journal of dentistry 42 (2014) 16

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The timing of significant arch dimensional changes

with fixed orthodontic appliances: Data from a
multicenter randomised controlled trial
Padhraig S. Fleming a,*, Robert T. Lee b, Tom Mcdonald b,
Nikolaos Pandis c,d, Ama Johal a
a

Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
Barts and The London School of Medicine and Dentistry, Barts Health Trust, United Kingdom
c
Private Practice, Corfu, Greece
d
University of Bern, Switzerland
b

article info

abstract

Article history:

Objectives: To identify the timing of significant arch dimensional increases during ortho-

Received 2 October 2013

dontic alignment involving round and rectangular nickel-titanium (NiTi) wires and rectan-

Received in revised form

gular stainless steel (SS). A secondary aim was to compare the timing of changes occurring

2 November 2013

with conventional and self-ligating fixed appliance systems.

Accepted 13 November 2013

Methods: In this non-primary publication, additional data from a multicenter randomised

trial initially involving 96 patients, aged 16 years and above, were analysed. The main prespecified outcome measures were the magnitude and timing of maxillary intercanine,

Keywords:

interpremolar, and intermolar dimensions. Each participant underwent alignment with a

Orthodontic

standard Damon (Ormco, Orange, CA) wire sequence for a minimum of 34 weeks. Blinding of

Expansion

clinicians and patients was not possible; however, outcome assessors and data analysts

Self-ligating

were kept blind to the appliance type during data analysis.

Bracket

Results: Complete data were obtained from 71 subjects. Significant arch dimensional
changes were observed relatively early in treatment. In particular, changes in maxillary
inter-first and second premolar dimensions occurred after alignment with an 0.014 in. NiTi
wire (P < 0.05). No statistical differences in transverse dimensions were found between
rectangular NiTi and working SS wires for each transverse dimension (P > 0.05). Bracket type
had no significant effect on the timing of the transverse dimensional changes.
Conclusions: Arch dimensional changes were found to occur relatively early in treatment,
irrespective of the appliance type. Nickel-titanium wires may have a more profound effect
on transverse dimensions than previously believed.
Clinical significance: On the basis of this research orthodontic expansion may occur relatively
early in treatment. Nickel-titanium wires may have a more profound effect on transverse
dimensions than previously believed.
# 2013 Elsevier Ltd. All rights reserved.

* Corresponding author at: Institute of Dentistry, Barts and The London School of Medicine and Dentistry, Queen Mary University of
London, London E1 2AD, United Kingdom. Tel.: +442073777397.
E-mail address: padhraig.fleming@gmail.com (P.S. Fleming).
0300-5712/$ see front matter # 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jdent.2013.11.010

1.

journal of dentistry 42 (2014) 16

Introduction

Orthodontic treatment with fixed appliances typically commences with initial alignment of grossly displaced teeth prior
to arch levelling, overbite reduction, overjet reduction and
space closure in extraction cases.1 Throughout this process,
arch form changes occur in tandem with alignment producing
marked alteration in transverse dimensions including intercanine, inter-premolar and inter-molar dimensions.2,3 These
changes are necessary for alleviation of crowding in nonextraction cases, while also potentially affecting dental
aesthetics, and occlusal inter-digitation and function.
Typical increases in maxillary arch dimensions during
orthodontic alignment in non-extraction cases range from
0.55 to 2.13 mm in the inter-canine region, peaking at up to
4.94 mm in inter-premolar dimensions, while expansion in
intermolar width ranging from 1.53 mm to 2.96 mm has been
reported.2,3 Classically, it is believed that arch expansion is
produced in stiff, rectangular stainless steel (SS) arch wires, as
these wires have sufficient rigidity to promote buccal
movement of posterior teeth. More recently, use of flexible
Copper Nickel-Titanium (CuNiTi) archwires with broad arch
forms has been proposed as a means of producing transverse
arch development.4,5
Self-ligating brackets (SLBs) are ligatureless brackets and
are classified as either active or passive. Active clips encroach
on the archwire during the later stages of alignment, while in
passive systems the clip or gate mechanism does not actively
press on the arch wire. The renewed interest in self-ligating
brackets and associated use of expanded nickel-titanium
(NiTi) alloy wires has raised the possibility of significant
expansion earlier during fixed appliance therapy than previously thought realistic.5,6 A recent prospective study
highlighted inter-premolar increases of up to 3.65 mm despite
not progressing beyond use of 0.016 in. round NiTi.7 It is,
therefore, possible that significant transverse dimensional
changes may be produced at a relatively early stage of
treatment. Moreover, despite a dearth of supporting evidence,8 passive self-ligating appliances have been claimed to
lend themselves to non-extraction based treatment. The
possibility of non-extraction treatment with these systems
relates to this potential for transverse expansion, prompting
the advancement of self-ligating brackets as an alternative to
more conventional approaches involving active expansion
with auxiliaries, such as rapid palatal expanders.9
The specific aims of this non-primary report of a clinical
trial were to pinpoint the timing of significant arch dimensional increases during orthodontic alignment involving
round and rectangular nickel-titanium wires and rectangular
stainless steel. A secondary aim was to assess whether
differences arise in the timing of changes with conventional
and self-ligating appliances.

