P. S. Fleming,*1 S. D. Springate2 and R. A. C.

Chate3

IN BRIEF

Delineates myth and reality in

orthodontics.
Clarifies the limitations and benefits of
definitive orthodontics.
Illustrates nine common misconceptions
concerning orthodontic treatment.

PRACTICE

Myths and realities

in orthodontics

Comprehensive orthodontic treatment typically comprises an initial phase of alignment over a period of four to six
months, followed by vertical, transverse and antero-posterior corrections, space closure, finishing and detailing to enhance
dental and facial aesthetics and function. Each course of treatment involves a series of decisions and alternatives relating
to objectives, appliance design and treatment mechanics. In recent years there has been increasing interest in short-term
approaches to treatment with more limited objectives and the avoidance of phases traditionally considered integral to
successful treatment. In this review the veracity of accepted truths in orthodontics are discussed; specifically, the importance of initial molar relationship, final incisor relationship, the merits of orthodontic extractions, anticipated treatment
times, the value of modern fixed appliance systems, the importance of torque expression and the relative merits of bonded
retainers and inter-proximal reduction are considered.
INTRODUCTION
The delivery of healthcare in the UK has seen
considerable change in recent years with
the reconfiguration of NHS healthcare commissioners, increasing emphasis on patientreported outcome measures, and budgetary
restrictions. Dentistry has not been immune
to these developments with contractual
changes particularly noteworthy. Historically,
orthodontic treatments were predominantly
undertaken by non-specialist general dental
practitioner (GDP) providers within the NHS,
but this situation gradually changed with the
acceptance that fixed appliances in the hands
of specialists were capable of superior results.1
In recent years, however, alternatives to conventional courses of fixed appliance orthodontics have emerged. Much of this treatment is
offered by GDPs, predominantly in the form of
accelerated orthodontics or treatment involving aesthetic removable and fixed appliances2
but this has been accompanied by a significant
increase in successful litigation claims.3
Similar patterns of care, with delivery
involving both specialists and non-specialists,
Barts and The London School of Medicine and Dentistry, Institute of Dentistry, Queen Mary University of
London, London, E1 2AD; 2Eastman Dental Institute,
London; 3Vice Dean, Faculty of Dental Surgery, The
Royal College of Surgeons of Edinburgh, Nicolson Street,
Edinburgh, EH8 9DW
*Correspondence to: Dr Padhraig Fleming
Email: padhraig.fleming@gmail.com
1

Refereed Paper
Accepted 26 June 2014
DOI: 10.1038/sj.bdj.2015.41
British Dental Journal 2015; 218: 105-110

have been observed in other dental disciplines including paediatric dentistry4 and
periodontics,5 and are also established internationally in orthodontics.6 What differentiates this trend within orthodontics from that
in other specialties is that a significant proportion of the treatments offered by general
practitioners have more limited objectives
than conventional specialist-delivered care;
some of it is also suggested as an adjunct
to produce a more conservative restorative
solution than would be possible without
recourse to orthodontics. In this paper, nine
areas of debate and misunderstanding concerning orthodontic planning and treatment
are discussed.

ARE MOLAR
RELATIONSHIPS RELEVANT?
The ideal Class I molar relationship was originally defined by Angle7 and later refined by
Andrews.8 Angles initial belief was that the
molars were the cornerstone to the occlusion.
While adolescent growth may alter skeletal
relationships, typically reducing the convexity of the lower face and improving skeletal
II relationships slightly,9 molar relationship
is generally considered to be constant once
the permanent dentition is established.10 The
molar relationship is integral to determining
the final incisor relationship. Specifically,
with Class I molar relationships and an
intact dentition devoid of inter-arch toothsize discrepancy, non-extraction treatment
is likely to translate into a Class I incisor
relationship. Moreover, in the presence of

