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Nickel-Titanium (NiTi) Arch Wires: The Clinical Signicance of Super Elasticity

Nikolaos Pandis and Christoph P. Bourauel


The introduction of nickel-titanium (NiTi) wires has revolutionized the eld of orthodontics by delivering light continuous forces over a wider range of displacements than the traditional stainless-steel wires. Over the years improvements in NiTi wire manufacturing and composition have been introduced; however, the claimed wire capabilities are not always easy to verify in the clinical setting. We aim at presenting an overview of the use and applications of NiTi alloys in orthodontics. The implications of the metallurgical and mechanical properties and intraoral aging of the wires in their clinical application is discussed. Finally, time variants of orthodontic therapy duration with the use of NiTi and alternative arch wires are presented, and the clinical implication of superelasticity is analyzed. (Semin Orthod 2010;16: 249-257.) 2010 Elsevier Inc. All rights reserved.

t was recognized early on that application of light continuous mechanical orthodontic forces translates into optimal tooth movement.1,2 Manufacturing of materials and systems that can provide ideal forces, decreased patient monitoring, and longer intervals between visits has been the focus of the orthodontic profession. Achievement of the aforementioned objectives depends heavily on the mechanical properties of the wires used in treatment. Kapila and Sachdeva3 suggested that the ideal orthodontic wire should combine low stiffness, good formability and high-energy storage, and large spring back. Brantley et al4 added to the foregoing characteristics biocompatibility, low surface friction, and the capability to be welded or soldered. It has been shown5 that a low load/deection ratio of an orthodontic wire provides desirable force and good control of force magnitude. The fact that NiTi wires possess those characteristics, among others, has made their use almost univer-

sal. NiTi alloys are used in the greater biomedical materials area and in dentistry are used in orthodontics, endodontics, and prosthodontics. Here, we aim to present an overview of the use and applications of NiTi alloys in orthodontics, analyze the metallurgical structure, and summarize the phase transformation characteristics of these wires. Recent evidence on the intraoral aging pattern of these materials will also be presented and the possible consequences on their clinical application. Finally, the implication of the metallurgical and mechanical properties of the wires in their clinical application is discussed in the light of recent evidence, which explore the time variants of orthodontic therapy duration using NiTi and alternative archwires.

Intraoral Aging of NiTi Alloys


Generally, it has been shown that the intraoral exposure of NiTi wires affects the topography and structure of the alloy surface creating pitting or crevice corrosion or formation of integuments.6 Retrieved NiTi orthodontic wires show the formation of a proteinaceous biolm, consisting mainly of alcohol, amides and carbonate, NaCl, KCl, and CaP crystalline precipitates.6 Clinically, this corrosion results in a slight increase of the Ni ion concentration in the pa249

Private Practice in Orthodontics, Corfu, Greece; Department of Prosthetic Dentistry, Preclinical Education and Materials Sciences, School of Dentistry, University of Bonn, Bonn, Germany. Address correspondence to Nikolaos Pandis, 29 P. Zaropoulou Street, Corfu 49100, Greece. E-mail: npandis@yahoo.com 2010 Elsevier Inc. All rights reserved. 1073-8746/10/1604-0$30.00/0 doi:10.1053/j.sodo.2010.06.003

Seminars in Orthodontics, Vol 16, No 4 (December), 2010: pp 249-257

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tients saliva (Fig 1); however, signicant corrosion defects on the surfaces of roughly 50% of the wires can only be identied after an extremely long intraoral exposure time of 24 weeks (Fig 2).7,8 At the wire edge opposing that engaged to the bracket, cracks and crevices were observed possibly caused by the presence of tensile forces produced from the wire engagement. These force induced changes in the microstructure of the alloy involving a reduction in grain size at the compressed locations that extend beyond the outer layer of the alloy. Changes in grain size have been documented in the NiTi metallurgy as stress-induced martensite where the martensitic transformation occurs below the transition temperature range when external stress is applied.9 The effects of the intraoral use of NiTi alloys via temperature changes, which causes repetitive-phase transformations, or via the cyclic mechanical loading, which is attributed to the masticatory forces initiating stress-induced martensite, may be expressed as an alteration in grain size. Phase transformation, ie, the martensitic transformation, occurs above the transition temperature range when external stress is applied9; however, the clinical effect of this intraoral phase transformation on superelasticity is not known. The microscopic evaluation of NiTi alloy wires has revealed material loss and various modes of corrosion, such as delamination, crevice, and pitting corrosion on the surfaces en-

