Atypical Swallowing: How to Correct Tongue Thrust and Use a Lingual Crib

Atypical swallowing, also known as tongue thrust swallowing, is characterized by an altered relationship between the tongue, teeth, lips, and surrounding musculature during deglutition.

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Instead of the tongue assuming a stable palatal position, its anterior portion may move against or between the incisors.

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This pattern may be associated with anterior open bite, increased overjet, altered incisor inclination, and instability during orthodontic treatment.
However, the relationship is not always strictly causal: an existing malocclusion may also promote an adaptive tongue posture. Current evidence therefore supports an individualized and often multidisciplinary approach rather than treating tongue thrust as an isolated habit.

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🔹 What Is Atypical Swallowing?
During a mature swallowing pattern, the tongue generally assumes a relatively elevated and posterior position, with coordinated activity of the lips, cheeks, tongue, and masticatory muscles.
In atypical swallowing, the tongue may protrude anteriorly, interpose between the incisors, or exert abnormal pressure during swallowing.

Clinically, the orthodontist may observe:
▪️ Anterior tongue thrust
▪️ Anterior open bite
▪️ Increased overjet or proclination of incisors
▪️ Lip incompetence or excessive perioral muscle activity
▪️ Altered tongue resting posture
▪️ Associated oral habits such as prolonged digit sucking
The clinical examination should also investigate potential contributing factors, including mouth breathing, nasal obstruction, enlarged adenoids or tonsils, and persistent oral habits. A 2024 systematic review and meta-analysis found an association between mouth breathing and atypical swallowing, reinforcing the importance of evaluating airway-related factors rather than focusing exclusively on the tongue.

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🔹 How Is Atypical Swallowing Corrected?
Treatment should address both the functional pattern and the occlusal consequences.

1. Identify and manage contributing factors
Persistent oral habits and airway problems should be identified before or during orthodontic treatment. If nasal obstruction or another airway-related problem is suspected, appropriate medical evaluation is indicated.

2. Orofacial myofunctional therapy
Orofacial myofunctional therapy (OMT) aims to establish more appropriate tongue posture, lip function, and neuromuscular coordination.
Evidence suggests that OMT can improve aspects of tongue strength and orofacial motor function in patients with tongue thrust. However, the strength of evidence remains limited. A 2025 scoping review found that although many studies reported positive outcomes, the available evidence was heterogeneous and insufficient to definitively confirm OMT effectiveness across orofacial myofunctional disorders.
Therefore, OMT is best considered an adjunctive functional intervention, particularly when persistent tongue dysfunction may compromise orthodontic stability.

3. Orthodontic correction
When atypical swallowing is associated with an anterior open bite, orthodontic treatment may be required to correct the resulting dentoalveolar discrepancy.
The appliance selection depends on the patient's age, dentition, skeletal pattern, severity of the open bite, oral habits, and functional findings.

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🔹 What Is a Lingual Crib Used For?
A lingual crib, also called a palatal crib or tongue crib, is an orthodontic habit-breaking appliance designed to limit anterior tongue interposition.

Its primary functions are to:
▪️ Prevent the tongue from advancing between the incisors
▪️ Reduce the mechanical influence of anterior tongue thrust
▪️ Provide a physical barrier during swallowing
▪️ Encourage a more favorable tongue posture
▪️ Assist correction of anterior open bite associated with tongue thrust or other oral habits
The appliance does not simply "push the tongue backward." Its principal effect is to prevent the tongue from occupying the anterior interdental space, allowing the dentoalveolar structures to respond to the altered functional environment.
Experimental evidence has demonstrated adaptation of tongue pressure and resting behavior during crib therapy, suggesting that the tongue can progressively adapt to the new intraoral environment.

🔹 Lingual Crib: Fixed vs. Removable

Appliance	Main Advantage	Clinical Consideration
Fixed lingual crib	Continuous restriction of anterior tongue interposition	Less dependent on patient compliance
Removable lingual crib	Easier hygiene and removal	Effectiveness depends strongly on patient adherence
Palatal crib with other appliances	Can simultaneously address open bite or transverse problems	Treatment should be individualized according to the malocclusion

Clinical studies have demonstrated improvement in anterior open bite with palatal crib therapy, predominantly through dentoalveolar changes rather than major skeletal modification.
A 2022 systematic review and meta-analysis found that fixed palatal cribs, removable palatal cribs, and bonded lingual spurs produced broadly comparable overbite changes in early anterior open-bite treatment, although the quality of evidence was low.

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🔹 When Should a Lingual Crib Be Considered?
A lingual crib may be particularly useful when there is:

▪️ Anterior open bite associated with tongue thrust
▪️ Persistent anterior tongue interposition
▪️ A need for continuous habit control
▪️ A functional component contributing to orthodontic instability
▪️ A mixed-dentition patient in whom early interception is appropriate
The appliance should not be prescribed solely because an anterior open bite is present. The clinician should establish whether tongue posture or thrusting is clinically relevant to the malocclusion.

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💬 Discussion
The management of atypical swallowing requires distinguishing between a functional disorder and its dental manifestations. A lingual crib can be highly useful for mechanically controlling anterior tongue interposition, but it should not be regarded as a complete treatment for the underlying neuromuscular pattern.
Evidence from clinical trials indicates that palatal crib therapy can produce meaningful improvement in anterior open bite, while long-term studies suggest favorable stability in selected growing patients. Nevertheless, treatment outcomes depend on the etiology, skeletal growth pattern, severity of the malocclusion, and persistence of the underlying functional factors.
Similarly, current evidence does not justify assuming that every patient with tongue thrust requires prolonged myofunctional therapy. OMT may provide functional benefits, but methodological limitations and heterogeneous treatment protocols remain important limitations in the literature.
Consequently, the most rational approach is etiologic diagnosis + orthodontic correction when indicated + functional rehabilitation when clinically necessary.

🎯 Clinical Recommendations
1. Do not diagnose atypical swallowing from an anterior open bite alone. Confirm tongue posture and swallowing behavior clinically.
2. Evaluate airway obstruction, mouth breathing, digit sucking, and other oral habits when relevant.
3. Consider a lingual crib when anterior tongue interposition is demonstrably contributing to the malocclusion.
4. Use orofacial myofunctional therapy selectively, particularly when abnormal tongue posture or muscular coordination persists.
5. During orthodontic treatment, monitor the functional pattern as well as overbite and overjet to reduce the risk of persistent dysfunction and relapse.
6. In complex cases, coordinate care between orthodontics, speech-language pathology/myofunctional therapy, and medical specialists when airway or other contributing factors are identified.