BRITISH DENTAL JOURNAL VOLUME 218 NO. 3 FEB 16 2015

moderate to severe crowding, consideration

should be given to symmetrical extraction of
four premolar units to preserve Class I molar
and incisor relationships.
With Class II molar relationships at the
outset in an intact dentition, simple alignment is likely to translate into a residual
overjet following treatment. Consequently,
consideration should be given to correcting
the molar relationship to Class I with one of
a number of adjuncts including: a functional
appliance, fixed Class II corrector, headgear
or upper and lower extractions if achievement of Class I incisors is a treatment objective (Fig.1). Alternatively, in an uncrowded
lower arch, consideration could be given to
accepting the Class II molar relationships
by camouflaging the incisor relationship
with the loss of maxillary premolars alone
(Fig.2). The alternative would be to accept a
residual overjet following treatment, but this
would have implications both for aesthetics
and post-treatment stability, likely requiring
a commitment to life-long retention.

IS A CLASS I INCISOR
WORTH AIMING FOR?
Traditionally, achievement of Class I incisors has been an objective of comprehensive orthodontic treatment. The rationale
for this relates to the likelihood of stability
and aesthetics associated with this relationship between the upper and lower incisors.
Stability stems from the combination of a
normal overjet and overbite with the maxillary incisors resting on the tips of the
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2015 Macmillan Publishers Limited. All rights reserved

PRACTICE
mandibular incisors, which in turn may be
stabilised with a fixed lingual retainer.
Retroclined incisors, characteristic of
Class II division 2 incisor relationship, in
particular are believed to be a by-product
of a high resting position of the lower lip.11,12
While alignment of upper incisors in such
cases tends to be particularly rapid, acceptance of a residual overjet is often unwise
because of a marked tendency for the lip-totooth relationship to re-establish itself following treatment.10 It is, therefore, highly
likely that the maxillary incisors will retrocline following treatment in the absence of
the stabilising effect of the lower incisors.
Occasionally, a decision may be made to
accept a residual overjet in the presence of
a skeletal II discrepancy not severe enough
to warrant orthognathic correction, whereby
retraction of the maxillary incisors would
compromise the support of the upper lip. In
such instances, permanent bonded retention
is mandatory and the potential instability of
the outcome should be discussed during the
informed consent process.13,14

SHOULD NON-EXTRACTION
TREATMENT BE UNDERTAKEN
WHEREVER POSSIBLE?
The reliance on extractions as part of orthodontic treatment has fluctuated over the
decades. At the turn of the twentieth century, Edward Angle espoused non-extraction fixed appliance treatment with arch
development involving buccal expansion
and incisor proclination.15 After initially following this philosophy, Tweed subsequently
abandoned such an approach, on the basis
that 80% of his recalls had poor facial aesthetics, occlusal instability and irreparable
damage of the investing tissues of the teeth
in the incisor and premolar regions.16
As a consequence, in the period between
the early 1950s to the late 1970s, many
orthodontic patients underwent premolar
extraction in the expectation of enhanced
post-treatment stability. Since then, there
has been a widespread desire within the
orthodontic community to curb the number
of permanent teeth removed for orthodontic
reasons; this tenet persists to the present day.
Although there is short-term inconvenience and discomfort associated with dental extractions,17 the severity of associated
pain has been shown to be less marked
than that arising from the initial engagement of an orthodontic aligning wire.18 In
addition, there is no proven risk to either
the oral health and function or to the facial
aesthetics of an individual who has had
dental extractions as part of orthodontic
treatment. Moreover, extractions are usually prescribed to relieve crowding in an

