Evidence-Based Clinical Orthodontics - quintpub

Evidence-Based Clinical Orthodontics



Evidence-Based
Clinical Orthodontics

Edited by

Peter G. Miles, bdsc, mds

Senior Lecturer
Department of Orthodontics
University of Queensland School of Dentistry

Brisbane, Australia
Visiting Lecturer

Graduate Program in Orthodontics
Seton Hill University Center for Orthodontics

Greensburg, Pennsylvania

Daniel J. Rinchuse, dmd, ms, mds, phd

Professor and Associate Director
Graduate Program in Orthodontics
Seton Hill University Center for Orthodontics

Greensburg, Pennsylvania

Donald J. Rinchuse, dmd, ms, mds, phd

Professor and Program Director
Graduate Program in Orthodontics
Seton Hill University Center for Orthodontics

Greensburg, Pennsylvania

Quintessence Publishing Co, Inc

Chicago, Berlin, Tokyo, London, Paris, Milan, Barcelona,
Istanbul, Moscow, New Delhi, Prague, São Paulo, and Warsaw

Dedication

This book is dedicated to our families, teachers, mentors, students, and in
particular to our patients. More importantly, this book is dedicated to you,
the reader, the present and future of orthodontics.

Library of Congress Cataloging-in-Publication Data

Evidence-based clinical orthodontics / edited by Peter G. Miles, Daniel J.
Rinchuse, Donald J. Rinchuse.

p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-86715-564-8
I. Miles, Peter G. II. Rinchuse, Daniel J. III. Rinchuse, Donald Joseph.
[DNLM: 1. Malocclusion--therapy. 2. Dental Bonding. 3. Evidence-Based
Dentistry. 4. Orthodontics--methods. WU 440]

617.6’43--dc23

2012017471

54321

© 2012 Quintessence Publishing Co Inc

Quintessence Publishing Co Inc
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www.quintpub.com

All rights reserved. This book or any part thereof may not be reproduced, stored in a
retrieval system, or transmitted in any form or by any means, electronic, mechanical,
photocopying, or otherwise, without prior written permission of the publisher.

Editor: Leah Huffman
Design: Ted Pereda
Production: Sue Robinson

Printed in China

Contents

In Memoriam  vii
Foreword  viii
Preface  ix
Contributors  x

1 Introduction: Evidence-Based Clinical Practice   1
Nikolaos Pandis, Daniel J. Rinchuse, Donald J. Rinchuse, James Noble

2 Early Intervention: The Evidence For and Against   7
Daniel J. Rinchuse, Peter G. Miles

3 Bonding and Adhesives in Orthodontics   17
Peter G. Miles, Theodore Eliades, Nikolaos Pandis

4 Wires Used in Orthodontic Practice   31
William A. Brantley

5 Class II Malocclusions: Extraction and Nonextraction Treatment   47
Peter G. Miles, Daniel J. Rinchuse

6 Treatment of Class III Malocclusions   61
Peter Ngan, Timothy Tremont

7 Subdivisions: Treatment of Dental Midline Asymmetries   89
Peter G. Miles

8 Evidence-Based Use of Orthodontic TSADs   107
James Noble

9 The Effectiveness of Treatment Procedures for Displaced and
Impacted Maxillary Canines   127
Tiziano Baccetti

10 Orthodontically Induced Inflammatory Root Resorption   137

M. Ali Darendeliler, Lam L. Cheng

11 Orthodontics and TMD   157

Donald J. Rinchuse, Sanjivan Kandasamy

12 Orthodontic Retention and Stability   167

Daniel J. Rinchuse, Peter G. Miles, John J. Sheridan

13 Accelerated Orthodontic Tooth Movement   179
Eric Liou

Index  201

In Memoriam

Dr Tiziano Baccetti (1966–2011)

Chapter 9 of this book, “The Effectiveness of Treatment Tiziano authored over 240 scientific articles on diverse
Procedures for Displaced and Impacted Maxillary Canines,” orthodontic topics. He has been described by those who
was written by Dr Tiziano Baccetti. This may well have knew him best as a “superman.” This is supported by what
been his last scholarly work; he completed this chapter he had accomplished in his short life. In 2011, Tiziano
just a few weeks before his untimely and tragic death on gave the Salzmann Lecture at the 111th Annual American
November 25, 2011, at the young age of 45. While posing Association of Orthodontists Session on “Dentofacial Or-
for a photograph on a historic bridge in Prague, Czech thopedics in Five Dimensions.” In concluding his presen-
Republic (he was the Keynote Speaker at the 9th Interna- tation, he explained how his grandfather in Italy had
tional Orthodontic Symposium held November 24 to 26, told him as a young boy that one day he would “find his
2011), he slipped on old stonework at the base of one of America” and fulfill his dreams. Tiziano said at the end of
the saintly statues that decorate the bridge and fell 8 me- his lecture, “I have found my America, fulfilled my dreams.”
ters to the rocks below. It was the Charles Bridge—Ponte Few, even with a long life, can say that they have fulfilled
Carlo in Italian, the same name as Tizanio’s beloved father, their dreams, their ambitions. We can be comforted that
who knows that bridge well and for whom the picture was Tiziano did.
intended.
We feel fortunate that we can share Tiziano’s excellent
chapter with our readers.

vii

Foreword

This text can serve as a reference guide for research and The topics are covered in detail with extensive illustra-
studies in many difficult clinical areas where there is a lack tions, cases, diagrams, and references. All discussions are
of evidence-based information. The distinguished editors based on current research findings, and when evidence is
are all involved in education, research, and practice, and not available, it is clearly stated as such. As the editors
they have invited other well-known experts and authori- point out, the purpose of this book is to provide the or-
ties to critically evaluate the literature and topics such thodontist with an evidence-based perspective on selected
as early treatment, extraction and nonextraction, Class important orthodontic topics and to stimulate practicing
III treatment, asymmetries, temporary skeletal anchorage orthodontists to reflect on their current treatment proto-
devices (miniscrews), impacted canines, root resorption, cols from an evidence-based view. In the future, clinical
temporomandibular disorders, retention, stability, and ac- decisions should be based ideally on evidence rather than
celerated orthodontic tooth movement. These are all criti- personal opinion, and treatment strategies should be prov-
cal areas in the full scope of clinical orthodontic practice. en to be both efficacious and safe.
I am sure that every orthodontist will learn from the enor-
mous contributions provided so clearly in this text. The I am very honored and privileged to have been asked
first chapter introduces and defines evidence-based clini- to present this foreword because this text should be the
cal practice. Every other chapter provides evidence for evidence-based text for EVERY orthodontist and student.
and against each controversy and concludes with a sum-
mary and points to remember. Robert L. Vanarsdall, Jr, dds
Assistant Dean for Advancement of Dental Specialties
Professor, Department of Orthodontics
University of Pennsylvania

