Introduction to Orthodontics

Department of Orthodontics
Boston University School of Dental Medicine
Anthony A. Gianelly, D.M.D., Ph.D., M.D.
Professor Emeritus

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 Table of Contents

Introduction 1
Reasons for Treatment 3
Extraction 8
Expansion 9
Expansion Potential 10
Lower arch as diagnostic arch 11
Lower arch considerations - extraction vs. expansion 13
Age and Extraction vs. Expansion 15
Leeway Space 16
Bite Depth 18
Facial Type 19
And Bite Depth 20
Facial Growth and Development 21
Growth Direction 22
andibular Rotation 23
Divergence 27
Facial Pattern 28
Biomechanics 30
Removable Appliances 31
Fixed Appliances 32
Wire Activity 32
Applied Forces 33
Action and Reaction Components 34
Anchorage 38
Maximum Anchorage Conditions 38
Moderate Anchorage Conditions 39
Minimum Anchorage Conditions 39
Anchorage Concepts Expanded 40
Force Systems 40
Force Types 42
Cephalometrics 47
Steiner Analysis 49
Vertical Dimension 53
Steiner Treatment Analysis and Profile Determination 54
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 Superimpositions 57
Diagnosis and Treatment Planning 58
Orthodontic Standard 58
Malocclusions 61
Class I 61
Class II 63
Class III 64-5
Treatment Planning 66
Tables 69
Non-Extraction Conditions 75
Mixed Dentition 76
Asymmetric Conditions 77
Movement of Anterior Teeth 80
Movement of Posterior Teeth 80
Stabilization Forces 82
Movement Systems 88
Treatment Planning and Biomechanics 90
Treatment Plan Reevaluation 93
Third Molar Extractions 96
Treatment Procedures 97
Fixed Appliances 98
Ideal Arches 103
Loops 105
Wire Placement 107
Hygiene 107
Cooperation 107
Effects of Extrusion 108
Force Vectors 108
Extraoral Appliances 109
Intra-arch (Class I) Systems 111
Inter-arch (Class II) Systems 112
Transverse Vectors 113
Vertical Components 114
Treatment Sequence 115

ii
 In orthodontics, teeth are repositioned to create a more
aesthetic and/or functional dental complex. This necessitates a
series of decisions and procedures that, in turn, require some
knowledge of the various disciplines intimately related to
orthodontics. These include growth and development of the denti-
tion and the face, tooth movement and a characterization of the
form and pattern of the dentofacial complex.
Our intent is to discuss and clarify these decisions and
procedures to provide a rationale for orthodontic treatment. In
this process, we will explain the pertinent disciplines. To this
end, we chose the following format. We started with the obvious
question: Why is orthodontic treatment done? The answer is: to
create a more esthetics and/or functional dental complex. If
treatment is indicated, a series of factors become relevant. One is
that tooth movement is obviously necessary to reposition the teeth.
Tooth movement, in turn, means that a space is necessary for
movement to occur. The space for movement is generally gained
either by extracting teeth or expanding the dental arches. This
choice constitutes a major decision and involves a number of
considerations including the age and the dental pattern of the
patient as well as the growth and development of the dentofacial
complex. (for growing children)
In addition, tooth movement means that the principles and
procedures of tooth movement need explanation. (This area is called
'biomechanics'--probably because mechanical systems are used to
move teeth in a biologic system.) Tooth movement, in orthodontic
context, means controlled tooth movement of selected teeth so that
they can be repositioned reasonably precisely. This entails the
application of forces to the teeth to produce the desired move-
ments. Accordingly, we will describe procedures, including specific
force systems that we have found successful in effecting accurate
tooth movements.
An important corollary related to tooth movement is the
spatial position of the dentition in the face because we can alter
this location by moving the teeth. The position of the dentition in
the face contributes to facial esthetics. And we want the face,
after treatment, to be more pleasing, if possible. As such, we make
an effort to reposition the dental complex in the face 'appropri-
ately ' if necessary. For this reason, we need a method to define
the 'correct' spatial position of the dentition. This is done by
analyzing the facial proportions of the patient by means of angular
and linear measurement to describe the 'harmony' or disharmony' of
the facial pattern and the contribution of the teeth to facial
esthetics. This is called cephalometrics and the information it
provides tells us where to relocate the dentition in the face to
enhance the esthetics of the face. It also gives an indication of
the prognosis of treatment because experience has shown that the
best results are achieved in the 'harmonious' faces.
These considerations: the rationale for orthodontic treatment,

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dentofacial growth and development, biomechanics and cephalometrics
constitute a basis for understanding and performing orthodontics in
a generic sense. To become clinically useful, the 'blue print' or
'master plan' which is the network of treatment steps required to
transform a specific dental complex into one which is more
esthetics and/or functional is necessary This is called the
treatment plan. The treatment plan includes answers to the
following questions:
1) Is treatment necessary?
2) How should space be gained to move the teeth?
3) What information does the growth of the dentofacial
complex of the patient offer to the choice of the space-
gaining procedure?
4) Where does the cephalometric analysis indicate that we
should reposition the dental complex in the face?
5) What tooth movements are required and how can they be
performed?
6) What is the prognosis of treatment?
Once the treatment plan is formulated, treatment is begun and
we then describe important treatment consideration.
In essence, we tried to provide a logical basis to understand the
principles and practice of orthodontics.

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 REASONS FOR ORTHODONTIC
TREATMENT

Why do people seek

orthodontic treatment? The
three most common reasons
are
1) "My teeth are
crooked" THIS IS CROWDING OF
THE DENTAL ARCH INVOLVING
THE INCISOR TEETH.

2) "My upper teeth stick

out" THIS REPRESENTS A
MAXILLARY ARCH PROTRUSION.

3) "My lips are too far

forward. Also, I show too
much teeth." THIS IS A
BIMAXILLARY PROTRUSION. The
word bimaxillary indicates
that the incisors of the
maxillary and mandibular
dental arches are 'leaning
too far forward-essentially
forcing the lips forward.
Incisors which 'lean too far
forward are also described
as proclined or procumbent.

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 Thus, patients are motivated
mainly by aesthetic considerations.
This means that patients want:
1) Straight teeth
2) No protrusion
3) No lip fullness

There are many other problems

which are important to correct. One
is a mandibular protrusion. Another
is a 'deep bite' condition with
palatal impingement, traumatizing the
tissues. This could lead to the loss
of underlying bone, compromising the
stability of the teeth.
Note: When there is no protrusion and
the incisors are aligned well, the

maxillary canines, premolars and

molars are 3-4 mm posterior to their
mandibular counterparts. Also, the
INCISOR OVERBITE relationship is
important. The mandibular incisors
should occlude incisal to the
cingulum of the maxillary incisors.
TEETH SHOULD FIT IN THIS MANNER WHEN
THERE IS NO PROTRUSION AND NO
CROWDING. Additionally, this occlusal
complex can fulfill gnathologic
criteria, including incisal guidance
and canine protection.

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How are these conditions
resolved? By repositioning the
teeth. To move teeth, we need
space and the space is generally
made behind the teeth to be
moved.

As an example, let's consider

the correction of crowding.in the
permanent dentition.
Generally, a space is made by
extracting first premolars.
The canines are then
retracted to gain the space to
align (straighten) the incisors.
The incisors are aligned. Any
remaining space is closed by
moving the molars and second
premolars mesially.

WHEN CROWDING IS PRESENT, IT IS VERY OFTEN PRESENT IN COMPARABLE

AMOUNTS IN BOTH ARCHES. FOR THIS REASON, THE TREATMENT OF CROWDING
GENERALLY NECESSITATES THE EXTRACTION OF THE FIRST PREMOLARS IN BOTH
ARCHES .i.e. FOUR FIRST PREMOLARS ARE REMOVED.

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 Now, let's turn our attention to the
correction of a maxillary arch protrusion.
Maxillary arch protrusions can coexist with a
mandibular arch which needs no major
treatment (as an example,-- a well aligned,
well positioned lower arch) or a mandibular
arch which requires treatment (such as one in
which the incisors are crowded). For purposes
of clarity, we will describe only the
condition in which the maxillary arch
protrusion is accompanied by a mandibular
arch which requires no major treatment. In
this instance, we prefer to gain the space to
retract the protruding maxillary incisors by
moving the molars posteriorly. This is ex-
pansion of the dental arch in a posterior
direction. The space gained by moving the
molars posteriorly is then used to retract
the premolars, canines and finally the
protruding incisors.

The mandibular arch is most often

treated to make it more ideal even though
there was no significant problem in that
area. The tooth movements are generally
minimal.
Another method of maxillary arch
expansion to correct a maxillary arch
protrusion entails moving the entire
maxillary dental arch posteriorly without
opening up spaces between the teeth. The
reason we prefer the sequential movement of
the teeth is that it is most often easier to
accomplish.

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BIMAXILLARY PROTRUSION:
(Extraction)

A bimaxillary protrusion, as
indicated, represents a condition in
which the LIPS ARE FULL AND OFTEN-
TIMES INCOMPETENT (i.e. IN REPOSE,
THE LIPS ARE APART, EXPOSING THE
TEETH) because of procumbent incis-
ors. The treatment for this
condition involves the retraction of
the incisor segments to allow the
lips to move lingually, improving
the lip contour and the 'profile' in
the perio-oral region. This is done
by extracting first premolars in
both arches and retracting the
incisor segments into the space made
available by the extractions.
Lingual movement of the incisor
segments provides the space to allow

the lips to move lingually.

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These examples give clues to an important aspect of correction-- how to
find the space necessary to move the teeth. In the examples cited,
there were two methods used to gain this space. One was extraction of
teeth; the other was the expansion of the dental arch.
EXTRACTION: This generally means the removal of the first
premolars in both arches because most conditions that we correct
involve principally incisor movements. For example, crowding is most
often corrected by repositioning the incisors. Protrusions are reduced
by retracting the maxillary and/or mandibular incisor segments.

EXPANSION: This most often involves moving the molars posteriorly.

In the example cited, the molars were moved posteriorly to gain the
space to sequentially retract the premolars, canines and incisors.

CONSEQUENCES OF EXTRACTION AND EXPANSION ON

BITE DEPTH AND LIP POSITION.

EXTRACTION:
There are a couple of important corollaries
to extraction procedures. They tend to deepen
overbites because the incisors generally move
lingually and toward the occlusal plane (up-
right). As such, extraction procedures may be
indicated when there is a tendency toward an open
bite. They may be contraindicated when there is a
deep bite.
Extraction procedures also encourage the
lips to move lingually ("flatten") as the
incisors move toward the tongue. This is the
reason why lip fullness is treated by extraction
type therapy--to encourage lingual movement of
the lips.

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EXPANSION:
Bite depth tends to decrease (i.e. the bite 'opens') when the
molars and premolars are moved posteriorly. For this reason expansion
procedures are indicated when the bite is "deep." Conversely, they are
contraindicated in open bite situations.
Expansion procedures have less effect on lip position. Only the

position of the maxillary lip, which becomes less

prominent, is affected appreciably.

LIMITATIONS OF THE ANTERIOR MOVEMENT OF THE LOWER

INCISORS: (EXPANSION IN AN ANTERIOR DIRECTION)

The example used to illustrate expansion of the dental arch

involved posterior movement of the molars to gain the space necessary
to retract protrusive incisors.

What about the treatment of crowding? Can the molars be moved

posteriorly to gain the space to align crowded incisors? The answer is
yes. Another question -- can the incisors and canines be moved labially
to gain the necessary space? Theoretically,
the answer is again yes...
However, the labial movement of the
incisors and canines is generally NOT DONE for
two important reasons. The first is that these
movements are not considered stable. This is
particularly true for the labial movement of
the canines, since almost all research
indicates that expansion of the intercanine
zone relapses over time.
Additionally, the labial plate of bone
and the labial aspect of the gingival tissue
may not tolerate these movements well as such,
dehiscences and mucogingival defects can
occur.

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EXPANSION POTENTIAL OF BOTH ARCHES

Therefore, EXPANSION MEANS

PRINCIPALLY THE POSTERIOR
MOVEMENT OF THE MOLARS. But
there's a rub because there are
differences in the ability to
move the molars posteriorly in
the respective arches. MAXILLARY
MOLARS CAN BE MOVED DISTALLY 5-7
MM. IN SHARP CONTRAST, THE
MANDIBULAR MOLARS CAN BE MOVED
POSTERIORLY ONLY 1-2 MM. AT
BEST. THUS, THE MAXILLARY ARCH
IS RELATIVELY PLASTIC WHILE THE
MANDIBULAR ARCH IS MUCH LESS
ADAPTABLE. THIS DIFFERENCE IN
EXPANSION POTENTIAL IS CRITICAL AND IS A FOCAL POINT IN THE DECISION
MAKING PROCESSES. It means that there is little choice between
expansion and extraction when space is necessary to reposition malposed
teeth in the mandibular arch. If more than 1-2 mm. of space is
necessary, extractions may be required because the amount of space
necessary exceeds the expansion potential of the arch. A similar
discrepancy in the maxillary arch can be solved either by extraction or
expansion.

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LOWER ARCH--DIAGNOSTIC ARCH

Thus far we have set up the following conditions. We most often

correct incisor crowding, maxillary arch protrusions and lip
fullness. As indicated, crowding
usually involves both arches. Lip
fullness almost always involves both
arches. Maxillary arch protrusions, on
the other hand, can be paired with a
mandibular arch which has neither
crowding nor a protrusion. In fact,
this combination is often encountered.
Conversely, the mandibular arch can
also require substantial treatment to
resolve crowded and/or protruding
incisors.

Treatment necessitates moving the

teeth to new positions. For this
purpose, we need a space. This space
can be gained by extracting teeth,
generally the first premolars in each
arch, providing equal amounts of space
in each arch. Important consequences of
extraction procedures are that they
tend to 'deepen' the overbite and
encourage lingual movement of the lips.

The space can also be gained by

expansion of the dental arches, moving
the molars distally. The potential for maxillary expansion is at
least 3-4x the potential for mandibular arch expansion. Also,
expansion procedures tend to 'open the bite' and encourage the lin-
gual movement of only the maxillary lip.

A MAJOR CONCERN IS - HOW DOES ONE CHOOSE THE APPROPRIATE SPACE

GAINING PROCEDURE? This is not difficult if we remember and apply a
few of the principles we discussed previously. In stepwise fashion,
we start only with an analysis of the 2 problems that affect the
mandibular arch most often; crowding and lip fullness.

We think of the maxillary arch later. At this point, a question

should arise. Why consider only the mandibular arch?

There are a few reasons. The principle one concerns the often
repeated inability to expand the mandibular dental arch more than l-
2mm/side. This constitutes a 'limiting factor.' If crowding and/or
incisor procumbency (forward leaning incisors) requires more than 1-
2 mm of space/side to correct, extractions are generally necessary
to provide adequate space for alignment. When premolars are
extracted in the mandibular arch, they are almost invariably
extracted in the maxillary arch. Thus, the decision to extract in
the mandibular arch means that teeth will be removed in the
maxillary arch. On the other hand, if little to no space is needed
11
for mandibular arch correction, maxillary arch problems are often
resolved by maxillary arch expansion. IN ESSENCE, MANDIBULAR ARCH
CONDITIONS GENERALLY DICTATE THE SPACE GAINING PROCEDURE FOR THE
MAXILLARY ARCH. IF TEETH ARE REMOVED IN THE MANDIBULAR ARCH, THEY
ARE ALSO REMOVED IN THE MAXILLARY ARCH. WHEN THEY ARE NOT REMOVED IN
THE MANDIBULAR ARCH THEY ARE GENERALLY NOT REMOVED IN THE MAXILLARY
ARCH.
The second reason for starting with the mandibular arch is that
mandibular arch discrepancies, as discussed previously, are almost
always accompanied by a problem in the maxillary arch. Crowding in
the mandibular arch is most often associated with crowding in the
maxillary arch. Less frequently it is coupled with a maxillary arch
protrusion. Proclined
(forward leaning) maxillary
incisors are very often
associated with proclined
mandibular incisors. Thus,
the space gaining procedures
that relate to the
conditions that exist in the
mandibular arch almost
automatically pertain to the
maxillary arch also. For
these reasons, THE MANDIBU-
LAR ARCH IS THE GUIDE AND --
TO REITERATE - THE
PREVAILING CONDITIONS IN THE
MANDIBULAR ARCH MOST OFTEN
CHOOSE BETWEEN EXTRACTION
AND EXPANSION. AS SUCH, THE
MANDIBULAR ARCH IS THE
'DIAGNOSTIC ARCH.'

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 LOWER ARCH CONDITIONS EXTRACTION OR EXPANSION

Now to return to the conditions that prevail in the mandibular

arch -- we ask ourselves two questions. Is there crowding in the
incisor region? If so -- how much crowding exists? If the answer is
yes, there is crowding and it exceeds 1-2 mm/side, we think of
extraction type treatment to gain the space to align the teeth. If the
answer to the first question is
no, we think of non-extraction
procedures.
The second question is: Is
the lower lip to far forward --
indicating that the lower
incisors may be excessively
proclined. If the answer is yes,
we think of extracting first
premolars to gain the space to
retract the incisors, allowing
the lips to move lingually. When
the lip and incisors are in
reasonable position, there is no
reason to consider extraction
type treatment to relocate the incisors and lips.
Obviously there is an interrelationship, since there are two
problems to consider. Crowding can exist with or without incisor
proclination. Similarly, proclined incisors can be present with or
without crowding.

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14
 EXTRACTION
AGE AND EXTRACTION - EXPANSION

At this point we have to refine this analysis a bit and discuss

two factors which can influence the extraction-expansion decision. One
is the relationship of mandibular incisor crowding and the age of the
patient. The other is bite depth.
AGE OF THE PATIENT
Simply stated, the 'dentition' exists
in 3 different developmental stages,-the
primary dentition, the mixed dentition and
the permanent dentition. The transition from
mixed to the permanent dentition is a focal
point because there are size differences
between the primary canines and molars and
the permanent canines and premolars.
Specifically, the mesio-distal diameter of
the primary canines is approximately lmm
smaller than the size of the permanent ca-
nines. The first primary molars are almost
lmm larger than the first premolars. The
second primary molars are usually 2.5mm
larger than the second premolars. These size
differentials mean that space becomes
available in the dental arches as the premo-
lars erupt --because the sum of the mesio-
distal widths of the primary teeth is larger than the sum of the
mesiodistal widths of permanent successors. THIS SPACE IS CALLED THE
"LEEWAY SPACE" AND CAN BE AS MUCH AS 2.5MM/SIDE IN THE LOWER ARCH
(which cannot be expanded easily.) In the maxillary arch, the space is
generally no more than 1 mm because the second primary molars are
almost the same size as the succedaneous second premolars.

Under normal condi-

tions, most of this space
is consumed as the first
molars spontaneously move
mesially into this space.
On the other hand, this
molar movement can be pre-
vented by holding the mo-
lars in place (by an appli-
ance). In this instance, the leeway space becomes
available and can be used, if necessary, for tooth
movement.
The essential point should be apparent. If 2mm/side of crowding
exists in the mixed dentition stage, the space necessary to resolve
this
crowding can be obtained by preserving this leeway space. THUS, THIS
CROWDING IN THE MIXED DENTITION DOES NOT HAVE THE SAME THERAPEUTIC
IMPLICATION AS COMPARABLE CROWDING IN THE PERMANENT DENTITION STAGE.
IN THE MIXED DENTITION, THE CROWDING CAN BE RESOLVED BY NON-EXTRACTION
PROCEDURES. (Technically this is not expansion because the intent is
15
to preserve the leeway space.) In the permanent dentition, extractions
would probably be necessary.
NOW WE CAN DISTINGUISH BETWEEN AN "APPARENT" CROWDING (mixed
dentition stage crowding which can be resolved by utilizing the leeway
space) and "true" crowding which most often necessitates extraction.
THIS MEANS - WHEN LOOKING AT THE DIAGNOSTIC LOWER ARCH APPARENT
CROWDING SPEAKS TO NON-EXTRACTION AND "TRUE" CROWDING OFTEN INDICATES
EXTRACTIONS.
We focused on the mandibular arch because it is the diagnostic
arch. In the maxillary arch, the leeway space is generally no more
than 1 mm/side because the second primary molars are almost the same
size as the second premolars. This space is also consumed as the first
molars move spontaneously, mesially. The preservation of the leeway
space is not critical as in the lower arch because it is smaller and,
as a consequence, does not have the same clinical impact. More
importantly, the maxillary arch can easily be expanded if space is
necessary (unlike the mandibular arch). As indicated, the leeway space
in both arches is lost mainly as the first molars migrate mesially
when the second primary molars are shed.

LEEWAY SPACE DETERMINATION IN THE MANDIBULAR ARCH

2.5 mm of mandibular arch leeway space represents an average

value. As such, it cannot be used for the individual patient. The
leeway space in each instance should be determined and there are many
methods for this analysis. A
simple procedure is as follows:
a) Measure on a study model
the mesio-distal diameter of the
primary teeth.
b) Measure on a long cone
X-ray, the mesio-distal
diameters of the canines and
premolars. Since the X-ray image
of the teeth presents an
enlargement factor, this must be
calculated. One way is to
compare the direct measurement
of a primary tooth with the X-
ray image of the same tooth:
E.F.= X-ray image(mm)-direct measurement
direct measurement
Size of primary teeth-size
of permanent teeth = Leeway
Space.
In sum, we make a distinction
concerning crowding.
a) Apparent crowding:
incisor crowding in the mixed
dentition stage of development
that can be resolved by
utilizing the leeway space.
b) True crowding: Incisor
crowding which requires
16
extraction of teeth to obtain the space. Most often, this occurs in
the permanent dentition.

17
 Thus, when the leeway space is available, up to 5 mm of space may
be available and its use generally leads to fewer extractions.
When the leeway space is lost, extractions are much more
prevalent.
As such, in the majority of instances when there is incisor
crowding, a logical time to start treatment is just prior to the
exfoliation of the second primary molar because most of the leeway
space will become immediately available. Its control could reduce the
need to extract teeth. For example, if a patient has 2-4 mm of lower
incisor crowding and 4 mm of leeway space, the crowding can be easily
resolved by leeway space control. The same amount of crowding in the

permanent dentition might

necessitate extractions.
There are a few observations concerning leeway space utilization that
may be useful. In the mixed dentition stage of development, a Class I
relationship of the primary canines is associated with 2 different
molar relationships and both are considered to be normal because of
the Class I canine positioning. One is the Class I intercuspal
position. The second is the terminal plane or cusp to cusp rela-
tionship.
When the molars are in the Class I position, the maxillary and
mandibular molars migrate mesially approximately equal amounts after
the second primary molars are shed. In this manner, the Class I molar
relationship is maintained and becomes the mature molar relationship.
When the molars are in the terminal plane position, the
mandibular
molars mi-
grate
mesially more
than the
maxillary
molars and
convert the
terminal
plane rela-
tionship to
the Class I
molar
18
positioning.

19
BITE DEPTH
Another factor to consider when deciding whether to
extract or expand is the depth of the overbite. At the
outset,
we indicated that the overbite relationship is important and
that the mandibular incisors should occlude incisal to the
cingulum of the maxillary incisors. This is an essential
relationship in establishing a proper fit for all the teeth.
The reason is related to the anatomy of the maxillary
incisors. the bucco-lingual thickness of these teeth (as with
all incisors) is greater at the neck of the teeth when
compared to the incisal edges because of the presence of the
cingulum. Incisal to the cingulum, the bucco-lingual
thickness of the teeth is 2-3 mm; gingival to the cingulum it is 4-5
mm. This means that when the lower incisors occlude gingival to the
cingulum, where the tooth is 4-5 mm thick, there will be at least a 2
mm space (an overjet) between the labial surface of the lower incisors
and the incisal aspect of the maxillary incisors. When the lower
incisors occlude incisal to the cingulum of the maxillary incisors,
there will be no space (no overjet) between the incisors because the
lower incisors are occluding with the thinnest part of the maxillary
incisor crowns. For this reason, we concentrate on establishing proper
incisor relationships.
DEEP BITE
A deep bite exists when the mandibular
incisors occlude gingival to the cingulum of the
maxillary incisors. In extreme instances, the
lower incisors occlude against the palatal tis-
sues. As indicated, when there is a deep bite,
there will always be an overjet.