Fig.1 In a growing patient this ClassII

molar relationship was corrected to
Class I. Consequently, incisor and canine
relationships were corrected allowing the
overjet to be reduced

effort to minimise either transverse or

antero-posterior arch length changes during treatment; it would therefore be counterintuitive to expect significant changes
in the facial profile to arise with carefully
planned treatment. At various times extractions have been implicated in causing (i)
temporo-mandibular joint dysfunction
(TMJD), purportedly stemming from posterior displacement of the mandible and
displacement of the articular disc; (ii) premature ageing, related to the loss of lip support; and (iii) compromised smile aesthetics
(Table1). Careful systematic review of the
available evidence has failed to support
such views;19 moreover, there is now wide
acceptance that extractions have the potential to improve both smile aesthetics and
facial aesthetics with careful planning.20,21
While there is some evidence of enhanced
stability with extraction approaches,22 in
other research little difference between posttreatment incisor irregularity with extraction or non-extraction treatment has been
reported.23,24 Reliable data on the merit of
orthodontic extractions cannot be derived
from retrospective research due to the inevitable confounding effects of contrasting
space conditions, likely to have prompted
the extraction decision before treatment. The
ideal study to assess this controversial area
would be a randomised controlled trial with
prolonged follow-up. At present, ethical concerns preclude conducting a trial in this area.
However, it is accepted that the decision to
extract should be made on an individual basis
accounting for space conditions, including

Fig.2 Class II division 1 incisor relationship

with Class II molar and canine relationships
of the left side. Non-extraction treatment
without active distal molar relationship to
Class I would lead to an increased overjet at
the end of treatment. Maxillary premolars
were therefore removed and anchorage
supported with temporary anchorage devices
to facilitate overjet reduction and relief of
crowding. The Class II molar relationships
were preserved but both incisor and canine
relationships corrected to Class I

Table 1 Adverse effects of orthodontics

Orthodontics is not without adverse consequences. For example, overly rapid tooth movements or heavy forces (especially in adults) can
lead to pulpal death but there is no convincing
evidence that orthodontic movement results in
TMJD or that carefully conducted treatment leads
to adverse effects on the face such as dishing-in
or collapse of the lips.

crowding, overjet, torque requirements and

facial aesthetics. Ideally, such decisions should
be supported with formal space analysis.25

DOES COMPREHENSIVE
ORTHODONTICS TAKE TWOTO
THREEYEARS TO COMPLETE?
Comprehensive orthodontic treatment
encompasses an initial phase of alignment
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PRACTICE
Table 2 Rapid tooth movement
Rapid movement of the crowns of teeth is not
new. It has certainly been around since the development of the round-wire Begg technique in the
1950s. With the introduction of shape-memory
effect (nickel-titanium) wires in the 1970s it
has been possible to align the crowns of very
irregular anterior teeth within just a few weeks,
even in adults. The problem is not the speed with
which the crowns are aligned; it is the stability of
the result, particularly as the roots of the teeth
remain close to their original positions. Therefore,
while orthodontic appliances can be removed
prematurely once alignment has been achieved,
it is recommended that torque expression and
occlusal detailing is undertaken to enhance
aesthetic and functional outcomes, enhancing the
prospect of prolonged stability.

Table3 Be wary of claims regarding

novel treatment methods

There should be an index of suspicion surrounding novel methods including those concerning
faster tooth movement, particularly when these
claims are made by those with vested financial interests.36 Tooth movement relies on the
remodelling or displacement of bone. Remodelling
proceeds at a finite pace, which has an upper
limit as does non-surgical displacement of bone.
Distraction osteogenesis provides the most rapid
physiological adjustment of bone position but as
yet this is not a primary orthodontic technique.

typically in nickel-titanium wires, usually taking in the region of four to six

months, followed by vertical, transverse
and antero-posterior corrections, space closure and finishing and detailing (Table 2).
The duration of orthodontic cases in both
adolescence and adulthood is typically in
the region of 15 months.26 Treatment involving extractions is usually slightly lengthier
than non-extraction treatment.27 Combined
orthodontic-surgical care is likely to result
in an extension to treatment, although treatment times can be quite variable; similarly,
treatment incorporating mechanical eruption
of unerupted or ectopic teeth is usually quite
prolonged.28,29

