Journal of the World Federation of Orthodontists 9 (2020) S59eS66

Special Clinical Article

Should the “envelope of discrepancy” be revised in the era of

three-dimensional imaging?
Takashi Ono*
Professor and Chair, Department of Orthodontic Science, Graduate School, Tokyo Medical and Dental
University (TMDU), Bunkyo-ku, Tokyo, Japan
Congress Chair, 9th International Orthodontic Congress, Executive Committee, World Federation of
Orthodontists (WFO), St. Louis, MO

a r t i c l e i n f o a b s t r a c t

Article history: Since their introduction in the field of orthodontics, temporary anchorage devices (TADs) have been
Received 5 August 2020 widely applied in the treatment of cases that have proven difficult to treat using conventional methods.
Accepted 18 August 2020 Although TADs have broadened the scope of orthodontic treatment by modifying the envelope of
Available online 30 September 2020
discrepancy, whether they represent the ultimate solution in all cases remains controversial. Cone-beam
computed tomography (CBCT) has recently been used to obtain three-dimensional images of the
Keywords:
craniofacial skeleton and teeth. Thus, CBCT has clarified the three-dimensional morphology/configura-
Cone-beam computed tomography
tions of structures that cannot be appropriately visualized using conventional imaging (i.e., cephalo-
Envelope of discrepancy
Incisive canal
metric and panoramic radiographs). These structures include the incisive canal and maxillary sinus. In
Maxillary sinus this review, I highlight the importance of understanding the mutual relationship between the roots of
Temporary anchorage devices the maxillary teeth and these structures for diagnosis and treatment planning, as well as potential need
to revise the envelope of discrepancy.
Ó 2020 World Federation of Orthodontists.

1. Introduction ensure appropriate insertion and placement to avoid failure [1,2],

mini-screw type TADs may represent a simple, efficient method for
Although the development of temporary anchorage devices fulfilling treatment goals. A recent retrospective study further re-
(TADs) has dramatically altered orthodontic treatment planning, it ported a success rate of 99% for the mini-plate type TAD [3].
may be a misconception to state that such devices have resulted in a Although these findings collectively suggest that TADs can broaden
complete paradigm shift within the field of modern orthodontics. the scope of orthodontic treatment, whether TADs represent the
Several studies have investigated the stability of the mini-screw ultimate solution in all cases remains controversial.
type TAD, which ranged from 75% to 90%. Thus, if care is taken to The introduction of cone-beam computed tomography (CBCT)
has led to improvements in orthodontic diagnosis, providing accu-
rate three-dimensional information related to impacted teeth,
Funding: The author has not declared a specific grant for this research from any
airway abnormalities, temporomandibular joint disorders, and other
funding agency in the public, commercial, or not-for-profit sectors.
Competing interest: The author have completed and submitted the ICMJE Form conditions. Moreover, CBCT can aid in treatment planning and
for Disclosure of potential conflicts of interest. None declared. deciding the appropriate site to insert TADs when moving the teeth
Provenance and peer review: Commissioned; Internally peer reviewed. in patients with bone deficiency. CBCT can also provide information
Patient / Parent consent : Consent obtained from patient. related to craniofacial structures that have not been visualized three-
* Corresponding author: Department of Orthodontic Science, Graduate School,
Tokyo Medical and Dental University (TMDU), 1e5e45 Yushima, Bunkyo-ku, Tokyo
dimensionally, including the incisive canal and maxillary sinus.
113e8549, Japan. In the present review, the concept of the “envelope of discrep-
E-mail address: [email protected]. ancy” as well as potential barriers in the maxilla, including the

2212-4438/$ e see front matter Ó 2020 World Federation of Orthodontists.

https://doi.org/10.1016/j.ejwf.2020.08.009
S60 T. Ono / Journal of the World Federation of Orthodontists 9 (2020) S59eS66

