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PreadjustedEdgewiseFixedOrthodonticAppliances
PreadjustedEdgewiseFixedOrthodonticAppliances
PrinciplesandPractice
Editedby FarhadB.Naini
BDS(Lond.),MSc(Lond.),PhD(KCL),FDS.RCS(Eng.),M.Orth.RCS(Eng.), FDS.Orth.RCS(Eng.),GCAP(KCL),FHEA,FDS.RCS.Ed
ConsultantOrthodontist
DepartmentofOrthodontics
KingstonHospitalNHSFoundationTrust
StGeorge’sUniversityHospitalNHSFoundationTrust
London,UK
DaljitS.Gill
BDS(Hons),BSc(Hons),MSc(Lond.),FDS.RCS(Eng.),M.Orth.RCS(Eng.), FDS(Orth)RCS(Eng.),FHEA
ConsultantOrthodontist
DepartmentofOrthodontics
GreatOrmondStreetHospitalNHSFoundationTrustandUCLHEastmanDentalHospital London,UK
Thiseditionfirstpublished2022 ©2022JohnWiley&SonsLtd.
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LibraryofCongressCataloging-in-PublicationData
Names:Naini,FarhadB.,editor.|Gill,DaljitS.,editor.
Title:Preadjustededgewisefixedorthodonticappliances:principlesand practice/editedbyFarhadB.Naini,DaljitS.Gill.
Description:Firstedition.|Hoboken,NJ:Wiley-Blackwell,2022.| Includesbibliographicalreferencesandindex.
Identifiers:LCCN2021014308(print)|LCCN2021014309(ebook)|ISBN 9781118817698(paperback)|ISBN9781118817582(adobepdf)|ISBN 9781118817599(epub)
Subjects:MESH:OrthodonticAppliances,Fixed
Classification:LCCRK521(print)|LCCRK521(ebook)|NLMWU426|DDC 617.6/43–dc23
LCrecordavailableathttps://lccn.loc.gov/2021014308
LCebookrecordavailableathttps://lccn.loc.gov/2021014309
CoverDesign:Wiley
CoverImage:(Top)CourtesyofRichardCousley;(Bottom)CourtesyofFarhadB.Naini
Setin9.5/12.5ptSTixTwoTextbyStraive,Chennai,India 10987654321
Contents
Preface xxi
Acknowledgements xxiii
Contributors xxv
Introduction:WhatisthePreadjustedEdgewiseAppliance? xxix
FarhadB.NainiandDaljitS.Gill
WhatDoes‘Edgewise’Mean xxix
WhatDoes‘Preadjusted’Mean xxxiv
TheThreeOrdersofToothMovement xxxiv
TheSixKeystoNormalOcclusion xxxv
CustomisationandPreprogrammingofBrackets xxxvii
Prescription xxxviii
Expression xxxviii
PreadjustedEdgewiseApplianceComponents xxxix
Brackets xxxix
Tubes/Bands xxxix
Archwires xxxix
Other xl
BracketDesignFeatures xl
HorizontalSlot,ClearanceandBearingPoints xl
Tie-wings xlii
Stem xlii
Base xlii
IdentificationMark xlii
AdditionalComponents xlii
ExtentofPreadjustment(Preprogramming) xliii
BracketPositioning xliii
StagesofTreatment xliv
Conclusion xliv
References xliv
PartIPrinciples 1
1PrinciplesofTreatmentPlanning 3
FarhadB.NainiandDaljitS.Gill
Introduction 3
PatientConcerns 4
PatientMotivationandCompliance 4
HandlingPatientExpectations 4
MedicalHistory 6
GeneralDentalHealth 6
PreviousOrthodonticTreatment 7
TreatmentTiming:WhenShouldTreatmentbeUndertaken? 7
TeasingandBullying 7
DentalHealthProblemsandHabits 8
RelevanceofGrowthandGrowthEstimation 8
ProblemList 9
TreatmentAims 11
Aesthetic-CentredversusOcclusion-CentredPlanning 11
StaticandFunctionalOcclusion,StabilityandHealth 13
PresentingtheTreatmentOptions 14
NoTreatment 15
TreatmentwithLimitedObjectives 15
OrthodonticsAlone 15
OrthodonticsinAssociationwithMultidisciplinaryCare 15
HowdowedecidewhetherornottoExtractTeeth? 15
SpaceAnalysisandSpacePlanning 17
InformedConsent 21
WhatShouldbeIncludedinaTreatmentPlan 23
TreatmentMechanics 23
References 26
2PrinciplesofOrthodonticBiomechanics 29
FarhadB.NainiandDaljitS.Gill
Introduction 29
BasicConceptsandPrinciples 30
SpatialPlanesandAxesofRotationasaFrameofReference 30
Force 30
CentreofResistance 33
Moment 34
Couple 35
CentreofRotation 37
PureRotation 37
RetractionandProtraction 37
RetroclinationandProclination 38
Tip 38
‘Tipping’ 38
Torque 38
Newton’sLawsofMotionandStaticEquilibrium 38
DisplacementofRigidBodies 39
HowdoTeethTranslatewithEdgewiseFixedAppliances? 40
ControlofToothMovement 41
ExtensionHooksandtheCentreofResistance 41
Moment-to-ForceRatiosandControllingRootPosition 42
TypesofToothMovement 44
Simple(‘Uncontrolled’)Tipping 46
ControlledTipping 46
Translation(BodilyMovement) 46
RootMovement 46
PureRotation 47
ClinicalApplicationsandRelevance 47
One-CoupleForceSystem 48
Two-CoupleForceSystem 48
SpaceClosure 49
SpaceClosurewithSlidingMechanics 49
SpaceClosurewithClosingLoopMechanics 52
Conclusion 54
References 55
3Anchorage 57
ZaidB.Al-Bitar
Introduction 57
Terminology 58
AnchorageValue 59
ForceLevelsandPressureDistributioninthePeriodontalLigament 59
QualityoftheSupportingStructures 60
OcclusalIntercuspation 60
FacialGrowthandtheVerticalDimension 60
RootMorphology 61
InterproximalContacts 61
AssessmentofAnchorageNeed 61