IS TREATMENT FASTER WITH

MODERN BRACKETS?
Orthodontic appliances have undergone
considerable refinement over the last
30years. The pre-adjusted edgewise appliance was introduced by Andrews in the
1970s,30 largely based on occlusal cornerstones derived from analysis of untreated
ideals. 8 Pre-adjusted edgewise brackets
were the first to be programmed to impart
specific degrees of tip, torque, in-out and
rotational control on each tooth thereby
reducing the need for wire-bending. The
most vaunted and positively marketed

C
Fig.3 Class I malocclusion with severe
crowding and palatal displacement of
both maxillary lateral incisors (Fig.3a).
Following alignment the lateral incisors
have been brought into the correct
position; however, there is inadequate
labial root torque on the upper left lateral
incisor (Figs3b-c). Thick wires with high
elastic modulus are required to address this.
Torque delivery can be time consuming but
is valuable in terms of prospective stability
and dental aesthetics

development since the introduction of

the pre-adjusted edgewise appliance have
been self-ligating brackets (Table3), which
incorporate either a slide or clip mechanism
to entrap the archwire, removing the need
for elastomeric or stainless steel auxiliary
ligatures.
However, there is no evidence to suggest reduced treatment times with modern self-ligating bracket systems.31 While
these brackets have demonstrated reduced
frictional resistance to archwire sliding in
laboratory studies, there is now a wealth of
prospective clinical evidence indicating that
this theoretical advantage does not translate
into shorter treatment times. In particular,
there have been three randomised trials comparing treatment duration with self-ligation
and conventional brackets, none of which
has demonstrated a time saving with the
newer systems.3235

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E
Fig.4 This Class I malocclusion with
palatally-displaced lateral incisors was
treated with fixed appliances (Figs4a-b).
Sufficient torque was delivered to the
maxillary lateral incisors producing an
acceptable aesthetic result following
15months of treatment (Fig.4c). Routine
follow-up 18 months following removal
of the appliances, the result has remained
stable despite the lack of bonded retention
(Figs4d-e)

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2015 Macmillan Publishers Limited. All rights reserved

PRACTICE

Fig.5 Class I crowded case treated with customised lingual appliances over a seven-month period. The lack of uniformity of lingual surfaces
mean that stock brackets may have poor adaptation to lingual surfaces making treatment more complex

IS TORQUE DELIVERY IMPORTANT?

Torque can be defined as rotation without
translation or preferential movement of the
root with a stationary crown. Torque is a
product of force couples generated between
bracket and wire; rectangular stainless steel
wires with high elastic modulus and minimal
play between wire and bracket slot are necessary for effective torque delivery (Fig.3).
Torque delivery is considered to be an integral part of orthodontic treatment; effective torque delivery is one of six recognised
occlusal keys necessary to produce an ideal
occlusal result.8 In addition, torque delivery
is often important in the buccal segments
as alleviation of crowding in round wires
results in bucco-lingual inclination changes,
which may compromise occlusal interdigitation, overbite and stability. In the anterior
regions, appropriate torque contributes to
dental aesthetics; the labial face of the maxillary central incisor should lie parallel to the
facial vertical for optimal dental aesthetics,
with greater requirement for palatal root
torque in the presence of increased lower
anterior facial height.37 In addition, torque
expression is important in producing stable

outcomes, particularly where teeth were significantly displaced before treatment (Fig.4).

ARE BETTER OUTCOMES ACHIEVED

WITH MODERN BRACKETS?
While novel techniques such as the use of
temporary anchorage devices (TADs) have
broadened the scope and enhanced the predictability of treatment (Table 4), there is
no evidence to suggest that refinement of
brackets has been accompanied by better
outcomes. Prospective research comparing
treatment times with self-ligating brackets
have also alluded to comparable levels of
occlusal improvement with these systems.3235
Clearly, the quality of a course of orthodontics is contingent more on the standards and
skills of the operator than on the bracket system used. Both labial and lingual customised
appliances have been produced, with either
brackets, wires or both tailored to the individual patient. Customised lingual appliances
have become particularly popular due to the
wide variation in the morphology of lingual
surfaces, which complicates adaptation of
stock brackets to these teeth and has a bearing on torque delivery (Fig.5).

