PLANETS OF

ORTHODONTICS
Volume III
Biomechanics and Tooth Movement
Authors:

Dr. Mohammed Almuzian

Specialist Orthodontist (UK)
BDS Hons (UoM), MDS Ortho. (Distinction), MSc.HCA (USA), Doctorate Clin.Dent. Ortho. (Glasgow), Cert.SR
Health (Portsmouth), PGCert.Med.Ed (Dundee), MFDRCSIre., MFDSRCSEd., MFDTRCSEd., MOrth.RCSEd.,
FDSRCSEd., MRACDS.Ortho. (Australia)

Dr. Haris Khan

Consultant Orthodontist (Pakistan)
Professor in Orthodontics (CMH Lahore Medical College)
BDS (Pakistan), FCPS Orthodontics (Pakistan), FFDRCS Ortho. (Ire.)

With

Dr. Ali Raza Jaffery

Specialist Orthodontist (Pakistan)
Associate Professor Orthodontics (Akhtar Saeed Medical and Dental College)
BDS (Pakistan), FCPS Orthodontics (Pakistan), MOrth.RCS (Edin.)

Dr. Farooq Ahmed

Consultant Orthodontist (UK)
BDS. Hons. (Manc.), MDPH (Manc.), MSc (Manc.), MFDS (RCS Ed.), PGCAP, MOrth.RCS (Eng.), FDSRCS Ortho.
(Eng.), FHEA
 Acknowledgments

This book is the sum and distillate of work that would not have been possible without the support of our families
and friends. Special thanks to the contributors who continuously provided advice in developing this book and
up-dating individual chapters.

Finally, we acknowledge the hard work and expertise of Ms Faiza Umer Hayat who was responsible for compiling
this volume.
 Contributors
Dr. Mark Wertheimer / Specialist Orthodontist (South Africa)
Dr. Samer Mheissen / Specialist Orthodontist (Syria/ Jordan)
Dr. Lina Sholi / Specialist Orthodontist (KSA/ Turkey)
Dr Mushriq Abid / Specialist Orthodontist and Professor in Orthodontics (Iraq/ UK)
Dr Emad Eddin Alzoubi / Specialist Orthodontist and Lecturer of Orthodontics (Malta)
Dr. Muhammad Qasim Saeed / Professor of orthodontics (Pakistan)
Dr. Asma Rafi Chaudhry / Assistant Professor of orthodontics (Pakistan)
Dr. Taimoor Khan / Specialist Orthodontics (Pakistan)
Dr. Maham Munir / Postgraduate Trainee in Orthodontics (Pakistan)
Dr. Eesha Najam / Postgraduate Trainee in Orthodontics (Pakistan)
Dr. Farhana Umer / Postgraduate Trainee in Orthodontics (Pakistan)
Dr. Ayesha Iqbal / House Officer (Pakistan)
 Copyrights

All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form or
by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior
written permission of Dr Mohammed Almuzian and Dr Haris Khan who have the exclusive copyright, except in
the case of brief quotations embodied in critical reviews and certain other non-commercial uses permitted by
copyright law. For permission requests, contact them at [email protected]
 Preface

Questions expose our uncertainty, and uncertainty has been our motive. The authors and con-tributors have
aggregated this book, and the series of books to follow, in answer to questions covering the breadth and depths
of orthodontics.

This volume covers tooth movement and biomechanics of orthodontics. The theme of this chapter is Saturn fea-
turing the beauty of this volume.

The writing of the book started with the amalgamation of orthodontic notes and the experience of the main two
authors, Dr Mohammed Almuzian and Dr Haris Khan. The other authors helped in proofreading, summarising
the key points in a form of the ‘exam night re-view’. There have been numerous contributors to this book, as
co-writers of specific chapters or as proofreaders, we seek to acknowledge them. To give credit where it is due,
the role of the authors and contributors of this volume are listed on the title page of each individual chapter.
Table of Contents
BONE METABOLISM.............................................. 1 Tooth preparation for orthodontic bonding...........................32

Bone cells and matrix.................................................................2 Resin primer (sealants)..............................................................32

D. Proteoglycans..........................................................................2 Moisture-insensitive primers....................................................33

Periodontal ligament .................................................................3 Self-etching primers (SEP)........................................................33

Cytokines and enzymes .............................................................3 Tooth surface preparation for orthodontic banding ............33

Biologic electricity......................................................................3 Bonding in Fluorosis..................................................................33

Bonding to porcelain, amalgam, veneers and gold.................33
TOOTH MOVEMENT............................................. 7
Impression materials .................................................................34
Biology of orthodontic tooth movement.................................8
Silicone impression materials....................................................34
Phases of OTM............................................................................8
Exam Night Review....................................................................36
Type of tooth movement based on the magnitude of force ..8
Tooth movement and force interval .......................................8 BIOMECHANICS.................................................... 41
Theories on tooth movement ...................................................8 Definition ....................................................................................42

Physiological response to sustained pressure..........................10 Forces............................................................................................42

Mechanical and biological factors in tooth movement..........11 Resultant force.............................................................................42

Theories of the relationship between force magnitude and Centre of Resistance...................................................................42

tooth movement .........................................................................11 Centre of Rotation......................................................................42
Types of tooth movements ........................................................12 Moment of force..........................................................................42
Enhancing and accelerating the rate of tooth movement......12 Force couple.................................................................................42
Effect of drugs on tooth movement .........................................13 Moment of couple or counterbalancing moment...................43
Bisphosphonates..........................................................................13 Effect of periodontal health on M/F ratio................................43
Theories of tooth eruption......................................................... 14 Effect of loops on M/F ratio.......................................................44
Exam Night Review ...................................................................14 Bracket dimensions and moments............................................44
ACCELERATION OF TOOTH MOVEMENT........ 19 Types of force system..................................................................44
Contraindications .....................................................................20 These include:..............................................................................44
Non-surgical intervention for accelerated tooth movement Advantages of a one couple force system.................................44
20
Examples of statically indeterminate systems.........................45
Surgical intervention for accelerated tooth movement .........22
Analogies and commonly used terms in biomechanics........46
Exam Night Review....................................................................24
FORCE DELIVERY SYSTEM................................... 53
ORTHODONTIC MATERIALS.............................. 29 Coil springs..................................................................................54
Ideal properties of adhesives and cements .............................30
Factors affecting force levels of coil springs .........................54
Pre-coated brackets.....................................................................30
Elastic power chain (EPC).........................................................54
Antibacterial composite adhesive.............................................31
Elastomeric Rubber Bands (ERB).............................................54
Cyanoacrylates (super glues).....................................................31
Physical properties of ERB........................................................55
GIC for bonding..........................................................................31
Other uses of elastomeric in orthodontics..............................55
Orthodontic banding .................................................................31
Laceback ligatures ......................................................................55
Resin modified GIC (RMGIC)..................................................32
Magnets........................................................................................56
Modified composite or Compomers (polyacid-modified resin
Sliding mechanism to close space ............................................56
composites) .................................................................................32
Mechanics of friction mechanics..........................................56
Glass polyphosphonate cements ..............................................32
Closing loop mechanism...........................................................57
 Specific recommendations for closing loop archwires...........57
Exam Night Review....................................................................57

FRICTION IN ORTHODONTICS.......................... 61
Definition.....................................................................................62
Types of Friction.........................................................................62
Friction in orthodontics.............................................................62
Clinical implications...................................................................63
Exam Night Review....................................................................64

ARCH FORM AND WIDTH................................... 67

Archform in orthodontics ........................................................68
Implications of the archform in orthodontics.........................68
Square archform..........................................................................68
Ovoid archform...........................................................................68
Systematic method to individualise the archform..................69
Individual patient form (IAF) technique.................................69
Effect of extraction on archform ..............................................69
Exam Night Review....................................................................69

SPACE CLOSURE IN ORTHDONTICS.................. 73

Mechanics of sliding mechanism..........................................74
Bidimensional wire and slot technique....................................74
Factor affecting the frictional resistance during space closure
.......................................................................................................74
Techniques to reduce frictional resistance .............................75
Type of tooth movements .........................................................75
Methods of force application.....................................................75
Specific recommendations for closing loop archwires...........76
En-masse or two-step retraction ..............................................76
Obstacles to space closure..........................................................77
Exam Night Review....................................................................78
 1
BONE METABOLISM
Written by: Mohammed Almuzian, Haris Khan, Maham Munir, Taimoor Khan Muhammad Qasim
Saeed

In this Chapter
1. Bone cells and matrix 13. Types of tooth movements
2. Periodontal ligament 14. Enhancing and accelerating of tooth movement
3. Cytokines and enzymes 15. Effect of drugs on tooth movement
4. Biologic electricity 16. Bisphosphonates
5. Biology of orthodontic tooth movement 17. Theories of tooth eruption
6. Phases of OTM 18. EXAM NIGHT REVIEW
7. Type of tooth movement based on the magnitude of
force
8. Tooth movement and force interval
9. Theories on tooth movement
10. Physiological response to sustained pressure
11. Mechanical and biological factors in tooth movement
12. Theories of the relationship between force magnitude
and tooth movement
Bone remodelling refers to an active process of resorption differentiation and maturation lead to a wide-range of disor-
and formation throughout the skeleton, essential for calcium ders such as osteogenesis imperfecta.
homeostasis and preserving the integrity of skeletal struc-
B. Osteoclasts
tures. Bone remodelling (or bone metabolism) is a lifelong
process. Osteoclasts arise from blood monocytes, which in turn
arise from bone marrow derived hematopoietic precur-
Bone turnover refers to the total volume of bone that is both
sor cells. They are large multinucleated bone cells, as
resorbed and formed over a period of time, usually expressed
many as 200 nuclei, which resorbs bone tissue.
as a percentage per year, estimated by measuring relevant
bone biomarkers (Proffit et al., 2018). Osteoclasts bind to bone through integrin proteins. The
side of the cell closest to the bone contains many small
Bone composition
projections (microvilli) that extend into the bone’s sur-
Generally, bone consists of: face, forming a ruffled (or brushed) border that is the
cell’s active region. Osteoclasts occupy small depressions
• 1/3 water
on the bone’s surface, called Howship lacunae; the lacu-
• 1/3 inorganic mineral component: Calcium and phos- nae are thought to be caused by erosion of the bone by
phate in the form of calcium hydroxyapatite crystals. enzymes from osteoclasts. Osteoclasts are under direct
and indirect control from hormones and growth factors
• 1/3 organic matrix (osteoid): Mostly type 1 collagen
(Graber et al., 2016). Osteoclasts are mediators of the
(90%), small amounts of non-collagenous proteins such
continuous resorption of bone via their enzymes, mainly
as growth factors, osteonectin, osteocalcin and proteo-
acid phosphatase, which dissolve both the organic col-
glycans.
lagen and the inorganic calcium and phosphorus of the
• Cells: Mainly osteoblasts, osteoclasts and osteocytes. bone. Mineralized bone is first broken into fragments,
Bone cells and matrix the osteoclast then engulf the fragments within cytoplas-
mic vacuoles. Calcium and phosphorus are released into
A. Osteoblasts the blood stream by the breakdown of mineralized bone.
Osteoblasts are bone forming cells which are derived Unmineralized bone (osteoid) is protected against osteo-
from mesenchymal precursor cells. External forces stim- clastic resorption, and consequently is removed by Zinc
ulate mesenchymal precursor cells, triggering osteoblas- proteases which is released by osteoblasts (Graber et al.,
tic differentiation and function. Osteoblasts are regulated 2016).
by growth factors (e.g. BMPs, FGFs), cytokines (e.g. IL1) C. Osteocytes
and hormones (e.g. PTH, Vitamin D and Estrogen).
Osteocytes are star-shaped mature bone cells that ac-
Osteoblast differentiation can be activated via multiple count for 90-95% of the total bone cells. They are termi-
molecular pathways including (Bonewald and Johnson, nally differentiated osteoblasts that become embedded in
2008, Capulli et al., 2014): the material it has secreted.
• The canonical Wnt signaling pathway. Osteocytes do not divide and have an average half-life
• Transforming growth factors (TGFs). of 25 years. Osteocytes have a dendritic process extend-
ing within the canaliculi, and have a direct connection
• Bone morphogenic proteins (BMPs). with other osteocytes, osteoblasts and bone lining cells
• Fibroblast growth factors (FGFs). through gap junctions. The mechanical osteocyte stimu-
lation pathway include:
• Gap junction protein (Cx40).
• Integrins (cell to extracellular matrix
• Connexin43 (Cx43). adhesion molecules).
• Calcium ion (Ca2+) mediated noncanoni- • Cytoskeletal structural proteins.
cal Wnt pathways.
• Purinergic receptors.
Osteoblast differentiation is also regulated by transcription
factors such as Runt-Related Transcription factor 2 (Runx2). • Connexin 43 hemichannels.
Osteoblasts produce the organic and inorganic components • Stretch-sensitive ion channels.
of bone after maturation. Mature osteoblasts are entrapped
in bone and are transformed into osteocytes. Osteoblasts are • Voltage-sensitive ion channels.
responsible for osteoclast activation and recruitment by pro- • Primary cilia.
ducing RANKL (Capulli et al., 2014). Defects in osteoblast
D. Proteoglycans

2 Bone metabolism
 The non-collagenous component of the extracellular pressed by osteoblasts. M-CSF stimulates angiogenesis,
matrix of the bone consists of proteoglycans and glyco- promotes recruitment of mononuclear osteoclastic pre-
proteins. Proteoglycans act as ‘biological’ shock absorb- cursor cells from bone marrow, and is involved in the
ers as most are able to retain water, hence, proteoglycans differentiation of osteoclastic precursor cells and osteo-
provide support to teeth during masticatory function. clasts survival.
Proteoglycans have viscoelastic properties during orth-
• RANKL is expressed by osteoblasts (Kong et al., 1999).
odontic loading: i.e. if pressure is placed on these mac-
RANKL knockout in mice results in no osteoclastic ac-
romolecules, water is displaced and moves into intermo-
tivity. Thus osteopetrosis occurs.
lecular spaces. This process minimises intermolecular
interactions and maximises water retention (Last et al., • Matrix Metallo Proteinases (MMP) are enzymes that
1988). depend on Zinc and Calcium ions for their activity. Tis-
sue inhibitors of metallo proteinases (TIMPs) are en-
Periodontal ligament
dogenous inhibitors of MMPs. Tissue breakdown occurs
A tooth is attached to the bundle bone through a specialized when MMP’s become in excess of TIMP. During orth-
collagenous supporting fibrous structure called periodontal odontic tooth movement, MMPs are expressed when os-
ligament (PDL). In addition to the collagenous network, teoclasts bind to bone surface via integrin αvβ3, in order
PDL has cellular and fluid component. PDL occupies 0.2 to to degrade bone matrix.
0.5mm of space between the root and bone socket, acting as
• Secondary messengers are involved in cellular signalling
shock absorber. PDL is believed to offer active stabilization
pathway resulting in cellular response e.g DNA synthesis.
against light unbalanced soft tissue forces of 5-10 gm/cm2.
There are three main second messenger systems which
Principal cells of PDL are undifferentiated mesenchymal cells transduce signals from a cell membrane to the inside
in addition to fibroblasts and osteoblasts. Fibroblasts are re- of a cell and ultimately to the nucleus, these are: cAMP,
sponsible for collagenous remodelling while osteoblasts are Inositol phosphates and Tyrosine kinases (Krishnan and
involved in bony remodelling. Davidovitch, 2006). Both cAMP and inositol phosphates
have implication during orthodontic tooth movement.
PDL has a vascular supply and innervation in the form of free
(Sandy et al., 1993).
nerve endings to sense pain as well as specialized endings for
proprioception. PDL is believed to be responsible for tooth Biologic electricity
eruption and post emergent eruption.
An external force on the bone produces flow of electrons
causing an electric current in crystalline substances. When a
heavy force is applied to the tooth structure, PDL (does not
Cytokines and enzymes
act as shock absorber) transfers heavy forces directly to the
These include: bone which bends in response. This bone bending produces
piezoelectric signals.
• Interleukins: A highly potent bone resorptive agent
(Meikle, 2006, Krishnan and Davidovitch, 2006). IL1β Piezoelectric current has a fast decay rate and it exhibits an
amplifies initial cellular response to mechanical load and equal but opposite response when the force is released.The
stimulates angiogenesis. voltage generated within the bone is called “streaming poten-
tial”.
• Prostaglandins: PDL cells have mechanoreceptors such
as focal adhesion kinases (FAK’s) that release prostaglan- Exam Night Review
din E-2 (Kang et al., 2010). PGE2 stimulates inflamma- Bone and bony metabolism
tory cytokine expression. PGE2 expression is important
for bone resorption and bone formation. PGE2 stimu- Bone remodelling → active process of resorption and forma-
lates RANKL expression and inhibits OPG expression by tion throughout skeleton¬- lifelong process→ mature bone
preventing pre-osteoblasts and osteoblast formation. removed new bone formed.
• Chemokines: A large family of chemotactic cytokines Bone turnover refers to total volume of bone that is both re-
which regulate inflammatory processes, migration, lo- sorbed and formed over a period of time.
calization and trafficking of bone cells (Garlet et al., Bone composition
2007)(Xing Z et al, 2010).
Generally, bone consists of:
• Tumour necrosis factors: TNFα stimulates angiogenesis,
production/secretion of additional biological factors and • 1/3 water.
osteoclastogenesis (Ren and Vissink, 2008). • 1/3 inorganic mineral component: calcium and phos
• Macrophage colony-stimulating factor: M-CSF ex-

Bone metabolism 3
• phate in the form of calcium hydroxyapatite crystals. References

• 1/3 organic matrix (osteoid): mostly Type 1 collagen BONEWALD, L. F. & JOHNSON, M. L. 2008. Osteocytes, mecha-
(90%), small amounts of non-collagenous proteins such nosensing and Wnt signaling. Bone, 42, 606-15.
as growth factors, osteonectin, osteocalcin and proteo- CAPULLI, M., PAONE, R. & RUCCI, N. 2014. Osteoblast and os-
glycans. teocyte: games without frontiers. Arch Biochem Biophys, 561, 3-12.
• Cells: mainly osteoblasts, osteoclasts and osteocytes. GARLET, T. P., COELHO, U., SILVA, J. S. & GARLET, G. P. 2007.
Cytokine expression pattern in compression and tension sides of
Osteoblasts the periodontal ligament during orthodontic tooth movement in
• Derived from mesenchymal precursors. humans. Eur J Oral Sci, 115, 355-62.
GRABER, L. W., VANARSDALL, R. L., VIG, K. W. & HUANG, G.
• External forces stimulate osteocytes triggering osteoblas-
J. 2016. Orthodontics-e-book: current principles and techniques,
tic differentiation and function. Elsevier Health Sciences.
• Osteoblasts are regulated by growth factors (e.g. BMPs, KANG, Y. G., NAM, J. H., KIM, K. H. & LEE, K. S. 2010. FAK
FGFs), cytokines (e.g. IL1) and hormones (e.g. PTH, vi- pathway regulates PGE(2) production in compressed periodontal
tamin D, estrogen), which are responsible for osteoclasts ligament cells. J Dent Res, 89, 1444-9.
recruitment and activation by producing RANKL (Ca-
KONG, Y. Y., YOSHIDA, H., SAROSI, I., TAN, H. L., TIMMS, E.,
pulli et al., 2014). CAPPARELLI, C., MORONY, S., OLIVEIRA-DOS-SANTOS, A.
Osteoclasts J., VAN, G., ITIE, A., KHOO, W., WAKEHAM, A., DUNSTAN, C.
R., LACEY, D. L., MAK, T. W., BOYLE, W. J. & PENNINGER, J. M.
• Arise from blood monocytes. 1999. OPGL is a key regulator of osteoclastogenesis, lymphocyte
development and lymph-node organogenesis. Nature, 397, 315-23.
• Derived from hematopoietic precursors.
KRISHNAN, V. & DAVIDOVITCH, Z. 2006. Cellular, molecular,
• Osteocloasts are large multinucleated cells. and tissue-level reactions to orthodontic force. Am J Orthod Den-
• Contain many small projections that extend into the tofacial Orthop, 129, 469.e1-32.
bone’s surface, forming a ruffled (or brushed) border. LAST, K. S., DONKIN, C. & EMBERY, G. 1988. Glycosaminogly-
cans in human gingival crevicular fluid during orthodontic move-
Osteocytes
ment. Arch Oral Biol, 33, 907-12.
• Star-shaped mature bone cell (90-95% of bone cells). MEIKLE, M. C. 2006. The tissue, cellular, and molecular regulation
Proteoglycans of orthodontic tooth movement: 100 years after Carl Sandstedt. Eur
J Orthod, 28, 221-40.
• Non-collagenous component (proteoglycans and glyco-
PROFFIT, W. R., FIELDS, H. W., LARSON, B. & SARVER, D. M.
proteins) that act as biological shock absorbers and re-
2018. Contemporary orthodontics-e-book, Elsevier Health Sci-
tain water. ences.
Periodontal ligament REN, Y. & VISSINK, A. 2008. Cytokines in crevicular fluid and
• 0.2 to 0.5mm of space between the root and alveolar orthodontic tooth movement. Eur J Oral Sci, 116, 89-97.
bone, which functions as shock absorber. SANDY, J. R., FARNDALE, R. W. & MEIKLE, M. C. 1993. Recent
advances in understanding mechanically induced bone remodel-
• Principle cells of PDL are undifferentiated mesenchymal ing and their relevance to orthodontic theory and practice. Am J
cells in addition to fibroblasts. Orthod Dentofacial Orthop, 103, 212-22.
• PDL also has vascular supply and innervation.
Cytokines and enzymes of the bone and PDL
• Interleukins IL1β
• Prostaglandins
• Chemokines-Tumour necrosis factors, TNFα
• Macrophage colony-stimulating factor RANKL
• Matrix Metallo Proteinases (MMP)
• Secondary messengers cAMP, Inositol phosphates and
Tyrosine kinases.

4 Bone metabolism
Bone metabolism 5
 2
TOOTH MOVEMENT
Written by: Mohammed Almuzian, Haris Khan, Maham Munir, Lina Sholi

In this Chapter
1. Biology of orthodontic tooth movement
2. Phases of OTM
3. Type of tooth movement based on the magnitude of
force
4. Tooth movement and force interval
5. Theories on tooth movement
6. Physiological response to sustained pressure
7. Mechanical and biological factors in tooth movement
8. Theories of the relationship between force magnitude
and tooth movement
9. Types of tooth movements
10. Enhancing and accelerating the rate of tooth move-
ment
11. Effect of drugs on tooth movement
12. Bisphosphonates
13. Theories of tooth eruption
14. EXAM NIGHT REVIEW
Biology of orthodontic tooth movement 3. Post lag phase
Orthodontic tooth movement (OTM) is a process of apply- The mains features are:
ing external forces on a tooth, which trigger a number of
• It is characterized by continuous rapid tooth move-
responses. OTM results in bone deposition in tension sites,
ment (Pilon et al., 1996).
and bone resorption in pressure sites (Meikle, 2006). OTM is
accompanied by minor reversible injury to tooth-supporting • During this phase, the hyalinized zones are removed
structures (King et al., 1991). by osteoclasts, which trigger bony surface resorption
facing the periodontal ligaments.
The process of OTM is a highly individual response and not
completely dependent on the amount of force applied (Pilon Type of tooth movement based on the magnitude of force
et al., 1996).
1. Frontal resorption
Phases of OTM
The mains features are:
The stages of OTM can be divided, based on the time-dis-
• The application of light forces achieves frontal re-
placement curves, into three phases (Graber et al., 2016):
sorption via stimulation of osteoclasts either locally
1. Pre-lag phase within the PDL or from blood flow.
The mains features are: • Osteoclasts remove the adjacent lamina dura from
the PDL side.
• Tooth movement occurs within its socket, as the
tooth moves, the width of the periodontal ligament • Tooth movement begins soon thereafter, usually
is reduced on the pressure side (Pilon et al., 1996). within 2 days after light force application.
• This movement is rapid but limited by hydrodynam- 2. Undermining resorption
ic damping (Bien, 1966).
The mains features are:
• It is usually followed by a delayed reaction due to the
• On the application of heavy forces, blood vessels are
viscoelastic properties of the periodontal ligament.
occluded completely as the forces are greater than
• This phase last from 1 to 3 days. capillary pressure.
2. Lag phase • Necrosis occurs resulting in cell death, the PDL fi-
bers are crushed on the pressure side resulting in the
The mains features are:
formation of an hyalinization zone.
• In this period, little or no tooth movement occurs,
• There is minimal osteoclast recruitment on the com-
though hyalinization occurs in the periodontal liga-
pressed PDL side, therefore, initial tooth movement
ment.
is delayed until phagocytes remove the hyalinized /
• The amount of hyalinized area is proportional to the necrotic tissue.
force magnitude (Reitan, 1947).
• Osteoclasts from adjacent bone marrow are recruit-
• It is important to notice that during bodily tooth ed to remove the hyalinized bone.
movement, forces are more symmetrically distrib-
• As resorption begins at a distant site (where the PDL
uted along the surface of the alveolar bone than dur-
capillaries have not been completely occluded), and
ing tipping movement, therefore less hyalinized ar-
continues to the site of hyalinization, undermining
eas are noticed during bodily movement (Burstone,
resorption occurs.
1962).
Tooth movement and force interval
• This phase continues for 0 to 35 days.
It is accepted that even light forces could occlude blood ves-
• An inter- and intra-individual variations are ob-
sels, therefore, OTM is the result of combined undermining
served during this phase due to the differences in
and frontal resorptions. Based on the previously mentioned
bone density, metabolic activity of bone, and meta-
information, orthodontic appliances should be reactivated no
bolic activity of periodontal ligaments (Pilon et al.,
less than 3-week intervals to allow smooth tooth movement.
1996).
A 4 to 6 week appointment cycle is preferred for physiological
• Other factors like age of the patient and alveolar tooth movement.
bone density also contribute to the duration of the
Theories on tooth movement
lag phase.
There are four main theories regarding tooth movement,

8 Tooth Movement
however, none have been universally accepted (Cobourne
and DiBiase, 2015, Proffit et al., 2006b). Evidence is more
compelling for some compared to others, with some overlap
between the theories (Meeran, 2012).
1. The Biomechanical / cellular response theory
The mains features are:
• When forces are applied, PDL fluid flows from a
zone of compression to a zone of tension.
• PDL fluid flow causes strain in the PDL and stretch-
es the intracellular cytoskeleton which is attached
through the cell wall to the extracellular matrix re-
sulting in external changes of the cell membrane, the
cytoskeleton and the surrounding matrix. Figure1: The Arachidonic acid pathway producing prosta-
glandins and leukotrienes
• Mechanical distortion of cell membranes activates
Phospholipase A2 which acts on phospholipids of 2. The Piezoelectric theory
cell membranes (Sandy et al., 1993). The mains features are:
• Phospholipase A2 initiates arachidonic acid metab- • It was introduced by Bassett in 1965 (McDonald,
olism. 1993).
• The arachidonic acid metabolism activates the lipo- • The bases of this theory is that pressure on the tooth
oxygenase pathway (leukotrienes LTs and HETE) is transferred to the alveolar bone, which bends in
and the cyclo-oxygenase pathway (prostaglandins response to the applied orthodontic force.
PGs).
• Bone bending result in deformation of the crystal
• As figure 1 shows, there is good clinical evidence structure of bone, which stimulates the flow of an
that both leukotrienes and PGs have been linked to electric current.
tooth movement (Yamasaki et al., 1984, Mohammed
• The electrons move from one part of the object to
et al., 1989).
another, this process of electrical activity is thought
• PGs feedback to receptors on the cell membrane to initiate metabolism of bone.
(Guanine nucleotide G-proteins) which stimulate
• The electric current is produced by the collagen, hy-
the second messenger cascade, resulting in a cellular
droxyapatite, or the mucopolysaccharide fraction of
response. G-proteins may have inhibitory or stimu-
the ground substance (Sandy et al., 1993).
latory response.
• The small voltage generated is called ‘streaming po-
• Second messengers induce signals from the cell
tential’ SP.
membrane to inside the cell, and eventually to the
nucleus to illicit a cell response i.e. DNA synthesis. • SP in turn activates the osteoclasts and osteoblasts,
resulting in resorption and deposition needed to
• There are three main types of second messengers:
move teeth through bone.
i) cAMP which activates protein kinase A.
• When the mechanical force is removed, piezoelec-
ii) Inositol phosphatase which activates pro- tric signals are triggered again, however in reverse.
tein kinase C.
• As the electric and magnetic fields are closely relat-
iii) Tyrosine kinase which activates protein ed, there is a belief they both play an influential role
(MAP) kinase. in tooth movement.
• It is not clear how tissues discriminate between ten- 3. The pressure-tension theory
sion and pressure, but it may be due to flattening of
The mains features are:
cells on the tension side.
• The pressure-tension theory was proposed by
• The flattened cells are anabolic (tension side) that
Schwartz in 1932 (Schwartz, 1932).
initiate DNA, protein and collagen synthesis, where-
as the rounded cells are catabolic which initiate tis- • According to this theory, on the pressure side the
sues destruction through proteases. disturbance of blood flow in the compressed PDL

