Effect of different attachment geometries on the mechanical load exerted by PET­G aligners during derotation of mandibular canines : An in vitro study.

AIM: Derotation of rounded teeth has proved difficult for aligners to achieve. In this study, we investigated the effect of aligner attachment geometry on the three-dimensional (3D) force and moment (F/M) values exerted during derotation of a mandibular canine. MATERIALS AND METHODS: The experiment setup comprised an acrylic mandibular arch model with a separated right canine (tooth 43) mounted on a hexapod via a 3D F/M sensor. Polyethylene terephthalate glycol (PET­G) aligners with thicknesses of 0.5, 0.625, and 0.75 mm were tested in combination with quarter-sphere, vertical-ellipsoid, and pyramidal attachments bonded to tooth 43. The experimentally measured movement consisted of mesio- and distorotation of tooth 43 in 1° steps up to ±15° in each direction. RESULTS: Compared with no attachment, vertical-ellipsoid and quarter-sphere attachments increased the rotational moment by a median factor of 1.5-12.3. Moment increases for pyramidal attachments were significantly smaller (Mann-Whitney U­test, p < 0.05). Quarter-sphere attachments inhibited the intrusive forces up to 6.07° distorotation, whereas the intrusion prevention range for most aligner attachment combinations was significantly smaller (2.95° for vertical-ellipsoid and 2.88° for pyramidal attachments; Mann-Whitney U­test, p < 0.05). None of the attachment geometries could completely prevent intrusive forces during mesiorotation. CONCLUSION: The quarter-sphere geometry had the best overall mechanical properties because it induced relatively high rotational moment increases and counteracted unwanted intrusive forces most effectively of all three geometries. The determined maximum attachment dislodgement and intrusion prevention angles of approximately 6° provide a guide to determining setup increments for mandibular canine derotation.

Mechanical Characterization of Thermoplastic Aligner Materials: Recommendations for Test Parameter Standardization.

Background: Understanding of the different mechanical properties of thermoplastic materials is essential for a successful aligner treatment and further developments. However, data of previous material testing studies are scarcely comparable. Aim of the current study was to evaluate the different test parameters to lay the foundations for guidelines for future, more standardized three-point-bending aligner material tests. Materials and Methods: Several parameters concerning the specimen preparation and experimental three-point-bending setup were varied. The specimens were collected from polyethylene terephthalate glycol (PET-G) Duran® foils with different thicknesses. Both raw foils and foils thermoformed using different geometrical forms were investigated. The three-point-bending tests were performed using span lengths of 8 and 16 mm and variable deflection ranges between 0.1 and 0.2 mm. The influence of water storage on the bending forces was studied using unloaded and loaded specimens. Experimental results were validated using a beam cantilever mathematical model. Results: Local macroscopic cracks after long-term loading could be avoided by keeping the deflections within a thickness-dependent individual range. The mathematical calculations confirmed that these individual deflection ranges lead to local stresses between 14 and 18 MPa. Constantly loaded specimens immersed for 24 hours in water showed a decrease of the bending force by 50%. This reduction was much smaller for the unloaded specimens (14%). Conclusion: During clinical aligner therapy, very small bending deflections are combined with small distances between the tooth surface regions supporting the aligner. In vitro aligner material testing by three-point bending should consider these geometrical aspects, while keeping the material stresses in a range between 14 and 18 MPa to avoid local microcracks. Considering these aspects, thickness-dependent deflections were established for three-point bending of the PET-G specimen for a span length of 8 mm. We recommend the application of these test parameters in future aligner material studies to achieve valid and comparable test results.

Mechanical load exerted by PET-G aligners during mesial and distal derotation of a mandibular canine : An in vitro study.

