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 Seminars in Orthodontics
VOL 25, NO 2 JUNE 2019

Orthodontic treatment in the age of

periodontal risk management

Introduction grafting, regeneration and implant therapy

I
can be implemented in orthodontic cases.
n 1996, Kokich accurately predicted ortho-
Delivering care to such broad range of age
dontists worldwide would experience signif-
groups and demanding populations allows the spe-
icant change in their practices: number of
cialized orthodontic practices an opportunity to
adult patients would increase and present a dif-
differentiate from other treatment avenues which
ferent set of challenges. He warned that adults
may provide limited or compromised orthodontic
have worn or abraded teeth, uneven gingival
services. Treating sophisticated cases allows the
margins, missing papillae, and periodontal
trained and credentialed orthodontist to showcase
bone loss, all of which can jeopardize the
innovative diagnosis and treatment planning.
esthetic appearance of the teeth after bracket
removal.1 Today, demand for improved quality
of life which comes from optimal oral health is
increasing. In the United States more and Goals for this issue
more people are exposed to the importance of
oral function, comfort and especially esthetics. The goal of this issue is to present compelling
The emerging global middle class is likewise review of literature, cases studies and original
exposed to media images featuring vibrant life- evidence to arm the orthodontist with patient
styles which accompany optimal cosmetic and assessment, management, and treatment
functional dental outcomes. From a business options which translate seamlessly to chairside
standpoint, these trends suggest orthodontists application to optimize treatment outcomes. A
are about to see the broadest set of challenging secondary goal is to highlight multidisciplinary
cases ever. teamwork between orthodontists and perio-
Under this backdrop, the American Acad- dontists allows orthodontists to implement pro-
emy of Periodontology (AAP) and the Euro- tocols known to periodontists through their
pean Federation of Periodontology(EFP) experience with grafting, regeneration and
recently convened to review periodontal clas- implant therapy.
sifications set forth in 1999 in light of major
advancements since then. The new, innovative Dr. Leena Palomo
model for understanding the periodo- Case Western Reserve University, 10900 Euclid Ave,
ntium mirrors medical model of personalized Cleveland, OH 44106, USA
health care in that it is based on individual E-mail: [email protected]
risk for periodontal pathology.2 Additionally,
it addresses the application of stakeho-
lders, like orthodontists, to integrate into
their protocols. Periodontics provides diag- References
nostics, risk assessment, and strategies to man- 1. Kokich VG. Esthetics: the orthodontic-periodontic restor-
age sophisticated cases. Strategies born from ative connection. Semin Orthod. 1996;2(1):21–30. Review.
2. Caton J, Armitage G, Berglundh T, et al. MA new classifica-
tion scheme for periodontal and peri-implant diseases and
conditions - introduction and key changes from the 1999
© 2019 Published by Elsevier Inc.
classification. J Clin Periodontol. 2018;45(Suppl 20):S1–S8.
https://doi.org/10.1053/j.sodo.2019.05.001

Seminars in Orthodontics, Vol 25, No 2, 2019: pp 109 109

Combining planned 3rd molar
extractions with corticotomy and
miniplate placement to reduce
morbidity and expedite treatment.
A case report with 3.5-year follow up
Dauro Douglas Oliveira, Ant^o nio de Albuquerque Brito,
Mariele Cristina Garcia Pantuzo, Laíze Rosa Pires Freitas, Leena Palomo, and
Rodrigo Villamarim Soares

Alveolar corticotomy (ACO) is increasingly popular to accelerate orthodontic

tooth movement. However, because it is an invasive surgical procedure,
there is still some resistance to its use. Combining ACO with other surgical
procedures is a means to employ the method without adding an additional
surgical intervention. Combining surgical interventions into one surgery
reduces trauma and down time for the patient and also allows clinicians to
maximize treatment outcomes. This article illustrates how the anticipation
of the 3rd molars extraction created a window of opportunity for the use of
ACO and miniplates, to successfully and efficiently retreat a moderate skele-
tal Class II on a young adult patient who did not accept orthognathic surgery
with orthodontics as a retreatment alternative. (Semin Orthod 2019; 25:110–
116) © 2019 Published by Elsevier Inc.

Introduction orthodontics. Skeletal anchorage has important

T
advantages over the traditional anchorage meth-
he search for an ideal orthodontic anchor-
ods. It reduces the challenge of patient compli-
age method lead to the development of
ance in wearing removable appliances,5,6,7 it
temporary skeletal anchorage devices
increases the number of sites available for force
(TADs).1,2,3,4 The use of miniscrews and/or min-
application,8 improves efficiency of orthodontic
iplates represented a major advancement in
mechanics,9,10 and creates the possibility of treat-
ing some moderate skeletal malocclusions in
Pontifical Catholic of Minas Gerais, Av. Dom Jose Gaspar, 500 - cases where orthognathic surgery is contraindi-
Pre dio 46, Sala 106 - 30.535-610, Belo Horizonte, MG, Brazil; Pri- cated or unacceptable.11,12
vate Practice, Belo Horizonte, Brazil; Department of Orthodontics, TADs have been used adjunctively with alveo-
Pontifical Catholic University of Minas Gerais, Belo Horizonte, Bra-
zil; School of Dental Medicine, Case Western Reserve University,
lar corticotomies (ACO) to enhance orthodontic
United States; School of Dentistry, Pontifical Catholic University of tooth movement13,14 reducing the overall treat-
Minas Gerais, Belo Horizonte, Brazil. ment time15,16 and facilitating the correction of
Conflict of interest: The authors whose names are listed immedi- complex malocclusions.17,18 However, despite
ately below certify that they have NO affiliations with or involvement the favorable results described in the litera-
in any organization or entity with any financial interest (such as hon-
oraria; educational grants; participation in speakers’ bureaus; mem-
ture,13,18 there is still some resistance to the use
bership, employment, consultancies, stock ownership, or other equity of ACO owing to surgery invasiveness and the
interest; and expert testimony or patent-licensing arrangements), or costs of an additional procedure.19,20,21 Combin-
non-financial interest (such as personal or professional relationships, ing ACO with other planned surgical procedures
affiliations, knowledge or beliefs) in the subject matter or materials dis- allows for its use in cases where it would other-
cussed in this manuscript.
Corresponding author. E-mail: [email protected]
wise be ruled out.
© 2019 Published by Elsevier Inc.
Third molars extraction is one of these oppor-
1073-8746/12/1801-$30.00/0 tunities, since after the completion of the ortho-
https://doi.org/10.1053/j.sodo.2019.05.003 dontic treatment, approximately 75% of the

110 Seminars in Orthodontics, Vol 25, No 2, 2019: pp 110 116

 Combining planned 3rd molar extractions with corticotomy and miniplate placement 111

patients are referred to an oral surgeon to have

their 3rd molars removed.22 Thus, the aim of this
article is to illustrate how planned surgical proce-
dures create a window of opportunity for the
rational use of ACO through a case which com-
bines 3rd molar extractions with miniplate place-
ment and ACO.

Case report
A 17-year-old male sought orthodontic retreat-
ment with the following chief complaint: “I
would like to know what are my options to cor-
rect my bite because it is still very bad.” He also Figure 2. Initial study models.
reported that during his previous treatment he
did not comply with wearing high-pull headgear pathologies, presence of all permanent teeth and
(HG). Beyond that, the patient’s medical and lack of space for appropriate eruption of the 3rd
dental history were within normal limits. We con- molars (M), which presented complete crown
cluded that HG compliance was the primary formation and initial stages of root development
obstacle to achieving optimal results. A strategy (Fig 3B).
other than HG would be needed to address the Two treatment options were presented to the
chief complaint. patient and his parents. The 1st option contem-
Extraoral evaluation revealed adequate facial plated the ideal treatment objectives and consisted
symmetry and passive lip sealing. However, the
lower facial third was moderately augmented,
the profile was convex and both lips were pro-
truded (Fig 1). Study cast evaluation showed that
both molars and canines presented in a Class II
relationship, with an increased overjet and a
reduced overbite. The transverse dimension of
both arches was adequate and there was mild
mandibular crowding (2 mm) (Fig 2).
Cephalometric analysis confirmed the presence
of a moderate skeletal Class II (ANB= 7°,
Witts = +6 mm) and an open bite (SN-GoGn = 43°).
Furthermore, protrusion and proclination of the
maxillary (U1-AP = +12 mm and U1-NS = 110°) and
mandibular (L1-AP = +6 mm and IMPA = 98°) inci-
sors were observed (Fig 3A). The pretreatment pan-
oramic radiograph revealed the absence of

Figure 1. Pretreatment extraoral photographs. Figure 3. Pretreatment radiographs.

112 Oliveira et al

on the use of maxillary and mandibular fixed appli- sides, extending from the mesial of the 1st pre-
ances, extraction of all 1st premolars (PM) to cor- molars to the distal of the 2nd molars (Fig 4).
rect both proclination and protrusion of the Additionally, I-shaped anchor miniplates were
incisors. These extractions would also allow to bilaterally implanted at the infrazygomatic crest
increase the overjet to create room for a subse- area to support the intrusion of the maxillary
quent mandibular advancement with orthognathic molars and premolars, as well as the distal move-
surgery that would also impact the maxilla and cor- ment of the entire maxillary dentition (Fig 4).
rect the increased skeletal vertical dimension. After One week after surgery, intrusion was initiated
thoroughly understanding the classical options, he with elastic chains ligating the maxillary 1st molar
patient and his parents rejected the surgical-ortho- tubes to the miniplates' hooks. Orthodontic check-
dontics treatment plan due to the risks and mor- ups took place every 2 weeks for intrusive force re-
bidity associated with orthognathic surgery. At the activation and after 3 months of intrusive mechan-
same time, they steadfastly demanded to correct ics, the anterior open bite was closed (Fig 5) due to
the residual malocclusion and insisted on innova- the counterclockwise rotation of the mandible.
tive options beyond those which were made avail- Subsequently, mandibular fixed appliances were
able during his first treatment. placed and the lower crowding was corrected with
In view of their request, the patient’s records interproximal enamel reduction performed on the
were re-evaluated and another treatment alterna- 6 anterior teeth. Final detailing was achieved with
tive, addressing the occlusal problems and the 0.016 £ 0.022-in SS wires and debonding was
other dental needs was suggested. Since the over- accomplished after a total treatment time of
all dental treatment plan anticipated 3rd molar 14 months.
extractions, titanium miniplate could be placed A lower fixed 3 £ 3 retainer was placed and a
at the zygomatic arch and regional ACO from wrap-around Hawley was inserted in the maxilla.
the 3rd molar to the 1st premolar area could be Full-time wear of the maxillary retainer during
performed during the same surgical procedure. the first 6 months post-treatment and night-time
Subsequent intrusion of the maxillary molars wear thereafter was requested. The post-treatment
and premolars, enhanced by the use of TAD’s records showed that a Class I relationship was
and the ACO effects, would enable counterclock- obtained for both molars and canines. Further-
wise rotation of the mandible and consequent more, accebtable overbite and overjet, as well as a
closure of the anterior open bite. After weighting canine-protected occlusion was achieved (Fig 6).
the advantages and disadvantages of both treat- Cephalometric superimpositions confirmed the
ment options, the patient and his parents chose intrusion of the maxillary molars and the
this treatment alternative and signed an
informed consent authorizing his treatment.
Initially, maxillary partial fixed appliances
(Mini Master SeriesTM , American Orthodontics,
Sheboygan, WI) were placed bilaterally from 1st
permolars to 2nd molars. Segmented leveling and
alignment was performed working up to a
0.019 £ 0.025-in stainless steel (SS) wire on both
sides. After 5 months of posterior segmented level-
ing, transpalatal arches with lingual crown torque
were placed on both 1st and 2nd molars to control
the buccal crown inclination tendency during
intrusion and the patient was referred to surgeon
to have the surgical procedures performed.
For the 3rd molar extractions, intravenous
sedation 5 mg of DormonidÒ (Roche, Basel, BS)
with 1 ml of FentanilÒ (Janssen, Beerse, BE)
diluted to 5 ml was implemented, and supra-api- Figure 4. Surgical photographs: (A) third molar
cal ACO was performed only on the buccal sur- extraction sites; (B) horizontal corticotomies; (C) I-
face of the alveolar bone on both right and left shaped miniplates inserted.
 Combining planned 3rd molar extractions with corticotomy and miniplate placement 113

Figure 5. Progress photos: (A, B) immediately post-

surgery; (C, D) three month post-surgery showing sig-
nificant posterior intrusion and anterior open bite clo-
sure. Figure 7. Post treatment cephalometric evaluation.
(A) Final ceph; (B) overall superimposition; (C) max-
illary superimposition.

Figure 8. Final panoramic radiograph.

to the consolidation of the skeletal Class II26 and

to the need for orthodontic retreatment. Poor
Figure 6. Final photographs.
patient compliance not only negatively influen-
ces treatment duration,27 but may also signifi-
consequent counterclockwise rotation of the man-
cantly compromise the final results of the
dible (Fig 7). The post-treatment panoramic
orthodontic therapy. Therefore, it is reasonable
radiographic evaluation revealed satisfactory root
to assume that a significant number of cases may
parallelism, adequate alveolar bone height and
need retreatment especially when moderate to
no signs of root resorption (Fig 8). Finally, the
complex malocclusions resulted from inappro-
3.5-year follow-up photographs showed that the
results remained stable (Fig 9).

Discussion
Interceptive orthodontic treatment of skeletal
Class II malocclusions with increased vertical
dimension has been traditionally performed with
HG.23,24 However, the lack of patients’ coopera-
tion when HG are recommended has consis-
tently been a concern to most orthodontists.5,25 Figure 9. Intraoral photographs 3.5 years post ortho-
This inadequate HG compliance frequently leads dontic treatment.
114 Oliveira et al

priate patient cooperation during phase I inter- tooth movement.2,6,8,10 Since our patient’s chief
ceptive orthodontics.11 complaint did not involve his facial esthetics, we
Approximately 34% of the orthodontically proposed the anticipation of the 3rd molar extrac-
treated patients may still present some indication tion and to use this surgical procedure to install
for retreatment.28 In this regard, inadequate cor- bilateral zygomatic miniplates and perform
rection of the initial malocclusion due to poor regional alveolar corticotomies to expedite treat-
patient compliance with the correct use of the ment and increase our chances of success. Both
recommended appliances, such as in the case the patient and his parents accepted this alterna-
presented here, has been described in the litera- tive very well because the removal of all 3rd
ture.11,12 Patients who seek orthodontic retreat- molars would be recommended anyway. They
ment usually present high demands for clinical mentioned that it was a rational opportunity to try
approaches that would achieve excellent results to avoid the orthognathic surgery.
in the shortest possible time with the least surgi- The alternative treatment plan contemplated
cal trauma. These demands may be related to intrusion of maxillary posterior teeth supported
the growing number of adults seeking orthodon- on TAD’s to allow mandibular counterclockwise
tic treatment29 because certainly, some of them rotation and closure of the anterior open bite.
have already had a previous treatment when they The efficacy of this treatment alternative was
were teenagers, as the case of the young adult recently confirmed with a systematic review.34
patient reported in this paper. Adult patients The previous lack of compliance, and the well-
require efficient orthodontic therapy due to the established and favorable results derived from
perceived negative impact that longer treatment skeletal anchorage described in the litera-
has in their quality of life.30,31 They may also ture1,3,5,6 further supported this option. The use
reject the possibility of extractions and orthog- of miniplates in Orthodontics was introduced by
nathic surgery11,12 because surgical procedures Sugawara & Nishimura3 and consists of a skeletal
produce the highest anxiety in dental patients.32 anchorage modality that is temporarily fixed in
Therefore, it was not surprising that our patient the maxilla or mandible.35 Miniplates provide
and his parents denied the idealistic treatment absolute anchorage35,36 and are indicated when
option which required removal of 4 premolars the application of greater orthodontic forces is
and orthognathic surgical procedures. required, or when a larger number of teeth must
In order to deal with this setting (retreatment; be moved without depending on patient’s coop-
low levels of patient compliance during the 1st eration.3,5 However, they also present disadvan-
treatment; demands for short treatment duration tages, such as the need for two surgical
and minimized surgical trauma), orthodontists procedures and additional costs.3,4 In the case
should be able to elaborate alternative orthodon- discussed here, both disadvantages were mini-
tic treatment plans with realistic goals.33 That is mized, since the miniplates’ costs are signifi-
exactly what happened with our patient and his cantly lower than those the family would have to
family. The parents alleged that they would not afford if orthognathic surgery was performed.
like their son to have teeth extracted. Even more Furthermore, the insertion of the miniplates dur-
importantly, they did not want their son exposed ing the anticipated 3rd molars’ extractions
to the risks involved in orthognathic surgery and reduced the number of surgical procedures. The
they could not bear the additional surgical costs. reduction of surgical procedures is accompanied
When a patient or his parents ask: “Isn’t there any- with a reduced need for anxiety control, anesthe-
thing else that can be done to avoid surgery?” sia, and post-operative pain control medication.
That opens the window of opportunity for the In the age of opioid abuse, the reduction of phar-
orthodontist to present an alternative treatment macologic agents is an added benefit.
plan. Although it is a consensus that orthognathic ACO have been used with the purpose of
surgery is indispensable to correct severe skeletal increasing bone turnover,37 promoting a tempo-
problems, when treatment planning moderate rary reduction in bone density,15,17,18 reducing
skeletal problems, such as in the present case, ade- orthodontic treatment time16,21,38 or facilitating
quate results may be obtained with less complex the correction of moderate to complex malocclu-
treatment options, such as TAD placement1,6 asso- sions18,39,40 However, ACO also run into the limita-
ciated with methods to accelerate orthodontic tion of being an invasive procedure.6-8,10 In the
 Combining planned 3rd molar extractions with corticotomy and miniplate placement 115

present case, the 3rd molar extraction and mini- relationships obtained in the treatment, and
plates insertion were performed under intravenous excellent periodontal condition were observed
sedation. Therefore, the ACO procedure was also after 3.5 years of follow-up. Therefore, this article
conducted in order to facilitate the orthodontic espouses the rational implementation of ACO
dental movement and to reduce the overall time associated with mini-plates during 3rd molars
period, as requested. A previous study reported extraction as a noteworthy option in the treat-
that the ACO acceleration may be achieved by buc- ment of similar moderate skeletal problems.
cal corticotomy only,6 and the adoption of this con-
servative technique also reduced the surgical time Conclusion
and post-operative discomfort that would occur if
palatal exposure and cortical bone perforations Orthodontists should be alert to windows of
were also conducted in this area.41 opportunity to add alveolar corticotomies and
Mimura2 recommended that the mini-implant miniplates as adjunct procedures to increase
should be inserted at least four weeks before the retreatment efficiency. The anticipation of 3rd
corticotomy, however, in the case reported here, molar extractions may be a good opportunities
advantage was taken of the surgical time of to combine other surgical procedures.
extraction to perform the two procedures, in
order to avoid a new surgical intervention. References
Although surgical procedures generate the high-
1. Creekmore TD, Eklund MK. The possibility of skeletal
est levels of anxiety in dental patients, extraction anchorage. J Clin Orthod. 1983;17:266–269.
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orthodontic patients.43 Although in most cases, Orthod. 1997;31:763–767.
3rd molars are not directly involved in orthodon- 3. Umemori M, Sugawara J, Mitani H, Nagasaka H, Kawa-
mura H. Skeletal anchorage system for open-bite correc-
tic treatment planning, a high percentage of
tion. Am J Orthod Dentofacial Orthop. 1999;115(2):166–174.
orthodontic patients are referred for 3rd molar 4. Ohmae M, Saito S, Morohashi T, et al. A clinical and his-
extraction post-treatment.44 The concept of tological evaluation of titanium mini-implants as anchors
needing 3rd molars extracted appears to have for orthodontic intrusion in the beagle dog. Am J Orthod
become an accepted concept among lay peo- Dentofacial Orthop. 2001;119(5):489–497.
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tic treatment plan chosen offer an excellent win- 7. Mohammed H, Wafaie K, Rizk MZ, Almuzian M, Sosly R,
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tions are probably the most common surgical pro- 2018;19(1):1–18.
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17. Oliveira DD, Oliveira BF, Soares RV. Alveolar corticoto- 2014;19(3):20–23.
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the case against corticotomy-induced orthodontics. Am J lar augmentation. J Oral Maxillofac Surg. 2009;67(10):2149–
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parents’, and orthodontists’ perceptions of the need for Souza MM, Medeiros PJ. Selective alveolar corticotomy to
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time. Am J Orthod Dentofacial Orthop. 2014;145(4 Suppl): Orthop. 2008;133(6):902–908.
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1981;80(6):604–622. Rojo-Moreno J, Pe~ narrocha-Diago M. Anxiety before
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(4):336–348. dontics. World J Clin Cases. 2015;16(2):132–140.
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Canine impaction A review of the
prevalence, etiology, diagnosis and
treatment
Yusuke Hamada, Celine Joyce Cornelius Timothius, Daniel Shin, and
Vanchit John

