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VOLUME 24 | NUMBER 4 | WINTER 2013

Published Quarterly by theInternational Association for Orthodontics

International Journal of

OrthodonticsIn this Issue:n Maxillary Canine Substitution for the Severely

Resorbed Root of Central Incisorn Use Of Tip-Edge In Vertically Growing

Individualn Using the Herbst Appliance With Atypical

Extractions in the Lower Dental Archn Effects of Molar Distalization with the Fast

Back Appliancen Modification of Uprighting Spring for

Derotation of Second Molarsn Enhanced Increase in Pharyngeal Airway Size

in Japanese Class II Children Following a 1-Year Treatment with an Activator Appliance

n Modified Protrusion arch for Anterior Crossbite Correction

n Management of Skeletal Class III Malocclusion Treated by Manifold Approach

n Multidisciplinary Approach to an Asymmetric Traumatic Occlusion

n Orthodontic Management of Maxillary Canine First Premolar Transposition

Visit the IAO online at www.iaortho.org

FEATURES

DEPARTMENTS

ADVERTISERS

Editor Michel Champagne, DMD, MAGD, IBO, CDE Brome, QC, Canada E-mail: [email protected]

Managing Editor Tamiko L. Kinkade Communication & Publication Solutions, Inc. 1300 Sunrise Drive Carterville, Illinois, USA 62918 Phone: 217/585-9065 Fax: 217/529-7178 E-mail: [email protected]

ConsultantsJohn Baar, DDS, IBO, Fulton, MD, USABill Buckley, DDS, IBO, Rocky River, Ohio USARichmond Cheng, DDS, IBO, Vancouver, BC, CanadaTimothy Cronin, DDS, Dallas, TX, USAScott Dillingham, DDS, Fayetteville, NY, USAJose Ma Rodriguez Flores, MD, DDS, MS, IBO, Malaga, SpainSteve Galella, DDS, IBO, Collierville, TN, USAJay W. Gerber, DDS, Parkersburg, WV, USADr. John Gordon, Yorkville, IL, USARick Grant, DDS, IBO, Winnemucca, Nevada USAP. Harikrishnan, BDS, MDS, FDSRCS, Chennai, IndiaThomas J. Hughes, DDS, IBO, Cassville, WI, USAYosh Jefferson, DMD, IBO, Mount Holly, New Jersey, USADuane Keller, DMD, IBO, St. Louis, MO, USAJean Noel Lavallee, DDS, IBO, MBA, Longueuil, QC, CanadaEdmund Liem, DDSMike Lowry, DDS, IBO, Lacombe, Alberta CanadaDerek Mahony, BDS, MSc, DOrth, MDorth, IBO, Sydney

AustraliaSylvan Morein, DDS, IBO, Glenside, PA, USAReuel Owen, DDS, IBO, Galesburg, IL USAAdrian Palencar, DDS, IBO, Thorold, ON, CanadaJae Hyun Park, DMD, MSD, MS, PhD, Mesa, Arizona, USAMilton Pedrazzi, DDS, IBO, San Jose, CA, USAPierre Pellan, DMD, Quebec, QC, CanadaKorrodi Ritto, DDS, PhD, Leiria, PortugalBrock Rondeau, DDS, IBO, London, ON, CanadaDave Singh DDSc PhD BDS, Portland, OR, USATerrence J. Spahl, DDS, St. Paul, MN, USABrendon Stack, DDS, MS, Vienna, VA, USAAlfredo Valera, DMD, Quezon City, Philippines

International Journal of Orthodontics, copyright 2013 (ISSN #1539-1450). Published quarterly (March, June, September, December) by International Association for Orthodontics, 750 North Lincoln Memorial Drive, #422, Milwaukee, WI 53202 as a membership benefit. All statements of opinion and of supposed fact are published on the authority of the writer under whose name they appear and are not to be regarded as views of the IAO. Printed in the USA. Periodical postage paid at Milwaukee, WI and additional mailing offices. Subscription for member $15 (dues allocation) annually; $40 U.S. non-member; $60 foreign. Postmaster: Send address changes and all correspondence to:

International Journal of Orthodontics750 North Lincoln Memorial Drive, #422

Milwaukee, WI, USA 53202Phone 414-272-2757 Fax 414-272-2754E-mail: [email protected]

IAO 2014 Annual Meeting ..........................................2Impact Research, Inc. ................................................4Dolphin Imaging Systems ...........................................8Murdock Laboratory .................................................14Myofunctional Research Company .......................32Dub King - 2013 IAO Annual Meeting Videos ........34Natural Orthodontic Products .................................39The Aligner System ....................................................40

AUTHOR’S GUIDELINES FOR THE INTERNATIONAL JOURNAL OF ORTHODONTICS POSTED ONLINE AT www.iaortho.org.Past IAO publications (since 1961) available online in the members only section at www.iaortho.org.

PWG Orthodontic Specialties, Ltd...........................44TMJ & Sleep Therapy Research ...............................51American Orthodontic Society ...............................52Protec Dental Labs ...................................................58Johns Dental Laboratories .......................................66Rondeau Seminars ....................................................71EODO USA/OrthOrama Seminars ..................Cover 3Jackson OrthoPlus Seminars ................... Back Cover

Maxillary Canine Substitution for the Severely Resorbed Root of Central Incisor: 12-Year Follow-up ..........................................................................................................................................................................9

By Yoshiyuki Koga, DDS, PhD; Jae Hyun Park, DMD, MSD, MS, PhD; Kiyoshi Tai, DDS, PhD

Use Of Tip-Edge In Vertically Growing Individual-A Case Report .................................................................15By H. Jyothikiran, BDS, MDS; Ravi Shanthraj, BDS,MDS; Pradeep Subbiah, BDS, MDS

Using the Herbst Appliance With Atypical Extractions in the Lower Dental Arch ..................................19By Leopoldino Capelozza Filho DDS, MS, PhD; Danilo Furquim Siqueira DDS, MS, PhD; Renata Cristina Faria Ribeiro de Castro DDS, MS, PhD; Rodrigo Comparim DDS; Mikaela Reginee Basso Blanco DDS; Mauricio de Almeida Cardoso DDS, MS, PhD

Effects of Molar Distalization with the Fast Back Appliance ...........................................................................25By Alaa Abdelsalam Alkasaby BDS, MSc; Yasser Lotfy Abdelnaby BDS, MSc, PhD, MOrth RCSEd; Shaza Mohammad Hammad, BDS, MSc, PhD

Modification of Uprighting Spring for Derotation of Second Molars .........................................................33By Vankre Mallikarjun, BDS, MDS; Madhukar Reddy Rachala, BDS, MDS; Kaladhar Reddy Aileni, BDS; MDS; Pyata Reddy Jaipal BDS; MDS

Enhanced Increase in Pharyngeal Airway Size in Japanese Class II Children Following a 1-Year Treatment with an Activator Appliance ................................................................................................................35

By Atsushi Horihata PhD; Hiroshi Ueda PhD; Myongsun Koh PhD; Genki Watanabe PhD; Kazuo Tanne PhD

Modified Protrusion arch for Anterior Crossbite Correction - A Case Report ...........................................41By Abhishek Singha Roy, MDS; Gulshan KR Singh; Pradeep Tandon; Ramsukh Chowdhry, MDS

Management of Skeletal Class III Malocclusion Treated by Manifold Approach: 5 Year Follow-up .....45By Roopa Tubaki, MDS; B.K. Sharmada, MDS; Sandesh. S. Pai, MDS; Shrikanth Shendre, MDS; Vishwanath A.E., MDS

Multidisciplinary Approach to an Asymmetric Traumatic Occlusion: A Case Report ............................53 By Pinho T, DDS, PhD; Coutinho-Alves C, DDS; Neves M, DDS

Orthodontic Management of Maxillary Canine First Premolar Transposition: A Conservative Approach ...........................................................................................................................................................................59

By Avesh Sachan BDS MDS; TP Chaturvedi BDS, MDS

Publication Member American Association of Dental Editors

Visit the IAO online atwww.iaortho.org

My Guru has Disappeared .......................................................................................................................................... 5 By Michel Champagne, DMD, MAGD, IBO, CDE

Ortho Points: Lateral Agenesis .............................................................................................................................63 By Pierre Pellan, DDS

Lit Review .....................................................................................................................................................................67 By Michel Champagne, DMD, MAGD, IBO, CDE

TABLE OF CONTENTS

WINTER 2013 n VOLUME 24 n NUMBER 4

International Journal of

Orthodontics

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5IJO VOL. 24 NO. 4 WINTER 2013

My Guru Has Disappeared

e have all learned orthodontics from another dentist. I have had many teachers who have had an influence on how I practice orthodontics today. I call these people my gurus. Orthodontics has

a steep learning curve at the beginning. The guru is there to smooth out things and make life easier. Some of us learned orthodontics through the specialty university course. For these people their guru(s) is (are) probably a certified orthodontist who is a university professor with maybe one or two individuals who had more influence. For a general dentist, the guru may be an orthodontist or another general dentist that had a great impact on the way he or she practices orthodontics. In my orthodontic education, I had many gurus. Some of which were general dentists and others who were specialists (Wilson, Roth, Gugino, Ricketts, Bimler, Mahony, Litt, Ricketts, Clark, Witsig, etc.). They all taught me a great deal and made me progress in orthodontics. In today’s world of continuing education learning is an everyday process. One of my guru told me in the beginning of my practice: “the earth makes a full revolution every day and if you stop learning for even one day, you will never be able to catch up.” This is a very serious allegation but we know it has some veracity. I can accept that learning is easier if I keep going to courses, if I keep in contact with my guru(s). The big question is where is my guru. Is he available to me? Does he offer lectures on a regular basis in my area. I do not care if you are a specialist orthodontist or a general practitioner, your at the moment guru has to offer you availability and support. He has to be available for questions and interrogation points. If a guru comes to your part of the world or resides there and teaches you the principles and techniques of his approach, he has to be available and offer support through study clubs, publications, etc. If he just comes in once and awhile but his never available for my interrogations, what good is his teaching to me. Now with the web, any guru can be very active and supportive via online publications, lectures and also online consultations or opinions. I sincerely would not recommend a guru that is not available. Yes, we all have seen guest lecturers that come in for a onetime lecture because they are the expert on a specific subject but they also should willing and happy to leave an email address for future questions. You have to be able to reach your guru. Where is your guru? That is the question. The annual meeting of our organization will be held in Florida from March 26 to 30 2014. I hope to see you there for another extraordinary learning experience.

French VersionOù est mon guru?Translation by Dr. Michel Champagne, Canada Nous avons tous appris l’orthodontie de quelqu’un d’autre, bien rares sont les autodidactes en ce domaine. Pour ma part, j’ai eu beaucoup de professeurs et mentors qui ont beaucoup influencé ma façon de pratiquer l’orthodontie. Ce sont ces personnes que je peux appeler mes gurus. L’orthodontie a une courbe d’apprentissage abrupte et le guru est là pour faciliter mon apprentissage et cela même pour ceux d’entre nous qui ont choisi la voie de la spécialité. Pour les praticiens généraux, souvent les gurus sont de formation mixtes, soient des confrères généralistes et des spécialistes. Mes gurus furent d’origines diverses dont les docteurs Wilson, Roth, Gugino, Ricketts, Bimler, Delaire, Litt, Mahony, Clark, Witzig, etc. Ils m’ont tous beaucoup influencé tout en faisant progresser mon orthodontie. De nos jours, la formation continue est une tâche quotidienne et une citation d’un de mes gurus le résume bien : « la terre fait une révolution complète sur elle-même toutes les 24 heures et si nous cessons d’apprendre une seule journée, il nous sera impossible de la rattraper ». Un peu exagéré me direz-vous mais également tellement vrai. Je peux aussi en déduire que ce processus d’éducation continue n’en est que facilité si je continue de suivre des cours, de lire et de me tenir en contacts avec mes gurus. Mais de fait la question ultime est surtout, où est mon guru, est-il disponible? Peu importe que je sois un dentiste généraliste ou un spécialiste en orthodontie, nous avons tous besoin de support de nos pairs et mes gurus doivent être disponibles à ce support. Mon guru doit offrir des formations sur une base régulière, il doit me laisser son adresse internet et son cercle d’étude se doit également d’être actif. Si mon guru ne fait que passer et m’offrir une conférence mais qu’il ne se rend jamais disponible, je devrais me poser de sérieuses questions sur sa crédibilité. Pour moi cette situation est inacceptable. Oui, il existe des situations dans lesquelles on invite un conférencier de l’extérieur possédant une expertise certaine sur un sujet mais même eux devraient se faire un devoir de laisser une adresse. Posez-vous donc la question. Se la poser c’est y répondre : où est mon guru?

EDITORIAL

Michel Champagne, DMD, MAGD, IBO, CDEEditor

6 IJO VOL. 24 NO. 4 WINTER 2013

Le prochain congrès annuel de notre association se tiendra très bientôt en Floride, du 26 au 30 mars 2014. Feuilletez l’excellent programme de cet évènement et j’espère vous y rencontrer.

Spanish Version¿Mi Mentor. Esta disponible?Translation by Dr. Alvin Cordona, Puerto Rico Hemos aprendido Ortodoncia de otros dentistas. He tenido muchos maestros y algunos han tenido gran influencia en la manera que practico la ortodoncia actualmente. Estos son los que llamo mis mentores. Al comienzo la Ortodoncia es un cam-po de muchos detalles y conceptos prácticos en su aprendizaje, pero el verdadero mentor es el que hace que la enseñanza se provea mas fácilmente. Algunos aprenden ortodoncia a través de una especialidad universitaria. Para estos su mentor es un profesor universitario que generalmente es un ortodoncista certi-ficado. Para un dentista general el mentor es un ortodoncista u otro dentista general a través de cursos de educación continuada han impactado sobremanera en su práctica ortodóntica. En mi educación ortodontica te tenido muchos mentores. Algunos han sido dentistas generales y otros especialistas certifi-cados. ( Wilson, Roth, Gugino, Ricketts, Bimler, Mahoney, Lit, Ricketts, Clark, Witzig etc.) Todos influyeron en mi educación y mi forma de practicar la Ortodoncia . Hoy día la educación continua es un aprendizaje diario. Uno de mis mentores me dijo al comenzar mi practica; “La tierra gira alrededor de su eje un día y si tu detienes el aprendizaje por un solo día, ese atraso te hará difícil alcanzarlo. Se que esta es una alegación seria pero sabemos que tiene cierta veracidad. Puedo aceptar que el apren-dizaje es mas fácil si sigo educándome y sigo en contacto con mis mentores. La gran pregunta sobre mi mentor? Esta accesible a mi? Ofrece cursos en forma regular en mi área de practica? No importa sea un dentista general u ortodoncista certificado debe ofrecerte su respaldo y disponibilidad para dudas e interrogantes. Si tu mentor te enseña los principios y técnicas de sus principios ortodónticos, debe estar disponible para continuar la enseñanza a sus estudiantes a través de grupos de estudios , publicaciones y consultas. Si no esta disponible para las dudas e inquietudes de sus estudiantes no podrá educarlos adecuadamente. Ahora con el Web muchos mentores pueden tener mas accesibilidad a través de publicaciones y consultas. No consideraría un mentor que no tenga esa disponibilidad. Hay conferencistas invitados que proveen conferencias por ser expertos en un tema en particular pero deberían estar di-sponibles para futuras interrogantes y dudas d e lo presentado a través de su correo electrónico y otras formas de comunicación. Debes tener disponibilidad de tu mentor. Sabes tu como comu-nicarte con el en estos momentos? Es muy importante. La próxima convención anual de la IAO será en Orlando, Florida desde Marzo 26 al 30 del 2014. Se que te veré allí para disfrutar de otra extraordinaria experiencia académica.

Portuguese VersionMeu Guru desapareceuTranslation by Dr. Cristiane Albuquerque, Australia Todos nos aprendemos orthodontia com outro dentista(s). Eu tive muitos professores e alguns deles tiveram muita influência sobre a forma como eu pratico ortodontia hoje. Estas são as pessoas que eu chamo meus gurus. Ortodontia tem uma curva de aprendizagem no início. O guru está lá para suavizar as coisas e tornar a vida mais fácil. Alguns de nós aprendemos a ortodontia com o curso de especialidade em Universidade. Para essas pessoas, o seu guru (s) é ( são) provavelmente um ortodontista certificado que é um professor Universitário com talvez um ou dois indivíduos que tinham mais influência. Para um dentista clínico geral, o guru pode ser um ortodontista ou outro dentista geral que teve um grande impacto sobre a forma como ele ou ela pratica Ortodontia. Na minha educação ortodôntico, tive muitos gurus. Alguns dos quais eram clínicos gerais e outros eram especialistas (Wilson, Roth, Gugino, Ricketts, Bimler, Mahony, Litt, Ricketts, Clark, Witsig, etc.) Todos eles me ensinaram muito e me fizeram progredir em Ortodontia. No mundo de hoje de continuar a aprendizagem da educação é um processo diário. Um dos meu guru me disse no início da minha prática: ‘’ a Terra faz uma volta completa a cada dia e se você parar de aprender , mesmo por um dia, você nunca será capaz de recuperar ‘’ . Eu sei que esta é uma acusação muito grave, mas nós sabemos que tem alguma veracidade. Eu posso aceitar que a aprendizagem é mais fácil se eu continuar indo aos cursos , se eu continuar em contato com meu(s) guru(s). A grande questão é onde está o meu guru. Ele está disponível para mim? Será que ele pode oferecer palestras sobre uma base regular na minha área . Eu não me importo se você é um ortodontista especialista ou um clínico geral , seu guru no momento tem para lhe oferecer disponibilidade e apoio. Ele tem que estar disponível para perguntas e pontos de interrogação. Se um guru vem a sua parte do mundo ou lá reside e ensina os princípios e técnicas da sua abordagem, ele tem que estar disponível e oferecer suporte através de grupo de estudo, publicações, etc... Se ele só vem uma vez e por algum tempo , mas sua nunca esta disponível para os meus interrogatórios , o quanto bom é o seu ensinamento para mim. Agora, com a web, qualquer guru pode ser muito ativo e solidário através de publicações on-line , palestras e também consultas ou opiniões online. Eu sinceramente não recomendaria um guru que não está disponível. Sim, todos nós temos visto palestrantes convidados que vêm para uma palestra de uma única vez , porque eles são o especialista em um assunto específico , mas eles também devem dispostos e felizes em deixar um endereço de e-mail para perguntas futuras. Você tem que ser capaz de atingir o seu guru. Onde está o seu guru ? Essa é a questão. A reunião anual da nossa organização será realizada na Flórida a partir de 26-30 março de 2014. Espero ver você lá para uma outra experiência extraordinária de aprendizagem.


Arabic VersionTranslation by Manhal Yazji, DDS, IBO, Florida, USA

German VersionIch habe meinen Guru verloren! Translation by Dr. Barbara Bimler-Rhodes, Germany Wir alle haben die Orthodontie von jemandem gelernt. Ich selbst hatte viele Lehrer, die teilweise einen großen Einfluss auf meine heutige Praxis hatten. Sie nenne ich meine „Gurus“. Am Anfang muss jeder viel lernen, und Gurus helfen dabei und erleichtern einem das Leben. Dies gilt für die Fachzahnärzte unter uns, die häufig die Spezialausbildung der Universitäten durchlaufen; für die Allgemeinzahnärzte wird der Guru ein Kieferorthopäde sein oder ein anderer Zahnarzt, der den Weg zur Kieferorthopädie vorzeichnet. In meiner Lehrzeit hatte ich viele Gurus, darunter manche Allgemeinpraktiker und manche Spezialisten (Wilson, Roth, Gugino, Bimler, Mahony, Litt, Ricketts, Clark, Witzig, etc.). Alle brachten mir viel bei und ließen mich in meinem Fach vorankommen. In der heutigen Welt der ständigen Weiterbildung ist Fortbildung eine tägliche Aufgabe. Einer meiner Gurus sagte mir: “Die Erde dreht sich täglich einmal ganz um sich selber, und wenn wir nur einen Tag mit dem Lernen aussetzen, können wir das nie wieder einholen.” Das ist vielleicht überspitzt formuliert, aber hat etwas Wahres. Dieser andauernde Lernprozess wird ermöglicht durch den Besuch von Fortbildungskursen und den Kontakt mit den Gurus. So stellt sich die Frage, wo ist mein Guru? Kann ich ihn erreichen? Gibt er regelmäßige Kurse in meiner Gegend? Egal, ob ich Allgemeinarzt bin oder Spezialist, wir alle brauchen Unterstützung von Kollegen und Gurus. Der Guru muss erreichbar sein für Fragen und grundsätzliche Klärungen. Was nützt es, wenn jemand einmal eine neue Methode vorstellt, aber dann nicht für Nachfragen und Auskünfte zur Verfügung steht. Er muss mit regelmäßigen Veröffentlichungen präsent sein, die Studienkreise besuchen und seine email-Adresse angeben für Beratungen und Hilfestellungen. Wenn mein Guru nach einem Vortrag verschwindet, wo bleibt dann seine Glaubwürdigkeit? So etwas ist für mich unakzeptabel. Sicher gibt es immer wieder die Lage, dass ein Redner von außerhalb zu einem Spezialthema einmal eingeladen wird, aber auch dieser sollte seine Kontaktdaten hinterlassen, damit er erreichbar ist. Wo ist mein Guru? – Das ist die Frage. Das nächste Jahrestreffen unserer Organisation wird vom 26. bis 30. März in Florida stattfinden. Sehen Sie sich das hervorragende Programm dieser Veranstaltung an, und ich hoffe, Sie zu einer neuen außergewöhnlichen Lernerfahrung begrüßen zu dürfen. abb. Nov. 2013

لقد اختفى استاذي

لدي كثير من كلنا تعلمنا تقويم األسنان من طبيب أخر .و تأثيرا كبيرا على كيفية المعلمين والبعض ترك

ممارستي لتقويم األسنان اليوم,ھؤالء الناس أدعوھم لتقويم األسنان منحنى تعليمي شديد الميالن ان أساتذتي .

في البداية .المعلم ھناك يسھل األشياء ويجعل الحياة تعلم تقويم األسنان عبر برامج أسھل .ان بعضا منا قد يكون استاذ ھؤالء االطباءان .جامعية اختصاصية

طبيب تقويم مختص وھو أيضا أستاذ جامعي مع وجود أكبر .ير واحد أو أثنين منھم له تأث

قد يكون طبيب األستاذفان بالنسبة لطبيب األسنان تقويم مختص أو طبيب أسنان اخر له تأثير كبير في

التقويمية لدي كيفية ممارسة تقويم األسنان .في ثقافتي كثير من المعلمين بعضھم كانوا أطباء أسنان واخرين

:ئييناخصا

Wilson, Roth, Gugino, Ricketts, Bimler, Mahony, Litt, Clark, Witsig

جميعھم علموني كثيرا وجعلوني أتقدم في تقويم األسنان

ان عالم التعليم المستمر اليوم ھي حالة تتقدم في كل يومولو ليوم واحد فانك لن تستطيع واذا توقفت عن التعلم

ابدا. تدارك ذلك

ھذا افتراض (ادعاء ) جدي لكن نعلم أن فيه أعلم أن الصحة .وأقبل أن التعليم سھل عبر الكورسات شيئا منلقاءات مع األساتذة .السؤال المھم ھو أين ھو وعبر ال

أستاذي ,ھل يمكن التواصل معه وھل يقدم المحاضرات بشكل منتظم في منطقتي ؟

اذا كنت أخصائي تقويم أو ممارسا عاما, من غير المھم المھم أن يقدم لك استاذك الدعم الدائم وأن يكون حاضرا

نطقتك .اذا أتى أستاذ ما الى ملألسئلة واالستفسارات بتعليمك مبادئ تقنيته وتص◌وره واستقرفيھا و بدأ

يكون حاضرا لتقديم الدعم من خالل منتديات فعليه أنفاذا أتى لمرة ولمدة وغيرھا الدراسة أو المطبوعات

قصيرة وھو غير حاضر لالستفسارات فما الفائدة من فعاال ت يمكن لألستاذ أن يكون نتعليمه .مع وجود االنتر

جدا وداعما من خالل المطبوعات (النشرات واالستشارات واالراء عبر )والمحاضرات االلكترونية

ت أيضا .االنترن

لنا شاھدنا محاضرين ال أفضل أستاذا غير متوفر . ك ضيوف يأتون لمرة واحدة ألنھم خبراء في موضوع معين .لكن عليھم أن يكونوا حاضرين لألسئلة (في

المستقبل) عبر االيميل الخاص بھم .عليك التواصل مع .أستاذك ھذاھو السؤال أو بيت القصيد

لنا شاھدنا محاضرين ال أفضل أستاذا غير متوفر . ك ضيوف يأتون لمرة واحدة ألنھم خبراء في موضوع معين .لكن عليھم أن يكونوا حاضرين لألسئلة (في

المستقبل) عبر االيميل الخاص بھم .عليك التواصل مع .أستاذك ھذاھو السؤال أو بيت القصيد

30-26اللقاء السنوي لمنظمتنا سيعقد في فلوريدا في ل أن نراكم ھناك لمزيد من العلم نأم 2014|مارس|

والمعرفة .