ClassificationsofAnchorage 61
ClassificationofAnchorageAccordingtotheSiteofAnchorage 61
ClassificationofAnchorageAccordingtotheAnchorageNeed(AnteroposteriorPlane) 61
ClassificationAccordingtothePlaneofAnchorage 62
AnchorageControlwithFixedAppliances 62
IntermaxillaryAnchorage 62
IncreasingtheNumberofTeethintheAnchorageUnit 63
ControllingPressureDistributionintheAnchorageandActiveUnits 64
ExtraoralAnchorage 66
AvoidingorReducingForcesontheAnchorageUnit 66
UtilisingIntraoralMusculature 71
Occlusion 71
MaintainingtheArchLength 71
BoneAnchorage 72
AdjunctiveMethodsforAnchorageControl 73
AnchorageCreation 73
Headgear 73
IntraoralDistalisingAppliances 74
DirectBoneAnchorage 74
AnchorageLoss 74
References 75
4Consent 79
GavinJ.Mack
Introduction 79
TypesofConsent 80
ImpliedConsent 80
VerbalConsent 80
WrittenConsent 80
ValidConsent 80
WithdrawalofConsent 81
TreatmentOptions 81
AvoidingOrthodonticTreatment 81
OrthodonticswithLimitedObjectives 81
ComprehensiveOrthodonticsforOcclusalCorrection 81
KeyFactorstobeCommunicatedwithPatients 82
TreatmentDuration 82
ExpectedCompliance 82
RetentionProtocol 82
TheCostsofTreatment 82
TreatmentBenefits 83
EnhancedSmileAesthetics 83
EnhancedDentalHealth 83
EnhancedOcclusalFunction 84
PsychosocialBenefits 84
UnfoundedClaimsfortheBenefitsofOrthodonticTreatment 84
TreatmentRisks 84
DamagetoTeeth 84
DamagetothePeriodontium 85
PainandDiscomfortduringTreatment 86
RareandUnusualInjuries 87
Relapse 87
EffectiveCommunication 88
PatientInformationLeaflets 88
Websites 88
ClinicalPredictions 89
InvolvementofFamilyandFriends 89
Conclusions 89
References 90
5DentolegalAspectsofOrthodonticTreatment 93
AlisonWilliams
Introduction 93
Advertising 94
TheInitialConsultation 94
RecordingthePatient’sConcerns 94
PretreatmentOrthodonticExamination 95
DentalHealthAssessment 95
TakingRadiographsasPartoftheOrthodonticAssessment 96
PretreatmentRecords 97
StorageofRecords 98
DentolegalandEthicalIssuesthatmayAriseDuringTreatmentPlanning 99
ObtainingConsent 100
WhoisAbletoProvideConsent? 102
DentolegalIssuesArisingDuringActiveOrthodonticTreatment 102
Transfers 105
Non-compliance 105
Non-attendance 105
Non-paymentofFees 106
SupervisionofOrthodonticTherapists 106
Retention 106
Relapse 107
DutyofCandour 107
RespondingtoaComplaint 108
References 109
PartIIThePreadjustedEdgewiseAppliance 111
6BracketDesign 113
ChrisD.Donaldson
TheOriginsofFixedApplianceBracketDesign 113
LeBandeau 113
AppareildeSchangé 114
EdwardAngleandhisAppliances 114
BeggAppliance 117
Tip-EdgeAppliance 117
FurtherApplianceImprovements 117
PreadjustedEdgewiseStraight-wireAppliance 117
AndrewsStraight-wireAppliance 118
Straight-wireAppliance:BracketPrescriptions 121
Non-customised 123
Semi-customised 127
FullyCustomised 128
OptimalBracketPositioning 128
Straight-wireAppliance:BracketModifications 129
BracketMaterial 129
SlotDimensions 132
AuxiliarySlots 132
BracketBase 132
Standard,Auxiliary,HeadgearandLipBumperTubes 133
Tie-wings 133
ArchwireLigation 134
Acknowledgements 135
References 135
7BracketPlacement 137
HemendranathV.Shah,DaljitS.Gill,andFarhadB.Naini
Introduction 137
DesignFeaturesofPreadjustedEdgewiseApplianceBrackets 137
PrimaryDesignFeatures 138
SlotSitingFeatures 138
AuxiliaryFeatures 139
ConvenienceFeatures 140
DirectversusIndirectBonding 140
AdvantagesofDirectBonding 141
DisadvantagesofDirectBonding 141
AdvantagesofIndirectBonding 141
DisadvantagesofIndirectBonding 141
DirectBondingTechnique 141
LocalisingtheFAPoint 141
MeasuringtheDistancefromtheIncisalEdge 141
IndirectBondingTechnique 142
StagesofIndirectBonding 142
BandingMolarsandPremolars 143
Separators 143
BandingTechnique 145
TipsforBracketSelectioninCertainSituations 145
References 146
8BondinginOrthodontics 147
DeclanMillett
History 147
BondingProcedure 148
BracketTypesandBonding 148
EnamelPreparation 148
BondingProcessafterEnamelEtching 150
BondingtoArtificialSubstrates 151
IndirectBonding 151
BondingAdhesives 152
HealthRisksAssociatedwithBonding 154
BlueLights 154
CytotoxicityofAdhesives 154
EffectivenessofAdhesives 154
FactorsAffectingClinicalBondFailure 154
BondingofOrthodonticBrackets 154
RebondingaDebondedAttachment 154
BondingofMolarTubes 154
EffectivenessoftheLight-curingUnits 155
Debonding 156
PatientAppraisal 156
ProcedureandEnamelDamage 156
Risks 156
ToothColourChange 156
ManagementofDemineralisationLesionsPostDebond 156
BondedRetainers 157
TypesandBonding 157
AdhesivesforBondingofFixedRetainers 157