OPEN BITE
An open bite exists when the incisors do not
meet in
occlusion. (Some might indicate that an open bite
also exists when only the incisal borders touch
in occlusion.) In these instances, there is no
incisal guidance.

We also indicated that extraction procedures

deepen bites and suggested that deep bite
conditions may contraindicate extractions.
Similarly, expansion procedures tend to open
bites. As such, they are suitable for deep bite
problems and may be contraindicated for open bite
tendencies.

When mandibular arch considerations dictate extraction procedures

and the overbite is not deep, there is consistency in the treatment
design. Extractions can provide the space necessary to align the teeth
and bite depth can be controlled.

By the same token, when mandibular arch conditions dictate

expansion procedures and the overbite is normal to deep, there is
20
consistency in the treatment design.

However, there are times when the mandibular arch considerations

suggest one space gaining procedure and bite depth indicates another.
This discrepancy is at times difficult to resolve. An example is
mandibular incisor crowding in the presence of a deep bite. The
crowding speaks to extraction and the bite depth to expansion.

How do we resolve this dilemma? With the information already dis-

cussed, it can't be done easily. We need more facts, specifically
information concerning the pattern of the face of the patient. The
reason is that we believe that there is a relationship between facial
pattern and bite depth. There are faces in which bite depth can be
controlled effectively with treatment. As such, the facial pattern
does not influence the decision to extract or expand. The decision is
based on the presence or absence of crowding and/or protrusion.

There are other facial types in which a deep bite is difficult to

open for reasons which are not clear. We think it relates to the
growth pattern of the face. These type faces influence the extraction-
expansion decision significantly. When a deep bite is present in the
face of this type, bite opening procedures become a focal point. This
means that we try to expand, even in the presence of more than 2 mm of
crowding/side. This at times necessitates moving the incisor segment
labially. However, it is a price we are willing to pay to open the
bite. It is an admission that 'nature' (i.e. facial growth) is working
hard toward 'closing the bite' and is very effective in this endeavor.
As such, we try not to give nature an assist by extracting teeth.

A similar analysis pertains to an open bite tendency in a face

which perpetuates an open bite. We avoid expansion and generally
orient towards extraction.
FACIAL TYPE
The obvious next question
is --- How do we identify each
facial type? For now, we do it
by analyzing selected facial
dimensions -- particularly the
height of the face (A
"precise" assessment will be
described when we discuss
cephalometrics). We divide the
height of the face, extending
from the bridge of the nose to
the bottom of the chin into an
upper face height and a lower face height. The dividing line is the
nasal-philtrum junction. Also, we note the profile with emphasis on
the position of the chin. The profile represents the alignment, in
sagittal view, of the forehead (glabella) the philtrum and the chin.

21
In the normal face, the one in which bite
depth can be reasonably well controlled
in any type treatment, the lower face
height (LFH) is about 55% of the total
face height. (If total face height is 100
mm, LFH 55mm and UFH 45mm.) In addition,
the profile is slightly convex because
the philtrum is slightly more anterior
than either the glabella or the chin.

In the deep bite face type, the one

in which our first thought is expansion
to open the bite, the lower face height
is often the same length or even shorter
than upper face height. The profile is
straight to convex (prognathic) because
the chin is more anteriorly positioned
relative to the normal alignment.
In the open bite face type, the one
in which extractions to 'close the bite'
are considered, the lower face height is
much larger; at least 60% of total face
height. Also the profile is convex,
reflecting a posterior (retrognathic) positioning of the chin.

FACIAL TYPE AND BITE DEPTH

Here we have to emphasize that not all LONG

FACES have open bites. A deep bite can be
present. Similarly, not all SHORT FACES have
deep bites. IT IS ONLY WHEN THE 2 FACTORS GO
HAND IN HAND THAT WE ARE CONCERNED. i.e. AN OPEN
BITE IN A LONG FACE AND A DEEP BITE IN A SHORT
FACE.
To understand why these relationships exist
and how they develop, we need information
concerning the growth of the face.

22
 FACIAL GROWTH DEVELOPMENT

For purposes of clarity, descriptions of

the growth of the face are divided into 3 areas.
A) the growth of the upper facial region
comprising the anterior aspect of the cranial
base and the frontal and nasal bones, B) the
growth of the midface consisting of the
maxillary bone and C) the growth of the lower
face, represented by the mandible.

UPPER FACE GROWTH

Up to 6 years of age
all the bones of the
upper part of the face
participate in the growth process. After this
age, the growth of the anterior cranial base
probably stops while the frontal and nasal
bones continue to grow. As the frontal bone
enlarges, the frontal sinus forms.

GROWTH OF THE MAXILLA

The growth of the maxilla occurs in both

in a vertical and anterior-posterior
direction. In a vertical plane, the growth
occurs at the superior margins of the
maxilla, the various sutures and
along the dentoalveolar border. The
anterior-posterior growth occurs at
the tuberosity. The other zones
participate in the remodeling process.

GROWTH OF THE MANDIBLE

The growth of the mandible occurs

primarily in 2 areas, the condyle and
the dentoalveolar region. The condyle
is the biggest contributor and its
growth, which is mainly in a
vertical direction, moves the mandible
downward and anteriorly, possibly
reflecting the oblique orientation of
the condyle and ramus.

23
GROWTH DIRECTION OF THE 3 ZONES OF THE FACE

The movement of the various parts of

the face during the growth process, to an
extent, determines the final form of the
face. To evaluate these changes, a reference
point is necessary. Most often, the
reference point is the anterior cranial
base, particularly the midpoint of Sella
Turcica(S). When viewed from Sella Turcica
(S): 1) the upper part of the face,
represented by the junction of the Frontal
and Nasal bones (called Nasion [N]) moves
anteriorly and slightly superiorly generally
along the line extending from the midpoint
of Sella Turcica(S) through Nasion (N). 2)
The maxilla moves downward and forward
generally along the line extending from
Sella Turcica (S) through the anterior
aspect of the junction of the alveolar bone
and basal bone called Pt. A). 3) the
mandible moves downward and forward along the line extending from Sella
(S) through the chin point (Gn). THUS THE MAJOR GROWTH DIRECTION OF THE
MAXILLA AND MANDIBLE IS DOWNWARD AND FORWARD.

In addition, the growth increments

of the various parts of the face are
DISSIMILAR. The lower part of the face
grows more than the midface region which
grows more than the upper part of the
face. This is differential growth and
has been accepted as an important
concept in facial growth. One
consequence of the greater mandibular
growth is that, with time, facial
(profile) convexity tends to decrease
spontaneously as the chin moves forward
in space more than the maxilla.

Thus, there is a tendency toward a

more prominent chin and facial
straightening with normal growth. In the
average person, the chin will move 2-4 mm
more anteriorly than the maxilla with age.

24
MANDIBULAR ROTATION

Another factor contributing to the

spontaneous straightening is the AP position
of the mandible.
Mandibular position, in turn, can be
influenced in many ways. One is the change in
the pattern of closure of the mandible. For
example, in an edentulous person, the
mandible closes more than it "normally" would
if teeth, which act as "stops" in the closing
movement, were present. This "overclosure"
represents an exaggerated rotary movement of
the mandible in an anterior direction (toward
the nose) because of the decreased vertical
dimension in the dentoalveolar zone. As a
result the chin is moved in an anterior
direction and the face at times appears
prominent. In addition,
the height of the face, specifically the
lower half of the face, is decreased and the
lower border of the mandible becomes flatter
(i.e. is parallel to the floor when the
patient holds his head straight). In
contrast, if the vertical dimension in the
molar region were increased, the mandible
would be "hinged open" - indicating that the
mandible could not close fully because of the
increased vertical dimension in the molar region. This indicates
that the chin would be posterior to its more normal position and the
mandible may appear recessive even though the size of the mandible
is "normal". Also, facial vertical height would be increased and the
lower border of the mandible becomes steeper.

These examples illustrate the

relationship between selected
vertical dimensions and the
anteroposterior position of the
mandible. In addition, forward
mandibular rotation moves the chin
forward, decreases the facial
vertical dimension and flattens the
mandibular border. Backward rotation
leads to posterior movement of the
chin, increased facial vertical
dimension and a steeper mandibular
border.

25
 How does rotation occur
in the growing face? It
occurs because the amount of
vertical growth in the back
part of the face is not
equal to the amount of
vertical growth in the front
part of the face.
Specifically, we divide the
face at the pterygo-maxil-
lary tuberosity. The area
behind the PTM is the pos-
terior part of the
face and the area anterior
to this one is the anterior
part of the face. In the
anterior region, the
vertical growth occurs in
the nasomaxillary region
(including the sutures) and
the dentoalveolar regions of
the maxilla and the mandible. In the posterior part of the face, the
growth occurs at the condylar-fossa area. In effect, the growth in
the condylar-fossa or posterior area competes with the vertical
growth in the anterior part of the face.

26
 Three conditions can
exist. When the vertical
growth of the condylar fossa
area is equal to the vertical
growth in the anterior part
of the face, the mandible
descends in space and no ro-
tation occurs.

On the other hand, if

the vertical growth of the
condylar fossa area is less
than the vertical growth of
the anterior part of the
face, the mandible is "hinged
open" as it descends and RO-
TATES BACKWARD. By conven-
tion, this is called "clock-
wise rotation". In this in-
stance, the vertical growth
imbalance is converted into a
posterior position of the
chin.

Conversely, if the ver-

tical growth of the condylar
fossa area is greater than
the vertical growth in the
anterior part of the face,
the mandible tends to rotate
forward as it descends in
space. This movement bears
the name" counterclockwise
rotation" and the excess of
vertical condylar fossa
growth is converted to a for-
ward positioning of the chin.

27
 In sum, rotation occurs
when there are dissimilar
amounts of vertical
growth in the various
growth zones of the face.
This vertical growth
discrepancy then results
in anteroposterior
movement of the chin.
According to Bjork
who placed implants in 21
people and studied their
growth patterns by means
of cephalometry, the
mandible of most indi-
viduals tends to rotate
in a forward (counter-
clockwise) direction
during growth. This
movement results in a
straighter profile with a
more prominent chin. In
addition, he noted that
the maxilla also tended
to rotate in a
counterclockwise direc-
tion. This indicates that
vertical facial
development in the pos-
terior part of the max-
illa is greater than the
vertical development in
the anterior part of the
maxilla.

In a similar context, Schudy, who was one of the first to

describe vertical facial relationships, categorized faces according
to their vertical form, or as he termed it, "divergence." Faces are
either normodivergent (balanced), hypodivergent or hyperdivergent
and each represents specific "growth" conditions.

28
NORMODIVERGENT

Balanced vertical growth

indicates that the condylar growth
essentially equals or is slightly
greater than the combined vertical
growth of the nasomaxillary complex
including the alveolar process.
This facial pattern is the most
common - representing at least 65-
70% of the population. In this
facial pattern, the chin generally
rotates in a forward (counter-
clockwise) direction.

HYPERDIVERGENT

When vertical growth of the

anterior part of the face exceeds
condylar growth, anterior face
height tends to be excessive and an
open bite tendency is often present.
In addition, the cant of the
mandibular border is steep and the
chin often retrognathic. These are
called HYPERDIVERGENT faces. It is
as if there were "underdevelopment"
of the condylar region, "causing"
the mandible to rotate in a
clockwise (backward) direction. This is the type of face -
representing 10-15% of the population - in which an open bite tends
to be perpetuated.

HYPODIVERGENT

When condylar growth is

relatively excessive, posterior
face height tends to exceed
anterior face height and the chin
is usually prominent. The lower
border of the mandible tends to be
"flat," reflecting the relatively
larger posterior face height, and
the bite tends to be deep. In
addition, the face height is often
shorter. The flat mandibular border
and prominent chin suggest that some counterclockwise (forward)
rotation may have occurred during growth. One could speculate that
the vertical growth of the anterior part of the face was inadequate
relative to the vertical growth of the condylar fossa area. These
faces are classified as HYPODIVERGENT. HOPEFULLY WE CAN RECOGNIZE
THAT THESE ARE THE TYPE FACES THAT TEND TO PERPETUATE DEEP BITE
CONDITIONS.
NOW WE CAN SPECULATE THAT ONE FACTOR WHICH CONTRIBUTES TO
29
FACIAL STRAIGHTENING IS A RELATIVE EXCESS OF CONDYLAR GROWTH WHICH
PROMOTES SIGNIFICANT COUNTERCLOCKWISE ROTATION WHICH, IN TURN,
TENDS TO DEEPEN THE BITE AND BRING THE CHIN FORWARD.
This discussion concerning rotation indicates that the final
anteroposterior mandibular position (and mandibular form) is
governed, at least in part, by the relationship between condylar
growth and vertical growth in the anterior part of the face.

FACIAL PATTERN

From a clinical viewpoint, facial pattern most often is an

assessment of the anteroposterior view of the face. From this per-
spective, the profile and vertical dimensions of the face can be
evaluated and these evaluations can be used to characterize the
facial pattern. In an anteroposterior plane (profile view) the
facial pattern is described as orthognathic, prognathic or retro-
gnathic (as was the facial profile). An orthognathic pattern
indicates that the chin is "normally" positioned and the profile,
exclusive of the nose, is straight. In a prognathic pattern, the
chin is protrusive and facial concavity is apparent. A retrognathic
pattern is represented by a retrusive chin which results in facial
convexity. In a vertical plane, faces as described as nor-
modivergent (normal), hypodivergent or hyperdivergent, as outlined
previously.
Basically, as the child grows, the face moves downward and
forward "out from under" the base of the skull. Broadbent demon-
strated that, with time, the chin point (gnathion) usually descends
on or close to the diagonal line extending from sella turcica
through the bottom of the chin. The maxillary first molars also
tend to be close to the same line. This suggests that facial form
and pattern are relatively immutable. This is not entirely true.
Although the growth of the maxilla and mandible are
coordinated, and the relationship of these bones and teeth remain
reasonably constant throughout maturation, the facial pattern does
change spontaneously in individuals. This is one reason why
prediction of the final form of the face is not much more than a
considered guess at the present time. However, the changes that do
occur tend to be small. Thus, the facial pattern does tend to
maintain itself within limits. For example, the proportions of the
upper and midface region tend not to change with age. On the other
hand, the chin moves more anteriorly that the rest of the face,
straightening the facial profile. In one study, the mean change was
only 2-4mm. Yet, there was wide variation. For this reason, the
proportions of some of the subjects changed little, while in
others, the change was considerable. The variation between
individuals, at times is remarkable, and it is one of the reasons
that prediction of growth increments and direction is difficult.
In the vertical dimension, the main change that occurs is that
the lower border of the mandible tends to flatten with time
(approximately 2-4 in most people). The "flattening" probably
reflects the greater increase in condylar growth than the vertical
growth of the anterior part of the face and may be accompanied by
counterclockwise rotation of the mandible.
On a practical level, the facial pattern of most individuals
30
will be "reasonably the same" because most of the changes that
alter the facial pattern are relatively small. It is unlikely,
though not impossible, that someone with a retrognathic mandible
will later develop a facial pattern in which the mandible is
prognathic. In most instances, it is safe to assume that a young
patient with a markedly retrognathic mandible will be likely to
have a retrognathic mandible at maturity. Hyperdivergent faces tend
to remain hyperdivergent and hypodivergent faces tend to remain
hypodivergent. The chance for a spontaneous change that
significantly alters the facial pattern is always present; yet, it
appears to be small. Retrognathic facial patterns rarely become
prognathic patterns. Similarly, hyperdivergent faces rarely become
hypodivergent. The hope is that the growth process will change
abnormal facial patterns to more normal ones. There are no data to
indicate the probability of this occurrence. Unfortunately, the
clinical impression is that an abnormal facial pattern which
develops into a more normal pattern is the exception rather than
the rule.
This means that if we can characterize the facial pattern of a
patient and understand, in part, its genesis, the "rules" that
apply to that face at one point in time will almost always apply.
We now have at our disposal most of the variables, in a
general sense, that relate to the extraction-expansion decision.
1) We start with an analysis of the lower arch crowding and/or
protrusion.
2) We "stage" the dentition to determine if crowding is
apparent or real.
3) We assess bite depth.
4) We temper these data with an evaluation of the facial
pattern of the patient.
5) We decide, based on a suitable mix of the variables, to
expand or extract.
a) dental conditions (crowding/protrusion) which indicate
extraction in a normal or hyperdivergent face---
EXTRACT
b) dental conditions which indicate non-extraction in a
normal or hypodivergent face---EXPANSION
c) dental conditions favoring extraction in the presence
of a deep bite and hypodivergent face - EXPANSION
d) dental conditions favoring expansion in an open bite
face in the presence of an open bite -- EXTRACTION
When the extraction-decision is not clear, we prefer to start
treatment on a non extraction basis because extractions can always
be done at a later date if non-extraction procedures are
unsuccessful.

31
 BIOMECHANICS
A second aspect of orthodontic treatment
is: how do we move the teeth? This area of
orthodontics is called BIOMECHANICS and includes
all the factors relating to tooth movement. (At
times, biomechanics can be troublesome to
understand. For this reason, some liberties will
be taken for the sake of clarity.)
Teeth are moved by applying a force (or a
force system) to them. As a rule, forces are
applied by means of a wire with an auxiliary
such as an elastic. Both mechanisms, when
activated, have 'memory' properties which allow
them to return to their original form and
dimension. As they try to return, they exert a
force on the teeth to which they are placed.
This force stimulates the necessary
remodeling changes in the attachment apparatus
to allow the teeth to be repositioned. The
classical description is ---bone is resorbed in
areas of pressure and apposed in areas of
tension.
The bone that envelops teeth is generally
divided into 2 types and each presumably reacts
somewhat differently to applied forces. One is
compact, cortical bone which extends from the
labial and lingual surfaces of the dentoalveolar
regions directly under the soft tissue covering,
towards the teeth. At some junction point, it
meets with the second type bone, the alveolar
bone, which is less dense and immediately
surrounds the teeth and fills the interdental
zones. Thus, the dentoalveolar housing is
composed of outer cortical plates with
intervening alveolar bone.
Teeth can be moved over relatively large
distances through alveolar bone
with relatively little damage
to both tooth and bone as the
bone appears to remodel with
little difficulty. On the other
hand, if teeth are moved in
areas of the cortical plate,
the movement may be slower and
root resorption and/or dehiscences can occur,
exposing the root of the tooth. This suggests that
the remodeling capacity of the cortical bone is
less than that of the alveolar bone.
The forces placed on the teeth to move them are applied by
means of a appliance. There are 2 appliance types--removable and
fixed.

32
REMOVABLE APPLIANCES

Removable appliances are those which can be inserted and

removed by the patient and are generally used from 12-24 hours/ day.
They are composed of a passive acrylic portion which is well adapted
to the palatal and lingual soft tissues, the teeth and an active
part such as a spring, screw or loop which can be activated to apply
a force to a tooth or group of teeth. The retention of the appliance
is generally achieved by means of clasps which are placed in the
acrylic portion of the appliance.

33
FIXED APPLIANCES

Fixed appliances rep-

resent a spectrum of appli-
ances which can be affixed
to the teeth. (As such they
cannot be removed by the
patient.) Most of the appli-
ances consist of attachments
placed on the crowns of the
teeth and wires and elastics
which can insert into/onto
the attachments. The
attachments are the passive components of the appliances and are
directly placed on the teeth or are welded onto bands which are
then fitted on the teeth and cemented in place. The wires and elas-
tics are the active components of the appliances.

WIRE ACTIVITY

Generally, the wire determines the quantity of tooth movement.

This occurs because wires, as indicated, have 'memory' properties
which allow them to return to their original form and position when
they are deformed within their elastic limits. This means that the
positions of each tooth (and therefore the form of the entire arch)
will be determined by the form of the wire. If a tooth is malposed
and a wire with ideal form is placed on the arch, the wire will be
distorted when it is attached to the malposed tooth. As the wire
returns to its original form, it exerts a force on the malposed
tooth stimulating the remodeling response to allow the tooth to
move until the wire is no longer distorted. Under these conditions,
the malposed tooth will move to an 'idealized' position dictated by
the form of the wire.

34
APPLIED FORCES

Consider as an example of tooth movement,

the closure of a diastema between the central
incisors by means of an activated elastic
placed on the attachments fixed to the central
incisors.
A relatively small elastic is stretched
(activated) to encircle the attachments.
The memory properties of the elastic indicates
that it will contract to regain its original dimension. As it
does, it exerts a force on the distal aspect of each tooth,
directing each tooth mesially.
This force, in turn, results in the
necessary changes in the attachment apparatus
and each tooth moves mesially toward the
midline.
At this point, a
few clinical examples
will be used to outline
some of the principles
of tooth movement in a
clinical setting.
Assume the following conditions.
A patient presents for treatment
because his 'teeth are crooked.' An
analysis of the diagnostic lower arch
indicates that all the permanent
incisors and premolars are present.
There are 8 mm of crowding which are
equally distributed indicating that
there are 4 mm of crowding on the
right and left sides of the arch. The
maxillary arch also has 8 mm of
crowding which is equally distribut-
ed. The facial pattern is normal and
lip position is good.
These conditions immediately
suggest that extractions of the four first premolars are necessary
to gain the space required to align the teeth. The premolars are
extracted and a 7 mm space is present distal to each canine.
Since there are 4 mm of crowding per side, each canine must
be retracted 4 mm to provide adequate intercanine space to align
the central and lateral incisors.
A common method to perform this movement is: after appliance
placement, a relatively small elastic is stretched (activated)
from the canine to the molar.
As the elastic attempts to contract to its original size, it
applies a force to direct the canine distally. The elastic applies
a force on the molar and premolar, directing them mesially. In
essence, the principles that applied to the closure of a diastema
between the central incisors also apply in this example. An
activated elastic attached to teeth on either side of a space will

35
tend to move the teeth toward the space (ultimately closing the
space). Thus an activated elastic or any other applied force has
in reality 2 force components which are equal and act in opposite
directions. One is at one end of the applied force; the second is
on the other end. In the present example, one is on the canine
while the second force is on the molar-premolar unit.

ACTION AND REACTION COMPONENTS OF APPLIED FORCES

In orthodontics, these 2 force components are given names.

ONE IS CALLED THE ACTION COMPONENT OR THE 'ACTION FORCE'. THE
OTHER IS CALLED THE REACTION COMPONENT OR THE 'REACTION FORCE.' By
convention, the action force is the force that should do the task
at hand. In the present example, the task is to
move the canine distally to gain the space to
align the incisors. Accordingly, the action force
is the force component applied to the canine.
The reaction force is the force component
applied to the molar and premolar, directing them
mesially.
Since the main reasons for treatment are to
correct incisor crowding and/or retract
protruding incisors, the
action force is most often
applied to one or a group of incisors.
After applying the elastic force, assume,
ideally, that the canine moved distally 4 mm
and the molar and premolar moved mesially 3
mm. (In practice equal amounts of movement do
not always occur.) This means that 4 mm of
space would be available mesial to each canine
and the extraction site would be closed.
A wire is then inserted to produce the
necessary forces to
align the teeth.
Once this is
completed, the basic
problem of incisor
crowding is resolved.

