THE

TWEED PROFILE

published by

THE CHARLES H. TWEED

INTERNATIONAL FOUNDATION FOR
ORTHODONTIC RESEARCH AND EDUCATION

Volume #8

2009
 CONTENTS

3 GOALS, CONCEPTS, AND GUIDELINES FOR COMPREHENSIVE CORRECTION OF

CLASS II MALOCCLUSIONS — HERB KLONTZ
OKLAHOMA CITY, OK

8 IN PRUSUIT OF A BEAUTIFIUL FACIAL PROFILE — KOHO HASE

KITAKAWABE SAITAMA, JAPAN

15 ESTHETICS AND DIRECTIONAL FORCES IN PATIENTS TREATED IN

TWO PHASES — MARIA GIACINTA PAOLONE
ROME, ITALY

23 THE USE OF TEMPORARY ANCHORAGE DEVICES (“TAD’S”) IN TWEED-MERRIFIELD

DIRECTIONAL FORCE ORTHODONTICS — DANIEL GEORGE
HOLLAND, MI

25 EXTRACTION OF A MANDIBULAR INCISOR IN ADULT ORTHODONTIC TREATMENT:

AN ACCEPTABLE COMPROMISE — GIOVANNI BIONDI
VARAGO DI MASERADA (TV), ITALY

28 CASE REPORT: NONSURGICAL CORRECTION OF A CLASS II, DIVISION 1 DEEP

OVERBITE SKELETAL MALOCCLUSION IN AN ADULT PATIENT — SHIGEYORI INAGE
YOKOHAMA, JAPAN

33 CASE REPORT: TWEED-MERRIFIELD PHILOSOPHY: SOME CLINICAL DETERMINATIONS FOR THE

ADULT PATIENT TREATMENT — SERGIO A. CARDIEL RÍOS
MORELIA, MICHOACÁN, MEXICO

39 GIVE ME BRACES, AND I’LL GIVE YOU BONE! — ELIE WILLIAM AMM
BEIRUT, LEBANON

43 SHOULD WE LEARN WIRE BENDING IN THE 21ST CENTURY? — CAMILLE MEDAWAR

PARIS, FRANCE

47 TWO PHASE TREATMENT IN CLASS TWO CORRECTION — ALBERTO CASALI

REGGIO EMILIA, ITALY

2
 GOALS, CONCEPTS, AND GUIDELINES FOR COMPREHENSIVE CORRECTION OF
CLASS II MALOCCLUSIONS

HERB KLONTZ
OKLAHOMA CITY, OK

The Class II malocclusion is a difficult problem for the balance, harmony and proportion. Facial balance can
specialty of orthodontics. If the practitioner can rou- be quantified by the use of Merrifield’s Z angle1. It
tinely and successfully correct Class II malocclusions, is an excellent guideline because it allows the ortho-
he/she generally has a good idea of treatment plan- dontist to quantify the soft tissue response to tooth
ning and the proper delivery of force systems. The movement. This patient (Fig. 1) has a very protru-
goals that one must establish prior to treatment of any sive Class II facial pattern. The initial Z angle is 54º.
Class II malocclusion are the same goals that must be After treatment with a proper treatment plan and force
achieved during the correction of a less difficult mal- system, the Z angle is 73º. This young man (Fig. 2)
occlusion. These goals are esthetics, health and func- has a pretreatment Z angle of 58º and a posttreatment
tion, stability, and treatment in harmony with growth. Z angle of 76º. The correction of his high angle Class
A good differential diagnosis will lead to a treatment II malocclusion required a well formulated treatment
plan that will insure successful treatment. All treat- plan and a force system that paid particular attention
ment plans, no matter what the malocclusion, should to vertical control during tooth movement.
be based on the dimensions of the dentition. This is a
fundamental concept, and it must not be violated if the
resolution of the malocclusion
is to be successful. When one is
treatment planning the Class II
malocclusion, it is important to
“compartmentalize” the various
aspects of the problem into a) the
face, b) the skeletal pattern, and
c) the dentition. The purpose of
this paper will be to share some
diagnostic, treatment planning Fig. 1
and force system guidelines that
will enable the practitioner to routinely and success- THE SKELETAL PATTERN
fully correct the difficult Class II malocclusion. An understanding of the skeletal pattern must be an
integral part of any orthodontic treatment plan. It is
THE FACE - FACES FIRST!! very difficult to change the vertical dimension of a
The goal of orthodontic treatment is to improve facial particular patient. Therefore, for the patient to have
balance, harmony and proportion, or to maintain facial good facial esthetics at the end of orthodontic treat-

3
 Fig. 2
ment, the clinician must carefully study and complete-
ly understand the skeletal pattern and how it will im-
pact the posttreatment facial result. These specimens
(Fig. 3) are illustrative of the type and divergence of
problems with which the orthodontist must work. The
high angle patient and the low angle patient, and all
patients in between these extremes, must be carefully
evaluated and treatment planned so that the skeletal
pattern does not adversely effect posttreatment facial
esthetics.
Fig. 3
THE DENTITION
The final piece of the puzzle is the dentition. A total
dentition space analysis must include a tooth/arch
discrepancy, a cephalometric discrepancy, and a curve
of Spee correction space requirement. The dentition is
divided into the anterior, midarch, and posterior seg-
ments (Fig. 4). The available space is measured. The
required space is measured. The difference is either
a surplus or a deficit. The posterior dentition area
must be carefully measured, and the expected increase
must be considered when the posterior discrepancy or
surplus is determined.
4
Fig. 4
An important part of the total dentition space analysis
is the cephalometric correction factor or cephalomet-
ric discrepancy. Dr. Tweed actually measured the
amount of mandibular incisor uprighting that was
needed to position the mandibular incisor upright
over basal bone (Fig. 5). He then measured, at the
occlusal plane, the amount of millimeters it would
take to put the mandibular incisors at a proper inclina-
tion and multiplied his measurement by two because
there were two sides of the arches. In today’s world
it is much easier to use a correction factor of .8 rather
than to measure the
cephalometric x-ray.
For example, if the
FMA is 30º or more,
FMIA should be
65º. Therefore, for a
patient whose FMA
is 30º, FMIA is 53º,
and IMPA is 97º, if
one takes the FMIA
to 65º, there is a dif-
ference of 12º from Fig. 5
65º to 53º. The 12º
of needed correction is multiplied by the correction
factor of .8. The cephalometric correction is 9.6 mil-
limeters. This 9.6 millimeters is the amount of space
in both sides of the arch that it will take to upright the
mandibular incisors in this particular example so that
the FMIA will be 65º. If FMIA is 65º, the patient will
have “balanced” facial esthetics.
Another important part of the total dentition space
analysis is the measurement of the depth of the curve
of Spee. It takes space to level a curve of Spee! If the
curve of Spee is 3 millimeters deep on one side and 2
millimeters deep on the other, these values are added
together and divided by 2. In this example it will take
2.5 millimeters of space to level the curve of Spee.
All of these variables must be carefully considered
when treatment is being planned so that the Class II
patient will receive an esthetic, healthy, functional,
and stable result.