The signs and symptoms of canine impaction can vary, with patients only
noticing symptoms when they are suffering from unsightly esthetics, faulty
occlusion, or poor cranio-facial development. While various surgical inter-
ventions have been proposed to expose and help erupt impacted canines,
these treatment modalities have a high degree of difficulty compared to
other types of dental cosmetic surgeries. This paper focuses on multi-disci-
plinary strategies for treating and managing canine impaction, reviews
patient and clinical selection criteria, and discusses the evidence underlying
existing interventions to reduce complications and improve patient-centered
outcomes following treatment. (Semin Orthod 2019; 25:117–123) © 2019
Elsevier Inc. All rights reserved.

Introduction canine guidance or group function occlusion. If

A
this condition is not treated properly, the out-
n impacted tooth is defined as a tooth that
come of orthodontic treatment might be less
fails to erupt after the normal development
desirable and the treatment duration might be
pattern is complete. Maxillary canines are the
extended. Additionally, under certain circum-
most common impacted tooth, following the
stances, the presence of an impacted canine may
third molar teeth. Tooth impaction is often
play a role in root resorption of adjacent teeth.
diagnosed during routine dental examination by
Thus, the aims of this paper are to review the
pediatric dentists, orthodontists, or general
prevalence and the etiology of canine impaction,
dentists. The early detection, timely manage-
methods for the radiographic assessment of
ment, and appropriate surgical and orthodontic
canine impaction, and treatment intervention
intervention can lead to esthetically and func-
based on the labio-lingual position of impacted
tionally acceptable outcomes. An interdisciplin-
canines. A patient case accompanies this article
ary patient care approach with specialists from
to highlight several key steps in treating and
different disciplines- orthodontists, pediatric
managing impacted canines.
dentists, periodontists, oral surgeons and general
dentists- cooperating and collaborating together
is necessary to manage this condition success- Prevalence and etiology of canine
fully. Proper positioning and alignment of can- impaction
ines plays an extremely important role in
establishing an acceptable facial contour, The maxillary canine is the second most com-
esthetic smile line, and occlusion especially for monly impacted tooth following the maxillary
third molar. Yet, the prevalence of the impacted
maxillary canine is actually quite low, with the
Department of Periodontology, Indiana University School of Den- prevalence ranging from 0.92% to 2.2% of the
tistry, 1121 W. Michigan St, Indianapolis, IN 46202, USA. population, and a predilection to affect females
Authors declare that there is no conflict of interest any products
more often than males, at a ratio of 2:1.1,2 Fur-
and devices discussed in this article.
Corresponding author. E-mail: [email protected] thermore, the unerupted impacted maxillary
© 2019 Elsevier Inc. All rights reserved.
canine tends to be positioned more palatally
1073-8746/12/1801-$30.00/0 than labially, at a ratio of 2:1 or 3:1.3 In compari-
https://doi.org/10.1053/j.sodo.2019.05.002 son, the prevalence of the mandibular canine

Seminars in Orthodontics, Vol 25, No 2, 2019: pp 117 123 117

118 Hamada et al

impaction is lower (0.35%) than that of the of canine impaction include the retention of pri-
impacted maxillary canine.2 mary canines and an absence of buccal and pala-
While the exact etiology of the unerupted tal bulges when compared to the contralateral
impacted maxillary canine remains somewhat elu- side of the affected area after a patient reaches
sive, there is strong evidence to suggest that multi- 12 15 years of age.1 Careful palpation of the
ple broad and complex mechanisms- namely, alveolar housing would be useful for clinicians to
genetic, systemic (like endocrine disorders, febrile identify the presence or absence of bulges. Other
conditions, and/or irradiation), and local factors- possible clinical signs include tipping or irregular
are involved. Several local factors- such as 1) tooth positioning of adjacent teeth.
size arch length discrepancies; 2) failure of the Although palpation of the alveolar ridge is
primary canine root to resorb; 3) prolonged one way of the most common clinical methods to
retention or early loss of the primary canine; 4) identify the location of the impacted canines,
ankylosis of the permanent canine; 5) cyst or neo- sometimes impacted canines are not clinically
plasm; 6) dilaceration of the root; 7) absence of palpable. Ericson showed that approximately
the maxillary lateral incisor; 8) variation in root 3 5% of impacted teeth are not clinically palpa-
size of the lateral incisor (peg-shaped lateral inci- ble based only on the clinical examinations.6,7
sor); and 9) variation in timing of lateral incisor Consequently, due to the limitations of clinical
root formation, are believed to play critical roles examinations, many radiographic assessment
in canine impaction. methods,such as panoramic, periapical, occlusal,
Of all the local factors listed above, arch length and lateral cephalometric radiographs have
deficiency is believed to be the most common been utilized to evaluate the presence and posi-
cause of labially impacted canines. Jacoby tion of impacted canines. If the tooth is not pal-
observed that while approximately 85% of palatally pable, 2 or more periapical radiographs taken at
impacted canines had sufficient space for erup- different angles can confirm the position of the
tion, only 17% of labially impacted canines had impacted tooth by utilizing the principle of the
sufficient space to erupt in the arch.4 Therefore, it SLOB or Clark’s rule. The SLOB rule means
was proposed that the primary etiology of the labi- “Same Lingual, Opposite Buccal”. If the beam
ally impacted canines is insufficient arch length angle moves mesially, then the image of the
which limits the amount of space available for the impacted canine moves mesially too. This means
unerupted canine to erupt normally. On the other the impacted tooth might be located on the lin-
hand, for palatally impacted canines, the absence gual or palatal side. On the other hand, if the
of the maxillary lateral incisor is believed to be the beam angle moves distally and the image of the
most common cause for eruption failure. In order impacted canine moves mesially, the tooth is
for a canine to erupt normally into the arch, the likely located on the buccal side. This principle
prevailing theory is that the root of the adjacent has been useful to locate the position of the
lateral incisor serves as a “guide” for the canine to tooth. Approximately 90% of the time, clinicians
erupt along it. However, when the adjacent lateral can identify the position of an impacted tooth on
incisor is either missing or malformed, there is no the labial or palatal sides.6 However, there are
“guide” for the canine to travel along; as a result, many limitations including measuring the exact
the canine will fail to erupt. This is known as the distance from the impacted tooth to the adjacent
“guidance theory.” To further substantiate this teeth and identifying the presence or absence of
important relationship between the erupting root resorption on adjacent teeth. Orthodontists
canine and the maxillary lateral incisor, Becker and surgeons need to be aware of the precise
reported an increase of 2.4 times in the incidence position of the tooth in order to generate appro-
of palatally impacted canines adjacent to missing priate treatment plans. Three dimensional analy-
lateral incisors compared to palatally impacted sis with cone beam computed tomography
canines in the general population.5 (CBCT) has significantly improved our ability to
localize the position of the tooth accurately.
After obtaining a CBCT scan, a panoramic radio-
Clinical and radiographic assessments
graph can also be recorded. The customized
Clinical examination usually involves a compre- arch is made on the panoramic view, and the cus-
hensive periodontal examination. Clinical signs tomized slice view can be used for accurate
 Canine impaction 119

Figure 1. Customized panoramic view from CBCT image.

detection of tooth position. (Figs. 1 and 2) In prevalence of root resorption associated with
addition to those sliced views, a 3D reconstructed canine impaction was 12% of lateral incisors with
view can be useful in identifying the exact loca- conventional 2D images.7 On the other hand,
tion of an impacted canine (Fig. 3). when using CBCT imaging, these same authors
Haney assessed inherent discrepancies when found that 38% of lateral incisors and 9% of cen-
comparing 2D images to 3D images in the diagno- tral incisors have some degree of root resorption
sis and treatment planning of impacted canines. with impacted canines. This study revealed that
The results showed that all clinicians have a much the detection of root resorption increased almost
higher degree of confidence of the precise posi- 50% with CT scanning.9 The presence of root
tion of the impacted teeth with CBCT images. resorption might affect the overall treatment plan
Due to differences in assessing the accurate posi- whether extraction or retention of those affected
tion and the relationship of the cusp tip location teeth are indicated. If extraction is indicated due
to adjacent tissue, 2D and 3D images generate dif- to the severity of root resorption, the orthodontic
ferent images on the same patients.8 CBCT also and restorative treatment plans need to be modi-
provides an additional benefit in identifying the fied accordingly.10 Therefore the use CBCT can
prevalence of root resorption on the central and definitely contribute to accurate and timely diag-
lateral incisors. Ericson revealed that the nosis and lead to proper treatment intervention.

Figure 2. Customized sliced view can show the position of tooth and the presence of bony housing.
120 Hamada et al

tooth is positioned beyond the mesial root sur-

face of the lateral incisor.13
In the presence of labially impacted maxillary
canines, Kokich recommends the usage of three
technique for surgical eruption: gingivectomy, api-
cally positioned flap and closed eruption techniques.13
Facially impacted canines can be uncovered by
an open or a closed approach based on the ade-
quacy of keratinized gingiva and the position of
the impacted tooth within the alveolar housing.
Coronally positioned labially impacted canines
with adequate amount of keratinized tissue can
be uncovered by any of the three techniques.
Figure 3. Three dimensional reconstructed view. This When these ectopic canines are not covered by
image can clearly shows the position of the maxillary
right canine and the prominence of the tooth.
bone, gingivectomy is the most preferred
approach as it leads to spontaneous eruption
without any orthodontic traction and is less trau-
matic to the patient. However, this is a rarely
Treatment interventions (classification of
used technique due to the possible loss of kerati-
canine positions)
nized gingiva and damage to the surrounding
Canine impactions are broadly classified based healthy periodontium.13, 14
on their labio-palatal positions in relation to the Apically positioned flaps are indicated when
alveolar ridge, the axial inclination and the the impacted canine is apical to the muco-gingi-
depth of the impacted tooth.11,12 Several classifi- val junction and is labially superimposed on the
cation systems have been formulated describing adjacent root of the lateral incisor. A partial
the location of the impacted canines, thus guid- thickness flap is reflected with mesial and distal
ing the clinician in choosing the most predict- vertical releasing incisions and apically posi-
able treatment option. The position of the tioned. This surgical technique conserves the
impacted tooth is usually classified per their rela- amounts of keratinized gingiva available, since
tion to the neighboring teeth and anatomical these situations are usually accompanied by a
structures. Similarly, mandibular impacted can- reduced width of keratinized gingiva. Frequent
ines were classified based on their labial and occurrence of post-operative gingival recession
unusual anatomical positions. The presence of and orthodontic relapse are commonly associ-
the ectopic maxillary canine based on the loca- ated with this technique.11,13
tion of impaction and relation to the neighbor- When the ectopic maxillary canine is located
ing lateral incisor root was classified by significantly apically to the muco-gingival junction,
Chapokas, as: Class I- palatal location, Class a closed eruption technique is advised. This tech-
II- center of the alveolar ridge or labial to the nique is implemented by the reflection of a full-
alveolar crest, without labial superimposition to thickness flap followed by the debridement of the
the root of the adjacent lateral incisor and Class surrounding follicle. A fixed attachment is imme-
III- labial to the long axis of the adjacent lateral diately bonded to the exposed tooth surface and a
incisor root.11 This classification was specifically wire or chain is attached. The flap is repositioned
formulated to guide the clinician in deciding the with the wire or chain emerging through the ini-
most optimal surgical interventional technique tial crestal incision and tied to orthodontic wire
for their eruption. passively. This would allow the orthodontist to
Spontaneous correction of an impacted apply traction to erupt the impacted canine to the
canine is highly predictable if the deciduous desired position.2,13 Closed eruption techniques
tooth is removed when the crown of the perma- are usually accompanied by a higher frequency of
nent ectopic canine was positioned over the root post-operative complications and incomplete
of the maxillary lateral incisor, not past the eruption necessitating a second surgery.14
mesial surface of the tooth. Surgical uncovering Palatally impacted canines can also be surgi-
of the impacted canine is necessary when the cally erupted using a closed or open approach,
 Canine impaction 121

facilitating spontaneous eruption. A fixed attach-

ment appliance is recommended to be con-
nected immediately after exposure, should the
spontaneous eruption fail to occur.15 Open
exposure techniques for palatally impacted can-
ines can be made with an open window eruption
or a tunnel traction. When the canine is horizon-
tally positioned near the lateral and central inci-
sors, an open window eruption technique allows
visualization of the crown and guiding the
Figure 4. Mandibular left impacted canine is noted.
impacted tooth to the desired location. However,
when the horizontally inclined impacted canines
are positioned higher up in the maxillary arch, a
closed flap technique is recommended followed
by immediate orthodontic traction. Some of the
most common complications associated with
these procedures are gingival overgrowth at the
surgical site and high infection rate.13,14
Tunnel traction is recommended when the
primary canine is present at the time of the surgi-
cal intervention. After the reflection of a full
thickness flap, a tunnel is created by extracting
the deciduous canine and removing adequate
bone at the seat of the deciduous canine root
Figure 5. Slight bulge on the coronal of #22 area was allowing the eruption of the ectopic canine via
noted upon palpation. traction.16
Since mandibular impacted teeth are usually
depending on the location of the ectopicity. located at a labial or intra-alveolar position, a
Most palatal canine impactions can be surgically closed flap approach to orthodontically erupt
approached via a gingivectomy procedure, the tooth to an ideal position is recommended.