viii

Preface

The specialty of orthodontics has evolved from an appren- that in fact there was no difference in discomfort or treat-
ticeship to a learned profession requiring academic training. ment time when self-ligating brackets were used compared
Nevertheless, many in our profession still cling to biased with conventional brackets. Yet despite the weight of evi-
beliefs and opinions rather than embracing evidence-based dence, these claims of faster treatment times and less dis-
practice. When evidence conflicts with what experience comfort are still made and supported by many orthodon-
has taught, it becomes even more difficult for such practi- tists. As Dr Lysle Johnston, Jr, pointed out, our specialty
tioners to change their views. Hence, there is complacency tends to have a pessimistic attitude toward evidence and
and resistance within the profession to adopt evidence- a minimal capacity to judge its quality. But what effect
based treatments. does this pessimism have on our patients? Can we as an
orthodontic profession really wait 17 years to incorporate
Most orthodontists experience at least enough treatment emerging quality evidence into our clinical practices?
success to support a practice. Yet treatment success does
not necessarily equate with treatment efficacy or even veri- With the exponential growth of information in today’s
fication of an appropriate diagnosis. This success can be world, how does the busy orthodontist evaluate evidence
the biggest obstacle to change. Clinical success may be as- that will affect his or her practice? This book was con-
sociated with a multitude of appliances, strong belief in a ceived out of a need for evidence regarding relevant clini-
particular philosophy, financial motivations (even unethi- cal topics and ongoing controversies in orthodontics such
cal ones such as inappropriate phase I treatments), the dif- as early treatment, bonding protocols, treatment of Class
ficulties involved in switching from an experience-based II and Class III malocclusions, asymmetries, impacted
practice to an evidence-based practice, and a simple lack canines, root resorption, retention, and accelerated tooth
of understanding of evidence-based clinical practice (de- movement. We have done our best to incorporate the best
scribed in chapter 1). In our profession, therefore, treat- evidence available regarding these topics, and hopefully
ment efficacy is currently evaluated broadly in relation to this book will show you not only how to judge quality evi-
benefits, costs, risks, burden, and predictability of success dence but also why it is so important to implement it.
with various treatment options.
Reference
No longer can the role of evidence-based decision mak-
ing be shunned and ignored in favor of clinical experience 1. Institute of Medicine. Crossing the Quality Chasm: A New Health
alone. From both ethical and legal perspectives, sound System for the 21st Century. Washington, DC: National Acade-
clinical judgment must be based on the best evidence mies Press, 2001.
available. Today a paternalistic view, whereby the doctor
knows what is best for the patient without soliciting pa- Acknowledgments
tient input, is unacceptable. Patients have a right to au-
tonomy and input into their treatment provided that it This book would not have been possible without the sup-
does no harm. port of the publisher, Quintessence, and the tedious and
dedicated work of our editor, Leah Huffman. We especially
The 2001 Institute of Medicine report estimated that it want to thank all of the contributing authors who have tak-
takes an average of 17 years for new, effective medical re- en the time to write chapters in this book.
search findings to become standard medical practice.1 For
example, there was a reemergence of the use of self-ligating
brackets in the mid-1990s amid claims not only of faster li-
gation but also of quicker and more comfortable treatment.
Several prospective clinical trials began to be published in
2005 and then two systematic reviews in 2010 concluded

ix

Contributors

Tiziano Baccetti, DDS, PhD* Theodore Eliades, DDS, MS, Dr Med, PhD

Assistant Professor Professor and Director
Department of Orthodontics Department of Orthodontics and Pediatric Dentistry
University of Florence University of Zurich
Florence, Italy Zurich, Switzerland

Thomas M. Graber Visiting Scholar Sanjivan Kandasamy, BDSc, BSc Dent, Doc Clin
Department of Orthodontics and Pediatric Dentistry
University of Michigan School of Dentistry Dent, MOrth RCS, MRACDS
Ann Arbor, Michigan Clinical Senior Lecturer
Department of Orthodontics
William A. Brantley, PhD University of Western Australia
Perth, Australia
Professor and Director
Graduate Program in Dental Materials Science Adjunct Assistant Professor
Division of Restorative, Prosthetic, and Primary Care Department of Orthodontics
Dentistry University of Saint Louis
College of Dentistry St Louis, Missouri
The Ohio State University
Columbus, Ohio Eric Liou, DDS

Lam L. Cheng, BDSc, MDSc, MOrth RCS (ED), Director
Department of Orthodontics and Craniofacial Dentistry
MRACD (Ortho) Chang Gung Memorial Hospital
Honorary Associate Professor Taipei, Taiwan
Department of Orthodontics
Faculty of Dentistry Program Director
The University of Sydney Department of Orthodontics
Sydney, Australia Graduate School of Craniofacial Medicine
Chang Gung University
M. Ali Darendeliler, BDS, PhD, Dip Orth, Certif Orth, Taoyuang, Taiwan

Priv Doc, MRACD (Ortho)
Professor and Chair
Department of Orthodontics
Faculty of Dentistry
The University of Sydney
Sydney, Australia

*Deceased.

x

Peter G. Miles, BDSc, MDS Nikolaos Pandis, DDS, MS, Dr med dent, MSc

Senior Lecturer Private practice
Department of Orthodontics Corfu, Greece
University of Queensland School of Dentistry
Brisbane, Australia Daniel J. Rinchuse, DMD, MS, MDS, PhD

Visiting Lecturer Professor and Associate Director
Graduate Program in Orthodontics Graduate Program in Orthodontics
Seton Hill University Center for Orthodontics Seton Hill University Center for Orthodontics
Greensburg, Pennsylvania Greensburg, Pennsylvania

