Published Quarterly by theInternational Association for Orthodontics

International Journal of

OrthodonticsIn this Issue:n Can We Move Traumatized Teeth?

n Rondeau Seminars Amalgamated Mid-Sagittal (Lateral) Cephalometric Analysis

n An Adjustment in NiTi Closed Coil Spring for an Extended Range of Activation

n The Loudon Chateau Repositioning Appliance

n A Simple Technique for Correction of Relapsed Overjet

n Maximum Cl II Therapy with Minimum Appliances

n Assessment of Safe Zone in Maxillary Molar Region for Miniscrew Placement in the Mixed Dentition Period – A Digital Volumetric Tomographic (DVT) Study

n Treatment Planning Considerations for Molar Uprighting

n Total Recall: An Update On Orthodontic Wires

n Difficulties Achieving Orthodontic Stability? The Answer May be Blowing in the Wind

n Orthodontic Exposure of Multiple Impactions: A Case Report

n Ortho Pearl: Gaining Space and Creating a Class I Molar Relationship

VOLUME 25 | NUMBER 3 | FALL 2014

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2 IJO � VOL. 25 � NO. 3 � FALL 2014

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 tkcps@comcast.net.

Author GuidelinesInternational Journal of Orthodontics

Revised Spring 2013

FEATURES

DEPARTMENTS

ADVERTISERS

Editor Michel Champagne, DMD, MAGD, IBO, CDE Brome, QC, Canada E-mail: editor@iaortho.org

Co-Editor Steve Galella, DDS, IBO Collierville, TN, USA E-mail: drsgalella@hotmail.com

Managing Editor Tamiko L. Kinkade Communication & Publication Solutions, Inc. 1300 Sunrise Drive Carterville, IL, USA 62918 Phone: 217/585-9065 Fax: 217/529-7178 E-mail: tk@tkcpsolutions.com

ConsultantsJohn Baar, DDS, IBO, Fulton, MD, USABill Buckley, DDS, IBO, Rocky River, OH, USARichmond Cheng, DDS, IBO, Vancouver, BC, CanadaScott Dillingham, DDS, Fayetteville, NY, USAJay W. Gerber, DDS, Parkersburg, WV, USARick Grant, DDS, IBO, Winnemucca, NV, USAP. Harikrishnan, BDS, MDS, FDSRCS, Chennai, IndiaThomas J. Hughes, DDS, IBO, Cassville, WI, USAYosh Jefferson, DMD, IBO, Mount Holly, NJ, USADuane Keller, DMD, IBO, St. Louis, MO, USAJean Noel Lavallee, DDS, IBO, MBA, Longueuil, QC, CanadaEdmund Liem, DDS, Chilliwack, BC, CanadaMike 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, AZ, 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

Orthorama Seminars .................................................4Myofunctional Research Company .....................10Smiles of St. George ................................................13Impact Research, Inc. ............................................14TMJ & Sleep Therapy Research .............................30

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.

Murdock Laboratory ...............................................37Rondeau Seminars ..................................................38 American Orthodontic Society .............................46Johns Dental Laboratories .....................................63Dolphin Imaging Systems ...................... Back Cover

Can We Move Traumatized Teeth? ......................................................................................................................11 By Arnaud Costi

Rondeau Seminars Amalgamated Mid-Sagittal (Lateral) Cephalometric Analysis ....................15 By Adrian J. Palencar, MUDr, MAGD, IBO, FADI, FPFA, FICD

An Adjustment in NiTi Closed Coil Spring for an Extended Range of Activation ........................21 By S.V.M. Raghu Ram Ravipati, MDS; Arunachalam Sivakumar MDS, MORTH RCSED; P. Sudhakar,

MDS; C.V. Padmapriya, MDS; Mummudi Bhaskar, MDS; Mohammad Azharuddin, MDS

The Loudon Chateau Repositioning Appliance ...........................................................................................23 By Merle Loudon, DDS

A Simple Technique for Correction of Relapsed Overjet .........................................................................31 By Neelima Kakkirala, MDS; Ruchi Saxena, MDS; Sharmada B K, MDS

Maximum Cl II Therapy With Minimum Appliances ...................................................................................33 By Larry White

Assessment of Safe Zone in Maxillary Molar Region for Miniscrew Placement in the Mixed Dentition Period – A Digital Volumetric Tomographic (DVT) Study ..................................................39 By Kavita Hotwani, MDS; Sudhindra Baliga, MDS; Nilima Thosar, MDS; Krishna Sharma, MDS

Treatment Planning Considerations for Molar Uprighting ....................................................................43 By Harsimrat Kaur, MDS; Pavithra US, MDS; Shabeer N. N, MDS; Reji Abraham, MDS

Total Recall: An Update on Orthodontic Wires .............................................................................................47 By H. Jyothikiran MDS; Ravi Shantharaj MDS; Panchali Batra MDS, MORTH RCS (Edinburgh);

Pradeep Subbiah MDS; Bhagya Lakshmi MDS; Vishal Kudagi MDS

Difficulties Achieving Orthodontic Stability? The Answer May be Blowing in the Wind .........57 By Daniel Hanson, BDS

Orthodontic Exposure of Multiple Impactions: A Case Report ............................................................59 By Maridin C. Munda-Lacson, DMD, IBO, FPFA, FICCDE; Adith Venugopal, BDS

Editorial: Is it Almost Done? ..........................................................................................................................................5 By Michel Champagne, DMD, MAGD, IBO, CDE

Ortho Pearl: Gaining Space and Creating a Class I Molar Relationship ..................................................... 62 By Rick Grant, DMD, IBO

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

TABLE OF CONTENTS

FALL 2014 n VOLUME 25 n NUMBER 3

International Journal of

Orthodontics

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: worldheadquarters@iaortho.org

Visit the IAO online atwww.iaortho.org

5IJO � VOL. 25 � NO. 3 � FALL 2014

Is It Almost Done?

ince I graduated from dental school, quite some time ago, orthodontic procedures have improved greatly. The way patients and doctors look at any orthodontic treatment is very different. We are in

an era where time has never been so precious. People do not have enough time in their life to do all the things they want to do. That is probably why many orthodontic clinicians advertise that they have a technique to treat faster. We all see the future of orthodontics being oriented towards faster and better treatment. A few questions come into my mind on this futuristic film of faster and better (don’t you think it sounds like a movie title). One of these questions is: “Are we really faster?” And, a second question,“Why do we want to be that fast?” It is probably easier to answer the second question than the first. Why? Patients demand a shorter treatment time. Doctors, have you had braces in your mouth as an adult? Not to mention teenagers who, the vast majority of the time, want the treatment to be finished by about the third month. As for me, I did have braces as an adult and, let me tell you, that time is of the outmost importance. For the patient, shorter treatment time is better. For young active adults with a career that may force them to be very mobile or for multidisciplinary cases that need orthodontic preparation, keeping the treatment time to a minimum has never been so important. And, since periodontal tissues dislike long treatment shorter is better. For the orthodontic clinician, the shorter treatment average promotes referrals and will increase productivity, being able to treat more patients in the same amount of chair time. Other motivating factors may be the influence of the advertisements and publications of the manufacturers with their marketing strategies to make us question ourselves if we do not get into that fast track approach. Some are motivated to treat faster when observing their competition and thinking that if they do not reduce their treatment time they are not in the game to the point where they may think that they are out of date or doing something wrong. For other clinicians, there may be many more reasons why they want to treat faster. The second question is: “Are we treating faster?” The answer is yes, without a doubt. With the progress of science and technology such as better understanding of growth and development, better memory wires and better manufacturing procedures, the control we can have has improved. Also, since the percentage of extraction cases is lower, we have less space to close with the consequence of reducing the duration of treatment.

We still have some gray areas and one is “are we more knowledgeable in growth and development and can we control treatment relapse?” Answering such questions may be difficult. Recently I heard a prominent chair of an orthodontic department making this opinion comment: “Many new graduates today are less knowledgeable and more mechanically oriented because they want to move teeth fast to be productive. When they come out of school, they want to be able to pay back their debts and benefit from a high standard of living as soon as possible.” We must ask ourselves if productivity should be our prime objective. We may get charmed by the manufacturers of different appliances like brackets and wires or stimulation assisting appliances and techniques that are supposed to boost treatment efficiency like Acceledent, Propel, Piezocision and others. I have nothing against improving my treatment outcomes, I am personally charmed and intrigued by all those new things but every time I have the temptation of using any new product or technique I go through a very strict review of the independent literature to decide myself that the change is worthwhile. I will not take position on any of them but I urge you to look at the literature and make your own decision in the seriousness of the literature and on the clinical effectiveness of any new product. After all this, I conclude that we take less time to treat for all of the above reasons. However, faster does not always equal better. Patient’s health, wellness, function and also attractiveness should be placed above all. Our biggest challenge today is to encourage patients to collaborate to the treatment that he or she NEEDS and not to the treatment that he or she WANTS knowing that we cannot all always have it our way.

EDITORIAL

Michel Champagne DMD, MAGD, IBO, CDEEditor

6 IJO � VOL. 25 � NO. 3 � FALL 2014

French VersionRapide et efficaceTranslation by Dr. Michel Champagne, Canada Depuis ma graduation de l’école dentaire, il y a déjà quelques années, les techniques orthodontiques ont grandement changé. Les patients et les cliniciens ont modifiés grandement leur perspective sur les traitements orthodontiques. Nous sommes à une époque où l’utilisation du temps est devenue cruciale. Les gens manquent de temps dans leur vie pour faire tout ce qu’ils veulent. Ce phénomène est sans doute relié à la tendance qu’ont les cliniciens d’annoncer qu’ils utilisent des techniques pour traiter plus rapidement que jamais. Nous voyons tous le futur de l’orthodontie comme étant orienté vers des traitements plus rapides et de meilleure qualité. Quelques questions me viennent cependant à l’esprit sur le cliché futuriste de l’orthodontie moderne que l’on pourrait décrire à la façon d’Hollywood comme ‘’Braces for the fast and furious’’. De grandes questions demeurent : sommes-nous vraiment plus rapides et pourquoi voulons-nous l’être? Il est probablement plus facile de répondre à la seconde question en premier. Pourquoi les patients demandent-ils des traitements plus courts. Facile d’y répondre si vous avez vous-même reçu un traitement orthodontique à l’âge adulte et nous ne discuterons même pas des adolescents qui demandent dès le début quand leur traitement se terminera-t-il. Pour ma part, j’ai reçu un traitement orthodontique à l’âge adulte et laissez-moi vous dire que la durée est d’une grande importance. Pour le patient la présentation d’un plan de traitement de courte durée est vraiment mieux perçue. Pensez à ces jeunes adultes actifs avec une carrière qui peut souvent leur demander beaucoup de mobilité ou dans les cas de traitements multidisciplinaires qui nécessitent une préparation orthodontique, le fait de garder la durée du traitement à un minimum n’a jamais eu autant d’importance. Pas si mal car les tissus parodontaux apprécient les traitements orthodontiques courts. Pour le clinicien qui peut rendre le traitement plus court, il s’agit d’une bonne approche marketing pour la vente du traitement et par le fait même il augmente sa productivité pouvant traiter plus de clients dans le même espace-temps. La compétition entre les praticiens se joue également sur la rapidité de traitement. Beaucoup de praticiens croient que pour faire partie de l’élite, ils doivent être rapides. La publicité des manufacturiers influence également cette approche de traitement sur la voie rapide. La réponse à la seconde question ‘’ traitons-nous vraiment plus rapidement aujourd’hui’’ est sans le moindre doute un OUI. Avec le progrès de la science et de la technologie comme une meilleure connaissance de la croissance et du développement, une meilleure métallurgie de fils à haute mémoire, des techniques de manufacturation plus précises, il est certain que notre contrôle s’est grandement amélioré. Le fait également que le pourcentage des cas nécessitant des extractions soit plus faible, nous avons moins d’espace à fermer, ce qui par conséquent dans plusieurs cas permet de réduire la durée du traitement.Il existe certes encore des zones grises et une d’entre elles repose sur notre connaissance de la croissance et du développement. En savons-nous vraiment assez et comment pouvons-nous contrôler la récidive qui nous hante depuis des décennies. La réponse à ces questions peut être difficile. Récemment j’ai eu

la chance d’entendre un chef de département d’orthodontie d’une grande université qui faisait ce commentaire suivant: ‘’en mon opinion, plusieurs nouveaux gradués aujourd’hui ont moins de connaissances des matières de base comme la croissance et de développement et sont tout simplement plus orientés mécaniquement parce qu’ils veulent bouger les dents de façon très rapide et ainsi améliorer leur productivité’’. Ces jeunes cliniciens veulent tout simplement être capables de payer leurs dettes et de bénéficier rapidement d’un niveau de vie élevé. Nous devons nous demander si la productivité se doit d’être notre premier objectif. Nous pouvons être charmés par ces nouvelles technologies comme les nouveaux boîtiers, les fils ou la stimulation osseuse assistée par ces appareils qui sont tous supposément des façons d’augmenter notre rapidité de traitement. J’ai en tête ces systèmes comme Acceledent, Propel, la Piezocision et les autres. Attention, je n’ai rien contre l’amélioration des résultats de traitement. Je suis personnellement charmé et en même temps intrigué par toutes ces nouvelles technologies que j’ai envie d’incorporer à ma pratique mais à chaque fois que j’ai cette tentation, je me dois de faire une revue sérieuse de la littérature indépendante afin de me convaincre que tous ces changements à apporter à ma pratique ont vraiment une valeur certaine. Je ne veux pas prendre position sur aucun de ces systèmes mais je vous prie de regarder de près la littérature pour en arriver à votre propre conclusion et surtout de porter une attention particulière au sérieux de cette littérature disponible pour pouvoir évaluer de façon efficace tout nouveau produit. Après bien des mots, ma conclusion est facile : oui nous prenons maintenant moins de temps à traiter nos patients pour toutes les raisons ci-haut mentionnées mais souvenez-vous que plus rapide n’est pas nécessairement meilleur. La santé des patients, leur bien-être, leur fonction et aussi leur apparence doivent être placées au-dessus de tout. Notre plus grand défi demeure de motiver nos patients à collaborer au traitement dont ils ont besoin et non nécessairement au traitement qu’ils désirent. Nous savons tous que ceci est un vœu pieux qui n’est pas toujours réalisable.

Spanish VersionYa esta casi hecho?Translation by Dr. Alvin Cordona, Puerto Rico Desde que me gradúe de la escuela dental, ya hace algún tiempo, los procedimientos ortodónticos han mejorado grandemente. También la manera en que los pacientes y doctores perciben el tratamiento ortodónticos es bien diferente. Estamos viviendo en una época donde el tiempo es muy importante o crucial. Las personas no tienen el tiempo suficiente en sus vidas para hacer todo lo que quisieran hacer. Esta es La razón de porque muchos clínicos ortodónticos proclaman que ejecutan técnicas ortodónticas mas rápidas que otras. Vemos el futuro de la ortodoncia orientado hacia mejores y más rápidos tratamientos. Muchas preguntas vienen a mi mente en esta época futura que pudiéramos catagolar como rápida y mejor. Entre estas: ¿son realmente rápidas? Y otra, ¿ Porque queremos ser tan rápidos? Probablemente es más fácil contestar la segunda pregunta primero. ¿ El Porque? Los pacientes demandan tiempos de

7IJO � VOL. 25 � NO. 3 � FALL 2014

tratamientos más cortos. Doctor en su época de adulto ha tenido Bracket (frenos)?. Ni siquiera hemos hablado de los adolescentes que quieren que sus tratamientos finalicen al tercer mes. Mi experiencia personal al tenerlos es que el tiempo es sumamente importante. Para el paciente mientras menos tiempo mejor especialmente para jóvenes adultos profesionales que su trabajo es transitorio y por ende sus tratamientos multidiciplinarios necesitan preparación ortodóntica rápida. También el tejido periodontal se afecta con tratamientos prolongados. Para el clínico ortodónticos esto le promueve referidos y hace que aumente su productividad al tratar más pacientes en el mismo tiempo. Otro factor motivacional puede ser la influencia de las estrategias de mercadeo de los manufactureros que nos hace ver como poco actualizados si no entramos en la ortodoncia rápida. Muchos se incluyen en esta modalidad para entrar en competencia. Para otros clínicos hay otras razones del porque tratamientos mas rápidos. La primera pregunta es si tratamos rápido y la respuesta es si sin duda alguna. Con el progreso tecnológico tenemos un mejor entendimiento del crecimiento y desarrollo y con el advenimiento de alambres de memoria de níquel titanio y mejores técnicas de manufactura nuestro control de tratamiento ha mejorado. En algunos casos el hacer menos extracciones hace que tengamos menos espacio que cerrar lo que reduce el tiempo de tratamiento. Todavía tenemos algunas áreas grises que aclarar. Una es, somos verdaderamente más conocedores del desarrollo y crecimiento y podemos controlar la residida post tratamiento. Contestar estas preguntas podrían ser difíciles. Recientemente escuche un reconocido director de un departamento de Ortodoncia haciendo el siguiente comentario: En su opinión muchos recién graduados son menos conocedores y orientados mas en la mecánica porque quieren mover dientes mas rápidos y ser mas productivos. Cuando terminan la residencia quieren pagar sus deudas y beneficiarse de alta calidad de vida lo más rápido posible. Pero tenemos que preguntarnos si la productividad debe ser nuestro primer objetivo. Se nos acercan manufactureros de diferentes técnicas y modalidades como alambres y brackets o utensilios que supuestamente son más eficientes y aceleran tratamientos como “ Acceledent, Propel, Piezocision y otros. No tengo nada en contra de acelerar y mejorar mis tratamientos y personalmente le doy consideración a nuevos productos, pero cuando tengo la tentación de utilizarlos hago una estricta evaluación de la literatura para convencerme a mi mismo que el cambio que haga vale la pena. No tomo posiciones de ninguno de ellos pero les exhorto que evalúen la literatura y hagan sus decisiones basados en la seriedad del estudio y su efectividad clínica. Después de este análisis mis conclusiones son que que tomamos menos tiempo en tratar por las razones anteriormente expuestas pero que el terminar rápido no necesariamente significa mejor calidad. El bienestar, la salud y la función del paciente y en adición la estética debemos tenerlos como prioridad y nuestro mayor reto es motivar y convencer al paciente a colaborar con el tratamiento que necesita y no necesariamente el que el desee aunque sabemos que no siempre podrá ser nesesariamente a nuestra manera.

Portuguese VersionEsta quase pronto? Translation by Dr. Cristiane Albuquerque, Australia Desde que me formei na faculdade de odontologia, há algum tempo atrás, os procedimentos ortodônticos melhoram muito. A forma como os pacientes e os médicos olham para qualquer tratamento ortodôntico é muito diferente. Estamos em uma era onde o tempo nunca foi tão crucial. As pessoas não têm tempo suficiente em sua vida para fazer todas as coisas que eles querem fazer. Isso deve provavelmente por isso que muitos ortodontistas tem anunciado que eles têm uma técnicas para o tratamento mais rápido do que nunca. Todos nós vemos o futuro da ortodontia sendo orientado para um tratamento mais rápido e melhor. Algumas perguntas vêm à mente neste filme futurista de melhor e mais rápido (você não acha que isso soa como um título de filme). Uma dessas questões é: estamos realmente mais rápido e outra é: por que nós queremos ser tão rápido? É provavelmente mais fácil de responder a segunda pergunta primeiro: Por quê? Os pacientes exigem um tempo de tratamento mais curto; dentistas, vocês tiveram aparelho em suas bocas quando eram adultos? Não vamos nem falar sobre os adolescentes que para a grande maioria querem que o tratamento seja concluído até o terceiro mês. Quanto a mim eu tive aparelho quando eu ear um adulto ja e entao deixe-me dizer-lhe que o tempo é da maior importância. Para o paciente mais curto é melhor. Para os jovens adultos ativos com uma carreira que pode forçá-los a ser casos muito móveis ou multidisciplinares que precisam de preparo ortodôntico mantendo o tempo de tratamento para um mínimo nunca foi tão importante. Não é tão ruim, já que tecidos periodontais não gostam tratamento longo. Para o clínico ortodôntico, a média de tratamento mais curto promove referências e vai aumentar a produtividade, sendo capaz de tratar mais pacientes com a mesma quantidade de tempo de cadeira. Outros fatores motivacionais pode ser a influência da publicidade e as publicações dos fabricantes, ou seja, suas estratégias de marketing para fazer-nos sentir como retardados ou doentes mentais, se não entrar nessa abordagem rápida. Alguns querem tratar mais rápido depois de olhar para a sua concorrência e acho que se eles não reduzirem o tempo de tratamento não estão no jogo para o ponto onde eles podem pensar que eles estão desatualizados ou fazendo algo errado. Para outros clínicos, pode haver muitas mais razões por que eles queiram tratar mais rápido. A segunda pergunta é: estamos tratando mais rápido e a resposta é sim, sem dúvida. Com o progresso da ciência e da tecnologia, como melhor compreensão do crescimento e desenvolvimento, melhores fios de memória, melhores processos de fabricação de controle que podemos ter melhorou. Também desde que o percentual de casos de extração é menor, temos menos espaço para fechar com a consequência de reduzir a duração do tratamento. Nós ainda temos algumas áreas cinzentas e um é ‘’estamos mais bem informados no crescimento e desenvolvimento e podemos controlar recaída tratamento? Responder a estas perguntas pode ser difícil e recentemente, ouvi uma renomada ortodontista fazendo o seguinte comentário: na sua opinião, muitos recém-formados hoje são menos experientes e mais orientados mecanicamente porque querem mover os dentes rapidamente para ser produtivo. Quando eles saem da escola, eles querem ser

8 IJO � VOL. 25 � NO. 3 � FALL 2014

capaz de pagar suas dívidas e beneficiar de um elevado padrão de vida o mais rápido possível. Devemos nos perguntar se a produtividade deve ser o nosso principal objectivo. Podemos ficar encantado com os fabricantes de aparelhos diferentes, como suportes e fios ou estimulação auxiliando aparelhos e técnicas que são supostamente para aumentar a eficiência do tratamento como Acceledent, Propel, Piezocision e outros. Não tenho nada contra melhorar meus resultados do tratamento, eu pessoalmente estou encantado e intrigado com todas essas coisas novas, mas toda vez que tenho a tentação de usar qualquer novo produto ou técnica que passar por uma avaliação muito rigorosa da literatura independente para me convencer de que o mudança valha a pena. Eu não vou tomar posição sobre qualquer um deles, mas exorto-vos a olhar para a literatura e fazer sua própria decisão na seriedade da literatura e sobre a eficácia clínica de qualquer novo produto. Depois de todas estas palavras minhas conclusões são que levam menos tempo para tratar de todas as razões acima, mas nem sempre o faz mais rápido igual a melhor. Saúde, bem estar, a função do paciente e também atratividade deve ser colocado acima de tudo e nosso maior desafio é convencer e motivar o paciente a colaborar com o tratamento que ele ou ela precisa e não ao tratamento que ele ou ela quer mesmo que todos nós sabemos que não podemos ter sempre o nosso caminho.

German VersionSind wir bald fertig?Translation by Dr. Barbara Bimler-Rhodes, Germany Seitdem ich die Universität verlassen habe, vor ziemlich langer Zeit, haben sich die orthodontischen Verfahren wesentlich verbessert. Patienten und Zahnärzte betrachten Behandlungen mit ganz anderen Augen. In keiner anderen Epoche war Zeit so wichtig. Die Leute haben nicht genug Zeit, um all die Dinge zu tun, die sie tun möchten. Wahrscheinlich deshalb weisen viele orthodontische Zahnärzte darauf hin, dass sie über eine Technik verfügen, die schneller als je zuvor eine Behandlung durchzieht. Wir sehen alle, dass sich die Zukunft der Orthodontie schnelleren und besseren Behandlungsmethoden hinwendet. Angesichts dieses futuristischen Kinos (klingt das für Sie nicht auch wie ein Filmtitel?) von „Schneller und Besser“ gehen mir einige Fragen durch den Kopf. Eine dieser Fragen lautet: „Sind wir wirklich schneller?“, und eine andere: „Warum wollen wir so schnell sein?“.

Einfacher lässt sich vermutlich erst die zweite Frage nach dem Warum beantworten. Die Patienten verlangen eine kürzere Behandlungszeit; „Herr Doktor, hatten Sie als Erwachsener eine Zahnspange?“ Die Teenager wollen wir gar nicht erwähnen, die in großer Mehrheit das Behandlungsende nach drei Monaten herbeiwünschen. Was mich angeht, hatte ich als Erwachsener eine Zahnbehandlung und kann Ihnen versichern, Zeit spielt eine große Rolle. Für die Patienten – je kürzer desto besser. Für die jungen aktiven Erwachsenen mit einer Berufslaufbahn, die sie ständig auf Achse hält, oder für die interdisziplinären Fälle, die orthodontische Vorbereitungen brauchen, war die kürzest-mögliche Behandlungszeit niemals so wichtig wie heute. Das ist nicht so schlecht, zumal dem Periodentalgewebe lange Behandlungszeiten auch nicht gut bekommen. Für den Zahnarzt bedeutet eine kürzere

Behandlungszeit mehr Empfehlungen und Überweisungen und ist produktivitätssteigernd, denn man kann in der gleichen Zeit mehr Patienten behandeln. Der Einfluss der Werbung und Veröffentlichungen der Hersteller mag auch eine Rolle spielen; ihre Marketingstrategien geben uns das Gefühl, Idioten zu sein, wenn wir nicht auch auf den „schnellen Zug“ aufspringen. Manche wollen schneller behandeln, nachdem sie die Kollegen gesehen haben und glauben, ohne Reduktion der Behandlungszeit wären sie nicht konkurrenzfähig oder gar altmodisch oder einfach unfähig. Für andere Kieferorthopäden kann es sogar noch mehr Gründe für eine schnelle Behandlung geben. Die zweite Frage ist: Behandeln wir tatsächlich schneller? Und die Antwort ist ja, ohne jeden Zweifel. Mit dem Fortschritt von Wissenschaft und Technologie sowie dem besseren Verständnis von Wachstum und Entwicklung, mit besserem memory wire und besseren Herstellungsprozessen üben wir eine bessere Kontrolle aus. Ebenso sinkt der Anteil der Extraktionsfälle, und mit weniger zu schließenden Lücken brauchen wir weniger Behandlungszeit.