Figure 6. CBCT images showed that the impacted tooth is buccal positioned, and there is no labial plate covering
tooth #22.
122 Hamada et al

However, in cases of severe impaction or transmi-

gration, mandibular impacted teeth are more
challenging to treat orthodontically. In these sit-
uations, it would be prudent to extract the
canine instead of performing any surgical inter-
vention to preserve the available bone and avoid
damaging adjacent tooth roots.13
Despite the technical differences in the closed
and open surgical exposure of impacted canines,
several studies have shown minimal statistical dif-
ferences in the surgical outcomes and post-oper-
ative adverse symptoms.17,18
Figure 8. Primary closure was obtained. Gold chain
Case was tied to the archwire to reduce the mobility of the
wound.
A 19-year old patient was referred to the Gradu-
ate Periodontology Clinic at the Indiana Univer-
sity School of Dentistry for surgical exposure and
recovery of the impacted mandibular left canine.
(Fig. 4) Upon palpation, a slight prominence on
the buccal keratinized gingiva in the missing
tooth #22 area was noted. (Fig. 5) A CBCT image
was taken to confirm the buccal positioning of
the impacted canine. Additionally, the CBCT
showed a buccal dehiscence associated with the
impacted tooth. (Fig. 6) Since most of the ana-
tomic crown of #22 was positioned apical to the
mucogingival junction in a vertical dimension, a
closed approach was selected as the interceptive Figure 9. Two weeks post-operative. Wound healing
was uneventful, and patient was referred to orthodon-
treatment. After the muco-periosteal flap was ele- tist to activate the movement of #22.
vated, the coronal aspect of #22 was visualized
and accessed. The dental follicle was removed
from the coronal aspect of the impacted tooth utilized an elevator to check for movement of the
with a curette. To determine whether the tooth. Obtaining proper hemostasis and salivary
impacted tooth was ankylosed, the authors control was essential to securing the gold button
of the orthodontic chain to the anatomic crown
of the tooth. (Fig. 7) Primary closure was then
obtained and the gold chain was tied to the
orthodontic arch wire to reduce premature
mobility of the chain and movement of the over-
lying soft tissue. (Fig. 8) At subsequent surgical
follow ups, no adverse post-surgical events were
noted, and the patient was referred back to the
orthodontist to activate the force on the
impacted canine. (Fig. 9)

Conclusions
Tooth impaction profoundly impacts esthetics
Figure 7. Resin was used to attach the gold button on and function for patients. However, there is
the tooth surface. Control of bleeding and saliva are increasing recognition among dental health care
the key success. providers that treatment intervention poses
 Canine impaction 123

challenges and are intricate and fallible, owing planning of maxillary impacted canines. Am J Orthod Den-
largely to the complex interrelationships between tofacial Orthop. 2010;137:590–597.
normal craniofacial development, functional out- 9. Ericson S, Kurol J. Resorption of incisors after ectopic
eruption of maxillary canines: a CT study. Angle Orthod.
comes, and esthetic results. This review paper is 2000;70:415–423.
timely because the number of articles related to 10. Alqerban A, Jacobs R, Lambrechts P, Loozen G, Willems
the surgical treatment and management of G. Root resorption of the maxillary lateral incisor caused
impacted canines is on the rise. The case study by impacted canine: a literature review. Clin Oral Investig.
2009;13:247–255.
provided in this paper suggests that early diagno-
11. Chapokas AR, Almas K, Schincaglia G-P. The impacted
sis and interception of impacted canines results in maxillary canine: a proposed classification for surgical
a predictable and successful esthetic and func- exposure. Oral Surg Oral Med Oral Pathol Oral Radiol.
tional outcomes when there is proper coordina- 2012;113:222–228.
tion and collaboration between the patient, the 12. Gashi A, Kamberi B, Ademi-Abdyli R, Perjuci F, Sahat-
general dentist, and the dental specialist. ciu-Gashi A. The incidence of impacted maxillary can-
ines in a kosovar population. Int Sch Res Not. 2014;2014:
370531.
13. Kokich VG. Surgical and orthodontic management of
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2. Cooke J, Wang H-L. Canine impactions: incidence and agement of impacted maxillary canines. J Am Dent Assoc.
management. Int J Periodontics Restorative Dent. 2006;26. 2009;140:1485–1493.
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Am J Orthod. 1983;84:125–132. GP. Short and long term periodontal evaluation of
5. Becker A. The Orthodontic Treatment of Impacted Teeth. New impacted canines treated with a closed surgical-
York: Abingdon, Oxon: Informa Healthcare; 2007:1–228. orthodontic approach. J Clin Periodontol. 2007;34:232–
6. Ericson S, Kurol J. Radiographic examination of ectopi- 242.
cally erupting maxillary canines. Am J Orthod Dentofacial 17. Parkin NA, Deery C, Smith AM, Tinsley D, Sandler J, Ben-
Orthop. 1987;91:483–492. son PE. No difference in surgical outcomes between
7. Ericson S, Kurol J. Incisor root resorptions due to ectopic open and closed exposure of palatally displaced maxillary
maxillary canines imaged by computerized tomography: canines. J Oral Maxillofac Surg. 2012;70:2026–2034.
a comparative study in extracted teeth. Angle Orthod. 18. Gharaibeh TM, Al-Nimri KS. Postoperative pain after sur-
2000;70:276–283. gical exposure of palatally impacted canines: closed-erup-
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Do alveolar corticotomy or piezocision
affect TAD stability? A preliminary
study
Carolina Morsani Mordente, Dauro Douglas Oliveira, Leena Palomo,
Nat

a lia Couto Figueiredo, Martinho Campolina Rebello Horta, and
Rodrigo Villamarim Soares

The aim of this study was to evaluate the occurrence of interradicular tempo-
rary anchorage devices (TAD) loss installed to anchor canine retraction per-
formed in association to alveolar corticotomy (AC) versus piezocision (PZ)
surgeries. One hundred maxillary self-drilling TAD were installed in 50
patients who needed first maxillary premolars extractions. One week later,
AC or PZ surgeries were performed surrounding the canine and the extrac-
tion sites. A group without any adjunct surgery to accelerate tooth move-
ment was used as control. TAD stability was evaluated throughout the 6
months of canine retraction. A total of 7, 8 and 9 TAD were lost in the AC, PZ
and control groups, respectively. No significant difference in TAD stability
among the groups was observed (p > 0.05). Despite the increased inflamma-
tory response due to AC or PZ, TAD stability was not compromised. (Semin
Orthod 2019; 25:124–129) © 2019 Elsevier Inc. All rights reserved.

Introduction usage.2,4 Factors such as bone quality and quan-

tity, screw diameter, length, and design have
emporary anchorage devices (TAD) are
T established as a powerful instrument to
improve anchorage during orthodontic treat-
been related to TAD stability.5,6
Orthodontic treatment efficiency may be
influenced by biomechanical and biological fac-
ment.1 Some of the most relevant advantages
tors. Thus, distinct procedures such as surgeries,
include minimal surgical intervention, absolute
laser irradiation and vibration forces have been
anchorage, immediate loading and low costs.2
used adjunctively to TAD to accelerate tooth
However, TAD occasionally need to be removed
movement and reduce the overall treatment
during treatment due to mobility.3 In this regard,
duration.7,8 In this regard, alveolar corticotomy
previous studies have investigated the risk factors
(AC) is a surgical technique that promotes the
associated with TAD failure in order to facilitate
regional accelerated tooth movement phenome-
non (RAP).9,10 RAP involves reducing resistance
Pontifical Catholic University of Minas Gerais, Belo Horizonte,
to tooth movement through alveolar bone decor-
Brazil; School of Dental Medicine, Case Western Reserve University,
United States. tication. Wound healing in decorticated areas
Conflict of interest: The authors whose names are listed immedi- progresses through recruitment of immune reg-
ately above certify that they have NO affiliations with or involvement ulatory and inflammatory cells. This targeted
in any organization or entity with any financial interest (such as hon- healing allows for guided bone remodeling.
oraria; educational grants; participation in speakers’ bureaus; mem-
Decreased resistance through bone facilitates
bership, employment, consultancies, stock ownership, or other equity
interest; and expert testimony or patent-licensing arrangements), or orthodontic tooth movement and results in treat-
non-financial interest (such as personal or professional relationships, ment time reduction.9,11 More recently, piezocision
affiliations, knowledge or beliefs) in the subject matter or materials dis- (PZ), a more controlled, less invasive decortication
cussed in this manuscript. method, was introduced as an alternative to AC.12
Corresponding author. E-mail:
This flapless technique involves a soft tissue incision
[email protected]
with a scalpel and alveolar bone decortication with
© 2019 Elsevier Inc. All rights reserved.
1073-8746/12/1801-$30.00/0 an piezo-scalpel tool. Like AC, PZ injuries are
https://doi.org/10.1053/j.sodo.2019.05.004 claimed to be capable to induce RAP and therefore

124 Seminars in Orthodontics, Vol 25, No 2, 2019: pp 124 129

 Do alveolar corticotomy or piezocision affect TAD stability 125

accelerate the orthodontic treatment, but with less

surgical trauma.10
Since decortication surgeries are used to
accelerate tooth movement they are increasingly
been performed as an adjunct with TAD, and
since decortication can interfere with TAD sur-
vival due to alteration in bone characteristics,
bone metabolism, and healing, the question
arises: is there any impact on TAD stability when
TAD are placed in conjunction with AC versus
PZ? Therefore, this study was conducted to evalu-
ate TAD loss in sites adjacent to AC versus PZ
decortication and no decortication (control).

Figure 1. Self-drilling TAD (1,5 £ 6 mm) placed par-

Material and methods allel to the occlusal plane between the roots of maxil-
lary second premolars and first molars on the muco-
Ethical approval gingival margin.
This study was approved by the Institutional gingival margin (Fig. 1). TAD were placed with-
Review Board of the Pontifical Catholic Univer- out flap elevation. No load was applied on the
sity of Minas Gerais (Protocol # 1.017.013) and insertion day and oral hygiene instructions were
was conducted in accordance with the principles given to the patients in order to maintain plaque
for medical research involving humans estab- control. TAD were observed for 180 days.
lished in the Helsinki Declaration. An informed
consent was obtained from all individuals prior
to their participation and subjects’ rights were Surgical decortication and piezocision
protected at all times. A randomization using the QuickCalcs program
(GraphPad Software, Inc., La Jolla, CA, USA)
determined the maxillary side in which would be
TAD placement
performed AC, PZ or no surgical procedure
A total of 100 interradicular maxillary TAD were (control). One week after TAD placement, all
installed by a trained surgeon in 50 patients (21 decortication surgeries were done by the surgeon
males and 29 females; age 15 38 years) at the under local anesthesia.
Graduate Program in Orthodontics of the Pontif- AC decortication involved a full-thickness muco-
ical Catholic University of Minas Gerais, Brazil. periosteal flap surgery with vertical and horizontal
Orthodontic treatment with fixed appliances was corticotomies using conventional handpiece and
initiated and all treatment plans involved first round bur. Corticotomies surrounding the canine
upper premolar extractions. The exclusion crite- root and on the extraction site (Fig. 2) were per-
ria included pregnant women, individuals with formed through cortical plate. Spherical perfora-
active periodontal disease, or signs of gingival tions limited to the depth of the cortical bone
inflammation and those with systemic diseases were also performed, the flap was then reposi-
and/or use of any medication that might influ- tioned and sutured.
ence on bone metabolism. PZ decortication involved three vertical linear
Bite-wing radiographs (with the film apically soft tissue incisions with a number 15 scalpel blade.
displaced to capture maximum root surfaces) Vertical bone decortication was performed with
were obtained prior to TAD placement in order 3 mm depth and 5 mm height using piezoelectric
to evaluate adequate space between the roots tips (SF3 insert Piezo DentSurg, CVDentusÒ , S~ao
and plan insertion site. All self-drilling TAD Jos
e dos Campos, SP, Brazil). Decortication
(1.5 £ 6 mm, MorelliÒ , Sorocaba, SP, Brazil) occurred mesially and distally to the canine root, as
were placed under local anesthesia, parallel to well as mesially to the second premolar (Fig. 3).
the occlusal plane between the roots of maxillary The incisions were not sutured, as suggested by the
second premolars and first molars on the muco- authors who initially described the PZ procedure.12
126 Mordente et al

Figure 2. Alveolar corticotomy performed with full-

thickness mucoperiosteal flap surgery.

Figure 4. Distalization mechanics of the canines.

the time (in days) of the occurrence of the follow-

ing event: TAD loss. Differences between groups
were analyzed using the Log-Rank test (Mantel-
Cox). Censured data were generated. The signifi-
cance level was set at 5%. Statistical analysis and
plotting were performed using GraphPad Prism
5.0 software (GraphPad Software, San Diego, Cali-
fornia, USA).

Results
Figure 3. Piezocision performed with piezoelectric tips.
Table 1 summarizes the amount of TAD loss in
each experimental and control groups, showing
Orthodontic activation the percentage of TAD loss, as well as the cen-
sured data. The first TAD loss occurred in the
Immediately following surgical decortication pro- control group (n = 34), with 15 days. In the AC
cedures, a closed NiTi coil spring (Dentsply group (n = 32), a total of 7 TAD was lost after 22,
Ò
GAC , Islandia, NY, USA) was attached from the 50, 78, 81, 92, 133 and 137 days during the total
TAD to a hook soldered on the canine bracket of 180 days of observation period. In the PZ
and a distalization force of 120 g was applied from group (n = 34), 8 TAD loss occurred after 34, 36,
this day until the end of the observation period of 44, 49, 57, 64, 72 and 162 days. In the control
6 months (Fig. 4). Every 14 days, the force was group, 9 TAD loss that occurred after 15, 43, 57,
measured and the coil spring was reactivated if 71, 72, 78, 94, 127 and 148 days were observed.
the load had decreased. TAD stability was verified TAD survival curves are shown on Fig. 5. The
at every appointment. TAD was considered lost Log-Rank test revealed no significant differences
when patient was without it at appointment time in the occurrence of TAD loss (TAD stability)
or if TAD presented mobility (which would inter- among groups (p > 0.05). The success rate of
fere in its use as an anchorage for the remaining TAD was 79% in AC group, 77% in PZ group,
orthodontic canine retraction). and 74% in control group.

Statistical analysis Discussion

A survival analysis was conducted to evaluate dif- The success rate of TAD, as well as the factors that
ferences in the TAD loss (TAD stability) among critically influence their stability, such as patient-
groups. The results obtained in each group were related, implant-related, orthodontic-related and
plotted in Kaplan-Meier survival curves, indicating location-related factors, are frequently investigated
 Do alveolar corticotomy or piezocision affect TAD stability 127

Table 1. Description of the sample, TAD loss occurrence and censured data
Group Total of TAD Loss occurrence (%) TAD loss in days Censured (days)*
Corticotomy 32 7 (21%) 22, 50, 78, 81, 92, 133, 137 1 (24)
Piezocision 34 8 (23%) 34, 36, 44, 49, 57, 64, 72, 162 2 (21, 24)
Control 34 9 (26%) 15, 43, 57, 71, 72, 78, 94, 127, 148 1 (21)
Total 100 24 (24%) 4

* Censured before the end of the 180-days follow-up period.

and discussed in the orthodontic literature.2,4,13 explained by the fact that the TAD were installed
Location-related factors include the bone quality in the interradicular area between the maxillary
and soft tissue characteristics around the insertion second premolar and first molar, and the surgeries
site, that have been described to be mandatory to were limited to the mesial portion of the second
TAD stability.5,13 It is intuitive that since AC and premolar. This specific location may also explain
PZ decortication surgeries intentionally cause why increased levels of immune-inflammatory
bone damage in order to decrease bone density mediators resulted from an exacerbated inflam-
and induce RAP,14,15 these procedures might matory response, which can compromise TAD sta-
affect local bone features, which could influence bility and induce its loss, did not occur.16,17
the success rate of TAD inserted in proximity to Study participants were well instructed about
decorticated sites. However, to the best of our the importance of careful oral hygiene in order
knowledge, studies investigating the possible influ- to avoid local soft tissue inflammation. Addition-
ence of AC and PZ in TAD stability during ortho- ally, hygiene quality was verified in each appoint-
dontic treatment were not encountered in the ment. Since it is well recognized that adequate
literature. biofilm control reduces the periodontal tissue
In the present study, a 180day evaluation of inflammation,18 the orientation and continuous
TAD stability during canine retraction was con- evaluation of this parameter might have contrib-
ducted, and it revealed that the occurrence of uted for the control of the level of local inflam-
TAD loss in areas where AC or PZ decortications mation and, in part, contributed to the similar
surgeries were performed was not different from rate of TAD loss in all groups. As such, the effects
control (no decortication). of local plaque biofilm induced inflammation on
These results suggest that in spite of the the survival of TAD was controlled.
increase of immune-inflammatory response initi- The number of TAD loss observed in all
ated after surgeries for wound healing,7 bone fea- groups in the current investigation was slightly
tures may not had been significantly altered on higher than that reported in previous stud-
the insertion site of TAD. These findings may be ies.4,19,20,22 The likely explanation of this finding

Figure 5. Survival curves indicating the time (in days) elapsed until TAD loss in each group.
128 Mordente et al

is that in the present study mobile and displaced Acknowledgments

TAD were considered lost, since it could inter-
The authors wish to thank the support from
fere in its successful usage as anchorage for the
Fundaç~ao de Amparo a Pesquisa do Estado de
orthodontic canine retraction. In this regard,
Minas Gerais (FAPEMIG), Coordenaç~ao de
studies presenting samples with more than 50
Aperfeiçoamento de Pessoal de Nível Superior
TAD were included in a systematic review13 that
(CAPES) and Conselho Nacional de Desenvolvi-
implemented meta-analysis, and a success rate
mento Científico e Tecnol
ogico (CNPq). DDO is
above 80% was described. It was also concluded
a research fellow of FAPEMIG (CDS-APQ-01354-
that TAD were more successful when inserted in
15). MCRH is a research fellow of FAPEMIG
the alveolar bone of the maxilla in comparison
(CDS-PPM-00653-16). CMM has a CAPES fellow-
with the mandible, and when they are used in
ship (Code - 001).
patients older than 20 years. The authors also
reported that good oral hygiene around TAD
site is very important because it prevents soft References
tissue inflammation, which is associated with
1. Baumgaertel S, Razavi MR, Hans MG. Mini-implant
higher TAD failure rates.13 anchorage for the orthodontic practitioner. Am J Orthod
Small sample size (100 TADs) in this prelimi- Dentofacial Orthop. 2008;133(4):621–627.
nary study is a limitation. Although studies have 2. Miyawaki S, Koyama I, Inoue M, Mishima K, Sugahara T,
investigated the capacity of AC and PZ techniques Takano-Yamamoto T. Factors associated with the stability
of titanium screws placed in the posterior region for
to accelerate the orthodontic tooth movement,
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none of them have analyzed the occurrence of 2003;124(4):373–378.
TAD loss. Moreover, this is a prospective 3. Costa A, Raffaini M, Melsen B. Miniscrews as orthodontic
study.4,21,22 In order to reduce the influence of anchorage: a preliminary report. Int J Adult Orthod Orthog-
patient-related factors and find results primarily nath Surg. 1998;13(3):201–209.
4. Lai TT, Chen MH. Factors affecting clinical success of
related to the local effects of AC and PZ, specific
orthodontic anchorage: experience with 266 temporary
exclusion criteria were adopted, and inclusion cri- anchorage devices. J Dent Sci. 2014;9(1):49–55.
teria determined that all participants should pres- 5. Deguchi T, Nasu M, Murakami K, Yabuuchi T, Kamioka
ent a similar type of malocclusion. All samples H, Takano-Yamamoto T. Quantitative evaluation of corti-
were submitted to similar conditions such as the cal bone thickness with computed tomographic scanning
for orthodontic implants. Am J Orthod Dentofacial Orthop.
site of TAD insertion, insertion performed by the
2006;129(6):721.e7–721.e12.
same surgeon, load implementation timing, magni- 6. Wilmes B, Rademacher C, Olthoff G, Drescher D. Param-
tude of force analyzed and maintained the same eters affecting primary stability of orthodontic mini-
during the entire 6-month period of evaluation implants. J Orofac Orthop. 2006;67(3):162–174.
and same tooth movement (canine retraction). 7. Camacho AD, Cujar SAV. Dental movement acceleration:
literature review by an alternative scientific evidence
Therefore, the risk of bias was reduced, and the
method. World J Methodol. 2014;4(3):151–162.
observed results indicate that AC and PZ did not 8. AlSayed Hasan MMA, Sultan K, Hamadah O. Low-level
significantly affect TAD stability. laser therapy effectiveness in accelerating orthodontic
tooth movement: a randomized controlled clinical trial.
Angle Orthodo. 2017;87(4):499–504.
Conclusion 9. Wilcko WM, Wilcko MT, Bouquot JE, Ferguson DJ. Rapid
orthodontics with alveolar reshaping: two case reports of
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encountered when TAD installed in regions that 9–19.
10. Abbas NH, Sabet NE, Hassan IT. Evaluation of cortico-
underwent AC versus PZ decortication surgeries
tomy-facilitated orthodontics and piezoincision in rapid
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regions that did not undergo any surgical proce- (4):473–480.
dure. This conclusion supports the combination 11. Wilcko W, Wilcko MT. Acceletating tooth movement: the
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dontists to expand the breadth of treatment Dentofacial Orthop. 2013;144(1):4–12.
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risks of TAD failure. 2009;30(6):342–344. 346, 348-350.
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13. Dalessandri D, Salgarello S, Dalessandri M, et al. Determi- 18. Aimetti M. Nonsurgical periodontal treatment. Int J Esthet
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scalloped dental implants: analysis of a case series. Clin (3):151–163.
Implant Dent Relat Res. 2008;10(3):157–165. 22. Chang C, Liu SS, Roberts WE. Primary failure rate for
17. Reichow AM, Melo AC, de Souza CM, et al. Outcome of 1680 extra-alveolar mandibular buccal shelf mini-screws
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Do fixed orthodontic appliances
adversely affect the periodontium?
A systematic review of systematic
reviews
Sherif A. Elkordy, Leena Palomo, Juan Martin Palomo, and Yehya A. Mostafa

This overview aimed to summarize the available systematic reviews that

assess the effects of treatment with fixed orthodontic appliances (FOAs) on
the periodontium. Unrestricted electronic search of nine databases and addi-
tional manual searches were performed up to January 2019. Systematic
reviews and meta analyses that assessed the effect of FOAs on the periodon-
tal parameters were included. The methodological quality of the included
reviews was evaluated using the A Measurement Tool to Assess Systematic
Reviews2 (AMSTAR 2). The initial search yielded 2529 articles from which 19
were included in the current study. AMSTAR 2 scores ranged from critically
low to high quality. The quality of evidence ranged from very low to low.
The superiority of the periodontal outcomes of self-ligating brackets over
conventional brackets could not be proven. The available evidence regarding
the effects of FOAs on the periodontium is controversial and of very low
quality. The short-term effects of FOAs were temporary worsening the peri-
odontal parameters. Some conclusions regarding the periodontal outcomes
of self-ligating brackets could be withdrawn. Future high-quality trials are
required. The review was registered at the International prospective register
of systematic reviews with registration number CRD42018106662. (Semin
Orthod 2019; 25:130–157) © 2019 Elsevier Inc. All rights reserved.