Tooth Movement 9
 causes necrosis (hyalinization). Hyalinized tissue is 1994).
removed by the macrophages while undermining
• The osteocytes in bone respond to the mechanical
bone resorption is undertaken by osteoclasts adja-
forces, which occur from the displacement of fluid
cent to the hyalinized tissue. This results in tooth
in the canaliculi (Goulet et al., 2008).
movement (von Bohl and Kuijpers-Jagtman, 2009,
Melsen, 1999). • Arguments against this theory are that the PDL sys-
tem is not a ‘closed system’, i.e. it is open from the
• On the tension side, the blood flow is stimulated
top. PDL is not likely to transfer forces to the bone
where the PDL is stretched, this encourages osteo-
in a closed system, as the theory states. In an ex-
blastic activity and osteoid deposition, which later
perimental study, it was found that tooth movement
mineralizes to form bone.
occurs even if PDL fibers are disrupted (Heller and
• Changes in blood flow induces changes in the chem- Nanda, 1979).
ical environment on both the pressure and tension
Physiological response to sustained pressure
side. On the pressure side, carbon dioxide levels in-
crease, while oxygen levels fall The events that occur when sustained pressure is maintained
on the tooth are given in table 1.
• on the tension sides. These chemical changes will
act directly, or via second messengers, to cause cell Table 1 : Physiologic Response to Sustained Pressure
differentiation. Against a Tooth (Proffit et al., 2006b)
• Another aspect of pressure tension theory is bone Phase Light Pressure Heavy Pressure
compression. According to Wolff ’s Law, applying Less than 1 sec- PDL fluid incom- PDL fluid incom-
pressure on bone causes the bone to remodel in or- ond pressible, caus- pressible, caus-
der to release/resolve that pressure. Metabolically ing alveolar bone ing alveolar bone
active bone produces electronegative charges pro- bending and bending and
portional to the activity. piezoelectric sig- piezoelectric sig-
• Due to the pressure which causes distortion of the nal release nal release along
cells and bone, there is an overlap between the pres- with pain
sure-tension theory and piezoelectric theory. 1-2 seconds PDL fluid ex- PDL fluid ex-
• However, the pressure-tension theory is about stress- pressed, tooth pressed, tooth
induced changes rather than electrical signals which moves in the PDL moves in the PDL
stimulate cellular differentiation and cause tooth space space
movement. Electrical signals are unlikely to be a 3-5 seconds Blood vessels in Blood vessels oc-
major component of tooth movement but may form PDL partly com- cluded on pres-
part of the initial signaling pathway in response to pressed on the sure side
pressure. pressure side, di-
lated on tension
• In favor of this theory is the evidence that a tooth is
side causing PDL
displaced 10 times more than the width of the PDL
fibers/cells to be
on initial orthodontic force, thus bone bending must
mechanically dis-
occur (Baumrind, 1969), however the argument op-
torted
posing this theory is that osteoblasts may not be able
to differentiate between the pressure and tension. Minutes Blood flow al- Blood flow cut off
tered, oxygen at the compressed
4. The Hydrodynamic theory tension changed, PDL area
The mains features are: pro s t a g l an d i ns
and cytokines re-
• This theory is considered the weakest of the tooth leased
movement theories.
Hour Enzyme levels Cells death in the
• According to this theory, when loading occurs inter- change and meta- compressed PDL
stitial fluid is squeezed through a thin layer of non- bolic/ chemical area occur
mineralized matrix adjacent to the cell bodies and messengers re-
cell processes. leased causing an
• This results in local strain of the cell membrane, and increase in cellu-
activation of affected osteocytes (Weinbaum et al., lar activity

10 Tooth Movement
 essential to evaluate the type of tooth movement, aswell
~4 hours Increased cAMP Cell differentia- as the amount of force required in obtaining optimum
to detectable lev- tion in the adja- force levels for tooth movement.
els and cellular cent bone spaces • Root surface area: Tooth movement is affected by root
d i f fe re nt i at i on resulting in un- surface area, the greater the root surface area covered by
begins within the dermining re- the bone, the greater the amount of force required for
PDL sorption tooth movement.
~2 days Tooth movement Undermining re-
• Force duration and force decay: The application of sus-
begins as osteo- sorption contin-
tained force is required for orthodontic tooth movement.
blasts/osteoclasts ues
The force must be applied for a minimum of 6 hours a
remodel the bony
day. Orthodontic force duration can be classified into
socket
(Proffit et al., 2006b):
7-14 days Tooth movement Undermining re-
continues sorption removes a) Intermittent: Force levels decline abruptly to
the lamina dura zero. For example, a removable appliance or remov-
adjacent to PDL ing intermaxillary elastics. A high force re-occurs
and delayed tooth on reinsertion of the appliance.
movement starts b) Interrupted: Force levels decline significantly
Mechanical and biological factors in tooth movement between activation. For example, power chain
elastics.
These include:
c) Continuous: Force levels remains almost the
• Magnitude of force: Different force levels required for same, from one appointment to next. For example,
different types of tooth movement, see figure 2 (Proffit et NiTi coil springs.
al., 2006b, Almuzian et al., 2016).
• Optimal orthodontic force level: It is defined as a mini-
mum level of force required to produce maximum bio-
logical response and tooth movement, with minimal ir-
reversible damage to the root, periodontal ligament and
alveolar bone (Storey, 1952). According to a systematic
review, the mathematical model developed from the pre-
vious research showed that there is no ideal force level;
patients have variable thresholds based on their biology.
It was found that a wide range of forces (104–454 gm)
over which the maximum rate of movement could be
ideally achieved (Ren et al., 2004).
• Active stabilization: Labial and lingual resting force
from the lips, tongue or cheeks are usually not balanced.
A phenomenon called active stabilization is produced
by the PDL, which explains why teeth are stable in the
presence unbalanced forces, that would otherwise cause
tooth movement (Proffit et al., 2006b).
• Force threshold: The minimum amount of force required
to produce movement. Classically, forces for orthodontic
tooth movement are those that just overcome capillary
blood pressure which equals 20-25gm/cm3 (Schwarz,
Figure 2 : Force magnitudes for different types of tooth 1932).
movement.
Theories of the relationship between force magnitude and
• Force distribution and type of movement: The amount of tooth movement
force experienced over the surface area of PDL is im-
Quinn & Yoshikawa in 1985 described four theories regard-
portant in determining the biologic effect of force. The
ing the relationship between force magnitude and tooth
PDL’s response is also determined by force per unit area
movement:
(Proffit et al., 2006a). The distribution of force within the
PDL differs with different types of tooth movement; it is 1. Hypothesis 1: A constant relationship between rate of

Tooth Movement 11
 movement and stress exists. The rate of movement does resorption occurs in one pressure side, whilst bone re-
not increase as the stress level is increased. However no sorption occurs in the tension side. The center of rota-
studies support this theory. tion is along the long axis of the tooth.
2. Hypothesis 2: A linear increase in the rate of tooth 4. Bodily Movement: Occurs through a force couple re-
movement as stress increases. Hypothesis 2 has not been sulting in a force theoretically over the whole alveolar
disproved as studies of force systems usually compare bone surface. Hyalinization and undermining bone re-
two different force magnitudes, and were unable to de- sorption appear in the pressure areas. On the tension
scribe the behaviour of tooth movement at higher force side, new bone spicules form along stretched fiber bun-
magnitudes (Johnston 1967). dles arranged obliquely.
3. Hypothesis 3: A constant relationship between the rate 5. Extrusion: Only areas of tension are created in the PDL,
of tooth movement and stress, until a maximum rate of no compression areas. Light forces are recommended
tooth movement is reached. Once this optimal level is to allow movement of the alveolar bone along with the
reached, additional stress causes the rate of movement to tooth.
decline. This hypothesis was originally proposed by Sto-
6. Intrusion: Light forces are required as the force is con-
rey 1952. The available literature suggests that hypothesis
centrated in a small area at the apex. Intrusion may
3 may not be an accurate representation of the data Lee
cause changes in the pulp tissue e.g. vascularization of
et al.1995.
the odontoblast and pulpal oedema (Stenvik and MjoĘr,
4. Hypothesis 4: Combination of the above theories. The 1970, Mostafa et al., 1991).
relationship of rate of movement and stress magnitude is
Enhancing and accelerating the rate of tooth movement
linear up to a point, after this point an increase in stress
causes no appreciable increase in tooth movement. This By reducing the treatment duration, the risks and side effects
theory had been supported later in other studies (Ow- of orthodontic treatment will be reduced, therefore research
man-Moll, 1996 and King, 1991). An RCT by Samuels in in the field of accelerated tooth movement has been popular.
1998 compared force magnitudes of 100g, 150g and 200g The advocated procedures include:
using NiTi springs, and found no difference between
1. Surgical methods
150gm and 200gm but a significant difference between
100g when compared to either 150g or 200g (Samuels et Surgical methods are thought to influence tooth move-
al, 1998). This clinical data may best support the inter- ment by a Regional Accelerated Phenomenon (RAP). A
pretation provided in hypothesis 4. RAP results in an increase in bone turnover and metabo-
lism, increased cellular activity and consequently an ac-
Types of tooth movements
celeration of tooth movement. Types of common surgical
There are many types of tooth movement including (Graber methods are:
et al., 2016):
• Corticotomy.
1. Tipping: It is the simplest form of orthodontic tooth
• Micro-osteoperforation.
movement. Tipping movement develops pressure in lim-
ited areas of the PDL. A center of rotation is formed, as • Piezocision, though evidence shows no
the crown tips in one direction, the root tips in the op- significant affect (Gibreal et al., 2019, Alfawal et
posing direction. It results in the formation of a hyalin- al., 2018, Abbas et al., 2016, Uribe et al., 2017)
ized zone slightly below the alveolar crest, particularly A Cochrane review of surgical adjunctive procedures for
when the tooth has a short or undeveloped root. accelerated tooth movements concluded that there is low
2. Torque: Torque is mainly controlled root movement. quality evidence of surgical procedures showing faster
With this type of movement, relatively greater move- canine retraction, however there was no effect on the
ment of the root apex occurs compared to the crown. The overall treatment duration. Further prospective research
main pressure area in the PDL is the middle region of the with longer follow‐up intervals was recommended to
root (due to PDL being most narrow in the middle 1/3 confirm any possible benefits (Fleming et al., 2015).
of the root). Bone resorption areas appear at the middle 2. Non-surgical methods
third of the root area, whilst the apical surface (widest
area of PDL) begins to compress adjacent periodontal fi- These include:
bers, and a wider pressure area is established. • Vibrational stimulation: Intermittent vibrational
3. Rotation: Rotation creates two areas of pressure and two forces have been proposed to increase tooth move-
areas of tension. Hyalinization and undermining bone ment through the action of low magnitude me-
chanical stimulation, increasing bone turnover, cel-

12 Tooth Movement
 lular activity and tooth movement (Nishimura et al., ment of arthritis, like Indomethacin (Zhou et
2008). Vibrational stimulation is effective at acceler- al., 1997). The concept of using locally ad-
ating canine retraction but not accelerating the rate ministered prostaglandin inhibitors has been
of alignment (Jing et al., 2017). However evidence proposed in order to decrease the movement of
shows that vibrational stimulation has statistical specific teeth for anchorage preservation.
and clinical insignificant effects on tooth movement
In general, drugs that effect the activity of prostaglandin
(Woodhouse et al., 2015, El‐Angbawi et al., 2015,
fall into two groups:
(Aljabaa et al., 2018, Lyu et al., 2019).
a) Drugs that interfere with prostaglandin synthe-
• Low level laser therapy (LLLT): According to a sys-
sis such as:
temic review, low density lasers produce more ef-
fective tooth movement, whereas high level density • Corticosteroids: reduce PG synthesis by inhibit-
reduces tooth movement. LLLT increases the motil- ing the formation of arachidonic acid.
ity and velocity of RANKL macrophages (Ge et al.,
• NSAIDS: inhibits the conversion of arachidonic
2015). Another study showed that LLLT decreases
acid to PGs.
treatment time by increasing the amount of tooth
movement (Imani et al., 2018). b) Other drugs such as;
• Drug therapy: It has been proposed to increase tooth • Tricyclic antidepressants (doxepin, amitripty-
movement in many in vitro studies, though it is as- line, imipramine).
sociated with root resorption and pain (Soma et al., • Antiarrhythmic agents (procainamide).
2000).
• Antimalarial drugs (quinine, quinidine, chloro-
Effect of drugs on tooth movement quine).
1. Drugs that accelerate tooth movement • Methyl xanthines.
These include: • Anticonvulsant drug (phenytoin).
• Local injection of parathyroid hormone accelerates • Tetracyclines (doxycycline).
tooth movement (Soma et al., 2000).
Bisphosphonates
• Systemic administration of prostaglandins acceler-
ate canine retraction (Yamasaki et al., 1984). Bisphosphonates can cause osteonecrosis (Bisphosphonates
induced osteonecrosis of Jaw, BRONJ, also known as medi-
• Direct administration of prostaglandins into the cation induced osteonecrosis of the jaw, MRONJ). Bisphos-
periodontal ligament has been shown to increase the phonates bind to hydroxyapatite in the bone and inhibit bone
rate of tooth movement, but this is relatively painful resorption.
(Yamasaki et al., 1984).
Bone remodeling is slow in patients on bisphosphonates
• Relaxin, a pregnancy hormone, increases the rate as their mode of action inhibits osteoclast-mediated bone
of early tooth movement (Liu et al., 2005) though resorption. Bisphosphonates decrease the number of os-
a double blinded randomized clinical trial did not teoclasts and also reduce their function. Following tooth
show any difference (McGorray et al., 2012). extraction, bisphosphonates can become incorporated into
2. Drugs that inhibit tooth movement the structure of bone with a potentially lengthy time prior
to removal (Zahrowski, 2009).According to NICE guidelines,
Two types of drugs are known to slow down the bio-
patients on bisphosphonates are classified into three groups
logical response to orthodontic forces, and may increase
on terms of risk of MRONJ/BRONJ:
treatment time:
• No risk patients: Patients on the new bisphos-
• Bisphosphonates; e.g. Alendronate or
phonates generation ‘denosumab’.
Risedronate. Bisphosphonates are used to treat
bone metabolism disorders such as osteopo- • Low risk patients: Patients on bisphosphates for
rosis, Paget’s disease, and bone metastasis. osteoporosis or other non-malignant bone diseases
Bisphosphonates bind strongly to bone mineral for less than 5 years. For low risk patients, atrau-
hydroxyapatite and inhibit bone and root re- matic extractions are recommended.
sorption (Huq et al., 1973). Due to a reduction • Higher risk patients include patients using
in bone resorption, tooth movement is reduced. bisphosphonates for more than 5 years, on bisphos-
• Prostaglandin inhibitors are used in treat- phonates for malignancy control, using a combina-

Tooth Movement 13
 tion of corticosteroids with bisphosphonates, or ABBAS, N. H., SABET, N. E. & HASSAN, I. T. 2016. Evaluation of
patients diagnosed with BRONJ previously. For corticotomy-facilitated orthodontics and piezocision in rapid ca-
high risk patients, non-extraction treatment should nine retraction. Am J Orthod Dentofacial Orthop, 149, 473-80.
be considered. If extractions are still indicated, then ALFAWAL, A. M. H., HAJEER, M. Y., AJAJ, M. A., HAMADAH, O.
atraumatic extraction in hospital should be under- & BRAD, B. 2018. Evaluation of piezocision and laser-assisted flap-
taken. It is recommended to avoid orthognathic less corticotomy in the acceleration of canine retraction: a random-
surgeries for these patients. ized controlled trial. Head Face Med, 14, 4.

For both low and high-risk patients, it is important to note ALJABAA, A., ALMOAMMAR, K., ALDREES, A. & HUANG, G.
the following points: Exam Night Review
• If healing doesn’t take place in 8 weeks time, Orthodontic Tooth Movement
referral to an oral surgery department should be Phases of OTM
considered.
Pre-Lag phase: Tooth movement occurs within its socket, width of
• Consenting the patients about risks of the PDL is reduced on the pressure side (Pilon et al., 1996).
MRONJ/BRONJ is crucial.
Lag phase: Little or no tooth movement occurs, hyalinization oc-
• Emphasizing an excellent oral hygiene is im- curs in the periodontal ligament.
portant. The amount of hyalinized area is proportional to the force magni-
• Advice to reduce alcohol intake and encourag- tude (Reitan, 1947).
ing the patient to stop smoking to reduce the risk of Post lag phase: Continuous rapid tooth movement (Pilon et al.,
MRONJ/BRONJ is recommended. 1996).
• Application of light optimal forces is advisable. Type of tooth movement

Theories of tooth eruption Frontal resorption: Light forces achieve frontal resorption via stim-
ulation of osteoclasts locally within the PDL. Osteoclasts remove the
These include: adjacent lamina dura.
• Pulp theory: According to this theory, teeth erupt as the Undermining resorption: Blood vessels are occluded as the forces
pulp propels the crypt upwards, though pulpless teeth are greater than capillary pressure; necrosis occurs resulting in cell
can erupt at the same rate as normal teeth. death and PDL fibers are crushed on the pressure side → hyaliniza-
tion zone.
• Vascular theory: Eruptive forces come from the PDL
Theories on tooth movement
blood vessels (Marks and Cahill, 1984), however some
evidence counters this theory on the bases that hypo- 1. The biomechanical / cellular response theory
tensive drugs appear to have no effect on eruption rates • When forces are applied, PDL fluid flows from a zone of com-
(Burn-Murdoch, 1990). pression to a zone of tension.
• Root elongation theory: Root development leads to • Mechanical distortion of cell membranes activates Phospholi-
tooth eruption. Evidence against this is that rootless pase A2 which act on phospholipids of cell membrane (Sandy
teeth can erupt into functional occlusion. et al., 1993).

• Alveolar bone growth: New bone is laid down beneath • Phospholipase A2 initiates Arachidonic acid metabolism.
the crypts of the teeth resulting in their eruption. • The Arachidonic acid metabolism activates the lipo-oxygenase
• Periodontal ligament theory: PDL generates tractional pathway (leukotrienes LTs and HETE) and the cyclo-oxygenase
pathway (prostaglandins PGs).
forces through fibroblast contraction. Evidence show
that teeth erupt in cases of periodontal disease and where • PGs feedback to receptors on the cell membrane (Guanine
PDL is disrupted (Berkovitz, 1990). nucleotide G-proteins) which stimulate second messenger cas-
cade.
• Follicular theory: Eruptive forces come from the follicle
• Second messengers induce signals from the cell membrane to
as a result of the activity of many cytokines and growth
inside of the cells and eventually to the nucleus to illicit a cell
factors, which aid in bone remodeling associated with
response i.e. DNA synthesis.
the tooth movement.
• There are three main types of second messengers:
• Genetic input: Eruption is absent in genetic growth re-
tardation syndromes which is associated with multiple 1. cAMP which activates protein kinase A.
primary failure of eruption. 2. Inositol phosphatase which activates protein kinase C.
References

14 Tooth Movement
3. Tyrosine kinase which activates protein (MAP) kinase. 2018. Effects of vibrational devices on orthodontic tooth movement:
A systematic review. Am J Orthod Dentofacial Orthop, 154, 768-
2. The Piezoelectric theory
779.
• Pressure on the tooth is transferred to the alveolar bone, which
ALMUZIAN, M., ALHARBI, F. & MCINTYRE, G. 2016. Extra-oral
bends in response to the applied orthodontic force.
appliances in orthodontic treatment. Dental update, 43, 74-82.
• Systemic administration of prostaglandins accelerate canine
BAUMRIND, S. 1969. A reconsideration of the propriety of the
retraction (Yamasaki et al., 1984).
“pressure-tension” hypothesis. Am J Orthod, 55, 12-22.
• Direct administration of prostaglandins into the periodontal
BERKOVITZ, B. K. 1990. The structure of the periodontal ligament:
ligament has been shown increase the rate of tooth movement
an update. Eur J Orthod, 12, 51-76.
(Yamasaki et al., 1984).
BIEN, S. M. 1966. Hydrodynamic damping of tooth movement.
4. Drugs that inhibit tooth movement
Journal of dental research, 45, 907-914.
• Two types of drugs are known to slow down the biological re-
BURN-MURDOCH, R. 1990. The role of the vasculature in tooth
sponse to orthodontic forces, and may increase treatment time:
eruption. Eur J Orthod, 12, 101-8.
• Bisphosphonates
BURSTONE, C. J. 1962. The biomechanics of tooth movement. Vis-
• Prostaglandin inhibitors tas in orthodontics, 197-213.
• In general, drugs that effect the activity of prostaglandin fall COBOURNE, M. T. & DIBIASE, A. T. 2015. Handbook of ortho-
into two groups: dontics, Elsevier Health Sciences.
• Drugs that interfere with prostaglandin synthesis are: FLEMING, P. S., FEDOROWICZ, Z., JOHAL, A., EL-ANGBAWI,
A. & PANDIS, N. 2015. Surgical adjunctive procedures for accelerat-
i. Corticosteroids: reduce PG synthesis by inhibiting the forma-
ing orthodontic treatment. Cochrane Database Syst Rev, Cd010572.
tion of arachidonic acid.
GE, M. K., HE, W. L., CHEN, J., WEN, C., YIN, X., HU, Z. A., LIU,
ii. NSAIDS: inhibits the conversion of arachidonic acid to PGs.
Z. P. & ZOU, S. J. 2015. Efficacy of low-level laser therapy for accel-
• Several other drugs such as; erating tooth movement during orthodontic treatment: a systematic
review and meta-analysis. Lasers Med Sci, 30, 1609-18.
i. Tricyclic antidepressants (doxepin, amitriptyline, imipramine).
GIBREAL, O., HAJEER, M. Y. & BRAD, B. 2019. Efficacy of piezoci-
ii. Antiarrhythmic agents (procainamide). sion-based flapless corticotomy in the orthodontic correction of se-
iii. Antimalarial drugs (quinine, quinidine, chloroquine). verely crowded lower anterior teeth: a randomized controlled trial.
Eur J Orthod, 41, 188-195.
iv. Methyl xanthines.
GOULET, G. C., COOPER, D. M., COOMBE, D. & ZERNICKE, R.
v. Anticonvulsant drug (phenytoin). F. 2008. Influence of cortical canal architecture on lacunocanalicu-
vi. Tetracyclines (doxycycline). lar pore pressure and fluid flow. Comput Methods Biomech Biomed
Engin, 11, 379-87.
Bisphosphonates
GRABER, L. W., VANARSDALL, R. L., VIG, K. W. & HUANG, G. J.
Bisphosphonates → binds to hydroxyapatite & inhibit bone resorp- 2016. Orthodontics-e-book: current principles and techniques, El-
tion. Thus, bone remodeling is slower in patients on bisphospho- sevier Health Sciences.
nates as they act as specific inhibitors of osteoclast-mediated bone
resorption. HELLER, I. J. & NANDA, R. 1979. Effect of metabolic alteration of
periodontal fibers on orthodontic tooth movement. An experimen-
Theories of tooth eruption tal study. Am J Orthod, 75, 239-58.
1. Pulp theory IMANI, M. M., GOLSHAH, A., SAFARI-FARAMANI, R. & SADE-
2. Vascular theory GHI, M. 2018. Effect of Low-level Laser Therapy on Orthodontic
Movement of Human Canine: a Systematic Review and Meta-anal-
3. Root elongation theory ysis of Randomized Clinical Trials. Acta Inform Med, 26, 139-143.
4. Alveolar bone growth JING, D., XIAO, J., LI, X., LI, Y. & ZHAO, Z. 2017. The effectiveness
5. Periodontal ligament theory of vibrational stimulus to accelerate orthodontic tooth movement: a
systematic review. BMC Oral Health, 17, 143.
6. Follicular theory
KING, G. J., KEELING, S. D., MCCOY, E. A. & WARD, T. H. 1991.
7. Genetic input Measuring dental drift and orthodontic tooth movement in re-
sponse to various initial forces in adult rats. Am J Orthod Dentofa-
cial Orthop, 99, 456-65.
LYU, C., ZHANG, L. & ZOU, S. 2019. The effectiveness of supple-
mental vibrational force on enhancing orthodontic treatment. A

Tooth Movement 15
systematic review. Eur J Orthod. SCHWARZ, A. M. 1932. Tissue changes incidental to orthodontic
tooth movement. International Journal of Orthodontia, Oral Sur-
MARKS, S. C., JR. & CAHILL, D. R. 1984. Experimental study in the
gery and Radiography, 18, 331-352.
dog of the non-active role of the tooth in the eruptive process. Arch
Oral Biol, 29, 311-22. SOMA, S., MATSUMOTO, S., HIGUCHI, Y., TAKANO-YAMA-
MOTO, T., YAMASHITA, K., KURISU, K. & IWAMOTO, M. 2000.
MCDONALD, F. 1993. Electrical effects at the bone surface. Eur J
Local and chronic application of PTH accelerates tooth movement
Orthod, 15, 175-83.
in rats. J Dent Res, 79, 1717-24.
MCGORRAY, S. P., DOLCE, C., KRAMER, S., STEWART, D. &
STENVIK, A. & MJOĘR, I. 1970. Pulp and dentine reactions to ex-
WHEELER, T. T. 2012. A randomized, placebo-controlled clinical
perimental tooth intrusion: a histologic study of the initial changes.
trial on the effects of recombinant human relaxin on tooth move-
American Journal of Orthodontics, 57, 370-385.
ment and short-term stability. American Journal of Orthodontics
and Dentofacial Orthopedics, 141, 196-203. STOREY, E. 1952. Force in orthodontics and its relation to tooth
movement. Australian J. Dent., 56, 11-18.
MEERAN, N. A. 2012. Biological response at the cellular level with-
in the periodontal ligament on application of orthodontic force - An URIBE, F., DAVOODY, L., MEHR, R., JAYARATNE, Y. S. N., AL-
update. J Orthod Sci, 1, 2-10. MAS, K., SOBUE, T., ALLAREDDY, V. & NANDA, R. 2017. Effi-
ciency of piezotome-corticision assisted orthodontics in alleviating
MEIKLE, M. C. 2006. The tissue, cellular, and molecular regulation
mandibular anterior crowding-a randomized clinical trial. Eur J Or-
of orthodontic tooth movement: 100 years after Carl Sandstedt. Eur
thod, 39, 595-600.
J Orthod, 28, 221-40.
VON BOHL, M. & KUIJPERS-JAGTMAN, A. M. 2009. Hyaliniza-
MELSEN, B. 1999. Biological reaction of alveolar bone to orthodon-
tion during orthodontic tooth movement: a systematic review on
tic tooth movement. Angle Orthod, 69, 151-8.
tissue reactions. Eur J Orthod, 31, 30-6.
MOHAMMED, A. H., TATAKIS, D. N. & DZIAK, R. 1989. Leukot-
WEINBAUM, S., COWIN, S. C. & ZENG, Y. 1994. A model for the
rienes in orthodontic tooth movement. Am J Orthod Dentofacial
excitation of osteocytes by mechanical loading-induced bone fluid
Orthop, 95, 231-7.
shear stresses. J Biomech, 27, 339-60.
MOSTAFA, Y. A., ISKANDER, K. G. & EL-MANGOURY, N. H.
YAMASAKI, K., SHIBATA, Y., IMAI, S., TANI, Y., SHIBASAKI, Y.
1991. Iatrogenic pulpal reactions to orthodontic extrusion. Ameri-
& FUKUHARA, T. 1984. Clinical application of prostaglandin E1
can Journal of Orthodontics and Dentofacial Orthopedics, 99, 30-
(PGE1) upon orthodontic tooth movement. Am J Orthod, 85, 508-
34.
18.
NISHIMURA, M., CHIBA, M., OHASHI, T., SATO, M., SHIMIZU,
ZAHROWSKI, J. J. 2009. Optimizing orthodontic treatment in pa-
Y., IGARASHI, K. & MITANI, H. 2008. Periodontal tissue activation
tients taking bisphosphonates for osteoporosis. American Journal of
by vibration: intermittent stimulation by resonance vibration accel-
Orthodontics and Dentofacial Orthopedics, 135, 361-374.
erates experimental tooth movement in rats. Am J Orthod Dentofa-
cial Orthop, 133, 572-83. ZHOU, D., HUGHES, B. & KING, G. 1997. Histomorphometric and
biochemical study of osteoclasts at orthodontic compression sites
PILON, J. J., KUIJPERS-JAGTMAN, A. M. & MALTHA, J. C. 1996.
in the rat during indomethacin inhibition. Archives of oral biology,
Magnitude of orthodontic forces and rate of bodily tooth move-
42, 717-726.
ment. An experimental study. Am J Orthod Dentofacial Orthop,
110, 16-23.
PROFFIT, W., FIELDS, H. & SARVER, D. 2006a. Contemporary Or-
thodontics 4th Edition. Mosby, USA, 411.
PROFFIT, W. R., FIELDS JR, H. W. & SARVER, D. M. 2006b. Con-
temporary orthodontics, Elsevier Health Sciences.
REITAN, K. 1947. Continuous bodily tooth movement and its his-
tological significance. Acta Odontologica Scandinavica, 7, 115-144.
REN, Y., MALTHA, J. C., VAN ‘T HOF, M. A. & KUIJPERS-JAGT-
MAN, A. M. 2004. Optimum force magnitude for orthodontic tooth
movement: a mathematic model. Am J Orthod Dentofacial Orthop,
125, 71-7.
SANDY, J. R., FARNDALE, R. W. & MEIKLE, M. C. 1993. Recent
advances in understanding mechanically induced bone remodeling
and their relevance to orthodontic theory and practice. Am J Or-
thod Dentofacial Orthop, 103, 212-22.
SCHWARTZ, A. 1932. Martin: Tissue Changes Incident to Orth-
odontic Tooth Movement, INTERNAT. J. ORTHO, 18, 331.