Allerdings gibt es da noch eine Grauzonen, zum Beispiel: Wissen wir wirklich mehr über Wachstum und Entwicklung und können wir den Rückfall kontrollieren? Dies ist nicht leicht zu beantworten, und kürzlich hörte ich folgenden Kommentar des prominenten Chefarztes einer KFO-Abteilung: Seiner Meinung nach hätten die heutigen Graduierten einen geringeren Wissensstand und seien mehr technisch orientiert, weil sie wegen der größeren Produktivität die Zähne schneller bewegen wollten. Wenn sie die Hochschulen verlassen, wollen sie ihre Schulden zurückzahlen können und so schnell wie möglich einen hohen Lebensstandard erreichen. Wir müssen uns fragen, ob eine hohe Patientenzahl unser erstes Ziel sein soll. Wir lassen uns vielleicht von den Herstellern der verschiedenen Apparaturen wie Brackets und Drähten oder Stimulations-Apparaten und –techniken bezaubern, wie Acceledent, Propel, Piezocision und manchen anderen. Ich habe persönlich nichts gegen eine Verbesserung meiner Behandlungsergebnisse, ich bin persönlich fasziniert und begeistert von all den Neuigkeiten, aber jedesmal, wenn ich in die Versuchung komme, irgend ein neues Produkt oder eine neue Methode auszuprobieren, sehe ich mir die unabhängige Literatur sehr genau an, um sicherzugehen, dass ein Wechsel sich lohnt. Ich will zu keinem Produkt Stellung beziehen, aber ich möchte Sie bitten, sich die Literatur anzusehen und danach erst eine persönliche Entscheidung über die Seriosität der Veröffentlichung und die klinische Effizienz eines neuen Produktes zu treffen.

Nach all dem komme ich zu dem Schluss, dass wir aus den erwähnten Gründen zwar weniger Zeit zur Behandlung brauchen, aber dass schneller nicht immer besser bedeutet. Die Gesundheit der Patienten, ihr Wohlbefinden, die Funktion und auch das Aussehen sollten über allem anderen stehen, und unsere größte Herausforderung besteht darin, die Patienten zu überzeugen und zu motivieren, bei DER Behandlung mitzuarbeiten, die sie BRAUCHEN und nicht der, die sie WÜNSCHEN, denn wie wir wissen, können wir nicht immer das bekommen, was wir wollen.

9IJO � VOL. 25 � NO. 3 � FALL 2014

for the IAO Annual Meeting

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Arabic VersionTranslation by Manhal Yazji, DDS, IBO

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10 IJO � VOL. 25 � NO. 3 � FALL 2014

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11IJO � VOL. 25 � NO. 3 � FALL 2014

FEATURE

Abstract: Dental traumas affect primarily the upper central incisors. The risk is particularly high in cases with protrusive maxillary teeth. Often the trauma will happen in a young patient when the root is not completely formed. With all the complications that can occur on a short term and also on a long-term, it is legitimate to ask the question of feasibility of orthodontic treatment following a dental trauma. In this article, presenting a clinical case, we will demonstrate that not only is it possible but also that there is a need for orthodontics to minimize the risk of another dental trauma at a later time. Keywords: Dental Trauma and Orthodontics.

ost-trauma ComplicationsThe trauma can include the teeth and or the periodontium. The pulp can be involved in different ways: reversible or irreversible pulpitis,

canal calcification and obliteration, internal or external resorption, necrosis… If the root is immature when the trauma happens, pulp vitality can stop root formation with an increased risk of root fracture. Some modifications in the periodontal ligament may increase the risk of ankylosis. This ankylosis is a limiting factor to orthodontics. The movement of a tooth with no desmodontium is impossible histologically; any tentative movement of such a tooth will provoke parasite effects on adjacent teeth (Figure 1).

Steps for a Secure Movement Before doing the orthodontic treatment we have to be aware of the dental and periodontal health of the teeth involved in the trauma. The emergency care on these teeth is normally done when we start the orthodontic treatment. It may have involved endodontic treatment with our without stabilization or even restorative treatment to reconstruct a partially or totally broken crown. The orthodontic treatment can follow if the teeth are not ankylosed; the clinical (percussion test, infraclusion) and radiologic (loss of periodontal ligament) evaluations will allow us to do the right diagnosis. We must use light forces in particular if we are thinking of root movement like ingression or torque. A dental trauma increases the risk of a post orthodontic radicular resorption.2,3 We have to keep in mind the possible complications that can occur, mainly pulpal complications that may awaken many years after the trauma. Sometimes the orthodontic movement can act as a trigger to this pulpal degradation.2,4,5 For this reason we must keep following the condition of the traumatized teeth and be aware that dental necrosis may occur before, during or after orthodontic treatment. In some cases the trauma may happen during orthodontic treatment. In that case, the clinician will have to facilitate the emergency treatment if he is not doing the treatment himself. The clinician will have to take off the wire and sometimes some

Can We Move Traumatized Teeth?

By Arnaud Costi

brackets. After the reduction of the luxation or re-implantation of an avulsed tooth it is recommended that a flexible stabilization be implemented to help periodontal healing.1,6 A flexible sectional orthodontic wire should be used to stabilize the teeth during healing. That wire must be 100% passive i.e. no force should be applied to the tooth or teeth. Orthodontic dental movement cannot be continued in the concerned arch and we will have to wait normally for 1 to 3 months before going back to our orthodontic movement. The healing time is correlated to the type and the severity of the trauma.

Figure 1: Ankylosis of first right bicuspid: radiograph shows fusion between the bone and the radicular dentin (a); orthodontic traction has been attempted but instead of getting eruption of the first bicuspid we can see parasite movement of the adjacent teeth, the inversion of the Curve of Spee shows that resistance (b).

12 IJO � VOL. 25 � NO. 3 � FALL 2014

Clinical Case We will illustrate our thoughts with Arthur’s case. He experienced a trauma involving his two permanent upper central incisors at the age of 8 ½. The accident involved pulp exposition on the two upper central incisors and the emergency treatment was not performed in good conditions on the day of the accident. The two central incisors became necrotic at the time where the root apexes were immature.

Endodontic Treatment Doing endodontic treatment on teeth with an immature apex poses a real problem because there is no apical constriction. The clinician has the choice between 3 techniques. The oldest technique utilizes calcium hydroxide Ca (OH) as an intra-canal medication to stimulate apexification. This technique has a high success rate, around 95% (77 to 98% depending on the study7) but the technique as some drawbacks beginning with the time it takes to obtain some results (from 6 to 18 months) and with the numbers of visits involved. Also it is now known that prolonged use of calcium hydroxide lowers the resistance of the dentin to fracture and can compromise the life of the tooth at medium and long-term.8 Another technique consists in plugging the apex with MTA (Mineral Trioxide Aggregate). This technique allows the clinician to close the canal with gutta-percha in the same visit and has a high success rate, as shown in the first clinical studies available.9,10 The only drawback is the possibility of root fracture due to the tenderness of the dental walls. It is also still possible to stimulate apexification with a technique called revascularization. The idea is tempting since the clinician is trying to regenerate the pulp from periapical souche cells. Compared to other apexification techniques, this

last one allows the obtention of a real root growth in width an in length.11 We now have a few cases published in the literature and they are convincing, but the protocol of this technique has not reach a consensus yet.12

In regards to our patient Arthur, MTA was used by the treating clinician for the reasons we have stated above. At a second visit the root canal finished with warm gutta-percha after verification that the MTA had hardened. Composite restorations were done to assure a good coronal seal (Figure 2).

Orthodontic Treatment The orthodontic treatment started two years after the accident, the patient was then 10 ½ years old. He had a large overjet and a class to Division I malocclusion with a retrusive mandible. The labial tipping of the upper incisors had those teeth in a position prone to a second trauma with the possibility of a root fracture which could have meant the loss of the two central incisors (Figure 3). The use of light forces allowed us to correct the malocclusion in a timely fashion (under 20 months), without doing any harm to the roots of the traumatize central incisors (Figure 4).

Figure 2: Both upper central incisors were necrotic following a trauma: pre-op periapical x-rays (a), master cone of gutta-percha in the root (b), apical MTA seal on left central incisor (c), gutta-percha seal and temporary seal of the cavity (d),; apical MTA seal on right central incisor (e), gutta-percha seal and temporary seal of the cavity (f). (Curtesy of Dr. Caron)

Figure 3: Case for full orthodontic treatment: initial photograph in the vestibular view (a), left lateral view (b) and maxillary occlusal view (c).

Figure 3: During orthodontic treatment photographs (d, e, f): after removal of brackets and bonding of the retention wire (g, h, i).

Figure 4: X-ray follow-up of the maxillary incisors: periapical x-rays before treatment (a), during orthodontic treatment (b), after the bracket removal and bonding of the retention wire (c).

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13IJO � VOL. 25 � NO. 3 � FALL 2014

In conclusion, traumatized teeth can be treated orthodontically if they are not ankylosed. We have to be sure that the emergency treatment on the roots has been successful, that a clinical and periodical re-evaluation is done during the orthodontic movement and most of all that the forces used are very light.

References1. DiAngelis AJ, Andreasen JO, Ebeleseder KA, Kenny DJ, Trope M,

Sigurdsson A, Andersson L, Bourgignon C, Flores MT, Hicks ML, Lenzi AR, MalmgrenB, Moule AJ, Pohl Y, Tsukiboshi M. International association of dental traumatology guidelines for management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Dent Traumatol 2012; 28: 2-12.

2. Brin I, Ben-Bassat Y, Heling I, Engelberg A. The influence of orthodontic treatment on previously traumatized permanent incisors. Eur J Orthod 1991; 13: 372-377.

3. Mavragani M, Vergari A, Selliseth NJ, Boe OE, Wisth PJ. A radiographic comparison of apical root resorption after orthodontic treatment with a standard edgewise and a straight-wire edgewise technique. Eur J Orthod 2000; 22: 665-674.

4. Bauss O, Röhling J, Sadat-Khonsari R, Kiliardis S. Influence of orthodontic intrusion on pulpal vitality of previously traumatized maxillary permanent incisors. Am J Orthod Dentofacial Orthop 2008; 134: 12-17.

5. Bauss O, Schäfer W, Sadat-Khonsari R, Knösel M. Influence of orthodontic extrusion on pupal vitality of traumatized maxillary incisors. J Endod 2010; 36 (2): 203-207.

6. Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, DiAngelis AJ, Kenny DJ, Sigurdsson A, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Tsukiboshi M. International association of

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dental traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2012; 28: 88-96.

7. Bakland LK, Andreasen JO. Will mineral trioxide aggregate replace calcium hydroxide in treating pulpal and periodontal healing complications subsequent to dental trauma? A review. Dent Traumatol 2012; 28: 25-32.

8. Andreasen JO, Farik B, Munksgaard EC. Long-term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dent Traumatol 2002; 18: 134-137.

9. Simon S, Rillard F, Berdal A, Machtou P. The use of mineral trioxide aggregate in one-visit apexification treatment: a prospective study. Int JEndod 2007; 40: 186-197.

10. Witherspoon DE, Small JC, Regan JD, Nunn M. Retrospective analysis of open apex teeth obturated with mineral trioxide aggregate. J Endod 2008; 34: 1171-1176.

11. Jeeruphan T, Jantarat J, Yanpiset K, Suwannapan L, Khewsawai P, Hargreaves KM. Mahidol study 1: comparison of radiographic and survival outcomes of immature teeth treated with either regenerative endodontic or apexification methods: a retrospective study. J Endod 2012; 38 (10): 1330-1336.

12. Hargreaves KM, Diogenes A, Teixeira FB. Treatment options : biological basis of regenerative endodontic procedures. Pediat Dent 2013; 35 (2): 129-140.

Translated with permission from L’Information Dentaire 22 - September 25

Dr. Arnaud Costi completed his ex-intern in odontology at U. Paris 7. He is a qualified specialist in dentofacial orthopedics and Assistant professor at University hospital of Paris 7. Dr. Costi can be reached at 21 avenue Niel, Paris 75017 France.

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15IJO � VOL. 25 � NO. 3 � FALL 2014

Rondeau Seminars Amalgamated Mid-sagittal (Lateral) Cephalometric AnalysisBy Adrian J. Palencar, MUDr, MAGD, IBO, FADI, FPFA, FICD

Abstract: The author presents a comprehensive International Association for Orthodontics – Rondeau Seminars Amalgamated Mid-sagittal (Lateral) Cephalometric Analysis. Norms on the Cephalometric Data Sheet are age and gender specific for the Caucasian population and the postings are color coded for visual attraction. If the patient is of a different ethnic group, the Norms should be adjusted accordingly. This Cephalometric Analysis is comprised of ten Sections, in alphabetical order and twenty nine Factors. The author expanded Rondeau Seminars Cephalometric Analysis by only six Factors, thus fulfilling the requirement for the case presentation for the Fellow of the IAO and the Diplomate of the IBO. Keywords: Cephalometric, section, factor, maxilla, mandible, skeletal, dental, vertical, angle, hyper-divergent, hypo-divergent, normo-divergent, horizontal

ntroductionThe author had the honor and privilege to be an IBO Examiner for the past nine years and an Assistant Instructor to Rondeau Seminars for

eleven years. Even though the IAO Cephalometric Analysis is well written, the author’s quandary was that there is not a single Factor denoting the mid-sagittal position of the maxilla and mandible and only one denoting the position of maxillary incisors. Fusion of the IAO and Rondeau Seminars mid-sagittal Cephalometric Analysis will bring together the best of both worlds.

Cephalometric Landmarks (clock-wise):S - Sella Turcica: The center of the hypophyseal fossa of the sphenoid bone.N – Nasion: Most anterior point on the Fronto-nasal suture.O – Orbitale: The most inferior point on the rim of the orbit of the eyes.ANS – Anterior Nasal Spine:

The most anterior tip of the bony process of the maxilla.A – Point: The most posterior point in the concavity of the maxillary alveolar process.B – Point: The most posterior point in the concavity of the mandibular alveolar process.Pg – Pogonion: The most anterior point on the symphysis.M – Menton: The most inferior point on the symphysis.Gn – Gnathion: The midway point on the symphysis between Pogonion and Menton.Go – Gonion: The midpoint on the curvature of the angle of the mandible located by bisecting the angle formed by lines tangent to the ascending ramus and the inferior border of the corpus of the mandible.Ba – Basion: The most inferior point of the anterior rim of the foramen magnum.

FEATURE This article has been peer reviewed.

Po – Anatomical Porion: The most superior point on the radiolucent area approximately 10 mm distally of the head of the condyle. Co – Condylion: The most superior and posterior point on the head of the condyle.PTM – Pterygomaxillare: The contour of the pterygomaxillary fissure formed anteriorly by the retro-molar tuberosity of the maxilla and posteriorly by the anterior curve of the pterygoid process of the sphenoid bone.PT Point – 10:30 (face of the clock) position on the circular outline of the superior border of the pterygomaxillary fissure.PNS - Posterior Nasal Spine: The posterior spine of the palatine bone.

Analysis123456

A – GROWTHFactor 1) Cervical Vertebral Maturation Stage3: CVMS 1 – 6. Please refer to Dr. Bulmario Gonzalez’s article in the IJO – Fall, 2012.

B – AIRWAYFactor 2) Adenoids: 7 – 18 mm (McNamara). Measure the narrowest area, just distally PNS.Factor 3) Tonsils: 10 – 12 mm (McNamara). Measure the narrowest area, just distally to Go.

C – DIRECTION OF GROWTHFactor 4) Facial (Growth) Axis: 90º ± 3º (Ricketts). Draw the line from Ba to N. Measure the inferior – posterior angle, connecting Ba – Pt.-Point – Gn.The smaller the angle is, the more vertical (hyper-divergent) the case is. The larger the angle is, the more horizontal (hypo-divergent) the case is.

16 IJO � VOL. 25 � NO. 3 � FALL 2014

D – MAXILLARY SKELETALFactor 5) SNA: 82º ± 2º (Steiner)Measure the inferior – posterior angle, connecting S – N – A.This measurement denotes the position of the maxilla to the anterior cranial base in the mid-sagittal plane.

Factor 6) Nasion Vertical to A – point: 0 ± 2 mm (McNamara)This measurement denotes the position of maxilla to the anterior cranial base in the mid-sagittal plane.

Factor 7) Co – A point: maxillary length (McNamara) This measurement denotes the length of the maxilla and not the position in respect to the mid-sagittal plane. It is age and gender sensitive.

E – MANDIBULAR SKELETALFactor 8) SNB: 80º ± 2º (Steiner)Measure the posterior – inferior angle connecting S – N – B.This measurement denotes the position of the mandible to the anterior cranial base in the mid-sagittal plane.

Factor 9) Nasion Vertical to Pg: -9 to +2 mm (McNamara) This measurement denotes the position of the mandible to the anterior cranial base in the mid-sagittal plane. It is age sensitive.

Factor 10) Co – Pg: mandibular length (McNamara)This measurement denotes the length of the mandible and not the position in respect to the mid-sagittal plane. It is age and gender sensitive.

F – MAXILLARY DENTALFactor 11) Maxillary incisor to S – N: 102º ± 4º (Ricketts)Measure the posterior – inferior angle connecting S – N – long axis of the maxillary incisor. This measurement denotes the position of the most prominent maxillary incisor in the mid sagittal plane and its relation to the anterior cranial base.

Factor 12) Maxillary Incisor to A – point Vertical: 4 ± 2 mm (McNamara)Draw a line parallel with Nasion perpendicular through A – point and measure the distance from this A – point vertical to the facial surface of the most prominent maxillary incisor. This measurement denotes the position of the most prominent maxillary incisor in mid-sagittal plane and its relation to the maxilla.

G – MANDIBULAR DENTALFactor 13) Mandibular Incisor to Go – M (IMPA): 95º ± 5º (Downs)Measure the posterior – superior angle connecting Go – M – long axis of the mandibular incisor. This measurement denotes the position of the most prominent mandibular incisor in the mid sagittal plane and its relation to the mandible.

Factor 14) Mandibular Incisor to A – Pg: –1 to +3 mm (Wilson -Ricketts)Measure the distance from the A – Pg Plane to the tip of the most prominent mandibular incisor. This measurement denotes the position of the most prominent mandibular incisor in mid sagittal plane and its relation to the maxilla and mandible.

Factor 15) Inter-incisal angle: 131º (Downs)Measure the posterior inter-incisal angle created by the intersection of the long axis of the maxillary and mandibular incisors.

H – VERTICALFactor 16) SN to Go – M: 32º ± 3º (Steiner)Measure the anterior angle connecting S – N and Go – M. This measurement denotes skeletal divergence.

Factor 17) Lower Gonial Angle: 73º ± 3º (Bjork)Measure the anterior – superior angle connecting M – Go – N. This measurement denotes skeletal divergence. The larger the angle is, the more vertical (hyper-divergent) the case is. The smaller the angle is, the more horizontal (hypo-divergent) the case is.

17IJO � VOL. 25 � NO. 3 � FALL 2014

Factor 18) Lower Anterior Face Height – ANS – M: (McNamara)This measurement denotes skeletal Lover anterior face height and it is age and gender sensitive.

Factor 19) Upper Anterior Face Height: Lower Anterior Face Height Ratio, N-ANS: ANS-M:Child 50%: 50%, Adult 45%: 55%.These measurements denote the ratio between Upper and Lover anterior face heights.

I – SAGITTAL SKELETALFactor 20) ANB: 2º ± 2º (Steiner)Measure the inferior angle connecting A – N – B. This measurement denotes the position of the maxilla and mandible in mid-sagittal plane in relation to each other. Unfortunately, the position of the Nasion and the skeletal divergence influences the final interpretation.

Factor 21) Wits Appraisal, AO to BO: Female: 0 ± 2 mm, Male: -1 ± 2 (Wits)Drop a perpendicular line from the A – Point to the Occlusal plane and B – Point to the Occlusal plane. Then, measure the difference. This measurement denotes the position of maxilla and mandible in mid-sagittal plane independent of the anterior cranial base. Unfortunately, the inclination of the Occlusal plane influences the final interpretation.

Factor 22) Harvold ∆, Maxillary and Mandibular Differential: (McNamara)Subtract the length of the maxilla (Co – A) from the length of the mandible (Co – Gn). This measurement denotes the difference between the maxillary length and mandibular length and it is age sensitive.

Factor 23) Angle of Convexity, NAPg: 0º ± 2º (Downs)Connect N – A – Pg, then extend the Pg to A – Point line cranially and measure the superior anterior or superior posterior angle created by this cranial extension and N – A line. This measurement denotes the degree of convexity, norm or concavity of the skeletal profile.

Factor 24) Pg to NB: 2 – 5 mm Connect N – B and then extend this line to Menton. Measure the perpendicular distance from this line to Pogonion. This measurement denotes position of Pogonion and the prominence of the chin.

Factor 25) Upper Incisor to ANS: 30 mmMeasure the distance between the ANS and the incisal edge of the maxillary incisor. This measurement denotes the height of the maxillary alveolar process and the clinical crown of the maxillary incisor.

Factor 26) Lower Incisor to M: 40 mmMeasure the distance between Menton and the incisal edge of the mandibular incisor. This measurement denotes the height of the mandibular alveolar process and the clinical crown of the mandibular incisor.

J – SOFT TISSUEFactor 27) Naso-labial angle: 102º ± 8º Measure the anterior inferior angle of a columella tangent and maxillary lip tangent. This measurement denotes prominence of the pre-maxilla and the procumbency of the maxillary lip.

Factor 28) Maxillary and Mandibular Lip to “S” Line: Concave, Normal, Convex (Steiner)Draw the line from the middle of the columella to the soft tissue Pogonion and measure the distance from the maxillary and mandibular lip to this “S” Line. This measurement denotes the procumbency of the lips relative to the chin and the nose.

Factor 29) Lip Seal: YES or NO

18 IJO � VOL. 25 � NO. 3 � FALL 2014

IAO – Rondeau Seminars Mid-sagittal Cephalometric Data Sheet

SECTION NORM PRE-TX Description POST-TXA – GROWTH DATE: 1) Stage of growth CVMS 1 – 6B – AIRWAY 2) Adenoids 7 -18 mm 3) Tonsils 10 – 12 mmC – DIRECTION OF GROWTH 4) Facial (Growth) Axis 90º ± 3ºD – MAXILLARY SKELETAL 5) SNA 82º ± 2º 6) Nasion vertical to A point 0 ± 2 mm 7) Co – A Age: 6 – 9 – 12 – 14 – 16 - 18 Female: 80 85 90 92 93 93 mm Male: 82 87 92 96 100 100 mmE – MANDIBULAR SKELETAL 8) SNB 80º ± 2 9) Nasion vertical to Pg (Age) -9 to +2 10) Co – Pg Age: 6 – 9 – 12 – 14 – 16 – 18 Female: 97 105 113 117 119 120 mm Male: 99 107 114 121 127 130 mmF – MAXILLARY DENTAL 11) Maxillary incisor to SN 102º ± 4º 12) Max. incisor to A point vertical 4 ± 2 mmG – MANDIBULAR DENTAL 13) Mand. Incisor to Go – M 95º ± 5º 14) Mand. Incisor to A – Pg -1 to + 3 mm 15) Inter-incisal angle 131ºH – VERTICAL 16) SN – GoM 32º ± 3º 17) N – Go – M (Lower gonial angle) 73º ± 3º 18) Lower anterior face height Age: 6 – 9 – 12 – 14 – 16 – 18 58 61 63 65 68 72 mm 19) UAFH : LAFH Child: 50%: 50%, Adult 45%: 55%I – SAGITTAL SKELETAL 20) ANB 2º ± 2º 21) Wits Female: 0 ± 2 mm Male: -1 ± 2 mm 22) Harvold Δ (MX – MN Differential) Age: 6 – 9 – 12 – 14 – 16 – 18 17 20 23 25 27 30 23) NAPg 2º 24) Pg to NB 2 – 5 mm 25) Maxillary incisor to ANS 30 mm 26) Mandibular incisor to Me 40 mmJ – SOFT TISSUE 27) Naso-labial angle 102º ± 8º 28) Max. and Mand. Lips to “S” line, Concave, Normal, Convex 29) Lip seal YES or NO

19IJO � VOL. 25 � NO. 3 � FALL 2014

Lateral Cephalometric Data Sheet

SECTION NORM PRE-TX Description POST-TXA – GROWTH DATE: 1) Stage of growth CVMS 1 – 6 CVMS – 3 CVMS - 5B – AIRWAY 2) Adenoids 7 -18 mm 10 mm 20 mm 3) Tonsils 10 – 12 mm 15 mm 12 mmC – DIRECTION OF GROWTH 4) Facial (Growth) Axis 90º ± 3º 93º 90 mmD – MAXILLARY SKELETAL 5) SNA 82º ± 2º 79º Retrognathic 79º 6) Nasion vertical to A point 0 ± 2 mm -3 mm Retrognathic -3mm 7) Co – A Age: 6 – 9 – 12 – 14 – 16 - 18 Female: 80 85 90 92 93 93 mm 92 mm 96 mm Male: 82 87 92 96 100 100 mmE – MANDIBULAR SKELETAL 8) SNB 80º ± 2 77º Retrognathic 77º 9) Nasion vertical to Pg (Age) -9 to +2 -7 mm Retrognathic -6 mm 10) Co – Pg Age: 6 – 9 – 12 – 14 – 16 – 18 Female: 97 105 113 117 119 120 mm 114 mm 122 mm Male: 99 107 114 121 127 130 mmF – MAXILLARY DENTAL 11) Maxillary incisor to SN 102º ± 4º 96º Retrusive 103º 12) Max. incisor to A point vertical 4 ± 2 mm 1 mm Retrusive 3 mmG – MANDIBULAR DENTAL 13) Mand. Incisor to Go – M 95º ± 5º 90º 88 mm 14) Mand. Incisor to A – Pg -1 to + 3 mm -3 Retrusive -1 mm 15) Inter-incisal angle 131º 140º Obtuse 136ºH – VERTICAL 16) SN – GoM 32º ± 3º 32º 34º 17) N – Go – M (Lower gonial angle) 73º ± 3º 69º Hypo-divergent 71º 18) Lower anterior face height Age: 6 – 9 – 12 – 14 – 16 – 18 61 mm Hypo-divergent 69 mm 58 61 63 65 68 72 mm 19) UAFH: LAFH Child: 50%: 50%, Adult 45%: 55% 47% - 53% 44% - 56%I – SAGITTAL SKELETAL 20) ANB 2º ± 2º 2º 2º 21) Wits Female: 0 ± 2 mm 2 mm 2 mm Male: -1 ± 2 mm 22) Harvold Δ (MX – MN Differential) Age: 6 – 9 – 12 – 14 – 16 – 18 22 mm 26 mm 17 20 23 25 27 30 23) NAPg 2º 5º Convex 2º 24) Pg to NB 2 – 5 mm 2 mm 3 mm 25) Maxillary incisor to ANS 30 mm 27 mm Short 29 mm 26) Mandibular incisor to Me 40 mm 38 mm Short 41 mmJ – SOFT TISSUE 27) Naso-labial angle 102º ± 8º 109º 123º 28) Max. and Mand. Lips to “S” line, Concave, Normal, Convex Concave Concave 29) Lip seal YES or NO YES YES

20 IJO � VOL. 25 � NO. 3 � FALL 2014

Dr. Adrian J. Palencar graduated from Komensky University with the degree of Doctor of Universal Medicine, specialty Stomatology in

Bratislava, Slovakia. He recertified at the UWO – Ontario, Canada in 1970. Dr. Palencar is Master of the AGD, Diplomate of the IBO, Fellow of the Academy of Dentistry International, Fellow of the Pierre Fouchard Academy and Fellow of the International College of Dentists. Dr. Palencar received his IAO Pinsker Award in 2003. He is also an Examiner for the IBO, Master Senior Instructor of the IAO, and an Assistant Instructor to Dr. Rondeau for the past 11 years.