Private practice Donald J. Rinchuse, DMD, MS, MDS, PhD
Caloundra, Australia
Professor and Program Director
Peter Ngan, DMD Graduate Program in Orthodontics
Seton Hill University Center for Orthodontics
Professor and Chair Greensburg, Pennsylvania
Department of Orthodontics
West Virginia University School of Dentistry John J. Sheridan, DDS, MSD
Morgantown, West Virginia
Clinical Associate Professor
James Noble, BSc, DDS, MSc, FRCD(C) School of Orthodontics
Jacksonville University
Visiting Lecturer Jacksonville, Florida
Division of Orthodontics
University of Manitoba Timothy Tremont, DMD, MS
Winnipeg, Manitoba
Canada Clinical Associate Professor
Department of Orthodontics
Visiting Clinical Lecturer West Virginia University School of Dentistry
Graduate Program in Orthodontics Morgantown, West Virginia
Seton Hill University Center for Orthodontics
Greensburg, Pennsylvania Private practice
White Oak, Pennsylvania

xi



Peter G. Miles
bdsc, mds

Theodore Eliades
dds, ms, dr med, phd

Nikolaos Pandis
dds, ms, dr med dent, msc

3CHAPTER
Bonding and Adhesives
in Orthodontics

Introduction studies cannot predict the clinical behavior of the adhe-
sives tested.5 Some of the limitations of in vitro studies
Treatment efficiency in orthodontics relies on several fac- include that most in vitro studies are conducted within
tors, including accurate bracket positioning and effective a short time after bonding (often within 24 hours), so the
bonding of brackets to the enamel. The advent of direct potential influence of the oral environment on the bond-
bonding of orthodontic attachments to the etched enamel ing material cannot be taken into account. Thermocycling
surface as first described by Newman1 was a major advance cannot replicate the effects of bond degradation by saliva,
in orthodontic treatment. He described a technique using and the loading rates are slow compared with chewing.
40% phosphoric acid for 60 seconds, and this technique Bond strength can also be affected clinically by pH and
remained basically unchanged for another 25 years. Short- microbial degradation.6,7 In a systematic review of bond
er etch times were later examined in clinical trials, and no studies, many factors were found to play a significant role
significant difference in bond failure rates were found be- in the final bond strength measured in laboratory studies.8
tween 60-second and 15-second etch times.2,3 Hence, over For example, water storage can decrease bond strength by
time we have seen a reduction in practitioner acid etch an average 10.7 MPa, each second of curing time with a
times from 60 seconds in 1986 to an average of 30 sec- halogen light can increase bond strength by 0.077 MPa,
onds by 1996, which has remained the same up to 2008.4 and each millimeter per minute of greater crosshead speed
Despite this reduction in etch times, the reported average of the Instron machine increases bond strength by 1.3 MPa.
bond failure in orthodontic offices has remained at 5%; The authors of the review concluded that many in vitro
however, this data comes from a survey,4 so it may well studies fail to report test conditions that could significant-
underestimate the true breakage rate. Bracket debonding ly affect the outcome.8
during treatment is inconvenient and costly to both the or-
thodontist and the patient. In our own practices, our goal Some clinicians will judge or select an adhesive from
is to have as low a bond failure risk as possible, so it is a laboratory study based on its mean or median bond
preferable to be 5% or lower. As demonstrated in Table strength without also considering the variation. For exam-
3-1, a practice with an average of 250 case starts per year ple, Fig 3-1 shows two curves representing bond strengths
and an average treatment time of 24 months can save 4 re- in MPa for two adhesives, both having the same mean
pairs per day (or 776 per year) if the bond failure risk can bond strength of 13 MPa, which is considered adequate
be reduced from 10% to 2%. for the orthodontic bonding of brackets. However, if we
pick an arbitrary bond strength of about 8 MPa, as sug-
So what steps should we take and what information can gested by Reynolds9 as the minimum (6 to 8 MPa) required
we gather from the literature to help us in such a basic bond strength to survive clinically, we can see that the
skill as the bonding of orthodontic brackets? Some may adhesive represented by the blue curve has substantially
choose to base their choice of adhesive or primer on the fewer brackets that could potentially fail compared with
myriad of laboratory studies that have been published over the adhesive represented by the pink curve. For these rea-
the years. However, there are a number of problems with sons, even a well-controlled, statistically valid laboratory
this approach. The American Dental Association Council study of bond strength should merely serve as a precur-
on Dental Materials reported that most laboratory bonding sor to a controlled clinical investigation. It is important
for the clinician to realize that most bond strength tests are

17

CHAP T E R 5 Class II Malocclusions: Extraction and Nonextraction Treatment

Anchorage loss Fig 5-1 Plotting normal curves based on the average and standard
deviation data from Heo et al.8 Note that a sizeable proportion of the
two-step cases moved slower than the en-masse cases (shaded area
under the pink two-step curve). En-masse space closure saved an
average 4.8 months (0.4 years) of treatment time with no noticeable
difference in anchorage loss.

En-masse
Two-step

0123
Years

ab c

de

fgh
Fig 5-2  (a to j) This patient had mild spacing in
the maxillary arch that would not be expected to
require “round tripping,” so en-masse space
closure has been selected. However, the man­
dibular arch exhibits crowding, with the mandib­
ular right central inc­isor blocked out and
showing signs of inadeq­uate attached gingiva
and a potential for gin­gival recession. For this
reason, two-step canine retraction is used in the
mandibular arch to “unravel” the crowding while
reducing the risk of proclining the mandibular

i j right incisor.

