VOLUME 11, NUMBER 1, 2010
adequate shear bond strength for ortho- produced with self-etching primers seems
dontic purposes ranges between 5.9 to
7.8 MPa. Our findings showed that all
groups were within this range. Other inves-
tigators pointed out that the maximum
bond strength should be less than the
hardness of enamel, which is about 14.0
MPa.18,19 If the shear bond strength of
brackets exceeds this value, the enamel
surface may be damaged during debond-
ing. Conventional sealing was found to be
near this limit. Shear bond strength using
self-etching primers is considerably below
this limit, making their use preferable in
regard to debonding.
Previous studies have shown that
water storage and thermocycling affect
the shear bond strength of brackets.10,11
In the absence of these procedures,
shear bond strength tests provide infor-
mation about only the initial bond
strength. Therefore, it is important to
thermocycle specimens to assess the
durability of a bond.
Overall, thermocycling causes a reduc-
tion of the shear bond strength,10,20 as
supported by the findings of this study.
Arıcı and Arıcı9 found that in no-mix adhe-
sives, the shear bond strength was
reduced by approximately 5.7% when the
specimens were thermocycled 200 times,
but by 17.9% when thermocycling
amounted to 20,000 times. To some
degree, this is supported by Davidson et
al,21 who found a significant decrease in
shear bond strength up to 300 thermal
cycles. In contrast to the aforementioned
articles, however, the decline in this study
varied between 18% and 41%.
The main reason for the shear bond
strength decrease after thermocycling is
believed to be a possible hydrolysis at the
adhesive-hybrid layer interface. Another
theory is that the different expansion
coefficients of enamel, adhesive, and
bracket will weaken the adhesion.22
The well-defined pattern of prismatic
and aprismatic enamel after conven-
tional etching enhances the formation of
resin tags that extend deeply into the
enamel. This fact is associated with a
high shear bond strength and thus a
superior survival rate of bonded brackets
in vivo. 23,24 In contrast, the thin lami-
nalike resin penetration into the enamel
© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE
MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Sökücü et al
to sustain cyclic stresses less favorably.25
However, this study showed that the
decrease following thermocycling was
similar independent of the primer used.
Still, in the self-etching primer group, the
shear bond strength approached the criti-
cal value reported by Reynolds.17
The aim of debonding is to remove a
bonded attachment from the tooth and
safely reestablish its pretreatment condi-
tion. The more deeply the adhesive pene-
trates the enamel surface, the greater
the risk of enamel damage becomes.26
The ARI was developed to help evaluate
this problem.
Before and after thermocycling, the
mean ARI scores for the conventional and
fluoride-releasing primer groups were
focused on score 2, which indicates a bond
failure predominantly at the bracket-adhe-
sive interface. In the two antimicrobial self-
etching primer groups, the ARI was pre-
dominantly between 1 and 2, indicating
more failures at the adhesive-enamel inter-
face. Failures at the bracket/adhesive
interface offer better protection of the
enamel during debonding. If the failures
occurs mainly at the adhesive/enamel
interface, less residual adhesive remains
on the tooth whose enamel is, however,
more prone to damage.27,28
CONCLUSION
From this study, the following conclusions
can be drawn:
• The shear bond strength after the use
of a standard and a conventional fluo-
ride-releasing primer was significantly
higher than that of an antimicrobial
self-etching fluoride primer.
• Thermocycling led to a general reduc-
tion of the shear bond strength.
• After thermocycling, the shear bond
strength using an antimicrobial self-
etching fluoride-releasing primer
approached the critical shear bond
strength limit.
• The bracket failure mode after thermo-
cycling shifted slightly from bracket-
adhesive to adhesive-enamel.
 Sökücü et al WORLD JOURNAL OF ORTHODONTICS

REFERENCES 16. Wickwire NA, Rentz D. Enamel pretreatment: A

critical variable in direct bonding systems. Am J
Orthod 1973;64:499–512.
1. Buonocore MG. A simple method of increasing
17. Reynolds IR. A review of direct orthodontic
the adhesion of acrylic filling materials to
bonding. Br J Orthod 1975;2:171–178.
enamel surfaces. J Dent Res 1955;34:
18. Retief DH. Failure at the dental adhesive-etched
849–853.
enamel interface. J Oral Rehabil 1974;1:
2. Gwinnet AJ, Buonocore MG. Adhesion and
265–284.
caries prevention; a preliminary report. Br Dent
19. Bowen RL, Rodriguez MS. Tensile strength and
J 1965;119:77–80.
modulus of elasticity of tooth structure and sev-
3. Gwinnet AJ, Matsui A. A study of enamel adhe-
eral restorative materials. J Am Dent Assoc
sives. The physical relationship between
1962;64:378–387.
enamel and adhesive. Arch Oral Biol 1967;12:
20. Titley K, Caldwell R, Kulkarni G. Factors that
1615–1620.
affect the shear bond strength of multiple com-
4. Bishara SE, Oonsombat C, Ajlouni R, Laffoon JF.
ponent and single bottle adhesives to dentin.
Comparison of the shear bond strength of
Am J Dent 2003;16:120–124.
2 self-etch primer/adhesive systems. Am J
21. Davidson CL, Abdalla Al, De Gee AJ. An investi-
Orthod Dentofacial Orthop 2004;125:348–350.
gation into the quality of dentin bonding
5. Bishara SE, Soliman M, Laffoon JF, Warren J.
sytems for accomplishing a durable bond.
Shear bond strength of a new high fluoride
J Oral Rehab 1993;20:291–300.
release glass ionomer adhesive. Angle Orthod
22. Øilo G, Austrheim EK. In vitro quality testing of
2008;78:125–128.
dentin adhesives. Acta Odotol Scand 1993;51:
6. Ogaard B, Larsson E, Henriksson T, Birkhed D,
263–269
Bishara SE. Effects of combined application of
23. Hannig M, Bock H, Bott B, Hoth-Hannig W.
antimicrobial and fluoride varnishes in ortho-
Inter-crystallite nanoretention of self-etching
dontic patients. Am J Orthod Dentofacial
adhesives at enamel imaged by transmission
Orthop 2001;120:28–35.
electron microscopy. Eur J Oral Sci 2002;110:
7. Gelgör IE. Büyükyilmaz T. A practical approach
464–470.
to white spot lesion removal. World J Orthod
24. Perdigão J, Lopes L, Lambrechts P, Leitao J,
2003;4:152–156.
Van Meerbeek B, Vanherle G. Effects of a self-
8. Büyükyılmaz T, Øgaard B, Dushner H, Ruben J,
etching primer on enamel shear bond
Arends J. The caries-preventive effect of tita-
strengths and SEM morphology. Am J Dent
nium tetrafluoride on root surfaces in situ as
1997;10:141–146.
evaluated by microradiography and confocal
25. Eliades G, Watts DC, Eliades T. Bonding to
laser scanning microscopy. Adv Dent Res
enamel 1 etched enamel structure and topog-
1997;11:448–452.
raphy: Interface with materials. In: Dental Hard
9. Arıcı S, Arıcı N. Effects of thermocycling on the
Tissues and Bonding. Heidelberg: Springer-Ver-
bond strength of a resin-modified glass
lag Berlin, 2005: 1–27.
ionomer cement: An in vitro comparative study.
26. Attar N, Taner TU, Tülümen E, Korkmaz Y.
Angle Orthod 2003;73:692–696.
Shear bond strength of orthodontic brackets
10. Cehreli ZC, Kecik D, Kocadereli I. Effect of self-
bonded using conventional vs one and two
etching primer and adhesive formulations on
step self-etching/adhesive systems. Angle
the shear bond strength of orthodontic brack-
Orthod 2007;77:518–523.
ets. Am J Orthod Dentofacial Orthop 2005;127:
27. Bishara SE, VonWald L, Laffoon JF, Jacobsen
573–579.
JR. Effect of altering the type of enamel condi-
11. Kiremitci A, Yalcin F, Gokalp S. Bonding to
tioner on the shear bond strength of resin-rein-
enamel and dentin using self-etch adhesive
forced glass ionomer adhesive. Am J Orthod
systems. Quintessence Int 2004;35:367–370.
Dentofacial Orthop 2000;118:288–294.
12. ISO Technical Report 11405. Dental materials-
28. Britton JC, McInnes P, Weinberg R, Ledoux WR,
guidance on testing of adhesion to tooth struc-
Retief DH. Shear bond strength of ceramic
ture. Geneva: International Organization for
orthodontic brackets to enamel. Am J Orthod
Standardization, 1994.
Dentofacial Orthop 1990;98:348–353.
13. Artun J, Bergland S. Clinical trials with crystal
growth conditioning as an alternative to acid-
etch enamel pretreatment. Am J Orthod 1984;
85:333–340.
14. Derks A, Katsaros C, Frencken JE, van’t Hof
MA, Kuipers-Jagtman AM. Caries-inhibiting
effect of preventive measure during orthodon-
tic treatment with fixed appliances. Caries Res
2004;38:413–420.
15. Bishara SE, Ostby AW, Ajlouni R, Laffoon JF,
Warren JJ. Early shear bond strength of a one-
step self-adhesive on orthodontic brackets.
Angle Orthod 2006;76:689–693.

10

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MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Ricardo Oliveira Chicri,
DDS, MS1 EFFECT OF ENAMEL PRETREATMENT ON
Robson Tetsuo Sasaki, SHEAR BOND STRENGTH OF BRACKETS
DDS2

Adriana S. Carvalho, DDS,

MSD, PhD3
Paulo Roberto Aranha
Nouer, DDS, MSD, PhD4
Ynara B. O. Lima-Arsati,
DDS, MSD, PhD4
BONDED WITH RESIN-MODIFIED
GLASS-IONOMER CEMENT
Aim: To evaluate the shear bond strength of brackets bonded with
resin-modified glass-ionomer cement (RMGIC) using various methods
of enamel conditioning. Methods: Forty-five human premolars were
randomly divided into five groups. The roots of these teeth were fixed
in acrylic resin cylinders, and brackets were bonded to the teeth’s
crowns using the following material combinations: RMGIC only;
RMGIC and corresponding primer; RMGIC, acid etching, and Scotch-
bond Multipurpose; RMGIC and two-step self-etching primer; and
RMGIC and one-step primer. All specimens were submitted to pH
cycling for 14 days before shear bond strength was assessed in a uni-
versal test machine. Results: The medians and standard deviations
(in MPa) were RMGIC only = 8.34 ± 1.11; RMGIC and corresponding
primer = 7.05 ± 2.24; RMGIC, acid etching, and Scotchbond Multipur-
pose = 7.00 ± 4.79; RMGIC and two-step self-etching primer = 0.54 ± 0.30;
and RMGIC and one-step primer = 10.61 ± 4.58. The value for RMGIC
and two-step self-etching primer was significantly lower than all other
values. Conclusion: It can be concluded that the tested RMGIC is
suitable for bonding orthodontic brackets, even when used by itself.
Different enamel preparations do not improve its performance. How-
ever, they can worsen its bonding capacity as the combination with the
two-step primer system clearly shows. World J Orthod 2010;11:11–15.

1São Leopoldo Mandic School of

Dentistry and Research Center, Key words: adhesive systems, resin-modified glass-ionomer cement,
Campinas, SP, Brasil. shear bond strength, enamel conditioning, glass-ionomer cement
2Assistant Professor, São Leopoldo

Mandic School of Dentistry and

Research Center, Campinas, SP,
Brasil.
3Associate Professor, São Leopoldo

Mandic School of Dentistry and

Research Center, Faculty of Pinda-
monhangaba, Campinas, SP, Brasil.
4Associate Professor, São Leopoldo

Mandic School of Dentistry and

Research Center, Campinas, SP,
Brasil.
CORRESPONDENCE
Dr Ynara Bosco de Oliveira Lima-Arsati
São Leopoldo Mandic School
of Dentistry and Research Center
Rua José Rocha Junqueira
13 Ponte Preta
13041-445 – Campinas, SP
Brasil
Email: ynaralima@yahoo.com
ith the introduction of adhesives
W used with acid etching as proposed
by Buonocore1 in 1955, brackets were
bonded directly onto the teeth. Among
the adhesives commonly used are resin
composites and glass-ionomer cements.
Resin composites offer a high bond
strength,2 but they need previous acid
etching, which could harm the tooth sur-
face during bracket removal.3,4
Glass-ionomer cements adhere chemi-
cally to enamel. They release fluoride ions
into the oral cavity,5 which diminish and
even help prevent enamel loss.6 However,
their bond strength is lower than that of
composite resins. More recently devel-
oped resin-modified glass-ionomer
cements (RMGIC) are a considerable alter-
native because they have a superior bond
strength3 but still release fluoride ions.5

11

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 Chicri et al
At present, adhesive systems can be
divided into conventional and self-etching
categories. The self-etching system may
be further categorized into one- and two-
step procedures. In two-step self-etching
adhesives, the conditioner and primer
come in separate compartments. Despite
their name, one-step adhesives come in
a two-blister receptacle unit in which the
two components are conveniently mixed
before application.7 All self-etching adhe-
sive systems etch the dental enamel less
intensively.8
The optimum bracket adhesion would
be one with a sufficient bond strength
that would not harm the enamel during
bracket removal. This is why it is impor-
tant to assess bracket bonding with
RMGIC with different enamel-preparation
procedures.
MATERIALS AND METHODS
Brackets were bonded with RMGIC to 45
extracted human premolars assigned to
five experimental groups of nine teeth
each. The evaluated parameters were
shear bond strength (MPa, quantitative)
and type of fracture (qualitative).
After extraction, all teeth were stored in
0.1% thymol before their roots were
embedded in a 2.0 ⫻ 2.5 cm PVC tube
with chemically activated acrylic resin (Jet
Clássico). Thus, only the crown of each
tooth would be exposed and cleaned with
pumice (S.S. White) for 10 seconds. To
delineate the adhesion area, 4.0-mm ⫻
4.0-mm molds of adhesive tape were
attached to the vestibular surfaces of all
teeth. Subsequently, all test specimens
were painted with nail polish. After this
polish had dried, the adhesive tape strip
was removed so only the 4.0-mm ⫻ 4.0-
mm area of untreated enamel was
exposed to the following procedures.
The brackets bonded were maxillary
Edgewise Slim brackets (Dental Morelli)
with a base of approximately 10.5 mm2
(3.0 mm ⫻ 3.5 mm). In all cases, the pri-
mary bonding material was the RMGIC
Vitremer (3M ESPE). The various enamel
pretreatments were as follows:
Group 1 (Vitremer only). One spoonful
of powder and one full drop of the corre-
12
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MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
WORLD JOURNAL OF ORTHODONTICS
sponding liquid were mixed on a block
with a cement spatula for 30 seconds on
average. This mixture was spread over
the entire bracket base before the
bracket was placed with holding tweez-
ers and slight pressure onto the tooth.
Excess cement was removed with an
exploratory probe before the RMGIC was
light polymerized for 40 seconds (10
seconds on each side, Optilight Plus;
Gnatus).
Group 2 (Vitremer with previous appli-
cation of the corresponding primer).
Before bonding, primer was applied to the
enamel surface with a disposable brush
(FGM, Joinvile) for 30 seconds, in accor-
dance with the manufacturer’s instruc-
tions. This coat was dried for 20 seconds
and light polymerized for 20 seconds. All
other manipulations were identical to
group 1.
Group 3 (Vitremer with previous con-
ventional acid-primer application).
All enamel surfaces were acid etched
(37% phosphoric acid; FGM, Joinvile) for
30 seconds, followed by 20 seconds of
water spray and 10 seconds of drying
with air from a triple syringe. Scotchbond
Multipurpose (3M ESPE) was applied
with a disposable brush (FGM, Joinvile)
for 20 seconds before this coat was light
polymerized for 20 seconds. All other
manipulations were identical to group 1.
Group 4 (Vitremer with application of
a two-step self-etching primer). One
drop from bottle 1 (acidified primer) of
the self-etching adhesive system Self
Etch Bond (Vigodent) was spread for 20
seconds on the enamel surface with a
disposable brush (FGM, Joinvile). This
coat was lightly dried before one drop
from bottle 2 (adhesive) was applied,
which was also dried before it was light
polymerized for 20 seconds. All other
manipulations were identical to group 1.
Group 5 (Vitremer with application of
one-step self-etching primer). The com-
partments of Adper Prompt L-pop (3M
ESPE) were squeezed for 5 seconds to
mix the two components. This mixture
was applied with the coupled disposable
brush for 20 seconds, followed by slight
dr ying and light polymerization for
10 seconds. All other manipulations were
identical to group 1.
VOLUME 11, NUMBER 1, 2010 Chicri et al

Table 1 Mean, median, standard deviation (SD), minimum, and maximum shear
bond strength values (in MPa), 95% confidence interval (CI 95%), and statistical
significance for the test groups
Group
1 2 3 4 5

Mean 7.95 7.13 7.85 0.57 11.55

Median 8.34 7.05 7.00 0.54 10.61
SD 1.11 2.24 4.79 0.30 4.58
Minimum 6.21 2.49 3.00 0.22 5.85
Maximum 9.34 10.56 17.04 1.20 18.38
CI 95% 7.23–8.68 5.67–8.59 4.72–10.98 0.38–0.77 8.56–14.54
* a a a b a

* Different letters indicate significant difference (P < .05; Kruskal-Wallis and Dunn method).

After bonding, all brackets were pH
cycled for 14 days to simulate intraoral
conditions. All specimens were immersed
in an acid solution for 6 hours (pH 4.3;
Ca 2.0 mM; P 2.0 mM; acetate buffer
0.075M) and a neutral solution for
18 hours (pH 7.0; Ca 1.5 mM; P 0.9 mM;
KCl 0.15 M; TRIS buffer 0.02M).9
The shear strength test was per-
formed with a universal testing machine
(EMIC Equipamentos e Sistemas de
Ensaio) with a 200 kgf load cell at a
crosshead speed of 0.5 mm/min. The
shear strength was calculated in kgf/cm2
with the formula: R = F/A, with R = shear
strength, F = load required to rupture the
bracket-tooth bond, and A = bracket base
area (0.105 cm2). The shear strength in
kgf/cm 2 was transformed into MPa by
multiplying the individual values by
0.0980665.
Further, after fracture, the enamel and
bracket surfaces were observed through a
stereoscopic lens (EK3ST, Eikonal Equipa-
mentos Ópticos e Analíticos) at 45⫻ mag-
nification to verify the fracture mode.
Adhesive failure was considered when the
bonding material detached from the
bracket base or tooth surface and cohe-
sive failure when the fracture occurred
within the bonding material.
RESULTS
Table 1 presents the shear strength val-
ues obtained in the five experimental
groups. Group 4 gave a significantly lower
shear bond strength than any of the
other groups. There were no other signifi-
cant differences among groups 1, 2, 3,
and 5.
In all cases, the fracture mode was of
the cohesive type, and no comparisons
were deemed necessary.
DISCUSSION
Since the introduction of acid etching
into orthodontics, many studies have
been conducted to detect the best
method for bonding brackets to
teeth.6,10–12 Mostly, composite resins are
used for orthodontic bonding. These
require initial etching of the enamel and
the application of a primer. This can be
avoided when RMGICs are used
instead.4,13,14
The results of the shear bond strength
obtained in this study with RMGIC, except
when used with a two-step self-etching
primer system, corroborated the results
of other studies.16–22
The similar values of group 1 and 2
can be explained by the fact that the pH
of the Vitremer liquid (pH 2.5 to 3.5) is
similar to the pH of its primer (pH 2.9 to
4.0). Thus, both products are initially
acidic with a pH below the critical pH
for enamel (5.5 23 ), causing a similar
demineralization as regular etching. The
existing chemical bond between RMGIC
and the enamel is therefore increased
mechanically.
Group 4 resulted in a median bond
strength of 0.54 MPa, which is unaccept-
able for clinical bracket bonding. The

13

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 Chicri et al
weak performance is in agreement with
the study of Cehreli et al.24 This inferior
behavior could be related to the pH of the
product, allegedly because two-step self-
etching primers are less acidic than one-
step self-etching systems.8 If this is the
case, the etching will not increase the
bond strength but impede the chemical
bond because the direct contact between
the ionomeric GIC and enamel is pre-
vented.
The result of group 5 is confirmed by
other studies. 15,25–27 The rather high
strength of median = 10.61 MPa could
perhaps be explained by the initial pH of
the etch-primer liquid, which is lower
(around 1.0) than that of other products,
which likely enhances the formation of
more or deeper microretentions.
When comparing the various enamel
preparations tested in this study, it
becomes clear that group 5 obtained a
better result than group 3. This was com-
bined with the advantage of a more con-
venient application, thus diminishing the
chance of technical failures. However, the
higher costs of this self-etching primer
must be considered, which might prevent
some orthodontists from using it regularly.
It has been suggested that a shear
bond strength of 6.0 to 8.0 MPa is ade-
quate for or thodontic bonding pur-
poses.28,29 All tested groups in this study
presented MPa values within this range
(with the exception of groups 4 [0.57
MPa] and 5 [11.55 MPa]). This hints at a
recent theory, according to which the
internal strength of the RMGIC not only
plays a role in bonding performance but
also its elasticity and that of the other
components of the bracket-cement-
enamel system.30
In regard to the type of fracture, the
result of this study is similar to the
results of other studies.2,13,19 Clinically,
this is significant because considerable
chair time is needed to remove the resid-
ual adhesive, and there is a possibility of
damaging the enamel.
Overall, RMGIC is adequate for bracket
bonding and may be used with or without
primer. It has the great advantage of
releasing fluoride ions, thus diminishing
or preventing enamel demineralization
around orthodontic brackets.
14
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WORLD JOURNAL OF ORTHODONTICS
CONCLUSIONS
From this study, it can be concluded that:
• RMGIC has an adequate shear bond
strength for bonding brackets to
enamel.
• When using RMGIC, enamel pretreat-
ment does not regularly improve bond
shear strength.
REFERENCES
1. Buonocore MG. A simple method of increasing
the adhesion of acrylic filling materials to
enamel surfaces. J Dent Res 1955;34:
849–853.
2. Grandhi RK, Combe EC, Speidel TM. Shear
bond strength of stainless steel orthodontics
brackets with a moisture-intensive primer. Am
J Orthod Dentofacial Orthop 2001;119:
251–255.
3. Capelozza Filho L, Faidiga AM, Corso ALM, Bas-
tos JRM. Comparative “in vitro” study of the ten-
sile bond strength of brackets bonded with a
glass ionomer cement (Fuji Ortho LC) and a
composite resin (Concise) [in Portuguese]. Rev
Dental Press Ortod Ortop Facial 1997;2:65–70.
4. White LW. Glass ionomer cement. J Clin Orthod
1986;20:387–391.
5. Wilson AD, Kent BE. A new translucent cement
for dentistry. The glass ionomer cement. Br
Dent J 1972;132:133–135.
6. Fricker JP. A 12-month clinical evaluation of a
glass polyalkenoate cement for direct bonding
of orthodontic brackets. Am J Orthod Dentofa-
cial Orthop 1992;101:381–384.
7. Carvalho RM, Carrilho MR de O, Pereira LCG, et
al. Adhesive systems: Fundamentals for the
understanding of its application and perfor-
mance in clinic [in Portuguese]. Rev Biodonto
2004;2:8–86.
8. Tay FR, Pashley DH. Aggressiveness of contem-
porary self-etching systems. I: Depth of pene-
tration beyond smear layers. Dent Mater
2001;17:296–308.
9. Serra MC, Cury JA. The in vitro effect of glass-
ionomer cement restoration on enamel sub-
jected to a demineralization and remineraliza-
tion model. Quintessence Int 1992;23:
143–147.
10. Amra I, Samsodien G, Shaikh A, Lalloo R. Xeno
III self-etching adhesive in orthodontic bonding:
The next generation. Am J Orthod Dentofacial
Orthop 2007;131:160.e11–15.
11. Buzzitta VAJ, Hallgren SE, Powers JM. Bond
strength of orthodontic direct-bonding cement-
bracket systems as studied in vitro. Am J
Orthod 1982;81:87–92.
VOLUME 11, NUMBER 1, 2010
12. Bishara SE, Oonsombat C, Soliman MM, War-
ren JJ, Laffoon JF, Ajlouni R. Comparison of
bonding time and shear bond strength
between a conventional and a new integrated
bonding system. Angle Orthod 2005;75:
233–242.
13. Cook PA, Youngson CC. An in vitro study of the
bond strength of a glass ionomer cement in the
direct bonding of orthodontic brackets. Br J
Orthod 1988;15:247–253.
14. Kirovski I, Madzarova S. Tensile bond strength
of light-cured glass ionomer cement when used
for bracket bonding under different conditions:
An in vitro study. Eur J Orthod 2000;22:
719–723.
15. Cacciafesta V, Sfondrini MF, De Angelis M, Scrib-
ante A, Klersy C. Effect of water and saliva cont-
amination on shear bond strength of brackets
bonded with conventional, hydrophilic, and self-
etching primers. Am J Orthod Dentofacial
Orthop 2003;123:633–640.
16. Rosenbach G, Cal-Neto JP, Oliveira SR,
Chevitarese O, Almeida MA. Effect of enamel
etching on tensile bond strength of brackets
bonded in vivo with a resin-reinforced glass
ionomer cement. Angle Orthod 2007;77:
113–116.
17. Komori A, Ishikawa H. Evaluation of a resin-
reinforced glass ionomer cement for use as an
orthodontic bonding agent. Angle Orthod
1997;67:189–195.
18. Silva Filho OG, Okada HY, Okada T, Freitas CA,
Feitas SF. Clinical evaluation of the effective-
ness of a photo-activated glass ionomer
cement (Vitrebond) for direct bonding of ortho-
dontic brackets during 4x2 leveling [in Por-
tuguese]. Rev Dental Press Ortod Ortop Facial
1999;4:31–44.
19. Souza CS, Francisconi PAS, Araújo PA. Bond
resistance of five cements used in orthodontics
[in Portuguese]. Rev FOB 1999;7:15-21.
20. Rix D, Foley TF, Mamandras A. Comparison of
bond strength of three adhesives: Composite
resin, hybrid GIC, and glass-filled GIC. Am J
Orthod Dentofacial Orthop 2001;119:36–42.
© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE
MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Chicri et al
21. Movahhed HZ, Ogaard B, Syverud M. An in vitro
comparison of the shear bond strength of a
resin-reinforced glass ionomer cement and a
composite adhesive for bonding orthodontic
brackets. Eur J Orthod 2005;27:477–483.
22. Reynolds IR, von Fraunhofer JA. Direct bonding
of orthodontic brackets—A comparative study
of adhesives. Brit J Orthod 1976;3:143–146.
23. Fejerskov O, Kidd E. Dental caries: The disease
and its Clinical Management, ed 2. Oxford:
Wiley-Blackwell, 2008.
24. Cehreli ZC, Kecik D, Kocadereli I. Effect of self-
etching primer and adhesive formulations on
the shear bond strength of orthodontic brack-
ets. Am J Orthod Dentofacial Orthop 2005;127:
573–579.
25. Campista C, Chevitarese O, Vilella O. Compari-
son of three dental adhesive systems concern-
ing shear bond strength in premolars [in Por-
tuguese]. J Bras Ortodontia Ortop Facial 2003;
8:59–66.
26. Grubisa HSI, Heo G, Raboud D, Glover KE,
Major PW. An evaluation and comparison of
orthodontic bracket bond strengths achieved
with self-etching primer. Am J Orthod Dentofa-
cial Orthop 2004;126:213–219.
27. Buyukyilmaz T, Usumez S, Karaman AI. Effect
of self-etching primers on bond strength—Are
they reliable? Angle Orthod 2003;73:64–70.
28. Øgaard B, Bishara SE, Duschner H. Enamel
effects during bonding-debonding and treat-
ment with fixed appliances. In: Graber TM, Eli-
ades T, Athanasiou AE, eds. Risk Management
in Orthodontics: Experts Guide to Malpractice.
Chicago: Quintessence, 2004:19–46.
29. Powers JM, Messersmith ML. Enamel etching
and bond strength. In: Brantley WA, Eliades T,
eds. Orthodontic Materials: Scientific and Clini-
cal Aspects. Stuttgart, Germany: Thieme, 2001:
105–122.
30. Algera TJ, Kleverlaan CJ, Prahl-Andersen B,
Feilzer AJ. The influence of dynamic fatigue
loading on the separate components of the
bracket-cement-enamel system. Am J Dent
2008;21:239–243.
15
EFFICIENCY AND EFFECTIVENESS Alana K. Saxe, DMD1

OF SURESMILE Lenore J. Louie, MSc,

DMD2

Aim: To examine the efficiency and effectiveness of the SureSmile process James Mah, DDS, MSc,
using the standards of the American Board of Orthodontists Objective DMSc3
Grading System (ABO OGS). Methods: Three diplomates of the American
Board of Orthodontics provided study casts of 62 patients whose ortho-
dontic treatment was consecutively completed. Patients treated using the
SureSmile process and a conventional approach were anonymized and
randomized prior to independent scoring by two ABO OGS–calibrated
examiners. Results: Intra- and interexaminer reliability was consistent in all
components with no differences between examiners (r = 0.96, P < .001).
The ABO OGS score for the SureSmile patients (mean 26.3) was 4.4 points
lower (P < .001) than for those treated conventionally (mean 30.7). Further-
more, treatment with the SureSmile process was shorter (14.7 months vs
20.0 months). Conclusion: The SureSmile process results in a lower mean
ABO OGS score and a reduced treatment time than conventional
approaches. The approach has great potential to both decrease treatment
time and improve quality. World J Orthod 2010;11:16–22.

Key words: computer, efficiency, orthodontics, treatment

fficient management of orthodontic months (SD 4.7, n = 366),3 similar to the

E patients in delivering timely care is an
important aspect of treatment.1 Ortho-
dontics is focused on developing meth-
ods or techniques to decrease treatment
time while maintaining quality outcomes.
Although orthodontists have pursued this
goal for quite some time, at present,
there is no conventional orthodontic bio-
mechanical treatment approach that has
demonstrated any greater efficiency or
effectiveness than any other. This is likely
due to the complexity of orthodontics and
the diversity of patients. Thus, it is imper-
ative to understand the factors that can
adversely impact the length of orthodon-
tic treatment and use this information to
implement measures that promote care
more predictably and timely.
Studies have shown that average
treatment time ranges from 23.1 to 31.2
months, depending on the design of the
investigation and other factors. 1,2 A
study from New Zealand determined
average treatment length to be 23.5
months with a range of 12.0 to 37.0
previously reported 23.1 months2 and
22.04 months from a comparable study.
However, longer treatment times (28.6
months 5 and 31.2 months 1 ) are also
found in the relevant literature.
Patient cooperation is well-recognized
as a factor of treatment duration. It
encompasses missed appointments,
compliance with appliance wear, broken
appliances, and poor oral hygiene. The
role of poor patient cooperation on treat-
ment length has been described in a
number of studies.2,3,5–8 Regardless of
patient age, 46% of the variability in 1Private Practice, Las Vegas, Nevada,
treatment duration and 24% of the vari- USA.
2Private Practice, Vancouver, British
ability in treatment effectiveness was
explained by the number of missed Columbia, Canada.
3Associate Clinical Professor,
appointments and broken appliances.6
School of Dentistry, University of
Poor elastic wear was shown to increase Nevada, Las Vegas, Nevada, USA.
treatment length by a mean of 1.4
months, while three or more poor oral CORRESPONDENCE
hygiene entries increased treatment time Dr James Mah
UNLV School of Dental Medicine
by 1.2 months.3 Similar findings of the 1001 Shadow Lane
effect of patient cooperation on treat- Las Vegas, NV 89106
ment time have been reported.9,10 Email: james.mah@sdm.unlv.edu

16

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VOLUME 11, NUMBER 1, 2010
Malocclusion severity is another major
factor that influences treatment duration.
It was significantly longer for patients
with a discrepancy index (DI) score
greater than 20 (32.9 months) compared
to those with a DI score between 10 and
19 (28.5 months) or less than 10 (26.3
months).11,12 Other studies have shown
that the Angle Class and magnitude of
overjet have an impact on treatment
length. Correction of Class II relationships
took 5 months longer than Class I occlu-
sions.13 The severity of overjet was found
to explain 46% of the variability in treat-
ment duration.7 Similarly, the pretreat-
ment Peer- Assessment Rating (PAR)
Index 14 was higher in patients with a
Class II occlusion compared to those with
a Class I relationship, reinforcing that it
takes a certain amount of time to correct
the buccal occlusion and overjet.7,15 How-
ever, there is one study that denies a
relationship between the severity of mal-
occlusions and treatment duration.16 No
differences in treatment duration or num-
ber of appointments were found between
Class 1 and Class 2 nonextraction/
extraction patients.17 Finally, one study
saw no significant association between
the magnitude of the overbite and overjet
with treatment duration.18
Further, extraction has been consid-
ered a factor that increases treatment
duration.2,4,8,13,15 This is particularly true
for premolar extractions, which could
extend treatment by 4.6 months com-
pared to nonextraction orthodontic ther-
apy. 4 Altering the course of treatment
from the original plan, often referred to
as trial nonextraction therapy, was also
found to be a significant cause of
increased treatment time. 9 However,
there are again studies that reported that
extractions do not significantly affect the
length of treatment.5,10
Treatment quality is another factor that
affects treatment duration. A good num-
ber of measures have been developed to
objectively determine the quality of ortho-
dontic treatment. One example is the
Objective Grading System (OGS), which
was developed by the American Board of
Orthodontics (ABO). It was designed by
a committee in 1994 with the goal of
establishing a more objective evaluation.
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MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Saxe et al
Beginning in 1995, it was revised over the
course of four field tests. In February
1999, the ABO officially implemented this
grading system for the assessment of
completed orthodontic therapies.19
The reliability of the ABO OGS has
been studied by four orthodontic faculty
members who assessed 36 randomly
selected posttreatment study models
gathered from six orthodontic offices.20
Intraexaminer differences were found to
range from three to six subtraction points
in the total score (r = 0.77) between two
grading sessions. The correlation was
greatest for occlusal relationships
(r = 0.83) and least for interproximal con-
tacts (r = 0.52). The interexaminer corre-
lation coefficient for the total ABO OGS
score was also good (r = 0.85), with the
greatest correlation for buccolingual incli-
nation (r = 0.85) and lowest for overjet
(r = 0.50). The data revealed that some
judges were much more lenient than oth-
ers, which resulted in a wide range of
total scores (19.7 to 27.5). Most deduc-
tions were found in the buccal segments
and related to the second molars. This
study suggests that the reliability and
objectiveness of the ABO OGS are
not absolute but render the index highly
valuable.
Severity of the initial malocclusion is an
important factor in establishing treatment
complexity. Thus, in 1999, the ABO began
developing a method to measure the level
of treatment difficulty to determine the
acceptability of patients submitted for
Phase III of the ABO OGS certification. As
a result, the DI was developed as an objec-
tive measure of the pretreatment maloc-
clusion. After 5 years of development and
field testing, the DI has replaced the case
category requirements previously used as
guidelines for submissions.19
Both the ABO OGS and the DI have
been compared in one study to the PAR
index and the comprehensive clinical
assessment (CCA); 126 pre- and post-
treatment records were therefore exam-
ined.21 There was no correlation between
the pretreatment PAR and the DI (with
cephalometric values) or between the
posttreatment PAR and ABO OGS. How-
ever, there was a statistically significant
correlation (r = 0.67, P < .0001) between
17
 Saxe et al
the PAR weighted scores and the DI when
its cephalometric values were deleted.
Both the PAR and the DI were determined
to be useful indexes for evaluating maloc-
clusion severity and treatment difficulty.21
Another major factor influencing both
treatment duration and quality is the bio-
mechanical therapy plan. Recently, a
novel computer-assisted approach has
been introduced. 22 The SureSmile
process (OraMetrix) begins with a direct
3D scan of the patient’s dentition using
an intraoral camera that produces images
to create a computer model of the denti-
tion. Various treatment simulations can
be performed, and the chosen approach
of therapy is used to design and create
wires with a bending robot. The deviations
of the bends and torques in stainless
steel wires are less than 1 degree.23
The impact of this system on ortho-
dontic treatment and its duration had yet
to be evaluated. Therefore, it was the
objective of this study to examine the
ef ficiency and ef fectiveness of the
OraMetrix SureSmile system compared to
conventional orthodontic treatment tech-
niques. The hypothesis was that there is
a significant difference (P < .05) between
the OGS scores of the completed
SureSmile patients and patients treated
by conventional methods.
MATERIALS AND METHODS
The authors collected the pre- and post-
treatment study models of the 62 most
recent consecutively completed SureSmile
and conventionally treated patients. The
pretreatment models were used to deter-
mine the DI score and the posttreatment
ones to define the OGS score. Treatment
length was determined as the time from
bonding to debonding. Exclusion criteria
were incomplete casts; ar ticulator-
mounted casts; or casts from patients
with missing molars, orthognathic surgery,
or prosthodontic restorations.
Before any scoring, the patients treated
with the SureSmile finishing wire (n = 38)
and those treated traditionally (n = 24) were
anonymized and randomized. Two inde-
pendent calibrated examiners (graders)
evaluated each model. Statistical analysis
18
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WORLD JOURNAL OF ORTHODONTICS
was conducted using the paired sample
t test, the results of which established the
intra- and interexaminer reliability.
The examiners were calibrated using
standardized models, the ABO OGS mea-
suring gauge, and the guidelines pro-
vided by the ABO OGS.19 After scoring of
each model, the results were reviewed
both separately and jointly. Cephalomet-
ric values and root parallelism were not
appraised as part of the DI in this study.
The congruent categories were then
scored again on the posttreatment mod-
els using the ABO OGS.
RESULTS
Data collection analysis
First to be tested using standard diagnos-
tic statistics was whether the data col-
lected by each grader was approximately
normally distributed. The distributions
had only a slight skew and no kurtosis.
This indicated that the data were approxi-
mately normally distributed and to be
tested with parametric statistical tests.
The mean values for all ABO OGS
scores for both examiners are listed in
Table 1. Mean value for grader 1 was
27.3 (SD = 7.8) and 28.7 (SD = 8.1) for
grader 2. The standard error of the mean
(SE), a statistic more appropriate than
standard deviation for comparing rela-
tively small samples, was low for the two
graders (0.99 and 1.03, respectively) and
essentially equal. This suggests that the
scores given consistent and therefore
reliable.
To compare the measurements of the
same patient made by the two graders,
the paired samples difference of means
test was used. This showed a significant
difference (P < .05). But a correlation
analysis of the two complete sets of mea-
surements showed that the Pearson rank
correlation coefficient was 0.96. This
suggests that while one grader consis-
tently assigned higher values to a given
measurement than the other, the two sets
of data were completely consistent with a
near one-to-one correspondence. Mea-
surements from both graders showed a
similar pattern.
VOLUME 11, NUMBER 1, 2010 Saxe et al

Table 1 Standard statistics for the ABO OGS score of both graders
SE Mean Significance Correlation Significance
Grader Mean SD mean difference (P) coefficient (r) (P)

1 27.3 7.8 0.99 –1.4 < .05 0.96 < .0001

2 28.7 8.1 1.03 < .05 0.96 < .0001

SD = standard deviation, SE = standard error.

Table 2 Standard statistics for the ABO OGS score of the two treatment modalities
Modality Mean n SD SE mean Mean difference SE difference P

SureSmile 26.3 76 6.8 0.78 –4.4 1.50 < .005

Conventional 30.7 48 8.9 1.28 –4.4 1.50 < .005

n = number of measurements, SD = standard deviation, SE = standard error.

Data analysis components, the SureSmile treatment

ABO OGS scores: SureSmile vs conven-
tional treatment. The independent sam-
ples dif ference of means test was
applied to determine whether the out-
comes for both clinical approaches were
statistically different. It showed a signifi-
cant difference (P < .005). The mean for
SureSmile (26.3) was, on average, 4.4
points lower than that for conventional
treatment (30.7) (Table 2).
Component ABO OGS scores: Sure-
Smile vs conventional treatment. All 14
components of the overall ABO OGS
score measured by the two graders were
evaluated using a paired comparison
t test. All pairs were strongly correlated
(significant at the 0.95 level with Pearson
rank correlation coefficients ranging from
0.76 to 0.92). This again suggests that
the scores of both graders were consis-
tent. In the interest of completeness, it
should be reported that the mean score
for occlusal relationship r of one grader
was noticeably higher than that of the
other. This is not surprising as this evalu-
ation is somewhat subjective.
Next, the scores for the 14 individual
components were evaluated for differ-
ences between the two clinical approach-
es. This data is summarized in Table 3
and Fig 1. The ABO OGS mean scores for
the patients treated with SureSmile were
lower for 11 components, equal for two,
and higher for one. The independent sam-
ple t tests showed that for five of the 14
resulted in a significantly lower score (95%
confidence level) than the conventional
treatment. For the remaining nine compo-
nents, there was no significant difference
between the two modes of treatment.
Treatment time. The check for treat-
ment time (notated in months) revealed
that the data was distributed approxi-
mately evenly, with only a slight skewness
and no evidence of a kurtosis.
The independent samples difference
of means test suggested that SureSmile
significantly reduced treatment time
(14.7 months vs 20.0 months, Table 4).
Level of difficulty. The level of treat-
ment difficulty was measured by the DI.
The pairwise correlation analysis of the
ABO OGS between the approaches indi-
cated no meaningful correlation between
the DI and ABO OGS for patients treated
with SureSmile (r = 0.05) or convention-
ally (r = 0.04) (Table 5). This suggests
that there was no relationship between
the level of difficulty and the treatment
result.
Figure 1 depicts the mean scores for
the components of the ABO OGS for the
two graders individually. As noted above,
the two Graders made statistically equiv-
alent measurements.
Figure 2a reflects the mean score of
the ABO OGS for both graders, whereas
Fig 2b compares the ABO OGS score and
the mean treatment time for the
patients treated with SureSmile to the
patients treated conventionally.

19

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 Saxe et al WORLD JOURNAL OF ORTHODONTICS

Table 3 Standard statistics for the individual components of the ABO OGS score
of the two treatment modalities
SureSmile Conventional Mean Significance
Component Mean SE Mean SE difference (t test, P)

Alignment and rotations (max) 1.8 0.09 2.7 0.14 0.9 < .05
Alignment and rotations (man) 2.0 0.11 2.3 0.14 0.3
Marginal ridges (max) 2.0 0.11 2.5 0.17 0.5 < .05
Marginal ridges (man) 2.4 0.12 2.4 0.16 0.0
Buccolingual inclination (max) 1.2 0.13 1.9 0.18 0.7 < .05
Buccolingual inclination (man) 2.3 0.17 1.9 0.17 –0.4
Overjet R 2.0 0.15 2.7 0.15 0.7 < .05
Overjet L 2.2 0.14 2.5 0.17 0.3
Occlusal contacts 3.3 0.18 3.7 0.16 0.4
Occlusal contacts lingual 3.4 0.18 3.6 0.18 0.2
Occlusal relationships R 1.8 0.15 2.2 0.18 0.4
Occlusal relationships L 1.3 0.13 1.3 0.13 0.0
Interproximal contacts R 0.2 0.05 0.4 0.07 0.2
Interproximal contacts L 0.2 0.05 0.5 0.09 0.3 < .05

SE = standard error, max = maxillary, man = mandibular.

4.0 3.7 3.4 3.6

4.0 SureSmile ± SE SureSmile ± SE
Score component measure

3.3
Score component measure

Conventional ± SE 3.5 Conventional ± SE

3.5
2.7 2.7
3.0 2.5 3.0 2.5
2.3 2.4 2.4 2.3 2.2
2.0 2.0 2.5 2.0 2.2
2.5 1.9 1.9 1.8
1.8
2.0 2.0
1.2 1.3 1.3
1.5 1.5
1.0 1.0
0.4 0.5
0.5 0.5 0.2 0.2

0 0
Maxilla Mandible Maxilla Mandible Maxilla Mandible R L R L R L R L
Alignment and rotations Marginal ridges Buccolingual inclination Overjet Occlusal contacts Occlusal Interproximal
relationships contacts

Fig 1 Results for the individual components of the ABO OGS score for both treatment modalities and both graders individually.

DISCUSSION treated patients in this study most closely

corresponds with the results reported by
This study examined the efficiency and Skidmore et al(23.5 months), 3 Fink
effectiveness of the SureSmile system and Smith (23.1 months), 2 and Alger
compared to that of conventional fixed (22.0 months).4
appliance straight wire therapy. Two mea- Having identified this difference in
sures were used to evaluate effective- treatment length, it was important to find
ness: treatment time and ABO OGS score. out whether it was due to a different
The average treatment time for con- severity of the initial malocclusion. How-
ventionally treated patients in this study ever, the DI scores for both patient
was 20.0 months with a standard devia- groups were similar (m = 9.2 ± 6.6 for
tion of 6.40 months. In contrast, in SureSmile, m = 11.0 ± 6.7 for conven-
SureSmile patients, it was significantly tional therapy). Further, the correlation
shorter with an average of 14.7 months. coefficients between ABO OGS and DI
This represents a 36% decrease. The were low, suggesting that severity was
treatment duration for the conventionally not a factor impacting these results.

20

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VOLUME 11, NUMBER 1, 2010 Saxe et al

Fig 2 ABO OGS mean scores

SureSmile
for (a) both graders individually 35 35
Conventional
and (b) mean score and treat- 30.7 ± 8.9
ment times (in months) for 30 28.7 ± 8.1 30
27.3 ± 7.8
SureSmile and conventional 26.3 ± 6.8

Mean score/treatment time

therapy. 25 25
20.0 ± 6.4

Mean score
20 20

14.7 ± 4.7
15 15

10 10

5 5

0 0
Grader 1 Grader 2 Mean OGS score Mean treatment time
a b (base = 62; P < .005) (mo; P < .001)

Table 4 Standard statistics for the treatment time of the two modalities
Modality Mean n SD SE Mean difference SE difference P

SureSmile 14.7 38 4.71 0.76 –5.3 1.51 < .001

Conventional 20.0 24 6.40 1.21 –5.3 1.51 < .001

n = number of patients, SD = standard deviation, SE = standard error.

Table 5 Standard statistics for

the discrepancy index (DI) of the
two modalities
Modality Mean n SD

SureSmile DI 9.2 76 6.58

Conventional DI 11.0 48 6.74

n= number of patients, SD = standard deviation.

Notably, the confidence level for total
treatment time with SureSmile is nar-
rower (4.71 SD) than that of conventional
treatment (6.40 SD), suggesting that less
variation in treatment time is to be
expected when treating with SureSmile.
This may translate to a better estimation
of treatment time.
Part of the standard care process with
conventional appliances is that toward
the end of therapy, a quality result is
generally accomplished through reposi-
tioning brackets, altering bracket prescrip-
tions, and/or archwire bending. In con-
trast, SureSmile prescriptive archwires
are derived from an optimal setup. Thus,
SureSmile customized archwires over-
come the vagrancies of traditional
straight-wire appliances and allow for an
earlier control. This may be a strong factor
for reduced treatment length.
Additionally, SureSmile archwires are
bent with high reliability and precision
using robotic technology. Unpublished
data suggests that the torsional and lin-
ear bends are accurate within ± 1 degree
and ± 0.2 mm, respectively. On the other
side, the bracket slots of straight-wire
appliances have a very large tolerance,
potentially leading to imprecise tooth
movements, which are generally cor-
rected by reactive measures resulting in
prolonged care.24,25
In addition to a shorter care cycle,
SureSmile patients demonstrated an
OGS score 14.3% better compared to
conventional therapy. This finding is
important because the prevalent thinking
is that better outcomes are related to
longer treatment times.26

21

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 Saxe et al
CONCLUSIONS
The treatment time for the SureSmile sys-
tem compared to conventional orthodontics
was significantly shorter by about 25.0%.
The ABO OGS score for the SureSmile
patients was, on average, 14.3% better
than for those patients treated with con-
ventional appliances.
ACKNOWLEDGMENTS
The authors wish to thank Drs Boyd Whitlock, Steve
Smith, and Ron Snyder for providing patient records.
The authors would also like to thank Harold T. Gross
and Michael E. Egan from The Dallas Marketing
Group for providing statistical analysis.
REFERENCES
1. Mavreas D, Athanasiou AE. Factors affecting the
duration of orthodontic treatment: A systematic
review. Eur J Orthod 2008;30:386–395.
2. Fink DF, Smith RJ. The duration of orthodontic
treatment. Am J Orthod Dentofacial Orthop
1992;102:45–51.
3. Skidmore KJ, Brook KJ, Thomson WM, Harding
WJ. Factors influencing treatment time in ortho-
dontic patients. Am J Orthod Dentofacial Orthop
2006;129:230–238.
4. Alger DW. Appointment frequency versus treat-
ment time. Am J Orthod Dentofacial Orthop
1988;94:436–439.
5. Beckwith FR, Ackerman RJ Jr, Cobb CM, Tira
DE. An evaluation of factors affecting duration
of orthodontic treatment. Am J Orthod Dentofa-
cial Orthop 1999;115:439–447.
6. Robb SI, Sadowsky C, Schneider BJ, BeGole EA.
Effectiveness and duration of orthodontic treat-
ment in adults and adolescents. Am J Orthod
Dentofacial Orthop 1998;114:383–386.
7. O’Brien KDO, Robbins R, Vig KWL, Vig PS,
Shnorhokian H, Weyant R. The effectiveness of
Class II, Division 1 treatment. Am J Orthod
Dentofacial Orthop 1995;107:329–334.
8. Taylor PJ, Kerr WJ, McColl JH. Factors associated
with the standard and duration of orthodontic
treatment. Br J Orthod 1996;23:335–341.
9. Shia GJ. Treatment overruns. J Clin Orthod
1986;20:602–604.
10. Popowich K, Nebbe B, Heo G, Glover KE, Major
PW. Predictors for Class II treatment duration.
Am J Orthod Dentofacial Orthop 2005;127:
293–300.
11. Cangialosi TJ, Riolo ML, Owens SE Jr, et al. The
ABO discrepancy index: A measure of case
complexity. Am J Orthod Dentofacial Orthop
2004;125:270–278.
22
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MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
WORLD JOURNAL OF ORTHODONTICS
12. Vu CQ, Roberts WE, Hartsfield JK, Ofner S Jr.
Treatment complexity index for assessing the
relationship of treatment duration and outcomes
in a graduate orthodontics clinic. Am J Orthod
Dentofacial Orthop 2008;133:9.e1–9.e13.
13. Vig KW, Weyant R, Vayda D, O’Brien K, Bennett
E. Orthodontic process and outcome: Efficacy
studies—strategies for developing process and
outcome measures: A new era in orthodontics.
Clin Orthod Res 1998;1:147–155.
14. Richmond S, Shaw WC, Roberts CT, Andrews M.
The PAR Index (Peer Assessment Rating): Meth-
ods to determine outcome of orthodontic treat-
ment in terms of improvement and standards.
Eur J Orthod 1992;14:180–187.
15. Turbill EA, Richmond S, Wright JL. The time-
factor in orthodontics: What influences the
duration of treatments in National Health Ser-
vice practices? Community Dent Oral Epidemiol
2001;29:62–72.
16. Grewe JM, Hermanson PC. Influence of severity
of malocclusion on the duration of orthodontic
treatment. Am J Orthod 1973;63:533–536.
17. Popowich K, Flores-Mir C, Nebbe B, Heo G,
Major PW. Comparison of Class I and Class II
treatment duration among three different
orthodontic practices. Semin Orthod 2006;12:
52–59.
18. Quimby ML, Vig KWL, Rashid RG, Firestone AR.
The accuracy and reliability of measurements
made on computer-based digital models. Angle
Orthod 2004;74:298–303.
19. Casko JS, Vaden JL, Kokich VG, et al. Objective
grading system for dental casts and panoramic
radiographs. Am J Orthod Dentofacial Orthop
1998;114:589–599.
20. Lieber WS, Carlson SK, Baumrind S, Poulton
DR. Clinical use of the ABO-Scoring Index: Reli-
ability and subtraction frequency. Angle Orthod
2003;73:556–564.
21. Deguchi T, Honjo T, Fukunaga T, Miyawaki S,
Roberts WE, Takano-Yamamoto T. Clinical
assessment of orthodontic outcomes with the
peer assessment rating, discrepancy index,
objective grading system, and comprehensive
clinical assessment. Am J Orthod Dentofacial
Orthop 2005;127:434–443.
22. Mah J, Sachdeva R. Computer-assisted ortho-
dontic treatment: The SureSmile process. Am J
Orthod Dentofacial Orthop 2001;120:85–87.
23. Sachdeva R, Fruge JF, Fruge AM, et al.
SureSmile: A report of clinical findings. J Clin
Orthod 2005;39:297–314.
24. Matasa CW. Defend yourself against faulty
brackets. J Gen Orthod 1991;2:5–9.
25. Eliezer R, James LS, Lewis K. Rotation of rec-
tangular wire in rectangular molar tubes: Part I.
Am J Orthod 1981;80:136–144.
26. Sameshima G. Ask us. Some orthodontists
claim they can complete treatment relatively
quickly, and they rarely treat patients patients
as long as 3 years. How can they do this and
still achieve high-quality results. Am J Orthod
Dentofacial Orthop 2005;127: 526.
Shahin Emami Meibodi,
DDS, MS1 THE EFFECT OF MANDIBULAR TONGUE
Seyed Amir Reza Fatahi CRIBS ON DENTOSKELETAL CHANGES
Meybodi, DDS2

Elham Morshedi Meybodi,

IN PATIENTS WITH CLASS II DIVISION 1
DDS3 MALOCCLUSIONS
Aim: To investigate the effect of a modified tongue crib appliance in
Class II Division 1 patients with anterior tongue thrust and mandibular
deficiency. Methods: Twenty-three patients (14 females, 9 males) with a
mean age of 10.09 ± 1.02 years, a moderate Class II Division 1 occlusion
due to a mandibular deficiency, and a mean overbite of –1.1 ± 0.8 mm
were treated with a mandibular tongue crib device. Pre- and posttreat-
ment lateral cephalograms were obtained and traced, and various
angular and linear variables were measured. These measurements
were compared using the paired t test. Results: The statistical assess-
ment indicated that SNB, facial angle, B-VL, Pog-VL, and interincisal
angle increased significantly. IMPA, 1-SN, ANB, and Wits appraisal
were significantly decreased (P < .05). The changes of Jarabak Index,
SN-MP, SNA, and Y-axis were not significant. In addition, the overjet
was reduced. Conclusion: During the mixed dentition phase, a tongue
crib appliance in the mandible is helpful to impede tongue thrust and
stimulate mandibular growth. World J Orthod 2010;11:23–26.

Key words: Class II Division 1, anterior open bite, tongue thrust,

mandibular tongue crib, functional appliance

1Associate
Professor, Department of
Orthodontics, Islamic Azad Univer-
sity, Tehran, Iran.
2Resident, Department of Orthodon-
tics, Tehran University of Medical
Sciences, Tehran, Iran.
3Private Practice, Tehran, Iran.
CORRESPONDENCE
Dr Fatahi Meybodi Seyed Amir Reza
Apartment 8, No 5, Jalinus Alley
Yarmohammadi Alley, Kolahdouz St
Shariati Ave
Tehran, Iran
1944863951
Email: dr.fatahi.articles@gmail.com
nterior open bites are among the most
A problematic malocclusions to treat. It
has been reported that tongue thrust
swallowing is an adaptation of an anterior
open bite to achieve an anterior seal.1,2 A
Class II Division 1 relationship is one of
the most prevalent disorders in antero-
posterior dimension and found in 12% to
49% of all patients.3,4 Tongue thrust fre-
quently accompanies these two malocclu-
sions. 2,5 One treatment modality for
tongue thrust is the insertion of a tongue
crib,6,7 which is usually applied to the
maxillary arch.7,8 It has been shown that
this appliance could have some protru-
sive effect on the premaxilla, which would
be beneficial in patients with a Class III
occlusion9 and cleft lips and palates.10 In
patients with a skeletal Class II relation-
ship, however, such a protrusion would be
unfavorable. On the other hand, it could
be of great value if applied to a retrusive
mandible. This study was carried out con-
sidering that mandibular deficiency is one
of the most common characteristics of
Class II Division 1 malocclusions,11 and
redirection of mandibular growth is there-
fore an important objective of functional
therapy.12,13 Specifically, the dentoskele-
tal effect of a mandibular removable
tongue crib in patients with a Class II Divi-
sion 1 relationship due to a mandibular
deficiency who, at the same time, a
tongue thrust was to be evaluated.

23

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VOLUME 11, NUMBER 1, 2010 Emami Meybodi et al

Table 1 Values of various dentoskeletal parameters before and after treatment

with a mandibular tongue crib appliance
Pretreatment Posttreatment Difference Paired t test (P)

SNA (degrees) 79.5 ± 5.0 79.9 ± 4.8 0.4 ± 1.2 < .2

SNB (degrees) 71.4 ± 2.1 73.0 ± 2.3 1.7 ± 0.9 < .05
ANB (degrees) 7.3 ± 2.7 6.2 ± 2.8 –1.1 ± 1.3 < .05
Wits (degrees) 3.9 ± 2.1 3.0 ± 2.0 –0.9 ± 1.0 < .05
Y-axis (degrees) 74.2 ± 5.0 73.8 ± 6.1 –0.4 ± 1.9 < .4
MP-SN (degrees) 37.8 ± 4.1 37.2 ± 5.0 –0.6 ± 3.4 < .4
Jarabak Index (%) 58.0 ± 3.9 58.5 ± 4.2 0.5 ± 1.2 < .1
B-VL (mm) 31.3 ± 2.7 33.0 ± 3.3 1.8 ± 1.9 < .05
Pog-VL (mm) 27.2 ± 2.5 29.7 ± 2.4 2.5 ± 1.2 < .05
Facial angle (degrees) 76.8 ± 3.2 79.3 ± 3.4 2.5 ± 3.4 < .05
IMPA (degrees) 98.3 ± 5.8 96.5 ± 5.5 –1.8 ± 3.4 < .05
1-SN (degrees) 102.2 ± 4.6 I00.8 ± 5.0 –1.3 ± 1.9 < .05
Interincisal (degrees) 121.8 ± 6.1 124.5 ± 6.0 2.8 ± 3.7 < .05

DISCUSSION occurring growth during this time span

Some controversy exists in the literature
regarding whether tongue thrusting is the
cause or result of an anterior open bite.
However, most authors agree that tongue
thrust is a secondary phenomenon of
anterior open bite and that the affected
patients place their tongue forward dur-
ing deglutition to create an anterior
seal.1,2,13–15 In any case, insertion of a
tongue crib can prevent the forward posi-
tioning of the tongue and allows the ante-
rior open bite to decrease.7,8
Tongue cribs are usually part of maxil-
lary appliances.7,8 The effect of this type
of device is a protrusion of the premax-
illa, thus increasing the overjet as was
shown especially in early mixed dentition
patients with Class III occlusions9 and
clef t lip and palates. 10 In Class II
patients, such an effect would be unfa-
vorable. Tongue cribs in the mandible
can overcome this disadvantage as
shown in the present study because they
will not result in an in SNA.
Stahl et al 16 studied longitudinal
growth changes in untreated individuals
with a Class II Division 1 occlusion based
on cervical vertebral maturation stages
(CS). They found that between CS1
(mean age 10.2 years) and CS3 (mean
age 12.1 years), SNB showed a mean
increase of 0.4 degrees and Pog–N per-
pendicular a mean decrease of 0.9 mm.
In contrast, SNB and Pog-VL increased in
this study 1.7 degrees and 2.5 mm,
respectively. Subtracting the natural
from the results found here provides a
hint about the therapeutic effect of the
presented appliance.
The growth difference can be explained
by the fact that the mandibular tongue
crib forces the mandible into a forward
position. Muscles such as the palatoglos-
sus, styloglossus, chondroglossus, and
hyoglossus have a protrusive force that
can be transferred via the tongue tip to
the tongue cribs to the mandible. It should
be mentioned, however, that the increase
in the abovementioned parameters was
not clinically significant and that a
mandibular tongue crib is not primarily a
functional appliance.
In the vertical dimension, the appli-
ance did not have any considerable
effect.
Dental changes observed were a
decrease in IMPA and 1-SN. This can be
explained by the fact that by omitting the
tongue force with a tongue crib, the lips
retrude the incisors. This decreased the
open bite. Another explanation for the
decrease of the open bite is that the
suppressing effect of the tongue on
incisor eruption was eliminated by the
tongue crib.
The mandibular tongue crib improved
the profile favorably as the maxillary
incisors retruded, the upper lip moved
back, and the lower lip was no longer
trapped behind the maxillary incisors. Lip
tension decreased positively because of
the maxillar y incisor retrusion and
mandibular protrusion.

25

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 Emami Meybodi et al
CONCLUSION
In Class II Division 1 patients with a
mandibular deficiency combined with an
anterior open bite and tongue thrust, it
can be recommended to use a tongue
crib on a mandibular appliance. Thus,
adverse effects on the maxilla (protru-
sion) can be avoided. In addition, the
open bite is reduced and mandibular
growth increased.
REFERENCES
1. Fujiki T, Takano-Yamamoto T, Noguchi H,
Yamashiro T, Guan G, Tanimoto K. A cineradi-
ographic study of deglutitive tongue movement
and nasopharyngeal closure in patients
with anterior open bite. Angle Orthod 2000;
70:284–289.
2. Proffit WR. Contemporary Orthodontics, ed 3.
St Louis, Mosby, 2000:135–137.
3. Ingervall B. Prevalence of dental and occlusal
anomalies in Swedish conscripts. Acta Odontol
Scand 1974;32:83–92.
4. Kim YH. A comparative cephalometric study of
Class II Division 1 nonextraction and extraction
cases. Angle Orthod 1979;49:77–84.
5. Fujiki T, Inoue M, Miyawaki S, Nagasaki T,
Tanimoto K, Takano-Yamamoto T. Relationship
between maxillofacial morphology and degluti-
tive tongue movement in patients with anterior
open bite. Am J Orthod Dentofacial Orthop
2004;125:160–167.
6. Sayin MO, Akin E, Karaçay S, Bulakbasi N. Ini-
tial effects of the tongue crib on tongue move-
ments during deglutition: A Cine-Magnetic reso-
nance imaging study. Angle Orthod 2006;76:
400–405 [erratum 2006;76:iii].
26
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MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
WORLD JOURNAL OF ORTHODONTICS
7. Huang GJ, Justus R, Kennedy DB, Kokich VG.
Stability of anterior openbite treated with crib
therapy. Angle Orthod 1990;60:17–24.
8. Cooper JS. A comparison of myofunctional ther-
apy and crib appliance effects with a matura-
tional guidance control group. Am J Orthod
1977;72:333–334.
9. Danaie SM, Salehi P. Cephalometric evaluation
of Class III patients with chin cap and tongue
guard. J Indian Soc Pedod Prev Dent 2005;23:
63–66.
10. Jamilian A, Showkatbakhsh R, Boushehry
MB.The effect of tongue appliance on the naso-
maxillary complex in growing cleft lip and
palate patients. J Indian Soc Pedod Prev Dent
2006;24:136–139.
11. McNamara JA Jr. Components of Class II maloc-
clusion in children 8–10 years of age. Angle
Orthod 1981;51:177–202.
12. Bishara SE, Ziaja RR. Functional appliances:
A review. Am J Orthod Dentofacial Orthop
1989;95:250–258.
13. Woodside DG. Do functional appliances have
an orthopedic effect? Am J Orthod Dentofacial
Orthop 1998;113:11–14.
14. Peng CL, Jost-Brinkmann PG, Yoshida N,
Miethke RR, Lin CT. Differential diagnosis
between infantile and mature swallowing
with ultrasonography. Eur J Orthod 2003;
25:451–456.
15. Subtelny JD, Sakuda M. Open-bite: Diagnosis
and treatment. Am J Orthod 1964;40:337–358.
16. Stahl F, Baccetti T, Franchi L, McNamara JA Jr.
Longitudinal growth changes in untreated sub-
jects with Class II Division 1 malocclusion. Am J
Orthod Dentofacial Orthop 2008;134:125–137.
Hans Pancherz, DDS,
Odont Dr, PhD1 DIVINE PROPORTIONS IN ATTRACTIVE
Verena Knapp, DDS, AND NONATTRACTIVE FACES
Dr Med Dent2
Aim: To test Ricketts’ 1982 hypothesis that facial beauty is measurable
Christina Erbe, DDS, by comparing attractive and nonattractive faces of females and males
Dr Med Dent3 with respect to the presence of the divine proportions. Methods: The
analysis of frontal view facial photos of 90 cover models (50 females,
Anja Melina Heiss, DDS, 40 males) from famous fashion magazines and of 34 attractive
Dr Med Dent4 (29 females, five males) and 34 nonattractive (13 females, 21 males)
persons selected from a group of former orthodontic patients was car-
ried out in this study. Based on Ricketts’ method, five transverse and
seven vertical facial reference distances were measured and com-
pared with the corresponding calculated divine distances expressed in
phi-relationships (␾ = 1.618). Furthermore, transverse and vertical
facial disproportion indices were created. Results: For both the mod-
els and patients, all the reference distances varied largely from respec-
tive divine values. The average deviations ranged from 0.3% to 7.8%
in the female groups of models and attractive patients with no differ-
ence between them. In the male groups of models and attractive
patients, the average deviations ranged from 0.2% to 11.2%. When
comparing attractive and nonattractive female, as well as male,
patients, deviations from the divine values for all variables were larger
in the nonattractive sample. Conclusion: Attractive individuals have
facial proportions closer to the divine values than nonattractive ones.
In accordance with the hypothesis of Ricketts, facial beauty is measur-
able to some degree. World J Orthod 2010;11:27–36.

Key words: divine proportions, facial proportions, attractiveness, esthetics

1Professor and Chair Emeritus,

Department of Orthodontics, Univer-
n 1982, Ricketts presented a much- divine proportions in the faces of a large
sity of Giessen, Giessen, Germany.
2Assistant Professor, Department of

Pediatric Dentistry, University of

Giessen, Giessen, Germany.
3Assistant Professor, Department of
Orthodontics, University of Mainz,
Mainz, Germany.
4Former Dental Student, Department
of Orthodontics, University of
Giessen, Giessen, Germany.
CORRESPONDENCE
Prof Dr Hans Pancherz
Department of Orthodontics
University of Giessen
Schlangenzahl 14
35392 Giessen
Germany
Email: Hans.Pancherz@
dentist.med.uni-giessen.de
I debated ar ticle 1 in which he con-
cluded: “The study strongly suggests
that esthetics can indeed be made sci-
entific rather than the need to resort to
subjective perceptions as in the past.”
The scientific value of Ricketts’ study
is, however, questionable. He analyzed
the divine proportions in only the faces
of 10 individuals using frontal pho-
tographs taken from magazine adver-
tisements. Allegedly, all were selected
for outstanding beauty and presented a
variety of races.
Therefore, the purpose of this investi-
gation was to test the conclusion of
Ricketts1 by assessing the existence of
and racially homogenous sample. As
nonattractiveness and sex differences
have not been considered in previous
publications,2,3 attractive and nonattrac-
tive females and males were compared
with each other.
FACIAL BEAUTY
AND ATTRACTIVENESS
Facial beauty implies social success and
has a positive influence in all areas of
modern society. 4,5 Facial esthetics do
not depend on any single feature.6 The
eyes, nose, oral region, and complexion

27

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 Pancherz et al
A C B Slideshow: 398 facial photos
Fig 1 (above) Arithmetic expression of
the golden (divine) ratio: AC/CB = AB/AC.
Fig 2 (right) The procedure that led to
the classification of individuals as having
attractive and nonattractive faces.
contribute to overall attractiveness. 7,8
There is evidence that a public agree-
ment of facial beauty exists9–11 and that
facial attractiveness is less subjective
than generally believed.1,9
The golden (divine) section is named Phi
after the famous Greek artist Phidias, who
used it in his architecture, including the
temple of Parthenon. However, the golden
section is very likely to have been known
long before Phidias. Euclid’s “Elements”
was the first known work to define it.
The golden section is said to have a
unique quality in the description of beauty,
harmony, and balance. It is defined as fol-
lows: Line AB is sectioned at point C in
accordance with the golden ratio when the
two subsections (AC and CB) correspond
to each other as does the whole distance
AB to the section AC (Fig 1). This relation-
ship is the phi value (␾ = 1.618).
Sixty years ago, Ghyka12 presented a
detailed analysis of the golden (divine) pro-
portions in relation to the human face,
and Bashour 13 more recently gave an
overview of the current concepts to ana-
lyze facial attractiveness. The divine pro-
portions are used as a guide in facial
reconstructive surgery.14,15 Furthermore,
the divine proportions were used in stud-
ies to evaluate the faces of models in com-
mercial photos1 and agreeable smiles,16
on cephalometric radiographs from attrac-
tive and nonattractive individuals,2 and of
manipulated frontal facial photographs.17
28
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WORLD JOURNAL OF ORTHODONTICS
Panel: 54 dental students
Facial appearance assessment
Most pleasing Pleasing Least pleasing
> 44 votes/photo > 44 votes/photo
Attractive face Nonattractive face
Females (n = 29); Females (n = 13);
males (n = 5) males (n = 21)
MATERIALS
Frontal view facial photographs with the
lips in a relaxed closed position from two
samples were examined:
• Ninety models (50 females, 40 males)
from the covers of renowned fashion
magazines who were considered to be
attractive and to represent the current
ideal of a beautiful face. All subjects
were Caucasian.
• Three hundred ninety-eight (201 fe -
males, 197 males) individuals ran-
domly selected from the files of the
Department of Orthodontics, University
of Giessen (patients) (Fig 2). Their ages
ranged from 14 to 25 years of age for
the females and from 16 to 25 years
for the males. Orthodontic treatment
was completed in all subjects.
The facial photos of these 398
patients were examined as a slideshow
by a panel of 54 dental students (29
females, 25 males) who themselves had
an average age of 21 years.
Every examiner had to categorize
each facial photo into one of the follow-
ing categories:
• Most pleasing look
• Pleasing look
• Least pleasing look
 Pancherz et al WORLD JOURNAL OF ORTHODONTICS

Table 1 Transverse reference distances and their phi Table 2 Vertical reference distances and their phi
(␾) values (␾) values
Transverse Calculation of the ideal values on the Vertical Calculation of the ideal values on the
reference distance basis of the divine proportion reference distance basis of the divine proportion

NW-NW Base value = 1.0 AL-MW Base value = 1.0

NB-NB 1:␾ = 0.618 EW-AL ␾ = 1.618
MW-MW ␾ = 1.618 MW-ME ␾ = 1.618
EW-EW ␾2 = 2.618 HL-HW ␾2 = 2.618
HW-HW ␾3 = 4.236 AL-ME ␾2 = 2.618
EW-MW ␾2 = 2.618
EW-ME ␾3 = 4.236

Table 3 Method error calculation for the various

reference distances and groups
Reference Models Attractive Nonattractive
distance (mm) (n = 90) (n = 34) (n = 34)

NB-NB 0.30 0.44 0.32

MW-MW 0.30 0.42 0.40
EW-EW 0.41 0.55 0.44
HW-HW 0.68 0.77 0.69
EW-AL 0.40 0.54 0.38
MW-ME 0.27 0.39 0.49
HL-HW 0.76 0.81 0.75
AL-ME 0.33 0.44 0.51
EW-MW 0.35 0.51 0.48
EW-ME 0.52 0.63 0.53

In the transverse plane, NW-NW (nose Statistical methods

width) was used as base value (1.0),
whereas in the vertical plane, it was AL-
MW (nose-lip distance). These two base
values were used to calculate the ideal
values for all distances using the phi-
relationship (Tables 1 and 2). The ideal
values were compared with the measured
reference distances, and the percentage
differences were calculated.
Facial disproportion index
Transverse and vertical facial dispropor-
tion indices were generated by calculating
the quotient of the sum of the absolute
percentage deviations of all measured
distances from their divine (ideal) values
and the number of the five transverse
and seven vertical reference distances.
For each variable, the arithmetic mean
(mean) and standard deviation (SD) were
calculated. All data were checked with
the Kolmogorov-Smirnov test for normal
distribution (P = .05). As the test results
revealed, there was no continuous distri-
bution for all test groups and the non-
parametric Mann-Whitney test was used
to identify significant differences among
groups. Graphically, the results are
depicted as box plots. The levels of signif-
icance were set at .001 (***), .01 (*),
and .05 (**); any probability ≥ .05 was
considered not significant.
Method error calculation
The total method error (locating and
marking the reference points and mea-
suring the reference distances) was cal-
culated for each variable on the base of
the duplicate registrations using
Dahlberg’s19 formula (Table 3).

30

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VOLUME 11, NUMBER 1, 2010 Pancherz et al

Table 4 Percent deviations (mean and SD) of all transverse and vertical reference
distances from their ideal values calculated on the basis of the divine proportions for
models
Female (n = 50) Male (n = 40) Female–male
Variable Meana SD Meana SD Mean (d) Significance

Transverse distances
NB-NB –0.7 3.2 –0.5 4.7 –0.2 NS
MW-MW –3.0 3.0 –4.1 4.6 +1.1 NS
EW-EW +1.1 3.0 –3.3 4.3 +4.4 ***
HW-HW –2.3 3.3 –5.6 4.5 +3.3 *
Transverse index 2.6 1.4 4.4 2.9 –1.8 *
Vertical distances
EW-AL +3.4 7.3 +4.6 7.8 –1.2 NS
MW-ME –2.1 3.8 +1.7 6.0 –3.8 *
HL-HW –3.4 5.8 –6.3 8.2 2.9 NS
AL-ME –2.1 2.5 +0.2 3.9 –2.3 *
EW-MW +2.0 3.8 +2.7 5.8 –0.7 NS
EW-ME +0.4 3.1 +2.3 5.2 –1.9 NS
Vertical index 3.5 2.1 5.0 3.3 –1.5 **

+ implies a value that is larger than ideal; – implies a value that is smaller than ideal.
***P < .001; *P < .01; **P < .05; NS = no significance.

Fig 5 Box plots of the trans-

verse and vertical reference
distance deviations from their 30
ideal values (0) calculated on Female
the basis of the divine propor- Male
tions in the 50 female and 40 20
male models.

10
Deviation (%)

–10

–20

–30
NB-NB MW-MW EW-EW HW-HW EW-AL MW-ME HL-HW AL-ME EW-MW EW-ME
Transverse Vertical

RESULTS In males, the largest and smallest aver-

Models
Transverse distances (Table 4, Fig 5). In
females, the largest and smallest average
deviations from the ideal values were
found for mouth width (MW-MW) and for
nose bridge width (NB-NB), respectively.
age deviations from the ideal values were
found for head width (HW-HW) and for
nose bridge width (NB-NB), respectively.
Vertical distances (Table 4, Fig 5). In
females, the largest average deviations
from the ideal values were found for fore-
head height (HL-HW) and for nose height
(EW-AL). The smallest deviation was seen
for total face height (EW-ME).

31

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 Pancherz et al
20
15
Deviation (%)
10
0
Transverse Vertical
Models
In males, the largest and smallest
average deviations from the ideal values
were found for forehead height (HL-HW)
and lower face height (AL-ME), respec-
tively.
Disproportion indices (Table 4, Fig
6). In females, the disproportion index for
the transverse reference distances was
2.6% and 3.5% for the vertical reference
distances.
In males, the disproportion index for
the transverse distances was 4.4% and
5.0% for the vertical reference distances.
Comparison of sex (Table 4, Figs 5
and 6). In the transverse plane, males
had significantly smaller eye width (EW-
EW) (P < .001) and head width (HW-HW)
(P < .01) than females.
In the vertical plane, males had signifi-
cantly larger chin height (MW -ME)
(P < .01) and lower face height (AL-ME)
(P < .01) than females.
The transverse (P < .01) and vertical
(P < .05) disproportion indices were sig-
nificantly larger in males than in females.
32
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Fig 6 Transverse and vertical
disproportion indices of the
female and male models and
Female of the female and male attrac-
Male tive and nonattractive patients.
Transverse Vertical Transverse Vertical
Attractive Nonattractive
Attractive patients
Transverse distances (Table 5, Figs 7
and 8). In females, the largest and small-
est average deviations from the ideal val-
ues were found for head width (HW-HW)
and eye width (EW-EW), respectively.
In males, the largest and smallest
average deviations from the ideal values
were found for mouth width (MW-MW)
and nose bridge width (NB-NB), respec-
tively.
Vertical distances (Table 5, Figs 7
and 8). In females, as well as in males,
the largest average deviations from the
ideal values were found for nose height
(EW-AL).
The smallest average deviations from
the ideal values were seen for chin
height (MW-ME) in females and for lower
face height (AL-ME) in males.
Disproportion indices (Table 5, Fig
6). In females, the disproportion index for
the transverse reference distances was
3.0% and 4.0% for the vertical reference
distances.
In males, the disproportion index for
the transverse distances was 4.7% and
5.1% for the vertical reference distances.
VOLUME 11, NUMBER 1, 2010 Pancherz et al

Table 5 Percent deviations (mean and SD) of all transverse and vertical reference distances from their ideal values
calculated on the basis of the divine proportions for attractive and nonattractive patients
Attractive Nonattractive
Attractive–nonattractive
Female Male Female Male
(n = 29) (n = 5) (n = 13) (n = 21) Female–male Females
Variable Meana SD Meana SD Meana SD Meana SD Mean (d) Significance Mean (d) Significance

Transverse distances
NB-NB +1.9 3.3 –1.3 3.7 +0.6 8.3 –3.7 8.5 +4.3 NS +1.3 NS
MW-MW –3.2 4.1 –6.4 4.0 –9.7 9.1 –11.0 9.9 +1.3 NS +6.5 *
EW-EW –0.7 2.1 –3.4 3.2 –4.4 9.1 –5.7 6.3 +1.3 NS +3.7 **
HW-HW –3.8 3.3 –5.8 1.7 –8.2 8.1 –5.8 6.0 –2.4 NS +4.4 NS
Transverse index 3.0 1.9 4.7 2.0 9.4 3.1 8.8 3.6 0.6 NS –6.4 ***
Vertical distances
EW-AL –7.8 5.7 –11.2 3.3 –10.9 8.3 –15.5 11.3 +4.6 NS +3.1 NS
MW-ME +0.3 4.4 +3.1 3.6 +5.7 11.0 +1.8 10.1 +3.9 NS –5.4 NS
HL-HW –3.4 5.2 –4.2 3.6 –6.3 12.7 –9.8 8.7 +3.5 NS +2.9 NS
AL-ME +1.0 3.2 +2.6 3.1 +3.1 7.0 +1.4 6.4 +1.7 NS –2.1 NS
EW-MW –3.6 3.2 –5.9 3.9 –5.7 5.7 –9.8 7.2 +4.1 NS +2.1 NS
EW-ME –2.7 3.2 –3.6 3.4 –2.0 7.0 –5.3 7.2 +3.3 NS –0.7 NS
Vertical index 4.0 2.8 5.1 2.0 8.7 3.0 9.9 3.5 –1.2 NS –5.0 ***

+ implies a value that is larger than ideal; – implies a value that is smaller than ideal.
***P < .001; *P < .01; **P < .05; NS = no significance.

Fig 7 Box plots of the trans-

verse and vertical reference
distance deviations from their 30
ideal values (0) calculated on Attractive
the basis of the divine propor- Nonattractive
tions in the 29 attractive and 13 20
nonattractive female patients.

10
Deviation (%)

–10

–20

–30
NB-NB MW-MW EW-EW HW-HW EW-AL MW-ME HL-HW AL-ME EW-MW EW-ME
Transverse Vertical

Comparison of sex (Table 5, Figs 6 to Nonattractive patients

8). As the attractive male patient group
comprised only five individuals, the two
sexes were not compared.
Transverse distances (Table 5, Figs 7
and 8). In females and males, the largest
and smallest average deviations from the
ideal values were found for mouth width
(MW-MW) and for nose bridge width (NB-
NB), respectively.

33

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 Pancherz et al
30
20
10
Deviation (%)
–10
–20
–30
NB-NB MW-MW EW-EW HW-HW EW-AL MW-ME HL-HW AL-ME EW-MW EW-ME
Transverse
Vertical distances (Table 5, Figs 7
and 8). In females, the largest and small-
est average deviations from the ideal val-
ues were found for nose height (EW-AL)
and total face height (EW-ME), respec-
tively.
In males, the largest and smallest
average deviations from the ideal values
were found for nose height (EW-AL) and
lower face height (AL-ME), respectively.
Disproportion indices (Table 5, Fig
6). In females, the disproportion index for
the transverse reference distances was
9.4% and 8.7% for the vertical reference
distances.
In males, the disproportion index for
the transverse reference distances was
8.8% and 9.9% for the vertical reference
distances.
Comparison of sex (Table 5, Figs 6 to
8). When comparing nonattractive
female and male patients, no significant
differences were found for any variable.
Comparison of attractive and non-
attractive patients (Table 5, Figs 6 to
8). A statistical group comparison was
performed for only females because the
attractive male group comprised just five
subjects.
34
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WORLD JOURNAL OF ORTHODONTICS
Fig 8 Box plots of the trans-
verse and vertical reference
distances deviations from their
Attractive ideal values (0) calculated on
Nonattractive the basis of the divine propor-
tions in the five attractive and
21 nonattractive male patients.
Vertical
In the transverse plane, nonattractive
females exhibited significant larger devia-
tion values for mouth width (MW-MW)
(P < .01) and eye width (EW-EW) (P < .05)
than attractive females. In the vertical
plane, no group differences existed.
The transverse and vertical dispropor-
tion indices were significantly larger
(P < .001) in nonattractive than in attrac-
tive female patients.
DISCUSSION
It has been said that beauty lies in the eye
of the beholder. This statement is basically
still true as the assessment of facial
attractiveness is very complex. Results
from studies evaluating computer-manipu-
lated male and female faces indicate that
bilateral symmetr y, 20–23 average-
ness,22,24–26 hormone markers,23,24,27 and
the menstrual cycle28,29 influence the per-
ception of attractiveness.
Ricketts1,30 was the first to stipulate
that instead of resorting to a subjective
perception, a face’s beauty should be math-
ematically analyzed on the basis of the
golden proportions. This was performed
VOLUME 11, NUMBER 1, 2010
in the present investigation, allowing an
appropriate comparison with Ricketts’
and other researchers’ results. Frontal
photographs were taken because this is
the perspective from which most cover
models are normally seen and what was
used in other studies.1,18
The composition of an examination
panel may have an effect on the ranking
of facial esthetics, but the relevant litera-
ture is not clear about the influence of
professional background, 31,32 age, 31,33
and sex32–34 on the panel’s decisions.
Panel size is another issue of contro-
versy.32,34–36 As the panel of the present
investigation was large and uniform (54
young adult dental students evenly dis-
tributed with respect to sex), common
esthetic norms were expected to exist.
Strict criteria were used to assign the
398 former orthodontic patients to either
the attractive or nonattractive group. At
least 44 of 54 (81%) votes were necessary
for each face to be distinctly grouped.
Differences in size of facial dimen-
sions amongst individuals will have an
input on whether a particular individual
has a normal or ideal facial relationship.
The use of the divine proportions over-
comes this problem.
The results of the present investiga-
tion revealed for both attractive and
nonattractive females and males large
interindividual variations of the different
transverse and vertical parameters. For
all variables in the female models and,
with one exception, in the attractive
female patients, the average deviations
from the divine proportions were rather
small (between 0.3% and 3.6%). The
exception was nose height (EW-AL) in
female patients, in which the deviation
amounted to 7.8% (shorter nose).
In male models and attractive male
patients, the average deviations of the
variables from their ideal values were
somewhat larger in general. The devia-
tions ranged between 0.2% and 6.3%,
except for nose height (EW-AL), which
amounted to 11.2% (smaller nose).
The sex differences found for the mod-
els could be explained by dif ferent
esthetic standards for females and
males,23,24,27,29 eg, in males, a prominent
chin (MW-ME) and an increased lower
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Pancherz et al
face height (AL-ME) are favored as they
are considered masculine. Thus, attrac-
tive male faces were less often verified
by the divine proportions than the female
ones.
In this context, it must be pointed out
that all ver tical measurements are
affected by the head position. Most likely,
females were photographed with their
heads tilted more forward than the males
as this adds to their attractiveness. The
geometric consequence of this head tilt
would be a relatively shorter lower face.
When comparing the female models
with the attractive female patients, simi-
lar deviations from the ideal proportions
for the different variables were found.
However, when comparing attractive and
nonattractive females, as well as male
patients, larger deviations from the ideal
values became obvious for the nonattrac-
tive subjects. This was especially appar-
ent when using the disproportion index.
The present study indicates that facial
attractiveness is partially related to the
divine proportions and is measurable, as
Ricketts1 stated.
It should be kept in mind that the
divine proportions are not absolute deter-
minants of facial attractiveness as they
are subjected to the same limitations as
other methods. While faces conforming
to the divine proportions may well be con-
ceived as esthetically pleasing, it is quite
possible that other methods of evalua-
tion would lead to an equally favorable
outcome. Thus, it seems that it is the
individual esthetic character of facial fea-
tures, not just their proportions, that sig-
nificantly influence the assessment of
facial beauty and attractiveness.
CONCLUSION
The facial proportions of the attractive
individuals were closer to the divine pro-
portions compared to those of the non-
attractive ones. Attractive females exhib-
ited facial proportions nearer to the divine
values than males. In accordance with
Ricketts’ hypothesis, this study indicates
that facial beauty, at least to some
degree, is based on the divine propor-
tions and can be measured.
35
 Pancherz et al
REFERENCES
1. Ricketts RM. The biologic significance of the
divine proportion and the Fibonacci series. Am
J Orthod 1982;81:351–370.
2. Matoula S, Pancherz H. Skeletofacial morphol-
ogy of attractive and nonattractive faces. Angle
Orthod 2006;76:204–210.
3. Bashour M. An objective system for measuring
facial attractiveness. Plast Reconstr Surg
2006;118:757–774.
4. Keating C. Gender and the physiognomy of
dominance and attractiveness. Soc Psychol
1985;48:61–70
5. Giddon DB. Orthodontic applications of psycho-
logical and perceptual studies of facial esthet-
ics. Semin Orthod 1995;1:82–93.
6. Tatarunaite E, Playle R, Hood K, Shaw W, Rich-
mond S. Facial attractiveness: A longitudinal
study. Am J Orthod Dentofacial Orthop 2005;
127:676–682.
7. Terry RL, Davis JS. Components of facial attrac-
tiveness. Percept Mot Skills 1976;42:918.
8. Terry RL. Further evidence on components of
facial attractiveness. Percept Mot Skills 1977;
45:130.
9. Bull R, Rumsey N. The social psychology of
facial appearance. New York: Springer-Verlag,
1988.
10. Alley TR, Hildebrandt KA. Determinants and
consequences of facial aesthetics. In: Alley TR,
ed. Social and Applied Aspects of Perceiving
Faces. Hillsdale: Lawrence Erlbaum Associates,
1988:101–140.
11. Edler RJ. Background considerations to facial
aesthetics. J Orthod 2001;28:159–168.
12. Ghyka M. The Geometry of Art and Life. New
York: Sheed and Ward, 1946.
13. Bashour M. History and current concepts in the
analysis of facial attractiveness. Plast Reconstr
Surg 2006;118:741–756.
14. Seghers MJ, Longacre JJ, deStefano GA. The
golden proportion and beauty. Plast Reconstr
Surg 1964;34:382–386.
15. Kawakami S, Tsukada S, Hayashi H, Takada Y,
Koubayashi S. Golden proportion for maxillofa-
cial surgery in Orientals. Ann Plast Surg 1989;
23:417–425.
16. de Castro MV, Santos NC, Ricardo LH. Assess-
ment of the “golden proportion” in agreeable
smiles. Quintessence Int 2006;37:597–604.
17. Filho EM, Martins MV, dos Santos da Silva MA,
Castilho JC, de Moraes LC, Gil CTL. Divine pro-
portions and facial esthetics after manipula-
tion of frontal photographs. World J Orthod
2007;8:103–108.
18. Heiß A. “Göttliche” Proportionen des attrak-
tiven Gesichts [thesis]. University of Giessen,
Germany, 2002.
36
© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE
MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
WORLD JOURNAL OF ORTHODONTICS
19. Dahlberg G. Statistical Methods for Medical
and Biological Students. New York: Inter-
science Publications, 1940.
20. Enquist M, Arak A. Symmetry, beauty and evo-
lution. Nature 1994;372:169–172.
21. Scheib JE, Gangestad SW, Thornhill R. Facial
attractiveness, symmetry and cues of good
genes. Proc Biol Sci 1999;266:1913–1917.
22. Rhodes G, Yoshikawa S, Clark A, Lee K, McKay
R, Akamatsu S. Attractiveness of facial avera-
geness and symmetry in non-western cultures:
In search of biologically based standards of
beauty. Perception 2001;30:611–625.
23. Fink B, Penton-Voak I. Evolutionary psychology
of facial attractiveness. Curr Dir Psychol Sci
2002;11:154–158.
24. Parret DI, Lee KJ, Penton-Voak I, et al. Effects
of sexual dimorphism on facial attractiveness.
Nature 1998;394:884–887.
25. Langlois JH, Roggman LA. Attractive faces are
only average. Psychol Sci 1990;1:115–121.
26. Halberstadt J, Rhodes G. The attractiveness of
nonface averages: Implications for an evolu-
tionary explanation of the attractiveness of
average faces. Psychol Sci 2000;11:285–289.
27. Fink B, Grammer K, Thornhill R. Human (Homo
sapiens) facial attractiveness in relation to skin
texture and color. J Comp Psychol 2001;115:
92–99.
28. Penton-Voak IS, Parrett DI, Castles DL, et al.
Menstrual cycle alters face preference. Nature
1999;399:741–742.
29. Johnston VS, Hagel R, Franklin M, Fink B,
Grammer K. Male facial attractiveness: Evi-
dence for hormone-mediated adaptive design.
Evol Hum Behav 2001;22:251–267.
30. Ricketts RM. Divine proportion in facial esthet-
ics. Clin Plast Surg 1982;9:401–422.
31. Spyropoulos MN, Halazonetis DJ. Significance of
the soft tissue profile on facial esthetics. Am J
Orthod Dentofacial Orthop 2001;119:464–471.
32. Kiekens RMA, van’t Hof MA, Straatman H,
Kuijpers-Jagtman AM, Maltha JC. Influence of
panel composition on aesthetic evaluation of
adolescent faces. Eur J Orthod 2007;29:95–99.
33. Cross JF, Cross J. Age, sex, race, and the per-
ception of facial beauty. Develop Psychol 1971;
5:433–439.
34. Howells DJ, Shaw WC. The validity and reliabil-
ity of ratings of dental and facial attractiveness
for epidemiologic use. Am J Orthod 1985;88:
402–408.
35. Phillips C, Tulloch C, Dann C. Rating of facial
attractiveness. Community Dent Oral Epidemiol
1992;20:214–220.
36. Jefferson Y. Facial beauty—Establishing a uni-
versal standard. Int J Orthod Milwaukee 2004;
15:9–22.ble 1
Simona Tecco, DDS1
PREVALENCE OF SIGNS AND SYMPTOMS
Felice Festa, MD, DDS2
OF TEMPOROMANDIBULAR DISORDERS
IN CHILDREN AND ADOLESCENTS WITH
AND WITHOUT CROSSBITES
This study investigated the prevalence of signs and symptoms of tem-
poromandibular disorders (TMD) in 1,134 orthodontically untreated
children and adolescents (593 boys, 541 girls; age range 5 to 15 years)
with and without crossbites. The sample with crossbites was further
grouped according to the type (anterior, posterior, unilateral, or bi-
lateral). The TMD symptoms bruxism (obvious active attrition/myalgia),
joint sounds (clicking/crepitation), deviation during opening, reduced
functional movements (maximum opening < 40 mm), and myopain
(originating in the masticatory muscles/related to masticatory func-
tions) were evaluated based on the standardized RDC/TMD protocol
(Research Diagnostic Criteria for Temporomandibular Disorders) and
compared among the various groups. Girls had a significantly higher
prevalence of myopain than boys (␹2 = 3.882, P < .05). Furthermore,
individuals with posterior unilateral crossbites showed a significantly
higher prevalence of TMD symptoms (␹2 = 33.877, P < .001) and
reduced functional movements (␹2 = 10.800, P < .05) than any other
group. In conclusion, sex and type of crossbite play a role in the preva-
lence of TMD signs and symptoms. World J Orthod 2010;11:37–42.

Key words: tempormandibular disorders, crossbites, RDC/TMD protocol

he prevalence of temporomandibular investigated TMD signs and symptoms in

1Fellowship, Department of Oral
Science, University G.D’Annunzio,
Chieti/Pescara, Italy.
2Full Professor, Department of Oral
Science, University G.D’Annunzio,
Chieti/Pescara, Italy.
CORRESPONDENCE
Dr Simona Tecco
Via Le Mainarde 26
65121 Pescara
Italy
Email: simtecc@unich.it,
simtecc@tin.it
T joint disorders (TMD) in children and
adolescents has been frequently investi-
gated.1–21 Most studies report a great
variation of TMD signs and symptoms.
This could be partially attributed to some
inter- and intraexaminer variation, as well
as the diagnostic methods that were
applied without considering the age or
cognitive development of children. Most
studies on TMD in young individuals were
cross-sectional4,7,10,14,17,18 and the risk
factors for TMD were determined by logis-
tic regression analysis.15 It became obvi-
ous that sex (girl odds ratio [OR] = 1.7)
and unilateral chewing (OR = 1.5) were
the most significant risk factors.
Prospective studies also revealed inter-
esting findings. Könönen and Nyström1
131 Finnish adolescents aged 14, 15,
and 18 years. They observed that clicking
was the most frequent sign, which
increased with age, although there was
considerable intraindividual fluctuation
over time with no predictable pattern.
Later, Suvinen et al6 followed a sample of
128 Finnish males and females (15, 18,
and 23 years old) for 8 years, recording
their TMD and psychosomatic symptoms.
They found that females were affected
approximately twice as often as males.
Even more recently, Magnusson et
al 12 found that unilateral crossbite is
associated, although weakly, with the
presence of TMD signs and symptoms.
Although sex and crossbite can seri-
ously be considered risk factors for TMD,

37

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 Tecco et al
many studies did not take them into
account. Thus, the aim of this investiga-
tion was to assess the TMD signs and
symptoms in a sample of Caucasian chil-
dren and adolescents who were divided
into groups on the basis of sex and pres-
ence and the type of crossbites.
PATIENTS AND METHODS
One thousand one hundred thirty-four
subjects (593 boys, 541 girls; age range
5 to 15 years) with TMD were selected for
this study. All individuals with muscle
affections clearly not associated with
TMD, such as polyarthritis, acute injuries,
metabolic diseases, neurologic disorders,
vascular diseases, neoplasia, psychiatric
disorders, or drug abuse were excluded.
Other exclusion criteria were medical-
dental emergencies, as well as visual,
auditory, and motor impairments. Finally,
all pa tients who received medication,
particularly that affecting the central ner-
vous system, were excluded. 22,23 The
study was approved by the Institutional
Review Board.
Two dentists (S.T. and F.F.) examined
all patients clinically, registered any sign
or symptom of TMD, and collected respec-
tive social and demographic informa-
tion. 24 All subjects were divided into
groups according to sex and the presence
and type of crossbites12,25: no crossbite
(645 patients), anterior crossbite (193
patients), posterior bilateral crossbite
(251 patients), and posterior unilateral
crossbite (45 patients). The examination
for TMD was based on the standardized
RDC/TMD protocol (Research Diagnostic
Criteria for Temporomandibular Disor-
ders).26
Signs were diagnosed if patients suf-
fered from bruxism, which was obvious by
myalgia associated with parafunctions27
and shiny, flat tooth surfaces (attritions).
Both clicking and crepitation were
classified as joint sounds, even though
they are very different in nature.
In a healthy masticatory system, the
mandible will move straight up and down
during opening and closing, so any
altered movement was recorded as a
deviation.
38
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WORLD JOURNAL OF ORTHODONTICS
The normal range of mandibular open-
ing is between 53 and 58 mm in adults.28
However, 5- to 6-year-old children can
normally open their mouth a maximum of
only 40 mm. 29 Hence, a restricted
mandibular opening was considered if
the distance between the incisal edges
was less than 40 to 50 mm, considering
both the overbite and the age of the
patient.13 Individuals between 6 and 11
years of age were categorized as children
in whom the standard opening distance
was fixed at 40 mm; those who were 12
to 15 years old were regarded as adoles-
cents with a standard opening distance
of 45 mm. In individuals 5 to 6 years of
age, the normal opening limit was set at
38 mm. Lateral and protrusive move-
ments were noted as limited if they were
less than 8 mm.29
Muscle tenderness or pain was evalu-
ated by manual palpation. Myopain was
diagnosed when it originated in the masti-
catory muscles and was related to masti-
catory function. Palpation was performed
with mainly the palmar surface of the mid-
dle finger, while the index and forefinger
tested the adjacent area. Soft but constant
pressure was applied in a small circular
motion to the respective muscle. The mus-
cles and tendons palpated were the super-
ficial masseter, anterior temporalis, middle
temporalis, posterior temporalis, posterior
cervicalis, sternocleidomastoideus, ante-
rior and posterior digastric, medial ptery-
goid, lateral pterygoid, temporalis tendon,
deep masseter, and upper trapezius. The
affected patients defined their degree of
pain (from none [0] to extreme [100]).
Symptoms were diagnosed when the
patients described or complained about
acute muscle discomfort or pain (ranging
from slight tenderness to extreme pain or
stiffness) in the joint area (arthralgia), the
neck and the shoulders, and during func-
tion; difficulties in mouth opening; or a
sensation of a stuck or locked TMJ.
Method error
To assess the inter- and intraobserver
method error, 10 patients were evaluated
separately a second time by two investi-
gators (F.F. and S.T.). The two evaluations
VOLUME 11, NUMBER 1, 2010 Tecco et al

Table 1 Prevalence of the various TMD signs and symptoms (%)

in boys and girls
Boys Girls ␹2 P

Bruxism 13.7 11.7 2.250 .134

TMJ sounds 2.7 5.4 3.756 .053
Deviation during opening 1.7 3.3 2.286 .131
Reduced movements (opening/laterotrusion/protrusion) 0.8 1.45 0.692 .405
Myopain 6.4 10.4 3.882 .049*
TMD symptoms 23.8 25.3 0.058 .810

* Significant difference.