✍️ Conclusion
Atypical swallowing should be managed as a functional and orthodontic problem rather than as an isolated habit. The lingual crib is useful because it mechanically restricts anterior tongue interposition and can facilitate correction of associated anterior open bite. However, successful long-term management requires identification of contributing factors and, when indicated, functional rehabilitation.
Current evidence supports the lingual crib as a useful orthodontic adjunct, while the evidence for orofacial myofunctional therapy remains promising but insufficiently standardized. A patient-specific, multidisciplinary strategy therefore provides the most defensible clinical approach.

📚 References

✔ Gómez-González, C., González-Mosquera, A., Alkhraisat, M. H., & Anitua, E. (2024). Mouth breathing and its impact on atypical swallowing: A systematic review and meta-analysis. Dentistry Journal, 12(2), 21. https://doi.org/10.3390/dj12020021
✔ Homem, M. A., Vieira-Andrade, R. G., Falci, S. G. M., Ramos-Jorge, M. L., & Marques, L. S. (2014). Effectiveness of orofacial myofunctional therapy in orthodontic patients: A systematic review. Dental Press Journal of Orthodontics, 19(4), 94–99. https://doi.org/10.1590/2176-9451.19.4.094-099.oar
✔ Mousa, M. R., Hajeer, M. Y., & Farah, H. (2021). Evaluation of the open-bite Bionator versus the removable posterior bite plane with a tongue crib in the early treatment of skeletal anterior open bite: A randomized controlled trial. European Journal of Orthodontics, 43(4), 163–171. https://doi.org/10.1016/j.ejwf.2021.08.001
✔ Shortland, H.-A. L., Hewat, S., Vertigan, A., & Webb, G. (2021). Orofacial myofunctional therapy and myofunctional devices used in speech pathology treatment: A systematic quantitative review of the literature. American Journal of Speech-Language Pathology, 30(1), 301–317. https://doi.org/10.1044/2020_AJSLP-20-00245
✔ Stefani, C. M., de Almeida de Lima, A., Stefani, F. M., Kung, J. Y., Flores-Mir, C., & Compton, S. M. (2025). Effectiveness of orofacial myofunctional therapy in improving orofacial function and oral habits: A scoping review. Canadian Journal of Dental Hygiene, 59(1), 59–72.
✔ Taslan, S., Biren, S., & Ceylanoglu, C. (2010). Tongue pressure changes before, during and after crib appliance therapy. The Angle Orthodontist, 80(3), 533–539. https://doi.org/10.2319/070209-370.1

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When to Use TMA vs Stainless Steel Archwires

Archwire selection should be based on the biomechanical requirements of each treatment stage rather than on wire material alone.

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Titanium-molybdenum alloy (TMA) and stainless steel (SS) are particularly useful during working and finishing stages because they provide substantially different combinations of stiffness, springback, formability, and friction.

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TMA has an elastic modulus intermediate between nickel-titanium and stainless steel, allowing greater activation with lower force levels. Stainless steel provides greater rigidity and dimensional stability, making it particularly useful when precise control of tooth position, torque, and arch form is required.
The clinical decision, therefore, is not simply whether TMA or stainless steel is "better," but which material provides the appropriate force system for the intended tooth movement.

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🔹 TMA vs Stainless Steel: Key Differences

Property	TMA (β-Titanium)	Stainless Steel
Stiffness	Moderate	High
Springback	Good	Moderate
Formability	Excellent	Good, but less forgiving
Force delivery	Lower and more flexible	Higher and more rigid
Friction	Generally higher	Generally lower
Loop and bend mechanics	Highly suitable	Suitable, but requires greater force
Root-control adjustments	Excellent	Excellent when rigid control is required
Finishing/detailing	Useful when controlled flexibility is needed	Preferred when maximum rigidity is required
Welding/auxiliary attachments	Highly suitable	Suitable

The mechanical distinction is clinically important. Experimental comparisons demonstrate that TMA has lower stiffness and bending moments than stainless steel of comparable dimensions, while maintaining useful springback and formability.

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🔹 When Should TMA Archwires Be Used?
TMA is particularly valuable when the clinician needs controlled flexibility combined with the ability to make permanent bends.

1. Individual tooth movement
TMA is well suited to individual tooth movements because its intermediate stiffness allows activation without producing the relatively high forces associated with similarly sized stainless steel wires. This makes it useful for auxiliaries, cantilevers, uprighting mechanics, and segmented mechanics.

2. Root positioning and controlled finishing
Rectangular TMA can be useful when root positioning or torque adjustments require a degree of flexibility that would make stainless steel excessively rigid.
It is particularly advantageous when a clinician needs to incorporate first-, second-, or third-order bends while maintaining a relatively moderate force system.

3. Loops and auxiliary mechanics
The excellent formability of β-titanium makes TMA appropriate for loops, closing mechanics, uprighting springs, cantilevers, and segmented archwires. Its ability to be manipulated and welded to auxiliaries further expands its clinical applications.

4. Situations requiring a more forgiving working wire
When a full-size stainless-steel archwire would generate excessive stiffness because of significant activation or tooth displacement, TMA can provide a more gradual force system while still allowing precise bends.

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🔹 When Should Stainless Steel Archwires Be Used?
Stainless steel is preferable when rigidity, dimensional stability, and low friction are priorities.

1. Space closure and sliding mechanics
Stainless steel is generally advantageous for sliding mechanics because its smooth surface and relatively low friction can reduce resistance at the bracket–archwire interface. The frictional behavior, however, depends on bracket material, ligation, angulation, wire dimensions, surface characteristics, and the presence of binding.

2. Maximum control of arch form
A rigid stainless-steel archwire is useful when the clinician wants to maintain or establish a specific arch form with minimal deformation.

3. Torque and finishing
Rectangular stainless steel is particularly useful during final torque expression, root control, arch coordination, and finishing, especially when the bracket prescription is expected to be expressed with minimal wire deformation.

4. Stabilization after active mechanics
Once the desired tooth positions have been achieved, stainless steel can provide a stable working platform for final detailing and coordination.