Springs Canine Retraction Decalcification Broken Brackets Fixed Retainer Mandibular

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Maxillary Canine Substitution for the Severely Resorbed Root of Central Incisor: 12-Year Follow-up

By Yoshiyuki Koga, DDS, PhD; Jae Hyun Park, DMD, MSD, MS, PhD; Kiyoshi Tai, DDS, PhD

Abstract: Ectopically erupting maxillary canines can cause problems that necessitate surgical, orthodontic, and restorative treatment. When a canine eruption disturbance causes resorption and requires subsequent extraction of the affected teeth, the resulting spaces are candidates for orthodontic repositioning and recontouring of the remaining teeth. To achieve successful results, the clinician must have a proper knowledge of tooth anatomy, root angulation, gingival margin position, restorative techniques, and occlusion. A collaborative effort from the pediatric dentist, orthodontist, and surgeon is required to produce an esthetic and functional result. This case report describes the substitution of maxillary canines for both the left central and right lateral incisors and substitution of the maxillary right lateral incisor for the maxillary right central incisor. Keywords: Ectopic eruption, root resorption, canine substitution.

ntroductionEctopically erupting maxillary canines can pose significant challenges to clinicians by either becoming impacted or causing root resorption of

adjacent teeth.1-3 While root resorption of the primary teeth is a normal physiological process, resorption of permanent teeth is a complex biological process that is not yet clearly understood, although a combination of local and general factors are likely to be responsible.4,5

It has been suggested that physical contact and pressure of the ectopically erupting tooth may cause resorption.6,7 Early treatment is beneficial in order to prevent further complications.5,8 In addition, early treatment can be less expensive, easier to perform and possibly more effective.9

However, if not diagnosed and treated at an early stage, ectopically erupting maxillary canines could resorb adjacent teeth.10,11 Otto12 reported that rapid and severe root resorption of the lateral and central incisors was caused by mesially angulated maxillary canines in the relatively short period of less than four years. While resorption is rare, it can require more extensive treatment such as extraction and orthodontic repositioning.11

It had been estimated that incisor root resorption from ectopic eruption of maxillary canines affects girls more than boys5 but more recent literature indicates that it is equally common among sexes.11,13 Ericson and Kurol11found that 48 % of ectopically erupting canines caused incisor root resorption. Most often the lateral incisors are affected, but occasionally the central incisors are involved as well.5,11 Rimes et al14 investigated maxillary incisor root resorption with regard to the presence of an ectopic canine. In their study, they found that in two-thirds of the cases, the pattern of root resorption involved both middle and apical thirds of the incisor root. The extent of the resorption will dictate the treatment

that is necessary regardless whether the approach is surgical, orthodontic, restorative or a combination thereof.15

The purpose of this article is to present the orthodontic treatment of a patient who required extraction of the left central incisor as the consequence of severe root resorption due to ectopic eruption of the maxillary canine. The resulting space was closed using a left canine substitution for the missing left central incisor. In addition, the right lateral incisor was substituted for the extracted right central incisor and the right canine was substituted for the right lateral incisor.

Case History A 12-year 2-month-old female patient was referred to the clinic for consultation because of incisor root resorption associated with her ectopically positioned canines. She was in good general health and had no history of major systemic diseases or dental trauma.

Diagnosis She had a convex profile and a Class II skeletal pattern. Intraorally, she had a maxillary left deciduous canine and both of her maxillary canines were not emerged. She had severe crowding on her mandibular arch and severe crowding was developing on her maxillary arch. Her maxillary left central incisor was much more proclined than the maxillary right central incisor. The mobility of both of her maxillary central incisors was within physiological limits. The mesiodistal width (including the cervical portion) of her maxillary lateral incisors was wider than normal. Her maxillary dental midline was shifted to the right approximately 1.5 mm. She had a 20% overbite on her maxillary left central incisor and 5 mm overjet with a Class I molar relationship on the left side and end-on Class II molar relationship on the right side. The canine relationship on both sides was not applicable (Figure 1).

FEATURE This article has been peer reviewed.


A panoramic radiograph demonstrated that there were no caries and all third molars were present. From a periapical radiograph, the maxillary left central incisor showed root resorption and there was middle and cervical third involvement in the vertical plane due to the ectopically erupting maxillary left canine.14 Even with pulpal involvement, the maxillary left central incisor did not have clinical symptoms such as those in previous reports.5,14,15 The maxillary right central incisor demonstrated a blunted and short root apex (Figure 2).

Treatment Objectives and Plan Treatment objectives were to determine the best treatment option for the ectopically erupting maxillary left canine, relieve the crowding on both arches, obtain an acceptable overbite and overjet, coordinate her dental midline, establish Class I molar relationship on her right side. Since the patient was growing and had a prognathic maxilla, the ideal treatment would be to restrict the maxillary growth using a headgear, however, the patient and her parents declined the use of functional appliances and wanted the orthodontic treatment to just focus on treating the ectopically erupting maxillary left canine. A diagnostic set-up was fabricated to determine the occlusal possibilities if maxillary central incisors and mandibular second premolars were extracted (Figure 3). Based on this and after an initial orthodontic consultation, the patient was referred to an oral surgeon to extract her maxillary left central incisor.

Treatment Progress The ectopically erupting maxillary canine was surgically exposed so a button could be bonded for orthodontic extrusion. A modified Nance appliance was delivered to apply forced eruption of the ectopic canine. After 6 months, the canine was fully erupted in the arch (Figure 4). When she was 13 years and 3 month old, the right maxillary canine was ectopically erupting on the labial position. The patient was referred to a general dentist to extract the mandibular second premolars and maxillary right central incisor which had a short root (Figure 5). After the labial surface of the crown of the maxillary left canine was contoured, preadjusted appliances with .018 brackets (Alexander Signature Line, Ormco, Orange, Calif ) were bonded for leveling and alignment. To control the torque and root angulations, the left central incisor bracket was used for the maxillary left canine. Additionally, prior to bonding, the incisal edge and proximal and lingual surfaces of the substituted canine were slightly reduced to create an incisal-edge shape on the central incisor and to eliminate functional stresses (Figure 6A and B).16-18 To make the root of the right lateral incisor

Figure 1. Pre-treatment intraoral photographs.

Figure 2. Panoramic and periapical radiographs.

Figure 3. Diagnostic set-up model photographs; (A) compromised maxillary anterior gingival margin; (B) improved maxillary anterior gingival margin by extruding and grinding (black color) the target teeth.

Figure 4. Progress intraoral photographs showing forced eruption of the ectopic canine using a modified Nance appliance.


more parallel with the adjacent substituted canine, a bracket was appropriately positioned (Figure 7).19-21

In addition, to make the substituted right canine appear less curved and more like a lateral incisor, the inverted mandibular left canine bracket (thus reversing the torque from -3º to +7º) was placed more distally in the center of the canine rather than at the height of contour.16 To improve gingival height of the substituted right canine, the bracket should be placed more gingivally, however, the patient and mother did not want to grind the certain amount of the cusp tip after extrusion of the tooth to match with the contralateral lateral incisor, even though it could compromise her anterior gingival margin level (Figure 3). The maxillary arch was leveled with continuous arch wires, starting with .016-in nickel-titanium and working up to .017 X .025-in nickel-titanium. To reduce excessive occlusal loading, the lingual cusps of the maxillary canines and first premolars were recontoured (Figure 6A and C).16-18 During the finishing stage, final detailing of the occlusion was accomplished with .017 X .022-in Elgiloy wires (Figure 8). Additional recontouring of the substituted teeth was done shortly before appliance removal to create an incisor-like shape (Figure 6B). Fixed retainers were placed on the anterior teeth in the maxilla and mandible after debonding. Wraparound removable retainers were also delivered to secure the stability of both arches. Total treatment time for this patient was approximately 30 months.

Treatment Results Post-treatment records indicate that the treatment objectives were achieved. The ectopically erupting maxillary canine was successfully substituted, the crowding on the both arches were successfully relieved, acceptable overbite and overjet were achieved and Class I molar relationship was established (Figure 9). The post-treatment panoramic radiograph shows proper space closure and acceptable root parallelism except between the maxillary left substituted canine and lateral incisor due to the different anatomy of the substituted canine compared with the central incisor. There were no significant signs of bone resorption compared with pre-treatment. However, the mandibular anterior teeth demonstrated signs of apical root resorption (Figure 10). At the 12-year follow-up, the orthodontic treatment results were maintained. However, because she did not wear her removable retainers, she had some relapse. The radiographs also revealed that her mandibular third molars had been extracted. In the previous studies,22,23 canine malposition appears to be highly associated with third molar agenesis. Even though the third molars were not missing in this case, her maxillary third molars were developing very slowly (Figures 11 and 12).

Figure 5. Progress panoramic radiograph.

Figure 6. Recontouring of the substituted canine and premolar to simulate the appearance of the substituted teeth and establish a balanced occlusion.

Figure 7. Converged roots to avoid triangular space and reduce open gingival embrasure.

Figure 8. Progress intraoral photographs at finishing stage.

Figure 9. Post-treatment intraoral photographs.


Discussion If an eruption disturbance is identified early, it may be possible to be halt or reverse the condition.24 All to often, the resorption is identified too late, necessitating extraction of the resorbed teeth.11 According to Rimes et al,14 the average age at which maxillary incisor root resorption is discovered is around 12.5, by which time 66% of the involved teeth have two- thirds of their roots resorbed. The authors report that a contributing factor to the late discovery of such extensive resorption is the fact that patients experience a low incidence of pain or mobility during the resorptive process.14

In order to effectively treat patients with root resorption due to canine displacement, it is beneficial to identify risk factors that may indicate the potential for impacted or ectopically erupting canines.10,13 Several etiologic factors (localized, systemic or genetic) for impacted or ectopically erupting canines have been proposed.25,26 However, the etiology is believed to be

Figure 12. 12-year post-treatment panoramic radiograph.

Figure 10. Post-treatment panoramic radiograph.

Figure 11. 12-year post-treatment intraoral photographs.

multi-factorial and disturbances in the eruption of permanent maxillary canines are common due to the fact that they develop deep within the maxilla and have the longest path to travel of any tooth in the oral cavity.25,26

When the maxillary central incisor necessitates extraction, the resulting space must be appropriately managed. In the case of a missing maxillary central incisor in young patients, there are three treatment options: orthodontic space closure, maintaining the edentulous space for a prosthetic replacement in adulthood, or autotransplantation of a premolar.19,27-29

The ultimate choice depends on a number of factors such as patient and parent preferences, finances, tooth shape and shade, soft tissue profile, lip level and the type of malocclusion.27-29

While canine substitution for missing lateral incisors is relatively well-documented in the literature because the lateral incisor is a commonly missing tooth,17-19,30,31 there is much less literature demonstrating a successful substitution of central incisors with canines. The advantages of repositioning a canine to close space are the avoidance of long-term maintenance of a prosthetic replacement and improved periodontal health.30,32 However, there are a number of factors such as canine shape, size, color and gingival margin levels that must be considered when transposing a canine into an incisor’s position.17,18,27-32 There are orthodontic and restorative treatments that can help to make canines more esthetically pleasing in either a central or lateral incisor position. After reducing the prominent labial ridge of the canine, incisor brackets need to be bonded to increase palatal root torque. To improve the gingival margin level, the brackets can be positioned more gingivally to extrude the canine.17,30-32 Restoratively, the tooth can be reduced on the incisal edge, interproximal, labial, and lingual surfaces to mask the shape of the canine.16-18,30-32 The lingual surface of the tooth should be reduced enough to provide for proper overbite and overjet. Resin composite may be added to the mesio-incisal and disto-incisal line angles to create a more “incisor-like” shape.31 Enamel reduction can cause exposure of more dentin which may change the shade of the tooth. This can be overcome by bleaching or veneering.18,29 In the case of a missing central incisor, one viable option is substitution with a lateral incisor.19,28

McDowall et al28 stated some indications for replacing a central incisor with a lateral incisor include age, gingival level on smiling, maxillary crowding, amount of overjet and size of the lateral incisor and root length. The authors state that the incisal edge of the lateral incisor should be disregarded and focus should be directed to matching the gingival margin to that of the adjacent central incisor.28


Kurth and Kokich20 showed that mean root angulations of the maxillary central incisors with normal gingival embrasures have an average convergence of 3.65˚ and an increase in root divergence by 1˚ raises the probability of an open gingival embrasure from 14 to 21 %. With orthodontic treatment, maxillary incisor roots could be paralleled to reduce or eliminate open gingival embrasures.20,21 Zachrisson19

recommends that when repositioning the lateral incisor, its root should be more parallel to the adjacent central incisor than what would normally be found in order to close the space that would otherwise result in a midline triangular space. The tooth should be intruded and later built up with restorative material to match the gingival margin of the neighboring incisor.19,27-29

The mesial emergence profile on central incisors is generally flatter than the distal, so the substituted lateral incisor should be brought as close as possible to the midline so that the porcelain laminate or full crown can be built up wider on the distal rather than the mesial aspect.19,28,29 This movement also helps support the interdental papilla by creating an appropriate contact point (Figure 7).19,27,28

Root resorption due to ectopic eruption can cause complex problems with space closure,19 at times requiring tooth substitution and recontouring.16-18,27-32 In order to produce an esthetic and functional result for the patient, various orthodontic and restorative techniques should be considered. When repositioning teeth, it is imperative that the newly positioned tooth resemble the tooth previously occupying the space. Knowledge of tooth shape, morphology, and function are necessary, especially when reshaping with burs and restorative materials. Equally as important is knowledge of proper root angulation and position in order to produce an esthetic gingival margin and interdental papilla.16-18, 27-32

Conclusion There are a number of restorative and orthodontic factors that must be considered when treating a patient who is experiencing root resorption from ectopically erupting canines. When the resorption causes the need for extraction, the resulting space can be managed in a number of ways. Two options that have been discussed for managing missing incisors are canine substitution and lateral incisor substitution for missing central incisor. The clinician must be aware of proper positioning and shaping of the tooth in order to offer the most esthetic and functional results for the patient.

References1. Ericson S, Kurol J. Resorption of maxillary lateral incisors caused by

ectopic eruption of the canine: a clinical and radiographic analysis of predisposing factors. Am J Orthod Dentofacial Orthop 1988;94:503-513.

2. Bjerklin K, Bondemark L. Management of ectopic maxillary canines. Angle Orthod 2008;78:852-859.

3. Howard RD. The displaced maxillary canine: positional variations associated with incisor resorption. Trans Br Soc Study Orthod 1971;57:149-157.

4. Saldarriaga JR, Patino MC. Ectopic eruption and severe root resorption. Am J Ortho Dentofacial Orthop 2003;123:259-265.

5. Ericson S, Kurol J. Incisor resorption caused by maxillary cuspids: a radiographic study. Angle Orthod 1987:57:332-346.

6. Mahdmina A, Malik O, Ashley M, Waring D. 3’2’1: Orthodontic re-positioning of canines into central incisors. Br Dent J 2012;212:369-375.

7. Ericson S, Bjerklin K, Falahat B. Does the canine dental follicle cause resorption of the permanent incisor roots? A computed tomographic study of erupting maxillary canines. Angle Orthod 2002;72:95-104.

8. Richardson G, Russell KA. A review of impacted permanent maxillary cuspids- diagnosis and prevention. J Can Dent Assoc 2000;66:497-501.

9. Kurol JK. Early treatment of tooth-eruption disturbances. Am J Ortho Dentofacial Orthop 2000;121:588-591.

10. Becktor KB, Steiniche K, Kjaer I. Association between ectopic eruption of maxillary canines and first molars. Eur J Orthod 2005;27:186-189.

11. Ericson S, Kurol J. Resorption of incisors after ectopic eruption of maxillary canines: a CT study. Angle Orthod 2000;112:415-423.

12. Otto RL. Early and unusual incisor resorption due to impacted maxillary canines. Am J Orthod Dentofacial Orthop 2003;124:446-449.

13. Leifert S, Jonas IE. Dental anomalies as a microsymptom of palatal canine displacement. J Orofac Orthop 2003;64:108-120.

14. Rimes RJ, Mitchell CNT, Willmott DR. Maxillary incisor root resorption in relation to the ectopic canine: a review of 26 patients. Eur J Orthod 1997;19:79-84.

15. Milberg DJ. Labially impacted maxillary canines causing severe root resorption of maxillary central incisors. Angle Orthod 2006;76:173-176.

16. Alexander WRG. The 20 Principles of the Alexander Discipline. Hanover Park, IL: Quintessence Publishing Co, Inc.; 2008:59-74.

17. Tuverson DL. Orthodontic treatment using canines in place of missing maxillary lateral incisors. Am J Orthod 1970;58:109-127.

18. Kokich VO, Kinzer GA. Managing congenitally missing lateral incisors. Part I: canine substitution. J Esthet Restor Dent 2005;17:1-6.

19. Zachrisson BU. Improving orthodontic results in cases with maxillary incisors missing. Am J Orthod 1978;73:274-289.

20. Kurth JR, Kokich VG. Open gingival embrasures after orthodontic treatment in adults: prevalence and etiology. Am J Orthod Dentofacial Orthop 2001;120:116-123.

21. Sharma AA, Park JH. Esthetic considerations in interdental papilla: remediation and regeneration. J Esthet Restor Dent 2010;22:18-30.

22. Peck S, Peck L, Kataja M. Concomitant occurrence of canine malposition and tooth agenesis: evidence of orofacial genetic fields. Am J Orthod Dentofacial Orthop 2002;122:657-660.

23. Peck S, Peck L, Kataja M. Site-specificity of tooth agenesis in subjects with maxillarv canine malpositions. Angle Orthod 1996;66:473-476.

24. Kurol J. Early treatment of tooth-eruption disturbances. Am J Orthod Dentofacial Orthop 2002;121:588-591.

25. Bishara SE. Impacted maxillary canines: a review. Am J Orthod Dentofacial Orthop 1992;101:159-171.

26. Bedoya MM, Park JH. A review of diagnosis and management of impacted maxillary canines. J Am Dent Assoc 2009;140:1485-1493.

27. Kokich VG, Crabill KE. Managing the patient with missing or malformed maxillary central incisors. Am J Orthod Dentofacial Orthop 2006;129:S55-63.

28. McDowall RJ, Yar R, Waring DT. 2’2’1: orthodontic repositioning of lateral incisors into central incisors. Br Den J 2012;212:417-423.

29. Zachrisson BU. Planning esthetic treatment after avulsion of maxillary incisors. J Am Dent Assoc 2008;139:1484-1490.

30. Brough E, Donaldson AN, Naini FB. Canine substitution for missing maxillary lateral incisors: the influence of canine morphology, size, and shade on perceptions of smile attractiveness. Am J Orthod Dentofac Orthop 2010;138:705.e1-9.

31. Carter AC, Sather AH. Case report: canine substitution. Am J Orthod Dentofac Orthop 1997; 112:316-319.

32. Savage RR, Kokich VG. Restoration and retention of maxillary anteriors with severe root resorption. J Am Dent Assoc 2002;133:67-71.


Dr. Koga graduated from the Dental School of Kyushu University in Japan. He is a Senior Assistant Professor, Department of Orthodontics and Dentofacial Orthopedics, Nagasaki University Graduate School of Biomedical Sciences. He is currently working as the clinical and laboratory instructor.

Dr. Park is a Board Certified Orthodontist. While at New York University College of Dentistry (NYUCD), he received the Dean’s Award, the Master of Science Resident Research Award, and the Post Graduate Resident Research Award. New York University submitted Dr. Park’s research for a patent. He also worked as an orthodontic teaching fellow and member of the undergraduate clinical orthodontic faculty. He was selected as the NYUCD orthodontic

resident representative to participate in the Orthodontic Resident Scholars Program during the 2006 American Association of Orthodontists (AAO) session in Las Vegas and won 1st place in the Orthodontic Resident Scholars Program. He is currently working as an associate professor and chair of the Postgraduate Orthodontic Program at Arizona School of Dentistry & Oral Health and as an adjunct professor for the Graduate School of Dentistry at Kyung Hee University in Seoul, Korea. He received the Joseph E Johnson Clinical Award at the AAO Table Clinic Competition during the 2011 AAO Annual Session. The AAO also appointed him to be the recipient of the AAO Academy of Academic Leadership Sponsorship Program (AALSP) Award for 2010.

Dr. Tai graduated from the Dental School of Tokushima University in Japan. He is a visiting adjunct assistant professor, Postgraduate Orthodontic Program, Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, AZ. He is also adjunct faculty at the Graduate School of Dentistry at Kyung Hee University in Seoul, Korea. He recently received his PhD degree, Department of Oral and Maxillofacial Reconstructive Surgery, Okayama University Graduate School of Medicine, Dentistry

and Pharmaceutical Sciences in Japan. He has several thriving orthodontic practices in Japan. He has lectured internationally on orthodontics.

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Abstract: Vertical control is one of the problems occasionally encountered in Straight wire treatment. Vertical problem was addressed in a more controlled manner using Tip-Edge technique In this case report Tip-edge was used in a vertically growing individual with mild crowding, proclined upper and lower incisors with skeletal class I malocclusion. Keywords: Tip-edge, vertical grower.

ntroduction The Tip-Edge® (TP Orthodontics Inc., La Pone, Indiana, USA) bracket was invented by Dr. Peter Kesling to introduce differential tooth movement

within an edgewise based bracket system.1-3 As its name suggests, Tip-Edge combines an initial degree of tooth tipping, which greatly facilitates tooth movement, prior to edgewise precision finishing. Based on extensive clinical experience, it is the belief of the Dr. Kesling that Tip-Edge is the most significant innovation in fixed appliance orthodontics since the original edgewise bracket.4, 5 While essentially a straight-wire appliance itself, in terms of pre-adjusted bracket specification and elimination of looped arch wires and finishing bends, it overcomes the fundamental limitations of today’s popularly accepted straight-wire systems, and opens up new horizons in fixed appliance treatment. The straight wire6 appliance gives supreme control and finishing potential, but there can be difficulties during the overbite reduction phase because of the continuous arch mechanics. The Begg7 appliance is renowned for its superb ability regarding overbite and overjet reduction because it is able to provide the consistent low forces required for intrusion. It does, however, often have a prolonged stage 3 while the case is finished to a high standard. Several appliances have been developed with the aim of enhancing vertical control without losing the finishing capabilities of the Edgewise mechanism. Two of the better known appliances are the Beddtiot8 appliance and the Tip-Edge appliance.

Patient ReportClinical and Radiographic Examination A healthy, 14-year-old male reported to the orthodontic clinic with the complaint of forwardly placed upper and lower front teeth. On extra oral examination, the patient showed a dolico facial pattern (Figure 1a) with convex profile, acute

Use Of Tip-Edge In Vertically Growing Individual-A Case Report

By H. Jyothikiran, BDS, MDS; Ravi Shanthraj, BDS,MDS; Pradeep Subbiah, BDS, MDS

naso-labial angle and he had severe lip incompetence; the patient displayed almost 100% of his maxillary incisors (Figure1b). The intra-oral examination, showed severely flared anterior teeth in both arches. Both sides revealed class I molar and canine relationship (Figure 2a and 2c). An over jet of 6-mm, overbite of 3-mm with a 3-mm curve of spee (Figure 2b). Both arches were U- shape, crowding owing with rotation (Figure 2d and 2e). The

Figure 1: Pre-treatment extraoral picture revealing convex profile with incompetent lips.

Figure 2: Pre-treatment intraoral photographs revealing flared incisors in upper and lower arches with mild crowding.

Figure 3: Pre-treatment casts.



facial and maxillary dental midline coincided, lower midline shifted to right by 2 mm (Figure 3a to 3d). The panoramic radiograph (Figure 4a) showed all permanent teeth. The cephalogram (Figure 4b) revealed a skeletal class I relationship with a vertical growth pattern. The dental analysis showed proclined maxillary and mandibular incisors.

Treatment ObjectivesI. Stage I Objectives

a. Alignment of upper and lower anterior segment. b. Correction of increased over jet.c. Maintenance of bite

II. Stage II Objectivesa. Space closure mainly by retraction of labial

segments.b. Correction of midline shift.c. Maintenance of Stage I correction.

III. Stage III Objectivesa. Correction of torque and tip angles for each tooth

individually.b. Final detailing.

IV. To achieve lip competency and an aesthetically pleasing profile.

Treatment progressStage I Treatment: Banding of first molars and bonding of other teeth except second premolars. 0.016” NiTi given in upper and lower arches for initial leveling and alignment, followed by 0.018” high tensile stainless arch wires with mild anchorage bend. Class II elastics were given to maintain the over bite in retraction of maxillary anterior teeth. At the end of Stage I (6a to 6e) upper incisors contact above lower anterior brackets with reduced over jet and over bite.

Stage II Treatment: Anchor bends were replaced with bite sweeps to retain over bite reduction. Second premolars were bonded for alignment and leveling. Upper and lower- 0.020” high tensile stainless steel arch wires with lower 0.016” NiTi arch. After decrowding of premolars 0.020” high tensile stainless steel arch wires with vertical bite sweeps were used to retain over bite reduction and space closure. Space closure with E-6 horizontal elastomeric links were routed through premolar brackets (Figure 7a to 7e). In end of stage II all the extraction space was closed with retroclined upper incisors (Figure 8a to 8e).

Stage III Treatment: Upper and lower 0.0215” x 0.028” pre torque stainless steel arch wires (Figure 9a to 9e), side winders were used to deliver the torque and tip prescription to each tooth against zero torque base setting in rectangular arch wire. End of stage III settling commenced with upper and lower 0.019” x 0.025” braided stainless steel arch wire, wearing nightly 3/16” seating elastics (Figure 10a to 10e).

Figure 4: Pre-treatment radiographs revealing all the permanent teeth and cephlogram showing proclined incisors.

Figure 6: End of Stage-I showing reduced over jet and over bite.

Figure 7: Stage II closing the extraction space using E- chain.

Figure 8: End of Stage II revealing full closure of extraction space.

Figure 9: Stage III using pre torque 0.0215” x 0.025” SS with side winders.


Retention: Conventional Begg wrap around retainer in upper arch and bonded lingual retainer in lower arch (Figure 11a to 11c) was used.

Results The active treatment lasted 19 months. The overall changes were as follows: Skeletal and soft tissue changes: There were no significant changes in skeletal relation between maxilla and mandible (Figure 12).

Figure 10: 0.019 x 0.025 braided SS with settling elastic of 3/16 ounces.

Figure 11: Begg wrap around retainer in upper and fixed lingual retainer in lower arch.

Figure 12: Post-treatment extraoral photographs showing straight profile with competent lips.

Figure 13: Post-treatment intraoral photographs revealing class I molar and canine relationship with normal over jet and over bite.

Figure 14: Post-treatment casts.

Figure 15: Post-treatment radiographs showing root paralleling (a) and reduced proclination of teeth (b).

Figure 16: Superimposition of Pre-treatment (blue) and post treatment (red) cephalometry.

Dental changes: Optimal overbite and overjet were achieved, crowding releaved, and all spaces were closed (Figure 13a to 13e) and (Figure 14a to 14d). Radiographic changes: Acceptable root parallelism was attained and no root resorption occurred during treatment (Figure 15a). Cephalometrically (Figure 15b), a significant reduction in proclination of upper incisor by 7 mm and 17 degree and in lower incisor by 7 mm and 15 degree. Inter-incisal angle also decreased by 32 degree. The soft tissue changes i.e. upper lip retruded by 4 mm and lower lip retruded by 4 mm. the profile of the patient changed from convex to straight type. There were no significant changes in vertical skeletal relationship. A superimposition of the pre- and post-treatment cephalometric tracings shows the decrease in proclination of upper and lower anterior teeth with a normal inter-incisal angle without any change in molar relationship (Figure 16). Occlusal changes: The occlusal changes, as assessed by the Index of Orthodontic Treatment Need (Brooke and Shaw, 1989) and Peer Assessment Rating (PAR) index (Richmond et al., 1992) have been favorable and suggest that the case has been greatly improved by orthodontic treatment.