Introduction aged
30 years present with periodontitis.2 The

existence of a strong relationship between peri-
nhancement of facial and dental aesthetics
E with preservation of the health and longevity
of the masticatory apparatus is a common goal
odontal and orthodontic treatments; especially in
adult patients, triggered the clinicians and
researchers from both ends to investigate a variety
that is shared by the orthodontic and periodontal
of questions pertaining to this interconnection.
professions. The number of adult patients seeking
The number of publications evaluating orthodon-
orthodontic treatment with fixed appliances has
tic and periodontal interactions published in the
increased steadily in recent decades.1 Additionally,
years (2011 2016) was equal to that of those pub-
a recent survey identified that 50% of Americans
lished in the previous 10 years (2000 2010),
which, in turn, almost equals the one of the previ-
Lecturer of orthodontics, Department of Orthodontics, Faculty of ous 60 years (1940 2000).3
Dentistry, Cairo University, Egypt; Associate Professor and Director of One of the previous assertions for orthodontic
DMD Program, Department of Periodontics, School of Dental Medi-
cine, Case Western Reserve University, Cleveland, OH; Professor and
treatment was to prolong the longevity of the
Director of Orthodontic Residency, Department of Orthodontics, individual's dentition through the correction of
School of Dental Medicine, Case Western Reserve University, Cleve- dental irregularities to allow better oral hygiene
land, OH; Professor of orthodontics, Department of Orthodontics, and reduce the incidence of gingivitis.4,5 On the
Faculty of Dentistry, Cairo University, Egypt. contrary, damaging effects of orthodontic treat-
Corresponding author. E-mail addresses:
[email protected], [email protected]
ment on the periodontium were on top of the
© 2019 Elsevier Inc. All rights reserved.
debatable topics in the dental field. It was
1073-8746/12/1801-$30.00/0 stated that fixed orthodontic appliances (FOAs)
https://doi.org/10.1053/j.sodo.2019.05.005 produce significant clinical attachment loss6 and

130 Seminars in Orthodontics, Vol 25, No 2, 2019: pp 130 157

 Effects of FOAs on the periodontium: A SR of SRs 131

lead to a shift in the subgingival bacterial micro- Information sources, search strategy, and study
flora and gingival inflammation regardless the selection
oral hygiene level.7
Search strategy
Orthodontic brackets and elastic modules
interfere with the effective removal of plaque, The electronic literature search was conducted
thereby increasing the risk of gingivitis.8,9 Self- in databases including PubMed, Embase,
ligating brackets (SLBs) were supported by Cochrane Library, LILACS, Scopus, Web of sci-
claims of superiority over the conventional brack- ence, SCIELO, Ovid, CINAHL via EBSCO in
ets (CBs) regarding the bacterial retention and March 2018 and was conducted again in January
plaque accumulation.10 Other studies refuted 2019. No restrictions of language or publication
the assumption of improved oral hygiene with date were applied. The implemented search
SLBs when compared to CBs;11,12 and the con- strategy is presented in Appendix 1.
troversy is still ongoing. Alternatives to FOAs Manual searching was performed in Google
include clear aligners that could have the advan- scholar, European Journal of Orthodontics, Jour-
tage of reduced plaque accumulation and nal of periodontology, Periodontology 2000,
improved gingival and periodontal parameters Journal of oral rehabilitation, Journal of clinical
when compared to FOAs.13 and oral investigations, Quintessence Publishing,
The primary studies underpinning the American Journal of Orthodontics and Dentofa-
orthodontic periodontal interrelationship suf- cial Orthopedics, the Angle Orthodontist, and
fer from low quality and lack of well-con- Seminars in Orthodontics. Bibliographies of the
ducted large-scale research. Meanwhile, the included full text articles were scanned for rele-
number of systematic reviews (SRs) and meta vant studies. Two investigators independently
analyses (MAs) focused on the orthodontic performed and repeated the searches.
periodontal propinquity has rapidly escalated. Unpublished literature was searched electroni-
The results of these reviews are sometimes cally at ProQuest and PROSPERO using the terms
contradictory, and their validity is highly influ- “orthodontic”, “periodont*”, “systematic review”,
enced by their methodology. “meta-analysis” and “gingiva”. Authors were con-
tacted to identify unpublished or ongoing system-
atic reviews and to clarify data as required.
Objectives
The aim of the current study is to evaluate the
Eligibility criteria
methodological quality of the available SRs and
MAs investigating the effects of FOAs on the The selection criteria that were applied for the
periodontium to offer the clinician a summary of inclusion of articles in this review are repre-
the current evidence and the quality of authenti- sented in Table 1.
cation. After removal of internal and external dupli-
cates, articles were screened based on title and
abstract. When titles and abstracts were insuffi-
cient to decide, the full text of the article was
Methods acquired. Assessment of the reviews for inclusion
was performed independently and in duplicate
Protocol registration
by two investigators. Disagreements regarding
This overview of systematic reviews followed the study inclusion were resolved by discussion to
Preferred Reporting Items for Systematic reach a final consensus
Reviews and Meta-Analyses (PRISMA) statement.
The review protocol was registered at the Inter-
Data items and collection
national prospective register of systematic
reviews (PROSPERO) with registration number Data extraction sheets were developed, and data
CRD42018106662. Few changes have been made were extracted independently by the two investi-
after the protocol registration including the gators. The collected data included: the design
change in the title. of the primary studies; the number of
132 Elkordy et al

Table 1. Eligibility criteria for the included studies in the systematic review.
Inclusion criteria Exclusion criteria
Study design SR or MA Narrative reviews, commentaries on
reviews and duplicate publications.
Design of the primary studies in - RCTs - Animal studies
the SRs - CCTs - Case reports
- Retrospective cohort studies - Case series
- Expert opinions.
Quality assessment Validated tool for quality assessment No quality assessment
of primary studies
Population Healthy periodontal patients undergo- Patients with periodontal disease or sys-
ing fixed appliance therapy temic conditions.
Subjects having adjunctive periodontal
surgeries to fixed appliance therapy
Intervention and comparator Any type of active fixed appliance Intervention has only removable applian-
therapy that is compared to no treat- ces, fixed retainers
ment or treatment with another ortho-
dontic appliance
Outcomes Include clinical periodontal Absence of clinical periodontal outcomes.
outcomes.

SR: systematic review. MA: meta-analysis. RCT: randomized controlled trial. CCT: clinical controlled trial.

participants and their grouping, description of quality, risk of bias, directness of evidence, incon-
the interventions and comparator, the quality of sistency, precision of effect estimates, and risk of
the primary studies, the outcomes, results and publication bias. The GRADE result was inter-
conclusions. preted as follows: “high quality” ‒ further
research is very unlikely to change the confi-
dence in the estimate of effect; “moderate qual-
Risk of bias/ quality assessment for the included
ity” ‒ further research is likely to have an
reviews
important impact on the confidence in the esti-
The methodological quality of the included SRs mate of effect and may change the estimate; “low
was assessed independently by two reviewers quality” ‒ further research is very likely to have
using the A Measurement Tool to Assess System- an important impact on the confidence in the
atic Reviews (AMSTAR 2) checklist.14 The tool estimate of effect and is likely to change the esti-
has 16 items to which responses are either yes, mate; and “very low quality” ‒ very uncertain
no, partial yes. The methodological quality was about the estimate.
scored as High (Zero or one non-critical weak-
ness), moderate (more than one non-critical
weakness), low (One critical flaw with or without Results
non-critical weaknesses), and critically low (more
Study selection and characteristics
than one critical flaw with or without non-critical
weaknesses). A total of 2524 articles were initially identified
through electronic search, and five articles were
obtained through manual searching. Initially, 55
Assessment of the overall quality of evidence
articles met the inclusion criteria and were
across studies
retrieved in full text. After reviewing the full
The results of the SRs that were shown to have texts, 36 articles were excluded. The most com-
moderate or high quality according to the mon reason for exclusion was the narrative
AMSTAR 2 checklist were used to construct the nature of the reviews. The list of excluded studies
overall body of evidence for each of the main is presented in Appendix 2. We contacted the
outcomes using the Grades of Recommendation, authors of four studies identified from PROS-
Assessment, Development, and Evaluation PERO to check the developing status of their
(GRADE) approach.15 The GRADE profiler was SRs, however they didn’t respond. Finally, nine-
used to evaluate studies for the methodological teen articles were included in the analysis. The
 Effects of FOAs on the periodontium: A SR of SRs 133

detailed literature search process is presented in reviews included RCTs and CCTs. Most of the
Fig. 1. remaining reviews included retrospective and
prospective cohort studies.
Four reviews assessed the periodontal effects
Characteristics of included reviews
of FOA therapy,18 21 while six studies16,17,22 25
The data of the included SRs is summarised in compared between the periodontal outcomes of
Table 2. From the included studies SRs, nine self-ligating brackets (SLBs) and conventional
included only qualitative analysis and ten brackets (CBs). Four reviews quantified the
included MAs. Regarding the study designs of changes in the oral microbiota secondary to
the included articles in the reviews, two SRs16,17 FOAs therapy.26 29 Two reviews tried to detect
included only RCTs, six reviews included cross the relation between orthodontic treatment and
sectional and non-controlled studies. Seven gingival recession.30,31 Finally, three SRs

Figure 1. PRISMA flow diagram for the study selection process.

 134
Table 2. Characteristics of included studies.
Study (SR/MA) Number and Design of Search strategy Total number of Intervention Comparator Outcomes Quality of Results Authors’ conclusions
primary studies participants and primary studies
grouping

Objectives: to compare between SLBs and CBs regarding; oral hygiene, periodontal parameters, accumulation of S. mutans colonies, prevention of malodour

Arnold et al., 8 studies (4 in MA) (May 2016) 326 subjects SLB (active and CBs (elastomeric Changes in Cochrane RoB After 3 6 months: PI: There is no evidence to
2016 (SR and 7 RCTs (3 of them Medline via Pubmed, (including split passive) or stainless-steel periodontal or tool The mean change in support the claim that
MA) were split mouth) CDSR, CENTRAL. mouth sub- ligatures) gingival inflam- 6 unclear RoB the intervention SLBs have relevant
1 CCT Clinicaltrials.gov jects) mation indices 2 high RoB groups was 0.14 higher clinical advantages
No language All patients including: GI: The mean change over CBs regarding the
restrictions. were (PI), (GI), in the intervention periodontal health in
adolescents BOP, (PPD). groups was 0.06 higher adolescents with
PPD: The mean bonded brackets
change in the interven-
tion group was 0.01
higher
Nascimento 6 studies (December 2012) 209 SLBs CBs (5 studies elas- Adhesion and Jadad scale. The increase in oral There is no evidence
et al., 2014 5 RCTs CENTRAL; Ovid, tomeric and 1 formation of S. All studies had microbiota (S. mutans for a possible influence
(SR) 1 CCT PubMed and Bireme study metal mutans high quality and Lactobacillus) is of bracket design (CB
no language ligation) colonies associated with the use or SLBs) over colony

Elkordy et al
restrictions of orthodontic applian- formation and adhe-
ces with both CBs and sion of S. Mutans
SLBs with no differen-
ces between them
Yang et al., 12 studies (8 in MA) (December 2015) 575 SLBs, (active and CBs Discomfort Cochrane RoB The results showed SLBs do not outper-
2016 (SR & RCTs Medline via OVID, 311 SLB- passive) Oral hygiene tool 10 studies passive SLB and CB did form CBs in reliving
MA) No split mouth studies EMBASE via OVID, treated evaluated unclear risk, 2 not differ significantly patients’ discomfort or
CENTRAL, World patients and through PI or studies low risk in plaque control [MD: promoting oral
Health Organization 264 CB-treated bacterial of bias ¡0.04, 95% CI hygiene
International Clini- patients colonization (¡0.30,0.22)].
cal Trials Registry SLB was not superior
Platform and the over CB in bacterial
Chinese BioMedical colonization.
Literature Database
Arbildo et al., 12 studies (8 in MA) (2012- December 485. SLBs (active and CBs PPD Cochrane RoB PPD, BOP, GI and PI No differences were
2018 (SR and RCTs 2017) PubMed, 234 SLBs passive) BOP tool showed no significant detected in the peri-
MA) 9 parallel Embase, SciELO, Sci- 251 CBs GI All studies have differences between odontal clinical effect
3 split mouth enceDirect, LILACS, Age (13.3 21) PI high ROB CB, active and passive of orthodontic treat-
BBO, Google Scholar SL brackets. ment with conven-
and in the CEN- tional and self-ligating
TRAL brackets
Grey literature: SIGLE

(continued on next page)

Table 2 (Continued)
Study (SR/MA) Number and Design of Search strategy Total number of Intervention Comparator Outcomes Quality of Results Authors’ conclusions
primary studies participants and primary studies
grouping

Longoni et al., 5 studies RCTs (1 par- April 2016 LILACS, 148 SLBs (active and CBs (3 studies elas- S. Mutans MAStARI No difference between SL brackets accumu-
2017 (SR) allel) quasi-RCTs (4; 3 PubMed, SCIELO, passive) tomeric and 2 colonization checklist; S. Mutans in CB and late less S. Mutans than
split mouth and 1 Science Direct, Sco- study metal 2 low risk, SLB after 3 months by conventional metallic
parallel) pus, and Google ligation) 3 moderate riskPCR. Stereomicro- brackets.
Scholar. of bias scope ST Mutans colo-
Grey literature; Open nization was more in
Grey CB than SLBs after 1,
4, 5, 12, and 24 weeks.
Huang et al., 4 studies (4 in MA) September 2016 172; SLBs, CBs CBs, untreated Oral malodour Cochrane RoB Fixed appliance versus FOAs are risk factors

Effects of FOAs on the periodontium: A SR of SRs

2018 (SR & 3 RCTs, PubMed, Ovid, SLB: 43 control scores, PI, gin- tool; control: for malodour at one
MA) 1 CCT Embase, and the CB: 77 gival index 3 unclear Malodour: CBs showed week after bonding
Cochrane Library CG: 62 (GI), and peri- 1 high risk of worse scores at the first with SLBs better than
odontal pocket bias week after bonding CBs.
depths. only. PI was worse one
PI: No difference month after bonding.
between CBs and CG
at 1 week.
At 1 month after bond-
ing; significantly
higher PI than control
GI: statistically higher
in CB only at 1 month
after bonding.
PPD: No significant
changes over the 3-
month period after
bonding.
SLB vs. CBs:
Malodour scores were
better in SLBs than
CBs at 1 week.
No significant differ-
ence in PI and GI.

(continued on next page)

135
 136
Table 2 (Continued)
Study (SR/MA) Number and Design of Search strategy Total number of Intervention Comparator Outcomes Quality of Results Authors’ conclusions
primary studies participants and primary studies
grouping

Objective: To determine the correlation between gingival recession/ bone height and incisor inclination (labial movement of incisors) in non-growing post-orthodontic patients compared to adult
untreated subjects or patients treated with different methodologies.

Aziz et al., 2011 7 studies, all were ret- July 2010 Medline, 590 (190 were Fixed appliance Fixed appliances Gingival Custom made Six studies denied an There is no association
(SR) rospective; 2 had no PubMed, Embase, CG) with labial move- with no labial recession tool for quality increased risk of gingi- between appliance
control group Web of Science, ment of incisors movement of assessment val recession after induced labial tipping
Cochrane Database incisors labial advancement of and gingival recession.
of Systematic Review, mandibular incisors Labial movement of
CENTRAL due to orthodontic incisors during ortho-
treatment. dontic treatment is not
One study concluded contributing to gingi-
that lower incisor pro- val recession
clination greater than
10° would inevitably
lead to gingival
recession.
Tepedino 2 studies June 2017. MED- 350 (150 FOAs (non-extrac- Adult untreated Gingival reces- New Castle Recession was signifi- No scientific evidence

Elkordy et al
et al., 2018 Retrospective LINE via untreated con- tion basis) subjects (1 study) sion and/or Ottawa scale. cantly higher in exists stating that pro-
(SR) PubMed, EMBASE, trol, 26 fixed or patients treated bone height, Moderate qual- treated patients com- clination of incisors fol-
Scopus, Web of Sci- appliances with with FOAs on and post-treat- ity of studies. pared to that in lowing orthodontic
ence, and Cochrane extraction, 174 extraction basis (1 ment position untreated controls but treatment with fixed
Library. non-extraction study) of incisors the difference was appliance increases the
Grey literature: fixed applian- minor and clinically risk of gingival
OpenGrey. ces) insignificant. recession
Age (22 65) No correlation was
found between the
final inclination of
lower teeth and gingi-
val recession.