AdditionalUsesofBondinginOrthodontics 158
FuturePossibilitiesofOrthodonticBonding 158
Summary 158
Acknowledgements 159
FurtherReading 159
References 159
9Debonding 165
LucyDavenport-Jones
Introduction 165
Preparation 166
StainlessSteelBrackets 166
CeramicBrackets 166
PolycrystallineAluminaBrackets 167
MonocrystallineAluminaBrackets 167
BracketFracture 167
Self-ligatingBrackets 168
LingualAppliancesandBiteTurbos 168
SolventUse 168
OrganicSolvents 168
PeppermintOil 168
ElectrothermalDebonding 168
LaserDebonding 168
BandRemoval 169
CompositeResinRemoval 169
MultiflutedTungstenCarbideBur 169
DiamondFinishingBur 169
Scalers 169
Lasers 169
FinishingTechniques 169
Enamel 169
Composite 170
Porcelain 171
IatrogenicDamage 171
Burns 171
EnamelFracturesandTear-outInjuries 171
PulpalInjury 171
DebandingInjuries 171
Particulates 171
Conclusions 172
References 172
10Archwires 175
LeilaKhamashta-Ledezma
Introduction 175
PropertiesofArchwires 176
Stress–StrainCurvesandPhysicalProperties 176
CantileverandThree-pointBendingTests 178
EffectsofChangingtheDiameterorLengthofArchwires 178
OtherLaboratoryTestsandPhysicalProperties 179
ArchwireShapeandArchForm 179
ArchwireMaterials 180
PreciousMetalAlloys 180
StainlessSteel 180
CobaltChromium 181
NickelTitanium 181
Beta-Titanium 184
AestheticArchwires 185
CoatedMetalArchwires 185
Fibre-reinforcedCompositeArchwires 186
Fatigue 187
CorrosionofMetalAlloys 188
TypesofCorrosion 188
ClinicalSignificanceofCorrosion 190
MethodstoReduceCorrosion 190
WhichistheBestAligningArchwireorArchwireSequence? 191
PainfromInitialArchwires 192
PharmacologicalManagement 192
Non-pharmacologicalManagement 193
RootResorptionfromDifferentArchwires 194
IsthereEvidencethatDifferentArchwiresCauseDifferentAmountsofRootResorption? 194
AllergytoNickel 195
PathologicalProcess 195
SignsandSymptomsandManagement 195
WhenandHowMuchNickelisReleasedfromAppliances? 196
AllergiestoOtherMetals 197
Acknowledgements 197
References 197
11TheUseofAuxiliariesinOrthodontics 203
AndrewT.DiBiaseandJonathanSandler
Introduction 203
AnchorageandSpaceManagement 203
IntermaxillaryTractionandtheUseofElastics 203
PalatalArches 204
LingualArchesandSpaceMaintainers 205
HeadgearandExtraoralTraction 207
ClassIICorrection 208
HerbstAppliance 209
FixedClassIICorrectors 211
ToothMovement 211
NickelTitaniumCoilSprings 211
ClosingLoops 212
UtilityandIntrusionArchwires 212
SectionalArchwires 214
TorquingSpurs 214
Hooks 216
PiggybackArchwires 216
BallistaSpring 217
Conclusion 217
References 218
12OptimisingFixedApplianceTreatmentwithOrthodonticMini-implants 219
RichardR.J.Cousley
Introduction 219
OMIAdvantages 220
FlexibleTimingofAnchorage 220
NoAdditionalRequirementsforPatientCompliance 220
PredictableTreatmentOutcomesandReducedTreatmentTimes 220
EnhancedControlofTargetTeethMovements 220
EffectiveAnchorageinallThreeDimensions 220
OMIDisadvantages 220
OMIFailure 220
Root/PeriodontalDamage 220
Pain 221
PerforationofNasalandMaxillarySinusFloors 221
DamagetoNeurovascularTissues 221
Mini-implantFracture 221
SoftTissueProblems 221
Mini-implantMigration 221
WhereDoesOMIanchorageComeFrom? 221
AnchorageOptions:DirectVersusIndirect 223
KeyClinicalStepsInvolvedinOMIUsagewithFixedAppliances 226
ClinicalandRadiographicPlanning 226
RootDivergence 226
Pre-insertionPreparation 226
OMIInsertion 226
ForceApplication 227
Explantation 227
Three-dimensionalAnchorageApplications 228
AnteroposteriorAnchorage 228
VerticalAnchorage 228
TransverseAnchorage 231
References 231
13CareofFixedAppliances 235
NazanAdali,DaljitS.Gill,andFarhadB.Naini
Introduction 235
BeforeFixedApplianceTreatment 236
DuringFixedApplianceTreatment 237
DentalPlaqueBiofilmControlMethods 238
StrengtheningoftheEnamelSurfaces 241
DietaryControl 244
ManagementofOrthodonticDiscomfort 244
AfterFixedApplianceTreatment 245
Conclusions 245
References 245
PartIIIStagesofTreatmentwithPreadjustedEdgewiseAppliances 247
14AlignmentandLevelling 249
FarhadB.NainiandDaljitS.Gill
Introduction 249
AnchorageRequirementsandPreparation 250
AnchorageReinforcementwithHeadgear 252
ArchForm 255
ToothMovementwithPreadjustedFixedAppliances 256
Alignment 257
BracketPositioningVariations 258
InitialAlignment 258
ChoiceofArchwireSizeandMaterial 263
PlacementofLacebacks 264
MethodsofArchwireLigation 267
CinchingversusBendBacks 269
Step-by-StepArchwirePlacement 271
ArchwireRemoval 273
SpaceCreationandRedistribution 277
CrossbiteCorrection 282
EctopicandImpactedCaninesandIncisors 283