16 Tooth Movement
Tooth Movement 17
 3
ACCELERATION OF
TOOTH MOVEMENT
Written by: Mohammed Almuzian, Haris Khan, Lina Sholi, Maham Munir

In this Chapter
1. Indications and contraindications
2. Non-surgical intervention for accelerated tooth
movement
3. Surgical intervention for accelerated tooth move-
ment
4. EXAM NIGHT REVIEW
A ccelerating methods of tooth movement are gaining
Tyrovola et al. (Tyrovola and Spyropoulos, 2001)
stated that vitamin D3 metabolites can reduce the
popularity due to adult demands for a shorter orthodontic speed of tooth movement.
treatment time (Nimeri et al., 2013). Short treatment time,
apart from decreasing the treatment cost, could minimise the b) Calcium: The additional use of calcium in local
associated iatrogenic like root resorption (Fox, 2005), white injection of prostaglandin E2 (PGE2) reduces the
spot lesions (Sundararaj et al., 2015), and periodontal prob- speed of tooth movement and stabilizes root resorp-
lems (Boke et al., 2014). tion in the process of accelerated orthodontic tooth
movement (Seifi et al., 2003).
Indications
c) Cytokine: High concentration of cytokines
Accelerated tooth movement is used to accelerate the treat- such as interleukins IL-1, IL-2, IL3, IL-6, IL-8, tu-
ment in comprehensive cases where treatment duration is mor necrosis factor alpha (TNF-α), growth factors,
long, or to facilitate mechanically challenging orthodontic and macrophage colony-stimulating factors were
movements and enhance the correction of moderate to severe found to play a major role in bone remodelling.
skeletal malocclusions.
d) Interleukin-1 (IL-1), stimulates osteoclast func-
Contraindications tion by increasing prostaglandin synthesis, hyper-
Non-surgical accelerated tooth movement should be avoided active osteoblasts activates osteoclasts through the
in patients with poor periodontal health, patients with pro- OPG-RANKL-RANK pathway.
longed use of corticosteroids, and in patients allergic to any e) Tumour necrosis factor (alpha, beta) (TNF-α,
specific medication (cytokines, Active vitamin D). Surgical β) - stimulate bone resorption and inhibit bone col-
accelerated procedures should be avoided in patients with lagen and non-collagenous protein synthesis. He et
haemophilia or other blood disorders, periodontal problems, al. (He et al., 2015) showed that systemic injections
immunocompromised patients, patients taking any medica- of TNF-α enhance bone resorption and, therefore,
tions that slow down bone metabolism, such as bisphospho- tooth movement. However, IL-1 and TNF-α have
nates and NSAIDs, and patients who do not want invasive a promoting impact on mechanically induced root
treatment. resorption (Zhang et al., 2003).
Different non-surgical and surgical interventions have been f) Epidermal growth factors (EGF) have a cata-
used over the years to decrease the duration of orthodontic bolic effect on bones and osteoclasts recruitment
treatment. Non-surgical techniques include modification of effect. The study of Marie et al. (Marie et al., 1990)
biomechanics by customization of brackets and archwires, on rats showed that high-dosed intraperitoneal
biological methods which include injection of different cell EGF injections increase the osteoclast rate (Marie et
mediators, and device-assisted methods, which include vi- al., 1990).
brational stimulation, pulsed electromagnetic fields, low-
level laser therapy, electric currents, and static magnetic field g) Osteocalcin: It is released from thyroid C-cells
(Nimeri et al., 2013). Surgical techniques include osteotomy in response to high serum calcium. It is a bone
or corticotomy procedures, interseptal alveolar surgery, mi- protein synthesized by osteoblasts and odontoblasts
cro-osteoperforations, corticision, discision, piezocision, and and is conducive in the activation of bone resorp-
piezopuncture. tion. Osteocalcin injections stimulate osteoclasts on
the pressured side of the alveolar bone surface. Ac-
Non-surgical intervention for accelerated tooth movement cording to histological studies, osteocalcin improves
1. Biological methods: Notably, the majority of biological the rate of orthodontic tooth movement by enhanc-
research to accelerate tooth movement was done on ani- ing osteoclastogenesis on the pressured side (Ko-
mals. But in general, it involves injecting the following bayashi et al., 1998). Hashimoto et al. (Hashimoto et
systematically or around the tooth socket: al., 2001) showed in rats that daily local osteocalcin
injections accelerate orthodontic tooth movement,
a) Active vitamin D3 (1,25 dihydroxy vitamin especially in the early phase of treatment (Hashi-
D3 (1,25[OH]2D3)): plays an important role in cal- moto et al., 2001).
cium homeostasis with calcitonin and parathyroid
hormone (PTH) (Kale et al., 2004) and it increases h) Prostaglandin: It stimulates bone resorption
bone formation (Hwang et al., 2014). In the study by directly increasing the number and activity of
of Kawakami et al. (Kawakami and Takano-Yama- osteoblasts. The hyperactive osteoblasts through
moto, 2004), local vitamin D3 injections in the sub- the OPG-RANKL-RANK pathway activate osteo-
mucosal palatal area in rats caused accelerated tooth clasts. Lee et al.(Lee, 1990) stated that systemic
movement without obvious side effects. Conversely, and local administration of PGE1 in rats has an

20 Acceleration Of Tooth Movement

 impact on tooth movement, the former (systemic l) Gene therapy: An alternative approach to
administration) being more efficient. Spielmann et accelerate tooth movement, gain stability, prevent
al. (Spielmann et al., 1989) observed after weekly relapse and gain anchorage is the transfer of genes
PGE1 injections individual differences in the rate in the periodontal ligament (Andrade et al., 2014).
of tooth movement. No side effects and no patho- It is based on the concept of delivering a gene to a
logic damage could be observed. As PGEs might be cell, so the gene products are expressed constantly.
involved in root resorption, Seifi et al. (Seifi et al., The advantages of local gene transfer is its mainte-
2003) administered injections with a combination nance in an effective concentration, independent
of PGE2 and calcium ions in rats. This reduced both of the blood circulation, the absence of systemic
root resorption and the speed of tooth movement., side effects (Kanzaki et al., 2006). Pain, frequency
but there was still an acceleration compared to the of administration, and possible side effects such as
control group. Nevertheless, it has been reported severe organ damage, varying compliance of the
that there is a high risk of root resorption, and patients, different response to treatment between
pain during the injection process (Huang 2014). males and females, and the priority of safety, could
be reasons for limited studies in humans (McGorray
i) Parathyroid hormone (PTH): It is released
et al., 2012). Examples of gene therapy to accelerate
from the parathyroid gland in response to low
tooth movement are:
serum calcium, phosphate, or vitamin D3. PTH and
increase bone resorption by increasing osteoclasts • Receptor Activator of Nuclear factor-Kap-
(Kaji et al., 1994, Huang et al., 2014). The continu- paB (RANK) ligand (RANKL): It is a mem-
ous systemic or local administration of PTH over a brane-bound protein on the osteoblasts thats
month can shorten the treatment time, but because bind to the RANK on the osteoclasts and causes
the undesired resorptions in other bones like verte- osteoclastogenesis. It is a member of the TNF
brae cannot be excluded; local injections could be family (Meikle, 2006). RANKL is controlled
more advantageous than the systemic administra- through OPG (OPG inhibit the osteoclasts
tion (Soma et al., 1999). Due to the long-term risks, formation and bone remodelling by binding
the application of PTH and thyroid hormones for to RANK receptor and blocking the RANKL
the acceleration of tooth movement is not practical. effect (Nimeri et al., 2013)). Because younger
patients have a higher RANKL/OPG ratio in
j) Relaxin: The role of relaxin is known in the
the gingival crevicular fluid, the tooth move-
remodelling of soft tissues rather than the re-
ment is quicker compared to older patients
modelling of bone. It is a peptide hormone of the
(Nimeri et al., 2013). Kanzaki et al. (Kanzaki et
insulin/relaxin family. It has been shown that it
al., 2006) showed in rats through the trans-
increases collagen in tension sites, and decreases it
fer of the RANKL gene a significantly higher
in compression sites during orthodontic movement
RANKL expression in the PDL. They observed
(Madan et al., 2007). So it stimulates tooth move-
an accelerated orthodontic tooth movement
ment by enhancing fibre and bone remodelling at
of about 30-70% without systemic side effects.
tension sites. Liu et al. (Liu et al., 2005) found that
Local RANKL gene transfer might be a useful
in rats, human relaxin may accelerate tooth move-
tool to accelerate tooth movement and to move
ment in early stages. However, a randomized clini-
ankylosed teeth (Kanzaki et al., 2006). A recent
cal trial reported that weekly injections of relaxin
study showed that prolactin hormone during
for eight weeks did not affect the speed of tooth
lactation was associated with increased expres-
movement (McGorray et al., 2012).
sion of RANK, RANKL, and osteoprotegerin
k) β-2 adrenergic receptor (Adrb2) is a regulator (OPG) in the maxilla and hence faster move-
of bone formation and plays a role in the regulation ment in rats (Macari et al., 2018).
of cardiac function and bone remodelling. In the
• Osteoprotegerin (OPG): OPG inhibits
study of Cao et al.(Cao et al., 2014) mice received
osteoclasts formation and bone remodelling
force application and intraperitoneally injections
(Meikle, 2006). Dunn et al (Dunn et al., 2007)
of vehicle or nonselective Adrb2 agonist isoproter-
showed that injections of OPG in rats twice a
enol for 6 days. Force application increased calcium
week inhibits osteogenesis and tooth move-
levels, consequently the Adrb2 expression in the
ment, which is beneficial for orthodontic an-
cells of the PDL increases. This lead to a rise of
chorage, retention and could lead to enhanced
osteoclasts through the RANKL/OPG rate, which
treatment efficacy.
fostered the SNS-regulated tooth movement.
2. Appliance design

Acceleration Of Tooth Movement 21

 These include: has shown that PEF accelerates tooth movement
(Showkatbakhsh et al., 2010).
a) Self-ligation brackets (SL): The low friction
and low force philosophy are claimed to be the c) Direct electric currents: Animal studies have
cause of rapid movement, and hence less anchorage shown that locally applied electric current can ac-
demand and OIIRR (Harradine, 2001). Harradine celerates tooth movement (Davidovitch et al., 1980).
(Harradine, 2001) claimed that treatment time with
d) Low-Intensity Pulsed Ultrasound (LIPUS):
SL brackets was on average 4 months shorter than
Theoretically, LIPUS stimulates human periosteal
conventional brackets, and the mean number of
cells to proliferate and differentiate into an os-
visits was reduced from 16 to 12 per patient. How-
teogenic cell lineage. This has a stimulatory effect
ever, other studies compared SL and conventional
on osteoclast numbers and activity in addition to
ligations appliances and they showed that:
increasing cell numbers, in both the tension and
• There is no difference in the treatment duration compression sides of the periodontal ligament.
during initial alignment of upper or lower arch
e) Resonance vibration: The basic concept of
(Wahab et al., 2012, Pandis et al., 2011, Fleming
this physical method is based on the belief that the
et al., 2009).
application of orthodontic force leads to bone bend-
• There is no difference in time or efficiency of ing and the development of bioelectrical potential.
En-masse space closure (Miles, 2007). RCTs by Miles et al. (Miles et al., 2012, Miles et al.,
2018, Miles and Fisher, 2016) showed that Ac-
• There is no difference in time or efficiency dur-
celeDent Aura appliance had no effect on relief of
ing canine retraction (Mezomo et al., 2011).
crowding, reduction of pain during alignment, rate
• Overall treatment duration: According to ran- of maxillary premolar extraction space closure, and
domized clinical trials, there is no difference in increasing anterior arch perimeter when compared
time or efficiency of self-ligating brackets when to a control. At present, contradictory systematic
compared to conventional brackets (Fleming reviews (Keerthana et al., 2020, Aljabaa et al., 2018)
et al., 2010, DiBiase et al., 2011). An RCT by have been published about the efficacy of vibratory
Songra (Songra et al., 2014) found that SL treat- devices in accelerating tooth movement.
ment requires longer treatment duration than
f) Battery-powered toothbrush: Some studies
conventional treatment during the initial align-
support the fact that electric toothbrushes accelerate
ment phase, but no difference between active,
tooth movement (Leethanakul et al., 2016) while
passive, and conventional ligation in the overall
others do not (Azeem et al., 2019).
treatment duration.
g) Low-level laser therapy (LLLT): Laser in
b) Clear aligner therapy: According to a retro-
wavelength 850-nm LED or 860-nm Ga-Al-As
spective study by Djeu (Djeu et al., 2005); Invisalign
diode are mostly used for this purpose. Laser has a
treatment took 1.4 years compared to 1.7 years
bio-stimulatory effect on bone regeneration. It has
for Tip-Edge treatment. So, Invisalign resulted in
been found that laser light stimulates the prolifera-
shorter treatment duration but with poorer out-
tion of osteoclast, osteoblast, and fibroblasts and
comes than Tip-Edge treatments.
thereby affects bone remodelling and accelerates
c) Robotic wire-bending: The median treatment tooth movement. The mechanism involved in the
time for the SureSmile patient pool (15 months) acceleration of tooth movement is by the produc-
was 8 months shorter than that of the conventional tion of ATP and subsequently enhancing the veloc-
patient pool (23 months) (Sachdeva et al., 2012). ity of tooth movement via RANK/RANKL and the
macrophage colony-stimulating (MCS) factor and
3. Physical (Biomechanical) methods: another ap-
its receptor expression. According to systematic
proach in accelerating tooth movement is by using device-
reviews (Imani et al., 2018, Ge et al., 2015, Yi et al.,
assisted therapy. This technique includes:
2017), LLLT can accelerate tooth movement at least
a) Magnetic fields: It is believed that the magnetic in the short term.
field can accelerate tooth movement by influencing
Surgical intervention for accelerated tooth movement
the rate of bone resorption and deposition. Rare
earth magnets made of Samarium Cobalt or Neo- Mode of action
dymium-Iron-Boron have been used in research for
Surgical adjunct procedures to accelerated orthodontic tooth
this purpose.
movement are based on the concept that an invasive stim-
b) Pulsed electromagnetic field (PEF): Research

22 Acceleration Of Tooth Movement

ulus would activate local inflammatory mediators, hence, bone is done by the same principle of distraction of PDL, with
optimize bone remodeling and accelerate tooth movement, the addition of more dissection and osteotomies performed
a mechanism known as regional acceleratory phenomenon at the vestibule side (Işeri et al., 2005) A prospective study
(RAP) (Vargas and Ocampo, 2016). In RAP, increased osteo- by Kurt et al (Kurt et al., 2017), concluded that dentoalveolar
clastic activity has been reported on the compression side, distraction osteogenesis is more effective for canine retrac-
while increased osteoblastic activity was found on the tension tion when compared to conventional techniques.
side of orthodontic tooth movement (Zou et al., 2019). Also,
5. Piezocision technique: Piezocision was first intro-
adjunct surgical procedures reduce bone density at the region
duced by Vercellotti (Vercellotti and Podesta, 2007) in 2007.
where orthodontic tooth movement is desired, which in turn
Initially flaps were raised for piezocision, but Dibart (Dibart
might accelerate tooth movement (Alikhani et al., 2013b).
et al., 2009) in 2009 recommended flapless technique using
1. Distraction osteogenesis: It involves sectioning of a piezosurgical micro saw for making 3 mm deep incisions
bone using a screw device to move the segments apart. It can and coined the term ‘Piezocision’ for this procedure. In this
accelerate tooth movement up to 1.2mm/week (Liou et al., technique, an ultrasonic microsaw is used under copious ir-
2000). Another study (Işeri et al., 2005) reported that tooth rigation to make an incision through the soft tissue and bone.
movement of 0.8 mm / day can be achieved by this technique The surgical incision is performed below the attached gingiva
without any adverse effects such as ankylosis, root resorption and is usually 5-10 mm long and 1 to 3 mm deep. A potential
or periodontal damage. complication of this procedure involves root damage while
performing the mucoperiosteal incision as there is no direct
2. Surgery first: This approach was proposed by Naga-
visualization of the root position. Radiographic metal guides
saka (Nagasaka et al., 2009). In this technique, orthognathic
placed on archwires have been advocated to avoid this com-
surgery is performed before comprehensive orthodontics. It
plication (Gibreal et al., 2019). According to a systematic re-
is proposed that besides other benefits; performing ortho-
view (Mheissen et al., 2020); piezocision is an effective surgi-
dontics after orthognathic surgery will accelerate the tooth
cal procedure in accelerating the rate of canine retraction, but
movement due to RAP.
the effects are transient for the first two months.
3. Corticotomies: Corticotomy is a procedure of rais-
6. Micro-osteoperforations (MOPS) (Alveocentesis): It
ing a mucoperiosteal flap combined with inter-radicular os-
is claimed to be an effective, comfortable, and safe procedure
teotomies. It was firstly reported by L.C. Bryan in 1893 (Var-
to accelerate tooth movement and significantly reduce the
gas and Ocampo, 2016) but only introduced to orthodontics
duration of orthodontic treatment (Alikhani et al., 2013a). In
in 1959 (Kole, 1959). Alveolar corticotomies can be done
2010, the first animal trial of MOPs procedure was report-
to move a block or a single tooth. Apart from accelerating
ed by Teixeira and team (Teixeira et al., 2010) followed by a
tooth movement, this technique can be used to move anky-
human trial in 2013 (Alikhani et al., 2013b). MOPs include
losed teeth. According to a systematic review (Mheissen et al.,
flapless trans-gingival shallow bony perforations (2-3 mm
2021), corticotomy was the most effective procedure to ac-
in depth and 1.5 mm in diameter). It can be performed us-
celerate tooth movement. A modification of the conventional
ing conventional orthodontic temporary anchorage devices
corticotomy technique is the addition of bone allograft over
(TADs) or by using a more sophisticated device like PROPEL
the decorticated regions, before the flaps is closed. This tech-
(Sivarajan et al., 2020). According to a systematic review (Ma-
nique is called “Wilckodontics” or ‘Accelerated Osteogenic
vreas and Athanasiou, 2008); MOPs increased the en-masse
Orthodontics (AOO)’ procedure. The proposed advantages
retraction rate by 0.31mm/month during the first month
of AOO are quicker canine retraction in difficult cases, and
following MOPs. This is a minimal effect when compared
helps in slow orthodontic expansion and molar intrusion in
with the total treatment duration. For maxillary incisors’
cases with open bites. It is also claimed that AAO prevents
retraction after micro-osteoperforation, a systematic review
mandibular dehiscence after decompensation in Class 3 cases
(Mheissen et al., 2020) suggested that using piezopunctures
as well as enhancing post-orthodontic stability (Hassan et al.,
decreases the incisor retraction duration by three weeks
2010).
(Mheissen et al., 2020). This effect is not clinically significant
4. Interseptal alveolar surgery (Liou and Huang, 1998): when compared with the total treatment duration (Mavreas
It is subdivided into distraction of PDL and distraction of the and Athanasiou, 2008). Taking into account the present evi-
dentoalveolar bone. In rapid distraction of PDL, 1 to 1.5 mm dence, a single intervention of micro-osteoperforation is not
interseptal bone is undermined distal to the canine after first clinically significant.
premolar extraction, and a round bur deepens the socket to
7. Corticision: This flapless technique was introduced
the length of the canine. This reduces the resistance on the
by Kim and Park (Kim et al., 2009). In this technique, a hard-
pressure site. According to a split-mouth RCT (Leethanakul
ened surgical blade (No. 15T, Paragon, Sheffield, UK) is used
et al., 2014), interseptal bone reduction can enhance the rate
to make buccal and lingual cuts through the gingiva and into
of canine retraction. Rapid distraction of the dentoalveolar
the cortical plate. Cuts are made in inter-radicular, attached

Acceleration Of Tooth Movement 23

gingiva 2 mm short of the gingival papilla and 1 mm above specified primary outcome. The available evidence is of
the mucogingival junction. The blade is tapped with a mallet low quality.
to a depth of approximately 8 mm. The angle of the blade is
• According to the latest umbrella review (Mheissen et al.,
approximately 45-60 degrees. The blade is changed after four
2021); there is low-level evidence that surgical assisted
to five slices. The goal is to cut the cancellous bone between
procedures reduce treatment duration but the accelera-
the roots to 50%-75% of the root length. The mobility of the
tion is minor and transient. The effect on anchorage loss
teeth is tested by forcibly trying to move them slightly. Orth-
is variable and technique-related. Side effects of SAPs are
odontic forces are applied immediately. The patient is seen
transient, but some might be aesthetically noticeable. A
every two weeks, and the teeth are forcibly mobilizing to in-
cost-benefit analysis of SAPs should be considered while
duce minor trauma to extend the effect.
making the treatment decision.
Exam Night Review
• According to randomized clinical trials, there is no dif-
ference in time or efficiency of self-ligating brackets
when compared to conventional brackets (Fleming et al.,
2010, DiBiase et al., 2011).
• An RCT by Songra (Songra et al., 2014) found that SL
treatment requires longer in terms of treatment duration
than conventional treatment during the initial alignment
phase, but no difference between active, passive, and
conventional ligation in the overall treatment duration.
• RCTs by Miles et al. (Miles et al., 2012, Miles et al., 2018,
Miles and Fisher, 2016) showed that AcceleDent Aura
appliance had no effect on relief of crowding, reduction
of pain during alignment, rate maxillary premolar ex-
traction space closure, and increasing anterior arch pe-
rimeter when compared with no appliance.
• According to a systematic review of systematic reviews
(Mheissen et al., 2021), corticotomy was the most effec-
tive procedure to accelerate tooth movement.
• According to a systematic review (Mavreas and Atha-
nasiou, 2008) MOPs increased the en-masse retraction
rate by 0.31mm/month during the first month following
MOPs. This is a minimal effect when compared with the
total treatment duration.
• For maxillary incisors retraction after micro-osteoperfo-
ration, a systematic review (Mheissen et al., 2020) sug-
gested that using piezopunctures decreases the incisor
retraction duration by three weeks.
• According to (El-Angbawi et al., 2015), there is very little
clinical research concerning the effectiveness of non-sur-
gical interventions to accelerate orthodontic treatment.
• According to a systematic review (Mheissen et al., 2020);
piezocision is an effective surgical procedure in acceler-
ating the rate of canine retraction but the effects are tran-
sient and effective for the first two months.
• According to another Cochrane review (Fleming et al.,
2015); there is limited research concerning the effective-
ness of surgical interventions to accelerate orthodontic
treatment, with no studies directly assessing our pre-

24 Acceleration Of Tooth Movement

References D. R. 2015. Non-surgical adjunctive interventions for accelerating
tooth movement in patients undergoing fixed orthodontic treat-
ALIKHANI, M., RAPTIS, M., ZOLDAN, B., SANGSUWON, C., ment. Cochrane Database Syst Rev, Cd010887.
LEE, Y. B., ALYAMI, B., CORPODIAN, C., BARRERA, L. M., AL-
ANSARI, S., KHOO, E. & TEIXEIRA, C. 2013a. Effect of micro-os- FLEMING, P. S., DIBIASE, A. T. & LEE, R. T. 2010. Randomized
teoperforations on the rate of tooth movement. Am J Orthod Den- clinical trial of orthodontic treatment efficiency with self-ligating
tofacial Orthop, 144, 639-48. and conventional fixed orthodontic appliances. Am J Orthod Den-
tofacial Orthop, 137, 738-42.
ALIKHANI, M., RAPTIS, M., ZOLDAN, B., SANGSUWON, C.,
LEE, Y. B., ALYAMI, B., CORPODIAN, C., BARRERA, L. M., AL- FLEMING, P. S., DIBIASE, A. T., SARRI, G. & LEE, R. T. 2009. Pain
ANSARI, S., KHOO, E. & TEIXEIRA, C. 2013b. Effect of micro- experience during initial alignment with a self-ligating and a con-
osteoperforations on the rate of tooth movement. American Journal ventional fixed orthodontic appliance system. A randomized con-
of Orthodontics and Dentofacial Orthopedics, 144, 639-48. trolled clinical trial. Angle Orthod, 79, 46-50.

ALJABAA, A., ALMOAMMAR, K., ALDREES, A. & HUANG, G. FLEMING, P. S., FEDOROWICZ, Z., JOHAL, A., EL-ANGBAWI,
2018. Effects of vibrational devices on orthodontic tooth movement: A. & PANDIS, N. 2015. Surgical adjunctive procedures for accelerat-
A systematic review. Am J Orthod Dentofacial Orthop, 154, 768- ing orthodontic treatment. Cochrane Database Syst Rev, Cd010572.
779. FOX, N. 2005. Longer orthodontic treatment may result in greater
ANDRADE, I., JR., SOUSA, A. B. & DA SILVA, G. G. 2014. New external apical root resorption. Evid Based Dent, 6, 21.
therapeutic modalities to modulate orthodontic tooth movement. GE, M. K., HE, W. L., CHEN, J., WEN, C., YIN, X., HU, Z. A., LIU,
Dental Press J Orthod, 19, 123-33. Z. P. & ZOU, S. J. 2015. Efficacy of low-level laser therapy for accel-
AZEEM, M., AFZAL, A., JAWA, S. A., HAQ, A. U., KHAN, M. & erating tooth movement during orthodontic treatment: a systematic
AKRAM, H. 2019. Effectiveness of electric toothbrush as vibration review and meta-analysis. Lasers Med Sci, 30, 1609-18.
method on orthodontic tooth movement: a split-mouth study. Den- GIBREAL, O., HAJEER, M. Y. & BRAD, B. 2019. Efficacy of piezoci-
tal Press J Orthod, 24, 49-55. sion-based flapless corticotomy in the orthodontic correction of se-
BOKE, F., GAZIOGLU, C., AKKAYA, S. & AKKAYA, M. 2014. Re- verely crowded lower anterior teeth: a randomized controlled trial.
lationship between orthodontic treatment and gingival health: A Eur J Orthod, 41, 188-195.
retrospective study. Eur J Dent, 8, 373-80. HARRADINE, N. W. 2001. Self-ligating brackets and treatment ef-
CAO, H., KOU, X., YANG, R., LIU, D., WANG, X., SONG, Y., ficiency. Clin Orthod Res, 4, 220-7.
FENG, L., HE, D., GAN, Y. & ZHOU, Y. 2014. Force-induced Adrb2 HASHIMOTO, F., KOBAYASHI, Y., MATAKI, S., KOBAYASHI, K.,
in periodontal ligament cells promotes tooth movement. J Dent Res, KATO, Y. & SAKAI, H. 2001. Administration of osteocalcin acceler-
93, 1163-9. ates orthodontic tooth movement induced by a closed coil spring in
DAVIDOVITCH, Z., FINKELSON, M. D., STEIGMAN, S., SHAN- rats. Eur J Orthod, 23, 535-45.
FELD, J. L., MONTGOMERY, P. C. & KOROSTOFF, E. 1980. Elec- HASSAN, A. H., AL-FRAIDI, A. A. & AL-SAEED, S. H. 2010. Cor-
tric currents, bone remodeling, and orthodontic tooth movement. ticotomy-assisted orthodontic treatment: review. Open Dent J, 4,
II. Increase in rate of tooth movement and periodontal cyclic nucle- 159-64.
otide levels by combined force and electric current. Am J Orthod,
77, 33-47. HE, D., KOU, X., YANG, R., LIU, D., WANG, X., LUO, Q., SONG,
Y., LIU, F., YAN, Y., GAN, Y. & ZHOU, Y. 2015. M1-like Macrophage
DIBART, S., SEBAOUN, J. D. & SURMENIAN, J. 2009. Piezocision: Polarization Promotes Orthodontic Tooth Movement. J Dent Res,
a minimally invasive, periodontally accelerated orthodontic tooth 94, 1286-94.
movement procedure. Compend Contin Educ Dent, 30, 342-4, 346,
348-50. HUANG, H., WILLIAMS, R. C. & KYRKANIDES, S. 2014. Accel-
erated orthodontic tooth movement: molecular mechanisms. Am J
DIBIASE, A. T., NASR, I. H., SCOTT, P. & COBOURNE, M. T. Orthod Dentofacial Orthop, 146, 620-32.
2011. Duration of treatment and occlusal outcome using Damon3
self-ligated and conventional orthodontic bracket systems in extrac- HWANG, J. S., TSAI, K. S., CHENG, Y. M., CHEN, W. J., TU, S.
tion patients: a prospective randomized clinical trial. Am J Orthod T., LU, K. H., HOU, S. M., YANG, S. H., CHENG, H., LAI, H. J.,
Dentofacial Orthop, 139, e111-6. LEI, S. & CHEN, J. F. 2014. Vitamin D status in non-supplemented
postmenopausal Taiwanese women with osteoporosis and fragility
DJEU, G., SHELTON, C. & MAGANZINI, A. 2005. Outcome assess- fracture. BMC Musculoskelet Disord, 15, 257.
ment of Invisalign and traditional orthodontic treatment compared
with the American Board of Orthodontics objective grading system. IMANI, M. M., GOLSHAH, A., SAFARI-FARAMANI, R. & SADE-
Am J Orthod Dentofacial Orthop, 128, 292-8; discussion 298. GHI, M. 2018. Effect of Low-level Laser Therapy on Orthodontic
Movement of Human Canine: a Systematic Review and Meta-anal-
DUNN, M. D., PARK, C. H., KOSTENUIK, P. J., KAPILA, S. & GI- ysis of Randomized Clinical Trials. Acta Inform Med, 26, 139-143.
ANNOBILE, W. V. 2007. Local delivery of osteoprotegerin inhibits
mechanically mediated bone modeling in orthodontic tooth move- IŞERI, H., KIŞNIŞCI, R., BZIZI, N. & TÜZ, H. 2005. Rapid canine
ment. Bone, 41, 446-55. retraction and orthodontic treatment with dentoalveolar distraction
osteogenesis. Am J Orthod Dentofacial Orthop, 127, 533-41; quiz
EL-ANGBAWI, A., MCINTYRE, G. T., FLEMING, P. S. & BEARN, 625.