Another factor to be considered during Class II cor- Fig. 7

rection is growth. One must ask, “What effect does
growth have on Class II correction?” It is safe to state
that growth does not correct the Class II relationship,
but growth helps the orthodontist correct it if verti-
cal control is a priority during mechanotherapy. The
patient can have no downward and forward displace-
ment of the mandible in relation to the maxilla if
anterior and posterior facial height is not controlled. If
molars are extruded, the chin will generally drop down
and back (Fig. 6). If the patient has a proper treat-
ment plan and vertical dimension is controlled during
mechanotherapy, the mandible should come down-
ward and forward in relation to the maxilla (Fig. 7).
When this transpires, the patient will have a wonderful
dentition, but most importantly, facial esthetics will be
drastically improved.
be carefully placed in their proper position in order for
success to be realized.
CASE REPORT
To illustrate the concepts which have been described,
a case report will be shown in its entirety. The pa-
tient, T.S., has a protrusive profile, an inverted lower
lip, and a recessive chin (Fig. 8). The casts (Fig. 9)
illustrate an Angle’s Class II dentition with protrusive
maxillary incisors and an impinging overbite.
The cephalogram (Fig. 10a) and its tracing (Fig 10b)
illustrate the Class II skeletal problem. The ANB is
8º, AO-BO is 6 millimeters, the Z angle is 66º, and
FMIA is 59º. The total dentition space analysis (Fig.
11) confirms a total space analysis deficit of 22.4 mil-
limeters and a total space analysis difficulty deficit

Fig. 6 Fig. 8
In summation, the clinician must carefully study the
face, the skeletal pattern, and the dentition in order to
arrive at a proper treatment plan for Class II malocclu-
sion correction. Growth and the effects of the treat-
ment plan, as well as the force system, on the patient’s
ability to manifest growth in a favorable direction
must be understood. All the pieces of the puzzle must Fig. 9

5
 Fig. 10a
Fig. 12

Fig. 10b Fig. 13

of 30.9 millimeters. A summary of the space require-
ments along with the Class II occlusal disharmony
(Fig. 12) illustrates a deficit of 16.4 millimeters in just
the anterior/midarch area. This 16.4 millimeters does
not include the posterior discrepancy which can be
resolved by extraction of third molars. The clinician
must find 16.4 millimeters of anterior/midarch man-
dibular space to correct this young man’s problem.
of the maxillary first premolars and the mandibular
second premolars. The pretreatment/recall facial pho-
tographs (Fig. 13) illustrate the drastic and dramatic
improvement in facial esthetics. The cephalometic x-
rays and the tracings (Fig. 14a, b) confirm the correc-
tion of the malocclusion due to movement of the teeth.
FMIA has increased from 59º to 72º. The Z angle has
improved from 66º to 78º. ANB has been reduced
from 8º to 1º. The slides of the teeth after “settling”
of the dentition
(Fig. 15) illustrate
a healthy and func-
tional dentition.

Class II correction
cannot be accom-
plished without a
proper treatment
plan and a proper
force system, both
Fig. 11 of which allow the
clinician to take
Patient T.S. was treatment planned for the extraction advantage of the patient’s genetic potential for the

6
Fig. 14a Fig. 14b

mandible to outgrow the maxilla in a downward and

forward direction. The pretreatment/recall photo-
graphs of patient, T.S. when viewed together (Fig. 16)
graphically illustrate what can happen for the Class II
patient if the “fundamentals” are followed. The treat-
ment goals of esthetics, health and function, stability,
and treatment in harmony with growth were achieved
for this patient. These things could not have been ac- Fig. 15
complished had the patient not been treatment planned
properly and had not the force systems been delivered
in a very sequential, careful, and controlled
manner.

In (Fig.17) are two sets of sisters. Each one

of these young ladies was treated with a dif-
ferent treatment plan. Starting from right to
left the treatment plans were: non-premolar
extraction, maxillary first premolars/mandibu-
lar second premolars, four first premolars,
four first premolars, maxillary, second molars Fig. 16
and mandibular third molars. All of them
have gorgeous smiles. The validation of the
treatment plan and the force system when the
Class II patient is treated is the smile!

Fig. 17

REFERENCE
Merrifield, L.L., The Profile as an Aid in Critically Evaluating Facial Esthetics, AJO/DO, 1966. 11, page 804-
822.

7
 “IN PURSUIT OF A BEAUTIFUL FACIAL PROFILE”
KOHO HASE
KITAKAWABE SAITAMA, JAPAN
INTRODUCTION
Due to differences in genetic make-up, Tweed’s FMA
and FMIA standards that “work” for the Caucasian
population do not necessarily apply for other ethnic
groups. In general, Japanese people tend to have flat-
ter noses, more anterior tooth protrusions and a more
dolichocephalic profile than Caucasians (Fig. 1).
Fig. 1 Fig. 2
After seeing the traditional Japanese dancing girl, the
Geisha, (Fig. 2) Westerners might ask “What is the
perception of Japanese facial beauty?” Is there any
difference between Japanese and western perceptions?
Fig. 3- Early 1990’s stars with high canine were
considered to be “lovely”
8
Indeed, during the early 90’s, Japanese movie stars
(Fig. 3) with “high canines” were considered to be
“lovely” and the “Gold tooth” (Fig. 4) was the symbol
of wealth and beauty. The Japanese have called them-
Fig. 4 - Not long ago gold teeth had been the symbol
of wealth and beauty
selves Yamato Minzoku (peace people) and have long
been affected by the philosophy of Zen, that requires
a spirit of acceptance of all nature. Therefore many
Japanese people might not criticize or discuss the mat-
ter of facial esthetics in public, or even in private.
Our generation has changed its perception of facial
beauty. Caucasian stars like Hilary Duff, and Cam-
eron Diaz are very popular in Japan. Their lovely
facial beauty is quite acceptable.(Fig. 5) One of the
most popular young Japanese movie stars is Miss Ueto
Aya (Fig. 6). Her lateral profile was examined and it
Fig. 5
was found that she has an Result
IMPA of 88°. Although Hase Dental Class I & II — 63 Samples
the profile of a Japanese is Tweed Value Before After Difference
different than the “Western FMIA 67 50.73 57.97 7.24
profile”, the perception
of good facial esthetics is FMA 25 33.67 34.10 0.43
virtually the same. Fig. 6 IMPA 88 95.60 87.98 -7.61SD4.3
SNA 82 82.34 81.48 -0.86
MATERIALS & METHODS SNB 80 76.80 77.23 0.43
The data from 80 patients treated with Tweed Mer- ANB 2 5.54 4.25 -1.30
rifield mechanics was studied and analyzed. These AO-BO 2mm 1.93 1.50 -0.43
80 patients, over the course of the past 13 years, have OCC PLANE 10 13.91 13.11 -0.8
enjoyed the success of the orthodontic treatment and Z ANGLE 75 56.58 67.51 10.94
are happy with their facial profiles. FAC. HT. INDEX .67 0.68 0.01
Fig. 8
In the sample are 27 Angle’s Class I malocclusions,
36 Angle’s Class II malocclusions and 17 Class III
malocclusions. Lat-
eral cephalograms Hase Dental Class III — 17 Samples
and study casts were Tweed Value Before After Difference
measured. The cepha- FMIA 67 59.53 67.35 7.82
logram measurements FMA 25 32.35 32.88 0.53
were performed by IMPA 88 90.08 82.17 -7.92
either traditional X-ray SNA 82 80.35 82.12 1.76
film tracing and/or by SNB 80 78.97 80.65 1.68
the software “Auto
Cad”. To know the ANB 2 0.76 0.89 0.13
deviation rate of the Fig. 7- Nose protrusion rate = AO-BO 2mm 4.35 0.82 3.53
length of nose tip to length of nose tip to SN/length OCC PLANE 10 11.47 10.24 1.24
SN line, a measure- of SN Z ANGLE 75 70.47 75.24 4.76
ment was made and the “protrusion rate of nose tip to FAC. HT. INDEX 0.69 0.69 0.00
SN” was calculated by the following equation (Fig. 7)
Protrusion rate of nose tip to SN= Length of the nose Fig. 9
tip to SN / Length of SN (%)
(Fig. 8). samples decreased 7.6° with a SD of 4.3°. Even the
Class III sample, which always requires an upright
The average pretreatment values of the 63 Class I mal- IMPA for dentition correction, had an IMPA decrease
occlusions and Class II malocclusions in the sample of 7.92° (Fig. 9).
before treatment were: FMIA 50.73°, FMA 33.67°,
and IMPA 95.60°. The values of the 17 Class III The protrusion rate of the nose tip to SN for Japanese
malocclusion sample were: FMIA 59.53, FMA 32.35°, and Caucasian Clinical Norm Bioprogressive Diagno-
and IMPA 90.08°. After the treatment, the average sis, by Nezu et. al is 43% and 52% respectively. The
value of the 63 Class I and Class II malocclusions im- average Length of nose tip to SN is 28mm and 52mm
proved to the following measurements: FMIA 57.97°, respectively. In my clinic the protrusion rate for the
FMA 34.10°, and IMPA 87.98°. The Class III group pre. and post treatment patients was 44% ( SDTEV
saw improvements to FMIA 67.35 , FMA 32.88°, 4.2%) and 45% respectively.
and IMPA 82.17°. The IMPA of Class I and Class II

9
The average length of nose tip to SN is 27.4mm (Pre.)
and 28.7mm (post.) respectively. There was a 1.3mm
increase due to orthodontic treatment (Fig. 7).
All the patients and their parents were satisfied with
the improved facial balance and harmony. There are
two samples (Fig. 10 - 17) who have similar pretreat-
ment and posttreatment cephalometric values that
correspond with the average for the Class I and Class
II malocclusion samples.

