uses of the mini-implant.
Cows So Coore +«4d

1) Cases with a normal posterior occlusal plane (Fig. 8-28)
To complete the treatment on the existing occlusal plane, a precise adjustment of the inclination
and angulation of the maxillary central incisors is required. Even after this is done, there may be no
changes in the molar area, and there may also be a high possibility of forming a U-shape arch form
after space closure
'1 \�
'
-
d
n
JD
h
IV
•
''L------------�
8-28 Case with a normal
Fig. occlusal posterior plane (PO)
A Tooth movement pattern when the pop is maintained the intrusion of mandibular incisors
and the lingual inclination and extrusion of maxillary incisors inevitably occur.
Tooth movement pattern when the POP is changed the lingual inclination and the extrusion
of maxillary incisors can be minimized by protracting and uprighting the mandibular molars
•
•
•
2) Cases with a steep posterior occlusal plane (Fig. 8-29)
f the space is closed while maintaining the pop_ severe lingual inclination and extrusion of
maxillary incisors can occur and the curve of Spee can still remain even after the treatment is
finished
»»cote Soc Coor

••••
••••
There are limitations in completing the treatment while maintaining the existing posterior occlusal
plane (POP) condition. Moreover, even when the patient has been diagnosed in this way, the
posterior occlusion can change during treatment, making the entire treatment procedure for more
complicated. Therefore, it is extremely important to decide whether to maintain or change the Pop
before the treatment. Here, the decision must be made after careful consideration of the
•
relationship and inclination of the posterior occlusion, the amount of curve of Spee, the skeletal
•
pattern, etc. Particularly in Class ll protrusion cases that are typically caused by low vertical •
dimension, the use of the mini-implant (for space closure) will induce the maximum retraction of
the incisor while maintaining the posterior occlusion. As a result, this can further aggravate the
vertical dimension problem and complicate the treatment procedure. This is because the position of
the mini-implant and its retraction method can influence the tooth angulation, torque, and occlusal
plane. Therefore, when the mini-implant is used to treat protrusion, the practitioner must be extra
careful
A[
I I
-
Br,
Fig.829Case with a steep posterior oclusal plane (POP)

A. Tooth movement pattern when the pop le maintained the intrusion of mandibular incisors
and the severe lingual inclination and extrusion of maxillary incisors inevitably Occur
B. Tooth movement pattern when the POP is changed the change of PO not only facilitates
aesthetic improvement but also prevents the linguoversion and extrusion of maxillary
In0IS0rS
a. Retrusive Control in Clinical Orthodontics
b Definition
This refers to the posterior disclusion guided by the contact between the inner incline of the palatal
cusp of the maxillary first premolar and that of the buccal cusp of the mandibular first premolar.
This can prevent the retrusive positioning of condyle and mandibular dentition (Fig. 8-30).
�II
.J
Fig.8.30 Retrusive control in clinical orthodontics

A. in closing the mandible, retrusion of the mandible can
be prevented by the contact in the maxillary and
mandibular first premolar areas
• g The mandiblular protraction becomes possible by
• making contact in the maxillary and mandibular fist
• premolar areas
.The lingual cusp of the maxillary first premolar should
come into contact with the distal marginal ridge of the
mandibular first premolar
D. The bu0cal cusp of the mandibular first premolar should
come into contact with the mesial marginal ridge of the
maxillary first premolar
E. The buccal cusp of the mandibular first premolar should
be separated from the mesial inner incline of palatal
Cusp of the maxillary first premolar,after the contact
36+» Cort Soon Coor

••••
••••
�
Significance
I)In cases of temporomandibular joint disorder (TMDy patients, the posterior condylar
displacement can be prevented. If the retrusive control is lost, the symptoms of TMD may be
•
aggravated due to the posterior condylar displacement. Due to this, the muscles and ligaments •
will keep exerting a forward force, and as a result, problems of loosened ligaments and a •
variety of muscle diseases can occur (Fig. 8-3).
2)In Class l and II high angle malocclusion or extraction cases, it is important to prevent
mandibular retrusion. Premolar extraction is common in high angle cases. These high angle
cases show a tendency for mandibular retrusion. However, in premolar extraction cases, for
aesthetic reasons, if the proper mechanisms are not applied, the mandible will move in the
posterior direction. In this situation, in order to finish the treatment, the maxillary incisors
should be severely lingually inclined or extruded inevitably. Here, what controls the
mandibular retrusion is the lingual cusp of maxillary first premolar or second premolar
(maxillary first premolar extraction case).
Fig.8.3f Cranio-mandibular system and

occlusion in Class l and II high angle
malocclusion or extraction cases, it is
important to prevent mandibular retrusion
cert so Coor 4dh

�
Application
1) Options for extraction
Fig. 8-32 Considerations in selecting the

extraction options
A. Canine relationship: Class Ikey.
B Premolar relationship. retrusive control
(1) Extraction of maxillary first premolars and maxillary second premolars
When extracting the maxillary second premolars, since the movement of the palatal cusp of the
first premolar cannot be easily obtained, the extraction space is likely to relapse. Therefore, if
the maxillary second premolars are not too small compared to the first premolars, it is more
desirable to extract the maxillary first premolars. In particular, when there is pneumatization of
the maxillary sinus, the maxillary first premolars should be extracted
(2) Extraction of mandibular first premolars and mandibular second

premolars
The mandibular first premolars can be extracted if there is a Class I molar relationship, a flat
curve of Spee, and if there is a normal posterior occlusal plane (IS or less). However, in most
•
• cases (except the aforementioned), it is more desirable to extract the mandibular second
• premolars. By doing so, it is possible to upright the anteriorly tilted mandibular first premolars
and move the mandibular dentition posteriorly in successfully closing the extraction space
Here, the maxillary extraction space is closed not only by the retraction of anterior teeth but
also by the protraction of posterior teeth. Therefore, retrusion of the mandible can be
prevented, by making contact between the maxillary second premolars and the mandibular first
premolars. In different cases, such as maxillary and mandibular first premolar extraction cases,
de»» colors_so Cr ••••

••••
it is recommended to close the extraction space while maintaining the normal relationship
between the maxillary and mandibular second premolars. To do this, the mandibular second
premolars should be placed more anteriorly in comparison to the maxillary second premolars
2) Strategic bonding
•
•
(1) Non-extraction cases •
When conducting strategic bonding, open coil springs are used to solve problems arising from
the mandibular incisor crowding. Here it is important to be cautious of the posterior movement
of the mandibular premolars. When the mandibular premolars move posteriorly, the mandible
becomes more retruded, thereby increasing the possibility of taking an extraction treatment
approach. This means that, in general, it is more desirable to move the teeth in a way that
permits the retraction of maxillary premolars and the protraction of mandibular premolars. To
achieve this, it is possible to use open coil springs in the mandibular posterior area and cheek
the anterior tilting of premolars. Here, if the tilting is observed, it is possible to use open coil
springs after applying the crown lingual torque to the anterior pant of the mandibular archwire.
Here, if there is a severe overjet or midline deviation in Class [l sub-division cases, the twin
block appliance, which first facilitates the mandibular forward movement, can be used. This
can prevent mandibular retrusion, and a non-extraction treatment can be applied by uprighting
the mesial angulation of mandibular premolars. Also, if there are lingually angulated maxillary
premolars, it is recommended to use maxillary expansion appliances to buccally upright those
teeth
(2) Extraction cases (Fig. 8-33)
(D Maxillary and mandibular first premolar extraction

lt is desirable to close the space while maintaining the maxillary and mandibular second
premolar relationship. To achieve this, it is recommended to place the mandibular second
premolars slightly more to the anterior direction in comparison to the maxillary second
premolars.
Cows_So Core « 49
(2 Maxillary first and mandibular second premolar extraction
Closing the extraction space can bring about the distal movement of mandibular dentition
The maxillary extraction space can, however, be closed not only by the retraction of
anterior teeth but also by the protraction of posterior teeth Tis facilitates the contaet
between the mandibular first premolars and the maxillary second premolars, and prevents
the retrusion of the mandible
3 Maxillary and mandibular second premolar extraction

lt is extremely important to first retract the maxillary first premolars. In other words, the
maxillary first premolars should be retracted before mandibular premolar retraction. Here,
when closing the second premolar extraction space, it is not desirable to use the energy
chain from the anterior teeth to the first or second molars. Instead, it is possible to use open
coil springs in the canine area, to distalize the premolars just to the extent that crowding
problems are solved, and to then bond the brackets in the canine area. Here, the first
premolar relationship must be checked consistently during the process of closing the space.
After anterior crowding problems are solved, the eight anterior teeth should all be grouped
as one unit, and then the second premolar extraction space should be carefully closed. The
main archwire used in this procedure is known as the 016"x 022" ideal archwire with
hook.
Al
..-:
•
•
•
4
•
8+
Fig. 8-33 Selection of extraction options

A Extraction of the maxillary and mandibular first premolars
B. Extraction of the maxillary first premolars and the mandibular second premolars
44[» Cos_Soc o
••••
••••
3) Space closure
(1) Space closure while maintaining retrusive control (Fig. 8-34 A)
Since retrusive control is maintained during treatment, the mandible is less likely to retrude.
•
Here, the mesial tilting of molars can cause a minor midline deviation and curve of Spee •
Nevertheless, this can be corrected during the finishing stages of treatment. •
(2) Space closure without maintaining retrusive control (Fig. 8-34 B)
This occurs mostly when the focus is only on closing the extraction space. In particular, when
there is a lack of retrusive control and the molars are anteriorly angulated, the mandible gets
more posteriorly placed as a consequence. If there is a full cusp Class Il tendency even after
space closure is completed, the entire treatment procedure can become very complicated. Just
at this moment, many orthodontists think of using ME
AW; in this case, in order to complete
the treatment, the occlusal plane should become steeper than the existing condition before the
mandible becomes more posteriorly placed. For these reasons, it is not desirable to use ME
AW
under these circumstances
fig.8.34Space closure in consideration of retrusive control

A. Closing the space while maintaining retrusive control
B Closing the space without maintaining retrusive control (night premolar site)
Chord So Coor ]
4) Finishing (Fig. 8-35)
f the premolars are extracted, the finishing phase may become a lot more complicated after
closing the extraction space. In this instance, the mandible gets retruded while a Class I canine
relationship is maintained. Here, it is recommended to check the maxillary premolar occlusion by
using articulating paper, [f the palatal cusp of the maxillary premolar does not occlude with the
opposing tooth, add flowable resin (3M) to the cusp to secure occlusion
A·1 •
Bf»
•
•
•
Fig.83 Retrusive control in the finishing stages of treatment
A. Pretreatment inraoral photographs
B. lntraoral photographs in the finishing stage
C Fowable resin (3M)
tL/
Crier--lea
dda»» cos_soc Coo

••••
••••
•
•
•
Fig. 8-35 (continued) Retrusive control in the finishing stages of treatment.

D.Aresin is added to the palatal cusp of the maxillary night second premolar and the buccal cusp of the
right mandibular fest premolar
E. Post-treatment intraoral photographs
F Comparison of the pre-, mid- and post-treatment photographs of the maxillary occlusal surface
Car Soc Co « 4
0 significance of the first premolar in occlusal reconstruction
When the MEAW appliance is used to treat malocclusion, it is more efficient to
reconstruct the occlusion based on the premolars. The reasons are as follows
1) The premolars are more prone to under-occlusion
2) They can be a point of reconstructing the occlusal plane.
3) They are positioned at the center of antero-posterior dentition in reconstructing
the occlusion
4)Masticatory muscle activity has little influence on occlusal reconstruction.
5) They are the farthest molars (the ones that determine the mandibular posture)
from the terporomandibular joint
6) They have a role in posterior guidance
►►►►►
•
•
•
dddd Chapter8Spee Cr
••••
••••
@ Archwire Fabrication for Space Closure

(D) Mandibular 016"x 022" ideal archwire with hook.
•
(2) Mandibular 018" shoe-hook. •
(3) Maxillary 016"x 022" combination loop for the retraction of incisors. •
1) .016".022" Ideal archwire (IA) with hook
(1)Basic form
This is an orthodontic archwire that has an anterior crown labial torque and adds the hooks
between the lateral incisors and the canines (Fig. 8-36)
Fig.8.36 016.022 Leal archwire (IA) with hook

A Basic form of ideal archwire with hook
B Intra0ral photographs
(2) Purpose
It is an orthodontic archwire with elastics or energy chain, which closes the mandibular space.
Comparison of archwires.
(016"x.022" L-loop: it has the same effects as the above archwire but requires loop
bending.
( Preformed ideal archwire with mini-implant To restrict anterior retraction and to
facilitate molar protraction, the mini-implant is used in the anterior area. Here, caution is
needed because an anterior implant can steepen the mandibular posterior occlusal plane
cows Se Coor « 45
(3) Indication
It is used to close the space when the mandibular incisors are uprighted or retroc lined (IMPA:
95 or less)
(4) Expected effect
lt is expected to triggers molar protraction rather than anterior retraction.
(5) Bending procedure (Fig. 8-37)
(D On each case, provide a different amount of crown labial torque (+7+10', or +13) and
form an anterior curvature to the anterior teeth by using the arch turret.
%. 47eown labial torque: used when the mandibular incisors are proclined.
b. +10 erown labial torque used when the mandibular incisors have normal inclination.
e. +13 grown labial torque: used when the mandibular incisors are retroclined.
Wen the .5 erown lingual torque brackets are used along with the zero-torque
preformed archwire, the mandibular incisors are likely to be severely retroclined.
Therefore, it is recommended to use the zero-torque brackets on mandibular incisors
Mark a spot between the lateral incisor and the canine.
g.7 de-torque is applied to the canine area
An arch form is made.
(The hook is attached to the marked point by using the crimpable hook pliers. Here, the hook
must be positioned mesio-gingivally.
• Fig.8.37 Fabrication of the

deal archwire (A) with hook
• A. Insert the center of 016
• 022 archwire into the T
turret slot
Rotate the turret to make
\ an antenior Curvature
C Ao-shaped anterior curvature
D. Crown labial torque
o»»Cots_soc Coo
••••
••••
Fig.8.37(continued) Fabrication of the ideal archwire (A) with hook
•
•
•
Ee. Alter checking the labial torque, mark the midpoint of the anterior arch
F After matching the mid-points of the archwire and the dentition, mark the points between the lateral
incisors and the canines
G.De-torque up to.7 from the marked point
H. De-torque from the contra-lateral point in the same way.
, ... .
l Attach the crimpable hooks to the marked point
J. Adjust the dental arch form
K.A completed ideal archwire with hook
Cc$%c Ce « 7
(6) Activation
D Mandibular second molar to the hook: 5/16" 6oz elasties

(2Mandibular first molar to the hook first, use the 1/4" 6oz elastics, and then substitute them
with the 3/16 6oz ones.
(Mandibular first and second molar to the hook: energy chain
2).018" shoe-hook
(1) Basic form
This is an orthodontic archwire with L-loops between the lateral incisors and the canines (Fig
8-38)
Fig.838 018 shoe-hook

A. Basic form of shoe-hook
B. intraoral photographs
•
•
•
d[» Cert Soc Coore

••••
••••
(2) Purpose
It is an orthodontic archwire with elastics or energy chain, which closes the mandibular
extracton space.
Comparison of archwires:
•
(9018" archwire: when elastics or energy chain are used directly from the first or second •
molars to the mandibular canines, the space is likely to be secured between the lateral •
Preformed ideal archwire with hook : when it is used on the labially tilted mandibular
canines, molar protraction can occur more frequently than incisor retraction.
(3) Indication
When the mandibular incisors show labial inclination (IMPA 95 or more), this wire should be
used for the purpose of closing pace and uprighting the mandibular incisors. After uprighting
the mandibular incisors to a certain extent, substitute it with the 016"x 02" ideal archwire
with hook and close the remaining space.
(4) Activation
D Mandibular second molar to the loop 5/16" 6oz elastics.

(2Mandibular first molar to the loop; 1/4" 6oz elastics are used first, and then substitute them
with the 3/16" 60z ones.
( Mandibular first and second molar to the loop: energy chain
(5) Bending method (Fig. 8-39)
D Form an anterior curvature to the anterior teeth

Mark the mid-point.
(9 Mark the contact points between the lateral incisors and the canines
( Bend the L-loop.
( Bend the L-loop in the opposite area.
6@Adjust the arch form
» Fig.8.39Fabrication of 018 shoe-hook
A. After matching the mid-points of the archwire and the dentition, mark the points between the lateral
B. Hold the marked point with the rectangular beak of Kim pliers and bend it to form a night angle
C. 4Move the beak 3em away from the bent point and bend it to form a right angle again with a rectangular
beak, so that it becomes parallel to the main archwire
D. Reposition the pliers 3mm away from the second bent point (C). Then, hold the wire with the first
(narrowest diameter) round beak and bend it approximately 136
E Move the pliers to the apex of the horizontal loop and bend it round so that the rest of the wire becomes
parallel to the main arch'wire
•
•
•
F. Place the round beak inside the loop and bend it 45
G.Move the beak slightly to the bent point and bend it again until the wire contacts the first bent point (8)
H. Hold the vertical portions with the rectangular beak and bend the wire to a night angle to form a straight
line
Dothe same in the contra-lateral side
J Acompleted bilateral shoe.hook
cos_soc co
5g»»
••••
••••
3) .016".022" combination loop with step
(1) Basic form
This is an orthodontic archwire used to efficiently close the space by providing vertical and
horizontal loops (Fig. 8-40).
•
Fig. 8-40 016.022 combination loop with step
(2) Purpose
[t is an orthodontic archwire used to retract the four maxillary incisors. It can control the
uprighting and extrusion of maxillary incisors that frequently arise during space closure.
(9 Prevention of the uprighting of maxillary incisors

a. SWA brackets are used for the four maxillary incisors (bracket with +12 torque for
maxillary central incisors, +8 torque for maxillary lateral incisors).
b. The additional crown labial torque (+7, +10',or +13) is applied to the orthodontic
archwire
47grown labial torque; used when the maxillary incisors are prochined
+10 crown labial torque used when the maxillary incisors have normal inclination.
+1crown labial torque used when the maxillary incisors are retroe lined
cows_So Coor +« S[
( Prevention of the extrusion of maxillary incisors
Provide the intrusion step to the maxillary incisor area. To achieve this, a loop should be
efficiently used to lower the load-deflection rate (LDR). For the first month, trigger the
incisor intrusion, and then activate the loop from the next month.
Comparison of archwires:
a. .016x.022" L-loop
An excessive fore can be applied to the incisors when intruding the maxillary
incisors
Activation amount is difficult to measure objectively,
b. Preformed keyhole, T-loop, and tear-drop loop
Since these wires have zero-degree torque, there is a greater possibility of
linguoversion of the incisors
(3) Bending procedure (Fig. 8-41, 42)
(9 Anterior curvature is formed by using an arch turret.

a. 47eown labial torque: used when the maxillary incisors are proclined.
b. +10 crown labial torque used when the maxillary incisors have noral inclination.
e. +13crown labial torque: used when the maxillary incisors are retroclined
(2Mark the loop position 2mm distal to the maxillary lateral incisor brackets. Bend the mark
point with a rectangular beak of Kim pliers.
( Bend it again with a round beak of Kim pliers 8-10mm away from the bent point
(Bend it again with a rectangular beak of Kim pliers 3mm away from the bent point until it
becomes parallel to the main archwire
Bend it again with a round beak of Kim pliers right beside the bent point until it becomes
parallel to the main archwire.
@Give Imm step to the wire so that it provides intrusion in the anterior area
•
• Make sure that .7 erown lingual torque is applied in the posterior area
• When seen from the front, the anterior part and the two posterior parts of the archwire
should be parallel to one another (Fig. 8-41, 42)
The posterior parts of the archwire are bent to form an ideal arch shape.
4d5a»» cord_Soc co
••••
••••
© <Z> 3
e \ '
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7
9 0
•
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[ •
•
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p
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[ s
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Fig.8.41Fabrication of 016 022 combination loop with step
Fig.842 Fabrication of 016 022 combination loop with step.
A. Insert the 016 022 stainless steel archwire into the 7 slot of turret.
B. Make a curve by rotating the turret bilaterally
C. Shaped anterior arch form
D. Mark the mid-point on the archwire

E.Make sure that the crown labial torque is embedded, and then overlap the marked point to the dental
midpoint Finally, mark the points between the lateral incisors and the canines
Fig.842 (continued) Fabrication of 016 022 combination loop with step
F, Hold the marked point with a rectangular beak of Kim pliers and bend it to form a night angle
G. Move 10mm upward, then hold the plier and form a loop so that the first round beak faces the gingova
from the first bent point. Then bend the wire approximately 135
H. Move the round beak to the apex of the loop and then bend it until it becomes parallel to the vertical leg
I Move the beak 3mm away from the loop apex and bend it until it forms a night angle to the rectangular
beak, and until it becomes parallel to the main archwire.
•
•
•
J. Move the beak 3mm away from the last bent point and bend it 135
into a round loop
K. Move the pliers to the apex of the horizontal loop and bend it until it
becomes parallel to the rest of the wire
[d»»cotes sec loo

••••
••••
Fig. 842 (continued) Fabrication of 016 022 combination loop with step
•
•
•
L.Use Kim pliers to form a loop that is the same as the vertical loop
and bend it until it forms a night angle
M. Bend the wire to make a night angle, while making 1mm step
N Bend the opposite side in the same way.