ImpactedMandibularSecondMolars 286
IntrusionofOvereruptedMaxillarySecondMolars 286
DiastemaClosureandFrenectomy 287
WireBending 288
PainfromInitialArchwires 291
AcceleratedToothMovement 292
Levelling 293
Conclusion 294
References 294
15ControlledSpaceClosure 297
DaljitS.GillandFarhadB.Naini
Introduction 297
AtCompletionofAlignmentandLevelling 298
ObjectivesduringSpaceClosure 298
ClassificationofAnchorage 299
TypesofSpaceClosure 299
SlidingMechanicswiththePreadjustedEdgewiseAppliance 300
The0.018-inchversus0.022-inchSlot 300
WorkingArchwires 300
MethodofForceApplication 303
ForceLevels 304
IncorporationofSecondMolars 304
Two-stageSpaceClosureversusEnMasseRetraction 305
FrictionlessMechanicswiththePreadjustedEdgewiseAppliance 306
GenerationofForces 306
GenerationofMoments 307
LoopDesigns 307
T-Loop 307
SegmentedArchMechanics 308
MonitoringSpaceClosure 308
Conclusion 309
References 309
16Finishing 311
MohammadOwaiseSharifandStephenM.Chadwick
Introduction 311
AimsandObjectivesofOrthodonticTreatment 312
CommonErrorsEncounteredattheFinishingStagesofTreatment 312
Alignment 312
MarginalRidgeDiscrepanciesandOcclusalContacts 313
InterproximalContacts(Spacing) 314
Centreline(DentalMidline) 314
RootAngulation 315
BuccolingualInclination 316
OcclusalRelationshipandOverjet 317
EfficientFinishing:theImportanceofDiagnosisandTreatmentPlanning 317
ToothSizeDiscrepancies 317
BracketAlterationstoMaximisetheEfficiencyofTreatmentandFinishing 318
PersonalisationofAppliances 318
IndirectBonding 318
IncisalEdgeRecontouringandInterproximalReduction 318
Conclusion 318
References 318
17Retention 321
SimonJ.Littlewood
Introduction 321
Historicalbackground 322
AetiologyofPost-treatmentChanges 323
Post-treatmentChangesduetoRelapse 323
Post-treatmentChangesduetotheAgeingProcess 323
ConsentandRetainers 323
ThirdMolarsandRelapse 324
ReducingRelapseDuringTreatment 324
ChoiceofRetainers 324
FixedRetainers 324
PlacementofaFixedRetainer 325
ProblemsandComplicationswithBondedRetainers 326
MaintenanceofBondedRetainers 326
RemovableRetainers 327
HowOftenShouldtheybeWorn? 327
AdherencewithRemovableRetainers 327
Hawley-typeRetainer 327
ClearPlasticRetainers 328
Positioners 328
ResponsibilitiesinRetention 329
ResponsibilitiesoftheOrthodontist 329
ResponsibilityofthePatient 329
ResponsibilityoftheGeneralDentist 329
Conclusions 329
Acknowledgements 329
References 329
PartIVManagementofMalocclusionswithPreadjustedEdgewiseAppliances 331
18ManagementofClassIIMalocclusions 333
MartynT.CobourneandMithranS.Goonewardene
Introduction 333
ManagementOptions 334
GrowthModification 334
OrthodonticCamouflage 335
OrthodonticsandOrthognathicSurgery 336
GrowthModification 336
RemovableFunctionalAppliances 336
FixedFunctionalAppliances(ClassIICorrectors) 338
OrthodonticCamouflage 342
MolarDistalisationStrategies 344
OrthodonticsandOrthognathicSurgery 356
References 356
19ManagementofClassIIIMalocclusions 359
GrantT.McIntyre
Introduction 359
TreatmentTimingforClassIIIMalocclusioninRelationtoFacialGrowth 360
Comprehensive,CamouflageorCompromiseTreatmentforClassIIICases 362
ComprehensiveTreatment 362
CamouflageTreatment 364
CompromiseTreatment 366
ManagingtheClassIIISurgical/OrthodonticPatientwithFixedAppliances 366
InterceptiveTreatmentforSurgical/OrthodonticCases 367
ClassIIIMalocclusionOccurringwithCleftLipand/orPalate 370
References 370
20ManagementofDeepIncisorOverbite 371
FarhadB.Naini,DaljitS.Gill,andUmbertoGaragiola
Introduction 371
Aetiology 372
Skeletal 373
SoftTissue 373
Dental 373
IndicationsforTreatment 373
ConsiderationsinTreatmentPlanning 374
Age 374
UpperLiptoMaxillaryIncisorRelationship 374
IncisorRelationship 374
VerticalSkeletalDiscrepancy 375
MethodsofOverbiteReduction 375
RelativeIntrusionoftheIncisors 375
AbsoluteIntrusionoftheIncisors 375
ProclinationoftheIncisors 375
AppliancesandTechniquesforOverbiteReduction 376
RemovableAppliances 376
FunctionalAppliances 376
FixedAppliances(ContinuousArchMechanics) 377
FixedAppliances(SegmentedArchMechanics) 378
Auxiliaries 380
Headgear 380
AbsoluteAnchorage 381
OrthognathicSurgery 381
SegmentalSurgery 381
ConservativeManagement 382
StabilityofOverbiteCorrection 382
Conclusion 384
References 384
21ManagementofAnteriorOpenBite 385
ChungH.KauandTimS.Trulove
Introduction 385
PrevalenceandIncidence 385
Aetiology 385
SkeletalOrigins 386
Characteristics 388
IncreasedLowerFaceHeight:LongFaceSyndrome 388
AnteriorOpenBite 389
ClinicalTreatment 389
Concepts 389
