Original Article

The biomechanics of posterior maxillary arch expansion using fixed labial

and lingual appliances
Harsimrat Kaura; Brandon Owenb; Bill Tranc; Raymond Guand; Jeramy Luod; Alexander Granleyd;
Jason P. Careye; Paul W. Majorf; Dan L. Romanykg

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ABSTRACT
Objective: To compare the biomechanics of straight labial, straight lingual, and mushroom lingual
archwire systems when used in posterior arch expansion.
Materials and Methods: An electro-mechanical orthodontic simulator allowing for buccal–lingual
and vertical displacements of individual teeth and three-dimensional force/moment measurements
was instrumented with anatomically shaped teeth for the maxillary arch. In-Ovation L brackets were
bonded to lingual surfaces, and Carriere SLX brackets were bonded to labial surfaces to ensure
consistency of slot dimensions. Titanium molybdenum archwires were bent to an ideal arch form,
and the teeth on the orthodontic simulator were set to a passive position. Posterior teeth from the
canine to second molar were moved lingually to replicate a constricted arch. From the constricted
position, the posterior teeth were simultaneously moved until the expansive force decreased below
0.2 N. Initial force/moment systems and the amount of predicted expansion were compared for
posterior teeth at a significance level of a ¼ 0.05.
Results: Archwire type affected both the expected expansion and initial force/moment systems
produced in the constricted position. In general, the lingual systems produced the most expansion.
The archwire systems were not able to return the teeth to their ideal position, with the closest
system reaching 41% of the intended expansion.
Conclusions: In general, lingual systems were able to produce greater expansion in the posterior
regions when compared with labial systems. However, less than half of the intended arch
expansion was achieved with all systems tested. (Angle Orthod. 2020;90:688–694.)
KEY WORDS: Orthodontic biomechanics; Arch expansion; Orthodontic simulator; Fixed
appliances

INTRODUCTION proved digital treatment planning techniques,1,2 fixed

lingual appliances pose a potential esthetic alternative
With the advent of new bonding techniques, archwire to fixed labial appliances. Despite their potential
materials, advanced laboratory techniques, and im- alternative, there is limited literature on the biome-

a
PhD Student, Department of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
b
Private Practice, Fort Collins, Colo, USA.
c
MSc Student, Department of Mechanical Engineering, Faculty of Engineering, University of Alberta, Edmonton, Alberta, Canada.
d
Undergraduate Student, Department of Mechanical Engineering, Faculty of Engineering, University of Alberta, Edmonton, Alberta,
Canada.
e
Professor and Associate Dean, Department of Mechanical Engineering, Faculty of Engineering, University of Alberta, Edmonton,
Alberta, Canada.
f
Professor and Department Chair, Department of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton,
Alberta, Canada.
g
Assistant Professor, Department of Mechanical Engineering, Faculty of Engineering and School of Dentistry, Faculty of Medicine
and Dentistry University of Alberta, Edmonton, Alberta, Canada.
Corresponding author: Dr Dan L. Romanyk, Assistant Professor, Department of Mechanical Engineering, Adjunct, School of Dentistry,
University of Alberta, Edmonton, Alberta, Canada
(e-mail: dromanyk@ualberta.ca)
Accepted: May 2020. Submitted: January 2020.
Published Online: June 29, 2020
Ó 2020 by The EH Angle Education and Research Foundation, Inc.

Angle Orthodontist, Vol 90, No 5, 2020 688 DOI: 10.2319/010520-859.1

ARCH EXPANSION BIOMECHANICS WITH FIXED APPLIANCES 689

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Figure 1. Overall schematic of the orthodontic simulator, an in vitro electromechanical device used to measure force and moment systems on
each tooth.