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🔹 TMA vs Stainless Steel: Which Should Be Used for Finishing?
There is no universal rule that finishing must be performed exclusively with one material.
A practical approach is:
Use TMA when finishing requires active bends, localized tooth movement, or controlled flexibility.
Use stainless steel when the primary objective is rigidity, arch-form control, torque expression, and maintaining already-corrected positions.
This distinction is particularly relevant with rectangular wires. A large rectangular TMA wire can provide substantial control while remaining more flexible than an equivalent stainless-steel wire. Conversely, stainless steel is advantageous when unwanted wire deformation would compromise the intended force system.

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🔹 Clinical Comparison by Treatment Objective

Clinical Objective	Preferred Material	Main Reason
Individual tooth movement	TMA	Controlled flexibility and good formability
Loops and cantilevers	TMA	Efficient activation with relatively moderate force levels
Sliding space closure	Stainless steel	Low friction and high rigidity
Arch-form control	Stainless steel	High stiffness and dimensional stability
Localized finishing bends	TMA	Excellent formability and controlled flexibility
Final torque and rigid finishing	Stainless steel	Maximum rigidity and torque expression

💬 Discussion
The principal clinical difference between TMA and stainless steel is their force–deflection behavior. Stainless steel has a higher elastic modulus and therefore resists deformation more strongly. TMA occupies an intermediate position between NiTi and stainless steel, allowing greater activation while producing lower stiffness.
However, material selection cannot be separated from wire dimension. Increasing the cross-sectional dimensions of a rectangular wire can markedly increase stiffness, meaning that a clinician should evaluate alloy and dimension together rather than assuming that every TMA or stainless-steel wire produces the same biomechanical response.
Friction is another relevant consideration. Stainless steel generally demonstrates favorable frictional characteristics, whereas TMA tends to exhibit greater surface roughness and friction. Nevertheless, friction alone should not determine archwire selection because binding, bracket angulation, ligation, wire size, and the overall force system can substantially influence clinical behavior.
Recent experimental evidence also indicates that environmental conditions may influence the mechanical behavior of β-titanium wires over time. Therefore, laboratory mechanical properties should be interpreted as material characteristics rather than direct predictors of individual clinical outcomes.

🎯 Clinical Recommendations
▪️ Choose TMA when controlled flexibility, extensive bends, loops, cantilevers, or localized tooth movement are central to the mechanics.
▪️ Choose stainless steel when rigidity, arch-form maintenance, low friction, space closure, or precise finishing is the primary objective.
▪️ For rectangular wires, select alloy and cross-sectional dimension together; changing either can substantially alter the force system.
▪️ Avoid selecting TMA solely because it is "softer." Its advantage is controlled flexibility with excellent formability, not simply lower stiffness.
▪️ During finishing, use TMA when additional active bending is required and stainless steel when rigid three-dimensional control is the priority.

✍️ Conclusion
TMA and stainless steel archwires are complementary rather than competing materials. TMA is particularly valuable when flexibility, springback, and formability are required, whereas stainless steel is advantageous when maximum rigidity, dimensional stability, low friction, and precise finishing are desired.
The most rational selection is therefore determined by the specific biomechanical objective, wire dimension, amount of activation, and stage of treatment rather than by a fixed sequence applicable to every patient.

📚 References

✔ Burstone, C. J., & Goldberg, A. J. (1980). Beta titanium: A new orthodontic alloy. American Journal of Orthodontics, 77(2), 121–132. https://doi.org/10.1016/0002-9416(80)90001-9
✔ Huffman, J., et al. (2026). The effect of pH on the mechanical properties of beta titanium orthodontic arch wires. European Oral Research.
✔ Kapila, S., & Sachdeva, R. (1989). Mechanical properties and clinical applications of orthodontic wires. American Journal of Orthodontics and Dentofacial Orthopedics, 96(2), 100–109. https://doi.org/10.1016/0889-5406(89)90251-5
✔ Kusy, R. P. (1997). A review of contemporary archwires: Their properties and characteristics. The Angle Orthodontist, 67(3), 197–207.
✔ Sernetz, F., & Franke, R. (2006). In-vitro evaluation of the material characteristics of stainless steel and beta-titanium orthodontic wires. European Journal of Orthodontics, 28(5), 487–492.
✔ Yıldırım, E., et al. (2017). Comparison of spring characteristics of titanium-molybdenum alloy and stainless steel. Journal of Clinical and Experimental Dentistry, 9(5), e620–e625.

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Best Archwire Sequence for Deep Bite Correction

Deep bite correction requires more than simply leveling the curve of Spee. The appropriate biomechanics depend on the etiology of the deep bite, facial pattern, incisor display, periodontal condition, and desired vertical tooth movement.

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Treatment may involve anterior intrusion, posterior extrusion, incisor proclination, or a combination of these movements.

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For patients in whom true anterior intrusion is indicated, the archwire sequence should progress from flexible alignment wires toward stiffer rectangular wires that permit increasingly precise three-dimensional control. However, there is no single archwire sequence that is universally superior for every deep-bite patient.
Importantly, evidence comparing complete archwire sequences specifically for deep-bite correction remains limited. Therefore, the following sequence should be considered an evidence-informed clinical framework, rather than a rigid protocol.

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🔹 Recommended Archwire Sequence
A practical sequence for fixed-appliance treatment is:

Treatment Phase	Suggested Archwire	Primary Objective
Initial Alignment	0.012–0.014 in NiTi	Gentle alignment and leveling
Progressive Alignment	0.016–0.018 in NiTi	Continue alignment and begin leveling
Early Rectangular Control	0.016 × 0.022 or 0.017 × 0.025 in NiTi	Improve torque and vertical control
Deep-Bite Correction	Rectangular NiTi, TMA, or segmented intrusion arch	Intrusion and leveling according to diagnosis
Working Phase	0.019 × 0.025 in stainless steel	Space closure and three-dimensional control
Finishing	0.017 × 0.025 or 0.019 × 0.025 in stainless steel	Torque, detailing, and occlusal finishing

The exact dimensions should be adapted to bracket prescription, slot size, initial malocclusion, periodontal limits, and anchorage requirements.

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1. Initial Alignment: Round NiTi
A 0.012–0.014-inch NiTi wire is appropriate when significant crowding or irregularity is present. A subsequent 0.016–0.018-inch NiTi wire can provide progressive alignment and leveling.
The objective at this stage is not to force rapid deep-bite correction. Excessive early leveling may produce unwanted incisor proclination or posterior effects before the clinician has established adequate anchorage.
Clinical trials evaluating archwire sequences have demonstrated that several commonly used sequences can achieve alignment, without establishing one universal sequence as clearly superior.