2.

Materials and methods

A multi-centre, three-arm, parallel-group randomised trial

was undertaken in 3 U.K. centres. Participants were recruited
from the orthodontic treatment waiting lists from April 2009 to

June 2011 with ethical approval from the Cambridgeshire 1

Research Ethics Committee, U.K. (09/H0304/45; Protocol:
NCT01320657). The selection criteria and treatment protocol
for much of this project has been outlined previously but are
summarised below.10
Inclusion criteria:
 Young adults aged 16 years and over.
 Fit and well and on no medication.
 In the permanent dentition with maxillary second molars
erupted.
 Maxillary arch crowding less than 6 mm.
 Amenable to non-extraction treatment in the maxillary
arch.
Exclusion criteria:





Cleft lip and palate and other craniofacial anomalies.

Previous orthodontic treatment.
Complex medical history and taking medications.
Congenital absence of teeth in the maxillary arch other than
3rd molars.

Each participant had study models taken a maximum of 1

month before placement of the fixed appliances (T1). An
unpredictable allocation sequence was developed using an
electronic randomisation programme with stratified randomisation for each centre. Randomisation was carried out in
random permuted blocks of size 12 in a ratio of 1:1:1. The
assignment of each subject was concealed from the clinician
until the appointment at which the appliance was to be placed
using sequentially numbered, opaque and sealed envelopes.
Outcome assessors and data analysts were kept blind to the
appliance type during data analysis.
Self-ligating (DamonQTM, Ormco Co, Orange, CA; InOvation
TM
C , Dentsply GAC, NY) or conventional (OvationTM, Dentsply
GAC, NY) pre-adjusted edgewise brackets with .022 in. slots
were placed based on the random allocation procedure. A .013
or 014 in. round copper nickel-titanium archwire (Damon,
Ormco Co, Orange, CA) of uniform arch form was placed in all
cases with attachments on all teeth from maxillary second
molar to second molar. The conventional twin brackets were
ligated with elastomeric modules. Subjects underwent treatment with a pre-determined Damon archwire sequence
involving .013 or .014 in. round CuNiTi; 0.014  0.025 in.
CuNiTi; 0.018  0.025 in. CuNiTi; 0.019  0.025 in. Stainless
Steel. All wires were of Damon arch form uncoordinated to
the original arch form or dimensions. Nickel-titanium wires
were changed after intervals of 10 weeks, 10 weeks and 6
weeks, respectively. The 0.019  0.025 in. Stainless steel wire
was left in place for a minimum of 8 weeks.

2.1.

Data collection

Alginate impressions of the maxillary arch were taken before

treatment (T1), after alignment with 0.014 in. CuNiTi (T2),
0.014  0.025 in. CuNiTi (T3), 0.018  0.025 in. CuNiTi (T4) and
0.019  0.025 in. SSW (T5), at which stage a 0.019  0.025 in.
stainless steel archwire was engaged passively. Data relating
to overall changes (T1T5) has previously been reported.10

journal of dentistry 42 (2014) 16

Models were measured as serial pairs, and numbered for

identification purposes with brackets obscured with wax on
post-treatment models during measurement. Measurements
were made consecutively on each cast by one examiner (PSF).

2.2.

3.

Transverse arch dimensions

The following transverse dimensions were recorded with

digital callipers (150 mm ISO 9001, Tesa Technology, Renens,
Switzerland):
 Inter-canine width: Distance between the maxillary canine
cusp tips.
 Inter-premolar widths: Distance between the buccal cusp tips
of both maxillary first or second premolars.
 Inter-molar width: Distance between the mesio-buccal cusp
tips of both maxillary first molars.
Measurements were made in duplicate and the average of
the two readings taken to a resolution of  0.01 mm.

2.3.

statistical software (Stata 13, StataCorp, College Station, TX,

USA) with a pre-specified level of statistical significance of
P < .05.