Discussion Mid–sagittal Cephalometric radiogram and analysis is a basic requirement for complete orthodontic treatment. This analysis is a compilation of: Downs’, Steiner, Ricketts. Wilson, McNamara, Wits Appraisal and Bjork analysis. A lateral photograph of the face gives us only a perception of the skeletal malocclusion. However, in order to qualify and quantify the case pre and post-treatment, a mid-sagittal Cephalometric analysis is paramount. There should be exercised caution in the interpretation of values of Factor 5) SNA, Factor 8) SNB, Factor 11) Maxillary incisor to SN and Factor 20) ANB, if:

1. The angle between S - N and Po – O (Frankfurt horizontal plane) is considerably more or less than 7º,

2. The Nasion and Sella are positioned too far anteriorly or posteriorly, and3. The case is excessively hyper-divergent or hypo-divergent.

For these reasons the author does not prefer Y – Axis to SN or Y – Axis to Frankfurt horizontal plane (Section C – DIRECTION OF GROWTH). The position of Nasion and Sella are unpredictable and the landmarks Porion and Orbitale are frequently indiscernible, on the mid-sagittal Cephalometric radiogram. Therefore, the author favors Factor 4) Facial (Growth) Axis (Ricketts), because Basion, Pt - Point, Nasion and Gnathion are all in all more discernible and stable. There should be also exercised caution in Factor 14) Mandibular incisor to A – Pg (Wilson Dental plane). The value -1 to +3 mm is a Norm only in Class I skeletal, normo-divergent cases. If the case is severe Class III skeletal malocclusion, the value may be -5 mm with the Factor 13) Mandibular Incisor to Go – M 95º. Corollary, if the case is severe Class II skeletal malocclusion, the value may be +7 mm with the Mandibular Incisor to Go – M 95º. Thus, it is prudent to draw with a dotted line the symphysis of the mandible (or the A – Point in the case of mid-face deficiency) into the ideal position and only then analyze Factor 14) Mandibular incisor to A - Pg. When there is a skeletal/facial and dento-alveolar asymmetry, a frontal photograph with a tongue depressor between the posterior teeth and an A – P (Frontal) Cephalometric radiogram is recommended.

ExamplesSNA 82º ± 2º NO NOTATION SNB 80º ± 2º NO NOTATIONSNA 85º - 87º PROGNATHIC SNB 77º - 75º RETROGNATHICSNA 88º - 90º PROGNATHIC SNB 74º - 72º RETROGNATHICSNA 91º > PROGNATHIC+ SNB 71º < RETROGNATHIC+

IMPA 95º ± 5º NO NOTATION SN – GoM 32º ± 3º NO NOTATIONIMPA 101º - 106º PROTRUSIVE SN – GoM 36º - 39º HYPER-DIVERGENTIMPA 107º - 112º PROTRUSIVE SN – GoM 40º - 43º HYPER-DIVERGENTIMPA 113º > PROTRUSIVE+ SN – GoM 44º > HYPER-DIVERGENT+

ANB 2º ± 2º CLASS I NASIO-LABIAL ANGLE 102º ± 8º NO NOTATIONANB -1 to -3 CLASS III NASIO-LABIAL ANGLE 111º - 119º OBTUSEANB -4 to -6 CLASS III NASIO-LABIAL ANGLE 120º - 128º OBTUSEANB -7 < CLASS III+ NASIO-LABIAL ANGLE 84º - 76º ACUTE

Cephalometric Data SheetInterpretation

The author proposes color coding the interpretation of the measurements and values. If the value is within the norm, there is no notation. If the value is one standard deviation from the Norm, there is a GREEN notation. If the value is two standard deviations from the Norm, there is a RED notation. If the value is more than two standard deviations from the Norm, there is a RED+ notation. There is no need to change the color of the typed words. The clinician may use only a highlighter - GREEN and RED.

Conclusion The author presented and dissected the amalgamated IAO - Rondeau Seminars Mid-sagittal Cephalometric Analysis. Over 20,000 dentists attended Rondeau Seminars over the past 33 years and for them, embracing this analysis would be a first step toward Fellow of the IAO and Diplomate of the IBO. The candidates have to learn only two extra landmarks (Ba and PT – Point) and six factors to complete the most challenging part - the Cephalometric Data Sheet. If only 5% of the Rondeau Seminars graduates would step forward and become candidates, we could have possibly 1000 additional Fellows and Diplomates. N.B. IAO – Rondeau Seminars Cephalometric Data Sheet may be downloaded from the IAO website: www.iaortho.org or Rondeau Seminars website: www.rondeauseminars.com.

References1. International Association for Orthodontics,

Successfully Achieving your Diplomate Status, CD, Version 2.0.

2. Rondeau Seminars. Introduction to Orthodontics, Level I, Session 1, pages: 60-121.

3. Gonzalez B, The cervical Vertebrae Maturation Stage Method, IJO, Fall 2012, Volume 23, Number 3, pages: 63-66.

4. Jacobson A, Radiographic Cephalometry, Quintessence Books, pages: 65-126.

5. English D, Mosby’s Orthodontic Review (2009), pages: 36-39.

6. Nanda R, Biomechanics and Esthetic Strategies in Clinical Orthodontics (2005), Elsevier – Saunders, pages: 63-69.

21IJO � VOL. 25 � NO. 3 � FALL 2014

Abstract: The Nickel Titanium (NiTi) closed coil springs serve as an efficient force delivery system in orthodontic space closure mechanics. The closed coil springs with the eyelets come in various lengths to broaden its force characteristics for an expedient space closure. However, at a certain point of time of progressive space closure, the coil spring can be expanded no further for an adequate force delivery. In such situations, the clinician prefers to replace the existing spring with another short length spring. The present article describes a simple conservative technique for progressively re-activating the same NiTi closed coil spring for complete space closure. Keywords: Nickel Titanium (NiTi) closed coil springs.

ntroductionThe Nickel Titanium (NiTi) closing coils serve as an effective force delivery system for en masse space closure, individual tooth retraction/protraction, distal movement of teeth, and traction of impacted

teeth. NiTi coils produce a continuous force with low load deflection rate and do not exhibit rapid force decay that is evident with elastomeric and elastic chains. However, towards the end of progressive space closure, further activation of the coil spring is difficult to take up and hence it has to be replaced with another short length spring. The present article describes a modest technique for complete space closure by progressively re-activating the same NiTi closed coil spring.

Clinical Situation The original spring that was used is a 15mm NiTi closed coil spring; during the initiation of retraction of the lower anteriors it exerted a force of 5 ounces when measured with a dynamometer, which is sufficient enough for the retraction. However, the force levels were descended as the retraction was at its halfway to 4 ounces (Figure 1). Hence, an adjustment in NiTi closed coil spring was done to get the initial force level of 5 ounces (Figure 2).

Procedure:1. Take out the NiTi closed coil spring from the patient’s

mouth and clean it to make it debris free (Figure 3) and extend it with two probes at its eyelets, about twice its initial length (Figure 4).

2. Mix a small quantity of primer and light cure adhesive resin in a glass slab with less than flowable consistency and add it with an applicator to one end of the spring spread through few coils (Figure 5). Care to be taken not to add more

An Adjustment in NiTi Closed Coil Spring for an Extended Range of Activation

By S.V.M. Raghu Ram Ravipati, MDS; Arunachalam Sivakumar MDS, MORTH RCSED; P. Sudhakar, MDS; C.V. Padmapriya, MDS; Mummudi Bhaskar, MDS; Mohammad Azharuddin, MDS

FEATURE This article has been peer reviewed.

Figure 1

Figure 2

Figure 3

22 IJO � VOL. 25 � NO. 3 � FALL 2014

primer as it may weaken the bonding with the coils as they are extended.

3. Shorten the NiTi spring to its original length, which will allow the adhesive resin to flow in and out of the lumen (Figure 6) and cure it immediately (Figure 7).

4. The consolidation of NiTi closed coil spring with resin composite at one end will ensure that the coils do not extend in that particular area (Figure 8).

5. Engage and activate the spring in the patient’s mouth for further space closure. Progressive reactivation of the spring ensures that the desired force levels are achieved (Figure 2).

6. Extend the resin blending to more coils if further activation is required.

Dr. P. Sudhakar is a Professor and Head of the department. His interests include manipulation with pulsed electromagnetic fields.

Dr. C.V. Padmapriya is a Professor of Orthodontics and Associate Dean of the student affairs of the institution. She is actively engaged in department and institutional activities in every level. Her interests include role of tongue in malocclusion and cleft lip and palate anomalies.

Dr. M. Bhaskar is a Professor of Orthodontics. He is a clinician par excellence and his interests include tooth transplantation and integrated orthodontics.

Dr. Mohammad Azharuddin is a Senior Lecturer in the department of Orthodontics, MNR Dental College & Hospital, Telangana, India. His topics of interests include miniscrew driven orthodontics.

Dr. S. V. M. Raghu Ram Ravipati is a Senior Lecturer in the department of Orthodontics, GSL Dental College & Hospital, Andhra Pradesh, India. He is a budding researcher and published [plus accepted] manuscripts in Medline indexed journals. His interests include TMJ dysfunction and lingual appliance therapy.

Dr. Arunachalam Sivakumar is a Professor of Orthodontics actively engaged in research and clinical activities. He has published many articles in indexed journals. His areas of interest include eruption anomalies, digital technology and principles of tooth movement.

IAO MEMBERS CAN ACCESS PAST ISSUES OF THE

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IN THE “MEMBERS ONLY” SECTION OF THE IAO WEBSITE

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Figure 7

Figure 5

Figure 4

Figure 6

Figure 8

23IJO � VOL. 25 � NO. 3 � FALL 2014

The Loudon Chateau Repositioning ApplianceBy Merle Loudon, DDS

Abstract: The LCR Appliance if fabricated and used properly, has many advantages over the Herbst and Twin Block appliances in solving tongue thrust, mandibular deficiency and repositioning with proper mandibular advancement and mandibular growth results. The regular Chateau appliance was named in 1904 after Dr. Chateau in Franc. It was originally used in Europe but was an uncomfortable removable appliance with wires used in the mandibular anterior lingual area to reposition the mandible. Keywords: Fixed anterior repositioning growth appliance; wear 24/7 for 10-12 months; triangular elastics at night; corrects vertical, AP to class I, tongue thrust, and esthetics.

ntroductionThe author, since reviewing and studying the Petit results with the Tavena appliance and John Mew’s results using his Stage 4 mandibular repositioning

appliance has revised the fabrication of the Chateau appliance to include an acrylic addition to the older Chateau wires. He also modified the ramp and the appliance, a fixed appliance that is worn 24/7 for 10-12 months. The resultant repositioning device has many advantages over most other mandibular repositioning appliances (Figure 1). It does a remarkable job of not only correcting mandibular deficiencies, but it also can be used to correct tongue thrust problems (most Class II, div. 1 cases), as well as help correct the vertical deficiencies as observed in both Class II, div. 1 and Class II, div. 2 cases. One distinct advantage over the Twin Block is that one can proceed with 2x4 utility arches and/or the full bracketing and banding at the same time the patient is wearing the LCR mandibular advancement appliance. Five essential facts need to be addressed before one can achieve a high degree of success: 1. The mandibular repositioning LCR Appliance can become more predictable and achieve greater success when the patient is fixed in a forward position for 24 hours a day. The

FEATURE This article has been peer reviewed.

mandible should not be able to return to the restrictive zone at any time. This was proven by Henri Petit in his studies at Baylor University. Even for the patient to return to the old position for just minutes a day could slow, retard or cancel any forward mandibular growth for that period of time (Figure 2). This fixed forward mandibular repositioning appliance should be worn 24 hours per day for at least 9 to 12 months to achieve great success in repositioning the mandible, obtaining posterior condylar changes, plus bone remolding and apposition to the posterior portion of the Glenoid fossa. 2. The patient needs to be able to close fully to touch the lingual area of the maxillary anterior teeth in Class I centric occlusion as well as not to retrude in back of the appliance at any time during the 9 to 12 month period. They also should be able to have freedom for lateral movements observed in the LCR Appliance. 3. Triangular, or up and down elastics, must be worn at night to hold the maxilla and mandible closed. This is to ensure nasal breathing and to prevent open mouth breathing which will result in downward growth and not horizontal growth. The Loudon Chateau Repositioning (LCR) Appliance has other advantages as well. It is a 24-hour fixed appliance and should be constructed on a flexible articulator to insure that the

Figure 1 Figure 2

24 IJO � VOL. 25 � NO. 3 � FALL 2014

mandibular anterior centrals are not allowed behind the acrylic pad in the normal maxillary and mandibular relaxed position. The tip of the acrylic pad is curved and behind the pre-treatment positioned mandible. It is very comfortable with a narrow, thin, small anterior acrylic plate (Figure 3). It is strong, durable and, with the anterior thin fixed ramp, no wider than the middle of the maxillary lateral incisors, the LCR is excellent at correcting mandibular deficiency and anterior tongue thrust. 4. Careful pre-treatment analysis, diagnosis and treatment planning needs to be done to ensure that the mandible, when placed forward, will enhance the profile of the patient. The anterior alignment must be in the exact desired position to achieve the results wanted by the dentist and the patient. It also has to be precluded with proper maxillary anterior positioning, widening and correcting maxillary anterior arch form. That segment of maxillary treatment needs to be done before the LCR Appliance is placed. If the closed mandible is not in the pre-planned position, and the treatment places the mandible in a less desired place, then the final fixed position of the mandible may require much more treatment. Careful pre-treatment analysis and planning is necessary to insure an esthetic, functional and pleasing final position. One necessary part of that planning is to have the Class II patient move his/her lower mandible forward to the desired post-treatment position during the initial interview. Observe the lateral profile of the patient from the side, as well as have any parents/guardians observe the desired post-treatment position. Be sure to get the parents/guardians consent before proceeding. Also, in planning the use of the LCR Appliance, it is necessary to determine the position of the maxillary anterior segment. This can best be done with your diagnosis which includes the ceph analysis, overbite measurement, and Mew indicator or Petit measurement line. If the maxillary anterior segment needs intruding, retruding, widening or other correcting, then these functions should be performed before you begin with the mandibular arch treatment. 5. The patient absolutely has to breathe through his/her nose with the teeth together and the mouth closed. Patients wearing any anterior mandibular protraction appliance will not respond to proper direction of growht nor to the controlled amount of growth while mouth breathing. It has been reported many times that at least six different adverse problems can occur with mouth breathers. a. The patient obtains no growth. Or, mouth breathing may deter both growth and proper growth changes. b. Mouth breathing can change the direction of and location of growth. This can cause an irreversible change to the glenoid fossa and posterior and superior condylar areas, plus a steeper, higher mandibular gonial angle. c. Open anterior configuration: Mouth breathers who wear an anterior protraction appliance sometimes end up with an anterior open bite. This is coupled with a more severe increase in tongue thrust and “open bite” swallowing. The LCR Appliance, if used correctly, will prevent this. d. Posterior prematurities may result, especially on protrusive and balancing movements, if the maxillary arch is not widened to compensate for the anterior advancement.

e. If a patient does not keep the teeth together and the mouth closed at night while wearing triangular elastics, it places the dentition in a difficult configuration making progressive therapy much more difficult. Note: The author and inventor of the LCR Appliance wants to emphasize here that triangular elastics should always be worn at, night to position the teeth closed at night or while sleeping. Elastics greatly enhance the growth potential and direction as it would in similar cases with the Twin Block, Rick-a-Nator; or Keller appliances.

Age Of Patient The Loudon Chateau Repositioning (LCR) Appliance should be used before the age of 16 years to insure optimum success. Use after age 16 may be unpredictable. The success rate may drop off very dramatically, an acquired or dual bite may result, or the time for treatment may be increased substantially. While Brendan Stack has shown that remodeling of the glenoid fossa occurs with permanent condylar repositioning, he does not say that growth of the mandible can or will occur after 16 years of age. The author has viewed records of adult patients who have worn appliances similar to the LCR Appliance. In some of these adult patients after 2-3 years of proper repositioning treatment, permanent anterior repositioning and growth has occurred. However, treatment time was extended from 10 months to 24-36 months, and was not guaranteed to be stable. After adult protraction treatment, many practitioners use a retainer with an anterior guide ramp which holds the patient in the anterior position.

Preparation Of The Maxillary Arch Prior To The Loudon Chateau Repositioning (LCR) Appliance Treatment We must remember that the greatest maxillary/mandibular discrepancies are in Class II, division 1 children who have a tongue thrust. This appliance helps direct the tongue in correcting the tongue thrust swallow, and holds the tongue in place 24 hours a day to train the tongue at the same time. It should be noted that when the anterior maxillary teeth are flared, one or two pretreatment widening and retruding (2 X 4 utility arch) appliances may be used for maxillary arch preparation and development, before the Loudon Chateau Repositioning (LCR) Appliance is placed. In most instances it

Figure 3

25IJO � VOL. 25 � NO. 3 � FALL 2014

The Parts of an LCR Appliance1. The LCR soldered appliance should be stabilized

with four fixed attachments. Molar bands: The first requirement is to place bands on the primary and first permanent molars. Instead of the two anterior bands an option is to use composite to attach to the two anterior primary molars, bicuspids, or cuspids. Mark sure there are four abutements.

2. 045 fixed solder wire to molar bands.3. .030 or .032 bended wire with 2 prongs down and

back, clearing the normal pre-treatment mandibular position into the predetermined Class 1 post-treatment position. This wire is soldered to the .045 wire in the anterior and is very narrow, usually no wider than the maxillary central incisors (Figure 6). The .030 wire is usually strong enough and easier to bend for the clearance needed.

4. Incisal ramp, clear or tooth-colored acrylics, with an extension back further than the normal pre-treatment closing position of the mandible (Figures 5 and 8).

5. This anterior incisal ramp, unlike the Rick-a-Nator ramp, is longer and much thinner (3 to 4 mm thick). The purpose of the ultra thin ramp is not only for patient comfort, but to allow the tongue to obtain a Class I swallowing position, with the base touching the cingulums of the maxillary anterior teeth.

6. The ramp contact in the closed position should be on the lingual gingival area below the cingulums of the anterior teeth and not on the teeth themselves.

Figure 4

Figure 5

Figure 6

Figure 7

Figure 8

26 IJO � VOL. 25 � NO. 3 � FALL 2014

is essential to align the anterior centrals and laterals (intruding, retruding, tip, and torque) to obtain maxillary anterior arch form as well as widen prior to the Loudon Chateau Repositioning (LCR) Appliance placement. Also, it is very, very important that the patient be able to breathe through the nose. It is absolutely essential to keep the teeth together and the mouth closed at all times except while eating or speaking. Any airway problems need to be resolved before appliance wear. No nasal or airway restrictions should exist. The practitioner must instruct the patient to breathe through the nose and keep the teeth together and mouth closed, as well as wear elastics at night. As stated earlier, any appliance wear in mouth breathers may result in several adverse dental changes. More importantly, it is absolutely essential that triangular elastics be worn at night to hold the mouth closed and teeth together.

The Construction Bites For The Loudon Chateau Repositioning (LCR) Appliance Unlike the bite for the Herbst Appliacnce, Twin Block or Rick-a-Nator, all of which position the mandible forward, we need a retruded bite for the London Chateau Repositioning (LCR) Appliance. This bite needs to be in the normal retruded closed position. Remember that the models need to be mounted (retruded) on a flexible spring articulator. This is to allow for the acrylic bite plate to extend two mm distal to the closing mandibular centrals and also gives the position that the laboratory needs to build the ramp to the Class 1 position (marked with pencil by the dentist). This means that the closing mandible does come forward, but the retruded closing bite needs to be 2 mm distal to the retruded mandible closing position. The difference being that the articulator on which the appliance is made needs to have a flexible coiled posterior spring that allows the lower mandibular segment to come forward. This can be the simple coiled crown and bridge articulator that many dentists use in their offices (Figure 9). With the bites and marked models, the laboratory has the retruded position plus the extended labial position of the wire and acrylic ramp, when flexing the mounted models forward on the flexible coil articulator.

The bite is taken with the mandible in the retruded position. When mounted on the flexible hinged articulator there will be two positions, retruded and an anterior class I position. When the LCR appliance is finished the maxillary and mandibular teeth should come together perfectly into a TOUCHING CLASS I BITE. The soft tissue facial profile also needs to be determined to enhance the esthetics. The anterior position of the ramp should never be determined without studying the facial profile in the class I position. Previous cephalometric measurements, x-rays, diagnostic records, and treatment plan needs to be done in advance.

Construction of the Loudon Chateau Repositioning (LCR) Appliance The maxillary arch needs to he physically prepared for the appliance, i.e., proper position and placement of the maxillary anterior teeth, plus move any teeth which may inhibit the proper Class 1 bite placement. Then:1. If needed, place separators mesially and distally to the teeth

to be banded (3-5 days).2. Remove the separators and take alginate or other

impressions of the in maxillary and mandibular arches;3. Take the necessary bite in the retruded centric position.4. Make a double pour of both impressions using a hard

plaster.5. Fit and festoon bands (if desired), although the orthodontic

laboratory will be able to do that. Use your regularly used molar bands.

6. Send the models, the bites and the properly fitted bands (if desired) to the lab, or; the lab can fit, festoon, and seat the bands if the practitioner desires.

7. Replace separators (if desired) to maintain space for seating the appliance.

8. Remember that you will need four secure anchors for the appliance. The anterior two may be bands which are placed on primary molars or bicuspids, or composite attachments placed after the molar bands and appliance has been seated. The posterior attachments however, should be your regular 1st permanent molar bands, or 2nd primary molar bands.

Mandibular Contact If the 1 to APo measurement is less than 3mm, the lower centrals and laterals could touch and engage the guide plate. (They should touch with equal pressure) However, the closed resting position of the acrylic should be on the gingival tissue below the lingual of the lower anterior teeth. The acrylic guide plate should be designed so that contact is on the gingival below the cingulums of the lower anterior teeth. While closing, the teeth should touch the acrylic lightly and evenly. In this position, there would be no labial torquing pressure of the lower anterior centrals. In all cases when closed, the author has designed the acrylic guide plate to touch the lingual tissue with no adverse problems.

Cementing The Loudon Chateau Repositioning (LCR) Appliance When the LCR Appliance is received from the lab, it needs to be tried in and the acrylic ramp checked to see that Figure 9

27IJO � VOL. 25 � NO. 3 � FALL 2014

the lower gingival contacts the tissue in closing position where the practitioner desires. Then check to see if the acrylic ramp is lightly touching the gingival tissue below the lower anterior teeth. If you want it to touch the tissue behind the lower teeth (1 to APo is 3, 4 or more mm) you may relieve or add acrylic to get the desired touching and working position. You do not need to worry about the gingival portion of the appliance torquing the maxillary or mandibular teeth as the design should not put any excessive force on the lingual of the maxillary centrals one way or the other. The ramp can also be relieved in the maxillary gingival area, if needed, to take any and all pressure off of the teeth. The ramp is ideally thin, which helps continue correction of Class II, division 1 tongue thrusters, and captures the tongue and guides it to the proper closing and swallowing position. The appliance should be designed to absolutely not allow the mandibular anterior teeth to get behind the ramp. After trying the appliance in and checking the desired fit and ramp position, the appliance can be cemented. In all cases, the author has been able to advance the mandible the full amount of the overjet, even up to 10 mm. It has not been necessary to restrict the mandible to any given maximum amount. In several cases the mandibles were advanced 10 mm in one initial advancement and excellent results were achieved. If the practitioner desires, the mandibular advancement may be done with two steps when there is a large A-P discrepancy. Some of these options are:1. The same frame may be used with the added labial acrylic

re-contoured to fit the desired position of the mandible upon closing. The only disadvantage here is the thicker acrylic base established for the second bite position. The .045 wire may also be cut and re-soldered with an overlay wire to extend the appliance.

2. If the practitioner does not desire that bulk of acrylic, he/she could cut the .045 wire in front of the anterior bands and solder an extension to both ends of wire, placing the ramp in the desired position.

3. Or, the doctor may decide to fabricate another appliance.

Advantages of the Loudon Chateau Repositioning (LCR) Appliance1. It is a fixed 24-hour, 10-12 month appliance.2. It can be worn with Vertical Dimension—Primary Molar

Buildup crowns.3. It can be worn with fixed wire brackets, bands, and Cl II

elastics so no time is lost correcting the Class II bite, the complete orthodontic treatment can be done in 24 months.

4. It will correct tongue thrust and enhance proper swallowing position.

5. It is a very comfortable appliance.6. Stops habits associated with prominent overjet, i.e., tongue

thrust, mentalis crease, and lip under the maxillary centrals when swallowing. Most importantly, with proper exercises, it will stop the “not closing while swallowing” habit which is very detrimental if not corrected and is the hardest of all swallowing habits to correct.

7. Reduces overjet and overbite to the exact Class I bite position.

8. Improves the health of the T.M.J.

9. Appliance needs to be left on long enough to insure proper mandibular growth and remodeling of the glenoid fossa.

10. Helps to correct and insure proper vertical position.11. You can choose the exact spot where you wish the lower

teeth to end up when you finish treatment.12. Treatment time (if desired) can be enhanced with a

mandibular reverse headgear such as the Petit mandibular advancement headgear or modifications for the Grummon reverse headgear to advance the mandible, or Class II elastics. Dr. Petit obtained excellent results using the fixed Tavena appliance (same principle as the LCR Appliance ) plus the mandibular advancement reverse headgear.

