.

MEAW
Multi-loop
Edgewise
Archwire
Kim Jeong-Il
Orthodontic treatment with MEAW W

i i i i i l l i

Well Publishing
ME AW
Multi-loop Edgewise Archw ire

Kim Jeong-Il

Well Publishing
 J
.(

MEAW
Multi-loop
Edgewise
Archwire
Kim Jeong-Il
Orthodontic treatment with MEAW W

M Well Publishing
 W ell P u b lish in g

Copyright © 2016 WELL Publishing

142-070. 22, Samyang-ro 118 gil, Gangbuk-gu, Seoul, Korea

T. 82. 2. 907. 2872 F. 82. 2. 907. 2873
E. [email protected]
H. www.wellpub.net

This book was originally published in Korea under the title o f :

MEAW Multi-loop Edgewise Archwire:Orthodontic treatment with MEAW
Kim Jeong-Il, DDS, PhD

ISBN. 978-89-97113-39-2 93510

All rights reserved. No part of this book may be reproduced in

any form without permission in writing from the publisher.
A damaged book is exchanged at WELL Publishing.

Printed in Korea
 • @ • ®

Dr. Kim Young-Ho

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

He introduced me to the MEAW concept and inspired me
to do research and practice with passion as an orthodontist.

5
 :t it

It has been over 30 years since I started practicing as an orthodontist. Although it took a little
while for me to absorb and understand the concept of orthodontics, I still believe I am
insufficiently trained and have a long way to go. Since I started practicing, I have encountered a
number of orthodontic methods and applied such methods in clinic. However, I have been always
concerned about what the best solution and analysis would be. About 25 years ago I met the
deceased Professor Kim Young-Ho, which was a turning point in my career. He enabled me to
apply the MEAW technique to my orthodontic approaches and raised the awareness of the some of
the most important aspects of daily orthodontic clinical practice which were used to be ignored up
to that time. This has further modified my personal views of patients.

MEAW, first designed by the deceased Dr. Kim, was initially used to treat the open bite cases
only, but is now regularly applied to all kinds of malocclusion cases. In other words, MEAW had
once been regarded as a tool that could only be applied to the open bite patients or, only as a
finishing wire that could be used at the finishing stage of treatment. Nevertheless, in contemporary
orthodontics, many orthodontists as well as the general practitioners now frequently use MEAW on
a daily basis to treat all sorts of malocclusion cases. Despite this popularity, the textbook that
formally teaches the MEAW technique has never been published in Korea. Also, the books that
were published in Japan were restricted to the non-extraction treatment method only and they did
not faithfully reflect the original concepts by Dr. Kim. As you can figure out from the book title,
this book is distinguished from the books published so far about MEAW. In this book, non­
extraction and premolar extraction cases are explained step by step according to the original
orthodontic philosophy and treatment methods founded by the late Dr. Kim.

The most important issue in orthodontic treatment is the exact understanding of malocclusion
and the diagnosis and treatment plan. Malocclusion itself cannot be treated without understanding
its specific problems and treatment strategy. Most orthodontists are aware of the usefulness of
MEAW technique, but it is notable that the MEAW technique brings about a meaningful result
only when accurate diagnosis and proper treatment are all accomplished.

► FOREWORD
• • •
 This book consists of three parts: Part I Orthodontic Diagnosis, Part II Orthodontic
Treatment, and Part III Clinical Cases.
Part I is based on the late Professor Kim’s diagnosis method, which provided us with the
guidance about what the orthodontists should consider before the treatment. This part focuses on
causes and problems of each malocclusion. Instead of making a diagnosis just based on the visible
problems, I believe that the identification of hidden factors is crucial, as they can further provide
the orthodontists with a wide range of diagnosis and treatment methods. Therefore, in this book,
the importance of cephalometric radiographic analysis, model analysis and facial aesthetic analysis
is emphasized. Additionally, it proposes the orthodontic differential diagnosis methods, which can
further be used both for the extraction and for the non-extraction treatments. In particular, in the
extraction treatment chapter, it explores the indications of the extraction of maxillary second
molars, the extraction of maxillary and mandibular first premolars, the extraction of maxillary first
premolars and mandibular second premolars, the extraction of incisors and the extraction of first
molars.

In part II, the basic principles of MEAW are explained, and the use of MEAW in various
malocclusion cases is demonstrated with abundant photographs and diagrams. The details of each
procedure -brackets, bracket positioning, leveling and alignment, space closure, finishing, and
retention- are carefully explained with the answers to common concerns that frequently arise in
practicing orthodontics. However, it should be acknowledged that the methods introduced in this
book are not the eventual solution, and the further variables may arise in each different real clinical
case.

In part III, five different cases are explained. Case 1 deals with the extraction of four first
premolars, Case 2 deals with the extraction of maxillary first premolars and mandibular second
premolars, Case 3 explains a non-extraction treatment in Class II malocclusion and Case 4 explains
a non-extraction treatment in Class III malocclusion. Case 5 deals with the midline deviation
treatment.
Again, the author would like to acknowledge that these are not the eventual solutions. I
believe that there is no absolute solution in orthodontics and the role of an orthodontist is to seek to
find a better solution for each different case. I believe that the orthodontists should never stop
learning and researching, driven by professionalism as well as by the sympathy toward his or her
patients. I would like to remind you to regard the cases presented in this book, as an indication
only, and try to develop their own treatment method. I hope this book encourages you to think
differently when treating the common problems that you may encounter in your daily orthodontic
practices.

FOREWORD <4 7
 About the Author

Kim Jeong-ll DDS, PhD

E mail: [email protected]

Dr. Kim Jeong-ll, DDS, PhD, currently serves as Chair in the Department of Orthodontics at
Kooalldam dental hospital in Incheon, South Korea. He is also appointed as Clinical Professor in the
Department of Orthodontics at Graduate School of Clinical Dentistry, Korea University, in Seoul, South
Korea. He is also Visiting Professor in the Department of Orthodontics at Dalian Medical University in
Dalian, China.

After graduating from Dental School at Seoul National University in 1987, he completed the
orthodontic residency at Seoul National University Dental Hospital in 1990. He acquired his PhD in the
Department of Orthodontic and Dentofacial Orthopedics at the Kanagawa Dental College in Yokosuka,
Japan, in 2006.

Dr. Kim was instructed to the MEAW concept in orthodontics by the late Professor Kim Young-
Ho, who first invented MEAW, when he took the 2-year long MEAW course from 1993 to 1994 in
Seoul. Since then, Dr. Kim has been a clinical instructor of MEAW society and adjunct Professor at
Seoul National University. He had completed the TMJ and Occlusion related courses taught by
Professor Rudolf Slavicek and Professor Sadao Sato from 2000 to 2001 in Austria, Japan and Boston.
His specialty lies in the malocclusion treatment in consideration of TMJ function, and the main
treatment approach he advocates for this purpose is the control of occlusal plane.

8 @m • ®
 © • • ©

Dr. Kim Young-Ho and Dr. Kim Jeong-ll, 2004

< Philosophy of Orthodontic Treatment>

The most important aspect in orthodontic treatment is accurate diagnosis and treatment planning. By
correcting the causes of malocclusion based on a comprehensive understanding of the skeletal and dental
patterns of each patient, an individualized orthodontic treatment planning should be made thoroughly.
Skeletal and denture patterns should be analyzed for accurate diagnosis. Based on accurate diagnosis,
simple but effective treatment method can be applied with the minimum need of wire bending, causing
the least discomfort to the patients. An orthodontist should be able to practice without any stress, but with
less need of orthodontic surgery or tooth extraction, as best as he or she can.

Professional Memberships:

In addition to serving as an educational instructor for the Korean Academy of Orthodontics, Dr. Kim is
a board member of the Korean Academy of Orthodontics, a regular member of Korean Academy of
Stomatognathic Function and Occlusion, and an honorary president of Korea Institute for Malocclusion
Study (KIMS).

Publications

Kim, J.I. (2015). Practical Clinical Orthodontics: Early Orthodontic Treatment. Vol.3. Seoul, Korea: Well Publishing.

Kim, J.I. (2013). Practical Clinical Orthodontics: Orthodontic Diagnosis. Vol.2. Seoul, Korea: Well Publishing

Kim, J.I. (2012). Practical Clinical Orthodontics: Orthodontic Treatment with MEAW. Voll. Seoul, Korea: Well Publishing

9
 AC KNO W LEDG EM ENT

First of all, I would like to express my special gratitude to my permanent teacher and mentor, the
late Professor, Kim Young-Ho, for introducing me to the MEAW concept in orthodontics. I was deeply
influenced by his passion as an orthodontist as well as by his professional expertise.

I also would like to express my special thanks to Professor Sadao Sato, who has inspired me to do
research and practice with passion in orthodontics.

I have realized how difficult it is to write a book on orthodontics in English as a non-native English
speaker. I would like to express a tremendous degree of appreciation to all those who have made this
English publication possible. Without the help from these people, this book could not have been
published. I would like to first thank Lee Chang-Bong, my close friend, Professor of English and
Linguistics at the Catholic University of Korea, and three training dentists in Kooalldam Hospital, Dr.
Yoo So-Young, Dr. Park Sang-Eun, and Dr. Seo Won-Chae, who worked as a team to finalize the
English translation based on the first English draft. I must express my deep gratitude to Kim Sung-Kue,
my second son, and Dr. Kim Ye-Jin, who produced the first draft version of English text. My special
thanks should go to Dr. Son Eun-Jeong and Kim Jung-Hoon for their help in collecting and organizing
the data and to DT Kim Jeong-Min, the chief executive officer of Credent Laboratory, as well, for
providing the necessary equipment. Last but not least, I would like to thank Mr. Bong Gi-Chul,
President of Well Publishing for kindly agreeing to publish and to edit my book.

• I would like to point out that some of the content in this book could be controversial and there can
even be objections from some readers. I take this as a natural and healthy situation in the field of
orthodontics. I strongly believe that without disagreement and ongoing dialogue, we cannot continue
our path to excellence in orthodontics. All the shortcomings and errors in this book are mine.

10 • • • •
 CONTENTS

PART I ORTHODONTIC DIAGNOSIS.............................................17

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

1. Patients............................................................................................................................20

2. Relationship between Orthodontist and Patient............................................................. 20

3. Orthodontists....................................................................................................................22

Chapter 2 _ CAUSES OF MALOCCLUSION.....................................................................38

1. Skeletal Factors.............................................................................................................. 40

2. Dental Factors...................................................... 42

3. Environmental Factors.....................................................................................................78

Chapter 3 _ SKELETAL PATTERN ANALYSIS................................................................. 92

1. Vertical Analysis...............................................................................................................96

2. Horizontal Analysis........................................................................................................100

3. Combination Factor (OF)...............................................................................................105

4. Extraction Index (E l)....................................................................... 113

5. Classification of Skeletal Pattern...................................................................................114

Chapter 4 _ DENTURE PATTERN ANALYSIS.................................................................122

1. Denture Pattern Analysis...............................................................................................124

2. Occlusal Plane............................................................................................................... 126

3. Changes of Occlusal Plane...........................................................................................135

CONTENTS ◄◄ 1 1
 Chapter 5 _ ORTHODONTIC DIAGNOSIS.....................................................................158

1. Orthodontic Differential Diagnosis.................................................................................160

2. Non-Extraction Treatment Method................................................................................170

1) Methods of non-extraction treatment................................................................................... 170

2) Reproximation......................................................................................................................188

3. Extraction Treatment..................................................................................................... 193

1) Third molar extraction.......................................................................................................... 194

2) Maxillary second molar extraction........................................................................................196

3) Premolar extraction..............................................................................................................202

4) Anterior teeth extraction....................................................................................................... 237

5) First molar extraction...........................................................................................................249

PART II ORTHODONTIC TREATMENT........................................ 259

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

1. Bracket System..............................................................................................................262

1) Bracket system................................................................................................................... 262

2) Important considerations for bracket selection...................................................................271

3) Bracket selection for non-extraction cases.......................................................................... 288

4) Bracket selection for premolar extraction cases.................................................................. 288

2. Positioning......................................................................................................................290

1) Accurate bracket positioning............................................................................................... 290

2) Bracket positioning for individual teeth.................................................................................316

3) Bracket positioning in various cases....................................................................................336

Chapter 7 _ LEVELING AND ALIGNMENT..................................................................... 346

1. Basic Orthodontic Terms........................................................................................... 348

1) Leveling and alignment........................................................................................................ 348

2) Simple leveling and strategic leveling..................................................................................350

3) Cinch back bends................................................................................................................352

4) Tight cinch back & loose cinch back....................................................................................353

1 2 ► CONTENTS
 2. Strategie Bonding........................................................................................................ 355

1) Definition............................................................................................................................. 355

2) Purposes............................................................................................................................. 355

3) Methods of application.........................................................................................................355

4) Considerations..................................................................................................................358

3. Archwires for Leveling and Alignment.......................................................................... 381

1) Initial archwires................................................................................................................... 381

2) Leveling archwire.................................................................................................................384

4. Strategic Leveling and Alignment................................................................................. 385

1) Strategies for non-extraction treatment................................................................................385

2) Strategies for premolar extraction treatment.......................................................................396

Chapter 8 _ SPACE CLOSURE......................................................................................... 402

1. Space Closing M ethod................................................................................................. 404

1) Sliding method vs loop method..........................................................................................404

2) Space closing method.........................................................................................................407

2. Space Closing Archwire............................................................................................... 425

3. Anchorage..................................................................................................................... 429

4. Retrusive Control in Clinical Orthodontics.................................................................... 436

5. Archwire Fabrication for Space Closure...................................................................... 445

Chapter 9 _ FINISHING...................................................................................................... 466

1. Finishing Archwire......................................................................................................... 468

2. Multi-loop Edgewise Archwire (MEAW)....................................................................... 469

1) Composition and basic form of MEAW..................... .........................................................469

2) Functions and mechanics of MEAW.................................................................................. 472

3) Instruments and materials for MEAW................................................................................ 473

4) Fabrication of MEAW...........................................................................................................474

5) First-, second- and third-order bends in MEAW.................................................................. 482

6) Completed MEAW...............................................................................................................490

7) Heat treatment for the completed MEAW............................................................................491

CONTENTS ◄« 1 3
 3. Prescription of M EAW .................................................................................................. 492

4. Basic Adjustment of M EAW ......................................................................................... 500

5. Elastics in M EAW ..........................................................................................................507

6. Finishing Methods for Special Conditions.................................................................... 519

1) MEAW adjustment for midline correction............................................................................519

2) Expansion archwires in MEAW........................................................................................... 521

3) MEAW adjustments in the case of peg lateralis.................................................................525

7. Orthodontic Normal Occlusion..................................................................................... 526

Chapter 10 _ RETAINERS................................................................................................. 542

1. General Types of Retainer........................................................................................... 544

2. Retainer for a Patient with Maxillary Anterior Crowding.............................................. 545

3. Retainer for a Patient with Mandibular Anterior Crowding.......................................... 546

4. Retainer for a Patient with Class III Malocclusion........................................................ 548

5. Retainer for a Patient with Class II Malocclusion......................................................... 550

6. Retainer for a Patient with Deep Bite........................................................................... 554

7. Retainer for a Patient with Open Bite........................................................................... 555

8. Retainer for a Patient with Posterior Cross Bite........................................................... 557

9. Retainer for a Patient with Space................................................................................. 559

PART III CLINICAL CASES............................................................. 565

Chapter 11 _ A CASE OF THE MAXILLARY

AND MANDIBULAR FIRST PREMOLAR EXTRACTION.......................... 566

1. Case summary...............................................................................................................568

2. Pre-treatment records....................................................................................................568

3. Diagnosis and treatment planning................................................................................ 571

4. Treatment pocedures....................................................................................................572

5. Post-treatment records................................................................................................. 578

14 i> CONTENTS
Chapter 12 _ A CASE OF THE MAXILLARY FIRST PREMOLAR
AND MANDIBULAR SECOND PREMOLAR EXTRACTION..................... 584

1. Case summary...............................................................................................................586

2. Pre-treatment records................................................................................................... 586

3. Diagnosis and treatment planning................................................................................ 589

4. Treatment pocedures .................................................................................................... 590

5. Post-treatment records................................................................................................. 594

Chapter 13 _ A NON-EXTRACTION TREATMENT CASE

IN CLASS II MALOCCLUSION....................................................................600

1. Case summary.................................................... 602

2. Pre-treatment records................................................................................................... 602

3. Diagnosis and treatment planning................................................................................ 606

4. Treatment pocedures................................................................................................... 607

5. Post-treatment records................................................................................................. 610

Chapter 14 _ A NON-EXTRACTION TREATMENT CASE

IN CLASS III MALOCCLUSION....................................................................616

1. Case summary.................................................................................. ...........................618

2. Pre-treatment records....................................................................................................618

3. Diagnosis and treatment planning................................................................................ 622

4. Treatment pocedures................................................................................................... 622

5. Post-treatment records................................................................................................. 628

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

1. Case summary...............................................................................................................636

2. Pre-treatment records....................................................................................................636

3. Diagnosis and treatment planning................................................................................ 639

4. Treatment pocedures....................................................................................................640

5. Post-treatment records................................................................................................. 643

CONTENTS <4 1
 PARTI

ORTHODONTIC DIAGNOSIS
 Chapter 1

CAUSES OF
ORTHODONTIC
TREATMENT FAILURE

1. Patients

2. Relationship between Orthodontist and

Patient

3. Orthodontists
 There are a number of factors that can negatively impact the finishing procedures of an orthodontic
treatment and its stability. The main causes can be categorized under the following:

1) Patients,
2) Relationship between orthodontist and patient,
3) Orthodontists.

| ^ Patients

The majority of orthodontic treatment failures have been caused by a lack of patient compliance.

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

2) Cases where patients do not wear their orthodontic appliance.
3) Cases where patients do not use the elastics.
4) Cases where patients have poor oral hygiene.

^3 Relationship between Orthodontist and Patient

To obtain the best orthodontic treatment results, it is essential to maintain a good relationship
between an orthodontist and patient.
Depending on the state of the relationship, the effectiveness and outcome of the orthodontic
treatment may vary. If they sustain a positive relationship, the orthodontic treatment becomes more
effective and leads to a more positive outcome. In contrast, if they have a negative relationship, the
procedure tends to become far more complicated.
If they have a poor relationship, the orthodontist may focus only on the process of teeth alignment.
On the other hand, an orthodontist with a good doctor-patient relationship will have greater
sympathy towards his/her patient who is suffering from malocclusion. Subsequently, they will

20 ►► Chapter 1 _ Causes of Orthodontic Treatment Failure p, n ^ ,=«,

 • • • •

listen more carefully to the complaints of the patients, and/or the parents of patients, and come up
with the best treatment procedures.
To conclude, keeping a positive orthodontist-patient relationship will prevent problems arising
from the lack of understanding between them and lead to better patient compliance. It is essential
for an orthodontist to diagnose his/her patients based not only on their teeth alignment but also on
chief complaints and the type of malocclusion that they are suffering from. In the case of any
potentially unsatisfactory results, an orthodontist should try to always provide sufficient
information to his/her patients, which enlightens them about the limitations of the orthodontic
treatment.

nical Tips: Limitations of orthodontic treatment

1. Periodontal ligament cells are the main cause of tooth movement. The ankylosis

teeth, which are missing a periodontal ligament, will soon face a restriction in

movement.

2. Tooth movement frequently occurs within the alveolar bone (Fig. 1-1).

1) In particular, when patients have a thin cortical bone in the anterior alveolar

area, there may be root resorption as well as dehiscence and/or fenestration

on the buccal surface.

2) The skeletal structure (retruded chin and prom inent m andibular angle also

com m only know n as square ja w ) ca n n o t be re ctifie d by an o rth o d o n tic

treatment.

3) U s u a lly , th e a n te ro -p o s te rio r and v e rtic a l m o v e m e n ts are m ade

simultaneously. ; ■ |:r>

Chapter 1 _ Causes of Orthodontic Treatment Failure 4« 21

 ►► F ig . 1-1 Radiographs that demonstrate a variety of premaxilla and symphysis thicknesses.
A. Patient who has thin premaxilla.
B. Patient who has thin symphysis.
C. A diagram that shows a thin premaxilla or symphysis.
D. Patient who has thick premaxilla.
E. Patient who has thick symphysis.
F. A diagram that shows a thick premaxilla or symphysis.

Orthodontists

©
Orthodontist must make an evidence-based orthodontic diagnosis and treatment plan. If a diagnosis
is made based on the practitioner’s personal convenience, it may lead to an inaccurate diagnosis. In
addition, this may pose some difficulties in the finishing procedures, consequently leading to an
unaesthetic facial profile or temporomandibular joint disorder.
Even monozygotic twins do not have identical dentition, facial profiles and skeletal patterns (Fig.
l-2). For this reason, it is important to understand the patients’ individual problems and make an
accurate diagnosis, followed by a logical treatment plan. To do so, an orthodontist must carefully

2 2 ►► Chapter 1 _ Causes of Orthodontic Treatment Failure

• • • •
 # • • •

analyze the patient’s skeletal pattern, denture pattern, personal physiological factors and facial
type. The majority of orthodontists pay too much attention to their patients’ current conditions
when diagnosing (Fig. 1-3). As a result, they often fail to notice the real causes of anterior
crowding, protrusion of maxillary anterior teeth, mandibular prognathism, anterior open bite, deep
bite and midline deviation. Instead of focusing on the visible problems, it is far more important to
examine the real causes of malocclusion when treating patients. If orthodontists understand the
main causes, it will then minimize the risk of treatment failure and a need for extraction and
orthognathic surgery treatment.

Treatment failure may be caused by the following reasons:

1) Diagnosis Problems,
2) Treatment Problems,
3) Retention Problems.

►► F ig . 1 -2 Facial and intraoral photographs and radiographs of monozygotic twins.

A. Facial and intraoral photographs and radiographs of older sister.

Chapter 1 _ Causes of Orthodontic Treatment Failure <◄ 23

 ►► Fig. 1-2 (c o n tin u e d ) Facial and intraoral photographs and radiographs of monozygotic twins.
B. Facial and intraoral photographs and radiographs of younger sister.
Although they are twins, dissimilar skeletal patterns, facial profiles and denture patterns are observed.

^ ► Chapter 1 _ Causes of Orthodontic Treatment Failure ® • • ©

 • • • •

► Fig. 1-3 A variety of malocclusion.

It is crucial to understand various patterns of malocclusion: anterior crowding, protrusion of maxillary
anterior teeth, mandibular prognathism, anterior open bite, deep bite and midline deviation.
A. Anterior crowding. B. Class II malocclusion. C. Class III malocclusion.
D. Open bite. E. Deep bite. F. Midline deviation.

Chapter 1 _ Causes of Orthodontic Treatment Failure ◄◄ 2 5

 Diagnosis Problems (Fig. 1-4)

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

limited understanding of denture patterns are often regarded as the causes of treatment failure. In
particular, the limited understanding of antero-posterior analysis and vertical analysis of skeletal
patterns can cause inaccurate analysis results. In denture pattern analysis, result-based analysis can
also lead to errors.

►► Fig. 1-4 A variety of orthodontic diagnosis methods.

A. Pre-treatment facial and intraoral photographs.

\ __________________________________
26 ►► Chapter 1 _ Causes of Orthodontic Treatment Failure
• • • @
 @ • ® ®

►► Fig. 1-4 (c o n tin u e d ) A variety of orthodontic diagnosis methods.

B. Post-treatment facial and intraoral photographs.

Tweed analysis FMA FMIA IMPA

Ideal (°) 25 65 90
Present (°) 24 47 109
Desired (°) 25 65 90
Correction factor In degrees 19
Correction factor(mm) 1mm / 2.5 * 2 15
Discrepancy(entlre arch) (mm) 1
Curve of spee(mm) 2
Total arch length needed (mm) 18
Extraction case 15
Total net following extraction 3

C. Tweed analysis: even after the extraction of the premolars, there is an insufficient amount of space.

Chapter 1 _ Causes of Orthodontic Treatment Failure 4 ◄ 2 7

 p- ► Fig. 1-4 (c o n tin u e d ) A variety of orthodontic diagnosis methods.

Steiner analysis Reference norm Lower arch + -

SNA(°) 82 83
SNB(°) 80 78 Discrepancy 1
ANB(°) 2 5 Expansion
SND(°) 76 or 77 75
U1 to NA(mm) 4 11 Curve of Spee 2
U1 to NA(°) 22 32 Relocation L1 16
L1 to NB(mm) 4 12
L1 to NB(°) 25 38 Relocation L6 0
Pog to NB(mm) not established 0.2 LE space 0
Pog & L1 to NB 1 : 24
HAD 131 105 Intermaxillary 4
OP to SN(°) 14 16 Extraction 15 5
GoGn to SN(°) 32 30
Arch length discrepancy 1 Total net 15 28

D. Steiner analysis: more space is needed with the use of headgear after the premolar extraction.

CHARTING THE ANCHORAGE PROBLEM +

1. Depth of curve of Spee in mm (-) 2
2. MM discrepancy (-) or space (+) in lower arch 1
3. MM to upright T SUBTRACT GOAL FROM PROBLEM AND MULTIPLY x 2 16
4. Add Line 2 and Line 3. Divide by 6 for molar anchorage loss while retracting 3~[3 (-) 3
5. ANB change : 1'Amm per degree for regular anchorage (-) R M
1mm per degree for major anchorage (-) 4.5 3
6. Mandibular plane 8° high (-1), 8° low (+1) (Now see directions A)
7. Use palatal bar (+1) if used at least one year. 1
8. Delay extractlonof 4]4 until ready to retract upper anteriors (+1) 1
9. Extraction values (See “Directions B” ) 15 3
10. See “Direction C” 17 28
11. See “Direction D” 11
12. Use Class III elastics. (+1) per month for number of months NET
9
figure is negative. (See note 1 below)
13. Use high-pull headgear. (+1) per six months of 10-12 hours daily Wear.
2
(see chapter on headgear.) Number 12 plus Number 13 should equal NET.
Note 1: Check 8~[8. Will third molars interfere with distal tips of 7T7 ? Extract if necessary.

E. Level Anchorage System analysis: after premolar extraction, the patients must use Class III
elastics for 9 months and headgear for one year.

28 ►► Chapter 1 _ Causes of Orthodontic Treatment Failure

• • • •
 ® ® • ®

> ► Fig. 1-4 (c o n tin u e d ) A variety of orthodontic diagnosis methods.

M easurem en t Mean S.D . 2 0 0 5 .0 8 .2 3

ODI 7 4 .5 0 6 .07 8 1 .9 7 *
APD I 8 1 .4 0 3 .79 7 9 .6 8
CF 1 5 5 .9 0 6 .52 1 61 .6 5
FMA (deg) 2 6 .0 0 4 .91 2 3 .2 0
UOP (deg) 9 .3 0 3 .8 3 1 2.27
POP (deg) 9 .3 0 3 .83 1 3 .8 5 *

U1 to FH (d eg) 1 1 4 .0 0 4 .6 0 1 2 2 .8 3 *
U1 edge to U p 3 .90 1 .38 6 .4 5 *
L I to MP (d eg) 9 1 .4 0 3 .78 1 0 9 .2 5 >>
IIA (deg) 1 2 7 .0 0 7 .00 1 0 4 .7 3 ***
UL (m m ) -1 .0 0 2 .00 2 .6 9 *
LL (m m ) 2 .0 0 3 .00 5 .61 *

F. MEAW analysis and the intraoral photographs of treatm ent procedure: A fter exam ining the MEAW
analysis and the values of ODI, APDI and CF, the m axillary first premolars and m andibular second
premolars were extracted. In this case, neither the mini-implant nor extra-oral appliance was used.

M easurem ent Mean S.D. 2 0 0 5 -0 8 -2 3 2 0 0 7 -0 7 -0 4

ODI 74.50 6.07 81.97 * 76.82

APDI 81.40 3.79 79.68 85.89 *
CF 155.90 6.52 161.65 162.71 *
FMA (deg) 26.00 4.91 23.20 23.07
UOP (deg) 9.30 3.83 12.27 11.69
POP (deg) 9.30 3.83 13.85 * 11.00
U1 to FH (deg) 114.00 4.60 122.83 * 108.13 *
U1 edge to Lip 3.90 1.38 6.45 * 4.68
L I to MP (deg) 91.40 3.78 109.25 >> 97.66 *
IIA (deg) 127.00 7.00 104.73 *** 131.13
UL (mm) -1.00 2.00 2.69 * -0.79
LL (mm) 2.00 3.00 5.61 * 0.59

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

Chapter 1 _ Causes of Orthodontic Treatment Failure 29

 Treatment Problems

Treatment failure may also occur from the enforced use of extraction treatment arising from a lack
of understanding of proper non-extraction treatment methods. In the case of premolar extraction
treatments, the SWA bracket is (especially on maxillary anterior teeth) highly effective.
Typically, in the case of non-extraction treatments, the SWA bracket can aggravate the labioversion
of maxillary anterior teeth, which will subsequently increase the likelihood of using an extraction
treatment. Also, the tendency to conduct treatments without correcting the mesial angulation of
posterior teeth has been gradually increasing among orthodontists. If these factors are not taken
into account (especially when there is a severe curve of Spee), labioversion of mandibular anterior
teeth may also occur to increase the possibility of premolar extraction treatment.

The relevant factors are as following:

(1) Limited understanding of orthodontic bracket (Fig. 1-5),
(2) Failure of terminal molar adjustment (Fig. 1-6),
(3) Failure of severe curve of Spee adjustment (Fig. 1-7),
(4) Failure of severe curve of Wilson (Fig. 1-7),
(5) Limitations in non-extraction treatment approach (Fig. 1-8).

^ Fig. 1-5 Limited understanding

of orthodontic bracket.
A. Tooth m ovem ent patterns
when the standard bracket
is used (black line).
B. Tooth m ovem ent patterns
when the SW A b racket is
used (red line).
C. C om parisons between the
standard bracket and the SWA
b ra c k e t: w hen co m p ared
with standard bracket (black
line), the SWA bracket(red
line) has a g re ate r crown
lingual torque and m esial
angulation.

...... ....
30 ►► Chapter 1 _ Causes of Orthodontic Treatment Failure • • « •
 © © • •

►► Fig. 1-6 Failure of terminal molar adjustment.

If terminal molars are ignored, anterior teeth are likely to face the labial torque. Although the mandibular
extraction space is closed, it still has the Class II canine relationship.
A. Simple leveling.
B. Case of simple leveling treatment.

Chapter 1 _ Causes of Orthodontic Treatment Failure <◄ 31

 ►► Fig. 1-7. Failure of severe curve of Spee and curve of Wilson adjustment.

▼A ▼B ▼C

►► Fig. 1-8 Limitations in non-extraction treatment approach.

However, because of simple leveling and open coil springs, labioversion of the maxillary anterior teeth
may be aggravated when the SWA bracket is placed on every tooth.
A. Tooth movement patterns of the standard bracket (black line) and the SWA bracket (red line).
B. Standard bracket + archwire with crown lingual torque + open coil springs.
C. SWA bracket + preformed archwire + open coil springs.

32 ►► Chapter 1 _ Causes of Orthodontic Treatment Failure

® • • •
 • • • •

Retainer Problems

After receiving treatment, all patients are advised to wear a retainer to maximize their treatment
results and to diminish the factors of malocclusion risk. The required retainer may vary depending
on the type of malocclusion; the individualized retainer appliance must be appropriately used
based on each malocclusion case.

• To minimize treatment failures, the followings are important

When treating malocclusion, it is essential to understand the concept of malocclusion itself. In

other words, orthodontists must identify the problems arising from each malocclusion and
make an accurate treatment plan for a successful treatment result. To do this, orthodontists
must always consider and understand the invisible as well as the visible problems.
When treating malocclusion, it is essential to identify the causes, to eliminate the etiological
factors, and to establish treatment methods.
For example, in the case of the visible Class I molar relationship, the final diagnosis can vary
after careful consideration of the skeletal pattern. In Class II skeletal pattern, it is
understandable to have a Class II molar relationship, or even a Class I molar relationship,
depending on the posterior movement of maxillary molar or the anterior movement of
mandibular molar. However, in this case, if only the molar relationship is taken into account,
further problems may arise (Fig. 1-9).
Therefore, for a successful or positive treatment result, instead of a routine extraction treatment
method or a routine treatment planning, an individualized treatment must be performed.

Chapter 1 _ Causes of Orthodontic Treatment Failure -M 33

 ►► Fig. 1-9 Skeletal pattern and molar relationship.

34 ►► Chapter 1 _ Causes of Orthodontic Treatment Failure

• • • ©
 • • # «

►> Fig. 1-9 (c o n tin u e d ) Skeletal pattern and molar relationship.

M easurem en t Mean S.D . 2 0 1 0 .0 6 .2 2

ODI 7 4 .5 0 6 .07 7 3 .5 2
APD I 8 1 .4 0 3 .7 9 7 6 .4 4 *
CF 1 5 5 .9 0 6 .52 1 49 .9 6
FMA (d eg) 2 6 .0 0 4 .91 3 1 .6 2 *
UOP (d eg) 9 .3 0 3 .83 1 1.0 8
POP (deg) 9 .3 0 3 .83 1 8 .4 4 **
U1 to FH (deg) 1 1 4 .0 0 4 .6 0 1 2 9 .7 4 ***
U1 edge to Lip 3 .90 1.38 2 .3 6 *
L I to MP (d eg) 9 1 .4 0 3 .78 9 9 .0 2 **
IIA (deg) 1 2 7 .0 0 7 .00 9 9 .6 1 ***
U L (m m ) -1 .0 0 2 .0 0 5 .1 4 ***
LL (m m ) 2 .0 0 3 .00 7 .1 0 *

B. Due to the dental compensation of molar (mesial angulation of lower molars and distal angulation of
upper molars), Class I molar relationship may be observed in Class II skeletal pattern. As a result, there
is a change in posterior occlusal plane.
B-1. Class II skeletal pattern and Class II molar relationship.
B-2. Class II skeletal pattern and Class I molar relationship.

Chapter 1 _ Causes of Orthodontic Treatment Failure << 35

 REFERENCES

1. Andrews LF. Straight wire, the concept and appliance, San Diego: LA Wells; 1986.
2. Andrews LF. The six keys to normal occlusion, Am J Orthod 62:296-309, 1972.
3. Arnett GW, and McLaughlin RP. Facial and Dental Planning for Orthodontists and Oral Surgeons.
Mosby, 2004.
4. Beckwith FR, Ackerman RJ, Cobb CM, and Tira DE. An evaluation of factors affecting duration of
orthodontic treatment. Am J Orthod Dentofacial Orthop 115:439-47,1999.
5. Bishara SE, Hoppens BJ, Jakobsen JR, Kohout, F. J. et al. Changes in the molar relationship between
the deciduous and permanent dentitions: a longitudinal study. Am J Orthod Dentofacial Orthop 93:19-
28, 1988.
6. Blake M, and Bibby K. Retention and stability: A reviews of the literature. Am J Orthod Dentofac
Orthop 114:299-306, 1998.
7. Burstone CJ. Lip posture and its significance in treatment planning. Am J Orthod 53:262,1967.
8. Creekmore TD. Inhibition or stimulation of the vertical growth of the facial complex: its significance to
treatment. Angle Orthod 37:285-97, 1967.
9. Daskalogiannakis J, and Ammann, A. Glossary of orthodontic terms, Quintessence, 2000.
10. Dougherty HL. The effect of mechanical forces upon the mandibular buccal segments during
orthodontic treatment. Am J Orthod 54:29-49, 1968.
11. Epker BN and O ’ Ryann F. Determinants of Class II dentofacial morphology: I. A biomechanical
theory. In McNamara JA Jr (ed). The effect of surgical intervention on craniofacial growth. Monograph
No. 12, Craniofacial Growth Series. Ann Arbor: Center for Human Growth and Development,
University of Michigan, 1982:169-205.
12. Fields HW, and Proffit WR. Facial pattern differences in long faced children and adults. Am J Orhod
85:217-23, 1984.
13. Fushima K, Kitamura Y, Mita H, et al. Significance of the cant of occlusal plane in Class II division 1
malocclusion. Europ J Orthodont 18:27-40,1996.
14. Giannelly A. One-phase versus two-phase treatment. Am J Orthod 108:556-559,1995.
15. Graber TM, Rakosi T, and Petrovic AG. Dentofacial Orthopedics with functional appliance, 2nd
edition, Mosby, 1997.
16. Kim Jl, Akimoto S, Shinji H, and Sato S. Importance of vertical dimension and cant of occlusal plane in
craniofacial development. Int J Stomatol Occlusion Med 2:114-121,2009.
17. Kim Jl. Practical Clinical Orthodontics, vol 1. Orthodontic treatment with MEAW. Well publishing Inc,
2012.
18. Kim Jl. Practical Clinical Orthodontics, vol 2. Orthodontic Diagnosis. Well publishing Inc, 2013.
19. Kim Jl. Practical Clinical Orthodontics, vol 3. Early orthodontic treatment. Well publishing Inc, 2015.

36 ►► Chapter 1 _ Causes of Orthodontic Treatment Failure @ @

 • © • •

20. Kim YH and Vietas JJ. Anteroposterior Dysplasia Indicator: An adjunct to cephalometric differential
diagnosis. Am J Orthod. 73:619-633. 1978.
21. Kim YH. A Comparative cephalometric study on Class II Division 1 non-extraction and extraction
cases. Angle Orthod. 49:77-84. 1979. •
22. Kim YH. Common undesirable side effects of straight archwire technic. Int J MEAW 1:85-104,1994.
23. Kim YH. Overbite Depth Indicator with particular reference to anterior open bite. Am J Orthod. 65:586-
611. 1974.
24. Lobb WK. Craniofacial morphology and occlusal variation in monozygous and dizygous twins. Angle
Orthod 57:219-233, 1987.
25. McNamara JA Jr, and Brudon WL. Orthodontics and Dentofacial Orthopedics. Needham Press, 2001.
26. Merrifield LL. Dimensions of the denture: back to the basics. Am J Orthod Dentofac Orthop 106:535-
542, 1994.
27. Moyers RE. Handbook of orthodontics. Chicago: Year-book Medical Publisher, 1988.
28. Nahoum HI, Horowitz SL, and Benedicto EA. Varieties of anterior openbite. Am J Orthod 61:486-92,
1972.
29. Proffit WR. Contemporary orthodontics, St Louis: CV Mosby company, 1986.
30. Ricketts RM. The influence of orthodontic treatment on facial growth and development. Am J Orhod
30:103-31, 1960.
31. Root TL. Level anchorage system. Koonja Publishing Inc, 1994.
32. Sato S. Alteration of occlusal plane due to posterior discrepancy related the development of
malocclusion-introduction of denture frame analysis. Bulletin of Kanagawa Dental College 15: US-
123, 1987.
33. Sato S. Orthodontic therapy with multiloop edgewise archwire (II). Shinhung International Inc, 2006.
34. Steiner CC. Cephalometries for you and me. Am J Orthod 39:729-755, 1953.
35. Steiner CC. Cephalometries in clinical practice. Angle Orthod 29:8-29. 1959.
36. Steiner CC. The use of cephalometries as an aid to planning and assessing orthodontic treatment.
Report of a case. Am J Orthod 46:721-735,1960.
37. Tweed CH. Clinical orthodontics, Mosby, St.Louis, 1966.
38. Tweed CH. The Frankfort-mandibular incisor angle (FMIA) in orthodontic diagnosis, treatment
planning, and prognosis. Am J Orhod 32:175-230, 1946.
39. Tweed CH. The Frankfort-mandibular plane angle in orthodontic diagnosis, classification, treatment
planning, and prognosis. Angle Orthod 24:121-169, 1954.
40. Vaden JL, Dale JG, and Klontz HK. The Tweed Merrifield edgewise appliance. In Graber TM,
Vanarsdall RL, Vig KWL, editors. Orthodontics: current principles and techniques, 4th edition, Elsevier
Mosby. 2005.

Chapter 1 _ Causes of Orthodontic Treatment Failure <M 37

 Chapter 2

CAUSES OF
MALOCCLUSION
 g ^ Skeletal Factors (Fig. 2-1)

1) Antero-posterior skeletal relationship: This relationship shows antero-posterior relationship

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

40 ►► Chapter 2 _ Causes of Malocclusion # @ ® ©

 • • • ®

▼A-1 ▼A-2

►► Fig. 2-1 Skeletal factors.

A. A n te ro -p o ste rio r skeletal

relationship.
A-1. Class II.
A-2. Class I.
A-3. Class III.

B. Vertical skeletal relationship.

B-1 .H ig h angle ske le ta l
pattern.
B-2. Low angle ske le ta l
pattern.

3-2 >

►► Fig. 2-2 Posterior vertical dimension (PVD).

A. Assessment method of posterior vertical dimension: take a perpendicular line from PNS to mandibular
plane.
B. Cephalometric radiograph of a patient with sufficient posterior vertical dimension.
C. Cephalometric radiograph of a patient with insufficient posterior vertical dimension.

Chapter 2 _ Causes of Malocclusion 41

 ►► Fig. 2-3 The difference between left and right side of posterior vertical dimension.
A. A case where there is no difference between the left and right posterior vertical dimension.
B. A case where there is a difference between the left and right posterior vertical dimension.

Dental Factors

Number of teeth

Abnormalities in the number of teeth can be caused by either congenital missing teeth or
supernumerary teeth.

1) Congenital missing teeth can cause a variety of malocclusion problems. The most common
sites are as follows:
(1) Mandibular second premolar,
(2) Mandibular anterior teeth (one or two),
(3) Maxillary second premolar,
# (4) Maxillary lateral incisor.
#
2) Supernumerary teeth: Depending on the positions of supernumerary teeth, they can cause a
variety of problems. If a supernumerary tooth is located between the maxillary central incisors,
it is closely related to diastema. In contrast, if supernumerary teeth are placed at the molar and
premolar sites, they have a relatively low correlation with malocclusion.

42 ►► Chapter 2 _ Causes of Malocclusion ® @ © @

 • • • •

Chapter 2 _ Causes of Malocclusion ◄ 4 3

 ► Fig. 2 -4 (c o n tin u e d ) Congenital missing teeth.

D. Missing maxillary lateral incisors.

\ _____________________
44 ►► Chapter 2 _ Causes of Malocclusion
• • • ©
 • # @ ®

Y Y Fig. 2-5 Supernumerary teeth.

A. Between the maxillary central incisors. A-1. Impacted supernumerary tooth.
A-2. Erupted supernumerary tooth.
B. Elsewhere. B-1. Maxillary lateral incisor region.
B-2. Mandibular canine region.
B-3. Para-molar or supernumerary tooth.

Chapter 2 _ Causes of Malocclusion <◄ 4 5

 S ize of teeth

1) Tooth size (Fig. 2-6)

In general, there is a low correlation between the mesio-distal width of crown and malocclusion.
For Koreans, the average mesio-distal width of maxillary central incisor is 8.5mm (male 8.55mm
(±0.45), female 8.19mm (±0.44)). Here, the size of the maxillary central incisor tends to have a
high correlation with the size of other teeth. In particular, when it is larger than the average size
(over 9.0mm), it is highly likely that the rest of the teeth are much larger too. In this case,
crowding may arise from the discrepancy between the tooth size and jaw size. This means that if
the tooth size is relatively smaller than the jaw size, space will be ensured.

►► Fig. 2-6 Tooth size.

A. Case where there is a normal size (maxillary central incisor width is 8.6mm).
B. Case where there is a larger size (maxillary central incisor width is 9.5mm).
C. Case where there is a smaller size (maxillary central incisor width is 7.5mm).

2) Tooth size discrepancy (Fig. 2-7)

By comparing the discrepancy between the maxillary and mandibular tooth size, it is possible to
check whether there is occlusion, overbite, and overjet after the orthodontic treatment. This can be
done by measuring the sum of the mesio-distal width of six mandibular anterior teeth and
comparing them with the sum of the mesio-distal width of six maxillary anterior teeth. The
equation is (sum of mandibular 6 / sum of maxillary 6) x 100. This value is known as the ABR
(Anterior Bolton Ratio). The value is usually 77.2% (± 1.65).

46 ►► Chapter 2 _ Causes of Malocclusion

• # • ©
 • • • @

(1) In cases where ABR is higher than 77.2% (Fig. 2-8), the following can
occur:

a. Mandibular anterior crowding,

b. Maxillary anterior space: when there is a small maxillary lateral incisor,
c. Shallow overbite and overjet.

In addition, as the patterns of malocclusion unfold, the following can occur.

a) In the case of Class I malocclusion: maxillary anterior space or mandibular anterior
crowding can be observed.
b) In the case of Class II malocclusion: Mesial angulation of the maxillary canine can
cause Class II canine relationship. This will aggravate the problem of Class II
malocclusion.
c) In the case of Class III malocclusion: Shallow overbite and overjet can cause a forward
movement of the mandible. This can also aggravate the problem of anterior cross bite.

Chapter 2 _ Causes of Malocclusion <« 47

 ▼A ▼B ▼C

►^ Fig. 2-8 Tooth size discrepancy (ABR > 77.2%).

A. Class I malocclusion: maxillary anterior space or mandibular anterior crowding can be observed.
B. Class II malocclusion: the mesial angulation of maxillary canine can cause Class II canine relationship,
which can aggravate the problem of Class II malocclusion.
C. Class III malocclusion: shallow overbite and overjet can cause a forward movement of mandible,
which can aggravate the problem of anterior cross bite.

(2) In cases where ABR is lower than 77.2% (Fig. 2-9), the following can
occur:

a. Maxillary anterior crowding,

b. Mandibular anterior space,
c. Excessive overbite and overjet.

48 ►► Chapter 2 _ Causes of Malocclusion

• • • •
 • • • •

Shape of Teeth

1) Abnormalities in tooth morphology (Fig. 2-10)

Abnormal tooth morphology can also cause malocclusion. More specifically, when there is an
abnormal maxillary lateral incisor, or when the mandibular second premolars or the mandibular
fusion teeth show a morphological problem, a variety of problems may occur during the final stage
of treatment or even during the retention period.

►► F ig . 2 -1 0 Abnormalities in
tooth morphology.
A. Abnormal crown morphology
of the maxillary lateral incisors.
B. Mandibular fusion teeth.
C. Abnormal crown morphology
of the mandibular second
premolars.

Chapter 2 _ Causes of Malocclusion 49

 2) Shovel teeth (Fig. 2-11)

The shape of maxillary anterior lingual surface is diverse. Amongst Asians, it is common to have
prominent marginal ridge at the anterior lingual surface. This is known as shovel teeth, and since it
is difficult to establish a correct overbite and overjet, it may cause an opposing mandibular anterior
teeth crowding, labioversion of maxillary anterior teeth, and the detachment of fixed retainer.

►► Fig. 2-11 Tooth morphology.

A. Lingual surface of normal anterior teeth.
B. Shovel tooth.
C. Maxillary incisor and lateral incisor with different labio-lingual thickness.
D. Diagram of maxillary and mandibular anterior crowding when there is a shovel tooth.
D-1. Diagram of a normal lingual surface of anterior teeth.
D-2. Diagram of shovel teeth: During treatment or in the final stage of treatment,
it is necessary to grind the lingual surfaces of the maxillary anterior teeth.

5Ü ►► Chapter 2 _ Causes of Malocclusion • • ® ®

 ® • • #

3) Crown shape (Fig. 2-12)

Anterior tooth morphology has an influence on aesthetics. When the face is seen from a frontal
view, the crown shape is observed. In general, these are square, triangular, barrel or ovoid shapes.
In the case of triangular shapes, black triangles are highly likely to appear, while in the case of
barrel shapes, space can be identified around the incisal edge after treatment.

►► Fig. 2 -1 2 Crown shape.

A. Square shape.
B. Ovoid shape.
C. Barrel shape.
D. Triangular shape.

Chapter 2 _ Causes of Malocclusion <◄ 51

 Position of teeth (Ideal arch form or first-order bends)

1) Mesial rotation and/or positional deviation of molars (Fig. 2-13)

The buccal surfaces of the maxillary left and right first molars must be parallel to one another. If
there is a decrease in dental arch length, buccal cusps will mesially rotate on the axis of the palatal
root of the maxillary first molar. As a result, this movement will shorten the dental arch length and
mesially rotate the entire lateral teeth. However, by correcting the mesially rotated maxillary first
molar in the parallel direction, it is possible to 1) gain space and 2) correct the dental arch shape.

► Fig. 2 -1 3 Position of teeth.

A. Case where there is a parallel rotation of maxillary first molars.

B. Case where there is a mesial rotation of maxillary first molars.
C. Mesial rotation vs parallel rotation: mesially rotated teeth can gain
space through parallel rotation.

52 ►► Chapter 2 _ Causes of Malocclusion m m ® ®

 # • • ©

►► Fig. 2 -1 3 (c o n tin u ed ) Position of teeth.

D. Case where there is no positional deviation.

E. Case where there is positional deviation of maxillary first molar.
F. Case where there is positional deviation of mandibular first molar.

'nicalTips: Positional deviation

Measure the distances from the end of the diagnostic model to the mesio-bucccal

cusp of the first molar and compare the ones between the left and right side.; ^

Chapter 2 _ Causes of Malocclusion <◄ 53

 2) Transpalatal width (TPW) (Fig. 2-14)

Maxillary transpalatal width: This indicates the shortest distance from the left-to-right palatal
gingival margin of the maxillary first molars. 35.3mm is the average distance for European-
Americans (Moyers et ah, 1976), but if this is less than 31mm after the maxillary first molar
eruption, the teeth may not reach normal size, as explained in Table 2-14 C (Moyers et ah, 1976).
In this case, because of an insufficient transverse growth of the dental arch, the dental arch itself is
expected to be protruded and be in a tapered arch form. Therefore, it is extremely important to
expand the maxillary first molar area and modify the dental arch form.

►► Fig. 2 -1 4 TPW (Transpalatal width).

▼A

Age N Mean S.D. Intial AW Intial AW Intial AW

< 31mm 31-35mm > 35mm
7 119 32.7 1.4 S.D. S.D.
Age Mean S.D. Mean Mean
8 171 33.2 1.5 7 28.9 1.3 32.8 0.9 36.5 1.2
9 181 33.2 1.4 8 29.3 1.1 33.1 1.1 37.1 1.2
10 179 33.7 1.5 9 30.0 1.1 33.6 1.3 37.4 1.1
11 159 34.5 1.4 10 30.3 1.4 34.0 1.4 37.5 1.1
11 30.4 1.6 34.3 1.7 37.5 0.9
12 128 35.2 1.4
12 30.9 1.3 34.5 2.1 37.5 1.2
13 116 35.4 1.5 13 31.4 1.4 34.7 1.6 37.5 1.6
14 93 35.2 1.4 14 31.7 1.6 35.0 1.6 37.8 1.6
15 74 35.3 1.4 15 32.2 1.4 35.3 1.9 38.2 1.9

A. TPW measuring method.

B. TPW value change according to growth (Moyers et al., 1976).
C. Longitudinal changes according to various TPW (Moyers et al., 1976).
D. Transition of arch form based on the changes in TPW.

54 ►► Chapter 2 _ Causes of Malocclusion

• • • @
 • © • •

►► Fig. 2 -1 4 (c o n tin u e d ) TRW (Transpalatal width).

E. Facial and intraoral photographs of a patient with small TPW (29.2mm).

F. Facial and intraoral photographs of a patient with normal TPW (35.5mm).

Chapter 2 _ Causes of Malocclusion <◄ 55

 3) Inter-canine width (ICW) (Fig. 2-15)

The inter-canine width indicates the distance from one side of the maxillary canine cusp tip to the
other. If the inter-canine width is small, the width between mandibular canines tends to be small,
too. This small width may then cause anterior crowding and restrict the mandibular forward
movement. As a result, Class II malocclusion may occur.

►► Fig. 2 -1 5 Inter-canine Width (ICW).

3 4 .0 7 m m
U :
± 1 .9 0

IC W 2 5 .8 7 m m
L:
± 1 .8 0

75 7 %
(Chang et al., 1991)

A. Measuring method of inter-canine width and its normal value.

56 ►► Chapter 2 _ Causes of Malocclusion Ç., ::

 • • • •

►► Fig. 2 -1 5 (c o n tin u e d ) Inter-canine Width (ICW).

C. Facial and intraoral photographs of a patient with normal ICW (35.5mm).

4) Symmetry of maxillary canines (Fig. 2-16)

The position of maxillary canines must maintain their bilateral symmetry. If a maxillary canine is
asymmetrically located, mandibular shift or tooth movement may occur to achieve its canine
guidance.

5) Positional deviation can be caused by prolonged retention of primary

teeth or premature exfoliation

In order to establish proper occlusion, maxillary and mandibular dentition must be arranged
without crowding. However, if occlusion is not proper, it may cause attrition, tooth displacement or
mandibular displacement.

Chapter 2 _ Causes of Malocclusion ◄◄ 5 7

 It is extremely important to check the changes in tooth position, especially when there are (Fig. 2-
17):
© positional deviation caused by premature exfoliation, and
© positional deviation caused by prolonged retention of primary teeth.

►^ Fig. 2 -1 6 Symmetry of maxillary canines.

A. Case where the maxillary canines are symmetrically positioned.

58 ►► Chapter 2 _ Causes of Malocclusion

• ® • ©
 • • • @

►► Fig. 2 -1 7 Case where there are a variety of tooth malpositions.

A. Case with premature exfoliation of primary teeth: premature exfoliation of the maxillary second primary
molars has caused 1) a space deficiency problem in the maxillary second premolars, and 2) anterior
cross bite.

B. Case with prolonged retention of a primary tooth: prolonged retention of a mandibular right primary
canine has caused 1) mandibular anterior crowding, 2) midline deviation, and 3) edge-to-edge bite.

Chapter 2 _ Causes of Malocclusion «◄ 59

 Mesio-distal angulation of teeth (tip-back bends or second-order bends)

In general, the main causes of open bite are extrusion of posterior teeth and intrusion of anterior
teeth. In contrast, the main causes of deep bite are intrusion of posterior teeth and extrusion of
anterior teeth. Here, depending on the vertical position of anterior and posterior teeth,
malocclusion may occur (Fig. 2-18).

►► Fig. 2 -1 8 Vertical position of

teeth.
A. Open bite and extrusion of
posterior teeth.
B. Open bite and intrusion of
anterior teeth.
C. Deep bite and intrusion of
posterior teeth.
D. Deep bite and extrusion of
anterior teeth.

#
©
9

60- Chapter 2 _ Causes of Malocclusion • © # ®

 © @ © #

Kim et al. (2009) argued that over-eruption of mandibular posterior teeth is apparent in Class II
malocclusion in the early stages of mixed dentition periods (Heilman dental age IIIB). They also
argued that there might be an over-eruption of maxillary posterior teeth in Class III malocclusion
in the completion stage of permanent dentition. Their findings show that in Class II malocclusion,
steep posterior occlusal plane (POP) is apparent, while in Class III malocclusion, flat POP is
apparent. Additionally, they observed that in Class II malocclusion, there is insufficient posterior
vertical dimension, and in Class III malocclusion, there is sufficient posterior vertical dimension.

The posterior occlusal plane (POP) is a line that connects the cusp tip of mandibular second
premolar to the disto-buccal cusp tip of the mandibular second molar. It is important to note here
that a posterior occlusal plane may vary depending on the vertical position of teeth and the mesio-
distal angulation of teeth.

The following demonstrates the factors which may influence the POP in the sagittal plane:

(1) Vertical height difference in posterior teeth (Fig. 2-19),

(2) Different mesio-distal angulation of posterior teeth (Fig. 2-20).

►^ Fig. 2 -1 9 Over-eruption and occlusal plane.

A. Extrusion of maxillary posterior teeth and changes in occlusal plane: counter-clockwise
(CCW) rotation of occlusal plane or flattening of occlusal plane.
B. Extrusion of mandibular posterior teeth and changes in occlusal plane: clockwise (CW)
rotation of occlusal plane or steepening of occlusal plane.

Chapter 2 _ Causes of Malocclusion «◄ 61

 ►► Fig. 2 -2 0 Posterior occlusal plane (POP).
A. POP: the line that connects the cusp tip of the mandibular second premolar to the disto-
buccal cusp tip of the mandibular second molar.
B. Over-eruption of mandibular posterior teeth and changes in posterior occlusal plane.
C. Mesially-tilted mandibular posterior teeth and changes in posterior occlusal plane.
D. Correlation between posterior occlusal plane and malocclusion.

nicalTips: Posterior discrepancy (Sato et al., 1991) (Fig. 2-21)

Disharmony of anterior teeth is called anterior discrepancy, whereas disharmony of

posterior teeth is called posterior discrepancy. Posterior discrepancy frequently

occurs when there is insufficient vertical dimension of the posterior area, which can

cause the mesial angulation of teeth or over-eruption. In this case, there may be

some changes in the posterior teeth or anterior teeth, and skeletal problems can

occur, too. ► ► ► ► ►

62 ►► Chapter 2 _ Causes of Malocclusion • # • ©

 @ « ® •

►► Fig. 2-21 Posterior discrepancy.

A. Anterior discrepancy and posterior discrepancy.
B. Posterior discrepancy may cause mesial angulation or over-eruption of teeth.

A steep posterior occlusal plane is one of the characteristics of Class II malocclusion. It is formed
either from a relative over-eruption in mandibular posterior teeth (when compared with the
maxillary posterior teeth) or from the mesial angulation of mandibular posterior teeth (Fig. 2-22).
In contrast, a flat posterior occlusal plane is one of the characteristics of Class III malocclusion,
and is formed either from a relative over-eruption in maxillary posterior teeth (when compared
with the mandibular posterior teeth) or from the uprighted condition of mandibular posterior teeth.

►► Fig. 2 -2 2 Characteristics of Class II malocclusion.

A. To compensate for Class II malocclusion, there may be a decrease in vertical dimension of
posterior teeth.
B. Differences in posterior occlusal plane are observed in different skeletal patterns. In Class II
m alocclusion, steep p o sterior occlusal plane can be observed, w hile in Class III
malocclusion, flat posterior occlusal plane is commonly observed (Kim et al., 2009).

Chapter 2 _ Causes of Malocclusion «◄ 63

 • Steep POP (Fig. 2-23)
In Class II malocclusion, the majority of patients who have steep occlusal plane may also
have the mesially angulated posterior teeth, showing a severe curve of Spee. Also, when
the patients have midline deviation, 1) different vertical heights of left and right posterior
teeth, and 2) different angulations of left and right mandibular posterior teeth are evident.
In other words, the affected side is likely to have more mesially tilted mandibular posterior
teeth and a severe curve of Spee (Fig. 2-24).

During the transition of deciduous to permanent dentition, it is essential to check the

changes in movement of first-, second-, and third-order bends in the following cases:

• Premature loss of deciduous teeth (Fig. 2-25),

• Premature extraction of permanent teeth (Fig. 2-26),
• Congenital missing teeth (Fig. 2-27),
• Ankylosis (Fig. 2-28),
• Abnormally eruptive teeth (Fig. 2-29),
• Dental caries (Fig. 2-30),
• Improper dental restorations (Fig. 2-30),
• Delayed eruption of permanent teeth (Fig. 2-31),
• Prolonged retention and abnormal resorption of deciduous teeth.

64 ►► Chapter 2 _ Causes of Malocclusion # • • •

 • • • •

►► Fig. 2 -2 3 Steep POP.

A. Diagram of steep POP (Fushima et al., 1996).
B. Class II malocclusion and over-erupted mandibular posterior teeth (Kim et al., 2009).
C. Mesial angulation of mandibular posterior teeth.
D. A patient with steep POP: the upper occlusal plane angle is 11.7° and the POP angle is 18.3°.
E. Severe curve of Spee or anterior open bite.
E-1. Case of severe curve of Spee (POP angle: 22.3°).
E-2. Case of anterior open bite (POP angle: 22.4°).
F. Protruded lips that have been caused by retruded mandible.
G. Temporomandibular joint disorder (Fushima et al., 1996).

Chapter 2 _ Causes of Malocclusion <■* 65

 ►► Fig. 2 -2 4 Difference between the left and right posterior occlusal plane of a patient who has midline
deviation.

Table. Occlusal plane difference between shifted side and

non-shifted side of dentitions In mandibular lateral
displacement malocclusion (n=77).
Occlusal Shifted side Non-shifted side
Difference
Plane Mean SD Mean SD
1-6 11.35 ± 4.12 10.49 ± 3.66 0.86
1-4 10.35 ± 4.36 9.63 ± 4.17 0.72
5-7 18.05 ± 12.29* 13.81 ± 5.85 4.24
6-7 20.39 ± 12.13* 15.22 ± 5.28 5.17
* Significantly different from non-shifted side at P<0.05 (Welch analysis)

A. The relationship between midline deviation and posterior occlusal plane (Sato et
• al., 2006).
B. Difference between the left and right posterior occlusal plane in a panoramic
radiograph.
C. The relationship between posterior vertical dimension and midline deviation.

66 ►► Chapter 2 _ Causes of Malocclusion

• ® • •
 # • • ©

►► Fig. 2 -2 4 (c o n tin u e d ) Difference between the left and right posterior occlusal plane of a patient who
has midline deviation.

D -2 ^

D. Midline deviation in the model.

E. The relationship between differences in POP and midline deviation: Different tooth angulation and
posterior occlusal plane may also imply the differences between the left and right posterior vertical
dimension. These are often regarded as the causes of midline deviation. The above diagram has a
severe curve of Spee on the right hand side and the midline deviates to the right.

Chapter 2 _ Causes of Malocclusion ◄◄ 67

#

►► Fig. 2 -2 6 Case where a difference in mesio-distal

angulation is observed due to premature extraction of
permanent teeth.
As the mandibular right first molar was lost prematurely,
a difference between the left and the right occlusal
plane is observed.

68 ►► Chapter 2 _ Causes of Malocclusion • • © ®

 © @ • @

►► Fig. 2 -2 7 Case where congenital missing teeth have

caused the difference in mesio-distal angulation.
Case where maxillary right first and second premolars,
m a x illa ry left second p re m o la r, and b ila te ra l
mandibular second premolars are missing. Mandible
deviates to the right due to a difference in mesial
angulation between the left and right first molar.

►► F ig . 2 - 2 8 Case where ankylosis has caused a

mesio-distal angulation of teeth.
The mandibular left second premolar is missing with
ankylosis of primary second molar, and the mandibular
left molars are mesially tilted. Although there is no
midline deviation, the left occlusion is unstable.

Chapter 2 _ Causes of Malocclusion < ◄ 69

A>

B►

►► Fig. 2 -2 9 Case where ectopic eruption of permanent

teeth has caused a difference in vertical position and
mesio-distal angulation of teeth.
O ver-eruption and m esial angula tion of prim ary
second molars are observed due to ectopic eruption of
maxillary and mandibular first molars.
A. Ectopic eruption of maxillary first molar.
B. Ectopic eruption of mandibular first molar.

►► Fig. 2 -3 0 Case where dental caries and improper

dental restorations have caused a difference in mesio-
distal angulation of teeth.
Dental caries are observed on the mandibular right
primary second molar, and mesial angulation is also
observed in the mandibular right first molar.

70 ►► Chapter 2 _ Causes of Malocclusion # • • •

 # © • •

A
■)

►► Fig. 2-31 Cases where delayed eruption of permanent teeth has caused a difference in mesio-distal
angulation of teeth.
A. Difference is observed in the eruption rate between the left and right molar: as the maxillary right first
molar has not yet erupted, mandibular midline deviates to the right.
B. Over-eruption of the maxillary second molar: over-eruption of the maxillary right second molar has
moved the mandibular midline to the left.

Chapter 2 _ Causes of Malocclusion 71

 Labio-lingual or buceo-lingual inclination of teeth
(torque or third-order bends)

Abnormal labio-lingual or bucco-lingual inclination of teeth restricts mandibular movement and

causes a variety of malocclusion. A severe lingual inclination of maxillary anterior teeth restricts
the forward movement of the mandible and causes Class II malocclusion or deep bite. According
to Sato et al. (2006), midline deviation can aggravate the buccal crown inclination of maxillary
posterior teeth on the affected side, and the lingual crown inclination of maxillary posterior teeth
on the unaffected side.

It is extremely important to check the following factors.

1) Anterior teeth inclination

(1) Maxillary anterior region (Fig. 2-32),

(2) Maxillary canine area (Fig. 2-33).

►^ Fig. 2 -3 2 Crown inclination

of maxillary anterior teeth.
A. Proclination of maxillary
anterior teeth.
B. Normal inclination of
maxillary anterior teeth.
C. Retroclination of maxillary
anterior teeth.

72 ►► Chapter 2 _ Causes of Malocclusion • @ • •

 • • • ft

ft
ft
ft

►► Fig. 2 .3 3 Various cases that show different torques of maxillary canines.

A. Case where the maxillary canine torque is normal.
B. Cases where there is a severe palatal inclination.
B-1. Normal maxillary inter-canine width (34.6mm).
B-2. Small maxillary inter-canine width (32.0mm).
C. A case where there is a difference in torque between the maxillary left and right canine: due to a severe
lingual crown torque of the maxillary right canine, the mandibular midline has deviated to the left.
D. A case where there is a difference in vertical height between the maxillary canines: due to severe
extrusion and linqual crown torque of the maxillary riqht canine, the mandibular midline has deviated
to the left.

Chapter 2 _ Causes of Malocclusion 73

 2) Inclination of posterior teeth (Fig. 2-34)

►► Fig. 2 -3 4 Various cases that show different torques of posterior teeth.

A. Normal torque of maxillary and mandibular posterior teeth.
B. Severe lingual crown inclination of mandibular posterior teeth.

74 ►► Chapter 2 _ Causes of Malocclusion

• • • •
 • • • ©

3) Differences in torque between the left and right side

►► Fig. 2 -3 5 Torque differences in posterior teeth.

A. Midline deviation and torque differences in posterior teeth.
B. Diagram: The maxillary posterior teeth on the affected side have a buccal crown inclination and the
maxillary posterior teeth on the unaffected side have a lingual crown inclination. On the other hand, a
lingual crown inclination is observed in the mandibular posterior teeth on the affected side, while a
buccal crown inclination is observed in the mandibular posterior teeth on the unaffected side.
Therefore, in order to correct the midline deviation, torque adjustment of posterior teeth should be
made accurately.

Chapter 2 _ Causes of Malocclusion 4 4 75

 Clinical Tips: Anterior component of force
Molars tend to move forward during our life time. There are a few factors that can

influence their movement. These factors consist of the following:

1) Morphology and angulation of teeth,

2) Occlusal force and muscle strength,

3) Trans-septal fibers.

Due to the factors above, teeth have a tendency of mesial angulation as we

get older. In particular, if the molars are already mesially tilted, they may be

even more mesially angulated over a period of time. At the same time, the
opposing teeth may also be mesially tilted, and the current condition of molar

occlusion is likely to persist. Also, the existing crowding on the maxillary and

mandibular anterior arch may be aggravated as we get older, in which case a

proper treatment is needed. [>>

,V < 3 finical Tips: Points to check when a patient has a midline deviation
(Fig. 2-36)
1. First-order bends: symmetry in the maxillary canines and the arch form, and the

posterior cross bite.

2. Second-order bends: differences in vertical position, mesio-distal angulation and

curve of Spee.

m 3. Third-order bends: torque differences in the maxillary canines and posterior teeth.

& —» Vertical, antero-posterior and transverse relationships are correlated with one

another (Fig. 2-37). ^ ^ ^ ^ ^ ^

76 ►► Chapter 2 _ Causes of Malocclusion • • • #

 • • • •

►► Fig. 2 -3 6 Points to check when a patient has a midline deviation.

A. Midline deviation.
B. First-order bends: symmetry in the maxillary canines and the arch form,
C. Second-order bends: differences in vertical position and mesio-distal angulation,
D. Third-order bends: torque differences in posterior teeth.

►► Fig. 2 -37 First-, second- and

Vertical third-order bends.
relationship Depending on the vertical
position and angulation of
posterior teeth, antero­
Sagittal Transverse posterior and transverse
relationship relationship relationship may also change.
Although the molar shows a
Class I relationship, a Class II
canine relationship is observed
due to the mesial angulation of
the mandibular right posterior
teeth.
A. Correlation of vertical, antero­
posterior and transverse
relationship.
B. A case with a midline
deviation.

Chapter 2 _ Causes of Malocclusion < < 77

 -sir

Environmental Factors

1) Habitual mouth opening (Fig. 2-38): Patients should keep their mouth closed without any tension
on their chins when resting. Malocclusions such as dolicho-facial face, retruded chin and
bimaxillary protrusion are observed amongst the patients with habitual mouth opening. Since
patients close their mouth with a mentalis muscle action, they have short maxillary lips, and show
a reverse curve of smile arc. Therefore, a careful examination of these factors must be made.

▼A ▼B ▼c

^ Fig. 2 -3 8 Lip seal.

A. Hypertonic lip. B. Normal lip seal. C. Lip incompetency.

2) Harmful (Bad) oral habits: Finger-sucking and nail biting are the pernicious habits that can
change the arch form and the facial profile. In particular, after the eruption of permanent teeth,
a finger-sucking habit is likely to lead to lip biting and may cause large overjet and an
unaesthetic facial profile (Fig. 2-39).

78 ►► Chapter 2 _ Causes of Malocclusion

@ • • •
 • « ® ®

3) Tongue thrusting habit: When the tongue is resting or during swallowing, a constant force is
applied to the mandibular dentition, and there can occur a variety of malocclusion such as open
bite, anterior cross bite or posterior cross bite (Fig. 2-40).

►► Fig. 2 -4 0 Tongue thrusting.

A. Active tongue thrusting: A case of open bite due to tongue thrusting. Due to active tongue thrusting,
the relapse possibility is relatively high, even after an orthodontic treatment. In this case, the occlusion
of molars and premolars is fine, but the labioversion of maxillary anterior teeth, the diverse occlusal
planes between the anterior and posterior region, and the root resorption of maxillary anterior teeth
are typically observed (Kim et al., 1987).
B. Passive tongue thrusting: A case where the existing open bite provokes the passive tongue thrusting
in order to close the anterior region. In this case, if the anterior relationship is corrected after an
orthodontic treatment, the tongue thrusting habit is improved naturally.

4) Tongue position: the resting position of the tongue is assessed through the vertical position
(tongue position) and the antero-posterior position (tongue posture) (Fig. 2-41).
(1) Vertical position (tongue position): In general, the tongue is located 2-3 mm away from the
palatal plane. If it is located on the maxillary alveolar bone, this is known as the middle
position. This is closely related to unilateral posterior cross bite. If it is located on the
occlusal plane, this is called the low position. This is closely related to the bilateral
posterior cross bite.
(2) Antero-posterior position (tongue posture): anterior tongue posture is closely related to
bialveolar protrusion or mandibular prognathism.

Chapter 2 _ Causes of Malocclusion «◄ 79

 ►► Fig. 2-41 Tongue position.
A. Measuring method of tongue position.
H: 2-3mm below the palatal plane,
M: at the maxillary alveolar bone level (closely related to unilateral posterior cross bite),
L: at the occlusal level (closely related to bilateral posterior cross bite).
B. A patient whose tongue is located upward.
C. A patient whose tongue is positioned at the maxillary alveolar bone level.
D. A patient whose tongue is at the occlusal plane level.
E. A patient whose tongue is in the forward position.

80 ►► Chapter 2 _ Causes of Malocclusion

• • # #
 • • • •

nical Tips: Transitional open bite

Transitional open bite is a temporary phenomenon that occurs due to the different

eruption time between the maxillary and mandibular incisor. j !►

5) Otolaryngological problems: Mouth breathing may cause cranial extension and mandibular
downward movement; thereby leading to dolicho-facial face, bimaxillary protrusion, retruded
chin or mandibular prognathism.

(1) Nose problems: the problems include the hypertrophy of nasal turbinate, deviation of nasal
septum and allergic rhinitis (Fig. 2-42).

B-1 ►

► Fig. 2 -4 2 Problems in nasal septum.

A. A patient with normal nasal septum.
B. A patient with nasal septum deviation.
B-1. Pre-surgical radiograph.
B-2. Post-surgical radiograph.

B-2>

Chapter 2 _ Causes of Malocclusion <H4 81

 (2) Hypertrophie adenoids: This can be examined by the distance from PNS to posterior
pharyngeal wall. According to McNamara (2001), if the distance is less than 5mm, it is
regarded as hypertrophic adenoids. In general, hypertrophic adenoids are closely related to
the inhibition of growth in the anterior craniofacial region (Fig. 2-43).

82 ►► Chapter 2 _ Causes of Malocclusion • • • •

 • • • •

(3) Hypertrophic tonsils: In cephalometric radiographs, this is marked as a radiopaque mass

located below the soft palate. This hypertrophy is closely related to posterior growth, and
can increase the risk of mandibular prognathism (Fig. 2-44). In particular, when the patient
is already suffering from ear, nose and throat (ENT) problems, he/she is likely to have
Class II open bite or Class III open bite. Therefore, when treating this type of malocclusion,
it is crucial to examine the ENT problems (Fig. 2-45). •

Chapter 2 _ Causes of Malocclusion < ◄ 83

 ►^ Fig. 2 -4 5 ENTproblems.

A. A case of Class III malocclusion with ENT problems (hypertrophic adenoids and tonsils).

Q 4 ►► Chapter 2 _ Causes of Malocclusion

• • • •
 n # @ H

►P- Fig. 2 -4 5 (c o n tin u e d ) ENT problems.

r *

B. A case of Class II malocclusion with ENT problems (hypertrophic adenoids and tonsils).

Chapter 2 _ Causes of Malocclusion «« 8 5

 6) Functional shift: Due to premature contact (especially on the primary canines), the mandible
can be forwardly or laterally deviated. In this case, the grinding of primary canines or the
expansion of maxillary dental arch may be needed (Fig. 2-46).

▼A-1 ▼A-2 ^ A-3 ▼B-1 ▼B-2 v B-3

►► Fig. 2 -4 6 Functional shift.

A. Class III malocclusion and functional shift.
A-1. Diagram of maximum intercuspal occlusion.
A-2. Skeletal Class III malocclusion.
A-3. Functional Class III malocclusion.
B. Class II malocclusion and functional shift.
B-1. Diagram of maximum intercuspal occlusion.
B-2. Skeletal Class II malocclusion.
B-3. Functional Class II malocclusion.
C. Midline deviation and functional shift.
C-1. Intraoral photographs of maximum intercuspal occlusion.
C-2. Intraoral photograph of an intentional mandibular shift in
order to match the maxillary and mandibular midlines.

\
86 ►► Chapter 2 _ Causes of Malocclusion • • • •
 • • • •

\
\

A summary of causes for malocclusion.

1. Skeletal, dental and environmental factors are all closely related (Fig. 2-47).
=>Differences in vertical relationship will cause antero-posterior and transverse problems.
2. Skeletal malocclusion may be caused by the following dental factors (Fig. 2-48).
In Class II malocclusion, there is insufficient posterior vertical dimension and steep a
posterior occlusal plane. In contrast, in the case of Class III malocclusion, there is •
sufficient posterior vertical dimension and flat posterior occlusal plane.
3. Skeletal malocclusion can be treated by adjusting the following dental factors (Fig. 2-49).
=>For Class II malocclusion treatment, it is necessary to increase the posterior vertical
dimension by flattening the posterior occlusal plane.
In contrast, in the case of Class III malocclusion, it is necessary to correct anterior cross
bite and simultaneously steepen the posterior occlusal plane. This means that the antero­
posterior relationship can be improved through a vertical adjustment.

►► Fig. 2 -4 7 Factors that cause malocclusion.

A. Relationship in the skeletal, dental and environmental factors.
B. Correlation in the vertical, antero-posterior and transverse relationships.

►!►Fig . 2 -4 8 Skeletal problems may arise F ig . 2 - 4 9 S keletal problem s can be

from dental problems. treated by correcting dental problems.

Chapter 2 _ Causes of Malocclusion 44 87

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46. McNamara JA Jr, and Brudon WL. Orthodontics and Dentofacial Orthopedics. Needham Press, 2001.
47. Melson B, Stensgaard K, and Pedersen J. Sucking habits and their influence on swallowing pattern
and prevalence on malocclusion. Eur J Orthod 1:271-280, 1979.
48. Moffitt AH. Eruption and function of maxillary third molars after extraction of second molar. Angle
Orthod 68:147-152, 1998.
49. Moss JP. The soft tissue environmental of teeth and jaws: an experimental and clinical study. I. Br, J
Orthod 7:107-137, 1980.
50. Moyers RE, Van der Linden FPGM, and Riolo ML. Standards of human occlual development.
M onograph No. 5, C raniofacial Growth Series. Ann Arbor: C enter for Human Growth and
Development, University of Michigan, 1976.
51. Moyers RE. Handbook of orthodontics. Chicago: Year-book Medical Publisher, 1988.
52. Muller TP, Hill IN, Petersen AC, and Blayney JR. A survery of congenitally missing permanent teeth. J
Am Dent Assoc 81:101-107, 1970.
53. Miyashita K. Contemporary cephalometric radiography. Tokyo, Quintessence, 1996.
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98:247-58, 1990.
55. Nanda SK. Patterns of vertical growth in the face. Am J Orhod Dentofacial Orthop 93:103-16, 1988.
56. Nanda R. Biomechanics and Esthetic strategies in clinical orthodontics, Elsevier Saunders, 2005.
57. Peck H, and Peck S. An index for assessing tooth shape deviations as applied to the mandibular
incisors. Am J Orthod 61:384-401, 1972.
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recommendations. J Am Dent Assoc 90:403-411, 1975.
60. Proffit WR. Lingual pressure patterns in the transition from tongue thrust to adult swallowing. Arch Oral
Biol 17:555-563, 1972.
61. Protacio C, and Sato S. the role of posterior discrepancy in the development of classm malocclusion:
its clinical importance. Int J MEAW 2:51-68, 1995.
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Orthop 118:624-628, 2000.
9 63. Rhee SH et al. Tooth size and arch parameters of normal occlusion in a large Korean sample. Korean
©
J Orthod 34:473-480, 2004.
•
64. Richardson ME. Development of the lower third molar from ten to fifteen years, Angle Orthod 43:191-
193, 1973.
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Rocky Mountain Orthodontics; 1979.