Acceleration Of Tooth Movement 25

KAJI, H., SUGIMOTO, T., KANATANI, M., MIYAUCHI, A., Orthop, 114, 372-82.
KIMURA, T., SAKAKIBARA, S., FUKASE, M. & CHIHARA, K.
LIU, C., CHEN, J., KUEI, C., SUTTON, S., NEPOMUCENO, D.,
1994. Carboxyl-terminal parathyroid hormone fragments stimulate
BONAVENTURE, P. & LOVENBERG, T. W. 2005. Relaxin-3/in-
osteoclast-like cell formation and osteoclastic activity. Endocrinol-
sulin-like peptide 5 chimeric peptide, a selective ligand for G pro-
ogy, 134, 1897-904.
tein-coupled receptor (GPCR)135 and GPCR142 over leucine-rich
KALE, S., KOCADERELI, I., ATILLA, P. & AŞAN, E. 2004. Com- repeat-containing G protein-coupled receptor 7. Mol Pharmacol, 67,
parison of the effects of 1,25 dihydroxycholecalciferol and prosta- 231-40.
glandin E2 on orthodontic tooth movement. Am J Orthod Dentofa-
MACARI, S., SHARMA, L. A., WYATT, A., DA SILVA, J. M., DIAS,
cial Orthop, 125, 607-14.
G. J., SILVA, T. A., SZAWKA, R. E. & GRATTAN, D. R. 2018. Lacta-
KANZAKI, H., CHIBA, M., ARAI, K., TAKAHASHI, I., HAR- tion induces increases in the RANK/RANKL/OPG system in maxil-
UYAMA, N., NISHIMURA, M. & MITANI, H. 2006. Local RANKL lary bone. Bone, 110, 160-169.
gene transfer to the periodontal tissue accelerates orthodontic tooth
MADAN, M. S., LIU, Z. J., GU, G. M. & KING, G. J. 2007. Effects
movement. Gene Ther, 13, 678-85.
of human relaxin on orthodontic tooth movement and periodontal
KAWAKAMI, M. & TAKANO-YAMAMOTO, T. 2004. Local injec- ligaments in rats. Am J Orthod Dentofacial Orthop, 131, 8.e1-10.
tion of 1,25-dihydroxyvitamin D3 enhanced bone formation for
MARIE, P. J., HOTT, M. & PERHEENTUPA, J. 1990. Effects of epi-
tooth stabilization after experimental tooth movement in rats. J
dermal growth factor on bone formation and resorption in vivo. Am
Bone Miner Metab, 22, 541-6.
J Physiol, 258, E275-81.
KEERTHANA, P., DIDDIGE, R. & CHITRA, P. 2020. Performance
MAVREAS, D. & ATHANASIOU, A. E. 2008. Factors affecting the
comparison of vibration devices on orthodontic tooth movement -
duration of orthodontic treatment: a systematic review. European
A systematic review and meta-analysis. J Oral Biol Craniofac Res,
Journal of Orthodics, 30, 386-95.
10, 814-823.
MCGORRAY, S. P., DOLCE, C., KRAMER, S., STEWART, D. &
KIM, S. J., PARK, Y. G. & KANG, S. G. 2009. Effects of Corticision
WHEELER, T. T. 2012. A randomized, placebo-controlled clinical
on paradental remodeling in orthodontic tooth movement. Angle
trial on the effects of recombinant human relaxin on tooth move-
Orthod, 79, 284-91.
ment and short-term stability. American Journal of Orthodontics
KOBAYASHI, Y., TAKAGI, H., SAKAI, H., HASHIMOTO, F., MAT- and Dentofacial Orthopedics, 141, 196-203.
AKI, S., KOBAYASHI, K. & KATO, Y. 1998. Effects of local admin-
MEIKLE, M. C. 2006. The tissue, cellular, and molecular regulation
istration of osteocalcin on experimental tooth movement. Angle
of orthodontic tooth movement: 100 years after Carl Sandstedt. Eur
Orthod, 68, 259-66.
J Orthod, 28, 221-40.
KOLE, H. 1959. Surgical operations on the alveolar ridge to correct
MEZOMO, M., DE LIMA, E. S., DE MENEZES, L. M., WEIS-
occlusal abnormalities. Oral surgery Oral Medicine Oral Pathology
SHEIMER, A. & ALLGAYER, S. 2011. Maxillary canine retraction
12, 413-20 contd.
with self-ligating and conventional brackets. Angle Orthod, 81, 292-
KURT, G., İŞERI, H., KIŞNIŞÇI, R. & ÖZKAYNAK, Ö. 2017. Rate of 7.
tooth movement and dentoskeletal effects of rapid canine retraction
MHEISSEN, S., KHAN, H., ALSAFADI, A. S. & ALMUZIAN, M.
by dentoalveolar distraction osteogenesis: A prospective study. Am J
2021. The effectiveness of surgical adjunctive procedures in the ac-
Orthod Dentofacial Orthop, 152, 204-213.
celeration of orthodontic tooth movement: A systematic review of
LEE, W. C. 1990. Experimental study of the effect of prostaglandin systematic reviews and meta-analysis. J Orthod, 1465312520988735.
administration on tooth movement--with particular emphasis on
MHEISSEN, S., KHAN, H. & SAMAWI, S. 2020. Is Piezocision ef-
the relationship to the method of PGE1 administration. Am J Or-
fective in accelerating orthodontic tooth movement: A systematic
thod Dentofacial Orthop, 98, 231-41.
review and meta-analysis. PLoS One, 15, e0231492.
LEETHANAKUL, C., KANOKKULCHAI, S., PONGPANICH, S.,
MILES, P. & FISHER, E. 2016. Assessment of the changes in arch
LEEPONG, N. & CHAROEMRATROTE, C. 2014. Interseptal bone
perimeter and irregularity in the mandibular arch during initial
reduction on the rate of maxillary canine retraction. Angle Orthod,
alignment with the AcceleDent Aura appliance vs no appliance in
84, 839-45.
adolescents: A single-blind randomized clinical trial. Am J Orthod
LEETHANAKUL, C., SUAMPHAN, S., JITPUKDEEBODINTRA, Dentofacial Orthop, 150, 928-936.
S., THONGUDOMPORN, U. & CHAROEMRATROTE, C. 2016.
MILES, P., FISHER, E. & PANDIS, N. 2018. Assessment of the rate
Vibratory stimulation increases interleukin-1 beta secretion during
of premolar extraction space closure in the maxillary arch with the
orthodontic tooth movement. Angle Orthod, 86, 74-80.
AcceleDent Aura appliance vs no appliance in adolescents: A single-
LIOU, E. J., CHEN, P. K., HUANG, C. S. & CHEN, Y. R. 2000. Inter- blind randomized clinical trial. Am J Orthod Dentofacial Orthop,
dental distraction osteogenesis and rapid orthodontic tooth move- 153, 8-14.
ment: a novel approach to approximate a wide alveolar cleft or bony
MILES, P., SMITH, H., WEYANT, R. & RINCHUSE, D. J. 2012. The
defect. Plast Reconstr Surg, 105, 1262-72.
effects of a vibrational appliance on tooth movement and patient
LIOU, E. J. & HUANG, C. S. 1998. Rapid canine retraction through discomfort: a prospective randomised clinical trial. Aust Orthod J,
distraction of the periodontal ligament. Am J Orthod Dentofacial 28, 213-8.

26 Acceleration Of Tooth Movement

MILES, P. G. 2007. Self-ligating vs conventional twin brackets dur- VARGAS, P. O. & OCAMPO, B. R. Y. 2016. Corticotomy: historical
ing en-masse space closure with sliding mechanics. Am J Orthod perspective. Revista Odontológica Mexicana, 20, e80-e90.
Dentofacial Orthop, 132, 223-5.
VERCELLOTTI, T. & PODESTA, A. 2007. Orthodontic microsur-
NAGASAKA, H., SUGAWARA, J., KAWAMURA, H. & NANDA, R. gery: a new surgically guided technique for dental movement. Int J
2009. “Surgery first” skeletal Class III correction using the Skeletal Periodontics Restorative Dent, 27, 325-31.
Anchorage System. J Clin Orthod, 43, 97-105.
WAHAB, R. M., IDRIS, H., YACOB, H. & ARIFFIN, S. H. 2012.
NIMERI, G., KAU, C. H., ABOU-KHEIR, N. S. & CORONA, R. Comparison of self- and conventional-ligating brackets in the align-
2013. Acceleration of tooth movement during orthodontic treat- ment stage. Eur J Orthod, 34, 176-81.
ment--a frontier in orthodontics. Prog Orthod, 14, 42.
YI, J., XIAO, J., LI, H., LI, Y., LI, X. & ZHAO, Z. 2017. Effectiveness of
PANDIS, N., POLYCHRONOPOULOU, A., KATSAROS, C. & ELI- adjunctive interventions for accelerating orthodontic tooth move-
ADES, T. 2011. Comparative assessment of conventional and self- ment: a systematic review of systematic reviews. J Oral Rehabil, 44,
ligating appliances on the effect of mandibular intermolar distance 636-654.
in adolescent nonextraction patients: a single-center randomized
ZHANG, D., GOETZ, W., BRAUMANN, B., BOURAUEL, C. &
controlled trial. Am J Orthod Dentofacial Orthop, 140, e99-e105.
JAEGER, A. 2003. Effect of soluble receptors to interleukin-1 and
SACHDEVA, R. C., ARANHA, S. L., EGAN, M. E., GROSS, H. T., tumor necrosis factor alpha on experimentally induced root resorp-
SACHDEVA, N. S., CURRIER, G. F. & KADIOGLU, O. 2012. Treat- tion in rats. J Periodontal Res, 38, 324-32.
ment time: SureSmile vs conventional. Orthodontics (Chic.), 13,
ZOU, M., LI, C. & ZHENG, Z. 2019. Remote Corticotomy Acceler-
72-85.
ates Orthodontic Tooth Movement in a Rat Model. Biomed Res Int,
SEIFI, M., ESLAMI, B. & SAFFAR, A. S. 2003. The effect of prosta- 2019, 4934128.
glandin E2 and calcium gluconate on orthodontic tooth movement
and root resorption in rats. Eur J Orthod, 25, 199-204.
SHOWKATBAKHSH, R., JAMILIAN, A. & SHOWKATBAKHSH,
M. 2010. The effect of pulsed electromagnetic fields on the accelera-
tion of tooth movement. World J Orthod, 11, e52-6.
SIVARAJAN, S., RINGGINGON, L. P., FAYED, M. M. S. & WEY, M.
C. 2020. The effect of micro-osteoperforations on the rate of orth-
odontic tooth movement: A systematic review and meta-analysis.
American Journal of Orthodontics and Dentofacial Orthopedics,
157, 290-304.
SOMA, S., IWAMOTO, M., HIGUCHI, Y. & KURISU, K. 1999. Ef-
fects of continuous infusion of PTH on experimental tooth move-
ment in rats. J Bone Miner Res, 14, 546-54.
SONGRA, G., CLOVER, M., ATACK, N. E., EWINGS, P., SHER-
RIFF, M., SANDY, J. R. & IRELAND, A. J. 2014. Comparative assess-
ment of alignment efficiency and space closure of active and passive
self-ligating vs conventional appliances in adolescents: a single-cen-
ter randomized controlled trial. Am J Orthod Dentofacial Orthop,
145, 569-78.
SPIELMANN, T., WIESLANDER, L. & HEFTI, A. F. 1989. [Accel-
eration of orthodontically induced tooth movement through the
local application of prostaglandin (PGE1)]. Schweiz Monatsschr
Zahnmed, 99, 162-5.
SUNDARARAJ, D., VENKATACHALAPATHY, S., TANDON, A. &
PEREIRA, A. 2015. Critical evaluation of incidence and prevalence
of white spot lesions during fixed orthodontic appliance treatment:
A meta-analysis. J Int Soc Prev Community Dent, 5, 433-9.
TEIXEIRA, C. C., KHOO, E., TRAN, J., CHARTRES, I., LIU, Y.,
THANT, L. M., KHABENSKY, I., GART, L. P., CISNEROS, G. &
ALIKHANI, M. 2010. Cytokine expression and accelerated tooth
movement. Journal of Dental Research, 89, 1135-41.
TYROVOLA, J. B. & SPYROPOULOS, M. N. 2001. Effects of drugs
and systemic factors on orthodontic treatment. Quintessence Int,
32, 365-71.

Acceleration Of Tooth Movement 27

 4
ORTHODONTIC MATERIALS
Written by: Mohammed Almuzian, Haris Khan

In this Chapter
1. Ideal properties of adhesives and cements 17. Self-etching primers
2. Bonding adhesives 18. Tooth surface preparation for orthodontic banding
3. Pre-coated brackets 19. Bonding in case of Fluorosis
4. Antibacterial composite adhesive 20. Bonding to porcelain, amalgam, veneers and gold
5. Cyanoacrylates 21. Impression materials
6. GIC for bonding 22. Silicone impression materials
7. Orthodontic banding 23. Acrylic for removeable appliances
8. Glass ionomer cements (GIC) 24. EXAM NIGHT REVIEWv
9. Types of GIC
10. Conventional glass ionomer
11. Resin modified GIC
12. Modified composite or Compomers
13. Glass polyphosphonate cements
14. Tooth preparation for orthodontic bonding
15. Resin primer (sealants)
16. Moisture-insensitive primers
Ideal properties of adhesives and cements DMA) can be used in addition to BisGMA to
decrease the viscosity. Some light cure compos-
Cements are widely used in orthodontics for cementation,
ites contain urethane dimethacrylate (UDMA)
such as cementation of fixed orthodontic appliances, bite
instead of BISGMA.
blocks, fixed-functional appliances, expanders etc. Although
cements are still being used, resins and resin hybrid materials • Filler particles such as glass beads, aluminium
are becoming popular due to enhanced physical properties silicate, barium, strontium and borosilicate
as well as lower solubility in oral fluids (PATIL et al., 2014). glass. Fillers reduce polymerization shrinkage
Ideally, orthodontic adhesives and cements should have the and coefficient of thermal expansion of materi-
following properties: al, provide radiopacity and enhance mechanical
properties and ease of handling.
• Cost-effective.
The mode of activation of the composite could be chemi-
• Antimicrobial effect.
cal cure where twin paste or paste/primer is used, or light
• Non-irritant to oral tissues. cured where visible light (440-480nm) is used for photo-
initiation to take place. In dual cure, both chemical and
• Ease of handling and application.
light activation are undertaken.
• The color of the materials should be different from tooth
Advantages of composite
color, however, it should be inconspicuous so it does not
show underneath the bracket. Colour stability in the oral These include:
environment is essential.
• Extended working time.
• Appropriate working time allows long enough time to
• Easy to remove excess.
position appliance/brackets, and short enough to be
com-fortable for patients. • Insoluble.
• Convenient mode of curing. Disadvantages of composite
• Easily debonded without harm to the underlying tooth These include:
structure and minimal patient discomfort.
• Moisture sensitive.
• Low viscosity permits penetration into the bracket mesh
• Technique sensitive.
and etched enamel.
• Etching / bonding agents are required prior to
• High bond strength.
use of adhesive.
• Fluoride releasing potential.
• Chemical cured composite has a short working
• Good wettability. time, which is insufficient for full arch bonding.
• Command set that provides an immediate and durable • Absence of fluoride release or recharge com-
bond. pared to GICs.
• Low solubility in oral fluids, thus minimize dimensional A Cochrane review has demonstrated that there is
changes. insufficient evidence to recommend one adhesive
over another for banding molars (MILLETT et al.,
Bonding adhesives
2016)
Acrylics
Pre-coated brackets
Acrylics are rarely used for orthodontic bonding in
Pre-coated brackets contain a layer of composite on the
contemporary orthodontics owing to decreased bond
bracket base prepared by the manufacturer.
strength. They are only used with plastic brackets.
Advantages
Composite (diacrylates)
These include:
Composites are used in orthodontics to bond brack-
ets and tubes. Composite contains inert filler and resin • The clinician needs to clean less adhesive flash.
monomer. The components of composite are:
• Some composite contain color changing fea-
• Resin (BisGMA) also known as Bowen’s Resin. tures to indicate when the material is set. The
Diethylene glycol dimethacrylate (DEGDMA) advantage is that excess flash can be seen and
or triethylene glycol dimethacrylate (TEG- easily removed.

30 Orthodontic Materials
 • Suitable for two handed dentistry Types of GIC
• These brackets offer better cross-infection con- Conventional glass ionomer
trol (BEARN et al., 1995).
The main features are:
Disadvantages
• It consists of liquid and powder, which lead to
Although pre-coated brackets are expensive, there is an acid-base reaction.
no difference in failure rate between pre-coated and
• The liquid is an aqueous solution of an organic
uncoated brackets (KULA et al., 2002).
acid, such as poly(acrylic) or poly(maleic) acid.
Antibacterial composite adhesive
• The powder consists of calcium aluminofluoro-
These composites incorporate metacryloyloxydodectyl- silicate glasses.
pyridium bomide (MDPB) which reduces demineral-
• The acid base reaction leads to the release of alu-
ization around bracket without reducing bond strength
minum and calcium from the surface of glass.
(BULUT et al., 2007). Some contemporary composite
materials release fluoride which helps in the prevention • The reaction of cement results in a covalent
of demineralization (BUREN et al., 2008). bond with the enamel surface.
Some composites contain other antimicrobial com- • First generation GIC was susceptible to mois-
pounds such as TiO2 and zinc into bonding resins ture contamination. This was overcome in the
(POOSTI et al., 2013). second generation cements where the liquid was
either water or an aqueous solution of tartaric
Cyanoacrylates (super glues)
acid, and the powder a blend of aluminosilicate
Cyanoacrylates is useful for indirect bonding and can glass and a powdered polyacid.
cure rapidly when in contact with small amounts of
Advantages of GIC
moisture.
These include:
Cyanoacrylates have rapid setting time of 5 seconds
which is considered a disadvantage for direct bonding. • Chemical adhesion to tooth, hence requires no
bonding agent (PATIL et al., 2014) or etching of
GIC for bonding
the surface.
The bonding strength of the GIC increases more than 15-
• Release of fluoride, therefore, decreasing the
20 times after 24 hours (FLORESA et al., 1999) while the
chances of decalcification and promoting rem-
final bond strength is achieved after 24 hours.
ineralization (FOLEY et al., 2002). However,
Some studies have suggested RMGIC has sufficient bond literature showed that there is no difference in
strength for orthodontic purposes, with a similar failure decalcification rate when GIC cement is used
rate to composite (SILVERMAN et al., 1995, CHOO et compared to composite (MILLETT et al., 1999).
al., 2001).
• High compressive and tensile strength cements.
Moreover, light cure GIC is especially useful in cases
• Low solubility after setting.
where etching is suboptimal e.g. fluorosis or amelogen-
esis imperfecta. Cochrane review showed that GIC is • Easy handling and removal.
weak and an unreliable bonding adhesive (MANDALL
• Longer working time than other cements.
et al., 2003).
• Adhesion to stainless steel and enamel though
Orthodontic banding
the GIC-metal bond strength is low, therefore,
Glass ionomer cements (Glass Polyalkenoate cements) sandblasting is commonly carried out to in-
(GIC) crease adhesion to metal surfaces (MILLETT et
al., 1995).s
GIC is the most commonly used cement for orthodon-
tic banding and was first introduced in 1972 (WILSON, • Bond in moist environments (HEGARTY and
1972). Before the introduction of GIC, zinc-oxyphos- MACFARLANE, 2002).
phate and zinc polycarboxylate cements were used for
orthodontic banding.
Disadvantages of GIC
GIC cements set by an acid base reaction between poly-
alkenoic acid and fluoroaluminosilicate glasses. These include:

Orthodontic Materials 31
 • Bond strength is less than that of composite These include:
resin cements.
• Aesthetics.
• Brittle cement.
• Low solubility.
• GIC needs 24 hours to reach the maximum
• High bond strength.
strength.
• Higher fracture toughness.
• Unpleasant taste due to presence of acid.
Disadvantages
• Moisture contamination can adversely affect the
the initial set of the materials. These include:
Resin modified GIC (RMGIC) • Bonding agents are required prior to the use of
cement.
RMGIC differs from conventional GIC as it contains a
resin component, namely HEMA (hydroxyethyl methac- • Less fluoride release than glass ionomers.
rylate). HEMA can be chemically or light activated, and
A Cochrane review has showed failure of molar tubes
contains up to 10% resin.
bonded, with either a chemically‐cured or light‐cured
The addition of the resin optimises the physical proper- adhesive, was considerably higher than that of molar
ties as well as counteract the issue of water solubility of bands cemented with glass ionomer cement. There was
conventional GIC. Moreover, the addition of resin re- less decalcification with molar bands cemented with
duces the fluoride and adhesion effects of conventional glass ionomer cement than with bonded molar tubes
properties (SIDHU and WATSON, 1995, FRICKER and cemented with a light‐,cured adhesive (MILLETT et al.,
DIP, 1998). The setting of RMGIC is usually dual cure 2017).
Advantages of RMGIC Glass polyphosphonate cements
These include: Usually used for banding and contains alumino-silicate
glass, poly (vinyl-phosphoric acid) and tartaric acid.
• Bond to tooth structure without the needs for
dentin bonding agent. Advantages
• Overall strength is twice that of conventional These include:
GIC
• A rapid setting reaction.
• Bond failure of RMGIC usually occurs at enam-
• A low solubility.
el adhesive interference, which means less ad-
hesive removal on debanding (HEGARTY and Tooth preparation for orthodontic bonding
MACFARLANE, 2002). Acid etch
• RMGIC is more aesthetic than glass ionomers. Pumice prior to acid etching is not routinely required
Modified composite or Compomers (polyacid-modified and does not significantly increase the bond strength
resin composites) (Lindauer, 1997).
Modified composite/compomer differs from RMGIC by 37% phosphoric acid is commonly used acid etch. Etch-
having a greater amount of resin, approximately 30-50% ing results in a demineralization depth of 14um to ac-
resin. commodate an average resin tag. Similar bracket failure
rates were observed for an etch time of 15 or 60 seconds
Compomers is supplied as an anhydrous single compo-
(BARRY, 1995). After etching, enamel is washed for 20
nent systems consisting of aluminosilicate glasses in the
seconds.
presence of carboxyl modified resin monomers and light
activated conventional resin monomers. Alternatively, Laser etching can be used though it results
in thermally-induced changes within the enamel to a
Compomers is light cured and its setting is initiated after
depth of 10 to 20μm, this depends on the type of laser
light activation. The delayed acid base reaction of GIC
and the energy applied to the enamel surface.
take place in the presence of water which usually come
from saliva, and this leads to leaching of fluorides and Sandblasting can also be used to micro-etch the enamel
other remineralizing ions from the glass component. surface, but it is usually reserved for etching metal or
porcelain surfaces.
Advantages
Resin primer (sealants)

32 Orthodontic Materials
 Resin primer is unfilled resin (methyl methacrylate et al., 2002, ALJUBOURI et al., 2004).
monomer) that penetrates exposed enamel pores de-
• Less discoloration of the tooth surface after
veloped during etching. Micro-mechanical retention is
debonding compared to conventional etching .
therefore achieved and increases the bond strength.
Disadvantage of SEP
Resin primer contains Bisphenol-A, which has been
reported to cause dermatitis to dental professionals on These include:
handling (PULGAR et al., 2000). Studies have shown
• Bond strength is lower than conventional etch-
that primer omission do not decrease the bond strength
ing (ALJUBOURI et al., 2004, KORBMACHER
(WANG and TARNG, 1991, TANG et al., 2000).
et al., 2002). According to the Cochrane review,
Moisture-insensitive primers there is insufficient evidence to conclude wheth-
er or not there is a difference in bond failure rate
Moisture-insensitive primers contain hydrophilic primers
between SEPs and conventional etching (HU et
that can bond in moderately wet fields, an example includes
al., 2013).
Transbond MIP by 3M Unitek. However, these primers can-
not overcome heavy saliva containation. • Difficulty in assessing when the clinical etch-
ing has been achieved, whereas in conventional
Self-etching primers (SEP)
etching, a chalky white appearance is visible
SEP contains both etch and primer combined in one so- (DORMINEY et al., 2003).
lution (WHITE, 2001, FLEMING et al., 2012). It contains
• It requires pumicing prior to its use to increase
methyle methacrylate phosphoric acid ester. There are
bond strength (BURGESS et al., 2006).
three mechanisms to stop the etching process in SEPs.
• It is a technique sensitive as SEPs needs agitating
• Acid groups attached to the monomer are
on each tooth surface for 3-5 seconds.
neutralised by forming a complex with calcium
from hydroxyapatite. • There is some report of microleakage under and
metal and ceramic brackets bonded (UYSAL et
• During the airburst step, the solvent is
al., 2008).
driven from the primer resulting in an increase
in viscosity, slowing the transport of acid Tooth surface preparation for orthodontic banding
groups to the enamel interface.
Commonly, there is no requirement to pumice tooth sur-
• When the primer is light cured the mono- faces before GIC cementation. However, 37% phosphoric
mers are polymerized, transport of the acid acid etching is a recommended surface preparation with light
groups to the interface is stopped. cured RMGIC (MILLETT and MCCABE, 1996).
Advantage of SEP Tooth surfaces should be cleaned but not dried, this is due to
10% polyacrylic acid component of GIC, which will mildly
The claimed advantages are:
etch the surface. According to the systemic review, there is
• Less chairside time: A systematic review and weak evidence that GIC is better than resin adhesive at pre-
meta-analysis found that on the average 23 sec- venting white spot lesions (ROGERS et al., 2010).
onds/bracket are saved with the use of SEP com-
Bonding in Fluorosis
pared to conventional etching (FLEMING et al.,
2012). In fluorosis cases, the enamel surface resists etching, there-
fore, a longer etch time i.e. 60 seconds is recommended. Al-
• Less enamel loss compared to conventional
ternatively, micro-abrasion of the enamel surface can be per-
etching (HOSEIN et al., 2004).
formed.
• Minimal discomfort for patients with the ab-
Silane coupling agents are used to increase bond strength e.g.
sence of acidic taste and potential burning sen-
Scotchbond Universal Adhesive.
sation in the mouth from conventional etch.
For cases with fluorosis, some recommended the use of
• Less moisture sensitive technique compared to
RMGIC instead of composite bonding where a thin mix of
conventional etching as SEP can tolerate some
RMGIC is used.
moisture contamination (CACCIAFESTA et al.,
2003, SFONDRINI et al., 2004). However, if bonding is not successful, banding of the involved
teeth is the alternative.
• According to some studies, failure rate of brack-
ets is similar to conventional etching (ASGARI Bonding to porcelain, amalgam, veneers and gold

Orthodontic Materials 33
Chemical surface preparation • Chlorhexidine and ammonium salts as
disinfectants.
To etch porcelain surfaces, 9.6% hydrofluoric acid for 2-4
minutes or 4% acidulated fluorophosphate (AFP) for 2 • Coloring and flavoring to make impres-
minutes are used (Zachrisson et al., 1995, Zachrisson and sions more acceptable and pleasant for the
Buyukyilmaz, 1993). Both acid etchants are highly erosive patient.
and can cause severe tissue burns, therefore, it is essential to
The setting reaction of alginate starts with the mixing of
protect the soft tissues.
water as a sol-gel reaction (water based reaction). The
After etching and drying, a silane coupling agent is used to in- setting reaction is as follow:
crease the bond strength (e.g. unhydrolyzed Porcelain Primer
Potassium alginate + calcium sulphate + water → calcium
by Ormco or prehydrolyzed Scotch prime by 3M). Then, an
alginate + potassium sulphate + water
intermediate resin is applied (e.g. All Bond 2, or other com-
mercially available primers used with commercially available The powder/water ratio is crucial in alginate mixing. Af-
luting cements). ter taking any impression, it is important to disinfect the
impression before sending it to a dental laboratory to re-
For bonding to gold/amalgam surfaces, the same steps are
duce cross-infection.
followed except that metal primer is used as an intermedi-
ate resin (e.g. 4 META primer by Reliance Orthodontics or Advantages of alginate
Amalgambond-Plus Parkell).
These include:
Mechanical surface preparation (ZACHRISSON et al.,
• Inexpensive.
1995, ZACHRISSON and BUYUKYILMAZ, 1993)
• Easy to manipulate.
These include:
• Can be used with stock trays.
• Diamond bur is used to roughen the surface. This is es-
pecially useful with temporary acrylic crowns. • Pleasant taste.
• Sandblasting with 50 microns aluminium oxide particles • Easily poured in gypsum.
for 2-4 seconds. • Adequate working and setting time.
• Tin plating. Disadvantages of alginate
• Laser etching. These include:
Impression materials • Poor tear strength.
Alginate • Dimensionally unstable –tendency to absorb and
Alginate is an elastic irreversible hydrocolloids. It is the lose water.
impression of choice for many orthodontists due to the • Has to be poured immediately.
ease in manipulation, patient comfort and cost effective-
ness. Alginate is supplied in powder form and its main • Low detail reproduction (FREY et al., 2005, MU-
composition is as follow: RATA et al., 2004, DOUBLEDAY, 1998, NANDINI
et al., 2008).
• Potassium alginate and calcium sulphate.
These two components form the alginate gel. Silicone impression materials
• Sodium phosphate; which acts as a re- Silicone impression materials are also known as non-aqueous
tarder to extend the working time by delaying elastomers, they were developed to overcome the two main
the reaction of calcium ions. drawbacks of hydrocolloids; the poor tear resistance and di-
mensional instability.
• Potassium sulphate; it is known as a
‘gypsum hardener’, which is added to counter The setting reaction is of a catalytic polymerization followed
the inhibiting effect of the set alginate on the by cross linking and increased elasticity. The setting of sili-
setting reaction of gypsum. cone impression material is affected by the products used in
the vulcanization of some latex gloves; this is known as “plati-
• Diatomaceous earth or other fillers to num poisoning”, ideally gloves should be washed with deter-
control viscosity of alginate before setting, and gent before mixing the impression materials or vinyl gloves
adds flexibility to the alginate after setting. used. Silicone impression materials are indicated for the fol-
• Glycols to make the powder dustless. lowing conditions.