Statistical methods

Mixed models were used with inter-dental width (separately

for inter-canine, inter-first and second premolar and intermolar) as the dependent variable and type of appliance,
period, age, gender, and amount of crowding at baseline as the
independent covariates. An appliance by period interaction
term was also considered. Predictive margins with 95%
confidence intervals were produced from the final adjusted
model. On an exploratory basis, the Tukeys HSD post hoc test
was used to compare between period changes overall (not by
appliance). All statistical analyses were conducted with

Results

Baseline demographic and clinical characteristics of participants are outlined in Table 1 overall and for each of the three
bracket systems. Overall, 101 participants were recruited; of
these 96 received one of the interventions. Seventy-one
participants had complete data from all 5 time points. Data
from either T1 or T5 were missing in 9 participants;
intermediate data (T2T4) were missing in a further 16
subjects (Fig. 1). In the overall sample, gender distribution
was almost equal with slightly more males (n = 49, 51%)
subjects than females. Participants had a wide range of
malocclusions with a large proportion of Class III (n = 42, 44%).
Subjects in the InOvation CTM (Dentsply GAC, NY) group were
slightly older than in the other bracket groups, with the mean
overall age being 20 years. The degree of crowding overall was
mild (2.47 mm, SD 2.28).
Increases in all four transverse dimensions were noted
overall with a progression throughout the initial CuNiTi phases
(Table 2). The greatest magnitude of change occurred in the
premolar region with mean overall differences of 4.1 mm and
3.84 mm for inter-first and inter-second premolar dimension,
respectively. Changes in inter-canine (1.48 mm) and intermolar (1.53 mm) width were relatively minor by comparison.
Little difference between bracket type and the timing or extent
of arch dimensional changes was observed (Table 2).
The predicted changes with 95% CIs for each dimension
from the adjusted mixed model are shown in Fig. 2. Arch

Table 1 Demographic and clinical characteristics of the overall sample (n = 96).

Appliance
TM

Damon Q

n (%) or Mean (SD)

In-ovation C

TM

n (%) or Mean (SD)

OvationTM

Overall

n (%) or Mean (SD)

n (%) or Mean (SD)

Site
East Kent Hospitals
The Royal London Dental Institute
Southend NHS Foundation Trust

21 (66)
11 (34)
0 (0)

22 (69)
10 (31)
0 (0)

22 (69)
8 (25)
2 (6)

65 (68)
29 (30)
2 (2)

Gender
Male
Female

14 (44)
18 (56)

14 (44)
18 (56)

21 (66)
11 (34)

49 (51)
47 (49)

Ethnicity
White Caucasian
Asian Caucasian
Afro-Caribbean
Oriental

26
5
1
0

(81)
(16)
(3)
(0)

27
3
2
0

(84)
(9)
(2)
(0)

28
2
1
1

(88)
(6)
(3)
(3)

81
10
4
1

(84)
(10)
(4)
(4)

Malocclusion
Class I
Class II/1
Class II/2
Class III

9
7
1
15

(28)
(22)
(3)
(47)

5
8
9
10

(16)
(25)
(28)
(31)

6
8
1
17

(19)
(25)
(3)
(53)

20
23
11
42

(21)
(24)
(11)
(44)

Age
Crowding (mm)
Total

18.9 (2.9)
2.3 (2.64)
32 (100)

22.5 (8.5)
2.59 (1.99)
32 (100)

18.6 (3.4)
2.56 (2.22)
32 (100)

19.7 (5.9)
2.47 (2.28)
96 (100)

journal of dentistry 42 (2014) 16

Suitable for inclusion (n= 102)

4.

Discussion

Refused to participate (n=1)

Randomised (n= 101)
Did not receive intervention
(n=5):
Did not proceed with treatment
Received intervention (n= 96)

Missing data (n=25)

Analyzed: Complete data (n=71)

Fig. 1 Summary of participant flow and data collection.

dimensional changes increased almost linearly until T4.

However, dimensions were largely unchanged following
engagement of the 0.019  0.025 SS wire with no mean
difference found in the inter-canine dimension between T4
and T5, while increases of no more than 0.19 mm were
observed during this interval for either inter-first premolar,
inter-second premolar and inter-molar dimension (Table 3).
Statistically significant differences in arch dimensional
changes were found between baseline and T4 overall,
suggesting significant differences arose during alignment
with 0.014 and 0.018  0.025 CuNiTi in each dimension.
However, increases in inter-premolar dimensions arose early
in treatment (at T2), while those in the inter-canine and intermolar dimensions were not statistically increased at this stage
(Table 3).