13. Triangular night elastics have to be used to help insure nose breathing and correct the vertical component at the same time. These elastics may be worn 24 hours daily. However, 8-12 hour night use is usually satisfactory, unless eruption is desired.

14. Helps provide more airway and tongue space.15. The appliance maintains the vertical growth component

while allowing the maxillary dentition to remain neutral without intrusion.

Disadvantages of The Loudon Chateau Repositioning (LCR) Appliance1. There may be a slight alteration of speech initially.2. Patient needs to learn to hold mandible forward and hold

the teeth together when closed by holding their lips and teeth closed at all limes and breathing through their nose.

3. Care needs to be taken in have all lower anteriors touch and slide at the same time (when 1 to APo is 3 mm or more) or the lower anteriors could become loose. The closed appliance, however, should only touch the lingual gingival tissue. This should be checked before and during treatment.

4. It is harder to widen, torque, or unravel while wearing the appliance. Since the appliance acts as a maxillary lingual arch, proper planning and maxillary treatment should be done prior to appliance placement.

5. It may be a bit hard to eat with the appliance initially. However, the patients seem to adapt very readily, even when there is a posterior open bite in many cases.

6. Patients cannot play wind musical instruments when wearing the LCR appliance.

Note: Many of the patients who have these appliances have been previously fitted with Vertical Dimension–Primary Molar Buildup crowns (V.D.–P.M.B.) and the vertical component has been corrected. If vertical correction is needed, it is easily done with V.D.–P.M.B. crowns, triangular elastics and/or sometimes normal eruption of the lower posterior permanent bicuspids and molars while the appliance is worn. When primary molars are present, it may be more desirable to use V.D.–P.M.B. crowns first (Figure 5). Space may open up over the mandibular primary molars if the first permanent molar is erupted while the primary molars keep the original position vertically. Placing V.D.–P.M.B. crowns may be an advantage in that respect. Between these two procedures, the vertical and A.P. components can be corrected in children under 16 years of age.

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Rationale For Using The Loudon Chateau Repositioning (LCR) Appliance Many factors help the clinician decide which appliances he wishes to use in functional treatment. During diagnosis and treatment planning, the order of importance should be: 1. T.M.J. 2. Esthetics 3. Habits and etiological Problems 4. Functional treatment 5. Fixed treatment Since the LCR Appliance is used mostly in children under 16 years of age, and since repositioning depends on remodeling and growth, many temporomandibular problems are not only prevented, but proper positioning of the condyles is obtained with the added benefit of permanent mandibular advancement and subsequent fossa and condylar remodeling. Thus satisfying T.M.J. health requirements. Esthetics are also a vital objective of orthodontics and here we need to be very careful in using our skills to obtain maximum correction with the accent on developing beautiful faces. When we know that the maxilla is in the proper position while the mandible is retruded, can we judge to protrude the mandible placement with a mandibular repositioning appliance. Careful records, analysis, skill, judgement and treatment planning are needed in planning for mandibular advancement.

Figure 10

Figure 11

Figure 12

Figure 13

Figure 14

Laboratory Procedure (for orthodontic lab) 1. Mount models with the retruded bite using a flexible, open posterior

spring single articulator (lower mandibular plaster model must have enough flexibility to come ahead and reach the cingulum of the maxillary centrals).

2. Fit maxillary bands to place. Four anchors are desired.3. Bend and fit .045 wire to the lingual of the maxillary centrals and

touching the lingual of the maxillary centrals in the desired ramp position (figure 10).

4. Bend and fit anterior Chateau .030 wire, cut off and flatten portion which will fit onto .045 skeleton. Also, the area of attachment to the .045 wire should be flattened for easier welding. The two wire loops should be no more than 8 mm long.

5. Spot weld the anterior .030 wire to the .045 wire (centered) in back of the centrals. These welds will be soldered later.

6. Sticky wax as shown and solder at junction of .030 ramp wire and bands (Figure 11).

7. Finish and polish solder joints.8. Put beeswax box around anterior .030 wire.9. Puff in, cure and finish anterior acrylic guide plate (Figure 6). Note

the thin (3 to 4 mm) as well as the narrow anterior acrylic plate is usually no wider than the middle of the maxillary laterals. The posterior tip of the acrylic pad must be behind the furthermost retruded position of the mandibular centrals and laterals as the patient closed. The ramp needs to be tapered slightly as it extends occlusally (Figure 13 and 14).

10. Finish and polish the appliance.11. 3M, MIA attachments, other lingual Mershon sheaths, attachments,

etc., can be used. However, the author has found that the soldered appliances are very stable, durable and stay very firmly in place the necessary 10 months of fixed wear. The soldered .045 wire is preferable because of its strength.

12. The appliance can easily be made with the Wilson 3D-DYS 3 mm modules. However, the base wire needs to be increased (soldered) from .040 to .045, and the occlusal wire also needs to be changed (soldered) to .045.

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Conclusion In the last twenty years, there has been a renaissance of functional orthodontic treatment appliances. With the experience that many of us have had with these appliances, there is an evolution taking place with several very good systems for Class II and Class III treatment. Most clinicians are converging upon some good fixed designs and practical applications of functional appliances, which are producing better and better results, i.e., Herbst appliance and fixed functional therapy. We now have at our fingertips more than a dozen excellent appliances which help us correct in all three dimensions, creating beautiful faces and winning smiles. The Loudon Chateau Repositioning (LCR) Appliance is such an asset for A-P correction. It is a good appliance and has several advantages over other A-P appliances and Class II elastics if prescribed and worn correctly. Distinct advantages are: it corrects tongue thrust easily; it is comfortable and not bulky; it is fixed so with proper elastic wear at night it completes the permanent mandibular repositioning in 10-12 months. Most of all, you can continue the use of the fixed banded appliance technique treatment while wearing the (LCR) Appliance which will speed up treatment time considerably. The LCR is small, strong, versatile, comfortable and seems to do an excellent job of mandibular advancement as well as helping correct the vertical position of Class II cases. Careful analysis, diagnosis and planning are needed for all patients. For Class II mandibular correction, the LCR Appliance may have an edge in comfort, habit correction and prevention. I feel that to insure proper growth, the practitioner should keep this appliance in for at least 10 months, using triangular clinical elastics every night to - hold the teeth together. When proper fabrication techniques are used, it will do a successful job of permanent mandibular advancement.

Figure 15.

Dr. Loudon has been an IAO member since 1975. He is an IBO diplomate and a master senior Instructor. With Dr. Nguyen he teaches 9 and 18 day Ortho and TMD treatment courses. He was instrumental in the development of the IAO instructor program and helped organize the Instructor Institute. He has taught advanced functional and fixed orthodontic and TMD treatment courses in the U.S., Canada, and many

foreign countries. He originated and was the first dentist to use vertical dimension-primary molar buildups to correct overclosed bites and Otitus Media in children. He has written many articles on orthodontics, TMD treatment, the 12 commandments of occlusion, the Loudon Chateau anterior repositioning appliance, how malocclusions develop, finishing orthodontic cases, vertical dimension-primary molar buildups and many other subjects.

Careful maxillary arch preparation and placement is essential before using any anterior repositioning appliance. Since most Class II, division 1, and Class II, division 2 cases are deficient in three dimensions, we must plan to correct any Class II malocclusions in these same dimensions. Proper arch preparation, sequencing and appliance selection are needed to insure the greatest percentage of success. All appliances (fixed and removable) have their place and will correct deficiencies if used properly over a given time. Esthetics should be a very important consideration in all appliance treatment. Most Class II, division 1 patients have habit-related problems. Stopping those habits and correcting the “not closing while swallowing” patients is very important and should be treated before or during the early part of orthodontic treatment The Loudon Chateau Repositioning (LCR) Appliance is a very good appliance to use as a follow-up after previous “habit appliances,” myotherapy, and maxillary arch development.

Case Finishing Usually after 3-4 months of proper wear an acquired bite is obtained. The tip of the acrylic ramp may be cut off with no - acrylic showing beyond the maxillary centrals (Figure15). This makes a pleasing appearance for the rest of the treatment time.We have at our fingertips excellent orthopedic and orthotropic appliances that can treat every aspect of malocclusion, should we wish to treat patients at an early age. Witzig, Mew, Omen, Herbst, Petit, Frankel, Thompson, Clark, Lynn, Sim, Keller, Chateau, etc., have all contributed to the many fine appliances and techniques used today. We should remember, however, that many of our patients will still need some form of fixed appliance therapy. It is hard for us to complete all leveling, aligning and rotating with functional appliances, as well as refining and aligning first and second molars. One great advantage of the LCR Appliance is that 2 X 4 utility arch treatment and full bracket and band treatment can be performed at the same time that the LCR Appliance is being worn.

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Abstract: Class III malocclusions are usually growth related discrepancies, which often become more severe when growth is completed. Orthognathic surgery can be a part of the treatment plan, although a good number of cases can be treated non-surgically by camouflage treatment. The purpose of this report is to review the relapse tendency in patients treated non-surgically. A simple technique is described to combat one such post-treatment relapse condition in an adult patient who had undergone orthodontic treatment by extraction of a single lower incisor. Keywords: Class III malocclusions, non-surgical treatment, relapse, adult patient.

ntroductionThe clinical presentation of a class III malocclusion has a large spectrum ranging from edge to edge bite to a large overjet, with extreme variations of underlying

skeletal jaw bases and great diversity of craniofacial forms.1,2,3 If the malocclusion exhibits a mild skeletal component and significant tooth mass/arch length discrepancies then such cases can benefit considerably by camouflage treatment without being subjected to orthognathic surgical procedures. Camouflage treatment involving extraction of a single lower incisor can not only correct the incisor relationship but can also harmonize the arch length/tooth size discrepancies. Relapse of Class III malocclusions treated by camouflage is common in orthodontics subjected to immediate post-treatment loss of follow-up for retention. A simple technique is described here to deal with one such condition. Retaining ideal overjet and overbite in Class III malocclusions managed with camouflage treatment is perhaps one of the most challenging tasks in orthodontics.4,5,6 Invariably minor amount of immediate post-treatment relapse in overjet is seen in most of the cases owing to flaring of the lower anteriors.7,8

We proposed a simple technique to overcome one such case of immediate post-treatment relapse previously treated with single lower incisor extraction. Case Report A 25-year-old male patient was referred with a chief complaint of spaces reopening, 5 months post orthodontic treatment. The patient gave a history of single incisor extraction before commencing orthodontic treatment and was under treatment for 20 months after which he did not comply with the retention protocol. On examination, there was an edge to edge incisor overbite, Class I molar and canine relationship and a pleasing profile. Since the patient refused to undergo re-treatment with a fully bonded appliance, it was decided to use minimal bonding technique to correct the relapsed overjet and overbite.

Technique1) Bond Begg Brackets/ horizontally with the bracket slots

facing distally, onto the buccal surface of the first and second molars, bilaterally in the lower arch (Figure 3). (Alternatively, Bondable buttons can be used instead of Begg Brackets)

2) Bond the labial surface of the lower central Incisors Similarly (Figure 3).

3) Pass a 0.010” ligature wire through the slots of the first and second molars on either sides and ligate them together (Figure 4).

4) Ligate both the central incisors together similarly (Figure 5).

5) Pass a light elastic from the second molar on one side, cross it over and engage it onto the central incisor bracket of the opposing quadrant in the same arch (Figure 6).Figure of eight elastics were used to reinforce cross-arch stabilization.

6) Repeat the same on the other side (Figure 7). Note: The Begg brackets were bonded horizontally as it can prevent slippage of ligature wire which is used to consolidate the first and second molars which were bonded together to act as an anchor unit. The patient was instructed to change the elastics on every alternate day. Once an ideal overjet is re-established (Figure 8), retain the changes for a sufficient period and proceed with the placement of bonded lingual retainer.

Treatment Outcome A positive overjet and overbite of 2mm was achieved in less than 2 months. Since the anchorage was reinforced by ligating first and second molars, there was no anchor loss or rotation of the molars observed. One year follow-up of the case showed no relapse tendency for overjet and overbite.

A Simple Technique For Correction Of Relapsed Overjet

By Neelima Kakkirala, MDS; Ruchi Saxena, MDS; Sharmada B K, MDS

FEATURE This article has been peer reviewed.

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Discussion In a class III case, if a non-surgical treatment alternative can produce results comparable with those that could be achieved surgically, then it should be considered and can be the treatment of choice for some patients. The relapse tendency is more with a non-surgical treatment plan, compared to a surgical treatment plan. In Skeletal Class III malocclusion, while a positive overjet is established with protrusion of the upper incisors, and retraction of lower anteriors, generally a post-treatment relapse of overjet can occur due to flaring of lower anteriors. There was mild Boltons discrepancy indicating mandibular anterior excess, hence proximal stripping of 2-3 mm was done. There was no post retention CO-CR discrepancy. The functional excursions was not a problem because Class I canines and good overbite/overjet relations are established. Incisal and canine guidance was achieved.

Figure 8: End of 2 months showing positive overjet.

Figure 1, Figure 2: Immediate post-treatment relapse showing edge to edge bite and appearance of diastema.

Figure 3: Bonding Begg Brackets Horizontally.

Figure 4, Figure 5: Ligating respective units.

Figure 6, 7: Light elastic force application in a figure 8 pattern.

Yoon-ah kook8 et al suggested the treatment of Class III relapse due to using miniscrew anchorage to correct lower anterior flaring. Riedel R A9 suggested single incisor extraction for post retention stability and to prevent relapse.

Conclusion This technique saves a considerable amount of time in terms of considering a re-treatment procedure for such cases, utilizing a fully bonded appliance. As an alternative, after completion of a case, partial debonding can be done leaving the lower central incisor brackets and molar tubes in place, so that immediate post-treatment relapse can be managed similarly.

References1. Sanborn RT, Differences between the facial skeletal patterns of class III

malocclusion and normal occlusion. Angle Orthod 1995;25:208-22.2. Guyer EC, Ellis EE, Mc Namara JA Jr, Behrents RG. Components of class

III malocclusion in adolescents. Angle Orthod 1986;56:7-30.3. Proffit W, White RP, Surgical Orthodontic Treatment. Louis Mosby, 1991;

Chapter 14.4. Fudalej P, Dragan M, Wedrychowska-Szul. B: Prediction of the outcome of

orthodontic treatment of Class III malocclusions--a systematic review, Eur J Orthod. Apr; 33(2): 190-197, 2011. Epub 2010 Jul 22.

5. Bahreman A A: Lower incisor extraction in orthodontic treatment, American Journal of Orthodontics 72: 560-567, 1977.

6. Jose-Antonio Canut: Mandibular incisor extraction: indications and long-term evaluation. European Journal of Orthodontics. 18: 485-489, 1996.

7. J.M. Battagel: Predictors of relapse in orthodontically treated class III malocclusions, Br.J.Orthod. 21: 1-13, 1994.

8. Yoon-Ah Kook, Seong-Hun; KIM Treatment of Class III Relapse Due to Late Mandibular Growth Using Miniscrew Anchorage JCO 2008; 42:07:400-411.

9. Riedel R A, Little R M, Bui T D: Mandibular incisor extraction-post retention evaluation of stability and relapse, Angle Orthodontist. 62: 103-116, 1992.

Dr. Neelima completed her post graduation from KLE Dental College and University, Belgaum. She was an instructor at K.L.E’s Dental College and University. She has over 7 years of clinical and Teaching experience in the field of Orthodontics and is currently working at Vydehi Institute of Dental Sciences, Whitefield. She resides in Bangalore, and has a private practice.

Dr. Ruchi Saxena completed her post graduation from KLE Dental College and University, Belgaum. She was an instructor at Vydehi Institute of Dental Sciences and Hospital. She has over 6 years of clinical and Teaching experience in the field of Orthodontics and currently resides in Delhi, and has a private practice.

Dr. Sharmada completed her post graduation from Rajarajeshwari Dental college, Bangalore. She is an instructor at Vydehi Institute of Dental Sciences and Hospital. She has over 2&1/2 years of clinical and teaching experience in the field of Orthodontics, and 5 yrs of Clinical experience in Dentistry, and currently resides in Bangalore, and has a private practice.

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ntroduction The correction of sagittal orthodontic malocclusions, i.e., Class II and Class III disorders presents orthodontic clinicians the most difficult

conditions with which they must contend. When a Class I malocclusion appears with maxillary and mandibular arch length discrepancies, space can be achieved by a number of methods, e.g., expansion, extraction or interproximal enamel reduction, and little thought or effort is expended correcting the posterior occlusion. Arch length discrepancies may also occur with a sagittal malocclusion, which only complicates an already difficult task, but the primary intention in treating Class II or Class III malocclusions resides in correcting the posterior occlusion. For many years the main therapy applied to both Class II and Class III malocclusions was with some type of cranial-supported force to the maxilla or mandible (Figure 1). It was not until Case1 and Baker developed the idea of using intermaxillary elastics late in the 19th century that clinicians had effective and easily applied forces for addressing sagittal discrepancies. When intermaxillary elastic pressure is used, teeth move, but the problem for modern orthodontic clinicians is the simple fact that fewer and fewer patients seem amenable to using them in a consistent manner. The reluctance of patients to use elastics has resulted in the development of several so-called noncompliant appliances, which are fixed and not easily removed from the mouth.

Maximum Cl II Therapy with Minimum Appliances

By Larry White

Nevertheless, the common feature of Class II correction that prevents more consistent and predictable correction of these malocclusions is a failure to correct the posterior occlusion first. This is what Carriere2 has called establishing the Class I platform. Once clinicians achieve Class I molars, the remaining treatment turns into a routine matter. The main factor that prevents early correction of the Class II posterior occlusion is the banding and bonding of too many teeth at the first of treatment. Such early application of brackets, bands and arch wires causes clinicians to embark on a regime of aligning and leveling, which in many cases causes the mandible to move downwards and backwards, complicating the Class II correction.

The Partial Maxillary Appliance Mulligan3 has treated Class II malocclusions for many years with a simple technique of bonding a 2 x 4 arrangement, i.e., two maxillary molars and four maxillary incisors (Figure 2). By applying slightly long round stainless steel maxillary arch wires with 45° bends against the molars, he is able to retract the molars into a Class I arrangement in a short period of time without flaring the incisors or employing Class II elastics, headgear or noncompliant Class II correctors, e.g., Herbst, Mara, MPA, Forsus, etc. The partial appliance allows clinicians to develop a desired force system that maximizes the moments and forces that will correct Class II molars, crossbites and overbites simultaneously.

FEATURE This article has been peer reviewed.

Figure 1: Cranial strap to limit mandibular growth.

Figure 2: A typodont illustration of the 2 x 4 partial appliance with a long, round arch wire and circle tiebacks against the molars.

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Figure 3 illustrates this partial appliance as seen from the front with the created forces and moments, while Figure 4 illustrates how the arch wire requires expansion to prevent the molars from moving into a crossbite from the lingual moments created by the extrusive forces produced by the tipback bends. Figure 5 illustrates the partial appliance as seen from the side with its forces and moments. Clinicians might think that the extra length of the arch wire would cause the incisors to move labially, but the large moment produced by the tip back bend against the molars overcomes the force and small moment against the incisors and would, in fact, cause the incisors to move into an anterior crossbite without that extra length.

Figure 3: Moments and forces created by the partial appliance.

Figure 4: Expansion of the arch wire necessitated by the molar lingual moments.

Figure 5: Side view of the partial appliance with its forces and moments.

Figures 6, 7 and 8 display a patient with a mild Class II malocclusion with a small mandibular arch length discrepancy and deep overbite treated with the partial appliance. The one caveat clinicians should keep in mind with this technique is to closely monitor the maxillary incisors because they can easily intrude excessively and may need subsequent extrusion. The maxillary premolars in this patient were never bonded.

The Carriére Appliance Carriére2,4 has advocated the creation of a Class I platform before embarking on full appliances. With this technique, clinicians attempt to take advantage of patients’ early enthusiasm for orthodontics when they are more likely to use Class II elastics, which are essential to the appliance.

Figure 6: Patient with a mild Class II malocclusion accompanied by a mandibular arch length discrepancy and a deep overbite.

Figure 7: Class II patient with maxillary partial appliance. Note the space created in the maxillary arch and rotation of the maxillary molars.

Figure 8: Final result of therapy with the partial maxillary appliance.

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The therapeutic premise is rather simple, i.e., establish the Class I platform with the appliance that retracts the posterior maxillary segments as a unit and then bond the teeth and complete the treatment. Figure 9 illustrates the Cariérre Distalizer reinforced with Class II elastics, while Figures 10, 11 and 12 display the effects of a patient treated with the appliance.

The Cantilever Appliance Clinicians use the cantilever appliance before bonding or banding many teeth with tubes or brackets and uses Class II mechanics for a retraction force. In that respect, it mimics the Carriére Distalizer, but it works by completely different biomechanical principles. The essential parts of the appliance consists of a 4mm hook bonded to the maxillary canine, a tube or band with tubes attached to the molar, and a .slightly long .016 x .022 stainless steel cantilever wire that has a tip-back bend against the molar (Figure 13). When the cantilever wire engages the hook bonded to the canine, the omega loop compresses and puts a distal force against the molar, a mesial force against the canine, while the cantilever simultaneously extrudes and creates a strong clockwise moment against the molar. The cantilever places an intrusive force with no moment on the canine (Figure 14). The addition of Class II mechanics with elastics or NiTi springs will cancel the forces on the canine as seen in Figure 15. Figures 16 through 18 illustrate the results the cantilever appliance can have in the treatment of a Class II malocclusion.

Figure 9: The Cariérre Distalize reinforced with Class II elastics.

Figure 10: Patient with a Class II malocclusion complicated witha large overjet and deep overbite.

Figure 11: Class II correction with Carriére Distalizer.

Figure 12: Completed Cl II therapy with the Carriére Distalizer.

Figure 13: The Cantilever Appliance with a bent and bonded hook on the canine, a banded molar and a slightly long edgewise cantilever wire.

Figure 14: The compression of the loop against the molar tube puts a distal force and a moment on the molar and a forward and upward force on the canine. The yellow arrow is a resultant force from the two forces on the molar.

Figure 15: The addition of the spring orClass II elastic cancels the anterior and intrusive forces on the canine.

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The compression of the loop against the tube puts a distal force on the Figure 15: The addition of the spring or Class II elastic cancels the anterior and intrusive forces on the canine.

The Posterior Occlusal Guides Posterior Occlusal Guides were first suggested by Fiorelli who discovered he could reposition the mandible and correct slight midline deviations, overjet and overbite discrepancies along with Class II subdivisions by building up the posterior teeth with Triad Gel while holding the mandible in the new position that corrected the midline, overbite and overjet. The posterior occlusal guides, which Dr. Fiorelli fortuitously developed act somewhat akin to fixed functional appliances

Figure 16: Class II patient with an overjet, and slight maxillary and mandibular arch length discrepancies.

Figure 17: The cantilever appliance has tipped the molars distally and even relocated the canines distally, while the premolars have erupted into a strong Class I occlusion.

Figure 18: The patient now has complete orthodontic appliances, and the treatment approaches completion.

Figure 19: Class II subdivision malocclusion with midline deviation.

Figure 20: POGs in place on the posterior teeth with corrected midline and canines in Class I positions.

Figure 21: Class II therapy completion after POGs use.

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that can cause temporomandibular fossae and dentoalveolar remodeling.5-7 He reveals this strategy with the following images of patient therapy (Figures 19-21). One final biomechanical feature clinicians should remember when treating Class II malocclusions is that merely widening the arch and rotating the maxillary molars can have a beneficial effect (Figure 22).

Conclusion Class II malocclusions offer clinicians enormous challenges, which demand their best efforts to apply diagnosis, treatment planning and therapy in the most intelligent and effective manner. This demands a complete knowledge of the armamentarium available to the profession and also the knowledge that can simplify an otherwise complex task.

The most obvious clinicians can do is to not handicap themselves by applying too many brackets in the beginning of therapy. Complete appliances places too many restrictions on the correction of Class II malocclusions and creates too many forces and moments that neutralize the efforts to put posterior teeth in a Class I occlusion. The achievement of a Class I platform should precede any effort to align and level the arches since once that is done, the completion of therapy becomes a routine and simplified mission.

References1. Case C. Disto-mesial intermaxillary force Chicago Dental Society.

Chicago, IL; 1893.2. Carrière L. A new Class II distalizer. J Clin Orthod. 2004 34:224-231.3. Mulligan TF. Common Sense Mechanics in Everyday Orthodontics.

Phoenix, AZ: CSM Publishing; 1998.4. Hamilton CF, et al. Adolescent patients’ experience with the Carriere

distalizer appliance. European journal of paediatric dentistry 2013;14:219-224.

5. Voudouris JC, Woodside, D.G., Altuna, G., Kuftinec, M.M., Angelopoulos, G, Bourque, P.J. Condyle-fossa modification and muscle interactions diuring Herbst treatment, Part 1. New technological methods. AJO-DO 2003;123:604-613.

6. Woodside DG, Altuna G, Harvold EP, Herbert M, Metaxas A. Primate experiments in malocclusion and bone induction. Am. J. Orthod. 1983;83:460-468.

7. Woodside DG, Metaxas A, Altuna G. The influence of functional appliance therapy on glenoid fossa remodeling. Am. J. Orthod. 1987;92:181-198.

Figure 22: Expansion and rotations of the maxillary molars can assist in the correction of Class II malocclusions.