chanical behavior3,4 of fixed lingual appliances. As set-up with the exception of the full amount of planned
forces and moments generated by activated applianc- expansion. Other authors have suggested that lingual
es are the driving factors for resulting tooth movement, appliances have restrictive transverse effect when
understanding the biomechanics of lingual fixed compared with their labial counterpart in the premolar
appliances is critical for their clinical efficacy. and molar region.10,11 Although qualitative evidence
The biomechanics of fixed lingual mechanotherapy surrounding archwire expansion exists, quantitative
is different from that of fixed labial appliances as the evidence regarding the amount of expected expansion
point-of-force application with respect to the center of and the force and moment systems produced remains
resistance (CR) of teeth varies between the two elusive. Thus, the overall goal of this in vitro study was
appliances and the interbracket distance is substan- to elucidate the initial biomechanical systems produced
tially smaller in lingual treatment. The mushroom by straight lingual, mushroom lingual, and fixed labial
lingual archwire, introduced by Fujita,5 has a first-order appliances and to simulate the expected amount of
bend between the canine and first premolar that expansion for posterior teeth using an expected force
increases the length of archwire between the canine threshold to produce tooth movement.
and first premolar. The bend also alters how the
archwire deforms when exposed to tooth movements MATERIALS AND METHODS
that, in turn, affects the magnitude of applied forces
and moments. The first-order bend further allows for a An in vitro electro-mechanical orthodontic simulator
close adaptation of brackets to the teeth for the (OSIM; Figure 1) was used to quantify the forces and
mushroom lingual archwire. The straight lingual arch- moments generated around a simulated maxillary arch.
wire6 requires a thicker composite base between the A full detailed description of the OSIM and its
tooth and bracket that further decreases the interbrack- components for reference was provided in previous
et distance for the lingual appliance and can potentially studies.7,12 Briefly, it has horizontal and vertical
change the location of load application with respect to micrometers that allow for the control of simulated
the CR.7 Prior research has also demonstrated tooth movement in the buccal–lingual and vertical
significant differences in the biomechanical systems directions, respectively. The point of load application at
of straight and mushroom lingual archwires.7,8 simulated teeth is away from the point of load
Dental arch expansion through an engaged archwire measurement using six-axis load cells (Nano17, ATI
is one of the strategies used in orthodontics to resolve Industrial Automation, Apex, NC), which are rigidly
dental crowding. Grauer and Proffit9 demonstrated that fixed to the simulated teeth, as highlighted in Figure 1.
fully customized lingual orthodontic appliances were A FARO arm coordinate measurement machine
accurate in achieving the goals planned in the initial (FARO, Lake Mary, Fla) was used to determine the

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690 KAUR, OWEN, TRAN, GUAN, LUO, GRANLEY, CAREY, MAJOR, ROMANYK

Table 1. Sign Conventions for Positive Sense of Forces and Table 2. Lingual Movement of Teeth to Simulate a Constricted
Moments of Interest in Quadrants 1 and 2 of the Simulated Maxillary Maxillary Arch
Archa
Tooth Lingual Movement (mm)
Region Fx Fy Mx
Second molar 0.96
Quadrant 1 Mesial Buccal Moment causing buccal root tip First molar 1.65
Quadrant 2 Distal Buccal Moment causing buccal root tip Second premolar 1.83
First premolar 1.70
a
Fx indicates mesial–distal force; Fy, buccal–lingual force; Mx,
third-order moment. Canine 0.69

Jacobian transformation matrices between the load cell ensure any cases of buccal-directed force were

