Orthodontics as a science:

The role of biomechanics

Charles Burstonea
Farmington, Conn

T he scientific basis of orthodontics rests on

a knowledge of anatomy, physiology and growth, and
in particular, biomechanicsthe relationship between
force systems and dental or orthopedic correction. Yet
much of clinical orthodontics is delivered without con-
sideration of forces or force systems. This suggests that
many clinicians believe that a fundamental knowledge
and application of biomechanics has little relevance on
a daily basis in their treatment. Let us consider why
biomechanics should be at the core of clinical practice.

Optimization of Tooth Movement

The application of correct forces and moments are
necessary for full control of tooth movement, influ-
encing the rates of tooth movement and accuracy in
producing different centers of rotation. Knowing
or estimating the force system is relevant to sliding
mechanics, intermaxillary elastics, headgear, and
functional appliances.

Anchorage Control
Anchorage control is based on combining force
levels and selective moments. All archwires produce
multiple effects. Many of the effects are undesirable,
which not only leads to anchorage loss, but to new
problems created during treatment. Biomechanics
allows the clinician to place proper bends or to use
special configurations to minimize or eliminate these
undesirable side effects.
Selection of Wires Brackets and Clinical Devices
There has been a proliferation of new materials,
wires, attachments, and other clinical devices. Which
are the best to use for treatment, and how do we indi-
vidualize their selection for patients? These mecha-
nisms are not interchangeable. For instance, a .014
aUniversity of Connecticut Health Center, Department of Orthodontics.
Reprint requests to: Dr Charles Burstone, DDS, MS, University of Connecticut
Health Center, Department of Orthodontics, Farmington, CT 06030.
Copyright 2000 by the American Association of Orthodontists.
0889-5406/2000/$12.00 + 0 8/1/106013
doi.10.1067/mod.2000.106013
598
Charles Burstone
superelastic NiTi wire is not the same as a .014 Niti-
nol, and hence its application is different.
Development and Use of a Scientific Terminology
Orthodontic appliances work by the delivery of
force systems. The terminology to describe forces and
the geometry of tooth position is part of a broader
knowledge used in science. Some specialized ortho-
dontic terms have produced a jargon that may not be
precise and is certainly unintelligible for other disci-
plines. Universal biomechanical language is the sim-
plest way to describe how an appliance works and is to
be used. It allows communication with other disci-
plines so joint research becomes simpler and more rel-
evant. It also enhances the teaching of clinical ortho-
dontics to new residents; emphasis is on principles
rather than techniques. The student better understands
how an appliance will work and how it is to be used. It
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 117, Number 5
shortens what has been referred to as clinical experi-
ence. It is said that clinical experience is nothing more
than the repetition of mistakes. If the student under-
stands the biomechanical basis of his appliance many
common mistakes will never be made. As new appli-
ances are developed the experienced orthodontist can
benefit from biomechanics. Explanations of both fabri-
cation and use based upon how forces are delivered
greatly simplifies the presentation of new material.
Explanation and Evaluation of Treatment Results
In clinical practice when patients return for a visit
many times, puzzling things are observed. Sometimes
this is attributed to biological variation. In reality, much
of the variation is in the biomechanics that has been
applied. An understanding of biomechanics allows the
clinician to more accurately determine what has hap-
pened and what should be done to correct the problem.
To predict outcomes of treatment requires a more precise
control and understanding of the force systems used.
Research
Clinical studies require control of important vari-
ables. Much of the clinical research does not define
the force systems that were used during treatment or
during one aspect of treatment. It is not enough to say
that headgear was used or even to specify it as an
occipital headgear in a study. Occipital headgears
have many different lines of action of force and
points of application. It is little wonder that results
sometimes are either imprecise or confusing. A bio-
mechanical approach to orthodontics opens up new
areas for research as what is the relationship between
force magnitudes, moment to force ratios, force con-
stancy on dental and orthopedic responses.
Minimization of Tissue Destruction
Orthodontic tissue destruction includes alveolar bone
loss, root resorption, and the clinical responses of patient
discomfort. Histologic studies can demonstrate a rela-
tionship between force magnitude and tissue destruction.
Clinical studies are less clear because many more vari-
ables are involved, particularly in root resorption where
major cases of root resorption seem to be associated with
other factors other than the force system. Nevertheless,
the quality of our treatment suggests control over force
magnitude. As in medicine, dosage does count.