Table 2 Prevalence of the various TMD signs and symptoms (%) according to
absence or existence and type of crossbite
Posterior Posterior
No Anterior bilateral unilateral
crossbite crossbite crossbite crossbite ␹2 P

Bruxism 12.4 12.4 12.8 17.8 1.800 .615

TMJ sounds 4.0 3.6 3.2 8.9 4.400 .221
Deviation during opening 2.8 1.6 2.4 2.2 0.333 .954
Reduced movements
(opening/laterotrusion/protrusion) 1.2 0.0 0.8 6.7* 10.800 .013
Myopain 7.5 9.4 10.2 9.0 0.222 .974
TMD symptoms 22.8 20.2 25.9 60.0* 33.877 .000

* Significant difference.

by the two investigators were compared
with respect to each variable. The error
variance was calculated using Dahlberg’s
formula30:
δ = √(⌺ d2/2N)
where d is the difference between the
first and the second measurement and N
the number of double registrations.
Statistical analysis
Standard statistical analysis was carried
out using SPSS 11.5 for Windows (SPSS).
The incidence of signs and symptoms of
TMD were compared among the various
groups using ␹2 analysis. The level of sig-
nificance was set at P < .05.
The prevalence of signs and symp-
toms of TMD according to age and sex is
displayed in Table 1. The ␹2 test revealed
a significantly higher prevalence of
myopain among females (10.4%) than
males (6.4%) (␹2 = 3.882, P < .05).
The prevalence of signs and symp-
toms of TMD in subjects with and without
crossbites is presented in Table 2. In this
study, the prevalence of TMD symptoms
was similar in patients with and without
crossbites (20.2% to 22.8%). Only
patients with posterior unilateral cross-
bites showed significantly more TMD
symptoms (60.0%, ␹2=33.877, P < .01)
and restricted functional movements
(6.7%, ␹2 = 10.800, P < .05) than any of
the other groups.
DISCUSSION

RESULTS The stratification of patients was based on

Magnusson et al,12 whose 20-year follow-
For each variable, the intra- and the inter- up study identified unilateral crossbite as
observer method error was found to be a risk factors for the development of TMD.
less than 5.0% of the biologic variance. However, in contrast to that study, this one

39

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 Tecco et al
was cross-sectional because the latency
period of the disease is long.31,32
The average percentage (25.0%) of
TMD symptoms obtained in this study is
similar to that found by other researchers
in cross-sectional investigations.3,4,5,11 It
was somewhat higher in the evaluation of
385 schoolchildren (230 females, 155
males; 12 to 16 years) by Feteih 16 in
which it amounted to 33.0%.
The findings are similar if the study
design is longitudinal. Suvinen et al 6
evaluated TMD and psychosomatic symp-
toms in 128 Finnish young adults over an
8-year period (at 15, 18, and 23 years).
About 6.0% to 12.0% of the subjects
reported pain, 12.0% to 28.0% demon-
strated dysfunction, and 4.0% to 7.0%
had a combination.
In the majority of studies, females
show a higher percentage of TMJ symp-
toms in general, with myopain being the
most prevalent.14,15,17,33–37 For instance,
Widmalm et al 4 noticed in 153 Cau-
casians and 50 African–American chil-
dren (4 to 6 years of age) that the girls
had a significantly higher prevalence of
“pain or tiredness during chewing” (a
type of pain that can be referred to as
myopain) than the boys. Wahlund 36
investigated 864 adolescents from a
public dental service clinic and also
found a higher prevalence of TMD pain
in girls. According to Suvinen et al,6 the
ratio of females to males with symptoms
is approximately 2 to 1. Nilsson et al19
studied adolescents at age 12 to
15 years and 16 to 19 years. Again, in
the entire sample, there was a signifi-
cantly higher incidence of TMD pain
among females (4.5%) than males (1.3%).
In addition, TMD pain increased with age
among girls significantly (P < .05) more
(3.0% to 6.9%) than in boys (1.7% to
2.6%). Finally, Huddleston Slater et al18
evaluated the prevalence and risk factors
for anterior disc displacement with reduc-
tion and TMJ hypermobility in children
(4 to 18 years), adolescents (19 to 30
years), and adults (older than 30 years).
A higher prevalence of TMJ hypermobility
was observed among girls (13.8%) than
boys (8.2%) with sex (OR = 2.07) and
muscle pain (OR = 1.95) as the main risk
factors.
40
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WORLD JOURNAL OF ORTHODONTICS
Only the studies by Otuyemi et al5 and
Bonjardim et al11 failed to report a gen-
eral difference between the sexes. How-
ever, Otuyemi et al investigated subjects
aged 17 to 32 years. Also, their index
was based on the intensity of signs and
symptoms (not significant, mild, and
severe); in the present study, the sign
myopain was considered independently
from the symptom pain. This remark
underscores the difficulty in comparing
the data of studies and emphasizes the
advantage of monitoring signs and symp-
toms (for example myopain/pain) inde-
pendently. Similarly, Bonjardim et al 11
classified signs and symptoms of TMD as
a single category. Though there was no
general difference between the sexes,
they reported a significantly higher preva-
lence of “tenderness of the lateral ptery-
goid muscles” in girls.
The findings of the present study
regarding bruxism are partly in agree-
ment with the current literature.
The study by Magnusson et al 12 and
Casa nova-Rosado et al 15 reported an
association between bruxism and TMD
symptoms. This could not be confirmed
by this study because it lacks follow-up
and a logistic regression analysis. Mag-
nusson et al 12 further concluded that
grinding is a predictor of TMD treatment
during the 20-year follow-up.
As far as crossbite is concerned, Mag-
nusson et al 12 observed only a weak
association between TMD signs and
symptoms and occlusion, although they
defined unilateral crossbite as a risk fac-
tor. Similarly, the logistic regression
analysis of Casanova-Rosado et al15 with
TMD as the dependent variable identified
unilateral chewing (OR = 1.5) as the vari-
able most often associated with TMD.
With regard to restricted functional
movements, the results of this study are
comparable to those of Otuyemi et al5
but in contrast to that of Hirsch et al,14
who repor ted that the values for
mandibular movements were influenced
by only age and sex.
Although the majority of the present
findings corresponds with those observed
in other studies, this one has several limita-
tions. One is that crossbites of just one pair
of antagonistic teeth were included and
VOLUME 11, NUMBER 1, 2010
that it was not checked if a crossbite was
forced or unforced (ie, a RCP-ICP difference
existed).
Finally, it was not taken into account
that a subject could have had one or
more signs and symptoms of TMD.
CONCLUSIONS
TMD signs and symptoms were recorded
in 1,134 subjects with and without cross-
bites. The sample was divided into
groups on the basis of sex, presence or
absence of crossbites, and type of cross-
bite (anterior, posterior, unilateral, or
bilateral). The prevalence of signs and
symptoms of TMD was compared among
the groups. Although there were some
limitations in the study design, females
showed a significantly higher prevalence
of myopain than males (␹ 2 = 3.882,
P < .05). Furthermore, individuals with
posterior unilateral crossbite had a signif-
icantly higher prevalence of TMD symp-
toms (␹2 = 33.877, P < .01) and reduced
functional movements (␹ 2 = 10.800,
P < .05). On the basis of these findings,
sex and type of crossbite seem to play a
role in the prevalence of TMD signs and
symptoms in children and young adoles-
cents.
ACKNOWLEDGMENTS
The authors would like to thank Prof Stefano Tetè
for suggestions in the interpretation of results, Prof
Letizia Perillo for her suggestions in the selection of
patients, and Dr Michele D’Attilio for his sugges-
tions in the statistical analysis.
REFERENCES
1. Könönen M, Nyström M. A longitudinal study of
craniomandibular disorders in Finnish adoles-
cents. J Orofac Pain 1993;7:329–336.
2. Nydell A, Helkimo M, Koch G. Craniomandibu-
lar disorders in children—A critical review of the
literature. Swed Dent J 1994;18:191–205.
3. Nourallah H, Johansson A. Prevalence of signs
and symptoms of temporomandibular disor-
ders in a young male Saudi population. J Oral
Rehabil 1995;22:343–347.
© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE
MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Tecco et al
4. Widmalm SE, Christiansen RL, Gunn SM, Haw-
ley LM. Prevalence of signs and symptoms of
craniomandibular disorders and orofacial para-
function in 4-6-year-old African-American and
Caucasian children. J Oral Rehabil 1995;22:
87–93.
5. Otuyemi OD, Owotade FJ, Ugboko VI, Ndukwe
KC, Olusile OA. Prevalence of signs and symp-
toms of temporomandibular disorders in young
Nigerian adults. J Orthod 2000;27:61–65.
6. Suvinen TI, Nyström M, Evalahti M, Kleemola-
Kujala E, Waltimo A, Könönen M. An 8-year fol-
low-up study of temporomandibular disorder
and psychosomatic symptoms from adoles-
cence to young adulthood. J Orofac Pain 2004;
18:126–130.
7. Akhter R, Hassan NM, Nameki H, Nakamura K,
Honda O, Morita M. Association of dietary
habits with symptoms of temporomandibular
disorders in Bangladeshi adolescents. J Oral
Rehab 2004;31:746–753.
8. Muhtarogullari M, Demirel F, Saygili G. Tem-
poromandibular disorders in Turkish children
with mixed and primary dentition: Prevalence
of signs and symptoms. Turk J Pediatr 2004;
46:159–163.
9. Tuerlings V, Limme M. The prevalence of tem-
poromandibular joint dysfunction in the mixed
dentition. Eur J Orthod 2004;26:311–320.
10. Nilsson IM, List T, Drangsholt M. Prevalence of
temporomandibular pain and subsequent den-
tal treatment in Swedish adolescents. J Orofac
Pain 2005;19:144–150.
11. Bonjardim LR, Gavião MB, Pereira LJ, Castelo
PM, Garcia RC. Signs and symptoms of tem-
poromandibular disorders in adolescents. Braz
Oral Res 2005;19:93–98.
12. Magnusson T, Egermark I, Carlsson GE. A
prospective investigation over two decades on
signs and symptoms of temporomandibular dis-
orders and associated variables. A final sum-
mary. Acta Odontol Scand 2005;63:99–109.
13. Hirsch C, John MT, Lautenschläger C, List T.
Mandibular jaw movement capacity in 10-17-yr-
old children and adolescents: Normative values
and the influence of gender, age, and temporo-
mandibular disorders. Eur J Oral Sci 2006;114:
465–470.
14. Hirsch C, John MT, Schaller HG, Turp JC. Pain-
related impairment and health care utilization
in children and adolescents: a comparison of
orofacial pain with abdominal pain, back pain,
and headache. Quintessence Int 2006;37:
381–390.
15. Casanova-Rosado JF, Medina-Solís CE, Vallejos-
Sánchez AA, Casanova-Rosado AJ, Hernández-
Prado B, Avila-Burgos L. Prevalence and associ-
ated factors for temporomandibular disorders
in a group of Mexican adolescents and youth
adults. Clin Oral Investig 2006;10:42–49.
16. Feteih RM. Signs and symptoms of temporo-
mandibular disorders and oral parafunctions in
urban Saudi Arabian adolescents: a research
report. Head Face Med 2006;16;2:25.
41
 Tecco et al
17. LeResche L, Mancl LA, Drangsholt MT, Huang
G, Von Korff M. Predictors of onset of facial
pain and temporomandibular disorders in early
adolescence. Pain 2007;129:269–278.
18. Huddleston Slater JJ, Lobbezoo F, Onland-
Moret N C, Naeije M. Anterior disc displace-
ment with reduction and symptomatic hyper-
mobility in the human temporomandibular
joint: prevalence rates and risk factors in chil-
dren and teenagers. J Orofac Pain 2007;21:
55–62.
19. Nilsson IM, List T, Drangsholt M. Incidence and
temporal patterns of temporomandibular disor-
der pain among Swedish adolescents. J Orofac
Pain 2007;21:127–132.
20. Nilsson IM. Reliability, validity, incidence, and
impact of temporormandibular pain disorders
in adolescents. Swed Dent J Suppl 2007;183:
7–86.
21. Barbosa Tde S, Miyakoda LS, Pocztaruk Rde L,
Rocha CP, Gavião MB. Temporomandibular dis-
orders and bruxism in childhood and adoles-
cence: Review of the literature. Int J Pediatr
Otorhinolaryngol 2008;72:299–314.
22. Goldberg MB, Mock D, Ichise M, et al. Neu-
ropsychologic deficits and clinical features of
posttraumatic temporomandibular disorders.
J Orofac Pain 1996;10:125–140.
23. Grossi ML, Goldberg MB, Locker D, Tenenbaum
HC. Reduced neuropsychologic measures as
predictors of treatment outcome in patients
with temporomandibular disorders. J Orofac
Pain 2001;15:329–339.
24. Pullinger AG, Seligman DA, Gornbein JA. A mul-
tiple logistic regression analysis of the risk and
relative odds of temporomandibular disorders
as a function of common occlusal features.
J Dent Res 1993;72:968–979.
25. Karjalainen M, Bell YL, Jämsä T, Karjalainen S.
Prevention of temporomandibular disorder-
related signs and symptoms in orthodontically
treated adolescents. Acta Odontol Scand
1997;55:319–324.
26. Dworkin SF, LeResche L. Research diagnostic
criteria for temporomandibular disorders.
J Craniomandib Disord 1992;6:301–355.
42
© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE
MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
WORLD JOURNAL OF ORTHODONTICS
27. Bell WE. Orofacial Pains: Differential Diagnosis,
ed 2. Chicago: Year Book Medical Publishers,
1979:62.
28. Agerberg G. Maximal mandibular movements in
young men and women. Swed Dent J 1974;
67:81.
29. Solberg W. Occlusion-related pathosis and its
clinical evaluation. Hagerstown: Harper & Row
Publishers; 1976;2:1–29.
30. Dahlberg G. Statistical methods for medical
and biological students. London: George Allen
and Unwin, 1940.
31. Velly AM, Gornitsky M, Philippe P. Contributing
factors to chronic myofascial pain: A case-con-
trol study. Pain 2003;104:491–499.
32. Hennekens CH, Buring JE. Epidemiology in
Medicine. Mass/Toronto Ontario, Canada: Little
Brown, 1987.
33. Selaimen CMP, Jeronymo JCM, Brilhante DP,
Lima EM, Grossi PK, Grossi ML. Occlusal Risk
Factors for Temporomandibular Disorders.
Angle Orthod 2007;77:471–477.
34. Pullinger AG, Seligman DA, John MT, Harkins S.
Multifactorial comparison of disk displacement
with and without reduction to normals accord-
ing to temporomandibular joint hard tissue
anatomic relationships. J Prosthet Dent 2002;
87:298–310.
35. Yap AUJ, Dworkin SF, Chua EK, List T, Tan KBC,
Tan HH. Prevalence of temporomandibular dis-
order subtypes, psychologic distress, and psy-
chosocial dysfunction in Asian patients. J Oro-
fac Pain 2003;17:21–28.
36. Wahlund K. Temporomandibular disorders in
adolescents. Epidemiological and methodologi-
cal studies and a randomized controlled trial.
Swed Dent J Suppl 2003;164:2-64.
37. de Oliveira AS, Dias EM, Contato RG, Berzin F.
Prevalence study of signs and symptoms of
temporomandibular disorder in Brazilian col-
lege students. Braz Oral Res 2006;20:3–7.
Ali Borzabadi-Farahani,
DDS, MScD (Cardiff),
MOrth RCS(Edin)1
Anahid Borzabadi-
Farahani, DDS2
Faezeh Eslamipour, DDS,
MS3
1Department
of Orthodontics, School
of Dentistry, College of Medical and
Dental Sciences, University of
Birmingham, Birmingham, UK.
2Private Practice, Tehran, Iran.
3Department of Community Den-
THE RELATIONSHIP BETWEEN THE ICON
INDEX AND THE DENTAL AND AESTHETIC
COMPONENTS OF THE IOTN INDEX
Aim: To determine the malocclusion complexity and orthodontic treat-
ment need in urban Iranian schoolchildren using the Index of Complex-
ity, Outcome, and Need (ICON) and the Index of Orthodontic Treatment
Need (IOTN) and to also assess the relationship between these indices.
Methods: The study sample comprised 502 individuals (253 girls and
249 boys, 11 to 14 years of age), of whom one girl and five boys already
had an orthodontic appliance at the time of the survey. In those individ-
uals not wearing orthodontic appliances (n = 496), the definitive treat-
ment need (ICON > 43) and compartments of the ICON were defined
and compared between sexes. The Aesthetic Component and Dental
Health Component (DHC) of the IOTN were also recorded. Scatter plots
and Spearman rank correlation coefficients were used to explore the
relationships between the ICON and DHC and the Aesthetic Compo-
nent (AC) of the IOTN. Results: According to ICON, DHC (IOTN), and
Aesthetic Component (IOTN), 46.6%, 36.1%, and 17.9%, respectively, of
the studied children needed orthodontic treatment; however, only 1.1%
wore an appliance. In terms of complexity, 26.4% of the studied individ-
uals were considered to have a difficult or very difficult malocclusion.
With regard to treatment needs, significant correlations existed
between the ICON scores and DHC (IOTN) (r = 0.93) and between the
ICON scores and the esthetic component (IOTN) (r = 0.96). The thresh-
old for treatment need was lower in the ICON than in the IOTN. Of the
children who were classified in the borderline category of the IOTN
(DHC = 3), 52.0% were in need of treatment according to their ICON
score (ICON > 43). No sex difference was found for treatment need
(ICON > 43, P > .05) and treatment complexity (P > .05). Conclusion:
According to the ICON, 46.6% of the Iranian schoolchildren need ortho-
dontic treatment. ICON is a good substitute for the IOTN, yet it results in
a lower treatment-need threshold. World J Orthod 2010;11:43–48.

tistry, School of Dentistry, Isfahan

University of Medical Sciences, Key words: orthodontic need, treatment-need threshold, complexity,
Isfahan, Iran. ICON, IOTN

CORRESPONDENCE
Dr Ali Farahani
Department of Orthodontics
School of Dentistry
University of Birmingham
St Chad’s Queensway
Birmingham B4 6NN
UK
Email: faraortho@yahoo.com
This paper was presented at the WJB
Houston Research Award Section of
the European Orthodontic Congress,
Helsinki, Finland, 2009.
here is increased interest in using
T indices or numerical scales to objec-
tively score malocclusions in terms of
their difficulty and also to assess the
outcome of treatments. In theory, this
helps the profession allocate limited
resources, identify the most effective
appliances, and increase professional
esteem among colleagues. Oral health–
related benefits of orthodontic treatment
are reduced susceptibility to dental
caries, periodontal disease, temporo-
mandibular disorders, and dental
trauma.1 However, rather than any func-
tional disadvantage, the main ill effect
of malocclusions is their esthetic and
related psychosocial impairment. 1–4
Therefore, any index should theoretically
integrate an assessment of esthetics,
even though the psychologic health gain
from orthodontic treatment has been
disputed.5

43

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 Borzabadi-Farahani et al
A satisfactory estimate of the need and
demand for orthodontic treatment in any
population is a prerequisite for developing
and organizing a meaningful service. In
this context, several indices have been
proposed that not only measure the preva-
lence of malocclusions but also try to
objectively quantify their severity. Exam-
ples include the Occlusal Index of Sum-
mers,6 the Handicapping Malocclusion
Assessment Record of Salzmann, 7 the
Dental Aesthetic Index, 8,9 the Index of
Orthodontic Treatment Need,10,11 the Peer
Assessment Rating (PAR),12 and the Nor-
wegian Orthodontic Treatment Index.13
These indices intend to objectively mea-
sure the severity of malocclusions, either
as deviations from normal occlusion or in
terms of perceived treatment need. They
usually have a cut-off point to differentiate
between those individuals who require
and do not require therapy.
Unfortunately, these indices are not
always comparable.14–16 The ICON was
developed by 97 practicing orthodontists
from nine countries.17–19 It is unique in
incorporating an esthetic score. Because
it not only defines treatment need but also
assesses malocclusion severity, it offers a
significant advantage over other indices.
To these authors’ knowledge, there is
no other study of the malocclusion com-
plexity and the orthodontic treatment
need in Iranians using the ICON. The pri-
mary aim of the present study was to
evaluate these two aspects in 11- to
14-year-old Iranian schoolchildren. The
secondary aim was to assess the rela-
tionship between the ICON and the IOTN
(DHC and Asthetic Component [AC]).
SUBJECTS AND METHODS
This cross-sectional study was approved
by the Research Ethics Committee and
Faculty of Community Dentistry, School
of Dentistry, Isfahan University of Medical
Sciences.
The target population was school-
children aged 11 to 14 years in Isfahan,
Iran. By this age, the permanent canines
and premolars have erupted, so the
majority of potential orthodontic prob-
lems are evident.
44
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MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
WORLD JOURNAL OF ORTHODONTICS
Exclusion criteria for this study were
subjects with craniofacial anomalies
(clefts and syndromes) and non-Iranian
nationals. To ensure random selection,
the 502 children (253 girls and 249 boys)
were chosen from six public schools from
different parts of Isfahan.
IOTN
The IOTN ranks malocclusions in terms of
the significance of various occlusal traits
for an individual’s dental health and per-
ceived esthetic impairment, with the inten-
tion of identifying those individuals who
would most likely benefit from an ortho-
dontic treatment. The index has an Aes-
thetic and Dental Health Component. The
Aesthetic Component consists of 10 color
photographs showing dentitions that differ
in attractiveness: grade 1 represents the
most attractive and grade 10 the least
attractive. The Dental Health Component
(DHC) incorporates the various occlusal
traits considered to increase the morbidity
of a dentition. There are five grades within
the DHC: grades 1 and 2 represent no
need for treatment, grade 3 represents
borderline need, and grades 4 and 5 rep-
resent a need for orthodontic treatment.
ICON
The ICON consists of five components: the
Aesthetic Component, assessment of max-
illary and mandibular crowding/spacing,
crossbites, anterior open bite/overbite, and
sagittal posterior occlusion. These can be
measured either on study casts or in a
patient’s mouth. It takes approximately 1
minute to appraise this index.17
The extra- and intraoral examination
using a mirror, ruler, and a digital sliding
caliper was conducted by one orthodon-
tist (A.F.) who was calibrated for the IOTN
and ICON.
Statistical analysis
All data were processed with SPSS 16
(SPSS), calculating descriptive statistics
such as means and standard derivations.
VOLUME 11, NUMBER 1, 2010 Borzabadi-Farahani et al

Table 1 Mean ICON scores, standard

60
deviation, and 95% CI for both sexes
and the total sample 50
n Mean SD 95% CI 40

Frequency
Boys 244 46.81 24.75 43.69–49.93 30
Girls 252 42.46 24.78 39.39–45.54
Total 496 44.60 24.83 42.41–46.79 20

SD = standard deviation, n = number of children 10

(six already in treatment were excluded).
0
0 20 40 60 80 100 120
ICON score

Fig 1 Distribution of ICON scores in the

study sample.

Table 2 Treatment need according to the ICON score and sex in absolute
numbers (and %)
Score Boys Girls Total

No need for ≤ 43 130 (53.3) 135 (53.6) 265 (53.4)

treatment
Treatment needed > 43 114 (46.7) 117 (46.4) 231 (46.6)
Total 244 (100) 252 (100) 496 (100)

Fisher exact test, P > .05.

Table 3 Distribution of orthodontic treatment complexity according to ICON for both

sexes in absolute numbers (%)
Complexity Grade Score Boys Girls Total

Easy < 29 73 (29.9) 94 (37.3) 167 (33.7)

Mild 29 to 50 67 (27.5) 56 (22.2) 123 (24.8)
Moderate 51 to 63 32 (13.1) 43 (17.1) 75 (15.1)
Difficult 64 to 77 36 (14.8) 36 (14.3) 72 (14.5)
Very difficult > 77 36 (14.8) 23 (9.1) 59 (11.9)
Total 244 252 496

Chi-square = 7.97, df = 4, P > .05.

Treatment need (ICON score > 43) for the RESULTS

two sexes was compared using the Fisher
Exact test. The individual ICON compo-
nents (easy, mild, moderate, difficult, and
very difficult) in both sexes were com-
pared with the chi-square test. Also, the
confidence intervals for the average ICON
scores in both sexes were calculated. The
relationships between the ICON scores
and the esthetic component and DHC of
the IOTN were explored with scatter plots
and Spearman rank correlation coeffi-
cients. Any P value < .05 was interpreted
as significant.
The mean ICON score was 44.6 (95% CI,
42.4 to 46.8) (Table 1, Fig 1). The mean
ICON scores for boys and girls were
46.8 ± 24.8 and 42.5 ± 24.8, respec-
tively. Treatment was needed (ICON
score > 43) in 46.6% of the sample with
no significant difference between the two
sexes (Table 2). Table 3 summarizes the
distribution of the subjects within the treat-
ment complexity compartments. Though a
higher proportion of boys was grouped into
the very difficult compartment (14.8%) as

45

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 Borzabadi-Farahani et al WORLD JOURNAL OF ORTHODONTICS

Table 4 Distribution of the AC and Dental Health Components (DHC) of the IOTN
for both sexes in absolute numbers (%)
Boys Girls Total

AC
1 to 4: No or little need 111 (45.5) 117 (46.4) 228 (46.0)
5 to 7: Borderline need 89 (36.5) 90 (35.7) 179 (36.1)
8 to 10: Definite need 44 (18.0) 45 (17.9) 89 (17.9)
DHC
1 and 2: No or little need 106 (43.4) 111 (44.0) 217 (43.8)
3: Borderline need 47 (19.3) 53 (21.0) 100 (20.2)
4 and 5: Definite need 91 (37.3) 88 (34.9) 179 (36.1)
Total 244 (100) 252 (100) 496 (100)

Fig 2 (left) Scatter plot of the

120 120 IOTN (DHC) vs the ICON
scores. Dashed lines show
100 100
treatment thresholds.
80 80
ICON

ICON

Fig 3 (right) Scatter plot of

60 60 the IOTN (esthetic compo-
40 40 nent) vs the ICON scores.
Dashed lines show treatment
20 20 thresholds.
0 0
0 2 4 6 8 0 2 4 6 8 10
IOTN (DHC) IOTN (AC)

compared to girls (9.1%), the differences
did not vary significantly between sexes
(P > .05). Overall, the difficult or very dif-
ficult complexity grade was found in only
26.4% of the studied population.
According to the esthetic component of
the IOTN, 17.9% of the studied children
showed a definite need for orthodontic
treatment, 36.1% a borderline need, and
46.0% a slight or no need (Table 4). Accord-
ing to the DHC of the IOTN, 36.1% had a
definite need for orthodontic treatment,
20.2% a borderline need, and 43.8%
showed a slight or no need for treatment.
Figures 2 and 3 show the scatter plots
of the ICON scores vs the esthetic com-
ponent and the DHC of the IOTN. For any
given IOTN grade, there was a range of
possible ICON scores. The association
between the ICON scores and the scores
of the DHC was significant (r = 0.93;
P < .01) as was the one between the ICON
and the esthetic component (r = 0.96;
P < .01). The threshold limit for treatment
need according to the ICON (> 43) was
lower than that for the DHC (4 and 5) and
the esthetic component (8 to 10). Table 5
and the relation between an ICON > 43 in
individuals with a borderline treatment
need according to the IOTN (DHC = 3).
Herein lies the main difference between
the two indices: 52.0% of the children
classified in the borderline category of
the IOTN were in need of treatment
according to the ICON (> 43). Reviewing
the treatment needs in children with an
ICON > 43 and a DHC of 3 (IOTN) shows
that 36.0% of them had an Aesthetic
Component of 5 and 86.5% an Aesthetic
Component of 6.
DISCUSSION
At the age of 11 to 14 years, not too many
children will have commenced orthodontic
therapy. However, their permanent denti-
tion is almost complete, thus allowing an
accurate occlusal assessment. The sample
used in this study was reasonably diverse
and represented a fairly broad range of
treatment needs, thus allowing a substanti-
ated assessment of the relationship
between ICON and IOTN.

46

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VOLUME 11, NUMBER 1, 2010 Borzabadi-Farahani et al

Table 5 Distribution of children with a DHC (IOTN) of 3 in relation to the

treatment need according to the ICON (> 43) in absolute numbers (%)
AC ICON > 43 ICON ≤ 44 Total

<5 11 (100.0) 0 11
5 32 (64.0) 18 (36.0) 50
6 5 (13.5) 32 (86.5) 37
>6 0 2 (100.0) 2
Total 48 (48.0) 52 (52.0) 100

Because of the shortcomings of the an Aesthetic Component < 5 by virtue of

IOTN and the PAR Index, the ICON was de-
veloped.17 The IOTN and PAR Index have
been validated against only UK orthodon-
tists’ conceptions, and they therefore do
not represent the international opinion. The
PAR Index has been criticized further for its
undue leniency of residual extraction
spaces, unfavorable incisor inclination, and
remaining rotations. The need for treatment
does not necessarily equate to the complex-
ity of the therapy.20 Therefore, there is a
need to assess the complexity to identify
the most appropriate treatment setting for
the patient (general practice, hosptial, or
specialized practices, inform the patient of
the likelihood of success, and identify
cases that will take more time to treat.
The ICON is a relatively new index that
will likely be used more frequently in the
future. It has been shown to be reliable
and valid for appraising orthodontic treat-
ment need.21, 22
The treatment need estimates of this
study were higher than those reported in
previous surveys in which the ICON was
used.23,24 Note that results should not be
compared if they were derived from dif-
ferent indices, such as the IOTN, as
hinted at by Daniels and Richmond.17
The ICON identifies all subjects with
DHC grades of 4 and 5 in need of treat-
ment. In this study, it identified a greater
proportion of the sample in need of treat-
ment (46.6%) compared to the DHC
(36.1%) and the Aesthetic Component
(17.9%). This was also expressed in the
statement of Daniels and Richmond during
the introduction of the ICON.17 Therefore,
definite need under the ICON is not neces-
sarily equivalent to definite need under the
IOTN. Theoretically, it is possible to calcu-
late ICON scores of > 43 in individuals with
the remaining four components of the
ICON. In a previous study comparing the
IOTN and the ICON, Fox et al25 used study
models for extracting the IOTN scores.
Therefore, it is possible that using the
study model protocol of IOTN will result in
higher scoring occlusal traits, such as DNC
4, regardless of the presence of displace-
ment. As a result, the percentage of cases
classed as having a definite need for treat-
ment was similar for the IOTN and ICON.
The National Health Service in United
Kingdom currently provides funding for all
patients with a DHC of 3 and an esthetic
component of 6 and above. In this study, the
ICON identified 86.5% of the children in that
category (AC = 6) as being in need of treat-
ment and 100.0% if the DHC and the
esthetic component were higher than the
aforementioned values. Therefore, the ICON
can be a good substitute to the currently
used indices in the United Kingdom and
other countries with similar healthcare sys-
tems. In terms of complexity, in slightly more
than a quarter of the studied children, the
therapy was considered difficult or very diffi-
cult. This indicates the high level of exper-
tise required to treat these individuals.
The good correlation between the ICON
and DHC in this study can be partially
explained by the diverse ordinal scale of
the DHC (a range between 1 and 5).26 The
very high correlation between the ICON
and the esthetic component is not surpris-
ing considering that ICON is heavily based
on the Aesthetic Component of the IOTN.
The lower level of correlation reported by
Fox et al25 could be because these authors
used a relatively small sample of 55.
Considering that 1.1% of the 11- to
14-year-olds were already wearing an
orthodontic appliance at the time of this

47

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 Borzabadi-Farahani et al
survey and that 36.1% were still in need
of treatment (according to the IOTN DHC)
brings the overall treatment need to
37.2%. The corresponding figure using
the ICON would be 47.7%. All in all, the
ICON and the results of this study are
useful for public health planning.
CONCLUSION
Based on the ICON, 46.6% of this study
sample needed orthodontic treatment.
According to the DHC (IOTN) and the Aes-
thetic Component (IOTN), the respective
numbers were 36.1% and 17.9%. In terms
of complexity, 26.4% of the treatments were
considered difficult or very difficult. Statisti-
cally significant correlations existed between
the ICON and the DHC (r = 0.93) and the
Aesthetic Component (IOTN) (r = 0.96). Over-
all, the ICON had a lower treatment need
threshold compared to the IOTN. No sex dif-
ferences were found between girls and boys
for treatment need (ICON > 43, P > .05) and
treatment complexity (P > .05).
REFERENCES
1. Burden DJ. Oral health-related benefits of ortho-
dontic treatment. Semin Orthod 2007;13:76–80.
2. Addy M, Griffiths GS, Dummer PM, et al. The
association between tooth irregularity and plague
accumulation, gingivitis and caries in 11-12 year
old children. Eur J Orthod 1988;10:76–83.
3. Helm S, Petersen PE. Causal relation between
malocclusion and caries. Acta Odont Scand
1989;47:212–221.
4. Howat A. Orthodontics and health: Have we
widened our perspectives? Community Dent
Health 1993;10:29–37.
5. Shaw WC, Richmond S, Kenealy PM, Kingdon A,
Worthington H. A 20-year cohort study of health
gain from orthodontic treatment: psychological
outcome. Am J Orthod Dentofacial Orthop 2007;
132:146–157.
6. Summers CJ, A system for identifying and scor-
ing occlusal disorders, Am J Orthod 1971;59:
552–567.
7. Salzmann JA. Handicapping malocclusion
assessment to establish treatment priority. Am J
Orthod 1968;54:749–765.
8. Cons NC, Jenny J, Kohout FJ. DAI: The Dental Aes-
thetic Index. Iowa City, Iowa: College of Dentistry,
University of Iowa, 1986.
9. Jenny J, Cons NC. Establishing malocclusion
severity levels on the Dental Aesthetic Index (DAI)
scale. Aust Dent J 1996;41:43–46.
48
© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE
MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
WORLD JOURNAL OF ORTHODONTICS
10. Evans R, Shaw WC, Preliminary evaluation of an
illustrated scale for rating dental attractiveness.
Eur J Orthod 1987;9:314–318.
11. Brook PH, Shaw WC. The development of an
orthodontic treatment priority index. Eur J Orthod
1989;11:309–320.
12. Richmond S, Shaw WC, O’Brien KD, et al. The
development of the PAR Index (Peer Assessment
Rating) reliability and validity. Eur J Orthod 1992;
14:125–139.
13. Espeland LV, Ivarsson K, Stenvik A. A new Norwe-
gian index of orthodontic treatment need related
to orthodontic concern among 11-year-olds and
their parents. Community Dent Oral Epidemiol
1992;20:274–279.
14. Banack AR, Cleall JF, Yip AS. Epidemiology of mal-
occlusion in 12-year-old Winnipeg schoolchildren.
J Canadian Dent Assoc 1972;38:437–455.
15. Albino JE, Lewis EA, Slakter MJ, Examiner reliabil-
ity for two methods of assessing malocclusion.
Angle Orthod 1978;48:297–302.
16. Järvinen S, Väätäjä P. Variability in assessment of
need for orthodontic treatment when using cer-
tain treatment-need indices. Community Dent
Oral Epidemiol1987;15:245–248.
17. Daniels CP, Richmond S. The development of the
index of complexity, outcome, and need (ICON).
J Orthod 2000;27:149–162.
18. Richmond S, Daniels CP. International compar-
isons of professional assessments in orthodon-
tics: Part 1—treatment need. Am J Orthod Dento-
facial Orthop 1998;113:180–185.
19. Richmond S, Daniels CP. International compar-
isons of professional assessments in orthodon-
tics: Part 2—treatment outcome. Am J Orthod
Dentofacial Orthop 1998;113:324–328.
20. Richmond S, Daniels CP, Fox NA, Wright J, The
professional perception of orthodontic treatment
complexity. Br Dent J 1997;183:371–375.
21. Koochek AR, Yeh MS, Rolfe B, Richmond S. The
relationship between Index of Complexity, Out-
come and Need, and patients’ perceptions of
malocclusion: A study in general dental practice.
Br Dent J 2001;191:325–329.
22. Firestone AR, Beck FM, Beglin FM, Vig KW. Valid-
ity of the Index of Complexity, Outcome, and
Need (ICON) in determining orthodontic treat-
ment need. Angle Orthod 2002;72:15–20.
23. Liepa A, Urtane I, Richmond S, Dunstan F. Ortho-
dontic treatment need in Latvia. Eur J Orthod
2003;25:279–284.
24. Ngoma PI, Diagnea F, Dieyeb F, Diop-Baa K, Thi-
amc F. Orthodontic treatment need and demand
in Senegalese schoolchildren aged 12–13 years.
An appraisal using IOTN and ICON. Angle Orthod
2007;77:323–330.
25. Fox NA, Daniels C, Gilgrass T. A comparison of
the Index of Complexity Outcome and Need
(ICON) with the Peer Assessment Rating (PAR)
and the Index of Orthodontic Treatment Need
(IOTN). Br Dent J 2002;192:225–230.
26. Roberts CT, Richmond S. The design and analy-
sis of reliability studies for the use of epidemio-
logical and audit indices in orthodontics. Br J
Orthod 1997;24:139–147.
Carla D’Agostini Derech,
DDS, MS1
Arno Locks, DDS, MS, PhD2
Ana Maria Bolognese,
DDS, MS, PhD3
HEIGHT AND WIDTH OF
ORTHODONTICALLY TREATED
PALATES IN CLASS II DIVISION 1
PATIENTS: A LONGITUDINAL STUDY
Aim: To assess the relationship between palatal height and width on
plaster casts from 33 growing individuals with Class II Division 1 rela-
tionships who received orthodontic treatment without extraction.
Methods: The palatal contours in the permanent canine and first
molar regions were registered with a digital pantograph before treat-
ment (T1), at the end of treatment (T2), and at least 5 years posttreat-
ment (T3). Results: The anterior palatal height did not change between
T1 and T2, but a significant reduction was observed between T2 and
T3. In the posterior palatal region, the height increased between T1
and T2 but not thereafter. No significant transverse changes were
found in the canine region between T1 and T2. In the posterior region,
however, the width increased significantly between T1 and T2. Conclu-
sion: Palatal morphology in orthodontically treated Class II patients
changed from an initially more triangular into a more square shape
due to an increase in height and basal width, as well as a decrease in
cervical width. World J Orthod 2010;11:49–54.

Key words: palatal morphology, palatal height, palatal width, palatal

dimensions, Class II Division 1 relationship

he shape and dimensions of the base.8,9 Therefore, it is crucial to investi-

1PhD Student, Department of Ortho-
dontics, University of Brazil, UFRJ,
Rio de Janeiro, RJ, Brazil.
2Associate Professor, Department of
Orthodontics, Federal University of
Santa Catarina, Florianópolis, SC,
Brazil.
3Full Professor of Orthodontics, Uni-
versity of Brazil, UFRJ, Rio de
Janeiro, RJ, Brazil
CORRESPONDENCE
Carla D’Agostini Derech
333, Rio Branco, room 306
Centro Florianópolis - SC
Brasil
88015 201
Email: carladerech@hotmail.com
T palate can determine or characterize
the severity of a malocclusion. However,
one cannot assume a pure cause-effect
relationship, although the premise that
craniofacial morphology determines the
occlusion seems reasonable.1
To some degree, facial development
obscures the growth of its individual
anatomical units. Therefore, it is prudent
to examine the bony components of the
face separately so as to better under-
stand total facial growth.2
Class II malocclusions have been fre-
quently studied. 3–7 Several of these
studies suggest that the mandible in
Class II patients is neither poorly devel-
oped nor retruded in relation to the skull
gate other facial parts, such as the skull
base and maxilla, to better comprehend
the factors influencing the development
of a Class II occlusion.
Shaw was a pioneer in measuring
palatal dimensions.10 Lebret11 measured
the palatal height in individuals aged 5 to
18 years, and, 4 years later, Redman et
al12 published data on the palatal dimen-
sions, including height, which were all
measured directly in the mouth. None of
these investigations specified their sub-
jects’ type of malocclusion, nor did they
refer to orthodontics. More recently, Heiser
et al studied the palatal height in Class II
Division 1 individuals treated orthodonti-
cally with or without extractions.5,6

49

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 Derech et al
Fig 1 Digital pantograph recording the
palatal contour at the maxillary first molar
region during data collection; a = mobile
sensors, b = mobile arms, black arrows =
reference points for the measurement of
the posterior cervical width, white arrow =
metal tip in contact with the cast during
reading of the palatal contour.
However, the changes of palatal mor-
phology in growing Class II patients are
still insufficiently clarified. Therefore, this
study aimed to evaluate the palatal height
and width in Class II Division 1 individuals.
MATERIALS AND METHODS
The sample comprised 33 Caucasian sub-
jects (10 males and 23 females) with a
Class II Division 1 relationship who under-
went nonextraction orthodontic treatment.
The individuals were selected from the
records of the Orthodontic Department of
the University of Brazil (UFRJ) (n = 25) and
from a private clinic (n = 8) in which the
patients were treated by a practitioner
trained in the UFRJ orthodontic program.
All individuals had a bilateral Class II molar
and canine relationship and an overjet of
at least 5 mm before treatment (T1). At the
end of treatment (T2), the occlusion was
Class I and the overjet corrected.13 This
correction was achieved primarily by cervi-
cal headgear and occasionally by Class II
elastics; no patient was treated with a
functional appliance.
The mean age of the patients at T1
was 10 years 9 months (range 8 years 8
50
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WORLD JOURNAL OF ORTHODONTICS
1 5 2
cw
hp
bw
3 4
6
Fig 2 Schematic drawing showing the
evaluated parameters: cervical width (cw),
basal width (bw) and palatal height (hp).
Cervical width (cw) = distance (in mm)
between (1) and (2) (hatched line), base
width (bw) = distance (in mm) between
(3) and (4) which, are 0.5 mm in the canine
region and 2.0 mm in the molar region
above the deepest point of the palate
(dotted line), and palatal height (hp) = dis-
tance (in mm) between (5) on the cervical
width line and the deepest point of the
palate (6) (continuous line).
months to 14 years 8 months). At T2, the
mean age was 15 years 1 month (range
11 years 9 months to 18 years 0 months).
Only four patients were older than 17
years of age at the end of the treatment.
At follow-up (T3), the mean age of the
patients was 26 years 3 months (range
20 years 5 months to 39 years 0 months).
On average, active treatment lasted
2 years and 8 months, maxillary reten-
tion 2 years and 3 months, and the non-
retention period 7 years and 7 months.
Study model measurement
The palatal contours in the canine and
molar regions were recorded with a digi-
tal pantograph (Fig 1).14
In the canine region, the reference
points were at the cervicogingival junction
of the permanent or primary maxillary right
or left canine. In the first molar region, the
reference points were at the cervicogingi-
val junction of the mesiopalatal cusp of
maxillary right and left first molar. Figure 2
shows the evaluated parameters. Each
reading produced a file that was processed
by software that automatically calculated
the value for each variable.
VOLUME 11, NUMBER 1, 2010 Derech et al

Table 1 Descriptive statistical analysis of mean values and standard deviation (SD)
of the changes (mm) in palatal height and cervical and basal widths in the canine and
molar regions with respective mean differences between T2–T1 and T3–T2
Canine T2–T1 T3–T2 Molar T2–T1 T3–T2

Palatal height
T1 3.66 ± 0.57 12.52 ± 1.89
T2 3.83 ± 0.71 0.17 (NS) 15.46 ± 1.94 2.94*
T3 3.35 ± 0.81 –0.48* 15.83 ± 2.10 0.37 (NS)
Cervical width
T1 24.11 ± 1.79 31.50 ± 2.60
T2 24.60 ± 1.60 0.49 (NS) 34.25 ± 2.26 2.75*
T3 23.74 ± 1.53 –0.86* 33.81 ± 2.18 –0.44*
Basal width
T1 8.13 ± 1.62 13.77 ± 2.44
T2 8.89 ± 2.34 0.76 (NS) 14.84 ± 3.04 1.07*
T3 10.40 ± 3.24 1.51* 15.15 ± 3.12 0.31 (NS)

NS = not significant, * = statistically significant (P ≤ .01).

Statistical evaluation were randomly selected in which the the

Mean values and standard deviations for
palatal height and cervical and basal
width in the canine and molar region at
T1, T2, and T3 were calculated with SPSS
for Windows 15 (SPSS). Because the
data were normally distributed, the non-
parametric Shapiro-Wilk test was used.
With the Student paired t test, significant
differences (P ≤ .01) between T1 and T2
and T2 and T3 based on the null hypoth-
esis (H0) of the equality among the mean
values were identified. The Student t test
was applied for independent samples to
compare the mean values between
males and females.
The ratios (%) between height and cer-
vical width (height ⫻ 100/cervical width),
height and basal width (height ⫻
100/basal width), and basal width and
cervical width (basal width ⫻ 100/cervi-
cal width) was established to assess
developmental discrepancies among
these variables.
Method error
All readings were performed sequentially
to minimize the systematic error. To
enhance the precision, each dental
region was measured 10 times. The arith-
metic mean of these measurements was
the final value. To determine the repro-
ducibility of the measurements, 12 casts
pantograph was repeated at 4-week inter-
vals. Comparisons between readings
were evaluated with the Student t test for
paired samples (95% significance
level).15,16 No significant difference was
found.
RESULTS
Table 1 shows the mean values and stan-
dard deviations for palatal height as for
cervical and basal widths in the canine and
molar regions. No significant difference
(P ≤ .01) was found between the sexes.
The palatal height in the canine region
was constant between T1 and T2; how-
ever, it decreased significantly between
T2 and T3. In contrast, the palatal height
in the posterior region increased signifi-
cantly between T1 and T2, whereas it
remained stable thereafter.
Transversely, the anterior cervical
region did not significantly change
between T1 and T2. However, between
T2 and T3, the cervical width decreased
(0.86 mm), whereas the basal width
increased (1.51 mm); both changes were
significant (P ≤ .01). In the posterior
region, both transverse measurements
increased significantly (P ≤ .01) between
T1 and T2 (cervical width = 2.75 mm;
basal width = 1.07 mm). Between T2 and
T3, a significant reduction (P ≤ .01) of
0.44 mm in the cervical width was found.

51

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 Derech et al
Table 2 Ratios (%) between palatal height and cervical/basal width, as well as
between basal width and cervical width
T1 T2
Palatal height ⫻ 100/cervical width
Canine 15.18 15.57
Molar 39.74 45.13
Palatal height ⫻ 100/basal width
Canine 45.01 43.08
Molar 90.92 104.17
Basal width ⫻ 100/cervical width
Canine 33.72 36.13
Molar 43.71 43.32
Table 2 shows the ratios (%) between
palatal height and width, as well as
between basal and cervical widths. In the
canine region, palatal height decreased
between T2 and T3 by approximately
11% in relation to basal width. In the
molar region, however, the same index
increased by 13% between T1 and T2.
The ratio between palatal height and cer-
vical width in the molar region increased
by 5% between T1 and T2.
Also, in the canine region, the basal
compared to the cervical width increased
between T2 and T3 by 8%. The remaining
ratio changes were too low to be of clini-
cal importance.
DISCUSSION
Between T1 and T2, the canine region
showed stability in basal and cervical
widths, a finding supported by other
authors,17–20 who deduced from this fact
that the intercanine width should be
maintained during orthodontic treatment.
However, between T2 and T3, signifi-
cant changes were found, which were, in
absolute values, greater in the transverse
than in the vertical dimension. This result
is supported by a study on nasomaxillary
growth that revealed a downward devel-
opment of the palate.2
52
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WORLD JOURNAL OF ORTHODONTICS
T2–T1 T3 T3–T2
14.11
0.39 –1.46
46.82
5.39 1.69
32.21
–1.93 –10.87
104.48
13.25 0.31
43.81
2.41 7.67
44.80
–0.39 1.48
It is important to emphasize that the
tendency toward a decrease in the rela-
tionship between height and width favors
the stability of a Class II correction
because posttreatment vertical growth of
the alveolar processes would contribute
to a clockwise rotation of the mandible.
Knott and Johnson21 conducted a fol-
low-up study on the palatal height of girls
receiving no orthodontic treatment and
found mean values of 12.7 and 13.5 mm
at ages 9 and 12, respectively. The
authors did not specify the type of occlu-
sion, but the dimensions they found are
compatible with those found in the pre-
sent study at T1 (12.5 mm). By age 17,
these authors reported a palatal height of
14.1 mm, which is comparable to that
found in the present study at phase T2
(15.4 mm). Despite being numerically
greater, such a difference is not clinically
relevant because of the large standard
deviation and eventual methodologic
differences.
The increased height in relation to the
cervical and basal widths in the posterior
portion of the palate between T1 and T2
was similarly demonstrated by Knott and
Johnson21 because height represented
40% of the cervical width at 9 years, 42%
at 15 years, and 43% at 17 years.
It is not possible to determine exactly
how much change in the anterior and
VOLUME 11, NUMBER 1, 2010
posterior region is due to normal growth,
remodeling, or corrective mechanical
forces. Ferrario et al 22 evaluated the
palate in adults without orthodontic treat-
ment for 10 years and found stability
between the third and fourth decades of
life. However, Hesby et al23 found incre-
ments when they assessed maxillary
transverse measurements (first molar
region) from untreated subjects at
approximately 7, 10, 13, 17, and 26 years
of age.
Cervical traction causes molar extru-
sion,24,25 resulting in an increase in vertical
face dimension.24–26 Therefore, such an
extraoral appliance should be carefully
controlled during follow-up visits27 or a
high-pull headgear should be considered.28
The height increase in combination
with a cervical width decrease leads to a
change from a more triangular shape of
the palate into a more square one with
parallel alveolar processes. The insuffi-
cient growth pattern could ultimately
reduce the possibility of achieving a har-
monious maxillary complex.29
Ladner and Muhl 30 compared the
palatal changes when using a Haas-type
expander or a quadhelix for maxillary
expansion. They found a significant
increase in palatal height, which sug-
gests that tooth extrusion is a conse-
quence of rapid maxillary expansion.
Therefore, especially in Class II patients,
the vertical facial development following
rapid maxillary expansion should be well
controlled.
CONCLUSION
Palatal morphology in orthodontically
treated patients with an Angle Class II
relationship changes from an initially
more triangular form into a squarer con-
figuration because of a relatively larger
increase in basal width and palatal height
than cervical width.
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MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Derech et al
REFERENCES
1. Moyers RE, Wainright RL. Skeletal contribu-
tions to occlusal development. In: McNamara
JA Jr, ed. Biology of Occlusal Development. Ann
Arbor, Michigan: University of Michigan Press,
1977:89–111.
2. Enlow D. Facial Growth. Philadelphia: Sauders,
1993.
3. Ciger S, Aksu M, Germec D. Evaluation of post-
treatment changes in Class II Division 1
patients after nonextraction orthodontic treat-
ment: Cephalometric and model analysis.
Am J Orthod Dentofacial Orthop 2005;127:
219–223.
4. Franchi L, Baccetti T. Transverse maxillary defi-
ciency in Class II and Class III malocclusions: A
cephalometric and morphometric study on pos-
teroanterior films. Orthod Craniofac Res 2005;
8:21–28.
5. Heiser W, Niederwanger A, Bancher B, Bitter-
mann G, Neunteufel N, Kulmer S. Three-dimen-
sional dental arch and palatal form changes
after extraction and nonextraction treatment.
Part 1. Arch length and area. Am J Orthod
Dentofacial Orthop 2004;126:71–81.
6. Heiser W, Niederwanger A, Bancher B, Bitter-
mann G, Neunteufel N, Kulmer S. Three-dimen-
sional dental arch and palatal form changes
after extraction and nonextraction treatment.
Part 2. Palatal volume and height. Am J Orthod
Dentofacial Orthop 2004;126:82–90.
7. Heiser W, Niederwanger A, Bancher B, Bitter-
mann G, Neunteufel N, Kulmer S. Three-dimen-
sional dental arch and palatal form changes
after extraction and nonextraction treatment.
Part 3. Transversal and sagittal palatal form. Am
J Orthod Dentofacial Orthop 2004;126:91–99.
8. Rothstein T, Phan XL. Dental and facial skeletal
characteristics and growth of females and
males with Class II Division 1 malocclusion
between the ages of 10 and 14 (revisited). Part
II. Anteroposterior and vertical circumpubertal
growth. Am J Orthod Dentofacial Orthop 2001;
120:542–555.
9. Rothstein T, Yoon-Tarlie C. Dental and facial
skeletal characteristics and growth of males
and females with Class II, Division 1 malocclu-
sion between the ages of 10 and 14 (revisited)—
Part I: Characteristics of size, form, and posi-
tion. Am J Orthod Dentofacial Orthop 2000;
117:320–332.
10. Shaw T. On the measurements of the palate in
idiots and imbeciles. J Ment Sci 1876;22:
196–201.
11. Lebret LM. Growth changes of the palate.
J Dent Res 1962;41:1391–1404.
12. Redman RS, Shapiro BL, Gorlin RJ. Measure-
ment of normal and reportedly malformed
palatal vaults. II. Normal juvenile measure-
ments. J Dent Res 1966;45:266–269.
13. Andrews LF. The six keys to normal occlusion.
Am J Orthod 1972;62:296–309.
53
 Derech et al
14. Arruda MBP. Avaliação da alteração morfológ-
ica do palato em casos tratados com expansão
rápida da maxila. Inicial à pós-contenção Facul-
dade de Odontologia. Rio de Janeiro: Universi-
dade Federal do Rio de Janeiro, 2003:145.
15. Johnson Jr. LE. Statistic as a second language:
A brief overview for the wary clinician. Semin
Orthod 2002;8:54-61.
16. Luiz RR, Costa AJL, Nadanovsky P. Epidemiolo-
gia e bioestatística na pesquisa odontológica.
São Paulo: Editora Atheneu, 2005.
17. Riedel RA. Retention and Relapse Orthodon-
tics: Currents Principles and Techniques.
Philadelphia: WB Saunders, 1975:850–890.
18. Little RM, Riedel RA. Postretention evaluation
of stability and relapse—mandibular arches
with generalized spacing. Am J Orthod Dento-
facial Orthop 1989;95:37–41.
19. Schulhof RJ, Lestrel PE, Walters R, Schuler R.
The mandibular dental arch: Part III. Buccal
expansion. Angle Orthod 1978;48:303–310.
20. Shapiro PA. Mandibular dental arch form and
dimension. Treatment and postretention
changes. Am J Orthod 1974;66:58–70.
21. Knott VB, Johnson R. Height and shape of the
palate in girls: A longitudinal study. Arch Oral
Biol 1970;15:849–860.
22. Ferrario VF, Sforza C, Dellavia C, Colombo A,
Ferrari RP. Three-dimensional hard tissue
palatal size and shape: a 10-year longitudinal
evaluation in healthy adults. Int J Adult Ortho-
don Orthognath Surg 2002;17:51–58.
23. Hesby RM, Marshall SD, Dawson DV, et al.
Transverse skeletal and dentoalveolar changes
during growth. Am J Orthod Dentofacial Orthop
2006;130:721–731.
54
© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE
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24. Melsen B. Effects of cervical anchorage during
and after treatment: An implant study. Am J
Orthod 1978;73:526–540.
25. Wieslander L. Intensive treatment of severe
Class II malocclusions with a headgear-Herbst
appliance in the early mixed dentition. Am J
Orthod 1984;86:1–13.
26. Derringer K. A cephalometric study to compare
the effects of cervical traction and Andreasen
therapy in the treatment of Class II, Division 1
malocclusion: Part I—skeletal changes. Br J
Orthod 1990:33–46.
27. Baumrind S, Molthen R, West EE, Miller DM.
Distal displacement of the maxilla and the
upper first molar. Am J Orthod 1979;75:
630–640.
28. Sandusky WC Jr. Cephalometric evaluation of
the effects of the Kloehn type of cervical trac-
tion used as an auxiliary with the edgewise
mechanism following Tweed’s principles for
correction of Class II, Division 1 malocclusion.
Am J Orthod 1965;51:262–287.
29. de Freitas FCN, Bastos EP, Primo LS, de Freitas
VL. Evaluation of the palate dimensions of
patients with perennial allergic rhinitis. Int J
Paediatr Dent 2001;11:365–371.
30. Ladner PT, Muhl ZF. Changes concurrent with
orthodontic treatment when maxillary expan-
sion is a primary goal. Am J Orthod Dentofacial
Orthop 1995;108:184–193.
Antonio David Corrêa
Normando, DDS, MS1 DENTOALVEOLAR CHANGES AFTER
Francisco Ajalmar Maia, UNILATERAL EXTRACTIONS OF
DDS, MS, PhD2

Weber José da Silva Ursi,

MANDIBULAR FIRST MOLARS AND
DDS, MS, PhD3 THEIR INFLUENCE ON THIRD MOLAR
José Leonardo Simone,
DDS, MS, PhD4
DEVELOPMENT AND POSITION
Aim: To investigate the spontaneous tooth position changes after uni-
lateral extraction of mandibular first molars and the influence on third
molar position. Methods: Panoramic radiographs of 111 individuals
(mean age 19 years 8 months) in whom one mandibular first molar
was extracted at least 5 years prior. Comparison of all measurements
of the control and the affected side was performed by paired Student
t test. Results: The mandibular second molars tipped mesially, whereas
the premolars, canines, and incisors moved distally toward the extrac-
tion space. Vertical alveolar resorption was significant, particularly in
older patients. Mesial inclination of the third molar occurred in only
subjects in whom this tooth was completely developed. No significant
vertical change of the third molars was observed. Conclusion: Unilat-
eral extraction of mandibular first molars causes a significant dis-
placement of all teeth of the affected side toward the extraction site
and a progressive vertical bone resorption of this area. The closer the
teeth are to the extraction site, the more they are affected. No signifi-
cant changes were observed on third molar vertical position. World J
Orthod 2010;11:55–60.

1Assistant Professor, Department of Key words: dentoalveolar changes, unilateral extraction, third molar
Orthodontics, Federal University of position
Pará, Faculty of Dentistry, Belém,
Brazil.
2Chair, Department of Orthodontics,

Paraiba State University, Campina

Grande, Brazil; Associate Professor,
Federal University of Rio Grande do
Norte, Natal, Brazil.
3Assistant Professor, Department of
Orthodontics, São Paulo State Uni-
versity, Faculty of Dentistry at São
José dos Campos, São Paulo, Brazil.
4Assistant Professor, Department of
Estomatology, University of São
Paulo (UNESP), Faculty of Dentistry,
São Paulo, Brazil.
CORRESPONDENCE
Dr Antonio David Corrêa Normando
Rua Boaventura da Silva
567-1201 Belém-Pa.
Brazil
Email: davidnor@amazon.com.br,
davidnormando@hotmail.com
rom the 1940s to the 1960s, two par-
F adigms competed regarding the
impact of the first molars on dental arch
morphology and occlusion. The first one
saw the first molar as the keystone to the
preservation of dental arch morphology. If
these teeth were extracted in the
mandible, lingual tipping of the incisors,
increasing overjet and overbite, and
migration of the second molars and sec-
ond premolars toward the extraction site
would occur.1–3 According to the second
paradigm, the extraction of the first
molars had, on average, no detrimental
effect on the incisal relationship. Thus,
the extraction of these teeth in young indi-
viduals with crowding was advocated. 4–6
The contradictory opinions regarding
the maintenance or extraction of the
first molars were found in both Europe
and the United States. At that time,
tooth loss was still very prevalent due to
a lack of effective caries prevention. 7
Later on, when caries control became
effectual in the Scandinavian countries
and North America, fewer studies were

55

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 Normando et al
conducted to scientifically assess the
occlusal changes resulting from the
extraction of first molars, except in
patients with hypomineralizations.8 Over-
all, molar loss became a clinical problem
in only older patients.
Although the extraction rate of
(mandibular) first molars due to caries
lesions is low in developed countries, it
is still high in third world nations. One
study from Brazil examined the effects
of mandibular first molar extraction on
the occlusal morphology in adolescents
and young adults.9 It showed a greater
frequency of midline deviations and
Class II canine relationships and an
increase in spacing in subjects with uni-
or bilateral loss of these teeth, but no
significant changes of the maxillary
incisor position regarding overjet and
overbite. However, cephalometric studies
evaluating the ef fects of bilateral
mandibular first molar extraction demon-
strated a trend of overjet and overbite
increase, associated with a lingual incli-
nation of the mandibular incisors,10,11 a
marked mesial movement of the second
molars, 11 and minor changes of the
facial growth pattern.11,12
Despite the changes in occlusal mor-
phology after the extraction of mandibu-
lar first molars, no adverse periodontal
conditions were observed. 13 Also, this
loss does not increase the potential for
extrusion of the opposing teeth, unless it
occurred 10 years prior and was associ-
ated with periodontally compromised
antagonistic teeth.14
While some aspects of mandibular
molar extraction on occlusion and the
periodontium have already been clarified,
there is not enough information on the
mechanism of how teeth migrate after
molar loss, neither qualitatively nor quan-
titatively. The relevant literature also
shows little evidence of the influence
mandibular first molar loss on third
molar eruption.15,16
56
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WORLD JOURNAL OF ORTHODONTICS
MATERIAL AND METHODS
Sample size calculation was based on the
second molar inclination as the primary
variable. The paired Student t test was
set to be able to read a 2.0-degree differ-
ence between the control and extraction
side with a power of 0.8, alpha = 0.05 in a
two-tailed distribution. The standard devia-
tion of the difference observed in the first
10 patients examined was 9.5 degrees.
The resulting sample size was determined
to be 105 individuals.
The sample used in this study con-
sisted of 111 panoramic radiographs
selected from 20,510 or thodontic
records. The main criterion for selection
was the unilateral extraction of a
mandibular first molar resulting from
caries. Patients were excluded if any
other mandibular teeth were extracted or
if the mandibular third molars were miss-
ing. Individuals were also left out if their
extractions occurred less than 5 years
before the radiographic examination.
However, some patients were not able to
remember exactly the time of the extrac-
tion, particularly when it was performed
between 7 and 10 years of age. The
majority of these individuals reported
that the loss had occurred so long ago
that they could not remember the exact
age; they were included in the trial. Those
who reported that they could not remem-
ber the exact date but that it was cer-
tainly after their 12th year were excluded.
The final sample was composed of 27
males and 84 females, with an average
age of 19 years 8 months ranging from
12 to 30 years.
To determine the influence of the
extraction in relation to the developmen-
tal stage of the mandibular third molars,
the sample was divided into two groups.
The first group was formed by 60 individ-
uals whose third molar on the control
side had not yet attained Nolla’s stage
10.17 The average age for this group was
15 years 7 months (range 12.0 to 22.3
years, Fig 1a). The second group was
composed of 51 individuals with a mean
age of 24 years 5 months (range 18.5 to
30.9 years) who had a fully developed
third molar17 (stage 10) on the control
side (Fig 1b).
VOLUME 11, NUMBER 1, 2010 Normando et al

a b

Fig 1 Example of the subsample with (a) developing third molars and (b) fully developed third molars (Nolla’s Stage 10).

2
3

8
1 7
8V 5
OV

Fig 2 Tracing of radiograph with reference lines to measure
mesiodistal angulation (mesial angle between the mandibular
reference line from [1] right to left gonion and [2] the long
tooth’s axis).
Fig 3 Tracing of radiograph with reference lines for linear
measurements: distance from mesial surface of the third molar
to mandibular midline (8), from second molar to midline (7), and
from the distal surface of second premolar to midline (5);
height of third molar (8V) and height of the alveolar bone (OV).

The radiographic tracings were per-
formed based on the method described
by Ursi et al18 (Figs 2 and 3).
Tracings and measurements were
repeated in 28 randomly chosen radio-
graphs (25% of the total sample). The
casual error was determined using
Dahlberg’s calculation and the system-
atic error was examined through intra-
class correlation.
Means and standard deviations were
obtained for the control and affected
side. The paired t test was used for the
analysis of the measurement differences
between these two sides. For the analy-
sis of the difference between the two
developmental stages of the third
molars,17 the independent Student t test
was used. The type I error (␣) of 5% was
set to all statistical analyses employed.

57

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 Normando et al WORLD JOURNAL OF ORTHODONTICS

Table 1 Casual (Dahlberg formula) and systematic (intraclass correlation) errors, means, standard deviations, mean
difference, t, and P values obtained from comparison between the control and extraction sides (n = 111)
Casual and systematic Control side Extraction side Mean t value P value
error- P value (ICC) mean (SD) mean (SD) difference (DF = 110) (paired t test)

Angular
8-ML 0.49 (< .0001) 50.34 (21.2) 48.11 (13.5) 2.23 1.04 0.3 (NS)
7-ML 0.18 (< .0001) 64.52 (6.82) 56.11 (8.73) 8.40 9.28 0.0000***
5-ML 0.50 (< .0001) 76.39 (7.32) 82.86 (7.79) –6.46 –7.67 0.0000***
4-ML 0.26 (<. 0001) 84.21 (6.58) 90.30 (7.27) –6.09 –8.14 0.0000***
3-ML 0.55 (< .0001) 86.52 (5.98) 91.24 (6.45) –4.72 –6.46 0.0000***
2-ML 0.84 (< .0001) 89.45 (5.65) 93.99 (6.12) –4.54 –5.77 0.0000***
1-ML 0.50 (< .0001) 87.59 (5.38) 91.63 (5.47) –4.03 –4.33 0.0000***
Linear
8-ML 2.36 (< .001) 58.72 (6.73) 55.64 (7.00) 3.07 3.46 0.0007***
7-ML 1.34 (< .0001) 44.36 (6.27) 40.78 (5.85) 3.58 4.78 0.0000***
5-ML 1.55 (< .0001) 32.61 (5.62) 36.76 (5.46) –4.15 –5.82 0.0000***
8V 0.75 (< .0001) 17.54 (6.41) 16.59 (6.62) 0.94 2.17 0.07 (NS)
OV 0.19 (< .0001) 6.16 (6.38) 4.34 (6.16) 1.82 7.58 0.0000***

(NS) = not significant; *** P < .001; DF = degrees of freedom; ICC = intraclass correlation.

5
4 3.33 3.73
10 3.07
7.98 8.60 3 2.48 2.25
8 7.33 2
6 0.92 0.85 1.21
4 1 -4.17 -3.75
2 0
0 –6.45 –6.27 –1
–2 –2
–4 –2.22 –3.32 –2.63 –3
–3.60 –4
–6 –5.30 –5.76 –5.82 –5.33
–8 –6.75 –5
8-ML 7-ML 5-ML 4-ML 3-ML 2-ML 1-ML 8-ML 7-ML 5-ML 8V OV
P = .01* P = .73 P = .91 P = .32 P = .13 P = .1 P = .14 P = .3 P = .47 P = .48 P = .89 P = .021*

Fig 4 Mean differences in tooth angulation between extrac-
tion and control side in subsample with developing third
molars (Nolla’s stage < 10, gray, n = 60) and subsample with
third molar completely developed (Stage 10, black, n = 51).
Negative values indicate distal angulation, positive values
indicate mesial angulation of the extraction side as compared
to control side; 8-ML = third molar to mandibular midline,
7-ML = second molar to mandibular midline, 5-ML = second
premolar to mandibular midline, etc. * = P < .05.
Fig 5 Mean differences in linear measurements between
extraction and control side in subsample with developing
third molars (Nolla's stage < 10, gray, n = 60) and subsample
with third molar completely developed (Stage 10, black,
n = 51). Negative values indicate distal movement, positive
values indicate mesial or occlusal movement of the extrac-
tion side as compared to control side; compare to Figs 3 and
4. * = P < .05.

RESULTS for all angular measurements and the

The error analysis revealed a very high
precision of the angular measurements
with a casual error of < 1 degree (0.17 to
0.84) and a reliable accuracy for the lin-
ear measurements with a casual error
between 2.4 and 0.2 mm. The system-
atic error analysis, examined by the intra-
class correlation, showed an excellent
replicability (r = 0.89 to 0.99, P < .0001)
linear measurements (r = 0.81 to 0.99,
P < .001).
Descriptive statistics (means, stan-
dard deviations, and mean differences)
between the two sides are presented in
Table 1. Figures 4 and 5 show the mean
and P values for the differences between
the two sides for all angular and linear
measurements of the third molars in
stage < 10 and stage 10.

58

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VOLUME 11, NUMBER 1, 2010
DISCUSSION
Spontaneous changes resulting from
mandibular first molar loss are important
for either orthodontic or prosthodontics
treatment planning. Caution is indicated
when retrieving angular measurements
from panoramic radiographs. 19,20 Vari-
ables such as type of radiography
(orthopantomogram/elipsopantomo-
graph21), radiographic unit,18,20 and head
positioning 20,22 could influence direct
measurements. To avoid such interfer-
ences, similar to other investigations23.24
an intraindividual analysis was used in
this study. Thus, the experimental group
was formed by the side with extraction,
while the other side was used as the con-
trol group because a good reproducibility
for vertical and angular measurements
was obtained when comparing both sides
in panoramic radiographs.25
The results of this study show that all
teeth adjacent to the extracted mandibu-
lar first molar move to some degree (Table
1). However, this movement varies in
magnitude and type according to the
tooth examined. Teeth close to the extrac-
tion site present more significant angular
changes. The data of this study are sup-
ported by clinical and cephalometric
research reporting a mesial drift of the
mandibular second mo lars, 11 a distal
movement of the canines,9 and a lingual
inclination of the incisors10 making it diffi-
cult to properly close the existing space.26
Thunold6 reported more movement of
the second molar compared to the sec-
ond premolar, as it was also observed in
the present investigation by angular mea-
surements of these teeth. However, in
assessing the anteroposterior crown
movement in relation to the mandibular
midline, it was observed that the results
of this study corroborate the Salzmann’s
repor ts, 1,2 according to which the
mandibular second molars and the sec-
ond premolars contribute likewise to the
closing of the extraction site.
No significant change in mesiodistal
angulation for the third molars was noted
when control and extraction sides were
compared (P = .3). The same held true for
the vertical position (P = .07). However, in
relation to the mandibular midline, the
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Normando et al
third molar of the extraction side moved
3.1 mm mesially (P < .01, Table 1). Thus,
the third molar is the only tooth that
moves bodily after the loss of the adja-
cent mandibular first molar, but only if
the loss takes place in the early intra-
osseous development stages of the third
molar (Figs 4 and 5). This mesial move-
ment could facilitate the eruption of such
third molars, although no ver tical
changes were noted. Such ver tical
changes, however, are described in
another recent study.15 Despite the dif-
ferent method of evaluation,15,16 the pre-
sent investigation confirms at least the
mesial movement.
A comparison of the vertical alveolar
bone height between the control and the
extraction side showed a resorption of
almost 2.0 mm on average on the extrac-
tion side (P < .001, Table 1). Still, in some
individuals, a much greater vertical bone
loss was observed. Overall, bone loss in
the extraction area likely affects more
alveolar width than height.
Alveolar bone height loss in the
mandibular first molar site differed signif-
icantly between groups of subjects in
whom the third molar was at a stage < 10
(1.21 mm) and at stage 10 (2.25 mm). The
mean difference of 1.03 mm (P = .013)
reveals an association between atrophy
and age—the older a patient, the greater
the vertical alveolar bone loss in the ex-
traction area is likely to be.
The obtained results also showed that
the development of the third molars has
only a minimal influence on the move-
ment of the second molars (Figs 4 and
5). This observation is confirmed by other
studies.6,13
Changes that occur after the loss of
mandibular molars are related to age at
the time of extraction and intercuspation
of the posterior teeth. However, no study
has yet to investigate these aspects. This
is probably due to the fact that this would
require a prospective examination, which
is unfeasible because of ethical reasons.
Although early extraction of mandibu-
lar first molars could have some benefi-
cial impact on third molar eruption, the
adjacent teeth will drift into the extrac-
tion space, resulting in an undesired den-
tal asymmetry.
59
 Normando et al
CONCLUSION
Findings of the present study are that unila-
teral extraction of mandibular first molars:
• Causes significant changes in the
position of the teeth next to the extrac-
tion site. While the second molars drift
mesially, the premolars, canines, and
incisors drift distally. The displace-
ment and angulation changes are
greater the closer the teeth are to the
extraction site.
• Produces a mesial displacement of
the mandibular third molars with tip-
ping when they are fully developed,
and a bodily movement when they are
not yet fully developed.
• Leads to a slight vertical alveolar bone
loss in the affected area. This resorp-
tion increases with age.
REFERENCES
1. Salzmann, JA. Variation in tooth position follow-
ing extraction of first molars in relation to inci-
dence and distribution of dental caries. J Dent
Res 1940;19:17–33.
2. Salzmann, JA. Influence of loss of permanent
first molar on position of eruption of second
premolar. J Dent Res 1942;21:489–492.
3. Hovell, JH. Malocclusion: Diagnosis and treat-
ment. In: Wather DP. Current Orthodontics.
Bristol: John Wright, 1966.
4. Hallet, GEM, Burle, PH. Symmetrical extraction
of first permanent molars. Trans Orthod Soc
1961;7:238–255.
5. McEwen JD, McHugh WD, Hitchin AD. The effects
of extraction of the four permanent molars. Trans
Eur Orthod Soc 1964;10:344–356.
6. Thurold K. Early loss of the first molars 25
years after. Rep Congr Eur Orthod Soc 1970;
14:349–365.
7. Douglass CW, Sheets CG. Patients’ expecta-
tions for oral health care in the 21st century.
J Am Dent Assoc 2000;131:99–102.
8. Jälevik B, Möller M. Evaluation of spontaneous
space closure and development of permanent
dentition after extraction of hypomineralized
permanent first molars. Int J Paediatr Dent
2007;17:328–335.
9. Normando ADC, Silva MC, Le Bihan R, Simone
JL. Alterações oclusais decorrentes da perda
dos primeiros molares permanentes inferiores.
Rev Dent Press Ortodon Ortopedia Facial
2003;8:15–23.
10. Richardson A. Spontaneous changes in the inci-
sor relationship following extraction of lower first
permanent molars. Br J Orthod 1979;6:85–90.
60
© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE
MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
WORLD JOURNAL OF ORTHODONTICS
11. Aihaja ESA, McSheny PF, Richardson A. A
cephalometric study of the effect of extraction
of lower first permanent molars. J Clin Pediatr
Dent 2000;24:195–198.
12. Érard E, Cannoni P, Deroze D. Incidence des
extractions précoces des premières molaires
sur la dimension verticale. Orthodont Fr
1989;60:635–640.
13. Ehrlich J, Yaffe A. The effect of first molar loss
on the dentition and periodontium. J Prosthet
Dent 1983;50:830–832.
14. Compagnon D. Mesure de l’egresson de la
primeire molaire superiere humaine en l’ab-
sence de dent antagoniste. J Parodontol 1990;
91:57–63.
15. Ay S, Agar U, Biçakçi AA, Kösger HH. Changes
in mandibular third molar angle and position
after unilateral mandibular first molar extrac-
tion. Am J Orthod Dentofacial Orthop 2006;
129:36–41.
16. Yaruz I, Baydas B, Ikbal A, Dagsuyu IM, Ceilar, I.
Effects of early loss of permanent molars on
the development of third molars. Am J Orthod
Dentofacial Orthop 2006;130:634–638.
17. Nolla CM. The development of permanent
teeth. J Dent Child 1960;4:254–266.
18. Ursi WJ, Almeida RR, Tavano O, Henriques JF.
Assessment of mesiodistal axial inclination
through panoramic radiography. J Clin Orthod
1990;24:166–173.
19. McKee IW, Williamson PC, Lam EW, Heo G,
Glover KE, Major PW. The accuracy of 4
panoramic units in the projection of mesiodis-
tal tooth angulations. Am J Orthod Dentofacial
Orthop 2002;121:166–175.
20. Stramotas S, Geenty JP, Petock P, Darendeliler
MA. Accuracy of linear and angular measure-
ments on panoramic radiographs taken at vari-
ous positions in vitro. Eur J Orthod 2002;24:
43–52.
21. Almeida SM, Boscolo FN, Montebello Filho A.
Estudo das distorções da imagem produzida
em aparelhos panorâmicos que se utilizam de
princípios ortopantomográficos e elipsopanto-
mográficos. Rev Odontol Univ São Paulo 1995;
9:91–99.
22. McKee IW, Glover KE, Williamson PC, Lam EW,
Heo OG, Major PW. The effect of vertical and
horizontal head positioning in panoramic radi-
ography on mesiodistal tooth angulations.
Angle Orthod 2001;71:442–451.
23. Gooris CG, Artun J, Joondeph DR. Eruption of
mandibular third molars after second-molar
extractions: A radiographic study. Am J Orthod
Dentofacial Orthop 1990;98:161–167.
24. Yamaoka M, Furusawa K, Hayama H, Kura T. Rela-
tionship of third molar development and root
angulation. J Oral Rehabil 2001;28:198–205.
25. Larheim TA, Svanaes, DB. Reproducibility of
rotational panoramic radiography: Mandibular
linear dimensions and angles. Am J Orthod
Dentofacial Orthop 1986;90:45–51.
26. Zachrisson BU, Bantleon HP. Optimal mechan-
ics for mandibular uprighting. World J Orthod.
2005;6:80–87.
Nair Galvão Maia, DDS,
MS1
Antonio David Corrêa
Normando, DDS, MS2
Francisco Ajalmar Maia,
DDS, MS, PhD3
Maria Angêla Fernandes
Ferreira, DDS, MS, PhD4
Maria Socorro Costa
Feitosa Alves, DDS, MS,
PhD4
1Assistant Professor, Federal Univer-
sity of Rio Grade do Norte, Brazil.
2Assistant Professor, Department of
Orthodontics, Federal University of
Pará, Faculty of Dentistry, Belém,
Brazil.
3Chair, Department of Orthodontics,
Paraíba State University, Campina
Grande, Brazil; Associate Professor,
Federal University of Rio Grande do
Norte, Natal, Brazil.
4Federal University of Rio Grande do
Norte, Brazil.
CORRESPONDENCE
Dr Antonio David Corrêa Normando
Rua Boaventura da Silva, 567-1201
Belém-Pa
Brazil
Email: davidnor@amazon.com.br,
davidnormando@hotmail.com
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MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
FACTORS ASSOCIATED WITH
ORTHODONTIC STABILITY:
A RETROSPECTIVE STUDY
OF 209 PATIENTS
Aim: To assess the long-term stability of orthodontic treatment and
some factors associated to posttreatment changes. Methods: Six
hundred twenty-seven dental casts of 209 patients were examined
with the PAR Index at pretreatment (T1), end of treatment (T2), and at
long-term follow-up (T3, mean 8.5 years posttreatment). Friedman test
and multiple regression analysis at P < .05 were used to evaluate
changes among the time points and factors associated with stability.
Results: After orthodontic treatment, the PAR Index improved by
94.2%. No significant change was observed between T2 and T3
(P > .05). However, when the sample was divided into a well- (PAR
Index ≤ 3) and a less well-finished (PAR Index > 3) group, it was
observed that well-finished patients experienced some deterioration
(P < .001), whereas the less well-finished ones showed some improve-
ment (P < .05). Even with the deterioration, the well-finished patients
still had a better PAR Index at T3 compared to the less well-finished
ones. Regression analysis showed that PAR Index at T1 and T2, age at
T1, and length of retainer wear had a slight association with occlusal
stability (R2 = 0.27). No significant association was observed between
stability and length of treatment, length of follow-up, sex, extraction,
or third molar status on the other side. Conclusion: Orthodontic
treatment is quite stable. Not so well-finished treatments tend to show
some improvement and well-finished ones deteriorate some. Well-
finished patients still have better occlusal characteristics. Retention
contributes to maintenance of the final orthodontic results. World J
Orthod 2010;11:61–66.
Key words: relapse, stability, retention, PAR Index, treatment
reatment stability is a main goal of orthodontic treatment results are main-
T orthodontic treatment. A multiplicity of
factors can interfere with posttreatment
tained in the long term, some are lost.2,3
However, the relevant literature is con-
results, leading to undesirable changes. tradictory regarding what factors have a
Several authors have used the PAR significant influence on any changes
Index1 to measure occlusal changes dur- observed after therapy. Therefore, the
ing and after orthodontic treatment. PAR crucial question is why some treatment
Index improvements reported range results improve while others get worse in
from 75% to 85%. 2,3 Although most the long run.
61
 Maia et al
Table 1 Median, 25 to 75 quartile (Q25–75), and mean
(SD) at the beginning (T1) and end (T2) of treatment and
at follow-up (T3) plus statistical significance of the differ-
ences between T1–T2 and T2–T3 (Friedman test)
Median Q25–75 Mean (SD)
T1 17 12.0 25.5 19.5 (10.2)
T2 1 0.0 2.0 17.0 (2.1)
T3 2 0.0 4.0 2.5 (3.1)
* Significant (P < .001), NS = not significant, SD = standard deviation.
MATERIALS AND METHODS
Two hundred nine of 4,102 patients with
an Angle Class I or II relationship from a
private clinic more than 5 years after
orthodontic treatment were selected for
this study. Posttreatment time ranged
from 5 to 25 years with a mean of 8.5
years. Class III patients and those treated
in combination with orthognathic surgery
were excluded. From all patients, dental
casts were available for three time points:
start of treatment (T1, mean age 14.3
years), end of treatment (T2, mean age
16.2 years), and follow-up (T3, mean age
24.9 years). Sample size was calculated
in a pilot study involving the first 20 con-
secutive patients. The minimum regres-
sion coefficient (r2) was considered to be
0.2, the primary variable (PAR Index
T3–T2) as having a standard deviation of
2, and an ␣ level of 5% in a two-tailed
model with a power of 80%. The esti-
mated sample size was 194 individuals.
Eighty-eight patients had a Class I and
121 a Class II relationship. All were
treated with straight-wire appliances.
Class I occlusion was obtained by head-
gear or functional appliances according
to mandibular size and position.
The occlusal changes during and after
orthodontic treatment were determined
on study casts with the PAR Index.1 The
score difference between T1 and T2
defined the occlusal improvement pro-
duced by the treatment, while the differ-
ence between T2 and T3 reflected the
long-term changes. The dif ferences
between the various PAR Index scores
were evaluated using the Friedman test
(P < .05).
62
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WORLD JOURNAL OF ORTHODONTICS
Table 2 Descriptive statistics of the sample
T2 score T2 mean (SD) T3 Mean (SD) Mean Diff T3-T2 P
0–1 (n = 111) 0.39 (0.5) 1.37 (1.8) 0.97 < .0001
2–3 (n = 75) 2.27 (0.5) 3.63 (3.9) 1.36 .006
T2–T1/T3–T2
> 3 (n = 23) 6.17 (2.9) 4.48 (3.0) –1.7 .0386
n = number of patients.
–17.8*
+0.8 NS
Multiple regression analysis was used
to assess the association between the
primary variable (PAR T3–T2) and the
independent variables: sex, age at T1,
PAR Index at T1 and T2, length of treat-
ment, length of retention, extractions,
and third molar extraction or absence.
The PAR Index was defined by two pre-
viously calibrated orthodontists. Intra-
and interexaminer reliability examination
were tested with the intraclass correla-
tion coefficient.
The research protocol was approved
by the research ethics committee of the
UFRN (Federal University of Rio Grande
do Norte) under no. 110/2005.
RESULTS
The intraclass coefficient for the intra-
and interexaminer reliability was 0.91
and 0.89, respectively. These results indi-
cate excellent method reliability.
The initial median PAR Index was 17. At
T2, it was improved by 94.2% on average.
Generally, this change remained stable,
because no overall significant difference
was observed between T2 and T3 (Table 1).
An interesting finding is noted when the
whole sample is divided into three sub-
groups according to the PAR score at T2
(Table 2). Patients who had a PAR Index ≤
3 presented minor relapse, while those
with a PAR score > 3 improved slightly
(Table 2, Figs 1 and 2). Relapse and
improvement balanced each other, which
explains the absence of a significant net
change in the entire sample. However, the
well-finished treatments were still better
than those finished not as well.
VOLUME 11, NUMBER 1, 2010 Maia et al

Fig 1 Dental casts of a patient at T2 (top) and T3 (bottom) (14 years after treatment) with extreme improvement (T2 PAR
score = 15; T3 PAR score = 0).

Fig 2 (right) Graphical representation of the regression analy-

sis of the PAR change between T3–T2 and PAR score at T2. 25

20

15
PAR change (T2–T3)

10

–5

–10

–15
5 10 15 20
PAR T2

In the total sample, PAR improvement 1, overbite and mandibular anterior

at T3 was observed for the buccal occlu-
sion, on the right (P < .001) and on the
left side (P = .045), while the condition in
the anterior region worsened (mandibular
anterior crowding = P < .001, overbite = P
< .001). In the PAR group with score 0 to
crowding deteriorated significantly. In the
less well-finished group (PAR > 3), signifi-
cant improvement was observed for
the buccal posterior occlusion (right side,
P = .04; left side, P =.02), but no signifi-
cant deterioration was observed.

63

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 Maia et al
Table 3 Multiple regression analysis (dependent variable = PAR score T3–T2)
␤ coefficient
PAR T2
PAR T1
Age at T1
Years without 3-3 retainer
Years Hawley retainer
Duration of treatment (y)
Time span of follow-up period (y)
Sex
Treatment with/without extraction
Third molar presence/absence
The factors that influenced treatment
stability significantly were, in descending
order: excellence of treatment result
(␤ = –0.555, P < .001), length of maxillary
Hawley retainer wear (␤ = –0.213,
P <.001), length without mandibular fixed
retainer (␤ = 0.211, P < .001), age at the
beginning of treatment (␤ = 0.053,
P <.001), and initial malocclusion severity
(␤ = 0.052, P < .01). All other variables,
ie, treatment length, follow-up duration,
sex, extraction, and third molar status,
did not show any significant association
with relapse (Table 3).
Treatment stability is influenced by so
many factors that the aforementioned
variables can explain only 27% of the
relationship (r2 = 0.27).
DISCUSSION
The 209 patients in this study were
treated at the same clinic with the same
method. The time since the conclusion of
treatment (at least 5 years, mean 8.5
years) seems adequate enough to assess
long-term or thodontic stability. The
insignificant increase of 0.8 in PAR
scores from T2 to T3 indicates good sta-
bility considering data published in the
literature.2–5
Some relapse in well-treated patients
was previously reported in the litera-
ture,2–6 but the improvement observed in
less well-finished treatments was either
hardly mentioned5 or flatly denied.6 Even
with some minor relapse, the well-fin-
ished treatment outcomes were still
superior to the the less well-finished
64
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WORLD JOURNAL OF ORTHODONTICS
t value P value
–0.555 –6.07 .000
0.052 3.13 .002
0.053 3.49 .000
0.211 3.09 .002
–0.213 –2.49 .013
0.015 1.00 .320
–0.056 –0.73 .470
0.146 0.24 .810
–0.442 –0.54 .590
0.338 0.61 .540
ones. This result is confirmed by a previ-
ous study 7 using the ABO OGS score.
However, it should be taken into consid-
eration that the improvement occurred in
the posterior occlusion, while the situa-
tion in the anterior region deteriorated.
To examine the factors that could have
some association to relapse, multiple
regression analysis was applied.
Although 10 variables were examined,
only five were significantly related to
changes after orthodontic treatment. Yet,
these five entities explain only 27% of
the observed phenomenon. This indi-
cates that many more unknown variables
are related to changes after orthodontic
treatment.
PAR score at T2 can be considered
one of the most important factors associ-
ated with posttreatment changes. The
statement that well-finished treatments
with ideal occlusions at the end of ortho-
dontic therapy are more stable2,8 is not
corroborated by this study.5,9
The fact that the examined sample
displayed good stability could be
explained by the fact that about 60% of
patients had a mandibular fixed retainer.
Mandibular incisor misalignment is con-
sidered by many authors to be the most
susceptible symptom to posttreatment
change. This aspect was confirmed by
the analysis of the effect each of the
assessed factors had independently. To a
lesser degree, this also applied to the
length of maxillary Hawley retainer wear,
which is confirmed by the findings of
Lang et al.10 However, Ormiston et al5 did
not observe any relationship between
stability and time and type of retention.
VOLUME 11, NUMBER 1, 2010
Older patients had better results after
treatment. This was verified by two stud-
ies,10,11 whereas Little et al,12 Ormiston
et al,5 and Harris et al13 declined such a
relationship.
Present findings support the fact that
in older patients, the orthodontist cannot
rely on the effective growth of craniofacial
structures anymore. This treatment will
be more restricted to dental movements,
sometimes using less stable dental com-
pensations. Previous reports 2,5 have
established that the severity of initial mal-
occlusion (PAR T1) was associated with
posttreatment changes. Findings confirm
these reports, as a significant association
between stability and the initial malocclu-
sion level (PAR T1) was observed. How-
ever, it seems that orthodontic stability
depends most on the orthodontic finish-
ing (PAR T2) than severity of initial maloc-
clusion (PAR T3) (Table 3).
The influence of extractions on
changes after treatment has been widely
investigated. The literature shows con-
flicting findings regarding this topic.
Some studies reported a higher degree
of crowding during postretention in
patients who had extractions.9,14 This is
in contrast to Lang et al, 10 who found
that patients without extractions had
more postretention crowding. Uhde et
al,15 Ormiston et al,5 and Birkeland et al2
saw little or no difference at all in stabil-
ity between patients treated with or with-
out extractions. In this study, 15% of the
patients were treated with extractions,
but no correlation was noticed between
extraction/nonextraction and posttreat-
ment changes.
In this study, extraction or genetic
absence of third molars did not have any
significant relation with stability, which is
in accordance with the experience of Lit-
tle16 but in contrast to Kahl-Nieke et al’s
findings.14
Although the present investigation did
not reveal any significant association
between posttreatment changes and sex,
a good number of studies2,5,10–12,14,17,18
reported higher posttreatment crowding
in males and linked this to their longer-
lasting facial growth.
In this study, the time span between
the end of orthodontic treatment and
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MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Maia et al
posttreatment examination was not signif-
icantly associated with any changes. This
finding contradicts previous papers.4,10
Finally, it should be reiterated that
many other factors can influence post-
treatment stability, ie, residual growth
and lack of posttreatment control, which
were not scrutinized in this investigation.
CONCLUSION
Overall, orthodontic treatment is stable.
Not so well-finished therapies tend to im-
prove along the time, whereas excellently
finished treatments tend to experience
minor relapse. That said, well-finished
patients are still better off in a long-term
perspective. Retention regimen contributes
to the stability of orthodontic results.
REFERENCES
1. Richmond S, Shaw WC, O’Brien KD, et al. The
development of the PAR Index (Peer Assessment
Rating): Reliability and validity. Eur J Orthod
1992;14:125–139.
2. Birkeland K, Furevik J, Boe OE, Wisth PJ. Evalua-
tion of treatment and posttreatment changes by
the PAR Index. Eur J Orthod 1997;19:279–288.
3. Wood M, Lee D, Crawford E. Finishing occlusion,
degree of stability and the PAR index. Aust
Orthod J 2000;16:9–15.
4. Al Yami EA, Kuijpers-Jagtman AM, van’t Hof MA.
Stability of orthodontic treatment outcome: Fol-
low-up until 10 years postretention. Am J Orthod
Dentofacial Orthop 1999;115:300–304.
5. Ormiston JP, Huang GJ, Little RM, Decker JD,
Seuk GD. Retrospective analysis of long-term sta-
ble and unstable orthodontic treatment out-
comes. Am J Orthod Dentofacial Orthop 2005;
128:568–574.
6. Freitas KMS, Janson G, Freitas MR, Pinzan A,
Henriques JFC, Pizan-Vercelino CRM. Influence of
the quality of the finished occlusal on the postre-
tention occlusal relapse. Am J Orthod Dentofa-
cial Orthop 2007;132:428.e9–14
7. Nett BC, Huang GJ. Long term posttreatment
changes measured by the American Board of
Orthodontics objective grading system. Am J
Orthod Dentofacial Orthop 2005;127:444–450.
8. Pavlow SS, McGorray SP, Taylor MG, Dolce C,
King GJ, Wheeeler TT. Effect of early treatment
on stability of occlusion in patientes with Class II
maloccusion. Am J Orthod Dentofacial Orthop
2008;133:235–244.
9. Årtun J, Garol JD, Little RM. Long-term stability of
mandibular incisors following sucessful treat-
ment of Class II, Division 1, malocclusions. Angle
Orthod 1996;66:229–238.
65
 Maia et al
10. Lang G, Alfter G, Göz G, Lang GH. Retention and
stability—taking various treatment parameters
into account. J Oraofac Orthop 2002;63:26–41.
11. Haruki T, Little RM. Early versus late treatment of
crowded first premolar extraction cases: postre-
tention evaluation of stability and relapse. Angle
Orthod 1998;68:61–68.
12. Little RM, Wallen TR, Riedel RA. Stability and
relapse of mandibular anterior alignment—first
premolar extraction cases treated by traditional
edgewise orthodontics. Am J Orthod 1981;80:
349–365.
13. Harris EFVJ, Dunn KL, Behrents RG. Effect of
patient’s age on post-orthodontic dentofacial
orthopedics. Am J Orthod Dentofacial Orthop
1994;105:25–34.
14. Kahl-Nieke B, Fischbach H, Schwarze CW. Post-
retention crowding and incisor irregularity: A long-
term follow-up evaluation of stability and relapse.
Br J Orthod 1995;22:249–257.
66
© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE
MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
WORLD JOURNAL OF ORTHODONTICS
15. Uhde MD, Sadowsky C, BeGole EA. Long-term
stability of dental relationships after orthodontic
treatment. Angle Orthod 1983;53:240–252.
16. Little RM. Stability and relapse of mandibular
anterior alignment: University of Washington
studies. Semin Orthod 1999;5:191–204.
17. Freitas KMS, de Freitas MR, Henriques JF, Pinzan
A, Janson G. Postretention relapse of mandibular
anterior crowding in patients treated without
mandibular premolar extraction. Am J Orthod
Dentofacial Orthop 2004;125:480–487.
18. McReynolds DC, Little RM. Mandibular second
premolar extraction—Postretention evaluation of
stability and relapse. Angle Orthod 1991;61:
133–144.
Renata Pilli Jóias, MSc1
EVALUATION OF THE BOLTON RATIOS
Leandro Gonçalves
Velasco, DDS2
ON 3D DENTAL CASTS OF BRAZILIANS
Marco Antonio Scanavini,
WITH NATURAL, NORMAL OCCLUSIONS
PhD3
Aim: To evaluate the Bolton ratios in Brazilians with natural, normal
occlusions. Methods: Thirty-five dental casts of Brazilian Caucasians
André Luis Ribeiro de
with a natural, normal occlusion from the files of the Postgraduate Pro-
Miranda, PhD4
gram in Orthodontics of the Methodist University of São Paulo were
scanned in three dimensions. On the scanned images, the greatest
Danilo Furquim Siqueira, mesiodistal distance of each tooth from right first molar to left first
PhD4 molar was measured with Geomagic Studio 5 software. The Bolton
ratios were then calculated. Results: The anterior ratio amounted to
78.66% (SD ± 2.72) and the total ratio to 91.58% (SD ± 2.20). Conclusion:
The anterior, but not the overall, ratio was significantly different from
the ratio suggested by Bolton. World J Orthod 2010;11:67–70.

Key words: Bolton ratios, tooth size relationship, mesiodistal tooth width,
3D scan, occlusion

he ideal proportions between the max- MATERIAL AND METHODS

1MS Student, Department of Ortho-
dontics, Methodist University of São
Paulo, São Paulo, Brazil.
2Specialist in Maxillofacial Surgery
and Traumatology, Face Hospital,
São Paulo, Brazil.
3Professor and Coordinator, Depart-
ment of Orthodontics, Methodist
University of São Paulo, São Paulo,
Brazil.
4Professor, Department of Orthodon-
tics, Methodist University of São
Paulo, São Paulo, Brazil.
CORRESPONDENCE
Dr Danilo Furquim Siqueira
Rua Costa Aguiar, 875, ap 111
Ipiranga, São Paulo, SP
Brasil
CEP 04204-000
Email:
danilosiqueira@ortodontista.com.br
T illary and mandibular teeth allow for
finished orthodontic treatments with a
proper occlusion, overjet, and overbite.
Bolton ratios1,2 or occlusograms3 can in-
dicate whether the size of the teeth in
both arches matches one another. In gen-
eral, tooth size is influenced by genetic
factors.4 Differences in tooth size between
sexes are small, and there is no significant
diversity in tooth size in patients with a
Class II, Class III, or normal occlusion.5,6
The Bolton analysis can be performed
on plaster casts or digital models using
mechanical or digital sliding calipers or
specialized software. 7–10 In any case,
digital models and software are effective
and efficacious for evaluations.11–14
This study determined Bolton tooth
size ratios on 3D dental casts of Brazil-
ians with natural, normal occlusions to
find out whether these indices would be
similar to the ones reported by Bolton. 
Out of a total of 6,118, 35 (8 males,
27 females) Caucasian school students
between 12 and 21 years of age (mean
age 16.03 years) were selected. They
presented with Andrews’ six keys15 and
had no previous orthodontic treatment.
Their dental casts were scanned with
a minimum accuracy of 50 µ (3shape
D-250). With the Geomagic Studio 5
sof tware (Geomagic), one operator
(R.P.J.) measured the greatest mesiodis-
tal distance of each tooth from right first
molar to left first molar in both dental
arches as described by Bolton.1,2 The
anterior teeth were measured on the
buccal aspect (Fig 1); the posterior teeth
were measured on the occlusal aspects
(Fig 2).

67

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VOLUME 11, NUMBER 1, 2010 Jóias et al

Table 2 Measurement error of individual

maxillary and mandibular teeth
Mean Mean
Tooth no. (1st (2nd
(FDI) measurement) measurement) P

Maxilla
16 10.42 10.34 .04*
15 6.71 6.67 .13
14 7.14 7.09 .22
13 8.03 8.01 .46
12 6.66 7.27 .13
11 8.69 8.57 .01*
21 8.66 8.57 .11
22 6.68 6.67 .91
23 8.11 8.07 .52
24 7.31 7.20 .14
25 6.75 6.66 .13
26 10.43 10.41 .78
Mandible
36 10.83 10.68 .07
35 7.08 7.00 .61
34 7.01 7.04 .62
33 6.85 6.69 .01*
32 5.92 5.87 .17
31 5.47 5.41 .32
41 5.41 5.39 .68
42 5.90 5.91 .68
43 6.90 6.78 .13
44 7.12 7.06 .37
45 7.10 7.17 .42
46 10.87 10.80 .30

* statistically significant.

The results of this study can be consid- REFERENCES

ered highly accurate because the data
derived from equipment that controlled dis-
tortion during image acquisition was more
precise (at least 50 µ) compared to other
investigations. 9 The software allowed
reliable and compatible measurements in
comparison with those attained via more
conventional gauges.11,12,14
CONCLUSIONS
In the present sample, the anterior tooth
size ratio differed significantly from the
value reported by Bolton. However, no
significant difference was found for the
overall ratio between this sample and the
one studied by Bolton.
1. Bolton WA. Disharmony in tooth size and its
relations to the analysis and treatment of mal-
occlusion. Angle Orthod 1958;28:113–130.
2. Bolton WA. The clinical application of a tooth-
size analysis. Am J Orthod 1962;48:504–529.
3. White LW. The clinical use of occlusograms.
J Clin Orthod 1982;16:92–103.
4. Baydas B, Oktay H, Dagsuyu IM. The effect of
heritability on Bolton tooth-size discrepancy.
Eur J Orthod 2005;27:98–102.
5. Basaran G, Selek M, Hamamci O, Akkus Z.
Intermaxillary Bolton tooth size discrepancies
among different malocclusion groups. Angle
Orthod 2006;76:26–30.
6. Akyalçin S, Dogan S, Dinçer B, Erdinc AM,
Öncag G. Bolton tooth size discrepancies in
skeletal Class I individuals presenting with
different dental angle classifications. Angle
Orthod 2006;76:637–643.
7. Kusnoto B, Evans CA. Reliability of a 3D surface
laser scanner for orthodontic applications. Am J
Orthod Dentofacial Orthop 2002;122:342–348.
8. DeLong R, Heinzen M, Hodges JS, Ko CC, Dou-
glas WH. Accuracy of a system for creating 3D
computer models of dental arches. J Dent Res
2003;82:438–442.

69

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 Siqueira et al WORLD JOURNAL OF ORTHODONTICS

9. Freshwater M. The cutting edge. J Clin Orthod 15. Andrews LF. The six keys to normal occlusion.
2003;37:101–103. Am J Orthod 1972;62:296–309.
10. Quimby ML, Vig KWL, Rashid RG, Firestone A. 16. Houston WJB. The analysis of errors in ortho-
The accuracy and reliability of measurements dontic measurements. Am J Orthod 1983;83:
made on computer-based digital models. Angle 382–390.
Orthod 2004;74:298–303. 17. Heusdens M, Dermaut L, Verbeeck R. The
11. Tomassetti JJ, Taloumis LJ, Denny JM, Fischer effect of tooth size discrepancy on occlusion:
Jr JR. A comparison of 3 computerized Bolton An experimental study. Am J Orthod Dentofa-
tooth-size analysis with a commonly used cial Orthop 2000;117:184–191.
method. Angle Ortho 2001;71:351–357. 18. Smith SS, Buschang PH, Watanabe E. Interarch
12. Zilberman O, Huggare JAV, Parikakis KA. Evalua- tooth size relationships of 3 populations: Does
tion of the validity of tooth size and arch width Bolton's analysis apply? Am J Orthod Dentofa-
measurements using conventional and virtual cial Orthop 2000;117:169–174.
orthodontic models. Angle Orthod 2003;73:
301–306.
13. Garino F, Garino GB. Comparison of dental arch
measurements between stone and digital
casts. World J Orthod 2002;3:250–254.
14. Stevens DR, Flores-Mir C, Nebbe B, Raboud
DW, Heo G, Major PW. Validity, reliability, and
reproducibility of plaster vs digital study mod-
els: Comparison of peer assessment rating and
Bolton analysis and their constituent measure-
ments. Am J Orthod Dentofacial Orthop 2006;
129:794–803.

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Dhirawat Jotikasthira, BSc,
DDS, MDSc1
Peter Sheffield, BSc, MS 2
Anmol Kalha, OSRE, BSc,
BDS, MDS3
Zameer Syed, BDS, MDS4
CROWN ANGULATION AND INCLINATION
OF NORTHERN THAIS WITH GOOD
OCCLUSION
When patients of differing ethnicities are treated with one bracket
system, negative consequences for the occlusion can result. This
study investigated the crown angulation and inclination on study
casts of 60 Northern Thais (30 males and 30 females) with a good
occlusion. In all study casts, each tooth (except the third molars) was
evaluated with the orthodontic Torque Angulation Device (TAD) twice
on the right side; this was also performed twice on the left side. The
mean of the two evaluations was used for the statistical analysis. The
means of the males and females were compared with the indepen-
dent Student t test. The results were that the crown angulation of the
mandibular first and second molars was significantly higher in
females (P <.01) and that the crown inclination of all teeth did not dif-
fer between the two sexes. World J Orthod 2010:71–74.

Key words: crown inclination, crown angulation, Northern Thais, normal

occlusion, Torque Angulation Device

ccurate bracket positioning is of The or thodontic Torque Angulation

1Associate
Professor, Department of
Orthodontics, Faculty of Dentistry,
Chiang Mai University, Chiang Mai,
Thailand.
2Manager, TAD Concept & Dental
Laboratory, Hexa Ceram, Chiang
Mai, Thailand.
3Dean and Head, Department of
Orthodontics, Institute Of Dental
Studies and Technology, Dehli,
India.
4Tutor, Department of Orthodontics,
Govt. Dental College, J&K, India.
CORRESPONDENCE
Dr Zameer Syed
Faculty of Dentistry
Department of Orthodontics
Government Dental College and Hospital
Karan Nagar
Srinagar 190010
India
A critical importance for biomechan-
ics and the realization of the potential
of preadjusted edgewise appliances.
Precise measurements of crown angu-
lation and inclination are crucial for the
construction of brackets for a specific
population.
The advent of sophisticated appli-
ances and materials has helped raise
the standard of orthodontic treatment.
As a result, achieving an ideal occlusion
has become a realistic aim. The current
concepts of ideal static occlusion are
based on Andrews’ keys of normal occlu-
sion, of which crown angulation and
inclination are important features. 1
Andrews stated that if these key factors
are not achieved, there will be a space
discrepancy in the dental arch or the
occlusion will be compromised.1 Crown
angulation and inclination vary among
populations. Only one study to date has
described these parameters in Northern
Thais. The measuring device used in this
investigation was a modified protractor.2
Device (TAD) is a device that measures
crown angulation and inclination in a
precise and objective fashion.
MATERIALS AND METHODS
The materials comprised 60 plaster
casts and facial and intraoral pho-
tographs of Northern Thais (30 males
and 30 females) from the Department of
Orthodontics, Faculty of Dentistry, Chi-
ang Mai University, Thailand. The age
distribution by sex and the number of
teeth are shown in Table 1.
Inclusion criteria were:
• Excellent or good occlusion with nor-
mal overjet and overbite
• No or only slight incisor crowding
• Pleasing profile
• No interproximal caries or extensive
restorations
• No previous orthodontic intervention

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 Jotikasthira et al WORLD JOURNAL OF ORTHODONTICS

Table 1 Mean age (y), standard deviation (SD), minimum, maximum, and
sample size separately and combined for both sexes
Total
Age SD Minimum Maximum subjects

Males 20.18 1.60 16.30 25.90 30

Females 19.19 2.62 15.60 28.80 30
Combined 20.00 2.30 15.60 28.80 60

Fig 1 (right) The orthodontic Torque Angulation Device (TAD). The blade was set to
lie along to long axis of the clinical crown by adjusting the fine angulation knob.
The crown angulation was read from a digital screen.

Seven orthodontists evaluated all
records to exclude any subject with an
unacceptable occlusion or facial appear-
ance.
On all casts, all teeth (except the third
molars) on the right side were evaluated
twice with the orthodontic Torque Angula-
tion Device (TAD). The evaluation was also
performed twice on the left side. The
study casts were fixated on an adjustable
table with the horizontal occlusal line
(HOL) parallel to the TAD platform (Fig 1).
The HOL is an imaginary line connecting
the right and left midcrown molar points
and the average of the clinical midcrown
points of both central incisors.
The crown angulation was measured
according to Andrews1: The long axis of
clinical crown (LACC) was drawn on the
labial surface of the clinical crown of
every tooth (Fig 2). On the LACC of each
tooth, the midpoint of the clinical crown
(L A point) was marked. It was con-
structed by bisecting the height of the
clinical crown (with 1.0 mm added for the
gingival sulcus) on the LACC.
The model was then moved toward the
blade of the TAD. At the same time, the ta -
ble was adjusted in height. When the blade
was running along the LACC, the crown
angulation could be read on the display.
The crown inclination was recorded by
moving the model until the middle of the
blade coincided with the LA point and the
curvature of the blade fitted optimally the
vestibular surface of the tooth being
measured. After this adjustment, the
crown inclination was displayed.
Statistical methods
The mean of the first and the second
measurement was used for the statistical
analysis. If the independent Student t test
showed no significant difference between
the right and left side, the values from
both sides were combined. The indepen-
dent Student t test was also used to com-
pare the means of the males and
females. To test the reliability of the mea-
surements, the intraobserver difference
was calculated on six randomly selected
models. Pearson correlation coefficient (r)
was 0.978.
RESULTS
Box plots of the crown angulation of all
teeth (right and left sides combined) of
both sexes are shown in Fig 3. The crown
angulation of the mandibular first and
second molars was significantly higher
(P < .01) in females.
Box plots of the crown inclination of all
teeth (right and left sides combined) of
both sexes are shown in Fig 4.

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VOLUME 11, NUMBER 1, 2010 Jotikasthira et al

Male maxillary arch Female maxillary arch

1.88 (0.34) 2.79 (0.34)
LACC
3.18 (0.48) 4.61 (0.42)
A LACC
3.72 (0.54) 3.81 (0.52)

0.07 (0.44) 0.67 (0.50)

I
0.42 (0,43) 1.57 (0.49)

0.96 (0,37) 0.74 (0.61)

LA point
Occlusal
plane –1.89 (1.09) –5.17 (1.15)

–30 –20 –10 0 10 20 20 10 0 –10 –20 –30

Fig 2 Construction of the long axis of the
Degrees Degrees
clinical crown (LACC) and the midpoint of
the clinical crown (LA point) to evaluate Central incisor Lateral incisor Canine First premolar
crown angulation (A) and inclination (I). By
connecting the average of the LA-points of Second premolar
First molar Second molar
the two central incisors with the mid-crown Degrees Degrees
molar points, the horizontal occlusal line –30 –20 –10 0 10 20 20 10 0 –10 –20 –30
(HOL) is established as a reference line.
7.92 (0.81) 11.17 (0.74)

3.29 (0.52) 6.15 (0.52)

2.18 (0.59) 3.00 (0.52)

0.28 (0.52) 1.66 (0.57)

0.33 (0.52) –0.26 (0.56)

0.05 (0.48) –0.12 (0.49)

0.05 (0.40) –0.19 (0.45)

Fig 3 Box plot graphs of the crown angula- Male mandibular arch Female mandibular arch

tion of all teeth in both sexes (right and left

sides combined). * = significant difference Outlying data P < .01
(P < .01) between male and female.