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and approximated CR of each tooth, as reported in mitigated to achieve an idealized initial position. In
previous work.7 The OSIM has been used previously to comparing the lingual displacements per tooth from the
investigate force and moment systems in simulated current study in Table 2 to those from Mikulencak,13 the
malocclusions for both fixed labial12 and lingual values used in this study were within one standard
appliances.7 The sign conventions for forces and deviation of the data from the clinical study.
moments of interest in this study are provided in Table Upon moving teeth from the canine to the second
1. Fy represents the amount of force directed in the molar to the initial constricted position, forces and
buccal–lingual direction causing expansion, and Mx moments of interest were recorded. From that position,
represents the expected third-order moment that would any tooth that had buccal forces (Fy) larger than a
arise from the applied expansion force at a distance threshold of 0.2 N were simultaneously moved in the
from the CR. As the OSIM can only move teeth in the buccal direction by 0.01 mm. This incremental opera-
buccal–lingual and vertical directions, Fx was also of tion occurred on a given tooth until the measured Fy
interest to observe how much force in the mesial–distal force fell below the threshold. The procedure for a
direction arises compared with the expected expansion given archwire trial continued until all teeth from the
force direct in the buccal direction. canine to the second molar had Fy values below 0.2 N.
Simulated stainless steel teeth on the OSIM were The threshold of 0.2 N was conservatively based on
positioned corresponding to a mushroom lingual arch the minimum force levels found in the orthodontic
form. In-Ovation L brackets with a 0.018 00 3 0.025 00 literature that resulted in clinically observed tooth
nominal slot dimension (Dentsply GAC, York, Pa) were movements.14–16 The distance that the teeth were
bonded using Transbond XT (3M Unitek, Morovia, moved was recorded for each archwire. The percent-
Calif) on the lingual surfaces of the simulated teeth. age of expansion achieved by the appliance was
The teeth were moved so that all forces and moments defined as a ratio between the total buccal displace-
acting on any tooth were less than 0.1 N and 5 Nmm, ment produced at a particular tooth and the amount of
respectively. The resulting archform represented the initial lingual movement to the constricted position.
ideal position for all groups tested. After the set-up for Archwires (n ¼ 30/group) were bent by a single
mushroom lingual archwire was completed, measure- experienced clinician (Dr Owen) using a template.
ments using 0.0175 00 3 0.0175 00 custom bent mush- For each archwire tested (ie, per trial), the initial
room lingual titanium molybdenum archwires (G&H force and moment values and the amount of expansion
Orthodontics, Franklin, Ind) were obtained. Following for each tooth (eg, canine in the first and second
the mushroom lingual archwire tests, the brackets were quadrants) were averaged across the arch. Repeated
rebonded to conform with a 0.0175 00 3 0.0175 00 straight
measures of analysis of variance were used to assess
lingual archwire also made from titanium molybdenum
the forces/moments and amount of expansion among
(G&H Orthodontics). A similar procedure was followed
the straight labial, mushroom lingual, and straight
for straight labial archwire testing where Carriere SLX
lingual archwires. Multiple comparisons were adjusted
brackets (Henry Schein Orthodontics, Carlsbad, Calif),
using Bonferroni corrections. Statistical significance
also with a 0.018 00 3 0.025 00 nominal slot size, and
was set at 0.05.
0.0175 00 3 0.0175 00 labial titanium molybdenum arch-
wires (G&H Orthodontics) were used.
RESULTS
For all three archwire groups, teeth from the canine
to second molar were moved in the lingual direction to The expansion data for all teeth are presented in
a narrow position simulating a constricted maxillary Tables 3 and 4. All three archwires produced maximum
arch (Table 2). Constricted values were first set using a expansion on the first premolar where straight lingual
mushroom lingual archwire based on the mean expanded the first premolar by 0.70 mm and straight
measured expansion per tooth in a related clinical labial and mushroom lingual archwires by 0.42 mm.
study by Mikulencak.13 They were then adjusted to The second molar experienced no expansion with any

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ARCH EXPANSION BIOMECHANICS WITH FIXED APPLIANCES 691

Table 3. Mean Expansion for the Three Archwire Groups Tested and Their Percent Expansion (n ¼ 30 for Each Archwire)
Tooth Group Mean Expansion (mm) 6 SDa % Expansion
Second molar Straight labial 0.02 6 0.034 –
Straight lingual 0.00 6 0.000 –
Mushroom lingual 0.02 6 0.019 –
First molar Straight labial 0.07 6 0.096 4
Straight lingual 0.36 6 0.064 22
Mushroom lingual 0.07 6 0.116 4
Second premolar Straight labial 0.18 6 0.075 10
Straight lingual 0.46 6 0.129 25
Mushroom lingual 0.18 6 0.102 10

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First Premolar Straight labial 0.42 6 0.070 25
Straight lingual 0.70 6 0.159 41
Mushroom lingual 0.42 6 0.119 25
Canine Straight labial 0.14 6 0.073 20
Straight lingual 0.19 6 0.090 28
Mushroom lingual 0.15 6 0.060 22
a
SD indicates standard deviation.