maxillary anterior teeth can occur on contact with the cortical bone
of the incisive canal. However, because the incisive canal is hardly
visible on two-dimensional images (i.e., lateral cephalometric ra-
diographs), careful attention to these details was not possible until
the introduction of CBCT.
The shape of the incisive canal is known to vary among patients.
Although cylindrical, funnel, hourglass, and spindle shapes are
possible, the former two are observed in 70% of cases [6]. Despite
such classification, no studies have investigated the relationships
between canal shape/configuration and neighboring structures
such as the maxillary incisors. In 2016, Chung et al. [7] reported two
cases of lip prominence and protrusion. In the first case, CBCT im-
aging revealed more severe root resorption in one maxillary central
incisor than in the other, even though they were moved nearly the
same distance in the posterior direction. In the second case, the
bilateral maxillary central incisors were moved approximately the
same distance and showed root resorption, which was attributed to
contact with the incisive canal. Although it remains uncertain
Fig. 1. Root resorption in the maxillary incisor in Case #1. Pre- (Pre Tx) and post- whether direct contact of the incisor root with the incisive canal is
treatment (Post Tx) CBCT images are shown. Root resorption along the cortical bone the only factor related to root resorption, the authors argued that
around the incisive canal was confirmed only in the right central incisor, which was in
three-dimensional evaluation of the location and morphology of
contact with the cortical bone. No such contact was observed between the left central
incisor and the cortical bone. Light yellow, incisive canal; white, cortical bone around the incisive canal can aid in preventing potential complications
the incisive canal; arrow, root resorption. when a large degree of maxillary incisor movement is necessary.
This concept is applicable to both posterior and lateral movement of
the maxillary incisors. In our previous case report [8], unilateral
incisive canal and maxillary sinus, which can cause iatrogenic root root resorption was observed in an incisor that was in contact with
resorption, are discussed in relation to findings from recent studies the incisive canal, whereas the contralateral incisor that lacked
and relevant cases. contact with the incisive canal remained intact (Fig. 1, Case #1) after
lateral movement.
2. The envelope of discrepancy In 2017, we published a quantitative analysis of the configura-
tional relationships among the maxillary incisor, the alveolar border,
The envelope of discrepancy is an essential component of and the incisive canal in 93 patients [9]. CBCT images with a limited
treatment planning, not only for appropriate positioning of the field-of-view (FOV, 81 mm  74 mm) that yielded a voxel size of
anterior and posterior teeth in the alveolar bone, but also for 0.146 mm were taken for comprehensive evaluation of the following
restoring stable occlusion. Proffit and Ackerman [4], in 1994, first parameters: the length of the incisive canal; angle between the
highlighted the importance of “the envelope of discrepancy” and it palatal plane and the maxillary alveolar border, incisive canal, and
portrays the limitations of the range for the maxillary and maxillary incisor; distance from the maxillary incisor to the incisive
mandibular teeth during orthodontic treatment (inner envelope), canal; and the cross-sectional areas of the incisive canal at three
orthodontic treatment combined with growth modification (mid- vertical levels. Our analysis revealed that 1) the incisive canal was
dle envelope), and orthognathic surgery (outer envelope). The significantly longer in male patients than in female patients, 2) the
latitude of the envelope is greater for the maxillary incisors than for inclination of the maxillary incisor was significantly correlated with
mandibular incisors. For example, the maxillary incisor can be that of the maxillary alveolar border and the axis of the incisive
retracted by 7 mm via orthodontic treatment alone, as indicated by canal, 3) the maxillary incisors were located closer to the incisive
the inner envelope of the sagittal projection. This limitation is canal at the level of the oral opening than at the level of the root
established by the lingual cortical plate. In contrast, the maxillary apex, and 4) the cross-sectional area of the incisive canal was
premolar can be moved buccally by 3 mm, as indicated by the inner significantly larger at the level of the maxillary incisor root apex than
transverse envelope of discrepancy. These limitations were initially at the levels of the oral and nasal openings. Because anatomic
established based on visibility in conventional two-dimensional patient-to-patient variation was observed in the anterior region of
cephalometric images. the maxillary alveolar bone, morphometric data may aid in planning
In modern orthodontics, TADs have been frequently used to treatment for maxillary protrusion. Moreover, some authors have
maximize tooth movement in part to avoid orthognathic surgery, suggested that FOV-limited CBCT can aid in orthodontic diagnosis.
and CBCT has also been used to investigate three-dimensional Considering the previously mentioned facts, CBCT-based diag-
morphology of the maxilla and mandible. An accurate analysis of nosis and treatment planning may be plausible. In a recent report
structures within the cortical bone, such as the incisive canal and [10], we discussed the case of a patient with bimaxillary protrusion,
maxillary sinus, which are usually not visible on conventional ra- wherein root resorption due to orthodontic treatment was mini-
diographs, can be performed with CBCT. mized by pretreatment evaluation of the anatomic structures in the
anterior region of the maxilla and simulation of maxillary central
3. The incisive canal incisor movement using CBCT (Figs. 2 and 3, Case #2). Considerable
retraction and intrusion of the maxillary incisors resulted in
The incisive canal, also known as the nasopalatine canal, is the marked improvement of the facial profile and smile without severe
midline anatomic structure that runs perpendicularly in the pos- root resorption. However, what steps should be taken in patients
terior region of the maxillary incisors [5]. The canal has two whose incisive canal prevents maximum retraction of the maxillary
openings: one at the inferior nasal cavity and the other at the su- incisors? An adult male patient with protrusion of the maxillary
perior oral cavity. Because it is surrounded by thick cortical bone incisors and mandibular retrusion exhibited a Class II molar rela-
and contains arteries, veins, and nerves, root resorption of the tionship, deep overbite, large overjet, and missing lower lateral
 T. Ono / Journal of the World Federation of Orthodontists 9 (2020) S59eS66 S61