2. Rectangular NiTi: Transition to Three-Dimensional Control
Once sufficient alignment has been achieved, a rectangular NiTi archwire can be introduced. Common choices include 0.016 × 0.022-inch or 0.017 × 0.025-inch NiTi, depending on the appliance system.
This transition is important because deep-bite correction frequently requires greater control of incisor inclination and vertical position, rather than simple alignment.

3. Active Deep-Bite Correction
This is the critical phase. The wire selected should reflect the mechanism of correction, not simply the severity of the overbite.
When anterior intrusion is indicated, a segmented intrusion arch, three-piece arch, or skeletal anchorage-assisted mechanics may provide better control than relying exclusively on continuous archwire leveling.
Burstone emphasized that successful intrusion depends on appropriate force magnitude, force location relative to the center of resistance, posterior anchorage control, and minimizing unwanted posterior eruption.
True incisor intrusion is achievable, although the average amount is relatively modest. A systematic review reported approximately 1.46 mm of maxillary incisor intrusion and 1.90 mm of mandibular incisor intrusion with segmented mechanics.

4. TAD-Assisted Intrusion When Maximum Vertical Control Is Required
Temporary anchorage devices (TADs) can be particularly useful when posterior anchorage must be preserved or when substantial anterior intrusion is required.
Recent evidence indicates that TAD-supported mechanics may produce slightly greater incisor intrusion and deep-bite reduction than conventional intrusion mechanics. However, the magnitude of the difference is generally modest and the certainty of evidence remains limited.
Therefore, TADs should not be considered mandatory for every deep bite. They are most useful when the biomechanical objective cannot be achieved predictably with conventional anchorage.

5. Working and Finishing Wires
After the vertical relationship has been corrected, a 0.019 × 0.025-inch stainless steel archwire is commonly appropriate for the working phase.
This wire provides high control of torque, angulation, arch form, and space closure and is particularly useful when extraction mechanics are involved.
A smaller rectangular stainless-steel wire may be preferable during finishing when greater flexibility is desirable. Final wire selection should be based on the amount of detailing required rather than following a predetermined sequence.

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🔹 How Should the Sequence Change According to the Deep Bite?

Clinical Situation	Preferred Emphasis	Practical Approach
Deep bite with excessive incisor display	Anterior intrusion	Rectangular control + intrusion mechanics
Deep bite with low facial height in a growing patient	Posterior eruption/extrusion may be acceptable	Leveling or bite-opening mechanics
Deep bite with excessive lower-incisor proclination risk	Avoid uncontrolled leveling	Segmental mechanics and anchorage control
Deep bite with gummy smile	Maxillary incisor intrusion	Intrusion mechanics ± TADs
Extraction deep bite with retroclined incisors	Intrusion + controlled retraction	Three-piece or segmental mechanics
Adult deep bite requiring posterior anchorage preservation	Controlled anterior intrusion	TAD-supported or segmented mechanics

The distinction is clinically important because overbite reduction does not necessarily mean true incisor intrusion. Continuous arch mechanics may reduce overbite partly through molar extrusion and mandibular rotation, whereas segmented mechanics can achieve greater anterior intrusion with less posterior extrusion.

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💬 Discussion
The concept of a "best" archwire sequence should therefore be interpreted as a biomechanical progression rather than a fixed series of wire dimensions.

A conventional sequence such as:
Round NiTi → Rectangular NiTi → Rectangular stainless steel
is adequate for many routine fixed-appliance cases. However, a patient with a clinically significant deep bite may require an additional vertical-control phase between rectangular NiTi and the final working archwire.

For example:
0.012–0.014 NiTi → 0.016 NiTi → 0.016 × 0.022 NiTi → intrusion mechanics → 0.019 × 0.025 stainless steel → finishing
may be more appropriate than attempting to correct the entire deep bite through progressive continuous-arch leveling.
Recent randomized evidence also suggests that reverse-curve mechanics can correct deep overbite but may influence lower-incisor proclination depending on wire design and torque. A 2025 randomized clinical study found comparable true intrusion among tested reverse-curve systems, while anterior crown torque substantially affected mandibular incisor proclination.
Consequently, wire selection should follow the intended tooth movement. The objective is not simply to use a larger archwire, but to generate the desired vertical and sagittal movements while controlling reciprocal effects.

🎯 Clinical Recommendations
1. Diagnose the source of the deep bite before selecting the archwire. Determine whether correction should primarily involve intrusion, extrusion, incisor inclination, or a combination.
2. Use flexible NiTi wires for initial alignment, but avoid relying on progressive continuous-arch leveling as the sole strategy when significant anterior intrusion is required.
3. Introduce rectangular control before active intrusion when incisor torque and root position need to be managed.
4. Consider segmented intrusion mechanics or TADs when posterior anchorage preservation is critical or when predictable anterior intrusion is the primary objective.
5. Use stainless steel rectangular wires for working and finishing control, particularly when space closure, torque expression, and detailed tooth positioning are required.
6. Do not equate overbite reduction with true intrusion. Evaluate the vertical changes of incisors and posterior teeth when treatment mechanics are being assessed.

✍️ Conclusion
The most appropriate archwire sequence for deep bite correction is individualized according to the vertical problem and the desired tooth movement. A practical sequence progresses from round NiTi alignment to rectangular NiTi control, dedicated intrusion mechanics when indicated, and rectangular stainless steel for working and finishing.
Current evidence supports the use of controlled intrusion mechanics, particularly when preservation of posterior anchorage is important. TAD-assisted intrusion may provide additional vertical control, although the available evidence does not justify considering it universally superior for every patient.
The key clinical principle is therefore biomechanical control rather than a predetermined wire sequence: the archwire should be selected according to the movement required to correct the patient's specific deep-bite phenotype.