PrimaryDentition/MixedDentition 389
LateMixedDentition/EarlyPermanentDentition 389
LatePermanentDentition 390
RetentionandStability 394
Conclusion 394
References 394
22ManagementoftheTransverseDimension 397
LucyDavenport-Jones
Introduction 397
Crossbites 398
IndicationsforMaxillaryExpansion 398
RemovableAppliances 399
UpperRemovableAppliance 399
CoffinSpring 399
FunctionalAppliances 400
Aligners 400
FixedAppliances 400
HeadgearwithFixedAppliances 400
ArchwiresandAuxiliaries 401
TranspalatalArch 401
LingualArch/UtilityArch 401
CrossElastics 401
W-Arch/PorterAppliance 401
Quadhelix(Bihelix/Trihelix) 403
NiTiExpanders 404
Mid-PalatalSuture 404
ProtractionHeadgear 404
RapidMaxillaryExpansion 405
SurgicalExpansion 409
SurgicallyAssistedRapidPalatalExpansion 409
SegmentalMaxillarySurgery 410
Retention 411
References 411
PartVAppendices 413
Appendix1OrthodonticInstruments 415
FarhadB.NainiandDaljitS.Gill
Appendix2OrthodonticElasticsandElastomericMaterials 423
FarhadB.NainiandDaljitS.Gill
Introduction 423
IntraoralElasticConfigurations 423
Intra-archElastics 423
Inter-archElastics 423
PointsofApplication 424
InstructionsforUseofIntraoralElastics 424
ElastomericMaterials 425
ElastomericModules 425
ElastomericChain 425
ElastomericThread/String 425 E-links 425
Index 427
Preface
‘Wefindthattheveryprincipleuponwhichteeth aremadetogrowirregularlyiscapable,ifproperly directed,ofbringingthemevenagain.Thisprincipleisthepowerwhichmanyparts(especially bones)haveofmovingoutofthewayofmechanical pressure.’
JohnHunter(1728–1793),ChapterVI, Irregularitiesoftheteeth, HistoryoftheHuman Teeth (1771)
Sustainedmechanicalpressurewillmoveteeththatare notankylosed.Needlesstosay,placingafixedappliance, ligatinganarchwireandwatchingtheteethmoveovertime mayappearrelativelyeasytotheuninitiated.However, plannedandguidedmovementofteethintotheirideal aesthetic,functionalandstablepositions,whilstmitigating theundesirableeffectsoftreatment,andachievingthisina reasonabletimeframewithminimumpatientdiscomfort, isfarfromeasy.
Dentalstudentsandorthodontictraineesintheirearly yearswilloftenobservetheirteachersassessingapatient’s teethintently,deepinthought.Itisnocoincidence thatorthodonticshaslongbeenknownasthe‘thinking person’sspecialty’,andis,infact,thefirstestablished specialtyindentistryandoneofthefirstthroughout medicine.Orthodonticsisacomplexandmultifaceted specialty,requiring,amongstotherthings,athorough understandingofnormalandaberrantcraniofacialgrowth anddevelopment,dentofacialaestheticsandfunction,and thebiomechanicalprinciplesandutilisationofavariety ofappliances.Assuch,learningorthodonticsrequires dedicationandhardwork–thereisnoeffortlesspathand noavailableshortcuts.
Mostcrediblegraduateorthodonticspecialtytraining programmesnowrunoverthreeyearsfull-time(this hasbeentheUKmodelformanyyears),orapart-time equivalent.IntheUK,thosedesiringtolearnmoreabout multidisciplinarycare,orthognathicsurgery,andcleft andcraniofacialsurgeryrequireanadditionaltwoyears offull-timetrainingandfurtherexaminations.First-year
graduatetraineesinorthodonticsoftenfeellikeoutsiders, overwhelmedbythehighlyesotericandtechnicallanguagebeingusedaroundthem,newconceptsandeven newinstruments.Confusionistheorderoftheday.Ittakes sustainedefforttoassimilateandgraspthesignificance ofallthefactorsrequiredinorthodontictreatment,particularlywithfixedappliances.However,overtime,and usuallybythemiddletotheendofthesecondyear,through practiceandimmersion,thelanguagebecomescomprehensible,theconceptsunderstandable,andtheinvisible connectionsbetweenthevariousaspectsoforthodontics becomevisible.
Modernpreadjustededgewisebracketdesignscantrace theirancestrytotheoriginaledgewiseappliance,designed byDrEdwardH.Angle,andfirstintroducedon2June 1925attheFourthAnnualMeetingoftheEdwardAngle SocietyofOrthodontists.Interestingly,initiallyAngledid notnametheappliance.Theterm‘edgewise’referstothe archwire,meaningthatarectangulararchwireisplaced intoahorizontalbracketslotviaitsnarroweredge,such thatithasalargerbuccolingualdimensioncompared withitsocclusogingivaldimension.Anumberofimportantadvancesinorthodonticsfollowed;however,froma technicalperspective,thenextnotableadvancewasthe introduction,byDrLawrenceAndrews,ofpreadjusted bracketstobeusedwithstraightwires.Addedtothiswas thedevelopmentoftheacid-etchbondingtechniqueand itssubsequentapplicationinorthodontics,togetherwith developmentsinarchwirematerials,allofwhichhave advancedfixedappliancetherapysignificantly.