Figure 2. Traces of corrosion on the surfaces of retrieved NiTi wires. The percentage of wires that showed corrosion defects after a certain intraoral exposure time is stated.

gaged to the bracket slots. In addition, retrieved wires engaged to the brackets exhibited signicant grain size alterations compared with the etched reference wires. Important differences also were observed in the surface prole morphology of the longitudinally-sectioned and polished wires relative to the as-received specimens. Surface regions engaged to the bracket slot showed surfaces demonstrating excessive wear, while characteristic patterns of delamination were observed. Those alterations may be assigned to compressive forces induced by wire activation through ligation, possible frictional damage produced inside the slot, and plowing during sliding of NiTi alloy wire on stainless-steel bracket slot. NiTi and beta-titanium (-Ti) wire alloys are most likely to present this effect because of the surfaces roughness they possess due the wire drawing process.

Clinical Implications of the Superelastic Properties and Aging of NiTi Alloys


NiTi wires have excellent spring-back and deliver the lightest force with the widest elastic range among the alloys used in orthodontics; however, these wires are comparably more expensive, have poor formability, and cannot be soldered or welded,4 and they exhibit high archwire-bracket friction compared with beta-titanium because of the rough wire surfaces that arise from the high titanium content. However, the limited clinical evidence currently available is not supportive of a difference in the duration of treatment in patients treated with NiTi alloys possessing distinctively different surface charac-

Figure 1. Nickel ion concentration in the patients saliva during treatment with a xed appliance: (1) before start of orthodontic treatment, (2) after placement of bands and brackets, (3) 2 weeks later and before placing the nickel titanium (NiTi) archwires, (4) immediatelly after insertion of the NiTi archwires, (5) 4 and (6) 8 weeks after insertion of the wires.

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teristics, ie, ion-bombarded NiTi and conventional NiTi.10 It is possible to use greater dimension NiTi arch wires in the early stages of treatment to accomplish various tasks simultaneously, such as correction of rotation, tipping, leveling, and torquing. The superelastic and shape-memory nickel-titanium wires are particularly useful where large deections are necessary for malpositioned teeth, whereas superelastic nickel-titanium coil springs, originally developed for orthodontics by Miura et al,11 have also found wide applicability. The force generated by the coil spring depends upon the dimensional characteristics of the austenite nal transformation temperature of the spring. These springs, by exerting continuous light forces over a very wide range, provide the clinician with an excellent vehicle for optimal tooth movement under the appropriate clinical conditions with little clinician intervention. However, it has been found that the force delivery of the superelastic coil springs can be substantially affected by small changes in temperature.4 Conclusive evidence is lacking regarding intraoral aging, as discussed in the previous section, which involves severe surface and structural alterations of the wires, on the martensite-austenite phase transformation characteristics. In a recent study investigating the phase transformation of NiTi endodontic rotary les, the authors reported that les exposed to clinically simulated procedures presented similar percentage of phase transformation to that found for the as-received products.12 However, extrapolating from the aforementioned study to orthodontic arch wires may be inappropriate because of the important differences in use and application; thus, further research on this issue is required before a denitive consensus is reached. The information on mechanical properties of the nickel-titanium arch wires that have been previously discussed, and specically on superelasticity, refer mostly to in vitro observations,13 whereas clinical studies in which investigators compared the rate of tooth movement during treatment by using different archwire alloys showed no signicant differences among superelastic, nonsuperelastic NiTi wires, and multistranded stainless-steel wires.14 Other researchers have proposed that superelasticity bears little or no clinical importance for torque applications, because at least 45 of activation was re-

quired to show deactivation plateau.15 Finally, three-point bending studies showed that superelastic wires required at least 2 mm of deection to exhibit a plateau region.16 It is encouraging that recent studies on mechanical behavior of NiTi alloys presented signicant progress in materials characteristics and thus in the stability and clinical applicability of superelasticity.17-19 The development of International Standardization Organization (ISO) standards for Orthodontic wires20 has facilitated a coherent and uniform approach in testing several mechanical properties of wires; however, biomechanical setups, which are more clinically meaningful have greatly assisted the extrapolation of clinically relevant information (Fig 3A, B). Although in the study of Kayser et al18 most of the wires showed plateau starts at deections as high as 1.5 mm or greater, in the study of Fischer,19 plateaus started at approximately 0.5

Figure 3. (A) Three-point bending test on an orthodontic NiTi wire according to the ISO standard 15,841. (B) Biomechanical testing of the wire in a simulated clinical situation. (Color version of gure is available online.)