90 m Chapter 2 _ Causes of Malocclusion

@ 4 9 9
 • « • •

68. Shah AA, Elcock C, and Brook AH. Incisor crown shape and crowding. Am J Orthod Dentofac Orthop
123:562-567, 2003.
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Chapter 2 _ Causes of Malocclusion « ◄ 91

• • •
 Chapter 3

SKELETAL PATTERN
ANALYSIS

............

1. Vertical Analysis

2. Horizontal Analysis

3. Combination Factor (CF)

4. Extraction Index (El)

5. Classification of Skeletal Pattern

 In the early stages of orthodontic treatment -leveling and alignment- different occlusal patterns and
various molar relationships are typically observed. For example, open bite may be closed or its
normal over bite could change to an anterior open bite during treatment. In this process, a Class I
relationship can always change to either a Class II or Class III relationship. For this reason, it is
important to bear in mind that the treatment outcomes may not always turn out as expected.

►► Fig. 3-1 Case with equal ANB values but different APDI values.
Although SNA and SNB values are equal, these two cases may have different skeletal
patterns. They have different APDI values. Case A (Class II division 1) is 75.5° and Case B
(Class I) is 80°.
A. ANB value (6°) shows Class II skeletal pattern and APDI value (75.5°) also shows Class II
skeletal pattern
B. ANB value (6°) shows Class II skeletal pattern but APDI value (80°) shows Class I skeletal
pattern.

Although they have the same ANB values, different skeletal patterns can be discovered.
Fig. 3-1 shows two patients with the equal values in ANB (6°) but different values in APDI. Here,
it is important to note that there is a big difference in the treatment method between someone who
is diagnosed as having Class II malocclusion (ANB=6°) and someone who is diagnosed as having
@ Class I malocclusion. This is because, although they both have Class I molar relationship, the
® treatment methods can be different depending on their hidden skeletal pattern conditions.
In the case of Class I malocclusion, a choice can be made to extract the upper and lower first
premolars as a treatment option. In the case of Class II malocclusion, it is important to consider the
dynamic conditions of Class II malocclusion because the extraction of the upper and lower first
premolars can cause more problems, such as overbite deepening and deterioration of Class II
relationship. For this reason, to treat Class II malocclusion, only the upper first premolars should
be extracted, or both the upper first premolars and the lower second premolars should be extracted.

94 ►► Chapter 3 _ Skeletal Pattern Analysis ® ® @ ®

 • • © •

• ROC (receiver operating characteristic) Analysis (Fig. 3-2)

1) Sensitivity: TPFTP+FN
This is a type of diagnosis method that can be used to confirm a malocclusion case. If a
patient is initially diagnosed as having Class II malocclusion, the sensitivity method can be
used to confirm the Class II malocclusion. This is similar to a medical case where a patient •
who is diagnosed as having pneumonia is confirmed as having pneumonia by some method.

2) Specificity: TN/FP+TN
This is a type of diagnosis method that can be used to confirm a non-malocclusion case. If
a patient is initially diagnosed as not having Class II malocclusion, the specifcity method
can be used to confirm the non-Class II malocclusion. This is similar to a medical case
where a patient who is diagnosed as not having pneumonia is confirmed as not having
pneumonia by some method.
Wardlaw et al. (1992) analyzed all the analysis methods of anterior open bite by using the
ROC method. Their research result shows that Overbite Depth Indicator (ODI) is one of
the most useful methods when assessing anterior open bite. Similarly, Han et al. (1998)
analyzed all the analysis methods of Class II and Class III malocclusion by using the ROC
method, and argued that Antero-posterior Dysplasia Indicator (APDI) is the best analysis
method when assessing Class II and Class III malocclusion.

Presence of Disease or Condition

(e.g. Class I skeletal pattern)

Present Absent Total

Test result Positive TP FP TP + FP

(e.g. ANB Negative FN TN FN + TN

angle) Total TP + FN FP + TN

►► Fig. 3-2 ROC Method.

Chapter 3 _ Skeletal Pattern Analysis < < 95

 | [ Vertical Analysis

Most of the vertical analysis methods used so far measures the angles between the mandibular
lower border and 1) SN line, 2) FH line, 3) palatal plane and 4) occlusal plane. As the picture
below shows, there are some limitations only when these angles are used to assess the vertical
relationship (Fig. 3-3).

►^ Fig. 3-3 Vertical analysis method.

A. Mandibular plane angles.
B. Differential diagnosis.
B-1. FMA frequency distribution of Group 2 and Group 4. A close overlap is observed in the
distribution pattern between the two groups.
B-2. ODI frequency distribution of Group 2 and Group 4. A clear separation is observed in the
distribution pattern between the two groups. Only 15-20% is overlapped.

9 6 ►► Chapter 3 _ Skeletal Pattern Analysis • • • ®

 • • • #

• Overbite Depth Indicator (ODI) (Table. 3-1)

According to Kim (1974), in Class II malocclusion there is a relatively higher deep bite
frequency than in Class III malocclusion. In Class III malocclusion, there is a relatively lower
deep bite but higher open bite frequency. Considering this frequency difference, they believed
that the vertical relationship could change under the influence of antero-posterior relationship.
Kim (1974) added the AB line to the list of evaluation factors and assessed it with the
mandibular lower border. Then, they also added the value of the palatal plane angle and named
it Overbite Depth Indicator (ODI). Palatal plane angle indicates the angle between palatal plane
and FH line, and it is measured from FH line. If it is anterior-superiorly sloped, its value is
negative(-) but if it is anterior-inferiorly sloped, its value is positive(+) (Fig. 3-4). Here, if the
palatal plane is parallel with the FH line, the ODI will be the angle between the AB line and
the mandibular lower border. In general, this is 74.5° in average and shows little variation by
race (Table. 3-2).

►► T a b le . 3-1 Depth of anterior over bite and correlation coefficient of other measured values of 500
malocclusion patients.
A. Distribution of 500 patients. B. Anterior overbite and correlation coefficient of
other measured values.
Measurement Max Mean Min S.D. C.C
1. FH to facial plane 95.0 85.9 77.0 3.12 -0.113
Group 2 : Deep bite
2. NS to facial plane 90.5 77.9 68.0 3.56 -0.088
Group 4 : Open bite
3. FH to MP 46.0 26.5 9.0 5.76 -0.311
4. NS to MP 53.6 34.1 14.0 6.01 -0.281
Class
5. Palatomandibular plane 45.0 27.8 14.0 5.65 -0.375
I I /1 I /2 I 6. Occlusomandibular plane 29.0 18.3 6.5 4.10 -0.199
Group Age No. Percent No. Percent No. Percent No. Percent 7. Gonial angle 150.0 125.9 105.0 6.29 -0.350
2 11 yrs. 9 mos. 46 21.4 108 44.1 20 71.4 0 0.0 8. Faclomandlbular plane 83.0 67.6 52.5 4.35 0.494
9. AB to MP 96.0 75.2 55.5 6.37 0.557
3 11 yrs. 9 mos. 134 62.3 126 51.4 8 28.6 2 16.7
10. AB to MP + FH to PP 98.5 74.0 53.7 7.31 0.588
4 12 yrs. 2 mos. 35 16.3 11 4.5 0 0.0 10. 83.3 181.0 128.0 100 10.40 0.298
11. Incisal angle
Total 215 43.0 245 49.0 28 5.6 12 2.4 12. Incisor overbite depth 11.0 3.5 -11.0 2.43 1.000
(Kim, 1974)

►► T a b le . 3-2 Overbite Depth Indicator (ODI).

N Mean S.D. Source

Caucasian 119 74.5° 6.07° Young H. Kim
Chinese 50 72.83° 5.22° Peking university
Japanese 46 72.34° 4.82° Koyama, Ikegami
Korean 190 71.95° 5.29° Suhr, Park

Chapter 3 _ Skeletal Pattern Analysis 4 <

 ►► Fig. 3-4 Overbite depth indicator (ODI).
AB plane to mandibular plane angle plus
or minus palatal plane to FH plane angle.
Palatal plane angle: if the palatal plane is
sloped anterior-inferiorly, it has a positive
value(+), and if the palatal plane is sloped
a n te rio r-s u p e rio rly , it has a negative
value(-).

If the ODI value is less than 65.5°, there is an open bite tendency, and if it is over 77.7°, there
is a deep bite tendency. This is also used to find out whether the causes of vertical problems
are from the maxilla or from the mandible. If the palatal plane angle is less than -4°, there is a
problem in the maxilla, and the mesial angulation of maxillary posterior teeth gets aggravated.
On the other hand, if the mandibular plane angle is over 30°, there is a problem in the
mandible, and the mesial angulation of mandibular posterior teeth becomes aggravated (Fig.
3-5).

►► Fig. 3-5 Causes of vertical disharmony.

A. When there is a problem in the mandible.
B. When there is a problem in the maxilla.

9 8 ►► Chapter 3 _ Skeletal Pattern Analysis • 9 • @

 # • 9 •

The ODI value can be used to assess the following (Fig. 3-6):
1) Patients can be classified into the following groups: skeletal open bite (50° s or 60° s in ODI),
open bite tendency (around 70° s in ODI), deep bite tendency (far above 70° s in ODI),
and skeletal deep bite (over 80° in ODI).
2) Patients with open bite tendency or open bite tend to have a weak masticatory force, so
there is a greater risk of tooth extrusion. •
3) Patients with deep bite tendency or deep bite tend to have a strong masticatory force, so
the risk of tooth extrusion is not high and tooth movement rarely occurs.
4) When a patient has a high ODI value, he/she has a greater tendency of anterior crowding
and deep bite. To achieve stable anterior teeth alignment, the anterior vertical
relationship must be adjusted. If there is an excessive ODI value, bites are highly likely
to get deeper, so an extra-careful examination is required in this case.
5) Patients who have a low ODI value show relatively faster tooth movement.
The tooth movement speed of the posterior teeth can be different in the maxillary and
mandibular area, even in the case of the same patient.
For example, the bigger the mandibular plane angle is, the bigger the mesial angulation
of the mandibular posterior teeth becomes, and the mandibular tooth movement becomes
faster. Meanwhile, if the palatal plane is anterior-superiorly sloped, the mesial angulation
of the maxillary posterior teeth becomes worse, and as a result, the anterior component
of force increases. Therefore, the tooth movement speed of the maxillary

►► Fig. 3-6 Clinical significance of ODI.

ODI

Chapter 3 _ Skeletal Pattern Analysis 4 < 99

 Horizontal Analysis

The ANB angle plays a crucial role in analyzing the antero-posterior skeletal pattern. However,
this angle has some weak points in that its value may change depending on the vertical and
horizontal position of nasion point (Na). Furthermore, the same ANB angle may still vary
according to the vertical height of its measuring points A and B (Fig. 3-7).

►► Fig. 3-7 Problems of ANB angle.

A. Horizontal position of nasion.
B. Vertical position of nasion.
C. Vertical position of A and B.

• Antero-posterior Dysplasia Indicator (APDI) (Table. 3-3)

According to Kim and Vietas (1978), APDI can be calculated from the equation: facial angle
± AB plane angle ± Palatal plane angle (Fig. 3-8). First, the antero-posterior position of
mandible can be assessed through the facial angle. AB plane angle is marked with a (+) sign, if
@ the point A is posteriorly located from the facial angle or with a (-) sign, if it is anteriorly
located. When the palatal plane is anterior-superiorly located on the basis of the FH line, the
palatal plane angle is marked with a (-) sign, whereas if it is located anterior-inferiorly, the
angle is marked with a (+) sign. For Westerners, the average value is 81.47 ° (±3.79), while
the average values of Koreans, Japanese and Chinese are listed in table 3-4. If this angle is
above 85°, there is a Class III malocclusion tendency. When this is below 77°, there is a Class
II malocclusion tendency (Fig. 3-9).

1 0 0 V » Chapter 3 _ Skeletal Pattern Analysis gi, m (S fg.

 • • • •

►► T a b le . 3-3 The correlation coefficient between molar displacement and variables.

1. Molar displacement 1.000

2. Facial angle (Downs’ ) 0.184
3. Convexity (Downs’ ) -0.434
4. AB plane (Downs’ ) angle 0.566
5. SNA 0.116
6. SNB 0.321
7. ANB -0.495
8. PP to FH plane angle 0.159
9. MP to FH plane angle 0.168
10. Palatomandibular plane angle 0.069
11. Gonial angle 0.155
12. Y axis angle 0.009
13. “Wits appraisal" -0.639
14. APDI 0.643
(Kim and Vietas, 1978)

►► Fig. 3-8 APDI.

• Facial angle ± AB plane angle ± PP angle.
• AB plane angle (Downs’ AB plane angle):
When point B is posteriorly located from
point A, its value is negative (-) but when it is
anteriorly located, its value is positive(+).
• Palatal plane angle: when the palatal plane
is a n te rio r-in fe rio rly sloped, its value is
positive (+) but when it is anterior-superiorly
sloped, its value is negative(-).

►► T a b le . 3-4 APDI.

N Mean S.D. Source

Caucasian 102 81.37° 3.79° Young H. Kim
Chinese 50 81.10° 4.04° Peking university
Japanese 46 80.61 ° 3.82° Koyama, Ikegami
Korean 90 81.04° 4.35° Chang

Chapter 3 _ Skeletal Pattern Analysis < ◄ 101

 ODI

►► Fig. 3-9 Clinical significance of APDI.

The APDI value can be used to assess the following:

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

If the three angles of APDI are calculated geometrically, it will coincide with the angle
between the palatal plane and AB plane (Fig. 3-10).

102 Chapter 3 _ Skeletal Pattern Analysis

 iSga. ¿S&i aSfii
W w w w

& ► Fig. 3 -1 0 APDI.

Facial angle ± AB plane angle ± PP angle = Palatal plane to AB plane angle.

• AB-maxillomandibular Triangle (Fig. 3-11)

This is a triangular shape that consists of the palatal plane, mandibular plane and AB plane.
Here, the angle between the palatal plane and AB plane indicates APDI, and the angle between
mandibular plane and AB plane indicates ODI. The sum of these two angles is known as the
combination factor (CF). Here, the equation for CF is “180° - palato-mandibular plane angle”.
Palatal plane is the line between the measuring points of ANS and PNS. When there is a severe
variation on the measuring point ANS, the posterior alar cartilage (PAC) can be used as an
alternative.
Mandibular plane is the line that connects the measuring points Go and Me. If there is an
excessive antegonial notch, take the center of the line that connects the mandibular lower
border to the deepest antegonial notch, and then connect the center to Me. This final line is
regarded as the mandibular plane (Fig. 3-12). This method can minimize errors when assessing
the arrangement of upper and lower dentition in the triangle. To sum up, this implies that the
function of the dentition is very much dependent upon the shape of the triangle.
In general, the skeletal pattern is marked as follows: 74.5/ 81.4/ 155.9. Here, 74.5 is the ODI
value, 81.4 is the APDI value, and 155.9 is the CF value. If the CF value is over 155, it is
regarded as high CF, and if it is lower than 150, it is regarded as low CF.

Chapter 3 _ Skeletal Pattern Analysis < < ^ 0 3

 TA

►► Fig. 3-11 AB-maxillomandibular triangle.

A. AB-maxillomandibular triangle.
B. Various cases of AB-maxillomandibular triangle.
B-1. Class I malocclusion.
B-2. Class II malocclusion.
B-3. Class III malocclusion.

▼B-1 ▼B-2 ▼B-3

Bt>

> > Fig. 3 -1 2 Palatal plane and mandibular plane.

A. Adjustment of palatal plane.
B. Adjustment of mandibular plane.
C. Different condition of palatal plane.
D. Different condition of mandibular plane.

104 ►► Chapter 3 _ Skeletal Pattern Analysis

@ • ® •
 • © @•

Combination Factor (CF)

Kim et al. (1979) carried out an experiment on two groups of Class II division 1 malocclusion
patients. One was treated with a non-extraction treatment and the other with an extraction
treatment. After the experiment, they discovered that the group of patients treated with the
extraction treatment had relatively lower ODI and APDI values (Fig. 3-13).
Afterwards, they regarded the sum of ODI and APDI values as the Combination Factor (CF).
Combination Factor (CF) = ODI + APDI

►► F ig . 3 -1 3 Summary of ODI and APDI

values in Class II division 1 non-extraction
and extraction cases.
These two groups have clear disparity in
ODI and APDI va lu e s. In the no n ­
extraction group, the ODI value was 80.3
and the APDI value was 75.6, while in the
extraction group, the ODI value was 74.2
and the APDI value was 73.7. (Kim et al.,
1979).

Chapter 3 _ Skeletal Pattern Analysis «◄ 105

 CF has the following meanings:
1) The skeletal patterns are classified by considering ODI/ APDI/ CF altogether.
(1) When assessing skeletal patterns with open bite tendency or deep bite tendency, assess
it by considering CF and ODI together instead of solely focusing on ODI.
(2) ODI itself can be influenced by the APDI value, so it is crucial to analyze its value by
making a comparison with CF.
(3) Skeletal patterns can be classified as follows (Table 3-5, Fig. 3-14):
© Class I high angle,
(D Class I low angle,
© Class II high angle,
@ Class II low angle,
© Class III high angle,
© Class III low angle.

►T ab le. 3-5 Classification of skeletal patterns.

APDI ODI CF
Class I high angle 78 < * < 85 <65.5 < 150
Class I low angle 78 < * < 85 >77.7 > 155
Class II high angle <77 < 150
Class II low angle <77 > 155
Class ill high angle >85 < 155
Class in low angle >85 > 160

ODI

ODI

►► Fig. 3 -1 4 Combination factor.

106 ►► Chapter 3 _ Skeletal Pattern Analysis • • • •

 • • • •

2) CF value remains steady during treatment and growth process.

(1) In the high angle case, it will remain as the high angle. In the low angle case, it will
maintain its low angle.
(2) After the treatment of a high angle case, it is highly unlikely that this would transform
into the low angle case. @
(3) Fig. 3-15. Bjork (1968)’ study. •

3) CF shows a growing pattern of a patient (Fig. 3-16).

A low CF value indicates the patient’s vertical growth tendency, while a high CF value
indicates the patient’s horizontal growth tendency.

►& Fig. 3 -1 5 Bjork (1968)’s study.

A. Changes in CF value from the normal
angle case.
B. Changes in CF value from the high
angle case.
C. C hanges in CF value from the low
angle case.

Chapter 3 _ Skeletal Pattern Analysis ◄◄ 107

#

►► Fig. 3 -1 6 Combination Factor.

A. Open bite. ODI/ APDI/ CF = 64.1/ 79.0/ 142.1
B. Open bite tendency. ODI/ APDI/ CF = 72.0/ 78.0/ 150.0
C. Normal bite. ODI/ APDI/ CF = 75.6/ 83.2/ 158.8
D. Deep bite tendency. ODI/ APDI/ CF = 80.5/ 83.5/ 164.0
E. Deep bite. ODI/ APDI/ CF = 89.5/ 82.5/ 172.0

^ 0 8 ►f- Chapter 3 _ Skeletal Pattern Analysis

• © • •
 • • • •

4) CF value shows the speed of tooth movement (Fig. 3-17).

(1) The speed of tooth movement is inversely proportional to the CF value.
(2) When the CF value is high, it means that the tooth movement is slow. When this value
is low, it means that the tooth movement is fast.
(3) In the case of a deep bite, it is difficult to move the teeth because of the powerful bite
force. •

►► Fig. 3 -1 7 Combination Factor (Epker and O’Ryann, 1981).

A. Lateral and frontal views of muscles.
B. Direction and size of muscle movement and skeletal pattern.
C. Shape of mandibular bone and skeletal pattern.

Chapter 3 _ Skeletal Pattern Analysis < < 1 0 9

 5) CF indicates the skeletal volume of teeth arrangement (Fig. 3-18).
(1) When the CF value is high, it means that teeth can be appropriately arranged by a non­
extraction treatment, but when the CF value is low, it means that an extraction treatment
is required (Fig. 3-19).
(2) The treatment plan can also vary depending on the size of teeth. If tooth size is small,
despite a small skeletal volume, appropriate arrangement is possible without extraction.
(3) If the CF value is high but an extraction treatment is applied, or if the CF value is low
but a non-extraction treatment is applied, a variety of problems can arise as a
consequence (Fig. 3-20, 21).

►► Fig. 3-18 Combination factor.

A. High angle (red line) and
low angle (blue line).
B. Radiograph of high angle
and low angle.
B-1. Radiograph of low angle.
B-2. Radiograph of high angle.

ODI Deep OB

^ ^ F i g . 3 - 1 9 The re la tio n sh ip betw een CF and

extraction or non-extraction treatment.

c
\
1 10 ►► Chapter 3 _ Skeletal Pattern Analysis
• • • •
 ® • • •

• Problems in premolar extraction when the CF value is above 155 (Fig. 3-20)

1. Aggravation of deep bite,

2. Mandibular anterior crowding,
3. Relapse of extraction space, 9
4. Higher risk of recurrence.

►► Fig. 3 -2 0 Problems in premolar extraction when the CF value is above 155.

A. Pre-treatment lateral profile (ODI/APDI/ CF are 80/ 81.5/ 161) and intraoral photograph.
B. Post-treatment lateral profile (ODI/ APDI/ CF are 78.5/ 84.5/ 163) and intraoral photograph.

Chapter 3 _ Skeletal Pattern Analysis «◄ 1 1 1

 Problems in non-extraction treatment when the CF value is below 150
(Fig. 3-21)

1. Bite opening that is difficult to control

2. Difficulties in completing the occlusion inside the dental arch
3. Higher risk of recurrence

►► Fig. 3-21 Problems in non-extraction treatment when the CF value is below 150.
A. Pre-treatment lateral profile (ODI/APDI/ CF are 63/ 83.5/ 146.5) and intraoral photograph.
B. Post-treatment lateral profile (ODI/ APDI/ CF are 63.5/ 83/ 146.5) and intraoral photograph.

1 12 ►► Chapter 3 _ Skeletal Pattern Analysis

• • # •
 @• • •

4
Extraction Index (El) = ODI + APDI + (IIA-130) / 5 - (LP-EL)

1) This is the value that reflects the degrees of maxilla-mandibular anterior protrusion and its
aesthetic lip protrusion in CF.
2) Maxilla-mandibular protrusion is marked as (IIA-130) / 5. For example, if IIA is 115°, mark it
as (115-130) / 5 = -3. If it is 135°, it will be (135-130) / 5 = +1.
3) Lip protrusion indicates the upper and lower lip protrusion to the aesthetic line, and is often
written in mm. If it is protruded, a negative value is used and if it is retruded, a positive value
is used. For example, if the upper lip is +3mm protruded and the lower lip is +2mm protruded,
mark it as - (3+2)=-5. However, if the upper lip is -2mm retruded and the lower lip is +lmm
protruded , mark it as -(-2+l)=l.

1. Extraction index is valuable and effective only in the case of Class I relationship

when the APDI value is around 80.

2. CF-EI: if it is above 10, there is a greater possibility of carrying out a premolar

extraction treatment (Fig. 3-22 A).

3. CF-EI : if it is below 10, a non-extraction treatment is possible (Fig. 3-22 B).

4. In the case of Class II and Class III, Extraction Index must be used cautiously

(Fig. 3-23).

► Fig. 3-22 Extraction Index.

Chapter 3 _ Skeletal Pattern Analysis « ^ ^ 3

 ▼A ▼B ▼C

►► Fig. 3 -2 3 Extraction Index (El).

A. Class I malocclusion. B. Class II malocclusion. C. Class III malocclusion.
ODI : 64.2 ODI 86.0 ODI 57.6
APDI : 79.3 APDI 71.1 APDI 96.1
CF : 143.5 CF 157.1 CF 153.7
El : 137.0 El 143.0 El 159.4

5 Classification of Skeletal Pattern

Class I high angle (Fig. 3-24 A)

i) This indicates patients who have skeletal patterns with an APDI value above 78 and below 85,
and with a CF value below 150. Most of the orthodontic patients belong to this category.
2) The patients have a normal antero-posterior relationship of maxillo-mandibular bone, but due
to the reduction of posterior vertical dimension, they have the steep mandibular plane or
retrognathic mandible. They also have the antero-superiorly sloped palatal plane with a
negative value.
3) Due to retrognathic mandible, the patients may have a protrusive profde or crowding.
4) The patients have a normal upper occlusal plane (UOP) and a steep posterior occlusal plane
(POP). This indicates a case of mandibular retrusion that has been caused by limited
mandibular adaptation due to over-eruption of the maxillary posterior teeth.

'I ' l 4 ►> Chapter 3 _ Skeletal Pattern Analysis • • • •

 © • © •

5) The characteristics of malocclusion.

(1) Protrusive profile,
(2) Anterior crowding,
(3) Excessive overjet,
(4) Anterior open bite.
•

Class I low angle (Fig. 3-24 B)

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

►► Fig. 3 -2 4 Class I high angle and Class I low angle.

A. Class I high angle. ODI/ APDI/ CF=63.8/ 84.3/ 148.1
B. Class I low angle. ODI/ APDI/ CF=77.5/ 82.4/ 159.9

Chapter 3 _ Skeletal Pattern Analysis ◄◄ ^ d5

 C la s s II high angle (Fig. 3-25 A)

1) This indicates patients who have skeletal patterns with an APDI value below 77, and with a CF
value below 150. They show vertical discrepancies as well as upper and lower antero-posterior
differences. Most of them show a retrognathic growth pattern of the mandible because the
posterior growth has been more developed than the anterior growth due to the extrusion of
maxillary posterior teeth.
2) In this case, the patients have a steep POP and show a steep mandibular plane and a long
LAFH due to the lack of posterior vertical dimension. Here, the UOP can be normal.
3) The characteristics of malocclusion.
(1) Anterior open bite,
(2) Protrusion: excessive overjet,
(3) Anterior crowding.

C la s s II low angle (Fig. 3-25 B)

1) This indicates patients who have skeletal patterns with an APDI value below 77, and with a CF
value over 155. They have a Class II antero-posterior relationship, but a favorable vertical
position of mandible.
2) Most of the patients show a significant anterior growth of mandible due to the extrusion of the
maxillary posterior teeth, and they also show a sufficient posterior vertical dimension and an
excessive growth pattern of the maxilla. In this case, the POP is flat and the mandibular plane
shows a flat pattern, too. This is a case where the mandibular position is normal but the maxilla
is anteriorly positioned.
3) The patients have either a normal or steep UOP due to the over-eruption of maxillary anterior
teeth with a normal POP.
9 4) The characteristics of malocclusion.
0 (1) Protrusion: excessive overjet,
(2) Anterior crowding,
(3) Deep bite.

Class II high angle has the characteristics of normal UOP and steep POP, while Class II low angle
has the characteristics of normal (or steep) UOP and normal POP.

\ l 6 ►► Chapter 3 _ Skeletal Pattern Analysis

 • # • •

►► Fig. 3 -2 5 Class II high angle and Class II low angle.

In this Class II high angle case (A), the patient has a normal ODI value (74.2). However, since he has a
low CF value (148.7), he should be regarded as a high angle patient, and an appropriate treatment
method must be applied accordingly. If an appropriate treatment method is not applied, the posterior
downward rotation of the mandible will be aggravated and other unexpected consequences may occur.
A. Class II high angle. ODI/ APDI/ CF=74.2/ 74.5/ 148.7
B. Class II low angle. ODI/ APDI/ CF=81.4/ 77.3/ 158.7

Class III high angle (Fig. 3-26 A)

1) This indicates patients who have skeletal patterns with an APDI value above 85, and with a CF
value below 155. They show a Class III antero-posterior relationship, but a vertically posterior
downward rotation of the mandible. They have a prognathic mandible as a result of the
posterior downward rotation of the mandible due to the extrusion of maxillary posterior teeth.
Therefore, they show a normal or steep mandibular plane.
2) In this case, the patients have a steep POP. They have a normal or flat UOP and show an over
eruption of maxillary posterior teeth. However, they show a lack of posterior vertical
dimension and a long anterior facial height.
3) Linguoversion of mandibular anterior teeth and labioversion of maxillary anterior teeth can
occur for dental compensation.
4) The characteristics of malocclusion.
(1) Mandibular prognathism and long facial profile: Class III anterior crossbite.
(2) Anterior crowding.

Chapter 3 _ Skeletal Pattern Analysis ◄◄ ^

 § Class III low angle (Fig. 3-26 B)

1) This indicates patients who have skeletal patterns with an APDI value above 85, and with a CF
value above 160. They show a Class III antero-posterior relationship, but a favorable vertical
position of mandible. This is a case where both the anterior and the posterior growth have
occurred due to the extrusion of maxillary posterior teeth.
2) In this case, the palatal plane angle has a positive value (+) with an anterior downward slope,
showing a lack of anterior vertical dimension. Here, due to the extrusion of the maxillary
posterior teeth, the mandible shows an over-closure condition with flat mandibular plane.
3) In spite of the Class III malocclusion, mandibular anterior teeth show normal inclination or
labioversion.
4) The patients have a normal or flat UOP and POP.
5) The characteristics of malocclusion.
(1) Mandibular prognathism: anterior cross bite,
(2) Anterior crowding.

Class III high angle has the characteristics of flat UOP and steep POP, while Class III low angle
has the characteristics of flat UOP and POP.

►► Fig. 3 -2 6 Class III high angle and Class III low angle.
In the case of Class III low angle (B), the patient has a low ODI value (62.8) showing open bite. However,
this patient should be regarded as having a low angle case because he has a high CF value (159.4).
A. Class III high angle. ODI/ APDI/ CF=53.9/ 93/ 146.9
B. Class III low angle. ODI/ APDI/ CF=62.8/ 96.6/ 159.4

1 1 8 ► Chapter 3 _ Skeletal Pattern Analysis

• • © ®
 • • © •

uote from Professor Kim Young-Ho

When you build a house, the most important factor is the details of foundation. [

REFERENCES

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17. Enlow DH, and Hans MG. Essentials of Facial Growth. Philadelphia: WB Saunders; 1996.

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 18. Epker BN, and O’Ryann F. Determinants of Class II dentofacial morphology: I. A biomechanical
theory. In McNamara JA Jr (ed). The effect of surgical intervention on craniofacial growth. Monograph
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edition, Mosby, 1997.
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characteristic (ROC) analysis on various cephalometric measurements. Am J Orthod Dentofacial
Orthop 113:538-545, 1998.
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characteristic(ROC) analysis on various cephalometric measurements. Am J Orthod Dentofacial
Orthop 113:538-545, 1998.
25. Kim Jl, Akimoto S, Shinji H, and Sato S. Importance of vertical dimension and cant of occlusal plane in
craniofacial development. Int J Stomatol Occlusion Med 2:114-121,2009.
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Dysplasia Indicator, Combination Factor, and Extraction Index. Int J MEAW 1:11-32, 1994.
31. Kim YH. A comparative cephalometric study of class II, Divisionl Nonextraction and Extraction cases.
Angle Orthod 49:77-84, 1979.
32. Kim YH. Aberrant growth of the mandible and its effect on the occlusion. Int J MEAW 6:5-22, 1999.
33. Kim YH. Anterior open bite and its treatment with Multiloop Edgewise Archwire. Angle Orthod 57:290-
321, 1987.
34. Kim YH. Overbite depth indicator (ODI) with particular reference to anterior open-bite. Am J Orthod
• 65:586-611, 1974.
• 35. Linder-Aronson S. Adenoids. Their effect on mode of breathing and nasal airflow and their relationship
to characteristics of the facial skeleton and dentition. Acta Otolaryngol Scand(Suppl 265), 1970.
36. Margolis H. Basic facial pattern and its application in clinical orthodontics. Am J Orthod Oral Surg
33:631-641, 1947.
37. McNamara JA Jr, and Brudon WL. Orthodontics and Dentofacial Orthopedics. Needham Press, 2001.
38. McNamara JA Jr. A method of cephalometric evaluation. Am J Orthod 86:449-469, 1984.
39. Merrifield LL, Klontz HA, and Vaden JL. Differential diagnostic analysis systems. Am J Orthod.

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 • @ ® ®

40. Merrifield LL. Differential diagnosis with total space analysis. J Charles H Tweed Int Found 6:10, 1978.
41. Merrifield LL. Differential diagnosis. Semin Orthod 2:241, 1996.
42. Merrifield LL. The dimensions of the denture: back to basics. Am J Orthod Dentofacial Orthop
106:535, 1994.
43. Merrifield LL. The profile line as an aid in critically evaluating facial esthetics. Am J Orthod 11:804,1966.
44. Miyashita K. Contemporary cephalometric radiography. Tokyo, Quintessence, 1996.
45. Moyers RE. Handbook of orthodontics. Chicago: Year-book Medical Publisher, 1988. •
46. Nanda R. Biomechanics and Esthetic strategies in clinical orthodontics, Elsevier Saunders, 2005.
47. Nanda SK. Growth patterns in subjects with long and short faces. Am J Orthod Dentofacial Orthop
98:247-58, 1990.
48. Nanda SK. Patterns of vertical growth in the face. Am J Orthod Dentofacial Orthop 93:103-16, 1988.
49. Proffit WR. Contemporary orthodontics. St Louis: CV Mosby company, 1986.
50. Proffit WR, Fields HW, and Nixon WL. Occlusal force in normal and long face adults. J Dent Res
62:566-571, 1983.
51. Proffit WR, and Fields HW. Occlusal forces in normal and long face children. J Dent Res ¡62:571-574,
1983.
52. Richardson A. Skeletal factors in anterior open-bite and deep overbite. Am J Orthod 56:114-127,1969.
53. Ricketts RW, Bench RW, Gugino CF, Hilgers JJ, and Schulhof RJ. Bioprogressive Therapy. Denver:
Rocky Mountain Orthodontics; 1979.
54. Riedel RA. An analysis of dentofacial relationships. Am J Orthod 43:103-119, 1957.
55. Sato S. A treatment approach to malocclusion under the consideration of craniofacial dynamics
(unpublished book). 1991.
56. Sato S. Orthodontic therapy with multiloop edgewise arch wire (II). Shinhung International Inc, 2006.
57. Sassouni V, and Nanda S. Analysis of dentofacial vertical proportions. Am J Orthod 50:801-823, 1964.
58. Sassouni V. A classification of skeletal types. Am J Orthod 55:109-123, 1969.
59. Schudy FF. The rotation of the mandible resulting from growth: its implications in orthodontic
treatment. Angle Orthod 35:36-50, 1965.
60. Schudy FF. Vertical growth versus anteroposterior growth as related to function and treatment, Angle
Orthod 34:75-93, 1964.
61. Slavicek, R. The Masticatory Organ. Gamma Dental Edition. 2002.
62. Steiner CC. Cephalometries for you and me. Am J Orthod 39:729-755, 1953.
63. Steiner CC. Cephalometries in clinical practice. Angle Orthod 29:8-29. 1959.
64. Steiner CC. The use of cephalometries as an aid to planning and assessing orthodontic treatment.
Report of a case. Am J Orthod 46:721-735, 1960.
65. Tweed CH. Clinical orthodontics. Vol1 and 2. St Louis: Mosby, 1966.
66. Tweed CH. The Frankfort mandibular incisor angle (FMIA) in orthodontic diagnosis, treatment
planning and prognosis. Am J Orthod Oral Surg 24:121, 1954.
67. Vaden JL, Dale JG, and Klontz HK. The Tweed Merrifield edgewise appliance. In Graber TM, Vanarsdall
RL, Vig KWL, editors. Orthodontics: current principles and techniques, 4th edition, Elsevier Mosby. 2005.
68. Wardlaw DW, Smith RJ, Hertweck DW, and Hildeboldt OF. Cephalometics of anterior open bite: A
receiver operating characteristic (ROC) analysis. Am J Orthod Dentofacial Orthop 101:234-243, 1992.
69. Wylie WL. The assessment of anteroposterior dysplasia. Angle Orthod 1947;17:97-109, 1947.

Chapter 3 _ Skeletal Pattern Analysis 4 ◄ ^ 2 ^

 Chapter 4

DENTURE PATTERN
ANALYSIS
 g ^ Denture Pattern Analysis

In orthodontic diagnosis, a dental analysis can be conducted by measuring the inter-incisal angle,
inclination of maxillary and mandibular anterior teeth, and occlusal plane.

1) Inter-incisal angle (IIA) (Fig. 4-1): This is the angle between the maxillary and mandibular
incisors’ tooth axes. Its normal value is generally 130°. However, if it is less than 120°, it
means that there are protruded maxillo-mandibular anterior teeth; therefore, there is a
greater possibility of extracting premolars. In particular, if the value is below 110°, the
possibility of extracting premolars increases, but if the value is around 115°, a non­
extraction approach is also possible. The decision can be made by considering the skeletal
pattern factors and other dental factors of individual patients.

►► F ig . 4-1 Inter-incisal angle

(IIA).
A. Diagram.
B. When the inter-incisal angle
has a normal value (128.4°).
C. When the inter-incisal angle
has a low value (112.6°).
D. When the inter-incisal angle
has a high value (143.9°).

2) Maxillary anterior tooth inclination (Fig. 4-2): Maxillary anterior tooth inclination is
marked as the angle between the axis of maxillary anterior tooth and FH plane or occlusal
plane. The angle with the FH plane is, in general, 114°. However, if it is over 120°, it means

1 2 4 » Chapter 4 _ Denture Pattern Analysis

• © © ©
 • • • •

that there is a labioversion of maxillary anterior teeth. Also, the angle with the occlusal
plane is approximately 55°, but if there is a labioversion of maxillary anterior teeth, this
problem can be addressed with a premolar extraction treatment method or through the use
of Class II elastics.

►► Fig. 4 -2 The inclination and position of

maxillary anterior teeth.
© Inclination: U1 to FH, U1 to NA.
© Vertical height: U1 to lip line (mm).
© A n te ro -p o ste rio r position: U1 to NA
(mm).

3) Mandibular anterior tooth inclination (Fig. 4-3): Mandibular anterior tooth inclination is
marked as the angle between the axis of mandibular anterior tooth and mandibular plane. In
general, its normal value is 90°. This angle reflects the different patterns of dental
compensation, according to skeletal patterns. In the case of Class II malocclusion,
mandibular anterior teeth show labioversion, while in the case of Class III malocclusion,
mandibular anterior teeth show linguoversion.
In particular, if the value is lower than 83°, it is one of the most important factors that
determine the need of surgical treatment for Class III patients.

►► Fig- 4 -3 The inclination and position of

mandibular anterior teeth.
© Inclination: L1 to mandibular plane, L1
to A-Pog, L1 to NB.
© Vertical height: L1 to lip line (mm).
©Antero-posterior position: L1 to A-Pog.

Chapter 4 _ Denture Pattern Analysis « ◄ 125

 4) Occlusal plane inclination (Fig. 4-4): This is the angle between the bisected occlusal plane
(the center of the maxillo-mandiblular incisal tips and the center of maxillo-mandiblular
first molars) and FH plane. Its normal value is 10°. This angle changes as patients grow,
and it tends to get flattened with posterior growth.

►f Fig. 4-4 Occlusal plane inclination.

A. Bisected occlusal plane: the line that connects the cusp tips of maxillo-mandibular first molar
to the center of the maxilla-mandibular incisal edges.
B. Functional occlusal plane: the line that connects the occlusal surface of the mandibular first
molar to the cusp tip of the mandibular first premolar.

Occlusal Plane

In previous orthodontic diagnosis approaches, a dental analysis was usually conducted by

measuring on a dental model. In a lateral cephalogram, inter-incisal angle, mandibular and
maxillary anterior teeth positions, and occlusal planes were measured and assessed. This kind of
occlusal plane is assessed, based mainly on Downs’ bisected occlusal plane.
• As for dental patterns, it is more desirable to assess the occlusal plane that reflects the occlusal
condition of the maxillo-mandibular teeth. To be precise, the occlusal plane does not have a flat
straight form but a curved shape. When the occlusal plane is viewed from the sagittal plane, curve
of Spee is observed, and when seen from the frontal plane, curve of Wilson is observed (Fig. 4-5).
When assessing the curve of Spee, the occlusal plane must be assessed from the perspectives of
level, cant and curvature. Level is the distance from U1 to the lip line, cant is an inclination of
upper occlusal plane, and curvature is an inclination of posterior occlusal plane.

1 2 6 ►► ChBpter 4 Denture Pattern Analysis ® @ # ®

 • • # •

These occlusal planes have the following meanings.

@
O

►► Fig. 4-5 Occlusal plane.

A. Curve of Spee. B. Curve of Wilson.

The meaning of occlusal plane

1) Masticatory efficiency (Fig. 4-6): If the occlusal plane has a curved shape rather than a straight
shape, the contact areas of maxillo-mandibular teeth become large, and therefore leads to
greater masticatory efficiency.

►► Fig. 4 -6 Occlusal plane and masticatory efficiency.

A. Flat occlusal plane.
B. Curved occlusal plane.

Chapter 4 _ Denture Pattern Analysis < ◄ 127

 2) Disclusion (Fig. 4-7): If there is a severe curved shape, the forward and lateral movements of
mandibular teeth will increase the risk of premature contact.

▼A vB-1 vB-2

►► Fig. 4 -7 Occlusal plane and posterior disclusion (Fushima et al.,1996).

A. The relationship between posterior occlusal plane and the sagittal condylar guidance.
B-1. Posterior disclusion in flat occlusal plane.
B-2. Posterior disclusion in curved occlusal plane.

3) Mandibular position (Fig. 4-8): According to Kim et al. (2009), a steep occlusal plane (UOP
and POP) increases the possibility of posterior positioning of mandible. In contrast, a flat
occlusal plane increases the possibility of anterior positioning of mandible.

▼A ▼B ▼C

►^ Fig. 4-8 Occlusal plane and mandible position (Kim et al., 2009).
A. Correlation between POP and skeletal pattern.
B. Class II malocclusion: steep POP.
C. Class III malocclusion: flat POP.

128 ►► Chapter 4 _ Denture Pattern Analysis @ © ® ®

 • • ® #

4) Aesthetics (Fig. 4-9): Cases with a steep occlusal plane (UOP and POP) show a protrusive
profile due to the posterior positioning of mandible. In contrast, cases with a flat occlusal plane
show a mandibular prognathism due to the anterior positioning of mandible. Additionally, even
when maxillary anterior teeth are extruded, there may still be a gummy smile and a protrusive
facial profile due to mandibular retrusion and the steep upper occlusal plane (UOP).
•

►► Fig. 4-9 Occlusal plane and anterior aesthetics.

A. The position of maxillary anterior teeth and anterior

aesthetics (Cozzani, 2000).

B. Extruded maxillary anterior teeth.

D. Intruded maxillary anterior teeth.

Chapter 4 _ Denture Pattern Analysis 4 4 129

 5) Denture pattern (Fig. 4-10): despite a similar skeletal pattern and intraoral manifestation,
denture patterns can still be different.

►► Fig. 4 -1 0 A variety of occlusal planes.

A. A variety of occlusal planes: A variety of occlusal planes in Class I, II and III
malocclusion subclasses (Naretto et al., 2009).
B. A variety of occlusal planes in Class II malocclusion.
B-1. Steep UOP (17.9°).
B-2. Normal UOP (7.2°) and POP (12.2°).
B-3. Normal UOP (11.1°) and steep POP (18.4°).

1 3 0 ►► Chapter 4 _ Denture Pattern Analysis g g g g

 • © # •

Evaluation factors of occlusal plane

1) Level (Fig. 4-11): This is the straight distance from U1 to the lip line. If the maxillary anterior
teeth are located lower than the lip line, it is marked as positive (+), but if they are located
higher than the lip line, it is marked as negative (-). In general, when the U1 incisor tip is 3mm
inferiorly away from the lip line, it is considered as normal. In particular, if it is over 5mm, the
intrusion of maxillary anterior teeth may be required.

►► Fig- 4-11 Occlusal plane level.

A. Vertical height of U1.
B. A variety of cases.
B-1. Normal maxillary anterior teeth (3.0mm).
B-2. Extruded maxillary anterior teeth (10.5mm).
B-3. Intruded maxillary anterior teeth (-2.0mm)

2) Cant (Fig. 4-12): This is the angle between UOP (upper occlusal plane) and FH line.
Here, UOP is a line that connects the tips of maxillary incisors to the center of the maxillary
first molar. In general, its normal value is 10°. This can be divided into two cases (1) a normal
UOP, and (2) a steep UOP (above 15°).

Chapter 4 _ Denture Pattern Analysis < ◄ 131

 ►► Fig. 4 -1 2 (c o n tin u e d ) Occlusal plane Cant.

▼B-1 ▼B-2 ▼B-3

B. A variety of cases.
B-1. Normal UOP (12.7°). B-2. Steep UOP (16.0°). B-3. Flat UOP (4.9°).

'l 32 C h a Pt e r 4 _ D e n tu r e PattemAna|ysis <§j • p%

 • • • #

3) Curvature (Fig. 4-13): This is the angle between the posterior occlusal plane (POP) and FH plane.
Here, the POP is a line that connects the cusp tip of mandibular second premolar to the distal
cusp tip of mandibular second molar. In the case of Class I malocclusion, its value is lower
than 13°. If the value is higher than 15°, it is called a steep POP (Fig. 4-14). This type of steep
POP is closely related to mandibular retrusion, typically showing Class II malocclusion. In
contrast, a flat POP is closely related to Class III malocclusion. @

▼B-1 ▼B-2 ▼B-3

B. A variety of cases.
B-1. Normal POP
(11.7°).
B-2. Steep POP
(18.9°).
B-3. Flat POP(9°).

C. Case showing normal POP (10.4°).

Chapter 4 _ Denture Pattern Analysis 133

 ^ ► Fig. 4 -1 3 (c o n tin u e d ) Occlusal plane curvature.

▼A ▼B

&

►► Fig. 4 -1 4 Steep POP.

A. Relatively over-erupted mandibular posterior teeth.
B. Excessive mesial angulation of mandibular posterior teeth.

1 3 4 » Chapter 4 _ Denture Pattern Analysis • © © •

 • • • ©

Changes of Occlusal Plane

O Change patterns of occlusal plane

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

® Normal growth (Fig. 4-15).

(2) Case of orthodontic treatment (Fig. 4-16).
(3) Case of orthognathic surgery (Fig. 4-17).

A ge F H -O P F H -M P P P -A B (A P D I)

6 16 .8 ± 3 .5 2 9 .8 ± 3 .3 80.1 ± 3 .8
7 1 6 .4 ± 3 .3 2 9 .0 ± 3 .0 8 1 .2 ± 3 .7
8 1 5 .7 ± 3 .3 2 8 .9 ± 3 .2 8 1 .1 ± 4 .0
9 1 5 .3 ± 3 .3 2 9 .2 ± 3.1 8 1 .8 ± 4 .5
10 1 3 .6 ± 3 .6 2 7 .9 ± 3 .8 8 1 .9 ± 3 .8
11 1 4 .3 ± 4.1 2 7 .7 ± 4 .2 8 2 .2 ± 3 .8
12 1 3 .9 ± 3 .7 2 6 .8 ± 4 .4 8 3 .0 ± 3 .6
13 1 3 .4 ± 4 .2 2 6 .8 ± 4 .4 8 3 .7 ± 4 .5
14 1 2 .7 ± 4.1 2 5 .9 ± 4 .3 84 .1 ± 4 .7

S. Sato et al, 1994, In t J M E A W Tech Res F ound

►► Fig. 4 -1 5 Normal growth (Sato et al., 1994).

►ft Fig. 4 -1 6 Case of orthodontic treatment.

Chapter 4 _ Denture Pattern Analysis 4 ◄ 135

 ►► Fig. 4 -1 7 Case of orthognathic surgery (Wolford et al., 1993).

1) During orthodontic treatment, a 1° change in occlusal plane can bring about a change of
0.5mm in dental occlusion (Fig. 4-18).
2) Changes in occlusal plane should be different depending on the type of malocclusion.
(1) In the case of a skeletal pattern with an open bite tendency, it is desirable for the occlusal
plane to rotate in a counter-clockwise direction, but in the case of a skeletal pattern with a
deep bite tendency, a clockwise rotation is desirable.
(2) Also, in the case of a skeletal pattern with a Class II open bite tendency, it is desirable for
the occlusal plane to rotate in a counter-clockwise direction, but in the case of a skeletal
pattern with a Class III deep bite tendency, a clockwise rotation is desirable.

►► Fig. 4 -1 8 Relationship between changes in occlusal plane

and occlusion.
A 1° change in occlusal plane can bring about a change of
0.5mm in dental occlusion (Braun and Legan,1997).

1 3 6 ►► Chapter 4 _ Denture Pattern Analysis 9 9 9 9

 • © • •

Stee p e n in g /C lo ckw ise rotation v s Flattening/C ounter-clockw ise

rotation

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

This is an orthodontic treatment that aligns the anterior teeth while maintaining the posterior
occlusion as much as possible. Diagnosis and treatment planning can be made relatively easily, but
some unexpected changes in the occlusal plane can occur during treatment, which can cause some
difficulties and complications. For this reason, this method is applied only to limited cases of
malocclusion, such as cases with an acceptable posterior relationship and flat curve of Spee.

►► Fig. 4 -1 9 Maintaining occlusal plane.

2) C hanges in occlusal plane

Most orthodontic patients have antero-posterior as well as vertical and transverse problems, so a
comprehensive assessment must be made. Maintaining the posterior occlusal plane can help
treatment, but in cases of Class II and III malocclusion, there may be a need for changes in the
posterior occlusal plane.

(1) Steepening/ Clockwise (CW) rotation (Fig. 4-20 A): This is when the occlusal plane rotates
in a clockwise direction, as the picture below shows. This change commonly occurs due to
the use of Class II elastics. Here, the mandible is more posteriorly positioned and, as a
result, mandibular anterior teeth show a labioversion. For this reason, during the treatment
of Class I and II malocclusion cases, occlusal conditions and aesthetics are highly likely to
get worse. Even when a non-extraction treatment method is applied, the need for premolar
extraction increases. However, in the case of Class III malocclusion, a positive outcome can
be expected due to the posterior movement of mandible.

Chapter 4 _ Denture Pattern Analysis «« 137

 (2) Flattening/ Counter-clockwise (CCW) rotation (Fig. 4-20 B): This is when the occlusal
plane rotates in a counter-clockwise direction, as the picture below shows. This change
commonly occurs due to the use of Class III elastics. Here, the mandible is more anteriorly
positioned and, as a result, mandibular anterior teeth show a linguoversion.
For this reason, during the treatment of Class I and II malocclusion cases, non-extraction
treatment approaches are not only possible but also can be applied easily. However, in the
case of Class III malocclusion, there may be a negative outcome due to the anterior
movement of mandible.

► Fig. 4 -2 0 Changes in
occlusal plane.
A. Steepening of occlusal
plane and clockwise
rotation: there is a
backward and downward
rotation of mandible,
linguoversion of maxillary
anterior teeth, and
labioversion of mandibular
anterior teeth.
B. Flattening of occlusal plane
and counter-clockwise
rotation: there is a forward
rotation of mandible,
labioversion of maxillary
anterior teeth, and
linguoversion of
mandibular anterior teeth.
C. Flattening of posterior
occlusal plane: counter­
clockwise rotation of
posterior occlusal plane
(POP).

138 ►► Chapter 4 _ Denture Pattern Analysis

• • • @
 C h a n g e s in o cclu sa l plane with orthodontic a p p lia n ce s

The common orthodontic appliances and their effects are as follows:

©
1) Extra-oral appliances •
9

(1) Headgear
CD High pull headgear (Fig. 4-21 A).
(2) Cervical pull headgear (Fig. 4-21 B).
(D J-hook type - High pull headgear.
(2) Face mask (Fig. 4-22)

> > Fig. 4-21 Head gear.

A. Diagram of high-pull headgear: intrusion and distal movement of maxillary posterior teeth,
and steepening of upper occlusal plane (UOP).
B. Diagram of straight-pull headgear: distal movement of maxillary posterior teeth.
C. Diagram of cervical headgear: extrusion and distal movement of maxillary posterior teeth,
and flattening of upper occlusal plane (UOP).
D. A patient with a cervical headgear on.

Chapter 4 _ Denture Pattern Analysis 4 4 1 3 9

 ►► Fig. 4 -2 2 Face mask.
A. Diagram of face mask: forward movement of maxilla, and the extrusion and forward
movement of the maxillary first molar.
B. A patient with a face mask on.

2) Removable appliances

(1) Anterior bite plate (ABP) (Fig. 4-23).

(2) Posterior bite block (PBB) (Fig. 4-24).
(3) Functional appliance (Fig. 4-25).

▼A ▼B ▼C

►► Fig. 4 -2 3 Anterior bite plate.

A. Anterior bite plate.
B. With an anterior bite plate on.
C. Force mechanisms after putting the anterior bite plate on the maxilla: due to the extrusion of
mandibular molars and the intrusion of mandibular anterior teeth, the mandibular occlusal plane
rotates in a clockwise direction.

1 4 0 ►► Chapter 4 _ Denture Pattern Analysis @ ® • @

 t:

▼C

►► Fig. 4 -2 4 Posterior bite block.

A. Posterior bite block.
B. With a posterior bite block on.
C. Force mechanisms after putting the posterior bite block on the
mandible: due to the intrusion of mandibular molars and the
extrusion of mandibular anterior teeth, mandibular occlusal plane
rotates in a counter-clockwise direction.

►► Fig. 4 -2 5 Functional appliance.

A. Twin block appliance (TB).
B. With a twin block appliance on.
C. Force mechanisms after putting the twin block appliance on both
arches: The molar freeway space is created by the forward
m ovem ent of the m andible. There may be an increase in
posterior vertical dimension due to the extrusion and uprighting
of the maxillary and mandibular posterior teeth.

Chapter 4 _ Denture Pattern Analysis 141

 3) Fixed appliance

(1) Transpalatal arch (TPA) (Fig. 4-26).

(2) Intrusion arch (double archwire (DAW) and utility archwire) (Fig. 4-27).
(3) MEAW (Fig. 4-28).

▼C
►► Fig. 4 -2 6 Transpalatal arch (TPA).
A. Transpalatal arch.
B. With a transpalatal arch on.
C. Force mechanisms after putting the transpalatal arch on the
maxilla: by placing the omega loop on the maxilla in the mesial
direction, it can prevent the extrusion of maxillary posterior teeth,
causing an intrusive effect (Cetlin and Hoeve, 1983).

▼A ▼B-1 ▼B-2

#
t C
►► Fig. 4 -2 7 Double archwire (DAW).
Due to the intrusion of maxillary anterior teeth and the extrusion of
maxillary posterior teeth, the maxillary occlusal plane rotates in a
co u n te r-clo ckw ise direction. For this treatm ent, neither the
transpalatal arch nor the high pull headgear are put on the maxillary
posterior teeth.
A. Double archwire.
B. With a double archwire on.
C. Force mechanisms after putting a double archwire on the maxilla.

142 ►► Chapter 4 _ Denture Pattern Analysis • @ « •

 © • • •

►► Fig. 4 -2 8 MEAW.
A. MEAW. •
B. With a MEAW on. •
C. Force m echanism s after
putting the MEAW on the arch.
Tip back activation triggers
intrusion and labioversion
of anterior teeth.

4) Inter-maxillary elastics

(1) Class I elastics (Fig. 4-29).

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

►► F ig . 4 - 2 9 Class I elastics:
since the same force is applied
on the intra-arch, no changes
are made on the occlusal plane.

Chapter 4 _ Denture Pattern Analysis < < 143

 ▼A ▼B

►► Fig. 4 -3 0 Class II elastics.

A. Ideal archwire and long Class II elastics: Force vector triggers the extrusion
and forward movement of mandibular posterior teeth and the extrusion and
backward movement of maxillary anterior teeth as well. The occlusal plane
rotates in a clockwise direction.
B. MEAW and short Class II elastics: Class II elastics trigger the backward
movement of maxillary anterior teeth and the entire maxillary dentition, and the
forward movement of mandibular dentition as well. The force mechanisms of
MEAW and short Class II elastics cause an intrusion and forward movement of
m andibular posterior teeth, and the extrusion and forward movement of
mandibular premolars as well. This means that the occlusal plane rotates in a
clockwise direction, but the maxillo-mandibular dental arch can still be antero-
posteriorly and vertically improved by controlling the extrusion of mandibular
posterior teeth.

►^ Fig. 4-31 Class III elastics.

A. Ideal archwire and long Class III elastics: Force vector triggers the extrusion
and forward movement of maxillary posterior teeth and the extrusion and
backward movement of mandibular anterior teeth as well. As a result, this can
facilitate a counter-clockwise rotation of the occlusal plane.
B. MEAW and short Class III elastics: Class III elastics trigger the backward
movement of mandibular anterior teeth and the entire mandibular dentition, and
the forward movement of maxillary dentition as well. The force mechanisms of
MEAW and short Class III elastics cause an intrusion and forward movement of
maxillary posterior teeth, and an extrusion and forward movement of maxillary
premolars as well. This means that the occlusal plane rotates in a counter­
clockwise direction, but the maxillo-mandibular dental arch can still be antero-
posteriorly and vertically improved by controlling the extrusion of maxillary
posterior teeth.

144 ►► Chapter 4 _ Denture Pattern Analysis

• • m o
 • # • #

►► Fig. 4 -3 2 Anterior vertical elastics (AVE).

Tip back activation triggers an intrusion and labioversion of anterior teeth, and an
intrusion and distal angulation of posterior teeth as well. The use of 3/16” 6oz
elastics on anterior teeth causes an extrusion and linguoversion of maxillo­
mandibular anterior teeth as well as an intrusion and distal movement of maxillo­
mandibular posterior teeth.

▼A ▼B

►► Fig. 4 -33 Long elastics.

A. Long Class II elastics: due to an extrusion of mandibular posterior and
maxillary anterior teeth, the occlusal plane rotates in a clockwise direction.
B. Long Class III elastics: due to an extrusion of maxillary posterior teeth and
mandibular anterior teeth, the occlusal plane rotates in a counter-clockwise
direction.

Chapter 4 _ Denture Pattern Analysis 145

 ▼A t B

. ►► Fig. 4 -3 4 Short elastics.

A. Short Class II elastics: The occlusal plane rotates in a clockwise direction, but
the extrusion of mandibular premolars and maxillary anterior teeth still occurs.
Depending on the type of main archwire used, the intrusion of mandibular
posterior teeth can also occur.
B. Short Class III elastics: The occlusal plane rotates in a counter-clockwise
direction but the extrusion of maxillary premolars and mandibular anterior
teeth still occurs. Depending on the type of main archwire used, the intrusion
of maxillary posterior teeth can also occur.

5) Mini-implant (Fig. 4-35)

►► Fig. 4 -3 5 Mini-implant.
A mini-implant can be used to close the extraction space
and to control the occlusal plane. Different orthodontic
forces can be applied depending on the positions of the
mini-implants (Park, 2001).

146 ►► Chapter 4 _ Denture Pattern Analysis

© • @ 6
 ® • • •

Methods of changing the occlusal plane

There are four methods of changing the occlusal plane, which require different orthodontic
appliances. These are as follows: ^
©

1) Counter-clockwise rotation of upper occlusal plane (UOP): extrusion of maxillary posterior

teeth and intrusion of maxillary anterior teeth (Fig. 4-36).

(1) Extrusion of maxillary posterior teeth.

© Cervical headgear.
(2) Anterior bite plate (ABP).
©Class III elastics.
©Face mask.
©Intrusion arch (double archwire and utility arch).

(2) Intrusion of maxillary anterior teeth.

©High pull headgear - J hook.
©Intrusion arch (double archwire and utility arch).
©MEAW.
©Mini-implant.

▼A ▼B tC

Extrusion of upper molars Intrusion of upper incisors

1. Cervical headgear 1. J hook - high pull headgear
2. Anterior bite plate
2. Intrusion arch
3. Class III elastics
(double archwire and utility arch)
4. Face mask
3. MEAW
5. Intrusion arch
(double archwire and utility arch) 4. Mini-implant

►► Fig. 4 -3 6 Counter-clockwise rotation of upper occlusal plane (UOP).

A. Flattening of upper occlusal plane (UOP).
B. Extrusion of maxillary posterior teeth.
C. Intrusion of maxillary anterior teeth.

Chapter 4 _ Denture Pattern Analysis < ◄ 147

 2) Counter-clockwise rotation of lower occlusal plane (LOP): intrusion of mandibular posterior
teeth and extrusion of mandibular anterior teeth (Fig. 4-37).

(1) Intrusion of mandibular posterior teeth.

©Cervical headgear.
© MEAW.
©Posterior bite block (PBB).
©Mini-implant.

(2) Extrusion of mandibular anterior teeth.

©Class III elastics.
©Posterior bite block (PBB).

►► Fig. 4 -3 7 Counter-clockwise rotation of lower occlusal plane (LOP).

A. Flattening of lower occlusal plane (LOP).
B. Intrusion of mandibular posterior teeth.
C. Extrusion of mandibular anterior teeth.

148 ►► Chapter 4 _ Denture Pattern Analysis

• • • •
 3) Clockwise rotation of upper occlusal plane (UOP): intrusion of maxillary posterior teeth and
extrusion of maxillary anterior teeth (Fig. 4-38).

(1) Intrusion of maxillary posterior teeth.

CDHigh pull headgear. #
©ME AW. •
©Posterior bite block (PBB).
©Transpalatal arch (TPA).
©Mini-implant.

(2) Extrusion of maxillary anterior teeth.

©Cervical headgear.
©Class II elastics.

▼A ▼B ▼C

Intrusion of upper molars Extrusion of upper incisors

1. High pull headgear
1. Cervical pull headgear
2. MEAW
2 Class ii elastics
3. Posterior bite block

4. Transpalatal arch

5. Mini-implant

►► Fig. 4 -3 8 Clockwise rotation of upper occlusal plane (UOP).

A. Steepening of upper occlusal plane (UOP).
B. Intrusion of maxillary posterior teeth.
C. Extrusion of maxillary anterior teeth.

Chapter 4 _ Denture Pattern Analysis «•< 4 9

 4) Clockwise rotation of lower occlusal plane (LOP): extrusion of mandibular posterior teeth and
intrusion of mandibular anterior teeth (Fig. 4-39).

(1) Extrusion of mandibular posterior teeth.

©Class II elastics.
© Anterior bite plate (ABP).
©Intrusion arch (double archwire and utility arch).

(2) Intrusion of mandibular anterior teeth.

©Intrusion arch (double archwire and utility arch).
©Anterior bite plate (ABP).
©MEAW.
©Class II elastics.
©Mini-implant.

▼A ▼B ▼c_____________________
E xtru sio n o f lo w e r m o la rs In tru sio n o f lo w e r in c is o rs

1. Class II elastics 1. Intrusion arch

2. Anterior bite plate (double archwire and utility arch)

2. Anterior bite plate
3. Intrusion arch
3. MEAW
(double archwire and utility arch) 4. Class i i elastics
5. Mini-implant

►► Fig. 4 -3 9 Clockwise rotation of lower occlusal plane (LOP).

A. Steepening of lower occlusal plane (LOP).
B. Extrusion of mandibular posterior teeth.
C. Intrusion of mandibular anterior teeth.

X
1 5 0 » Chapter 4 _ Denture Pattern Analysis ® • • •
 • ® • #

Correlation between the changes of occlusal plane and extraction

(Fig. 4-40)

The changes in occlusal plane are closely related to the extraction of mandibular first or second
premolars. In the case of an extraction of the mandibular first premolars, it is difficult to upright ©
the mandibular posterior dentition (second premolars and first and second molars) after the space
closure. For these reasons, to treat the cases of flat curve of Spee and normal posterior occlusal
plane, an extraction of the mandibular first premolars is possible. However, to treat severe curve of
Spee and steep posterior occlusal plane, a non-extraction method is desirable. If an extraction
method is inevitable, the extraction of the mandibular second premolars is recommended rather
than the extraction of the first premolars.
For an effective orthodontic treatment, the skeletal patterns of a patient must be first analyzed
accurately, and based on this analysis his or her dental patterns must be evaluated. If a non­
extraction treatment method is difficult to be applied, then an extraction treatment method becomes
inevitable. In this case, it is desirable to decide which tooth to extract after considering whether the
occlusal plane should be maintained or changed. Only after all of this is done should a decision on
the proper orthodontic force be made.

▼A-1 ▼A-2 ▼B

►► Fig. 4 -4 0 Correlation between the premolar extraction and changes of occlusal plane.
In the case of mandibular first premolar extraction, positive outcomes are typically accompanied by the
anterior growth and uprighting of mandibular posterior teeth (Refer to Fig. A-1). However, when treating
adult patients, there occurs only an anterior teeth movement without the changes in mandibular posterior
teeth (Refer to Fig. A-2). In contrast, in the case of mandibular second premolar extraction, both the
forward movement and uprighting of mandibular posterior teeth occur, as demonstrated in Fig. B.
A. Changes in occlusal plane after the mandibular first premolar extraction.
B. Changes in occlusal plane after the mandibular second premolar extraction.

Chapter 4 _ Denture Pattern Analysis < ◄ 151

 The assessment procedures of an individualized orthodontic treatment

1. Evaluate the aesthetic conditions of the patient.

2. Analyze the skeletal patterns of the patient.
3. Examine whether changes can be made on the skeletal patterns. To treat growing patients,
changes on the skeletal patterns are possible. In the case of a high CF, a desirable skeletal
change is probable, but in the case of a low CF, a desirable change is less likely. As for
adult patients, changes in skeletal patterns are impossible.
4. Analyze the denture patterns of the patient. Check to see whether a non-extraction treatment
method or an extraction treatment method is required.
1) Positional changes in the maxillary anterior teeth.
2) Changes in the upper occlusal plane.
3) If you decide to change the posterior occlusal plane, you must check the possibility of
tooth movement.
5. Solve the chief complaints (CC) of the patient.
6. Fully understand the correlation between skeletal and denture patterns.

►► Fig. 4-41
Individualized orthodontic treatment.

1 5 2 - Chapter 4 _ Denture Pattern Analysis

• • • •
 • • • •

nical Tips: Making decisions on the position of the occlusal plane.

1. Decide the position of maxillary anterior teeth.

1) Vertical position: make sure that the distance from U1 to the lip is 3mm and

the lower lip line is placed on the incisal third of maxillary anterior teeth.

2) Inclination: the angle from U1 to FH should be set close to 114° as much as m

®
possible.
2. Decide the position of mandibular anterior teeth: make sure that the overjet and

overbite are approximately 3mm apart.

3. Decide the position of occlusal plane:

1) In general, the occlusal plane passes by the stomion, incisal tip of mandibular

anterior teeth and the Xi point.

2) Form a perpendicular angle from the posterior occlusal plane to the AB plane

as best as possible.
4. Decide the position of molars: form a perpendicular angle from the posterior occlusal

plane to the molars (especially the mandibular molars) as best as possible. | j;►

finical Tips: Changes in occlusal plane

1. First, choose which tooth to extract from various options.

1) Examine how the occlusal plane will change after the extraction.

2) In order to make the finishing procedure simple and easy, make the molar

relationship as the cusp-to-cusp relationship. In other words, it is important not

to make a full cusp Class II molar relationship. Try to make a Class I canine

relationship as best as possible.

2. Treat each patient by considering whether the occlusal plane should be changed

or maintained.

1) Occlusal plane rotates in a counter-clockwise direction.

2) Occlusal plane rotates in a clockwise direction. ► ► ► ► ►

Chapter 4 _ Denture Pattern Analysis < < 153

 REFERENCES

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27. Graber TM, Rakosi T, and Petrovic AG. Dentofacial Orthopedics with functional appliance, 2nd
edition, Mosby, 1997.
28. Hara;abakis NB, and Sifakakis IB. The effect of cervical headgear on patients with high or low
mandibular plane angles and the “myth” of posterior mandibular rotation. Am J Orthod Dentofacial
Orthop 126:310-317, 2004.
29. Huynh T, Kennedy DB, Joondeph DR, et al. Treatment response and stability of slow maxillary
expansion using Haas, hyrax and quad-helix appliances. Am J Orthod Dentofacial Orthop 136:331-
339, 2009.
30. Hwang DH, Akimoto S, and Sato S. Occlusal plane and mandibular posture in the hyperdivergent type
of malocclusion in mixed dentition subjects. Bull Kanogawa Dent Coll 30:87-92, 2002.
31. Ingervall B, Gollner P, Gebauer U, et al. A clinical investigation of the correction of unilateral molar
crossbite with a transpalatal arch. Am J Orthod Dentofacial Orthop 107:418-425, 1995.
32. Iscan HN, and Sarisoy L. Comparison of the effects of passive posterior bite-blocks with different
construction bites on the craniofacial and dentoalveolar structures. Am J Orthod Dentofac Orthop
112:171-178, 1997.
33. Ishii H, Morita S, Takeucho Y, and Nakamura. Treatment effect of combined maxillary protraction and
chincup appliance in severe skeletal Class III cases. Am J Orthod Dentofacial Orthop 92:304-312,1987.
34. Kim JH, MC Viana, TM Graber, FF Omeraza, and EA BeGole. The effectiveness of protraction face
mask therapy: A meta-analysis. Am J Orthod Dentofac Orthop 115:675-685, 1999.
35. Kim Jl, Akimoto S, Shinji H, and Sato S. Importance of vertical dimension and cant of occlusal plane in
craniofacial development. Int J Stomatol Occlusion Med 2:114-121,2009.
36. Kim Jl. Practical Clinical Orthodontics. Vol 1. Orthodontic treatment with MEAW. Well publishing Inc,
2012.
37. Kim Jl. Practical Clinical Orthodontics. Vol 2. Orthodontic Diagnosis. Well publishing Inc, 2013.
38. Kim Jl. Practical Clinical Orthodontics. Vol 3. Early orthodontic treatment. Well publishing Inc, 2015.
49. Kim YH and Vietas JJ. Anteroposterior dysplasia indicator: An adjunct to cephalometric differential
diagnosis. Am J Orthod 113:619-633, 1978.
40. Kim YH, Caulfield Zoe, Chung WN, and Chang Yl. Overbite Depth Indicator, Anteroposterior
Dysplasia Indicator, Combination Factor, and Extraction Index. Int J MEAW 1:11-32, 1994.
41. Kim YH, and Han UK. The Versatility and Effectiveness of the Multiloop Edgewise Archwire(MEAW) in
Treatment of Various Maloccclusions. World J Orthod 2:208-218, 2001.

Chapter 4 _ Denture Pattern Analysis -*◄ 155

 42. Kim YH. A comparative cephalometric study of class II, Divisionl Nonextraction and Extraction cases.
Angle Orthod 49:77-84, 1979.
43. Kim YH. Anterior openbite and its treatment with Multiloop Edgewise Archwire. Angle Orthod 57:290-
321, 1987.
44. Kim YH. Anterior openbite and its treatment with Multiloop Edgewise Arch-Wire. Angle Orthod 57:290-
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45. Kim YH. Overbite depth indicator(ODI) with particular reference to anterior open-bite. Am J Orthod
65:586-611, 1974.
46. Kim YH. Treatment of anterior openbite and deep overbite malocclusions with Multiloop Edgewise
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 • • « •

64. Ricketts RW, Bench RW, Gugino CF, Hilgers JJ, and Schulhof RJ. Bioprogressive Therapy. Denver:
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Chapter 4 _ Denture Pattern Analysis < 4 157

 Chapter 5

ORTHODONTIC
DIAGNOSIS

. Orthodontic Differential Diagnosis

. Non-Extraction Treatment Method

1) Methods of non-extraction treatment
2) Reproximation

. ExtractionTreatment
1) Third molar extraction
2) Maxillary second molar extraction
3) Premolar extraction
(1) Maxillary and mandibular first premolar extraction
(2) Maxillary first premolar and mandibular second premolar extraction
(3) Maxillary premolar extraction only
(4) Maxillary and mandibular second premolar extraction
(5) Three premolar extraction
(6) Unusual premolar extraction
(7) Unilateral premolar extraction
4) Anterior teeth extraction treatment
(1) Mandibular anterior teeth extraction
(2) Maxillary anterior teeth extraction
© Maxillary central incisor extraction
© Maxillary lateral incisor extraction
© Maxillary canine extraction
5) First molar extraction
 Orthodontie Differential Diagnosis

After the introduction of fixed orthodontic appliances, there are growing concerns regarding the
treatment method. The orthodontist should make a final decision on whether to exercise an
extraction or non-extraction treatment method.
When making this decision, the following data must be carefully analyzed:
1. Aesthetic analysis, 2. Cephalometric analysis, 3. Model analysis.

The procedures of orthodontic differential diagnosis are as follows (Table. 5-1):

a. First, analyze the aesthetics of the patient (Fig. 5-1).

In Class II malocclusion, move the mandible at its forward position, and in Class III
malocclusion, place the mandible at its posterior position. However, if there is a midline
deviation, reconcile the midline and then analyze the facial profile (Fig. 5-2). From this, there
can be two types of outcomes: 1) acceptable facial profile, and 2) unacceptable facial profile. If
the profile is acceptable, a non-extraction treatment can be conducted appropriately based on
the size of crowding. However, if the profile is still unaesthetic, an extraction treatment or a
surgery-combined orthodontic treatment is advised (Fig. 5-3).

►► T a b le . 5-1 Orthodontic differential diagnosis.

1. Aesthetic Acceptable Poor

2. CF High High Low Low High Low
3. Non-extraction Possible Difficult Possible Difficult
approach
1) VD
2) OP
3) Space gaining
Tx. Method Non-Ext Ext Non-Ext Ext Ext Ext

> ► Fig. 5-1 Aesthetic assessment.

A. Profile view of a patient with Class II malocclusion.
B. Profile view of a patient with Class III malocclusion.
C. Front view of a patient who has midline deviation.

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►► Fig. 5-2 Profile and front assessment of edge-to-edge occlusion.

A. A patient with Class II malocclusion.

A-1. Facial and Intraoral photographs of maximum bite.
A-2. Facial and Intraoral photographs after moving the mandible forward.

Chapter 5 _ Orthodontic Diagnosis "1 B ^ l

 ►► Fig. 5-2 (c o n tin u e d ) Profile and front assessment of edge-to-edge occlusion

B-1>

B-2>

B. A patient with Class III malocclusion.

B-1. Facial and intraoral photographs of maximum bite.
B-2. Facial and intraoral photographs after moving the mandible in a backward direction for edge-to-
edge bite.

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C. A patient who has midline deviation.

C-1. Facial and intraoral photographs of maximum bite.
C-2. Facial and intraoral photographs after moving the mandible and matching the midlines.

Chapter 5 _ Orthodontic Diagnosis < ◄ 1B3

 ▼A-1 ▼A-2 ▼A-3

Good Poor

Normal Mx
Retmsive Mn

Vertical Vertical excess

deficiency problem
problem (esp, LAFH)

▼B-1 ▼B-2 vB-3

▼C-1 ▼C-2 ▼C-3

Good Poor

Dental Skeletal problems

problems

Orthodontically Surgico-
treatable orthodontically
treatable

►► Fig. 5-3 Profile and front assessment of edge-to-edge occlusion.

A-1. A patient with Class II malocclusion: assessment of profile view when the mandible is moved in a
forward direction.
A-2. Maxillary protrusion.
A-3. Long lower anterior facial height (LAFH).
B-1. A patient with Class III malocclusion: assessment of profile view when the mandible is moved in a
backward direction.
B-2. Mandibular prognathism.
B-3. Long lower anterior facial height (LAFH).
C-1. A patient who has midline deviation: assessment of front view when the midline is correctly
matched.
• C-2, 3. Lip canting.
©

164 ►► Chapter 5 _ Orthodontic Diagnosis

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b. Examine the value of CF. If it is over 155, a non-extraction treatment can be used, but if it is
below 150, an extraction treatment may be required (Fig. 5-4).

ODI Deep OB

►► Fig. 5-4 Combination factor (CF) assessment.

A. An explanatory diagram of ODI/ APDI/ CF: if CF is over 155, a non-extraction treatment can be used.
B. Profile, intraoral photograph, and cephalometric radiograph of Class II low angle
(ODI/APDI/CF = 80/ 77/ 157).
C. Profile, intraoral photograph, and cephalometric radiograph of Class II high angle
(ODI/ APDI/ CF = 71/ 73.5/ 144.5).