Occlusal changes PRE Rx POST RxIOTN(DHC) 4 1IOTN(AC) 7 1PAR score 33 0(100%)

Discussion According to the result of this case we found that Tip-edge could be used in vertical grower without changing the inter jaw relationship. The Madibular plane angle, Jarabak ratio, Lower anterior facial height and Y- axis have not changed significantly. The incisor proclination had drastically changed in upper and lower arches with a change in inter-incisal angle and naso-labial angle.


Table 1: Cephalometric Summary

Pre-RX Post-RXSagittal skeletal relationshipSNA(degree) 82 80

SNB(degree) 79 77

ANB(degree) 3 3

Wits appraisal(mm) 0.5 1

Vertical skeletal relationshipANS/PNS-MP(degree) 35 33

SN-MP(degree) 38 36

Jarabak ratio 56 58

ANS-Me(mm) 70 70

Y-axis(degree) 70 71

Facial axis(degree) -5 -6

Dental base relationshipU1 to NA(mm and angle) 12/37 5/20

L1 to NB(mm and angle) 12/39 5/24

UI to SN(degree) 120 105

LI to MP(degree) 110 90

Dental relationshipUI-LI(degree) 101 133

LI to APg(degree) 38 24

Over bite(mm) 6 2

Over jet(mm) 3 2

Soft tissueUpper lip to E-Plane(mm) 5 1

Lower lip to E-plane(mm) 8 4

Nasolabial angle(degree) 88 107

The flexible main arch wire, however, gives good control over rotation and, even in the lower arch in a high-angle case; the tipping of teeth into the extraction sites that one might expect is not seen. This is because of the added control given by the 0.018-inch Australian wire, giving all the advantages of tip-back mechanics. This particular wire was chosen as the auxiliary for two main reasons.9 First, it has a proven record with respect to vertical control; also, the small-dimension round wire slides easily through the molar tubes, keeping the frictional resistance of the system low. The forces needed for space closure are very light for this reason. To further improve the low-friction qualities of the system, the author now uses self-ligating brackets on premolars in extraction cases, which is proving to be very efficient. By balancing the forces of intrusion and retraction, it is possible to guide the upper incisor apices palatally, thereby reducing the need for root torque to finish the case.10 Therefore, the use of rectangular wire early in treatment is not necessary, and these wires can be placed later for finishing. This again helps to reduce friction and to apply more predictable and reliably light forces to the teeth.

Conclusion By addressing the limitations of the edgewise appliance from a fresh perspective–identifying the bracket slot as the source of anchorage problems–the Tip-Edge concept produced the first edgewise appliance to allow the use of differential tooth movement, without sacrificing the precision finishing of edgewise therapy. Major tooth repositioning and apical base corrections can be accomplished with simplified mechanics and very light intraoral forces.

References1. Kesling PC. Expanding the horizons of the edgewise arch wire slot.

American Journal of Orthodontics 1988; 94: 26-37.2. Kesling PC. Differential tooth movement Tip-Edge concept and the

differential straight-arch technique. Journal of Indian Orthodontics 1988; 19: 31-35.

3. Kesling PC. Dynamics of the Tip-Edge bracket. American Journal of Orthodontics 1989; 96: 16-28.

4. Parkhouse RC New thinking with Tip-Edge. Kieferorthop 1995; 9: 137-142.

5. Parkhouse RC. JlOS-lnterviews: Dr Richard Parkhouse on Tip-Edge. Journal of Indian Orthodontic Society 1992; 23: 67-73.

6. Andrews LF. The straight wire appliance, origin, controversy, commentary. J Clin Orthod. 1976; IV: 49–114.

7. Begg PR, Kesling PC. Begg Orthodontic Theory and Technique. 3rd ed. Philadelphia, Pa: WB Saunders Company; 1982.

8. Hocevar RA. Begg edgewise diagnosis determined totally individualized orthodontic treatment: foundations, description and rationale. Am J Orthod. 1985; 88:31–46.

9. Helen Taylor. Use of a Tip-Edge Stage-1 Wire to Enhance Vertical Control during Straight Wire Treatment: Two Case Reports. Angle Orthodontist, 2003; Vol 73, 1:93-99.

10. Jayne E. Harrison. Early experiences with Tip Edge appliances. Br J Orthod, 1998; 25:1-9.

Dr. H. Jyothi Kiran is Associate Professor, Department of Orthodontics and Dentofacial Orthopaedics, J.S.S. Dental College and Hospital, Mysore, Karnataka, India.

Dr. Ravi S. is Associate Professor, Departmet of Orthodontics and Dentofacial Orthopaedics, J.S.S. Dental College and Hospital, Mysore, Karnataka, India.

Dr. Pradeep S. is lecturer at the Department of Orthodontics and Dentofacial Orthopaedics, J.S.S. Dental College and Hospital, Mysore, Karnataka, India.


Abstract: This article reports the case of a patient with severe mandibular deficiency and crowding in the mandibular arch treated with atypical extractions of two premolars followed by mandibular advancement with the Herbst appliance. It became clear that this therapy corrected the malocclusion while improving facial. Keywords: Class II; Herbst appliance;atypical extractions.

ntroductionThe morphological characterization of Class II malocclusion varies widely, and can be caused by both dental and skeletal changes.

This sagittal problem is reflected in the isolated presence of maxillary prognathism, mandibular retrognathia, maxillary dentoalveolar protrusion, mandibular dentoalveolar retrusion or a combination of these factors, whereas mandibular retrognathia is often the key factor behind this discrepancy.1,2,3,4,5 Many removable or fixed appliances have been designed in an attempt to find a solution for Class II malocclusion with mandibular retrognathia, producing postural changes in the mandible and moving it forward in order to stimulate its growth. According to each appliance inventor, their invention produces specific dental and skeletal changes and each is fabricated and employed in a wide range of methods. Determining the ideal mechanism depends on the professional’s knowledge or preference, depending on where the discrepancy is located as well as on patient compliance. With a view to eliminating the compliance factor, HERBST6 devised an apparatus that effectively addresses mandibular protrusion without depending on patient cooperation while providing continuous forces for 24 hours. The main changes arising from the use of this appliance in treating patients with Class II, Division 1 occlusal relationship are reported in the orthodontic literature. According to these reports, the Herbst induces a restriction or redirection of the anterior displacement of the maxilla, an increase in anteroposterior mandibular growth rate, an increase in lower anterior facial height, a significant improvement in facial profile and maxillomandibular relationship and a significant proclination of the mandibular incisors.7-14

This article reports the treatment of a young patient presenting with severe mandibular deficiency and crowding in the mandibular arch. The patient was treated with continuous mandibular advancement using the Herbst appliance to correct a Class II occlusal relationship and improve facial relations,

especially the facial profile. “Atypical” premolar extractions were performed in order to correct a pronounced model discrepancy in the lower arch, i.e., to allow leveling and alignment without producing compensation, and create an occlusal error consistent with the facial error, thereby enabling maximum mandibular advancement. Diagnosis and Etiology The 13-year-old patient (L.B.S.L.) sought the Specialization Program in Orthodontics at the University of the Sacred Heart (Universidade do Sagrado Coração, Bauru-SP/Brazil) with the chief complaint of protrusion in the maxillary teeth. In assessing the face frontally, there was symmetry, decreased lower anterior facial height, marked mentolabial sulcus and virtually non-existent nasogenian sulcus. In evaluating the facial profile, one could observe increased facial convexity, adequate nasolabial angle, forced lip competence, marked mentolabial sulcus,

Using the Herbst Appliance With Atypical Extractions in the Lower Dental Arch

By Leopoldino Capelozza Filho DDS, MS, PhD; Danilo Furquim Siqueira DDS, MS, PhD; Renata Cristina Faria Ribeiro de Castro DDS, MS, PhD; Rodrigo Comparim DDS; Mikaela Reginee Basso Blanco DDS; Mauricio de Almeida Cardoso DDS, MS, PhD

Figure 1. Pre-treatment extraoral and intraoral photographs.



relatively short chin-neck line in relation to facial depth, and open chin-neck angle (Figure 1), unmistakable signs of mandibular deficiency. Occlusal assessment showed that the patient was at the end of the second transitional period of mixed dentition, with only teeth 53 and 83 not yet exfoliated. There was a Class II occlusal relationship (1/4) with pronounced overbite and overjet,

dentoalveolar atresia with consequent moderate crowding in the upper arch, and severe crowding in the lower arch. Tooth 43 was found to be positioned intraosseously with not enough space for eruption, whereas some bulging in the palatal region of the tooth 83 could be seen. The lower dental midline coincided with the upper midline (Figure 1 and 2). In evaluating the panoramic radiograph, one could observe the presence of three supernumerary teeth in the posterior region of the lower dental arch, two in the region of tooth 34 and one in the region of tooth 44 (Figure 3). Teeth 13 and 43 were still erupting but lacked space. The upper and lower third molars were still forming. The TMJ condition was normal. Analysis of standardized lateral radiographs (Figure 3) confirmed the clinical findings after morphological evaluation of the face, which revealed mandibular retrusion (SNB=77th) with mild maxillary protrusion (SNA= 84th), and predominance of vertical growth (SN.SGn=73º and SN.GoMe=37o). The maxillary incisors were slightly inclined lingually (1.NA=19º and 1-NA=3mm), and the lower incisors were proclined and protruded (1.NB=31º, IMPA=97º and 1-NB= 7mm). Such incisor position is compensatory and adaptive in patients with mandibular deficiency. Assessment of the clinical and radiographic examinations made it possible to diagnose the patient as presenting with a moderate mandibular deficiency and mild maxillary protrusion, with a Class II occlusal relationship (1/4), maxillary dentoalveolar atresia and severe mandibular crowding, with upper and lower compensated incisors.

Treatment Objectives Treatment goals were to (1) solve the upper and lower crowding issue, (2) correct the dental Class II malocclusion, consequently correcting overjet and overbite, (3) achieve a Class I canine relationship, Class III molar relationship and (4) improve facial aesthetics, despite the limitations.

Treatment Alternatives The therapeutic options available to this patient involved distinct approaches with substantially different therapeutic goals and treatment plans. All therapeutic hypotheses were extensively discussed with the patient’s legal guardians taking into account cost-effectiveness, age and growth management. As a result of the upper crowding and especially the more severe lower crowding, one option would be to start treatment by extracting four premolars, followed by retraction of the upper incisors, which would involve some anchorage loss in the maxillary arch to correct the Class II occlusal relationship. Since there was no protrusion in the upper incisors, it seemed illogical

Figure 2. Initial dental casts.

Figure 3. Initial panoramic, periapical and cephalometric radiographs.


to propose retraction of these teeth. Another possibility would be to extract only two maxillary premolars in order to correct the Class II and one lower incisor to address the crowding in the mandibular arch. This option would be unproductive since the Class II molar relationship (¼) would require a significant loss of anchorage to enable a full Class II relationship at the end of treatment, while providing little space to correct the overjet. Given these limitations, both hypotheses were ruled out as both posed potential risk to the patient’s profile and/or undermined overjet correction. Another treatment option submitted to the legal guardians was surgical mandibular advancement, which would very likely yield gains in facial and occlusal relationships. Such treatment would be indicated after pubertal growth spurt. This option was rejected by the patient and his legal guardians owing to the costs and risks implied, the impossibility of immediate treatment and difficulties in decision-making given the patient’s age. Although an admittedly limited alternative, a compensatory treatment with corrective intent15 was ultimately proposed and accepted. In these circumstances, treatment planning includes removal of the compensation in both dental arches, thereby exposing the skeletal discrepancy. The difference is that instead of using a mandibular advancement orthognathic surgery treatment, which might have a corrective bias, advancement is made with a fixed mandibular protractor (Herbst appliance), rendering the treatment compensatory in nature. In order for these proposed objectives to be achieved, extraction of two lower premolars (other than supernumerary) was planned as well as correction of the mandibular crowding, followed by rapid maxillary expansion and placement of the Herbst appliance, along with mandibular advancement to correct the sagittal occlusal relationship and ensure a more balanced face. The treatment plan also established that treatment with fixed orthodontic appliances would be completed with the goal of eliminating any unwanted outcomes from the orthopedic treatment, and that a Class I canine relationship and a Class I or III molar relationship would be attained.

Treatment Progress The orthopedic/orthodontic treatment was initiated with the extraction of teeth 34 and 44, in addition to the supernumerary teeth in the lower arch. The main objective was to correct the lower anterior intra-arch model discrepancy and create enough overjet to allow continuous mandibular advancement with the Herbst appliance in a second phase (Figure 4). In other words, decompensation. After the extractions, the initial retraction of canines was started with 0.016” steel wire combined with a moderate lip-bumper anchorage in the mandibular arch. During the partial retraction of the

Figure 4. Finish of alignment and leveling phase.

Figure 5. Cephalometric, extraoral and intraoral photographs immediately after placement of Herbst appliance.

Figure 6. Post-treatment extraoral and intraoral photographs.


canines, incisors were not included to avoid protrusion. After creating the necessary spaces for alignment, the incisors were included in the mechanics and were therefore bonded with Capelozza II3M Plus prescription brackets (+20 angulation, +80 torque)16. The mechanics continued until the extraction spaces were closed, with the canine relationship evolving into a full Class II (Figure 4). Six months after beginning the mechanics in the lower arch, a Haas type appliance was placed in the upper arch to perform rapid maxillary expansion to correct the dentoalveolar atresia, and thus make room for the eruption of tooth 23 and in particular tooth 13 - while also serving as anchorage for the Herbst, thereby minimizing the effect of the telescoping mechanism on the maxilla. The amount of expansion is defined by the inter-arch transverse relation with predictive mandibular advancement. This advancement was simulated with the Herbst. Also during the retention phase of the rapid maxillary expansion, direct bonding was performed on the incisors, canines and second premolars with Capelozza I3M prescription brackets17 (Figure 4), aiming at the full alignment and leveling of these teeth. The combination of protrusive mechanics in the upper arch and restrictive mechanics in the lower arch created suitable conditions (sufficient overjet or exposure of the sagittal malocclusion) for the orthopedic stage of the mandibular advancement process. As planned, a compensatory treatment with corrective intent was performed. The Herbst appliance, inserted with the purpose of correcting the canine relationship - which created in one single advancement an edge-to-edge bite in the incisors - remained attached to the maxillary (Haas expander) and mandibular (modified lingual arch, with bands on teeth 33, 36, 43 and 46) anchorages, and was maintained for a period of eight months (Figure 5). After removal of the Herbst appliance, the first upper and lower molars were banded, the upper and lower second premolars, and the lower canines were bonded. Leveling in both arches proceeded until the use of 0.019”x0.025” steel wire, with hooks in the upper arch mesially to the canines to allow the use of Class II vector elastics to stabilize the mandibular advancement and improve intercuspation. The fixed orthodontic appliance was removed and the retainers (Hawley retainer and lower 3x3) were placed twenty-three months after the beginning of treatment (Figure 6).

Treatment Results Final photographs and radiographs show that the orthopedic/orthodontic treatment produced typical characteristics of a normal occlusion, with a favorable aesthetic impact on the face, characterized by a reduction in facial convexity. The occlusal relationships were satisfactory with considerable compensation, especially in the lower arch, as well as increased buccal inclination of mandibular incisors and mesial movement of posterior teeth. This implied limitations that were predicted in the prognosis, and which define the treatment as compensatory. The final occlusal relationship was a Class III in first molars and Class

Figure 7. Final panoramic and cephalometric radiographs.

Figure 8. Cephalometric superimposition (pre-treatment and post-treatment).

Figure 9. Extraoral and intraoral photographs one year and four months post-treatment.

Figure 10. Dental casts one year and four months post-treatment.


mandible. In the clinical case described in this study, restriction to maxillary growth along with stimulation of mandibular growth resulted in a significant improvement in facial profile and maxillomandibular relationship.7,8,10,18,19 The main changes in soft tissue profile resulting from treatment with the Herbst are: upper lip retrusion, lower lip retrusion or protrusion, decreased facial convexity and improved facial profile.3,11

Orthopedic effects are most evident when the Herbst is placed at growth spurt. When the Herbst is used after craniofacial growth spurt, dental changes are predominant at the expense of skeletal changes.12,20 Thus, the ideal time to introduce Herbst treatment is when permanent dentition is complete, or shortly after statural growth spurt. The treatment performed in permanent dentition allows proper occlusal engagement after therapy, which enhances long-term stability.21,22,23 The upper incisors exhibit no significant changes in their position.7,8,9 On the other hand, the lower incisors tend to procline.7,8,9,19,24 In this case, mandibular incisors showed lower dentoalveolar compensation due to the use of such a rigid system. The mandibular posterior teeth, especially molars, showed a strong tendency to move mesially, corroborating the literature.7,8,9,18,19,24

First premolar extraction was aimed at correcting the lower anterior intra-arch model discrepancy and creating enough overjet as to allow ongoing mandibular advancement with the Herbst appliance. In other words, the goal was to align the lower anterior teeth, averting protrusion in the first phase, while allowing a certain amount of occlusal discrepancy consistent with the facial error. These are typical treatment procedures of a descompensatory treatment performed prior to mandibular advancement surgery. This surgery was replaced - in a new proposal presented in this study, called compensatory treatment with corrective intent - by orthopedic advancement of the mandible, with the advantages and disadvantages inherent in this method. At this stage of canine retraction and mandibular arch leveling, the use of moderate anchorage was preferred over skeletal anchorage, whereas extractions were indicated to correct the model discrepancy in the lower arch, but not for lower incisor uprighting. Given the longer time required to close the spaces, treatment was begun in the lower arch. It is of paramount importance that patient and legal guardian(s) understand the limitations of this treatment modality, named compensatory treatment with corrective intent, to avoid false expectations. As described in the literature,25 management of mandibular growth may prove inadequate, regardless of age or the appliance used to promote growth. In the clinical case presented, the occlusal relationship was corrected and the facial convexity reduced, although both the correction and reduction were extremely limited compared to surgical advancement. This assertion is particularly important since some studies correlate - mandibular retrusion with respiratory problems, including OSAS.26 In adulthood, if the patient’s complaint is of an aesthetic or functional (breathing) character, a decompensatory orthodontic treatment in preparation for orthognathic surgery is bound to be limited in terms of lower arch decompensation, since the first premolars will have already been extracted to enable the correction of lower arch crowding and orthopedic advancement. As a rule, this should not be an unsolvable problem, considering that

I in canines, with a significant overjet reduction and overbite correction (Figure 6). The final panoramic radiograph showed adequate parallelism between the roots of the teeth. Bone loss was observed in the region of tooth 34, and resulted from extraction of the supernumerary teeth. This region is still undergoing repair and require radiographic follow-up. Likewise, the upper third molars should be monitored and extracted in due course, since these teeth have no antagonists in the lower arch. The dental and skeletal changes that occurred during the orthodontic/orthopedic treatment - characterized by a sagittal compensation of the dental arches - could be confirmed by cephalometric analysis and comparison/superimposition of initial and final radiographs (Figure 7 and 8 – Table 1). Intraoral and facial control photographs taken one year and four months after removal of the appliances show that the facial and occlusal relationships remained stable (Figure 9 and 10).

Discussion Class II malocclusion can involve the basal bones in the sagittal, vertical and transverse direction. It is characterized by a maxillomandibular discrepancy and, in most cases, a convex facial profile. Assessment of Class II sagittal changes reveals that mandibular retrognathia is considered one of the main factors responsible for this malocclusion. Additionally, the upper arch often exhibits compensatory transverse atresia, requiring expansion prior to mandibular advancement. This diagnosis is essentially morphological. It is reached based on an isolated evaluation of the upper dental arch and the inter-arch relationship with the advanced mandible, predictively in relation to Class I.15, 16 Given the need for frequent maxillary transverse decompensation, the Haas type expansion appliance appears as an optional anchorage method for continuous mandibular advancement with the Herbst appliance. The Haas appliance optimizes clinical treatment time since after the active expansion phase, during the retention period, the expander itself can be used as anchorage for mandibular advancement, as in this case. It is noteworthy that given a lack of space for maxillary canines, prior expansion worked even more effectively in providing a resource for creating space for alignment of the upper teeth. Given that the Herbst is tooth supported, it induces major changes in the dentoalveolar component and a more stable and significant orthopedic effect in the maxilla than in the

Table 1: Initial and final cephalometric values

Initial values Final valuesSNA 84 o 82 o

SNB 77 o 77 o

ANB 7 o 5 o

SN.SGN 73 o 74 o

SN.GoMe 37 o 38 o

1.NA 19 o 17 o

1-NA 3 3 o

1.NB 31o 40 o

1-NB 7 mm 8mmIMPA 97 o 108 o


the recommended surgery for patients with compensated mandibular deficiency as well as those presenting with OSAS, usually require maxillary and mandibular advancement.

Conclusions The atypical treatment approach used in this case is defined as a compensatory treatment with corrective intent (CTCI). It combines the extraction of two lower premolars to eliminate mandibular crowding and thereby expose the sagittal skeletal discrepancy while allowing continuous mandibular advancement using Herbst’s rigid system. As a result, Angle Class II occlusal relationship was corrected and facial relationships improved.

References1. Baccetti, T. et al. Early dentofacial features of Class II malocclusion: a

longitudinal study from the deciduous through the mixed dentition. Amer J Orthod Dentofac Orthop 1997;111:502-9.

2. Balbridge, J.P. A study of relation of the maxillary first permanent molars to the face in Class I and Class II malocclusion. Angle Orthod 1941;11:100-9.

3. Buschang, P.H. et al. Mathematical models of longitudinal mandibular growth for children with normal and untreated Class II, division 1 malocclusion. Europ J Orthod 1988;10:227-34.

4. Carter, N.E. Dentofacial changes in untreated Class II Division 1 subjects. Brit J Orthod 1987;14:225-34.

5. Nelson, W.E.; Higley, L.B. The length of mandibular basal bone in normal occlusion and Class I malocclusion compared to Class II, division 1 malocclusion. Amer J Orthod 1948;34: 610-7.

6. Herbst, E. New ideas and apparatus in orthodontics. Int J Orthod 1932;18:962-9.

7. Pancherz, H. Treatment of Class II malocclusions by jumping the bite with the Herbst appliance. a cephalometric investigation. Amer J Orthod, v.76, n.4, p.423-42, Oct. 1979.

8. Pancherz, H. The mechanism of Class II correction in Herbst appliance treatment. A cephalometric investigation. Amer J Orthod 1982;82:104-113.

9. Pancherz, H. The Herbst appliance. its biologic effects and clinical use. Amer J Orthod 1985;87:1-20.

10. Pancherz, H. et al. Class II correction in Herbst and Bass terapy. Eur J Orthod 1989;11:17-30.

11. Pancherz, H. The effects, limitations, and long-term dentofacial adaptations to treatment with the Herbst appliance. Semin Orthod 1997;3:232-43.

12. Pancherz, H. Dentofacial orthopedics or orthognatic surgery: is it a matter of age? Amer J Orthod Dentofac Orthop 2000;117:571-4.

13. Pancherz, H.; Anehus-Pancherz, M. Facial profile changes during and after Herbst appliance treatment. Eur J Orthod 1994;16:275-86.

14. Pancherz, H.; Hägg, U. Dentofacial orthopedics in relation to somatic maturation. an analysis of 70 consecutive cases treated with the Herbst appliance. Amer J Orthod 1985;88: 273-87.

15. Capelozza FL. Diagnóstico em Ortodontia. Maringá: Dental Press, 2004.16. Capelozza Filho L. Metas terapêuticas individualizadas. Maringá: Dental

Press; 2011.17. Capelozza Filho L, Silva Filho OG, Ozawa TO, Cavassan AO.

Individualização de braquetes na técnica de Straight- Wire: revisão de conceitos e sugestão de indicações para uso. Rev Dental Press Ortod Ortop Facial 1999;4:87-106.

18. Valant, J.R.; Sinclair, P.M. Treatment effects of Herbst appliance. Amer J Orthod Dentofac Orthop 1989; 95:138-47.

19. Croft, R.S. et al. A cephalometric and tomographic evaluation of Herbst treatment in the mixed dentition. Amer J Orthod Dentofac Orthop 1999;116:435-43.

20. Hägg, U.; Pancherz, H. Dentofacial orthopedics in relation to chronological age, growth period and skeletal development. An analysis of 72 male patients with Class II division 1 malocclusion treated with the Herbst appliance. Eur J Orthod 1988;10:169-76.

21. Hansen, K.; Pancherz, H.; Hägg, U. Long-term effects of the Herbst appliance in relation to the treatment growth period: a cephalometric study. Eur J Orthod 1991;13:471-81.

22. Konik, M.; Pancherz, H.; Hansen, K. The mechanism of Class II correction in late Herbst treatment. Amer J Orthod Dentofac Orthop 1997;112:87-91.

23. Rothstein, T.L. Facial morphology and growth from 10 to 14 years of age in children presenting Class II, division 1 malocclusion: a comparative roentgenographic cephalometric study. Amer J Orthod 1971;60:619-20.

24. Mcnamara Júnior, J.A.; Howe, R.P.; Dischinger, T.G. A comparison of the Herbst and Fränkel appliances in the treatment of Class II malocclusion. Amer J Orthod Dentofac Orthop 1990;98:134-44.

25. Capelozza Filho, L et al. New perspective on Herbst therapy for skeletal Class II malocclusions: a proposal for maxillary protrusion management. Orthodontics 2012;13:188-207.

26. Cardoso, M. A et al. Tratamento ortodôntico-cirúrgico de má oclusão do Padrão II relacionado à SAOS: relato de caso. Revista Clínica de Ortodontia Dental Press 2012;11:70-82.

Dr. Leopoldino Capelozza Filho is Chairman Professor, Discipline of Orthodontics in Graduation, Specialty and MS Program, Dental School in University Sagrado Coração USC, Bauru, Brazil.

Dr. Danilo Furquim Siqueira is Assistant Professor, Discipline of Orthodontics in Graduation and MS Program, Dental School in University Sagrado Coração USC, Bauru, Brazil.

Dr. Renata Cristina Faria Ribeiro de Castro is Assistant Professor, Discipline of Orthodontics in Graduation and MS Program, Dental School in University Sagrado Coração USC, Bauru, Brazil.

Dr. Rodrigo Comparim, is a Student at MS Program (Orthodontics), Dental School in University Sagrado Coração USC, Bauru, Brazil.

Dr. Mikaela Reginee Basso Blanco is a Specialist in Orthodontics, Dental School in University Sagrado Coração USC, Bauru, Brazil.