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mm (Fig 4) Moreover, clearly decreased forces could be observed for the modern, superelastic wires, with numerous wires having forces of around 0.5 N at a deection of 2 mm (Fig 5). Nevertheless, wires with forces up to 2 N at a 2-mm deection still exist (Fig 5), indicating signicant uctuations of the materials characteristics of NiTi wires.

Support to the foregoing conclusion has been provided by a study revealing that many superelastic wires exhibit no superelastic properties in vivo, or at least no advantage over conventional NiTi wires.21 These wires required a tooth displacement of at least 1 mm to express a plateau region and a force level at the plateau reached 500 g, a magnitude far beyond the typical limits of orthodontic

Figure 4. Selected load/deection curves in three-point bending. Note the variability of hysteresis curves and the differing heights on the unloading plateaus.

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Figure 5. Forces on the unloading plateau in three point bending. (Color version of gure is available online.)

force application, whereas others have estimated a maximum vertical force of 390 g, by simulating 1 and 2 mm crowding with 20 angulation.22 Thus, in vivo studies revealed no superelastic behavior of superelastic NiTi wires and no differences on tooth migration in cases treated with these wires compared with the therapeutic results of the conventional NiTi wires. Pandis et al23 comparatively explored mandibular arch alignment efciency between NiTi and CuNiTi wires. Sixty patients were included in this single-center, single-operator, doubleblind randomized trial. All patients were bonded with the In-Ovation-R self-ligating bracket (GAC, Bohemia, NY) of 0.022-inch slot and the amount of crowding of the lower anterior dentition was assessed by the use of the irregularity index. The patients were randomly allocated into two groups: the 0.016-inch CuNiTi 35C (ORMCO, Glendora, CA) group, and the 0.016-inch NiTi (ModernArch, Wyomissing, PA) group (Figs 6A, B and 7A, B). This study revealed no difference in mandibular alignment during the rst 6 months of treatment between the ORMCO copper NiTi (CuNiTi) thermoactive arch wires and ModernArch NiTi wires, whereas increased irregularity resulted in longer treatment periods (Fig 8A, B; Table 1). The fact that no differences were observed in vivo between the arch wires may be attributed to mechanical and biological reasons. As it was discussed earlier, intraoral aging imposes signicant morphologic and structural alterations, including destruction of the structural integrity of NiTi wire, delamination, formation of craters, and increased porosity precipitation of calcium and phosphorus complexes, arising from the calcication of adsorbed integument.6

Although several studies have highlighted the alterations of wires in vivo, the sole evidence on the effect of intraoral conditions on transformation of copper NiTi (CuNiTi) wires derives from a recent study, in which the authors assessed the differential scanning calorimetric parameters of intraorally exposed and as-received wires.24 This investigation reported no difference between as-received and clinically retrieved wires in key variables related to transformation, except for a signicant reduction in heating enthalpy associated with the martensiteto-austenite transition in the 27C CuNiTi arch wires. Therefore, the hypothesis assigning the lack of difference between NiTi and CuNiTi specimens cannot be assigned to intraoral conditions, which affect the phase transformation variables of the latter. Although the foregoing discussion shows that used wires can present transformation character-

Figure 6. (A) Mandibular arch on the day of bonding tted with CuNiTi 0.016-inch wire. (B) Degree of alignment at 180 days with CuNiTi 0.016-inch wire. (Color version of gure is available online.)

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Figure 7. (A) Mandibular arch on the day of bonding tted with NiTi 0.016-inch wire. (B) Degree of alignment at 180 days with NiTi 0.016-inch wire. (Color version of gure is available online.)

istics within the range of their as-received counterparts, studies have shown exceptional temperature sensitivity for superelastic NiTi wires. Thus, alterations in mouth temperature could cause a stress uctuation in nickel-titanium wires during orthodontic treatment. Iijima et al25 investigated the effects of temperature changes on mechanical properties of the wires by examining the response of NiTi wires at constant temperature and stepwise temperature changes from 37 to 60C and back to 37C and from 37 to 2C and back to 37C. It was determined that the load expressed by the superelastic nickel-titanium wires increased with heating and decreased with cooling, phenomena attributed to a change in the critical stress for martensite transformation induced by temperature uctuations. Interestingly, in the stepwise temperature changes on heating, the load measured at body temperature as the nal step was much higher than that measured at body temperature initially; that im-