0. Fabricated combination loop
Adjust the arch shape
cows_soc coo « 55
Fig. 8-42 (continued) Fabrication of 016 022 combination loop with step.
0
Q. Adjust the loop shape and do not impinge the gingiva
R Apply 7 crown lingual torque to the posterior canine area
S.A completed combination loop.
(4) Activation (Fig. 8-43)

•
•
• (D Clinically, the posterior wire is moved distally until both of the vertical loop legs are
overlapped with each other. Then, do the cinch back afterwards.
(When the posterior part of archwire is pulled forward, the archwire should not be moved
(9When the combination loop is used for the maxillary arch, four incisors are ligated with the
figure of 8 tie
456» Crs Soc Coor

••••
••••
•
•
Fig.843 Activation of 016 02? combination loop with step
•
Cautions in using the combination loop(Fig. 8-44)

a. Excessive activation can cause the lingual inclination and extrusion of maxillary
Ines0rs
b. When Class ll elastics are used to close the space, there will be more severe lingual
tiliting and extrusion of maxillary incisors due to the actions of both the elastics and
combination loop. For this reason, it is not desirable to use Class II elastics along with
the combination loop
e. If the loop is too distally positioned, subsequent contact between the loop and the
bracket can restrict tooth movement. Therefore, it is recommended to place the loop in a
position where it can be at the center of the adjacent teeth after space closure
Fig. 8-44 Cautions in using the combination loop

A. Excessive activation can aggravate the lingual tilting and extrusion of maxillary incisors
B. If Class Il elastics are used along with the combination loop, it can aggravate the lingual tilting and
extrusion of maxillary incisors.
C Tooth movement can be restricted due to the distally positioned loop and the subsequent contact
between adjacent teeth Here, the loop should be at the center of the teeth after space closure
Cows so Core « 457

9lnicol
Tips: the combination loop
1 Make sure that the loop is not impinging the lip or gingiva
2If possible, place the loop at the distal side of the lateral incisor bracket.
3.Make sure that both anterior and posterior wire parts are parallel to one another
4. tis undesirable to apply an excessive force when retracting. ii
Premolar extraction strategy can be summarized as follows:

a. Bond the SWA on the four maxillary incisors and the standard edgewise appliances with
zero-degree torque on the rest of the teeth.
b. Avoid contact between the mandibular orthodontic appliances and maxillary opposing
teeth
e. If possible, close the extraction space while maintaining the upper occlusal plane.
Caution is needed when extending the appliances up to the maxillary second molars for
the maximum retraction of maxillary anterior teeth
d. After the maxillary first molars form a parallel relationship, use the energy chain to
retract the canines. If there is space among the four incisors, use the energy chain to
close the space and ligate the four incisors with the figure of 8 tie. It is important not to
retract the maxillary canines to the positions of the maxillary second premolars.
e. After obtaining a Class I canine relationship, substitute the maxillary archwire with the
combination loop with step, and then wait for the intrusion of four incisors. In this
process, it is extremely important to keep retracting the canines
f (lose the space while maintaining the Class I canine relationship.
g. When there is maxillary or mandibular crowding, use the open coil springs to secure the
space and solve the crowding problem.
h. Space closure must be done only after uprighting the mesially tilted mandibular molars
• and premolars, If there is severe mesial tilting, it is recommended to extract the
• mandibular second premolars (not the first premolars). Here, the open coil springs
• should be used in the mandibular canine area to sufficiently upright the first premolars,
and to then bond the bracket on the canines
i. When extracting the mandibular first premolars, space closure must be conducted while
maintaining premolar and molar occlusion.
j. Maintain retrusive control in the leveling and alignment process and in closing the space
as well
05e» Cort Soc Coo

••••
••••
@ The maxillary and mandibular first premolar extraction method (Fig. 8-45, 46)
a. Bond the brackets on every tooth except for first molars and crowded teeth
b, When the open coil springs are used in the first molar area, the mandibular second
molars are uprighted and de-rotated. The mandibular second premolars are moved in the
mesia direction.
•
c. Bond the brackets on the first molars •
d. Space closure •
e. Finishing
A +
Pretreatment-
oetreatent
+E
Fig.845 The maxillary first premolar extraction method

A.f there is no anterior crowding, bond the brackets on all the teeth except the first molars
B Tooth movement towards the ideal arch form
C.Use the open coil springs in the first molar area for the parallel rotation of the resially rotated
maxillary second molars. After this, f there is a mesialty rotated fest molar, bond the brackets and
apply the energy chain with a light force on the first and second molars to facilitate the de-rotation
D. Before retracting the maxillary canines, the first molars must be in a parallel relationship
E. Use the energy chain on the first molars to retract the maxillary canines. After obtaining the Class I
relationship with the mandibular canines, the combination loop must be used to retract the four
maxillary anterior teeth Here, the maxillary canines are retracted within the archwire
f Releveling after the space closure
G Comparison of the pre- and post-treatment maolary arch in the maollary first premolar etraction cars.e
Corso Coor « 4db6

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Pre.treatment-
Post-treatment-
fig.846 The mandibular first premolar extraction method

A.If there is no anterior crowding, bond the brackets on all the teeth
except the fist molars
• Use the open coil springs in the first molar area for the parallel
rotation and uprighting of mesially tilted and rotated mandibular
second molars
C Bond the brackets on the mandibular first molars
D. Space closure in consideration of the relationship with the
maxillary teeth
E.Comparison of pre- and post-treatment mandibular arch in the
mandibular first premolar extraction case
•
•
•
6c Cr Soc Coo
••••
••••
The maxillary first premolar and mandibular second premolar extraction method (Fig. 8-47, 48)
a. Bond the brackets on all the teeth except for the mandibular canines and second molars.
b. Use the open coil springs in the canine area to upright the mesially tilted first premolars.
e. After uprighting the first premolars and decrowding the anterior teeth, bond the brackets
on the canines and do the re-leveling
•
d. Space closure.
•
e. Adjust the arch form after bonding the tubes on the second molars. •
Fig.8.47 The mandibular second premolar extraction method (tapered arch form)
" » I
) R l % 8
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/
• - I I
± (
R) D
I 3 J I
2 nl
8 • I • I
, /
nl
H)
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u
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cL
%.8
A. Bond the brackets on all the teeth except for the mandibular
canines and second molars
B. Use the open 0oil springs in the canine area to upnight the mesially
tilted first premolars
C. Bond the brackets on the canines and do the levelling after
uprighting the first premolars and solving the anterior crowding
problem
Cord S Coor « f[
Fig. 8.47 (continued) The mandibular second premolar extraction method (tapered arch form)
% r
J,;
..
n
D
�
.-
D.Space closure
E Leveling and alignment after bonding the tubes on the second
z==
molars
F Comparison of pre- and post-treatment mandibular arch in the
mandibular second premolar extraction case
•
•
•
62»» Cors Soon Coor

••••
••••
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)
I
Fig.8.48 The mandibular second premolar extraction method (square arch form)
A. Bond the brackets on all the teeth except for the mandibular canines and second molars
B Use the open coil springs in the canine area to upnight the mesially tilted fest premolars
C. Bond the brackets on the canines and do the leveling after uprighting the first premolars and solving
the crowding problem
D. Space closure
E Leveling and alignment after bonding the tubes on the second molars
f Comparison of pre- and post-treatment mandibular arch in the mandibular second premolar extraction
case.
cars_So coo +« 4Go

REFERENCES
1 BadawiH, et al. Three dimensional orthodontic force measurements. Am J Orthod Dentofacial Ortop
136.518-528, 2009.
2 Begg R. Orthodontic theory and technique. 3rd e. Philadelphia WB Saunders, 1977
3 Bennett JC, and McLaughlin RP,Orthodontic management of the dentition with the preadjusted
appliance. lsis Medical Media, 1997.
4 Booth FA. MS Thesis Optimum forces with orthodontic loops. Houston, University of Texas Dental
Branch, 1971.
5 Braun S, Sjursen RC, and Legan HL On the management of extraction sites. Am J Orthod
Dentofacial Orthop 112.645-655, 1997
6. Byloff KF, and Darendeliler MA. Distal molar movement using the pendulum appliance. Part
Clinical and radiological evaluation. Angle Orthod 67-249-260, 1997
7 Byloff KF,and Darendeliler MA Distal molar movement using the pendulum applianoe. Part n, The
effects of maxillary molar root uprighting bends. Angle Orthod 64.261-270, 1997.
8 Daskalogiannakis J, and Ammann, A Glossary of orthodontic terms, Quintessence, 200O.

9 Eden JD, and Waters N. An investigation into the characteristics of the PG canine retraction spring
Am J Orthod Dentofacial Orth0p 105.49-60, 1994.
10 Gunduz E, Schneider-Del Savio T, Kucher G, Schneider B, and Bantele n Hp Acceptance rate of

palatal implants: A questionnaire stury. Am J Orthod Dentofacial Orthop 126.623-626, 2004
11. wasaki LR, et al. Clinical ligation forces and intraoral friction during sliding on a stainless steel
archwire. Am J Orthod Dentofaial Orthop 123.408-415, 2000
12 Joondeph DR graber TM, Vararsdell Rt, and Vig KWL, eds. Orthodontics Current Principle and
Techniques. 4th edition. St Louise: Mosby, 2005.
13 Josell SD et al. Force degradation in el tomenic chains. Semin Orth0d 3.189.197, 1997
14 Kim JI, Akimoto S, Shinj H, and Sato S. importance of vertical dimension and cant of occlus.al plane in
craniofacial development. Int J Stomattol Occlusion Med 2-114.121,2009
15 Kim JI. Practical Clinical Orthodontics. Vol1. Orthodontic treatment with MEAW_ Well publishing Inc,
2012
16 Kim JI. Practical Clinical Orthodontics. Vol 2. Orthodontic Diagnosis. Well publishing Inc, 2013.
•
• 17 Kim JI. Practical Clinical Orthodontics. Vol3. Early orthodontic treatment Welt publishing Inc, 2015.
• 18. Marcott MR. Biomechanics in Orthodontics. St Louis.CV Mosby, 1990
19 McLaughlin RP, and Bennett JC. The extraction-nonextraction dilemma as it relates to T4MD, Angle
Orth0od 65.175-186, 1995
20 Moffitt AH. Eruption and function of maxillary third molars after extraction of second molar. Angle
Orth0d 68.147.152, 1998
f4d»» Cagers Soc Cr

••••
••••
21.Nanda Ravindra. Biomechanics and Esthetic strategies in clinical orthodontics, Elsevier Saunders,
2005.
22 Northway WM. The nuts and bolts of hemisection treatment: managing congenitally missing
mandibular second premolars. Am J Orthod Dentofacial Orth0p 127.606-610, 2005 •
23. Proffit WR. Contemporary orthodontics. St Louis CV Mosby company, 1986. •
24. Ricketts RW, Bench RW, Gugino CF, Hilgers 4J, and Schulhof RJ. Bioprogressive Therapy. •
Denver.Rocky Mountain Orthodontics, 1979
TMD. Am J Orthod Dentolaial Orth0p 127.249-254, 2005.
26. Rona F, Kleinert W, Melsen B, and Burstone CJ. Force system developed by V bends in an elastic
orthodontic wire. Am J Orthod Dentofacial Orth0p 96.295-301, 1989
27. Roth RH. Functional occlusion for the orthodontist. J Clin Orthod 1541--4), 1981,
28. Scheffler NR Patient and provider perceptions of skeletal anchorage in orthodontics. MS Thesis,
University of Northo Carolina, 2005
29. Schwarz AM, and Gratzinger M. Removable orthodontic appliances. Philadelphia wB Saunders,
1966
30. Shroff B, Yoon WM, Lindauer SJ, et al. Simultaneous intrusion and retraction using a three-piece base
arch. Angle Orth0d 67455-462, 1997
31. Siatkowski RE Continous archwire closing loop design, optimization and verification. Part I. Am J
0rthod Dentofacial Orth0p 112-393-401, 1998
32. Siatkowski RE. Continous archwire closing loop design, optimization and verification. Part IL. Am J
Orthod Dentofacial Orthop 112484-495, 1998
33. Stucki N, and lngervall B. The use of the Jasper Jumper for correction of Class n malocclusion in the
young permanent dentition. Eur J Orthod 20.271-281, 1998.
34. Tent fy Alas of orthodontic appliances, Caravel, 1985
35 ThurOw RC Atlas of orthodontic principles, Mosby, 1977
36. Tweed CH. Clinical orthodontics. Vol1 and 2. St Louis Mosby, 1966
cows_soc coo 6
••••
. -- .... . .
. . . . . . . ..
. . . .. .. -- . -- .. . .
Chapter 9_
FINISHING
n· Finishing Archwire
Typically, stainless steel archwires, NiTi, and TMA wires are used as finishing archwires. In
MEAW, a.016"x022" MEAW or a rectangular ideal archwire is commonly used
(IArchwire size: 016" 022" stainless steel archwire
(2) Requirements
a. It must allow individual tooth movement.
b. It must be able to upright a mesially angulated tooth.
c. It must be able to control the tooth axis.
d. It must be able to adjust the occlusal plane and the vertical dimension,
e. It must be able to establish the interdigitation.
f It must be able to move the entire dentition.
g.Three-dimensional tooth movement must be possible.
AW technique is required in various cases. However. the
To meet the above requirements, the ME
MEAW has some disadvantages in that D) it is relatively difficult to make up the MEAW, 2) the
patient's cooperation is essential in the use of the elastics, and ) it is difficult to maintain oral
hygiene. The following cases can be finished by using NiTi or TMA instead
b Cases that do not require individual tooth movement
(D)A4case where there is no difference in the marginal ridges.

(2A4 case where torque control is not required.
()A4 case where tooth axis control is not required
• -._
• Cases that do not require occlusal plane adjustment
•
(Flat curve of Spee
(2)Normal posterior occlusal plane (POP)
However, it is extremely rare to find cases where the above requirements are all satisfied in the
finishing stages of treatment. Therefore, MEAW is frequently used to overcome remaining
problems, and a clear understanding of MEAW is needed to do so.
46»» cs_Fong
••••
••••
� 'Multi-loop Edgewise Archwire (MEAW)
'b Composition and basic form of MEAW

•
•
•
' 5 • 3 2
··�------------
Fig.9-f Basic shape of MEAW
A. Basic shape of MEAW. B. Clinical use of MEAW
Multi-loop edgewise archwire (MEAW)is a type of archwire that was created by Dr. Kim Young-Ho
lt has a L-shape horizontal loop (L-loop) in teeth contact areas from the distal side of lateral
incisors to the terminal molars. In general, 016"x 022" stainless steel rectangular wires are used
to construet the archwire. Here, even though the arch shape, loop length, etc. are all different
depending on the size or shape of dentition, the basic shape is the same as shown in Fig. 9.I. The
basic form of MEAW is the ideal arch that is frequently used in the final stages of the edgewise
technique. It should incorporate all of the anatomical forms of dentition. Here, the three
dimensional bends, (I) first-order bends, (2) second-order bends, and () third-order bends, should
all be included in the ideal arch. The following figure (Fig. -2) explains the horizontal loop and
the name and the action of each part or area.
(l Horizontal loop: it reduces the vertical force and adjusts the vertical tooth movement.
(2) Vertical leg (breaker): along with the horizontal adjustment, it secures the independent
movement of an individual tooth
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(3) Loop base: this is the part where the two perpendicularly bent angles meet with each other,
and where the tip-back bends or torque is controlled
(4) Horizontal part of archwire This is the part that is inserted into the bracket's slot and
conveys the archwire force to the teeth. This part should be straight because the wires
should be slipped well into the slot in accordance with the tooth movement.
hoe0et.a ice
Fig.92Basic form of L-loop
L-loop is the basic component of MEAW
t Horizontal loop
beaker
Two separated vertical legs (breaker)
Horizontal part of arc#wire
Base of L-loop
I \
horontl pat ol ache 0a0toll006
MEAW is 2.5-3 times longer than the normal archwire because the horizontal loop is applied to
the ideal archwire. This difference reduces the orthodontic treatment forces by I/S of a 016
,022" ideal archwire and makes it possible to apply a consistent orthodontic force to an
individual tooth as well as to the whole dentition. As a result. the ideal tooth movement occurs
simultaneously in the entire dentition due to a three dimensional wire adjustment.
(I)By reducing the load-deflection rate (LDR), a consistent orthodontic force can be
continuously applied to the dentition
(2) Although MEAW is a continuous archwire, individual tooth movement can be controlled
easily because the horizontal loop and breaker control each individual tooth separately.
(3) Uprighting, extrusion, intrusion, and torque control can be done with ease.
•
• (4 The use of elastics along with the above actions can facilitate occlusal plane adjustment.
•
• •••
••••
The method of bending an L-loop is as follows (Fig. 9-3).
·•
_J_ , •
- E
,-C\
$
'
�
•
.
•
•
I\ <
Fig.9.3Fabrication of L-loop.
'
A. Hold the marked point with the rectangular beak of Kim pliers and bend it to a night angle.
B.Move the beak 3mm away from the bent point and bend it until it is parallel to the main archwire and
perpendicular to the rectangular beak
C Reposition the pliers 3mm away from the second bent point and hold the wire until the first (narrowest
diameter) round beak faces the gingiva. Then, bend the wire approximately 135
D. Move the pliers to the apex of the horizontal loop and bend it round untd the rest of the horizontal loop
is parallel to the main archwire
E. Place the round beak inside the loop and bend 45
F Move the beak slightly towards the bent point and bend it again until the wire Cornes into contact with
the first bent point
G.Hold the rectangular beak in its mesial side and bend the wire until it forms a straight line
Cars_fir + 7]
�
Functions and mechanics of MEAW (Fig. 9-4)
The basic treatment mechanics of the ME

AW appliance is as follows:
(I)By uprighting the mesially tilted teeth, it is possible to gain the mesio-distal space as well
as improvements in vertical dimension and changes in the occlusal plane. This is achieved
by applying the tip-back bends. The amount of tip-back bends may vary depending on each
case, the inclination of the occlusal plane, and the treatment plan. However, in general, a
3-5 angulation is applied to each tooth and a total amount of I5-20 angulation is
applied. Here, by engaging these archwires in the entire dentition and by using the elastics
in the anterior pant of dentition, the overall improvement of dentition can be achieved
(2) To improve the arch form, secure the horizontal space by de-rotating the mesially rotated
teeth and by expanding the arch
(3) By uprighting the bucco-lingually tilted teeth, it is possible to gain bucco-lingual space,
and to obtain an improvement in vertical dimension, an establishment in proper guidance,
and a functional occlusion
The completed MEAW is as follows:
A.f A.2
.
�r
r • .\
;
; '• l I
i I
t I
•
•
g.f
Ulooe E
AW
w
82
Lower MEAW
+C
'
• •
'
•
t¢
- _9
AW
Lower £
Fig.94 Functions and mechanics of ME

AW
A. Fist-order bends. B. Second-order bends C Third-order bends.
7a»» cows foe ••••

••••
1) Upper MEAW
(I) By applying the tip-back bends, it is possible to give the compensating curve of Spee to the
upper areh
(2) Give a crown labial torque (+7) to the anterior teeth.
•
() Give a gradual crown lingual torque from the back of canine
•
(4 In the case of Class HI malocclusion, a crown lingual torque (-T) should be given to the •
anterior teeth
2) Lower MEAW
(I)By applying the tip-back bends, it is possible to give the reverse curve of Spee to the lower arch
2) Give a crown lingual torque (-7) to the anterior teeth
() Give a gradual crown lingual torque from the back of canine.
(4) In the case of Class IHI malocclusion, a crown labial torque (+7) should be given to the
anterior teeth.
(5) In the case of Class Ill malocclusion and open bite malocclusion, after using the reverse curve
of Spee, it is necessary to deactivate it and apply a compensating curve of Spee
�
Instruments and materials for MEAW
(I) 016"x022" stainless steel archwire (2)Kim pliers

(3) Tweed arch forming pliers (4) Three prong pliers
(5) Arch turret (6) Marking pencil
(7) Case models
•-- Fig. 9.5 Instruments and materials for

MEAW fabrication
I 016022 stainless steel wires

Kim pliers
Tweed arch torrning pliers
Three prong pliers
+ Arch turret
Marking pencil
Case models
Cos foe
�
Fabrication of MEAW
1) Upper MEAW
insert the center of a wire into the 7T slot of 016" arch turret (Fig. 9.6 A)
( Rotate the turret 90' to the left and right, and form a curved shape (Fig. 9-6 B)
This is the anterior semi-circular arch shape that is curved by turreting (Fig. 9-6 C)
(Mark the center of anterior arch with crown labial torque (Fig. 9-6 D)
Place the center of the wire on the center of dentition and mark the contact points between the
lateral incisors and the canines (Fig. 9-6 E)
Fig.9-6Fabrication of upper MEAW
• A insert the center of a wire into the 7 slot of 016 arch turret
• B. Bilaterally rotate the turret 90'
• C. Shaped anterior arch form
D.Mark the mnid-point on the archwire, while making sure that the crown labial torque is embedded
E Place the marked point on the dental mid-point and mark the contact points between the lateral incisors
and the canines
7»»cors_oh
• •••
••••
@ Hold the point with the rectangular beak of Kim pliers in the mesial side and bend it gingivally
until it forms a right angle (Fig.9.6 F)

Move the rectangular beak 3mm away from the bent point and bend the wire until it forms a
right angle, and until it becomes parallel to the main archwire (Fig. 96 G)
8 Move the first round beak 3mm away from the bent point and bend the horizontal loop 135
towards the gingival direction (Fig. 9.61H).
•
Fig.9-6(continued) Fabrication of upper MEAW
F Hold the point with Kim pliers and bend it until it forms a night angle
G.Move the rectangular beak 3mm away from the bent point and bend the wire until it becomes parallel and
perpendicular to the main archwire
4 Move the first round beak 3mmn awary from the bent point and bend the horizontal l00p 135 towards the
gingival side
cert_foe 7S
9 Move the round beak to the apex of the horizontal loop and bend the wire until the remaining
wire is parallel to the main archwire (Fig. 9.6
Place the round beak inside the loop and bend the wire 45 (fig. 9.6J.
Move the pliers Imm closer to its bent point and complete the bending until the two legs are
parallel to each other, 0.5mm away from each other (Fig. 9-6K)
$ Hold the legs towards the distal direction and make sure that they are parallel to the main
archwire (Fig.9-6L)
The completed first loop (Fig. 9-6 M)
After applying the same method to its opposite wire, the bilateral first horizontal loops are
completed (check symmetry and flatness)(Fig. 9-6 N)
Make sure that the center of the wire is in line with the center of dentition, and then mark the
contact points between the canines and first premolars (Fig. 9.6 0).
Apply the same method to the second loops (the length of loop should be 70% of inter-bracket
distance)(Fig.9-6 P)
Fig.96(continued) Fabrication of upper MEAW
•
•
• • By moving the round beak to the apex of the horizontal loop and by bending the wire around the beak, it
becomes parallel to the main archwire
J. Locate the round beak inside the loop and bend it 45
K. Move the beak slightly towards the bent point and bend it again until the wire comes into contact wth the
first bent point
Llaoe the rectangular beak towards the distal direction and bend the wire untd#tis inine with the main arch@ire
M Completed first loop
N Do the same on the contra-lateral side Note the completed bilateral first loops
• •••
••••
Completed bilateral second horizontal loops after bending the opposite wire in the same way
(Fig.9-6,0)
Overlap the centers of both the wire and dentition, and mark the contact points of the first and
second premolars.
The third loops are bent in the same way (the length of horizontal loop must be 70% of the
•
inter-bracket distance)(Fig. 9-6 R) •
Overlap the centers of both the wire and dentition, and mark the contact points of the second •
premolars and first molars.
( The fourth loops are bent in the same way (the length of horizontal loop must be 70% of the
inter-bracket distance) (Fig. 9-6 $)
second molars
( The fifth loops are bent in the same way (the length of horizontal loop must be 70% of the
inter-bracket distance) (Fig. 9.6 T)
The completed upper MEAW (the inter-loop distance should be at least 2mm, and the distance
between the fourth and fifth loops should be 3-4 mm)(Fig. 9-6 U).
Fig.96(continued) Fabrication of upper ME

AW
p
O 4Make sure that the center of the wire and the center of (dentition are
matched, and mark the contact points between the canines and first
premolars.
p Hold the marked point with a rectangular beak and bend it so that it
becomes perpendicular to the main wire
0 Same methods of first loop is applied to the second loop
R. Third loops are fabricated in the same way
S. Fourth loops are fabricated in the same way
ff loops are fabricated in the same way
U. Adjust the shape of the completed upper MEAW
Cote$foe + 7
2) Lower MEAW (Fig. 9-7)
Insert the center of a wire into the 7 4lot of 016" arch turret (Fig. 9-7 A)
Rotate the turret 90' to the left and right, and form a curved shape (Fig. 9-7B)
( This is the anterior semi-circular arch shape, which is curved through turreting (Fig. 9.7€)
(Mark the center of the anterior arch with crown lingual torque (Fig. 9.7 D).
Place the center of the wire on the center of dentition, and mark the contact poits of the lateral
incisors and canines (Fig. 9.7 E)
@Hold the point with the rectangular beak of Kim pliers in the mesial side and bend it gingivally
until it forms a perpendicular angle (Fig. 9.7 F)
Fig.9.7Fabrication of lower MEAW
A. Insert the center of a wire into the 7 $lot of 016 arch turret
B. Bilaterally rotate the turret 90'
C Shaped anterior arch form
D.Mark the mid-point on the archwire and confirm that the crown lingual torque is embedded
E place the marked point on the dental mid-point and mark the contact points of the lateral incisors and
canes
F Hold the point with Kim pliers and bend it 90'
7»» core_Foe
••••
••••
Move the rectangular beak 3mm away from the bent point and bend the wire until it forms a
right angle, parallel to the main archwire (Fig. 9-7 G)
Move the first round beak 3mm away from the bent point and bend the horizontal loop 135 in
the gingival direction (Fig. 9.7 1H
(9 Move the round beak to the apex of the horizontal loop and bend the wire until the remaining is
•
parallel to the main archwire (Fig. 9-7 I •
Place the round beak inside the loop and bend the wire 45 (Fig. 9-7J). •
0 Move the pliers Imm closer to its bent point and complete the bending until the legs are parallel
to each other, 0.mm away from each other (Fig 9-7K).
Hold the legs towards the distal direction and make sure that they are in parallel to the main
archwire (Fig. 9-7L)
Fig.97 (continued) Fabrication of lower MEAW
G.Move the rectangular beak 3mm away from the bent point and bend the wire until it forms a night angle
parallel to the main archwire
H. Move the first round beak 3mm away from the bent point and bend the horizontal loop 135 f0wards the
gingival side
l. Move the round beak to the apex of the horizontal loop and bend the wire until the remaining wire is
parallel to the main archwire
J. Locate the round beak inside the loop and bend it 45
K.Move the beak slightly towards the bent point and bend it again until the wire comes into contact with the
first bent point
L Hold the rectangular beak towards the distal direction and bend the wire until it is in line with the main
arcwire.
cow_row« 7g
4 The completed first loop (Fig. 9.7 M)
After applying the same method to the opposite wire, the bilateral first horizontal loops are
completed (check symmetry and flatness(Fig. 9.7 N)
Make sure that the center of the wire is in line with the center of dentition, and then mark the
~ contact points between the canines and first premolars (Fig, 9.70)
Apply the same method to the second loops (the length of loop should be 70% of its inter-
bracket distance) (Fig. 9.7 Py
Completed bilateral second horizontal loops after bending the opposite wire in the same way
(Fig.9-7,0
second premolars (Fig. 9.7R)
Fig.97 (continued) Fabrication of lower ME

AW
• M. Completed first loop.