IS BONDED RETENTION
A GUARANTEE OF STABILITY?
The increasing emphasis on non-extraction treatment has brought the use of
fixed retainers into sharper focus (Table5).
Bonded retention is not without problems:
fixed lingual retainers may encourage plaque
accumulation with potential periodontal
implications.38 Consequently, their use may
not be appropriate in the presence of poor
oral hygiene. Failure rates with fixed retainers have been shown to be high.39 As such,
permanent retention does not remove the
requirement that the teeth are placed in positions of soft tissue balance. Additionally,
prediction of relapse on an individual
basis has proven impossible, invoking the
need for a long-term retention strategy for
many patients.
Furthermore, while bonded retainers may
maintain rotational correction of teeth, they
may be inadequate to resist soft tissue pressures, for example, those arising following correction of bimaxillary proclination.
Consequently, inclination changes and tooth
migration may arise despite intact retainers; augmentation of fixed retainers with
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PRACTICE
Table 4 Some newer techniques are well
proven and highly effective
TADs have dramatically advanced the range and
type of orthodontic tooth movements that are
achievable. Where growth has slowed to adult
levels, certain types of tooth movement that
were once impossible can now be carried out
routinely including intrusion of blocks of teeth to
reduce a deep overbite or to intrude over-erupted
molars, thereby correcting anterior open bites
previously only correctable through a combined
orthodontic-surgical approach, involving superior
repositioning of the posterior maxilla with an
osteotomy.

Table5 Fixed retainers will not always

hold poorly planned tooth positions
If the dentition is moved beyond the zone of
soft tissue balance, the standard methods of
retention will not hold the new tooth positions
for long. Even fixed retainers will allow relapse,
the magnitude, nature and direction of which is
unpredictable.

removable retainers may moderate this tendency. It has also been demonstrated that
residual activity in bonded retainers may
lead to dramatic inclination changes;40 prolonged supervision of retention is therefore
advisable (Fig.6).

IS INTER-PROXIMAL
REDUCTION SAFE?
There is long-term evidence indicating the
safety of inter-proximal reduction.41 In this
research no increased risk of either caries or
periodontal problems tenyears subsequent
to the procedure was demonstrated. All
inter-proximal reduction in the study was
carried out by an internationally-renowned
orthodontist; therefore, while the procedure
may well be performed safely, it is important
that it is undertaken with care and attention
aiming to produce a smooth surface without
inter-proximal ledges risking plaque accumulation and associated risk of periodontal
compromise, sensitivity and caries progression (Fig.7).

Fig.6 Presentation of an orthodontic

case tenyears following removal of
fixed appliances with rotation and axial
inclination changes of terminal teeth on
the retainer (22, 43). The changes may
stem from residual activity in the bonded
retainer wire

may improve alignment in the short term,

it is important that treatment of this nature
is carefully planned, restricted to amenable
cases and suitably retained.
1.

2.
3.
4.

5.

6.

7.

CONCLUSION
Traditional orthodontics involves a complex decision-making process not merely
a binary decision of whether one form of
treatment is appropriate or otherwise. The
treating clinician is charged with choosing between an array of treatment options,
appliances and auxiliaries based on a range
of considerations including facial aesthetics,
dental aesthetics, and intra- and inter-arch
relationships. There is a wide diversity of
presentations of malocclusion warranting
tailored treatment planning and mechanics.
Therefore, while short courses of orthodontics performed on a non-extraction basis

8.
9.
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12.
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Fig.7 This patient presented having

commenced treatment with a general
practitioner with a removable aligner
system. The practitioner had undertaken
liberal inter-proximal reduction of the
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