Considerable disagreement has surrounded the timing, extent

and nature of transverse dimensional changes during orthodontic treatment. McNamara et al.11 in a survey of orthodontic
practitioners, drew attention to both practical variation and
philosophical disagreement in this respect, highlighting that
the arch form and width of initial NiTi archwire was considered
important by 16% and 23% of respondents, respectively.
Clinicians believed the transverse width of wires to be more
important in the later stages of treatment. The present research
casts doubt on this contention, indicating that the opposite may
be true. Based on the present study arch dimensional changes
appear to be expressed with flexible rectangular NiTi alloys,
particularly in the premolar region. It also appears that when
NiTi and SS archwires of identical arch form and dimension are
used, the effect of SS wires on arch dimensions is limited.
A gradual increase in arch dimensional change was noted
in the present research. Previous related studies have lacked
the volume and frequency of intermediate data to facilitate
complete comparison.7,1214 However, it appears that although
the magnitude of the changes found in the present study was
slightly less significant during the round wire phase (peaking
at 2.23 mm in the inter-first premolar region), the pattern of
expansion was in keeping with those previously observed
during initial alignment with round NiTi wires7 and following
overall alignment after use of rectangular steel wires both with
conventional and self-ligating brackets.1214 In particular,
Franchi et al.7 noted inter-molar expansion of 1.71 mm with
use of light round NiTi wires with more significant increases
(up to 3.65 mm) in the inter-premolar region. In the present
study this pattern was replicated with the inter-premolar
dimension again increasing maximally during the initial
stages; this trend persisted throughout alignment with both

Table 2 Mean (SD) arch dimensions at T1T5 overall and for each bracket system.
T1
Inter-canine width
Overall
Damon Q
In-Ovation C
Ovation

32.84
32.73
32.57
33.31

Inter-first premolar width

Overall
Damon Q
In-Ovation C
Ovation

T3

T4

T5

33.17 (2.42)
33.02 (2.25)
32.8 (2.67)
33.79 (2.3)

33.83
33.83
33.72
33.98

(2.14)
(1.81)
(2.55)
(2.04)

34.32 (2.02)
34.3 (1.8)
34.26 (2.33)
34.42 (1.95)

34.32
34.42
34.25
34.29

(1.93)
(1.58)
(2.34)
(1.83)

38.66 (3.73)
38 (3.3)
38.96 (3.59)
39.04 (4.39)

40.59
40.65
40.16
41.04

(2.92)
(2.46)
(3.11)
(3.19)

42.02
42.11
41.79
42.22

(2.53)
(2.06)
(2.82)
(2.71)

42.71
42.72
42.28
42.97

(2.17)
(1.77)
(2.49)
(2.17)

42.76
42.58
42.72
43.03

(2.08)
(1.66)
(2.54)
(1.93)

Inter-second premolar width

43.84 (3.76)
Overall
Damon Q
43.51 (3.72)
43.83 (3.67)
In-Ovation C
44.23 (4.05)
Ovation

45.59
45.72
45.24
45.88

(3.04)
(2.68)
(3.31)
(3.17)

46.8 (2.82)
46.98 (2.31)
46.42 (3.3)
47.06 (2.78)

47.48
47.42
47.34
47.73

(2.6)
(2.04)
(3.14)
(2.55)

47.68 (2.47)
47.5 (1.94)
47.61 (3.00)
47.95 (2.4)

Inter-molar width
Overall
Damon Q
In-Ovation C
Ovation

49.47
49.65
49.23
49.55

(3.39)
(2.85)
(4.12)
(3.07)

50.11
50.33
49.77
50.29

50.68
50.66
50.56
50.86

(2.89)
(2.34)
(3.57)
(2.64)

50.83 (2.91)
50.7 (2.32)
50.71 (3.55)
51.11 (2.91)

49.25
49.45
48.82
49.55

(2.66)
(2.65)
(2.74)
(2.64)

T2

(3.71)
(3.24)
(4.32)
(3.52)

(3.09)
(2.51)
(3.83)
(2.73)

journal of dentistry 42 (2014) 16

Fig. 2 Graphical display of mean arch dimensional changes (inter-canine, inter-premolar and inter-molar) at all 5 time
intervals (T1T5) overall.