Fig. 13 - Five years after debanded

Fig. 10 - Case 1 “Standard Japanese

malocclusion” Age:14 Fig. 14 - Case 2 “Standard Japanese
Treatment period: 36 months malocclusion” Age:14
Treatment period: 17 months

Fig. 11 - Pretreatment Class II Bimaxillary Protrusion

Fig. 15 - Pretreatment Class II deep bite

Fig. 12 - Posttreatment Class II Bimaxillary Protrusion

Fig. 16 - Three years after debanded

10
 Hase Dental Class I & II — 63 Samples
Before After Improvement
FMIA 50.73 57.97 7.24
FMA 33.67 34.10 0.43
IMPA 95.60 87.98 -7.61
(-8.79 away from Japan Norm 96.8)

Hase Dental Class III — 17 Samples

Before After Improvement
FMIA 59.53 67.35 7.82
Fig. 17 - Posttreatment FMA 32.35 32.88 .53
IMPA 90.08 82.17 -7.92

DISCUSSION Tweed Formula for Head film correction: if

In our world, the cultural differences between coun- FMA 35 34
tries are becoming less and less evident due to mass FMIA 65 65
communication. This “borderless” phenomenon has IMPA 80 81
been a strong trend among Japan’s “young” genera-
tion. The Japanese perception of beauty of the facial Fig. 18- Compensating the inclination of the
profile is becoming closer to that of the Caucasian. It mandibular incisors for varying FMA
is inevitable and necessary to consider the facial pro-
file during orthodontic treatment, especially because
of this new sense of what is considered beautiful.
In the 1950’s Tweed’s sample of 95 patients was se-
lected on the basis of good facial esthetics. The sample
had an incisor mandibular plane angle (IMPA) of
87.88° which is 3.52° less than the average of 91.4°,
a “norm” used by Down’s in his study of a Caucasian Fig. 19 Despite different genetic makeup - High FMA
sample. Compared to Caucasians, the Japanese have angle the IMPA was able to achieve uprightness to the
higher FMA values. The samples of Class I and II value of IMPA 88 (87.98) and good facial esthetics
who came to my office showed average FMA val-
ues of 33.67° and an IMPA 95.60° before treatment.
These two values quite matched the malocclusion
values of FMA 34.02° and IMPA 94.49° which are
Japanese measurements done by Iwasawa’s 1969 team
at Japan University. In this study, by using Tweed
Merrifield Mechanics, I have improved the patient’s
IMPA from the average of 95.60° to 87.98° which is
almost 8.79° less than the average Japanese IMPA
value of 96.77° (Iwasawa Fig. 18, 19). The improved
IMPA value is almost the same as the IMPA value Dr. Fig. 20 - IMPA of 88°
Tweed decided should be the standard 50 years ago. the sample who were treated to an IMPA of 88° (Fig.
It is worthwhile to note that the initial Japanese FMA 20-29) and four other patients for whom the treatment
and FMIA values were quite different from Tweed’s created improvement of facial esthetics due to the
standard value. There were two high angle patients in IMPA of 88° (Fig. 30-33).

11
 Pre Post
FMIA 39 49
FMA 45 43
IMPA 96 88
SNA 80 75
SNB 71 71
ANB 9 4
AO-BO 8 5
0CC 23 20
Z 48 60
UL 14 13
TC 16 14 Fig. 24
PFH 40 47
AFH 70 68
INDEX .58 .69

Fig. 21 - Pretreatment and Posttreatment measure-

ments

Fig. 25

Fig. 22

Fig. 26

Fig. 23

12
 Pre Post
FMIA 39 46
FMA 48 46
IMPA 93 88
SNA 82 82
SNB 76 76
ANB 6 6
AO-BO -1 4
0CC 23 18
Z 54 63
UL 12 10
TC 15 14
PFH 53 50
AFH 82 80
INDEX .65 .62

Fig. 27

Fig. 30

Fig. 28

Fig. 31

Fig. 29 - Two years after debanding

13
 CONCLUSION
Due to the Japanese population having a high FMA
value, the use of Tweed Merrifield Mechanics has to
focus on the IMPA rather than the FMIA.

1. The change in the IMPA angle should be limited

to be around 7.6° SD±4.3 to 7.9°, therefore the
Tweed Cephalometric correction Formula is not
quite as appropriate for the high angle Japanese
patient.
2. Strategically implementing ways to reach an
IMPA of 88°during the initial stages of treatment
will lead to success and to good esthetics.
3. An IMPA of 88° will “guarantee” good facial
esthetics for most Japanese people.

Fig. 32 - Nose protrusion rate 46% to 47%

(Caucasian norm 52%)

Fig. 33 - Nose protrusion rate 43%

(Caucasian norm 52%)

14
 ESTHETICS AND DIRECTIONAL FORCES IN PATIENTS TREATED IN TWO PHASES

MARIA GIACINTA PAOLONE

ROME, ITALY

The increased awareness of craniofacial growth and
the possibility of using growth as an “orthodontic
appliance” offers the opportunity of treating younger
patients. The opportunity to treat younger patients
requires the orthodontist to understand that he/she is
treating not only teeth, but growing faces. Orthodon-
tics is changing facial balance and harmony in chil-
dren who are preparing to become adults. So, which
direction should the face be moved? Or, better, which
direction should growth be moved? Growth can be an
orthodontic appliance.
orthodontic appliances in order to work on dental
compensations, the cant of the occlusal plane, and
functional interferences. This type of treatment will
prepare the patient for a second phase treatment in
which growth is already “redirected” and ready to
contribute pure directional forces which is guaranteed
by Tweed mechanics.
The following clinical case reports illustrate this con-
cept.

The plan of treatment in younger children must take Merrifield L:L:; Cross J:J:: Directional forces. Am J
into account the effects of “growth”. Is growth free to Orthod 1970; 57(5): 435-463
express itself or is there any necessity to give a new
direction, a new freedom? Is the natural growth of
the patient in the direction of the correction needed?
Are there any interferences or dental compensations
that might be able to push the face towards a pathway
which guarantees future facial esthetics, function and
stability?

One’s mechanical directional forces must be in com-

plete harmony with the patient’s growth so that growth
can have free “expression” without obstacles, interfer-
ences and compensations. In this situation two phases
of treatment might allow clinicians to detect and treat,
as early as possible, the direction of the growth with

15
Patient 1: This patient has an Angle’s Class II occlusion and bilateral posterior crossbites.

16
Patient 1: The palatal construction is corrected.

17
Patient 1: The posttreatment face and teeth.

18
Patient 1: Recall face and teeth.

19
Patient 2 – Pretreatment: Palatal constriction and a tooth arch discrepancy.

20
Patient 2 – Posttreatment: The face and the teeth.

21
Patient 2 – Recall: The face and the teeth.

22
 THE USE OF TEMPORARY ANCHORAGE DEVICES (“TAD’S”)
IN TWEED -MERRIFIELD DIRECTIONAL FORCE ORTHODONTICS

Daniel George
HOLLAND, MI

The purpose of this presentation is to illustrate the use TAD’s can be used to intrude teeth (Fig. 1a, b). The
of technology that can help us achieve our treatment maxillary canine to canine segment can be intruded
goals. Over the past several years, an alternative, ad- and retracted simultaneously. Treatment time is re-
junctive appliance, the Temporary Anchorage Device duced (Fig. 2a, b).
(TAD) has arrived. It is now possible to prepare the
ideal mandibular arch and not compromise it, as well It is possible to distalize the maxillary arch as far as
as to correct the Class II or Class III malocclusion by necessary without the use of headgear (Fig. 3a, b).
using TAD’s for skeletal anchorage.
Fig. 2a: TAD’s used to
TAD’s can provide virtually 100% skeletal anchorage. retract and intrude the
anterior segment. A new
They help increase control in all three planes of space.
way to reduce treatment
It is possible to retract, protract, intrude, upright im- time in a controlled man-
pacted teeth, etc., without patient cooperation. TAD’s ner.
have also reduced the need for orthognathic surgery to
correct some skeletal dysplasia’s. In some instances
TAD’s eliminate implants to replace congenitally
missing teeth — such as mandibular second premo-
lars.
Fig.1a: Absolute maxillary
incisor intrusion using TAD’s.