of the three archwires. Straight lingual archwires N) was measured on the first premolar for all groups
created significantly (P , .05) more expansion on all with a significant difference (P , .001) between the
teeth compared with the mushroom lingual and straight straight lingual and the other two archwires. Straight
labial archwires. Specifically, the straight labial and lingual archwires exerted significantly larger initial
mushroom lingual archwires produced comparable buccal–lingual forces on all teeth except for the second
expansion (0.42 mm), but significantly less (P , premolar, where the mushroom lingual archwire
.001) than the straight lingual archwire for the first measured the largest mean Fy (0.95 N). The straight
premolar. For the second premolar and first molar, the labial archwires exerted the lowest initial force on all
straight lingual archwire produced significantly greater teeth except the first premolar where the mushroom
expansion (P , .001 and P , .001, respectively) lingual group was the lowest (1.18 N).
compared with the straight labial and mushroom lingual The maximum Mx was generated at the first
archwires. The straight lingual archwire produced premolar by the straight labial (12.81 Nmm), straight
marginally (P , .05) more expansion compared with lingual (12.40 Nmm), and mushroom lingual (11.63
the straight labial and mushroom lingual archwires on Nmm) archwires. The straight labial archwire produced
the canine. significantly lower moment at the canine (0.35 Nmm)
The initial Fy, Mx, and Fx values collected at the and first molar (0.02 Nmm) compared with the fixed
initial constricted position are provided in Tables 5 to 9. lingual archwires. Moments varied among teeth for
The maximum initial buccal force (straight lingual, 1.88 straight and mushroom lingual archwires. For the
N; straight labial, 1.28 N; and mushroom lingual, 1.18 canine (7.71 Nmm) and second premolar (8.20

Table 4. Pairwise Comparisons of Expansion Among the Three Archwires With Bonferroni Corrections (a ¼ 0.05)a
Mean
Tooth Group Group Difference (mm) SE P 95% CI
Second molar Straight labial Straight lingual 0.02 0.01 .01* 0.03 to 0.00
Mushroom lingual 0.01 0.01 1.00 0.01 to 0.01
Mushroom lingual Straight lingual 0.02 0.01 .01* 0.03 to 0.00
First molar Straight labial Straight lingual 0.29 0.02 .00** 0.33 to 0.24
Mushroom lingual 0.00 0.02 1.00 0.05 to 0.05
Mushroom lingual Straight lingual 0.29 0.02 .00** 0.33 to 0.24
Second premolar Straight labial Straight lingual 0.28 0.03 .00** 0.33 to 0.23
Mushroom lingual 0.00 0.03 1.00 0.05 to 0.05
Mushroom lingual Straight lingual 0.28 0.03 .00** 0.33 to 0.23
First premolar Straight labial Straight lingual 0.28 0.03 .00** 0.34 to 0.23
Mushroom lingual 0.00 0.03 1.00 0.01 to 0.06
Mushroom lingual Straight lingual 0.28 0.03 .00** 0.34 to 0.23
Canine Straight labial Straight lingual 0.05 0.02 .02* 0.09 to 0.01
Mushroom lingual 0.01 0.02 .68 0.05 to 0.03
Mushroom lingual Straight lingual 0.04 0.02 .05 0.08 to 4.9E-5
a
CI indicates confidence interval; SE, standard error. * significant; ** highly significant.

Angle Orthodontist, Vol 90, No 5, 2020

692 KAUR, OWEN, TRAN, GUAN, LUO, GRANLEY, CAREY, MAJOR, ROMANYK

Table 5. Mean Buccal–Lingual Forces, Fy, Acting on the Teeth of Table 7. Mean Third-Order Moment, Mx, Acting on the Teeth of
Interest (n ¼ 30 for Each Archwire) Interest (n ¼ 30 per Archwire)
Tooth Group Mean (N) 6 SDa Tooth Group Mean (Nmm) 6 SDa
Second molar Straight labial 0.23 6 0.09 Second molar Straight labial 0.65 6 1.87
Straight lingual 0.60 6 0.05 Straight lingual 3.65 6 0.89
Mushroom lingual 0.30 6 0.26 Mushroom lingual 3.02 6 1.97
First molar Straight labial 0.08 6 0.19 First molar Straight labial 0.02 6 1.91
Straight lingual 0.70 6 0.10 Straight lingual 6.07 6 1.32
Mushroom lingual 0.17 6 0.41 Mushroom lingual 0.52 6 2.80
Second premolar Straight labial 0.03 6 0.11 Second premolar Straight labial 0.85 6 1.25
Straight lingual 0.29 6 0.12 Straight lingual 0.10 6 1.15

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Mushroom lingual 0.95 6 0.45 Mushroom lingual 8.20 6 3.73
First premolar Straight labial 1.28 6 0.28 First premolar Straight labial 12.81 6 4.99
Straight lingual 1.88 6 0.17 Straight lingual 12.40 6 1.21
Mushroom lingual 1.18 6 1.14 Mushroom lingual 11.63 6 5.21
Canine Straight labial 0.04 6 0.41 Canine Straight labial 0.35 6 4.80
Straight lingual 0.67 6 0.24 Straight lingual 6.80 6 2.77
Mushroom lingual 0.60 6 1.09 Mushroom lingual 7.71 6 6.59
a
SD indicates standard deviation. a
SD indicates standard deviation.