• N. Do the same on the contra-lateral side. Note the completed bilateral first loops
• 0.Place the enter of the wire at the enter of dentition, and then mark the contact points between the
canines and first premolars
p Dothesame on the second loop
0.Do the same on the opposite side and complete the bilateral second horizontal loops
ROverlap the enters of both the wire and dentition, and then mark the contact points between the first and
second premolar$
BU»» cos_one
• •••
••••
The third loops are bent in the same way (the length of horizontal loop should be 70% of its
inter-bracket distance) (Fig. 9.7 $)
Overlap the centers of both the wire and dentition, and then mark the contact points of the
second premolars and first molars (Fig. 9.7T)
( The fourth loops are bent in the same way (the length of horizontal loop should be 70% of its
•
inter-bracket distance) (Fig. 9-7U). •
( Overlap the centers of both the wire and dentition, and then mark the contact points of the first •
and second molars (Fig. 9.7V)
( The fifth loops are bent in the same way (the length of horizontal loop should be 70% of its
inter-bracket distance)(Fig. 9.7 W)
( The completed form of lower MEAW (inter-loop distance should be at least 2mm, and the
distance between the fourth and fifth loops should be 3-4mm)(Fig. 9-7X)
Fig.9.7 (continued) Fabrication of lower MEAW
S. Third loops are fabricated in the same way

T 4Make sure that the second premolars and the first molars are overlapped (the centers of both the wire
and dentition and mark the contact points)
U. Fourth loops are fabricated in the same way
V.Make sure that the first and second molars are overlapped (the centers of both the wire and dentition and
mark the contact points)
W.Fifth loops are fabricated in the same way
X. Adjust the arch form: the completed lower MEAW
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�
First•, second- and third-order bends in MEAW
(D First-order bends (Fig. 9-8--10)

When the dentition is seen from an occlusal view, due to the tooth movement, it bends in
the horizontal direction, Tooth movement is motivated to match the upper passive centric
line with the lower active centric line. The lateral inset, canine eminence, and molar offset
are all included in first-order bends, To make first-order bends, the arch turret should be
used first to form an anterior arch. Here, it is important to note that the incisor torque of
both the upper and lower MEAW should be considered. Next, by considering the different
crown thickness (upper central and lateral incisors), lateral inset should be given to the
wires, and by considering the shape of lingual surfaces (lateral incisors and canines),
canine eminence should be given to the wires. Also, by considering the buccal surfaces of
the first molars, the molar offsets should be bent. Here, the pliers used for bending are
called Tweed arch forming pliers. It is notable, however, that, as in-and-out is inherently
incorporated into the KIMS bracket for individual teeth, there is no need to follow the
above procedures in the case of using KIMS bracket.
•
•
•
Fig.9-8Lower dental arch form
The notable morphological feature of the lower dental arch form is that the bu0cal cusp tip of
fist premolars and lower incisor edges are aligned with the above circle The center of this line
is connected to the mesial contact point of the first molars. Mere, the image of the dental arch is
egg-shaped (Shirasu and Sato, 2008)
8a»» cwt_foe ••••

••••
es
30
25
20
:15
···-···-·
5 • ··-· ---·
·-•.: :·_::�_.:::
··-···-· •
10 •
15--
•
15
Fig. 9-9MEAW construction guide

A. Arch form
B Tip-back activation
C Torque
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e- ",.
i
. •'
.
', I I
\r
$
i I
t t
•
c• MEAW
Fig. 9-10 Fist-order bends in ME
A Make canine ermine0e
Lower MEAW
AW
B. Make an arch form from the second loop to the final loop
'
• C. Completed upper and lower ME AW$
•
de4d+» captors_foe
••••
••••
2 Second-order bends (Fig. 9-11, 12)

The bends that are perpendicular to first-order bends are called second-order bends. These
are the bends that are seen from the lateral view, including mesio-distal and vertical tooth
movements. Here, the tip-back bends and step bends are all included, and they can all be
obtained by the adjustment of L-loop. The adjustment of L-loop is one of the most
•
fundamental operations of MEAW; the Kim pliers are used for this purpose. Tip-back •
bends can be achieved by angulating the wires from the second loop with Kim pliers. In •
contrast, step bends can be achieved by adjusting the length of the legs in the horizontal
loop with Kim pliers.
Fig.94fSecond-order bends
in MEAW
C
,-a---------
D
A kMesially tilted molars
B. Upnighted molars
C. Required tooth movement
D. Tip-back bends
.
j
cs_roe « AB
Fig.942Second-order bends in MEAW
A. Flat MEAW
B. Tip-back activation
Angulate the posterior part
about 3.5 from the second
loop to the final loop
C.Upper MEAW with tip-back

activation
• D
•
• r 6 p.Tip-back bends
e e Upper AW
ME
curve of Spee
6
1$ • Lower ME
AW
• reverse curve of Spee
BG»» cars_Fote
••••
••••
3 Third-order bends (Fig. 9-13)

The labiolingual and buecolingual inclination (torque) of a tooth are known as third-order
bends. There are two types of torque: passive torque and active torque. The passive torque
is the torque that does not change the tooth inclination. The active torque is, however, the
torque that triggers the changes in tooth inclination. Here, when fabricating the ME
AW
•
appliance, it is recommended to use the torque slot of arch turret and to form a dental shape •
by applying the torque. However, it is important to note that in ME
AW treatment, the need •
for further torque adjustment may arise during treatment procedures
Fig.913 Third-order bends

in MEAW
- A. Crown labial torque of four

maxillary incisors
8. Maxillary canines zero-
degree torque
C. Maxillary molars
progressive crown lingual
torque.
D. Mandibular molars
progressive crown lingual
torque
Two torque-controlling methods are as follows
(D Hold the distal part of the canine with the Tweed pliers, and then laterally tilt the second
loop up to $Here, in order to offer a progressive torque and to set the loop away from the
gingival tissue, the same procedure must be repeated on the third, fourth and fifth loop (Fig.
9-14)
After bringing two Tweed arch forming pliers into contact, gain torque control by twisting
the horizontal inclination in turns
By applying the torque on each tooth in this way, the L-loop is laterally angulated and free from
the impingement of the gingiva
Fig.9-14 Third-order bends in ME

AW
A. Hold the main wire with the pliers and incline the second lop
outwardly. Then, continue to incline the third, fourth and fifth loop
outwardly.
•
•
•
••
B. Check the flatness and symmetry. The loops of the completed MEA is outwardly inclined from the
gingiva
4BB»» cows_rote
••••
••••
Fig.9-14 (continued) Third-order bends in ME

AW
• •
•
cl •
C.Crown labial torque of four maxillary incisors
D]
-
D.Zero-degree torque of maxillary canines
E Progressive crown lingual torque from the maxillary premolars to the second molars
F MEAWis outwardly inclined curved from the gingiva
cars for 4ES

�
Completed MEAW (Fig. 9-15)
(/)A completed MEAW must possess a proper torque for each tooth.
(2) In order to prevent the impingement of gingiva, the MEAW should be outwardly angulated
() It must be symmetrical.
(4) It must have an ideal arch form
(5) The upper arch form should be mm wider than the lower areh form.
(6) The completed upper MEAW should have curve of Spee, and the completed lower MEAW
should have reverse curve of Spee.
•
•
•
°m"
••
Fig.9.fs Check points of the completed ME
AW
A. Coordination
B Fatness.
C. Symmetry
49G+ cos_Foe
••••
••••
�
Heat treatment for completed MEAW
A three-minute heat treatment (900'F/ 475C) is carried out on the Big Jane machine, which
increases the stiffness and resilience of the orthodontic archwires. The heat treatment turns the
•
archwires into a brown color, so it is important to polish the wires for LS seconds in an acid bath to •
make them look aesthetically better. •
Fig.9-16Heat treatment of ME AW
Heat treatment
- 900'F (475C. 3 minutes
- to increase the stiffness and the
resile nee
j Polishing in an acid bath
Cows roe lg
�Prescription of MEAW
Before prescribing the MEAW technique, the following data is needed:

(I)Lateral cephalometric radiograph,
(2Panoramic radiograph,
(3)Study models.
48 Lateral cephalometric radiograph (Fig. 9-17)
() Decide where to place the upper incisors. Thie is assessed from the distance between the UL
and the lip line. 3mm is considered as normal, but if the distance is less than 0 mm, the
extrusion of upper incisors is required, and then the Class II elastics can be used. If it is 6mm
or more, the intrusion of upper incisors is required first.
(2) Check the ideal inclination of the occlusal plane. This is the angle between the upper occlusal
plane (UOP) and the FH plane, where I0 is considered as normal.
(3) Assess the antero-posterior angulation of lower molars against the occlusal plane. This is the
angle between the posterior occlusal plane (POP) and the FH plane, where 13 is considered as
normal. Here, if possible, it is important to make sure that the lower buccal teeth form a right
angle with the occlusal plane.
Fig.9.f7 Check points in lateral

cephalometric radiograph in the finishing
stages of treatment
• 1.Position and angulation of upper incisors
• 2 Angulation of upper occlusal plane

(UoP)
• 3 Angulation of posterior occlusal plane
(POP)
49a»» cows_roe
••••
••••
�
Panoramic radiograph (Fig. 9-18)
•
•
•
Fig. 9-18Check points in panoramic radio0graph

in the finishing stages of treatment
1. Angulation and parallelism of root
2. Developmental stage of third molars.
1) Root parallelism
Tis is assessed to confirm the parallel angulation relationship of all the teeth. Here, an assessment
is made on whether to bond the bracket again or to adjust it by using finishing archwires. It is
recommended for the brackets to be bonded again, if there are two or more bracket positioning
errors per unilateral jaw, but a finishing archwire must be used for adjustments, if, however, there
is only one error per unilateral jaw. Special attention is needed in the following situations
(I) Root parallelism of the teeth adjacent to the extraction site,
(2) Aesthetic condition of the anterior teeth (artistic bends)
2) Conditions of the third molars
The correction of posterior crowding is very important in orthodontic treatment. This is considered
to be even more important, if there is insufficient posterior vertical dimension (PVDy. In a non-
extraction (of other teeth) case, a third molar extraction is essential. Also, the extraction of the
lower third molars may be required to upright the mesially tilted lower molars. In particular, if the
crown is already formed and the roots are developing in the lower third molars, it is more desirable
to extract the lower third molars in order to upright the lower molars before the finishing stages of
treatment
cs_fr 49
..
Study models (Fig. 9-19)
Fig.919Check points in study models in the finishing stages of treatment

1. Relationship of marginal ridge.
2. Ideal arch form
3. Canine relationship and overjet
4. Overbite
5. Aesthetic bends of anterior teeth
6. Difference in left and night curve of Spee
7.Torque.
)Torque of upper canines whether to increase or decrease
2) Torque difference of molars upper and lower, left and night
1) Marginal ridge relationship with adjacent teeth
The marginal ridge relationship of adjacent teeth must all be coincided. Most of the miss-matches
•
• occur due to bracket positioning errors. In order to solve this problem, the archwires should be
• adjusted in the finishing stages of treatment.
2) Ideal arch form
The correction of arch form is extremely difficult to do so in the finishing stages of treatment.
AW, the arch form can be modified to a
However, by changing individual tooth positions in ME
Ad»» cors_foe
••••
••••
certain extent. Particularly in premolar extraction cases, if there is a V-shaped (tapered) arch form,
it can be corrected by moving the posterior teeth forward by taking advantages of the extraction
space
3) Canine relationship and overjet

•
•
In order to solve the problem of canine relationship and overjet, elastics should be used. In other •
words, to improve excessive overjet and Class II relationship, Class ll elastics should be used.
Here, the action of elastics can cause the extrusion and lingual inclination of upper incisors, as well
as labial inclination of lower incisors. Therefore, to compensate for this, a crown labial torque (+7°
or +10°) should be applied to the upper anterior teeth, and a crown lingual torque (-7) to the lower
anterior teeth. In contrast, Class Ill elastics are used to correct the problems of anterior cross bite
and Class IHI relationship. The action of Class Ill elastics can cause the labial inclination of upper
incisors, and the extrusion and lingual tilting of lower incisors. Therefore, to compensate for this, a
crown lingual torque (-7) should be applied to the upper anterior teeth, and a crown labial torque
(+7°)to the lower anterior teeth
4) Overbite
In most cases, the conventional form of MEAWis used. However, if the overbite is 4 mm or more it is
more desirable to use the reverse MEAW to extrude the lower molars and to intrude the lower incisors
5) Aesthetic bends
After an orthodontic treatment, the upper and lower incisors should be in an aesthetically
acceptable condition. For this purpose, the mesio-distal angulation and the vertical height of crown
are evaluated in a model, and identified through a panoramic radiograph. If problems are still
remained, the aesthetic bends should be used
6) Discrepancy between the left and right curve of Spee in the lower model
The discrepancy between the left and right curve of Spee is one of the main contributing factors of
midline deviation, so it must be checked in the finishing stages of treatment. In particular, when the
midline deviation is found to the direction of severe curve of Spee, it is essential to upright the
molars in such areas
cars_roe «« 449S
7) Torque
(1)Upper anterior torque
The inclination of upper incisors is essential not only for aesthetic reasons, but also for the
completion of occlusion. In many extraction cases, the extrusion and excessive lingual
inclination of upper incisors are commonly observed. After a careful cephalometric analysis, if
there is a need for occlusal plane improvement and the intrusion of upper incisors, the utility
arch can be used in the finishing stages of treatment.
(2) Upper canine torque
Severe canine lingual inclination can diminish masticatory muscle activity and cause the
retrusion of mandible and condyles. Therefore, a careful evaluation must be made about this
problem. Here, if there is severe lingual inclination in the upper canines, it must be solved and
the crown labial torque should then be applied conversely. Furthermore, as midline deviation is
likely to occur due to the discrepancy of lingual inclination in the left and right upper canines,
a careful examination is also required.
(3)Upper and lower molar torque and the difference in the left and right
torques
The more posteriorly the upper and lower molars are located, the more lingually inclined they
will become progressively. This becomes more evident as it goes down to the lower molar
area. The crown of the upper second molars should be slightly more lingually inclined than that
of the upper first molars. However, here, the difference between the lingual cusps and the
buccal cusps should be no more than Imm. Also, if there is midline deviation as well as a
difference in torque between the left and right molars in the upper and lower jaws, the torque
•
• difference should, if possible, be adjusted first. Here, the upper molars in the unaffected area
• are likely to show a more severe crown lingual inclination, while the upper molars in the
affected area are likely to show a more severe crown buccal inclination. In contrast, the lower
molars in the unaffected area are likely to show a weaker crown lingual inclination (relatively
more severe crown buccal inclination), while the lower molars in the affected area are likely to
show a more severe crown lingual inclination. Therefore, if midline deviation and torque
differences in molars are apparent, individualized adjustments must be made
496»» cows_roe ••••

••••
�
MEAW prescription (Fig. 9-20)
The following is a MEAW prescription form.
•
•
•
E --
- -= --
-- -= -=- •
Fig. 9.20 MEAW prescription form.
4.... -
--9-•----��-
1) Bracket slot size (Fig. 9-21)
Check whether the bracket size is 018" slot or 022" slot. Here, it is more desirable to use the 0I
slot bracket. The archwires used in this case are 016"x 022" stainless steel archwires. If the 022"
slot bracket is used, 01"x 022" stainless steel archwires are required. However, when MEAW is
used together with the $WA appliances, additional wire adjustments may be needed.
8
Fig.921 018 slot or 022 slot
A. If the bracket size is 018 slot,
use the 016x.022 stainless steel
wires to make ME
AW
·I 8 fte bracket size is 022 slot in the

swA appliance, use the 018x
022 stainless steel archwire to
1IH make ME AW and to prevent the

impingement of gingiva in the
posterior area
cows for +« 49 7
2) Shape of MEAW
It can be classified into two categories: the standard MEAW shape and the reverse ME
AW shape
(Fig. 9-22. In many cases, the standard MEAW is used, but if there is a severe overbite or if there
is a deep overbite after space closure, the reverse MEAW is used. However, the use of the reverse
MEAW can cause molar extrusion and incisor intrusion, so it should only be used in the
mandibular arch.
Also, when there is a need for height control of individual teeth, use step-up bends to trigger
extrusion or step-down bends to trigger intrusion (Fig. 9-23).
Fig.922 Standard ME
AW and reverse MEAW
A. Standard MEAW
B. Reverse MEAW
HH
•
•
• l
Fig.9-23 Step-up bends and step-down bends
A. Step-up bends
Bracket re-bonding or wire bending is required for tooth extrusion. ere, the bends that
trigger the extrusion are called the step-up bends
B. Step-down bends
Bracket re-bonding or wire bending is required for tooth intrusion. Here, the bends that
trigger the intrusion are called the step-down bends
4doe»» caters_Fote d«
••••
3) Condition of malocclusion
lt is important to distinguish whether it is Class I, Il or Ill malocclusion.

In the case of Class I or Class II malocclusion, Class ll elastics can be used for finishing. Here, the
action of Class II elastics can cause the extrusion and lingual inclination of upper incisors, and
•
labial inclination of lower incisors. Therefore, to compensate for this, a crown lingual torque t.7° •
should be applied to the lower incisors, while a crown labial torque t+7° « +10°) should be •
applied to the upper incisors (Fig. 9-24)
In the case of Class Ill malocclusion, Class Ill elastics can be used for finishing. Here, the action of
Class Ill elastics can cause the labial inclination of upper incisors and the extrusion and lingual
inclination of lower incisors. Therefore, to compensate for this, a crown labial torque (+7°) should be
applied to the lower incisors, while a crown lingual torque (7°) to the upper incisors (Fig. 9-25)
... �.
. .. I
+
-
..
».
Fig.9.24 Torque in Class ll case
A When Class ll elastics are used, extrusion and lingual inclination can occur in the upper
anterior teeth, and intrusion and labial inclination can occur in the lower anterior teeth
T0compensate for this,a crown labial torque should be applied to the upper incisors, while a
crown lingual torque to the lower incisors in AME AW
Fig.9.25 Torque in Class IHI case

A If(lass Ill elastics are used, intrusion and labial inclination can occur in the upper anterior
teeth, and extrusion and lingual inclination can occur in the lower anterior teeth
B To compensate for this, a crown lingual torque should be applied to the upper incisors, while
a crown labial torque to the lower incisors in ME
AW
cows_fawn « 4Joe
Es»ae +as«mt tweAw
In general, the shape of MEAW should be able to maintain its ideal dental arch form. Therefore,
the first-order bends should be applied properly, and the lingual surfaces should coincide with each
other in the anterior area, while the mandibular active centric line and the maxillary passive centric
line should be matched. For this purpose, additional wire adjustments may be needed. Then, a
gradual crown lingual torque should be applied to all the teeth behind the canines. Here, due to the
properly applied posterior torque, the loop becomes outwardly angulated as it goes down to the
posterior teeth. In other words, it is adjusting the third-order bends. Then, adjust the second-order
bends and modify the arch form at the end.
1) Tip-back activation (Fig. 9-26)
Tip-back activation is applied from the second loop of MEAW. After holding the second loop with
Kim pliers, bend the posterior leg of archwire 3.5 posteriorly, and bend the rest of the loops in the
same way. By doing so, the lower MEAW will achieve the shape of a reverse curve of Spee, while
the upper MEAW will achieve the shape of a curve of Spee (refer to Fig. 9-12). Here, it is possible
to gain LS mm in space due to the S tip-back activation. Therefore, in a non- extraction treatment
case, four out of fie loops can obtain 20 tip-back activation, thereby securing 6mm in space. In
contrast, in an extraction treatment case, due to three out of four loops, 4.5mm space can be
secured. Here, the degree of activation is determined by checking the amount of anterior
angulation of lower molars after the proper overbite and overjet are established by moving the
mandible forward.
•
•
•
• •••
••••
A A
I5men
I st
.. I No-ere
0a
feeeol
er cad
•
•
3 12 036mm4 9(27mm
5
'
l 20 (6nm 15 445mm •
Fig. 9.26 Tip-back activation
1 After moving the mandible to the normal overbite and overjet relationship, check the posterior
disclusion and freeway space, and then determine the amount of activation
2. Do not activate more than 3-5 per tooth
3. In the case of deep curve of Spee, use the reverse MEAW first (instead of the standard MEAW), and
then apply the tip-back activation
A. MEAW with tip-back activation
B.15mm of space is gained by the 5 tip-back activation
C Expected space for nor-extraction cases and extraction cases
2) Tip-back deactivation (Flat MEAW) (Fig. 9-27)
This is the initial MEAW shape. This is also used to correct the bite in the case of Class Ill
malocclusion and open bite. The upper curve of Spee shape and the lower reverse curve of Spee
shape, created by the tip-back activation, should be changed into flat MEAW, In these cases,
anterior vertical elastics (3/16" 6oz) are used generatt
' ' • 2
El
Fig.9.27Tip-back deactivation Flat ME

AW
Hold the MEAin the same way as for the tip-back activation Then, remove the tip-back activation from
AW
the second loop to the last loop to flatten the ME
0cs for «So]

3) Step-up bends (Fig. 9-28)
This is used when there is a marginal ridge discrepancy. Here, the marginal ridge relationship can
be corrected by extruding the relevant tooth. When a tooth is extruded, a crown lingual torque
occurs due to the bonded bracket. For this reason, in extruding the teeth, additional crown buccal
torque should be applied carefully after considering this point.
• •
«p
U t
Fig. 928 Step-up bends for extrusion
Extrusion of teeth can result in linguoversion of crown in both jaws Therefore, in using the step-up
bends, it is essential to decrease the additional crown lingual torque
4) Step-down bends (Fig. 9-29)
This is used to correct the extrusion of tooth. When a tooth is intruded, a crown buccal torque
occurs due to the bonded bracket. For this reason, in intruding the teeth, additional crown lingual
torque should be applied by considering this point.
•
•
•
Fig. 929 Step-down bends for intrusion

Intrusion of maxillary and mandibular teeth can result in labioversion of crown
step-down bends, an additional crown lingual torque should be further applied
50»» cows_roar ••••

••••
5) Curve of Spee (COS) MEAW (Fig. 9-30)
When there is Class Ill malocclusion and open bite, the tip-back activation is carried out for the
posterior angulation of the lateral teeth to make Class I occlusion. After this is completed, the COS
MEAW is used. Unlike in tip-back activation, the curve of Spee is given to this MEAW, and is
•
applied only to the lower first and second molar areas. Such a MEAW shape is only used to treat
•
the open bite or Class HI malocclusion, along with anterior vertical elastics (3/16 602) •
Fig. 930COS MEAW: as the wire mesially angulates the lower molars, the COS MEAW should only
be used when the premolar occlusion is well established
Condition of molars before treatment red lie
Distal tilting and uprighting by tip-back activation blue line
Normal angulation achieved by COS MCAW: black line
6) Progressive step-up (PSU) MEAW (Fig. 9-31)
When a non-surgical treatment method is used to treat Class Ill malocclusion, Class [ll elastics are
used, but arguably this can increase the risk of fat smile are in the anterior areg. Therefore, to
compensate for this, it is necessary to apply progressive step-up bends to the upper incisors, as
shown in the figure below. This is P'SU MEAW and should only be used after the Class I canine
relationship is established. P'SU MEAW is used together with anterior vertical elasties (3/16" 602)
r%
Fig.9.31 PSU MEAW
Upper ME AW with tip-back bends can cause labioversion of incisors and an unaesthetic outcome. Here,
after deactivating the tip-back, flat MEAW should be inserted, and then SU ME AW should be used with
anterior vertical elastics (AVE) to trigger the extrusion of upper incisors fora better aesthetic outcome
■ Basic adjustment of MEAW
The main characteristics of MEAW appliances are as follows. First, the horizontal components of
loops can reduce the load deflection rate of wires and provide a continuous light force. Also, the
vertical loops can function as a breaker between the teeth and facilitate individual tooth movement.
In other words, by adjusting tip-back bends, step bends or torque, tooth movement can be
delicately controlled with the use of rectangular wires. In addition, as all the teeth move
simultaneously, all the combined bends can work effectively, and the treatment goal can be
achieved in a relatively shorter period of time.
(I) Step-up bends, step-down bends

The main purpose of step bends is to correct the marginal ridge discrepancy in the molar area
and to make a more aesthetic relationship in the incisor area. An extrusive bend is generally
called a step-up bend, and an intrusive bend is called a step-down bend. It is desirable to mark
the adjustment points on the model in the initial phase of MEAW fabrication, but it can also be
adjusted during treatment
Here, as the crowns of premolars and molars are likely to be more lingually inclined by the
step-up bends, the application of compensatory torque is required
(2) Second-order bends (tip-back bends)

le MEAW, a continuous tip-back bends is applied. Due to this feature, the entire dentition can
be uprighted simultaneously. Also, the molar interference can be removed by the curve
mechanics that is made by tip-back bends and AVEs. Here it is important to note that Kim
pliers can also be used to give the tip-back bends from the premolars to the molars.
(3) Third-order bends (torque)

In order to establish a functional occlusion, an appropriate tooth guidance that harmonizes the
condylar path is required for individual teeth. Therefore, a torque should be applied for the
•
• purpose of appropriate guidance, and should be carried out to compensate for the inclination of
• tooth that arises from the second-order bends. Finally, by appropriately lifting the loops from
the posterior gingiva, it can prevent the impingement.
504»» cows_rotes
••••
••••
The torque that labially or buccally angulates the crown is called crown labial torque, and the
torque that lingually angulates the crown is known as crown lingual torque
()Using Class Il elastics: apply a crown labial torque to the upper incisors and a crown
lingual torque to the lower incisors
(2)Using Class [ll elasties: apply a crown lingual torque to the upper incisors and a crown
•
labial torque to the lower incisors. •
()As the premolars and molars are likely to be more lingually inclined through the use of •
step-up bends, an additional crown labial torque should be applied as a form of
compensation,
Extra caution is needed when torqueing the following teeth

(l)Upper canines When there is an excessive upper canine torque, there is also likely to be a
Class II malocclusion that restricts the mandibular growth. In this case, the torque of zero.
degree or even(+) 7 gould be applied to the upper canines. By doing so, this can provide
a clearance with the lower canines and facilitate the free mandibular movement
(2) The bilateral symmetry of torque between the upper left and right canines.
()Apply an appropriate amount of crown lingual torque to the upper premolars.
(4) The bilateral symmetry of torque between the upper left and right first molars.
(5)A gradual increase in crown lingual torque as it gets closer to the upper second molars
(6) Intercoronal opening angle (I0A) between the upper and lower canines (Fig. 9-32)
(7)4 gradual increase in crown lingual torque as it gets closer to the lower molars.
(8)Nor-excessive crown lingual torque of lower molars.
Fig. 9.32 lntercoronal opening angle (I0A)

A. This is the angle between the lingual surfaces of maxillary incisors/ canines and the labial surfaces of
mandibular incisors/ canines. tis usually 4T
8 When the angle is decreased, the forward movement of mandible is restricted and thereby the
mandible is further retruded.
C\When seen from the frontal view,a difference in intercoronal opening angle between the canines is
apparent
cows re +«SC
The following table summarizes the average amounts of torque prescribed (Table. 9-1):
Table. 9.f General torque prescription

In the case of Class I, Il elastics In the case of Class Ill elastics
Upper arch
+7
Corn ding teeth
' 1.2
Lower arch
•
Upper arch
7
Cor
' 1.2gee Loesch
+7
0
-10
3
4,5
•
-15
0
-10
3
45
7
-15
-15 6,7 -20 -15 6.7 -20
Oadjustment
sequence of MEAW is as follows:
1) Make an ideal arch form.
2) Apply torque to individual teeth.
3) Check the ideal arch form again.
4) Apply the tip-back bends from the second loop
5) Check the ideal arch form. bbbb)
•
•
•
• •••
••••
@ Elastics in MEAW
� •
Purposes •
•
I) Uprighting of the dentition
2) Establishment of interdigitation
3) Control of tooth axis
4) Control of cant of occlusal plane.
5) Control of vertical dimension
6) En-masse movement of entire dentition
lo»..
1) Position
(1) Long elastics (Fig. 9-33)
These are the elastics that are used from the anterior area to the first or second molars in the
opposite arch. Due to the vector components of force, a stronger horizontal force can (when
compared with the vertical force) be applied. However, the vertical force here can trigger
molar extrusion. Therefore, it should not be used in high angle cases, but should only be
selectively used in low angle cases.
cows_for «« SO7
Extrusion + distal
'----'---
Clockwise rotation
Steepening
Fig.9.33Long Class l elastics.