Note difference on occlusal plane

of incisors to cuspids. Fig. 2b: Immediately Post-retraction
of the canine to canine segment.

Fig. 1b: Post treatment occlusion.

23

Fig. 3a: Distal “en masse” move-
ment with 1.5mm x 9.0mm TAD
and 250g Niti spring.
Fig. 3b: 5 months later. Note the
need for constant, active lingual
root torque in the maxillary inci-
sors during distal en masse force
application in order to prevent
lingual crown inclination.
One can retract the mandibular arch to upright man-
dibular incisors to the desired position without head-
gear or Class III elastics (Fig. 4a, b, c).
Open bite patients can be treated by intrusion of max-
illary (or mandibular) posterior teeth without using
the unstable biomechanics of extruding maxillary and
mandibular anterior teeth to close the bite (Fig. 5).
These are just some of the possibilities of how TAD’s
can help orthodontics. TAD’s help eliminate the
patient compliance issue and can reduce the need for
headgear, elastics, and other non-compliant therapies.

Fig. 4a: Class III with TAD’s in the Oblique Ridge to retract the mandibular
arch.

Fig. 4b: Mandibular arch distal en masse movement.

Fig. 4c: Radiograph of mandibular TAD’s in the

Oblique Ridge.

Fig. 5: Open bite closure with TAD’s. Note: No upper anterior brackets to prove the bite was closed with up-
per posterior intrusion only.

24
 EXTRACTION OF A MANDIBULAR INCISOR IN ADULT ORTHODONTIC TREATMENT:
AN ACCEPTABLE COMPROMISE?
GIOVANNI BIONDI
VARAGO DI MASERADA (TV), ITALY
During orthodontic treatment of adults, compromise
can be a daily necessity. Extraction of a mandibular
incisor is a compromise extraction choice for some
patients. The aim of this study was to determine the
conditions in which this kind of compromise can be
deemed acceptable.
MATERIAL AND METHOD
A rapid review of the literature revealed that, as far
back as 1959, Berger1 was questioning the wisdom of
extracting a mandibular incisor to treat patients with
considerable mandibular dental crowding. Richardson2
in 1963 and Levin3 in the following year raised the
same question. In 1975, Brand and Safirestein4 fol-
lowed by Bahremann5 in 1977 presented a series of in-
dications for which extraction of a mandibular incisor
could be regarded as the treatment of choice: therefore
a shift occurred from “therapeutic compromise” to
“therapeutic indication”.
In 1984, Kokich and Shapiro6 wrote: “…although the
indications for this type of extraction are relatively
rare, the possibility of mandibular incisor extraction
should be a part of every clinician’s portfolio of treat-
ment techniques. If it is carefully planned and execut-
ed in the proper situation, mandibular incisor extrac-
tion can be an effective way of satisfying a particular
set of treatment objectives”.
By subsequently analyzing the records of our patients,
we noted that, out of 3,925 patients in our practice, the
85 patients who had been treated with extraction of a
mandibular incisor represented 2.16% of our patients.
However, when we analysed the group of 1,438 adult
patients, the percentage of patients who had an with
extraction of a mandibular incisor increased to 5.91%
and even reached 14.46% if one took into consider-
ation only the 588 adult patients for whom extraction
was mandatory.
Hence Kokich’s use of the terms “relatively rare”
makes sense and, in relation to the “proper situation”
(Kokich’s words once again), one can mention Bahre-
mann’s article in which he advocates the extraction
of a mandibular incisor as the first therapeutic choice
in “…Class I malocclusions with normal maxillary
dentition and a good buccal interdigitation, which
show arch length deficiency in the mandibular anterior
segment of over 4 to 5mm and an anterior ratio greater
than 0.83 are the cases of first choice for extraction of
one mandibular incisor.”
By using this concept and by observing our own pa-
tient pool, we looked for the dental and cephalometric
parameters of the 85 patients treated with extraction of
a mandibular incisor.
Cephalometric parameters were (Table 1):
• FMA: the value ranged between 16° and 33° with
an average of 24.88° (normodivergent)
• IMPA: the value ranged between 88° and 103°
with an average of 93.08° (incisor slightly tipped
on its bony base)
• ANB: the value ranged between -2° and 6° with an
average of 2.29° (skeletal Class I)
25
Table 1: Cephalometric Parameters
FMA 24.88 Range 16 33
IMPA 93.08 88 103
ANB 2.29 -2 6

From the occlusal point of view, Bahremann considers

that the best results are obtained when antero-inferior
crowding is 4 to 5mm and with an anterior Bolton
index greater than 0.83. By the analyzing these two
parameters of our 85 patients (Table 2), we obtained Fig. 2
a mean anterior crowding score of 5.38mm (norm
between 3 and 8mm) and a mean Bolton index of 0.79
(norm between 0.74 and 0.86). These results show
crowding at the upper limit of that indicated by Bahre-
mann and, conversely, a Bolton index slightly higher
than that considered optimal by the same author for
extraction of a mandibular incisor (even if it is beyond
the upper limit of 0.772 considered as an ideal stan-
dard). Of course, the highest Bolton indices corre-
spond to better posttreatment overjets (Fig. 1).

Fig. 3

Fig. 1
Table 2: Dental – 85 Patients
Fig. 4
Crowding 5.38 Range 3 8
Bolton Index 79.02 74 86 Our experience has led us to
add another factor to this list,
Once the decision has been made to treat a patient
namely, incisor axis (Fig. 6).
by extracting a mandibular incisor, it is important to
In similar periodontal or end-
determine which incisor should be extracted. Bahre-
odontic situations, the choice
mann, the author who has contributed the most to
of extraction will involve the
codifying the choice for this type of treatment, advo-
incisor which will best facili-
cates four factors that need to be kept in mind:
tate uprighting of the remain-
• amount of mandibular anterior arch length defi-
ciency (Fig. 2) ing three incisors. It is there-
• amount of anterior root ratio (Fig. 3) Fig. 5 fore important to carefully
• periodontal and tooth health condition (Fig. 4) examine the axes of the teeth
• maxillary and mandibular midline relationship without being influenced exclusively by crowding
(Fig. 5) because to do so might lead one to extract the tooth