Nmm), the mushroom lingual archwire exerted signif- archwire groups. There was negligible expansion and
icantly (P , .001) greater moment compared with the initial expansion forces exerted by any of the three
straight lingual archwire. Alternatively, the straight archwire groups on the second molar.
lingual archwire produced significantly more (P , The fixed straight lingual archwire produced more
.001) moment at the first molar (6.07 Nmm) compared mean expansion than the labial counterpart and
with the mushroom lingual archwire. mushroom lingual archwire for the same amount of
When considering Fx (mesial–distal forces), only the activation for almost all the tested teeth. The inter-
straight labial archwire produced a force on the second bracket distance between teeth (ie, length of archwire
molar that surpassed the proposed threshold of 0.2 N between two teeth) is less for the fixed lingual
necessary to cause tooth movement. Compared with appliances compared with a fixed labial appliance.
buccal–lingual forces, Fy, the measured mesial–distal The reduced distance increases the stiffness of an
forces were substantially smaller in magnitude (Table 9). archwire, and thus the force generated is more by the
two lingual archwire systems compared with the labial
DISCUSSION archwire. However, the initial buccal forces generated
Initial force levels and the total amount of expansion at the first premolars by the mushroom lingual archwire
varied among the tested archwire groups. Maximum was less compared with the other two archwires. This
expansion, expansion buccal–lingual forces, and mo- could be explained by the first-order bend between the
ments were observed at the first premolar for all three canine and first premolar that incorporates more

Table 6. Pairwise Comparisons of Buccal–Lingual Forces, Fy, With Bonferroni Corrections (a ¼ 0.05)a
Mean
Tooth Group Group difference (N) SE P 95% CI
Second molar Straight labial Straight lingual 0.35 0.05 ,.001** 0.28 to 0.46
Mushroom lingual 0.07 0.05 .10 0.2 to 0.16
Mushroom lingual Straight lingual 0.30 0.05 ,.001** 0.21 to 0.39
First molar Straight labial Straight lingual 0.62 0.07 ,.001** 0.75 to 0.48
Mushroom lingual 0.25 0.07 .001** 0.11 to 0.38
Mushroom lingual Straight lingual 0.86 0.07 ,.001** 0.99 to 0.73
Second premolar Straight labial Straight lingual 0.32 0.08 ,.001** 0.17 to 0.47
Mushroom lingual 0.92 0.08 ,.001** 1.07 to 0.76
Mushroom lingual Straight lingual 1.24 0.08 ,.001** 1.09 to 1.39
First premolar Straight labial Straight lingual 0.61 0.18 .001** 0.96 to 0.26
Mushroom lingual 0.10 0.18 .58 0.25 to 0.45
Mushroom lingual Straight lingual 0.71 0.18 ,.001** 1.06 to 0.35
Canine Straight labial Straight lingual 0.71 0.18 ,.001** 0.37 to 1.06
Mushroom lingual 0.56 0.18 .002** 0.91 to 0.21
Mushroom lingual Straight lingual 1.27 0.18 ,.001** 0.92 to 1.62
a
CI indicates confidence interval; SE, standard error; **, highly significant.

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ARCH EXPANSION BIOMECHANICS WITH FIXED APPLIANCES 693

Table 8. Pairwise Comparisons of Third-Order Moments, Mx, of the Three Archwires With Bonferroni Corrections (a ¼ 0.05)a
Mean
Tooth Group Group Difference (Nmm) SE P 95% CI
Second molar Straight labial Straight lingual 4.30 0.43 ,.001** 5.15 to 3.45
Mushroom lingual 3.68 0.43 ,.001** 4.52 to 2.83
Mushroom lingual Straight lingual 0.62 0.43 .15 1.47 to 0.23
First molar Straight labial Straight lingual 6.10 0.54 ,.001** 5.02 to 7.18
Mushroom lingual 0.50 0.54 .36 1.57 to 0.58
Mushroom lingual Straight lingual 6.59 0.54 ,.001** 5.51 to 7.67
Second premolar Straight labial Straight lingual 0.75 0.61 .22 1.96 to 0.46
Mushroom lingual 7.34 0.61 ,.001** 6.13 to 8.56