Fig. 2. CBCT-based diagnosis and treatment planning in Case #2. (A) CBCT images were used to determine the morphologies of the maxillary incisor roots, the incisive canal, and the
maxillary alveolar bone. (B) Treatment simulation. Gray, pretreatment incisors; Blue, alveolar bone; Yellow, incisive canal; Red, simulation of the incisor movement. Reproduction
permitted by the Korean Journal of Orthodontics.

Fig. 3. Pre- (Pre Tx) and posttreatment (Post Tx) facial profile and occlusion in Case #2. Reproduction permitted by the Korean Journal of Orthodontics.
S62 T. Ono / Journal of the World Federation of Orthodontists 9 (2020) S59eS66

Fig. 4. (A) Pretreatment records in Case #3. (B) Posttreatment records in Case #3.

incisors (Fig. 4A, Case #3). The lower third molars on both sides 37. The mandibular incisors were proclined. Pretreatment CBCT
were impacted. A Class II skeletal relationship with a small images revealed that the incisive canal was large, and that the
mandibular plane angle was apparent. The ANB (A point, nasion, B distance between the incisive canal and maxillary incisors was
point) angle was 11, and the FMA (Frankfort mandibular angle) was small. We proposed two treatment options to the patient. The first
 T. Ono / Journal of the World Federation of Orthodontists 9 (2020) S59eS66 S63

Fig. 5. Superimposition of pre- and posttreatment lateral cephalometric radiographs in Case #3.

option was an orthodontic treatment, including extraction of the resorption of the maxillary central incisors did not progress after
maxillary first premolars and mandibular third molars on both switching the treatment plan. Superimposition of the pre- and
sides, followed by orthognathic surgery due to the severe Class II posttreatment lateral cephalometric radiographs demonstrated
skeletal relationship. Orthodontic treatment with TADs following mandibular autorotation associated with impaction of the maxilla,
extraction of the maxillary first premolars and mandibular third leading to improvements in the patient's profile (Fig. 5).
molars was presented as an alternative option. The patient chose Indeed, numerous reports have documented root resorption in
the latter option. During orthodontic treatment using TADs, CBCT the maxillary incisors following posterior movement. Whether
revealed contact between the roots of the maxillary central incisors this occurred owing to contact between the root and incisive
and the incisive canal. Thus, the treatment plan was changed to canal is controversial, as two-dimensional imaging provided
orthognathic surgery to close the remaining space in the premolar incomplete visualization of the size and position of the canal. To
area via Le Fort I and Wunderer osteotomies. Acceptable occlusion date, no studies have demonstrated that remodeling of the
was established at the end of active treatment (Fig. 4B). Root cortical bone of the incisive canal occurs following contact with

Fig. 6. Classification of the vertical relationship between the root apex of the maxillary tooth and inferior wall of the maxillary sinus (dotted line) in the sagittal (A) and coronal (B)
sections. MS, maxillary sinus. Reproduction permitted by the American Journal of Orthodontics and Dentofacial Orthopedics.
S64 T. Ono / Journal of the World Federation of Orthodontists 9 (2020) S59eS66

Fig. 7. Proportion of the various classification relationships in the sagittal and coronal sections. 3, the root of the canine; 4, the root of the first premolar; 5, the root of the second
premolar. Reproduction permitted by the American Journal of Orthodontics and Dentofacial Orthopedics.