36
 Now, consider a second
example. Assume that a pa-
tient is seeking treatment
because the "top teeth stick
out." Analysis of the
diagnostic lower arch indi-
cates that there is no in-
cisor crowding. Turning our
attention to the maxillary
arch, we find that there is
maxillary arch protrusion. In
addition, the bite is deep.
The facial pattern and lip
position are good.
These conditions indi-
cate that one solution to the
problem is to move the molars
distally to expand the
maxillary arch for the
sequential posterior movement
of the premolars and canines
and finally the retraction of
the central and lateral
incisors.
A commonly used mechan-
ism to move the molars
distally is to place a
headgear against the molars.
The headgear is an appliance
which consists of 2 parts,
one intra-oral, the other is
extra-oral. The intra-oral
part is a wire placed against
both molars. The wire has ex-
tensions with hooks that ex-
tend out of the mouth. The
extra-oral part is an elastic
which is placed on the head
and/or neck. The force is applied to the molar (i.e. the headgear is
activated) by stretching the elastic from the head and/or neck area
and attaching this to the hooks on the extensions of the wire placed
against the molars. Thus, the activated elastic applies the distally
directed force against the molars. This is the action component of
the applied force. The reaction component is placed against the head
and/or neck.
Once the molars have been moved distally (a procedure which
usually takes 6 mo.- 1 yr. to complete) a space exists between the
molars and the teeth anterior to the molars.
The second premolar is then moved distally by means of an
elastic extending from the molar to the premolar.

37
 The action component directs the premolar distally. The reaction
component directs the molars mesially. However, we just spent at
least 6 months moving the molars distally and we want to maintain
this molar position. Thus, we are faced with a problem. How can we
apply the action force to move the premolar distally while nullifying
the effect of the reaction force? One solution to this problem is to
reapply the headgear which places a distally directed force against
the molars. The function of the headgear is not to move the molar
further distally. IT IS TO COUNTERACT THE MESIAL COMPONENT OF FORCE
ARISING FROM THE REACTION FORCE. The headgear, in effect, stabilizes
the molar position. The completed force system is:
To repeat, the headgear applies a distally directed force
against the molars. The intent of this force is to "block" any mesial
molar movement that may result from the
placement of the elastic. Under ideal
conditions, the 2 opposite forces on the
molar balance and the molar position in
unchanged...because there is no net force
in any direction against the molar. If no
headgear were applied, the elastic would
inevitably move the molar mesially. Any
mesial movement of the molar would impinge
upon the space necessary for the movement
of the premolars, canines and incisors.
Without adequate space for the movement of
these teeth, the protrusion of the
incisors cannot be corrected successfully.
Once the
second premolars
are retracted, the
first premolars
and canines are
moved distally in
a similar manner--
an elastic extend-
ing from the molars to the respective teeth.
The reaction force is again stabilized by the
use of the headgear. After the canines are
moved distally, the space is available to
retract the central and lateral incisors and
these teeth are retracted.
These two examples illustrate some
important principles of biomechanics.
Specifically, to move a tooth, a force is
applied. This force has an 'action' component
and a 'reaction' component and both are
capable of moving teeth. The action component
has to do the intended task. In the first
example, an elastic was placed to move the
canines distally 4 mm. In the second example,
after the distal movement of the molars, an
elastic was placed to move the second pre-
molars (and sequentially the first premolars
and canines) posteriorly and the incisors lingually. In both
38
instances, the action forces were placed to produce the desired tooth
movements and this is generally true in all conditions. The action
force is expected to produce tooth movement.
The conditions relating to the reaction force are not so
straight forward. In the first example involving EXTRACTIONS, the
molars and premolars had to be moved 3 mm mesially by the reaction
force because the required distal movement of the canines was only 4
mm while the available space was 7 mm. The 3 mm of mesial movement
was necessary to close the space that remained after the canines were
in position.
In the second example in which EXPANSION was done, the reaction
force was not allowed to produce tooth movement because the entire
available space was necessary for the movements of the premolars,
canines and incisors. To prevent mesial molar movement, a counter-
force in the form of a headgear (placing a distally directed force
against the molars) was used. To repeat, if the reaction force
produced mesial molar movement, the space available for the required
premolar, canine and incisor movements would be inadequate and the
treatment would be compromised.
The difference in the evaluation of the 'action' and the
'reaction' force is fundamental in orthodontics. A clue to the
thinking process is: controlled tooth movement is essential to
resolve problems well. For controlled movement, allow only the
desirable tooth movement from each force component. As indicated, the
tooth movement produced by the action component of the applied force
is just about always desirable since the action force is selected to
do the 'job.'
On the other hand, tooth movement produced by the reaction
component of the applied force can either be desirable or
undesirable, depending on the clinical conditions. WE HAVE TO DECIDE
WHEN IT IS DESIRABLE AND WHEN IT IS NOT-- i.e. should the reaction
force move teeth or not? This decision is very important. One reason
is that treatment is successful only when the desired movements
occur. This means that the action force has "first call" on the
available space. As indicated, if the necessary space is consumed by
movement provoked by the 'reaction' force, the success of treatment
would be compromised because the space available to reposition the
malposed teeth would now be inadequate. As an example, if, after
extracting a first premolar, the available space were 6 mm and the
canine had to be retracted 6 mm in order to gain enough space to
align the incisors, --the job at hand is to produce 6 mm of distal
movement of the canine by means of the action force while not
provoking any mesial movement of the molars and premolars. Assume
that we place an elastic, extending from the canine to the molar to
retract the canine. This force system places the reaction force on
the molar-premolar unit. As such, its tooth movement capacity has to
be "blocked" to preserve the entire 6 mm of available space for the
movement of the canine.
IT SHOULD BE APPARENT THAT A CRITICAL DECISION IS: "WHAT SHOULD
BE DONE TO CONTROL THE TOOTH MOVEMENT POTENTIAL OF THE REACTION
FORCE?"

39
 ANCHORAGE
The control of the reaction force is discussed under the heading
ANCHORAGE, an umbrella word used to encompass and represent many
clinical situations involving the appropriate management of the
available space. Accordingly, the word ANCHORAGE is an important part
of the language of orthodontics. At first, it may be difficult to
grasp how one word can mean so many things. Why not just describe the
clinical conditions in plain English rather than adopt a new word?
Unfortunately, the word is a key one and is universally used. As
such, we have to accept it as part of the vocabulary and master its
meaning.
The word anchorage probably arose because someone made a
comparison between the ability of the reaction force to be dissipated
so that it does not move teeth and the ability of a boat to remain in
place when it is anchored. Be that as it may, the parallel between
the placement of the reaction force and the 'anchor' idea is firmly
entrenched and we accept the fact that the area to which the reaction
force is placed is the 'anchor unit.'
The anchor unit may be many things including one or a group of
teeth. WHEN THE ANCHOR UNIT IS ONE OR A GROUP OF TEETH, IT IS
GENERALLY ONE OR A GROUP OF POSTERIOR TEETH. This probably reflects
the fact that the action force is most often placed on the incisors
to resolve the previously mentioned incisor problems--crowding and
protrusions.
When the anchor unit is
one or a group of posterior
teeth, it can obviously be
easily moved since the teeth
cannot distinguished between
the action and reaction
components of the applied
force.
There are three main
anchorage conditions that are
described: MAXIMUM, MODERATE
AND MINIMUM ANCHORAGE
CONDITIONS: (In the following
descriptions the anchor unit
represents a group of
posterior teeth.)
a) MAXIMUM ANCHORAGE
CONDITIONS:
There are times when the
anchor unit should not move.
Thus, it should act as "stable
an anchor." These conditions
are described as maximum
anchorage conditions. Since
the anchor unit should remain
stable, the reaction force should produce no movement. Accordingly,
only the action component of the applied force should produce tooth
movement when maximum anchorage conditions exist. This analysis leads
to a method of defining anchorage by the following questions - Should
40
only the action force move teeth in the available space - or should
movement also result from the reaction force? Consider the following
clinical example: To gain space to resolve crowding in the incisor
region, first premolars were extracted, leaving 7 mm of space on each
side of the arch. According to the treatment plan the canines must be
distalized 7 mm. by the action force. For this reason, the posterior
teeth (the anchor unit) should not move anteriorly into the
extraction space, indicating maximum anchorage conditions. i.e. Only
the "action" force applied to the canine should produce movement.
Arbitrarily maximum anchorage conditions exist when at least 2/3
of available space must be used for movements produced by the action
force and no more than 1/3 of the available space can be used for
movement of the anchorage unit.

b) MODERATE ANCHORAGE CONDITIONS:

Intermediate situations exist and these
are called Moderate Anchorage Conditions.
In these instances some movement of the
anchor unit is expected - utilizing be-
tween 1/2 and 2/3 of the available space.

c) MINIMUM ANCHORAGE CONDITIONS: Finally,

there are other times when movement of the
"anchor unit" should consume the majority, or
at least 2/3 of the available space. These
are minimum anchorage conditions - indicating
that the anchor unit should move extensively.
In other words, the "reaction" force should
produce extensive tooth movement. At first
glance this may seem inconsistent since we
have most often emphasized that the anterior segment should move more
than posterior segments and the "action force" should produce more
tooth movement that the "reaction force. In this instance, the an-
terior segment should move little and the reaction force should

produce more movement.

This apparent contradiction occurs because we want to keep the
anchorage classifications uniform and continue to describe the
component force placed on the posterior teeth as the "reaction force"
for 2 reasons. One reason is for ease of classification. The other is
that the more frequent clinical conditions are those of maximum and
moderate anchorage.
Admittedly, it could be argued that minimum anchorage conditions
indicate that the incisor unit is under conditions of maximum
41
anchorage.

42
 ANCHORAGE CONCEPTS -
EXPANDED

There is one special circumstance which needs discussion. The

posterior movement of the molar to gain space for subsequent
movements represents maximum anchorage conditions for the maxillary
arch.
Previously, we said that anchorage pertains to the appropriate
use of the available space. How is this situation relevant since
there is no space? In this instance, anchorage is used in
anticipation of having available space to manage. In the initial
examples in which the anchorage conditions were defined, the space
was provided by extractions. Since extractions take no time and no
movement (i.e. force application) is involved, the word anchorage is
not applied to the procedure. On the other hand, distal movement of
the molars requires both force application and time, and when the
space becomes available, it almost always must be controlled under
maximum anchorage conditions --- THE MOLARS MUST NOT MOVE MESIALLY.
The term anchorage is also used in a broader context. (In fact,
this may be the more common usage.) "Maximum Anchorage" describes
clinical situations in which posterior teeth either are moved
distally or should not move mesially; "Moderate Anchorage" indicates
that posterior teeth can move mesially to an extent and "Minimum
Anchorage" indicates that posterior teeth must move anteriorly a
large distance. (When there are minimum anchorage conditions relating
to the posterior units, the anterior unit should not move more than
1/3 the available space. Thus, in this instance maximum anchorage
conditions pertain to the incisor segment.)
A clinical description might be: maximum anchorage conditions
exist for the maxillary posterior teeth and moderate anchorage
conditions for the mandibular posterior teeth. This immediately
brings to mind: 1) The maxillary posterior teeth should not move
mesially, 2) The mandibular posterior teeth should move mesially to
consume at least 1/3-2/3 of the available space.

FORCE SYSTEMS AND PLACEMENT OF ACTION AND

REACTION FORCES IN VARIOUS ZONES

There are 3 basic force systems used to

move teeth:
a) The action and reaction forces can be
applied in the same arch - an intra-
arch system.
b) The action force can be applied in one
arch and the reaction force in the
other arch. This is an interarch
system.
c) The action force can be applied to one
arch and the reaction force extra-
dentally.

a) Intraarch System (Action and Reaction forces in the same

arch-sometimes called Class I forces). Consider as an example an
elastic extending from the molar to canine to retract the canine. The
43
action force is applied to the canine and the reaction force to the
molar premolar unit. Another example is the use of a removable ap-
pliance. This appliance distributes the reaction force over all the
structures it touches (palate, teeth, etc.) (As such the tooth
movement capacity of the reaction force becomes reduced.)

b) Interarch system (Action and Reaction

Forces In Different Arches)
1) Class II elastics (Class II
forces)
These are elastics extending from
the anterior aspect of the maxillary
arch to the molar region of the lower
arch. In terms of anchorage, the action
force is applied to the maxillary in-
cisor region while the reaction force is
placed on the lower molar region.

2) Class III elastics (Class III

forces)
These are elastics extending from
the lower incisor region to the maxillary
molars. They place the action force on
the lower incisors and the reaction force
on the maxillary molars.

C) Reaction forces placed

extradentally
1) An example of this force
system is an extraoral appliance
used to move the maxillary molars
posteriorly. The action force is
placed on the teeth while the
reaction force is placed on the
head/neck region.

2) A second example is the use of a lip bumper which is placed

against the lower molars. The appliance is a large bar type appliance
whose length is longer than the length of the lower arch. When placed
against the molars, it extends anteriorly past the lower incisors and
44
"bumps" into the lip. Reflex contraction of the lip pushes the bumper
against the molars. The action force is thus applied to the molars
while the reaction force is placed against the lip.

45
FORCE TYPES

Only 2 forces are used to move teeth.

These are:
1) a 'single' force which is used to
move the crowns of the teeth with reason-
able precision. When a single force is ap-
plied to a tooth to move the crown, the
crown moves in the direction of the applied
force and the root moves in the opposite
direction. THE ROOT MOVEMENT IS OFTEN UN-
DESIRABLE. Movements resulting from the
application of a 'single' force are called
"tipping" movements. A typical example of
the application of a single force is the
use of a finger spring on a removable
appliance or an elastic placed on a fixed
appliance.

A CENTER OF ROTATION is
established in the apical
1/3 of the tooth. Incisal
to this point, the crown
moves in the direction of
the applied force. Apical
to the COR, the root moves in the opposite direction.

2) A "force couple" which is used to move the roots of the

teeth with reasonable precision. The crowns move in the
opposite direction and THIS MOVEMENT IS GENERALLY
UNDESIRABLE. A "force couple" may be conceptually somewhat
difficult to visualize for those unaccustomed to applying
force to teeth. The definition of a "force couple" is the
application of a force which simultaneously applies 2
moments (moment=force x distance) which are equal in
magnitude, parallel and act in opposite directions.

46
Movements resulting from the application of a couple are called
"torquing" movements. Couples can be applied routinely only with
fixed appliances. This means that removable appliances are extremely
limited because they cannot apply "force couples" easily. As such,
they cannot control root position effectively.
Wire bent to Wire inserted: Force couple is ap-
apply force couple plied as wire returns
directing the root to original shape
distally.

Root moves distally:

Crown moves mesially

47
Since there are 2 forces, there are only 3 methods to apply these
forces:
a) a single force can be applied by itself
b) a "force couple" can be applied by itself
c) a force couple and a single force can be applied at the same time.
1) SINGLE FORCE APPLICATION-This is very
commonly used and the crowns of the teeth can
be moved extensive distances. The axial
inclination of the teeth changes as the roots
move in the opposite direction. The
undesirable root movement is generally
corrected after the crowns have been
positioned.
2) A "FORCE COUPLE" BY ITSELF - Generally
this is NOT done for a number of reasons. One
reason is that the undesirable crown movement
may be exaggerated.
3) A FORCE COUPLE AND A SINGLE FORCE
SIMULTANEOUSLY-This is a common force system
and probably the most often used with fixed
appliance therapy. It is used to produce 2
particular types of movement.
a) controlled root movement in which the
root is moved in the desired direction and
crown position remains unchanged and
b) bodily movement in which both crown
and root move in the same direction at the
same rate.
l)Controlled root movement: The root is moved
by means of the application of the "force
couple." The function of the single force is
to block the undesirable crown movement that
results from the application of the force
couple. For example, if the root of a canine
is directed distally by applying a force couple, the crown will move
mesially. To block the mesial crown movement, a single force such as an
elastic is placed on the canine and extended posteriorly to apply a
distally directed force to the crown of the canine. In this manner, the
root moves distally while the crown remains in position.

48
 Controlled Root Movement - Center of Rotation at the
incisal border.

2) Bodily movement:
Assume the same condi-
tions as in the previous
example. As explained,
the root moves distally
while crown position
remains stable because
the single force coun-
teracts the expected
mesial crown movement
induced by the
application of the force
couple. Now assume that
the magnitude of the
single force is increased. In this in-
stance, it not only blocks the mesial
crown movement but in fact moves the crown
distally. THUS BOTH ROOT AND CROWN MOVE
DISTALLY. Conceivably, if the relationship
between the force couple and the single
force were adjusted 'perfectly', the root
and crown can be moved in the same direc-
tion at the same rate, EFFECTING BODILY
MOVEMENT.
In the examples cited, the force
couple was formed to move the root of the
canine distally. Force couples are
routinely formed to move the roots of
teeth in either the mesio-distal or bucco-
lingual planes of space. In orthodontic
terminology, root movements in the mesio-
distal plane o£ space are called second
order (II order) movements. Bends in the
wire which apply a force couple to direct
the roots either mesially or distally are
called second order bends.

BODILY MOVEMENT:
THERE IS NO ROTATION. AS SUCH, THERE IS NO
CENTER OF ROTATION - i.e., THE COR IS AT
INFINITY

49
 Root movements in a bucco-lingual direction are called third
(III order) movements and bends in wires which produce bucco-lingual
root movements are called third order bends.
Bucco-lingual root movement is generally more difficult to
produce than mesiodistal root movement because it often necessitates
the use of an adjusted rectangular wire (which usually requires more
technical proficiency) to apply the force couple in a bucco-lingual
direction.
TORQUE
In orthodontic terminology, a force couple applied to a tooth
is also identified as a TORQUE
placed on a tooth. Thus torque
application means the placement
of a force couple-generally to
direct the root of a tooth in a
mesio-distal or bucco-lingual
plane of space.
In sum, a single force and a force couple
are used follows:
a) a single force to control crown
position
b) a couple to control root position
c) the simultaneous application of a
couple and a single force to:
1) to produce controlled root
movement - i.e. moving the
root while maintaining crown
position
2) to move the tooth bodily
The difference between controlled root movement and bodily
movement is the relationship between the magnitude of the couple and
the single force.
The most commonly used systems are:
a) a single force
b) the simultaneous application of a couple and a single
force
At this point, some general comments should be reviewed
concerning the relationship between crown and root movement. As a
rule, crown movement is a relatively simple and uncomplicated
movement to produce. It occurs readily with modest effort. On the
other hand, root movement is both difficult and complicated to
produce.
Large overjets, on the order of 5-6 mm can be reduced in 3-4
months, reflecting the ease of crown movement. In contrast, the
necessary root movement can take up to 1 1/2 years. And the
appliance system to accomplish the root movement is much more
complex than the one used only for crown movement. IN EFFECT THE
CONTROL OF THE FORCE COUPLE IS A CRITICAL ASPECT OF FORCE DELIVERY
AND IT IS NOT ALWAYS EASY.

50
 CEPHALOMETRICS
We have just described some of the general considerations
concerning the extraction-expansion decision and introduced
biomechanics. We said that if crowding is present, extraction
procedures come to mind. If lips are protrusive, extractions again
come to mind. However, these are somewhat imprecise evaluations. If
we extract teeth to retract the incisor segments to allow the lips
to move lingually, how much retraction is required to encourage the
"proper amount" lingual movement of the lips? It is not enough to
indicate
that the incisor segments should move lingually,- - we have to
decide specifically how much lingual movement is required. In short,
more precision is necessary.
For this purpose, we have to introduce another topic-
Cephalometrics-because one important function of cephalometric
evaluation is to define the proper spatial position of the incisor
segments. In addition, cephalometrics is indispensable if we want to
define specific facial patterns in concrete terms. (Unfortunately,
cephalometrics, for most, is an entirely new language. As such, it
can be cumbersome in the beginning stages.)
From lateral cephalograms, selected structures are measured to
determine the facial pattern. An X-ray source and a head fixator or
cephalostat are used to obtain the cephalograph.
The distance between the x-ray beam and the midsagittal plane of the
head is constant and standardized at 5 feet. These requirements are
achieved in the following manner: The patient's head is placed in a
headholder which is situated at a fixed distance from the x-ray
tube. The film is placed in a cassette which is inserted into a
receptacle on the headholder.
The relationship between Kvolt, milliampere and exposure time we use
is as follows:
KV Time Age
(msec)
80 0.3 <7 years old
90 0.7 7-12 years old
90 0.7 teens
90 0.8 adult
(with rare earth film, times can be reduced)
To outline the soft tissue profile, a lead shield can be
inserted in the x-ray tube or a hand held shield can placed near the
soft tissue contour of the cheeks by the patient when the x-ray is
taken.
Once the x-ray is developed, a tracing of the film can be made.
For this purpose, acetate paper is placed over the film while it is
illuminated on a viewer and a pencil tracing is made to include at
least the following structures:
a) the molars and incisors of both arches
b) the maxilla and the mandible
c) the anterior cranial base
d) the soft tissue profile
The facial pattern of an individual patient is characterized by
comparing a given patient's pattern to a norm or standard which
represents a balanced face i.e. has normal dentofacial
51
relationships. The "norm" is usually obtained by analyzing lateral
cephalograms of individuals whose faces are "harmonious." This
analysis generally entails an evaluation of linear and angular
measurements using selected landmarks as reference points for these
determinations. The same measurements are made for the patient and
these are compared to the 'normal values.'
There are over 100 different cephalometric analyses which means
that it is virtually impossible to master all of them. Basically,
most analyses usually have a skeletal and a dental component. The
skeletal part describes relationships between various cranial and
facial structures and the dental aspect indicates the relationship
of the teeth to themselves, their supporting structures and the
face.
We will use the Steiner analysis (named after its originator-Cecil
Steiner) to illustrate some aspects of the role of cephalometrics in
orthodontics.
Some of the structures and planes used in this analysis are:
Sella (S) the geometric center
of Sella Turcica
Nasion (N, Na) the intersection
of the frontal and nasal bone in the
midsagittal plane.
Pogonion (Pog) the most
anterior point on the chin
Point A (Pt.A) the deepest
point of the concavity in the
midline of the premaxilla between
the anterior nasal spine (ANS) and
prosthion. It indicates, in the
sagittal plane, the intersection of
basal and alveolar bone and it is
used to represent two entities, the
maxilla and the anteriorsuperior
aspect of the maxillary arch basal
bone (apical base). It therefore
represents the most anterior posi-
tion of the maxilla in the sagittal
plane.
Point B (Pt.B) the most distal point in the concavity between
infradentale and the chin point (pogonion); it represents the
anterior-inferior aspect of the mandibular basal bone (apical
base)
Gnathion (Gn) the most anterior, inferior point of the chin
Gonion (Go) the most outward point of the mandibular angle at
the junction of the ramus and body
The reference planes are:
1) Sella-Nasion (SN) a line connecting the Sella to Nasion.
It is used to represent the anterior cranial base.
2) Nasion-Pt.B (NB) a line connecting Nasion to Point B
3) Mandibular Plane (MP) a line drawn through Go-Gn

Dental landmarks:
1 the maxillary central incisor
1 the mandibular central incisor
52
6 the maxillary first molar
6 the mandibular first molar

53
STEINER ANALYSIS

Although the Steiner analysis is not divided into skeletal and dental
components, it can arbitrarily be separated as follows:
SKELETAL RELATIONSHIPS:
1) SNA angle: 82. This angle is
measured at the intersection of the SN plane
to N-PT. A. plane and relates the maxillary
apical base to the cranial base. It
indicates the antero-posterior position of
the maxilla. Angles above 82 represent
increasing maxillary prognathism; below 82
- increasing maxillary retrognathism.
2) SNB angle: 80.
This angle is
measured at the
intersection of the SN plane and N-PT.B. plane and
relates the mandibular apical base position to the
cranial base. Angles above 80 represent increasing
mandibular prognathism; below 80 - increasing man-
dibular retrognathism.
3) ANB angle: 2.
This angle, formed
at the intersection
of the NA and NB
planes, relates the antero-posterior
positions of the maxillary and mandibular
apical bases to each other. Above 2 in-
dicates increasing facial convexity; below
2 - increasing facial concavity.
4) SND angle: 76.
(Pt. D is the mid-
point of the
symphysis.) This angle, measured at the intersection
of the SN and N-Pt.D. plane indicates the normal
antero-posterior position of the mandible. Its sig-
nificance is the same as for SNB. Steiner used Pt. D
as the reference landmark for the mandible because he
believed that it was more stable than Pt. B. which
changes with tooth position.

54
 4) SN-GoGn angle: 32. this angle
is formed at the intersection
of the SN plane and the GoGn
plane. It indicates the slope
of the mandibular plane. Above
32 indicates an increasingly
steep mandibular plane; below
32 an increasingly flat
mandibular border.