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Mushroom lingual Straight lingual 8.09 0.61 ,.001** 9.31 to 6.88
First premolar Straight labial Straight lingual 0.41 1.09 .71 2.58 to 1.75
Mushroom lingual 1.18 1.09 .28 3.34 to 0.99
Mushroom lingual Straight lingual 0.76 1.09 .49 1.40 to 2.93
Canine Straight labial Straight lingual 7.15 1.28 ,.001** 9.70 to 4.60
Mushroom lingual 7.36 1.28 ,.001** 4.80 to 9.91
Mushroom lingual Straight lingual 14.51 1.28 ,.001** 17.06 to 11.95
a
CI indicates confidence interval; SE, standard error; **, highly significant.

archwire length and the changed shape of the archwire lingual archwires. This is in accordance with the
that could alter the resulting mechanics. The initial difference in the force applied by the fixed labial and
buccal force levels were significantly more with straight fixed lingual appliances. This reflects that there will be
lingual archwires compared with the mushroom lingual less of a change in third-order rotation with fixed labial
archwires possibly because of the short interbracket appliances compared with fixed lingual appliances.
span17 of straight lingual archwires caused by the Overall, all three archwires produced less than 42%
increased thickness of the composite base for the of the intended expansion with maximum expansion at
bracket compared with closely adapted mushroom the premolar region. These results were consistent
lingual brackets. with the clinical results of the study by Grauer and
All three archwires generated clinically significant Proffit9 that suggested that a fully customized lingual
(.5 Nmm)7 moments on the first premolars even appliance did not achieve the full planned expansion.
though an archwire cross-section of 0.0175 3 0.0175
Therefore, clinically, this study suggests minimum
titanium molybdenum archwire (TMA) was used that is
activation to be twice the intended expansion for both
suggested to be of sufficient thickness to create a
labial and lingual fixed archwires in orthodontic
couple (in the 0.018 00 3 0.025 00 bracket system) to
patients. Straight lingual archwires produced more
counter the moment created by the application of force
expansion than the mushroom lingual and straight
away from the CR of the tooth.18 Moments generated
by the three archwires concurred with the applied labial archwires on the tested teeth for a simulated
forces except for the canine where mushroom lingual constricted arch. From a clinical standpoint, should
archwires generated more moment that could tip the archwire expansion be a likely component of treatment,
root buccally compared with the straight lingual these results make a good argument for using straight
archwires that generated an opposing moment that lingual archwires for constricted arch cases. Interest-
could potentially tip the root lingually. This again ingly, the second molar experienced a restrictive
probably resulted because of the shape of the transverse effect with all three archwires for 0.96 mm
mushroom lingual archwire between the canine and of activation. Thus, in a clinical scenario, archwire
first premolar that changed the biomechanics com- expansion may not be adequate for expansion at the
pared with a straight archform. Fixed labial archwires second molar for 0.96 mm of activation, and alternate
had less moment generated compared with fixed methods such as overlay wires could be applied.

Table 9. Mean Mesial–Distal Forces (Fx) Acting on Teeth of Interest at the Initial Crowded Position for Labial Straight, Lingual Straight, and
Lingual Mushroom Archwires
Second First Second First
Archwire Group Molar, Fx (N) Molar, Fx (N) Premolar, Fx (N) Premolar, Fx (N) Canine, Fx (N)
Mushroom lingual 0.15 0.15 0.14 0.18 0.13
Straight lingual 0.03 0.04 0.01 0.14 0.09
Straight labial 0.25 0.05 0.09 0.15 0.07

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694 KAUR, OWEN, TRAN, GUAN, LUO, GRANLEY, CAREY, MAJOR, ROMANYK

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ACKNOWLEDGMENTS orthodontic tooth movement with fixed appliances: a
systematic review. Am J Orthod Dentofacial Orthop. 2019;
The authors acknowledge the financial support of the Natural
156:582–592.
Sciences and Engineering Research Council of Canada, the
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McIntyre Fund (School of Dentistry, University of Alberta), and
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the Department of Mechanical Engineering and Faculty of
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Angle Orthodontist, Vol 90, No 5, 2020