INTRODUCTION: The six force-moment (F/M) components exerted by aligners of different thickness during simulated mesiorotation and distorotation of a mandibular canine were studied. MATERIALS AND METHODS: An acrylic mandibular model with a separated right canine mounted on a hexapod via a 3D F/M sensor was used. Duran+® aligners (Scheu Dental, Germany) of thickness 0.5, 0.625, and 0.75 mm were fabricated on plaster models with the measurement tooth in its neutral position. The F/M values were recorded during progressive mesiorotation or distorotation of tooth 43 in 1° steps up to ±15°, corresponding to 0.5 mm displacements of the tooth's interdental contacts. Each rotation step included renewed seating of the aligner on the acrylic model. Three aligners were tested three times each for each thickness and direction of rotation. RESULTS: The median rotational moments for the 0.5 mm aligner and 15° distorotation of tooth 43 was 27.49 Nmm (interquartile range, IQR 1.45 Nmm). The corresponding values for the 0.625 and 0.75 mm aligners were 41.04 Nmm (IQR 5.62 Nmm) and 42.48 Nmm (IQR 2.17 Nmm), respectively. The average rotational moments for distorotation were 15% higher than for mesiorotation (p = 0.01). Relatively high collateral F/M components, specifically an intrusive force and labiolingual and mesiodistal tipping moments, were observed. CONCLUSION: To avoid overloading of periodontal structures, derotation of lower canines should be limited to 10° per setup step, leading to rotational moments of about 15 Nmm. The mechanical behavior of the 0.625 and 0.75 mm aligners were similar; thus, it may be omitted from the aligner sequence. Further studies are required to investigate specific aligner modifications or attachments for minimizing collateral F/M components or unwanted movements, respectively, during canine derotation.

Motor unit activity within the depth of the masseter characterized by an adapted scanning EMG technique.

OBJECTIVE: To study motor unit activity in the medio-lateral extension of the masseter using an adapted scanning EMG technique that allows studying the territories of multiple motor units (MUs) in one scan. METHODS: We studied the m. masseter of 10 healthy volunteers in whom two scans were performed. A monopolar scanning needle and two pairs of fine-wire electrodes were inserted into the belly of the muscle. The signals of the fine wire electrodes were decomposed into the contribution of single MUs and used as a trigger for the scanning needle. In this manner multiple MU territory scans were obtained simultaneously. RESULTS: We determined 161 MU territories. The maximum number of territories obtained in one scan was 15. The median territory size was 4.0mm. Larger and smaller MU territories were found throughout the muscle. CONCLUSIONS: The presented technique showed its feasibility in obtaining multiple MU territories in one scan. MUs were active throughout the depth of the muscle. SIGNIFICANCE: The distribution of electrical and anatomical size of MUs substantiates the heterogeneous distribution of MUs throughout the muscle volume. This distributed activity may be of functional significance for the stabilization of the muscle during force generation.

The clinical utility of botulinum toxin injections targeted at the motor endplate zone in cervical dystonia.

BACKGROUND AND PURPOSE: Cervical dystonia (CD) patients usually receive repeated botulinum neurotoxin (BoNT) injections. The aims of this study were to evaluate the feasibility of motor endplate zone (MEZ) detection of relevant cervical muscles in CD patients receiving chronic BoNT treatment and to compare the treatment effect of half-dosed, endplate-targeted injections to standard BoNT injections. METHODS: In study 1, high-density surface electromyography (HD-sEMG) was recorded from the sternocleidomastoid (SCM) and splenius capitis (SC) muscles in 18 CD patients with ongoing BoNT treatment, by which the location of the MEZ was determined. In study 2, nine additional patients with rotational-type CD participated in a treatment effect study where they received either half of their regular BoNT dose through endplate-targeted injections or their normal BoNT dose through standard injections (crossover design). Dystonia severity was recorded before and 4 weeks after each treatment session (Toronto Western Spasmodic Torticollis Rating Scale severity subscore). RESULTS: In the SCM muscle the MEZ was located at the lower border of the superior third part of the muscle, and in the SC muscle at half muscle length. Endplate-targeted, half-dosed BoNT injection resulted in a similar treatment effect to injecting the full dose in the standard technique. CONCLUSIONS: Half-dosed, endplate-targeted BoNT injections lead to a similar treatment effect to the standard BoNT injection protocol. MEZ detection confronts the clinician with some technical challenges, such as the ability of accurate and technically optimal placement of the electrode grid and correct interpretation of the HD-sEMG signal.