Long Class ll elastics are used from the upper canine area to the lower molar area, and tniggers
the forward movement and the extrusion of lower posterior teeth
The clockwise rotation of occlusal plane and the steepening of the posterior occlusal plane
(POP) can occur
5/16 6oz (for the mandibular second molar) and 1/4 6oz (tor the mandibular first mnolar) are
used
Ossible
compllcalions In the use of long elastics
1) Molar extrusion: the lower molars may get extruded when the Class ll elastics are
used and the upper molars may get extruded when the Class Ill elastics are
used.
2) Mandibular opening movement: this takes place more often, especially when the
CF value is low and there is a vertical growth pattern.
3) Excessive change in the occlusal plane

4) Increased possibility of dual bite.
5) Overloaded temporomandibular joint (TMD)
•
•
•
• •••
••••
(2) Short elastics (Fig. 9-34)
These are the elastics that are used from the anterior area to the first or second premolars in the
opposite arch. Due to the vector components of force a stronger vertical force (when compared
with the horizontal force) is applied The vertical force causes the premolar
•
extrusion, thereby flattening the curve of Spee. Here, when Class II elastics are used, the tip-
•
back activation of lower ME AW can trigger molar uprighting and intrusion, and easy •
protraction of lower dentition. In contrast, when continuous archrwires are used, the effects of
molar uprighting and extrusion are weak, so in high angle cases, short elastics must be used
The effects of long and short elastics are as shown below (Table. 9-2)
f long elastics are used when the MEAW appliances are applied both to the upper and
lower arch, it can cause the mesial rotation of terminal molars. Therefore, in such cases,
only short elastics should be used (Fig. 9-35)
Fig. 9-34 Short elastics.

Short Class ll elastics are the elastics that are used from the upper canine area to the lower
premolar area This can trigger the forward movement and extrusion of lower premolars
Due to the AME
AW effect, there may be a forward movement and a minor intrusion of lower
molars
3/16 6oz elastics are used
Table. 92Long Class ll elastics and short Class ll elastics
Long elastics Shot elates

1kManacre ideal AW MAW
- -
2Skeletal petter oh CF Low CF/Hg OF
3Dorabole tooth movement
1)0olusai plane Norma4Poe Steep POP
Antenor-pose0or movement More eecte
3Vertical moron
-f gore etctve
- 4)hiduai tooth movoront Moreeecve
-
cows_row « SO9
Fig. 9-3 Problems in using long elastics in the upper and lower MEAWs
The use of long elastics may aggravate the mesial rotation and extrusion of terminal molars
Therefore, it is important to use short elastics in both the upper and lower AEAWg
(3) Inter-maxillary elastics
These elastics are used in between the opposing dental arches to improve the antero-posterior,
transverse, and vertical relationships. Class II, Class III, or cross bite elastics are the examples
of this.
(4) Intra-maxillary elastics
These elastics are used in the same dental arch. For example, the Class I
elastics are used to close space with a sliding mechanism
(5) Box elastics
These rectangular-shaped elastics are used for tooth extrusion, 1/4" 6oz is the main tool in such
elastics. This is used to improve the interdigitation in the final stages of treatment
•
•
•
S1(»»cows_foneg
••••
••••
(6) Triangular elastics (Fig. 9-36)
These triangular-shaped elastics are used for tooth extrusion. 1/4" 6a is the main tool in such
elastics.
The triangle apex brings about more tooth extrusion, which makes it more effective for
•
leveling the curve of Spee. •
•
Fig.9.36 Triangular elastics

Elastics used for more tight occlusion in
the premolar area
1/46o elastics are used
2) Purposes
(1) Class l elastics (Fig. 9-37)
These elastics are used within the same dental areh. For example, when closing the extraction
space with through a sliding mechanism, the elastics are used from the canines or from the
anterior hook or loop to the first molars (1/4" 6oz) or second molars (5/16" 60)
Fig.9.37Class l elastics
Class !elastics can cause the retraction of
anterior teeth and the protraction of
posterior teeth. As a result, the extraction
$pace is closed and there are no changes
in the occlusal plane
cw_for ««]]
(2) Anterior vertical elastics (AVE) (Fig. 9-38)
These elastics are used in open bite cases. Here, in order to extrude the incisors and improve
the occlusal plane, the elastics must be placed in between the first loops of both the upper and
AW, The elastics used are known as 3/16 60
lower ME
» Fig.9-38 AVE
A Due to the tip-back bends, the upper AME AW forms the curve of Spee and the lower AME AW
forms the reverse curve of Spee such a formation can aggravate the anterior open bite
When the elastics are used on anterior teeth 1) the extrusion of upper and lower anterior
teeth may occur, and 2) distalization and intrusion may occur in the posterior teeth
C Intraoral photograph of AVE in use.
D. Diagram of teeth movement after using AVE
•
•
•
S1»»cows rote
••••
••••
(3) Class II elastics (Fig. 9-39)
These inter-maxillary elastics are used unilaterally or bilaterally from the anterior area of upper
arch to the posterior area of lower arch (e.g. from the upper canines to the lower first molars).
It is used to improve the Class l relationship and decrease overjet. Class l elastics can trigger%
a vertical and transverse force as well as an antero-posterior force.
•
s -
--�------------� p ....__
- I
Fig.9.39Class ll elastics
A. Class ll elastics triggers a postenior and lingual movement of upper incisors and extrusion
and forward movement of lower teeth. As a result, the Class fl canine relationship is
improved.
+ tn particular, ME
AW can cause an effective posterior movement of upper dentition
on the lower ME
Also, by using tip-back bends AW, the extrusion of lower molars can be
prevented
B. ntraoral photograph of Class ll elastics in use
cows_few + 513
(4) Class Ill elastics (Fig. 9-40)
These inter-maxillary elastics are used unilaterally or bilaterally from the anterior area of lower
areh to the posterior area of the upper arch (e.g. from the lower canines to the upper first
molars). They are used to improve Class Ill relationship, to protract upper molars, and to
increase incisor overjet. These Class Ill elastics can trigger a vertical and transverse force as
well as an antero-posterior force
Fig. 940 Class Ill elastics.

A. Class Ill elastics triggers a posterior and lingual movement of lower incisors and extrusion
and forward movement of upper teeth. As a result, the canine relationship and overjet are
improved
+ Aw can lead to an effective posterior movement of lower dentition. Also,
in particular, ME
by using tip-back bends on the upper AME AW, the extrusion of upper molars can be
prevented
B. intraoral photograph of Class Ill elastics in use
•
•
•
S14+»»Corson
••••
••••
(5) Cross bite elastics (Fig. 9-41)
These elastics are used when there is cross bite. Since these elastics can cause an undesirable
bucco-lingual inclination of individual teeth and aggravate malocclusion, one should be extra
cautious when using them.
•
•
•
Fig. 9.4fCross bite elastics

A. In most unilateral posterior cross bite cases, the upper posterior teeth in the affeded side
tend to show crown buccal inclination and the lower posterior teeth in the affeded side tend
to show crown lingual inclination
B. in this case, cross bite elastics should be used to increase the crown labial torque of upper
molars and the crown lingual torque of lower molars This can solve posterior cross bite
problems, but it can also bring about problems of midlie and occlursal changes
cos fr « 515
3) Types of elastics (Fig. 9-42)
(1) 3/16" 60z
This is the main elastic tool. Here, shont elastics or anterior vertical elastics are used in most
cases.
(2) 1/4" 60z
This is used when applying the elastics from the upper or lower incisor area to the first molar
area. Here, to raise the tight interdigitation, box elastics or triangular elastics should be used.
(3) 5/16" 60z
This is used when applying long elastics from the upper or lower incisor area to the upper or
lower second molar area. Here, the opposing teeth can extrude, so it is important to be extra
careful when using these elastics.
••
•
•
•
0»
Fig.942 Type and site of the elastics

A. 3/16 602z
C.5/16 6oz
516»»cows_rote ••••
••••
4) Procedures of using the elastics
()First, the elastics should be applied in the direction that can improve Class I canine
relationship. All the midlines should also be matched. Here, it is not desirable to hang the
elastics diagonally from the midline (Fig. 9-43 A). Instead, it is more desirable to hang short
•
Class II or shont Class Ill elastics after carefully examining the skeletal pattern. In particular, in •
areas where Class I canine relationships are established, shorter elastics should be used. •
(2) The elastics should be applied in the direction of improving the antero-posterior relationship
and the canine relationship
(3) After establishing a Class I canine relationship, the elastics are used to improve the vertical
relationship. Here, in an open-bite case, an AVE must be used, while in a deep bite case, a
triangular elastic must be used in the premolar area to trigger molar extrusion.
Fig. 9.4344£AW adjustment of a patient who has midline deviation

Alf the elastics are used as the above figure demonstrates, even if the dental midlie is matched, the
facial and occlusal plane asymmetry are aggravated
B in the affected side, the vertical dimension (VD) decreases and the crown bucal inclination of
maxillary teeth increases To overcome this problem, the affected side of VD should be increased and
more crown lingual torque should be applied to the affected upper molars
Upper night side step-up bends for extrusion and more crown lingual torque
Lower night side step-up bends for extrusion and less crown lingual torque
caws_foe « S17
5) Precautions
(I) Elastics must be worn all day, except for eating times and when brushing teeth. Tooth brushing
after eating is the main responsibility of a patient. To remove the food particles that are stuck in
the loop at buccal segments, the use of a water-pick appliance is recommended
AW and elastics, the whole dentition begins to move, and the
(2) About 6 hours after using ME
patient begins to feel tenderness around the teeth. The intensity increases for about 18 hours
and then wears off, If the elastics are wom all day as indicated, tenderness does not reoccur.
However, if the elastics are worn intermittently, the tenderness continues. Therefore, it is
important to explain the action of MEAW and its relationship to the elastics. It is also better to
notify the patients how such tenderness is related to the overall outcome. Here, it is important
to note that the patients' comfort levels and success of treatment are proportional to their level
of cooperation
6) Points to be checked in the finishing stage
(I)Cheek whether the elastics have been worn or not. If the elastics have been used in MEAW, it
is necessary to inform the patients that the remaining treatment will take about -6 months.
(2) The state of oral hygiene should be checked
(3) Premature contact is checked. In MEAW, as the entire dentition (not only the individual teeth)
is moved at once, there is a great risk of premature contact between the teeth and the
orthodontic appliances. Therefore, tooth mobility must always be checked in the final stages of
treatment, If mobility is detected, an occlusal equilibration should be conducted, or the affected
teeth must be ligated with a figure of 8 tie.
•
•
•
51[»»cows_Fote
••••
••••
rn Finishing Methods for Special Conditions
'b MEAW adjustment for midline correction (Fig. 9-43, 44)

•
•
•
f there is a midline deviation, it is extremely important to find the cause of it. To correct this, a
three-dimensional movement of both upper and lower teeth is required, and all of the first-,
second-, and third-order bends should be adjusted. It is notable that most causes of midline
deviation are found in the decrease of vertical dimension and the steep POP of the affected side.
Here, step-up bends for tooth extrusion should be applied to correct the midline deviation, and this
must be applied on both the upper and lower arch. In contrast, tip-back activation should only be
applied to the unaffected side, and the elastics should be used for the purpose of correcting the
canine relationship. In the upper molar area, severe crown buccal inclination on the affected side
and severe crown lingual inclination on the unaffected side are observed. Similarly, in the lower
molar area, severe crown lingual inclination on the affected side and severe crown buccal
inclination on the unaffected side are observed. To conclude, if there is a midline deviation, the
adjustment of second- and third-order bends is required on individual teeth, in which the ME
AW
plays an essential role. The use of MEAW is absolutely necessary.
•
•
•
Fi.9.44 AM£AW adjustment ofa patient who has a midline deviation

A. Pre-treatment intraoral photographs
B. Mid-treatment intraoral photographs
C Post-treatment intraoral photographs
D Ooclusal view of the maxilla before and after the orthodontic treatment
5a0»» cows_rows
••••
••••
-'\;S'lnlcal
Tips: Using MEAW for the correction of midline deviation
1. Upper and lower MEAW with tip-back activation (bilateral symmetry) + Elastics
2 More tip-back activation in deep curve of Spee side + Elastics
3.A case where there is a midline deviation, despite having flattened both the left
•
and right curve of Spee
•
1)Affected side: step-up bends (upper molars with more crown lingual torque •
and lower molars with more root lingual torque)
2) Unaffected side: tip-back bends (upper molars with more root lingual torque
and lower molars with more crown lingual torque)
and elastics bb)bl
�
Expansion archwires in MEAW (Fig. 9-45-47)
In the case of posterior cross bite, even if the arch has been expanded, it is common to find
posterior cross bite again in the finishing stages of orthodontic treatment. In this case, additional
arch expansion can be carried out, by using ME
AW and an expansion archwire made of 0.7mm
stainless steel archwire. Here, in ME AW, it is more desirable to excessively apply the lingual
torque (20°) to the upper molars. Also, this can be used again in a Class [l extraction case, if there
is a lingual inclination in the lower premolar area.
Fig.9.d5Fabrication of expansion archwire
A.The bird beak pliers should be used to bend the end of the 0.7mm wire with a length of 2mm. This hook
ls hung to the main archwire at the mesial side of the upper fest molar Make sure that the open side of
the hook faces the occlusal side
B. Bend the wire to form a night angle with the hook
cows_row « Sal
Fig. 945 (continued) Fabrication of expansion archwire
C. Mark the contact point of the upper central incisors (1men shorter to
the contact point)
D. Use the bird beak pliers to bend an open type loop of 3mm height
E Bend the opposite side until the initial wire is straightened
•
•
•
FL/sea measuring tape to mark the distance from the upper central incisor contact to the mesial side of the
upper night fest molar bracket.
G.Bend the hook 2mm to hang it onto the main archwire
H. Polish the sharp ends
52a»» coos foe

••••
••••
Fig.9.d6 Activation of expansion archwire
•
•
•
''L J
A. Ligate after curving the archwire 30' outwardly and bilaterally
B. Place the hook on the main archwire and use the Weingart pliers 1) to tighten it, and 2) to minimize the
risk of it coming off.
C Ligate it with the ligature wires
,,._
I • -
,
4' 24
-, 'i
�
• ' .. •
A
f .: ' '
I
' .
-
• > ••
-~ �-
D Expansion archwire in use

E Intraoral photographs of the expansion archwires on
Fig. 9.47 Application of expansion archwires
A. Posterior cross bite
B. Narrow upper inter-canine width and excessive lingual inclination of the maxillary canines
C»
C. Midline deviation caused by the torque difference of maxillary canines and molars
•
•
•
D Severe crown lingual inclination of the lower premolars and molars
50»» caws_one
••••
••••
4t) MEAW adjustments in the case of peg lateralis (Fig. 9-48)

ln cases where the upper lateral incisors are small, the size-up of lateral incisors may be required
AW should first be used for the distal movement of entire dentition to
In this case, the upper ME
•
make the Class I canine relationship as close as possible. Then, it is necessary to replace the wire •
with a 016" stainless steel archwire, and to insert the open coil springs in the mesial and distal •
sides of lateral incisors (when activating, the length of each spring must be about half of the
bracket width). Then, hang the elastics from the upper canines to the lower ME
AW to adjust
occlusion before carrying out prosthodontic treatment on small lateral incisors.
Fig. 948 MEAW adjustment in the case of peg lateralis

A. Pre-, mid-, and post-treatment intraoral photograph of a Class ll malocclusion patient If the lateral
incisors are left untreated, the mesial tilting of canines is highly likely to cause a Class ll canine
relationship. Therefore, the size-up of lateral incisors is necessary
B. Pre-, mid-, and post-treatment intraoral photograph of a Class Ill malocclusion patient in closing the
incisor space, the upper anterior arch length may decrease to cause the relapse of cross bite and
traumatic occlusion between anterior teeth Therefore, the size-up of lateral incisor is necessary
fj Orthodontic Normal Occlusion
._,
Management of occlusal plane (Fig. 9-49)
(I) Match the bisected occlusal plane (BOP) with the posterior occlusal plane (POP),
Bisected occlusal plane (BOP a line connecting the point that bisects the incisal overbite
to the point at the first molar area
Posterior occlusal plane (Pop a line connecting the cusp tip of the lower second premolar
to the disto-buccal cusp tip of the lower second molar.
(2) The lower molars and premolars should be uprighted against this occlusal plane
(3) Later, the anterior component of fore can stabilize the occlusal plane by angulating the teeth
in the anterior direction.
(4) Here, as the occlusal force is vertically applied to the long axis of the tooth, no excessive force
s applied to the tooth
Fig.949 Management of occlusal plane
'
0 [\
r
,,- I
A Relationship between BO and POP
• I)
- ,_
• I)/
• •
526»» cwtees row

••••
••••
Fig.9-49 (continued) Management of occlusal plane
•
8 Pre.treatment intraoral photographs and lateral cephalometric •
radiograph •
C. Post-treatment intraoral photographs and lateral cephalometric

radiograph
cows_row « 5S7
'49 Occlusal contacts (Fig. 9-50)
(D) Both the upper and lower canines must have a Class I canine relationship. This means that the
premolars also come to form a Class I relationship.
(2) When extracting the upper premolars only, the molars must have a Class I relationship
However, in other cases, they must have a Class I molar relationship
Fig. 9.50 Occlusal contacts.

�
A. Class I canine relationship and Class ll molar relationship when only the upper premolars are extracted
A1 Pre-treatment intraoral photographs
A2. Post-treatment intraoral photographs
91
•
•
B-1 re-treatment intraoral photographs
528»» cos roe

••••
••••
Fig. 950 (continued) Occlusal contacts
•
•
•
' ) •
8-2
.# 7 l
[[I
I .I
I
B-2The conditions of a set-up model after extracting the upper first premolars, the lower left second
premolar, and the lower night lateral incisor Here, it is possible to see Class I canine and molar
relationship
B-3. Post-treatment intraoral photographs
cows roe +« 5a9

48 Correct marginal relationship, contact points, and crown length
(Fig. 9-51)
(I)No marginal discrepancy: the marginal ridge relationships between the adjacent teeth must be
identical
(2) Proper crown length: the teeth (especially the upper central incisors) should have an
appropriate tooth length. Aesthetically, the ideal upper central incisor length is about IOmm.
However, when treating a patient whose upper central incisors are worn out, the following
points must be checked:
[) Whether to finish the treatment as its current condition.
2) Whether to perform a crown lengthening surgery
3) Whether to carry out an aesthetic prosthodontic treatment after intruding the upper incisors.
•
•
•
Fig. 9.5f Correct the marginal ridge relationships, contact points and crown length
A Pre.treatment facial and intraoral photographs
50»» cw_Fane
••••
••••
'b Favorable alignment (Fig. 9-52)
(I) Rotation control: there should be no rotation and crowding.