48

Fig 5-3  The width of the bracket determines the size of the moment Extraction Treatment
arm (one-half the bracket width) and the contact angle between the
wire and the bracket corner. The wider bracket thereby requires less Moment arm
force to generate the moment necessary to upright the root. (Adapted Contact
from Proffit.13) angle

the spaces were 0.9 years (1 standard deviation = 0.6 to When sliding mechanics are used, a wider bracket has a
1.3 years) in the en-masse group versus 1.3 years (1 stan- smaller contact angle and requires less force to generate
dard deviation = 0.6 to 2.0 years) in the two-step retrac- the moment during space closure (Fig 5-3). Conversely,
tion group (Fig 5-1). Two-step retraction demonstrated no single wing and narrow brackets, including some self-
benefit in terms of anchorage loss and a tendency to take ligating bracket designs, potentially require more force
longer than en-masse retraction. No difference in anchor- or demonstrate a greater resistance to sliding because of
age loss was also found in a pilot randomized controlled the greater contact angle and smaller moment arm. This
trial (RCT) comparing en-masse retraction with two-step is supported by two clinical trials evaluating the rate of
retraction.9 Therefore, en-masse retraction is the treatment maxillary canine retraction and en-masse space closure.15,16
of choice for efficiency. However, there are individual cas- Both studies found a conventional twin bracket resulted
es in which initial sectional canine retraction or a trapped in a slightly faster rate of space closure (1.2 mm/month)
coil on a continuous archwire is preferred to alleviate an- compared with the slightly narrower self-ligating brackets
terior crowding (Fig 5-2), such as when not “unraveling” (1.1 mm/month and 0.9 mm/month).
the crowded anterior teeth first would “round trip” them
and possibly create periodontal concerns. This treatment Anchorage
philosophy is supported by Burstone,10 who argued that
separating the retraction of canines from that of the inci- As previously described, it appears from the best evidence
sors makes little sense because all six teeth can be retract- available that there is no advantage to two-step retraction
ed at once with relatively low forces; the only patients for over en-masse retraction when it comes to anchorage.
whom separate canine retraction is appropriate, he contin- However, there are other options available for reinforcing
ued, are those with anterior crowding as a result of arch- anchorage, such as transpalatal arches (TPAs), headgear,
length problems. With the trend toward longer treatment and, more recently, temporary skeletal anchorage devices
times with two-step retraction, there may be an associated (TSADs) or miniscrews. When examining the effect of the
risk of greater root resorption. However, in a clinical trial TPA during extraction treatment, Zablocki et al17 found no
investigating this, no clinically or statistically significant significant effect on either the anteroposterior or vertical
difference could be found.11 position of the maxillary first molars. In a study comparing
TPAs, headgears, and TSADs, the TSADs and headgears
Some believe that tipping mechanics during canine helped to control anchorage during leveling and alignment
retraction may be more efficient than bodily retraction. while the TPA group experienced anchorage loss (mean
However, a split-mouth study in 14 subjects found that of 1.0 mm; P < .001).18 However, during the space closure
bodily retraction was faster than tipping because of less phase, only the TSAD group was stable. Overall, the an-
time spent uprighting the roots, with anchorage loss chorage loss per incisor retraction was 2% for the TSAD
similar in both groups (17% to 20% or 1.2 to 1.4 mm).12 group, 15% for the headgear group, and 54% for the TPA
The authors also found that the use of a Nance button did group. A potential confounder in this study was that com-
not provide absolute anchorage. A previous study had pliance with headgear wear was not measured, so compli-
found no difference in the rate of canine retraction but did ance was assumed when molars remained stable and non-
not measure tipping or time spent uprighting.13 The split- compliance suspected when they were not, representing
mouth study also recorded a greater anchorage loss with what would happen clinically. Other authors found a simi-
the tipping mechanics. Another option when retracting lar 1.2-mm anchorage saving with 1.4 mm greater retrac-
canines is to use either a single wing or a twin (also called tion of the anterior teeth when using skeletal anchorage
a Siamese) bracket. The advantage of a wider bracket in (miniplates, miniscrews, or microscrews),19 while others
this situation is that it allows better tip control because have found palatal implants to be at least as effective as
it is easier to generate the required moments needed to
bring the roots parallel to one another at extraction sites.14

49

CHAP T E R 6 Treatment of Class III Malocclusions
a bcd
e fg
h

Fig 6-4 (a to j) An 8-year-old boy presented

with an anterior crossbite and a maxillary trans­

i j verse deficiency. Green outlines indicate optimal
tooth positions within the jaws.

64

Early Orthodontic Treatment

k lm

nop

qr s
Fig 6-4  (cont) (k to s) Treatment with a Hyrax expander and fixed appliances.

Early Orthodontic Treatment Maxillary expansion and partial fixed
appliances
Indications
Figure 6-4 shows a patient who presented with an anterior
Objectives of early Class III treatment may include (1) crossbite and a maxillary transverse deficiency. Associated
preventing progressive hard or soft tissue damage, such with the transverse discrepancy is inadequate arch length
as enamel abrasion and bony or gingival dehiscence; (2) for the unerupted maxillary lateral incisors. This particu­
improving skeletal discrepancies and possibly avoiding lar patient had a near optimal anteroposterior positioning
orthognathic surgery; (3) improving occlusal function; (4) of the maxilla and mandible, as indicated by the relation­
developing arch length; and (5) improving dental and fa­ ship of the optimal incisors to the GALL (Fig 6-4j). The
cial esthetics.17 Common conditions warranting early treat­ panoramic radiograph (Fig 6-4h) showed that the lateral
ment are anterior or posterior crossbites with or without incisors were ready to erupt but were blocked out of the
functional shifts and blocked-out maxillary lateral inci­ arch. The primary first molars had minimal root resorption
sors. Favorable factors for successful early treatment in­ and, along with the permanent first molars, provided good
clude mild to moderate skeletal disharmony, no familial anchor units for rapid maxillary expansion (RME).
mandibular prognathism, a convergent facial type, sym­
metric condylar growth, and expected good cooperation. A Hyrax expander was inserted, and brackets were bond­
Patients and parents should be informed that unpredict­ ed to the central incisors and primary canines (maxillary
able dysplastic skeletal growth in the future may necessi­ premolar brackets were used on the primary canines) (Figs
tate orthognathic surgery despite early intervention. 6-4k to 6-4m). Skeletal expansion was accomplished with
two turns per day for 10 days. The expander was tied off,
Borrie and Bearn18 published a systematic review of 45 and a 0.012-inch nickel-titanium (Ni-Ti) wire was inserted
articles to identify the appropriate method for anterior from the right primary first molar through the right canine,
crossb­ ite correction. The authors found low-level evidence, central incisors, left canine, and left primary first molar.
and no statistical methods were employed for the analysis. Six weeks later, a 0.018-inch Ni-Ti wire was inserted, and a
They stated that higher-level studies are necessary before Ni-Ti open coil was compressed between the incisors and
definitive conclusions can be made. the primary canines (Figs 6-4n to 6-4p). The archwire was
cinched distal to the primary first molar brackets to direct