Dr. Mauricio de Almeida Cardoso, is Assistant Professor, Discipline of Orthodontics in Graduation, Specialty and MS Program, Dental School in University Sagrado Coração USC, Bauru, Brazil.


Abstract: Few studies had investigated the effectiveness of the Fast Back appliance. As a result of that, this study was concerned about evaluating the dental and skeletal effects of the Fast Back appliance used in distalization of maxillary first molars. Materials and Methods: The sample was consisted of 14 female patients. However, four of them discontinued the treatment due to different causes. As a result of this, the study was performed on 10 female patients, with their age ranged from 11-13 years. All patients had skeletal Class I, space deficiency in the upper arch less than 8 mm, and non-extraction lower arch. Distalization using the Fast Back appliance was started at the beginning of the treatment and continued until an overcorrected Class I molar relation was achieved. Lateral cephalometric radiographs and dental casts were obtained before and immediately after distalization, and statistical evaluation of the variables measured on them were done. Results: The maxillary first molars were distalized into an overcorrected Class I in a mean duration of 3.8 months. They were distalized significantly according to cephalometric measurements and dental cast measurements (3.4 ± 0.71 and 3.69 ± 1.51 mm respectively) (p< .05), with a significant distal tipping about 3.55 ° ± 3.95° and a significant increase in intermolar width by 3.55 ± 2.58 mm (p< .05). However, the vertical positions of the upper first molars were insignificantly changed (p>.05), and rotations of these teeth were negligible (p>.05). Loss of anchorage was evidenced by the significant mesial movements of the upper first premolars. They were significantly tipped mesially, rotated , and extruded (p< .05). On the other hand, the interpremolar distance was insignificantly changed. The overjet was significantly increased and the overbite was significantly decreased. The skeletal changes sagitally and vertically were insignificant, except for the increase in mandibular plane angle (FMA angle) which was significant. Conclusions: The Fast Back is an efficient noncompliance appliance to distalize molars without rotations. However, these movements are associated with distal molar tipping and anchorage loss of the anterior teeth. Keywords: Distal molar movement;Non-compliance fixed distalizer;Fast Back distalizer;cephalometric and dental cast evaluation.

ntroductionDistalization is a common nonextraction strategy for treatment of moderate crowding malocclusion in which extraction is not indicated.1,2 Various

appliances have been routinely used for molar distalization, and can be classified as compliance or non-compliance appliances.3 Dependence on patients’ cooperation is a cornerstone for the drawbacks of compliance modalities, such as, extraoral traction and removable appliances.4, 5, 6 As a result of that, the creation and use of non-compliance, fixed, intramaxillary appliances for molar distalization, such as; Pendulum,7 Distal Jet,8 Jones Jig,9 Keles Slider,10 and First Class Appliance,3 have been done through advancements of biomechanics, technology, and materials. However, they may have unfavorable side effects, including different degrees of anchorage loss, mesial tipping of premolars, maxillary first molar tipping, posterior rotation of the mandibular plane, proclination of the incisors, and lip protrusion.11 These side effects can vary among different techniques and appliances. Lanteri et al12 in 2001 had developed the Fast Back appliance for the distalization of upper molars. They suggested that the appliance was fully programmable, with reduced bulk and causing minimal patient discomfort. Francolini13 and Amato14 pointed out that Fast Back appliance could deliver continuous and constant forces. The intensity and direction of the forces applied to the molars could be accurately controlled. To our knowledge, few studies had investigated the treatment outcome of the Fast Back appliance. As a result of

Effects of Molar Distalization with the Fast Back Appliance

By Alaa Abdelsalam Alkasaby BDS, MSc; Yasser Lotfy Abdelnaby BDS, MSc, PhD, MOrth RCSEd; Shaza Mohammad Hammad, BDS, MSc, PhD

that, this study was concerned about evaluating the dental and skeletal effects of the Fast Back appliance used in distalization of maxillary first molars.

Material and Methods The study was approved by the research ethical committee of Mansoura University and informed consents were obtained from the patients. The sample of this study was obtained from the outpatient clinic of the Department of Orthodontics, Faculty of Dentistry, Mansoura University. Patients were selected according to the following criteria: skeletal Class I, space deficiency in the upper arch less than 8 mm, non-extraction lower arch, ages ranged from 11 to 13 years, good oral hygiene, no oral habits, and no previous orthodontic treatment. The

Figure 1. Fast Back Appliance.



Figure 2. Cephalometric landmarks: is (incisor superior): the incisal tip of most prominent maxillary central incisor. ia (incisor apex): the apex of most prominent maxillary central incisor. ii (incisor inferior): the incisal tip of most prominent mandibular central incisor. ms (molar superior): the mesial contact point of maxillary permanent first molar, determined by tangent perpendicular to occlusal line (OL). ma (molar apex): the apex of mesio-buccal root of maxillary permanent first molar. mmc (mesial molar cusp): the mesio-buccal cusp tip of maxillary first permanent molar. dmc (distal molar cusp): the disto-buccal cusp tip of maxillary first permanent molar. ps (premolar superior): the mesial contact point of maxillary first premolar, determined by tangent perpendicular to occlusal line (OL). pa (premolar apex): the apex of buccal root of maxillary first premolar. pc (premolar cusp): the buccal cusp tip of maxillary first premolar. Where double image of molars or second premolars gave rise to two points, midpoint was used. Or: orbitale. S: sella. N: nasion. Me: menton. Go: gonion. ANS: anterior nasal spine. PNS: posterior nasal spine. Po: porion.

Figure 4. Sagittal and vertical dental linear measurements. Sagittal dental linear measurements (Pancherz’s superimposition method): 1. ms ┴ Olp, 2. ps ┴ Olp, 3. is ┴ Olp, 4. Overjet (is ┴ Olp minus ii ┴ Olp). Vertical dental linear measurements: 5. Overbite (ii ┴ OL), 6. mmc ┴ SN, 7. pc ┴ SN, 8. Is ┴ SN.

Figure 3. Skeletal and dental angular measurements. Skeletal sagittal measurements: 1. SNAo , 2. SNBo, 3. ANBo . Dental angular measurements: 4. is-ia/SNo, 5. pc-pa/SNo, 6. mmc-ma/SNo. Skeletal vertical measurements: 7. SN-MPo, 8. FMAo, 9. PP-MPo.

Figure 5. Angular and linear cast measurements. Angular measurements: MV-4: the mean of MV- 5”RU4” and MV- 12”LU4”, MV-6: the mean of MV- 3”RU6” and MV- 14”LU6”. Linear measurements: MH ┴ 4: the mean of MH ┴ 5”RU4” and MH ┴12” LU4”, MH ┴ 6: the mean of MH ┴ 3”RU6” and MH ┴ 14”LU6”. Inter premolar distance, Inter molar distance.

total number of patients was 10 who underwent distalization of maxillary first molars using the Fast Back appliance at the beginning of the treatment. The Fast Back appliance was constructed according to manufacturer instructions (Figure 1).12,13,14 The Nickel-Titanium coil springs delivered the preset force when they were activated by a minimum of 20% to a maximum of 80% of their capacity.13 So, the distalizer was activated 4 activations by opening the screw, to deliver a continuous, preset force (300 grams). Every activation generated 0.2 mm of spring compression. After the beginning of distalization, reactivation was carried out every 30 days.13,14 Once an overcorrected Class


Table I: Cephalometric measurementsVariables Description

SNA° Measures the position of the maxilla in relation to the anterior base of the skull

SNB° Measures the position of the mandible in relation to the anterior base of the skull

ANB° Measures the sagittal position between maxilla and mandible

FMA° Expresses the inclination of the mandible in relation to Frankfurt’s horizontal planeMandibular plane was drawn from the point (Me) to the point (Go).

SN-MP° Expresses the inclination of the mandible in relation to the anterior base of the skull

PP-MP° Expresses the inclination of the mandible in relation to the palatal plane (PP).

6-SN° The angle between (SN) line and the long axis of the maxillary first molar determined by the line passing through (mmc-ma).mmc; mesial molar cusp, ma; molar apex.

4-SN° The angle between (SN) line and the long axis of the maxillary first premolar which was determined by the line passing through (pc-pa).pc: premolar cusp, pa: premolar apex.

1-SN° The angle between (SN) line and the long axis of maxillary central incisor which was determined by the line passing through (is-ia).Is: incisor superior, Ia: incisor apex.

ms ┴ OLp The perpendicular distance from point (ms) to (OLp).ms: molar superior, OL (Occlusal Line): it was extended from the point (is) to the distobuccal cusp tip of the maxillary first permanent molar (dmc). OLp (Occlusal Line Perpendicular): It was extended through the point (S) and perpendicular to occlusal line (OL).

ps ┴ OLp The perpendicular distance from point (ps) to (OLp).

ps: premolar superior.is ┴ OLp The perpendicular distance from point (is) to (OLp).

Overjet The perpendicular distance from point (is) to (Olp) minus the perpendicular distance from point (ii) to (Olp).

ii: incisor inferior.mmc ┴ SN The perpendicular distance from point (mmc) to (SN).

pc ┴ SN The perpendicular distance from point (pc) to (SN).

is ┴ SN The perpendicular distance from point (is) to (SN)

Overbite The perpendicular distance from point (ii) to (OL ).

I molar relation was achieved, the appliance was converted into a modified Nance appliance for retention by separating the anterior arms from the first premolars bands. Lateral cephalometric radiographs and dental casts were obtained before and immediately after distalization. Cephalometric landmarks were illustrated in Figure 2. Skeletal and dental angular measurements were shown in Table I and Figure 3. Sagittal and vertical dental linear measurements were demonstrated in Table I and Figure 4.3 Pancherz’s superimposition method was used to assess sagittal dental linear changes. Consequently, we could avoid errors due to possible variations in the inclination of the occlusal plane after molar distalization.15 Regarding the measurements on the dental casts, landmarks were marked on the predistalization and postdistalization study casts. Angular and linear measurements on the photocopies of the cast were declared in Table II and Figure 5.16 All lateral cephalometric radiographs and cast photocopies were traced and analyzed by one investigator. Then, they were randomly retraced and analyzed again by the same

investigator after the first assessment. The method error, which was determined by Dahlberg’s formula, was less than 1 mm and 1 degree.

Statistical analysis Descriptive statistics including mean values, and the standard deviations were performed for each pre-treatment and post-treatment parameters. Paired t-test and its significance were calculated for the differences between pre-treatment and post treatment values, for each parameter, in each group. The level of significance was set at P≤0.05. Statistical analysis was performed using SPSS software for Windows (version 15.0, SPSS, Chicago, Ill).

Results The mean treatment period to achieve an overcorrected Class I molar relation was 3.8 months. The means, standard deviations (SD) and results of paired t-test for pre and post distalization measurements are listed in Tables III and IV. The


Table II: Cast measurements

Variables DescriptionMV- 6 The mean of right and left anterior angles formed by (mb-dp) lines of right and left maxillary first

molars and (MV) line.

mb: mesiobuccal cusp tip of the maxillary first molar, dp: distobuccal cusp tip of the maxillary first molar, MV: vertical reference line.

MV- 4 The mean of right and left anterior angles formed by (bc-pc) lines of right and left maxillary first premolars and (MV) line.

bc: buccal cusp tip of the maxillary first premolar. pc: palatal cusp tip of the maxillary first premolar.

MH ┴ 6 The mean of the perpendicular distances between (CMR) and (CML) to (MH) line.

mp: mesiopalatal cusp tip of the maxillary first molar. db: distobuccal cusp tip of the maxillary first molar. CMR: center of maxillary first molar on right side, CML: center of maxillary first molar on left side, both were determined by the point bisecting the (mb-dp) line with (mp-db) line on the maxillary first molar. MH: horizontal reference line.

MH ┴ 4 The mean of the perpendicular distances between (CPR) and (CPL) to (MH) line.

CPR: (center of maxillary first premolar on right side), CPL: center of maxillary first premolar on left side, both were determined by the midpoint of (bc-pc) line.

Interpremolar distance

The distance between (CPR) and (CPL).

Intermolar distance

The distance between (CMR) and (CML).

Overbite The vertical overlap of the lower incisors by the upper incisors.

Overjet The horizontal distance from the incisal edge of the most protruded maxillary incisor to the labial surface of the opposing mandibular incisor.

maxillary first molars were distalized significantly about 3.4 mm according to cephalometric measurements (Table III), and about 3.69 mm according to dental cast measurements (Table IV). Additionally, they were significantly tipped distally about 3.55° (Table III). The maxillary first molars showed a nonsignificant tendency to intrude (Table III), and a negligible rotation (Table IV). The intermolar width was significantly increased by 3.55 mm (Table iV). The upper first premolars were significantly moved mesially about 3.21 mm according to cephalometric measurements (Table III), and about 2.11 mm according to dental cast measurements (Table IV). Furthermore, they were significantly tipped mesially about 3° (Table III), and significantly rotated about 2.71° (Table IV). Regarding the vertical position, upper first premolars were extruded significantly about 3.12 mm (Table III). In the anterior region, a significant mesial movement of the maxillary incisors of 1.63 mm, was associated with a significant labial inclination about 2.55° (Table III). The overjet was increased significantly by 2.05 mm according to cephalometric measurements (Table III), and about 1.25 mm mm according to dental cast measurements (Table lV). However, the overbite was significantly decreased about 0.76 mm according to cephalometric measurements (Table III), and about 0.8 according to dental cast measurements (Table IV). Except for the significant increase in FMA angle (1.58°), no statistically significant differences were found when evaluating skeletal measurements (Table III). Intraoral photographs of one of the patients before and after distalization and also at the finishing stage of treatment are

shown in Figures 6, 7, and 8. Cephalometric superimposition, using palatal plane as a reference line and Anterior Nasal Spine (ANS) as a registering point, was done to represent the effect of the appliance on maxillary dentition (Figure 9).

Discussion The strength of the study is attributed to many factors. The first one is the inclusion criteria which applied to all patients. The second is the estimation of intraexaminar error of the method. The results of the study showed less molar tipping than other studies.3, 7, 17, 18, 19, 20, 21 However, it was more than that reported by Caprioglio et al.22 The Fast Back is provided with a rigid guiding system (the posterior arm sliding inside the palatal tube) which was positioned parallel to the occlusal plane to minimize the distal tipping. Additionally, the screws of the appliance were placed as close as possible to the center of resistance of the first molars inducing them to distalize bodily. Despite the heavy distalizing force, the appliance was able to minimize the amount of molars tipping. According to the results of the study, the vertical position of the upper first molars was insignificantly changed. The rigid guiding system was positioned parallel to the occlusal plane to minimize the vertical changes of molars. The intermolar width was significantly increased indicating that first molars were moved buccally. The result was matched with those of Ghosh and Nanda.17 However, Fuziy et al23 demonstrated a decrease in intermolar width, while, Keles and Sayinsu24


Table III. The means, standard deviations (SD) and P-Values of pre and post distalization skeletal and dental cephalometric measurements.

VariablesPre distalization

Mean± SDPost distalization

Mean± SDChangesMean± SD

P-Value

Skeletal angular measurements (sagittal)

SNAº 78.39 ± 2.07 78.50 ± 2.32 0.11±1.28 0.793

SNBº 76.06 ± 2.05 76.17 ± 2.29 0.11±0.94 0.722

ANBº 2.33 ± 1.12 2.37 ± 0.91 0.04±1.04 0.906

Skeletal angular measurements (vertical)

FMA° 29.65 ± 2.33 31.23 ± 2.50 1.58±1.58 0.012*

SN-MP° 39.90 ± 3.65 40.74 ± 3.91 0.84±1.46 0.103

PP-MP ° 30.31 ± 4.39 30.60 ± 5.54 0.29±1.58 0.578

Dental angular measurements

6-SN° 69.65 ± 3.64 66.10 ± 5.68 -3.55 ± 3.95 0.019*

4-SN° 86.1 ± 2.49 89.1 ± 3.16 3.00 ± 1.61 0.000*

1-SN° 105.50 ± 7.62 108.05 ± 6.52 2.55 ± 2.79 0.018*

Dental linear measurements (sagittal)

ms ┴ OLp 54.55 ± 2.21 51.15 ± 2.45 -3.4 ± 0.71 0.000*

ps ┴ Olp 69.25 ± 2.25 72.46 ± 2.15 3.21 ± 1.55 0.000*

is ┴ OLp 82.92 ± 1.97 84.55 ± 1.80 1.63 ± 1.60 0.011*

Overjet 2.95 ± 0.63 5.00 ± 0.63 2.05 ± 0.51 0.000*

Dental linear measurements (vertical)

mmc ┴ SN 69.35 ± 3.1 68.84 ± 3.45 -0.51 ± 1.28 0.241

pc ┴ SN 74.85 ± 2.72 77.97 ± 3.65 3.12 ± 1.77 0.000*

is ┴ SN 80.08 ± 3.00 81.27 ± 3.64 1.19 ± 2.05 0.101

Over bite 1.97 ± 1.48 1.21 ± 1.07 - 0.76 ± 0.61 0.003**Significant p≤ .05, PP (palatal plane), MP (mandibular plane), ms (molar superior), ps (premolar superior), is (incisor superior), mmc (mesial molar cusp), pc (premolar cusp)

Table IV. The means, standard deviations (SD) and P-Values of pre and post distalization measurements of the dental cast.

VariablesPre distalization

Mean± SDPost distalization

Mean± SDChangesMean± SD

P-Value

Angular measurements

6-MV° 30.43 ± 5.52 30.49 ± 5.07 0.05 ± 2.77 0.951

4-MV° 77.28 ± 6.00 80.00 ± 5.05 2.71 ± 3.06 0.021*

Linear measurements

6┴MH 12.14 ± 2.69 15.83 ± 1.84 3.69 ± 1.51 0.000*

4 ┴ MH 4.17 ± 2.26 6.27 ± 2.22 2.11 ± 1.36 0.001*

Overjet 2.42 ± 0.66 3.67 ± 0.72 1.25 ±0.23 0.000*

Overbite 2.85 ± 1.15 2.05 ± 1.01 - 0.8 ± 0.42 0.000*

IPD 33.75 ± 1.96 34.30 ± 1.92 0.55 ± 1.94 0.534

IMD 45.46 ± 2.20 49.01 ± 2.91 3.55 ± 2.58 0.006*

*Significant p≤ .05, MV: vertical reference line, MH: horizontal reference line, IPD: inter premoalr distance, IMD: inter molar distance)


reported no change. In the present study, rotation of molars was insignificant. The increase in intermolar width and the lack of molar rotation after distalization can be attributed to the rigid guiding system of the Fast Back appliance which helped to distalize the molars toward the posterior wider part of the dental arch and guarded the molars against the rotation. The upper first premolars were tipped mesially, rotated, and extruded. However, The interpremolar distance was insignificantly changed. Some researches reported less anchorage loss regarding the mesial movement, tipping, and extrusion of the first premolars.7,10,18,22 Distalization of molars with 300 grams of force produced reciprocal mesial and vertical forces that was delivered to the crowns’ of the first premolars, away from their center of resistance. This led to tipping, mesial movement and extrusion of these teeth. The anterior arm of the Fast Back appliance which was palatally soldered to the first premolars’ bands delivered rotating force to these teeth. The trans-palatal bar helped keeping the interpremolar distance without change.Regarding the maxillary incisors, they were moved and tipped labially. The findings were in agreement with several studies.3,10,21,23 On the other hand, our results were less than other studies.8, 10, 22, 23, 24 It was evidenced that the upper incisors were insignificantly extruded. Proclination of the maxillary central incisors was associated with an increase in overjet. The results were in harmony with those of Keles.10 Meanwhile, the decrease in overbite was less than those declared by other studies.7, 8, 10, 22, 23, 24 In our study, the increase in mandibular plane angle (FMA angle) indicated

Figure 6. Intraoral photographs of the patient before the distal movement of the molars.

Figure 7. Intraoral photographs of the patient after the distal movement of the molars.

Figure 8. Intraoral photographs of the patient during the finishing stage of treatment.

Figure 9. Cephalometric superimposition shows effects of the Fast Back appliance on maxillary dentition.

that the lower vertical dimension was increased leading to reduction in overbite. Furthermore, proclination of the maxillary central incisors would decrease the overbite. The changes in sagittal and vertical skeletal measurements were insignificant, except for the increase in mandibular plane angle (FMA angle) which was significant. The skeletal measurements were not affected significantly due to a relatively short period of distalization time. However, the significant increase in FMA angle would have been mostly caused by distalizing the maxillary molars into the wedge (the arc of closure).

Conclusions1. The Fast Back appliance is an effective distalizer with an

easy way of activation.


Dr. Alaa Abdelsalam Alkasaby is an Orthodontist at Mansoura University Hospital and has an MSc in Orthodontics, Faculty of Dentistry, Mansoura University, Mansoura Egypt.

Dr. Yasser Lotfy Abdelnaby is a Professor of Orthodontics, Faculty of Dentistry, Mansoura University, Mansoura, Egypt.

Dr. Shaza Mohammad Hammad is an Associate Professor of Orthodontics, Faculty of Dentistry, Mansoura University, Mansoura, Egypt.

2. Distalization of maxillary first molars is accompanied by significant distal tipping of these teeth and significant increase in inter molar distance; however, the intrusion and rotation of molars are insignificant.

3. There is reciprocal anchorage loss expressed by the increase in overjet, reduction in overbite, and mesial movements of the maxillary first premolars and incisors.

4. The skeletal changes sagitally and vertically are insignificant, except for the slight increase in mandibular plane angle (FMA angle).

References1. Proffit W, Fields H.Jr, & Sarver D. Contemporary Orthodontics. 4th ed.

St. Louis, Missouri; Mosby; 2007:268-290. 2. Burrow S. To extract or not to extract: A diagnostic decision, not a

marketing decision. Am J Orthod Dentofacial Orthop 2008;133:341-342.3. Fortini A, Lupoli M, Giuntoli F, & Franchi L. Dentoskeletal effects

induced by rapid molar distalization with the first class appliance. Am J Orthod Dentofacial Orthop 2004;125(6):697-705.

4. Orton H, Battagel J, Ferguson R, & Ferman A. Distal movement of buccal segments with the “en masse” removable appliance its value in treating patients with mild Class II, Division 1 malocclusions: Part I, clinical techniques (how to do it). Am J Orthod Dentofacial Orthop 1996;109(3):234-243.

5. Chung K, Park Y, & Ko S. C-Space regainer for molar distalization. J Clin Orthod 2000;34(1):32-39.

6. Gumus A, & Arat Z. A removable Class II appliance for simultaneous distalization and expansion. J Clin Orthod 2005;39(10):613-617.

7. Bussick T, & McNamara J.Jr. Dentoalveolar and skeletal changes associated with the pendulum appliance. Am J Orthod Dentofacial Orthop 2000;117(3):333-343.

8. Ngantung V, Nanda R, & Bowman S. Post-treatment evaluation of the distal jet appliance. Am J Orthod Dentofacial Orthop 2001;120(2):178-185.

9. Jones R, & White J. Rapid Class II molar correction with an open-coil jig. J Clin Orthod 1992;26(10):661-664.

10. Keles A. Maxillary unilateral molar distalization with sliding mechanics: a preliminary investigation. Eur J Orthod 2001;23(5):507-515.

11. Fontana M, Cozzani M, & Caprioglio A. Non-compliance maxillary molar distalizing appliances: an overview of the last decade. Prog Orthod 2012;13(2):173-184.

12. Lanteri C, Francolini F, & Lanteri V. Distalization Using the FAST BACK Expansor,Requirements, Ideas, Comparisons and Applications. Ortho News 2003;1(25):2-3.

13. Francolini F. The ‘Fast Back’ appliance for molar distalization (technical overview and construction guidelines). Available on line at: www.leodont.co.nz/media/447/fastback_construction guidelines.pdf. Accessed March 3, 2012.

14. Amato L. The Fast Back: a non-compliance distalising device. The Dental Technician 2010;63:6-9.

15. Pancherz H. The mechanism of Class II correction in Herbst appliance treatment A cephalometric investigation. Am J Orthod Dentofacial Orthop 1982;82(2):104-113.

16. Kucukkeles N, Cakirer B, & Mowafi M. Cephalometric evaluation of molar distalization by hyrax screw used in conjunction with a lip bumper. World J Orthod 2006;7(3):261-268.

17. Ghosh J, & Nanda R. Evaluation of an intraoral maxillary molar distalization technique. Am J Orthod Dentofacial Orthop 1996;110(6):639-646.

18. Schütze S, Gedrange T, Zellmann M, & Harzer W. Effects of unilateral molar distalization with a modified pendulum appliance. Am J Orthod Dentofacial Orthop 2007;131(5):600-608.

19. Khoury S, Manso G, Rodríguez M, & Rivas Y. Evaluation of Belussi’s molar distalizer. (Evaluación del distalador molar Belussi). Rev Cubana Estomatol 2008;45:1-9.

20. Muse D, Fillman M, Emmerson W, & Mitchell R. Molar and incisor changes with Wilson rapid molar distalization. Am J Orthod Dentofacial Orthop 1993;104(6):556-565.

21. Itoh T, Tokuda T, Kiyosue S, Hirose T, Matsumoto M, & Chaconas S. Molar distalization with repelling magnets. J Clin Orthod 1991;25(10):611-617.

22. Caprioglio A, Beretta M, & Lanteri C. Maxillary molar distalization: Pendulum and Fast-Back, comparison between two approaches for Class II malocclusion. Prog Orthod 2011;12(1):8-16.

23. Fuziy A, Almeida R, Janson G, Angelieri F, & Pinzan A. Sagittal, vertical, and transverse changes consequent to maxillary molar distalization with the pendulum appliance. Am J Orthod Dentofacial Orthop 2006;130(4):502-510.

24. Keles A, & Sayinsu K. A new approach in maxillary molar distalization: intraoral bodily molar distalizer. Am J Orthod Dentofacial Orthop 2000;117(1):39-48.


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Modification of Uprighting Spring for Derotation of Second Molars

By Vankre Mallikarjun, BDS, MDS; Madhukar Reddy Rachala, BDS, MDS; Kaladhar Reddy Aileni, BDS; MDS;Pyata Reddy Jaipal BDS; MDS

ntroduction One of the most efficient ways for the correction of rotated upper molars is derotation with a transpalatal arch, but this appliance is usually

favorable when the need for correction is the same on both sides of the dental arch. Derotation of unilateral upper second molar is a difficult task, especially when there is no accessible tooth or attachment is available distal to it for the application of couple forces. We have designed a modification of uprighting spring which is far more convenient than using the conventional method of TPA for derotation of unilateral upper second molar. Unilateral rotated upper second molar (Figure A). Rotation spring prepared with 0.014” SS wire (Figure B), a modification of the uprighting spring placed in the auxiliary tube of upper first molar before activation (Figure C). Activate the spring by engaging it into the buccal attachment (either Begg bracket as in this case /second molar buccal tube in vertical position/any pre-adjusted bracket with vertical slot) on the second molar (applies pushing force on it) (Figure D).