DISCUSSION CONCLUSION

The values of crown inclination and angu-
lation measured in this study were simi-
lar to those of a previous study.2 In the
maxillary and mandibular arch, the crown
angulations in the present study were
smaller than those of Andrews,1 except
for the first and second molars.
The crown angulation of the central
and lateral incisors in the present study
was greater than that of studies by Vardi-
mon and Lambertz3 and Dellinger.4
This study investigated the crown angula-
tions and inclination of Northern Thais with
good occlusion. Measurements of each
tooth (except third molars) from the study
casts of 60 subjects (30 males and 30
females) were performed twice by using
the Orthodontic Torque Angulation Device
(TAD). The means of both measurements
were used for statistical analysis. The
respective values of the two sexes were
compared with the independent Student

73

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 Jotikasthira et al WORLD JOURNAL OF ORTHODONTICS

Fig 4 Box plot graphs of the crown incli-

Male maxillary arch Female maxillary arch
7.32 (0.51) 8.22(0.63)
nation of all teeth in both sexes (right and
left sides combined).
5.52 (0.61) 6.65 (0.64)

–5.50 (0.67) –6.79 (0.65)

–7.88 (0.67) –8.33 (0.76)

–9.29 (0.62) –9.25 (0.71)

–8.39 (0.70) –7.83 (0.72)

–11.97 (0.86) –11.90 (0.77)

–30 –20 –10 0 10 20 20 10 0 –10 –20 –30

Degrees Degrees

Central incisor Lateral incisor Canine First premolar

Second premolar First molar Second molar

Degrees Degrees
–30 –20 –10 0 10 20 20 10 0 –10 –20 –30

–29.15 (0.69) –28.88(0.71)

–20.38 (0.95) –20.23 (0.94)

–18.38 (0.84) –16.48 (1.04)

–14.73 (0.89) –11.52 (0.88)

–0.51 (0.85) –2.89 (0.70)

1.16 (0.82) 2.69(0.57)

4.32(0.82) 5.24 (0.66)

Male mandibular arch Female mandibular arch

Outlying data

t test. The results were that females have a REFERENCES

significantly higher (P < .01) crown angula-
tion of the mandibular first and second
molars and that there is no significant dif-
ference of the crown inclination of all teeth
between the two sexes.
ACKNOWLEDGMENTS
The authors are grateful to Hexa Ceram, Chiang
Mai Province, Thailand, for providing the Torque
Angulation Device (TAD). The authors are also
thankful to Dr Piyanart Chatiketu for her sugges-
tions concerning statistical analysis.
1. Andrew LF. The six keys to normal occlusion.
Am J Orthod 1972;62:296–309.
2. Duangtaweeesub S, Jotikasthira D. Crown
inclination and crown angulation of northern
Thais with good occlusion. CM Dent J 2003;
24:61–67.
3. Vardimon AD, Lambertz W. Statistical evalua-
tion of torque angles in reference to straight-
wire appliance (SWA) theories. Am J Orthod
1986;89:55–66.
4. Dellinger EL. A scientific assessment of the
straight-wire appliance. Am J Orthod 1978;
73:290–299.

74

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Olga-Elpis Kolokitha, DDS,
MSD, DrDent1 RAPID PALATAL EXPANDER:
Alexandra K. Papadopoulou, AN ANCHOR UNIT FOR SECOND MOLAR
DDS, MDS2
DISTALIZATION IN ANGLE CLASS II
TREATMENT
Distal movement of maxillary molars is a common approach for
nonextraction treatment of Angle Class II patients. Because of known
difficulties involving moving the maxillary first molars distally in the
presence of second molars, this article describes how the distally
directed force is applied immediately to the second molars. A rapid
palatal expander can be used as a reliable unit to facilitate the distal
movement of the second maxillary molars. World J Orthod
2010;11:75–84.

Key words: distal molar movement, rapid palatal expander, Class II

occlusion, anchorage, bodily movement

1Assistant
Professor, Department of
Orthodontics, School of Dentistry,
Aristotle University of Thessaloniki,
Greece.
2Orthodontist, PhD thesis candidate,
Department of Oral Surgery, Implan-
tology, and Radiology, Aristotle Uni-
versity of Thessaloniki, Greece.
CORRESPONDENCE
Dr Olga-Elpis G. Kolokitha
Department of Orthodontics
School of Dentistry
Aristotle University of Thessaloniki
GR - 54124 Thessaloniki
Greece
Email: okolok@dent.auth.gr
istal movement of the maxillary first
D molars is a common approach for
nonextraction treatment of Angle Class II
patients. In such situations, extraoral
traction and removable spring appli-
ances (Schwarz plate-type appliances)
are the most frequently used adjuncts.1
Recently, numerous devices for the
same purpose were developed that have
largely eliminated patient cooperation.
These appliances are categorized mainly
according to the direction of the exerted
force and the anchorage unit in inter-
and intramaxillary appliances. The inter-
maxillary devices include the Herbst
appliance and its modifications, the
Jasper jumper, and a variety of springs
that force the mandible in a more pro-
truded position while at the same time
moving the maxillary dentition posteriorly.
The intramaxillary adjuncts are repelling
magnets, Pendulum appliances, and
open Ni-Ti coil springs. In recent years,
these were supplemented with mini-
implants and plates that supply absolute
anchorage.2–7
Normally, in Angle Class II patients,
the maxillary first molars are the first
teeth that are moved distally. That is why
the most effective results have been
reported in patients with mixed dentition
and those in whom the maxillary second
molars have not yet erupted. 8,9 When
the second molars are present, treat-
ment time is prolonged, the amount of
distal movement of the first molars is
significantly reduced, and anchorage
loss with maxillary incisor protrusion is
increased.10,11
In light of these difficulties, this arti-
cle describes how the distal force can be
applied directly to the second molars
using a rapid palatal expander (RPE) as
anchorage.

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 Kolokitha/Papadopoulou
Fig 1 Initial extraoral photographs.
PATIENT REPORT
The patient was a Caucasian girl 12 years
8 months of age with no conspicuous
medical history. Her chief complaint was
“crooked teeth.” Extraoral examination
and photographs revealed a well-balanced
profile (Fig 1). Intraorally, the patient was
found to be an Angle Class II with 5.0 mm
overjet, 5.5 mm overbite, and a bilateral
posterior crossbite (Fig 2). The analysis of
her study casts gave evidence of 5.0 mm
of maxillary anterior crowding and a con-
striction of the maxillary arch.
The panoramic radiograph showed
that all teeth were present (Fig 3). Accord-
76
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WORLD JOURNAL OF ORTHODONTICS
Fig 2 Initial intraoral photographs.
ing to the cephalometric analysis, the
convexity of the hard tissue profile was
normal (Table 1, Fig 4). Vertical skeletal
measurements indicated a hypodivergent
facial configuration. The maxillary poste-
rior teeth had moved mesially, whereas
the maxillar y incisors were mildly
retruded. In contrast, their mandibular
counterparts were somewhat protruded.
This patient was diagnosed as having
a dental Angle Class II, Division 1 maloc-
clusion with a mesial migration of the
maxillary posterior teeth and a bilateral
posterior crossbite due to a constricted
maxilla with a normal skeletal pattern.
VOLUME 11, NUMBER 1, 2010 Kolokitha/Papadopoulou

Fig 3 Initial panoramic radiograph. Fig 4 Initial lateral cephalometric

tracing.

Table 1 Means and standard deviations (SD) of the various parameters and
respective values in the initial and final cephalogram
Parameter Mean SD Initial Final

SNA (degrees) 81.0 3.6 81.0 81.0

SNB (degrees) 78.0 3.4 77.0 77.0
Pog-NB (mm) 1.3 1.5 3.7 3.0
ANB (degrees) 3.7 2.4 4.0 4.0
Wits (mm) –1.0 2.0 2.0 2.0
Facial angle (degrees) 88.0 3.6 90.0 92.0
Mandibular length (mm) 113.1 36.0 114.6 115.7
Y-axis (degrees) 59.4 33.8 53.0 53.0
SN-NL (degrees) 7.0 2.8 12.0 13.0
SN-OP (degrees) 16.0 3.3 18.0 20.0
SN-ML (degrees) 34.0 5.1 28.0 28.0
ArGoMe (degrees) 126.2 5.9 114.0 115.0
SGo:NMe (%) 66.1 4.4 66.4 64.0
Is-NA (degrees) 24.0 6.5 18.9 19.0
Is-NA (mm) 4.3 2.8 3.0 3.0
Ii-ML (degrees) 92.6 6.7 106.0 110.0
Ii-APog (mm) 1.0 2.0 –2.0 2.0
Ii-APog (degrees) 22.0 4.0 27.0 31.0
Is-Ii (degrees) 132.0 9.8 129.7 126.0

TREATMENT OBJECTIVES TREATMENT ALTERNATIVES

The treatment objectives for this patient
were to:
• Correct the dental Class II occlusion
• Eliminate the overjet and correct the
overbite
• Resolve the maxillary anterior crowding
• Correct the posterior crossbite
After considering the patient’s facial pro-
file, the only reasonable treatment alter-
natives were nonextraction therapy with
either cervical traction headgear or distal
movement with noncompliance mechan-
ics (combined with Class II elastics).

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 Kolokitha/Papadopoulou WORLD JOURNAL OF ORTHODONTICS

a b c

Fig 5 (a to d) Intraoral photographs

and (e) occlusal radiograph after open-
ing the midpalatal suture with the
Hyrax expander.

d e

a b
Fig 6 Intraoral photograph at the initia- Fig 7 (a) Intraoral photograph and (b) occlusal view of a study cast after distal
tion of the distal movement of the max- movement of the maxillary second molars, which are retained with the inserted
illary second molar. transpalatal bar.

TREATMENT PLAN was secured with a brass wire (Fig 5).

The two treatment options were dis-
cussed with the patient who refused to
wear headgear. Thus, it was decided to
use fixed distal movement mechanics
with rapid maxillary expansion for cross-
bite correction. Tooth alignment was
accomplished with fixed preadjusted
edgewise appliances (Roth technique).
TREATMENT PROGRESS
The maxilla was expanded with a banded
Hyrax-type RPE device. The patient was
asked to activate this appliance 0.5 mm
per day. The active expansion was termi-
nated after 5 weeks when the expander
Fixed preadjusted edgewise brackets and
bands (0.022-inch slot) were placed, and
leveling and aligning were accomplished
with a 0.016-inch Ni-Ti archwire. After
banding the maxillary second molars and
conver ting the maxillar y first molar
bands, a 0.016 ⫻ 0.022-inch stainless
steel wire was inserted to start the distal
movement of the second molars with a
compressed Sentalloy coil spring (Fig 6).
Within 40 days, the maxillary second
molars had been moved about 3.0 mm
distally. After being in place for 6 months
so as to retain expansion and provide
adequate anchorage for the distal move-
ment of the first molars, the RPE was
removed and replaced by a transpalatal
bar (Fig 7).

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VOLUME 11, NUMBER 1, 2010 Kolokitha/Papadopoulou

Fig 8 Intraoral photographs with (a)

inserted modified Nance appliance on
the maxillary first premolars, (c to e)
spring between maxillary first premo-
lars and first molars to start distal
movement of the latter, and (b) overjet
evaluation.

a b

c d e

Fig 9 Intraoral photographs document-

ing spontaneous distal drifting of the
second premolars.

A modified Nance appliance was As the maxillary first molars were

anchored to the maxillary first premolars
to provide anchorage for the distal move-
ment of the maxillary first molars. The
second premolar brackets were removed
and the first molars driven back with a
Sentalloy coil spring on a 0.016 ⫻ 0.022-
inch stainless steel wire. At that stage, a
cinched back mandibular 0.016-inch Ni-Ti
reverse curve archwire was also inserted.
The overjet at this time still measured the
initial 5.0 mm (Fig 8).
moved distally, the second premolars
shifted distally spontaneously, leading to
an increase space between them and the
premolars. Distal driving anchorage loss
expressed in mesial movement of the left
first premolar and canine was noticed
(Fig 9). Thus, a 0.018 ⫻ 0.025-inch stain-
less steel archwire with anterior lingual
crown torque and a reverse curve of Spee
was tied in the mandibular arch, which
was supplemented with Class II elastics

79

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 Kolokitha/Papadopoulou
(3.5 oz, 0.25 inch; Fig 10). Four months
after moving the first maxillary molars
distally, they occluded in a Class I rela-
tionship (Fig 11). At this point, the second
and first maxillary molars were tied
together and the remaining posterior
teeth were gradually moved distally
(Fig 12).
The patient continued to wear her
Class II elastics until the canines were in a
complete Class I relationship. The maxil-
lary incisors were then retracted as a unit
with a 0.018 ⫻ 0.025-inch stainless steel
wire with a reversed curve of Spee and
Class II elastics. Final detailing was
achieved with individualized, coordinated
0.018 ⫻ 0.025-inch stainless steel arch-
wires. Active treatment ended after 26
months (Fig 13). The maxillary arch was
retained with a wraparound retainer, and
a bonded 3-to-3 retainer was placed in the
mandibular arch.
RESULTS
All planned treatment objectives and
goals were achieved. Maxillary superim-
position according to best fit on the
palate immediately after distal movement
revealed an almost pure translation of
the first molars and a mild distal tipping
of the second molars (Fig 14a). The labial
crown inclination of the maxillary incisors
was mildly increased, which was desir-
able because they were initially mildly
retruded. The mandibular superimposi-
tion showed a mesial migration of all
teeth (Fig 14b). This was an expected
adverse effect attributed to the use of the
Class II elastics. Bone apposition on the
frontal surface of the chin was a conse-
quence of normal growth.
The posttreatment cephalometric
analysis confirmed no change in the
skeletal relationship (Table 1, Fig 15a).
The overall treatment superimposition
illustrated that the Class I intercuspation
was due to about 2.0 mm distal move-
ment of the maxillary posterior teeth and
about 2.0 mm mesial movement of the
mandibular teeth (Fig 15b). The final
occlusion, tooth inclination, and root par-
allelism were all acceptable (Fig 16).
80
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WORLD JOURNAL OF ORTHODONTICS
DISCUSSION
The primary objective of nonextraction
treatment of dental Angle Class II patients
is distal movement of the maxillary teeth.
This can be accomplished with (cervical)
headgear in the late mixed or even early
permanent dentition if patients are willing
to cooperate. 2 This, as well as the
absence of the second molars, are two
major components for success.
The majority of maxillary distal move-
ment modalities is employed in patients in
the late mixed dentition and is designed to
act on the first molars. To overcome the
resistance of both the first and second
maxillary molars, a sophisticated anchor-
age preparation and a complicated biome-
chanical force system are required. The
respective appliances are often bulky,
causing patient discomfort in addition to
prolonging treatment time.12–15
The significant distal tipping of the
second molars observed here is sup-
ported by other studies, according to
which unerupted teeth (in this case, the
third molars) act as fulcrums. 11,16 The
same studies concluded that translation
of both molars was evident when the sec-
ond molars had completely erupted and
the third molars had been extracted.
Sagittal maxillomandibular discrepan-
cies are frequently accompanied by a
maxillary constriction, even though a pos-
terior crossbite may not be present in all
patients.17 A skeletal expansion of the
maxilla with an RPE is successful even in
the long term.18,19 Additionally, an RPE
produces spontaneous adaptations of
the mandible and mandibular denti-
tion.19,20 Thus, in the presence of second
maxillary molars, anRPE should not only
be used for maxillary expansion but also
to increase anchorage for the distal
movements of the second molars.
Anchorage is of great importance in
maxillary molar distal movement appli-
ances. When anchorage is lost, not only
will the maxillary molars move distally,
but the premolars also shift mesially and
the anterior teeth protrude. 21–28 This
could be avoided in the patient presented
here because of the RPE, modified Nance
appliance, and Class II elastics.
VOLUME 11, NUMBER 1, 2010 Kolokitha/Papadopoulou

Fig 10 Intraoral photographs at the initiation of Class II elastics wear.

Fig 11 Intraoral photographs after

accomplishing a Class I molar relation-
ship.

Fig 12 Sliding mechanics for sequential distal movement of all posterior teeth.

Fig 13 Final extra- and intraoral photographs.

81

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Kolokitha/Papadopoulou WORLD JOURNAL OF ORTHODONTICS

Fig 14 Superimpositions of
initial tracings (straight lines)
and those immediately after
maxillary molar distal move-
ment (dotted lines) for (a) the
maxilla and (b) mandible.

a b

Fig 15 (a) Final lateral cepha-

lometric and (b) overall treat-
ment superimposition.

a b

Fig 16 Final panoramic radio-

graph.

82

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VOLUME 11, NUMBER 1, 2010
When the crowns of the molars tip sig-
nificantly during distal movement, bite
opening is expected, as is a subsequent
increase of the lower anterior facial
height.15 This did not happen in the pre-
sented patient as the sliding of the molars
occurred on a stiff stainless steel wire.
Distal movement of the maxillary sec-
ond molars will relapse, especially if the
third molars are still in place. To avoid
this, their removal was recommended to
this patient. The Hyrax expander
remained in place to stabilize the skele-
tal expansion. During this stage of treat-
ment, the RPE appliance on the first
molars and premolars served as an
excellent anchor unit for the initial distal
movement of the second molars.
CONCLUSION
RPEs can be used as reliable anchor
units for second molar distalization while
using the palate, first molars, and premo-
lars as anchorage for this distalization
process. The force can be directly applied
to the second molars with a compressed
coil spring, so distal tipping is minimized
and bite opening avoided.
Remaining third molars should be
extracted to avoid relapse.
Miniscrews and miniplates have pro-
vided stable anchorage for molar distal-
ization in nonextraction Class II treat-
ment. However, surgical intervention can
be frustrating, especially for young
patients. This article provides an alterna-
tive approach, and future clinical studies
could give quantitative information of the
efficacy of the method.
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Kolokitha/Papadopoulou
REFERENCES
1. Mills CM, Holman RG, Graber TM. Heavy inter-
mittent cervical traction in class II treatment: A
longitudinal cephalometric assessment. Am J
Orthod 1978;74:361–379.
2. McSherry PF, Bradley H. Class II correction—
reducing patient compliance: A review of the
available techniques. J Orthod 2000;27:
219–225.
3. Papadopoulos MA. Classification of the non-
compliance appliances used for Class II correc-
tion. In: Papadopoulos MA, ed. Orthodontic
Treatment of the Class II Noncomliant Patient.
Current Principles and Techniques. St Louis:
Mosby Elsevier, 2006:9–17.
4. Upadhyay M, Nagaraj K, Yadav S, Saxena R.
Mini-implants for en masse intrusion of maxil-
lary anterior teeth in severe Class II division 2
malocclusion. J Orthod 2008;35:79–89.
5. Polat-Ozsoy O, Kircelli BH, Arman-Ozcirpici A,
Pektas ZO, Uckan S. Pendulum appliances with
2 anchorage designs: Conventional anchorage
vs bone anchorage. Am J Orthod Dentofacial
Orthop 2008;133:339.e9–339.e17.
6. Gelgor IE, Karaman AI, Buyukyilmaz T. Compari-
son of 2 distalization systems supported by
intraosseous screws. Am J Orthod Dentofacial
Orthop 2007;131:161.e1–8.
7. Escobar SA, Tallez PA, Moncada CA, Villegas
CA, Latrore CM, Oberti G. Distalization of maxil-
lary molars with the bone supported pendulum:
A clinical study. Am J Orthod Dentofacial
Orthop 2007;131:545–549.
8. Bussick TJ, McNamara JA Jr. Dentoalveolar and
skeletal changes associated with the pendu-
lum appliance. Am J Orthod Dentofacial Orthop
2000;117:333–343.
9. Kinzinger GS, Wehrbein H, Gross U, Diedrich
PR. Molar distalization with pendulum appli-
ances in the mixed dentition: Effects on the
position of unerrupted canines and premolars.
Am J Orthod Dentofacial Orthop 2006;129:
407–417.
10. Karlsson I, Bondemark L. Intaraoral maxillary
molar distalization. Angle Orthod 2006;76:
923–929.
11. Kinzinger GS, Fritz UB, Sander FG, Diedrich PR.
Efficiency of a pendulum appliance for molar
distalization related to second and third molar
eruption stage. Am J Orthod Dentofacial Orthop
2004;125:8–23.
12. Kinzinger GS, Fritz UB, Stenmans A, Diedrich P.
Pendulum K-group: Pendulum appliances for
noncompliance molar distalization in children
and adolescents [in German]. Kieferorthop
2003;7:11–24.
13. Gianelly AA, Vaitas AS, Thomas WM, Berger OG.
Distalization of molars with repelling magnets.
J Clin Orthod 1988;22:40–44.
14. Jeckel N, Rakosi T. Molar distalization by intra-
oral force application. Eur J Orthod 1991;3:
43–46.
83
 Kolokitha/Papadopoulou
15. Gianelli AA. Distal movement of the maxillary
molars. Am J Orthod Dentofacial Orthop 1998;
114:66–72.
16. Bolla E, Muratore F, Carano A, Bowman SJ. Eval-
uation of maxillary molar distalization with the
distal jet: a comparison with other contempo-
rary methods. Angle Orthod 2002;72:481–494.
17. Bacceti T, Franchi L, Mc Namara J, Tollaro I.
Early dentofacial features of Class II malocclu-
sion: A longitudinal study from the decidous
through the mixed dentition. Am J Orthod
Dentofacial Orthop 1997;111:502–509.
18. Haas AJ. The treatment of maxillary deficiency
by opening the midpalatal suture. Angle Orthod
1965;35:200–217.
19. Haas AJ. Palatal expansion: Just the beginning
of dentofacial orthopedics. Am J Orthod 1970;
57:219–254.
20. Mc Namara JA. Maxillary transverse deficiency.
Am J Orthod Dentofacial Orthop 2000;117:
567–570.
21. Runge ME, Martin JT, Bukai F. Analysis of rapid
maxillary distal movement without patient
cooperation. Am J Orthod Dentofacial Orthop
1999;115:153–157.
22. Brickman CD, Sinha PK, Nanda RS. Evaluation
of the Jones jig appliance for distal molar
movement. Am J Orthod Dentofacial Orthop
2000;118:526–534.
84
© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE
MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
WORLD JOURNAL OF ORTHODONTICS
23. Gulati S, Kharbanda OP, Parkash H. Dental and
skeletal changes after intraoral molar distaliza-
tion with sectional jig assembly. Am J Orthod
Dentofacial Orthop 1998;114:319–327.
24. Papadopoulos MA, Mavropoulos A, Kara-
mouzos A. Cephalometric changes following
simultaneous first and second maxillary molar
distalization using a noncompliance intraoral
appliance. J Orofac Orthop 2004;65:123–136.
25. Mavropoulos A, Karamouzos A, Kiliaridis S,
Papadopoulos MA. Efficiency of non compli-
ance simoultaneous first and second upper
molar distalization: a 3D tooth movement
analysis. Angle Orthod 2005;75:468-–475.
26. Toroglu MS, Uzel I, Cam OY, Hancioglu ZB.
Cephalometric evaluation of the effects of pen-
dulum appliance on various vertical growth pat-
terns and of the changes during short term sta-
bilization. Clin Orthod Res 2001;4:15–27.
27. Kucukkeles N, Cakirer B, Mowafi Ms. Cephalo-
metric evaluation of molar distalization by
Hyrax screw used in conjunction with a lip
bumper. Word J Orthod 2006;7:261–268.
Table 1
Hussam M. Abdel-Kader,
BDS, BMMSc, HDD, A RARE EXAMPLE OF COMPLETE
HDD, PhD1
OSSIFICATION OF THE STYLOHYOID
LIGAMENT
adiographic evidence of an ossifica-
R tion of the stylohyoid ligament among
the general adult population ranges
between 2% and 4%. Sexual dimorphism
was reported, with males being more fre-
quently affected than females (60% vs
40%, respectively). 1 The incidence
increases significantly with age. Stylohy-
oid ossification has a different impor-
tance in adults than in juveniles.2
Subjects with ossification of the stylo-
hyoid ligament suffer from dysphagia
and discomfort when turning their head
sideways.3 A relationship between elon- Fig 1 Lateral cephalometric radiograph
gated styloid processes and ossified sty- of a 36-year-old patient with complete
lohyoid ligaments to symptoms of stylo- ossification of his stylohyoid ligaments
hyoid syndrome (Eagle’s syndrome) is (arrow).
recorded in the literature. Stylohyoid syn-
drome is an anatomical anomaly that
The patient was unaware of his condi-
can develop early or late in life.4
tion. Because of the potential for compli-
An ossified stylohyoid ligament in an
cations due to his age, he was referred
80-year-old patient can be an indicator
to a head and neck surgeon.
of high bone density and serum calcium
concentration level.5 Its detection in a
panoramic radiograph can be lifesaving
for an elderly person. A stylohyoidectomy
REFERENCES
is the treatment of choice to completely 1. Camarda AJ, Deschamps C, Forest D. II. Stylohyoid
resolve the existing symptoms.6 chain ossification: A discussion of etiology. Oral
Because the complete ossification of Surg Oral Med Oral Pathol 1989;67:515–520.
the stylohyoid ligament is very rare, it is 2. Krennmair G, Piehslinger E. Variants of
a challenge for every orthodontist to ossification in the stylohyoid chain. Cranio
2003;21:31–37.
detect it during a routine examination of 3. Monsour PA, Young WG. Variability of the
orthodontic radiographs. The following styloid process and stylohyoid ligament in
patient was the only one observed with panoramic radiographs. Oral Surg Oral Med
1Professorof Orthodontics, Faculty of Oral Pathol 1986;61:522–526.
this condition during more than 30 years
Dental Medicine, Al-Azhar University, of this author’s orthodontic practice. 4. Camarda AJ, Deschamps C, Forest D. I. Stylohyoid
Cairo, Egypt. chain ossification: A discussion of etiology. Oral
A 36-year-old male was scheduled for Surg Oral Med Oral Pathol 1989;67:508–514.
CORRESPONDENCE orthognathic surgery for his skeletal 5. Okabe S, Morimoto Y, Ansai T, et al. Clinical sig-
Prof Hussam M. Abdel-Kader bimaxillary protrusion (Fig 1). His med- nificance and variation of the advanced calci-
TownHouse B 25 ical anamnesis did not reveal a history fied stylohyoid complex detected by panoramic
Mena Garden City of a cervicopharyngeal trauma. The radiographs among 80-year-old subjects.
6 October City Dentomaxillofac Radiol 2006;35:191–199.
12582
patient felt no discomfort while swallow- 6. Manganaro AM, Nylander J. Eagle’s syndrome:
Egypt ing but experienced modest discomfort A clinical report and review of the literature.
Email: hmkader@hotmail.com upon turning his head from side to side. Gen Dent 1998;46:282–284.

85

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Felice Festa, MD, DDS1
MAXILLARY AND MANDIBULAR BASE
Luigi Capasso, MD2
SIZE IN ANCIENT SKULLS AND OF
Ruggero D’Anastasio, MD3
MODERN HUMANS FROM OPI, ABRUZZI,
Guiseppe Anastasi, MD4

Mario Festa5
ITALY: A CROSS-SECTIONAL STUDY
Sergio Caputi, DDS1 Aim: The size and shape of the jaws are related to occlusion and masti-
catory muscle function. Consequently, teeth and muscles are consid-
Simona Tecco, DDS6 ered the functional matrix for the two jaws. Existing studies did not
focus on the relationship between maxillary and mandibular base but
on just their absolute dimensions. As the relationship between the two
is of interest to orthodontists, the aim of this study was to calculate the
maxillary-mandibular ratio (m-m ratio) in individuals from Central Italy
and to compare it to that of ancient skulls from the same geographic
area. Methods: Forty individuals from Opi, a small, isolated mountain
village in Central Italy, and 40 ancient skulls from the same region were
the sample of this study. The lengths of the maxillary and mandibular
base were assessed on lateral cephalograms, the m-m ratio was calcu-
lated, and the measurements between the groups were compared.
Results: Due to a significantly shorter maxillary base in the modern
human sample, the m-m ratio was significantly lower in these subjects.
Conclusion: This finding supports the hypothesis that growth of the
skull is strongly modulated by the functional matrix, within which a
morphologic unit develops. World J Orthod 2010;11:e1–e4.

Key words: ancient skulls, cephalometry, maxillary and mandibular base,

evolution, functional matrix

1Full Professor, Department of Oral

Science, University G.D’Annunzio,
Cheiti/Pescara, Italy.
2Full Professor, Department of

Anatomy, University G.D’Annunzio,

any researchers have investigated The masticatory muscles show more
Cheiti/Pescara, Italy.
3Fellowship, Department of Anatomy,

University G.D’Annunzio, Cheiti/

Pescara, Italy.
4Full Professor, Department of
Anatomy, University of Messina,
Italy.
5Student, University La Sapienza,
Rome, Italy.
6Fellowship, Department of Oral
M the development of the mandibular
and maxillary base. 1–21 The general
hypothesis of these studies is that the
development of the mandible seems to be
more influenced by functional factors,
while the development of the maxilla pri-
marily follows the growth pattern of the
strain on the mandible than any other
muscle. 5 As such, several studies indi-
cated that variations in mandibular mor-
phology are strongly linked to the mechan-
ical demands of different diets. 6–10
However, not only does function contribute
to mandibular development, but the devel-

Science, University G.D’Annunzio,

mandible mediated by the occlusion. Con-
Cheiti/Pescara, Italy. sequently, the development of both jaws
does not seem to be characterized by
CORRESPONDENCE identical allometric patterns.10,11,13,19 It is
Dr Simona Tecco
generally accepted that the parts of the
Via Le Mainarde 26
65121 Pescara mandible show a relatively local indepen-
Italy dent growth pattern because of locally dis-
Email: simtecc@unich.it tinct functional influences.1–4
opment and eruption of teeth should be
taken into consideration, as well.12
In this study, the absolute length of the
maxilla and mandible of ancient skulls
and modern humans from Opi, Abruzzi,
Italy, were measured on tracings of lateral
cephalograms. A ratio between these two
variables was calculated and compared.

e1

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 Festa et al
Thus, the hypothesis to be tested was that
the relationship between the mandibular
and maxillary base changed over time as
a reaction to different functional demands.
The results should reveal whether there is
a general pattern of ontogenetic develop-
ment of skulls, as well as if potential dif-
ferences support the hypothesis that the
maxillary-mandibular base relationship
(m-m ratio) is largely controlled by the
functional matrix.
MATERIAL AND METHODS
The sample comprised 40 individuals
from Opi in Central Italy (mean age 26 ±
6 years, range 18 to 47 years, 23 women
and 17 men) and 40 adult skulls from
the same area (dated 300 to 200 BC).
According to Shea, all skull specimens
were dental class 7, ie, they had a full
permanent dentition, a closed basilar
suture, and heavy tooth wear.22
The 40 adults were consecutive
patients originating from Opi (grandpar-
ents had to have been born in Opi) who
consulted the Dental Unit of the National
Health System for treatment. Informed
consent was obtained from all subjects.
e2
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WORLD JOURNAL OF ORTHODONTICS
Fig 1 Cephalogram with the vari-
ous landmarks and reference lines.
Mandibular length, Pog’-Gog;
maxillary length, ANS-PNS.
In every case, a lateral cephalogram
was taken with the same equipment under
the same conditions. These cephalograms
were traced and measured (Fig 1).
Statistical analyses
To assess the error due to landmark identi-
fication, duplicate measurements were
made of 10 tracings. The error of variance
was calculated using Dahlberg’s formula,22
␦ = √ (∑d 2 / 2N)
where d is the difference between the
first and the second measurement and N
the number of double registrations.
Differences of the various parameters
were checked by Student t test. Because
the m-m ratio often violated distributional
assumptions, the arcsine (or angular)
transformation was applied to the m-m
ratio before subjecting the data to statis-
tical testing.19 All the statistical analyses
were performed with SPSS 8.0 (SSPS) at
a significance level of P < .05.
VOLUME 11, NUMBER 1, 2010 Festa et al

Table 1 Means and standard deviations (SD) in ancient skulls and modern humans
for the length of the mandible and maxilla and ratio between the two
Mandible Maxilla Ratio
Specimen Mean SD Mean SD Mean SD

Skull 135.6 8.3 99.9 6.5 0.7 0.1

Human 122.2 7.1 83.6* 5.5 0.7* 0.0

* = significant differences between the groups calculated by t test.

Maxillary/mandibular ratio
Mandibular length (mm)
Maxillary length (mm)

120 160 0.90

** 0.80 **
100 140
120 0.70
80 0.60
100 0.50
60 80 0.40
40 60 0.30
20 40 0.20
20 0.10
0 0 0
Ancient skulls Modern humans Ancient skulls Modern humans Ancient skulls Modern humans

Fig 2 Means and standard deviations Fig 3 Means and standard deviations Fig 4 Ratio between mandibular and
of maxillary lengths in ancient skulls of mandibular lengths in ancient skulls maxillary lengths in ancient skulls and
and modern humans. ** P < .05. and modern humans. modern humans. ** P < .05.

RESULTS reasons, angular measurements are sel-

The intraobserver method error for all
variables was found to be less than 5% of
the variance for the entire sample.
Descriptive statistics are summarized
in Table 1. A significant difference was
observed for the maxillary length, which
was distinctly larger in the ancient skulls
(Fig 2). Although modern humans showed
a smaller mandible, this difference was
not significant (Fig 3). Finally, the m-m
ratio was significantly smaller in modern
humans as in the ancient skulls (Fig 4).
DISCUSSION
The skull and mandible were separate in
the ancient sample, so the skull was
placed with the occipital foramen on the
table and the mandible was placed and
oriented to the maxilla so that the denti-
tion seemed to best fit. The lack of infor-
mation about the original occlusion of
the ancient skulls was the primary rea-
son to omit any angular measurements.
In fact, because of the aforementioned
dom considered in anthropological stud-
ies on skulls.
In the anthropological literature, noth-
ing is known about the m-m ratio: During
cranial measurements, the two jaws
are evaluated independently of one
another. 4–13,15–17,20 The fact that the
maxillary base was shorter in recent indi-
viduals is in accordance with the hypo-
thesis that only two factors generally
influence the two skeletal bases: the de-
velop ment of the dentition and func-
tional occlusion.19 However, the maxilla
is surrounded by many bony elements
and must integrate different functional
influences, whereas the mandible may
be confronted with fewer conflicting
demands13 and thus be more ready to
reflect changing masticatory conditions.
Also, the various components of the
mandible are subjected to different func-
tions, which is why there is no uniform
relation of their size, shape, or position
to one another. 2 Also, from an embry-
ologic point of view, there appears to be
a basis for the independence of these
developmental units.4

e3

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 Festa et al
Another limitation of this study was
that the sex distribution was unknown for
the skulls. However, sex has a definite
affect on size, as well as proportion of
the mandible and maxilla.
CONCLUSION
The lengths of the maxillary and mandibu-
lar base of ancient skulls and modern
humans were assessed on lateral
cephalograms. Due to a significantly
shorter maxillary base in the modern
sample, the m-m ratio was significantly
lower in the same group, suggesting that
growth of the skull is strongly modulated
by the functional matrix, within which a
morphologic unit develops.
REFERENCES
1. Moss ML. Functional analysis of human man-
dibular growth. J Prosthet Dent 1960;10:
1149–1159.
2. Moss ML. Functional cranial analysis of mam-
malian mandibular ramal morphology. Acta Anat
1968;71:423–447.
3. Moss ML. A functional cranial analysis of primate
craniofacial growth. Symposium of the IVth Inter-
national Congress of Primatology, vol 3. Craniofa-
cial Biology of Primates, Karger, Basel. 1973;
191–208.
4. Atchley WR, Hall BK. A model for development
and evolution of complex morphological struc-
tures. Biol Rev Camb Philos Soc 1991;66:
101–157.
5. Hylander WL, Johnson KR. Strain gradients in the
craniofacial region of primates. In: Davidovitch Z
(ed). The Biological Mechanisms of Tooth Move-
ment and Craniofacial Adaptation. Columbus,
Ohio: Ohio State University College of Dentistry,
1992:559–569.
6. Hylander WL. The functional significance of pri-
mate mandibular form. J Morphol 1979;160:
223–240.
7. Bouvier M. A biomechanical analysis of mandibu-
lar scaling in Old World monkeys. Am J Phys
Anthropol 1986;69:473–482.
e4
© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE
MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
WORLD JOURNAL OF ORTHODONTICS
8. Bouvier M. Biomechanical scaling of mandibular
dimensions in New World monkeys. Int J Primatol
1986;7:551–567.
9. Ravosa MJ. Structural allometry of the prosimian
mandibular corpus and symphysis. J Hum Evol
1991;20:3–20.
10. Daegling DJ. Mandibular morphology and diet in
the genus Cebus Int J Primatol 1992;13:
545–570.
11. Daegling DJ. Geometry and biomechanics of
hominoid mandibles. [PhD dissertation]. New
York: The State University of New York at Stony
Brook, 1990.
12. Dean MC, Beynon AD. Tooth crown heights, tooth
wear, sexual dimorphism and jaw growth in homi-
noids. Z Morph Anthropol 1991;78:425–440.
13. Smith RJ. The mandibular corpus of female pri-
mates: Taxonomic, dietary and allometric corre-
lates of interspecific variations in size and shape.
Am J Phys Anthropol 1983;61:315–330.
14. Chamberlain AT, Wood BA. A reappraisal of varia-
tion in hominid mandibular corpus dimensions.
Am J Phys Anthropol 1985;66:399–405.
15. Enlow DH. Rotations of the mandible during
growth. In: McNamara JA Jr (ed). Determinants of
Mandibular Form and Growth. Craniofacial
Growth Series, vol 4. Ann Arbor, Michigan: Cen-
ter for Human Growth and Development, Univer-
sity of Michigan, 1975:65–76.
16. Wood B, Lieberman D. Craniodental variation in
Paranthropus boisei: A developmental and func-
tional perspective. Am J Phys Anthrop 2001;116:
13–25.
17. Plavcan JM. Taxonomic variation in the patterns
of craniofacial dimorphism in primates. J Hum
Evol 2002;42:579–608.
18. Sokal F, Rohlf J. Biometry, ed 3. New York: W.H.
Freeman and Company, 1995.
19. Daegling DJ. Growth in the mandibles of African
apes. J Hum Evol 1996;30:315–341.
20. Johnson PA, Atkinson PJ, Moore WJ. The develop-
ment and structure of the chimpanzee mandible.
J Anat 1976;122:467–477.
21. Coolidge HJ. A revision of the genus Gorilla. Mem-
oirs of the Museum of Comparative Zoology Har-
vard 1929;50:291–381.
22. Shea BT. Size and diet in the evolution of African
ape craniodental form. Folia Primatol 1983;40:
32–68.
23. Dahlberg G. Statistical Methods for Medical and
Biological Students. London: George Allen and
Unwin, 1940.
 GUEST EDITORIAL
Prof Athanasiou on WFO Past Accomplishments
and Expectations for the Future
ith the foundation of the WFO in 1995,
W the oldest dental specialty became
truly international. In my leadership posi-
tions, I witnessed the evolvement of an ex-
tensive communication and cooperation
network of orthodontic organizations in al-
most all five continents. The assistance of
the WFO was crucial in advancing national
orthodontic associations all over the world.
Based on collective leadership, all mem-
bers of the Executive Committee contributed
significantly to the efficient governance of our
organization and the promotion of its goals. I
am proud about the following WFO actions
during the last 5 years, which are very impor-
tant for our specialty and our organization:
• The WFO Executive Committee approved and adopted an ex-
emplary curriculum for postgraduate orthodontic studies,
which was published in the June 2009 issue of the WJO.
• The WFO Committee on National and Regional Orthodontic
Boards established a network of boards around the world
and assisted in the development of standards and guide-
lines for new national and regional certifying boards.
• The WFO hosted last February the very successful 7th Inter-
national Orthodontic Congress in Sydney, Australia. The sci-
entific program covered all aspects of contemporary
orthodontics and related sciences presented by the best lec-
turers in the corresponding fields. The joint efforts of the
WFO, the Australian Society of Orthodontists, and the Asian
Pacific Orthodontic Society maximized the scientific, cultural,
and political impact of this event, which was highly appreci-
ated by thousands of participants from all over the world.
• The WFO affiliated at the end of 2008 with the Chinese Or-
thodontic Society, which was a historic moment because one
of the biggest orthodontic societies in the world joined our
organization. Since then, about 1,000 Chinese colleagues re-
ceive all WFO membership benefits and enjoy the hospitality
of the international orthodontic community.
Looking into the future of our specialty,
much must be improved. However, looking
back, significant progress in sciences, edu-
cation, and legislation as related to ortho-
dontics can be observed. This should make
us optimistic. Challenges of the future are:
• The standards of orthodontic education
will continue to rise and orthodontic or-
ganizations will become more involved in
community politics, thus facilitating bet-
ter orthodontic services. In many parts of
the world, individuals will get access to
orthodontic treatment for the first time.
• Developing countries will improve their
postgraduate education, which will re-
flect positively on dentistry, including or-
thodontics. Well-structured university programs; dedicated,
qualified, and ambitious teachers; and enthusiastic and hard-
working students will result in well-trained modern orthodon-
tic specialists.
• Patient awareness regarding the merits of treatment of maloc-
clusion by qualified specialists will increase and be supported
as one of the prime goals by the orthodontic organizations.
I am confident that the WFO will continue to contribute to the
advancement of the art and science of orthodontics throughout
the world by fulfilling various organizational and educational ob-
jectives.
Athanasios E. Athanasiou, DDS, MSD, Dr Dent
Professor and Chairman
Department of Orthodontics
Aristotle University of Thessaloniki, Greece
WFO President (2005–2010)
WFO Vice-President (2000–2005)
WFO Executive Committee Member (1995–2000)
105
Umal H. Doshi, BDS, MDS1
Wasundhara A. Bhad-Patil,
BDS, MDS2
EARLY MANAGEMENT OF SKELETAL
OPEN BITE WITH SPRING-LOADED AND
MAGNETIC BITE BLOCKS
The purpose of this study was to evaluate the effects of spring-loaded
and magnetic bite blocks in growing individuals with skeletal open
bites. The sample consisted of patients between 8 and 13 years of
age randomly divided into two groups. One group was treated with
spring-loaded bite blocks while the other received treatment with
magnetic bite blocks. Further, a group matched for age, sex, and
mandibular plane angle served as a control. The treatment effects
were evaluated clinically and cephalometrically and by electromyo-
graphic (EMG) examination of the masseter and temporalis muscles
after 8 months. Both appliances showed significantly (P < .05) favor-
able orthopedic effects. The spring-loaded bite blocks closed the
existing open bite by 3.3 mm on average with a significant maxillary
incisor extrusion and molar intrusion. Magnetic bite blocks produced
an average of 4.9 mm of open bite closure with significant intrusion
of the molars in both arches. Overall, both appliances significantly
enhanced condylar growth, altered it to a more anterosuperior direc-
tion, and produced significant true forward mandibular rotation. Sig-
nificant increases in masseter and temporalis muscle activity at rest
and maximum clenching were noted in both groups, which could be
a positive factor in retaining the achieved result. After 10 months of
retention with passive bite blocks, cephalograms indicated only an
insignificant relapse. World J Orthod 2010;1:107–116.

Key words: skeletal open bite, bite blocks, springs, magnet

1Former Resident, Department of

Orthodontics and Dentofacial Ortho-
pedics, Government Dental College
and Hospital, Nagpur, Maharashtra,
India.
2Associate Professor and Head,
Department of Orthodontics and
Dentofacial Orthopedics, Govern-
ment Dental College and Hospital,
Nagpur, Maharashtra, India.
CORRESPONDENCE
Dr Umal H. Doshi
Room No. 104
Department of Orthodontics and
Dentofacial Orthopedics
Government Dental College and
Hospital
Government Medical Campus
Nagpur-440003
Maharashtra, India
Email: Umal_16@rediffmail.com
iagnosis and treatment of patients
D with a skeletal open bite are among
the most difficult orthodontic problems.
Skeletal open bites are usually caused
by an overeruption of the posterior teeth
or an increased vertical growth of the
posterior dentoalveolar structures. 1
Either can lead to a posterior rotation of
the mandible or a superior repositioning
of the glenoid fossa due to an underde-
velopment of the middle cranial fossa
and the anterior portion of the maxilla; a
combination of the two is also possible.
A vertical growth pattern can often be
associated with a muscular imbalance of
the tongue and other orofacial muscles.
In adults, severe skeletal open bites
are best treated with or thognathic
surgery (with pre- and postsurgical ortho-
dontic phases). However, as any facial
growth pattern is established at an early
age,2 treatment of a skeletal open bite in
growing individuals can have favorable
results. In early treatment, the goal is to
inhibit vertical development of the poste-
rior dentoalveolar structures or intrusion
of the posterior teeth by means of high-
pull headgear,3–8 vertical chin cups,9–11
functional appliances, 12–17 or passive
and active bite blocks. 18–34 Posterior
bite blocks proved to be effective in pro-
ducing condylar growth and a forward

107
 Doshi et al
rotation of the mandible.34 They hinge
the mandible open approximately 3.0 to
4.0 mm beyond the rest position, thus
maintaining pressure on the mandible’s
neuromuscular system.
In 1986, Dellinger20 introduced the so-
called active vertical corrector, an appli-
ance with repelling magnets embedded in
maxillary and mandibular posterior bite
blocks. Woodside and Linder-Aronson21
used bite blocks affixed to the mandibular
arch, which were connected to the maxil-
lary appliance by a spring that exerted an
intrusive force on the posterior teeth.
Another treatment approach is training
and strengthening the masticatory mus-
cles, which is promising because individu-
als with long face morphology have weak
masticatory muscles.35–37 It was shown
that training of the masticatory muscles in
children with skeletal open bites resulted
in a forward rotation of the mandible with
closure of the open bite.38,39 One of the
treatment effects of bite blocks could also
be an increase in muscle strength.28,40
The relevant literature still does not
report conclusively on whether active
posterior bite blocks truly intrude the pos-
terior teeth or merely increase muscle
strength. Further, the direction of condy-
lar growth and its effect on the treatment
is yet unclear.
Thus, the purpose of this study was to
evaluate and compare the effects of
spring-loaded and magnetic bite blocks
on facial morphology, condylar growth,
and masticatory muscle strength in grow-
ing individuals with a skeletal open bite
using clinical, cephalometric, and EMG
examination.
MATERIALS AND METHODS
Sample selection
The total sample consisted of 20 patients
(8 boys, 12 girls) between 8 and 15 years
of age with skeletal open bites. They
were randomly divided into two groups of
10 patients. Group 1 comprised 5 boys
and 5 girls and was treated with spring-
loaded bite blocks, while group 2 was
made up of 3 boys and 7 girls and was
treated with magnetic bite blocks.
108
WORLD JOURNAL OF ORTHODONTICS
The data for the control group were
drawn from the longitudinal growth study
collected by the Human Growth Research
Center, University of Montreal, Quebec,41
and matched for age and sex.
Patient selection criteria
Patients were selected based on the fol-
lowing criteria:
• Anterior open bite on clinical inspection
• Cephalometrically confirmed steep
mandibular plane, increased gonial
angle, and increased lower anterior
facial height
• Class I or II occlusion
• No finger-sucking habits
• No evidence of enlarged tonsils or
adenoids
APPLIANCE FABRICATION
Spring-loaded bite block
The construction bite was taken by hinging
the mandible open 3.0 to 4.0 mm beyond
the rest position in centric relation. This
resulted in 6.0 to 8.0 mm of vertical open-
ing in the second premolar region. The
appliance (Fig 1) was then constructed
as described by Woodside and Linder-
Aronson21 with two modifications.
One, it consisted of a mandibular
removable plate with occlusal coverage
and an occlusal acrylic resin bite block,
which were connected by a buccal and
lingual helical spring made of 0.9-mm
stainless steel wire. The lower end of the
buccal spring was soldered to an Adam’s
clasp (0.8 mm, stainless steel), whereas
its occlusal end was completely embed-
ded into the occlusal bite block. The lin-
gual spring was inserted with both ends
in the acrylic resin of the occlusal bite
block and mandibular plate.
Two, a 0.9-mm stainless steel hook was
placed buccally into the occlusal bite block
in the molar region to measure the
amount of activation with a Dontrix gauge.
During each appointment (every 4
weeks), the springs were activated to
apply an intrusive force of 250 to 300 cN.
VOLUME 11, NUMBER 2, 2010 Doshi et al

Fig 1 Intraoral view of the spring-loaded bite block and detailed depiction showing that
the appliance consists of a mandibular plate with occlusal coverage and two posterior bite
blocks connected to each other by two 0.9-mm springs on each side. The hooks in the bite
blocks served to gauge the compression force.

Fig 2 Occlusal, frontal, and lateral views of the magnetic bite block showing that the appli-
ance consists of four posterior bite blocks each containing one magnet inserted in repelling
mode. The individual bite blocks are connected to each other by a 1.0-mm steel bar.

Magnetic bite block circular (1.5 ⫻ 10.0 mm) neodymium-iron-

The construction bite was taken as in the
spring-loaded bite blocks. The design of
the appliance (Fig 2) was based on the
active vertical corrector principles pro-
posed by Dellinger20: in each arch, two
boron magnets (Rare Earth Magnetics)
were inserted in repelling mode in the
first molar region. Such magnets are three
times stronger than typical samarium-
cobalt magnets. The appliance itself
consisted of a posterior maxillary and

109
 Doshi et al
900
800
700
600
Force (cN)
500
400
300
200
100
0
0 1 2 3
Distance (mm)
mandibular occlusal bite block. The right
and left bite blocks were connected by a
1.0-mm steel bar; both bite blocks were
retained by two Adam’s clasps in each
quadrant. To prevent the development of
a crossbite due to shearing forces, buc-
cal shields that extended occlusally were
added to the mandibular bite block.
Evaluation of the magnetic force
The forces generated by the neodymium-
iron-boron magnets were measured on a
universal testing machine (Instron). Two
magnets chosen at random were posi-
tioned in an attractive mode on two plas-
tic blocks. Because the attracting forces
were equal but opposite to the repelling
forces, the universal testing machine dis-
tanced the magnets at a rate of 1.0 mm
per minute, while the force (cN) was mea-
sured on a continuous scale. At 0.0 mm,
825 cN was measured between the two
magnets. At 1.0 mm, it dropped to 428 cN,
and at 2.0 mm, it was 300 cN (Fig 3).
Thus, with a normal freeway space of
about 2 mm, the force applied to the
teeth was about 300 cN.
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WORLD JOURNAL OF ORTHODONTICS
Fig 3 Neodymium-iron-
boron magnet load curve.
4 5 6 7 8 9 10 11
Cephalometric analysis
Lateral cephalograms were taken in cen-
tric occlusion before (T1) and after (T2)
treatment, which achieved at least an
edge-to-edge bite and took a maximum of
8 months. Postretention cephalograms
were taken after 10 months of retention
with passive posterior bite blocks. For all
cephalograms, a single machine (PM
2002, Planmeca) was used. Every lateral
cephalogram was traced on lead acetate
paper, and 18 linear and 16 angular
parameters were measured (Fig 4).
The true rotation of the mandible dur-
ing the observation period was analyzed
by superimposing the cephalograms
using the natural reference structures of
the mandible as described by Björk and
Skieller.42 Based on these superimposi-
tions, the vertical and horizontal displace-
ment of key landmarks were calculated
and compared with the control group.
Method error
All tracings and measurements were
repeated by the same operator at 2-week
intervals. The combined error was calcu-
lated with the Dahlberg formula. The
mean difference was within 0.2 mm for
linear and 0.8 degrees for angular mea-
surements and was insignificant.
VOLUME 11, NUMBER 2, 2010 Doshi et al

Fig 4 Landmarks and refer-

ence lines used for cephalo-
metric evaluation. N

Co
ANS
Ar PNS
A

UMC
LIE UIE
LMC

Go
B
Pg
Gn
Me

Table 1 Mean changes ± standard deviation (SD), P value, and significance in

overjet and overbite between the two groups over 8 months
Spring-loaded bite block Magnetic bite block
Parameter (mean ± SD) (mean ± SD) P

Overjet –0.6 ± 0.3 –1.7 ± 0.49 .000

Overbite 3.4 ± 1.2 4.9 ± 1.47 .026

EMG examination ferences, standard deviations, and stan-

The EMG activity of the masseter and
temporalis muscles was quantitatively
registered on a RMS recorder and Medi-
care system with EMS EMG EP Mark II
software. Recordings were performed at
T1 and T2 at the postural rest position
and maximal voluntary clenching in maxi-
mum intercuspation. All measurements
were repeated three times for both condi-
tions without changing the electrode; the
mean value of both registrations was used
for the statistical analysis.
Statistics
For all clinical, cephalometric, and EMG
parameters at T1 and T2, the mean dif-
dard errors were calculated. Between-
group comparisons were performed by
using an unpaired t test. The paired t test
was used to assess the differences within
the spring-loaded and magnetic bite block
groups. Significance was determined at
both .05 and .01 levels of confidence.
RESULTS
Clinical changes
The decrease in overjet and increase in
overbite was remarkable in both groups
but significantly (P = .000) more so in the
magnetic bite block group (Table 1). This
was later confirmed by cephalometric
analysis.

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 Doshi et al WORLD JOURNAL OF ORTHODONTICS

Table 2 Mean changes ± standard deviation (SD) and P value in cephalometric

measurements between the two groups over 8 months
Spring-loaded bite block Magnetic bite block
Measurement (mean ± SD) (mean ± SD) P

Anteroposterior skeletal angular

SNA (degrees) 0.1 ± 0.2 0.1 ± 0.3 1.000
SNB (degrees) 1.2 ± 0.7 1.6 ± 0.5 .000*
ANB (degrees) –1.2 ± 0.6 –0.5 ± 0.6 .000*
Beta (degrees) 0.6 ± 0.6 1.2 ± 0.8 .000*
Vertical skeletal angular
SN-GoGn (degrees) –1.8 ± 0.8 –1.9 ± 1.2 .913
Ar-Go-Me (degrees) –1.2 ± 0.8 –1.4 ± 0.7 .651
Ar-Go-N (degrees) 0.0 ± 0.2 0.2 ± 0.2 .176
N-Go-Me (degrees) –1.2 ± 0.8 –1.6 ± 0.7 .256
S-Gn/FH (degrees) –1.2 ± 0.6 –1.5 ± 0.8 .535
SN/ANS-PNS (degrees) 0.6 ± 0.3 1.0 ± 0.4 .040*
SN/UOP (degrees) 1.4 ± 0.4 1.5 ± 0.3 .547
SN/LOP (degrees) –1.3 ± 0.6 –1.4 ± 0.3 .817
S-Ar-Go (degrees) –0.6 ± 0.7 –0.9 ± 0.5 .498
SN/Go-Ar (degrees) –0.7 ± 0.3 –1.0 ± 0.5 .209
Vertical skeletal linear
SN-ANS (mm) 0.6 ± 0.3 0.7 ± 0.4 .764
SN-PNS (mm) –0.8 ± 0.6 –0.9 ± 0.3 .640
S-Go (mm) 0.8 ± 0.3 0.9 ± 0.2 .448
N-Me (mm) –1.3 ± 0.4 –1.4 ± 0.4 .791
S-Go/N-Me ⫻ 100% 1.5 ± 0.3 1.5 ± 0.5 .816
ANS-Me (mm) –1.1 ± 0.3 –1.2 ± 0.3 .306
Ar-Go (mm) 0.9 ± 0.2 0.9 ± 0.5 .764
Go-Me (mm) 0.7 ± 0.6 0.9 ± 0.2 .358
Dentoalveolar
UI-NA (degrees) –1.9 ± 0.8 –1.5 ± 0.7 .251
LI-NB (degrees) –1.9 ± 0.6 –1.8 ± 0.4 .665
UIE-NA (mm) –1.3 ± 0.3 –1.8 ± 0.9 .141
LIE-NB (mm) –1.7 ± 0.7 –2.0 ± 0.8 .382
UIE-ANS-PNS (mm) 1.5 ± 0.4 0.9 ± 0.4 .002*
LIE-Go-Gn (mm) 0.7 ± 0.6 0.7 ± 0.5 1.000
UMC-ANS-PNS (mm) –0.8 ± 0.3 –1.1 ± 0.4 .031*
LMC-Go-Gn (mm) –0.2 ± 0.3 –0.8 ± 0.4 .000*
Overjet (mm) –1.7 ± 0.7 –2.5 ± 0.8 .022*
Overbite (mm) 3.4 ± 1.2 4.9 ± 1.6 .025*
Soft tissue
Upper lip-S line (mm) –1.5 ± 0.4 –1.1 ± 0.6 .121
Lower lip-S line (mm) –1.4 ± 0.9 –1.6 ± 0.8 .609

*Statistically significant.

Cephalometric evaluation became obvious between the spring-

Cephalometric values are noted in Table 2.
Anteroposterior skeletal angular mea-
surements. There was a significant
increase in mandibular prognathism with
both appliances, but it was significantly
greater in the magnetic bite block group.
Vertical skeletal angular measure-
ments. A significant autorotation could
be observed in both groups. Ramal incli-
nation and articular angle decreased in
both groups. However, except for
SN/ANS-PNS, no significant difference
loaded and magnetic bite block group.
Vertical skeletal linear measure-
ments. Considerable increase in
mandibular length, ramal height, and
posterior face height was noted; ANS-Me
decreased in both the groups.
Dentoalveolar measurements. Com-
pared to the magnetic bite block group,
there was a significant increase in maxil-
lary anterior dentoalveolar height along
with a significant decrease in maxillary
posterior dentoalveolar height in the
group with the spring-loaded bite blocks.

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VOLUME 11, NUMBER 2, 2010 Doshi et al

Table 3 Mean horizontal, vertical, and rotational Table 4 Mean horizontal, vertical, and rotational
changes and standard deviations (SD) and group changes and standard deviations (SD) and group
difference in key landmarks between the spring-loaded differences in key landmarks between the magnetic
bite block and control groups over 8 months bite block and control groups over 8 months
Spring-loaded Magnetic
bite block group Control group bite block group Control group
Landmark (mean ± SD) (mean ± SD) Difference Landmark (mean ± SD) (mean ± SD) Difference

Horizontal (mm) Horizontal (mm)

Co 0.2 ± 0.8 –0.6 ± 1.4 0.8** Co 0.4 ± 0.5 –0.6 ± 1.4 1.0 **
Go –1.1 ± 0.9 0.9 ± 1.1 –0.2 Go –1.2 ± 1.0 –0.9 ± 1.1 –0.3
L1 –1.5 ± 0.7 0.7 ± 0.9 –2.2* L1 –1.8 ± 1.0 0.7 ± 0.9 –2.5 *
U1 –1.1 ± 0.2 0.7 ± 0.9 –1.8* U1 –1.6 ± 0.4 0.7 ± 0.9 –2.3 *
Vertical (mm) Vertical (mm)
Co 3.5 ± 0.7 2.6 ± 1.8 0.9* Co 3.9 ± 0.9 2.6 ± 1.8 1.3 *
Go 1.8 ± 0.5 1.5 ± 1.4 0.3 Go 1.6 ± 0.7 1.5 ± 1.4 0.1
L1 0.7 ± 0.7 0.8 ± 0.7 –0.2 L1 0.8 ± 1.0 0.8 ± 0.7 0.0
L6 –0.3 ± 1.1 0.6 ± 1.2 –0.9** L6 –0.6 ± 1.2 0.6 ± 1.2 –1.2 **
U1 1.5 ± 0.8 0.9 ± 0.7 –0.6** U1 0.6 ± 0.4 0.9 ± 0.7 –0.4 **
U6 –0.8 ± 1.2 0.6 ± 1.2 –1.4* U6 –0.9 ± 0.5 0.6 ± 1.2 –1.5 *
True rotation (degrees) –1.7 ± 0.5 –0.6 ± 2.2 –1.1* True rotation (degrees) –1.9 ± 0.4 –0.6 ± 2.2 –1.3 *

*P < .05, **P < .01. *P < .05, **P < .01.

Similarly, the magnetic bite block group
showed a significant reduction in maxil-
lary and mandibular posterior dentoalve-
olar height.
Soft tissue measurements. There
was a remarkable reduction in lip protru-
sion in both groups.
Positional changes in key
variables
activity at rest and maximum clenching
after treatment with both appliances
(Tables 5 to 8).
After 10 months of retention with pas-
sive bite blocks, most results were main-
tained with only insignificant amounts
of relapse. The overbite was reduced by
0.3 mm for both devices. All skeletal para-
meters were stable with a mean mandib-
ular forward rotation of 0.5 degrees.

When comparing the changes measured DISCUSSION

on the mandibular superimpositions
(Tables 3 and 4), the spring-loaded and
magnetic block groups showed 3.5 and
3.9 mm vertical condylar growth, respec-
tively, which was more than in the controls.
There was also a tendency for less poste-
rior condylar growth (0.80 vs 0.95 mm),
with the difference approaching signifi-
cance. Along with physiologic incisor erup-
tion, an appreciable amount of bimaxillary
molar intrusion was seen. Finally, true
mandibular forward rotation was almost
three times greater in both treatment
groups than in the control sample.
EMG evaluation
There was a highly significant increase
(P = .000) in masseter and temporalis
There were no adverse transverse effects
with magnetic bite blocks, as described
elsewhere.23,24 This was probably because
of the incorporation of buccal shields on
the mandibular acrylic resin splints. How-
ever, the spring-loaded bite block appli-
ance broke in seven patients.
Although treatment was directed at the
vertical dimension, it clearly increased
mandibular prognathism in both the
groups, but more so in the magnetic bite
block group. This was also recorded by
Altuna and Woodside19 due to the signifi-
cant anterior rotation of the mandible.
The registered rotations of 1.8 and 1.9
degrees (P < .010) were significantly
more than the normal annual rotation of
1 degree reported by Björk and Skieller.42

113
 Doshi et al WORLD JOURNAL OF ORTHODONTICS

Table 5 Mean change ± standard deviation in
masseter activity (peak to peak amplitude in µV)
at rest and maximum clenching over 8 months in the
spring-loaded bite block group
Muscle condition Pretreatment After 8 months
Table 6 Mean change ± standard deviation in
temporalis activity (peak to peak amplitude in µV)
at rest and maximum clenching over 8 months in the
spring-loaded bite block group
P Muscle condition Pretreatment After 8 months P

Rest 2.4 ± 1.7 3.2 ± 1.7 .000 Rest 4.9 ± 2.0 6.6 ± 1.9 .000
Maximum clenching 185.5 ± 79.8 433.3 ± 138.5 .000 Maximum clenching 374.2 ± 193.6 875.4 ± 224.1 .000

Table 7 Mean change ± standard deviation in Table 8 Mean change ± standard deviation in
masseter activity (peak to peak amplitude in µV) temporalis activity (peak to peak amplitude in µV)
at rest and maximum clenching over 8 months in the at rest and maximum clenching over 8 months in the
magnetic bite block group magnetic bite block group
Muscle condition Pretreatment After 8 months P Muscle condition Pretreatment After 8 months P

Rest 2.0 ± 1.1 3.1 ± 1.3 .000 Rest 5.3 ± 2.1 7.7 ± 1.9 .000
Maximum clenching 172.2 ± 77.8 461.4 ± 136.2 .000 Maximum clenching 420.1 ± 226.9 988.0 ± 290.6 .000

In the present study, the gonial angle
decreased in both groups. This is in con-
trast to the studies by Işcan et al,27 Kuster
and Ingervall,28 and Iscan and Sarisoy.33
The ramal inclination angle decreased in
both groups in accordance with studies in
animals18,43 and humans.27,33 It can be
explained by a remodeling effect of the
condyle 44,45 because opening of the
mandible beyond rest position places the
condyle downward and forward. The sub-
sequent forward rotation leads to a
decrease in the ramal inclination angle. It
seems noteworthy that both devices redi-
rect condylar growth in a more anterosu-
perior direction compared to other
orthopedic appliances, which induce a
more posterior growth that is disadvanta-
geous in hyperdivergent patients.1,42,45
There was a significant decrease in
anterior and an increase in posterior face
height in both groups. The decrease in
anterior face height of 1.3 and 1.4 mm
with spring-loaded blocks and magnetic
blocks, respectively, during the treatment
period was significant (P < .010) com-
pared to the annual increase of 1.9 mm
in normally growing individuals of similar
age, as reported by Riolo et al.46
The increase in mandibular corpus
length of 0.7 mm with spring-loaded and
0.8 mm with magnetic blocks was almost
the same (1.0 mm) as the value given by
Rakosi et al47 for vertical growers.
With both appliances, lingual tipping
and passive eruption of the maxillary and
mandibular incisors was noticeable. As
noted by Barbre and Sinclair, 26 these
changes are a response to the increased
pressure of the stretched circumoral
muscles.
According to Riolo et al,46 the physio-
logic annual eruption rate of molars for a
sample of similar age is 0.7 mm. In the
present study, these teeth showed a sig-
nificant intrusion with both appliances
(P < .010). All other forms of vertical treat-
ment result in at least some mandibular
molar eruption.
The intrusion obtained appears to be
the result of the muscle stretch sec-
ondary to the increased vertical dimen-
sion. This view is supported by Woods
and Nanda, 23 who also attributed the
depression of the mandibular posterior
segment directly to the repelling magnets.
Additionally, increased cellular activity
due to the intermittent electromagnetic
field exposure cannot be excluded.20
Overjet decreased with both appli-
ances, which was mainly because of the
autorotation of the mandible. The increase
in overbite was significant for both appli-
ances compared to the normal annual
increase of 0.3 mm found by Moyers et
al.48

114
VOLUME 11, NUMBER 2, 2010
It is known that open bites are prone to
relapse, mainly because of the weak mus-
culature of the affected patients. Both
appliances increased muscle activity,
which could be regarded as a stabilizing
factor because there was an insignificant
relapse in only overbite along with a slight
increase in forward mandibular rotation
after 10 months of retention with passive
posterior bite blocks.
CONCLUSION
Treatment of vertically growing patients
with open bites using spring-loaded and
magnetic bite blocks resulted in the fol-
lowing:
• Clinically, both appliances increased
overbite and reduced overjet. These
corrections were more pronounced in
the magnetic bite block group.
• Spring-loaded bite block therapy led,
on average, to 3.3-mm open bite clo-
sure during 8 months via incisor extru-
sion and molar intrusion in the maxilla.
• Magnetic bite block therapy produced
an average of 4.9 mm of open bite clo-
sure, mainly by molar intrusion in both
arches.
• Both therapies had a significant ortho-
pedic effect consisting of increased
true forward mandibular rotation, de-
creased gonial angulation, increased
condylar growth, and more anterosu-
perior condylar growth. The forward
rotation significantly improved the
sagittal chin position, which is advan-
tageous in skeletal Class II hyperdiver-
gent patients.
• Intrusion obtained with both appli-
ances was because of muscular stretch
secondary to the increased vertical
dimension. Further, the electromag-
netic properties of the magnets might
have had an additional effect.
• A significant increase in the activity of
the masseter and temporalis muscles
at rest and maximum clenching was
noted in both groups. This increased
activity could be a positive factor for
the retention of the results.
• Modified magnetic bite blocks with
neodymium-iron-boron magnets prove
Doshi et al
to be simple, comfortable, and effi-
cient appliances for early interception
in growing patients with a skeletal
open bite. Spring-loaded bite blocks
were difficult to manage because of
frequent wire breakages.
REFERENCES
1. Björk A. A prediction of mandibular growth rota-
tion. Am J Orthod 1969;55:585–599.
2. Brodie AG. On the growth pattern of the human
head from the third month to the eighth year of
life. Am J Anat 1941;68:209–262.
3. Watson WG. A computerized appraisal of the
high-pull face-bow. Am J Orthod 1972;62:
561–579.
4. Worms FW, Isaacson RJ, Speidel TM. A concept
and classification of centers of rotation and
extraoral force systems. Angle Orthod 1973;
43:384–401.
5. Elder JR, Tuenge RH. Cephalometric and histo-
logic changes produced by extra-oral high pull
traction to the maxilla in Macaca mulatta. Am J
Orthod 1974;66:599–617.
6. Meldrum RJ. Alterations in the upper facial
growth of Macaca mulatta resulting from high-
pull headgear. Am J Orthod 1975;67:393–411.
7. Baumrind S, Korn EL, Molthen R, West EE.
Changes in facial dimensions associated with
the use of forces to retract the maxilla. Am J
Orthod 1981;80:17–30.
8. Caldwell SF, Hymas TA, Timm TA. Maxillary trac-
tion splint: A cephalometric evaluation. Am J
Orthod 1984;85:376–384.
9. Pearson LE. Vertical control in treatment of
patients having backward-rotational growth ten-
dencies. Angle Orthod 1978;48:132–140.
10. Haas AJ. A biological approach to diagnosis,
mechanics and treatment of vertical dysplasia.
Angle Orthod 1980;50:279–300.
11. Işcan HN, Dinçer M, Gültan A, Meral O, Taner-
Sarisoy L. Effects of vertical chincap therapy on
the mandibular morphology in open-bite
patients. Am J Orthod Dentofacial Orthop
2002;122:506–511.
12. Weinbach JR, Smith RJ. Cephalometric
changes during treatment with the open bite
bionator. Am J Orthod Dentofacial Orthop
1992;101:367–374.
13. Fränkel R, Fränkel C. A functional approach to
treatment of skeletal open bite. Am J Orthod
1983;84:54–68.
14. Erbay E, Ug̈ur T, Ulgen M. The effects of
Frankel’s function regulator (FR-4) therapy on
the treatment of Angle Class I skeletal anterior
open bite malocclusion. Am J Orthod Dentofa-
cial Orthop 1995;108:9–21.
15. Stellzig A, Steegmayer-Gilde G, Basdra EK. Elas-
tic activator for treatment of open bite. Br J
Orthod 1999;26:89–92.
115
 Doshi et al
16. Defraia E, Marinelli A, Baroni G, Franchi L, Bac-
cetti T. Early orthodontic treatment of skeletal
open-bite malocclusion with the open-bite bion-
ator: A cephalometric study. Am J Orthod
Dentofacial Orthop 2007;132:595–598.
17. Cozza P, Baccetti T, Franchi L, Mucedero M.
Comparison of 2 early treatment protocols for
open-bite malocclusions. Am J Orthod Dentofa-
cial Orthop 2007;132:743–747.
18. McNamara JA Jr. An experimental study of
increased vertical dimension in the growing
face. Am J Orthod 1977;71:382–395.
19. Altuna G, Woodside DG. Response of the mid-
face to treatment with increased vertical
occlusal forces. Treatment and posttreatment
effects in monkeys. Angle Orthod 1985;55:
251–263.
20. Dellinger EL. A clinical assessment of the
Active Vertical Corrector—A nonsurgical alterna-
tive for skeletal open bite treatment. Am J
Orthod 1986;89:428–436.
21. Woodside DG, Linder-Aronson S. Progressive
increase in lower anterior facial height and the
use of posterior bite block in its management.
In: Graber LW (ed). Orthodontics: State of Art,
Essence of Science. St Louis: Mosby, 1986:
200–221.
22. Woods MG, Nanda RS. Intrusion of posterior
teeth with magnets. An experiment in growing
baboons. Angle Orthod 1988;58:136–150.
23. Woods MG, Nanda RS. Intrusion of posterior
teeth with magnets: An experiment in nongrow-
ing baboons. Am J Orthod Dentofacial Orthop
1991;100:393–400.
24. Kalra V, Burstone CJ, Nanda R. Effects of a
fixed magnetic appliance on the dentofacial
complex. Am J Orthod Dentofacial Orthop
1989;95:467–478.
25. Kiliaridis S, Egermark I, Thilander B. Anterior
open bite treatment with magnets. Eur J Orthod
1990;12:447–457.
26. Barbre RE, Sinclair PM. A cephalometric evalu-
ation of anterior openbite correction with the
magnetic active vertical corrector. Angle Orthod
1991;61:93–102.
27. Işcan HN, Akkaya S, Koralp E. The effects of
the spring-loaded posterior bite-block on the
maxillo-facial morphology. Eur J Orthod
1992;14:54–60.
28. Kuster R, Ingervall B. The effect of treatment of
skeletal open bite with two types of bite-blocks.
Eur J Orthod 1992;14:489–499.
29. Melsen B, McNamara JA Jr, Hoenie DC. The
effect of bite-blocks with and without repelling
magnets studied histomorphometrically in the
rhesus monkey (Macaca mulatta). Am J Orthod
Dentofacial Orthop 1995;108:500–509.
30. Darendeliler MA, Yüksel S, Meral O. Open-bite
correction with magnetic activator device IV.
J Clin Orthod 1995;29:569–576.
31. Dellinger EL, Dellinger EL. Active vertical correc-
tor treatment—Long-term follow-up of anterior
open bite treated by the intrusion of posterior
teeth. Am J Orthod Dentofacial Orthop 1996;
110:145–154.
116
WORLD JOURNAL OF ORTHODONTICS
32. Akkaya S, Haydar S. Post-retention results of
spring-loaded posterior bite-block therapy. Aust
Orthod J 1996;14:179–183.
33. Iscan HN, Sarisoy L. Comparison of the effects
of passive posterior bite-blocks with different
construction bites on the craniofacial and den-
toalveolar structures. Am J Orthod Dentofacial
Orthop 1997;112:171–178.
34. Sankey WL, Buschang PH, English J, Owen AH
3rd. Early treatment of vertical skeletal dyspla-
sia: The hyperdivergent phenotype. Am J
Orthod Dentofacial Orthop 2000;118:317–327.
35. Ringqvist M. Isometric bite force and its rela-
tion to dimensions of the facial skeleton. Acta
Odontol Scand 1973;31:35–42.
36. Ingervall B, Helkimo E. Masticatory muscle
force and facial morphology in man. Arch Oral
Biol 1978;23:203–206.
37. Proffit WR, Fields HW, Nixon WL. Occlusal
forces in normal- and long-face adults. J Dent
Res 1983;62:566–570.
38. Ingervall B, Bitsanis E. A pilot study of the
effect of masticatory muscle training on facial
growth in long-face children. Eur J Orthod
1987;9:15–23.
39. Lindsey CA, English JD. Orthodontic treatment
and masticatory muscle exercises to correct a
Class I open bite in an adult patient. Am J
Orthod Dentofacial Orthop 2003;124:91–98.
40. Akkaya S, Haydar S, Bilir E. Effects of spring-
loaded posterior bite-block appliance on masti-
catory muscles. Am J Orthod Dentofacial
Orthop 2000;118:179–183.
41. Demirjian A, Brault DM, Jenick M. Etude com-
parative de la croissance de l’enfant canadien
d’origine francais a Montreal. Can J Pub Hlth
1971;62:111–119.
42. Björk A, Skieller V. Normal and abnormal
growth of the mandible. A synthesis of longitu-
dinal cephalometric implant studies over a
period of 25 years. Eur J Orthod 1983;5:1–46.
43. Harvold EP, Vargervik K, Chierici G. Primate
experiments on oral sensation and dental mal-
occlusions. Am J Orthod 1973;63:494–508.
44. Moss ML, Salentijn L. The capsular matrix. Am
J Orthod 1969;56:474–490.
45. Björk A, Skieller V. Facial development and
tooth eruption. An implant study at the age of
puberty. Am J Orthod 1972;62:339–383.
46. Riolo ML, Moyers RE, McNamara JA, Hunter
WS. An Atlas of Craniofacial Growth, Cephalo-
metric Standards from the University School
Growth Study. Monograph no. 2, Craniofacial
Growth Series, ed 2. Ann Arbor: Center for
Human Growth and Development, The Univer-
sity of Michigan, 1974.
47. Rakosi TR, Graber TM, Petrovic AG. Dentofacial
Orthopedics with Functional Appliances.
St Louis: Mosby, 1985.
48. Moyers RE, Van der Linden FPG, Riolo ML,
McNamara JA, Hunter WS. Standards of Human
Occlusal Development. Monograph no. 5,
Craniofacial Growth Series, ed 2. Ann Arbor:
Center for Human Growth and Development,
The University of Michigan, 1976.
Ahmet Yagci, DDS1
THE EFFECTS OF MYOFUNCTIONAL
Tancan Uysal, DDS, PhD2
APPLIANCE TREATMENT ON THE
Sadik Kara, PhD3
PERIORAL AND MASTICATORY MUSCLES
Sukru Okkesim, PhD4
IN CLASS II, DIVISION 1 PATIENTS
Aim: To evaluate the effect of a myofunctional appliance—the pre-
orthodontic trainer (POT)—on the perioral and masticatory muscles
by electromyography (EMG) in individuals with an Angle Class II,
Division 1 malocclusion. Methods: Twenty children were treated with
a POT appliance, which had to be worn every day for 1 hour and
overnight. The EMG recordings were made at the beginning and end
of POT therapy during maximal clenching, swallowing, and sucking.
For statistical evaluation, the Wilcoxon nonparametric test was used
at the P < .05 level. Results: During POT treatment, the EMG value for
clenching of the anterior temporal muscle decreased significantly (P <
.001). Also, for the mentalis muscle, the EMG value during clenching
decreased significantly; for the orbicularis oris muscle, this was true
for sucking (P < .05) and clenching (P < .01). For the masseter muscle,
all EMG values were decreased during treatment but significantly
only for clenching. Conclusion: During the 6 months of POT treat-
ment, the perioral and masticatory muscles of Class II, Division 1
patients improved significantly. World J Orthod 2010;11:117–122.

Key words: preorthodontic trainer, EMG, myofunctional appliances,

perioral muscles, masticatory muscles

1Research Assistant, Department of he effects of abnormal lip and tongue Animal studies have shown that appli-
Orthodontics, Faculty of Dentistry,
Erciyes University, Kayseri, Turkey.
T functions and habits on craniofacial
development have been reported in the
ances that position the mandible anteriorly
can considerably stimulate mandibular
2Associate Professor and Chair,

Department of Orthodontics, Faculty
of Dentistry, Erciyes University,
Kayseri, Turkey; Visiting Professor,
King Saud University, Riyadh,
Saudi Arabia.
3Professor, Institute of Biomedical
Engineering, Fatih University, Istanbul,
Turkey.
4Research Assistant, Department of
Electrics and Electronics, Faculty of
Engineering, Fatih University, Istanbul,
Turkey
CORRESPONDENCE
Dr Tancan Uysal
Erciyes Universitesi
Dis Hekimligi Fak. Ortodonti AD
Melikgazi, Kayseri
Turkey 38039
Email: tancanuysal@yahoo.com
literature since the 19th century. Various
appliances 1–5 and protocols 6,7 have
been presented to treat this problem.
The main intent of the advocated appli-
ances is to eliminate oral dysfunctions,
establish muscular balance, and correct
or diminish maxillary incisor protrusion.8
Recent studies have shown that maloc-
clusions might be caused by a child’s ha-
bit or the way he swallows and breathes.
Bass9 indicated that the most frequent
skeletal problem in Class II preadoles-
cents is mandibular retrognathia. This
suggests that an appliance with the doc-
umented ability to significantly stimulate
mandibular growth should be an impor-
tant part of a clinician’s armamentarium.
growth, primarily by enhanced remodeling
of the condyle.10–12
Cheney 13,14 introduced a myofunc-
tional appliance called the oral shield.
This appliance was designed to activate
the lips and other facial muscles. As a
result of using this appliance, the maxil-
lary incisors uprighted and lip closure
was improved. Myofunctional appliances
are simple and economical, but require
a careful selection of indication.15
Early treatment of deleterious habits
is easier than correction after years of
habit practice. 16 Moreover, young
patients are considered to be more coop-
erative than adolescents.16 The preortho-
dontic trainer (POT), a functional device

117
 Yagci et al
most advantageously used in children
from 4 to 10 years of age (Fig 1), is ideal
for treating this population.
The trainer allegedly has the orthope-
dic effect of a functional appliance, as
well as the capacity to align teeth and
train muscles. It repositions the mandible
and decreases mouth breathing, tongue
thrusting, and thumb sucking. By distanc-
ing the lower lips from the dental arch,
the trainer can prevent the patient from
positioning the tongue against the lower
lip during swallowing.15 It can further pre-
vent acquired crowding and jaw discrep-
ancies that are not frequently genetically
induced.12,17
Usumez et al15 investigated the treat-
ment effects brought about by POT appli-
ances and demonstrated that they
stimulated dentoalveolar changes that
result in a significant reduction of the
overjet. Thus, they could be used well
with appropriate patient selection.
118
WORLD JOURNAL OF ORTHODONTICS
Fig 1 Frontal and oblique views of the preorthodontic trainer,
which is commonly made of silicone or polyurethane.
Electromyography (EMG) signals indi-
cate electrical potentials generated by
the cells of skeletal muscles. 18 Gross-
man et al19 suggested the use of EMGs
for orthodontic diagnosis and treatment
planning. Ahlgren20 used it to evaluate
mastication in children with special refer-
ence to occlusion, and Möller21 investi-
gated the action of the masticator y
muscles with facial morphology.
Surface and needle electrodes can be
used for EMG. Surface electrodes have
been widely employed because they are
noninvasive, easy to adhere to the skin,
and able to detect the total activity of any
muscle. However, separation of single
motor unit action potential is not easy
with such electrodes.22
The purpose of this study was to eval-
uate the effect of the POT appliance on
the anterior temporal, mental, orbicularis
oris, and masseter muscles during vari-
ous activities in children.
VOLUME 11, NUMBER 2, 2010
MATERIALS AND METHODS
Subjects
The sample consisted of 20 Caucasian
patients (10 boys and 10 girls) with an
Angle Class II, Division 1 relationship
treated between 2006 and 2007. The
ANB angle of all patients was > 4.0
degrees and their overjet > 4.5 mm
(mean ANB 5.5 ± 1.4 degrees, mean
overjet 6.0 ± 1.2 mm). Ages ranged from
7.8 to 11.5 years (mean 10.1 ± 3.1
years). None had a thumb-sucking habit,
and all were treated exclusively with the
POT appliance (T4K, Myofunctional
Research). Each patient was instructed to
use the POT every day for 1 hour and all
night for 6 months.
Positioning of the electrodes
Before each recording session, the proce-
dure was explained in detail to all
patients and their parents to allay anxi-
ety. All participants were asked to wash
their face with soap and water. Next, the
skin over the muscles was cleaned with
alcohol and thoroughly dried. Then, bipo-
lar EL 254S shielded Biopac Silver-silver
chloride (Ag-AgCl) disk surface electrodes
(4.0-mm diameter) were covered with
electrode gel and fixated with adhesive
washers. The common ground electrode
was adhered to the forehead, whereas
the active electrodes were placed over
the respective muscles.
For the right anterior temporal muscle
and the right superficial masseter mus-
cle, the electrodes were placed 1.0 cm to
1.5 cm distal of their anterior border. The
site at the right anterior temporal muscle
was located by palpation during clench-
ing.23,24 The vertical site over the superfi-
cial masseter was defined as the middle
of a line connecting the inferior border of
the zygomatic arch at the zygomaticotem-
poral suture with the gonial angle. The
electrodes for the upper orbicularis oris
muscles were placed above the vermilion
border of the lips. The positions of the
electrodes at the first session were
marked on each patient’s chart and used
as a guide at each subsequent recording.
Yagci et al
Additionally, photographs were taken at
the first session as a reference for future
electrode placement.
EMG recording
The EMG signals were recorded at the
start of the treatment and at the end of
the sixth month. The recordings were
made of maximal clenching in centric
occlusion (four clenches), swallowing of
saliva (two swallows), and sucking on a
straw (six suckings).8 These actions were
practiced beforehand by copying the
observer. All participants were instructed
to avoid protruding their jaw or tongue
during a recording. For all recordings, the
patients were seated upright in a dental
chair with their head in natural balance.
The swallowing recordings were taken
when a patient indicated that a sufficient
amount of saliva had accumulated. For
the sucking recordings, the patient
sucked on a plastic straw placed in front
of the anterior teeth and closing the open
end of the straw with a finger.
The EMG signals were acquired by a
Biopac-MP150 unit (BIOPAC Systems).
The EMG-100C Biopac was used as an
amplifier with a 2,000 gain. Its high-pass
filter was set to 1.0 Hz and its low-pass
filter to 500.0 Hz. The serial output of the
EMG recorder was sampled at 5,000
samples per second and then sent to a
computer via an Ethernet card.
Statistical method
All statistical analyses were performed
using the Statistical Package for Social
Sciences 13.0 (SPSS). Arithmetic means
and standard deviations (SD) were calcu-
lated for each measurement. The Wilcoxon
test was used to test the significance of
the mean differences of the EMG vari-
ables between the two observations.
119
 Yagci et al WORLD JOURNAL OF ORTHODONTICS

Table 1 Mean EMG (in decibel/Hertz) and SD values of the various muscles and functions at pre- and posttreatment,
difference between the two time points, and statistical evaluation
Pretreatment (T1) Posttreatment (T2) Difference
Muscle/Functions Mean SD Mean SD (T2–T1) Wilcoxon test

Anterior temporalis
Swallowing 0.155 0.387 0.038 0.065 –0.117 NS
Sucking 0.040 0.091 0.003 0.003 –0.037 NS
Clenching 0.610 0.645 0.201 0.444 –0.409 ***
Mentalis
Swallowing 0.104 0.188 0.074 0.076 –0.030 NS
Sucking 0.249 0.296 0.297 0.393 0.047 NS
Clenching 0.958 0.232 0.538 0.593 –0.420 **
Orbicularis oris
Swallowing 0.048 0.053 0.093 0.135 0.045 NS
Sucking 0.288 0.456 0.407 0.463 0.119 **
Clenching 0.016 0.215 0.144 0.060 0.128 *
Masseter
Swallowing 0.044 0.103 0.006 0.014 –0.038 NS
Sucking 0.124 0.360 0.015 0.057 –0.109 NS
Clenching 0.781 0.863 0.185 0.353 –0.596 *
SD = standard deviation, NS = not significant, * P < .01, ** P < .05, *** P < .001.

RESULTS activity brought about by its use. There

The EMG values of the sample at pre-
and posttreatment are shown in Table 1.
For the anterior temporal muscle, only
the EMG activity during clenching at the
beginning of treatment was significantly
(P < .001) higher than that at posttreat-
ment. In regard to the mentalis muscle,
again, only the EMG activity during
clenching at the beginning of treatment
was significantly (P < .05) higher than
that at posttreatment. The EMG activities
during sucking (P < .05) and clenching
(P < .01) at the beginning of treatment
were significantly lower than that at post-
treatment for the orbicularis oris muscle.
For the masseter muscle, all EMG values
were decreased during treatment but
significantly (P < .01) for only clenching.
DISCUSSION
The POT is a flexible, passive appliance
that assists in retraining the musculature
and changing the mode of breathing and
swallowing. Because there are no studies
about this device, the present study was
designed especially to evaluate the EMG
have been no reports that the POT appli-
ance has any harmful effects.
Angle 25 wrote that according to his
observation, almost every malocclusion
has some sof t tissue involvement.
Another study showed that early treat-
ment with an orthopedic appliance is
successful in 80% of malocclusions; the
remaining 20% require fixed appli-
ances.26 Muscle function and particularly
tongue position and function have a
great impact on the dentition and can
lead to a deterioration of an orthodontic
correction or even a recurrence of the
original problem if not alliviated.27
The POT is made from nonthermoplas-
tic silicone or polyurethane, which gives
the appliance its flexibility and inherent
memory. Schendel et al 28 showed no
mutagenic, toxic, or irritating properties
in their biocompatibility tests on syn-
thetic materials; Skomro 29 came to a
similar conclusion.
The front part of the POT appliance
incorporates a sort of oral screen that
encourages nasal breathing. Graber 30
stated that oral screens are indicated in
mild Class II occlusions and that the con-
struction bite for these patients should

120
VOLUME 11, NUMBER 2, 2010
not be as protrusive as for activators. The
use of myofunctional appliances such as
the oral/vestibular screens in the primary
and mixed dentitions are mentioned fre-
quently in the literature,8,15 but only two
studies have been published about the
EMG changes these appliances induce.8,31
In the present study, during maximal
clenching, the anterior temporal muscle
activity decreased significantly after
6 months of POT use. Tallgren et al 8
reported similar changes.
Also, the activity of the mentalis mus-
cle in individuals with incompetent lips
under various functions was examined in
some previous studies. 32–35 Further,
Stavridi and Ahlgren36 studied the mas-
seter, buccinator, and mentalis muscles
with EMG and found a significant
decrease in mentalis muscle activity dur-
ing swallowing. In the current study, POT
treatment decreased the mentalis activity
only during clenching.
Similarly, Takada et al37,38 looked into
the EMG activity of the inferior orbicularis
oris muscles, Schieppati et al 39 re -
searched that of the perioral muscles dur-
ing mastication, and Schievano et al31
examined that of the orbicularis oris
muscle before and after myofunctional
therapy to find that it increased signifi-
cantly. All thought that myofunctional
therapy influences the perioral muscles
because lip closure is established after
therapy. Finally, Tallgren et al8 found that
the sucking activity of the lips decreased
significantly after 6 months and after 1
year of myofunctional appliance treat-
ment. In contrast, the present research
revealed that POT treatment increased
the orbicularis oris activity during sucking.
CONCLUSION
During the 6 months of POT treatment,
the masticatory and perioral muscles of
Class II, Division 1 patients improved
significantly.
Yagci et al
ACKNOWLEDGMENTS
The authors are grateful for the grant support pro-
vided by The Scientific & Technological Research
Council of Turkey—TÜBITAK, contract number
106E144.
REFERENCES
1. Day AJ, Trotter PA, Norris N. A modified oral
screen made of latex. Br Dent J 1949;87:
143–147.
2. Jonast I, Schlenter W, Man W. The effect of the
perforated vestibular screen on nasal respira-
tion. Eur J Orthod 1990;12:198–208.
3. Townend BR. The mouth screen. Br Dent J
1960;108:20–22.
4. Iizuka Y, Tanaka M, Nakano H, Seino Y, Miura
H. Three cases of orthodontic treatment for
openbite with habit breakers in a growing
period [in Japanese]. Dent J Iwate Med Univ
1999;24:251–262.
5. Saito M. A study on improving tongue functions
of open-bite children at the mixed dentition
period—Modifications of a removable habit-
breaker appliance and their sonographic analy-
sis [in Japanese]. Kokubyo Gakkai Zasshi
2001;68:193–207.
6. Graber TM. Orthodontics: Principles and Prac-
tice, ed 3. Philadelphia: Saunders, 1996.
7. Hotz R. Othodontie in der teaglichen Praxis, 4
Aufl. Bern: Hans Huber, 1970.
8. Tallgren A, Christiansen RL, Ash M Jr, Miller RL.
Effects of a myofunctional appliance on orofa-
cial muscle activity and structures. Angle
Orthod 1998;68:249–258.
9. Bass NM. Dento-facial orthopaedics in the cor-
rection of Class II malocclusion. Br J Orthod
1982;9:3–31.
10. Charlier JP, Petrovic A, Herrman-Stutzmann J.
Effects of mandibular hyperpropulsion on the
prechondroblastic zone of young rat condyle.
Am J Orthod 1969;55:71–74.
11. Stöckli PW, Willert HG. Tissue reactions in the
temporomandibular joint resulting from ante-
rior displacement of the mandible in the mon-
key. Am J Orthod 1971;60:142–155.
12. McNamara JA Jr. Neuromuscular and skeletal
adaptations to altered function in the orofacial
region. Am J Orthod 1973;64:578–606.
13. Cheney EA. Factors in the early treatment and
interception of malocclusion. Am J Orthod 1958;
44:807–826.
14. Cheney EA. Treatment planning and therapy in
the mixed dentition. Am J Orthod 1963;49:
568–580.
15. Usumez S, Uysal T, Sari Z, Basciftci FA, Kara-
man AI, Guray E. The effects of early preortho-
dontic trainer treatment on Class II, Division 1
patients. Angle Orthod 2004;74:605–609.
121
 Yagci et al
16. Papadopoulos MA. Orthodontic Treatment of
the Class II Noncompliant Patient: Current Prin-
ciples and Techniques. Edinburgh: Elsevier
Mosby, 2008:69–91.
17. Ung N, Koenig J, Shapiro PA, Shapiro G, Trask G.
A quantitative assessment of respiratory pat-
terns and their effects on dentofacial develop-
ment. Am J Orthod Dentofacial Orthop 1990;
98:523–532.
18. Reaz MB, Hussain MS, Mohd-Yasin F. Tech-
niques of EMG signal analysis: Detection, pro-
cessing, classification, and applications. Biol
Proced Online 2006;8:11–35.
19. Grossman WJ, Greenfield BE, Timms DJ. Elec-
tromyography as an aid in diagnosis and treat-
ment analysis. Am J Orthod 1961;47:481–497.
20. Ahlgren J. Mechanism of mastication. A quanti-
tative cinematographic and electromyographic
study of masticatory movements in children,
with special reference to occlusion of the teeth.
Acta Odontol Scand 1966;24:5–109.
21. Möller E. The chewing apparatus. An electro-
myographic study of the action of the muscles
of mastication and its correlation to facial mor-
phology [thesis]. Acta Physiol Scand Suppl
1966;280:1–229.
22. Pozzo M, Farina D, Merletti R. Biomedical
Technology and Devices Handbook. Florida:
CRC Press, 2004:1–60.
23. Gay T, Rendell J, Majoureau A, Maloney FT. Esti-
mating human incisal bite forces from the elec-
tromyogram/bite-force function. Arch Oral Biol
1994;39:111–115.
24. Leung DK, Hägg U. An electromyographic inves-
tigation of the first six months of progressive
mandibular advancement of the Herbst appli-
ance in adolescents. Angle Orthod 2001;71:
177–184.
25. Angle EA. Treatment of Malocclusion of the
Teeth, ed 7. Philadelphia: SS White, 1907.
26. Rondeau BH. Class II malocclusion in mixed
dentition. J Clin Pediatr Dent 1994;19:1–11.
27. Vlachakis M, Bratu E. Functional possibilities of
prevention in orthodontics. Ovidius Univ Dent
Med J 2007;4:35–38.
28. Schendel KU, Erdinger L, Komposch G,
Sonntag HG. Neon-colored plastics for ortho-
dontic appliances. Biocompatibility studies
[in German]. Fortschr Kieferorthop 1995;56:
41–48.
122
WORLD JOURNAL OF ORTHODONTICS
29. Skomro P. Orthodontic appliance made from
silicone elastomer, evaluated clinically and
from patient opinions after treatment for mal-
occlusion [in Polish]. Ann Acad Med Stetin
2000;46:293–304.
30. Graber TM. The use of muscle forces by simple
orthodontic appliances. Am J Orthod 1979;76:
1–20.
31. Schievano D, Rontani RM, Bérzin F. Influence
of myofunctional therapy on the perioral mus-
cles. Clinical and electromyographic evalua-
tions. J Oral Rehabil 1999;26:564–569.
32. Eckardt L, Harzer W, Schneevoigt R. Compara-
tive study of excitation patterns in the masseter
muscle before and after orthognathic surgery.
J Craniomaxillofac Surg 1997;25:344–352.
33. Tosello DO, Vitti M, Berzin F. EMG activity of the
orbicularis oris and mentalis muscles in chil-
dren with malocclusion, incompetent lips and
atypical swallowing—Part I. J Oral Rehabil
1998;25:838–846.
34. Tosello DO, Vitti M, Berzin F. EMG activity of the
orbicularis oris and mentalis muscles in chil-
dren with malocclusion, incompetent lips and
atypical swallowing—Part II. J Oral Rehabil
1999;26:644–649.
35. Gustafsson M, Ahlgren J. Mentalis and orbicu-
laris oris activity in children with incompetent
lips. Acta Odontol Scand 1975;33:355–363.
36. Stavridi R, Ahlgren J. Muscle response to the
oral-screen activator. An EMG study of the mas-
seter, buccinator, and mentalis muscles. Eur J
Orthod 1992;14:339–349.
37. Takada K, Miyawaki S, Tatsuta M. The effects
of food consistency on jaw movement and pos-
terior temporalis and inferior orbicularis oris
muscle activities during chewing in children.
Arch Oral Biol 1994;39:793–805.
38. Takada K, Yashiro K, Sorihashi Y, Morimoto T,
Sakuda M. Tongue, jaw, and lip muscle activity
and jaw movement during experimental chew-
ing efforts in man. J Dent Res 1996;75:
1598–1606.
39. Schieppati M, Di Francesco G, Nardone A. Pat-
terns of activity of perioral facial muscles dur-
ing mastication in man. Exp Brain Res 1989;
77:103–112.
Anitha Vijayakumar, MDS1
Sundaram Venkateswaran,
MDS, Dip NB (Ortho)2
N. Rengarajan Krishnaswamy,
MDS, MOrtho RCS (Edin),
Dip NB (Ortho)3
EFFECTS OF THREE ADHESION BOOSTERS
ON THE SHEAR BOND STRENGTH OF
NEW AND REBONDED BRACKETS—
AN IN VITRO STUDY
Aim: To evaluate the effects of three adhesion boosters—All-Bond 2,
Enhance LC, and Ortho Solo—on the shear bond strength of new and
rebonded (previously debonded) brackets. Methods: One hundred
new and 100 sandblasted debonded brackets were bonded to 200
extracted human premolars and divided into eight groups. Results:
The new brackets/Ortho Solo group yielded the highest bond
strength, followed by the new brackets/All-Bond 2 and the new brack-
ets/Enhance LC groups. During rebonding, Ortho Solo improved the
bond strength significantly; however, All-Bond 2 and Enhance LC did
not. Conclusion: (1) Bond strength is significantly improved when
new brackets are bonded with an adhesion booster; (2) without any
adhesion booster, sandblasted rebonded brackets yield a significantly
lower bond strength than new brackets; (3) Enhance LC failed to
improve the bond strength of rebonded brackets; (4) Ortho Solo
increased the bond strength of rebonded brackets significantly; and
(5) brackets rebonded with Ortho Solo yielded comparable bond
strength as new brackets without any adhesion booster. World J
Orthod 2010;11:123–128.

Key words: adhesion boosters, rebonding, shear bond strength

1Former Postgraduate Student,
Department of Orthodontics, Ragas
Dental College and Hospital,
Chennai, India.
2Professor, Department of Orthodontics,
Ragas Dental College and Hospital,
Chennai, India.
3Professor and Head, Department of
Orthodontics, Ragas Dental College
and Hospital, Chennai, India.
CORRESPONDENCE
Dr Anitha Vijayakumar
Department of Orthodontics
Ragas Dental College and Hospital
East Coast Road, Uthandi
Chennai 600119
India
Email: aneethaa11@gmail.com
n previous decades, advances in the
I
development of orthodontic adhesives
greatly increased the efficiency of bond-
ing brackets (and other attachments).
However, bond failure is still among the
most frustrating occurrences in ortho-
dontic practice. Studies have shown that
such failures occur in about 5% to 7% of
patients with brackets. 1,2 In addition,
clinicians may intentionally debond
brackets during orthodontic treatment to
rebond them in a superior position. 3
Thus, rebonding of brackets is common
during orthodontic treatment.
Repeated bond failure in a single tooth
is of particular clinical concern. Mizrahi4
stated that the initial failure rate is 4%,
which increases to 14% after rebonding
and 25% after a second rebonding. One
of the main causes for an increased fail-
ure rate could be an alteration of the
enamel (adhesive remnants) in conjunc-
tion with the repeated bonding.
Bishara et al 5 found that rebonded
brackets had an inconsistent and signifi-
cantly lower shear bond strength. They
suggested the use of an adhesion
booster to improve bond strength. Adhe-
sion promoters (boosters) are multifunc-
tional molecules that adhere chemically
to the enamel and at the same time
interact with the resin.6

123
 Vijayakumar et al
The aims and objectives of this study
were:
• To find out whether there is any signifi-
cant difference in the shear bond
strength between initial bonding and
rebonding
• To find out whether there is any signifi-
cant difference in shear bond strength
when using an adhesion booster dur-
ing initial bonding and rebonding
• To compare the effect of three adhe-
sion boosters (All-Bond 2, Enhance LC,
and Ortho Solo) on initial bonding and
rebonding
METHODS AND MATERIALS
Two hundred human maxillary first pre-
molars extracted for orthodontic pur-
poses with intact buccal enamel were
cleaned of tissue debris and stored in
distilled water with 0.1% thymol crystals
to inhibit bacterial growth. The bonded
attachments were stainless steel, pread-
justed edgewise brackets, Roth prescrip-
tion, with 0.022-inch slots for maxillary
premolars with a foil-mesh base (surface
area 9.8 mm 2 ) (Gemini, 3M Unitek).
These were placed along the crown axis
by one operator. The adhesion boosters
tested were: All-Bond 2 (Bisco), consist-
ing of a primer A (Na-N-tolylglycine gly-
cidylmethacrylate, acetone, and ethanol)
and a primer B (biphenyl dimethacrylate,
acetone, and ethanol); Enhance LC
(Reliance), composed of HEMA (hydroxy-
ethyl methacrylate), tetrahydro-furfuryl
cyclohexane dimethacrylate and ethanol;
and Ortho Solo (Ormco), consisting of
ethyl alcohol, alkyldimethacrylate resin,
barium aluminoborosilicate glass, silicon
dioxide, and sodium hexafluorosilicate.
All teeth were embedded in acrylic
resin approximately to the level of the
cementoenamel junction and stored in
an airtight, humid environment to pre-
vent dehydration. One hundred of the
200 teeth were randomly assigned to the
following four groups of 25 teeth each:
group A, new brackets/no adhesion
booster; group A1, new brackets/All-Bond
2; group A2, new brackets/ Enhance LC;
and group A3, new brackets/Ortho Solo.
124
WORLD JOURNAL OF ORTHODONTICS
The remaining 100 teeth were etched
and bonded with brackets using Light
Bond (Reliance). After careful removal of
all bonding material excess, they were
light cured for 10 seconds with an Elipar
light-curing unit (3M Unitek) on each of the
four sides. These brackets were subse-
quently separated with debonding pliers
using light pressure from the respective
teeth. While debonding, care was taken to
prevent distortion of the bracket bases.
These bases were sandblasted with a
microetcher at 65 psi for 7 to 12 seconds
with 50-µm aluminum oxide particles and
inspected under 10⫻ magnification to be
certain that all visible adhesive was
removed. Each sandblasted bracket base
was then wiped with acetone on a cotton
pledget and dried with air.7 The residual
composite on the teeth was removed with
a no. 12 fluted tungsten carbide bur using
a high-speed air rotor handpiece until no
resin was apparent on visual inspection.5,8
The teeth were then cleaned at slow
speed with a prophy cup and a non -
fluorided oil-free pumice paste, rinsed with
water, and dried with oil-free air. The
enamel was etched with 37% phosphoric
acid for 15 seconds, rinsed again, and air
dried. These 100 teeth were divided into
the following four groups of 25 teeth each:
group B, rebonded brackets/no adhesion
booster; group B1, rebonded brackets/
All-Bond 2; group B2, rebonded brackets/
Enhance LC; and group B3, rebonded
brackets/Ortho Solo.
All group A teeth were thinly coated
with Light Bond sealant, which was light
cured for 10 seconds; Light Bond paste
was applied to the bracket base.
The slightly moist enamel of all teeth in
group A1 was thinly (4 to 5 brush strokes)
coated with a mixture of All-Bond 2 primer
A and B according to the manufacturer’s
recommendation. This coat was lightly
dried until it looked glossy. A thin layer of
Light Bond sealant was then applied
directly on the All-Bond 2 coat and light
cured for 10 seconds. Light Bond paste
was applied to the bracket base.
All teeth in group A2 were thinly (4 to
5 brush strokes) coated with Enhance LC
and lightly dried according to the manu-
facturer’s recommendation. A thin layer
of Light Bond sealant was then applied
VOLUME 11, NUMBER 2, 2010
Fig 1 Setup for shear bond strength test
in this study (Lloyd’s universal testing
machine).
directly on the Enhance LC coat and light
cured for 10 seconds. Light Bond paste
was applied to the bracket base.
All teeth in group A3 were thinly (4 to 5
brush strokes) coated with Ortho Solo,
and the bracket was directly bonded with
Light Bond paste. According to the manu-
facturer, Ortho Solo itself primes the
enamel when light cured.
All teeth in group B were thinly coated
with Light Bond sealant, which was light
cured for 10 seconds. Light Bond paste
was applied to the sandblasted bracket
base.
The slightly moist enamel of all teeth
in group B1 was thinly (4 to 5 brush
strokes) coated with a mixture of All-Bond
2 primer A and B according to the manu-
facturer’s recommendation. This coat
was lightly dried until it looked glossy. A
thin layer of Light Bond sealant was then
applied directly on the All-Bond 2 coat
and light cured for 10 seconds. Light
Bond paste was applied to the sand-
blasted bracket base.
All teeth in group B2 were thinly (4 to
5 brush strokes) coated with Enhance LC
and lightly dried according to the manu-
facturer’s recommendation. A thin layer
of Light Bond sealant was then applied
directly on the Enhance LC coat and light
cured for 10 seconds. Light Bond paste
was applied to the sandblasted bracket
base.
All teeth in group B3 were thinly (4 to
5 brush strokes) coated with Ortho Solo,
and the sandblasted bracket was directly
Vijayakumar et al
bonded with Light Bond paste. According
to the manufacturer, Ortho Solo itself
primes the enamel when it is light cured.
After bonding, all samples were stored
in distilled water at room temperature for
24 hours. After being suspended from a
stainless steel wire, the specimens were
placed in the mounting jig of a Lloyd’s
universal testing machine and loaded
with a shear force in the occlusogingival
direction at a crosshead speed of 1
mm/min (Fig 1). The force necessary for
debonding was recorded in N and con-
verted to MPa. Debonded specimens
were randomly examined at 50⫻ magni-
fication to evaluate the bond failure
mode, which was determined on the
basis of the Adhesive Remnant Index
(ARI) of Årtun and Bergland.9
Statistical methods
Descriptive statistics, including means,
standard deviations, and minimum and
maximum values, were calculated. Two-
way analysis of variance (ANOVA) was
used to determine any significant differ-
ences among the various groups. In case
of a significant difference, a pairwise
multiple comparison was performed by
one-way ANOVA, followed by the Student
Newman-Keuls test. The chi-square test
was used to determine significant differ-
ences in the ARI scores among the
groups. Significance for all statistical
tests was P ≤ .05.
125
 Vijayakumar et al WORLD JOURNAL OF ORTHODONTICS

Table 1 Mean (MPa), standard deviation (SD),

minimum, and maximum of shear bond strength of 30
the eight test groups. 27.8

24.9
Group Mean SD Minimum Maximum 25
21.3
A 18.1 4.1 10.8 26.4 20
18.1
A1 24.9 4.0 18.3 33.6 17.1
A2 21.3 3.7 14.3 29.1 15.0

MPa
15
A3 27.8 2.9 20.1 32.1 13.2
11.4
B 13.2 3.0 6.2 18.3
10
B1 15.0 2.7 10.0 20.6
B2 11.4 3.0 5.3 17.1
5
B3 17.1 4.1 10.1 25.2
See text for description of groups. 0
Group A Group A1 Group A2 Group A3 Group B Group B1 Group B2 Group B3

Fig 2 Mean shear bond strength of the various test groups.