Chapter 5 _ Orthodontic Diagnosis < ◄ 165

 c. Check whether a non-extraction treatment approach is possible.
a) Check the possibility of space preservation (Fig. 5-5). Depending on the size difference
between primary teeth and permanent teeth, maxillo-mandibular crowding of mixed
dentition can be treated through the use of Leeway space. In these cases, Kim et al.
(2009) pointed out that Class II malocclusion is closely related to the over-eruption of
mandibular molars in the early mixed dentition period. In addition, Class III
malocclusion is closely related to the over-eruption of maxillary first molars in the early
permanent dentition period. Therefore, in non-extraction Class II malocclusion cases, it
is advised to use a lingual arch on the mandible, whereas in non-extraction Class III
malocclusion cases, the transpalatal arch (TPA) should be used on the maxilla for
desirable outcomes.
b) Check whether space can be gained or not (Table. 5-2):
(a) Gain space by solving the mesial rotation.
(b) Gain space by expanding the dental arch laterally.
(c) Gain space by distally moving the molar.
(d) Gain space through stripping.
(e) Gain space through the labioversion of incisors.
c) Changes in occlusal plane (Fig. 5-7):
(a) If the occlusal plane is rotating in a counter-clockwise direction in Class I and II
malocclusion, a non- extraction treatment is possible.
(b) If the occlusal plane is rotating in a clockwise direction in Class III malocclusion, a
non-extraction treatment is possible.
d) Changes in vertical dimension: When there is insufficient vertical dimension, there will
also be a change in teeth inclination(often, an increase in vertical dimension).This
implies that a non-extraction treatment method is possible (Fig. 5-8).
If the space cannot gained through this method, some tooth should be extracted.
The thinking process of orthodontic differential diagnosis is as follows (Fig. 5-9):
(1) Should I adopt a non-extraction treatment method or an extraction treatment method?
@ (2) If I decide to do an extraction treatment, should I extract the anterior teeth or the
posterior teeth?
(3) Should I extract the first premolars or the second premolars?
(4) If there are abnormal anterior and posterior teeth, which one should I extract?

166 ►► Chapter 5 _ Orthodontic Diagnosis

• • • •
 ® m m ®

&

►► Fig. 5-5 Arch length preservation.

A. Transpalatal arch (TPA) of maxillary arch.
B. Ungual arch of mandibular arch.

> ► Fig. 5-6 Alteration of vertical height of the maxillary and mandibular first molars (Kim et al., 2009).
Skeletal Class II malocclusion is closely related to the over-eruption of mandibular posterior teeth at the
beginning of Heilman dental age NIB. Also, the skeletal Class III malocclusion is closely related to the
over-eruption of maxillary posterior teeth in the final stage of permanent dentition.

Chapter 5 _ Orthodontic Diagnosis < 4 167

 ►► Fig. 5-7 Changes in occlusal
plane.
A. Class I, II malocclusion:
The treatment direction
should be in the counter­
clockwise rotation of
occlusal plane.
B. Class III malocclusion: The
treatment direction should
be in the clockwise rotation
of occlusal plane.

▼A

Posterior VD

► Fig. 5-8 Changes in vertical

dimension.
A. A n te rio r and p o s te rio r
vertical dimension
B. Anterior vertical dimension
(AVD).
B-1. Long anterior vertical
dimension.
B-2. Short anterior vertical
dimension.
C. Posterior vertical dimension
(PVD).
C-1. S u ffic ie n t p o s te rio r
vertical dimension.
C-2. Insufficient posterior
vertical dimension.

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1. Third molar extraction

1) Third molar extraction

2) Maxillary second molar extraction

— Non-Extraction
2. Premolar extraction

1) Maxillary and mandibular first premolar extraction

>
Extraction 2) Maxillary first premolar and mandibular second premolar extraction
3) Maxillary premolar extraction only
4) Maxillary and mandibular second premolar extraction
5) Three premolar extraction
6) Unusual premolar extraction
7) Unilateral premolar extraction

3. Unusual extraction

1) Mandibular anterior tooth extraction

2) Maxillary central incisor extraction
3) Maxillary lateral incisor extraction
4) Maxillary canine extraction
5) First molar extraction

►► Fig. 5-9 Various extraction options.

Chapter 5 _ Orthodontic Diagnosis «◄ 169

 ^3 Non-Extraction Treatment Method

Methods of non-extraction treatment

Non-extraction treatment can be conducted by lateral expansion, molar distalization and forward
movement of anterior teeth. However, it is difficult to apply such methods systematically in actual
clinical cases. There is a tendency to rely mostly on reported cases of clinical diagnosis, which
leads to difficulties in actual diagnosis and treatment processes. The dogmas for non-extraction
treatment methods are as follows:

1) Maxillary molars cannot make a posterior bodily movement. In particular, such a movement
is impossible after eruption of the maxillary second molar.
2) The dental arch cannot be expanded in any direction in any circumstances.
3) The inter-canine width cannot be increased.
4) To maximize post-treatment stability, the patient is advised to wear a retainer for a long
period of time.

For these reasons, many orthodontists take extraction treatment approaches.

Cetlin and Vanarsdall (2005) proposed the following guidelines for non-extraction treatment
methods:

1) When crowding is less than 8mm.

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

To take a non-extraction treatment approach, the patient must have a good facial profile. In the
case of slight protrusion, a non-extraction treatment is still applicable, if the crowding problem can
be solved by maintaining the position of anterior teeth. However, if there is a severe protrusion, the
extraction treatment approach is highly likely.

170 ►► Chapter 5 _ Orthodontic Diagnosis ® • • •

 ft # • @

• Strategic leveling (Fig. 5-10): The shape of the dental arch can be modified through
uprighting the mesially tilted molars or de-rotating the mesially rotated molars. Strategic
leveling is necessary to get this result. Strategic leveling is a process of aligning the anterior
teeth first, and then uprighting or de-rotating the molars with no appliances attached to the
teeth in front of the terminal teeth in the early stages of treatment. As a result, it is possible
to minimize the labioversion of anterior teeth and secure the space that is required to solve
the crowding problems by flattening the posterior occlusal plane.
This is one of the most fundamental points in the MEAW treatment. This method makes it
possible to minimize the labioversion of anterior teeth and solve the crowding problems
while still maintaining the position of anterior teeth.

▼A-1 ▼A-2

►► Fig. 5 -1 0 Strategic leveling

and alignment.
A. Strategic leveling.
B. Tight cinch back.
C. Loose cinch back.

Chapter 5 _ Orthodontic Diagnosis 4 4 171

 • Method of non-extraction treatment.

1. Space gaining methods (Table. 5-2).

1) Gain space through the parallel rotation of mesially rotated molars (Fig. 5-11).
2) Gain space through the distal movement of posterior teeth (Fig. 5-12-14).
3) Gain space through the lateral expansion (Fig. 5-15-17).
4) Gain space through the stripping of proximal surface of teeth (Fig. 5-18).
5) Gain space through the labioversion of anterior teeth.
Labioversion of anterior teeth is a common phenomenon that frequently occurs
during an orthodontic treatment. Flowever, this kind of labioversion of anterior teeth
may lead to an unaesthetic facial profile and thereby it increases the possibility of an
extraction treatment approach. Therefore, caution is needed.

►► T a b le . 5-2 Space gaining methods.

Upper arch Lower arch

Required arch length

Non-extraction treatment

1. Molar rotation

2. Transverse dimension

3. Distal movement of molars

4. Reproximation

5. Advancement of incisors

Arch length gain : total

172 ►► Chapter 5 _ Orthodontic Diagnosis

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 • • • #

F ig . 5 -1 1 Space gaining
through the parallel rotation of
mesially rotated molars.
M ost of the m a x illa ry firs t
molars mesially rotate on the
axis of palatal root and, thereby,
the d e ntal arch show s the
tapered arch form. Via parallel
rotation of the molars, space
can be gained. However, in
cases th a t show a parallel
relation to the buccal surfaces
of the molars, it is extremely
d iffic u lt to gain space, and
th e re fo re the e x tra c tio n
treatm ent approach is highly
likely.

A. A parallel relation with the

buccal surfaces of the maxillary
first molars.
B. A mesial rotation of maxillary
first molar.

▼A-1 ▼A-2
6mm

▼B ▼C

► F ig . 5 - 1 2 Space gaining
through a distal movement.
A. A diagram of full cusp Class
II molar relationship: through
the distal movement of molars,
it is possible to gain 6mm of
space per unilateral.
▼D B. Distal movement of molars
Average time Cephalograms Model through the use of mini­
Intraosseous 4 6 months 3.95mm 4.85mm Gelgor et al. implant.
screw 9.05° distal tip AJODO C. Distal movement of molars
(premaxilla) 2007:131:161 el- through the use of pendulum
161 e8 appliance.
Pendulum 3.37mm Ghosh et al. D. A comparison of the mini
8.36° distal tip AJODO im p la n t and pendulum
cf. U4 2.55mm 1996;110:639-46 appliance approaches in the
1.29° mesal tip papers.

Chapter 5 _ Orthodontic Diagnosis « « 173

 ►► Fig. 5 -1 3 Posterior available space (PAS).
A. The distance from the distal surface of the mandibular second molar
to the anterior border of ramus.
B. Cephalometric radiograph and panoramic view of a patient who has
sufficient PAS.
C. Cephalometric radiograph and panoramic view of a patient who has
insufficient PAS.

&

174 ►► Chapter 5 _ Orthodontic Diagnosis

• # • •
 *

►^ Fig. 5 -1 4 Normal curve of Spee and deep curve of Spee.

In the case of a normal curve of Spee, it is difficult to gain the space
needed to solve the crowding problem. The possibility of an extraction
treatment approach therefore increases.
In contrast, in the case of deep curve of Spee, gaining space is
possible by uprighting the m esially tilted molars, and the non­
extraction treatment approach therefore becomes possible. Here, if the
CF value is low, the extrusion of the posterior teeth causes the
backward rotation of the mandible, and the extraction treatment
approach becomes highly likely. However, if the CF value is high, even
with the extrusion of the posterior teeth, the backward rotation of the
mandible rarely occurs, so a non-extraction treatm ent approach
becomes more likely.
A. A model showing normal curve of Spee.
B. A model showing deep curve of Spee.

►► Fig. 5 -1 5 Space gaining through lateral expansion.

Improvement of arch form: the lateral expansion of posterior teeth (1mm) increases the length
of arch perimeter (approximately 0.7mm) (Adkins et al., 1990).

Chapter 5 _ Orthodontic Diagnosis «◄ 175

 ▼A-1 ▼A-2 ▼B

►S*> Fig. 5 -1 6 Expansion appliances.

A. Maxillary expansion appliances.
A-1. Slow maxillary expansion (SME).
A-2. Rapid maxillary expansion (RME).
B. Mandibular expansion appliance: Schwarz appliance.

►I- Fig. 5 -1 7 Limitation of mandibular arch

expansion (Proffit et al., 2013).
Increase in the mandibular inter-canine
width can negatively affect post-treatment
stability.

xyà linicalTips

© Active enlargement: actively expanding the mandibular dental arch.

(2) Passive enlargement: subtle and natural expansion of the maxillary dental arch

leads to an enlargement of the mandibular dental arch. ^ ^

176 ►► Chapter 5 _ Orthodontic Diagnosis

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 © • • @

►► F i g . 5 - 1 8 Space gaining
through reproximation.
A. Square shape crown.
B. Ovoid shape crown.
C. Barrel shape crown.
D. T ria n g u la r shape: space
can be gained by reducing
the proximal surface.

2. Changes in occlusal plane (Fig. 5-19).

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

3. Changes in vertical dimension (Fig. 5-20).

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

Chapter 5 _ Orthodontic Diagnosis «◄ 177

 ►► Fig. 5 -1 9 Changes in occlusal plane.
A. Flattening of occlusal plane: desirable for Class I and II malocclusion treatment.
B. Steepening of occlusal plane: desirable for Class III malocclusion treatment.

►► Fig. 5 -2 0 Changes in vertical dimension.

A. By increasing the insufficient anterior vertical dimension, a non-extraction treatment approach
becomes possible.
B. By increasing the insufficient posterior vertical dimension, a non-extraction treatment approach
becomes possible.
C. When the anterior vertical dimension is long: the patient already has an unaesthetic condition, so the
non-extraction treatment alone cannot solve the problems entirely.

178 ►► Chapter 5 _ Orthodontic Diagnosis

• « © •
 • • • •

The thinking process for non-extraction treatment should be as follows (Fig. 5-21):

1. Posterior cross bite or case where the transpalatal width (TPW) is less than 31mm
(Fig. 5-15, 22): These indicate maxillary lateral expansion. There are usually two types
of maxillary expansion appliances, SME type and RME type, which are reported to have
similar effects. The author usually adopts the SME type and rotates it two or three times •
a week. Per rotation, approximately 0.25mm of lateral expansion is made. However, for
high angle cases (Fig. 5-23), the PBB type and SME appliances, which cover the
posterior occlusal surfaces, are recommended because the backward rotation of
mandible can occur due to the extrusion of palatal cusp of maxillary molars.

2. When more than 2mm of curve of Wilson is observed in the mandible (Fig. 5-24): This
means a severe lingual inclination of mandibular posterior teeth. Here, the Schwarz
appliance, which has a screw that is applied on the mandibular anterior lingual surface,
should be used and rotated once or twice a week.

3. When there are excessive overjet and midline deviation (the cases that show an
acceptable facial profile in edge-to-edge bite): The twin block appliance is used to
induce a forward movement of mandibular teeth and, simultaneously, to match the
midlines (Fig. 5-25). Here, to expand the posterior teeth, a slow maxillary expansion
(SME) type can be used on the maxilla, and the Schwarz type on the mandible.

4. If E11 to lip line is greater than 5mm (Fig. 5-26): When the upper occlusal plane is steep
(UOP is greater than 15°), a double archwire (DAW) is used to intrude the maxillary
anterior teeth and to extrude the maxillary posterior teeth. This as a result flattens the
upper occlusal plane and a non-extraction treatment approach becomes possible.

5. When there is a full cusp Class II molar relationship: First, it is important to move the
maxillary posterior teeth distally (Fig. 5-27). To achieve this, a pendulum appliance
(when the maxillary second molars are not erupted), a mini-implant (when the maxillary
second molars are erupted), or the MEAW (when there is anterior open bite with anterior
crowding) can be used.

Chapter 5 _ Orthodontic Diagnosis 4-« 179

 Expansion
Strategic leveling

Schwarz appliance
Strategic leveling

Twin block
->• Strategic leveling

Intrusion arch
Strategic leveling ►► Fig. 5-21 Thinking process
for non-extraction treatment.
Molar distalization
-» Strategic leveling

Strategic leveling

Reproximation
Strategic leveling

►► Fig. 5-22
Maxillary expansion appliances.
A. Comparison of effectiveness
betw een rapid and slow
expansion appliances: there
is a difference during the
first two weeks, but in 10
weeks, the result is almost
the same (Proffit, 1986).
B. Slow expansion appliance.
C. Rapid expansion appliances.

1 8 0 » Chapter 5 _ Orthodontic Diagnosis • • @ @

 • ® • @

▼A-1 t A-2

►► Fig. 5-23 Expansion appliance

in high angle cases.
A. Changes that arise from the
use of expansion appliance.
A-1. Change in bucco-lingual
inclination of molars.
A-2. Changes in the mandible:
due to molar extrusion,
there may be a posterior
rotation of the mandible.
B. Preventions.
B-1. SME with PBB.
B-2. Schwarz appliance with
PBB.

►► Fig. 5-24 Mandibular expansion

appliance.
A. Indication of m andibula r
expansion appliance: more
than 2mm of m andibular
curve of Wilson.
B. Schwarz appliance.
C . S chw arz applian ce with
PBB.

Chapter 5 _ Orthodontic Diagnosis •«◄ 181

 ►► Fig. 5 -2 5 Twin block appliance.
A. Photographs of twin block appliance.
B. Intraoral photographs after putting twin block appliance on.

182 ►► Chapter 5 _ Orthodontic Diagnosis

• ® © •
 • • • •

▼A-1 ▼A-2

►► Fig. 5 -2 6
Double archwire (DAW).
A. P h o to g ra p h s of double
archwire appliance.
B. M echanism of double
archwire appliance.
C. Intraoral photograph after
p u ttin g double a rch w ire
appliance on.

►► Fig. 5-27 Molar distalization.

A. Full cusp C lass II m olar
relationship.
B. Pendulum appliance.
C. Mini-implant.

Chapter 5 _ Orthodontic Diagnosis 183

 6. Triangular crown shape (Fig. 5-28): Through reproximation, the space required for
solving crowding problems can be gained. In particular, adults who have a triangular
crown shape are likely to suffer from black triangle after the premolar extraction.
Therefore, for the borderline group of extraction and non-extraction treatment, a non­
extraction treatment can be accomplished by choosing reproximation.

►► Fig. 5 -2 8 Reproximation.
A. Pre-treatment intraoral photographs.
B. Post-treatment intraoral photographs after reproximantion.

7. Mesially rotated and angulated molars: Dental arch shape can be modified through
parallel rotation and by uprighting the mesially angulated posterior teeth. To achieve this,
strategic leveling is required. Strategic leveling is the process of parallel rotation and
uprighting of the molars after aligning the anterior teeth in the early stages of treatment.
This could, as a result, gain the space for crowding by minimizing the labioversion of
anterior teeth and flattening the posterior occlusal plane. Such an approach can help
maintaining the current position of anterior teeth and solving the problems of crowding.
This is the most basic aspect of MEAW treatment. In such treatment methods, other
appliances such as twin block and mini-implant can be used, too.

184 ►► Chapter 5 _ Orthodontic Diagnosis

 • ® * #

• Indications of non-extraction treatment.

1) Must have an acceptable facial profile.
2) Must have a high combination factor (CF>155).
3) Dental factors: a non-extraction treatment approach should be possible.
4) Environmental factors: the patients must be able to close their mouth without any form v
of tension (with proper lip competency).

nicalTips: Non-extraction and extraction treatment (Fig. 5-29).

A. Non-extraction treatment: must have an acceptable facial profile along with the

following conditions:

A -1. Mesial rotation of molars.

A-2. Deep curve of Spee.

A-3. Steep POP.

B. Extraction treatment.

B-1. Parallel rotation of molars.

B-2. Flat curve of Spee.

B-3. Flat POP. : jîp» ► ►

►► Fig. 5 -2 9 Clinical tips.

A. Non-extraction treatment.
B. Extraction treatment.

Chapter 5 _ Orthodontic Diagnosis ◄◄ 185

 • Points to note during a non-extraction treatment.
1. Betts et al. (1995) argued that an excessive expansion of the maxillary arch can increase
the fenestration risk of the premolar and molar roots. They advised us not to make a
transverse tooth movement more than 3mm.
2. The increase in the inter-canine width of mandible can be one of the main causes of
relapse. Therefore, in non-extraction treatment, it is important not to actively increase
the inter-canine width of mandible. Here, it is important to first treat the maxillary arch
and then attach the appliance on the mandibular arch after an increase in the inter-canine
width of maxilla. This is called a passive enlargement.
3. In cases of small teeth, it is better to perform a non-extraction treatment method.

• Here are the problems that can arise in non-extraction treatment when the CF value is below
150:
1. Uncontrollable opening of the bite,
2. Difficulties in articulating the dentition,
3. Inevitable relapse of the occlusion.

►^ Fig. 5 -3 0 A non-extraction treatment case when the CF value is below 150.

A. Pre-treatment facial and intraoral photographs.

1 8 B ►► Chapter 5 _ Orthodontic Diagnosis • « • •

 • • « •

►► Fig. 5 -3 0 (c o n tin u e d ) A non-extraction treatment case when the CF value is below 150.

B. Post-treatment facial and intraoral photographs.

D. Post-retention facial and intraoral photographs (2 years after the treatment).

Chapter 5 _ Orthodontic Diagnosis 187

 Reproximation

The reduction of proximal sides of the teeth (Fig. 5-31) is referred to as stripping, reproximation or
slenderizing. According to Boese (1980), there are two advantages of stripping:
1) Improves the contact stability through broad contact points, and
2) Increases the space availability around the mandibular anterior area.

►► Fig. 5-31 Inter-proximal stripping.

When using the reproximation method, Kolcich (2005) emphasizes that the following points must
be considered:
1)
2)
3)
4)
5)

• 6)
• 7)
• 8)

If the mandibular anterior teeth size is greater than l.6mm compared to the maxillary anterior teeth
size, the following methods can be considered: reproximation, the extraction of one mandibular
anterior tooth, or maxillary anterior restoration.

1 8 8 » Chapter 5 _ Orthodontic Diagnosis • • © »

 • • • •

Summary of indication
1) Stripping proximal surfaces:
(1) When there is a triangular crown shape.
(2) When there is a sufficient amount of interproximal enamel.
(3) When the root width is narrow in the cervical area of the maxillary anterior teeth.
2) Extraction of one mandibular anterior tooth: when Bolton discrepancy is greater than 2mm @

per unilateral.
3) Anterior restoration: when there is a maxillary peg lateralis.

In the finishing stage of treatment, when shallow overjet and overbite are observed after securing a
Class I canine relationship, reproximation should be conducted to solve the tooth size discrepancy
of anterior teeth.
If there is a crowding problem in the mandibular anterior area, reproximation of mandibular
anterior teeth must be conducted. However, if there is no crowding problem, a restorative treatment
can be conducted after gaining the maxillary lateral incisor space.

When applying a reproximation treatment, the following points must be considered:

1) Amount of reproximation: According to Sheridan (1985), proximal portions of enamel can
be stripped up to 50%. This means that 8.9mm (0.5mm x 5+0.8mm x4 x 2 = 8.9mm) can be
stripped overall: 0.5mm in the anterior area and 0.8mm in the posterior area.
2) Dental caries and periodontal diseases: When stripping the proximal surfaces, be cautious
about the occurrence of secondary caries. In particular, the patients who are still growing
tend to show secondary caries due to poor oral hygiene, so a reproximation method should
be adopted for adult patients only. Also, after a reduction of proximal surfaces, the roots
become very closely located to one another, which can cause periodontal problems.
3) Reproximation method (Fig. 5-32)
Roh et al.( 1999) pointed out that when stripping the enamel, it is possible to get the best
results by using separation strip with etchant, soft-Lex strip and pumice.

If linguoversion of lower incisors occurs after the extraction of the first premolars, with the
possibility of aggravating the black triangle, either a non-extraction treatment through
reproximation or extraction of the mandibular second premolars can be considered alternatively
(Fig. 5-32).

Chapter 5 _ Orthodontic Diagnosis « < 1 8 9

 In general, the indications for reproximation are as follows (Fig. 5-33):
1) Adult patient,
2) Triangular crown shape,
3) Black triangle.

►► Fig. 5 -3 2 Reproximation methods.

A. Perforated diam ond-coated

disk (Komet, grain size<30(/m).

1 9 0 ►► Chapter 5 _ Orthodontic Diagnosis q fS q

 • ® © @

►► Fig. 5 -3 2 (c o n tin u e d ) Reproximation methods.

D. S u per-S na p fin is h in g and

polishing disk. ©

E. Smallest diamond point burs

and sand paper.

F. Finishing strips.

' %t

Chapter 5 _ Orthodontic Diagnosis «◄ 191

 ►► Fig. 5 -3 2 (c o n tin u e d ) Reproximation methods.

G. Photographs of m andibular
anterior reproximation treatment.
G-1. Pre-treatment intraoral
photographs.
G-2. Post-treatment intraoral
photographs.

►► Fig. 5-33
Triangular crown shape.
A. Pre- and post-treatment
intraoral photographs after
extracting the maxillary and
mandibular first premolars:
severe black triangles are
observed between the
adjacent teeth.
B. Pre- and post-treatment
intraoral photographs after
stripping the proximal
surfaces.
C. Pre- and post-treatment
intraoral photographs after
extracting the maxillary first
premolars and mandibular
second premolars.

192 ►► Chapter 5 _ Orthodontic Diagnosis ® • ® •

 • • • •

Extraction Treatment

If there are problems in the anterior area, it is better to extract the anterior teeth, and if there are
problems in the posterior area, it is better to extract the posterior teeth (Fig. 5-34). On the other hand,
there are many cases in which the anterior problems look worse due to posterior problems. Most of
these cases are caused by a steep mandibular plane or anterior-superiorly tilted palatal plane.
If there are problems in the posterior area, an extraction treatment can be conducted in the
following ways:
1) Third molar extraction: If there is a third molar and the force is applied in a forward
direction, the distal movement of the second molars becomes very difficult. Therefore, the
extraction of the third molar facilitates the uprighting and the distal movement of the
mesially angulated second molar.
2) Second molar extraction: If there is an eruption of the second molar, there may also be an
extrusion and mesial angulation of the first molar due to posterior discrepancy. Here, if the
condition of the maxillary third molar is satisfactory, it is possible to extract the maxillary
second molar(s), and then to upright and distally move the mesially angulated first molar.
3) First molar extraction: When closing the extraction space, there must be a mesial movement
of the roots of the posterior teeth. However, such tooth movements are difficult to achieve.
Therefore, the extraction of the first molars must be carried out only in special
circumstances (for example, severe cavity cases or failure of endodontic treatment).

►► Fig. 5-34 Anterior discrepancy

and posterior discrepancy.
A. A nterior discrepancy and
posterior discrepancy.
B. When the CF value is low:
© T h e re is a decrease in
posterior vertical dimension.
© A t firs t, the p o s te rio r
teeth are affected.
© The greater the decrease
in p o s te rio r v e rtic a l
d im e n sio n , the more
affected anterior teeth
become.

Chapter 5 _ Orthodontic Diagnosis 4 4 193

 Third molar extraction

The distance from the distal surface of mandibular second molar to the anterior border of ramus is
referred to as the posterior available space (PAS), which is used to evaluate posterior discrepancy.
As shown in Fig. 5-35, if the third molar is erupted, impacted, or missing, there are some important
factors to consider when moving the posterior teeth distally. First, if the third molar is erupted, it is
possible to move the tooth distally by taking advantage of the space created after the extraction.
However, if the third molar is missing, the distal movement of posterior teeth is restricted, and the
possibility of exercising premolar extraction increases. The distal movement of posterior teeth is
related to the distance from the anterior border of ramus to the terminal molar. If this distance is
sufficient, the distal movement is possible, but if not, the movement is restricted. Furthermore, if
the CF value is high, the distal movement is possible, but if it is low, a backward rotation of the
mandible is likely to occur rather than a distal movement.

• Indications of third molar extraction

1) Must have an acceptable facial profile

2) After extracting the erupted third molar, a distal movement of the entire dentition must be
possible. Most of these cases show high CF values.
3) After the application of a non-extraction treatment, an extraction treatment can be applied in
the case of a relapse due to third molar eruption.
4) If there is a posterior discrepancy in relation to the third molar, an extraction treatment should
be applied.

A. P o s te rio r a v a ila b le space

(PAS).
A-1. PAS from a panoram ic
view.
A-2. PAS from a cephalometric
radiograph.

1 9 4 - Chapter 5 _ Orthodontic Diagnosis

@ ® m ©
 • • • ©

►► Fig. 5 -3 5 (c o n tin u e d ) Posterior available space (PAS).

B. When third molars exist.

B-1. Sufficient PAS.
B-2. Insufficient PAS.

C. When third molars are missing.

C-1. Sufficient PAS.
C-2. Insufficient PAS.

nicalTips: Posterior Available Space (PAS).

In general, the distal movement of a tooth is limited to 2-3mm away from the anterior

border of ramus. The distance from the anterior border of ramus to the distal surface

of mandibular second molar is called posterior available space (PAS). This can be

examined by both panoramic and cephalometric radiographs. If there is sufficient

space, the molar can move to the posterior direction, but if there is insufficient

space, the movement is almost impossible.

Here, space can be gained by extracting the third molar or premolars. However, if the

second or third molars have erupted, it is difficult to predict posterior space. In general,

the distance from the distal surface of first molar to the anterior border of ramus grows

1.5 mm/side per year, up to the age of 14 for females and 16 for males. ^ !►

Chapter 5 _ Orthodontic Diagnosis 4 < 195

 Maxillary second molar extraction

The conditions of third molars are quite diverse (Fig. 5-36).

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

^ ► Fig. 5 -3 6 Third molar growth and development.

A. The grow th pattern of third

m olars a fte r e xtra ctin g the
m a x illa ry and m a n d ib u la r
second molars.
M a x illa ry th ird m olars are
erupted at normal positions but
m andibular third molars are
erupted at abnormal positions.
T herefore, a retreatm ent is
needed.

196 ►► Chapter 5 _ Orthodontic Diagnosis

© • • •
 • • # •

Maxillary second molars should be extracted when the maxillary third molar crown begins to form;
that is, when root forming starts. When the first, second, and third molars show a stair structure due to
posterior discrepancy, it is an indication of second molar extraction, as shown in the figures below. The
best timing for the extraction is when the second molar is already erupted or about to erupt (Fig. 5-37).

►> Fig. 5 -3 6 (c o n tin u e d ) Third molar growth and development.

▼B-1 ▼B-2 &

B. The growth pattern of maxillary

third molars.
B-1. Erupted m a xillary third
molars.
B-2. M issing m a xilla ry third
▼B-3 ▼B-4
molars.
B-3. Impacted maxillary third
molars.
B-4. Sm all m a x illa ry third
molars.

▼C-1 ▼C-2

C. The grow th pattern of

mandibular third molars.
C-1. Erupted mandibular third
molars.
C-2. Missing mandibular third
▼C-3 ▼C-4
molars.
C-3. Impacted mandibular third
molars.
C-4. Sm all m andibula r third
molars.

►► T a b le . 5-3 Comparison of the maxillary second molar extraction group and the non-extraction group in
Class II malocclusion.
• Class II malocclusion treatment is determined by ODI.
• The lower the ODI value is, the greater the possibility of extracting second molars or premolars.

Class II Class n
Maxillary second molar ext. Non-ext
Age 11.7 1.21 11.8 2.07
ODI 76.57 5.78 79.27 5.59
APDI 74.17 3.14 74.16 3.46
CF 150.74 6.23 153.43 5.96
(Chung and Kim, 1992)

Chapter 5 _ Orthodontic Diagnosis 197

 B -U

B-2*

►^ Fig. 5 -3 7 Maxillary second molar extraction.

A. Posterior discrepancy (Sato, 1991).
CD The distance from the maxillary first molar posterior area to PNS is short.
(D The angle between the line that connects the maxillary first, second and third
molars to the maxillary occlusal plane is big.
(D The axial angle between the maxillary second molar and the third molar ranges
from 30° to 45°.
B. Normal third molars and posterior discrepancy: this is an indication of the maxillary
second molar extraction.
B-1. Class II malocclusion.
B-2. Class III malocclusion.
C. Abnormal third molars and posterior discrepancy: this is a contra-indication of the
maxillary second molar extraction.

1 9 8 » Chapter 5 _ Orthodontic Diagnosis

 • • © •

• Indications of maxillary second molar extraction

1) Aesthetics is good and the maxillary third molars are in good condition.
2) A moderate crowding: especially when there is no or moderate crowding in the mandible.
3) Skeletal patterns: when the posterior vertical dimension is insufficient (generally the CF value #
is lower than 150). ©

4) When the mandible is under-developed (retrognathic mandible).

5) Unusual reactions to Class II malocclusion treatment.
6) When there is a greater possibility of relapse after the non-extraction treatment of Class II
malocclusion.
7) When the posterior teeth show a strong anterior component of force.
8) When the second molars have severe caries or abnormal root shapes.
9) Where there is a very limited space around the tuberosity.

• Contra-indications of maxillary second molar extraction

1) When the third molars are missing,

2) When the third molars are small or have abnormal shapes,
3) When the third molars have already erupted, a third molar extraction is recommended rather
than a second molar extraction,
4) Compared to the second molar, the angulation of the third molar is below 25°.

• The advantages of maxillary second molar extraction

1) A shorter treatment period,

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

Chapter 5 _ Orthodontic Diagnosis «◄ 1 9 9

 According to Quinn (1985), after a second molar extraction, 75% of the third molars are successfully
erupted without causing any problems. Here, after the extraction of maxillary second molars, third
molars are likely to erupt at the second molar positions, but after the extraction of mandibular second
molars, an additional uprighting and repositioning of the mandibular third molars are likely to be
required. In the meantime, after the maxillary second molar extraction, there can be an over-eruption
of the mandibular second molars, so the occlusal conditions must be carefully analyzed.
Maxillary second molar extraction can be done in following malocclusion cases (Fig. 5-38).
1. When a severe cavity on maxillary second molars increases the need for extraction treatment.
2. When occlusal changes due to the over-eruption of maxillary second molars.
1) Deteriorate Class III malocclusion,
2) Aggravate midline deviation,
3) Cause scissor bite.
3. An orthodontic treatment becomes highly effective when treating:
1) Class I or II crowding,
2) Class III maxillary crowding.
4. Post-treatment stability:
1) Solving posterior discrepancy enhances stability,
2) Post-treatment stability after the Class II malocclusion treatment: if the APDI value is
below 77 after the non-extraction treatment of Class II malocclusion, the second molar
must be extracted to enhance stability,
3) Post-treatment stability after the Class III malocclusion treatment: if there is an extrusion
of the maxillary first molar due to the maxillary second molar, the maxillary second
molar should be extracted to enhance stability.

►► Fig. 5 -3 8 Maxillary second molar extraction.

A. Class III maxillary crowding.

A-1. Pre-treatment photographs.

200 ►► Chapter 5 _ Orthodontic Diagnosis « « • •

 • • • •

► Fig. 5 -3 8 (c o n tin u e d ) Maxillary second molar extraction.

&
A. Class III maxillary crowding.
A-2. Post-treatment
photographs.
A-3. Post-retention
photographs after the
maxillary third molar
eruption.

B. Scissor bite in the maxillary second molar area.

B-1. Pre-treatment photographs.
B-2. Post-treatment photographs.

Chapter 5 _ Orthodontic Diagnosis ◄◄ 2Ü1

 Premolar extraction

Premolars are the teeth that are responsible for functioning the guidance and occlusal support (Fig.
5-39). Since the premolars are located at the center of dental arch, they are frequently extracted
during treatment. In particular, when there is an anterior protrusion or a severe crowding, the
extraction of first premolars becomes far simpler.
The general indications of first premolar extraction are as following.

• Indications

1) Crowding that is bigger than 12mm,

2) Protrusion, when the inter-incisal angle is less than 120°,
3) Combination of two cases above.

However, the majority of orthodontic problems arise from the case where the inter-incisal angle is
less than 120°. This includes the extraction of four maxillary and mandibular first premolars.

►► Fig. 5 -3 9 The role of premolars (Slavicek, 2002).

Guidance and occlusal support.

202 ►► Chapter 5 _ Orthodontic Diagnosis

• @ • •
 • • • ©

• The orthodontic problems that can arise from m axillary and

mandibular first premolar extraction (Fig. 5-40).

1) A severe deep bite may occur.

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

►► Fig. 5 -4 0 Problems of maxillary and mandibular first premolar extraction.

Chapter 5 _ Orthodontic Diagnosis 4 4 203

 ►► Fig. 5 -4 0 (c o n tin u e d ) Problems of maxillary and mandibular first premolar extraction.

B. A patient who has open bite and an aggravated lateral facial profile during the first premolar extraction
treatment (ODI/ APDI/ CF: 70/ 73/ 143, Class II high angle, inter-incisal angle: 107.9°).

• Problems that can arise from premolar extraction and high CF values
(over 155) (Fig. 5-41)
•
1. Bite deepening,
# 2. Crowding of the mandibular anterior teeth,
3. Space opening in extraction site,
4. Inevitable relapse in occlusion.

204 ►► Chapter 5 _ Orthodontic Diagnosis • • « •

 • • # •

►&►Fig. 5-41 A patient after maxillary and mandibular first premolar extraction treatment.
O D I/APDI/CF: 70/ 94/ 164,
Class III low angle,
IMPA: 60.8°,
Inter-incisal angle (IIA): 173.1°.

1) Maxillary and mandibular first premolar extraction

Maxillary and mandibular first premolar extraction is used 1) when there is a Class I skeletal and
canine relationship, and 2) when patients have a normal posterior occlusal plane and flat curve of
Spee, but are difficult to treat with a non-extraction approach (Fig. 5-42). Patients who come to the
clinic for the purpose of treating protrusion and crowding often suffers from malocclusion caused
by mandibular retrusion. Therefore, although there is a visible Class I canine relationship, its inner
skeletal pattern may be Class II or III. This means that in order to compensate for the skeletal
disharmony, the maxillo-mandibular teeth angulation must be adjusted, and the assessment of the
posterior occlusal plane must be made to correct the angulation. If the posterior occlusal plane

Chapter 5 _ Orthodontic Diagnosis < 4 205

 angulation is underestimated, and only the extraction treatment is exercised to match the current
molar and canine relationship, unexpected consequence may arise. Therefore, to make an accurate
diagnosis with a correct treatment plan, a skeletal pattern analysis that focuses on ODI/ APDI/ CF
and a denture pattern analysis, which is based on the U1 position and UOP-POP, must be carefully
done. Here, the treatment purpose of first premolar extraction should always be to maintain the
normal posterior occlusal plane and to close the extraction space.

►> Fig. 5 -4 2 Maxillary and mandibular first premolar extraction.

A. Pre-treatment facial and intraoral photographs.

Measurem ent Mean S.D. 2005.1 2 .2 3

ODI 7 4.50 6.07 73.96

APDI 8 1.40 3.79 8 7 .7 3 *

CF 155 .9 0 6.52 161.69
FMA (deg) 26.00 4.91 24.57
UOP (deg) 9.3 0 3.83 9.57
POP (deg) 9.3 0 3.83 8.10
U1 to FH (deg) 114 .0 0 4 .6 0 115.43
U1 edge to Lip 3.90 1.38 3.58
L I to MP (deg) 9 1.40 3.78 90.05

IIA (deg) 127 .0 0 7.00 129.94

UL (mm) -1 .0 0 2.00 -1.29

LL (m m ) 2.00 3.00 -0 .0 4

B. Pre-treatment cephalometric measurements.

206 ►► Chapter 5 _ Orthodontic Diagnosis • ® ®

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C. Post-treatment facial and intraoral photographs.

D. Pre- and post-treatment cephalometric measurements and superimposition.

• Indications of maxillary and mandibular first premolar extraction.

1. Skeletal pattern: Class I malocclusion.

2. Denture pattern: 1) Class I molar relationship,
2) Normal posterior occlusal plane (POP),
3) Normal overjet and overbite,
4) Flat curve of Spee,
5) Inter-incisal angle (IIA): less than 120°,
6) Arch length discrepancy (ALD): in cases that cannot be treated
through a non-extraction treatment or when there is severe crowding.
3. Facial profile: protrusion.

Chapter 5 _ Orthodontic Diagnosis ◄« 2G7

 2) Extraction of maxillary first and mandibular second premolars

Maxillary first and mandibular second premolar extraction is the type of extraction options used
frequently to treat Class II malocclusion. In Class II malocclusion, a mandibular second premolar
extraction is more effective than a mandibular first premolar extraction. The main purpose of
mandibular second premolar extraction is to move the mandibular first molars in a forward
direction and to cover the mandibular second premolar area. The treatment results, however, have
not been always consistent. These inconsistent outcomes have encouraged many orthodontists to
return to the mandibular first premolar extraction treatment method. Nevertheless, when this is

►► Fig. 5 -4 3 Maxillary first premolar and mandibular second premolar extraction.

Measurem ent Mean S.D. 2 01 0.06.22

ODI 74.50 6 .0 7 73.52

APDI 8 1.40 3.79 76.44 *
CF 155.90 6.52 149.96
FMA (deg) 2 6.00 4.91 31.62 *
UOP (deg) 9 .3 0 3.83 11.08
POP (deg) 9 .3 0 3.83 18.44 **
U1 to FH (deg) 114 .0 0 4.6 0 1 29.74 ***
U1 edge to Lip 3 .9 0 1.38 2 .3 6 *
L I to MP (deg) 91.40 3.7 8 9 9 .0 2 **
IIA (deg) 127 .0 0 7.00 99.61 ***
UL (m m ) -1 .0 0 2.00 5.14 ***
LL (m m ) 2.00 3.00 7.1 0 *

B. Pre-treatment cephalometric measurements.

2Ü8 ►► Chapter 5 _ Orthodontic Diagnosis • • @ •

 m êà
• É&
w w w

viewed from the perspective of occlusal plane control, the mandibular second premolar extraction
treatment can be far more useful and effective. This means that the maxillary first premolar and
mandibular second premolar extraction methods must be used when all the following conditions
are apparent: when there are a Class II skeletal and molar relationship, a steep posterior occlusal
plane and deep curve of Spee, and when a non-extraction treatment approach is difficult (Fig. 5-
43). In this situation, the main purpose of the treatment is to flatten the steep posterior occlusal
plane and to close its extraction space.

P- ► Fig. 5 -4 3 (c o n tin u e d ) Maxillary first premolar and mandibular second premolar extraction.

C. Post-treatment facial and intraoral photographs.

D. Pre- and post-treatment cephalometric measurements and superimposition.

Chapter 5 _ Orthodontic Diagnosis < ◄ 2Ü9

 Indications of maxillary first premolar and mandibular second premolar
extraction
1) Skeletal pattern: Class I or Class II malocclusion.
2) Denture pattern.
(1) Steep posterior occlusal plane (POP),
(2) Class I or Class II molar relationship,
(3) Excessive or normal overjet,
(4) Deep curve of Spee,
(5) Inter-incisal angle (IIA): less than 120°,
(6) Arch length discrepancy (ALD): when it cannot be treated through non-extraction
treatment or when there is severe crowding.
3) Facial profile: protrusion.

The advantages of second premolar extraction (Schudy, 1992)

1) Since the mesio-distal dimension of maxillary first premolar is greater than that of the
second premolar, a satisfactory occlusion can be obtained.
2) Since the maxillary first premolar has two long roots, it can resist the lateral force.
3) Maxillary first premolar has a long buccal cusp, so it may appear more aesthetic.
4) Maxillary first premolar has a long buccal cusp, so when there is a lateral movement,
posterior disocclusion becomes far simpler.
5) Throughout treatment, the buccal cusp of the maxillary first premolar is mesially located at
the mandibular first molar position, so permanent and stable occlusion can be achieved.
6) Since the mandibular second premolar has greater mesio-distal dimension compared to the
mandibular first premolar, it is moved in a forward direction to obtain better occlusion.
7) If the mandibular canine is distally angulated from the extraction space, its root can be
placed even closer to the labio-alveolar bone, and the crown can be lingullay angulated for
easier torque adjustment.
8) There is less need for canine movement, so a more stable dental arch can be formed.

Rationale of second premolar extraction

1) Second premolar extraction prevents excessive lingual movement of the mandibular
anterior teeth.
2) It constrains the intrusion of mandibular canine and mandibular anterior teeth.
3) It prevents bite deepening after treatment.
4) It is more effective to extract the distally located teeth.

210» Chapter 5 _ Orthodontic Diagnosis • • 9 9

 • # • •

5) Since there is less need for mandibular canine movement, it becomes easier for mandibular
canines to maintain a correct axis.
6) It would be far more effective to maintain the inter-canine width.
7) Since the maxillaryfirst premolar is placed in in front of the mandibular first molar, an exact
antero-posterior relationship can be established. ^
8) More teeth can be preserved. •
9) A more stable outcome can be achieved.
10) Treatment procedure becomes far simpler.
11) Canine and first premolar relationship improves.
12) It is easier to obtain the canine guidance occlusion.

• Problems of second premolar extraction

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

• Comparison of maxillary and mandibular first premolar extraction (U44,

L44 extraction), and maxillary first premolar and m andibular second
premolar extraction (U44, L55 extraction) (Fig. 5-44 and Table. 5-4—6).

^ ► Fig. 5 -4 4 Comparison of maxillary and mandibular first premolar extraction (U44, L44 extraction), and
maxillary first premolar and mandibular second premolar extraction (U44, L55 extraction).
A. Maxillary and mandibular first premolar extraction. A-1. Adult patient.
A-2. Growing patient.
B. Maxillary first premolar and mandibular second premolar extraction (Adult patient).

Chapter 5 _ Orthodontic Diagnosis ◄◄ 211

 4 4 /4 4 Ext 4 4 /5 5 Ext
M ean SD M ean SD P

ODI 0.1 1.3 -0 .5 1.1

APDI -0 .6 1.7 0.3 1.3
CF -0 .5 1.0 -0 .2 0.9
UL -1.3 1.0 -1.2 0.8
LL -2 .9 1.7 -2 .3 1.2
N a s o la b ia la n g le 7.7 7.4 4.0 5.2
11A 28.1 8.5 15.3 9.2 ••
T a b le . 5 -4 Maxillary and mandibular
U ltoFH -17.1 4.9 -9 .8 4.7 ** first premolar extraction vs maxillary first
and m a n d ib u la r second p re m o la r

CO
CO
L lto M P -10.8 4.7 5.9

I
U1 e d g e to lip 2.4 1.5 0.0 1.1 **
O ver bite 2.4 1.0 **
extraction (Lee et al., 2011).
0.8 1.4
O ver jet -0 .8 1.6 -1.5 1.7
FM A -0 .2 0.9 0.3 1.2
UOP 5.8 2.2 2.6 1.6 **
POP -2 .2 1.4 -3 .6 2.4
V e rtica l d im e n sion ratio -0 .5 1.4 0.1 1.9
S e lla V to U6 1.8 1.5 4.3 1.3 **

S e lla V to L6 1.5 1.4 4.2 1.4 **

Pre-treatment values Post-treatment values

4 4 /4 4 Ext
M ean SD M ean SD P
ODI 68.1 3.2 68.2 3.6
APDI 81.6 1.8 81.0 2.4
CF 149.7 2.7 149.2 2.8
UL 1.5 1.6 -0 .3 1.6 *

LL 3.8 1.6 0.9 2.0 **

N a s o la b ia la n g le 95.3 13.2 102.0 11.5 *

T a b le . 5 -5 Pre-and post-treatm ent
IIA 109.1 6.3 137.2 6.8 **

U ltoFH 120.1 4.6 103.0 4.7 **

comparison of maxillary and mandibular
L lto M P 98.5 5.8 87.7 6.2 ** firs t prem olar extra ctio n (Lee et al.,
U1 e d g e to lip 3.4 1.7 5.3 2.7 * 2011 ).
O ver bite 0.0 1.1 2.3 1.0 **
O ver jet 4.4 1.0 3.6 0.8 *
FM A 32.3 2.8 32.1 3.2
UOP 12.1 3.9 17.9 3.6 **
PO P 15.5 3.3 13.4 3.4 **
V e rtica l d im e n sion ratio 62.2 3.6 41.1 4.1
S e lla V to U6 41.1 4.1 42.9 5.1 **
S e lla V to L6 39.2 4.9 40.6 5.1 **

P re -trea tm e n t v alu e s Post-tre atm e nt v a lu e s

4 4 /5 5 Ext
M ean SD M ean SD P

ODI 70.2 3.8 69.7 3.5

APDI 80.1 1.9 80.4 1.2
CF 150.3 3.9 150.1 3.4
UL 2.1 1.6 1.4 1.7
LL 4.5 2.6 2.2 2.4 **
N a s o la b ia la n g le 100.0 10.7 105.0
CD

11A 111.1 7.7 126.5 8.5 . «. ►► T a b le . 5 -6 P re-and post-treatm ent

U ltoFH 118.4 3.5 108.5 5.1 ** comparison of maxillary first premolar
*
L lto M P 99.2 6.5 93.3 7.5 and mandibular second premolar extraction
U1 e dge to lip 4.4 1.9 4.3 1.2
O ver bite 1.3 0.8 2.0
(Lee et al., 2011).
1.2
O ver jet 5.4 1.7 3.9 1.0 *
FM A 31.3 3.9 31.7 2.9
UOP 12.8 3.0 15.4 2.9 **
POP 16.2 3.5 12.6 2.8 **
V e rtica l d im e n sion ratio 62.3 3.5 61.8 3.5
S e lla V to U6 36.9 3.2 41.2 2.7 **
S e lla V to L6 35.0 3.1 39.2 2.4 **

212» Chapter 5 _ Orthodontic Diagnosis

 • ® • #

V *
©

►► Fig. 5 -4 5 Forward movement of mandibular molar and changes in

occlusal plane.
By using Class I elastics, anterior and posterior teeth movement can
close the extracted space without changing the occlusal plane. When a
mini-implant is set as an anchorage, a steep mandibular occlusal plane
can be formed after the space closure.
A. Teeth movement arising from Class I elastics.
B. Teeth movement when a mini-implant is used to close the space.

uote from the late professor Kim Young-Ho

“There should be no malocclusion that you cannot treat.

It takes a keen sense of judgment to produce a successful result and

a satisfaction of accomplishment.” ►►►►►►

Chapter 5 _ Orthodontic Diagnosis « < 213

 Malocclusion treatment

1. Maintaining posterior occlusal plane.

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

►► Fig. 5 -4 6 Maintaining posterior occlusal plane.

A. Normal posterior occlusal plane.
B. Steep posterior occlusal plane.

214 ►► Chapter 5 _ Orthodontic Diagnosis

• • • •
 • • • •

2. Changes in posterior occlusal plane

1) When there is a normal posterior occlusal plane (Fig. 5-47A),
2) When there is a steep posterior occlusal plane (Fig. 5-47B).
If the tooth movement is caused by the changes in the posterior occlusal plane, strategic
leveling can be highly effective in non-extraction treatment. In premolar extraction, the
uprighting and forward movement of molars are restricted, thereby making it •
undesirable to change the posterior occlusal plane. Nevertheless, when closing the space,
along with the minimization of lingual inclination of anterior teeth, the uprighting and
forward movement of the posterior teeth can be accomplished through the use of
mechanics. Here, if the MEAW technique is used in the finishing stage of treatment, the
process of uprighting can become much simpler.
When there is a normal posterior occlusal plane, extrusion and crown lingual torque of
maxillary anterior teeth can be minimized by uprighting and moving the posterior teeth
in a forward direction. If there is a steep posterior occlusal plane, the force attempts to
flatten the occlusal plane, so the posterior teeth get uprighted, which minimize the
extrusion and crown lingual torque of maxillary anterior teeth. This becomes a crucial
treatment threshold when treating Class II malocclusion, so an exact differential
diagnosis between maxillary and mandibular first premolar extraction, and maxillary
first premolar and mandibular second premolar extraction must be made (Table. 5-7).

►► Fig. 5 -4 7 Changes in posterior occlusal plane.

A. Normal posterior occlusal plane.
B. Steep posterior occlusal plane.

Chapter 5 _ Orthodontic Diagnosis < < 215

 ►► T a b le . 5-7 A differential diagnosis of maxillary and mandibular first premolar extraction vs maxillary
first premolar and mandibular second premolar extraction.

Skeletal pattern Molar relation POP Curve of Spee ALD IIA

Maxillary and mandibular
Class I Class I Normal Flat Severe < 120
first premolar extraction
Maxillary first premolar and
mandibular second premolar Class I or II Class I or n Steep Deep Slight < 120
extraction

3) Maxillary premolar extraction only

When only the maxillary premolar is extracted, the canine relationship becomes Class I, and its
molar relationship changes into the full cusp Class II molar relationship after treatment.

Indications are as following:

1) A case where there is excessive overjet and full Class II canine and molar relationship,
2) A case where there is normal overjet and severe crowding on the maxillary arch.

In this, there must be no or minor crowding on the mandibular arch (Fig. 5-48).

▼A ▼B ▼C

►► Fig. 5 -4 8 Maxillary premolar extraction only.

A. A diagram of Class I canine relationship and Class II molar relationship.
B. Excessive overjet and Class II canine relationship.
C. Normal overjet and Class I molar relationship.

216 ►► Chapter 5 _ Orthodontic Diagnosis # @ @ ©

 © ® • •

• Merel et al. (2004) argued that when only the maxillary first premolar is extracted, there is a
more posterior rotation of mandible. This causes extrusion or lingual angulation of maxillary
anterior teeth. In other words, as no mandibular teeth are extracted, no changes are made on the
mandible.
Nevertheless, it is important to note that depending on the skeletal pattern, the mandible may
also posteriorly rotate. If this is the case, there must be extrusion and lingual inclination of
maxillary anterior teeth in order to finish the treatment (Fig. 5-49). Therefore, it is advised that
one should extract maxillary premolars only, if the CF value is high (over 155). If the CF value
is low (below 150), it is advised that one should extract both the maxillary first premolars and
mandibular second premolars.

►► Fig. 5 -4 9 Maxillary premolar extraction only.

A. Low CF.
A-1. When mandibular third molars are not extracted.
A-2. When mandibular third molars are extracted.
B. High CF.

Chapter 5 _ Orthodontic Diagnosis 217

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

To minimize this, one should:

©Form a deep curve of Spee through the extrusion of mandibular anterior teeth.
©Form a flat curve of Spee by uprighting the mandibular posterior teeth (Fig. 5-50 B).

Different teeth movement must, however, be made depending on the skeletal and denture
patterns.

▼A ▼B

►► F ig . 5 -5 0 Tooth movement when only maxillary premolars are

extracted.
A. When the m andibular posterior occlusion is maintained, there
occurs severe extrusion and lingual inclination of maxillary anterior
teeth.
B. When the mandibular posterior occlusion is uprighted, extrusion and
lingual inclination of maxillary anterior teeth can be minimized.

«
The indications of maxillary premolar extraction only are as follows:
1. Skeletal pattern: Class I or II malocclusion, and high combination factor (CF).
2. Denture pattern.
1) Class II molar (cusp-to-cusp or full cusp) relationship,
2) Mandibular arch: when there is no or minor crowding.
3. Aesthetics: protrusion or satisfactory facial profile.

218- Chapter 5 _ Orthodontic Diagnosis • • © @

 © • • •

• Differential diagnosis of maxillary second molar extraction and maxillary premolar extraction
only (Fig. 5-51).
In order to extract the maxillary second molars, the maxillary third molars and current
aesthetics must be in good conditions with a normal inclination of mandibular anterior teeth,
minor crowding and flat curve of Spee. Nevertheless, in order to extract the maxillary
premolars only, there must be a protruded facial profile, with a normal inclination of
mandibular anterior teeth, minor crowding and flat curve of Spee. This means that if there is
labioversion of mandibular anterior teeth and deep curve of Spee, not the maxillary second
molar extraction method but the maxillary premolar extraction method should be performed.

►► Fig. 5-51 Maxillary premolar

extraction only vs m axillary
second molar extraction.
A. Maxillary premolar extraction
only.
B. Maxillary second molar
extraction: acceptable third
molars and aesthetic
conditions.

Chapter 5 _ Orthodontic Diagnosis 219

 • Differential diagnosis of maxillary first premolar and mandibular second premolar extraction,
and maxillary premolar extraction only (Fig. 5-52).
In order to extract the maxillary premolars only, there must be Class 1 canine and Class II
molar relationship, but in order to extract the maxillary first premolars and mandibular second
premolars, there must be Class I canine and Class I molar relationship. Similarly, when there is
a need for extraction treatment -arising from overjet and high combination factor (CF)- only
the maxillary premolars must be extracted. If the CF value is low, the maxillary first and
mandibular second premolars must all be removed.

►^ F ig . 5 -5 2 Maxillary premolar extraction only vs maxillary first premolar and mandibular second
premolar extraction
A. Maxillary premolar extraction only.
B. Maxillary first premolar and mandibular second premolar extraction.

220 ►► Chapter 5 _ Orthodontic Diagnosis

• • # #
 • • © ©

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

►► Fig. 5 -5 3 Maxillary first premolar extraction only vs maxillary second premolar extraction only.

▼A-1 ▼A-2 ▼B

A. Maxillary first premolar extraction only.

A-1. Closing the extraction space through the backward movement of the maxillary anterior teeth.
A-2. Closing the extraction space through the forward movement of the maxillary posterior teeth
B. Maxillary second premolar extraction only.

Chapter 5 _ Orthodontic Diagnosis < « 221

 ►►Fig. 5-53 (continued) Maxillary first premolar extraction only vs maxillary second premolar extraction only.

C-2*>

C. Maxillary second premolar extraction only.

C-1. Pre-treatment intraoral photographs.
C-2. Mid-treatment intraoral photographs.
C-3. Post-treatment intraoral photographs.

222 ►► Chapter 5 _ Orthodontic Diagnosis ® @ ® ®

 • • • •

▼A-1 ▼A-1 ▼A-2

►> Fig. 5 -5 4 Bracket positioning in cases of maxillary premolar extraction only.

A. Bracket positioning in cases of maxillary premolar extraction only.
A-1. Accurate bracket placement.
A-2. Inaccurate bracket placement.
B. Intraoral photographs in cases of maxillary premolar extraction only.

4) Maxillary and mandibular second premolar extraction

When the anterior teeth are lingually inclined and the facial profile is concaved, the teeth may be
labially tilted during a non-extraction treatment. Post-treatment problems in stability and aesthetics
may occur. Here, if the first premolars are extracted, the anterior teeth are highly likely to be
further lingually tilted, and the facial profile is likely to become even more unaesthetic. Therefore,
if a non-extraction treatment approach is not probable, it is more desirable to extract the maxillary
and mandibular second premolars (Fig. 5-55).
Here, the main purpose of this treatment is to move the molars forward whilst minimizing the
lingual movement of anterior teeth. For this purpose, a SWA bracket is recommended for the
maxillary anterior teeth and a standard bracket for the mandibular anterior teeth. By providing the
crown labial torque on the anterior portion, the lingual movement of anterior teeth can be
minimized.

Chapter 5 _ Orthodontic Diagnosis < ◄ 223

 Orthodontic patients tend to show a difference in tooth size between the maxillary first premolar
and second premolar (Fig. 5-56). If the maxillary second premolar is notably smaller than the first
premolar, the first premolar extraction can bring about the unaesthetic shape of gingival margin as
well as the opening of extraction site. Therefore, if the maxillary second premolars are small in
size, it is more desirable to extract the second premolars. Nonetheless, even if protrusion is the
main complaint, it is better to close the extraction site after extracting the maxillary second
premolars. Here, a mini-implant or a transpalatal arch on the maxilla can be additionally used to
reinforce the stability of anchorage.

►► Fig. 5 -5 5 Closing the space of missing maxillary and mandibular second premolars.

A. Pre-treatment data.
A-1. Pre-treatment facial and intraoral photographs.
A-2. Pre-treatment panoramic radiograph.
(1) Four missing maxillary and mandibular second
premolars,
(2) Remains of second primary teeth,
(3) Impacted maxillary left first premolar.

►► Chapter 5 _ Orthodontic Diagnosis

• • • #
 • • • •

B. Post-treatment data.
B-1. Post-treatment facial and intraoral photographs.
B-2. Post-treatment panoramic radiograph.

M e asu rem e n t Mean S.D. 2 01 0-01 -1 8 2 0 1 2 -0 7 -2 5

ODI 74.50 6.07 73.35 71.38

APDI 81.40 3.79 87,54 * 88.65 *
CF 155.90 7.13 160.89 160.03
FMA (deg) 26.00 4.91 21.74 23.01
UOP (deg) 9.30 3.83 9.01 9.15
POP (deg) 9.30 3.83 12.96 9.30
U lt o F H (deg) 114.00 4.60 116.39 114.89
U1 edge to Lip 3.90 1.38 -0.01 ** -0.09 **
LI to MP (deg) 91.40 3.78 88.46 83.66 **
IIA (deg) 127.00 7.00 133.41 138.43 *
UL (mm) 1.00 2.00 -1.82 * -2 .9 4*
LL (mm) 1.67 2.00 1.77 0.57

C. Comparison of pre- and post-treatment cephalometric measurements, and superimposition.

Chapter 5 _ Orthodontic Diagnosis 225

 ► Fig. 5 -5 6 Maxillary second premolar extraction.

A. The shape of maxillary

premolars and the gingival
margin of first molars.
A-1. Acceptable gingival
margin.
A-2. Unaesthetic gingival
margin.

226 ►► Chapter 5 _ Orthodontic Diagnosis

m • • m
 • • • •

However, when closing the extracted space after a maxillary second premolar extraction, the
buccal-side tooth movement becomes easy, while the palatal-side tooth movement may get
difficult. As a result, this can increase the distance from the palatal cusp of the maxillary first
premolar to that of the first molar. To prevent this, lingual buttons should be attached to the lingual
side of first premolar and first molar, and the bucco-lingual surface should be closed (Fig. 5-57).
However, in the case of sinus pneumatization, caution is needed when extracting the maxillary
second premolars.

▼A-1 ▼A-2 ▼B

► Fig. 5 -5 7 Problems in maxillary second premolar extraction.

A. Increase in distance from the palatal cusp of the maxillary first premolar to that of the first molar.
B. Space closure through the use of lingual buttons and energy chain.

In Class III high angle malocclusion (Fig. 5-58), due to its insufficient posterior vertical
dimension, it is difficult to maintain the stability of occlusion when treating the mandible with a
non-extraction treatment method. Since this type of malocclusion has the lingually inclined
mandibular incisors, the maxillary and mandibular second premolars should be extracted to
facilitate the forward movement of molars. Then, the MEAW technique can be used to complete
the occlusion. Here, if the mandibular first premolars are extracted to overcome the problems of
Class III molar relationship, the lingually tilted mandibular anterior teeth will be even more
lingually tilted. In this, if Class III elastics are used, the mandibular anterior teeth will be further
lingually tilted. As a result, the extracted space is highly likely to relapse.
Even if a Class III molar relationship is observed, the extraction of maxillary second premolars and
mandibular first premolars is not recommended.

Chapter 5 _ Orthodontic Diagnosis ◄◄ 227

 M ea su re m en t Mean S.D. 2 0 1 0 -0 8 -1 3 2 0 1 2 -1 2 -0 7

ODI 74.50 6.07 53.48 *** 53.10 ***

APDI 81.40 3.79 94.33 *** 94.43 ***

CF 155.90 7.13 147.81 * 147.54 *

FMA (deg) 26.00 4.91 23.26 24.88
UOP (deg) 9.30 3.83 0.67 * * 3.24 *

POP (deg) 9.30 3.83 3.61 * 4.50 *

© U1 to FH (deg) 114.00 4.60 136.99 >> 125.69 * *
U1 edge to Lip 3.90 1.38 2.95 3.69
L I to MP (deg) 91.40 3.78 92.48 81.76 * *
IIA (deg) 127.00 7.00 107.26 * * 127.67
UL (mm) 1.00 2.00 -0.57 -0.36
LL (mm) 1.00 2.00 6.22 * * 2.84
o
►► Fig. 5 -5 8 Maxillary and mandibular second premolar extraction.
A. Pre-treatment facial and intraoral photographs.
B. Post-treatment facial and intraoral photographs.
C. Comparison of pre- and post-treatment cephalometric measurements, and superimposition.

228 ►► Chapter 5 _ Orthodontic Diagnosis

• • • •
 © ® © ©

• Differential diagnosis for the first premolar extraction and the second premolar extraction
(Table. 5-8).

►^ T a b le . 5-8 Comparison of the first premolar extraction and the second premolar extraction.

Skeletal pattern Molar relation POP Curve of Spee ALD IIA

First premolar extraction Class I Class I Normal Flat Severe <120

Slight <120
Second premolar extraction Class I or III Class I or m * Flat
or Severe or > 130

• The indications of maxillary and mandibular second premolar extractions are as follows:
1. Class I or III skeletal pattern,
2. When the inter-incisal angle is over 130°,
3. The mandibular anterior teeth are lingually tilted,
4. The crowding problem on mandibular teeth is moderate or severe,
5. Class I or III molar relationship,
6. When the mandibular canines are distally angulated.

Chapter 5 _ Orthodontic Diagnosis « ◄ 229

 5) Extraction of three premolars (maxillary bilateral first premolars and
one mandibular unilateral premolar)

• The indications of extraction of three premolars are as follows:

1. Class II sub-division,
2. Midline deviation,
3. Three mandibular incisors.

In the case of Class II division 1 sub-division, midline deviation can cause Class I molar
relationship on the unaffected side, and Class II molar relationship on the affected side;
therefore, theoretically either three or four premolars can be extracted. When four premolars
are extracted, there may be limited improvements to problems in midline, canine and molar
relationships after the space closure. Furthermore, the canting of the occlusal plane or lip
canting can be aggravated even after treatment. Here, the extraction of three premolars can be
considered instead (Fig. 5-59).

-
©

►► Fig. 5 -5 9 Class II sub-division.

A. Extraction of three premolars.
B. Extraction of four premolars.

230 ►► Chapter 5 _ Orthodontic Diagnosis • • © ©

 • • • •

Method.
1. The extraction of maxillary bilateral first premolars and one mandibular premolar on
unaffected side (Class I molar relationship).
According to Janson et al. (2003), the problems of midline deviation can be improved more
successfully by extracting three premolars than by extracting four premolars. It is also
possible to expect a greater success rate in treatment. Here, the symmetry of the maxillary
. . . . n
canine positions is important.
The indication of this extraction option is when maxillary canines are in a nonnal position,
and the mandible shows a lateral deviation due to a difference between the left and right
sides. Here, due to the severe curve of Spee, the premolar on the affected side is not
extracted; instead, one premolar on the unaffected side and the maxillary bilateral first
premolars should be extracted. Also, the mandibular molars on the non-extraction side
should be uprighted.

Indications of the extraction of three premolars (maxillary bilateral premolars and one
mandibular premolar) are as follows:
1. Class II division 1 sub-division (when there is midline deviation),
2. Premolar extraction when there are three mandibular incisors (Fig. 5-60).

In the case of three mandibular incisors, it is difficult to achieve an accurate occlusion either by
a non-extraction method or by the extraction of four premolars. If the premolars are extracted,
the condition of the occlusion should be assessed based on a set-up model, in which the two
maxillary premolars and one mandibular premolar are extracted as in the figure below. Here,
the mandibular first premolar takes over the role of the mandibular canine.

Chapter 5 _ Orthodontic Diagnosis < ◄ 231

 ► Fig. 5 -6 0 Premolar extraction when there are three mandibular incisors.

A. Pre-treatment intraoral
photographs.

6) Unusual premolar extraction

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

232 ►► Chapter 5 _ Orthodontic Diagnosis

® @ ® •
 • • @ •

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

►► Fig. 5-61 Symmetry of maxillary canines.

A. Maxillary canine symmetry.

A-1. Maxillary canine symmetry and
molar symmetry.
A-2. Maxillary canine symmetry and
molar asymmetry.

B. Maxillary canine asymmetry.

B-1. M axillary canine asym m etry
and molar symmetry.
B-2. M axillary canine asym m etry
and molar asymmetry.

C. Maxillary arch asymmetry.

Chapter 5 _ Orthodontic Diagnosis < 4 233

 ►► Fig. 5 -6 2 Maxillary midline, facial midline and palatal midline.

A. When all three midlines are matched.

B. Deviation in maxillary midline.

234 ►► Chapter 5 _ Orthodontic Diagnosis

• # ® •
 # # • •

7) Unilateral extraction

It is extremely rare to extract the unilateral premolar only. Many dentists tend to extract the
unilateral premolar to solve crowding problems in the ectopic erupted maxillary canine. However,
such an approach can aggravate the asymmetry of dental arch and cause a temporo-mandibular
joint disorder. Even in the problem of unilateral crowding, many different cases are observed. If
the maxillary canines are asymmetrical, a unilateral premolar can be extracted to achieve the
symmetry of maxillary canines (Fig. 5-63).

►► Fig. 5 -6 3 Asymmetry of maxillary canines.

A. Intraoral photographs of dental arch form after the extraction of a
unilateral maxillary left second premolar (the maxillary right
second premolar is congenitally missing).
B. Intraoral photographs of dental arch form after the extraction of
bilateral maxillary premolars.
C. Intraoral photographs after a unilateral maxillary premolar is
extracted to achieve canine symmetry.

Chapter 5 _ Orthodontic Diagnosis 235

 • Indications.
1. Extraction of one maxillary unilateral premolar solely for the purpose of achieving the
maxillary canine symmetry.
2. Mandibular unilateral premolar extraction in full cusp Class III malocclusion: After the
extraction of the mandibular unilateral premolar, there are no opposing teeth in the maxillary
posterior area. For this reason, the maxillary terminal molar is highly likely to get over­
erupted, and the mandibular third molar should never be extracted in this kind of treatment.
If the mandibular third molar is missing, different extraction options should be considered.

►► Fig. 5 -6 4 Problems arising from the unilateral mandibular premolar extraction: there must be
interdigitation between the maxillary second molar and the mandibular third molar.
A. Pre-treatment intraoral photographs.
B. Post-treatment intraoral photographs.
C. Panoramic radiographs after the mandibular third molar eruption.

236 ►► Chapter 5 _ Orthodontic Diagnosis @ ® m m

 3 Anterior teeth extraction treatment

In general, the anterior tooth extraction treatment is not applied except for special circumstances.
This is particularly because the extraction of anterior teeth should be decided in relation to the
premolar extraction by considering aesthetic factors. ©

1) Extraction of one mandibular anterior tooth

Since the extraction of one mandibular anterior tooth can result in three incisors, further increasing
the buccal overjet between the maxillary and mandibular canine, it is not recommended even in the
case of severe crowding (Fig. 5-65). However, if there is a severe tooth size discrepancy between
the maxillary and mandibular anterior teeth, it is possible to extract one of the mandibular anterior
teeth. For example, if the anterior Bolton ratio (ABR) is large, it means that there is a big tooth size
discrepancy between the maxillary and mandibular anterior teeth, despite the Class I canine
relationship. This condition can aggravate mandibular anterior crowding or decrease overjet. Here,
the extraction of one mandibular anterior tooth, reproximation or the size-up restoration of
maxillary lateral incisor can be conducted.
1) Extraction of one mandibular anterior tooth: when the Bolton discrepancy is more than
2mm per unilateral.
2) Reproximation
(1) Triangular shape crown,
(2) Sufficient amount of interproximal enamel,
(3) When the root width is narrow in the cervical area of the maxillary anterior teeth.
3) Anterior tooth restoration: when peg lateralis is observed.

The extraction of one mandibular anterior tooth can be considered 1) if there is a severe crowding
problem in the mandibular anterior teeth, 2) if there is a big discrepancy in the anterior Bolton ratio,
3) in the case of a normal overjet, and 4) depending on the shape of the crown (the triangular shape
of the anterior teeth is not an indication). However, the most challenging problem that can arise
from the extraction is black triangle. Therefore, if there is a need for extraction of one mandibular
anterior tooth, it must be notified to the patients in advance. The problem of black triangle can be
solved to some extent by reproximation, but the canine relationship can be aggravated after
reproximation in the case of Class II malocclusion. On the other hand, in the case of Class III
malocclusion, there can be improvement in the control of overjet and overbite (Fig. 5-66).

Chapter 5 _ Orthodontic Diagnosis «« 237

 ►► Fig. 5 -6 5 Occlusion in three mandibular incisors.
A. When there is good canine buccal overjet.
B. When there is excessive canine buccal overjet.

►^ Fig. 5 -6 6 Things to consider in the extraction of one mandibular anterior tooth: The black triangle
formed after the extraction of one mandibular anterior tooth should be treated by reproximation. In the
case of Class III malocclusion, there are usually no further problems, but in the case of Class II
malocclusion, excessive overjet can be formed if reproximation is performed.
A. Class III malocclusion.
B. Class II malocclusion.

238 ►► Chapter 5 _ Orthodontic Diagnosis • • • •

 • • • •

2) Extraction of maxillary anterior teeth

When there are missing teeth in the maxillary anterior area, the following treatment methods must
be considered:
1. Space closure through orthodontic treatment, 9
2. Premolar auto-transplantation, •
3. Prosthodontic treatment or implant after gaining the space.

Since the restoration treatment of the maxillary anterior teeth can cause an unaesthetic condition
after treatment, an extraction treatment approach is not desirable unless there is a serious
pathological, traumatic, or unaesthetic problem. If an extraction treatment is applied, full cusp
Class II molar relationship (through a non-extraction treatment on the mandible) and Class I molar
relationship (through a premolar extraction treatment on the mandible) can be formed depending
on the occlusion patterns (Fig. 5-67). Here, caution is needed when extracting the mandibular
teeth. If the maxillary anterior teeth are missing, it is essential to restore the Class I relationship
through a forward movement of the posterior teeth, so it is desirable to extract the mandibular
second premolars (Fig. 5-68).When the maxillary lateral incisor is missing and the maxillary
canine replaces the maxillary lateral incisor, the shape and color of the canine must be carefully
checked. If the color of the maxillary canine is too dark, caution is needed because an additional
restoration treatment is required. Also, since the maxillary premolar takes over the role of the
maxillary canine, it (maxillary first premolar) must have a long buccal cusp (Fig. 5-69).

▼A t B

►► Fig. 5 -6 7 Occlusion after the extraction of maxillary anterior teeth.

A. Non-extraction on the mandible: Class II molar relationship.
B. Premolar extraction on the mandible: Class I molar relationship.

Chapter 5 _ Orthodontic Diagnosis « ◄ 239

 ▼A-1 ▼A-2

►► Fig. 5-68 Mandibular premolar

e x tra c tio n when m a x illa ry
anterior teeth are extracted.
A. Diagram after a mandibular
premolar extraction.
A-1. Mandibular first
premolar extraction.
A-2. Mandibular second
premolar extraction.
B. Intraoral photographs after
extracting the mandibular
second premolar.

▼A-1 ^A-1

►► Fig. 5 -6 9 Considerations in
the extraction of the maxillary
anterior teeth.
A. When the maxillary canine
takes over the role of the
lateral incisor:
A-1. When the shape and
color of the maxillary
canine are good.
A-2. When the shape and
color of the maxillary
canine are unaesthetic.
B . W hen the m a x illa ry firs t
pre m o la r takes over the
role of the maxillary canine:
B-1. When the shape of the
maxillary first premolar
is good.
B-2. When the shape of the
maxillary first premolar
is unaesthetic.

2 4 Q ► Chapter 5 _ Orthodontic Diagnosis

• • • •
 • • • •

, V j 3 linicalTips: Considerations in the extraction of the maxillary

anterior teeth (Fig. 5-69).
A. Maxillary canine: B. Maxillary first premolar:
© Shape, © Shape,
(2 ) Color, © Mesio-distal angulation,
(3) Mesio-distal angulation, © Labio-lingual inclination.
© Labio-lingual inclination.

(1) Maxillary central incisor extraction

Czochrowska et al. (2003) found out that when the maxillary central incisor space is closed,
most patients are satisfied with the treatment outcome.
Here, when closing the space, the following must be carefully examined:
1) The size, length and shape of the maxillary lateral incisor;
2) Malocclusion patterns and occlusal relationship;
3) Relationship between crowding and space, etc;
4) Shape and color of the canine crown.

Particularly in the case of growing patients, a permanent prosthodontic treatment on the

missing maxillary incisor is difficult to apply. The space closure is desirable, if the size of the
lateral incisor is appropriate.
If a restorative treatment is applied to growing patients, their pulp would be exposed, and their
gingival shape can become unaesthetic due to the eruption of teeth. Therefore, a permanent
prosthodontic treatment can be considered only after they become adults. If the maxillary
lateral incisor has a small size, the space closure in this area is not desirable (Fig. 5-70).

Chapter 5 _ Orthodontic Diagnosis «« 241

 A-1 ►

►► Fig. 5 -7 0 Missing maxillary

central incisors.
A. Prosthodontic treatment after
maintaining the space.
A-1. Pre-treatment intraoral
photographs.
A -2> A-2. Post-treatment intraoral
photographs.
B. Space closure (m axillary
left central incisor).
B-1. Pre-treatment intraoral
photographs.
B-2. Post-treatment intraoral
photographs.
B -U

(2) Maxillary lateral incisor extraction

The majority of maxillary anterior tooth extraction falls under this category.
Nordquist and McNeill (1975) and Robertsson and Mohlin (2000) argued that space closure is
better than a prosthodontic treatment in the lateral incisor area, not only to satisfy the patients
# but also for their periodontal health.
When the impacted canine causes a root resorption of the maxillary lateral incisor or when the
lateral incisor has a small size, an extraction treatment can be needed. Here, it is important to
consider the shape and color of the maxillary canine and the shape of the first premolar as well.
For example, if the maxillary canine is worn out or if the maxillary first premolar has a long
and sharp cusp, it is possible to expect a good treatment outcome, if the maxillary incisor is
extracted and the space is closed afterwards.

242 ►► Chapter 5 _ Orthodontic Diagnosis

• • • •
 • • • •

The following considerations are needed in the extraction of the maxillary lateral incisor:
1) Bilateral symmetry: the lateral incisors have normal shape and size.
2) Bilateral symmetry: the lateral incisors have normal shape but small size.
3) Bilateral symmetry: the lateral incisors have peg lateralis.
4) Bilateral asymmetry: a peg lateralis and a normal size lateral incisor.
5) Bilateral asymmetry: a small-size lateral incisor and a normal-size lateral incisor.

►► Fig. 5-71 Various sizes and shapes of maxillary lateral incisiors.

A. Maxillary lateral incisors in bilateral symmetry.

A-1. Normal shape and size.
A-2. Normal shape but slightly smaller.
A-3. Peg lateralis.
A-4. Congenitally missing.

Chapter 5 _ Orthodontic Diagnosis ◄◄ 243

 ►► Fig. 5-71 (c o n tin u e d ) Various sizes and shapes of the maxillary lateral incisors.

B-1 *>

B. Maxillary lateral incisors in bilateral asymmetry.

B-1. Congenitally missing and normal shape and size.
B-2. Congenitally missing and slightly smaller.
B-3. Congenitally missing and peg lateralis.
B-4. Normal shape and size, and peg lateralis.

#
m

244 ►► Chapter 5 _ Orthodontic Diagnosis

• • @ •
 • ® • ©

In the case of maxillary lateral incisor extraction, since the maxillary first premolar takes over
the role of the maxillary canine, the torque and crown angulation of the maxillary first
premolar should be adjusted (Fig. 5-72).