DENTAL PATTERN

1) 1:NA: 4mm. This linear measurement, made

from the labial surface of the maxillary incisors
to the NA line, indicates the antero-posterior
position of the maxillary incisors relative to the
maxillary apical base. Above 4mm represents an
increasing incisor protrusion; below 4mm, an in-
creasing retrusion.
2) 1:NA 22. This
angle is formed at the
intersection of a line drawn through the long axis
of the incisors and the NA plane. It describes the
axial relationship of the incisor to its apical
base. Above 22 indicates procumbency of the
incisors; below 22 signifies upright incisors.
3) 1:NB 4mm. This
linear measurement,
determined from the labial
surface of the lower
incisors to the NB line, relates the antero-posterior
position of the lower incisors to the mandibular a-
pical base. It indicates incisor protrusion (above
4mm) and retrusion (below 4mm).

5) 1:NB: 25. This

angular relationship,
measured at the in-
tersection of a line drawn in the long axes of the
lower incisors to the NB plane, represents the
axial relationship of the lower incisors to the
mandibular apical base. It indicates proclination
(above 25) or retroclination
(below 25) of the lower inci-
sors.
6) PO and 1:NB: 0mm. this linear measurement
represents the difference between the position of the
lower incisors and pogonion relative to Pt. B. It has
been adapted from the studies of Reed Holdaway and is
based on the idea that harmony exists if Pt. B is lin-
early equidistant (or almost so) from the labial tip of
the lower incisor and pogonion. Under these conditions,
55
the mandibular teeth are placed 'correctly' both in their base and in the
face-i.e. skeleto-dentally correct.
WHEN INCISORS ARE MORE FORWARD THAN POGONION, THEY SHOULD BE RETRACTED
UNTIL THEY ARE IN THE EQUIDISTANT POSITION-i.e. THE PROFILE SHOULD BE
REDUCED. The amount of space necessary to bring the incisors to the
equidistant position is a reasonable estimate of the profile requirement.

7) 1:1: 131. This angle is formed at the intersection

of the line connecting the long axes of the
incisors. Above 131 indicates upright incisors.
Below 131 indicates incisor procumbency.
8) SN:Occlusal plane:
14. This angle is
measured at the
intersection of NS and
occlusal planes. It
reflects the steepness
of the occlusal plane and its significance
is similar to that of the cant of the
mandibular plane.
Some comments concerning the apical base relationship (ANB angle) are
in order because the teeth are encased in these bones and our job during
treatment is to move the teeth. Since the teeth can only move where there is
bone, it is important to understand the relationship of the apical bases of
the teeth because they can constitute "limiting factors." Essentially, the
apical bases should almost be in a straight line. To explain the reason for
this, we have to digress a bit and talk
about the overjet that exists between the
maxillary and mandibular incisors when the
teeth are in occlusion.
Previously we indicated that there
should not be an overjet, indicating that
there should be no space between the
lingual aspect of the maxillary incisors
and the labial aspect of the mandibular
incisors. This relationship places the
maxillary incisors slightly anterior to
the mandibular incisors so that the labial
surfaces of the maxillary incisors are 2-
3mm anterior to the labial surfaces of the
mandibular incisors.(This distance
reflects the bucco-lingual thickness of the crown tips of the maxillary
incisors incisal to the cingulum.
Now to return to the apical bases which "house" the teeth. The
maxillary apical base should be only 2-3 mm anterior to the mandibular
apical base.(This is the meaning and ANB angle of 2. Essentially, the
supporting bones should be the mirror image of the positions of the teeth.
When the apical bases deviate, protrusions are generally apparent. For
example, in maxillary arch protrusions, the maxillary apical base is often
more than 2-3 mm anterior to the maxillary apical base, leading to facial
convexity (ANB>4. When the mandibular incisors protrude, the maxillary
apical base is less than 2 mm anterior to the mandibular apical base and
facial concavity is often present.
56
 Furthermore, ideal dental relationships can only exist when the apical
bases are related correctly. Ideal relationships indicate that both the
positions of the crowns and roots are 'correct.' Now we are talking about
the axial inclinations of the teeth, particularly the incisors, and the
relationships of the roots to the bases. Generally, the roots of the
incisors are slightly lingual to the crowns. And the roots are not more than
a few millimeters from the labial aspect of the apical base. This means that
both the crowns and roots of the maxillary and mandibular incisors can be
reasonably well related only when the apical bases are normally positioned.
This is one of the reasons that aligning the apical bases to approximate the
normal relationship is an important treatment objective. A second reason is
that the more severe malocclusions tend to be associated with apical base
discrepancies. If the apical base relationship can be corrected, the problem
becomes easier to resolve.
Why make such a fuss about this? One reason is that aligning the apical
bases is not so easy. This view reflects the accepted belief that we can
reposition teeth far more readily than we can alter the relationships of the
'skeletal' structures. Dental malocclusions, representing essentially
crowding within the framework of normal apical base relationships, can be
resolved relatively easily because only tooth movement is involved. On the
other hand, a skeletal imbalance poses many problems. One concerns incisor
root position.
When the apical base
relationship is normal,
indicating that the
maxillary base is 2-3 mm
anterior to the mandibular
base, the roots of the
maxillary incisors are also
a few millimeters anterior
to the roots of the
mandibular incisors. This
is normal positioning and
treatment generally would
not attempt to change this relationship. As such, most incisor movements
involve mainly crown movements. As an example, if an incisor protrusion
exists, it is corrected by retracting only the crowns of the incisors
because the roots are in normal position.
In contrast, when the apical bases are far apart and a protrusion
exists, the roots of the maxillary incisors are more than a few millimeters
anterior to the roots of the mandibular incisors. In treatment, this
relationship is changed, if possible, to approximate the more normal
position. This indicates that root movement is necessary. In this instance,
correction of an incisor protrusion involves movement of both crowns and
roots. The required root movement is much more difficult to accomplish than
a similar amount of crown movement. Not facetiously, when comparing crown to
root movement, it's like the "ounce to the pound." In one technique, it is
common to reduce a protrusion by retracting the crowns of the incisors
first. When the crowns are in position, the roots are then moved to restore
proper axial inclination. Large overjets, on the order of 7-8mm can be
reduced in 3-4 months, reflecting the ease of crown movement. The necessary
root movement can take up to 1 1/2 years. And the appliance system to
accomplish the root movement is much more complex than one used for only
crown movement. For this reason, the apical base relationship has important
57
diagnostic, treatment planning and prognostic implications. In addition, an
apical base discrepancy, to an extent, defines the degree of difficulty of
the problem because, as indicated previously, the more severe malocclusions
are most often associated with poor apical base relationships. Patients with
normally related apical bases usually are easiest to treat and they have the
best prognosis. Patients with apical bases that are "far apart" are harder
to treat and carry a less favorable prognosis. Furthermore, the prognosis
becomes less favorable as the severity of the apical base involvement
increases.
VERTICAL DIMENSION
Many different parameters are used to define normal vertical rela-
tionships. Two important ones are the anterior face height and the steepness
of the lower border of the mandible. They are significant because they
identify, to an extent, two particular vertical dimension problems that we
encounter; a hyperdivergent face which is "too long" and a hypodivergent
face which is "too short." One reason
for detecting these patterns is that
"SHORT AND LONG FACES TEND INDICATE
SPECIFIC TREATMENT PLANS AND
OBJECTIVES." As an example, in
hypodivergent "short" faces, the chin
is often prominent and the bite is
"deep." This suggests that treatment
procedures which tend to deepen the
bite and/or make the chin more
prominent should be avoided, if
possible. One such procedure is the
extraction of teeth. In hyperdivergent
"long faces," there is often a tendency
toward an open bite and a retrognathic
chin. Thus, treatment procedures which orient toward bite opening and
backward displacement of the mandible might be contraindicated. One such
procedure is the distal movement of the posterior teeth--as in non
extraction treatment.(The above analyses are gross generalizations and serve
only to indicate that vertical dimension is important. The variations that
occur in long and short faces indicate that these considerations are at best
partial guides.)
As discussed previously, anterior face height can be divided into upper
face height as measured from N to ANS and lower face height as measured from
ANS to the bottom of the chin. Normally, lower face height is approximately
55% of total face height. Grossly different proportionalities may indicate
abnormal vertical relationships. (However, there is no clear cut-off point.)
Faces in which the lower face height is less than 50-55% of the total face
height are usually considered the "short" type faces and the previously
described conditions for short faces tend to pertain.
When the lower face height exceeds 55-60% of total face height, the
face is "long" and the long face implications
may be applicable.
The steepness of the lower border of
the mandible is measured by means of an angle
formed at the intersection of a line along
the mandibular plane and a line through a
reference plane such as the SN plane. For
example, the mandibular plane is not steep
58
(i.e. harmony exists) when the SN-MP angle is approximately 32. Although
there is no specific number to indicate vertical dysplasia, angles below 28
and above 38-40 arouse suspicion.

A face with a MP angle below 28 (low angle) often has a shorter lower
face, prominent chin and a deep bite. Thus, the 'short face' conditions
exist. Conversely, a face with a MP angle above 38-40 or the "high angle"
type face is usually associated with 'long face' conditions.

59
 STEINER TREATMENT ANALYSIS AND PROFILE DETERMINATION

An ideal apical base difference of 2 places the maxillary apical base

slightly anterior to the mandibular apical base. This reflects the fact that
the labial aspect of the maxillary incisor is slightly (approx. 2mm)
anterior to the labial aspect of the mandibular incisor. Under these
conditions the incisors can be paced in ideal positions. When the apical
bases are further apart (as the ANB angle is greater than 2) the positions
of the incisors must be changes to compensate for the apical base "spread."
Under these conditions the mandibular incisors are inclined more labially
and the maxillary incisors more lingually in an attempt to close the apical
base gap.
Steiner has described a mathematical system for determining these
changed inclinations which is explained as follows:

I Patient’s problem II Estimate ANB angle at end of

ANB (1) treatment (A)

(B) values from chart

(2) 1:NA (mm) (3) 1:NA (?) of compromises

(C) values from chart

of compromises
(4) 1:NB (mm) (5) 1:NB (? )

IV (problem resolved) ANB

III. (add pogonion-D) estimate (A)

G = (B+F)/2 I – from chart of

F = E-(C-B) compromises

(E) Same as H = (C+E)/2 J – from chart of

estimated for compromises
Pog:NB

Estimate Pog:NB at end

of treatment (D)

60
NUMBERS AND LETTERS CORRESPOND TO APPROPRIATE POSITIONS ON FIGURE

I. On the problem chevron record from the Steiner analysis.

1. Patient's initial ANB value
2. Upper incisor to NA value in millimeters (1/NA)
3. Upper incisor to NA line in degrees
4. Lower incisor to NB line in millimeters (1/NB)
5. Lower incisor to NB line in degrees
II. To determine the ANB chevron: (Note: ANB REDUCTIONS EQUALS 50% OF THE
DISCREPANCY.)
A. Improvement in ANB angle during treatment is estimated by:
1. Take patient's original ANB value and subtract the ideal ANB
value (2) from it (This is your discrepancy value)
2. Take this new value and divide it by 2
3. This resultant value is the amount of ANB reduction possible
for this patient which may be achieved during treatment
PROBLEM ANB-2
2 = ANB REDUCTION: RESOLVED ANB = PROBLEM ANB
(A) minus ANB REDUCTION
Record this value at (A) on the chevron
B. The positions of the upper and lower central incisors that this
new ANB angle dictates are determined using the acceptable
compromises chevrons:
2? 4? 6? 8?

4mm 22? 2mm 20? 0mm 18? -2mm 16?

4mm 25? 4.5mm 27? 5mm 29? 5.5mm 31?

- Acceptable compromises

4. Find the appropriate chevron for your resolved ANB value

5. Record at (B) the upper incisor to NA line (mm) value
obtained from this acceptable compromise chevron
A. Again using the same compromise chevron for this resolved ANB
value:
1. Record at (C) the lower incisor to NB line (mm) value
obtained from the chevron
III. Estimation of what Pog to NB line will be at the end of treatment
A. This estimation takes into consideration: sex (males generally
have more pronounced chins), age (males usually complete growth
(13-18yrs.) later than females (11-13yrs.), past growth magnitude
and directions (flat mandibular planes generally more change in
Pog-NB relationship than if steep mandibular plane), pubertal
status, etc.
i.e. 13 yr. old male with flat MP may have 2-3 mm more increase
in size at Pog while 12 yr. old female with steep P may only have
0.5 to 0 mm further change at Pog.
B. Remember to add your estimate of further Pog development to the
initial Pog measurement to achieve the Pog to NB value for (D).
C. Holdaway, utilizing his Utah Study Group, believed that ideally
61
 the lower central incisor and Pog should be equidistant from the
NB line at the conclusion of treatment. Therefore at (E) record
the same millimeter measurement that you obtained for Pog to NB
at the end of treatment (value at D)
D. F = E-(C-B) where C, B and E are known values. Solve for F.
According to Moyers, F and E now hold the same relative
relationship to the NA and NB lines in both the ANB and Pog
chevrons. (F is ahead of E the same distance that B is ahead of C
in their respective chevrons.)
IV. The resolved chevron combines the positions of the upper and
lower incisors as they are dictated by the ANB angle and position
of Pog to NB line. To do so:
A. The resolved ANB (A) and Pog (D) values are carried over from
their respective chevrons.
B. The final distance (G) of the upper incisor in millimeters from
the NA line is formed from the average of the upper incisor
position in the ANB chevron (B) and the Pog chevron (F)
C. The final relationship of the lower incisor to the NB line in mm
(H) is the average of the lower incisor positions from the ANB
chevron (C and Pog chevron (E) H = C+E
2
D. Again utilizing the acceptable compromise chevron for the
resolved ANB value, determine what the angle for the upper
incisor to NA line should be and record at (I)
E. To complete the resolved chevron, determine the angle of the
lower incisor to NB line from the acceptable compromise chevron
and record at (J)
To determine the amount of profile reduction required by Steiner:
6 Take the patient's initial lower incisor to NB line value in
millimeters (number 4 on the problem chevron)
7. From this, subtract the resolved lower incisor to NB line
value (mm) (H in the resolved chevron)
8. The resultant value (record at relocation 1) tells how many
millimeters PER SIDE the lower incisor must be retracted
according to Steiner to obtain an esthetics profile for the
for the resolved ANB and Pog positions.
NOTE: These are only estimates and therefore only useful as a guide.
They may be modified for individual circumstances. It may also
be necessary to round off numbers in determining final positions
using the acceptable compromise chevrons.

62
 SUPERIMPOSITIONS

Tracings of serial cephalographs

are often compared by superimposing one
over the other to determine the changes
that occurred in the craniofaciodental
relationships during the intervening
periods. For example, if a radiograph
were taken of a person at 8 years of
age and another radiograph of the same
subject taken at 11 years of age, and
tracings of the films were
superimposed, the changes noted in
facial form represent the growth
changes that occurred. Similarly, we
can also analyze changes that occur
during treatment by superimposing
tracings of pretreatment and post-
treatment radiographs.
An indispensable aspect of su-
perimposition is to establish reference
points or reference planes as a basis
for comparison. Our preferences are:
1. to determine the gross changes
that occurred in the entire cran-
iofaciodental complex, superimpose on
the SN line registering on S.
2. to determine the changes that
occurred in the maxilla, superimpose on
the internal contour of the maxilla
between the floor of the nose and the
palate.
3. to determine changes that
occurred in the mandible, superimpose
on the internal contour of the sym-
physis and the mandibular canal. (If
the canal
is not visible, use the lower border of
the mandible.)
The tracings of 2 or more ra-
diographs can be superimposed. For this
purpose, the individual tracings are made of different colors. For
instance, the Angle Society suggestions for the analysis of treatment
changes is:
Black--pretreatment tracing
Blue--midtreatment tracing
Red-- posttreatment tracing
Green--postretention tracing

Summary of some of the indications of cephalometry

1. To analyze craniofaciodental relationships
2. To function as a common language
3. To help define a more precise diagnosis and treatment plan
4. To study the craniofaciodental changes that occur during growth and
63
 development
5. To evaluate the changes that occur in the dentofacial complex during
and after treatment
DIAGNOSIS AND TREATMENT PLANNING
In the preceding sections we have outlined some background information
that explains many of the clinically relevant principles of orthodontics.
Our next step is to discuss specific factors used to formulate a precise
diagnosis and treatment plan, including effective treatment procedures for
every patient.
The starting point is a description of the goals of treatment,
identified as the 'Orthodontic Standard' and the various malocclusion
syndromes which represent the problems we treat.

ORTHODONTIC STANDARD

Orthodontic treatment is based on the premise that a malocclusion

exists and will be corrected. We said earlier that most orthodontics is done
to resolve crowding and or a protrusion. Crowding and
protrusions, then, are the more common signs of a
malocclusion. If we can say this, it means that we have
in mind a 'standard' as a basis for comparison and this
standard, as mentioned earlier, has no crowding or
protrusion.
It's worth reviewing this standard in more detail
because it serves 2 important and fundamental purposes.
It is the basis for comparison to evaluate the presence
or absence of a malocclusion. It also represents the
end point of treatment. For example, if the standard
has ideal alignment as a component, then crowding
represents a malocclusion and ideal alignment is the
treatment objective. (i.e. the position we want the
teeth in after treatment.)
For orthodontic purposes, the Class I "ideal"
occlusion (in centric relation) is the 'norm' for the
dental complex because it fulfills orthodontic objec-
tives of perfect alignment, no overjet, a modest over-
bite with the lower incisors occluding incisal to the
cingulum of the maxillary incisors. (This occlusal
pattern also meets gnathologic criteria.) In the
sagittal plane, these dental relationships place the
maxilla slightly anterior to the mandible and the
upper lip slightly anterior to the lower lip.
Secondly, the mesiobuccal cusp of the maxillary
first molar must occlude with the mesiobuccal grove of
the mandibular first molar.
This molar arrangement, which
was first described and
classified by Edward H. Angle
as the Angle Class I molar
relationship, places the
posterior segments of the
maxillary dentition 1/2-1
cusp (2.5-3mm) posterior to the buccal segments of the mandibular dentition.
64
It follows that the maxillary cuspids are 1/2 cusp distal to the mandibular
cuspids (Class I cuspid relationship), providing more space across the
anterior part of the upper arch to fit the larger maxillary incisors. thus,
the more posterior position of the maxillary buccal segments is necessary to
accommodate the larger maxillary incisors without a protrusion or crowding.

A Class l occlusion can only exist when certain conditions are met. One
is that the teeth in one arch must be a perfect match for the teeth in the
other arch. Since the mandibular teeth are more lingually positioned
relative to the maxillary teeth, the mandibular arch perimeter is smaller
than the maxillary arch perimeter. Therefore the tooth substance of the
mandibular arch must be smaller. According to one index,(the Bolton index)
the combined mesiodistal width of the mandibular teeth, including all teeth
from first molar to first molar, must be 91% of the combined mesiodistal
width of the comparable teeth in the maxillary arch for proper relation-
ships. Any discrepancy will force a compromise in the requirements of
'normal' occlusion. For instance, if the combined mesiodistal width of the
maxillary tooth substance is the same as the mandibular booth substance,
intercuspation is impossible without spacing in the upper arch.
When comparing the combined mesiodistal width of the maxillary and
mandibular six incisors (canine to canine), the width of the lower teeth is
only 77% of the width of the upper teeth.

65
 In addition, the midlines of each arch must be
coincident.
Finally, the axial inclinations of the teeth must
conform to a pattern. In the maxillary arch, the
incisor roots are tipped
palatally and the cuspid
roots are tipped distally.
The premolars are upright
and the molars are tipped
slightly distally. In the
lower arch, the incisors are
lingually inclined and the
canine roots are tipped
distally. The premolars and
molars are essentially up-
right.
We mentioned previously the position of the dental complex in the face
is an important aspect of facial esthetics. In orthodontics, this is defined
as the 'skeletal' requirement of 'normal' occlusion. This means that the
dentition and its supporting structures must relate 'harmoniously' to the
rest of the face and head so that the midlines of the dentition align with
the middle of the face and no gross protrusions or retrusions are apparent.
A maxillary protrusion is an obvious example of a dento-facial imbalance. In
this instance, the protrusion should be reduced by retracting the protruding
teeth to a point that places the dentition in harmony with the rest of the
face.
Thus, in orthodontics, 'normal' occlusion is a description of the
anatomic relations in the dentofacial complex. Dentally, the alignment is
perfect and the axial inclinations of the teeth are correct. When the teeth
are in contact in centric relation, the molars and canines are in Class I
relationship and the interdigitation is maximum. If these conditions are
met, the midlines will be coincident and there
will be no overjet and little overbite. Finally,
the dental complex and the rest of the face are
in harmony.
These occlusal relationships are not normal
in a biologic sense because they do not exist in
the majority of the population. On the other
hand, a principle goal of orthodontic therapy is
to transform the dentofacial complex of the
patient to this idealized pattern. As suggested
previously, it serves as a basis for diagnosis
and treatment planning as well as a model for the expected result. It is,
therefore, an excellent parameter to assess the success of treatment. In a
sense, it both simplifies and complicates the life of an orthodontist. It
simplifies his/her existence because it constantly reminds her/him of
certain basic aims of treatment. As such, it is an invaluable reference
point. It complicates her/his existence because the success of treatment is
easily measured.

66
MALOCCLUSIONS

The Class I ideal occlusal pattern with no crowding and no overjet also
represents the 'reference norm' to indicate the presence of a malocclusion.
Essentially, any significant deviation from this pattern represents a
malocclusion.
When registering occlusal relationships, it is important to establish
that the condylar-fossa relationships of the patient are acceptable. This
means that any difference between centric relation and centric occlusion
should be no more than 1 mm. Larger deviations can lead to an incorrect
analysis of the dentofacial relationships.

CLASS I MALOCCLUSIONS

Classically, three main

variations (Angle classification)
are described and divided
according to molar position. When
the molars are in the Class I
position and crowding and/or a
protrusion exists in either or
both arches, a CLASS I MALOC-
CLUSION exists.
The facial pattern is
generally normal in these patients (i.e. the apical
bases are well aligned etc.) and the usual skeletal
problem is a bimaxillary protrusion.
Classically, three main variations (Angle
classification) are described and divided according to molar position. When
the molars are in the Class I position and crowding and/or a protrusion
exists in either or both arches, a CLASS I MALOCCLUSION exists.
The facial pattern is generally normal in these patients (i.e. the apical
bases are well aligned etc.) and the usual skeletal problem is a bimaxillary
protrusion.

67
CLASS I MALOCCLUSIONS CAN REPRESENT:

68
 CLASS II MALOCCLUSIONS

When the maxillary

molars are anterior to
the normal Class I
position,(i.e. in mesio-
occlusion) a CLASS II
MALOCCLUSION is present.
This molar position, in
effect, means that the
maxillary arch is forward
when compared to the
mandibular arch. It also means that the incisor
segment is anterior, as evidenced by the mesial
positioning of the canines.

CLASS II, DIVISION I

MALOCCLUSION

Expectedly a maxillary arch protrusion is

commonly present. In this instance, the syndrome
is called a CLASS II DIVISION I MALOCCLUSION,
indicating mesial positioning of the molars and
the presence of an overjet.
The facial profile of patients with Class II
Division I malocclusions is often convex,
reflecting a 'spread' between the apical bases (an
apical base discrepancy). This discrepancy can
result from a) a prognathic maxilla, b) a
retrognathic mandible or c) a combination of the
two factors. Skeletal involvement obviously
indicates that the degree of difficulty is
increased and the prognosis less favorable.

In Class II malocclusions, the mandibular

arch can be 'good,' protrusive and/or crowded.

69
 CLASS II DIVISION 2
MALOCCLUSION

Another Class II malocclusion type, which occurs

less frequently, is characterized by incisor crowding
rather than the presence of an overjet. One specific
pattern of crowding, when the maxillary central
incisors are lingually inclined and the lateral
incisors are labially inclined, is commonly
encountered. This variant is called a CLASS II
DIVISION II MALOCCLUSION.
The facial profile in patients with Class II
Division II malocclusions, is most often straight to
slightly concave, and the facial pattern is
characteristically hypodivergent with relatively
short lower face height,
prominent chin point, flat
mandibular plane and a deep bite.