Table 2 Result of the ANOVA followed Table 3 Distribution of the Adhesive

by the Student Newman-Keuls test on Remnant Index9 of the eight test groups
the significance of the mean shear
bond strengths (MPa) in the individual Score
test groups Group 0 1 2 3
Shear bond strength A 0 6 14 5
Group Mean SD P A1 0 0 11 14
A2 0 3 16 6
A 18.1c 4.1 < .001 A3 0 0 7 18
A1 24.9e 4.0 < .001 B 5 16 4 0
A2 21.3d 3.7 < .001 B1 1 11 12 1
A3 27.8f 2.9 < .001 B2 8 16 1 0
B 13.2ab 3.0 < .001 B3 0 7 14 4
B1 15.0b 2.7 < .001
See text for description of groups.
B2 11.4a 3.0 < .001
B3 17.1c 4.1 < .001
Different letters indicate significant differences between
groups. See text for description of groups.

RESULTS Group A3 (27.8 ± 2.9 MPa) had a sig-

Means and standard deviations of all
groups studied are given in Table 1 and
Fig 2. In general, all groups with
rebonded brackets demonstrated much
lower shear bond strengths. A booster
effect was apparent in only the new
brackets. As Table 2 shows, a significant
dif ference existed among all the A
groups, and between groups A and B, B1
and B2, and B3 and B.
nificantly higher bond strength than any
other group, followed by group A1 (24.9 ±
4.0 MPa) and group A2 (21.3 ± 3.7 MPa).
During rebonding, Ortho Solo improved
the bond strength significantly compared
to rebonding without adhesion booster.
Most of the failures in the B groups
occurred at the adhesive-bracket inter-
face, which indicates that more cleanup
of the bracket base is necessary before
rebonding (Table 3). The exception is
group B2, which showed more bond fail-
ures toward the enamel-resin interface.

126
VOLUME 11, NUMBER 2, 2010
DISCUSSION
Various compounds, including polyfunc-
tional surface-active amine accelerators,
have been recommended to promote
adhesion. These adhesion boosters sup-
posedly increase the bond strength by
interacting with surface metal ions and
by functioning as a polymerization accel-
erator for dental resins.10 Clark et al11
compared bonding with a composite and
an unfilled acrylic resin containing 5% of
the adhesion promoter 4-META. The latter
material achieved a significantly higher
bond strength through the 4-META, a bi-
functional monomer exhibiting a hydropho-
bic methacrylate group and a hydrophilic
aromatic anhydride group, which both
enhance diffusion into the tooth surface.
Bishara et al5 found that in general,
the highest shear bond strengths were
obtained after bonding new brackets.
Rebonded brackets showed significantly
lower and inconsistent values. This is con-
firmed by the present study. The changes
in bond strength may be related to
changes in the morphology of the etched
enamel surface as a result of remaining
adhesive.
Egan et al12 reported that the applica-
tion of Enhance LC on the base of
debonded brackets failed to improve
rebonding strength. Chung et al7 evalu-
ated the effects of Enhance LC and All-
Bond 2 on new and rebonded brackets.
Their results were that the new brack-
ets/All-Bond 2 group yielded the highest
strength (20.8 ± 7.5 MPa), followed by the
groups new brackets/Enhance LC (18.6 ±
6.5 MPa), rebonded brackets/All-Bond 2
(17.3 ± 7.2 MPa), new brackets/no
booster (16.8 ± 6.3 MPa), rebonded
brackets/no booster (14.2 ± 7.2 MPa),
and rebonded brackets/Enhance LC
(13.6 ± 6.7 MPa). These findings are simi-
lar to the results obtained in this study,
where All-Bond 2 and Enhance LC
improved the bond strength of new brack-
ets, but Enhance LC failed to show any
improvement in the case of rebonding.
The difference among the adhesion
boosters might be attributed to their
chemical compositions.
Newman et al13 reported that the bond
strength of sandblasted new brackets
Vijayakumar et al
was was greater when Megabond adhe-
sion booster was used.
Vicente et al14 showed that the appli-
cation of Or tho Solo significantly
increased the bond strength when used
with Transbond-XT; however, All-Bond 2
primer did not. In the present study, both
adhesion boosters increased the bond
strength significantly, which could be
ascribed to the Light Bond sealant/paste
adhesive system. Another advantage of
Ortho Solo is that it makes primer appli-
cation unnecessary and thereby reduces
chair time.
This in vitro study cannot truly reflect
the intraoral situation. Also, the universal
testing machine measured the pure
shear force; in the clinic, shear, tensile,
and torsional forces individually or in any
combination can lead to debonding. In
addition, the loading of the machine is
constant, whereas forces in vivo arise
abruptly and fluctuate. The results
reported here may therefore exaggerate
the effect of adhesion boosters on shear
bond strength of orthodontic brackets
bonded with composite resin.
Various studies have suggested that
clinical bond strengths ranging from 6 to
10 MPa are adequate.15–17 No reliable
protocol for measuring bond strength in
vivo has been described yet.18 The bond
strengths observed in vitro may be higher
than those experienced clinically.19 Still,
in vitro studies provide a guideline for the
selection of the optimal bracket-adhesive
system. The high shear bond strengths in
this study might also be a result of the
buccal tooth surface curvature, which
may have made it difficult for the opera-
tor to place the testing machine’s blade
precisely parallel to the bracket base.20
CONCLUSION
The six results of this study are:
1. The bond strength during initial bond-
ing was higher than during rebonding.
2. Adhesion boosters improve the initial
bond strength significantly. New brack-
ets/Ortho Solo had the highest bond
strength, followed by new brackets/All-
Bond 2, and new brackets/Enhance LC.
127
 Vijayakumar et al
3. During rebonding, Ortho Solo improved
the bond strength significantly.
4. All-Bond 2 and Enhance LC did not
improve the bond strength during
rebonding.
5. ARI scores revealed a significant dif-
ference in the site of the bond failure
among the groups. The cleanup proce-
dure after debonding was easier and
faster for group B2 (rebonded brack-
ets/Enhance LC), followed by group B
(rebonded brackets/no adhesion
booster), and B1 (rebonded brackets/
All-Bond 2).
6. Many factors that might affect intra-
oral bond strength are difficult to
reproduce in the laboratory. Hence, in
vitro studies give only a hint about the
optimal bonding procedure.
ACKNOWLEDGMENTS
The authors wish to express their gratitude to Dr
M.K. Anand from the Department of Orthodontics
for his valuable comments. They also thank Mr
Ravanan from the Department of Statistics, Presi-
dency College, Chennai, India, for his statistical
assistance, as well as Mr Ashok for his technical
assistance, Mr Rajendran for his photographs, and
Mr Karthikeyan of Central Institute of Plastic Engi-
neering and Technology, Chennai, India, for his help
in testing the bond strength.
The authors do not have any commercial inter-
est in any of the products used in the study.
REFERENCES
1. O’Brien KD, Read MJ, Sandison RJ, Roberts CT.
A visible light-activated direct-bonding material:
An in vivo comparative study. Am J Orthod
Dentofacial Orthop 1989;95:348–351.
2. Underwood ML, Rawls HR, Zimmerman BF.
Clinical evaluation of a fluoride-exchanging
resin as an orthodontic adhesive. Am J Orthod
Dentofacial Orthop 1989;96:93–99. 
3. Koo BC, Chung CH, Vanarsdall RL. Comparison
of the accuracy of bracket placement between
direct and indirect bonding techniques. Am J
Orthod Dentofacial Orthop 1999;116:346–351. 
4. Mizrahi E. Success and failure of banding and
bonding. A clinical study. Angle Orthod 1982;
52:113–117. 
128
WORLD JOURNAL OF ORTHODONTICS
5. Bishara SE, VonWald L, Laffoon JF, Warren JJ.
The effect of repeated bonding on the shear
bond strength of a composite resin orthodontic
adhesive. Angle Orthod 2000;70:435–441. 
6. Jedrychowski JR, Caputo AA, Foliart R. Effects
of adhesion promoters on resin-enamel reten-
tion. J Dent Res 1979;58:1371–1376.
7. Chung CH, Fadem BW, Levitt HL, Mante FK.
Effects of two adhesion boosters on the shear
bond strength of new and rebonded orthodon-
tic brackets. Am J Orthod Dentofacial Orthop
2000;118:295–299. 
8. Mui B, Rossouw PE, Kulkarni GV. Optimization of
a procedure for rebonding dislodged orthodontic
brackets. Angle Orthod 1999;69:276–281.
9. Årtun J, Bergland S. Clinical trials with crystal
growth conditioning as an alternative to acid-
etch enamel pretreatment. Am J Orthod 1984;
85:333–340.
10. Antonucci JM, Bowen RL. Adhesive bonding of
various materials to hard tooth tissues: XIII Syn-
thesis of a polyfunctional surface-active amine
accelerator. J Dent Res 1977;56:937–942.
11. Clark SA, Gordon PH, McCabe JF. An ex vivo
investigation to compare orthodontic bonding
using a 4-META-based adhesive or a composite
adhesive to acid-etched and sandblasted
enamel. J Orthod 2003;30:51–58.
12. Egan FR, Alexander SA, Cartwright GE. Bond
strength of rebonded orthodontic brackets. Am
J Orthod Dentofacial Orthop 1996;109:64–70. 
13. Newman GV, Newman RA, Sun BI, Ha JLJ,
Ozsoylu SA. Adhesion promoters, their effect on
the bond strength of metal brackets. Am J
Orthod Dentofacial Orthop 1995;108:237–241.
14. Vicente A, Bravo LA, Romero M, Ortíz AJ, Can-
teras M. Effects of 3 adhesion promoters on
the shear bond strength of orthodontic brack-
ets: An in-vitro study. Am J Orthod Dentofacial
Orthop 2006;129:390–395. 
15. Reynolds IR. A review of direct orthodontic
bonding. Br J Orthod 1975;2:171–178. 
16. Keizer S, ten Cate JM, Arends J. Direct bonding
of orthodontic brackets. Am J Orthod 1976;69:
318–327. 
17. Akin-Nergiz N, Nergiz I, Behlfelt K, Platzer U.
Shear bond strength of a new polycarbonate
bracket—An in vitro study with 14 adhesives.
Eur J Orthod 1996;18:295–301.
18. Eliades T, Brantley WA. The inappropriateness of
conventional orthodontic bond strength assess-
ment protocols. Eur J Orthod 2000;22:13–23.
19. Pickett KL, Sadowsky PL, Jacobson A, Lacefield
W. Orthodontic in vivo bond strength: Compari-
son with in vitro results. Angle Orthod 2001;71:
141–148. 
20. Chung CH, Cuozzo PT, Mante FK. Shear bond
strength of a resin-reinforced glass inomer
cement: An in vitro comparative study. Am
J Orthod Dentofacial Orthop 1999;115:52–54.
Tancan Uysal, DDS, PhD1
AMORPHOUS CALCIUM PHOSPHATE–
Esra Yilmaz, DDS2
CONTAINING ORTHODONTIC CEMENT
Sabri Ilhan Ramoglu, DDS,
PhD3 FOR BAND FIXATION: AN IN VITRO STUDY
Aim: To evaluate the shear bond strength (SBS) and fracture mode of
amorphous calcium phosphate (ACP)–containing and conventional
glass-ionomer cement (GIC) for band fixation. Methods: Sixty
extracted human third molars were embedded in acrylic resin blocks,
leaving the buccal surface of the crowns parallel to the base of the
molds. The teeth were randomly divided into two groups containing
30 teeth each. GIC (group 1, Ketac-Cem) or ACP-containing orthodon-
tic cement (group 2, Aegis-Ortho) was applied onto microetched strip
band material (4.0 ⫻ 3.8 mm), which was then attached to the tooth
surfaces. With a universal testing machine, each cemented band strip
was shear mode loaded until failure. Thereafter, all teeth and band
strips were examined under 10⫻ magnification. The remaining
cement was assessed with a modified Adhesive Remnant Index (ARI).
The SBS data were analyzed using the t test and the fracture modes
by the chi-square test. Results: There was no significant difference
between the bond strength of group 1 (GIC, mean: 28.9 ± 15.2 MPa)
and group 2 (ACP-containing cement, mean: 26.3 ± 11.8 MPa). The
fracture modes differed significantly between the two groups (P < .01).
Conclusion: Both groups had a similar level of SBS. The fracture sites
of the ACP-containing cement were predominantly in the enamel-
cement interface. World J Orthod 2010;11:129–134.

Key words: bond strength, amorphous calcium phosphate, glass-

ionomer cement, shear bond strength, band cementation

1Associate Professor and Chair,

Department of Orthodontics, Faculty
of Dentistry, Erciyes University,
Kayseri, Turkey.
2 Research Assistant, Department of
Orthodontics, Faculty of Dentistry,
Erciyes University, Kayseri, Turkey.
3Assistant Professor, Department of
Orthodontics, Faculty of Dentistry,
Erciyes University, Kayseri, Turkey.
CORRESPONDENCE
Dr Tancan Uysal
Erciyes Universitesi
Dis Hekimligi Fak. Ortodonti AD
Melikgazi, Kayseri
Turkey 38039
Email: tancanuysal@yahoo.com
lthough bonding of brackets using
A composite resin and acid-etching
techniques have become common prac-
tice, orthodontic bands continue to be
used (particularly on molars)1 due to the
high failure rates of bonded molar
tubes,2 especially when devices such as
headgear are used.
Initial caries results from decalcifica-
tion of the enamel surface or subsur-
face, which is also referred to as white
spot formations or lesions. This kind of
initial caries commonly corresponds with
the use of bonded brackets and
cemented bands.3–5 Because they are
positioned posteriorly in the mouth,
teeth with bands are more difficult to
clean, which results in a greater accu-
mulation of plaque. 5 Gillgrass et al 6
reported that microleakage between
cement and enamel can lead to micro-
bial ingress and consequently enamel
demineralization beneath bands. There-
fore, orthodontic bands are believed to
cause more enamel demineralization
than brackets.5

129
 Uysal et al
To prevent white spot lesions, research
has focused largely on fluoride interven-
tion. The anticariogenic and remineraliz-
ing effects of a long-lasting fluoride
release from conventional glass-ionomer
cements (GICs) are well-accepted. There
are also indications that resin-modified
glass-ionomer cements have a similar
effect.7 However, these cements do not
prevent enamel demineralization if bands
are loose or if the cement has been
removed.8
Schumacher et al9 developed biologi-
cally active restorative materials that may
stimulate the repair of tooth structure
through the release of various materials
including calcium and phosphate. Amor-
phous calcium phosphate (ACP) is a
bioactive filler that can be encapsulated
in a polymer base.10–12 In response to
changes in the oral environment caused
by bacterial plaque or acidic food, calcium
and phosphate ions will be released from
such composites and be deposited into
the enamel as an apatite, which is similar
to the naturally existing hydroxyapatite.13
ACP has the properties of both a pre-
ventive and restorative material, which
justifies its use as a sealant, composite,
and more recently as a cement for not
only general dental purposes but also for
orthodontic band cementation. ACP-filled
composites have been shown to recover
71% of the lost mineral content of decal-
cified enamel. 13 One ACP-containing
cement is Aegis-Ortho (Bosworth), which
is light-curing and boosts the formation
of hydroxyapatite.14 This advantage can
be maintained for a considerable time,
thus preventing future white spots.15
Recent studies demonstrated the rem-
ineralization potential 11,13,16 and bond
strengths of ACP-containing materi-
als,7,15,17 but no study has investigated
their strength for cementation of ortho-
dontic bands.
The aim of this in vitro study was to
compare the shear bond strength (SBS)
and fracture mode of a commercially
available orthodontic cement containing
ACP with a conventional GIC. The null
hypothesis was that there are no signifi-
cant differences in (1) bond strength and
(2) fracture mode between these two
materials.
130
WORLD JOURNAL OF ORTHODONTICS
METHODS AND MATERIALS
Sample preparation
Sixty extracted human mandibular third
molars were stored in distilled water in a
refrigerator following decontamination in
0.5% chloramine before being embedded
in acrylic resin blocks with the buccal sur-
faces of the crowns parallel to the base of
into two groups, each containing 30 teeth.
To standardize specimen preparation, only
one operator (E.Y.) performed band mate-
rial preparation and cementation.
GIC (Ketac-Cem, 3M ESPE) or ACP-con-
taining orthodontic cement (Aegis Ortho)
were applied to the microetched strip
band material, which was cut to the
dimension of 4.0 ⫻ 3.8 mm. These strips
were attached to tooth surfaces accord-
ing to the procedures described below.
Group 1. Powder and liquid Ketac-
Cem were mixed and applied directly to
the surface of each material strip. Follow-
ing placement, excess cement was
removed with a scaler and the material
was allowed to bench cure for 5 minutes.
Group 2. The tooth surface was cov-
ered with a thin layer of Aegis Ortho. A
similar amount was applied to the
microetched band material, which was
immediately pressed onto the cement on
the tooth surface. Following the manufac-
turer’s recommendation, excess cement
was not removed. A quartz tungsten halo-
gen light unit (Hilux 350, Express Dental
Products) with a 10.0-mm-diameter light
tip was used for curing the specimens for
40 seconds.
Prior to measuring the shear debond-
ing force, all specimens were placed in
distilled water for 24 hours.
Debonding procedure
The embedded specimens were secured
in a jig attached to the base plate of a
universal testing machine (Hounsfield
Test Equipment, Salfords). A chisel-edge
plunger was mounted onto the movable
crosshead of the testing machine and
positioned so that the leading edge was
aimed at the enamel-cement interface.
The crosshead moved with a speed of
VOLUME 11, NUMBER 2, 2010 Uysal et al

Table 1 Descriptive statistics and results of the t test comparing bond strength of the
two cement groups tested
Bond strength (MPa)
Group Mean SD SE Minimum Maximum Significance

GIC 28.9 15.2 3.4 6.6 59.2

NS (P = .29)
ACP-containing cement 26.3 11.8 3.1 14.6 58.4

SD = standard deviation, SE = standard error, NS = not significant.

Table 2 Failure mode after shear bond testing

ARI scores
Group 0 1 2 3 Significance

GIC 0 (0%) 0 (0%) 7 (35%) 13 (65%)

(P < .01)
ACP-containing cement 12 (60%) 4 (20%) 4 (20%) 0 (0%)
ARI = Adhesive Remnant Index. See text for description of ARI scores.

0.5 mm/min. The maximum load neces- Statistical methods

sary to detach the band material was
recorded in Newtons (N), and the SBS
(1 MPa= 1 N/mm 2) was calculated by
dividing the force by the band base area
(15.20 mm2).
Residual adhesive
After band failure the breakage site was
assessed at 10⫻ magnification. The
remaining cement on the tooth surface
was assessed visually by one operator
(T.U.) and rated according to a modifica-
tion 18 of the adhesive remnant index
(ARI) of Årtun and Bergland19 as follows:
0 = no cement on the tooth surface
1 = less than half of the tooth surface
under the band material covered by
cement
2 = more than half the tooth surface
under the band material covered by
cement
3 = the entire tooth surface under the
band material covered by cement
All statistical analyses were performed
with SPSS 13.0 software (SPSS). Descrip-
tive statistics, including mean, standard
deviation, standard error, and minimum
and maximum values, were calculated
for both groups. The Shapiro-Wilk nor-
mality test and the Levene variance
homogeneity test were used to analyze
the SBS data, which showed a normal
distribution and homogeneity of vari-
ance. The Student t test for two indepen-
dent variables was used to compare the
SBSs of the two tested materials. Frac-
ture modes were analyzed using the
Pearson chi-square test. Significance
was predetermined at P < .05.
RESULTS
The descriptive statistics for each group
are presented in Table 1. The mean bond
strengths of group 1 and group 2 were
28.9 ± 15.2 MPa and 26.3 ± 11.8 MPa,
respectively. According to the Student
t test, this difference is not significant.
Thus, the first null hypothesis could be
accepted.
The fracture mode of the specimens
is shown in Table 2. In group 1, a greater
percentage of fractures were at the
band-cement interface (score 3 = 65%),

131
 Uysal et al
whereas in group 2, most of the failures
occurred at the cement-enamel interface
(score 0 = 60%). This difference was sig-
nificant (P < .01) and is why the second
null hypothesis was rejected.
DISCUSSION
Various new products, including those for
band cementation, have been assessed
in different clinical and laboratory stud-
ies.8,18,20–27 Most of the laboratory stud-
ies with various or thodontic band
cements indicated a significantly differ-
ent shear/peel strength and site of bond
failure.18,20,22,23 In two clinical investiga-
tions, Fricker24 compared modified light-
activated cement for orthodontic bands
over a 12-month period, whereas in the
Millett et al25 investigation, the observa-
tion lasted 5 years.
Several authors tested materials to
prevent demineralizations under ortho-
dontic bands. Foley et al26 compared three
band cements and suggested the use of
fluoride-releasing materials. Millett et al27
investigated chlorhexidine-modified GIC
for band cementation to minimize plaque
accumulation and subsequent develop-
ment of generalized gingival hyperplasia
and enamel demineralization. They sug-
gested that this modified material may
perform clinically similar to standard GIC.
However, ACP-containing cement, which
has a positive effect against demineraliza-
tion, was never before tested for orthodon-
tic bands.
The introduction of ACP in dentistry
allows reversing enamel demineraliza-
tion. Only a few articles have investigated
the incorporation of calcium phosphates
into orthodontic composites. Sudjalim et
al28 evaluated the effects of sodium fluo-
ride (NaF) and 10% casein phosphopep-
tide-amorphous calcium phosphate
(CPP-ACP) on enamel demineralization
adjacent to orthodontic brackets. He
found that the addition of CPP-ACP, NaF,
or CPP-ACP/NaF significantly prevented
enamel demineralization when used for
bonding. Foster et al15 and Dunn17 com-
pared the SBS of metallic orthodontic
brackets bonded to enamel using ACP-
containing cement to that of brackets
132
WORLD JOURNAL OF ORTHODONTICS
bonded with a conventional orthodontic
composite and found a lower but accept-
able bond strength value for the former.
Similar to earlier laboratory investiga-
tions, conventional GIC Ketac-Cem was
used as the control in this study. Ketac-
Cem is a second-generation water-hard-
ening cement whose polyacid is a
copolymer of acrylic and maleic acid
freeze-dried into the powder. The glass
ionomer is formed by an acid-base set-
ting reaction between aluminosilicate
glass and the polyacid.
In the present study, microetched
standard strip band material was
employed to simulate contemporary clini-
cal practice. Microetching has been
shown to improve bond strength20,21 and
thus reduce clinical band failure rates.29
The 30 teeth used per cement group
have been recommended as optimal for
studies of this nature.30 Also, specimen
storage before testing complied with the
guidelines in the or thodontic litera-
ture.21,29,30,31 In one study, acrylic blocks
rather than teeth were used, to which
6.0 ⫻ 6.0 mm strips of stainless steel
band were attached with a cyanoacrylate
adhesive, but only 10 specimens were
bonded with each cement type.21
Williams et al23 indicated that when
using third molars to investigate band
strength in vitro, it is likely that the cement
thickness varies considerably for each
individual tooth. They further emphasized
that not only the film thickness but also
the film uniformity is important. Thus, to
test the pure SBS and failure characteris-
tics, standard strip material was adapted
to every tooth surface in this study.
In the present investigation, the mean
SBS of GIC and ACP-containing cement
were 28.9 ± 15.2 MPa and 26.3 ± 11.8
MPa, respectively. Millett and McCabe32
reported that in vitro GIC studies typically
show large standard deviations in bond
strength values that may create concern
over the reliability of both the test system
and the bond strength achieved. These
high ranges can also be seen in the cur-
rent study. They suggest that the manipu-
lation of GICs is technique-sensitive. It
should be noted that this range was lower
for the ACP-containing cement (14.6 to
58.4 MPa) than that of the standard GIC
VOLUME 11, NUMBER 2, 2010
(6.6 to 59.2 MPa). This might be due to
its inferior bond strength and standard
deviation (Table 1). The lower standard
deviation indicates, though, that the ACP-
containing cement produces a relative
consistent bond.
A minimum bond strength of 5.9 to
7.8 MPa has been suggested as ade-
quate for most clinical purposes in ortho-
dontics.33 On this basis, Ketac-Cem and
Aegis Ortho can be expected to perform
clinically adequate. However, bands on
molars are likely to be subjected to
greater shear forces than attachments
bonded to teeth more anteriorly in the
mouth. 2 Moreover, clinical conditions
may significantly differ from an in vitro
setting,34 as there are stress, tempera-
ture fluctuations, variable electrolytes,
microorganisms, and other factors.
In the ACP-containing cement speci-
mens of this study, failure occurred pre-
dominantly (60%) at the enamel-cement
interface. For the remaining specimens,
less than half of the surface under the
strip material was covered with cement.
This concurs with the results of previous
research in which microetched bands
were used. 29 With Ketac-Cem, most
(65%) samples had a remnant score of
3, indicating that the entire tooth surface
under the band material was covered by
cement. These findings are not con-
firmed by a previous study in which these
cements were also used.29 Although the
percentage of GIC remaining on the band
after debanding has been recorded in a
previous publication,18 this study did not
utilize strip band material, which is why
the results cannot be compared objec-
tively with those of the present study. On
the basis of this study’s findings,
cleanup af ter debanding might be
slightly faster if bands are cemented with
ACP-containing cement rather than con-
ventional GIC.
Uysal et al
CONCLUSION
From the results of this study, the follow-
ing conclusions can be drawn:
The mean SBS of standard strip molar
band material with microetched surfaces
cemented with ACP-containing cement
did not differ significantly from conven-
tional GIC.
The amount of GIC cement remaining
on the tooth after removal was signifi-
cantly larger than that of ACP-containing
cement.
REFERENCES
1. Keim RG, Gottlieb EL, Nelson AH, Vogels DS
3rd. 2002 JCO study of orthodontic diagnosis
and treatment procedures. Part 1. Results and
trends. J Clin Orthod 2002;36:553–568.
2. Millett DT, Hallgren A, Fornell AC, Robertson M.
Bonded molar tubes: A retrospective evaluation
of clinical performance. Am J Orthod Dentofa-
cial Orthop 1999;115:667–674.
3. Gorelick L, Geiger AM, Gwinnett AJ. Incidence
of white spot formation after bonding and
banding. Am J Orthod 1982;81:93–98.
4. Mizrahi E. Surface distribution of enamel opaci-
ties following orthodontic treatment. Am J
Orthod 1983;84:323–331.
5. Ogaard B, Rølla G, Arends J. Orthodontic appli-
ances and enamel demineralization. Part 1.
Lesion development. Am J Orthod Dentofacial
Orthop 1988;94:68–73.
6. Gillgrass TJ, Millett DT, Creanor SL, et al. Fluo-
ride release, microbial inhibition and micro-
leakage pattern of two orthodontic band
cements. J Dent 1999;27:455–461.
7. Uysal T, Ulker M, Akdogan G, Ramoglu SI, Yil-
maz E. Bond strength of amorphous calcium
phosphate–containing orthodontic composite
used as a lingual retainer adhesive. Angle
Orthod 2009;79:117–121.
8. Rezk-Lega F, Ogaard B, Arends J. An in vivo
study on the merits of two glass ionomers for
the cementation of orthodontic bands. Am J
Orthod Dentofacial Orthop 1991;99:162–167.
9. Schumacher GE, Antonucci JM, O’Donnell JNR,
Skrtic D. The use of amorphous calcium phos-
phate composites as bioactive basing materials:
Their effect on the strength of the composite/
adhesive/dentin bond. J Am Dent Assoc 2007;
138:1476–1484.
10. Skrtic D, Antonucci JM, Eanes ED. Amorphous
calcium phosphate-based bioactive polymeric
composites for mineralized tissue regeneration.
J Res Natl Inst Stands Technol 2003;108:
167–182.
133
 Uysal et al
11. Skrtic D, Antonucci JM, Eanes ED, Eidelman N.
Dental composites based on hybrid and sur-
face-modified amorphous calcium phosphates.
Biomaterials 2004;25:1141–1150.
12. Antonucci JM, Skrtic D. Matrix resin effects on
selected physicochemical properties of amor-
phous calcium phosphate composites. J Bioact
Comp Polym 2005;20:29–49.
13. Skrtic D, Hailer AW, Takagi S, Antonucci JM,
Eanes ED. Quantitative assessment of the effi-
cacy of amorphous calcium phosphate/
methacrylate composites in remineralizing
caries-like lesions artificially produced in bovine
enamel. J Dent Res 1996;75: 1679–1686.
14. Skrtic D, Antonucci JM, McDonough WG, Lui
DW. Effect of chemical structure and composi-
tion of the resin phase on mechanical strength
and vinyl conversion of amorphous calcium
phosphate-based composites. J Biomed Mater
Res A 2004;68:763–772.
15. Foster JA, Berzins DW, Bradley TG. Bond
strength of a calcium phosphate-containing
orthodontic adhesive. Angle Orthod 2008;78:
339–344.
16. Antonucci JM, Skrtic D, Eanes ED. Remineraliz-
ing dental composites based on amorphous
calcium phosphate. Polymer Prepr 1995;36:
779–780.
17. Dunn WJ. Shear bond strength of an amor-
phous calcium-phosphate-containing orthodon-
tic resin cement. Am J Orthod Dentofacial
Orthop 2007;131:243–247.
18. Millett DT, Duff S, Morrison L, Cummings A,
Gilmour WH. In vitro comparison of orthodontic
band cements. Am J Orthod Dentofacial Orthop
2003;123:15–20.
19. Årtun J, Bergland S. Clinical trials with crystal
growth conditioning as an alternative to acid-
etch enamel pretreatment. Am J Orthod 1984;
85:333–340.
20. Mennemeyer VA, Neuman P, Powers JM. Bond-
ing of hybrid ionomers and resin cements to
modified orthodontic band materials. Am J
Orthod Dentofacial Orthop 1999;115:143–147.
21. Aggarwal M, Foley TF, Rix D. A comparison of
shear-peel band strengths of 5 orthodontic
cements. Angle Orthod 2000;70:308–316.
22. Millett DT, Cummings A, Letters S, Roger E,
Love J. Resin-modified glass ionomer, modified
composite or conventional glass ionomer for
band cementation?—An in vitro evaluation.
Eur J Orthod 2003;25:609–614.
134
WORLD JOURNAL OF ORTHODONTICS
23. Williams PH, Sherriff M, Ireland AJ. An investi-
gation into the use of two polyacid-modified
composite resins (compomers) and a resin-
modified glass poly(alkenoate) cement used to
retain orthodontic bands. Eur J Orthod 2005;
27:245–251.
24. Fricker JP. A 12-month clinical comparison of
resin-modified light-activated adhesives for the
cementation of orthodontic molar bands. Am J
Orthod Dentofacial Orthop 1997;112:239–243.
25. Millett DT, Hallgren A, Cattanach D, et al. A 5-
year clinical review of bond failure with a light-
cured resin adhesive. Angle Orthod 1998;68:
351–356.
26. Foley T, Aggarwal M, Hatibovic-Kofman S. A
comparison of in vitro enamel demineralization
potential of 3 orthodontic cements. Am J Orthod
Dentofacial Orthop 2002;121:526–530.
27. Millett DT, Doubleday B, Alatsaris M, et al.
Chlorhexidine-modified glass ionomer for band
cementation? An in vitro study. J Orthod 2005;
32:36–42.
28. Sudjalim TR, Woods MG, Manton DJ, Reynolds
EC. Prevention of demineralization around
orthodontic brackets in vitro. Am J Orthod
Dentofacial Orthop 2007;131:705.e1–9.
29. Millett DT, McCabe JF, Bennett TG, Carter NE,
Gordon PH. The effect of sandblasting on the
retention of first molar orthodontic bands
cemented with glass ionomer cement. Br J
Orthod 1995;22:161–169.
30. Fox NA, McCabe JF, Buckley JG. A critique of
bond strength testing in orthodontics. Br J
Orthod 1994;21:33–43.
31. Millett DT, Kamahli K, McColl J. Comparative
laboratory investigation of dual-cured vs. con-
ventional glass ionomer cements for band
cementation. Angle Orthod 1998;68:345–350.
32. Millett DT, McCabe JF. Orthodontic bonding
with glass ionomer cement—A review. Eur J
Orthod 1996;18:385–399.
33. Reynolds IR. A review of direct orthodontic
bonding. Br J Orthod 1975;2:171–178.
34. Swartz ML. Limitations of in vitro orthodontic
bond strength testing. J Clin Orthod 2007;41:
207–210.
Jossette Vo, DMD1
A CLINICAL TRIAL TO EVALUATE THE
Dipak N. Chudasama, BDS,
MSc, MOrth RCS, MBA2 EFFECTS OF PROPHYLACTIC FLUORIDE
Donald J. Rinchuse, DMD, AGENTS ON THE SUPERELASTIC
MS, MDS, PhD3

Richard Day, PhD4

PROPERTIES OF NICKEL-TITANIUM WIRES
Aim: To study the effects of a prophylactic fluoride regimen on the
mechanical properties of nickel-titanium (Ni-Ti) archwires under clini-
cal conditions. Method: The unloading properties of 100 Ni-Ti wires
were tested using a three-point bending test at five deflections (0.5
mm, 1.0 mm, 2.0 mm. 3.0 mm, and 3.1 mm). Sixty-six 0.016 ⫻ 0.022-
inch Ni-Ti wires were tested after being used intraorally for 6 weeks
using two protocols. Thirty-three wires were evaluated after the use
of fluoride-containing Crest toothpaste (sodium fluoride 0.243%,
0.15% w/v fluoride ion) and Equate fluoride rinse (sodium fluoride
0.05%, fluoride ion 0.0226%). Another 33 wires were examined after a
nonfluoridated natural toothpaste (Tom’s of Maine; calcium carbon-
ate, xylitol, myrrh, propolis, sodium lauryl sulfate, carrageenan,
spearmint and peppermint oils, glycerin, and water) was used.
Another 34 Ni-Ti wires served as a control; they were tested as
received. Statistical analyses were carried out with a linear-mixed
model (analysis of variance [ANOVA]). Results: Force degradation
occurred within both groups of intraorally used wires but not in the
unused archwires. When compared to unexposed wires, those with
fluoride exposure exhibited slightly higher force degradation at 3.1
and 3.0 mm deflection, but they displayed less force degradation at
0.5 and 1.0 mm deflection. Conclusions: Topical fluoride regimens
decreased the unloading property of Ni-Ti wires at higher deflections
but increased it at lower deflections. World J Orthod 2010;11:135–141.

Key words: fluoride, nickel-titanium wires

1Private Practice, Jacksonville,

Florida, USA.
2Assistant Professor, School of Ortho-
dontics, Jacksonville University,
Jacksonville, Florida, USA.
3Professor and Associate Director,
Seton Hill University Graduate Pro-
gram in Orthodontics, Greensburg,
Pennsylvania, USA.
4Associate Professor, Biostatistics,
School of Public Health, University of
Pittsburgh, Pittsburgh, Pennsylvania,
USA.
CORRESPONDENCE
Dr Donald J. Rinchuse
510 Pellis Road
Greensburg, PA 15601
Email: rinchuse@setonhill.edu
ome of the greatest developments in
S orthodontics can arguably be seen in
straightwire and preadjusted appliances,
bonding, and highly resilient wires. The
efficacy of self-ligating brackets is con-
troversial, and more evidence is needed
to make a final determination.1–4 Cer-
tainly, superelastic titanium wires have
made orthodontic treatments faster and
more efficient than traditional wires.
Understanding and evaluating the proper-
ties of wires is important when orthodon-
tists have to select the most appropriate
archwire for a given clinical situation.5–8
The most popular wires include stainless
steel, nickel-titanium (Ni-Ti), copper nickel-
titanium (CuNi-Ti), and beta titanium.
Archwire properties can be affected by
various functional and oral environmental
factors. These include (but are not lim-
ited to) masticatory forces, type of food
ingested, intraoral pH, and, for the pur-
pose of this study, fluoride.
Ni-Ti wires are able to deliver a con-
stant force because of their superelasticity
and shape memory.9 The transformation
of the crystal structure from austenite to
martensite (ie, the passage from a cubic

135
 Vo et al
lattice structure through a rhomboidal
phase to a hexagonal close-packed lattice
structure), due to a temperature change
or the application or removal of stress,
accounts for these characteristics. 8,10
When the wire is unloaded and deacti-
vated, it transforms back to its original
austenitic structure. This reversion gener-
ates force and therefore orthodontic tooth
movement.9–12
Ni-Ti alloys are generally resistant to
corrosion due to the formation of a thin
oxide layer through passivation. 13,14
Nonetheless, it has been reported that
this layer can be chemically disrupted by
various entities (including chloride, artifi-
cial saliva, sliding friction, and fluoride),
leading to an increased risk of
corrosion.9,11,15–20 The effects of many of
these entities on both tensile strength
and microhardness have been addressed
in a study by Asgharnia and Brantley.21
Orthodontists routinely use systemic
and topical fluorides as a proactive, sup-
portive adjunct to improve patients’ oral
health. However, fluoride agents can
cause both Ni-Ti and CuNi-Ti wires to dis-
color and corrode.9 They can also affect
the mechanical properties of Ni-Ti, though
not of CuNi-Ti wires. This was shown by
Walker et al9, who placed 10 Ni-Ti and
10 CuNi-Ti wires in a bath containing 2 mL
each of Phos-fur gel (Colgate), Prevident
solution (equivalent to 3 months of 1-
minute application per day), and distilled,
deionized water for 1.5 hours at 37°C.
Because fluoride does not affect the
mechanical properties of CuNi-Ti, even
though it changes their surface configu-
ration, it is assumed that there is no
direct link between such changes and
any mechanical properties. 9 Nonethe-
less, the corrosive effect of fluoride is
believed to cause a loss of the protective
oxide film exposing the underlying tita-
nium alloy to hydrogen absorption and
embrittlement (ie, oxidative reduction).
Titanium and hydrogen have a high
binding affinity and form titanium hydride,
which degrades the alloy’s mechanical
properties by way of a body-centered
tetragonal structure.9 The copper compo-
nent of CuNi-Ti wires apparently protects
the alloy against subsequent hydrogen
penetration.9 At least in vitro, fluoride gels
136
WORLD JOURNAL OF ORTHODONTICS
can negatively affect the unloading of
Ni-Ti wires, which could contribute to less
efficient, prolonged orthodontic tooth
movements. Parenthetically, Walker et
al22 recently also demonstrated a nega-
tive effect of fluoride on stainless steel
and beta titanium wires in vitro.
There are many reports that have eval-
uated the mechanical properties of super-
elastic titanium archwires. 7,8,10–12,21,23
However, there are no in vivo studies that
have quantified the effect of fluoride
agents on such wires. Thus, the purpose
of this investigation was to evaluate this
effect on the unloading properties of Ni-Ti
archwires.
METHODS AND MATERIALS
Seventeen patients undergoing ortho-
dontic treatment (aged 11 to 30 years) at
the School of Or thodontics at Jack-
sonville University participated in this
prospective clinical trial after approval
from the university’s Institutional Review
Board. The ethical dilemma the study
faced was the cessation of fluoride appli-
cation in all patients for 6 weeks. Hence,
excellent oral hygiene was a requirement
for participation.
For leveling and aligning, the patients
initially received a 0.018-inch Ni-Ti arch-
wire (G & H Wire) for 6 weeks. These wires
were not used in this study. The logic to
use them before 0.016 ⫻ 0.022-inch Ni-Ti
test wires were placed was to minimize
any adverse effect on the properties of
these wires due to too great an initial
stress. The composition of the Ni-Ti wires
of this study was 50% titanium, 49%
nickel, and 1% other metals. The reasons
for choosing 0.016 ⫻ 0.022-inch wires
were that they are intermediate archwires
between the initial flexible and the stiff
finishing stainless steel wires and that
this is a commonly used size.
After the wires were inserted, a 6-week
fluoride regimen was initiated. The
respective agents were Crest anticavity
fluoride toothpaste (Procter & Gamble;
sodium fluoride 0.243%, 0.15% w/v fluo-
ride ion) and Equate fluoride rinse (Wal-
mart; sodium fluoride 0.05%, fluoride ion
0.0226%). These products were chosen
VOLUME 11, NUMBER 2, 2010
because they are popular, readily avail-
able, inexpensive, and often prescribed.
All patients were instructed to use them
to the manufacturer’s instructions—brush
and rinse twice daily. Patients were fur-
ther informed that it was extremely
important to follow these instructions; at
each appointment, they were queried to
ensure maximum cooperation. After 6
weeks, 33 wires (17 maxillary and 16 man-
dibular) were removed and lab tested; one
wire was accidentally cut too short prior to
testing.
New 0.016 ⫻ 0.022-inch Ni-Ti arch-
wires were placed in the same individuals
for an additional 6 weeks. All patients
were then instructed to use a nonfluori-
dated toothpaste (Tom’s of Maine natural
toothpaste; calcium carbonate, xylitol,
myrrh, propolis, sodium lauryl sulfate, car-
rageenan, spearmint and peppermint oils,
glycerin, and water). The common proto-
col was to brush twice a day with this
toothpaste and rinse twice daily with tap
water. To match the number of the first
trial, one wire was discarded so that 33
wires remained for lab testing.
Thirty-four unused archwires (17 maxil-
lary and 17 mandibular) of the same
dimension served as controls (in vitro
study). No attempt was made to control
background fluoride (fluoride from food
or drinks) during this study. Because the
same 17 individuals were employed for
both study phases, the very same back-
ground fluoride was assumed to be pre-
sent during both test phases. In addition,
the wires were not separated into maxil-
lary or mandibular ones. All wires were
chosen randomly from the same batch.
Lab tests
Mechanical testing was based on the
American National Standard/American
Dental Association Specification no. 32
(Orthodontic Wires; American Dental
Association, 2000). As per the Walker et
al study,9 all specimens were tested with
a three-point bending test on an univer-
sal testing machine (serial number
32168, MTS Insight 1 Material Testing
System) in a water bath at 37°C. This
testing was performed over the wide
Vo et al
(0.022-inch) and small (0.016-inch) side
of the wires. The configuration of the
three-point fixture was a support span of
12 mm each—a 0.05- to 0.130-mm radii
and a striker. Each specimen was
deflected up to 3.1 mm and then
unloaded to zero deflection at a
crosshead speed of 1 mm/min. Force, in
Newtons (N), and deflection, in millime-
ters (mm), were collected every 100 ms
for both loading and unloading by using
Testwork 4.9 software, which also gener-
ated respective load-deflection curves.
After the testing machine was calibrated,
each wire was loaded onto the brass fix-
tures under the load cell and its chisel
was manually positioned as close to the
wire as possible without contacting it. Data
for all wires were generated at 0.5 mm,
1.0 mm, 2.0 mm 3.0 mm, and 3.1 mm
extensions.
STATISTICAL METHODS
A total of 100 wires were tested (34 con-
trols, 66 test wires [33 each with and
without fluoride exposure]). All analyses
were carried out using analysis of vari-
ance (ANOVA). Within the experiment,
modality (fluoride/no fluoride exposure)
and deflection (0.5 mm, 1.0 mm, 2.0 mm,
3.0 mm, and 3.1 mm) were treated as
repeated measures. Fluoride exposed,
fluoride not exposed, and control wires
were treated as independent groups. For
repeated measures analyses, compound
symmetry was specified for the residual
covariance structure. This decision was
made on the basis of a visual inspection
of the residual covariance matrix and the
results from several commonly used
goodness-of-fit tests (for example, –2 log
likelihood and Akaike information criterion).
RESULTS
Table 1 summarizes the means, standard
deviations, and medians of the observed
load at the five deflections for the two
wire diameters and all three wires. The
null hypothesis that intraoral use had no
effect on the mechanical properties of
these Ni-Ti wires was rejected. The control
137
 Vo et al WORLD JOURNAL OF ORTHODONTICS

Table 1 Means, standard deviations (SD), and medians of the recovery

load (grams) at the various deflections, and wires and wire dimensions
0.016-inch 0.022-inch
n Mean SD Median Mean SD Median

3.1 mm
Control 34 383.0 7.8 382.0 563.7 17.4 572.4
Fluoride 33 369.9 14.4 369.6 553.4 22.9 554.4
Nonfluoride 33 385.7 42.9 374.7 574.0 73.9 557.9
3.0 mm
Control 34 299.7 8.9 302.2 436.0 16.8 444.4
Fluoride 33 278.7 13.2 276.4 412.5 19.2 412.5
Nonfluoride 33 302.1 42.4 292.65 444.4 65.1 430.2
2.0 mm
Control 34 221.4 6.8 222.5 311.1 9.3 316.3
Fluoride 33 201.7 18.1 202.3 282.8 22.2 278.6
Nonfluoride 33 204.5 45.1 205.1 268.2 85.2 285.1
1.0 mm
Control 34 205.6 5.4 205.0 281.0 5.4 284.2
Fluoride 33 189.8 18.5 186.9 244.5 67.7 259.7
Nonfluoride 33 118.3 88.5 173.6 135.5 129.6 159.7
0.5 mm
Control 34 211.3 4.5 210.3 252.7 9.6 255.3
Fluoride 33 190.8 38.1 199.5 207.7 78.0 234.8
Nonfluoride 33 103.3 98.4 130.1 108.3 113.9 28.2
n = number of wires studied.

wires significantly outperformed the fluo-
ride exposed wires in both dimensions
and at all deflections (Tables 1 to 3). The
nonfluoride exposed (intraoral) wires per-
formed better than those under fluoride
exposure at 3.0 mm deflection, almost
equivalent at 3.1 mm deflection, and
equivalent at 2.0 mm deflection. At 1.0
mm and 0.5 mm deflection, the fluoride
exposed wires performed better than the
nonfluoride exposed wires. Table 2 also
indicates that there was no significant dif-
ference between the recovery loads for
nonfluoride exposed and control wires for
3.1 mm and 3.0 mm deflection. Below
these reflections, the control wires
showed a significantly higher recovery. At
the two smallest deflections, the nonfluo-
ride exposed wires gave significantly
worse results than both the control wires
and the fluoride exposed ones. The large
standard deviations for 0.5 mm and 1.0
mm deflection suggest that the differ-
ences between the fluoride- and nonfluo-
ride-exposed wires may be insignificant in
spite of the statistical significance.
Table 3 provides data on the changes
that occurred between the individual
deflections. From 3.1 mm to 2.0 mm, all
three wires showed a significant decline
in recovery for both diameters. At 1.0 mm
and 0.5 mm, both intraoral wires tended
to flatten out, showing only marginal dif-
ferences. Although the statistical tests
demonstrate a significantly different per-
formance for the control wires (due to
their very small standard error), they too
demonstrated a marked flattening effect.
The coef ficient of variation was
markedly increased when the wires were
not exposed to fluoride (Fig 1). In con-
trast, it remained essentially constant for
the control wire at all five deflections and
across both diameters.
Figures 2 and 3 show the mean recov-
ery load for the three treatment condi-
tions (fluoride, nonfluoride exposed, and
as received) for the 0.016- and 0.022-
inch diameters.

138
VOLUME 11, NUMBER 2, 2010 Vo et al

Table 2 P values for the comparison of the mean recovery loads at the various deflections for the
different wires (as received [control], with [fluoride], and without fluoride exposure [nonfluoride]) and
both wire dimensions
Deflection (mm)
Wire diameter/group 3.1 3.0 2.0 1.0 0.5

0.016-inch
Fluoride vs nonfluoride .045 .003 .716 < .001 < .001
Fluoride vs control < .001 < .001 < .001 < .001 .003
Nonfluoride vs control .671 .669 .040 < .001 < .001
0.022-inch
Fluoride vs nonfluoride .152 .008 .356 < .001 < .001
Fluoride vs control .042 < .001 < .001 < .001 .001
Nonfluoride vs control .465 .395 .006 < .001 < .001

Table 3 P values comparing the mean 120

recovery loads at the largest and smallest Flouride 0.016 inch
deflections for the different wires Flouride 0.022 inch
(as received [control], with [fluoride], and 100
Nonflouride 0.016 inch
without fluoride exposure [nonfluoride]) Nonflouride 0.022 inch
and both wire dimensions 80 Control 0.016 inch
Deflections (mm) Control 0.016 inch
60
Wire diameter/group 3.1 to 2.0 1.0 and 0.5

0.016-inch 40
Fluoride < .001 .897
Nonfluoride < .001 .500
Control < .001 < .001 20
0.022-inch
Fluoride < .001 .045 0
Nonfluoride < .001 .370 3.1 mm 3.0 mm 2.0 mm 1.0 mm 0.5 mm
Control < .001 < .001
Deflection

Fig 1 Coefficient of variation at the various deflections for the

different wires (as received [control], with [fluoride] and without
fluoride exposure [nonfluoride]) and both wire dimensions.

400 600
Flouride Flouride
350 Nonflouride Nonflouride
500
Control Control
300
400
250
300
200
200
150

100 100

50 0
3.1 mm 3.0 mm 2.0 mm 1.0 mm 0.5 mm 3.1 mm 3.0 mm 2.0 mm 1.0 mm 0.5 mm
Deflection Deflection
Fig 2 Mean recovery load at the various deflections for the Fig 3 Mean recovery load at the various deflections for the
different wires (as received [control], with [fluoride] and without different wires (as received [control], with [fluoride] and without
fluoride exposure [nonfluoride]) and the 0.016-inch dimension. fluoride exposure [nonfluoride]) and the 0.022-inch dimension.

139
 Vo et al
DISCUSSION
The results of this study demonstrate
that clinically used Ni-Ti wires have a
reduced unloading curve when compared
to as-received wires. The effect of the flu-
oride exposure was nonlinear. At great
deflection, these wires had a lower
unloading curve than the nonfluoride
exposed wires, around 2.0 mm there was
a crossover, and at the smallest deflec-
tions, they showed significantly higher
unloading. Parenthetically, it should be
noted that orthodontists would not typi-
cally use 0.016 ⫻ 0.022-inch Ni-Ti wires
for tooth movements of 3.0 mm. One
explanation for the difference between
the intraoral wires at large deflections
could be the study protocol, ie, the inser-
tion of the wires first with fluoride expo-
sure and then without. It is possible that
the wires used for the first 6 weeks were
more stressed than the second because
the teeth were initially less well-aligned.
The results of this study are somewhat
contradictory to that of Walker et al9 who
demonstrated in a laboratory-only experi-
ment that fluorides (topical gels Phos-flur
and Prevident) decreased the mechanical
properties of Ni-Ti wires. Perhaps the
main reason for the dissimilar outcome
could be the difference in study design.
Both studies also differed in the type and
dose of the applied fluoride. Although the
dose difference of the two studies cannot
be properly defined, it was likely higher in
that of Walker et al.9 Finally, Walker et al9
exposed their wires to fluoride for 3
months, while in the present study, the
fluoride regimen lasted only 6 weeks.
This study could have been designed
as a randomized clinical trial. That is,
instead of using the same 17 subjects,
different individuals could have been
enrolled to randomly assign all 34 sub-
jects to one of the two treatment regi-
mens. However, using the same patients
for both parts of the study helped to neu-
tralize some of the extrinsic, confounding
factors (including the difference in the
original malocclusion, treatment plan,
background fluoride, etc). In addition,
maxillary and mandibular archwires
could have been evaluated and analyzed
separately rather than collectively.
140
WORLD JOURNAL OF ORTHODONTICS
Also, it could be debated as to why this
study was initiated with the fluoride regi-
men. There exists a remote possibility
that this could have led to remnants of
small amounts of fluoride. The counterar-
gument is that the earlier fluoride is
applied in treatment, the more the
patient will benefit from it. It is possible
that a day or two “wash” between the flu-
oride and nonfluoride regimens would
have been a logical consideration to
make certain that the fluoride was out of
the subjects’ systems. Another possibility
could have been to randomly alternate
the order of the fluoride and nonfluoride
regimen. Finally, the current study did not
investigate the topographical changes
electron microscopically (or by x-ray dif-
fractometry/photoelectron spectroscopy)
as did Walker et al9; this certainly would
have aided in the interpretation of the
results.
Wire performance has an impact on
orthodontic tooth movement. To know
what effect commonly prescribed fluo-
ride regimens would have on the efficacy
of orthodontic archwires should be in any
orthodontist’s interest. Based on the
findings of this investigation, fluoride-
exposed 0.016 ⫻ 0.022-in Ni-Ti wires
have sufficient unloading force to pro-
duce adequate tooth movements only
after initial leveling and aligning when
only tooth movements in the range of 0.5
and 1.0 mm are still required.
CONCLUSIONS
The results of this study are:
• Force degradation occurs when wires
are exposed to the oral environment.
• Wires exposed to fluoride exhibit less
force degradation than wires without
fluoride exposure at 0.5 mm and 1.0
mm deflection, but they demonstrate
a slightly higher force degradation at
3.0 and 3.1 mm deflection.
VOLUME 11, NUMBER 2, 2010 Vo et al

REFERENCES 13. Kim H, Johnson JW. Corrosion of stainless

steel, nickel-titanium, coated nickel-titanium,
and titanium orthodontic wires. Angle Orthod
1. Swartz ML. Fact of friction: The clinical rele-
1999;69:39–44.
vance of in vitro steady-state friction studies.
14. Iijima M, Endo K, Ohno H, Yonekura Y,
J Clin Orthod 2007;41:427–432.
Mizoguchi I. Corrosion behaviour and surface
2. Miles PG. Self-ligating vs conventional twin
structure of orthodontic Ni-Ti alloy wires. Dent
brackets during en-masse space closure with
Mater J 2001;20:103–113.
sliding mechanics. Am J Orthod Dentofacial
15. Eliades T, Athanasiou AE. In vivo aging of ortho-
Orthop 2007;132:223–225.
dontic alloys: Implications for corrosion poten-
3. Rinchuse DJ, Miles PG. Self-ligating brackets:
tial, nickel release, and biocompatibility. Angle
Present and future. Am J Orthod Dentofacial
Orthod 2002;72:222–237.
Orthop 2007;132:216–222.
16. Watanabe I, Watanabe E. Surface changes
4. Pandis N, Polychronopoulou A, Eliades T. Self-
induced by fluoride prophylactic agents on tita-
ligating vs conventional brackets in the treat-
nium-based orthodontic wires. Am J Orthod
ment of mandibular crowding: A prospective
Dentofacial Orthop 2003;123:653–656.
clinical trial of treatment duration and dental
17. Kaneko K, Yokoyama K, Moriyama K, Asaoka K,
effects. Am J Orthod Dentofacial Orthop 2007;
Sakai J. Degradation in performance of ortho-
132:208–215.
dontic wires caused by hydrogen absorption
5. Segner D, Ibe D. Properties of superelastic
during short-term immersion in 2.0% acidu-
wires and their relevance to orthodontic treat-
lated phosphate fluoride solution. Angle Orthod
ment. Eur J Orthod 1995;17:395–402.
2004;74:487–495.
6. Jones ML, Richmond S. Initial tooth movement:
18. Toms AP. The corrosion of orthodontic wire.
Force application and pain—A relationship?
Eur J Orthod 1988;10:87–97.
Am J Orthod 1985;88:111–116.
19. Alexander SA, Ripa LW. Effects of self-applied
7. Kusy RP. A review of contemporary archwires:
topical fluoride preparations in orthodontic
Their properties and characteristics. Angle
patients. Angle Orthod 2000;70:424–430.
Orthod 1997;67:197–207.
20. Cohen WJ, Wiltshire WA, Dawes C, Lavelle CL.
8. Burstone CJ, Qin B, Morton JY. Chinese NiTi
Long-term in vitro fluoride release and rere-
wire: A new orthodontic alloy. Am J Orthod
lease from orthodontic bonding materials con-
1985;87:445-452.
taining fluoride. Am J Orthod Dentofacial
9. Walker MP, White RJ, Kula KS. Effect of fluoride
Orthop 2003;124:571–576.
prophylactic agents on the mechanical proper-
21. Asgharnia MK, Brantley WA. Comparison of
ties of nickel-titanium-based orthodontic wires.
bending and tension tests for orthodontic
Am J Orthod Dentofacial Orthop 2005;127:
wires. Am J Orthod 1986; 89:228–236.
662–669.
22. Walker MP, Ries D, Kula K, Ellis M, Fricke B.
10. Thayer TA, Babby MD, Moore RN, DeAngelis RJ.
Mechanical properties and surface characteri-
X-ray diffraction of nitinol orthodontic arch
zation of beta titanium and stainless steel
wires. Am J Orthod Dentofacial Orthop 1995;
orthodontic wire following topical fluoride treat-
107:604–612.
ment. Angle Orthod 2007;77:342–348.
11. Andreasen GF, Hilleman TB. An evaluation of 55
23. Santoro M, Nicolay O, Cangialosi TJ. Pseudoe-
cobalt substituted Nitinol wire for use in ortho-
lasticity and thermoelasticity of nickel-titanium
dontics. J Am Dent Assoc 1971;82:1373–1375.
alloys: A clinically oriented review. Part II: Deac-
12. Bishara SE, Winterbottom JM, Suleiman AHA,
tivation forces. Am J Orthod Dentofacial Orthop
Rim K, Jakobsen JR. Comparisons of thermo-
2001;119:594–603.
dynamic properties of three nickel-titanium
orthodontic archwires. Angle Orthod 1995;65:
117–122.

141
DIGITAL SUBTRACTION RADIOGRAPHY Ioulia Ioannidou-
Marathiotou, DDS,
Dr Dent1
OF PANORAMIC RADIOGRAPHS TO
Moschos A. Papadopoulos,
EVALUATE MAXILLARY CENTRAL DDS, Dr Med Dent2

INCISOR ROOT RESORPTION AFTER Athina Kondylidou-Sidira,

DDS, Dr Dent3
ORTHODONTIC TREATMENT Andreas Kokkas, DDS4

Aim: To quantitatively assess the extent of morphologic changes of Vassilis Karagiannis,

the apical root area and root length of maxillary central incisors after Dr Math5
orthodontic treatment using digital subtraction radiography (DSR)
and to investigate possible contributing parameters. Methods: The
subtracted images of panoramic radiographs of 21 patients before and
after orthodontic treatment were evaluated using I/RAS C and Image J
software. The retrieved data were analyzed by means of SPSS statisti-
cal software, and the method’s error was assessed. Results: There was
a small but significant decrease of the root dimensions of the maxillary
central incisors at the end of orthodontic treatment. The amount of
root resorption was not significantly influenced by sex, age, dentition,
malocclusion classification, extraction, overjet, overbite, elastic wear,
and number of teeth with resorption as measured by DSR. Conclusion:
DSR of pre- and posttreatment panoramic radiographs was able to
confirm minor root resorption of the maxillary central incisors after 1Associate Professor, Department of
orthodontic treatment. World J Orthod 2010;11:142–152. Orthodontics, School of Dentistry,
Aristotle University of Thessaloniki,
Thessaloniki, Greece.
2Associate Professor and Program
Key words: root resorption, panoramic radiographs, subtraction
Coordinator, Department of Ortho-
radiography, orthodontic treatment, orthodontic tooth movement
dontics, School of Dentistry, Aristotle
University of Thessaloniki,
Thessaloniki, Greece.
3Lecturer, Department of Dentoalveo-

lar/Implant Surgery and Radiology,

ince the first observation of root
S resorption by Ottolengui and
Ketcham in 1914 and 1927, respectively
School of Dentistry, Aristotle Univer-
sity of Thessaloniki, Thessaloniki,
age,19,20 type of tooth,21 stage of root
development,22,23 presence of ectopic
teeth,18,24,25 abnormal apical root for-
Greece.
4Dentist, Graduate Student, Depart-

ment of Endodontics, School of

Dentistry, Aristotle University of
(cited by Beck and Harris1), many arti- mation,2,18,26–30 trauma or endodontic Thessaloniki, Thessaloniki, Greece.
cles have confirmed a relationship treatment,17,22,27,28,31–33 tongue dysfunc- 5Research Associate, Department of

between orthodontic treatment and
external root resorption of the
incisors, 2–9 as well as that of other
teeth.10–15
Root resorption is an unpredictable
and irreversible pathologic adverse
effect of orthodontic treatment. Its
causes are unclear, but systemic,
genetic, and treatment-related factors
may be involved.16 Systemic or genetic
factors may include sex, 17,18 patient
tion (open bite),23,34,35 and allergies,36
as well as endogenetic features.2
Treatment-related factors of apical root
resorption may involve duration of ortho-
dontic treatment 19,21,22,26,37,38; specific
orthodontic appliances and/or treatment
techniques1,22,39,40; type of tooth move-
ments, such as intrusion, extrusion, or
change in inclination2,41–43; magnitude of
applied forces21,22,26,44; and intermaxillary
elastics and headgear.40,45
Fundamental Dental Sciences,
School of Dentistry, Aristotle Univer-
sity of Thessaloniki, Thessaloniki,
Greece.
CORRESPONDENCE
Dr Moschos A. Papadopoulos
Department of Orthodontics
School of Dentistry
Aristotle University of Thessaloniki
GR-54124 Thessaloniki
Greece
Email: mikepap@dent.auth.gr

142
VOLUME 11, NUMBER 2, 2010
According to current literature, it seems
that after orthodontic treatment, patients
usually experience mild to moderate api-
cal root resorption of the maxillary central
incisors. The amount of resorption varies
between 1.00 mm to almost 3.00
mm.3,7,8,22,41,46–49 These differences may
be attributed to one of the aforemen-
tioned therapy-related factors, as well as
to the length of the follow-up period.
In previous investigations, root resorp-
tion was detected mainly through periapi-
cal, panoramic, and cephalometric
radiographs, as well as through light and
scanning electron microscope images.
The degree of apical root resorption was
usually evaluated by visual scor-
ing. 1,3,26,43,50,51 These visual compar-
isons have, however, inherent limitations,
such as interpretation disagreement
between two evaluators, or of the same
evaluator at different times, as well as
limitations to detect small lesions.51–54
During the past 3 decades, digital sub-
traction radiography (DSR) was intro-
duced into dental radiology. It proved to
be efficient in the detection of small
lesions of hard tooth tissue. This tech-
nique is based on the digital subtraction
of one radiographic image from another;
thus, the resultant image shows only the
differences between the first and second
image.55–58
However, the accuracy of DSR is ques-
tionable because radiographic images
are seldom standardized in brightness,
noise, contrast, or projection geometry. In
addition, no mechanical device can pre-
serve image geometry. Since 1980, new
methods were introduced to correct
inconsistencies in image contrast or geo-
metric discrepancies by means of geo-
metric reconstruction algorithms using
specific reference points.59–63 Dunn et
al61,62 showed that it takes four reference
points to align a pair of digital radi-
ographic images taken at different pro-
jection angles, for example, as a
consequence of orthodontic tooth move-
ment. Recently, subtraction registration
templates are used to accurately process
digitized images and minimize the
amount of noise in the subtracted
images, further enhancing the efficiency
of the DSR technique.64,65
Ioannidou-Marathiotou et al
Further, specialized software, such as
EMAGO (Oral Diagnostic Systems, ACTA),
I/RAS C (Intergraph), MicroStation (Bent-
ley Systems), and DIGORA for Windows
(Soredex) have increased diagnostic
accuracy.
In contrast to the significant number
of studies dealing with the quantitative
evaluation of root resorption in orthodon-
tic patients by means of conventional
radiographs, 1,8,20,26,41,46 the literature
concerning root resorption assessed by
DSR is relatively lacking.55,56,63,66
It was hypothesized that (1) the DSR
of panoramic radiographs cannot detect
any external apical root resorption of the
maxillary incisors following orthodontic
treatment and (2) the parameters
involved in orthodontic treatment, such
as sex, age, dentition, malocclusion clas-
sification, extractions, overjet, overbite,
and elastics wear, do not affect the
amount of root resorption.
Therefore, the aim of this retrospective
study was to quantitatively assess the
changes of the root area and length of
the maxillary incisors following orthodon-
tic treatment by means of DSR of
panoramic radiographs, as well as to
assess whether such changes are related
to any of the various parameters involved
in orthodontic treatment.
MATERIAL AND METHODS
To select the appropriate number of
patients for this investigation, a power
analysis for sample size calculation with
␣ = .05, 1-␤ = 0.8, and effect size index
d = 0.7 was performed.67 With regard to
the hypothesis of no changes in root mor-
phology of the maxillary incisors following
or thodontic treatment, calculations
revealed that a sample of at least 19
patients was necessary. However, more
patients were initially included to account
for eventual exclusions or dropouts.
This retrospective investigation was
based on panoramic radiographs of
patients taken with the same equipment
(Or thopantomograph 10E, Palomex
Instrumentarium) before and after ortho-
dontic treatment. These radiographs were
part of the standard diagnostic records
143
 Ioannidou-Marathiotou et al WORLD JOURNAL OF ORTHODONTICS

patients with dental agenesis or a history

Table 1 Characteristics of the study
sample of trauma or endodontic treatment of the
maxillary incisors were excluded from the
n % sample (n = 5). Thus, 21 patients (12
Sex females and 9 males) remained for fur-
Male 9 42.9 ther evaluation.
Female 12 57.1 The mean age of the sample at the
Age
≤ 12 y 7 33.3
start of orthodontic treatment was 13.7
> 12 y 14 66.7 ± 2.7 years (range 9.0 to 21.0 years),
Dentitional stage suggesting that at this time, the maxillary
Mixed 2 9.5 incisors had fully developed roots, 68
Permanent 19 90.5 except of one 9-year-old patient with
Malocclusion classification
Class I 3 14.3
probable residual root growth. The
Class II 18 85.7 detailed characteristics of the study sam-
Tooth extractions ple are presented in Table 1.
With 5 23.8 The complete DSR procedure was per-
Without 16 76.2 formed by one investigator. Initially, all
Overjet
≤ 4 mm 9 42.9
panoramic radiographs were converted
> 4 mm 12 57.1 into digital images by scanning them with
Overbite an Epson Per fection 3170 scanner
≤ 3 mm 11 52.4 (Epson) at a resolution of 300 dpi. Image
> 3 mm 10 47.6 processing was performed with a Com-
Wear of elastics
Yes 15 71.4
paq Presario Notebook 705EA equipped
No 6 28.6 with a 15-inch SVGA monitor using the
No. of teeth with resorption Windows-based I/RAS C 7.0 software
1 tooth 13 61.9 (academic edition).
2 or more teeth 8 38.1 The I/RAS C software has several
tools, of which some can adjust contrast
and modify image geometry. The geome-
try commands allow for image registration
and point collection to warp and manipu-
late the geometric orientation of an
image. The coordinates of one image
and consecutively selected from the must first be assigned, which is referred
archives of the Postgraduate Clinic of the to as warping, so the image is altered to
Department of Orthodontics of the Aristo- best fit the coordinates. The actual math-
tle University of Thessaloniki, Greece. ematic algorithms that convert the source
Informed written consent was obtained coordinates to those of another coordi-
from all patients or their guardians. nate system are called transformation
A total of 26 consecutive patient files models.
were selected initially. The selected In the present study, projective trans-
patients presented with a Class I or II formation models were used. This trans-
relationship and were treated with or formation has eight parameters that
without premolar extractions and fixed describe a 2D projection between two
appliances. Some Class II patients were planes from one center of perspective.
treated additionally with extraoral forces The I/RAS C software was also used
or functional appliances. All treatments for gamma correction to match the his-
were performed by the postgraduate stu- togram of the follow-up to the baseline
dents of the depar tment under the image. After the density and contrast of
supervision of faculty members. the images were corrected, the same
Inclusion criteria were complete software was used to adjust the images
records, including patient history and for reversible projection errors at the x-
treatment plans, study casts, and pre- and y-axis, as well as to geometrically
and posttreatment panoramic and lat- transform each follow-up image to match
eral cephalometric radiographs. Files of the corresponding baseline image.

144
VOLUME 11, NUMBER 2, 2010 Ioannidou-Marathiotou et al

c
a b

Fig 1 Subtraction radiography to assess a possible root resorption of

the right maxillary central incisor of a 12-year-old girl. (a) Section of the
panoramic radiograph before treatment, (b) corresponding section after
treatment, and (c) application of the I/RAS C software to collect control
points to match the follow-up with the baseline image. (ci) Selection of
approximate control points on the follow-up image, (cii) selection of a
refined control point close to the approximate control point at the
zoomed-in area of the same image, (ciii) selection of approximate input
points on the baseline image, and (civ) selection of a refined input point e
close to the approximate input point at the zoomed-in area of the same
image. (d) The subtraction of the baseline and reconstructed image
performed by means of Adobe Photoshop software. (e) The resulting
subtracted image corresponding to the morphologic changes occurred
in the apical root area of the right maxillary central incisor during orth-
odontic treatment. Note the minimal root resorption that took place.
d

Due to the magnification error usually
inherent to panoramic radiographs, it was
decided to evaluate only the maxillary
incisors. Because the focal trough is
aligned with the maxillary dentition and
the patient is instructed to bite forward
into the bite rod positioning device, these
teeth seemed to be less distorted than
the mandibular incisors.8,69,70 Therefore,
the maxillary incisor section was cropped
from all initial and follow-up images.
To correlate the pre- and posttreat-
ment radiographs, four recognizable
anatomical landmarks were identified on
the initial image: (1) the crest of the max-
illa at the mesial surface of the maxillary
incisors, (2) the crest of the maxilla at the
distal surface of the maxillary incisors,
(3) the anterior nasal spine, and (4) the
floor of the nasal cavity or the junction
with the anterior border of the maxillary
sinus. These reference points were as far
from each other as possible, but still
readily identifiable. When the crest of the
maxilla was not clear, the proximal and
distal edges of the incisors were used.
Following identification of the corre-
sponding points on the follow-up image,
the I/RAS C software applied the projec-
tive algorithm to identify and correlate
the coordinates of each pixel of the initial
image with the corresponding one of the
follow-up one. After detection of the pat-
tern, the points of the two images were
matched and a correlation value was cal-
culated. A correlation between 0.8 and
1.0 was considered good. If it was less
than 0.8, the entire procedure was
repeated until a higher value could be
accomplished. Only then was the follow-
up image reconstructed according to the
wrap model.

145
 Ioannidou-Marathiotou et al
a c
b
e traction. (d) The subtraction of the baseline and reconstructed
d
After mathematic correction of the dis-
tortion, the Emboss filter was applied to
both radiographs using Adobe Photoshop
6.0 software (Adobe Systems). Then, the
two images were superimposed with the
Move tool, creating a two-layer image. The
opacity of the second layer was approxi-
mately 40% to 60% decreased to observe
both images simultaneously. In the next
step, the apical region of the incisors of
the baseline image was subtracted from
the follow-up one. The resulting image
represented the root resorption, which
took place during orthodontic treatment
(Figs 1 and 2). This difference was mea-
sured as absolute and relative root
resorption by means of the Image J soft-
ware 1.240 (http://rsb.info.nih.gov/ij/).
The absolute root resorption (area
measurement) was calculated by count-
146
WORLD JOURNAL OF ORTHODONTICS
Fig 2 Subtraction radiography to assess a possible root resorption
of the right maxillary central incisor of a 14-year-old boy. (a) Section
of the panoramic radiography before treatment, (b) corresponding
section after treatment, and (c) application of the I/RAS C software
to match the follow-up with the baseline image. (ci) Section of the
follow-up image, (cii) corresponding section of the baseline image,
(ciii) matching of the two images after selection of the appropriate
control points, and (civ) reconstructed image to be used for sub-
image performed by means of Adobe Photoshop software. (e) The
resulting subtracted image corresponding to the morphologic
changes occurred in the apical root area of the right maxillary cen-
tral incisor during orthodontic treatment. Note the amount of root
resorption that took place.
ing the total number of pixels of the sub-
tracted image. The relative root resorption
(length measurement) was determined
using the formula (L1–L2)/L1⫻100,
where L1 is the tooth length in pixels
before and L2 the tooth length in pixels
after treatment. Furthermore, to allow a
comparison of these data with the results
of previous studies, the mean value of rel-
ative root resorption was converted to mil-
limeters using the equation 1 pixel =
0.085 mm, since all images were
scanned at a resolution of 300 dpi.66
To assess the method error, the DSR
and the measurement procedure were
repeated for all variables and patients
after a 4-week interval by the same investi-
gator. The magnitude of the method’s
error s(i) was calculated by means of the
Dahlberg formula,71 and the reproducibility
VOLUME 11, NUMBER 2, 2010
Table 2 Error of the method s(i) and
Pearson correlation coefficient (r)
Variable
Absolute root resorption (area)
Relative root resorption (length)
Table 3 Results of the Student t test evaluation for the variables under
investigation
s(i) r Variable
2.64 0.966 Absolute root resorption (area) [pixels]
0.9 0.968 [With observations 1 and 20]
Absolute root resorption (area) [pixels]
[Without observations 1 and 20]
Relative root resorption (length) [%]
*Result of the Shapiro-Wilk test.
of the measurements (intraexaminer cor-
relation) by means of the Pearson corre-
lation coefficient (r).
Initially, descriptive statistics were per-
formed. Then, data distribution for each
variable was evaluated by means of the
Shapiro-Wilk test. According to the
results of these tests, the one-sample
Student t test was applied. However,
because the Shapiro-Wilk test revealed a
skewed distribution for the absolute root
resorption (area) variable, two observa-
tions (1 and 20) were omitted because
they deviated remarkably in the total
number of pixels (50 and 49 pixels,
respectively, as compared to 5 to 36 pix-
els for the rest of the sample).
Analysis of variance (ANOVA) and the
two independent samples Student t test
were used to investigate whether the var-
ious parameters/factors involved in
orthodontic treatment affect the amount
of root resorption.
All statistical evaluations were performed
by means of the software SPSS 14.0 for
Windows (SPSS) and the level of signifi-
cance for all analyses was set at P < .05.
RESULTS
The evaluation of the maxillary central
incisor root resorption by means of DSR
was associated with a significantly small
method error and a large positive correla-
tion, as shown in Table 2.
Ioannidou-Marathiotou et al
N Mean SD Min Max P value
21 19.48 12.59 5 50 Skewed distribution*
19 16.32 8.09 5 36 < .001
21 7.72 5.19 0 16.76 < .001
According to the results of the Student
t test evaluation (Table 3), there was a
small but statistically significant differ-
ence concerning the absolute root
resorption (area) (16.32 ± 8.09 pixels,
P <.001) when the two outliers were
excluded from the evaluation, as well as
concerning the relative root resorption
(length) (7.72 ± 5.19 pixels, P < .001).
The Student t test, as well as the
ANOVA, revealed that there were no sta-
tistically significant effects of the various
parameters to the mean value of root
resorption (Table 4).
DISCUSSION
External apical root resorption has been
often associated with orthodontic treat-
ment, while maxillary incisors are consid-
ered the most af fected among all
teeth. 1–5,7,8,14,22,26,31,41,72,73 However,
data concerning the amount of root
resorption are difficult to compare due to
the lack of a standardization of serial
radiographs and of quantitative evalua-
tion of root resorption.
The initial sample in the current inves-
tigation contained 26 patients, from
which 5 were excluded, resulting in 21 for
the final analysis. Hence, a computation
of the power of a two-sided one-sample
t test with n = 21 showed that the proba-
bility of rejecting a false null hypothesis
was greater that 84%.
147
 Ioannidou-Marathiotou et al WORLD JOURNAL OF ORTHODONTICS

Table 4 Results of the assessment of the effects of the various factors of the study sample on the corresponding
variables under investigation by means of the Student t test and ANOVA
Absolute root resorption (area) [pixels] Relative root resorption (length) [%]
P P
Factor/levels Mean SD t ANOVA Mean SD t ANOVA

Sex
Male 24.11 15.40 6.20 5.54
.149 .312 .256 .535
Female 16.00 9.23 8.86 4.83
Age
≤ 12 years 23.57 13.84 5.92 4.12
.304 .190 .272 .958
> 12 years 17.43 11.92 8.62 5.57
Dentitional stage
Mixed 15.00 4.24 1.30 1.84
.610 .339 .064 .197
Permanent 19.95 13.15 8.39 4.97
Malocclusion classification
Class I 11.00 4.36 9.40 6.75
.216 .924 .558 .690
Class II 20.89 13.02 7.44 5.08
Tooth extractions
With 16.40 8.44 10.85 5.75
.545 .981 .125 .373
Without 20.44 13.73 6.74 4.78
Overjet
≤ 4 mm 14.78 6.96 7.06 5.57
.111 .580 .625 .497
> 4mm 23.00 14.89 8.22 5.08
Overbite
≤ 3 mm 17.09 11.94 8.13 17.09
.376 .872 .714 .319
> 3 mm 22.10 13.40 7.27 22.10
Wear of elastics
Yes 20.53 14.24 7.58 4.75
.557 .966 .853 .566
No 16.83 7.44 8.07 6.67
No. of teeth with resorption
1 tooth 20.08 14.52 6.64 4.23
.788 .910 .288 .284
2 or more 18.50 9.50 9.48 6.38

This retrospective study presents some
limitations. The increase in distortion and
magnification of panoramic radiographs
as compared to periapical ones may lead
to an overestimation of root resorption of
20% or more. 70 Nevertheless, it was
found that panoramic radiographs are
sufficiently accurate for measuring root
changes if the occlusal plane is not tilted
more than 10 degrees.74 Panoramic radi-
ographs were used for this evaluation
because they are routinely taken before,
during, and after orthodontic treatment.
Another drawback to register 3D struc-
tures in 2D images is that during ortho-
dontic treatment, tooth inclination may
change, which affects the radiographically
depicted root length.51 Further, the pre-
sent study lacks data of a control
(untreated) patient sample. However, for
ethical reasons, exposing individuals to
radiation without treatment benefit can-
not be justified.
In the present study, root resorption of
the maxillar y central incisors was
assessed by means of DSR. Because DSR
allows direct comparison of two images of
the same object at two time points, the
focus of this study was mainly the effi-
ciency and reproducibility of the method.
The method error evaluation revealed no
significant inaccuracy. In addition, a good
intraexaminer correlation was observed
between the initial and the repeated mea-
surements. Thus, DSR per se, as well as
the methodology used in this study, could
be considered appropriate.
Because only a few studies concern-
ing root resorption assessed by means of
DSR have been published to date, the
comparison of the results of this study
with data from other studies can only be
limited. Absolute root resorption
amounted to 19.5 ± 12.6 pixels, with a
minimum of 5.0 and a maximum of 50.0
pixels. After exclusion of the outliers, the

148
VOLUME 11, NUMBER 2, 2010
mean value decreased to 16.3 ± 8.1 pix-
els, which was still statistically signifi-
cant. Even if the apex of the maxillary
central incisors seems to be frequently
affected by orthodontic treatment, the
amount of root resorption is minimal;
although it is statistically significant, it is
of less clinical importance. In fact, the
observed small amount of root resorption
would not impact treatment planning
decisions. However, DSR may be used
optionally in everyday clinical practice
because it enables early detection of root
resorption.
To obtain a more representative
assessment of the apical root resorption,
the extent of root length shortening was
also measured. To correlate a given loss
of the root length, the relative amount of
root length shortening was evaluated,
which amounted to 7.7% ± 5.2% (range:
0% to 16.8%). This is in agreement with
the results of Reukers et al 45 who
observed a mean loss of 7.8% of the ini-
tial total tooth length.
After conversion of pixels to mm, 66
the mean value of root shor tening
observed in this study was 0.7 mm ± 0.4,
which is again in agreement with Heo et
al55 and Smale et al,75 who found a root
resorption of approximately 0.5 mm.
Consequently, concerning both the
amount of absolute root resorption (area)
as well as of relative root resorption
(length), the present findings are compa-
rable to those of other studies also using
DSR.46,56,66,75
According to the results of this investi-
gation, no significant relationship was
found between sex, patient age, denti-
tional stage, classification of malocclu-
sion, tooth extractions, overjet, overbite,
use of intermaxillary elastics, and number
of teeth presented with root resorption on
one side and the absolute or relative root
resorption of the maxillary central incisors
on the other side. These results are not in
accordance with those of some previous
studies, which reported that the degree of
resorption is correlated with factors such
as sex, tooth extractions, and type of mal-
occlusion. 26,40,42,49 This inconsistency
could be attributed either to the small
sample of the current study or to the
methods used in the various studies.
Ioannidou-Marathiotou et al
The detection of even minimal lesions
in the current investigation may suggest
that DSR is a valuable diagnostic tool in
everyday clinical practice. The early
detection of root morphology changes
during orthodontic treatment is clinically
important to prevent irreversible defects.
Finally, it should be also taken into
consideration that root resorption is a 3D
phenomenon, while DSR, which uses
conventional or digital radiographs, can
assess hard tissue alterations in only 2D.
Future advances and more sophisticated
methods based on mainly the introduc-
tion of new imaging technologies, such
as computed tomography (CT) or cone
beam CT,76–80 may lead to an accurate
3D evaluation of morphologic root
changes during orthodontic treatment.
CONCLUSION
According to the results of this investiga-
tion, the application of DSR in panoramic
radiographs was able to detect minimal
changes of root morphology of the maxil-
lary central incisors after orthodontic
treatment. DSR was associated with a
significantly small method error and a
positive intraexaminer correlation, thus
indicating that the technique may be suf-
ficiently reliable for clinical use. Although
the observed changes were statistically
significant, they were too small to be clin-
ically significant.
In addition, no significant relationship
was found between the various factors
under investigation and root resorption
of the maxillary central incisors.
REFERENCES
1. Beck BW, Harris EF. Apical root resorption in
orthodontically treated subjects: Analysis of
edgewise and light wire mechanics. Am J
Orthod Dentofacial Orthop 1994;105:350–361.
2. Kaley J, Phillips C. Factors related to root
resorption in edgewise practice. Angle Orthod
1991;61:125–132.
3. Copeland S, Green LJ. Root resorption in maxil-
lary central incisors following active orthodon-
tic treatment. Am J Orthod 1986;89:51–55.
149
 Ioannidou-Marathiotou et al
4. Remington DN, Joondeph DR, Artun J, Riedel
RA, Chapko MK. Long-term evaluation of root
resorption occurring during orthodontic treat-
ment. Am J Orthod Dentofacial Orthop 1989;
96:43–46.
5. Levander E, Malmgren O, Eliasson S. Evaluation
of root resorption in relation to two orthodontic
treatment regimes. A clinical experimental
study. Eur J Orthod 1994;16:223–228.
6. Levander E, Malmgren O, Stenback K. Apical
root resorption during orthodontic treatment of
patients with multiple aplasia: A study of maxil-
lary incisors. Eur J Orthod 1998;20:427–434.
7. Taner T, Ciğer S, Sençift Y. Evaluation of apical
root resorption following extraction therapy in
subjects with Class I and Class II malocclu-
sions. Eur J Orthod 1999;21:491–496.
8. Brin I, Tulloch JF, Koroluk L, Philips C. External
apical root resorption in Class II malocclusion:
A retrospective review of 1- versus 2-phase
treatment. Am J Orthod Dentofacial Orthop
2003;124:151–156.
9. Kinomoto Y, Noro T, Ebisu S. Internal root
resorption associated with inadequate caries
removal and orthodontic therapy. J Endod
2002;28:405–407.
10. Kennedy DB, Joondeph DR, Osterberg SK, Little
RM. The effect of extraction and orthodontic
treatment on dentoalveolar support. Am J
Orthod 1983;84:183–190.
11. Kurol J, Owman-Moll P, Lundgren D. Time-
related root resorption after application of a
controlled continuous orthodontic force. Am J
Orthod Dentofacial Orthop 1996;110:303–310.
12. Acar A, Canyürek U, Kocaaga M, Erverdi N. Con-
tinuous vs. discontinuous force application and
root resorption. Angle Orthod 1999;69:159–163.
13. Alwali S, Marklund M, Persson M. Apical root
resorption of upper first molars as related to
anchorage system. Swed Dent J 2000;24:
145–153.
14. Fritz U, Diedrich P, Wiechmann D. Apical root
resorption after lingual orthodontic therapy.
J Orofac Orthop 2003;64:434–442.
15. Weiland F. Constant versus dissipating forces
in orthodontics: The effect on initial tooth
movement and root resorption. Eur J Orthod
2003; 25:335–342.
16. Brezniak N, Wasserstein A. Root resorption
after orthodontic treatment. Part 1. Literature
review. Am J Orthod Dentofacial Orthop 1993;
103:62–66.
17. Spurrier SW, Hall SH, Joondeph DR, Shapiro
PA, Riedel RA. A comparison of apical root
resorption during orthodontic treatment in
endodontically treated and vital teeth. Am J
Orthod Dentofacial Orthop 1990;97:130–134.
18. Kjaer I. Morphological characteristics of denti-
tions developing excessive root resorption dur-
ing orthodontic treatment. Eur J Orthod 1995;
17:25–34.
19. McFadden WM, Engstrom C, Engstrom H,
Anholm JM. A study of the relationship between
incisor intrusion and root shortening. Am J
Orthod Dentofacial Orthop 1989;96:390–396.
150
WORLD JOURNAL OF ORTHODONTICS
20. Hendrix I, Carels C, Kuijpers-Jagtman AM, Van’T
Hof M. A radiographic study of posterior apical
root resorption in orthodontic patients. Am J
Orthod Dentofacial Orthop 1994;105:345–349.
21. Sharpe W, Reed B, Subtelny JD, Polson A.
Orthodontic relapse, apical root resorption, and
crestal alveolar bone levels. Am J Orthod
Dentofacial Orthop 1987;91:252–258.
22. Linge BO, Linge L. Apical root resorption in upper
anterior teeth. Eur J Orthod 1983;5:173–183.
23. Linge L, Linge BO. Patient characteristics and
treatment variables associated with apical root
resorption during orthodontic treatment. Am J
Orthod Dentofacial Orthop 1991;99:35–43.
24. Bakland LK. Root resorption. Dent Clin North
Am 1992;36:491–507.
25. Kojima R, Taguchi Y, Kobayashi H, Noda T.
External root resorption of the maxillary perma-
nent incisors caused by ectopically erupting
canines. J Clin Pediatr Dent 2002;26:193–197.
26. Levander E, Malmgren O. Evaluation of the risk
of root resorption during orthodontic treatment:
A study of upper incisors. Eur J Orthod 1988;
10:30–38.
27. Mirabella AD, Artun J. Prevalence and severity
of apical root resorption of maxillary anterior
teeth in adult orthodontic patients. Eur J
Orthod 1995;17:93–99.
28. Mirabella AD, Artun J. Risk factors for apical
root resorption of maxillary anterior teeth in
adult orthodontic patients. Am J Orthod Dento-
facial Orthop 1995;108:48–55.
29. Horiuchi A, Hotokezaka H, Kobayashi K. Corre-
lation between cortical plate proximity and api-
cal root resorption. Am J Orthod Dentofacial
Orthop 1998;114:311–318.
30. Hartsfield JK Jr, Everett ET, Al-Qawasmi RA.
Genetic factors in external apical root resorp-
tion and orthodontic treatment. Crit Rev Oral
Biol Med 2004;15:115–122.
31. Malmgren O, Goldson L, Hill C, Orwin A, Petrini
L, Lundberg M. Root resorption after orthodon-
tic treatment of traumatized teeth. Am J Orthod
1982;82:487–491.
32. Andreasen JO. External root resorption: Its
implication in dental traumatology, paedodon-
tics, periodontics, orthodontics and endodon-
tics. Int Endod J 1985;18:109–118.
33. Brin I, Ben-Bassat Y, Heling I, Engelberg A. The
influence of orthodontic treatment on previ-
ously traumatized permanent incisors. Eur J
Orthod 1991;13:372–377.
34. Odenrick L, Brattström V. Nailbiting: Frequency
and association with root resorption during
orthodontic treatment. Br J Orthod 1985;12:
78–81.
35. Harris EF, Butler ML. Patterns of incisor root
resorption before and after orthodontic correc-
tion in cases with anterior open bites. Am J
Orthod Dentofacial Orthop 1992;101:112–119.
36. Owman-Moll P, Kurol J. Root resorption after
orthodontic treatment in high- and low-risk
patients: Analysis of allergy as a possible predis-
posing factor. Eur J Orthod 2000;22:657–663.
37. Goldin B. Labial root torque: Effect on the max-
illa and incisor root apex. Am J Orthod Dentofa-
cial Orthop 1989;95:208–219.
VOLUME 11, NUMBER 2, 2010
38. Vlaskalic V, Boyd RL, Baumrind S. Etiology and
sequelae of root resorption. Semin Orthod
1998;4:124–131.
39. Malmgren O, Omblus J. Treatment with an
orthopaedic appliance system. Eur J Orthod
1985;7:205–214.
40. McNab S, Battistutta D, Taverne A, Symons AL.
External apical root resorption following ortho-
dontic treatment. Angle Orthod 2000;70:
227–232.
41. Dermaut LR, De Munck A. Apical root resorp-
tion of upper incisors caused by intrusive tooth
movement: A radiographic study. Am J Orthod
Dentofacial Orthop 1986;90:321–326.
42. Parker RJ, Harris EF. Directions of orthodontic
tooth movements associated with external api-
cal root resorption of the maxillary central
incisor. Am J Orthod Dentofacial Orthop 1998;
114:677–683.
43. Han G, Huang S, Von den Hoff JW, Zeng X,
Kuijpers-Jagtman AM. Root resorption after
orthodontic intrusion and extrusion: An intra-
individual study. Angle Orthod 2005;75:
912–918.
44. Hollender L, Rönnerman A, Thilander B. Root
resorption, marginal bone support and clinical
crown length in orthodontically treated
patients. Eur J Orthod 1980;2:197–205.
45. Reukers EA, Sanderink GC, Kuijpers-Jagtman
AM, van’t Hof MA. Radiographic evaluation of
apical root resorption with 2 different types of
edgewise appliances. Results of a randomized
clinical trial. J Orofac Orthop 1998;59:100–109
[erratum 1998;59:251].
46. van Loenen M, Dermaut LR, Degrieck J, De
Pauw GA. Apical root resorption of upper incisors
during the torquing stage of the tip-edge tech-
nique. Eur J Orthod 2007;29:583–588.
47. Costopoulos G, Nanda R. An evaluation of root
resorption incident to orthodontic intrusion. Am J
Orthod Dentofacial Orthop 1996;109:543–548.
48. Mavragani M, Vergari A, Selliseth NJ, Bøe OE,
Wisth PL. A radiographic comparison of apical
root resorption after orthodontic treatment with
a standard edgewise and a straight-wire edge-
wise technique. Eur J Orthod 2000;22:665–674.
49. Mohandesan H, Ravanmehr H, Valaei N. A radio-
graphic analysis of external apical root resorption
of maxillary incisors during active orthodontic
treatment. Eur J Orthod 2007;29:134–139.
50. Harris EF, Baker WC. Loss of root length and cre-
stal bone height before and during treatment in
adolescent and adult orthodontic patients. Am J
Orthod Dentofacial Orthop 1990:98:463–469.
51. Apajalahti S, Peltola JS. Apical root resorption
after orthodontic treatment—A retrospective
study. Eur J Orthod 2007;29:408–412.
52. Gelfand M, Sunderman EJ, Goldman M. Relia-
bility of radiographical interpretations. J Endod
1983;9:71–75.
53. Gröndahl HG, Gröndahl K. Subtraction radiog-
raphy for the diagnosis of periodontal bone
lesions. Oral Surg Oral Med Oral Pathol 1983;
55:208–213.
Ioannidou-Marathiotou et al
54. Petrikowski CG, elBadrawy HE, Boehlau EE,
Grace MG. Interobserver variability in radi-
ographic interpretation of pediatric dental dis-
eases: A pilot study. J Can Dent Assoc 1996;
62:723–726, 728–730.
55. Heo MS, Lee SS, Lee KH, Choi HM, Choi SC,
Park TW. Quantitative analysis of apical root
resorption by means of digital subtraction radi-
ography. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2001;91:369–373.
56. Kravitz LH, Tyndall DA, Bagnell CP, Dove SB.
Assessment of external root resorption using
digital subtraction radiography. J Endod 1992;
18:275–284.
57. Giannopoulou M, Kondilidou A, Parissis N. Digi-
tal subtraction radiography - General principles -
Practice in Dentistry. Stoma 2005;33:187–191.
58. van der Stelt PF. Research methods in dentistry.
8. Methods for longitudinally detecting differ-
ences in bone density: Digital subtraction radi-
ography [in Dutch]. Ned Tijdschr Tandheelkd
2005;112:46–50.
59. Ruttimann UE, Webber RL, Schmidt E. A robust
digital method for film contrast correction in
subtraction radiography. J Periodontal Res
1986;21:486–495.
60. Wenzel A. Effect of manual compared with ref-
erence point superimposition on image quality
in digital subtraction radiography. Dentomax-
illofac Radiol 1989;18:145–150.
61. Dunn SM, van der Stelt PF. Recognizing invari-
ant geometric structure in dental radiographs.
Dentomaxillofac Radiol 1992;21:142–147.
62. Dunn SM, van der Stelt PF, Ponce A, Fenesy K,
Shah S. A comparison of two registration tech-
niques for digital subtraction radiography.
Dentomaxillofac Radiol 1993;22:77–80.
63. Reukers EA, Sanderink GC, Kuijpers-Jagtman
AM, van’t Hof MA. Assessment of apical root
resorption using digital reconstruction.
Dentomaxillofac Radiol 1998;27:25-29.
64. Eraso FE, Parks ET, Roberts WE, Hohlt WF,
Ofner S. Density value means in the evaluation
of external apical root resorption: An in vitro
study for early detection in orthodontic case
simulations. Dentomaxillofac Radiol 2007;36:
130–137.
65. Kozakiewicz M, Bogusiak K, Hanclik M,
Denkowski M, Arkuszewski P. Noise in subtrac-
tion images made from pairs of intraoral radi-
ographs: A comparison between four methods
of geometric alignment. Dentomaxillofac Radiol
2008;37:40–46.
66. Artun J, Smale I, Behbehani F, Doppel D, Van’t
Hof M, Kuijpers-Jagtman AM. Apical root
resorption six and 12 months after initiation of
fixed orthodontic appliance therapy. Angle
Orthod 2005;75:919–926.
67. Cohen J. Statistical Power Analysis for the
Behavioral Sciences, ed 2. Hillsdale, NJ:
Erlbaum, 1988.
68. Proffit WR. Early stages of development. In:
Proffit WR. Contemporary Orthodontics, ed 3.
St Louis: Mosby, 2000:63–93.
69. Pasler FA. Radiology. Stuttgart: Georg Thieme
Verlag, 1993.
151
 Ioannidou-Marathiotou et al
70. Sameshima GT, Asgarifar KO. Assessment of
root resorption and root shape: Periapical vs
panoramic films. Angle Orthod 2001;71:
185–189.
71. Dahlberg G. Statistical Methods for Medical
and Biological Students. London: George Allen
and Unwin, 1940:122–132.
72. Levander E, Bajka R, Malmgren O. Early radio-
graphic diagnosis of apical root resorption dur-
ing orthodontic treatment: A study of maxillary
incisors. Eur J Orthod 1998;20:57–63.
73. Janson GR, De Luca Canto G, Martins DR, Hen-
riques JF, De Freitas MR. A radiographic com-
parison of apical root resorption after
orthodontic treatment with 3 different fixed
appliance techniques. Am J Orthod Dentofacial
Orthop 2000;118:262–273.
74. Stramotas S, Geenty JP, Petocz P, Darendeliler
MA. Accuracy of linear and angular measure-
ments on panoramic radiographs taken at various
positions in vitro. Eur J Orthod 2002;24:43–52.
75. Smale I, Artun J, Behbehani F, Doppel D, van’t
Hof M, Kuijpers-Jagtman AM. Apical root
resorption 6 months after initiation of fixed
orthodontic appliance therapy. Am J Orthod
Dentofacial Orthop 2005;128:57–67.
152
WORLD JOURNAL OF ORTHODONTICS
76. Papadopoulos MA, Christou PK, Christou PK, et
al. Three-dimensional craniofacial reconstruc-
tion imaging. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2002;93:382–393.
77. Chan EKM, Darendeliler MA. Exploring the third
dimension in root resorption. Orthod Craniofac
Res 2004;7:64–70.
78. Cevidanes LHS, Styner MA, Proffit WR. Image
analysis and superimposition of 3-dimensional
cone-beam computed tomography models. Am J
Orthod Dentofacial Orthop 2006;129:611–618.
79. Lane C, Harrell W Jr. Completing the 3-dimen-
sional picture. Am J Orthod Dentofacial Orthop
2008;133:612–620.
80. Quereshy FA, Savell TA, Palomo JM. Applica-
tions of cone beam computed tomography in
the practice of oral and maxillofacial surgery.
J Oral Maxillofac Surg 2008;66:791–796.
Philipp Meyer-Marcotty,
DDS1
Georg W. Alpers, PhD2
Antje B.M. Gerdes, PhD3
Angelika Stellzig-
Eisenhauer, DDS, PhD4
HOW OTHERS PERCEIVE ORTHOGNATHIC
PATIENTS: AN EYE-TRACKING STUDY
Aim: To test the hypothesis that the faces of patients with a severe
Class III are contemplated differently from and assessed more nega-
tively than skeletal Class I patients in direct face-to-face interaction.
Method: The eye movements of 24 randomly recruited evaluators
were analyzed with a noninvasive, infrared high-speed camera while
looking at 18 standardized frontal photographs of adult orthognathic
Class III patients and 18 photographs of adults with skeletal Class I
relationships as controls. Additionally, all images were assessed for
appearance, symmetry, and facial expression. Results: The Class III
patients were rated significantly more negatively in terms of appear-
ance, symmetry, and facial expression than the Class I individuals.
The eye movement data revealed that orthognathic patients were
appraised differently from the Class I individuals, with fewer fixations
in the face center, especially around the mouth. Conclusion: Skeletal
Class III patients were characterized as less attractive than Class I indi-
viduals. Faces of Class III patients were visually perceived with different
eye movements. These differences in visual perception are described
for the first time in the present study. Although they were small, they
are an indication of an objectively different perception of faces that are
rated subjectively as less attractive and more asymmetric and exhibit-
ing a more negative expression. World J Orthod 2010;11:153–159.