Preadjustededgewiseorthodonticappliancesprovidethe clinicianwiththeuniqueabilitytocontroltoothmovement reliably,inthethreeplanesofspaceandroundthethree axesofrotation.Thisthree-dimensionalcontrolovertooth movementrequiresexpertise,discretionaryjudgementand finesse,andissubjecttomisapplicationinuntrainedhands. Didacticteachingoforthodonticscanonlybedelivered insegments,eachofwhich,metaphoricallyspeaking,is analogoustothefragmentsofajigsawpuzzle.Nomatter inwhichorderthesegmentsarepresentedtothestudent,
untilallthesegmentshavebeenpositionedaccurately,the fullpicturewillnotbeapparentorcompletelycoherent. Thepurposeofthisbookisspecific:itistocovercomprehensivelytheinformationrequiredtounderstandanduse preadjustededgewiseappliances.Itisourintentionthat havingreadallthechaptersinthisbook,togetherwith practicalchairsidetraining,thereaderwillviewthewhole pictureofpreadjustededgewisefixedappliancetreatment withcompleteclarity.
Thebookcomprises22chaptersseparatedintofour sections.Althoughmostofthechapterscanbereadindependently,theideashavebeenpresentedinanorder chosenwithsomecare.SectionI(Principles)coversthe principlesoftreatmentplanning,orthodonticbiomechanics,anchorage,consentanddentolegalconsiderations.
SectionII(ThePreadjustedEdgewiseAppliance)providesanin-depthdescriptionoftheappliancesystems, includingbracketdesign,bracketplacement,bonding, debonding,archwires,theuseoforthodonticauxiliaries, mini-implants(temporaryanchoragedevices)andcareof fixedappliances.SectionIII(StagesofTreatment)provides acomprehensive,step-by-stepaccountofthefourstages oftreatment,withseparatechaptersonalignmentand levelling,controlledspaceclosure,finishingandretention. SectionIV(Managementofmalocclusions)coversthe treatmentofeachmajorcategoryofmalocclusion,with separatechaptersonthemanagementofClassIImalocclusions,ClassIIImalocclusions,deepbitemalocclusions, anterioropenbitemalocclusions,andmalocclusionswith transverseproblems.Thetwoappendicesattheendcover orthodonticinstrumentsandorthodonticelastics.
Manyoftheauthorsinvitedtocontributechapterstothis bookareinternationallyrenownedleadersinorthodontics. Thecontributingauthorshaveprovidedcomprehensive
andpracticalchapters,analysingthescientificliterature andprovidingtheirtechnicalexpertise,allcomplemented withsoundjudgement.Theyhavedescribedtherationalefortheirdecisionsbasedonup-to-dateevidenceand long-termclinicalexperience.Theeditors’desireisthat thechaptersinthisbookwillbeusedbythespectrum ofclinicians,fromjuniortraineesthroughtoqualified orthodontistsatalllevels.
Thereisasimpleruleforclinicalpractice:excellent cliniciansproduceconsistentlyexcellentresults,and‘bad workmenblametheirtools’.Thereisavastarrayofbracket designsandfixedappliancesystems,andproponentsof eachextoltheirvirtueswhilsttrivialisingthelimitations. Thisistobeexpectedinthemarketplace,buthasno placeinascientificallybasedclinicalendeavoursuchas orthodontics,wherethedominatingvalueistheabilityto achievereliablyexcellentresultsforconsecutivepatients. Thedevelopmentoforthodonticmaterialsandrefinements intechniqueswillnodoubtcontinue,butnonewillreplace soundclinicaljudgementbasedonacomprehensive understandingofbiologicalprinciples,thebiomechanical foundationsoffixedappliancetreatment,andthearduous taskofobtainingandcultivatingtechnicalabilityand therebygaininglegitimateexperience.Thebestclinicians arethosewhocanidentifytheproblems,judgeandplan theappropriatetreatmenttogetherwiththepatient,and applyselectivelytheappropriateapplianceandmechanics todealwiththepatient’spresentingproblems.
Orthodonticsisabeautifulspecialty.Unlikemostof medicine,ourpatientsdonotjustneedtreatment,they desireit,makingtheabilitytoundertakeorthodontic treatmentforpatientsadistinctprivilege.
FarhadB.NainiandDaljitS.Gill
Acknowledgements
Theinfluenceofgreatteachersalwaysremainswiththeir students.Weoweadebtofgratitudetoourteachersin orthodontics.Wewereveryfortunatetoundertakeour specialtytrainingatatimewhenourteacherswereattheir peak;manywerepioneersintheintroduction,developmentanduseofpreadjustededgewiseappliancesinthe UK.Mostarenowretiredandsomeare,sadly,nolonger withus,buttheirinfluenceremainsthroughtheirstudents andthecontinuingexcellenceoftheirdepartments.
ThankyoutothestaffattheArchivesCenter,National MuseumofAmericanHistory,SmithsonianInstitution, Washington,DCforthesuperbpictureofDrEdward AnglethatappearsintheIntroduction.Oursincerethanks alsotoProfessorJamesL.Vaden,MrsBonnieShewairy andtheCharlesH.TweedInternationalFoundationfor OrthodonticResearchandEducationforthepictureofDr CharlesTweed,whichalsoappearsintheIntroduction.