▼A-1 t A-2 ▼A-3

■V

▼B
►► Fig. 5-72 Bracket selection and positioning for space closure after
extracting the maxillary lateral incisor.
A. Maxillary canine.
A-1. Vertical position: by considering the gingival margin of
central incisor, a modification of appearance must be made
after the extrusion.
A-2. Labio-lingual inclination: palatal surface reduction after
giving the crown labial torque of the lateral incisor to the
canine.
A-3. Mesio-distal inclination: crown mesial angulation after root
parallelism.
B. Maxillary first premolar: vertical position.

,v<3linical Tips: Considerations in bracket selection and positioning

after the maxillary lateral incisor extraction (Fig. 5-72).
A. Maxillary canine replaces maxillary lateral incisor.

© Vertical height: the gingival margin of maxillary canine should be closer to the

incisor edge than to the central incisor.

(2) Mesio-distal angulation.

© Labio-lingual inclination: should have crown labial torque.

B. Maxillary first premolar replaces maxillary canine.

0 Vertical height.

(2) Mesio-distal angulation: must have crown mesial angulation.

@ Labio-lingual inclination. ¡ ► ^ |

Chapter 5 _ Orthodontic Diagnosis 245

 (3) Maxillary canine extraction

Except for cases where the maxillary canine is difficult to tract because of its position, the
application of the maxillary canine extraction is not usually desirable. In the premolar
extraction case, it is always difficult to decide whether to extract the first premolar, the
impacted canine or the small-size maxillary lateral incisor (Fig. 5-73). In the case of growing
patients, auto-transplantation of the maxillary canine can be considered (Fig. 5-74).

► Fig. 5-73 A dilemma for orthodontists: whether to extract the first premolar, the impacted canine or the
small-size maxillary lateral incisor.

A. Pre-treatment intraoral photographs: two mandibular incisors are observed, and an ectopically erupted
right maxillary canine and an impacted left canine are observed.

B. Pre-treatment panoramic radiograph.

246» Chapter 5 _ Orthodontic Diagnosis

• # # ®
 • • • •

►► Fig. 5 -7 3 (c o n tin u e d ) A dilemma for orthodontists: whether to extract the first premolar, the impacted
canine or the small-size maxillary lateral incisor.

C. Post-treatment intraoral photographs: after the extraction of the maxillary right first premolar and the left
lateral incisor.

D. Post-treatment panoramic radiograph.

Chapter 5 _ Orthodontic Diagnosis ◄◄ 247

 ►► Fig. 5 -7 4 Maxillary canine auto-transplantation.

A. Pre-treatment intraoral photographs and panoramic radiograph: an impacted maxillary left canine.

B. Post-treatment intraoral photographs and panoramic radiograph: auto-transplantation of the impacted

maxillary left canine.

248 ►► Chapter 5 _ Orthodontic Diagnosis ® © ® •

 m • • •

First molar extraction

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

• Indications of first molar extraction are as follows:

a. Third molars in good condition,
b. First molar has a severe dental cavity,
c. High angle skeletal pattern,
d. Severe anterior crowding.

1) Maxillary first molar extraction

(1) Class II malocclusion case with maxillary protrusion: the overjet problem should be solved by
a posterior movement of the anterior teeth through the extracted space of the first molar.
(2) Class III malocclusion case with maxillary undergrowth: the anterior crowding problem should
be solved through the extracted space of the first molar.

2) Mandibular first molar extraction

If there is a steep mandibular plane angle, it can be treated by the extraction of the mandibular first
molar. However, if the mandibular first molar is extracted, the overjet problem can be aggravated
due to the posterior movement of the mandibular anterior teeth. Here, it is desirable to close the
space after the extraction of a maxillary tooth (usually the first premolar). As a result, a Class II
molar relationship will be formed (Fig. 5-75).

Chapter 5 _ Orthodontic Diagnosis «◄ 249

 p. p- Fig. 5 -7 5 Mandibular first molar extraction.

A. Pre-treatment intraoral photographs and panoramic

radiograph.
CD Severe cavity on the mandibular right first molar and
missing left first molar.
(D Mesially impacted mandibular right third molar.

250 ►► Chapter 5 _ Orthodontic Diagnosis

• • © •
 • ® • ©

►► Fig. 5 -7 5 (c o n tin u e d ) Mandibular first molar extraction.

C. Post-treatment intraoral photographs and panoramic

radiograph: space closure in the mandibular first molar
site and uprighting of the mandibular right third molar.

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113:538-545, 1998.
48. Hilgers JJ. The pendulum appliance for Class II non-compliance therapy. J Clin Orthod 26:706-714,1992.
49. Huynh T, Kennedy DB, Joondeph DR, et al. Treatment response and stability of slow maxillary
expansion using Haas, hyrax and quad-helix appliances. Am J Orthod Dentofacial Orthop 136:331-
339, 2009.
50. Isaka F, Suzuki Y, Hwang DH, Tuazon R, and Sato S. Non-extraction therapy of Class II crowding
malocclusion with high mandibular plane angle. Bulletin of Kanagawa Dental College. 28 (1):47-54, 2000.
51. Iscan HN, and Sarisoy L. Comparison of the effects of passive posterior bite-blocks with different
construction bites on the craniofacial and dentoalveolar structures. Am J Orthod Dentofac Orthop
112:171-178, 1997.

Chapter 5 _ Orthodontic Diagnosis «« 253

 52. Janson G, Dainesi EA, Henriques JF, de Freitas MR, de Lima, and KJ. Class II subdivision treatment
success rate with symmetric and asymmetric extraction protocols. Am J Orthod Dentofac Orthop
124:257-264, 2003.
53. Kim E, and Gianelly AA. Extraction vs non-extraction: arch widths and smile esthetics. Angle Orthod
73:354-358, 2003.
54. Kim JH, MC Viana, TM Graber, FF Omeraza, and EA BeGole. The effectiveness of protraction face
mask therapy: A meta-analysis. Am J Orthod Dentofac Orthop 115:675-685, 1999.
55. Kim JH, Kim Jl, et al. Pretreatment characteristics of adolescents with Class II malocclusion treated by
maxillary second molar extraction. Korea J Orthod35:182-195, 2005.
56. Kim Jl, Akimoto S, Shinji H, and Sato S. Importance of vertical dimension and cant of occlusal plane in
craniofacial development. Int J Stomatol Occlusion Med 2:114-121,2009.
57. Kim Jl. Practical Clinical Orthodontics. Vol 1. Orthodontic treatment with MEAW. Well publishing Inc,
2012.
58. Kim Jl. Practical Clinical Orthodontics. Vol 2. Orthodontic Diagnosis. Well publishing Inc, 2013.
59. Kim Jl. Practical Clinical Orthodontics. Vol 3. Early orthodontic treatment. Well publishing Inc, 2015.
60. Kim YH and Vietas JJ. Anteroposterior dysplasia indicator: An adjunct to cephalometric differential
diagnosis. Am J Orthod 113:619-633, 1978.
61. Kim YH, Caulfield Z, Chung WN, and Chang Yl. Overbite Depth Indicator, Anteroposterior Dysplasia
Indicator, Combination Factor, and Extraction Index. Int J MEAW 1:11-32, 1994.
62. Kim YH. A comparative cephalometric study of Class II, Divisionl Nonextraction and Extraction cases.
Angle Orthod 49:77-84, 1979.
63. Kim YH. Aberrant growth of the mandible and its effect on the occlusion. Int J MEAW 6:5-22, 1999.
64. Kim YH. Anterior open bite and its treatment with Multiloop Edgewise Archwire. Angle Orthod 57:290-
321, 1987.
65. Kim YH. Overbite depth indicator(ODI) with particular reference to anterior open-bite. Am J Orthod
65:586-611, 1974.
66. Kim YH. Treatment of anterior open bite and deep overbite malocclusions with Multiloop Edgewise
Arch-Wire (MEAW) therapy. The enigma of the vertical dimension, J.A. McNamara, Craniofacial
Growth Series 36, Center for human Growth and Development, The University of Michigan. Ann
Arbor. 2000.
67. Kim YH. Treatm ent of severe open bite malocclusion without surgical intervention. Growth
modification: What works, what doesn’t, and why. J.A. McNamara, Craniofacial Growth Series 35,
Center for human Growth and Development, The University of Michigan. Ann Arbor. 1999.
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69. Kokich VG, and Mathews DP. Surgical and orthodontic management of impacted teeth. Dent Clin N
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254 ►► Chapter 5 _ Orthodontic Diagnosis • • • •

 © ® © ©

70. Kokich VG, Nappen DL, and Shapiro PA. Gingival contour and clinical crown length: their effect on the
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71. Kokich VG, and Spear F. Guidelines for managing the orthodontic-restorative patient. Semin Orthod
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72. Kokich VO Jr, Kiyak HA, and Shapiro PA. Comparing the perception of dentists and lay people to
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73. Lee DK, and Kim Jl. Personal communication, 2011.
74. Lehman R. A consideration of the advantages of second molar extraction on orthodontics. Europ J
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75. Liddle DW. Second molar extraction in orthodontic treatment. Am J Orthod 72:599-161, 1977.
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77. Little RM, Riedel R, and Engst ED. Serial extraction of first premolars-postretention evaluation of
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79. Luppapornlap S, and Johnston LE. The effects of premolar extraction: a long-term comparison of
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82. McReynolds DC, and Little RM. Mandibular second premolar extraction-postretention evaluation of
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83. Merrifield LL, Klontz HA, and Vaden JL. Differential diagnostic analysis systems. Am J Orthod
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 91. O’Grady PW, McNamara JA Jr, Bacceti T, et al. A long-term evaluation of the mandibular Schwarz
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 © • • •

109. Sato S. A treatment approach to malocclusion under the consideration of craniofacial dynamics
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Chapter 5 _ Orthodontic Diagnosis « ◄ 257

 PART II

ORTHODONTIC TREATMENT
 ọ
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Hi
S
I

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 Chapter B

BRACKET SYSTEM
AND BRACKET
POSITIONING

Bracket System
1) Bracket system
2) Important considerations for bracket selection
3) Bracket selection for non-extraction cases
4) Bracket selection for premolar extraction cases

Positioning
1) Accurate bracket positioning
(1) Criteria for bracket positioning
(2) Bracket positioning errors
(3) Accurate bracket positioning in clinical practice
2) Bracket positioning for individual teeth
3) Bracket positioning in various cases
 g ^ Bracket System

Bracket system

1) Basic configuration and components (Fig. 6-1)

►& Fig. 6-1 A typical bracket.

A. Shape of a typical bracket. B. Names of the bracket parts.

a. Wire slot : This is a part of the bracket which the orthodontic archwire is inserted into. The
slot is made up of two sizes: .018” slot (.018” x .025”) or .022” slot (.022” x .028”).

b. Bonding base : This is a part of the bracket that comes in direct contact with a tooth.
Here, to ensure strong bonding, two types of bracket bases are used: a bondable mesh type,
or a weldable type.

c. Bracket width : This is the distance between the mesial and distal sides of the bracket.
Depending on the number of wings, brackets can be classified into two types: a single
bracket, or a twin bracket.

d. Bracket height : This is the distance from the base of the bracket to its top. There are
three different bracket heights: low profile, standard profile, and high profile. Since a high
profile bracket can cause premature contact with the opposing tooth, a low profile bracket is
recommended.

262 ►► Chapter 6 _ Bracket System and Bracket Positioning

• • • ©
 • • # •

e. In-and-out : This is the distance from the bottom of the wire slot to the bonding base. In
order to form an ideal dental arch, different in-and-out values should be applied to the
bracket of each tooth - this is the fundamental base of SWA appliance. Since the size,
thickness and shape of the teeth are different among various races (e.g. Asians or
Westerners), there can be various in-and-out options. 9
#
f. Tie wing : This is the place where the bracket is ligated in order to ensure tight fit of the
orthodontic archwire into the wire slot. The tips of these tie wings are usually curved
inward so that the bracket can be ligated more effectively with a ligature wire or an O-ring.

(1) Labial and lingual brackets (Fig. 6-2)

Brackets are categorized according to bonding areas. A labial bracket is attached to the labial
surface of a tooth, and a lingual bracket is bonded to the lingual surface of a tooth.

►► Fig. 6-2 Labial and lingual brackets.

These images show maxillary lingual brackets and mandibular labial brackets.

(2) Edgewise brackets and Begg brackets (Fig. 6-3)

Brackets are classified into two different types: Edgewise and Begg brackets. In Edgewise
brackets, a rectangular wire is used to ensure three-dimensional movement of the teeth, while
in Begg brackets, a round wire is used to ensure tipping movement of the teeth.

Chapter 6 _ Bracket System and Bracket Positioning 4 ◄ 263

 (3) .018” slot and .022” slot (Fig. 6-4)

Brackets can be classified by their slot size: .018” (.018” x .025”) slot and .022” (.022” x .028”) slot.
For the MEAW technique, brackets with .018” slots are recommended.

►► F ig . 6 -3 Edgewise bracket and Begg ►► Fig. 6-4 .018” slot and .022” slot.
bracket. A. .018” x.025” slot bracket.
A. Edgewise bracket. B. .022” x.028” slot bracket.
B. Begg bracket.

(4) Single brackets and twin brackets (Fig. 6-5)

Brackets are also classified into two types based on the number of wings: single brackets and
twin brackets. The single bracket only has one wing, but the twin bracket has two wings. The
single bracket can increase the inter-bracket distance, but it can be difficult to control the
rotation of teeth. In contrast, in the case of a twin bracket, the control of the rotation of teeth
becomes easy, but the inter-bracket distance can be decreased. To solve these problems,
strategic bonding is also needed along with the twin bracket.

264 ►► Chapter 6 _ Bracket System and Bracket Positioning tl • • •

 • © • •

Ap
►►Fig. 6-5 Single brackets and twin brackets.
A. Single brackets.
B. Twin brackets.
* Inter-bracket distance

(5) Metal brackets and aesthetic brackets (Fig. 6-6)

Brackets can be also classified by the type of material: metal brackets and aesthetic brackets
(plastic and ceramic brackets). Plastic brackets are advantageous for aesthetics, but
discoloration or wear-out can occur. Ceramic brackets can increase bonding strength, so they
can damage the teeth when are being removed.

►► Fig. 6-6 Metal brackets and ceramic brackets.

A. Metal brackets.
B. Ceramic brackets.

Chapter 6 _ Bracket System and Bracket Positioning 265

 (6) Standard brackets and SWA brackets (Fig. 6-7)

There are two types of brackets: standard brackets and straight wire appliance (SWA) brackets.
In-and-out, angulation, torque, and rotation are incorporated into SWA brackets, while none of
these are incorporated into standard brackets.

Maxillary Central Lateral Cuspid 1st Bicuspid 2st Bicuspid 1st Molar 2st Molar
Torq. Ang. Torq. Ang. Torq. Ang. Rot. Torq I Ang. Rot. Torq. Ang. Rot. Torq. Ang. ! Rot. Torq. Ang. Rot.
Butterfly LP V-Slot +14 +5 +8 +9 0 +9 0 -7 ! o 0 -8 -3 0 -14 I -6 ! 8 -14 0 7
Roth +12 +5 +8 +9 -2 +10 4 -7 0 2 -7 0 2 -10 0 14 -10 0 7
McLaughlin Bennett (MBT) +15 +5 +8 +9 -7 +10 0 -7 0 0 -7 0 0 -14 ! 0 -14 0 7
10
Straight Wire +12 +5 +8 +9 -7 +10 0 -7 o 0 -7 0 0 -10 0 Í 8 -10 0 7
Modified Straight Wire +15 +5 +8 +9 -3 +10 0 -7 I 0 0 -8 +4 0 -10 0 ! 15
Alexander +12 +5 +8 +9 -3 +10 0 -7 ! o 0 -7 0 0 -10! 0 ! 14 -10 0 7
Bio-Progressive +22 +5 +4 +8 +7 +7 0 -7 0 0 -7 0 0 -10 0 15 -10 0 8-
V-Slot +14 +5 +8 +9 -1 +10 0 -7 0 0 -7 0 0 -10 ! 0 14 -10 0 0
Level Anchorage - Regular +15 +5 +5 +7 0 +6 0 -7 ! o 0 -7 0 0 -10! 0 ! 15 -10 15 -7
IBD +12 +5 +8 +9 -7 +10 0 -7 0 0 -7 0 0 -10 0 8 -10 0 7
IBD Level Anchorage +15 +5 +7 +9 0 +5 0 -7 0 0 -7 0 0 -10 ! 0 8 -10 0 7
Micro Bonds +12 +5 +9 +8 -2 +12 0 -10 ! o 0 -10 0 0 -10 ! 0 ! 0 -10 0 0
Friction Free +12 +5 +8 +9 -2 +10 0 -7 0 0 -7 0 0 I1 1 1
Channel-Edge +12/+20 +5 +8/+16 +9 0/0 +9 0 -7/-7 0 0 -71-7 0 0 -10 ! 0 10 -10 0 6
Mini Standard Edgewise 0 0 0 0 0 0 0 0 I 0 0 0 0 0 o ! 0 ! 0 0 0 0
Mini Tweed 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mandibular Central Lateral Cuspid 1st Bicuspid 2st Bicuspid 1st Molar 2st Molar
Torq. Ang. Torq. Ang. Torq. Ang. Rot. Torq Ang. Rot. Torq. Ang. Rot. Torq. Ang. ! Rot. Torq. Ang. Rot,
Butterfly LP V-Slot -5 +2 -5 +5 -3 6 3 -7 ! o 0 -9 -3 0 -10/0! -6 ! 6 -10/0 0 7
Roth 0 0 0 0 -11 +7 2 -17 ! 0 4 -22 0 4 -25 0 ! 8 -30 0 7
McLaughlin Bennett (MBT) -5 0 -5 0 -7 +3 0 -11 +2 0 -17 +2 0 -20 ! +2 ! o -10 +2 0
Straight Wire 0 0 0 0 -11 +7 0 -17 ! o 0 -22 0 0 -25 ¡ 0 ! o -30 0 0
Modified Straight Wire -5 +2 -5 +4 -6 +6 0 -7 +3 0 -9 +3 0 -10 0 0 -10 0 7
Alexander -5 0 -5 0 -7 6 0 -11 0 0 -17 0 0 -25 ! -6 ! 8 -25 6 7
Bio-Progressive 0 0 0 0 +7 +5 0 -11 ! o 0 -17/-22 0 0 -25¡ -5 ! 8 -30 -5 7
V-Slot 0 0 0 0 -7 +7 0 -11 0 0 -17 0 0 -25 -6 8 -25 0 7
Level Anchorage - Standard 0 +2 0 +2 0 +6 0 -11 -4 0 -11 -4 0 -25 ! -5 ! 12 -25 -10 7
« i1 i1 -11 -6 0 -11 -6 0 -25 -10 ! 12 -25 -15 7
Level Anchorage - FHigh
IBD 0 0 0 0 -11 +7 0 -17 0 0 -22 0 0 -25 0 0 -30 0 0
IBD Level Anchorage 0 0 0 0 0 -5 0 -11 0 0 -11 0 0 -25 ! 0 ! 0 -30 0 0
Micro Bonds 0 0 0 0 -11 +8 0 -15 o 0 -15 0 0 -25 0 o -30 0 0
Friction Free 0 0 0 0 -11 +7 0 -17 0 0 -20 0 0 II II
Channel-Edge 0/0 0 0/0 0 -11/0 +5 0 -19/C! o 0 -19/0 0 0 -25 ! 0 ! 5 -30 0 7
Mini Standard Edgewise 0 0 0 0 0 0 0 0 o 0 0 0 0 o 0 ! o 0 0 0
Mini Tweed 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 I 0 0 0 0

►► Fig. 6-7 Standard brackets and SWA brackets.

A. Standard bracket.
B. SWA bracket.
C. Various kinds of SWA brackets (Orthodontic Product Catalogue of American Orthodontics, 2011).

266 ►► Chapter 6 _ Bracket System and Bracket Positioning

• • • m
 • • • •

(7) Ligation brackets and self-ligation brackets (Fig. 6-8)

Brackets can be further categorized by the type of required ligation: ligation brackets and self­
ligation brackets. For ligation brackets, O-rings or ligature wires are used, but for self-ligation
brackets, a built-in ligation clip is used.
©

►► Fig. 6-8 Ligation brackets and self-ligation brackets.

A. Metal ligation brackets.
B. Ceramic ligation brackets.
C. Metal self-ligation brackets.
D. Ceramic self-ligation brackets.

Chapter 6 _ Bracket System and Bracket Positioning 4 4 267

 2) Buccal tubes

Terminal molars should not be ligated with conventional brackets; small-sized equipment -single
buccal tubes with a slot size of .018” x .025”- must be used. However, when a headgear is used to
treat the maxillary protrusion, a double buccal tube is used.

The following tube types are commonly used:

A. Single buccal tube,
B. Single convertible bracket,
C. Double buccal tube.

(1) Maxillary and mandibular second molars (Fig. 6-9)

Single buccal tubes are frequently used to treat the terminal molars. A hook should be placed
on the mesio-gingival side of the tooth.

▼A ▼B

►► Fig. 6-9 Single buccal tube for the maxillary and mandibular second molars.
When used on the terminal molars, the hook is placed on the m olar’s mesio-gingival side to facilitate the
use of an elastic or energy chain. Therefore, the same appliance should be used interchangeably on the
maxillary right side and on the mandibular left side. The same appliance should be used interchangeably
on the maxillary left side and on the mandibular right side. The appliance in figure A is the tube that is
frequently used on the maxillary left molars or on the mandibular right molars.

V'

2B8 ►► Chapter 6 _ Bracket System and Bracket Positioning

• • • @
 • • @ @

(2) Maxillary first molars (Fig. 6-10)

CD Wide bracket
This bracket is commonly used on the maxillary first molars when the appliance is
extended to the maxillary second molars. $

(D Convertible bracket
This bracket is used on the maxillary first molars before the appliance is extended to the
maxillary second molars. During treatment, if the appliance is extended to the maxillary
second molars, this bracket can be converted into a wide bracket by removing its cap.

(3) Double buccal tube

This type of bracket is used when there is a need for an extra-oral appliance. The .045”
tube is commonly used and is placed on the occlusal side of the tooth.

▼A ▼B ▼C

►> Fig. 6 -1 0 Orthodontic appliances on the maxillary first molars.

Chapter 6 _ Bracket System and Bracket Positioning «•< 269

 (3) Mandibular first molars (Fig. 6-11)

CD Wide bracket
This is the type of bracket that is frequently used on the mandibular first molars when the
appliance is extended to the mandibular second molars.

(D Single buccal tube

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

▼A ▼B

►► Fig- 6-11 Orthodontic appliances on mandibular first molars.

A. Wide bracket.
B. Single buccal tube.

#
#

270 ►► Chapter 6 _ Bracket System and Bracket Positioning

• • ® •
 ® • • ®

Important considerations for bracket selection

1) Third-order bends (Fig. 6-12)

This refers to the labio-lingual or bucco-lingual inclination of a tooth. For each SWA appliance, <3
based on the treatment goal, crown labial inclination on the four maxillary anterior teeth, and
crown lingual inclination on the maxillary canines, premolars, and molars are incorporated into the
brackets.
On the mandibular anterior teeth, zero-degree torque or crown lingual torque is incorporated into
the brackets, and on the mandibular canines, premolars and molars, crown lingual inclination is
incorporated into the brackets.

►► Fig. 6 -1 2 Third-order bends.

A. Crown inclination of each individual tooth (Andrews,1972).
B. When the standard bracket is bonded to a maxillary incisor and to a mandibular molar.
C. When the SWA bracket is bonded to a maxillary incisor and to a mandibular molar.
D. A comparison of inclination difference: standard bracket (black line) and SWA bracket(red
line) on maxillary incisors and on mandibular molars.

Chapter 6 _ Bracket System and Bracket Positioning ◄◄ 271

 (1) Class III malocclusion case

In general, when a SWA appliance is used, crown labial torque is incorporated into the
maxillary anterior teeth, and zero-degree torque or crown lingual torque is incorporated into
the mandibular anterior teeth. However, in the case of Class III malocclusion, due to the dento-
alveolar compensation, labial inclination of the maxillary anterior teeth and lingual inclination
of the mandibular anterior teeth are commonly observed. When treating such cases, the use of
a typical SWA appliance with Class III elastics can worsen these compensatory inclinations. In
the MEAW technique, however, after using the zero-degree torque brackets on the maxillary
and mandibular anterior teeth, a positive treatment outcome can be expected by using 1) the
maxillary MEAW that has crown lingual torque on the maxillary anterior teeth, 2) the
mandibular MEAW that has crown labial torque on the mandibular anterior teeth, and 3) Class
III elastics.

▼A ▼B ▼C

►► Fig. 6 -1 3 Class III malocclusion.

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

272 ►► Chapter 6 _ Bracket System and Bracket Positioning

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(2) Non-extraction treatment case (Fig. 6-14)

In general, in the case of the SWA appliance, crown labial torque is incorporated into the
maxillary anterior teeth. Therefore, for a non-extraction treatment, labioversion of the
maxillary anterior teeth can be aggravated. However, in the MEAW treatment, labioversion of
the maxillary anterior teeth can be minimized and the space can be secured 1) by using a
standard bracket on the maxillary anterior teeth and 2) by effectively using the open coil
springs on a rectangular archwire that already has crown lingual torque on the maxillary
anterior teeth.

►► Fig. 6 -1 4 Non-extraction treatment.

A. Standard bracket (black line) + archwire with crown lingual torque + open coil springs.
SWA bracket (red line) + preformed archwire with zero-degree torque + open coil springs.
B. A comparison of tooth movement (inclination): standard bracket (black line) and SWA bracket (red
line). When the SWA bracket is used, the crown is more labially inclined than when the standard
bracket is used, thereby increasing the need of an extraction treatment.
C. Intraoral photograph: standard brackets + archwire with crown lingual torque + open coil springs.

Chapter 6 _ Bracket System and Bracket Positioning «« 273

 (3) Maxillary canine inclination (Fig. 6-15,16)

There has always been controversy over the ideal inclination of the maxillary canine.
Appropriate inclination of the maxillary canine is important because the excessive lingual
inclination of the maxillary canine can cause retrusion of the mandible as well as
temporomandibular joint disorder (TMD). In general, a bracket with zero-degree torque is used
on the maxillary canines in MEAW.

►► Fig. 6 -1 5 Maxillary canine inclination.

A. A comparison of tooth movement (inclination): standard bracket (black line) and SWA bracket (red
line). When a SWA bracket is used, the crown tends to have a greater lingual inclination than when a
standard bracket is used. Excessive crown lingual inclination of the maxillary canines has the effect of
reducing activation of the masticatory muscles, while increasing the risk of mandibular retrusion and
compression of mandibular condyle. Therefore, a cautious approach is needed when a crown lingual
torque bracket is used on the maxillary canines.
B. Comparison of condylar movement (Tamaki et al., 2001).
B-1. A maxillary canine with appropriate inclination.
B-2. A maxillary canine with excessive crown lingual inclination (-10°).

►► Fig. 6 -1 6 Maxillary canine inclination.

A. Pre-treatment intraoral photograph.
B. Mid-treatment intraoral photograph.
C. Post-treatment intraoral photograph: excessive lingual inclination of the maxillary canines.

274 ►► Chapter 6 _ Bracket System and Bracket Positioning

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 (4) Extraction treatment case (Fig. 6-17)

In a SWA bracket, since there is 0 to -5° of crown lingual torque, mandibular anterior teeth
may be excessively inclined when closing the extraction site. In MEAW, however, a zero-
degree torque bracket is recommended to prevent severe lingual inclination of the mandibular
anterior teeth.

▼A ▼B

►► Fig. 6 -1 7 Extraction treatment.

A. In the case of a premolar extraction treatment, lingual inclination will inevitably occur (caused by the
retraction of the anterior teeth). In these cases, the use of a bracket with crown lingual torque on the
mandibular anterior teeth can aggravate the linguoversion.
B. A comparison of tooth movement (inclination): standard bracket (black line) and SWA bracket (red
line). When a SWA bracket is used, the crown shows greater linguoversion than when a standard
bracket is used.

Chapter 6 _ Bracket System and Bracket Positioning 4 4 275

 (5) Class II malocclusion case (Fig. 6-18)

Unlike Class I II malocclusion, in the case of Class II malocclusion, when a SWA bracket is
used (crown labial torque on the maxillary anterior teeth, and zero-degree troque or crown
lingual torque on the mandibular anterior teeth), similar results can be achieved as when a
standard bracket is used with the maxillary and mandibular MEAWs and Class II elastics
together.

►^ Fig. 6 -1 8 Class II malocclusion.

A. Characteristics of Class II malocclusion: linguoversion of the m axillary anterior teeth and/or
labioversion of the mandibular anterior teeth.
B. In the finishing stages of Class II malocclusion treatment, Class II elastics are likely to be used. In this
case, an undesirable tooth movement may occur. To solve this problem, crown labial torque should be
applied on the maxillary anterior teeth and crown lingual torque should be applied on the mandibular
anterior teeth.
C. Comparison of tooth movement pattern: standard brackets (black line) and SWA brackets (red line).
©

276 ►► Chapter 6 _ Bracket System and Bracket Positioning

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 (6) Torque of posterior teeth (Fig. 6-19)

From premolars to second molars, there is a progressive increase in crown lingual inclination
both on the maxillary posterior teeth and on the mandibular posterior teeth. Especially in SWA
brackets, since the same torque is given to the maxillary first and second molars, the lingual
cusps of maxillary second molars are more likely to be extruded.

►► Fig. 6 -1 9 Torque of a posterior tooth.

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

Chapter 6 _ Bracket System and Bracket Positioning -so 277

 (7) Torque differences between left and right posterior teeth (Fig. 6-20)

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

►► Fig. 6 -2 0 Torque differences

between left and right posterior
teeth.
A. Torque differences in the
case of midline deviation.
B. Comparison of pre- and
post-treatment intraoral
photographs: the changes
in inclination are observed
on the maxillary right
posterior teeth.
B-1. Pre-treatment intraoral
photographs.
B-2. Post-treatment intraoral
photographs.

278» Chapter 6 _ Bracket System and Bracket Positioning

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2) Second-order bends (Fig. 6-21)

Second-order bends refers to the mesio-distal angulation of the crown long axis. This should be
placed so that the cervical area of the tooth is placed more in the distal direction than the incisal
edge is. Depending on the goal of the treatment, various SWA brackets can be used.

►► Fig. 6-21 Second-order bends.

A. Mesio-distal angulation of each individual tooth (Andrews, 1972).
B. Tooth movement with standard brackets (black line).
C. Tooth movement with SWA brackets (red line).
D. Comparison of tooth movement pattern: standard brackets (black line) and SWA brackets (red line).
When standard brackets are used, the process of uprighting can be made much easier.
E. When SWA brackets are used, due to crown mesial angulation, the possibility of premature molar
contact increases.
F. Tooth movement with standard brackets (black line).
G. Tooth movement with SWA brackets (red line).
H. Comparison of tooth movement pattern: standard brackets (black line) and SWA brackets (red line).
When standard brackets are used, the process of uprighting can be made much easier.

Chapter 6 _ Bracket System and Bracket Positioning 279

 (1) Angulation problems (Fig. 6-22)

In using SWA brackets, which permit the crown mesial angulation in the molar and premolar
areas, there is an increasing possibility of occlusal interference with molars. During space
closure (in an extraction case), due to the mesial angulation of the crowns, the possibility of the
molars being mesially tilted increases more than the possibility of the posterior movement of
anterior teeth. Therefore, in MEAW, the bracket that restricts the mesial angulation of the
crowns should be used in order to upright the premolars and molars successfully.

►► Fig. 6 -2 2 Angulation problems.

Posterior occlusion can be influenced by the mesio-distal angulation. For example, even in the
case of Class II malocclusion, a Class I molar relationship can be maintained due to the mesial
angulation of the mandibular molars.

<§
,A

280» Chapter 6 _ Bracket System and Bracket Positioning

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(2) Occlusal plane problems (Fig. 6-23)

In the SWA system, the posterior occlusion of mesially angulated molars is maintained even
after the entire treatment procedure is finished. In contrast, in MEAW, the mesial angulation of
molars is considered as one of the main contributing factors to malocclusion. Therefore, when
using MEAW, it is essential to correct the mesial angulation of the molars. This means that the
treatment can be done by using standard brackets that have zero-degree angulation and by
using strategic leveling and MEAW (tip-back bends).

►► Fig. 6 -2 3 Occlusal plane problems.

A. The mesial angulation of posterior teeth can be evaluated from the posterior occlusal plane.
An abnormal posterior occlusal plane is considered to be one of the contributing factors to
malocclusion. Therefore, the posterior occlusal plane should be aggressively controlled and
corrected when treating malocclusion.
B. Class II malocclusion with a steep posterior occlusal plane (POP).
Class III malocclusion with a flat posterior occlusal plane (POP).

Chapter 6 _ Bracket System and Bracket Positioning ◄◄ 281

 (3) Vertical dimension problems (Fig. 6-24)

Differences in the vertical dimension between the left and right sides of dentition are caused by
the differences in occlusal planes. Therefore, when treating this type of malocclusion,
differences in the vertical dimension between the left and right sides can be treated by
improving the occlusal planes. To achieve this, the independent movement of each molar is
needed.

►► Fig. 6 -2 4 Vertical dimension

problems.
A. Tooth angulation and
occlusal plane differences
can lead to differences in
the posterior vertical
dimension; the main causes
of midline deviation.
B. A model for a patient who
has severe curve of Spee in
the right side with midline
deviation to the right.

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3) First-order bends (Fig. 6-25)

This refers to the arch form (when seen from the occlusal view) that has a natural curve on the
maxillary and mandibular anterior lingual surface, on the lines that connect the fossa of the
maxillary posterior teeth, and on the lines that connect the cusp tips of the mandibular posterior
teeth. In order to achieve this in the SWA system, the thickness of the bracket must be pre-adjusted
for appropriate alignment of the tooth without bending the wire.

►^ Fig. 6 -2 5 First-order bends.

A. Comparison of tooth movement pattern: standard brackets (black line) and SWA brackets
(red line).
When a standard bracket (black line) is used, the labial movement of the maxillary lateral
incisors and the mesial rotation of the maxillary first and second molars becomes easier than
when a SWA bracket (red line) is used.
B. An in-and-out is incorporated into the SWA bracket.

(1) In-and-out

Since there is a difference in thickness among teeth, an in-and-out is incorporated into the
SWA bracket to compensate for the differences. In most cases, minimal wire bending is used,
but if severe thickness differences are observed, some form of wire bending may be required.

Chapter 6 _ Bracket System and Bracket Positioning ◄◄ 283

 (2) Dental arch form (Fig. 6-26)

In general, there are three different arch forms: ovoid, tapered, and square. In SWA, the
archwire that perfectly fits into the pre-existing arch shape is used to maintain a patient’s
current arch form. However, in some cases, a correction of the arch form may be needed, in
which case, the stable arch form is known as the ovoid shape. To achieve this, the proper
selection of appliance as well as the appropriate adjustment of archwire is required.

▼A ▼B ▼c

►► Fig. 6 -2 6 Dental arch form.

A. Square arch form (U-shape).
B. Ovoid arch form.
C. Tapered arch form (V-shape).

(3) Passive centric line and active centric line (Fig. 6-27)

The passive centric line that connects the central fossa of the maxillary molars to the lingual
surfaces of the maxillary anterior teeth should match the active centric line that connects the
cusp tips of the mandibular molars to the edges of the mandibular anterior teeth.

284 ►► Chapter 6 _ Bracket System and Bracket Positioning

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• Centric stop : The position of mandible is determined by the inter-cuspation of the

maxillary and mandibular teeth. When the teeth establish maximum inter-cuspation, the
contact points of the maxillary and mandibular teeth are known as centric stop.
• Passive centric : The centric stop of the maxillary teeth exists in the maxillary dental
arch. This is considered to be in a relatively fixed state because the maxilla is connected to
the cranium, while the mandible is in a movable state. Moreover, as this is considered to be
a passive contact point that accepts the functioning cusps of the mandibular teeth, it is
called passive centric.
• Active centric : The centric stop of the mandibular teeth is an actively moving centric
when compared with the passive centric of the maxilla. Therefore, the centric stop of the
mandible is called active centric.

The goal of an orthodontic treatment is to match these centric stops of the maxillary and
mandibular teeth perfectly. In a Class I malocclusion case, the passive centric stops of the
maxillary first and second premolars are located in the mesial marginal ridge.

Chapter 6 _ Bracket System and Bracket Positioning «◄ 285

 4) KIMS bracket system (Fig. 6-28)

To sum up, a standard bracket should be used to overcome the problems of angulation and
inclination, while a SWA bracket should be used to minimize wire bending. The KIMS bracket has
the in-and-out incorporated inside to minimize wire bending. It is also possible to use preformed
archwires. However, since the second- and third-order bends are not incorporated into the KIMS
bracket, it becomes possible to perform a treatment based on the diagnosis. Furthermore, the KIMS
bracket is made up of a self-ligation type to minimize the patient’s discomfort and to reduce chair­
time.

▼A ▼B-1 t B-2

►► Fig. 6 -2 8 KIMS bracket system.

A. KIMS bracket.
B. Opened and closed view of a KIMS bracket clip.
C. Stages by wire size.
C-1. Passive stage: tooth movement with weak frictional force.
C-2. Interactive stage: combining the sliding mechanism with the torque control.
C-3. Active stage: satisfactory control of torque and rotation.

2 8 6 ►► Chapter 6 _ Bracket System and Bracket Positioning ® • % •

 ® ® <® #

cket system should have the following characteristics:

1. It should be able to minimize wire bending.

2. It should be able to offer a unique mesio-distal angulation and torque to each
patient.
3. It should be able to provide weak force.
4. Only a minimal amount of orthodontic archwire must be used. ► ►►

(1) KIMS bracket

The KIMS bracket has the following characteristics:

® It uses a .018” slot.
® It does not require basic wire bending as an in-and-out is already built into it.
(DIt can effectively use the preformed archwires.
© It uses the orthodontic archwires and transmits a weak force.
© It can move teeth effectively without causing crown angulation or torque (crown
inclination) to the bracket.
© It can move teeth effectively using MEAW.

(2) Applications of KIMS brackets

© It is possible to use the same KIMS bracket interchangeably on both maxillary central
incisors.
© The same brackets can be used both on maxillary lateral incisors and on four mandibular
incisors interchangeably.
© The same brackets can be used interchangeably on the maxillary right and mandibular
left canines, and the maxillary left and mandibular right canines. The hook must be
placed on the distal side.
© The same brackets can be used interchangeably on the maxillary and mandibular first
premolars. The same standard brackets can be used on the maxillary and mandibular
canines as well as on the first and second premolars.
© The appliances on the maxillary and mandibular first and second molars can be used as
shown in Fig. 6-9, 10 and 11.

Chapter 6 _ Bracket System and Bracket Positioning «s◄ 287

 Bracket selection for non-extraction cases

In non-extraction cases, the standard edgewise brackets with .018” slots are used. A single buccal
tube with .018” x .025” slot is used for the terminal (usually the second) molars, and a wide bracket
is used for the first molars.
• It should be able to prevent the labioversion of the maxillary incisors.
• It should be able to prevent the labioversion of the mandibular incisors.
• It should be able to control the curve of Spee.
• It should be able to control the curve of Wilson.
• It should be able to prevent the retrusion of the mandible that has been caused by excessive
crown lingual torque of the maxillary canines.
• Use of standard brackets.
• The terminal molars: use of a buccal tube.

Bracket selection for premolar extraction cases (Fig. 6-29)

In premolar extraction cases, the Roth prescription brackets (.018” slot) are used only for the four
maxillary anterior teeth. It is recommended to use a bracket with +12° torque for the maxillary
central incisors and a bracket with +8° torque for the maxillary lateral incisors. In addition to using
a bracket with crown labial torque, it is possible to minimize the possibility of extrusion and
linguoversion of the maxillary incisors in extraction cases by using a combination loop with step
that has crown labial torque in the anterior region.
For the remaining teeth, a standard edgewise bracket with a .018” slot is used. When treating the
terminal molars (usually the second molars), a single buccal tube with a .018” slot is used, and a
wide bracket is used for the first molars. In particular, when a SWA appliance on the mandibular
premolars and molars is utilized, the lingual inclination of the molars can be aggravated during
treatment due to the lingual inclination that is already built into the SWA appliance. Also, in
extraction cases, curve of Wilson can be aggravated. Additionally, mesial angulation of the
mandibular molars can be aggravated through the use of an orthodontic appliance that has a mesial
angulation built into it. In some severe cases, there is a high possibility of premature contact
between the maxillary and mandibular terminal molars. Therefore, it is recommended to use the
standard appliances on all teeth except for the four maxillary anterior teeth.

288 ►► Chapter 6 _ Bracket System and Bracket Positioning

• * • •
 • # • •

►► Fig. 6 -2 9 Bracket selection in premolar extraction cases.

Crown lingual inclination, which can occur during space closure, can be minimized by giving
additional crown labial torque to the wire.
A. Standard bracket.
B. SWA bracket.

• Linguoversion and extrusion of maxillary anterior teeth should be prevented.

• Curve of Spee should be controlled.
• Curve of Wilson should be controlled.
• Retrusion of the mandible caused by excessive crown lingual torque of the maxillary
canines should be prevented.

Chapter 6 _ Bracket System and Bracket Positioning 4 4 289

 Positioning

Accurate bracket positioning

1) Criteria for bracket positioning

When placing a bracket or a tube on a tooth, a three-dimensional assessment is essential:

(1) Vertical height,
(2) Mesio-distal position,
(3) Slot angulation.

First, the crown is examined. If an imaginary line is drawn on the facial axis of a crown, it will be
a FACC (Facial Axis of Clinical Crown). The mid-point of this line is the FA point. In principle,
the bracket must be placed at this FA point (Fig. 6-30).

A>

►► Fig. 6 -3 0 FACC (Facial Axis of Clinical

Crown) and FA point.
A. The shape of clinical and anatomical
crown.
B. FACC of maxillary teeth.
C. FACC of mandibular teeth.
D. FACC and FA point (Andrews, 1986).

290 ►► Chapter 6 _ Bracket System and Bracket Positioning

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 • • • •

(1) Vertical height

This refers to the distance from the bracket slot to the cusp tip or incisal edge. By accurately
placing the brackets vertically, ideal occlusion as well as the appropriate relationship of
marginal ridge can be formed in the flat archwire (Fig. 6-31).

►► Fig. 6-31 Things to consider

for bracket positioning:
• Reference points.
1. Long axis of the tooth,
2. Facial axis of the clinical
crown,
3. Incisal edge of incisor
and cusp tip of premolar
and molar,
4. Marginal ridge
relationship,
5. Contact points,
6. Type of malocclusion.

linical Tips: Bracket positioning

1. Check the parallelism of the long axis of each tooth.

2. Mark the FACC and FA points of each tooth.

3. Mark the existence and the degree of marginal ridge discrepancy of the adjacent teeth.

a) When there is no marginal ridge discrepancy:

(1) The height of the slot should be lined with the height of the adjacent teeth.

In this case, the brackets should be placed at the FA point.

b) When there is a marginal ridge discrepancy:

(1) Amount of marginal ridge discrepancy = Expected distance between the

slots. In this case, the brackets should be placed at the FA point.

(2) Amount of marginal ridge discrepancy =# Expected distance between the

slots. In this case, the brackets should be placed at the FA point ±*m m .

4. Place the center of the slot at the mesio-distal center of the tooth.

5. Place the slot perpendicularly to the long axis of the tooth. The wing of the bracket

must be parallel to the long axis of the tooth.

6. Make sure that the base of the bracket is in tight contact with the tooth s u rfa c |f^ ^

Chapter 6 _ Bracket System and Bracket Positioning < 4 291

 © In general, the ideal bracket heights are as listed below:
Maxilla 5.0mm (Ul), 4.5mm (U2), 5.0mm (U3), 4.5mm (U4), 4.5mm (U5), 4.0mm (U6), 3.5mm (U7)
4.5mm (U1), 4.0mm (U2), 4.5mm (U3), 4.0mm (U4), 4.0mm (U5), 3.5mm (TJ6), 3.0mm (U7)
Mandible 4.5mm (LI), 4.5mm (L2), 5.0mm (L3), 4.5mm (LA), 4.5mm (L5), 4.0mm (L6), 4.0mm (L7)
4.0mm (LI), 4.0mm (L2), 4.5mm (L3), 4.0mm (L4), 4.0mm (L5), 3.5mm (L6), 3.5mm (L7)

The vertical height of a bracket is measured by a bracket positioning gauge. However,

depending on its assessment method, there may be a high possibility of making an error
(Fig. 6-32).

▼A-1 ▼A-2 vB-1

►► Fig. 6 -3 2 Bracket positioning gauge.

Instead of using a bracket positioning gauge, an eye-ball measurement must be used for accurate
bracket bonding. In this case, a positioning gauge must first be used to check the height, and then the FA
point should be marked. The bracket then should be bonded after careful consideration of its adjacent
teeth.
A. A different position of bracket, depending on the angulation of its bracket positioning gauge.
B. Different types of bracket positioning gauges.

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 • ® • •

The following guidelines should always be considered when determining bracket height
(Fig. 6-33, Table. 6-1):

a. The average aesthetic length of the upper central incisor is 10mm. The height of this
midline is known to be 5mm. If the patient has shorter teeth, a slightly lower height -
4.5mm- is also acceptable. In these cases, it is undesirable to place a bracket deeper
than 5mm.
b. If the bracket is bonded on a lateral incisor, it should be attached approximately
0.5mm closer to the incisal edge than the height of central incisor. Therefore, the ideal
height of the bracket on the lateral incisor would be 4.5mm (if the height of the
central incisor is 5.0mm) or 4.0mm (if the height of the central incisor is 4.5mm).
c. In general, the bracket on a maxillary canine must be bonded at the same height as the
central incisor.
d. Brackets for maxillary first and second premolars are positioned at the same height.
Usually, for the second premolar, it is normal for the bracket to be placed 0.5mm closer
to the occlusal edge than the first premolar. However, due to the under-eruption of
second premolars and a step in the first molar, it is recommended to place the brackets
on the same height as the first premolar. This is 0.5mm closer in the occlusal direction
than the maxillary central incisors and canines are. Here in average, the distance of
premolar area is known to be either 4.0mm or 4.5mm away form the cusp tip.
e. The bracket on a maxillary first molar should be placed 0.5mm closer to the occlusal
surface than a second premolar is, which is usually 0.5mm deeper than the second molar.
f. The height of a bracket on the four mandibular anterior teeth must, after considering
the contact with opposing teeth and crown length, be bonded on the height of 4.5mm
or 4.0mm. In this case, it is also important not to place the bracket deeper than its
center of crown.
g. The bracket of a mandibular canine must be placed 0.5mm deeper than the one on the
mandibular anterior teeth.
h. The brackets of mandibular first premolars and second premolars must all be placed
at the same height. When treating a second premolar, it is normal to place the bracket
0.5mm closer to its occlusal surface. However, due to the under-eruption of second
premolars and step of first molars, it is recommended to place the brackets at the
same height. Additionally, it is better to place the bracket 0.5mm closer to the
occlusal surface than the mandibular canines are, which are approximately 4.5mm or
4.0mm away.

Chapter 6 _ Bracket System and Bracket Positioning ◄◄ 293

 i. The bracket of a mandibular first molar should be placed 0.5mm closer to the occlusal
surface than the second premolar, but attached at the same height as the second molar.
Here, it is normal to place the second molar 0.5mm closer in the occlusal direction,
but if there is no difference in marginal ridges, it is recommended to bond the bracket
at the same height.

►► T a b le . 6-1 Reference table of different

bracket heights.

Central Lateral First Second First Second

Canine
incisor incisor premolar premolar molar molar
X+0.5 X X+0.5 X X X-0.5 X-1.0
X 5.0 4.5 5.0 4.5 4.5 4.0 3.5
E
4.5 4.0 4.5 4.0 4.0 3.5 3.0
X X X+0.5 X X X-0.5 X-0.5
_Q
TD 4.0 4.0 4.5 4.0 4.0 3.5 3.5
05
E 4.5 4.5 5.0 4.5 4.5 4.0 4.0

►& Fig. 6 -3 3 Reference of brackets height.

Bracket slots are bonded in reference to the
d is ta n c e from the cusp tip of the firs t
premolar to its crown center.

294 ►► Chapter 6 _ Bracket System and Bracket Positioning

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 # # • •

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

► Fig. 6-34 Problems of contact

between mandibular brackets
and maxillary teeth.
1. Tooth mobility and bracket
detachment.
2. Lingual inclination of the
crown.
B► 3. Retrusion of the mandible.

Chapter 6 _ Bracket System and Bracket Positioning < < 295

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

▼A-1 ▼A-2

▼B-1 ▼B-2
TV ►► Fig. 6 -3 5 Vertical height of
brackets.
A-1. Gingivally-positioned
bracket.
A-2. Tooth movement that has
been caused by a
gingivally-placed bracket.

Jf?
B-1. Accurate bracket
positioning.
B-2. Expected tooth
movement.

296 ►► Chapter 6 _ Bracket System and Bracket Positioning V © V A

 • • • •

The following errors commonly occur (Fig. 6-36):

a. Inconsistencies in the marginal ridge of the posterior region,
b. Inconsistencies in the maxillary and mandibular incisal edges.

▼A-1 t B-1 ▼C-l

►► Fig. 6 -3 6 Vertical positioning errors.

A. Tooth movement is caused by incorrectly placed brackets on the right incisors.
B. Tooth movement when the brackets are accurately bonded on the first premolar and second molar
that have the discrepancy of marginal ridge relationship.
C. Bracket positioning and its adjustment on partially erupted teeth:
1) The bracket is occlusally placed on the maxillary left second premolar.
2) Post-treatment intraoral photograph.

The following errors commonly occur:

a. When treating partially erupted teeth, it is not compulsory to follow its strategic bonding
and to place a bracket on the tooth. If there is a difference in vertical bracket height, an
archwire adjustment must be made in the finishing phases or the bracket should be re­
bonded into an ideal position after the leveling procedure.
b. When treating a patient who has a crown fracture or attrition on the incisal edge or
occlusal surface, a bracket must be positioned after the occlusal adjustment. Here,
however, if the patient is still growing or the amount of attrition is small, a bracket must
be positioned after the incisal edge adjustment.

Chapter 6 _ Bracket System and Bracket Positioning -<◄ 297

 On the other hand, when treating an adult, it is important to discuss what their main
purpose of the treatment is i.e. aesthetic prosthesis, occlusal adjustment, etc. A
discussion must be carried out whether to perform a prosthodontic treatment after
modifying the vertical height in the early stage of treatment, or whether to grind the
incisal edges before bonding the brackets.
c. When the buccal cusp is too long and sharp, appliances must be bonded after a re­
shaping of the maxillary canine.

(2) Mesio-distal position

The bracket is positioned at the mesio-distal center of the crown (Fig. 6-37).
a. In the anterior dentition, the natural shape of the lingual surface can be maintained.
b. The line that connects the central fossa of the posterior dentition is natural and smooth.
c. In the occlusal view, the buccal surface of the maxillary first molars should be as parallel
as possible.

►► Fig. 6 -3 7 Mesio-distal position.

At the incisor, canine and premolar area, the brackets should be positioned at the mesio-distal
center of the crown, but at the molar area, the brackets should be positioned at the buccal
groove.

298 ►► Chapter 6 _ Bracket System and Bracket Positioning

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 • • • •

2) Bracket positioning errors

(1) Horizontal positioning errors (Fig. 6-38, 39)

This refers to the positioning of a bracket that improves the mesio-distal position relative to the
long axis of crown. When a bracket is placed on its mesial position, the bonded tooth rotates in
a distal direction, and if a bracket is placed on its distal position, the attached tooth rotates in a
mesial direction. Here, the special considerations are as follows:

►► Fig. 6-38 Horizontal positioning error on

the m axillary right lateral incisor. The
bracket is positioned too far distally.

►► Fig. 6 -3 9 Horizontal positioning error on

the maxillary right lateral incisor.
A. The bracket is distally positioned.
B. Tooth movement caused by a distally
positioned bracket.
C. E xpected tooth m ovem ent: m esial
rotation of the tooth is induced by the
distally positioned bracket.

Chapter 6 _ Bracket System and Bracket Positioning 299

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

▼A ▼B ▼C
►► F ig . 6 -4 0 Mesial rotation and parallel
rotation of the maxillary first molar.
A. A correctly placed bracket on the maxillary
first molar: the slot entrance is placed at
the center of the mesio-buccal cusp.
B. A b racket is d is ta lly placed on the
maxillary first molar.
C. E xpected tooth m ovem ent: m esial
rotation of the tooth is induced by the
distally positioned bracket.

© Crowding in the maxillary and mandibular anterior areas (Fig. 6-41)

a. Between the central and lateral incisors: In the case of a mesially rotated lateral incisor,
crowding can be corrected by positioning the bracket more on its mesial direction than
the long axis of the tooth. However, if it is placed more in a distal direction, a correction
of the mesially rotated lateral incisor would be difficult to achieve.
b. Between the lateral incisors and the canines: Most errors occur from the mesial rotation
of the canine. Therefore, it is important to place the bracket slightly more in a mesial
direction than the long axis of the canine crown.

▼A ▼B ▼c

►>■ Fig. 6-41 Maxillary incisors.

A. Accurately positioned bracket on the center of the tooth.
B. The right side (red line) of the brackets is distally positioned.
C. Expected tooth movement: mesial rotation of the tooth is induced by the distally positioned brackets.

300- Chapter 6 _ Bracket System and Bracket Positioning

• ® © •
 « • • •

As a result, the bracket is placed closer to the mesio-distal center of the crown. In a Class II
malocclusion case, in order to induce the distal rotation of maxillary premolars, the bracket
must be placed more towards the mesial direction. In Class III malocclusion, in order to
induce the mesial rotation of the maxillary premolar, the bracket must be placed more in
the distal direction. Here, however, the bracket should also be placed in the mesial
direction of the mandibular dentition to induce the distal movement of mandibular
dentition (Fig. 6-42).

►► Fig. 6 -4 2 Bracket positioning in the case of Class II and Class III malocclusion.
A. Brackets positioned at the mesio-distal center of the crown.
B. In the case of Class II malocclusion, the brackets on the maxillary premolars are bonded more in the
mesial direction to permit the distal rotation of the teeth and mesial rotation of the palatal cusps.
C. In the case of Class III malocclusion, the brackets on the maxillary premolars can be placed more in a
distal direction to facilitate the mesial rotation of the teeth. Here, the brackets on the mandibular
premolars must be positioned more in the mesial direction to induce the distal rotation of the teeth.
* In this case, the brackets should not be bonded in the opposite direction.

Chapter 6 _ Bracket System and Bracket Positioning 3Ü1

 (D Bracket angulation in relation to the long axis of the tooth
The bracket slot must form a right angle with the long axis of the tooth. In order to achieve
this, the panoramic image must be referred to when positioning the bracket. In particular, in
the KIMS bracket, crown inclination is not included, so the following must be considered
in order, when positioning: long axis of the tooth, FACC, and then the incisal edge (in the
case of anterior teeth) (Fig. 6-43).
a. The bracket slot should form a right angle with the long axis of the tooth.
b. The bracket slot should be perpendicular to the FACC.
c. The bracket slot should be parallel to the incisal edge on the incisors, and the cusp
tips on the molars.
d. When closing space, the crown is likely to be angulated towards the extraction site.
Therefore, the bracket slot must be placed more on the gingival side.
e. When only the maxillary premolars are extracted, the mesial sides of maxillary molar
brackets should be positioned towards the gingival side in order to obtain a proper
occlusion, and to further induce the anterior root movement.
f. Artistic bends in the anterior dentition: In the case of four anterior teeth, the roots
should be parallel to each other not only for aesthetic purposes, but also to prevent the
close proximity of roots.

►k Fig. 6 -4 3 Bracket angulation on teeth.

1. Long axis of the tooth.
2. Long axis of the clinical crown.
3. Incisal edge of incisors and cusp tips of
molars.
4. Extraction site.

302» Chapter 6 _ Bracket System and Bracket Positioning

• • • •
 @ • • ©

(2) Angulation errors (Fig. 6-44)

The bracket slot should be perpendicular to the long axis of the tooth. If not, the long axis of
the tooth will not be parallel to each other. Therefore, when treating the following cases,
special attention must be paid. ©
©
▼A ▼B ▼c

►► Fig. 6 -4 4 Angulation errors.

A. Mesial side of the gingivally-positioned bracket on the molar.
B. Extrusion of mesio-buccal cusp on the molar.
C. Expected tooth movement.

© Tooth adjacent to the extraction site (Fig. 6-45)

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

▼A ▼B ▼C

►► Fig. 6 -4 5 Bracket positioning of adjacent teeth around the extraction site.

A. Tooth movement with the ideal bracket position: crowns tilt in a converse direction towards the
extraction site, while the roots tilt in a diverse direction.
B. Tooth movement when the bracket is gingivally-positioned towards the extraction site: tooth movement
is accomplished through tooth uprighting and root movement.
C. Tooth movement when the bracket is occlusally positioned towards the extraction site: roots tilt more
in a diverse direction.

Chapter 6 _ Bracket System and Bracket Positioning ■*< 3Ü3

 (D Maxillary lateral Incisor area (Fig. 6-46)
Due to the different shapes of the maxillary lateral incisors, the tooth axis may become
very close to its adjacent teeth. Therefore, when positioning the bracket, special attention
should be given to root parallelism.

A> I

►► Fig. 6 -4 6 Bracket positioning in the maxillary lateral incisor area.

A. Post-treatment intraoral photographs.
B. Post-treatment panoramic radiograph: inadequate root angulation is observed.
C. Mid-treatment intraoral photographs.
Jr : the bracket angulation that required adjustment.

3Ü4 ►► Chapter 6 _ Bracket System and Bracket Positioning

® • • •
 • • • •

(3) Thickness errors (Fig. 6-47)

When a bracket is not properly bonded, tooth rotation and subsequent crowding may occur.
Therefore, the brackets must all be accurately attached on the tooth surfaces.

►► Fig. 6 -4 7 Thickness error.

A. Intraoral photographs: tooth rotation is caused by a thickness error.
B. Diagram of thickness error.

Chapter 6 _ Bracket System and Bracket Positioning ◄◄ 305

 3) Precise bracket positioning in clinical practice.

There are a couple of different bracket positioning methods that are used in the clinical field. These
are 1) direct bonding procedures, where the practitioner bonds the bracket directly, and 2) indirect
bonding procedures, where the brackets are placed on a model and then transferred into a patient’s
mouth using a template or a tray. Advantages of direct bonding procedures are that a bracket can
be bonded easily, eliminate the need for laboratory work and thereby lowering the cost. The main
disadvantage of direct bonding procedures is the increased difficulty (for the practitioner) of
precise bracket positioning. In the case of indirect bonding procedures, precise bonding can be
achieved, but is important to bear in mind that it is more expensive and there is a greater risk of
detachment. Each procedure has its own advantages and disadvantages. It is recommended to
perform direct bonding for visible procedures, and indirect bonding for lingual orthodontic
procedures (Fig. 6-48).

►► Fig. 6 -4 8 Direct bonding system and indirect bonding system.

A. Direct bonding system.
B. Indirect bonding system.

(1) Necessary materials for direct bonding procedures (Fig. 6-49)

•
There are different types of adhesives: mix type, no-mix type, and light curing type.
Nowadays, the light curing type is preferred, as it makes the adjustment procedure much easier
and has greater bond strength. The entire bracket base must be accurately attached onto the
labial surface of tooth. If not, the adhesive will be squeezed into the apex of the curvature,
forming a weak bond. Too much stress may be placed on this procedure, thereby increasing the
risk of bond failure. Here, the layer of adhesive between the bracket base and the tooth must be

306 ►► Chapter 6 _ Bracket System and Bracket Positioning

 # # # •

^ ► Fig. 6-49 Materials for direct bonding system (DBS).

A. Bonding kit. 0 Etchant, 0 Bonding agent,
0 Bonding resin, @ Tweezers,
© Timer, © Brush,
@ Plastic spatula, © Dapper glass.
B. Etchant, bonding agent, bonding resin, brush.

(2) Direct bonding procedures (Fig. 6-50)

© Oral prophylaxis
First, to maximize its boding effect, an oral prophylaxis must be completed perfectly. This
should be done with a pumice that is soaked in water, using a brush or a rubber cup. If a
paste that contains oil, glycerin, or fluoride is used, it will diminish the effect of acid
etching.

© Moisture control
Salivary inflow can be blocked by a lip retractor, cotton roll, and gauze.

© Acid etching
37% phosphoric acid must be used to carry out etching for 20 seconds. Nowadays, the
etchant is spread via a syringe onto an area of the tooth surface that is slightly larger than
the bracket base. After 20 seconds, the tooth’s surface is washed and dried. If it is properly
etched, it would show a white chalky surface.

Chapter 6 _ Bracket System and Bracket Positioning 4◄ 307

 © Primer
Apply a thin layer of primer onto the etched surface of tooth and the bracket’s base.

© Resin and bonding paste

After holding the bracket with tweezers, bonding paste is added on top of the previously
applied primer.

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

® Light curing
Indurate by shooting a light curing gun for about 20 seconds.

308 ►► Chapter 6 _ Bracket System and Bracket Positioning g , ,

 • • • •

►► Fig. 6 -5 0 Direct bonding procedures.

▼A ▼B-1 ▼B-2

A. Pumice and Robinson brush.

B. Oral prophylaxis.
C. Water wash.
D. Moisture control.
E. Bonding kit.
F. Acid etching.
G. After water wash.
H. Primer application: apply the primer on the tooth surface.
I. A bracket held by tweezers.

Chapter 6 _ Bracket System and Bracket Positioning ◄◄ 309

 ►► Fig. 6 -5 0 (c o n tin u e d ) Direct bonding procedures.

J. Primer application on the bracket base.

K. Applying resin on the primered bracket: a suitable amount of resin must be applied on the bracket base.
L. Resin is evenly distributed on the bracket base.
M. Bonding the bracket on the tooth.
N. The bracket is accurately positioned and firm pressure is applied.
O. Correcting the bracket position, and removing the excess resin is accomplished by using an explorer.
P. Accurate positioning and angulation of bracket is verified.
Q. Light curing.

310- Chapter 6 _ Bracket System and Bracket Positioning

• @ • •
 • • • #

(3) Bracket bonding in special cases

© Bonding to porcelain (Fig. 6-51)

a. The gingiva and lips are protected using Kool-Dam (pulpdent) and cotton rolls.
b. Etching is done for 3 minutes, with 9.6% hydrofluoric acid. m
c. Using a cotton roll, the hydrofluoric acid is carefully wiped off. #
d. Water rinse.
e. Application of porcelain primer (Silane): wait 1 minute.
f. Activation of solvent using air.
g. Bonding primer is applied, and using the same method as on a natural tooth, the bracket
is bonded with bonding resin.

(D Bonding to amalgam
a. Small amalgam filling with sound enamel surrounding.
a) Treat the surface with a sandblaster for 3 seconds.
b) Use 37% phosphoric acid to etch for 15 seconds.
c) Similar to the case of natural tooth, the bonding agent is applied. The bracket is
bonded with bonding resin.

b. Large amalgam restoration

a) Treat the surface with a sandblaster for 3 seconds.
b) Apply Reliance metal primer and wait for 30 seconds.
c) Use air to activate the solvent.
d) Similar to the case of natural tooth, the bonding agent is applied. The bracket is
bonded with bonding resin.

Chapter 6 _ Bracket System and Bracket Positioning ◄

◄311
 ▼A-1 ▼A-2 t A-3

►y Fig. 6-51 Bracket bonding to porcelain.

A. Application of hydrofluoric acid for 3 minutes.
B. Removal of hydrofluoric acid by using a cotton roll.
• C. Water wash.
D. Application of porcelain primer, waiting 1 minute.
E. Activation of solvent by air.
F. Bonding primer and bonding resin application (same procedure as on a natural tooth).

312 ►► Chapter 6 _ Bracket System and Bracket Positioning # • @ •

 # • • ®

(3) Bonding to gold

a. Onlay with sound enamel surrounding (Fig. 6-52).
a) Surface is treated with a sandblaster for 3 seconds.
b) Etching is done for 15 seconds, using 37% phosphoric acid.
c) Reliance metal primer is applied: wait 30 seconds.
d) Activate the solvent by air.
e) As on a natural tooth, the bonding agent is applied, and the bracket is bonded with
bonding resin.

►► Fig. 6 -5 2 Bracket bonding to amalgam or gold inlay.

A. Sandblasting.
B. Acid etching.
C. Check for rough and chalky surface.
D. Metal primer.
E. Apply the Reliance metal primer and wait for 30 seconds. Then activate the solvent by air.
F. Bracket bonding.

Chapter 6 _ Bracket System and Bracket Positioning <■< 313

 b. Gold crown restoration or Large BO inlay (Fig. 6-53).
a) Existing methods do not provide sufficient bonding strength and have a higher risk of
treatment failure. Therefore, if possible, band fabrication should be performed.
b) Surface is treated with a sandblaster for 3 seconds.
c) Either intermediate resin (All-Bond 2 Primer A and B) or 4-META metal bonding
resin (Superbond C&B) should be applied.
d) When applying the intermediate resin, the application should be done twice in 30
seconds. The solvent is then activated using air.
e) Similar to the case of natural tooth, apply the bonding agent and then bond the
bracket with bonding resin.
f) When applying 4-META metal bonding resin, there is no need to follow the
procedures like in the case of natural tooth. Simply follow the manufacturer’s
instructions/guidance.

▼C-1 ▼C-2

► F ig . 6 -5 3 Bracket bonding
on the gold crown.
A. Sandblast the metal surface.
B. Check for rough surface.
C. Apply metal primer.
D. Apply bonding agent (primer)
and light-curing.
E. Bond the bracket.

314 ►► Chapter 6 _ Bracket System and Bracket Positioning

• « • •
 • • • •

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

a. Reliance Plastic Conditioner is applied and then wait for 1 minute.
b. Leave it under room temperature.
c. Similar to the case of natural tooth, apply the bonding agent and then bond the bracket
with bonding resin.
©

►► Fig. 6 -5 4 Reliance Plastic Conditioner.

Chapter 6 _ Bracket System and Bracket Positioning «•« 315

 Bracket positioning for individual teeth

1) Maxillary central incisor (Fig. 6-55)

/K>

►►Fig. 6 -5 5 Accurately positioned brackets on the maxillary central incisors.

A. Frontal view. B. Occlusal view.

(1) Mesio-distal relationship

The bracket is placed at the mesio-distal center of the crown.

(2) Bracket angulation

CDMake sure that the positions of bracket slots are perpendicular to the long axis of the tooth.
(2) If there is attrition on the incisal edge, the bracket proximal margin should be parallel to the
proximal margin of crown.
m
(3) Vertical relationship

© Place the bracket at the center of crown.

(D As is clearly stated on the guideline, the bracket should be placed about 5.0mm away from
the incisal edge.
(3) Ensure that there is no difference between the incisal edge and the adjacent central incisor.

3 1 B ►► Chapter 6 _ Bracket System and Bracket Positioning

 • ® • ©

(4) Common errors (Fig. 6-56)

CD Height discrepancy between the central incisors: This commonly arises from the
discrepancy of the bracket heights. To prevent this, it is recommended to place the bracket
from the frontal view, while considering the incisal edge and gingival margin.
(I) Mesio-distal positional error can cause crowding.
(3) Distortion of root parallelism between adjacent teeth.

►► Fig. 6 -5 6 Common errors in bracket positioning on maxillary central incisors.

A. Height discrepancy between the central incisors caused by a bracket positioning error.
B. Anterior crowding caused by a horizontal positioning error.
C. Distortion of root parallelism caused by a bracket angulation error on the maxillary right central incisor.

Chapter 6 _ Bracket System and Bracket Positioning 4« 3 1 7

 2) Maxillary lateral incisor (Fig. 6-57)

(1) Mesio-distal relationship

CD Place the bracket at the mesio-distal center of the crown.

CDWhen there is a need for overcorrection, place the bracket towards the mesial side.

(2) Angulation

CD Make sure that the positions of bracket slots are perpendicular to the long axis of the tooth.
(2) If there is attrition on the incisal edge, the proximal margin of the bracket must be parallel to
the proximal margin of crown.

(3) Vertical relationship

CD Place the bracket at the center of crown.

(2) As is clearly stated on the guideline, the bracket must be placed about 4.5mm away from the
incisal edge.
© There should be a difference of 0.5mm from the incisal edge to its central incisor.

318» Chapter 6 _ Bracket System and Bracket Positioning

• @• •
 • • • •

(4) Common errors (Fig. 6-58 A~D)

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

Chapter 6 _ Bracket System, and Bracket Positioning 4 4 319

 ►► Fig. 6 -5 8 Common errors in bracket positioning on maxillary lateral incisors.

A. Mesial rotation of tooth caused

by a distally positioned bracket.
B. Ideal bracket positioning on
mesially rotated lateral incisors.
C. Tooth extrusion caused by a
gingivally-positioned bracket.

▼D-1 ▼D-2 ▼D-3

▼E-1 ▼E-2 ▼E-3

D. Mesial tilting of the root caused by inaccurate bracket angulation.

E. Unaesthetic maxillary right lateral incisor due to insufficient labial movement of root.
E-1. Pre-treatment intraoral photographs.
E-2. Mid-treatment intraoral photographs.
E-3. Post-treatment intraoral photographs.

320 ►► Chapter 6 _ Bracket System and Bracket Positioning

 • • • •

3) Maxillary canine

►► Fig. 6 -5 9 Accurately positioned bracket on the maxillary canines.

A. Frontal view. B. Occlusal view.

(1) Mesio-distal relationship

The bracket is placed at the mesio-distal center of the crown.

(2) Angulation

Make sure that the bracket slot is perpendicular to the long axis of the tooth.

(3) Vertical relationship

© Place the bracket at the center of crown.

(2) As is clearly stated on the guideline, the bracket must be positioned about 5.0mm away
from the cusp tip.
(3) When there is a pointy cusp tip, the bracket should be appropriately positioned under the
consideration of the occlusal adjustment.
@ When there is attrition, the bracket should be placed slightly more towards the gingival side,
considering the re-contouring of maxillary canine.

Chapter 6 _ Bracket System and Bracket Positioning 321

 (4) Common errors (Fig. 6-60)

© Excessive distal positioning of the bracket on a maxillary canine:

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

►P- Fig. 6 -6 0 Common errors in

bracket positioning on
maxillary canines.
A. Mesial rotation of tooth
caused by a distally
positioned bracket.
B. Extrusion of the maxillary
left canine caused by a
bracket positioning error
C. Under-eruption of the
maxillary right canine
caused by an occlusally-
positioned bracket.
D. Inadequate root angulation
of the maxillary left canine
caused by a bracket
angulation error.

322 ►► Chapter 6 _ Bracket System and Bracket Positioning ® • © •

 • # • •

4) Maxillary first premolar and second premolar (Fig. 6-61)

et-

^ ^ Fig. 6-61 Accurately positioned brackets on the maxillary premolars.

A. Frontal view. B. Occlusal view.

(1) Mesio-distal relationship

Place the brackets at the center of crown.

(2) Angulation

Place the bracket so that the slot forms a right angle with the long axis of the tooth.

(3) Vertical relationship

As is clearly stated on the guideline, the bracket must be placed about 4.5mm away from the
cusp tip.

Chapter 6 _ Bracket System and Bracket Positioning < 4 323

 (4) Common errors (Fig. 6-62)

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

►► Fig. 6 -6 2 Common errors in

bracket positioning on maxillary
premolars.
A. Under-occlusion (between
the maxillary and mandibular
right premolars) caused by an
occlusally positioned bracket.
Here, MEAW is used to extrude
the tooth that has problems.
B. Inadequate root angulation
of the m a xilla ry left firs t
premolar caused by a bracket
angulation error.
C. Distal rotation of the maxillary
right first premolar caused by
a mesially positioned bracket.

324 ►► Chapter 6 _ Bracket System and Bracket Positioning

• • • ©
 • • • •

5) Maxillary first molar and second molar (Fig. 6-63)

►► Fig. 6 -6 3 Accurately positioned bracket on the maxillary molars.

A. Frontal view. B. Occlusal view.

(1) Mesio-distal relationship

The entrance of the bracket slot should be located at the center of the mesio-buccal cusp.

(2) Angulation

The bracket slot must be positioned to form a right angle with the long axis of the tooth.

(3) Vertical relationship

As is clearly stated on the guideline, the bracket should be positioned about 4.0mm (maxillary
first molar) or 3.5mm (maxillary second molar) away from the cusp tips.

Chapter 6 _ Bracket System and Bracket Positioning ◄◄ 325

 (4) Common errors (Fig. 6-64)

© Differences in vertical height: An over-erupted maxillary first molar (when compared to a

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

►P- Fig. 6 -6 4 Common errors in

bracket positioning on maxillary
molars.
A. Under-occlusion caused by
a bracket positioning error.
B. Mesial rotation of maxillary
right first molar caused by a
distally positioned bracket.

Chapter 6 _ Bracket System and Bracket Positioning

• • • •
 • • • •

6) Mandibular incisor (Fig. 6-65)

►► Fig. 6 -6 5 Accurately positioned brackets on mandibular incisors.

A. Frontal view. B. Occlusal view.

(1) Mesio-distal relationship

Place the bracket at the mesio-distal center of crown.

(2) Angulation

Make sure that the bracket slot is perpendicular to the long axis of the tooth.

(3) Vertical relationship

CDPlace the bracket at the center of crown.

(2) As is clearly stated on the guideline, the bracket should be placed about 4.5mm away from
the incisal edge.
(3) Make sure that there is no difference in the incisal edge on the adjacent tooth.

Chapter 6 _ Bracket System and Bracket Positioning < < 327

 (4) Common errors (Fig. 6-66)

® Height difference between the central and lateral incisors: This occurs because of a height
difference between the brackets on the four mandibular incisors.
When there is crowding in the mandibular anterior area, the bracket must be accurately
placed, under careful consideration of crowding and attrition.
CD Crowding caused by a mesio-distal positioning error.
© Distorted parallelism between the root and adjacent teeth.

►► Fig. 6 -6 6 Common errors in bracket positioning on mandibular incisors.

A. Height discrepancy caused by a bracket positioning error.
A-1. Mid-treatment intraoral photographs.
A-2. Post-treatment intraoral photograph.
B. Gingivally-positioned brackets on lower incisors.
C. Crowding on mandibular left central incisor caused by a distally positioned bracket.

328 ►► Chapter 6 _ Bracket System and Bracket Positioning

 • • • •

7) Mandibular canine (Fig. 6-67)

►► Fig. 6 -6 7 Accurately positioned brackets on mandibular canines.

A. Frontal view. B. Occlusal view.

(1) Mesio-distal relationship

Place the bracket at the mesio-distal center of crown.

(2) Angulation

Make sure that the bracket slot is perpendicular to the long axis of the tooth.

(3) Vertical relationship

CD Place the bracket at the center of crown.

(D As is clearly stated on the guideline, the bracket must be placed about 5.0mm away from the
cusp tip.
(3) When there is a pointy cusp tip, the bracket should be appropriately positioned under
consideration of the occlusal adjustment.
0 When there is attrition, the bracket should be placed slightly more on its gingival side,
considering the re-contouring of mandibular canine.

Chapter 6 _ Bracket System and Bracket Positioning 329

 (4) Common errors (Fig. 6-68)

CD Excessive mesial rotation of the mandibular canine due to the distal positioning of bracket:
Because of this, the mandibular canine rotates mesially to cause a step between the lateral
incisor and the canine. Therefore, it is more desirable to place the mandibular canine on its
mesial side away from the center of crown.
(D Over-erupted mandibular canine.
© Distorted parallelism between the root and adjacent teeth.
@ Unaesthetic mesio-distal inclination (or angulation) of the mandibular canine.

►► Fig. 6 -6 8 Common errors in bracket positioning on m andibular

canines.
A. Mesial rotation of tooth caused by a distally positioned bracket.
B. H eight d iscrep a ncy of m an dib ular left canine caused by an
occlusally positioned bracket.
C. Inaccurate root position of mandibular right canine caused by a
bracket angulation error.

33Ü ►► Chapter 6 _ Bracket System and Bracket Positioning ® © • @

 « • • •

8) Mandibular first and second premolar (Fig. 6-69)

►► Fig. 6 -6 9 Accurately positioned brackets on mandibular premolars.

A. Frontal view. B. Occlusal view.

(1) Mesio-distal relationship

Place the bracket at the center of the mesio-buccal cusp.

(2) Angulation

Make sure that the bracket slot is perpendicular to the long axis of the tooth.

(3) Vertical relationship

As is clearly stated on the guideline, the bracket must be placed about 4.5mm away from the
cusp tip.

Chapter 6 _ Bracket System and Bracket Positioning < ◄ 331

 (4) Common errors (Fig. 6-70)

CD Difference in vertical height.

(2) Insufficient mesio-distal rotation.
(D Broken root parallelism with adjacent teeth.

►► Fig. 6 -7 0 Common errors in bracket positioning on mandibular premolars.