Localised task-dependent motor-unit recruitment in the masseter.

Localised motor-unit (MU) recruitment in the masseter was analysed in this study. We investigated whether differential activation behaviour, which has already been reported for distant masseter regions, can also be detected in small muscle subvolumes at the level of single MUs. Two bipolar fine-wire electrodes and an intra-oral 3D bite-force transmitter were used to record intra-muscular electromyograms (EMG) resulting from controlled bite-forces of 10 healthy human subjects (mean age 24.1 ± 1.2 years). Two-hundred and seventeen decomposed MUs were organised into localised MU task groups with different (P < 0.001) force-direction-specific behaviour. Proportions of MUs involved in one, two, three or four examined tasks were 46%, 31%, 18% and 5%, respectively. This study provides evidence of the ability of the neuromuscular system to modify the mechanical output of small masseter subvolumes by differential control of adjacent MUs belonging to distinct task groups. Localised differential activation behaviour of the masseter may be the crucial factor enabling highly flexible and efficient adjustment of the muscle activity in response to complex local biomechanical needs, for example, continually varying bite-forces during the demanding masticatory process.

Locating the center of resistance in individual teeth via two- and three-dimensional radiographic data.

OBJECTIVES: The preferred reference point to describe the force-moment system exerted upon a tooth is its center of resistance (CR). Morphological data on the dentoalveolar complex can be used to locate this point either three-dimensionally (3D) with the finite element (FE) method, or two-dimensionally (2D) with a mathematical method calculating the centroid of the projected dental root. This study aimed to compare and appraise these two methods with regard to their accuracy and time requirements. METHODS: Three radiological datasets with permanent teeth were included. Each single 3D dataset was used in each of these patients to derive both a 3D and 2D morphological model of the upper right central incisor. CR levels were evaluated in percent, indicating the relative height as measured from the (averaged levels of the mesial and distal) bony ridge margin to the tooth's apex. RESULTS: Mean CR levels of 42.8% for distalization and 56.5% for lingual movement were obtained from the 3D FE simulations of initial tooth movement. The 2D mathematical model yielded a mean CR level of 44.5%. Compared to this mathematical approach, the 3D FE simulations were around 15 times more time-consuming, with an interactive requirement of around 15 h. CONCLUSION: Because they contain so much more morphological information, 3D FE simulations should offer superior predictability. In addition, they are the only method offering detailed CR identification for specific directions of tooth movement. Before this method can be used in clinical practice, however, there is still a major need to reduce time requirements via further automation of process steps and to investigate how it should be applied to different tooth types.

An analysis of the measurement principle of smart brackets for 3D force and moment monitoring in orthodontics.

Measuring the three-dimensional (3D) force-moment (F/M) systems applied for correcting tooth malposition is highly desirable for accurate spatial control of tooth movement and for reducing traumatic side effects such as irreversible root resorption. To date, suitable tools for monitoring the applied F/M system during therapy are lacking. We have previously introduced a true-scale orthodontic bracket with an integrated microelectronic stress sensor system for 3D F/M measurements on individual teeth with a perspective for clinical application. The underlying theoretical concept assumes a linear correlation between externally applied F/M systems and mechanical stresses induced within the smart bracket. However, in combined applications of F/M components the actual wire-bracket contacts may differ from those caused by separate applications of corresponding individual F/M components, thus violating the principle of linear superposition of mechanical stresses. This study systematically evaluates this aspect using finite element (FE) simulations and measurements with a real smart bracket. The FE analysis indicated that variability in the wire-bracket contacts is a major source for measurement errors. By taking the critical F/M combinations into account in the calibration of the real smart bracket, we were able to reduce the mean measurement error in five of the six F/M components to values <0.12 N and <0.04 N cm. Bucco-lingually directed forces still showed mean errors up to 0.21 N. Improving the force measurement accuracy and integrating components for telemetric energy and data transfer are the next steps towards clinical application of intelligent orthodontic appliances based on smart brackets.