(2) Space closure: there should be no space between the adjacent teeth
•
•
•
Fig.952Favorable alignment
A Non-extraction case with
fine alignment
A1.Pre-treatment intra0ral
photographs
A.2Post-treatment intraoral
photographs
8 eemolar extraction case
with fine alignment
Bf.Pre-treatment intraoral
photographs
B-2. Post-treatment intraoral
photographs
cows roe « 531

48 Adequate tooth inclination (Fig. 9-53)
1) Anterior tooth inclination
(1) Upper anterior teeth
Te upper incisors should have an appropriate inclination in relation to the facial profile and
upper occlusal plane. In particular, in premolar extraction cases, there should be no loss in
anterior crown labial torque due to the excessive hinguoversion of incisors. In contrast, in non-
extraction cases, there should not be an excessive crown labial torque due to the labioversion
of incisors
Fig.9.53 Adequate tooth inclination
•
•
•
A. Non-extraction case with adequate anterior teeth inclination

A.1 Pre.treatment facial and intraoral photographs
A2 Post-treatment facial and intraoral photographs
5a»» cs_roan
••••
••••
•
(2) Upper canines •
•
The excessive lingual inclination of upper canines can establish a canine guidance occlusion,
but it is important to bear in mind that it can also cause condylar and mandibular retrusion.
Therefore, it is necessary to check the symmetry of both the upper left and right canine torques.
lt is essential not to make the lingual inclination of upper canines excessive
Fig.953(continued) Adequate tooth inclination
8 Premolar extraction case with adequate anterior teeth inclination

B-1. Pre-treatment facial and intraoral photographs
B.2 Post-treatment facial and intraoral photographs
cows roe « 533

2) Posterior tooth inclination
(1) Progressive crown lingual inclination
The lingual crown inclination of both the upper and lower molars progressively increases from
the premolars to the second molars. This is represented as the curve of Wilson. Here, the lower
molars have a slightly larger lingual crown inclination than the upper molars, but the height
difference between the occlusal plane and the lingual cusps of lower molars should not exceed
mm. If there is a difference of more than 2mm, not only is the forward growth of the
mandible limited, but also the occlusal interference in lateral movement is likely to increase
due to the extrusion of upper lingual cusps.
(2) Symmetrical posterior torque
The bilateral symmetry of molars is important. Asymmetry can cause a midline deviation and
pose some difficulties in finishing procedures. Here, the lingual crown inclination gets
aggravated in the unaffected upper molar area, while the buccal crown inclination gets
aggravated in the affected upper molar area. Therefore, it is extremely important to check the
bilateral symmetry of molars first. Reversely, the lingual crown inclination gets aggravated in
the affected lower molar area, while the buccal crown inclination gets aggravated in the
unaffected lower molar area. Therefore, in the finishing stages of treatment, it is important to
make the left and right posterior torques as symmetrical as possible
•
•
•
53»» cos_roe
••••
••••
�
Overcorrection of overbite and overjet
1) Overcorrection of overbite (Fig, 9-54 A)
•
If there is a deep overbite, attempts must be made to gain an edge-to-edge occlusion. In contrast, if •
there is an open bite, the overcorrection should be performed until the upper incisor edges come •
into contact with the lower incisor brackets
Fig. 954 Overcorrection of overbite and overjet
., ,4!..
�
' \
"
h ./
- • t
••
"vw •
-- .
-
.
.,
·'l', ! a
«
•
A. Treatment of open bite case
A.1 pee.treatment intraoral photographs
2. Post-treatment intraoral photographs
A3. Post-retention intraoral photographs (3 years and 10 months after the treatment)
cows_ow +S35
2) Overcorrection of overjet (Fig. 9-54 B)
fthere is a severe overjet in Class ll malocclusion, attempts must be made to gain an edge-to-edge
bite. In a Class Ill case, the overcorrection should be performed until the upper incisors come into
contact with the lower incisor brackets.
Fig.9.54 (continued) Overcorrection of overbite and overjet
8. Treatment of deep bite and Class ll malocclusion case

• B-ft.Pre-treatment intraoral photographs
• B-2.Post-treatment intraoral photographs
• B-3. Post-retention intraoral photographs (1 year and month after the treatment').
56+» cows_Foe
••••
••••
'b Root paralleHsm (Fig. 9-55)
After treatment, all the teeth and roots should be parallel to one another. In particular, in the case of
adults, if the adjacent roots are too closely positioned, a periodontal damage is likely to occur
•
when performing a restorative treatment later on. Therefore, in the finishing stages of treatment, a
•
panoramic radiograph must be taken to check root parallelism. If the brackets are bonded •
incorrectly, the re-bonding or adjustment of finishing archwires should be performed
Fig. 9.55 Root paraleligm

A. Adequate root parallelism
8 inadequate root parallelism
cw9_fr«+ 537
cynical Tips: The condition for making finishing easier
1.If possible, move the teeth while maintaining the Class I canine relationship.
1) Retract the upper canines first.
2) Prevent an excessive lingual movement of lower incisors
2 There should be no rotation
1) Precise bracket positioning is essential
2) Correction of tooth size discrepancy must be made.
3. Avoid the bite from deepening.
The curve of Spee must be 2mm or less
4. The space should be 1mm or less
5 There should be no bad oral habits
The control of mouth opening and tongue thrusting is required. JJ
•
•
•
58+» or roe ••••

••••
REFERENCES
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321, 1987.
Mult Edgewise
34. Kim YH. Treatment of anterior openbite and deep overbite malocclusions with loop
Arch-Wire(MEAW) therapy. The enigma of the vertical dimension, JA McNamara, Craniofacial
• Arbor 2000.
• 35. Kim Y4 Treatment of severe openbite malocclusion without surgical intervention. Growth
• modification What works, what doesn't, and why. JA McNamara, Craniofacial Growth Series 35,
Center for human Growth and Development, The University of Michigan. Ann Abot, 1999
36. Kolich VG, and Kolich VO. Interrelationship of orthodontics with periodontics and restorative
dentistry. In Nanda R, ed. Bi0mechanics and Esthetic Strategies in Clinical Orthodontics
Philadelphia Elsevier/Saunders, 2005.
[»» cos_foe
• •••
••••
37 Lee JH, and Nahm DS. Mechanical analysis on the shape memory wire. Korea J Orthod 24739-758,
1994
38. Lee YK, and Chang YI The load deflection rate of multiloop edgewise arch-wire. J Dent College SNU
16.195-218
39. Merrifield LL. and Cross JJ. Directional force. Am J Orth0d 57435, 1970
40. Merrifield LL. The systems of directional force. J Charles H Tweed int Found 10.15, 1982 •
Othman S, and Harradine N. Tooth size discrepancies in an orthodontic population. Angle Orthod
•
41
77668-674, 2007.
•
42. Peck H, and Peck S. An index for assessing tooth shape deviations as applied to the mandibular
incisors. Am J Orthod 61.384-401, 1972
43. Proffit WR. Contemporary orthodontics. St Louis CV Mosby company, 1986
44. Ricketts RW, Bench RW, Gugino CF, Hilgers 4J, and Schulhof RJ. Bi0progressive Therapy
Denver.Rocky Mountain Orthodontics, 1979.
MD. Am J Orthod Dentofacial 0rthop 127-249-254, 2005
46. Roth RH. Functional occlusion for the orthodontist. 4 Clin Orthod 15414), 1981
47. Sato S. Application of Multiloop Edgewise Arch-Wire (MEAW) on the occlusal reconstruction of
malocclusion. Japan Ortho Practice 5-57.73, 1989
48. Shin SJ, and Chang yI Three dimensional finite element analysis of the phenomenon during en
masse movement of the maxillary dentition. Korea J Orthod 28.563-580, 1999.
49. Steffen JM, and Haltom FT. The five-cent tooth positioner, J Cin Orth0d 21.528-529, 1987.
50. Thurow RC. Atlas of orthodontic principles, Mosby, 1977
51 Tweed CH. Clinical orthodontics. Vol1 and 2. St Louis.Mosby, 1966
Cow_Fi «Sd]
••••
. . . . . . . . . . . . .. -- .. ·:. .. ..
. .. .. .. ,
......
I
0
Chapter 10_
RETAINERS
D General Types of Retainer (Fig. 10-1)
In general, a wrap-around type of retainer is used on the maxilla, and a canine-to-canine bonded
retainer is used on the mandible. Since a Hawley type retainer can cause a space relapse due to the
contact between the posterior wires of the maxillary canines and the mandibular teeth, such a
method is not recommended in the first premolar extraction cases. In the following malocclusion
cases, examples of different retainers will be demonstrated.
•
•
•
Fig. 10.f General types of retainer
A. Maxillary retainer (wrap-around retainer) on a model
B lntraoral photographs of a patient with a maxillary wrap-around retainer on
C. Mandibular retainer (canine-to-canine bonded retainer) on a model.
D. intraoral photograph of a patient with a mandibular bonded retainer on
d»» cw o_tar
••••
••••
�
Retainer for a Patient with Maxillary Anterior Crowding (Fig. 10-2)
When the rotated maxillary incisors, winging teeth, or severely lingually positioned lateral incisors
•
are detected in a case of maxillary anterior crowding, a bonded retainer is recommended on the •
lingual surfaces of the six maxillary anterior teeth. Since the maxillary bonded retainer could •
increase the contact with the mandibular teeth, and increase the risk of detachment, such a retainer
should only be used in severe crowding cases. In most of the crowding cases, a wrap-around
retainer is, along with a spring retainer, frequently used in the maxillary anterior area
Fig. 10-2 +Retainer for a patient

with maoary anterior crowding
A Mallary spring retainer on
a model
8+ At, Wrap-around retainer
wit.ha spring retainer
A2 Haley retainer with a
spring retainer
B. intraoral photographs of a
patient with a maxillary wrap-
around retainer a.0d a $00ng
retainer On
C Photographs of a model
with a bonded retainer on
D. intraoral photographs of a
patient with mnapolary wrap-
around retainer anda bonded
retainer 0on
0»
co iv_mows S45
�
Retainer for a Patient with Mandibular Anterior Crowding
In the cases of mandibular anterior crowding, it is recommended to bond a bonded retainer on the
lingual surfaces of the six mandibular anterior teeth. However, when there is a minor crowding in
the mandibular anterior area, it is first recommended to use a canine-to-canine spring retainer (to
solve the crowding), and then to se a canine-to-canine bonded retainer after de-crowding. A
diagram of the action of a spring retainer is as indicated below (Fig. 10-4)
•
•
•
Fig. 10-3 Retainer for a patient with mandibular anterior crowding
A Photograph of a model with a mandibular spring retainer on
B intraoral photographs of a patient with a mandibular $ping retainer on
C Photograph of a model with a mandibular canine-to-canine bonded retainer on
D. intraoral photograph ofa patient with a mandibular canine-to-canine bonded retainer on
d6»» cw tvo_Reties
••••
••••
The guidelines for applying a lower retainer are as follows.

(l)After the removal of the appliance, an inter-canine or inter-first premolar bonded retainer is
applied.
(2) The check-up must be followed a year after the treatment. During the check-up, the
followings are checked:
( Oral hygiene, If the oral hygiene is in good condition, the retainer should be worm
continuously •
(Gingival problems. If the gingival problems, such as calculus deposition, are detected,
the scaling must be performed. Also, if there is no improvement in oral hygiene (6
months after the scaling), the mandibular bonded retainer must be removed, and a spring
retainer should be wom only at night.
Fig. 104 Action of spring retainer

A photographs of a model with a mandibular spring retainer on
B-1. Model of a rotated mandibular night central incisor
8-2 Fabrication of spring retainer after set-up
B-3.Application of spring retainer (The arrows show the direction to which the force is applied)
B-4 After the alignment
Coe to fr +« ST
� Retainer for a Patient with Class Ill Malocclusion
In the Class Ill malocclusion cases, the mandibular growth is frequently prolonged. Therefore, it is
difficult to control the mandibular growth and to maintain the retention, The most influencing
factor of mandibular growth is the extrusion of the maxillary molars. Therefore, for the retention of
Class Ill malocclusion, it is essential to control the excessive maxillary molar extrusion. In general,
when a non-surgical treatment is used to treat the Class Ill malocclusion cases, a wrap-around type
retainer with a tongue hole is used to facilitate the tongue training. In particular, if the maxillary
second molars are under-erupted, the transpalatal arch (TPA), lingual arch or labio-lingual arch
should be placed in between the maxillary first molars. In addition, if there is a posterior cross bite,
such a method can also be highly effective to treat the Class Ill malocclusion cases with crowding.
When there is a Class IHI malocclusion with small maxillary lateral incisors, it is more desirable to
use a retainer after increasing the size of teeth, or by placing auxiliary springs both on the mesial
sides and on the distal sides of the teeth.
Fig. 10. Retainer for a patient with Class Ill malocclusion.
• A. Maxilla Trans.palatal arch (TPA) with lingual arch
• B. Maxilla T9A with lingual arch and canine-to-canine bonded retainer
• C Maxilla Wrap-around retainer with a tongue hole
4@»» Coro_et
••••
••••
Fig. 105 (continued) Retainer for a patient with Class Ill malocclusion.
•
•
•
D-1. Pre-treatment intraoral photographs of a patient with Class Ill malocclusion
D-2. Post-treatment intraoral photographs of a patient with Class Ill malocclusion

The canine-to-canine bonded retainer an TpA with lingual arch
car toe ««D

@ Retainer for a Patient with Class II Malocclusion
When the Class lH malocclusion is treated, the short-term relapse still frequently occurs due to the
characteristics of teeth (the tendency of returning to their original positions)j, Due to the Class ll
elastics used in the finishing stages of treatment, the labially inclined lower incisors are moved to
the original position after treatment. In contrast, the long-term relapse occurs as a form of
protrusion of maxillary teeth due to the mandibular retrusion. There can be various contributing
factors for this problem, such as the loss of retrsive control in the premolar area, the peg lateralis,
and so on. Also, the mesial angulation of the mandibular molars can cause the deep curve of Spee
and mandibular retrusion. In order to prevent the Class II malocclusion relapse due to the
mandibular retrusion, it is recommended to bond a retainer between the mandibular first premolars.
To summarize, when treating the Class Il malocclusion cases, a wrap-around type retainer is
recommended on the maxilla, and a bonded retainer is recommended in between the mandibular
first premolars.
Fig. 10.6 Retainer for a patient with Class ll malocclusion

A. Retainer on the maxilla wrap-around retainer
B. Retainer on the mandible: bonded retainer between the first premolars.
•
•
•
55»» cw to_Ree
••••
••••
If the Class ll malocclusion relapse occurs even after treating the Class Il malocclusion, a twin
block type retainer is recommended (Fig. 10.7). If, however, there is a maxillary anterior
crowding, it would be more desirable to use the wrap-around retainer, which consists of a spring
retainer. If an extraction treatment method is performed and the CF value is still low, a tongue hole
should be maintained in the wrap-around retainer and the tongue training must be facilitated. In
•
contrast, when treating the anterior deep overbite cases, a wrap-around retainer that has an anterior •
bite plate is recommended. In other words, if there is a Class II malocclusion and the maxillary •
lateral incisors are small, a retainer should be used only after increasing the size of teeth, or by
placing auxiliary springs both on the mesial sides and on the distal sides of the teeth (Fig. 10-8).
ln general, an inter-canine bonded retainer is used on the mandible, but it is more effective to use a
bonded retainer between the first premolars, if there is a Class II malocclusion with severe curve of
Spee.
Fig. 10-7Class ll twin block type retainer
A.Twin block type retainer
cc to_e « SSt
Fig. 10-7 (continued) Class ll twin block type retainer
r.
«d
'
• Bf Post-treatment intra0ral
photographs
B-2. Intraoral photographs of a

patient with a twin block type
retainer on
8-2
B3 Post-retention intraoral
photographs (two years after
• the treatment)
•
•
552»» cow vo_Reis

••••
••••
•
•
•
Fig. 10.8A patient with small maxillary lateral incisors.

A Photographs of a model with auxiliary springs both on the mesial sides and on the distal sides of the
maxillary lateral incisors
B. An intraoral photograph of a patient with the retainer that has auxiliary springs on the distal sides of
maxillary lateral incisors.
cow voe « 5S5

rn Retainer for a Patient with Deep Bite
In orthodontic treatment, the deep bite can be treated through the intrusion of incisors, the
extrusion of molars, or desirable jaw growth. The deep bite relapse is closely related to the
mandibular antero-superior growth. Also, the lingual inclination and the extrusion (of mandibular
incisors) can cause the relapse of mandibular anterior crowding, and the aggravation of deep bite
These demonstrate the reasons why a wrap-around retainer with an anterior bite plate is
recommended for the case of an anterior deep bite. Here, when the retainer is placed on the
maxilla, I the mandibular incisors will come in direct contact with the retainer, and 2) the
mandibular molars will come in direct contact with the maxillary molars. Also, in the cases of deep
bite, a bonded retainer is recommended in between the mandibular first premolars
Fig. 109Retainer for a patent

with deep bite
A Anterior bite plate (ABP)
type-retainer on the maxilla
• B Bonded retainer between
• the mandibular first premolars
• C. Mandibular spring retainer
554+» cow vo me ••••

••••
fj Retainer for a Patient with Open Site
Regardless of treatment method (orthodontic or surgically combined orthodontic treatment), the

•
possibility of relapse could still remain high (20%) after the open bite treatment. Such a risk must •
be clearly notified to the patients before the treatment begins •
To prevent the relapse, the patients' harmful oral habits must be monitored. In general, a wrap-
around type retainer is used to treat the open bite cases after creating a tongue hole or tongue crib
on the maxilla, and facilitating the tongue training. In most cases, the tongue hole retainer is
recommended on the maxilla than the tongue crib type
In the open bite cases, the importance of lip seal and swallowing exercise must be re-emphasized,
and the patients must always be encouraged to follow these exercises. During the lip seal exercise,
it is recommended to practice the maxillary lip close than elevating the mentalis muscle, and in the
swallowing exercise, it is important for the patients to place the tongue on the palatal surface
Fig. 10-10 Retainer for a patient with open bite
A Wrap-around retainer with a tongue hole on the maxilla
Wrap-around retainer with tongue cnib on the mandible
cc ivo mer «« S55

Fig. 10-10 (continued) Retainer in patient with open bite
C-1.Pre-treatment intraoral photographs of a patient with open bite.
C-2. Post-treatment intraoral photographs of a patient with open bite
c3»5.
•
•
• C-3. Intraoral photographs of a patient weaning retainers.
556» car to_ms

••••
••••
rn Retainer for a Patient with Posterior Cross Bite
Relapse occurs in the posterior cross bite case more frequently than any other malocclusion cases.
•
ln particular, if a retainer is not worn consistently, the tongue would come even closer to the •
mandible to narrow down the maxillary arch width, thereby increasing the possibility of relapse. •
Therefore, it is very important to prevent the tongue from coming closer to the mandible.
Fig. 10.1f Retainer for a patient with posterior cross bite.

A. On the maxilla Transpalatal arch (TPA) with lingual arch
B. On the maxilla TpA with labio-lingual arch
C. On the maxilla TpA with lingual arch and bonded retainer between the canines
car to_Reos 5S7

If the crowding is minor, the transpalatal arch (TPA) with a lingual arch or labio-lingual arch is
recommended. In contrast, if there is severe crowding, an extra bonded retainer is recommended
between the maxillary canines along with the TPA with lingual arch (Fig. 10-12). Here, depending
on the oral hygiene, the TPA with lingual arch should be re-cemented every 6 months or every year
to minimize the caries susceptibility
••
Ci
Fig. 10.f2Retainer fora patient with posterior cross bite
• A Pretreatment intraoral photographs
• 8. Post-treatment intraoral photographs of a patient weaning a retainer
• C. Post-retention intraoral photographs (35 months after the treatment)
55»» Corvo_et
••••
••••
@ Retainer for a Patient with Space
If there is spacing, there is a great risk of relapse; therefore, a bonded retainer is recommended. In
•
particular, if the adult patients suffer from spacing (between the maxillary central incisors), a semi- •
permanent bonded retainer is recommended. Also, if there is spacing in the mandibular arch, a •
bonded retainer should be used to prevent the risk of relapse. Here, it is essential to bond the
bonded retainer between the first premolars (not between the canines)
For the first 6 months, this retainer should always be worn except for eating times and brushing.
Then, for the following one year, the retainer should only be worn in the night (however, in the
deep bite cases, it must be used for the following 2-3 years). After this, the patients are
recommended to stop wearing the retainer and to check their condition on a regular basis during
the observation period. Theoretically, the retainer should be wom at least 2 years, and should be
wor semi-permanently, only if severe crowding is detected
Fig. 10-13 Retainer for a patient with spacing
{
1
cow to_Rei « So9

Fig. 1013 (continued) Retainer for a patient with spacing
8 post-treatment intraoral photographs of a patient wearing a retainer
•
•
•
560»» cw ivo me0air

••••
••••
22!
•• KOOAUDAM
Post.treatment Analysis Sheet ]

[
Date
.
Name
•
•
1 Treatment result LSatistied LUnsatrshed
•
2. Notification about relapse
3. Retainer
[ooera! toah!
4. Past Dental History
5. Total lees
6. Others
Department of Orthodontics ll 4ill
Fig. 10-14 Post-treatment Analysis Sheet
car iv__tis « 5G]

REFERENCES
1. ANimni K, AI Habashneh R, and Obeidat M. Gingival health and relapse tendency a prospective
study of two types of lower foxed retainers. Australian Orthod 25.142-146, 2009
2 Barrer HG. Protecting the integrity of mandibular incisor position through keystoning procedure and
spring retainer. J Clin Orth0d 9.486-494, 1975
3 Betrents RG. A treatise on the continuum of growth in the aging craniofacial skeleton. Ann Arbor,
Mich:. University of Michigan Center for Human Growth and Development, 1984
4 Bennett JC, and McLaughlin RP, Orthodontic management of the dentition with the preadjusted
appliance. lsis Medical Media, 1997.
5. Blake M, and Bibby K. Retention and stability: A review of the literature. Am J Orthod Dentofacial
Orth0p 114.299-306, 1998
6 Boese LR. Fberotomy and reproximation without lower retention 8 years in retrospect Part Al. Angle
Orth0d 50-169-178, 1980
7 Bolton WA. Disharmony in tooth size and its relationship to the analysis and treatment of
malocclusion. Angle Orth0d 28.113-130, 1958
8 Bolton WA The clinical application of a tooth size analysis. Am J Orth0d 48504.529, 1962
9 Booth FR. Effect on periodontal health of long-term bonded mandibular canine-to-canine retainers.
Angle Orthod, Pending
10 Daskalogiannakis J, and A Ammann Glossary of orthodontic terms, Quintessence, 2000.
11. Edwards JG. A long-term prospective evaluation of the circumferential supracrestal fiberotomy in
alleviating orthodontic relapse. Am J Orthod Dentofacial Orth0op 93.380-387, 1988
12 Edwards JG. Soft-tissue surgery to alleviate orthodontic relapse. Dent Cli North Amn 37205-225,
1993
13 Gardner RA, Harris EF,Vaden JL. Postorthodontic dental changes a longitudinal study. Am J Othod
Dentofacial Orthop 114.582-7, 1998
14 Huang Gd, Justus R, Kennedy DB, and Kolich VG Stability of anterior openbite treatment with ceb
therapy. Angle Orth0d 60.17-24, 1990
15 Joondeph DR. Retention and relapse. In.graber TM, Vararsdaf RL Vig WL, eds. Orthodontics
Current Principle and Techniques.
• Ed4. St Louise: Mosby, 2005.
• 16 Kim JI, Akimoto S, Shinj H, and Sato S. Importance of vertical dimension and cant of occlusal plane in
• craniofacial development. Int J Stomatol Occlusion Med2114.121,2009

17 Kim JI. Practical Clinical Orthodontics. Vol 1. Orthodontic treatment with ME
AW. Well publishing Inc,
2012
18. Kim JI. Practical Clinical Orthodontics. Vol 2. Orthodontic Diagnosis. Welt publishing in, 2013.
19 Kim JI. Practical Clinical Orthodontics. Vol3. Ealy orthodontic treatment. Welt publishing inc, 2015
562»» cwee vo moors

••••
••••
20. Little RM, Riedel RA, and Artun J. An evaluation of changes in mandibular anterior alignment from 10-
20 years post retention. Am J Orthod 93.423-428, 1988
21 Little RM, Wallen TR and Riedel RA Stability and relapse of mandibular incisor alignment - first
premolar extraction cases treated by traditional edgewise orthodontics. Am J Ort0 80-349.365, •

1981. •
22. Little RM. Stability and relapse of dental arch alignment. Br J Orthod 17235-241, 1990 •
23. McNamara JA Jr, and Brudon WL Orthodontics and Dentofacial Orthopedics. Needham Press, 2001.
24. McReynolds DC, and Little RM. Mandibular second premolar extraction- postretention evaluation of
stability and relapse. Angle Orth0d 61.133-144, 1991.
25. Nanda RN, and Burstone CJ. Retention and stability in orthodontics. WB Saunders, 1993
26. Nanda RS, and Nanda SK. Considerations of dentofacial growth in long-term retention an stability ls
active retention needed? Am J Orthod Dentofacial Orthop 101.297-302, 1992
27.Othman S, and Harradine N. Tooth size discrepancies in an orthodontic population. Angle Orthod
77668-674, 2007.
28. Proffit WR. Contemporary orthodontics. St Louis. CV Mosby company, 1986
29. Reitan K. Tissue rearrangement during the retention of orthodontic lly rotated teeth. Angle Orthod
29.105-113, 1959
30. Rchuse DJ, and Kandasamy S. Evidence-based versus experience-based views on occlusion and
TMD. Am J Orthod Dentofacial 0rthop 127-249-254, 2005.
31. Rossouw PE,and Tortorella. Enamel reduction procedures in orthodontic treatment. J Can Dent Assn
69.378-383, 2003.
32. Roth RH. Functional occlusion for the orthodontist. 4 Cin Orth0od 1541-4), 1981.
33. Shah AA, Elcock C, and Brook AH. incisor crown shape and crowding. Am J Orthod Dentofacial
Orth0p 118.624-628, 2000
34. Sheridan 4J. Air Rotor Stripping (AR.S) Manual New Orleans: Raintree Essix, 2005
35. Straub WJ. Malfunction of the tongue. Part I. A J Orthod 46.404-424, 1960.
36. Straub WJ Malfunction of the tongue. Part Am J Ortho4 47.596-617, 1961.
37. Straub WJ. Malfunction of the tongue. Part. Am J Orthod 48.486-503, 1962
38. Zachrisson BU, and Mor A Remodeling of teeth by grinding. Am J Orthod 68.545-553, 1975.
39. Zachrisson BU. Long-term experience with bonded retainers update and clinical advice. J Cin Orthod
41.728-737, 2007.
cc to_or « 563
PART Ill
CLINICAL CASES
••••
. . .. .. .. . . . . . . . . . .
............. ........
. . . . . . . . . . . . ..
Chapter 11
A CASE OF THE
MAXILLARY AND
MANDIBULAR
FIRST PREMOLAR
EXTRACTION
.._,
Case summary
This 124 year-old boy had chief complaints on crowded anterior teeth and about protrusive lips.
The facial asymmetry was observed from the frontal view, and the protruded lips were detected
from the lateral view. According to the intraoral photographs, the molars and canines were in
bilateral Class I relationship, and the dental crowding was observed in the anterior area of both
maxilla and mandible (4mm of space deficiency in the maxilla and 6mm in the mandible)
Skeletally, he had a Class I low angle pattern
Even a steep occlusal plane was observed, and the maxillary and mandibular molars and canines
had a Class I relationship. Therefore, it was decided to extract the maxillary and mandibular first
premolars to solve the problems of anterior crowding and the protruded lips. The 018" slot
standard brackets were used.
The total treatment duration was LS months. A wrap-around type removable retainer was used on
the maxilla, and a bonded retainer was placed in between the mandibular second premolars.
�
Pre.treatment records
1) Pre-treatment facial photographs (Fig. 11-1)
From the lateral view, protruded hips are apparent.