OursincerethankstoMrAllanThom,ProfessorRoberto JustusandDrDavidBirniefortheirkindnessandhelpas wewereobtainingpermissionforsomeoftheimagesused inthebook.AspecialthankyouisrequiredtoProfessor LeeW.GraberandtheWorldFederationofOrthodontists forthepictureofProfessorCharlesBurstonethatappears inChapter2.
OurthanksalsotoDrDavidSpary,DrElifKeserand JamesGreenforanumberofimages,andtoProfessorTheodoreEliadesforadviceonmaterials.Oursincere thankstoDrRobChateforhisadviceandkindness,extendingovermanyyears.ThankyoutoMissSarahAl-Bitar forherexcellenceingraphicdesignandworkingwithher fathertocreatetheimagesinChapter3.Ourthanksalsoto MatronHelenHollandandseniororthodonticnursesJanet BarnesandSoniaSteer,andtoourtrainees,particularly DrsReemAl-Hadhoud,SerenaAmin,ChrisDonaldson, EmilyHooper,GeorginaKane,ClaudiaLever,Ahmed Omran,RachelPeacock,JayaPindoriaandSamuelReeves
fortheirhelpinthetakingofsomeofthephotographs inthisbook.OurthanksalsoextendtoTanyaMcMullin andtheteamatWiley-Blackwellfortheirsupportinthe developmentofthisbook.
FarhadB.NainiandDaljitS.Gill
Tomyparentsandbrother,whointroducedmetothe importanceofattemptingtounderstandtheworld,with gratitude,admirationandlove.
Asever,Iamindebtedtomywife,Hengameh,forher unyieldingsupport.Aswellasbeingagraphicdesigner, Hengamehisaconsultantinanimalbehaviourandwelfare andheadveterinarynurseinabusyveterinarysurgeryin Kent,the‘GardenofEngland’.Thisbookwascompleted duringthetimeofaglobalpandemic.Duringthisdifficult time,sherefusedtostayawayfromwork,andworkedtirelesslytocareforsick,injuredandvulnerableanimals.Yet, shemadetimetocreatetheillustrationsformychapters. Iamforeverhumbledbyherintellect,compassionand dedication.Shedemonstrates,everyday,thatittakesalot morecourageandstrengthofcharactertostandagainst thecrowdandshowthatkindnessandcompassionto non-humananimals,withwhomwesharethissmall planet,arefarmoreimportantthanantiquatedattitudes, unjustifiablehabitsandtheexcuseof‘tradition’.Thisbook wouldnothavebeenpossiblewithoutherenthusiasmand commitment.
FarhadB.Naini
ThereareagreatlistofpeopleandinstitutionswhoIwould liketothank,rangingfromtheNationalHealthService, whichhasprovidedtheopportunitiesandinfrastructureto learnorthodontics,Universitiesandindividualpeoplewho haveinspiredmewiththeirteaching,dedicationandlove
xxiv Acknowledgements
fororthodontics,dentistryandmedicine.Inparticular,the lateProfessorCrispianScullywhowasalwaysinspirational, fromthetimeofbeingadentalstudenttobecomingaConsultantinOrthodontics,becauseofhisprolificnatureand hisloveanddedicationtowardshisprofession.Myfather, DrGurmailGill,whohasalwaysgivenmehiswisdomin logicalandscientificthought.Mymother,JasvirGill,who hasgivenlove,dedicationandahome.Iwouldalsolike tothankmygrandparents,sister(Sumanjit)andfriendsfor
theirloveandguidance,andfinallymywife(Balpreet)and mychildren,AranandAnika,fortheirloveandsupport. Maythey,andallotherchildren,begiventhesameopportunitiesthatIhavebeenfortunatetohavereceived.
DaljitS.Gill
WearedonatingtheroyaltiesforthisbooktoanimalwelfarecharitieschosenbyHengamehNaini.
Contributors
NazanAdali,MSc,BDS(Hons),BSc,FDS.RCS(Orth), M.Orth.RCS(Eng),MFDS.RCS(Eng),FHEA ConsultantOrthodontistandCleftLipandPalateLead MaxillofacialCentre LutonandDunstableUniversityHospitalNHSFoundation Trust
VisitingPostgraduateLecturer,King’sCollegeLondon London,UK
ZaidB.Al-Bitar,BDS,MSc,MOrth.RCS(Eng.) ProfessorofOrthodontics ViceDeanforGraduateAffairs FacultyofDentistry,UniversityofJordan SeniorConsultantOrthodontist UniversityofJordanHospital Amman,Jordan
StephenM.Chadwick,FDSRCS,MSc,MOrthRCS,MA, FDS(Orth)RCS,FDS(Orth)RCPS ConsultantOrthodontist CountessofChesterHospitalNHSFoundationTrust Chester,UK
MartynT.Cobourne,BDS(Hons),FDS.RCS(Eng.),FDS.RCS (Ed.),MSc,MOrth.RCS(Eng.),FDS.Orth.RCS,PhD,FHEA ProfessorandHonoraryConsultantinOrthodontics AcademicHeadofOrthodontics CentreforCraniofacialandRegenerativeBiology FacultyofDental,OralandCraniofacialSciences King’sCollegeLondon Guy’sHospital London,UK
RichardR.J.Cousley,BSc,BDS,MSc,FDS,MOrth,FDS(Orth) RCS