Key words: orthognathic patients, skeletal Class III occlusion, asymmetry,

face perception, eye tracking

1Lecturer, Department of Orthodontics,

Dental Clinic of the Medical Faculty,

University of Wuerzburg, Wuerzburg,
Germany.
2Professor, Department of Psychology,
University of Wuerzburg, Wuerzburg,
Germany; Professor, Department of
Psychology, University of Eichstaett,
Eichstaett, Germany.
3Lecturer, Department of Psychology,
University of Wuerzburg, Wuerzburg,
Germany.
4Chair and Professor, Department of
Orthodontics, Dental Clinic of the
Medical Faculty, University of
Wuerzburg, Wuerzburg, Germany
CORRESPONDENCE
Dr Philipp Meyer-Marcotty
Department of Orthodontics
Dental Clinic of the Medical Faculty
Pleicherwall 2
D-97070 Wuerzburg
Germany
Email:
Meyer_P1@klinik.uni-wuerzburg.de
he face is the principal source of
T communication in human interac-
tions. Facial perception and rating of
facial attractiveness are controlled by
factors such as averageness, youthful-
ness, and symmetry.1 A harmonious and
symmetric body shape is a central cue
for attractiveness. Evolutionary theories
explain this with the assumption that
symmetry may be a signal of health and
genetic fitness. Because only healthy
individuals can maintain symmetric
development under environmental
stress, symmetry may serve as an indi-
cator of superior phenotypic, as well as
genotypic, quality.
Patients with severe facial deformities
have been reported to be judged more
negatively than controls.2 In particular,
Philipps et al reported that subjects with
Class I profiles are rated as more attrac-
tive than those with a Class II or Class III
profile by patients, laypersons, orthodon-
tists, and oral surgeons.3 Furthermore, it
has been shown that malocclusions might
cause social deprivation.4,5 It was also
pointed out that children with open and
deep bites, Class III relationships, and
crowding are commonly teased.6 There-
fore, dentofacial deviations have been
reported to be associated with an
increased risk for psychologic distur-
bances.7 Patients who need orthognathic
surgery are often stigmatized in social sit-
uations (including lack of popularity,
decreased opportunities for marriage, and
frequent targets of insults).2 Thus, the pri-
mary reason for undergoing surgery is
often the patients’ desire to improve their
facial and dental appearance.8

153
 Meyer-Marcotty et al
The face plays a particularly important
role in social cognition. The visual pro-
cessing of faces is unique because faces
are processed rapidly and holistically
along a specialized subcortical route.9
Symmetric faces are judged to be more
attractive. Thus, facial disharmony in
patients with a skeletal Class III relation-
ship might be a source of social and
emotional distress. However, to date, no
study has examined how others perceive
the faces of orthognathic patients with
severe skeletal Class III malocclusions
and whether they are contemplated dif-
ferently from faces of Class I patients.
A recent approach to study how faces
are envisioned is to analyze the eye move-
ments of the observer. Eyes move contin-
uously as they inspect objects. Therefore,
analysis of their movement provides valu-
able information about the perception
process. Visual perception during natural
viewing is characterized by a gaze-con-
trolled sampling strategy.10 The eyes alter-
nate between fixations and saccades,
rapid-eye movements that lead to a new
fixation in an area of interest (AOI). Noton
and Stark11 demonstrated that the distri-
bution of fixations and saccades is not
random. When individuals look at an
object, their eyes wander from feature to
feature in a regular sequence, referred to
as the scan path. Based on this principle,
Mertens et al10 analyzed how faces are
scrutinized by monitoring the perceiver’s
scan path with an eye-tracking camera.
Although it is generally agreed that severe
skeletal Class III individuals are associ-
ated with inferior facial attractiveness,
there have been no studies that objec-
tively analyzed the perception.
Therefore, the aims of this study were
to determine how faces of adult patients
with severe skeletal Class III relationships
are rated for appearance, symmetry, and
expression and whether adults with a
severe Class III occlusion are scanned dif-
ferently (for example, with an aberrant
eye-movement pattern compared to a
control group with a Class I occlusion).
154
WORLD JOURNAL OF ORTHODONTICS
METHODS AND MATERIALS
Evaluators
Twenty-four evaluators (13 women and
11 men) with a mean age of 25.4 ± 4.2
years were recruited via a newspaper
classified ad. They were paid €10 for
their participation. Inclusion criteria were
(1) normal vision, (2) not members of the
medical/dental community, (3) no cur-
rent medical or dental treatment, and (4)
no congenital facial deformity or other
distinctive facial feature.
Visual material
Black-and-white preoperative pho-
tographs of 18 adult patients presenting
with a severe skeletal Class III relation-
ship (8 women and 10 men, mean age
24.5 ± 6.8 years) and 18 individuals with
a skeletal Class I, age- and sex-matched
to the Class III group, who served as con-
trols were shown to the evaluators. All
patients and controls had consented to
the use of their photographs. The Class
III patients were designated for com-
bined orthodontic-surgical treatment in
the Department of Orthodontics, Medical
Faculty of the University of Wuerzburg.
Inclusion criteria for the Class III patients
was a Wits appraisal < –3 mm; for the
control individuals, it had to be in the
range of 0 ± 2 mm.
All faces were photographed in front
of a dark background with a neutral
expression and the eyes looking straight
ahead (Fig 1). None of the faces exhib-
ited a distinctive feature such as a pierc-
ing or tattoo. Every face was covered
beneath the chin and around the head
so that ears, hair, and other peripheral
features were screened out. The picture
size was set to 412 ⫻ 581 pixels at a
resolution of 96 pixels per inch.
Tracking device
The surveyors were seated comfortably
50 cm in front of a 17-inch monitor (with a
resolution of 1,024 ⫻ 768). The head
was stabilized by a chin and a forehead
VOLUME 11, NUMBER 2, 2010
Fig 1 (left) Example of a
frontal picture of a face used
in this study. The eye move-
ment analysis differentiated
between the central (sur-
rounded by a white line) and
the peripheral AOI (differenti-
ated by a red line).
Fig 2 (right) Experimental
setup of this study, which
recorded the examiners’ eye
movements with an infrared
camera while they viewed
facial photographs.
support to eliminate any head move-
ment (Fig 2). Picture presentation was
controlled by Presentation 0.90 (www.
neurobs.com).
Eye movements were recorded with a
video-based iView X Hi-Speed infrared
camera (SensoMotoric Instruments).
Images of the eye’s position were sam-
pled at 238 Hz and a spatial resolution of
approximately 0.5 to 1.0 degree. The eye
tracker was calibrated for each evaluator’s
right eye using an 11-point calibration
procedure.
Procedure
Photo rating. In the first part of the study,
all surveyors were instructed to rate every
photograph on a 9-point interval scale for
three conditions: appearance (1 = very
poor, 9 = very good), symmetry (1 = very
asymmetric, 9 = very symmetric), and
facial expression (1 = very negative, 9 =
very positive). These three aspects had to
be dealt with separately in random order
to avoid serial dependence of the differ-
ent ratings. By doing so, each picture was
rated three times. This resulted in a total
of 108 trials (3 ⫻ 36 pictures). The length
of inspection was evaluator-defined.
Meyer-Marcotty et al
Eye tracking. In the second part of
the study, the eye movements of the
evaluators were recorded continuously
while they viewed the individual facial
photographs. The surveyors were intro-
duced to this procedure by on-screen
instructions and four practical trials.
They were told that they would see a
series of photographs of faces at which
they could look in any way they wished.
Before each picture was displayed, a
fixation cross was presented in the center
of the screen. After the cross was continu-
ously fixated for 1.5 seconds, pho-
tographs were presented in random order.
They appeared on either the left or right
side of the screen to attain a first saccade
toward the face. Each picture was pre-
sented for 5.0 seconds. The intertrial
interval was 250 milliseconds (ms). The
experiment was interrupted by a short
break after half the photographs were
inspected. The study was conducted in
accordance with the ethical standards
established by the Institutional Board of
the Department of Orthodontics, Medical
Faculty of the University of Wuerzburg,
and with the Helsinki Declaration of
1983. All evaluators took part voluntarily
and were interviewed individually.
155
 Meyer-Marcotty et al WORLD JOURNAL OF ORTHODONTICS

100
Class III patients Central AOI P < .001
8 Class I probands Peripheral AOI
80
P < .001 P < .001 P < .001

First six fixations (%)

6
60
Rating

4
40

2
20

0 0
Appearance Symmetry Facial expression Relevant facial regions

Fig 3 Mean and standard error of the rating for appear- Fig 4 Mean and standard error of the percentage of the
ance, symmetry, and facial expression on an arbitrary nine- first six fixations in the central and the peripheral AOI in both
point interval scale. picture categories.

Data analysis

Fixations were defined as scan path data

Fig 5 Scan path of one randomly chosen
evaluator looking at a picture of a skeletal
Class III patient. Each circle represents a fix-
ation and the circle’s size the duration of the
fixation; most fixations are in the central
AOI.
limited to a maximum visual angle of
2.02 degrees for at least 80 ms (BEGAZE
Software, SensoMotoric Instruments).
For the analysis of the eye movement,
data-distinctive morphologic areas of the
face were marked as AOIs. The eyes,
nose, and mouth were defined as the
central AOI, whereas the forehead,
cheeks, and chin were subsumed as the
peripheral AOI. The cumulative duration
of all fixations was analyzed for each AOI
as an index of sustained attention span.
Furthermore, the first three fixations in
the AOI eyes, nose, and mouth (1–3)
were recorded as the index of initial
attention capture.
SPSS 14.0 (SPSS) was used for statis-
tical analysis. The t test (two-tailed) for
paired groups was used to analyze both
the eye-tracking data and the data of the
photo rating. For all analyses, the ␣-level
was set at P = .05.

156
VOLUME 11, NUMBER 2, 2010
37,000
Class III patients P = .043
Class I probands
36,000
First three fixations (%)
Duration all fixations (ms)
35,000
34,000
33,000
32,000
31,000
30,000
Central AOI
Fig 6 Mean and standard error of the duration of all fixa- Fig 7 Mean and standard error of the percentage of the
tions in the central AOI of Class III patients and Class I first three fixations in the AOI eyes, nose, and mouth in
probands. Class III patients and Class I probands.
RESULTS
Photo rating
The results of the photo rating show a sig-
nificant difference between the two groups
in every aspect (Fig 3). The photos of the
Class III patients were rated significantly
more negatively in terms of appearance,
symmetry, and facial expression than
those of the Class I individuals. The highest
mean difference was found in appearance
(Class III: mean = 3.32, SD = 1.11; Class
I: mean = 5.32, SD = 1.13; P < .001), fol-
lowed by symmetry (Class III: mean =
4.42, SD = 1.04; Class I: mean = 6.05,
SD = 0.95; P < .001), and facial expression
(Class III: mean = 3.99, SD = 0.73; Class I:
mean = 5.56, SD = 0.81; P < .001).
Eye tracking
Areas of interest. Initially, the first six fix-
ations in the central and peripheral AOI of
the evaluator’s gaze were analyzed. There
was a significant difference between the
central and the peripheral AOI: t (23) =
31.71, P < .001 (Fig 4). Overall, 88.7%
(SD = 5.98) of the first six fixations were
on the central AOI, whereas only 11.3%
on the peripheral AOI (SD = 5.98). In
Meyer-Marcotty et al
Class III patients
Class I probands
25
P = .73 P = .77 P = .046
20
15
10
5
Eyes Nose Mouth
Fig 5, one surveyor’s scan path is shown
exemplarily while scanning a photo of a
skeletal Class III patient.
Sustained attention span. The dura-
tion of all fixations in the central AOI were
registered and compared for the Class III
and I individuals. The mean fixation time
while scanning pictures of both groups is
presented in Fig 6. In Class III patients,
the mean fixation duration on the central
AOI was significantly shorter than in the
Class I individuals (Class III: mean =
34,145.86 ms, SD = 6,733.83 ms; Class I:
mean = 35,148.37 ms, SD = 6,510.71 ms;
P = .043).
Initial attention capture. To examine
the initial attention capture in facial scan-
ning of the two groups, the mean (%) of
the first three fixations was calculated.
For a more sophisticated analysis, the
central AOI of the two groups was subdi-
vided into the three AOIs: eyes, nose, and
mouth. The photos of the Class III
patients were significantly less fixated in
the mouth region than those of the Class I
individuals (Class III: mean = 5.29%, SD =
3.77; Class I: mean = 6.36%, SD = 3.96;
t(23) = 2.12, P = .046), but no significant
difference was found between the two
groups for the eyes and nose AOIs (Fig 7).
157
 Meyer-Marcotty et al
DISCUSSION
This study is the first of its kind. The
underlying hypothesis was that severe
Class III patients are perceived differently
from and judged more negatively than
skeletal Class I individuals. The fact that
Class III individuals are rated as less
attractive than matched ones with a
skeletal Class I is consistent with previ-
ous data.2,12,13
Other studies analyzed attractiveness
of facial profiles, 14,15 but there is evi-
dence that individuals primarily scan the
full faces (frontal view) of other people.16
Therefore, frontal views of the sample
were selected and they were shown to
evaluators from outside the medical com-
munity to most closely approximate real-
life situations.
The rating of the photographs by the
evaluators revealed that symmetry is a
decisive feature of attractiveness. Even-
tually, this was one reason why the sur-
veyors defined orthognathic Class III
patients as being less attractive overall.
Within this context, it should be men-
tioned that patients with mandibular
prognathism objectively exhibit a higher
degree of mandibular deviation from the
midline. 17 The more negative rating of
the facial expression in Class III patients
could be explained by the functional
organization of facial expressions across
the upper-lower facial axis. Both face
parts express emotions, but the lower
one prevails for happy-pleasant kinds of
expressions.18 The fact that a prominent
and dominant mandible or a noticeable
asymmetry are in a decoding area for
normally happy-pleasant type of expres-
sions could explain the more negative
rating observed in this study.
It is somewhat surprising that the
focus of the facial perception was on the
central AOI while the peripheral ones
comprised approximately 70% of the total
face. This finding is consistent with previ-
ous eye-movement studies. 10 For the
benefit of clinical practitioners, it has to
be emphasized that a harmonic morphol-
ogy in the central AOI should have the
greatest impact on treatment decisions.
158
WORLD JOURNAL OF ORTHODONTICS
CONCLUSION
The faces of Class III or thognathic
patients were perceived as less attractive
than those of a control group. In direct
face-to-face inspection, these patients
were contemplated differently. The eye
movements during visual perception of
patients with a severe Class III occlusion
were characterized by fewer fixations in
the central face area, especially around
the mouth. Although the differences
between the two groups were small, this
finding is an indication that faces of
severe Class III patients are rated subjec-
tively as less attractive and more asym-
metric and as exhibiting a more negative
facial expression.
REFERENCES
1. Rhodes G. The evolutionary psychology of facial
beauty. Annu Rev Psychol 2006;57:199–226.
2. Lee LW, Chen SH, Yu CC, Lo LJ, Lee SR, Chen
YR. Stigma, body image, and quality of life in
women seeking orthognathic surgery. Plast
Reconstr Surg 2007;120:225–231.
3. Phillips C, Griffin T, Bennett E. Perception of
facial attractiveness by patients, peers, and
professionals. Int J Adult Orthodon Orthognath
Surg 1995;10:127–135.
4. Stricker G, Clifford E, Cohen LK, Giddon DB,
Meskin LH, Evans CA. Psychosocial aspects of
craniofacial disfigurement. A “State of the Art”
assessment conducted by the Craniofacial
Anomalies Program Branch, The National Insti-
tute of Dental Research. Am J Orthod 1979;
76:410–422.
5. Heldt L, Haffke EA, Davis LF. The psychological
and social aspects of orthognathic treatment.
Am J Orthod 1982;82:318–328.
6. Kijak HA. Cultural and psychologic influences
on treatment demand. Semin Orthod 2000;6:
242–248.
7. Rivera SM, Hatch JP, Rugh JD. Psychosocial fac-
tors associated with orthodontic and orthog-
nathic surgical treatment. Semin Orthod 2000;
6:259–269.
8. Hunt OT, Johnston CD, Hepper PG, Burden DJ.
The psychosocial impact of orthognathic
surgery: A systematic review. Am J Orthod
Dentofacial Orthop 2001;120:490–497.
9. Alpers GW, Gerdes AB. Here is looking at you:
Emotional faces predominate in binocular
rivalry. Emotion 2007;7:495–506.
10. Mertens I, Siegmund H, Grüsser OJ. Gaze
motor asymmetries in the perception of faces
during a memory task. Neuropsychologia
1993;31:989–998.
VOLUME 11, NUMBER 2, 2010
11. Noton D, Stark I. Eye movements and visual
perception. Sci Am 1971;224: 35–43.
12. van Steenbergen E, Litt MD, Nanda R. Presurgi-
cal satisfaction with facial appearance in
orthognathic surgery patients. Am J Orthod
Dentofacial Orthop 1996;109:653–659.
13. Stirling J, Latchford G, Morris DO, Kindelan J,
Spencer RJ, Bekker HL. Elective orthognathic
treatment decision making: A survey of patient
reasons and experiences. J Orthod 2007;34:
113–127.
14. Czarnecki ST, Nanda RS, Currier GF. Percep-
tions of a balanced facial profile. Am J Orthod
Dentofacial Orthop 1993;104:180–187.
15. Johnston C, Hunt O, Burden D, Stevenson M,
Hepper P. The influence of mandibular promi-
nence on facial attractiveness. Eur J Orthod
2005;27:129–133.
Meyer-Marcotty et al
16. Lundström A, Popovich F, Woodside DG. Panel
assessments of the facial frontal view as
related to mandibular growth direction. Eur J
Orthod 1989;11:290–297.
17. Good S, Edler R, Wertheim D, Greenhill D. A
computerized photographic assessment of the
relationship between skeletal discrepancy and
mandibular outline asymmetry. Eur J Orthod
2006;28:97–102.
18. Ross ED, Prodan CI, Monnot M. Human facial
expressions are organized functionally across
the upper-lower facial axis. Neuroscientist
2007;13:433–446.
159
THE USE OF CARIOGRAM TO EVALUATE Anas H. Al Mulla, BDS, MSc1

CARIES-RISK PROFILES IN ORTHODONTIC Saad Al Kharsa, DDS, MSc2

Heidrun Kjellberg, BDS, PhD3

PATIENTS
Dowen Birkhed, BDS, PhD4
This article describes the usefulness of Cariogram software in three
orthodontic patients with high-, medium-, and low-risk caries profiles.
Caries-related indicators and information needed for the Cariogram
model were registered. The prebonding decayed and filled surfaces
(DFS) indices for patient 1 (15-year-old girl) and patient 2 (18-year-old
woman) were > 5, while in patient 3 (15-year-old boy), the DFS index
was < 2. The data were entered into the interactive Cariogram soft-
ware, which shows the various caries-related indicators. Patients 1, 2,
and 3 had 6%, 58%, and 87%, respectively, actual chance of avoiding
new caries. Patient 1 had high lactobacilli and medium mutans strep-
tococci scores and a high caries risk. Patient 2 had a high DFS index
and low buffer capacity, resulting in a medium caries risk. Patient 3
had low mutans streptococci and high lactobacilli scores and a low
DFS index, resulting in a low caries risk. The Cariogram is available
free online and is a useful educational model to illustrate a patient’s
caries risk. World J Orthod 2010;11:160–167.

Key words: Cariogram, caries risk, DFS, risk indicator, risk model, mutans
streptococci

1Dentist and PhD Resident, Depart-

aries affects individuals differently,
C which makes it essential to identify
high-risk patients so preventive strategies
ments of Cariology and Orthodontics,
The Sahlgrenska Academy, University
on various caries indicators, such as
saliva, microbiology, diet, oral hygiene,
and caries history.7 Caries experience6;
of Gothenburg, Gothenburg, Sweden.
2Private Practice; Consultant, Visiting

Faculty, Department of Orthodon-

can be undertaken. Krasse introduced
the term risk assessment in relation to
dental caries more than 20 years ago.1
Since then, it has been an interesting
topic in dentistry.
The concept of caries-risk assess-
ment is simple and straightforward. The
idea is to (1) identify patients who are
most likely to develop caries and (2) pro-
vide these individuals with appropriate
preventive measures to stop caries
occurrence. Caries-risk assessment and
prediction have been focus areas for the
past 2 decades. 2 Many studies have
been published in this field,3–6 centered
decayed, missing, filled surfaces or
decayed, missing, filled teeth (DMFS or
DMFT) 8 ; and the amount of mutans
streptococci in plaque or saliva 9 are
related to caries risk. A free online pro-
gram, the Cariogram,10 has been devel-
oped to illustrate caries-risk profiles in
teenagers and adolescents. It is interac-
tive software that illustrates various
caries-related indicators and expresses
the actual chance of avoiding new caries.
The purpose of this article is to demon-
strate the usefulness of Cariogram in clin-
ical orthodontics by presenting three
patients with different caries-risk profiles.
tics, King Saud University, Riyadh,
Kingdom of Saudi Arabia.
3Associate Professor and Clinical
Director of Postgraduate Education,
Department of Orthodontics, The
Sahlgrenska Academy, University of
Gothenburg, Gothenburg, Sweden.
4Professor and Chair, Department
of Cariology, The Sahlgrenska
Academy, University of Gothenburg,
Gothenburg, Sweden.
CORRESPONDENCE
Dr Anas H. Al Mulla
PO Box 450, SE-405 30
Gothenburg
Sweden
Email: a.almulla@mac.com

160
VOLUME 11, NUMBER 2, 2010
Fig 1 A Cariogram as it appears after
entering the data for a patient. The pie
chart shows the actual chance to avoid
new caries (green sector, 27% in this
example).
METHODS AND MATERIALS
From an earlier study11 of 100 patients,
three subjects were selected for this
report. They were chosen to present the
three major caries-risk groups: high,
medium, and low. The preorthodontic
examination charts, panoramic radio -
graphs, and intraoral photos of these
patients were carefully examined by the
same orthodontist. Prebonding, patient 1
(a 15-year-old girl) and patient 2 (an 18-
year-old woman) both had DFS indices
> 5, while in patient 3 (a 15-year-old boy),
it was < 2. None underwent any restora-
tive therapy during their orthodontic ther-
apy. They were treated with fixed
appliances in both jaws for 1 to 2 years
(mean treatment duration 18 months).
Synergy brackets were used (Rocky
Mountain Orthodontics), bonded with
Reliance light bond material (Reliance
Orthodontic Products). After bonding, rou-
tine instructions were given to all three
patients to brush their teeth three times
daily with fluoride toothpaste.
After debonding, the patients were
examined again in the following order:
data collection, plaque score, caries
examination, saliva sample, radiographs
(bitewing and panoramic), and intraoral
digital photographs.
A standardized form was used to col-
lect the data needed for the Cariogram.
Each of the 10 parameters was ranked
from 0 to 2 or 0 to 3 according to the man-
ual10 (Table 1). All data were entered into
the software to illustrate the chance of
avoiding caries as a percentage (Fig 1).
Not to change the built-in evaluation, the
tenth factor—clinical judgment—was set to
score 1 in all three patients. In accordance
Al Mulla et al
10%
27%
26%
21%
16%
Diet Bacteria Susceptibility
Actual chance to
Circumstances avoid new caries
with the Cariogram manual,10 all three
individuals were asked about the pres-
ence of general disease, diet frequency,
and fluoride. They are described as re-
lated diseases, diet frequency, and fluo-
ride program, respectively, in Table 1.
Prophylaxis and flossing were per-
formed before caries registration. Using
optimal light, a mirror, and an explorer, all
types of caries lesions, in both the enamel
and dentin, diagnosed clinically and on
the bitewing radiographs, were included in
the DFS index. White spot lesions were
registered but not included. Thus, only
caries was captured in the caries experi-
ence, in accordance with the Cariogram.10
For plaque scoring, four scores were
used according to Silness and Löe 12
(Table 1). The amount of plaque in the
cervical part of teeth 16, 12, 24, 36, 32,
and 44 were registered buccally and lin-
gually and on the proximal surfaces (FDI
tooth-numbering system).
Paraffin-stimulated whole saliva was
collected for 3 minutes; the secretion rate
was expressed in mL/min and trans-
formed to a score (Table 1). The same
stimulated saliva was used to evaluate
buffer capacity and the number of cario-
genic microorganisms. Buffer capacity
was checked by giving one drop of saliva
on a buffer strip (Dentobuff Strip, Orion
Diagnostica). Depending on the color, the
saliva was scored (blue = 0, green = 1, yel-
low = 2). The remaining saliva was poured
on the Dentocult LB (Dentocult LB, Orion
Diagnostica) agar and incubated at 37°
for 4 days to estimate the lactobacillus
(LB) count. Subsequently, the colony den-
sity on the agar was compared to the
respective model chart (Table 1). To deter-
mine the count of mutans streptococcus
161
 Al Mulla et al WORLD JOURNAL OF ORTHODONTICS

Table 1 Sectors, variables, and scores of the Cariogram

Sector Variable Score

Circumstances Caries experience 0: DFS = 0, caries-free and no fillings

(yellow sector) 1: DFS = 1–2, better than normal for age group
2: DFS = 2–4, normal for age group
3: DFS > 4, worse than normal for age group
Circumstances Related diseases 0: No systemic disease
(yellow sector) 1: Diseases/condition, mild degree
2: Severe degree, long lasting
Diet Diet content, 0: LB < 102 CFU/mL
(dark blue sector) Lactobacillus count (LB) 1: 102 ≤ LB < 103 CFU/mL
2: 103 ≤ LB < 104 CFU/mL
3: LB ≥ 104 CFU/mL
Diet Diet frequency, 0: Maximum 3 intakes per day
(dark blue sector) number of intakes per day 1: Maximum 5 intakes per day
(meals and snacks) 2: Maximum 7 intakes per day
3: More than 7 intakes per day
Bacteria Plaque amount 0: No plaque
(red sector) 1: Film of plaque adhering to the free gingival margins and adjacent area of the tooth
2: Moderate accumulation of soft deposits in the gingival pocket or on the tooth gingival margins
3: Abundance of soft matter within the gingival pocket and/or on the tooth gingival margins
Bacteria Mutans streptococci 0: MS < 103 CFU/mL
(red sector) count (MS) 1: 103 ≤ MS < 104 CFU/mL
2: 104 ≤ MS < 105 CFU/mL
3: MS ≥ 105 CFU/mL
Susceptibility Fluoride program 0: Fluoride toothpaste plus fluoride tablets, rinsing, and varnishes (frequently)
(light blue sector) 1: Fluoride toothpaste plus fluoride tablets, rinsing, and varnishes (infrequently)
2: Only fluoride toothpaste
3: No fluoride
Susceptibility Saliva secretion rate 0: 1.1 mL/min or more
(light blue sector) 1: From 0.9 to less than 1.1 mL/min
2: From 0.5 to less than 0.9 mL/min
3: Less than 0.5 mL/min
Susceptibility Saliva buffer capacity 0: pH > 5.5
(light blue sector) 1: pH < 5.5–4.5
2: pH < 4.5
– Clinical judgment 0: More positive than what the Cariogram shows based on the scores entered
1: Normal setting, risk according to the other values entered
2: Worse than what the Cariogram shows based on the scores entered
3: Very high caries risk, examiner is convinced that caries will develop, irrespective of what the
Cariogram shows based on the scores entered

(MS), a tongue swab of Dentocult SM illustrate five color-coded sectors with

(Strip Mutans, Orion Diagnostica) was
incubated at 37° for 2 days. Thereafter,
the colony density on the test strip was
compared with a model chart (Table 1).
Figure 1 shows how the Cariogram
appears on-screen. The respective values
have to be entered on the right side. The
country and group have to be defined to
determine whether there is a low, me -
dium, or high risk of caries development.
This will dramatically affect the overall
Cariogram profile. After entering at least
seven (preferably 10) variables/factors,
the Cariogram pie chart appears. Based
on the formula inserted in the Cariogram,
all values interact with each other and
percentage values. The green sector indi-
cates the chance of avoiding caries. The
program was developed by Douglas
Bratthall more than 10 years ago13 and
was recently evaluated by Petersson et
al.14–17
RESULTS
The Cariogram-related factors and the
scores for the three patients of this study
are shown in Table 2. All were healthy, con-
sidered free from caries-related diseases,
ate a maximum of three meals/snacks per
day, and used only fluoride toothpaste.

162
VOLUME 11, NUMBER 2, 2010 Al Mulla et al

Fig 2 Patient 1. The clinical photo -

graphs show several white spot lesions
and the bitewing radiographs show one
approximal caries lesion. The Cariogram
shows a 6% chance to avoid new caries
because of many negative indicators,
including diet, mutans streptococci, lacto-
bacilli, and saliva secretion rate.

5%
6%

8%

8%

72%

Diet Bacteria Susceptibility

Actual chance to Table 2 Debonding caries status and caries-related variables
Circumstances avoid new caries
according to Cariogram for patients 1, 2, and 3*
Patient
Factor 1 2 3

DFT/DFS 10/12 (3) 12/17 (3) 1/1 (1)

Related diseases No (0) No (0) No (0)
Lactobacilli High (3) Low (1) Very low (0)
Diet frequency (0) (0) (0)
Plaque Index (1) (3) (1)
Mutans streptococci Medium (2) Low (1) Very low (0)
Fluoride program (2) (2) (2)
Secretion rate Very Low (3) Normal (0) Normal (0)
Buffer capacity Reduced (1) Reduced (1) Adequate (0)

*Scores in parentheses.

Patient 1 and medium MS (score 2), respectively.

The actual chance of avoiding new caries
was 6% in patient 1 (Fig 2), which meant
she had a high risk for developing new
caries. The dark blue and red sectors
(diet and bacteria, respectively) were 8%
and partly related to high LB (score 3)
The susceptibility (light blue sector) was
72% due in part to a low secretion rate
(score 3). The absence of caries-related
diseases (score 0) and high DFT/DFS
(score 3) contributed in part to 5% other
circumstances (yellow sector). Her clinical
photographs showed multiple composite

163
 Al Mulla et al
fillings, sealed fissures, and white spot
lesions on the buccal surfaces of her
molars, and the bitewing radiographs
revealed one proximal caries lesion (dis-
tal to tooth 23).
Patient 2
Patient 2’s actual chance of avoiding new
caries was 58%, which meant she had a
medium risk for developing new caries
(Fig 3). Low LB (score 1) and appropriate
diet frequency (score 0) contributed to 4%
diet (dark blue sector). The Cariogram
bacteria (red sector) share was 17%, par-
tially due to a high plaque score (score 3).
Her low buffer capacity (score 1), the use
of only fluoride toothpaste (score 2), and
a normal secretion rate (score 0) resulted
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WORLD JOURNAL OF ORTHODONTICS
Fig 3 Patient 2. The clinical pho-
tographs show many amalgam fillings
and enamel deficiencies. There are two
approximal caries lesions. The Cario -
gram shows a 58% chance to avoid
new caries, mostly because of many
positive indicators (except plaque
amount).
4%
17%
58% 13%
8%
Diet Bacteria Susceptibility
Actual chance to
Circumstances avoid new caries
in 13% susceptibility (light blue sector).
Her other circumstances (yellow sector)
were 8%, due in part to high DFT/DFS
(score 3). Her clinical photographs
showed many amalgam fillings and multi-
ple enamel defects, which made the diag-
nosis of white spot lesions difficult. On
her bitewing radiographs, two proximal
caries lesions were obvious (mesial and
distal to tooth 35).
Patient 3
Patient 3’s actual chance of avoiding
new caries was 87%, which hinted at a
low caries risk (Fig 4). A low LB (score 0)
and an appropriate diet frequency (score
0) contributed to 1% diet (dark blue sec-
tor). Low MS (score 0) and Plaque Index
VOLUME 11, NUMBER 2, 2010
Fig 4 Patient 3. The clinical photo -
graphs show no sign of caries (but den-
tal fluorosis). One approximal caries
lesion is obvious on his bitewing radio-
graphs. The Cariogram shows overall
positive indicators and 87% chance to
avoid new caries.
3%
1% 7%
2%
87%
Diet Bacteria Susceptibility
Actual chance to
Circumstances avoid new caries
(score 1) resulted in 3% bacteria (red sec-
tor). His normal buffer capacity (score 0),
use of only fluoride toothpaste (score 2),
and normal secretion rate (score 0)
brought susceptibility (light blue) to 7%.
The absence of caries-related diseases
and low DFT/DFS (score 1) contributed in
part to 2% other circumstances (yellow
sector). His photographs showed signs of
dental fluorosis and no fillings. On his
bitewing radiographs, only one proximal
caries lesion was detected (mesial to
tooth 46).
DISCUSSION
After therapy with fixed orthodontic appli-
ances, enamel demineralization occurs
in up to 50% of all patients.18,19 A study
Al Mulla et al
by Benson et al20 concluded that ortho-
dontic patients display increased enamel
demineralization after wearing fixed
appliances. Many studies described how
to prevent and reduce caries during
orthodontic treatment,21–29 but orthodon-
tists are still not always implementing the
available action plans to prevent enamel
demineralizations. 30,31 Or thodontic
patients are often young and have many
newly erupted teeth, which increases the
risk of demineralization in those regions
adjacent to brackets.32
In this report, the caries risk profiles of
three patients at debonding based on the
Cariogram are demonstrated. This educa-
tional model has previously been used in
children, adults,15,33 and specifically in
orthodontic patients.11 It assesses and
predicts the caries risk and can be used
165
 Al Mulla et al
5%
6%
8%
8%
72%
Diet Bacteria Susceptibility
Actual chance to
Circumstances avoid new caries
routinely in the clinic. It illustrates caries-
related factors and suggests respective
actions. Only seven values are required for
its application. The chairside microbiologic
tests are easy to perform and can be eval-
uated by dental assistants. The model is
freeware, user-friendly, and easy to under-
stand. It can be used to motivate patients
and develop preventive strategies.
The Cariogram varies dramatically if
individual values are changed. For exam-
ple, patient 1 is highly affected by low
saliva secretion, so increasing it will also
increase her actual chance of avoiding
new caries (Fig 5). The reason for this low
saliva secretion has to be investigated,
especially since she is still young. In any
case, she could use sugar-free chewing
gum and lozenges to stimulate her saliva
secretion.
Many studies have been aimed at the
reduction of caries in or thodontic
patients.21–24,26,27,29 Taking bitewing radio-
graphs in teenagers before orthodontic
treatment is important for caries-risk
assessment. They allow clinicians to diag-
nose initial approximal caries lesions,
which may not be detected clinically. In
this study, white spot lesions were regis-
tered but not used as DFT/DFS values in
the Cariogram according to the manual.10
However, with white spot lesions or areas
of demineralization are caries lesions of
varying depths.18,19,34 Therefore, not to
include them and bitewing radiographs
seems to be a weakness of the Cariogram.
They should be considered if it is changed
in the future, especially for teenagers
undergoing orthodontic treatment.
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WORLD JOURNAL OF ORTHODONTICS
Fig 5 Two Cariograms for
patient 1. By increasing the
9% saliva secretion rate, thus
reducing the score from 3 to 2,
the green sector will dramati-
24% 38% cally increase from 6% to
38%.
14%
14%
Diet Bacteria Susceptibility
Actual chance to
Circumstances avoid new caries
Orthodontists should be aware of their
patients’ caries-risk profiles, and patients
with a high risk should be informed of it.
An effective fluoride program can be
helpful. At the same time, these patients
should be seen more frequently to
receive professional prophylaxis including
topical fluoride application. Superior oral
hygiene and rinsing with fluoride solu-
tions once or twice daily should be
advised. There is still not much informa-
tion available about caries-related pre-
ventive measures that orthodontists
actually use.30 Therefore, practice guide-
lines need to be developed including
caries-risk assessment.
CONCLUSION
The Cariogram software is available free
online. It could be a useful tool to edu-
cate patients about their individual
caries-risk profile. If this risk is known,
the orthodontist can easily install an ade-
quate customized preventive program.
REFERENCES
1. Krasse B. Biological factors as indicators of
future caries. Int Dent J 1988;38:219–225.
2. Hausen H. Caries prediction. In: Fejeskov O,
Kidd E (eds). Dental Caries, The Disease and
Its Clinical Management, ed 2. Oxford: Black-
well Munksgaard, 2008:527–541.
3. Disney JA, Abernathy JR, Graves RC, Mauriello
SM, Bohannan HM, Zack DD. Comparative
effectiveness of visual/tactile and simplified
screening examinations in caries risk assess-
ment. Community Dent Oral Epidemiol 1992;
20:326–332.
VOLUME 11, NUMBER 2, 2010
4. van Loveren C, van Palenstein Helderman WH.
Identification of caries risk patients 1. An
overview of predictive models [in Dutch]. Ned
Tijdschr Tandheelkd 2003;110:435–438.
5. Schiffner U, Torres-Quintero A. Reproducibility
of a new caries risk test under different oral
conditions. Clin Oral Investig 2005;9:187–191.
6. Zhang Q, van Palenstein Helderman WH.
Caries experience variables as indicators in
caries risk assessment in 6-7-year-old Chinese
children. J Dent 2006;34:676–681.
7. Leverett DH, Proskin HM, Featherstone JD, et al.
Caries risk assessment in a longitudinal discrim-
ination study. J Dent Res 1993;72:538–543.
8. Motohashi M, Yamada H, Genkai F, et al. Employ-
ing dmft score as a risk predictor for caries devel-
opment in the permanent teeth in Japanese
primary school girls. J Oral Sci 2006;48:233–237.
9. Thenisch NL, Bachmann LM, Imfeld T, Leise-
bach Minder T, Steurer J. Are mutans strepto-
cocci detected in preschool children a reliable
predictive factor for dental caries risk? A sys-
tematic review. Caries Res 2006;40:366–374.
10. Cariogram computer program manual.
http://www.mah.se/fakulteter-och-omraden/
Odontologiska-fakulteten/Avdelning-och-kansli/
Cariologi/Cariogram. Accessed 4 April 2010.
11. Al Mulla A, Kharsa SA, Kjellberg H, Birkhed D.
Caries risk profiles in orthodontic patients at
follow-up using Cariogram. Angle Orthod 2009;
79:323–330.
12. Silness J, Löe H. Periodontal disease in preg-
nancy. II. Correlation between oral hygiene and
periodontal condtion. Acta Odontol Scand
1964;22:121–135.
13. Bratthall D. Dental caries: Intervened—inter-
rupted—interpreted. Concluding remarks and
cariography. Eur J Oral Sci 1996;104:486–491.
14. Petersson GH, Bratthall D. Caries risk assess-
ment: A comparison between the computer
program ‘Cariogram’, dental hygienists and
dentists. Swed Dent J 2000;24:129–137.
15. Hänsel Petersson G, Twetman S, Bratthall D.
Evaluation of a computer program for caries
risk assessment in schoolchildren. Caries Res
2002;36:327–340.
16. Petersson GH. Assessing caries risk—Using the
Cariogram model. Swed Dent J Suppl
2003:1–65.
17. Hänsel Petersson G, Fure S, Bratthall D. Evalua-
tion of a computer-based caries risk assess-
ment program in an elderly group of individuals.
Acta Odontol Scand 2003;61:164–171.
18. Artun J, Brobakken BO. Prevalence of carious
white spots after orthodontic treatment with
multibonded appliances. Eur J Orthod 1986;
8:229–234.
19. Gorelick L, Geiger AM, Gwinnett AJ. Incidence
of white spot formation after bonding and
banding. Am J Orthod 1982;81:93–98.
20. Benson PE, Pender N, Higham SM. An in situ
caries model to study demineralisation during
fixed orthodontics. Clin Orthod Res 1999;2:
143–153.
Al Mulla et al
21. Hua YM, Chen J, Jean G. The preventive effective-
ness in reducing tooth decay and decalcification
of different concentration of fluoride toothpaste
for orthodontic patients [in Chinese]. Hua Xi Kou
Qiang Yi Xue Za Zhi 2006;24:146–147.
22. de Moura MS, de Melo Simplício AH, Cury JA. In-
vivo effects of fluoridated antiplaque dentifrice
and bonding material on enamel demineraliza-
tion adjacent to orthodontic appliances. Am J
Orthod Dentofacial Orthop 2006;130:357–363.
23. Cain K, Hicks J, English J, Flaitz C, Powers JM,
Rives T. In vitro enamel caries formation and
orthodontic bonding agents. Am J Dent 2006;
19:187–192.
24. Ahn SJ, Lim BS, Lee YK, Nahm DS. Quantitative
determination of adhesion patterns of cario-
genic streptococci to various orthodontic adhe-
sives. Angle Orthod 2006;76:869–875.
25. Benson PE, Shah AA, Millett DT, Dyer F, Parkin
N, Vine RS. Fluorides, orthodontics and dem-
ineralization: A systematic review. J Orthod
2005;32:102–114.
26. Zimmer BW, Rottwinkel Y. Assessing patient-
specific decalcification risk in fixed orthodontic
treatment and its impact on prophylactic proce-
dures. Am J Orthod Dentofacial Orthop 2004;
126:318–324.
27. Pascotto RC, Navarro MF, Capelozza Filho L,
Cury JA. In vivo effect of a resin-modified glass
ionomer cement on enamel demineralization
around orthodontic brackets. Am J Orthod
Dentofacial Orthop 2004;125:36–41.
28. Demito CF, Vivaldi-Rodrigues G, Ramos AL,
Bowman SJ. The efficacy of a fluoride varnish
in reducing enamel demineralization adjacent
to orthodontic brackets: An in vitro study.
Orthod Craniofac Res 2004;7:205–210.
29. Borutta A, Pala E, Fischer T. Effectiveness of a
powered toothbrush compared with a manual
toothbrush for orthodontic patients with fixed
appliances. J Clin Dent 2002;13:131–137.
30. Derks A, Kuijpers-Jagtman AM, Frencken JE,
Van’t Hof MA, Katsaros C. Caries preventive
measures used in orthodontic practices: An
evidence-based decision? Am J Orthod Dento-
facial Orthop 2007;132:165–170.
31. O’Neill J. Little evidence exists about optimal
caries-prevention strategies during orthodontic
treatment. Evid Based Dent 2004;5:97.
32. Kukleva MP, Shetkova DG, Beev VH. Compara-
tive age study of the risk of demineralization
during orthodontic treatment with brackets.
Folia Med (Plovdiv) 2002;44:56–59.
33. Alian AY, McNally ME, Fure S, Birkhed D.
Assessment of caries risk in elderly patients
using the Cariogram model. J Can Dent Assoc
2006;72:459–463.
34. van der Veen MH, Mattousch T, Boersma JG.
Longitudinal development of caries lesions
after orthodontic treatment evaluated by quan-
titative light-induced fluorescence. Am J Orthod
Dentofacial Orthop 2007;131:223–228.
167
THE HYBRID ORTHODONTIC TREATMENT Tomio Ikegami, DDS, MS1

SYSTEM (HOTS) Ricky Wing-Kit Wong,

PhD2

This paper describes the Hybrid Orthodontic Treatment System Urban Hägg, DDS3
(HOTS), an innovative method used in first premolar extraction cases.
It comprises the following three components: (1) a miniscrew, (2) Wilson Lee, MOrthRCSEd4
dual-dimension wires, and (3) multiloop edgewise archwires. HOTS
consists of four clearly defined treatment steps: (1) setup, (2) leveling, Kyoko Hibino,
(3) separate but simultaneous anterior and canine teeth retraction, MOrthRCSEd5
and (4) final adjustment. HOTS achieves a predictable treatment out-
come with a shorter treatment time. World J Orthod 2010;11:168–179.

Key words: HOTS, treatment mechanics, treatment efficiency, sliding

mechanics

or the treatment of first premolar the lingual cortical bone. Consequently,

F extraction cases with edgewise
mechanics, the traditional methods of
retracting the six anterior teeth are initial
retraction of the two canines followed by
the retraction of the four incisors (two-
stage retraction) 1–4 or moving all six
anterior teeth lingually (en masse retrac-
this may lead to prolonged treatment
times. What is needed then is an effi-
cient treatment system that achieves
predictable treatment outcomes with a
shorter treatment time without being
dependent upon patient compliance.
Three advances in the field of ortho-
1Honorary Clinical Associate Professor,
Discipline of Orthodontics, Faculty
of Dentistry, The University of Hong
Kong SAR, China; Kumamoto Ortho-
dontic Center, Kumamoto City,
Japan.
2Associate Professor, Discipline of

tion).5,6 Each method has its advantages
and disadvantages. The former has an
advantage when retracting the canines;
they can travel along the alveolar trough,
which is between the labial and lingual
cortical bone in the narrow canine area.
This method requires a longer treatment
time because each separate retraction
can take as long as 6 months to com-
plete. In the latter method, it is advanta-
geous that the full retraction can be
star ted earlier than in the former
method, but the direction of the canine
retraction might not be as favorable
because the canines are retracted
straight backward, which interferes with
dontics have led to the creation of a new Orthodontics, Faculty of Dentistry,
treatment system for first premolar The University of Hong Kong SAR,
extraction cases: (1) the miniscrew7–9; China.
3Chair and Professor, Discipline of
(2) the dual-dimension wire (DDW), which
Orthodontics, Faculty of Dentistry,
has an anterior rectangular portion and The University of Hong Kong SAR,
a round posterior portion10; and (3) the China.
4Private Practice in Orthodontics,
multiloop edgewise archwire (MEAW),
which is a 0.016 ⫻ 0.022-inch stainless Hong Kong SAR, China.
5Private Practice in Orthodontics,
steel rectangular wire with multiple
Singapore.
L-loops. 11,12 Because this new system
combines these three devices with a CORRESPONDENCE
new treatment concept, it is named the Dr Tomio Ikegami
Hybrid Orthodontic Treatment System 64 Karashima-chou
Kumamoto-city
(HOTS). This paper describes HOTS and Kumamoto 860-0804
illustrates its use with a case report. Japan
Email: tiddsms@koc.or.jp

168
VOLUME 11, NUMBER 2, 2010
HOTS
The essential feature of this system is the
insertion of miniscrews into the buccal
sides of the maxillary alveolar bone usu-
ally between the maxillary second premo-
lars and the first molars, allowing the
maxillary canines to be retracted along
the canine curvature with the round por-
tion of the DDW, simultaneously retract-
ing the four incisors with the rectangular
portion controlling their torque (Fig 1).
Simultaneous movements are achieved
with the utilization of multiple elasto -
meric modules or closed coil springs that
run from the inserted miniscrew on the
left and right sides of the maxillary arch,
respectively. This method of anterior
retraction clearly differs from the previ-
ously mentioned traditional methods. In
the finishing stage, after the closure of
the extraction space, MEAW is used to
further fine-tune the overjet, overbite, and
posterior occlusal relationship. Thus,
HOTS combines the simplicity of the slid-
ing mechanics with the versatility of the
MEAW treatment method, improving
treatment efficiency and quality without
being dependent upon the patient com-
pliance, which is one of the major unpre-
dictable factors in orthodontic treatment.
HOTS SETUP
HOTS can use either standard or pread-
justed edgewise bracket systems. In this
paper, all descriptions are made presup-
posing a 0.018-inch slot size. Users of
the 0.022-inch slot size should adjust the
size of the wires accordingly. Double buc-
cal tubes are used for both the maxillary
and mandibular first molars to control
the anterior overbite by using intrusion
arch mechanics.13,14 Because headgear
is not used in this system, the auxiliary
tube at the maxillary first molar is used
to accommodate auxiliary archwires. The
double tube is also used, especially in
the mandibular arch, to accommodate
the distal end hook (DEH), which was
developed to allow an alternative to
miniscrews (Fig 2). In HOTS, miniscrews
are usually placed only in the maxilla
between the maxillary second premolar
Ikegami et al
CR CR
Fig 1 HOTS with simultaneous retraction
of the maxillary canine and the incisors.
CR = center of resistance.
and first molar bilaterally. In our experi-
ence, miniscrews placed in the mandible
are likely to have a greater tendency to
fail. This observation is in accordance
with the results obtained by Sung et al.15
In addition, it is more difficult to place
miniscrews in the proper position due to
the narrow attached gingival area.
Besides, the broad mesial surface areas
of the roots of the mandibular molars
leads to less anchorage loss than that of
the maxillary first molars, providing they
are protracted in an upright position,
something that is possible with the DEH.
Insertion of miniscrews in the mandible
is considered only if maximum anchorage
is required.
DISTAL END HOOK
The DEH is 5 to 7 mm in height and
inserted from the posterior to the anterior
through the mandibular first molar auxil-
iary tube (Fig 2a). As this hook is currently
not marketed, the clinician has to create
one by bending 0.017 ⫻ 0.025-inch stain-
less steel wire. To reduce deformations,
prior to use, the hook needs to be heat
treated to increase its stiffness. The DEH
is a removable auxiliary device, which can
be utilized only when its use is indicated.
As the point of force application is near
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 Ikegami et al WORLD JOURNAL OF ORTHODONTICS

a b c
Fig 2 (a) Insertion of DEH at the mandibular left first molar, (b) DEH in place with a coil spring to an anterior hook, and
(c) position of the molar after space closure. Note how the tooth has become upright by comparing it with the lamina dura
showing the previous position.

0.012 Ni-Ti wire 0.016 Ni-Ti wire

0.016 X 0.022 Ni-Ti wire Dual-dimension wire

0.017 X 0.025 anterior & 0.016 posterior

MEAW 0.016 X 0.022 Stainless steel wire

Fig 3 Wires used in HOTS with 0.018 ⫻ 0.025-inch bracket slots.

the center of resistance, the mesial tip-
ping tendency of these teeth will be pre-
vented, as well as increasing anchorage.
When protraction of the mandibular pos-
terior teeth is intended, though, the DEH
enables bodily mesial movement of these
teeth, although the protracting speed is
significantly reduced (Figs 2b and 2c).
One possible adverse effect of this
force system is the occurrence of buccal
flare out of the distal part of the mandibu-
lar first molars and the consequent buccal
displacement of the adjacent second
molars. There are two ways to avoid this
unfavorable effect. One is to counterrotate
the first molar by incorporating a strong
distal offset. The other is to make the sec-
ond molars occlude tightly to accomplish
stabilization. Of course, stiff continuous
archwires, including DDWs, should be
used rather than thin archwires, soft arch-
wires, or MEAW because all of these wires
allow relatively free and uncontrollable
individual tooth movement.

170
VOLUME 11, NUMBER 2, 2010
a b
d e
Fig 4 Steps of HOTS treatment: (a) Stage I, (b) Stage II-1, (c) Stage II-2, (d) Stage II-3, (e) Stage III, and (f) Stage IV.
ARCHWIRES USED IN HOTS
For 0.018 ⫻ 0.025-inch slot edgewise
bracket systems, the following sequence
of five archwires are usually used (Fig 3):
0.012-inch Ni-Ti round archwire, 0.014-
inch or 0.016-inch round Ni-Ti archwire,
0.016 ⫻ 0.022-inch rectangular Ni-Ti
archwire, DDW (anterior 0.017 ⫻ 0.025-
inch rectangular and posterior 0.016-inch
round archwire for the 0.018-inch slot
size), and MEAW (0.016 ⫻ 0.022-inch
stainless steel archwire with multiple L-
loops). The MEAW is used effectively in
the final stage of the treatment to solve
any residual problems, such as slightly
more or less than optimal overjet or over-
bite, with poor occlusion of the posterior
teeth, even after all the spaces have
been closed. MEAW also works very effi-
ciently in flattening the dumped dentition
often seen after closing the extraction
space (see the Case Report section of
this article, Fig 9e).
Ikegami et al
c
f
STEPS IN THE HOTS
TREATMENT
The HOTS treatment consists of four
clearly divided steps (Fig 4), and the pre-
dicted total treatment time ranges from
approximately 18 to 22 months, averag-
ing around 20 months.
Stage I (1 to 2 months)
Insertion of the miniscrews in the maxilla
and bond-up of both arches followed by
the insertion of an initial leveling arch of
0.012-inch Ni-Ti wire. The first premolars
to be extracted are also temporarily
bonded with the bracket height 1 mm
more gingival than the adjacent teeth to
loosen and extrude these teeth to make
extractions easier. The extractions of the
first premolars are intentionally delayed
until after the initial leveling so that canine
retraction can utilize the enhanced tissue
reaction at the extraction site (Fig 4a).16
171
 Ikegami et al
Stage II (5 to 6 months)
This stage consists of leveling the maxil-
lary and mandibular arches and can be
subdivided into the following three sub-
stages:
Stage II-1. Leveling with 0.014- or
0.016-inch Ni-Ti archwire and extraction
of the first premolars followed by the
immediate start of canine retraction (Fig
4b).
Stage II-2. Further leveling and canine
retraction with 0.016-inch Ni-Ti archwire
(Fig 4c). Normally, the maxillary canine is
pulled to the miniscrew, and the
mandibular canine is pulled to the DEH.
Stage II-3. Further leveling with 0.016
⫻ 0.022-inch Ni-Ti archwire (Fig 4d). To
achieve the full leveling of the posterior
teeth, a larger Ni-Ti archwire (for example,
0.017 ⫻ 0.025-inch) can be used. Canine
retraction at this stage is optional. They
can be further retracted in Stage III along
the round portion of the DDW.
Stage III (6 months)
Simultaneous retraction of the canines
and the additional four incisors by multi-
ple traction modules, such as elastomeric
modules and coil springs on the DDW
(Fig 4e).
Stage IV (6 months)
Final overjet and overbite correction and
settling of posterior teeth with MEAW (Fig
4f). In the limited number of cases that
do not require any further correction, this
final stage can be omitted.
DUAL-DIMENSION WIRE
The DDW comprises an anterior rectangu-
lar portion (0.017 ⫻ 0.025-inch) and a
posterior round portion (0.016-inch),
which fits the 0.018 ⫻ 0.025-inch slot
edgewise bracket system. For the 0.022-
inch slot bracket system, a somewhat
thicker wire size (0.019 ⫻ 0.025-inch)
should be used. If a clinician prefers to
use this combination, an additional 13 to
172
WORLD JOURNAL OF ORTHODONTICS
15 degrees of torque may be necessary
for better control of the incisors to com-
pensate for the increased play.17 When
DDW was introduced in the early 1980s
by Wool, miniscrews were not yet com-
monly available, and the DDW was used
with intra- and/or intermaxillary elastics;
however, the control of posterior teeth
was insufficient with this combination
since the posterior portion of this wire
was round, which allowed too much play
in the rectangular slot. In contrast, using
DDW to retract the anterior teeth from the
MISs (rather than from the anchor teeth)
allows more efficient retraction of the
anterior teeth, causing much less friction
in the posterior region. Thus, the potential
of the DDW can be fully expressed only in
combination with miniscrews.
CONSIDERATIONS ON THE
FORCE APPLICATION
During the retraction of the maxillary
anterior teeth, there are three types of
sagittal movements: lingual crown tip-
ping, bodily movement, and lingual root
tipping. Sia 18 measured the initial dis-
placement of the maxillary central incisor
in vivo when a retraction force parallel to
the occlusal plane was applied at differ-
ent levels of vertical hooks soldered bilat-
erally between the lateral incisor and the
canine onto the 0.016 ⫻ 0.022-inch Blue
Elgiloy wire (Rocky Mountain Morita).
These results imply that when the hook is
placed approximately 7 mm above the
bracket slot and MISs are inserted at the
same level in the posterior region, it
becomes possible to retract the anterior
teeth almost bodily. Theoretically, if the
height of the hook is below this level, the
anterior teeth will be retracted with
accompanying lingual crown tipping, and
if it is above this level, they will be
retracted with lingual root tipping. In a
later in vivo study, Sia et al19 found that
the center of resistance was located at
0.78 of the root length from the root
apex. For an average sized maxillary
incisor (23.8 mm) in Japanese popula-
tions,20 it is equivalent to a point 8 mm
above the average slot height.
VOLUME 11, NUMBER 2, 2010
Fig 5 Newly developed crimpable hook
with labially located variable height disks
(Discopender468, Bio Materials Korea).
DEVELOPMENT OF A NEW
VARIABLE HEIGHT CRIMPABLE
VERTICAL HOOK
The Sia et al study inspired the develop-
ment of a new type of crimpable vertical
hook that has three labial disks placed at
the heights of 4, 6, and 8 mm (Fig 5). This
crimpable hook was designed to allow
retraction of the four maxillary incisors in
three different modes when retracted
from the heights of 4, 6, and 8 mm: tip-
ping movement, controlled tipping move-
ment, and bodily movement, respectively.
The lower level disks can also be used to
allow the direction of the force to be more
horizontal when the residual space has to
be closed by protracting the posterior
teeth. Figure 1 illustrates Stage III of
HOTS, which is the simultaneous space
closing stage using the DDW and the
newly developed crimpable vertical hook,
which was named the Discopender468.
AMOUNT OF FORCE USED
WITH HOTS
The amount of force used with HOTS may
be about half that of the conventional en
masse retraction method used, due to the
significantly decreased amount of friction
generated by the 0.016-inch round wire
sliding through the 0.018 ⫻ 0.025-inch
slot. The amount of friction will be almost
negligible if a self-ligation type bracket is
used in the posterior region. In HOTS, the
appropriate amount of force necessary for
Ikegami et al
8 mm
6 mm
4 mm
the canine retraction, sliding on the 0.016-
inch round wire, will be around 100 cN.
For the retraction of the four incisors, a
total of 300 cN (150 cN on each side) of
force will be applied, exerting 75 cN of
force on each tooth. This will be approxi-
mately half of the amount used with
conventional en masse retraction. An ade-
quate amount of play between the round
portion of the DDW and the rectangular
slot, and the significantly lower level of
force used in this system, will eliminate
the unfavorable side effect of intrusion of
the maxillary posterior teeth and a resul-
tant rotational change of the entire denti-
tion, which is frequently observed with the
conventional en masse retraction system
in combination with inserted miniscrews.21
DEVELOPMENT OF A NEW
CLOSED COIL SPRING
To bring the abovementioned light force
concept into practice, an adjustable sin-
gle-eyelet Ni-Ti closed coil spring, which is
preset to exert exactly 100 cN of force
when activated to the lengths of 1 cm,
was developed. With this unique coil
spring, what a clinician has to do in the
retraction phase (Stages II and III) is to
maintain the designated length of the
spring, not to measure the amount of
force which is more cumbersome, to
apply the exact preset amount of force at
each adjustment. This coil spring, there-
fore, was named the smart coil spring
(SCS) (Fig 6).
173
 Ikegami et al
8.5 mm
6.5 mm
Fig 6a A single eyelet SCS, which is
preset to exert 100 cN of force when
activated to 1 cm of distance (bottom),
compared with a shortest available dou-
ble eyelet closed coil spring (top).
DISCUSSION
Traditionally, in the treatment of first pre-
molar extraction cases, two major ante-
rior retraction methods have been used:
the two-stage retraction method and the
en masse retraction method. Although
the first approach seems to exert better
biomechanical control over the canine
movement, its major shortcoming is the
extended time required for the retraction
of the six anterior teeth because the
retraction of the four incisors starts only
after the completion of the retraction of
the canines. The narrow corner area
where the canine is located is supported
by hard labial and lingual cortical bone of
the alveolar ridge (Fig 7). Retraction of
the canines separately along the corner
curve (as with the two-stage retraction
method) will provide more favorable out-
174
WORLD JOURNAL OF ORTHODONTICS
100cN
1 cm
Fig 6b An SCS placed in the mouth.
The original length of the SCS is
designed to be as short as possible to
ensure application throughout the
retraction phase.
Fig 7 (right) Anatomical relationship of
the cortical bone, cancellous bone, and
canine root in the mandibular canine area.
Note how narrow the alveolar trough in
this area is.
comes because it is possible to avoid
having the roots of these teeth interfere
with the cortical bone, compared to when
one is retracted straight backward with
thick rectangular wire (as in the en
masse retraction method) (Fig 8a, left).
With HOTS, the canines are retracted
along the corner curve of the canine area,
sliding on the round portion of the DDW,
while the four incisors are retracted simul-
taneously using the rectangular anterior
portion. The canines can travel along the
alveolar trough smoothly without having
their roots interfere with the cortical bone
because they can wiggle around the round
wire while they are traveling (Fig 8a, right).
In Stage II, while the canines are travel-
ing along the less stiff 0.016-inch Ni-Ti
round wire, the distal tipping of the
canine and consequent deepening of the
anterior bite may occur because the line
VOLUME 11, NUMBER 2, 2010
Fig 8a Comparison of retraction (right) with HOTS and Fig 8b Comparison of arch forms after retraction of the six
(left) en masse retraction. Note the difference of the traveling anterior teeth (right) with HOTS and (left) the en masse
paths of the left and right canines. retraction.
of action of the retraction force passes
below the center of resistance. Develop-
ment of longer canine hooks may be the
simplest and the best solution for this
problem. Nevertheless, this tendency will
not be of impor tance because the
canines travel only a short distance in this
stage. They are retracted only to resolve
the crowding in the anterior region. The
major retraction of the canines occurs
during Stage III, together with the incisors,
sliding on the much stiffer round portion
of the DDW. Although the canines may
also demonstrate a distal tipping ten-
dency in this stage, the 8-mm-long verti-
cal hooks placed bilaterally between the
lateral incisors and canines will prevent
deepening of the anterior bite. The ante-
rior segment of the archwire will be raised
upward by the cantilever effect derived
from the bending movement produced at
the junction of the vertical hooks and the
archwire. Anterior bite deepening, a con-
sequence of distally sliding canines, will
not occur with the mechanics at work in
Stage III. This opinion has been well-sup-
ported by the recent 3D finite element
method study.22
Thus, HOTS simultaneously achieves
the full merits of the round wire sliding
mechanics for the canine retraction and
the full torque control of the anterior
teeth. Furthermore, with the en masse
Ikegami et al
retraction method, the canines tend to
move inward as they are retracted back-
ward, requiring further correction of the
arch form after the completion of the
retraction (Fig 8b). Since HOTS allows the
canines to move along the canine curva-
ture, further correction of the arch form
should not be required. This lack of
necessity for arch form correction with
HOTS will further reduce treatment time.
CASE REPORT
The treatment procedure of a 23-year-old
woman with a Class II steep mandibular
plane is described in Figs 9 to 12. The
active treatment time was a mere 20
months. Treatment with four first premolar
extractions followed by HOTS was applied
to improve her facial profile, as well as to
resolve her severe crowding. HOTS was
used to fully utilize the extraction space
without affecting the mandibular plane,
which was already steep at the onset of
treatment. In this patient, the use of Class
II elastics would have aggravated the con-
dition with a clockwise rotation of the
mandible as a consequence of the extru-
sion of the mandibular molars. HOTS over-
comes the problems associated with
Class II elastics by completing the
mechanics within a single arch.
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 Ikegami et al WORLD JOURNAL OF ORTHODONTICS

Fig 9 A 23-year-old woman was diagnosed as having a Class II steep mandibular plane angle with severe crowding.

(a) Pretreatment intraoral photographs.

(b) Three months into treatment (Stage I). Maxillary arch: Canines were retracted on 0.014-inch
Ni-Ti archwire with a retraction module from the inserted miniscrews. Mandibular arch: The
same mechanics as with the maxillary arch. However, the canines were retracted from the
DEHs, not from the miniscrews.

(c) Four months into treatment (Stage II). Further leveling with 0.016-inch Ni-Ti archwire. Retrac-
tion of maxillary and manibublar canines was continued.

(d) Eight months into treatment (Stage III). Maxillary arch: DDW with variable height vertical
hooks (Discopender468) was placed for the simultaneous retraction of the six anterior teeth.
Mandibular arch: 0.016 ⫻ 0.022-inch Ni-Ti archwire was placed since the extraction space had
already closed.

(e) Seventeen months into treatment (Stage IV). Maxillary arch: 0.017 ⫻ 0.022-inch titanium-
molybdenum alloy (TMA) wire was placed as a final wire. Mandibular arch: MEAW (0.016 x
0.022-inch stainless steel wire) was placed with the activation adjusted into a reversed curve
form to flatten the mandibular dentition. Reversed triangular elastics were used bilaterally to
raise the deepest part of the mandibular dentition.

176
VOLUME 11, NUMBER 2, 2010 Ikegami et al

(f) Intraoral view after 20 months of active treatment. Good occlusion was achieved. Note that
the maxillary incisors were not excessively upright, indicating that bodily retraction of the
incisors has been successfully achieved.

(g) One year after the end of the active treatment period, stable treatment results were demon-
strated.

Fig 10 (a) Pre- and (b) post-

treatment facial photographs
show significant changes in
facial appearance.

177
 Ikegami et al WORLD JOURNAL OF ORTHODONTICS

ANS-PNS at ANS

Before treatment
23 y 8 m Go-Me at Me

After treatment
25 y 6 m

Fig 11 Superimposed (black) pre- and (red) posttreatment cephalometric tracings show that this steep mandibular plane angle
case was treated without any significant change of the molar positions or of the mandibular plane except for a slight forward
movement of the mandibular molars.

a b

Fig 12 (a) Pre- and (b) posttreatment panoramic radiographs reveal that almost no root resorption occurred during the course
of the treatment. Third molars were left untouched for the possible future use as donor teeth. They might need to be removed
in the future.

CONCLUSION ACKNOWLEDGMENTS

Although further investigation and refine- The authors deeply appreciate the critical review
and invaluable advice of Professor Noriaki Yoshida
ment are required, with the features and
of Nagasaki University, Nagasaki City, Japan.
merits of HOTS, the treatment time may
be reduced by up to 6 months compared
with the conventional edgewise extrac-
tion treatment system without being
dependent on patient compliance.

178
VOLUME 11, NUMBER 2, 2010
REFERENCES
1. Tweed CH. Clinical Orthodontics. St Louis:
Mosby, 1966:746–848.
2. Ricketts RM, Bench RW, Gugino CF, Hilgers JJ,
Schulhof RJ. Bioprogressive Therapy. Denver:
Rocky Mountain Orthodontics, 1979:263–266.
3. Burstone CJ. The segmented approach to
space closure. Am J Orthod 1982;82:361–378.
4. Alexander, RG. The Alexander Discipline. Glen-
dora, California: Ormco, 1986:211–212.
5. Root TL. The level anchorage system for correc-
tion of orthodontic malocclusions. Am J Orthod
1981;80:395–410.
6. Mclaughlin RP, Bennett JC, Trevisi HJ. System-
ized Orthodontic Treatment Mechanics. Edin-
burgh: Mosby, 2001:173.
7. Gainsforth BL, Higley LB. A study of orthodontic
anchorage possibilities in basal bone. Am J
Orthod Oral Surg 1945;31:406–417.
8. Linkow LI. The endosseous blade implant and
its use in orthodontics. Int J Orthod 1969;17:
149–154.
9. Roberts WE, Smith RK, Zilberman Y, Mozsary
PG, Smith RS. Osseous adaptation to continu-
ous loading of rigid endosseous implants. Am J
Orthod 1984;86:95–111.
10. Wool A. D-D Arches S & E Appliance Technique.
Wyomissing, Pennsylvania: Wonder Wire, 1991:
1–30.
11. Kim YH. Anterior openbite and its treatment
with multiloop edgewiseh archwire. Angle
Orthod 1987;57:290–321.
12. Kim YH, Han UK. The versatility and effective-
ness of the multiloop edgewise archwire
(MEAW) in treatment of various malocclusions.
World J Orthod 2001;2:208–218.
13. Burstone CJ. Deep overbite correction by intru-
sion. Am J Orthod 1977;72:1–22.
Ikegami et al
14. Greenfield RL. Simultaneous torquing and
intrusion auxiliary. J Clin Orthod 1993;27:
305–318.
15. Sung JH, Kyung HM, Bae SM, Park HS, Kwon
OW, McNamara JA. Microimplants in Orthodon-
tics. Daegu, Korea: Dentos, 2006:172
16. Häsler R, Schmid G, Ingervall B, Gebauer U. A
clinical comparison of the rate of maxillary
canine retraction into healed and recent extrac-
tion sites—A pilot study. Eur J Orthod 1997;19:
711–719.
17. Creekmore TD, Kunik RL. Straight wire: The next
generation. Am J Orthod Dentofacial Orthop
1993;104:8–20.
18. Sia SS, Iwabe T, Koga Y, Yoshida N. Speedy,
accurate and controllable anterior teeth retrac-
tion by an improved method: A sliding mechan-
ics force system with power arms. Proceedings
of the 8th International Conference on the Bio-
logical Mechanisms of Tooth Eruption, Resorp-
tion and Movement. Boston: Harvard Society
for the Advancement of Orthodontics, 2006:
297–303.
19. Sia SS, Koga Y, Yoshida N. Determining the
center of resistance of maxillary anterior teeth
subjected to retraction forces in sliding
mechanics. An in vivo study. Angle Orthod
2007;77:999–1003.
20. Fujita T, Kirino T. Dental Anatomy. Tokyo: Kin-
bara Shuppan, 1949:30.
21. Jung MH, Kim TW. Biomechanical considera-
tions in treatment with miniscrew anchorage.
Part 1: The sagittal plane. J Clin Orthod 2008:
42:79–83.
22. Tominaga J, Tanaka M, Koga Y, Gonzales C,
Kobayashi M, Yoshida N. Optimal loading condi-
tions for controlled movement of anterior teeth
in sliding mechanics. Angle Orthod 2009;79:
1102–1107.
179
COMPOSITE PONTICS FOR ORTHODONTIC Renato Parsekian Martins,
DDS, MS, PhD1

PATIENTS WITH EXTRACTION SPACES Amanda Fahning Magno,

DDS, MS2
Esthetic orthodontic appliances continue to appeal to more patients,
which results in objections to extraction spaces that remain for sev- Isabela Parsekian Martins,
eral months during orthodontic therapy. This has led orthodontists DDS3
to design temporary pontics that fill extraction sites and that can be
reduced as the spaces close. This report describes a simple, efficient, Lidia Parsekian Martins,
and expeditious technique for making such pontics. World J Orthod DDS, MS, PhD4
2010;11:180–184.
Larry W. White, DDS, MS5

Key words: extractions, lingual orthodontics, pontics

ll orthodontic patients desire a great As spaces close, clinicians can

A smile at the completion of their treat-
ment. But many have concerns about
esthetics during therapy. This has caused
many patients to choose less noticeable
orthodontic devices. 1,2 Some patients
elect lingual braces to completely avoid
visible appliances.3 However, due to the
high cost of lingual appliances, other
reduce the width of these pontics. Sev-
eral methods of occupying extraction
spaces during orthodontic therapy have
been described previously.4–6
Prefabricated acrylic crowns have the
disadvantage of availability and inven-
tory cost, which makes them less desir-
able for many or thodontists. If the
1Assistant Professor of Orthodontics,
FAEPO/UNESP and
GESTOS/FAMOSP, Araraquara,
São Paulo, Brazil; Private Practice,
Araraquara, São Paulo, Brazil.
2PhD Candidate, Universidade

patients opt for ceramic or plastic brack-
ets that do show but are more discrete
than conventional metal brackets.
Regardless of what appliances a
patient chooses, premolar extractions will
practitioner constructs temporary com-
posite pontics, impressions for that pur-
pose become necessary.
Recent developments in composite
technique supply clinicians with a simpler
Estadual Paulista, UNESP,
Araraquara, Brazil.
3Graduate Student, Universidade
Estadual Paulista, UNESP,
Araraquara, Brazil.
4Professor, Universidade Estadual

cause the display of vacant areas for sev-
eral months. Many patients have voiced
social and esthetic objections if such
spaces become apparent. Patients who
have selected lingual, ceramic, or plastic
brackets often have an extraordinary sen-
sitivity to visible extraction spaces. By
using temporary pontics4–6 in extraction
spaces, clinicians can assuage such
objections.
and more efficient method of producing
such replacements with a minimum of
material, time, and expense. Laboratory
technicians can use the patients’ original
study casts to form and shape light-cured
composite pontics.
This article describes the technique
for making temporary pontics that obvi-
ate patient objections to extraction
spaces during orthodontic therapy.
Paulista, UNESP, Araraquara, and
GESTOS/FAMOSP, Araraqura,
São Paulo, Brazil.
5Clinical Faculty, Baylor College of
Dentistry, Dallas, Texas, USA.
CORRESPONDENCE
Dr Renato Parsekian Martins
Rua Voluntários da Pátria 1766 #12
14801320, Araraquara, SP
Brazil
Email: dr_renatopmartins@hotmail.com

180
VOLUME 11, NUMBER 2, 2010 Martins et al

Fig 1 (left) Application of the

separator medium on the study
cast.

Fig 2 (right) Application of

composite over the facial sur-
face of the tooth to be ex -
tracted.

Fig 3a (left) Occlusal view of

pontics prepared for labial ap-
pliances.

Fig 3b (right) Lateral view of

pontics prepared for lingual
appliances.

Fig 4a (left) Smoothed and

polished pontic for labial ap -
pliances.

Fig 4b (right) Smoothed and

polished pontic for lingual ap-
pliances.

LABORATORY PROCEDURE • In patients with labial and lingual

The laboratory technician needs the
patient’s original study casts, separating
solution, and a small brush to apply the
separating solution to the teeth planned
for extraction and their adjacent teeth.
He also needs some ordinary bonding
composite of an acceptable shade.
The steps of the technique are as
follows:
• The separator liquid is applied to the
teeth to be extracted and the adjacent
teeth (on the lingual surface for labial
appliances; on the labial surface for
lingual appliances) on the patient’s
study cast (Fig 1).
appliances, the entire facial surface of
the tooth to be extracted is covered
with composite (Fig 2). This is allowed
to set for a few seconds before curing
to avoid polishing. For lingual appli-
ances, the facial surface of the adja-
cent tooth is also covered with a thin
layer of light-curing composite.
• After the composite is cured, the cast
is immersed in water for 10 to 20 min-
utes before the pontics are detached
from the cast (Fig 3).
• The edges of the pontics are smoothed
with a minicut bur or similar instru-
ment (Fig 4).

181
 Martins et al
CLINICAL PROCEDURES
After extraction, the following steps are
taken:
• The adjacent posterior tooth is etched
(lingually for labial and facially for lin-
gual appliances), and primer is applied
(Figs 5 and 6).
• Composite is placed on the internal
surface of the retainer portion for its
attachment, as well as on the pontic to
reinforce it (Fig 7).
• The pontic is positioned on the adja-
cent tooth and the adhesive flash
removed before the composite is light
cured (Fig 8).
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WORLD JOURNAL OF ORTHODONTICS
Fig 5 (left) Etching of the
tooth adjacent to the extraction
site for labial appliances.
Fig 6 (right) Subsequent ap-
plication of sealant.
Fig 7a (left) Composite appli-
cation to the retentive portion
of the pontic for its attachment.
Fig 7b (right) Composite
application to the inner surface
of the pontic to add bulk and
decrease fragility.
Fig 8 (left) Light-curing of the
inserted pontic.
Fig 9 (right) Application of
additional composite to the
mesial surface of the adjacent
tooth (arrow).
• With labial appliances, composite is
added to the mesial surface of the
adjacent tooth, which cannot be per-
formed on the study cast (Fig 9).
• The pontic is checked for contacts and
adjusted as necessary.
• A space of 1 to 2 mm is left between
the pontic and anterior teeth, as well
as between the pontic and gingiva.
• A high-speed bur is used to remove
composite as the anterior teeth retract
and the extraction space closes.
Clinical examples are shown in Figs 10
to 13.
VOLUME 11, NUMBER 2, 2010 Martins et al

Fig 10 (left) Maxillary pontic

for the right first premolar in a
patient with ceramic brackets.

Fig 11 (right) Maxillary pontic

for the left first premolar in a
patient with lingual brackets.

Fig 12a (left) Occlusal view

of bonded pontics with labial
appliances.

Fig 12b (right) Occlusal view

of bonded pontics with lingual
appliances.

Fig 13a (left) Patient smiling

with bonded pontics and labial
appliances.

Fig 13b (right) Patient smil-

ing with bonded pontics and lin-
gual appliances.

DISCUSSION tics. That is also why patients should be

instructed to avoid hard food and to chew
Clinicians must ensure that the pontics as little as possible in the area of any
do not interfere with tooth movements or pontics.
jeopardize oral hygiene or the healing of The pontics described in this article
extraction spaces. Small spaces between can be used not only in patients with
the pontic and anterior teeth must be (first) premolar extractions, but also in
provided to allow for their alignment and patients who have genetically missing
retraction. A tiny gap between the pontic teeth, extractions of other teeth, or
and gingiva will allow for better cleaning, require long-term space maintenance.
thus preventing plaque from accumulat-
ing in the extraction site. As the anterior
teeth retract, the pontic has to be reduced
gradually.
Moreover, occlusal contacts with the
pontics should be minimized because
such contacts can dislodge these pon-

183
 Martins et al
CONCLUSION
This article describes an appealing,
effective, and reasonable technique for
intercepting patient complaints about
visible extraction spaces during ortho-
dontic therapy.
184
WORLD JOURNAL OF ORTHODONTICS
REFERENCES
1. Alexander CM, Alexander RG, Sinclair PM. Lin-
gual orthodontics: A status report. Part 6.
Patient and practice management. J Clin
Orthod 1983;17:240–246.
2. Caniklioglu C, Oztürk, Y. Patient discomfort: A
comparison between lingual and labial fixed
appliances. Angle Orthod 2005;75:86–91.
3. Hohoff A, Wiechmann D, Fillion D, Stamm T,
Lippold C, Ehmer U. Evaluation of the parame-
ters underlying the decision by adult patients to
opt for lingual therapy: An international com-
parison. J Orofac Orthop 2003;64:135–144.
4. Lew KK. Temporary pontics in aesthetic ortho-
dontics—A new design. Br J Orthod 1990;17:
317–319.
5. Scuzzo G, Takemoto K. Extraction Mechanics.
Berlin: Quintessence, 2003.
6. Vassalo D, Terranova S. Temporary esthetic
composite pontic. J Clin Orthod 2003;37:
278–279.
Rosalia Leonardi, DDM,
MS1 ALIGNMENT OF A BUCCALLY DISPLACED
Valeria Licciardello, DDM, MAXILLARY CANINE IN THE LATE MIXED
MS, PhD2

Mariagrazia Greco, DDM2

DENTITION WITH A MODIFIED UTILITY
Bruno Rossetti, DM, MS3
ARCH: A PATIENT REPORT
Ersilia Barbato, DDM, MS4 Maxillary canines and first molars are the most common ectopic
teeth in young people. Ectopic buccal eruption of maxillary canines is
strongly associated with lack of space or crowding in the dental arch.
This report demonstrates the management of a buccally erupted
maxillary canine in an 11-year, 8-month-old boy without sufficient
space. The patient had a mostly dental Class II occlusion and was in
the late mixed dentition, and the root development of his canines
was consistent with his dental age. To correct the distal occlusion and
gain space in the maxillary arch for the eruption of both canines, the
patient received cervical headgear. To guide the maxillary left canine
into occlusion, it was surgically exposed and a modified utility arch
inserted. The result of this approach proves that a custom-designed
utility arch allows the distal movement of a buccally displaced
canine, while at the same time increasing the maxillary arch length.
World J Orthod 2010;11:185–190.

Key words: utility arch, buccally displaced maxillary canine, mixed dentition

1Director of Graduate Orthodontics,
Chair of Pediatric Dentistry, Depart-
ment of Surgery and Medicine,
University of Catania, Catania, Italy.
2PhD Fellow, Department of Ortho-
dontics, University of Catania,
Catania, Italy.
3Chair of Periodontology, Department
of Surgery and Medicine, University
of Catania, Catania, Italy.
4Professor, Department of Orthodon-
tics, Rome Dental College, University
La Sapienza, Rome, Italy.
CORRESPONDENCE
Prof R. Leonardi
Department of Surgery and Medicine
II Dental Unit
University of Catania
Via S. Sofia. Policlinico
95123 Catania
Italy
Email: rleonard@unict.it
axillary canines and first molars are
M the most frequent ectopic teeth in
young patients.1–3 The prevalence of dis-
placed canines ranges from 0.92% to
4.30%.4 General and local causes can
affect canines during their long and com-
plicated path of eruption, leading to
retarded and ectopic eruption.5,6 Palatal
displacement of maxillary canines 7
seems genetic in origin, in contrast to
buccal displacement, which is strongly
associated with lack of space or crowd-
ing in the dental arch.8–10 In Europeans,
palatal impaction of the maxillary canine
is at least two to three times more fre-
quent than labial impaction. 7,11,12
Because the normal eruption path of a
permanent canine is slightly buccal to
the line of the arch, reduced space in the
canine area, as well as the close proxim-
ity to the adjacent teeth, will prevent this
tooth from taking its normal position in
the arch so that it will remain buccally
displaced.9
The most common treatment proce-
dure in children and adolescents in such
a situation is to gain space, to expose
the canine surgically,13–15 and to align
this tooth orthodontically. Alternatively,
the displaced canine can be extracted
and reimplanted. Ultimately, it could be
prosthetically replaced by an implant or
fixed partial denture. Space closure is
also possible. 16–18 This patient report
demonstrates the successful manage-
ment of a buccally displaced maxillary
permanent canine, which originally over-
lapped the lateral incisor and did not
have enough space to be aligned in the
dental arch. The main therapy adjunct
was a modified utility arch according to
the bioprogressive technique.19–21

185
 Leonardi et al WORLD JOURNAL OF ORTHODONTICS

Fig 1 Pretreatment intraoral photographs showing a mixed dentition with spaces between the maxillary incisors, insuffi-
cient space for the maxillary canines, and a reduced overbite.

b
Fig 2 Pretreatment (a) cephalometric radiograph showing a slight Class II
occlusion and decreased lower facial height and (b) panoramic radiograph
revealing that all permanent teeth are present and that the crowns of the
a maxillary canines are close to the roots of the lateral incisors.

PATIENT REPORT The patient had a symmetric face.

Diagnosis
An Italian boy, 11 years 8 months of age,
of Caucasian background was referred to
the Graduate Orthodontic/Pedodontic
Clinic of the School of Dentistry of the
University of Catania for evaluation of his
malocclusion. His chief complaint was
impaired esthetics due an early loss of
his primary maxillary canines (Fig 1).
His intraoral examination showed that
he had a dental Class II relationship and
was in the late mixed dentition. The den-
tal midlines were nearly coincident with
each other and the face, the patient had
no mandibular shift, and there was a lack
of space for the eruption of both canines.
Cephalometrically, he showed a very mild
skeletal Class II relationship and a slight
decrease in lower facial height (Fig 2a).
He had no signs or symptoms of a tem-
poromandibular disorder, and his medical
and dental histories were unremarkable.
His panoramic radiograph showed
that all permanent teeth were present
(Fig 2b). The root development of both
the patient’s maxillary canines was con-
sistent with his dental age. The crowns of
both canines were near the apices of the
lateral incisors.
According to the measurements pro-
posed by Ericson and Kurol,22 these two
canines were in a position where the risk of
lateral incisor root resorption during ther-
apy was low ( angle < 25 degrees, cusps
inside sector 3 were between the axis of
the lateral incisor and the first premolar).

186
VOLUME 11, NUMBER 2, 2010
a b
Fig 3 (a) Surgical exposure of the buccally erupting left canine, (b) apically repositioned mucoperiosteal flap, and
(c) the utility arch with a helix on the left bridge to facilitate disto-occlusal traction.
Other radiographic examinations for
the localization of the maxillary canines
were not under taken because the
mother was worried about exposing her
child to too much radiation.
Treatment objectives
The objectives of the orthodontic treat-
ment were to correct the mainly dental
Class II malocclusion, to gain space in
the maxillary arch to allow the eruption of
both canines, and to level and align all
teeth to obtain a bilateral Class I relation-
ship without any interferences and a nor-
mal overjet and overbite.
Based on the patient’s overall soft tis-
sue profile and cephalometric analysis, it
was determined that a treatment without
(premolar) extractions would be the best
option.
To achieve these objectives, it was
decided to (1) use a cervical headgear to
restrain maxillary growth for the correction
of the Class II occusion and to gain space
by moving his molars distally and to
(2) place fixed appliances in both arches.
Treatment progress
After initial oral prophylaxis and topical
fluoride application, the headgear was
inserted. All bonds and bands had 0.018

0.025-inch slots and standard biopro-
gressive prescription. The headgear had
a long outer bow adjusted so that the
resultant force passed through the center
of resistance of the first molars. The pa-
tient was instructed to wear his headgear
Leonardi et al
c
12 hours a day; he was seen every 2
weeks.
Three months after headgear applica-
tion, the maxillary left permanent canine
started to erupt in front of the left lateral
incisor, but there was still not enough
space to align this tooth. The three prob-
lems that had to be immediately ad -
dressed were to gain sufficient space,
start the alignment of the displaced
canine, and ensure periodontal integrity
of the left lateral incisor and canine.
To accomplish these items, the canine
was exposed in a single-step surgical pro-
cedure and a utility arch was inserted
with the tooth’s immediate alignment. A
full-thickness mucoperiosteal flap was
raised, initially without vertical incisions
(Fig 3a). Vertical releasing incisions were
then placed mesially and distally, and an
apically positioned flap was formed and
sutured with silk thread. This flap ensured
that adequate keratinized gingiva was
maintained cervical to the canine crown.
The enamel of this tooth was etched
with 37% phosphoric acid for 60 seconds
and kept dry using suction and gauze.
Then, a button with a ligation chain (TP
Orthodontics) was bonded with light-curing
resin cement (Unitek, Transbond XT;
exposed at 470 nm for 40 seconds; Fig 3b).
Four days after the exposure, all maxil-
lary incisors were bonded and an individ-
ualized utility arch inserted. This archwire
was constructed with a helix on the left
bridge to allow the ligation of the metallic
chain to move the canine distally and
slightly occlusally (Fig 3c). Moreover, all
spaces between the incisors were closed
with an elastic chain to gain more space;
headgear wear was continued.
187
 Leonardi et al
a b
Fig 5 (a and b) Both maxillary canines have been nearly leveled and guided into
occlusion (c) with sufficient space in the dental arch.
When the patient was seen about 2
weeks after surgery, the sutures were
removed and the eruption situation, gin-
gival tissue response, sulcus probing
depth, and infection status assessed.
Because the space condition was not
yet satisfactory and the overjet was
nearly 1 mm, a protraction utility arch
was inserted.
Three months later, both canines were
well-enough aligned to be rebonded, and
leveling was continued with T-loops (Fig 4)
until both canines were nearly in their
final position (Fig 5). At this time, all
remaining teeth in both arches were
bonded with standard bioprogressive
appliances with 0.018
0.025-inch slots;
further treatment was uneventful and car-
ried out with routine archwire sequence.
188
WORLD JOURNAL OF ORTHODONTICS
Fig 4 Alignment of both canines with
utility sections (with T-loops) according
to the bioprogressive technique.
c
DISCUSSION
Of all maxillary teeth mesial to the first
molar, the permanent canine is the final
one to erupt. At this point, the permanent
lateral incisor and first premolar have
found their places in the dental arch.
Thus, if space is missing, it is the canine
that will usually be buccally displaced.23
Canines with an anomalous position
could resorb the roots of adjacent teeth
such as the lateral incisors.24,25 Recent
studies have revealed that such resorp-
tions are a relatively common phenome-
non. 26–28 Hence, Ericson and Kurol 29
observed via intraoral radiographs sup-
plemented with computed tomography
that root resorptions occurred in 48% of
their sample. Buccal eruptions do not
cause more frequent resorptions than
palatal ones; in both conditions, they
amount to roughly 40%.
VOLUME 11, NUMBER 2, 2010
Early supervision of canine eruption is
the best appraisal to prevent incisor root
resorption. The most common treatment
procedure in children and adolescents is
a surgical-orthodontic approach, 13–15
even though alternative treatments have
been described.16–18
According to Proffit and Fields,30 the
three problems of a surgical-orthodontic
approach in impacted teeth are surgical
exposure,31–33 attachment integrity, and
orthodontic alignment. Bishara13 advo-
cates the surgical exposure of impacted
canines with no subsequent orthodontic
traction when their axial inclination is
correct. However, such teeth rarely erupt
once their root formation is complete.
For uncovering buccally impacted
canines, oral surgeons can choose
between two methods: an apically posi-
tioned flap or a repositioning of the flap
after attachment fixation for a closed
eruption.34 Using the apically positioned
flap technique, Vanarsdall and Corn
found no marginal bone loss or gingival
recession. 35 According to Vermette et
al,34 labially impacted maxillary anterior
teeth uncovered with an apically posi-
tioned flap are periodontally and estheti-
cally more compromised than if a closed
eruption is per formed. If teeth are
impacted high in the vestibule or on the
middle of the alveolus, the closed-erup-
tion approach may be preferable.
In the present case, root formation
was nearly complete and the canine was
erupting buccally of the lateral incisor. In
accordance with Kokich and Mathews,36
an apically positioned flap was formed to
ensure that a maximum amount of kera-
tinized gingiva was maintained cervical to
the crown.
Generally, headgear is used to move
buccally displaced teeth distally to correct
a Class II malocclusion and to gain space
in the dental arch. In patients such as the
one presented here, this is not sufficient
and other approaches must be initiated.
However, target-orientated arch expansion
is sometimes difficult, especially in situa-
tions with reduced anchorage. Therefore,
a custom utility arch was used to support
the expansion. At first, this arch allowed a
distal and occlusal movement of the
canine and simultaneous closing of the
Leonardi et al
anterior space to further increase arch
length. After sufficient space was avail-
able, a protraction utility arch was used to
gain the final space necessary to allow
the alignment of the canine in the dental
arch.
CONCLUSION
A custom maxillary utility arch can allow
buccally displaced canines to move dis-
tally while at the same time increasing
arch length. This kind of archwire is par-
ticularly useful when primary molars will
soon exfoliate. The advantage of the
methods applied in this case report
resulted in improved function and esthet-
ics with a full complement of teeth.
REFERENCES
1. Wei SH. Pediatric Dentistry: Total Patient Care,
ed 1. Philadelphia: Lea and Febiger, 1988:
462–463.
2. Sim JM. Movimientos Dentarios Menores en
Ninos, ed 1. Buenos Aires: Editorial Mundi,
1973:22–24.
3. Barberia-Leache E, Suarez-Clúa MC, Saavedra-
Ontiveros D. Ectopic eruption of the maxillary
first permanent molar: Characteristics and
occurrence in growing children. Angle Orthod
2005;75:610–615.
4. Crescini A. Trattamento Chirurgico-Ortodontico
dei Canini Inclusi. Bologna: Martina Ed, 1998.
5. Bishara SE. Impacted maxillary canines: A
review. Am J Orthod Dentofacial Orthop 1992;
101:159–171.
6. Dewel BF. The upper cuspid: Its development
and impaction. Angle Orthod 1949;19:79–90.
7. Peck S, Peck L, Kataja M. The palatally dis-
placed canine as a dental anomaly of genetic
origin. Angle Orthod 1994;64:249–256.
8. Jacoby H. The etiology of maxillary canine
impactions. Am J Orthod 1983;84:125–132.
9. Becker A. Etiology of maxillary canine
impactions. Am J Orthod 1984;86:437–438.
10. Thilander B, Jakobsson SO. Local factors in
impaction of maxillary canines. Acta Odontol
Scand 1968;26:145–168.
11. Stewart JA, Heo G, Glover KE, Williamson PC,
Lam EW, Major PW. Factors that relate to treat-
ment duration for patients with palatally
impacted maxillary canines. Am J Orthod
Dentofacial Orthop 2001;119:216–225.
12. Fleury JE, Deboets D, Assaad-Auclair C, Maffre
N, Sultan P. The impacted canine. Review of
212 cases. General principles of treatment
[in French]. Rev Stomatol Chir Maxillofac 1985;
86:122–131.
189
 Leonardi et al
13. Bishara SE. Clinical management of impacted
maxillary canines. Semin Orthod 1998;4:87–98.
14. Boyd RL. Mucogingival considerations and their
relationship to orthodontics. J Periodontol
1978;49:67–76.
15. Vanarsdall RL, Corn H. Soft-tissue management
of labially positioned unerupted teeth. July
1977. Am J Orthod Dentofacial Orthop 2004;
125: 284–293.
16. Mazor Z, Peleg M, Redlich M. Immediate place-
ment of implants in extraction sites of maxillary
impacted canines. J Am Dent Assoc 1999;130:
1767–1770.
17. Berglund L, Kurol J, Kvint S. Orthodontic pre-
treatment prior to autotransplantation of
palatally impacted maxillary canines: Case
reports on a new approach. Eur J Orthod 1996;
18:449–456.
18. Moss JP. Autogenous transplantation of maxil-
lary canines. J Oral Surg 1968;26:775–783.
19. Ricketts RM. Bioprogressive therapy as an
answer to orthodontic needs. Part II. Am J
Orthod 1976;70:359–397.
20. Ricketts RM. Bioprogressive therapy as an
answer to orthodontic needs. Part I. Am J
Orthod 1976;70:241–268.
21. Ricketts RM. The wisdom of the bioprogressive
philosophy. Semin Orthod 1998;4:201–209.
22. Ericson S, Kurol J. Early treatment of palatally
erupting maxillary canines by extraction of the
primary canines. Eur J Orthod 1988;10:
283–295.
23. Lo RT, Moyers RE. Sequence of eruption of the
permanent dentition. Am J Orthod 1953;39:
460–467.
24. Alqerban A, Jacobs R, Lambrechts P, Loozen G,
Willems G. Root resorption of the maxillary lat-
eral incisor caused by impacted canine: A liter-
ature review. Clin Oral Investig 2009;13:
247–255.
25. Turpin DL, Woloshyn H. Two patients with
severely displaced maxillary canines respond
differently to treatment. Angle Orthod 1995;65:
13–22.
190
WORLD JOURNAL OF ORTHODONTICS
26. Ericson S, Kurol J. Radiographic examination of
ectopically erupting maxillary canines. Am J
Orthod Dentofacial Orthop 1987;91:483–492.
27. Kurol J, Ericson S, Andreasen JO. The impacted
maxillary canine. In: Andreasen JO, Kolsen-Ped-
ersen J, Laskin DM (eds). Textbook and Color
Atlas of Tooth Impactions, ed 1. Copenhagen:
Munksgaard, 1997:125–175.
28. Ericson S, Kurol J. Radiographic assessment of
maxillary canine eruption in children with clini-
cal signs of eruption disturbance. Eur J Orthod
1986;8:133–140.
29. Ericson S, Kurol J. Resorption of incisors after
ectopic eruption of maxillary canines: A CT
study. Angle Orthod 2000;70:415–423.
30. Proffit WR, Fields HW. Contemporary Orthodon-
tics, ed 3. St Louis: Mosby, 2000:538–542.
31. Levin MP, D’Amico RA. Flap design in exposing
unerupted teeth. Am J Orthod 1974;65:
419–422.
32. Frank CA, Long M. Periodontal concerns associ-
ated with the orthodontic treatment of
impacted teeth. Am J Orthod Dentofacial
Orthop 2002;121:639–649.
33. Coatoam G, Behrents RG, Bissada NF. The width
of keratinized gingiva during orthodontic treat-
ment: Its significance and impact on periodontal
status. J Periodontol 1981;52:307–313.
34. Vermette ME, Kokich VG, Kennedy DB. Uncov-
ering labially impacted teeth: Apically posi-
tioned flap and closed-eruption techniques.
Angle Orthod 1995;65:23–32.
35. Vanarsdall RL, Corn H. Soft-tissue management
of labially positioned unerupted teeth. Am J
Orthod 1977;72:53–64.
36. Kokich VG, Mathews DP. Surgical and ortho-
dontic management of impacted teeth. Dent
Clin North Am 1993;37:181–204.
 WORLD NEWS
WFO Executive Committee elects
Dr Allan Thom as vice-president in March
The World Federation of Orthodon-
tists (WFO) Executive Committee
elected Dr Allan Thom of Tunbridge
Wells, England, to serve as vice-
president in March. Dr Thom has
completed one five-year term on the
Executive Committee (2005-2010)
and was elected to another five-year
term during the 7th International
Orthodontic Congress (IOC) and 4th
Meeting of the WFO in February in
Sydney, Australia.
Dr Thom, along with Dr Thierry De Coster of Brussels, Belgium,
represents Europe on the Executive Committee. As vice-presi-
dent, Dr Thom will assume the duties of the president at the pres-
ident's request or in the president's temporary absence. While Dr
Thom will not automatically succeed Dr Roberto Justus of Mexico
City, Mexico, as WFO president in 2015, he, along with the mem-
bers of the 2010–2015 and 2005–2010 Executive Committees,
will be eligible to be elected to the office of president.
“I am very pleased to announce that Dr Thom will serve the
WFO in the capacity of vice-president,” Dr Justus said. “He has
proved his leadership abilities in many ways over the years
through his involvement with the British Orthodontic Society and
the European Federation of Orthodontics. He also
has steadfastly dedicated his time
and given his support to the
WFO and its goals.”
Dr Thom is a past president of the British Orthodontic Society
(BOS), the European Federation of Orthodontics, and the British
Orthodontic Technicians Association. A life member of the BOS, Dr
Thom is also the recipient of the BOS Special Service Award. He is
a member of the European Orthodontic Society and the American
Association of Orthodontists.
Dr Thom served as a consultant orthodontist and honorary
senior lecturer for Guy’s Hospital in London from 1997 to 2008.
He has been in part-time private practice for more than 30 years.
Dr Thom also has a master’s degree in law and maintains a med-
ical law and medical ethics practice through which he works
closely with attorneys.
“To be elected by one’s peers to a position of responsibility
and leadership is a great honor,” Dr Thom said. “I am very con-
scious and respectful of this. I have, for the past 5 years, jointly
represented Europe on the WFO Executive Committee and very
much look forward to continuing in this role and working with the
newly elected executives who bring a wealth of knowledge to the
WFO. It will be a pleasure being alongside the new president, Dr
Roberto Justus, who has and I know will continue to contribute
so much to the WFO.
“There will be challenges and opportunities, which will be uti-
lized to enhance the specialty of orthodontics globally. The WFO,
amongst many other activities, will support new and emerging
orthodontic societies, encourage the coordination of training pro-
grams leading to the practice of high-quality ethical treatment for
our deserving patients around the world, and continue to pro-
mote and support the best interests of our fellows.”
More than 3,600 delegates attended the 7th International Orthodontic
Congress and 4th Meeting of the World Federation of Orthodontists
(WFO), February 6–9, in Sydney, Australia. The delegates, of which
more than 2,200 were orthodontists, represented 93 countries
and 90 WFO affiliate organizations. The largest delegations
came from, in order, the Australian Society of Orthodon-
tists, the American Association of Orthodontists, the
British Orthodontic Society, the Japanese Ortho-
dontic Society, France, the Chinese Orthodontic
Society, the New Zealand Association of
Orthodontists, Germany, and Indonesia.
Photo by Marco Palmero.
 World News WORLD JOURNAL OF ORTHODONTICS

WFO Council convenes,

elects new Executive Committee
The World Federation of Orthodontists (WFO) Council convened
February 4 prior to the 7th International Orthodontic Congress
(IOC) and 4th Meeting of the WFO in Sydney, Australia. Seventy-
eight of the 133 councilors were able to attend the Council meet-
ing. During this session, the WFO Council elected the members
of the Executive Committee and approved two amendments to
the WFO Bylaws. It also received reports from Dr Athanasios E.
Athanasiou, the 2005–2010 president, and Dr William DeKock,
secretary-general, as well as a report from the Executive Commit-
tee. Dr Richard Olive of the Australian Society of Orthodontists
and Dr Paul Jonathan Sandler of the British Orthodontic Society
reported on the 7th IOC and the 8th IOC, respectively.
During the past 15 years, the WFO has seen tremendous
growth in both its affiliate organizations and general member-
ship. In his report to the Council, Dr DeKock noted that the num-
ber of WFO affiliate organizations has grown from 69 organiza-
tions in 1995 to 108 in 2010. The WFO has also had a 21%
increase in membership since the 6th IOC in 2005. Today, the
WFO membership exceeds 8,000 individuals.
The Council elected the new Executive Committee, and Dr Lee
Graber, past president of the WFO and president-elect of the Amer-
ican Association of Orthodontists, installed the new committee. On
the 2010–2015 committee, Dr Joseph Bouserhal represents
Africa and the Middle East; Dr Himawan Halim represents Aus-
tralia, Indonesia, Malaysia, New Zealand, Philippines, and Singa- The Australian Society of Orthodontists (ASO) recognized Dr David
pore; Dr Keiji Moriyama and Dr Somchai Satravaha represent Cen- Taylor of Australia (left) for his book A Brace of Orthodontists and also
tral and East Asia; Dr Kurt Faltin Jr represents Central and South awarded him with the ASO Distinguished Service Award. Dr William
America; Dr Theirry De Coster and Dr Allan Thom represent Proffit, Kenan Professor of Orthodontics at the University of North Car-
olina-Chapel Hill and author of Contemporary Orthodontics, congratu-
Europe; and Dr Thomas Ahman, Dr F. Amanda Maplethorp, and
lates him on these honors February 8. Dr Proffit delivered the WFO
Dr David Turpin represent North America. Dr Roberto Justus is Lecture February 6 during the 7th International Orthodontic Congress
president, and Dr DeKock is secretary-general. Dr Sandler, chair of (IOC) and 4th Meeting of the WFO. Photo by Marco Palmero.
the 8th IOC, represents the British Orthodontic Society, host of the
8th IOC, on the Executive Committee.
Dr Justus formally recognized the retiring members of the
2005–2010 Executive Committee: Dr Athanasios E. Athanasiou,
Greek Orthodontic Society; Dr James Gjerset, American Association
of Orthodontists; Dr Julia Harfin, Sociedad Argentina de Ortodoncia;
Dr Larson Keso, American Association of Orthodontists; Dr Jung
Kook Kim, Korean Association of Orthodontists; Dr Francesca
Miotti, Società Italiana di Ortodonzia; Dr Richard Olive, Australian
Society of Orthodontists; Dr B. Ian Watson, Australian Society of
Orthodontists; and Dr Abbas Zaher, Egyptian Orthodontic Society.
The WFO Council also approved two amendments to the WFO
Bylaws. Article 8.3.3 was amended to ensure proper budgeting of
the Executive Committee meetings. Article 13.1 now states that
proposals for amendments to the WFO Bylaws must be submitted
to the Executive Committee not less than 5 months prior to the
next Council meeting. The Executive Committee must forward pro-
posed amendments to the Council not less than 3 months before
the next Council meeting, and the Executive Committee must
approve its recommendations regarding amendments to the
Bylaws by a two-thirds vote before submitting them to the Council.
Dr Justus also announced that Requests for Proposals for the
9th IOC in 2020 will be sent to all affiliate organizations by Dec-
cember 31, 2010. The deadline to reply will be December 31,
2011. The Executive Committee will choose the host organization
in 2012.