34 Orthodontic Materials
 • For cleft lip and palate patients. placed in a hydroflask to cure for 10 minutes. This
hydroflask contains warm water under pressure to
• For aligners impressions.
accelerate the setting of acrylic.
• Fabrication of indirect implant supported appli-
• Cold-cure or self-cure acrylic appliances are used
ances.
where less strength and durability is required, for
• Patients allergic to alginate. example an appliance is required for short term use.
They are of two types of silicone impression materials: • Cold-cure or self-cured acrylic are not commonly
used due to their poor mechanical properties, high
• Condensation silicone materials are Polysi-
residual monomer content and water uptake. (Fal-
loxanes or conventional silicones. They are Hydro-
termeier et al.,2012)
phobic and require a dry field, and liberate alcohol
by-product on setting, therefore should be poured Heat cured acrylic
immediately.
The main features are:
• Addition silicone materials (Polyvinylsilox-
• Heat cured acrylic is chemically activated.
anes) which can be either hydrophilic or hydro-
phobic. Compared to their counterpart (condensa- • The powder contains the initiator, di-benzoyl perox-
tion silicones), Polyvinylsiloxanes exhibit better ide.
accuracy, dimensional stability and pouring may
• The monomer and polymer are mixed together and
be delayed. Furthermore, Polyvinylsiloxanes have
placed on the dental model. The dental model is
superior dimensional stability and tear resistance
packed into a plaster mould and heated to a temper-
compared to alginate. Polyvinylsiloxanes are
ature of approximately 72°C, for a period of 16 hours
available in four viscosities; light body, regular
under a pressure of about 3000 kp/cm2.
body, heavy body and putty. However, the main
drawback of Polyvinylsiloxanes is the high cost • Strong and durable appliances can be made from
compared to alginate. Therefore, Polyvinylsiloxanes heat cured acrylic, even in a thin cross section.
are used where high accuracy is required in fixed
• Heat cured acrylic is a material of choice in con-
prosthodontics and orthodontics (KEYF, 1994).
struction of functional appliances, retainers and dis-
Acrylic for removeable appliances talization appliances in orthodontics.
The main features are: • They are superior in terms of lower water uptake,
color stability, and mechanical properties, mainly
• Acrylic is based on methyl methacrylate which is a
due to a higher conversion of monomer to polymer
liquid at room temperature.
than cold and self cured acrylic. (Faltermeier A et
• Metyl methacrylate undergoes polymerisation by al.,2007)
addition of free radical to form poly methyl meth-
Modified/reinforced acrylic resins
acrylate or PMMA.
The main features are:
• The free radical comes from the initiator, usually a
peroxide e.g. di-benzoyl peroxide. • Reinforced acrylic resin cured by heat.
• The initiator is activated by heat, chemicals or elec- • It is a resin reinforced with rubber (butadiene-sty-
tromagnetic radiation. rene polymethylmethacrylate). Hence, it is consid-
ered a high impact resin.
Cold cure acrylics
• Butadiene particles are grafted into MMA for en-
The main features are:
hanced adhesion with PMMA. Subsequently, rein-
• Cold cure acrylics is chemically activated. forced acrylic resin have superior impact strength
and fatigue properties.
• Monomer liquid and polymer powder are mixed to-
gether on the stone working model. Fibre reinforced acrylics
• The monomer contains an activator such as a tertia- The main features are:
ry aromatic amine (e.g. dimethyl-p-toluidine) and a
• Carbon / graphite, glass, aramid and polyethylene
stabilizer hydroquinone. The stabilizer prevents po-
fibres are added to reinforce acrylic.
lymerization prior to use.
• Of those fibres, glass fibres have an ability to consid-
• After adapting the acrylic on the dental model, it is

Orthodontic Materials 35
 erably increase the mechanical properties of poly- poly(acrylic), poly(maleic) acid.
mers, as well as decrease the water sorption.
• Powder → calcium alumino-fluoro-silicate glasses.
• Fibre reinforcement has shown to have a positive im-
Resin modified GIC (RMGIC)
pact in preventing cracks and reducing crack propa-
gation, this is in part due to bidirectional fibres of • Contain resin component HEMA (hydroxyethyl meth-
the polymetric component (RANTALA et al., 2003). acrylate).
• HEMA can be chemically or light activated and can con-
tain up to 10% of the resin.
Advantages of RMGIC
Exam Night Review
• Bond to tooth structure without use of a dentin bonding
Ideal properties of bonding and banding materials agent.
• Non-irritant. • Transverse strength is twice that of conventional GIC
• Long working time. • Bond failure of RMGIC usually occurs at enamel adhe-
sive interference.
• Convenient mode of curing.
• More esthetic than glass ionomers.
• High bond strength.
Modified composite or Compomers
• Easily debond.
• →Greater amount of resin approximately 30-50% resin.
• Low viscosity.
Advantages of Compomers
• Ease of handling.
• They have excellent aesthetics.
• Antimicrobial.
• Low solubility.
• Cost effective.
• High bond strength.
• Color: Should be different from tooth color.
• Higher fracture toughness.
• Fluoride releasing potential.
Disadvantages of Compomers
• Good wettability.
• Bonding agents required prior to use of cement.
• Command set.
• Less fluoride release than glass ionomers.
• Color stability in oral environment.
Glass polyphosphonate cements
• Low solubility: In oral fluids thus to minimise dimen-
sional changes. Advantages
Advantages of GIC • A rapid set.
• Adhesion to S/S & enamel. • A high compressive strength.
• Release fluoride. • A low solubility.
• Offer high retentive strength. Bonding adhesives
• Easy handling and removal. Composite (diacrylates)
• Longer working time than other cements. • Resin (BisGMA): Diethylene glycol dimethacrylate
(DEGDMA) or triethylene glycol dimethacrylate (TEG-
• Wet bonding.
DMA).
• Light cured glass ionomer cements has adequate bond
• Filler particles: Consists of glass beads, aluminium sili-
strength and sets quickly.
cate, barium, strontium and borosilicate glass.
Conventional GIC
Advantages of Composite
• Liquid & powder, mixing → acid base cement reaction →
• Extended working time.
release of aluminium and calcium.
• Easy to remove excess.
• Liquid →aqueous solution of an organic acid, such as

36 Orthodontic Materials
• Reduce chance of moisture contamination as insoluble RMGIC.
in oral fluids.
Bonding to porcelain, amalgam, veneers and gold
Disadvantages of Composite
• 9.6% hydrofluoric acid for 2-4 minutes or 4% acidulated
• Moisture sensitive. fluorophosphate (AFP) for 2 minutes.
• Technique sensitive. • Silane coupling agent to increase the bond strength.
• Etching / bonding agents required prior to use of adhe- Impression materials
sive.
Alginate
• Chemical cured composite have short working time.
Elastic irreversible hydrocolloids. It composed of:
• No fluoride release or recharge compared to GICs.
• Potassium alginate and calcium sulphate.
Acid etch
• Sodium phosphate.
• 37% phosphoric acid used to etch the enamel for 15-60
• Potassium sulphate →gypsum hardener.
seconds.
• Diatomaceous earth or other fillers →control viscosity
• Washed for 20 seconds.
• Glycols → make powder dustless.
• Pumice: Not needed.
• Chlorhexidine and ammonium salts → disinfectants.
• Sandblasting →Reserved for etching on metal or porce-
lain crowns. • Coloring and flavoring
Resin primer (sealants) Advantages of alginate
• Unfilled resin (methyl methacrylate monomer) → for • Inexpensive.
complete penetration of exposed enamel pores.
• Easy to manipulate.
Moisture-Insensitive Primers
• Can be used with stock trays.
• Hydrophilic primers → bond in wet fields.
• Pleasant taste.
Self-etching primers (SEP)
• Easily poured in gypsum.
• The active ingredient of the SEPs → methacrylate phos-
• Adequate working and setting time.
phoric acid ester → dissolves calcium from hydroxyapa-
tite. Disadvantages of alginate
Advantages of SEP • Poor tear strength.
• Less chairside. • Dimensionally unstable –tendency to absorb and lose
water.
• Less enamel loss during etching.
• Has to be poured immediately.
• Rinsing is not required.
• Low detail reproduction.
• Less decalcification.
Silicone impression materials
• Less moisture sensitivity.
• Setting reaction
• Less discoloration.
• → Non aqueous elastomers →set by catalytic polymer-
Disadvantages of SEP
ization followed by cross linking and increased elasticity.
• Bond strength is lower than conventional etching.
• Two type:
• Difficult to judge the completion of etching.
1. Condensation silicone materials.
• Requires pumice prophylaxis.
2. Addition silicone materials (Polyvinylsiloxanes).
• Microleakage.
Cold cure acrylics
Bonding in case of Fluorosis
• Cold cure / self-cure acrylic appliances → for less strength
• Greater resistance to etching of enamel surface, may re- and durability.
quires 60 second etching time / saline coupling agents /

Orthodontic Materials 37
Heat cured acrylic Refrences

• Strong and durable appliance in thin sections can be ALJUBOURI, Y., MILLETT, D. & GILMOUR, W. 2004. Six and 12
made from heat cured materials. months’ evaluation of a self-etching primer versus two-stage etch
and prime for orthodontic bonding: a randomized clinical trial. The
• Heat cured acrylic is a material of choice in the construc- European Journal of Orthodontics, 26, 565-571.
tion of functional appliances, retainers and distalization
ASGARI, S., SALAS, A., ENGLISH, J. & POWERS, J. 2002. Clini-
appliances. cal evaluation of bond failure rates with a new self-etching primer.
Journal of clinical orthodontics: JCO, 36, 687.
BARRY, G. 1995. A clinical investigation of the effects of omission
of pumice prophylaxis on band and bond failure. British Journal of
Orthodontics, 22, 245-248.
BEARN, D. R., AIRD, J. C. & MCCABE, J. F. 1995. Ex vivo bond
strength of adhesive precoated metallic and ceramic brackets. Brit-
ish Journal of Orthodontics, 22, 233-236.
BIN ABDULLAH, M. S. & ROCK, W. 1996. The effect of etch time
and debond interval upon the shear bond strength of metallic orth-
odontic brackets. British journal of orthodontics, 23, 121-124.
BULUT, H., TÜRKÜN, M., TÜRKÜN, L. Ş. & IŞıKSAL, E. 2007.
Evaluation of the shear bond strength of 3 curing bracket bonding
systems combined with an antibacterial adhesive. American Journal
of Orthodontics and Dentofacial Orthopedics, 132, 77-83.
BUREN, J. L., STALEY, R. N., WEFEL, J. & QIAN, F. 2008. Inhibi-
tion of enamel demineralization by an enamel sealant, Pro Seal: an
in-vitro study. American Journal of Orthodontics and Dentofacial
Orthopedics, 133, S88-S94.
BURGESS, A. M., SHERRIFF, M. & IRELAND, A. J. 2006. Self-
etching primers: is prophylactic pumicing necessary? A randomized
clinical trial. The Angle Orthodontist, 76, 114-118.
CACCIAFESTA, V., SFONDRINI, M. F., BALUGA, L., SCRIB-
ANTE, A. & KLERSY, C. 2003. Use of a self-etching primer in com-
bination with a resin-modified glass ionomer: effect of water and
saliva contamination on shear bond strength. American journal of
orthodontics and dentofacial orthopedics, 124, 420-426.
CHOO, S. C., IRELAND, A. & SHERRIFF, M. 2001. An in vivo
investigation into the use of resin‐modified glass poly (alkenoate)
cements as orthodontic bonding agents. The European Journal of
Orthodontics, 23, 403-409.
DORMINEY, J. C., DUNN, W. J. & TALOUMIS, L. J. 2003. Shear
bond strength of orthodontic brackets bonded with a modified
1-step etchant-and-primer technique. American Journal of Ortho-
dontics and Dentofacial Orthopedics, 124, 410-413.
DOUBLEDAY, B. 1998. Impression materials. British journal of or-
thodontics, 25, 133-140.
FALTERMEIER, A., ROSENTRITT, M. & MÜSSIG, D. 2007. Acryl-
ic removable appliances: Comparative evaluation of different post-
polymerization methods. American Journal of Orthodontics and
Dentofacial Orthopedics, 131, 301. e16-301. e22.
FLEMING, P. S., JOHAL, A. & PANDIS, N. 2012. Self-etch prim-
ers and conventional acid-etch technique for orthodontic bonding:
a systematic review and meta-analysis. American journal of ortho-
dontics and dentofacial orthopedics, 142, 83-94.
FLORESA, A. R., EB, G. S. & BARCELÓC, F. 1999. Metallic bracket

38 Orthodontic Materials
to enamel bonding with a photopolymerizable resin-reinforced glass MILLETT, D. T., MANDALL, N. A., MATTICK, R. C., HICKMAN,
ionomer. American journal of orthodontics and dentofacial ortho- J. & GLENNY, A. M. 2017. Adhesives for bonded molar tubes during
pedics, 116, 514-517. fixed brace treatment. Cochrane Database of Systematic Reviews.
FOLEY, T., AGGARWAL, M. & HATIBOVIC-KOFMAN, S. 2002. A MURATA, H., KAWAMURA, M., HAMADA, T., CHIMORI, H. &
comparison of in vitro enamel demineralization potential of 3 orth- NIKAWA, H. 2004. Physical properties and compatibility with den-
odontic cements. American journal of orthodontics and dentofacial tal stones of current alginate impression materials. Journal of oral
orthopedics, 121, 526-530. rehabilitation, 31, 1115-1122.
FREY, G., LU, H. & POWERS, J. 2005. Effect of mixing methods on NANDINI, V. V., VENKATESH, K. V. & NAIR, K. C. 2008. Alginate
mechanical properties of alginate impression materials. Journal of impressions: A practical perspective. Journal of conservative den-
Prosthodontics: Implant, Esthetic and Reconstructive Dentistry, 14, tistry: JCD, 11, 37.
221-225.
PATIL, P., KAUR, S., KAUR, M., KAUR, M., VINUTA, S. & KAUR,
FRICKER, J. P. & DIP, G. 1998. A new self-curing resin-modified R. K. 2014. Orthodontic cements and adhesives: a review. J Adv Med
glass-ionomer cementfor the direct bonding of orthodontic brackets Dent Sci Res, 2, 35-8.
in vivo. American journal of orthodontics and dentofacial orthope-
PAWAR, R. L., RONAD, Y. A., GANIGER, C. R., SURESH, K., PHA-
dics, 113, 384-386.
PHE, S. & MANE, P. 2012. Cements and Adhesives in Orthodon-
HEGARTY, D. J. & MACFARLANE, T. V. 2002. In vivo bracket re- tics-An Update. Biological and Biomedical Reports, 2, 342-347.
tention comparison of a resin-modified glass ionomer cement and a
POOSTI, M., RAMAZANZADEH, B., ZEBARJAD, M., JAVADZA-
resin-based bracket adhesive system after a year. American journal
DEH, P., NADERINASAB, M. & SHAKERI, M. T. 2013. Shear bond
of orthodontics and dentofacial orthopedics, 121, 496-501.
strength and antibacterial effects of orthodontic composite contain-
HOSEIN, I., SHERRIFF, M. & IRELAND, A. J. 2004. Enamel loss ing TiO2 nanoparticles. European journal of orthodontics, 35, 676-
during bonding, debonding, and cleanup with use ofa self-etching 679.
primer. American Journal of Orthodontics and Dentofacial Ortho-
PULGAR, R., OLEA-SERRANO, M. F., NOVILLO-FERTRELL, A.,
pedics, 126, 717-724.
RIVAS, A., PAZOS, P., PEDRAZA, V., NAVAJAS, J.-M. & OLEA,
HU, H., LI, C., LI, F., CHEN, J., SUN, J., ZOU, S., SANDHAM, A., N. 2000. Determination of bisphenol A and related aromatic com-
XU, Q., RILEY, P. & YE, Q. 2013. Enamel etching for bonding fixed pounds released from bis-GMA-based composites and sealants by
orthodontic braces. Cochrane Database of Systematic Reviews. high performance liquid chromatography. Environmental health
perspectives, 108, 21-27.
KEYF, F. 1994. Some properties of elastomeric impression materi-
als used in fixed prosthodontics. Journal of Islamic Academy of Sci- RANTALA, L., LASTUMÄKI, T., PELTOMÄKI, T. & VALLITTU,
ences, 7, 44-48. P. 2003. Fatigue resistance of removable orthodontic appliance re-
inforced with glass fibre weave. Journal of oral rehabilitation, 30,
KORBMACHER, H., KLOCKE, A., HUCK, L. & KAHL-NIEKE, B.
501-506.
2002. Enamel conditioning for orthodontic bonding with a single-
step bonding agent. Journal of Orofacial Orthopedics/Fortschritte ROGERS, S., CHADWICK, B. & TREASURE, E. 2010. Fluoride-
der Kieferorthopädie, 63, 463-471. containing orthodontic adhesives and decalcification in MILLETT,
D. T., MANDALL, N. A., MATTICK, R. C., HICKMAN, J. & GLEN-
KULA, K., SCHREINER, R., BROWN, J. & GLAROS, A. 2002.
NY, A. M. 2017. Adhesives for bonded molar tubes during fixed
Clinical bond failure of pre‐coated and operator‐coated orthodontic
brace treatment. Cochrane Database of Systematic Reviews.
brackets. Orthodontics & craniofacial research, 5, 161-165.
SFONDRINI, M. F., CACCIAFESTA, V., SCRIBANTE, A., DE AN-
MANDALL, N. A., HICKMAN, J., MACFARLANE, T. V., MAT-
GELIS, M. & KLERSY, C. 2004. Effect of blood contamination on
TICK, R. C., MILLETT, D. T. & WORTHINGTON, H. V. 2003. Ad-
shear bond strength of brackets bonded with conventional and self-
hesives for fixed orthodontic brackets. Cochrane Database of Sys-
etching primers. American journal of orthodontics and dentofacial
tematic Reviews.
orthopedics, 125, 357-360.
MILLETT, D. & MCCABE, J. 1996. Orthodontic bonding with glass
SIDHU, S. K. & WATSON, T. F. 1995. Resin-modified glass iono-
ionomer cement. The European Journal of Orthodontics, 18, 385-
mer materials. A status report for the American Journal of Dentistry.
399.
American Journal of Dentistry, 8, 59.
MILLETT, D., MCCABE, J., BENNETT, T., CARTER, N. & GOR-
SILVERMAN, E., COHEN, M., DEMKE, R. S. & SILVERMAN, M.
DON, P. 1995. The effects of sandblasting on the retention of first
1995. A new light-cured glass ionomer cement that bonds brackets
molar orthodontic bands cemented with glass ionomer cement.
to teeth without etching in the presence of saliva. American Journal
British journal of orthodontics, 22, 161-169.
of Orthodontics and Dentofacial Orthopedics, 108, 231-236.
MILLETT, D., NUNN, J., WELBURY, R. & GORDON, P. 1999. De-
TANG, A. T., BJÖRKMAN, L., ADAMCZAK, E., ANDLIN-SOB-
calcification in relation to brackets bonded with glass ionomer ce-
OCKI, A. & EKSTRAND, J. 2000. In vitro shear bond strength of
ment or a resin adhesive. The Angle Orthodontist, 69, 65-70.
orthodontic bondings without liquid resin. Acta Odontologica
MILLETT, D. T., GLENNY, A. M., MATTICK, R. C., HICKMAN, J. Scandinavica, 58, 44-48.
& MANDALL, N. A. 2016. Adhesives for fixed orthodontic bands.
UYSAL, T., ULKER, M., RAMOGLU, S. I. & ERTAS, H. 2008. Mi-
Cochrane Database of Systematic Reviews.

Orthodontic Materials 39
croleakage under metallic and ceramic brackets bonded with orth-
odontic self-etching primer systems. The Angle Orthodontist, 78,
1089-1094.
WANG, W. N. & TARNG, T. H. 1991. Evaluation of the sealant in
orthodontic bonding. American Journal of Orthodontics and Den-
tofacial Orthopedics, 100, 209-211.
WHITE, L. W. 2001. An expedited indirect bonding technique.
Journal of clinical orthodontics: JCO, 35, 36.
WILSON, A. D. 1972. A new translucent cement for dentistry: the
glass-ionomer cement. Br Dent J, 132, 133-135.
WRIGHT, A. B., LEE, R. T., LYNCH, E. & YOUNG, K. A. 1996.
Clinical and microbiologic evaluation of a resin modified glass ion-
omer cement for orthodontic bonding. American journal of ortho-
dontics and dentofacial orthopedics, 110, 469-475.
ZACHRISSON, B. U. & BUYUKYILMAZ, T. 1993. Recent advances
in bonding to gold, amalgam, and porcelain.
ZACHRISSON, B. U., BÜYÜKYILMAZ, T. & ZACHRISSON, Y.
1995. Improving orthodontic bonding to silver amalgam. The Angle
Orthodontist, 65, 35-42.

40 Orthodontic Materials
 5
BIOMECHANICS
Written by: Mohammed Almuzian, Haris Khan, Maham Munir,Taimoor Khan

In this Chapter
1. Forces and resultant force
2. Centre of resistance and rotation
3. Moment of force
4. Force couple
5. Moment of couple
6. Effect of periodontal health on M/F ratio
7. Effect of loops on M/F ratio
8. Bracket dimensions and moments
9. Types of force system
10. Advantages of a one couple force system
11. Statically indeterminate systems
12. Analogies in biomechanics
13. The six geometry
14. EXAM NIGHT REVIEW
Definition resistance moves apically with loss of periodontal
support (Melsen et al., 1988), moves coronally with
Biomechanics combines knowledge of physics and engi-
severe root resorption
neering along with that of biological sciences.
• Root length
Forces
• Root morphology
It represents the action that maintain, alter, or distort the
motion of a body (Whitehead and Russell, 1997). Force is a • Tooth inclination
vector quantity, which causes an object in space to change
• Level of alveolar bone height
its place or its shape.
• Direction of applied force
Force quantity depends on features of magnitude, point of
application and direction to which the vector acts (sense of • Direction of tooth movement as the centre
force). Traditionally, force is expressed in grams but scien- of rotation differs in mesiodistal movement when
tifically, a centi-Newton (cN) is the correct unit for force compared to labiolingual movement
(1gm is equal to 0.98 cN).
• Point of force application
Resultant force
• Method of connection: If teeth are connected
A single force that can substitute the individual forces, pro- by a rigid wire the centre of rotation moves apically.
ducing the same net effect. Resultant forces can be calculat-
• Moment to force ratio: By changing the
ed subjectively using graphic methods (either parallelogram
moment-to-force ratio, the centre of rotation of
of enclosed polygon), however, the objective approach is by
tooth movement can be varied to produce the type
using trigonometric functions and Pythagoras theory.
of tooth movement desired (Table 1).
Centre of Resistance
Type of movement Location of the centre of
Centre of resistance of an object is also defined as a point rotation
on which application of a single force will produce bodily
Root movement Incisal/occlusal edge
movement of the object. The centre of resistance is similar
to the centre of mass for any object in free space Controlled tipping Nearer to the apex

Centre of resistance is the point where resistance to move- Uncontrolled tipping At or slightly apical to the
ment can be considered to be concentrated. A tooth, howev- centre of rotation
er, is a restrained object within the bone and the periodontal Translation/Intrusion/Ex- Perpendicular to the long
ligament surrounded by muscle forces. Therefore, the centre trusion axis of the tooth (infinity)
of resistance must be considered a balance point of the re- Moment of force
strained objects.
It represents the rotational capibility of a force applied to a
Centre of Rotation body at a distance from the centre of resistance. The mag-
The centre of rotation is the point around which the body nitude of a moment is calculated by multiplying the magni-
appears to rotate, as determined from its initial and final tude of force and the perpendicular distance from point of
position. A force with a single point of contact will produce force application to the centre of rotation. The unit of mo-
a rotation of the body about the point of the centre of rota- ment of force is N/mm (Smith and Burstone, 1984a).
tion. Increasing the force magnitude or the perpendicular dis-
The centre of rotation of a single rooted tooth is at the ap- tance from the point of force application to the centre of
proximate midpoint of the embedded portion of the root rotation increases the moment, and therefore the rotation.
on its long axis, about half way between the root apex and Moment force is considered positive if its direction is clock-
the crest of the alveolar bone (Burstone and Pryputniewicz, wise or negative when if its direction is counterclockwise.
1980b). For a multi-rooted tooth, the centre of resistance is
roughly at the furcation area or 1-2 mm apical to the furca- Force couple
tion, assuming that the periodontal support is intact (Bur- A couple is a system of two non-linear, parallel forces of
stone, 1981). equal magnitude acting in opposite directions. Hence, a
The location of the centre of rotation is dependent on the couple consists of two moments.
following variables: Each point of a body has a rotational effect in the same di-
• Characteristics of the supporting structures rection and magnitude.
(Pryputniewicz and Burstone, 1979). The centre of

42 Biomechanics
• The magnitude of a couple is calculated by multiply- there is no rotation in the system. The centre
ing the force by the perpendicular distance between the of rotation is non-existent (approaches infin-
forces. ity) and the tooth undergoes translation/bodily
movement. There is equal movement of crown
• Unit of couple is N/mm.
and root in the direction of applied force with-
Moment of couple or counterbalancing moment out tipping. Clinically, this is a desirable move-
ment but it is hard to achieve and maintain.
• The tooth rotation / tipping produced by a moment
can be avoided by applying an equal moment in the op- d) If the Mc/F is more than 10/1, torque
posite direction to the original moment (counter-mo- movement will happen: If the counterbalancing
ment) with the aid of auxillary springs or rectangular moment is increased even more so that the mo-
arch wire in a rectangular bracket slot. ment of couple becomes greater than the mo-
ment from applied force, the centre of rotation
• The counter moment must be generated across the two
moves closer to the incisal edge while the root
points of contact of the rectangular wire within the
is free to move in the direction of applied force
bracket slot.
allowing the root apex to move further than the
• Bodily tooth movement requires both a force to move crown (root torque).
the tooth in the direction of the desired movement, and
e) If the Mc/F is more than 12/1, pure root
a couple to produce the necessary counter-moment,
movement will happen with the centre of rota-
neutralizing the rotational effect of the applied force.
tion located at the incisal edge.
The relationship between the moment, force and counter-
II. Mc/Mf Ratios
moment
Ratio between counter balancing moment (Mc) generated
Type of tooth movement is determined by either Mc/F
by a couple within the bracket and moment created when
(Burstone and Pryputniewicz, 1980a) ratio or Mc/Mf (Yo-
a force is applied to the crown of a tooth (Mf) can more
shikawa, 1981).
precisely describe how a tooth will move compared to M/F
I. Moment to force (M/F) ratios ratio (Yoshikawa, 1981).
• Moment of the force (Mf) is the magnitude of force • Mc/Mf = 0 – Pure tipping/ uncontrolled tipping:
applied at the bracket multiplied by the perpendicu- Tooth rotates around centre of rotation.
lar distance from line of force application to the cen-
• 0 < Mc/Mf < 1 – Controlled tipping: Mainly crown
tre of resistance.
movement occurs while the apex of the root remains
• For most teeth the Mf is approximately 8 to 10 mm, relatively stationary with the centre of rotation dis-
so the moment of force will be 8 to 10 times the force placed away from center of rotation.
applied. A force of 100 gm applied to a tooth will,
• Mc/Mf = 1 – Bodily movement/translation: Equal
therefore, require an anti-rotational/counterbalanc-
movement of crown and root occurs with the centre
ing moment (Mc) of 800-1000 gm/mm to obtain
of rotation displaced to infinity.
bodily movement/translation (Mc/F=10) (Smith
and Burstone, 1984b, Lindauer, 2001). • Mc/Mf >1 – Root torque: Centre of rotation is at the
crown of the tooth and only root movement occurs.
a) If the Mc/F is 0, uncontrolled tipping will
happen: A single force applied at the bracket of Effect of periodontal health on M/F ratio
a tooth (no counterbalancing moment) results
• Moment-to-force ratios must be adjusted when the
in uncontrolled tipping with the centre of rota-
normal 8 to 10 mm distance from the point of force
tion at or just apical to the centre of resistance.
application to the centre of rotation is different, for ex-
It causes movement of crown and root apex
ample in periodontally compromised cases.
in opposite directions and is usually clinically
undesirable. • As the distance to centre of rotation increases second-
ary to bone loss, a larger counterbalancing moment is
b) If the Mc/F is < 8/1, controlled tipping will
required to control tipping and produce bodily move-
happen.
ment/translation. However, a lighter force (force ap-
c) If the Mc/F is 8/1 to 10/1, bodily move- plied) is advised, to not only to preserve the health of
ment will happen. When the counterbalancing periodontal ligament but to reduce the tendency for
moment is increased to equal the moment of tipping (a heavier force applied would result in a lower
force, the moments neutralize each other and Mc/Mf, therefore tipping occurs). Therefore, to obtain

Biomechanics 43
 a higher M/F ratio (for controlled / bodily / root move- Types of force system
ment), brackets should be placed gingivally, to reduce
These include:
the Mf arm length, alternatively, a custom-made brack-
et with gingivally positioned slots can be used. I. A statically determinate force system (One couple
force system): It is also called ‘one-couple’ as one cou-
Effect of loops on M/F ratio (Burstone and Koenig, 1976)
ple is generated. In this force system it is possible to
The main principle of using retraction loops in orthodontics calculate /determine the applied forces and moments,
is flexibility, light force and full slot engagement. Full size and to a certain extent, the resulting tooth movement
coiled loops are made from flexible wire (TMA or NiTi) that (Lindauer and Isaacson, 1995). In a one couple force
allows full expression of Mc and better controlled bodily system, there is normally a long inter-bracket span be-
movement. tween both points of attachment. The wire is inserted
into a bracket or tube at one end, where the couple is
Increasing the number of loops generates a low resultant
created, and is tied to a single point of contact at the
force, and therefore requires a lower counterbalancing mo-
other end, where a simple force is applied without a
ment to produce more controlled movements.
couple depending on the region of the bend and the
Initially, when the loop is fully activated, the highest amount result force geometry.
of force is produced resulting in uncontrolled tipping (low
Advantages of a one couple force system
Mc/Mf). As the loop is gradually deactivated or secondary
to load decay, the resultant force decreases and produces These include:
more controlled tipping. At the end of the activation cycle,
• Relatively simple design.
the Mc/Mf reaches its highest value and produce transla-
tion/bodily movement. Therefore, the centre of rotation is • Predictable tooth movement as it can be designed to
dynamic and fluctuating constantly, subsequently, bodily move a single or block of tooth.
movement/translation is likely to occur by a series of tip-
• No need for multiple attachments.
ping and uprighting movements (Isaacson et al., 1993c,
Burstone, 1982). • Large range of activation so less frequent appointment
intervals for reactivation.
Bracket dimensions and moments
• Better control of force magnitude.
The interaction between bracket slot and archwire gener-
ates the necessary moment (Mc) to control mesiodistal root • Ability to limit unwanted side effects by additional in-
movement for parallelism of teeth during space closure. tra-arch, inter-arch or extra-oral mechanics.
Bracket width determines the length of this moment arm Examples of such appliances
and thus the magnitude of Mc. Bracket width also affects the
contact angle which subsequently affects the degree of bind- These include:
ing between the wire and corners of the bracket. Binding 1. Extrusion arch which is used for the closure of anterior
also depends on the force with which the bracket contacts open bites.
the archwire.
2. Extrusion springs are used to actively move an im-
Increase bracket width increases length of the moment arm pacted canine/incisor and sometimes second molars in
(Mc) and reduces the force needed to generate the necessary the arch, such as maxillary canines. As the extrusion
moment (Mc), it also reduces the contact angle between spring is activated, a couple is produced in the molar
archwire and brackets, and subsequently the binding.If 100 tube along with an intrusive force, while an extrusive
gm retraction force is applied for retracting a canine into the force is generated on opposite terminal end, of the wire
first premolar extraction site, at a distance of 10 mm from which can be engaged on the displaced tooth. The sum
centre of rotation of the tooth, 1000 gm/mm moment is re- of the extrusive and intrusive forces, and the moments
quired across the bracket for counterrotation, in order to which are equal in magnitude and opposite in direc-
achieve root parallelism (tip control). A 1mm wide bracket tion, is zero, hence, the force system is said to be in
requires 1000 gm force at each corner of the bracket to gen- static equilibrium.
erate the necessary moment. While a 4 mm wide bracket
requires 250 gm force at each corner of bracket. For this rea- Disadvantages of extrusive springs
son, siamese brackets with large bracket widths offer greater These include:
mesiodistal control of root position (tip control) compared
to single wing brackets that often require auxiliary springs • The spring may rotate the canine crown palatally as the
in a vertical slot to deliver second order prescription. point of extrusive force is buccal to its centre of resis-
tance.

