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in orthodontics orthodontics.
PRACTICE
• Clarifies the limitations and benefits of
definitive orthodontics.
• Illustrates nine common misconceptions
P. S. Fleming,*1 S. D. Springate2 and R. A. C. Chate3 concerning orthodontic treatment.
Comprehensive orthodontic treatment typically comprises an initial phase of alignment over a period of four to six
months, followed by vertical, transverse and antero-posterior corrections, space closure, finishing and detailing to enhance
dental and facial aesthetics and function. Each course of treatment involves a series of decisions and alternatives relating
to objectives, appliance design and treatment mechanics. In recent years there has been increasing interest in short-term
approaches to treatment with more limited objectives and the avoidance of phases traditionally considered integral to
successful treatment. In this review the veracity of accepted truths in orthodontics are discussed; specifically, the impor-
tance of initial molar relationship, final incisor relationship, the merits of orthodontic extractions, anticipated treatment
times, the value of modern fixed appliance systems, the importance of torque expression and the relative merits of bonded
retainers and inter-proximal reduction are considered.
INTRODUCTION have been observed in other dental disci- moderate to severe crowding, consideration
The delivery of healthcare in the UK has seen plines including paediatric dentistry4 and should be given to symmetrical extraction of
considerable change in recent years with periodontics,5 and are also established inter- four premolar units to preserve Class I molar
the reconfiguration of NHS healthcare com- nationally in orthodontics.6 What differenti- and incisor relationships.
missioners, increasing emphasis on patient- ates this trend within orthodontics from that With Class II molar relationships at the
reported outcome measures, and budgetary in other specialties is that a significant pro- outset in an intact dentition, simple align-
restrictions. Dentistry has not been immune portion of the treatments offered by general ment is likely to translate into a residual
to these developments with contractual practitioners have more limited objectives overjet following treatment. Consequently,
changes particularly noteworthy. Historically, than conventional specialist-delivered care; consideration should be given to correcting
orthodontic treatments were predominantly some of it is also suggested as an adjunct the molar relationship to Class I with one of
undertaken by non-specialist general dental to produce a more conservative restorative a number of adjuncts including: a functional
practitioner (GDP) providers within the NHS, solution than would be possible without appliance, fixed Class II corrector, headgear
but this situation gradually changed with the recourse to orthodontics. In this paper, nine or upper and lower extractions if achieve-
acceptance that fixed appliances in the hands areas of debate and misunderstanding con- ment of Class I incisors is a treatment objec-
of specialists were capable of superior results.1 cerning orthodontic planning and treatment tive (Fig. 1). Alternatively, in an uncrowded
In recent years, however, alternatives to con- are discussed. lower arch, consideration could be given to
ventional courses of fixed appliance orthodon- accepting the Class II molar relationships
tics have emerged. Much of this treatment is ARE MOLAR by camouflaging the incisor relationship
offered by GDPs, predominantly in the form of RELATIONSHIPS RELEVANT? with the loss of maxillary premolars alone
‘accelerated orthodontics’ or treatment involv- The ideal Class I molar relationship was orig- (Fig. 2). The alternative would be to accept a
ing aesthetic removable and fixed appliances2 inally defined by Angle7 and later refined by residual overjet following treatment, but this
but this has been accompanied by a significant Andrews.8 Angle’s initial belief was that the would have implications both for aesthetics
increase in successful litigation claims.3 molars were the cornerstone to the occlusion. and post-treatment stability, likely requiring
Similar patterns of care, with delivery While adolescent growth may alter skeletal a commitment to life-long retention.
involving both specialists and non-specialists, relationships, typically reducing the convex-
ity of the lower face and improving skeletal IS A CLASS I INCISOR
1
Barts and The London School of Medicine and Den- II relationships slightly,9 molar relationship WORTH AIMING FOR?
tistry, Institute of Dentistry, Queen Mary University of is generally considered to be constant once Traditionally, achievement of Class I inci-
London, London, E1 2AD; 2Eastman Dental Institute,
London; 3Vice Dean, Faculty of Dental Surgery, The
the permanent dentition is established.10 The sors has been an objective of comprehen-
Royal College of Surgeons of Edinburgh, Nicolson Street, molar relationship is integral to determining sive orthodontic treatment. The rationale
Edinburgh, EH8 9DW the final incisor relationship. Specifically, for this relates to the likelihood of stability
*Correspondence to: Dr Padhraig Fleming
Email: padhraig.fleming@gmail.com with Class I molar relationships and an and aesthetics associated with this relation-
intact dentition devoid of inter-arch tooth- ship between the upper and lower incisors.