From the frontal view, due to the excessive hyper activity mentalis muscle, the patient has
facial asymmetry and finds it difficult to close the lips unconsciously.
•
•
•
Fig.11.f Pre-treatment facial photographs
••••
••••
2) Pre-treatment intraoral photographs (Fig. 11-2)
The left and right sides of molars and canines are in a Class I relationship, and the dental
crowding is observed in the anterior area of both the maxilla and the mandible (4mm of space
deficiency in the maxilla and 6mm in the mandible).
•
The buccal surfaces of maxillary first molars are parallel to each other, and the mandibular
•
second molars are mesially rotated •
The mandibular arch form has a minor U-shape.
Fig. 11.2Pre-treatment intraoral photographs
3) Pre-treatment panoramic radiograph (Fig. 11-3)
The maxillary second molars are erupted and the tooth germs of mandibular third molar are
formed. The posterior teeth in the right side of mandible are more mesially inclined than the
ones at the opposite side
ts
Fig.11.3Pre-treatment panoramic radiograph
4) Pre-treatment cephalometric radiograph (Fig. 11-4)
Protruded maxillary incisors are observed.

The mandibular second molars are more extruded than the mandibular first molars.
Insufficient eruption space for the mandibular second and third molars is observed.
814 379 798

156.9 652 156.2
26 491 336
10 178
t1edge toner 3.9

L1ordeg 94
ideg 1a 7
timer 283 2
2
fig.11.dPee.treatment cephalometric radiograph and the measurement values
The skeletal patter (0DE: 75.4, APDE 79.8 and CF: 155.2) showed a Class I low angle
The denture pattern was as follows
a) UI to lip line: 5.2mm
b) UOP to FH: 178°
e) POP t FH- 24.2
• d) UI to FH: 122.9
• e) IMPA: 103
• D II4: 100.5
This indicated that the patient suffered from the protrusive lips
From the E.Jine, the upper lip was protruded about 3.7men, and the lower lip was protruded
about 7.6mm.
• •••
••••
'9 Diagnosis and treatment planning
1) Problem lists
•
Protrusive lips,
•
Protruded maxillary and mandibular incisors, •
Class I relationship of the canines and molars,
Tooth size discrepancy (anterior Bolton ratio (ABR): 87.6% - 2.8mm excess per side in the
mandible).
2) Diagnosis
Skeletal Class low angle
3) Treatment plan
Although the patient suffered from steep posterior occlusal plane, his maxillary and mandibular
molars and canines were in Class I relationship. Therefore, to solve the problems of protrusive lips
and crowding, the premolar extraction was planned
Despite a steep posterior occlusal plane (POP), the maxillary and mandibular first premolars had to
be extracted due to the Class l canine and molar relationship
Here, the 08" slot standard brackets were used as a fixed orthodontic appliance.
b Treatment procedures
The crowded lateral inesiors were excluded when bonding the brackets.
The maxillary first molars were bonded with the convertible brackets, while the mandibular
first molars were bonded with the single buccal tubes
014" NiTi wire was inserted both to the maxillary and mandibular arch, and protective sheaths
were added to prevent mucosal irritation.
Fig. 11-intraoral photographs of initial archwires
The maxilla: after aligning the lateral incisors, an energy chain was used (on the 06" stainless
• steel archwie) from the canines to the first molars to retract the canines.
• The mandible: in order to gain the space for the lateral incisors and to trigger teeth movement,
• 016" stainless steel archwire with open coil springs was used.
• •••
••••
•
•
•
Fig1t.6 lntraoral photographs after 2 months of treatment
The maxilla: In order to induce the canine retraction, the 016" stainless steel archwire was
used from the first molars to canines along with energy chain. Here, the energy chain closed
the minor space that already existed in the four maxillary anterior teeth area.
Te mandible: after gaining the space for the lateral incisors, the brackets were bonded to the
lateral incisors, and the 014" NiTi was used to align the teeth
Fig. 11.7 lntraoral photographs after 3 months of treatment
Ca¢rt_AC of Moody Pet Pooler Oreo [

The maxilla: the canine was continuously retracted
Te mandible; On the mandibular incisors, the 016"x 022" stainless steel archwire with a
crown labial torque was used, and the hooks were attached bilaterally between the lateral
incisors and canines. Subsequently, the energy chain was used from the first molars to the
hooks for space closure
Fig. 11-8 lntraoral photographs after 5 months of treatment
The maxilla:.016"x 022" combination loop (made from the stainless steel archwire), that has
mm intrusion step and crown labial torque on the anterior teeth, was used to close the anterior
space. Here, the canines were continuously retracted on the posterior direction.
The mandible: In order to close the extraction space successfully, the mandibular second
• premolars were moved to the forward direction (slightly to the right), To further induce the
• backward movement of anterior teeth and the forward movement of molars, the extraction
• space had to be closed through the use of archwire with crown labial torque. By following the
above steps, bite deepening and the changes in the occlusal plane could be prevented
••••
••••
•
•
•
Fig.1t.9lintraoral photographs after 6 months of treatment
When closing a mandibular extraction space (Fig. 11-10)

I. Retraction of the mandibular anterior teeth: In order to form a Class I canine relationship,
the mandibular anterior teeth were moved posteriorly. In general, when closing the first
premolar extraction space, the retraction of anterior teeth occurs more than the protraction
of posterior teeth; this is a normal phenomenon. Here, if there was excessive retraction of
anterior teeth, the bite deepening as well as the aggravated curve of Spee would have been
observed
2. Protraction of molars: When the canines were retracted towards the second premolar area,
in order to correct the occlusion, the mandibular second premolars were placed between the
maxillary canines and the second premolars. Here, the 046" 022" stainless steel
archwires that has crown labial torque on the anterior area were used to induce the forward
movement of mandibular molars
Fig. 11.-10 Closing the extraction space
Chor tt AC ot fry oar fest Por Orion [7[

The Class l relationship (of canines and premolars) was maintained.
The energy chain was used to close a minor space in the mandible
After closing the extraction space, the appliance was extended to the maxillary and mandibular
second molars, and then re-leveling and re-alignment were performed
Fig. 11-ffintraoral photographs after 10 months of treatment
•
•
•
[7[ Cort AC of f Moyd Mo et Pecor Doon

••••
••••
In order to establish an acceptable occlusion while leveling the curve of Spee and forming the
Class I canine relationship, MEAW was used as a final archwire. Here. due to the tip-back
activation, the maxillary ME AW formed the shape of curve of Spee, and the mandibular
MEAW formed the shape of reverse curve of Spee. Sine these shapes re-opened the extraction
space both on the maxilla and on the mandible, an energy chain or a figure of 8 tie was used on
•
the first molars. By using 3/16" 6oz elastics from the first loop of maxillary MEAW to the third •
AW, the mandibular premolars were extruded, and by intruding and
loop of mandibular ME •
uprighting the mandibular molars, the mandible was moved forward. These corrected the
occlusion accurately, and during this procedure it was essential to apply the crown lingual
torque on the mandibular MEAW
Fig. 1t.f2 lntraoral photographs after 12 months of treatment
Cha ft _AC of Mey ft Pol Ooton ST

�
Post-treatment records
1) Post-treatment facial photographs (Fig. 11-13)
Fig.11.f3Post-treatment facial photographs
2) Post-treatment intraoral photographs (Fig. 11-14)
+ Desired tooth alignment and Class I canine and molar relationship were obtained.
•
•
•
Fig. 11-14 Post-treatment intraoral photographs
••••
••••
3) Post-treatment panoramic radiograph (Fig. 11-15)
•
•
•
Fig. 11.15Post-treatment panoramic radiograph
4) Post-treatment cephalometric radiograph (Fig. 11-16)
f Me $0 20It14
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Choir1t_AC et f ya er Pet Peno Section [7_

5) Cephalometric superimpositions (Fig. 11-17)
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Fig.11.fr superimposition and comparison of pre. and post-treatment measurement values
•
•
•
• •••
••••
6) Pre- and Post-treatment facial photographs (Fig. 11-18)
•
•
•
Fig.11.18A. Pre-treatment facial photographs

8. Post-treatment facial photographs
7) Pre- and Post-treatment intraoral photographs (Fig. 11-19)
Fig. 11.19A. Pre-treatment intraoral photographs

Post-treatment intraoral photographs
8) Post-retention facial and intraoral photographs (Fig. 11-20)
Fig. 11-20 Post-retention facial and intraoral photographs (16 months after the treatment)
•
•
•
bf'Chapter1tACa of T Moy Motl fest or Do

••••
••••
REFERENCES
1. Kim BH, and Yang wS. Regional load deflection rate of multiloop edgewise archwire. Korea J Orthod
29.673-688, 1999.
2 Kirn4I, Akimoto S, Shinji H, and Sato S. importanoe of vertical dimension and cant of occlusal plane in
craniofacial development. Int J Stomatol Occlusion Med 2-114.121,2009 •
3. Kim4I. Practical Clinical Orthodontics. Vol1. Orthodontic treatment with ME
AW. Well publishing inc, 2012 •
4. Kim JI. Practical Clinical Orthodontics. Vol 2. Orthodontic Diagnosis. Well publishing Inc, 2013. •
5. Kim YH Anterior openbite and its treatment with Mutiloop Edgewise Archwire. Angle Orthod 57290-
321, 1987.
6. Kim YH Treatment of severe openbite malocclusion without surgical intervention. Growth
modification. What works, what doesn't, and why. JA McNamara, Craniofacial Growth Series 35,
Center for human Growth and Development, The University of Michigan. Ann Abot,1999
7. Kim YH. Treatment of anterior openbite and deep overbite malocclusions with Multiloop Edgewise
Arch.Wire (MEAW) therapy. The enigma of the vertical dimension, JA. McNamara, Craniofacial
Arbor. 2000
••••
.. . . . . . . . . . . . .
.
. .. .. .. - -�
-� - .
. . .. ... . .
.............
%
Chapter 12_
A CASE OF THE MAXILLARY

FIRST PREMOLAR AND
MANDIBULAR SECOND
PREMOLAR EXTRACTION
._
Case summary
This 14.3 year-old patient had chief complaints about his protrusive lips. The facial asymmetry
was observed from the frontal view, and the protruded lips and the retruded chin were observed
from the lateral view. From the intraoral photograph, Class I molar and canine relationship, the
protrusion of maxillary anterior teeth, and the mandibular anterior crowding were detected.
Skeletally, he had a Class I low angle patter.
The molars and canines had a Class I relationship, and the maxillary first premolars and the
mandibular second premolars were extracted I) to retract the anterior teeth, 2) to protract the
posterior teeth, and ) to correct the occlusal plane. The 01" slot standard brackets were used for
the treatment
The total treatment period was 2 months. A wrap-around type removable retainer was used on the
maxilla, and a premolar-to-premolar bonded retainer was applied on the mandible
"b Pre-treatment records
From the lateral view, the protruded hips and the retrusive chin were observed.
From the frontal view, due to the excessive hyperactive mentalis muscle, the patient found it
difficult to close the lips unconsciously.
•
•
•
Fig.121Pre-treatment facial photographs
[[» Caper1?_ACa oft My fest Peeole and Man oar Sood Poor Ocon
••••
••••
Class I canine and molar relationship, and the labioversion of anterior teeth and dental
crowding were observed in the mandibular anterior area (6mm arch length diserepaney in the
mandibular arch)
•
The buccal surfaces of maxillary first molars were parallel to each other, and the mandibular •
first molars were mesially rotated. •
The mandibular dental arch had a minor L-shape
Fig. 122re-treatment intraoral photographs
The maxillary and mandibular second molars were erupting, and the tooth germs of mandibular
third molars were formed
Fig. 123Pre-treatment panoramic radiograph

Protruded maxillary incisors were observed

• Severe curve of Spee, which had been caused by the mesial tilting of mandibular molars, was
observed
Insufficient eruption space for the maxillary second and third molars was observed
II ••••
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10 133
13 128
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deg 12 7 1043
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2
Fig.12d Pretreatment cephaloretric radio0graph and measurement values
The skeletal patter (ODE: 74.0, APDE 8L. and CF: 155.1) showed a Class I low angle
The denture pattern was as follows
a)Ul to lip line: 5.9rm
b) UOP to FH: 13.3
e) POP to FH: 12.8
d) UI to FH: 124.1"
•
• e)1MPA: 103.9'
• II: 104.3
This indicated that the patient had a severe protrusive pattern.
From the E-line, the upper lip was protruded about S.mm, and the lower hip was protruded
about 0.7mm
[Chge12AC of.oyPt Pole Molar Sc6fer Oreo

••••
••••
�
Diagnosis and treatment planning
1) Problem lists
•
Protrusive lips,
•
Retrusive chin, •
Protruded maxillary incisor and excessive overjet,
Class canine and molar relationship
2) Diagnosis
Skeletal Class I low angle
3) Treatment plan
Although the patient had flat posterior occlusal plane, the premolar extraction was performed to
solve the problems of (lass l canine and molar relationship, and the problems of severe anterior
crowding and protrusion as well. Due to excessive overjet, the maxillary first premolars and
mandibular second premolars were decided to be extracted
Here, the 0I" slot standard brackets were used as a fixed orthodontic appliance
'b Treatment procedures
In order to prevent the lip biting habit, a posterior bite block (PBB) that includes a lip bumper
was placed on the mandible, and then a 014" N;fi wire was used to perform the leveling and
aligning the maxillary teeth
Fig. 12-5ltraoral photographs after 1 month of treatment
The mandibular PBB was used to induce the mandibular molar intrusion and the mandibular
incisor extrusion. This could improve the Class Il relationship by rotating the occlusal plane in
the counter-clockwise direction and by moving the mandible forward
•
•
•
Fig. 12-6 lntraoral photographs after applying the mandibular PBB. and a diagram of its effects
••••
••••
The maxilla: After the canine retraction, the 046"x 02" combination loop (made of stainless
steel archwire), that has Imm intrusion step and crown labial torque in the anterior area, was
used to close the anterior space. During this procedure, the canines were retracted continuously
The mandible: in order to upright and retract the first premolars, open coil springs (OCSy were
used along with the 016" stainless archwire.
•
•
•
Fig. 12-7 ltraoral photographs after 4 months of treatment
The maxilla re-leveling was performed after closing the extraction space
The mandible The 016" 022 stainless archwire with crown labial torque was used and the
bilateral mandibular hooks were added between the lateral incisors and canines. Then, an
energy chain was used from the mandibular first molar to the hooks to close the space.
Chae12AC of.fe Peele .e $coo foe Sb.co '[

The appliance was extended to second molars, and the leveling and alignment were re-
performed after closing the mandibular extraction space.
The maxilla: MEAW was used to elevate the occlusion.
Fig 12-9lntraoral photographs after 15 months of treatment
In order to establish an acceptable occlusion while leveling the curve of Spee and forming the
Class l canine relationship, MEAW was used as a final archwire. Here, due to the tip-back
activation, the maxillary ME AW formed the shape of curve of Spee, and the mandibular
ME AW formed the shape of reverse curve of Spee. Since these shapes re-opened the extraction
space both on the maxilla and on the mandible, an energy chain or a figure of 8 tie was used on
the first molars. By using 3/16" 6oz elastics from the first loop of maxillary MEAW to the third
• loop of mandibular ME
AW, the mandibular premolars were extruded, and by intruding and
• uprighting the mandibular molars, the mandible was moved forward.

• These, corrected the occlusion accurately, and during this procedure, it was essential to apply
the crown lingual torque on the mandibular MEAW
[@[»»Chart?ACa of tr MoyPernolr ad Me er Second Poor Orton

••••
••••
•
•
•
In order to correct the midline deviation, 3/16" 6oz elastics were used from the first loop of the
maxillary MEAW to the third loop of the mandibular MEAW during the day time, and extra
elastics on the left side were used from the second loop of the maxillary ME
AW to the fourth
loop of the mandibular MEAW during the night time
..+.. ··2-
�,
�.
•
' •
. ii t, •
- ...._'
'i' 4
. '
.
' - •
Fig. 12.1fitraoral photographs after 20 months of treatment " +
Chart2ACa oft Moo.fcnor M oder Son Poor Scio PG

�
Post-treatmentrecords
Fig. 1212Post-treatment facial photographs
•
•
•
Fig. 1243Post-treatment intraoral photographs
••••
••••
•
•
•
Fig. 12-14 Post-treatment panoramic radiograph
le $.0 20i1119
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fig.1.4spost-treatment cephalomertic radiograph and measurement values
Char2_AC of Moy Pet Pool r cod Peeler recto «[

5) Cephalometric superimposition (Fig. 12-16)
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Fig. 12.16 Superimposition and comparison of pre- and post-treatment measurement values
•
•
•
• •••
••••
•
•
•
Fig. 1247A. Pre-treatment facial photographs

B. Post-treatment facial photographs
Fig. 1218A. Pre-treatment intraoral photographs

B. Post-treatment intraoral photographs.
Cart2_AC of Mooty Pet Pono tr Sood erolr Oro _@h

Fig. 1219Post-retention facial and intra@oral photographs (16 months after the treatment')
•
•
•
Fig. 12-20 intraoral photographs of the patient with a retainer on
[»Cort2_AC of e Moy ft Polar and Mor Sood nor Oro

••••
••••
REFERENCES
1. lscan HN, and Sanisoy L. Comparison of the effects of passive posterior bite-blocks with different
construction bites on the craniofacial and dentoalveolar structures. Amn J Orthod Dentofa Orthop
112171-178, 1997
2 Kim BH, and Yang ws Regional load defection rate of multiloop edgewise archwire. Korea J Orthod •
29.673-688, 1999 •
3. Kim JAM, Akimoto S, Shinj H, and Sato S. importance of vertical dimension and cant of occlusal plane in •
craniofacial development. Int J Stomatol Occlusion Med2-114.121, 2009
4. Kim JI. Practical Clinical Orthodontics. Vol 1, Orthodontic treatment with ME
AW_ Well publishing inc
2012
5. Kim JI. Practical Clinical Orthodontics. Vol 2. Orthodontic Diagnosis. Well publishing Inc, 2013
6. Kim YH. Anterior openbite and its treatment with Multiloop Edgewise Arch»ire. Angle Orthod 57290-
321, 1987
7. Kim YH. Treatment of severe openbite malocclusion without surgical intervention. Growth
modification what works, what doesn't, and why. JA McNamara, Craniofacial Growth Series 35,
Center for human Growth and Development, The University of Michigan. Ann Arbor 1999
8. Kim YH Treatment of anterior openbite and deep overbite malocclusions with Multiloop Edgewise
Arch-Wire (MEAW) therapy The enigma of the vertical dimension, JA McNamara, Craniofacial
Arbor. 2000.
••••
. . . . . . .. .. . .
. . . . . . . . .. .. .. .. .. .. .. . . . . . -- -- .
Chapter 13_
A NON-EXTRACTION
TREATMENT CASE
IN CLASS II
MALOCCLUSION
�
Case summary
This IL.I0 year-old boy had chief complaints on his protruded anterior teeth. The facial asymmetry
was observed from the frontal view, and the protrusive lips were observed from the lateral view.
According to the intraoral photographs, Class ll canine and molar relationship, excessive overjet
and the labioversion of maxillary incisors were all apparent. Skeletally, he had a Class II high
angle pattern.
Despite the protrusive lips, the lateral view was still aesthetically acceptable when the mandible
was consciously moved to the anterior direction. Also due to the steep posterior occlusal plane
(POP), the twin block appliance was used ) to move the mandible forward, and 2) to upright and
extrude the mesially tilted mandibular molars. In this, the 018" slot standard brackets were used
for the treatment.
The total treatment duration was L2 months. A wrap-around type removable retainer was used on
the maxilla, and a bonded retainer was placed between the first premolars.
'9 Pre-treatment records
, protrusive maxillary lips and retrusive mandibular lips were observed.
•
•
•
Fig. 13.4Pre-treatment facial photographs
• •••
••••
The molars and canines were in Class ll relationship, and the labioversion of anterior teeth was
observed
There was excessive overjet.
•
The buccal surfaces of the maxillary first molars and the mandibular first molars were mesially
•
rotated •
The maxillary and mandibular dental arch had a V-shape arch form.
Fig. 132re-treatment intraoral photographs
• Besides the maxillary and the mandibular third molars, all the permanent teeth were erupted.
Fig. 133Pre-treatment panoramic radiograph

Maxillary protrusion and labioversion of upper incisors were observed

Thin premaxillary alveolar region was observed.
Deep curve of Spee was observed in the mandible
Insufficient eruption space for the second and the third molars was observed.
A0pr
OF
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2010.45
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69
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325
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tttoMdeg g14 378 90.8
deg
tAnmn
127
283 '2 108
57
Lime 233 2 46
Fig.13d Pretreatment cephalometric radiograph and measurement values
The skeletal patter (ODr: 70.0, APDE 69.0 and CF: 139) showed a Class I high angle.
The denture pattern was as follows:
a) U1 to lip line: I.Imm,
b) UOP to FH: 12.9'
e) POP to FH: 19.0°
• d) UI to FH: 126.6°
• e) IMPA: 92.8
• D IA 108.1
Tis showed that the patient suffered from protrusion.
From the E-line, the upper lip was protruded about S.7mm, and the lower lip was protruded
about 4.6mm
fd»»corn3 ANor-neon Trot Ca C Mocco

••••
••••
•
•
A
•
••
Fig. 13A.Facial photographs of maximum bite
B. Facial photographs of the forward positioning of the mandible.
Fig. 13-6A. lntraoral photographs of maximum bite

B Intraoral photographs of the forward positioning of the mandible
'9 Diagnosis and treatment planning
1) Problem lists
Protruded maxillary incisors, and excessive overjet,

Class ll canine and molar relationship
Mandibular retrusion
2) Diagnosis
Skeletal Class II high angle
3) Treatment plan
Although the patient had excessive overjet, high angle Class It malocclusion and Class ll canine
and molar relationship, the lateral view was still aesthetically satisfying, when the mandible was
deliberately moved forwand.Therefore, a non-extraction treatment was approachable
Despite a steep posterior occlusal plane (POP, the twin block appliance was used I) to move the
mandible forward, and 2) to extrude and upright the mesially tilted mandibular molars.
Here, the 018" <Lot standard brackets were used as a fixed orthodontic appliance
•
•
•
• •••
••••
A twin block appliance with an expansion screw both on the maxilla and on the mandible (the
maxillary SME type, the mandibular Schwarz type), was used. Here, the expansion device both on
the maxilla and on the mandible was activated twice a week. d
•
Fig.13.7 lntraoral photographs of the patient with a twin block appliance on
Chat
Strategic leveling and alignment
After using a twin block appliance, bracket bonding was done strategically both on the maxilla
and on the mandible to correct the occlusion. Here, the conditions of forward positioned
mandible remained consistent
The open coil springs were used only in the maxillary second premolar area. In addition,
besides the mandibular second premolars and the mandibular first molars, the brackets were
bonded to all the teeth
Fig. 13-8 intraoral photographs after 4 months of treatment
•
•
•
[f»Choe3 Aon-oleo root Ca Cl cc.