44 Biomechanics
• There is a predisposition to rotate the molar crown tion of the labial segment teeth, to prevent its rotation
buccally as the point of force application (intrusive) is labially. Another method to prevent flaring the labial
buccal to its centre of rotation. However, where the ca- segment is to maintain the arch length, by using a tight
nine tooth lies palatal to the molar tooth, as the spring laceback connected to molars, miniscrews or Class 2
is activated, it will be rotated palatally, creating a mo- elastics. Alternaitively, cinching the archwire behind
ment to rotate the crown of the molar tooth in a palatal the molar tubes can be used to restrain the labial move-
direction. ment of the labial teeth at the expense of anteroposte-
rior anchorage loss (Isaacson et al., 1993b).
• The unwanted canine tooth movement can be over-
comed by tying the appliance directly into the canine • The extrusive force at the molar teeth is buccal to the
bracket, rather than tying it as a point contact and in- centre of rotation, therfore, palatal tipping occurs due
troducing lingual root torque into the archwire. How- to the created moment. A transpalatal arch can aid in
ever, this will make the force system indeterminate. stabilising the anchor unit in the transverse plane. Al-
ternatively, progressive posterior buccal root torque can
3. Laceback: A passive laceback prevents distally tipped
be added to the archwire. The use of high pull headgear
canines from mesial movement during the alignment
can counteract the extrusive force if it is undesirable.
phase, an active laceback can be used to retract the ca-
nine. II. Statically indeterminate systems (Two-couple force
system): It represents appliances that are inserted into a
4. Burstone intrusion arch is a one couple force system
bracket slot and tube at both ends of the appliance cre-
that is used to intrude the upper labial segment. This
ates two couples and two forces on both ends of wire/
appliance is made of an active archwire inserted into
appliance. In such a complex system, it is difficult to
tubes on the right and left molar teeth (the anchorage
evaluate precisely all the forces and moments at work.
unit) and to a single point of contact on the labial seg-
ment (active unit). Sectional archwires are placed in the Examples of statically indeterminate systems
posterior segment (molar - canine), and the anterior
1. Ricketts Utility Intrusion arch is a classic example of a
segment (lateral-lateral incisor). The anterior sectional
two-couple force system. It has been used to intrude la-
wire ensures the anterior teeth move vertically as a unit,
bial segment teeth (Engel et al., 1980, Dave and Sinclair,
maintaining relative vertical relationships lateral-later-
1989). Utility Intrusion arch is composed of a rectangu-
al incisor. Moreover, the intrusion arch is not engaged
lar archwire (segmental) engaging all the bracket slots
in the bracket slot, and is therefore a point contact,
of the anterior labial teeth and the first molar teeth as
not a couple (Isaacson et al., 1993a). Activation of the
the anchorage unit (Figure 3). The segmental archwire
Burstone intrusion arch occurs through pulling the in-
does not engage the premolar or canine teeth, via step
trusion wire vertically and tying it at the level of the
up bend. Placing tip back bends mesial to the molar
bracket between the canine and lateral incisor as this
tubes activate the wire in a way that when it is passive,
represents the centre of rotation of the anterior teeth.
the anterior aspect of the archwire lies apical to the la-
The magnitude of force used with an intrusion arch is
bial segment brackets. On activation, the archwire is
approximately 60g for four upper incisors, 15-20g per
tied into the labial segment brackets, which results in
tooth (Burstone, 2001), and 50g for four lower inci-
an intrusive force on the labial segment teeth and a an-
sors, 12.5g per tooth (Bishara and Saunders, 2001). It is
ticlockwise couple, while there is an extrusive force and
important to notice that greater forces result in further
clockwise couple of the same magnitude on the poste-
posterior molar extrusion. With the intrusion arch,
rior teeth.
molars receive extrusive force and a positive couple.
Tip back of the upper molar teeth may be an advanta- Disadvantages of Ricketts Utility Intrusion arch
geous in Class II cases as it helps in improving the buc-
These include:
cal segment relationship.
• The intrusive force on the labial segment teeth is labial
Disadvantages of Burstone intrusion arch:
to centre of rotation, which forms a moment that tips
These include: the crowns labially. This line of action cannot be var-
ied as the archwire is tied into the bracket slots (unlike
• Flaring of the labial segment which increases the arch
the case with an intrusion arch / Burstone intrusion
length, if line of action of the intrusive force is labial to
arch). The direction and magnitude of this moment is
the centre of resistance of the labial teeth i.e. anterior to
dependents on the location of the activation bend and
the lateral incisors. This can be overcome by tying the
the wire properties (Davidovitch and Rebellato, 1995).
intrusion arch behind the lateral incisor brackets such
Preventing the labial tipping of the crowns of the inci-
that the intrusive force can pass through centre of rota-
sor teeth can be achieved by:

Biomechanics 45
 a) Incorporating labial root torque into the ante- wire engaged into brackets attached to the six anterior
rior segment of the utility arch. teeth (canine to canine) and both first molars.
b) Applying a distal force to retract the incisors, • The appliance can be activated in the transverse dimen-
by a laceback or cinching the archwire, thereby, cre- sion, resulting in constriction or expansion of inter-
ating a lingual force at the incisor brackets restrain- molar width and first order molar rotations (Rebellato,
ing labial tipping of the incisor teeth. 1995).
• There is an extrusive force acting on the molar teeth, • Both symmetric and asymmetric dental expansion and
buccal to their centre of rotation tending to roll these constriction can be achieved with minimal movement
teeth palatally and tip them distally. This can be mini- of the anterior teeth (Burstone, 1962, Burstone, 1966).
mized by using a transpalatal arch.
Tipping and uprighting movement during sliding
2. Torquing arch is an appliance system used to place
These include:
third order (torque/ couple) on one or more incisors in
the same direction. A second couple is created where • Phase I: During this phase the Mc is less than the Mf,
the appliance/arch wire is inserted into the molar tubes there is frictionless uncontrolled tipping within the
posteriorly. Torquing arch is an effective system for de- slot’s play.
livering anterior root torque (Isaacson and Rebellato,
• Phase II: During this phase, the tipping movement
1995).
becomes controlled as the Mc is equal or larger than
3. Transpalatal arch: The traditional transpalatal arch the Mf, and the wire bends within its resiliency’s limit,
(TPA) is made of a rigid stainless-steel wire, of 0.9 mm increasing the binding and resulting in a force couple,
diameter, that extends from the palatal aspect of one this phenomenon is also termed appliance ankylosis.
maxillary first molar band to the band on the other
• Phase III: During this phase, bodily movement starts to
maxillary first molar contralaterally. TPA wire follows
appear as the Mc and the Mf become equal.
the contour of the palate but yet lies approximately
2-3mm away and commonly has a U-loop in the mid- • Phase IV: During this phase the Mc is greater than Mf,
line to allow for adjustment. TPA is soldered to the and root uprighting moment results in root movement.
middle or occlusal portion of maxillary molar bands on Analogies and commonly used terms in biomechanics
the palatal aspect. Generally, a TPA is used for:
• Bauschinger effect: When bending a wire, the elastic
• Anchorage reinforcement in vertical and transverse property is greatest in the original direction of bending
plane. or twisting, this phenomenon is known as the Bausch-
• Space maintenance. inger effect (Graber et al., 2016).
• Retention secondary to maxillary arch expansion. • Wagon-wheel effect: In the straight wire appliance,
adding palatal root torque to the anterior segment ap-
• Unilateral distal movement of an upper molar using
proximates the anterior roots. Therefore, adding torque
a unilateral toe-in bend.
negates the pre-existing incisors’ tip by a ratio of 4 to
• Bilateral or unilateral mesiopalatal molar rotation. 1 (Andrews, 1972). For example, adding 4˚of palatal
torque on the incisors will decrease tip by 1˚.
• Unilateral molar extrusion.
• Roller coaster effect: In the straight wire appliance, if
• Expansion of the intermolar width by activating the
the anterior teeth are retracted on light wire, then, the
midline U-loop. This will only produces dental ex-
heavy forces could induce uncontrolled tipping and
pansion by tipping as the points of force application
deepen the anterior overbite, open a posterior lateral
are occlusal to the centre of rotation of the molar
bite and rotate the molars in a counter clock-wise direc-
teeth (area of bifurcation), thereby creating a mo-
tion (McLaughlin and Bennett, 2015).
ment to tip the crowns buccally and roots palatally.
Both symmetric and asymmetric dental expansion • Bowing effect: The bowing effect is expressed in two
and constriction can be achieved with minimal planes i.e. the vertical and the transverse bowing ef-
movement of the anterior teeth (Burstone, 1962, fects. The vertical bowing effect is identical to the roller
Burstone, 1966). coaster effect while the transverse bowing effect occurs
when the incisors and canines are retracted on a lighter
4. 2 x 6 appliance
wire resulting in the premolars expansion while the
• 2 x 6 appliance is is a two couple statically indetermi- molar rotates in a mesio-buccal direction. The bowing
nate appliance system, consisting of a rectangular arch
• For rotation , 35-60g of force is required

46 Biomechanics
effect can be prevented by using a thick archwire for sliding, • For root uprighting, 50-100 g of force is required
or double cable mechanics (Hutchinson, 2011).
Brackets’ width
• Row-boat effect: if canines are mesially tipped, regard-
Ideally, the maximum practical width of a wide bracket
less of the presence of the space distal to them, full en-
should be about half the width of a tooth. However, man-
gagement of the brackets results in a tendency of the
ufacturers produce wider and narrow brackets, each has
incisors teeth to procline. This can be prevented by
some pros and cons.
avoiding full arch engagement, segemental retaction
of the canine, by-passing canine brackets or by-passing Advantages of the wide bracket
incisors, until enough spaces are provided for anterior
• Less force is required to generate a moment
alignemnt. Rowboat effects are also seen in engaging
distally orientated canines in a continuous wire, which • Decreased contact angle (where the corner of bracket
results in extrusion and proclination of incisors. meets the archwire)
• Gable bends: They are incorporated into the retraction • Reduced binding during space closure
loop configuration to provide a negative counter-mo- Disadvantages of the wide bracket
ment (Braun and Garcia, 2002). Ideally placed 40-45°,
closer to the posterior teeth each side to increase the • Interbracket span between adjacent teeth is reduced
arm of the counter- moment (Proffit et al., 2006). Bends which decreases the length of wire segment between
on the mesial side are called alpha bends while the dis- brackets
tal bends are known as beta bends (Katona et al., 2013). • Springiness & range of archwire decreases
Geometry Classification Advantages of the narrow bracket
The relationship of slot angulation of one bracket slot (A) • Inter-bracket span between adjacent teeth is increased
to an adjacent bracket slot angulation (B) can be classified which increases wire segment between brackets
into six geometries which determines the end results of the
force system: • Springiness &range of action of archwire increases

• Class I geometry: The bracket slots are parallel but not- • Advantageous during alignment of severely misaligned
Gin a straight line (A/B=+1). teeth

• Class II geometry: The ration between A/B is equal to Disadvantages of the narrow bracket
+0.8. • More force is required to generate a moment
• Class III geometry: The ration between A/B is equal to • Increased contact angle (where the corner of bracket
+0.5. meets the archwire)
• Class IV geometry: The ration between A/B is equal to • Increased binding during space closure by sliding me-
-0.5. chanics
• Class IV geometry: The ration between A/B is equal to
-0.75.
• Class V geometry: The ration between A/B is equal to
-0.4.
• Class VI geometry: The ration between A/B is equal t
o -1.
Forces required to move teeth
The magnitude of the forces required to move teeth varies
depending on the type of movement and type of teeth.
It is generally agreed that:
• For bodily movement, 70-120 g of force is required
• For intrusion, 10-20 g of force is required
• For tipping, 35-60 g of force is required
• For extrusion, 35-60g of force is required

Biomechanics 47
Exam Night Review force application to the centre of rotation
Forces Unit of moment of force is N/mm (Smith and Burstone,
1984a).
Force is a vector quantity, which causes an object in space to
change its place or its shape. Expressed in grams. Moment of couple
Resultant force A couple is a system, with a pair of non-colinear, parallel
forces of equal magnitude acting in opposite directions.
A single force that can substitute the individual forces, pro-
ducing the same net effect. Magnitude of couple: Force (one of the force) x perpendicu-
lar distance between the forces.
Centre of Resistance (COR)
Unit of couple is N/mm.
A point on which application of a single force will produce
bodily movement of the object. Moment-to-force (M/F) Ratios
COR moves apically with loss of periodontal support Type of movement demonstrated by a tooth is determined
(Melsen et al., 1988). by the ratio between:
COR of single rooted tooth is at approximate midpoint of 1. Magnitude of the moment from the applied couple or
the embedded portion of the root. moment of couple (Mc)
For a multi-rooted tooth, the centre of resistance is at furca- 2. The force applied to the tooth (Burstone and Pryput-
tion area or 1-2 mm apical to the furcation niewicz, 1980a).
Centre of Rotation In plain terms M/F is Mc/F.
The centre of rotation is the point around which the body Moment-to-force ratios required for various types of
appear to rotate as determined from initial and final posi- tooth movement
tions.
(Smith and Burstone, 1984b, Lindauer, 2001)
The location of this point is dependent on many variables:
• M/F = 0 → uncontrolled tipping with the centre of rota-
• Root length, tion at or just apical to the centre of rotation. Move-
ment of crown and root apex occurs.
• Tooth inclination,
• M/F < 8/1 → controlled tipping occurs causing the tooth
• Morphology and length of the root,
to tip around a circle of greater radius with the centre of
• Level of alveolar bone height, rotation located at the apex of the tooth.
• Direction of the applied force, • M/F = 8/1 to 10/1 → moments neutralize each other
and there is no rotation in the system.
• Direction of the movement as the centre of rotation dif-
fers in mesiodistal movement compared to labiolingual • M/F > 10/1 → centre of rotation moves closer to the in-
movement, cisal edge.
• Point of force application, • M/F = 12/1 or 13/1 → centre of rotation is located at the
incisal edge resulting in mainly root movement.
• Whether the teeth are connected by rigid wire or not as
the centre of rotation move apically when the teeth are M/F ratio in periodontally compromised cases
joined together.
Loss of attachment decreases the area of supported root
• Moment to force ratio. within bone and displaces the centre of rotation apically.
• Variation in the position of the centre of rotation will Effect of loops on M/F ratio (Burstone and Koenig, 1976)
produce different movements.
Increasing the number of loops or adding flexible loops gen-
Moment of force erates low resultant force
The tendency of a force to produce rotation or tipping • Mc/Mf = 0 – Pure tipping/ uncontrolled tipping: Tooth
around the centre of rotation is defined as moment of force. rotates around centre of rotation.
The magnitude of moment is calculated by: • 0 < Mc/Mf < 1 – Controlled tipping: Mainly crown
movement occurs while the apex of the root remains
Magnitude of force x perpendicular distance from point of
relatively stationary with the centre of rotation

48 Biomechanics
 displaced away from centre of rotation. Disadvantages
• Mc/Mf = 1 – Bodily movement/translation: Equal a) Proclinations of anterior teeth
movement of crown and root occurs with the centre of
b) Rolling the molars lingually and tip them
rotation displaced to infinity.
distally.
• Mc/Mf >1 – Root torque: Centre of rotation is at the
2. Torquing arch
crown of the tooth and only root movement occurs.
Third order bend (torque/ couple) on one or more incisors
Types of force system
(treating all of these teeth as one big unit and one bracket).
A statically determinate force system (One couple force
3. Transpalatal arch
system)
0.9 mm diameter, extends from U6 to U6. Follows the con-
Examples include:
tour of the palate but 2-3mm away U-loop in the midline.
1. Extrusion arch It is soldered to the middle or occlusal portion of maxillary
molar bands on palatal aspect.
.Disadvantages:
Uses:
a) May rotate the canine crown palatally.
• Anchorage reinforcement in vertical and transverse
b) Predisposition to rotate the molar crown buc-
plane,
cally
• Space maintenance,
2. Lace back:
• Retention secondary to maxillary arch expansion,
Passive→ During tip expression
• Unilateral distal movement of an upper molar using
Active laceback → during canines retraction.
a unilateral toe-in bend,
3. Burstone intrusion arches:
• Bilateral or unilateral mesiopalatal molar rotation
One couple force system to flare /intrude (theoretically
• Unilateral molar extrusion,
speaking) ULS.
• The transpalatal arch can be used to expand the in-
Disadvantages:
termolar width by activating the midline U-loop.
a) Proclination of anterior teeth
4. 2 x 6 appliance
b) Rolling molars lingually and tipping them
A 2 x 6 appliance is two couple statically indeterminate ap-
distally.
pliance system, consisting of a rectangular arch wire en-
Advantages of a one couple force system gaged into brackets attached to the six anterior teeth (canine
to canine) and both first molars.
• Relatively simple design,
• Bauschinger effect: Elastic property is greatest in
• Predictable tooth movement as it can be designed to
original direction of bending or twisting.
move single or blocks of teeth,
• Wagon-wheel effect: Adding a palatal root torque
• No need of multiple attachments,
to the anterior segment would bring anterior roots
• Large range of activation so less need for appliance re- closer to each other.
activation,
• Roller coaster effect: If anterior teeth are retracted
• Better control of force magnitude, on light wire, then heavy forces could deepen the
• Ability to limit unwanted side effects by additional in- bite, open lateral bite & rotate molars.
tra-arch, interarch or extra-oral mechanics. • Gable bends: Counter-moment to prevent the root
Statically indeterminate systems (Two-couple force sys- apices of the teeth from moving in a direction op-
tem) posing to that of their crowns (uncontrolled tipping)
(Braun and Garcia, 2002).
Difficult to evaluate precisely all the forces and moments e.g:
1. Ricketts Utility Intrusion arch
Two-couple force system. used to level COS by intrusion of
LLS(Engel et al., 1980, Dave and Sinclair, 1989).

Biomechanics 49
Forces required to move teeth REFERENCES

MOVEMENT FORCES (g) ANDREWS, L. F. 1972. The six keys to normal occlusion. Am J
Orthod, 62, 296-309.
• Intrusion 10-20
BISHARA, S. E. & SAUNDERS, W. 2001. Textbook of orthodon-
• Tipping 35-60
tics, Saunders Book Company.
• Extrusion 35-60
BRAUN, S. & GARCIA, J. L. 2002. The gable bend revisited.
• Rotation 35-60 American journal of orthodontics and dentofacial orthopedics,
122, 523-527.
• Root Uprighting 50-100
BURSTONE, C. 1981. Centers of resistance of the human man-
• Bodily 70-120
dibular molar. J Dent Res, 60, 515.
BURSTONE, C. J. 1962. Rationale of the segmented arch. Am J
Orthod, 48, 805-22.
BURSTONE, C. J. 1966. The mechanics of the segmented arch
techniques. Angle Orthod, 36, 99-120.
BURSTONE, C. J. 1982. The segmented arch approach to space
closure. Am J Orthod, 82, 361-78.
BURSTONE, C. J. Biomechanics of deep overbite correction. Sem-
inars in Orthodontics, 2001. Elsevier, 26-33.
BURSTONE, C. J. & KOENIG, H. A. 1976. Optimizing anterior
and canine retraction. Am J Orthod, 70, 1-19.
BURSTONE, C. J. & PRYPUTNIEWICZ, R. J. 1980a. Holograph-
ic determination of centers of rotation produced by orthodontic
forces. Am J Orthod, 77, 396-409.
BURSTONE, C. J. & PRYPUTNIEWICZ, R. J. 1980b. Holograph-
ic determination of centers of rotation produced by orthodontic
forces. American Journal of Orthodontics, 77, 396-409.
DAVE, M. L. & SINCLAIR, P. M. 1989. A comparison of the Rick-
etts and Tweed-type arch leveling techniques. American Journal of
Orthodontics and Dentofacial Orthopedics, 95, 72-78.
DAVIDOVITCH, M. & REBELLATO, J. Two-couple orthodon-
tic appliance systems utility arches: a two-couple intrusion arch.
Seminars in orthodontics, 1995. Elsevier, 25-30.
ENGEL, G., CORNFORTH, G., DAMERELL, J., GORDON, J.,
LEVY, P., MCALPINE, J., OTTO, R., WALTERS, R. & CHACO-
NAS, S. 1980. Treatment of deep-bite cases. American Journal of
Orthodontics and Dentofacial Orthopedics, 77, 1-13.
GRABER, L. W., VANARSDALL, R. L., VIG, K. W. & HUANG, G.
J. 2016. Orthodontics: current principles and techniques, Elsevier
Health Sciences.
HUTCHINSON, I. 2011. Lingual orthodontics: a new approach
using the STb light lingual system and lingual straight wire. Euro-
pean Journal of Orthodontics, 33, 598-598.
ISAACSON, R. J., LINDAUER, S. J. & RUBENSTEIN, L. K. 1993a.
Activating a 2× 4 appliance. The Angle Orthodontist, 63, 17-24.
ISAACSON, R. J., LINDAUER, S. J. & RUBENSTEIN, L. K. 1993b.
Moments with the edgewise appliance: incisor torque control.

50 Biomechanics
American Journal of Orthodontics and Dentofacial Orthopedics,
103, 428-438.
ISAACSON, R. J., LINDAUER, S. J. & RUBENSTEIN, L. K. 1993c.
Moments with the edgewise appliance: incisor torque control. Am
J Orthod Dentofacial Orthop, 103, 428-38.
ISAACSON, R. J. & REBELLATO, J. Two-couple orthodontic ap-
pliance systems: torquing arches. Seminars in orthodontics, 1995.
Elsevier, 31-36.
KATONA, T. R., ISIKBAY, S. C. & CHEN, J. 2013. Effects of first-
and second-order gable bends on the orthodontic load systems
produced by T-loop archwires. The Angle orthodontist, 84, 350-
357.
LINDAUER, S. J. The basics of orthodontic mechanics. Seminars
in Orthodontics, 2001. Elsevier, 2-15.
LINDAUER, S. J. & ISAACSON, R. J. One-couple orthodontic ap-
pliance systems. Seminars in orthodontics, 1995. Elsevier, 12-24.
MCLAUGHLIN, R. P. & BENNETT, J. C. 2015. Evolution of treat-
ment mechanics and contemporary appliance design in orthodon-
tics: A 40-year perspective. American Journal of Orthodontics and
Dentofacial Orthopedics, 147, 654-662.
MELSEN, B., AGERBAEK, N., ERIKSON, J. & TERP, S. 1988. New
attachment through periodontal treatment and orthodontic intru-
sion. American Journal of Orthodontics and Dentofacial Ortho-
pedics, 94, 104-116.
PROFFIT, W. R., FIELDS JR, H. W. & SARVER, D. M. 2006. Con-
temporary orthodontics, Elsevier Health Sciences.
PRYPUTNIEWICZ, R. J. & BURSTONE, C. J. 1979. The effect of
time and force magnitude on orthodontic tooth movement. Jour-
nal of dental research, 58, 1754-1764.
REBELLATO, J. Two-couple orthodontic appliance systems: acti-
vations in the transverse dimension. Seminars in orthodontics,
1995. Elsevier, 37-43.
SMITH, R. J. & BURSTONE, C. J. 1984a. Mechanics of tooth
movement. American Journal of Orthodontics, 85, 294-307.
SMITH, R. J. & BURSTONE, C. J. 1984b. Mechanics of tooth
movement. Am J Orthod, 85, 294-307.
WHITEHEAD, A. N. & RUSSELL, B. 1997. Principia mathematica
to* 56, Cambridge University Press.
YOSHIKAWA, D. 1981. Biomechanical principles of tooth move-
ment. Dental Clinics of North America, 25, 19-26.

Biomechanics 51
 6
FORCE DELIVERY SYSTEM
Written by: Mohammed Almuzian, Haris Khan, Hassan Saeed

In this Chapter
1. Coil springs
2. Elastic power chain (EPC)
3. Elastomeric rubber bands (ERB)
4. Laceback ligatures
5. Magnets
6. Recommended force system for space closure
7. Sliding mechanism to close space
8. Mechanics of sliding technique
9. Closing loop mechanism
10. Specific recommendations for closing loop arch-
wires
11. EXAM NIGHT REVIEW
Coil springs This force degradation is in the range of 8 to 17% (An-
golkar et al., 1992).
They are supplied as open (to open spaces) or closed (to
close space) coil spring, made of stainless steel (SS) or nickel • NiTi springs can accumulate food particles.
titanium (NiTi) springs.
• NiTi springs cannot be used in patient with nickel
Factors affecting force levels of coil springs (Miura et al., allergy.
1988)
• NiTi springs are relatively expansive.
These include:
• Relatively more irritable to the soft tissue especially
• Degree of stretch and material of the alloy. the cheek when compared to EPC.
• Diameter of the wire: Force delivered by the spring Elastic power chain (EPC)
is directly proportional to an increase in diameter.
There are four types depending on the distance between the
• Lumen size of the spring: Force delivered by the elastic rings.
spring is inversely proportional to changes in lumen size
• Closed/continuous.
in both open and closed springs. When activating an
open coil spring, the lumen becomes larger. For closed • Short.
coil springs the lumen becomes smaller as a result of
• Long.
spring stretching.
• Extra-long.
• Pitch of the spring coil: Fine pitch has lower super
elasticity than coarse pitch. Long and extra-long EPC are used in the upper arch while
closed and continuous EPC are mainly used in lower arch,
• Length of the spring: long spring has high super-
due to interbracket distance.
elasticity.
Advantages of EPC
Advantages of coil springs
These include:
These include:
• PCE engages easily on the bracket tie wings.
• Low and continuous force level, due to NiTi super-
elastic properties. • PCE is cost-effective and efficient in space closure.
• Effective space closure: A systematic review and • PCE has a wide range of force application (Chung
meta-analysis found moderate quality of evidence that et al., 1989),
NiTi coil spring closes space faster by 0.2mm /month in • PCE is more effective in closing anterior spaces and
comparison to elastometic power chain (EPC) (Mo- minor spaces.
hammed et al., 2018).
• PCE produces equal force in all directions.
• Patient compliance is not required when compared
to intermaxillary elastics. • PCE can be used in patients with nickel allergy.
• NiTi springs are biocompatible in the oral environ- Disadvantages of EPC
ment with minimal change of their mechanical proper- These include:
ties.
• Permanent staining and food accumulation,
• Force level can be controlled by changing the
length / activation of the spring. • Irritation to the soft tissues.

Disadvantages of coil springs • Rapid stress relaxation, resulting in loss of force.

These include: • EPC needs to be changed every 4 weeks due to fast

force degradation (Dixon et al., 2002).
• NiTi springs continue to be active until removed.
If the patient misses an appointment, springs will keep • Force levels vary significantly between different
opening or closing space without supervision. manufacturers of EPC (Lu et al., 1993).