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39IJO � VOL. 25 � NO. 3 � FALL 2014

Assessment of Safe Zone in Maxillary Molar Region for Miniscrew Placement in the Mixed Dentition Period – A Digital Volumetric Tomographic (DVT) Study

By Kavita Hotwani, MDS; Sudhindra Baliga, MDS; Nilima Thosar, MDS; Krishna Sharma, MDS

ntroduction Guidance of eruption and development of the primary, mixed and permanent dentitions are integral components of comprehensive oral

health care for all pediatric dental patients.1 Early diagnosis and successful treatment of developing malocclusions can have both short-term and long-term benefits while achieving the goals of occlusal harmony, function and dentofacial esthetics.2-4 The premature loss of primary teeth due to caries, trauma, ectopic eruption or other causes may lead to undesirable tooth movements of primary and/or permanent teeth including loss of arch length.5 Loss of space in the dental arch that interferes with the desired eruption of the permanent teeth requires evaluation. The use of space maintainers and regainers is recommended to maintain/recover lost arch width and perimeter and improve eruptive position of succedaneous teeth.6 However, the conventional appliances used for this purpose have shown adverse effects like dislodged or broken appliances, plaque accumu lation, caries, undesirable tooth movement or tipping movements, soft tissue impingement and decreased patient compliance.5,7-9 Various modifications have been tried to minimize these effects. The introduction of skeletal anchorage devices in orthodontics may have potential application to overcome these disadvantages and aid in comprehensive space management. Miniscrews have been widely used as intraoral anchorage devices.10 In the mixed dentition period, the use of miniscrew implants as an adjunctive therapy needs to be assessed in view of the array of clinical applications implicated with miniscrews. However, concerns about detrimental effects on developing permanent tooth buds, in conjunction with the

FEATURE

Abstract: Assessment of bone thickness in maxillary first molar region for miniscrew placement during the mixed dentition period with reference to the following variables a) mesio-distal bone width b) buccal cortical plate thickness c) palatal cortical plate thickness d) bucco-palatal bone depth. DVT images of fifteen healthy patients aged 8-10 years with early exfoliated maxillary second deciduous molar were obtained using the Kodak 9000 extra-oral imaging system. The scanned images were analyzed using Kodak dental imaging software [3DmoduleV2.2] and the bone thickness measurements were obtained at six mm and eight mm apical to the cemento-enamel junction. The mean and standard deviation for the measurements was calculated and data was statistically analysed using paired ‘t’ test. The Method error calculations were performed using the Dahlberg formula. The mean values for the mesiodistal width, buccopalatal depth, buccal and palatal cortical bone thickness were found to be sufficient for miniscrew placement up to 1.2mm diameter and 10mm length. The bone thickness measurement and assessment of safe zone in maxillary posterior region from the present study showed potential for miniscrew placement in pediatric age group. Miniscrews can be considered as a promising aid in pediatric space management; so also, they can be used for molar distalization and space regaining in early mixed dentition period. Keywords: cortical bone thickness; Digital Volumetric Tomography; miniscrew; mixed dentition period.

limited interradicular space, still represent a barrier for the application of miniscrews in growing patients. In addition, the bone quality and quantity are relatively poor in young patients, compromising primary stability of miniscrews.11 Consequently, the selection of an implant site in pediatric age group requires special considerations. Numerous anatomical sites for miniscrew application have been presented in adults.12 However in the mixed dentition age group few data is available for assessment of miniscrew placement. In addition, space loss and subsequent malocclusions are more commonly seen in early mixed dentition period. Hence, this study was aimed to assess the bone thickness with respect to mesiodistal bone width, bucco-palatal bone depth and cortical plate thickness on buccal and palatal sides of maxilla for miniscrew placement in children.

Method and Materials The study protocol was in accordance with the Helsinki Declaration of Human Rights and was approved by the Ethical Committee. Digital volumetric tomographic (DVT) images of 15 healthy children with dental age 8-10 years were obtained using Kodak 9000 extra-oral imaging system(Carestream Dental LLC, Atlanta,GA). Informed written consent was taken from the parent/guardian accompanying the patient prior to the DVT scan. Patients with early exfoliated or recently extracted maxillary second deciduous molar and 2-4mm of bone covering present over the erupting maxillary second premolar were included in the study. A preoperative intraoral periapical radiograph was obtained to confirm these findings. Patients with severe facial or dental asymmetries, systemic diseases or bone pathologies and vertical or horizontal periodontal bone loss were excluded from the study.13,14

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The scanned images obtained were analyzed by using Kodak dental imaging software (3D module V2.2, Carestream Dental LLC, Atlanta,GA). Before measurement, the images were oriented in all 3 planes of space (Figure 1). The sagittal slice was used to locate the interradicular area of interest. The slice was then oriented so that the vertical reference plane was parallel to the long axes of the roots14 and the horizontal reference plane was marked along the cemento-enamel junction (CEJ) of maxillary first permanent molar (Figure 2). The vertical level of

the measurement was established 6 mm and 8mm apical to the CEJ. Mesiodistal bone width and bucco-palatal bone depth in the maxillary first molar region were measured in the sagittal and coronal slices (Figures 3, 4). The thickness of the buccal cortical plate of the maxilla was measured in the areas between the unerupted second premolar and permanent first molar. The palatal cortical plate thickness was measured at the same location (Figure 5). For each patient, either the right or the left quadrant of the maxilla was randomly chosen for the measurements. Only one side was measured because it was previously shown that there are no differences in cortical thickness between sides of the jaws.15-17

The data was statistically analysed using paired‘t’ test for measurement at 6mm and 8mm.The volumetric tomographic images were measured by the same observer after a two week interval. The Method error (ME) calculations were performed using the Dahlberg formula.12

Figure 5: Buccal and palatal cortical plate thickness measurements in coronal slice.

Figure 1: Obtained DVT scan depicting orientation of axial, coronal and sagittal slices.

Figure 2: Vertical and horizontal reference planes in sagittal slice.

Figure 3: Mesiodistal bone width measurement in sagittal slice.

Figure 4: Bucco-palatal bone depth measurement in coronal slice.

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Results Out of the 15 scanned images obtained, 3 were discarded from the analysis due to the superimposition of maxillary sinus lining at vertical reference plane. Mean and standard deviation for each variable was calculated. The differences in measurements between 6mm and 8mm were not statistically significant. The method error calculation was performed for each variable after a two week interval (Table 1). The mesiodistal bone width measurements ranged from 0.7-3.2 mm. The results for buccal and palatal cortical plate thickness ranged between 0.8-1.6 mm and 0.7-1.8 mm respectively. The bucco-palatal bone depth was found ranging from 13-15.4 mm (Table 2). The mean values for the mesiodistal bone width, bucco-palatal bone depth, buccal and palatal cortical plate thickness at 6mm and 8mm were found to be sufficient for the placement of miniscrews up to 1.2mm diameter and 10mm length (Table 1, 2).

Discussion In recent times, the use of miniscrew implants has become an accepted and reliable method for providing orthodontic anchorage.[18] The placement of miniscrews in the interradicular bone has been frequently recommended for treatment of skeletal Class II malocclusions, distalisation of molars, correction of open bite, molar uprighting, alignment of dental midlines, extrusion of impacted canines and space closures.10

Radiographic analysis is a prerequisite in determining implant placement sites.19 In the present study, prospects of DVT as a quantitative tool for obtaining linear and area measurements of craniofacial complex have been investigated taking into consideration the low radiation dose ascribed to DVT. A commonly preferred site for mini-implant placement is between the maxillary second premolars and first molars because of the large space and easy accessibility for various orthodontic mechanics.13 In the region of palatal alveolus between the maxillary first molar and second premolar, the position of the first molar’s palatal root and the buccal angulation of the second premolar is favourable and provides excellent access for direct insertion of a miniscrew. This location offers the largest interradicular space, a sufficiently wide cortical plate, and moderately thick attached gingiva.20

Table 1: Statistical data with method error calculations Mean (Standard deviation) Method error P value 6mm 8mmMDW* 2.25(0.34) 2.33(0.84) 0.20 0.79||BCPT† 1.02(0.15) 0.83(0.67) 0.30 0.52||PCPT‡ 1.05(0.22) 1.03(0.84) 0.09 0.96||BPD§ 13.63(0.58) 9.88(7.66) 1.36 0.32||* Mesio-distal bone width† Buccal cortical plate thickness‡ Palatal cortical plate thickness§ Bucco-palatal bone depth || Not significant (P>0.05)

Table 2: Descriptive data of measurements made at 6mm and 8mm from cemento-enamel junction

Patient MDW* BCPT† PCPT‡ BPD§ 6mm 8mm 6mm 8mm 6mm 8mm 6mm 8mm1 2.1 2.3 0.8 1.4 1 1.8 13.2 14.82 2.5 3.2 1.1 1.5 1 1.5 13.7 14.63 2.1 2.5 1.1 1 0.8 1.3 13.8 15.44 2.6 3.1 1.2 1.6 0.9 1.6 13.6 14.55 2.3 2.7 1.3 1.2 1 1.5 13.6 15.26 2.3 0.9 0.8 1.2 1 1.3 13.1 14.47 2.4 2.9 1 1.4 0.7 1.4 13.8 14.78 1.9 2.1 1 1.2 1.2 2 13.4 159 2 2 0.9 1.3 1.3 2.1 13.5 14.910 2.2 2.4 1.2 1.1 0.7 1.4 13.7 15.311 2.1 0.7 1 1 1.2 1.5 13.3 14.612 2.2 1 0.9 1.1 0.9 1.2 13 14.5

* Mesio-distal bone width† Buccal cortical plate thickness‡ Palatal cortical plate thickness§ Bucco-palatal bone depth

The CEJ was selected as the reference for the measurements, unlike other studies that used the alveolar crest, which could be affected by different periodontal problems.12,21 As it is advisable to place the mini-implants in this region, the maximum level of measurement in this study was selected to be 6 mm and 8mm from CEJ.22

The present study showed that adequate cortical plate thickness is available in mixed dentition period for miniscrew placement. However, very few age specific investigations have been conducted previously and most of them have considered the adolescent age group.14 This could be the reason attributed to the lack of constancy of the results obtained. Difference in cortical thickness between younger and older patients might be explained by allometry. The age effects appear to be partially hormonally based. Age-related differences in cortical bone thickness might also be explained by changes in functional capacity, because maximum bite forces, masticatory muscle size, and muscle activity all tend to increase with age. Changes in functional capacity that alter the biomechanical stresses and strains have been shown to influence cortical bone thickness and bone density. The increased strains within a certain range increases cortical bone thickness and bone mineral density.14

For a clinical evaluation of the data, it is important to combine the interradicular mesiodistal space measurements with cortical plate thickness and depth of bone available. The selection of proper miniscrew diameters and length are governed by these variables. It is assumed that a minimum clearance of one mm of alveolar bone around the screw could be sufficient for periodontal health.12 Thus, combining this value with the

42 IJO � VOL. 25 � NO. 3 � FALL 2014

obtained data and the screw diameter, the safer zones for screw insertion in the interradicular spaces are recognized. Published opinions on the amount of surrounding bone needed to provide sufficient retention for the implant vary between 0.5mm and 1mm on either side.12,23 Recently, it is reported that in order to avoid root contact, periodontal width should be included in this calculation, adding 0.25 mm per side. Therefore, for a 1.2 mm-diameter miniscrew an adequate amount of mesiodistal bone width would be 2.2-2.7 mm.24

Thus, the bone thickness measurement and assessment of safe zone in maxillary posterior region from the present study showed potential for miniscrew placement in pediatric age group. In the maxillary molar region, greater bone thickness was present on the palatal side. This indicates that more sites for a safe screw insertion are available on the palatal side than on the buccal side. Cortical bone is typically thicker in the palate than at buccal interradicular insertion sites, and favourable attached gingiva is readily available, ensuring high success rates. In addition, miniscrews placed in this area will not contact dental roots or inhibit tooth movement.20 The mesiodistal bone width measurements were found to be less than the bucco-palatal ones and, therefore, they represent the key parameter to define a safe zone suitable for miniscrew insertion. Consequently, miniscrews can be placed during mixed dentition period safely as an adjunct to existing appliances used in routine clinical practice. In 20% of the measured maxillae, the maxillary sinus was found to be superimposing at 8mm vertical level. Hence, the proximity of the maxillary sinus and the density of bone in the posterior region need to be assessed in mixed dentition period to provide a three dimensional analysis for miniscrew placement. Creation of a surgical guide can also be considered in order to prevent damaging the developing tooth germ. However, the results of the present study need to be correlated with clinical assessment to maintain optimum periodontal health and miniscrew stability.

Conclusion The bone thickness measurement and assessment of safe zone in maxillary posterior region from the present study showed potential for miniscrew placement in pediatric age group. They can be considered as a promising aid in pediatric space management. They can also be used for molar distalisation and space regaining in early mixed dentition period. The mini implant system can also be a valuable tool for cases where enhanced anchorage is required. In addition, the use of mini screws as interim abutment prosthesis in growing patient adds another dimension to the clinical applicability of miniscrews in children.

References1. American Academy of Pediatric Dentistry. Guideline on Management of

the Developing Dentition and Occlusion in Pediatric Dentistry. Pediatr Dent 2008-2009;30(7 Suppl):184-95.

2. Bishara SE. Textbook of Orthodontics. Philadelphia: Saunders, 2001.3. Woodside DG. The significance of late developmental crowding to early

treatment planning for incisor crowding. Am J Orthod Dentofacial Orthop 2000;117(5):559-61.

4. Kurol J. Early treatment of tooth-eruption disturbances. Am J Orthod Dentofacial Orthop 2002;121(6):588-91.

5. Brothwell DJ. Guidelines on the use of space maintainers following premature loss of primary teeth. J Can Dent Assoc 1997;63(10):753-66.

6. Laing E, Ashley P, Naini FB, Gill DS. Space maintenance. Int J Paediatr Dent 2009;19(3):155-62.

7. Dincer M, Haydar S, Unsal B, Turk TS. Space maintainer effects on intercanine arch width and length. J Clin Pediatr Dent 1996;21(1):47-50.

8. Qudeimat MA, Fayle SA. The longevity of space maintainers: A retrospective study. Pediatr Dent 1998;20(4):267-72.

9. Cuoghi OA, Bertoz FA, de Mendonca MR, Santos EC. Loss of space and dental arch length after the loss of the lower first primary molar: A longitudinal study. J Clin Pediatr Dent 1998;22(2):117-20.

10. Carano A, Velo S, Leone P, Siciliani G. Clinical applications of the Miniscrew Anchorage System. J Clin Orthod 2005;39(1):9-24.

11. Lee JS, Kim JK, Park YC, Vanarsdall RL. Applications of Orthodontic Mini-Implants: Quintessence Pub. Co, 2007.

12. Poggio PM, Incorvati C, Velo S, Carano A. “Safe zones”: a guide for miniscrew positioning in the maxillary and mandibular arch. Angle Orthod 2006;76(2):191-7.

13. Kim SH, Yoon HG. Evaluation of interdental space of the maxillary posterior area for orthodontic mini-implants with cone-beam computed tomography. Am J Orthod Dentofacial Orthop 2009;135:635-41.

14. Farnsworth D, Rossouw PE, Ceen RF, Buschangd PH. Cortical bone thickness at common miniscrew implant placement sites. Am J Orthod Dentofacial Orthop 2011;139:495-503.

15. Kang S, Lee SJ, Ahn SJ, Heo MS, Kim TW. Bone thickness of the palate for orthodontic mini-implant anchorage in adults. Am J Orthod Dentofacial Orthop 2007;131(Suppl):S74-81.

16. Schwartz CL, Dechow PC. Variations in cortical material properties throughout the human dentate mandible. Am J Phys Anthropol 2003;120:252-77.

17. Deguchi T, Nasu M, Murakami K, Yabuuchi T, Kamioka H. Quantitative evaluation of cortical bone thickness with computed tomographic scanning for orthodontic implants. Am J Orthod Dentofacial Orthop 2006;129:721.e7-12.

18. Wahl N. Orthodontics in 3 millennia. Chapter 15: Skeletal anchorage. Am J Orthod Dentofacial Orthop 2008;134(5):707-10.

19. Nanda R, Uribe FA. Temporary anchorage devices in orthodontics: Mosby, 2008.

20. Ludwig B, Glasl B, Bowman SJ, Wilmes B, Kinzinger GSM, Lisson JA. Anatomical Guidelines for Miniscrew Insertion: Palatal Sites. J Clin Orthod 2011;45(8):433-441.

21. Fayed MM, Pazera P, Katsaros C. Optimal sites for orthodontic mini-implant placement assessed by cone beam computed tomography. Angle Orthod 2010;80(5):939-51.

22. Melsen B. Mini-implants: where are we? J Clin Orthod 2005;39:539–547.

23. Schnelle MA, Beck FM, Jaynes RM, Huja SS. A radiographic evaluation of the availability of bone for placement of miniscrews. Angle Orthod 2004;74(6):832-7.

24. Ludwig B, Glasl B, Kinzinger GS, Lietz T, Lisson JA. Anatomical guidelines for miniscrew insertion: Vestibular interradicular sites. J Clin Orthod 2011;45(3):165-73.

Dr. Kavita Hotwani completed her post-graduation in Pedodontics and Preventive Dentistry in 2013. She is a gold medalist in Pediatric Dentistry and MDS University Topper. She has been involved in clinical dentistry, research and academics.

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Abstract: Molar uprighting cases require individualized treatment planning depending upon condition of ridge, growth pattern of patient, periodontal condition, lower facial height, position of third molar and anchorage. Uprighting of molar was done in two cases - effectively using simple tip back spring in one case and implant in another. Keywords: First molar; second molar; molar uprighting; mini-screw; uprighting springs

ntroductionDue to the early exposure of the first molar to the oral environment, its survival is at risk.1 Prevalence of first molar caries varies from one region to

another depending on the preventive measures. Its prevalence is 30% for American Indian/Alaska native second grade children2 whereas for Saudi Arabian children is 87%,3 resulting in its early loss. This early loss can lead to many consequences as shown in (Figure 1). Mesial tipping of the second molar is a frequent outcome, because it can act as a plaque harboring area, which ultimately leads to periodontal destruction. Repositioning of the second molar eliminates pathologic condition and further

facilitates path of insertion of prosthesis.4 An added advantage is that the alignment of roots perpendicular to the occlusal plane allow the tooth to withstand the forces of occlusion. The reason is that vertical forces are best tolerated by periodontium, with maximum in number of oblique fibers (Figure 2). To remedy this, surgical uprighting of the second molar can be done.5 Without doubt, this gives quick results, but requires removal of bone distal to second molar and causes trauma to apical vessels which can lead to devitalisation of uprighted tooth. There are possibilities of post-surgical infection and pulpal calcification, which reflects on possible drawbacks of this procedure. However, such an invasive approach is generally not required, as excellent results can be obtained by using numerous uprighting springs.6,7,8,9,10

Case Report 1: A 28-year-old post pubescent female patient presented with bi-maxillary dento-alveolar protrusion, class I skeletal and horizontal skeletal pattern. The patient desired correction of her procumbent anterior teeth and she was conscious of the space in lower left posterior region. The patient presented with missing 36(19) and mesially tipped 37(18) (Figure 3, 4). She had proper bucco-lingual width of the alveolar ridge favouring space closure of 36(19), by either retraction of the anterior teeth, or by protraction of the molar. Extraction was planned for her in first, second and fourth quadrant utilizing 36(19) space in third quadrant for retraction

Treatment Planning Considerations for Molar Uprighting

By Harsimrat Kaur, MDS; Pavithra US, MDS; Shabeer N. N, MDS; Reji Abraham, MDS

FEATURE This article has been peer reviewed.

Figure 1: Mesial tipping of second molar, distal tipping of second premolar and supraeruption of antagonist tooth.

Figure 2: Oblique fibres are maximum in number in PDL. They are responsible for tolerating vertical forces.

of the anterior teeth. Uprighting of 37(18) was performed by distal crown movement that will further provide space for anterior retraction. After initial leveling and aligning space, closure was performed on 0.017 x 0.025 S.S. in 0.018 Roth slot. After partial space closure, molar Helical uprighting spring was placed (Figure 5).

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Figure 3: Intraoral view – left lateral showing missing 36(19) and mesially tipped 37(18).

Figure 4: Pre-treatment panoramic view.

Figure 5: Uprighting spring. Figure 6: Force applied away from CR, thus moment is created which is responsible for distal crown movement.

Figure 7: Intraoral view a) left lateral after space closure b) uprighting spring activated after space closure.

Figure 8: Panoramic radiographs: a) Pre-treatment showing mesially tipped 37(18) b) Post treatment showing upright 37(18).

The mesial arm of the spring lied passively in vestibule and was activated by placing it over the arch wire in anterior segment. Lingual curve was placed in the helical uprighting spring to prevent buccal flaring of the anchorage unit. As the force is applied away from the center of resistance of the second molar, thus movement is created (Figure 6). This movement leads to distal crown tipping. Total treatment duration was 30 months (Figure 7, 8).

Case Report 2: An 18-year-old post pubescent female presented with the chief complaint of procumbent maxillary anterior teeth. She was diagnosed as a skeletal class I, with average skeletal pattern and with class I canine relation. She had missing 36(19) and 45(29) (Figure 9). She had a knife-edge ridge in the extraction site of 36(19), which did not allow either mesial movement of the root of 37(18), or retraction of anteriors. Thus uprighting of 37(18) with distal crown moment will be followed by prosthetic replacement of 36. Mini- screw supported jig with open coil spring was used to upright the second molar (Figure 10). Uprighted molar was retained with passive open coil spring (Figure 11), With the help of mini screws (TADs) absolute anchorage can be obtained and uprighting can be performed simultaneously with retraction. Total time of treatment was 18 months.

Figure 9: Pre-treatment intraoral left lateral view.

Figure 10: Mid treatment intraoral photograph a) simultaneous mini screw supported retraction and molar up righting b) components of mini screw supported jig.

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Discussion In both cases, molar uprighting was done by distal crown moment. In Case 1, bucco-lingual width of ridge was proper, thus uprighting could be performed by mesial root movement. We required space for retraction of anteriors thus molar uprighting was performed by distal crown moment. In Case 2, bucco-lingual width of ridge was narrow, thus molar protraction or anterior retraction would have caused dehiscence. As a solution, molar uprighting was done by distal crown moment. Distal tipping in both cases lead to extrusion of the second molar. This could lead to a clockwise rotation of the mandible and can worsen the lower facial proportion. In the first case, the patient had horizontal skeletal pattern and in the second case, the patient had average skeletal pattern. Thus in both cases, extrusion of the molar did not influence the facial proportions. Both patients had an antagonist tooth, which further limited the amount of extrusion. The bite did not open during the uprighting in both cases, as the mandible occludes approximately 2000 times a day during functional and para-functional movements4 and is in rest position most of the time. Further occlusal clearance does not limit extrusion during uprighting. Forced eruption with molar uprighting can correct vertical osseous defect11, 12 and make mesial tooth surface accessible for cleaning. Periodontal disease was under control before the start of orthodontic treatment. Periodontium was given adequate care prior, during and after orthodontic uprighting. In both cases, where the uprighting of the second molar was performed the third molar could have been driven it into an area where maintenance of oral hygiene is difficult. If the third molar is tipped and it is destined uprighted position is favourable for the periodontium, it should be uprighted with the second molar. For uprighting both molars, biomechanics has to be changed accordingly, with due care given to anchorage. Force is required to move teeth and every appliance that exerts an equal and opposite force on another object.13,14 One movement that is difficult to accomplish without untoward effect is molar uprighting with intrusion.15 In Case 1, an anchor unit was formed by premolar and canine, and thus exerted intrusive forces. As forces passed buccal to the center of resistance of the anchor unit, they tend to flare bucally. To prevent buccal flaring, a lingual curve was added via a helical spring. As the loading point passed through the centre of resistance of the molar, there was no bucco-lingual moment of second molar (figure 13). Bucco-lingual moment of the second molar depends upon the loading point, and not on the buccal tube.16

In contemporary orthodontics, mini screws (Temporary Anchorage Devices) are considered in cases where anchorage requirements are critical. In such cases, position of the head of the screw will decide force vector and thus final destination of second molar. In Case 2, a mini screw supported jig was used to upright the second molar. Here we have applied force by an indirect method, and thus the position of the head of implant was not the deciding factor for force vector. A mini screw was used in Case 2 for the simultaneous retraction of anterior teeth and uprighting of the second molar. Treatment time for Case 1 was 30 months and for Case 2, 18 months. Three to four months were saved in Case 2 by simultaneous retraction of anterior teeth and molar uprighting. The rest of the difference in treatment time of the two cases can be due to the difference in growth patterns. Case 1 had a horizontal skeletal pattern and Case 2 had an average skeletal pattern. Hence, mini-screw supported anchorage, reduced treatment duration in Case 2 by simultaneous retraction and uprighting. Of course, the patients should be informed about the risks and benefits of placement mini screws and the orthodontic clinician should proceed only after patient’s consent.

Conclusion Molar uprighting is a simple procedure, which requires appropriate individualized treatment planning for every case. Treatment can vary from patient to patient, depending particularly upon the condition of the alveolar ridge, growth pattern, peridontium, third molars and anchorage requirements.

Figure 13: Loading point being in line with centre of resistance of second molar thus, there will not be any bucco-lingual movement of second molar.

Figure 11: Retention of up righted molar with passive open coil spring.

Figure 12: Panoramic radiograph a) pre-treatment b) post treatment.

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Dr Harsimrat Kaur completed her post graduation in 2012. She was distinction holder in Orthodontics in final year of graduation. She was awarded scholarship by IDA. She was second in Rajiv Gandhi university of health sciences in post graduation examination scoring 73% marks.

Dr. Shabeer NN : Senior lecture; Srer Anjaneya Institute Of Dental Sciences; Calicut, Kerala

Dr. Reji Abraham is a professor and post graduate guide at Sri Hasanambha Dental College, Hassan.

References1. Todd JE, Dodd T. Children’s Dental Health in the United Kingdom.

London: Office of Population Censuses and Surveys, 1983.2. Phipps, K. R., Ricks, T. L. and Blahut, P. (2013), Permanent first molar

eruption and caries patterns in American Indian and Alaska Native children: challenging the concept of targeting second grade for school-based sealant programs. Journal of Public Health Dentistry. doi: 10.1111/jphd.12011.

3. Al-Shammery AR, Guile EE, el-Backly M. Prevalence of caries in primary school children in Saudi Arabia. Community Dentistry and Oral Epidemiology. 1990;18:320–321

4. Proffit WR. Contemporary Orthodontics. 2nd ed. St Louis: Mosby; 1986.5. M. Anthony Pogrel. The surgical uprighting. Am J Orthod Dentofac Orthop

1995;108:180-36. Tuncay OC, Biggerstaff RH, Cutcliffe JC and Berkowitz JB. Molar

uprighting with T-loop springs. J. Am. Dent. Assoc. 1980;100:863-866. 7. Roberts WW, Chacker FM and Burstone CJ. A segmental approach to

mandibular molar uprighting. Am. J. Orthod. 1982;81:177-184.8. Weiland FJ, Bantleon HP, and Droschl H. Molar uprighting with crossed

tipback springs. J. Clin. Orthod. 1992;26:335-337. 9. Capelluto E. and Lauweryns I. A simple technique for molar uprighting. J.

Clin. Orthod. 1997;31:119-125. 10. Shellhart WC and Oesterle LJ. Uprighting molars without extrusion. J.