📚 References

✔ Burstone, C. R. (1977). Deep overbite correction by intrusion. American Journal of Orthodontics, 72(1), 1–22. https://doi.org/10.1016/0002-9416(77)90121-X
✔ Weiland, F., Bantleon, H. P., & Droschl, H. (1992). The orthodontic treatment of deep bite in adults—a comparison of the straight wire appliance and the segmented arch technique. American Journal of Orthodontics and Dentofacial Orthopedics, 101(5), 403–410. https://doi.org/10.1016/0889-5406(92)70114-F
✔ Ng, J., Major, P. W., Heo, G., & Flores-Mir, C. (2005). True incisor intrusion attained during orthodontic treatment: A systematic review and meta-analysis. American Journal of Orthodontics and Dentofacial Orthopedics, 128(2), 212–219. https://doi.org/10.1016/j.ajodo.2004.04.025
✔ Mandall, N. A., Lowe, C., Worthington, H. V., Sandler, J., Derwent, S., Abdi-Oskouei, M., & Ward, S. (2006). Which orthodontic archwire sequence? A randomized clinical trial. European Journal of Orthodontics, 28(6), 561–566. https://doi.org/10.1093/ejo/cjl030
✔ Atalla, A. I., AboulFotouh, M. H., Fahim, F. H., & Foda, M. Y. (2020). Effectiveness of orthodontic mini-screw implants in adult deep bite patients during incisor intrusion: A systematic review. Contemporary Clinical Dentistry, 10(2), 372–381. https://doi.org/10.4103/ccd.ccd_618_18
✔ Sosly, R., Mohammed, H., & Riedy, C. A. (2020). Effectiveness of miniscrew-supported maxillary incisor intrusion in deep-bite correction: A systematic review and meta-analysis. The Angle Orthodontist, 90(2), 291–304.
✔ Bardideh, E., Tamizi, G., Shafaee, H., Rangrazi, A., Ghorbani, M., & Kerayechian, N. (2023). The effects of intrusion of anterior teeth by skeletal anchorage in deep bite patients: A systematic review and meta-analysis. Biomimetics, 8(1), 101. https://doi.org/10.3390/biomimetics8010101
✔ Lee, W. Y., Othman, S. A., & Sivarajan, S. (2026). Anterior intrusion mechanics for adult deep bite correction: A systematic review of randomised controlled trials. BMC Oral Health. https://doi.org/10.1186/s12903-026-09120-w
✔ Shakhtour, F., & Al-Nimri, K. (2025). Comparison between effects of reverse curve of Spee nickel titanium archwire and stainless steel archwires with and without torque on the lower incisors in deep overbite treatment: A randomized control study. The Angle Orthodontist, 95(1), 27–34. https://doi.org/10.2319/051524-376.1

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Can Testosterone Affect Orthodontic Tooth Movement?

A 2026 animal study published in the Journal of Periodontology investigated how altered testosterone levels affect orthodontic tooth movement (OTM), alveolar bone remodeling, periodontal tissues, and root resorption.

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The findings indicate that both testosterone deficiency and high-dose anabolic-androgenic steroid exposure can modify the biological response to orthodontic force in a pubertal male rat model.

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The study provides experimental evidence that testosterone-related disturbances may influence the tissues involved in orthodontic tooth movement. However, because the research was conducted in rats, the findings cannot be directly applied to human orthodontic treatment.

🔹 Study Design
The researchers used a pubertal male rat model to investigate the effects of testosterone dysfunction during orthodontic tooth movement.
Testosterone deficiency was induced through orchiectomy. The researchers subsequently administered testosterone undecanoate, an anabolic-androgenic steroid (AAS), at replacement and high doses.
Orthodontic tooth movement was produced by applying a closed-coil spring to the maxillary right first molar. The surrounding alveolar bone and periodontal ligament were evaluated at 5 and 10 days after orthodontic force application.
The investigators used several analytical methods, including micro-computed tomography (micro-CT), reverse-transcription quantitative polymerase chain reaction (RT-qPCR), and immunohistochemistry. Root resorption and plasma concentrations of testosterone and adrenocorticotropic hormone were also evaluated.

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🔹 Testosterone Dysfunction Altered Bone Microarchitecture
Both testosterone deficiency and high-dose AAS exposure produced significant changes in bone microarchitecture.
The researchers reported reductions in trabecular thickness and bone connectivity, together with changes involving bone lacunae.
These findings indicate that altered testosterone conditions affected the alveolar bone response during the experimental orthodontic procedure.
The study also found that testosterone dysfunction was associated with greater rotation and intrusion of the orthodontically moved tooth. These observations were obtained from the animal model and should not be interpreted as evidence that testosterone manipulation produces predictable changes in the rate or direction of orthodontic tooth movement in humans.

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🔹 High-Dose Anabolic Steroids and Root Resorption
One of the clinically relevant findings involved inflammatory changes and root resorption.
According to the study, high-dose AAS exposure intensified the inflammatory infiltrate and root resorption associated with orthodontic tooth movement.
Root resorption is a biological consequence that can occur during orthodontic tooth movement. In this experimental model, the researchers found that high-dose androgen exposure was associated with a greater resorptive response.
The study therefore identifies a potential relationship between androgen disturbance and orthodontically induced tissue changes. However, it does not establish that anabolic-androgenic steroid use causes clinically significant root resorption in human orthodontic patients.

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🔹 Changes in Bone-Related Gene Expression
The investigators also examined molecular markers associated with bone metabolism.
Testosterone dysfunction altered the expression of several genes, including:
▪️ Runx2
▪️ Bmp2
▪️ Spp1
▪️ Bglap
The study also identified deregulation of the RANK/RANKL/OPG pathway following testosterone disturbances.
These molecular findings provide additional evidence that altered testosterone conditions affected biological pathways involved in bone remodeling during orthodontic tooth movement.

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🔹 Testosterone Replacement Did Not Fully Restore the Response
An important finding was that administration of AAS at replacement doses did not normalize the inflammatory infiltrate, orthodontic tooth movement, or the expression of the studied genes to control levels.
Therefore, the experimental response observed in testosterone-deficient animals was not simply reversed by testosterone administration at the replacement dose used in the study.
This finding suggests that the biological effects associated with testosterone disturbance were not completely restored under the experimental conditions evaluated.

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🔹 What Do These Findings Mean for Orthodontics?
The study provides evidence that testosterone dysfunction can influence several biological processes associated with orthodontic tooth movement, including:
▪️ alveolar bone microarchitecture;
▪️ periodontal inflammatory response;
▪️ tooth movement characteristics;
▪️ root resorption; and
▪️ expression of genes involved in bone metabolism.
However, the study does not establish a clinical protocol for modifying testosterone levels during orthodontic treatment.
It also does not demonstrate that testosterone supplementation can accelerate orthodontic treatment or that testosterone deficiency necessarily causes slower tooth movement in humans.
The experimental findings should therefore be interpreted as evidence of a biological relationship that requires further investigation.