the tooth root. Therefore, the incisive canal can be the boundary contrast, Type III relationships were most frequently observed in
on three-dimensional CBCT imaging to reconsider the envelope of the roots of the first/second molars on both sagittal and frontal
discrepancy, if complete retraction of the maxillary incisors is sections. The highest ratio of Type III relationships (i.e., where the
attempted. root projects most deeply into the maxillary sinus) was observed
in the mesio-buccal root of the second molar on both types of
4. The maxillary sinus sections. We also examined potential differences in ASD between
men and women. Interestingly, significant sex-related differences
Researchers have debated whether tooth movement is possible were observed among individuals ranging from 30 to 49 years in
through the maxillary sinus without root resorption [11,12]. A age. Men in this age group exhibited significantly larger ASD
critical systematic review in 2018 [13], which discussed ortho- values than their female counterparts. There was also a significant
dontic tooth movement through the maxillary sinus, concluded negative correlation between the ASD and age. Although we are
that no evidence-based protocol exists to guide movement beginning to evaluate posttreatment CBCT images in the same
through the maxillary sinus. At that time, the available evidence cohort, the influence of maxillary sinus evaluations on ortho-
included only a few case reports or case series, and longitudinal/ dontic treatment planning is still unclear.
controlled studies in this area were lacking. This may be partly due Fig. 8A depicts the case of an adult female patient whose chief
to the lack of baseline studies reporting three-dimensional concern was protrusion of the maxillary incisors (Case #4). She
morphometric data for the maxillary sinus. Although orthodontic exhibited a Class I skeletal relationship with minor crowding, the
treatment outcomes are conventionally evaluated using two- ANB and the FMA angles were 4 and 34 , respectively. The maxillary
dimensional images (e.g., anteroposterior and lateral cephalo- incisors were proclined, whereas the mandibular incisors were
metric images), it is difficult to quantify volumetric root resorption retroclined. Although panoramic radiographs revealed that the
via planar analysis. maxillary sinus floor was located slightly occlusally, no other
Therefore, after screening 500 patients who required CBCT morphological abnormalities were apparent. Based on these find-
imaging for diagnosis, we performed a baseline study to clarify ings alone, the treatment plan was relatively straightforward.
the three-dimensional relationships between the maxillary si- However, CBCT images revealed additional features (Fig. 8B).
nuses and the 4800 roots of the maxillary teeth [14]. A compre- Sagittal projections highlighted the potential for molar movement,
hensive classification of the positional relationships between the although the floor of the maxillary sinus was located inferiorly. This
maxillary root apices (including those of the canine, first/second inferior location of the maxillary sinus floor could pose a challenge
premolars, and first/second molars) and the inferior wall of the to the intrusion of molars, even with the aid of TADs. Frontal images
maxillary sinus into four types (Fig. 6) was proposed, following indicated that buccal molar movement may be difficult, whereas
which each type was evaluated using two cross-sectional CBCT horizontal images indicated that molar movement in any direction
images. The apex-sinus distance (ASD), namely vertical dimen- may not have been possible. For example, given that the sinus oc-
sion, was measured on both sagittal and frontal images simulta- cupies the entire area between the molar roots and buccal cortical
neously. Type I relationships between the root and sinus floor bone, many orthodontists may not be confident in the ability to
were most frequently observed for the root of the maxillary ensure buccal movement of the molars via slow expansion. This
canine and first/second premolars on sagittal sections (Fig. 7). In case highlights the difference in the accuracy of evaluation of the
 T. Ono / Journal of the World Federation of Orthodontists 9 (2020) S59eS66 S65

Fig. 8. (A) Pretreatment records in Case #4. (B) Pretreatment CBCT images of the maxilla in the sagittal (a), frontal (b), and horizontal (c) projections in Case #4.

relationship between the maxillary tooth root and maxillary sinus 5. Conclusions
floor with panoramic and CBCT images [15]. Moreover, when sub-
stantial root movement of the maxillary teeth is intended, CBCT Clinical application of TADs may necessitate revision of the en-
imaging may be necessary. velope of discrepancy in sagittal and vertical dimensions and
incorporation of limitations in transverse movement of the
S66 T. Ono / Journal of the World Federation of Orthodontists 9 (2020) S59eS66

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