Botulinum toxin has an increased effect when targeted toward the muscle's endplate zone: a high-density surface EMG guided study.

OBJECTIVES: To compare the effect of endplate-targeted injections of a low Botulinum neurotoxin type A (BoNT-A) dose with that of injections at defined distances from the motor endplate zone. METHODS: In eight healthy volunteers, the main endplate zones of the right and left extensor digitorum brevis (EDB) muscles were localized using high-density surface EMG. On the study side BoNT-A was injected at fixed distances from the endplate zone. On the control side, BoNT-A was administered into the endplate zone. Compound muscle action potential (CMAP) prior to the injection and 2, 12, and 24 weeks later were recorded. RESULTS: On the control side, the mean CMAP reduction 2 weeks after BoNT-A injection was 79.3%. The difference in CMAP reduction between both EDB muscles was significantly related to the injection distance from the endplate zone. Increasing the injection distance by 1cm reduced the effect of BoNT-A by 46%. CONCLUSIONS: Guided injection of a reduced BoNT-A dose into the muscle's endplate zone(s) is a promising strategy for optimizing the therapeutic effectiveness of BoNT-A and for minimizing side-effects such as unwanted weakness of adjacent muscles. SIGNIFICANCE: Precise endplate-targeted injections increase the effect of BoNT-A and may thus prove to reduce required dosage and treatment costs.

Evidence of potential averaging over the finite surface of a bioelectric surface electrode.

Most bioelectric signals are not only functions of time but also exhibit a variation in spatial distribution. Surface EMG signals are often "summarized" by a large electrode. The effect of such an electrode is interpreted as averaging the potential at the surface of the skin beneath the electrode. We first introduce an electrical equivalent model to delineate this principle of averaging. Next, in a realistic finite element model of EMG generation, two outcome variables are evaluated to assess the validity of the averaging principle. One is the change in voltage distribution in the volume conductor after electrode application. The other is the change in voltage across the high impedance double layer between tissue and electrode. We found that the principle of averaging is valid, once the impedance of the double layer is sufficiently high. The simulations also revealed that skin conductivity plays a role. High-density surface EMG provided experimental evidence consistent with the simulation results. A grid with 120 small electrodes was placed over the thenar muscles of the hand. Electrical nerve stimulation assured a reproducible compound muscle response. The averaged grid response was compared with a single electrode matching the surface of the high-density electrodes. The experimental results showed relatively small errors indicating that averaging of the surface potential by the electrode is a valid principle under most practical conditions.

Smart bracket for multi-dimensional force and moment measurement.

Atraumatic, well-directed, and efficient tooth movement is interrelated with the therapeutic application of adequately dimensioned forces and moments in all three dimensions. The lack of appropriate monitoring tools inspired the development of an orthodontic bracket with an integrated microelectronic chip equipped with multiple piezoresistive stress sensors. Such a 'smart bracket' was constructed (scale of 2.5:1) and calibrated. To evaluate how accurately the integrated sensor system allowed for the quantitative determination of three-dimensional force-moment systems externally applied to the bracket, we exerted 396 different force-moment combinations with dimensions within usual therapeutic ranges (+/- 1.5 N and +/- 15 Nmm). Comparison between the externally applied force-moment components and those reconstructed on the basis of the stress sensor signals revealed very good agreement, with standard deviations in the differences of 0.037 N and 0.985 Nmm, respectively. We conclude that our methodological approach is generally suitable for monitoring the relatively low forces and moments exerted on individual teeth with fixed orthodontic appliances.