• Prone to fracture, most commonly between eyelet • 50-70% force decay occurs in the first 21st days.
and coil. Elastomeric Rubber Bands (ERB)
• Force loss (degradation) occurs over a period of Different types of ERB are used in orthodontics (Figure 1).
time mainly during the first 24 hours for most springs. Apart from space closure, ERB can be used in the correction

54 Force Delivery Systems

of crossbite, midlines, extrusion and settling of teeth during 2. In extraction Class 2 or 3 cases, a force level
finishing. Some manufacturers claim that in order to apply of 4-5 ounces per side is required, the distance
the amount of force mentioned on the elastics packet, ERB between the two points of ERB’s attachment is
should be stretched 2-3 times of their initial diameter or even 18-22 mm, therefore, 1/4” or 5/16” ERBs with
4-5 times if ERBs are made from non-latex materials. 4-5 ounce are used.
3. For settling purpose, a force level of 2
ounce per two teeth is required, therefore, 3/8”
ERBs with 1.5-2 ounce are used.
A study found that 1/4” elastics covered a wider range of force
levels compared to 3/16” elastics. 1/4” elastics is adequate
to cover almost all needs except for box elastics (Mansour,
2017).
Physical properties of ERB
ERB show following physical properties (Baty et al., 1994):
• Stress relaxation.
• Pre-stretching effects.
• Hysteresis and hysteresis loss.
Figure 1: Different size and force generated by ERBs.
Advantage of ERB
These include:
How to select the right ERB?
• Low cost.
To properly choose the ERBs, the following need to be consid-
• Different range of forces can be applied by varying
ered:
the diameter of the elastics.
• How to select the right ERB?
• Different types of tooth movements can be
• To properly choose the ERBs, the following need to achieved by use of elastics.
be considered:
Disadvantages of ERB
A. Size and force: To select the ideal size and force of
These include:
ERB, the following principles need to be considered:
• ERB apply a very heavy initial force, which can
• 1 ounce is equal to 28.3gm.
reduce by up to 50-75% within in first 24 hours (Brant-
• 1 inch is equal to 25.4mm. ley et al., 1979).
• ERB used for sagittal correction have a high force • Force loss varies among different manufacturers
level requirement (bodily movement) while those (Baty et al., 1994).
used for vertical correction have a low force level
• Elastic properties can be affected by the oral envi-
(extrusion).
ronment (Ash and Nikolai, 1978).
B. Force measurement: There are three main approaches
• Dependent on patient compliance.
to select the right ERB including:
• ERB can cause a latex allergy, in such susceptible
• Eye balling, (subjective method).
patient’s non-latex elastics should be used.
• Using force gauge (objective method).
Other uses of elastomeric in orthodontics
• Occlusal analysis which is another objective meth-
Elastomerics are used for ligatures modules or separators,
od. The principles of occlusal analysis are:
and in space closing mechanics in combination with a lace-
1. In non-extraction Class 2 or 3 cases, a back wire (Active tie or Berman ties).
force level of 5-6 ounces per side is required.
Laceback ligatures
The distance between the two points of ERB’s
attachment usually 25- 30 mm, therefore, 3/8” Laceback wires have been used in orthodontics as a force
or 5/16” ERBs with 5-6 ounces are used. delivery system for canine retraction, as well as control of

Force Delivery Systems 55

canine tip during levelling and alignment. An RCT (Sueri • Costly.
and Turk, 2006) found that laceback ligature are effective for
Advantages of magnets in orthodontics
canine retraction but less canine movement is observed in
comparison to NiTi springs. These include:
Magnets • Minimal patient cooperation.
The use of magnets for orthodontic tooth movement was • Frictionless mechanics.
first reported by Blechman and Smiley (Cerny, 1979).
• Force decays with distance and not with increase in
Magnets in orthodontics work on the principle that same time.
poles repel each other while opposite poles attract. Magnets
• Good directional force control.
follow Coulomb’s Law, which states that force between two
magnetic poles is proportional to their magnitudes and • Reduced chair side time.
inversely proportional to the square of the distance between • Magnets can be recycled and reused.
them. The usage of magnets are almost obsolete now in
contemporary practice of orthodontics. Recommended force system for space closure (Quinn and
Yoshikawa, 1985)
Types of orthodontic magnets (Shastri et al., 2014)
Sliding mechanism to close space
These include:
It is recommended to use 100-200g during sliding mechan-
• Aluminium-nickel-cobalt. ics (friction mechanics) (Samuels et al., 1998).
• Samarium-cobalt. Advantages of friction mechanics
• Neodynium-iron-boron. These include:
Uses of magnets in orthodontics • Simple as minimal wire bending is required.
These include: • Less time consuming.
• Space opening (repelling). • Enhances patient comfort.
• Space closure (attraction). • Measurable force.
• Distal movement (repelling). • Greater potential range of activation when com-
• Movement of impacted teeth (Vardimon et al., pared to loop mechanics.
1991). • Maintain arch form with good vertical control and
• Correction of cross bite. root parallelism.
• Functional Orthopedic Magnetic Appliances Disadvantage of friction mechanics
(FOMA) for both Class II and III correction (Vardimon These include:
et al., 1989).
• Lack of efficiency compared to frictionless mechan-
• Intrusion in anterior open bite cases (repelling). ics.
• Retention for median diastema (attraction). • Uncontrolled tipping.
• Propellant Unilateral Magnetic Appliance (PUMA) • Deepening of overbite.
for stimulation of autogenous costochondral graft in
hemifacial microsomia (Chate, 1995). • High friction and binding.
• Magnetic appliance for OSA. • Loss of anchorage.
• Magnetic brackets (Kawata et al., 1987). • Increased risk of orthodontically induced inflam-
matory root resorption (OIIRR).
Disadvantages of magnets in orthodontics
Mechanics of friction mechanics
These include:
The main features are:
• Force allows inverse square law .
• A full sized conventional archwire, for example in a
• Bulky and brittle (Darendeliler et al., 1997), .022 slot. a 019 x .025 SS archwire should be utilised for
• Corrosion in mouth; questionable toxicity. space closure.

56 Force Delivery Systems

 • Intermediary archwires are required following These include:
alignment for levelling (phase 2), and prior to inser-
• Continuous arch with loop.
tion of the full size SS rectangular archwires. 3 different
intermediary archwires have been proposed: • Segmented loop with sectional archwire.
• 020 round SS: This is preferred when torque align- Design of closing loop mechanism
ment is good, and vertical control is required (deep
These include:
overbite case).
• Vertical loop.
• 0.018 x 0.025 rectangular or 0.020 x 0.020 square
Niti: This is preferable to reduce significant torque dif- • T-loop.
ferences. • Mushroom loop.
• 0.017 x 0.025 SS is a third alternative to address • PG Retraction Spring.
both requirements of vertical control and torque initia-
tion. Specific recommendations for closing loop archwires
Closing loop mechanism These include:
Wire loops are mostly made from TMA or stainless-steel • 16× 22 wire (on 0.018 slot), delta or T-shaped loops,
wire, NiTi loops are also commercially available. Closing 7 mm vertical height, the horizontal part of the loop
loop archwires should be fabricated from rectangular wire increasing the total length to 10 mm.
to prevent the wire from rolling in the bracket slot. There are • Gable bend of 40 to 45 degrees total (half on each side
three methods to maintain the loop archwire in the active of the loop). The gable bend should be reactivated after
position: 4mm of retraction.
• By cinching the end of the archwire gingivally behind • Loop placement 4 to 5 mm distal to the center of the ca-
the last molar tube. nine tooth, at the center of the space between the canine
• To place an attachment—usually a soldered tieback over and second premolar with the extraction site closed.
the archwire.
• Placing a crimpable hook over the archwire/loop close Exam Night Review
to the terminal molar and using an active laceback/tie Coil springs
back from the hook/loop to the molar hook.
• Open (to open spaces) or closed (to close space).
Advantages of closing loop mechanism
• SS/NiTi springs.
These include:
• NiTi coil springs →expensive & irritant to oral
• Precise control of space closure. mucosa.
• Adequate ‘rebound time’ for uprighting and arch Factors affecting force levels of coil spring
levelling.
• Degree of activation.
• Some immediate improvement.
• Material of alloy.
Disadvantages of closing loop mechanism
• Size of the wire.
These include:
• Lumen size of the spring.
• Requires wire bending.
• Pitch of the spring coil.
• Soft tissue irritation.
• Length of the spring.
• Plaque accumulation.
Advantages of coil spring
• Tipping of teeth.
• Low and continuous force level.
• Distortion of the wire with difficulties to control
the movement in three planes of space. • Effective space closure.

• No fail safe mechanics in most of the designs. • Patient compliance not required.

Types of closing loop mechanism • Biocompatible.

Force Delivery Systems 57

 • Force level can be controlled. (Baty et al., 1994).
Disadvantages of coil spring • Elastic properties can be affected by oral environ-
ment (Ash and Nikolai, 1978).
• No fail safe.
• Heavily dependent on patient compliance.
• Prone to fracture.
• Elastomeric can cause latex allergy, in such suscep-
• Force loss (degradation) occur over the period of
tible patients’ non-latex elastics should be used.
time.
Sliding mechanism
• Can accumulate food.
Advantages
• Cannot be used in nickel allergic patients.
• Simple as minimal wire bending is required.
• Expensive.
• Less time consuming.
• Irritable.
• Enhances patient comfort.
Elastomeric Power Chain (EPC)
• Measurable force.
Advantages of EPC
• Greater potential range of activation when com-
• Secured easily.
pared to loop mechanics.
• Cost effective & efficient.
• Maintains arch form with good vertical control and
• Wide range of force application. root parallelism.
• Effective closing anterior spaces. Disadvantage
• Effective closing minor spaces. • Lack of efficiency compared to frictionless mechan-
ics.
• Same force in all direction.
• Uncontrolled tipping.
• Used in nickel allergic patients.
• Deepening of overbite.
• Patient compliance not required.
• High friction and binding.
Disadvantages of EPC
• Loss of anchorage.
• Permanent staining and food accumulation.
• Another concern with space closure is the risk of
• Irritate.
orthodontically induced inflammatory root resorption
• Gradual loss of effectiveness. (OIIRR).
• Changed every 4 weeks (Dixon et al., 2002). Closing loop mechanism
• Force levels varies significantly between different Advantages
manufacturers of EPC (Lu et al., 1993).
• Precise control of space closure.
• 50-70% force decay of the EPC occurs by 21st days.
Advantage of OE
• Low cost.
• Different range of forces can be applied by varying
the diameter of the elastics.
• Different types of tooth movements can be
achieved by use of elastics.
Disadvantages of OE
• Elastic modules apply very heavy initial forces with
50-75% reduction of initial force occur in first 24 hours
(Brantley et al., 1979).
• Force loss varies among different manufacturers

58 Force Delivery Systems

 • Adequate ‘rebound time’ for uprighting and arch MIURA, F., MOGI, M., OHURA, Y. & KARIBE, M. 1988. The
levelling. super-elastic Japanese NiTi alloy wire for use in orthodontics. Part
III. Studies on the Japanese NiTi alloy coil springs. Am J Orthod
• Some immediate improvement. Dentofacial Orthop, 94, 89-96.
Disadvantages MOHAMMED, H., RIZK, M. Z., WAFAIE, K. & ALMUZIAN, M.
2018. Effectiveness of nickel-titanium springs vs elastomeric chains
• Requires wire bending. in orthodontic space closure: A systematic review and meta-analy-
• Soft tissue irritation. sis. Orthod Craniofac Res, 21, 12-19.

• Plaque accumulation. NORMAN, N. H., WORTHINGTON, H. & CHADWICK, S. M.

2016. Nickel titanium springs versus stainless steel springs: A ran-
• Tipping of the teeth. domized clinical trial of two methods of space closure. J Orthod,
43, 176-85.
• Distortion of the wire with difficulties to control the
movement in three planes of space. QUINN, R. S. & YOSHIKAWA, D. K. 1985. A reassessment of force
magnitude in orthodontics. Am J Orthod, 88, 252-60.
• No fail safe mechanics in most of the designs.
SAMUELS, R. H., RUDGE, S. J. & MAIR, L. H. 1998. A clinical
References study of space closure with nickel-titanium closed coil springs and
ANGOLKAR, P. V., ARNOLD, J. V., NANDA, R. S. & DUNCAN- an elastic module. Am J Orthod Dentofacial Orthop, 114, 73-9.
SON, M. G., JR. 1992. Force degradation of closed coil springs: an in SHASTRI, D., TANDON, P., SHARMA, S. & SINGH, G. K. J. O. U.
vitro evaluation. Am J Orthod Dentofacial Orthop, 102, 127-33. 2014. The role of magnets in orthodontics and dentofacial ortho-
ASH, J. L. & NIKOLAI, R. J. 1978. Relaxation of orthodontic paedics. 7, 122-128.
elastomeric chains and modules in vitro and in vivo. J Dent Res, 57, SUERI, M. Y. & TURK, T. 2006. Effectiveness of laceback ligatures
685-90. on maxillary canine retraction. Angle Orthod, 76, 1010-4.
BATY, D. L., VOLZ, J. E. & VON FRAUNHOFER, J. A. 1994. Force VARDIMON, A. D., GRABER, T. M., DRESCHER, D. &
delivery properties of colored elastomeric modules. Am J Orthod BOURAUEL, C. 1991. Rare earth magnets and impaction. Am J
Dentofacial Orthop, 106, 40-6. Orthod Dentofacial Orthop, 100, 494-512.
BRANTLEY, W. A., SALANDER, S., MYERS, C. L. & WINDERS, R. VARDIMON, A. D., STUTZMANN, J. J., GRABER, T. M., VOSS,
V. 1979. Effects of prestretching on force degradation characteristics of L. R. & PETROVIC, A. G. 1989. Functional orthopedic magnetic
plastic modules. Angle Orthod, 49, 37-43. appliance (FOMA) II--modus operandi. Am J Orthod Dentofacial
CERNY, R. 1979. The biological effects of implanted magnetic fields. Orthop, 95, 371-87.
Part 1. Mammalian blood cells. Aust Orthod J, 6, 64-70.
CHATE, R. A. 1995. The propellant unilateral magnetic appliance
(PUMA): a new technique for hemifacial microsomia. Eur J Orthod,
17, 263-71.
CHUNG, P. C., WEI, S. H. & REYNOLDS, I. R. 1989. In vitro testing
of elastomeric modules. Br J Orthod, 16, 265-9.
DARENDELILER, M. A., DARENDELILER, A. & MANDURINO,
M. 1997. Clinical application of magnets in orthodontics and biologi-
cal implications: a review. Eur J Orthod, 19, 431-42.
DIXON, V., READ, M. J., O’BRIEN, K. D., WORTHINGTON, H. V.
& MANDALL, N. A. 2002. A randomized clinical trial to compare
three methods of orthodontic space closure. J Orthod, 29, 31-6.
KAWATA, T., HIROTA, K., SUMITANI, K., UMEHARA, K.,
YANO, K., TZENG, H. J. & TABUCHI, T. 1987. A new orthodon-
tic force system of magnetic brackets. Am J Orthod Dentofacial
Orthop, 92, 241-8.
LU, T. C., WANG, W. N., TARNG, T. H. & CHEN, J. W. 1993. Force
decay of elastomeric chain--a serial study. Part II. Am J Orthod
Dentofacial Orthop, 104, 373-7.
MASOUD, A. I., TSAY, T. P., BEGOLE, E. & BEDRAN-RUSSO,
A. K. 2014. Force decay evaluation of thermoplastic and thermo-
set elastomeric chains: A mechanical design comparison. Angle
Orthod, 84, 1026-33.

Force Delivery Systems 59

 7
FRICTION IN ORTHODONTICS

Written by: Mohammed Almuzian, Haris Khan, Maham Munir

In this Chapter
1. Definition
2. The laws of friction
3. Types of friction
4. Friction in orthodontics
5. Factors effecting friction in orthodontics
6. Clinical implications
7. EXAM NIGHT REVIEW
Definition The force of binding represents materials catching each other
(BI) while notching is the deforming of the material (NO).
Friction is defined as a phenomena that opposes the tendency
of movement of one object relative to another, as it retards The components of ploughing, inter-locking and shearing are
motion. Or it can be defined as tangential to the mutual experienced in passive configuration and effect static friction
boundary of the bodies in contact. In orthodontics, friction (Prashant et al., 2015). Binding and notching are greater in
occurs at various contact points along the archwire (Drescher effect with a high angle and torque arrangements. Therefore,
et al., 1989, Graber et al., 2016) on the sliding velocity (Kusy the static component of CoF is larger than the kinetic coun-
and Whitley, 1997). terpart (Frank and Nikolai, 1980).
Types of Friction RS = (FR) + BI + NO
Static friction represents the smallest amount of force RS = (PL + IN + SH) + BI + NO
needed to commence the process of sliding of an objects. BI: Binding
Static friction is dependent upon:
FR: Static and kinetic friction
a) Coefficient of Friction (µ ∝ shear strengths of
the junction/yield strength of the material). IN: Roughness inter-locking
• Nature of the contacting surface, which is not NO: Notching
affected by the area of contact. PL: Ploughing
• The ploughing component relates to the asperi- RS: Resistance to sliding
ties (true areas of surface contact), and the extent of
the harder surface ploughing into the softer surface SH: Shearing
(Omana, 1992). Factors effecting friction in orthodontics
Friction formulas 1. Bracket dimension
FF=µ X FN The main features are:
FF: Frictional force • A narrow bracket produces less friction in under-
µ: Coefficient of Friction sized archwires than wider brackets (Graber et al.,
FN: Normal force directed at 90° to the archwire 2016).
FF: 2µ X M/W • Bracket width does not affect friction when a single
FF: Frictional force force is employed, and when the magnitude of force
is the same.
µ: Coefficient of Friction
M: Moment produced in a couple • With tip and torque forces, if there are is identical
magnitude of the moment, a wider bracket will have
W: Mesio-distal
less resistance.
Kinetic friction represents the amount of force resisting the • Narrow brackets have an increased critical angle,
motion during motion. It is the product of normal force and binding and friction for conventional ‘full size’ arch-
the coefficient of kinetic friction (Frank and Nikolai, 1980). wires (Tidy and Orth, 1989).
Friction in orthodontics • The friction is inversely proportional to the bracket
Teeth move along the archwire by a successive processes of width.
tipping and uprighting. Therefore, static friction is more im- 2. Bracket material
portant in orthodontics than kinetic friction. The total fric-
tional resistance (FR) or resistance to sliding of orthodontic The main features are:
brackets has three sub-components (Kusy and Whitley, 1997): • Ceramic brackets produce greater friction than
• The component of force employed in, plough- stainless steel brackets due to the rough surface tex-
ing (PL) ture of the ceramic brackets (Bednar et al., 1991).
• The resistance experienced in the inter-locking • Friction is the same for ceramic brackets with metal
of surface roughness (IN) slots and conventional metal brackets, as the same
material is in contact with the bracket (Thorstenson
• Force required in shearing all of the junctions and Kusy, 2003).
(SH)

62 Friction
3. Ligation and Nikolai, 1980).
The main features are: • Slop and archwire-bracket angle (slop angle): The
free space between the wire and the bracket slot
• The ligation force adds to the friction force, a phe-
(slop or play) decreases with an increase in the di-
nomena that is undesirable (Graber et al., 2016).
ameter of the wire and the amount of tip required
• Tight ligation increase the friction force, therefore, to achieve critical contact angle decreases (Prashant
pre-stretched ligatures decreases friction force and et al., 2015).
facilitate sliding on the archwire (Hain et al., 2003).
• Bends in the wire: Kinks in the archwire produce
• Elastomeric ligatures have 60-70% more frictional more binding.
force than stainless steel ligatures (Edwards et al.,
5. Type of tooth movement
1995).
The main features are:
• Teflon-coated ligatures aid in reducing the friction,
however, the coating has a tendency to come off. • Different stages of tooth movement are seen during
sliding mechanisms i.e. tipping, bodily and root up
• Super-slick modules offer no benefit over conven-
righting (Graber et al., 2016).
tional round cross-section modules, however super-
slick modules are better than rectangular cross sec- • Larger moments produce larger frictional force. For
tional modules (Griffiths et al., 2005). translational and bodily movements, large moments
are necessary. Hence, large friction is produced.
• Stress-relaxing composite ligature wires may help in
reducing friction (McKamey and Kusy, 1999). 6. Biological factors
• The number of attachments (brackets,tubes etc) The main features are:
through which the wire engages, increases the fric-
• Human saliva reduces friction by 15-19%. Saliva can
tion of the system (Taylor and Ison, 1996).
also act as a lubricant or an adhesive depending on
• Self-ligating brackets have the least resistance to the bracket-archwire combination (Prashant et al.,
sliding, when compared to elastomeric and steel 2015).
ligatures (Sims et al., 1993).
• Occlusion: Teeth contact numerous times during
4. Archwires chewing, swallowing and speaking (Braun et al.,
1999). This produces motion in the appliance, par-
The main features are:
ticularly at the bracket-archwire contact interface,
• Materials: The archwire with greatest friction is which reduces friction.
beta-titanium or titanium molybodium wires (BTA
• Jiggling effect overcomes the friction force (Proffit
or TMA), followed by Nickle titanium (NiTi) wires,
et al., 2006).
Elgiloy wires (chromium nickle) and finally stainless
steel wires (SS) (Angolkar et al., 1990). Clinical implications
• Surface texture: The difference in the surface texture A practitioner must apply greater mechanical force to over-
of the archwire produces different frictional values come the frictional force progressively throughout treatment,
(Downing et al., 1994). The surface topography of which can also lead to detrimental effects on anchorage. Fric-
the archwires affects friction. Ion-implantation of tion should be controlled during space closure. If the overall
the archwire reduces friction in vitro. (Ryan et al., resistance is high, slow progress and unnecessary elongation
1997) of the treatment time may result (AlSubaie et al., 2016).
• Diameter: An archwire of larger diameter has in- The loss of applied force due to friction is reported in 12%
creased resistance to sliding compared to the smaller to 70% of cases (Montasser et al., 2014) (Kusy and Whitley,
diameter archwire. The archwires with greater diam- 1997).
eter has increased stiffness, hence, the corner of the
brackets slot produces more notching in the wire.
• Cross section: Rectangular archwires produce more
friction compared to round archwires in specific cir-
cumstances. The occluso-gingival dimension of the
archwire is a most critical factor for determining the
friction than other dimensions of the wire (Frank

Friction 63
Exam Night Review References

Friction Alsubie, M., and Talic, N.2016 Variables affecting the frictional re-
sistance to sliding in orthodontic brackets .Dental, Oral and Cranio-
Definition facial Research. 2(Ericson S & Kurol J 1987), 271-275
• Friction is defined as a phenomenon that opposes the ALSUBAIE, M., TALIC, N., KHAWATMI, S., ALOBEID, A.,
tendency of movement of one object relative to another, BOURAUEL, C. & EL-BIALY, T. 2016. Study of force loss due to
it retards motion. friction comparing two ceramic brackets during sliding tooth
movement. J Orofac Orthop, 77, 334-40.
• In orthodontics, friction occurs at various contact points
along the archwire (Drescher et al., 1989, Graber et al., ANGOLKAR, P. V., KAPILA, S., DUNCANSON JR, M. G. & NAN-
DA, R. S. 1990. Evaluation of friction between ceramic brackets and
2016).
orthodontic wires of four alloys. American Journal of Orthodontics
• Static friction is thus more important in orthodontics and Dentofacial Orthopedics, 98, 499-506.
than kinetic friction BEDNAR, J. R., GRUENDEMAN, G. W. & SANDRIK, J. L. 1991. A
• Resistance to sliding is the sum of: comparative study of frictional forces between orthodontic brackets
and arch wires. American Journal of Orthodontics and Dentofacial
a. The component of force employed in. Orthopedics, 100, 513-522.
b. The resistance experienced in the inter-locking of sur- BRAUN, S., BLUESTEIN, M., MOORE, B. K. & BENSON, G. 1999.
face roughness. Friction in perspective. American Journal of Orthodontics and
Dentofacial Orthopedics, 115, 619-627.
c. Force required in shearing of all junctions.
DOWNING, A., MCCABE, J. & GORDON, P. 1994. A study of fric-
d. The force of binding; materials catching each other. tional forces between orthodontic brackets and archwires. British
Journal of Orthodontics, 21, 349-357.
e. Notching is the deforming of the material.
DRESCHER, D., BOURAUEL, C. & SCHUMACHER, H.-A. 1989.
Factors influencing orthodontic friction: Frictional forces between bracket and arch wire. American Journal
• Bracket material. of Orthodontics and Dentofacial Orthopedics, 96, 397-404.
EDWARDS, G., DAVIES, E. & JONES, S. 1995. The ex vivo effect of
• Bracket width.
ligation technique on the static frictional resistance of stainless steel
• Bracket surface features. brackets and archwires. British journal of orthodontics, 22, 145-153.

• Archwire-bracket angle (see the formula below). ERICSON S & KUROL J 1987, R. A. O. E. M. C., AJODO, 91 ;483-
492.
• Archwire material.
FRANK, C. A. & NIKOLAI, R. J. 1980. A comparative study of
• Archwire cross-section. frictional resistances between orthodontic bracket and arch wire.
American Journal of Orthodontics, 78, 593-609.
• Archwire surface features.
GRABER, L. W., VANARSDALL, R. L., VIG, K. W. & HUANG, G.
• The ligation mechanism. J. 2016. Orthodontics-e-book: current principles and techniques,
• Saliva. Elsevier Health Sciences.
GRIFFITHS, H. S., SHERRIFF, M. & IRELAND, A. J. 2005. Re-
• Occlusal locking.
sistance to sliding with 3 types of elastomeric modules. American
• Various biological factors (Prashant et al., 2015, Proffit Journal of Orthodontics and Dentofacial Orthopedics, 127, 670-
et al., 2006). 675.
HAIN, M., DHOPATKAR, A. & ROCK, P. 2003. The effect of liga-
tion method on friction in sliding mechanics. American journal of
orthodontics and dentofacial orthopedics, 123, 416-422.
KUSY, R. P. & WHITLEY, J. Q. Friction between different wire-
bracketconfigurations and materials. Seminars in Orthodontics,
1997. Elsevier, 166-177.
MCKAMEY, R. P. & KUSY, R. P. 1999. Stress-relaxing composite
ligature wires: formulations and characteristics. The Angle Ortho-
dontist, 69, 441-449.
MONTASSER, M. A., EL-BIALY, T., KEILIG, L., REIMANN, S.,
JÄGER, A. & BOURAUEL, C. 2014. Force loss in archwire-guided
tooth movement of conventional and self-ligating brackets. Eur J

64 Friction
Orthod, 36, 31-8.
OMANA, H. M. 1992. Frictional properties of metal and ceramic
brackets. J. Clin. Orthod., 26, 425-432.
PRASHANT, P., NANDAN, H. & GOPALAKRISHNAN, M. 2015.
Friction in orthodontics. Journal of Pharmacy And Bioallied Sci-
ences, 7, 334-338.
PROFFIT, W. R., FIELDS JR, H. W. & SARVER, D. M. 2006. Con-
temporary orthodontics, Elsevier Health Sciences.
RYAN, R., WALKER, G., FREEMAN, K. & CISNEROS, G. J. 1997.
The effects of ion implantation on rate of tooth movement: An in
vitro model. American journal of orthodontics and dentofacial or-
thopedics, 112, 64-68.
SIMS, A., WATERS, N., BIRNIE, D. & PETHYBRIDGE, R. 1993.
A comparison of the forces required to produce tooth movement
in vitro using two self-ligating brackets and a pre-adjusted bracket
employing two types of ligation. The European Journal of Ortho-
dontics, 15, 377-385.
TAYLOR, N. G. & ISON, K. 1996. Frictional resistance between
orthodontic brackets and archwires in the buccal segments. The
Angle Orthodontist, 66, 215-222.
THORSTENSON, G. & KUSY, R. 2003. Influence of stainless steel
inserts on the resistance to sliding of esthetic brackets with second-
order angulation in the dry and wet states. The Angle Orthodontist,
73, 167-175.
TIDY, D. & ORTH, D. 1989. Frictional forces in fixed appliances.
American Journal of Orthodontics and Dentofacial Orthopedics,
96, 249-254.

Friction 65
 8
ARCH FORM AND WIDTH
Written by: Mohammed Almuzian, Haris Khan, Eesha Najam

In this Chapter
1. Archform in orthodontics
2. Factors effecting archforms
3. Implications of the archform in orthodontics
4. Types of the archform
5. Individual patient form (IAF) technique
6. Effect of extraction on archform
7. EXAM NIGHT REVIEW
Archform in orthodontics • MBT archform: Three archforms are available in the
MBT system (tapered, square, ovoid).
Archform can be described as the imaginary arch shape
formed by the buccal and facial surfaces of the teeth when • Computer prediction: Various other archforms have been
viewed from the occlusal surfaces. Orthodontic treatment constructed using algebraic equations (Begole, 1979).
should aim to minimally change the archform.
• Individualized archform.
Factors effecting archforms
• Lee archform: It was suggested that a range of archforms
These include: are used, identical in shape but varying in size. A clear Per-
spex sheet with varying archform sizes (90%, 95%, 100%
• Ethnicity: In the Caucasian population, 45% have ovoid
and 105%) should be placed over a model of the patient’s
archforms, 45% have tapered archforms and 10% have
lower arch before the start of treatment to determine the
square archforms (Burke et al., 1998).
most appropriate size of archform to be used throughout
• Genetic factors which affect the basal bone formation treatment (Lee, 1999). It was frequently found that the
which in turn affect the archform. 100% archform is suitable for non-extraction cases with
intercanine widths of 24mm, while extraction cases have
• Musculature as it represents the force that affects the
intercanine widths of 26mm. The 95% or 90% archforms
dentition to establish the zone of equilibrium.
should be used where the inter-canine width is smaller,
• Environmental factors such as habits. particularly in crowded extraction cases.
Implications of the archform in orthodontics Research into archforms concluded the following (Felton et
These include: al., 1987):

• Space requirements. • There is no generalisable archform.

• Treatment mechanics consideration. • Archforms should be tailored to the original arch shape
of dentition otherwise, it will relapse.
• Bracket prescription.
• No particular archform was the closest match for more
• Wire selection. than 20% of the cases, individual adjustment is necessary.
• Stability and prognosis. • 65% of cases had changes in their archform, and 65% re-
Types of the archform turned to their pre-treatment shape (total relapse).