26
 Fig. 6
Fig. 7
which has been pushed furthest outside the limit of the
incisal arch (Fig. 7). When closing spaces, a poor axial
inclination choice could make it more difficult to cor-
rect rotations and upright the other incisor.
Finally, to achieve the best final result, it is essential to
estimate the shape of the incisors (Fig. 8). It is impor-
tant to bear in mind that some incisors have a me-
sio-distal diameter at the incisal edge which is much
greater than the diameter at the incisor neck (more
“triangular” crowns). This tooth morphology will pro-
mote the emergence of dark gaps at the papilla level.
This negative esthetic factor will be less evident with
incisors which have approximately similar measure-
ments at the incisal edge and neck (more “rectangular”
teeth)
RESULTS AND CONCLUSION
The answer to the initial question about whether
extraction of a mandibular incisor can offer an accept-
able compromise choice in adult orthodontic treatment
can definitely be answered in the affirmative. Obser-
vation of clinical results and analysis of the values of
treated patients with the best results confirm the valid-
ity of this treatment option. The option is valid in so
far as the following conditions are respected:
Fig. 8
• skeletal Class I (or dental Class III)
• normodivergence of the bone base
• antero-inferior crowding ranging between 4 and
5mm
• a high Bolton index (ideally above 0.83)
• a judicious choice of the incisor to be extracted
bearing in mind periodontal and endodontic health,
as well as the axes and the shapes of the incisors.
Similarly, one can consider this choice as being con-
traindicated for patients who present with problems
in the vertical dimension, a bialveolar protrusion or
crowding that requires extraction of other teeth.
REFERENCES
1. H. Berger Some considerations regarding mandibular incisor
crowding and its treatment, TRANSACTIONS OF THE
EUROPEAN SOCIETY FOR THE STUDY OF ORTHO-
DONTICS 1959.
2. ME. Richardson Extraction of mandibular incisor in orth-
odontic treatment planning, DENTAL PRACTITIONER 14,
1963.
3. S. Levin An indication for three incisor case, ANGLE OR-
THOD 36, 1964.
4. S. Brandt, R. Safirestein Different extractions for different
malocclusions, AM J ORTHOD 68, 1975.
5. AA. Bahremann Mandibular incisor extraction in orthodontic
treatment, AM J ORTHOD 72, 1977.
6. VG. Kokich, PA Shapiro Mandibular incisor extraction in
orthodontic treatment, ANGLE ORTHOD 54, 1984.
ADDITIONAL SUGGESTED READING
• JT. Dacre The long term effects of one mandibular incisor
extraction EUR J ORTHOD 7, 1985.
• RA. Riedel, RM. Little Mandibular incisor extraction.
Postretention evaluation of stability and relapse ANGLE
ORTHOD 62, 1992.
• E. Faerovig, BU. Zachrisson Effects of mandibular incisor
extraction on anterior occlusion in adults with class III mal-
occlusion and reduced overbite, AMJ ORTHOD 115, 1999.
27
 CASE REPORT: NONSURGICAL CORRECTION OF A CLASS II, DIVISION 1
DEEP OVERBITE SKELETAL MALOCCLUSION IN AN ADULT PATIENT

SHIGEYORI INAGE D.D.S., PH.D.

YOKOHAMA, JAPAN

INTRODUCTION Intraorally, gingivitis was observed. (Fig. 2) Many of

An adult malocclusion with severe horizontal and the teeth had been restored and the mandibular left
vertical skeletal discrepancies is often difficult to treat second molar had been extracted due to caries. She
without a surgical orthodontic approach. A patient had a “V-shaped” maxillary arch and a moderately
with these problems always presents a difficult diag-
nostic and therapeutic challenge, especially when the
patient does not want surgical orthodontics.

HISTORY AND FINDINGS

A 30 year, 10-month old female presented and sought
orthodontic correction of the protruded teeth. There
was nothing noteworthy about her medical history.
The face was symmetrical but convex. (Fig. 1) The
lips were apart both at rest and in occlusion with a Fig. 2
protrusive upper lip and an everted lower lip. Marked
strain was noted in the orbicularis oris and mentalis crowded mandibular arch. In the mandibular left
muscles upon lip closure. The upper and lower den- quadrant, the second premolar was lingually inclined
tal midlines were coincident and matched the facial and the third molar had a severe mesiolingual incli-
midline. nation. The overjet was 11mm and the overbite was
5mm. (Fig. 3) The occlusal relationship of the first

Fig. 1
Fig. 3

28
molars was Angle’s Class II. Although clicking was suggested that the Cranial Facial Difficulty Total of
noted in the left joint during opening, the patient could 137 was attributable to unfavorable positions of the
open more than 40mm and had no spontaneous pain or maxilla and mandible in the horizontal and vertical
tenderness on motion. (Fig. 4) planes.
The initial orthopantomogram showed a small amount
Ceph. Difficulty
Normal Range Difficulty
Value Factor
FNA 22-28 31.5 5 17.5

ANB 1-5 8.0 15 45.0

Z-ANGLE 70-80 54.0 3 32.0

Fig. 4 OCC. PLANE 8-12 11.0 3 0.0

SNB 78-82 75.5 5 12.5

of horizontal bone loss around the maxillary anterior
teeth and a distally inclined and impacted mandibular
right third molar. The maxillary and mandibular right
first molars and the maxillary right second premolar
were nonvital. There was a periapical lesion around
the mesial root of the mandibular right first molar but
there were no subjective or objective symptoms.
ANALYSIS
Many pretreatment cephalometric measurements (Fig.
5) were outside the normal range: FMIA 45.5°, FMA
31.5°, IMPA 103°, SNB 75.5°, ANB 8°, AO-BO
11mm, Z-angle 54°, Posterior Facial Height 38mm,
Anterior Facial Height 69mm and Facial Height
Index 0.55. The Cranial Facial Analysis (Fig. 6) had
a difficulty total of 137. The Space Analysis total was
PFH/AFH 0.65-0.75 .55 3 30.0
C.F. Difficulty Total 137.0
Fig. 6
There was also a Bolton tooth-size problem. The sizes
of the mandibular teeth from central incisor to first
molar were larger than those for the respective norma-
tive means. The anterior ratio was 84.12% greater than
the normative mean plus its 2.8 SD. The overall ratio
was even higher, 98.35%, which was greater than the
normative mean plus its 3.3 SD.
DIAGNOSIS, TREATMENT OBJECTIVES
AND TREATMENT PLANNING
The patient was diagnosed as a Class II, division 1
deep overbite malocclusion with tooth size discrepan-
cy. The treatment objectives were to eliminate crowd-
ing, resolve the tooth size discrepancy, level the curve
of Spee, establish proper overjet and overbite, create
solid intercuspation and achieve a balanced facial
profile.

Prior to developing a treatment plan, “setup” casts

Fig. 5
49.0mm but the Space Analysis Difficulty total was
53.5mm. The Total Difficulty was 190.5, an indication
that the malocclusion was severe. A detailed study
(Fig. 7) were constructed in order to make the optimal
extraction decision. As a result, the extraction of two
maxillary first premolars, a mandibular right third mo-
lar and mandibular right central incisor was found to
be optimal for the achievement of the treatment goals.

29
 obicularis oris and mentalis muscles on lip closure
disappeared. The opening click in the left joint re-
solved. The final intraoral photographs (Fig. 9) show
that the same occlusion as predicted with the pretreat-
ment “setup” casts was obtained. Favorable changes
were produced cephalometrically: FMIA from 45.5°
to 51.0°, FMA from 31.5° to 31.0°, IMPA from 103°
to 98°, AO-BO from 11.0mm to 5.5mm and Z Angle
from 54.0° to 66.0°. (Fig. 10, Fig. 11) The overjet and
overbite were also improved from 11mm to 4mm and

Fig. 7
The molar relationship would remain an Angle’s Class
II at the end of treatment.

It was explained to the patient, using the figures of the

Cranial Facial Analysis, that her malocclusion would
be extremely difficult to treat with orthodontics alone. Fig. 9
Based on the information from the “setup” casts, a
combination of orthodontic treatment with extraction 5mm to 4mm, respectively (Fig. 12). The superimpo-
of two maxillary first premolars, the mandibular right sition of pretreatment and posttreatment cephalomet-
third molar and central incisor along with a maxillary ric tracings (Fig. 13) showed that the maxillary first
anterior alveolar segmental osteotomy was proposed. molar was intruded 2mm and moved mesially 2mm
The patient refused this plan because she could not while the mandibular first molar was distally upright-
afford hospitalization for orthognathic surgery. An ed 1mm. The result was a counterclockwise rotation
alternative plan of treatment with extraction of the of the mandible.
maxillary first premolars, and the mandibular right
central incisor along with the use of a high-pull J hook
headgear to both maxilla and mandible was presented.
This plan was accepted by the patient.

TREATMENT RESULTS
After active treatment and 2 years of retention, the
convex profile with a protrusive upper lip and an
everted lower lip was improved to a balanced fa-
cial and lip profile. (Fig. 8) The severe strains of the

Fig. 10

Fig. 8

30
 Fig. 11

Fig. 12

Fig. 13

31
 CONCLUSION
A combination of orthodontic treatment and orthog-
nathic surgery would have been ideal for this patient.
However, the patient refused this plan because it
required hospitalization. She chose the compromise
option of only orthodontic treatment that was based on
the Tweed-Merrifield Philosophy. A pleasing pro-
file and a functional occlusion were obtained due to
extremely good patient compliance with a high-pull
Fig. 14
J-hook headgear.