Figure A: Rotated upper second molar.

Figure B: Modification of the uprighting spring for derotation.

Figure C: Rotation spring placed in the auxillary tube of the first molar tube.

Figure D: Engaged into the attachment of the second molar.

Figure E: couple force applied with pulling force with E-chain from palatal aspect and pushing for with rotation spring on buccal aspect.

CLINICAL PEARL

Abstract: One of the most efficient ways for the correction of rotated upper molars is derotation with a transpalatal arch, but this appliance is usually favourable when the need for correction is same on both sides of the dental arch. Derotation of unilateral upper second molar is a difficult task, especially when there is no accessible tooth/ any attachment is available distal to it for the application of couple forces. We have designed a modification of uprighting spring which is far more convenient than using the conventional method of TPA for derotation of unilateral upper second molar. Keywords: Uprighting spring, derotation, second molar.

Application of couple forces i.e pulling force on the palatal aspect with E-chain and pushing force on buccal aspect with spring on the rotated tooth (Figure E). Anchorage is reinforced with transpalatal arch on first molars. Derotated upper second molar (Figure F).


Dr. Vankre Mallikarjun completed his undergraduate degree B.D.S. in 2004 from Coorg institute of Dental Sciences, Virajpet, Karnataka, and his Master’s degree M.D.S. in Orthodontics in 2012 from SVS Institute of Dental Sciences, Mahabubnagar, Andhrapradesh, India. He is presently working as senior lecturer in the same institute.

Dr. Madhukar Reddy Rachala completed his undergraduate degree B.D.S. in 2003 from Government Dental College & Hospital, Vijayawada, Andhrapradesh and his Master’s degree M.D.S. in Orthodontics in 2008 from A.M.E.’S Dental College & Hospital, Raichur, Karnataka. He is currently reader in department of Orthodontics and Dentofacial Orthopedics at S.V.S. Institute of Dental Sciences, Mahabubnagar, Andhrapradesh, India.

Dr..Kaladhar Reddy Aileni is a professor & HOD, received his undergraduate degree B.D.S. in 1995 from Meenakshi Ammal Dental College and Hospital, Chennai, India and his Master’s degree M.D.S. in orthodontics from Saveertha Dental college and hospital, Saveetha University, Chennai, India in the year 1999. He is a Post Graduate guide since 3 yrs and presently he is professor and HOD in department of Orthodontics and Dentofacial Orthopedics at, S.V.S. Institute of Dental Sciences, Mahabubnagar Andhra Pradesh, India.

Dr. Pyata Reddy Jaipal received his undergraduate degree B.D.S. in 1999 and his Master’s degree M.D.S. in Orthodontics in 2003 from M.R .Ambedkar Dental College & Hospital, Rajiv Gandhi University, Banglore, Karnataka. He is currently reader in department of Orthodontics and Dentofacial Orthopedics at S.V.S. Institute of Dental Sciences, Mahabubnagar, Andhrapradesh, India.

Figure F: Derotated second molar.


Abstract: Objective: The aim of this study was to assess the upper airway soft-tissue structures in Class II Japanese children following activator treatment by means of cephalometric analysis. Study Design: A lateral cephalometric radiograph was taken of each patient at T1 (prior to the placement of the activator; mean age: 11 years, 5 months) and T2 (after 1 year of activator treatment; mean age: 12 years, 5 months). Tracings of the lateral cephalometric radiographs were made on acetate paper, and several soft-tissue points and contours of the tongue, soft palate, hyoid, and pharynx were digitised. Results: The sizes of the oropharynx and hypopharynx were significantly smaller in Class II patients than in Class I patients. Moreover, significant differences were observed in the sizes of the tongue and soft palate between Class I and II patients at the age of 12. In terms of the ratio of change relative to the initial values between the 2 skeletal patterns, the width and dimension of the pharyngeal airway in Class II patients showed considerable increases after activator use. Conclusion: The pharyngeal airway soft tissue structures of Class II patients using the activator exceeded normal growth after 1 year. This finding suggests that correction of skeletal Class II discrepancies by the activator in orthodontic treatment could reduce the risk of respiratory problems, such as severe snoring, obstructive sleep apnoea, and excessive daytime sleepiness in the future. Keywords: pharyngeal airway size; skeletal Class II discrepancy; mandibular growth; activator appliance.

ntroductionObstructive sleep apnoea (OSA) and habitual snoring (HS) are important causes of morbidity in both adults and children.1-4 In children, OSA and HS are well-known factors for neurobehavioral and

growth-related problems, and can negatively affect academic performance.5-8 The estimated prevalence of OSA and HS in children occurs at a low but appreciable rate, ranging from 1-3% and 7-12%, respectively,9-12 thus affecting a significant number of children. Obesity is a major risk factor for sleep-disordered breathing, including OSA in adults and children.13-15 However, the degree of obesity is comparatively low in Japanese patients with OSA, and obesity may not be a crucial cause of OSA in Japanese adult and child patients.16, 17 Moreover, in previous studies, abnormal craniofacial structure correlated better than obesity with OSA in oriental populations.18, 19 In addition, the occlusion of the airway in OSA patients was highly associated with the anatomic structure of the upper airway and mandible (e.g. hyperplasia of the pharyngeal and palatine tonsils, severe mandibular deficiency) as the major cause of OSA in children.20-23 Hence, the correction of abnormal craniofacial structures could significantly reduce the prevalence of OSA and HA among Japanese children. The oral appliance (OA) has been established as a lifelong treatment tool for patients with primary snoring and mild to moderate OSA.24, 25 The OA is used to reposition the mandible forward in OSA patients and thereby to enlarge the upper airway. The design of an OA for OSA patients is primarily derived from functional orthodontic appliances, such as an activator.26 However, an OA is not a permanent cure for OSA or HS. Further, for non-growing adults, the desired outcome

is that an OA (e.g. an activator) does not produce permanent dentofacial structural changes.24, 25, 27 By contrast, functional appliances for Class II growing patients are unique among orthodontic appliances in terms of producing morphologic alterations in the dentoalveolar structure through providing direct stimuli to the masticatory system.28, 29 The activator is representative of these appliances and is used to enhance mandibular growth in growing Class II patients with small and/or distally located mandibles. However, little information is available in the literature about morphological changes in the upper pharyngeal airway in Japanese children as a result of activator treatment. Hence, the aim of this study was to assess the upper airway soft-tissue structures in Class II Japanese children following activator treatment.

Materials and MethodsSubjects and appliance Fifty subjects in this study were Class I (7 males, 18 females) and Class II (10 males, 15 females) patients in the

Enhanced Increase in Pharyngeal Airway Size in Japanese Class II Children Following a 1-Year Treatment with an Activator Appliance

By Atsushi Horihata PhD; Hiroshi Ueda PhD; Myongsun Koh PhD; Genki Watanabe PhD; Kazuo Tanne PhD

Figure 1 - An overall view of the activator appliance.



Figure 2 - Diagrammatic representation of landmarks and linear variables used to obtain tongue, soft palate, and upper airway measurements. Tongue length (TGL) was measured as the distance from the tip of the tongue (TT) to the base of the epiglottis (Eb). Tongue height (TGH) was defined as the maximum perpendicular distance from the plane TT-Eb to the dorsum of the tongue. The soft palate length (PNS-P) was measured from the posterior nasal spine (PNS) to the inferior tip of the soft palate (P), and the soft palate thickness (MPT) was measured on the line perpendicular to the PNS-P line. The superior posterior airway space (SPAS) was measured between the posterior pharyngeal wall and the posterior border of the soft palate on a line parallel to Go-B through the midpoint of PNS-P. The middle airway space (MAS) was measured between the posterior pharyngeal wall and the dorsum of the tongue on　a line parallel to Go-B through the tip of the soft palate (P). The inferior airway space (IAS) was defined as the width of the pharynx measured between the posterior pharyngeal wall and the dorsum of the tongue on a line joining gonion (Go) to the supramentale (B). 1, TGL; 2, TGH; 3, PNS-P; 4, MPT; 5, SPAS; 6, MAS; 7, IAS.

Figure 3 - Diagrammatic representation of landmarks and contours used to identify tongue, soft palate, nasopharynx, oropharynx, and hypopharynx cross-sectional areas. The tongue area is the area outlined by the dorsum of the tongue surface and the lines that connect TT (the centre of the lead disc attached to the border between the ventral and dorsal surfaces of the tongue tip), RGN (retrognathion), H (anterior-superior point of the hyoid), and Eb. The soft palate area is defined by the outline of the soft palate that starts and ends at PNS through P. The nasopharynx is outlined by a line between R (the point on the posterior pharyngeal wall constructed by the line from PNS to the cross-sectional point of the cranial base and the lateral pterygoid plate) and PNS, an extension of the palatal plane to the posterior pharyngeal wall, and the posterior pharyngeal wall. The oropharynx is outlined by the inferior surface of the tongue, a line parallel to the palatal plane through point Et (the most superior point of the epiglottis), and the posterior pharyngeal wall. The hypopharynx is outlined by the inferior border of the oropharynx, the posterior surface of the epiglottis, a line parallel to the palatal plane through point C4 (the most inferior and anterior point on the fourth cervical vertebrae), and the posterior pharyngeal wall. For the measurement of the cross-sectional areas, the tongue, soft palate, and pharyngeal area outlines were quantified by reading the drawn sheets on a personal computer via a flat-bed scanner. A custom-made program developed by Sano et al. (2007) computed the cross-sectional area of each soft tissue from the reproduced image. 1, Tongue; 2, Soft Palate; 3, NASO; 4, ORO; 5, HYPO.

Department of Orthodontics, Hiroshima University Hospital. Twenty-five patients were in each class, and the patients were 11- and 12-years-old. All Class II patients were treated with functional appliances to enhance mandibular growth to correct for a small and/or distally located mandible. All Class I patients with mild crowding were treated with a lingual arch or removable expansion appliances. This study was approved by the Ethics Committee of Hiroshima University Hospital. The functional appliance used in this study was designed according to Ahlgren.28 The construction bite was taken in the edge-to-edge incisal position with an interincisal vertical distance of 2–4 mm at the incisors and 5-6 mm at the molars (Figure 1). The patients were asked to use the appliance for more than 8 h per day.

Cephalometric analysis A lateral cephalometric radiograph was taken of each patient at T1 (prior to the placement of the activator; mean age: 11 years, 5 months) and T2 (after 1 year of activator treatment; mean age: 12 years, 5 months). Each patient was seated in the

upright position, with the Frankfort horizontal plane parallel to the floor. The natural head posture in the upright position was determined by visual feedback in a mirror. Each patient was instructed to swallow and then to breath normally while contacting the molars lightly to bring the mandible into the natural position. Tracings of the lateral cephalometric radiographs were made on acetate paper by one of the investigators (AH). In addition to conventional analysis, which Lowe et al.30 described in detail, several soft-tissue points and contours of the tongue, soft palate,


(SD). Unpaired t-tests were used to compare all variables between male and female groups and between Class I and II patients. Wilcoxon’s matched paired tests were used to estimate the treatment effect by computing the net changes between T1 and T2. A P value of <0.05 was considered significant.

ResultsReliability of measurements All measurements were repeated on 10 cephalograms randomly selected by the same operator (AH). The reliability of all measurements was found to be clinically acceptable, as shown by the interclass correlation coefficients, which ranged from 0.88 to 0.95.

Comparisons of pharyngeal structures between Class I and II patients No significant differences were observed in the baseline measurements (T1) between male and female patients, indicating that the measured variables for the 25 subjects in each class could be used for the following statistical comparisons. The measurements for the tongue, soft palate, and pharyngeal airway are shown at 11 (T1) and 12 (T2) years of age in Tables 1 and 2, respectively. In Class II patients at T1, the mean length (TGL) and height (TGH) of the tongue were 66.6 and 34.3 mm. These values were significantly larger and smaller than those in Class I patients (58.9 and 38.8 mm), respectively. The length of the soft palate (PNS-P) was significantly smaller in Class II patients (28.7 mm) than that in Class I patients (31.5 mm). In terms of the width of the upper airway, only SPAS was significantly smaller in Class II patients (13.7 mm) than in Class I patients (17.0 mm). Meanwhile, the mean MAS and IAS in Class II patients were 10.3 and 10.7 mm, respectively. These values were smaller than those in Class I patients (9.6 and 9.9 mm, respectively); however, the differences were not statistically significant. In regards to the cross-sectional dimension, the tongue and soft palate were significantly smaller in Class II patients (28.8 and 2.3 cm2, respectively) than in Class I patients (31.7 and 2.6 cm2, respectively). The sizes of the oropharynx and hypopharynx were also significantly smaller in Class II patients (5.1 and 1.8

hyoid, and pharynx were digitised; a number of linear measurements were quantified using these soft-tissue points and contours (Figures 2 and 3). Bony measurements included the ANB angle, which is the angle between the line from A (subspinale—the deepest point on the anterior surface of the maxillary alveolar bone) to N (nasion) and the line from B (supramentale—the deepest point on the anterior surface of the mandibular alveolar bone) to N. The ANB angle is a measure of the maxillo-mandibular discrepancy; the larger the angle, the greater the degree of mandibular retrognathia.

Statistical analysis Data are presented as percentages or as the mean +/- the standard deviation


cm 2, respectively) than in Class I patients (6.6 and 2.4 cm2, respectively) (Table 1). Significant differences were observed in the sizes of the tongue and soft palate between Class I and II patients at the age of 12. By contrast, no significant differences were found between the 2 groups in terms of the airway width and dimension, including the SPAS, MAS, IAS, nasopharynx, oropharynx, and hypopharynx areas (Table 2).

Changes in pharyngeal structures in Class I and II patients In terms of the ratio of change relative to the initial values between the 2 skeletal patterns, the width and dimension of the pharyngeal airway in Class II patients showed considerable increases after using the activator (Table 3). As for the comparison of the ratio of changes between the 2 skeletal patterns, the width of the lower oropharynx (IAS) and the cross-sectional dimension of the oropharynx showed significant differences (P < 0.05). Other pharyngeal airway measurements, such as SPAS, MAS, the dimensions of the nasopharynx and hypopharynx, showed larger net changes in Class II than in Class I patients; however, these changes were not statistically significant.

Discussion This study demonstrated significant differences in the pharyngeal airway and tongue sizes between Class II and Class I children. Class II children had an upper pharynx with a narrower width and a middle and lower pharynx of a smaller dimension, as well as a longer tongue length and lower tongue height. After one year of activator treatment, significant differences observed in the pharyngeal airway size (e.g. the width of the oropharynx) between Class II and I patients at

baseline had disappeared. Moreover, when changes in the pharyngeal airway were compared in terms of skeletal patterns after one year, the width of the lower pharynx (the oropharynx) and the dimension of the middle pharynx (oropharynx) showed significant increases. In general, the main risk factor for OSA symptoms in Japanese children is considered to be upper airway obstruction, which is directly associated with adenotonsillar hypertrophy and craniofacial morphology. Published data on cephalometric measurements of OSA patients have demonstrated a more anterior position of the maxilla, a retro-positioned mandible, and a prominent maxillo-mandibular discrepancy in OSA patients compared with control groups.30-32 Matsumoto et al.4 found that children with an apnoea-hypopnea index (AHI) ≥ 3 showed a more retrognathic position of the mandible compared to the group with an AHI < 3. In the present study, the ANB angle in Class II patients changed from 5.6 to 4.6 degrees after one year of treatment with an activator. Studies examining the effects of OA on upper airway size are somewhat conflicting. Tsuiki et al.33 found increases in the retropalatal area of the oropharynx on cephalograms taken in the supine position. Ferguson et al.34 found that mandibular

protrusion increased the cross-sectional area of the oropharynx and hypopharynx by using awake endoscopy. Moreover, in a study using supine cephalometry, Liu et al.35 found a difference in the changes in the sagittal cross-sectional area of hypopharynx, which was increased in the good response group but decreased in the poor response group in OSA patients. With respect to other functional appliances, similar results have been reported in several studies. Jene et al.36 showed that the oropharynx and hypopharynx depth was increased significantly by the Twin-Block appliance in Class II subjects with a retrognathic mandible. Restrepo et al.37 concluded that the only airway dimensions that increased after 1-year treatment with a Bionator appliance were the ones located at the nasopharynx. These results indicate that the changes in pharyngeal measurements depend on the method of detection, the subject’s body position at taking cephalograph, and the type of appliance. However, it remains clear that the simple active anterior movement of the tongue or mandible by any OA can increase the cross-sectional airway size in subjects with and without OSA.As mentioned above, some investigators have assumed that OAs exert their effects predominantly in the oropharynx rather than in the hypopharynx and nasopharynx. In particular, the oropharynx is thought to be the most common site of upper airway obstruction during sleep. Indeed, several important aspects of our findings were that the significant difference in the dimension of the oropharynx between Class I and II at T1 had disappeared at T2, and that a significant increase in the dimension of the oropharynx occurred after activator treatment for 1 year. Thus, these findings suggest that the use of the activator could produce a major and consistent effect in the


oropharynx and result in a relatively high success rate for the OA in relieving pharyngeal obstruction.A limitation of this study was the use of cephalometric analysis, since the data are 2-dimensional. However, this method allows easy comparison of the data. Future studies will require 3-dimensional imaging techniques, which could potentially provide additional information about the mechanism of action of the activator appliance.

Conclusion We evaluated the effect of activator treatment on changes in the pharyngeal airway in Japanese Class II children. The prevalence of OSA symptoms is much lower among children than adults. Nonetheless, if the retroposition and/or undergrowth of a mandible with a narrow pharyngeal airway size is improved, it can have a long-term effect on normal breathing and even dentofacial development. Based on the results, the pharyngeal airway soft tissue structures of Class II patients using the activator exceeded normal growth after 1 year. This suggests that correction of the skeletal Class II discrepancy by the activator in orthodontic treatment could reduce the risk of respiratory problems, such as severe snoring, OSA, and excessive daytime sleepiness in the future. Hence, activator treatment could lead to sound physical and psychological development in children.

Funding The authors declare no conflict of interest.

References1. Ali NJ, Pitson DJ & Stradling JR. Snoring, sleep disturbance and behavior

in 4–5 year olds. Arch Dis Child 1993;68:360–366.2. Schechter MS. Section on pediatrics pulmonology subcommittee

obstructive sleep apnea syndrome. Technical report: Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2002;109:e69.

3. Gottlieb DJ, Vezina RM, Chase C, Lesko SM, Heeren TC, Weese-Mayer DE, Auerbach SH & Corwin MJ. Symptoms of sleep-disordered breathing in 5-year-old children are associated with sleepiness and problem behaviors. Pediatrics 2003;112:870–877.

4. Matsumoto E, Tanaka E, Tabe H, Wakisaka N, Nakata Y, Ueda H, Hori T, Abe T & Tanne K. Sleep architecture and the apnoea-hypopnoea index in children with obstructive-sleep apnoea syndrome. J Oral Rehabil 2007;34:112–120.

5. Downey R, Perkin RM & MacQuarrie J. Upper airway resistance syndrome: Sick, symptomatic but underrecognized. Sleep 1993;16:620–623.

6. Owens J, Opipari L, Nobile C & Spirito A. Sleep and daytime behavior in children with obstructive sleep apnea and behavioral sleep disorders. Pediatrics 1998;102:1178–1184.

7. Gozal D. Sleep-disordered breathing and school performance in children. Pediatrics 1998;102:616–620.

8. Gozal D & Pope DW. Snoring during early childhood and academic performance at ages thirteen to fourteen years. Pediatrics 2001;107:1394–1399.

9. Corbo GM, Fuciarelli F & Foresi A. Snoring in children: Association with respiratory symptoms and passive smoking. BMJ 1989;299:1491–1494.

10. Carroll JL, McColley SA, Marcus CL, Curtis S & Loughlin GM. Inability of clinical history to distinguish primary snoring from obstructive sleep apnea syndrome in children. Chest 1995;108:610–618.

11. Gislason T & Benediktsdóttir B. Snoring, apneicepisodes, and nocturnal hypoxemia among children 6 months to 6 years old: An epidemiologic study of lower limit of prevalence. Chest 1995;107:963–966.

12. Brunetti L, Rana S, Lospalluti ML, Pietrafesa A, Francavilla R, Fanelli M & Armenio L. Prevalence of obstructive sleep apnea syndrome in a cohort of 1207 children of southern Italy. Chest 2001;120:1930–1935.

13. Partinen M, Guilleminault C, Quera-Salva MA & Jamieson A. Obstructive sleep apnea and cephalometric roentgenograms. The role of anatomic upper airway abnormalities in the definition of abnormal breathing during sleep. Chest 1988;93: 1199–1205.

14. Tsuchiya M, Lowe AA, Pae EK & Fleetham JA. Obstructive sleep apnea subtypes by cluster analysis. Am J Orthod Dentofacial Orthop 1992;101:533–542.

15. Lowe AA, Fleetham JA, Adachi S & Ryan CF. Cephalometric and computed tomographic predictors of obstructive sleep apnea severity. Am J Orthod Dentofacial Orthop 1995;107:589–595.

16. Ohta Y, Okada T, Kawakami Y, Suetsugu S & Kuriyama T. Prevalence of risk factors for sleep apnea in Japan: A preliminary report. Sleep 1993;16:S6–S7.

17. Esaki K. Morphological analysis by lateral cephalography of sleep apnea syndrome in 53 patients. Kurume Med J 1995;42:231–240.

18. Liu Y, Lowe AA, Zeng X, Fu M & Fleetham JA Cephalometric comparisons between Chinese and Caucasian patients with obstructive sleep apnea. Am J Orthod Dentofacial Orthop 2000;117:479–485.

19. Ip M, Lam B, Lauder IJ, Tsang KW, Chung KF, Moy YW & Lam WK. A community study of sleep-disordered breathing in middle aged Chinese men in Hong Kong. Chest 2001;119:62–69.

20. Brouillette RT, Fernbach SK & Hunt CE. Obstructive sleep apnea in infants and children. J Pediatr 1982;100:31–40.

21. Randall P. The Robin anomalad: Micrognathia and glossoptosis with airway obstruction. In: Converse J M (ed.) Reconstructive plastic surgery. WB Saunders; Philadelphia; 1987.

22. Teculescu DB, Caillier I, Perrin P, Rebstock E & Rauch A. Snoring in French preschool children. Pediatr Pulmonol 1992;13:239–244.

23. Suen JS, Arnold JE & Brooks LJ. Adenotonsillectomy for treatment of obstructive sleep apnea in children. Arch Otolaryngol Head Neck Surg 1995;121:525–530.

24. Almeida FR, Lowe AA, Sung JO, Tsuiki S & Otsuka R. Long-term sequellae of oral appliance therapy in obstructive sleep apnea patients: Part 1. Cephalometric analysis. Am J Orthod Dentofacial Orthop 2006;129:195–204.

25. Almeida FR, Lowe AA, Otsuka R, Fastlicht S, Farbood M & Tsuiki S. Long-term sequellae of oral appliance therapy in obstructive sleep apnea patients: Part 2. Study-model analysis. Am J Orthod Dentofacial Orthop 2006;129:205–213.

26. Graber TM & Neumann B. Removable orthodontic appliance. 2nd ed. WB Saunders; Philadelphia; 1984.

27. Ueda H, Almeida FR, Lowe AA & Ruse ND. Changes in occlusal contact area during oral appliance therapy assessed on study models. Angle Orthod 2008;78: 866–872.

28. Ahlgren J. The neurophysiologic principles of the Andresen method of functional jaw orthopaedics. A critical analysis and new hypothesis. Swed Dent J 1970;63:1–9.

29. Ahlgren J. Early and late electromyographic response to treatment with activators. Am J Orthod 1978;74:88–93.

30. Lowe AA, Santamaria JD, Fleetham JA & Price C. Facial morphology and obstructive sleep apnea. Am J Orthod Dentofacial Orthop 1986;90:484–491.

31. Reily RW, Guilleminault C, Herran J & Powell NB. Cephalometric analysis and flow-volume loops in obstructive sleep apnea patients. Sleep 1983;6:306–311.

32. Tangugsorn V, Skatvedt O, Krogstad O & Lyberg T. Obstructive sleep apnoea: A cephalometric study. Part I. Cervico-craniofacial skeletal morphology. Eur J Orthod 1995;17:45–56.

33. Tsuiki S, Hiyama S, Ono T, Imamura N, Ishiwata Y, Kuroda T & Lowe AA. Effects of a titratable oral appliance on supine airway size in awake non-apneic individuals. Sleep 2001;24:554–560.

34. Ferguson KA, Love LL & Ryan CF. Effect of mandibular and tongue protrusion on upper airway size during wakefulness. Am J Respir Crit Care Med 1997;155:1748–1754.

35. Liu Y, Zeng X, Fu M, Huang X & Lowe AA. Effects of a mandibular repositioner on obstructive sleep apnea. Am J Orthod Dentofacial Orthop 2000;118:248–256.


Dr. Horihata is a postdoctoral fellow, Dr. Ueda and Dr. Koh are assistant professors, Dr. Watanabe is a clinical researcher and Dr. Tanne is a professor and chairman, Department of Orthodontics and Craniofacial Developmental Biology, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan.

36. Jena AK, Singh SP & Utreja AK. Effectiveness of twin-block and mandibular protraction appliance-IV in the improvement of pharyngeal airway passage dimension in Class II malocclusion subjects with a retrognathic mandible. Angle Orthod 2012; Dec 14, Epub ahead of print.

37. Restrepo C, Santamaria A, Pelaez S & Tapias A. Oropharyngeal airway dimensions after treatment with functional appliance in class II retrognathic children. J Oral Rehabil 2011;38:588–594.