rectangular NiTi and SS wires. These arch form changes may

reflect both the initial location of crowding, which commonly
manifests as initial displacement of canines, limiting the
magnitude of inter-canine increases during alignment, and
anchorage values; both multi-rooted maxillary first molars
and maxillary canines have a considerably larger root surface
area than adjacent premolars.
Of particular note was the significant change arising
between baseline and removal of 0.018  0.025 in. NiTi,
highlighting that undersized, flexible, rectangular wires are
capable of producing considerable transverse increases. In
particular, increases were observed at a relatively early stage
in the premolar dimension, while expansion developed at a
later stage in the canine and molar region. This pattern may
relate to the increased root length and surface area associated
with these teeth in comparison with relatively small premolars. This finding is new and may reflect the metallurgic
properties of these NiTi wires, and the wider arch form
incorporated in DamonTM arch wires. Wires of this dimension
are meeting with increased popularity.11 The use of NiTi as an

auxiliary to promote expansion is not new, with use as an

alternative to SS based auxiliaries including quadhelices and
RPE promoted and tested.15 Nevertheless, it should be noted
that the magnitude of expansion arising during alignment in
the present study was relatively minor in the molar region.
The latter suggests that use of the present wire sequence
would likely be insufficient to address posterior crossbites,
particularly those involving molar teeth unless the arch form
was actively changed by the clinician.
A further finding from the present research was the lack of
difference between passive self-ligation, active self-ligation
and conventional brackets with respect to transverse dimensional changes. This finding is in general agreement with
previous research,12,13 although two previous studies have
reported statistically significant but minor differences in arch
dimensional changes in the mandibular inter-molar region,
with slightly greater expansion observed with SLBs.13,14 This
study, however, is the first to demonstrate similarity in the
timing of these dimensional changes with different bracket
systems; significant change from baseline was observed after

Table 3 Pattern of arch dimensional changes across appliances following expression of each wire: 0.014 in. CuNiTi (T2),
0.014 T 0.025 in. CuNiTi (T3), 0.018 T 0.025 in. CuNiTi (T4) and 0.019 T 0.025 in. SSW (T5). Margins sharing a letter in the
group label are not significantly different at the 5% level.
ICW

Period
Margins
T1
T2
T3
T4
T5

32.81
33.13
33.80
34.28
34.28

IPM1W
Scheffe
contrasts
B
BC
AC
A
A

Margins
38.68
40.60
42.04
42.72
42.78

Scheffe
contrasts
B
C
D
A
A

IPM2W
Margins
43.90
45.65
46.86
47.54
47.74

Scheffe
contrasts
C
D
A
AB
B

IMW
Margins
49.32
49.54
50.19
50.76
50.90

Scheffe
contrasts
B
BC
AC
A
A

journal of dentistry 42 (2014) 16

8 weeks of engagement of the 0.018  0.025 NiTi wire with all

three tested brackets.
Uncritical inspection of the timing of arch dimensional
changes, may lead to the conclusion that the use of SS wires to
complete alignment may offer little additional value. In
addition, given the risks of root resorption associated with
delivery of high forces, prolonged treatment and torque
application,16 an argument for avoiding routine use of SS
wires may be made. However, torque delivery is known to be
markedly more effective with stainless steel wires.17 Given the
inevitable need for torque delivery and expression during
alignment of grossly displaced and crowded teeth, the use of
rectangular steel wires remains an integral and important
treatment phase. However, based on the present research, the
influence of steel wires when preceded by large NiTi wires on
arch dimensions appears to be negligible. Nevertheless, SS
wires are versatile and may be adapted to alter arch
dimensions, for example, to achieve further expansion or to
tailor the final arch form to the initial in an attempt to improve
the prospects of stability.18 This property of SS was not
exploited in the present research as an identical NiTi and SS
wire form was used throughout.
As previously reported, the present study is restricted to
skeletally mature participants to avoid confounding effects of
growth on arch dimensional changes in the maxillary arch;
mean annual changes of as little as 0.025 mm from 17 to 48
years have been reported.19 This protocol obviated the need
for an untreated control group. A further limitation was the
relatively high proportion of Class III patients in the present
study reflecting referral patterns and acceptance criteria in the
research centres, with a high proportion of these participants
proceeding to undergo combined orthodontic-surgical care.
Consequently, while the results are likely to be representative
of most orthodontic discrepancies, further research is needed
to confirm this.

5.

Conclusions

In this clinical trial, significant maxillary arch dimensional

changes were reported between baseline and insertion of
undersized NiTi archwires. Little additional change in transverse dimension was found with SS wires, and no effect of
bracket type was observed. NiTi wires may have a more
profound effect on transverse dimensions than previously
believed.

6.

Conflicts of Interest

The authors have no conflicts of interest to report.

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