A. Infraocclusion caused by an occlusally positioned bracket.
B. Mesial rotation of the mandibular premolars caused by a distally positioned bracket.
C. Inaccurate root angulation of mandibular left first premolar caused by a bracket angulation error.

332 ►► Chapter 6 _ Bracket System and Bracket Positioning

• ® • •
 • # • •

9) Mandibular first and second molar (Fig. 6-71)

►► Fig. 6-71 Accurately positioned bracket and tube on mandibular molars.

A. Frontal view. B. Occlusal view.

(1) Mesio-distal relationship

Place the entrance of bracket slot at the center of the mesio-buccal cusp.

(2) Angulation

Make sure that the bracket slot is perpendicular to the long axis of the tooth.

(3) Vertical relationship

As is clearly stated on the guideline, the bracket must be placed about 4.0mm (mandibular first
molar) or 3.5mm (mandibular second molar) away from the cusp tips.

Chapter 6 _ Bracket System and Bracket Positioning <◄ 333

 (4) Common errors (Fig. 6-72)

CD Difference in vertical height.

(2) Insufficient mesial rotation.
© Over-eruption of the mesial part of a tooth.
@ Contact with maxillary teeth: If the bracket of a mandibular molar comes into contact with a
maxillary tooth, unexpected movement occurs. If it is left untreated, a lingual inclination of
mandibular tooth can occur.

C -2 *

►► Fig. 6 -7 2 Common errors in bracket positioning on mandibular molars.

A. Under-occlusion caused by a bracket positioning error.
B. Over-eruption of the mesio-buccal cusp of the mandibular left second molar caused by placing the
mesial side of the bracket more towards the gingival side.
C. Mandibular bracket that comes into contact with a maxillary tooth: if the bracket on the mandibular left
molar comes into contact with the maxillary first molar, the lingual inclination of the mandibular molar
can be aggravated.

334 ►► Chapter 6 _ Bracket System and Bracket Positioning

 • • • •

Accurately positioned brackets on a model (Fig. 6-73).

►► Fig. 6 -7 3 Accurately positioned brackets.

Chapter 6 _ Bracket System and Bracket Positioning « 335

 ( c l Bracket positioning in various cases

© Bracket positioning to secure the space for a maxillary lateral incisor (Fig. 6-
74, 75).
When gaining space for an implant at its missing lateral incisor site, the mesio-distal
distances between the adjacent roots, as well as the distance between the crowns, are
essential.
To accomplish this successfully, the root of the maxillary central incisor needs to move

►► Fig. 6 -7 4 Accurate bracket positioning to secure space for a maxillary lateral incisor implant.
A-1. Tooth movement during space gaining for the maxillary lateral incisor.
A-2. Sufficient amount of space is secured not for the root but for the crown. As a result, the
space is closed by adjacent roots.
©
B-1. To prevent this, the mesial side of the canine bracket and the distal side of the incisor
bracket must be placed more towards the occlusal direction.
B-2. Expected tooth movement.
C. Periapical radiograph showing a correct tooth movement.
D. Bracket positioning for space closure of a missing lateral incisor: opposite to the above
instructions.

336 ►► Chapter 6 _ Bracket System and Bracket Positioning

• @ • m
 • © • •

more towards its mesial direction. Also, the bracket angulation must be altered so that the
distal side of the bracket is placed more towards the incisal direction, and the mesial side is
located more towards the gingival direction. In contrast, in the case of maxillary canines,
the root needs to be placed more towards the distal direction. This means that the bracket
angulation should be altered so that the mesial side of the bracket is positioned more
towards the incisal direction, and the distal side is located more towards the gingival
direction. Here, the vertical height of the bracket should remain consistent, and the
horizontal relationship should be placed at the center of crown.

►► Fig. 6 -7 5 Accurate bracket positioning to secure the space for a maxillary lateral incisor.
A. Changes in bracket positions on the maxillary right canine and the central incisor.
B. Pre-treatment intraoral photographs.
C. Post-treatment panoramic radiograph.
D. Intraoral photographs after the implant treatment.

Chapter 6 _ Bracket System and Bracket Positioning « « 337

 (2) Proper bracket positioning to gain space for a mandibular first premolar (in the
case of a missing mandibular second premolar) (Fig. 6-76).
When there is a missing mandibular second premolar, there must be a posterior movement
of the first premolar to secure the space for implant. Here, the root movement of the first
premolar and the canine is required. However, to accomplish the above movement, the
bracket angulation must be altered: the distal side of the first premolar bracket must be
placed in the gingival direction, and the mesial side, in the occlusal direction. On the other
hand, in the case of canine, its root should be moved more towards the mesial direction.
Here, to accomplish the above movement, the bracket angulation must also be altered: the
distal side of the canine bracket must be placed in the incisal direction, and the mesial side,
in the gingival direction. In this case, the vertical height of the bracket should also be
consistent, and the horizontal relationship must be placed at the center of crown.

►► Fig. 6 -7 6 Accurate bracket positioning to secure the space for a mandibular first premolar (in the case
of a missing mandibular second premolar).

A. Tooth movement when the mandibular first premolar is shifted distally: distal crown angulation
and mesial root angulation.
B. To prevent this, the distal part of the first premolar bracket must be placed in the gingival
direction and the mesial part, in the occlusal direction. In contrast, the distal part of the canine
bracket should be placed in the occlusal direction and the mesial part, in the gingival direction.
•

338 ►
►Chapter 6 _ Bracket System and Bracket Positioning • ® © •
 • • • •

►► F ig . 6 -7 6 (c o n tin u e d ) Accurate bracket positioning to secure the space for a mandibular first
premolar (in the case of a missing mandibular second premolar).

C -U

C. Intraoral photographs.
C-1. Pre-treatment intraoral photographs.
C-2. Mid-treatment intraoral photographs.
C-3. Post-treatment intraoral photographs.
C-4. Intraoral photograph after the implant treatment.
D. Panoramic radiograph after the implant treatment.
This is similar to bracket positioning in an extraction case: i.e. the bracket sides that are close to the
“extraction space should be tilted more towards the gingival side for space closure” and more towards the
occlusal side for space gaining.

Chapter 6 _ Bracket System and Bracket Positioning ◄◄ 339

 (3) Bracket positioning for the leveling of six maxillary anterior teeth which are
worn and extrusive (Fig. 6-77)
For adults, when leveling the six maxillary anterior teeth that are extruded due to attrition,
the leveling of the gingiva, rather than of the incisal edge, is important.
In other words, the brackets must be at a position where the gingival margins of the central
incisors are parallel, and where the gingival margins of central incisor and canine are at the
same height. Here, the gingival margin of the maxillary lateral incisor must be placed more
towards the occlusal direction (when compared with the central incisor).

▼A-1 ▼A-2 ^A-3

►► Fig. 6 -7 7 Bracket positioning for the leveling of the six maxillary anterior teeth which are worn and
extrusive.
A-1. Pre-treatment intraoral photograph: anterior space and unaesthetic gingival margin.
A-2. The width-height ratio of the maxillary central incisors is 8mm-8mm.
A-3. Prosthodontic treatment after obtaining an aesthetic gingival margin.
B-1. Bracket positioning after obtaining an aesthetic gingival margin.
B-2. Intraoral photograph after the completion of leveling.
B-3. Intraoral photograph after removing the orthodontic appliance.
C-1. Pre-treatment intraoral photograph.
C-2. Post-treatment intraoral photograph.
C-3. Post-retention intraoral photograph (two years after the treatment).

340» Chapter 6 _ Bracket System and Bracket Positioning

• • • •
 • ® • •

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

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

▼A

►► F ig . 6 - 7 8 Proper bracket
p o s itio n in g in the case of
maxillary premolar extraction
only.
A. If the bracket is placed at
the normal position, mesial
movement of posterior
teeth can cause unstable
occlusion.
B. The bracket is accurately
positioned for stable
occlusion and desirable
tooth movement.
C. Standard brackets should
be used to facilitate the
mesial rotation of posterior
teeth.

Chapter 6 _ Bracket System and Bracket Positioning 341

 Bi^

►► Fig. 6 -7 9 Proper bracket positioning in the case of maxillary premolar extraction only.
When only maxillary premolars are extracted, the occlusion of the left and right posterior area will differ.
Arguably, this is due to the different angulation of maxillary first molars i.e. the normal bracket angulation
is enforced on the right first molar, but the bracket on the left side is placed more towards the mesial side
and tilted towards the gingiva. Here, the desirable occlusion is obtained only on the left side.

B►

►► Fig. 6 -8 0 Proper bracket positioning in the case of maxillary premolar extraction only.
A. Case when only maxillary premolars are extracted: the mesial side of the maxillary first molar bracket
is bonded more towards the gingival side.
B. Post-treatment intraoral photographs.

342 ►► Chapter 6 _ Bracket System and Bracket Positioning

• @ • •
 • • • •

REFERENCES

1. Adams DM, Powers JM, and Asgar K. Effects of brackets and ties on stiffness of an arch wire. Am J
Orthod Dentofac Orthop 91:131-136, 1987.
2. Aguirre MJ, King GJ, and Waldron JM. Assessment of bracket placement and bonding strength when
comparing direct bonding to indirect bonding techniques. Am J Orthod 82:269, 1982.
3. American Orthodontics. Orthodontic Product Catalog, 2011.
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brackets. Am J Orthod Dentofacial Orthop 133:721-728, 2008.
9. Begg R. Orthodontic theory and technique. 3rd ed. Philadelphia: WB Saunders, 1977.
10. Bell WR. A study of applied force as related to the use of elastics and coil springs. Angle Orthod
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11. Bennett JC, and McLaughlin RP. Orthodontic management of the dentition with the preadjusted
appliance. Isis Medical Media, 1997.
12. Bishara SE, and Andresen GF. A comparison of time related forces between plastic alastics and latex
elastics. Angle Orthod 40:319-328, 1970.
13. Boone GN. Archwires designed for individual patients. Angle Orthod 33:178-185, 1963.
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Orthod 80:438-445, 2010.
15. Burstone CJ, Bai Qin MS, and Morton JY. Chinese NiTi wire: A new orthodontic alloy. Am J Orthod
87:445-452, 1985.
16. Cozzani Giuseppe. Garden of Orthodontics. Quintessence. 2000.
17. Daskalogiannakis J, and Ammann, A. Glossary of orthodontic terms, Quintessence, 2000.
18. G & H wire company. Orthodontic Product Catalog. 8th edition.
19. Grauer D, and Proffit WR. Accuracy in tooth positioning with fully customized lingual orthodontic
appliances. Am J Orthod Dentofac Orthop 140:433-443, 2011.
20. Gurgel J, kerr S, Powers JM, and LeCrone, V. Force-deflection properties of super-elastic nickel-
titanium archwires. Am J Orthod Dentofac Orthop 120:378-382, 2001.
21. Harraine NWT. Self-ligating brackets and treatment efficiency. Clin Orthod Res 4:220-227, 2001.
22. Harraine NWT. Self-ligating brackets: where are we now? J Orthod. 30:262-273, 2003.
23. Iwasaki LR, et al. Clinical ligation forces and intraoral friction during sliding on a stainless steel
archwire. Am J Orthod Dentofacial Orthop 123:408-415, 2000.

Chapter 6 _ Bracket System and Bracket Positioning « 343

 24. Joondeph DR. graber TM, Vararsdall RL, Vig KWL, eds. Orthodontics: Current Principle and
Techniques. Ed4. St Louise: Mosby, 2005.
25. Josell SD, Leiss JB, and Rekow ED. Force degradation in elastomeric chains. Semin Orthod 3:189-
197, 1997.
26. Khambay B, Millett D, and Me Hugh S. Evaluation of methods of archwire ligation on frictional
resistance. Eur J Orthod 26:327-332, 2004.
27. Kim Jl, Akimoto S, Shinji H, and Sato S. Importance of vertical dimension and cant of occlusal plane in
craniofacial development. Int J Stomatol Occlusion Med 2:114-121,2009.
28. Kim Jl. Practical Clinical Orthodontics. Vol 1. Orthodontic treatment with MEAW. Well publishing Inc,
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31. Maijer R, Smith DC. Time saving with self-ligating brackets. J Clin Orthod 24:29-31, 1990.
32. McNamara JA Jr, and Brudon WL. Orthodontics and Dentofacial Orthopedics. Needham Press, 2001.
33. Pandis N, Bourauel C, and Eliades T. Changes in the stiffness of the ligating mechanism in retrived
active self-ligating brackets. Am J Orthod Dentofacial Orthop 132:834-837, 2007.
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35 Pizzoni L, Raunholt G, and Melsen B. Frictional forces related to self-ligating brackets. Eur J Orthod
20:283-291, 1998.
36 Proffit WR. Contemporary orthodontics. St Louis: CV Mosby company, 1986.
37 Ricketts RW, Bench RW, Gugino CF, Hilgers JJ, and Schulhof RJ. Bioprogressive Therapy. Denver:
Rocky Mountain Orthodontics; 1979.
38 Roth RH. Functional occlusion for the orthodontist. J Clin Orthod 15(1-4), 1981.
39 Sato S, Akimoto S, Matsumoto A, Shirasu A, and Yoshida J. MEAW -Manual for the clinical
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40 Shivapuja PK, and Berger J. A comparative study of conventional ligation and self-ligation bracket
systems. Am J Orthod Dentofacial Orthop 106:472-480, 1994.
• 41 Stefanos S, Secchi AG, Coby G, et al. Friction between various self-ligating brackets and archwire
• couples during sliding mechanics. Am J Orthod Dentofacial Orthop. 138:463-467, 2010.
•
42 Strang RH. Highlights of sixty-four years in orthodontics. Angle Orthod 44, 1974.
43 Tamaki et al. A pilot study on masticatory muscles activities during grinding movements in occlusion
with different grinding areas on working side. Bulletin of Kanagawa Dental College. 29:26-27, 2001.
44 Tenti FV. Atlas of orthodontic appliances, Caravel, 1985.

344 ►► Chapter 6 _ Bracket System and Bracket Positioning

• • • •
 • • ® •

45. Thomas RB et al. Force extension characteristics of orthodontic elastics. Am J Orthod 72:296-302,
1977.
46. Thorstenson BS, and Kusy RP. Comparison of resistance to sliding between different self-ligating
brackets with second order angulation in the dry and saliva states. Am J Orthod Dentofacial Orthop
121:472-782, 2002.
47. Tomy International Inc. Tomy Orthodontic Product Catalog, vol. 4.0, 2009.
48. Tweed CH. A philosophy of orthodontic treatment. Am J Orthod Oral Surg. 31:74, 1945.
49. Tweed CH. Clinical orthodontics. Vol1 and 2. St Louis: Mosby, 1966.
50. Tweed CH. Report of cases treated with the edgewise arch mechanism. Angle Orthod 2:236, 1932.
51. Tweed CH. The application of the principles of the edgewise arch in the treatment of Class II,
Divisionl, part I. Angle Orthod 6:198-208, 1936.
52. Tweed CH. The application of the principles of the edgewise arch in the treatment of Class II,
Divisionl, part II. Angle Orthod 6:255-257, 1936.
53. Wrong AK. Orthodontic elastic materials. Angle Orthod 46:196-204, 1976.

Chapter 6 _ Bracket System and Bracket Positioning <M 345

Chapter __
 Chapter 7

LEVELING AND
ALIGNMENT

..... i«»**îîîîîîîî::::.....

Basic Orthodontic Terms

1) Leveling and alignment
2) Simple leveling and strategic leveling
3) Cinch back bends
4) Tight cinch back & loose cinch back
2. Strategic Bonding
1) Definition
2) Purposes
3) Methods of application
4) Considerations
Archwires for Leveling and Alignment
1) Initial archwires
2) Leveling archwire
Strategic Leveling and Alignment
1) Strategies for non-extraction treatment
2) Strategies for premolar extraction treatment
 1 Basic Orthodontic Terms

Leveling and alignment

1) Leveling

This refers to an orthodontic treatment procedure for flattening the curve of Spee (along the
vertical plane) until the marginal ridges of all the teeth are positioned at the same level (Fig. 7-1).

• ►► Fig. 7-1 Leveling.

A. Maxillary teeth leveling. B. Mandibular teeth leveling.

348 ►► Chapter 7 _ Leveling and Alignment @ • • ®

 • ® ® •

2) Alignment

This refers to an orthodontic treatment procedure that moves the teeth bucco-lingually (in the
horizontal plane) to form an ideal arch form.

►► Fig. 7-2 Alignment.

A. Maxillary teeth alignment.
B. Mandibular teeth alignment.

3) Ideal arch form

The teeth move on a continuous archwire while maintaining its ideal arch form (Fig. 7-3).

►► Fig. 7-3 The concept of ideal

arch form.
Tooth movement on a continuous
archwire is a basis for both
extraction and non-extraction
treatment.

Chapter 7 _ Leveling and Alignment <!« 349

 Simple leveling vs strategic leveling

1) Simple leveling

Simple leveling refers to the process of bonding the brackets on all the mandibular teeth (even
including the terminal molars). If the terminal molars are included, the labioversion of mandibular
incisors would be aggravated due to the interactions of mandibular incisors and mandibular
molars. It is notable here that there will be no changes in the posterior occlusal plane, and that the
labioversion of incisors will get aggravated (Fig. 7-4).

►'$> Fig. 7-4 Simple leveling.

If the brackets are bonded on every tooth excluding the terminal molar, labioversion of
anterior teeth will get aggravated.

350 ►► Chapter 7 _ Leveling and Alignment

• • • •
 • © • ©

2) Strategic leveling

This refers to the process of aligning the eight or ten anterior teeth, and then uprighting the
terminal molars without bonding the brackets to the teeth that are located in front of the terminal
molars (mostly the second premolars and/or the first molars) in the mandible (Fig. 7-5). In this
case, a non-extraction treatment becomes possible because the space is gained when the mesially
tilted and rotated second molars are uprighted and de-rotated as the anterior teeth are used as an
anchor. It is notable here that there will be some changes in the posterior occlusal plane and a
slight labioversion of the incisors.

▼A-1 ▼A-2

▼B vC

►► Fig. 7-5 Strategic leveling.

A. Strategic leveling refers to the process of aligning the eight or ten anterior teeth, and
then uprighting the terminal molars without bonding the brackets to the teeth in front of
the terminal molars (mostly the second premolars and/or the first molars) in the
mandible.
B. An example of incorrect strategic leveling: open coil springs (OCS) are first used on the
posterior teeth.
C. An example of correct strategic leveling: open coil springs (OCS) are first used on the
anterior teeth to align them.

Chapter 7 _ Leveling and Alignment ◄◄ 351

 Cinch back bends (Fig. 7-6)

This is gingivally and/or mesially directed bends of archwire, which is distal to the terminal
attachments in an arch. The main purposes of these bends are to maintain the current position of
the archwire, to prevent the archwire from sliding to an anterior direction, and to protect the soft
tissue from being damaged. In particular, distal end bends can be used to prevent the excessive
labioversion of anterior teeth during leveling.

▼A

▼B-1 ▼B-2 ▼B-3

▼C ▼D ▼E

►► Fig. 7-6 Cinch back bends.

A. Cut the wire 3 mm away from the distal end of buccal tube.
B. Hold the wire with utility pliers and bend it inward.
C. Bend it gingivally again.
D. Cinch back bends.
E. Weingart utility pliers.

352 ►► Chapter 7 _ Leveling and Alignment ® • © ©

 Tight cinch back & loose cinch back

After bonding the appliance strategically (strategic bonding), open coil springs (OCS) should be
appropriately applied to gain space at the crowded site. If the appliances are bonded to every tooth,
anterior teeth will be labially inclined due to the interaction of posterior and anterior teeth, and the
need for an extraction treatment will increase. Nevertheless, if 1) strategic bonding is achieved, 2)
the open coil springs (OCS) are used to solve crowding, and 3) the tight cinch back is conducted to
remove any remaining extra distal archwire (behind the buccal tube), inter-canine expansion will
occur rather than labioversion of incisors. Here, if the brackets are not attached to the first
premolars, such an expansion could negatively influence the premolars (inducing the palatal
displacement or extrusion). Therefore, the lingually positioned lateral incisors are likely to move in
the anterior direction after the space opening. If the above procedures are successfully done, the six
anterior teeth can, as a result, be accurately aligned with minimal labioversion of incisors. Next,
the palatally positioned premolars should be aligned in the same way as mentioned above. Here, to
upright and de-rotate the mesially angulated and rotated second molars, the open coil springs
(OCS) should be applied to the first premolars and/or the first molars. In this case, the loose cinch
back should be conducted to make some extra room in the archwire after the buccal tube. This
entire treatment procedure makes it possible to solve crowding with minimum labioversion of
maxillary incisors. As a result, the possibility of non-extraction treatment increases and this leads
to a change in arch form from a V-shape to an ovoid-shape.

1) Tight cinch back (Fig. 7-7 A)

(1) Ligate all the brackets.

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

Chapter 7 _ Leveling and Alignment 353

 2) Loose cinch back (Fig. 7-7 B)

(1) Ligate only one central incisor.

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

▼A ▼B

^ ► Fig. 7-7 Tight cinch back and loose cinch back.

A. Tight cinch back.
1) Ligate all the bonded teeth.
2) Do the cinch back bends on one side, and do another cinch back bends on the other side while
pulling it posteriorly.
• Note that the wire should not be popped out when it is pulled posteriorly.
B. Loose cinch back.
1) Ligate only one anterior tooth and then do the cinch back bends on both ends of archwire.
2) Ligate all the remaining teeth.

354 ►► Chapter 7 _ Leveling and Alignment • • • •

 ® • ® •

Strategic Bonding

#
Definition @
#

This is the process of bonding appliances strategically to meet their treatment objectives. In this
process, an appliance is only attached selectively, and is regarded as the second most important
factor after diagnosis and bracket positioning in MEAW concept. Such bonding methods can be
applied both in extraction cases and in non-extraction cases.

Purposes

(1) Efficient tooth movement.

(2) Increase the inter-bracket distance.
(3) Shorten the treatment period.
(4) Increase the possibility of non-extraction treatment.
(5) Reduce the possibility of orthognathic surgery.

Methods of application

(1) First, the appliances should not be bonded to the teeth in front of the terminal molars. This
means that if an appliance is attached to the second molars, it should not be further bonded to
the first molars.
(2) If possible, appliances should be bonded to both of the maxillary central incisors.
(3) If possible, the four maxillary and mandibular incisors should be aligned in advance.
(4) If there is a vertical discrepancy in the maxillary canine area, the appliances should be bonded
later. In this case, the appliances should be first attached to the four maxillary incisors and the
maxillary first premolars. However, if there is no vertical discrepancy in the maxillary canine
area, the appliances should be first bonded to the canines to gain space for the palatally
positioned lateral incisors (Fig. 7-9).

Chapter 7 _ Leveling and Alignment 355

 (5) In the case of mesially tilted premolars, brackets should not be attached to the teeth, that are
located in front of these premolars, for effective uprighting.
(6) In non-extraction cases, if there is a full cusp Class II molar relationship, the maxillary first
molars should be moved posteriorly in advance. Here, different treatment methods may be
required depending on the eruption status of second molars. Before the eruption, a pendulum
appliance is recommended to be used, while after the eruption mini-implants are recommended
between the second premolars and the first molars. In this case, there must be sufficient molar
distalization to make a super Class I molar relationship.
(7) In premolar extraction cases, the appliances should be attached first to maintain the Class I
canine and premolar relationship. This means that in the extraction cases of both maxillary and
mandibular first premolars, the maxillary canines should be moved posteriorly, and the
mandibular second premolars should be moved anteriorly. Here, it is very important not to
move the maxillary second premolars anteriorly in advance.

► Fig. 7-8 Strategic leveling.

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

356 ►► Chapter 7 _ Leveling and Alignment © • • ©

 © • • •

V:

m
@

A-2.

B-2 i

►► Fig. 7-9 Strategic bonding.

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

Chapter 7 _ Leveling and Alignment 4 ◄ 357

 Considerations

(1) Utilization of open coil springs (OCS).

(2) Management of molar rotation.
(3) Management of upper occlusal plane (UOP).
(4) Management of posterior occlusal plane (POP).
(5) Elimination of occlusal force.

1) Utilization of open coil springs (OCS)

(1) Purposes (Fig. 7-10)

© Space opening effect

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

©Tooth uprighting effect.

It is used to upright the mesially tilted mandibular first premolars and molars.

►► Fig. 7 -1 0 Strategic bonding with the open coil springs (OCS).

A. Opening the space for de-crowding.
B. Uprighting the mesially tilted teeth: uprighting can be done successfully by using the open
coil springs (OCS) in the anterior area of the mesially tilted teeth.

(2) Minimal archwire thickness: .016” stainless steel archwire

358 ►► Chapter 7 _ Leveling and Alignment • • • ®

 • • • •

(3) Force generation by open coil springs (Fig. 7-11)

CD For activation, open coil springs must be inserted 30% longer than the inter-bracket distance
(2) To gain the space of one tooth, the width of the open coil springs must be inserted as much
as the width of one bracket.
(D After the insertion of open coil springs, make sure that slight compression is felt.

►► Fig. 7-11 Strategic utilization of open coil springs (OCS).

A. Open coil springs (OCS).
B. For activation, open coil springs must be inserted 30% longer than the inter-bracket distance.

2) Management of molar rotation

The buccal surfaces of both first molars should be parallel to each other (Fig. 7-12). If maxillary
second molars (or first moalrs) are mesially rotated, and the appliances are attached to all the teeth,
the mesially rotated second molars can be de-rotated, or reversely, the labioversion of anterior teeth
can be aggravated. This side effect can be solved by using the open coil springs (OCS) to de-rotate
the mesially tilted molars, instead of attaching the appliances to the teeth in front of the terminal
molars. This is a type of strategic leveling and alignment that can correct the maxillary and
mandibular arch form (Fig. 7-13). If the arch form is in a V-shape (tapered), and the appliances are
attached to all the teeth, there is a limitation in tooth rotation because of the rotation in the brackets
and the toe-in bend in archwire. This means that it becomes far easier to secure the space and
change the arch form by de-rotating the terminal molars without attaching the appliances to the
teeth in front of the terminal molars in the early stages of treatment.
To treat the maxillary first molars that are already parallel to each other, a non-extraction treatment
can be done only through the expansion of maxillary arch or labioversion of incisors, which means
that there is a greater possibility of taking a premolar extraction treatment approach.

Chapter 7 _ Leveling and Alignment < ◄ 359

 In this case, since the maxillary molars are already parallel to each other, it is important to maintain
the current position of the molars and to close the extraction space. On the other hand, in premolar
extraction cases with mesially rotated maxillary first molars, open coil springs (OCS) should be
first used in the first molar area 1) to recover the parallel relationship of maxillary second molars,
2) to de-rotate the maxillary first molars, and 3) to secure space for extraction by using the energy
chain between the second molars and first molars (Fig. 7-14).

Bt

►► Fig. 7 -1 2 Management of molar rotation.

The buccal surfaces of maxillary first molars should be parallel to each other.
A. Parallelized first molars. B. Mesially rotated first molars.

►► Fig. 7 -1 3 Molar rotation in non-extraction cases.

Through the parallel rotation of mesially rotated molars and the modification of arch form,
a non-extraction treatment approach becomes possible.

360» Chapter 7 _ Leveling and Alignment

m • • •
 ® • • •

►► Fig. 7 -1 4 Molar rotation in premolar extraction cases.

A. Mesially rotated maxillary first molars: the mesial movement of molars becomes far easier
when closing the space.
B. Parallelized maxillary first molars.
C. When the open coil springs are inserted between the second molars and second premolars,
the mesially rotated first molars can be parallelized through the use of the energy chain
between the first and second molars.
D. After parallelizing the first molars, the maxillary canines should be retracted from the first
molars.

Chapter 7 _ Leveling and Alignment ◄◄ 361

 • Decrowding

Although there are various methods for de-crowding (multi-loop archwire, super-elastic
archwire, etc.), it is more desirable to gain space first by using the open coil springs, and then
to try to align the teeth effectively. Here, it is possible to gain space and minimize labioversion
of anterior teeth by using the aforementioned tight cinch back method. To successfully
accomplish this, a standard edgewise bracket should be bonded on the anterior teeth, and the
open coil springs should be inserted into the .016” x.022” stainless steel archwire with crown
lingual torque.

To align the palatally positioned teeth, the following methods can be used:
© Elastic thread,
(2) Ligature wire,
© L-loop,
© Overlay archwire.

▼C ▼D

•
►► Fig. 7-1 5 Solutions for de-crowding.
• The teeth should be aligned after the space opening.
• The following methods can be used:
A. Elastic thread,
B. Ligature wire,
C. Overlay archwire,
D. L-loop.
In the cases of A, B or C method, it is recommended to align the
teeth with the open coil springs (OCS) inserted.

362 ►► Chapter 7 _ Leveling and Alignment

• • • •
 • • • ®

After the space is secured, the bracket or lingual button should first be attached to the palatally
positioned teeth, and then the teeth should be tracted by using the elastic thread or ligature wire
with the open coil springs (OCS) inserted. After the teeth are aligned to the extent of arch form,
the overlay archwire (.014” NiTi) or .014” L-loop can be used for further alignment. If there is a
need for three dimensional control (first-, second-, and third-order bends), loop bending is highly
effective. Next, leveling archwire can be used again to re-level and re-align the teeth (Fig. 7-16).

▼A-2 ▼A-3

►► Fig. 7 -1 6 Alignment of palatally positioned teeth (maxillary lateral incisors).

A. In the case of palatally positioned maxillary lateral incisors, even if they are aligned to the dental arch,
they look unaesthetic because of limited root movement.
A-1. Pre-treatment photographs.
A-2. M id-treatment photographs after leveling and alignment. The maxillary left lateral incisor looks
unaesthetic.
A-3. Post-treatment photographs.
B. Orthodontic treatment procedure.
B-1. L-loop treatment.
B-2. The maxillary lateral incisor looks unaesthetic because of limited root movement.
B-3. Tooth movement pattern after applying root labial torque to the maxillary iateral incisor.

Chapter 7 _ Leveling and Alignment 363

 /V
Clinical Tips: Alignment methods for palatally positioned maxillary
lateral incisors.
1. Bond the SWA (+8°) bracket on the maxillary lateral incisor in the reverse direction.
2. Bond the bracket slightly towards the gingival side (about 0.5mm).
3. Use the .016” x .022” torque control archwire to ensure root labial movement.
4. Keep the torque controlling wire for 6 months.
5. If necessary, grind the incisal edges. fj ► j ■>

In premolar extraction cases with crowding problems, it is easy to solve the issue of crowding
by moving the tooth towards the extraction space in the early stages of treatment.
However, in non-extraction cases, the teeth should be aligned based on the current positions of
maxillary and mandibular incisors, and to do this strategic leveling and alignment are essential.
In particular, for non-extraction cases, a standard bracket (with zero-degree torque), open coil
springs, and .016” x.022” stainless steel archwire (with crown lingual torque) should all be
used to minimize the labioversion of maxillary and mandibular incisors (Fig. 7-17).
This is specifically important for non-surgical or non-extraction treatment approaches when
treating Class III malocclusion patients (who also have crowding on the maxillary anterior
teeth due to maxillary deficiency). In this case, due to the dental compensation of Class III
malocclusion, maxillary incisors show normal or even labial inclination. If there is a normal
inclination, this can be solved by a non-surgical or non-extraction treatment approach. Here,
although there is crowding in the maxillary canines, excessive labioversion of anterior teeth is
not desirable when correcting the Class III relationship.

The treatment procedures are as follows (Fig. 7-18):

© Strategic bonding: bonding the standard bracket with zero-degree torque.
(D .016” stainless steel archwire with open coil springs (OCS) and tight cinch back.
© Activation of open coil springs (OCS).
0 .0 1 6 ” x.022” stainless steel archwire (crown lingual torque) with open coil springs.
(OCS) and loose cinch back.
© Activation of open coil springs (OCS).
© .016” stainless steel archwire with open coil springs (OCS) (the anterior area) and tight
cinch back ((D is repeated).
© Bonding the appliances on the remaining teeth.

364 ►► Chapter 7 _ Leveling and Alignment

• • © •
 • • • •

►► Fig. 7 -1 7 Crown lingual torque.

Standard bracket + archwire with crown lingual torque + open coil
springs (OCS): due to the effects of the archwire with crown lingual
torque and open coil springs(OCS), the crown remains in the
current position and the root moves to the labial direction.
A. Standard bracket and SWA bracket
(Left -Standard bracket, Right - SWA bracket).
B. Archwire with crown lingual torque.
C. Open coil springs (OCS).
D. Intraoral photograph.

nical Tips: non-extraction treatment approach to crowding

• Minimize the labioverison of anterior teeth.

1. Bond the .018” slot standard edgewise bracket on the anterior teeth.

2. Apply the .016” x . 022” stainless steel archw ire with crown lingual torque

(approximately -7°) to the anterior part of archwire.

3. Use the open coil springs (OCS) in the under-erupted or crowding areas.

• Expected results.

By using an archwire with crown lingual torque and open coil springs (OCS),

the crown of anterior teeth can be successfully aligned from the current

antero-posterior position. Nevertheless, due to labial movement of the root,

the labioversion of anterior teeth can be minimized, and the space for de­
crowding can be secured. [ j

Chapter 7 _ Leveling and Alignment < ◄ 365

 ▼G

^ ► Fig. 7 -1 8 Crown lingual torque application.

A. Pre-treatment intraoral photograph: insufficient space for canines and severe anterior cross bite.
B. Use the posterior bite block (PBB) in the mandible and open coil springs (OCS) on the maxillary
canines. Then do the tight cinch back at the end.
C. Use the .016” x .022” stainless steel archwire with crown lingual torque and open coil springs (OCS).
D. Remove the posterior bite block (PBB) and apply a resin cap on the mandibular second primary molar.
E. Extract the primary molar. Then level and align the maxillary canines.
F. Finish the treatment by using the maxillary and mandibular MEAWs.
G. Post-treatment intraoral photograph.
H. Post-retention photograph (one year after the treatment).
* For the details of orthodontic treatment procedure, refer to Chapter 14: a non-extraction treatment case
in Class III malocclusion (From Fig. 14-1 to Fig. 14-23).

366 ►► Chapter 7 _ Leveling and Alignment • # • •

 • • • •

3) Management of upper occlusal plane (UOP)

The upper occlusal plane (UOP) represents the angle between the FH plane and the plane that
connects the incisal edge of the maxillary central incisors to the midpoint of maxillary first molars
on the occlusal surface. This value is approximately 10° (Fig. 7-19).
When the upper occlusal plane (UOP) is normal, it is desirable to maintain its value in both
extraction and non-extraction cases. In particular, for premolar extraction cases, caution is needed
to control the upper occlusal plane. If the appliance is extended to the distally tilted maxillary
second molars (for the purpose of anchorage reinforcement), the upper occlusal plane (UOP) will
become steeper. This means that it is not desirable to extend the appliance to the maxillary second
molars, and therefore it is better to extend the appliance only to the maxillary first molars and to
close the extraction space. In other words, the decision of whether to extend the appliance to the
maxillary first molars or to the maxillary second molars should be made during the diagnosis, and
caution is required not to make the upper occlusal plane (UOP) too steep (Fig. 7-20). When the
upper occlusal plane (UOP) is steep, it means that the maxillary incisors are extruded excessively
and/or the maxillary molars are intruded. Here, the vertical position of the maxillary incisors is
important, and this position can be determined by the distance from the U1 to lip line (distance,
mm). In cases where the maxillary incisors are excessively extruded, a counter-clockwise rotation
of the upper occlusal plane (UOP) should be applied, which arises from the intrusion of maxillary
incisors and the extrusion of maxillary molars, to induce the forward rotation of mandible.

Chapter 7 Leveling and Alignment < 4 367

 ►► Fig. 7 -1 9 Upper occlusal plane (UOP).

A. Upper occlusal plane (UOP): a line connecting the incisal tip of the maxillary central incisors to the mid­
point of the maxillary first molars.
In the lateral cephalometric radiograph, it is marked as the angle between the FH plane and upper
occlusal plane (UOP). This value is generally 10°.
B. Lateral cephalometric radiograph, intraoral photographs, and dental models of a patient who has normal
upper occlusal plane (UOP).
•

368 ►► Chapter 7 _ Leveling and Alignment • • • •

 • • • @

►► Fig. 7 -1 9 (c o n tin u e d ) Upper occlusal plane (UOP).

C. Lateral cephalometric radiograph, intraoral photographs, and dental models of a patient who has steep
upper occlusal plane (UOP).

Chapter 7 _ Leveling and Alignment 4 <i 369

 ►► Fig. 7 -2 0 Precautions in extending the appliance to the maxillary second molar.
A. Extrusion of maxillary anterior teeth when the appliance is attached to the maxillary second
molar.
B. If the appliance is bonded on the maxillary second molar, the steps must be applied on the
archwire (between the first molar and the second molar).

• Double archwire (DAW) appliance

Double archwire was first invented by Dr. Cetlin NM for the purpose of bodily retraction of the
maxillary incisors (without using an extra oral appliance). However, because the reaction of
incisor intrusion frequently caused the distal tilting or extrusion of a molar, it was not widely
used. Recently, its drawbacks have been minimized and have been used increasingly for the
purposes of intruding the maxillary incisors, extruding the maxillary molars, improving the
occlusal plane, and increasing the vertical dimension.
In particular, this appliance is now used in the early stages of treatment for disto-occlusion
cases with an over-erupted maxillary incisor or a steep upper occlusal plane (UOP). By altering
the positions of anterior sectional arch, labially or lingually inclined incisors are now
accurately adjusted. In other words, from the lateral view, if the hook is located more in the
anterior direction (in comparison to the center of rotation of anterior teeth), labial inclination is
likely to occur, while if the hook is located more in the posterior direction, lingual inclination
is likely to occur. A double archwire (DAW) is used to treat growing patients, who have Class
II malocclusion. The indication for using the double archwire here is that the distance from the
U1 to lip line is 5mm or longer and the upper occlusal plane (UOP) is 15° or steeper (Fig. 7-

370 ►► Chapter 7 _ Leveling and Alignment # • # •

 • # • •

21). By using this appliance, the maxillary incisor is intruded and the maxillary molar is
extruded to cause the changes in upper occlusal plane(UOP); thereby there is no need to
reinforce the anchorage at the maxillary molars. However, if the high-pull headgear (HG) or
mini-implant is used to reinforce the anchorage, the molars will be intruded and the upper
occlusal plane (UOP) will get steeper, which would as a consequence, restrict the forward
movement of the mandible. •
In general, a double archwire (DAW) is used after the 2x4 appliance is used in the early mixed
dentition period. It is composed of labial archwire (.016” x .022” stainless steel archwire) in the
molar area and sectional archwire (.016” x.022” stainless steel archwire) in the incisor area.
There are hooks to be used to hang onto the main archwire at the end of the anterior sectional
archwire. By hanging these hooks onto the main archwire, an intrusive force can be applied to
the maxillary incisors. Here, the exerted intrusive force is usually 60~80gm (for the four
maxillary incisors). The force system of a double archwire (DAW) changes the upper occlusal
plane (UOP) through the extrusion of molars and intrusion of incisors. The methods of
fabricating a double archwire (DAW) are shown in Fig. 7-22 and 23.

►► Fig. 7-21 Mechanics of double archwire (DAW).

A. Double archwire (DAW) mechanically causes the extrusion of maxillary molars and the
intrusion of incisors.
B. Labial or lingual tipping of incisor is controlled by the hook position of the anterior archwire.
B-1. If the hooks are placed more in the anterior direction (than the center of rotation of
anterior teeth), the incisors will be labially angulated and intruded.
B-2. If the hook position is in line with the center of rotation, an intrusive force is applied.
B-3. If the hooks are placed more in the posterior direction (than the center of rotation of
anterior teeth), the incisors will be lingually angulated and intruded.

Chapter 7 _ Leveling and Alignment 4 ◄ 371

 ►^ Fig. 7 -2 2 Fabrication of double archwire (DAW).

A. Insert the center of .016” x .022” stainless steel archwire into the zero-degree slot of arch turret.
B. Equally rotate the turret with the same amount of force.
C. Form the ovoid shape of the anterior arch after turreting.
D. Mark the mid-point of anterior arch on the archwire.
E. Bilaterally mark the mesial contact points of the first molars on the archwire.

▼F-1 ▼F-2 ▼F-3

▼G ▼H ▼I

#
@

F. Hold the marked point with the round beak of Kim pliers and bend the archwire to form a helix.
G. Move the round beak in the occlusal direction and bend the archwire with the rectangular beak until it
becomes parallel to the main arch form.
H. The same method should be applied to the opposite side.
I. Fabricated double archwire (DAW).

372 ►► Chapter 7 _ Leveling and Alignment

• ® • ®
 • • # •

►► Fig. 7 -2 3 Fabrication of double archwire (DAW) for anterior sectional arch.

▼A ▼B-1 ▼B-2

▼C ▼D

A. Insert the midpoint of .016” x .022” stainless steel archwire into the zero-degree slot of turret.
B. Rotate the turret.
C. Mark the mid-point on the bent archwire.
D. Mark the distal contact points of the bilateral lateral incisors.

▼E-1 ▼E-2 ▼F

E. Bend it inward and form a hook.

F. Fabricated anterior archwire.
G. Bend the distal end of the main archwire in the gingival direction until the force reaches 60~80gm.
FI. Photographs after placing the double archwire (DAW): frontal and lateral view.

Chapter 7 _ Leveling and Alignment ◄◄ 373

 4) Management of posterior occlusal plane (POP)

The posterior occlusal plane (POP) represents the angle between the FH plane and the line that
connects the cusp tip of mandibular second premolar to the disto-buccal cusp tip of mandibular
second molar (Fig. 7-24).

It is divided into two cases: 1) when the posterior occlusal plane (POP) is normal (14° or less), and
2) when the posterior occlusal plane (POP) is steep (15° or more). This is closely related to
mandible retrusion. If there are skeletal problems, such as Class II or Class III malocclusion, a
positive orthodontic treatment can be achieved by controlling the posterior occlusal plane (POP)
(Fig. 7-25).
When the posterior occlusal plane (POP) is normal, it is more desirable to maintain the current
condition, and if an extraction treatment is required, the extraction of maxillary and mandibular
first premolars is recommended. In other words, it is more desirable to close extraction space while
maintaining the posterior occlusion.

►► Fig. 7 -2 4 Posterior occlusal plane (POP).

A. Posterior occlusal plane (POP): the angle between the FH plane and the line that connects
the cusp tip of mandibular second premolar to the disto-buccal cusp tip of mandibular
second molar.
© B. Posterior occlusal plane (POP) tends to be steep in Class II malocclusion, and flat in Class
III malocclusion.

374 ►► Chapter 7 _ Leveling and Alignment « © • •

 • • • •

►► Fig. 7 -2 5 Flat POP vs Steep POP.

A. Intraoral photograph, model and cephalometric radiograph of a patient who has flat POP.
B. Intraoral photograph, model and cephalometric radiograph of a patient who has steep POP.

Chapter 7 _ Leveling and Alignment «◄ 375

 When there is severe curve of Spee in the mandible, the decision of whether to maintain or change
the posterior occlusal plane (POP) must be made carefully (Fig. 7-26). In particular, if the posterior
occlusal plane (POP) is steep, leveling should be done while flattening the posterior occlusal plane
(POP). Such an application is effective for both extraction and non-extraction treatment cases, and
it is regarded as one of the most important factors in the MEAW concept.

▼A ▼B ▼c

►► Fig. 7 -2 6 Deep curve of Spee.

A. Deep curve of Spee.
B. Maintaining the POP during leveling (red dotted line).
C. Changing the POP during leveling (blue line).

In other words, if the posterior occlusal plane (POP) is steep, it must be rotated in the counter­
clockwise direction. This can be applied for both extraction and non-extraction cases. In non­
extraction cases, as mentioned above, the mesially angulated terminal molars can be uprighted
through strategic leveling and alignment (Fig. 7-27). In contrast, in extraction cases, mandibular
second premolars should be extracted (not the first premolars), and it is recommended to upright
the mesially angulated mandibular first premolars at the very beginning. To successfully
accomplish this, it is recommended to use the open coil springs (OCS) in the mandibular canine
• area and to bond the appliance later.

376- Chapter 7 _ Leveling and Alignment • • @ •

 • ® • •

►► Fig. 7 -2 7 Changing the POP for non-extraction treatment cases.

A. Apply the open coil springs (OCS) in the canine area and then do the tight cinch back to upright the
mesially angulated mandibular first premolars.
B. Bond the brackets on the canines and level them after uprighting.
C. Use the open coil springs (OCS) in the first molar and second premolar areas and do the loose cinch
back to upright and de-rotate the second molars. Then, bond the brackets on the first molars and
second premolars before leveling them.

►► Fig. 7 -2 8 Changing the POP for premolar extraction treatment cases.

A. Mandibular second premolar extraction.
B. Apply the open coil springs (OCS) in the canine area and do the tight cinch back to upright the
mesially angulated mandibular first premolars.
C. Bond the brackets on the canines and level them after sufficient uprighting.
D. Close the space.
E. Bond the brackets on the second molars and level them.

Chapter 7 _ Leveling and Alignment <4 377

 5) Elimination of occlusal force

(1)Purposes

CD Due to contact among opposing teeth, bracket bonding becomes very difficult. For this
reason, it is necessary to eliminate the occlusal force.
(D By eliminating occlusal force, effective tooth movement becomes possible.

(2) Problem s that arise from the occlusion of opposing teeth and the
bracket (Fig. 7-29)

CD Increase in tooth mobility.

CD Severe crown lingual inclination of mandibular molars.
(3) Aggravated mandibular curve of Wilson.
@ Restricted forward growth of mandible.

►► Fig. 7-2 9 Problems arising from the contact between mandibular

appliances and maxillary teeth.
1. Increase in tooth mobility.
2. Severe crown lingual inclination of mandibular posterior teeth.
3. Aggravated mandibular curve of Wilson.
4. Restricted forward growth of mandible: this is aggravated more
in extraction cases.

9
9 (3) Methods (Fig. 7-30)

© Do not bond the appliances in the early stages of treatment.

(2) If possible, use the smallest bracket.
(D Use the resin build up.
® Use the anterior bite plate.
© Use the posterior bite block.

378 ►► Chapter 7 _ Leveling and Alignment # 9 9 ®

 • il • •

¡n;
►► Fig. 7 -3 0 Methods that can prevent the contact between bracket and tooth.
1. If possible, use the smallest bracket.
2. Do not bond the appliances in the early stages of treatment.
3. If there is a mesially angulated tooth, upright it first by strategic leveling, and then increase the vertical
dimension.
4. Use the following appliances to move the teeth effectively without any occlusal force:
A. Anterior bite plate (ABP),
B. Posterior bite block (PBB),
C. Resin build up.

(4) Anterior bite plate (ABP)

© Design (Fig. 7-31 A)

© Effects
a. Intrusion and labial inclination of mandibular incisors.
b. Extrusion of mandibular molars.
c. Mandibular occlusal plane: rotates in the clockwise direction.
— It is used when there is a deep bite with normal or lingual inclination of mandibular
incisors with a deep skeletal pattern (High CF > 155).

(5) Posterior bite block (PBB)

® Design (Fig. 7-31 B)

© Effects
a. Extrusion and lingual inclination of mandibular incisors.
b. Intrusion of mandibular molars.
c. Mandibular occlusal plane: rotates in the counter-clockwise direction.
— It is used when there is a deep bite with labial inclination of mandibular incisors with
an open bite skeletal pattern (low CF < 150).

Chapter 7 _ Leveling and Alignment 4 < 379

 When these removable appliances are used, it is possible to achieve positive treatment results
after careful evaluation of skeletal and dental patterns of individual patients. Here, it is
important for patients to seal their lips consciously.

A*-

c-u

►► Fig. 7-31 Anterior bite plate (ABP) and posterior bite block (PBB).
A. Anterior bite plate (ABP).
B. Posterior bite block (PBB).
C. Anterior leveling and alignment while using the mandibular posterior bite block (PBB).
D. When these removable or functional appliances are used, it is important for patients to seal their lips
consciously.

380 ►► Chapter 7 _ Leveling and Alignment

• • ® •
 • • • ©

Archwires for Leveling and Alignment

( ^ ) Initial archwires
#

1) Purposes

This is used to trigger a minor tooth movement by provoking an osteoclastic response within the
bone.

2) Requirements

(1) It should be sufficiently flexible.

(2) It should be able to endure the occlusal force.
(3) It should have a narrow diameter.
(4) The frictional force with the bracket should be weak.

3) Archwires (Fig. 7-32)

►► Fig. 7 -3 2 Initial orthodontic archwires.

A. .014” NiTi. B. .015” Co-ax.

Chapter 7 _ Leveling and Alignment «•< 381

 (1) .014” NiTi: This is the first wire used right after bracket bonding. Since it has special shape
memorizing and super-elastic properties, this archwire can be inserted even into crowded teeth.
Nonetheless, due to this special super-elastic property, the gingival area behind the tube can be
damaged. Therefore, in order to minimize the patient’s discomfort, the NiTi cinch back plier
should be used, or the cinch back must be done after applying the heat to the wires for
permanent deformation (Fig. 7-33).

►► Fig. 7 -3 3 Cinch back bends for NiTi wire.

A. Apply heat to the wire for permanent deformation. Then, use the utility pliers to complete the cinch
back bends.
B. NiTi cinch back pliers.
• C-1. Maxillary arch: place the archwire behind the molar tube and bend it inward.
C-2. Mandibular arch: place the archwire behind the molar tube and bend it mesio-gingivally.

382 ►► Chapter 7 _ Leveling and Alignment @ @ @ @

 6 • • #

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

►► Fig. 7 -3 4 Co-ax archwire.

A. Method of shaping the Co-ax wire in an arch form.
B. Bent archwire.

nical Tips: Initial orthodontic archwire.

1. There is no need to pay too much attention to the arch form.

2. In the early stages of treatment, it is essential to minimize the patient’s discomfort.

3. Once the wire is ligated, place a finger right behind the terminal molars, and then

check the distal ends of the archwire. If any discomfort is detected even after the

cinch back, flowable resin must be used to relief the discomfort. ^ ^ ^

Chapter 7 _ Leveling and Alignment 4 ◄ 383

 Leveling archwire

1) Purposes

(1) This archwire is used to secure the alignment space by using the open coil springs (OCS) after
the use of initial archwires.
(2) This is the archwire that is used again for leveling and alignment after space closing.

2) Archwire: .016” stainless steel archwire

(1) It is an archwire that is used along with the open coil springs (OCS) or energy chain to open or
close the space.
(2) It is an archwire that is frequently used to close the space through the sliding mechanism.
(3) It is an archwire that is used again for leveling and alignment, after space closure and before
the finishing stages of treatment.

r:

\ __________________ ___
384 ►► Chapter 7 _ Leveling and Alignment
• ® ®
 • ® @•

4 Strategic Leveling and Alignment

Strategies for non-extraction treatment

(1) If there is crowding, perform strategic bonding. The appliances should not be attached to the
teeth that are located in front of the terminal molars. When the appliances are extended to
second molars, the first molars should not be bonded, and when extended to first molars,
second premolars should not be bonded.

(2) A standard bracket with zero-degree torque is used.

(3) Use the open coil springs (OCS) to secure sufficient space.

(4) In non-extraction cases, the labioversion of maxillary and mandibular anterior teeth should be
minimized.

(5) When there is a tendency of labioversion, the torque adjustment of anterior teeth should be
conducted during the space opening.

(6) After aligning the eight or ten anterior teeth, space can be secured by uprighting and de-
rotating the terminal molars. Here, if the CF value is high, sufficient amount of space can be
secured, but if the CF value is low, the posterior vertical dimension (PVD) is insufficient, and
thereby the process of uprighting and de-rotating the terminal molars becomes very difficult.
Therefore, the need for extraction treatment increases.

(7) De-rotate posterior teeth to successfully secure the space.

(8) If there is severe protrusion caused by the insufficient anterior vertical dimension, the vertical
dimension should be increased first by using the twin block appliance. Then, the teeth should
be aligned strategically. Here, the use of maxillary and mandibular arch expansion appliances
may be considered.

Chapter 7 _ Leveling and Alignment « ◄ 385

 (9) First of all, if there is a full cusp Class II molar relationship, it should be modified first to a
Class I relationship, and then the teeth should be aligned strategically.
CD If the maxillary second molars are under-erupted, the pendulum appliance should be used
first.
(D If the maxillary second molars are erupted, the mini-implant should be used.
(D If there is a tendency of anterior open bite with anterior crowding, use the MEAW first.

(10) Conduct strategic leveling while doing the reproximation.

(11) Strategically align the teeth while intruding the maxillary anterior teeth.

(12) If it is difficult to gain space through the aforementioned procedures, an extraction treatment
approach should be considered.
CD Methods of non-extraction treatment through the modification of maxillary arch form (Fig.
7-35).
(D Methods of non-extraction treatment when there is severe curve of Spee in the mandible
(Fig. 7-36).

inicalTips: Non-extraction.
The basic concept of non-extraction treatment is to move the teeth through strategic
le ve lin g and a lig n m e n t. In m ost cases, a n o n -e xtra ctio n tre a tm e n t approach
becomes possible by using strategic leveling and alignment. If additional appliances
(i.e. maxillary and mandibular expansion appliances) are used adjunctively before
strategic leveling, the non-extraction treatment becomes much easier and shortens
the treatment duration, too. j- j_

386 ►► Chapter 7 _ Leveling and Alignment • m 9 ©

 • • • •

►► Fig. 7 -3 5 Non-extraction treatment strategy to solve crowding.

▼A-1 ▼A-2

9
■S
&

A. Schematic figure of tooth movement.

A-1. Pre-treatment maxillary occlusal view.
A-2. When there is no anterior crowding, bond the appliance to the eight anterior teeth and second
molars. When there is anterior crowding, bond the appliance to every tooth except the crowded teeth
and first molars.
A-3. Apply the open coil springs (OCS) to the crowded canines and do the tight chinch back. After
securing the space, bond the appliances to the canines.
A-4. By using the open coil springs (OCS) and doing the loose cinch back on .016” stainless steel
archwire, the mesially rotated second molars can be de-rotated.
A-5. After bonding the appliances to maxillary first molars and leveling the teeth, the open coil springs are
used again in the premolar area to de-rotate the mesially rotated first molars.
A-6. Bond the appliances to second premolars and then align the teeth.
A-7. Post-treatment maxillary occlusal view.

Chapter 7 _ Leveling and Alignment -«-<8 387

 ►► Fig. 7 -3 5 (c o n tin u e d ) Non-extraction treatment strategy to solve crowding.

388 ►► Chapter 7 _ Leveling and Alignment ® • • ®

 #
*

►> Fig. 7 -3 6 Severe curve of Spee in the mandible: non-extraction treatment strategy.
A. Bond the appliances on the four mandibular incisors, first premolars, and second molars.
B. Use the open coil springs (OCS) in the canine area, and then perform the tight cinch back to upright
the mandibular first premolars, and to solve the problems of crowding and mesial angulation.
C. Bond the appliances on mandibular canines and then align the teeth.
D. This shows the alignment of eight anterior teeth.
E. After the alignment of eight anterior teeth, the open coil springs (OCS) are used to upright and de­
rotate the terminal molars.
F. Bond the appliances on the rest of the teeth -first molars and second premolars- and align them.
G. Diagram of the mandible after leveling and alignment.
H. Before and after the treatment.
* If these methods (strategic leveling and alignment) are used to align the teeth, the anterior teeth can
stay or move in the lingual direction due to the modification of dental arch form. At the same time, the
anterior teeth will move in the anterior direction due to the correction of deep curve of Spee. As a
result, the final position of anterior teeth can be maintained during leveling and alignment.

Chapter 7 _ Leveling and Alignment < « 389

1) Expansion appliances

If there is a posterior cross bite or a small transpalatal width (TPW) that is less than 3 1mm (Fig. 7-
37), a maxillary expansion appliance can be used. Here, depending on the case, a rapid maxillary
expansion (RME) appliance or even a slow maxillary expansion (SME) appliance can be used. The
rapid maxillary expansion (RME) appliance is rotated once a day and this expands the maxilla by
0.25mm/rotation (it takes about 4 weeks). In contrast, the slow maxillary expansion (SME)
appliance is rotated two or three times a week and should be worn for 3 months (Fig. 7-38).

▼A

►► Fig. 7-37 Transpalatal width (TPW).

A. The distance between the gingival margins of mesio-palatal
cusps of maxillary first molars (check the arrow).
B. Normal maxillary dental arch.
C. Narrow maxillary dental arch.
D. Changes in arch form and arch perimeter due to transpalatal
width (TPW) modification.

▼B ▼C ▼D
 • # • ©

By using these maxillary expansion appliances, we can gain the space in the central incisor area; as
a result, the non-extraction treatment approach becomes possible. If there is severe lingual
inclination in the maxillary premolar area, the maxillary expansion appliances could be used again
to improve the tooth axis.
If there is severe lingual inclination in the mandibular molar area (lingual cusps are more than
2mm away from the line connecting the occlusal plane), the Schwarz appliance (mandibular
expansion appliance) can be used to upright the molars, and should be rotated once or twice a
week. When the mandible is retruded, the twin block appliance, which includes both maxillary and
mandibular expansion appliances, can be used to move the teeth (Fig. 7-39).

2) Molar distalizalization

In the case of full cusp Class II molar relationship, it is more effective to conduct strategic leveling
and alignment while using the following appliances (Fig. 7-40):

►► Fig. 7 -4 0 Full cusp Class II

molar relationship.
A. Full cusp Class II m olar
relationship.
B. Dental models of a patient
with full cusp Class II molar
relationship.

Chapter 7 _ Leveling and Alignment 4 4 391

 (1) Pendulum appliance (Fig. 7-41)

This is an appliance used to posteriorly distalize the maxillary molars without any patient
compliance. This appliance is advantageous for inducing distal movement of posterior teeth,
but has a side effect of mesial tilting of first premolars. Therefore, in order to use this appliance
effectively, it is important to first change the molar relationship into a super Class I molar
relationship, and then perform strategic leveling and alignment of the mesially tilted first
premolars. This makes it possible to align the teeth while minimizing anterior protrusion. Here,
it is important to note that this appliance is particularly effective when there are non-erupted
maxillary second molars.

►► Fig. 7-41 Pendulum appliance.

If strategic leveling and alignment are performed after the pendulum
appliance is attached, the teeth can be aligned even more
effectively without moving the anterior teeth forward.
A. Photograph of pendulum appliance.
B. Intraoral photographs of a patient with a pendulum appliance on.

392 ►► Chapter 7 _ Leveling and Alignment © ® • •

 • © • ©

(2) Mini-implant (Fig. 7-42)

If the maxillary second molars are already erupted, the posterior teeth can be even more
distalized by using a mini-implant between the maxillary second premolars and the first
molars.
&
Q

►► Fig. 7 -4 2 Mini-implant.
Intraoral photographs after using the mini-implant.
If strategic leveling and alignment are performed after using the mini-implant, the teeth can be aligned
without causing the proclination of anterior teeth.

Chapter 7 _ Leveling and Alignment ◄◄ 393

 (3) MEAW (Fig. 7-43)

If crowding is mild with an anterior open bite, a modified offset archwire (MOAW) or MEAW
can be used to close the open bite or to achieve the distalization and the intrusion of molars
simultaneously. In this case, patient cooperation is essential (in wearing elastics in the early
stages of treatment).

394 ►► Chapter 7 _ Leveling and Alignment

• © • ®
 • m • •

3) Reproximation and stripping (Fig. 7-44)

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

►► Fig. 7 -4 4 Reproximation.
If the reproximation is performed, followed by strategic leveling and alignment, it can minimize the
labioversion of anterior teeth and facilitate the successful alignment.

4) Strategic leveling and alignment

While undertaking the aforementioned methods, brackets should not be bonded to the teeth that are
located in front of the terminal molars (usually first molars when the second molars are bonded).
Anterior crowding can be successfully solved through strategic bonding, open coil springs and
tight cinch back. Here, de-rotation and uprighting should then be performed on terminal molars
after grouping the anterior teeth into one unit.

Chapter 7 _ Leveling and Alignment «◄ 395

 Strategies for premolar extraction treatment (Fig. 7-45).

(1) The Roth type SWA (.018” slot) is attached to the four maxillary incisors, and the zero-degree
standard edgewise appliance is attached to the remaining teeth.
(2) The orthodontic appliances on the mandible should never come into contact with the opposing
maxillary teeth.
(3) Since it is essential to retract the maxillary canines after confirming its parallel relationship to
the maxillary first molars, the problems in such contact must be detected and overcome in the
early stages of leveling treatment.
CD Parallelized first molars: retract the maxillary canines from the first molars.
(D Mesially rotated first molars: First and foremost, the mesially rotated maxillary first molars
should be de-rotated. This can be achieved by using the energy chain between the maxillary
second and first molars, and by using the open coil springs in the maxillary first molar area.
(4) Since the maxillary extraction space should be closed while maintaining its upper occlusal
plane (UOP), extending the appliance to maxillary second molars for the maximum retraction
of the maxillary anterior teeth should be cautiously performed in the early stages of treatment.
However, the mesially rotated maxillary first molars are an exception. In this case, the rotated
maxillary first molars should be de-rotated beforehand, by bonding an appliance to the
maxillary second molars.
(5) The teeth should be moved so that the maxillary and mandibular canine relationship can form
or maintain a Class I relationship.
Here, it is extremely important not to retract the mandibular canine in advance.
(6) If there are maxillary and mandibular crowding, open coil springs should be used to solve
crowding problems.
(7) The space should be closed after uprighting the mesially angulated mandibular molars and
premolars. Here, if there is severe mesial angulation, a mandibular second premolar extraction

9
is recommended (more than the mandibular first premolar extraction). For this, the open coil
springs should be used in the mandibular canine area to sufficiently upright the first premolars,
and then the appliances should be bonded on the canines.
(8) In the case of mandibular first premolar extraction, space should be closed while maintaining
the premolar and molar occlusion.
(9) The teeth should be aligned while maintaining its retrusive control, and then the space should
be closed afterwards (Refer to Chapter 8: Space closure).

396 ►► Chapter 7 _ Leveling and Alignment @ • • •

 ® • © ©

In premolar extraction cases, if the leveling is not sufficient or the leveling is done without
considering the upper occlusal plane (UOP), difficulties will arise in the next stage of space closing
and in the finishing stages of treatment.

▼A-1 ▼A-2

► Fig. 7 -4 5 Leveling and alignment in premolar extraction cases.

A. Use the SWA brackets to treat the four maxillary anterior teeth.
A-1. Standard brackets.
A-2. SWA brackets (recommended).
B. Establish the parallel relationship of maxillary first molars.
C. Maintain the upper occlusal plane (UOP).
D. Maintain the Class I canine relationship.
E. Sufficiently upright the mandibular posterior teeth.
E-1. V-shaped arch form.
E-2. Mesially angulated mandibular posterior teeth.
E-3. By conducting strategic bonding and using the open coil springs in the first molar area, the
second molars can be successfully uprighted and de-rotated (mandibular first premolar extraction
case).

Chapter 7 _ Leveling and Alignment < ◄ 397

 ( W h e purposes of strategic leveling and alignment can be summarized
as follows:
1. Tooth movement must be in accordance with the diagnosis.

1) The extraction options and subsequent tooth movement may differ depending

on the diagnosis (whether to maintain or change the posterior occlusion).

2) The m axillary incisor position and upper occlusal plane (UOP) should be

established in the early stages of treatment, and tooth movement should be

done in accordance to the diagnosis.

2. In extraction cases, tooth m ovem ent should be done to make space closing

effective. To achieve this, the sufficient leveling of mandible curve of Spee and

the adjustment of upper occlusal plane (UOP) are required.

3. Tooth movement in the finishing stages of treatment: Tooth movement is done to

m ake the fin is h in g pro ce d u re s of tre a tm e n t easier. T his a p p lie s fo r both

extraction and non-extraction cases. In clinical cases, it is important to maintain a

Class I relationship before the finishing stages of treatment, and it is not desirable

to exceed the cusp-to-cusp relationship. j

398 ►► Chapter 7 _ Leveling and Alignment « • ® •

 # • « •

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36. Kim Jl, Akimoto S, Shinji H, and Sato S. Importance of vertical dimension and cant of occlusal plane in
craniofacial development. Int J Stomatol Occlusion Med 2:114-121,2009.
37. Kim Jl. Practical Clinical Orthodontics. Vol 1. Orthodontic treatment with MEAW. Well publishing Inc,
2012.
38. Kim Jl. Practical Clinical Orthodontics. Vol 2. Orthodontic Diagnosis. Well publishing Inc, 2013.
39. Kim Jl. Practical Clinical Orthodontics. Vol 3. Early orthodontic treatment. Well publishing Inc, 2015.
40. Kusy RP. A review of contemporary archwires: Their properties and characteristics. Angle Orthod
63:197-207, 1997.
41. Marcott MR. Biomechanics in Orthodontics. St Louis:CV Mosby, 1990.

4ÜÜ ►► Chapter 7 _ Leveling and Alignment • • # •

 • • • •

42. McNamara JA Jr, and Brudon WL. Orthodontics and Dentofacial Orthopedics. Needham Press, 2001.
43. Miura F, Mogi M, Ohura Y, and Hamanaka H. The super-elastic property of the Japanese NiTi alloy
wire for use in orthodtontics. Am J Orthod Dentofacial Orthop 90:1-10 1986.
44. Nanda Ravindra. Biomechanics and Esthetic strategies in clinical orthodontics, Elsevier Saunders,
2005.
45. Oliveira NL, Da Silveira AC, Kusnoto B, and Viana G. Three-dimensional assessment of morphologic
changes of the maxilla : A comparison of 2 kinds of palatal expanders. Am J Orthod Dentofacial
Orthop 126:354-362,2004.
46. Pandis N, and Bourauel CP. Nickel-titanium (NiTi) archwires: The clinical significance of super
elasticity. Semin Orthod 16:249-257, 2010.
47. Proffit WR. Contemporary orthodontics. St Louis: CV Mosby company, 1986.
48. Rhee SH, and Nahm DS. Triangular-shaped incisor crowns and crowding. Am J Orthod Dentofac
Orthop 118:624-628, 2000.
49. Ricketts RW, Bench RW, Gugino CF, Hilgers JJ, and Schulhof RJ. Bioprogressive Therapy. Denver:
Rocky Mountain Orthodontics, 1979.
50. Rinchuse DJ, and Kandasamy S. Evidence-based versus experience-based views on occlusion and
TMD. Am J Orthod Dentofacial Orthop 127:249-254, 2005.
51. Roth RH. Functional occlusion for the orthodontist. J Clin Orthod 15(1-4), 1981.
52. Sandler JP. An attractive solution to unerupted teeth. Am J Orthod Dentofacial Orthop 100:489-493,
1991.
53. Sarver DM, and Johnston MW. Skeletal changes in vertical and anterior displacement of the maxilla
with bonded rapid palatal expansion appliances. Am J Orthod Dentofacial Orthop 95:462-466, 1989.
54. Scheffler NR. Patient and provider perceptions of skeletal anchorage in orthodontics. MS Thesis,
University of Northo Carolina, 2005.
55. Schudy FF. The control of vertical overbite in clinical orthodontics. Angle Orthod 38:19-39, 1968.
56. Schwarz AM, and Gratzinger M. Removable orthodontic appliances. Philadelphia: WB Saunders,
1966.
57. Silleul MP, and Jordan L. Torsional properties of NiTi and Cu-NiTi wires: The effect of temperature on
physical properties. Eur J Orthod 19:637-646, 1997.
58. Tenti FV. Atlas of orthodontic appliances, Caravel, 1985.
59. Thurow RC. Atlas of orthodontic principles, Mosby, 1977.
60. Tomy International Inc. Tomy Orthodontic Product Catalog, vol. 4.0, 2009.
61. Tweed CH. Clinical orthodontics. Vol 1 and 2. St Louis: Mosby, 1966.
62. Vardimon AD, Graber TM, Drescher D, and bourauel C. Rare earth magnets and impaction. Am J
Orthod Dentofacial Orthop 100:494-512, 1991.
63. Vermette ME, Kokich VG, and Kennedy DB. Uncovering labially impacted teeth-apically positioned
flap and closed-eruption techniques. Angle Orthod 65:23-32, 1995.

Chapter 7 _ Leveling and Alignment < ◄ 401

 Chapter 8

SPACE CLOSURE

Space Closing Method

1) Sliding method vs loop method
2) Space closing method
(1) Maxillary canine retraction
(2) Mandibular en-masse retraction
(3) Maxillary anterior teeth retraction

Space Closing Archwire

. Anchorage

Retrusive Control in Clinical Orthodontics

Archwire Fabrication for Space Closure

 g^ Space Closing Method

Sliding method vs loop method

To close the space, two different methods can be used: the sliding method (frictional method) and
the loop method (frictionless method). The sliding method (frictional method) is used with elastics,
coil springs, etc., and facilitates tooth movement on the archwires. The loop method (frictionless
method) is used to move the teeth along with the archwire that has a loop (Fig. 8-1).

►► Fig. 8-1 Space closing method.

1) Sliding method.
2) Loop method.

Advantages of the sliding method:

1) Minimal wire bending,
2) Effective sliding on the archwire,
3) Reduced chair time.

Disadvantages of the sliding method:

1) There is no clear indicator for the optimum amount of force necessary for tooth movement.
Since there is friction between the bracket and the archwire, the applied force should be
greater than both the frictional and tooth-moving forces to cause tooth movement.
2) In the early stages of treatment, if the elastic or spring force is excessively activated, tilting
may occur initially.
3) The recovery time required for successful uprighting may be insufficient.
4) Tooth movement does not occur when the archwire is damaged or deformed.

404 ►► Chapter 8 _ Space Closure Q O O ©

 # • • •

In clinical orthodontics, depending on the doctor’s preference, various methods such as energy
chain, elastics, coil springs, etc., can be used to induce the sliding movement of teeth.

Advantages of the loop method:

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

Disadvantages of the loop method:

1) Time consuming due to wire bending.
2) All the activation is lost once the loop comes into contact with the bracket, and as a result
the archwire must be made again.
3) The initial activation force is strong.
4) The loop can cause some discomfort.

In MEAW, to induce effective tooth movement, an extraction space must be closed by a

combination of sliding and loop methods.
The conventional treatment procedures are as follows.
First, retract the maxillary canines. To do this, the sliding method should be used with the energy
chain. Next, align the six or eight mandibular anterior teeth, and the .018” shoe-hook or .016”
x .022” ideal archwire with hook should be used to close the space. Then, the sliding method - the
elastics or energy chain - should be used. When retracting the four maxillary incisors, the loop
method should be used with the .016” x.022” combination loop with step to close the space (Fig.
8-2). In MEAW, the space closing is done differently case by case, but in most cases, the tooth
movement pattern should be the combination of the retraction of anterior teeth and the protraction
of posterior teeth, rather than the maximum retraction of maxillary and mandibular anterior teeth.
In other words, space closing in MEAW can be more efficiently done by the combination of
vertical and antero-posterior tooth movement, but not by relying solely on the antero-posterior
space closure. By doing so, the finishing procedure can be done more easily and can prevent bite
deepening, which frequently occurs when closing space. Also, if the molars are mesially angulated,
the MEAW technique can solve such problems in the finishing stages of treatment by uprighting
and space closure with MEAW.

Chapter 8 _ Space Closure ■* ◄ 405

 k ► Fig. 8-2 Clinical method of space closure.

vV rgy chain (Fig. 8-3).

1. Its function is closing space.

1) Through the individual tooth movement, a small amount of space can be closed.

2) Caution is needed not to deform the arch form or not to reduce the arch length.

2. Uses it on the archwire that has a minimum .016” diameter.

3. In general, it loses 2/3 of its activation force in 48 hours.

►^ Fig. 8-3 Energy chain and tension

gauge.
A. Energy chain (power chain).
B. Tension gauge.
C. 250gm force is the optimum
force for the maxillary canine
re tra c tio n , c o n s id e rin g the
friction.
©
©
©

406 ►► Chapter 8 _ Space Closure • © • •

 # # ® ©

Space closing method

1) Maxillary canine retraction (Fig. 8-4)

@

^ ► Fig. 8-4 Maxillary canine retraction.

A. Tooth movement pattern with an ideal arch form on the continuous archwire.
B. Canine retraction with energy chain.
C. Problems in the maxillary canine retraction on the continuous archwire.
D. Canine retraction with open coil springs.

CD The main archwire used for maxillary canine retraction is either .016” stainless steel archwire
or .016” x .022” stainless steel archwire.
The main archwire is not a segmented archwire but a continuous archwire that creates an ideal
arch form. Here, since the maxillary canine is retracted on the continuous archwire, the
maxillary incisors can be extruded to a certain extent.
(2) Retract the maxillary canines from the maxillary first molars by using the energy chain. The
maxillary canine should first be moved until a Class I canine relationship is formed. The
required force for maxillary canine retraction is 250gm. This value includes the tooth
movement force as well as the frictional force.

Chapter 8 _ Space Closure < < 407

 (3) When there is crowding in the maxillary and mandibular anterior teeth, the open coil springs
(OCS) should be used to align the crowded teeth after securing the extraction space. Here, even
though there is severe crowding in the mandibular anterior area, it is not desirable to retract the
mandibular canine first.
0 For canine retraction, many orthodontists tend to extend the appliance to the maxillary second
molars for the purpose of maximum retraction of the maxillary anterior teeth. Here, the
angulation of the maxillary second molar, the upper occlusal plane, and the posterior occlusal
plane should all be considered. In other words, if the maxillary second molars are uprighted
with a normal upper occlusal plane and posterior occlusal plane, the canine retraction from the
maxillary second molars can be made without any difficulties. However, if the maxillary
second molars are distally tilted, it is more desirable to retract the canine from the maxillary
first molar because there is a greater possibility of extruding and lingually angulating the
maxillary incisors (Fig. 8-5).

►► Fig. 8-5 Maxillary canine retraction considering the upper occlusal

plane.
A. Distally angulated maxillary second molar.
B. Problems in inserting the archwire to the distally tilted maxillary
second molar: extrusion of the maxillary anterior teeth and
steepening of the upper occlusal plane.
C. Space closure considering the upper occlusal plane.
D. Intraoral photograph of maxillary canine retraction.

408 ►► Chapter 8 _ Space Closure • ® 9 •

 • • © •

(1) Class II case (Fig. 8-6)

►► Fig. 8-6 Cases of premolar extraction in Class II malocclusion.

A. Posterior movement of maxillary canine in Class II malocclusion.
B. Posterior movement of maxillary canine while using mandibular posterior bite block (PBB) in Class II
malocclusion.
C. Maxillary canine retraction while intruding maxillary incisors in Class II malocclusion.

CD First, retract the maxillary canine by using the energy chain.

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

Chapter 8 _ Space Closure « ◄ 409

 ►► Fig. 8-7 An extraction case of maxillary premolar only in Class II malocclusion.
Close the space after extracting the maxillary premolars only. The canine key and overjet should be
analyzed, and a decision on mandibular premolar extraction should be made in consideration of the
remaining space and the extent of mandibular crowding.
A. If there is mandibular crowding with more than 3mm space of maxilla, there is high possibility of
extracting the mandibular premolars.
B. If there is minor mandibular crowding with less than 2mm space of maxilla, there is a high possibility of
performing a non-extraction treatment method.
C. Intraoral photographs.
C-1. Pre-treatment intraoral photographs.
C-2. Intraoral photographs during the space closure after extracting the maxillary premolars only.
C-3. Post-treatment intraoral photographs.

\ _________________
4 1 0 - Chapter 8 _ Space Closure @ m m ®
 • • • •

(2) Class III malocclusion (Fig. 8-8)

(D If there is maxillary anterior crowding, open coil springs should be used to move the
maxillary canines posteriorly and to secure space for the alignment of crowded teeth. Here,
a weak force should be applied, by using the energy chain, to retract the maxillary canine.
After this is done, the crowded teeth should all be aligned.
(D When a non-surgical orthodontic treatment is used to treat Class III malocclusion, caution is
needed because the lingual retraction of the maxillary incisors can lead to the excessive
lingual retraction of the mandibular incisors.
To prevent this, the .016” x .022” ideal archwire with hook having a crown labial torque on
the anterior portion should be used to cause an en-masse retraction of the six maxillary
anterior teeth.

Chapter 8 _ Space Closure ◄◄ 411

 Es-
►► Fig. 8-8 Premolar extraction in Class III malocclusion.
A. Pre-treatment intraoral photographs.
B. Maxillary canine retraction using the open coil springs: maxillary canine retraction while preventing the
excessive linguoversion of maxillary incisors.
C. The case of a patient who refused to have surgical treatment; the mandibular second premolars are
extracted to achieve space closure and normal overjet.
D. Finishing stages of Class III malocclusion treatment, using the MEAWs on the maxilla and mandible.
E. Post-treatment intraoral photographs.

412 ►► Chapter 8 _ Space Closure • • • •

 • © ® •

• Parallel rotation of maxillary first molar

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

▼A-1 A-2
►► Fig. 8-9 Mesial rotation and
parallel rotation of the
maxillary first molars.
A. The maxillary first molars
should be parallelized
before the space closure.
A-1. Parallelized maxillary
first molars.
A-2. Mesially rotated maxillary
first molars.
B. If the maxillary first and
second molars are mesially
rotated, the open coil
springs should be used in
the first molar area for the
parallel rotation of first and
second molars. Then, the
energy chain should be
used with a weak force
between the first and
second molars for the
parallelization of first
molars.
C. After parallelizing the first
molars, the canines must
be retracted from the first
molars.