plies that perhaps sequential heating-cooling cycles of clinically applied NiTi wires may result in greater load expression at mouth temperature. Also, it has been shown that the effects on the wire vary depending on whether cooling/heating is applied during the activation or deactivation phases. Cooling induces transient effects on a wire in its deactivation phase, but prolonged effects when the wire was tested in the activation phase. In contrast, the effect of short-term heating was transient when the wire was tested in the activation phase, but prolonged when the wire was tested in the deactivation phase.26 Evidence indicating the association of mechanical properties of superelastic NiTi wires on temperature changes; have also been presented by others by the use of a different approach. Meling and Odegaard27 have reported that some true shape memory wires continued to exert sub-baseline bending force after shortterm application of cold water, and this effect remained even after 30 minutes of postexposure restitution. In addition, it has been indicated that annulling of this effect required a temperature increase to about 50C through intake of a hot drink.28 Therefore, despite the lack of significant phase transformational changes noted after use, the temperature dependence of thermoactive wires may differ from their behavior in vivo. An alternative hypothesis, which may be formulated to explain the observations of the Pandis23 study, pertains to the differences of loading conditions between the laboratory conditions and the oral cavity. In general, loading of the NiTi arch wire arising from its engagement into the bracket slot walls, presents a much different pattern than free NiTi wire segments subjected to three-point, or cantilever bending. The unique character of loading during engagement is due to the presence of free play or slack between the archwire and the slot.29 Such a pattern cannot be simulated in laboratory congurations and may differentiate the performance of the material. As a result, the simplied in vitro mechanical testing of NiTi wires may preclude the expression of the actual clinical performance of NiTi arch wires. The use of self-ligating appliances that may minimize the variability of the engagement by eliminating the variation caused by elastomeric ligation has not been shown to have an effect on NiTi wire performance. This nding may imply that the free play caused by

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A
1.00

Kaplan-Meier failure estimates (wiretype)

0.00 0

Proportion Aligned 0.25 0.50 0.75

50

100 analysis time wire = CuNiTi

150 wire = NiTi

200

0.00

Proportion Aligned 0.25 0.50 0.75

1.00

Kaplan-Meier failure estimates (crowding)

50

100 analysis time

150 irregularity > 5mm

200

irregularity < 5mm

Figure 8. (A) KaplanMeier failure estimation plot showing the variation of treatment duration by type of wire. Y-axis gives proportion of patients still in treatment (not aligned) at different times (days on x-axis); failure pertains to event, which here indicates completion of alignment. By drawing line perpendicular to x axis at given time value, proportion of patients not completed for each crowding group (moderate or severe) is extrapolated from corresponding value given in y axis. Note persistence of similarity of alignment completion pattern until day 120. The frequent crossing-over of the blue and red lines indicates no difference in time to alignment (failure) between wire types. After day 120, the lines begin to diverge showing a preference for NiTi; however, KaplanMeier plots are less reliable on the right side because the lines represent smaller sample sizes.30 (B) KaplanMeier failure estimation plot shows the variation of treatment duration with severity of crowding. Y-axis gives proportion of patients still in treatment (not aligned) at different times (days on x-axis), failure means event which here indicates completion of alignment. By drawing line perpendicular to x-axis at given time value, proportion of patients not completed for each crowding group (moderate or severe) is extrapolated from corresponding value given in y axis. Note persistence of alignment completion pattern through entire treatment period: severe crowding has higher percentage of incomplete patients compared with moderate crowding at any treatment time. (Color version of gure is available online.)

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Table 1. Treatment Time to Alignment Characteristics by Wire System and Crowding Severity (in days)
Total n Wiretype CuNiTi NiTi Irregularity Severe (5 mm) Moderate (5 mm) 30 30 29 31 Successfully Aligned 19 22 16 25 Mean Time to Alignment, Days 129.4 121.4 138.5 113.1 Min, Days 32 28 32 28 Median, Days 142.5 116.5 152.0 104.0 Max, Days 195.0 190.0 190.0 195.0

Adapted with permission from Pandis et al.23

the difference of wire/bracket slot size may be a factor even if the stress relaxation of elastomeric ligatures is excluded.

Conclusions
In conclusion, metallurgical and testing of NiTi wires may facilitate useful information on key properties of NiTi wires. However, when used to extrapolate evidence on the clinical performance of NiTi wires, these studies fail to provide reliable data. In addition, the authors of clinical trials indicate a lack of an effect of superelasticity on the crowding alleviation in vivo, an effect that can be attributed to the free play of bracket and wire inside the slot walls, as well as potential aging of the involved elements (bracket, arch wires). More clinical trials are necessary to elucidate the mechanism underlying these observations which question the clinical meaning of in vitro evidence.