70
 CLASS III MALOCCLUSIONS

When the maxillary molars are posterior to

the normal position (distal occlusion) the
maxillary arch most often is posterior to the
mandibular arch. Thus the mandibular incisors are
protrusive and the profile is concave. These
problems are called CLASS III MALOCCLUSIONS.
There are 2 types: pseudo and true.
A Pseudo Class III malocclusion is, in
reality, Class I problem complicated by an
anterior cross bite. The reason that this
condition resembles a Class III malocclusion is
that the cross bite 'provokes' an eccentric path
of closure for the mandible in an anterior
direction. In centric relation, the facial
pattern is normal and the incisor relationships
are generally edge to edge.

In a true Class III malocclusion, a skeletal imbalance is present. This

can represent: a) a retrognathic maxilla, b) a prognathic mandible, or c) a
combination of the two factors.
A guess at the frequency of the various
malocclusions may be: Class I type 60-70%
Class II, 20-30% and Class III, 1-3%. In
clinical practice most problems treated are
Class II malocclusions, reflecting the
type problem people want most to treat.

71
 TREATMENT PLANNING
Up to this point, we have discussed some of the various conditions
that are involved in our extraction-expansion decision. To review briefly,
we evaluate the crowding in the lower arch. If crowding exists in the mixed
dentition stage of development, we calculate the leeway space to determine
if it is adequate to resolve the crowding. We then assess bite depth,
facial profile with emphasis on lip position and the facial type to
categorize the pattern of growth.
Crowding in the lower arch, the presence of 'full' or incompetent
lips, bite depth which is normal or a tendency toward an open bite suggest
extractions when the facial pattern is normal to hyperdivergent.
Conversely, minimal to no crowding, 'flat' lips, a deep bite and a
facial pattern which is normal to hypodivergent suggest non extraction
procedures.
We also outlined some of concepts of biomechanics.
Now we are ready discuss more precisely how the extraction-expansion
decision is made and how to plan the appropriate tooth movements to
resolve a malocclusion. This involves formulating a treatment plan which
in effect:
a) chooses between extraction and expansion
b) decides which teeth or group of teeth should be moved, how much
and in what direction
c) decides which teeth or group of teeth should not move (i.e.
defines the anchorage conditions)
d) chooses appropriate force systems to produce the
desired tooth movements and to stabilize where necessary, other teeth
or groups of teeth.
Characteristically we start by evaluating
the 'diagnostic' lower arch for a couple of
reasons. One, and probably the most important,
is the difference in expansion potential of
the mandibular and maxillary arches. To
review, in the mandibular arch, expansion,
which almost always means distal movement of
the molars, is usually limited to l-2mm/ side.
On the other hand, expansion in the
maxillary arch can provide much more generous
space. For example, it is possible to gain 5-7
mm of space per side by moving the molars
distally and this procedure is commonly done.
Clinically, the limited expansion potential of the mandibular arch
indicates only minor amounts of crowding and/or a protrusion - on the
order of a few mm - can be resolved by expansion. Essentially, the lower
arch must be born "good" to avoid extractions. "Good" means that little to
no incisor crowding and/or protrusion exists. Or, if it exists, there is
adequate space somewhere in the dental arch to allow the crowding to be
corrected. In the mixed dentition stage of development, the leeway space
represents available space. Otherwise, extractions are generally
necessary. Accordingly, mandibular arch conditions generally dictate
whether the space necessary for tooth movement should be gained by
extraction or expansion.
For convenience we use a 'mathematical' aid to make the extraction-
expansion decision and to plan treatment. This does not mean that we treat
people by 'numbers.' The numbers serve as a means of outlining the
72
conditions of a malocclusion (In addition, they are useful in communicat-
ing these conditions to others.)
CROWDING
The first step is to quantify he amount of crowding in the lower
arch. In the permanent dentition, it is usually calculated by direct
measurement on a study model. We divide the arch into a left and right
segment and measure the mesiodistal diameters of the teeth in each segment
starting from the mesial of the first molar. We then measure the arch
perimeter of each segment by placing a brass wire, with symmetrical arch
form, across the marginal ridges of the teeth in the existing arch up to
the midline. If teeth are not in the boundaries of the arch, such as a
labially placed canine, they are nor included. The wire is then straight-
ened and the length recorded. This represents the available space for the
teeth. Tooth size is then compared to arch size. When there is a space
deficiency, it is recorded with a minus (-) sign in mm. For instance, if
the combined mesiodistal width of the teeth on each side of the arch is
32mm and the arch length for each half of the arch is 29 mm, the discrep-
ancy is -3mm/side. This indicates that to align the teeth, 2 mm of
space/side must be made available.
R L
1) Crowding -2 -2

CURVE OF SPEE CORRECTION

The second factor to evaluate is the curve of Spee. In treatment, the
curve of Spee must be flattened. One reason for this is that maximum
intercuspation can be achieved more readily when the arches are flat. To
reduce the curve of Spee, space is necessary. However, the actual amount
of space is difficult to calculate precisely. Empirically, we use the
following method which is both simple and reasonably accurate" We place a
straight edge over the occlusal surfaces of the teeth in the mandibular
arch, extending from the most posterior tooth anteriorly. We then measure
the vertical distance from the most inferior aspect of the arch (generally
in the premolar area) to the straight edge. This value represents the
amount of space necessary on each side of the arch to flatten the curve of
Spee.
R L
1) CROWDING -2 -2
2) COS -2 -2

MIDLINE
The third factor is midline evaluation. The midline of the lower arch
should be coincident with the middle of the face so that both sides of the
dental arch are symmetrically positioned in the mandible and the face.
(This is in preparation for placing the midline of the maxillary arch over
the lower midline. In this manner, dental and facial midlines will be
coincident.) When the midline of the lower arch and the midline of the
face are coincident, there is no discrepancy. In this instance we assign a
value of O mm-indicating that no discrepancy exists.
If, on the other hand, the midline of the lower arch were located 1.5
mm to the left of the midline of the face, we have to move it to the RIGHT
to correct its position. This means that we need 1.5 mm of space on the
RIGHT side of the arch for this purpose. It also means that we will
liberate space on the left side of the arch as the teeth are shifted to
the right. We quantify this situation as follows: Right side: -1.5mm - -
indicating the need for space Left side: +1.5mm - -indicating the gain in
73
space
R L
1) CROWDING -2 -2
2) COS -2 -2
3) MIDLINE 0 0

74
 PROFILE CORRECTION

The fourth factor is the need for space to correct the profile. i.e.
to retract incisors which are protrusive. As indicated previously, this is
a cephalometric determination and we use the Steiner analysis (as outlined
previously) to quantify the amount of movement necessary to correct the
profile. When lingual movement of the incisors is necessary, a minus sign
is used to indicate the need for space in the arch. For instance, if 2 mm
of incisor retraction /side is indicated, a designation of -2mm/side is
made.
Ordinarily, there is no designation with a positive (+) sign because
we almost never move the incisors anteriorly for the reasons discussed
previously.
The correction of the spatial position of the lower incisors repre-
sents a 'skeletal' correction since it adjusts the position of the dental
complex in the face appropriately.
These 4 parameters represent the needs for space to obtain a skeleto-
dental correction of a malocclusion. Three of these; the resolution of
crowding, curve of Spee and midline correction represent the dental
component. The fourth, profile correction, is the skeletal component.

R L
1) CROWDING -2 -2
2) COS -2 -2
3) MIDLINE 0 0
4) PROFILE 0 0
5) SPACE NECESSARY -4 -4

75
 We then set up a table from which we can "read" a diagnosis and
treatment plan. For the sake of illustration, let's assume that we have the
following problem--a Class I malocclusion in which there is 6 mm of crowding
in the lower arch, uniformly distributed, a moderate curve of Spee,
requiring 1 mm/side to 'flatten', and the midline is coincident with the
midline of the face. In addition, the spatial position of the lower incisor
is good--needing no correction. We start be listing the 4 factors previously
cited: Crowding, COS, Midline and Profile as follows:

Lower Arch Analysis:

R L
1) Crowding -3 -3
2) COS -1 -1
3) Midline 0 0
4) Profile 0 0
5) SPACE NECESSARY -4 -4 Item #5 is the sum of factors 1-4. It
indicates that 4 mm of space is necessary on
each side of the arch to correct the crowding,
COS, etc.
6) EXT or EXP +7 +7 Item #6 asks the question: "How can the
necessary space be gained? By EXTRACTION or
EXPANSION? The appropriate choice is under-
lined.
7) MOVEMENT 6 6 +3 +3 Item #7 represents the amount of space
'left' after the crowding and profile
requirements are resolved. (Thus the alignment
and spatial position of the incisor segment
should be correct.) The amount of space left
is derived by subtracting from the space
gained by extraction (7mm) the space necessary
for correction(4mm). In this example, 3 mm of
space would be 'left.' To close this space,
the molars and premolars must be moved
anteriorly.

It should be apparent that, up to this point, we haven't included the

maxillary arch in our space analysis since we don't record any crowding or
protrusion of the maxillary arch. This is not because we don't worry about
maxillary arch crowding or protrusions. We do, but we don't discuss them
directly. Rather we concern ourselves principally with maxillary molar
position because of the reasonably rigid relationship between the maxillary
and mandibular teeth. When the molars are in the Class I position, the
maxillary and mandibular arches are, most often, "mirror images". (As long
as there are the same number of teeth in both arches.) If crowding exists in
the mandibular arch, the maxillary arch will almost invariably exhibit
crowding. If the lower incisors are protrusive, the maxillary incisors will
also be protrusive. This is the important thought. It means that when the
mandibular arch, skeletodentally, is correct and the molar position is Class
I, the maxillary arch should also be correct at the end of treatment. If
mandibular arch correction requires the removal of teeth, comparable teeth
are almost always extracted in the maxillary arch. Normally, the teeth
extracted are the first premolars. This means that when mandibular premolars
are extracted, maxillary premolars are also removed.
Because of these close relationships, the Class I molar position is an
76
indispensable reference point. In essence, molar position is a "short hand"
method of describing maxillary crowding and/or protrusion after an analysis
of the lower arch is done. In addition, it gives a clue to the space
necessary for their resolution. If molar position is Class I, space should
be available in the maxillary arch to correct any crowding and/or
protrusion. If molar position is Class II, adequate space may not be
available unless the molars are moved to the Class I position. If molar
position is Class III, there may be too much space in the maxillary arch
unless the molars are moved to the Class I position. For this reason, we
include molar relationships in our table, and we outline the steps necessary
to arrive at the Class I position, with the assumption that if we achieve a
Class I molar relationship, we can place the maxillary arch over the
corrected mandibular arch to achieve an 'ideal' Class I occlusion.
We classify the molar relationship in the following manner. When the
molars are in Class I relationship we say that there is no discrepancy
between the molars. Arithmetically, the discrepancy is O mm.
A Class II malocclusion is characterized by the mesial placement of the
molars (and the maxillary arch) in relation to the mandibular molars (and
arch). There are 2 common Class II molar relationships. One is the cusp to
cusp pattern and the mesial edges of the molars are on the same vertical
plane. This means that the maxillary molars are approximately 3 mm anterior
to the 'norm' position. For this reason we identify this molar relationship
as a discrepancy -3mm. (The negative sign is used to indicate that the
maxillary molars theoretically should move distally 3 mm to arrive at the
'normal' relationship.) The second common Class II molar position is when
the maxillary molars are one full cusp anterior to the mandibular molars.
This pattern represents a discrepancy of -5mm - indicating that 5 mm of
molar movement would correct this molar position.
In Class III malocclusions, the situation is reversed. the maxillary
molars can be l-5 mm posterior to the 'norm' position in relation to the
mandibular molars. This molar discrepancy is designated +l-5 mm, indicating
that mesial movement of the maxillary molar is necessary.

77
The molar relationship at the start of treatment--Designated as
RELATIONSHIP 6 6
6 6
becomes item #8 in the table. Adding item 8, the table for this Class I
malocclusion is now as follows:

R L
l) CROWDING -3 -3
2) COS -1 -1
3) Midline 0 0
4) Profile 0 0

5) Space Necessary -4 -4
6) EXT/EXP +7 +7
7) Movement 6 6 +3 +3
8) 6 6
6 6 relationship 0 0 This represents the Class I molar
relationship that was present at the
9) To complete the table, we re- start of treatment. As such, there was
cord the movement of the no discrepancy in molar position.
MAXILLARY MOLARS necessary to (i.e. 0mm)
achieve a CLASS I molar rela-
tionship DESIGNATED AS:

6 6 MOVEMENT +3 +3 This value is obtained by adding

the amount of mesial movement that
would occur (item #7) to the molar
relationship (item #8). In the present
example, it indicates that the
maxillary molars must move forward 3
mm to achieve a Class I relationship.
This makes sense because the original
molar relationship was Class I and the
lower molars were moved anteriorly 3
mm to close the lower arch space after
the incisor requirements were
completed. It follows that the
maxillary molars also must move
mesially. Otherwise, a Class III
relationship would be present.

78
 How would this table be changed if the malocclusion characterized by
identical lower arch conditions and a cusp to cusp, -3mm molar position.
This molar relationship can be resolved in one of 3 ways: a) Distal movement
of the maxillary molars, b) anterior movement of the mandibular molars and
c) a combination of distal movement of the maxillary molars combined with
mesial movement of the lower molars. In context of the present example, a)
the maxillary molars can be moved distally 3 mm. b) the mandibular molar can
be moved mesially 3 mm or c) the maxillary molar can be moved distally 1 mm
in combination with 2 mm of anterior movement of the mandibular molars. In
each instance, the combined amount of movement is 3 mm--equaling the amount
of molar discrepancy.
In the table, items #1-7 would be identical to those outlined
previously since the lower arch conditions are the same.

R L
1) Crowding -3 -3
2) COS -1 -1
3) Midline 0 0
4) Profile 0 0

5) Space necessary -4 -4
6) EXT-EXP +7 +7
7) Movement 6 6 +3 +3
8) 6 6 Relationship -3 -3
6 6
9) 6 6 Movement 0 0 This indicates that to achieve a
Class I molar relationship, the
maxillary molars MUST STAY IN
POSITION. The total amount of molar
discrepancy will be resolved by mesial
movement of the lower molars. TOTAL
MOLAR MOVEMENT IS 3 MM.

79
 How would the table change if the malocclusion were a Class II
malocclusion characterized by identical lower arch conditions and a molar
relationship which is one full cusp Class II, a -5 mm discrepancy. Again
items #1-7 would be identical.

R L
1) Crowding -3 -3
2) COS -1 -1
3) Midline 0 0
4) Profile 0 0

5) Space necessary -4 -4
6) EXT-EXP +7 +7
7) Movement 6 6 +3 +3

8) 6 6 Relationship -5 -5
6 6

9) 6 6 Movement -2 -2 This indicates that THE MAXILLARY MOLARS

MUST MOVE DISTALLY 2 MM to arrive at the
Class I position. Thus, the molar
relationship is resolved by a combination of
3 mm anterior movement of the lower molars
and 2 mm distal movement of the maxillary
molars. TOTAL MOLAR MOVEMENT IS 5MM.

80
 EXAMPLE: BIMAXILLARY PROTRUSION
Let's now focus on the problem of a patient who wants treatment because
"my lips are too far forward." The molar relationships are Class I. An
analysis of the lower arch skeletodental conditions indicate that there is
only 2 mm of crowding, evenly distributed, a COS requiring 1 mm/side to
flatten and a coincident midline. Finally, the profile requirements are 5
mm/side. In table form:

R L
1) Crowding -1 -1
2) COS -1 -1
3) Midline 0 0
4) Profile -5 -5

5) Space necessary -7 -7
6) EXT-EXP +7 +7

7) movement 6 6 0 0 The mandibular molars should not move--

because all the available space is necessary
for incisor alignment, COS and profile reduc-
tion.

8) Relationship 6 6
6 6 0 0 Class I molar relationships at the start
of treatment.

9) Movement 6 6 0 0 The maxillary molars must not move

because they are in the Class I position and
the mandibular molars are not to be moved.

From this table, the tentative diagnosis and preliminary treatment plan
is that extractions are necessary to gain space to resolve the crowding and
reduce the profile. Also, the extent of the space requirement to resolve
these problems means that the TOTAL space gained by the extractions will be
used to correct the crowding. This means that no space will be left after
the crowding is resolved. Thus, the lower molars must be held in position
and not be permitted to move toward the extraction site. Since the maxillary
molars were in the Class I position at the outset of treatment, they also
must not be moved toward the extraction site. Their positions must be
maintained.

81
 NON EXTRACTION CONDITIONS

We noted previously that many problems can be resolved by EXPANSION

(i.e. non-extraction). A focal point for non extraction treatment is that a)
the lower arch, skeletodentally, is basically 'good', indicating that there
was essentially no crowding, midline discrepancy or profile requirement or
b) if crowding is present, the space could be gained either by LEEWAY SPACE
CONTROL (MIXED DENTITION) or posterior movement of the molars (which is
limited to 1-2 mm/side).
Two examples, one in the permanent dentition stage of development and
one in the mixed dentition stage, will be used to illustrate how these
factors are represented in our diagnostic scheme.
1) In the permanent dentition, a common clinical problem is a patient
with a Class II malocclusion is which the maxillary molars are one full cusp
Class II (-5mm discrepancy) and the lower arch is 'good.' A detailed
analysis indicates that there is slight space available (1 mm/side) the COS
needs only 1 mm to correct and no midline or profile requirement.
A table would be:
R L
1) Crowding +1 +1
2) COS -1 -1
3) Midline 0 0
4) Profile 0 0

5) Space necessary 0 0
6) EXT-EXP 0 0

7) Movement 6 6 0 0

8) 6 6 Relationship -5 -5
6 6 This represents a Class II relationship
in which the maxillary molars are one full
cusp anteriorly positioned.
9) Movement 6 6 -5 -5
MOLARS MUST BE MOVED DISTALLY to resolve
the molar discrepancy and arrive at the Class
I position. When the molars are in position,
they must be 'held' there during the
retraction procedures involving the remaining
teeth in the maxillary arch.

82
 MIXED DENTITION
In the mixed dentition, we often encounter a patient with a Class II
malocclusion in which the maxillary molars are one full cusp Class II ( -5
MM Discrepancy) and lower arch crowding. An analysis of lower arch
conditions reveals that there is 4 mm of crowding, uniformly distributed and
a minimal COS-requiring 0.5mm/side to flatten. The midline and profile need
no correction. IN THIS CIRCUMSTANCE, WE HAVE TO EVALUATE THE LEEWAY SPACE TO
DETERMINE IF IT IS ADEQUATE TO ALLOW RESOLUTION OF THE CROWDING ETC. (MOST
OFTEN, IT IS, WHEN THE CROWDING IS LESS THAN 2 MM/SIDE.)
A table would be.
R L
1) Crowding -2 -2
2) COS -0.5 -0.5
3) Midline 0 0
4) Profile 0 0

4A) LEEWAY SPACE +2.5 +2.5 The Leeway space provides adequate
space to allow resolution without ex-
5) Space necessary 0 0 tractions.

6) EXT or EXP 0 0

7) Movement 6 6 0 0

8) Relationship 6 6
6 6 -5 -5

9) Movement 6 6 -5 -5 Final: molars were moved 5mm distally

It should be apparent that this table can accommodate almost any

condition and help us to decide whether to extract teeth to gain the
necessary space for correction or to expand the dental arch. In addition, it
helps us define where individual teeth should be positioned to arrive at a
class I ideal skeletodental complex.

83
ASYMMETRIC DENTAL CONDITIONS (WITH SYMMETRICAL FACIAL BONES AND FACIAL
FORM)

In the diagnostic lower arch, asymmetric dental conditions reflect;

a) crowding which is UNEVENLY distributed so that there is more crowding
on one side of the arch and/or b) a midline which is deviated to one
side of the dental arch because the incisors have 'shifted' laterally in
the alveolar bone. In this instance, the dental midline is NOT
COINCIDENT with both the midpoint of the mandible and the face. This
means that the face is symmetric, with the philtrum of the nose and the
chinpoint in a reasonably straight line, while the dental midline is
located to one side of the mandibular and facial midlines.
Dental asymmetries most often arise because of the premature loss
of a primary tooth or teeth. An example is the early loss of only one
primary canine. Under these conditions, the incisors 'shift' toward the
space made by the loss of the primary canine. When incisor movement is
sufficient, the result is a deviant dental midline. In addition, the
shifted incisors would now occupy some of the space necessary to allow
the canine to erupt properly -- meaning that the canine will erupt
ectopically and crowding will occur more on the side to which the
midline is shifted. (These are the reasons for the common clinical
situation in which one canine has erupted ectopically and the midline is
deviated to the side of the ectopically erupted canine.)
There is another condition with a deviant lower midline which does
NOT represent a dental asymmetry, and must be differentiated from a
dental asymmetry. This occurs when there is a deviant path of mandibular
closure - generally due to a prematurity -- leading to a functional
shift of the mandible in a lateral direction and an apparent facial
asymmetry in centric occlusion. In this instance the dental midline is
coincident with the midpoint of the mandible (since no dental asymmetry
exists). However, BOTH the dental midline and the midpoint of the
mandible are deviated to one side, reflecting the aberrant path of
closure. In centric relation, the dental and mandibular midlines
normally are aligned with the midline of the face.

84
 The analysis of asymmetric dental conditions is not complicated. As
an example, assume that a Class II Division I malocclusion with an edge
to edge molar relationship (-3mm. discrepancy) and a normal overbite is
present. In the mandibular arch)there is 8 mm. of crowding with UNEVEN
distribution, 5 mm. on the right and 3 mm. on the left, a COS requiring
lmm/side to correct, a midline deviated 2 mm to the right and no profile
requirement. In table form:

R L
l) crowding -5 -3
2) COS -1 -1
3) midline +2 -2
4) profile O 0

5) space necessary -4 -6
6) EXT or Exp +7 +7

7) movement 6 6 +3 +1 The mandibular right molar is to be moved

mesially 3mm while the left molar only 1mm.
8) relationship 6 6
6 6 -3 -3
The maxillary right molar position must
9) movement 6 6 0 -2 be maintained while the left molar must be
moved posteriorly 2 mm.

85
 There is an asymmetric dental condition involving the maxillary arch
which merits discussion. It exists when the left and right molar relation-
ships are not the same. The most common example is the presence of a Class II
molar relationship on one side of the arch and a Class I molar relationship
on the other side. This is called a Class II malocclusion - subdivision,
indicating that one side is Class II and the other is Class I. In this
instance, one of 2 factors which suggests maxillary arch asymmetry should be
present; a) the maxillary midline should he 'shifted' to the opposite (Class
I) side and/or b) there should be more crowding on the Class II side.

If the maxillary midline is coincident with the facial midline and/or

the crowding is evenly distributed -- factors which speak to maxillary arch
symmetry, one should suspect a subtle mandibular shift during closure in
which the mandible rotates in a lateral direction. This rotation has the
effect of moving one molar mesially and the other distally. Under these
conditions, in centric occlusion, the right and left molar relationships
would be dissimilar even though the maxillary arch is symmetrical.

When the maxillary arch is asymmetric, correction involves moving one

molar more than the other to restore symmetry of molar position. This in turn
establishes the space to make the maxillary arch symmetrical.