Chapter 8 _ Space Closure 413

 (3) Factors to be checked in maxillary canine retraction

© Patterns of tooth movement: Check to see whether the canine is retracted or the first molar
moves forward. In maxillary canine retraction, a space should be secured between the
lateral incisor and the canine. If this space is not secured, and instead the space is secured in
the maxillary first molar area, the posterior anchorage should be reinforced because this is
highly likely to be caused by the mesial angulation of maxillary first molars. Here, it is
important to note that it is more desirable to close the extraction space after placing the
mini-implant between the maxillary second premolars and the first molars.
(2) Extrusion and linguoversion of the maxillary incisors: If the maxillary canine is retracted on
a continuous archwire, there is an inevitable risk of linguoversion and extrusion of
maxillary incisors. Therefore, when retracting the maxillary canine, it is better to move the
canines until a Class I canine relationship is formed. Do not attempt to trigger a full canine
movement from the maxillary canine to the second premolar. Instead, it is more desirable to
substitute the maxillary archwire with the combination loop with step to retract the
maxillary canine successfully.
(3) Bowing effect (Fig. 8-10).
® Mesial rotation of the maxillary first molars: In canine retraction, the mesial movement of
maxillary first molars is permitted only to a certain extent. In order to maintain the position
of the maxillary first molar, the maxillary incisors must be retracted as much as possible.
However, such movements can cause excessive extrusion, linguoversion and an unaesthetic
appearance, which can make the finishing stages of orthodontic treatment a lot more
complicated. Therefore, when starting the maxillary canine retraction, it should make sure
that the buccal surfaces of the first molars are parallelized.

414 ►► Chapter 8 _ Space Closure • • • •

 • • • •

►► Fig. 8 -1 0 Bowing effect when closing the extraction space: when

closing the space, the bowing appearance of the teeth adjacent to
the extraction site is apparent.

2) Mandibular en-masse retraction

(1) Space closing method after the extraction of mandibular first premolars

(D Severe proclination of the mandibular incisors (IMPA>95) (Fig. 8-11)

a. To upright the severely proclined mandibular incisors and to close the space,
the .018” archwire with shoe-hook, the energy chain, or elastics should be
used. Tooth movement occurs more frequently in the anterior area than in the
posterior area. Here, if a rectangular wire, instead of a round wire, is used,
there is a greater possibility of causing the anterior movement of posterior
teeth than the posterior movement of anterior teeth.
b. When the mandibular Incisors are fully uprighted after the Class I canine
relationship is formed, a different wire -the ,016”x.022” ideal archwire with
hook- should be used to move the posterior teeth forward.

Chapter 8 _ Space Closure «◄ 415

 ►► Fig. 8-11 Space closing after the mandibular first premolar extraction (in case of excessive labioversion
of mandibular incisors).
A. If a rectangular wire is used, there is a greater resistance between the slot and the wire; therefore, the
anterior movement of molars occurs more than the posterior movement of incisors.
B. When a round wire is used, there is a greater possibility of lingual movement of crowns; therefore, the
posterior movement of incisors can occur more easily.
C. Shoe-hook.
D. Intraoral photographs of shoe-hook.
E. Problems in closing the extraction space through the excessive posterior movement of mandibular
incisors:
1. Excessive lingual inclination and extrusion of mandibular incisors,
2. Bite deepening and deep curve of Spee,
3. Class II canine relationship.

416 ►► Chapter 8 _ Space Closure

• ® • •
 • • • •

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

a. Space closure is done by using the energy chain or elastics on the .016” x.022” ideal
archwire with hook. Here, depending on the situation of each patient: +7°, +10°, or
+ 13°, a different amount of crown labial torque can be given to the mandibular incisors.
In general, -7° torque is applied to the posterior area of the mandibular canine, and the
hook is placed in between the mandibular lateral incisor and the canine.
b. If there is remaining space in the mandibular arch even after closing the maxillary space,
which forms a Class I canine relationship, it is more desirable to use the .016” x .022”
ideal archwire with hook for space closure (Fig. 8-12 B). Here, caution is needed when
closing the space through further retraction of mandibular incisors, as a Class II canine
relationship may be formed to complicate the finishing procedure.
c. If the lingual inclination of mandibular incisors is to be avoided during space closure, it
is recommended to apply the crown labial torque to the anterior part of mandibular
archwire.

► Fig. 8 -1 2 Space closing after the mandibular first premolar extraction (in case of normal inclination of
mandibular incisors).
A. When a round wire is used, the lingual movement of crown can be made more easily. This leads to a
greater possibility of posterior movement and linguoversion of incisors.
B. When a rectangular wire is used, there is a greater resistance between the slot and the wire.
Therefore, anterior movement of molars occurs more than the posterior movement of incisors, and the
extraction space can be closed to prevent aggravation of the existing incisor axis.
C. Archwire with crown labial torque in the lower anterior area.

Chapter 8 _ Space Closure «« 417

 (2)Space clo sin g m ethod after the e xtra ctio n of m an d ib u la r second
premolars (Fig. 8-13)

CD This is a type of space closing method which is used after grouping the eight mandibular
anterior teeth as one unit.
(D The extraction space of the mandibular second premolar is closed through the protraction of
posterior teeth and the retraction of anterior teeth.
(D To achieve this, the space is closed by using an energy chain or elastics on the .016” x .022”
ideal archwire with hook.
There are different amounts of crown labial torque given to the mandibular incisors
depending on the situation of each patient: +7°, +10°, or +13°. In general, -7° torque is
applied to the posterior area of the mandibular canine, and the hook is placed in between the
mandibular lateral incisor and the canine.

►► Fig. 8 -1 3 Space closing after extracting

the mandibular second premolars.
If the m andibula r second prem ola r is
extracted, a rectangular wire must be used
to close the space in order to induce the
protraction of the posterior teeth (not the
retraction of the anterior teeth).

418 ►► Chapter 8 _ Space Closure ® • • ©

 • « © •

(3) Factors when closing the mandibular extraction space (Fig. 8-14)

© Excessive lingual inclination and the retraction of mandibular incisors,

© Bite deepening,
© Bowing effect,
© Excessive mesial angulation of mandibular molars.

The above phenomena occur mostly from space closing in the mandibular first premolar
extraction area with deep curve of Spee. Therefore, in making a diagnosis, it is necessary to
check the mesial angulation of mandibular premolars and molars to determine the appropriate
extraction option and treatment mechanics. Also, if premolar and molar brackets have
excessive crown lingual torque, it can cause the lingual inclination of mandibular molars,
thereby restricting the forward movement of the mandible. In particular, this problem is
aggravated due to the contact between the mandibular molar brackets and the maxillary teeth.
If the premolar is extracted despite an incomplete anterior leveling, the mandibular molars are
likely to be tilted forward during the space closure. This problem gets worse particularly when
the posterior occlusal plane is steep. Therefore, even after the extraction space is closed in this
way, mandibular retrusion, unaesthetic appearance, and undesirable Class II relationship can
appear. This means that if the posterior occlusal plane is steep, it is better to extract the
mandibular second premolar rather than the mandibular first premolar. Here, it is important to
sufficiently upright the mandibular first premolars by using the open coil springs and the
MEAW.

►► T a b le . 8-1 Guidelines for selection of mandibular space closing archwire.

Position of anterior teeth Ideal teeth movement

.018” shoe-hook + Class I elastics Proclinatlon (IMPA > 95) Lingual movement of incisors
Combination loop
.016” x .022" Ideal AW + Class I, II elastics Normal or retroclination (IMPA < 95) Anterior movement of molars

Chapter 8 _ Space Closure ^ ◄ 419

 ►^ Fig. 8 -1 4 Check points when closing the mandibular space:
A. Molar relationship: Class I with flat curve of Spee.
B. FACC shows that the mesial angulation of the mandibular premolars and molars are apparent.
C. Intraoral photographs after extracting the mandibular second premolar: excessive mesial angulation of
the first premolar and the first molar.
D. Posterior movement of maxillary and mandibular canines.
E. Intraoral photographs of uprighted maxillary and mandibular canines: For a desirable tooth movement,
the maxillary canine retraction should occur before the mandibular canine retraction. To achieve this,
the anterior movement of molars should occur before the posterior movement of canines and incisors
in the mandible.

Methods of preventing the bite deepening during the mandibular space closure

1. Make sure that severe curve of Spee is not formed.

(1) Avoid the excessive lingual movement of mandibular incisors.
(2) Use the standard brackets in the mandibular incisor area.
2. Make sure that severe curve of Wilson is not formed.
(1) Avoid any occlusal contact between the mandibular appliances and the maxillary teeth.
(2) Do not cause severe lingual tilting of mandibular molars.
(3) Use the standard brackets in the mandibular molar area.
3. Close the space while maintaining the Class I canine relationship.
4. Move the teeth in the direction of maintaining the premolar occlusion. Jl>

420 ►► Chapter 8 _ Space Closure

® • • •
 • • • •

If bite deepening occurs during the mandibular space closure, it is important to stop the space
closing process and induce bite opening. In most cases, bite deepening occurs due to the
deformation of mandibular archwires. Therefore, if there is a tendency of bite deepening with
severe curve of Spee, the mandibular archwires should be carefully examined (Fig. 8-15).
#

►► Fig. 8 -1 5 Bite deepening when closing the mandibular space.

A. Bite deepening when closing the mandibular space.
B. Deformed mandibular archwire: it is important to be wary of the
possibility of wire deformation in the case of unwanted severe
bite deepening.
C. Bite raising through the extrusion of premolars and the intrusion
of incisors and molars.
D. Mandibular dentition after bite raising.

Chapter 8 _ Space Closure <◄ 421

 Solutions for bite deepening.
CD Combination loop with gable bends and elastics: When closing the mandibular space,
bite raising can be achieved by giving the gable bends to the mandibular combination
loop, and by using the triangular elastics between the loop and the opposing teeth. By
doing so, the extraction space can be opened again. If the roots become parallelized to a
certain extent, the space should be closed again by activating the loop. However, bite
deepening may not be improved despite using the combination loop. In this case, it is
important to check whether the combination loop is deformed or not. If the wire is
actually deformed, remove it and use MEAW to raise the bite.
(D MEAW with tip-back bends and elastics: The effects and mechanisms of MEAW will be
explained in detail in the next chapter. If the tip-back bends are applied to the
mandibular MEAW, it will form the reverse curve. This triggers the extrusion of
premolars and the intrusion of incisors and molars, thereby raising the bite. Here, if the
triangular (1/4” 6oz) or short Class II elastics (3/16” 6oz) are used in between the loop
and the opposing teeth, the bite will be raised. The extraction space can be closed with
the use of an energy chain from the first molar to the first loop; however, the energy
chain should never be used on the mandibular second molar in such cases. By following
the procedures above, it is possible to achieve bite raising by uprighting the molars,
which are already mesially angulated with bite deepening.
(D Reverse MEAW with tip-back bends and elastics (Fig. 8-16): Reverse MEAW makes
the direction of the loop posterior. This loop direction triggers the effects of molar
extrusion and incisor intrusion. It is highly effective when treating bite deepening with
molars that are vertically low positioned and mesially angulated.

▼A ■» B ▼c

►► Fig. 8 -1 6 Reverse MEAW with tip-back bends and elastics.

A. Pre-treatment intraoral photograph.
B. Intraoral photograph after the space closure in the extraction case of the maxillary first and the
mandibular second premolars: major problems such as deep curve of Spee and deep bite, etc.
C. Post-treatment intraoral photograph.

422 ►► Chapter 8 _ Space Closure HD © S

 • • 9 ®

3) Maxillary anterior teeth retraction (Fig. 8-17)

© Use the .016” x .022” stainless steel archwire to close the space of the four maxillary incisors.
© The maxillary incisor torque can, depending on the anterior inclination, be divided into different
degrees: +7°, +10°, or +13°.
© Apply 1mm step between the maxillary lateral incisor and canine for the intrusion of four
maxillary incisors.
© Apply -7° torque to the teeth behind the maxillary canine.
© In the first visit, do not activate the loop before engaging the combination loop.
© In the following visits, activate the loop by moving the wires until the loop legs overlap with
each other, and by doing the cinch back. If the wires cannot be pulled in the forward direction,
it means that the cinch back has been done well.
© In the next visit, check the deactivation and then re-activate.

▼A

►► Fig. 8 -1 7 Retraction of four maxillary incisors.

A. Standard bracket and a wire with crown labial torque.
B-1. SWA bracket (crown labial torque) and a wire with crown labial torque.
B-2. A wire with crown labial torque for anterior teeth.
B-3. Application of 1mm step between the anterior and posterior parts of wire.

Chapter 8 _ Space Closure ◄◄ 423

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

CD Excessive linguoversion of maxillary incisors.

(2) Excessive extrusion of maxillary incisors.

To prevent the above:

a. Use the SWA appliance that has crown labial torque on the four maxillary incisors.
b. The appliance should be carefully extended to the maxillary second molars. In doing so,
the upper occlusal plane must be checked and controlled.
c. Do not retract the canines excessively as they can come into contact with the second
premolars.
d. Do not retract the canines by giving force directly from the maxillary mini-implant.
e. To close the space of the four maxillary incisors, it is desirable to trigger the intrusion of
those teeth by applying the additional crown labial torque to the maxillary archwire, and
by providing 1mm step between the lateral incisor and the canine (Fig. 8-18).
f. In the first month of treatment, keep the combination loop deactivated until the next visit.
When activating, slight activation is desirable, as excessive force may aggravate the
extrusion and linguoversion of incisors.

►► F ig . 8 -1 8 R etraction of fo ur m axillary
incisors.
A. U se th e S W A b ra c k e ts on th e fo u r
maxillary incisors.
B. Space closing with the consideration of
upper occlusal plane: do not extend the
appliances to the second molars.
C. Avoid the excessive retraction of maxillary
canines.
D. Use the main archwire that has crown
labial torque in the anterior area.
E. 1mm step should be applied between
the lateral incisor and the canine.

424» Chapter 8 _ Space Closure • ® © ©

 • @ ® •

Space Closing Archwire

Orthodontic archwire size

(1) .016” stainless steel archwire,

(2) .018” stainless steel archwire,
(3) .016” x .022” stainless steel archwire.

(P4) Orthodontic archwire for space closure in the maxilla

(1) .016” stainless steel archwire

CD This is an orthodontic archwire used to retract maxillary canines.

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

(2) .016” x .022” stainless steel archwire (Combination loop with step)

© This is an orthodontic archwire used to retract the four maxillary incisors.

(2) Apply the crown labial torque to the maxillary incisors.
© De-torque the maxillary canines to give the -7° inclination to them.
0 1mm step is given for the intrusion of the four incisors.
© First, apply only the intrusive force, and then perform the loop activation in the patient’s
next visit.
© By doing so, the anterior and posterior teeth move to a similar extent and the extraction
space is closed as a result.

Chapter 8 _ Space Closure ◄◄ 425

 Orthodontic archwire for space closure in the mandible

(1) .018” stainless steel archwire (Shoe-hook)

(D This is an orthodontic archwire used for the retraction of the six or eight mandibular
incisors.
© Place the loop between the mandibular lateral incisors and the canines.
© The archwire is used when there are severe proclined mandibular incisors.
0 Space closure is done through a sliding mechanism, which uses the elastics or the energy
chain from the loop to the terminal teeth.
0 The 1/4” 6oz elastics must be used for the first molars, while the 5/16” 6oz elastics must be
used for the second molars
© By doing so, more retraction of the anterior teeth (when compared with the posterior teeth)
is made to close the extraction space.
© When the mandibular incisors are severely retroclined (severe linguoversion), the .016”
x .022” ideal archwire must be used to close the space.

(2) .016” x .022” stainless steel archwire (ideal archwire with hook)

© This is an orthodontic archwire used to close the posterior space of the six or eight
mandibular incisors.
© Apply the crown labial torque to the mandibular anterior teeth.
© De-torque the mandibular canines to give the -7° inclination to them.
0 Place the hook in between the mandibular lateral incisors and the canines.
© A sliding mechanism, which uses elastics or energy chain, can be conducted to close the
space from the loop to the terminal teeth.
© The 1/4” 6oz elastics must be used for the first molars, while the 5/16” 6oz elastics must be
used for the second molars.
© By doing so, more protraction of the posterior teeth (when compared with the anterior teeth)
is made to close the extraction space.

426 ►► Chapter 8 _ Space Closure # ® • •

 • © • it

(3) .016” x .022” stainless steel archwire (Combination loop)

(D This is an orthodontic archwire used to close the posterior space of the six or eight
mandibular teeth.
© Apply the crown labial torque to the mandibular incisors.
© De-torque the mandibular canines to give the -7° inclination to them. •
© Give a 30° gable bends to the loop of anterior and posterior wires.
© It is used when there is minor curve of Spee.
© If the teeth collapse toward the extraction space, the 3/16” 6oz elastics can be used to close
the space between the maxillary canines and the mandibular loop.
© By doing so, the space is closed with a similar amount of contribution from the anterior and
posterior teeth while maintaining the root parallelism.

Summary of space closure (Fig. 8-19)

►► F ig . 8-1 9 Procedures of space closure.

Chapter 8 _ Space Closure «◄ 427

 (1) After leveling the maxillary and mandibular teeth, retract the maxillary
canines first.

The maxillary canines should be moved until a Class I canine relationship is achieved.
Only a certain amount of mandibular canine movement is required to solve anterior crowding.
Here, if there are any signs of Class II canine relationship, the mandibular canines should start
moving after the maxillary canines have moved.

(2) Extraction space closure in the mandible

® When there are severely proclined mandibular incisors, the .018” shoe-hook must be used to
close the space. If the incisors are uprighted and lingually tilted during the procedure, the
archwire should be changed to the .016” x .022” ideal archwire with hook to complete space
closure.
(2) If the mandibular incisors are normally inclined, the .016” x .022” ideal archwire with hook
should be used to close the space.

(3) Retraction of maxillary incisors (after the Class I canine relationship is

achieved)

Retract the canines after inserting the combination loop archwire in between the lateral incisors
and the canines.

-leveling after space closure

If the appliances are extended to the maxillary and mandibular first molars and the

space is closed, it is essential to extend the appliances to the mandibular second

molars before the final stage of treatment. Here, it is important to consider the arch

form and move the teeth individually in the final stage.

428» Chapter 8 _ Space Closure

• • • •
 • • • •

Anchorage

©
Minimum anchorage (Fig. 8-20)
:o

►► F ig . 8-20 Minimum anchorage.

This means closing more than 3/4 of the space by protracting the posterior teeth.
The methods are as follows:

(1) .016” x .022” ideal archwire with hook + Class I elastics (1/4” 6oz or 5/16” 6oz, Fig. 8-21 A):
protraction of posterior teeth can be achieved more than the retraction of anterior teeth, if
the crown labial torque is applied to the anterior part of archwire.
(2) Maxillary combination loop + mandibular MEAW + short Class III elastics (Fig. 8-21 B):
In cases of maxillary premolar extraction only, the extraction space can be closed by using
the maxillary combination loop and Class III elastics to move the maxillary molars
forward. This is also a space closing method which is used when there is severe mandibular
curve of Spee and when maxillary incisors are protruded as well. Additionally, depending
on the canine relationship, this method can be used again, if there is a lack of space for
mandibular incisors in closing the maxillary space. Here, if there is severe curve of Spee,
the combination of MEAW with tip- back bends and short Class III elastics can be used to
trigger the retraction of mandibular dentition and protraction of maxillary molars, thereby
raise occlusion eventually.

Chapter 8 _ Space Closure «◄ 429

 (3) Second premolar extraction (Fig. 8-21 C): when the second premolars are extracted,
posterior teeth can be protracted more than when the first premolars are extracted.
(4) Maxillary MEAW + mandibular combination loop + short Class II elastics: This is one of
the methods that is applicable in theory, but not commonly used in actual clinical cases.

►► Fig. 8-21 Methods to obtain minimum anchorage.

A. .016” x .022” ideal archwire with Class I elastics or power chain.
B. Maxillary combination loop + mandibular MEAW + short Class III elastics.
C. Extraction of second premolars.

43 0 ►► Chapter 8 _ Space Closure

• • ® •
 ® @ • ©

Maximum anchorage (Fig. 8-22)

This means closing 1/4 of the space by protracting the posterior teeth. This method is used most
frequently. ©
€

►► Fig. 8-22 Maximum anchorage.

In the maxillary dentition (Fig. 8-23):

(1) First, retract the maxillary canines only;
(2) Next, retract the four maxillary incisors by using the combination loop.

►► Fig. 8 -2 3 Methods to obtain the maximum anchorage in the maxilla:

A. Retract the maxillary canines first.
B. Use the combination loop for the retraction of the four maxillary inciosrs.

Chapter 8 _ Space Closure ◄◄ 431

 In the mandibular dentition (Fig. 8-24)
(1) Close the space by using the .018” stainless steel archwire with shoe-hook + Class I elastics
(1/4” 6oz or 5/16” 6oz).

►► Fig. 8 -2 4 Methods to obtain the maximum anchorage in the mandible.

Use the round archwire (.018” shoe-hook) for maximum retraction of the mandibular incisors.

Moderate anchorage (Fig. 8-25)

This means closing more than 1/4 and less than 1/2 of space by protracting the posterior teeth.
Here, the .016” x .022” combination loop is frequently used (Fig. 8-26).

►► Fig. 8 -2 5 Moderate anchorage.

►* Fig. 8 -2 6 Methods to obtain moderate anchorage.

A. Combination loop. B. Intraoral photograph of combination loop.

432 ►► Chapter 8 _ Space Closure

• 9 #•
 • • • #

'
( ^ ) Absolute anchorage (Fig. 8-27)

This is the process of space closure that is achieved by restricting the protraction of posterior teeth.
The mini-implant is used for this process; however, if the mini-implant is used to solve a protrusive
profile, and only the anterior retraction is permitted with the posterior protraction restricted, the
following problems may occur.

▼A-1 ▼A-2

►► Fig. 8 -2 7 Absolute anchorage.

A. Retraction of anterior teeth by using the mini-implant.
B, C, D. Clinical uses of the mini-implant.

Chapter Space Closure 4 4 433

 1) Cases with a normal posterior occlusal plane (Fig. 8-28)

To complete the treatment on the existing occlusal plane, a precise adjustment of the inclination
and angulation of the maxillary central incisors is required. Even after this is done, there may be no
changes in the molar area, and there may also be a high possibility of forming a U-shape arch form
after space closure.

►^ F ig . 8 -2 8 Case with a normal posterior occlusal plane (POP).

A. Tooth movement pattern when the POP is maintained: the intrusion of mandibular incisors
and the lingual inclination and extrusion of maxillary incisors inevitably occur.
B. Tooth movement pattern when the POP is changed: the lingual inclination and the extrusion
of maxillary incisors can be minimized by protracting and uprighting the mandibular molars.

2) Cases with a steep posterior occlusal plane (Fig. 8-29)

If the space is closed while maintaining the POP, severe lingual inclination and extrusion of
maxillary incisors can occur and the curve of Spee can still remain even after the treatment is
finished.

4 3 4 -- Chapter 8 _ Space Closure ®9 • •

 • • • •

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

►► F ig . 8 -2 9 Case with a steep posterior occlusal plane (POP).

A. Tooth movement pattern when the POP is maintained: the intrusion of mandibular incisors
and the severe lingual inclination and extrusion of maxillary incisors inevitably occur.
B. Tooth movement pattern when the POP is changed: the change of POP not only facilitates
aesthetic improvement but also prevents the linguoversion and extrusion of maxillary
incisors.

Chapter 8 _ Space Closure ◄« 435

 É=
1

4 Retrusive Control in Clinical Orthodontics

$ Definition

This refers to the posterior disclusion guided by the contact between the inner incline of the palatal
cusp of the maxillary first premolar and that of the buccal cusp of the mandibular first premolar.
This can prevent the retrusive positioning of condyle and mandibular dentition (Fig. 8-30).

►► Fig. 8-30 Retrusive control in clinical orthodontics.

A. In closing the mandible, retrusion of the mandible can
be prevented by the contact in the m axillary and
mandibular first premolar areas.
m B. The m andiblular protraction becomes possible by
making contact in the maxillary and mandibular first
» premolar areas.
C . The lingual cusp of the maxillary first premolar should
come into contact with the distal marginal ridge of the
mandibular first premolar.
D. The buccal cusp of the mandibular first premolar should
come into contact with the mesial marginal ridge of the
maxillary first premolar.
E. The buccal cusp of the mandibular first premolar should
be separated from the mesial inner incline of palatal
cusp of the maxillary first premolar, after the contact.

436 » Chapter 8 _ Space Closure

• ® ® •
 • • • •

Significance

1) In cases of temporomandibular joint disorder (TMD) patients, the posterior condylar

displacement can be prevented. If the retrusive control is lost, the symptoms of TMD may be
aggravated due to the posterior condylar displacement. Due to this, the muscles and ligaments
will keep exerting a forward force, and as a result, problems of loosened ligaments and a
variety of muscle diseases can occur (Fig. 8-31).
2) In Class I and II high angle malocclusion or extraction cases, it is important to prevent
mandibular retrusion. Premolar extraction is common in high angle cases. These high angle
cases show a tendency for mandibular retrusion. However, in premolar extraction cases, for
aesthetic reasons, if the proper mechanisms are not applied, the mandible will move in the
posterior direction. In this situation, in order to finish the treatment, the maxillary incisors
should be severely lingually inclined or extruded inevitably. Here, what controls the
mandibular retrusion is the lingual cusp of maxillary first premolar or second premolar
(maxillary first premolar extraction case).

►► Fig. 8-31 Cranio-mandibular system and

occlusion: in Class I and II high angle
m alocclusion or extraction cases, it is
important to prevent mandibular retrusion.

Chapter 8 _ Space Closure « ◄ 437

 Application

1) Options for extraction

►► Fig. 8-32 Considerations in selecting the

extraction options.
A. Canine relationship : Class I key.
B. Premolar relationship : retrusive control.

(1) Extraction of maxillary first premolars and maxillary second premolars

When extracting the maxillary second premolars, since the movement of the palatal cusp of the
first premolar cannot be easily obtained, the extraction space is likely to relapse. Therefore, if
the maxillary second premolars are not too small compared to the first premolars, it is more
desirable to extract the maxillary first premolars. In particular, when there is pneumatization of
the maxillary sinus, the maxillary first premolars should be extracted.

(2) E xtraction of m a n d ib u la r firs t prem olars and m a n d ib u la r second

premolars

The mandibular first premolars can be extracted if there is a Class I molar relationship, a flat
curve of Spee, and if there is a normal posterior occlusal plane (15° or less). However, in most
cases (except the aforementioned), it is more desirable to extract the mandibular second
premolars. By doing so, it is possible to upright the anteriorly tilted mandibular first premolars
and move the mandibular dentition posteriorly in successfully closing the extraction space.
Here, the maxillary extraction space is closed not only by the retraction of anterior teeth but
also by the protraction of posterior teeth. Therefore, retrusion of the mandible can be
prevented, by making contact between the maxillary second premolars and the mandibular first
premolars. In different cases, such as maxillary and mandibular first premolar extraction cases,

438» Chapter 8 _ Space Closure • © • •

 • • • •

it is recommended to close the extraction space while maintaining the normal relationship
between the maxillary and mandibular second premolars. To do this, the mandibular second
premolars should be placed more anteriorly in comparison to the maxillary second premolars.

2) Strategic bonding •
«
(1) Non-extraction cases •

When conducting strategic bonding, open coil springs are used to solve problems arising from
the mandibular incisor crowding. Here, it is important to be cautious of the posterior movement
of the mandibular premolars. When the mandibular premolars move posteriorly, the mandible
becomes more retruded, thereby increasing the possibility of taking an extraction treatment
approach. This means that, in general, it is more desirable to move the teeth in a way that
permits the retraction of maxillary premolars and the protraction of mandibular premolars. To
achieve this, it is possible to use open coil springs in the mandibular posterior area and check
the anterior tilting of premolars. Here, if the tilting is observed, it is possible to use open coil
springs after applying the crown lingual torque to the anterior part of the mandibular archwire.
Here, if there is a severe overjet or midline deviation in Class II sub-division cases, the twin
block appliance, which first facilitates the mandibular forward movement, can be used. This
can prevent mandibular retrusion, and a non-extraction treatment can be applied by uprighting
the mesial angulation of mandibular premolars. Also, if there are lingually angulated maxillary
premolars, it is recommended to use maxillary expansion appliances to buccally upright those
teeth.

(2) Extraction cases (Fig. 8-33)

© Maxillary and mandibular first premolar extraction

It is desirable to close the space while maintaining the maxillary and mandibular second
premolar relationship. To achieve this, it is recommended to place the mandibular second
premolars slightly more to the anterior direction in comparison to the maxillary second
premolars.

Chapter 8 _ Space Closure « ◄ 439

 (D Maxillary first and mandibular second premolar extraction.
Closing the extraction space can bring about the distal movement of mandibular dentition.
The maxillary extraction space can, however, be closed not only by the retraction of
anterior teeth but also by the protraction of posterior teeth. This facilitates the contact
between the mandibular first premolars and the maxillary second premolars, and prevents
the retrusion of the mandible.

© Maxillary and mandibular second premolar extraction

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

►V Fig. 8 -3 3 Selection of extraction options.

A. Extraction of the maxillary and mandibular first premolars.
B. Extraction of the maxillary first premolars and the mandibular second premolars.

440 > Chapter 8 _ Space Closure

• • © •
3) Space closure

(1) Space closure while maintaining retrusive control (Fig. 8-34 A)

Since retrusive control is maintained during treatment, the mandible is less likely to retrude.
Here, the mesial tilting of molars can cause a minor midline deviation and curve of Spee.
Nevertheless, this can be corrected during the finishing stages of treatment.

(2) Space closure without maintaining retrusive control (Fig. 8-34 B)

This occurs mostly when the focus is only on closing the extraction space. In particular, when
there is a lack of retrusive control and the molars are anteriorly angulated, the mandible gets
more posteriorly placed as a consequence. If there is a full cusp Class II tendency even after
space closure is completed, the entire treatment procedure can become very complicated. Just
at this moment, many orthodontists think of using MEAW; in this case, in order to complete
the treatment, the occlusal plane should become steeper than the existing condition before the
mandible becomes more posteriorly placed. For these reasons, it is not desirable to use MEAW
under these circumstances.

►► Fig. 8 -3 4 Space closure in consideration of retrusive control.

A. Closing the space while maintaining retrusive control.
B. Closing the space without maintaining retrusive control (right premolar site).

Chapter 8 _ Space Closure ◄◄ 441

 4) Finishing (Fig. 8-35)

If the premolars are extracted, the finishing phase may become a lot more complicated after
closing the extraction space. In this instance, the mandible gets retruded while a Class I canine
relationship is maintained. Here, it is recommended to check the maxillary premolar occlusion by
using articulating paper. If the palatal cusp of the maxillary premolar does not occlude with the
opposing tooth, add flowable resin (3M) to the cusp to secure occlusion.

A-1 ►

f\-2>

B -1 ^

<'■>

B-2>

►► Fig. 8-35 Retrusive control in the finishing stages of treatment.

A. Pre-treatment intraoral photographs.
B. Intraoral photographs in the finishing stage.
C. Flowable resin (3M).
C►

442 ►► Chapter 8 _ Space Closure

• • • •
 • • • •

D-1 ►

D-2i>

E -U >

►► Fig. 8 -3 5 (c o n tin u e d ) Retrusive control in the finishing stages of treatment.

D. A resin is added to the palatal cusp of the maxillary right second premolar and the buccal cusp of the
right mandibular first premolar.
E. Post-treatment intraoral photographs.
F. Comparison of the pre-, mid- and post-treatment photographs of the maxillary occlusal surface.

Chapter 8 _ Space Closure ◄◄ 443

 \ Th . significance of the first premolar in occlusal reconstruction
W hen the MEAW appliance is used to treat malocclusion, It is more efficient to

reconstruct the occlusion based on the premolars. The reasons are as follows:

1) The premolars are more prone to under-occlusion.

2) They can be a point of reconstructing the occlusal plane.

3) They are positioned at the center of antero-posterior dentition in reconstructing

the occlusion.
4) Masticatory muscle activity has little influence on occlusal reconstruction.

5) They are the farthest molars (the ones that determine the mandibular posture)

from the temporomandibular joint.

6) They have a role in posterior guidance.

444 ►► Chapter 8 _ Space Closure • • m @

 ® « © ©

5 Archwire Fabrication for Space Closure

(1) Mandibular .016” x .022” ideal archwire with hook.

(2) Mandibular .018” shoe-hook.
(3) Maxillary .016” x .022” combination loop for the retraction of incisors.

1) .016” X.022” Ideal archwire (IA) with hook

(1) Basic form

This is an orthodontic archwire that has an anterior crown labial torque and adds the hooks
between the lateral incisors and the canines (Fig. 8-36).

(2) Purpose

It is an orthodontic archwire with elastics or energy chain, which closes the mandibular space.
Comparison of archwires:
(D .016” x .022” L-loop: it has the same effects as the above archwire but requires loop
bending.
(2) Preformed ideal archwire with mini-implant: To restrict anterior retraction and to
facilitate molar protraction, the mini-implant is used in the anterior area. Here, caution is
needed because an anterior implant can steepen the mandibular posterior occlusal plane.

Chapter 8 _ Space Closure « ◄ 445

 (3) Indication

It is used to close the space when the mandibular incisors are uprighted or retroclined (IMPA:
95 or less).

(4) Expected effect

It is expected to triggers molar protraction rather than anterior retraction.

(5) Bending procedure (Fig. 8-37)

© On each case, provide a different amount of crown labial torque (+7°,+ 10°, or +13°) and
form an anterior curvature to the anterior teeth by using the arch turret.
a. +7° crown labial torque: used when the mandibular incisors are proclined.
b. +10° crown labial torque: used when the mandibular incisors have normal inclination.
c. +13° crown labial torque: used when the mandibular incisors are retroclined.
When the -5° crown lingual torque brackets are used along with the zero-torque
preformed archwire, the mandibular incisors are likely to be severely retroclined.
Therefore, it is recommended to use the zero-torque brackets on mandibular incisors.
© Mark a spot between the lateral incisor and the canine.
© -7° de-torque is applied to the canine area.
© An arch form is made.
© The hook is attached to the marked point by using the crimpable hook pliers. Here, the hook
must be positioned mesio-gingivally.

►► Fig. 8 -3 7 Fabrication of the

Ideal archwire (IA) with hook.
A. Insert the center of .016”
x .022” archwire into the 7°
turret slot.
B. Rotate the turret to make
an anterior curvature.
C. Arc-shaped anterior curvature.
D. Crown labial torque.

446 ►► Chapter 8 _ Space Closure i: G i G

 • • • «

►► Fig. 8 -3 7 (c o n tin u e d ) Fabrication of the Ideal archwire (IA) with hook

▼E-1 ▼E-2 ▼F

▼G ▼H-1 ▼H-2

E. After checking the labial torque, mark the midpoint of the anterior arch.
F. After matching the mid-points of the archwire and the dentition, mark the points between the lateral
incisors and the canines.
G. De-torque up to -7° from the marked point.
H. De-torque from the contra-lateral point in the same way.

I►

I. Attach the crimpable hooks to the marked point.

J. Adjust the dental arch form.
K. A completed ideal archwire with hook.

Chapter Space Closure ◄◄ 4 4 7

 (6) Activation

© Mandibular second molar to the hook: 5/16” 6oz elastics

(D Mandibular first molar to the hook: first, use the 1/4” 6oz elastics, and then substitute them
with the 3/16” 6oz ones.
(D Mandibular first and second molar to the hook: energy chain

2) .018” shoe-hook

(1) Basic form

This is an orthodontic archwire with L-loops between the lateral incisors and the canines (Fig.
8-38).

►► F ig . 8 -3 8 .018” shoe-hook.
A. Basic form of shoe-hook.
B. Intraoral photographs.

448 ►► Chapter 8 _ Space Closure

• • © •
 • • # •

(2) Purpose

It is an orthodontic archwire with elastics or energy chain, which closes the mandibular
extraction space.
Comparison of archwires:
CD .018” archwire: when elastics or energy chain are used directly from the first or second
molars to the mandibular canines, the space is likely to be secured between the lateral
incisors and the canines.
(2) Preformed ideal archwire with hook : when it is used on the labially tilted mandibular
canines, molar protraction can occur more frequently than incisor retraction.

(3) Indication

When the mandibular incisors show labial inclination (IMPA: 95 or more), this wire should be
used for the purpose of closing space and uprighting the mandibular incisors. After uprighting
the mandibular incisors to a certain extent, substitute it with the .016” x.022” ideal archwire
with hook and close the remaining space.

(4) Activation

CD Mandibular second molar to the loop: 5/16” 6oz elastics.

(2) Mandibular first molar to the loop: 1/4” 6oz elastics are used first, and then substitute them
with the 3/16” 6oz ones.
© Mandibular first and second molar to the loop: energy chain.

(5) Bending method (Fig. 8-39)

CD Form an anterior curvature to the anterior teeth.

(2) Mark the mid-point.
© Mark the contact points between the lateral incisors and the canines.
© Bend the L-loop.
© Bend the L-loop in the opposite area.
© Adjust the arch form.

Chapter 8 _ Space Closure •«◄ 449

 ►► Fig. 8 -3 9 Fabrication of .018” shoe-hook.

A. After matching the mid-points of the archwire and the dentition, mark the points between the lateral
incisors and the canines.
B. Hold the marked point with the rectangular beak of Kim pliers and bend it to form a right angle.
C. Move the beak 3mm away from the bent point and bend it to form a right angle again with a rectangular
beak, so that it becomes parallel to the main archwire.
D. Reposition the pliers 3mm away from the second bent point (C). Then, hold the wire with the first
(narrowest diameter) round beak and bend it approximately 135°.
E. Move the pliers to the apex of the horizontal loop and bend it round so that the rest of the wire becomes
parallel to the main archwire.

▼F ▼G ▼H

F. Place the round beak inside the loop and bend it 45°.
G. Move the beak slightly to the bent point and bend it again until the wire contacts the first bent point (B).
H. Hold the vertical portions with the rectangular beak and bend the wire to a right angle to form a straight
line.
I. Do the same in the contra-lateral side.
J. A completed bilateral shoe-hook.

450 ►► Chapter 8 _ Space Closure

• @ • •
 • • • •

3) .016” x .022” combination loop with step

(1) Basic form

This is an orthodontic archwire used to efficiently close the space by providing vertical and
horizontal loops (Fig. 8-40).

►V Fig. 8 -4 0 .016” x .022” combination loop with step.

(2) Purpose

It is an orthodontic archwire used to retract the four maxillary incisors. It can control the
uprighting and extrusion of maxillary incisors that frequently arise during space closure.

0 Prevention of the uprighting of maxillary incisors

a. SWA brackets are used for the four maxillary incisors (bracket with +12° torque for
maxillary central incisors, +8° torque for maxillary lateral incisors).
b. The additional crown labial torque (+7°, +10°, or +13°) is applied to the orthodontic
arch wire.
• +7° crown labial torque: used when the maxillary incisors are proclined.
• +10° crown labial torque: used when the maxillary incisors have normal inclination.
• +13° crown labial torque: used when the maxillary incisors are retroclined.

Chapter 8 _ Space Closure «◄ 4 F ) 1

 (D Prevention of the extrusion of maxillary incisors
Provide the intrusion step to the maxillary incisor area. To achieve this, a loop should be
efficiently used to lower the load-deflection rate (LDR). For the first month, trigger the
incisor intrusion, and then activate the loop from the next month.

Comparison of archwires:
a. .016” x .022” L-loop
• An excessive force can be applied to the incisors when intruding the maxillary
incisors.
• Activation amount is difficult to measure objectively.
b. Preformed keyhole, T-loop, and tear-drop loop
• Since these wires have zero-degree torque, there is a greater possibility of
linguoversion of the incisors.

(3) Bending procedure (Fig. 8-41,42)

(D Anterior curvature is formed by using an arch turret.

a. +7° crown labial torque: used when the maxillary incisors are proclined.
b. +10° crown labial torque: used when the maxillary incisors have normal inclination.
c. +13° crown labial torque: used when the maxillary incisors are retroclined.
(2) Mark the loop position 2mm distal to the maxillary lateral incisor brackets. Bend the mark
point with a rectangular beak of Kim pliers.
(3) Bend it again with a round beak of Kim pliers 8~10mm away from the bent point.
® Bend it again with a rectangular beak of Kim pliers 3mm away from the bent point until it
becomes parallel to the main archwire.
(5) Bend it again with a round beak of Kim pliers right beside the bent point until it becomes
parallel to the main archwire.
© Give 1mm step to the wire so that it provides intrusion in the anterior area.
• (7) Make sure that -7° crown lingual torque is applied in the posterior area.
When seen from the front, the anterior part and the two posterior parts of the archwire
should be parallel to one another (Fig. 8-41,42).
© The posterior parts of the archwire are bent to form an ideal arch shape.

452 ►► Chapter 8 _ Space Closure m• • •

 • • • •

CV

►► Fig. 8-41 Fabrication of .016” x .022” combination loop with step.

►► Fig. 8 -4 2 Fabrication of .016” x .022” combination loop with step.

A. Insert the .016” x .022” stainless steel archwire into the 7° slot of turret.
B. Make a curve by rotating the turret bilaterally.
C. Shaped anterior arch form.

D. Mark the mid-point on the archwire.

E. Make sure that the crown labial torque is embedded, and then overlap the marked point to the dental
midpoint. Finally, mark the points between the lateral incisors and the canines.

Chapter 8 _ Space Closure 453

 ►► Fig. 8 -4 2 (c o n tin u e d ) Fabrication of .016” x .022” combination loop with step.

▼F-1 ▼F-2 ▼F-3

F. Hold the marked point with a rectangular beak of Kim pliers and bend it to form a right angle.

▼G-1 ▼G-2 t H

G. Move 10mm upward, then hold the plier and form a loop so that the first round beak faces the gingiva
from the first bent point. Then bend the wire approximately 135°.
H. Move the round beak to the apex of the loop and then bend it until it becomes parallel to the vertical leg.

▼ 1-1 ▼I-2 ▼I-3

I. Move the beak 3mm away from the loop apex and bend it until it forms a right angle to the rectangular
beak, and until it becomes parallel to the main archwire.

J. Move the beak 3mm away from the last bent point and bend it 135°
into a round loop.
K. Move the pliers to the apex of the horizontal loop and bend it until it
becomes parallel to the rest of the wire.

454 ►► Chapter 8 _ Space Closure

# « • •
 mm®®

►► Fig. 8 -4 2 (c o n tin u e d ) Fabrication of .016” x .022” combination loop with step.

L. Use Kim pliers to form a loop that is the same as the vertical loop,
and bend it until it forms a right angle.

M. Bend the wire to make a right angle, while making 1mm step.

▼N ▼O

N. Bend the opposite side in the same way.

O. Fabricated combination loop.

P. Adjust the arch shape.

Chapter 8 _ Space Closure < ◄ 455

 ►► Fig. 8 -4 2 (c o n tin u e d ) Fabrication of .016” x .022” combination loop with step.

Q. Adjust the loop shape and do not impinge the gingiva.

S. A completed combination loop.

(4) Activation (Fig. 8-43)

CD Clinically, the posterior wire is moved distally until both of the vertical loop legs are
overlapped with each other. Then, do the cinch back afterwards.
(2) When the posterior part of archwire is pulled forward, the archwire should not be moved.
© When the combination loop is used for the maxillary arch, four incisors are ligated with the
figure of 8 tie.

456 ►► Chapter 8 _ Space Closure • • « ©

 i© # & ©■

►► Fig. 8 -4 3 Activation of .016” x .022” combination loop with step. •

© Cautions in using the combination loop (Fig. 8-44)

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

▼A ▼b ▼c

►► Fig. 8 -4 4 Cautions in using the combination loop.

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

Chapter 8 _ Space Closure ◄◄ 457

 nical Tips: the combination loop
1. Make sure that the loop is not impinging the lip or gingiva.

2. If possible, place the loop at the distal side of the lateral incisor bracket.

3. Make sure that both anterior and posterior wire parts are parallel to one another.

4. It is undesirable to apply an excessive force when retracting. ►

(5) Premolar extraction strategy can be summarized as follows:

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

458 ►► Chapter 8 _ Space Closure ® • • •

 • • © •

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

►► F ig . 8 -4 5 The maxillary first premolar extraction method.

A. If there is no anterior crowding, bond the brackets on all the teeth except the first molars.
B. Tooth movement towards the ideal arch form.
C. Use the open coil springs in the first molar area for the parallel rotation of the mesially rotated
maxillary second molars. After this, if there is a mesially rotated first molar, bond the brackets and
apply the energy chain with a light force on the first and second molars to facilitate the de-rotation.
D. Before retracting the maxillary canines, the first molars must be in a parallel relationship.
E. Use the energy chain on the first molars to retract the maxillary canines. After obtaining the Class I
relationship with the mandibular canines, the combination loop must be used to retract the four
maxillary anterior teeth. Here, the maxillary canines are retracted within the archwire.
F. Re-leveling after the space closure.
G. Comparison of the pre- and post-treatment maxillary arch in the maxillary first premolar extraction case.

Chapter 8 _ Space Closure 459

 ►^ F ig . 8 -4 6 The mandibular first premolar extraction method.
A. If there is no anterior crowding, bond the brackets on all the teeth
except the first molars.
B. Use the open coil springs in the first molar area for the parallel
rotation and uprighting of mesially tilted and rotated mandibular
second molars.
C. Bond the brackets on the mandibular first molars.
D. Space closure in consideration of the relationship with the
maxillary teeth.
E. Comparison of pre- and post-treatment mandibular arch in the
mandibular first premolar extraction case.
t
©

460 ►► Chapter 8 _ Space Closure

 • • • •

(7) The maxillary first premolar and mandibular second premolar extraction method (Fig. 8-47, 48)
a. Bond the brackets on all the teeth except for the mandibular canines and second molars.
b. Use the open coil springs in the canine area to upright the mesially tilted first premolars.
c. After uprighting the first premolars and decrowding the anterior teeth, bond the brackets
on the canines and do the re-leveling.
d. Space closure.
e. Adjust the arch form after bonding the tubes on the second molars.

► F ig . 8 -4 7 The mandibular second premolar extraction method (tapered arch form).

A. Bond the brackets on all the teeth except for the mandibular
canines and second molars.
B. Use the open coil springs in the canine area to upright the mesially
tilted first premolars.
C. Bond the brackets on the canines and do the levelling after
uprighting the first premolars and solving the anterior crowding
problem.

Chapter 8 _ Space Closure < ◄ 461

 ►► Fig. 8 -4 7 (c o n tin u e d ) The mandibular second premolar extraction method (tapered arch form).

Pre-treatment
Post-treatment

D. Space closure.
E. Leveling and alignment after bonding the tubes on the second
molars.
F. Comparison of pre- and post-treatment mandibular arch in the
mandibular second premolar extraction case.

462 ►► Chapter 8 _ Space Closure ® @ • •

 # ® # •

►► F ig. 8 -4 8 The mandibular second premolar extraction method (square arch form).
A. Bond the brackets on all the teeth except for the mandibular canines and second molars.
B. Use the open coil springs in the canine area to upright the mesially tilted first premolars.
C. Bond the brackets on the canines and do the leveling after uprighting the first premolars and solving
the crowding problem.
D. Space closure.
E. Leveling and alignment after bonding the tubes on the second molars.
F. Comparison of pre- and post-treatment mandibular arch in the mandibular second premolar extraction
case.

Chapter Space Closure ◄◄ 463

 REFERENCES

1. Badawi H, et al. Three dimensional orthodontic force measurements. Am J Orthod Dentofacial Orthop
136:518-528, 2009.
2. Begg R. Orthodontic theory and technique. 3rd ed. Philadelphia: WB Saunders, 1977.
3. Bennett JC, and McLaughlin RP. Orthodontic management of the dentition with the preadjusted
appliance. Isis Medical Media, 1997.
4. Booth FA. MS Thesis: Optimum forces with orthodontic loops. Houston, University of Texas Dental
Branch, 1971.
5. Braun S, Sjursen RC, and Legan HL. On the management of extraction sites. Am J Orthod
Dentofacial Orthop 112:645-655, 1997.
6. Byloff KF, and Darendeliler MA. Distal molar movement using the pendulum appliance. Part*00,
Clinical and radiological evaluation. Angle Orthod 67:249-260, 1997.
7. Byloff KF, and Darendeliler MA. Distal molar movement using the pendulum appliance. Part I I , The
effects of maxillary molar root uprighting bends. Angle Orthod 64:261-270, 1997.
8. Daskalogiannakis J, and Ammann, A. Glossary of orthodontic terms, Quintessence, 2000.
9. Eden JD, and Waters N. An investigation into the characteristics of the PG canine retraction spring.
Am J Orthod Dentofacial Orthop 105:49-60, 1994.
10. Gunduz E, Schneider-Del Savio T, Kucher G, Schneider B, and Banteleon HP. Acceptance rate of
palatal implants: A questionnaire stury. Am J Orthod Dentofacial Orthop 126:623-626, 2004.
11. Iwasaki LR, et al. Clinical ligation forces and intraoral friction during sliding on a stainless steel
archwire. Am J Orthod Dentofacial Orthop 123:408-415, 2000.
12. Joondeph DR. graber TM, Vararsdall RL, and Vig KWL, eds. Orthodontics: Current Principle and
Techniques. 4th edition. St Louise: Mosby, 2005.
13. Josell SD et al. Force degradation in elastomeric chains. Semin Orthod 3:189-197, 1997.
14. Kim Jl, Akimoto S, Shinji H, and Sato S. Importance of vertical dimension and cant of occlusal plane in
craniofacial development. Int J Stomatol Occlusion Med 2:114-121,2009.
15. Kim Jl. Practical Clinical Orthodontics. Vol 1. Orthodontic treatment with MEAW. Well publishing Inc,
2012.

• 16. Kim Jl. Practical Clinical Orthodontics. Vol 2. Orthodontic Diagnosis. Well publishing Inc, 2013.

• 17. Kim Jl. Practical Clinical Orthodontics. Vol 3. Early orthodontic treatment. Well publishing Inc, 2015.
• 18. Marcott MR. Biomechanics in Orthodontics. St Louis:CV Mosby, 1990.
19. McLaughlin RP, and Bennett JC. The extraction-nonextraction dilemma as It relates to TMD, Angle
Orthod 65:175-186, 1995.
20. Moffitt AH. Eruption and function of maxillary third molars after extraction of second molar. Angle
Orthod 68:147-152, 1998.

464- Chapter 8 _ Space Closure

• • • •
 @ ® • •

21. Nanda Ravindra. Biomechanics and Esthetic strategies in clinical orthodontics, Elsevier Saunders,
2005.
22. Northway WM. The nuts and bolts of hemisection treatment: managing congenitally missing
mandibular second premolars. Am J Orthod Dentofacial Orthop 127:606-610, 2005.
23. Proffit WR. Contemporary orthodontics. St Louis: CV Mosby company, 1986.
24. Ricketts RW, Bench RW, Gugino CF, Hilgers JJ, and Schulhof RJ. Bioprogressive Therapy.
DenvenRocky Mountain Orthodontics, 1979.
25. Rinchuse DJ, and Kandasamy S. Evidence-based versus experience-based views on occlusion and
TMD. Am J Orthod Dentofacial Orthop 127:249-254, 2005.
26. Ronay F, Kleinert W, Melsen B, and Burstone CJ. Force system developed by V bends in an elastic
orthodontic wire. Am J Orthod Dentofacial Orthop 96:295-301, 1989.
27. Roth RFH. Functional occlusion for the orthodontist. J Clin Orthod 15(1-4), 1981.
28. Scheffler NR. Patient and provider perceptions of skeletal anchorage in orthodontics. MS Thesis,
University of Northo Carolina, 2005.
29. Schwarz AM, and Gratzinger M. Removable orthodontic appliances. Philadelphia: WB Saunders,
1966.
30. Shroff B, Yoon WM, Lindauer SJ, et al. Simultaneous intrusion and retraction using a three-piece base
arch. Angle Orthod 67:455-462, 1997.
31. Siatkowski RE. Continous archwire closing loop design, optimization and verification. Part I. Am J
Orthod Dentofacial Orthop 112:393-401, 1998.
32. Siatkowski RE. Continous archwire closing loop design, optimization and verification. Part II. Am J
Orthod Dentofacial Orthop 112:484-495, 1998.
33. Stucki N, and Ingervall B. The use of the Jasper Jumper for correction of Class II malocclusion in the
young permanent dentition. Eur J Orthod 20:271-281, 1998.
34. Tenti FV. Atlas of orthodontic appliances, Caravel, 1985.
35. Thurow RC. Atlas of orthodontic principles, Mosby, 1977.
36. Tweed CH. Clinical orthodontics. Vol1 and 2. St Louis: Mosby, 1966.

Chapter 8 _ Space Closure < ◄ 465

 Chapter 9

FINISHING

............
1. Finishing Archwire
2. Multi-loop Edgewise Archwire (MEAW)
1) Composition and basic form of MEAW
2) Functions and mechanics of MEAW
3) Instruments and materials for MEAW
4) Fabrication of MEAW
5) First-, second- and third-order bends in MEAW
6) Completed MEAW
7) Heat treatment for completed MEAW
Prescription of MEAW
4. Basic Adjustment of MEAW
5. Elastics in MEAW
6. Finishing Methods for Special Conditions
1) MEAW adjustment for midline correction
2) Expansion archwires in MEAW
3) MEAW adjustments in the case of peg lateralis
7. Orthodontic Normal Occlusion
 1
Typically, stainless steel archwires, NiTi, and TMA wires are used as finishing archwires. In
MEAW, a .016” x .022” MEAW or a rectangular ideal archwire is commonly used.
(1) Archwire size: .016” x .022” stainless steel archwire
(2) Requirements
a. It must allow individual tooth movement.
b. It must be able to upright a mesially angulated tooth.
c. It must be able to control the tooth axis.
d. It must be able to adjust the occlusal plane and the vertical dimension.
e. It must be able to establish the interdigitation.
f. It must be able to move the entire dentition.
g. Three-dimensional tooth movement must be possible.
To meet the above requirements, the MEAW technique is required in various cases. However, the
MEAW has some disadvantages in that 1) it is relatively difficult to make up the MEAW, 2) the
patient’s cooperation is essential in the use of the elastics, and 3) it is difficult to maintain oral
hygiene. The following cases can be finished by using NiTi or TMA instead:

Cases that do not require individual tooth movement

(1) A case where there is no difference in the marginal ridges.

(2) A case where torque control is not required.
(3) A case where tooth axis control is not required.

-
Cases that do not require occlusal plane adjustment

(1) Flat curve of Spee

(2) Normal posterior occlusal plane (POP)
However, it is extremely rare to find cases where the above requirements are all satisfied in the
finishing stages of treatment. Therefore, MEAW is frequently used to overcome remaining
problems, and a clear understanding of MEAW is needed to do so.

468 ►► Chapter 9 _ Finishing • « @ ©

 • # © #

-dt-

Multi-loop Edgewise Archwire (MEAW)

Composition and basic form of MEAW #

►► Fig. 9-1 Basic shape of MEAW.

A. Basic shape of MEAW. B. Clinical use of MEAW.

Multi-loop edgewise archwire (MEAW) is a type of archwire that was created by Dr. Kim Young-Ho.
It has a L-shape horizontal loop (L-loop) in teeth contact areas from the distal side of lateral
incisors to the terminal molars. In general, .016” x .022” stainless steel rectangular wires are used
to construct the archwire. Here, even though the arch shape, loop length, etc. are all different
depending on the size or shape of dentition, the basic shape is the same as shown in Fig. 9-1. The
basic form of MEAW is the ideal arch that is frequently used in the final stages of the edgewise
technique. It should incorporate all of the anatomical forms of dentition. Here, the three
dimensional bends, (1) first-order bends, (2) second-order bends, and (3) third-order bends, should
all be included in the ideal arch. The following figure (Fig. 9-2) explains the horizontal loop and
the name and the action of each part or area.

(1) Horizontal loop: it reduces the vertical force and adjusts the vertical tooth movement.
(2) Vertical leg (breaker): along with the horizontal adjustment, it secures the independent
movement of an individual tooth.

Chapter 9 _ Finishing 469

 (3) Loop base: this is the part where the two perpendicularly bent angles meet with each other,
and where the tip-back bends or torque is controlled.
(4) Horizontal part of archwire: This is the part that is inserted into the bracket’s slot and
conveys the archwire force to the teeth. This part should be straight because the wires
should be slipped well into the slot in accordance with the tooth movement.

horizontal loop
►► Fig. 9-2 Basic form of L-loop.

1 '
breaker
L-loop is the basic component of MEAW
• Horizontal loop.

1
• Two separated vertical legs (breaker).
• Horizontal part of archwire.
• Base of L-loop.
/ \
horizontal part of archwire base part of loop

MEAW is 2.5-3 times longer than the normal archwire because the horizontal loop is applied to
the ideal archwire. This difference reduces the orthodontic treatment forces by 1/5 of a .016”
x .022” ideal archwire and makes it possible to apply a consistent orthodontic force to an
individual tooth as well as to the whole dentition. As a result, the ideal tooth movement occurs
simultaneously in the entire dentition due to a three dimensional wire adjustment.

( 1) By reducing the load-deflection rate (LDR), a consistent orthodontic force can be

continuously applied to the dentition.
(2 ) Although MEAW is a continuous archwire, individual tooth movement can be controlled
easily because the horizontal loop and breaker control each individual tooth separately.

• (3 ) Uprighting, extrusion, intrusion, and torque control can be done with ease.
« (4 ) The use of elastics along with the above actions can facilitate occlusal plane adjustment.
•

470» Chapter 9 _ Finishing • ® • •

 • • • •

The method of bending an L-loop is as follows (Fig. 9-3).

▼A vB t C ▼D

►► Fig. 9-3 Fabrication of L-loop.

A. Hold the marked point with the rectangular beak of Kim pliers and bend it to a right angle.
B. Move the beak 3mm away from the bent point and bend it until it is parallel to the main archwire and
perpendicular to the rectangular beak.
C. Reposition the pliers 3mm away from the second bent point and hold the wire until the first (narrowest
diameter) round beak faces the gingiva. Then, bend the wire approximately 135°.
D. Move the pliers to the apex of the horizontal loop and bend it round until the rest of the horizontal loop
is parallel to the main archwire.
E. Place the round beak inside the loop and bend 45°.
F. Move the beak slightly towards the bent point and bend it again until the wire comes into contact with
the first bent point.
G. Hold the rectangular beak in its mesial side and bend the wire until it forms a straight line.

Chapter 9 _ Finishing 471

 Functions and mechanics of MEAW (Fig. 9-4)

The basic treatment mechanics of the MEAW appliance is as follows:

(1) By uprighting the mesially tilted teeth, it is possible to gain the mesio-distal space as well
as improvements in vertical dimension and changes in the occlusal plane. This is achieved
by applying the tip-back bends. The amount of tip-back bends may vary depending on each
case, the inclination of the occlusal plane, and the treatment plan. However, in general, a
3~5° angulation is applied to each tooth and a total amount of 15-20° angulation is
applied. Here, by engaging these archwires in the entire dentition and by using the elastics
in the anterior part of dentition, the overall improvement of dentition can be achieved.
(2) To improve the arch form, secure the horizontal space by de-rotating the mesially rotated
teeth and by expanding the arch.
(3) By uprighting the bucco-lingually tilted teeth, it is possible to gain bucco-lingual space,
and to obtain an improvement in vertical dimension, an establishment in proper guidance,
and a functional occlusion.

The completed MEAW is as follows:

▼A-1 ▼A-2

►► F ig . 9 -4 Functions and mechanics of MEAW.

A. First-order bends. B. Second-order bends. C. Third-order bends.

472 ►► Chapter 9 _ Finishing • • • •

 • • • •

1) Upper MEAW

(1) By applying the tip-back bends, it is possible to give the compensating curve of Spee to the
upper arch.
(2) Give a crown labial torque (+7) ° to the anterior teeth.
(3) Give a gradual crown lingual torque from the back of canine.
(4) In the case of Class III malocclusion, a crown lingual torque (-7°) should be given to the
anterior teeth.

2) Lower MEAW

(1) By applying the tip-back bends, it is possible to give the reverse curve of Spee to the lower arch.
(2) Give a crown lingual torque (-7°) to the anterior teeth.
(3) Give a gradual crown lingual torque from the back of canine.
(4) In the case of Class III malocclusion, a crown labial torque (+7°) should be given to the
anterior teeth.
(5) In the case of Class III malocclusion and open bite malocclusion, after using the reverse curve
of Spee, it is necessary to deactivate it and apply a compensating curve of Spee.

Instruments and materials for MEAW

(1) .016” x .022” stainless steel archwire (2) Kim pliers

(3) Tweed arch forming pliers (4) Three prong pliers
(5) Arch turret (6) Marking pencil
(7) Case models

►^ F ig . 9 -5 Instruments and materials for

MEAW fabrication.
• .016” x .022” stainless steel wires.
• Kim pliers.
• Tweed arch forming pliers.
• Three prong pliers.
• Arch turret.
• Marking pencil.
• Case models.

Chapter 9 _ Finishing ◄◄ 473

 Fabrication of MEAW

1) Upper MEAW

CD Insert the center of a wire into the 7° slot of .016” arch turret (Fig. 9-6 A).
(2) Rotate the turret 90° to the left and right, and form a curved shape (Fig. 9-6 B).
(3) This is the anterior semi-circular arch shape that is curved by turreting (Fig. 9-6 C).
© Mark the center of anterior arch with crown labial torque (Fig. 9-6 D).
© Place the center of the wire on the center of dentition and mark the contact points between the
lateral incisors and the canines (Fig. 9-6 E).

►► F ig . 9-6 Fabrication of upper MEAW.

▼A ▼B ▼c

▼D-1 ▼D-2 ▼E

A. Insert the center of a wire into the 7° slot of .016” arch turret.
B. Bilaterally rotate the turret 90°.
C. Shaped anterior arch form.
D. Mark the mid-point on the archwire, while making sure that the crown labial torque is embedded.
E. Place the marked point on the dental mid-point and mark the contact points between the lateral incisors
and the canines.

474 ►► Chapter 9 _ Finishing

O - O O)
 • ® • •

© Hold the point with the rectangular beak of Kim pliers in the mesial side and bend it gingivally
until it forms a right angle (Fig. 9-6 F).
© Move the rectangular beak 3mm away from the bent point and bend the wire until it forms a
right angle, and until it becomes parallel to the main archwire (Fig. 9-6 G).
© Move the first round beak 3mm away from the bent point and bend the horizontal loop 135°
towards the gingival direction (Fig. 9-6 H).

►► Fig. 9-6 (c o n tin u e d ) Fabrication of upper MEAW.

▼F-1 ▼F-2 ▼F-3

▼F-4 ▼G-1 ▼G-2

▼H-1 ▼H-2 ▼H-3

F. Hold the point with Kim pliers and bend it until it forms a right angle.
G. Move the rectangular beak 3mm away from the bent point and bend the wire until it becomes parallel and
perpendicular to the main archwire.
FI. Move the first round beak 3mm away from the bent point and bend the horizontal loop 135° towards the
gingival side.

Chapter 9 _ Finishing «◄ 475

 © Move the round beak to the apex of the horizontal loop and bend the wire until the remaining
wire is parallel to the main archwire (Fig. 9-6 I).
® Place the round beak inside the loop and bend the wire 45° (Fig. 9-6 J).
@ Move the pliers 1mm closer to its bent point and complete the bending until the two legs are
parallel to each other, 0.5mm away from each other (Fig. 9-6 K).
® Hold the legs towards the distal direction and make sure that they are parallel to the main
archwire (Fig. 9-6 L).
© The completed first loop (Fig. 9-6 M).
@ After applying the same method to its opposite wire, the bilateral first horizontal loops are
completed (check symmetry and flatness) (Fig. 9-6 N).
© Make sure that the center of the wire is in line with the center of dentition, and then mark the
contact points between the canines and first premolars (Fig. 9-6 O).
© Apply the same method to the second loops (the length of loop should be 70% of inter-bracket
distance) (Fig. 9-6 P).

►► Fig. 9-6 (c o n tin u e d ) Fabrication of upper MEAW.

▼I ▼J ▼K

I. By moving the round beak to the apex of the horizontal loop and by bending the wire around the beak, it
becomes parallel to the main archwire.
J. Locate the round beak inside the loop and bend it 45°.
K. Move the beak slightly towards the bent point and bend it again until the wire comes into contact with the
first bent point.
L. Place the rectangular beak towards the distal direction and bend the wire until it is in line with the main archwire.
M. Completed first loop.
N. Do the same on the contra-lateral side. Note the completed bilateral first loops.

476 ►► Chapter 9 _ Finishing • • • •

 • • • ©

© Completed bilateral second horizontal loops after bending the opposite wire in the same way
(Fig. 9-6, Q).
© Overlap the centers of both the wire and dentition, and mark the contact points of the first and
second premolars.
© The third loops are bent in the same way (the length of horizontal loop must be 70% of the
inter-bracket distance) (Fig. 9-6 R). •
© Overlap the centers of both the wire and dentition, and mark the contact points of the second
premolars and first molars.
© The fourth loops are bent in the same way (the length of horizontal loop must be 70% of the
inter-bracket distance) (Fig. 9-6 S).
@ Overlap the centers of both the wire and dentition, and mark the contact points of the first and
second molars.
© The fifth loops are bent in the same way (the length of horizontal loop must be 70% of the
inter-bracket distance) (Fig. 9-6 T).
© The completed upper MEAW (the inter-loop distance should be at least 2mm, and the distance
between the fourth and fifth loops should be 3-4 mm) (Fig. 9-6 U).

►► Fig. 9-6 (c o n tin u e d ) Fabrication of upper MEAW.

▼O ▼P ▼Q

▼R ▼S ▼T

O. Make sure that the center of the wire and the center of dentition are
matched, and mark the contact points between the canines and first
premolars.
P. Hold the marked point with a rectangular beak and bend it so that it
becomes perpendicular to the main wire.
Q. Same methods of first loop is applied to the second loop.
R. Third loops are fabricated in the same way.
S. Fourth loops are fabricated in the same way.
T. Fifth loops are fabricated in the same way.
U. Adjust the shape of the completed upper MEAW.

Chapter 9 _ Finishing < 4 477

 2) Lower MEAW (Fig. 9-7)

CD Insert the center of a wire into the 7° slot of .016” arch turret (Fig. 9-7 A).
(2) Rotate the turret 90° to the left and right, and form a curved shape (Fig. 9-7 B).
© This is the anterior semi-circular arch shape, which is curved through turreting (Fig. 9-7 C).
@ Mark the center of the anterior arch with crown lingual torque (Fig. 9-7 D).
© Place the center of the wire on the center of dentition, and mark the contact points of the lateral
incisors and canines (Fig. 9-7 E).
© Hold the point with the rectangular beak of Kim pliers in the mesial side and bend it gingivally
until it forms a perpendicular angle (Fig. 9-7 F).

►► F ig . 9-7 Fabrication of lower MEAW.

A. Insert the center of a wire into the 7° slot of .016” arch turret.
B. Bilaterally rotate the turret 90°.
C. Shaped anterior arch form.
® D. Mark the mid-point on the archwire and confirm that the crown lingual torque is embedded.
E. Place the marked point on the dental mid-point and mark the contact points of the lateral incisors and
canines.
F. Hold the point with Kim pliers and bend it 90°.

478 ►► Chapter 9 _ Finishing

• ® • •
 • • # •

(7) Move the rectangular beak 3mm away from the bent point and bend the wire until it forms a
right angle, parallel to the main archwire (Fig. 9-7 G).
® Move the first round beak 3mm away from the bent point and bend the horizontal loop 135° in
the gingival direction (Fig. 9-7 H).
© Move the round beak to the apex of the horizontal loop and bend the wire until the remaining is
parallel to the main archwire (Fig. 9-7 I).
® Place the round beak inside the loop and bend the wire 45° (Fig. 9-7 J).
@ Move the pliers 1mm closer to its bent point and complete the bending until the legs are parallel
to each other, 0.5mm away from each other (Fig. 9-7 K).
® Hold the legs towards the distal direction and make sure that they are in parallel to the main
archwire (Fig. 9-7 L).

►► Fig. 9-7 (c o n tin u e d ) Fabrication of lower MEAW.

▼G ▼H ▼I

G. Move the rectangular beak 3mm away from the bent point and bend the wire until it forms a right angle,
parallel to the main archwire.
H. Move the first round beak 3mm away from the bent point and bend the horizontal loop 135° towards the
gingival side.
I. Move the round beak to the apex of the horizontal loop and bend the wire until the remaining wire is
parallel to the main archwire.
J. Locate the round beak inside the loop and bend it 45°.
K. Move the beak slightly towards the bent point and bend it again until the wire comes into contact with the
first bent point.
L. Hold the rectangular beak towards the distal direction and bend the wire until it is in line with the main
archwire.

Chapter 9 _ Finishing «◄ 479

 © The completed first loop (Fig. 9-7 M).
© After applying the same method to the opposite wire, the bilateral first horizontal loops are
completed (check symmetry and flatness) (Fig. 9-7 N).
© Make sure that the center of the wire is in line with the center of dentition, and then mark the
contact points between the canines and first premolars (Fig. 9-7 O).
© Apply the same method to the second loops (the length of loop should be 70% of its inter­
bracket distance) (Fig. 9-7 P).
© Completed bilateral second horizontal loops after bending the opposite wire in the same way
(Fig. 9-7, Q).
© Overlap the centers of both the wire and dentition, and mark the contact points of the first and
second premolars (Fig. 9-7 R).

►► Fig. 9-7 (c o n tin u e d ) Fabrication of lower MEAW.

▼M ▼N ▼O

M. Completed first loop.

N. Do the same on the contra-lateral side. Note the completed bilateral first loops.
O. Place the center of the wire at the center of dentition, and then mark the contact points between the
canines and first premolars.
P. Do the same on the second loop.
Q. Do the same on the opposite side and complete the bilateral second horizontal loops.
R. Overlap the centers of both the wire and dentition, and then mark the contact points between the first and
second premolars.

480 ►► Chapter 9 _ Finishing

 • • • •

® The third loops are bent in the same way (the length of horizontal loop should be 70% of its
inter-bracket distance) (Fig. 9-7 S).
© Overlap the centers of both the wire and dentition, and then mark the contact points of the
second premolars and first molars (Fig. 9-7 T).
® The fourth loops are bent in the same way (the length of horizontal loop should be 70% of its
inter-bracket distance) (Fig. 9-7 U).
(§) Overlap the centers of both the wire and dentition, and then mark the contact points of the first
and second molars (Fig. 9-7 V).
(§) The fifth loops are bent in the same way (the length of horizontal loop should be 70% of its
inter-bracket distance) (Fig. 9-7 W).
@ The completed form of lower MEAW (inter-loop distance should be at least 2mm, and the
distance between the fourth and fifth loops should be 3-4mm) (Fig. 9-7 X).

►► Fig. 9-7 (c o n tin u e d ) Fabrication of lower MEAW.

S. Third loops are fabricated in the same way.

T. Make sure that the second premolars and the first molars are overlapped (the centers of both the wire
and dentition and mark the contact points).
U. Fourth loops are fabricated in the same way.
V. Make sure that the first and second molars are overlapped (the centers of both the wire and dentition and
mark the contact points).
W. Fifth loops are fabricated in the same way.
X. Adjust the arch form: the completed lower MEAW.

Chapter 9 _ Finishing 481

 First-, second- and third-order bends in MEAW

0 First-order bends (Fig. 9-8—10)

When the dentition is seen from an occlusal view, due to the tooth movement, it bends in
the horizontal direction. Tooth movement is motivated to match the upper passive centric
line with the lower active centric line. The lateral inset, canine eminence, and molar offset
are all included in first-order bends. To make first-order bends, the arch turret should be
used first to form an anterior arch. Here, it is important to note that the incisor torque of
both the upper and lower MEAW should be considered. Next, by considering the different
crown thickness (upper central and lateral incisors), lateral inset should be given to the
wires, and by considering the shape of lingual surfaces (lateral incisors and canines),
canine eminence should be given to the wires. Also, by considering the buccal surfaces of
the first molars, the molar offsets should be bent. Here, the pliers used for bending are
called Tweed arch forming pliers. It is notable, however, that, as in-and-out is inherently
incorporated into the KIMS bracket for individual teeth, there is no need to follow the
above procedures in the case of using KIMS bracket.

►► Fig. 9-8 Lower dental arch form.

The notable morphological feature of the lower dental arch form is that the buccal cusp tip of
first premolars and lower incisor edges are aligned with the above circle. The center of this line
is connected to the mesial contact point of the first molars. Here, the image of the dental arch is
egg-shaped (Shirasu and Sato, 2008).

482 ►► Chapter 9 _ Finishing •' ■ 6 V:

 • • • •

►► Fig. 9-9 MEAW construction guide.

A. Arch form.
B. Tip-back activation.
C. Torque.

Chapter 9 _ Finishing 4 8 3
 %

l
/ >I
Low er M EAW
f
►^ Fig. 9 -1 0 First-order bends in MEAW.
A. Make canine eminence.
B. Make an arch form from the second loop to the final loop.
C. Completed upper and lower MEAWs.

484 Chapter 9 _ Finishing

• • • #
 # • # ®

(D Second-order bends (Fig. 9-11,12)

The bends that are perpendicular to first-order bends are called second-order bends. These
are the bends that are seen from the lateral view, including mesio-distal and vertical tooth
movements. Here, the tip-back bends and step bends are all included, and they can all be
obtained by the adjustment of L-loop. The adjustment of L-loop is one of the most
fundamental operations of MEAW; the Kim pliers are used for this purpose. Tip-back
bends can be achieved by angulating the wires from the second loop with Kim pliers. In
contrast, step bends can be achieved by adjusting the length of the legs in the horizontal
loop with Kim pliers.

►► Fig. 9-11 Second-order bends

in MEAW.
A. Mesially tilted molars.
B. Uprighted molars.
C. Required tooth movement.
D. Tip-back bends.

Chapter 9 _ Finishing ◄
◄485
 ►> Fig. 9-12 Second-order bends in MEAW.

A. Flat MEAW.

▼B-1 ▼B-2

B. Tip-back activation.
A ngulate the p o ste rio r part
▼B-3 ▼B-4
about 3-5° from the second
loop to the final loop.

C. Upper MEAW with tip -b a ck

activation.

▼D

D. Tip-back bends.
• Upper MEAW:
curve of Spee.
• Lower MEAW:
reverse curve of Spee.

486 ►► Chapter 9 _ Finishing • ft • •

 • • ® •

(3) Third-order bends (Fig. 9-13)

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

▼A ▼B

►► Fig. 9 -1 3 Third-order bends

in MEAW.
A. Crown labial torque of four
maxillary incisors.
B. Maxillary canines: zero-
degree torque.
C. Maxillary molars:
progressive crown lingual
torque.
D. Mandibular molars:
progressive crown lingual
torque.

Chapter 9 _ Finishing «◄487

 Two torque-controlling methods are as follows:
CD Hold the distal part of the canine with the Tweed pliers, and then laterally tilt the second
loop up to 5°. Here, in order to offer a progressive torque and to set the loop away from the
gingival tissue, the same procedure must be repeated on the third, fourth and fifth loop (Fig.
9-14).
(2) After bringing two Tweed arch forming pliers into contact, gain torque control by twisting
the horizontal inclination in turns.

By applying the torque on each tooth in this way, the L-loop is laterally angulated and free from
the impingement of the gingiva.

►► Fig. 9 -1 4 Third-order bends in MEAW.

A. Hold the main wire with the pliers and incline the second loop
outwardly. Then, continue to incline the third, fourth and fifth loop
outwardly.

488 ►► Chapter 9 _ Finishing m • • #

 • • • •

P’ ► Fig. 9 -1 4 (c o n tin u e d ) Third-order bends in MEAW.

c. Crown labial torque of four maxillary incisors.

E. Progressive crown lingual torque from the maxillary premolars to the second molars.

F. MEAW is outwardly inclined curved from the gingiva.

Chapter 9 _ Finishing ◄◄ 489

 C o m p leted M EA W (Fig. 9-15)

(1) A completed MEAW must possess a proper torque for each tooth.
(2) In order to prevent the impingement of gingiva, the MEAW should be outwardly angulated.
(3) It must be symmetrical.
(4) It must have an ideal arch form.
(5) The upper arch form should be 3mm wider than the lower arch form.
(6) The completed upper MEAW should have curve of Spee, and the completed lower MEAW
should have reverse curve of Spee.

►► F ig . 9 -1 5 Check points of the completed MEAW.

A. Coordination.
B. Flatness.
C. Symmetry.

490 ► Chapter 9 _ Finishing

• • ® •
 • # • •

Heat treatment for com pleted M EA W

A three-minute heat treatment (900°F/ 475°C) is carried out on the Big Jane machine, which
increases the stiffness and resilience of the orthodontic archwires. The heat treatment turns the
archwires into a brown color, so it is important to polish the wires for 15 seconds in an acid bath to
make them look aesthetically better.

►► F ig . 9 -1 6 Heat treatment of MEAW.