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Abstract: Borderline and mild skeletal Class III relationships in adult patients are usually treated by orthodontic camouflage. Reasonably good results have been achieved with nonsurgical teatment of anterior crossbite. Class III malocclusion may be associated with mandibular prognathism, maxillary retrognathism, or both. Class III maxillary retrognathism generally involves anterior crossbite, which must be opened if upper labial brackets are to be bonded. If multiple teeth are in crossbite, after opening the bite usual step is to ligate forward or advancement arch made of 0.018” or 0.020” stainless steel or NiTi wire main arch that must be kept separated 2 mm from the slot of upper incisor braces.Two stops or omegas are made 1 mm mesial to the tubes of the molar bands that will impede main arch from slipping,and in this manner the arch will push the anterior teeth forward. Here we have fabricated a modified multiple loop protrusion arch to correct an anterior crossbite with severe crowding that was not amenable to correct by advancement arches. Keywords: Cross bite correction, Multiple loop, Protrusion arch.

ntroductionModified Protrusion-arch: The drawbacks with the advancement arches (Figure 1A,B,C) are they require a reasonably good alignment of the

upper anteriors, so it is difficult to ligate in severely crowded situations. Secondly they have the potential to cause transverse expansion across the premolar, that might not be desirable if the archform is already wide. The multiple loop protrusion arch only engages the crowded upper anteriors bypassing the premolars. A system made of .016 x .016 blue elgiloy (.018” brackets) and .018 x .018 blue elgiloy (.022” brackets) has been proven effective in achieving simultaneous extrusion and protraction of incisors. This protrusion arch has a centered “T” loop and two helical “L” loops that were placed distal to the central incisors on either side (Figure 2A,B). Construction: A small rounded bird beak plier is used to bend the loop into a straight length Blue elgiloy archwire (Figure 2A,2B). The vertical legs and horizontal part of the centered “T” loop is 8 mm and 10 mm repectively with a loop diameter of 2mm. Similarly, “L” loops were made with a mesial and distal leg of 8 mm and 6 mm respectively along with a 8 mm horizontal extension incorporating a 2 mm helix. Vestibular segment extended up to the level of molar tube. To facilitate slight extrusion of the upper incisors and correct the smile arc, we added 30° reverse tipback bends on each side (Figure 2C). Case Report A 13-year-old female presented with the chief complaint of irregularly placed upper front teeth and protruding lower jaw (Figure 3). Initial evaluation revealed a normal profile with tenderness in the right TMJ on palpation and bilateral clicking in opening and closing. The patient had a super-Class I molar relationship with an overjet of -2.5mm, overbite of 3mm, and maxillary and mandibular arch-length discrepancies of 10

Modified Protrusion arch for Anterior Crossbite Correction - A Case Report

By Abhishek Singha Roy, MDS; Gulshan Kr Singh, MDS; Pradeep Tandon, MDS; Ramsukh Chowdhry, MDS

mm and 3mm respectively. She had completed 95.8% of her skeletal growth. In the functional examination, she could move the mandible back to an edge-to-edge position . Pre-treatment cephalogram showing a retrusive maxilla and retriclination of upper front teeth (Figure 4). Maxillary constriction in the sagittal plane had resulted in maxillary retrusion relative to the cranial base, retroclination of the upper incisors, and retrusion of the upper lip. The

Figure 1. Stops are made 1 mm posterior to the main slot on both side .Passive (1A), Activated(1B); thereby separating the forward arch 2 mm from the slots of the anterior braces (1C).


1A

1C

1B


main treatment objectives were elimination of the anterior crossbite, correction of the upper arch-length discrepancy, and improvement of the patient’s soft-tissue profile. Non-extraction treatment approach was selected for this patient with standard edgewise appliance (022 slot).To resolve the arch-length discrepancy, flaring the anteriors in upper arch and proximal stripping in the lower arch were considered .

Treatment Progress Maxillary edgewise brackets were placed, and an .018” × .018” multiple loop protrusion arch was used to protrude the upper incisors (Figure 5A-C). A customized .036” stainless steel transpalatal arch was inserted between the first molars to control molar width and axial inclination in the frontal plane. To temporarily open the bite an interim bite raiser attached to

the occlusal surfaces mandibular posteriors was used. To facilitate slight extrusion of the upper incisors and correct the smile arc, we added 30° reverse tipback bends on each side of the protrusion arch. After four months of treatment with multiple loop protrusion arch positive overjet had been attained, maxillary crowding eliminated and the bite

raisers were removed. The protrusion arch was left passively in place for an additional two months for stabilization (Figure 6A, 6B). Edgewise brackets were then bonded in the lower arch. Proximal stripping were done in the lower anteriors to resolve the crowding. 120g Class III elastics were used to achieve a Class I canine and molar relationship (Figure 7). After an ideal buccal occlusion, overjet, and overbite had been attained, the appliances were debonded (Figure 8A-8E). A canine-guided occlusion with incisal guidance was achieved .Functional efficiency during chewing was markedly improved, and the TMJ pain was relieved with correction of the crossbite. At the end of treatment, the patient showed no clicking on opening and closing.Post treatment cephalogram (Figure 9) reveals flared upper anterior ,upright mandibular incisors and forwardly placed soft tissue point “A”. Although anterior crossbites typically do not require retention, the patient’s upper anterior rotations and crowding and lower crowding indicated the need for a removable Hawley retainer in the upper arch and

a bonded 4-4 lingual retainer in the lower. Discussion Malocclusions involving four or more teeth in anterior crossbite occur mostly in Class III cases, where the lower lip is often protruded relative to the upper lip. Anterior crossbite should be

corrected as early as possible, before eruption of the permanent canines, given that delay can result in the development of a full skeletal and dental Class III malocclusion1-5, requiring surgical intervention at a later stage. While nonsurgical treatment of adult patients with this type of malocclusion is challenging, reasonably good results have been reported 6-7. This article has discussed the principle of incisor extrusion and flaring in correction of anterior crossbite with the help of a multiple-loop protrusion arch that is capable of controlled flaring and

Figure 2. Multiple loop protrusion arch. Front (2A) & Side (2B) view. Figure 2C. Dimension of the loops showing 300 reverse tip-back bend.

A B

C

Figure 3: Pre-treatment photographs. Right buccal (3A), Frontal (3B), Left buccal (3C), Upper occlusal (3D), Lower occlusal (3E).

Figure 5: Multiple loop protrusion arch in place. Right buccal (5A), Frontal (5B), Left buccal (5C).

Figure 6: Protrusion arch left passively. Front (6A) and occlusal view (6B).

Figure 4: Pre-treatment Cephalogram.

3A 3B

3D 3E

5A 5C5B

6B6A


extrusion of upper incisors with minimal side effects on the posterior teeth.

References:1. Humphreys HF, Leighton BC. A survey of antero-posterior abnormalities

of the jaws in children between the ages of 2 and 51⁄2 years of age. Br Dent J. 1950; 88:3-15.

2. Massler M, Frankel JM. Prevalence of malocclusion in children aged 14 to 18 years. Am J Orthod. 1951;37:751- 768.

3. Newman GV. Prevalence of malocclusion in children six to fourteen years of age and treatment in preventable cases. J Am Dent Assoc. 1956;52:566-575.

4. Björk A. Sutural growth of the upper face studied by the implant method.Eur Orthod Soc. 1964;40:49-65.

5. Ast DB, Carlo JP, Cons NC.The prevalence and characteristics of malocclusion among senior high school students in upstate New York. Am J Orthod. 1965; 51:437-445.

6. Graber TM, Rakosi T, Petrovic AG.Treatment of Class III malocclusion. Dentofacial Orthopedics with Functional Appliances, 2nd ed. Mosby St. Louis. 1997, p. 462.

7. Subtelny JD.Mandibular skeletal prognathism. Early Orthodontic Treatment. Quintessence. Chicago, 2000.

Figure 7: Class III elastics continued.

Figure 9: Post-treatment Cephalogram.

Figure 8: Post treatment photographs. Right buccal (8A), Frontal (8B), Left buccal (8C), Upper occlusal(8D), Lower occlusal (8E).

Dr. Abhishek Singha Roy is a Senior Lecturer, Department of Orthodontics & Dentofacial Orthopedics. ITS Dental College Hospital and Research Centre. Greater Noida,Uttar Pradesh, India.

Dr. Gulshan Kr. Singh is a Professor, Department of Orthodontics & Dentofacial Orthopedics.King George Medical University, Department of Orthodontics & Dentofacial Orthopedics at King George Medical University, Lucknow,Uttar Pradesh, India.

Dr. Pradeep Tandon is a Fellow W.F.O. USA. He is Professor and Head of the Department of Orthodontics & Dentofacial Orthopedics at King George Medical University, Lucknow, Uttar Pradesh, India.

Dr. Ramsukh Chaudharty is a Senior Resident, Department of Orthodontics & Dentofacial Orthopedics. King George Medical University,Lucknow,Uttar Pradesh, India.

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Abstract: The goal of early treatment of Class III malocclusion is focused on providing a more favourable environment for normal growth and on improving the psychosocial development of the child by improving the facial appearance. Rapid palatal expansion with maxillary protraction and facemask has provided a predictable and effective approach to managing the treatment. We are presenting a case report of a growing Class III treated using maxillary protraction therapy, (Rapid maxillary expansion using bonded RME appliance, to loosen the nasomaxillary sutures and Petit face mask with bonded occlusal splint to unlock the maxilla). With early intervention, patient compliance is much better, most of them achieving overcorrection in less than a year. Close monitoring and follow up was done for 5 years to ensure stability of the treatment, and there was no relapse tendency. Key words: Growing Class III, Maxillary Protraction Therapy, Rapid Maxillary Expansion.

Management of Skeletal Class III Malocclusion Treated by Manifold Approach: 5 Year Follow-up

By Roopa Tubaki, MDS; B.K. Sharmada, MDS; Sandesh. S. Pai, MDS; Shrikanth Shendre, MDS; Vishwanath A.E., MDS

Figure 1: Pre-treatment extra-oral frontal view shows mid-face deficiency, sunken eye appearance.Figure 2: Pre-treatment extra-oral lateral view shows concave profile and anterior divergence.Figure 3: Pre-treatment extra-oral oblique view shows deficiency in the maxillary region.Figure 4: Pre-treatment extra-oral frontal smile revealed only the lower incisors, with no gingival display.Figure 5: Pre-treatment extra-oral oblique smile revealed only the lower incisors, with no gingival display.

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ntroductionThe aetiology of developing Class III malocclusion can include maxillary skeletal retrusion with antero posterior and vertical maxillary deficiency, and

normal or prognathic mandible, or a combination of both.1 Other factors include genetics, ethnicity, environment, and habitual posture.2 Clinically, the dental compensation includes maxillary dentoalveolar protrusion and mandibular dentoalveolar retrusion. 3, 4 Extraoral clinical features include midface deficiency, prominent chin and lower lip. A posterior or anterior crossbite with reverse overjet is also frequent.5, 6

The prevalence of this malocclusion in Indian population is reported to be about 3.4%.7

The goal of early treatment of Class III malocclusion is focused on providing a more favourable environment for normal growth and on improving the psychosocial development of the child by improving the facial appearance.8

Early strategies for management of Class III malocclusion focused on aggressively restraining the growth of mandible, and it was only from the late 1960 s that the awareness of maxillary deficiency as a key component of Class III malocclusion entered the orthodontic consciousness. Rapid palatal expansion with maxillary protraction and facemask has provided a predictable and effective approach to managing the treatment. The correction occurs by a combination of skeletal and dental movements in both the antero-posterior and vertical planes of space.9

Early intervention, improves the skeletal relationships, which in turn minimize excessive dental compensation such as overclosure of the mandible and retroclination of the mandibular incisors. It also prevents progressive irreversible soft tissue and bony changes. Also correction of the anterior



crossbite often helps in eliminating centric occlusion/centric relation (CO/CR) discrepancies, and avoids adverse growth potential. Clinical studies focusing on maxillary protraction, report downward and forward displacement and counter-clockwise rotation of the maxilla, downward and backward rotation of the mandible, and increased lower face height. Most importantly, in mild and moderate Class III patients, early orthopedic treatment may eliminate the necessity for orthognathic surgery.10

We are presenting a case report of a growing Class III treated using maxillary protraction therapy (RME and Facemask), retention with Frankel III and 5 year follow up.

Case Report A 10 year old growing male patient came with a chief complaint of lower front teeth overlapping upper front teeth, unaesthetic appearance of his maxillary anterior teeth, which were completely locked behind the mandibular incisors. There were no significant findings in his medical and dental histories. Familial history revealed absence of strong genetic predilection for Class III malocclusion, although one of the parents had clinical features of maxillary deficiency. Extra oral examination revealed symmetric mesoproscopic face with mid-face deficiency, sunken eye appearance, concave profile, anterior divergence and lower lip positioned ahead of upper. The nasolabial angle was obtuse and there was decreased lower facial height conferring a premature aged appearance (Figures 1-5). Smile appeared unaesthetic, with upper incisors completely masked by the lower incisors with no gingival display (Figure 4). Intraoral examination revealed the presence of mixed dentition of teeth with presence of all permanent first molars, lower incisors and upper centrals. There was missing deciduous and permanent laterals, both clinically and radiographically. Anterior collapsed bite with maxillary incisors locked in to mandibular incisors with reverse overbite of 7 mm and reverse overjet of 7 mm. The molar relationship was Class I on both sides. Upper and lower dentition was well aligned with absence of crowding or rotation (Figure 6-10). On functional examination, there was no mandibular deviation on closure or clicking of TMJ. There was no CO- CR discrepancy or functional shift of the mandible. As there was no occlusal interference or prematurities in the anterior region, and there was good posterior occlusion, CO-CR was matching. Hence the probability of Pseudo class III was ruled out, also there was clinical features of classic mid -face deficiency. The probable reason for Class I molar relationship being congenitally missing lateral incisors, leading to mesial drift of posterior segment.

Figure 6: Pre-treatment intraoral frontal view shows anterior collapsed bite with maxillary incisors locked in to mandibular incisors with reverse overbite of 7mm and reverse overjet of 5 mm.Figure 7: Pre-treatment intraoral right lateral view shows Angle’s Class I molar relation showing absence of posterior cross bite.Figure 8: Pre-treatment intraoral left lateral view shows Angle’s Class I molar relation showing absence of posterior cross bite.Figure 9: Pre-treatment intraoral upper occlusal view shows missing laterals.Figure 10: Pre-treatment intraoral lower occlusal view.

Figure 11: Pre-treatment lateral Cephalogram.

Figure 12: Pre- Treatment OPG.

Figure 13: Bonded RME frontal view showing bite blocks.

Figure 14: Bonded RME occlusal view.

Figure 15: Bonded RME with Petit Face Mask.

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Figure 16: Frontal view immediately after maxillary protraction showing improved maxillary projection. Figure. 17: oblique smile view immediately after maxillary protraction showing positive overjet and overbite and visibility of maxillary incisors.Figure 18 : Frontal smile view immediately after maxillary protraction showing positive overjet and overbite and visibility of maxillary incisors.Figure 19: Profile view immediately after maxillary protraction showing improvement of profile. Figure 20: Oblique view immediately after maxillary protraction showing improvement of maxillary projection.

Figure 21: Intra-oral frontal view immediately after maxillary protraction.Figure 22: Intra-oral right lateral view immediately after maxillary protraction.Figure 23: Intra-oral left lateral view immediately after maxillary protraction.Figure 24: Upper occlusal view immediately after maxillary protraction.Figure 25: Lower occlusal view immediately after maxillary protraction.

Figure 26: Lateral Cephalogram Post RME and maxillary protraction.

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Figure 28: Retention using Frankel III appliance.

Figure 27: OPG Post RME and maxillary protraction.

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On radiographic examination, the ortho-pentamogram (OPG) revealed that the deciduous and permanent upper lateral incisors were congenitally missing. There was no evidence of bone or dental pathology and no defective restorations. The cephalometric findings revealed CVMI stage I, with horizontal growth pattern, Class III skeletal pattern with deficient maxilla and normal mandible. The lower anterior facial height was short. The mandibular incisors were upright (Figures 11, 12). Treatment objectives were to improve the soft tissue profile, protraction of maxilla, attaining positive overjet, correction of skeletal class III, retention and revaluation until completion of growth. The treatment plan was Rapid maxillary expansion using bonded RME appliance, to loosen the nasomaxillary sutures and Petit face mask with bonded occlusal splint to unlock the maxilla, followed by finishing and detailing using fixed appliance.

Treatment Progress It was decided to use RME in conjunction with maxillary protraction, to unlock the collapsed anterior bite. Petit face mask was given with forces of 400 grams per side and worn for 10-12 hours a day. The acrylic component of the bonded occlusal splint extended from deciduous canine to first permanent molar, was 3mm, enough to disocclude the collapsed maxillary dentition. Hooks were placed between deciduous canine and first deciduous molar as superior as patient’s comfort allowed. The activation cycle was quarter turn, four times a day for one week (Figures 13-15). At the end of one week, RME was completed, the Hyrax screw was stabilized and the RME appliance was continued to retain transverse expansion up to 6 months. Petit Face mask was continued till the achievement of positive overjet (Figures 16-27).


Figure 29: 5 year post treatment- Frontal view showing stability of the corrections achieved and maintenance of correction of sunken eye appearance.Figure 30: 5 years post-treatment. Frontal Smile view showing maintained correction of over jet, overbite. Figure 31: 5 years post-treatment. Oblique view. Figure 32: 5 years post-treatment. Oblique Smile view. Figure 33: 5 years post-treatment. Profile view showing good facial balance.

Figure 34: 5 years post-treatment, Intraoral frontal view showing the stability of overjet and overbite correction.Figure 35: 5 years post-treatment, intraoral right lateral view showing stability of molar relation.Figure 36: 5 years post-treatment, intraoral left lateral view showing stability of molar relation. Figure 37: 5 years post-treatment, intraoral upper occlusal view. Figures 38: 5 years post-treatment, intraoral lower occlusal view.

Figure 39: 5 year post treatment Lateral cephalogram.

Fig 40: 5 year post treatment OPG.

Figure 41: Superimposition of Pre-treatment (Black), Immediately after RME (Red) and Post Retention (Green) 5 years.

Hawley’s retainer was given for a period of one year for maintenance of transverse correction. Frankel III appliance was fabricated with advancement of 5 mm. Periodic follow up was done every 3 months with necessary adjustments. Every year a new appliance was fabricated. The duration of Frankel III has now been reduced to 8-10 hours per day, till the eruption of all the permanent teeth, for Phase II treatment to begin (Figure 28).

Treatment Outcomes Soft tissue: Overall facial balance was improved with correction of midface deficiency. Orthognathic profile was achieved with noticeable improvement in lip, nose and chin relation.

29 33323130

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The treatment effects were a combination of skeletal and dental changes of maxilla and mandible. Dental assessment: Positive overjet of 5mm and overbite of 3mm was achieved over duration of 3 months. Correction was achieved with a combined effect of proclination of upper anteriors and retroclination of lower anteriors. There was extrusion of molars by 2 mm. Skeletal: There was significant protraction of the maxilla, with Point A relocating anteriorly, mandibular retrusion of 5 degrees, leading to orthognathic profile. The maxilla moved downward and forward, with upward movement of the anterior palatal plane, and downward movement of the posterior palatal plane resulting in extrusion of the posteriors. There was downward and backward rotation of the mandible, resulting in an increase in lower anterior facial height, decreasing the chin prominence (Table 1).

Longterm Changes Five years post treatment, the patient exhibited excellent frontal and profile esthetics. End on end molar relationship has been maintained. There is still presence of over retained deciduous lateral incisors as the permanent lateral incisors are congenitally missing. The dental age of this patient is lagging behind his chronological age, hence still presenting with mixed dentition (Figures 29-40). Cephalometric superimpositions showed that during treatment proclination of maxillary incisors and retroclination of lower incisors occurred, along with some extrusion of maxillary molars and backward rotation of the mandible. The clinical correction of overjet and overbite was maintained and there was no relapse. Soft tissue fullness increased during retention phase as patient continued to wear FR 3 appliance (Figure 41).

Discussion The use of face mask therapy for the management of mid face deficient class III malocclusion has conventionally been recommended in the deciduous and mixed dentition.11, 12, 13

The treatment was done at a very young age in early mixed dentition to enhance forward displacement of the maxilla by sutural growth. Baccetti et al examined the differences in early versus late treatment in 2 groups of children treated with bonded maxillary expanders and facemasks. The younger group showed significantly greater advancement of maxillary structures and significantly more upward and forward direction of condylar growth after treatment.14

It has been shown by Melsen in her histological findings that the midpalatal suture was broad and smooth during the ‘infantile’ stage (8 to 10 years of age) and became more squamous and overlapping in the ‘juvenile’ stage (10 to 13 years). Also, the circummaxillary sutures were smooth and broad before age eight and became more heavily interdigitated around puberty.15,16 A number of studies have described the general treatment effects of rapid maxillary expansion and facemask therapy (RME/FM) during a single phase of treatment, with a combination of skeletal and dentoalveolar modifications noted in both the maxilla and the mandible. This combined therapy produces more favorable outcomes in patients treated in the deciduous or early mixed dentition than in late mixed dentition with respect to untreated Class III controls.17

As the face mask therapy and RME were simultaneously started, the treatment duration significantly reduced a positive overjet of and overbite was achieved in 3 months. Although RME was not an indication in this case, as the patient had an uncrowded dentition, and well aligned arches, absence of posterior crossbite, it was still included

Parameters Pre-treatment

Post treatment

5 years posttreatment

MaxillaSNA 76 77 78N perpendicularPt.A(mm) -14 -8 -9Midfacial length(mm) 85 87 87Angle of Convexity(o ) -27 -7 -4MandibleSNB 83 78 79N perpendicular Pog (mm) -4 -7 -4Effective mand. Length Co-Gn 115 115 116Facial angle (O ) 90 87 90Maxilla-MandibleAO-BO (mm) -2 0 1.5ANB(o ) -7 -1 -1Maxillo-mandibular difference(mm) 31 29 30

VerticalFMA 20 27 27SN to MP 25 27 27Y axis 52 54 53Facial axis -8 -2 -4Maxillary incisorsU 1 to NA angular ( O) 29 31 30U 1 to NA Linear(mm) -2 5 7U 1 to SN( O) 106 108 110U 1 to PP( O) 110 112 115Mandibular incisorL 1to NB angular ( O) 30 10 12L 1 to NB linear (mm) 3 -1 0IMPA( O) 87 77 78Soft tissueNaso labial angle( O) 95 100 100UL toE line(mm) -5 -1 -1.5LL to E line(mm) 2 2 0OthersInter incisal angle 142 149 145Saddle angle 113 118 118Articular angle 155 118 155Gonial angle 117 111 110Overjet -9 5 6Overbite -6 3 5


in the treatment plan to aid in loosening the circummaxillary sutures. Thus simultaneous downward and forward movement of maxillary complex was initiated with face mask. Various soft tissue changes combined to improve the Class III profile. Forward movement of the upper lip, retraction of the lower lip, combined with downward and backward movement of soft tissue pogonion and menton, contributed to the more straight profile. Nartallo-Turley and Turley18 and Kapust et al19 also reported these changes. The observed soft tissue effects appeared to result from the induced skeletal changes. This is consistent with observations by Ngan et al20 that significant correlations were found between changes of the sagittal relationships of skeletal and soft tissue profiles in both the maxilla and the mandible. Considering the high rate of relapse tendency in treated Class III cases and the early onset of treatment, long term retention plan has been advocated. Follow up was done for 5 years to ensure stability of the treatment, and there was no relapse tendency. Over correction helped to retain long term stability. Follow will be continued till the transition to permanent dentition occurs, to start phase II treatment.

Conclusion This case report shows that facemask and RME protocol followed by retention with FR III is an effective method for treatment of growing class III, in early mixed dentition cases, with stable results, and earlier intervention might provide a better orthopedic response. Careful case selection, excellent patient cooperation, and deliberate over –correction could ensure a treatment result that is stable functional and esthetic in the long term.

References1. McNamara JA Jr. An orthopaedic approach to the treatment of Class III

malocclusion in growing children, J Clin Orthod 1987; vol 21: 598-608.1a. Delaire J, Maxillary development revisited, Relevance to the orthopedic

treatment of Class III malocclusion, Eur J Orthod 1997, 19, 289-311.2. Williams S, Anderson CE. The morphology of the potential Class III

skeletal pattern in the growing child, Am J Orthod 1986; vol 89; 302-311.3. Hopkins GB. Cranio-facial pattern in mesio-occlusion. Ned Vereiniging

Orthod Studie 1965; 81-105.4. Haas AJ. Palatal expansion: just the beginning of dentofacial orthopedics.

Am J Orthod 1970; vol 57: 219-255.5. Haas AJ. Rapid palatal expansion: a recommended pre requisite to Class III

treatment. Trans Eur Orthod Soc 1973: 311-8.5a. Kharbanda OP, Sindhu SS, Sundaram KR, Shukla DK, Prevalance of

malocclusion and its traits in Delhi, J Indian Orthod Soc 1995, 26 (3), 98-103.6. Gregory A. Vaughn, Brian Mason, The effects of maxillary protraction

therapy with or without rapid palatal expansion: A prospective, randomized clinical trial. Am J Orthod Dentofacial Orthop 2005; vol 128; 299-309.

7. Patrick K. Turley, Managing the developing Class III malocclusion with palatal expansion and facemask therapy, American Journal of Orthodontics and Dentofacial Orthopedics October 2002;122; 349-352.

8. P Kapoor, OP Kharbanda, Correction of skeletal Class III in a growing male patient by reverse pull facemask. J Indian Soc Pedod Prev Dent 2011;29; 273-277.

9. Petit HP. Adaptation following accelerated facial mask therapy. In: McNamara JA Jr, Ribbens KA, Howe RP, editors. Clinical Alteration of the Growing Face. Monograph 14, Craniofacial Growth Series. Ann Arbor, Mich: Center for Human Growth and Development, University of Michigan; 1983.

10. Delaire J. La croissance maxillaire. Trans Eur Orthod Soc 1971; vol 82 , 81-102.11. McNamara JA Jr. An orthopedic approach to the treatment of Class III

malocclusion in young patients. J Clin Orthod 1987, vol 21; 598-608.

12. Baccetti T, McGill JS, Franchi L, McNamara JA Jr, Tollaro I. Skeletal effects of early treatment of Class III malocclusion with maxillary expansion and face-mask therapy. Am J Orthod Dentofacial Orthop 1998; vol 113; 333-43.

13. Melsen B, Melsen F. The postnatal development of the palatomaxillary region studied on human autopsy material. Am J Orthod 1982 vol 82, 237-54.

14. Melsen B. Palatal growth studied on human autopsy material: A histologic microradiographic study. Am J Orthod 1975, vol 68, 329-42.

15. Suda N, Suzukl MI, Hirose K, Hiyama S, Suzuki S, Kuroda T. Effective treatment plan for maxillary protration: is the bone age useful to determine the treatment plan? Am J Orthod Dentofacial Orthop 2000, vol 118, 56-62.

16. Nartallo-Turley PE, Turley PK. Cephalometric effects of combined palatal expansion and facemask therapy on Class III malocclusion. Angle Orthod 1998, vol 68, 217-24.