Am. Dent. Assoc. 1999;130:381-385.11. Brown IS. The effect of orthodontic therapy on certain types of

periodontal defects. J. Periodontol.1973; 44:742.12. Ingber J. Forced eruption. Part I. A method of treating isolated one

and two wall infrabony osseous defects - Rationale and case report. J. Periodontol. 1974;45: 199.

13. Burstone CJ, Koenig HA. Force systems from an ideal arch. Am J Orthod 1974;65: 270-289.

14. Shellhart WC. Equilibrium clarified. Am J Orthod Dentofacial Orthop 1995;108: 394-401.

15. Shellhart WC, Moawad M. Case Report: Implants as anchorage for molar uprighting and intrusion. Angle Orthod 1996;66:169-172.

16. Yukio Kojima, Toshihiro Mizuno, and Hisao Fukui. A numerical simulation of tooth movement produced by molar uprighting spring. Am J Orthod Dentofacial Orthop 2007;132:630.

Dr. David Jackson’s Basic OrthodonticsA Comprehensive Level 1 Course

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Introductory Straight Wire and FunctionalsA Comprehensive Orthodontic Course for

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Not pictured: Dr Pavithra US : Professor & Head of Department, Department of Orthodontics, Sri Hasanambha Dental College, Hassan, Karnataka.

47IJO � VOL. 25 � NO. 3 � FALL 2014

Abstract: Orthodontic therapy is a force management procedure largely based on use of arch wires for storing and distributing biologically tolerable forces by means of which position of teeth is altered.1,2,3 Advances in material science and technology has resulted in an array of newer arch wire materials, opening new vistas in orthodontic treatment. Materials with widely diverging properties are in the market today and their usage has profound implications on appliance mechanics, and are very much different from stainless steel which is popular even today. The dentists who practise orthodontics have to therefore clearly outline the phases of treatment and select the arch wire most suited for attaining specific treatment goals.1,2 Key words: Arch wires, Orthodontics.

ntroductionUnravelling of crowded teeth, is an important early treatment goal and to accomplish this several orthodontic arch wires are currently available. The

first generation wires comprised of Nitinol followed by TMA, super elastic Japanese and Chinese NiTi. Body heat activated NiTi wires are the current trend. The most recent of these super elastic wires is Copper NiTi wire, which clinically shows maximal super elastic range and very low hysteresis.1,2

The finishing stages of orthodontic treatment necessitate wires with very special properties and the recently introduced Niobium – Titanium alloy wires are a distinct step in this direction. Their unique load-deflection property and formability facilities occlusal finishing to contemporary orthodontic treatment goals.1, 2

In the period prior to the seventies when gold and stainless steel were the only available materials, increments in wire stiffness during treatment were instituted by progressively increasing the cross section of stainless steel wires i.e., from small to large and its geometry i.e., round and rectangular. Complicated loop designs were required to alter the stiffness characteristics of the wire for a chosen tooth movement and small wires were used for light forces and larger wires for heavy forces. This strategy of wire selection and usage as Dr. Burstone refers is “Variable Cross Section Orthodontics.” In the mid seventies, a host of new arch wire materials became available i.e., Nitinol and Beta titanium. With the availability of wires with widely varying moduli it became possible for the clinician to select wires with lower moduli for the early stages of treatment and increase the moduli to higher levels towards the finish of the treatment takeing advantage of different materials while maintaining the same or similar cross sections. This approach has been referred by Dr.Burstone as “Variable Modulus Orthodontics.” There are definite advantages in using wires, of varying materials in optimizing control of tooth movement.4

In the 90’s, NiTi arch wires that have super elastic and thermodynamic properties were available that is Copper

Total Recall: An Update On Orthodontic Wires

By H. Jyothikiran MDS; Ravi Shantharaj MDS; Panchali Batra MDS, MORTH RCS (Edinburgh); Pradeep Subbiah MDS; Bhagya Lakshmi MDS; Vishal Kudagi MDS

FEATURE This article has been peer reviewed.

NiTi, Neo-Sentalloy etc. By taking advantage of the body temperature and setting the alloys transformation temperature (Af ) for martensitic transformation, precise control of memory phenomenon can be affected. This is called “Varying Transformation Temperature Orthodontics.” The constant unrelenting quest for a better wire which can deliver optimal orthodontic force, has lead to invention of a lot of innovative wires. Rapid strides in the field of arch wire material producing in its wake a plethora of arch wires varying widely in material geometry, configuration, manufacturing process and physical properties.

Criteria of an Ideal Arch Wire5

Several characteristics of orthodontic wires are considered desirable for optimum performance during treatment. These include (Figure 1):

• High strength• Low stiffness• High range • Large spring back • High formability • High stored energy • Biocompatibility • Environmental stability

• Low surface friction • Poor biohostability • Resilience• Weldable and solderable • Esthetics • Economical• Corrosion resistance

Figure 1. Criteria of an Ideal Arch Wire

48 IJO � VOL. 25 � NO. 3 � FALL 2014

Classification of Orthodontic WiresGold alloysStainless Steel alloys a) Multistranded /Braided wires b) Australian arch wiresCobalt Chromium alloy/ElgiloyNickel Titanium alloys a) Conventional NiTi/M- NiTi b)Pseudo Elastic NiTi /A-NiTi c) Thermo Dynamic Ni-Ti d) Graded Thermo Dynamic NiTi e) Chinese NiTi f ) Japanese NiTi g) Copper NiTiAlpha TitaniumBeta TitaniumCombination wiresAesthetics wires a) Coated wires b) Composite wiresTitanium Niobium and Timolium wires

Gold Wires Gold wires were first used in orthodontic practice, although these noble metal wires have minimal use currently because of their much greater cost and low yield strength compared to the popular base metal wires.3

Stainless Steel Alloys In the mid 21st century, stainless steel was applied to dentistry and orthodontics although it was between 1903 and 1921 that Harry Brearley, F .M. Becket, Benno Strauss and Edward Maurer shared the honors for the development of the material. Austenitic stainless steel with its greater strength, higher modulus of elasticity, good resistance to corrosion, moderate cost was introduced as an orthodontic wire in 1929 and shortly afterward it gained popularity over gold. 1, 2, 3

When at least 10 to 13% chromium was present in the alloy, a coherent oxide layer formed that passivated the surface, thereby rendering the alloy “stainless.” Stainless steels were strong, typically about five times stronger than structural girders and their stiffness were 93% to 100% that of conventional carbon steels. As the ‘50s came to a close, Rocky mountain orthodontics was offering two tempers of cold-worked stainless steels.6

1. Standard 2. Extra large grade.

American orthodontics advertises three grades of Stainless steel wire;1. Standard2. Gold tone3. Super gold tone

Commonly used types of stainless steel are AISI 302 and 304 Stainless Steel. Type 304 has slightly lower carbon and higher chromium specification. Most of their strength is desired from cold working and Carbon interstitial hardening. 1, 2, 3

The only heat treatment used with this wire is for stress relieving -typically done at 850°F for less than ten minutes. They have high yield strength. The high modulus necessitates

the use of smaller diameter wires for alignment procedures where lower forces are indicated. It has greater spring back than gold and excellent formability and corrosion resistance (although the solder joints do corrode in the oral cavity) and can be soldered.7,8,9

• Recommended temperature time schedule for stress relieving Stainless Steel is 750°F (399°C) for 11 minutes.8,9

• Large modulus of elasticity and its associated high stiffness of Stainless Steel necessitate the use of sma1ler wires for alignment of displaced teeth.

• Reduction in wire size results in a poorer fit in the bracket and may cause loss of control during tooth movement.

• Yield strength to elastic modulus ratio (Y s/E) indicates a lower spring back of Stainless Steel than those of newer titanium based alloys.

• The stored, energy of activated Stainless Steel wires is substantially less than that of Beta-Titanium and Nitinol which implies that Stainless Steel wires produce higher forces that dissipate over shorter periods of time thus requiring frequent activations or arch wire changes.

• Joinability with Stainless Steel is possible by soldering but may be demanding. Can be fused together by welding but requires reinforcement with solder.

• Corrosion resistances is good although solder joints may corrode in the oral cavity.

• Although the amounts of nickel and chromium released are below the average dietary intake, the liberated element & may sensitize patients or produce reactions in already sensitized persons.

• Low levels of bracket/wire friction have been reported with experiments using Stainless Steel wires -offer lower resistance to tooth movement than other orthodontic alloys.

Stainless Steel Variants1, 2

A.J. Wilcok Wires:3,10,11 Mr. Arthur Wilcock of Whittlesea, Victoria, Australia originally developed this special orthodontic wire at the request of Dr. P.R. Begg nearly 40 years ago. Available in a variety of diameter sizes, grades of resiliency, coiled or in St. Lengths. St. Length wire is usually not considered to be as resilient as coiled wire due to the straightening process. Each grade is easily identified by a colored label (Figure 1).

Figure 1: Aj Wilcock Wire Spools. a)Special Plus; b) Premium Plus; c) Supreme; d) Premium.

a b

c d

49IJO � VOL. 25 � NO. 3 � FALL 2014

Unique properties of Wilcock wires• It is an ultra high tensile austenitic steel arch wire• Zero stress relaxation(allows the wire to maintain its force over a longer period of time, yet resists permanent deformation from elastic load)

This wire forms backbone of Begg’s appliance. Color coding of the wires are as follows (Figure 2):• Regular-White Label• Regular Plus-Green Label• Special-Black Label• Special plus-Orange Label• Extra Special Plus-Blue Label• Premium-Purple Label• Premium Plus-Orange Label• Supreme-Yellow Label• Supreme Plus-Cream Label The wires are available in following dimensions and gradesRegular/RegularPlus/Special/Special Plus/Extra Special Plus/Premium-0.016”.0.018”, 0.020”, 0.022”.Premium Plus-0.010”0.012’, 0.014”, 0.016”, 0.018”.Supreme-0.008”,0.009”,0.010”,0.011”,0.012”.

Premium wires To maintain arch forms.Premium Plus To fabricate up-righting and torquing springs.Supreme Ultra high tensile wires used for alignment in lingual Orthodontics, to fabricate reciprocal torquing springs,mini springs.

Combination Arch Wires The wire is combination of two diameters. In the posterior segment diameter is 0.018” ovoid whereas anterior segment 0.018” x 0.022”. In Begg’s technique it can be used in St. III, which fills the bracket slot and avoids torque loss in anterior and lesser friction in posteriors during retraction/anchor loss.

Respond Wires Respond is a strand, spiral wrap with a central core wire (coaxial) (Figure 2). Respond can deliver light, initial forces while filling the archwire slot for greater control.

3. A finishing arch wire, where torque control is desired yet resilient to permit inter-arch occlusal “settling”

4. Torque control with vertical and / or anterior box elastics.

Force-9 Braided Preformed Force -9 (Figure 4) is a 9-strand, Inter-woven rectangular wire. Its high flexibility, together with 3 -dimensional control and slot filling capabilities make it ideally suited for multiple applications as D-Rect wires.Force-9 delivers about 50% more force than 8-stranded D-Rect.Its selection is based on similar applications where slightly more forces seems to be indicated.

Figure 2: Respond (Co-Axial).

D-rect (Braided Preformed and straight) D-Rect is an 8-stranded, inter-woven rectangular wire (Figure 3). Its high flexibility, together with 3-dimensional control and slot filling capabilities, make it ideally suited for multiple applications:

1. Initial torque control.2. Picking up second molars later in treatment.

Figure 3: D-Rect (Braided Rectangular Stainless Steel).

Figure 4: Force -9 (Braided Rectangular Stainless Steel).

Figure 5: Turbo Wire (Braided Rectangular Niti).

HT/Gold Heat Treated Stainless Steel Is a high temper stainless steel wire which provides higher force levels and greater spring back (working range) than traditional stainless steel wire. It should be considered in applications where resistance to deformation is a primary factor. The higher force levels and rigid nature of this wire make it an excellent choice for transverse arch form control.

Menzanium (Non-nikel containing alloys) Is fabricated in a patented high pressure melting process where Manganese and Nitrogen replace allergic components of Ni.

1. Ideal for Ni sensitive patient.2. Corrosion resistant and durable.

Cobalt Chromium Alloys (Elgiloys) 1, 3, 12, 13

Developed by Elgin National Watch Company in the mid century. Main advantage of this wire over stainless steel is, it is easier to bend in its “as received state.” So it is preferred in techniques in which loops in arch wires are used. It can be heat

50 IJO � VOL. 25 � NO. 3 � FALL 2014

treated after manipulation to achieve hardness approximately equal to that of Stainless Steel where formability is modified by heat treatment. It can be supplied in a softer and more formable state and then can be hardened by heat treatment after being shaped. Once the appliance is fabricated no formability is required. In order resilience is desired to capitalize on the inherent elasticity of the material, which could be achieved by heat-treating the alloy at 482°C for 7 to 12 minutes. This precipitation hardening heat treatment increases the ultimate strength and resilience of these arch wires without changing the stiffness. So after heat treatment the softest Elgiloy becomes equivalent to regular stainless steel, while harder initial grades are equivalent to the super grade. Along with stainless steel it is considered the most ideal and economic finishing wire. Cobalt chromium alloys (Co-Cr) are available commercially as Nu-Edge, Elite-Opti-MIM, Elgiloy, Azura and Multiphase. Manufactured in four tempers in increasing order of resilience. Wires of different tempers are color coded.

Soft : BlueDuctile : YellowSemi resilient : GreenResilient : Red

Substituted Titanium Alloys: Nickel Titanium Alloys1, 2,3,14,15,16,17,18,19,20

Titanium has been used as a structural metal ever since 1952 and its possible use in orthodontics has been suggested periodically. Arch wire materials with component of titanium became available to orthodontics in the 1970’s. The first of these, a nickel titanium alloy marketed as Nitinol in 197I, was developed for space programme but has proved to be very useful in clinical orthodontics. The alloy was developed by William F. Buehler a research metallurgist in the year 1960 at the Naval ordinance Laboratory, now called the Naval surface weapons Centre in Silver Springs, Maryland. The name Nitinol is an acronym derived from the elements which comprises the alloy (Ni- Nickel, Ti- Titanium, “nol” -Naval ordinance laboratory). Nitinol has excellent springback property but it does not possess shape memory or super elasticity as it was manufactured by a work hardening process.. It is available as NiTi; Nitinol, Orthonol, Sentinol and Titanol.

Nitinol is obtained in two types 1. Thermal Nitinol 2. Elastic Nitinol

Thermal Nitinol18

The original composition comprised of atomic ratio of Nickel and Titanium. Nickel 55%, Titanium 45%. However, in order to bring the transition temperature range down to 37°C, the amount of cobalt added to the alloy is 1.6%. The unique feature of this alloy is the memory phenomenon, which allows the wire to be plastically deformed or stretched/formed at a temperature below its transition temperature range and to maintain form until it is heated through the TTR at which time the wire will deform to its original pre stretched form. The alloy has a martensitic grain structure. The transition brings about a

change in the grain structure from martensite to austenite. The alloy has shape memory in the martensite form and this property is exploited. The arch wire is formed to the desired shape in the martensite form and it goes through the TTR to the austenite grain structure. In the austenite grain structure it is deformed to conform to the irregularities in the arch form; taking the wire through TTR again will result in its original shape in the martensitic form.

Elastic Nitinol22

This alloy of Nickel and Titanium without the use of cobalt has proved to be of practical orthodontic use. The advantage is its outstanding characteristic elasticity and flexibility which result in lighter; continuous forces.

Nickel-Titanium Wires Most advantageous properties are good spring back and flexibility, which allow for large elastic deflections. High spring back is useful in circumstances that require large deflections but low forces. It has a large recoverable energy than Stainless Steel or Titanium Molubdinum Alloys which results in increased clinical efficiency. For a given amount of activation they produce more constant forces on teeth than SS. Rectangular wire of this inserted early in treatment accomplishes simultaneous levelling, torquing and correction of rotations. Heat treatment of Nitinol results in substantial alterations in mechanical properties of the alloy. Changes in crystallographic arrangement caused by heating produce the memory affect in this alloy. Shape memory is the phenomenon whereby the alloy is soft and readily formable at a low temperature, but can easily be returned to its original configuration when heated to a suitable transition temperature. This change from distorted to original form involves a transformation of nitinol from the martensitic to the austenitic phase. Bracket/wire frictional forces with nitinol wires are higher than those with stainless steel and lower than those with beta-titanium wires.

Advantages• Fewer arch wire changes.• Less chair side time.• Reduction in time required to accomplish rotation and

levelling.• Less patient discomfort.

Limitations • Poor formability of the wires implies that they are best

suited for pre adjusted systems.• Any first, second and third order bends have to be over

prescribed to obtain the desired permanent bend.• Fractures readily when bent over a sharp edge. This

bending adversely affects the springback property of this wire. The bending of loops and stops in nitinol is therefore not recommended.

• Crimpable hooks and stops are recommended for use.• Cinch-backs distal to molar buccal tubes can be

obtained by resistance or Flame-annealing the end of the wire.

51IJO � VOL. 25 � NO. 3 � FALL 2014

• Dark blue color indicates the desired annealing temperature.

• Findings on resistance to corrosion of Nitinol wires have been inconsistent. Various authors have found Nitinol to be more susceptible to corrosion than Stainless Steel wires.

Nitinol does not have shape memory or super elasticity because a work hardening process manufactures it. Super elasticity is the property demonstrated when the stress value remains fairly constant up to a certain point of wire deformation and stays constant as the wire rebounds. Because of such unique properties it has been widely used in the industrial, medical and other scientific fields23 24

Chinese And Japanese NiTi Miura has shown that the super elasticity of Japanese NiTi (marketed as sentalloy) allows it to deliver a relatively constant force for a long period. Such force application is considered physiologically desirable for tooth movement and for patient comfort. Another super elastic wire Chinese NiTi, can be deflected 1.6 times as far as Nitinol while producing only 36% of the force as demonstrated by Burstone et al.24

The new super elastic NiTi wires (A-NiTi) are significantly different from earlier work-hardened NiTi (M-NiTi) wires and from Stainless Steel. Their super elasticity assures light, constant force at mouth temperature regardless of the amount of activation. Shape memory allows easy arch wire placement at lower temperatures, while the wires are in their martensitic phase. The combination of super elasticity and shape memory makes these wires quite comfortable for patients, even as rectangular initial arch wires. Non-linear unloading shows a rapid initial drop in the force applied to the teeth, implying that less force is delivered with a greater activation. Since stiffness increases and the wire become more efficient toward the end of movement, the clinician should not change the wire too often. A two-month appointment interval is usually sufficient, although treatment can be expedited if necessary by simply untying and retying the arch wires at monthly intervals, which will return them to their initial activation level. To take advantage of the temperature sensitivity of A-NiTI wires, orthodontists may want to advise their patients to alternate a cold drink with a hot meal once a day. Theoretically, the cold drink will cause the wires to enter their plastic, martensitic phase and to momentarily self-adjust in the bracket slots as the teeth move between appointments. Chinese and Japanese NiTi has unique characteristics and offers significant potential in the design of orthodontic appliances. These possess excellent spring back, shape memory and super elasticity.23,24 In the mid-eighties, super elastic nickel titanium was introduced for use by the orthodontist. This alloy distinguished itself from other materials by demonstrating thermo-elastic martensitic transformation ‘behavior, a reversible crystallographically driven structural change. This phenomenon provides the basis for the large recovery strains (6%) demonstrated by this material. The most important characteristic of super elastic nickel titanium behavior to the

clinician was the generation of more constant forces for large deflections. Now, “variable transformation temperature orthodontics” represents another major advance from “variable modulus mechanics”. Two distinguishing improvements are:

1. Changing the transformation temperature precisely changes the magnitude of the load.

2. Unloading (tooth moving) forces are constant.

Types• Thermo dynamic NiTi• Graded thermo dynamic NiTi• Copper NiTi

Thermodynamic NiTi This is a feature where identical dimension arch wires are produced in heavy, medium, and light forms depending on percentage of austenite present at mouth temperature. The arch wire force/deflection characteristics vary at different temperatures leading to unwanted changes in loading and un-loading forces for a given wire.

Graded Thermo dynamic NiTi The area of periodontium and variable transformation temperature was taken into consideration and graded force delivery with in the same aligning arch wire,providing light forces for anteriors,medium forces for premolars, and heavy forces for molars.

Copper NiTi Copper NiTi is a new quaternary (nickel, titanium, copper and chromium) generates a more constant force over long activation span than other nickel titanium alloys and does so, on a consistent basis, from arch wire. These show a thermally induced super elastic effect.25

Copper Ni-Ti wire consists of nickel, titanium, copper and chromium. The addition of copper to nickel titanium enhances the thermal-reactive properties of the wire, thereby enabling the clinician to provide optimal forces for consistent tooth movement.

Differences between copper Ni-Ti and traditional Ni-Ti alloys Copper Ni-Ti is more resistant to permanent deformation and exhibits better spring back. Copper Ni-Ti demonstrates a smaller loading force for the same degree of deformation, making it possible to engage severely mal posed teeth with less patient discomfort and potential for root resorption. The decreased hysteresis and flatter unloading curve result in more consistent forces that are active longer within the optimal range for tooth movement. Copper Ni-Ti exhibits a more constant force/deformation relationship, providing superior consistency from arch wire to arch wire. As Copper is an efficient conductor of heat, Copper Ni-Ti demonstrates consistent transformation temperatures that ensure consistency. This equates to consistent effectiveness in moving teeth.

52 IJO � VOL. 25 � NO. 3 � FALL 2014

Copper Ni-Ti arch wires comes with precise and consistent transformation temperatures. 270 C Super elastic Copper Ni-Ti

350 C Super elastic Copper Ni-Ti

400 C Super elastic Copper Ni-Ti

270 C Super Elastic Copper Ni-Ti (Round and Rectangular) This Ni-Ti wire generates forces in the high range of physiological force limits and produces constant unloading forces that can result in rapid tooth movement. Engagement force is lower than with other super elastic wires because of the lower loading forces built into copper alloy; at the same time, unloading force levels are comparable to traditional super elastic nickel titanium wires.

350 C Thermo-Active Copper Ni-Ti (Round, Rectangular and Square) 350 C Copper Ni-Ti generates mid-range constant force levels when the wire reaches mouth temperature. Early ligation is easier with full-size arch wires due to the lower loading forces. Unloading are forces are higher and more sustained than other shape memory wires when the wire reaches body temperature are desired,350C Copper Ni-Ti is the ideal wire.

400 C Thermo-Active Copper Ni-Ti (Rectangular) 400 C Copper Ni-Ti provides intermittent forces that are activated when the mouth temperature exceeds 400 C. It is useful as an initial wire and can be used to engage severely malaligned teeth (such as high cuspids) without creating damaging or painful levels of force or unwanted side effects. It is also the wire of choice for patients scheduled for long intervals between visits when control of tooth movement is a concern.

Variants of NiTi WiresSuper cable wires: These comprise of seven individual strands that are woven together in a long, gentle spiral to maximize flexibility and minimize force delivery.

Turbo wire (Braided preformed nickel titanium)1

Turbo wire (Figure 5) combines the advantages of highly resilient NiTi with rectangular braided wire. The braiding process actually increases the super elastic properties of NiTi. This combination yields an efficient means to achieve torque control, with an initial wire, in even the most severe malocclusion. The wire is recommended as an initial wire to unravel and level while controlling torque and engaging brackets fully. It is also effective as a finishing wire, retaining torque but allowing vertical elastic use.

Uses of NiTi• NiTi is the ideal arch wire for initial levelling and aligning.• NiTi is used for tooth separation.• In transverse expansion of maxilla, NiTi is used as palatal

expander.• Titanal-XR is a NiTi which can be bent or contoured and

which will not creep back.

• In BMA or “Bendable Marsel Alloy “cinched ends do not straighten out and accepts elastic hooks,tear drops, bayonets, and stops thus eliminating needs for auxiliaries.

• Turbo is the first braided NiTi wire is the choice when immediate torque control is essential during initial stages of levelling and aligning.

Alpha Titanium Consists of Titanium, Aluminium, and Vanadium. Because of its hexagonal lattice, it possesses fewer slip planes making it less ductile than Beta-Titanium. Alpha –Titanium gets hardened by absorbing intra oral free hydrogen ions which turn it into Titanium hydride, at oral temperature of 370C and 100% humidity. The wire becomes rather brittle to bend after a period of 6 weeks in the mouth. This phenomenon is due to Vanadium content. The wire is available as a combination, the anterior section is 0.018 x 0.025” rectangular for torque control and braking while the posterior section which is oval, tapering from 0.018” to 0.017 inch. Hence it can be used as a closing wire.