This outline of treatment planning represents "what to do" in a general

sense. This is only one aspect of the treatment planning process. To be more
complete, we have to add "how to do" the dictates of the treatment plan.
Essentially biomechanical considerations should be included in the treatment
plan. To this end, we will expand our discussion on biomechanics to include:
a) the most common movements of the anterior and posterior groups of
teeth.
b) the more common force systems used to produce these movements and
c) the most common force systems used to control the reaction forces
that are present ed anchorage control)

THE MOST COMMON DIRECTION OF MOVEMENT OF THE ANTERIOR AND POSTERIOR GROUPS OF
TEETH.
When we describe the direction of movement of various teeth, we divide
the arch into an anterior and posterior segment. The anterior portion
includes the canines, lateral and central incisors. The posterior segment
includes the premolars and molars. (In actuality, this means that there are 8
segments in total, 2 anterior and 2 posterior segments in each arch.)
For the anterior group of teeth, the most common direction of movement
is posterior (distal). In fact, the posterior movement of the canines is
probably the most common type movement in orthodontics. Canine retraction
liberates the necessary intercanine space to align and/or retract the central
and lateral incisors. Rarely, canines and incisors are moved anteriorly.

86
 MOVEMENT OF THE ANTERIOR TEETH
There are 2 principle
force systems used to retract
the maxillary canines and in-
cisors. These are the intra-
arch (Class I) and the inter-
arch (Class II) force
systems.
The Class I force system
is probably the most effi-
cient-meaning that teeth move
faster with less applied
force.
Similarly, to retract the
mandibular incisors, intra-arch
(Class I) and inter-arch (Class
II) force systems are used.
Again, the intra-arch (Class I)
system is probably the more
efficient.

In the posterior part of

the arch, the teeth are
commonly moved in both an
anterior and posterior direction. Anterior movement usually occurs when
extractions were necessary to gain the necessary space to move the teeth.
Most often, it represents the condition in which the extractions provided
more space than is required for correction. To close the space, the posterior
teeth are protracted. The distal movement of the posterior teeth generally
represents non-extraction conditions. The distal movement of the posterior
teeth effectively expands the arch in a posterior direction and provides the
space necessary for correction.

MOVEMENT OF THE POSTERIOR TEETH IN AN ANTERIOR DIRECTION

a) Anterior Direction: To move the posterior teeth

in an anterior direction, only intra-arch (Class I)
forces are generally used. Class II and Class III
forces are theoretically possible to use because
they place mesially directed force components on
the posterior teeth.
However, in our experience,
they do not often move the
teeth appreciably. For this
reason we effectively use only the intra-arch (class
I) force systems when protracting posterior teeth.

87
 MOVEMENT OF POSTERIOR TEETH IN A POSTERIOR (DISTAL) DIRECTION

The distal movement of the maxillary

posterior teeth most often means the distal
movement of the molars. This is done by
means of headgears or removable appliances
which have finger springs applying the
distally directed forces to the teeth. Both
appliances
can move the
molars 5-7
mm.

To move the mandibular molars distally,

lip bumpers are generally used. However, as
indicated previously, lower molar distal movement is limited to 1-2 mm side.
(A headgear produces no more movement than a lip bumper.)

Since we
placed the 'action' forces on teeth, we have placed 'reaction' forces
elsewhere at the same time, because each applied force has equal and opposite
components. To review, when using intra-arch (Class I) forces, the action
component is usually placed on the posterior segment of the same arch. For
Class II and Class III forces, the action component is placed on the anterior
segment while the reaction component is placed against the posterior teeth of
the opposing arch. The reaction component of the headgear is applied to the
head and/or neck region. The reaction force of the lip bumper is placed
principally against the mentalis muscle. Removable appliances fit the palate,
enveloping alveolar structures and teeth. For this reason, the reaction force
is placed against all of these structures.
An important distinction is that some of these force systems place the
reaction force on other teeth. These include the Class I, II, and III forces
and removable appliances. Others such as a headgear or lip bumper place the
reaction force on non-dental structures.

88
 STABILIZATION FORCES

We indicated that a major pre-

occupation is: what do we do with this
reaction force when it is applied to
teeth? Sometimes we want it to move
the teeth. Under these conditions, we
leave it alone. On the other hand, we
frequently do not want to move the
teeth with these forces. As such, we
need mechanisms to block any tooth
movement that can arise from these
reaction forces. We call these
STABILIZING FORCES--indicating that we
are placing a force to maintain the
position of the unit to which the
reaction force is applied.
There are 2 principles used in
stabilizing groups of teeth when a
reaction force is applied to them. One
is to apply in the same segment a
second or 'counter' force which is at
least as powerful as the reaction
force and acts in the opposite di-
rection. Appropriately placed, this
counter force should prevent any move-
ment that might occur because of the
placement of the reaction force.
Consider, as an example, the retrac-
tion of a maxillary canine by means of
an activated elastic extending from
the molar to the canine. The action
force is placed on the canine, moving
it distally. The reaction force is
applied to the molar-premolar unit,
directing it mesially. If we want to
maintain molar position, we add a
headgear which exerts a distally
directed force against the molar.
The intent is to use the distally
directed force component resulting
from the application of the headgear
to block any possible mesial movement
arising from the placement of the reaction force.

89
 The second principle is to apply the reaction
force over a large enough surface area so that the
force/area is too low to move the teeth in a
clinically useful time. Often, removable
appliances are used in this manner. For example,
if an intra-arch (Class I) force system is placed
to move a maxillary canine posteriorly and the
reaction force is placed on the molar, it is quite
possible that the reaction force will move the
molar. If, however, a removable appliance were in-
serted and it closely fits around the molar,
palate, and all the teeth of the maxillary arch,
the force on the molar would be considerably re-
duced because the same reaction force would now be
distributed over all the structures contacted by
the removable appliance. This, in turn, would
considerably reduce the tooth movement potential
of the reaction force. A removable appliance is
only one of several methods used to distribute
reaction forces over large surface areas.
Another method is to disburse the reaction force over an entire intact
arch. As an example, Class II force systems, with relatively light forces,
are commonly used to retract maxillary incisors. The resultant reaction force
is placed on the entire mandibular arch. There are some who believe that the
mandibular arch can resist any movement since the applied force/unit area is
lower than the force/unit area of the maxillary incisor segment. (For the
sake of completeness, others disagree and feel that stabilization of the
mandibular arch is important if anterior movement resulting from the reaction
force is to be avoided.)

STABILIZATION OF SPECIFIC SEGMENTS

Maxillary Posterior Segment

Headgears and removable appliances are used to stabilize the maxillary
posterior segments. To reiterate,
the headgear is placed against the
molars and delivers a distally
directed force. This is by far the
most common stabilization force
used because it actually opposes
anterior movement. A removable
appliance, incorporating a larger
surface area, reduces the
force/unit area of a reaction
force, hopefully below the level
necessary to move teeth in a
clinically useful time period.

90
Mandibular Posterior Segments:
For the mandibular posterior segments, lip bumpers and headgears which
both apply distally directed forces are used. The bumper is probably the more
common appliance.

Addendum:
In many instances, the posterior segments are 'stabilized' even when a
reaction force is not placed on them. Initially, this may not make sense.
However, if we remember that there is a natural tendency for molars to drift
mesially if a space is present (and a space must be present if we are to move
teeth) we also should realize that any mesial movement of the molars can
consume some of the space we need to correct any crowding or protrusion. This
oftentimes is undesirable and can jeopardize the expected result. For this
reason, we guard against this possibility by placing stabilizing forces
against the molars, particularly in the maxillary arch. It represents a form
of insurance to preserve the space we need for correction.
As a rule of thumb, when maximum anchorage conditions exist (indicating
that at least 2/3 of the available space is necessary for incisor alignment
and/or retraction) the posterior teeth are stabilized even is reaction force
is not placed against these teeth--to prevent any spontaneous anterior
movement of the posterior teeth.

91
 STABILIZATION OF THE INCISOR SEGMENTS

MAXILLARY INCISORS:
CONTROL OF LABIAL MOVEMENT

The anterior teeth are generally stabilized

only when reaction forces which may produce
undesirable labial or lingual movement of the
incisors are placed. Reaction forces that may move
the incisors labially are often blocked by
applying a headgear with a lingually directed
force against the incisors. For example, assume
that a maxillary first premolar is palatally
positioned and there is adequate space to move the
tooth into the arch. The reaction force tends to
move the incisors labially. A headgear with a
lingually directed force then placed against the
incisor segment to control any possible labial
movement of the incisors resulting from the re-
action force.
Thus we have 2 forces applied to the incisor
segment--one tending to move the teeth labially
(the reaction force of the removable appliance)
and one moving them lingually, (the headgear)

MAXILLARY INCISORS:
CONTROL OF LINGUAL MOVEMENT

Reaction forces that move

incisors lingually are blocked by placing, on the incisors
segment, force couples which direct the crowns of the
incisors labially. (To avoid confusion, force couples can
move the crowns of the incisors labially or lingually
depending on the design.) In this manner, the lingual
crown movement provoked by the reaction force is opposed
by the labial crown movement arising from the placement of
the force couple.
Root movement can occur as a result of the placement
of the force couples. This movement is a function of the
activation placed on the force couples and the time period
that the force remains active. Normally the root movement
is inconsequential. One reason is that the force couples,
particularly on the incisors, are activated on 5.

92
MANDIBULAR INCISOR SEGMENT

CONTROL OF LINGUAL MOVEMENT

A common clinical example is the application of

an intra-arch (Class I) elastic to close an ex-
traction site in the mandibular arch by moving the
molar-premolar unit mesially. The action force is
placed on the molar-premolar unit while the reaction
force is applied to the anterior teeth, directing
them lingually. Force couples are placed on the
incisors, directing the crowns anteriorly. In
addition, an auxiliary, called an uprighting spring,
which applies a force couple in an antero-posterior
direction is placed into a vertical slot in each
canine bracket. The uprighting springs direct the
crowns of the canines anteriorly. Thus force couples
are placed on the 6 incisor teeth.
Again, there are 2 force systems applied to the
incisor segment and which act in opposite directions.
As indicated in the previous example, root
movement will occur. Normally, it is inconsequential.

93
 MANDIBULAR INCISOR SEGMENT

CONTROL OF LABIAL MOVEMENT

Another common situation concerning

incisor stabilization occurs when a Class II
(intermaxillary) force is used. As indicated,
the action component of this force is placed on
the maxillary incisor segment while the
reaction force is placed on the entire
mandibular arch. The reaction force can often
move The mandibular teeth anteriorly. This
movement, most often, is undesirable. As such,
it can be blocked by applying to the incisors
force couples which direct the crowns of the
incisors lingually. Again, any root movement
would be inconsequential.
Thus, there are only 4
appliance systems used to
stabilize teeth: the headgear
lip bumper, force couple and
removable appliance. In order
of frequency of use, the
headgear is the most common
and is most often applied to
the posterior part of the
dental arch. It is generally
worn 12-16 hours/day,
avoiding wear 'outside the
house.' Next may be the lip
bumper which is used all the
time except when eating. This
is probably followed by the use of force couples which act
continuously since they are placed on the dental arch. Finally the removable
appliance, which is worn all the time except when eating, is the least often
used.
Dividing the arches in quadrants, the headgear is most often used in the
maxillary posterior and maxillary anterior segments. The lip bumper is the
most frequent in the mandibular posterior segments and force couple placement
is most common in the mandibular anterior segment.
As an exercise, we can set up two tables--one representing force systems
to move the various groups of teeth (exclusive of distal movement of the
molars) and the second table indicating the force systems to stabilize the
various segments--to visualize where the action-reaction forces are and what
mechanisms are available to control reaction forces.

94
 MOVEMENT SYSTEMS

For example, assume that the directing the crowns anteriorly.

maxillary incisors must be re-
tracted and maximum anchorage
conditions exist in the maxillary
arch. Immediately we can visual-
ize the maxillary incisors should
move lingually while the posteri-
or segment should essentially
remain in position.
From Table A, we see that we
can choose a Class I (intra-arch)
or a Class II (inter-arch) force
system. When we select a Class I
system, we know that the maxil-
lary posterior teeth need stabi-
lization.
From Table B, we note 2
choices - a headgear or a remov-
able appliance. Normally, we se-
lect a headgear because of the
distally directed force it ap-
plies. Thus the complete mechano-
therapy is a Class I force to
move the incisors lingually and a
headgear to block the reaction
force and stabilize the posterior
teeth.
If we select a Class II sys-
tem to retract the incisors, the
reaction force is placed on the
mandibular arch, directing it
anteriorly. We can stabilize the
mandibular arch in one of 2 ways.
If we choose to apply the stabi-
lizing force on the posterior
segment, we can use a lip bumper
or a headgear. If we apply the
stabilizing force anteriorly, we
use appropriate force couples
which direct the crowns of the
teeth lingually.
Another example is the
anterior movement of the molars.
When we want to protract molars,
a Class I force is used, extend-
ing from the incisor segment to
the molars. Lingual movement of
the incisors can occur because of
the Class I force. When
stabilization of the incisor
segment is necessary, we place
force couples on the incisors,
95
 CLASS I CLASS
I
CLASS
II

CLASS III

CLASS I
CLASS I

TABLE A - FORCE SYSTEMS USED TO

MOVE TEETH OR GROUPS OF TEETH
(EXCLUDING DISTAL MOVEMENT OF
THE MOLARS)

GEARS GEARS

(removables)
(force

couples)

LIP BUMPER
FORCE

COUPLES

TABLE B - FORCE SYSTEMS USED TO

STABILIZE TEETH OR GROUPS OF
TEETH

96
 As indicated previously, a major preoccupation in orthodontics is the
control of reaction forces when applied to teeth so that they do not produce
undesirable movements of the anchor units (which most often are the posterior
teeth). This worry is the reason why some orthodontists say that orthodontics
is anchorage control. This means that action forces will generally produce
the expected movement without much difficulty. On the other hand, the
reaction force must be carefully controlled so that the space available for
correction is used adequately. It emphasizes the view that the proper control
of the reaction force will most often lead to successful treatment since it
indicates that teeth are moving according to the desired plan. One could
summarize by suggesting that the appropriate use of available space is the
'essence' of orthodontics and the control of the reaction force is a critical
and indispensable aspect of space management.
Now we have to address another issue. Reaction forces cause concern
because they are generally places on teeth which can move as result of this
force. But, there are force systems which do not place the reaction forces on
the teeth. The most obvious example is a headgear. It applies a posteriorly
directed 'action' force and the reaction force is applied to the head and/or
neck. Why not use a headgear to retract canines and move the other teeth? In
this manner, some of the problems associated with reaction forces applied to
posterior teeth can be avoided. In fact, some orthodontists do just this.
They use headgears to move the incisors to avoid the reaction force problem.
However, most do not follow this idea for a few reasons. One involves
the use of intermittent versus continuous force systems and the clinical
efficiency of each. Headgears are most often used intermittently 14-18
hours/day while intra-arch (Class I) and inter-arch (Class II, III) systems
generally work continuously. A second reason is that headgears are more
cumbersome and unsightly to wear than the other force systems. Third, more
cooperation is generally needed when headgears are used. Other force systems
can be applied with little effort and some require no cooperation. Fourth,
when a headgear is applied to the anterior teeth, another headgear is not
used to stabilize the posterior segment. Some prefer the 'security' of
posterior stabilization. For these and other reasons, most orthodontists
adopt continuous acting intra and interarch forces to move teeth and
headgears most often are used for stabilization.

97
TREATMENT PLAN PLUS BIOMECHANICS
We're now ready to discuss the treatment planning scheme with
biomechanical considerations (particularly anchorage considerations) to
evolve a more definitive treatment plan. We will use as illustrations
the previously described clinical examples.
Assume the conditions that were described in Example I: There was
a class I malocclusion with normal overbite, 12mm of crowding that is
evenly distributed, a COS needing 1mm/side to correct and no midline
or profile requirement.
R L
1) Crowding -6 -6
2) COS -1 -1
3) Midline 0 0
4) Profile 0 0
5) Space necessary -7 -7
6) EXP/EXT +7 +7
7) 6 6 Movement 0 0 These values indicate maximum
8) 6 6 6 6 0 0 anchorage conditions because all of the
9) 6 6 0 0 space made available by extracting teeth
is necessary to align the incisors.

Thus, the molars cannot move anteriorly into the extraction space.
For this reason, the posterior segments require stabilization to prevent
any anterior movement. This usually means a headgear on the maxillary
arch and a lip bumper on the mandibular arch (Table B). To retract the
canines to gain space to align the incisors, there are 2 possibilities.
For the maxillary arch, a Class I or Class II force system can be used.
For the mandibular arch, a Class I or Class III system is used. There
are three common methods of applying the necessary forces.

1) posterior segment anterior segment

maxillary arch headgear Class I force

mandibular arch lip bumper Class I force

This is logical because the action forces are applied to the

anterior segments by intra-arch (Class I) forces and the reaction forces
are placed against the posterior segments which are being stabilized by
the headgear (maxillary arch) and lip bumper (mandibular arch).

2) posterior segment anterior segment

maxillary arch Class II force

mandibular arch headgear or lip bumper Class I force

This system is logical because the actions forces are applied by

Class II and Class I forces and the reaction forces are applied to the
mandibular molars which are stabilized by means of a headgear or lip
bumper.

3) posterior segment anterior segment

maxillary arch headgear Class I force

98
 mandibular arch -0- Class III force

This is a similar system as described in the previous example. The

difference is that the reaction forces are now applied to the maxillary
molars which are stabilized by means of a headgear.
The most commonly used system is probably the one described in the
first example - in which both molars are stabilized and the incisor
segments aligned by means of intra-arch forces.
Another example of a class I malocclusion is:
R L

1) Crowding -3 -3
2) COS -1 -1
3) Midline 0 0
4) Profile 0 0
5) Space necessary -4 -4

6) EXP/EXT +7 +7

7) space left for

movement
of 6 6 +3 +3 These indicate moderate anchorage
conditions. We can visualize that
8) 6 6 relationship about 50% of the space must be
6 6 0 0 used for incisor requirements and
50% available for molar protrac-
9) 6 6 +3 +3 tion. This means we can apply
a force system in which both action and reaction components of an
applied force can move teeth. A logical force system is a Class I
(intraarch) force and no stabilization is necessary at the outset.

99
 Let's look at another example: Example 3 - Class II
malocclusion (molar relationship edge to edge with the following
characteristics:

R L

1) Crowding -3 -3
2) COS -1 -1
3) Midline 0 0
4) Profile 0 0
5) Space necessary -4 -4
6) EXT/EXP +7 +7 Anchorage
This indicates moderate an-
7) 6 6 movement +3 +3 chorage conditions and the previous
considerations also apply since the
8) 6 6 lower arch problem is the same.
6 6 -3 -3 (see above)

9) 6 6 movement 0 0 This indicates maximum anchor-

age conditions.

All space gained from extractions must be used to align and

retract the incisors and the posterior segments should be stabilized
with a headgear to prevent any possible mesial migration. For incisor
movements we can choose either a Class I (intraarch) and Class II
(interarch) force. The reaction force of the Class I system tends to
move the molar mesially. The headgear, applying an opposing force,
should be adequate to prevent mesial movement. This system provides
the most efficient movement. If a Class II force is chosen, the
reaction force is placed on the posterior segments of the lower arch.
These do not need stabilization since they must be moved mesially.
The advantage of this system is that no anteriorly directed force is
applied to the maxillary molars. Some prefer the Class I system
because of its efficiency; other use Class II forces because of the
"safety."

100
 TREATMENT PLAN RE-EVALUATION
The preceding descriptions are adequate for the initial diagnosis and
treatment plan. They pertain to the "static" conditions that exist before
teeth are moved. When teeth move, the initial "static" conditions obviously
change. In sum, orthodontic diagnosis and treatment planning is an "ongoing"
process which is adapted and related to the existing conditions.
We can accommodate this need for constant adjustment with our treatment
planning scheme by adding only one factor; the available space. In actuality
we substitute the available space for the space gained by expansion or
extraction (factor #6) This makes sense because the decision to gain space by
extraction or expansion has already been made. Now it is important to
determine the use of this space each and every time the patient is seen. To
illustrate how we make this adjustment, we'll return to example #2 which is a
Class I malocclusion with the following problems and initial treatment plan.

R L

1) Crowding -3 -3
2) COS -1 -1
3) Midline 0 0
4) Profile 0 0

5) Space necessary -4 -4
6) EXP/EXT +7 +7

7) 6 6 move +3 +3 MODERATE ANCHORAGE - can use UNOPPOSED

Class I forces
8) 6 6
6 6 -3 -3

9) 6 6 0 0 MAXIMUM ANCHORAGE - STABILIZE WITH A

HEADGEAR

Since moderate anchorage conditions exist-with about 60% of the space

necessary for incisor requirements and 40% to be used by anterior movement
of the molars, we can use Class I forces on both arches with no stabilizing
mechanisms on the posterior segments.

101
 Assume that 4-6 months have passed and the teeth have moved consider-
ably. Accordingly, the original numbers no longer pertain and a new analysis
is necessary. Clinically, we see that there is 2mm of crowding in each side
of the arch; the Curve of Spee flattened and the molar relationship is still
Class I. The extraction space has been reduced considerably and only 3mm of
space is left on each side of the arch. For this new 'in treatment'
evaluation, we again use the original chart and INSERT THE SPACE AVAILABLE AS
ITEM #6 - (replacing the space gaining procedure). The table now reads:

1) Crowding -2 -2
2) COS 0 0
3) Midline 0 0
4) Profile 0 0
5) Space necessary -2 -2
6) Space available +3 +3
7) 6 6 movement +1 +1 MAXIMUM ANCHORAGE: STABILIZE WITH A LIP
8) 6 6 BUMPER
6 6 relationship 0 0
9) 6 6 movement +1 +1 MAXIMUM ANCHORAGE: CONTINUE USE OF THE
HEADGEAR

Maximum anchorage conditions now exist since 2 of the 3 mm of available

(66%) is necessary for aligning the incisors. Thus, molar stabilization is
indicated. For this reason - if Class I forces are used, a headgear should be
applied to the maxillary posterior segment and a lip bumper to the mandibular
posterior segment.
This is only one example. There are literally scores of possible changes
that occur during treatment. But the thinking process is the same for each
situation. As such, the changes that occur during treatment are not difficult
to analyze if they are assessed systematically and the treatment planning
chart is one example of a systematic appraisal. The chart illustrates reason-
ably clearly the movements which are necessary to resolve the problem and
suggests mechanotherapy.
In addition, it establishes reference points during treatment. Reference
points are indispensable when analyzing changing conditions because they
establish points of continuity and allow the thinking process (in this
instance, the treatment plan), to go from one step to another. To
recapitulate, utilizing the chart, we start with the lower arch and compare
the space requirements of the lower incisor region to the available space. If
adequate space is present, we do not extract teeth to make more space. If
adequate space is not available, we extract teeth. We then design mechanical
systems to produce the necessary incisor movements--in the available space.
When incisor crowding has been corrected and there is no further profile
requirement, there is no need to retract mandibular canines further because
there is no need for more space for the incisors. the canines can then be
reference points since they are now in their correct and final position.
Thus, the relationship of crowding and/or profile adjustment to existing
space, in effect, dictates the final position of the canines.
Once mandibular canine position has been established, we turn our
attention to attaining the final position of the mandibular molar. If at this
point there is space distal to the canines, the molar (and premolars) are
moved mesially to close the space. (If there is no space, no movement is
indicated.) Thus the final position of the lower molar is established.
102
 Once lower molar position is achieved, it becomes a reference point for
the maxillary molars which must be in a Class I relationship at the end of
treatment. If molar position is Class I, it must not be changed. If it is
not, the molar must be moved to the Class I position.
The indispensable nature of reference points leads to another consid-
eration - a fundamental difference between extraction and non-extraction
treatment. In extraction treatment there are spaces in all quadrants of the
maxillary and mandibular arches. As such there is movement in all quadrants
and this movement requires analysis with adequate reference points (as
discussed in the previous examples). In non-extraction type treatment the
lower arch is "stable" or "static" and significant movement occurs only in
the maxillary arch. As such, it is less complicated to "analyze" and the
selected reference point is generally only the molar relationship. When the
molar relationship is converted to Class I and this molar position main-
tained, the intermolar space should be precisely adequate to align and/or
retract all of the teeth in the arch.