Refereed Paper size discrepancy, non-extraction treatment Stability stems from the combination of a
Accepted 26 June 2014
DOI: 10.1038/sj.bdj.2015.41 is likely to translate into a Class I incisor normal overjet and overbite with the max-
©British Dental Journal 2015; 218: 105-110 relationship. Moreover, in the presence of illary incisors resting on the tips of the
Fig. 5 Class I crowded case treated with customised lingual appliances over a seven-month period. The lack of uniformity of lingual surfaces
mean that stock brackets may have poor adaptation to lingual surfaces making treatment more complex
IS TORQUE DELIVERY IMPORTANT? outcomes, particularly where teeth were sig- IS BONDED RETENTION
Torque can be defined as ‘rotation without nificantly displaced before treatment (Fig. 4).
A GUARANTEE OF STABILITY?
translation’ or ‘preferential movement of the The increasing emphasis on non-extrac-
root with a stationary crown’. Torque is a ARE BETTER OUTCOMES ACHIEVED tion treatment has brought the use of
product of force couples generated between WITH MODERN BRACKETS? fixed retainers into sharper focus (Table 5).
bracket and wire; rectangular stainless steel While novel techniques such as the use of Bonded retention is not without problems:
wires with high elastic modulus and minimal temporary anchorage devices (TADs) have fixed lingual retainers may encourage plaque
play between wire and bracket slot are nec- broadened the scope and enhanced the pre- accumulation with potential periodontal
essary for effective torque delivery (Fig. 3). dictability of treatment (Table 4), there is implications.38 Consequently, their use may
Torque delivery is considered to be an inte- no evidence to suggest that refinement of not be appropriate in the presence of poor
gral part of orthodontic treatment; effec- brackets has been accompanied by better oral hygiene. Failure rates with fixed retain-
tive torque delivery is one of six recognised outcomes. Prospective research comparing ers have been shown to be high.39 As such,
occlusal keys necessary to produce an ideal treatment times with self-ligating brackets ‘permanent’ retention does not remove the
occlusal result.8 In addition, torque delivery have also alluded to comparable levels of requirement that the teeth are placed in posi-
is often important in the buccal segments occlusal improvement with these systems.32–35 tions of soft tissue balance. Additionally,
as alleviation of crowding in round wires Clearly, the quality of a course of orthodon- prediction of relapse on an individual
results in bucco-lingual inclination changes, tics is contingent more on the standards and basis has proven impossible, invoking the
which may compromise occlusal interdigita- skills of the operator than on the bracket sys- need for a long-term retention strategy for
tion, overbite and stability. In the anterior tem used. Both labial and lingual customised many patients.
regions, appropriate torque contributes to appliances have been produced, with either Furthermore, while bonded retainers may
dental aesthetics; the labial face of the max- brackets, wires or both tailored to the indi- maintain rotational correction of teeth, they
illary central incisor should lie parallel to the vidual patient. Customised lingual appliances may be inadequate to resist soft tissue pres-
facial vertical for optimal dental aesthetics, have become particularly popular due to the sures, for example, those arising follow-
with greater requirement for palatal root wide variation in the morphology of lingual ing correction of bimaxillary proclination.
torque in the presence of increased lower surfaces, which complicates adaptation of Consequently, inclination changes and tooth
anterior facial height.37 In addition, torque stock brackets to these teeth and has a bear- migration may arise despite intact retain-
expression is important in producing stable ing on torque delivery (Fig. 5). ers; augmentation of fixed retainers with
Dentofacial Orthop 1988; 93: 423–428. 29. Fleming P S, Scott P, Heidari N, Dibiase A T. Influence conventional appliances in adolescents: a single-
23. Luppanapornlarp S, Johnston L E Jr. The effects of of radiographic position of ectopic canines on the centre randomized controlled trial. Am J Orthod
premolar-extraction: a long-term comparison of duration of orthodontic treatment. Angle Orthod Dentofacial Orthop 2014; 145: 569–578.