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🔹 Important Study Limitation
The principal limitation is the experimental model.
The study was conducted in pubertal male rats, and orthodontic tooth movement was produced experimentally using a closed-coil spring on a maxillary first molar. The observation periods were limited to 5 and 10 days.
Human orthodontic treatment differs substantially from this experimental model in anatomy, skeletal development, treatment duration, biomechanics, hormonal physiology, and clinical management.
Consequently, the findings cannot currently be used to predict how an individual human patient will respond to orthodontic treatment based on testosterone levels.

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💬 Discussion
The 2026 study by Reis et al. provides experimental evidence that testosterone dysfunction can modify bone remodeling, periodontal inflammation, orthodontic tooth movement, and root resorption in a pubertal male rat model.
Both testosterone deficiency and high-dose anabolic-androgenic steroid exposure produced alterations in alveolar bone microarchitecture. High-dose AAS exposure was additionally associated with increased inflammatory infiltration and root resorption, while testosterone disturbances affected several genes and signaling pathways involved in bone metabolism.
These findings expand the experimental understanding of systemic hormonal influences on orthodontic tooth movement. Nevertheless, human clinical studies are required before the findings can be translated into orthodontic treatment recommendations.

📚 References

Reis, C. L. B., Galisteu-Luiz, K., Pedroso, G. L., Puls, G. L., Cassaro, L., Vieira, B. B., Lourenço Romano, F., Küchler, E. C., Kirschneck, C., de Oliveira, D. S. B., Stuani, M. B. S., & Matsumoto, M. A. N. (2026). Effects of testosterone and high-dose anabolic steroids on orthodontic-induced bone remodeling and root resorption: An animal study. Journal of Periodontology. Advance online publication. https://doi.org/10.1002/jper.70068

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Vertical Malocclusions in Primary, Mixed, and Permanent Dentition

Vertical malocclusions are bite problems that affect the vertical relationship between the upper and lower teeth. Instead of meeting normally when the mouth closes, the teeth may overlap too much or fail to touch at all.

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These conditions can influence chewing, speech, facial appearance, and jaw function.

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Vertical discrepancies may appear during primary, mixed, or permanent dentition and can result from genetic factors, oral habits, or altered facial growth. Early diagnosis helps guide treatment at the most appropriate stage of development, often reducing the need for more complex procedures later in life.

🔹 What Is a Vertical Malocclusion?
A vertical malocclusion is an abnormal relationship of the teeth or jaws in the vertical dimension. The two most common forms are:

▪️ Deep Bite (Excessive Overbite)
▪️ Anterior Open Bite
These conditions may have a dental origin, a skeletal origin, or a combination of both.

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🔹 Main Types of Vertical Malocclusions

1. Deep Bite (Deep Overbite)
A deep bite occurs when the upper front teeth excessively overlap the lower front teeth, sometimes covering most or all of the lower incisors.
Common characteristics
▪️ Excessive vertical overlap of anterior teeth
▪️ Increased risk of palatal trauma
▪️ Tooth wear
▪️ Functional limitations in severe cases
Deep bite is frequently associated with short lower facial height and strong bite muscles.

2. Anterior Open Bite
An anterior open bite is present when the upper and lower front teeth do not touch when the back teeth are in contact.
Common characteristics
▪️ Space between upper and lower incisors
▪️ Difficulty biting food
▪️ Speech alterations
▪️ Tongue thrusting in some patients
Open bite may be dental, skeletal, or functional.

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🔹 Vertical Malocclusions by Dentition Stage

Primary Dentition
Vertical problems during primary dentition are commonly associated with:
▪️ Thumb sucking
▪️ Prolonged pacifier use
▪️ Tongue thrusting
▪️ Mouth breathing
Many mild cases improve after harmful habits stop, but persistent open bites require professional evaluation.

Mixed Dentition
The mixed dentition provides an excellent opportunity for interceptive orthodontic treatment.
Management may include:
▪️ Habit interception
▪️ Myofunctional therapy
▪️ Orthodontic appliances
▪️ Growth modification when indicated
Early treatment improves the chances of correcting developing skeletal discrepancies.

Permanent Dentition
Once facial growth is complete, treatment becomes more individualized.
Options may include:
▪️ Fixed orthodontic appliances
▪️ Temporary Anchorage Devices (TADs)
▪️ Orthognathic surgery for severe skeletal open bite or deep bite
▪️ Multidisciplinary treatment when necessary

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🔹 Main Causes
Vertical malocclusions often result from multiple factors, including:

▪️ Genetic facial growth patterns
▪️ Thumb or finger sucking
▪️ Prolonged pacifier use
▪️ Tongue thrust habit
▪️ Mouth breathing
▪️ Abnormal eruption patterns
▪️ Neuromuscular factors
▪️ Skeletal growth discrepancies

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🔹 Clinical Signs
Patients may present with:

▪️ Deep Bite
▪️ Excessive incisor overlap
▪️ Lower incisor wear
▪️ Palatal trauma
▪️ Reduced lower facial height

Anterior Open Bite
▪️ Visible gap between front teeth
▪️ Difficulty biting foods
▪️ Speech difficulties
▪️ Tongue thrust during swallowing
▪️ Increased lower facial height in skeletal cases

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🔹 Diagnosis
A comprehensive diagnosis includes:

▪️ Medical and dental history
▪️ Clinical examination
▪️ Facial analysis
▪️ Occlusal evaluation
▪️ Measurement of overbite
▪️ Functional assessment
▪️ Digital models or study casts
▪️ Cephalometric analysis
▪️ CBCT, only when clinically justified
Differentiating dental from skeletal vertical discrepancies is essential for selecting the correct treatment.

🔹 Treatment Overview

Condition	Preferred Management
Dental Deep Bite	Orthodontic intrusion of anterior teeth, bite-opening mechanics, bite turbos, or arch leveling depending on the patient's needs.
Skeletal Deep Bite	Growth modification in growing patients or orthognathic surgery combined with orthodontic treatment in severe adult cases.
Dental Anterior Open Bite	Elimination of oral habits, myofunctional therapy when indicated, and orthodontic correction with fixed or removable appliances.
Skeletal Anterior Open Bite	Treatment with Temporary Anchorage Devices (TADs), skeletal anchorage mechanics, or orthognathic surgery for severe skeletal discrepancies.

🔹 Possible Consequences if Untreated
Untreated vertical malocclusions may lead to:

▪️ Abnormal tooth wear
▪️ Chewing difficulties
▪️ Speech problems
▪️ Periodontal trauma
▪️ Poor smile aesthetics
▪️ Reduced occlusal stability
▪️ Temporomandibular disorders in susceptible individuals

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💬 Discussion
Recent orthodontic evidence emphasizes that vertical malocclusions require individualized diagnosis, as the underlying cause determines the most effective treatment. While habit-related open bites often respond well to early intervention, skeletal discrepancies may require orthopedic treatment during growth or surgical correction in adulthood. Careful evaluation of facial growth, dental eruption, and oral function is essential for achieving stable long-term results.