192
VOLUME 11, NUMBER 2, 2010
Dr Shane Fryer, now immediate past president of the Australian Society
of Orthodontists (ASO), greets the 7th IOC delegates during the Open-
ing Ceremony February 6. The World Federation of Orthodontists, the
ASO, and the Asian Pacific Orthodontic Society were the hosts of the
7th IOC and 4th Meeting of the WFO. Photo by Marco Palmero.
World News
The Scientific Programme for the 7th International Orthodontic Con-
gress (IOC) and 4th Meeting of the World Federation of Orthodontists
featured electronic poster presentations (pictured here). Delegates
could download the posters to memory sticks. In addition, more than
300 speakers participated in the 7th IOC, which was held February 6–9
in Sydney, Australia. Photo by Marco Palmero.
Give a Smile™ (GAS) is the pro bono charitable program of the Aus-
tralian Society of Orthodontists (ASO). Every year, each participating
ASO orthodontist treats one orthodontic patient from the public den-
tal health waiting list. Since the program was founded in 2005, more
than 250 ASO orthodontists (60% of the membership) have joined the
program and treated more than 700 patients, reducing the waiting list
by 10%. Here, the GAS Executive Committee meets with the new ASO
president, Dr Mike Razza, and representatives from Thrive PR to dis-
cuss the GAS public relations campaign. The group met February 8
during the 7th International Orthodontic Congress and 4th Meeting of
the World Federation of Orthodontists in Sydney, Australia. From left
are Dr Ted Crawford, Annette Armitage (standing), Leah Robinson, Dr
Jono Skilton, Dr John Armitage, Lisa Poisel (Thrive PR), Sarah Bamford
(Thrive PR), and Dr Razza. Photo by Marco Palmero.
WFO to part ways with the
World Journal of Orthodontics
As of December 31, 2010, the World Journal of Orthodontics
(WJO) will no longer be the official journal of the World Federa-
tion of Orthodontists (WFO). The WFO will continue to contribute
to the WFO World News section in the WJO through December.
193
 World News
Symposium on Orthodontic Certifying Boards
ignites interest in board certification
More than 100 orthodontists convened for the first Symposium
on Orthodontic Certifying Boards February 5 prior to the 7th
International Orthodontic Congress (IOC) and 4th Meeting of the
World Federation of Orthodontists (WFO) in Sydney, Australia.
These orthodontists included presidents of WFO affiliate organi-
zations and representatives from the 15 recognized orthodontic
boards around the world.
One of the WFO’s priorities is to support and encourage the
development of orthodontic boards. Specifically, in 2005, the WFO
set out to affiliate orthodontic boards around the world; to support
the development of national and regional orthodontic certifying
boards by providing guidelines; and to provide a board standard
against which any of the orthodontic boards could be measured.
At the beginning of the symposium, Dr Roberto Justus, incom-
ing WFO president and chair of the Committee on National and
Regional Orthodontic Boards, announced the completion of these
original objectives as stated 5 years ago during the 6th IOC, in-
cluding the establishment of the Committee on National and
Regional Orthodontic Boards and the creation of the WFO Guidelines
on the Establishment of New National and Regional Orthodontic
Certifying Boards. This document, developed with the help of rep-
resentatives from the recognized boards, offers recommended
examination standards. He then introduced the two speakers,
Dr Jeryl English, president-elect of The American Board of Ortho-
dontics (ABO), and Dr John Carter, past president of the College of
Diplomates of the American Board of Orthodontics (CDABO).
Dr English offered specific examples of how the ABO selects
and trains examiners and how the ABO examination is designed
to be completely objective through use of the objective grading
system, discrepancy index, and case management form.
“Dr English also explained how, for many years, the ABO was
not able to increase the percentage of boarded orthodontists
until it came up with the Initial Certification Examination (ICE)
and the Gateway Program,” Dr Justus said. “The ICE is similar to
the medical model through which the medical doctors are able
to get board certification at the time they graduate or soon after.
The Gateway Program gives certification to those orthodontists
who have completed the ABO’s written examination and who
sign a contract that they will present their clinical cases within a
5-year period. Dr English reported that by using the ICE and the
Gateway Programs, the ABO has been able to increase the num-
ber of boarded orthodontists to 54%. In addition, over 300 ortho-
dontists presented their clinical cases at this year’s examination
in February. This highlights the success of both programs. His
lecture ended up taking a full hour, rather than 25 minutes,
because attendees asked him many questions.”
Dr English appreciated the attendees’ questions. “My obser-
vations were that many countries are trying very hard to estab-
lish a board-certification process to ensure the quality of care is
at the highest level to protect the public,” he said. “I do think the
other boards are following the ABO in the board-certification
process. It is my hope that each country will establish a board
that is similar in makeup to that of the ABO. One of the missions
of the ABO is to assist other countries in establishing certifying
boards, and meetings, such as the one in Australia, help
immensely with firsthand exchange of information.”
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WORLD JOURNAL OF ORTHODONTICS
Dr Carter’s presentation included specific examples of how
CDABO helps the ABO by giving preparatory courses to potential
candidates, as well as the methods currently used to educate res-
idents, faculty, and orthodontists about the board-certification
process. He also explained the training that CDABO members
receive to become examiners to aid the ABO directors in the clini-
cal examination of candidates and discussed how CDABO encour-
ages board certification and provides continuing education at its
annual meeting.
Following the two presentations, all attendees were divided
into five breakout sessions to answer six questions. Each group
was led by representatives from a certifying board. The groups
discussed the following topics:
• Potential changes to the current WFO Guidelines on the
Establishment of New National and Regional Orthodontic Cer-
tifying Boards
• How to make the public aware of the importance of receiving
treatment by a board-certified orthodontist
• The advantages of establishing a College of Diplomates
• The methodology of training, selecting, calibrating and syn-
chronizing examiners
• Methods to encourage orthodontists to become boarded
• The current statistics on the number of board-certified ortho-
dontists in each country or region
Dr Simon Freezer of Adelaide, Australia, participated in the
session that focused on ways to encourage board membership
and to make the public aware of the importance of board certifi-
cation. The group concluded that “there is a need to promote the
awareness of the process and benefits of board certification (to
orthodontists) through printed, Web-based information and other
material presented at congresses and regional meetings,” he
said. With the help of this type of information and future sym-
posia, Dr Freezer hopes that organizations will establish new cer-
tification boards.
For those organizations considering the formation of a new
board, the symposium attendees suggested that “small affiliate
organizations should join other affiliate organizations in estab-
lishing a regional board before establishing individual affiliate
boards,” Dr Justus said.
The breakout groups also came to the following conclusions:
1. All educationally qualified orthodontists should initially be
given time-limited board certification with the understanding
that later examination will be necessary.
2. A deadline date for accepting initial board certification by
educationally qualified orthodontists must be established
and publicized.
3. Recertification of boarded orthodontic specialists is impor-
tant to maintain a high level of the standard of care.
4. All board-certified orthodontists should be recertified periodi-
cally. The interval of certification should be established by
the board of directors of the certifying board and not be less
than 5 years or more than 12 years.
5. Recertification should include the submission of clinical cases.
VOLUME 11, NUMBER 2, 2010
6. Those orthodontists selected to serve on the board of directors
should not have commercial interests.
7. Ideally, a board of directors should represent equally all regions or
constituencies within the area that the board represents.
8. Board directors should agree to serve a minimum of 3 years. The
maximum length of service should not exceed the number of regions
or constituencies represented. (If there are 8 regions, the maximum
term of service would be 8 years.)
9. Board directors should be replaced in a planned manner.
10. All orthodontists, including recent graduates, who completed their
orthodontic training within 36 months of application and who pos-
sess the educational qualifications approved by the board, should be
able to apply and take the board exam.
11. Candidates must display clinical cases (5 to 10). Candidates who are
within 36 months of their graduation may have a lesser case display
requirement and may display cases treated during their residency.
12. All educationally qualified orthodontists, including residents in their
final year of their training program, may take the written examination.
13. Specific requirements for the case display should be set by the board
of directors and be prominently publicized so they are accessible to
all candidates.
14. A College of Diplomates within the organization can be a support
group from which orthodontists can seek professional help.
15. The orthodontic board can seek advice from the college regarding
policies and guidelines for the examination process, as well as to
assist in problem solving when needed.
16. A College of Diplomates enhances camaraderie among diplomates
and their families through social activities/interaction.
17. Calibration should include some form of repetitive measure of the
models, radiographs, and photographs, possibly utilizing a gold-stan-
dard case(s) for practice. Some form of training should be provided
for examiners. Each scoring measure from two to three different
examiners, when added together and averaged, should yield the
inter-examiner variability provided for the student examination.
18. Annual calibration should take place, regardless of the examiner’s
skill level or prior experience.
19. There should be an emphasis on the importance of video and audio
recording in the testing environment, even for oral examinations and
evaluation of models.
20. During the initial selection of examiners, boards should look to experi-
enced clinicians and/or university professors.
“This symposium was planned in an excellent way in order to initiate
representatives to the actual situation of the orthodontic boards,” said
WFO Executive Committee member Dr Joseph Bouserhal of Beirut,
Lebanon. He participated in the breakout group that discussed the WFO
guidelines for orthodontic certifying boards. “There was high interest and
a good presence from the invited organizations and an interactive discus-
sion. The symposium was a real success and should be repeated. Estab-
lishing certifying boards is an important step for the advancement of the
specialty of orthodontics. We hope these boards will reevaluate their sta-
tus and compare their bylaws to the WFO guidelines and the recommen-
dations of the symposium. For those who have the intention to create
new certifying boards, they were initiated to the way to do it and given the
guidelines to follow. Their task has been enormously facilitated.”
The WFO Committee on National and Regional Orthodontic Boards will
study the recommendations from this symposium and determine its next
steps. Dr David Turpin of Federal Way, Washington, USA, and Dr Thomas
Ahman of Lima, Ohio, USA, are the new chair and co-chair, respectively,
of the committee. Both are members of the WFO Executive Committee.
World News
Request a copy of the WFO guidelines for
establishing orthodontic certifying boards
The World Federation of Orthodontists (WFO) Committee
on National and Regional Orthodontic Boards recently
developed the WFO Guidelines for the Establishment of
New National and Regional Orthodontic Certifying
Boards. Contact Terri Wise of the WFO Secretariat for
copies of the guidelines at wfo@wfo.org. She may also
be reached by telephone at +1-314-993-1700, ext 555.
The WFO Secretariat fax number is +1-314-993-5208.
Contact the WFO Committee on
National and Regional Orthodontic Boards
If you would like to learn more about orthodontic certi-
fying boards, contact the orthodontists who are serving
on the World Federation of Orthodontists (WFO) Com-
mittee on National and Regional Orthodontic Boards
(see the list below). Dr David Turpin of Federal Way,
Washington, USA, is the new chair of the committee.
His email address is dlturpin@aol.com. Dr Thomas
Ahman of Lima, Ohio, USA, is the co-chair. His email
address is tahman@woh.rr.com. Dr Sang-Cheol Kim of
the Korean Board of Orthodontics recently joined the
committee as well.
• American Board of Orthodontics:
Dr Jeryl English, Jeryl.D.English@uth.tmc.edu
• Argentinean Board of Orthodontics:
Dr José Carlos Elgoyhen,
elgoyhen@datamarkets.com.ar
• Australasian Orthodontic Board:
Dr Steven Langford, ortho@adam.com.au
• Brazilian Board of Orthodontics:
Dr Thelma Martins de Araujo, tmatelma@globo.com
• European Board of Orthodontists:
Dr Frank Weiland, frank@weiland.at
• French Board of Orthodontics:
Dr Patricia Lambrey, p.lambrey@wanadoo.fr
• German Board of Orthodontics:
Dr Bärbel Kahl-Nieke, kfo@uke.uni-hamburg.de
• Indian Board of Orthodontics:
Dr Mani K. Prakash, mkprak@gmail.com
• Italian Board of Orthodontics:
Dr Sandro Cociani, bidisanco@libero.it
• Japanese Orthodontic Board: Dr Yasuhiko Asai,
y_asai5@ybb.ne.jp or info@asai-kyousei.com
• Korean Board of Orthodontics:
Dr Sang-Cheol Kim, sangkim@wonkwang.ac.kr
• Mexican Board of Orthodontics:
Dr Ricardo Ramos Treviño, rramos@uacj.mx;
• Philippine Board of Orthodontics:
Dr Ermelinda Sabater-Galang,
lindagalang@gmail.com
• Taiwan Board of Orthodontics:
Dr Yeong-Charng Yen, yencharn@ms46.hinet.net
• Thai Board of Orthodontics:
Dr Somchai Satravaha, samsunshine5@yahoo.com
195
 World News
World Village Day provides global exposure to
participating WFO affiliate organizations
The 7th International Orthodontic Congress (IOC) and 4th Meeting of
the World Federation of Orthodontists (WFO) featured the unique
World Village Day February 8. Through this special event, IOC atten-
dees participated in the 22nd Australian Orthodontic Congress, the
7th Asian Pacific Orthodontic Conference (APOC), lectures offered by
the Arab Orthodontic Society, lectures offered by the British Ortho-
dontic Society, the European Village Day, and the South American
Village Day.
“Our decision to hold the World Village Day on the third day worked
well,” said Dr Richard Olive, chair of the Sydney International Ortho-
dontic Congress Committee. “All the sessions were well-attended.”
The World Village Day provided participating organizations with
global exposure, and the attendees were able to evaluate their treat-
ment practices on an international scale.
“It is always beneficial to see what is happening in the way of
research and best practice in other countries,” said Dr Winifred
Harding of the New Zealand Association of Orthodontists. She
served as chair of the APOC. “It can be reassuring that what you are
doing is of the highest standard, or it can leave you to return home
striving to improve.”
22nd Australian Orthodontic Congress
More than 70% of the Australian Society of Orthodontists (ASO) mem-
bers attended the 22nd Australian Orthodontic Congress. The ASO
served as one of the hosts of the 7th IOC. Drs Andrew DiBiase of the
United Kingdom, Dave Gane of the United States, Hong He of the Chi-
nese Orthodontic Society, Lysle Johnston of the United States, Chung
How Kau of the United States, Young Guk Park of Korea, Richard
Roblee of the United States, Wayne Sampson of Australia, David
Sarver of the United States, Kenji Takada of Japan, and Mark
Yanosky of the United States were all speakers for the Congress.
One of the highlights of the Congress was the Stanley Wilkinson
Memorial Oration and International Reception that was held Febru-
ary 7 at the Sydney Opera House. During this event, Dr Olive
received honorary life membership from the ASO. Dr Mike Razza of
Western Australia succeeded Dr Shane Fryer of New South Wales as
president of the ASO.
The ASO also presented Distinguished Service Awards to Drs
John Armitage and David Taylor in recognition of their services to the
ASO. The ASO also recognized Dr Taylor for the launch of his book A
Brace of Orthodontists, which offers the history of the ASO.
The Australasian Orthodontic Board presented Quality Awards to
Drs Armitage, Ted Crawford, and Jim Hawkins in recognition of their
contributions to the Board.
Asian Pacific Orthodontic Conference
The Asian Pacific Orthodontic Society (APOS), a host of the 7th IOC
and 4th Meeting of the WFO, incorporated its 7th APOC into the
World Village Day. The theme was “Looking Ahead.” The speakers
included Drs Wey Mang Chek of Malaysia, Yinzhong Duan of the Chi-
nese Orthodontic Society, Maria Therese S. Galang of the United
States, Shigemi Goto of Japan, Himawan Halim of Indonesia, Christo-
pher Ho of Australia, Sang-Cheol Kim of Korea, Nathamuni Rengara-
jan Krishnaswamy of India, Jiu-Xiang Lin of the Chinese Orthodontic
Society, Wei Lin of the Macau Association of Orthodontics, Kai-Woh
Loh of Singapore, Somchai Manopatanakul of Thailand, Isao Mat-
suno of Japan, Hideo Mitani of Japan, Christopher Robertson of New
Zealand, Tian-Min Xu of the Chinese Orthodontic Society, and Yan-Qi
Yang of the Hong Kong Society of Orthodontists.
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WORLD JOURNAL OF ORTHODONTICS
“The presentations were well thought out and showcased the
best from the APOS orthodontic organizations,” Dr Harding said.
The APOS also introduced the Hendro Kusnoto Memorial Lecture.
“It was very special to have had this occasion for Dr Shigemi Goto to
deliver the inaugural lecture,” she said.
Arab Orthodontic Society Lectures
Between 80 and 100 orthodontists attended the lectures offered by
the Arab Orthodontic Society. WFO President Dr Roberto Justus
began the meeting, and Dr Abbas Zaher, immediate past vice-presi-
dent of the WFO Executive Committee, delivered a lecture on behalf
of Dr Samir Bishara of the United States, who could not attend the
meeting. Dr Joseph Bouserhal of Lebanon and Dr Zaher of Egypt
chaired the first session. Dr Akram al-Huwaizi of Iraq and Dr Adel
Bahaitham of Saudi Arabia chaired the second session.
“The meeting was a good opportunity to gather all attendees
from the Arab societies and was also a setting to present to other
attendees from other parts of the world the work carried out in the
Arab societies,” Dr Zaher said.
British Orthodontic Society Lectures
The British Orthodontic Society’s lectures attracted more than 300
attendees. The program featured eight orthodontists.
Drs Alison Murray and James Spencer, both of the United King-
dom, offered clinical research presentations in which they shared
their experiences and results from clinical trials they are carrying
out. Dr Nigel Hunt, of the Eastman Dental Institute in London, pre-
sented his work on the involvement of muscles in the etiology of
malocclusion, while Dr Marco Rosa of Italy discussed the treatment
of missing lateral incisors. Dr Tania Murphy of the United Kingdom
shared her personal experience of undergoing an osteotomy, and Dr
Trevor Hodge discussed the challenges faced in the United Kingdom
following the introduction of orthodontic therapists. Dr Timothy
Wheeler of the United States demonstrated what could be achieved
when treating with aligners. Dr Sverker Toreskog of Sweden com-
pleted the day’s sessions with a presentation on his clinical work.
European Village Day
The European Federation of Orthodontics (FEO) coordinated the Euro-
pean contribution to the World Village Day. Drs Francesca Miotti of Italy
and Olivier Mauchamp of France, president and immediate past presi-
dent of the FEO, respectively, co-chaired the European Village Day.
The theme for the European Village Day was “Orthopedics and
Function: A Century of Research in Europe,” with the lectures show-
casing state-of-the-art orthodontic treatment in Europe. The invited
speakers, representing the various FEO affiliate societies, illustrated
their most recent work.
“A general overview and an update on functional treatment was
provided by all enthusiastic speakers to a very attentive and inter-
ested audience, who provided the presenters with many very stimu-
lating questions,” Dr Miotti said. “The FEO is proud to have been a
part of a very important and successful event in Sydney.”
Dr Jose Dahan of Belgium illustrated the relationship between
form and function and the various appliances available. Dr William
Clark of the United Kingdom reported on his 30 years of experience in
using the Twin-block appliance on Class II malocclusions. Dr Juha Var-
rela of Finland presented the effectiveness of early orthodontic treat-
ment with an eruption guidance appliance. Dr Veronica Giuntini of
Italy illustrated her team’s research on the efficiency and long-term
VOLUME 11, NUMBER 2, 2010
stability of Class II treatment and emphasized the important role of
timing and mandibular morphology in the individual response to func-
tional treatment. Dr Letizia Perillo of Italy reported on a 20-year follow-
up after FR-2 treatment on the Class II malocclusion. Dr Urban Hägg of
the Hong Kong Society of Orthodontists critically summarized the
treatment of Class II malocclusion. Dr Olivier Sorel of France pre-
sented a study on the immediate effect and the long-term value of
functional treatment with different activators, including the Herbst,
Andresen and Teucher. Dr Christian Sander of Germany illustrated the
application and the skeletal influence provided by the bite-jumping
appliance in more than 300 cases and compared the results with acti-
vator and bionator treatment. Dr Gregory Antonarakis of Greece
emphasized the importance of individual response to treatment
related to the variations of magnitude of the anteroposterior intermax-
illary forces. Dr Michael Hanggi of Switzerland discussed the correla-
tion between the pharyngeal airway and the skeletal pattern and its
role in determining obstructive sleep apnea. Dr Michel Limme of Bel-
gium illustrated his long experience with the “neuro-occlusal rehabili-
tation” in 5- to 6-year-old children. Dr Yocheved Ben Bassat of Israel
reported on functional treatment for craniofacial asymmetry patients.
British Orthodontic Society debuts Web site for
8th International Orthodontic Congress in 2015 in London
The British Orthodontic Society (BOS), host of the 8th International
Orthodontic Congress (IOC), reached out to orthodontists and their staff
members during the 7th IOC in Sydney, Australia, to promote the next
congress. The 8th IOC will be held September 27–30, 2015, in London.
The organization announced the newly created Web site for the
8th IOC, www.wfo2015london.org, and distributed more than 4,000
key rings bearing the URL. The BOS also hosted a cocktail party Feb-
ruary 6 to build excitement for the upcoming IOC. More than 150
British orthodontists attended the 7th IOC.
The BOS provided additional information on the 8th IOC and London
from its exhibit booth. Those who stopped by could relax on couches
and take tea. A large-screen TV featured a specially recorded inter-
view with London Mayor Boris Johnson, who encouraged delegates
to visit London and explore the many benefits of the United Kingdom
capital.
AAO offers support to WFO Executive Committee,
strengthens connections with WFO affiliates
For the first time, members of the American Association of Orthodon-
tists (AAO) Board of Trustees met with the World Federation of Ortho-
dontists (WFO) Executive Committee during an International Orthodon-
tic Congress (IOC). The two groups met February 4 prior to the 7th IOC
and 4th Meeting of the WFO in Sydney, Australia. This meeting, meet-
ings with several other WFO affiliate organizations, the WFO Council
meeting, an AAO-sponsored reception for international orthodontic
residents and a booth in the Exhibit Hall were all ways the AAO partici-
pated in the 7th IOC.
The formal meeting between the AAO trustees and WFO Executive
Committee members allowed the two groups to explore how they
might assist each other in the future. Dr Robert James Bray, now the
AAO immediate past president, said they discussed how the AAO might
help with the 8th IOC in London in 2015, among other topics. In 2005,
one of the AAO constituent organizations held its annual meeting dur-
ing the 6th IOC in Paris. Dr Bray hopes that this might occur again dur-
ing the 8th IOC. “The more we are aware of the needs of the WFO, the
more we can adapt to them,” he said. “The opportunities are endless.”
World News
South American Village Day
The South American Village Day explored the different approaches of
open-bite treatment. More than 80 people, representing the various
organizations from Latin America, attended this conference. The
speakers included Drs Gerson Cabezas of Ecuador, Octavio del Real
of Chile, Kurt Faltin Jr. of Brazil, Laura Irurzun of Argentina, Lawrence
Koenig of Peru, Nelson Mucha of Brazil, Julio Saldarriaga of Colom-
bia, and Augusto Ureña of Argentina.
“The subject of treatment of open-bite malocclusions is a very diffi-
cult one because it involves facial harmony, diagnosis, neuromuscular
behavior, the best treatment plan for each individual patient, the treat-
ment by itself with clinical evidence, and the stability after treatment
in the long term,” Dr Faltin said. “All these aspects were taken into
account during the various presentations, which were all of high qual-
ity in essence, material, and communication.”
While the lecture timetable did not allow for discussion, the atten-
dees had the opportunity to meet with the speakers at the end of the
conference, Dr Faltin said. “It was a very efficient World Village Day.”
London, a world-class city, will be ready for the 8th IOC, said Dr
Paul Jonathan Sandler, chair of the 8th IOC. “After staging the 2012
Olympics, London will have the infrastructure and stature to put it on
a world footing. 2015 also looks like it will be a bumper year for Lon-
don. It is hosting the Rugby World Cup at the same time as the World
Orthodontic Congress, so, if you are a fan of the game, there could
be no better time to be in London. In fact, you might consider com-
bining your professional and sporting interests.”
If you are interested in speaking at the 8th IOC, go to www.
wfo2015london.org. Select the “Contact” link. From there, you can
send an email to Dr Sandler to inform him of your interest.
The BOS is a member organization of more than 1,800 orthodon-
tists and is the largest dental specialist group in the United Kingdom.
WFO President Dr Roberto Justus appreciated this time to meet
with the AAO representatives. “I thanked the AAO trustees for attend-
ing the 7th IOC and for wishing to explore mutual areas of interest. We
discussed joint ventures to promote international student member-
ship in both organizations and to increase the students’ participation
in orthodontic meetings. We also discussed resources we might share,
as well as how to help orthodontists obtain visas so they can attend
orthodontic meetings.”
The AAO also held individual meetings with the Australian Society
of Orthodontists (ASO), the British Orthodontic Society, the Chinese
Orthodontic Society, the Japanese Orthodontic Society, and the Tai-
wan Association of Orthodontists. The meetings allowed the AAO
leaders to establish new relationships and to discuss how the AAO
might better serve its international members, Dr Bray said. Since the
7th IOC concluded, Dr Bray has received more than 100 emails from
the orthodontists he met while in Sydney.
Overall, the experience has opened doors for future meetings,
said Dr Bray, who appreciated the hospitality of the ASO members.
197
 World News
“We got a lot accomplished. All the trustees, the WFO Executive
Committee, and others—everyone was really thrilled with how these
meetings played out.”
The AAO delegation, which also included AAO President-elect Dr
Lee Graber; Secretary-treasurer Dr Michael Rogers; and trustees Dr
John Buzzatto, Dr Gayle Glenn, Dr Robert Varner, Dr Morris Poole,
and Dr Brent Larson, took part in the WFO Council meeting February
4. The AAO, as a WFO affiliate organization, holds eight voting seats
on the Council. Dr David Turpin, editor-in-chief of the American Jour-
nal of Orthodontics and Dentofacial Orthopedics and an ad hoc
member of the AAO Board of Trustees; Dr Thomas Ahman, immedi-
ate past speaker of the AAO House of Delegates; and Dr F. Amanda
Asian Pacific Orthodontic Society announces
new officers, host of 9th APOC in 2014
The Asian Pacific Orthodontic Society (APOS) held its executive meet-
ing February 7 in conjunction with the 7th International Orthodontic
Congress (IOC) and 4th Meeting of the World Federation of Ortho-
dontists (WFO) in Sydney, Australia. Dr Somchai Satravaha, immedi-
ate past president, presided over this meeting, during which the
Executive Committee elected new officers and announced the host
of the 9th Asian Pacific Orthodontic Conference (APOC).
Since the founding of the APOS in 2001, the organization has
grown from nine affiliate member organizations to 16. “This demon-
strates the respect and goodwill that the APOS has earned through-
out the past years,” said Dr Crissie Santayana, the immediate past
secretary-general of the APOS. “It is noteworthy to mention that most
of the TAD innovators have come from the Asian-Pacific region, and,
hence, are some of the most sought-after conference speakers.”
The following individuals were elected to officer positions: Dr Kai-
Woh Loh of the Association of Orthodontists, Singapore is president;
Dr Kazuo Tanne of the Japanese Orthodontic Society is vice presi-
dent; Dr Tanan Jaruprakorn of the Thai Association of Orthodontists
is secretary-general; and Dr Girish Karandikar of the Indian Ortho-
dontic Society is the honorary treasurer.
The following individuals represent the affiliate member organiza-
European Federation of Orthodontics
convenes for annual General Assembly
The European Federation of Orthodontics (FEO) held its annual Gen-
eral Assembly and Board Meeting in December 2009 in Thessaloniki,
Greece, in conjunction with the 12th Panhellenic Congress of the
Greek Orthodontic Society and the Orthodontic Society of Northern
Greece.
The FEO promotes orthodontics and dentofacial orthopedics in
Europe by improving cooperation among the constituent associa-
tions, harmonizing programs and training sessions, and encouraging
research. The FEO now represents 19 scientific orthodontic societies.
The following individuals are serving on the 2010 FEO Board: Dr
Francesca Miotti of Padova, Italy, president; Dr Bärbel Kahl-Nieke of
Hamburg, Germany, vice president; Dr Julian O’Neill of Northampton-
shire, England, secretary-general; Dr Panagiotis Skoularikis of Athens,
Greece, secretary-general adjunct; Dr Michel Steil of Luxembourg,
Luxembourg, treasurer; Dr Jose Dahan of Brussels, Belgium, adminis-
trator; and Dr Olivier Mauchamp of Grenoble, France, immediate past
president.
As part of its 2009 General Assembly, the FEO presented the 2007
and 2008 FEO Awards. This honor recognizes the best paper published
within the previous two years in an FEO affiliate society journal.
198
WORLD JOURNAL OF ORTHODONTICS
Maplethorp, an AAO member and past president of the Canadian
Association of Orthodontists, were elected to the WFO Executive
Committee during the WFO Council meeting.
In an effort to reach out to orthodontic residents, the AAO held a
reception for the students February 5. “It was very well-received, in
my opinion,” Dr Bray said, noting that all the AAO representatives
were dressed alike in a distinctive Hawaiian shirt for the reception.
This allowed the orthodontic residents to find the AAO leaders easily
in the crowd.
The AAO also had its first exhibit booth at an IOC. The trustees took
turns working at the exhibit. “We really got to see the individuals who
wanted to learn more about the AAO,” Dr Bray said.
tions on the APOS Executive Committee: Dr Bryce Lee, Association of
Orthodontists, Singapore; Dr Crissie Santayana, Association of Philip-
pine Orthodontists; Dr Shane Fryer, Australian Society of Orthodon-
tists; Dr Mohammad Emadul Haq, Bangladesh Orthodontic Society;
Dr Tian-Min Xu, Chinese Orthodontic Society; Dr Urban Hägg, Hong
Kong Society of Orthodontists; Dr Girish Karandikar, Indian Ortho-
dontic Society; Dr Himawan Halim, Indonesian Association of Ortho-
dontists; Dr Kazuo Tanne, Japanese Orthodontic Society; Dr Cheol-
Ho Paik, Korean Association of Orthodontists; Dr Wei Lin, Macau
Association of Orthodontics; Dr Noraini Binti Hj. Alwi, Malaysian Asso-
ciation of Orthodontists; Dr Winifred Harding, New Zealand Associa-
tion of Orthodontists; Dr Prakash Bhattari, Orthodontic & Dentofacial
Orthopaedic Association of Nepal (ODOAN); Dr Mubassar Fida, Pak-
istan Association of Orthodontists; and Dr Tanan Jaruprakorn, Thai
Association of Orthodontists.
The APOS Executive Committee announced that the Malaysian
Association of Orthodontists will host the 9th APOC in 2014. The 8th
APOC will be held November 23–26, 2012, in New Delhi, India. The
APOS held its 7th APOC in conjunction with the 7th IOC; please see
the related article on the World Village Day.
To learn more about the APOS or APOC, go to www.ap-os.org.
Dr Hilary Bekker and co-authors J. Stirling, G. Latchford, D.O. Morris,
J. Kindelan, and R.J. Spencer received the 2007 award for the paper
“Elective Orthognathic Treatment Decision Making: A Survey of
Patient Reasons and Experiences,” which was published in the Journal
of Orthodontics (J Orthod, June 2007;34:113–127).
Dr Paola Cozza and co-authors F. Ballanti, M. Castellano, and E.
Fanucci received the 2008 FEO Award for the paper “The Role of
Computed Tomography in the Evaluation of Orthodontic Treatment in
Adult Patients with Obstructive Sleep Apnea Syndrome (OSA),” which
was published in Progress in Orthodontics (Prog Orthod 2008;
9(1):6–16).
The 2010 FEO General Assembly and the FEO Award Ceremony
will be held in November in Florence, Italy, during the Annual Scien-
tific Congress of the Società Italiana di Ortodonzia (SIDO), which will
host the FEO event.
The FEO welcomes prospective full and corresponding members.
To learn more about the FEO, go to www.feo-online.com. You may also
contact Dr Miotti at francesca@francescamiotti.it; Dr Kahl-Nieke at
kahl-nieke@uke.uni-hamburg.de; or Dr O’Neill at julizone@yahoo.co.uk.
 EDITORIAL
The least loved persons of the
World Journal of Orthodontics . . .
are often its reviewers. This is especially true if a manuscript re-
ceives an unfavorable evaluation. But how justified is this negative
perception? Admittedly, some reviewers may not be so nice, get
personal, or presume to know it all better. But in my experience as
editor, I have found this journal to have many exceptionally good
reviewers. They spend a lot of time scrutinizing submitted manu-
scripts, giving precise and constructive recommendations as to how
they could be improved. Still, some authors feel poorly treated. Can
it be that educated individuals look at the same subject and have
opposite opinions? Absolutely!
These authors have studied hard, developed a brilliant idea, and
worked long hours to come up with a new solution to an old prob-
lem. But these enthusiasts may not have been the best writing stu-
dents. Their skills did not improve later because, more than likely,
they were not taught how to write scientific manuscripts during their
undergraduate education or postgraduate training, as they should
have been. And consider that the most frequent exposure to profes-
sional scientific material comes from reading. It is here where a vi-
cious circle starts: Poorly written articles and books are consumed
and serve as templates. As bad as this situation is, it is worse still
when authors are not submitting their findings in their mother lan-
guage, but in English, which is more (less often) or less (more often)
familiar to them.
Authors, for one moment, put yourselves in the position of a re-
viewer. He or she reads your words and struggles to understand what
you wanted to express, notices that key references and information
are missing, reads misleading English syntax, and then more and
more, and this over long and longer pages. At this point, you expect
the reviewer to be as enthusiastic as you were when you clicked the
“Save” button the final time? Instead of being as enthusiastic, your
reviewer confronts you with questions and propositions. And all to
make your article fit for publication in an acknowledged journal such
as the World Journal of Orthodontics, which hopefully will happen.
Because of all their efforts, the reviewers of the World Journal of
Orthodontics

. . . should be highly respected!

Rainer-Reggie Miethke
Editor-in-Chief

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PREDICTION OF SOFT TISSUE PROFILE Ahmad Sodagar, DDS, MS1

CHANGES FOLLOWING ORTHODONTIC Darab Gholami Borujeni,

DDS2

RETRACTION OF INCISORS IN Gholamhosein Amini, DDS3

IRANIAN GIRLS
Aim: To study the relationship between incisor retraction and soft tis-
sue profile alterations and to identify and quantify the parameters that
influence it. Methods: Pre- and posttreatment lateral cephalograms of
37 Class I and Class II Division 1 Iranian females in whom at least one
maxillary premolar was bilaterally extracted were analyzed and com-
pared. Results: Significant positive correlations were found between
retraction of the maxillary and mandibular incisors and posterior
movement of the upper lip (r = 0.53, P < .001), the lower lip (r = 0.63,
P < .001), thickness increase of the upper (r = 0.59, P < .001) and lower
(r = 0.69, P < .001) lip, increase of the soft tissue lower anterior face
height (r = 0.81, P < .001) and lower soft tissue component (r = 0.49,
P < .001), and an increase of the nasolabial angle (r = 0.43, P < .01). The
ratio of maxillary incisor to upper lip retraction was 2:1. Conclusion: In
Iranian girls, a strong correlation exists between anterior tooth retrac-
tion and the position and configuration of both lips. World J Orthod
2010;11:262–268.

Key words: prediction, profile, incisor retraction, lip position, extraction

therapy

ne purpose of orthodontic treatment movements, orthopedic growth modula-

O is to improve the dentoskeletal rela-
tionship for good esthetics. The soft tis-
sue of the face is like a mask overlying
the skeletal framework, which is
affected by changes of the bones and
teeth in direct contact with it. Lip posi-
tional changes is critical for treatment
tions, and surgery. 6,7 Changing tooth
position and inclination by either pro-
traction or retraction has the potential to
directly influence the lips.8–18 When the
main treatment objective is to decrease
lower facial convexity and the fullness of
the lips, retraction of the maxillary and
1AssistantProfessor, Orthodontic
Department, Faculty of Dentistry,
Tehran University of Medical Sci-
ences, Tehran, Iran.
2Postgraduate student, Orthodontic
Department, Faculty of Dentistry,
Tehran University of Medical Sci-
ences, Tehran, Iran.
3General Dentist, Tehran, Iran.

planning, especially in patients who mandibular anterior teeth becomes nec-

require premolar extractions.1 Predicting
and quantifying such changes provides
important information about treatment
alternatives.2 Hard tissue changes of the
lower facial third will affect the lip, nose,
and chin,3 as well as the nasolabial and
labiomental angle.4,5 Such hard tissue
changes can be brought about by tooth
CORRESPONDENCE
essary, which cannot be accomplished
Dr Darab Gholami Borujeni
without extraction. Tehran University of Medical
Repositioning of the upper lip in Sciences
response to maxillary incisor retraction Faculty of Dentistry
is commonly expressed as a ratio. The Ghods St.
Enghelab St.
reported ratios vary remarkably in rela-
Tehran, Iran
tion to sex, ethnicity, and treatment 14176-14411
modality. Hershey9 concluded a 3:1 ratio Email: d_gholami@razi.tums.ac.ir

262

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VOLUME 11, NUMBER 3, 2010 Sodagar et al

Table 1  Mean, standard deviation (SD), maximum, and

minimum of various dental, skeletal, and soft tissue
measurements before treatment
Variable Mean SD Maximum Minimum

Overjet (mm) 2.1 1.5 5.5 0.0

Overbite (mm) 5.3 2.2 12.0 2.0
SNA (degrees) 78.9 3.3 86.0 69.0
SNB (degrees) 74.4 3.6 82.0 63.0
ANB (degrees) 4.4 1.6 8.0 0.0
FMA (degrees) 30.3 6.1 47.0 20.0
Sum angle (degrees) 401.9 6.5 424.0 393.0
Facial plane angle (degrees) 86.4 3.1 93.5 81.0
Nasolabial angle (degrees) 106.1 10.2 125.0 73.0
Mentolabial angle (degrees) 134.1 17.5 170.0 94.0
U1-SN (degrees) 107.8 7.5 122.0 85.0
L1-MP (degrees) 96.3 9.4 128.0 75.0

in adult white females. In a study involv-
ing 60 preadolescent boys, Wisth 11
reported a 2:1 ratio for nonextraction
patients and a 3:1 ratio for patients with
extractions. Rains and Nanda14 stated a
ratio of 1.6:1.0 for 15- to 23-year-old
white females, while Rudee19 noted a 2:1
ratio af ter studying 85 individuals
between 6 and 22 years of age. Kokodyn-
ski et al 20 studied individuals of both
sexes 16 years and older and described
this ratio as 1.5:1.0 for females and
1.6:1.0 for males.
According to Brock et al,21 any soft tis-
sue changes in blacks occur generally
more downward, whereas in whites, they
occur in a more backward direction. Gar-
ner conducted two studies on blacks and
found a 3.7:1.0 ratio for both sexes and a
2.0:1.0 ratio for only females.22 Also, for
black females, Diels et al23 and Caplan et
al 24 repor ted ratios of 3.2:1.0 and
1.6:1.0, respectively. For an Asian popula-
tion, Lew 25 delineated a 2.1:1.0 ratio,
whereas also for Asians, Yogosawa 26
stated this ratio to be 2.5:1.0 (for maxil-
lary incisor retraction to lower lip re -
traction, it amounted to 1.4:1.0). In an
Indonesian population, Kusnoto and
Kusnoto27 observed 0.4 mm of upper and
0.6 mm of lower lip retraction per mil-
limeter of mandibular incisor retraction.
Talass et al16 stated more generally in
their study of 80 white females that
retraction of the maxillar y incisors
causes a retraction of the upper lip and
an increase of the lower lip length and
the nasolabial angle. Similarly, other stud-
ies described changes in lip position,
length, and width.28,29 Because there are
little relevant data for Iranians, this study
was initiated.
MATERIAL AND METHODS
The material consisted of cephalograms
with good midfacial soft tissue resolution
from 37 females before (T1) and after
(T2) orthodontic therapy. All individuals
were treated in two orthodontic practices
and chosen at random. The mean age at
pretreatment was 13.9 years (range
10 to 18 years), whereas at the end of
treatment, it was 16.0 years. On average,
the treatments lasted 25 months. The six
inclusion criteria for the patients were:
• Bilateral extraction of at least one
maxillary premolar
• Class I or Class II division 1 occlusion
• Treatment with Edgewise appliances
and maximum anchorage
• No vertical facial configuration as
defined by the mandibular plane angle
• No syndromes, asymmetries, or con-
genitally missing teeth
• No previous orthognathic surgery.
In 10 patients, the maxillary first pre-
molars had been extracted; in 17 others,
all four first premolars had been removed.
Measurements of the sample are summa-
rized in Table 1.

263

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VOLUME 11, NUMBER 3, 2010 Sodagar et al

Table 2a  Names, abbreviations, and definitions of the soft and hard tissue cephalometric landmarks used in this study
Landmark Abbreviation Definition

1. Soft tissue nasion N’ Most posterior point between nose and forehead
2. Nasal tip point Pn Most anterior point of the nose
3. Subnasale Sn Intersection of nasal septum and upper lip
4. Sulcus superior Ss Most posterior point between Ls and Sn
5. Labrale superius Ls Most anterior point on the upper lip
6. Stomion superius Sts Most inferior point on the upper lip vermilion
7. Stomion St Conjunction of upper and lower lip
8. Stomion inferius Sti Most superior point on the lower lip vermilion
9. Labrale inferius Li Most anterior point on the lower lip
10. Sulcus inferius Si Most posterior point between Li and soft tissue pogonion
11. Soft tissue pogonion Pg’ Most anterior point on the soft tissue chin
12. Soft tissue menton Me’ Most inferior point on the soft tissue chin
13. Nasion N Most anterior point of the nasofrontal suture
14. Sella S Center of the pituitary fossa
15. Porion Po Most superior point of the external auditory tube
16. Orbitale Or Most inferior point on the lower border of the orbit
17. Anterior nasal spine ANS Most anterior point of the nasal floor
18. Subspinale A Most posterior point below ANS
19. Maxillary incisor labial crown Most anterior point of labial surface of most anterior maxillary incisor
20. Incisor superius Is Maxillary incisor incisal edge
21. Incisor inferius Ii Mandibular incisor incisal edge
22. Mandibular incisor labial crown point Most anterior point on labial surface of most anterior mandibular incisor
23. Supramentale B Most posterior point between Pog and Infradentale
24. Pogonion Pog Most anterior point of chin
25. Menton Me Most inferior point of mandibular symphysis
26. Gonion Go Conjunction of tangents to the mandibular corpus and ramus
27. Maxillary incisor apex Isa Root tip of maxillary incisor
28. Mandibular incisor apex Iia Root tip of mandibular incisor
29. Structured anterior nasal spine Most anterior point of nasal floor at 3 mm thickness
30. Columella tangent point Midpoint between Pn and Sn
31. Prosthion Pr Most inferior and anterior point on maxillary alveolar process between central incisors

Table 2b  Definition of the cephalometric variables investigated in this study

Variable Definition

U1 – upper lip relationship Pr–Sts on Y plane

U1 – lower lip relationship Is–Sti on Y plane
Upper lip width Ls to most anterior point of maxillary incisors on X plane
Lower lip width Li to most anterior point of mandibular incisors on X plane
Interlabial gap Sts–Sti on Y plane
Upper lip length Sn–Sts on Y plane
Lower lip length Si–Sti on Y plane
Lower anterior face height (LAFH) ANS–Me on X plane
Lower soft tissue component (LSTC) Sti–Me’ on Y plane
Upper vermilion length Ls–St on Y plane
Lower vermilion length Li–St on Y plane
Total vermilion length Ls–Li on Y plane
Soft tissue thickness at Pog Pog–Pog’ on X plane
Horizontal growth of nasal tip Initial to final Pn on Y plane

also retracted with maxillary incisor retrac-
tion, but this correlation was not as strong
as the previous one (r = 0.38, P < .05).
Again, the correlation coefficient between
maxillary incisor retraction and lower lip
retraction amounted to decreased overjet
to r = 0.68 (P < .001), vertical facial con-
figuration to r = 0.43 (P < .01), lip compe-
tency to r = 0.57 (P < .05), increased
upper lip thickness to r = 0.52 (P < .05),
and decreased lower lip thickness to
r = 0.44 (P < .05).

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 Sodagar et al WORLD JOURNAL OF ORTHODONTICS

Table 3  Mean, standard deviation (SD), minimum, maximum, correlation coefficient

with maxillary incisor retrusion (r) and P value of upper and lower lip retraction and
amount of increase and decrease of various cephalometric parameters as a result of
treatment and growth
Variable Mean SD Maximum Minimum r P

Upper lip retraction (mm) 1.1 2.0 5.0 –3.0 0.53 < .001
Lower lip retraction (mm) 0.5 2.1 5.5 –4.0 0.63 < .001
Increase in upper lip thickness (mm) 2.1 2.0 8.5 –1.5 0.59 < .001
Increase in lower lip thickness (mm) 0.6 1.6 5.0 –3.0 0.69 < .001
Decrease in interlabial gap (mm) 1.9 2.5 1.0 –9.5 0.68 NS
Increase in upper lip length (mm) 0.9 1.6 5.5 –1.5 0.52 < .01
Increase in lower lip length (mm) 1.8 1.7 6.0 –0.5 0.37 < .01
Increase in LAFH (mm) 2.8 2.5 8.0 –2.0 0.81 < .001
Increase in LSTC (mm) 2.8 2.3 10.0 –1.0 0.49 < .01
Increase in nasolabial angle (degrees) 3.9 8.6 26.0 –10.0 0.43 < .01
Increase in mentolabial angle (degrees) 3.4 11.4 27.0 –25.0 0.46 NS
Decrease in upper vermilion height (mm) 0.4 1.6 5.0 –4.0 0.40 NS
Increase in lower vermilion height (mm) 0.2 1.2 2.0 –2.0 0.34 NS
Decrease in total vermilion height (mm) 1.9 3.5 6.0 –9.0 0.49 NS
Increase in soft tissue thickness at Pog (mm) 0.4 1.1 3.0 –2.0 0.37 NS

NS = not significant.

A significant increase of 2.1 ± 1.9 mm DISCUSSION

in upper lip thickness (r = 0.59, P < .001)
and of 1.1 ± 1.6 mm in lower lip thickness
(r = 0.69, P < .001) occurred with incisor
retraction. Maxillary incisor retraction led
to an average increase of 0.9 ± 0.6 mm in
upper lip length (r = 0.52, P < .01) and of
1.8 ± 1.7 mm in lower lip length (r = 0.37,
P < .01). Lower lip length increase corre-
lated with initial lower lip length (r = 0.35,
P < .05), initial SNB (r = 0.33, P < .05),
and initial overjet (r = 0.32, P < .05).
Also, lower anterior face height (LAFH)
and lower soft tissue component (LSTC)16
were increased following maxillary incisor
retraction (r = 0.81, P < .001 and r = 0.49,
P < .01, respectively). The ratio between
the increase in soft and hard tissue lower
facial height was 0.7:1.0; both were
strongly correlated. Finally, maxillary
incisor retraction produced an average
nasolabial angle increase of 3.9 degrees
(r = 0.43, P < .01).
The overall ratio of maxillary incisor
retraction to upper lip retraction was 2:1.
A reliable method for predicting changes
in the soft tissue profile in response to
tooth movement could be valuable to all
orthodontists. However, this response
varies largely among ethnicities. Most
studies regarding soft tissue profiles
have been carried out on white individu-
als. 9,14,16,20 Aside from this, a recent
study on adults emphasized a pro-
nounced variability among patients that
may explain why it seems impossible to
accurately predict the behavior of soft
tissue following maxillary incisor move-
ments.30
The pretreatment age span (10 to
18 years) of the sample of this study
appears appropriate because most
patients seeking orthodontic treatment
are of this age. All subjects were females
to avoid variations between sexes that,
as demonstrated in previous studies,
would jeopardize an interpretation of the
results.13,31

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VOLUME 11, NUMBER 3, 2010
To assess the dental, skeletal, and
soft tissue changes, a horizontal refer-
ence line (X) was introduced, which runs
7 degrees below SN through S. This refer-
ence is commonly applied to approximate
the true horizontal line and minimize the
variability of the intracranial structures.16,24
The ratio of upper lip retraction to
maxillary incisor retraction obtained in
this study was 2:1. The correlation coeffi-
cient between these two variables was
increased in patients with decreased
overjet, a long face tendency (increased
FMA) before treatment. This finding is
coincident with the results of previous
studies.9,11,14,16,20,22–25,31 Lower lip retrac-
tion was more strongly correlated with
mandibular incisor retraction than upper
lip retraction with maxillary incisor retrac-
tion. This correlation was higher in
patients with small overjet and thin lower
lips at pretreatment, which is confirmed
by the study of Conley et al.32 Besides
this, several earlier studies have empha-
sized that only retraction of the mandibu-
lar incisors is correlated with a change of
the upper and lower lip. 5,24,26,33 Other
studies, however, stated that all soft tis-
sue changes are more strongly correlated
with maxillary than mandibular incisor
retraction 34 or even that mandibular
incisor movements do not change the
position of either the upper or lower lip.14
Kasai remarked in this context that the
lower lip is more adaptable than the
upper one.35 One study found only minor
changes and concluded that the pretreat-
ment lip morphology is the best predictor
of the posttreatment configuration.36
Increase in upper and lower lip width is
also verified by previous investiga-
tions. 16,21,27 The increase in upper lip
length was smaller in patients with a
decreased overbite. Lower lip length
increase had a positive correlation with
pretreatment lip length. Increase in LSTC
was also significant, although it had less
clinical significance.16
In the current study, no significant
increase in the mentolabial angle was
shown after incisor retraction, which is in
accordance with the study of Talass et
al16; however, in yet another study, this
angle as the nasiolabial angle increased
significantly.26
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Sodagar et al
Whether the observed changes are a
result of the extraction of the first premo-
lars cannot easily be answered. At a mini-
mum, the influence of growth has to be
included. Surprisingly, a recent study
stated that in patients with a Class II rela-
tionship, a treatment protocol with
extraction of two maxillary premolars pro-
vides similar soft tissue results as treat-
ment without extraction.37
CONCLUSION
There was a strong correlation
between anterior tooth retraction and the
anteroposterior position of both lips in
Iranian girls, and the ratio of maxillary
incisor retraction to upper lip retraction
was 2:1.
REFERENCES
1. Hodges A, Rossouw PE, Campbell PM, Boley JC,
Alexander RA, Buschang PH. Prediction of lip
response to four first premolar extractions in
white female adolescents and adults. Angle
Orthod 2009;79:413–421.
2. Mirabella D, Bacconi S, Gracco A, Lombardo L,
Siciliani G. Upper lip changes correlated with
maxillary incisor movement in 65 orthodonti-
cally treated adult patients. World J Orthod
2008;9:337–348.
3. Morris W. An orthodontic view of dentofacial
esthetics. Compendium 1994;15:378–389.
4. Kusnoto H. Soft tissue profile changes after
orthodontic treatment in Class III malocclusion.
Ind Dent Assoc J 1994;43:72–76.
5. Roos N. Soft tissue profile changes in Class II
treatment. Am J Orthod 1977;72:165–175.
6. Proffit WR, Fields HW, Ackerman JL, Sinclair
PM, Thomas PM, Tulloch JF. Contemporary
Orthodontics. St Louis: Mosby, 1993.
7. Graber TM, Vanarsdall RL. Orthodontics: Cur-
rent principles and techniques. St Louis: Mosby,
2000.
8. Bloom LA. Perioral profile changes in orthodon-
tic treatment. Am J Orthod 61;47:371–379.
9. Hershey HG. Incisor tooth retraction and subse-
quent profile change in postadolescent female
patients. Am J Orthod 1972;61:45–54.
10. Anderson JP, Joondeph DR, Turpin DL. A
cephalometric study of profile changes in
orthodontically treated cases 10 years out of
retention. Angle Orthod 1973;43:324–336.
11. Wisth J. Soft-tissue response to upper incisor
retraction in boys. Br J Orthod 1974;2:199–204.
12. Haynes S. Prevalence of upper lip posture and
incisor overjet. Comm Dent Oral Epidemiol
1977;5:87–90.
267
 Sodagar et al
13. Oliver BM. The influence of lip thickness and
strain on upper lip response to incisor retrac-
tion. Am J Orthod 1982;82:141–149.
14. Rains MD, Nanda R. Soft-tissue changes asso-
ciated with maxillary incisor retraction. Am J
Orthod 1982;81:481–488.
15. Holdaway RA. A soft tissue cephalometric
analysis and its use in orthodontic treatment
planning: Part I. Am J Orthod 1983;84:1–28.
16. Talass MF, Talass L, Baker RC. Soft-tissue pro-
file changes resulting from retraction of maxil-
lary incisors. Am J Orthod Dentofacial Orthop
1987;91:385–394.
17. Ricketts RM. Influence of orthodontic treat-
ment on facial growth and development. Angle
Orthod 1960;30:103–133.
18. Park S, Kudlick EM, Abrahamian A. Vertical
dimensional changes of the lips in the North
American black patient after four first-premolar
extractions. Am J Orthod Dentofacial Orthop
1989;96:152–160.
19. Rudee DA. Proportional profile changes associ-
ated with maxillary incisor retraction. Am J
Orthod 1964;50:421–434.
20. Kokodynski RA, Marshall SD, Ayer W, Wein-
traub NH, Hoffman DL. Profile changes associ-
ated with maxillary incisor retraction in the
postadolescent orthodontic patient. Int J Adult
Orthod Orthognath Surg 1997;12:129–34.
21. Brock RA 2nd, Taylor RW, Buschang PH,
Behrents RG. Ethnic differences in upper lip
response to incisor retraction. Am J Orthod
Dentofacial Orthop. 2005;127:683–691.
22. Garner LD. Soft-tissue changes concurrent with
orthodontic tooth movement. Am J Orthod
1974;66:367–377.
23. Diels RM, Kalra V, DeLoach N, Powers M, Nel-
son SS. Changes in soft tissue profile of
African-Americans following extraction treat-
ment. Angle Orthod 1995;65:285–292.
24. Caplan MJ, Shivapuja PK. The effect of premo-
lar extractions on the soft-tissue profile in adult
African-American females. Angle Orthod 1997;
67:129–136.
25. Lew KK. Changes in lip contour following treat-
ment of maxillary protrusion with esthetic
orthodontic appliances. J Esthetic Dent 1992;
4:16–23.
268
© 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
WORLD JOURNAL OF ORTHODONTICS
26. Yogosawa F. Predicting soft tissue profile
changes concurrent with orthodontic treat-
ment. Angle Orthod 1990;60:199–206.
27. Kusnoto J, Kusnoto H. The effect of anterior
tooth retraction on lip position of orthodonti-
cally treated adult Indonesians. Am J Orthod
Dentofacial Orthop 2001;120:304–307.
28. Steyn CL, Maritz JS, du Preez RJ, Harris AM.
Facial profile changes with various orthodontic
premolar extraction sequences during growth.
SADJ. 2004;59:139–141, 143–145.
29. Valentim ZL, Capelli Júnior J, Almeida MA, Bai-
ley LJ. Incisor retraction and profile changes in
adult patients. Int J Adult Orthodon Orthognath
Surg 1994;9:31–36.
30. Mirabella D, Bacconi S, Gracco A, Lombardo L,
Siciliani G. Upper lip changes correlated with
maxillary incisor movement in 65 orthodonti-
cally treated adult patients. World J Orthod
2008;9:337–348.
31. Baum AT. Age and sex differences in dentofacial
changes following orthodontic treatment and
their significances in treatment planning. Am J
Orthod Dentofacial Orthop. 1961;47:355–369.
32. Scott Conley R, Jernigan C. Soft tissue changes
after upper premolar extraction in Class II cam-
ouflage therapy. Angle Orthod 2006;76:59–65.
33. Assuncao ZLV, Cappelli J, Almeida MA, Bailey
LJ. Incisor retraction and profile and profile
changes in adult patients. Int J Adult Orthod
Orthognath Surg 1994;9:31–36.
34. Ozaki T, Ozaki S, Kuroda K. Premolar and addi-
tional first molar extraction effects on soft tis-
sue. Effects on high Angle Class II division 1
patients. Angle Orthod 2007;77:244–253.
35. Kasai K. Soft tissue adaptability to hard tissues
in facial profiles. Am J Orthod Dentofacial
Orthop 1998;113:674–684.
36. Bokas J, Collett T. Effect of upper premolar
extractions on the position of the upper lip.
Aust Orthod J 2006;22:31–37.
37. Janson G, Fuziy A, de Freitas MD, Henriques
JFC, de Almeidac RR. Soft-tissue treatment
changes in Class II Division 1 malocclusion
with and without extraction of maxillary premo-
lars. Am J Orthod Dentofacial Orthop 2007;32:
729.e1–729.e8
James Noble, BSc, DDS,
MSc, FRCD(C)1 FUTURE PROVISION OF ORTHODONTIC
Nicholas Karaiskos, BSc, CARE FOR PATIENTS WITH CRANIOFACIAL
DDS, MSc, FRCD(C)2

William A. Wiltshire,
ANOMALIES AND CLEFT LIP AND PALATE
BChD(HONS), MDent,
Objective: To determine whether Canadian and United States (US)
MChD, DSc, FRCD(C)3
orthodontic programs provide training in treating patients with cleft
lip and palate (CLP) and craniofacial anomalies (CFA) and whether res-
idents will treat these patients in their future practices. Methods: An
email with a personalized link to an anonymous, multi-item, online
questionnaire was sent to all 54 Canadian and 335 of the approxi-
mately 700 US orthodontic residents. The two questions asked were:
“Do you plan to include the treatment of CLP and CFA patients in your
practice?” and “Does your program contain formal training in treating
patients with CLP and CFA?” Results: A total of 44 Canadian and 136
US residents responded. In Canada, 30% plan to treat patients with
CLP and CFA after graduation, 14% said no, 48% said maybe, and 9%
were unsure. In the US, 53% said yes, 7% said no, 36% said maybe,
and 4% were unsure. When asked if their program offers formal train-
ing in the treatment of these patients, 45% of Canadian residents said
yes, 34% said no, and 20% were unsure, whereas 82% of US residents
said yes, 12% said no, and 5% were unsure. Conclusion: Most pro-
grams in the US and approximately half in Canada provide training in
CLP and CFA, and more than half of US and almost one-third of Cana-
dian residents plan to be involved in the care of patients with CLP and
CFA, which is considerably less than those receiving training. Ortho-
dontic programs need to increase the number of postgraduate stu-
dents who are interested in providing care to CLP and CFA patients
after becoming orthodontists. World J Orthod 2010;11:269–272.

Key words: orthodontic care, cleft lip and palate, craniofacial anomalies,
postgraduate orthodontic programs, fellowship programs

1Staff Orthodontist, Bloorview Kids

Rehab Hospital, Toronto, Ontario,
Canada; Private Practice, Toronto,
Ontario, Canada.
2Private Practice, Ottawa, Ontario,

here is a growing concern in North orthodontic postgraduate fellowship

Canada.
3Professor and Head of Orthodontics

and Head of the Department of Pre-

ventive Dental Science, University of
Manitoba, Winnipeg, Manitoba,
Canada.
CORRESPONDENCE
Dr James Noble
75 The Donway West, Suite 414
Toronto, Ontario M3C2E9
Canada
Email: drjamesnoble@gmail.com
T America that there may be a future
deficiency in the provision of orthodontic
care for patients with cleft lip and palate
(CLP) and craniofacial anomalies (CFA).
This concern may be due to the poten-
tially increased complexity and difficulty
of treatment, the long-term care that is
needed, and often minimal financial
benefit. Perhaps for this reason, there is
a growing interest in the accreditation of
training programs that specialize in the
treatment of patients with CLP and CFA.
The purpose of this study was to
investigate the extent that orthodontic
specialty programs in Canada and the
United States (US) provide formal training
to residents in the treatment of patients
with CLP and CFA and to explore whether
the residents plan to treat these patients
in their future practices.

269

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 Noble et al
60
Canada
50 US
40
Percent
30
20
10
0
Yes No Maybe Unsure
METHODS
Ethics approval was obtained from the
University Research Ethics Board to
administer a questionnaire to orthodontic
residents in Canada and the US. Ortho-
dontic program chairs and directors (this
was the same person in some of the pro-
grams) from each of the 5 Canadian and
the 65 US accredited orthodontic pro-
grams were contacted by email for con-
sent for their residents to participate
in this survey. The questionnaire was
included as an attachment to an email,
and a request was made for permission to
contact their residents by email and invite
them to participate in the investigation
anonymously. Program directors or chairs
who did not respond were then contacted
an additional three times by telephone.
An online program was used to send
an email with a personalized online link
to all 54 Canadian orthodontic residents
in November 2006 and to a total of 335
residents from 37 orthodontic programs
distributed throughout the US in May
2007. The personalized online link pre-
vented respondents from completing the
questionnaire more than once. To ensure
privacy and anonymity, no personal infor-
mation was collected, and this was
clearly emphasized to all residents with
each email communication. The ques-
tionnaire was divided into the following
segments: demographics, reasons for
choosing orthodontics, evaluation of the
program, and future directions. Data
were then compiled into a Microsoft
270
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WORLD JOURNAL OF ORTHODONTICS
Fig 1 Distribution (%) of the answer to
the question: Do you plan on treating
patients with cleft lip and palate and cran-
iofacial anomalies after you graduate?
Excel spreadsheet and categorized by
demographic variables. Basic statistics
and comparative analyses using chi-
square analysis were undertaken by sex,
age, and year of training.
The two questions relevant to the cur-
rent publication that were asked were:
1. Do you plan to include the treatment
of patients with cleft lip and palate
and craniofacial anomalies in your
practice?
2. Does your program contain formal
training in treating patients with cleft
lip and palate and craniofacial anom-
alies?
RESULTS
A total of 44 Canadian and 136 US ortho-
dontic residents responded, giving a
response rate of 81.5% and 40.6%,
respectively. Chi-square analysis was
undertaken for sex with no significance
found (P < .05).
In Canada, 30% said they plan to treat
patients with CLP and CFA after gradua-
tion, 14% said no, 48% said maybe, and
9% were unsure. In the US, 53% said yes,
7% said no, 36% said maybe, and 4%
were unsure (Fig 1). When asked if their
program offers formal training in the
treatment of patients with CLP and CFA,
45% of the Canadian residents said yes,
34% said no, and 20% were unsure. In
the US, 82% of the residents said yes,
VOLUME 11, NUMBER 3, 2010
Fig 2 Distribution (%) of the answer to
the question: Does your program contain
formal training in treating patients with
cleft lip and palate and craniofacial anom-
alies?
12% said no, and 5% were unsure (Fig 2).
Chi-square analysis found a significant
difference between Canadian and US res-
idents, with more US residents saying yes
(P = .045).
DISCUSSION
This investigation is unique in that there
has never been a questionnaire or study
administered to orthodontic residents
inquiring about the extent of training they
receive in treating patients with CLP and
CFA or if they plan on treating these
patients after their graduation. These are
important questions, as they can help
predict future issues with access to care
for patients with CLP and CFA.
A series of surveys of orthodontic pro-
grams in the US and Canada were previ-
ously sponsored by the American
Association of Orthodontists Council on
Education, but these were administered
to program directors, not the orthodontic
residents themselves.1–4 These studies,
though extensive, did not ask program
directors whether orthodontic residents
received any training in the treatment of
patients with CLP and CFA, nor did they
ask if their residents had any clinical
experience treating such patients.
According to the current study, most
orthodontic programs in the US and only
approximately half in Canada provide for-
mal training in the treatment of patients
with CLP and CFA. More than half of US
residents and almost one-third of Cana-
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NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Noble et al
90
80
Canada
70 US
60
50
Percent
40
30
20
10
0
Yes No Unsure
dian residents plan to be involved in the
care of these patients after graduation.
Disappointingly, this is considerably less
than the number of residents who
receive training. Numerous reasons may
exist as to why residents who have
received respective training are still not
willing to treat these patients upon grad-
uation. One reason might be that the
extent of the training they received may
have been too limited, so the residents
may not feel prepared to treat more com-
plex malocclusions. Another reason
could be that residents may not have the
desire to treat CLP/CFA patients because
their malocclusions are very complex,
which leads to an increased length of
treatment time, which often translates to
reduced financial benefits.
A limitation of this study is that the
extent and scope of the training was not
investigated. This additional information
could be important to assist postgradu-
ate orthodontic fellowship training pro-
grams in attaining accreditation. If a
limited amount of training in graduate
orthodontic programs exists, this would
demonstrate a need for such fellowship
programs, as they would guarantee
orthodontists graduate with the special-
ized diagnostic and clinical skills neces-
sary to treat patients with CLP and CFA.
This study demonstrated that issues
with access to care for patients with CLP
and CFA are likely to be more prevalent in
Canada, with significantly fewer residents
from Canada indicating that they will treat
these patients in their future practice.
271
 Noble et al
This may not only be a lack of willingness
of Canadians to treat these patients, but
may also be a function of residents from
Canada not receiving enough postgradu-
ate training, leaving them feeling unpre-
pared to treat such patients.
According to the residents’ answers,
most orthodontic training programs in the
US, but only approximately half in
Canada, provide formal training in treat-
ment of patients with CLP and CFA. How-
ever, orthodontic programs need to have
formal theoretical and practical training in
the treatment of such patients. Some res-
idents may later practice in locations
where no orthodontist with special train-
ing is available and may find themselves
as the orthodontic member of a cleft and
craniofacial team. Further, programs
should graduate residents who will treat
patients with difficulties accessing care,
which includes patients with CLP and
CFA. Optimal orthodontic programs, there-
fore, should have multidisciplinary semi-
nars and courses, hospital rotations, and
even specialized craniofacial clinics so
residents can acquire hands-on clinical
experience. Residents should also be
taught their limits when treating such
patients and their responsibility to refer
them to a consultant orthodontist in a
craniofacial center. This type of education
272
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NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
WORLD JOURNAL OF ORTHODONTICS
may stimulate more residents to become
eager and proficient participants in the
care of these patients after graduation,
despite the challenges they may
encounter in treatment.
Orthodontic programs also need to
convey to their residents the personal
rewards and fulfillment associated with
developing a long-term relationship in the
treatment of patients with CLP and CFA,
as well as the satisfaction of being a
member of a craniofacial team of diverse
specialists. In addition, to ensure the
future provision of care for these
patients, orthodontic programs should
accept students who express a genuine
interest in the treatment of this segment
of the population.
REFERENCES
1. Keim RG, Sinclair PM. Orthodontic graduate
education survey, 1983–2000. Am J Orthod
Dentofacial Orthop 2002;121:2–8.
2. Rudolph DJ, Sinclair PM. Orthodontic graduate
education survey. Am J Orthod Dentofacial
Orthop 1997;112:418–424.
3. Sinclair PM, Alexander RG. Orthodontic gradu-
ate education survey. Am J Orthod 1984;85:
175–181.
4. Sinclair PM, Rudolph DJ. Orthodontic graduate
education survey. Am J Orthod Dentofacial
Orthop 1991;100:465–471.
Marcelo Emir Requia Abreu,
DDS, MsD1 INFRARED LASER THERAPY AFTER
Vinícius Nery Viegas, DDS, SURGICALLY ASSISTED RAPID PALATAL
MsD1

Rogério Miranda Pagnoncelli,

DDS, MsD, PhD2
Eduardo Martinelli
Santayama de Lima,
DDS, MsD, PhD3
Alessandro Marchiori Farret,
DDS, MsD4
Fernando Zugno Kulczynski,
DDS, MsD5
Marcel Marchiori Farret,
DDS, MsD, PhD4
1PhD student, Department of Oral
and Maxillofacial Surgery, Pontifícia
Universidade Católica do Rio
Grande do Sul–PUCRS, Porto Alegre,
Rio Grande do Sul, Brazil.
2Professor, Department of Oral and
Maxillofacial Surgery, Pontifícia
Universidade Católica do Rio
Grande do Sul–PUCRS, Porto Alegre,
Rio Grande do Sul, Brazil.
3Professor, Department of Orthodon-
EXPANSION TO DIMINISH PAIN AND
ACCELERATE BONE HEALING
The aim of this study was to illustrate how gallium arsenite alu-
minum diode laser (824 nm) irradiation can reduce postsurgical
edema and discomfort and accelerate sutural osseous regeneration
after surgically assisted rapid palatal expansion (SARPE). An adult
patient with an 8-mm transverse maxillary discrepancy was treated
with SARPE. Infrared laser therapy was started on the 7th postopera-
tive day, with a total of eight sessions at intervals of 48 hours. The
laser probe spot had a size of 0.2827 cm2 and was positioned in con-
tact with the following (bilateral) points: infraorbital foramen, nasal
alar, nasopalatine foramen, median palatal suture at the height of the
molars, and transverse palatine suture distal to the second molars.
The laser was run in continuous mode with a power of 100 mW and a
fluency of 1.5 J/cm2 for 20 seconds at each point. Subsequently, an
absence of edema and pain was observed. Further, fast bone regener-
ation in the median palatal suture could be demonstrated by occlusal
radiographs. These findings suggest that laser therapy can accelerate
bone regeneration of the median palatal suture in patients who have
undergone SARPE. World J Orthod 2010;11:273–277.
Key words: low-level laser therapy, maxillary constriction, rapid palatal
expansion, SARPE, bone regeneration

tics, Pontifícia Universidade Católica

do Rio Grande do Sul–PUCRS, Porto
hen maxillary transverse deficien- Lasers were developed in the 1960s,
Alegre, Rio Grande do Sul, Brazil.
4PhD student, Department of Ortho-

dontics, Pontifícia Universidade

Católica do Rio Grande do
Sul–PUCRS, Porto Alegre,
Rio Grande do Sul, Brazil; Private
Practice, Santa Maria, RS, Brazil.
5MsD student, Department in Oral
and Maxillofacial Surgery, Pontifícia
Universidade Católica do Rio
Grande do Sul–PUCRS, Porto Alegre,
Rio Grande do Sul, Brazil; Private
Practice, Porto Alegre, RS, Brazil.
CORRESPONDENCE
Dr Marcel Marchiori Farret
1000/113 Floriano Peixoto St.
Santa Maria, RS
Brazil 97015–370
Email: marcelfarret@yahoo.com.br
W cies are diagnosed early in children
and adolescents, they may be ade-
quately treated by rapid maxillary expan-
sion. However, after skeletal maturation,
the exclusive use of an expander can be
unsuccessful and result in dentoalveolar
expansion that is prone to relapse and
accompanied by pain and gingival reces-
sions. Therefore, in adults, osteotomies
of the areas that limit or impede the
transversal disjunction of the maxilla are
indicated. This surgical procedure may
be performed under general or local
anesthesia. With or without surgical
intervention, there will be edema and
pain.
and since then, they have been utilized
for multiple purposes. In medicine, two
types of lasers are mainly employed:
high- and low-intensity lasers. The for-
mer deposit high densities of energy in
irradiated tissues and have the ability to
cut, coagulate, and evaporate tissues by
extremely elevating their temperature.
Low-intensity lasers biomodulate irradi-
ated tissues, and depending on the
intensity, type, potential, and dose, they
may accelerate or decelerate physiologic
or pathologic processes.
Studies have suggested that laser
therapy, as an auxiliary to orthodontic
therapy, can reduce pain and accelerate

273

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NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Abreu et al
a b
Fig 1 Facial points of laser application. (a and b) Bilateral nasal alar, (c and d) bilateral infraorbital foramen.
tooth movements and alveolar remodel-
ing.1–4 Maxillary osteotomies rarely heal
completely, and the formation of new
bone after surgically assisted rapid
palatal expansion (SARPE) occurs slowly
(4 to 6 months). 5–7 One reason for
relapse after maxillary expansion is insuf-
ficient osseous regeneration of the
median palatine suture.7 Thus, accelera-
tion of the bone remodeling of the
median palatine suture after expansion
would be helpful to prevent relapse and
shorten the retention period.8 According
to the relevant literature, low-intensity
lasers are beneficial during and after
SARPE to reduce discomfort, pain, and
tissue necrosis and accelerate bone
deposition in the sutural region.8–14
This article presents an adult patient
who underwent SARPE and infrared
(824 nm) laser therapy with the intent to
diminish postoperative edema and pain
and accelerate bone healing of the
osteotomy areas.
PATIENT REPORT
The patient was a 20-year-old man with
good general health, no cavities, and no
periodontal affections. His facial analysis
revealed a normal sagittal skeletal relation-
ship, straight profile, and normodivergent
274
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NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
WORLD JOURNAL OF ORTHODONTICS
c d
configuration. The clinical examination
showed a Class II, division 1 occlusion, a
marked overjet, no overbite, and mild
crowding in both arches (arch length defi-
ciency 4 mm in the maxilla and 3 mm in
the mandible). The maxilla demonstrated a
skeletal transverse deficiency of 8 mm
with a bilateral crossbite. A dental compen-
sation was contraindicated because of
possible periodontal damages (gingival
recession and root exposure).
Because the patient was an adult,
conventional rapid maxillary expansion
was not a good option. Therefore, SARPE
was chosen. A Hyrax appliance was
inserted with a 13-mm screw soldered to
the bands of both first molars and first
premolars. The surgery was performed
under general anesthesia. The osteotomy
included the lateral wall of the maxilla
from the piriform opening to the ptery-
goid process, which freed the nasal sep-
tum. Complete separation was confirmed
intrasurgically via the absence of any
impediment to expansion. The extended
osteotomy has the disadvantages of caus-
ing increased edema and discomfort.
Seven days postoperatively, the Hyrax
appliance was activated and laser ther-
apy initiated. The expansion per day
amounted to 0.5 mm and continued for
16 days. In total, eight sessions of irradi-
ation with infrared (824 nm) Thera-Laser
VOLUME 11, NUMBER 3, 2010 Abreu et al

Fig 2 Intraoral points of laser

application. (a) Nasopalatine
foramen, (b) median palatine
suture between the first
molars, and (c and d) trans-
verse palatine suture bilaterally
distal to the second molars.

a b

c d

(DMC) were applied at 48-hour intervals. DISCUSSION

The tip of the device was 0.2827 cm2
and brought into direct contact with the
affected regions. The laser worked in
direct mode with a fluency of 1.5 J/cm2
and an automatic dosage calculation for
20 seconds per point. These points were
the left and right infraorbital foramen,
left and right nasal alar, nasopalatine
foramen, median palatine suture at the
height of the first molars, and transverse
palatine suture distally to the second
molars (Figs 1 and 2).
No edema developed, and af ter
23 days, excellent bone healing was
observed. During activation of the Hyrax
appliance, the patient did not experience
any pain. Any discomfort was relieved
after application of the laser.
The radiographic examinations
revealed an advanced formation of new
bone in the median palatine suture. At
days 25 and 45, the existing radiopacity
had diminished. At day 90, complete
osseous healing of the suture was
observed (Fig 3).
SARPE is the treatment of choice for cor-
rection of posterior crossbites after the
median suture of the maxilla is ossified
and transverse maxillary deficiency is
greater than 5 mm.6,10,15–23 Both condi-
tions were present in the studied patient.
Conventional rapid maxillary expansion in
adults can cause discomfort, buccal corti-
cal fenestration, and long-term instability.
SARPE surpasses these problems and is
performed even more frequently in adults
with good long-term stability.16,19,20
The use of low-intensity lasers as
favorable modulators of biological phe-
nomena has been reported in the litera-
ture for quite some time. 19,20 In this
patient, the laser was directed at the
affected areas as described in the litera-
ture.2–5 The patient felt less pain after
each laser application. At the end of
expansion, no gingival inflammation was
observed, which corroborates the litera-
ture findings. 1,2,11,12,22,23 According to
Malmström and Gurgel,7 who analyzed

275

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 Abreu et al
a b
d e
occlusal radiographs after SARPE, the
amount of bone regeneration without
laser after 120 days is insufficient. Only
45 days after SARPE, this patient showed
advanced osseous regeneration of the
median palatine suture.8,9–12 Due to this
superior bone formation, an increased
stability can be expected. 5,18,24
CONCLUSION
Laser application can be effective in pro-
moting acceleration of bone formation
and reducing pain, tissue irritation, and
hemorrhage during surgically assisted
rapid maxillary expansion.
276
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WORLD JOURNAL OF ORTHODONTICS
c
Fig 3 Occlusal radiographs. (a) Initial,
(b) after expansion, (c) 25 days after
expansion, (d) 45 days after expansion,
and (e) 90 days after expansion.
REFERENCES
1. Honmura A, Ishii A, Yanase M, Obata J, Haruki
E. Analgesic effect of Ga-Al-As diode laser irra-
diation on hyperalgesia in carrageenin-induced
inflammation. Lasers Surg Med 1993;13:
463–469.
2. Lim HM, Lew KK, Tay DK. A clinical investiga-
tion of the efficacy of low level laser therapy in
reducing orthodontic postadjustment pain. Am J
Orthod Dentofacial Orthop 1995;108:614–622.
3. Harazaki M, Takahashy H, Ito A, Isshiki Y. Soft
laser irradiation induced pain reduction in
orthodontic treatment. Bull Tokyo Dent Coll
1998;39:95–101.
4. Kawasaky K, Shimizu N. Effects of low-energy
laser irradiation on bone remodeling during
experimental tooth movement in rats. Lasers
Surg Med 2000;26:282–291.
5. Souza JEP, Pinheiro FHSL, Andrade Júnior P,
Janson GRP, Freitas MR, Henriques JFC. Surgi-
cally assisted rapid palatal expansion: A case
report. Rev Dent Press Ortod Ortop Facial
2002;7:81–86.
VOLUME 11, NUMBER 3, 2010
6. Silverstein K, Quinn P. Surgically-assisted rapid
palatal expansion for management of trans-
verse maxillary deficiency. J Oral Maxillofac
Surg 1997;55:725–727
7. Malmström MFV, Gurgel JA. Evaluation of new
bone formation at the midpalatal suture by digi-
tized radiography after surgically assisted max-
illary expansion. Rev Dent Press Ortod Ortop
Facial 2007;12:82–93.
8. Saito S, Shimizu N. Stimulatory effects of
low–power laser irradiation on bone regenera-
tion in midpalatal suture during expansion in
the rat. Am J Orthod Dentofacial Orthop 1997;
111:525–532.
9. Brugnera AJ, Santos AECG, Bologna ED,
Ladolardo TCGPC. Atlas de laserterapia aplicada
à clínica odontológica. São Paulo: Santos, 2003.
10. Abreu MER, Viegas VNRM, Pagnoncelli RM. Bio-
modulation with low-laser (830 nm) in surgi-
cally assisted maxillary expansion. The 9th
International Congress on Laser Dentistry:
2004, 21–24.
11. Pagnoncelli RM, Abreu MER, Viegas VN. Bio-
modulation with low-laser (830 nm) in surgi-
cally assisted maxillary expansion. Brazilian
Dent J. 2004;15:122.
12. Abreu MER, Viegas VN, Pinto PR, Lima, EMS,
Pagnoncelli RM. Lasers na Ortodontia.
Ortodontia Gaúcha. 2005;9:135–141.
13. Suri L, Taneja P. Surgically assisted rapid palatal
expansion: A literature review. Am J Orthod
Dentofacial Orthop 2008;133:290–302.
14. Lanigan DT, Mintz SM. Complications of surgi-
cally assisted rapid palatal expansion: Review
of the literature and report of a case. J Oral
Maxillof Surg 2002;60:104–110.
15. Betts NJ, Vanarsdall RL, Barber HD, Higgins-
Barber K, Fonseca RJ. Diagnosis and treatment
of transverse maxillary deficiency. Int J Adult
Orthodon Orthognath Surg 1995;10:75–96.
© 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Abreu et al
16. Progel MA, Kaban L. Surgical assisted rapid
maxillary expansion in adults. Int J Adult Ortho-
don Orthognath Surg 1992;7:37–41.
17. Morgan TA, Fridrich KL. Effects of the multiple-
piece maxillary osteotomy on the periodontium.
Int J Adult Orthodon Orthognath Surg 2001;16:
255–265.
18. Tavares CAE, Scheffer MS. Surgically assisted
rapid maxillary expansion (SARPE) prior to com-
binated Le Fort I and sagittal osteotomy: A case
report. Int J Adult Orthodon Orthognath Surg
2001;16:200–206.
19. Gilon Y, Heymans O, Limme M, Brandt L, Raskin
S. Indications and implications of surgical maxil-
lary expansion in orthodontic surgery. Rev Stom-
atol Chir Maxillofac. 2000;101:252–258.
20. Clayman L, Kuo P. Lasers in Maxillofacial
Surgery and Dentistry. New York: Thieme, 1997.
21. Brugnera AJ, Pinheiro A. Lasers na Odontologia
Moderna. São Paulo: Pancast, 1998.
22. Mezawa S, Iwata K, Naito K, Kamogawa H. The
possible analgesic effect of soft-laser irradia-
tion on heat nociceptores in the cat tongue.
Arch Oral Biol 1988;33:693–694.
23. Gurgel JA, Sant’ana E, Henriques JFC. Ortho-
dontic-surgical treatment of transverse maxil-
lary deficiency. Rev Dent Press Ortod Ortop
Facial 2001;6:59–66.
24. Koustaal MJ, Poort LJ, Van der Wal KG, Wolvius
EB, Prahl-Andersen B, Schulten AJ. Surgically
Assisted Rapid Maxillary Expansion (SARME):
a review of the literature. J Oral Maxillofacial
Surg 2005;34:709–714.
277
TREATMENT OF AN ADOLESCENT WITH Nihal Hamamcı, DDS, PhD1

TOTAL ANKYLOGLOSSIA Törün Özer, DDS, PhD2

Orhan Hamamcı, DDS,

This is a report about the orthodontic treatment of a 13-year, 10-month- PhD3
old boy with total ankyloglossia combined with a Class III occlusion.
The patient’s tongue was fixed to the floor of his mouth and could not Emin Caner Tümen, DDS,
be elevated at all. He had a maxillary deficiency and a mandibular pro- PhD4
trusion with a negative overjet. However, he was able to retrude his
mandible to an edge-to-edge position. Before orthodontic treatment, Engin Ağaçkıran, DDS5
the ankyloglossia was surgically rectified. Orthodontic treatment was
initiated to improve the patient’s occlusion and facial appearance by
correcting his retruded maxilla by means of a face mask, fixed appli-
ances, and Class III elastics. This led to a functional occlusion and an
acceptable facial appearance. World J Orthod 2010;11:278–283.

Key words: ankyloglossia, Class III occlusion, face mask, maxillary

deficiency, tongue dysfunction

nkyloglossia is a congenital anomaly surgical and orthodontic treatment.

A that influences the mobility of the
tongue (eating and speaking), as well as
a patient’s oral hygiene is also
affected.1,2 Because ankyloglossia pre-
vents contact between the anterior
palate and tongue, affected patients
have an infantile swallow pattern that
results in jaw deformities such as
mandibular prognathism.3
The incidence of ankyloglossia ranges
from 0.002% to 4.8%. The wide range
may be due to the lack of an objective
grading system.4 In addition, there is dis-
agreement among professionals about
the importance of this problem, as docu-
mented by Messner and Lalakea. 5
According to the literature, ankyloglossia
is generally characterized by a short,
thick labial frenulum that is connected
to the very tip of the tongue.1–6 The man-
DIAGNOSIS AND ETIOLOGY
The patient was a still-growing 13-year,
10-month-old boy who complained about
his appearance and difficulties with eat-
ing and speaking (Fig 1). He said he felt
socially embarrassed and therefore did
not talk much.
Intraoral examination revealed total
ankyloglossia (Fig 2). His tongue was
attached to the floor of his mouth, and
as such, the patient could not elevate it
at all. He had a negative overjet but was
able to retrude his mandible into an
edge-to-edge position. As a result, the
patient was diagnosed with a pseudo
Class III occlusion resulting from a tether-
ing of his tongue to the floor of his
1Assistant
Professor, Department of
Orthodontics, Dicle University,
Diyarbakir, Turkey.
2Associate Professor, Department of
Orthodontics, Dicle University,
Diyarbakir, Turkey.
3Professor, Department of Orthodon-
tics, Dicle University, Diyarbakir,
Turkey.
4Assistant Professor, Department of
Pedodontics, Dicle University,
Diyarbakir, Turkey.
5Research Assistant, Department of

ifestation varies from mild to severe.3
Total ankyloglossia in adolescents is
very rare because it is generally treated
early in childhood to correct feeding and
speech limitations.
This report also presents the craniofa-
cial measurements of an adolescent
with untreated total ankyloglossia and
demonstrates the results of combined
mouth. For financial reasons, he had not Pedodontics, Dicle University,
Diyarbakir, Turkey.
undergone any previous surgical tongue
intervention. He further presented with CORRESPONDENCE
mandibular crowding, an increased curve Dr Nihal Hamamci
of Spee, and a maxillary diastema (Fig 3). Dicle University
Faculty of Dentistry
The lateral cephalometric analysis
Department of Orthodontics
revealed a Class III relationship with an 21280 Diyarbakır
ANB of –12 degrees. The distance from Turkey
Steiner’s S-line to the upper lip was Email: nhamamci@dicle.edu.tr

278

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VOLUME 11, NUMBER 3, 2010 Hamamcı et al

Figs 1a to 1c Pretreatment
facial photographs revealing a de-
creased lower facial height, an
underdeveloped maxilla with a
very low lip line, and a prognathic
mandible.

a b c

Fig 2 (left) Position of the tongue prior to surgical intervention.

Figs 3a to 3f (below) Pretreatment intraoral photographs showing a severe Class III

occlusion with a deep reversed overjet, a bilateral crossbite, congenitally missing
maxillary lateral incisors, and severly retruded mandibular anterior teeth. The
patient is still able to achieve an edge-to-edge bite (Fig 6), indicating a long slide
from centric relation into centric occlusion.

a b c

d e f

–4 mm; to the lower lip, it was 8 mm. Treatment objectives

BaPtmGn was 102 degrees, indicating an
anterior position of the mandible. The
anterior face height was 116 mm, and
the posterior face height, 80 mm, which
reflected a skeletal deep bite with an
S-Go/N-Me ratio of 69% (Figs 4 and 5,
Table 1).
The patient underwent surgical removal
of his ankyloglossia, correction of the
anterior crossbite and the sagittal maxil-
lary deficiency to provide a normal overjet
and overbite. Also, the deep curve of
Spee was levelled. The ultimate goal was
to achieve an acceptable facial appear-
ance and a stable occlusion.

279

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 Hamamcı et al WORLD JOURNAL OF ORTHODONTICS

Fig 4 Pretreatment cephalometric radiograph Fig 5 Pretreatment panoramic radiograph showing that all
indicating a severe Class III occlusion with a deep teeth except for the maxillary lateral incisors are present.
reversed overjet, a retruded maxilla, a protruded
mandible, and decreased lower facial height.

Table 1 Pre- and posttreatment cephalometric

measurements
Parameter Pretreatment Posttreatment

SNA (degrees) 73 74
SNB (degrees) 85 80
ANB (degrees) –12 –6
SND (degrees) 83 79
Co-A (mm) 88 92
Co-Gn (mm) 131 132
Na-Me (mm) 116 126
ANS-Me (mm) 55 65
SNGoMe (degrees) 29 33
SN-OcP (degrees) 3 10
ArGoGn (degrees) 128 130
ANS-PNS-SN (degrees) 7 4
NSBa (degrees) 120 130
S-Go/Na-Me (%) 69 67
S-Go (mm) 80 83
BaPtmGn (degrees) 102 98
U1-upper lip (mm) 16 13
L1-lower lip (mm) 15 13
Pog-Pogs (mm) 10 14
Soft tissue/S-line (maxillary/mandibular) –4/+8 –5/0
Maxillary depth (degrees) 78 80
Nasolabial angle (degrees) 50 74
U1-NA (mm) 25/4 30/6
L1-NB (mm) 8/–6 10/–3
U1-L1 (degrees) 176 154

Treatment progress to correct his jaw relationship because

The patient underwent tongue surgery at
the Plastic and Reconstructive Surgery
Department of Dicle University. The
patient’s parents then decided that their
son should not have a second operation
the possible esthetic improvement would
not be worth the increased cost and risk.
Because of this decision, the sagittal
maxillary deficiency had to be corrected
with a face mask during orthodontic
treatment.

280

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VOLUME 11, NUMBER 3, 2010
a b
Figs 6a to 6e Posttreatment intraoral
photographs after space closure in the
maxilla and extraction of one mandibu-
lar incisor with Class II occlusion but
normal overjet and overbite. The cross-
bite was eliminated, and the maxillary
lateral incisors were reshaped to
resemble lateral incisors.
d e
This treatment began in the maxilla
with 0.018-inch ⫻ 0.025-inch Roth
straight-wire appliances. As there was a
crossbite (tendency), an occlusal splint
was used to unlock the occlusion. After
leveling the maxillary arch, a 0.016-inch
⫻ 0.022-inch stainless steel archwire was
inserted and a face mask applied to move
the maxilla ventrally while simultaneously
moving the maxillary posterior teeth ante-
riorly to close all existing spaces resulting
from the congenitally missing lateral
incisors. The force of the face mask
amounted to 350 cN per side, and the
force vector was parallel and slightly
above the occlusal plane so that the max-
illary plane rotated anteriorly. The patient
complied with face mask wear very well,
so the anterior crossbite was eliminated
af ter 5 months. To compensate the
Bolton discrepancy that resulted from the
missing lateral incisors, one mandibular
incisor was extracted.
After a positive overjet was established,
the mandibular teeth were bonded. The
remaining maxillary diastema was closed
with the assistance of Class III elastics.
RESULTS
By the end of treatment, the anterior
crossbite, deep overbite, maxillary retru-
sion, and the mandibular crowding were
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NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Hamamcı et al
c
corrected (Fig 6). The ANB had increased
to –6 degrees by a posterior mandibular
and anterior maxillary rotation (Figs 7 to 9,
Table 1). In addition, an acceptable
esthetic facial appearance was achieved
(Fig 10); the patient wore Hawley retain-
ers for retention.
DISCUSSION
Ankyloglossia is an oral anomaly result-
ing from failing cellular degradation of
the tongue frenum between the 8 th to
11th prenatal week.7,8 It is more common
in males.9,10 Ballard et al11 found a posi-
tive family history, although this was not
the case here.
There is no standard definition or
grading system for ankyloglossia. Simi-
larly, the possible consequences and
management of ankyloglossia are contro-
versial. Lalakea and Messner4 noted that
besides problems while speaking and
eating, pain and cuts of the frenum may
occur while wetting one’s lips and kiss-
ing. In addition, the aforementioned prob-
lems may be noticed only later in
childhood, as small children may be
unable to recognize or report any nega-
tive effect. In addition, problems with
kissing, for instance, may not be noted
until later in adolescence.
281
 Hamamcı et al WORLD JOURNAL OF ORTHODONTICS

Fig 7 Posttreatment cephalometric radiograph Fig 8 Posttreatment panoramic radiograph after space clo-
indicating remarkably improved sagittal and verti- sure with good root parallelism.
cal jaw and profile relationship.

Fig 9 (right) Superimpo-

sition of cephalometric
tracings from the begin-
ning and end of treatment.

Figs 10a to 10c (below)

Posttreatment facial photo-
Pretreatment graphs underlining the re-
markably improved sagittal
Posttreatment and vertical jaw and profile
relationship.

a b c

282

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VOLUME 11, NUMBER 3, 2010
There are various interventions for
ankyloglossia. Horton et al3 believe that
individuals with ankyloglossia can com-
pensate for the limited tongue motion
when it comes to speech. For example, if
sounds such as “en”, “tee”, “dee”, and
“ell” are impeded, they will be compen-
sated by dentalization. To produce the
sound “arr,” an elevation of the mandible
can compensate for the restricted tongue
movement. Overall, Horton et al3 propose
compensatory strategies, not surgery.
Intervention for ankyloglossia includes
laser surgery in the form of a frenotomy
(also called frenectomy or frenulectomy)
or frenuloplasty.12 These procedures are
indicated for patients of any age with a
tight frenulum, as well as objective and
subjective impairments.
A viable alternative to surgery is to
wait and see. 4 Ruffoli et al 13 reported
that the tongue frenulum naturally
recedes between 6 months and 6 years
of age. As this patient was already older
than 13 years, more waiting likely would
not have improved his condition.
The craniofacial configuration of this
patient was clearly abnormal. According
to the equilibrium theory of Weinstein et
al,14 the pressure from the tongue and
lips near the maxillary second premolars
and first molars and maxillary anterior
teeth is balanced. In patients with anky-
loglossia, there is no tongue pressure
against the maxilla, so transverse and
sagittal growth is inhibited. As the maxil-
lary anterior teeth had no antagonists,
they continued to erupt and the maxillary
occlusal plane rotated posteriorly. Con-
versely, the overerupting mandibular
anterior teeth rotated the mandibular
occlusal plane anteriorly. Because the
force vector of the face mask acted
below the center of resistance of the
maxillary dentition, the maxillary anterior
dentition rotated anteriorly while estab-
lishing a positive overjet. The decrease in
the SN-OcP (7 degrees), the increase in
SNA (1 degree), and the increase in Co-A
(4 mm) indicated an anterior rotation of
the maxilla, whereas the 5 degree SNB
decrease and the increase in facial
height can be attributed to a posterior
rotation of the mandible.
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NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Hamamcı et al
CONCLUSION
Because his parents could not afford the
costs for or thognathic surger y, this
patient was treated with orthodontics
alone. However, the patient ultimately
attained a functional occlusion and
acceptable facial appearance.
REFERENCES
1. Messner AH, Lalakea ML. The effect of anky-
loglossia on speech in children. Otolaryngol
Head Neck Surg 2002;127:539–545.
2. Travis LE. Handbook of Speech Language
Pathology and Audiology. New York: Meredith,
1971.
3. Horton CE, Crawford HH, Adamson JE, Ashbell
TS. Tongue-tie. Cleft Palate J 1969;6:8–23.
4. Lalakea ML, Messner AH. Ankyloglossia: Does
it matter? Pediatr Clin North Am 2003;50:
381–397.
5. Messner AH, Lalakea ML. Ankyloglossia: Contro-
versies in management. Int J Pediatr Otorhino-
laryngol 2000;54:123–131.
6. Lalakea ML, Messner AH. Ankyloglossia: The
adolescent and adult perspective. Otolaryngol
Head Neck Surg 2003;128:746–752.
7. Kalu PU, Moss ALH. An unusual case of anky-
loglossia superior. Br J Plast Surg 2004;57:
579–581.
8. Gartlan MG, Davies J, Smith RJH. Congenital
oral synechiae. Ann Otol Rhinol Laryngol 1993;
102:186–197.
9. Harris EF, Friend GW, Tolley EA. Enhanced
prevalence of ankyloglossia with maternal
cocaine use. Cleft Palate Craniofac J 1992;29:
72–76.
10. Ricke LA, Baker NJ, Madlon-Kay DJ, DeFor TA.
Newborn tongue-tie: Prevalence and effect on
breast-feeding. J Am Board Fam Pract 2005;
18:1–7.
11. Ballard JL, Auer CE, Khoury JC. Ankyloglossia:
Assessment, incidence, and effect of frenulo-
plasty on the breast-feeding dyad. Pediatrics
2002;110:e63.
12. Lalakea ML, Messner AH. Frenotomy and frenu-
loplasty: If, when, and how. Oper Tech Otolaryn-
gol Head Neck Surg 2002;13:93–97.
13. Ruffoli R, Giambelluca MA, Scavuzzo MC. Anky-
loglossia: A morphofunctional investigation in
children. Oral Dis 2005;11:170–174.
14. Weinstein S, Donald CH, Morris LY, Snyder BB,
Attaway HE. On an equilibrium theory of tooth
position. Angle Orthod 1963;33:1–26.
283
INTERDISCIPLINARY TREATMENT OF A Gülnaz Marşan, PhD1

PATIENT WITH AMELOGENESIS Irem Sakarya Aksu, PhD2

Hanefi Kurt, PhD3

IMPERFECTA, A SKELETAL CLASS III
Samet Vasfi Kuvat, MD4
RELATIONSHIP, AND AN ANTERIOR Nil Cura, PhD5
OPEN BITE
An adult woman with amelogenesis imperfecta, a skeletal Class III rela-
tionship, long face syndrome, and a severe anterior open bite received
interdisciplinary treatment (orthodontics, orthognathic surgery, and
prosthodontics). Presurgical orthodontic treatment was followed by a
maxillary posterior impaction with anterior advancement and a
mandibular setback. After surgery, the patient received ceramic
crowns. Function and esthetics were successfully re-established.
World J Orthod 2010;11:284–291.

Key words: interdisciplinary treatment, amelogenesis imperfecta, skeletal

Class III relationship, anterior open bite

keletal Class III relationships and The types of amelogenesis imper-

S anterior open bites are orthodonti-
cally most difficult to treat.1,2 Reten-
tion of open bite af ter closure
frequently proves to be very difficult. If
a skeletal malocclusion is diagnosed
after a patient’s growth spurt and
treated with an orthodontic extrusion
of the anterior teeth, relapse is
unavoidable.3,4 In this situation, surgi-
cal impaction of the posterior part of
the maxilla is considered to be the
most ef fective treatment alterna-
tive.1,2,5,6 Various studies have demon-
fecta are hereditary and characterized
by a remarkable genetic and clinical
heterogeneity affecting enamel miner-
alization in the primary and perma-
nent dentition.2,6,8–22 The hypoplastic
type of amelogenesis imperfecta is
generally transmitted via an X-linked
dominant trait and involves most of
the enamel of all teeth. The condition
was described initially as unassociated
with any biochemical or morphologic
abnormalities.22
1Associate Professor, Department of
Orthodontics, Faculty of Dentistry,
Istanbul University, Istanbul, Turkey.
2PhD Student, Department of Ortho-
dontics, Faculty of Dentistry, Istan-
bul University, Istanbul, Turkey.
3Research Assistant, Department of
Removable Prosthethics (Total and
Partial Prosthetics), Faculty of Den-
tistry, Istanbul University, Istanbul,
Turkey.
4Research Assistant, Department of
Plastic and Reconstructive Surgery,
Medical Faculty of Istanbul Univer-
sity, Istanbul, Turkey.
5Professor and Head, Department of

strated that anterior open bites are Orthodontics, Faculty of Dentistry,

often associated with maxillary con-
striction, high angle skeletal pattern,
and long lower face height.7–9 The sur-
gical posterior impaction of the maxilla
allows for a counterclockwise rotation
of the mandible, which reduces the
lower anterior face height.2,5–7
Istanbul University, Istanbul, Turkey.
CASE HISTORY
CORRESPONDENCE
The patient was an 18-year, 2-month-old Dr Gülnaz Marşan
woman without any abnormal medical Department of Orthodontics
Faculty of Dentistry, Istanbul University
findings besides amelogenesis imper-
Çapa 34093
fecta. The patient’s father, uncle, and Istanbul, Turkey
brother suffered from the same condition. Email: gulnaz.marsan@yahoo.com

284

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VOLUME 11, NUMBER 3, 2010 Marşan et al

Fig 1 Extra- and intraoral photographs, cephalogram, and panoramic radiograph

before orthodontic treatment.

The patient had an asymmetry with
her chin deviating to the right side and a
concave profile with a long lower face
height (SN-GoMe, 39 degrees) (Fig 1).
Further, she had a skeletal Class III rela-
tionship (ANB, –3 degrees) and a –6.0-mm
anterior open bite. Both dental midlines
deviated 2.0 mm to the right in relation to
the facial midline. Also, 4.0-mm overjet, a
50% incisor display when smiling, and
2.7-mm maxillary and 1.0-mm mandibu-
lar crowding were evident.
For the cephalometric analysis, the
anterior cranial base (S-N) and the true
horizontal plane (HOR, 7 degrees to S-N
at S) were used as reference lines (Figs 4
to 6). The true horizontal plane was
employed as the y-axis for vertical mea-
surements. The x-axis (vertical reference
plane) for horizontal measurements was
perpendicular to HOR at S. These two ref-
erence planes were transferred from the
preoperative lateral cephalogram to the
subsequent ones.

285

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 Marşan et al WORLD JOURNAL OF ORTHODONTICS

Fig 2 Extra- and intraoral photographs, cephalogram, and panoramic radiograph

after 14 months of presurgical orthodontic treatment with levelling and aligning of
both dental arches.

TREATMENT OBJECTIVES ORTHODONTIC AND

The aims of treatment were to improve
function and facial and dental appear-
ance. This included correction of the
facial asymmetry, Class III occlusion,
negative overjet, anterior open bite, and
midline deviation.
ORTHOGNATHIC TREATMENT
SYNOPSIS
Levelling and aligning initally began with
fixed appliances. The presurgery period
was completed in 14 months (Fig 2).
In the maxilla, the bimaxillary surgery
comprised a 5.0-mm posterior impaction
and a 5.0-mm anterior advancement; in
the mandible, it involved a 5.0-mm set-
back and counterclockwise rotation.

286

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VOLUME 11, NUMBER 3, 2010 Marşan et al

Fig 3 Extra- and intraoral photographs, cephalogram, and panoramic radiograph

1 year after the completion of retention and prosthetic restoration.

After surgery, the profile, facial asymme- PROSTHETIC TREATMENT

try, and vertical and sagittal dental rela-
tionship were improved. There was a
Class I molar and canine relationship,
the midlines were corrected, and over-
bite and overjet were acceptable.
Five months postsurgery, the ortho-
dontic appliances were removed. Fixed
retainers were bonded between the first
premolars in the maxilla and mandible.
SYNOPSIS
Six months after treatment, the amelo-
genesis imperfecta were addressed
prosthetically. Mainly because of eco-
nomic reasons, ceramic veneers were
chosen. All teeth were prepared with a
circumferential shoulder margin under
local anesthesia. For the fabrication of
acrylic provisionals, silicone impressions
were taken (Durosil L, PD President).

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 Marşan et al WORLD JOURNAL OF ORTHODONTICS

Fig 4 Reference points and lines for hard tissue angular Fig 5 Reference points and lines for hard tissue linear
measurements. measurements.

Fig 6 Reference points and lines for soft tissue angular Fig 7 Superimposition of the pre- (solid line) and postoper-
and linear measurements. ative (dashed line) cephalometric tracings.

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VOLUME 11, NUMBER 3, 2010 Marşan et al

Table 1 Pre- and postoperative and 1-year Table 2 Pre- and postoperative and 1-year
postretention hard tissue measurements postretention soft tissue measurements
Preoperative Postoperative Postretention Preoperative Postoperative Postretention

Angles (degrees) Soft tissue angles (degrees)

SNA 81 84 84 G’SnPog’ 171 162 162
SNB 84 80 81 CmSnLs 105 102 110
ANB –3 4 3 LiMlfPog’ 147 133 136
SN-GoMe 39 40 40 Soft tissue linear measurements (mm)
NAPog –4 4 3 Sagittal changes
ArGoGn 132 126 127 Ls-Vert 82 83 82
NSGn 69 71 70 Li-Vert 81 75 76
NSAr 123 123 123 Sn-Vert 81 80 82
U1/SN 115 105 100 Mlf-Vert 75 69 70
L1/Go-Me 91 94 92 Pog’-Vert 76 71 72
U1/L1 114 122 123 Pn-Vert 96 96 97
Distances (mm) Vertical changes
Co-ANS 87 92 91 Ls-HOR 65 65 66
Co-Pog 125 120 121 Li-HOR 83 80 81
A-Vert 62 67 66 Pog’-HOR 108 106 105
B-Vert 64 58 59 Mlf-HOR 96 93 92
Pog-Vert 67 59 60 Sn-HOR 49 49 50
ANS-Vert 68 73 72 Pn-HOR 38 37 37
PNS-Vert 17 21 21
PNS-ANS 49 50 50
Vertical measurements (mm)
ANS-HOR 43 45 44
PNS-HOR 41 36 36
N-ANS 49 50 50
ANS-Me 77 71 72
N-Me 126 121 122
U1/HOR 72 74 75
U6/HOR 69 65 66
L1/HOR 77 72 71
L6/HOR 71 67 66
S-Ar 35 34 34
Ar-Go 47 46 46
S-Go 82 80 80
Go-Pog 77 74 75

Centric relation was recorded in a semi-
adjustable articulator (Artex Type TR,
Jensen Industries) in which the provi-
sional crowns were produced. They were
cemented with noneugenol zinc oxide
cement (TempBond NE, Kerr). Five days
later, these restorations were removed
to take the final impressions (Panasil,
Kettenbach). Each arch was constructed
in three parts: one section from canine
to canine and two parts from the first
premolars to the molars. This helped
also with retention. After this restoration
was complete, satisfactory function and
esthetics were established (Fig 3).
The occlusion was adjusted to ensure
that no functional interferences existed.
Mandibular excursions occurred under
anterior group function. The smile was
significantly improved.
All cephalometric measurements and
a superimposition are presented in
Tables 1 and 2 and Fig 7.

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 Marşan et al
CONCLUSION
In the primary and early permanent den-
tition, full coverage restorations are likely
most effective to manage tooth sensitiv-
ity and poor esthetics in patients with
amelogenesis imperfecta. 22 Here, a
patient was treated with contributions of
three dental specialties. Thus, the Class III
relationship and the 6.0-mm anterior
open bite were corrected, and the
appearance of the asymmetric long face
was improved. Final dental esthetics and
function were achieved by prosthetic
restorations. The result was stable 1 year
after retention.
REFERENCES
1. Akın H, Tasveren S, Yeter DY. Interdisciplinary
approach to treating a patient with amelogene-
sis imperfecta: A clinical report. J Esthet Restor
Dent 2007;19:131–135.
2. Kuroda S, Sakai Y, Tamamura N, Deguchi T,
Tekano-Yamamuto T. Treatment of severe ante-
rior open bite with skeletal anchorage in adults:
Comparison with orthognathic surgery out-
comes. Am J Orthod Dentofacial Orthop 2007;
132:599–605.
3. Denny JM, Weiskircher MA, Dorminoy JC. Ante-
rior open bite and overjet treated with camou-
flage therapy. Am J Orthod Dentofacial Orthop
2007;131:670–678.
4. de Figueirdo MA, Siqueira DF, Bommarito S,
Scanavini MA. Orthodontic compensation in
skeletal Class III malocclusion: A case report.
World J Orthod 2007;8:385–396.
5. Aldred MJ, Savarirayan R, Crawford PJ. Ameloge-
nesis imperfecta: A classification and catalogue
for the 21st century. Oral Dis 2003;9:19–23.
6. Nicodemo D, Pereira MD, Ferreira LM. Effect of
orthognathic surgery for Class III correction on
quality of life as measured by SF-36. Int J Oral
Maxillofac Surg 2008;37:131–134.
7. Keles A, Pamukçu B, Isık F, Gemalmaz D, Güzel
MZ. Improving quality of life with a team
approach: A case report. Int J Adult Orthodon
Orthognath Surg 2001;16:293–299.
8. Noble J, Karaiskos N, Wiltshire WA. Diagnosis
and clinical management of patients with
skeletal Class III dysplasia. Gen Dent 2007;55:
543–547.
290
© 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
WORLD JOURNAL OF ORTHODONTICS
9. Rios SAC. Class II correction in a severe hyper-
divergent growth pattern, bilateral open bite
and oral compromise. Angle Orthod 2005;75:
870–880.
10. Ayers KM, Drummond BK, Harding WJ, Salis
SG, Liston PN. Amelogenesis imperfecta—Multi-
disciplinary management from eruption to
adulthood. Review and case report. N Z Dent J
2004;100:101–104.
11. Crawford PJ, Aldred MJ, Bloch-Zugan A. Amelo-
genesis imperfecta. Orphanet J Rare Dis 2007;
4:2–17.
12. Gökçe K, Canpolat C, Özel E. Restoring function
and esthetics in a patient with amelogenesis
imperfecta: A case report. J Contemp Dent
Pract 2007;8:95–101.
13. Kostoulas I, Kourtis S, Andritsakis D, Douk-
oudakis A. Functional and esthetic rehabilita-
tion in amelogenesis imperfecta with all-
ceramic restorations: A case report. Quintes-
sence Int 2005;36:329–338.
14. Lindunger A, Smedberg JI. A retrospective
study of the prosthodontic management of
patients with amelogenesis imperfecta. Int J
Prosthodont 2005;18:189–194.
15. Öztürk N, Sarı Z, Öztürk B. An interdisciplinary
approach for restoring function and esthetics in
a patient with amelogenesis imperfecta and
malocclusion: A clinical report. J Prosthet Dent
2004;92:112–115.
16. Robinson FG, Haubenreich JE. Oral rehabilita-
tion of a young adult with hypoplastic ameloge-
nesis imperfecta: A clinical report. J Prosthet
Dent 2006;95:10–13
17. Sadowsky SJ. An overview of treatment consider-
ations for esthetic restorations: A review of the
literature. J Prosthet Dent 2006;96:433–442.
18. Sarı T, Üsümez A. Restoring function and
esthetics in a patient with amelogenesis imper-
fecta: A clinical report. J Prosthet Dent 2003;
90:522–525.
19. Siadat H, Alikhasi M, Mirfazaelian A. Rehabilita-
tion of a patient with amelogenesis imperfecta
using all-ceramic crowns: A clinical report.
J Prosthet Dent 2007;98:85–88.
20. Toksavul S, Ulusoy M, Türkün M, Kümbüloglu
Ö. Amelogenesis imperfecta: The multidiscipli-
nary approach. A case report. Quintessence Int
2004;35:11–14
21. Yip HK, Smales RJ. Oral rehabilitation of young
adults with amelogenesis imperfecta. Int J
Prosthodont 2003;16:345–349.
22. Ng FK, Messer LB. Dental management of
amelogenesis imperfecta patients: A primer on
genotype-phenotype correlations. Pediatr Dent
2009;31:20–30.
Luciane Quadrado Closs,
DDS, MsD, PhD1 COMBINED PERIODONTAL AND
Sabrina Carvalho Gomes, ORTHODONTIC TREATMENT IN A PATIENT
MSc2

Rui Vicente Oppermann,

WITH AGGRESSIVE PERIODONTITIS:
PhD2 A 9-YEAR FOLLOW-UP REPORT
Vivian Bertoglio1
A combined periodontal and orthodontic treatment demands a
detailed evaluation in both specialties, particularly when the peri-
odontium is reduced. This is especially true for adult patients, but
young patients can also suffer from advanced periodontitis. This arti-
cle describes combined periodontal and orthodontic therapy in a
young patient with severe localized and aggressive periodontitis,
tooth crown abnormalities, and missing maxillary second premolars.
Periodontal treatment was carried out. Once attachment gain and
bone stability were confirmed, orthodontic therapy commenced. It
lasted 32 months, during which segmented mechanics and only light
forces were used. The result of this intervention was satisfactory, and
long-term stability (9 years) with periodontal maintenance was
achieved. World J Orthod 2010;11:291–297.