103
 THIRD MOLAR EXTRACTION

The distal movement of the first molars to gain space to align and/or
retract incisors is a common method of treatment. There are however, a number
of factors to consider. As an example, in the maxillary arch, distal movement
of the first molars (which can be up to 5-7 mm) can lead to labial
displacement of the second molars, particularly if the second molars are
erupting. This is not a difficult problem to resolve and the second molars
can readily be moved lingually into the arch.
On the other hand, there is the possibility that the space for the third
molars would be reduced, leading to impaction. This would represent an
indication for third molar extraction. The frequency of any impaction as a
result of distal movement of the molars is not known.
In the lower arch, distal movement on the lower first molars can, at
times, impede the eruption of the second molars. For this reason, we do not
attempt to move the lower first molars posteriorly unless the second molars
have at least erupted past the contact points of the first molars or there is
space between the first and second molars.
This leads to another consideration-the early extraction of the third
molars to reduce the possibilities of second molar problems and third molar
impaction. If this procedure is considered, one suggestion is to extract the
third molars as early as 9-10 years old, when the crown is not yet calcified.
Under these conditions, third molar enucleation is a relatively simple
procedure.
Maxillary third molars do not have to be removed at the same time
because there is little fear that adequate space for the second molars will
not be available even if the first molars are moved distally 5-7 mm. The
third molars can be removed, if necessary, at a later time -at age 18-20.
The third molar problem has led some to say that non-extraction
treatment does not often exist-suggesting that if premolars are not removed
at the outset of treatment, third molar removal would frequently occur at a
later date.
Those who prefer not to remove premolars frequently suggest that:
a) Third molars do not always erupt under normal conditions. When they do,
hygiene in the third molar area is difficult to maintain and periodontal
problems can result.
b) Many times, third molars do not erupt even after the removal of premolars.
c) In boys, in whom growth of the face does not stop until at least 17-20
years old, early premolar extraction can lead to an excessively flat profile.
d) At times, non extraction procedures are less complicated than extraction
procedures.

104
 TREATMENT PROCEDURES
Practical applications of appliances:
The intent of this section is to describe the principles and illustrate
examples of both non-extraction and extraction type treatment. To this end,
we will expand our discussion of appliance therapy to include:
a) the components and placement of the edgewise appliance as well as
selected properties of wires.
b) the indications and contraindications of the most commonly used force
systems--headgears, intra-arch (Class I) and interarch (Class II,
III) forces and an evaluation of the force vectors generated by these
systems.
c) a technique called the 'bidimensional technique.'
Removable appliances:(excluding activators)
To review, removable appliances are generally
made of acrylic and have clasps, springs and loops
and expansion screws added to them. An example of a
removable appliance is an appliance with an
expansion screw. The acrylic portion covers the
occlusal and part of the buccal surfaces of the
teeth. The expansion screw can be placed in a
transverse plane or a sagittal plane. When placed
in the transverse plane, activation of the screw
widens the arch. Accordingly, it can be used when
arch widening is indicated such as a constricted
maxillary arch. When placed in a sagittal plane, activation of the screw
lengthens the arch. For this reason, it is used to move teeth in an
anteroposterior direction, such as moving a molar distally.
Another example is the ACCO appliance which is
used to move molars distally. In this appliance,
springs are placed mesial to the first molar. When
activated, they move the molars distally. The reaction
force placed on the rest of the arch and palate is
controlled by placing an extra-oral appliance on the
anterior aspect of the appliance.

105
FIXED APPLIANCES

Fixed appliances are the appliances of

choice because they allow us to control the
position of each tooth in all planes of
space reasonably precisely. There are many
'types' of appliances and at times are
named after the designer of the specific
appliance. All appliances have similar
fundamental characteristics. Basically,
they consist of:
attachments applied directly to teeth with composite attachments welded to
bands which are fitted to the teeth and cemented in place wires of different
sizes and shapes.
The attachment for all teeth except the
terminal teeth in the appliance is a small metal
structure called a bracket. In the EDGEWISE tech-
nique, which is the technique described
in this book, there is a horizontal slot
in the bracket which is rectangular in
shape.
The wire is inserted into the bracket. Above and below the
slot are 'wings' around which 'ties' are placed to maintain the
wire in the horizontal slot. These 'ties' are made of thin (.010
in. soft) ligature wire or small elastic like modules that encircle
the wings.
On the terminal teeth, tubes are placed. There are 3 types of 'tubes.'
1) Single tubes -These are rectangular in shape. when the wire is in-
serted into the tube, no ligation is necessary because the
wire cannot slip out of the tube.
2) Double tubes--These are 2 tubes, aligned so that
one is placed directly over the other. One of the tubes is

rectangular; the other is round. The rectangular tube is

for wire insertion. The round tube is for the placement of
an extra-oral appliance or a lip
bumper.
3) Convertible tubes-- These are
2 tubes as previously described. The difference is that
the rectangular tube, in reality is a bracket covered by
a metal piece which can be removed. When the metal piece
is in place, the bracket functions like a
tube. When the metal piece is removed, the
bracket functions like a bracket and liga-
tion of the wire becomes necessary.
Convertible tubes are generally placed on
first molars when it is not possible to put bands on second molars because
they have not fully erupted. They represent a transition tube. When tubes are
placed on the second molars, the metal piece on the convertible tube is
removed.

106
 ATTACHMENTS PLACED DIRECTLY ON THE TEETH

Brackets and tubes are commonly placed directly on the labial surfaces
of the teeth with composites. In this instance, the bases of the
attachments are individually contoured for each tooth to gain maximum
adaptation of the attachments to the teeth.
The usual method for the application of composites is followed. The
teeth are pumiced, isolated, and etched. The composite is generally placed
on the attachment base and the attachment placed on the tooth.

PLACEMENT OF A FIXED APPLIANCE

The placement of a fixed appliance is extremely important because the

appliance dictates the final positions o f the teeth and the form of the
dental arch. To repeat, the appliance consists of 2 main parts-- the
bracket or tube placed on the individual teeth (either directly or by means
of a band) and a wire inserted into the bracket or tube.
Since the wire transmits its forces to the teeth be means of its
engagement into the attachment, the attachment must be placed 'correctly'
to transmit 'correct' forces to the teeth when the wire is inserted. A
'correct' wire inserted into an 'incorrectly placed bracket will impart an
incorrect force. Thus, the 2 parts of the system, the placement of the
attachment and the wire design must be in synchrony.
How do we define correct placement of attachments?. As indicated, we
place attachments on the labial surfaces of the teeth. There are 2 planes
of space to consider. On is the mesio-distal; the other is the vertical.
Mesio-distally, tubes, as indicated previously, are placed so that the
anterior part of the tube is aligned with the mesio-buccal cusp tip of the
molar. Brackets are placed at the at the midpoint of the mesio-distal width
of the labial surface of the tooth. one reason that we 'center' the
brackets is to place the midpoint of the applied force at the center of the
labial surface of the tooth. When aligning teeth, 'centered' forces tend to
control rotations of teeth more easily because they act at the midpoint of
the teeth. In this manner, both the mesial and distal aspects of the teeth
are moved equal distances. Conversely, eccentrically placed forces tend to
produce rotations because eccentric forces move one side of the tooth more
than the other.
The second consideration is the height of the attachments. Each arch
has different requirements.
MAXILLARY ARCH
We place the first molar tubes at 3.5mm gingival to the tip of the
mesio-buccal cusp. The premolar brackets are set at 4.0 mm while the canine
brackets are located at 4.5 mm gingival to the cusp tip.
There are 2 reasons for the more gingival placement of the premolar
brackets. One is to align the marginal ridges of the premolars with those
of the molars. The gingival placement of the premolar brackets reflects the
fact that the cusp heights of the premolars--from the tips of the cusps to
the marginal ridges- are higher than the cusp heights of the molars. The
more gingival placement of the premolar attachments compensates for this
cusp height difference and aligns the marginal ridges 'more physiological-
ly.'
(If the cusp tips of the molars and premolars were on the same occlusal
level, the marginal ridges of these teeth would not be aligned because of
the differences in the cusp heights of these teeth.)
The second reason for the gingival placement of the premolar brackets
107
is to produce maximum intercuspation. Maximum intercuspation means that the
maxillary premolars and canines occlude between the cusps of the mandibular
molars, premolars and canines (intercuspal) rather
the on the occlusal surfaces of these teeth. This is
not entirely consistent with some of the principles
of restorative dentistry which maintain that the
lingual cusps of the premolars should occlude with
the fossae of the opposing premolars. The difference
relates in part to the size and form of natural
teeth when compared to teeth which have been 'recon-
structed'. For example, the size of the lingual
cusps of the maxillary premolars of reconstructed
teeth are shorter than the lingual cusps of natural
premolars because they are made to occlude with the
fossae of mandibular premolars (cusp to fossa
position) If natural teeth occluded in this manner,
the longer lingual cusps of the natural premolars
might lead to a prematurity particularly in lateral excursions (Curve of
Wilson.)
The intercuspal position of the natural teeth also allows the mandible
to move freely along the curve of Wilson. If the maxillary premolars were in
the cusp to fossa position, the longer cusp might
contact the lower premolars prematurely.
Since the molars occlude on the opposing
molars, and the premolars and canines between the
opposing teeth, the cusps of the premolars (and
canines) must be positioned more occlusally than
the cusp tip of the molars. The more gingival
placement of the premolar brackets relative to the
molar attachments, as suggested, moves the cusp
tips of the premolars move occlusally. Under these
conditions, contact in the premolar region is more readily established when
maximum interdigitation exists.
Thus, the more gingival placement of the premolar brackets serves
2 main purposes. One is to align marginal ridges more favorably. The second
is to produce contact in the premolar region in the maximum intercuspal
position.
The canine bracket height is 4.5 mm-tending to place the canines
slightly more occlusally than the cusp tips of the molars and premolars.
This is done to establish a canine protected occlusion in lateral excur-
sions.
The central incisors are placed at 4.5 mm while the lateral incisors
are 4.0 mm. This means that the lateral incisors are slightly more gingival
than the central incisors and canines. The more gingival placement of the
lateral incisors is necessary to allow a space for the mandibular canines
to move freely in protrusive excursion. Otherwise, a prematurity would be
created.
MANDIBULAR ARCH:
The first molars and incisors are placed at the same height while the
premolars and canines are placed 0.5 mm more gingivally than the molars and
incisors for marginal ridge control. Generally the molars and incisors are
placed at 3.5 mm and the premolars and canines at 4.0 mm.
SECOND MOLAR TUBE HEIGHT:
The height of the tubes of the second molars in both arches is either
the same as that of the first molars (i.e.3.5 mm) or 0.5 mm less (3.0.mm).
108
The tubes are positioned less gingivally when bite depth is shallow-
indicating that any extrusion of the posterior teeth could lead to an open
bite.
Mesiodistally, the brackets are centered on the teeth. The molar tubes
are placed as described previously.

109
ANGULATED ATTACHMENTS
Attachments are placed not only to
align the crowns but also the roots of the
teeth, both in a mesiodistal and bucco-
lingual direction. There are 2 methods
used to align the roots of the teeth. One
is to place the attachments on the teeth
so that the long axes of the teeth inter-
sect the slots of the attachments at right
angles. When the attachments are placed in
this position, root position is controlled
by placing appropriate bends in the wire
to "angle" the roots appropriately. In a
mesiodistal direction this means moving
the roots of the maxillary central
incisors distally 5 ,and the roots of the
lateral incisors and canines 7 distally by
placing second order bends(force couples
in a m-d direction) in the wire.
The second method is to 'angle' the
attachments appropriately relative to the
long axes of the teeth. This is generally
done by angulating the brackets on their
bases. In this instance, there is no need
to place bends in the wire to control root
position. (i.e. a straight wire can be
used.)
Attachments which are tipped on their
bases are called 'ANGULATED' attachments.
Attachments in which the horizontal slot
is angulated in a buccolingual direction
are called 'torqued' brackets. Torqued
brackets reduce the need to place 3rd
order bends in the wire.
Because of the obvious advantages,
most at least use angulated attachments.
Many use both angulated and torqued at-
tachments.

110
 CONSEQUENCES OF INCORRECT PLACEMENT OF ATTACHMENTS
Vertical orientation
When an attachment is placed too far
gingivally, a relative extrusion of the tooth will
occur. When it is placed too far occlusally, there
will be a relative intrusion.

Mesiodistal plane
When an attachment is not
centered, mesiodistally, on a
tooth, it can lead to rotation of the tooth because of the
eccentric placement of the forces.
Since incorrectly placed attachments lead to errors
in tooth position, one suggestion is to correct the
position f the attachments as soon as the problem is
noted.
LINGUAL ATTACHMENTS
Lingual attachments which
function to hold fixed or removable
elastics are also placed on the teeth,
either directly or welded to a band,
to provide access to the lingual
surfaces of the teeth. There are two
main types. One is a 'button'; the
other is a 'cleat.' They are used for
many purposes. One important use is
rotation control.
WIRES
Two types of wires, which come in many sizes, are
used in orthodontics. One is round; the other
rectangular.
There are certain relationships between the size
and form of the wire
and the amount of
force the wires apply
to the teeth.
Increasing wire size
applies more force. On
the other hand,
increasing wire length
between the attachments applies less force. Thick short wires apply the
most force(and have relatively little elasticity) Thin long wires apply the
least force (and have greater elasticity).
Specifically, the stiffness of a round wire is directly proportional to
the 4th power of its diameter (D4), while the deflection of the wire is
inversely proportional to the 3rd power of its length (1/L3).
Thus, when the diameter of a round wire is doubled, the amount of force
necessary to deflect the wire is 8x less.
The stiffness of a rectangular wire is directly proportional only to the
3rd power of its thickness while the deflection of the wire is again inversely
proportional to the 3rd power of its length.
With round wire, crown position can be controlled in all planes of space.
In addition, the positions of the roots of the teeth in a MESIODISTAL
111
direction can also be controlled. On the other hand, the positions of the
roots of the teeth in a BUCCOLINGUAL DIRECTION CANNOT BE CONTROLLED WITH ROUND
WIRE.
In contrast, with rectangular wire, the positions of the crowns and
roots of the teeth can be controlled in all planes of space. THUS ONLY
RECTANGULAR WIRE IS A UNIVERSAL WIRE.

112
 IDEAL ARCHES
During treatment, the shapes of the arches are made to conform to an
ideal pattern which has as essential component, ideal alignment. m e
maxillary and mandibular ideal arches are coordinated in a manner that places
the maxillary teeth 'ideally' over the mandibular teeth.
MAXILLARY ARCH
From the occlusal view, the lingual surfaces of
the six incisors should be tangent to the same arc of a
circle. Since the bucco-lingual thickness of the
lateral incisors is less than the thickness of the
central incisors and canines, the labial surfaces of
the teeth cannot be aligned tangentially along the arc
of a circle. The labial surfaces of the lateral
incisors will be more lingually positioned relative to
the labial surfaces of the central incisors and
canines. The form of the arch wire has to reflect these size and position
differences. To this end, 'insets' called the lateral insets, is made in the
arch wire between the central and lateral incisors.
Between the lateral and canine, the wire is contoured labially and
curved around the canines so that 'bulges', called canine eminences, exist in
the wire in the canine regions.
From the canines to the molars, the wire is reasonably straight and
diverges slightly laterally.
At the first molar position, another wire adjustment is necessary
because the first molars are thicker, buccolingually, than the second
premolars. To compensate for this discrepancy, 'bayonet' bends are made which
move the wire labially adjacent to the first molars. Distal to the first
molars, the wire is slightly constricted.
MANDIBULAR ARCH:
The occlusal view should be essentially a mirror
image of the maxillary arch. The lateral
insets are not necessary in the lower arch wire because
the central and lateral incisors have the same buccolin-
gual thickness. Canine eminences are necessary because of
the increased thickness of the canines. Posteriorly,
bayonet bends are also placed in the wire after which,
the wire is slightly constricted.

113
COORDINATED IDEAL ARCHES
The ideal arches of the maxillary and mandibular arches must be
coordinated to reflect the intended positions of the teeth. When placed
together, the mandibular arch must 'fit' into the maxillary arch, so that
the maxillary arch is slightly labial, in almost all areas, to the
mandibular arch reflecting the slightly labial positioning of the maxillary
teeth. (In the molar region, the wires often are aligned over each other.
this occurs because the slopes of the buccal cusps of the first molars are
greater than the slopes of the cusps of the maxillary first molars. In
effect, this means that the tube of the lower first molar is 'moved' more
labially, and, as a consequence, the wire is formed more labially in this
area.
The canine eminences and the bayonet bends of the mandibular arch
should be approximately 3 mm anterior to those in the mandibular arch to
reflect Class I positioning.

114
 LOOPS
Loops are permanent bends in the arch wire
and are placed between brackets of adjacent
teeth. They serve two principle functions.
1) We previously described that we can align
teeth by using wires because wires can be de-
formed within their elastic limits and will
return to their original shape. If the wire
is shaped in an ideal arch form any malposed
tooth to which the wire is attached will
move. However, there are times when the
archwire cannot be placed in the attachment
of a malposed tooth without permanently
deforming - rendering the wire ineffective.
This occurs because the force necessary to
insert the wire exceeds the limits that the
wire can withstand.
2) Under these conditions, LOOPS which
increase the length of the wire between the
attachments, thereby
increasing the wire's
elasticity, can be placed in the wire to allow it
to be attached to the malposed tooth without
permanent deformation.
Wires can be made with vertical loops or
vertical loops with horizontal components.

VERTICAL LOOPS
Vertical loops can be readily deflected in the
antero-posterior and bucco-lingual planes of space. As
such, they are used to correct A-P and B-L discrepan-
cies.

115
HORIZONTAL LOOPS

A horizontal component of a loop allows the wire to be easily

deflected in a vertical plane of space. As such, there are indicated when
vertical movements are necessary.

CHANGES IN ARCH LENGTH

A second, more common use of loops is to change the length of the
dental arch. This can occur because loops can be made either to open or
close - lengthening or shortening the dental arch to which the wire is
attached.
The type forces applied with looped archwires are intra-arch, (Class
I) forces.

116
 WIRE PLACEMENT AND LIGATION
The archwire is inserted into the first molar tubes and then into the
horizontal slots of the brackets. It is held firmly in place with a thin
(.010) 'dead soft' ligature wire or elastomeric tie on each bracket.
When ligating an arch wire in place, a sequence can be
followed. The central incisor of one side can be tied, followed by the
other central incisor. The other teeth can then be sequentially ligated.
lateral-lateral, canine-canine etc.
Any excess arch wire that exits the tubes should be cut at or near the
distal part of the tube. If a small portion of the wire is exposed in back
of the tube, it can be bent slightly toward the band to avoid contact with
the soft tissue.

ORAL HYGIENE

Adequate oral hygiene is a fundamental component of a healthy stomato-

gnathic complex. Orthodontic appliances tend to trap debris which can lead
to caries formation if not thoroughly removed from the teeth, and/or
gingival inflammation. For this reason, they should only be placed after
the patient is caries free and any periodontal disease controlled
During orthodontic treatment, the hygiene regimen should become more
fastidious . We suggest the use of a fluoride rinse for all patients.

PATIENT COOPERATION

Patient cooperation is indispensable to successful orthodontic

treatment. The best diagnosis, treatment plan and appliance selection can,
at times, be rendered useless if the patient is not cooperative. For
example, if maximum anchorage conditions exist and the patient is given an
appliance, such as a headgear, to control the anchor unit, treatment can
succeed if the patient uses the headgear. If the headgear is not used, the
treatment objectives probably will not be achieved. Some orthodontists
believe that establishing a comfortable doctor-patient relationship tends
to make patients more comfortable.

117
EFFECTS OF EXTRUSION OF TEETH ON BITE DEPTH AND FACIAL FORM
An important consideration during treatment
is the effect of extruding teeth (i.e. moving
them toward the occlusal plane) on bite depth and
facial form.

EXTRUSION OF POSTERIOR TEETH

A) Bite depth:
Extrusion of posterior teeth generally opens
the bite (i.e. reduces bite depth).
B) Facial Form:
Extrusion of posterior teeth can lead to
clockwise rotation of the mandible. This
indicates that lower facial height would in-
crease and the chin would be positioned in a
posteriorly. The ANB angle would increase and
any Class II tendencies would be aggravated.
If posterior teeth are extruded and
clockwise rotation of the mandible does not
occur, it is said that condylar growth was
sufficient to 'compensate' for the extrusion.

EXTRUSION OF ANTERIOR TEETH

A) Bite depth:
Extrusion of anterior teeth tends to close the
bite (i.e. increase bite depth)
B) Facial form:
There is generally no effect on facial form
when anterior teeth are extruded.

FORCE VECTORS OF VARIOUS FORCE SYSTEMS:

Each force system produces forces in more
than one plane of space.

118
 EXTRA-ORAL APPLIANCES:
As outlined previously, these appliances, which are made up of an
intra-oral wire and an extra-oral elastic, are used for 2 main purposes.
One is to move teeth, particularly molars, posteriorly. The other is to
control reaction forces the molar teeth or the incisor segments.
The wires that are inserted on the posterior part of the arch are
different from those that are used on the anterior part of the arch.

POSTERIOR INSERTION: Kloen face bow.

A Kloen face bow is composed of 2 wires joined in their central
portions. The inner wire is a continuous wire extending from molar to molar
and has 'stops' in the form of loops which will not allow the wire to slide
through the tube past the stop. The outer
portion extends extra-orally and has
terminal loops on both sides
for the placement of the
elastic.
The elastic can be made
to "pull" from various direc-
tions, depending on the type
strap used. The elastics can
pull from the neck, from the
face, near the ear or from
the cranium.
With this appliance, the
action force is placed
against the molars and the
reaction force placed against the head and/or neck.
The Kloen face bow is used for 2 main purposes: a) to move molars
distally and b) to stabilize the posterior segments when anteriorly
directed reaction forces are placed on these teeth.
ANTERIOR INSERTION- Facial Wires:
When the extra-oral appliance is applied to the anterior segment of
the arch, 2 separate wires, called facial wires, extend from the strap to
insert on the anterior part of the archwire by means of loops bent into the
arch wire or hooks soldered onto
the wires.
As with the Kloen face bow,
the elastics can he made to pull
from the neck, face or cranium.
In this instance, the action
force is placed against the
incisor segment while the reaction
force is placed against the head
and/or neck.
Facial wires are used a) to
move the incisor segment and/or
the canines (individually) in a
posterior direction and b) to
stabilize the anterior segment
when an anteriorly directed reaction force is placed against the incisors.
An important concern is the direction of pull of the elastics because
each direction places different force vectors on the teeth. The plane of
reference to determine force directions is the occlusal plane.
119
 There are 3 general directions of pull:
a) Traction which is parallel to the occlusal plane. This is called
STRAIGHT PULL--Since the direction of pull is along the occlusal plane, the
principle force vectors are antero-posterior.
b) Traction which is above the occlusal plane called HI-PULL. Since
the direction of pull is both posterior and superior, this appliance places
a posterior, superior vector on the segment to which it is attached.
In the MAXILLARY arch this indicates INTRUSION.
In the MANDIBULAR arch this represents EXTRUSION.
c) Traction which is active below the occlusal plane--called LOW-PULL.
This places a posterior inferior vector on the segment to which it is
attached.
In the MAXILLARY arch this indicates EXTRUSION.
In the MANDIBULAR arch this represents INTRUSION.