Objective: To assess the effect of comprehensive treatment with fixed orthodontic appliances on periodontal outcomes, inflammation indices and clinical attachment levels in adolescent and adult
periodontally healthy patients.

Bollen 12 studies; (8 in MA) June 2007 1670; 821 inter- Fixed or removable No treatment Alveolar bone Cochrane RoB Alveolar bone loss: was There is an absence of
2008 1 RCT, 3 CCT, 8 cross MEDLINE; Web of vention group, appliances loss, PPD, clini- tool for RCTs, 0.13 mm (0.07 0.20) reliable evidence on
(SR and MA) sectional studies Science; and the 849 in the cal attachment New Castle greater in the interven- the positive effects of
excluded studies that CENTRAL, CDSR, untreated CGs. loss, gingival Ottawa scale tion group than con- orthodontic therapy
assessed periodontal DARE and Health Age (12 47) recession and for NRCTs. All trols. on periodontal status.
outcomes only at the Technology Assess- gingivitis. had high risk PPD: intervention The available evidence
time of appliance ment. of bias group had pocket suggested a small
removal. Grey literature: Clini- depths that were, mean worsening of
caltrials.gov, ProQuest 0.23 mm (0.15 0.30)

(continued on next page)

Table 2 (Continued)
Study (SR/MA) Number and Design of Search strategy Total number of Intervention Comparator Outcomes Quality of Results Authors’ conclusions
primary studies participants and primary studies
grouping

deeper than those of periodontal status after

the control groups. orthodontic therapy.
Gingival recession: The
intervention group
had gingival recession
0.03 mm (0.01 0.04)
greater than did the
control group.
Verussio et al., 10 studies July 2016 421, 274: Fixed Orthodontic Untreated patients BOP Cochrane RoB Patients undergoing The use of orthodontic

Effects of FOAs on the periodontium: A SR of SRs

2018 (SR) 7 RCTs (2 of them CENTRAL, Embase, appliances treatment or patients with dif- GI tool (results orthodontic therapy appliances, particularly
were split mouth), 3 Medline 78 removable ferent orthodontic PI NR) show an increase in fixed appliances, can
CCTs appliances treatment PPD BOP, GI and PI favour the increase of
69 untreated CAL The highest inflamma- periodontal tissue
control tory values were associ- inflammation.
ated with fixed
traditional orthodontic
treatment
Papageorgiou 9 studies (9 in MA) February 2017 335; 231 FOAs FOAs Untreated patients Clinical attach- ROBINS-I tool, FOAs were associated Orthodontic treatment
et al., 2017 (SR prospective non-ran- Medline via Pubmed, 104 untreated (3 studies only) ment loss dur- 8 had moder- with a clinical attach- with fixed appliances
and MA) domized trials Scopus, Embase, CG Other orthodontic ing orthodon- ate RoB, 1 had ment loss of 0.11 mm, might have little to no
Web of Knowledge, Age treatment tic treatment serious RoB which was neither sta- clinically relevant detri-
CENTRAL, CDSR, (11.4 42.1) tistically nor clinically mental effect on the
Virtual Health significant. CAL
Library Untreated patients
Grey Literature: showed CAL 0.07 mm
ISRCTN registry Intrusion of anterior
teeth was associated
with a slight attach-
ment gain of 0.63 mm
Cerroni et al., 5 studies cohort studies From January 1997 128 Fixed orthodontic NR BOP Customized Long term outcomes: There is moderate
2018 SR (prospective and to April 2017 appliances GI quality assess- studies reported no evidence that fixed
retrospective) Pubmed and PI ment tool permanent effects on appliances influence
Cochrane PPD (excluded 3 gingival status and that periodontal status.
articles who periodontal values Orthodontic applian-
had low tended to normalize 3 ces developed
quality) months- 2 years after generalized plaque
fixed appliance accumulation and
removal. gingivitis in a short
follow-up.

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137
 138
Table 2 (Continued)
Study (SR/MA) Number and Design of Search strategy Total number of Intervention Comparator Outcomes Quality of Results Authors’ conclusions
primary studies participants and primary studies
grouping

Objective: to assess evidence from human studies about qualitative changes in the subgingival microbiota/ plaque induced by orthodontic treatment.

Freitas et al., 4 studies (1 study pro- May 2012 139 Fixed orthodontic No control group Microbial colo- Customized Placement of FOAs Moderate evidence
2014 (SR) spective longitudinal, 1 PubMed; Web of appliances nization in quality assess-
increased quantity and showed that FOAs
study longitudinal, 2 Knowledge and Ovid orthodontic ment tool quality of oral micro- influenced the quan-
studies NM) databases. (English fixed (excluded 4 biota. tity and quality of oral
language) appliances articles who Aa increased in subgin- microbiota. This might
had low gival plaque (2 studies) be a transitional effect
quality) Aa didn’t increase (1 that depends on oral
study) hygiene control.
Increased Streptococci
(1 study)

Elkordy et al
Guo et al., 2017 13 studies (4 in MA) November 2016 752 Fixed orthodontic 3 studies had frequency of MINORS mod- Following FOAs inser- The levels of subgingi-
(SR & MA) (two CCTs, three PubMed, Cochrane Age 13 36 treatment with untreated controls, periodonto- erate scientific tion, the frequencies of val pathogens pre-
cohort studies and Library, and metal brackets and 8 self-controlled pathogen in evidence Pg and Aa showed no sented temporary
eight non-controlled EMBASE bands studies the subgingival significant change, the increases after FOAs
Studies) plaques frequency of Tf signifi- placement and
cantly increased in appeared to return to
short-term (0 3 pre-treatment levels
months). several months later.
During >6 months Orthodontic treatment
observation, the levels might not permanently
of subgingival perio- induce periodontal dis-
dontopathogens exhib- ease by affecting the
ited a transient level of subgingival
increase but decreased periodontal
to the pre-treatment pathogens.
levels afterwards.
After removal of the
FOAs, the 4 periodon-
topathogens showed
no significant differ-
ence compared with
before removal.

(continued on next page)

Table 2 (Continued)
Study (SR/MA) Number and Design of Search strategy Total number of Intervention Comparator Outcomes Quality of Results Authors’ conclusions
primary studies participants and primary studies
grouping

Papageorgiou 24 studies August 2017 1271, only 4 Orthodontic treat- (1) Untreated sub- Qualitative and Cochrane’s The presence of Aa in Insertion of FOAs
et al., 2018 (SR 3 were RCTs, Medline via Pubmed, studies had ment with any jects quantitative RoB tool for the subgingival crevicu- seemed to be associ-
and MA) 5 were prospective Scopus, Embase, untreated fixed appliances (2) Other form of analysis of the RCTs, and a lar fluid of orthodontic ated with a qualitative
NRCTs, and 16 were Web of science, CEN- controls orthodontic subgingival checklist based patients was increased change of subgingival

Effects of FOAs on the periodontium: A SR of SRs

nonrandomized stud- TRAL, CDSR, virtual treatment microbiota. on Downs and 3 6 months after microbiota, which
ies of unclear design health library, Goo- Time-points Black tool for FOAs insertion com- reverts to some extent
gle Scholar, Grey Lit- were pre-treat- nonrandom- pared to untreated back to normal in the
erature: ISRCTN ment, short- ized studies. patients (RR = 15.54). first months after
registry, Clinical- term mid-treat- All studies had There was still appliance removal
Trials.gov ment; long high RoB. increased subgingival
term mid-treat- prevalence of Aa
ment; short- (RR = 3.98) and Tf in
term post-treat- orthodontic patients
ment; long- up to 6 months after
term post- appliance removal
treatment. compared to untreated
patients.
Lucchese et al., 51 studies; (study October 2017 1863 Any type of ortho- NR Qualitative Swedish Coun- Orthodontic applian- Orthodontic appliances
2018 (SR) designs were inade- PubMed, PMC, Sco- dontic appliance. change in oral cil on Technol- ces influence the oral significantly influence
quately reported) pus, Lilacs, Scielo, CBs: (29 studies). microbiota ogy Assessment microbiota with an the oral microbiota with
Cochrane Trial SLBs: (8 studies) after FOA in Health Care increase in the counts alterations appearing
Library, Web of Lingual brackets insertion. Criteria for of S. mutans and Lac- one month after the
Science (4 studies) Periodontal Grading tobacillus and in the start of treatment.
parameters as Assessed Stud- percentage of poten- Removable appliances
PI, BOP ies’ methods. tially pathogenic gram- had less impact on oral
1 study: high negative bacteria. bacteria than fixed
quality. ones.
37 studies:
moderate qual-
ity. 12 studies:
low quality

(continued on next page)

139
 140
Table 2 (Continued)
Study (SR/MA) Number and Design of Search strategy Total number of Intervention Comparator Outcomes Quality of Results Authors’ conclusions
primary studies participants and primary studies
grouping

Objective: to compare periodontal health in patients undergoing orthodontic treatment with clear aligners with that of those undergoing orthodontic treatment with fixed appliances.

Lu et al., 2018 7 studies (7 in MA) October 2017 368, 183 Invisalign FOA GI The Newcastle- GI and PPD: no signifi- The meta-analysis indi-
(SR and MA) All were Prospective Cochrane Library, patients in the PI, Ottawa Scale. cant difference cated that compared
cohort studies EMBASE, PubMed, invisalign PPD All studies were
between the invisalign with FOAs, patients
Medline, Chinese group and 185 sulcus bleeding of high qualitygroup and the CG, at treated with invisalign
Biomedical Litera- patients in the index (SBI). (more than 7 1,3 and 6 months. had a better periodon-
ture CG stars) PI: Invisalign had a sig- tal health.
Database, CNKI, and nificantly lower PI, at 1
Wan Fang Data. month (OR=¡0.53), 3
months (OR=¡0.69),
and 6 months
(OR=¡0.91).

Elkordy et al
SBI: Invisalign showed
a lower SBI, at 1 month
(OR=¡0.44), 3 months
(OR=¡0.49), and 6
months (OR=¡0.40)
10 studies; (9 August 2017 427 patients (190 Clear aligners FOA GI, PI, BOP, PPD Cochrane RoB Clear aligners Clear aligners were
in MA) PubMed, Web of Sci- patients used clear tool for RCTs, were better better for periodontal
3 RCTs, 7 ence, Cochrane aligners, and 237 The Newcastle- than FOA for; health than FOAs and
cohort studies Library, and Embase patients used fixed Ottawa Scale PI (MD ¡0.53) might be recom-
Grey literature. appliances) for non RCTs moderate level mended for patients at
9 studies of evidence high risk of developing
medium qual- GI (MD, gingivitis
ity, 1 study high ¡0.27) mod-
quality. erate level of
GRADE evidence
assessment PPD: (MD,
¡0.35) low
level of
evidence.
Rossini et al., 5 studies (the results of September 2014 173 patients Clear aligners FOA GI, PI, BOP, A grading sys- A significant decrease Periodontal health, as
2015 SR 4 of them were Pubmed, National 92 with FOA 1 study had PPD tem described of periodontal indices well as quantity and
included) Library of Medicine’s 71 with clear by the Swedish (GI, PBI, BoP and quality of plaque, were

(continued on next page)

 Effects of FOAs on the periodontium: A SR of SRs 141

ventional bracket, PI: plaque index, GI: gingival index, PPD: probing pocket depth, BOP: bleeding on probing, SBI: sulcus bleeding index, FOA: fixed orthodontic appliance; CAT:
SR: systematic review, MA: meta-analysis, RCT: randomized controlled trial, NRCT: non randomized controlled trials, CCT: clinical controlled trials, SLB: self-ligating bracket, CB: con-

International Standard Randomised Controlled Trial Number, DARE: Database of Abstracts of Reviews of Effects, RoB: risk of bias, MAStARI: Meta-analysis of Statistics Assessment and
FOA treatments. (mod-

Review Instrument, MINORS: methodological index for non-randomized studies, CG: control group, 3D: three-dimensional, MD: mean difference, CI: confidence interval, NR: not
clear aligner therapy; CAL: clinical attachment level, S. mutans: Streptococcus mutans, Aa: Aggregatibacter actinomycetemcomitans, Pg: Porphyromonas gingivalis, Pi: Prevotella inter-
media, Tf: Tannerella forsythia, PCR: polymerase chain reaction; CENTRAL: cochrane central register of controlled trials, CDSR: Cochrane Database of Systematic Reviews, ISRCTN:
compared the periodontal outcomes of clear

better during aligner

therapy than during
Authors’ conclusions aligners with that of FOAs.32 34 The primary and

erate evidence)
secondary outcomes included the plaque index
(PI), gingival index (GI), clinical attachment lev-
els, probing pocket depth (PPD) and bleeding
on probing (BOP).
PPD) during CAT was
observed in the ana-

Methodological quality and the quality of

lyzed sample of

evidence in the included reviews

patients.

The quality of the included reviews was variable;

Results

where two reviews were of high quality, eight had

moderate, seven showed low quality and two
(grade B) in all
Assessment in

Quality of the
primary studies

collected evi-
Health Care.

reviews showed critically low quality. The answers

Technology
Council on

dences was

the studies
moderate
Quality of

to AMSTAR 2 questions for the included SRs are

shown in Table 3 and are graphically presented
in Fig. 2.
The results of the overall quality of evidence
using GRADE are summarized in Appendix 3.
Outcomes

Forty-four comparisons were assessed, and the

quality of the extracted evidence ranged from
very low to low.
untreated control
Comparator

Effects of intervention
group

The periodontal outcomes of FOA

therapy
The effects of FOAs on different periodontal
Total number of Intervention

parameters including the PI, GI, PPD, BOP, alve-

olar bone loss and clinical attachment level were
assessed by four SRs.18 concluded that FOAs
participants and

Knowledge, Scopus, control group

10 untreated

caused a slight worsening of the periodontal sta-

tus where there was 0.13 mm more alveolar bone
grouping

aligners

loss, 0.23 mm deeper PPD than the control

groups.19 stated that FOAs resulted in an
Google Scholar, and

increase of the periodontal tissue inflammation,

CENTRAL, Web of
Medline, Embase,

BOP, GI, and PI.21 found that FOAs resulted in a

Search strategy

slight change in the clinical attachment level

LILACS.

(0.11 mm) which was neither statistically nor clin-

ically significant.20 stated that FOAs developed
generalized plaque accumulation and gingivitis
in a short follow-up with no evidence of perma-
1 RCT, 3 prospective
Number and Design of

nent gingival and periodontal changes in the

primary studies

long term.
Table 2 (Continued)

studies

The relation between orthodontic

treatment with FOAs and gingival recession
Study (SR/MA)

Two SRs30,31 correlated between gingival reces-

reported.

sion and incisor inclination after FOAs therapy.

Both studies agreed that there was no evidence
 142
Table 3. Quality of the included reviews assessed by the AMSTAR 2 tool.
AMSTAR 2 question Arnold Nascimento Yang Arbildo Longoni Huang Aziz Tepedino Bollen Verussio Papageorgiou Freitas Guo Papageorgiou Lucchese Lu et al. Jiang Rosini Cerroni
et al. et al. 2014 et al. et al. et al. et al. et al. et al. 2008 et al. et al. 2017 et al. et al. et al. 2018 et al. 2018 et al. et al. et al.
2016 2016 2018 2017 2018 2011 2018 2018 2014 2017 2018 2018 2015 2018

(1) Did the research Yes Yes Yes No Yes Yes No Yes Yes Yes Yes No Yes Yes No No Yes Yes Yes
questions and inclu-
sion criteria for the
review include the
components of
PICO?
(2) Did the report of No No Partial No Yes No No Yes No No Yes No No Yes Yes No No Partial yes No
the review contain an yes
explicit statement
that the review meth-
ods were established
prior to the conduct
of the review and did
the report justify any
significant deviations
from the protocol?
(3) Did the review Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes No Yes Yes No Yes Yes Yes Yes
authors explain their

Elkordy et al
selection of the study
designs for inclusion
in the review?
(4) Did the review Yes Partial Partial Partial Partial Partial Partial Partial Yes Partial Yes Partial Partial Yes Partial Partial Yes Partial Partial
authors use a com- yes yes yes yes yes yes yes yes yes yes yes yes yes yes
prehensive literature
search strategy?
(5) Did the review Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
authors perform
study selection in
duplicate?
(6) Did the review Yes No No Yes No Yes No Yes No Yes Yes No Yes Yes Yes Yes Yes Yes No
authors perform data
extraction in
duplicate?
(7) Did the review No No No No Partial No Yes No No No Yes Yes No Yes No No yes No Yes
authors provide a list yes
of excluded studies
and justify the
exclusions?
(8) Did the review Partial Partial Yes Partial Yes Partial Partial Partial Yes Yes Yes No Partial Yes Partial Partial Yes Partial Partial
authors describe the yes yes yes yes yes yes yes yes yes yes yes
included studies in
adequate detail?

(continued on next page)

Table 3 (Continued)
AMSTAR 2 question Arnold Nascimento Yang Arbildo Longoni Huang Aziz Tepedino Bollen Verussio Papageorgiou Freitas Guo Papageorgiou Lucchese Lu et al. Jiang Rosini Cerroni
et al. et al. 2014 et al. et al. et al. et al. et al. et al. 2008 et al. et al. 2017 et al. et al. et al. 2018 et al. 2018 et al. et al. et al.
2016 2016 2018 2017 2018 2011 2018 2018 2014 2017 2018 2018 2015 2018

(9) Did the review Yes/ Partial No/ Yes Yes Yes Partial Yes Yes Yes Yes Yes/ Partial Yes No Yes Yes No/ Partial Yes Yes Partial No
authors use a satisfac- yes yes yes yes yes
tory technique for
assessing the risk of
bias (RoB) in individ-
ual studies that were
included in the
review?
(10) Did the review No No No No No No No No Yes No No No No No No No Yes No No
authors report on the

Effects of FOAs on the periodontium: A SR of SRs

sources of funding
for the studies
included in the
review?
(11) If meta-analysis Yes NA Yes Yes NA Yes/ No NA NA Yes NA Yes NA Yes Yes NA Yes Yes NA NA
was performed did
the review authors
use appropriate
methods for statisti-
cal combination of
results?
(12) If meta-analysis No NA No No NA No NA NA No NA Yes NA No Yes NA Yes Yes NA NA
was performed, did
the review authors
assess the potential
impact of RoB in
individual studies on
the results of the
meta-analysis or
other evidence
synthesis?
(13) Did the review Yes No Yes Yes No Yes No Yes Yes No Yes Yes Yes Yes No yes Yes No Yes
authors account for
RoB in individual
studies when inter-
preting/ discussing
the results of the
review?
(14) Did the review Yes No No Yes Yes No No Yes Yes No Yes Yes Yes Yes No Yes Yes Yes No
authors provide a sat-
isfactory explanation
for, and discussion
of, any heterogeneity
observed in the
results of the review?