65

CHAP T E R 7 Subdivisions: Treatment of Dental Midline Asymmetries

ab c

de f

Fig 7-10  (a to d) The maxillary right first molar required extraction, so miniscrew anchorage was used to protract the second molar into its place. This
was done prior to placement of full fixed appliances to reduce the overall time in full braces. (e and f) The second molar has taken the place of the

maxillary right first molar, and the third molar erupted and aligned to replace the second molar.

ab c

de f

Fig 7-11  (a to q) Inappropriate extraction of the

maxillary right first premolar as a child resulted in

a midline shift and Class III canine relationship.

Space was reopened in the less visible second

g h premolar position for implant and crown place-
ment.

100

Other Asymmetries Other Asymmetries

Asymmetries can also be created by the inappropriate ex- braces were then placed to commence aligning the remain-
traction of teeth in crowded dentitions, by congenitally ing teeth and permit root uprighting on the second molar.
absent teeth or impacted teeth, or by the loss of teeth. For Use of the miniscrew maintained the canine relationship,
example, the patient in Fig 7-10 had an internally resorb- thereby preventing an asymmetry from developing in this
ing maxillary right first molar that required extraction. Be- case.
cause she had only minor crowding in a Class I occlusion,
a nonextraction approach was preferred. After consulta- Inappropriate removal of a tooth can result in an asym-
tion with the family, miniscrews were placed to protract metry that was not originally present. The patient in Fig
the second molar into the first molar space. After 6 months 7-11 had a blocked-out maxillary right premolar removed
and six visits, the extraction space was closed with no as a child, which resulted in a reasonable alignment but
movement of the anterior teeth (Figs 7-10c and 7-10d). Full also created a Class III subdivision malocclusion with the
maxillary midline skewed to the right side. In this case,
treatment would involve either extraction of three other
teeth to match or the reopening of the space for prosthetic
replacement, which was the option chosen by the patient.

ij k
lm n

o p q
Fig 7-11  (cont) 101

CHAPTER 13 Accelerated Orthodontic Tooth Movement

ab c
Fig 13-2  (a to c) Schematic illustrations of maxillary rapid canine retraction through distraction of the PDL with an intraoral distraction device.

Surgical-Assisted Approach bone complex is transported distally inside of the extrac-
tion socket. On the tension side, it is a distraction of the
Surgical-assisted accelerated orthodontic tooth movement PDL followed by osteogenesis and ossification.91
is currently the most effective technique experimentally
and clinically in accelerating orthodontic tooth move- Clinical and surgical procedures
ment. This approach includes the techniques of rapid
canine retraction through distraction of the PDL,91–95 rap- Bonding and banding are performed before extraction of
id canine retraction through distraction of the dentoal- the first premolars. The first molars and second premolars
veolus,96–98 corticotomy-assisted rapid orthodontic tooth are the anchor units. A triple tube is welded on the buccal
movement,99,100 and corticision.101 side of the canine band and the molar band. No archwire
or active appliance is placed on the anchor units before
Rapid canine retraction through extraction, but a segment of Ni-Ti archwire is placed in the
distraction of the PDL anterior teeth for the initial alignment and activation of the
periodontal cells. The period of predistraction preparation
This technique is beneficial in treating adult patients, for is 1 to 2 months.
whom treatment duration may be a deciding factor toward
the acceptance of treatment. The rate of orthodontic tooth At the time of the first premolar extractions, surgery is
movement in adults, particularly in the beginning of treat- performed with surgical burs to undermine and reduce the
ment, is slower than in adolescents.102–104 Two basic compo- thickness of the interseptal bone distal to the canine. The
nents, the alveolar bone and PDL, are encountered during surgery is then performed inside the extraction socket of
orthodontic tooth movement and affect its rate based on the first premolar without a mucoperiosteal flap and os-
factors such as cellular activity,105,106 mechanical strength teotomy. The length of the canine can be either obtained
of the PDL,107 and bony resistance of alveolar bone.108–110 directly from cone beam computed tomography (CBCT)
In the initial stage of tooth movement, Young’s modulus or estimated by applying the ratio of the premolar length
(stiffness) of the PDL is higher in adults than in adoles- (which can be measured after extraction) to the canine
cents, and this might produce a reduction in the biologic length on the periapical film.
response of the PDL, leading to a delay in the early stage of
tooth movement.107 However, Young’s modulus decreases The socket of the first premolar is deepened to the same
markedly 4 to 7 days after application of orthodontic force depth as that of the canine with a 4-mm carbide surgical
and does not last through the entire period of orthodontic round bur (Figs 13-3a and 13-3b). Then a cylinder carbide
tooth movement.111 The rate of tooth movement is shown surgical bur is used to reduce the thickness of the intersep-
to depend on the state of alveolar bone resistance, and it is tal bone distal to the canine. This procedure is critical to
faster in alveolar bone with loose bone trabeculae.108–110,112 the distraction results. The interseptal bone is better re-
duced to 1.0 to 1.5 mm in thickness. The last step is to
Mechanism undermine the interseptal bone distal to the canine. A
1-mm carbide fissure bur is used to make two vertical
By incorporating a surgical procedure on the interseptal grooves, running from the socket bottom to the alveolar
bone distal to the canine at the time of extraction of the crest, on the mesiobuccal and mesiolingual corners inside
first premolar, the resistance on the pressure side of ca- the extraction socket. These two vertical grooves extend
nine retraction is reduced, thus enhancing rapid canine and join obliquely toward the base of the interseptal bone
retraction through distraction of the PDL91 (Fig 13-2). This (Figs 13-3c and 13-3d).
approach is based on the bifocal distraction osteogenesis
technique. On the pressure side, the canine–interseptal A custom-made intraoral distraction device (Fig 13-4)
is delivered immediately after the extraction and surgical
procedures. It is activated 0.5 mm/day right after the sur-
gery until the canine is distracted into the desired position
(Fig 13-5). Patients are seen once a week during the dis-
traction procedure.