A thin, flexible multielectrode grid for high-density surface EMG.

Although the value of high-density surface electromyography (sEMG) has already been proven in fundamental research and for specific diagnostic questions, there is as yet no broad clinical application. This is partly due to limitations of construction principles and application techniques of conventional electrode array systems. We developed a thin, highly flexible, two-dimensional multielectrode sEMG grid, which is manufactured by using flexprint techniques. The material used as electrode carrier (Polyimid, 50 microm thick) allows grids to be cut out in any required shape or size. One universal grid version can therefore be used for many applications, thereby reducing costs. The reusable electrode grid is attached to the skin by using specially prepared double-sided adhesive tape, which allows the selective application of conductive cream only directly below the detection surfaces. To explore the practical possibilities, this technique was applied in single motor unit analysis of the facial musculature. The high mechanical flexibility allowed the electrode grid to follow the skin surface even in areas with very uneven contours, resulting in good electrical connections in the whole recording area. The silverchloride surfaces of the electrodes and their low electrode-to-skin impedances guaranteed high baseline stability and a low signal noise level. The electrode-to-skin attachment proved to withstand saliva and great tensile forces due to mimic contractions. The inexpensive, universally adaptable and minimally obstructive sensor allows the principal advantages of high-density sEMG to be extended to all skeletal muscles accessible from the skin surface and may lay the foundation for more broad clinical application of this noninvasive, two-dimensional sEMG technique.

A surface EMG electrode for the simultaneous observation of multiple facial muscles.

With previous surface electromyography (sEMG) electrodes it has been difficult to combine small outer dimensions and secure skin attachment. We resolved this problem by developing a new skin attachment technique that yields firm electrode fixation without requiring an acrylic housing. Consequently, we could reduce the outer electrode dimensions to 4-mm diameter and only 1.5-mm thickness. In a bipolar montage, this electrode allows an inter-electrode distance of 8 mm. This improves measurement selectivity and, because of the small dimensions, makes possible the non-invasive observation of multiple facial muscles with a minimum of obstruction. Our new technique was tested on a group of 11 professional trumpeters. They were instructed to perform a series of muscle-specific facial poses and to play exercises on their instruments while EMG signals were recorded simultaneously from seven different perioral muscles. Although the skin attachment was subjected to high stress during trumpet playing, more than 98% of electrode placements yielded a secure mechanical and electrical connection. Muscle selectivity of the signals recorded during the facial poses was similar to that obtained in a previous investigation using intra-muscular fine-wire electrodes. Crosstalk in the perioral area was estimated to be lower than 25%. The availability of an unobstructive sEMG electrode for simultaneously observing multiple facial muscles opens up a wide range of applications (e.g. in speech research, psychophysiology and orthodontics).

The importance of the level of the lip line and resting lip pressure in Class II, Division 2 malocclusion.

Many clinicians hypothesize that retroclination of the maxillary central incisors in Class II, Division 2 malocclusion is caused by increased resting lip pressure against these teeth. The purpose of this study was (1) to verify this assumption by means of simultaneous lip-pressure measurements at two different levels on the maxillary central incisor crowns, and (2) to examine factors that could possibly contribute to the increased resting lip pressure. This is the first study to prove that individuals with Class II, Division 2 malocclusion (n = 21) have the upper central incisors exposed to significantly higher lip pressure than those with Class I malocclusion (n = 21). Our statistical evaluation revealed that this is primarily attributed to a high lip line and not to a hypertonic peri-oral musculature. We concluded that orthodontic treatment of Class II, Division 2 cases should include intrusion of the maxillary incisors, to eliminate the non-physiologically high pressure exerted by the lower lip on these teeth and, consequently, to reduce the high risk of a post-orthodontic relapse.