••••
••••
Finishing
To correet the midline deviation, and the maxillary and mandibular occlusion, the maxillary
and mandibular ME AW's and 3/16" 6oz elastics were used from the first loop of the maxillary
AW to the third loop of the mandibularMEAW, As the midline deviated to the left side, the
ME
patient was advised to wear the additional elastics from the second loop of the maxillary
MEAW to the fourth loop of the mandibular MEAW during the night.
•
Fig. 139intraoral photographs after 8 months of treatment

49 Post-treatment records
Fig.1310 Post-treatment facial photographs
•
•
•
Fig. 13-ff Post-treatment intraoral photographs
••••
••••
•
•
•
Fig. 1312Post-treatment panoramic radio0graph
Shallow overbite and overjet

Flattened mandibular curve of Spee.
Uprighted mandibular second molars
ea rent eon $.0 2011426

00 745 607 676
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LtoMdel 914 3r8 1106
(deg 12 7 1129
Urn 2.83 2 3.9
LL/mm 2.33 2 5.6
fig. 13.13Post-treatment cephalomertic radiograph and measurement values
The linguoversion of maxillary incisors and the labioversion of mandibular incisors were
observed
There was a Class II high angle malocclusion due to the small skeletal patterm (ODl/ APDL/
CF =70/69/139). Relatively insufficient condylar growth was detected.
Tooth inclination was changed due to the increase in vertical dimension
In general, the tooth movement induced by the uprighting and extrusion of maxillary molars,
help to generate an acceptable outcome (not the labioversion of mandibular incisors).
However, in this case, the CF value was very low (139), so the uprighting and extrusion of
mandibular molars were difficult to be obtained, and the clockwise rotation of the mandible
occurred as a result.
j
•
0or
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rent
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7
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Fig.13.1d Superimposition and comparison of pre and post-treatment measurements
••••
••••
•
•
•
Fig. 13-15A. Pre-treatment facial photographs

8. Post-treatment facial photographs
Fig. 1316A. Pre-treatment intraoral photographs

B. Post-treatment intraoral photographs
Fig. 13.417Post-retention facial and intraoral photographs (14 months after the treatment')
•
•
•
• •••
••••
REFERENCES
1. Clark WJ. The twin block technique a functional appliance system. Am J Orthod Dentofacial Orthop
93.1-18, 1988
2 Clark WJ. Twin block functional therapy. London, Mosby-Wolfe, 1995
3. Kim BH, and Yang wWS Regional load deflection rate of multiloop edgewise arch@ire. Korea J Orthod •
29.673-688, 1999. •
4. Kim JI, Akimoto S, Shinji H, and Sato S. Importance of vertical dimension and cant of occlusal plane in •
craniofacial development. Int J Stomatol Occlusion Med 2.114-121, 2009.
5. Kim JI. Practical Clinical Orthodontics. Vol 1. Orthodontic treatment with MEAW. Well publishing lnc
2012
6. Kim JI. Practical Clinical Orthodontics. Vol 2. Orthodontic Diagnosis. Well publishing inc, 2013.
7.Kim JI. Practical Clinical Orthodontics, Vol 3. Early orthodontic treatment. Welt publishing inc, 2015
8. Kim YH Anterior openbite and its treatment with Multiloop Edgewise Archwire. Angle Orthod 57290-
321, 1987.
modification What works, what doesn't, and why. JA McNamara, Craniofacial Growth Series 35,
Center for human Growth and Development, The University of Michigan. Ann Arbor. 1999
10. Kim YH. Treatment of anterior openbite and deep overbite malocclusions with Multiloop Edgewise
Arch-Wire (MEAW) therapy. The enigma of the vertical dimension, JA McNamara, Craniofacial
Arbor. 2000.
••••
...........
.......
Chapter 14_
A NON-EXTRACTION
TREATMENT CASE
IN CLASS Ill
MALOCLUSION
'b Case summary
This 10.11 year-old boy had the chief complaints about anterior cross bite and mandibular
prognathism. Previously, he had a treatment at another clinic (having wom a face mask before), but
due to the recurrence he decided to visit our clinic, The patient had a family history of (lass IL
malocclusion, and was suffering from otolaryngeal problems. The facial asymmetry was observed
from the frontal view, and maxillary undergrowth as well as mandibular prognathism were all
detected from the lateral view. According to the intraoral photograph, the patient had anterior cross
bite, deep over bite, and severe curve of Spee. Here, the patient was going through the mixed
dentition exchange period. The edge-to-edge bite was possible and an insufficient space for
maxillary canine eruption was detected. Skeletally, he had a Class II low angle pattern
Due to the edge-to-edge bite and a Class Ill low angle malocclusion, a non-surgical and non-extraction
treatment was planned. Also, to gain the maxillary canine space, the open coil springs and a 016"
x022" stainless steel archwire that has crown lingual torque, were used along with the face mask. In
order to induce the over-eruption of mandibular molars, the resin caps were applied on the mandibular
second primary molars. In this, the 018" slot standard brackets were used for the treatment.
The total treatment duration was 4 months. Only a wrap-around type removable retainer was used
on the maxilla, and no retainer was used on the mandible.
--
Pre-treatment records
From the lateral view a concaved profile with maxillary deficiency was observed
•
•
•
Fig.14-f Pretreatment facial photographs
••••
••••
Anterior cross bite and deep overbite were identified, and deep curve of Spee was observed in
the mandibular dentition.
Here, the patient was going through the mixed dentition exchange period.
•
The edge-to-edge bite was possible and an insufficient space for maxillary canine eruption was
•
detected •
Fig. 14.2Pre-treatment intraoral photographs
3) Pre-treatment panoramic radlograph (Fig. 14-3)
The tooth germs were formed on the maxillary and mandibular third molars, and insufficient
space for the maxillary canine eruption was apparent.
» -,,,
'•
«• •.
'
..
' - - ,
Fig. 14.3Pre-treatment panoramic radiograph

Anterior cross bite and mandibular prognathism were observed

Posterior discrepancy was observed.
Enlarged tonsils was apparent.
Asymmetry in the mandible and midline deviation to the right were observed
Me $0 2006.28
74$ 60 6009
814 379 994
1559 652 143
26 49 23
10 187
13 6.3
•• ...·- Urton4deg
U1edge0lp#nerd
4
39
914
46
1.,38
106
57
Lio 378 86
12 7 139.9
•• 283 2 18
• ·- 2.33 2 0.1
•
• Fig.1d.Pre.treatment cephalometric radio0graph and measurement values
• •••
••••
The skeletal patter (ODE: 60.9, APDE 93.4 and CF: 154.) showed a Class I low angle
a) UI to lip line: 5.7mm
b) UOP to FH: I8.T
e) POP to FH: 6.3°
•
d) UI to FH: 106.7 •
e) IMPA: 86.1 •
D IA: 139.9°
This indicated that the patient was suffering from mandibular prognathism.
From the E-line, the upper lip was retruded about L.8mm, and the lower lip was protruded
about 0.Imm
Fig. 14.5Posterior discrepancy

f. Over-eruption of molars
2AMesial angulation of molars
Char t4Alo-Oreo Tot Ca C4.eccl. «f

"b Diagnosis and treatment planning
1) Problem lists
Anterior cross bite,

Maxillary undergrowth and mandibular prognathism,
Class III molar relationship,
Insufficient space for maxillary canine eruption,
Mixed dentition period in the mandible
2) Diagnosis
Skeletal Class II low angle.
3) Treatmentplan
The edge-to-cdge bite was possible. Since this was a Class Ill low angle malocclusion case, a non-
surgical and non-extraction treatment was planned.
A face mask, an archwire that has crown lingual torque, and open coil springs were used
simultaneously to gain the sufficient space for maxillary canines.
Here, the 018" slot standard brackets were used as a fixed orthodontic appliance.
•
• As usual, the mandibular posterior bite block (PBB) was used I) to eliminate the bite force,
• 2)to increase the anterior vertical dimension and ) to bond the brackets on the maxillary
dentition with ease. At first, PBB and open coil springs were used and the tight cinch back was
performed to gain a sufficient amount of space for the maxillary canines. Then, the 0I6"
stainless steel arehwire was used as a main arehwire
••••
••••
•
Fig. 14-6 lntraoral photographs after 1 month of treatment •
•
To control the maxillary first molar rotation, the 016"x 022" stainless steel archwire, which
already has crown lingual torque, and open coil springs, were used. Here, the archwire could
gain a sufficient amount of space for canine eruption by I) inducing the labial root movement
and 2) minimizing the labioversion of anterior teeth (Fig. 14-7).
Fig. 14.7 ntraoral photographs after 2 months of treatment.
€
•
Fig. 1-8 Space gaining for the maxillary canines

By using the 016"x 02" stainless steel archwire, the labial crown movement was minimized
and the sufficient labial root movement was made. In other words, an adequate amount of
space was gained for canines. Here, along with a face-mask, 5/16" 6oz elastics were used from
the first premolars to move the whole maxillary dentition forward.
�
-
e -, '9:
-
__._ ''
•
' - •
le
$ ¢
I
.' hi
'
I ' -
+
• ,- '«
- -
• After improving the anterior relationship, the patient was advised to wear a face mask
• continuously, and the resin caps were, instead of PBB, used on mandibular second primary
• molars. Due to the resin caps, the mandibular molars were over-erupted, and the skeletal
pattern was changed into the Class I or It relationship, With such a change, Class Ill
malocclusion could be treated successfully
Anterior cross bite could be solved by moving the maxilla forward and by rotating the
mandible in the clockwise direction.
• •••
••••
•
•
•
The mandibular first molars in Class ll malocclusion tend to over-erupt in the early stages of
mixed dentition. In contrast, in Class Ill malocclusion, the maxillary first molars tend to over-
erupt in the final stage of permanent dentition
IM
...4
(44
;
4
•
i
f• •
•
�-
.
• Fig. 14.ff Changes due to different vertical heights of the
! IM
.4 d maxillary and mandibular first molars
l
'
- 4l
4
•
rs
l"
- '
•
• d fd
ft
-
%
625
Depending on the types of malocclusion, the inclination of posterior occlusal plane (POP'y and
the vertical dimension may vary. For example, in Class ll malocclusion, there are steep
posterior occlusal plane (POP) and insufficient posterior vertical dimension, and in Class Ill
malocclusion, there are flat posterior occlusal plane (POP) and sufficient posterior vertical
dimension
(lass IL Class IHI
Fig. 14-12Characteristics of skeletal Class It and Class Ill malocclusion
The patient had a maxillary archwire on and waited for the eruption of permanent teeth. Here
in most cases, the eruption of mandibular molars occurs more readily than the eruption of the
maxillary molars.
The patient had to wait for the ex foliation of mandibular second primary molars.
•
•
•
[[f»» Cot4 Ao-retie fort Cain C Mocco

••••
••••
After the sufficient eruption of maxillary canines, the brackets were bonded strategically to the
maxillary canines for alignment.
•
•
•
Fig.14.1d intraoral photographs after 16 months of treatment.
Maxilla and mandible: MEAW and short elastics for midline correction
After bonding the brackets on the mandibular teeth (just like the ones on the maxilla), MEAWs
were inserted onto the maxillary and mandibular arch. Then, to treat the occlusion and midline
deviation, on the right hand side, shont Class ll elastics (3/16" 6oz) were used from the first
loop of the maxillary MEAW to the third loop of the mandibular MEAW, while, on the left
hand side, shont Class HI elastics (3/16" 6oz) were used from the first loop of the mandibular
MEAW to the third loop of the maxillary MEAW

48 Post-treatment records
More aesthetically satisfying frontal and lateral facial views were observed
Fig.14.16 Post-treatment facial photographs.
Class I canine and molar relationship was obtained.

No midline deviation was observed.
•
•
•
Fig. 14.17Post-treatment intraoral photographs
[[e»cw ANotrcicon fret C

- ••••
••••
Including the second molars, the completed occlusion was obtained.

Tooth germs on the maxillary and mandibular third molars were observed.
•
•
•
Fig. 1418Post-treatment panoramic radiograph
Including the second molars, the completed occlusion was obtained.

Despite having a Class Ill malocclusion, curve of Spee was apparent on the mandible.
O0
PO
..
745
814
$0 2006.212
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379
66f
88.8
OF 155.9 6.52 155.0
Neg 26 491 264
u0reg 10 95
Pode, 13 n13
Uoieg 14 46 122.3
Ur tole4 3.9 1.38 33
914 3m% 8096
12 7 1218
UAire 283 2 08
-· Leer 2.3
Fig. 14.19Post-treatment cephalomertic radiograph and measurement values

2 04
M a:ar e so 2006.2.8 2006.2.12

0Or 745 607 609 66
PDE 814 379 904 888
CF 155.9 6s2 154.3 156.0
Neg 26 491 27.3 264
00rel 0 187 95
PoPdeg 13 6.3 11,3
U1to P4deg 4 1067 1223
U ode tolino "'
39 1,38 57 3.3
L1to4deg gr4 378 861 896
12 1399 1218
idol
Ure 2.83 '
2 .18
01
08
04
LL(mer 233 2
Fig. 1429 superimposition and comparison of pre- and post-treatment measurement values
•
•
•
• •••
••••
•
•
•
A»)Fl
Fig. 14.21A.Pretreatment facial photographs.

Fig. 1422A Pretreatment intraoral photographs.

B. Post-treatment intraoral photographs
Fig. 1423 Post-retention facial and intraoral photographs (20 months after the treatment)
•
•
•
B
[[[»Caler 4ANor-Orton Tot Cao Miccio
••••
••••
REFERENCES
1. Baik HS. Clinical results of the maxillary protraction in Korean children. Amn J Orthod Dentofac Orthop
108.583-592, 1995.
2 Kim BH, and Yang WS. Regional load deflection rate of multiloop edgewise archwire. Korea J Orthod
29.673-688, 1999 •
3. Kim JH, AMC Viana, TM Graber_FF Omneraza, and EA BeGole. The effectiveness of protraction face •
mask therapy. A meta-analysis. Am J Orthod Dentolac Orthop 115.675-685, 1999. •
4. Kim AM, Akimoto S, Shinj H, and Sato S. importance of vertical dimension and cant of occlursal plane in
craniofacial development. Int J Stomatol Occlusion Med 2-114.121,2009
AW, Well publishing inc
2012
6. Kim JI. Practical Clinical Orthodontics. Vol 2. Orthodontic Diagnosis. Well publishing Inc, 2013.
7 Kim JI. Practical Clinical Orthodontics. Vol3. Early orthodontic treatment Well publishing Inc, 2015.
8. Kim YH Anterior openbite and its treatment with Multloop Edgewise Archwire. Angle Otho 57290-
321, 1987.
modification. What works, what doesn't, and why. LA McNamara, Craniofacial Growth Series 35,
Center for human Growth and Development, The University of Michigan. Ann Arbor, 1999
10. Kim YH Treatment of anterior openbite and deep overbite malocclusions with Mutiloop Edgewise
Arch.Wire (MEAW) therapy The enigma of the vertical dimension, J.A McNamara, Craniofacial
Arbor 2000
••••
. -- . .. .. .. -- .
. . . . . . . . . . ..
I
G
Chapter 15_
A NON-EXTRACTION
TREATMENT CASE OF
MIDLINE DEVIATION
�
Case summary
This 18.2 year-old male patient had chief complaints about uncomfortable right
temporomandibular joint disorder (TMD), and midline deviation. Although the patient had an
aesthetically satisfying facial profile, facial asymmetry was detected from the frontal view
According to the intraoral photographs, I) adjacent teeth tilted due to a missing mandibular right
first molar, 2) occlusal plane was tilted within the maxillary canines, ) the midline deviated to the
right side, 4) there was Class II canine and molar relationship in the right side, and 5) excessive
crown buccal torque was observed in the maxillary right molar area. Skeletally, he had a Class I
low angle pattern
Since he had a good facial profile, a non-extraction treatment was planned. It was decided to close
the space, which was already created from the extraction of the mandibular right first molar, by
moving the second and third molars. The restorative treatment was also planned after increasing
the size of maxillary lateral incisors. In this, the 018" slot standard brackets were used for the
treatment
The total treatment duration was 24 months. A wrap-around type removable retainer was used on
the maxilla, and a canine-to-camine bonded retainer was used on the mandible
�
Pre-treatment records
•
•
•
Fig. 1.4Pre-treatment facial photographs
••••
••••
The adjacent tooth movement was observed due to the missing mandibular right first molar
Occlusal plane was tilted within the maxillary canines.
The midline was deviated to the right side
•
In the right side, Class II canine and molar relationship was observed. •
Excessive crown buccal torque was observed in the maxillary night molar area. •
Fig. 152Pre-treatment intraoral photographs
Fig. 153 Pre-treatment panoramic radiograph

'
Mee $D 2005.1.24
745 607 746 I
ep 814 379 839 I
156.9 1585
OF
Neg 26
652
49 201 l
iI
00Poe, 10 9.2
Poet 13 78
Uto Pdeg ft4 46 1129
U1edge to.line 3.9 138 59
tiowoe 914 378 $
- - @deg
Ure
Lime
12
283
23
7
2
2
134g
5.3
26
I
Fig.15.Pee.treatment ephal0metric radiograph and measurement values
The skeletal patter (ODE 74.6, APDE: 83.9 and CF; 158.5) showed a Class I low angle
a) UI to lip line: 5.9m
•
• b) UOP to FH: 9.2
• e)POP to FH-7.8°
d) UI to FH: 1H2.9°
e) 1MPA: 92.1
0I 134.9°
From the E-line, the upper lip was retruded about S.3mm, and the lower lip was retruded about
2.6mm
[[»» choir ts Ao-Oreo Peet Ca ote Dion

••••
••••
.._,
Diagnosis and treatment planning
1) Problem lists
•
Discomfort on the right temporomandibular joint, •
Movement of adjacent teeth caused by the missing mandibular right first molar, •
Tilting of occlusal plane within the maxillary canines,
Midline deviation to the right,
Class II canine and molar relationship in the right side,
Excessive crown buccal torque in the maxillary right molar area
2) Diagnosis
Skeletal Class I low angle.
3) The main objectives of treatment
Improve Class I canine and molar relationship.

Correct the mdline deviation
Gain the maxillary canine symmetry
Upright the mandibular right second and third molars
Gain the upper occlusal plane symmetry.
Control the maxillary molar torque.
Gain the sufficient space for maxillary lateral incisor size-up.
4) Treatment plan
Since the patient had an aesthetically acceptable profile, a non-extraction treatment was planned. It
was decided to use second and third molars to close the space that was already formed from the
extraction of the mandibular right first molar. A restorative treatment was planned after the
orthodontic treatment to increase the size of maxillary lateral incisors,
The 08" lot standard brackets were used as a fixed orthodontic appliance
Except for the maxillary first molar, the brackets were bonded to all the teeth to achieve the
strategic leveling.
The open coil springs were used to improve the right canine relationship, and to upright the
second molar
Fig. 155lntraoral photographs after 5 months of treatment
After aligning the maxillary teeth, MEAW had to be inserted to induce the three dimensional
maxillary teeth movement.
After leveling and aligning the mandibular teeth, in order to improve the midline and right
canine relationship, the short Class ll elastics (3/16" 6o ) were used from the first loop of the
maxillary ME AW to the mandibular right second premolar.
l
• .A
•
• .g
'¥
Fig.15.6 intra0ral photographs after 15 months of treatment
f» chrs ANo-recto Tenet Ca owe Delon

••••
••••
The mandibular wire was replaced with MEAW, and the shont Class II elastics (3/16" 6oz)
were used from the first loop of the maxillary MEAW to the third loop of the mandibular
•
ME AW, Here, the additional elastics were used from the second loop of the maxillary MEA\W
•
to the fourth loop of the mandibular MEAW in the right side during the night time •
Fig. 157 lntraoral photographs after 16 months of treatment
The midline and the right canine relationship were improved I) by removing the molar
interference, 2) by activating the elastics, and 3) by applying the tip-back activation to the
mandibular MEAW
Fig. 15.8 intraoral photographs after 18 months of treatment

In order to gain the space for small-size lateral incisors, the open coil springs were inserted on
the mesial and distal sides of maxillary lateral incisors, and then the shont Class II elastics
were used from the maxillary canines to the mandibular second premolar in the right side and
to the mandibular first premolar in the left side
Fig. 159lntraoral photographs after 20 months of treatment
In order to obtain tight occlusion, the triangular elastics (1/4" 6oz) were used from the second
loop of the maxillary MEAW to the second and third loops of the mandibular MEAW
•
• Fig. 15.10 lntraoral photographs after 22 months of treatment.
[[» Cort4No-recto Trot Ca ote Orio

••••
••••
4t) Post-treatment records
1) Post-treatment facial photographs (Fig, 15-11)
•
•
•
Fig. 15ff Post-treatment facial photographs
Fig. 1512Post-treatment intraoral photographs

Fig. 1513Post-treatment panoramic radiograph
•• •
-
74$
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2007123
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•
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.
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• Ure0dge tore
tttoMoog
39
914
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27
1046
• deg 12
' 1182
urr 283 2 4
Lim4 233 2 09
Fig.15.1d Post-treatment cephalomertic radiograph ad measurement values
••••
••••
•
•
•
APO
CF
-745
814
155.9
$0
60
31
652
2005.1 24
746
84.9
158.5
2007123
76.3
834
1997
Neg
u0reg
poeel
UoPdeg
UIe09geopier4
26
10
13
4
39
4 91
46
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2011
93
8
1129
59
.
235
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1137
27
Lttodeg 914 378 gt 1046
tog 12 7 1349 182
Um 283 2 5.3 47
LL#mer 233 2 26 09
Fig.4s.4s Superimposition and comparison of pre- and post-treatment measurement values

Fig.1516A. Pre-treatment facial photographs

•
•
•
• •••
••••
7) Pre- and Post-treatment intraoral photographs (Fig, 15-17)
•
•
•
Fig. 15.17A. Pre-treatment intraoral photographs

Post-treatment intraoral photographs
Fig. 1518 Post-retention facial and intraoral photographs (59 months after the treatment').
•
•
•
• •••
••••
REFERENCES
1. Kim JI, Akimoto S, Shinj H, and Sato S. importance of vertical dimension and cant of occlusal plane in
craniofaial development. int J Stomatol Occlusion Med 2114.121, 2009
2 Kim JI. Practical Clinical Orthodontics. Vol 1. Orthodontic treatment with MEAW. Well publishing inc
2012 •
3. Kim JI. Practical Clinical Orthodontics. Vol 2. Orthodontic. Diagnosis. Well publishing Inc, 2013. •
4. Kim YH. Anterior openbite and its treatment with Multiloop Edgewise Archwire. Angle Orthod 57290- •
321, 1987.
5. Kim YH Treatment of severe openbite malocclusion without surgical intervention. Growth
modification. What works, what doesn't, and why. JA McNamara, Craniofacial Growth Series 35,
Center for human Growth and Development, The University of Michigan. Ann Arbor, 1999
6. Kim YH Treatment of anterior openbite and deep overbite malocclusions with AMultiloop Edgewise
Arch-Wire (MEAW) therapy. The enigma of the vertical dimension, JA McNamara, Craniofacial
Arbor 2000.
Chart_ANorecto 'rt Ca of Mr Doto [d