These include: • Tapered archform

• Bonwill-Hawley archform: The ideal arch is based on an Common applications are:

equilateral triangle with a base representing the inter- • Patients’ with narrow tapered archforms.
condylar width (Germane et al., 1992).
• Gingival recession at the canine and premolar region,
• Catenary curve: It is a shape formed by a length of chain this situation occurs most frequently in adult cases.
held at each end and allowed to drop. The catenary arch-
form’s weakness is the shape distal to the 1st molars, • Cases with tapered archforms undergoing partial treat-
which is not ideal (Mac and Scher, 1949). ment in one arch only could benefit from this archform,
so that no expansion occurs in the treated arch.
• Brader/Trifocal Ellipse: It is similar to the anterior seg-
ment of the catenary curve but the posterior segments Square archform
taper inwards providing a narrower arch posteriorly Common applications are:
(Brader, 1972).
• Cases with broad archforms.
• Conical section: It represents plane curves, provided
• Cases that require buccal uprighting and expansion of
the second and third molars are not included (Currier,
the arch.
1969).
• If over expansion has been achieved.
• Andrews archform: It was developed based on a com-
puter analysis of 120 non-orthodontic norms. Ovoid archform
• Roth archform: It is broader labially than Andrews’ arch- Common applications are:
form.
• This archform is used in the majority of cases.
• Bennet archform: It is smaller than Andrews’ archform.
• Used during initial archwire stages.

68 Arch Form and Width

When using round and rectangular stainless steel wires (wires Exam Night Review
that significantly influence archform), one of the above three
Archform in orthodontics
archforms should be selected based on the pre-treatment
archform and maintained. • Archforms can be described as the imaginary arch shape
formed by buccal and facial surfaces of the teeth when
Systematic method to individualise the archform
viewed from the occlusal surfaces
These include:
Implications of the archform and width in orthodontics
• Initial light archwire: Commonly, this can be of any arch-
• Smile aesthetics.
form as it has little influence because of their low force,
flexibility and short period of usage in the initial phase of • Space requirements.
levelling and alignment.
• Treatment mechanics.
• Intermediate archwire: When it is required and if it is
• Bracket prescription.
made from stainless steel, it might need to be customized
by using a clear template to select the archform from the • Archwire selection.
original study model or Individual Patient Form (IAF) • Stability and prognosis.
technique.
Types of the archform
• Rigid working archwire: Should be customized using a
clear template to select the archform from pretreatment • Bonwill-Hawley Archform:.
study models or IAF technique (see below). • Catenary curve
Individual patient form (IAF) technique • Brader/Trifocal Ellipse
After alignment stage, a wax template is moulded over the • Conical section
lower arch to record the indentations of the brackets. The
working stainless steel archwire is bent to the indentations • Andrews archform
in the wax bite. The wire is then compared with the starting • Roth archform.
lower model, or a Xerox copy of the model of 1:1 ratio, to
ensure that it closely resembles the overall starting shape. • Bennet archform

The wire is then checked for symmetry on a template. • MBT archform

Finally, a Xerox copy of the wire is made and stored in the • Computer prediction
patient’s notes. Archwire coordination is important through-
out treatment, especially with the heavy stainless steel wires. • Individualized archform.
Hence, upper archwires are 3 mm wider than the lowers. • Lee archform
Effect of extraction on archform Effect of extraction on archform
These include: • Non-extraction cases: The archform tends to expand in
• Non-extraction cases: The archform tends to expand in the intermolar and interpremolar width.
the intermolar and interpremolar area. • Extraction cases: The archform tends to contract in the
• Extraction cases: The archform tends to contract in the intermolar and interpremolar width.
intermolar and interpremolar area.
• If the archform changes during orthodontic treatment,
in many cases, there will be tendency for relapse to the
original dimensions; this is particularly true for the in-
ter-canine width (Burke et al., 1998).

Arch Form and Width 69

References
BEGOLE, E. A. 1979. A computer program for the analysis of den-
tal arch form using the cubic spline function. Comput Programs
Biomed, 10, 136-42.
BRADER, A. C. 1972. Dental arch form related with intraoral forces:
PR=C. Am J Orthod, 61, 541-61.
BURKE, S. P., SILVEIRA, A. M., GOLDSMITH, L. J., YANCEY, J.
M., VAN STEWART, A. & SCARFE, W. C. 1998. A meta-analysis
of mandibular intercanine width in treatment and postretention.
Angle Orthod, 68, 53-60.
CURRIER, J. H. 1969. A computerized geometric analysis of human
dental arch form. Am J Orthod, 56, 164-79.
FELTON, J. M., SINCLAIR, P. M., JONES, D. L. & ALEXANDER, R.
G. 1987. A computerized analysis of the shape and stability of man-
dibular arch form. Am J Orthod Dentofacial Orthop, 92, 478-83.
GERMANE, N., STAGGERS, J. A., RUBENSTEIN, L. & REVERE,
J. T. 1992. Arch length considerations due to the curve of Spee: a
mathematical model. Am J Orthod Dentofacial Orthop, 102, 251-5.
LEE, R. T. 1999. Arch width and form: a review. Am J Orthod Den-
tofacial Orthop, 115, 305-13.
MAC, C. M. & SCHER, E. A. 1949. The ideal form of the human
dental arcade, with some prosthetic application. Dent Rec (London),
69, 285-302, illust.

70 Arch Form and Width

Arch Form and Width 71
 9
SPACE CLOSURE IN
ORTHDONTICS
Written by: Mohammed Almuzian, Haris Khan, Farhana Umer

In this Chapter
1. Types of space closure mechanics
2. Factors affecting the frictional resistance
3. Techniques to reduce friction resistance
4. Type of tooth movements
5. Methods of force application
6. Specific recommendations for closing loop arch-
wires
7. En-masse or two step retraction
8. How to perform effective space closure?
9. Obstacles to space closure
10. EXAM NIGHT REVIEW
Space closure is in orthodontics is used to close close pre- as the working archewire for space closure. It is necessary to
existing spaces, elective extraction spaces or movement of fit an intermediate wire before the final rectangular arches
teeth. Different force-delivery systems are used in contempo- can be placed, and this should be either:
rary orthodontics for space closure. The ideal force-delivery
• .020 round S.S. This is preferred when torque align-
system should meet the following criteria:
0ment is good, and vertical control is required (deep
• Economical. overbite case).
• Provide optimal tooth-moving forces that elicit the de- • 0.018 x 0.025 rectangular or .020 x .020 square Niti.
sired effects. This is preferable to reduce significant torque differ-
ences in the slot line between adjacent teeth.
• Require minimal operator manipulation and chair time.
• 0.017 x 0.025 steel is a third alternative to address
• Comfortable and hygienic for the patient.
both requirements of vertical control and torque ini-
• Require minimal patient cooperation. tiation.
For details about the force delivery system, please read the Bidimensional wire and slot technique
relevant chapter.
Bidimensional edgewise technique (Wire Technique): In
Sliding mechanism to close space this technique non-preadjusted 0.022 * 0.028-inch brackets
are used for all the teeth, and a 0.016 * 0.022-inch archwire is
Advantages of sliding mechanism
used with a 90-degree twist immediately distal to the lateral
These include: incisors so as to form a 0.022 * 0.016-inch ribbon segment
• No or minimal wire bending. that fills the anterior brackets and two 0.016 * 0.022-inch
edgewise segments that fit into the buccal brackets, with
• Less time consuming. a clearance of 0.006 inches. This is a ‘‘bidimensional wire’’
• Enhances patient comfort. technique,

• Long duration between appointments. Bidimensional-slot technique: In this technique the 0.018-
inch slot brackets are placed on the incisors, while the 0.022-
• Measurable force. inch slot brackets are placed on other teeth. When a 0.018
• No running out of space for activation. * 0.022-inch SS archwire is engaged, it is ‘‘full-sized’’ in the
anterior brackets, but leaves clearance of 0.004 inches in the
• Maintain arch form. buccal brackets. Li et al (Li et al., 2012) found that both tech-
• Vertical control. niques are effective in torque control compared to control.

• Root parallelism. Factor affecting the frictional resistance during space clo-
sure
Disadvantage of sliding mechanism
These include (Frank and Nikolai, 1980, Khambay et al., 2004,
These include: Dholakia, 2012).
• Lack of efficiency compared to frictionless mechan- • Bracket material.
ics.
• Archwire material.
• Uncontrolled tipping.
• Method of ligation.
• Deepening of overbite.
• Bracket width.
• Loss of anchorage.
• Wear of the wire.
• High friction and binding.
• Archwire diameter.
• Risk of orthodontically induced inflammatory root
resorption (OIIRR). However, a study evaluating • Archwire cross-sectional.
OIIRR in patients consecutively assigned to either a • Archwire shape.
continuous arch sliding mechanics group or a sec-
tional closing showed similar levels of OIIRR in both • Wire stiffness.
groups (Alexander, 1996). • Surface roughness of the wire.
Mechanics of sliding mechanism • Interbracket distance.
With 0.022 slot, a 0.019 x .0.025 archwires should be utilised • Active torque.

74 Space closure in orthodontics

• Bracket-wire angulations. chapter.
• Sliding velocity. Frictionless mechanics or closing loop mechanism
• Saliva. The main features are:
Techniques to reduce frictional resistance • It is ideally suited with 0.018-inch slot.
Frictional resistance caused by ligation resistance can be re- • Closing loop archwires should be fabricated from rectan-
duced by the following methods (Dholakia, 2012, Mah, 2002, gular wire to prevent the wire from rolling in the bracket
Franchi and Baccetti, 2006): slots.
1. Bracket system such as self-ligating brackets. • Appropriate closing loops in a continuous archwire will
produce approximately 60:40 closure of the extraction
2. Ligation material and methods such as:
space if only the second premolar and first molar are in-
• Slackened stainless steel ligatures, cluded in the anchorage unit and some uprighting (distal
tipping) of the incisors is allowed.
• Stainless steel ligatures coated with fluorinc-con-
taining resins, • Greater retraction will be obtained if the second molar
is part of the anchorage unit, less if incisor torque is re-
• Modified elastomeric modules,
quired.
• Superslick ligatures (TP orthodontics, Laporte, ind)
There are two ways to hold the archwire in its activated posi-
• Slide ligatures (leone, Sesto Fiorentino, Italy) (non- tion.
conventional elastomeric modules). They were in-
• By bending the end of the archwire gingivally behind the
troduced in 2005 and made of a special polyurethane
last molar tube.
mix for medical use which is manufactured by the
injection molding technique. The ligature interacts • The alternative is to place an attachment—usually a sol-
with the bracket slot to form a tube-like structure. dered tieback
The combination takes the shape of a passive self-
Advantages of closing loop mechanism
ligating bracket. The ligature forms the fourth wall
of the slot with its incisal and occlusal edge resting These include:
along the buccolabial surface of the tie wings. This
• Precise control of space closure.
permits the bracket to slide over the archwire freely
while transmitting most of the tooth-moving forces • Adequate ‘rebound time’ for uprighting and arch level-
to the surrounding dentoalveolar structures. ing.
Type of tooth movements • Some immediate improvement.
There are three types of movement during space closure Disadvantages of closing loop mechanism
• Alpha, anterior tooth movement. These include:
• Beta, posterior tooth movement. • Need wire bending.
• Vertical and horizontal (buccopalatal). • Soft tissue irritation.
The ratio between moments to force ratio M/F will determine • Plaque accumulation.
the resultant movement (Tanne et al., 1988):
• High force.
• 7/1 cause tipping
• Short appointment intervals needed.
• 10/1 cause bodily
• Tipping.
• 12/1 cause root uprighting
• Distortion of the wire with difficulties to control the
However, in periodontal compromised patients, the centre of movement in three planes of space
rotation will be apical, and the need for a greater M/F ratio
• No fail-safe mechanics in most of the designs.
in order to control the transitional movement. This topic is
discussed in detail in the chapter of biomechanics. Types of closing loop mechanism
Methods of force application These include:
This topic is discussed in detail in the Force Delivery System • Continuous arch with loop.

Space closure in orthodontics 75

• Segmented loop with sectional arch. loop is placed intra-orally.
Design of loops • Its location relative to adjacent brackets (i.e., the extent
to which it serves as a symmetric or asymmetric bend in
These include:
the archwire).
• Vertical loop.
Additional feature in the closing loops
• T-loop (Keng (Keng et al., 2012) compared the T closing
These include:
loop of NiTi and TMA and found no difference except
that NiTi one has more resistant to deformation. • “Fail safe.” This means that although a reasonable
range of action is desired from each activation, tooth
• Mushroom loop.
movement should stop after a prescribed range of
• PG Retraction Spring. movement, even if the patient does not return for a
scheduled adjustment.
Specific recommendations for closing loop archwires
• Convenience: It is important the design is as simple
The main features are:
as possible because more complex configurations
• 0.016× 0.022-inch wire, delta or T-shaped loops, 7 mm are less comfortable for patients, more difficult to
vertical height, and additional wire incorporated into the fabricate clinically, and more prone to breakage or
horizontal part of the loop to make it equivalent to 10 distortion.
mm of vertical height.
• Open or close loop: A third design factor relates to
• Gable bends of 40 to 45 degrees total (half on each side whether a loopd is activated by opening or closing.
of the loop). The gable bend should be reactivated after All else being equal, a loop is more effective when
4mm of retraction. it is closed rather than opened during its activation.
• Loop placement 4 to 5 mm distal to the centre of the ca- On the other hand, a loop designed to be opened
nine tooth, at the centre of the space between the canine can be made so that when it closes completely, the
and second premolar with the extraction site closed. vertical legs come into contact, effectively prevent-
ing further movement and producing the desired
The performance of a closing loop, from the perspective of fail-safe effect. A loop activated by closing, in con-
engineering theory, is determined by three major character- trast, must have its vertical legs overlap. This creates
istics (Siatkowski, 1997) : a transverse step, and the archwire does not develop
• Spring properties (i.e., the amount of force it delivers the same rigidity when it is deactivated.
and the way the force changes as the teeth move); the En-masse or two-step retraction
spring properties of a closing loop are determined al-
most totally by the wire material (at present, either steel Two-step retraction refers to separate canine and incisor
or beta-Ti), the size and cross section (should be rect- retraction. There are different techniques for two step retrac-
angular) of the wire, and the distance between points of tion including:
attachment (This distance in turn is largely determined Alexander- Vari-simplex discipline in which a power chain
by the amount of wire incorporated into the loop and the on + 0.016” round wire to retract canine sfirst. Heavy forces
distance between brackets). of 250-300 gm are used which can cause cuspids to rotate
• The moment it generates, so that root position can be and tip lingually. This power chain is changed every 4 weeks
controlled. If the centre of resistance of the tooth is 10 and canine retraction takes 4-6 months. Once canine retrac-
mm from the bracket, a canine tooth being retracted tion is completed a 0.018 x 0.025” closing loop is used for
with a 100 gm force must receive a 1000 gm-mm mo- anterior retraction.
ment if a bodily movement is required. If the bracket is 1 Viazis: Triangular (Viazis) bracket is used with bioforce
mm wide, a vertical force of 1000 gm must be produced wires. The brackets are claimed to produce 10 times less fric-
by the archwire at each side of the bracket. This require- tion while it is claimed that the wires cause 11 % reduction
ment to generate a movement limits the amount of wire in friction. Space closure is done in two parts after leveling
that can be incorporated to make a closing loop springier and alignment.
because if the loop becomes too flexible, it will be un-
Proffit recommendation: Canine retraction is performed by
able to generate the necessary moments even though the
segmental loop made from 16*22 SS or 17*25 TMA or by
retraction force characteristics are satisfactory. It mainly
sliding mechanics on 18*25 SS or 19*25 SS. The ideal force
depends on the wire size, length, inter bracket distance,
to slide a canine distally is 150 to 200 gm, since at least 50 to
and loop configuration. Additional moments must be
100 gm will be used to overcome binding and friction. Once
generated by gable bends (or their equivalent) when the

76 Space closure in orthodontics

canine retraction is completed incisor retraction is done ing of the wire and this in itself may increase
either by closing loop or sliding mechanics. friction.
En-masse anterior retraction • Multiple brackets distal to the space, yet to close
will increase friction.
There are two main techniques for one step retraction
including: • Conventional ligation increase friction especial-
ly with elastomeric modules asnd if they are in a
• MBT recommendation in which the main archwire
figure of 8 configuration
is 0.019 x 0.025 SS that provides good overbite
control. Sliding mechanics with light forces which b) Incorrect force levels: Forces above the recom-
is either provided by active tiebacks at the start mended levels can cause tipping and friction, and
of treatment, or NiTi coil springs latter when the thus prevent space closure. Inadequate force may be
patient is on heavy working wires. a cause of slow or non-space closure in adults. Force
levels need to be in balance during space closure
• Proffit recommendation: En masse retraction can be
and sliding mechanics.
done using the segmented arch approach for space
closure. It works by incorporating the anterior teeth B. Biological factors
into a single segment, and both the right and left
a) Intramaxillary causes including:
posterior teeth into a single segment, with the two
sides connected by a stabilizing lingual arch. A re- • Soft tissue resistance: Gingival overgrowth in
traction spring is used to connect these stable bases. the extraction sites can prevent space closure, and
As the spring is separated from the wire sections can cause space to re-open after appliance removal.
and an auxiliary rectangular tube, usually posi- It can also be a problem when closing a midline
tioned vertically, a force is applied to on the canine diastema. Care is needed to maintain good oral
bracket or on the anterior wire segment to provide hygiene and avoid rapid space closure, as this can
an attachment for the retraction springs. The poste- contribute to local gingival overgrowth. In few cases
rior end of each spring fits into the auxiliary tube on local soft tissue surgery may be indicated.
the first molar tooth.
• Roots too close.
How to perform effective space closure?
• Necking of the bone.
These include:
b) Intermaxillary causes including:
• For large spaces, it is recommended to use NiTi coil
• Interference from opposing teeth: Occlusal in-
spring.
terferences can halt space closure. This can be
• If 2-3mm, it is recommended to use active tie backs. due to bracket positioning errors as well.
• For small spaces, it is recommended to use power chains. • Overbite
Obstacles to space closure c) Individual variation: In many instances, no def-
inite cause can be found. The study by Pilon (Pilon
These include:
et al., 1996) supports the view that tooth movement
Mechanical factors such as: varies markedly between individuals because of
variation in inherent metabolic factors.
a) Excessive friction which is asscoiated with
extreme active forces between bracket and wire Methods to assist in managing a failure of space closure with
(unlevelled arch). Hence, working archwires should sliding mechanics
be in place for at least a month to ensure levelling
• Check for causes as listed above and eliminate them as
and resolution of posterior torquing forces.
appropriate
• The end of the arch wire is inside the molar tube.
• If no cause can be found, especially if the wire seems
• A bracket or tube may have distorted or been hard to swivel, assume that the friction is too high.
inadvertently crimped with distal-end cutters.
• Take all sensible steps to lower friction.
• Ceramic brackets produce more friction than
• Use thinner wires through the brackets.
stainless steel brackets (Kusy and Whitley, 1990)
• If the overbite situation permits, remove almost all the
• Sometimes excessive space-closing force plus
curve of spee.
vigorous curve of Spee produces a marked bow-

Space closure in orthodontics 77

• Ensure that any elastomeric ligatures on the sliding teeth et al., 2009): Accelerated tooth movement for space clo-
are in a plain “O” configuration on one tie-wing only sure can be done by corticotomy, micro-osteoperfora-
tions, piezocision, interseptal alveolar surgery, cortici-
• Consider propping the bite with glass ionomer cement
sion, discision and piezo puncture.
on the lower molars.
• Increase the force for one visit. If space-closing coils are Exam Night Review
being used, the addition of elastomeric chain is often ef- • NiTi coil springs are better than tie backs but there is
fective, providing an initial increase in force which then no difference in tooth position produced by the two sys-
reduces to the level previously provided by the coil alone. tems after space closure (Samuels et al., 1993). Moreover,
• Consider attaching the coilspring/elastics to the first mo- there is no evidence of greater patient discomfort with
lar, leaving the second molar out of space closure for a the springs.
visit or two • A study concluded that 150 gram and 200-gram coil
• Change the archwire: In general, archwires with time in- spring produced a faster rate of space closure while 100
crease debris accumulation and friction (Normando et grams of elastic module produce less effect (Samuels et
al., 2013). Cleaning with a steel wool sponge for 1 min- al., 1998).
ute or ultrasound cleaning for 15 minutes can be done to • According to a RCT (Dixon et al., 2002) NiTi springs
decrease friction. produced more space closure per unit time and may
Alternative mechanics for space resistant to closure be considered the treatment of choice. However, power
chain provides a cheaper and effective treatment option.
These include:
Additionally, from this study, there was lack of effect of
A. Switching to closing loops as the means of space closure. inter-arch elastics on the rate of space closure. From their
results, the time required to close a 6 mm extraction
• If sliding through ceramic brackets (this usually applies
space would average 17 months with an active ligature,
to anterior spaces), change the archwire. The archwire
10 months with elastic chain and 7.5 months with NiTi
surface may have been roughened by the ceramic bracket
coil spring.
material
The reasons for lack of effect of inter-arch elastics are as fol-
• Tiebacks with 2 modules
low:
• Wonder or bi-dimensional wire: This dual diameter wire
a. The study lacked statistical power to detect an elastic ef-
has a rectangular anterior segment to maintain torque
fect.
control in that region but with buccal segments which
are round in cross section (usually 0.018”). Such wires b. The elastic force may not have been sufficient to influ-
are now available with the buccal segment section being ence rates of tooth movement.
0.016” x 0.022”. This would probably retain sufficient ri-
c. Patients may not be co-operating totally with full time
gidity to adequately control overbite and buccal segment
elastic wear.
alignment whilst significantly reducing friction on those
teeth. d. The inter-arch elastics are moving blocks of teeth in each
arch in an anterior or posterior direction without signifi-
• Self-ligating brackets.
cantly adding to the space closing effect.
• Sectional mechanics.
e. For certain force levels, the addition of elastics may not
• Hycon device: In these mechanics, a centimeter segment increase the rate of tooth movement at the histological
of 0.021 x 0.025 SS wire is soldered to a 7mm screw de- level.
vice. The wire is placed in a double or triple tube of mo-
• A study by Nightingale (Nightingale and Jones,
lar. The screw is activated twice a week, one full turn and
2003) found that NiTi coil springs and elastomeric
the amount of space closure is 1mm/ month.
chain closed spaces at a similar rate.
• Prevention is better than cure. Hence, if treatment goals
• Force decay in nickel titanium ranged from 8% to
can be achieved without extractions, then this removes
17% of the original force over 28 days (Angolkar et
space closure as a problem. It is also important to con-
al., 1992).
sider early retraction of upper canines to a Class I rela-
tionship. This prevents occlusal interference with lower • Elastic force decay (Baty et al., 1994) of 50% to 70%
canine brackets. in the first day with only 30% to 40% at remaining
3 weeks. He also reported that pre-stretching the
• Surgery assisted space closure (Ahn et al., 2012, Wilcko
chain in order to reduce the rapid decay in force only

78 Space closure in orthodontics

 increased the residual force at 3 weeks by 5% clini-
cally insignificant. Reference
• Bishara (Bishara and Andreasen, 1970) showed that AHN, H. W., LEE, D. Y., PARK, Y. G., KIM, S. H., CHUNG, K. R.
power chain (PC) lost half of its force after 24 h and & NELSON, G. 2012. Accelerated decompensation of mandibular
the remaining force remain for 4 weeks and recom- incisors in surgical skeletal class III patients by using augmented
mend over extension of the power chain. corticotomy: a preliminary study. Am J Orthod Dentofacial Orthop,
142, 199-206.
• Study comparing continuous versus intermittent
forces (PC) found that the continuous force (NiTi) ALEXANDER, S. A. 1996. Levels of root resorption associated with
continuous arch and sectional arch mechanics. Am J Orthod Dento-
was more effective for tooth movement, with no
facial Orthop, 110, 321-4.
difference in the amount or severity of OIIRR (Ow-
man-Moll, 1995). ANGOLKAR, P. V., ARNOLD, J. V., NANDA, R. S. & DUNCAN-
SON, M. G., JR. 1992. Force degradation of closed coil springs: an
• Storie et al (Storie et al., 1994) found that fluoride- in vitro evaluation. Am J Orthod Dentofacial Orthop, 102, 127-33.
releasing chain was unable to deliver a satisfactory
BARLOW, M. & KULA, K. 2008. Factors influencing efficiency of
force level for more than one week compared to 3
sliding mechanics to close extraction space: a systematic review. Or-
weeks for the conventional chain used for compari- thod Craniofac Res, 11, 65-73.
son.
BATY, D. L., STORIE, D. J. & VON FRAUNHOFER, J. A. 1994. Syn-
• Heo (Heo et al., 2007), found no difference in re- thetic elastomeric chains: a literature review. Am J Orthod Dentofa-
gard to degree of anchorage loss between en-masse cial Orthop, 105, 536-42.
retraction and two step retraction.
BISHARA, S. E. & ANDREASEN, G. F. 1970. A comparison of time
• According to a systematic review by Barlow (Barlow related forces between plastic alastiks and latex elastics. Angle Or-
and Kula, 2008) NiTi coil springs produce more thod, 40, 319-28.
consistent force and a faster rate of closure when DHOLAKIA, K. D. 2012. Friction and anchorage loading revisited.
compared with active ligatures as a method of force Orthodontics (Chic.), 13, 200-9.
delivery to close extraction space along a continu-
DIXON, V., READ, M. J., O’BRIEN, K. D., WORTHINGTON, H. V.
ous arch wire; however, elastomeric chain produces & MANDALL, N. A. 2002. A randomized clinical trial to compare
similar rates of closure when compared with NiTi three methods of orthodontic space closure. J Orthod, 29, 31-6.
springs. Clinical and laboratory research suggest
FRANCHI, L. & BACCETTI, T. 2006. Forces released during align-
little advantage of 200 g NiTi springs over 150 g
ment with a preadjusted appliance with different types of elastomer-
springs. ic ligatures. Am J Orthod Dentofacial Orthop, 129, 687-90.
FRANK, C. A. & NIKOLAI, R. J. 1980. A comparative study of fric-
tional resistances between orthodontic bracket and arch wire. Am J
Orthod, 78, 593-609.
HEO, W., NAHM, D. S. & BAEK, S. H. 2007. En masse retraction
and two-step retraction of maxillary anterior teeth in adult Class I
women. A comparison of anchorage loss. Angle Orthod, 77, 973-8.
KENG, F. Y., QUICK, A. N., SWAIN, M. V. & HERBISON, P. 2012.
A comparison of space closure rates between preactivated nickel-
titanium and titanium-molybdenum alloy T-loops: a randomized
controlled clinical trial. Eur J Orthod, 34, 33-8.
KHAMBAY, B., MILLETT, D. & MCHUGH, S. 2004. Evaluation of
methods of archwire ligation on frictional resistance. Eur J Orthod,
26, 327-32.
KUSY, R. P. & WHITLEY, J. Q. 1990. Coefficients of friction for arch
wires in stainless steel and polycrystalline alumina bracket slots. I.
The dry state. Am J Orthod Dentofacial Orthop, 98, 300-12.
LI, Y., TANG, N., XU, Z., FENG, X., YANG, L. & ZHAO, Z. 2012.
Bidimensional techniques for stronger anterior torque control in
extraction cases: a combined clinical and typodont study. Angle Or-
thod, 82, 715-22.
MAH, E. 2002. Investigation of frictional resistance on orthodontic

Space closure in orthodontics 79

brackets when subjected to variable moments.
NIGHTINGALE, C. & JONES, S. P. 2003. A clinical investigation
of force delivery systems for orthodontic space closure. J Orthod,
30, 229-36.
NORMANDO, D., DE ARAÚJO, A. M., MARQUES IDA, S., BAR-
ROSO TAVARES DIAS, C. G. & MIGUEL, J. A. 2013. Archwire
cleaning after intraoral ageing: the effects on debris, roughness, and
friction. Eur J Orthod, 35, 223-9.
OWMAN-MOLL, P. 1995. Orthodontic tooth movement and root
resorption with special reference to force magnitude and duration.
A clinical and histological investigation in adolescents. Swed Dent J
Suppl, 105, 1-45.
PILON, J. J., KUIJPERS-JAGTMAN, A. M. & MALTHA, J. C. 1996.
Magnitude of orthodontic forces and rate of bodily tooth move-
ment. An experimental study. Am J Orthod Dentofacial Orthop,
110, 16-23.
SAMUELS, R. H., RUDGE, S. J. & MAIR, L. H. 1993. A comparison
of the rate of space closure using a nickel-titanium spring and an
elastic module: a clinical study. Am J Orthod Dentofacial Orthop,
103, 464-7.
SAMUELS, R. H., RUDGE, S. J. & MAIR, L. H. 1998. A clinical
study of space closure with nickel-titanium closed coil springs and
an elastic module. Am J Orthod Dentofacial Orthop, 114, 73-9.
SIATKOWSKI, R. E. 1997. Continuous arch wire closing loop de-
sign, optimization, and verification. Part I. Am J Orthod Dentofacial
Orthop, 112, 393-402.
STORIE, D. J., REGENNITTER, F. & VON FRAUNHOFER, J. A.
1994. Characteristics of a fluoride-releasing elastomeric chain. An-
gle Orthod, 64, 199-209; discussion 210.
TANNE, K., KOENIG, H. A. & BURSTONE, C. J. 1988. Moment
to force ratios and the center of rotation. Am J Orthod Dentofacial
Orthop, 94, 426-31.
WILCKO, M. T., WILCKO, W. M., PULVER, J. J., BISSADA, N. F.
& BOUQUOT, J. E. 2009. Accelerated osteogenic orthodontics tech-
nique: a 1-stage surgically facilitated rapid orthodontic technique
with alveolar augmentation. J Oral Maxillofac Surg, 67, 2149-59.

80 Space closure in orthodontics