ConsultantOrthodontist
ThePriestgateClinic,PeterboroughandHonoraryConsultantOrthodontistatPeterboroughCityHospital Peterborough,UK
LucyDavenport-Jones,BDS(Hons),MSc,MFDS.RCS(Edin.), M.Orth.RCS(Edin.),FDS.Orth.RCS(Edin.) ConsultantOrthodontist
StGeorge’sUniversityHospitalandKingstonHospital ClinicalLeadforDentistry
StGeorge’sUniversityHospital London,UK
AndrewT.DiBiase,BDS(Hons),FDS.RCS(Eng.),MSc, M.Orth.RCS(Eng.),FDS.Orth.RCS ConsultantOrthodontist
EastKentHospitalsUniversityNHSFoundationTrust Canterbury,UK
ChrisD.Donaldson,MBBS(Lond.),BDS(Lond.),MFDS.RCS (Ire.),MSc(KCL),M.Orth.RCS(Edin.) SeniorSpecialistRegistrar DepartmentofOrthodontics
King’sCollegeHospitalandStGeorge’sHospital London,UK
UmbertoGaragiola,DDS,PhD ProfessorofOrthodontics BiomedicalSurgicalandDentalDepartment Maxillo-FacialandOdontostomatologyUnit FondazioneCàGrandaIRCCS OspedaleMaggiorePoliclinico SchoolofDentistry
UniversityofMilan Milan,Italy
DaljitS.Gill,BDS(Hons),BSc(Hons),MSc(Lond.),FDS.RCS (Eng.),M.Orth.RCS(Eng.),FDS(Orth)RCS(Eng.),FHEA ConsultantOrthodontist DepartmentofOrthodontics
GreatOrmondStreetHospitalNHSFoundationTrustand UCLHEastmanDentalHospital London,UK
MithranS.Goonewardene,BDSc(Hons),Cert.Ortho.,MMedSc, FICD,FADI,FPFA
HeadofOrthodontics
UWADentalSchool
FacultyofHealthandMedicalSciences
Oral,DevelopmentalandBehaviouralSciences
UniversityofWesternAustralia
Perth,Australia
ChungH.Kau,BDS,MScD,MBA,PhD,MOrthEdin,FDSGlas,FDSEdin,FFDIre(Ortho),FICD,FACD,FAMS(Ortho),Cert (Ortho),ABO
ProfessorandChairman
DepartmentofOrthodontics
SchoolofDentistry
UniversityofAlabama
SeniorScientist
GlobalCenterforCraniofacial,OralandDentalDisorders, UniversityofAlabama
Director
UABCraniofacialDisordersClinicinCollaborationwith Children’sRehabilitationServicesofAlabama,University ofAlabama Birmingham,Alabama,USA
LeilaKhamashta-Ledezma,BDS(Lond.),MJDF.RCS(Eng.),MSc (KCL),M.Orth.RCS(Edin.),FDS.Orth.RCS(Edin.),GCAP(KCL), FHEA
SpecialistOrthodontist Wetzikon,Switzerland
FormerConsultantOrthodontist DepartmentofOrthodontics
Guy’sandStThomas’NHSFoundationTrust London,UK
SimonJ.Littlewood,BDS,MDSc,FDS(Orth)RCPS(Glasg), MOrthRCS(Edin),FDSRCS(Eng)
ConsultantOrthodontistandSpecialtyLead OrthodonticDepartment
StLuke’sHospital Bradford,UK
GavinJ.Mack,BDS(Hons),MSc,MFDS.RCS(Eng),M.Orth.RCS, FDS.Orth.RCS(Eng)
ConsultantOrthodontist DepartmentofOrthodontics King’sCollegeHospitalLondon London,UK
GrantT.McIntyre,BDS,FDS.RCPS,M.Orth.RCS,PhD, FDS.Orth.RCPS ConsultantOrthodontist ProfessorofOrthodontics DundeeDentalSchoolandHospital Dundee,Scotland
DeclanMillett,BDSc,DDS,FDS.RCPS(Glasg.),FDS.RCS(Eng.), DOrth.RCS(Eng.),M.Orth.RCS(Eng.),FHEA ProfessorandHeadofOrthodontics OrthodonticUnit
CorkUniversityDentalSchoolandHospital UniversityCollegeCork Cork,Ireland
FarhadB.Naini,BDS(Lond.),MSc(Lond.),PhD(KCL),FDS.RCS (Eng.),M.Orth.RCS(Eng.),FDS.Orth.RCS(Eng.),GCAP(KCL), FHEA,FDS.RCS.Ed ConsultantOrthodontist DepartmentofOrthodontics
KingstonHospitalNHSFoundationTrust
StGeorge’sUniversityHospitalNHSFoundationTrust London,UK
JonathanSandler,BDS(Hons),MSc,PhD,FDS.RCPS, M.Orth.RCS ConsultantOrthodontist
ChesterfieldRoyalHospital ProfessorofOrthodontics UniversityofSheffield Sheffield,UK
HemendranathV.Shah,BDS(Bris),MFDS.RCS(Eng),PGCert MedEd(Bris),MOrth.RCS(Ed),DDS(Bris),FDS.Orth.RCS(Eng) ConsultantOrthodontist
RoyalBerkshireHospitalNHSFoundationTrust Reading,UK SpecialistPractitioner Staines-Upon-ThamesandWatford,UK
MohammadOwaiseSharif,BDS(Hons),MSc(Merit),MJDF.RCS (Eng),MOrth.RCS.Ed,FDS(Orth)RCS(Eng),FHEA ClinicalLecturer/HonoraryConsultantOrthodontist UCLEastmanDentalInstitute London,UK
TimS.Trulove,DMD,MS
AdjunctFullProfessor DepartmentofOrthodontics SchoolofDentistry UniversityofAlabama,Birmingham,Alabama,USA Director,AmericanBoardofOrthodontics
AlisonWilliams,BDS,MSc,PhD,FDS,M.Orth,FDS(Orth)RCS (Eng.),LLM SpecialistOrthodontist
Part-timeClinicalDentalAdvisortotheGeneralDental Council(UK)
BankOrthodonticAdvisortotheNHSBusinessServices Authority London,UK