Key words: interdisciplinary treatment, periodontitis, attachment loss,

segmented mechanics, light forces

he maintenance of periodontal health the development of new techniques and

1Universidade Luterana do Brasil,
Canoas, Brazil.
2Universidade Federal do Rio Grande
do Sul, Porto Alegre, Brazil.
CORRESPONDENCE
Dra Luciane Quadrado Closs
Marcelo Gama, 1249, 3º andar
CEP: 90540 041
Porto Alegre, RS
Brazil
Email: lucloss@uol.com.br
T during and after complex orthodontic
treatment is considered a challenge.1–5
Patients with a history of destructive
periodontal disease therefore should be
submitted to a thorough evaluation to
preserve the integrity of the periodontal
structures, assure successful treatment,
and achieve long-term maintenance.3,6
Until a few decades ago, it was mostly
young patients who were treated ortho-
dontically due to the possibility of achiev-
ing both orthodontic and orthopedic
changes.7 These were often patients with
no history of periodontal disease. As time
went on, adults increasingly requested
orthodontic therapy, motivated largely by
a desire to improve the appearance of
their teeth. These treatments required
the application of light forces. 1,3,6,8,9
Nevertheless, the periodontal condition
of adult patients had to be adequate.
The orthodontic forces frequently
applied in adolescents were considered
appropriate for adults with normal peri-
odontal support. Recently, such forces
were used even in patients with reduced
alveolar suppor t. 1,6,9,10 Histologic
assessments showed that this did not
result in a loss or permanent damage of
the periodontium structures. It is gener-
ally agreed, though, that lower forces
should be employed in these patients to
prevent adverse effects, including root
resorption, and further damage to the
periodontal ligament, which can lead to
excessive dental mobility.9,11

291

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 Closs et al WORLD JOURNAL OF ORTHODONTICS

a b c
Fig 1 Periapical radiographs of the maxillary incisors showing a reduced bone level on the distal surface of the maxillary right
lateral incisor in (a) 2000, (b) 2001, and (c) 2007.

Most reports found in the literature Radiographic findings

describe orthodontic therapy in mature
patients with chronic periodontitis, previ-
ously referred to as adult periodontitis.6,9
The absence of similar reports on young
patients with aggressive periodontitis
may be explained by its generally low
prevalence in this population. The pre-
sent repor t describes the results
obtained with combined periodontal and
orthodontic treatment in a young patient
with aggressive periodontitis.
PATIENT REPORT
The initial radiographic examination
revealed the agenesis of the maxillary
second premolars. Posterior bitewing
radiographs showed areas of incipient
bone loss. Periapical radiographs of max-
illary incisors disclosed bone loss to the
apex of the maxillary right lateral incisor
(Fig 1a). The mandibular incisors pre-
sented moderate bone loss. The radi-
ographic examination suggested the
presence of invaginations (dens in dente)
in the incisors.

Periodontal assessment Periodontal treatment

In 1999, a 22-year-old woman was In addition to providing oral hygiene

referred for periodontal evaluation. The
clinical examination revealed ubiquitous
plaque accumulation, generalized gingi-
val bleeding, calculus on all teeth from
the mandibular left canine to the right
first premolar, clinical attachment loss
± 2 to 3 mm in the molars and incisors,
and a general sulcus probing depth of
3 to 4 mm (except for the distal surface
of the maxillary right lateral incisor, which
presented a sulcus probing depth and
clinical attachment loss of > 10 mm). The
patient was diagnosed with generalized
gingivitis and severe and localized
aggressive periodontitis.12
instruction to the patient, supragingival
scaling was carried out quadrant-wise for
1 month. Following the successful reduc-
tion of plaque, gingival bleeding, bleeding
on probing, and sulcus probing depth,
treatment concentrated on the sites that
exhibited continued bleeding on probing
and increased probing depth. This ther-
apy consisted of scaling and root planing,
which was performed under local anes-
thesia. Again, the quadrants were treated
one at a time, and the overall interven-
tion lasted 2 months.

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VOLUME 11, NUMBER 3, 2010
Fig 2 Intraoral photographs prior to
orthodontic treatment.
Recalls every 18 months showed that
the maxillary right lateral incisor (distal)
and canine (mesial) did not respond to
any procedures. Subsequently, total flap
surgery was executed in these teeth.
Their roots were scaled and planed with
the use of 1% chlorhexidine gel. Also,
500 mg azithromycin per day orally was
prescribed for 3 days.
Recalls at 3- and 6-month intervals
revealed a reduction in sulcus probing
depth, as well as an attachment gain
(Figs 1b and 1c).
Two years after periodontal treatment,
the patient was referred to an orthodon-
tist to evaluate the feasibility of orthodon-
tic therapy to deal with her esthetic
concerns.
Orthodontic assessment
The patient presented with a convex
facial profile, an Angle Class I relation-
ship, 5-mm maxillary crowding, 2-mm
mandibular crowding, a reverse overjet of
the maxillary and mandibular left lateral
incisors, a protrusion of the maxillary right
lateral incisor, and a crossbite of the max-
illary primary left second premolar and
maxillary and mandibular left first molars
(Fig 2). The maxillary primary right and
left second molars were still in place, and
the left one was ankylosed. The crowns of
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Closs et al
the maxillary anterior teeth and mandibu-
lar right canine and second premolar
showed anatomical and structural abnor-
malities. Orthodontic treatment was initi-
ated in January 2001.
Cephalometrically, a brachycephalic
pattern with retruded maxillary and pro-
truded mandibular incisors became obvi-
ous (Fig 3e).
Orthodontic treatment
Orthodontic treatment was initiated with
a maxillary fixed appliance (Roth pre-
scription, slot sizes 0.022-inch) and
extraction of the maxillary primary sec-
ond molars. A passive posterior segment
with transpalatal anchorage was estab-
lished. Segmented mechanics were used
to level and align the maxillary lateral
incisors. A 0.014-inch and a 0.016-inch
nickel-titanium (Ni-Ti) wire were inserted
sequentially; also, a 0.018-inch beta-tita-
nium alloy (TMA) T-loop was applied to
align the anterior teeth. Once they were
leveled, the teeth were stabilized with a
0.017-inch ⫻ 0.025-inch TMA wire. The
extraction space was closed mainly by
mesial movement of the maxillary molars
utilizing a 0.016-inch ⫻ 0.022-inch TMA
coil spring. After 11 months of treatment
exclusively in the maxillary arch, the
mandibular arch was also aligned and
293
 Closs et al WORLD JOURNAL OF ORTHODONTICS

Fig 3 Radiographs prior to orthodontic

treatment. (a) Panoramic radiograph,
(b and c) perapical images of the maxil-
lary incisors, (d) periapical image of the
mandibular incisors, and (e) cephalo-
gram.

b c d e

Fig 4 Intraoral photographs after com-

pletion of orthodontic treatment.

leveled with a sequence of Ni-Ti and TMA
archwires. Final occlusal adjustments in
both arches were made with braided
0.017-inch ⫻ 0.025-inch archwires. To
eliminate the crossbite, intermaxillary
elastics were worn for 1 month.
Treatment was finished with the max-
illary molars in a good transverse inter-
cuspation, but their crowns were tipped
slightly mesially (Fig 4). Considering the
diminished bone support, the occlusion
was considered stable. After appliance

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VOLUME 11, NUMBER 3, 2010 Closs et al

Fig 5 Final radiographs. (a) Panoramic

radiograph, (b) periapical image of
mandibular incisors, (c) periapical
image of maxillary incisors, and (d)
cephalogram.

b c

removal, a circumferential maxillary Haw- ments. Periapical radiographs were

ley appliance and a lingual canine-to- taken at approximately 5-month intervals
canine fixed retainer were inserted. (Fig 5).
Or thodontic treatment lasted 32
months and was supported by preven-
tive periodontal maintenance appoint-

295

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 Closs et al
RESULTS AND DISCUSSION
This report shows that orthodontic treat-
ment and posttherapy stability are possi-
ble in young patients with severe and
localized aggressive periodontitis. The
interdigitation of the posterior teeth was
improved on mainly the right side and
good occlusal contacts were established,
as well as anterior guidance. Esthetics
were also satisfactory.
This success was probably a result of
the adequate periodontal and orthodon-
tic treatment. Only two similar reports are
available in the literature,2,6 even though
the principles of orthodontic treatment in
patients with a history of chronic peri-
odontitis have long been established.
Periodontal treatment prior to ortho-
dontic movement is essential, 3,10
because lack of periodontal integrity
could lead to unstable results.6,13 In the
present report, orthodontic treatment was
initiated only 2 years after periodontal
stability had been both clinically and radi-
ographically confirmed. An optimal
supragingival condition is of great impor-
tance because it guarantees the reduc-
tion of inflammation and subgingival
microbiota4,14 and therefore the long-term
success of any subgingival therapy.13
In this patient, most of the periodontal
treatment was nonsurgical. Surgical
approaches may become necessary
whenever access to the subgingival
biofilm is inadequate 15 as in this
patient’s maxillary right lateral incisor.
Haas et al 16 found that the use of
azithromycin in association with a surgi-
cal intervention in aggressive periodonti-
tis provides an attachment gain > 1 mm
in a high number of sites. Attachment
gain, more than a reduced sulcus probing
depth, is a long-term indicator of peri-
odontal stability and is therefore consid-
ered the gold standard for the
assessment of lasting results.17 During
the 9-year follow-up period of this patient,
stability in the treated sites was con-
firmed. In addition, the continued preven-
tive maintenance regimen probably
helped minimize the risk of relapse.18
The literature clearly indicates that
orthodontic tooth movements are possi-
ble independent of the attachment level
296
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WORLD JOURNAL OF ORTHODONTICS
and without worsening it. In this patient,
a segmented arch approach with light
force was chosen, 1,8 although other
mechanics have been repor ted.
Mavreas,9 for instance, used low friction,
passive self-ligating brackets with long
activation spans to exert very low forces.
Fukunaga et al10 suggested the employ-
ment of mini-implants for force control. In
any case, the key for optimal force appli-
cation is to locate the center of resis-
tance and rotation of the teeth to be
moved.8
The magnitude of applied forces was
related to the surface of the infrabony
root and maintained via flexible wires,
respecting the attachment limit of the
compromised periodontium.6 Cardaropoli
and Gaveglio11 suggested that optimal
forces will produce favorable tissue
responses, whereas high forces or a
reduced periodontal support have a detri-
mental effect because they induce necro-
sis (hyalinization). This type of tissue
reaction will delay tooth displacement
and increase the risk for bone loss.11
In 2009, Noda et al19 suggested that,
in rats, the use of light continuous forces
< 1.6 g maintains the vascular structure
during tooth movement, whereas contin-
uous forces > 4.0 g destruct the vascular
system in the early stages of tooth move-
ment; that is followed again by a dynamic
regeneration of the periodontal vascular-
ity. Ren et al20 stated in their systematic
review that no evidence for an optimal
orthodontic force could be extracted from
the literature.
CONCLUSION
The present report provides evidence
that periodontal and orthodontic therapy
opens new perspectives for the restora-
tion of the dentition in patients with a his-
tory of aggressive periodontitis.
VOLUME 11, NUMBER 3, 2010 Closs et al

REFERENCES 12. Armitage GC. Development of a classification

system for periodontal diseases and condi-
tions. Ann Period 1999;4:1–6.
1. Ong MA, Wang HL, Smith FN. Interrelationship
13. Axelsson P, Nyström B, Lindhe J. The long-term
between periodontics and adult orthodontics.
effect of a plaque control program on tooth
J Clin Periodontol 1998;25:271–277.
mortality, caries and periodontal disease in
2. Re S, Corrente G, Abundo R, Cardaropoli D.
adults. Results after 30 years of maintenance.
Orthodontic treatment in periodontally compro-
J Clin Periodontol 2004;31:749–757.
mised patients: 12-year report. Int J Periodon-
14. Gomes SC, Nonnenmacher C, Susin C, Opper-
tics Restorative Dent 2000;20:31–39.
mann RV, Mutters R, Marcantonio RAC. The
3. Feng X, Oba T, Oba Y, Moriyama K. An interdis-
effect of a supragingival plaque-control regi-
ciplinary approach for improved functional and
men on the subgingival microbiota in smokers
esthetic results in a periodontally compromised
and never-smokers: Evaluation by real-time
adult patient. Angle Orthod 2005;75:
polymerase chain reaction. J Periodontol 2008;
1061–1070.
79:2297–2304.
4. Gomes SC, Varela CC, da Veiga SL, Rösing CK,
15. Gunsolley JJ, Zambon JJ, Mellott CC, Brooks
Oppermann RV. Periodontal conditions in sub-
CN, Kaugars CC. Periodontal therapy in young
jects following orthodontic therapy. A prelimi-
adults with severe generalized periodontitis.
nary study. Eur J Orthod 2007;29:477–481.
J Periodontol 1994;65:268–273.
5. Closs LQ, Grehs B, Raveli DB, Rosing CK. Occur-
16. Haas AN, de Castro GD, Moreno T, et al.
rence, extension, and severity of gingival mar-
Azithromycin as an adjunctive treatment of
gin alterations after orthodontic treatment.
aggressive periodontitis: 12-months random-
World J Orthod 2008;9:e47–e52.
ized clinical trial. J Clin Periodontol 2008;35:
6. Braun S, Winzler J, Johnson BE. An analysis of
696–704.
orthodontic force systems applied to the denti-
17. Badersten A, Nilveus R, Egelberg J. Effect of
tion with diminished alveolar support. Eur J
nonsurgical periodontal therapy (VIII). Probing
Orthod 1993;15:73–77.
attachment changes related to clinical charac-
7. Henneman S, Von den Hoff JW, Maltha JC.
teristics. J Clin Periodontol 1987;14:425–432.
Mechanobiology of tooth movement. Eur J
18. Sanders NL. Evidence-based care in orthodon-
Orthod 2008;30:299–306.
tics and periodontics: A review of the literature.
8. Melsen B. Tissue reaction to orthodontic tooth
J Am Dent Assoc 1999;130:521–527.
movement—a new paradigm. Eur J Orthod
19. Noda K, Nakamura Y, Kogure K, Nomura Y.
2001;23:671–681.
Morphological changes in the rat periodontal
9. Mavreas D. Self-ligation and the periodontally
ligament and its vascularity after experimental
compromised patient: A different perspective.
tooth movement using superelastic forces.
Semin Orthod 2008;14:36–45.
Eur J Orthod 2009;31:37–45.
10. Fukunaga T, Kuroda S, Kurosaka H, Takano-
20. Ren Y, Maltha JC, Kuijpers-Jagtman AM. Opti-
Yamamoto T. Skeletal anchorage for orthodon-
mum force magnitude for orthodontic tooth
tic correction of maxillary protrusion with adult
movement: A systematic literature review.
periodontitis. Angle Orthod 2006;76:148–155.
Angle Orthod 2003;73:86–92.
11. Cardaropoli D, Gaveglio L. The influence of
orthodontic movement on periodontal tissues
level. Semin Orthod 2007;13:234–245.

297

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 LETTER TO THE EDITOR
The problem with normal orthodontic
shear bond strength values

s most orthodontists may know, articles related to or- This author’s suggestion for those who pursue re-
A thodontic shear bond strength tests constitute a con-
siderable amount of the orthodontic literature. But the
search in the field of orthodontic bond strength, as well
as for journal referees, is not to rely solely on a devised
disturbing fact is that the results of many of these studies range of 6.0 to 8.0 MPa as normal unless the method of
are incomparable because of their different testing meth- a study is the same as that of the Reynolds article.
ods. In other words, a universally accepted test method
does not exist. Faramarz Mojtahedzadeh, DMD, MSc
But what is even more shocking is that although the Assistant Professor, Dental Research Center, Tehran
problem of varying methods has been previously ad- University of Medical Sciences, Tehran, Iran
dressed from different aspects, many studies still base
and compare their results with Reynolds’ well-known arti-
cle,1 in which he had recommended a 6.0 to 8.0 MPa REFERENCES
range as a normal value for orthodontic shear bond
strength. That is where the concern arises. 1. Reynolds IR. A review of direct orthodontic bonding. Br J Orthod
1975;2:171–178.
There is no intention here to discuss or criticize
2. Mojtahedzadeh F, Akhoundi MSA, Noroozi H. Comparison of wire
Reynolds’ suggestion, but the problem with this range is loop and shear blade as the 2 most common methods for testing
that it cannot be applied to all shear bond strength stud- orthodontic shear bond strength. Am J Orthod Dentofacial Orthop
ies. Although this issue might have been previously dis- 2006;130:385–387.
cussed,2 a re-emphasis and even a word of caution seem 3. Bishara SE, Laffoon JF, VonWald L, Warren J. Effect of time on the
shear bond strength of cyanoacrylate and composite orthodontic
to be necessary. For further clarification, take the follow-
adhesives. Am J Orthod Dentofacial Orthop 2002;121:297–300.
ing as an example: 4. Northrup RG, Berzins DW, Bradley TG, Schuckit W. Shear bond
Consider a well-known adhesive like Transbond XT (3M strength comparison between two orthodontic adhesives and self-
Unitek). This adhesive has undoubtedly gained worldwide ligating and conventional brackets. Angle Orthod 2007;77:
acceptance in terms of clinical efficacy. The popularity of 701–706.
this adhesive is such that many studies use it as a control
when assessing a more recent product.
The problem becomes evident when the shear bond
strength of such a clinically accepted adhesive is reported
to have a bond strength of 5.2 ± 2.9 MPa in one article
and 23.2 ± 5.3 MPa in another.3,4 In such a circumstance
and based on the 6.0 to 8.0 MPa normal range, how
should one judge this adhesive? Should we consider it to
be too weak to resist clinical loading, or is it so strong that
it might cause enamel damage?

210

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Sujala Ganapati Durgekar,
BDS, MDS1
Nagaraj K, BDS, MDS1
Vijay Naik, BDS, MDS2
THE IDEAL SMILE AND ITS
ORTHODONTIC IMPLICATIONS
Aim: To determine the parameters for an ideal smile. Methods: Ten
laypersons classified frontal photographs of 62 smiling individuals
between 18 and 25 years of age into five categories: 1, poor; 2, fair;
3, good; 4, very good; and 5, excellent. The scores obtained for each
smile were averaged. The five smiles with each the highest and lowest
scores were analyzed for seven parameters: buccal corridor, smile
index, smile symmetry, smile line ratio, upper lip line, smile arc, and
upper lip curvature. Results: The five smiles with the highest scores
were symmetrical with an average upper lip line and a consonant smile
arc. Three of the five had an upward upper lip curvature. The smile line
ratio, buccal corridor, and smile index for all five subjects ranged from
1.0 to 1.3 mm, 9.0% to 11.0%, and 4.0 to 6.0 mm, respectively. Two of
the five smiles with the lowest scores were asymmetrical and three
had a high upper lip line and a downward curvature, but all five had a
nonconsonant smile arc. The smile line ratio, buccal corridor, and smile
index for all five subjects ranged from –1.0 to 1.3 mm, 18.0% to 22.0%,
and 7.0 to 10.0 mm, respectively. Conclusion: The seven investigated
smile parameters can define characteristics of an ideal smile. These
smile components should be included in the orthodontic problem list
to help clinicians select the appropriate mechanotherapy. World J
Orthod 2010;11:211–220.

Key words: smile, esthetics, frontal photographs

1Assistant Professor, Department of
Orthodontics and Dentofacial Ortho-
pedics, KLE Vashwanath Katti Insti-
tute of Dental Sciences, KLE
University, JNMC Campus, Belgaum,
India.
2Associate Professor, Department of
Orthodontics and Dentofacial Ortho-
pedics, KLE Vashwanath Katti Insti-
tute of Dental Sciences, KLE
University, JNMC Campus, Belgaum,
India.
CORRESPONDENCE
Dr Sujala Ganapati Durgekar
Orthodontics and Dentofacial
Orthopaedics
KLE Vk Institute of Dental Sciences
Nehrunagar
Belgaum 590010
India
Email: sujala2003@yahoo.com
he face is the most important individ-
T ual factor determining the physical
appearance of individuals; the mouth
and teeth are considered fundamental
in facial esthetics. The smile is rightfully
deemed a valuable means of nonverbal
social communication and a sound crite-
rion of facial attractiveness. Although
orthodontic treatment is based primarily
on occlusal relationships, greater atten-
tion is now paid to the facial esthetics
influenced by the smile. Since 1950,
esthetics in orthodontics have mainly
been evaluated via profile images due to
cephalometrics and the emphasis on
the anteroposterior dimension in maloc-
clusions. Even though patients often
seek orthodontic treatment to improve
their smile,1,2 the orthodontic literature
mainly contains studies on skeletal
structures, 3–6 which implies that the
smile receives relatively little attention.
In recent years, smile analyses and
attempts to include smile aspects into
treatment planning have become key
or thodontic elements. 7–10 Although
some objective criteria exist for assess-
ing the attributes of an attractive smile,
to date, no study has included all para-
meters of smile analyses. Even though it
would be good to have some sort of tool
to quantitatively assess beauty, none
currently exists and probably never will.
As a result, an eye for beauty is among
the most important prerequisites for
orthodontists. This study was undertaken
to determine the parameters for an objec-
tive evaluation of smiles and discuss
treatment approaches to achieve an ideal
smile.

211

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 Durgekar et al
MATERIALS AND METHODS
From individuals on the campus of the
Institute of Dental Sciences, 150 consec-
utive patients between 18 and 25 years
of age were selected for this study if they
fulfilled the following criteria: no craniofa-
cial anomaly, no significant skeletal
asymmetry, orthognathic profile, full com-
pliment of teeth (except third molars) in
both arches, no crossbite, no fracture of
any anterior tooth, and no spacing (only
individuals with an arch length discrep-
ancy of +/–2.0 mm were included).
This sample was reduced to 100
based on the following exclusion criteria:
no malformed teeth causing a tooth-size
arch length discrepancy and no obvious
dental restorations.
Of these 100 subjects, 38 rejected
being photographed. Therefore, the
remaining 62 subjects (42 females and
20 males) constituted the final sample.
After gaining ethical clearance, informed
consent was obtained from each of the
individuals, and standardized frontal pho-
tographs were taken with a Panasonic
Lumix digital camera.
Smile capturing method
The individual’s head was fixed in a
cephalostat so that the Frankfort horizon-
tal plane11,12 was parallel to the floor and
the midsagittal plane was aligned with the
center of the camera lens. The focus of
the camera was adjusted to obtain a
sharp image of the face from the tip of the
nose to the tip of the chin. Before taking
the photograph, each person was asked
to rehearse the phrase “Chelsea eats
cheesecake on the Chesapeake.”11 Once
comfortable, the probands were prompted
to repeat the phrase and then smile show-
ing their teeth. Three exposures of each
individual were taken, and the photo that
best represented the patient’s natural
unstrained social smile was selected for
the subsequent evaluation.
212
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WORLD JOURNAL OF ORTHODONTICS
Smile rating scale
All 62 photographs were cropped so only
a rectangular area of a proportionate
size and shape surrounding each smile
was exposed. A panel of laypersons con-
sisting of five men and five women with
no dental training were given a standard
set of instructions to rate the photos as
per the attractiveness of the individual
smile by classifying each photo in one of
the five categories. 13 These were:
1, poor; 2, fair; 3, good; 4, very good; and
5, excellent.
All photographs were projected for
5 seconds on a laptop monitor, and the
panel members evaluated them without
being aware of the subject’s identity.
Each photograph was scored 10 times,
once by each member. The mean score
obtained for each photograph was calcu-
lated. For the final evaluation, the five
smiles with the highest and lowest scores
were selected.
Statistical analysis
Because of the wide spread of rating for
each smile, panel members were asked
to repeat their evaluation at least
2 weeks later to determine whether their
previous ratings could be replicated. The
difference in the rank for each smile
between the first and second appraisal
was compared for every member with the
rank-order coefficient of correlation. The
Mann-Whitney test was employed to com-
pare the parameters found for the five
most and least preferred smiles.
Smile analysis
To facilitate the smile analysis, the follow-
ing 11 landmarks 13 were used (Fig 1):
1, midpoint between the two central
incisors; 2, midpoint on the curvature of
the upper lip; 3, midpoint on the curva-
ture of lower lip; 4 and 4’, intersection of
the long axes of the maxillary lateral
incisors with their respective incisal
edges; 5 and 5’, innermost points on the
lip commissures; 6 and 6’, points on the
curvature of the lower lip directly inferior
VOLUME 11, NUMBER 3, 2010 Durgekar et al

2
57 7’ 5’

4 1 4’ 4 h 4’
6 1
6’ 6 6’
3
3

Fig 1 Landmarks used for smile analysis in this study. See Fig 2 Landmarks used for measurement of the smile line
text for description of numbers. ratio. See text for explanation. Compare to Fig 1.

2
5 5’ 5 5’
7 7’

Fig 3 Landmarks used for measurement of buccal corridor. Fig 4 Landmarks used for smile index measurement. See
See text for explanation. Compare to Fig 1. text for explanation. Compare to Fig 1.

Fig 5 Landmarks used for smile symmetry measurement.

See text for explanation. Compare to Fig 1.
2

4 4’

to points 4 and 4’; and 7 and 7’, most
lateral exposed points of the maxillary
dentition.
The seven parameters used for smile
analysis were as follows:
1. Smile line ratio.13 Product of the per-
pendicular distance between line h
(4 to 4’) to point 1 divided by the per-
pendicular distance between line i
(6 to 6’) to point 3 (Fig 2).
2. Buccal corridor.14,15 Ratio of the differ-
ence between distance 7 to 7’ and
distance 5 to 5’ divided by the dis-
tance 5 to 5’ (Fig 3).
3. Smile index. 16,17 Product of the dis-
tance 5 to 5’ divided by the distance
2 to 3 (Fig 4).
4. Smile symmetry.13 Product of the sum
of distance 2 to 4 and distance 3 to 4
divided by the sum of distance 2 to 4’
and distance 3 to 4’ (Fig 5).

213

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 Durgekar et al WORLD JOURNAL OF ORTHODONTICS

a b

c Fig 6 Classification of the upper lip line: (a) high, (b) average,
and (c) low.

a b

Fig 7 Classification of the smile arc: (a) consonant and (b) nonconsonant.

5. Upper lip line.18,19 Classified into: high,
100% of the maxillary anterior teeth
plus a band of the maxillary gingiva
are exposed on smiling (Fig 6a); aver-
age, 75% to 100% of the maxillary
anterior teeth are exposed on smiling
(Fig 6b); and low, less than 75% of the
maxillary anterior teeth are exposed
on smiling (Fig 6c).
6. Smile arc.14, 20,21 Classified into: con-
sonant, the curvature of the maxillary
incisal edges is parallel to the curva-
ture of the lower lip upon smiling
(Fig 7a); and nonconsonant, the curva-
ture of the maxillary incisal edges is
not parallel to the curvature of the
lower lip upon smiling (Fig 7b).

214

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VOLUME 11, NUMBER 3, 2010 Durgekar et al

a b

Fig 8 Classification of the upper lip curvature: (a) upward, (b)

downward, and (c) straight.

Table 1 Characteristics of the seven smile parameters in the five smiles with the
highest score
Smile I Smile II Smile III Smile IV Smile V

Smile line ratio (mm) 1.3 1.0 1.2 1.3 1.0

Buccal corridor 11.0% 9.0% 10.0% 9.0% 10.0%
Smile index (mm) 5.0 6.0 4.0 6.0 5.0
Smile symmetry Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical
Upper lip line Average Average Average Average Average
Smile arc Consonant Consonant Consonant Consonant Consonant
Upper lip curvature Straight Upward Upward Upward Straight

7. Upper lip curvature.10,13, 22–24 Classi- RESULTS

fied into: upward/positive, corner of
the mouth is higher than the central
lip portion (Fig 8a); downward/nega-
tive, corner of the mouth is lower than
the central lip portion (Fig 8b); and
straight, corner of the mouth and cen-
tral lip portion are at the same level
(Fig 8c).
All five most preferred smiles were sym-
metrical with an average upper lip line
and a consonant smile arc. Three of
these smiles had an upward curvature,
and the remaining two, a straight upper
lip curvature.
The smile line ratio, buccal corridor,
and smile index for these five individuals
ranged from 1.0 to 1.3, 9.0% to 11.0%,
and 4.0 to 6.0, respectively (Table 1).

215

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 Durgekar et al
Table 2 Characteristics of the seven smile parameters in the five smiles with the lowest score
Smile VI
Smile line ratio (mm) –1.0
Buccal corridor 20.0%
Smile index (mm) 10.0
Smile symmetry Asymmetrical
Upper lip line Low
Smile arc Nonconsonant Nonconsonant
Upper lip curvature Straight
Two of the five least preferred smiles
were asymmetrical, while three had a
high upper lip line and a downward upper
lip curvature. All five had a nonconsonant
smile arc.
The smile line ratio, buccal corridor,
and smile index for all five subjects
ranged from –1.0 to 1.3, 18.0% to
22.0%, and 7.0 to 10.0, respectively
(Table 2).
A correlation coefficient of 0.83 indi-
cated that the panel members assessed
the photos fairly consistently. However,
for buccal corridor and smile index evalu-
ation, there was a significant difference
between the appraisals (P = .007).
DISCUSSION
In this investigation, each photograph was
cropped to minimize the influence of the
cheeks, nose, and chin on facial attrac-
tiveness: These features are not under
orthodontic control.25–30 The focus was
on the tooth/lip relationship on smiling:
the miniesthetic elements of a smile. Fur-
ther, features of smile microesthetics
such as tooth shade, tooth shape,29 gingi-
val texture, and contour 11,30 were not
included; however, they play an important
role in establishing an esthetic smile.
In the present investigation, the posed
social smile of individuals was analyzed.
It is the voluntary expression when unfa-
miliar persons are introduced or when
taking photographs for passports/ortho-
dontic records. Studies have found that
216
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WORLD JOURNAL OF ORTHODONTICS
Smile VII Smile VIII Smile IX Smile X
–1.0 1.0 1.3 1.0
22.0% 18.0% 19.0% 20.0%
7.0 7.0 10.0 9.0
Symmetrical Asymmetrical Symmetrical Symmetrical
High High Low High
Nonconsonant Nonconsonant Nonconsonant
Downward Downward Straight Downward
posed smiles in natural head position of
the same individual show little difference
when repeated.12, 16,31,32 The social smile
can mature and might not be consistent
over time. However, this influence was
excluded in this study because of the
sample’s age range.
For this study, a five-point numerical
scale was devised to rate each smile.
Similarly, Hulsey13 used a 10-point scale.
He compared smile line ratio, buccal corri-
dor, upper lip curvature, upper lip line,
and smile symmetry in orthodontically
treated and untreated individuals with
normal occlusion. Among these, buccal
corridors appeared to be of no signifi-
cance for an attractive smile. However,
Hulsey calculated them as the ratio of the
distance between the maxillary canines to
the distance between the corners of the
lips, which does not actually reflect the
buccal corridors. Therefore, it is no sur-
prise that his investigation came to a con-
clusion in complete contrast to this.
In the present study, the buccal corri-
dor in the least preferred smiles ranged
from 18.0% to 22.0%, whereas in the
most preferred smiles, the range was only
9.0% to 11.0%. This clearly shows that an
increase in negative space is unattractive.
Moore et al33 also studied the influ-
ence of buccal corridors on smile attrac-
tiveness with laypersons as judges. They
found that broad smiles (2.0% buccal cor-
ridors) were rated best, followed by
medium-broad ones (10.0% buccal corri-
dors), medium ones (15.0% buccal corri-
dors), and medium-narrow ones (22.0%
VOLUME 11, NUMBER 3, 2010
buccal corridors). Narrow smiles with
28.0% of buccal corridors were rated
least attractive. They concluded that mini-
mal buccal corridors are preferred in both
men and women. A similar study was con-
ducted by Dunn et al25 in which layper-
sons found subjects to be more attractive
if a great number of teeth was displayed
during smiling. Both previously mentioned
studies agree with the current findings.
It is important to be aware of the fact
that because of their position in the den-
tal arch, posterior teeth are less exposed
to light, which makes them appear
darker, seemingly increasing the buccal
corridor.12 In the present investigation,
the lighting while photographing the sub-
jects was arranged to rule out that a lack
of light would influence the appearance
of the buccal corridors in the sample.
When the smile index ranged from 4.0
to 6.0 among the most acceptable
smiles, it showed that laypersons prefer
smiles in which larger areas are covered
by the vermilion borders of the lips.
Among the 10 smiles analyzed, eight
were symmetrical, which clearly demon-
strates that symmetry plays an important
role in smile esthetics.34–37
Vig and Brundo38 reported a gradual
decrease of the exposure of the maxillary
incisors from age 30 years to older than
60 years. Mandibular incisors were corre-
spondingly more exposed with increasing
age. This is due to a sagging of the peri-
oral soft tissue and natural flattening,
stretching, and decreasing elasticity of
the skin. Therefore, age is an important
factor to consider because a patient’s
smile should be adequate. In this study,
the five most preferable smiles had an
average smile line. According to Peck et
al,39 least preferable smiles have a low lip
line with a dimorphism between males
and females. In females, the upper lip line
is positioned at maximum smile 1.5 mm
more superiorly than in males. Orthodon-
tists should therefore regard a moderately
high lip line (often referred to as gummy
smile) as an acceptable anatomical varia-
tion, especially in women.7,38
The parameters evaluated in this study
are useful in improving the esthetic out-
come of orthodontic treatment. The smile
line ratio and smile symmetry parameters
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Durgekar et al
were almost similar in both the most and
least preferable smiles, whereas the
other five parameters showed significant
differences between the highest and low-
est scored smiles. Because the differ-
ence in the smile line index among the
most and least preferred smile is insignifi-
cant (P = .15), the buccal corridor, smile
index, upper lip line, upper lip curvature,
and smile arc are the parameters that
influence laypersons most in determining
the attractiveness of an individual smile.
An ideal smile will have a buccal corridor
of 9% to 11%, a smile index between 4 to
6 mm with an average upper lip line, an
upward upper lip curvature, and a conso-
nant smile arc.
CLINICAL IMPLICATIONS
Smile line ratio
To a limited degree, this parameter can
be altered by extrusion/intrusion of the
maxillary anterior teeth.
Buccal corridor
Orthopedic or surgical maxillary expan-
sion is indicated to correct maxillary
transverse deficiencies. At the same
time, it will reduce large buccal corridors.
Thus, it might be decisive in borderline
situations.33
Anteroposterior positioning of the max-
illary arch also has an influence on buc-
cal corridors. As the maxilla is advanced,
a wider portion of it comes forward, thus
reducing the buccal corridor space.21,40
However, the buccal corridors must not
be completely obliterated because this
results in a denture–like smile.
Smile index
The height of smile depends on the
upper lip elevation, which is muscle-dri-
ven and not under the control of the
orthodontist.
217
 Durgekar et al
Smile symmetry
Orthodontists usually align the midline of
the dentition with the midline of the face.
Additionally, aligning of the dental mid-
line with the center of the smile must be
considered. If lack of smile symmetry is
due to a muscular tonus deficiency on
one side of the face, myofunctional exer-
cises41,42 might help overcome it.
Upper lip line
Treatment of very high upper lip lines
(severe gummy smiles) may require surgi-
cal impaction of the entire maxilla (Le
Fort I) or of only the anterior part (seg-
ment osteotomy). 20 However, this
approach is limited because the upper lip
may be considerably shor tened. To
lengthen the upper lip, a V-Y cheiloplasty
can be considered.
If the gummy smile is caused by a
hyperfunction of the upper lip elevator
muscles, Botox injections 43–45 can be
used for temporary improvement. It
would be a mistake, though, to correct it
with marked incisor intrusion or maxillary
impaction surgery because that would
result in little or no incisor display at rest
and thus make the patient look old. 10
Likewise, if a low lip line is due to a hypo-
mobile lip, extensive incisor extrusion
would result in a deep overbite with
excessive incisor display at rest.
Periodontal treatment for high lip line
would consist mainly of gingivectomy. It is
primarily indicated in patients who have
excessive gingival tissue and short clini-
cal crowns.46,47
Inadequate incisor display could be
due to a combination of vertical maxillary
deficiency, limited smile area, and short
clinical crowns. If this is the case, it must
be determined whether the condition is a
consequence of insufficient tooth erup-
tion, attrition, or gingival hyperplasia. In
such situations, esthetic crown lengthen-
ing or periodontal surgery should be per-
formed.
218
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WORLD JOURNAL OF ORTHODONTICS
Smile arc
In cases of high labial ectopic maxillary
canines, levelling with a continuous arch-
wire is contraindicated because the max-
illary incisors would be intruded, thus
flattening the smile arc. Segmented arch
technique using cantilevers38,48 controls
levelling much better without affecting
the occlusal plane.
Bracket slot heights should not be
same for parallel, flat, and reverse smile
arcs.21 For instance, in a reverse smile
arc, brackets should be positioned more
gingivally than usual on the maxillary
central incisors and progressively more
incisally on the lateral incisors and
canines.
Overintrusion of the anterior teeth to
correct a gummy smile without monitor-
ing the incisor/lip relationship at rest
may result in a flattening of the smile
arc.19 Thus, indiscriminate use of utility
arches or wires with an accentuated
curve of Spee can not only flatten the
smile arc, but also result in a low lip line
at rest and a smile that makes patients
look older than they actually are.
Finally, archform is also a contributing
factor. The broader it becomes, the less
the curvature of the anterior segment will
be, which increases the likelihood of a
flat smile arc.
Upper lip curvature
Upper lip curvature is muscle-driven and
therefore not subject to alteration by
orthodontic therapy. Therefore, orthodon-
tists should concentrate on factors within
their control.
Static photographs are routinely taken as
part of pretreatment orthodontic records.
Although they provide some information
about an individual’s smile, dynamic
smile recordings21,40 in conjunction with
digital videography are superior.
VOLUME 11, NUMBER 3, 2010
CONCLUSION
The seven smile parameters (smile line
ratio, buccal corridor, smile index, smile
symmetry, upper lip line, smile arc, and
upper lip curvature) are important in
establishing a balanced smile. Among
these, the parameters that influenced
laypersons most were buccal corridor,
smile index, upper lip line, upper lip cur-
vature, and smile arc. Any comprehensive
orthodontic problem list should contain
descriptive terms such as obliterated buc-
cal corridors, inadequate maxillary incisor
display, excess gingival display, and non-
consonant smile arc. The clinician should
rank these attributes in order of their
importance. This will help determine the
optimal treatment approach.
REFERENCES
1. Nagaraj K, Upadhyay M, Yadav S. Impacted
maxillary central incisor, canine, and second
molar with 2 supernumerary teeth and an
odontoma. Am J Orthod Dentofacial Orthop
2009;135:390–399.
2. Canavarro C, Zanella E, Medeiros PJA, Capelli J
Jr. Surgical–orthodontic treatment of Class II
malocclusion with maxillary vertical excess.
J Clin Orthod 2009;43:387–392.
3. Holdaway RA. A soft-tissue cephalometric
analysis and its use in orthodontic treatment
planning Part I. Am J Orthod 1983;84:1–28.
4. Holdaway RA. A soft-tissue cephalometric analy-
sis and its use in orthodontic treatment plan-
ning Part II. Am J Orthod 1984;85:279–293.
5. Arnett GW, Bergman RT. Facial keys to ortho-
dontic diagnosis and treatment planning. Part I.
Am J Orthod Dentofacial Orthop 1993;103:
299–321
6. Arnett GW, Bergman RT. Facial keys to ortho-
dontic diagnosis and treatment planning. Part
II. Am J Orthod Dentofacial Orthop 1993;103:
395–341.
7. Peck S, Peck L, Kataja M. The gingival smile
line. Angle Orthod 1992;62:91–100.
8. Mackley RE. Animated orthodontic treatment
planning. J Clin Orthod 1993;27:361–365.
9. Morley J, Eubank J. Macroesthetic elements of
smile design. J Am Dent Assoc 2001;132:
39–45.
10. Sabri R. The eight components of a balanced
smile. J Clin Orthod 2005;155–167.
11. Ackerman MB, Ackerman JL. Smile analysis
and design in the digital era. J Clin Orthod
2002;34:221–234.
12. Ritter DE, Gandini LG Jr, dos Santos Pinto A,
Ravelli DB, Locks A. Analysis of the smile pho-
tograph. World J Orthod 2006;7:279–285.
© 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Durgekar et al
13. Hulsey CM. An esthetic evaluation of lip–teeth
relationships present in the smile. Am J Orthod
1970;57:132–144.
14. Frush JP, Fisher RD. The dynesthetic interpreta-
tion of the dentogenic concept. J Prosthet Dent
1958;8:558–581.
15. Ritter DE, Gandini LG Jr, dos Santos Pinto A,
Locks A. Esthetic influence of negative space in
the buccal corridor during smiling. Angle Orthod
2006;76:198–203.
16. Ackerman JL, Ackerman MB, Brensinger CM,
Landis JR. A morphometric analysis of the
posed smile. Clin Orthod Res 1998;1:2–11.
17. Ackerman MB. Digital video as a clinical tool in
orthodontics; dynamic smile design in diagno-
sis and treatment planning. In: 29th Annual
Moyer’s Symposium. Vol 40. Ann Arbor: Univer-
sity of Michigan Department of Orthodotics,
2003.
18. Tjan AHL, Miller GD. The JGP: Some esthetic fac-
tors in a smile. J Prosth Dent 1984;51:24–28.
19. Zachrisson BU. Esthetic factors involved in
anterior tooth display and the smile: Vertical
dimension. J Clin Orthod 1998;32:432–445.
20. Sarver DM. The importance of incisor position-
ing in the esthetic smile: The smile arc. Am J
Orthod Dentofacial Orthop 2001;120:98–111.
21. Sarver DM, Ackerman MB. Dynamic smile visu-
alization and quantification: Part 1. Evolution
of the concept and dynamic records for smile
capture. Am J Orthod Dentofacial Orthop 2003;
124:4–12.
22. Philips E. The anatomy of a smile. Oral Health
1996;86:7–13.
23. Philips E. The classification of smile patterns.
J Can Dent Assoc 1999;65:252–254.
24. Dong JK, Jin TH, Cho HW, Oh SC. The esthetics
of the smile: A review of some recent studies.
Int J Prosthodont 1999;12:9–19.
25. Dunn WJ, Murchison DF, Broome JC. Esthetics:
Patients’ perceptions of dental attractiveness.
J Prosthodont 1996;5:166–171.
26. Kokich VO Jr, Kiyak HA, Shapira Pa. Comparing
the perception of dentists and lay people to
altered dental esthetics. J Esthet Dent 1999;
11:311–324.
27. Johnson DK, Smith RJ. Smile esthetics after
orthodontic treatment with or without extrac-
tion of four first premolars. Am J Orthod 1995;
108:162–167.
28. McNamara L, McNamara JA, Ackerman MB,
Baccetti T. Hard and soft tissue contributions to
the esthetics of the posed smile in growing
patients seeking orthodontic treatment. Am J
Orthod Dentofacial Orthop 2008;133:491–499.
29. Sarver DM. Principles of cosmetic dentistry in
orthodontics: Part 1. Shape and proportionality
of anterior teeth. Am J Orthod Dentofacial
Orthop 2004;126:749–753.
30. Nicholas C. Devis smile design. Dent Clin N Am
2007;51:299–318.
31. Rigsbee OH, Sperry TP, BeGole EA. The influ-
ence of facial animation on smile characteris-
tics. Int J Adult Orthodon Orthognath Surg
1988;3:233–239.
219
 Durgekar et al
32. Showfety KJ, Vig PS, Matheson S. A simple
method for taking natural-head-position
cephalograms. Am.J Orthod 1983;83:495–500.
33. Moore T, Southard KA, Casko JS, Fang Qian,
Southard TE: Buccal corridors and smile esthet-
ics. Am J Orthod Dentofacial Orthop 2005;127:
208–213.
34. Peck H, Peck S. A concept of facial esthetics.
Angle Orthod 1970;40:248–318.
35. Margolis MJ. Esthetic considerations in ortho-
dontic treatment of adults. Dent Clin North Am
1997;41:29–48.
36. Allen EP. Use of mucogingival surgical proce-
dures to enhance esthetics. Dent Clin North Am
1998;32:307–330
37. Jerrold L, Lowenstein LJ. The midline: Diagnosis
and treatment. Am J Orthod Dentofacial Orthop
1990;97:453–462.
38. Vig RG, Brundo GC. The kinetics of anterior tooth
display. J Prosthet Dent 1978;39:502–504.
39. Peck S, Peck L, Kataja M. Some vertical linea-
ments of lip positions. Am J Orthod Dentofacial
Orthop 1992;101:519–524.
40. Sarver DM, Ackerman MB. Dynamic smile visu-
alization and quantification: Part 2. Smile
analysis and treatment strategies. Am J Orthod
2003;124:116–127.
220
© 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
WORLD JOURNAL OF ORTHODONTICS
41. Rogers AP. Exercises for development of the
muscles of the face with a view to increasing
their functional activity. Dental Cosmos 1918;
60:857–876.
42. Gibson RM. Smiling and facial exercise. Dent
Clin N Am 1989;33:139–144.
43. Benedetto AV. The cosmetic uses of botulinum
toxin type A. Int J Dermatol 1999; 38:641–655.
44. Polo M. Botulinum toxin type A in the treatment
of excessive gingival display. Am J Orthod
Dentofacial Orthop 2005;127:214–218.
45. Polo M. Botulinum toxin type A (Botox) for the
neuromuscular correction of excessive gingival
display on smiling (gummy smile). Am J Orthod
Dentofacial Orthop 2008:133:195–203.
46. Rosenberg ES, Torosian J. Periodontal problem
solving: Interrelationship of periodontal therapy
and esthetic dentistry. Dent Clin North Am
1989;33:201–209,221–261.
47. Graber DA. Problems of the high lip line—The
gummy smile. In: Bell WH, ed. Modern Practice
in Orthognathic and Reconstructive Surgery.
Philadelphia: WB Saunders, 1992: 252–261.
48. Braun S. Diagnosis driven vs appliance driven
treatment outcomes. In: RCL Sachedeva, ed.
Orthodontics for the Next Millennium. Glendora,
Calif: Ormco, 1997:32–45.
Anmol S Kalha, BSc, BDS,
MDS, Osre2
Viral Ashok Kachiwala,
BDS, MDS, MOrth RCS1
Singatagere Nagaraj
Govardhan, BDS, MDS3
Richard P. McLaughlin,
DDS4
Syed Zameer Khurshaid,
BDS, MDS5
1Orthodontist,
Armed Forces Hospi-
tal, Al Khoud, Sultanate of Oman.
2Professor and Head, Department of
Orthodontics; Director, Center for
Evidence Based Dentistry, Institute
of Dental Studies and Technologies,
Modinagar, Uttar Pradesh, India.
3Assistant Professor, Department of
Orthodontics, SJM Dental College,
Chitradurga, Karnataka, India.
4Clinical Professor, University of
Southern California, Los Angeles,
California; Associate Professor, St
Louis University, St Louis, Missouri,
USA.
5Lecturer, Department Of Orthodon-
tics, Government Dental College,
Srinagar, J&K State, India.
CORRESPONDENCE
Dr Viral Ashok Kachiwala
PO Box 106, Postal Code-100
Muscat
Sultanate of Oman
Email: viral.kachiwala@gmail.com
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REDEFINING ORTHODONTIC SPACE
CLOSURE: SEQUENTIAL REPETITIVE
LOADING OF THE PERIODONTAL
LIGAMENT—A CLINICAL STUDY
Aims: To assess the rate of tooth movement, anchorage loss, root
resorption, and alkaline phosphatase (ALP) activity in the gingival
crevicular fluid (GCF) as a marker for bone remodeling during ortho-
dontic space closure using two different mechanisms. Methods: Space
closure was completed in 20 patients with extraction of all 4 premolars.
Lateral cephalograms and radio–visiographs taken before (T1) and
after (T2) space closure were assessed for anchorage loss and root
resorption. Alkaline phosphatase levels were measured in 10 patients,
which were divided into two groups of five each. Spaces were closed
with a screw device in the first group and with active tie-backs in the
second. Gingival crevicular fluid samples, collected at intervals, were
assayed for alkaline phosphatase spectrophotometrically in each
patient. Results: The mean rate of tooth movement was 1.32 ± 0.22
mm/month. The mean amount of anchorage loss in the maxilla and
mandible was 1.23 ± 0.60 mm and 1.08 ± 0.65 mm, respectively. Sixty
(25%) roots showed no root resorption, while 180 (75%) roots dis-
played mild to moderate blunting of their apices. Gingival crevicular
fluid–alkaline phosphatase level increased significantly from day 7 to
day 28 in both groups, but significantly more in the screw retraction
group (P < .05). Conclusion: It is possible to infer that space closure
occurs more rapidly with sequential repetitive loading of the periodon-
tal ligament than with conventional active tie-backs. This observation is
in concurrence with a significant increase in the gingival crevicular
fluid–alkaline phosphatase level. World J Orthod 2010;11:221–229.
Key words: space closure, periodontal ligament, alkaline phosphatase,
root resorption, anchorage loss
rthodontic space closure is time-con- responses that again lead to more rapid
O suming. There is no consensus as to
how to accomplish it most efficiently.
tooth movements. Each activation
causes an upregulation of the various
While the concepts of optimal force markers (interleukins, prostaglandins,
magnitude and duration have received etc) associated with remodeling
substantial attention, 1 frequency of processes within the periodontal liga-
force application has not received due ment.3 Research has proven that chang-
consideration. Studies on distraction ing force magnitude produces better
osteogenesis2 show that repetitive acti- reaction from bone and cartilage cells
vations result in favorable cellular than a constant force.4,5
221
 Kalha et al
a b
Recently, a screw-type appliance, the
Hycon screw5,6 (Adenta) was proposed as
a new method for space closure (Figs 1a
and 1b). It allows precise activation so
that force delivery can be adjusted. The
first part of this study was conducted to
assess the effect of sequential repetitive
loading of the periodontal ligament dur-
ing space closure using fixed appliances
and the aforementioned screw. The aim
was to assess the rate of tooth move-
ment and the amount of anchorage loss
and root resorption.
A number of gingival crevicular fluid
constituents have been shown to be diag-
nostic markers of bone remodeling as
indicated by an elevation in alkaline and
acid phosphatase levels.7,8 Therefore, in
the second part of this study, the alkaline
phosphatase level in the GCF during
space closure was evaluated.
222
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WORLD JOURNAL OF ORTHODONTICS
Fig 1a Hycon screw as used
in this study for space closure.
Fig 1b Hycon screw set up
on a cast.
Fig 2 FEM model of canine, premolar, and
molar region after a full turn activation (0.35 mm)
of a Hycon screw and a 0.021 ⫻ 0.025-inch
stainless steel wire; over the periodontal liga-
ment, distributed forces were uniform in the
7 cN/mm2 range on the pressure sites.
METHOD AND MATERIALS
As a precursor to the clinical study, a 2D
finite element model (FEM) of the canine,
premolar, and molar region was con-
structed using Engineering Mechanical
Research Corporation (EMRC) display;
NISA III software (Cranes); and a peri -
apical radiograph of the molar, premolar,
and canine region as a reference. The
model consisted of 2,185 nodes and
4,135 elements. To reflect normal
anatomy, the teeth were connected to the
surrounding alveolar bone through a vir-
tual periodontal ligament.
The different structures (alveolar bone,
teeth, and periodontal ligament) were
assigned their respective material con-
stants as determined previously by Tanne
et al9; the experimental archwire received
the mechanical properties of stainless
steel. The load distribution within the peri-
odontal ligament was then studied for
one full turn (0.35 mm) of the Hycon
screw (Fig 2). The model showed minimal
VOLUME 11, NUMBER 3, 2010
Fig 3a Radiovisiograph image of canine
region before activation; compare width of
the tension side (arrow) with width after
activation.
Fig 3b Radiovisiograph image of canine
region after activation; compare width of the
tension side (arrow) with width before acti-
vation. Also note uniform compression of the
distal periodontal ligament.
tipping of the teeth into the extraction
site due to controlled activation and the
presence of guidance by the 0.021-inch
⫻ 0.025-inch wire. The stress on the pres-
sure side was generally low (13 cN/mm2)
and uniformly distributed along the root
surfaces. This was also reflected on the
radiovisiographs (RVGs) before and after
activation (Figs 3a and 3b). Image inver-
sion with Dexis 3.0 software depicted
any changes in the periodontal ligament
more clearly.
For the clinical part of this study,
10 males and 10 females (mean age
19.9 ± 3.8 years) requiring extraction of
all first premolar were randomly selected.
Inclusion criteria were healthy periodon-
tal status, healthy medical status, maxi-
mum anchorage requirements, identical
ethnicity, and signed informed consent.
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Kalha et al
All patients were bonded with 0.022-
inch slot brackets. Anchorage prepara-
tion included banding all second molars
and placing a transpalatal and lingual
arch. Leveling and aligning was initiated
with 0.016-inch and completed with
0.019-inch ⫻ 0.025-inch heat-activated
Ni-Ti wires. Finally, 0.021-inch ⫻ 0.025-
inch stainless steel wires were placed
with passive tie-backs for 4 weeks. After
leveling and aligning, lateral cephalo-
grams and RVGs of the canine and
molar–premolar regions were taken.
For retraction, the Hycon screw as
described by McLaughlin et al 5 and
Kachiwala et al6 was used. All patients
were advised to activate this screw half a
turn every 3 days until space closure was
complete.
223
 Kalha et al WORLD JOURNAL OF ORTHODONTICS

a b c
Figs 4a to 4c Intraoral images showing patient before space closure with a Hycon screw.

a b c
Figs 5a to 5c Intraoral images showing patient after space closure with a Hycon screw.

Data collection 0 = No apical root resorption

Rate of tooth movement. Tooth move-
ment was evaluated by measuring the
distance between the distal wing of the
canine and the mesial wing of the second
premolar bracket with Vernier calipers
(Dentaurum). The readings were noted
every 4 weeks until space closure was
completed. Figs 4 and 5 show a clinical
example before and after space closure.
Incisor retraction and anchorage
loss. Pre- (T1) and posttreatment (T2) lat-
eral cephalograms were traced using the
Pancherz method.10 The distance from
the occlusal line perpendicular to the tip
of the maxillary and mandibular incisors
was measured, the difference being the
amount of incisor retraction.
Also, the distance from the occlusal
line perpendicular to the distal aspect of
the maxillary and mandibular molars was
measured; this difference indicated the
amount of anchorage loss.
Root resorption. The RVGs were taken
with an UltraCam (Ultrak Inc.) and pro-
jected on a computer screen using Dexis
3.0 software. The canine and molar/pre-
molar regions were scored according to
the criteria given by Sharpe et al11:
1 = Slight blunting of the apex
2 = Moderate blunting of the apex up
to one fourth of the root length
3 = Excessive blunting of the apex
beyond one fourth of the root length
By adding the resorption scores for all
the teeth examined, the total resorption
score for each patient was determined.
Alkaline phosphatase activity. For the
alkaline phosphatase study, six females
and four males (mean age 20.6 ± 3.2
years) with the same inclusion criteria
stated previously were enrolled. Leveling
and aligning was performed as described
earlier. In five randomly selected patients,
the anterior teeth were moved with the
Hycon screw; in the remaining five, active
tie-backs were used.
Sampling of gingival crevicular fluid
followed the protocol of Perinetti et al.7
All samples were collected from the dis-
togingival margin of the four canines
using a volumetric micropipette of 1 µl
capacity. The collection took place 1 hour
before and 1 hour after activation and at
7-, 14-, 21-, and 28-day intervals. The
screw was activated by half turn, twice
weekly, while the active tie-backs were
changed every 4 weeks.

224

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VOLUME 11, NUMBER 3, 2010 Kalha et al

Table 1  Total (mm), mean (mm/month) ± SD (standard Table 2  Mean ± SD (standard deviation) and range (mm)
deviation) and range of extraction space closure in the of retraction and anchorage loss in the maxilla and
maxilla and mandible, including t and P value mandible, including t and P value
Total Mean ± SD Range t* P Maxilla Mandible

Maxilla 4.50 ± 1.41 1.36 ± 0.21 0.87–1.77 1.85 .07 Mean ± SD Range Mean ± SD Range t* P
Mandible 4.24 ± 1.32 1.27 ± 0.23 0.50–1.70
Retraction 3.90 ± 0.82 3.0–5.0 3.70 ± 0.86 2.0–5.0 0.75 .46
*Unpaired t test. Anchorage 1.23 ± 0.60 0.0–2.0 1.08 ± 0.65 0.0–2.0 0.76 .45
loss

*Unpaired t test.

STATISTICAL ANALYSIS and 1.27 ± 0.23 mm/month in the

For the first part of the study, descriptive
data are presented as means ± SD and
95% confidence limits wherever applica-
ble. One-way ANOVA was used for multi-
ple group and Student t test for
group-wise comparisons. Correlations
between measurements were assessed
by Pearson correlation coefficient. Statis-
tical significance was set at a probability
level of ≤ .05.
For the alkaline phosphatase study,
means ± SD were calculated; categorical
data were presented as absolute values
and percentages. The increase in alka-
line phosphatase level for each time
interval was reflected as percentage of
the baseline value (1 hour before activa-
tion). ANOVA was performed to statisti-
cally compare the measurements at
intervals to the baseline values. The
Mann-Whitney test was then performed
to determine any significant mean differ-
ences between the groups at each site.
RESULTS
Space closure
mandible (Table 1). The overall rate of
tooth movement was thus calculated to
be 1.32 ± 0.22 mm/month. Unpaired t
test did not show a significant difference
between tooth movements in both jaws
(P > .05).
Incisor retraction and anchorage
loss
The amount of incisor retraction was
3.90 ± 0.82 mm for maxillary incisors
and 3.7 ± 0.86 mm for mandibular
incisors, the difference not being signifi-
cant (P > .05) (Table 2).
The average anchorage loss
amounted to 1.23 ± 0.60 mm for the
maxillary molars and 1.08 ± 0.65 mm for
the mandibular molars; the difference
was not significant (P > .05). The Pearson
correlation test showed a positive, but not
significant, correlation between the
amount of anchorage loss and incisor
retraction in the maxilla (r = 0.32, P > .05)
and the mandible (r = 0.18, P > .05).
Approximately 3.2 mm of maxillary and
3.4 mm of mandibular incisor retraction
resulted in 1.0 mm of anchorage loss.

The average space closure was 4.51 ±

1.40 mm in the maxilla and 4.23 ± 1.33 mm
in the mandible. The mean space closure
thus was calculated as 4.37 ± 1.37 mm.
The average time to complete space clo-
sure was 3.34 ± 0.94 months.
Rate of tooth movement
The mean rate of tooth movement was
1.36 ± 0.21 mm/month in the maxilla
Root resorption
Of the 240 roots assessed, 60 (25%)
exhibited no root resorption, 132 (55%)
showed slight root resorption, and 48
(20%) had a moderate blunting of their
apices. The resorption scores did not dif-
fer significantly for the individual teeth in
the maxilla and mandible (P > .05) (Table
3). The ANOVA test showed that the com-
bined resorption scores for the canines,

225

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 Kalha et al
Table 3  Mean ± SD (standard deviation) and total
resorption score in the maxilla and mandible for canines,
premolars, and molars
Maxilla Mandible t*
Canines 1.4 ± 0.9 1.6 ± 0.9 0.50
Premolars 1.5 ± 0.8 1.9 ± 1.0 1.18
Molars 2.5 ± 1.1 2.4 ± 1.1 0.29
*Student t test.
premolars, and molars were significantly
different from one another (P < .01). The
unpaired t test again revealed that the
molars were characterized by signifi-
cantly greater root resorption than the
canines (P < .01) and premolars (P < .01)
(Table 4).
Alkaline phosphatase activity
Compared with the baseline measure-
ment, the mean concentrations of alka-
line phosphatase levels were significantly
increased in both groups at the various
time intervals (Tables 5 and 6). The one-
way ANOVA showed that the values dif-
fered significantly between groups. There
was an increase of about 200% in the
alkaline phosphatase level between days
21 and 28 in the active tie-back group at
all sites, while that in the retraction screw
group was more than 260%. Also,
between day 14 and 28, the difference in
the alkaline phosphatase level between
the two groups was significant for all four
sites.
DISCUSSION
Despite their varying force magnitude,
traditional tooth-moving devices (closing
loops, elastic chains/modules, and
springs) produce consistently hyaliniza-
tion12 because their activation length is
beyond the width of the periodontal
space (0.25 mm).13 Thus, the blood sup-
ply is reduced, leading to cell-free zones.
The impact of force-application fre-
quency with a controlled minimum activa-
tion length on a biologic system has not
yet received due attention. In this study,
226
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WORLD JOURNAL OF ORTHODONTICS
Table 4  Statistical comparison of the resorption scores
among canines, premolars, and molars
t* P
Total
Canines vs premolars 0.81 .43
resorption
P score Canines vs molars 3.52 .01
Premolasr vs molars 2.80 .01
.62 3.0 ± 1.6
.25 3.4 ± 1.6 *Unpaired t test.
.77 4.9 ± 1.9
besides classical tie-backs, the Hycon
retraction screw was used for space
closure. If it is activated one full turn
(360 degrees), it contracts 0.350 mm.5,6
Because force distribution occurs recipro-
cally, one full turn would produce approxi-
mately 0.175 mm activation on both
sides of the extraction site. This is less
than the width of the periodontal ligament
so blood supply can be maintained. In
this study, the screw was turned only one
half turn (180 degrees) twice a week. The
ef ficient and rapid space closure
observed here is an indication that the
activation sequence used ensured ade-
quate tissue response while not impeding
blood supply to the periodontium. This is
optimal for metabolism and subsequent
osteoclast and osteoblast activity.12
The force generated by a full turn acti-
vation was determined to be 410 cN5; it
is in the 200 cN range for a 180-degree
activation. This force is sufficient to over-
come the friction generated between the
0.021- ⫻ 0.025-inch stainless steel wire
and the 0.022-inch bracket slot. A full-
sized wire used for en masse retraction
of the anterior teeth will minimally deflect
and thus allow a better inclination control
as clinical observation also signified.
Tooth movements as high as 1.98 mm/
month could be achieved, although the
mean was 1.32 ± 0.22 mm/month
(95% CI = 0.88 mm to 1.98 mm/month).
Ninety-five percent showed a movement of
1.5 mm/month or more, and 40% showed
even more than 1.9 mm/month. Smaller
movements may be attributed to the vari-
ability in bone density and trabeculation
pattern. At the end of 4 months, space
closure was completed in 91% of the
80 quadrants studied. In comparing the
present data with those of Dixon et al,14
 VOLUME 11, NUMBER 3, 2010

Table 5  Mean alkaline phosphatase values ± SD (standard deviation) (IU/l) in the gingival crevicular fluid, difference to baseline value (BL), and P value
for the maxillary right and left canines in the tie-back and Hycon groups at the various time points and differences between groups
Maxillary right canine Maxillary left canine

Tie-back Hycon screw Tie-back Hycon screw

Difference Difference
Difference Difference between Difference Difference between
Time Mean ± SD to BL P Mean ± SD to BL P groups** Mean ± SD to BL P Mean ± SD to BL P groups**

Before activation 58.4 ± 11.5 – – 60.6 ± 2.6 – – – 59.6 ± 8.6 – – 63.8 ± 5.9 – – –
After activation 79.0 ± 11.5 20.6 ± 2.4 < .05 81.8 ± 1.9 21.2 ± 2.8 < .01 NS 79.2 ± 7.2 19.6 ± 2.6 < .01 85.2 ± 5.3 21.4 ± 3.0 < .01 NS
Day 7 150.6 ± 9.4 92.2 ± 7.3 < .01 169.4 ± 14.5 108.8 ± 13.7 < .01 S 150.0 ± 7.0 90.4 ± 8.4 < .01 173.8 ± 10.8 110.0 ± 13.9 < .01 NS
Day 14 164.0 ± 5.7 105.6 ± 6.3 < .01 177.8 ± 41.3 137.2 ± 12.5 < .01 S 165.6 ± 3.8 106.0 ± 5.6 < .01 201.4 ± 13.7 137.6 ± 17.0 < .01 S
Day 21 172.0 ± 11.6 113.6 ± 5.1 < .01 229.2 ± 5.4 168.6 ± 6.5 < .01 S 175.8 ± 6.5 116.2 ± 11.1 < .01 233.6 ± 6.6 169.8 ± 6.1 < .01 S
Day 28 171.6 ± 12.1 113.2 ± 4.4 < .01 232.2 ± 4.4 171.6 ± 5.4 < .01 S 174.8 ± 5.6 115.2 ± 9.8 < .01 234.6 ± 6.1 170.8 ± 5.1 < .01 S
ANOVA*          F = 115.0, P < .001, LSD = 20.6 F = 380.2, P < .001, LSD = 8.5 F = 301.6, P < .001, LSD = 12.9 F = 370.8, P < .001, LSD = 16.8

*One-way ANOVA, ** Mann- Whitney test, NS = not significant, S = significant, F = ratio of model mean square to error of mean square, LSD = least significant difference.

Table 6  Mean alkaline phosphatase values ± SD (standard deviation) (in IU/l) in the gingival crevicular fluid, difference to baseline value (BL), and P value
for mandibular left and right canines in the tie-back and Hycon groups at the various time points and differences between groups
Mandibular right canine Mandibular left canine

Tie-back Hycon screw Tie-back Hycon screw

Difference Difference
Difference Difference between Difference Difference between
Time Mean ± SD to BL P Mean ± SD to BL P groups** Mean ± SD to BL P Mean ± SD to BL P groups**

Before activation 63.6 ± 4.2 – – 65.4 ± 8.0 – – – 64.8 ± 4.8 – – 67.2 ± 4.5 – – –
After activation 83.2 ± 6.5 19.6 ± 4.4 < .01 89.2 ± 4.9 25.4 ± 4.2 < .01 NS 85.0 ± 3.1 20.2 ± 4.5 – 90.0 ± 4.9 22.8 ± 3.3 < .01 NS
Day 7 151.2 ± 7.9 87.6 ± 7.8 < .01 154.0 ± 36.5 90.2 ± 33.4 < .01 NS 150.0 ± 6.4 85.2 ± 8.6 < .01 178.2 ± 14.2 111.0 ± 11.4 < .01 S

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Day 14 165.8 ± 4.8 102.2 ± 4.0 < .01 204.6 ± 11.3 140.8 ± 15.6 < .01 S 168.4 ± 3.8 103.6 ± 5.8 < .01 208.0 ± 12.7 140.8 ± 10.8 < .01 S
Day 21 179.0 ± 5.7 115.4 ± 8.6 < .01 234.8 ± 6.6 169.4 ± 14.2 < .01 S 175.6 ± 8.5 110.8 ± 11.1 < .01 232.4 ± 5.6 165.2 ± 6.8 < .01 S
Day 28 177.6 ± 4.4 114.0 ± 7.4 < .01 235.2 ± 2.9 169.8 ± 10.6 < .01 S 171.6 ± 5.5 106.8 ± 9.7 < .01 235.2 ± 4.2 235.2 ± 4.1 < .01 S

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ANOVA*         F = 388.2, P < .001, LSD = 11.6      F = 380.2, P < .001, LSD = 16.6             F = 366, P < .001, LSD =11.1        F = 350.6, P < .001, LSD = 16.5

*One-way ANOVA, ** Mann- Whitney test, NS = not significant, S = significant, F = ratio of model mean square to error of mean square, LSD = least significant difference.

227
Kalha et al
 Kalha et al
Nightingale and Jones,15 and Barlow,16 it
can be inferred that the mean space clo-
sure with the Hycon screw is much faster
and more efficient than traditional space-
closing mechanisms. As mentioned, this
may be attributed to the repetitive loading
of the periodontal ligament. The upregula-
tion of the various markers involved in the
anabolic and catabolic modeling activities
during tooth movement was demonstrated
by Lee et al3 and Carano and Siciliani.4
As an exudate, gingival crevicular fluid
reflects metabolic changes in the peri-
odontal tissues. The increase in alkaline
phosphatase activity in the gingival
crevicular fluid seems to be related to
orthodontic force application because
alkaline phosphatase is considered to be
a marker for bone remodeling.8,9,17 Sev-
eral studies have reported changes in
alkaline phosphatase activity in
osteoblasts during experimental tooth
movements in both animals and
humans.18–20
In this study, gingival crevicular
fluid–alkaline phosphatase activity was
assayed longitudinally during tooth move-
ment in relation to the type of force sys-
tem used. Significant increases in the
gingival crevicular fluid–alkaline phos-
phatase activity level were found over a
1-month period. The particularly signifi-
cant alkaline phosphatase increase in
the Hycon retraction group between days
14 and 28 as compared to the tie-back
group can be explained by the fact that
the elastomeric modules used in the lat-
ter sample generally lose 50% to 70% of
their initial force during the first day of
loading; at 3 weeks, they retain only 30%
to 40% of their original force. In contrast,
retraction screws do not wear out.
The mean amount of incisor retraction
achieved was 3.90 ± 0.81 mm for the
maxillary and 3.70 ± 0.86 mm for the
mandibular incisors, and the mean
anchorage loss was 1.23 ± 0.60 mm and
1.08 ± 0.65 mm for the maxillary and
mandibular arches, respectively. Thus, the
anchorage loss accounted for 24% to 27%
of the total space closure (4.37 ± 1.37
mm), which is acceptable for maximum
posterior anchorage and comparable to
other methods of space closure.21,22
228
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WORLD JOURNAL OF ORTHODONTICS
Root resorption occurs when pressure
on the cementum exceeds its reparative
capacity. Subsequently, dentin is
exposed, thereby allowing multinucleated
odontoclasts to degrade the root surface.
Movement of teeth typically produces
some blunting of root apices indepen-
dent of the type of appliance used.23 The
relevant literature describes a prevalence
ranging from 3% to 100% of the treated
patients.24,25
Of the 240 roots in this study, 55%
(132) encountered a slight blunting, 20%
(48) showed moderate blunting, and 25%
(60) revealed no apex blunting at all.
Studies by Beck et al24 and McNab et
26
al have shown that among the poste-
rior teeth, the most frequently resorbed
are the mandibular molars followed by
the maxillary molars, mandibular premo-
lars, maxillary first premolars, and maxil-
lary second premolars. In this study,
molars showed significantly greater api-
cal root resorption than premolars and
canines (P < .01), which is confirmed by
the findings of Sharpe et al.11 There was,
however, no difference of resorption
between canines and premolars.
The length of treatment time and root
resorption are positively correlated 27 ;
increased treatment length makes roots
more prone to resorption. If space clo-
sure is completed quickly in a controlled
manner as in this study, treatment dura-
tion is reduced, as is the risk of root
resorption.
CONCLUSION
Sequential repetitive loading of the peri-
odontal ligament with small and con-
trolled activations (approximately 0.175
mm) is effective for space closure as indi-
cated by a significantly higher increase of
the gingival crevicular fluid–alkaline
phosphatase level if a retraction screw is
used instead of active tie-backs (a supe-
rior force application); a shorter treat-
ment length because, with traditional
methods, activation intervals, force lev-
els, and activation length vary signifi-
cantly; and minimal anchorage loss and
root resorption.
VOLUME 11, NUMBER 3, 2010
ACKNOWLEDGMENTS
The authors would like to thank the staff of Dental
Sciences, Davangere, India, where the study was
carried out. We would also like to thank Dr Aparna
P for her contributions during the FEM study.
REFERENCES
1. Quinn RS, Yoshikawa DK. A reassessment of
force magnitudes in orthodontics. Am J Orthod
1985;88:252–260.
2. Liou EJW, Huang CS. Rapid canine retraction
through distraction of the periodontal ligament.
Am J Orthod Dentofacial Orthop 1998;114:
372–382.
3. Lee KJ, Park YC, Yu HS, Choi SH, Yoo YJ. Effects
of continuous and interrupted force on IL-1 and
PgE2 production in gingival crevicular fluid. Am J
Orthod Dentofacial Orthop 2004;125:168–177.
4. Carano A, Siciliani G. Effects of continuous and
intermittent forces on human fibroblasts in
vitro. Eur J Orthod 1996;18:19–26.
5. McLaughlin RP, Kalha AS, Scheutz W. An alter-
native method of space closure: The Hycon
Device. J Clin Orthod 2005;39:474–484.
6. Kachiwala VA, Kalha AS, Vigneshwaran J.
Space closure using the Hycon device: A case
report. Aust Orthod J 2007;23:72–75.
7. Perinetti G, Paolantonio M, D’Attilio MD,
D’Archivio D, Tripodi D, Femminella B. Alkaline
phosphatase activity in gingival crevicular fluid
during human orthodontic tooth movement.
Am J Orthod Dentofacial Orthop 2002;122:
548–556.
8. Perinetti G, Paolantonio M, Serra E, D’Archivio
D, D’Ercole S, Festa F. Longitudinal monitoring
of subgingival colonization by Actinobacillus
actinomycetemcomitans, and crevicular alka-
line phosphatase and aspartate aminotrans-
ferase activities around orthodontically treated
teeth. J Clin Periodontol 2004;31:60–67.
9. Tanne K, Sakuda M, Burstone. Three dimen-
sional finite element analysis for stress in the
periodontal tissue by orthodontic forces. Am J
Orthod Dentofacial Orthop 1987;92:499–505.
10. Pancherz H. A cephalometric analysis of skele-
tal and dental changes contributing to Class II
correction in activator treatment. Am J Orthod
1984;85:125–132.
11. Sharpe W, Reed B, Subtenly JD, Polson A.
Orthodontic relapse, apical root resorption, and
crestal alveolar bone levels. Am J Orthod
Dentofacial Orthop1997;91:252–257.
12. Ren Y, Maltha JC, Kuijpers-Jagtman AM. The rat
model for orthodontic tooth movement—A criti-
cal review and a proposed solution. Eur J
Orthod 2004;26:483–490.
© 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Kalha et al
13. Newman MG, Talkei HH, Caranza FA. Clinical
Periodontology, ed 9. Philadelphia: Elsevier,
2003:36–41.
14. Dixon V, Read MJF, O’Brien KD, Worthington
HV, Mandall NA. A randomized controlled trial
to compare three methods of orthodontic
space closure. J Orthod 2002;29:31–36.
15. Nightingale P, Jones SP. A clinical investigation
of force delivery systems for orthodontic space
closure. Orthod 2003;30:229–236.
16. Barlow M, Kula K. Factors influencing efficiency
of sliding mechanics to close extraction space:
A systematic review. Orthod Craniofac Res
2008;11:65–73.
17. Keeling SD, King GJ, McCoy EA, Valdez M.
Serum and alveolar bone phosphatase
changes reflect bone turnover during orthodon-
tic tooth movement. Am J Orthod Dentofacial
Orthop 1993;103:320–326.
18. Insoft M, King GJ, Keeling SD. The measure-
ment of acid and alkaline phosphatase in gingi-
val crevicular fluid during orthodontic tooth
movement. Am J Orthod Dentofacial Orthop
1996;109:287–296.
19. Takimoto K, Deguchi T, Mori M. Histochemical
detection of acid and alkaline phosphatases in
periodontal tissues after experimental tooth
movement. J Dent Res 1968;47:340.
20. Christenson RH. Biochemical markers of bone
metabolism: An overview. Clin Biochem 1997;
30:573–593.
21. Williams R, Hosila FJ. The effect of different
extraction sites upon incisor retraction. Am J
Orthod 1976;69:388–410.
22. Heo W, Nahm DS, Baek SH. En masse retraction
and two-step retraction of maxillary anterior
teeth in adult Class I women: Comparison of
anchorage loss. Angle Orthod 2007;6:973–978.
23. Reukars EA, Sanderink GC, Kuijpers-Jagtman
AM, Van’t Hof MA. Radiographic evaluation of
apical root resorption with two different types of
edgewise appliance. Results of randomized clin-
ical trial. J Orofac Orthop 1998;59:100–109.
24. Harris EF. Root resorption during orthodontic
therapy. Semin Orthod 2000;6:183–194.
25. Beck BW, Harris EF. Apical root resorption in
orthodontically treated subjects—Analysis of
edgewise and lightwire mechanics. Am J Orthod
Dentofacial Orthop 1994;105:350–361.
26. McNab S, Battistutta D, Taverne A, Symons AL.
Apical root resorption following orthodontic
treatment. Angle Orthod 2000;70:227–232.
27. Krishnan V. Critical issues concerning root
resorption: A contemporary review. World J
Orthod 2005;6:30–34.
229
EFFECTIVENESS OF TWIN BLOCKS AND Álvaro Francisco Carrielo
Fernandes, DDS, MSc1

EXTRAORAL MAXILLARY SPLINT Ione Helena Portela

Brunharo1
(THUROW) APPLIANCES FOR THE Cátia Cardoso Abdo
CORRECTION OF CLASS II RELATIONSHIPS Quintão, DDS, MSc,
PhD1
Aim:The aim of this study was to evaluate the skeletal and dentoalve- Myrela Galvão Cardoso
olar changes due to treatment with twin block and Thurow appliances Costa, DDS, MD2
in patients with Class II occlusions. Method: The sample consisted of
19 randomly selected patients in each group, as well as 20 individuals Mickelson Rio Lima de
in the control group. All patients were treated during the prepubertal Oliveira-Costa, DDS,
growth spurt for 12 months. Lateral cephalograms were analyzed at MD, PhD3
the beginning of active treatment and 12 months later. All data were
tested with the ANOVA and Bonferroni tests. Results and Conclusion:
These tests showed that the twin block promotes a significant
increase (P < .001) in the total length of the mandible, as well as an
increase in anterior facial height. In contrast, ANB and NAPog were
reduced. In both treatment groups, the maxillary incisors retruded
significantly (P < .001), although more so in the twin block group. In
the Thurow appliance group, the mandibular incisors protruded sig-
nificantly (P < .001). All other differences between the two treated
groups were not significant. World J Orthod 2010;11:230–235.

Key words: twin blocks, extraoral maxillary splint, Thurow appliance,

Class II occlusions

keletal Class II occlusions are very
S common and vary in their structural
configuration. They can be caused by
maxillary protrusion, mandibular retru-
sion, or a combination of the two. The
treatment of choice depends on the
location of the problem. Often, one of
the many functional/orthopedic appli-
ances is used for the correction of the
skeletal and occlusal disharmony.
Among functional appliances, the twin
block, originally developed by Clark, 1
and the Thurow appliance, developed by
Thurow,2 seem to be viable options.
The twin block consists of a maxillary
and mandibular plate with bite blocks
that force the mandible forward during
closure.1,3 The Thurow appliance is a rigid
splint that engages all or just some of the
maxillary teeth. It inhibits the anterior
and caudal displacement of the maxilla
and its concurrent tooth movements.4
The best results with both appliances
occur when the peak of mandibular and
maxillary growth occurs in the treatment
period.
The objective of the present study
was to compare the skeletal and dento -
alveolar changes produced by twin
blocks and Thurow appliances in sub-
jects with an Angle Class II Division 1
occlusion.
1Professor, Department of Orthodon-
tics, Rio de Janeiro State University,
Rio de Janeiro, RJ, Brazil.
2Doctoral Degree Student, Rio de
Janeiro State University, Rio de
Janeiro, RJ, Brazil.
3Professor, Department of Orthodon-
tics, Bahiana School of Medicine
and Public Health, Salvador, BA,
Brazil.
CORRESPONDENCE
Dr Myrela Galvão Cardoso Costa
Department of Orthodontics
Rio de Janeiro State University
Rio de Janeiro, RJ
Brazil
Email: myrelacardoso@yahoo.com.br

230

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VOLUME 11, NUMBER 3, 2010
Fig 1 Lateral view of the twin block func- Fig 2 Occlusal view of the Thurow appliance used.
tional appliance used.
METHODS AND MATERIALS
This study was approved by the relevant
ethics committee. The patients were
selected from the Orthodontic Post Grad-
uate Clinic of Rio de Janeiro State Univer-
sity. After providing consent, 58 patients
were included in the sample. They met
the following criteria: a skeletal Class II
relationship (ANB > 4.0 degrees); a Class
II molar relationship; overjet ≥ 6.0 mm;
no previous orthodontic treatment; and
ascending segment of their individual
pubertal growth spurt as identified by the
hand and wrist indicators of Hassel and
Farman.5
The twin block group consisted of
12 boys and 7 girls with a mean age of
9.5 years (⫾ 8 months); the Thurow group
was made up of 10 boys and 9 girls with
a mean age of 10.0 years (⫾ 6 months).
An untreated Class II Division 1 group of
13 boys and seven girls with a mean age
of 9.9 years (⫾ 13 months) was used as
the control group. The analysis of vari-
ance (ANOVA) test verified the initial
homogeneity of the sample.
The design of the twin block followed
Clark 1 with modifications by Brunharo
and Quintão6 (Fig 1). All patients were
instructed to wear their appliance full-
time and to document this in a compli-
ance form.
The Thurow appliance followed the
design of Thurow 2 (Fig 2). All patients
were instructed to wear it at night (approx-
imately 10 hours per day). The outer bows
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Fernandes et al
of the high-pull headgear ended in the
region of the maxillary first molars; the
applied force was around 400 cN.
Lateral cephalograms in centric occlu-
sion were taken of all subjects at the
beginning of active treatment (T1) and
12 months later (T2). These radiographs
were subsequently scanned using the
Deskscan program (HP) with standard
definition. All cephalograms were ana-
lyzed by the same operator using the
Radiocef 2.0 Memory studio software
(Radiocef, Floresta).
A vertical reference line, originating
from S and perpendicular to S-N, was
constructed as previously described by
Brunharo and Quintão. 10 The analysis
was based on measurements of the
Steiner,8 Ricketts,9 and McNamara analy-
ses.18 The various reference points and
lines as the measured angles and dis-
tances are represented in Fig 3.
To minimize possible errors, every ref-
erence point was digitized by a single
operator. Also, the method error was eval-
uated in four randomly selected radi-
ographs, which were digitized 10 times
by the same operator. The intraclass cor-
relation coefficient (ICC) was calculated,
and a value of > 0.88 was obtained.
Descriptive statistics included the cal-
culation of means and standard devia-
tions. The changes resulting from growth
and treatment were evaluated using
ANOVA. To test the differences among
groups, the Bonferroni test was used. A
P value of .05 was considered significant.
231
 Fernandes et al WORLD JOURNAL OF ORTHODONTICS

Fig 3 Linear and angular

cephalometric measurements:
SNA, SNB, ANB, Co–A (maxil-
lary length), Co–Gn (mandibu-
N
S N lar length), 1/NA (angle and
S mm), 1/NB (angle and mm),
V-Line.
V Line
Co

s
An
A
A
DU6-VL
DL6-VL
B’
MU6-VL A’
Go
Go
B
B

Gn Pog
Me Gn
Me

Table 1  Mean values and standard deviations (SD) of the various cephalometric
parameters for the three groups at T1 and P values (ANOVA) for repeated measurements
Twin block Thurow appliance Control
Parameter Mean SD Mean SD Mean SD P

SNA (degrees) 82.5 4.2 83.1 3.9 82.4 4.7 .840

Co-A (mm) 92.9 3.7 91.0 4.6 90.5 5.2 .230
SNB (degrees) 75.7 3.7 76.1 3.6 76.2 3.7 .930
Co-Gn (mm) 111.1 4.0 109.9 5.5 110.7 7.8 .818
ANB (degrees) 6.8 1.7 6.3 1.8 6.3 1.8 .497
NAPog (degrees) 13.0 4.3 14.1 5.4 12.5 4.8 .556
AB OcP (degrees) 5.9 3.2 4.7 3.9 6.4 6.3 .502
GoGn-SN (degrees) 33.7 5.6 34.5 4.5 33.4 5.2 .773
Ans-Me (mm) 65.2 5.2 65.0 4.0 64.9 4.7 .980
SN-Gn (mm) 68.1 4.3 69.3 3.0 68.1 3.2 .479
S-Go (mm) 69.6 4.5 69.2 4.8 68.5 4.8 .757
U1-NA (mm) 3.3 2.7 6.3 2.8 5.3 2.7 .502
U1-NA (degrees) 27.8 7.1 26.0 7.3 26.0 6.0 .662
L1-NB (mm) 6.4 2.6 7.4 2.3 6.2 2.3 .276
L1-NB (degrees) 28.9 5.7 31.0 6.9 27.7 6.6 .266
L1-GoGn (degrees) 99.4 6.3 100.3 6.4 99.2 7.3 .860
U1-L1 (degrees) 116.6 8.2 115.9 8.1 115.9 8.1 .840
MU6-VL 33.0 5.3 30.8 3.5 32.0 4.2 .325
DU6-VL 22.8 5.3 20.8 3.4 21.9 3.9 .364
DL6-VL 30.5 5.7 28.3 3.6 29.9 4.5 .320

RESULTS could be detected only between the twin

The cephalometric values for all three
groups at T1 are listed in Table 1. The
parametric ANOVA demonstrated that
there were no significant differences
among the groups.
ANB was reduced in both treated
groups but increased in the control
group, though a significant difference
block and control group (P = .01) (Table
2). NAPog was also reduced, especially in
the twin block group. This led to a signifi-
cant difference when compared to the
control group (P ≤ .05). Co-Gn indicated a
length increase of the mandible in all
patients with a significant difference
between only the twin block and control
group (P = .016).

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VOLUME 11, NUMBER 3, 2010 Fernandes et al

Table 2  Mean differences and standard deviations (SD) between T1 and T2 of the various cephalometric parameters and
Bonferroni significance test between paired groups.
Significance
Twin block (n = 19) Thurow appliance (n = 19) Control (n = 20) Twin block/ Thurow/ Twin block/
Parameter Mean SD Mean SD Mean SD control group control group Thurow

SNA (degrees) –0.4 1.5 –0.7 2.0 1.0 3.2 NS NS NS

Co-A (mm) 1.8 5.4 1.8 2.7 1.5 4.2 NS NS NS
SNB (degrees) 1.2 1.1 0.1 1.4 0.9 3.0 NS NS NS
Co-Gn (mm) 4.4 3.0 1.8 2.7 1.5 4.2 * NS NS
ANB (degrees) –1.5 0.8 –0.8 1.2 0.1 1.4 * NS NS
NAPog (degrees) –3 1.9 –1.9 3.0 0.1 3.2 * NS NS
AB OcP (degrees) –3.1 2.8 –0.8 2.5 –0.6 5.8 NS NS NS
GoGn-SN (degrees) –0.3 2.2 –0.7 1.9 –1.3 2.1 NS NS NS
Ans-Me (mm) 2.7 2.8 1.6 1.5 –0.7 4.8 * NS NS
SN-Gn (mm) –0.4 1.4 0.1 1.2 –0.7 2.0 NS NS NS
S-Go (mm) 2.7 2.3 2.6 1.7 2.1 2.2 NS NS NS
U1-NA (mm) –7.6 5.1 –3.4 3.2 0.7 2.6 * * *
U1-NA (degrees) –1.7 2.0 1.7 1.8 0.5 1.2 * * NS
L1-NB (mm) 2.0 2.6 –1.4 2.8 2.7 5.0 NS * *
L1-NB (degrees) 1.2 1.3 –0.1 0.7 0.4 0.9 NS NS *
L1-GoGn (degrees) 1.2 3.1 –0.9 2.9 1.5 3.2 NS NS NS
U1-L1 (degrees) 7.2 4.9 5.7 4.7 –2.4 2.5 NS NS NS
MU6-VL –1.3 4.9 –0.5 3.4 1.5 3.1 NS NS NS
DU6-VL 1.0 3.8 –0.7 3.0 1.8 2.7 NS NS NS
DL6-VL 2.7 2.3 1.7 4.2 1.3 3.8 NS NS NS

NS = not significant; asterisk denotes statistically significant difference.

U1-NA (mm) was significantly different
for all three groups, but for U1-NA
(degrees), a significant difference existed
merely between the twin block and con-
trol groups as between the Thurow and
control groups (P = .01). L1-NB (mm)
increased in the twin block and control
groups, and a significant difference
became apparent between the Thurow
and twin block groups.
DISCUSSION
After treatment, the maxilla was retruded
in the twin block and Thurow groups
(SNA: Thurow = –0.7 degrees, twin block
= –0.4 degrees), whereas in the control
group, it increased (SNA = 1.0 degree). SNB
increased with no significant difference
in any group (twin block = 1.2 degrees,
Thurow = 0.1 degrees, control group =
0.9 degrees), which is in accordance with
the relevant literature. 11–15 Similar to
other studies, Co-Gn increased in all
three groups, but only the difference
between the twin block and control group
was significant (P < .05).2,16–18
ANB was reduced in both treated
groups in comparison to the control
group, which is also supported by other
studies.4,12–16,19–21
ANS-Me demonstrated an increase in
both treated groups and a reduction in
the control group. Trimming of the maxil-
lary posterior blocks will allow the molars
to erupt, which will lead to an extra
increase in posterior facial height that is
favorable in patients with a deep bite.
U1-NA was reduced especially in the
twin block group. This effect is likely due
to the labial bow of the appliance.
Because the force vector of the headgear
in the Thurow group ran through the cen-
ter of resistance of the maxillary com-
plex, the maxillary incisors tipped less
palatally in this group.

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 Fernandes et al
L1-NB (degrees) increased during
treatment in the twin block group,
whereas L1-NB (mm/degrees) became
smaller in the Thurow group. These den-
toalveolar changes are supported by
many other studies.4,13–17,19,20
The molar relation in the control group
did not show any improvement as previ-
ously found by Ritter and Almeida 14 ;
instead, the maxillary molars moved
mesially (in relation to the vertical refer-
ence line), which aggravated the Class II
relationship. In the Thurow group, the
Class II relation was improved because
the maxillary molars were moved distally
by the headgear.14,23–26
In the twin block group, the maxillary
molars moved 1.0 mm mesially (in rela-
tion to the vertical reference line), which
differs entirely from other publications
that reported a distal movement of the
maxillary posterior teeth, calling it the
appliance headgear effect.16,18–20,27
The nonsignificant increase of the dis-
tance between the mandibular molar and
vertical reference line in all groups con-
tributed to the correction of the Class II
relationship in 85% of all treated patients.
CONCLUSION
The following conclusions were drawn
from this study:
• The position of the maxilla in both
treated groups as compared to the
control group changed significantly
between the beginning of treatment
and the follow-up 12 months later.
• The twin block group demonstrated
significant mandibular growth, which
improved the sagittal relationship
between both jaws in comparison to
the control group.
• The anterior facial height increased in
the twin block group as compared to
the control group.
• The maxillary incisors were retruded
significantly in both treated groups in
comparison to the control group.
• The maxillary and mandibular molar
position was not significantly altered
during the evaluated time interval.
234
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WORLD JOURNAL OF ORTHODONTICS
REFERENCES
1. Clark WJ. The Twin Block technique. A func-
tional orthopedic appliance system. Am J
Orthod Dentofacial Orthop 1988;93:1–18.
2. Thurow RC. Craniomaxillary orthopedic correc-
tion with en masse dental control. Am J Orthod
1975;68:601–624.
3. Clark WJ. Twin Block functional therapy. Appli-
cations in dentofacial orthopedics. Zurin:
Mosby-Wolf, 1995: 28–79.
4. Seckin O, Sürücü R. Treatment of Class I, Divi-
sion 1 cases with a maxillary traction splint.
Quintessence Int 1990;3:17–23.
5. Hassel B, Farman A. Skeletal maturation evalu-
ation using cervical vertebrae. Am J Orthod
Dentofacial Orthop 1995;107:58–66.
6. Brunharo IP, Quintão CA. O aparelho funcional
Twin Block – confecção laboratorial e aplicação
clínica. Revista Brasileira de Odontologia 2001;
58:373–377.
7. Broadbent BH. A new X-ray technique and its
application to orthodontics. Angle Orthod 1931;
1:45–66.
8. Steiner CC. Cephalometric for you and me. Am
J Orthod 1953;39:729–755.
9. Ricketts RMS. A foundation for cephalometric
communication. Am J Orthod 1960;46:
330–357.
10. McNamara JA. A method of cephalometric eval-
uation. Am J Orthod 1984;84:449–469.
11. Fotis V, Melsen B, Williams S. Vertical control
as an important ingredient in the treatment of
severe sagittal discrepancies. Am J Orthod
Dentofacial Orthop 1984;86: 224–232.
12. Malmgren O, Ömblus J. Treatment with an
orthopedic appliance system. Eur J Orthod
1985;15:205–214.
13. Orton HE, Battagel JM, Ferguson R, Ferman
AM. Distal movement of buccal segments with
“en masse” removable appliance–Its value in
treating patients with mild Class II Division 1
malocclusions. Part II: The model measuring
system and results. Am J Orthod Dentofacial
Orthop 1996;109:379–385.
14. Ritter DE, Almeida MA. Tratamento precoce da
maloclusäo de Classe II, divisäo 1, com splint
de traçäo maxilar—estudo clínico prospectivo.
Ortodontia Gaúcha 2002;6:154–166.
15. Trenouth MJ. Cephalometric evaluation of the
Twin Block appliance in the treatment of Class II
Division 1 malocclusion with matched normative
growth data. Am J Orthod Dentofacial Orthop
2000;117:55–59.
16. Lund DL, Sandler PJ. The effects of Twin-blocks:
A prospective controlled study. Am J Orthod
Dentofacial Orthop 1998;113:104–110.
17. Malmgren O, Ömblus J, Hägg U. Treatment with
an orthopedic appliance system in relation to
treatment intensity and growth periods. A study
of initial effects. Am J Orthod Dentofacial Orthop
1987;91:143–151.
VOLUME 11, NUMBER 3, 2010
18. Toth LR, McNamara JA. Treatment effects pro-
duced by the Twin-block appliance and the FR-
2 appliance of Fränkel compared with
untreated Class II sample. Am J Orthod Dento-
facial Orthop 1999;116:597–609.
19. Baccetti T, Franchi L, Toth LR, McNamara JA. A
treatment timing for Twin-Block therapy. Am J
Orthod Dentofacial Orthop 2000;118:159–170.
20. Mills CM, McCulloch KJ. Treatment effects of
the Twin Block appliance: A cephalometric
study. Am J Orthod Dentofacial Orthop 1998;
114:15–24.
21. Üner O, Yücel-Eroglu E. Effects of a modified
maxillary orthopedic splint: A cephalometric
evaluation. Eur J Orthod 1996;18:269–286.
22. Baumrind S, Korn EL, Isaacson RJ, West EE,
Molthen R. Quantitative analysis of the ortho-
dontic and orthopaedic effects of maxillary
traction. Am J Orthod 1983;84:384–398.
23. Baumrind S, Korn EL. Patterns of change in
mandibular and facial shape associated with
the use of forces to retract the maxilla. Am J
Orthod 1981;79:31–47.
© 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Fernandes et al
24. Burke M, Jacobson A. Vertical changes in high-
angle Class II Division 1 patients treated with
cervical or occipital pull headgear. Am J Orthod
Dentofacial Orthop 1992;102:501–508.
25. Cura N, Saraç M. The effect of treatment with
the Bass appliance on skeletal Class II maloc-
clusions: A cephalometric investigation. Eur J
Orthod 1997;19:691–702.
26. Orton HS, Slattery DA, Orton, S. The treatment
of severe ‘gummy’ Class II Division 1 malocclu-
sion with the maxillary intrusion splint. Eur J
Orthod 1992;14:216–223.
27. Illing HM, Morris DO, Lee RT. A prospective
evaluation of Bass, Bionator and twin block
appliances. Part I—The hard tissues. Eur J
Orthod 1998;20:501–516.
235
A CLINICAL, MRI, AND EMG ANALYSIS Neeraj S. Rohida, MDS1

COMPARING THE EFFICACY OF TWIN Wasundhara Bhad, MDS2

BLOCKS AND FLAT OCCLUSAL SPLINTS

IN THE MANAGEMENT OF DISC
DISPLACEMENTS WITH REDUCTION
Internal derangement of the temporomandibular joint (TMJ) is charac-
terized by an abnormal disc-condyle relationship. Of all the various
treatment modalities used in the management of disc displacements,
flat occlusal and anterior repositioning splints are the most commonly
used. Myofunctional appliances (such as bite-jumping appliances) are
also advocated to treat anterior disc displacements. The present study
compares the efficacy of twin blocks with conventional flat occlusal
splints in patients with anterior disc displacement with reduction
using clinical examination, MRI, and EMG. The sample consisted of
20 subjects between 12 and 20 years of age, who were randomly
divided into two groups of 10 patients each: Group 1 was treated with
twin blocks, while group 2 was treated using maxillary flat occlusal
splints. The twin block is more effective in relieving joint pain, dimin-
ishing joint dysfunction, reducing joint clicking, and eliminating mus-
cle tenderness in patients with anterior disc displacement with
reduction as compared to the occlusal splint. World J Orthod 2010;
11:236–244.

Key words: twin blocks, occlusal splints, disc displacements, temporo-

mandibular joint disorder, MRI

emporomandibular joint disorders dysfunction (muscle tenderness and joint

T (TMDs) and their relationship with the
function of the masticatory system have
been a topic of interest in dentistry for
many years. The relationship among
TMDs, occlusion, and oral function is
clicking). The incidence of TMD is high in
preadolescents and adolescents.1–4
Over time, various modalities of ther-
apy have been recommended to manage
internal derangements of the TMJ.
1Assistant Professor, Department of
Orthodontics, Government Dental
College, Nagpur.
2Associate Professor, Department of

quite complex. Lack of knowledge has
stimulated numerous concepts, theo-
ries, and treatment methods, which
have led to much confusion.1
Internal derangement of the temporo-
mandibular joint (TMJ) is characterized
by an abnormal disc-condyle relationship
or a normal relationship associated with
disc immobility. Both conditions can
result in symptoms (pain) and signs of
Among these, flat occlusal and anterior Orthodontics, Government Dental
repositioning splints are the most com- College, Nagpur.
monly used. However, the relevant litera- CORRESPONDENCE
ture regarding such splints reflects Dr Neeraj S. Rohida
equivocal long-term treatment outcomes. Department of Orthodontics
Also, myofunctional appliances (such Government Dental College
and Hospital
as bite-jumping appliances) were advo-
GMC Campus
cated to treat anterior disc displace- Nagpur
ments. There are only a few studies Maharashtra, India 440003
evaluating the effect of such appliances. Email: dr_neerajrohida@yahoo.co.in

236

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VOLUME 11, NUMBER 3, 2010
This holds particularly true for the twin
block in subjects who have an anterior
disc displacement with reduction.
The present study compares the effi-
cacy of twin blocks with conventional flat
occlusal splints in patients with anterior
disc displacement with reduction. The
efficacy of the two appliances was evalu-
ated clinically as by magnetic resonance
imaging (MRI) and electromyography
(EMG).
The objectives of this study were:
• To evaluate and compare the clinical
ef ficacy of twin blocks and flat
occlusal splints to reduce pain and/or
masticatory muscle tenderness with
joint clicking (symptomatic clicking)
• To evaluate the rate of disc recapture
with twin blocks and flat occlusal
splints by assessing the disc–condyle
relationship with MRI
• To evaluate the effect of twin blocks
and flat occlusal splints on the postural
activity of the masticatory muscles—
masseter and temporalis—using EMG.
SAMPLE AND METHODS
The individuals included in this study had
an anterior disc displacement with reduc-
tion, which was provisionally diagnosed
clinically and confirmed by MRI. The diag-
nostic records included a history and clin-
ical examination form (Protocol of the
European Academy of CMD 4 ), study
casts, MRIs, and EMGs.
Inclusion criteria were the presence of
either TMJ pain or masticatory muscle
tenderness with joint clicking (opening or
reciprocal click).
Exclusion criteria were asymptomatic
TMJ clicking or a nonrecaptured disc dur-
ing mouth opening or mandibular protru-
sion (disc displacement without reduction).
The final sample consisted of 20 sub-
jects (13 female, 7 male) between 12
and 20 years of age. This sample was
randomly divided into 2 groups of
10 patients: Group 1 was treated with
twin blocks, while those in group 2
received treatment via full coverage
maxillary flat occlusal splints.
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Rohida/Bhad
MRI
To confirm the preliminary diagnosis, the
TMJs of the subjects with positive clinical
findings were imaged with a 1.5 Tesla
Philips (Holland Made) MRI machine
using bilateral flexible circular surface
TMJ coils 11 cm in external diameter with
an 8-cm opening. Sagittal T1 weighted
images were recorded with closed and
open mouth. In addition, an MRI was
recorded with the construction bite for a
bite block in place.
Parameters used for MRI were
10 slices 1.5-mm thick with a field of
view (FoV) of 150 mm. The matrix size
was 240
192, there were two excita-
tions, and there was 0 mm between the
slices.
The evaluation included the assess-
ment of the sagittal disc position5 and
measurements with the Philips Medical
Systems DICOM software MxLiteView
1.24. The disc position was defined by
the method of Chintakanon et al,5 which
is a variation of that by Drace and Enz-
mann,6 who defined a 12 o’clock posi-
tion of the disc relative to the condylar
head (Fig 1).
To measure the disc position, a tan-
gent to the posterior border of the ramus
and the condyle (PC line) was initially con-
structed. A line parallel to the PC line pass-
ing through the condylar center and the
roof of the fossa defined the 12 o’clock
position. The position of the posterior
band of the joint disc was subsequently
measured as the angle relative to the
12 o’clock position. Thus, three distinct
disc positions could be determined: nor-
mal position and anterior and posterior
displacement. According to Silverstein et
al,7 the range for a normal sagittal disc
position is 25.7 to –18.7 degrees.
According to the MRIs, the morphology
of the joint disc was normal in all study
participants.
237
 Rohida/Bhad WORLD JOURNAL OF ORTHODONTICS

12 o’clock

45.7°

PC line

Line parallel to PC line

a b
Fig 1 12 o’clock position as defined by a tangent to the posterior border of the ramus and the
condyle (PC line) and a line parallel to the PC line passing through the condylar center and the roof of
the fossa. The position of the posterior band of the disc is measured as the angle relative to the 12
o’clock position. (a) Schematic drawing (C = center of condyle), (b) reference line arrangement on an
actual MRI with an angle of 57 degrees between the PC parallel and the posterior attachment of the
disc indicating that it is anteriorly displaced.