184

Fig 13-3  Schematic illustrations of the surgical a Surgical-Assisted Approach
procedure for undermining the interseptal bone b
distal to the canine in rapid canine retraction
through distraction of the PDL. (a and b) The
socket of the first premolar is deepened to the
same depth as that of the canine with a 4-mm
carbide surgical round bur. (c and d) A 1-mm
carbide fissure bur is used to make two vertical
grooves, running from the socket bottom to the
alveolar crest, on the mesiobuccal and mesiolin-
gual corners inside the extraction socket, and
these two vertical grooves extend and join
obliquely toward the base of the interseptal
bone.

c d
b
Fig 13-4 The intraoral distraction device for
rapid canine retraction through distraction of the
PDL.

Fig 13-5  The clinical progress of maxillary rapid
canine retraction through distraction of the PDL
in a 23-year-old woman. The canine retraction
was completed in 3 weeks. (a and b) Before dis-
traction. (c and d) After 2 weeks of distraction.
(e and f) After 3 weeks of distraction.

a

cd

e f
185

Index

Page numbers followed by “f” indicate figures; those followed by “t” Arch crowding, 78f–79f
indicate tables; those followed by “b” indicate boxes Arch expansion. See also Mandibular arch.

A limits of, 12f
maxillary, 10–13, 12f
Absolute anchorage, 107 Arch length, 14
Accelerated orthodontic tooth movement Arch perimeter, 167–168
Archwire, 41–43
baseline bone metabolism effects on, 193 Articulators, 161–162
biomechanical approach for, 179–180 Asymmetries, midline. See Midline asymmetries.
bone density effects on, 193 Austenitic wires
bone metabolism–density guided orthodontics, 193–194 nickel-titanium, 35, 38
direct electric current stimulation for, 180, 180f stainless steel, 33–34
low-level laser therapy for, 180–181
overview of, 179 B
pharmacologic approach for, 181–183
physiologic approach for, 180–181 Baseline bone metabolism, 193
prostaglandins for, 181–182 Begg appliances, 140
relaxin for, 182–183 Behavioral therapies, 164
self-ligating bracket system for, 179–180 Beta-titanium orthodontic wires, 32, 40–41
submucosal injection of platelet-rich plasma for, 191–193, 192f Bicortical anchorage, 111
surgical-assisted approaches for Biocatalytic fuel cell, 180, 180f
Biopsychosocial model, 158t, 162
corticision, 189f–190f, 189–191 Bleached enamel, bonding to, 19–20
rapid canine retraction, 183–186, 183f–186f Blue light, 25–26
selective alveolar decortication, 186–189, 187f Bonded expansion appliance, 67
Acid etching Bonding. See also Adhesives.
description of, 17–18
enamel, 21–22 air abrasion before, 20
hydrofluoric, 20–21 to bleached enamel, 19–20
microetching before, 20 to ceramic, 20–21
Active ligatures, 50 enamel preparation for, 20
Active self-ligating brackets, 179 failure of, 25
Adhesives history of, 17
bond strength of, 17, 18f indirect, 23
fillers in, 24 microetching before, 20
fluoride-releasing, 22 to porcelain, 20–21
light-cured, 23f, 24–25 pumice prophylaxis before, 18, 20
selection of, 17 saliva contamination avoidance during, 19
Air abrasion, 20 Bone density, 193
Air embolus/emphysema, 121 Bone metabolism–density guided orthodontics, 193–194
Alveolar bone density, 193 Brackets
Anchorage canine retraction using, 49, 49f
absolute, 107 gingivally offset, 22
bicortical, 111 self-ligating, 179–180
direct, 112, 112f Buccal alveolus, maxillary, 111
in extraction treatment, 49–50
history of, 107 C
indirect, 112, 113f–117f
nomenclature associated with, 108 Canine(s)
options for, 107 palatally displaced. See Palatally displaced canines.
orthodontically induced inflammatory root resorption affected by, 141 palatally impacted. See Palatally impacted canines.
temporary skeletal anchorage devices for. See Temporary skeletal tie-backs, 47
anchorage devices.
Angle’s paradigm, 175 Canine retraction. See also En-masse retractions.
Anterior crossbite, 68f–69f, 71, 72f–73f, 76f–77f, 82f–83f Class II malocclusion treated with, 47, 48f, 49
Anterior open bite, 122–123, 190f, 191 rapid
Anterior positioning appliance, 162 through dentoalveolus distraction, 184–186
Appliances. See Fixed appliances; Functional appliances. through periodontal ligament distraction, 183f, 183–184, 185f