143
(continued on next page)
 144
Table 3 (Continued)
AMSTAR 2 question Arnold Nascimento Yang Arbildo Longoni Huang Aziz Tepedino Bollen Verussio Papageorgiou Freitas Guo Papageorgiou Lucchese Lu et al. Jiang Rosini Cerroni
et al. et al. 2014 et al. et al. et al. et al. et al. et al. 2008 et al. et al. 2017 et al. et al. et al. 2018 et al. 2018 et al. et al. et al.
2016 2016 2018 2017 2018 2011 2018 2018 2014 2017 2018 2018 2015 2018

(15) If they per- No NA No No NA No NA NA Yes NA Yes NA No Yes NA No Yes NA NA

formed quantitative
synthesis did the
review authors carry
out an adequate
investigation of publi-
cation bias (small
study bias) and dis-
cuss its likely impact
on the results of the
review?
(16) Did the review No Yes Yes Yes Yes Yes No Yes No No Yes Yes Yes Yes Yes Yes No No Yes
authors report any
potential sources of
conflict of interest,
including any fund-
ing they received for
conducting the

Elkordy et al
review?
Overall review quality Moderate Critically Moderate Moderate Low Low Low Moderate Moderate Low High Low Moderate High Critically Moderate Moderate Low Low
low low
 Effects of FOAs on the periodontium: A SR of SRs 145

Figure 2. Graphic presentation for the answers to AMSTAR 2 questions for the included studies.

of association between the FOAs-induced incisor changes started by an increase in the pathogens
proclination and gingival recession and that after FOAs insertion that was transient in nature.
FOAs couldn’t be considered as a risk for gingival
recession. On the other hand,18 assessed gingival
Comparison between SLBs and CBs
recession after FOAs and showed that FOAs
group had gingival recession 0.03 mm Results from six SRs16,17,22 25 showed that there
(0.01 0.04) greater than the control group. were no differences in the PI, GI, PPD, BOP
between SLBs and CBs. SLBs did not surpass the
CBs regarding the accumulation of bacterial col-
onies. One SR23 concluded that SLBs showed
The qualitative changes in the subgingival
better malodour scores than CBs.
microbiota induced by FOAs
Results of the included reviews revealed that
Comparison between periodontal health
placement of FOAs was associated with qualita-
in patients undergoing FOAs therapy with
tive and quantitative changes in the oral micro-
those treated with clear aligners
biota. The investigated periodontopathogens
included Streptococcus mutans (S. mutans), Different periodontal parameters were assessed
Aggregatibacter actinomycetemcomitans (Aa), including the PI, GI, PPD, SBI, and BoP. Two
Porphyromonas gingivalis (Pg), Prevotella inter- SRs33,34 agreed that clear aligners showed a sig-
media (Pi), Tannerella forsythia (Tf) and lacto- nificantly lower PI than FOAs.33 showed that
bacilli. Most of the reviews agreed that the aligners showed a lower GI, and PPD as
146 Elkordy et al

compared to FOAs.32 concluded that the peri- Summary of evidence and effects of interventions
odontal health, as well as quantity and quality of
Regarding the effects of FOAs on the periodon-
plaque, were better during aligner therapy than
tium, the investigated parameters included the PI,
during FOA treatments.
GI, PPD, BoP and CAL. Loss of clinical attach-
ment was reported to result from FOAs however,
Discussion the value was 0.11 mm that, despite being statisti-
cally significant, was far from being of clinical
Multiple SRs assessed the effects of FOAs on
importance.21 The same applies for the reported
the periodontium. Systematic reviews (or over-
0.13 mm alveolar bone loss and the 0.23 increased
views) of reviews are a logical and appropriate
pocket depth.18 Interestingly, intrusion of anterior
next step, allowing the findings of separate
teeth was associated with a slight attachment gain
reviews to be compared and contrasted, pro-
of 0.63 mm which is in consistence with previous
viding clinical decision makers with the evi-
reports that orthodontic intrusion improved the
dence they need.35
level of clinical attachment.40 Other parameters
SRs that included animal studies were
including PI, GI and BoP showed increased values
excluded to avoid the effect of the included ani-
with FOAs versus controls indicating the periodon-
mal studies on the final outcomes. Discordance
tal inflammation.19 Long term studies were scarce
between human and animal studies is well estab-
and failed to prove any permanent long-term
lished and is attributed to the failure of the ani-
effects of FOAs on the periodontal parameters.20
mal models to simulate the clinical disease
Labial inclination of the lower incisors by
accurately.36 SRs that included subjects having
FOAs was frequently debated in the literature to
periodontal disease and/or defects were
result in gingival recession. Two SRs tried to
excluded due to the difference in the reaction of
investigate the relationship between gingival
healthy and periodontally compromised subjects
recession and incisor proclination and failed to
to orthodontic treatment.37
find evidence of association.30,31 On the other
hand 0.03 mm of gingival recession was reported
Quality of the included reviews with FOAs which is of questionable clinical
value.18 It is worth mentioning that gingival
The AMSTAR 2 checklist14 is modified from
recession is a multifactorial condition where
the original AMSTAR tool38 to fit systematic
many factors are involved. FOAs themselves are
reviews that included both RCTs and non-ran-
not risk factors for gingival recessions however,
domized studies (NRCTs). NRCTs are subject
the injudicious movement of the incisors outside
to a range of biases that are either not present
the bone envelope can be a contributing fac-
or are less noticeable in RCTs and thus
tor.41 Other factors were proven to be more cor-
require different risk of bias assessments.
related to gingival recession including thin
Responses to AMSTAR2 items do not derive
gingival biotype and reduced buccal bone
an overall score, unlike the original AMSTAR
thickness.3,42
instrument. It is believed that an overall score
The effects of FOAs on the periodontium was
may mask critical weaknesses that should
also investigated on the microbiological level.
diminish confidence in the results of a system-
The importance of such an assessment is to iden-
atic review.39
tify whether FOAs predispose to progression of
According to GRADE, the quality of the
gingivitis to periodontitis through increasing
extracted evidence ranged from low to very low
periodontopathogens in the subgingival environ-
which shows the increased uncertainty regarding
ment. Two reviews reported that FOAs resulted
the extracted estimates. The main reason for
in a shift in the composition of the subgingival
downgrading the evidence was the high risk of
microbiota that tended to return to near the nor-
bias inherent in the NRCTs and observational
mal levels few months after appliance
studies. Other reasons for downgrading were the
removal.21,27 The results from the other two
imprecision that resulted from the very wide con-
reviews, which were of lower quality, were
fidence intervals together with the increased het-
directed towards a more dramatic change in the
erogeneity in the reported outcomes that yielded
subgingival pathogens after FOAs insertion.26,29
high inconsistency.
 Effects of FOAs on the periodontium: A SR of SRs 147

SLBs are appliances that were claimed to out- emphasize that we do not need any further SRs
perform CBs in the treatment efficiency, treat- underpinning this topic, but research plans
ment duration, chairside time and oral should be modified to include well-designed pri-
hygiene.10,43 Previous SRs concluded that there mary studies instead.
was no significant difference between CBs and The evidence retrieved from this systematic
SLBs as regards treatment efficiency and dura- review must be taken with caution because the
tion.44,45 The results of the reviews included in level of evidence ranged from low to very low. A
our study confirmed the plethora of evidence quantitative analysis of the periodontal status
against the superiority of SLBs over CBs. No dif- before and after treatment would have been
ferences were reported regarding the PI, GI, meaningful in summarizing the evidence however,
BoP and PPD. The only reported difference was because of the substantial methodological hetero-
regarding the malodour scores that were better geneity in the included SRs, it was not possible.
in the SLBs group however, this was only assessed Examples of the methodological flaws in the
after one week of appliance insertion. Claims included SRs included pooling data from adults
regarding the superiority of SLBs seem to be and adolescents which could affect the accuracy
only supported by the manufacturing companies of the estimates. Moreover, the types of FOAs
and their sales representatives and to be inter- were not specified in all SRs; it is well known that
preted with due consideration of the current sci- the use of orthodontic bands can adversely affect
entific knowledge.46 the periodontium when compared to bondable
Clear aligners, being removable, are expected tubes on the molars.47 Data from patients who
to allow for better oral hygiene and superior gin- were treated with extractions were pooled with
gival health than FOAs. This is reflected on the those treated on a non-extraction basis. Report-
results of the reviews that confirmed the superi- ing an aggregate pooled effect might be mislead-
ority of clear aligners regarding the PI, GI and ing if there are important reasons to explain the
PPD over the FOAs. However, different aspects variable treatment effects.48
regarding the appliance efficiency need to be
properly investigated before its routine use as a
more hygienic alternative to FOAs. Conclusions
It can be mentioned according to the avail-
able evidence, that FOAs cause a temporary wors- (1) The SRs on the effects of FOAs on the perio-
ening of the periodontal parameters that tends dontium present a heterogeneous methodo-
to revert after appliance removal. From another logical quality. Only two SRs were judged of
perspective, these findings also highlight the high quality. The level of the extracted evi-
utmost importance of giving strict oral hygiene dence ranged from low to very low.
maintenance protocols to patients treated with (2) FOAs cause a slight temporary worsening of
FOAs. It can be deduced that FOAs are not risk the periodontal status when compared to
factors of inducing periodontal disease, but they control groups.
rather provide a transient condition of gingivitis (3) Orthodontic treatment with FOAs might not
and plaque accumulation. permanently induce a periodontal disease by
affecting the levels of subgingival periodonto-
pathogens. The changes are temporary and
Strengths and limitations
revert after the FOAs removal.
The included SRs suffered from methodological (4) The relation between treatment with FOAs
limitations and most of their included primary and the development of gingival recessions is
studies were of cross sectional and retrospective highly debatable and needs further research.
nature. It can be debated that this umbrella The current weak evidence failed to prove an
review is not currently needed because well- association between the labial inclination of
designed primary studies would be much more the incisors by FOAs and the incidence of
timely than SRs at this juncture. However, the gingival recession.
benefits of performing a SR of SRs is to help to (5) SLBs do not outperform the CBs regarding
set implications for future research. It can their periodontal outcomes. Using SLBs
148 Elkordy et al

instead of CBs for the purpose of having bet- 9. Pender N. Aspects of oral health in orthodontic patients.
ter periodontal health is not recommended. Br J Orthod. 1986;13(2):95–103.
(6) The periodontal health is proven to be bet- 10. Mummolo S, Marchetti E, Giuca MR, et al. In-office bacte-
ria test for a microbial monitoring during the conven-
ter with clear aligners in comparison with tional and self-ligating orthodontic treatment. Head Face
FOAs. Med. 2013;9:7.
11. Othman SA, Mansor N, Saub R. Randomized controlled
clinical trial of oral health-related quality of life in
Implications for research patients wearing conventional and self-ligating brackets.
Korean J Orthod. 2014;44(4):168–176.
(1) It seems more useful for future research to 12. Pandis N, Papaioannou W, Kontou E, Nakou M, Makou
analyze more homogeneous groups of M, Eliades T. Salivary Streptococcus mutans levels in
patients with conventional and self-ligating brackets. Eur J
patients (regarding age, type of malocclu- Orthod. 2010;32(1):94–99.
sion), appliances, treatment protocols, and 13. Levrini L, Mangano A, Montanari P, Margherini S, Cap-
means of outcome assessment for studying rioglio A, Abbate GM. Periodontal health status in
the effects of FOAs on the periodontium. patients treated with the Invisalign(Ò ) system and fixed
(2) The complex relationship between the FOAs orthodontic appliances: a 3 months clinical and microbio-
logical evaluation. Eur J Dent. 2015;9(3):404–410.
and the development of gingival recessions 14. Shea BJ, Reeves BC, Wells G, et al. AMSTAR 2: a critical
still needs to be thoroughly studied. appraisal tool for systematic reviews that include rando-
(3) The long-term effects of FOAs on the perio- mised or non-randomised studies of healthcare interven-
dontium need further investigation. tions, or both. BMJ. 2017;358:j4008.
15. Guyatt G, Oxman A, Vist G, Kunz R, Falck-Ytter Y, Alonso-
Coello P. GRADE: an emerging consensus on rating qual-
Funding ity of evidence and strength of recommendations. BMJ.
2008;336:924–926.
The authors did not receive any funding during 16. Arbildo H, Gamarra L, Rojas S, Infantes E, Cruzado F,
performing this systematic review. V
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150 Elkordy et al

Appendix 1. Search strategy in different databases

Database Number
of hits
Scopus ALL (orthodont* OR “orthodontic tooth movement” OR “tooth movement” OR 676
bracket OR appliance OR aligner OR invisalign OR braces) AND ALL (periodont* OR
gingivitis OR “gingival recession” OR recession OR gingiv* OR periodontium OR “peri-
odontal health”) AND TITLE (“systematic review” OR “meta analysis")
PubMed ((((((((((((periodont*) OR parodont*) OR perio* OR gingivitis) OR gingival reces- 447
sion) OR recession) OR gingiv* OR periodontium[MeSH Major Topic]) OR periodon-
tal health) OR Periodontics[MeSH Major Topic]))))))) AND ((((((((((orthodont*)
OR appliance*) OR aligner) OR orthodontic tooth movement) OR tooth movement)
OR bracket*) OR invisalign) OR brace*) OR Orthodontic Appliances[MeSH Major
Topic]) OR retain*)) AND (((systematic review[Title/Abstract]) OR meta analysis
[Title/Abstract]) OR meta analyses[Title/Abstract])
Web of TS=(orthodont* OR “orthodontic tooth movement" OR “tooth movement" OR bracket 93
Science OR appliance OR aligner OR invisalign OR braces) AND TS=(periodont* OR gingivitis
OR “gingival recession” OR recession OR gingiv* OR periodontium OR “periodontal
health”) AND TI=(“systematic review” OR “meta analysis”)
LILACS (tw:((tw:(othodont*)) OR (tw:(appliance)) OR (tw:(bracket)) OR (tw:(aligner)) OR 362
(tw:(tooth movement)))) AND (tw:((tw:(gingivitis)) OR (tw:(periodontal disease)) OR
(tw:(gingival recession)) OR (tw:(periodontium)) OR (tw:(periodont* health)) OR (tw:
(periodont*)))) AND (tw:((tw:(systematic review)) OR (ti:(meta analysis)) OR (ti:
(meta-analysis))))
CINAHL TX (periodont* OR parodont* OR perio* OR gingivitis OR “gingival recession” OR 383
“EBSCO” periodontium OR “periodontal health”) AND TX (orthodont* OR appliance* OR
“orthodontic tooth movement" OR bracket* OR “Orthodontic Appliances”) AND TI
(“systematic review” OR “meta analysis”)
SCIELO (periodont* OR parodont* OR perio* OR gingivitis OR “gingival recession” OR perio- 63
dontium OR “periodontal health” OR gingiva) AND (orthodont* OR appliance* OR
“orthodontic tooth movement” OR bracket* OR “Orthodontic Appliances” OR brace*
OR “tooth movement”) AND ("systematic review" OR “meta analysis" OR review)
ProQuest (periodont* OR parodont* OR perio* OR gingivitis OR “gingival recession” OR perio- 121
dontium OR “periodontal health”) AND TX (orthodont* OR appliance* OR “ortho-
dontic tooth movement” OR bracket* OR “Orthodontic Appliances”) AND TI
(“systematic review” OR “meta analysis”)

Appendix 2. List of excluded studies with reasons

Reason for exclusion Excluded studies
Narrative reviews or commentaries on sys- (Dersot, 2012), (Ngom, Benoist, Soulier-Peigue, & Niang, 2010), (Antoun, Mei,
tematic reviews Gibbs, & Farella, 2017), (van Gastel, Quirynen, Teughels, & Carels, 2007),
(Atack, Sandy, & Addy, 1996), (Brignardello-Petersen, 2018), (Shin, 2017)
Included animal studies (Gkantidis, Christou, & Topouzelis, 2010), (Najeeb et al., 2017), (Joss-Vassalli,
Grebenstein, Topouzelis, Sculean, & Katsaros, 2010), (G€ olz, Reichert, & J€ager,
2011)
Discussed methods of oral hygiene con- (Migliorati et al., 2015), (M. Pithon et al., 2017), (M. M. Pithon et al., 2015),
trol during fixed appliances therapy only (Tang, Sensat, & Stoltenberg, 2016), (Gray & McIntyre, 2008), Kaklamanos and
(Kaklamanos & Kalfas, 2008), (Goh, 2007), (Al-Anezi & Harradine, 2012)
Included patients with periodontal dis- (Roberto Rotundo et al., 2010), (R Rotundo et al., 2011), (Zasciurinskiene,
ease and/or periodontal defects Lindsten, Slotte, & Bjerklin, 2016)
Interventions did not include fixed ortho- (Al-Moghrabi, Pandis, & Fleming, 2016), (Foz, Artese, Horliana, Pannuti, &
dontic appliances Romito, 2012), (Buzatta et al., 2016)
Intervention included combined surgical (Incerti-Parenti, Checchi, Ippolito, Gracco, & Alessandri-Bonetti, 2016), (Klou-
periodontal treatment kos, Eliades, Sculean, & Katsaros, 2014).
Did not report periodontal outcomes (Ata-Ali et al., 2016), (Alhadlaq, 2015), (Kapoor, Kharbanda, Monga, Miglani, &
Kapila, 2014), (Perinetti, Primozic, Castaldo, Di Lenarda, & Contardo, 2013)
Discussed implant site development with (Korayem, Flores-Mir, Nassar, & Olfert, 2008), (Gonçalves Zen
obio et al., 2015),
fixed appliances only (Magkavali-Trikka et al., 2015), (Somar, Mohadeb, & Huang, 2016)
Duplicate publication (Bollen, 2008)
 Effects of FOAs on the periodontium: A SR of SRs 151