• Heat treatment.
- 900°F (475°C), 3 minutes.
- to increase the stiffness and the
resilience.
• Polishing in an acid bath.

Chapter 9 _ Finishing ◄« 4 Q / |
 sâ -

Prescription of MEAW

Before prescribing the MEAW technique, the following data is needed:

(1) Lateral cephalometric radiograph,
(2) Panoramic radiograph,
(3) Study models.

Lateral cephalom etric radiograph (Fig. 9-17)

(1) Decide where to place the upper incisors. This is assessed from the distance between the U1
and the lip line. 3mm is considered as normal, but if the distance is less than 0 mm, the
extrusion of upper incisors is required, and then the Class II elastics can be used. If it is 6mm
or more, the intrusion of upper incisors is required first.
(2) Check the ideal inclination of the occlusal plane. This is the angle between the upper occlusal
plane (UOP) and the FH plane, where 10° is considered as normal.
(3) Assess the antero-posterior angulation of lower molars against the occlusal plane. This is the
angle between the posterior occlusal plane (POP) and the FH plane, where 13° is considered as
normal. Here, if possible, it is important to make sure that the lower buccal teeth form a right
angle with the occlusal plane.

► F ig. 9 -1 7 Check points in lateral

cephalometric radiograph in the finishing
stages of treatment.
1. Position and angulation of upper incisors.
2. A ngulatio n of upper occlusal plane
(UOP).
3. Angulation of posterior occlusal plane
(POP).

492 ►► Chapter 9 _ Finishing

• ® ® •
 • • « •

►► Fig. 9-18 Check points in panoramic radiograph

in the finishing stages of treatment.
1. Angulation and parallelism of root.
2. Developmental stage of third molars.

1) Root parallelism

This is assessed to confirm the parallel angulation relationship of all the teeth. Here, an assessment
is made on whether to bond the bracket again or to adjust it by using finishing archwires. It is
recommended for the brackets to be bonded again, if there are two or more bracket positioning
errors per unilateral jaw, but a finishing archwire must be used for adjustments, if, however, there
is only one error per unilateral jaw. Special attention is needed in the following situations:
(1) Root parallelism of the teeth adjacent to the extraction site,
(2) Aesthetic condition of the anterior teeth (artistic bends).

2) Conditions of the third molars

The correction of posterior crowding is very important in orthodontic treatment. This is considered
to be even more important, if there is insufficient posterior vertical dimension (PVD). In a non­
extraction (of other teeth) case, a third molar extraction is essential. Also, the extraction of the
lower third molars may be required to upright the mesially tilted lower molars. In particular, if the
crown is already formed and the roots are developing in the lower third molars, it is more desirable
to extract the lower third molars in order to upright the lower molars before the finishing stages of
treatment.

Chapter 9 _ Finishing 493

 Study m odels (Fig. 9-19)

►► F ig . 9 -1 9 Check points in study models in the finishing stages of treatment.

1. Relationship of marginal ridge.
2. Ideal arch form.
3. Canine relationship and overjet.
4. Overbite.
5. Aesthetic bends of anterior teeth.
6. Difference in left and right curve of Spee.
7. Torque.
1) Torque of upper canines: whether to increase or decrease.
2) Torque difference of molars: upper and lower, left and right.

1) Marginal ridge relationship with adjacent teeth

The marginal ridge relationship of adjacent teeth must all be coincided. Most of the miss-matches
occur due to bracket positioning errors. In order to solve this problem, the archwires should be
adjusted in the finishing stages of treatment.

2) Ideal arch form

The correction of arch form is extremely difficult to do so in the finishing stages of treatment.
However, by changing individual tooth positions in MEAW, the arch form can be modified to a

494 ►► Chapter 9 _ Finishing • • # ©

 • • ® •

certain extent. Particularly in premolar extraction cases, if there is a V-shaped (tapered) arch form,
it can be corrected by moving the posterior teeth forward by taking advantages of the extraction
space.

3) Canine relationship and overjet

•
In order to solve the problem of canine relationship and overjet, elastics should be used. In other
words, to improve excessive overjet and Class II relationship, Class II elastics should be used.
Here, the action of elastics can cause the extrusion and lingual inclination of upper incisors, as well
as labial inclination of lower incisors. Therefore, to compensate for this, a crown labial torque (+7°
or +10°) should be applied to the upper anterior teeth, and a crown lingual torque (-7°) to the lower
anterior teeth. In contrast, Class III elastics are used to correct the problems of anterior cross bite
and Class III relationship. The action of Class III elastics can cause the labial inclination of upper
incisors, and the extrusion and lingual tilting of lower incisors. Therefore, to compensate for this, a
crown lingual torque (-7°) should be applied to the upper anterior teeth, and a crown labial torque
(+7°) to the lower anterior teeth.

4) Overbite

In most cases, the conventional form of MEAW is used. However, if the overbite is 4 mm or more, it is
more desirable to use the reverse MEAW to extrude the lower molars and to intrude the lower incisors.

5) Aesthetic bends

After an orthodontic treatment, the upper and lower incisors should be in an aesthetically
acceptable condition. For this purpose, the mesio-distal angulation and the vertical height of crown
are evaluated in a model, and identified through a panoramic radiograph. If problems are still
remained, the aesthetic bends should be used.

6) Discrepancy between the left and right curve of Spee in the lower model

The discrepancy between the left and right curve of Spee is one of the main contributing factors of
midline deviation, so it must be checked in the finishing stages of treatment. In particular, when the
midline deviation is found to the direction of severe curve of Spee, it is essential to upright the
molars in such areas.

Chapter 9 _ Finishing ◄◄ 495

 7) Torque

(1) Upper anterior torque

The inclination of upper incisors is essential not only for aesthetic reasons, but also for the
completion of occlusion. In many extraction cases, the extrusion and excessive lingual
inclination of upper incisors are commonly observed. After a careful cephalometric analysis, if
there is a need for occlusal plane improvement and the intrusion of upper incisors, the utility
arch can be used in the finishing stages of treatment.

(2) Upper canine torque

Severe canine lingual inclination can diminish masticatory muscle activity and cause the
retrusion of mandible and condyles. Therefore, a careful evaluation must be made about this
problem. Here, if there is severe lingual inclination in the upper canines, it must be solved and
the crown labial torque should then be applied conversely. Furthermore, as midline deviation is
likely to occur due to the discrepancy of lingual inclination in the left and right upper canines,
a careful examination is also required.

(3) Upper and lower molar torque and the difference in the left and right
torques

The more posteriorly the upper and lower molars are located, the more lingually inclined they
will become progressively. This becomes more evident as it goes down to the lower molar
area. The crown of the upper second molars should be slightly more lingually inclined than that
of the upper first molars. However, here, the difference between the lingual cusps and the
buccal cusps should be no more than 1mm. Also, if there is midline deviation as well as a
difference in torque between the left and right molars in the upper and lower jaws, the torque
difference should, if possible, be adjusted first. Here, the upper molars in the unaffected area
are likely to show a more severe crown lingual inclination, while the upper molars in the
affected area are likely to show a more severe crown buccal inclination. In contrast, the lower
molars in the unaffected area are likely to show a weaker crown lingual inclination (relatively
more severe crown buccal inclination), while the lower molars in the affected area are likely to
show a more severe crown lingual inclination. Therefore, if midline deviation and torque
differences in molars are apparent, individualized adjustments must be made.

496 ►► Chapter 9 _ Finishing <

§• 9 ®
 • • • •

( ^ ) MEAW prescription (Fig. 9-20)

The following is a MEAW prescription form.

►► Fig. 9 -2 0 MEAW prescription form.

1) Bracket slot size (Fig. 9-21)

Check whether the bracket size is .018” slot or .022” slot. Here, it is more desirable to use the .018”
slot bracket. The archwires used in this case are ,016” x .022” stainless steel archwires. If the .022”
slot bracket is used, ,018” x.022” stainless steel archwires are required. However, when MEAW is
used together with the SWA appliances, additional wire adjustments may be needed.

T a VB
►► Fig. 9-21 .018” slot or .022” slot.
A. If the bracket size is .018” slot,
use the ,016”x.022” stainless steel
wires to make MEAW.
B. If the bracket size is .022” slot in the
SWA appliance, use the ,018”x
.022” stainless steel archwire to
make MEAW and to prevent the
im pingem en t of gingiva in the
posterior area.

Chapter 9 _ Finishing «« 497

 2) Shape of MEAW

It can be classified into two categories: the standard MEAW shape and the reverse MEAW shape
(Fig. 9-22). In many cases, the standard MEAW is used, but if there is a severe overbite or if there
is a deep overbite after space closure, the reverse MEAW is used. However, the use of the reverse
MEAW can cause molar extrusion and incisor intrusion, so it should only be used in the
mandibular arch.
Also, when there is a need for height control of individual teeth, use step-up bends to trigger
extrusion or step-down bends to trigger intrusion (Fig. 9-23).

►► Fig. 9 -2 2 Standard MEAW and reverse MEAW.

A. Standard MEAW.
B. Reverse MEAW.

V'
W

►► Fig. 9 -2 3 Step-up bends and step-down bends.

A. Step-up bends.
Bracket re-bonding or wire bending is required for tooth extrusion. Here, the bends that
trigger the extrusion are called the step-up bends.
B. Step-down bends.
Bracket re-bonding or wire bending is required for tooth intrusion. Here, the bends that
trigger the intrusion are called the step-down bends.

498 ►► Chapter 9 _ Finishing • • @ •

 • • • #

3) Condition of malocclusion

It is important to distinguish whether it is Class I, II or III malocclusion.

In the case of Class I or Class II malocclusion, Class II elastics can be used for finishing. Here, the
action of Class II elastics can cause the extrusion and lingual inclination of upper incisors, and
labial inclination of lower incisors. Therefore, to compensate for this, a crown lingual torque (-7°)
should be applied to the lower incisors, while a crown labial torque (+7° or +10°) should be
applied to the upper incisors (Fig. 9-24).
In the case of Class III malocclusion, Class III elastics can be used for finishing. Here, the action of
Class III elastics can cause the labial inclination of upper incisors and the extrusion and lingual
inclination of lower incisors. Therefore, to compensate for this, a crown labial torque (+7°) should be
applied to the lower incisors, while a crown lingual torque (-7°) to the upper incisors (Fig. 9-25).

^ ► F ig . 9 -2 4 Torque in Class li case.

A. When Class II elastics are used, extrusion and lingual inclination can occur in the upper
anterior teeth, and intrusion and labial inclination can occur in the lower anterior teeth.
B. To compensate for this, a crown labial torque should be applied to the upper incisors, while a
crown lingual torque to the lower incisors in MEAW.

►► F ig . 9 -2 5 Torque in Class III case.

A. If Class III elastics are used, intrusion and labial inclination can occur in the upper anterior
teeth, and extrusion and lingual inclination can occur in the lower anterior teeth.
B. To compensate for this, a crown lingual torque should be applied to the upper incisors, while
a crown labial torque to the lower incisors in MEAW.

Chapter 9 _ Finishing «◄ 499

 4

4
In general, the shape of MEAW should be able to maintain its ideal dental arch form. Therefore,
the first-order bends should be applied properly, and the lingual surfaces should coincide with each
other in the anterior area, while the mandibular active centric line and the maxillary passive centric
line should be matched. For this purpose, additional wire adjustments may be needed. Then, a
gradual crown lingual torque should be applied to all the teeth behind the canines. Here, due to the
properly applied posterior torque, the loop becomes outwardly angulated as it goes down to the
posterior teeth. In other words, it is adjusting the third-order bends. Then, adjust the second-order
bends and modify the arch form at the end.

1) Tip-back activation (Fig. 9-26)

Tip-back activation is applied from the second loop of MEAW. After holding the second loop with
Kim pliers, bend the posterior leg of archwire 3-5° posteriorly, and bend the rest of the loops in the
same way. By doing so, the lower MEAW will achieve the shape of a reverse curve of Spee, while
the upper MEAW will achieve the shape of a curve of Spee (refer to Fig. 9-12). Here, it is possible
to gain 1.5 mm in space due to the 5° tip-back activation. Therefore, in a non- extraction treatment
case, four out of five loops can obtain 20° tip-back activation, thereby securing 6mm in space. In
contrast, in an extraction treatment case, due to three out of four loops, 4.5mm space can be
secured. Here, the degree of activation is determined by checking the amount of anterior
angulation of lower molars after the proper overbite and overjet are established by moving the
mandible forward.

500 ►► Chapter 9 _ Finishing • @ • ©

 • • # •

▼A ta
5° T ip - b a c k activa tion : 1 ,5m m
1,5mm

5°{ ( f f i l l P
▼A
Non-extraction Premolar
case extraction case
3° 12° (3.6mm) 9: (2.7mm)
5° 20° (6mm) 15=(4.5mm)

►► F ig . 9 -2 6 Tip-back activation.
1. After moving the mandible to the normal overbite and overjet relationship, check the posterior
disclusion and freeway space, and then determine the amount of activation.
2. Do not activate more than 3-5° per tooth.
3. In the case of deep curve of Spee, use the reverse MEAW first (instead of the standard MEAW), and
then apply the tip-back activation.
A. MEAW with tip-back activation.
B. 1,5mm of space is gained by the 5° tip-back activation.
C. Expected space for non-extraction cases and extraction cases.

2) Tip-back deactivation (Flat MEAW) (Fig. 9-27)

This is the initial MEAW shape. This is also used to correct the bite in the case of Class III
malocclusion and open bite. The upper curve of Spee shape and the lower reverse curve of Spee
shape, created by the tip-back activation, should be changed into flat MEAW. In these cases,
anterior vertical elastics (3/16” 6oz) are used generally.

►^ F ig . 9 -2 7 Tip-back deactivation: Flat MEAW.

Hold the MEAW in the same way as for the tip-back activation. Then, remove the tip-back activation from
the second loop to the last loop to flatten the MEAW.

Chapter 9 _ Finishing 5Ü1

 3) Step-up bends (Fig. 9-28)

This is used when there is a marginal ridge discrepancy. Here, the marginal ridge relationship can
be corrected by extruding the relevant tooth. When a tooth is extruded, a crown lingual torque
occurs due to the bonded bracket. For this reason, in extruding the teeth, additional crown buccal
torque should be applied carefully after considering this point.

►► F ig . 9 -2 8 Step-up bends for extrusion.

Extrusion of teeth can result in linguoversion of crown in both jaws. Therefore, in using the step-up
bends, it is essential to decrease the additional crown lingual torque.

4) Step-down bends (Fig. 9-29)

This is used to correct the extrusion of tooth. When a tooth is intruded, a crown buccal torque
occurs due to the bonded bracket. For this reason, in intruding the teeth, additional crown lingual
torque should be applied by considering this point.

►► F ig . 9 -2 9 Step-down bends for intrusion.

Intrusion of maxillary and mandibular teeth can result in labioversion of crown. Therefore, in using the
step-down bends, an additional crown lingual torque should be further applied.

502 ►► Chapter 9 _ Finishing • • • ©

 • • • •

5) Curve of Spee (COS) MEAW (Fig. 9-30)

When there is Class I I I malocclusion and open bite, the tip-back activation is earned out for the
posterior angulation of the lateral teeth to make Class I occlusion. After this is completed, the COS
MEAW is used. Unlike in tip-back activation, the curve of Spee is given to this MEAW, and is
applied only to the lower first and second molar areas. Such a MEAW shape is only used to treat
the open bite or Class I II malocclusion, along with anterior vertical elastics (3/16” 6oz).

►► F ig . 9 -3 0 COS MEAW: as the wire mesially angulates the lower molars, the COS MEAW should only
be used when the premolar occlusion is well established.
• Condition of molars before treatment: red line.
• Distal tilting and uprighting by tip-back activation: blue line.
• Normal angulation achieved by COS MEAW: black line.

6) Progressive step-up (PSU) MEAW (Fig. 9-31)

When a non-surgical treatment method is used to treat Class III malocclusion, Class i l l elastics are
used, but arguably this can increase the risk of flat smile arc in the anterior area. Therefore, to
compensate for this, it is necessary to apply progressive step-up bends to the upper incisors, as
shown in the figure below. This is PSU MEAW and should only be used after the Class I canine
relationship is established. PSU MEAW is used together with anterior vertical elastics (3/16” 6oz).

( e __ y rr-n V -E E lA l V cm
tu d

►► F ig . 9-31 PSU MEAW.

Upper MEAW with tip-back bends can cause labioversion of incisors and an unaesthetic outcome. Here,
after deactivating the tip-back, flat MEAW should be inserted, and then PSU MEAW should be used with
anterior vertical elastics (AVE) to trigger the extrusion of upper incisors for a better aesthetic outcome.

Chapter 9 _ Finishing «◄ 503

 ■ Basic adjustment of MEAW

The main characteristics of MEAW appliances are as follows. First, the horizontal components of
loops can reduce the load deflection rate of wires and provide a continuous light force. Also, the
vertical loops can function as a breaker between the teeth and facilitate individual tooth movement.
In other words, by adjusting tip-back bends, step bends or torque, tooth movement can be
delicately controlled with the use of rectangular wires. In addition, as all the teeth move
simultaneously, all the combined bends can work effectively, and the treatment goal can be
achieved in a relatively shorter period of time.

(1) Step-up bends, step-down bends

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

(2) Second-order bends (tip-back bends)

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

(3) Third-order bends (torque)

In order to establish a functional occlusion, an appropriate tooth guidance that harmonizes the

& condylar path is required for individual teeth. Therefore, a torque should be applied for the
® purpose of appropriate guidance, and should be carried out to compensate for the inclination of
tooth that arises from the second-order bends. Finally, by appropriately lifting the loops from
the posterior gingiva, it can prevent the impingement.

504» Chapter 9 _ Finishing • @ m •

 • • • •

The torque that labially or buccally angulates the crown is called crown labial torque, and the
torque that lingually angulates the crown is known as crown lingual torque.
(1) Using Class II elastics: apply a crown labial torque to the upper incisors and a crown
lingual torque to the lower incisors.
(2) Using Class III elastics: apply a crown lingual torque to the upper incisors and a crown
labial torque to the lower incisors.
(3) As the premolars and molars are likely to be more lingually inclined through the use of
step-up bends, an additional crown labial torque should be applied as a form of
compensation.

Extra caution is needed when torqueing the following teeth:

(1) Upper canines: When there is an excessive upper canine torque, there is also likely to be a
Class II malocclusion that restricts the mandibular growth. In this case, the torque of zero-
degree or even (+) 7° should be applied to the upper canines. By doing so, this can provide
a clearance with the lower canines and facilitate the free mandibular movement.
(2) The bilateral symmetry of torque between the upper left and right canines.
(3) Apply an appropriate amount of crown lingual torque to the upper premolars.
(4) The bilateral symmetry of torque between the upper left and right first molars.
(5) A gradual increase in crown lingual torque as it gets closer to the upper second molars.
(6) Intercoronal opening angle (IOA) between the upper and lower canines (Fig. 9-32).
(7) A gradual increase in crown lingual torque as it gets closer to the lower molars.
(8) Non-excessive crown lingual torque of lower molars.

▼A ▼B ▼C

►► Fig. 9 -3 2 Intercoronal opening angle (IOA).

A. This is the angle between the lingual surfaces of maxillary incisors/ canines and the labial surfaces of
m andibular incisors/ canines. It is usually 47°.
B. W hen the angle is decreased, the forw ard m ovem ent of m andible is restricted and thereby the
mandible is further retruded.
C. When seen from the frontal view, a difference in intercoronal opening angle between the canines is
apparent.

Chapter 9 _ Finishing 4 4 5Q5

 The following table summarizes the average amounts of torque prescribed (Table. 9-1):

►► T a b le . 9-1 General torque prescription.

In the case of Class I, II elastics In the case of Class III elastics

Upper arch Corresponding teeth Lower arch Upper arch Corresponding teeth Lower arch
+7 1,2 -7 -7 1,2 +7
0 3 -7 0 3 -7
-10 4,5 -15 -10 4,5 -15
-15 6, 7 -20 -15 6, 7 -20

Th. adjustment sequence of MEAW is as follows:

1) Make an ideal arch form.
2) Apply torque to individual teeth.
3) Check the ideal arch form again.
4) Apply the tip-back bends from the second loop.
5) Check the ideal arch form. p> ^ ^ ^

506 ►► Chapter 9 _ Finishing © • • ®

 ® # # ©

“ Tsé-
1

5
Purposes

1) Uprighting of the dentition.

2) Establishment of interdigitation.
3) Control of tooth axis.
4) Control of cant of occlusal plane.
5) Control of vertical dimension.
6) En-masse movement of entire dentition.

Types

1) Position

(1) Long elastics (Fig. 9-33)

These are the elastics that are used from the anterior area to the first or second molars in the
opposite arch. Due to the vector components of force, a stronger horizontal force can (when
compared with the vertical force) be applied. However, the vertical force here can trigger
molar extrusion. Therefore, it should not be used in high angle cases, but should only be
selectively used in low angle cases.

Chapter 9 _ Finishing ◄« 5Ü7

 Lower molars Extrusion + mesial tipping

Upper incisors Extrusion + distal movement

Occlusal plane Clockwise rotation

POP Steepening

►► F ig . 9 -3 3 Long Class II elastics.

• Long Class II elastics are used from the upper canine area to the lower molar area, and triggers
the forward movement and the extrusion of lower posterior teeth.
• The clockwise rotation of occlusal plane and the steepening of the posterior occlusal plane
(POP) can occur.
• 5/16” 6oz (for the mandibular second molar) and 1/4” 6oz (for the mandibular first molar) are
used.

, V Possible complications in the use of long elastics

1) Molar extrusion: the lower molars may get extruded when the Class II elastics are

used and the upper molars may get extruded when the Class III elastics are

used.
2) Mandibular opening movement: this takes place more often, especially when the

CF value is low and there is a vertical growth pattern.

3) Excessive change in the occlusal plane.

4) Increased possibility of dual bite.

5) Overloaded temporomandibular joint (TMD). |

508 ►► Chapter 9 _ Finishing va v:, to ©

 ® • # •

(2) Short elastics (Fig. 9-34)

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

►^ Fig. 9 -3 4 Short elastics.

• Short Class II elastics are the elastics that are used from the upper canine area to the lower
premolar area. This can trigger the forward movement and extrusion of lower premolars.
Due to the MEAW effect, there may be a forward movement and a minor intrusion of lower
molars.
• 3/16” 6oz elastics are used.

►► T a b le . 9-2 Long Class II elastics and short Class II elastics.

Long elastics Short elastics

1. Main archwire Ideal AW MEAW
2. Skeletal pattern High CF Low OF/ High CF
3. Desirable tooth movement
1) Occlusal plane Normal POP Steep POP
2) Anterior-posterior movement More effective
3) Vertical movement More effective
4) Individual tooth movement More effective

Chapter 9 _ Finishing 5Ü9

 ►► F ig. 9 -3 5 Problems in using long elastics in the upper and lower MEAWs.
The use of long elastics may aggravate the mesial rotation and extrusion of terminal molars.
Therefore, it is important to use short elastics in both the upper and lower MEAWs.

(3) Inter-maxillary elastics

These elastics are used in between the opposing dental arches to improve the antero-posterior,
transverse, and vertical relationships. Class II, Class III, or cross bite elastics are the examples
of this.

(4) Intra-maxi Ilary elastics

These elastics are used in the same dental arch. For example, the Class I
elastics are used to close space with a sliding mechanism.

(5) Box elastics

These rectangular-shaped elastics are used for tooth extrusion. 1/4” 6oz is the main tool in such
elastics. This is used to improve the interdigitation in the final stages of treatment.

m
©

5 1 0 m . Chapter 9 _ Finishing
• « © ©
 • • # #

(6) Triangular elastics (Fig. 9-36)

These triangular-shaped elastics are used for tooth extrusion. 1/4” 6oz is the main tool in such
elastics.
The triangle apex brings about more tooth extrusion, which makes it more effective for
leveling the curve of Spee. •

►k Fig. 9 -3 6 Triangular elastics.

• Elastics used for more tight occlusion in
the premolar area.
• 1/4” 6oz elastics are used.

2) Purposes

(1) Class I elastics (Fig. 9-37)

These elastics are used within the same dental arch. For example, when closing the extraction
space with through a sliding mechanism, the elastics are used from the canines or from the
anterior hook or loop to the first molars (1/4” 6oz) or second molars (5/16” 6oz).

►P- Fig. 9 -3 7 Class I elastics.

Class I elastics can cause the retraction of
a n te rio r teeth and the p ro tra c tio n of
posterior teeth. As a result, the extraction
space is closed and there are no changes
in the occlusal plane.

Chapter 9 _ Finishing «◄ 511

 (2) Anterior vertical elastics (AVE) (Fig. 9-38)

These elastics are used in open bite cases. Here, in order to extrude the incisors and improve
the occlusal plane, the elastics must be placed in between the first loops of both the upper and
lower MEAW. The elastics used are known as 3/16” 6oz.

►► Fig. 9 -3 8 AVE.
A. Due to the tip-back bends, the upper MEAW forms the curve of Spee and the lower MEAW
forms the reverse curve of Spee: such a formation can aggravate the anterior open bite.
B. When the elastics are used on anterior teeth: 1) the extrusion of upper and lower anterior
teeth may occur, and 2) distalization and intrusion may occur in the posterior teeth.
C. Intraoral photograph of AVE in use.
D. Diagram of teeth movement after using AVE.

512 ►
►Chapter 9 _ Finishing © © • •
 ® • • ®

(3) Class II elastics (Fig. 9-39)

These inter-maxillary elastics are used unilaterally or bilaterally from the anterior area of upper
arch to the posterior area of lower arch (e.g. from the upper canines to the lower first molars).
It is used to improve the Class II relationship and decrease overjet. Class II elastics can trigger
a vertical and transverse force as well as an antero-posterior force.
#

► Fig. 9 -3 9 Class II elastics.

A. Class II elastics triggers a posterior and lingual movement of upper incisors and extrusion
and forward movement of lower teeth. As a result, the Class II canine relationship is
improved.
• In particular, MEAW can cause an effective posterior movement of upper dentition.
Also, by using tip-back bends on the lower MEAW, the extrusion of lower molars can be
prevented.
B. Intraoral photograph of Class II elastics in use.

Chapter 9 _ Finishing <« 513

 (4) Class III elastics (Fig. 9-40)

These inter-maxillary elastics are used unilaterally or bilaterally from the anterior area of lower
arch to the posterior area of the upper arch (e.g. from the lower canines to the upper first
molars). They are used to improve Class III relationship, to protract upper molars, and to
increase incisor overjet. These Class III elastics can trigger a vertical and transverse force as
well as an antero-posterior force.

►► Fig. 9 -4 0 Class III elastics.

A. Class III elastics triggers a posterior and lingual movement of lower incisors and extrusion
and forward movement of upper teeth. As a result, the canine relationship and overjet are
improved.
• In particular, MEAW can lead to an effective posterior movement of lower dentition. Also,
by using tip-back bends on the upper MEAW, the extrusion of upper molars can be
prevented.
B. Intraoral photograph of Class III elastics in use.

&

514» Chapter 9 _ Finishing © • © ®

(5) Cross bite elastics (Fig. 9-41)

These elastics are used when there is cross bite. Since these elastics can cause an undesirable
bucco-lingual inclination of individual teeth and aggravate malocclusion, one should be extra
cautious when using them.

►► F ig . 9-41 Cross bite elastics.

A. In most unilateral posterior cross bite cases, the upper posterior teeth in the affeded side
tend to show crown buccal inclination and the lower posterior teeth in the affeded side tend
to show crown lingual inclination.
B. In this case, cross bite elastics should be used to increase the crown labial torque of upper
molars and the crown lingual torque of lower molars. This can solve posterior cross bite
problems, but it can also bring about problems of midline and occlusal changes.

Chapter 9 _ Finishing «◄ 515

 3) Types of elastics (Fig. 9-42)

(1) 3/16” 6oz

This is the main elastic tool. Here, short elastics or anterior vertical elastics are used in most
cases.

(2) 1/4” 6oz

This is used when applying the elastics from the upper or lower incisor area to the first molar
area. Here, to raise the tight interdigitation, box elastics or triangular elastics should be used.

(3) 5/16” 6oz

This is used when applying long elastics from the upper or lower incisor area to the upper or
lower second molar area. Here, the opposing teeth can extrude, so it is important to be extra
careful when using these elastics.

►► Fig. 9 -4 2 Type and size of the elastics.

A. 3/16” 6oz. B. 1/4” 6oz.
C. 5/16” 6oz. D. Elastic holder.

516» Chapter 9 _ Finishing • • • •

 • • • •

4) Procedures of using the elastics

(1) First, the elastics should be applied in the direction that can improve Class I canine
relationship. All the midlines should also be matched. Here, it is not desirable to hang the
elastics diagonally from the midline (Fig. 9-43 A). Instead, it is more desirable to hang short
Class II or short Class III elastics after carefully examining the skeletal pattern. In particular, in
areas where Class I canine relationships are established, shorter elastics should be used.
(2) The elastics should be applied in the direction of improving the antero-posterior relationship
and the canine relationship.
(3) After establishing a Class I canine relationship, the elastics are used to improve the vertical
relationship. Here, in an open-bite case, an AVE must be used, while in a deep bite case, a
triangular elastic must be used in the premolar area to trigger molar extrusion.

P- ► Fig. 9 -4 3 MEAW adjustment of a patient who has midline deviation.

A. If the elastics are used as the above figure demonstrates, even if the dental midline is matched, the
facial and occlusal plane asymmetry are aggravated.
B. In the affected side, the vertical dimension (VD) decreases and the crown buccal inclination of
maxillary teeth increases. To overcome this problem, the affected side of VD should be increased and
more crown lingual torque should be applied to the affected upper molars.
• Upper right side: step-up bends for extrusion and more crown lingual torque.
• Lower right side: step-up bends for extrusion and less crown lingual torque.

Chapter 9 _ Finishing ◄◄ 517

 5) Precautions

(1) Elastics must be worn all day, except for eating times and when brushing teeth. Tooth brushing
after eating is the main responsibility of a patient. To remove the food particles that are stuck in
the loop at buccal segments, the use of a water-pick appliance is recommended.
(2) About 6 hours after using MEAW and elastics, the whole dentition begins to move, and the
patient begins to feel tenderness around the teeth. The intensity increases for about 18 hours
and then wears off. If the elastics are worn all day as indicated, tenderness does not reoccur.
However, if the elastics are worn intermittently, the tenderness continues. Therefore, it is
important to explain the action of MEAW and its relationship to the elastics. It is also better to
notify the patients how such tenderness is related to the overall outcome. Here, it is important
to note that the patients’ comfort levels and success of treatment are proportional to their level
of cooperation.

6) Points to be checked in the finishing stage

(1) Check whether the elastics have been worn or not. If the elastics have been used in MEAW, it
is necessary to inform the patients that the remaining treatment will take about 3-6 months.
(2) The state of oral hygiene should be checked.
(3) Premature contact is checked. In MEAW, as the entire dentition (not only the individual teeth)
is moved at once, there is a great risk of premature contact between the teeth and the
orthodontic appliances. Therefore, tooth mobility must always be checked in the final stages of
treatment. If mobility is detected, an occlusal equilibration should be conducted, or the affected
teeth must be ligated with a figure of 8 tie.

#
9

518 ►► Chapter 9 _ Finishing

• ® @ •
 • B ® ©

Finishing Methods for Special Conditions

MEAW adjustment for midline correction (Fig. 9-43, 44) e

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

Chapter 9 _ Finishing 4 4 519

 Br

C-2>

►► F ig . 9 -4 4 MEAW adjustment of a patient who has a midline deviation.

A. Pre-treatment intraoral photographs.
B. Mid-treatment intraoral photographs.
C. Post-treatment intraoral photographs.
D. Occlusal view of the maxilla before and after the orthodontic treatment.

520 ►► Chapter 9 _ Finishing • ® © •

 • • • ®

,v < 3 ilnical Tips: Using MEAW for the correction of midline deviation

1. Upper and lower MEAW with tip-back activation (bilateral symmetry) + Elastics

2. More tip-back activation in deep curve of Spee side + Elastics

3. A case where there is a midline deviation, despite having flattened both the left

and right curve of Spee

1) Affected side: step-up bends (upper molars with more crown lingual torque

and lower molars with more root lingual torque)

2) Unaffected side: tip-back bends (upper molars with more root lingual torque

and lower molars with more crown lingual torque)

and elastics ► I, !> ► |> »

Expansion archwires in MEAW (Fig. 9-45—47)

In the case of posterior cross bite, even if the arch has been expanded, it is common to find
posterior cross bite again in the finishing stages of orthodontic treatment. In this case, additional
arch expansion can be carried out, by using MEAW and an expansion archwire made of 0.7mm
stainless steel archwire. Here, in MEAW, it is more desirable to excessively apply the lingual
torque (-20°) to the upper molars. Also, this can be used again in a Class II extraction case, if there
is a lingual inclination in the lower premolar area.

►► F ig . 9 -4 5 Fabrication of expansion archwire.

▼A ▼B-l ▼B-2

A. The bird beak pliers should be used to bend the end of the 0.7mm wire with a length of 2mm. This hook
is hung to the main archwire at the mesial side of the upper first molar. Make sure that the open side of
the hook faces the occlusal side.
B. Bend the wire to form a right angle with the hook.

Chapter 9 _ Finishing ◄◄ 521

 Fig. 9 -4 5 (c o n tin u e d ) Fabrication of expansion archwire.

▼C-1 ▼C-2

C. Mark the contact point of the upper central incisors (1mm shorter to
the contact point).
D. Use the bird beak pliers to bend an open type loop of 3mm height.
E. Bend the opposite side until the initial wire is straightened.

▼F-1 ▼F-2 ▼F-3

mm

▼G ▼H

F. Use a measuring tape to mark the distance from the upper central incisor contact to the mesial side of the
upper right first molar bracket.
G. Bend the hook 2mm to hang it onto the main archwire.
FI. Polish the sharp ends.

522 ►► Chapter 9 _ Finishing o © (3

 • • • •

►► Fig. 9 -4 6 Activation of expansion archwire.

A. Ligate after curving the archwire 30° outwardly and bilaterally.

E>

O
B. Place the hook on the main archwire and use the Weingart pliers 1) to tighten it, and 2) to minimize the
risk of it coming off.
C. Ligate it with the ligature wires.

D. Expansion archwire in use.

E. Intraoral photographs of the expansion archwires on.

Chapter 9 _ Finishing «◄ 523

 ►► Fig. 9 -4 7 Application of expansion archwires.

A. Posterior cross bite.

B. Narrow upper inter-canine width and excessive lingual inclination of the maxillary canines.

C. Midline deviation caused by the torque difference of maxillary canines and molars.

ty

Dt>

D. Severe crown lingual inclination of the lower premolars and molars.

524 ►► Chapter 9 _ Finishing

• • • •
 © M © &

MEAW adjustments in the case of peg lateralis (Fig. 9-48)

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

►► F ig . 9 -4 8 MEAW adjustment in the case of peg lateralis.

A. Pré-, mid-, and post-treatment intraoral photograph of a Class II malocclusion patient: If the lateral
incisors are left untreated, the mesial tilting of canines is highly likely to cause a Class II canine
relationship. Therefore, the size-up of lateral incisors is necessary.
B. Pré-, mid-, and post-treatment intraoral photograph of a Class III malocclusion patient: In closing the
incisor space, the upper anterior arch length may decrease to cause the relapse of cross bite and
traumatic occlusion between anterior teeth. Therefore, the size-up of lateral incisor is necessary.

Chapter 9 _ Finishing « ◄ 525

 7
Management of occlusal plane (Fig. 9-49)

(1) Match the bisected occlusal plane (BOP) with the posterior occlusal plane (POP).
- Bisected occlusal plane (BOP): a line connecting the point that bisects the incisal overbite
to the point at the first molar area.
- Posterior occlusal plane (POP): a line connecting the cusp tip of the lower second premolar
to the disto-buccal cusp tip of the lower second molar.
(2) The lower molars and premolars should be uprighted against this occlusal plane.
(3) Later, the anterior component of force can stabilize the occlusal plane by angulating the teeth
in the anterior direction.
(4) Here, as the occlusal force is vertically applied to the long axis of the tooth, no excessive force
is applied to the tooth.

►^ Fig. 9 -4 9 Management of occlusal plane.

A. Relationship between BOP and POP.

526 ►► Chapter 9 _ Finishing • • « ©

 ® • • •

►► Fig. 9 -4 9 (c o n tin u e d ) Management of occlusal plane.

C. Post-treatment intraoral photographs and lateral cephalometric

radiograph.

Chapter 9 _ Finishing <◄ 527

 Occlusal contacts (Fig. 9-50)

(1) Both the upper and lower canines must have a Class I canine relationship. This means that the
premolars also come to form a Class I relationship.
(2) When extracting the upper premolars only, the molars must have a Class II relationship.
However, in other cases, they must have a Class I molar relationship.

►► Fig. 9 -5 0 Occlusal contacts.

A. Class I canine relationship and Class II molar relationship when only the upper premolars are extracted.
A-1. Pre-treatment intraoral photographs.
A-2. Post-treatment intraoral photographs.

B-1. Pre-treatment intraoral photographs.

528 ►► Chapter 9 _ Finishing

• © • @
 • • • ©

►^ Fig. 9 -5 0 (c o n tin u e d ) Occlusal contacts.

B-2. The conditions of a set-up model after extracting the upper first premolars, the lower left second
premolar, and the lower right lateral incisor. Here, it is possible to see Class I canine and molar
relationship.

B-3. Post-treatment intraoral photographs.

Chapter 9 _ Finishing 529

 Correct marginal relationship, contact points, and crown length
(Fig. 9-51)

(1) No marginal discrepancy: the marginal ridge relationships between the adjacent teeth must be
identical.
(2) Proper crown length: the teeth (especially the upper central incisors) should have an
appropriate tooth length. Aesthetically, the ideal upper central incisor length is about 10mm.
However, when treating a patient whose upper central incisors are worn out, the following
points must be checked:
1) Whether to finish the treatment as its current condition.
2) Whether to perform a crown lengthening surgery.
3) Whether to carry out an aesthetic prosthodontic treatment after intruding the upper incisors.

►► Fig. 9-51 Correct the marginal ridge relationships, contact points and crown length.
A. Pre-treatment facial and intraoral photographs.
B. Post-treatment facial and intraoral photographs.

53Ü ►► Chapter 9 _ Finishing # @ • ©

 J ) Favorable alignment (Fig. 9-52)

(1) Rotation control: there should be no rotation and crowding.

(2) Space closure: there should be no space between the adjacent teeth.

A-1 ►

►► Fig. 9-52 Favorable alignment.

A. N on-extraction case with
fine alignment.
A-1. Pre-treatment intraoral
photographs.
A-2»
A-2. Post-treatment intraoral
photographs.
B. Prem olar extraction case
with fine alignment.
B-1. Pre-treatment intraoral
photographs.
B-2. Post-treatment intraoral
photographs.

B-2>

Chapter 9 _ Finishing < 4 531

 Adequate tooth inclination (Fig. 9-53)

1) Anterior tooth inclination

(1) Upper anterior teeth

The upper incisors should have an appropriate inclination in relation to the facial profile and
upper occlusal plane. In particular, in premolar extraction cases, there should be no loss in
anterior crown labial torque due to the excessive linguoversion of incisors. In contrast, in non­
extraction cases, there should not be an excessive crown labial torque due to the labioversion
of incisors.

►► F ig . 9 -5 3 Adequate tooth inclination.

A. Non-extraction case with adequate anterior teeth inclination.

A-1. Pre-treatment facial and intraoral photographs.
A-2. Post-treatment facial and intraoral photographs.

532 ►► Chapter 9 _ Finishing • • • •

 • • • •

(2) Upper canines

The excessive lingual inclination of upper canines can establish a canine guidance occlusion,
but it is important to bear in mind that it can also cause condylar and mandibular retrusion.
Therefore, it is necessary to check the symmetry of both the upper left and right canine torques.
It is essential not to make the lingual inclination of upper canines excessive.

►► Fig. 9 -5 3 (c o n tin u e d ) Adequate tooth inclination.

B-1 ► B-2>

B-U

B. Premolar extraction case with adequate anterior teeth inclination.

B-1. Pre-treatment facial and intraoral photographs.
B-2. Post-treatment facial and intraoral photographs.

Chapter 9 _ Finishing ◄◄ 533

 2) Posterior tooth inclination

(1) Progressive crown lingual inclination

The lingual crown inclination of both the upper and lower molars progressively increases from
the premolars to the second molars. This is represented as the curve of Wilson. Here, the lower
molars have a slightly larger lingual crown inclination than the upper molars, but the height
difference between the occlusal plane and the lingual cusps of lower molars should not exceed
1mm. If there is a difference of more than 2mm, not only is the forward growth of the
mandible limited, but also the occlusal interference in lateral movement is likely to increase
due to the extrusion of upper lingual cusps.

(2) Symmetrical posterior torque

The bilateral symmetry of molars is important. Asymmetry can cause a midline deviation and
pose some difficulties in finishing procedures. Here, the lingual crown inclination gets
aggravated in the unaffected upper molar area, while the buccal crown inclination gets
aggravated in the affected upper molar area. Therefore, it is extremely important to check the
bilateral symmetry of molars first. Reversely, the lingual crown inclination gets aggravated in
the affected lower molar area, while the buccal crown inclination gets aggravated in the
unaffected lower molar area. Therefore, in the finishing stages of treatment, it is important to
make the left and right posterior torques as symmetrical as possible.

534 ►► Chapter 9 _ Finishing • ® • •

 • • @ •

Overcorrection of overbite and overjet

1) Overcorrection of overbite (Fig. 9-54 A)

If there is a deep overbite, attempts must be made to gain an edge-to-edge occlusion. In contrast, if
there is an open bite, the overcorrection should be performed until the upper incisor edges come
into contact with the lower incisor brackets.

►► F ig . 9 -5 4 Overcorrection of overbite and overjet.

A-1 ►

A-2>

A -3 >

A. Treatment of open bite case.

A-1. Pre-treatment intraoral photographs.
A-2. Post-treatment intraoral photographs.
A-3. Post-retention intraoral photographs (3 years and 10 months after the treatment).

Chapter 9 _ Finishing •«« 535

 2) Overcorrection of overjet (Fig. 9-54 B)

If there is a severe overjet in Class II malocclusion, attempts must be made to gain an edge-to-edge
bite. In a Class III case, the overcorrection should be performed until the upper incisors come into
contact with the lower incisor brackets.

►► Fig. 9 -5 4 (c o n tin u e d ) Overcorrection of overbite and overjet.

B. Treatment of deep bite and Class II malocclusion case.

B-1. Pre-treatment intraoral photographs.
B-2. Post-treatment intraoral photographs.
B-3. Post-retention intraoral photographs (1 year and 1 month after the treatment).

536 ►► Chapter 9 _ Finishing

- ■ > ,
 • • • •

Root parallelism (Fig. 9-55)

After treatment, all the teeth and roots should be parallel to one another. In particular, in the case of
adults, if the adjacent roots are too closely positioned, a periodontal damage is likely to occur
when performing a restorative treatment later on. Therefore, in the finishing stages of treatment, a
panoramic radiograph must be taken to check root parallelism. If the brackets are bonded
incorrectly, the re-bonding or adjustment of finishing archwires should be performed.

►► F ig . 9 -5 5 Root parallelism.
A. Adequate root parallelism.
B. Inadequate root parallelism.

Chapter 9 _ Finishing 537

 ,V < 3 finical Tips: The condition for making finishing easier
1. If possible, move the teeth while maintaining the Class I canine relationship.

1) Retract the upper canines first.

2) Prevent an excessive lingual movement of lower incisors.

2. There should be no rotation.

1) Precise bracket positioning is essential.

2) Correction of tooth size discrepancy must be made.

3. Avoid the bite from deepening.

The curve of Spee must be 2mm or less.

4. The space should be 1mm or less.

5. There should be no bad oral habits.

The control of mouth opening and tongue thrusting is required. j

538 ►► Chapter 9 _ Finishing • @ • ®

 • • • •

REFERENCES

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Orthod Dentofacial Orthop 123:79-83, 2003.
3. Begg R. Orthodontic theory and technique. 3rd ed. Philadelphia: WB Saunders, 1977.
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5. Bolton WA. Disharm ony in tooth size and its relationship to the analysis and treatm ent of
malocclusion. Angle Orthod 28:113-130, 1958.
6. Bolton WA. The clinical application of a tooth size analysis. Am J Orthod 48:504-529, 1962.
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alleviating orthodontic relapse. Am J Orthod Dentofacial Orthop 93:380-387, 1988.
13. Edwards JG. Soft-tissue surgery to alleviate orthodontic relapse. Dent Clin North Am 37:205-225,
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14. Eliades T, Gioka C, Eliades G, and Makou M. Enamel surface roughness following debonding using
two resin grinding method. Eur J Orthod 26:333-338, 2004.
15. Fields HW. Orthodontic-restorative treatment for relative mandibular anterior excess tooth size
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16. Gianelly AA. Asymmetric space closure. Am J Orthod Dentofacial Orthop 90:335-341, 1986.
17. Isaacson RJ, and Rebellato J. Two-couple orthodontic appliance systems: Torquing arches. Semin
Orthod 1:31-36, 1995.
18. Isaka F, Suzuki Y, Hwang DH, Tuazon R, and Sato S. Non-extraction therapy of Class II crowding
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19. Jin IJ, and Yang WS. A study of holographic interferometry on the initial reaction of maxillofacial
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Chapter 9 _ Finishing ◄◄ 539

 20. Joondeph DR. graber TM, Vararsdall RL, Vig KWL, eds. Orthodontics: Current Principle and
Techniques. Ed4. St Louise: Mosby, 2005.
21. Kim BH, and Yang WS. Regional load deflection rate of multiloop edgewise archwire. Korea J Orthod
29:673-688, 1999.
22. Kim Jl, Akimoto S, Shinji H, and Sato S. Importance of vertical dimension and cant of occlusal plane in
craniofacial development. Int J Stomatol Occlusion Med 2:114-121,2009.
23. Kim Jl. Practical Clinical Orthodontics. Vol 1. Orthodontic treatment with MEAW. Well publishing Inc,
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24. Kim Jl. Practical Clinical Orthodontics. Vol 2. Orthodontic Diagnosis. Well publishing Inc, 2013.
25. Kim Jl. Practical Clinical Orthodontics. Vol 3. Early orthodontic treatment. Well publishing Inc, 2015.
26. Kim YH and Vietas JJ. Anteroposterior dysplasia indicator: An adjunct to cephalometric differential
diagnosis. Am J Orthod 113:619-633, 1978.
27. Kim YH, Caulfield Zoe, Chung WN, and Chang Yl. Overbite Depth Indicator, Anteroposterior
Dysplasia Indicator, Combination Factor, and Extraction Index. Int J MEAW 1:11-32, 1994.
28. Kim YH, Han UK, Lim DD, et al: Stability of anterior openbite correction with multiloop edgewise
archwire therapy: A cephalometric follow-up study. Am J Orthod Dentofacial Orthop 118:43-54, 2000.
29. Kim YH, and Han UK. The Versatility and Effectiveness of the Multiloop Edgewise Archwire(MEAW) in
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30. Kim YH. A comparative cephalometric study of class I I , Divisionl Nonextraction and Extraction cases.
Angle Orthod 49:77-84, 1979.
31. Kim YH. Anterior openbite and its treatment with Multiloop Edgewise Archwire. Angle Orthod 57:290-
321, 1987.
32. Kim YH. Overbite depth indicator (ODI) with particular reference to anterior open-bite. Am J Orthod
65:586-611, 1974.
33. Kim YH. Anterior openbite and its treatment with Multiloop Edgewise Arch-Wire. Angle Orthod 57:290-
321, 1987.
34. Kim YH. Treatment of anterior openbite and deep overbite malocclusions with Multiloop Edgewise
Arch-Wire(MEAW) therapy. The enigma of the vertical dimension, J.A. McNamara, Craniofacial
Growth Series 36, Center for human Growth and Development, The University of Michigan. Ann
Arbor. 2000.
j 35. Kim YH. Treatm ent of severe openbite malocclusion w ithout surgical intervention. Growth
>'ï>
modification: What works, what doesn’t, and why. J.A. McNamara, Craniofacial Growth Series 35,
Center for human Growth and Development, The University of Michigan. Ann Arbor. 1999 .
36. Kokich VG, and Kokich VO. Interrelationship of orthodontics with periodontics and restorative
dentistry. In: Nanda R, ed. Biom echanics and Esthetic Strategies in Clinical Orthodontics.
Philadelphia: Elsevier/Saunders, 2005.

540 ►► Chapter 9 _ Finishing @ • • ®

 • • • «

37. Lee JH, and Nahm DS. Mechanical analysis on the shape memory wire. Korea J Orthod 24:739-758,
1994
38. Lee YK, and Chang Yl. The load deflection rate of multiloop edgewise arch-wire. J Dent College SNU
16:195-218.
39. Merrifield LL, and Cross JJ. Directional force. Am J Orthod 57:435, 1970.
40. Merrifield LL. The systems of directional force. J Charles H Tweed int Found 10:15, 1982.
41. Othman S, and Harradine N. Tooth size discrepancies in an orthodontic population. Angle Orthod
77:668-674, 2007.
42. Peck H, and Peck S. An index for assessing tooth shape deviations as applied to the mandibular
incisors. Am J Orthod 61:384-401, 1972.
43. Proffit WR. Contemporary orthodontics. St Louis: CV Mosby company, 1986.
44. Ricketts RW, Bench RW, Gugino CF, Hilgers JJ, and Schulhof RJ. Bioprogressive Therapy.
Denver:Rocky Mountain Orthodontics, 1979.
45. Rinchuse DJ, and Kandasamy S. Evidence-based versus experience-based views on occlusion and
TMD. Am J Orthod Dentofacial Orthop 127:249-254, 2005.
46. Roth RH. Functional occlusion for the orthodontist. J Clin Orthod 15(1-4), 1981.
47. Sato S. Application of Multiloop Edgewise Arch-Wire (MEAW) on the occlusal reconstruction of
malocclusion. Japan Ortho Practice 5:57-73, 1989.
48. Shin SJ, and Chang Yl. Three dimensional finite element analysis of the phenomenon during en
masse movement of the maxillary dentition. Korea J Orthod 28:563-580, 1999.
49. Steffen JM, and Haltom FT. The five-cent tooth positioner. J Clin Orthod 21:528-529, 1987.
50. Thurow RC. Atlas of orthodontic principles, Mosby, 1977.
51. Tweed CH. Clinical orthodontics. Vol1 and 2. St Louis.’Mosby, 1966.

Chapter 9 _ Finishing 541

 Chapter 10

RETAINERS

ttti: .................. !îî!!î!î!!!!:::::::...............

1. General Types of Retainer

2. Retainer for a Patient with Maxillary Anterior Crowding

3. Retainer for a Patient with Mandibular Anterior Crowding

4. Retainer for a Patient with Class III Malocclusion

5. Retainer for a Patient with Class II Malocclusion

6. Retainer for a Patient with Deep Bite

7. Retainer for a Patient with Open Bite

8. Retainer for a Patient with Posterior Cross Bite

9. Retainer for a Patient with Space

 1 General Types of Retainer (Fig. 10-1)

In general, a wrap-around type of retainer is used on the maxilla, and a canine-to-canine bonded
retainer is used on the mandible. Since a Hawley type retainer can cause a space relapse due to the
contact between the posterior wires of the maxillary canines and the mandibular teeth, such a
method is not recommended in the first premolar extraction cases. In the following malocclusion
cases, examples of different retainers will be demonstrated.

▼A-1 ▼A-2 ▼A-3

▼B-1 t B-2 ▼B-3

©
©

►► Fig. 10-1 General types of retainer.

A. Maxillary retainer (wrap-around retainer) on a model.
B. Intraoral photographs of a patient with a maxillary wrap-around retainer on.
C. Mandibular retainer (canine-to-canine bonded retainer) on a model.
D. Intraoral photograph of a patient with a mandibular bonded retainer on.

544 ►► Chapter 10 _ Retainers , ::i (

 • • # •

Retainer for a Patient with Maxillary Anterior Crowding (Fig. 10-2)

When the rotated maxillary incisors, winging teeth, or severely lingually positioned lateral incisors
are detected in a case of maxillary anterior crowding, a bonded retainer is recommended on the
lingual surfaces of the six maxillary anterior teeth. Since the maxillary bonded retainer could
increase the contact with the mandibular teeth, and increase the risk of detachment, such a retainer
should only be used in severe crowding cases. In most of the crowding cases, a wrap-around
retainer is, along with a spring retainer, frequently used in the maxillary anterior area.

►► Fig. 10-2 Retainer for a patient

with maxillary anterior crowding.
A. Maxillary spring retainer on
a model.
A-1. W rap-around retainer
with a spring retainer.
A-2. Hawley retainer with a
spring retainer.
B. Intraoral photographs of a
patient with a maxillary wrap­
around retainer and a spring
retainer on.
C. P hotogra phs of a model
with a bonded retainer on.
D. Intraoral photographs of a
patient with a maxillary wrap­
around retainer and a bonded
retainer on.

Chapter 10 _ Retainers «« 545

 Retainer for a Patient with Mandibular Anterior Crowding

In the cases of mandibular anterior crowding, it is recommended to bond a bonded retainer on the
lingual surfaces of the six mandibular anterior teeth. However, when there is a minor crowding in
the mandibular anterior area, it is first recommended to use a canine-to-canine spring retainer (to
solve the crowding), and then to use a canine-to-canine bonded retainer after de-crowding. A
diagram of the action of a spring retainer is as indicated below (Fig. 10-4).

▼A

▼B-1 ▼B-2

►► Fig. 10-3 Retainer for a patient with mandibular anterior crowding.

A. Photograph of a model with a mandibular spring retainer on.
B. Intraoral photographs of a patient with a mandibular spring retainer on.
C. Photograph of a model with a mandibular canine-to-canine bonded retainer on.
D. Intraoral photograph of a patient with a mandibular canine-to-canine bonded retainer on.

k\
54B ►► Chapter 10 _ Retainers
© © @ •
 • # • •

The guidelines for applying a lower retainer are as follows.

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

▼A-1 ▼A-2

▼B-1 ▼B-2

► F ig . 1 0 -4 Action of spring retainer.

A. Photographs of a model with a mandibular spring retainer on.
B-1. Model of a rotated mandibular right central incisor.
B-2. Fabrication of spring retainer after set-up.
B-3. Application of spring retainer (The arrows show the direction to which the force is applied).
B-4. After the alignment.

Chapter 10 _ Retainers 547

 Retainer for a Patient with Class III Malocclusion

In the Class III malocclusion cases, the mandibular growth is frequently prolonged. Therefore, it is
difficult to control the mandibular growth and to maintain the retention. The most influencing
factor of mandibular growth is the extrusion of the maxillary molars. Therefore, for the retention of
Class III malocclusion, it is essential to control the excessive maxillary molar extrusion. In general,
when a non-surgical treatment is used to treat the Class III malocclusion cases, a wrap-around type
retainer with a tongue hole is used to facilitate the tongue training. In particular, if the maxillary
second molars are under-erupted, the transpalatal arch (TPA), lingual arch or labio-lingual arch
should be placed in between the maxillary first molars. In addition, if there is a posterior cross bite,
such a method can also be highly effective to treat the Class III malocclusion cases with crowding.
When there is a Class III malocclusion with small maxillary lateral incisors, it is more desirable to
use a retainer after increasing the size of teeth, or by placing auxiliary springs both on the mesial
sides and on the distal sides of the teeth.

►► F ig . 10-5 Retainer for a patient with Class III malocclusion.

▼A t B t C

A. Maxilla: Transpalatal arch (TPA) with lingual arch.

<$ B. Maxilla: TPA with lingual arch and canine-to-canine bonded retainer.
C. Maxilla: Wrap-around retainer with a tongue hole.

548 ►► Chapter 10 _ Retainers ® @ © @

 • ® • @

►► Fig. 10-5 (c o n tin u e d ) Retainer for a patient with Class III malocclusion.

#
#

D-1. Pre-treatment intraoral photographs of a patient with Class III malocclusion.

D-2. Post-treatment intraoral photographs of a patient with Class III malocclusion.

The canine-to-canine bonded retainer and TPA with lingual arch.

Chapter 10 _ Retainers 549

 5 Retainer for a Patient with Class II Malocclusion

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

▼A ▼B-1 t B-2

►► Fig. 10-6 Retainer for a patient with Class II malocclusion.

A. Retainer on the maxilla: wrap-around retainer.
B. Retainer on the mandible: bonded retainer between the first premolars.

"-X

550» Chapter 10 _ Retainers

• • ® •
 • • # •

If the Class II malocclusion relapse occurs even after treating the Class II malocclusion, a twin
block type retainer is recommended (Fig. 10-7). If, however, there is a maxillary anterior
crowding, it would be more desirable to use the wrap-around retainer, which consists of a spring
retainer. If an extraction treatment method is performed and the CF value is still low, a tongue hole
should be maintained in the wrap-around retainer and the tongue training must be facilitated. In
contrast, when treating the anterior deep overbite cases, a wrap-around retainer that has an anterior
bite plate is recommended. In other words, if there is a Class II malocclusion and the maxillary
lateral incisors are small, a retainer should be used only after increasing the size of teeth, or by
placing auxiliary springs both on the mesial sides and on the distal sides of the teeth (Fig. 10-8).
In general, an inter-canine bonded retainer is used on the mandible, but it is more effective to use a
bonded retainer between the first premolars, if there is a Class II malocclusion with severe curve of
Spee.

►► Fig. 10-7 Class II twin block type retainer.

A. Twin block type retainer.

Chapter 10 _ Retainers •«« 551

 ►► Fig. 1 0-7 (c o n tin u e d ) Class II twin block type retainer.

552 ►► Chapter 10 _ Retainers

• © • •
 • • • •

►► Fig. 10-8 A patient with small maxillary lateral incisors.

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

Chapter 10_ Retainers ◄◄ 553

 Retainer for a Patient with Deep Bite

In orthodontic treatment, the deep bite can be treated through the intrusion of incisors, the
extrusion of molars, or desirable jaw growth. The deep bite relapse is closely related to the
mandibular antero-superior growth. Also, the lingual inclination and the extrusion (of mandibular
incisors) can cause the relapse of mandibular anterior crowding, and the aggravation of deep bite.
These demonstrate the reasons why a wrap-around retainer with an anterior bite plate is
recommended for the case of an anterior deep bite. Here, when the retainer is placed on the
maxilla, 1) the mandibular incisors will come in direct contact with the retainer, and 2) the
mandibular molars will come in direct contact with the maxillary molars. Also, in the cases of deep
bite, a bonded retainer is recommended in between the mandibular first premolars.

554 ►► Chapter 10 _ Retainers • @ © #

 • • • •

7 Retainer for a Patient with Open Bite

Regardless of treatment method (orthodontic or surgically combined orthodontic treatment), the

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

►> Fig. 1 0 -1 0 Retainer for a patient with open bite.

A. Wrap-around retainer with a tongue hole on the maxilla.

B. Wrap-around retainer with a tongue crib on the mandible.

Chapter 10 _ Retainers «◄ 555

 ►► Fig. 1 0 -1 0 (c o n tin u e d ) Retainer in patient with open bite.

C-1f

C-1. Pre-treatment intraoral photographs of a patient with open bite.

C-2. Post-treatment intraoral photographs of a patient with open bite.

556 ►► Chapter 10 _ Retainers

m • ® •
 © # • #

rsâr

8 Retainer for a Patient with Posterior Cross Bite

Relapse occurs in the posterior cross bite case more frequently than any other malocclusion cases.
In particular, if a retainer is not worn consistently, the tongue would come even closer to the
mandible to narrow down the maxillary arch width, thereby increasing the possibility of relapse.
Therefore, it is very important to prevent the tongue from coming closer to the mandible.

►► Fig. 10-11 Retainer for a patient with posterior cross bite.

A. On the maxilla: Transpalatal arch (TPA) with lingual arch.
B. On the maxilla: TPA with labio-lingual arch.
C. On the maxilla: TPA with lingual arch and bonded retainer between the canines.

Chapter 10 _ Retainers < ◄ 557

 If the crowding is minor, the transpalatal arch (TPA) with a lingual arch or labio-lingual arch is
recommended. In contrast, if there is severe crowding, an extra bonded retainer is recommended
between the maxillary canines along with the TPA with lingual arch (Fig. 10-12). Here, depending
on the oral hygiene, the TPA with lingual arch should be re-cemented every 6 months or every year
to minimize the caries susceptibility.

► Fig. 1 0 -1 2 Retainer for a patient with posterior cross bite.

A. Pre-treatment intraoral photographs.
B. Post-treatment intraoral photographs of a patient wearing a retainer.
C. Post-retention intraoral photographs (35 months after the treatment).

558 ►► Chapter 10 _ Retainers £ pi q q

 • • • •

Retainer for a Patient with Space

If there is spacing, there is a great risk of relapse; therefore, a bonded retainer is recommended. In
particular, if the adult patients suffer from spacing (between the maxillary central incisors), a semi­
permanent bonded retainer is recommended. Also, if there is spacing in the mandibular arch, a
bonded retainer should be used to prevent the risk of relapse. Here, it is essential to bond the
bonded retainer between the first premolars (not between the canines).

For the first 6 months, this retainer should always be worn except for eating times and brushing.
Then, for the following one year, the retainer should only be worn in the night (however, in the
deep bite cases, it must be used for the following 2~3 years). After this, the patients are
recommended to stop wearing the retainer and to check their condition on a regular basis during
the observation period. Theoretically, the retainer should be worn at least 2 years, and should be
worn semi-permanently, only if severe crowding is detected.

Chapter 10_ Retainers 5 5 9

 ►► Fig. 1 0 -1 3 (c o n tin u e d ) Retainer for a patient with spacing.

560 ►► Chapter 10 _ Retainers

• • • •
 © • • #

4 -3 4
KOO DAM

■ ■ K O O A L L D A M .........................
Date
Post-treatment Analysis Sheet
Name

Doctor «

1. Treatment result : □ Satisfied □ Unsatisfied

2. Notification about relapse

3. Retainer

(Upper arch) (Lower arch)

4. Past Dental History

5. Total fees

6. Others

Department of Orthodontics IDcjiU

►► F ig . 1 0 -1 4 Post-treatment Analysis Sheet.

Chapter 10 _ Retainers 4 4 561

 REFERENCES

1. Al-Nimri K, Al Habashneh R, and Obeidat M. Gingival health and relapse tendency: a prospective
study of two types of lower fixed retainers. Australian Orthod 25:142-146, 2009.
2. Barrer HG. Protecting the integrity of mandibular incisor position through keystoning procedure and
spring retainer. J Clin Orthod 9:486-494, 1975.
3. Behrents RG. A treatise on the continuum of growth in the aging craniofacial skeleton. Ann Arbor,
Mich: University of Michigan Center for Human Growth and Development, 1984.
4. Bennett JC, and McLaughlin RP. Orthodontic management of the dentition with the preadjusted
appliance. Isis Medical Media, 1997.
5. Blake M, and Bibby K. Retention and stability: A review of the literature. Am J Orthod Dentofacial
Orthop 114:299-306, 1998.
6. Boese LR. Fiberotomy and reproximation without lower retention 9 years in retrospect: Part II. Angle
Orthod 50:169-178, 1980.
7. Bolton WA. Disharm ony in tooth size and its relationship to the analysis and treatm ent of
malocclusion. Angle Orthod 28:113-130, 1958.
8. Bolton WA. The clinical application of a tooth size analysis. Am J Orthod 48:504-529, 1962.
9. Booth FR. Effect on periodontal health of long-term bonded mandibular canine-to-canine retainers.
Angle Orthod, Pending.
10. Daskalogiannakis J, and A. Ammann. Glossary of orthodontic terms, Quintessence, 2000.
11. Edwards JG. A long-term prospective evaluation of the circumferential supracrestal fiberotomy in
alleviating orthodontic relapse. Am J Orthod Dentofacial Orthop 93:380-387, 1988.
12. Edwards JG. Soft-tissue surgery to alleviate orthodontic relapse. Dent Clin North Am 37:205-225,
1993.
13. Gardner RA, Harris EF, Vaden JL. Postorthodontic dental changes: a longitudinal study. Am J Orthod
Dentofacial Orthop 114:582-7, 1998.
14. Huang GJ, Justus R, Kennedy DB, and Kokich VG. Stability of anterior openbite treatment with crib
therapy. Angle Orthod 60:17-24, 1990.
15. Joondeph DR. Retention and relapse. In:graber TM, Vararsdall RL, Vig KWL, eds. Orthodontics:

© Current Principle and Techniques. Ed4. St Louise: Mosby, 2005.

9 16. Kim Jl, Akimoto S, Shinji H, and Sato S. Importance of vertical dimension and cant of occlusal plane in
9 craniofacial development. Int J Stomatol Occlusion Med 2:114-121,2009.
17. Kim Jl. Practical Clinical Orthodontics. Vol 1. Orthodontic treatment with MEAW. Well publishing Inc,
2012.
18. Kim Jl. Practical Clinical Orthodontics. Vol 2. Orthodontic Diagnosis. Well publishing Inc, 2013.
19. Kim Jl. Practical Clinical Orthodontics. Vol 3. Early orthodontic treatment. Well publishing Inc, 2015.

562 ►► Chapter 10 _ Retainers

© • ® ®
 • • @ ®

20. Little RM, Riedel RA, and Artun J. An evaluation of changes in mandibular anterior alignment from 10-
20 years post retention. Am J Orthod 93:423-428, 1988.
21. Little RM, Wallen TR, and Riedel RA. Stability and relapse of mandibular incisor alignment - first
premolar extraction cases treated by traditional edgewise orthodontics. Am J Orthod 80:349-365,
1981.
22. Little RM. Stability and relapse of dental arch alignment. BrJ Orthod 17:235-241, 1990.
23. McNamara JA Jr, and Brudon WL. Orthodontics and Dentofacial Orthopedics. Needham Press, 2001.
24. McReynolds DC, and Little RM. Mandibular second premolar extraction- postretention evaluation of
stability and relapse. Angle Orthod 61:133-144, 1991.
25. Nanda RN, and Burstone CJ. Retention and stability in orthodontics. WB Saunders, 1993.
26. Nanda RS, and Nanda SK. Considerations of dentofacial growth in long-term retention an stability: Is
active retention needed? Am J Orthod Dentofacial Orthop 101:297-302, 1992.
27. Othman S, and Harradine N. Tooth size discrepancies in an orthodontic population. Angle Orthod
77:668-674, 2007.
28. Proffit WR. Contemporary orthodontics. St Louis: CV Mosby company, 1986.
29. Reitan K. Tissue rearrangement during the retention of orthodontically rotated teeth. Angle Orthod
29:105-113, 1959.
30. Rinchuse DJ, and Kandasamy S. Evidence-based versus experience-based views on occlusion and
TMD. Am J Orthod Dentofacial Orthop 127:249-254, 2005.
31. Rossouw PE, and Tortorella. Enamel reduction procedures in orthodontic treatment. J Can Dent Assn
69:378-383, 2003.
32. Roth RH. Functional occlusion for the orthodontist. J Clin Orthod 15(1-4), 1981.
33. Shah AA, Elcock C, and Brook AH. Incisor crown shape and crowding. Am J Orthod Dentofacial
Orthop 118:624-628, 2000.
34. Sheridan JJ. Air Rotor Stripping (ARS) Manual. New Orleans: Raintree Essix, 2005.
35. Straub WJ. Malfunction of the tongue. Part I . Am J Orthod 46:404-424, 1960.
36. Straub WJ. Malfunction of the tongue. Part II. Am J Orthod 47:596-617, 1961.
37. Straub WJ. Malfunction of the tongue. Partin. Am J Orthod 48:486-503, 1962.
38. Zachrisson BU, and Mjor IA. Remodeling of teeth by grinding. Am J Orthod 68:545-553, 1975.
39. Zachrisson BU. Long-term experience with bonded retainers: update and clinical advice. J Clin Orthod
41:728-737, 2007.

Chapter 10 _ Retainers ◄◄ 563

 PART III

CLINICAL CASES
 Chapter 11

A CASE OF THE
MAXILLARY AND
MANDIBULAR
FIRST PREMOLAR
EXTRACTION
 Case summary

This 12.4 year-old boy had chief complaints on crowded anterior teeth and about protrusive lips.
The facial asymmetry was observed from the frontal view, and the protruded lips were detected
from the lateral view. According to the intraoral photographs, the molars and canines were in
bilateral Class I relationship, and the dental crowding was observed in the anterior area of both
maxilla and mandible (4mm of space deficiency in the maxilla and 6mm in the mandible).
Skeletally, he had a Class I low angle pattern.

Even a steep occlusal plane was observed, and the maxillary and mandibular molars and canines
had a Class I relationship. Therefore, it was decided to extract the maxillary and mandibular first
premolars to solve the problems of anterior crowding and the protruded lips. The .018” slot
standard brackets were used.

The total treatment duration was 15 months. A wrap-around type removable retainer was used on
the maxilla, and a bonded retainer was placed in between the mandibular second premolars.

Pre-treatment records

1) Pre-treatment facial photographs (Fig. 11-1)

• From the lateral view, protruded lips are apparent.

• From the frontal view, due to the excessive hyper activity mentalis muscle, the patient has
facial asymmetry and finds it difficult to close the lips unconsciously.

►► Fig. 11-1 Pre-treatment facial photographs.

568 ►► Chapter 11 _ A Case of I he Maxillary and Mandibular First Premolar Extraction q ^ q

 • • 9 9

2) Pre-treatment intraoral photographs (Fig. 11-2)

• The left and right sides of molars and canines are in a Class I relationship, and the dental
crowding is observed in the anterior area of both the maxilla and the mandible (4mm of space
deficiency in the maxilla and 6mm in the mandible).
• The buccal surfaces of maxillary first molars are parallel to each other, and the mandibular
second molars are mesially rotated.
• The mandibular arch form has a minor U-shape.

►► F ig - 1 1 - 2 Pre-treatment intraoral photographs.

3) Pre-treatment panoramic radiograph (Fig. 11-3)

• The maxillary second molars are erupted and the tooth germs of mandibular third molar are
formed. The posterior teeth in the right side of mandible are more mesially inclined than the
ones at the opposite side.

►► Fig. 11-3 Pre-treatment panoramic radiograph.

Chapter 11 _ A Case of The Maxillary and Mandibular First Premolar Extraction < ◄ 569
 4) Pre-treatment cephalometric radiograph (Fig. 11-4)

• Protruded maxillary incisors are observed.

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

Measurement Mean S.D. 2009.10.13

ODI 74.5 6.07 75.4
APDI 81.4 3.79 79.8
CF 155.9 6.52 155.2
FMA(deg) 26 4.91 33.6
UOP(deg) 10 - 17.8
POP(deg) 13 - 24.2
U1 to FH(deg) 114 4.6 122.9
1)1 edge to lip(mm) 3.9 1.38 5.2
L1 to MP(deg) 91.4 3.78 103
IIA(deg) 127 7 100.5
UL(mm) 2.83 2 3.7
LL(mm) 2.33 2 7.6

►► F i g - 1 1 -4 Pre-treatment cephalometric radiograph and the measurement values.

• The skeletal pattern (ODI: 75.4, APDI: 79.8 and CF: 155.2) showed a Class I low angle.
• The denture pattern was as follows:
a) U1 to lip line: 5.2mm
b) UOPtoFH: 17.8°
c) POP to FH: 24.2°
d) U1 to FH: 122.9°
e) IMPA: 103°
f) IIA: 100.5°
This indicated that the patient suffered from the protrusive lips.
• From the E-line, the upper lip was protruded about 3.7mm, and the lower lip was protruded
about 7.6mm.

570 ►► Chapter 11 _ A Case of The Maxillary and Mandibular First Premolar Extraction
© @ tt ©
 • • • •

Diagnosis and treatment planning

1) Problem lists

• Protrusive lips,
• Protruded maxillary and mandibular incisors,
• Class I relationship of the canines and molars,
• Tooth size discrepancy (anterior Bolton ratio (ABR): 87.6% - 2.8mm excess per side in the
mandible).

2) Diagnosis

Skeletal Class I low angle.

3) Treatment plan

Although the patient suffered from steep posterior occlusal plane, his maxillary and mandibular
molars and canines were in Class I relationship. Therefore, to solve the problems of protrusive lips
and crowding, the premolar extraction was planned.
Despite a steep posterior occlusal plane (POP), the maxillary and mandibular first premolars had to
be extracted due to the Class I canine and molar relationship.

Here, the .018” slot standard brackets were used as a fixed orthodontic appliance.

Chapter 11 _ A Case of The Maxillary and Mandibular First Premolar Extraction 571
 Treatment procedures

• The crowded lateral incsiors were excluded when bonding the brackets.
• The maxillary first molars were bonded with the convertible brackets, while the mandibular
first molars were bonded with the single buccal tubes.
• .014” NiTi wire was inserted both to the maxillary and mandibular arch, and protective sheaths
were added to prevent mucosal irritation.

F ig . 11-5 Intraoral photographs of initial archwires.

• The maxilla: after aligning the lateral incisors, an energy chain was used (on the .016” stainless
steel archwire) from the canines to the first molars to retract the canines.
• The mandible: in order to gain the space for the lateral incisors and to trigger teeth movement,
.016” stainless steel archwire with open coil springs was used.

572 Chapter 11 _ A Case of The Maxillary and Mandibular First Premolar Extraction
• • • •
 • © © •

►► Fig 11-6 Intraoral photographs after 2 months of treatment.

• The maxilla: In order to induce the canine retraction, the .016” stainless steel archwire was
used from the first molars to canines along with energy chain. Here, the energy chain closed
the minor space that already existed in the four maxillary anterior teeth area.
• The mandible: after gaining the space for the lateral incisors, the brackets were bonded to the
lateral incisors, and the .014” NiTi was used to align the teeth.

►► F ig . 11-7 Intraoral photographs after 3 months of treatment.

Chapter 11 _ A Case of The Maxillary and Mandibular First Premolar Extraction 44 573
 • The maxilla: the canine was continuously retracted.
• The mandible: On the mandibular incisors, the .016” x.022” stainless steel archwire with a
crown labial torque was used, and the hooks were attached bilaterally between the lateral
incisors and canines. Subsequently, the energy chain was used from the first molars to the
hooks for space closure.

►► Fig. 11-8 Intraoral photographs after 5 months of treatment.

• The maxilla:.0l6” x .022” combination loop (made from the stainless steel archwire), that has
l mm intrusion step and crown labial torque on the anterior teeth, was used to close the anterior
space. Here, the canines were continuously retracted on the posterior direction.
• The mandible: In order to close the extraction space successfully, the mandibular second
premolars were moved to the forward direction (slightly to the right). To further induce the
backward movement of anterior teeth and the forward movement of molars, the extraction
space had to be closed through the use of archwire with crown labial torque. By following the
above steps, bite deepening and the changes in the occlusal plane could be prevented.

574 ►► Chapter 11 _ A Case of The Maxillary and Mandibular First Premolar Extraction
© • • •
 • • ® •

►► F ig. 11-9 Intraoral photographs after 6 months of treatment.

• When closing a mandibular extraction space (Fig. 11-10).

1. Retraction of the mandibular anterior teeth: In order to form a Class I canine relationship,
the mandibular anterior teeth were moved posteriorly. In general, when closing the first
premolar extraction space, the retraction of anterior teeth occurs more than the protraction
of posterior teeth; this is a normal phenomenon. Here, if there was excessive retraction of
anterior teeth, the bite deepening as well as the aggravated curve of Spee would have been
observed.
2. Protraction of molars: When the canines were retracted towards the second premolar area,
in order to correct the occlusion, the mandibular second premolars were placed between the
maxillary canines and the second premolars. Here, the .016” x.022” stainless steel
archwires that has crown labial torque on the anterior area were used to induce the forward
movement of mandibular molars.

►► F ig . 1 1 -1 0 Closing the extraction space.

Chapter 11 _ A Case of The Maxillary and Mandibular First Premolar Extraction < ◄ 575
 • The Class I relationship (of canines and premolars) was maintained.
• The energy chain was used to close a minor space in the mandible.
• After closing the extraction space, the appliance was extended to the maxillary and mandibular
second molars, and then re-leveling and re-alignment were performed.

►► Fig. 11-11 Intraoral photographs after 10 months of treatment.

576 ►► Chapter 11 _ A Case of The Maxillary and Mandibular First Premolar Extraction
• • • •
 # @ 9 •

• In order to establish an acceptable occlusion while leveling the curve of Spee and forming the
Class I canine relationship, MEAW was used as a final archwire. Here, due to the tip-back
activation, the maxillary MEAW formed the shape of curve of Spee, and the mandibular
MEAW formed the shape of reverse curve of Spee. Since these shapes re-opened the extraction
space both on the maxilla and on the mandible, an energy chain or a figure of 8 tie was used on
the first molars. By using 3/16” 6oz elastics from the first loop of maxillary MEAW to the third
loop of mandibular MEAW, the mandibular premolars were extruded, and by intruding and
uprighting the mandibular molars, the mandible was moved forward. These corrected the
occlusion accurately, and during this procedure it was essential to apply the crown lingual
torque on the mandibular MEAW.

►► F ig . 1 1 -1 2 Intraoral photographs after 12 months of treatment.