Canine-protected occlusion, 159
Cementoenamel junction, 111

201

Index Crossbite
anterior, 68f–69f, 71, 72f–73f, 76f–77f, 82f–83f
Cementum, in orthodontically induced inflammatory root resorption, posterior, 10–12, 11f, 15, 76f–77f, 82f–83f
137, 138f
Crowding
Centric occlusion, 157 arch, 78f–79f
Centric relation, 160–161 arch perimeter decreases as cause of, 167–168
Ceramics corticision for accelerating tooth alignment in patient with, 190f
E-space for, 13–14, 14t
bonding to, 20–21 intercanine width decreases as cause of, 167–168
types of, 21 mandibular incisor, 168–169
Cervical vertebral maturation, 53, 127, 128f maxillary expansion for. See Maxillary expansion.
Children maxillary midline deviation with, 103
Class III malocclusion in, 64f–66f, 68f–69f
eruption guidance appliances for, 54, 54f C-terminal telopeptide of type I collagen, 193
Chin cup therapy, 71, 72f–73f Cytokines, 181
Chinese nickel-titanium orthodontic wires, 35
Circumferential supracrestal fiberotomy, 168 D
Class I malocclusion, 63, 116f
Class II malocclusion Decalcification, 21–22, 22f
early interventions for, 7–10, 52–53 Dental midline asymmetries. See Midline asymmetries.
extraction treatment of Dentoalveolus distraction, rapid canine retraction through, 184–186
Deprogramming appliances, 160–161
anchorage options, 49–50 Diagnosis, articulators use for, 161–162
appointment intervals, 51–52 Direct anchorage, 112, 112f
canine retraction, 47, 48f, 49 Direct bonding, 17
canine tie-backs, 47 Direct electric current stimulation, 180, 180f
en-masse retraction, 47, 48f, 49 Disc displacements, 162
premolars, 50 Displacement
space closure, 50–51
functional appliances for, 7–8, 52–53 maxillary canines, 127. See also Palatally displaced canines.
maxillary expansion for, 10–13 temporomandibular joint disc, 162
nonextraction treatment of Distalization, molar, 55–58, 56f–57f
molar distalization, 55–58, 56f–57f Dolichofacial patients, 14
overview of, 52
second phase of treatment predictions, 54–55 E
timing of, 52–55
Class III malocclusion Early caries lesions, 21, 22f
anteroposterior jaw positions, 62, 62f Early interventions/treatments
craniofacial complex aberrations associated with, 62
dental etiology of, 62, 63f Class II malocclusion, 7–10, 52–53
differential diagnosis of, 61–64 Class III malocclusion. See Class III malocclusion, early treatment of.
early treatment for functional appliances for, 7–8, 15
benefits of, 61 Edgewise appliances, 140
chin cup therapy, 71, 72f–73f Eicosanoids, 181
indications for, 65 Elastic bending stiffness, 32
maxillary expansion and partial fixed appliances, 65–66, 65f–66f Elastic modulus, 32, 38, 40
objectives of, 65 Elastomeric chain, 50
protraction face mask therapy, 66–71, 68f–69f Elgiloy wires, 35
nonsurgical treatment of Enamel
extraction, 73–77, 73f–77f acid etching of, 21–22
nonextraction, 77, 77f–79f air abrasion of, 20
pseudo skeletal, 63 bleaching of, 19–20
skeletal etiology of, 62–63, 63f microetching of, 20
surgical treatment of Endothelial growth factors, 191
mandibular surgery, 82f–83f, 83 En-masse retractions
maxillary and mandibular surgery, 84f–85f, 85f description of, 47, 48f, 49
maxillary surgery, 80, 80f–81f space closure in, 50–51
presurgical orthodontics, 79 Eruption guidance appliances, 54
three-dimensional planning, 79 E-space, 13–15, 14t. See also Leeway space.
types of, 62, 63f Etching. See Acid etching.
Clinical decision making, 1 Evidence categories, 1, 3t
Cobalt-chromium wires, 32, 35 Evidence-based clinical practice, 4–5
Cochrane Collaboration, 1, 42 Evidence-based dentistry, 1
Comprehensive early treatment, 8 Evidence-based orthodontics, 4
Cone beam computed tomography Extractions
anchorage value of root surface area evaluated using, 193 Class II malocclusion treated with. See Class II malocclusion,
Class II subdivision midline asymmetry, 90
site evaluation before temporary skeletal anchorage device extraction treatment of.
placement, 111 Class III malocclusion treated with, 73f–77f, 73–77
Conventional etch and prime technique, 18–19 inappropriate, midline asymmetry caused by, 100f–101f, 101
Copper nickel-titanium orthodontic wires, 37, 39, 43 mandibular incisor, 104, 104f–105f
Corticision, 189f–190f, 189–191 orthodontically induced inflammatory root resorption affected by, 147
Council on Scientific Affairs, 12 premolar. See Premolar extractions.
Craniofacial sutures, 67 primary maxillary canine, 129–130, 132
third molars, 168–170
Extrusive force, 143, 144f

202

F Index

Face mask therapy, for Class III malocclusion, 66–71, 68f–69f J
Facial sutures, 67
Fiberotomy, circumferential supracrestal, 168 Japanese nickel-titanium orthodontic wires, 35–36
Filled sealers, 22
Fixed appliances. See also specific appliance. L

Class II spring correctors used with, 55, 56f–57f Lacebacks, 47, 50
functional appliance components mimicked in, 58, 59f Lambert’s law, 24
midline asymmetries treated with, 98f–99f Lamps, polymerization, 24–26
partial, for Class III malocclusion, 65–66, 65f–66f Laser lights, 24
Fixed bonded retainers, 170–171, 171f LED light curing units, 24–25
Flexural rigidity, 32 Leeway space, 13–14, 14t, 54. See also E-space.
Fluoride Light curing units, 24
adhesives that release, 22 Light-cured adhesives
nickel-titanium orthodontic wires affected by, 39
orthodontically induced inflammatory root resorption prevention and, curing sources for, 24
degree of cure of, 24–25
149–150 indirect bonding use of, 23f
Force LED light curing units for, 24–25
polymerization initiation in, 24
extrusive, 143, 144f Lower lingual arch, 14–15
intermittent versus continuous, 141–142, 142t Low-intensity pulsed ultrasound, 151
interproximal, 168 Low-level laser therapy, 180–181
intrusive, 143, 143f
orthodontically induced inflammatory root resorption affected by, M

139, 141–147, 142f–146f, 142t Malocclusion
tipping, 144f, 145 Class I, 63, 116f
Full-thickness flaps, 186 Class II. See Class II malocclusion.
Functional appliances Class III. See Class III malocclusion.
Class II malocclusion treated with, 7–8, 52–53
components of, 55 Mandible
early treatment using, 7–8, 15, 52 chin cup effects on, 71
fixed appliance mimicking of components of, 58, 59f prognathism of, 82f–83f
myofunctional, 54, 54f protrusive, 71
skeletal maturation determinations, 53 temporary skeletal anchorage device placement in, 111
timing of use, 53
Functional occlusion, 159–160 Mandibular arch
E-space preservation, 13–14
G space-creation strategies in, 12t