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 Effects of FOAs on the periodontium: A SR of SRs 153

Appendix 3. Quality assessment of the existing evidence using the GRADE tool for the
outcomes of the moderate and high-quality reviews
Study Intervention/ Outcome Study type Effect estimate Number of Conclusions GRADE
comparator participants
(studies)
Arnold et al., SLBs versus PI after 4 6 MA MD: 0.09 (95% 72 (2 studies) No significant ⨁⨁
2016 CBs weeks CI: ¡0.18 0.36) difference LOW a,b
between SLBs
and CBs
PI after 3 6 MD= ¡0.14 (95% 105 (3 No significant ⨁⨁
months CI: ¡0.31 0.02) studies) difference LOW a,b
between SLBs
and CBs
GI after 4 6 MD: 0.02 (95% 65 (2 studies) No significant ⨁⨁
weeks CI: ¡0.19 0.22) difference LOW a,b
between SLBs
and CBs
GI after 3 6 MD: ¡0.02 (95% 65 (2 studies) No significant ⨁⨁
months CI: ¡0.35 0.32) difference LOW a,b
between SLBs
and CBs
PPD MD: ¡0.03 (95% 65 (2 studies) No significant ⨁⨁
CI: ¡0.17 0.11) difference LOW a,b
between SLBs
and CBs
Yang et al. SLBs vs. CBs PI MA MD: ¡0.04 (95% 159 (4 No significant ⨁
CI: ¡0.3 0.22) studies) difference VERY LOW a,c,d
between SLBs
and CBs
St mutans narrative 158 (4 No significant ⨁⨁
studies) difference LOW a,d
between SLBs
and CBs
Arbildo et al. SLBs vs. CBs PPD MA SMD= 0.11 (95% 243 (5 RCTs) No significant ⨁
CI: ¡0.14, 0.36) difference VERY LOW a,b
between SLBs
and CBs
BoP SMD: ¡0.37 [95% 226 (4 RCTs) No significant ⨁
CI: ¡0.77, 0.02] difference VERY LOW a,b,c
between SLBs
and CBs
GI SMD= 0.59 [95% 321 (7 RCTs) No significant ⨁
CI: ¡0.25, 1.43] difference VERY LOW a,b,c
between SLBs
and CBs
PI SMD: 0.49 [95% 361 (8 RCTs) No significant ⨁
CI: ¡0.08, 1.06] difference VERY LOW a,b,c
between SLBs
and CBs
Tepedino et al. FOA versus Gingival SR Narrative 324 (2 One study ⨁
untreated recession studies) showed clinically VERY LOW d,e
controls (1 non-significant
study) Extrac- more recession
tion versus in FOA group
non-extrac- versus untreated
tion (1 study) controls. The
other study
showed
0.4 0.8 mm
increase in clini-
cal crown length
in non-extraction
group versus
0.4 1.1 mm in
extraction group
Bollen et al. Alveolar bone SR MD: 0.13 (95% 254 (3 FOA could prob- ⨁
loss CI: 0.07, 0.20) studies) able show more VERY LOWe
(continued)
154 Elkordy et al

(Continued)
Study Intervention/ Outcome Study type Effect estimate Number of Conclusions GRADE
comparator participants
(studies)
FOA versus alveolar bone
untreated loss.
controls
PPD MD: 0.23 (95% 194 (2 FOA could prob- ⨁
CI: 0.15, 0.30) studies) able show more VERY LOW c,e
PPD than
untreated
subjects.
Gingival MD 0.03 (95% 659 (3 No significant ⨁
recession CI: 0.01, 0.04) studies) difference in gin- VERY LOWe
gival recession
Attachment Narrative 449 (3 One study ⨁
loss studies) showed 0.11 mm VERY LOW c,d,e
(0.07 0.15)
more attachment
loss in FOA
group. Two stud-
ies showed 0.05,
0.06 mm less
attachment loss
in the FOA
group
Papageorgiou et FOA versus Attachment MA MD: 0.14 mm loss 182 patients There may be lit- O O O
al., 2017 untreated level (com- (95% CI 0.17 mm (2 studies) tle or no attach- VERY LOW c,g
controls prehensive gain to 0.45 mm ment loss with
treatment) loss) FOA treatment
Attachment MD: 0.49 mm gain 20 patients Intrusion with O O
level (0.36 mm 0.62 mm (1 study) FOA could prob- LOW e
(intrusion) gain) ably allow some
attachment gain
Papageorgiou et FOA versus Prevalence of MA RR: 15.54 (95% 44 patients Orthodontic O O O
al., 2018 untreated Aa after appli- CI: 3.19 75.85) (2 studies) patients 3.0 6.0 VERY LOW a,b
controls ance months after
insertion appliance inser-
tion have proba-
bly higher
subgingival A.a.
prevalence than
untreated
patients
Prevalence of RR: 3.98 (95% 166 patients Orthodontic O O O
Aa after appli- CI: 1.23 12.89) (3 studies) patients 1.0 6.0 VERY LOW a,b
ance removal months after
appliance
removal might
have higher sub-
gingival A.a.
prevalence than
untreated
patients
Prevalence of RR: 2.25 (95% 44 patients Orthodontic O O O
Tf after appli- CI: 1.41 3.61) (2 studies) patients 0.3 3.0 VERY LOW a,b
ance removal months after
appliance
removal might
have higher sub-
gingival T.f. prev-
alence than
untreated
patients
Jiang et al. FOA versus PI in RCTs MA MD: 1.79 (95% 67 (2 RCTs) PI is probably ⨁⨁⨁  a
clear aligners higher in MODERATE
CI: 1.45 2.13) patients with
FOA than those
(continued)
 Effects of FOAs on the periodontium: A SR of SRs 155

(Continued)
Study Intervention/ Outcome Study type Effect estimate Number of Conclusions GRADE
comparator participants
(studies)
with clear
aligners
PI in observa- MD: 0.21 (95% 282 (6 PI is probably ⨁
tional studies CI: 0.03 0.45) studies) slightly higher in VERY LOW c,e
patients with
FOA than those
with clear
aligners
PI (all MD: 0.53 (95% 349 (8 PI is probably ⨁
studies) CI: 0.20 0.85) studies) slightly higher in VERY LOW c,e
patients with
FOA than those
with clear
aligners
GI MD: 0.27 (95% 362 (6 GI is probably ⨁
CI: 0.17 0.37) studies) slightly higher in VERY LOW c,e
patients with
FOA than those
with clear
aligners
PPD in RCTs MD: 0.21 (95% 67 (2 RCTs) There is probably ⨁
CI: 0.77 1.19) no difference in VERY LOW a,b,c
PPD in patients
with FOA and
those with clear
aligners
PPD in obser- MD: 0.39 (95% 240 (5 PPD is probably ⨁
vational CI: 0.03 0.75) studies) slightly higher in VERY LOW c,e
studies patients with
FOA than those
with clear
aligners
PPD all MD: 0.35 (95% 307 (7 PPD is probably ⨁
studies CI: 0.03 0.67) studies) slightly higher in VERY LOW c,e
patients with
FOA than those
with clear
aligners
Lu et al. FOA versus GI 1 month MA SMD 0.24 (95% 145 (3 There is probably ⨁⨁
clear aligners CI: ¡0.09 0.57) studies) no significant dif- LOW e
ference in GI
after 1 month
between FOA
and clear
aligners.
PI 1 month SMD 0.53 (95% 191 (4 PI after 1 month ⨁
CI: 0.18 0.89) studies) is probably VERY LOW c
slightly higher in
FOA than clear
aligners.
PPD 1 month SMD 0.39 (95% 218 (4 There is probably ⨁
CI: ¡0.21 0.98) studies) no significant dif- VERY LOW b,c
ference in PPD
after 1 month
between FOA
and clear
aligners.
Sulcus bleed- SMD 0.44 (95% 258 (5 Sulcus bleeding ⨁⨁
ing index at 1 CI: 0.19 0.7) studies) index after 1 LOW e
month month is proba-
bly slightly
higher in FOA
than clear
aligners.
(continued)
156 Elkordy et al

(Continued)
Study Intervention/ Outcome Study type Effect estimate Number of Conclusions GRADE
comparator participants
(studies)
GI 6 months SMD: 0.78 (95% 255 (5 There is probably ⨁
CI: ¡0.05 1.62) studies) no significant dif- VERY LOW b,c,e
ference in GI
after 6 months
between FOA
and clear
aligners.
PI at 6 SMD 0.91 (95% 301 (6 PI after 6 months ⨁
months CI: 0.35 1.47) studies) is probably VERY LOW c,e
slightly higher in
FOA than clear
aligners.
PPD at 6 SMD 0.38 (95% 261 (5 There is probably ⨁
months CI: ¡0.17 to 0.93) studies) no significant dif- VERY LOW b,c,e
ference in PPD
after 6 months
between FOA
and clear
aligners.
Sulcus bleed- SMD 0.4 (95% 191 (4 Sulcus bleeding ⨁⨁
ing index at 6 CI: 0.07 0.73) studies) index after 6 LOW e
months months is proba-
bly slightly
higher in FOA
than clear
aligners.
Guo et al. FOA versus Pg 3 months MA MD: 0.47 (95% 60 (1 study) One study ⨁
no treatment after CI: ¡0.12 1.06) showed that VERY LOW e,f
(only 2 insertion there is probably
studies) no significant
increase in Pg 3
months after
FOA insertion
versus untreated
controls
Aa 3 months MD: 0.004 (95% 60 (1 study) One study ⨁
after CI: ¡0.11 0.12) showed that VERY LOW e,f
insertion there is probably
no significant
increase in Aa 3
months after
FOA insertion
versus untreated
controls
Tf 3 months MD: 0.47 (95% 60 (1 study) One study ⨁
after CI: ¡0.44 1.38) showed that VERY LOW e,f
insertion there is probably
no significant
increase in Tf 3
months after
FOA insertion
versus untreated
controls
Pi 3 months MD: 0.67 (95% 60 (1 study) One study showed ⨁
after CI: ¡0.31 1.65) that there is prob- VERY LOW e,f
insertion ably no significant
increase in Pi 3
months after FOA
insertion versus
untreated
controls
(continued)
 Effects of FOAs on the periodontium: A SR of SRs 157

(Continued)
Study Intervention/ Outcome Study type Effect estimate Number of Conclusions GRADE
comparator participants
(studies)
Aa 10 days Narrative 122 (1 study) One study ⨁
after appli- showed that Aa VERY LOW e,f
ance removal decreased
10 days after
appliance inser-
tion to be similar
to the untreated
controls
Pg 10 days Narrative 122 (1 study) One study ⨁
after appli- showed that Pg VERY LOW e,f
ance removal didn’t change
10 days after
appliance inser-
tion and is not
significantly
greater than in
untreated
controls
Pi 10 days Narrative 122 (1 study) One study ⨁
after appli- showed that Pi VERY LOW e,f
ance removal didn’t change
10 days after
appliance inser-
tion and is not
significantly
greater than in
untreated
controls
Td 10 days Narrative 122 (1 study) One study showed ⨁
after appli- that Td signifi- VERY LOW e,f
ance removal cantly decreased
10 days after
appliance inser-
tion to be not sig-
nificantly greater
than in untreated
controls

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the
relative effect of the intervention (and its 95% CI).
CI: Confidence interval; MD: Mean difference; SMD: standardized mean difference; DG: downgrade; Aa: Aggregatibacter actino-
mycetemcomitans; GRADE: Grading of Recommendations Assessment, Development and Evaluation; RR: relative risk; Tf: Taner-
rela forsythia; Pg: P. gingivalis; Pi: P. intermedia; Td: T. denticola; FOA: Fixed orthodontic appliance; SLB: self ligating brackets;
CB: conventional brackets
GRADE Working Group grades of evidence
High certainty: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect,
but there is a possibility that it is substantially different.
Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of
the effect.
Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the
estimate of effect.
Explanations
(a) High and/or Unclear risk of bias in some items.
(b) Imprecise due to Wide Confidence interval and inclusion of few studies with limited sample size.
(c) High I2 value.
(d) Imprecise because data was not pooled.
(e) Data from non-randomized studies, retrospective and/or cross-sectional studies.
(f) Single study data with small sample size and a wide 95%CI that included no effect.
Other documents randomly have
different content
The Project Gutenberg eBook of Our Summer
Migrants
This ebook is for the use of anyone anywhere in the United States
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Title: Our Summer Migrants

Author: James Edmund Harting

Illustrator: Thomas Bewick

Release date: May 21, 2019 [eBook #59567]

Language: English

Credits: Produced by Chris Curnow, Stephen Hutcheson, and the

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*** START OF THE PROJECT GUTENBERG EBOOK OUR SUMMER

MIGRANTS ***
 OUR SUMMER MIGRANTS.

OUR SUMMER MIGRANTS.

AN ACCOUNT OF

THE MIGRATORY BIRDS

WHICH PASS THE SUMMER IN
THE BRITISH ISLANDS.

BY J. E. HARTING, F.L.S., F.Z.S.

AUTHOR OF A “HANDBOOK OF BRITISH BIRDS,” A NEW EDITION OF WHITE’S “SELBORNE,” ETC.,
ETC.

ILLUSTRATED FROM DESIGNS BY THOMAS BEWICK.

 LONDON:
BICKERS AND SON,
1, LEICESTER SQUARE.
1875.

CHISWICK PRESS:—PRINTED BY WHITTINGHAM AND WILKINS,

TOOKS COURT, CHANCERY LANE.

v
 PREFACE.

For those who reside in the country and have both leisure and
inclination to observe the movements and habits of birds, there is not
a more entertaining occupation than that of noting the earliest arrival
of the migratory species, the haunts which they select, and the
wonderful diversity which they exhibit in their actions, nidification,
and song.

There is something almost mysterious in the way in which numbers

of these small and delicately formed birds are found scattered in one
day over a parish where on the previous day not one was to be seen;
and the manner of their arrival is scarcely more remarkable than the
regularity with which they annually make their appearance.

That most of them reach this country after long and protracted
flights, crossing the Mediterranean, the Bay of Biscay, and the vi
English Channel is an undoubted fact. They have been seen to
arrive upon our shores, and have been observed at sea during their
passage, often at a considerable distance from land.

But how few of those who notice them in this country know where
they come from, why they come, what they find here to live upon,
how, when, and where they go for the winter!

In the following chapters an attempt has been made to answer these

questions, and to give such information generally about our summer
migratory birds as will prove acceptable to many who may be glad to
possess it without knowing exactly where to look for it. Some of
these sketches were originally published in the Natural History
columns of “The Field” during the summer of 1871, and as a reprint
has frequently been asked for, I have now carefully revised them and
made some important additions and emendations, besides adding to
the series a dozen or more chapters which have never before
appeared.

The illustrations, from designs by Thomas Bewick, will, it is vii

conceived, add considerably to the attractiveness of the
volume, and will enable the reader to dispense with particular
descriptions of the species, which it might be otherwise desirable to
furnish. These may be found, moreover, in other works devoted to
British Ornithology.

James Edmund Harting.

July, 1875.

ix
 CONTENTS.

Page
The Wheatear 1
The Whinchat 9
The Stonechat 13
The Wood Warbler 16
The Willow Warbler 24
The Chiff-chaff 28
The Nightingale 32
The Blackcap 44
The Orphean Warbler 51
The Garden Warbler 59
The Common Whitethroat 67
The Lesser Whitethroat 71
The Redstart 74
The Sedge Warbler 81
The Reed Warbler 83
The Grasshopper Warbler 86
Savi’s Warbler 88
The Aquatic Warbler 91
The Marsh Warbler 92
The Great Reed Warbler 101
The Rufous Warbler 103
The Pied Wagtail 106
The White Wagtail 110
The Grey Wagtail 112
The Yellow Wagtail 117
The Grey-headed Wagtail 121
The Meadow Pipit 124
The Rock Pipit 130
The Tree Pipit 135
The Water Pipit 138
Richard’s Pipit 142
The Tawny Pipit 146
The Pennsylvanian Pipit 149
The Red-throated Pipit 152
The Spotted Flycatcher 155
The Pied Flycatcher 160
The Swallow 170
The Martin 184
The Sand Martin 187
The Common Swift 191
The Alpine Swift 199
The Nightjar 204
The Cuckoo 219
The Wryneck 242
The Hoopoe 249
The Golden Oriole 262
The Red-backed Shrike 276
The Turtle-dove 282
The Landrail or Corncrake 288
General Observations 299
Conclusion 330
Index 335

1
 THE WHEATEAR.
(Saxicola œnanthe.)

One of the earliest of our feathered visitors to arrive is the Wheatear,

which comes to us as a rule in the second week of March; and,
although individuals have been seen and procured occasionally at a
much earlier date, there is reason to believe that the spring migration
does not set in before this, and that the birds met with previously are
such as have wintered in this country; for it has been well
ascertained that the Wheatear, like the Stonechat, occasionally 2
remains with us throughout the year. It is a noticeable fact that
those which stay the winter are far less shy in their habits, and will
suffer a much nearer approach.

The name Wheatear may have been derived either from the season
of its arrival, or from its being taken in great numbers for the table at
wheat harvest. Or, again, it may be a corruption of whitear, from the
white ear which is very conspicuous in the spring plumage of this
bird. Many instances are on record of Wheatears having come on
board vessels several miles from land at the period of migration, and
from the observations of naturalists in various parts of the country it
would appear that these birds travel by night, or at early dawn. I do
not remember any recorded instance in which they have been seen
to land upon our shores in the daytime.
[1]
In Ireland, according to Mr. Thompson, the Wheatear arrives 3
much later than in England, and does not stay the winter. With
[2]
regard to Scotland, Macgillivray states that it is nowhere more
plentiful than in the outer Hebrides, and in the Orkney and Shetland
Islands; and from the fact of his having observed the species near
Edinburgh on the 28th of February, we may infer that a few, as in
England, occasionally remain throughout the year.

The number of Wheatears which used to be taken years ago upon

the South Downs in autumn was a matter of notoriety.