The root apex of the maxillary central incisor was

intruded 1mm and the incisal edge was retracted
12mm. The root apex of the mandibular central incisor
was intruded 5mm and the incisal edge was uprighted
3mm. The upper and lower lips were retracted 6mm
and 5mm, respectively. As a result of these favorable
changes, the profile line that passed approximately
25mm in front of the nose before treatment came in
contact with the tip of the nose after treatment (Fig.
14).

REFERENCES
1. Vaden J.L., Dale J.G., Klontz H.A.: The Tweed-Merrifield
Edgewise Appliance: Philosophy, Diagnosis and Treatment.
In: Graber T.M., Vanarsdall R.L., Vig K.W.L.: Orthodontics:
Current Principles and Techniques. Elsevier Inc, 2005:675-
715.
2. Merrifield L.L., Klontz H.A., Vaden J.L: Differential di-
agnostic analysis system. Am J Orthod Dentofacial Orthop
106:641-648, 1994.
3. Emrich SC. An adult nonsurgical patient whose treatment
required combined dental disciplines. Am J Orthod Dentofac
Orthop 1996; 110: 163-9.
4. Munoz AM. Correction of a Class II deep overbite skeletal
and dental asymmetric malocclusion in an adult patient. Am
J Orthod Dentofacial Orthop 2005;127:611-7.

32
 TWEED-MERRIFIELD PHILOSOPHY: SOME CLINICAL DETERMINATIONS FOR
THE ADULT PATIENT TREATMENT
SERGIO A. CARDIEL RÍOS
MORELIA, MICHOACÁN, MEXICO

Orthodontic management of the adult patient fre-

quently differs from the young patient since many
adult patients have dental decay, missing teeth, poor
bridges, unesthetic restorations and TMJ disorders as
well as certain types of periodontal disease.

This case report illustrates the benefits of integrating

orthodontics and other dental disciplines in the man-
agement of adult patients who have underlying dental
decay and periodontal defects. The key to treating Fig. 1
these patients is communication and a proper treat-
ment plan before orthodontic therapy as well as a con-
tinued dialogue with the multidisciplinary team during
orthodontic treatment.

CASE DESCRIPTION
The case report of a 24-year old Mexican patient
is presented. He had a class II division 1 malocclu-
sion with a negative medical history. The patient’s
complaint was that he exhibited an unesthetic dental
appearance when smiling and he had some discomfort
when chewing. A “deficient” chin was also consid-
ered when evaluating the patient’s facial balance (Fig.
1).

Intraoral views showed both midlines deviated due

to the missing maxillary canines and the mandibular
right first molar. Gingival recession was present,
particularly on the mandibular canines and premolars.
An unesthetic crown was present on the maxillary
left lateral incisor. Moderate anterior crowding was
evident (Fig. 2).
Fig. 2

33
The panoramic radiograph showed considerable
divergence in root parallelism, the presence of maxil-
lary third molars and the impacted mandibular left
third molar. According to the periodontist, the patient
showed acceptable bone levels except in edentulous
areas (Fig. 3).

Fig. 3
Cephalometrically, his maxillo-mandibular relation-
ship was retrognathic SNB (77°). His FMA (29°) and
FHI (72°) confirm a, normal vertical skeletal pattern.
Occlusal plane (16°) was high but the Z angle (67°)
was close to normal (Fig. 4).

Fig. 5

DIAGNOSIS AND TREATMENT PLANNING

Fig. 4
Since the patient had gingival recession on the man-
dibular canines, mild recession on some premolars,
poor gingival margin heights and a questionable
bridge in the maxilla, a multidisciplinary team ap-
proach was required.
Tweed-Merrifield diagnosis and treatment philosophy
is designed to give maximum facial and dental esthet-
ics, maximum functional efficiency, optimal health
of teeth and surrounding tissues, and long term stabil-
ity for each patient. To realize these goals requires a
sound and careful treatment plan. The craniofacial
and dental analysis had a total difficulty index score of
66.5.
The dental problems had to be solved as did the peri-
odontal problems. The mandibular incisors had to be
placed in their proper positions. Space in the edentu-
lous areas had to be managed so that the dental resto-
rations could be placed. (Figs. 5 and 6). The treatment
plan required the extraction of maxillary third molars,
the mandibular left third molar and the mandibular
canines. The bridge replacing the maxillary teeth had
to be removed prior of placing orthodontic appliances.

34
 Maxillary lateral incisors were carefully managed
in order to consider a morphologic mesio-distal re-
lationship in shape, proportion, width and length for
the future prosthetic restorations. The dentist placed
laminate veneers during the retention period once gin-
gival recontouring was done and gingival health was
assured. The maxillary and mandibular first premolars
Pre Restorative Phase
were reshaped with a bur to give them a “canine ap-
pearance” (Fig. 6).

Post Restorative Phase
RESULTS
The face shows harmony and balance. The smile line
and buccal corridors have improved as has the nose-
lip-chin spatial relationship (Figs. 7, 8, 12 and 13).
Teeth and gingiva are healthy and esthetic. Good “ar-
chitecture” of the gingival complex is evident. A Class
I occlusion on both sides was achieved along with
proper “canine” guidance. The occlusal plane was
controlled (Figs. 2, 8 and 10). Overbite and overjet
are ideal, thus providing for optimal anterior guidance
(Fig. 8).

Fig. 6

Mechanotherapy was designed so that Tweed-Mer-

rifield Class II mechanics could be used to distalize
the maxillary teeth to obtain a Class I occlusion and
improve the intercuspation of the teeth. The mandibu-
lar arch required space management of crowded teeth. Fig. 7
The mandibular right molars were carefully uprighted
and moved mesially. Patient cooperation was excel-
lent. Treatment time was 39 months.

Periodontal concerns were considered during a careful

preorthodontic evaluation, and the periodontist agreed
to begin orthodontic treatment prior to periodontal
therapy. However, he recontoured the gingival mar-
gins to a more ideal level before prosthetic restorations
on the maxillary lateral incisors. The periodontist also
did a supracrestal fiberotomy from premolar to premo-
lar in both arches three months prior to the removal of
orthodontic appliances. The patient was periodically Fig. 8
examined during orthodontic treatment to evaluate
oral hygiene and tissue conditions (Fig. 5).

35
Fig. 9 Fig. 10

Fig. 11

Fig. 12

36
 Fig. 13

The panoramic radiograph shows acceptable root
parallelism with good health of the roots and the
alveolar bone (Fig. 9).The cephalometric tracing
confirms maxillo-mandibular and dental changes.
Control of FMA, ANB and facial height is confirmed.
Merrifield’s Z angle quantified the harmony, balance
and improvement of the face (Figs. 10, 11 and 13).
Superimposition on S-N verifies vertical control of the
maxillo-mandibular complex since teeth were moved
with vertical, sagittal and transverse control (Fig. 11).

REFERENCES
1. Kokich, V.: Esthetics and Anterior Tooth Position: An Orthodontic Perspective, Part I: Crown Length; Part II: Vertical Position;
Part III: Mediolateral Relationships, J. Esth. Dent. 5:19-23, 174-178, 200-207, 1993.
2. Kokich, V.: Esthetics: The Orthodontic- Periodontic- Restorative Connection. Semin. Orthod. 2:21-30. 1996.
3. Mathews, D.P., Kokich,V.: Managing Treatment for the Orthodontic Patient with Periodontal Problems. Semin. Orthod.. 3:21-28,
1997.
4. Gartrell, J.G., Mathews, d.p.: Gingival Recession: The Condition, Process and Treatment. Dental Clin. North AM., 1:199-
213,1976.
5. Vanarsdall,R.L.: Periodontal Problems Associated with Orthodontic Treatment. In Barrer H. Editor: Orthodontics: The State of
the Art, Philadelphia, 1981.
6. Vanarsdall, R.L.: Periodontal Considerations in Corrective Orthodontics. In Clark JW Editor: Clinical Dentistry, Vol 2, Hager-
stown, MD, 1978, Harper & Row.
7. Kokich, V., Nappen, D., Shapiro,P.: Gingival Contour and Clinical Crown Length: Their Effect on the Esthetic Appearance on
Maxillary Anterior Teeth. AJO. 86:89-94,1984.
8. Edwards, J.: A Surgical Procedure to Eliminate Rotational Relapse. AJO 57:35, 1970.