17. Kapust AJ, Sinclair PM, Turley PK. Cephalometric effects of face mask/expansion therapy in Class III children: a comparison of three age groups. Am J Orthod Dentofacial Orthop 1998, vol 113; 204-12.

18. Ngan P, Wei SH, Hägg U, Yui KY, Merwin D, Stickel B. Effect of protraction headgear on Class III malocclusion. Quintessence Int 1992, vol 23, 197-207.

Dr. Roopa Tubaki completed her post graduate work at Oxford Dental College, Bangalore. She has 3 years of teaching experience at Vydehi Institute of Dental Sciences and Hospital and has 4 years of clinical experience in the field of Orthodontics. She is currently working at Vydehi Institute of Dental Sciences, Whitefield, and resides in the Bangalore, Whitefield area.

Dr. Sharmada. B.K completed her post graduation from Rajarajeshwari Dental College, Bangalore. She has 2 years of teaching experience in Vydehi Institute of Dental Sciences and Hospital and 4 years of clinical experience in the field of Orthodontics. She is am currently working at Vydehi Institute of Dental Sciences, Whitefield and resides in Bangalore.

Dr. Sandesh. S Pai has 14 years of teaching experience and currently works at Vydehi Institute of Dental Sciences, as the Professor and Head of the Department of Orthodontics.

Dr. Srikant Shindre has 14 years of teaching experience and is currently working at Oxford Dental college, as Professor in the Department of Orthodontics.

Dr. Vishwanath A E has 7 years of teaching experience in Vydehi Institute of Dental Sciences and Hospital. He currently works at Vydehi Institute of Dental Sciences, Whitefield. He resides in Bangalore.


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Multidisciplinary Approach to an Asymmetric Traumatic Occlusion: A Case Report

By Pinho T, DDS, PhD; Coutinho-Alves C, DDS; Neves M, DDS

Abstract: The case of a 47-year-old female patient with an asymmetric traumatic occlusion, great alveolar destruction in the mandibular left central incisor, gingival recession with attachment loss and lack of keratinized tissue more accentuated in the crossbite teeth is described. This situation was caused by the traumatic position of the teeth, aggravated by a forced asymmetric anterior position of the mandible and aggravated by mandibular movements. After the extraction of the left central mandibular incisor, keratinized tissue reconstruction and alveolar bone regeneration were performed to obtain enough bone to move the adjacent teeth in this direction and allow the correct placement of an implant at the end of orthodontic treatment. The orthodontic treatment achieved general stable occlusal contacts and esthetic results that were finalized with a definitive prosthetic treatment. This interdisciplinary management was important to solve in the present case the seriously compromised function and esthetics that would never be achieved without this combination. Key Words: Periodontics; orthodontics; implants; traumatic occlusion.

ntroductionA traumatic occlusion can be a risk factor to periodontal disease in the anterior region of the mouth. This is caused by strong anterior contacts and consequently bone loss. Additionally, if

the patient originally has dental and/or skeletal orthodontic problems, the severe loss of periodontal tissues worsens or adversely affects such problems.1, 2

One of the main objectives of the orthodontic treatment is to help the control of periodontal disease by creating a healthy physiologic typology in the alveolar bone through alterations in radicular positioning.3

There is no restriction to orthodontic treatment in patients with periodontal disease, as long as the disease is under control.1,

2, 4 Nevertheless, if the bone loss is very significant around the affected tooth, the orthodontic goals and mechanics should be modified, with the help of restorative, prosthodontic and/or surgical procedures.1, 2, 5

Orthodontic treatment is complicated in patients with cant of the occlusal plane associated with periodontally compromised teeth.1 When there are also severe skeletal components associated with a cant of the occlusal plane, such as a vertical growth pattern and a retruded mandible, a combined surgical approach would be the best treatment option.6

Diagnosis and Etiology A 47-year-old woman complained about the unattractive appearance of her protruding mandibular teeth on the right side. Also about the high mobility of the left central incisor, asymmetric appearance of her smile showing different heights on both incisors sides, and the dysfunctional aspect of her masticatory system (Figs. 1-3). The smile photo showed asymmetry of the lower third of the face and a shift of the mandible to the right, with an occlusal plane canted upward on the same side (Figure 3).

Intra oral photos exhibited a Class I molar and canine relationship, exception on the right cross-bite canines that presented a Class II relationship. The mandibular dental midline showed 4 mm deviation to the right shift side in relation to the maxillary dental midline. No crowding was present, however a slight narrowing arch was present on the lateral and anterior right maxilla arcade due to lingual inclination from the right central incisor to the second premolar. On the other hand on the mandibular arcade there was a labial inclination on teeth that were in a crossbite relation (from lateral incisor to second premolar) (Figure 4). Generalized moderate chronic periodontitis was present, except on the mandibular left central incisor and on mesial face of the adjacent teeth region (mesial face of left lateral incisor and right central incisor), that presented an advanced localized chronic periodontitis with complete alveolar bone destruction on the mandibular left central incisor (Figs. 1a and 3). Due to this condition, the mandibular left central incisor was removed and alveolar bone regeneration was performed at the time of scaling and root planning (initial periodontal treatment phase) (Figure 1b, c). A free gingival graft was performed on the mandible incisor region in order to stabilize, improve periodontal inflammation and control periodontal support loss. After keratinized tissue gain, bone regeneration was preformed to improve crestal bone condition and width before orthodontic tooth movement (Figure 1d-f ). In the panoramic radiograph, we can observe that the crown of mandibular left central incisor was extracted and bonded to the adjacent teeth with composite resin. The alveolar bone destruction of the mandibular left central incisor region was also present, with a large space between the adjacent roots, more divergent on the right central incisor. The right mandibular third molar was present (Figure 5).


Figure 1. Periodontal treatment on the left central incisor region and periapical x-ray control; a) severe destruction of the alveolar bone; b, c) after the extraction and its crown retained in the adjacent teeth with composite resin; d, f) enamel protein derivative (EMDOGAIN®) and a hydroxiapatite (Bio-oss®) regeneration with a collagen membrane; e) after the free gingival graft.

A B

C D

E F

Figure 2. Initial periodontogram.

Figure 3. Pre-treatment facial and intraoral photos, after the free gingival grafts and alveolar bone regeneration, with the crown of the left mandibular incisor retained in the adjacent teeth with composite resin.

Figure 4. Pre-treatment dental casts.

Figure 5. Pre-treatment panoramic x-ray.


On the cephalometric analysis at maximum inter-cuspidation (Figure 6 and Table 1), the patient presented a skeletal Class I relationship (ANB= 2.6 mm), but a Class III in the sagittal disparity between Ao and Bo (-3.7mm); hypodivergent mandibular pattern (FMA=20.7º); the mandibular incisors were proclined (IMPA= 102.8º), but the maxillary incisor was in a normal inclination, so the interincisal angle was a little low (122.4º). The overjet and the overbite were normal (1.8 and 3.1 mm respectively). The patient complained of temporomandibular joint (TMJ) pain during mouth opening and difficulty in eating due to masticatory dysfunction.

Treatment Objectives The treatment objectives established for this patient were: 1) extraction of mandibular left central incisor treatment to control the ongoing periodontal disease; 2) gain of keratinized tissue at mandible incisor region; 3) orthodontic treatment with occlusal plane reconstruction for levelling, extruding and correcting torque of the teeth that were in a cross-bite condition to improve the smile and occlusal trauma as well as the periodontal problem; 4) dental implant on the central mandibular left incisor, initially with a provisory crown, later replaced by a definitive fixed supported prostheses at the end of the orthodontic treatment.

Treatment ProgressPeriodontal Treatment The periodontal disease was treated by non-surgical and surgical methods (Figure 1). An hygienic phase of plaque control was initiated and full mouth scaling and root planning was performed in two separate appointments. After the extraction of the mandibular left central incisor, a surgical phase of periodontal treatment was attempted in the residual bone as well as in the mesial surface of the adjacent teeth (left lateral incisor and right central incisor). Also a free gingival graft from the palate was sutured to this area, in order to improve keratinized tissue amount. Periodontal /bone regeneration was performed applying enamel protein derivative gel (EMDOGAIN®) and a hydroxyapatite (Bio-oss®) (Figure 1d-f ). The extracted crown of mandibular left central incisor was retained in the adjacent teeth with composite resin. The right mandibular third molar was extracted. Periodontal control visits were scheduled every three months during orthodontic treatment.

Orthodontic treatment The orthodontic treatment was initiated three months after the periodontal treatment. In the first stage, a fixed appliance 0.022’’ slot was applied on maxillary and mandibular arcade. For initial maxillary and mandibular teeth alignment 0.014’’ and 0.018’’ nickel titanium arches were used, later replaced by stainless arches, 0.018’’, 0.016 x 0.022’’ and 0.018 x 0.025’’ on the mandibular arcade (Figure 7). In order to move the left mandibular teeth to a more mesial position, and to allow the mesial root movement of the right mandibular central incisor, tooth material was removed

Figure 6. Pre-treatment cephalometric x-ray and tracing.

Figure 8. Intra-oral photos at the end of orthodontic treatment with a temporary acrylic tooth with normal measures adapted in the mandibular left central incisor place.

Table 1. Cephalometric analysis before and after treatment.

Cephalometric Analyse Norm Before T After T

FMIA 67º+ 3º 56.5º 60.4ºFMA 25º+ 3º 20.7º 22.9º IMPA 88º+ 3º 102.8º 96.7º SNA 82º+ 2º 83.2º 84.7ºSNB 80º+ 2º 80.6º 81.2º ANB 1º- 5º 2.6º 3.5º Ao Bo 2mm+ 2 -3.7mm -2.4mm UI/NA 22º+2º 20.6º 18ºAngle Z 75º+ 5º 76.2º 77.8º Overjet 2.5mm+ 2.5 1.8mm 2.1mmOverbite 2.5mm+ 2.5 3.1mm 2.8mmInterincisal Angle 126º+ 10º 122.4º 130.6º

Figure 7. Intra-oral photos during straight wire technic teeth alignment.


Figure 11. Post-treatment panoramic x-ray.

Figure 12. Post-treatment lateral cephalometric x-ray and tracing.

Figure 13. Pre-treatment and post-treatment cephalometric tracings superimposed on the sella-nasion plane at sella; maxilary, mandibular and perfil superpositions. Red lines, post-treatment; black lines, pre-treatment.

Figure 14. Intraoral photos after cervical composite restorations on the lower and upper incisors crowns.

Figure 9. Extra- and intra-oral photos after the orthodontic treatment.

Figure 10. Post-treatment dental Casts.

on the mesial face of the crown of the left central incisor that was extracted and ligatured to the wire. On the rectangular stainless arches, the teeth that were in a crossbite position were compensated with additional torque. A positive torque was applied from the maxillary right central incisor to the second premolar. On the mandibular arch, a negative torque was applied from lateral incisor to second premolar. One year after the beginning of the orthodontic treatment, a sectional and full multiloop edgewise arch wire (0.016 x 0.022’’stainless steel) was applied respectively on the maxillary and mandibular arcade to increase the vertical dimension on the teeth that were in a crossbite position. Class I and Class III elastics were applied on the right and left side respectively to obtain a synergetic effect during vertical compensation by extrusion of the teeth since the right central incisor to the second premolar on the maxillary arcade and intrusion from lateral incisor to second premolar on the mandibular arcade.


A nitinol open coil spring was applied between the distal face of brackets on the crown on the left central incisor (that was extracted and ligatured to the wire) and the adjacent lateral central incisor. This was to increase the synergetic effect of the Class III elastic and move the mandibular left teeth to a more distal position to improve the canine Class I relation. Then a temporary acrylic tooth with normal measures was inserted in the mandibular left central incisor place. An implant was applied four months before the end of the active orthodontic treatment (Figure 8). The active treatment took 22 months. Photographs, dental casts, panoramic and cephalometric x-rays were done at the end of the treatment and impressions were taken to elaborate a maxillary wrap-around. In the mandible a lingual bonded retainer was placed on the lingual surfaces of the lower incisors and canines. On the same day that the orthodontic appliance was removed, the temporary crown was affixed to the implant to improve the adjacent soft tissue (Figure 9).

Treatment Results The major goal of obtaining a stable dental articulation was accomplished, partly due to compensation of teeth torque and a good patient collaboration in the use of intra-oral elastics. After-treatment photographs showed a Class I canine relation, in spite of a slightly lower dental midline deviation to the right that persisted. However, there was an acceptable overjet and overbite relation (Figs. 9 and 10). The final panoramic radiograph (Figure 11) confirmed good root positioning in general, specifically on the teeth that are near the implant. The cephalometric superimposition at the end of the treatment (Figure 12 and Table 1) allowed us to visualize the changes that occurred during the treatment (Fig.13). Frontal facial smile analysis showed that the canted occlusal plane was improved and that right and left facial height were more symmetrical (Figure 9).

Restorative treatment The final ceramic crown restoration was done, approximately one year after the end of orthodontic treatment (Figs. 14 and 15). The significant deficiencies in the harmonious gingival scallop were not improved to a satisfactory level. So, cervical pink composite restorations were placed on the lower incisors adjacent to the implant. On the maxillary incisors the black holes were due to a triangular morphology. Then normal composite restorations were placed to improve the incisors morphology and papilla formation and also to fill the black holes for esthetic reasons (Figure 14).

Discussion In mandibular lateral deviation, the mandible is not the only structure that is displaced. The maxilla is also affected. In the present case this confirmation was evident in the smile photograph with asymmetry of the occlusal plane, which was upward in the cross-bite side.6

Usually, the chin moves to the side where the maxillary height is lower just to get in occlusion.7 The orthodontist clinician, therefore, should realize that midline discrepancy is

only one of the various symptoms of the mandibular lateral displacement and that occlusal deviation and displacement of the mandible may be induced by craniomaxillary system dysfunction in growing children. With this in mind, we will be able to administer the best and simplest treatment to the patient by affecting skeletal improvement and help the masticatory system withstand the rigors of long-term function.8

The customary masticating side is usually the side that has the lower vertical dimension 9. The torque and vertical teeth compensation on crossbite teeth, as well as the Class I elastics on the right side and short Class III elastics on the left side became essential to increase the vertical dimension on this side, thereby allowing a right Class I canine relation. In addition, for the extrusion, the loops activation was important to apply differentiated orthodontic forces on each side and use of intermaxillary elastics as an additional orthodontic force device was indispensable. In these periodontal compromised teeth, the loops allowed light orthodontic forces that should be applied to minimize further attachment loss, tipping movement and root resorption.1, 10

This is a periodontal patient presenting localized advanced chronic periodontitis affecting mainly the teeth that were in a cross-bite condition. The mandibular central incisor presented a challenge due to a severe periodontal bone loss in this region worsened by a high traumatic occlusion during mandibular movements. The occlusal trauma, allows increased vascularity, vascular permeability and osteoclast activity during the traumatic event.11 Therefore, secondary trauma from occlusion (ie, premature and balance contacts) is frequently seen in periodontally compromised patients and is positively correlated with the severity of attachment loss.12

In the present case, one way to control traumatic movements was through disarticulation of the displaced teeth that were in a cross-bite and its compensation with additional torque in order to eliminate the traumatic occlusion. Dentitions with reduced periodontal support show a marked tendency to return to their pre-treatment position following active appliance therapy, however the correct overjet and overbite at the end of the treatment are also indispensable to stabilize the dental relation.

Figure 15. Dental Casts, after cervical composite restorations on the lower and upper incisors crowns.


7. Pinho T. Treatment of a Class II subdivision based on occlusal plane control – clinical case. Orthodontics (Chic.) 2012; 13:128-37.

8. Sato S, Kim J, Kim K-M, Tokiwa O, Yoshimi H, Onodera K, et al. Significance of Early Orthodontic Treatment of Malocclusion with Dysfunction in the Craniomandibular System. Bulletin of Kanagawa Dental College 2004; 32(1):37-48.

9. Shimazaki T, Motoyoshi M, Hosoi K, Namura S. The effect of occlusal alteration and masticatory imbalance on the cervical spine. Eur J Orthod 2003; 25(5):457-63.

10. Johal A, Ide M. Orthodontics in the adult patient, with special reference to the periodontally compromised patient. Dent Update 1999; 26(3):101-4, 06-8.

11. Svanberg G, Lindhe J. Vascular reactions in the periodontal ligament incident to trauma from occlusion. J Clin Periodontol 1974; 1(1):58-69.

12. Branschofsky M, Beikler T, Schafer R, Flemming TF, Lang H. Secondary trauma from occlusion and periodontitis. Quintessence Int 2011; 42(6):515-22.

13. Mathews DP, Kokich VG. Managing treatment for the orthodontic patient with periodontal problems. Semin Orthod 1997; 3(1):21-38.

14. Pinho T. Posterior scissor-bite and lateral open bite with missing lower first molar and second premolar. Int J Stomatol Occlusion Med 2012; 5(3):134-42.

15. Wennstrom JL. Mucogingival considerations in orthodontic treatment. Semin Orthod 1996; 2(1):46-54.

16. Greenstein G, Cavallaro J, Scharf D, Tarnow D. Differential diagnosis and management of flared maxillary anterior teeth. Am J Orthod Dentofacial Orthop 2008; 139(6):715-23.

17. Pinho T, Coutinho-Alves C, Neves M. Management of Pathological Tooth Migration in Patients with Advanced Periodontal Disease Journal Clinical Orthodontics:JCO. 2013;47(9):520-528.

The vestibular gingival recession did not improve at the end of the treatment, however no bone destruction occurred on the interproximal faces as seen in the radiograph at the end of orthodontic treatment. In the past, it was assumed by authors that when keratinized gingiva levels were less than 2 mm there was indication for a free gingival graft.13-15 In the present case, due to advanced localized chronic periodontitis with complete alveolar bone destruction on the mandibular left central incisor region, it was necessary to apply a free gingival graft to enlarge the keratinized tissue. Also to improve the periodontal regeneration in bone defects, so as to obtain enough bone to move the adjacent teeth in this direction and allow the correct placement of an implant at the end of orthodontic treatment. In this case the mandibular left anterior teeth before orthodontic treatment, had a particular predisposition to flare and elongate because they had no anteroposterior contacts due to a cross-bite. Although orthodontic intrusion was planned as a beneficial treatment approach for patients with pathologic migration,1 in the present case extrusion was done in the teeth that were in a cross-bite condition, in order to improve the open bite tendency.16 In spite of not being the best option because pathological tooth migration involving the extrusion of teeth which already had long clinical crowns. The collapse of the interproximal papillary dimension and the dark triangles created an unpleasant negative gingival architecture, with esthetic and functional implications. In spite of significant improvement of the gingivo-marginal condition at the end of the orthodontic therapy, black holes in gingival embrasures were present. These interproximal spaces and gingival margins were camouflaged by pink restorative composite procedures in the lower incisor teeth adjacent to the implant to replace the papillary reshaping that was lost due to the high gingival recession.17 On the other hand, on the upper incisors, a white composite restoration was done to reshape normal morphology of central incisors that were slightly triangular. This case clearly demonstrates the importance of interdisciplinary management to solve seriously compromised functional and esthetic adult cases that would never be achieved without this combination.17

References1. Pinho T, Neves M, Alves C. Multidisciplinary management including

periodontics, orthodontics, implants, and prosthetics for an adult. Am J Orthod Dentofacial Orthop 2012; 142(2):235-45.

2. Pinho T, Silva JA, Alfaiate D. Orthodontic management of a case with missing upper posterior teeth, severe Spee curve and periodontal problems. Int J Stomatol Occlusion Med 2012; 5(4):188–97.

3. Mihram W, Murphy N. The Orthodontist’s Role in 21st Century Periodontic-Prosthodontic Therapy. Semin Orthod 2008; 14:272-89.

4. Thilander B. Infrabony pockets and reduced alveolar bone height in relation to orthodontic therapy. Semin Orthod 1996; 2(1):55-61.

5. Miyamoto M, Yamashiro T, Takano-Yamamoto T. Surgical orthodontic treatment for severe maxillary protrusion with aggressive periodontitis. Orthodontic Waves 2008; 67:171-78.

6. Pinho T, Figueiredo A. Orthodontic-orthognathic surgical treatment in a patient with Class II subdivision malocclusion: occlusal plane alteration. Am J Orthod Dentofacial Orthop 2011;140(5): 703-12.

Dr. Teresa Pinho is Professor of Orthodontics and Odontopediatrics in Instituto Superior de Ciências da Saúde-Norte, Portugal. She is alsoCoordinator, Craniodentofacial Morphogenesis Research Group, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde (IINFACTS)/CESPU.

Dr. Alves C, Postgraduation in Periodontology, University of Oporto, Portugal.

Dr. Neves M, Postgraduation in Implantology and Oral Rehabilitation, Director of Manuel Neves Clinic.



Abstract: Among dentitional anomalies, tooth transposition is considered the most difficult to manage clinically. Unilateral maxillary canine-first premolar (Mx.C.P1) transpositions are found more often than bilateral transpositions, and the left side is more frequently involved than the right. A case of maxillary canine – first premolar (Mx. C.P1) complete transposition is presented in which transposition was maintained during the treatment. Aligning the teeth in the transposed order would probably require less treatment time than correcting the transposition. Management of transposition must be assessed on a case to case basis. Dental transposition can be corrected orthodontically, but the mechanics are complex, treatment time is long, and damage is possible to the supporting dental tissue. Keywords: Transposition, Correct, Maintain, Orthodontic management.

ntroductionTransposition of maxillary teeth is a disturbance of eruptive position, occurring approximately in one out of 300 patients and provides the clinician with

a special challenge in diagnostic and therapeutic management. A long needed unifying definition has recently been published. Tooth transposition is the positional interchange of two adjacent teeth, specially their roots, or the development or eruption of a tooth in a position occupied normally by a non-adjacent tooth.1 Tooth transposition is a designation applied to extreme type of ectopic eruption. All the transpositions are a kind of ectopic eruption but, all the ectopic eruptions may not be teeth transposition. Transposition may be incomplete when the crowns overlap each other but the root apices are in their relative normal position, or complete when both the crown and roots are parallel in their transposed malpositions.On the basis of anatomic factors, 5 types of maxillary tooth transpositions have been firmly identified. The 5 maxillary transposition types were named and abbreviated according to teeth involved.2

1. Canine – First premolar (Mx. C.P1)

2. Canine – Lateral Incisor (Mx. C.I2)

3. Canine – To first Molar site (Mx. C. to M1)

4. Lateral incisor – Central Incisor (Mx. I2 I

1)

5. Canine to central incisor site (Mx. C to I1)

Etiologic Factors: The Mx. C.P

1 transposition was recently determined to

be an anomaly resulting from genetic influences with a multi-factorial inheritance model. Supporting a polygenic cause were finding of elevated frequencies of associated dental anomalies, elevated bilateral occurrence, familial occurrence, and significant differences in male: female prevalence of the anomaly. 3-4

At least 26% cases demonstrated the absence of one or permanent teeth (excluding third molars) in association with

the Mx. C.P1 transposition anomaly. 27% of the cases shown

bilateral expression and 11% had one or more family members known to express the trait.5 The male: female prevalence rates derived from the available data yielded a sex ratio M1: F1.55 for Mx. C.P

1 transposition. Unlike the other four types of maxillary

transposition, there is no evidence that early dentofacial trauma or tooth losses are contributory factors in the causes of Mx. C.P

1

transposition. There is general agreement6 on keeping the transposed tooth order in most cases, especially in adult. But when detected early enough, transposition can sometimes be corrected without damaging the canine and the first premolar roots.7-9

Case Report A 19-year-old male presented with the chief complaint of retained milk tooth and in maxillary arch malposition of adjacent teeth. His face was proportional and symmetric, with a straight profile and a pleasant smile (Figure 1). All permanent teeth except third molars were present, and the left deciduous maxillary canines were retained. There was mild dental crowding in both arches. The maxillary left canine had erupted buccally between the premolars and the left first premolar was rotated (Figure 2). The molar relationship was Angle Class-I.

Orthodontic Management of Maxillary Canine First Premolar Transposition - A Conservative Approach

By Avesh Sachan BDS MDS; TP Chaturvedi BDS, MDS

Figure 1: Pre-treatment extra-oral photographs.


On Radiographic examination, there was resorption of the root of deciduous canine and transposition of the crown and the root of left maxillary canine and first premolar, with the roots diverging apically (Figure 3-5). Cephalometric evaluation revealed a skeletal Class- I relationship ( ANB angle=3°) with an average growth pattern (SNGoGn=32°) (Figure 6). Etiologic possibilities for the transposition included genetics (although there were no similar cases in the patient’s family), retained primary teeth, deviation of the affected tooth during the path of eruption and abnormality in the sequence of eruption with consequent lack of space for the maxillary canine.

Treatment Objectives Because facial appearance was satisfactory, correcting tooth transposition was the highest priority. The treatment objectives Figure 9: Post-treatment extra oral photographs.

Figure 2: Pre-treatment intraoral photographs.

Figure 3: Pre-treatment OPG.

Figure 4: Pre-treatment upper occlusal x-ray.

Figure 6: Pre-treatment lateral head cephalogram.

Figure 5: Pre-treatment IOPA X-Ray (Left).

Figure 7: Intraoral photographs during treatment.

Figure 8: Post-treatment intra-oral photographs.


were to (1) Maintain a Class I molar and canine relationship, (2) create ideal over-jet and overbite (3)correct the alignment of transposed canine and first premolar, (4)correct the rotation of the maxillary first premolars, (5) maintain facial balance. Treatment Alternative• Correcting the order of transposed teeth• Extraction of one of the transposed teeth• Maintaining the order of transposed teeth

Treatment Plan The orthodontic treatment plan of choice involved the correction of transposition (in the order of transposition) without the extraction of the premolars. A 0.022´´ pre-adjusted edgewise system (MBT prescription) was used and the deciduous canine was extracted in the initial stage of the treatment.

Treatment Progress After extraction of deciduous canine, the permanent first molars were banded, during the bonding procedure; the canine bracket was bonded onto the first premolar crown to achieve the canine prominence in left side. Alignment was carried out 0.016”NiTi progressively and then 0.017×0.025” stainless steel arch wire was placed with NiTi open-coil spring between first and the second premolar to gain space for the buccally transposed canine. The canine was then bonded with the premolar bracket and aligned into the arch. The patient was treated for 10 months with edgewise appliances (Figure 7). Hawley plate was used for retention. The lingual tuberculum of the first premolar was ground to avoid occlusal interference with the opposing arch. Because of the mesiodistal size differential between the canine and the first premolar, which also could have prevented proper interdigitation, we ground the canine on the mesial and distal sides and rotated the first premolar mesially. Thus, the first premolar took on the larger appearance of the canine.