“Hereabouts,” says an old chronicle of East-Bourne, “is the chief place

for catching the delicious birds called Wheatears, which much
resemble the French Ortolans;” and Wheatears play an important
part in the history of this town. Squire William Wilson, of Hitching,
Lord of the Manor of East-Bourne, was in Oliver Cromwell’s time
vehemently suspected of loyalty to the Stuarts; and one 4
Lieutenant Hopkins, with a troop of dragoons, swooped down on
Eastbourne to search the squire’s house, and, if needful, arrest him
as a Malignant. The squire was laid up with the gout; but Mistress
Wilson, his true wife, with the rarely-failing shrewdness of her sex,
placed before Lieutenant Hopkins and his troopers a prodigious pie
filled with Wheatears, “which rare repast,” the chronicle goes on to
say, “the soldiers did taste with so much amazement, delight, and
jollity,” that the squire upstairs had ample time to burn all the papers
which would compromise him, and when Lieutenant Hopkins, full of
Wheatear pie, came to search the house, there was not so much
treasonable matter found as could have brought a mouse within peril
of a præmunire. At the Restoration the Lord of the Manor became Sir
William Wilson of Eastbourne, a dignity well earned by his devotion to
the Royal cause; but the chronicle goes on to hint that Charles II.
was passionately fond of Wheatears, and that possibly the liberality
of the squire, in supplying his Majesty’s table with these 5
delicacies, may have had something to do with the creation of
the baronetcy.

The abundance of Wheatears at certain seasons on the Hampshire

downs was noticed by Gilbert White in a letter to the Hon. Daines
Barrington in Dec. 1773. Since this excellent naturalist penned his
observations, however, many changes in the haunts and habits of
birds have been remarked. For example, the Hawfinch, which he
referred to as “rarely seen in England, and only in winter,” is now
found to be resident throughout the year, and nesting even in the
proximity of London and other large cities. The Landrail, which he
noted as “a bird so rare in this district that we seldom see more than
one or two in a season, and those only in autumn,” is now so plentiful
in the same neighbourhood that I have shot as many as half a dozen
in one day in September, within a few miles of Selborne. The
Common Bunting, which in 1768 was considered to be a “rare bird” in
the district referred to, may now be heard there in full song—if 6
song it can be called—throughout the month of May. Whilst
walking from Liss to Selborne, I have on two occasions met with a
bird which Gilbert White had not observed—the Cirl Bunting; and, to
return to the Wheatears, these birds, which were formerly so plentiful
in autumn that the shepherds trapped them by dozens, are now far
less numerous at the same season, and the practice of snaring them
[3]
has perceptibly declined. It was remarkable that, although in the
height of the season—i.e., at wheat harvest—so many hundreds of
dozens were taken, yet they were never seen to flock, and it was a
rare thing to see more than three or four at a time; so that there
must have been a perpetual flitting and constant progressive
succession.

The Wheatear is partial to commons and waste lands, old 7

quarries, sand hills, and downs by the sea, and it is in these
situations that we may now look for him without much fear of
disappointment. Like all the chats, the Wheatear is very terrestrial in
its habits, seldom perching on trees, although often to be seen on
gate-posts and rails, where a broader footing is afforded it. Its song
is rather sprightly, and is occasionally uttered on the wing. The
contrast between the spring and autumn plumage of this bird is very
remarkable. If an old bird be examined in September, it will be found
that the white superciliary streak has almost disappeared; the colour
of the upper parts has become reddish brown; the throat and breast
pale ferruginous, lighter on the flanks and belly; while the primaries
and tail at its extremity are much browner. On raising the feathers of
the back, it will be found that the base of each feather is grey; and in
spring this colour supersedes the brown of winter, which is worn off,
and the upper parts assume a beautiful bluish grey, while the under
parts become pure white. In this species, therefore, it is evident 8
that the seasonal change of plumage is effected by a change of
colour in the same feather, and not by a moult.

The nest of the Wheatear is generally well concealed in the crevice of

a cliff or sandbank, or in an old rabbit burrow. Where these
conveniences are not accessible, the nest may be found at the foot of
a bush, screened from view by grass or foliage. The eggs, five or six
in number, are of a delicate pale blue, occasionally spotted at the
larger end with pale rust colour.

The geographical range of the Wheatear is very extensive for so

small and short-winged a bird. It is found in the Faroe Isles, Iceland,
and Greenland; in Lapland, Norway, Sweden, and Denmark;
throughout Europe to the Mediterranean; in Egypt, Arabia, Asia Minor,
and Armenia.

9
 THE WHINCHAT.
(Saxicola rubetra.)

Seldom appearing before the end of the first week in April, the
Whinchat arrives much later than the Wheatear, and is much less
diffused than that species. By the end of September it has again left
the country, and I have never met with an instance of its remaining
in England during the winter months. On several occasions
correspondents have forwarded to me in winter a bird which they
believed to be the Whinchat, but which invariably proved to be 10
a female, or male in winter plumage, of the Stonechat—a
species which is known to reside with us throughout the year, yet
receiving a large accession to its numbers in spring, and undergoing
corresponding decrease in autumn.

In the southern counties of England the Whinchat is sometimes very

numerous, and may be found in every meadow perched upon the tall
grass stems or dockweed. The abundance or scarcity of this species,
however, varies considerably according to season. In some years I
have noticed extraordinary numbers of this little bird, and in others
have scarcely been able to count two or three pairs in a parish. I
have generally found that a cold or wet spring has so affected their
migration as to cause them apparently to alter their plans, and induce
them to spend the summer but a short distance to the north or
north-west of their winter quarters.

It is a little remarkable that in Ireland the Whinchat is far less

common than the Stonechat, the reverse being the case in England.
Mr. Thompson says, in the work already quoted (p. 175), “In 11
no part of Ireland have I seen the Whinchat numerous, and
compared with the Stonechat it is very scarce.” In the south of
Scotland, according to Macgillivray, it seldom makes its appearance
before the end of April, that is, more than a fortnight after its arrival
in England. It extends to Sutherland, Caithness, and the outer
Hebrides (cf. More, “Ibis,” 1865, p. 22), and has occasionally been
met with in Orkney, but not in Shetland. In winter it migrates to the
south-east, and at that season is not uncommon in Egypt, Nubia, and
Abyssinia, travelling also through Asia Minor, Arabia and Persia, as far
eastward as the north-west provinces of India. In a south-westerly
direction this species, passing through Spain and Portugal, proceeds
down the west coast of Africa to Senegal, Gambia, and Fantee.

The Whinchat differs a good deal in its habits from the Wheatear, and
on this account, as well as on account of certain differences of
structure, it has been placed with the Stonechat and other 12
allied species in a separate genus (Pratincola). It is doubtful,
however, whether these differences are sufficient to entitle them to
anything more than a specific separation.

The Whinchat perches much more than does the Wheatear, and may
be seen darting into the air for insects, after the manner of a
Flycatcher. It derives its name, of course, from the fact of its being
found upon the whin, or furze, a favourite perch also for its congener
the Stonechat. The derivation of the word whin I have never been
able to ascertain.

Although the two species are frequently confounded, the Whinchat

may be always distinguished from the Stonechat by its superciliary
white streak, by the lighter-coloured throat and vent, and by the
white bases of the three outer tail feathers on each side. Both
species make a very similar nest, which is placed on the ground and
well concealed, and lay very similar eggs, of a bright blue faintly
speckled at the large end with rust colour.

13
 THE STONECHAT.
(Saxicola rubicola.)

As has been already stated, the Stonechat may be found in a few

scattered pairs throughout the country all the year round. At the
beginning of April, however, a considerable accession to its numbers
is observed to take place, owing to a migration from the south and
south-east. It takes up its residence on moors and heaths, and many
a lonely walk over such ground is enlivened by the sprightly actions
and sharp “chook-chook” of this little bird. The male in his 14
wedding dress, with jet black head, white collar, and
ferruginous breast, is extremely handsome; and the artist who is fond
of depicting bird-life would scarcely find a prettier subject than a
male Stonechat in this plumage upon a spray of furze in full bloom.

In Ireland the Stonechat is considered to be a resident species, and

this is attributed by Mr. Thompson to the mild winters of that island.
In Scotland, on the contrary, Sir Wm. Jardine has observed that the
Stonechat is not nearly so abundant as either the Whinchat or the
Wheatear, and frequents localities of a more wild and secluded
character. It ranges, however, to the extreme north of the mainland
of Scotland, and is included by Dr. Dewar in his list of birds which he
found nesting in the Hebrides. It is said not to breed in either Orkney
[4]
or Shetland.

The geographical range of the Stonechat is rather more extensive

than that of the Whinchat, for besides being found throughout 15
the greater part of Europe to the Mediterranean, it goes by way
of Senegal to South Africa, and extends eastward through Asia Minor,
Palestine, and Persia, to India and Japan. In Europe, however, its
distribution is somewhat remarkable, inasmuch as it is confined
chiefly to the central and southern portions of the continent, and in
Norway and Sweden is unknown. The Whinchat, on the other hand,
breeds in these countries, and has been met with as far north as
Archangel. In winter the male Stonechat loses the black head, and
the colours in both sexes are much less vivid than in summer. Here
again, as with the Wheatear, the change of plumage seems to be
effected by a change of colour in the same feathers, and not by a
moult.

Apropos of this subject, the reader may be referred to an article

contributed by me to the Natural History columns of “The Field,” 16th
September, 1871, on variation of colour in birds.

16
 THE WOOD WARBLER.
(Phylloscopus sibilatrix.)

Although often taken to comprehend every species of warbler,

[5]
Professor Newton has recently shown that the genus Sylvia of
Latham should be restricted to the group of fruit-eating warblers next
to be described, and that the generic term which has priority for the
willow wren group is Phylloscopus of Boie.

From its larger size, brighter colour, and finer song, the Wood
Warbler deserves to be first noticed; and the first step should 17
be to distinguish it from its congeners. Perhaps none of the
small insectivorous birds have been more confounded one with
another than have the members of this group, not only by observers
of the living birds, but by naturalists with skins of each before them.
Taking the three species which annually visit us—i. e., the Wood
Warbler, the Willow Warbler, and the Chiff-chaff—it will be found on
comparison that they differ in size as follows—

Length. Wing. Tarsus.

Wood Warbler 5·2 in. 3·0 in. 0·7 in.
Willow Warbler 5·0 ” 2·6 ” 0·7 ”
Chiff-chaff 4·7 ” 2·4 ” 0·6 ”

Not only is the Wood Warbler the largest of the three, but it has
comparatively the longest wings and the longest legs. The wings,
when closed, cover three-fourths of the tail. In the Willow Wren,
under the same circumstances, less than half the tail is hidden. The
Chiff-chaff’s wing is shorter again. In my edition of White’s
“Selborne,” founded upon that of Bennett, 1875, pp. 56, 57, will 18
be found a long footnote on the subject, with woodcuts
illustrating the comparative form of the wing in these three birds. Mr.
Blake-Knox, in “The Zoologist” for 1866, p. 300, has pointed to the
second quill-feather, depicted in a sketch accompanying his
[6]
communication, as being an unfailing mark of distinction. When we
reflect, however, upon the variation which is found to exist in the
length of feathers, owing to the age of the bird, moult, or accident,
too much stress ought not to be laid upon this as a character. At the
same time there is no doubt that, taken in connection with other
details, it will often assist the determination of a species. After
examining a large series of these birds, I have come to the
conclusion that, as regards the wings, the following formulæ may be
relied on: Wood Warbler, 2nd=4th; 3rd and 4th with outer 19
webs sloped off towards the extremity. Willow Warbler,
2nd=6th; 3rd, 4th, and 5th sloped off. Chiff-chaff, 2nd=7th; 3rd, 4th,
5th, and 6th sloped off.

The Wood Warbler is much greener on the back and whiter on the
under parts than either of its congeners, and has a well-defined
superciliary streak of sulphur-yellow, which, in the Willow Wren, is
much shorter and paler. The legs of the Wood Warbler and Willow
Wren are brownish flesh-colour, while those of the Chiff-chaff are
dark brown. After the first moult, the young of all three species are
much yellower in colour than their parents. Hence the mistake which
Vieillot made in describing the young of P. trochilus as a distinct
species under the name of flaviventris.

Although the majority of the Sylviidæ are fruit-eaters, the species

[7]
now under consideration are almost entirely insectivorous; they are
also more strictly arboreal in their habits, and as regards the 20
character of their nests, they differ remarkably from other
members of the Sylviidæ in building domed nests on or near the
ground, instead of cup-shaped nests at a distance from it. The
Yellow-billed Chiff-chaff—or Icterine Warbler, as it should now be
 [8]
called —however, forms an exception to the rule, as will be seen
later. As these little birds make their appearance at a season when
caterpillars and destructive larvæ begin to be troublesome, the good
they do in ridding the young leaves and buds of these pests is
incalculable. I have watched a Willow Wren picking the green aphis
off a standard rose-tree, and have been as much astonished at the
quantity which it consumed as at the rapidity of the consumption.
The Wood Warbler is not nearly so sociable as either the Willow
Warbler or the Chiff-chaff. It keeps to the tops of trees in woods and
plantations, and seldom comes into gardens; hence it is not so often
seen. Although not rare, it is somewhat local, and in the British 21
Islands, it appears, is confined exclusively to England and the
south of Scotland. Mr. Thompson has included it with hesitation
amongst the birds of Ireland; for although the description given to
him of certain birds and eggs seemed to apply to this species, it was
stated that the nest which contained the eggs was lined with
feathers. Now, the Willow Wren invariably makes use of feathers for
this purpose, but the Wood Warbler does not. The nest of the latter is
composed entirely of dry grass and leaves, occasionally mixed with a
little moss; and although I have sometimes found horsehair inside, I
do not remember to have seen or heard of an instance in which any
feathers were employed. The eggs, five or six in number, are white,
closely freckled over with reddish brown.

Mr. Blake-Knox, a well-known naturalist, resident in the county of

Dublin, says (“Zoologist,” 1866, p. 300), “I tried very hard this year to
add the Wood Wren to our Dublin avifauna, and though I killed 22
some dozens of snowy-white-bellied Willow Wrens, they were
all the common Sylvia trochilus. That the bird is Irish I am sure, for I
have heard it. Should an Irish ornithologist see this, will he try for it,
if he should live in a wooded district, such as the counties Wicklow
and Wexford? I am sure it is neglected for want of a certain
distinction.” Since this note was published, the Wood Wren has
actually been obtained in Ireland, a specimen having been shot in the
county of Fermanagh by Sir Victor Brooke, and preserved by him in
June, 1870. Another was obtained the same year at Glen Druid in the
county of Dublin, as reported by Mr. Blake-Knox. Both Sir William
Jardine and Macgillivray have referred to the Wood Warbler being
found northward to the middle districts of Scotland, a circumstance
which appears to have been overlooked by Mr. Yarrell, since he says
(vol. i. p. 349, 3rd edit.), “I am not aware of any record of its
appearance in Scotland.” This statement, however, has been rectified
in the fourth edition of this standard work by Professor 23
Newton, who remarks: “In Scotland it is known to breed
regularly in the counties of Dumfries, Wigton, Lanark and Berwick,
the Lothians and Perthshire, and occasionally in those of Roxburgh,
Selkirk, Renfrew and Stirling.” Mr. A. G. More, in an article “On the
Distribution of Birds in Great Britain during the Nesting Season,”
published in the “Ibis” for 1865, observes (p. 26), that the Wood
Warbler “in Scotland ranges further north than the Chiff-chaff, having
been observed by the Duke of Argyle in Argyleshire and at Balmoral.”

According to Mr. Robert Gray, of Glasgow, it has been observed in

Inverness and Aberdeenshire, and Mr. Edwards has found it in
Banffshire.

Beyond the British Islands the Wood Warbler is found throughout

Europe, though rare in the north, and it extends eastward to Siberia
and southward to Algeria, Egypt and Abyssinia. It arrives in this
country generally about the middle of April, and leaves again in
September.

24
 THE WILLOW WARBLER.
(Phylloscopus trochilus.)

The Willow Warbler is much more generally distributed than the last-
named bird; but it is possible that it is considered commoner from
the difference in the haunts of the two species—the Wood Warbler, as
already remarked, keeping further away from habitations. As a rule,
the Willow Wren arrives in this country about the end of the first
week in April—that is to say, before the Wood Warbler, but not 25
so early as the Chiff-chaff, which is the first of the genus to
appear.

Yarrell speaks of these birds as “having acquired with us the general

name of Willow Warblers, or Willow Wrens, from their prevailing
green colour;” but Thompson, in his “Birds of Ireland” (i. p. 192),
says, “this name was doubtless bestowed upon the bird originally on
account of its partiality to willows, which I have frequently remarked,
the twigs and branches of the common osier (Salix viminalis)
abounding with aphides, being on such occasions its chief favourite.”
There is yet another suggestion—i. e., that the name may have been
bestowed from the circumstance that these little birds make their
appearance just as the willow is budding.

It is marvellous how these tiny creatures can sustain the protracted

flights which are necessary to transport them from their winter to
their summer quarters; and yet that they make these long journeys is
well ascertained. On the 23rd of April a Willow Wren came on board a
vessel eighty miles from Malta and fifty from Cape Passaro, the 26
nearest land. Two days later another alighted on the rigging
sixty miles from Calabria, and one hundred and thirty-five from Mount
Etna. On the 26th of April, eighty miles from Zante and one hundred
and thirty from Navarino, a Willow Wren and a Chiff-chaff were found
dead on board, presumably from exhaustion, as they were apparently
uninjured. Many other such instances are on record.

The present species may be regarded as the commonest of the three

which visit us, being generally dispersed in favourable localities over
the whole of Great Britain and Ireland. Although it has not been met
with in the Hebrides, the Willow Wren has occasionally been seen in
Orkney, and the late Dr. Saxby has recorded a single instance of its
occurrence in Shetland. Through every country in Europe it seems to
be well known as a periodical migrant.

The winter quarters of the Willow Wren are to a certain extent those
of its congeners, that is to say, Northern Africa and Palestine, where
it is very numerous in the cold season, but it has been found 27
much further southward. Mr. Ayres sent a specimen to Mr.
Gurney from Natal; the late Mr. Andersson met with it in Damaraland,
S.W. Africa; and Mr. Layard some years since procured specimens at
the Cape. As is often the case with allied species, the remarks as to
habits and food which have been applied to the Wood Warbler will
apply almost equally well to the present species. The distinction
between the birds themselves has been already pointed out. The
nests of the Willow Wren and Chiff-chaff are both lined with feathers,
the eggs of the former being white spotted with red; while those of
the latter are white spotted with purple, chiefly at the larger end.

Varieties in this group of birds are rarely met with, and it may
therefore be worth notice that in May, 1861, a primrose-coloured
Willow Wren was shot at Witley Park, in the parish of Witley, Surrey,
and forwarded for inspection to the editor of “The Field.”

28
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