37
9. Zachrisson, B.U.: Orthodontics and Periodontics in Clinical Periodontology and Implant Dentistry. 3rd Ed. J. Lindhe, T. Karring,
and N:P: Lang, Munksgaard, Copenhagen, pp 741-793, 1997.
10. Kokich, V. Spear, F.: Guidelines for Managing the Orthodontic-Restorative Patient. Semin. Orthod. 3:3-20. 1997.
11. Zachrisson, B.U.: Esthetic Factors Involved in Anterior Tooth Display and the Smile: Vertical Dimension, JCO, Vol. 32-7, July
1998.
12. Janzen, E.K.: A Balanced Smile- a Most Important Treatment Objective, AJO, 72:359-372, 1977.
13. Merrifield, L. Klontz, H., Vaden,J.: Differential Diagnosis Analysis System. AJO-DO 1994; 106: 641-648.
14. Vaden, J., Dale, J.,Klontz,H.: The Tweed-Merrifield Edgewise Appliance. In Graber and Vanarsdall Eds. Orthodontics: Current
Principles and Techniques. 3rd ED. Mosby 647-707. 2003.
15. Jegou,I.: Smile… With Tweed Technics, J.Ch. Tweed Found., Vol 14. Pp. 97-109.1986.
16. Isaacson, Lindauer and Rubenstein: Incisor Torque Control, AJO- DO, May 1993, pp. 428-438.
17. James,R.: Evaluation: Tipped Teeth, Anchorage, and Tweed Occlusion. J Charles Tweed Foundation. 1983; 11:123-141.
18. Peretta, R.: Biomechanical Analysis of the Sequential Class II System. J Charles Tweed Foundation. 1992; 18: 15-35.
19. Lamarque, S.: The Importance of Occlusal Plane Control During Orthodontic Mechanotherapy. AJO DO 1995; 107: 548-558.
20. Lamarque, S.: Esthetic Prognosis and Edgewise Therapeutics. Int Orthodontics 2003; 1:257-284.

38
 GIVE ME BRACES, AND I’LL GIVE YOU BONE!

ELIE WILLIAM AMM

BEIRUT, LEBANON

Current practice trends for treatment of alveolar bone alternate proposal was orthodontic extrusion of #’s 23
deficiency before implant placement advocate surgi- and 24 until their extraction (Fig. 2 a, b, c).
cal procedures such as bone grafting, GBR, distraction During this type of orthodontic “extraction”, teeth
osteogenesis, etc. However, the usefulness of orth- bring with them new bone suitable for implant place-
odontic tooth movement in generating alveolar bone
and soft tissue suitable for implant placement may be
underestimated, even when properly indicated and
when traditional ways have their limitations.

This paper will attempt to point out the advantages of

orthodontics in implant site development by selected Fig. 2: orthodontic extraction: a. day1─b. 3months
─c. 14 months
examples of vertical and horizontal alveolar bone defi-
ciency, and outline its indications. ment (Fig. 3a, b, c) and attached gingival. New bone
Patient # 1. Orthodontic extraction: and more gingiva are very difficult to obtain by sur-
gery (Fig. 4a, b).
A 28 years old man came to the periodontist’s office
with acrylic “gum” around tooth numbers 23 and 24
(Fig. 1a). The problems caused by the splint were
vertical gingival recession (Fig. 1b) and bone loss to
almost 2/3rd of the bicuspid root (Fig. 1c).

Fig. 3: a. bone augmentation in height on x-ray

– b. bone volume in situ c. implants placement

Fig. 1a: “fake gum ─b: gingival recession ─c: vertical bone
defect

The periodontist advocated the extraction of # 23 and

24 followed by bone grafting before implant place-
Fig. 4: favorable soft tissue profile – a. temporary crowns six
ment. But the defect was very large and the prognosis
weeks after surgery – b. 2 years later with final crowns
of such a procedure is poor, especially when stretching
the gingival soft tissue to cover the bone graft. An

39
 Fig. 5: a. extraoral and intraoral photographs showing lip incompetence and generalized spaces – b. x-ray
showing fractured right central incisor.

Fig. 6: a. endodontic treatment of the apical fragment – b. orthodontic extrusion of the apical fragment – c.
central incisor inset to guide the extrusion axis in the alveolar bone

and volume as well as attached gingiva (Fig. 6), end-

PATIENT # 2. ORTHODONTIC EXTRUSION
A 12 year old boy visited his dentist for his fractured
central incisor. He also asked for orthodontic treat-
ment because of his lip incompetence and the spaces
between the teeth (Fig. 5). The fracture line was in the
apical third of the root (Fig. 5), so the dentist proposed
the extraction of the tooth and its replacement by an
implant after bone maturity. The problem with this
suggested protocol would manifest itself in the future
at the time of implant placement; alveolar bone will
be resorbed during the latent period while waiting for
bone maturity. Since the patient needed orthodontic
treatment, in order to preserve alveolar bone height
odontic treatment (Fig. 7), and orthodontic extrusion
of the apical third of the root was proposed. Premolar
extraction would give good results in most patients
with the same pattern but in this patient further extrac-
tions were avoided because the patient was already
missing a central incisor. With the help of directional
force system and J-hook headgear, the results are sat-
isfying (Fig. 8).
PATIENT # 3. ORTHODONTIC DISTAL MOVEMENT:
A 20 year old lady was referred by her periodontist.
She underwent earlier orthodontic treatment, and the
implant site for #45 and #46 was managed (Fig. 9).

40
Fig. 7: a. height of the bone gained after orthodontic extrusion – b. height of
the attached gingiva gained and soft tissue profile with 2 to 3 mm of over-
correction to be used by the periodontist at the time of implant placement
Fig. 8: extraoral and intraoral photographs after orth-
for better esthetics.
odontic treatment

But
the periodontist was facing three major problems (Fig.
10): a.) narrow crestal bone that required major sur-
gery for its enlargement b.) a large mesio-distal space
that was too large for one implant and too small for
two implants, and c.) a mental foramen position that Fig. 11: a. lateral view for distalising 44. b. Occlusal view show-
necessitated a short implant, or an attempt to avoid the ing the thickness and volume of the crestal ridge mesila to 44.
area entirely and place the implant in the middle of the c- d. implant placement in site of 44. e. x-ray of the implant in
place avoiding the mental foramen.

for replacement of his missing teeth, mainly those in

the maxillary posterior region. He presented with a
Fig. 9: Intraoral photographs after previous orthodontic treatment.
Note the space left for implants to replace 45 an 46.
class III skeletal pattern (Fig. 12) and severe periodon-
titis complicated by total bone loss around the maxil-
lary incisors which had exaggerated mobility.

It was easy for the periodontist to place two implants

Fig. 10: Occlusal view and x-ray showing the difficulties before
implant placement.
into the molar sites because the maxilla was narrower
than the mandible. The real problem was the maxillary
anterior area. It required the extraction of all four inci-
sors and major bone grafting surgery! The axis of the
maxillary anterior implant would be much too buccal

space (too large to handle one single implant).

Distalization of #44 into the site of #45 and mesializa-
tion of #47 into site of #44 was proposed. The volume
and quality of the bone left behind #44 would be better
for implant placement without any additional surgery
or grafting (Fig. 11b, 11c, 11d and 11e).

PATIENT # 4. COMBINATION OF HORIZONTAL AND

VERTICAL MOVEMENTS:
A 40 year old male presented to a periodontist’s office
Figure 12: a.b.c: intraoral views d.e: x-rays. Note the severe
periodontitis and the bone loss around the upper incisors, and the
upper incisors inclination

41
if a potential anterior cross bite was to be avoided.
After an initial phase of periodontal therapy the ex-
traction of the “weakest” mandibular incisor and the
extraction of the maxillary central incisors (Fig.13a)
was proposed. The extractions would be followed by
mesial movement of the maxillary lateral incisors into
the central incisor positions with anchorage provided
by molar implants. The laterals would bring bone
behind them suitable for two implants in their former
sites (Fig. 13a, b, c), (Fig. 14a, b, c), (Fig. 15a, b, c).
A bridge that used the lateral incisor implant abut-
ments was then fabricated (Fig. 16b).
These patient records illustrate the symbiotic relation-
ship between orthodontics and other specialties in
dentistry. Working in teams offers the best results for
our patients.