Beta Titanium Wires (TMA) 26

Beta titanium wire was developed by Dr. Burstone CJ in 1980. It is commercially available as TMA (Titanium-molybdenum alloy). Beta titanium has a modulus of elasticity that is less than that of stainless steel and about twice that of Nitinol. This makes its use ideal in situations in which force less than those of stainless steel are necessary and in instances in which a lower modulus material such as Nitinol is inadequate to produce the desired force magnitudes. Furthermore, the relatively lower forces generated by beta-titanium wire imply that the counterproductive force vectors generated by beta. Titanium wires can be counteracted by smaller forces than those required for comparable stainless steel wires. Extaoral anchorage demands with best titanium wires will therefore be less than those for stainless steel wires. With half the force but twice the working range of stainless steel, TMA has indications for all stages of treatment. Because of its intermediate stiffness between stainless steel and Ni-Ti memory alloys, it is especially beneficial as a main working arch wire.TMA has good flexibility and spring back characteristics along with predictable forces for consistent control. In the initial stages, TMA is recommended for tooth alignment, space closure and curve of spee. In the intermediate stages, TMA is recommended for early torque control with moderate forces.TMA also provides complete modification of the wire for dimensional control. Indications include use as an ideal retraction arch while exerting more constant moderate forces over a longer period of time.In the final stage of the treatment, TMA is used as a detailing wire with moderate force. The springback for beta titanium is superior to that of stainless steel. A beta-titanium wire can therefore be deflected almost twice as much as a stainless steel wire without permanent deformation. This makes it an excellent choice for auxiliary springs and for intermediate and finishing archwires, especially rectangular wires for the late stages of edgewise treatment. Its properties are intermediate between SS and M-NiTi. When compared with Nitinol, TMA was inherently smoother, could

53IJO � VOL. 25 � NO. 3 � FALL 2014

be welded and had good formability. When compared with SS, TMA produced greater linear forces per unit of deactivation and had more range and springback. Beta titanium wires also deliver about half the amount of force as do comparable stainless steel wires for example, and 0.018” x 0.025” inch beta -titanium wire delivers approximately the same force as a .014” x .020” SS in a second-order activation. The former configuration has the added advantage of full bracket engagement and a resultant greater torque control than the smaller stainless steel wire.27

The good formability of beta-titanium wire allows stops and loops to be bent into the wire. However, Burstone and Goldberg recommend that these wires should not be bent over a sharp radius. Helices that are commonly used with stainless steel to lower that load deflection rate of the appliance may not be necessary with beta-titanium wires because of their low modulus of elasticity and high springback. This helps to simplify appliance design by eliminating the need to place loops and helices in the wire.28

It is possible to attach stops, hooks, and active auxiliaries by welding to beta- titanium wires, thereby increasing the versatility of the wire. However, adequate strength of the weld without loss in wire properties is achieved within a narrow optimal voltage setting on a resistance spot welder. Nelson, Burstone, and Golberg have provided values for these optimal voltage settings. A flat-to-flat electrode configuration is recommended for welding because it produces a strong joint with low levels of distortion. Overheating of the wire causes it to become brittle.28,29

Beta-titanium has a corrosion resistance comparable to stainless steel and cobalt -chromium alloys. Beta-titanium wires demonstrate higher levels of bracket / wire friction than either Stainless Steel or Co-Cr wires. This may imply slower rates of tooth movement during canine retraction and space consolidation with beta- titanium wire than, with stainless steel or co-cr wires. Absence of nickel makes it useful in patients allergic to nickel.30

The composition of TMA is: Titanium 79%

Molybdenum 11 % ‘IZirconium 6%Tin 4%

The metastable BCC structure of Titanium can be retained at room temperatures by using a variety of allowing additives such as Molybdenum, Vanadium or Chromium and the final properties can be significantly altered by the thermal and mechanical processing used to produce the small diameter wire.In TMA, the friction is probably due to its relative softness, and surface treatment by Ion can increase the hardness and reduce the coefficient of friction of TMA wire while maintaining its desirable mechanical properties, Ion implantation is a process by which various elements or compounds are joined arid then accelerated toward target -in this case, the orthodontic archwire. Ion implantation takes place in a vacuum chamber, in which a Vapor flux of Ions is generated with an electron beam evaporator and deposited on the substrate. Gas ions nitrogen and oxygen are simultaneously extracted from plasma and accelerated in the growing physical vapor deposition film at energies of several hundred to several thousand electron volts. Various colored TMAS (purple, Violet, aqua honey dew) are produced by

Ion implantation. They have the same coefficient of friction as stainless steel and in some cases (purple, honeydrew) even lower.30

The Ions penetrate the surface of the wire on impact, building up a structure that consists of both the original wire and a layer of tin compounds (TIN and TIO) on the surface and immediate subsurface. This layer is extremely hard and creates a considerable amount of compressive forces in the material at the atomic level. The compressive forces and the increased surface hardness improve the fatigue resistance and ductility and reduce the coefficient of friction of the wire. The superficial compressive forces also minimize any detrimental effects of surface flaws.30

Unlike conventional coating process, ion implantation produces no sharp interface between coating and wire, which can lead to bond failure or delamination. Also unlike coating ion implantations does not alter wire dimensions; thus it allows the production of high quality wires with close dimensional tolerances. The depth, distribution and concentration profile can be controlled by varying the ion dosage and energy. Ion implantation can take place at relatively low temperatures -from subzero to 700°C. The thickness of the implanted surface layer can be precisely controlled and its properties engineered to affect characteristics such as hardness, friction, wear resistance, ductility and fatigue resistance.30

Reverse curve TMA TMA with reverse curve of spee is ideal for bite opening, arch leveling, space closure and early three-dimensional manipulation and torque control. In addition ,this arch wire provides the mechanics necessary for leveling deep bites and countering undesirable tipping tendencies during space closure. With twice the resiliency of stainless steel, TMA delivers continuous, uniform forces for rapid,efficient tooth movement.

Reverse curve TMA with “T”Loops Reverse Curve TMA with “T” loops offers a superior titanium alloy with proven treatment mechanics. The “T” loop design allows for effective anterior retraction, intrusion of anterior segment and torquing.

Low friction and colored TMA If sliding mechanics and minimum friction are your goals, then colored low friction TMA is the choice of wire. Ion beam implantation procedure provides wire that has the same coefficient of friction as stainless steel and in some cases even lower.

Timolium Archwire These are intermediary in properties between TMA and Stainless steel wires. It is an excellent addition in clinician’s armamentarium.

Titanium Niobium-FA (Finishing Archwire) Designed for precision tooth to tooth finishing. Its unique metallurgical properties allow most precise intra oral detailing option available today. At 80% of the stiffness of TMA, it is perfect for holding bends yet light enough not to override the arch to arch relationship which is very hard to achieve.

54 IJO � VOL. 25 � NO. 3 � FALL 2014

Titanium Niobium FA is an innovative new arch wire designed for precision, tooth-to-tooth finishing. The unique metallurgical properties of Titanium Niobium FA make it the most precise intra oral detailing option available today. At 80% of the stiffness of TMA, it is perfect for holding bends, yet light enough not to over ride the arch-to-arch relationship that you work so hard to achieve. It is recommended for use with finishing elastics and even though it feels soft and pliable, it possesses a resiliency after bending that is equal to stainless steel.

Esthetic Arch Wires There are two types of Esthetic Arch Wires: Coated and Composite.

Coated Archwires These are stainless steel/NiTi Wires coated with Teflon/4META/Tooth colored epoxy resins (Figure 6a and 6b).

Composite ArchwiresOptiflex:31

A composite structure formed by top-coating optical glass fibers which are pure silicon dioxide with a hot melt adhesive

and a nylon skin. The result is a 17 mil wire with an 8 mil glass core. Optiflex is a new orthodontic archwire that is: 1. Made of clear optical fiber, it comprises three layers.

2. A silicon dioxide core that provides the force for moving teeth.

3. A silicon resin middle layer that protects the core from moisture and adds strength.

4. A strain-resistant nylon outer layer that prevents damage to the wire and further increases its strength.

The wire can be either round or rectangular and is manufactured in various sizes. Its mechanical properties include a wide range of action and the ability to apply light, continuous force. Sharp bends must be avoided, since they could fracture the core. Otherwise, optiflex has practically no deformation. It is a highly resilient arch wire that is especially effective in the alignment of crowded teeth and has excellent esthetics.

Marsenol: Tooth colored nickel titanium wire manufactured by glenroe technologies.It is E.T.E. coated nickel titanium. (Elastomeric poly tetra flor ethylene emulsion). Marsenol exhibits all same working characteristics of an uncoated super elastic nickel titanium wire.

Lee white wire: These are Stainless steel or nickel titanium archwire bonded to tooth colored epoxy coating.

Organic polymer retainer wire It is made from 1.6mm diameter round polytheline terephthalate. This material can be bent with a plier, but will return to its original shape if it is not heat–treated for a few seconds at temperature less than 230°C (melting point).

Other Newer ArchwiresAzurloy (preformed and straight) Azurloy (Figure 7) is a heat-treatable alloy with excellent formability in its non-treated form. Applications that take advantage of this formability, followed by heat-treating to increase the spring rate, might include:

• Multiple-loop systems• Utility arches• Overlay intrusion or Base Arches

Dual Flex Arch Wires Dual flex arch has its anterior segment made up of 0.016” or .0016” x 0.022” titanol. It is a Nickel Titanium alloy manufactured by Lancer pacific, the posterior segment is made up of 0.016” or 0.018” Stainless Steel thus combining anterior and posterior segments of different stiffness Graded Thermodynamic/Tri Force Arch Wire It has been pre programmed to deliver the right amount of force for each area of the mouth (Figure 8). Strongest to more deeply rooted molars, medium at the bicuspids and gentle at the anteriors. It is an Austenitic wire delivering force constantly. It prevents dumping of molars and unwanted rotation of premolar and gentle force to anterior teeth causing no discomfort. It gives three dimensional control early in the treatment.

Figure 6B: Gold Coated Archwires.

Figure 7: Azuralloy.

Figure 6A: Tooth Color Coated Archwire.

55IJO � VOL. 25 � NO. 3 � FALL 2014

Wallaby (High temper continuous roll): For use with light wire or edgewise appliances, wallaby is a higher temper than standard chrome alloy wire. Its higher yield strength over equivalent diameter stainless steel provides higher force for a given deflection.

Drift free archwires: A built in 1 mm midline stop prevents lateral arch wire shift. The shifting of arch wire might injure the buccal mucosa on one side and the wire is out of the buccal tube on the other side. The permanent midline stop also acts as a reference point where measurements can be taken easily. Many times the mark or the spot to demarcate the midline wears off

Conclusion Recent advances in orthodontic wire alloy have resulted in varied array of wire that exhibit a wide spectrum of properties. Presently the orthodontist may select, from all the available wire types, one that best meets the demands of a particular clinical situation.The selection of an appropriate wire size and alloy type in turn would provide the benefit of optimum and predictable treatment results. The clinician must therefore be conversant with the mechanical properties and the clinical application of these wires.

References1. Proffit W.R. Contemporary orthodontics. 4th Edition 2007. 2. T.M. Graber, Robert L. Vanarsdall, Vig Orthodontic: Current Principles And

Technique 4th Edition. 3. William A. Brantley, Theodore Elades Orthodontic materials Scientific

and clinical aspects.4. Burstone C.J. Variable modulus orthodontics. Am. J. Orthod. 1981. Vol.

80: 9-16.5. R.P. Kusy A review of contemporary archwires Their properties and

characteristics. Angle Orthod, 1997: Vol. 67: 197-208 6. Kusy RP, Dilley GJ, Whitley JQ. Mechanical prop erties of stainless steel

orthodontic archwires. Clini cal Materials 1988: Vol. 3: 41-59.

7. Backofen W.A. and Gales G.F.: The low temperature heat treatment of stainless steel for orthodontics. Angle Orthod. 1951: Vol. 21 117-128.

8. Funk A.C. Heat treatment of stainless steel. Angle. Orthod 1951: Vol. 21: 129 - 138.

9. Backofen W.A. Heat treatment of stainless steel for orthodontics. Am. J. Orthod, 1952: Vol. 38: 755 - 765.

10. Wilcock A.J. Applied materials engineering for orthodontic wires. Aust. Orthod. Journal 1989: Vol. 11: 22 - 29.

11. JCO interviews: Arthur J. Wilcock, Jr. on orthodontic wires. J. Clin. Orthod 1988. Vol. 08: 484 - 489.

12. Tomilson J.C., Fillmore G.M. Alloy wire. Angle Ortho. 1976. Vol. 46: 187-195.

13. Martin R.L., Sarkar N.K. Effect of heat treatment on various properties of Blue elgiloy. J Clin Orthod 1984 Vol. 28: 432 - 435.

14. Kusy RP, Greenberg AR. Effects of composition and cross section on the elastic properties of orthodon tic arch wires. Angle Orthod 1981: Vol 51:325-341.

15. Andersen G.F. Marrow R.E. Laboratory and clinical analysis of nitinol wire. Am. J. Orthod. 1978. Vol. 73: 142 - 151.

16. Ackerman J.L. et al., Nitinol wire round table J. Clin. Orthod. 1978. Vol. 22: 479 485.

17. Lopez L. et al., Bending characteristics of nitinol wire. Am. J. Orthod. 1979. Vol. 75: 569 - 575.

18. Anderson G.F. A clinical trail of alignment of teeth using 0.019” thermol nitinol wire with a transition range between 310 and 45°C. Am. J. Orthod 1980. Vol. 78: 528 - 537.

19. Edie J.W. Andersen G.F. et al., Surfaces corrosion of ntinol and stainless steel under clinical conditions. Angle Orthod. 1981. Vol. 57: 319 - 324.

20. Drake S.R. Wayne D.M. et al. Mechanical properties of orthodontic wires in tension, bending and torsion. Am. J. Orthod. 1982. Vol. 82:45-49

21. Schwannger B. et al. Effect of Long term immersion corrosion on flexural properties of nitinol. Am. J. Orthod. 1982. Vol. 82: 45 - 49.

22. Fujio Miura et al. The super elastic property of nickel – titanium wire for use in orthodontics. Am. J. Orthod. 1986. Vol. 90: 01 - 10.

23. Burstone C.J. et al, Chinese Niti - a new orthodontic alloy. Am. J. Orthod. 1985. Vol. 87: 445 - 452.

24. Fujio Miura et al. Japanese Niti - alloy wire, use of direct electric resistance heat treatment. Eur J Orthod 1988 Vol. 10:187 - 191.

25. Fuijo Miura et al. New application of super - elastic Niti rectangular wires. J. Clin. Orthod 1990. Vol. 24: 544 - 548.

26. Burstone C.J. et al., Beta - Titanium, A new orthodontic alloy. Am. J. Orthod. 1980. Vol. 77: 121 - 132.

Figure 8: Graded Thermodynamic Archwire.

56 IJO � VOL. 25 � NO. 3 � FALL 2014

27. Kusy R.P. Comparison of Niti and Beta titanium wire sizes to conventional orthodontic arch wire material. Am. J. Orthod. 1981. Vol. 79: 625 - 629.

28. Burstone C.J. Goldberg A.J. Maximum forces and deflections from orthodontic appliances. Am. J. Orthod 1985. Vol. 84: 95 – 103.

29. Burstone C.J. et al. Optimal welding of Beta titanium orthodontic archwires Am. J. Orthod 1987. Vol. 92: 213 - 219.

30. Burstone C.J. and Parrokh Farzin. Production of low friction and colored TMA by ion implantation. J. Clin. Orthod. 1995. Vol. 29: 453 - 461.

31. Talass M.F. Optiflex archwire treatment of a skeletal class Ill open bite. J. Clin. Ortho. 1992. Vol. 26: 245 – 252.

Dr. Jyothikiran is working as Associate Professor at J.S.S. Dental College and Hospital in Mysore, Karnataka, India. He has a special interest in orthognathic surgical areas. And, has many publications to His credit in National and indexed International Journals. He has chaired scientific sessions at Orthodontic conferences.

Dr. Ravi Shantharaj is an Associate Professor in the Department of Orthodontics and Dentofacial Orthopaedics at JSS Dental College and Hospital in Mysore, Karnataka, India.

Dr. Panchali Batra is working as Assistant Professor in the Department of Orthodontics and Dentofacial Orthopaedics at Jamia Millia Islamia Dental College and Hospital in New Delhi, India. She has a special interest in cleft lip and palate areas. She has many publications in indexed national and international journals to her credit.

Dr. Pradeep Subbiah is a Lecturer in the Department of Orthodontics and Dentofacial Orthopaedics at JSS Dental College and Hospital in Mysore, Karnataka, India.

Dr. Bhagya Lakshmi is a Reader in the Department of Orthodontics and Dentofacial Orthopaedics at JSS Dental College and Hospital in Mysore, Karnataka, India.

Dr. Vishal Kudagia is a Lecturer in the Department of Orthodontics and Dentofacial Orthopaedics at JSS Dental College and Hospital in Mysore, Karnataka, India.

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57IJO � VOL. 25 � NO. 3 � FALL 2014

Difficulties Achieving Orthodontic Stability? The Answer May be Blowing in the Wind

By Daniel Hanson, BDS

he majority of children today exhibit some degree of malocclusion1,2 and it has been well documented that this is related to soft tissue dysfunction.3,4 In fact, it is now so well accepted that the muscles of

the tongue, lips and cheeks play a major role in tooth position and jaw development,5,6 there are contemporary pre-orthodontic clinics around the world, using myofunctional philosophy to treat children between five and 15-years-old (Myobrace Pre-Orthodontic Center®). However, despite these evolutionary myofunctional treatment systems achieving outstanding results, a small percentage of cases that prove difficult to treat remains. This raises questions regarding what is causing these stubborn cases as well as how best to treat them when all obvious poor myofunctional habits, such as digit sucking, tongue postural issues, and dysfunctional swallowing patterns, have been addressed in the myofunctional sense. It appears that answers may be uncovered by examining the child’s airways and breathing patterns. Relevant literature explains how mouth breathing is a significant factor in the aetiology of malocclusion.7,8,9,10,11,12 In short, when mouth breathing occurs, the tongue moves down in the mouth to allow the passage of air above it. Furthermore, an open mouthed posture can affect the direction of growth as the muscles pulling on the jaws are affected. However, the real details of why children habitually mouth breath are not so well documented.

Factors Involved in Children (or Adults) with Breathing DysfunctionFactor 1: Tongue and Head Posture Breathing through the mouth causes the tongue to lower as well as alters the head posture. This low tongue posture then leads to reduced maxillary growth13,14 and increases in vertical growth (Figure 1).

Factor 2: The Bohr effect and Cellular Hypoxia It is important to be mindful that breathing dysfunction includes more than just mouth breathing. It also includes habitual hyperventilation, which means the patient will constantly be breathing an excess of air. This will then cause the bond between haemoglobin and oxygen to be strengthened (Bohr Effect) and while blood oxygen saturation can be normal, oxygenation at a cellular level may be reduced due to poor oxygen release from haemoglobin. As a result cells become stressed and this cellular hypoxia can lead to dysfunction on a cellular level.

FEATURE This article was submitted by Myofunctional Research Co.www.myoresearch.com and has not been peer reviewed.

Figure 1: Mouth breathing and low tongue posture causes crowding and a narrow upper arch.

Figure 2: The central proposition of the Bohr Effect states oxygen affinity to hemoglobin depends on absolute CO2 concentrations and reduced CO2 values decrease oxygen delivery to body cells. Habitual hyperventilation leads to reduced arterial CO2 and therefore, less oxygen released to cells.

My observations as a breathing educator and dentist practicing myofunctional orthodontics is that in addition to maloclussions, patients with poor breathing patterns also tend to have sinus congestion, asthma, hay-fever, enlarged adenoids or tonsils as well as ADD, Asperger’s and other syndromes on the autism spectrum (Figure 2).

Factor 3: Becoming Locked into a Cycle of Habitual Hyperventilation Patients who habitually hyperventilate become accustomed to breathing greater than the physiological norm (> 4-5L/min at rest). It is hypothesied habitual hyperventilation causes the trigger point at which the brain detects a level of CO2 sufficient to prompt the breathing reflex to become too low and patients become sensitive to healthy CO2 levels causing them to breathe an excess of air. Because they are locked into this cycle of habitual hyperventilation, breaking the mouth breathing habit may be difficult for these patients and they may require extra help.

58 IJO � VOL. 25 � NO. 3 � FALL 2014

What can be done to help these patients? An increasing number of dental professionals are focusing on innovative techniques to help these patients break their cycle of habitual hyperventilation. These techniques involve a combination of breathing and airway awareness exercises intended to assist the patient to become accustomed to breathing smaller, healthier volumes of air. As a result these patients learn to breathe less (retain more CO2) and more O2 is released to their cells and tissues. Additionally, airways remain clearer, patients often become healthier, and tongue posture improves when mouths remain closed. These techniques are used by Myobrace® Pre-Orthodontic Centers to treat the difficult 5% of cases where the patient does not adapt to a better breathing habit using Myobrace® appliances along with myofunctional and breathing activities alone. To predict which patients may require help correcting their airway dysfunction, they can be divided into three groups during treatment planning (see below). It is important to note the groups remain flexible.

Group 1: Unlikely to require assistance – five percent of patients. - No asthma - No Hx of ENT - No medications - No regular illnessGroup 2: May possibly require assistance – 90 percent of patients. - Previous asthma - Previous ENT - Medications - Regular illnessGroup 3: Likely to require assistance – five percent of patients. - Current asthma - Current ENT - Multiple / several medications - Constant illness Patients classified into Groups 1 and 2 are likely to change their airway dysfunction after treatment with the Myobrace System™, which encourages correct breathing. However, patients classified into Group 3, and in some instances those in Groups 1 and 2, are likely to require additional assistance.

How can a habitual hyperventilator be identified? Generally, they will show:• Mouth breathing, lips apart at rest.• Shoulder / upper chest breathing at rest• Audible breathing at rest• Medical history of enlarged tonsils and/or adenoids, asthma,

hay-fever, recurrent respiratory infections, snoring, teeth grinding or sleep apnea.

• Narrow upper arch form.• Forwards head / shoulder posture.• Venous pooling (see description below). A note on Venous Pooling: Typically, mouth breathers will exhibit venous pooling, which occurs as a result of the inferior orbital becoming constricted due to low levels of CO2, which usually has a vasodilatory effect. Additionally, this causes a reduction in N2O (found in the paranasal sinuses),15 which is also vasodilatory and mixes with air when nasal breathing is predominate. Furthermore, patients with narrow maxillae can be expected to have a smaller than average pterygomaxillary fissure. As a result of these two factors there is less venous drainage from the inferior orbital vein, which has to pass through the narrowed pterygomaxillary fissure. Deoxygenated or venous blood then pools beneath the eyes. When a patient habitually breathes through their mouth and has a narrow maxilla they will show symptoms of venous pooling.

Summary of factors associated with venous pooling: • Low blood CO2 caused by habitual hyperventilation.• Low N2O caused by a lack of nasal breathing.• Reduced vasodilation caused by low CO2 and N2O.• Small pterygomaxillary fissure as a result of constricted maxilla.• Low tongue posture.

Conclusions It is clear a correctly functioning tongue acts as a natural retainer but when a patient habitually breathes through their mouth, the tongue is prevented from functioning in this correct way. In contrast, when the mouth remains closed and the tongue sits correctly, increased orthodontic stability can be expected. Furthermore, when a patient maintains a closed mouth posture and high tongue posture, treatment time can be expected to lessen as forces exerted on the teeth and jaws will work favorably. Finally, it has been well-documented mouth breathing is not in the best interests of health, growth and correct development.16,17 Therefore, it is reasonable to assume encouraging correct functional breathing patterns will have a much more far-reaching effect than just correcting crooked teeth and jaws. Simply fixing the teeth and jaws is potentially missing a huge piece of the puzzle at the expense of possible health gains and future orthodontic stability.

References:1. Birgit Thilander, Lucia Pena, Clementina Infante, Sara Stella Parada, Clara de

Mayorga. Prevalence of malocclusion and orthodontic treatment need in children and adolescents in Bogota, Columbia. European Journal of Orthodontics.

2. Fabio Ciuffolo, Lamberta Manzoli, Michele D’Attilo, Simona Tecco, Filippo Muratore, Felice Festa, Ferdinando Romano. Prevalence and distribution by gender of occlusal characteristics in a sample of Italian secondary school students: a cross-sectional study. European Journal of Orthodontics.

3. German O. Ramirez- Yanez, Chris Farrell. Soft Tissue Dysfunction: a missing clue when treating malocclusions. International Journal of Functional Orthopedics (2005).

4. Rohan Wijey. Muscling in on the truth. Australasian Dental Practice.5. German O. Ramirez-Yanez. Insights into Orthodontic Treatment. Dental Asia

(July/August 2006).6. German O. Ramirez-Yanez. The Trainer System in the context of treating

malocclusions. Ortho Tribune (August / September 20097. Dante Bresolin, Peter A. Sharpiro, Gail G. Shapiro, Chapko, M.K., Dassel, S.,

Brasilia, D.F. Mouth breathing in allergic children: Its relationship to dentofacial development. A Journal of Orthodontics and Dentofacial Orthopedics 1983.

8. Souki BQ, Pimenta GB, Souki MQ, Franco LP, Becker HM, Pinto JA. Prevalence of malocclusion among mouth breathing children: do expectations meet reality? Int J Pediatr Otorhinolaryngol. 2009 May; 73(5): p.767-773.

9. Abreu RR, Rocha RL, Lamounier JA, Guerra AF. Etiology, Clinical Manifestations and Concurrent Findings in Mouth-breathing Children. J Pediatr (Rio J). 2008 Nov-Dec; 84(6): p.529-535.

10. Costa JR, Pereira SR, Weckx LL, Pignatari SN, Uema SF. Radiological evaluation of facial types in mouth breathing children: a retrospective study. Int J Orthod. 2008 Winter; 19(4): p. 13-16.

11. Flutter, J. The negative effect of mouth breathing on the body and development of the child. Int J Orthod. 2006 Summer; 17(2): p. 31-37.

12. Katherine W. L. Vig. Nasal Obstruction and Facial Growth: The Strength of Evidence for Clinical Assumptions. Dentofacial Ortholi 1998; 113:663-11.

13. German O. Ramirez-Yanez. Insights into Orthodontic Treatment. Dental Asia (July/August 2006).

14. German O. Ramirez-Yanez. The Trainer System in the context of treating malocclusions. Ortho Tribune (August / September 2009).

15. Lundberg JO, Farkas-Szallasi T, Weitzberg E, Rinder J, Lidholm J, Anggaard A, Hokfelt T, Lundberg JM, Alving K. High nitric oxide production in human paranasal sinuses. Nat Med 1995 April; 1(4): 370-3.

16. Flutter J. The negative effect of mouth breathing on the body and development of the child. Int J Orthod. 2006 Summer; 17(2): p. 31-37.

17. Katherine W. L. Vig. Nasal Obstruction and Facial Growth: The Strength of Evidence for Clinical Assumptions. Dentofacial Ortholi 1998; 113:663-11.

59IJO � VOL. 25 � NO. 3 � FALL 2014

Abstract: There are rare cases of impacted permanent central incisors with dilacerations, a dental deformity characterized by pronounced angulations of the longitudinal tooth axis. Impaction of maxillary canines is an orthodontic anomaly that causes facial and dentoalveolar system problems, both functional and esthetic. A combination of surgery and orthodontics is important in bringing impacted teeth to their ideal position in the dental arch. This is a case report of a 10-year-old patient with impacted and dilacerated right central incisor and impacted left maxillary canine, following surgical exposure and appropriate orthodontic traction, the impacted teeth were surgically exposed and aligned into the dental arch. Keywords: Multiple Impactions, Cone beam computerized tomography, Orthodontics.