Reduction of Patient Cooperation
The reduction of undesirable side effects and the
concomitant reduction in treatment time can minimize
the use of intermaxillary elastics or headgears and
other appliances that require patient compliance. We
Burstone 599
should not ask our patients to cover up our mistakes
with the use of these devices.
Evaluation of New Appliances
New appliances and variations of old appliances are
continually presented in the literature and at meetings.
These appliances can be evaluated with the use of fun-
damental biomechanical principles. The other approach
is to try these appliances clinically and see how they
work. This trial and error approach is time consuming
and is not fair to our patients. A high percentage of sug-
gested appliances do not stand the test of time.
Development of New Appliances
Orthodontics has always been a very creative field
with many clinicians developing new and exciting
appliances. An analysis and diagrams on a sheet of
paper are far better than unneeded experimentation on
our patients with new approaches.
Knowledge Transfer From Appliance to Appliance
Certain clinical procedures can be successful, and the
orthodontist may want to apply the force systems from
that used in the past to a new appliance, For instance, if
one wants to used a different type of wire or different
material, or if the orthodontics is going to be done on the
lingual rather than on the facial surfaces, biomechanical
principles allow an easy transfer of equivalent force sys-
tems that should produce the same results.
Reducing Commercialization
There has been much commercialization in ortho-
dontics with exaggerated claims made by both clini-
cians and orthodontic companies. Wires, brackets, sys-
tems, and devices are claimed to be superior.
Hyperbole is used to describe these appliances such as
controlled ... hyper, super(superelastic wires is a
correct term for NiTi wires and is descriptive), effi-
cient, biological, and space-age. Knowledgeable
clinicians with good biomechanical background are not
easily swayed by such presentations.
Biomechanics and its derivative orthodontic biome-
chanics applies to all appliances and techniques. At a
minimum it would enhance any given technique used
by a clinician. Currently, not all graduate students are
being trained in biomechanics in any depth. When a
student graduates from a program, an understanding of
biomechanics should be second nature. Otherwise he
or she will be not able to apply it clinically on a daily
basis. The training of students and clinicians in biome-
chanics can include a broad array of topics. It is sug-
gested that the central core of such training should
include the following:
600 Burstone
1. The basics of forces, moments, equivalent force
systems, resultants, and components
2. Static equilibrium and its application to solving
orthodontic problems
3. The biomechanics of tooth movement: moment
to force ratios, force deflection ratios, and the
relationship of the force system to the biology
of tooth movement
4. Principles of appliance design, including the rela-
tionship of design, wires, friction, materials, and
other variables to the forces produced
5. Material science applied to wires and appliances
in general
6. The ability to develop a mechanics plan for a
patient that has as its starting place the force sys-
tem to optimize tooth movement with minimal
undesirable side effects
The conventional wisdom in orthodontics has
emphasized the appliance. Graduate students and ortho-
dontists were taught to fabricate appliances, make
bends or adjustment in these appliances, and perhaps in
some approaches (as straight wire orthodontics), no
bends or adjustments at all. Perhaps there was some lip
service given to biomechanics forces or biology, but
basically the clinician was a fabricator and user of
American Journal of Orthodontics and Dentofacial Orthopedics
May 2000
appliances. Treatment procedures were organized in a
cookbook fashion. This rather unscientific approach to
clinical practice led to the development of different
schools of thought, sometimes identified by the name of
a leading clinician with cookbook sequences.
A new wisdom is needed in orthodontics that is not
appliance oriented. It involves a thinking process
where the clinician identifies goals at least in 3-dimen-
sional space, establishes a sequence of treatment, and
then develops the force systems that will be used to
achieve that goal. Only after force systems have been
carefully established are the appliances selected and
adjusted to obtain those force systems. This is quite
different than orthodontics where the clinician is only
aware of wire shape, bracket formulas, tying mecha-
nism, and friction and play, without any consideration
whatsoever of the forces produced.
Orthodontic biomechanics is not just a theoretical
subject for graduate students and academics. It is the
core of clinical practice; orthodontists are biophysicists
since daily bread and butter orthodontics is the cre-
ative application of sound biomechanical principles. The
21st century in orthodontics will be characterized by a
major shift from orthodontic techniques to a biomechan-
ical approach to treatment; and with it will come rapid
changes in treatment and procedures and concepts.