EFFECT ON MAXILLARY MOLARS

HI-PULL GEAR: intrudes and moves the molars distally, closing
the bite depth.
This is used when a gear is necessary for a patients
with an open bite tendency and/or hyper divergent facial
pattern.
It is not used when the bite is deep in patients with a hypo-
divergent pattern.
STRAIGHT-PULL GEAR: moves the molars distally with slight ex-
trusion of the molar-opening the bite slightly.
This is used in patients with normal bite depth and
normal facial pattern.
It is not used when there is an open bite and the face
is hyperdivergent.
LOW-PULL or CERVICAL GEAR: moves the molars distally while
extruding them - opening the bite.
This is used in patients with normal bite depth and
normal to hypodivergent facial pattern.
It is not used when there is an open bite or hyperdivergent facial
pattern.
EFFECT ON LOWER MOLARS
HI-PULL GEAR: This is generally not used.
STRAIGHT-PULL GEAR: This gear is also not used.
LOW-PULL or CERVICAL GEAR: moves the molars posteriorly (very little) and
intrudes them slightly.
The gear is not used often. One application is the support lower molar
position when Class I mechanics are used. (i.e. anchorage control)

EFFECT ON THE MAXILLARY INCISORS

HI-PULL GEAR: moves the incisors posteriorly and
intrudes them.
It is used when a posterior, intrusive force on the
incisors is necessary. One example is incisor retraction
when the bite is deep.
It is not used when there is an open bite tendency or
an open bite.
STRAIGHT-PULL GEAR: moves the incisor segment
posteriorly and extrudes it slightly. It is used when a
posteriorly directed force against the incisors is
120
necessary. An example is the control of the reaction force against the
incisors when a coil spring is used to move the molars distally. It is not
used when an open bite is present.
LOW PULL GEAR: moves the incisors posteriorly and extrudes them. It is
used when a posterior-inferior force against the incisors is indicated. One
example is maxillary incisor retraction in the presence of an open bite. It
is not used when there is a deep bite.
EFFECT ON THE MANDIBULAR INCISORS:
HI-PULL GEAR: moves the incisors lingually and extrudes them. It is
used mainly in Class III treatment with open bite conditions.
It is not used in the presence of a deep bite.
STRAIGHT PULL GEAR: moves the incisors lingually and may
extrude them slightly. It is used to retract the incisors
when little or no change in bite depth is desired.
It is not used in deep bite conditions.
LOW-PULL or CERVICAL GEAR: moves the incisors lingually
and incisors and intrudes them. It is used when incisor
retraction and intrusion are desired--such as Class III
treatment in the presence of deep bite. It is not used with
open bite conditions.

LIP BUMPER

The lip bumper is a large gauge wire (.045 in) with 'stops' mesial to
the molars. and is approximately 2-3 mm longer and wider than the
mandibular dental arch. When it is inserted into appropriate molar tubes,
it extends from the molars, past the incisor segment to 'push' against the
lower lip. the reflex lip contracture applies a distal directed force
against the molars.
The amount of distal
movement produced by a lip
bumper is modest-l mm.
Additionally, the dental
arch sometimes widens
spontaneously as the bumper
'keeps' the cheeks
(buccinator muscle) away
from the teeth.
There is a tendency for the molars to ' upright' with the use of a lip
bumper - opening the bite. As such, it may be contraindicated when open
bite conditions are present.
In terms of anchorage, the action force is placed against the incisors
while the reaction force is placed against the lip.

INTRA-ARCH (CLASS I) FORCE SYSTEMS: (example- an elastic extending from the

molar tube to the bracket on the canine to retract
the canine. The action and reaction forces are
active in the same arch. As such, the principle
vectors produced by this force system are antero-
posterior. In addition, transverse vectors are
also active, reflecting the peculiarities of arch
form. In the maxillary arch, the canine is
positioned more palatally than the molar-premolar
unit. In the mandibular arch, this difference is
121
less marked. As such, the transverse force vectors are less pronounced.
In an A-P plane, one force vector tends to move the canine posteriorly
and one tends to move the molar premolar unit anteriorly. In a transverse
plane, there is a force which tends to move the canine labially and move
the molar-premolar unit palatally.
The maxillary arch wire is constricted in the canine region to
compensate for the expansive vector placed on the tooth. No expansion is
placed in the posterior region of the wire because experience has shown
that the molar-premolar unit is generally unaffected by the palatal vector
arising from the Class I force. (Since palatal movement occurs infrequent-
ly, this zone of the arch wire is expanded only after any constriction is
noted.)
One way to reduce the tendency for expansion to occur in the canine
region is to apply the Class I forces on the lingual surfaces of the teeth.
These tend to act more in a straight line. As such, they have few lateral
vectors.
In the mandibular arch, no compensation is placed in the arch wire
because experience has shown that it is not necessary.
When Class I forces are
placed on the attachments on
the labial surfaces of the
teeth, there are also forces
tending to rotate the teeth.
The canines tend to rotate
disto-lingually; the molar-
premolar units rotate
mesiolingually. To
counteract these, 'anti-
rotation' forces are placed
on the teeth. On the canine, a 'tie' is often placed from the lingual
attachment, extending around the distal surface to the tooth to the arch
wire. This functions to prevent the crown of the canine from rotating as it
moves distally.
A similar tie can be placed on the molar-premolar unit. Often, a tie
is placed on the premolar, extending from the lingual attachment on the
premolar to the wire. Molar rotation is then controlled by placing a bend
in the arch wire, called a 'toe-in' bend, to counteract the molar rotation
produced by the Class I force.
When forces are placed on both the labial and lingual surfaces, there
is less tendency for rotation to occur because the rotations produced by
the labially placed and lingually placed Class I forces are in opposite
direction. As such, they tend to counteract each other.

CLASS II FORCES
(INTER-ARCH)
Since these extend from the maxillary
incisor region to the mandibular molar region,
they apply principally horizontal and vertical
vectors. The horizontal component represents
3/4 of the applied force; the vertical vector,
only 1/4. In addition, there is a slight
transverse component because the maxillary anterior region is more
lingually placed than the mandibular molar region.
Horizontal vectors:
122
 Class II forces place a
posterior vector on the maxillary
arch and a mesially directed vector
on the mandibular arch. The force on
the maxillary arch is most often
desirable. On the other hand, the
mesially directed vector can
generally be blocked by a lip bumper
etc (see page ) if necessary.

Vertical vectors:
Class II forces place an extrusive vector on the anterior aspect of
the maxillary arch and the posterior aspect of the mandibular arch. The
vector placed on the maxillary
arch can be controlled by
placing a headgear (hi-pull
type) to the incisor region or
appropriate bends in the arch
wire. The vector placed on the
mandibular arch can presumably
be controlled by placing bends
in the arch wire.
Transverse vectors:
There is a lateral vector tending to expand the maxillary anterior
region and a lateral vector tending to constrict the mandibular molar
region. maxillary incisor region is clinically insignificant. As such, no
compensation is made for this bend. The lingual vector on the mandibular
molar region is controlled by expanding the wire a few mm. (At times, when
a 'heavy' rectangular wire is used, expansion of the wire may not be
necessary since the constrictive force of the elastic is insufficient to
overcome the 'rigidity' of the archwire.)
From the preceding analysis, it is apparent that there are 4 principle
side effects that are important to consider when using Class II elastics.
1) Extrusion of the maxillary incisors. If pronounced, this can lead
to a smile in which excessive gingival tissue is seen when a person smiles
(called a 'gummy' smile). This movement is generally undesirable.
2) Extrusion of the posterior teeth. This movement can change the
occlusal plane by elevating it in the posterior region. This, in turn, can
lead to clockwise rotation of the mandible, exacerbating Class II tenden-
cies by increasing facial convexity (see pg ). This movement is considered
undesirable except in a patient with a hypodivergent facial pattern.
3) Constriction of the mandibular posterior segments. This movement
poses few problems since it can be controlled relatively easily.
4) Anterior movement of the mandibular arch. This movement is, most
often, undesirable. As such, it should be controlled. One stabilizing
appliance is a lip bumper.

INDICATIONS OF CLASS II ELASTICS

The principle use of Class II elastics is to move the maxillary
anterior segment and/or the entire maxillary arch. In addition they are
used to help open the bite in patients with hypodivergent facial patterns.
This reflects the fact that the extrusion of the mandibular posterior teeth
is a more 'efficient' mechanism for opening the bite when compared to the
bite closing effects of the extrusion of the incisor segment. Also, the
123
extrusion of the incisor segment can be controlled relatively easily with
an appliance such as a hi-pull headgear.
A logical assumption is that Class II elastics would also be useful to
protract lower molar-premolar units in extraction situations. However, in
our experience, these elastics do not readily protract posterior teeth. For
this reason, we do not routinely use them for this purpose.
CONTRAINDICATIONS
The most significant contraindication is an open bite tendency or an
open bite condition-because extrusion of the posterior teeth can exacerbate
the problem.
Additionally, the anterior vector on the lower arch, in many instanc-
es, can result in a bimaxillary protrusion unless adequately controlled.
CLASS III ELASTICS
These elastics, extending from the mandibular anterior region to the
maxillary posterior region also applies forces in all 3 planes of space.
(Essentially the same considerations that pertain to Class II elastics
apply to Class III elastics--only in reverse order.) Horizontal components:
The elastics apply a distally directed force against the mandibular arch
and an anteriorly directed force against the
maxillary arch. The distally directed force
against the mandibular arch is most often
desirable. When necessary, the anterior force
component placed on the maxillary arch can be
controlled with the use of a headgear.

Vertical components:
There are extrusive vectors on the
maxillary posterior and mandibular anterior segments. As with Class II
elastics, the extrusive component in the posterior region can change the
cant of the occlusal plane, open the bite and lead to clockwise mandibular
rotation, etc. Mandibular incisor
extrusion tends to deepen the bite.
The extrusive component on the
maxillary molars can be controlled
with a hi-pull headgear. Appropriate
arch form can presumably control the
extrusion of the mandibular anterior
teeth.

Transverse components: these forces

tend to constrict the maxillary
posterior regions and expand the
mandibular anterior region. To
compensate for the constriction
tendencies in the maxillary arch, the arch wire is expanded a few mm.
Nothing is done to compensate for the expansive components on the lower
incisor region.

INDICATIONS
The principle indication is to apply a distally directed force against
the lower arch. Under these conditions, the reaction force placed against
124
the maxillary arch is controlled by a headgear. These elastics are also
used to treat patients with Class III malocclusions.

CONTRAINDICATIONS
The presence of an open bite tendency or an open bite is the main
contraindication of Class III elastics.

125
 TREATMENT SEQUENCE
Non-extraction treatment:
In non-extraction treatment, the first procedure is to establish a
Class I molar relationship, generally by moving the molars posteriorly. For
this purpose, a gear and/or removable appliance can be used. At this point,
only the molars are banded. The rest of the teeth in the maxillary arch are
then banded and bracketed and a highly elastic, flexible leveling wire,
such one made of Nickel Titanium, is placed for bracket alignment. Next,
the premolars and canines are sequentially retracted by moving the teeth
posteriorly along a .016 x .022 wire. This is followed by incisor
retraction, as described, using a .018 x .022 wire. After adding Class I
forces, Class II forces are placed against the maxillary canines to help
maintain the posterior group of teeth in position (maintain anchorage).

Extraction treatment:
In extraction type treatment, initial bracket alignment is done as
previously cited - using a "leveling" wire. The canines are then retracted
along an .016 x .022 wire to gain the appropriate space for incisor
alignment and/or retraction. The incisor segment is controlled with an .018
x.022 wire. Uprighting springs are placed, where necessary, to control
incisor anchorage.

EXAMPLE I: NON-EXTRACTION TREATMENT

A patient requests treatment because "my upper teeth stick out." Upon
examination, we note a Class II Division 1 malocclusion and a deep bite.
Analysis of the study models, radiographs and photographs reveals that
there is no crowding in the lower arch, a flat Curve of Spee and no midline
discrepancy, In addition, there is no profile requirement. Finally, the
facial pattern is slightly hypodivergent.
In table form:
R L
1) Crowding +1 +1
2) COS -1 -1
3) Midline 0 0
4) Profile 0 0
5) Space necessary 0 0
6) EXT or EXP 0 0
7) Movement of 6 6 0 0
8) Relationship 6 6
6 6 -5 -5
9) Movement 6 6 -5 -5 The maxillary molars must be moved
distally 5mm
Our evaluation indicates that maxillary arch expansion by means of
molar distal movement is the method of choice to gain space to align and
retract, sequentially, the premolars, canines and incisors.

126
Step 1: Molar Distal Movement
Bands with double tubes are fitted and cemented on the maxillary first
molars and a headgear placed. Because of the facial pattern (hypodivergent)
and the deep bite, a Kloen type cervical traction gear is selected.
The gear, which applies 500-700 grams/side, should be worn at least
12-14 hours/day. This indicates that PATIENT COOPERATION IS AN INDIS-
PENSABLE FACTOR since it is the patient who moves his/her molars poste-
riorly.
When worn 14 hours/day, and no second molars are present (i.e. late
mixed dentition - early treatment dentition) molar movement usually occurs
at the rate of up to 1 mm/month. This means that 5 mm of distal movement of
the molars can be accomplished in 6-8 months.

BIOMECHANICS:
Force type: the application of
a cervical traction gear applies a
'single force' to the molars.
Consequently, the molars are TIPPED
distally.

ANCHORAGE CONDITIONS:
Maximum anchorage conditions
are present.

VECTORS:
The cervical traction gear is
a low pull type gear - applying
posterior, extrusive vectors to the
molars. This extrusive vector helps
in bite opening. It also could lead
to some clockwise rotation of the
mandible which, in a patient with a
hypodivergent facial pattern, is
tolerable.

127
STEP 2:
After achieving Class I molar
relationships, attachments are placed on
the remaining teeth in the maxillary
arch. A leveling wire which is extremely
flexible and therefore quite 'elastic'
is usually inserted to align the brac-
kets. A flexible, highly 'elastic' wire
is necessary because in the initial
phases of treatment the brackets are too
unevenly positioned to allow a straight
.016 or .018 arch wire to be inserted
without deformation. The choice then
becomes a flexible wire or a wire with
loops. Most choose a flexible wire
because it is as effective as a looped
wire and easier to insert. THE GEAR IS
STILL WORN AND WILL BE WORN THROUGHOUT
TREATMENT - TO MAINTAIN MOLAR POSITION -
not to move the molars further distally.
An .016 x .022 wire with an ac-
centuated Curve of Spee for bite opening
purposes and stops mesial to the molars
is then placed. When the arch wire is
ligated to the remaining teeth in the
arch, the stops function to help main-
tain molar position because the molars
cannot move anteriorly unless the rest
of the teeth in the maxillary arch move
anteriorly. In effect, the stops place
the maxillary incisors against the
molars, forming a unit. The molars cannot move mesially unless the incisors
also move mesially.

Biomechanics:
The insertion of the wire places a 'force
couple' on the molars because the wire is straight
while the molar tubes are angled, reflecting the
change in inclination as the molars moved distally.
The force couple moves the roots posteriorly
and the crowns anteriorly. The anterior crown
movement is 'blocked' by the use of the gear and the
stops in the wire.

ANCHORAGE CONDITIONS:
Maximum anchorage conditions continue to be
present. Molar position is now maintained by:
a) the use of the gear
b) stops in the arch wire

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STEP 3:
Once the molars have been uprighted (or almost
uprighted), intraarch elastics are sequentially
placed to retract the second premolars, first premo-
lars and canines.
The elastics can be placed both labially and
lingually to control rotations as the teeth move
distally.
Once the individual teeth arrive in correct
position, they are usually 'tied back' to the molar
with a steel ligature tie - to prevent any anterior
migration that could occur.

BIOMECHANICS:
With the application of the
elastics, the first movement
occurs as a tipping movement. Once
the teeth begin to incline, the arch wire is forced
against the corners of the attachments - creating a
'force couple' - uprighting the roots of the teeth. In
effect, sliding the teeth along the archwire has the same
effect as applying a single force (the elastic) and a
force couple (bracket-wire interface) together.

ANCHORAGE CONDITIONS:
Maximum anchorage conditions
exist, While the premolars and
canines are moved posteriorly,
attachments are placed on the
teeth of the lower arch and a
series of archwires inserted to
develop an ideal arch.

Step 4

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MAXILLARY ARCH:

When the distal movement of the

premolars and canines has been completed, the
central and lateral incisors, as a group, are
retracted to reduce the overjet. For this
purpose, an .021 x .025 rectangular wire with
closing loops distal to the lateral incisors
can be used. Hooks, which are located next to
the distal aspect of the attachment of the
second premolars, are soldered onto the arch-
wire. Fifteen to twenty degrees of lingual
root torque on the incisor segment of the
wire and an accentuated Curve of Spee are
placed in the wire.
The wire is activated by sliding it
through the terminal tubes (see page ???) A
tie wire is placed around the terminal tube
and ligated to the hook on the wire to hold
the wire in the activated position.
Class II elastics are then placed
against the maxillary canines to help hold
the posterior teeth in position. (Anchorage
support)

MANDIBULAR ARCH:
An ideal .021 x .025 rectangular
archwire with second order bends in the
terminal molar region is inserted.

BIOMECHANICS
The force system is the simultaneous placement of a
couple and a single force. the force couples are placed
on the incisor teeth by means of a rectangular wire,
directing the roots lingually. The closing loops
represent the single force. If the couple/force ratio is
adjusted properly, bodily movement will occur.

ANCHORAGE CONDITIONS
Maximum anchorage conditions exist for both arches.
In the maxillary arch, the headgear and Class II elas-
tics are used to control the position of the posterior
segments. In the mandibular arch, the second order bends
are to counteract the Class II elastics. If the elastics are to be used
more than 6 weeks, a lip bumper is used to control lower arch position.

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Step 5

After maxillary arch space closure,

ideal arches are placed to develop final
ideal and coordinated arch form in both
arches. This necessitates control of both
crown and root position. (Evaluation of
root position may, at times, require a
radiographic analysis.) The ideal
archwires are 'individualized' to compen-
sate for any discrepancies. If root
position is adequate, undersized, .016 x
.022 wires are used to produce final arch
form, If root position needs change,
particularly in a bucco-lingual plane,
.021 x .025 rectangular wires are
indicated.

BAND AND BRACKET REMOVAL:

One procedure for band and bracket
removal is to remove all attachments
except those on the canines and terminal
molars. An activated ligature wire is then
placed from the molars to the canines to
close band spaces.

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 EXAMPLE II: EXTRACTION TREATMENT

A patient seeks treatment because of lower incisor crowding and

maxillary arch protrusion. An analysis of the study models, radiographs and
photographs indicates that there is a Class II malocclusion with the
following characteristics: normal bite depth; 5 mm of lower incisor
crowding, evenly distributed; a Curve of Spee requiring 1.5 mm/side to
flatten; no midline discrepancy; and no profile requirement. In addition,
the facial pattern is hypodivergent. In table form:
R L
1) Crowding -2.5 -2.5
2) COS -1.5 -1.5
3) Midline 0 0
4) Profile 0 0
5) Space necessary -4 -4

6) EXT or EXP +7 +7
7) Movement 6 6 +3 +3 Moderate anchorage conditions
8) Relationship 6 6
6 6 -3 -3
9) Movement 6 6 0 0

AN IMPORTANT OBSERVATION IS THAT CLASS II CORRECTION CAN BE GAINED BY

LOWER MOLAR PROTRACTION.

Step 1:
MAXILLARY ARCH:
Band the first molars, with convertible
double tubes on the bands. A HI-PULL gear (because
of the hyperdivergent facial pattern) is then
inserted and is to be worn at least 12-14
hours/day THROUGHOUT TREATMENT. Once the gear is
in place, first premolars are extracted.
MANDIBULAR ARCH:
Extract the first premolars.

132
Step 2
MAXILLARY ARCH:
Attachments are placed on the remaining teeth in the arch, including
the second molars, if present. (If the second molar is banded, the tube on
the first molar is converted into a bracket.)
Wire placement begins with a flexible wire
for initial bracket alignment. This is followed by
an .016 x .022 'working' wire with stops mesial to
the first molar brackets. The second molar, first
molar and second premolar are ligated together
with ligature wire to form a unit. Class I
elastics are then extended from the labial and
lingual surfaces of the molars to the labial and
lingual surfaces of the canines.

MANDIBULAR ARCH:
Attachments are placed on all teeth,
including the second molars. Wire insertion starts
with a flexible wire and progresses to an .016 x
.022 wire. If any of the crowded incisors cannot be easily ligated to the
wire because of their positions, they are not included in the wire until
adequate space is present.
The posterior teeth are united with a ligature tie and labial and
lingual Class I elastics extended from the first molars to the canines.

BIOMECHANICS:
MAXILLARY ARCH:
Canine retraction occurs in a reasonably bodily
fashion because the force system includes a single
force applied by means of the elastics and a force
couple which occurs at the bracket-wire interface.
(see page ???)
In effect the .016 x .022 wire in the .022
bracket permits little inclination of the canines.
Molar position is stabilized by means of a headgear.

MANDIBULAR ARCH:
For reasons described, the canines move
posteriorly and the molar-premolar unit anteriorly in
a "quasi" bodily manner.

ANCHORAGE:
MAXILLARY ARCH:
Maximum anchorage conditions exist. The molars
are stabilized by w methods. One is the HEADGEAR. The
other is the stopped archwire, which means that the
incisors, as well as the molars and premolars are
included in the anchor unit.

MANDIBULAR ARCH:

Moderate anchorage conditions exist. For this reason, no stabilizing

forces reaction force.

133
 When moderate anchorage conditions exist,
particular attention must be paid to the space
closure procedure. AS INDICATED IN THE TREATMENT
PLAN, THE IMPORTANT GOAL IS TO CREATE ADEQUATE
SPACE ANTERIOR TO THE CANINES TO ALIGN THE IN-
CISORS. Any remaining space is closed by mesial
movement of the posterior teeth. THUS THE IMPOR-
TANT REFERENCE POINT IS THE AMOUNT OF CROWDING
RELATIVE TO THE AMOUNT OF SPACE CREATED ANTERIOR
TO THE CANINE.

If there are 2mm of incisor crowding and 2mm

of space has been created anterior to the canine,
canine retraction has been completed. Any
remaining space is closed by protraction the
posterior teeth.

On the other hand, if there is 2mm of

crowding and only 2mm of space remains, this means
that all the available space is necessary for
canine retraction. THUS, THE MOLAR-PREMOLAR UNIT
MOVED TOO FAR ANTERIORLY AND MAXIMUM ANCHORAGE
CONDITIONS NOW EXIST. THE POSTERIOR UNITS MUST BE
STABILIZED by means of a lip bumper or another
stabilizing mechanism.

134
 Three specific circumstances can occur:
a) The space can close by equal amounts of
posterior movement of the canine and anterior
movement of the molar-premolar unit. Under these
conditions, 2mm of space closure would represent
1mm of canine distal movement and 1mm of mesial
movement of the molar-premolar unit. In this
circumstance, the Class I forces are religated.
When the canine has been retracted 3mm, molar-
premolar protraction would also be 3mm. The
final mm of space closure would occur by molar-
premolar protraction.

b) The molar-premolar unit can move

anteriorly more quickly than the canines move
distally. Under these conditions, the posterior
group of teeth is STABILIZED by placing a lip
bumper etc. and Class I forces placed.

c) The canines can move posterior faster

than the molar-premolar units move mesially.
Under these conditions, incisor alignment can
occur and space still exists distal to the
canines. The incisor segment is then stabilized
by placing labial crown torque on the incisor and
uprighting springs on the canines during space
closure.

135
STEP 3:
MAXILLARY ARCH:
After canine retraction, the incisor
segment can be retracted by inserting an
.021x.025 closing loop arch wire with torque as
necessary on the incisor segment of the wire to
control the positions of the incisor roots. An
accentuated Curve of Spee is also placed in the
wire and the wire activated as previously de-
scribed. Class II elastics are extended from
the maxillary canine.

MANDIBULAR ARCH:
At this point, space closure in the man-
dibular arch has been completed and the molar relationship is Class I
because of the mesial movement of the molars. An ideal .021x.025
rectangular wire is placed with a tip back in the terminal molar region to
counteract the vectors of the Class II elastics.

BIOMECHANICS:
The biomechanical considerations
are as described in the previous
example. Force couples (torque in the
incisor segment of the wire) and a
single force (closing loop) are placed
on the incisors to retract them
'bodily'
ANCHORAGE:
MAXILLARY ARCH:
Maximum anchorage conditions: The
headgear and Class II elastics are
placed to maintain the positions of the
posterior teeth.
MANDIBULAR ARCH:
Maximum anchorage
conditions: A lip bumper is necessary if the Class II
elastics are to be used more than 6 weeks.

Step 4
Refinement of
Final Arch Form

136