Orthodontic Exposure of Multiple Impactions: A Case Report

By Maridin C. Munda-Lacson, DMD, IBO, FPFA, FICCDE; Adith Venugopal, BDS

ntroductionEruption is the axial or occlusal movement of the tooth from its developmental position within the jaw to its functional position in the occlusal plane.1 Teeth that cease to erupt before the emergence are

known as impacted teeth. It is well known that maxillary canines are among the teeth most frequently impacted, and palatal impactions occur three times as frequently as labial impactions. These impactions occur in a ratio of 3:1 in females as compared to males.2, 3 Impacted teeth come with a varied array of diverse etiology, some of them are prolonged retention or early loss of deciduous tooth, abnormal position of tooth bud, presence of alveolar cleft, lack of space, ankylosis, alveolar or dental trauma and dilacerations of teeth.4 Delayed shedding of the deciduous predecessor was the primary etiology in the presented case. Another uncommonly occurring defect is dilacerations. It is defined as the abrupt deviation of the long axis of the crown or root portion of teeth, resulting from the non axial traumatic displacement of already formed hard tissue relative to the developing soft tissue. The most frequently encountered type of dilacerations is root angulations of the maxillary incisors when the crowns are inverted, because of their close topographic relationship with the frequently injured primary teeth. The etiology of dilacerations is not fully understood and there is no consensus among researchers. The most acceptable explanation considers acute mechanical trauma on the deciduous predecessor as the cause of dilacerations to the underlying developing permanent tooth.5

Exact three-dimensional localization of impacted teeth is invaluable in orthodontic diagnosis and treatment planning. Accurate diagnosis is the key to a good treatment. Cone Beam CT technique enables three-dimensional imaging and has the additional advantages of lower cost, smaller device size, and smaller radiation dose when compared to conventional CT. This technique yields the advantage of full volumetric morphology, clear separation between impacted teeth and the surrounding tissue, and also the position and angulations of impacted teeth in all three spatial dimensions could be assessed.6

FEATURE This article has been peer reviewed.

The aim of this article is to present the successful orthodontic treatment of a patient whose permanent maxillary central incisor was impacted and presented root dilaceration along with an impacted canine and the resulting successful tooth alignment in the dental arch.

Diagnosis A 10-year-old female patient was referred to the orthodontic office. The chief complaint of the patient was misaligned upper and lower teeth and spacing between her teeth. Extra oral examination of the patient revealed a straight profile with competent upper and lower lips. Intraoral examination of the patient revealed an asymmetrical upper and lower arch, dental midline is off to the right missing 11(8) and 23 (11) with moderate crowding in the upper and lower arch, partially impacted 17 (2) and 47 (31) and increased overjet. The upper arch was relatively narrow (Figures 1-8).

Figure 1-8: Pre-treatment extraoral and intraoral photographs of the patient.

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Panoramic radiograph confirmed the presence of impacted 11 (8) and 23 (11). Both the impacted teeth had well-developed roots and were mesially angulated. The 11 (8) also presented with dilacerated root. Cephalometric findings showed an orthognathic maxilla and mandible with a skeletal class I and within normal upper and lower facial heights. Upper incisors were proclined. (Table 01) (Figure 9-10).

Treatment Objectives1. To bring the impacted teeth to occlusion2. To correct the arch asymmetry.3. To achieve ideal overbite and overjet.4. To achieve proper interdigitation.

Treatment Progress Brackets were placed on the lower arch with an expansion device on the upper arch in order to gain space to compensate for the impacted teeth. After three months in active and stabilization phase of expansion on the upper arch, the brackets were placed. (Figure 11-12). After initial leveling and alignment, NiTi open coil springs were placed between 12 (7), 21 (9) and 22(10), 24 (12). After gaining space for six months the surgical exposure of 11 (8) was done in the office. The surgical exposure of the impacted 23 (11) was conducted five months later. The angulations and positions of the impacted teeth with respect to the remaining dentition were studied closely with the help of a cone beam CT.

Area Pre Tx Post TX1-Growth Stage - CVM - Hand Wrist RadiographDirection - Y Axis - Facial Axis

Stage 5

66° 61°93°

Stage 6

59° 59°89°

2-Airways Upper Airway Lower Airway

22 mm11 mm

21 mm16 mm

3-Vertical – Skeletal FMA LAFH UFH/LFH SN – Go Gn

21°60 mm50-50%24°

19°63 mm45-55%23°

4-Sagittal –Skeletal Length Max Mnd Cond to A Cond to Gn Difference: By Age

94 mm119 mm25 mm

94 mm121 mm27 mm

5-Dental IMPA Wit’s

Interincisal Angle ANB Mx incisor to SN Mn incisor to A-Pog

92°Class 12.5 mm130°83°-80°3°112°1 mm

99°Class 11.5 mm122°90°-87°3°116°3 mm

6-Soft Tissue Rickett’s esthetic Line Naso-labial angle Lip seal Steiner’s S-Line

-2 mm111°YesUpper lip retrusive

-3 mm98°YesUpper lip retrusive

Figure 9-10: Pre-treatment lateral cephalometric and panoramic image of the patient.

Figure 11-12 Rapid Expansion Device was installed, parent was instructed to turn it twice a day and activation must be made for two (2) weeks.

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Figure 20-21: Alignment of 17 (2) and 47(31).

Figure 16-17: Exposure and activation of impacted 11 (8)

Figure 13-15: Cone Beam CT Images of the impacted 11 (8) and 23 (11).

Figure 18-19: Exposure and activation of impacted 23 (11).

Figure 22-23:Impacted and dilacerated 11 (8) into the arch.

Figure 24-26: Alignment of impacted canine into the arch.

Figure 27: Progress Treatment (Right side Class I canine, Edge to edge bite)

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After concentrating on the major issues of impacted 11 (8) and 23 (11), now the alignment of 17 (2) and 47 (31) was carried out and the tooth was banded to get it into proper occlusion. The impacted teeth were in the dental arch at around one year and nine months from the start of treatment. Overlay mechanics with NiTi open coil system were the mechanics of choice to achieve proper alignment. The patient was asked to wear ¼” 6 oz intermaxillary elastics twenty four hours a day for eight weeks to correct the overjet, canine relationship and further intercuspation. Inasmuch as the Class II elastics are in progress to achieve the Class I canine relationship , the overjet of the patient is affected as it produces an edge to edge bite and the midline are getting off centric. The active treatment time lasted for 2 years and 10 months after which the spaces in the dentition were closed and the teeth were well aligned. The facial appearance of the patient also improved considerably. Since the patient was in the period of her pre pubertal growth spurt the skeletal changes in the superimposition were drastic.

Discussion An ideal orthodontic finished was not completely achieved due to the tooth size discrepancy of upper right lateral incisor, a good locked in Class canine relationship was truly compromised as the patient was non cooperative in the placement of the Class II elastics, mobility and midline off centric were the resultant force as we placed the open coil spring in between upper canine and lateral. The patient’s mother was hesitant on placing a build up on the upper right lateral to achieve a tooth size proportionality. Root parallelism on upper right lateral incisor must have been perfected and properly angulated. The flaring on the lower anteriors

Figure 38: Superimposition of pre-treatment(black) and post-treatment (black broken line) cephalometric analysis of the patient on SN, registered at Sella)

Figure 28-35:Post-treatment extraoral and intraoral photographs of the patient.

Figure 36-37: Post treatment panoramic and lateral cephalometric image of the patient

Figure 38: Very pleased and happy patient.

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5. Nikolaos Topouzelis, Phoebus, Tsaousoglou, Anastasia Gofa. Management of root dilaceration of an impacted maxillary central incisor following orthodontic treatment: an unusual therapeutic outcome. Dental Traumatology 2010; 26: 521–526.

6. Hashimoto K, Arai Y, Iwai K et. al (2003). A comparison of a new limited cone beam computed tomography machine for dental use with a multidetector row helical CT machine. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 95(3):371–377.

Dr. Maridin C. Munda-Lacson graduated from the international program of Orthodontics in New York University (1996-1998). She is a faculty in the Department of Orthodontics of the University of the East,Graduate School in Manila,Philippines. Currently she is undertaking the Master of Science in Dental Education at U.E. Graduate School. Dr.Munda-Lacson received her Fellow (2007) and Diplomate (2012)

Status and Master Senior Instructor from the IAO She has been in practice for 22 years (Graduated,1992- University of the East) and was awarded as the “Distinguished Dental Clinician.”

Dr. Adith Venugopal graduated in 2010 with a Bachelor of Dental Surgery from College of Dental Sciences, Davangere,India. He is senior post graduate resident of the University of the East, Department of Orthodontics, Graduate School.

were attributed to the -6.2 mm arch length discrepancy which were leveled and aligned without any extraction on the lower arch. Thus, a lingual bonded retainer were placed and Hawley’s retainer were instructed to use as a retention.

Conclusion Comprehensive diagnosis is the key to a good treatment result. An array of tools are available for us to identify the problem and set precise treatment objectives. This case manifested the combination of multiple impacted teeth, comprehensive diagnosis and competent clinical skills to reach the treatment goal and objective.

References1. Orban’s oral histology and embryology 12th edition, Mosby, India 2009.2. Abou-Bakr Mahmoud Rabie, YuMeng Deng, David O’Donnell & Wong

Wai Lan Fanny. Treatment of a palatally impacted canine accompanied by root resorption of incisors: A case report. Quintessence International Vol. 27, Number 7/1996: 473-478

3. Mladen M. Kuftinec, D. Stom.,DMD, ScD Yehoshua Shapira, DMD. The Impacted Maxillary Canine.(II)Orthodontic Considerations and Management. Quintessence International 9/1984.

4. Sujatha G, Sivapathasundharam B, Sivakumar G, Nalinikumar S, Ramasamy M, T Srinivasa Prasad. Idiopathic multiple impacted unerupted teeth: a case report and discussion. Journal of Oral and Maxillofacial Pathology. Vol 16 Issue 1 Jan-Apr 2012: 125-127.

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64 IJO � VOL. 25 � NO. 3 � FALL 2014

ave you ever had a case in which you are close to a molar class I but not quite there? Or perhaps you needed a little more posterior space but for some reason you could not gain in the molar area?

One way to do this is a using the flat on flat plier as a vise (Figure 1).

ORTHO PEARLGaining Space and Creating a Class I Molar Relationship

Rick Grant, DMD, IBOIAO Master Senior Instructor

You may want to look at the rotation of your upper molars and in particular the first molars. Ideally the tip of the distobuccal cusp and the tip of the mesiobuccal cusp should line up with the center of the cuspid on the opposite side of the arch (Figure 2). Make a mark on the wire just mesial to the molar tube. Place the tip of a flat on flat plier on the mark. Hold the plier as a vise. With your thumb, bend the portion of the wire mesial to the mark out. Then without moving the pliers as a vise bend the distal portion of the wire in. The amount of tow in on the distal bend will be determined by the amount of rotation that is needed (Figure 3).

The bend is then towed in to create the rotation. The severity of the rotation will dictate the amount of tow in bend (Figure 4). It is important to make sure that the wire extends completely through the molar tube. If it is short it will not rotate the tooth fully. Of course, if it is too long it will irritate the patient’s cheek. The rotation of the molar will ensure a better molar Class one relationship and help you to gain space (Figure 5).

Figure 1 - Molar offset.

Figure 2 - ML cusp and the DB cusp should be in line with the center of the opposing cuspid. This allows for a Class I dental molar relationship.

Figure 3 - Molar offset. Out on the mesial/in on the distal.

Figure 4.

Figure 5 - Molar offset. Rotation allows for Class I molar relationship.

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LIT REVIEW

Controlling Your Practice’s Image. Levin RP: J Am Dent Assoc; 2013;144 (November): 1296-1297. Nobody wants bad comments on social medias; is it possible to get some control. Patients who have had a negative experience in your practice are more likely to vent their feelings on social media than the ones who had a positive experience. The best way to avoid negative comments on social media is to provide patients a method for expressing their concerns prior to leaving your office. This can be done by offering patients a feedback survey at the end of their visit and by having a front desk staff member ask them a simple question such as “how was your visit today?” Patients are more likely to express their concerns to staff members than they are to you. It is important that you have the attitude that you want to know about any negative experiences in your practice rather than avoid them. It is also important that you be aware of any negative comments about your practice that are appearing on social media. You or a staff member should monitor social media regularly and respond to any negative comments with a low-key humble response. Reviewer’s Comments:  It seems like basic principles based on common sense. Are you willing to take the time to avoid image problems?

Effect of Micro-Osteoperforations on the Rate of Tooth Movement. Alikhani M, Raptis M, et al: Am J Orthod Dentofacial Orthop; 2013;144 (November): 639-648. We all want to be able to deliver faster treatment with minimally invasive methods. Are there methods available that can increase the rate of tooth movement? This study evaluated the effect of micro-osteoperforations on the rate of tooth movement. The authors took 20 adult patients who had Class II Division 1 malocclusions requiring the extraction of maxillary first premolars. The patients were subdivided into treatment and control groups of 10 patients each. All of the patients had maxillary canines retracted using the same segmental appliance, which was anchored by a temporary anchorage device. In the experimental group, alternate sides of the maxilla received 3 micro-osteoperforations vertically in the center of the maxillary first premolar extraction space. Plaster casts were used to measure the rate of tooth movement after 28 days. The micro-osteoperforations were simple to perform, minimally invasive, and increased the rate of tooth movement 2.3-fold after 28 days. This was achieved by inducing inflammation, which increased the level of cytokines, which in turn increased the production of osteoclasts thereby increasing the rate of tooth movement. We can conclude that micro-osteoperforations are easy to perform and can increase the rate of tooth movement. Reviewer’s Comments: Including cellular changes rather than performing significant periodontal or cortical bony surgery can induce the rate of tooth movement. Since it calculated the rate of tooth movement after only 28 days, one could imagine

that repeating the non-invasive procedure could restart the process. Other studies will have to be done to see if the logic holds.

Release of Metal Ions From Fixed OrthodonticAppliance: An In Vitro Study in Continuous Flow System. Mikulewicz M, Chojnacka K, Wolowiec P: Angle Orthodod; 2014;84 (January): 140-148. The biocompatibility of orthodontic metal appliances is an important factor both for the patient and the treating dentist. The oral environment exposes orthodontic appliances to factors such as pH, mechanical stress, and corrosion, which may cause the release of metal ions from alloys. Exposed to the oral environment release of metal ions has been reported in metal intraoral appliances. The metals are known to be allergenic, cytotoxic, and mutagenic at certain levels. To assess the level of release of ions from metal fixed orthodontic appliances over time, the authors attempted to closely mimic an in vivo intraoral test environment. Stainless steel archwires, brackets, and bands from 2 companies were tested at various intervals over 28 days. A control was used over the same conditions and time without the appliances in the artificial saliva. The metal ion concentration was assessed by a spectrometry device. The measured mass of released metal ions from the tested appliance during 28 days of the study was as follows: nickel, 18.7 mg; chromium, 5.47 mg; copper, 31.3 mg. There was a greater release of ions in the first 2 hours of measurement. They could conclude using the 28-day values, an estimated release of nickel, chromium, and copper was calculated over a 2-year hypothetical treatment period. These total ion level values were well below the toxic dose to humans. The exposure to metal ions during orthodontic treatment is probably not of significance. Reviewer’s Comments: Some patient are concerned that this metal ion release may affect their health. With this study, the clinician has some information on the biocompatibility of orthodontic metal appliances and can answer patient’s questions.

Three-Dimensional Analysis of Effects of Rapid Maxillary Expansion on Facial Sutures and Bones: A Systematic Review. Bazargani F, Feldmann I, Bondemark L: Angle Orthod; 2013;83 (November): 1074-1082. Rapid maxillary expansion (RME) is a common technique used to gain maxillary width that has been around for more than a century. A number of studies have employed 2-dimensional radiographs to assess the changes generated by RME. Computed tomography and cone beam computed tomography (CT/CBCT) enable a 3-dimensional evaluation of the effects of RME expansion. The authors wanted to review the evidence on the effects of RME treatment on young patients as measured by CT/CBCT imaging. A search of the literature was performed using the PubMed, Embase, and Cochrane Library electronic databases from January 1966 to December 2012. The search

Reviewer Michel Champagne DMD, MAGD, IBO, CDE

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inclusion criteria consisted of randomized controlled trials, prospective controlled studies, and prospective case series articles. Two reviewers independently examined the data and assessed the quality of the studies. Ten abstracts or full-text articles met the inclusion criteria. The evidence reported on the effects of RME treatment was that the midpalatal suture opening is 20% to 50% of the total screw expansion. Whether the midpalatal sutural opening is parallel or triangular is not supported by consistent evidence. There appears to be more dentoalveolar change than skeletal change. The RME effect on the nasal cavity dimensions is an enlargement between 17% and 33% of the total screw expansion. The spheno-occipital synchondrosis and the circummaxillary sutures appear to be affected by expansion but with small inconclusive changes. We can conclude from these studies that RME treatment opened the midpalatal suture 20% to 50% of the screw expansion, and there were significant changes in the nasal cavity dimensions. There was a lack of quality in the reviewed articles and additional randomized controlled CBCT studies are needed. Reviewer’s Comments:  We are all aware of the effectiveness of RME and with CBCT to assess the treatment changes we can now put numbers on the effects on both the different bones and the airway.

Thirty-Two-Year Follow-Up Study of Herbst Therapy: A Biometric Dental Cast Analysis.Pancherz H, Bjerklin K, et al: Am J Orthod Dentofacial Orthop; 2014;145 (January): 15-27. The great potential of the Herbst appliance in the clinical management of Class II malocclusions has been documented.  The authors re-examined previous adolescent patients (aged 12 to 14 years) at least 30 years after treatment. For this portion of the 3-part study, a biometric analysis of dental casts was performed.  14 patients from a sample of 22 with Class II Division 1 malocclusions consecutively treated with the banded Herbst appliance were included. They were re-examined 32 years after therapy. Dental casts were analyzed from before (T1) and after (T2) treatment, and at 6 years (T3) and 32 years (T4) after treatment. The following variables were examined and recorded: maxillary and mandibular arch perimeters, intermolar and intercanine widths, mandibular incisor irregularity, sagittal molar and canine relationships, as well as overjet and overbite. Minor changes in maxillary and mandibular dental arch perimeters and arch widths were seen during treatment and post-treatment. Mandibular incisor irregularity remained, on average, unchanged during treatment but increased continuously during the 32-year follow-up period. Class II molar and canine relationships were normalized in most patients from T1 to T2. During the early 6-year post-treatment period, there was a minor relapse; during the later post-treatment period (T3 to T4), molar and canine relationships remained, on average, unchanged. Overjet and overbite were reduced to normal values in all subjects during treatment. After treatment, overjet remained, on average, unchanged, but overbite increased insignificantly. 32 years after Herbst therapy, acceptable long-term results were seen overall. Stability was found in 64% of the patients for sagittal molar relationships, in 14% for sagittal canine relationships, in 86% for overjet, and in 86% for overbite. A Class II relapse seemed

to be caused by an unstable interdigitation of the occluding teeth, a persisting oral habit, or an insufficient retention regimen after treatment. Most post-treatment changes occurred during the first 6 years after treatment. After the age of 20 years, only minor changes were noted. Long-term post-treatment changes in maxillary and mandibular dental arch perimeters and widths as well as in mandibular incisor irregularity seemed to be independent of treatment and a result of physiologic dentoskeletal changes throughout adulthood. Reviewer’s Comments:  We all know of the great potential of the Herbst appliance. The authors are to be commended for conducting such a long-term study. Although they concluded that acceptable long-term results were seen overall, 46% of patients relapsed toward a half-cusp Class II molar relationship and 86% demonstrated relapse toward a half-cusp Class II canine relationship. What are our results with our technique 32 years after treatment? Do we personally know?

Evaluating the Agreement of Skeletal Age Assessment Based on Hand-Wrist and Cervical Vertebrae Radiography.Beit P, Peltomäki T, et al: Am J Orthod Dentofacial Orthop; 2013;144 (December): 838-847. In an attempt to accurately predict the initiation of peak growth, orthodontists have used 2 radiographic systems for predicting the pubertal growth spurt. One is the hand-wrist radiograph, and the other is the cervical vertebral maturation index. Are these systems more effective than chronological age in predicting peak growth? The authors compared chronologic age to these other techniques for their precision. The study included a total of 730 untreated subjects between the ages of 6 and 18 years. Cephalometric and hand-wrist radiographs were taken close to each subject’s birthday. The data from the 2 sets of x-rays were statistically analyzed to determine the amount of agreement between the 2 methods. Additionally, chronologic age was evaluated as a predictive factor.  Calculating skeletal age based on cervical vertebral morphology does not contain enough information for accurate age estimation. The cervical spine evaluation offers no advantage over chronologic age in assessing either skeletal age or predicting the pubertal growth spurt. Peak height velocity will be missed in only a few patients if chronologic age is used as the predictive factor. They concluded that cervical spine evaluation offers no advantage over chronologic age in predicting the pubertal growth spurt. Reviewer’s Comments: From the results of this study I will probably continue to look at the cervical vertebrae maturation but will also give greater importance to the chronological age.

The Influence of Excessive Chewing Gum Use on Headache Frequency and Severity Among Adolescents.Watemberg N, Matar M et al: Pediatr Neurol; 2014;50 (January): 69-72. It is not uncommon for adolescents to suffer from chronic migraine or tension headaches, we all have seen that in our offices. The authors wanted to assess the impact of excessive gum chewing on headache occurrence among children and adolescents. Their study included 30 subjects who reported chronic headaches and

67IJO � VOL. 25 � NO. 3 � FALL 2014

excessive gum chewing. The sample was divided into 4 groups based on the amount of gum chewing per day. Group 1 was up to 1 hour; group 2, 1 to 3 hours; group 3, 3 to 6 hours; and group 4 >6 hours per day. All of the patients were asked to stop gum chewing for 1 month. At that point, their symptoms were evaluated and they were asked to renew their gum chewing habit exactly as it was before discontinuation; a second interview was carried out 2 to 4 weeks later. The study showed that following the discontinuation of gum chewing, 19 of the 30 patients reported complete resolution of headaches and 7 described some improvement in headache frequency and intensity. No improvement occurred in 4 patients. The duration of the headache symptoms before stopping gum chewing did not play a role in the clinical response because some children who reported full or significant improvement had suffered from chronic headache for up to 6 years. All 20 of the patients who reported either complete or partial headache relief reported relapse of their headaches within days to a week of resuming gum chewing. Ten of the 30 patients in this study reported chronic symptoms related to the temporomandibular joint, and these symptoms also improved upon gum chewing discontinuation. We can conclude that the discontinuation of excessive gum chewing can effectively eliminate chronic headaches in some adolescents. Reviewer’s Comments: Not surprising, but we now have data.

Treatment Effects of the Forsus Fatigue Resistant Device Used With Miniscrew Anchorage.Aslan BI, Kucukkaraca E, et al: Angle Orthod; 2014;84 (January): 76-87. Removable and fixed functional appliances are often utilized in Class II malocclusions. A factor in functional appliance Class II correction is the mesial movement of the mandibular dentition and the subsequent proclination of the lower incisors. This may not be a desired movement in many cases, thus is a potential contraindication for conventional functional appliance use. The study wanted to assess treatment effects of the Forsus appliance technique that incorporates miniscrew anchorage (FRDMS) compared to conventional Forsus and an untreated Class II control group. This was a prospective study with 48 Class II subjects; 15 were untreated controls, 17 were treated with a conventional Forsus FRD appliance (FRD), and 16 were treated with a Forsus FRD appliance with miniscrew anchorage (FRDMS). The mean age of the 3 groups was 14 years ± 6 months. In the treated groups, 0.018” fixed appliances were placed and the Forsus was inserted after 0.016 x 0.022” stainless steel archwires were engaged passively. In one group, miniscrews were placed between the mandibular canines and first premolars and attached to the canine brackets. Lateral cephalograms were taken just before Forsus insertion and after Class I molar correction. Cephalograms were also taken of the controls at 2 observation periods. The radiographs were measured and analyzed statistically to compare the groups. In the treated groups, a Class I molar was achieved and overjet reduced in a mean period of 6.5 months in the FRDMS sample and 5.5 months in the FRD group. In both treatment groups, there was distalization of maxillary molars, extrusion of mandibular molars, and extrusion and retrusion of the maxillary incisors. In both treatment groups, there were no measured skeletal treatment effects. The FRD group had a

greater overbite correction and significantly greater mandibular incisor proclination (L1/MP + 9.0o) than did the FRDMS group (L1/MP + 3.6o). They concluded that the achieved Class II molar correction and overjet reduction was solely dentoalveolar. Proclination of the mandibular incisors from Forsus treatment mechanics was minimized with miniscrew anchorage. Reviewer’s Comments:  In cases where compliance is an issue, fixed mandibular repositioning appliances may be a solution if we keep in mind that there will be no or very little skeletal effect. The major effects being dental but rarely do we want the lower incisors to procline. The use of a Forsus with miniscrews appears to be an option with promise.

Force Loss in Archwire-Guided Tooth Movement of Conventional and Self-Ligating Brackets. Montasser MA, El-Bialy T, et al: Eur J Orthod; 2014;36 (February): 31-38. The goal of this study was to investigate how different bracket and archwire combinations affect force lost to friction. We are all aware, or should be, that optimal forces for tooth movement during orthodontic treatment are significantly affected by friction. The Orthodontic Measurement and Simulation System was used for force measurements in this study. It consists of 2 computer-controlled measurement tables that can precisely alter their position (6 degrees of freedom) and can measure applied forces and moments through a 3D transducer. A resin replica of a maxillary dental arch was fabricated with the right canine and premolar removed to accommodate 1 force sensor. Brackets were bonded from the maxillary right second premolar to the left second premolar, with a canine bracket attached to the force sensor. Six different 0.022” bracket systems were used: Mini-Taurus (RMO), Victory Series (3M), Synergy (RMO), SmartClip (3M), Time3 (American Orthodontics), and SPEED. Stainless steel, nickel titanium (NiTi), and beta-titanium 0.019” x 0.025” archwires were placed in each bracket system. Traditional twin brackets were ligated with stainless steel ligatures. A 100g NiTi coil spring was then attached from the second force sensor to the canine hook to provide a distalizing force on the canine. The canine position was slowly adjusted for 4 mm of canine retraction based on the applied force using an estimated center of resistance 8.5 mm apical and 4.5 mm lingual of the bracket. The final force being applied by the NiTi coil and being felt by the tooth was recorded 20 times for each bracket and wire combination. Significant differences were seen based on various bracket and archwire combinations. The Victory Series, SmartClip, and Time3 brackets showed the lowest force loss, and therefore were the least affected by friction. The SPEED brackets generally showed the highest force loss (although the specific wires designed for the SPEED brackets were not tested). Stainless steel wires showed the lowest amount of force loss, followed by NiTi archwires. Beta-titanium wires showed the highest force loss, generally 10% higher than stainless steel wires. We can conclude that brackets and archwires both significantly influence the amount of force loss due to friction during canine retraction. Stainless steel wires showed the lowest force loss. Reviewer’s Comments:   Retracting teeth on a TMA wire is more and more popular but we should take into consideration the loss of effectiveness due to friction.

Springs Canine Retraction Decalcification Broken Brackets Fixed Retainer Mandibular

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