Gingival crevicular fluid, 150 Mandibular incisors
Gingivally offset brackets, 22 crowding of, 168–169
Glass-ionomer cement, 22 extraction of, 104, 104f–105f
Goal anterior limit line, 62, 73–75, 77
GRADE approach, 2, 3f Mandibular intercanine width, 10
Growth factors, 191 Mandibular lingual arch, 14–15
Mandibular setback surgery, 83f, 85f
H Mandibular splints, 163, 163f
Martensitic nickel-titanium, 35, 38
Halogen lamps, 24–25 Maxilla
Hawley-type retainers, 171–172, 172f, 174
Headgear anteroposterior deficiency of, 68f–69f, 76f, 80f–81f
anteroposterior position of, 62, 62f
anchorage use of, 49, 52 buccal alveolus, 111
Class II malocclusion treated with, 7–8, 52 temporary skeletal anchorage device placement in, 111
interarch appliances and, 55 transverse deficiency of, 78f–79f, 84f–85f
palatally displaced canines treated with, 130, 130f Maxillary canines
Hydrofluoric acid etching, 20–21 buccal displacement of, 127
Hyrax rapid palatal expansion appliance, 70, 75f, 81f cervical vertebral maturation stages for eruption of, 127, 128f
displacement of, 127. See also Palatally displaced canines.
I eruption of, 127, 131
impaction of
Immediate loading, of temporary skeletal anchorage devices, 118–119
Impacted canines. See Palatally impacted canines. palatal. See Palatally impacted canines.
Indirect anchorage, 112, 113f–117f prevalence of, 127
Indirect bonding, 23 midline asymmetry caused by, 115f
Informed consent, 153 Maxillary expansion
Infrazygomatic crest, 111 Class II malocclusion treated with, 10–13, 15
Interarch appliances, 55 Class III malocclusion treated with, 65–66, 65f–66f
Intercanine width, 167–168 indications for, 10
Internal derangements, 162 postretention stability of, 11
Interproximal enameloplasty, 174–175 rapid, 12, 130–132
Interproximal force, 168 Maxillary protraction
Intraoral distraction device, 184, 185f case study of, 66–71, 68f–69f
Intrusive force, 143, 143f treatment timing for, 70–71
utility of, 71
Maxillary transverse deficiency, 64f
Maximal intercuspation, 157

203

Index case report of, 151–152, 151f–152f
cementum properties in, 137, 138f
Meta-analyses, 2, 2t clinical consequences of, 148
Microetching, 20 craters caused by, 147–148, 148f
Midline asymmetries definition of, 137
early treatments as risk factor for, 53
acceptance amount of, 89 with edgewise appliances, 140
Class II subdivisions extraction protocol effects on, 147
factors that affect
cone beam computed tomography study of, 90
definition of, 90 appliances, 140–141
Type 1, 90, 92f–93f, 93–94, 95f description of, 137, 138b
Type 2, 90, 96f–97f, 97 direction of force, 142–147
Type 1/Type 2, 98, 98f–99f extrusive force, 143, 144f
Class III subdivisions, 102f–105f, 103–104 force magnitude, 139
inappropriate tooth extractions as cause of, 100f–101f, 101 intermittent versus continuous force, 141–142, 142t
maxillary canine as cause of, 115f intrusive force, 143, 143f
overview of, 89–90 rotational force, 146, 146f
tooth extractions as cause of, 100f, 101 tipping force, 144f, 145
treatment approaches for tooth movement distance, 139
early interventions, 91, 91f–92f torque movement, 145, 145f
overview of, 90 treatment duration, 139
Midline shifts, 89, 90f treatment techniques, 140–141
Miniscrew implants, 107 fluoride effects on, 149–150
Modulus of resilience, 32 gingival crevicular fluid tests, 150
Molar(s) low-intensity pulsed ultrasound effects on, 151
distalization, 55–58, 56f–57f nonextraction protocol effects on, 147
intrusion, 123, 123f prevention of, 149–152
third. See Third molars. radiographic monitoring of, 149
Moment of inertia, 32 repair of, 147–148, 147f–148f
Mucoperiosteal flap reflection, 189 risk reduction for, 149, 153
Mutually protected occlusion, 159 with sequential aligners, 141
Myofunctional appliance, 54, 54f skeletal anchorage effects on, 141
space closure concerns, 50
N treatment planning considerations for, 151–152
Osteoprotegerin, 150–151
Narrative reviews, 1–2 Osteotomy, 184–185
Neutral axis, 32 Overjet correction
Nickel-titanium coil springs, for space closure, 50–51, 51f alignment and, 55
Nickel-titanium orthodontic wires twin block for, 8, 9f

austenitic, 35, 38 P
copper, 37, 39, 43
corrosion of, 39 Palatally displaced canines
elastic behavior of, 32 cephalometric superimposition of, 131f
elastic modulus of, 38 definition of, 127
fluoride effects on, 39 dental anomalies associated with, 128, 129b, 129f
heating curve for, 36f eruption of, 130, 133f
history of, 35 interceptive therapies for
martensitic, 35, 38 cervical headgear, 130, 130f
mechanical properties of, 35–36, 36f description of, 130–131
nonsuperelastic, 42 initiation of, 128
superelastic, 35–36, 39, 42–43 outcome evaluations of, 132–133
surface modification of, 39 primary canine extraction, 129–130, 132
surface roughness of, 38 rapid maxillary expansion, 130–133
thermoelastic effect of, 38 studies on, 132t
Nitinol, 35 transpalatal arch, 131–132
Nonextraction treatments palatally impacted canine progression of
Class II malocclusion treated with. See Class II malocclusion, cervical vertebral maturation stage as predictor of, 127, 128f
description of, 129, 132
nonextraction treatment of. prevalence of, 127
Class III malocclusion treated with, 77, 77f–79f risk indicators for, 128
orthodontically induced inflammatory root resorption affected by,
Palatally impacted canines
147 orthodontic-surgical repositioning of, 133
palatally displaced canine progression to
O cervical vertebral maturation stage as predictor of, 127, 128f
description of, 129, 132
Occlusal contacts, 159, 175 “tunnel technique” for, 133–134, 134f
Occlusal interference, 159
Occlusal splints, 163, 163f Palate
Orthodontic force. See Force. rapid palatal expander, 10, 70
Orthodontic wire. See Wire. temporary skeletal anchorage device placement in, 111
Orthodontically induced inflammatory root resorption
Partial fixed appliances, for Class III malocclusion, 65–66, 65f–66f
animal studies of, 149
apical region predilection of, 142, 148
with Begg appliances, 140
biologic markers of, 150
blood and saliva test for, 150–151

204