References
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8. Petoumenou E, Arndt M, Keilig L, et al: Nickel concentration in the saliva of patients with nickel-titanium orthodontic appliances. Am J Orthod Dentofac Orthop 135:59-65, 2009 9. Weyman CM: Shape memory alloys. Mater Resour Soc Bull 18:49-56, 1993 10. Kula K, Phillips C, Gibilaro A, et al: Effect of ion implantation of TMA archwires on the rate of orthodontic sliding space closure. Am J Orthod Dentofac Orthop 114:577-581, 1998 11. Miura F, Mogi M, Ohura Y, et al: The super-elastic property of the Japanese NiTi alloy wire for use in orthodontics. Am J Orthod 90:1-10, 1986 12. Brantley WA: Orthodontic wires, in Brantley WA, Eliades T (eds): Orthodontic Materials: Scientic and Clinical Aspects. Stuttgard, Germany, Thieme, 2001 13. Gioka C, Eliades T: Superelasticity of NiTi alloys: metallurgical structure and clinical implications. Hel. Orthod Rev 5:111-127, 2002 14. Cobb HW III, Kula KS, Phillips C, et al: Efciency of multi-strand steel, superelastic NiTi and ion-implanted NiTi archwires for initial alignment. Clin Orthod Res 1:12-19, 1998 15. Meling TR, Odegaard J: The effect of short-term temperature changes on the mechanical properties of rectangular nickel titanium archwires tested in torsion. Angle Orthod 68:369-376, 1998 16. Tonner RIM, Waters NE: The characteristics of superelastic NiTi wires in three-point bending. part I: The effect of temperature. Eur J Orthod 16:409-419, 1994 17. Kayser D: Comparison of mechanical properties of orthodontic nickel-titanium wires. Doctoral Thesis, University of Bonn, 2001 18. Kayser D, Bourauel C, Braumann B, et al: mechanischer eigenschaften orthodontischer nickel-Titan-Drhte. Biomed Technol 47:334-342, 2002 19. Fischer C: Materials science and biomechanichal analysis of current NiTi wires. Doctoral Thesis, University of Bonn, 2009 20. ISO 15841. DentistryWires for use in orthodontics. ISO 15841, 2006 21. Segner D, Ibe D: Properties of superelastic wires and their relevance to orthodontic treatment. Eur J Orthod 17:395-402, 1995 22. Schumacher HA, Bourauel C, Drescher D: Deaktivierungsverhalten und Effektivitt verschiedener orthodontischer Nivellierungsbgen eine dynamische analyse der Kraftsysteme. Fortsch Kiefer 53:273-285, 1992 23. Pandis N, Polychronopoulou A, Eliades T: Alleviation of mandibular anterior crowding with copper-nickel-titanium

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vs nickel-titanium wires: a double-blind randomized control trial. Am J Orthod Dentofac Orthop 136:e1-e7, 2009 24. Biermann MC, Berzins DW, Bradley TG: Thermal analysis of as-received and clinically retrieved copper-nickel-titanium orthodontic archwires. Angle Orthod 207 77:499-503, 2007 25. Iijima M, Ohno H, Kawashima I, et al: Mechanical behavior at different temperatures and stresses for superelastic nickel-titanium orthodontic wires having different transformation temperatures. Dent Mater 18:88-93, 2002 26. Meling TR, Odegaard J: The effect of short-term temperature changes on superelastic nickel-titanium archwires activated in orthodontic bending. Am J Orthod Dentofac Orthop 119:263-273, 2001

27. Meling TR, Odegaard J: On the variability if cross-sectional dimensions and torsional properties of rectangular nickel-titanium arch wires. Am J Orthod Dentofac Orthop 113:546-557, 1998 28. Airoldi G, Riva G, Vanelli M, et al: Oral environment temperature changes induced by cold/hot liquid intake. Am J Orthod Dentofac Ortop 112:58-63, 1997 29. Sebanc J, Brantley WA, Pincsak JJ, et al: Variability of effective root torque as a function of edge bevel on orthodontic arch wires. Am J Orthod 86:43-51, 1984 30. Pocock SJ, Clayton TC, Altman DG: Survival plots of time-to-event outcomes in clinical trials: good practice and pitfalls. Lancet 359:1686-1689, 2002

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