INDEX
.....................................•...... ,,,, ,,,,11:::;:;::::::: .
. .. -- .. ..
........ ..... ..... .. .
-·. .. ..
A Bi force, 109, 622
Black triangle, $1, 184, 189, 190, 192,237, 238, 9$
Al-mail lomandibular triangle, 103, 104 Bonding
Abnormal tooth morphology, 4 gar. 1
Absolute anchorage, 43 oposste LS
Acid etching, 307, 309,313 old. 31
Active centric line, 284, 285, 480, 498 porcelain. 4
Aeve enlargement, I76 Bonding base, 262, 26
Adhesive, 306 Box elastics, 50,$416
Aesthete analysis, I60 Bracket argoltion, 30, 16, 337,1.38
Aesthetic bends, 494, 495 Becket height, 262, 292 293,295$,291,317
Aesthetic bracket, 26$ Bracket slot, 291, 302, 303, 321.333,497
Affected side, 62, 72, 230, 231, 519,5$21 Bracket width, 262 5$25
Alveolar bone 2I,79,210 Bual tube. 268, 269, 270,288, 3126, 31$3, 3$4, $72
Angultion error, 303, 317, 322, 324, 330
Ankylosis, 21, 64, 6
Antegonial notch, 10 c
Anterior bite plate, 141, 147, 1$0, 378, 379, 551,$$4
Anterior Bolton ratio, 46, 237,$71 Caine retractioe, 407, 408, 413,414, 425, $94
Anterior component of force, 76, 99,I99,526 Caine-to»cane boded retainer,$44,$46, 66
Anterior crowding, 23,2$,47, 48, $0, 56, $9,99,141, Center of rotation, 370 34
1$-119, 179,237, 249, 317, 3186-195, 411, 428, Centric stop. 28.5
440, 4$9, 460, 461, $4$, $46, $51, $$4, $68, $86, Ceramic bracket, 265
$89 Cervical headge,, 147, 148, 149
Anterior discrepaney,62, 63, I9.3 Chief complaint, 21, 1$2, $68, $86, 60.2, 618,636
Anterior vertical elastics, 141, $04, $03, $12.$16 Cinch back bends, JS2
Antero-posterior dysplasia indicator (AP'DD), 9$, I00 (lss l
Arch length discrepaney, 207,210, 5$87 elastios, 143 21A, 418. 429. 430, 432. 540, S4#
Asymmetry, 40, 233,23$,243,244,249, 517,534, $68, high angle, 106, 14, 1HS
• 602. 618, 620, 636 low angle, 106. $, 203. $68, $70, $71, $86, S88.
• Auto-transplantation, 239,246, 248 $89, 6.316, 638, 6.39
• Auriliary spring, S48, $54,$5 malocclusion, 47, 48. 94, 10 104, 44. 13A. 20
28$
molar, 33. 4, 3$, 94, 207, 214, 216, 220, 221, 20,
• 21, 219. 280. 356, 32. 438, $28, 586

skeletal pater, 4
Begg bracket, 263, 264 Class
Bite deepening. 4, 204, 2I0, 405, 416, 419, 420, 42, elastics, AS, 137 143-1$0, 276, 422, 430, 457, 49-
422, $74,$75 499, $0$.$13, $$0, 627, 640.642
650» woe
••••
••••
high agde, 106, 116, 147, 16$, 204, 6021-606, 612 triangular, S4, 103, 177, 184, 189, 190, 192 247, 9$
low angle, 106, 146, 117, 16.5 square, S4, AT
malocclusion, 2S, 47, 48, 56, 61-65, 785-104, 44 Curve of Spee
12S, 128. 130, 133, 160-167, 196-200, 208. 210, deep. 7s, 8S, 2o9. 2I0, 214, 218, 219. 376, 389,
215, 231, 238, 249, 276, 280, 281, 301. 324, 370, 416, 419, 422, $01, $21, 5$0, 604, 619
374, 409, 410, 499, $0$, $2$, 536, 5$0, 551, 606, moral, IS
625, 6.26 6,
severe, 30, 52. 64, 6.$, 151, 231, 282, 376, 3A86 •
molar, 33, 35, 193, 173, 179, 183, 210, 216, 2I8 389, 420, 421, 429, 495, 5$4, 588. 618 •
220, 221, 230, 239. 249. 300. 156, 386, 391, 5$28
skeletal pattern, 3, 34, 3$, 94,95
MEA, S0 •
cuss II
elastics, 28, 138-148, 227, 272, 409, 429. 430. 495
499, 503-5$17, 62
high angle. 106, 11, 118, 227 D
low angle, 106, 118, 20.5, 618, 621, 622
malocclusion, 2$, 47, 48, 6, 63,84.8795,97, 400 Decrowding, 362, 365, 46l
104, 114, 148, 125S, 128, 133-138, 160-78, 18, Delayed eruption, 64, 7l
200, 2316-249, 272.281, 301, 64.74, 411. 412 Denture parter aalysis, 26, 123, 124, 2O6
473, 499-503. 525, 548. 549. 618-6.2
molar, 227, 622
Clockwise rotation, 136, 137, 147, 148, 149, 150, 612 Diclusion, 128. 436
Combination factor (CF), 40, 103, 10$, 18$, 218, 220, Differential diagnosis, 160, 166. 215,219,220.221.229
409
Combination loop, 288, 405, 409, 414, 422, 423, 424,
425, 427, 428, 429, 430, 431, 432, 445$, 452, 456, Doable archowire, 142, 147, 150, 179,370,37
457,458
Congenital missing teeth, 42, 64
Contact points, 188, 285, 449, 474, 476, 477, 478, 480, EE
481, 530
Correlation coefficient, 9, I0 Ectopic eruption, 70
Counterclockwise rotation, 137, 147, 148, 367 Edge-to-edge, 179, $3$,$36, 618, 619,622
Cortical bone. 2I Edgewise bracket, 263, 264, 288, 362, 6.5
Cross bite elastics, $10, $15 Elates
Crown inclination (Torque), 72,287, 302,$34 Class l, 143, 213, 419, 429, 430, 432. $10, $4
Crown labial torque, 223,245,272.273,276,288, 319, n,
Clas 2S, 17, 14-1$0, 276, 422, 430, 487, 4.2-
411. 417, 418, 424, 425, 426,427, 429, 44$, 446, $13, $$0, 627, 640-642
45$1, 452, 473, 474, 49$,496, 499, $05,$32,$74, Class int, 28, 8. 14-48, 227, 272 409. 429, 430.
$75,$91 49$, 499, $03-$17,627
Crown lergth, 293,530 Anterior vertical, 143$, 14$, $01, $03, $4 $46
Crown lingual torque, 214, 21$,271,272.271,275$.276, Log. 143, 14$, $07, $08-$40, $46
288, 289, 319, 3162, 64, 365, 419,439,446. 452, Short, 143, 146, $09, $40, $16, 62
473, 478, 495, 499, $00. $02, $05, $21,$77.992, Elastic thread. 62, 36.
618, 622, 623 Enengy chain, 6, 384, 96, 40$, 406, 40, 409, 41,
Crown shape 413, 41$, 417, 418, 422, 425, 4.26, 440, 44$, 448,
barrel, SA, 1 449, 458, $72. $73, $74, 576, $77, 591,$92
ovoid. $1, 177, 1$3,372 Em.me etnetoe, 4I,4lS
oe« 651
Environmental factor, 78,87, I85 Horizontal pontoong error, 299,4
Expansion archwire, $21, 5$22, 523, 524 Hydrofluoric acid 311, 3M2
Expansion screw, 607
Extraction index, 113,II4
Extrusion I
anterior teeth, b
posterior teeth, 60 ldeal arch fonm, S2, 349, 407, 490, 49.4, $06
deal achrwire with hook, 40$, 411,41$,418, 426, 428,
429,440, 44$,449
F incisor mandibular plane angle (MA, 41$,417,446,
449, $70, $88, 604, 621, 638
Face mask, 139, 140, 147, 618,622,624 lndirest bonding. 306
Facial asymmetry, 40, 568, 586, 602, 6I8, 66 lndrvidualied treatment. 3
facial axis of clinical crown, 2% to-and-out, 263,266, 283,286, 287,482
Finger sucking habit, 7 later-bracket dist.ace, 480
first molar extraction, 169, 193, 249,250, 25 later-canine width, 56, $7,73, 170,176, 186, 2IL, 524
First-order bends, 52,76, 77,283,469,472, 482, 484, lntercoronal opening angle, S
48$, 500 laterincisa angle, 4$
Fat MEAW, 486, $01, $03 lnterproximal stripping, 8.8
Flattening. 61, 87, 137, 138, 139, 147, 148. 171,177, lntruof
178, 184, 348, 376, 509 anterior teeth 60
Force vector, I4 posterior teeth, 0
Friction, 286, 381, 404, 406, 407 Intrusion eh, 142, 147, I$0
Full cusp Class IM molar, 1$3,179,216, 221, 239,3$6,
386, 391
Functional appliance, 140, 141, 380
Functional shift. 86
G
K
Gable bend, 422, 427
Guidance, $7, 202, 211, 314, 444, 472, $04, $33 Kim pliers, 372,4$0,4$2, 4$4, 471, 473, 47$, 478, 48$,
$00, $04
KIMS Becket, 286, 287, 302, 482
H
• Habit, 78, 79, $38, 555, 590 L
• Hawley retainer, 4S
Headgear, 139, 147, 148, 149,268,371
Labial bclet, 26.
Leeway space, lot
Heat treatment, 494 Level anchorage system analysis, a
Hellman dental age, 6l, I67 Leveling
High angle, 40, 106, 107, 114, 116, 117, 118, 179,227, simple. I, A, 3.50
249,4317, $07, $09, 602, 604, 606, 612 strategic, 7, 184, 2IS, 281, 3$0. 98, 60.8. 640
High-pull headgear, 139,317 Ligation bracket, 26T
•
•
Light curing, 306, 308, 310, 314 Metal primer, 41, 31,14
gual arch, 166, 167, 5$48, 549, $$7,558 Midie deviation, 23,22,40, $9,64, 66, 67, 69,72,7$,
Lingual bracket, 263 76, 77,86, 160, 163, 164, 179, 200, 230, 231, 278,
Lingual button, 227, 36.J 282,439,441, 495, 496, $17, $19, 520, $21, 5$24,
L-loop, 319,62, 363, 445, 448, 449, 452, 469,470, $34, $93,609, 620, 627, 628, 636, 639
471, 485, 48 Mii-implant, 29, 146, 147, 148, 149, 1$0, 179,183,
Load deflection rate, 452,470, $04 184, 213, 224, 249, 3$6, 372, 386, 393, 414, 424, •
Long sis, 279,291 433,43$,445 •
Long elastics, 299, 300, 302, 303, 316, 318, 319, 321,
323, 325, 327, 329, 331, 333, $26
Minima anchorage, 429,40
Misod dentition, 6l, 154, 166, 71, 618, 619,622,625
•
Loop method, 404, 405 Mobility, 295$, 378, 518
Loose cinch back,
171, 353, 354, 364, 3TT, 38T Model aalysis, 160
Low angle, 40, 41, 106, 107, 110, 11$, 116, 117, 18, Moderate anchorage, 432
16$, 203, 205, 507, $68, $70, $71, 586, 588, $89, Moderate crowding,I9
618,621, 622, 636,638,639 Molar distalization, I9
Molar rotation, 358, 359, 360, 36I, 62)
Mouth breathing 8l
M
Mandibular expansion, 176, 181,3186, 390, 391 N

Mandibular plane angle, 96, 8, 99, 101, 103, 203, 249
Marginal ridge discrepancy, 291, $02, 504 Nasal septum, 8l
Masticatory efficiency, 127 Normal growth, IS
Mallary canine
symmetry, 233, 236, 6.39
asymmetry, 23.l 0
Maxillary deficieney, 364,618
Maxillary expansion 0eclusal contacts, $28, $29
low, 76, 30 Oectusal force, 76, 3$8, 378, 379, 381,$26
rapid, 176, 390 Oechorsal plane
Maximum anchorage, 44,4" bisected, 126, $26
Maximum incisor retraction, 396, 405 cant, 13, 1
MEAW curvature, 1A, 14
adfoment, $47, $19, 520, $25 flat, 127, 128, 12
analysis, level, 80, 1I
prescriptiot 49 posterior, 35, 61, 6. 6l 66, 67, 87, 114, 145, 126
Mesial angulation, 30, 3$,47,48, 62, 63, 6$, 68, 69, 70, 128, 133, 137, 138, 154, 152, 193,171,177,184,
76, 77, 98, 99,134, 193, 196, 221, 245, 279, 280, 205
281, 288, 389, 396, 414, 419, 420, 439, $$0. 62l steep. 64, 128, 129,177,214, 56.
Mesil rotation, $2, 166, 173, 185, 283,299, 300, 301, oper, 6$, 114, 115$, 126, 129, 131, 139, 47, 149,
320, 322, 3126, 330, 332, 3134, 341, 413, 414, 509, 15$2 179, 31$8.371, 396.198, 408, 413. 424, 4.$8,
510 42. 932. 63
Mesisl tilting, 320, 341, 392, 441, 4$8, 525, 5$88 Open coil springs, 12,273,351,3$3, 31$8.3166, 3176,377,
Mesi-distal angulation, 6l, 70 384, 385, 387, 389, 39$, 397, 407, 408. 411, 412,
Mesio-distal width, 46 413, 419, 439, 440, 4$8, 459, 460, 461, 463, 525
Metal bracket, 26.5 $72, 608, 618, 622, 623, 640, 642
oe «« 653
Otolaryngological problems, 8 oral. I15, 1$1, 20$, 206, 207, 214, 21$, 434, 438,
orthodontic force, 146, 151,470 46.8
Orthogathie surgery, 23, 13$, 136, 35 step. 6l, 63, 87, 114, 151, 177, 209, 210, 214, 2IS,
Overcorrection, 318, 535, 536 281, 434, 435, $71, 602, 606, 6.26
Overbite depth indicator (0D), 95,97, 98 fostenor vertea dnenon
Over-eruption, 61,62, 63, 70, 71, 114, 116, 166, 167, sufficient, 40, 41, 61,87, 116, 168, 626
196, 200, 326, 334, 618, 621 insufficient, 40, 41,61,87, 168, 177,178, 227,49,
Overlay archrwire, 62 626
Ovoid arch form 28-4 eformed archrwire, 32,273,446
Premature contacts, 86, 128, 262, 288, 5I8
Premature loss, -4, 6.8
p Premaoll, 22, 17
Prescription, 288, 49, 497, 506
PAC (Posteriorlarcartilage'), 103 Primary tooth
Parallel rotation, $2, 172, 173, 184, 185$, 300, 360,413, prolonged retention, $,$8, $9,64
459, 600 pre ture erfoliaticot, $7, $8, S
Passive centric line, 284, 285, 48.2, 500 Pricer, 308-314
Passive enlargement, 176, 186 Progressive step-up ME
AW, $0.
Patient compliance, 20, 392 Protraction of posterior teeth, 40$, 418, 429,433, 438,
Peg lateralis, 189,237,243,244, 5$25$, $50 440, $11, $7$
Pendulum appliance, 173,179,183,356, 386, 392 Protrusion, 23,2$, 40,78,79,$1, 113, 15, 116, 164,
Periodontal disease, 189 170, 202, 205, 207, 210, 218, 224, 249, 268, 385,
Periodontal ligament, 2 392,43$, $$0, $86, $89, 604
Phosphoric acid, 307, 311, 31 Protrusive lips, $68, 570, $71, $86, $89, 602
Plane
48, 98, 100, 101, 102, 103, 1$
machibwlar, 28, 40, 41, 96104. 14-48, 12$, 193, RR
203. 24
palatal, 79, 80, 96104, 144, 48, 19. Rapid maxillary epaunion, 176, 90
occluosal, 35, 61-96, 114-129, 131-153, 168-184, I8 Rectangular achwire 27
20$-230, 281-2196, 34$0-358, 367, 368-379. 391-
398, 408-496, $07.$90, 60,2, 606, 6,26, 636, 637, Relapse,79,11, 186, 194, 199, 204, 227,438, $2$, $44,
6.3 5$$0, 551, 5$4, 5$$,55$7,5599
Porcelain primer, 11, 2 Removable appliances, 140, 30
Positional deviation, $2, $3,57,58 Reproiratio, 172,177,184, 188, 1$9, 190, 192,221,
Posterior available space, 174, 194, I95 27, 238, 386, 9$
Posterior bite block, 140, 141, 148, 149, 366, 378, 379, Resin caps, 618, 624
• 380, 409, $90,622 Retrognathie mandible I44, I
• Posterior cross bite Retrusin, 40, 124, 129, 133,205$,274,278,289,29$,
• bilateral, 80
unilateral, 79,80, $4$
174, 419,4.36, 437-440, 46, 533, 550, 606
kRetrusive control, 324, 396,46, 47,4318,441,442, 443,
Posterior crowding. 49. 4$8, 4$0
Posterior discrepancy, 62, 63, 193, 194, 196, 197, 198, Revere curve of Spee, 473, 486, 490, $00, 501,512,$77,
200, 621 $92
Posterior oeelusad plane Revere MEAW, 422, 495,498, 50l
flat, 63, 87, 281, $88. 6.26 RO€ analysis, .5
654» woe
•••
Root labial torque, 349, 16.3 swA bracket, 30, 32, 223, 266, 271,272, 273,274,27$,
Root lingual torque, 199, 52 276, 271,79, 280, 283, 286, 289, 316$, 397, 423,
Root parallelism, 203, 24$, 303,317, 319,332,427,493, 424,45l
$37 Symmetry, 40, 57, 58, 76, 77, 120, 231,232, 233,23$,
Root resorption, 21,79,24l 236, 243,244,249,2$3, 476, 480, 488, 490, $05$,
Rotation $17$21, 533,5$34, 5$68, 586, 602, 618, 620, 636,
mesial, 52, 166, 173, 18$, 283, 299.301, 3120-341, 413, 639 •
41«4, $09, $40 Symphysis, 22 •
parallel, 52 172 173, 184, 185, 300, 360, 413, 4599, 460 •
T
• Tapered arch fonm, 54, 173,284, 461, 462, 49$
Sandblasting, 313 Teeth; see Tooth
Schwarz appliance, 156, 176, 179, 181,256, 39I bco-lingual inclination, , A81, 71, S4
Second molar extraction, I2, 1$9,169, 193, 196, 197, mesitdistal angulatioat, 60, 6l, 6.#1,6970 7I, 76,
198, 199, 200, 201, 219,252, 254, 255 77,241. 245, 27. 280, 287, 495
Second-order bends, 60, 76, 77, 279,469, 472, 485, 486, amber, 4D
$00, $04 position, S 53, S8
Self-ligation bracket, 267, 343, 344 shape 49
Sensitivity, 95 vie, 46, 47, 48, 110, 189, 188. 224, 287. 538. $71
Shoe-hook, 40$, 415, 416, 426, 428, 432, 448, 450 Teeporomnadibolr joint disorder, 2, 6$,274, 41,
Short elastics, 143, 146, 509, 510,516, 627 437,636
Shont face, 90, 12I Tension gage, 406
Shovel teeth, $0 Thickness error, 30$
Simple leveling, 12, 31,32, 347, 1$0 T premoll, 22,604
Single bracket, 262, 264, 265 Third molar extraction, 12,1$9, 169, 193, 194, 199,
Skeletal pattern analysis, 206 203, 49.3
Sliding method, 13, 40.3, 40-4, 405 Third-order bends, 123,64,72,6,77,271,286, 36.3,
Space preservation, I6 467,469, 472, 48.2, 487, 488, 489, $00, $04, $19
Specificity, 95 Three mandibular incisors, 230. 21, 232, 28
Square arch form, 284,46. Tie wing, 26.l
Spring retainer, S4$, 546, 547, $541, $$4, $62 Tight cinch back, 12,171, 347,31$3,31$4, 162, 64,
Standard bracket, 30, 32, 223, 266, 271,272.273,274, 66, 77, 389, 39$,622
275,276, 271, 278, 279, 281, 283, 286, 287, 288, Tip back activation, 143, 45, 48.3, 486, 500, $04, 50.3,
289, 341, 364, 165, 385$, 397, 420, 423, $71, $86, 519,521,$77,992, 641
$89, 602, 606, 618, 622, 636, 639 Ti back bends, 60, 281, 422, 429, 470, 472, 473, 48$,
Steiner analysis, 28 486, $03, $04, $06, 512, 513, 5$14, 5$21
Strategic bonding. 13, 264, 297, 347, 353, 355$, 357, 3$8, Ti back deactivation, S0
364, 38$, 395,197, 439 Tongue nib, 555
Steepening, 61, 137, 138, 139, 149, 1$0, 178, 408, $0 Toge hole, $48, 548, $51,5$5
Step-down bends, 498, $02, $04 Tong position, 79, 80
Step-up bends, 498, $02, $03, $04, $0$, $17, 5$19, $21 Tongue posture, 79
Stripping. 166, 172, 188, 189, 192, 256, 257, 395, $6. Tongue thrusting habit
Superimposition, 29, 187, 207, 209, 22$,228, $80, 96, active, '9
612, 630, 645 poooe, 7
oe«« 655
Tooth movement, 21, 30, 32, $7, 99, 109, 1$2, 186, V
193, 214, 21$, 218, 227, 272, 273, 274, 275, 276
271,279,283, 286, 296, 297, 299, 300, 303, 336, Vertical analysis, 1,26, 93,9%
338. 341, 349, 3$3, 3$5, 363, 378, 381, 387, 398, Vertical dimension
404, 405, 406, 407, 414, 415, 420, 434, 43$, 457, anterior, 48, 1688, 8. 38S. 622
4$9,468, 469, 470, 482, 48$, $04, 509, 612, 67 posterior, 40-42, 61. 66, 687 114-117 141, 16.8
Tooth size discrepancy, 46, 47, 48, 189,237,$38, $7 17,178, 193,199,227, 282. 385. 493. 6.26
Torque difference, 75, 76, 77, 278, 494, 496, 524 Vertical pontoong error, 6,2T
Trspalatal arch, 142, 149, 154, 15$, 166, 167,224, Vertical problems, 98
$48, $$7, $58 Vertical relationship, 40,$7, 96, 97,99,11$,196, 6,
Transpalatal width, S4, 5$, 179,3190 318, 321, 323, 32$, 327, 329, 331, 333, 510, 511
Tewnsverse problem, 40,87, 137
Triangular crown shape, 184, 189, 190, 192
Triangular elastics,422. 511,516, 642 w
Tweed analysis, 2
Twin block appliance, 141, 179, 182. 385$, 391, 439, Wide bracket, 269, 270, 28.8
602,606, 607,608 Wraparound retainer, $44, 54$, 548, 5$0, 551,554,
Twin bracket, 262, 264, 265 555
u
UI to lip line, 125,179, 367, 370, $70, 5$88, 604, 621,
638
Unaffected side, 72, 7$, 230, 231, 519,5$21
Upper occlusal plane
flat, 127, 128, 12
normal, 130, 12
steep, 64, 128, 129, 177, 214, 568
Utility arch, 142, 147, 150, 49%
•
•
•
656» oe
CONTENTS
Part I Orthodontic Diagnosis

Causes of Orthodontic Treatment Failure
Causes ofMalocclusion
Skeletal Pattern Analysis
Denture Pattern Analysis
Orthodotic Diagnosis
Part II Orthodontic Treatment

Bracket System and Bracket Positioning
Leveling and Alignment
Space Closure
Finishing
Retainers
Part IHI Clinical Cases

A Case of the Maxillary and Mandibular First Premolar Extraction
A Case of the Maxillary First Premolar
and Mandibular Second Premolar Extraction
A Non-extraction Treatment Case in Class II Malocclusion
A Non-extraction Treatment Case in Class IHI Malocclusion
A Non-extraction Treatment Case ofMidline Deviation
IA

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Multi-loop

/,n Well Publishing

/,n Well Publishing

142-070.22, Samyang-r 118 gil, Gangbuk-gu, Seoul, Korea

ISBN, 978.-89.97113-39.2 93510

All rights reserved No pant of this book may be reproduced in

This book is dedicated to the late Professor Kim Young-Ho

Kim Jeong-II DDS, PhD

Dr. Kim was instructed to the ME

De Kim Young-lo and Dr Km Jeong-l. 20O4

<Philosophy of Orthodontic Treatment>

PART I ORTHODONTIC DIAGNOSIS 17

Chapter 1 _ CAUSES OF ORTHODONTIC TREATMENT FAILURE.......------... 18

1. Pabems ····-----······------·····-··-··············---···· ... ..... .. _ . -··· ·······-··----····· 20

Chapter 2_CAUSES OF MALOCCLUSION ..o...38

Chapter 3 _SKELETAL PATTERN ANALYSIS....om.....92

1. Vertic:al Atlalysis ·-··--······-·······················-··· ·····--·- 96

Chapter 4_DENTURE PATTERN ANALYSIS.coo....122

1. Dentlnl Pattern Allalysis----········-··-·-·······--··----··· . .. • •............. 124

3)Pmmolar --·· --·-· -·· -·· ----·----·---·------""

PART II ORTHODONTIC TREATMENT 259

Chapter 6 _ BRACKET SYSTEM AND BRACKET POSITIONING ...........260

4)packet selection for premolar era90010a0$ .coo coo.28.8

• Chapter T_LEVELING AND ALIGNMENT.......346

3.Archwires for Leveling and Alignment. •• ooooooo..381 d

1. Space Closing Method ···············-·········--------··--···········----··-··-·····-··---····- 404

Chapter 9_FIN ISH I N G ··-········-···-··-···-··-···-··-··-··-··-··-··-··-··-··-··-···-···-··-···- <1-66

expansion&chines in44£A/oooooo ..el

7. Orthodontic Nofrrllal Ocdi ISDl ·------······· .•... ·············-··------··-···---------· 526

Chapter 10 __RETAINERS ..........ooooooooooo.......542

1. General Types of Retainer . ......

9. Retainer for a Paben! Wilh Space·----············· ... ·········-··-······----··-··---··--· 559

PART Ill CLINICAL CASES 565

Chapter 11 _ A CASE OF THE MAXILLARY

1. Case Sl.mlTIIIIY·········-···· ··-··-··-····---------················ ••.••.•.••. 568

• 3. Diagnosis and treatment plarring. ······-··. ·-- •• - . ··-··---····--·····---------······ 571

Chapter 13 _A NON-EXTRACTION TREATMENT CASE

1. Ca5e so..mma,y ·-····· 602

Chapter 14_A NON-EXTRACTION TREATMENT CASE

1. Case summary.... . .. , ······-···········- ·-············· 618

Chapter 15 _ A NON-EXTRACTION TREATMENT CASE OF MIOLINE DEVIATION.... 634

1. Case surrrnary. . -- .. ········· .. -··--- _. 636

)Cases where patients fail to visit their clinic on a regular basis.

• between an orthodontist and patient

Fig.1.f Radiographs that demonstrate a variety of premaxilla and symphysis thicknesses

Treatment failure may be caused by the following reasons:

Fig. 1-2Facial and intraoral photographs and radiographs of mono2zygotic twins

Fig. 13Avariety of malocclusion

Lack of uniformity in diagnosis methods, insufficient understanding of skeletal patterns, and

Fig. 1+4A variety of orthodontic diagnosis methods

A Pre.treatment facial and intraoral photographs

Fig. 14 (continued) A variety of orthodontic diagnosis methods

B. Post-treatment facial and intraoral photographs

CHARTING THE ANCHORAGE PROBLEM • .

[t}Captor'Ca of Oodons Poet are

G.Comparison of pre- and post-treatment superimposition and measurement values

The relevant factors are as following:

• B. Tooth movement patterns