Chapter 11 _ A Case of The Maxillary and Mandibular First Premolar Extraction « ◄ 577
 Post-treatment records

1) Post-treatment facial photographs (Fig. 11-13)

►► F ig . 1 1 -1 3 Post-treatment facial photographs.

2) Post-treatment intraoral photographs (Fig. 11-14)

• Desired tooth alignment and Class I canine and molar relationship were obtained.

578 ►► Chapter 11 _ A Case of The Maxillary and Mandibular First Premolar Extraction
• • ® •
 • • • ©

3) Post-treatment panoramic radiograph (Fig. 11-15)

► Fig. 1 1 -1 5 Post-treatment panoramic radiograph.

4) Post-treatment cephalometric radiograph (Fig. 11-16)

Measurement Mean S.D. 2011.1.4

ODI 74.5 6.07 68.2
APDI 81.4 3.79 82.5
CF 155.9 6.52 150.6
FMA(deg) 26 4.91 37.4
UOP(deg) 10 - 17.5
POP(deg) 13 - 21.3
U1 to FH(deg) 114 4.6 109.3
U1 edge to lip(mm) 3.9 1.38 4.6
L1 to MP(deg) 91.4 3.78 99.1
IIA(deg) 127 7 114.2
UL(mm) 2.83 2 0.8
LL(mm) 2.33 2 1.7

►► Fig. 1 1 -1 6 Post-treatment cephalomertic radiograph and measurement values.

Chapter 11 _ A Case of The Maxillary and Mandibular First Premolar Extraction ◄◄ 579
 5) Cephalometric superimpositions (Fig. 11-17)

Measurement Mean S.D. 2009.10.13 2011.1.4

ODI 74.5 6.07 75.4 68.2
APDI 81.4 3.79 79.8 82.5
CF 155.9 6.52 155.2 150.6
FMA(deg) 26 4.91 33.6 37.4
UOP(deg) 10 - 17.8 17.5
POP(deg) 13 - 24.2 21.3
U1 to FH(deg) 114 4.6 122.9 109.3
U1 edge to lip(mm) 3.9 1.38 5.2 4.6
L1 to MP(deg) 91.4 3.78 103 994
HA(deg) 127 7 100.5 114.2
UL(mm) 2.83 2 3.7 0.8
LL(mm) 2.33 2 7.6 1.7

►► Fig. 1 1 -1 7 Superimposition and comparison ofpre-and post-treatment measurement values.

580 ►► Chapter 11 _ A Case of The Maxillary and Mandibular First Premolar Extraction
@ @ • ®
 • ® • •

6) Pre- and Post-treatment facial photographs (Fig. 11-18)

►► Fig. 1 1 -1 8 A. Pre-treatment facial photographs.

B. Post-treatment facial photographs.

7) Pre- and Post-treatment intraoral photographs (Fig. 11-19)

►► Fig. 1 1 -1 9 A. Pre-treatment intraoral photographs.

B. Post-treatment intraoral photographs.

Chapter 11 _ A Case of The Maxillary and Mandibular First Premolar Extraction < ◄ 581
 8) Post-retention facial and intraoral photographs (Fig. 11-20)

►► F ig . 1 1 -2 0 Post-retention facial and intraoral photographs (16 months after the treatment).

582 ►► Chapter 11 _ A Case of The Maxillary and Mandibular First Premolar Extraction
 • • • @

REFERENCES

1. Kim BH, and Yang WS. Regional load deflection rate of multiloop edgewise archwire. Korea J Orthod
29:673-688, 1999.
2. Kim Jl, Akimoto S, Shinji H, and Sato S. Importance of vertical dimension and cant of occlusal plane in
craniofacial development. Int J Stomatol Occlusion Med 2:114-121,2009.
3. Kim Jl. Practical Clinical Orthodontics. Vol 1. Orthodontic treatment with MEAW. Well publishing Inc, 2012.
4. Kim Jl. Practical Clinical Orthodontics. Vol 2. Orthodontic Diagnosis. Well publishing Inc, 2013.
5. Kim YH. Anterior openbite and its treatment with Multiloop Edgewise Archwire. Angle Orthod 57:290-
321, 1987.
6. Kim YH. Treatm ent of severe openbite malocclusion w ithout surgical intervention. Growth
modification: What works, what doesn’t, and why. J.A. McNamara, Craniofacial Growth Series 35,
Center for human Growth and Development, The University of Michigan. Ann Arbor. 1999.
7. Kim YH. Treatment of anterior openbite and deep overbite malocclusions with Multiloop Edgewise
Arch-Wire (MEAW) therapy. The enigma of the vertical dimension, J.A. McNamara, Craniofacial
Growth Series 36, Center for human Growth and Development, The University of Michigan. Ann
Arbor. 2000.

Chapter 11 _ A Case of The Maxillary and Mandibular First Premolar Extraction « 583
 Chapter 1 2

A CASE OF THE MAXILLARY

FIRST PREMOLAR AND
MANDIBULAR SECOND
PREMOLAR EXTRACTION
 C a s e sum m ary

This 14.3 year-old patient had chief complaints about his protrusive lips. The facial asymmetry
was observed from the frontal view, and the protruded lips and the retruded chin were observed
from the lateral view. From the intraoral photograph, Class I molar and canine relationship, the
protrusion of maxillary anterior teeth, and the mandibular anterior crowding were detected.
Skeletally, he had a Class I low angle pattern.

The molars and canines had a Class I relationship, and the maxillary first premolars and the
mandibular second premolars were extracted 1) to retract the anterior teeth, 2) to protract the
posterior teeth, and 3) to correct the occlusal plane. The .018” slot standard brackets were used for
the treatment.

The total treatment period was 23 months. A wrap-around type removable retainer was used on the
maxilla, and a premolar-to-premolar bonded retainer was applied on the mandible.

Pre-treatment re co rd s

1) Pre-treatment facial photographs (Fig. 12-1)

• From the lateral view, the protruded lips and the retrusive chin were observed.
• From the frontal view, due to the excessive hyperactive mentalis muscle, the patient found it
difficult to close the lips unconsciously.

►► Fig. 12-1 Pre-treatment facial photographs.

58B ►► Chapter 12 _ A Case of the Maxillary First Premolar and Mandibular Second Premolar Extraction
 • • • •

2) Pre-treatment intraoral photographs (Fig. 12-2)

• Class I canine and molar relationship, and the labioversion of anterior teeth and dental
crowding were observed in the mandibular anterior area (6mm arch length discrepancy in the
mandibular arch). ;
• The buccal surfaces of maxillary first molars were parallel to each other, and the mandibular
first molars were mesially rotated.
• The mandibular dental arch had a minor U-shape.

►► F ig. 12-2 Pre-treatment intraoral photographs.

3) Pre-treatment panoramic radiograph (Fig. 12-3)

• The maxillary and mandibular second molars were erupting, and the tooth germs of mandibular
third molars were formed.

►► F ig . 12-3 Pre-treatment panoramic radiograph.

Chapter 12 _ A Case of the Maxillary First Premolar and Mandibular Second Premolar Extraction « ◄ 587
 4) Pre-treatment cephalometric radiograph (Fig. 12-4)

• Protruded maxillary incisors were observed.

• Severe curve of Spee, which had been caused by the mesial tilting of mandibular molars, was
observed.
• Insufficient eruption space for the maxillary second and third molars was observed

Measurement Mean S.D. 2009.2.13

ODI 74.5 6.07 74
APDI 81.4 3.79 81.1
CF 155.9 6.52 155.1
FMA(deg) 26 4.91 27.7
UOP(deg) 10 - 13.3
POP(deg) 13 - 12.8
U1 to FH(deg) 114 4.6 124.1
U1 edge to lip(mm) 3.9 1.38 5.9
L1 to MP(deg) 91.4 3.78 103.9
IIA(deg) 127 7 104.3
UL(mm) 2.83 2 5.3
LL(mm) 2.33 2 10.7

►► F ig . 12 -4 Pre-treatment cephalometric radiograph and measurement values.

• The skeletal pattern (ODI: 74.0, APDI: 8l.l and CF: 155.1) showed a Class I low angle.
• The denture pattern was as follows:
a) Ul to lip line: 5.9mm
b) UOP to FH: 13.3°
c) POP to FH: 12.8°
d) Ul to FH: 124.1°
e) IMPA: 103.9°
f) IIA: 104.3°
This indicated that the patient had a severe protrusive pattern.
• From the E-line, the upper lip was protruded about 5.3mm, and the lower lip was protruded
about 10.7mm.

588 ►► Chapter 12 _ A Case of the Maxillary First Premolar and Mandibular Second Premolar Extraction
• • • •
 9 9 ® @

© D ia g n o sis and treatment planning

1) Problem lists

• Protrusive lips, &

• Retrusive chin,
• Protruded maxillary incisor and excessive overjet,
• Class I canine and molar relationship.

2) Diagnosis

Skeletal Class I low angle.

3) Treatment plan

Although the patient had flat posterior occlusal plane, the premolar extraction was performed to
solve the problems of Class I canine and molar relationship, and the problems of severe anterior
crowding and protrusion as well. Due to excessive overjet, the maxillary first premolars and
mandibular second premolars were decided to be extracted,
ffere, the .018” slot standard brackets were used as a fixed orthodontic appliance.

Chapter 12 _ A Case of the Maxillary First Premolar and Mandibular Second Premolar Extraction ◄◄ 589
 Treatment pro ced u re s

• In order to prevent the lip biting habit, a posterior bite block (PBB) that includes a lip bumper
was placed on the mandible, and then a .014” NiTi wire was used to perform the leveling and
aligning the maxillary teeth.

►► Fig. 12-5 Intraoral photographs after 1 month of treatment.

• The mandibular PBB was used to induce the mandibular molar intrusion and the mandibular
incisor extrusion. This could improve the Class II relationship by rotating the occlusal plane in
the counter-clockwise direction and by moving the mandible forward.

►► Fig. 12-6 Intraoral photographs after applying the mandibular PBB, and a diagram of its effects.

590 ►► Chapter 12 _ A Case of the Maxillary First Premolar and Mandibular Second Premolar Extraction
• ® • •
 «3 0 0

• The maxilla: After the canine retraction, the .016” x .022” combination loop (made of stainless
steel archwire), that has 1mm intrusion step and crown labial torque in the anterior area, was
used to close the anterior space. During this procedure, the canines were retracted continuously.
• The mandible: in order to upright and retract the first premolars, open coil springs (OCS) were
used along with the .016” stainless archwire.
•
#

►► Fig. 12-7 Intraoral photographs after 4 months of treatment.

• The maxilla: re-leveling was performed after closing the extraction space.
• The mandible: The .0l6” x .022” stainless archwire with crown labial torque was used and the
bilateral mandibular hooks were added between the lateral incisors and canines. Then, an
energy chain was used from the mandibular first molar to the hooks to close the space.

►► Fig. 12-8 Intraoral photographs after 8 months of treatment.

Chapter 12 _ A Case of the Maxillary First Premolar and Mandibular Second Premolar Extraction < « 591
 • The appliance was extended to second molars, and the leveling and alignment were re­
performed after closing the mandibular extraction space.
• The maxilla: MEAW was used to elevate the occlusion.

►► Fig 1 2-9 Intraoral photographs after 15 months of treatment.

• In order to establish an acceptable occlusion while leveling the curve of Spee and forming the
Class I canine relationship, MEAW was used as a final archwire. Here, due to the tip-back
activation, the maxillary MEAW formed the shape of curve of Spee, and the mandibular
MEAW formed the shape of reverse curve of Spee. Since these shapes re-opened the extraction
space both on the maxilla and on the mandible, an energy chain or a figure of 8 tie was used on
the first molars. By using 3/16” 6oz elastics from the first loop of maxillary MEAW to the third
loop of mandibular MEAW, the mandibular premolars were extruded, and by intruding and
uprighting the mandibular molars, the mandible was moved forward.
These, corrected the occlusion accurately, and during this procedure, it was essential to apply
the crown lingual torque on the mandibular MEAW.

592 ►► Chapter 12 _ A Case of the Maxillary First Premolar and Mandibular Second Premolar Extraction
 • • • •

►► Fig. 1 2 -1 0 Intraoral photographs after 17 months of treatment.

• In order to correct the midline deviation, 3/16” 6oz elastics were used from the first loop of the
maxillary MEAW to the third loop of the mandibular MEAW during the day time, and extra
elastics on the left side were used from the second loop of the maxillary MEAW to the fourth
loop of the mandibular MEAW during the night time.

►► Fig. 12-11 Intraoral photographs after 20 months of treatment.

Chapter 12 _ A Case of the Maxillary First Premolar and Mandibular Second Premolar Extraction «◄ 593
 Post-treatmentrecords

1) Post-treatment facial photographs (Fig. 12-12)

►► Fig. 1 2 -1 2 Post-treatment facial photographs.

594 ►► Chapter 12 _ A Case of the Maxillary First Premolar and Mandibular Second Premolar Extraction
• • • #
 • # « •

►► Fig. 1 2 -1 4 Post-treatment panoramic radiograph.

4) Post-treatment cephalometric radiograph (Fig. 12-15)

Measurement Mean S.D. 2011.1.19

ODI 74.5 6.07 67.0
APDI 81.4 3.79 82.2
CF 155.9 6.52 149.2
FMA(deg) 26 4.91 29.8
UOP(deg) 10 - 12
POP(deg) 13 - 10.5
U1 to FFI(deg) 114 4.6 114.8
U1 edge to lip(mm) 3.9 1.38 4.2
L1 to MP(deg) 91.4 3.78 99.8
HA(deg) 127 7 115.6
UL(mm) 2.83 2 4.1
LL(mm) 2.33 2 5.5

►► Fig. 1 2 -1 5 Post-treatment cephalomertic radiograph and measurement values.

Chapter 12 _ A Case of the Maxillary First Premolar and Mandibular Second Premolar Extraction 595
 5) Cephalometric superimposition (Fig. 12-16)

Measurement Mean S.D. 2009.2.13 2011.1.19

ODI 74.5 6.07 74 67.0
APDI 81.4 3.79 81.1 82.2
CF 155.9 6.52 155.1 149.2
FMA(deg) 26 4.91 27.7 29.8
UOP(deg) 10 - 13.3 12
POP(deg) 13 - 12.8 10.5
U1 to FH(deg) 114 4.6 124.1 114.8
U1 edge to lip(mm) 3.9 1.38 5.9 4.2
L1 to MP(deg) 91.4 3.78 103.9 99.8
IIA(deg) 127 7 104.3 115.6
UL(mm) 2.83 2 5.3 4.1
LL(mm) 2.33 2 10.7 5.5

p- ► F ig . 1 2 -1 6 Superimposition and comparison of pre- and post-treatment measurement values.

596 ►► Chapter 12 _ A Case of the Maxillary First Premolar and Mandibular Second Premolar Extraction © V"v
 9 9 • ®

6) Pre- and Post-treatment facial photographs (Fig. 12-17)

►► F ig . 1 2 -1 7 A. Pre-treatment facial photographs .

B. Post-treatment facial photographs .

7) Pre- and Post-treatment intraoral photographs (Fig. 12-18)

►► F ig. 1 2 -1 8 A. Pre-treatment intraoral photographs.

B. Post-treatment intraoral photographs.

Chapter 12 _ A Case of the Maxillary First Premolar and Mandibular Second Premolar Extraction < « 597
 8) Post-retention facial and intraoral photographs (Fig. 12-19)

►► F ig . 1 2 -1 9 Post-retention facial and intraoral photographs (16 months after the treatment).

►► F ig . 1 2 -2 0 Intraoral photographs of the patient with a retainer on.

598 ►► Chapter 12 _ A Case of the Maxillary First Premolar and Mandibular Second Premolar Extraction
• • • •
 • • © ®

REFERENCES

1. Iscan HN, and Sarisoy L. Comparison of the effects of passive posterior bite-blocks with different
construction bites on the craniofacial and dentoalveolar structures. Am J Orthod Dentofac Orthop
112:171-178, 1997.
2. Kim BH, and Yang WS. Regional load deflection rate of multiloop edgewise archwire. Korea J Orthod
29:673-688, 1999.
3. Kim Jl, Akimoto S, Shinji H, and Sato S. Importance of vertical dimension and cant of occlusal plane in
craniofacial development. Int J Stomatol Occlusion Med 2:114-121,2009.
4. Kim Jl. Practical Clinical Orthodontics. Vol 1. Orthodontic treatment with MEAW. Well publishing Inc,
2012.
5. Kim Jl. Practical Clinical Orthodontics. Vol 2. Orthodontic Diagnosis. Well publishing Inc, 2013.
6. Kim YH. Anterior openbite and its treatment with Multiloop Edgewise Archwire. Angle Orthod 57:290-
321, 1987.
7. Kim YH. Treatm ent of severe openbite m alocclusion w ithout surgical intervention. Growth
modification: What works, what doesn’t, and why. J.A. McNamara, Craniofacial Growth Series 35,
Center for human Growth and Development, The University of Michigan. Ann Arbor. 1999.
8. Kim YH. Treatment of anterior openbite and deep overbite malocclusions with Multiloop Edgewise
Arch-Wire (MEAW) therapy. The enigma of the vertical dimension, J.A. McNamara, Craniofacial
Growth Series 36, Center for human Growth and Development, The University of Michigan. Ann
Arbor. 2000.

Chapter 12 _ A Case of the Maxillary First Premolar and Mandibular Second Premolar Extraction ◄◄ 599
 Chapter 13

A NON-EXTRACTION
TREATMENT CASE
IN CLASS II
MALOCCLUSION
 Case summary

This 11.10 year-old boy had chief complaints on his protruded anterior teeth. The facial asymmetry
was observed from the frontal view, and the protrusive lips were observed from the lateral view.
According to the intraoral photographs, Class II canine and molar relationship, excessive overjet
and the labioversion of maxillary incisors were all apparent. Skeletally, he had a Class II high
angle pattern.

Despite the protrusive lips, the lateral view was still aesthetically acceptable when the mandible
was consciously moved to the anterior direction. Also due to the steep posterior occlusal plane
(POP), the twin block appliance was used 1) to move the mandible forward, and 2) to upright and
extrude the mesially tilted mandibular molars. In this, the .018” slot standard brackets were used
for the treatment.

The total treatment duration was 12 months. A wrap-around type removable retainer was used on
the maxilla, and a bonded retainer was placed between the first premolars.

Pre-treatment records

1) Pre-treatment facial photographs (Fig. 13-1)

• Protrusive maxillary lips and retrusive mandibular lips were observed.

►► Fig. 13-1 Pre-treatment facial photographs.

602 ►► Chapter 13 _ A Non-extraction Treatment Case in Class II Malocclusion

 • # • •

2) Pre-treatment intraoral photographs (Fig. 13-2)

• The molars and canines were in Class II relationship, and the labioversion of anterior teeth was
observed.
• There was excessive overjet.
• The buccal surfaces of the maxillary first molars and the mandibular first molars were mesially
rotated.
• The maxillary and mandibular dental arch had a V-shape arch form.

►► F ig . 13-2 Pre-treatment intraoral photographs.

3) Pre-treatment panoramic radiograph (Fig. 13-3)

• Besides the maxillary and the mandibular third molars, all the permanent teeth were erupted.

►► F ig . 13-3 Pre-treatment panoramic radiograph.

Chapter 13 _ A Non-extraction Treatment Case in Class II Malocclusion <« 603

 4) Pre-treatment cephalometric radiograph (Fig. 13-4)

• Maxillary protrusion and labioversion of upper incisors were observed.

• Thin premaxillary alveolar region was observed.
• Deep curve of Spee was observed in the mandible.
• Insufficient eruption space for the second and the third molars was observed.

Measurement Mean S.D. 2010.4.5

ODI 74.5 6.07 70
APDI 81.4 3.79 69
CF 155.9 6.52 139
FMA(deg) 26 4.91 32.5
UOP(deg) 10 - 12.9
POP(deg) 13 - 19
U1 to FH(deg) 114 4.6 126.6
U1 edge to lip(mm) 3.9 1.38 1.1
L1 to MP(deg) 91.4 3.78 92.8
IIA(deg) 127 7 108.1
UL(mm) 2.83 2 5.7
LL(mm) 2.33 2 4.6

►► Fig. 1 3 -4 Pre-treatment cephalometric radiograph and measurement values.

• The skeletal pattern (ODI: 70.0, APDI: 69.0 and CF: 139) showed a Class II high angle.
• The denture pattern was as follows:
a) Ul to lip line: 1.1mm,
b) UOP to FH: 12.9°
c) POP to FH: 19.0°
d) Ul to FH: 126.6°
e) IMPA: 92.8°
f ) IIA: 108.1°
This showed that the patient suffered from protrusion.
• From the E-line, the upper lip was protruded about 5.7mm, and the lower lip was protruded
about 4.6mm.

604 ►► Chapter 13 _ A Non-extraction Treatment Case in Class II Malocclusion

 © @ « •

►► F ig. 1 3-5 A. Facial photographs of maximum bite.

B. Facial photographs of the forward positioning of the mandible.

►k F ig . 1 3 -6 A. Intraoral photographs of maximum bite.

B. Intraoral photographs of the forward positioning of the mandible.

Chapter 13 _ A Non-extraction Treatment Case in Class II Malocclusion <■* B05

 Diagnosis and treatment planning

1) Problem lists

• Protruded maxillary incisors, and excessive overjet,

• Class II canine and molar relationship
• Mandibular retrusion

2) Diagnosis

Skeletal Class II high angle.

3) Treatment plan

Although the patient had excessive overjet, high angle Class II malocclusion and Class II canine
and molar relationship, the lateral view was still aesthetically satisfying, when the mandible was
deliberately moved forward. Therefore, a non-extraction treatment was approachable.

Despite a steep posterior occlusal plane (POP), the twin block appliance was used 1) to move the
mandible forward, and 2) to extrude and upright the mesially tilted mandibular molars.
Here, the .018” slot standard brackets were used as a fixed orthodontic appliance.

BOB ►► Chapter 13 _ A Non-extraction Treatment Case in Class II Malocclusion • • • •

r< « Treatment procedures

A twin block appliance with an expansion screw both on the maxilla and on the mandible (the
maxillary SME type, the mandibular Schwarz type), was used. Here, the expansion device both on
the maxilla and on the mandible was activated twice a week. •

►► Fig. 1 3 -7 Intraoral photographs of the patient with a twin block appliance on.

Chapter 13 _ A Non-extraction Treatment Case in Class II Malocclusion 607

 • Strategic leveling and alignment
After using a twin block appliance, bracket bonding was done strategically both on the maxilla
and on the mandible to correct the occlusion. Here, the conditions of forward positioned
mandible remained consistent.
The open coil springs were used only in the maxillary second premolar area. In addition,
besides the mandibular second premolars and the mandibular first molars, the brackets were
bonded to all the teeth.

►► Fig. 13-8 Intraoral photographs after 4 months of treatment.

608» Chapter 13 _ A Non-extraction Treatment Case in Class II Malocclusion

• @ • ©
 « # • •

• Finishing
To coiTect the midline deviation, and the maxillary and mandibular occlusion, the maxillary
and mandibular MEAWs and 3/16” 6oz elastics were used from the first loop of the maxillary
MEAW to the third loop of the mandibular MEAW. As the midline deviated to the left side, the
patient was advised to wear the additional elastics from the second loop of the maxillary
MEAW to the fourth loop of the mandibular MEAW during the night.
©

►^ Fig. 13-9 Intraoral photographs after 8 months of treatment.

Chapter 13 _ A Non-extraction Treatment Case in Class II Malocclusion 609

 Post-treatment records

1) Post-treatment facial photographs (Fig. 13-10)

►► Fig. 1 3 -1 0 Post-treatment facial photographs.

2) Post-treatment intraoral photographs (Fig. 13-11)

610» Chapter 13 _ A Non-extraction Treatment Case in Class II Malocclusion

• • ® ©
 • • • •

3) Post-treatment panoramic radiograph (Fig. 13-12)

►► Fig. 1 3 -1 2 Post-treatment panoramic radiograph.

4) Post-treatment cephalometric radiograph (Fig. 13-13)

• Shallow overbite and overjet.

• Flattened mandibular curve of Spee.
• Uprighted mandibular second molars.

Measurement Mean S.D. 2011.4.26

ODI 74.5 6.07 67.6
APDI 81.4 3.79 70.1
CF 155.9 6.52 137.7
FMA(deg) 26 4.91 33.7
UOP(deg) 10 - 17.5
POP(deg) 13 - 14.5
U1 to FH(deg) 114 4.6 102.8
U1 edge to lip(mm) 3.9 1.38 3.6
L1 to MP(deg) 91.4 3.78 110.6
IIA(deg) 127 7 112.9
UL(mm) 2.83 2 3.9
LL(mm) 2.33 2 5.6

►► Fig. 1 3 -1 3 Post-treatment cephalomertic radiograph and measurement values.

Chapter 13 _ A Non-extraction Treatment Case in Class II Malocclusion 611

 5) Cephalometric superimposition (Fig. 13-14)

• The linguoversion of maxillary incisors and the labioversion of mandibular incisors were
observed.
• There was a Class II high angle malocclusion due to the small skeletal pattern (ODI/ APDI/
CF = 70/ 69/ 139). Relatively insufficient condylar growth was detected.
• Tooth inclination was changed due to the increase in vertical dimension.
• In general, the tooth movement induced by the uprighting and extrusion of maxillary molars,
help to generate an acceptable outcome (not the labioversion of mandibular incisors).
However, in this case, the CF value was very low (139), so the uprighting and extrusion of
mandibular molars were difficult to be obtained, and the clockwise rotation of the mandible
occurred as a result.

Measurement Mean S.D. 2010.4.5 2011.4.26

ODI 74.5 6.07 70 67.6
APDI 81.4 3.79 69 70.1
CF 155.9 6.52 139 137.7
FMA(deg) 26 4.91 32.5 33.7
UOP(deg) 10 - 12.9 17.5
POP(deg) 13 - 19 14.5
U1 to FH(deg) 114 4.6 126.6 102.8
U1 edge to lip(mm) 3.9 1.38 1.1 3.6
L1 to MP(deg) 91.4 3.78 92.8 110.6
IIA(deg) 127 7 108.1 112.9
UL(mm) 2.83 2 5.7 3.9
LL(mm) 2.33 2 4.6 5.6

►► Fig. 1 3 -1 4 Superimposition and comparison of pre- and post-treatment measurements.

612- Chapter 13 _ A Non-extraction Treatment Case in Class II Malocclusion

• ® • #
 • • # •

6) Pre- and Post-treatment facial photographs (Fig. 13-15)

►► F ig. 1 3 -1 5 A. Pre-treatment facial photographs.

B. Post-treatment facial photographs.

7) Pre- and Post-treatment intraoral photographs (Fig. 13-16)

►► F ig . 1 3 -1 6 A. Pre-treatment intraoral photographs.

B. Post-treatment intraoral photographs.

Chapter 13 _ A Non-extraction Treatment Case in Class 11Malocclusion i◄613

<
 8) Post-retention facial and intraoral photographs (Fig. 13-17)

►p- Fig. 1 3 -1 7 Post-retention facial and intraoral photographs (14 months after the treatment).

614 ►► Chapter 13 _ A Non-extraction Treatment Case in Class II Malocclusion

• • • •
 • • • •

REFERENCES

1. Clark WJ. The twin block technique: a functional appliance system. Am J Orthod Dentofaciai Orthop
93:1-18, 1988.
2. Clark WJ. Twin block functional therapy. London, Mosby-Wolfe, 1995.
3. Kim BH, and Yang WS. Regional load deflection rate of multiloop edgewise archwire. Korea J Orthod
29:673-688, 1999.
4. Kim Jl, Akimoto S, Shinji H, and Sato S. Importance of vertical dimension and cant of occlusal plane in
craniofacial development. Int J Stomatol Occlusion Med 2:114-121,2009.
5. Kim Jl. Practical Clinical Orthodontics. Vol 1. Orthodontic treatment with MEAW. Well publishing Inc,
2012.
6. Kim Jl. Practical Clinical Orthodontics. Vol 2. Orthodontic Diagnosis. Well publishing Inc, 2013.
7. Kim Jl. Practical Clinical Orthodontics. Vol 3. Early orthodontic treatment. Well publishing Inc, 2015.
8. Kim YH. Anterior openbite and its treatment with Multiloop Edgewise Archwire. Angle Orthod 57:290-
321, 1987.
9. Kim YH. Treatm ent of severe openbite malocclusion w ithout surgical intervention. Growth
modification: What works, what doesn’t, and why. J.A. McNamara, Craniofacial Growth Series 35,
Center for human Growth and Development, The University of Michigan. Ann Arbor. 1999.
10. Kim YH. Treatment of anterior openbite and deep overbite malocclusions with Multiloop Edgewise
Arch-Wire (MEAW) therapy. The enigma of the vertical dimension, J.A. McNamara, Craniofacial
Growth Series 36, Center for human Growth and Development, The University of Michigan. Ann
Arbor. 2000.

Chapter 13 _ A Non-extraction Treatment Case in Class II Malocclusion 615

 Chapter 14

A NON-EXTRACTION
TREATMENT CASE
IN CLASS III
MALOCLUSION

. Case summary

2. Pre-treatment
■
records

. Diagnosis and treatment planning

Treatment procedures

5. Post-treatment records
 Case summary

This 10.11 year-old boy had the chief complaints about anterior cross bite and mandibular
prognathism. Previously, he had a treatment at another clinic (having worn a face mask before), but
due to the recurrence he decided to visit our clinic. The patient had a family history of Class III

malocclusion, and was suffering from otolaryngeal problems. The facial asymmetry was observed
from the frontal view, and maxillary undergrowth as well as mandibular prognathism were all
detected from the lateral view. According to the intraoral photograph, the patient had anterior cross
bite, deep over bite, and severe curve of Spee. Here, the patient was going through the mixed
dentition exchange period. The edge-to-edge bite was possible and an insufficient space for
maxillary canine eruption was detected. Skeletally, he had a Class III low angle pattern.

Due to the edge-to-edge bite and a Class III low angle malocclusion, a non-surgical and non-extraction
treatment was planned. Also, to gain the maxillary canine space, the open coil springs and a .016”
x .022” stainless steel archwire that has crown lingual torque, were used along with the face mask. In
order to induce the over-eruption of mandibular molars, the resin caps were applied on the mandibular
second primary molars. In this, the .018” slot standard brackets were used for the treatment.

The total treatment duration was 24 months. Only a wrap-around type removable retainer was used
on the maxilla, and no retainer was used on the mandible.

Pre-treatment reco rd s

1) Pre-treatment facial photographs (Fig. 14-1)

From the lateral view a concaved profile with maxillary deficiency was observed.

►► F ig .14-1 Pre-treatment facial photographs.

G1 8 ►► Chapter 14 _ A Non-Extraction Treatment Case in Class III Malocclusion

• © @ ©
 • © ® ©

2) Pre-treatment intraoral photographs (Fig. 14-2)

• Anterior cross bite and deep overbite were identified, and deep curve of Spee was observed in
the mandibular dentition.
• Here, the patient was going through the mixed dentition exchange period.
• The edge-to-edge bite was possible and an insufficient space for maxillary canine eruption was
detected.

►► Fig. 14-2 Pre-treatment intraoral photographs.

3) Pre-treatment panoramic radiograph (Fig. 14-3)

• The tooth germs were formed on the maxillary and mandibular third molars, and insufficient
space for the maxillary canine eruption was apparent.

Chapter 1 4 _ A Non-Extraction Treatment Case in Class III Malocclusion 4« 619

 4) Pre-treatment cephalometric radiograph (Fig. 14-4)

• Anterior cross bite and mandibular prognathism were observed.

• Posterior discrepancy was observed.
• Enlarged tonsils was apparent.
• Asymmetry in the mandible and midline deviation to the right were observed.

620- Chapter 14 _ A Non-Extraction Treatment Case in Class III Malocclusion

• ® • •
 « • @«

The skeletal pattern (ODI: 60.9, APDI: 93.4 and CF: 154.3) showed a Class III low angle.
The denture pattern was as follows:
a) U1 to lip line: 5.7mm
b) UOP to FH: 18.7°
c) POP to FH: 6.3°
d ) Ul to FH: 106.7°
e) IMPA: 86.1°
f) IIA: 139.9°
This indicated that the patient was suffering from mandibular prognathism.
From the E-line, the upper lip was retruded about 1.8mm, and the lower lip was protruded
about 0.1mm.

►► Fig. 14-5 Posterior discrepancy.

1. Over-eruption of molars.
2. Mesial angulation of molars.

Chapter 14 _ A Non-Extraction Treatment Case in Class III Malocclusion < < B21
 Diagnosis and treatment planning

1) Problem lists

• Anterior cross bite,

• Maxillary undergrowth and mandibular prognathism,
• Class III molar relationship,
• Insufficient space for maxillary canine eruption,
• Mixed dentition period in the mandible.

2) Diagnosis

Skeletal Class III low angle.

3) Treatmentplan

The edge-to-edge bite was possible. Since this was a Class III low angle malocclusion case, a non-
surgical and non-extraction treatment was planned.
A face mask, an archwire that has crown lingual torque, and open coil springs were used
simultaneously to gain the sufficient space for maxillary canines.
Here, the .018” slot standard brackets were used as a fixed orthodontic appliance.

Treatment procedures

© • As usual, the mandibular posterior bite block (PBB) was used 1) to eliminate the bite force,
2) to increase the anterior vertical dimension and 3) to bond the brackets on the maxillary
dentition with ease. At first, PBB and open coil springs were used and the tight cinch back was
performed to gain a sufficient amount of space for the maxillary canines. Then, the .016”
stainless steel archwire was used as a main archwire.

622 ►► Chapter 14 _ A Non-Extraction Treatment Case in Class III Malocclusion

 • • © ®

• To control the maxillary first molar rotation, the .016” x.022” stainless steel archwire, which
already has crown lingual torque, and open coil springs, were used. Here, the archwire could
gain a sufficient amount of space for canine eruption by 1) inducing the labial root movement
and 2) minimizing the labioversion of anterior teeth (Fig. 14-7).

►► Fig. 14-7 Intraoral photographs after 2 months of treatment.

►► Fig. 14-8 Space gaining for the maxillary canines.

Chapter 14 _ A Non-Extraction Treatment Case in Class III Malocclusion 623

 • By using the .016” x .022” stainless steel archwire, the labial crown movement was minimized
and the sufficient labial root movement was made. In other words, an adequate amount of
space was gained for canines. Here, along with a face-mask, 5/16” 6oz elastics were used from
the first premolars to move the whole maxillary dentition forward.

►► Fig. 14-9 Intraoral photographs after 5 months of treatment.

• After improving the anterior relationship, the patient was advised to wear a face mask
continuously, and the resin caps were, instead of PBB, used on mandibular second primary
molars. Due to the resin caps, the mandibular molars were over-erupted, and the skeletal
pattern was changed into the Class I or II relationship. With such a change, Class III
malocclusion could be treated successfully.
• Anterior cross bite could be solved by moving the maxilla forward and by rotating the
mandible in the clockwise direction.

_________________________________________
624 ►► Chapter 14 _ A Non-Extraction Treatment Case in Class III Malocclusion
• • © •
 • • • •

►► F ig . 1 4 -1 0 Intraoral photographs after 6 months of treatment.

• The mandibular first molars in Class II malocclusion tend to over-erupt in the early stages of
mixed dentition. In contrast, in Class III malocclusion, the maxillary first molars tend to over-
erupt in the final stage of permanent dentition.

►^ F ig . 14-11 Changes due to different vertical heights of the

maxillary and mandibular first molars.

Chapter 1 4 _ A Non-Extraction Treatment Case in Class III Malocclusion 625

 • Depending on the types of malocclusion, the inclination of posterior occlusal plane (POP) and
the vertical dimension may vary. For example, in Class II malocclusion, there are steep
posterior occlusal plane (POP) and insufficient posterior vertical dimension, and in Class III
malocclusion, there are flat posterior occlusal plane (POP) and sufficient posterior vertical
dimension.

►y Fig. 1 4 -1 2 Characteristics of skeletal Class II and Class III malocclusion.

• The patient had a maxillary archwire on and waited for the eruption of permanent teeth. Here,
in most cases, the eruption of mandibular molars occurs more readily than the eruption of the
maxillary molars.
• The patient had to wait for the exfoliation of mandibular second primary molars.

626» Chapter 14 _ A Non-Extraction Treatment Case in Class III Malocclusion @ # @ ®

 • • # •

• After the sufficient eruption of maxillary canines, the brackets were bonded strategically to the
maxillary canines for alignment.

►► F ig .1 4 -1 4 Intraoral photographs after 16 months of treatment.

• Maxilla and mandible: MEAWs and short elastics for midline correction
After bonding the brackets on the mandibular teeth (just like the ones on the maxilla), MEAWs
were inserted onto the maxillary and mandibular arch. Then, to treat the occlusion and midline
deviation, on the right hand side, short Class II elastics (3/16” 6oz) were used from the first
loop of the maxillary MEAW to the third loop of the mandibular MEAW, while, on the left
hand side, short Class III elastics (3/16” 6oz) were used from the first loop of the mandibular
MEAW to the third loop of the maxillary MEAW.

►► F ig . 1 4 -1 5 Intraoral photographs after 21 months of treatment.

Chapter 14 _ A Non-Extraction Treatment Case in Class III Malocclusion ◄◄ 627

 Post-treatment records

1) Post-treatment facial photographs (Fig. 14-16)

More aesthetically satisfying frontal and lateral facial views were observed.

►► F ig .1 4 -1 6 Post-treatment facial photographs.

2) Post-treatment intraoral photographs (Fig. 14-17)

Class I canine and molar relationship was obtained.

No midline deviation was observed.
 • • • •

3) Post-treatment panoramic radiograph (Fig. 14-18)

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

• Tooth germs on the maxillary and mandibular third molars were observed.

►► Fig. 1 4 -1 8 Post-treatment panoramic radiograph.

4) Post-treatment cephalometric radiograph (Fig. 14-19)

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

• Despite having a Class III malocclusion, curve of Spee was apparent on the mandible.

Measurement Mean S.D. 2008.2.12

ODI 74.5 6.07 66.1
APDI 81.4 3.79 88.8
CF 155.9 6.52 155.0
FMA(deg) 26 4.91 26.4
UOP(deg) 10 - 9.5
POP(deg) 13 - 11.3
U1 to FH(deg) 114 4.6 122.3
U1 edge to lip(mm) 3.9 1.38 3.3
L1 to MP(deg) 91.4 3.78 89.6
IIA(deg) 127 7 121.8
UL(mm) 2.83 2 0.8
LL(mm) 2.33 2 0.4

►^ Fig. 1 4 -1 9 Post-treatment cephalomertic radiograph and measurement values.

Chapter 1 4 _ A Non-Extraction Treatment Case in Class III Malocclusion ◄◄ 629

 5) Cephalometric superimposition (Fig. 14-20)

Measurement Mean S.D. 2006.2.8 2008.2.12

ODI 74.5 6.07 60.9 66.1
APDI 81.4 3.79 93.4 88.8
CF 155.9 6.52 154.3 155.0
FMA(deg) 26 4.91 27.3 26.4
UOP(deg) 10 - 18.7 9.5
POP(deg) 13 - 6.3 11.3
U1 to FFI(deg) 114 4.6 106.7 122.3
U1 edge to lip(mm) 3.9 1.38 5.7 3.3
L1 to MP(deg) 91.4 3.78 86.1 89.6
IIA(deg) 127 7 139.9 121.8
UL(mm) 2.83 2 -1.8 0.8
LL(mm) 2.33 2 0.1 0.4

►► Fig. 1 4 -2 0 Superimposition and comparison of pre- and post-treatment measurement values.

630 ►► Chapter 14 _ A Non-Extraction Treatment Case in Class III Malocclusion • • • 0

 @ 0 • •

►► Fig. 14-21 A. Pre-treatment facial photographs.

B. Post-treatment facial photographs.

7) Pre- and Post-treatment intraoral photographs (Fig. 14-22)

►► Fig. 1 4 -2 2 A. Pre-treatment intraoral photographs.

B. Post-treatment intraoral photographs.

Chapter 14 _ A Non-Extraction Treatment Case in Class III Malocclusion < < 6 3 1

 8) Post-retention facial and intraoral photographs (Fig. 14-23)

►► Fig. 1 4 -2 3 Post-retention facial and intraoral photographs (20 months after the treatment).

632 ►► Chapter 14 _ A Non-Extraction Treatment Case in Class III Malocclusion • • • •

REFERENCES

1. Baik HS. Clinical results of the maxillary protraction in Korean children. Am J Orthod Dentofac Orthop
108:583-592, 1995.
2. Kim BH, and Yang WS. Regional load deflection rate of multiloop edgewise archwire. Korea J Orthod
29:673-688, 1999. •
3. Kim JH, MC Viana, TM Graber, FF Omeraza, and EA BeGole. The effectiveness of protraction face
mask therapy: A meta-analysis. Am J Orthod Dentofac Orthop 115:675-685, 1999.
4. Kim Jl, Akimoto S, Shinji H, and Sato S. Importance of vertical dimension and cant of occlusal plane in
craniofacial development. Int J Stomatol Occlusion Med 2:114-121,2009.
5. Kim Jl. Practical Clinical Orthodontics. Vol 1. Orthodontic treatment with MEAW. Well publishing Inc,
2012.
6. Kim Jl. Practical Clinical Orthodontics. Vol 2. Orthodontic Diagnosis. Well publishing Inc, 2013.
7. Kim Jl. Practical Clinical Orthodontics. Vol 3. Early orthodontic treatment. Well publishing Inc, 2015.
8. Kim YH. Anterior openbite and its treatment with Multiloop Edgewise Archwire. Angle Orthod 57:290-
321, 1987.
9. Kim YH. Treatm ent of severe openbite m alocclusion w ithout surgical intervention. Growth
modification: What works, what doesn’t, and why. J.A. McNamara, Craniofacial Growth Series 35,
Center for human Growth and Development, The University of Michigan. Ann Arbor. 1999.
10. Kim YH. Treatment of anterior openbite and deep overbite malocclusions with Multiloop Edgewise
Arch-Wire (MEAW) therapy. The enigma of the vertical dimension, J.A. McNamara, Craniofacial
Growth Series 36, Center for human Growth and Development, The University of Michigan. Ann
Arbor. 2000.

Chapter 14 _ A Non-Extraction Treatment Case in Class III Malocclusion 633

 O
s
!>
Hi
S
I

CÄ
 Chapter 1 5

A NON-EXTRACTION
TREATMENT CASE OF
MIDLINE DEVIATION

! 1. Case summary

2. Pre-treatment records

3. Diagnosis and treatment planning

Jl U* Q
<V* * & *■>* cV gr# ° ^ b |j ^Y « ' f[ a ? * ; \ i; , r y *

4. Treatment procedures
 Case summary

This 18.2 year-old male patient had chief com plaints about uncom fortable right
temporomandibular joint disorder (TMD), and midline deviation. Although the patient had an
aesthetically satisfying facial profile, facial asymmetry was detected from the frontal view.
According to the intraoral photographs, 1) adjacent teeth tilted due to a missing mandibular right
first molar, 2) occlusal plane was tilted within the maxillary canines, 3) the midline deviated to the
right side, 4) there was Class II canine and molar relationship in the right side, and 5) excessive
crown buccal torque was observed in the maxillary right molar area. Skeletally, he had a Class I
low angle pattern.

Since he had a good facial profile, a non-extraction treatment was planned. It was decided to close
the space, which was already created from the extraction of the mandibular right first molar, by
moving the second and third molars. The restorative treatment was also planned after increasing
the size of maxillary lateral incisors. In this, the .018” slot standard brackets were used for the
treatment.

The total treatment duration was 24 months. A wrap-around type removable retainer was used on
the maxilla, and a canine-to-canine bonded retainer was used on the mandible.

Pre-treatment records

1) Pre-treatment facial photographs (Fig. 15-1)

►► F ig. 15-1 Pre-treatment facial photographs.

636 ►► Chapter 15 _ A Non-Extraction Treatment Case of Midline Deviation g £ £

 m• • @

2) Pre-treatment intraoral photographs (Fig. 15-2)

• The adjacent tooth movement was observed due to the missing mandibular right first molar.
• Occlusal plane was tilted within the maxillary canines.
• The midline was deviated to the right side. •
• In the right side, Class II canine and molar relationship was observed.
• Excessive crown buccal torque was observed in the maxillary right molar area.

►► F ig . 15-2 Pre-treatment intraoral photographs.

3) Pre-treatment panoramic radiograph (Fig. 15-3)

►► Fig. 15-3. Pre-treatment panoramic radiograph.

Chapter 15 _ A Non-Extraction Treatment Case of Midline Deviation 44 637

 4) Pre-treatment cephalometric radiograph (Fig. 15-4)

►► Fig. 1 5 -4 Pre-treatment cephalometric radiograph and measurement values.

• The skeletal pattern (ODI: 74.6, APDI: 83.9 and CF: 158.5) showed a Class I low angle.
• The denture pattern was as follows:
a) Ul to lip line: 5.9mm
• b) UOP to FH: 9.2°
c) POP to FH: 7.8°
d) Ul to FH: 112.9°
e) IMPA: 92.1°
f) IIA: 134.9°
• From the E-line, the upper lip was retruded about 5.3mm, and the lower lip was retruded about
2.6mm.

638 ►► Chapter 15 _ A Non-Extraction Treatment Case of Midline Deviation

© « • •
 « m ® ®

D ia g n o sis and treatment planning

1) Problem lists

• Discomfort on the right temporomandibular joint,

• Movement of adjacent teeth caused by the missing mandibular right first molar,
• Tilting of occlusal plane within the maxillary canines,
• Midline deviation to the right,
• Class II canine and molar relationship in the right side,
• Excessive crown buccal torque in the maxillary right molar area.

2) Diagnosis

Skeletal Class I low angle.

3) The main objectives of treatment

• Improve Class I canine and molar relationship.

• Correct the midline deviation.
• Gain the maxillary canine symmetry.
• Upright the mandibular right second and third molars.
• Gain the upper occlusal plane symmetry.
• Control the maxillary molar torque.
• Gain the sufficient space for maxillary lateral incisor size-up.

4) Treatment plan

Since the patient had an aesthetically acceptable profile, a non-extraction treatment was planned. It
was decided to use second and third molars to close the space that was already formed from the
extraction of the mandibular right first molar. A restorative treatment was planned after the
orthodontic treatment to increase the size of maxillary lateral incisors.
The .018” slot standard brackets were used as a fixed orthodontic appliance.

Chapter 15 _ A Non-Extraction Treatment Case of Midline Deviation < ◄ 639

 Treatment procedures

• Except for the maxillary first molar, the brackets were bonded to all the teeth to achieve the
strategic leveling.
• The open coil springs were used to improve the right canine relationship, and to upright the
second molar.

►► Fig. 1 5-5 Intraoral photographs after 5 months of treatment.

• After aligning the maxillary teeth, MEAW had to be inserted to induce the three dimensional
maxillary teeth movement.
• After leveling and aligning the mandibular teeth, in order to improve the midline and right
canine relationship, the short Class II elastics (3/16” 6oz ) were used from the first loop of the
maxillary MEAW to the mandibular right second premolar.

sy

►► Fig. 15-6 Intraoral photographs after 15 months of treatment.

\ ______________________________
640 ►
►Chapter 15 _ A Non-Extraction Treatment Case of Midline Deviation • © • «
 • • • •

• The mandibular wire was replaced with MEAW, and the short Class II elastics (3/16” 6oz)
were used from the first loop of the maxillary MEAW to the third loop of the mandibular
MEAW. Here, the additional elastics were used from the second loop of the maxillary MEAW
to the fourth loop of the mandibular MEAW in the right side during the night time.

►► Fig. 15-7 Intraoral photographs after 16 months of treatment.

• The midline and the right canine relationship were improved 1) by removing the molar
interference, 2) by activating the elastics, and 3) by applying the tip-back activation to the
mandibular MEAW.

►► Fig. 15-8 Intraoral photographs after 18 months of treatment.

Chapter 15 _ A Non-Extraction Treatment Case of Midline Deviation «◄ 641

 • In order to gain the space for small-size lateral incisors, the open coil springs were inserted on
the mesial and distal sides of maxillary lateral incisors, and then the short Class II elastics
were used from the maxillary canines to the mandibular second premolar in the right side and
to the mandibular first premolar in the left side.

►► Fig. 1 5 -9 Intraoral photographs after 20 months of treatment.

• In order to obtain tight occlusion, the triangular elastics (1/4” 6oz) were used from the second
loop of the maxillary MEAW to the second and third loops of the mandibular MEAW.

642 ►► Chapter 15 _ A Non-Extraction Treatment Case of Midline Deviation

• • © •
 - ^ @

Post-treatment records

1) Post-treatment facial photographs (Fig. 15-11)

►► Fig. 15-11 Post-treatment facial photographs.

2) Post-treatment intraoral photographs (Fig. 15-12)

►► Fig. 1 5 -1 2 Post-treatment intraoral photographs.

Chapter 15 _ A Non-Extraction Treatment Case of Midline Deviation 643

 3) Post-treatment panoramic radiograph (Fig. 15-13)

p
►► Fig. 1 5 -1 3 Post-treatment panoramic radiograph.

4) Post-treatment cephalometric radiograph (Fig. 15-14)

Measurement Mean S.D. 2007.1.23

ODI 74.5 6.07 76.3
APDI 81.4 3.79 83.4
CF 155.9 6.52 159.7
FMA(deg) 26 4.91 23.5
UOP(deg) 10 - 11.5
POP(deg) 13 - 8.6
U1 to FH(deg) 114 4.6 113.7
U1 edge to lip(mm) 3.9 1.38 2.7
L1 to MP(deg) 91.4 3.78 104.6
HA(deg) 127 7 118.2
UL(mm) 2.83 2 -4.7
LL(mm) 2.33 2 -0.9

►& Fig. 1 5 -1 4 Post-treatment cephalomertic radiograph and measurement values.

644 ►► Chapter 15 _ A Non-Extraction Treatment Case of Midline Deviation • • • •

 • • • •

5) Cephalometric superimposition (Fig. 15-15)

Measurement Mean S.D. 2005.1.24 2007.1.23

ODI 74.5 6.07 74.6 76.3
APDI 81.4 3.79 84.9 83.4
CF 155.9 6.52 158.5 159.7
FMA(deg) 26 4.91 20.11 23.5
UOP(deg) 10 - 9.3 11.5
POP(deg) 13 - 7.8 8.6
U1 to FH(deg) 114 4.6 112.9 113.7
U1 edge to lip(mm) 3.9 1.38 5.9 2.7
L1 to MP(deg) 91.4 3.78 92.1 104.6
IIA(deg) 127 7 134.9 118.2
UL(mm) 2.83 2 -5.3 -4.7
LL(mm) 2.33 2 -2.6 -0.9

►► Fig. 1 5 -1 5 Superimposition and comparison of pre- and post-treatment measurement values.

Chapter 15 _ A Non-Extraction Treatment Case of Midline Deviation B45

 6) Pre- and Post-treatment facial photographs (Fig. 15-16)

►► F ig. 1 5 -1 6 A. Pre-treatment facial photographs.

B. Post-treatment facial photographs.

646 ►► Chapter 15 _ A Non-Extraction Treatment Case of Midline Deviation ® ® • ©

 • © • •

7) Pre- and Post-treatment intraoral photographs (Fig. 15-17)

►► Fig. 1 5 -1 7 A. Pre-treatment intraoral photographs.

B. Post-treatment intraoral photographs.

Chapter 15_ A Non-Extraction Treatment Case of Midline Deviation 6 4 7

 8) Post-retention facial and intraoral photographs (Fig. 15-18)

►> F ig . 1 5 -1 8 Post-retention facial and intraoral photographs (59 months after the treatment).

0 4 8 ►► Chapter 15 _ A Non-Extraction Treatment Case of Midline Deviation

• • • •
REFERENCES

1. Kim Jl, Akimoto S, Shinji H, and Sato S. Importance of vertical dimension and cant of occlusal plane in
craniofacial development. Int J Stomatol Occlusion Med 2:114-121,2009.
2. Kim Jl. Practical Clinical Orthodontics. Vol 1. Orthodontic treatment with MEAW. Well publishing Inc,
2012. •

3. Kim Jl. Practical Clinical Orthodontics. Vol 2. Orthodontic Diagnosis. Well publishing Inc, 2013.
4. Kim YH. Anterior openbite and its treatment with Multiloop Edgewise Archwire. Angle Orthod 57:290-
321, 1987.
5. Kim YH. Treatm ent of severe openbite m alocclusion w ithout surgical intervention. Growth
modification: What works, what doesn’t, and why. J.A. McNamara, Craniofacial Growth Series 35,
Center for human Growth and Development, The University of Michigan. Ann Arbor. 1999.
6. Kim YH. Treatment of anterior openbite and deep overbite malocclusions with Multiloop Edgewise
Arch-Wire (MEAW) therapy. The enigma of the vertical dimension, J.A. McNamara, Craniofacial
Growth Series 36, Center for human Growth and Development, The University of Michigan. Ann
Arbor. 2000.

Chapter 15 _ A Non-Extraction Treatment Case of Midline Deviation *4◄ 649

 18 8I

A Bite force, 109, 622

Black triangle, 51, 184, 189, 190, 192, 237, 238, 395
AB-maxillomandibular triangle, 103, 104 Bonding
Abnormal tooth morphology, 49 amalgam, 313
Absolute anchorage, 433 composite, 315
Acid etching, 307, 309, 313 gold, 313
Active centric line, 284, 285, 480, 498 porcelain, 313
Active enlargement, 176 Bonding base, 262, 263
Adhesive, 306 Box elastics, 510, 516
Aesthetic analysis, 160 Bracket angulation, 302, 316, 337, 338
Aesthetic bends, 494, 495 Bracket height, 262, 292, 293, 295, 297, 317
Aesthetic bracket, 265 Bracket slot, 291, 302, 303, 321-333, 497
Affected side, 62, 72, 230, 231, 519, 521 Bracket width, 262, 525
Alveolar bone, 2 1 ,7 9 ,2 1 0 Buccal tube, 268, 269, 270, 288, 326, 353, 354, 572
Angulation error, 303, 317, 322, 324, 330
Ankylosis, 21, 64, 69
Antegonial notch, 103 C
Anterior bite plate, 141, 147, 1 5 0 ,3 7 8 ,3 7 9 ,5 5 1 ,5 5 4
Anterior Bolton ratio, 46, 237, 571 Canine retraction, 407, 408, 413, 414, 425, 591
Anterior component o f force, 76, 99, 199, 526 Canine-to-canine bonded retainer, 544, 546, 636
Anterior crowding, 23, 25, 47, 48, 50, 56, 59, 99, 111, Center o f rotation, 370, 371
115-119, 179, 237, 249, 317, 386-395, 411,428, Centric stop, 285
440, 459, 460, 461, 545, 546, 551, 554, 568, 586, Ceramic bracket, 265
589 Cervical headgear, 147, 148, 149
Anterior discrepancy, 62, 63, 193 C hief complaint, 21, 152, 568, 586, 602, 618, 636
Anterior vertical elastics, 141, 501,503, 512, 516 Cinch back bends, 352
Antero-posterior dysplasia indicator (APDI), 95, 100 Class I
Arch length discrepancy, 207, 210, 587 elastics, 143, 213, 419, 429, 430, 432, 510, 511
Asymmetry, 40, 233, 235, 243, 244, 249, 517, 534, 568, high angle, 106, 114, 115
• 6 0 2 ,6 1 8 ,6 2 0 ,6 3 6 low angle, 106, 115, 203, 568, 570, 571, 586, 588,
Auto-transplantation, 239, 246, 248 589, 636, 638, 639
Auxiliary spring, 548, 551, 553 malocclusion, 47, 48, 94, 102, 104, 114, 133, 207,
285
molar, 33, 34, 35, 94, 207, 214, 216, 220, 221, 230,
B 231, 239, 280, 356, 392, 438, 528, 586
skeletal pattern, 94
Begg bracket, 263, 264 Class II
Bite deepening, 94, 204, 210, 405, 416, 419, 420, 421, elastics, 125, 137, 143-150, 276, 422, 430, 457, 492-
422, 574, 575 499, 505-513, 550, 627, 640-642

65Ü ► INDEX
 high angle, 106, 116, 117, 165, 204, 602-606, 612 triangular, 51, 103, 177, 184, 189, 190, 192, 237, 395
low angle, 106, 116, 117, 165 square, 51, 177
malocclusion, 25, 47, 48, 56, 61-65, 72, 85-104, 114, Curve o f Spee
125, 128, 130, 133, 160-167, 196-200, 208, 210, deep, 175, 185, 209, 210, 214, 218, 219, 376, 389,
215, 237, 238, 249, 276, 280, 281, 301, 324, 370, 416, 419, 422, 501, 521, 550, 604, 619
374, 409, 410, 499, 505, 525, 536, 550, 551, 606, normal, 175
625, 626 severe, 30, 32, 64, 65, 67, 151, 231, 282, 376, 386,
molar, 33, 35, 153, 173, 179, 183, 210, 216, 218, 389, 420, 421, 429, 495, 551, 588, 618
220, 221, 230, 239, 249, 300, 356, 386, 391, 528 MEAW, 503
skeletal pattern, 33, 34, 35, 94, 95 Curve o f W ilson
Class III severe, 30, 420
elastics, 28, 138-148, 227, 272, 409, 429, 430, 495,
499, 503-517, 627
high angle, 106, 117, 118, 227 D
low angle, 106, 118, 205, 618, 621, 622
malocclusion, 25, 47, 48, 61, 63, 84-87, 95, 97, 100- Decrowding, 362, 365, 461
104, 114, 118, 125, 128, 133-138, 160-178, 198, Delayed eruption, 64, 71
200, 236-249, 272-281, 301, 364-374, 411, 412, Denture pattern analysis, 26, 123, 124, 206
473, 499-503, 525, 548, 549, 618-629 Derotation, 324, 459
molar, 227, 622 Diastema, 42
Clockwise rotation, 136, 137, 147, 148, 149, 150,612 Disclusion, 128, 436
Combination factor (CF), 40, 103, 105, 185, 218, 220, Differential diagnosis, 160, 166, 215, 219, 220, 221,229
409 Direct bonding, 306, 307
Combination loop, 288, 405, 409, 414, 422, 423, 424, Disto-occlusion, 370
425, 427, 428, 429, 430, 431,432, 445, 452, 456, Double archwire, 142, 147, 150, 179, 370, 371
457, 458
Congenital missing teeth, 42, 64
Contact points, 188, 285, 449, 474, 476, 477, 478, 480, E
481, 530
Correlation coefficient, 97, 101 Ectopic eruption, 70
Counter-clockwise rotation, 137, 147, 148,367 Edge-to-edge, 179, 535, 536, 618, 619, 622
Cortical bone, 21 Edgewise bracket, 263, 264, 288, 362, 365
Cross bite elastics, 510, 515 Elastics
Crown inclination (Torque), 72, 287, 302, 534 Class I, 143, 213, 419, 429, 430, 432, 510, 511
Crown labial torque, 223, 245, 272, 273, 276, 288, 319, Class II, 125, 137, 143-150, 276, 422, 430, 457, 492-
411,417, 418, 424, 425, 426, 427, 429, 445, 446, 513, 550, 627, 640-642
451, 452, 473, 474, 495, 496, 499, 505, 532, 574, Class III, 28, 138, 143-148, 227, 272, 409, 429, 430,
575,591 495, 499, 503-517, 627
Crown length, 293, 530 Anterior vertical, 143, 145, 501, 503, 512, 516
Crown lingual torque, 214, 215, 271, 272, 273, 275, 276, Long, 143, 145, 507, 508-510, 516
288, 289, 319, 362, 364, 365, 419, 439, 446, 452, Short, 143, 146, 509, 510, 516, 627
473, 478, 495, 499, 500, 502, 505, 521,577, 592, Elastic thread, 362, 363
618, 622, 623 Energy chain, 360, 384, 396, 405, 406, 407, 409, 411,
Crown shape 413, 415, 417, 418, 422, 425, 426, 440, 445, 448,
barrel, 51, 177 449, 458, 572, 573, 574, 576, 577, 591, 592
ovoid, 51, 177, 353,372 En-masse retraction, 411,415

INDEX «
 Environmental factor, 78, 87, 185 Horizontal positioning error, 299, 317
Expansion archwire, 521, 522, 523, 524 Hydrofluoric acid, 311,312
Expansion screw, 607
Extraction index, 113, 114
Extrusion I
anterior teeth, 60
posterior teeth, 60 Ideal arch form, 52, 349, 407, 490, 494, 506
Ideal archwire with hook, 405, 411,4 1 5 , 418, 426, 428,
429,440, 445, 449
F Incisor mandibular plane angle (IMPA), 415, 417, 446,
4 4 9 ,5 7 0 ,5 8 8 ,6 0 4 , 621,638
Face mask, 139, 140, 147, 618, 622, 624 Indirect bonding, 306
Facial asymmetry, 40, 568, 586, 602, 618, 636 Individualized treatment, 33
Facial axis o f clinical crown, 290 In-and-out, 263, 266, 283, 286, 287, 482
Finger sucking habit, 78 Inter-bracket distance, 480
First molar extraction, 169, 193, 249, 250, 251 Inter-canine width, 56, 57, 73, 170, 176, 186, 211, 524
First-order bends, 52, 76, 77, 283, 469, 472, 482, 484, Intercoronal opening angle, 505
485, 500 Interincisal angle, 115
Flat MEAW, 486, 501,503 Interproximal stripping, 188
Flattening, 61, 87, 137, 138, 139, 147, 148, 171, 177, Intrusion
178, 184, 3 4 8 ,3 7 6 ,5 0 9 anterior teeth, 60
Force vector, 144 posterior teeth, 60
Friction, 286, 381,404, 406, 407 Intrusion arch, 142, 147, 150
Full cusp Class II molar, 153, 179, 216, 221,239, 356,
386,391
Functional appliance, 140, 141, 380 J
Functional shift, 86
J-hook headgear, 139, 147

G
K
Gable bend, 422, 427
Guidance, 57, 202, 211, 314, 444, 472, 504, 533 Kim pliers, 372, 450, 452, 454, 471, 473, 475, 478, 485,
500,504
KIMS bracket, 286, 287, 302, 482
H

Habit, 78, 79, 538, 555, 590 L

Habitual mouth opening, 78
Hawley retainer, 545 Labial bracket, 263
Headgear, 139, 147, 148, 149, 268, 371 Leeway space, 166
Heat treatment, 491 Level anchorage system analysis, 28
Heilman dental age, 61, 167 Leveling
High angle, 40, 106, 107, 114, 116, 117, 118, 179, 227, simple, 31, 32, 350
249, 437, 507, 509, 602, 604, 606, 612 strategic, 171, 184, 215, 281, 350-398, 608, 640
High-pull headgear, 139, 371 Ligation bracket, 267

652 > INDEX # # # #

Light curing, 3 0 6 ,3 0 8 ,3 1 0 ,3 1 4 Metal primer, 311, 313, 314
Lingual arch, 166, 167, 548, 549, 557, 558 Midline deviation, 23, 22, 40, 59, 64, 66, 67, 69, 72, 75,
Lingual bracket, 263 76, 77, 86, 160, 163, 164, 179, 200, 230, 231, 278,
Lingual button, 227, 363 282, 439, 441 ,4 9 5 , 496, 517, 519, 520, 521, 524,
L-loop, 319, 362, 363, 445, 448, 449, 452, 469, 470, 534, 593, 609, 620, 627, 628, 636, 639
4 7 1 ,4 8 5 ,4 8 8 Mini-implant, 29, 146, 147, 148, 149, 150, 179, 183,
Load deflection rate, 452, 470, 504 184, 213, 224, 249, 356, 372, 386, 393, 414, 424,
Long axis, 279, 291 4 3 3 ,4 3 5 ,4 4 5
Long elastics, 299, 300, 302, 303, 316, 318, 319, 321, Minimun anchorage, 429, 430
323, 325, 327, 329, 331, 333, 526 Mixed dentition, 61, 154, 166, 371, 618, 619, 622, 625
Loop method, 404, 405 Mobility, 295, 378, 518
Loose cinch back, 171, 353, 354, 364, 377, 387 Model analysis, 160
Low angle, 4 0 ,4 1 , 106, 107, 110, 115, 116, 117, 118, Moderate anchorage, 432
165, 203, 205, 507, 568, 570, 571, 586, 588, 589, Moderate crowding, 199
6 1 8 ,6 2 1 ,6 2 2 , 636, 638,639 Molar distalization, 199
M olar rotation, 358, 359, 360, 361, 623
Mouth breathing, 81
M

M andibular expansion, 176, 181, 386, 390, 391 N

M andibular plane angle, 96, 98, 99, 101, 103, 203, 249
Marginal ridge discrepancy, 291, 502, 504 Nasal septum, 81
Masticatory efficiency, 127 Normal growth, 135
Maxillary canine
symmetry, 233, 236, 639
asymmetry, 233 o
M axillary deficiency, 364, 618
Maxillary expansion Occlusal contacts, 528, 529
slow, 176, 390 Occlusal force, 76, 358, 378, 379, 381, 526
rapid, 176, 390 Occlusal plane
M aximum anchorage, 431, 432 bisected, 126, 526
Maximum incisor retraction, 396, 405 cant, 131, 132
MEAW curvature, 133, 134
adjustment, 517, 519, 520, 525 flat, 127, 128, 129
analysis, 29 level, 80, 131
prescription, 492 posterior, 35, 61, 62, 63, 66, 67, 87, 114, 115, 126,
Mesial angulation, 30, 35, 47, 48, 62, 63, 65, 68, 69, 70, 128, 133, 137, 138, 151, 152, 153, 171, 177, 184,
76, 77, 98, 99, 134, 193, 196, 221, 245, 279, 280, 205
281,288, 389, 396, 414, 419, 420, 439, 550, 621 steep, 64, 128, 129, 177, 214, 568
Mesial rotation, 52, 166, 173, 185, 283, 299, 300, 301, upper, 65, 114, 115, 126, 129, 131, 139, 147, 149,
320, 322, 326, 330, 332, 334, 341,413, 414, 509, 152, 179, 358-371, 396-398, 408, 413, 424, 458,
510 492, 532, 639
Mesial tilting, 320, 341, 392, 441, 458, 525, 588 Open coil springs, 32, 273, 351, 353, 358-366, 376, 311,
M esio-distal angulation, 61, 70 384, 385, 387, 389, 395, 397, 407, 408, 411,412,
M esio-distal width, 46 413, 419, 439, 440, 458, 459, 460, 461, 463, 525,
Metal bracket, 265 572, 608, 618, 622, 623, 640, 642

INDEX 4 4 653
 Otolaryngological problems, 81 normal, 115, 151, 205, 206, 207, 214, 215, 434, 438,
Orthodontic force, 146, 151, 470 468
Orthognathic surgery, 23, 135, 136, 355 steep, 61, 63, 87, 114, 151, 177, 209, 210, 214, 215,
Overcorrection, 318, 535, 536 281, 434, 435, 571, 602, 606, 626
Overbite depth indicator (ODI), 95, 97, 98 Posterior vertical dimension
Over-eruption, 61, 62, 63, 70, 71, 114, 116, 166, 167, sufficient, 40, 41, 61, 87, 116, 168, 626
196, 200, 3 2 6 ,3 3 4 ,6 1 8 , 621 insufficient, 40, 41, 61, 87, 168, 177, 178, 227, 493,
Overlay archwire, 362 626
Ovoid arch form, 284 Preformed archwire, 32, 273, 446
Premature contacts, 86, 128, 262, 288, 518
Premature loss, 64, 68
P Premaxilla, 22, 173
Prescription, 288, 492, 497, 506
PAC (Posterioralarcartilage), 103 Primary tooth
Parallel rotation, 52, 172, 173, 184, 185, 300, 360, 413, prolonged retention, 57, 58, 59, 64
459,600 premature exfoliation, 57, 58, 59
Passive centric line, 284, 285, 482, 500 Primer, 308-314
Passive enlargement, 176, 186 Progressive step-up MEAW, 503
Patient compliance, 20, 392 Protraction o f posterior teeth, 405, 418, 429, 433, 438,
Peg lateralis, 189, 237, 243, 244, 525, 550 4 4 0 ,5 1 1 ,5 7 5
Pendulum appliance, 173, 179, 183, 356, 386, 392 Protrusion, 2 3 ,2 5 ,4 0 ,7 8 ,7 9 ,8 1 , 113, 115, 116, 164,
Periodontal disease, 189 170, 202, 205, 207, 210, 218, 224, 249, 268, 385,
Periodontal ligament, 21 392, 435, 550, 586, 589, 604
Phosphoric acid, 307, 311,313 Protrusive lips, 568, 570, 571, 586, 589, 602
Plane
AB, 98, 100, 101, 102, 103, 153
mandibular, 28, 40, 41, 96-104, 114-118, 125, 193, R
203, 249
palatal, 79, 80, 96-104, 114, 118, 193 Rapid maxillary expansion, 176, 390
occlusal, 35, 61-96, 114-129, 131-153, 168-184, 198, Rectangular archwire, 273
205-230, 281-296, 350-358, 367, 368-379, 391- Reinforcement, 367
398, 408-496, 507-590, 602, 606, 626, 636, 637, Relapse, 79, 111, 186, 194, 199, 204, 227, 438, 525, 544,
639 550, 5 5 1 ,5 5 4 ,5 5 5 ,5 5 7 , 559
Porcelain primer, 311,312 Removable appliances, 140, 380
Positional deviation, 52, 53, 57, 58 Reproximation, 172, 177, 184, 188, 189, 190, 192,221,
Posterior available space, 174, 194, 195 237, 2 3 8 ,3 8 6 ,3 9 5
Posterior bite block, 140, 141, 148, 149, 366, 378, 379, Resin caps, 618, 624
380, 409, 590, 622 Retrognathic mandible, 114, 199
Posterior cross bite Retrusion, 40, 124, 129, 133, 205, 274, 278, 289, 295,
bilateral, 80 374, 419, 436, 437-440, 496, 533, 550, 606
unilateral, 79, 80, 515 Retrusive control, 324, 396, 436, 437, 438, 441,442, 443,
Posterior crowding, 493 458,450
Posterior discrepancy, 62, 63, 193, 194, 196, 197, 198, Reverse curve o f Spee, 473, 486,490, 500, 501, 512, 577,
200, 621 592
Posterior occlusal plane Reverse MEAW, 422, 495, 498, 501
flat, 63, 87, 281, 589, 626 ROC analysis, 95

654 ► INDEX • # « ®
Root labial torque, 319, 363 SWA bracket, 30, 32, 223, 266, 271, 272, 273, 274, 275,
Root lingual torque, 199, 521 276, 277, 79, 280, 283, 286, 289, 365, 397, 423,
Root parallelism, 203, 245, 303, 317, 319, 332, 427, 493, 424,451
537 Symmetry, 40, 57, 58, 76, 77, 120, 231, 232, 233, 235,
Root resorption, 21, 79, 241 236, 243, 244, 249, 253, 476, 480, 488, 490, 505,
Rotation 517 521, 533, 534, 568, 586, 602, 618, 620, 636,
mesial, 52, 166, 173, 185, 283, 299-301, 320-341, 413, 639
414, 509, 510 Symphysis, 22
parallel, 52, 172, 173, 184, 185, 300, 360, 413, 459, 460

T
s
Tapered arch form, 54, 173, 284, 461,462, 495
Sandblasting, 313 Teeth; see Tooth
Schwarz appliance, 156, 176, 179, 181,256, 391 bucco-lingual inclination, 72, 181, 271, 515
Second molar extraction, 12, 159, 169, 193, 196, 197, mesio-distal angulation, 60, 61, 68, 69, 70, 71, 76,
198, 199, 200, 201, 219, 252, 254, 255 77, 241, 245, 279, 280, 287, 495
Second-order bends, 60, 76, 77, 279, 469, 472, 485, 486, number, 42
500,504 position, 52, 53, 58
Self-ligation bracket, 267, 343, 344 shape, 49
Sensitivity, 95 size, 46, 47, 48, 110, 189, 188, 224, 237, 538, 571
Shoe-hook, 405, 415, 416, 426, 428, 432, 448, 450 Temporomandibular joint disorder, 2 2 ,6 5 ,2 7 4 ,3 4 1 ,
Short elastics, 143, 146, 509, 510, 516, 627 437,636
Short face, 90, 121 Tension gauge, 406
Shovel teeth, 50 Thickness error, 305
Simple leveling, 12, 31, 32, 347, 350 Thin premaxilla, 22, 604
Single bracket, 262, 264, 265 Third molar extraction, 12, 159, 169, 193, 194, 199,
Skeletal pattern analysis, 206 203, 493
Sliding method, 13, 403, 404, 405 Third-order bends, 123, 64, 72, 6, 77, 271, 286, 363,
Space preservation, 166 467, 469, 472, 482, 487, 488, 489, 500, 504, 519
Specificity, 95 Three mandibular incisors, 230, 231, 232, 238
Square arch form, 284, 463 Tie wing, 263
Spring retainer, 545, 546, 547, 551, 554, 562 Tight cinch back, 12, 171, 347, 353, 354, 362, 364,
Standard bracket, 30, 32, 223, 266, 271, 272, 273, 274, 366, 77, 389, 395, 622
275, 276, 277, 278, 279, 281, 283, 286, 287, 288, Tip back activation, 143, 145, 483, 486, 500, 501, 503,
289, 341, 364, 365, 385, 397, 420, 423, 571, 586, 519, 5 2 1 ,5 7 7 ,5 9 2 , 641
589, 602, 606, 618, 622, 636, 639 Tip back bends, 60, 281, 422, 429, 470, 472, 473, 485,
Steiner analysis, 28 486, 503, 504, 506, 512, 513, 514, 521
Strategic bonding, 13, 264, 297, 347, 353, 355, 357, 358, Tip back deactivation, 501
3 6 4 ,3 8 5 ,3 9 5 ,3 9 7 , 439 Tongue crib, 555
Steepening, 61, 137, 138, 139, 149, 150, 178, 408, 508 Tongue hole, 548, 548, 551, 555
Step-down bends, 498, 502, 504 Tongue position, 79, 80
Step-up bends, 498, 502, 503, 504, 505, 517, 519, 521 Tongue posture, 79
Stripping, 166, 172, 188, 189, 192, 256, 257, 395, 563 Tongue thrusting habit
Superimposition, 29, 187, 207, 209, 225, 228, 580, 596, active, 79
612, 630, 645 passive, 79

INDEX «◄ 655
 Tooth movement, 21, 30, 32, 57, 99, 109, 152, 186, V
193, 214, 215, 218, 227, 272, 273, 274, 275, 276,
277, 279, 283, 286, 296, 297, 299, 300, 303, 336, Vertical analysis, 11, 26, 93, 96
338, 341, 349, 353, 355, 363, 378, 381, 387, 398, Vertical dimension
404, 405, 406, 407, 414, 415, 420, 434, 435, 457, a n t e r io r , 118, 168, 178, 3 8 5 , 6 2 2

459, 468, 469, 470, 482, 485, 504, 509, 612, 637 p o s t e r io r , 4 0 -4 2 , 61 , 66 , 67 , 8 7 , 1 1 4 -1 1 7 , 1 4 1 , 1 6 8 ,

Tooth size discrepancy, 46, 47, 48, 189, 237, 538, 571 177, 178, 193, 199, 2 2 7 , 2 8 2 , 3 8 5 , 4 9 3 , 6 2 6

Torque difference, 75, 76, 77, 278, 494, 496, 524 Vertical positioning error, 296, 297
Transpalatal arch, 142, 149, 154, 155, 166, 167, 224, Vertical problems, 98
548, 557, 558 Vertical relationship, 40, 87, 96, 97, 99, 115, 196, 316,
Transpalatal width, 54, 55, 179, 390 318, 321, 323, 325, 327, 329, 331, 333, 510, 517
Transverse problem, 4 0 ,8 7 ,1 3 7
Triangular crown shape, 184, 189, 190, 192
Triangular elastics, 422, 511,516, 642 w
Tweed analysis, 27
Twin block appliance, 141, 179, 182, 385, 391,439, W ide bracket, 269, 270, 288
602, 606, 607, 608 W rap-around retainer, 544, 545, 548, 550, 551, 554,
Twin bracket, 262, 264, 265 555

u
U1 to lip line, 125, 179, 367, 370, 570, 588, 604, 621,
638
Unaffected side, 72, 75, 230, 231, 519, 521
Upper occlusal plane
fla t, 127, 128, 1 2 9

n o r m a l, 130, 132

ste e p , 64, 128, 129, 177, 2 1 4 , 5 6 8

Utility arch, 1 4 2 ,1 4 7 ,1 5 0 ,4 9 6

656 ► INDEX # # # #
 CONTENTS

Part I Orthodontic Diagnosis

Causes o f Orthodontic Treatment Failure
Causes o f Malocclusion
Skeletal Pattern Analysis
Denture Pattern Analysis
Orthodotic Diagnosis

Part II Orthodontic Treatment

Bracket System and Bracket Positioning
Leveling and Alignment
Space Closure
Finishing
Retainers

Part III Clinical Cases

A Case o f the Maxillary and Mandibular First Premolar Extraction
A Case o f the Maxillary First Premolar
and Mandibular Second Premolar Extraction
A Non-extraction Treatment Case in Class II Malocclusion
A Non-extraction Treatment Case in Class III Malocclusion
A Non-extraction Treatment Case o f Midline Deviation