🎯 Recommendations
▪️ Perform routine orthodontic screening during childhood.
▪️ Eliminate thumb sucking and prolonged pacifier use early.
▪️ Monitor tongue posture and swallowing patterns.
▪️ Refer patients with persistent open bite or deep bite for orthodontic evaluation.
▪️ Base treatment decisions on growth stage and skeletal diagnosis rather than age alone.
▪️ Use advanced imaging only when clinically indicated.

✍️ Conclusion
Vertical malocclusions are common developmental conditions that may affect patients from primary through permanent dentition. Their impact extends beyond tooth alignment, influencing facial growth, oral function, and long-term stability. Early identification of harmful habits and accurate differentiation between dental and skeletal causes allow clinicians to provide more effective, less invasive treatment and improve overall oral health outcomes.

📊 Summary Table

Aspect	Key Information
Definition	Abnormal vertical relationship between the upper and lower teeth or jaws.
Main Types	Deep bite (deep overbite) and anterior open bite.
Primary Dentition	Often associated with thumb sucking, prolonged pacifier use, tongue thrusting, and mouth breathing.
Mixed Dentition	Ideal stage for interceptive orthodontics, habit control, and growth modification.
Permanent Dentition	Treatment may include fixed appliances, TADs, or orthognathic surgery depending on severity.
Main Causes	Genetics, oral habits, tongue thrust, mouth breathing, and skeletal growth discrepancies.
Diagnosis	Clinical examination, facial analysis, overbite measurement, study models, cephalometric analysis, and CBCT when indicated.
Early Intervention	Improves treatment outcomes, supports normal facial growth, and may reduce the need for surgery later.

📚 References

✔ Graber, L. W., Vanarsdall, R. L., Vig, K. W. L., & Huang, G. J. (2023). Orthodontics: Current Principles and Techniques (7th ed.). Elsevier.
✔ Proffit, W. R., Fields, H. W., Larson, B. E., & Sarver, D. M. (2023). Contemporary Orthodontics (7th ed.). Elsevier.
✔ Ngan, P., & Fields, H. W. (1997). Open bite: A review of etiology and management. Pediatric Dentistry, 19(2), 91–98.
✔ Greenlee, G. M., Huang, G. J., Chen, S. S., Chen, J., Koepsell, T., & Hujoel, P. (2011). Stability of treatment for anterior open-bite malocclusion: A meta-analysis. American Journal of Orthodontics and Dentofacial Orthopedics, 139(2), 154–169.
✔ American Association of Orthodontists. (2024). Clinical Practice Resources. American Association of Orthodontists.

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How Can Excessive Tooth Mobility Be Managed During Orthodontics?

Maintaining tooth stability during orthodontic treatment is essential for safe, predictable, and successful tooth movement.

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Although mild tooth mobility is a normal biological response to braces or clear aligners, excessive mobility may indicate that the supporting tissues need additional attention.

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Orthodontic treatment is designed to move teeth through gentle, controlled forces that stimulate natural bone remodeling. During this process, teeth may temporarily feel slightly loose before becoming stable again.
The goal is not to eliminate mobility completely, but to keep it within healthy physiological limits while protecting the bone, gums, and periodontal ligament.
Understanding how tooth stability is maintained, how to minimize unnecessary mobility, and when excessive movement becomes a concern helps patients actively participate in their treatment and supports long-term oral health.

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🔹 What Is Tooth Stability?
Tooth stability refers to a tooth's ability to remain securely supported within the jawbone while still allowing the small amount of natural movement provided by the periodontal ligament.
Healthy teeth are never completely rigid. Instead, they are suspended by the periodontal ligament (PDL), which cushions chewing forces and allows controlled orthodontic movement without damaging the surrounding tissues.
Throughout orthodontic treatment, the objective is to maintain this delicate balance between controlled tooth movement and healthy periodontal support.

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🔹 Why Does Tooth Mobility Increase During Orthodontic Treatment?
When orthodontic appliances apply gentle force to a tooth, the tissues surrounding the root begin to remodel.

This biological process includes:
▪️ Bone resorption on the pressure side.
▪️ New bone formation on the tension side.
▪️ Temporary widening of the periodontal ligament.
As a result, teeth may feel slightly more mobile while they are moving. In healthy patients, this increase in mobility is temporary and expected.

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🔹 How Is Tooth Stability Maintained During Orthodontic Treatment?
Maintaining tooth stability depends on both the orthodontist and the patient.

1. Using Light, Controlled Orthodontic Forces
Modern orthodontics relies on continuous, low-force mechanics rather than heavy pressure.
Gentle forces:
▪️ reduce unnecessary stress on the periodontal ligament,
▪️ promote healthy bone remodeling,
▪️ decrease the risk of excessive mobility,
▪️ lower the chance of root resorption.

2. Maintaining Excellent Oral Hygiene
Healthy gums provide a stronger foundation for tooth movement.
Daily brushing, flossing, and professional cleanings help prevent gingivitis and periodontitis, which can significantly increase tooth mobility.

3. Controlling Gum Inflammation
Inflamed periodontal tissues become more susceptible to movement.
Treating gingivitis early helps preserve the supporting bone and improves overall tooth stability throughout treatment.

4. Following Orthodontic Instructions
Patients should:
▪️ Wear aligners for the recommended number of hours each day.
▪️ Use elastics exactly as prescribed.
▪️ Avoid skipping appointments.
Following the treatment plan allows tooth movement to occur at a healthy biological pace.
5. Avoiding Excessive Biting Forces
Hard foods and harmful habits can place unnecessary stress on already moving teeth.
Patients should avoid:
▪️ ice
▪️ hard candy
▪️ popcorn kernels
▪️ chewing pens or fingernails
▪️ opening packages with their teeth
Reducing unnecessary forces helps protect the periodontal ligament.

6. Monitoring Periodontal Health
Regular clinical examinations allow the orthodontist to evaluate:
▪️ gum health,
▪️ bone support,
▪️ tooth mobility,
▪️ treatment progress.
Early detection of periodontal problems helps prevent complications.