Fig. 13 a: maxillary central inciosrs extraction – b. c. d: lateral incisors mesialisation

with class III correction

Fig. 14: a.b.c. maxillary lateral incisors in place of central incisors.

Fig. 15: 3-D topography of the implant site a: vertical bone height – b: hori-
zontal bone thickness during implant placement – c: implant axis inclination

Fig. 16 a: orthodontic extraction of lateral incisors – b: temporary

bridge after lateral incisor extraction

42
 SHOULD WE LEARN WIRE BENDING IN THE 21ST CENTURY?
CAMILLE MEDAWAR
PARIS, FRANCES
The 1970s was an exciting decade for orthodontics.
One development was the first “fully programmed”
Andrews appliance. Commercial interest developed
rapidly around this approach to mechanics. While
Andrew’s stated that one prescription was not enough
to cover all common malocclusions, his admonitions
were, unfortunately, disregarded by the specialty. The
“one fits all” logic prevailed and orthodontic compa-
nies invested literally millions of dollars into the de-
Fig. 1a – Lateral incisor rebonded and off-set bend is put on the arch
Fig. 1b – Lower arch alignment
Fig. 1c – Final occlusal results
velopment of pre-adjusted brackets that were supposed
to give teeth their correct position with minimum wire
bending. This paper shows clinical examples in which
early individualized control is necessary in order to
reach acceptable occlusal results.
All orthodontists have been confronted with very com-
mon situations such as shown in Figure 1a. A bond
failure occurred and the lateral incisor rotated. If light
wires are placed to realign the tooth, class II elastics
have to be discontinued. Instead, an off-set bend was
made on a .018X.025 S.S. wire. The retraction of the
maxillary incisors continued with the patient wearing
short and light elastics. No treatment time was wasted
on a realignment procedure. Figures 1b and 1c show
satisfactory mandibular arch alignment and occlusal
results.
In the next example, this class I hyperdivergent patient
had severely malpositionned maxillary and mandibu-
lar left canines (Fig. 2a, 2b, 2c).
Figures 3a, 3b, 3c show the evolution of the treatment.
Third order control is poor on both maxillary canines
four weeks after the insertion of a .019X.025 NiTi
wire. In the mandibular arch second premolar extrac-
tion and routine alignment procedures gave enough
43
 place for the left canine.
However, because of its
initial ectopic position,
the midline was deviated
2.5mm. An attempt to
correct the midline with
a power chain produced a
toe-out on the first molar
Fig. 2a, 2b, 2c on the same side.

The poor clinical situation

was overcome by incor-
porating the needed third
order bends on the maxil-
lary canines into the max-
illary archwire, by bending
omega loops with correct
toe-in on the mandibular
first molar and by using
Fig. 3a – Incorrect torque on maxillary canines.
coordinated .019x.025 S.S.
Fig. 3b, 3c – intra-arch asymmetry
and .021x.025 S.S. wires.
Fig. 4a, 4b and 4c show
the final results.

Figures 5a - 5f show the

initial malocclusion and
the evolution of treatment
that was rendered for
an 11 year old girl who
presented with a Class
Fig. 4a, 4b, 4c Third order correction and mid-line control achieved. I bialveolar protrusion.
After alignment, finishing
elastics could not be placed
because of the premature
contact between the maxil-
lary and mandibular right
canines. Because the gingi-
val margin of the maxillary
canine was in the correct
position; extrusion of this
tooth with elastics would
produce unesthetic tooth
display.

Fig. 5a - 5f – Class I bialveolar protrusion; note lines showing gingival

margins of the anterior teeth.

44
 Fig. 6a, 6b, 6c, 6d

Fig. 7a–7d. Severe midline deviation and total crossbite on the left side.

Fig. 8a Second order bends on the maxillary incisors.

Fig. 8b, 8c, 8d. Midline correction and stable arch coordination are achieved.

A careful look at Figures 5e shows poor arch coordi-
nation. The expanded mandibular arch and unsuffici-
ant lingual crown torque in the mandibular right quad-
rant appear to be the problem. The adequate amount
of third order was placed on the canine and the first
premolar. Figures 6a - 6d show satisfactory occlusal
and facial results after individualized wire bending.
In the last example, this 37 year old male patient pre-
sented with a minor skeletal Class III. The maxillary
arch collapse was due to the impacted maxillary right
central incisor (Fig. 7a - 7d). The patient was aware of
his midline deviation and asked for the best possible
result without orthognatic surgery. Treatment objec-
tives were to re-open space for an implant, rebuild
arch coordination and close the space.
To push the left central incisor 5mm distally using an
undersized arch would necessitate 2nd order bends in
the wire to keep the roots parallel. On the other hand,
non-individualized arches would only prepare the
patient for surgery. Arch coordination was done with
expanded maxillary arches along with lingual torque
to prevent relapse in both arches. Post-retention photos
(Fig. 8a - 8d) show acceptable occlusal results despite
some bone loss around the implant.

45
CONCLUSIONS
These clinical examples show that normal torque and
angulation are different from one patient to another.
Final tooth position is directly related to the initial
malocclusion and the response of the teeth to forces
generated by wires and brackets. If better cusp in-
terdigitation is reached, research has demonstrated
that treatment results will show better stability. In-
dividualizing the forces and moments according to
the patient’s needs with wire bending helps solve the
problem of unequal tooth deviation from normality.
Wire manipulation must therefore be a concern during
all stages of treatment.

46
 TWO PHASE TREATMENT IN CLASS TWO CORRECTION

ALBERTO CASALI
REGGIO EMILIA, ITALY

From time immemorial, orthodontists have tried to
modify craniomandibular growth with fixed or re-
movable appliances, both in Class III and in Class II
patients, in order to improve skeletal deficits.
“correct” growth phase, 2) the dental crowding should
be only mild to moderate, and 3) good compliance is
absolutely necessary.
Choosing the correct time for Class II intervention is
essential. The clinician must recognize the pre-puber-
al growth peak in order to exploit the growth poten-
tial.1 It is not useful to begin therapy too early if the
goal is to gain significant mandibular growth.2

SANDER BITE-JUMPING APPLIANCE

As an example of functional therapy, the Sander bite-
jumping appliance (BJA) is presented. While treating
with the BJA, forward advancement of the mandible
can be done simultaneously with the coordination of
the maxillary and mandibular dental arches.3

Orthodontics has various devices that attempt this The picture repre-
change sents the direction of
the force that acts on
• Intermaxilary class II elastics the maxilla’s center
• Fixed orthopedic appliances (Herbst, Jasper-Jump- of resistance with the
er, SUS, etc…) Sander appliance.
• Functional Appliances (Frankel, Bionator) If the inclination of
sledges is 60°, the
How does an activator work? — It positions the man- vector of the force
dible forward acts exactly on the
line of this resistance
There are three issues that must be addressed if activa- centre. If the inclina-
tor therapy is considered: 1) the patient must be in the tion of the sledges is

47
55°, the vector acts over the center of resistance. If an Here we present the cephalograms and the intraoral
open bite has to be reduced, it’s useful to increase the pictures before treatment, after BJA treatment and
angulation of the sledges to 65° in order to make the after refinement with an edgewise appliance.
vector act behind the center of resistance.

The literature leaves the specialty with some reason-

able doubts: is the Class II correction really due to
an orthopedic and skeletal effect or to a dento-alveo-
lar compensation? Is it possible that the mandibular
change is due only to the natural cranio-facial growth
of the patient?4

REFERENCES

1. The long-awaited Cochrane review of 2-phase treatment Da-

vid L. Turpin, Editor-in-Chief Seattle, Wash AJoO October
2007.
2. A Modern Rationale for Orthopedics and Orthopedic Reten-
tion, William A. Wiltshire and Susan Tsang Seminars in
Orthodontics, Vol 12, No 1 (March), 2006: pp 60-66.
3. The bite-jumping appliance SANDER FG, WEINREICH A.
4. Simon Y. Est-il possible de stimuler la croissance mandibu-
laire? Revue de litterature. Intern. Orthod. 2005; 3 : 307-327.

48