outcomes in “clear-cut” extraction and nonextraction 2009; 79: 442–446. 36. O’Brien K, Sandler J. In the land of no evidence, is
Class II patients. Angle Orthod 1993; 63: 257–272. 30. Andrews L F. The straight-wire appliance. Explained the salesman king? Am J Orthod Dentofacial Orthop
24. Paquette D E, Beattie J R, Johnston L E Jr. A long- and compared. J Clin Orthod 1976; 10: 174–195. 2010; 138: 247–249.
term comparison of nonextraction and premolar 31. Fleming P S, Johal A. Self-ligating brackets in ortho- 37. Ross V A, Isaacson R J, Germane N, Rubenstein L K.
extraction edgewise therapy in ‘borderline’ Class dontics: a systematic review. Angle Orthod 2010; 80: Influence of vertical growth pattern on faciolingual
II patients. Am J Orthod Dentofacial Orthop 1992; 575–584. inclinations and treatment mechanics. Am J Orthod
102: 1–14. 32. Fleming P S, DiBiase A T, Lee R T. Randomized clini- Dentofacial Orthop 1990; 98: 422–429.
25. Kirschen RH, O’Higgins E A, Lee R T. The Royal cal trial of orthodontic treatment efficiency with 38. Pandis N, Vlahopoulos K, Madianos P, Eliades T.
London Space Planning: an integration of space self-ligating and conventional fixed orthodontic Long-term periodontal status of patients with man-
analysis and treatment planning: Part I: Assessing appliances. Am J Orthod Dentofacial Orthop 2010; dibular lingual fixed retention. Eur J Orthod 2007;
the space required to meet treatment objectives. Am 137: 738–742. 29: 471–476.
J Orthod Dentofacial Orthop 2000; 118: 448–455. 33. Di Biase A T, Nasr I H, Scott P, Cobourne M T. 39. Booth F A, Edelman J M, Proffit W R. Twenty-year
26. Hamilton R, Goonewardene M S, Murray K. Duration of treatment and occlusal outcome using follow-up of patients with permanently bonded
Comparison of active self-ligating brackets and Damon3 self-ligated and conventional orthodontic mandibular canine-to-canine retainers. Am J Orthod
conventional pre-adjusted brackets. Aust Orthod J bracket systems in extraction patients: a prospective Dentofacial Orthop 2008; 133: 70–76.
2008; 24: 102–109. randomized clinical trial. Am J Orthod Dentofacial 40. Renkema A M, Renkema A, Bronkhorst E, Katsaros
27. Mavreas D, Athanasiou A E. Factors affecting the Orthop 2011; 139: e111–e116. C. Long-term effectiveness of canine-to-canine
duration of orthodontic treatment: a systematic 34. Johannson K, Lundstrom F. Orthodontic treatment bonded flexible spiral wire lingual retainers. Am J
review. Eur J Orthod 2008; 30: 386–395. efficiency with self-ligating and conventional Orthod Dentofacial Orthop 2011; 139: 614–634.
28. O’Brien K, Wright J, Conboy F et al. Prospective, edgewise twin brackets. A prospective randomized 41. Zachrisson B U, Nyøygaard L, Mobarak K. Dental
multi-centre study of the effectiveness of ortho- clinical trial. Angle Orthod 2012; 82: 929–934. health assessed more than 10 years after inter-
dontic/orthognathic surgery care in the United 35. Songra G, Clover M, Atack N E et al. Comparative proximal enamel reduction of mandibular anterior
Kingdom. Am J Orthod Dentofacial Orthop 2009; assessment of alignment efficiency and space teeth. Am J Orthod Dentofacial Orthop 2007; 131:
135: 709–714. closure of active and passive self-ligating vs 162–169.
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