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🔹 What Happens If Tooth Mobility Becomes Excessive?
Although mild mobility is normal, excessive tooth mobility should never be ignored.
When movement exceeds normal physiological limits, it may indicate that the supporting tissues are under excessive stress or affected by another condition.

Possible causes include:
▪️ Excessive orthodontic forces
▪️ Poor oral hygiene
▪️ Gingivitis or periodontitis
▪️ Traumatic biting forces
▪️ Reduced bone support
▪️ External root resorption
▪️ Systemic conditions affecting bone health
If left untreated, excessive mobility may slow orthodontic progress and increase the risk of periodontal complications.

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🔹 Warning Signs That Require Professional Evaluation
Patients should contact their orthodontist if they experience:

▪️ A tooth that suddenly becomes much looser than before.
▪️ Persistent pain lasting several days.
▪️ Swollen or bleeding gums around a mobile tooth.
▪️ Pus or signs of infection.
▪️ Difficulty chewing because a tooth feels unstable.
▪️ Mobility that continues to worsen instead of improving.
Early evaluation helps identify the cause before permanent damage occurs.

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🔹 Can Excessive Tooth Mobility Be Reduced?
Yes. In most cases, excessive tooth mobility can be reduced once the underlying cause has been identified and corrected. The primary objective is to allow the periodontal ligament and surrounding alveolar bone to recover before additional tooth movement is attempted.

1. Temporarily Pause Active Tooth Movement
If mobility is greater than expected, the orthodontist may temporarily stop active mechanics on the affected tooth.
In most cases, active forces are suspended for approximately 2–6 weeks, depending on:
▪️ the degree of tooth mobility,
▪️ periodontal health,
▪️ the presence of inflammation,
▪️ radiographic findings,
▪️ and the patient's biological response.
This pause allows the periodontal ligament to reorganize and bone remodeling to progress without additional mechanical stress.

2. Use Passive Orthodontic Wires
Rather than removing the orthodontic appliance completely, clinicians often place a passive stainless steel archwire that stabilizes the tooth while minimizing active force delivery.
Common examples include:
▪️ 0.016-inch stainless steel round wire
▪️ 0.018-inch stainless steel round wire
▪️ 0.016 × 0.022-inch stainless steel rectangular wire (when greater stability is required)
The wire should remain passive, without activating bends or closing mechanics.

3. Maintain Bracket Engagement
Keeping the bracket engaged with passive elastic ligatures or stainless steel ligatures may help maintain tooth position while avoiding additional orthodontic force.
The goal is stabilization rather than movement.

4. Eliminate Contributing Factors
Before restarting treatment, the orthodontist should address any factors contributing to excessive mobility, such as:

▪️ Plaque accumulation
▪️ Gingival inflammation
▪️ Traumatic occlusal contacts
▪️ Excessive orthodontic force
▪️ Poor patient compliance with appliance instructions
Professional periodontal therapy may be indicated if inflammation is present.

5. Reassess Before Reactivating Treatment
Treatment should only resume after clinical signs indicate that the supporting tissues have recovered.

Positive findings include:
▪️ Reduced tooth mobility compared with the previous appointment.
▪️ Healthy pink gingiva without bleeding on probing.
▪️ No spontaneous pain or tenderness to percussion.
▪️ Improved patient comfort during chewing.
▪️ No progressive radiographic signs of bone loss or root resorption.
Once stability improves, orthodontic movement is typically restarted using light continuous forces, avoiding heavy activation.

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💬 Discussion
Scientific evidence shows that temporary tooth mobility is an expected part of orthodontic tooth movement, reflecting normal bone remodeling rather than damage. The key objective is not to eliminate mobility, but to ensure that it remains within physiological limits while the periodontal ligament and alveolar bone adapt to the applied forces.
Excessive mobility, however, deserves careful clinical evaluation. It may result from excessive orthodontic forces, periodontal inflammation, inadequate bone support, or external root resorption. Fortunately, when these factors are identified early and managed appropriately, treatment can often continue successfully without compromising long-term tooth stability.
Successful orthodontic treatment therefore depends on the combination of appropriate biomechanics, healthy periodontal tissues, and active patient cooperation.

🎯 Recommendations
▪️ Maintain excellent oral hygiene throughout treatment.
▪️ Attend every scheduled orthodontic appointment.
▪️ Wear aligners, elastics, and retainers exactly as instructed.
▪️ Avoid hard foods and habits that overload moving teeth.
▪️ Do not intentionally test or wiggle mobile teeth.
▪️ Report any sudden increase in tooth mobility, pain, swelling, or bleeding immediately.
▪️ Keep regular periodontal evaluations, especially if you have a history of gum disease.

✍️ Conclusion
Tooth stability during orthodontic treatment depends on maintaining a healthy balance between controlled tooth movement and periodontal health. Mild tooth mobility is a normal and temporary response to orthodontic forces, but excessive mobility should always be assessed to identify possible underlying causes.
With gentle orthodontic mechanics, excellent oral hygiene, healthy gums, and regular professional monitoring, most patients complete treatment safely while preserving long-term tooth stability. Early recognition of abnormal mobility allows timely intervention and helps protect both the teeth and their supporting tissues.

📚 References

✔ Krishnan, V., & Davidovitch, Z. (2006). Cellular, molecular, and tissue-level reactions to orthodontic force. American Journal of Orthodontics and Dentofacial Orthopedics, 129(4), 469.e1–469.e32. https://doi.org/10.1016/j.ajodo.2005.10.007
✔ Nanci, A. (2021). Ten Cate's Oral Histology: Development, Structure, and Function (10th ed.). Elsevier.
✔ Proffit, W. R., Fields, H. W., Larson, B., & Sarver, D. M. (2023). Contemporary Orthodontics (7th ed.). Elsevier.
✔ Ren, Y., Maltha, J. C., & Kuijpers-Jagtman, A. M. (2003). Optimum force magnitude for orthodontic tooth movement: A systematic literature review. The Angle Orthodontist, 73(1), 86–92.
✔ Roberts, W. E., Viecilli, R. F., Chang, C., Katona, T. R., & Paydar, N. H. (2015). Biology of tooth movement. In R. Nanda & T. F. Ackerman (Eds.), Orthodontics: Current Principles and Techniques (6th ed.). Elsevier.
✔ Zachrisson, B. U. (2007). Orthodontics and periodontics. In J. Lindhe, N. P. Lang, & T. Karring (Eds.), Clinical Periodontology and Implant Dentistry (5th ed.). Blackwell Munksgaard.

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