Results The maxillary left canine and first premolar were successfully aligned into the arch maintaining the order of transposition. Angle’s class-I molar relationships were maintained. Good intercuspation and root parallelism were achieved in the area of transposition (Figure 8). Patient’s pleasing facial profile was maintained (Figure 9). Patient was not willing for orthodontic treatment in mandibular arch so crowding persisted in lower arch.

Discussion The maxillary permanent canine develops under the orbit, above and palatal to the first premolar and lateral incisor. During its long eruptive path, the canine moves labially and mesially and can be palpated high in the labial sulcus. On deviation from the normal eruptive path, the canine may become impacted or may migrate and erupt into position of another tooth. It is for this reason the maxillary canine, more than any other tooth, becomes impacted or transposed. It has been strongly suggested

that abnormal pre-eruptive migration, rather than a change in its position at the initial stage, is the cause of transposition.10

It also has been stated that dilacerations and rotation of teeth often result from trauma causing disturbance in the growth of the epithelial sheath of Hertwig the developmental period of teeth. Therefore, trauma to the deciduous dentition was suggested as the possible cause for transposition in the reported cases with dilacerated teeth adjacent to transposed teeth. Generally, it is preferable to move teeth to their correct position in the dental arch. Treatment options in transposition cases include alignment of teeth in their transposed positions, extraction of one or both transposed teeth, or orthodontic movement to their correct positions in the arch.11

All factors such as the position of the root apices, esthetic and acceptable occlusion, patient cooperation, and length of treatment time, should be considered in making the treatment decisions. Considerable care and time is required to avoid possible damage to the teeth and supporting structures. Some authors suggest that correction of transposed teeth to their normal positions should not be attempted especially in the lower arch.12-13 Alignment in their transposed positions, concomitant with reshaping of their incisal and/or occlusal surfaces, and the use of composite materials for esthetic purposes may be an acceptable compromise.14

Conclusion It was advantageous to treat the patients when the canine was still not fully erupted. When the teeth involved in the transposition are fully erupted and completely or almost completely aligned in the transposed position, a satisfactory result can be obtained by maintaining the transposition, and correction, even if possible, would not always be advisable from a cost-benefit point of view.

References1. Sandham A, Harvie H. Ectopic eruption of the maxillary canine resulting

in transposition with adjacent teeth. Tandlaegebladet; 1985; 89:9-11.2. Peck S, Peck L. Classification of maxillary tooth transpositions. Am J

Orthod Dentofacial Orthop 1995; 107:505-17.3. Peck L, Peck S, Attia Y. Maxillary canine-first premolar transposition,

associated dental anomalies and genetic basis. Angle Orthod 1993; 63:99-109.

4. Chattopadhyay A, Srinivas K. Transposition of teeth and genetic etiology. Angle Orthod 1996; 66:147-52.

5. Ruprecht A, Batniji S, El-Neweihi E. The incidence of transposition of teeth in dental patients. J Pedod 1985; 9:244-9.

6. Shapira Y. Transposition of canines. J Am Dent Assoc 1980; 100:710-2.7. Sato K, Yokozeki M, Takagi T, Moriyama K. An orthodontic case of

transposition of the upper right canine and first premolar. Angle Orthod 2002; 72:275-8.

8. Bocchieri A, Braga G. Correction of a bilateral maxillary canine-first premolar transposition in the late mixed dentition. Am J Orthod Dentofacial Orthop 2002; 121:120-8.

9. Lieberman MA, Gazit E. Cuspid transposition and treatment timing. Case report. Angle Orthod 1983; 53:143-5.

10. Shapira Y, Kuftinec MM. Tooth transpositions—a review of the literature and treatment considerations. Angle Orthod 1989; 59: 271-6.

11. Ciarlantini R, Melsen B. Maxillary tooth transposition: Correct or accept?. Am J Orthod Dentofacial Orthop 2007;132:385-94

12. Newman GV. Transposition: orthodontic treatment. J Am Dent Assoc 1977; 94:544-7.


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13. Weeks EC, Power SM. The presentations and management of transposed teeth. Br Dent J 1996; 181:421-4.

14. Demir A, Basciftci FA, Gelgor IE, Karaman AI. Maxillary canine transposition. J Clin Orthod 2002; 36:35-7.

Dr. Avesh Sachan graduated with his BDS degree from King George’s Medical University, Lucknow, India, followed by MDS in Orthodontics in 2009 from C.S.M. Medical University Lucknow India (Upgraded King George’s Medical University Lucknow). He is currently Senior Resident in Department of Orthodontics, faculty of dental sciences, IMS, B.H.U. Varanasi, India.

Dr. TP Chaturvedi completed his BDS and MDS from KGMC Lucknow, India. He has received many awards from the Indian Orthodontic Society and Indian Dental Association. He has published more than 50 articles in various International and National journals. He has presented many papers and delivered many guest lectures and organized many academic programs. He has held many administrative positions in different Universities in India. He is currently serving as Dean in Faculty of Dental Scciences, IMS, B.H.U. Varanasi, India.


ome of the orthodontic situations that present to our office by reference, or after a routine panogram taken around age 8, imply congenitally missing one or two upper lateral incisors. In classifying such a malocclusion, the diagnosis has been arbitrarily

described as mild hypodontia (1-2 missing teeth).1 83% of patients presenting with hypodontia only have one or two missing teeth. Then the bilateral absence of the upper lateral incisor is more frequent than its unilateral absence (54%).2

Throughout the years I found many dentists to be confused about the “rules of engagement” when that situation occurs. What should we do now? What should we postpone? After the parents are informed of the facts, they may even put pressure on the dentist to get something done quickly. Let’s review some of the features to be taken into consideration before making a final decision. In orthodontics, a problem usually doesn’t come alone, and it is very common to find something else going on after we found a congenitally missing tooth. For example, patients with upper lateral agenesis have a 2.4 greater chance of having a palatally impacted cuspid (Becker and al, 1981), probably due to lack of guidance of eruption from the lateral root.

Clinical Issues What is usually seen in cases with missing upper laterals is the uneven distribution of space after the cuspids have erupted following the path of least resistance, mostly where the laterals should have erupted (Figure 1). In cases of prosthetic replacement, optimal and functional results will be achieved when spaces are at the appropriate location and of natural dimension. In cases of lateral-cuspid substitution, it will be

ORTHO POINTS

Pierre Pellan, DMDIAO Master Senior Instructor

mandatory to identify patient’s expectations and verify that they are realistic. Nevertheless, a decision will have to be made between either opening the space or spaces for prosthetic replacement, or closing the space and transform the permanent cuspid into a lateral incisor.

Figure 1 - Most often, the permanent cuspid will erupt in lateral incisor position, which is favorable on a periodontal standpoint.

Figure 3 - It is noticed on the x-ray that both lower 2nd bicuspids are distally inclined.

Lateral Agenesis

Figure 2 - At this point, nothing is to be done that could better help the case. It is more convenient to postpone orthodontic treatment after complete eruption of upper permanent cuspids


Opening or closing the spaceOpening If decision is oriented towards an opening of the upper lateral space, the advantages and disadvantages have to be analysed: Advantages: 1- Balanced dental mass between upper and lower arches, allowing for dental class one relationship and normal overbite and overjet, 2-Functional cuspid rise, 3-Regularly shaped anterior teeth, provided that the the prosthesis offers a pleasing result. Disadvantages: 1- Additionnal costs for the patient (for both temporary and final prosthesis), 2- Possibly compromised esthetics since it is an anterior challenge with bone and soft tissues concerns and dental laboratory, 3-Possible longer duration of treatment to ensure proper preparation of the site for a future implant, and the need to postpone implant placement after vertical growth is over. All these details have to be explained to the patient (or parents) and this requires a period of quiet time in a private office room, with pictures and models to get an honest informed consent. Timing is of great importance if this option is selected, and the possibility of starting orthodontic treatment later in order to place implants right at the end of treatment instead of using a temporary should be considered. If no implant will be used, then treatment may start right after the eruption of the permanent cuspid.

Clinical Case After a panoramic x-ray was taken on an eight-year-old girl, it was discovered that both upper lateral incisors were missing. Clinical evaluation confirmed a light skeletal class 3 tendency and edge-to-edge upper and lower incisor relationship. This situation favored the need to eventually open the spaces and obtain a firm and hopefully more stable occlusion. In class 3 situations, the maxilla is oftentimes a little smaller than normal, so therefore the need to add tooth mass to the maxilla by replacing the missing lateral incisors seemed the right choice. Parents insisted that the problem be addressed as soon as possible, even if that implied using temporary bridges, and implants after growth has ceased. The parents were informed that it was in the best interest of their daughter to postpone any orthodontic treatment until permanent cuspids had fully erupted (Figure 2), so that bone would have sufficiently increased in width in the upper lateral incisor area. It was noted that lower 2nd premolars were erupting ectopically. In orthodontics, one problem never comes alone (Figure 3). Records to initiate treatment were taken (Figure 4a to 4g). In order to create an ideal site for future implants, the first step is to close upper central incisor diastema (Figure 5), and then bring the permanent cuspids directly next to the central incisors. This is done on a fairly big and rigid wire, like a 0.018 x 0.025 CuNiTi. Since the roots of the cuspids are very large bucco-lingually, this will create a wide enough bone to welcome the implants in adulthood. When using this approach, the resorption rate has been shown to be very low (± 1%) in the long term. (Spear, Matthews & Kokich)

Figure 4.

Figure 5: First step is to close the spaces between the cuspids and the central incisors.

Figure 6: The space for the upper laterals is re-opened, leaving adequate ridge of bone for future implants.

Figure 7: For easier mechanics, extraction of primary cuspids is done just when ready to retract the upper cuspid.

D E

BA

C

G

F


Next step is to open the space or spaces the right amount in anticipation of placing lateral pontics made of composite, on which brackets are placed for esthetic reasons (Figures 6 and 7). It is very advisable to consult with the dentist who will place the implants before removing the braces in order to make sure adequate space will be available. If required, it is then still possible to move teeth if roots angulation was to be corrected (Figures 8a to 8g show the end result).

Closing If decision is made to close the upper lateral space, the advantages and disadvantages frequently are as follows: Advantages: 1- No additional costs for the patient since no prosthesis will be required, 2- Less hassle for hygiene around bridges or implants, 3- Great esthetics when well performed and with color matching nicely, 4- Sometimes shorter treatment time since cuspid is very often already next to the central incisor, 5- No need to postpone treatment until growth is completed Disadvantages: 1- Discrepancy in dental mass between upper and lower arches, sometimes leading to an anterior edge-to-edge relationship, 2- No cuspid rise, 3-Darker color of the cuspid compared to an incisor, sometimes requiring a porcelain veneer, 4- If unilateral, anchorage control can make it harder to have dental midline at the right place. Besides the good habit of using an upper cuspid bracket on the upper first premolar and an upper lateral bracket on the upper cuspid for root position purposes, adequate ameloplasty should be performed to make the cuspid looks like a lateral incisor.

Transformation procedure includes:1- Flattening of the cusp tip to mimic the upper lateral

incisal edge2- Make the mesio-incisal angle rounder3- Generous lingual reduction4- Decrease the buccal surface eminence5- Decrease the width of the crown

Usually, only minimal tooth movement will be necessary to achieve a good occlusion, since it is frequent that molars on the side of the missing lateral will already be in a class 2 relationship and the cuspid, close to the central incisor. In this situation, the option of closing the lateral incisor space may prove to result in a shorter treatment time.

Clinical case In 2008, a 13-year-old boy consulted with the chief complaint that he didn’t like the fact he had missing tooth when he laughed in the mirror. He had a slightly retrognathic mandible, and a mixed malocclusion with an 8 mm-class 2 cuspid on the left side. Both his upper and lower midlines were deviated 3 mm to the left (Figure 9 a to g). After discussing with the parents, they opted for an alternative treatment plan that included only treating the upper arch. He had attrition on teeth 13 to 21 and 32 to 42, and teeth 23 and 33 were in crossbite. Also, as it is often the case when missing an upper lateral incisor, the contralateral tooth was very small in size. Treatment objectives included: 1-keeping the horizontal relationship of quadrants 1 and 4 as much as possible,

Figure 8.

Figure 9.

G

FE

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ED

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2-improving the horizontal aspect of quadrants 2 and 3 towards a better interdigitation, in a class 2 molar relationship, without compromising the anterior anchorage and deviating the upper midline too much, 3-altering the upper left cuspid to make it look like a lateral incisor. To achieve these objectives, a mini-screw between teeth 23 and 24 was used while protracting upper left posterior teeth (fig. 10), and a porcelain veneer on tooth 23 allowed for better esthetics of the final result. Also the width of the right lateral incisor was increased. Treatment time was 19 months (Figure 11a to 11f ). These orthodontic cases offer more esthetic challenge to the clinician and make a true difference in the life of our patients.

References1. Goodman et al., 1994; Dhanrajani, 2002; Nunn et al., Jones, 20092. Polder et al. (2004). 3. Carter AC, Sather HS : Canine substitution. Am J Orthod Dentofacial

Orthop 112 :316-9.4. Kokich VO jr, Kinzer GA: Managing congenitally missing lateral incisors,

part 1: Caanine substitution. J Esth Restor Dent 2005; 17: 1-6.5. Kokich V.Jr: Early management of congenitally missing teeth. Sem in

Orthodontics 11: 146-151.

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A 40 Years Follow-Up of Dental Arch Dimensions and Incisor Irregularity in Adults. Tsiopas N, Nilner M, et al:Eur J Orthod; 2013; 35 (April): 230-235. The authors decided to evaluate the long-term changes in dental arch dimensions and incisor irregularity in non-growing adults. Their sample group of 35 subjects (22 males, 13 females; mean age, 22.7 years) were studied between 1949 and 1960. In 1989, subjects were recalled to obtain an additional set of study casts. Eighteen subjects (16 males and 2 females) were available for study casts and had not undergone extractions, orthodontic treatment, or prosthodontic treatment. Their results showed significant dento-alveolar changes over the 40-year study. In the maxilla, small decreases in arch length (0.5 mm), intercanine width (0.8 mm), and arch depth (0.9 mm) were noted. In the mandible, a decrease in arch length (0.7 mm) and intercanine width (1.1 mm) was also seen, along with an increase in Little’s irregularity index (mean, 1 mm). No significant changes in malocclusion traits, overbite, and overjet were observed. They could conclude that long-term changes occur in the dental arch dimensions over time, even in non-growing adults and these changes have to be considered when planning orthodontic retention. Reviewer’s Comments: We all heard about the changes in transverse but the results in vertical showing good stability did surprise me.

Diagnosis and Treatment of Temporomandibular Disorders: An Ethical Analysis of Current Practices Reid KI, Greene CS:J Oral Rehabil; 2013; 40 (July): 546-561. We have seen an enormous change in the clinical management of temporomandibular disorders (TMDs) based on the training and treatment philosophies of different dentists, ranging from inexpensive and conservative techniques to costly and invasive treatment for the same symptoms. The question is: can we suggest an ethical framework for the treatment of TMDs based on current scientific literature. The authors made a retrospective review of the subject looking 131 current scientific articles found on PubMed (November 9, 2009). The current literature has repeatedly shown that TMDs are often self-limiting and generally not progressive (although symptoms may fluctuate over time). Cases most frequently occur in women between 15 and 45 years of age. Occlusion, maxilla-mandibular relationships, condylar position, and other structural factors generally do not cause TMD. Additional diagnostic aids such as electromyography and electronic jaw tracking have not been found to have the sensitivity and specificity to add diagnostic value. Many patients have been shown to have significant improvement in TMD solely by proper explanation of the issue,

good pain management, home self-care, and possibly splint therapy. This bio-psychosocial -medical model for treatment differs greatly from many older invasive treatment techniques, such as occlusal equilibration, orthodontic treatment, bite opening, prosthodontic treatment, or surgical intervention. These techniques are based on the belief that static and dynamic occlusion relationships are the primary etiological factors of TMD, which is not supported by the current literature. They concluded that multiple systematic review articles have shown that conservative and reversible management of TMDs can successfully treat most cases. There is no evidence to justify routine initial treatments that are invasive, irreversible, and expensive. With this evidence, the ethical principles of respect for patient autonomy and non-malfeasance support proper patient education about current scientific evidence and providing conservative, reversible initial treatment for TMD. Reviewer’s Comments: I have chosen this review knowing that it will get much interest and criticism since many clinicians refute the literature. You will have to make your own conclusions and review the literature but remember that most clinicians on the planet agree that the initial approach should be reversible.

Upper-Incisor Root Control With Invisalign AppliancesCastroflorio T, Garino F, et al: J Clin Orthod; 2013; 47 (June): 346-351 Since clear aligners are believed to have biomechanical limitations for certain tooth movements, the authors decided to examine the effectiveness of Invisalign(R) Power Ridges (a “twist” of the aligner surface near the gingival margin to increase stiffness while maintaining a uniform thickness) in controlling the inclination of upper incisors during orthodontic treatment. They examine 6 consecutive patients (4 females, 2 males, mean age of 26 years) seeking orthodontic treatment. All patients were treated using Invisalign with Power Ridges for torque control by 1 of 2 experienced clinicians. The Invisalign ClinCheck(R) was compared with scanned initial and final study models for each case. Coordinates of 3D landmarks and torque measurements were obtained using Rhinoceros 4.0 modeling software. Torque was measured as the angle between the facial axis of the clinical crown and a true vertical line. All maxillary central incisors were measured, but 3 incisors which showed greater crown movement than root movement were excluded. They showed that the mean torque values prior to treatment were 21 degrees on both the virtual setup and scanned models, while the final torque values were 10.5 degrees for both measurement methods. Therefore, the average torque change was 10.4 degrees , with the final measurements from the study casts closely matching the ClinCheck (linear correlation coefficient close to 1). No

Reviewer Michel Champagne, DMD, MAGD, IBO, CDE


statistically significant differences were found between torque measurements on the ClinCheck compared to the final models. They could conclude that Invisalign treatment with Power Ridges showed good torque control on upper incisors, with no significant deviations from the ClinCheck. Reviewer’s Comments: The evolution of Invisalign has been great and the torque accessories are better than before but we still need bigger samples to really judge their effectiveness.

Mechanical Evaluation of Orthodontic Mini-Implants of Different Lengths Pithon MM, Figueiredo DSF, Oliveira DD: J Oral Maxillofac Surg; 2013; 71 (March): 479-486 The objective of the study was to evaluate the possible advantage of using a longer mini-implant for orthodontic anchorage. 400 mini-implants were obtained in different lengths, including 6 mm, 8 mm, and 10 mm lengths. The authors tested fracture strength, flexural strength, and insertion torque. They concluded that the increase in screw length does not increase the mechanical strength of the implant, but it could reinforce the initial stability. Reviewer’s Comments: in orthodontics a longer implant providing greater initial stability is very important since most clinicians load their mini-implants immediately at insertion.

Preorthodontic Uncovering and Autonomous Eruption of Palatally Impacted Maxillary Canines Kokich VG:Semin Orthod; 2010; 16 (September): 205-211 The study wanted to summarize the current knowledge on outcomes of various methods of exposing maxillary canines. In young patients where the crown of the impacted canine is not past the lateral incisor root, extraction of the primary maxillary canine can be an effective method of redirecting the eruption of the permanent canine. However, in cases of severe impaction or delayed referral to the orthodontist, surgical exposure is needed. Two main options exist for surgical exposure: a closed technique with orthodontic guidance of eruption or an open exposure with autonomous eruption of the canine into the palate. With the closed eruption technique, a mucoperiosteal flap is reflected, bone around the canine crown is removed, a gold chain is attached, and the flap is closed with the chain exiting through the palatal tissue. The initial force direction should erupt the canine palatally away from the lateral incisor and then bring the canine laterally into the dental arch. However, inappropriate force direction can cause root resorption, bone loss, poor periodontal outcomes, and increased treatment times. Using an open exposure technique, the tissue is removed over the canine after the surgical exposure, allowing for autonomous eruption prior to the placement of orthodontic appliances. A cleat is typically bonded to the crown to improve retention of a surgical dressing to protect the exposure site. The canine will typically erupt into the palate within 6 to 9 months. Then, orthodontic appliances can be placed to align the tooth. This method has shown improved periodontal outcomes (no significantly increased pocket depths or inflammation) and decreased orthodontic treatment time, and can easily be performed in the mixed dentition. Autonomous eruption of palatally impacted

canines offers a predictable method for treatment of impacted canines with minimal side effects. Reviewer’s Comments: Having performed both approaches over the past 20 years, the biggest issue with the open approach was managing the wound and post-surgical pain often necessitating palatal coverage with a removable appliance but placing a bonded button and a periodontal pack solved the problem in a faster and simpler way. The open approach in my opinion has great advantages.

Long-Term Effect of Root Proximity on Periodontal Health After Orthodontic Treatment Artun J, Kokich VG, Osterberg SK: Am J Orthod Dentofacial Orthop; 1987; 91 (February): 125-130 With the popularity of interproximal reduction for crowding, reshaping teeth for open gingival embrasures, or dilacerated roots, the authors wanted to verify how root proximity affects long-term periodontal health. A split-mouth clinical trial was done with 25 patients (9 males, 16 females, aged 28 to 55 years) and showed radiographic evidence of roots closer than 0.8 mm. This sample was taken from 400 patients recalled at least 16 years after orthodontic treatment with fully banded appliances (0.022” slot). These cases were treated by the orthodontic faculty or graduate students at the University of Washington. For each case of root proximity, clinical assessment was done to determine Plaque Index, Gingival Index, pocket depth, attachment level, and alveolar bone height. Adjacent and/or contralateral teeth were used as controls when possible. The average patient was recalled 24 years after treatment (range, 16 to 32 years). Root proximity was diagnosed bilaterally in 8 patients and unilaterally in 17 patients. The average distance between roots in the root proximity cases was 0.4 mm versus 1.4 mm on control teeth. The majority of cases (72%) were found between maxillary central and lateral incisors. No significant differences were found, compared to control teeth, in Plaque Index, Gingival Index, attachment levels, or alveolar bone height. They concluded that the rate of periodontal breakdown was not significantly different in finished orthodontic cases with root proximity. Reviewer’s Comments: the article clearly supports that finishing with roots closer than ideal is not a problem if space requirements demand crown reproximation to provide a better esthetic and functional outcome.


MANUSCRIPT SUBMISSION Manuscripts are to be submitted electronically at http://iaortho.edmgr.com. If the manuscript is written in a language other than English, the author(s) must submit an English translation. The author may also submit a copy in his or her native language that will published in the online version only with a mention in the printed issue that the article is availabile online in his or her own language. The manuscript must be original and submitted exclusively to IJO.

The Journal invites authors to submit:• Clinical reports• Technique articles• Review articles• Case reports

MANUSCRIPT FORMAT Abstract. Must include a short abstract no more than 50 words that describe the significance of the article. Keywords. Must include keywords to help categorize the article. Length. Manuscript should be no longer than 15 double-spaced pages, excluding figures and illustrations. Tooth Numbering. The numbering of teeth should be international numbering. (US numbering can be added and put in parentheses.) Non-English Manuscripts. Authors are encouraged to submit the manuscript in languages other than English for posting on the IAO website. A mention will be added to the English version published in the International Journal of Orthodontics, directing readers online for other translations. Illustrations. Images must be available electronically as separate files. High quality digital images must be presented in one of the following formats: .tiff, .eps, or .jpg with resolution of a minimum 300 dpi. Images must not be imbedded in software programs such as Word or Power Point. The names on the digital files for photo/illustration files should match the manuscript reference. For example, if manuscript copy references Figure 1, electronic file should be titled Fig 1.jpg. No more than 16 photographs, figures, & illustrations are recommended; if greater than 16, IJO has the right to select and limit the number if necessary. Figures must be clearly referenced as to their placement in the manuscript. Brief captions for the figures, identified by number, must be provided. All images must be titled. Radiographs must be of superior quality. References. References must be included in the article and authors are responsible for the accuracy of references. Manuscripts without them will be returned. Cite references in the text as endnotes and number them consecutively. Citations must be referenced in the following style: Periodical: 1. Sim JM, Jefferson Y, Dillingham SE, & Keller DC. Diagnosing an orthodontic patient using three different analyses. IJO 1990; 1(4):101-106. Book: 2. Fonder AC. The Dental Physician. 2nd ed. Rock Falls, IL; Medical Dental Arts; 1985:25-82.

World Wide Web site: 3. Health Care Financing Administration. 1996 statistics at a glance. Available at: http://www.hcfa.gov/stats/stathili.htm”. Accessed Dec. 2, 1996. Products: Any products mentioned in the manuscript should be footnoted disclosing the company name and address.* *XYZ Orthodontic Co., 123 Main St., Los Angeles, CA 90000.

REVIEW AND EDITING PROCESS Editor. Articles will initially be reviewed by the editor. If author fails to adhere to the guidelines set forth, manuscript will be returned to the author for revision and correction. Peer review. Articles in IJO are subject to an anonymous peer review process. Reviews may take up to eight weeks to complete. Decision. Once the reviewing consultants have completed their critiques, the editor examines their comments and makes a decision to accept, accept with minor revisions, revise and resubmit, or reject. Editing. IJO reserves the right to edit manuscript for conciseness, clarity, and stylistic consistency. The author has final approval before publication.

AUTHOR RESPONSIBILITIES Copyright transfer. IAO holds the copyright for all editorial content published in the journal. All accepted manuscripts become the permanent property of the International Association for Orthodontics, and may not be published elsewhere in full or in part, in print or electronically, without written permission from the International Association for Orthodontics. Reprint permission. The author is responsible for obtaining written permission from the publisher, or the person or agency holding the copyright for any material that is reproduced from a published source. Consent forms. Any patient who is clearly identified in the article must sign a form indicating his or her consent to be thus depicted in the article. It is the author’s responsibility to confirm consent. Author’s photo and bio. The author(s) must submit a headshot (preferably professional) and current biographical sketch. If author holds a teaching position, the title, department and school should be included. Any position or relationship with a dental manufacturer must be identified. The sketch should include rank or title and station of authors who are in federal service, and should be limited to 60 words or less. Conflict of interest. The author will identify any conflicts of interest upon submission of any articles.

REPRINTS The International Journal of Orthodontics provides the corresponding author a final electronic copy of the journal in which the article appears as well as an electronic copy (.pdf ) of the pages where the article appears. Requests for individual reprints of the article should be directed to Tamiko Kinkade, Managing Editor, 217-585-9065 or at [email protected].

Author GuidelinesInternational Journal of Orthodontics

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