EMG the upper border of the zygomatic arch,

To check the postural activity of the mas-
seter and temporalis, EMGs were
recorded with surface electrodes using
an RMS EMG EP machine. Twenty
healthy individuals between 12 and
20 years of age without any TMD signs or
symptoms served as controls.
The electrodes used in the present study
were dual-channel circular silver chloride
disc electrodes 10.5 mm in diameter. Silver
chloride electrodes were chosen because
they have a stable polarization potential
that results in noise-free recordings.
The electrodes were placed in a stan-
dardized manner for every patient. For
the masseter muscle, the active elec-
trode (black) was 2.5 cm above and in
front of the mandibular angle, the refer-
ence electrode (red) was over the zygo-
matic bone, and the ground electrode
(green) was over the symphysis.
For the temporalis muscle, the active
electrode (black) was 2.5 cm posterior to
the lateral margin of the orbit and above
the reference electrode (red) was over
the zygomatic bone, and the ground elec-
trode (green) was over the symphysis.
The EMG recordings were taken with
the patients sitting and carried out in a
shielded room to avoid electrical interfer-
ence. The patients were instructed about
the procedure, which also was demon-
strated to alleviate anxiety. Before the
actual registration, the skin over the
respective muscle to be recorded was
scrubbed with 70% alcohol and carefully
dried. The electrode position was marked
with ink. The electrodes were coated with
a thin gel layer (Acquasonic, Medigel) and
secured with adhesive tape.
All patients were instructed to wear
their appliances 24 hours a day including
during meals. They were recalled after a
week to check for appliance fit and com-
fort. After this, all patients were seen
every 4 weeks over the 6-month study
period. Every visit comprised of a clinical
examination and an assessment of the
TMD signs and symptoms. Appliance

238

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VOLUME 11, NUMBER 3, 2010 Rohida/Bhad

Fig 2 Example of an anteriorly displaced disc. Fig 3 Example of a physiologically positioned,

Arrow indicates its posterior band. recaptured disc. Arrow indicates its posterior
band.

adjustments were carried out as required.
At the end of 6 months, appliance wear
was gradually reduced or even discontin-
ued when existing signs and symptoms
had ceased.
After 12 months, the final records
were collected and assessed as they
were at the beginning of therapy.
RESULTS
At the end of 12 months, pain relief and
reduction of muscle tenderness was
seen in all 10 twin block patients, while
clicking was eliminated in eight of the 10.
In the splint group, pain relief occurred in
seven of the 10 patients, reduction of
muscle tenderness in two of the three
affected patients, and elimination of
clicking in three of the 10 patients.
MRI evaluation showed that at the end
of 12 months, eight of 10 patients in the
twin block group had a normal disc–
condyle relationship. The mean pretreat-
ment sagittal disc position in this group
was 37.4 ± 4.6 degrees, indicating an
anterior displacement; after 12 months, it
was 4.1 ± 14.8 degrees, reflecting a physi-
ologic position (Figs 2 and 3). In the splint
group, only three of 10 patients showed a
normal disc position (ie, disc displacement
persisted in the remaining seven). Here,
the mean pretreatment sagittal disc posi-
tion was 33.8 ± 3.7 degrees, again indi-
cating an anteriorly displaced disc. After
12 months, the respective values were
25.9 ± 9.0 degrees, proving that, on aver-
age, the disc displacement persisted.
Table 1 shows the mean difference in the
pre- and posttreatment sagittal disc posi-
tion between the two groups, which differs
significantly according to the independent
samples test (t test).
The EMG evaluation showed a mean
activity decrease of the masseter and
anterior temporalis in both groups, which
is significantly different between both
groups as indicated by the independent
samples test (t test) (Tables 2 and 3).

239

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 Rohida/Bhad WORLD JOURNAL OF ORTHODONTICS

Table 1  Mean difference, standard deviation (SD), standard error mean in degrees, and
t and P value of pre- and posttreatment sagittal disc position in the two study groups
Group Mean SD Standard error mean t value P value

Twin block 33.3 13.8 4.4

6.6636 0
Flat occlusal splint 7.9 8.1 2.6

Table 2  Mean decrease, standard deviation (SD), standard error mean in µV (peak to
peak amplitude), and t and P value of pre- and posttreatment postural activity of the
masseter muscle in the two study groups
Group Mean SD Standard error mean t value P value

Twin block 16.9 13.2 4.2

2.4404 .04
Flat occlusal splint 6.4 6.6 2.1

Table 3  Mean decrease, standard deviation (SD), standard error mean in µV (peak to
peak amplitude), and t and P value of pre- and posttreatment postural activity of the
anterior temporalis muscle in the two study groups
Group Mean SD Standard error mean t value P value

Twin block 24.3 16.3 5.1

2.3887 .04339
Flat occlusal splint 10.5 11.8 3.7

DISCUSSION ment with reduction, the disc is recap-

Paesani et al8 and Larheim9 studied the
prevalence of internal TMJ derangements
in patients with TMD using MRI and indi-
cated that almost 80% of those with
signs and symptoms had some form of
internal derangement. Overall, anterior
and anteromedial disc displacements are
the most common.
In a healthy TMJ, the condyle in rest
position is positioned in contact with the
intermediate and posterior bands of the
disc. According to Drace and Enzmann,6
this is the 12 o’clock position. As the disc
is displaced anteriorly, the condyle is
positioned directly against the retrodiscal
tissue, which is well-innervated and vas-
cularized, leading to retrodiscitis and
subsequently to pain. In disc displace-
tured during jaw opening and/or during
mandibular protrusion, causing the char-
acteristic click. During closure, the disc
slips again anteriorly off the condylar
head, eventually generating a closing
(reciprocal) click.
Not all patients with anterior disc dis-
placement are symptomatic. Further,
Okeson 1 has stated that patients with
asymptomatic joint clicking may not
require any therapy. However, if anterior
disc displacement is associated with pain
or muscle tenderness, the treatment
should aim to eliminate them by recap-
turing the disc.
MRI is a noninvasive diagnostic tool to
examine both soft and hard tissues of the
TMJ. Larheim,9 Schach and Sadowsky,10
Dalkiz et al, 11 and Taskaya-Yilmaz and

240

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VOLUME 11, NUMBER 3, 2010
Ogutcen-Toller 12 pointed out that MRI
should be used to detect pathological
conditions of the TMJ, especially internal
derangements.
Various studies13–16 have shown that
signs and symptoms of TMD are associ-
ated with increased activity of the masti-
catory muscles, which can be assessed
by EMG. The increased activity leads to a
protective muscle cocontraction (muscle
splinting), but it can also result in a
myospasm, which is a CNS-induced tonic
muscle contraction due to muscle fatigue
or deep pain input. 1 EMG is the only
quantitative method to measure the
severity, progression, and treatment
response of muscle dysfunctions in TMD
patients. Though there are controversies
regarding the accuracy and reliability of
EMG recordings, they are a valuable
adjunctive research tool, especially when
combined with other multidimensional,
subjective, pain-related methods.17
Over the years, various treatment
modalities have been recommended for
the management of internal TMJ
derangement, which can be broadly clas-
sified into supportive and definitive inter-
ventions. Supportive therapy is directed
toward altering the patients’ symptoms
and often has no effect on the cause of
the disorder, thus providing only tempo-
rar y (symptomatic) relief. Examples
include pharmacologic agents; physical
therapies, such as cold application; ultra-
sound; or manual techniques, such as
massage and muscle conditioning.
Definitive therapies aim to eliminate or
control the cause(s) of a disorder—for
instance, by re-establishing a physiologic
disc–condyle relationship. For this purpose,
flat occlusal and anterior repositioning
splints are most common. The extensive lit-
erature regarding their use is replete with
diverse and often diametrically opposite
statements, especially as far as their long-
term success is concerned.
Flat occlusal splints reduce the force
exer ted on the retrodiscal tissues,
thereby reducing retrodiscitis and permit-
ting healing. 1 Because such splints
relieve existing signs/symptoms without
causing irreversible occlusal changes,
many clinicians19–21 favor them to man-
age disc displacements. However, the
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Rohida/Bhad
major limitation of such splints is that
they do not correct the abnormal
disc–condyle relationship. Hence, they
provide just temporary relief.
In contrast, anterior repositioning
splints allow disc recapture and therefore
better healing of the retrodiscal tissues.
But even with these splints, long-term
results remain questionable.20,22 That is
why an appliance is needed to alleviate
the signs and symptoms of TMD, recap-
ture the displaced disc, ascertain a nor-
mal disc–condyle relationship, and
improve facial muscle balance.
According to Clark,23 Eberhard et al,24
Franco et al, 25 and Kinzinger et al, 26
myofunctional appliances can accom-
plish this. Clark23 added that the reduc-
tion of the condylar compression by a
muscular advancement of the mandible
has to be followed by some form of
occlusal reconstruction to support the
condyle in its advanced position.
The twin block acts as an anterior
repositioning splint by actively positioning
the mandible downward and forward and
subsequently recapturing the anteriorly
displaced disc. Functional appliances
also retrain the muscle function pattern.
In addition, they facilitate settling of the
occlusion in the new position of the
mandible so the physiologic disc–condyle
relationship is maintained in the long run.
In the present study, after treatment
with a twin block, pain and muscle ten-
derness were relieved in all patients,
while clicking was eliminated in eight of
the 10. These results are consistent with
the findings of Lundh et al,22 Okeson,27
and Anderson and Schulte,28 though they
used mandibular repositioning splints.
Similar findings have been reported by
numerous other clinicians.24,29–35 Finally,
it seems noteworthy that Clark 23 sug-
gested twin block therapy for pain relief
and clicking elimination in patients with
anterior joint displacement with reduc-
tion.
The results of the splint group are sup-
por ted by the work of Carraro and
Caffesse,19 Lundh et al,22 Anderson and
Schulte,28 and Kurita et al.36 Kurita et al36
also stated that even if disc recapture
occurs, it can slip back anteriorly after
splint wear is discontinued. Recapturing
241
 Rohida/Bhad
seems to be most likely when the dis-
placement is very mild or at an initial
stage.18 More positive were the results of
Maloney and Howard,20 but this can be
explained by the different sample size
and study duration. Also, these authors
based their conclusions on only clinical
evaluations, not MRIs.
The MRI evaluation of the present
study is in accordance with Lundh and
Westesson,30 Summer and Westesson,33
and Kurita et al,37 who found recapturing
of discs and eliminating of clicks in 82%,
75%, and 70%, respectively, of their
patients after mandibular repositioning.
Similarly, Eberhard et al24 showed signifi-
cant disc recapture after repositioning
therapy. Also, Franco et al 25 and
Kinzinger et al26 noted that in TMJs with
early partial or total anterior disc dis-
placement, the disc position can be
improved with functional appliances.
If this is in contrast to Chintakanon et
al,5 it can be explained by the fact that in
that study, only three of the 40 children
presented with an MRI-confirmed ante-
rior disc displacement—in other words,
the incidence in their sample was proba-
bly too low.
One reason why two patients of the
current study failed disc recapture could
be that their displacement had already
existed for a long time. Another explana-
tion could be that they suffered from a
very severe disc displacement, which irre-
versibly altered the morphology of their
discs or their retrodiscal lamina (poste-
rior attachment). In such patients, recap-
turing therapy does not seem to be
effective.24 Even if the disc is not recap-
tured, twin blocks can still cause a condy-
lar distraction, thus decreasing the
compression of the retrodiscal tissues
and at the same time eliminating disturb-
ing occlusal factors. This explains the
symptom relief without disc recapture.
EMG evaluation showed that in the
twin block group, the pretreatment pos-
tural activity of the masseter and anterior
temporalis was reduced, so the final val-
ues were close to those of the control
group. This is in agreement with Sessle et
al,38 Lacouture al,39 and Isberg et al.14
242
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WORLD JOURNAL OF ORTHODONTICS
CONCLUSION
The following conclusions can be drawn
from the present study:
• The twin block is effective in relieving
joint pain, diminishing joint dysfunc-
tion, reducing joint clicking, and elimi-
nating muscle tenderness in patients
with anterior disc displacement with
reduction.
• The resolved joint pain and reduced
dysfunction were associated with
recapturing the joint disc and estab-
lishing a normal disc–condyle relation-
ship, as evidenced on MRIs.
• The elimination of pain and muscle
tenderness was also associated with a
decrease in the postural activity of the
masticatory muscles as demonstrated
by EMG.
• Flat occlusal splints are effective to
reduce joint pain and muscle tender-
ness but are less successful as far as
joint clicking is concerned.
• Flat occlusal splints do not lead to any
significant disc recapturing.
Further, in regard to clinical relevance
for the orthodontic practice, there are
several items of note.
• One, patients presenting with TMJ
pain, muscle tenderness, or joint click-
ing suffer generally from an internal
TMJ derangement (most commonly,
anterior disc displacement). Most
studies show a high correlation
between clinical and MRI findings.
Hence, the diagnosis of disc displace-
ment can be made in many patients
on the basis of the clinical findings
alone.
• Two, MRIs are indicated in patients
with a long-standing history of TMD
symptoms and signs, a closed lock,
and symptoms that remain even with
repositioning therapy. An MRI may
then reveal degenerative joint changes
or an abnormal disc morphology.
Repositioning appliances may not be
effective in some conditions.
VOLUME 11, NUMBER 3, 2010
In patients with a Class I relationship,
the construction bite for a twin block
should sagittally be only so far advanced
that the clicking is eliminated during
mouth opening from this advanced posi-
tion. Also, undesirable effects of twin
blocks may indicate the development of a
posterior open bite and a protrusion of
the mandibular incisors.
These adverse effects can be mini-
mized by a support phase using an ante-
rior inclined plane to bring about settling
of the occlusion before a posterior open
bite develops and capping of the
mandibular incisors to prevent flaring.
REFERENCES
1. Okeson JP. Management of Temporomandibu-
lar Disorders and Occlusion, ed 5. St Louis:
Mosby, 2003.
2. Solberg WK, Woo MW, Houston JB. Prevalence
of mandibular dysfunction in young adults.
J Am Den Assoc 1979;98:25–34.
3. Egermark-Eriksson I, Carlsson GE, Ingervall B.
Prevalence of mandibular dysfunction and oro-
facial parafunction in 7-, 11-, and 15-year-old
Swedish children. Eur J Orthod 1981;3:
163–172.
4. Athanasiou AE. Orthodontics and cranio-
mandibular disorders. In: Bishara SE (ed). Text-
book of Orthodontics. Philadelphia: Saunders,
2001.
5. Chintakanon K, Sampson W, Wilkinson T,
Townsend G. A prospective study of Twin Block
appliance therapy assessed by magnetic reso-
nance imaging. Am J Orthod Dentofacial
Orthop 2000;118:494–504.
6. Drace JE, Enzmann DR. Defining the normal
TMJ: Closed-, partially open-, and open-mouth
MR imaging of asymptomatic subjects. Radiol-
ogy 1990;177:67–71.
7. Silverstein R, Dunn S, Binder R, Maganzini A.
MRI assessment of the normal temporo-
mandibular joint with the use of projective
geometry. Oral Surg Oral Med Oral Pathol
1994;77:523–530.
8. Paesani D, Westesson P, Hatala M, Tallents R,
Kurita K. Prevalence of temporomandibular
joint internal derangement in patients with
craniomandibular disorders. Am J Orthod
Dentofacial Orthop 1992;101:41–47.
9. Larheim TA. Role of magnetic resonance imag-
ing in the clinical diagnosis of the temporo-
mandibular joint. Cells Tissues Organs 2005;
180:6–21.
10. Schach RT, Sadowsky PL. Clinical experience
with magnetic resonance imaging in internal
derangements of the TMJ. Angle Orthod 1988;
1:21–32.
© 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Rohida/Bhad
11. Dalkiz M, Pakdemirli E, Beydemir B. Evaluation
of temporomandibular joint dysfunction by
magnetic resonance imaging. Turk J Med Sci
2001;31:337–343.
12. Taskaya-Yilmaz N, Ögütcen-Toller M. Clinical
correlation of MRI findings of internal derange-
ments of the temporomandibular joints. Br J
Oral Maxillofac Surg 2002;40:317–321.
13. Mercuri LG, Olson RE, Laskin DM. The speci-
ficity of response to experimental stress in
patients with myofascial pain dysfunction syn-
drome. J Dent Res 1979;58:1866–1871.
14. Isberg A, Widmalm S, Ivarsson R. Clinical,
radiographic, and electromyographic study of
patients with internal derangement of the tem-
poromandibular joint. Am J Orthod Dentofacial
Orthop 1985;88:453–460.
15. Miller AJ, Nielsen IL. Neuromuscular Compen-
sation in Subjects with Craniomandibular Disor-
ders. EMG of Jaw Reflexes in Man. Leuven:
Leuven University Press, 1989.
16. Dahlstrom L. Electromyographic studies of
craniomandibular disorders: A review of the lit-
erature. J Oral Rehabil 1989;16:1–20.
17. Suvinen TI, Kemppainen P. Review of clinical
EMG studies related to muscle and occlusal
factors in healthy and TMD subjects. J Oral
Rehabil 2007;34:631–644.
18. Kovaleski WC, De Boever J. Influence of
occlusal splints on jaw position and muscula-
ture in patients with temporomandibular joint
dysfunction. J Prosthet Dent 1975;33:321.
19. Carraro JJ, Caffesse RG. Effect of occlusal
splints on TMJ symptomatology. J Prosthet
Dent 1978;40:563–566.
20. Maloney F, Howard J. Internal derangements of
the temporomandibular joint. Part III: Anterior
repositioning splint therapy. Aust Dent J 1986;
31:30–39.
21. Okeson JP. Long-term results of treatment for
temporomandibular disorders: An evaluation by
patients. J Am Dent Assoc 1986;112:473–478.
22. Lundh H, Westesson P, Kopp S, Tillstrom B.
Anterior repositioning splint in the treatment of
temporomandibular joints with reciprocal click-
ing: Comparison with a flat occlusal splint and
an untreated control group. Oral Surg Oral Med
Oral Pathol 1985;60:131–136.
23. Clark WJ. Twin Block Functional Therapy—
Applications in Dentofacial Orthopedics, ed 2.
St Louis: Mosby, 2002.
24. Eberhard D, Bantleon HP, Steger W. The effi-
cacy of anterior repositioning splint therapy
studied by magnetic resonance imaging. Eur J
Orthod 2002;24:343–352.
25. Franco AA, Yamashita HK, Lederman HM, Cevi-
danes LHS, Proffit WR, Vigorito JW. Frankel
appliance therapy and the temporomandibular
disk: A prospective magnetic resonance imag-
ing study. Am J Orthod Dentofacial Orthop
2002;121:447–457.
243
 Rohida/Bhad
26. Kinzinger GS, Roth A, Gulden N, Bucker A,
Diedrich PR. Effects of orthodontic treatment
with fixed functional orthopedic appliances on
the disc–condyle relationship in the temporo-
mandibular joint: A magnetic resonance imag-
ing study (Part II). Dentomaxillofac Radiol
2006;35:347–356.
27. Okeson JP. Long-term treatment of disk-interfer-
ence disorders of the temporomandibular joint
with anterior repositioning occlusal splints.
J Prosthet Dent 1988;60:611–616.
28. Anderson GC, Schulte JK. Comparative study of
two treatment methods for internal derange-
ment of the temporomandibular joint. J Pros-
thet Dent 1985;53:392–397.
29. Davies SJ, Gray RJ. The pattern of splint usage
in the management of two common temporo-
mandibular disorders. Part III: Long-term follow-
up in an assessment of splint therapy in the
management of disc displacement with reduc-
tion and pain dysfunction syndrome. Br Dent J
1997;183:279–283.
30. Lundh H, Westesson P. Long-term follow-up
after occlusal treatment to correct abnormal
temporomandibular joint disk position. Oral
Surg Oral Med Oral Pathol 1989;67:2–10.
31. Tallents RH, Katzberg RW, Macher DJ, Roberts
CA. Use of protrusive splint therapy in anterior
disk displacement of the temporomandibular
joint: A 1- to 3-year follow-up. J Prosthet Dent
1990;63:336–341.
32. Davies SJ, Gray RJ. The pattern of splint usage
in the management of two common temporo-
mandibular disorders. Part I: The anterior repo-
sitioning splint in the treatment of disc
displacement with reduction. Br Dent J 1997;
183:199–203.
244
© 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
WORLD JOURNAL OF ORTHODONTICS
33. Summer JD, Westesson PL. Mandibular reposi-
tioning can be effective in treatment of reduc-
ing TMJ disc displacement. A long-term clinical
and MR imaging follow up. Cranio 1997;15:
107–120.
34. Santacatterina A, Paoli M, Peretta R, Bambace
A, Beltrame A. A comparison between horizon-
tal splint and repositioning splint in the treat-
ment of ‘disc dislocation with reduction.’
Literature meta-analysis. J Oral Rehab 1998;
25:81–88.
35. Gokalp H, Turkkahraman H. Changes in posi-
tion of the temporomandibular joint disc and
condyle after disc repositioning appliance ther-
apy: A functional examination and magnetic
resonance imaging study. Angle Orthod 2000;
70:400–408.
36. Kurita H, Kurashina K, Kotani A. Effect of full
coverage occlusal splint therapy for specific
temporomandibular disorder conditions and
symptoms. J Prosthet Dent 1997;78:506–510.
37. Kurita H, Kurashina K, Baba H, et al. Evaluation
of disk recapture with a splint repositioning
appliance: Clinical and critical assessment with
MR imaging. Oral Surg Oral Med Oral Pathol
1998;85:377–380.
38. Sessle BJ, Woodside DG, Bourque P, et al.
Effect of functional appliances on jaw muscle
activity. Am J Orthod Dentofac Orthop 1990;
98:222–230.
39. Lacouture C, Woodside DG, Sectakof PA,
Sessle BJ. The action of three types of func-
tional appliances on the activity of the mastica-
tory muscles. Am J Orthod Dentofac Orthop
1997;112:560–572.
Paul Chalakkal, MDS1
COMPARISON BETWEEN THE
Abi Mathew Thomas,
MDS2 DIMENSIONS OF LATERAL INCISOR
Saroj Chopra, MDS2 CROWNS ADJACENT TO UNERUPTED
PALATALLY DISPLACED AND
NONDISPLACED CANINES
Aim: To compare the dimensions of lateral incisor crowns adjacent to
unerupted palatally displaced and nondisplaced permanent maxillary
canines. Methods: The sample consisted of 36 children between 10
and 12 years of age with unerupted maxillary canines. Each pre-
sented with a unilaterally palatally displaced (with respect to the lat-
eral incisor) canine. The lateral incisor next to the palatally displaced
canine was considered the experimental tooth; the tooth on the con-
tralateral side was considered the control tooth. Measurements were
crown width (mesiodistal), thickness (labiopalatal), taper (conver-
gence of the crown toward the incisal edge), taper type, and crown
length. Results: No association was found between the experimental
and control lateral incisors for crown width and thickness. However, a
significant correlation was found for crown taper (P = .048) and
length (P = .01). The experimental lateral incisors had a higher mean
crown taper (0.54 mm) than the controls (0.24 mm). The mean crown
length was smaller for the experimental lateral incisors (6.74 mm)
than the control ones (7.55 mm). Conclusion: There is a significantly
greater possibility of finding lateral incisors with greater crown taper
and shorter length next to palatally displaced canines. However, there
is no significant difference in crown width or thickness. World J
Orthod 2010;11:245–249.

Key words: canine, lateral incisor, palatal displacement, crown dimensions,

crown taper

1Lecturer, Department of Pedodon-

tics and Preventive Dentistry, Goa
Dental College and Hospital, Goa,
India.
2Professor, Department of Pedodon-
tics and Preventive Dentistry, Christ-
ian Dental College and Hospital,
Ludhiana, Punjab, India.
CORRESPONDENCE
Dr Paul Chalakkal
Pedodontics and Preventive Dentistry
Goa Dental College and Hospital
Bambolim, Goa 403202
India
Email: atomheartpaul@yahoo.com
econd to only the third molar, the
S permanent maxillary canine is the
most frequently displaced and impacted
tooth. 1–3 The prevalence of maxillary
canine impaction can vary from 1% to
3%. 3–6 Impaction occurs more fre-
quently palatally (85%) than labially.7,8 It
is predominantly a European trait, occur-
ring five times more often in Europeans
than in Asians.9
The exact etiology of palatal canine
displacement is unknown; however, two
common theories attempt to explain the
phenomenon: the Guidance theory and
the Genetic theory. Guidance theory, in
its simplest form, regards the distal
aspect of the lateral incisor root as the
lead to allow the canine to erupt into its
proper position. If the lateral incisor is
anomalous or missing, this guidance is
lost, resulting in palatal displace-
ment.10,11 The Genetic theory focuses on
other dental abnormalities, such as
tooth size, shape, number, and struc-
ture, all of which are determined geneti-
cally.9,12,13

245
 Chalakkal et al
Becker et al 14 concluded from their
study that there was no dif ference
between the tooth size of the affected
and unaffected side in patients with uni-
lateral palatally displaced canines. How-
ever, many authors have reported the
occurrence of anomalous lateral incisors
adjacent to palatally displaced
canines.10,15–20 The aim of this study was
to compare the crown dimensions of lat-
eral incisor adjacent to unerupted
palatally displaced and nondisplaced per-
manent maxillary canines.
METHODS
Each child reporting to the department of
Pedodontics and Preventive Dentistry of
Christian Dental College and Hospital,
Ludhiana, India, was analyzed in regard
to the following criteria: an age of
between 10 and 12 years; unerupted per-
manent maxillary canines; and orthopan-
tomographic evidence of a unilaterally
palatally displaced canine whose cusp tip
overlapped the adjacent permanent lat-
eral incisor root (the palatal displace-
ment was verified with periapical
radiographs using the horizontal tube
shift method); the contralateral side
showed a normally positioned canine.
The first 36 children (21 males, 15 fe-
males) who fulfilled these criteria made
up the study sample. The palatally dis-
placed canines in this study could not be
referred to as palatally impacted as none
was beyond the normal age of eruption.
Alginate impressions of all subjects’
maxillary arches were taken and immedi-
ately poured with dental stone (type III).
Models with porosities or fractures were
discarded and replaced.
All measurements were made with
either a digital Vernier caliper (Mitutoyo), a
Boley gauge (Medis), or a fine-point
divider to the nearest 0.1 mm. When mea-
surements were made with a fine-point
divider, the instrument’s ends were
pierced into a data sheet, which laid on a
viewing box. The distance between the
two marks was then measured with the
digital Vernier caliper. The divider was
used only when the beaks of the caliper
did not allow precise placement on a cast.
246
WORLD JOURNAL OF ORTHODONTICS
The maxillary lateral incisors adjacent
to palatally displaced canines consti-
tuted the experimental teeth (n = 36) and
the contralateral ones the control teeth
(n = 36). Each measurement was made
three times at weekly intervals. The mean
of the two closest readings was taken as
the final reading. All measurements were
made by a single examiner, who was
unaware of the side with the palatally dis-
placed canine. The following distances
and characteristics were measured/
registered.
Mesiodistal crown width
Gingival: This is the distance between
the interproximal mesial and distal gingi-
val margin. Incisal: This measurement is
between the most mesial and distal
point, 1 mm beneath the incisal edge
because the incisal 1 mm curves to
merge with the incisal edge.
Crown taper
The mesiodistal taper was calculated by
subtracting the mesiodistal width at the
incisal level from that at the gingival level.
Taper type
Depending on the result of the taper, the
type was registered as positive, negative,
or zero.
Labiopalatal crown thickness
This measurement is the distance
between the midpoint of the labial sur-
face at the gingival margin and the mid-
point of the palatal surface at the gingival
margin measured with a Boley gauge.
Crown length
The distance between the midpoint of
the labial surface at the gingival margin
and the midpoint of the labial surface at
the incisal edge was measured with a
caliper or a fine-point divider.
VOLUME 11, NUMBER 3, 2010 Chalakkal et al

Table 1  Mean, standard deviation (SD), range, and 95% Table 2  Mean, standard deviation (SD), range, and 95%
confidence interval (CI) of the mesiodistal crown width confidence interval (CI) of the mesiodistal crown width
(mm), gingival level for the experimental and control (mm), and incisal level for the experimental and
teeth (t = 1.23, P = .22) control teeth (t = 0.53, P = .60)
Teeth Mean SD Range 95% CI Teeth Mean SD Range 95% CI
Experimental 7.70 0.64 6.20 to 8.90 7.49 to 7.91 Experimental 7.17 0.70 5.50 to 8.40 6.94 to 7.40
Control 7.50 0.74 5.20 to 8.80 7.25 to 7.74 Control 7.26 0.74 5.70 to 8.80 7.02 to 7.50

Table 3  Mean, standard deviation (SD), range, and 95% Table 4  Type of taper of the experimental and the
confidence interval (CI) of the crown taper (mm) for the control teeth (␹2 = 3.51, df = 2, P = .173)
experimental and control teeth (t = 2.01, P = .0482)
Experimental Control
Teeth Mean SD Range 95% CI
Type of taper n % n %
Experimental 0.54 0.57 –0.80 to 1.40 0.35 to 0.72
Control 0.24 0.69 –1.30 to 1.30 0.01 to 0.46 0 1 2.78 2 5.56
Negative 5 13.89 11 30.56
Positive 30 83.33 23 63.88
Total 36 100.00 36 100.00

n = number of teeth

Table 5  Mean, standard deviation (SD), range, and 95% Table 6  Mean, standard deviation (SD), range, and 95%
confidence interval (CI) of the labiopalatal crown thickness confidence interval (CI) of the crown length (in mm)
(mm) for the experimental and control teeth for the experimental and control teeth
(t = 0.94, P = .35) (t = 2.56, P = .01)
Teeth Mean SD Range 95% CI Teeth Mean SD Range 95 % CI

Experimental 6.57 1.17 3.30 to 8.50 6.19 to 6.95 Experimental 6.74 1.54 3.80 to 10.20 6.23 to 7.24
Control 6.81 0.98 5.50 to 9.30 6.49 to 7.13 Control 7.55 1.11 4.50 to 10.20 7.19 to 7.92

For all measurements, mean, stan-
dard deviation, range, 95% confidence
interval, and P value (from student t test)
were obtained. The chi-square test was
used to obtain the P value for the types
of taper.
RESULTS
The mean mesiodistal crown width at the
gingival level was higher in the experi-
mental teeth (7.70 mm) than in the con-
trol ones (7.50 mm) (Table 1). This
difference was not significant (P = .22).
The mean mesiodistal crown width at
the incisal level was less in the experi-
mental teeth (7.17 mm) than in the con-
trol ones (7.26 mm) (Table 2). Again, this
difference was not significant (P = .60).
The mean crown taper value was sig-
nificantly higher (P = .048) in the experi-
mental teeth (0.54 mm) than in the
control ones (0.24 mm) (Table 3).
According to the chi-square test, there
was no significant difference between the
type of taper for the experimental and con-
trol teeth (␹2= 3.51, P = .173) (Table 4).
The mean labiopalatal crown thick-
ness was lower in the experimental teeth
(6.57 mm) than in the control ones
(6.81 mm) (Table 5). This difference was
also not significant (P = 0.35).
The mean crown length was signifi-
cantly lower (P = .01) in the experimental
teeth (6.74 mm) than in the control ones
(7.55 mm) (Table 6).

247
 Chalakkal et al
DISCUSSION
Mesiodistal crown width
Becker et al10 found that in patients with
unilaterally palatally displaced canines,
the width of the lateral incisors adjacent
to the displaced canines was 0.2 to 2.3
mm less than that of the contralateral
ones. However, in a subsequent study,
Becker et al 10 found no dif ference
between tooth size on the affected and
nonaffected side. Oliver et al21 concluded
that lateral incisors adjacent to unilater-
ally impacted permanent maxillar y
canines are generally smaller than those
on the contralateral side. Finally, Brench-
ley and Oliver18 found that lateral incisors
on the side of palatally impacted canines
had a greater mesiodistal width at the
gingival margin than on the not affected
side. This is confirmed by the present
study; however, the difference (0.2 mm)
was not significant.
Crown taper
In this study, the mean crown taper was
significantly higher for lateral incisors
adjacent to palatally displaced canines.
Even though Brenchley and Oliver18 came
to a similar result, a comparison between
the two studies cannot be made, as
Brenchley and Oliver sample consisted of
subjects with palatally impacted canines.
Taper type
The probability of finding small or peg-
shaped lateral incisors next to palatally
displaced canines has been reported by
various authors.10,14–18,20–22
In this study, a lateral incisor was
referred to as peg-shaped if its width at
the gingival level was the greatest, simi-
lar to the guideline suggested by Becker
et al.10 Peg-shaped lateral incisors next to
palatally displaced canines have been
found in 9.4% to 17.4% of the
population.10,12,15,16 In this study, it was
83.3% (30 of 36).
248
WORLD JOURNAL OF ORTHODONTICS
Labiopalatal crown thickness
The mean labiopalatal thickness was
lower, though not significantly, for lateral
incisors next to palatally displaced
canines. This is in accordance with other
authors18–21; yet again, the samples of
their studies consisted of subjects with
palatally impacted canines.
Crown length
In the present study, the mean crown
length was significantly lower for lateral
incisors next to palatally displaced
canines. Because this length was the
clinical crown length, it could mean
either that the anatomical length actually
is smaller or that the tooth on the side of
the palatally displaced canine was less
erupted.
The labiopalatal orientation of the
canine cusp tip with respect to the lateral
incisor was evaluated using the horizon-
tal tube shift method (based on two intra-
oral images). This method was found by
Ericson and Kurol to have an accuracy of
only 92%.7 Therefore, the diagnosis of
palatally displaced canines in this study
could not be referred to as confirmatory.
The results of this study are in agree-
ment with the Guidance theory but only in
terms of short crown length and high
taper of the maxillary lateral incisors.
However, genetically induced anomalies
of adjacent teeth (in this case, lateral
incisors) may cause the palatal displace-
ment of canines.11 Therefore, maxillary
lateral incisors with unusual taper and
short clinical crowns must alert orthodon-
tists to the possible presence of palatally
displaced canines. The greater the palatal
overlap of the maxillary canine cusp tip
over the lateral incisor, the greater the
chances of a future impaction.23 Thus,
interceptive measures can be taken
before palatally displaced canines
become palatally impacted.
VOLUME 11, NUMBER 3, 2010
CONCLUSION
There is a significant possibility of finding
lateral incisors with pronounced crown
taper (convergence toward the incisal
edge) and shorter crown length next to
palatally displaced canines. However,
crown width and thickness do not differ
significantly.
REFERENCES
1. Kay LW. The impacted maxillary canine 1. Dent
Update 1977;4:335–339.
2. Beeching BW. Developmental abnormalities,
part 2. Unerupted, impacted and misplaced
teeth. Dent Update 1979;6:23–46.
3. Bass TB. Observations on the misplaced upper
canine tooth. Dent Pract Dent Rec 1967;18:
25–33.
4. Dachi SF, Howell FV. A survey of 3,874 routine
full mouth radiographs. II. A study of impacted
teeth. Oral Surg Oral Med Oral Pathol 1961;14:
1165–1169.
5. Shah RM, Boyd MA, Vakil TF. Studies of perma-
nent teeth anomalies in 7,886 Canadian indi-
viduals. II: Congenitally missing, supernumerary,
and peg teeth. Dent J 1978;44:262–264.
6. Grover PS, Norton L. The incidence of unerupted
permanent teeth and related clinical cases.
Oral Surg Oral Med Oral Pathol 1985;59:
420–425.
7. Ericson S, Kurol J. Radiographic examination of
ectopically erupting maxillary canines. Am J
Orthod Dentofacial Orthop 1987;91:483–492.
8. Jacoby H. The etiology of maxillary canine
impactions. Am J Orthod 1983;84:125–132.
9. Peck S, Peck L, Kataja M. The palatally dis-
placed canine as a dental anomaly of genetic
origin. Angle Orthod 1994;64:249–256.
10. Becker A, Smith P, Behar R. The incidence of
anomalous lateral incisors in relation to
palatally displaced cuspids. Angle Orthod
1981;51:24–29.
11. Becker A. In defense of the guidance theory of
palatal canine displacement. Angle Orthod
1995;65:95–98.
Chalakkal et al
12. Pirinen S, Arte S, Apajalahti S. Palatal displace-
ment of canine is genetic and related to con-
genital absence of teeth. J Dent Res 1996;75:
1742–1746.
13. Peck S, Peck L, Kataja M. Palatal canine dis-
placement: Guidance theory or an anomaly of
genetic origin? Sense and nonsense regarding
palatal canines. Angle Orthod 1995;65:99–102.
14. Becker A, Sharabi S, Chaushu S. Maxillary
tooth size variation in dentitions with palatal
canine displacement. Eur J Orthod 2002;24:
313–318.
15. Brin I, Becker A, Shalhav M. Position of the
maxillary permanent canine in relation to
anomalous or missing lateral incisors: a popu-
lation study. Eur J Orthod 1986;8:12–16.
16. Zilberman Y, Cohen B, Becker A. Familial trends
in palatal canines, anomalous lateral incisors,
and related phenomena. Eur J Orthod 1990;
12:135–139.
17. Peck S, Peck L, Kataja M. Prevalence of tooth
agenesis and peg-shaped maxillary lateral
incisor associated with palatally displaced
canine (PDC) anomaly. Am J Orthod Dentofacial
Orthop 1996;110:441–443.
18. Brenchley Z, Oliver R G. Morphology of anterior
teeth associated with displaced canines. Br J
Orthod 1997;24:41–45.
19. Langberg BJ, Peck S. Tooth-size reduction asso-
ciated with occurrence of palatal displacement
of canines. Angle Orthod 2000;70:126–128.
20. Al-Nimri K, Gharaibeh T. Space conditions and
dental and occlusal features in patients with
palatally impacted maxillary canines: An aetio-
logical study. Eur J Orthod 2005;27:461–465.
21. Oliver RG, Mannion JE, Robinson JM. Morphol-
ogy of the maxillary lateral incisor in cases of
unilateral impaction of the maxillary canine.
Br J Orthod 1989;16:9–16.
22. Baccetti T. A controlled study of associated den-
tal anomalies. Angle Orthod 1998;68:267–74.
23. Warford JH, Grandhi RK, Tira DE. Prediction of
maxillary canine impaction using sectors and
angular measurement. Am J Orthod Dentofa-
cial Orthop 2003;124:651–655.
249
EVALUATION OF FRICTIONAL FORCES Daniel J. Fernandes, DDS,
MScD1

OF POLYCARBONATE SELF-LIGATING José Augusto M. Miguel,

DDS, MScD, PhD2
BRACKETS Catia C.A. Quintão, DDS,
MscD, PhD2
Aim: To evaluate the frictional forces generated by ceramic- (Opal,
Ultradent) and glass-fiber–reinforced polycarbonate self-ligating
Carlos N. Elias, MSc, PhD3
brackets (Oyster, Gestenco) and compare the effectiveness of these
ligatureless systems with glass-fiber–reinforced polycarbonate con-
ventional brackets (Blonde, Gestenco). The hypothesis is that there is
no difference between frictional forces generated by ceramic- and
glass-fiber–reinforced polycarbonate self-ligating and glass-
fiber–reinforced polycarbonate conventional brackets. Methods:
Twelve preadjusted 0.022
0.028-inch maxillary canine brackets
were tested, divided into three groups: Opal, Oyster, and Blonde. Fric-
tional tests were conducted with the Emic DL 10000 testing machine
with a 20 N loadcell for 40 seconds at a 0.5 cm/min speed. Each
bracket-wire combination was tested five times. The data generated
were analyzed by parametric analysis of variance (one-way ANOVA)
and Bonferroni tests. Results: Analysis of variance indicated signifi-
cant differences for the three groups (P < .01). The frictional forces of
the Oyster glass-fiber–reinforced polycarbonate self-ligating brackets
were significantly lower (37.0 ± 8.9 cN) than those of the Opal ceramic-
reinforced polycarbonate self-ligating brackets (49.5 ± 10.1 cN), while
the Blonde glass-fiber–reinforced conventional bracket frictional
forces were 105.8 ± 6.4 cN. Conclusion: Oyster glass-fiber–reinforced
polycarbonate brackets produced less friction than Opal ceramic-rein-
forced polycarbonate brackets. The polycarbonate ligatureless sys-
tem showed significantly lower frictional forces compared to Blonde
conventional polycarbonate brackets tied with elastomeric ligatures.
The study rejected the initial hypothesis because there are significant
differences of frictional forces among the tested systems. World J 1PhD Candidate in Orthodontics,
Orthod 2010;11:250–255. Department of Orthodontics, State
University of Rio de Janeiro, Rio de
Janeiro, Brazil; Research Fellow in
Biomaterial Science, Military Insti-
tute of Engineering, Rio de Janeiro,
Brazil.
2Associate Professor, Department of

Orthodontics, State University of Rio

de Janeiro, Rio de Janeiro, Brazil.
3Professor, Department of Biomater-

wide range of metal, polymeric, and
A ceramic brackets is used in ortho-
dontics. Among self-ligating brackets,
dependence on ligatures. However, an ial Science, Military Institute of Engi-
unforeseen benefit of self-ligating
bracket systems is their low frictional
neering, Rio de Janeiro, Brazil.

stainless steel is the most widely em -
ployed material. Its low cost and reactiv-
ity are two reasons for its popularity.1
Self-ligating brackets are ligatureless
systems with built-in mechanical devices
to close the slots.2–5 These brackets may
have originally been developed to reduce
resistance.3,5 Two types of self- ligating
brackets have been developed: one
incorporates a spring clip that presses
the archwire into the bracket slot (active)
whereas the other has a ligating system
that does not generate wire pressure
(passive). 3–7 With every self-ligating
CORRESPONDENCE
Dr Daniel J. Fernandes
BL. 28 de Setembro 157 Sala 230
Faculdade de Odontologia-UERJ
Departamento de Ortodontia
CEP: 20551-030
Vila Isabel - Rio de Janeiro
Brasil
Email: fernandes.dj@gmail.com

250

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VOLUME 11, NUMBER 3, 2010 Fernandes et al

Fig 1 Front and lateral views

of the brackets tested in this
study. (Left) closed position;
(right), open position. (1) Opal
ceramic-reinforced polycarbon-
ate self-ligating bracket;
(2) Oyster glass-fiber–rein-
forced polycarbonate self-ligat- 1 2 3 1 2 3
ing bracket; (3) Blonde glass-
fiber–reinforced polycarbonate
conventional bracket.

1 1

2 2

3 3

bracket, whether active or passive, the
movable wall of the bracket is used to
convert the slot into a tube, contributing
to friction reduction.8 Other factors that
contribute to friction are the shape,
dimension, and width of both wire and
slot; ligating forces; angulation; and wire
and/or bracket material.4,5,9,10
Patient demands have led to in-
creased use of tooth-colored brackets,
especially in the anterior area. Polycar-
bonate brackets were developed as an
esthetic replacement for stainless steel,
resulting in commercially available plas-
tic brackets11 initially manufactured from
unfilled acrylic. The first generation of
these attachments presented excessive
creep deformation related to archwire
load and discoloration during clinical
use.12 Nowadays, various materials are
used to produce plastic brackets. The
addition of ceramic particles and glass
fibers improved any brackets' mechanical
properties,11 while novel formulations are
developed in an attempt to overcome
esthetic concerns associated with discol-
oration.12 However, orthodontists are reg-
ularly confronted with polycarbonate's
poor frictional behavior compared to
other esthetic materials. Handling plastic
brackets calls for precise knowledge of
their frictional properties.
The aim of the present study was to
evaluate the frictional forces generated
by polycarbonate self-ligating brackets
and compare the effectiveness of two lig-
atureless systems with conventional poly-
carbonate brackets tied with elastomeric
ligatures. The hypothesis was that there
is no difference between the frictional
forces generated by the three systems.

251

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 Fernandes et al
MATERIALS AND METHODS
Twelve preadjusted 0.022
0.028-inch
slot maxillary canine brackets were
tested and divided into three groups of
four brackets each: conventional glass-
fiber–reinforced polycarbonate brackets
(Blonde, Gestenco), self-ligating ceramic-
reinforced polycarbonate brackets (Opal,
Ultradent), and self-ligating glass-fiber–
reinforced polycarbonate brackets (Oyster,
Gestenco) (Fig 1).
All brackets were tested on segments
of 0.019
0.025-inch in diameter and
5.0-cm long stainless steel wire (Rocky
Mountain). Each bracket-wire combination
was tested five times, totalling 60 friction
samples.
All brackets and wires were cleaned
with ethanol before they were submitted
to mechanical tests with the Emic DL
10000 testing machine. A stainless steel
252
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WORLD JOURNAL OF ORTHODONTICS
Fig 2 Emic DL 10000 test
machine in (a) frontal and (b)
lateral view. The brackets were
glued to a metallic cylinder in a
standardized 0-degree angula-
tion pattern.
cylinder apparatus was designed to over-
come the –2 degree angulation of the
preadjustment. All brackets were glued to
the center of the cylinder with cyanoacry-
late adhesive (Super Bonder, Loctite).
The wire segments ran parallel with the
slot bases (Fig 2). Each bracket and arch-
wire was changed after each test.
The ligation of the wire to the Blonde
brackets was standardized by the use of
elastic ligatures (Unitek) that were imme-
diately positioned before each sliding.
The crosshead speed was 0.5 cm/min,
and each test was carried out for 40 sec-
onds. The machine’s 20 cN load cell reg-
istered the means and maximum forces
(in cN). The data were analyzed by Tesc
3.04 software. The statistical analysis
was performed by Stata 9.1 software
(Stata/SE) applying parametric analysis
of variance (one-way ANOVA) and a Bon-
ferroni adjustment (P < .01).
VOLUME 11, NUMBER 3, 2010 Fernandes et al

Table 1 Means and standard devia-

tions (SD) of the frictional forces in cN 120
generated by the three bracket systems
tested (P < .01) 100
Mean SD 80

cN
Blonde 105.8 6.4
Opal 49.5 10.1 60
Oyster 37.0 8.9
Total 64.1 31.3 40

20
Blonde Opal Oyster

Fig 3 Box plot for frictional forces of Blonde, Opal, and

Oyster brackets.

RESULTS increase of friction could be the rein-

The conventional glass-fiber–reinforced
polycarbonate Blonde bracket demon-
strated the significantly highest fric-
tional force value (P < .01), followed in
decreasing order by the Opal self-ligat-
ing ceramic-reinforced polycarbonate
and the Oyster self-ligating glass-
fiber–reinforced polycarbonate brackets
(Table 1). Figure 3 shows the distribu-
tion of the values. The ANOVA showed
significant differences among the three
groups (P < .01).
DISCUSSION
The result shows that due to the kind of
polycarbonate reinforcement, the Opal
bracket had a higher mean friction than
the Oyster system. One cause for the
forcement material. Ceramic particles
increase roughness, hardness, and stiff-
ness compared to a conventional poly-
crystalline matrix. This behavior negates
the acclaimed friction reduction of this
self-ligating bracket system.
Reicheneder et al also showed a dif-
ference in friction between Opal and
Oyster brackets. 7 According to their
study, however, Oyster brackets pro-
duced a higher friction than Opal ones.
This conclusion could be explained by a
different testing method.2
Some manufacturers have intro-
duced metallic-slot inserts in an effort
to reduce friction but still maintain the
cosmetic advantages of ceramic brack-
ets as in the In-Ovation esthetic system
(GAC) and the Damon III brackets
(Ormco). However, these brackets were
not tested in the present study due to

253

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 Fernandes et al
the metal cover because it makes these
brackets less esthetic. For the same rea-
son, stainless steel brackets were also
not evaluated because they have been
analyzed in previous studies with similar
methods.4,5,9,13–15
Each bracket-archwire combination
was submitted to frictional testing only
once, and five values were recorded dur-
ing each test. This protocol is in accor-
dance with other studies in which brack-
ets were also not repeatedly used due to
surface wear.8,11,12
Conventional wire ligation is a variable
that could have influenced the friction in
the Blonde group. The force applied by a
stainless steel ligature is subjective, vary-
ing according to each orthodontist.19 On
the other hand, elastomeric ligatures
lose elasticity with time, which again
alters the frictional force values.3 To stan-
dardize ligation forces and prevent any
force decay, the ligatures were replaced
before each friction test.
No study between Oyster and Blonde
brackets was previously performed with
the method used here.
The literature reports routinely that an
increase in angulation will increase fric-
tion. 2,6,8,9,13,17,18 To standardize the
bracket position and to prevent the influ-
ence of angulation on the results, all
brackets were attached to the test
machine in a 0-degree angulation posi-
tion. Despite all efforts to minimize the
method error, the correct position of the
wire in the self-ligating slot was arduous
to achieve because the bracket slot is not
visible when the mechanical cover is
closed. Subsequently, small amounts of
angulation could have occured and affect
the study outcome.
A previous study focused on the fric-
tion increase to an increase in archwire
cross-section. 3 Several studies further
stated that rectangular wires exhibit
higher friction than round ones. 9,17,18
Despite that, wires with a 0.019

0.025-inch cross-section were selected
because of this material's better fit in
0.022
0.028-inch slots.13,18
254
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WORLD JOURNAL OF ORTHODONTICS
The friction of self-ligating reinforced
polycarbonate brackets could be
decreased if the slot walls were covered
with stainless steel or gold insertions.
Still, this would not affect estethics.
CONCLUSION
Oyster glass-fiber–reinforced polycarbon-
ate self-ligating brackets generate lower
friction than Opal ceramic-polycarbonate
reinforced ones. In regard to ligation, self-
ligating brackets produce significantly
lower friction compared to Blonde conven-
tional polycarbonate brackets in combina-
tion with elastomeric ligatures. This study
found significant differences of friction
among the two self-ligating systems and
one conventional bracket type tested.
ACKNOWLEDGMENTS
The authors wish to thank State Research of Rio de
Janeiro Fund for financial support (process no.
E26/100.975/2010) and Ultradent for its donation
of test samples.
REFERENCES
1. Thorstenson GA, Kusy R. Influence of stainless
steel inserts on the resistance to sliding of
esthetics brackets with second-order angula-
tion in the dry and wet states. Angle Orthod
2003;73:167–175.
2. Sims APT, Waters NE, Birnie DJ, Pethybridge RJ.
A comparison of the forces required to produce
tooth movement in vitro using two self-ligating
brackets and a pre-adjusted bracket employing
two types of ligation. Eur J Orthod
1993;15:377–385.
3. Harradine NWT. Self-ligating brackets: Where
are we now? J Orthod 2003;30:262–273.
4. Kim T, Kim KD, Baek SH. Comparison of fric-
tional forces during the initial leveling stage in
various combinations of self-ligating brackets
and archwires with a custom-designed
typodont system. Am J Orthod Dentofacial
Orthop 2008;133:187.e15–e24.
5. Rinchuse DJ, Miles PG. Self-ligating brackets:
Present and future. Am J Orthod Dentofacial
Orthop 2007;132:216–222.
VOLUME 11, NUMBER 3, 2010
6. Thorstenson GA, Kusy RP. Effects of ligation
type and method on the resistance to sliding of
novel orthodontic brackets with second-order
angulation in the dry and wet states. Angle
Orthod 2003;73:418–430.
7. Reicheneder CA, Baumert U, Gedrange T, Proff
P, Faltermeier A, Muessig D. Frictional proper-
ties of aesthetic brackets. Eur J Orthod 2007;
29:359–365.
8. Cacciafesta V, Sfondrini MF, Ricciardi A, Scrib-
ante A, Klersy C, Auricchio F. Evaluation of fric-
tion of stainless steel and esthetic self-ligating
brackets in various bracket-archwire combina-
tions. Am J Orthod Dentofacial Orthop 2003;
124:395–402.
9. Redlich M, Mayer Y, Harari D, Lewinstein I. In
vitro study of frictional forces during sliding
mechanics of “reduced-friction brackets.” Am J
Orthod Dentofacial Orthop 2003;124:69–73.
10. Mendes K, Rossouw PE. Friction: Validation of
manufacturer’s claim. Semin Orthod
2003;9:236–250.
11. Sadat-Khonsari R, Moshtaghy A, Schlegel V,
Kahl-Nieke B, Möller M, Bauss O. Torque
deformation characteristics of plastic brackets:
A comparative study. J Orofac Orthop 2004;
65:26–33.
12. Zinelis S, Eliades T, Eliades G, Makou M, Silikas
N. Comparative assessment of the roughness,
hardness, and wear resistance of aesthetic
bracket materials. Dent Mater 2005;21:
890–894.
© 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Fernandes et al
13. Khambay B, Millett D, McHugh S. Evaluation of
methods of archwire ligation on friction resis-
tance. Eur J Orthod 2004;26:327–332.
14. Thorstenson GA, Kusy RP. Effect of archwire
size and material on the resistance to sliding of
self-ligating brackets with second-order angula-
tion in the dry state. Am J Orthod Dentofacial
Orthop 2002;122:295–305.
15. Henao SP, Kusy RP. Frictional evaluations of
dental typodont models using four self-ligating
designs and a conventional design. Angle
Orthod 2005;75:75–85.
16. Henao SP, Kusy RP. Evaluation of the frictional
resistance of conventional and self-ligating
bracket designs using standardized archwires
and dental typodonts. Angle Orthod 2004;
74:202–211.
17. Pandis N, Eliades T, Partowi S, Bourauel C.
Forces exerted by conventional and self-ligating
brackets during simulated first- and second-
order corrections. Am J Orthod Dentofacial
Orthop 2008;133:738–742.
18. Pandis N, Bourauel C, Eliades T. Changes in the
stiffness of the ligating mechanism in retrieved
active self-ligating brackets. Am J Orthod
Dentofacial Orthop 2007;132:834–837.
19. Bednar JR, Gruendeman GW, Sandrik JL. A
comparative study of frictional forces between
orthodontic brackets and archwires. Am J
Orthod Dentofacial Orthop
1991;100:513–522.
255
PERIODONTAL STATUS AND Suwannee Luppanaporn-
larp, BSc, DDS, MSc,
PhD1
ORTHODONTIC TREATMENT NEED
Pattarawadee
OF AUTISTIC CHILDREN Leelataweewud, DDS,
MS2
Aim: To evaluate the periodontal status and orthodontic treatment need
Pongstorn Putongkam,
of autistic children and compare these findings to nonaffected, same-
DDS, MSc3
age individuals. Method: The periodontal status and orthodontic treat-
ment need were evaluated in 32 autistic and 48 nonautistic boys and
Sutasinee Ketanont, DDS4
girls age 8 years to 12 years (mean 9.7 ± 1.2 years and 9.9 ± 1.1 years,
respectively). The periodontal status of all subjects was recorded using
the Community Periodontal Index of Treatment Need (CPITN) with a
slight modification. The orthodontic treatment need was determined
using the Dental Aesthetic Index (DAI). Chi-square test and odds ratio
were used for statistical analysis. Results: No significant sex differ-
ences were found in the autistic or nonautistic groups. The autistic
children presented with a significantly poorer periodontal status than
the nonautistic children (P < .05). No significant differences in terms of
the various malocclusion categories were found between both groups
(P > .05); however, children with autism showed missing teeth, spac-
ing, diastemas, reverse overjets, open bites, and Class II molar relation-
ship tendencies in a higher percentage than nonautistic individuals. In
all, autistic children and nonautistic children frequently needed ortho-
dontic treatment. Conclusion: This study suggests that children with
autism require special dental management to improve their oral
hygiene as well as their dental esthetics. More care from parents, gen-
eral dentists, and pedodontists/orthodontists should be provided rou-
tinely to autistic children. World J Orthod 2010;11:256–261.

Key words: autism, treatment need, periodontal condition, Dental 1Assistant Professor, Department of
Aesthetic Index, Community Periodontal Index of Treatment Need Orthodontics, Mahidol University,
Faculty of Dentistry, Bangkok,
Thailand.
2Assistant Professor, Department of
utism is one form of the autistic spec- the Queen Sirikit National Institute of
A trum disorders (ASDs) characterized
by a complex, behaviorally defined, static
Child Health.1
Several studies have shown that
Pediatric Dentistry, Mahidol Univer-
sity, Faculty of Dentistry, Bangkok,
Thailand.
3Instructor, Department of Orthodon-
immature brain disorder that is of great autistic children may demonstrate not
tics, Mahidol University, Faculty of
concern to various professions. The symp- only significant disturbances in language Dentistry, Bangkok, Thailand.
toms of autism, which can be detected and reciprocal social interactions, but 4Instructor, Department of Pediatric

early in life, vary from mild to severe. Sev-
eral studies have repor ted a large
increase in the rate of diagnosed ASDs
worldwide. The prevalence of autism has
grown significantly every year and is
much higher than previously estimated.1–3
In Thailand, the incidence among outpa-
tients younger than 12 years of age has
increased from 1.43/10,000 in 1998 to
6.94/10,000 in 2002, as reported by
also anomalous symptoms such as self-
injurious behavior (SIB), aggression, odd
responses to sensory stimuli, unusual
food likes or dislikes, abnormalities of
affect and mood (spontaneous giggling
and weeping), and excessive fear. Autis-
tic children with SIB may cause injuries
to their head, neck, or mouth. They also
may bite their fingernails, oral tissues, or
foreign objects, as well as pinch their
Dentistry, Mahidol University, Fac-
ulty of Dentistry, Bangkok, Thailand.
CORRESPONDENCE
Dr Suwannee Luppanapornlarp
Department of Orthodontics
Faculty of Dentistry
Mahidol University
6 Yothi Street
Prayatai, Bangkok, 10400
Thailand
Email: dtslp@mahidol.ac.th

256

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VOLUME 11, NUMBER 3, 2010
oral structures. Finally, they may be inca-
pable of cooperating during dental treat-
ment, because autistic children typically
do not tolerate exposure to foreign
sounds, lights, odors, and colors. In all,
this makes it difficult to achieve good
oral health.4,5
Poor oral hygiene has been reported in
autistic children, and they also have
shown a higher rate of periodontal dis-
eases and dental caries than nonaffected
children. 6–9 In contrast, some studies
found that autistic and nonautistic chil-
dren present with similar dental prob-
lems. 10,11 A recent study on the oral
health status of individuals with special
health care needs also reported a high
prevalence of caries, although oral
hygiene was better than in previous inves-
tigations.12 Finally, a study on oral health
in 124 Thai autistic children aged
between 3 and 5 years who attended the
early stimulation unit at Queen Sirikit
National Institute of Child Health showed
that more than half presented with poor
oral hygiene and dental caries. Caries
may lead to early loss of teeth and subse-
quently to malocclusions.7
The Community Periodontal Index of
Treatment Need (CPITN) was developed to
assess the condition of an individual’s
periodontium and is recommended by the
World Health Organization (WHO). This
index was finalized and described in detail
by Ainamo et al in 1982.12 It appears to
satisfy the needs of epidemiology, health
services, and dental practices because it
is a realistic approach to routine screening
for periodontal disease indicators.13,14
The Dental Aesthetic Index (DAI) is one
method to assess the severity of maloc-
clusions; it has been accepted by the
WHO to be reliable and valid.15 This index
is numerical, and the respective values
are obtained by measuring specific
occlusal traits selected on the basis of
their potential for causing a psychosocial
handicap. It is generally agreed that the
DAI is quick, relatively simple to use, and
universally acceptable.15–18
Overall, the objectives of this study
were to evaluate the periodontal and mal-
occlusion status of autistic children at a
significant age interval using the CPITN
and the DAI and to compare the data
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NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Luppanapornlarp et al
obtained to nonautistic children. The
hypothesis of this study was that there is
no significant difference between both
groups in all variables.
SUBJECTS AND METHODS
Approval to conduct this study was
obtained, and the parents of all potential
participants signed a consent form.
Approximately 200 children with diag-
nosed autism from various areas in
Bangkok were screened for this study.
The selection criteria for the sample of
this investigation were: age between
8 and 12 years and no orthodontic treat-
ment before or during the examination.
Exclusion criteria were inability to cooper-
ate in the oral examination. Thirty-two
autistic children (25 boys and 7 girls)
with a mean age of 9.7 ± 1.2 years met
the inclusion criteria.
The control group consisted of average
children of the pediatric clinic, Faculty of
Dentistry, Mahidol University, Bangkok,
Thailand. The final group consisted of
48 children (19 boys and 29 girls) with a
mean age of 9.9 ± 1.1 years.
The periodontal status was recorded
using the CPITN.12,13 Because the oral
examinations were especially difficult in
the autistic children, the CPITN was modi-
fied. Thus, pocket depths and dental
caries were not recorded. According to the
CPITN, the dentition was divided into six
sections (left/right maxillary/mandibular
posterior teeth, maxillary/mandibular
anterior teeth). Each section was exam-
ined only if two or more teeth were pre-
sent and not scheduled for extraction.
Score 1 of the CPITN indicates a
healthy periodontium, score 2 indicates
calculus and other plaque-retentive fac-
tors, and score 3 indicates bleeding of
the gingiva on gentle probing. A treat-
ment need (TN) code 0 indicates no need
for periodontal treatment, TN code 1 indi-
cates a need for only oral hygiene instruc-
tions, TN code 2 indicates a need for oral
hygiene instructions and cleaning, and
TN code 3 indicates the need for profes-
sional cleaning including root planing.
For the DAI, 10 occlusal components
were multiplied by the appropriate
257
 Luppanapornlarp et al WORLD JOURNAL OF ORTHODONTICS

Table 1 The ten components of the Dental Aesthetic Index (DAI), ratings, and rounded weights
Component Rating Rounded weight

1. Missing teeth Number of missing incisors, canines, and premolars 6

2. Crowding in the incisal segments 0 = No segment crowded 1
1 = 1 segment crowded
2 = 2 segments crowded
3. Spacing in the incisal segments 0 = No spacing 1
1 = 1 segment spaced
2 = 2 segments spaced
4. Midline diastema In millimeters 3
5. Anterior maxillary irregularity Largest anterior irregularity in the maxilla (mm) 1
6. Anterior mandibular irregularity Largest anterior irregularity in the mandible (mm) 1
7. Anterior maxillary overjet In millimeters 2
8. Anterior mandibular overjet In millimeters 4
9. Vertical anterior open bite In millimeters 4
10. Anteroposterior molar relation Largest deviation from normal either left or right side 3
0 = Normal
1 = 1⁄2 cusp mesial or distal
2 = Full cusp or more mesial or distal
Constant 13

DAI score = Sum of all ratings ⫻ rounded weights + constant.

weights, summed, and added to the
constant value to calculate the standard
DAI score (Table 1). In this study, the first
component of the DAI score was adjusted
when the individual was still in the mixed
dentition stage. The space from a
recently exfoliated deciduous tooth was
not scored as a missing tooth, as the per-
manent tooth would have replaced it
within a short time.17,18 The adjusted DAI
scores were divided into four treatment-
need categories:
1. < 26: little or no treatment need
2. 26 to 30: treatment elective
3. 31 to 35: treatment highly desirable
4. > 35: treatment mandatory18
Statistical analysis
To evaluate the reliability of the method,
30 randomly selected children with or
without autism were reexamined by the
same investigator on the same day.
Spearman rank correlation coefficients
were used to ascertain intraexaminer reli-
ability. The chi-square test was used to
evaluate sex and group differences. Also,
means and standard deviations of the
DAI scores for boys and girls of both
groups were calculated and analyzed.
Because of the small number in each
category, individuals were not separated
according to sex. Odds ratio was used to
determine the differences between the
two groups. Statistical significance was
accepted at P < .05.
RESULTS
The computed intrarater correlation coef-
ficient for repeated measurements was
0.98 (P < .001), indicating a high reliabil-
ity of the measurements. The periodontal
status of the total sample is found in
Table 2 and the respective treatment
need in Table 3. According to this,
approximately three-fourths of the autis-
tic children presented with gingival bleed-
ing and needed professional cleaning
(78.1% and 71.9%, respectively), while in
the control group, the respective values
were 14.5% and 18.8%. Only three autis-
tic children had healthy oral tissues as
compared to 14 in the control group.
The chi-square test demonstrated a
significant difference in periodontal sta-
tus between the autistic and nonautistic
children (P < .05).
Table 4 shows the distribution of the
10 DAI component scores for both groups.
In the autistic children, malocclusion
symptoms such as missing teeth, spacing,
diastemas, reverse overjets, open bites,

258

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VOLUME 11, NUMBER 3, 2010 Luppanapornlarp et al

Table 2 Distribution of the periodontal status of the autistic and control children according to the modified Community
Periodontal Index of Treatment Need (CPITN) scores
Autistic children Control children
Boys Girls Total Boys Girls Total
Periodontal status % n % n % n % n % n % n

Healthy 8.0 2 14.3 1 9.4 3 15.8 3 37.9 11 29.2 14

Calculus 16.0 4 0.0 0 12.5 4 57.9 11 55.2 16 56.3 27
Bleeding 76.0 19 85.7 6 78.1 25 26.3 5 6.9 2 14.5 7
Total 100.0 25 100.0 7 100.0 32 100.0 19 100.0 29 100.0 48

Sex difference in the autistic children: ␹2 = 1.417, df = 2, P = .492.

Sex difference in the control children: ␹2 = 4.913, df = 2, P = .086.
Difference between the autistic and the control children: ␹2 = 32.403, df = 2, P = .000.

Table 3 Periodontal treatment needs of the autistic and control children according to the modified Community
Periodontal Index of Treatment Need (CPITN) scores
Autistic children Control children
Boys Girls Total Boys Girls Total
Treatment need % n % n % n % n % n % n

No treatment 8.0 2 14.3 1 9.4 3 15.8 3 37.9 11 29.2 14

Oral hygiene instructions 0.0 0 0.0 0 0.0 0 15.8 3 17.2 5 16.7 8
Oral hygiene instructions 24.0 6 0.0 0 18.8 6 47.4 9 27.6 8 35.4 17
and professional cleaning
Professional cleaning and 68.0 17 85.7 6 71.9 23 21.1 4 17.2 5 18.8 9
root planing
Total 100.0 25 100.0 7 100.0 32 100.0 19 100.0 29 100.0 48

Sex difference in the autistic children: ␹2 = 2.149, df = 2, P = .341.

Sex difference in the control children: ␹2 = 3.301, df = 3, P = .347.
Difference between the autistic and the control children: ␹2 = 24.274, df = 3, P = .000.

and Class II molar relationship tenden-
cies were found at a higher percentage
than in the control group. The DAI scores
and the four treatment-need categories
for the autistic and the control children
are given in Table 5. The odds ratio of
0.69 (0.27 to 1.77) with a 95% confi-
dence interval denotes no significant dif-
ferences between the two groups.
DISCUSSION
This study evaluated the periodontal and
occlusal condition of autistic children age
8 to 12 years and compared it to nonaf-
fected children of the same age. This age
group was chosen because it is generally
the proper time for interceptive orthodon-
tic treatment. Additionally, comprehensive
corrective treatment for these autistic
patients might not be possible before
their condition is addressed by a medical
and behavior-management team.
The CPITN was reported to have the
major advantages of being simple,
speedy, and internationally accepted.12,13
Because of the autistic children’s behav-
ior, in the present study, the pocket-depth
measurements had to be omitted, and
thus the index categories were reduced
to only three scores. Independent of this,
the results show that the oral hygiene
status of the autistic children was signifi-
cantly poorer than that of the nonautistic
children.6,19 Lack of understanding any
oral hygiene instructions requires parents
and dental professionals to find practical
solutions to manage this special group of
individuals.
The WHO-recommended DAI was cho-
sen for this study because it has proven
to be useful for epidemiological surveys to
assess unmet orthodontic treatment
needs. Most importantly, it has been
reported to be a simple screening tool to
separate between handicapping and non-
handicapping malocclusions.15–18 In this

259

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 Luppanapornlarp et al WORLD JOURNAL OF ORTHODONTICS

Table 4 Distributions (%) of the 10 DAI component scores between the autistic and
the control children
DAI component Autistic children Control children

Missing teeth (≥ 1) 6.3 0.0

Crowding (1 to 2 incisal segments) 59.4 83.3
Spacing (1 to 2 incisal segments) 43.8 33.3
Midline diastema (≥ 1 mm) 31.3 20.8
Anterior maxillary irregularity (≥ 1 mm) 40.6 62.5
Anterior mandibular irregularity (≥ 1 mm) 31.3 60.4
Anterior maxillary overjet (≥ 3 mm) 56.3 70.8
Anterior mandibular overjet (≥ 0 mm) 18.8 2.1
Open bite (≥ 0 mm) 6.3 0.0
Molar relationship (≥ 1⁄2 cusp) 62.5 52.1

Table 5 Distribution (%) of the DAI scores in the autistic and the control children
DAI Autistic children Control children
score Severity levels and treatment need % n % n

≤ 25 Normal or minor malocclusion,

no treatment need or slight need 37.5 12 29.0 14
26–30 Definite malocclusion,
treatment needed 25.0 8 29.0 14
31–35 Severe malocclusion,
treatment highly desirable 22.0 7 27.0 13
≥ 36 Very severe (handicapping) malocclusion,
treatment mandatory 15.5 5 15.0 7

Because of the small number in each severity level, the numbers of all malocclusion levels (from ≤ 25 to ≥ 36)
were summed in the autistic and control groups.
Odds ratio = 0.686 (P > .05); lower = 0.266, upper = 1.772.

study, it was found that the malocclusions
and the orthodontic treatment needs of
autistic children are similar to those of
nonautistic children. Also, there were no
significant DAI component differences
between the two sexes. The approxi-
mately 60% DAI scores from ≤ 25 to ≥ 36
were comparable to the data presented
by Onyeaso, 19 whose sample was also
made up of handicapped children.
Fahlvik-Planefeldt and Herrstrom9 com-
pared the oral health in autistic and aver-
age children and showed a greater
orthodontic treatment need among the
autistic children. One reason for this con-
clusion could be that these authors did
not use the DAI to determine existing mal-
occlusions.
The fact that missing teeth, spacing,
reverse overjets, open bites, and Class II
molar relationship tendencies were found
in a higher percentage in the autistic
than the control children is in agreement
with Onyeaso. 19 Some of these symp-
toms may be related to these patients’
deviant behaviors, such as finger suck-
ing, biting fingernails/foreign objects, or
self-extraction of teeth. 4 The higher,
though not significantly different, per-
centage of missing teeth is in agreement
with the findings of Namal et al.17 This
could be a consequence of tooth extrac-
tion being preferred to tooth restoration
in autistic children as compared to
nonautistic individuals.
Poorer oral hygiene and increased peri-
odontal disease in handicapped children
was demonstrated in two earlier stud-
ies.8,20 Fahlvik-Planefeldt and Herrstrom9
stated that these children (including
those with autistic disorders) may need
more dental care and frequently more
orthodontic treatment. Finally, Loo et al18
found that a high percentage of autistic
patients are uncooperative and require
special dental management.

260

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VOLUME 11, NUMBER 3, 2010
CONCLUSIONS
1. A modified CPITN did not reveal any sig-
nificant differences between sexes or
between autistic and nonautistic chil-
dren. However, the autistic children had
significantly poorer oral hygiene and
significantly more periodontal problems
than the nonautistic children.
2. The DAI was similar in the autistic and
the nonautistic children. However, the
percentages of missing teeth, spacing,
reverse overjet, open bites, and Class
II molar relationship tendencies were
higher in children with autism.
3. More than half of both groups had a
dental appearance that indicated
orthodontic treatment need.
4. It is suggested that children with
autism receive special care so their oral
hygiene as well as their dental esthet-
ics are improved. Intensive care for
autistic children by parents, general
dentists, pedodontists, and orthodon-
tists should be consistently considered.
ACKNOWLEDGMENTS
The authors would like to thank Assistant Professor
Chanvit Pornnoppadol, the Child Psychiatric Sec-
tion of Siriraj Hospital, for his kind support. Special
thanks go to Clinical Professor Paisal Chaiwat,
fourth-year dental students (N. Udomchaisakul, R.
Kallayanapark, S. Saengmanee, and H. Netiwara-
non), the Thai Autistic Vocational Center, the Autis-
tic Inclusive Education and Demonstration schools,
and the Research Unit, Faculty of Dentistry, Mahi-
dol University, for their assistance in this project.
REFERENCES
1. Plubrukarn R, Piyasil V, Moungnoi P, Tanprasert
S, Chutchawalitsakul V. Trend study of autistic
spectrum disorders at Queen Sirikit National
Institute of Child Health. J Med Assoc Thai
2005;88:891–897.
2. Rutter M. Incidence of autism spectrum disor-
ders: Changes over time and their meaning.
Acta Paediatr 2005;94:2–15.
3. McCarthy M, Hendren RL. Autism spectrum dis-
orders have increased dramatically in preva-
lence in recent years. Preface. Psychiatr Clin
North Am 2009;32:13–15.
© 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Luppanapornlarp et al
4. Sæmundsson SR, Roberts M. Oral self-injuri-
ous behavior in the developmentally disabled:
Review and a case. ASDC J Dent Child 1997;
64:205–209.
5. Medina AC, Sogbe R, Gomez-Rey AM, Mata M.
Factitial oral lesions in an autistic paediatric
patient. Int J Paediatr Dent 2003;13:130–137.
6. Lowe O, Lindemann R. Assessment of the
autistic patient’s dental needs and ability to
undergo dental examination. ASDC J Dent Child
1985;52:29–35.
7. Tharapiwattananon T. Autistic child and dental
management. CU Dent J 1994;17:1–10.
8. Shapira J, Mann J, Tamari I, et al. Oral health
status and dental needs of an autistic popula-
tion of children and young adults. Spec Care
Dentist 1989;9:38–41.
9. Fahlvik-Planefeldt C, Herrstrom P. Dental care of
autistic children within the non-specialized Public
Dental Service. Swed Dent J 2001;25:113–118.
10. Kopycka-Kedzierawski DT, Auinger P. Dental
needs and status of autistic children: Results
from the National Survey of Children’s Health.
Pediatr Dent 2008;30:54–58.
11. Oredugba FA, Akindayomi Y. Oral health status
and treatment needs of children and young
adults attending a day centre for individuals
with special health care needs. BMC Oral
Health 2008;8:30.
12. Ainamo J, Barmes D, Beagrie G, Cutress T, Mar-
tin J, Sardo-Infirri J. Development of the World
Health Organization (WHO) community peri-
odontal index of treatment needs (CPITN). Int
Dent J 1982;32:281–291.
13. Cutress TW, Ainamo J, Sardo-Infirri J. The com-
munity periodontal index of treatment needs
(CPITN) procedure for population groups and
individuals. Int Dent J 1987;37:222–233.
14. World Health Organization. Oral Health Sur-
veys: Basic Methods, ed 4. Geneva: WHO,
1997:47–52.
15. Cons NC, Jenny J, Kohout FJ. DAI: The Dental
Aesthetic Index. Iowa City: University of Iowa
College of Dentistry, 1986.
16. Jenny J, Cons NC. Comparing and contrasting
two orthodontic indices, the Index of Orthodon-
tic Treatment Need and the Dental Aesthetic
Index. Am J Orthod Dentofacial Orthop 1996;
110:410–416.
17. Namal N, Vehit HE, Koksal S. Do autistic chil-
dren have higher levels of caries? A cross-sec-
tional study in Turkish children. J Indian Soc
Pedod Prev Dent 2007;25:97–102.
18. Loo CY, Graham RM, Hughes CV. The caries
experience and behavior of dental patients
with autism spectrum disorder. J Am Dent
Assoc 2008;139:1518–1524.
19. Onyeaso CO. Orthodontic treatment need of
mentally handicapped children in Ibadan, Nige-
ria, according to the Dental Aesthetic Index.
J Dent Child 2003;70:159–163.
20. Jenny J, Cons NC, Kohout FJ, Jakobsen J. Pre-
dicting handicapping malocclusion using the
Dental Aesthetic Index (DAI). Int Dent J 1993;
43:128–132.
261
 EDITORIAL
Welcome . . .
to a special issue of the World Journal of Orthodontics. This issue is
special in more ways than one. First is its focus on a fast-developing
aspect of orthodontics—mini-implants. These little adjuncts have
changed orthodontics so fundamentally that indeed the term “para-
digm shift” seems indicated. We live in a world of harsh competition,
and so every slight modification of an orthodontic adjunct is consid-
ered an absolute novelty, or better a revolution, or at best a paradigm
shift. If we were reasonable, we would refer to new features and
modifications simply as improvements that make our daily practice
better and easier. At least the majority of new innovations could be
categorized as such, as some of the advances indeed turned out to
be quite risky. Or have you already forgotten about the first ceramic
brackets? In terms of related risks, mini-implants have performed ex-
ceptionally well with few adverse effects to date. In short: I feel they
are a paradigm shift and they deserve to be the core of this issue.
It is further a special issue, most notably for me, because it will be
the last one for which I will serve as editor-in-chief. With the termina-
tion of the contract between the World Federation of Orthodontists
and Quintessence Publishing Company at the end of 2010, so ends
my work for the World Journal of Orthodontics. I would like to take
this opportunity to thank the WFO for entrusting me with this chal-
lenging job. I hope I met its expectations at least partially. I also
thank my assistant editor, Prof Moschos Papadopoulos, who sup-
ported me so generously and effectively. I thank all the authors who
contributed to the diversified character that WJO always offered.
I thank all the reviewers who responded to my requests for their ad-
vice and who with their evaluations promoted the advancement of
our specialty so unselfishly. I also thank the Quintessence editorial
staff for their expert assistance in publishing issues. And finally
I thank the WJO readers who trusted me to do my best to make their
reading of this journal well-invested time. In every sense, this editor-
ship represents a very interesting period of my life. I know we will
meet again, but now it is time to once more say thank you

. . . and farewell.

Rainer-Reggie Miethke
Editor-in-Chief

319

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Benedict Wilmes, DDS,
DMD, PhD1
Manuel Nienkemper, DDS2
Dieter Drescher, DDS,
DMD, PhD3
1Associate
Professor, Department of
Orthodontics, University of Duessel-
dorf, Duesseldorf, Germany.
2Postgraduate Student, Department
of Orthodontics, University of Dues-
seldorf, Duesseldorf, Germany.
3Professor and Head, Department of
Orthodontics, University of Duessel-
dorf, Duesseldorf, Germany.
CORRESPONDENCE
Dr Benedict Wilmes
Department of Orthodontics
University of Duesseldorf
Moorenstr 5
40225 Duesseldorf
Germany
Email:
wilmes@med.uni-duesseldorf.de
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APPLICATION AND EFFECTIVENESS OF
A MINI-IMPLANT– AND TOOTH-BORNE
RAPID PALATAL EXPANSION DEVICE:
THE HYBRID HYRAX
Aim: Rapid palatal expansion (RPE) is used for treatment of skeletal
crossbites. It may be combined with a face mask if the maxilla is to be
protracted. Conventional tooth-borne appliances rely on an almost com-
plete dentition to transmit the relatively high forces to the bony struc-
tures of the maxilla and midface. In most situations, tooth-borne
appliances produce adverse effects such as buccal tipping of the lateral
teeth, imposing the risk of recessions and vestibular bone fenestrations.
To overcome these drawbacks, an RPE appliance was developed that uti-
lizes mini-implants anteriorly in the palate for skeletal anchorage.
Because this device is also attached to the first molars, it can be denomi-
nated as a bone- and tooth-borne appliance (hybrid hyrax). The objective
of this clinical pilot study was to investigate its dental and skeletal
effects. Methods: RPE was performed in 13 patients (seven females, six
males; mean age 11.2 years). In 10 patients with a skeletal Class III occlu-
sion, a face mask was used simultaneously for maxillary protraction.
Three-dimensional scans of the individual study models were digitally
superimposed for the assessment of the dental effects. Skeletal effects
were evaluated by lateral cephalograms taken before and after RPE and
protraction. Results: The time needed to achieve the intended expansion
ranged from 4 to 14 days (mean 8.7 ± 3.6 days). The mean expansion in
the first premolar/first primary molar region was 6.3 ± 2.9 mm and 5.0 ±
1.5 mm in the first molar region. The Wits appraisal changed from –5.2 ±
1.3 mm to –2.5 ± 1.5 mm (mean improvement 2.7 ± 1.3 mm). The right
first molar migrated 0.4 ± 0.6 mm mesially and the left one 0.3 ± 0.2 mm.
Conclusions: The hybrid hyrax is effective for RPE and can be employed
especially in patients with reduced anterior dental anchorage. Since most
teeth are not in the appliance, regular orthodontic treatment can start
early. The combination of the hybrid hyrax with a face mask for maxillary
protraction appears to be effective in minimizing mesial migration of the
dentition. World J Orthod 2010;11:323–330.
Key words: rapid palatal expansion, Class II treatment, mini-implant, maxillary
protraction
apid palatal expansion (RPE) is con- was produced in 1908 by Landsberg.
R sidered the optimum orthodontic
procedure to widen the maxilla skele-
Nevertheless, it was not until the middle
of the 20th century that RPE was broadly
tally. Angell1 first described this method established and reintroduced in the
in 1860; it received comprehensive dis- United States.2 Today, RPE is considered
approval at that time due to the lack of a midpalatal suture distraction osteo-
radiologic confirmation. This verification genesis. For the treatment of patients
323
 Wilmes et al
h posteriorly, in the present approach, the
g
f the middle of the palate. 12 Since this
e appliance is both tooth- and bone-borne,
d
c
a
b
Fig 1 The various components of the
Benefit system. (a) Mini-implant; (b) labo-
ratory analog; (c) impression cap; (d) wire
abutment; (e) bracket abutment; (f) stan-
dard abutment; (g) slot abutment; (h)
screwdriver for fixation of the abutments.
with a Class III occlusion caused by a ret-
rognathic maxilla, RPE is combined with
a face mask for protraction.
Since the orthopedic forces are trans-
mitted to the skeletal structures via
anchor teeth, distribution of the forces to
as many teeth as possible, as well as
completion of their root development, is
considered essential. In spite of these
considerations, adverse effects such as
buccal tipping, gingival recessions, fenes-
trations of the buccal cortex, and root
resorptions of the posterior teeth were
repeatedly reported. 3,4 To avoid such
complications, orthodontists have advo-
cated pure bone-borne RPE devices.5,6
However, the insertion and removal of
such distractors are invasive since they
need flap preparation. Further, they
increase the risk of root lesions and
infections.5,7 As a consequence, distrac-
tors of this type could not establish them-
selves as standard devices for RPE.
To minimize the surgical procedure,
Harzer et al introduced the Dresden Dis-
tractor, which is attached solely to an
implant and a mini-implant. 8–10 Mini-
implants attracted great attention in
recent years because they are versatile,
minimally invasive, and low cost.11 Due
to the risk of root lesions during the
324
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WORLD JOURNAL OF ORTHODONTICS
insertion of mini-implants in the lateral
posterior alveolar process and lack of
available bone in the middle of the palate
first molars were chosen as the posterior
anchorage unit. Anteriorly, there is suffi-
cient bone available for mini-implants in
it can be designated a hybrid hyrax.11,13
The aim of this study was to assess
the clinical applicability and 3D effects of
RPE using the hybrid hyrax. The skeletal
effects of the combination hybrid hyrax
and face mask for maxillary protraction
were also evaluated.
METHOD AND MATERIALS
RPE with the hybrid hyrax was performed
in 13 patients (seven females, six males;
mean age 11.2 years). Ten of these 13
patients were simultaneously treated with
a face mask for protraction of the maxilla.
Clinical application and construction
of the hybrid hyrax appliance
After local anesthesia, soft tissue thick-
ness was measured using a dental probe
so a region with thin mucosa coverage
could be identified. This is important to
achieve sufficient primary stability and
avoid long lever arms. 14–19 In young
patients, predrilling is not needed due to
the low bone mineralization. After insertion
of two Benefit mini-implants (2
9 mm;
Figs 1a and 2), bands were fitted to the
maxillary first molars at this first appoint-
ment. After application of transfer caps
(Fig 1c), a silicone impression (Provil) was
taken. In situations in which the distance
between the mini-implants was too small,
the transfer caps were trimmed to fit side
by side. The angle between the two trans-
fer caps was secured by connecting them
intraorally with Transbond LR (3M). The
impressions were completed by inserting
laboratory analogues (Fig 1b) into the
transfer caps, as well as by inserting the
molar bands. The resulting laboratory
model reflected the intraoral situation
(Fig 3).
VOLUME 11, NUMBER 4, 2010
Fig 2 Two mini-implants (2
9 mm, Ben-
efit system, PSM Mondeal) after insertion
in the anterior palate next to the midpalatal
suture and near the second and third
palatal rugae.
Fig 4 Hybrid hyrax appliance on the cast.
Subsequently, two standard abut-
ments (Fig 1f) of the Benefit system were
screwed onto the laboratory analogues
and a regular split palate screw (Hyrax,
Dentaurum) was connected by laser weld-
ing to the two abutments and the molar
bands (Fig 4). Parallelism of the two mini-
implants is advisable, but not a prerequi-
site: Even if they are not absolutely
parallel, the appliance can be fitted onto
the mini-implant. The complete appliance
was inserted 7 to 10 days after placing
the mini-implant. During the insertion,
screwing of the two abutments on the
mini-implant alternated with the final
adjustment of the molar bands (Fig 5).
During this time, the hybrid hyrax should
be gently pressed against the mini-
implant to facilitate fixation. To allow ade-
quate time to install the hybrid hyrax,
light-curing acr ylic resin (Band-Lok,
Reliance Orthodontic Products) should be
used for molar band cementation.
If a simultaneous protraction of the
maxilla was intended, segmental arch-
wires were inserted into the molar tubes
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Wilmes et al
Fig 3 Cast with the two laboratory
analogs (see Fig 1b) and the two molar
bands.
Fig 5 The hybrid hyrax in situ.
(Figs 5 and 6). The sagittal split screw
was activated twice a day by a 90–degree
turn immediately after insertion of the
hybrid hyrax (Fig 7). This resulted in a
daily activation of 0.8 mm. RPE was con-
tinued until a 30% overcorrection was
achieved (Fig 8). After this, the hybrid
hyrax remained in situ for a 3-month
retention phase, during which the maxil-
lary incisors migrated mesially sponta-
neously (Figs 9 and 10).
In 10 of 13 patients, a face mask was
prescribed for approximately 6 months to
simultaneously protract the maxilla. The
applied elastics (5 oz, 1⁄4 inch; RMO Ortho-
dontics) were anterocaudally angulated
(Fig 6).
In one of 13 patients, the maximum
expansion of the sagittal split screw was
attained before sufficient expansion of the
maxilla was achieved. Thus, the hybrid hyrax
was removed, a second impression taken,
and a new appliance fabricated. To prevent
relapse, the first hybrid hyrax was reinserted
until the second one could be used.
325
 Wilmes et al WORLD JOURNAL OF ORTHODONTICS

b
Fig 6a Patient with a face mask for
(simultaneous) protraction of the maxilla.

Fig 6b Semischematic illustration of a

hybrid hyrax with simultaneous protraction
of the maxilla by a face mask. The applied
force is transferred to the maxilla via the
a
molars an anterior mini-implants.

Fig 7 (left) Activation of the

sagittal split screw.

Fig 8 (right) Situation at the

completion of RPE.

Fig 9 Same patient as in Fig 8 after 3

months of retention with the hybrid hyrax
still in situ. The maxillary incisors have Fig 10 Same patient as in Figs 8 and 9. Panoramic radiograph at the end of
spontaneously migrated mesially. the retention phase with the hybrid hyrax in situ.

Evaluation of the dental RPE effects
Pre- and post-RPE models (6 to 9 months after RPE) were
scanned with cone beam computed tomography. Transver-
sal expansion and tooth tipping (first premolar/first primary
molar and first molar) were measured using DigiModel soft-
ware (Orthoproof). The overall transversal effect was quanti-
fied by gauging the distance of four corresponding points
before and after expansion (Fig 11). Tooth tipping was eval-
uated by calculating the difference of the buccal surface
angle of the first premolar/first primary molar and first
molar before and after RPE (Fig 12). To assess the symme-
try of the expansion, as well as the molar mesial migration,
the 3D scans were digitally superimposed using the three-
point method of the DigiModel software (Figs 13 and 14).

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VOLUME 11, NUMBER 4, 2010 Wilmes et al

a b
Fig 11 Three-dimensional scans employing cone beam computed tomography (a) before and (b) after expansion.

Fig 12 Cut of the 3D scan before expansion. The angle of the Fig 13 Digital superimposition of two 3D scans using the
buccal surface of the first premolar is measured to a vertical to three-point method of the DigiModel software.
the occlusal plane.

Fig 14 (right) Assessment of the expansion symmetry and

sagittal molar migrations using the superimposed 3D scans.

327

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 Wilmes et al WORLD JOURNAL OF ORTHODONTICS

Fig 15 (a) Pre- and (b) post-

treatment overjet and (c) pre-
and (d) posttreatment profile of
one of the 10 patients who
wore a face mask.

a b

c d

Evaluation of the skeletal The mean expansion in the first premo-

protraction effects
Pre- and posttreatment lateral cephalo-
grams of the 10 patients wearing face
masks were scanned, and the Wits values
were calculated and compared.
RESULTS
All 26 mini-implants were primarily stable
with an adequate maximum insertion
torque (5 to 15 Ncm), and they were still
stable at the time of the hybrid hyrax
insertion and at its removal. The time
needed to achieve the planned expansion
ranged from 4 to 14 days (mean 8.7 ± 3.6
days).
lar/first primary molar region was 6.3 ±
2.9 mm and 5.0 ± 1.5 mm in the first
molar region. The mean difference
between right and left expansion in the
region of the first molar was 0.8 ± 0.5 mm.
The mean buccal tipping of the first pre-
molar/first primary molar amounted to
3.2 ± 0.8 degrees on the right and 4.0 ±
0.7 degrees on the left side. The mean
tipping of the first molar was 5.3 ± 0.9
degrees on the right and 6.5 ± 1.7
degrees on the left side.
During protraction, the right first molar
migrated 0.4 ± 0.6 mm mesially and the
left one 0.3 ± 0.2 mm. The Wits value
changed from –5.2 ± 1.3 mm to –2.5 ± 1.5
mm (mean improvement 2.7 ± 1.3 mm).
See Fig 15 for pre- and posttreatment pho-
tographs of one of the patients who wore
a face mask.

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VOLUME 11, NUMBER 4, 2010
a b
Fig 16a Same patient as in Figs 8 to 10.
Intraoral situation after removal of the
hybrid hyrax; mini-implants are still stable.
Fig 16b Components of the Beneplate
system for the connection of mini-implants.
(a) Beneplate with bracket; (b) Beneplate
with wire; (c) Beneplate standard; and
(d) fixation screw.
Fig 16c Skeletal retention by the insertion
of a miniplate.
DISCUSSION
The hybrid hyrax with two mini-implants
with exchangeable abutments is effective
for RPE. An anterior mini-implant inser-
tion approximately 2 mm from the palatal
suture seems to be preferable. Sufficient
bone is available only in this area.12
The 3D scan evaluation of the dental
casts to measure the amount of expan-
sion and mesial migration of the molars
was very suitable. In some instances,
however, the tipping was difficult to
assess due to the curvature of buccal
sur faces. In this situation, frontal
cephalograms might offer an advantage,
but the radiation exposure does not jus-
tify their application.
The achieved mean expansion in this
study was less than in other studies.20
This can be explained by the fact that in
this study, RPE was utilized not only for
maxillary expansion, but also for protrac-
tion by a face mask. In patients in whom
this was the primary goal, the expansion
was deliberately limited to activate the
midfacial sutures.
The application of the hybrid hyrax is
surgically minimally invasive compared
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Wilmes et al
b
a c
d
c
with pure bone-borne RPE devices, such
as distractors. 5,6 To employ the first
molars as posterior and mini-implants as
anterior anchorage units provides several
advantages. Application is possible in
patients with:
• Inferior anterior dental anchorage due
to missing primary molars or primary
molars with resorbed roots
• Immature premolar roots
• A need for early Class III treatment
with a face mask and in whom RPE
supports the maxillary advancement
by weakening the midface sutures,
thus enhancing the skeletal effects of
the extraoral traction
• Reduced dental adverse effects, ie,
buccal tipping and mesial migration
It seems advisable to retain the skele-
tal expansion for some time by fixing a
miniplate (Beneplate, PSM Mondeal)21 on
the mini-implants with two tiny screws (Fig
16). An additional approach may be the
use of the mini-implant–supported hybrix
hyrax with a miniplate (Mentoplate) placed
in the anterior portion of the mandible,
thus avoiding an unesthetic face mask.22
329
 Wilmes et al
ACKNOWLEDGMENT
Dr Benedict Wilmes is a codeveloper of the Benefit
mini-implant system.
CONCLUSION
The hybrid hyrax is effective for rapid
palatal expansion. It can be employed
even in patients with reduced dental
anchorage. The anterior teeth are not
included in the appliance, and regular
orthodontic treatment can therefore be
started early. The combination of the
hybrid hyrax with a face mask for maxil-
lary protraction is helpful to minimize
adverse effects, such as mesial migra-
tion of the anterior teeth.
REFERENCES
1. Angell E. Treatment of irregularities of perma-
nent or adult teeth. Dent Cosmos 1860;1:
540–544, 599–600.
2. Timms DJ, Emerson C. Angell (1822–1903).
Founding father of rapid maxillary expansion.
Dent Hist 199;32:3-12.
3. Garib DG, Henriques JF, Janson G, de Freitas
MR, Fernandes AY. Periodontal effects of rapid
maxillary expansion with tooth-tissue-borne
and tooth-borne expanders: A computed
tomography evaluation. Am J Orthod Dentofa-
cial Orthop 2006;129:749–758.
4. Schuster G, Borel-Scherf I, Schopf PM. Fre-
quency of and complications in the use of RPE
appliances—Results of a survey in the Federal
State of Hesse, Germany. J Orofac Orthop
2005;66:148–161.
5. Mommaerts MY. Transpalatal distraction as a
method of maxillary expansion. Br J Oral Max-
illofac Surg 1999;37:268–272.
6. Koudstaal MJ, van der Wal KG, Wolvius EB,
Schulten AJ. The Rotterdam Palatal Distractor:
Introduction of the new bone-borne device and
report of the pilot study. Int J Oral Maxillofac
Surg 2006;35:31–35.
7. Fuck L, Wilmes B, Drescher D. Rapid palatal
expansion with a transpalatal distractor [in Ger-
man]. Kieferorthopädie 2008;22:251–258.
8. Hansen L, Tausche E, Hietschold V, Hotan T,
Lagravere M, Harzer W. Skeletally-anchored
rapid maxillary expansion using the Dresden
Distractor. J Orofac Orthop 2007;68:148–158.
330
© 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
WORLD JOURNAL OF ORTHODONTICS
9. Harzer W, Schneider M, Gedrange T. Rapid
maxillary expansion with palatal anchorage of
the hyrax expansion screw—Pilot study with
case presentation. J Orofac Orthop 2004;65:
419–424.
10. Harzer W, Schneider M, Gedrange T, Tausche E.
Direct bone placement of the hyrax fixation
screw for surgically assisted rapid palatal
expansion (SARPE). J Oral Maxillofac Surg
2006;64:1313–1317.
11. Wilmes B. Fields of application of mini-implants.
In: Ludwig B, Baumgaertel S, Bowman J (eds).
Mini-Implants in Orthodontics: Innovative
Anchorage Concepts. Berlin: Quintessenz, 2008.
12. 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.
13. Wilmes B, Drescher D. A miniscrew system with
interchangeable abutments. J Clin Orthod
2008;42:574–580.
14. Wilmes B, Rademacher C, Olthoff G, Drescher
D. Parameters affecting primary stability of
orthodontic mini-implants. J Orofac Orthop
2006;67:162–174.
15. Wilmes B, Ottenstreuer S, Su YY, Drescher D.
Impact of implant design on primary stability of
orthodontic mini-implants. J Orofac Orthop
2008;69:42–50.
16. Wilmes B, Su YY, Sadigh L, Drescher D. Pre-
drilling force and insertion torques during
orthodontic mini-implant insertion in relation to
root contact. J Orofac Orthop 2008;69:51–58.
17. Wilmes B, Su YY, Drescher D. Insertion angle
impact on primary stability of orthodontic mini-
implants. Angle Orthod 2008;78:1065–1070.
18. Buchter A, Wiechmann D, Koerdt S, Wiesmann
HP, Piffko J, Meyer U. Load-related implant
reaction of mini-implants used for orthodontic
anchorage. Clin Oral Implants Res 2005;16:
473–479.
19. Wilmes B, Drescher D. Impact of insertion
depth and predrilling diameter on primary sta-
bility of orthodontic mini-implants. Angle
Orthod 2009;79:609–614.
20. Koudstaal MJ, Wolvius EB, Schulten AJ, Hop
WC, van der Wal KG. Stability, tipping and
relapse of bone-borne versus tooth-borne surgi-
cally assisted rapid maxillary expansion: A
prospective randomized patient trial. Int J Oral
Maxillofac Surg 2009;38:308–315.
21. Wilmes B, Nienkemper M, Drescher D. A mini-
plate system for improved stability of skeletal
anchorage. J Clin Orthod 2009;43:494–501.
22. Ludwig B, Glasl B, Bowman J, Drescher D,
Wilmes B. Miniscrew-supported Class III treat-
ment with the hybrid advancer. J Clin Orthod (in
press).
Benedict Wilmes, DDS,
DMD, PhD1 APPLICATION AND EFFECTIVENESS OF
Dieter Drescher, DDS, THE BENESLIDER: A DEVICE TO MOVE
DMD, PhD2
MOLARS DISTALLY
Aim: Distal movement of maxillary molars is a reasonable but often chal-
lenging treatment alternative for patients with a dental Class II occlusion
and an increased overjet or anterior crowding. One problem is that most
of the conventional noncompliance devices that distally move maxillary
molars lead to some anchorage loss. As such, a new appliance was
designed that is connected to two coupled mini-implants with exchange-
able abutments. The aim of this study was to evaluate the effectiveness
of this system for distal movement and the extent of its adverse effects.
Methods: Maxillary molar distal movement was performed in 18 patients
(10 females, eight males) in 6 to 10 months. The appliance (Beneslider)
combined elements of the distal jet and Keles slider with two abutment
mini-implants (spider screws or Benefit mini-implants). Pre- and post-
treatment casts were scanned with cone beam computed tomography.
To assess the amount of molar distal movement, molar rotation and
transverse expansion the 3D scans were digitally superimposed. Lateral
cephalograms were used to measure molar tipping. Results: The mean
distal movement of the first molars amounted to 4.6 ± 1.5 mm, the mean
mesial rotation to 3.4 ± 2.0 degrees, the transverse expansion in the first
molar region to 1.9 ± 1.0 mm, and the distal tipping to 1.9 ± 1.3 degrees.
Conclusion: Two coupled mini-implants with exchangeable abutments
and a heavy wire were an effective way to bodily move maxillary molars
distally. World J Orthod 2010;11:331–340.

Key words: molar distalization, TADs, mini-implants, Class II treatment

1Associate Professor, Department of
Orthodontics, University of Duessel-
dorf, Duesseldorf, Germany.
2Professor and Head, Department of
Orthodontics, University of Duessel-
dorf, Duesseldorf, Germany.
CORRESPONDENCE
Dr Benedict Wilmes
Department of Orthodontics
University of Duesseldorf
Moorenstr 5
40225 Duesseldorf
Germany
Email:
wilmes@med.uni-duesseldorf.de
or patients with a dental Class II
F occlusion with increased overjet or
anterior crowding, moving the maxillary
molars distally is recommended when
extraction therapy is not indicated. Due
to esthetic drawbacks and the length of
wear, distal movement with headgear is
unpleasant for many patients.1,2 There-
fore, intraoral appliances with minimal
need for patient cooperation are prefer-
able. However, most of the conventional
devices for noncompliance molar distal
movement result in some anchorage loss
(mesial migration of premolars or protru-
sion of the anterior teeth).3,4 One way to
reduce this adverse effect is the use of
palatal acrylic pads (Nance buttons). Yet,
the anchorage stability of any soft tis-
sue–borne element is questionable.
Moreover, such buttons impede optimal
oral hygiene.
To minimize or eliminate anchorage
loss, skeletal anchorage devices have
been integrated into distal-movement
appliances. 5–14 In par ticular, mini-
implants have attracted great attention
in recent years because of their versatil-
ity, minimal surgical invasiveness, and
low cost.15–20 Still, most of these devices
do not solely rely on mini-implants, but
still employ teeth or Nance buttons as
additional anchorage elements.

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 Wilmes/Drescher
a b
c d
The major drawback of devices
employing indirect anchorage is that they
require two treatment phases: (1) distal
movement of the molars and (2) reten-
tion of the molars and distal movement
of the premolars or retraction of the ante-
rior dental segment. Entering the second
phase involves a major reconstruction of
mechanics.
Consequently, a device for maxillary
distal movement establishing direct
anchorage on mini-implants is advanta-
geous because it is a one-phase treat-
ment so appliance reconstrution is not
necessar y; Nance buttons are not
needed, which improves patient comfort
and hygiene; and anchorage loss is
avoided since teeth are not included in
the anchorage unit.
To profit from these advantages, the
Beneslider,20,21 a distal-movement appli-
ance connected to two coupled mini-
implants with exchangeable abutments
in the anterior palate, was designed.
The aim of this study was to assess
whether mini-implants alone can provide
sufficient anchorage for maxillary molar
distal movement. The effectiveness of
distal movement and extent of possible
adverse effects were also evaluated.
332
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WORLD JOURNAL OF ORTHODONTICS
Fig 1 (a) Two mini-implants
with a diameter of 2.0 mm are
inserted into the anterior region
of the palate. (b) Transfer caps
and laboratory analogs are
positioned in the impression.
(c) Plaster cast with molar
bands and laboratory analogs.
(d) Beneslider appliance com-
prising activation locks and coil
springs from the distal jet and
headgear tubes from the Keles
slider soldered on the molar
bands. The 1.1-mm stainless
steel wire is laser-welded to
the two mini-implants.
METHOD AND MATERIALS
Maxillary molar distal movement was per-
formed in 18 patients (10 females and
eight males). Twelve were children or ado-
lescents (10 to 15 years of age, mean age
12.4 years), while six were adults (aged
25 to 47 years, mean age 35.2 years).
Clinical application and construction
of the Beneslider
After local anesthesia, two mini-implants
were inserted with a contra-angle in the
anterior median region of the palate next
to the second and third palatal rugae (Fig
1a). A dental probe was used to identify a
region with thin mucosa, which is impor-
tant to avoid a large lever arm and thus to
achieve sufficient primary stability.22,23 In
four patients, spider screws (HDC) were
inserted, while 14 patients received Bene-
fit mini-implants21 (PSM, Tuttlingen, Mon-
deal). The implant diameter was 2.0 mm
because previous studies have shown
that implant diameter and primary stabil-
ity are positively correlated.24–27 Depend-
ing on the available bone, as observed in
the patient’s cephalogram, the lengths of
VOLUME 11, NUMBER 4, 2010 Wilmes/Drescher

Fig 2 The spider screw system (2.0 ⫻

11.0 mm) with its acrylic abutment is
secured by a tiny screw and screw-
driver.

a b c

Fig 3 The Beneslider attached to a spider screw (2.0 ⫻ 11.0 mm) with its acrylic abutment, around which a small premolar band
was bonded. This band was laser-welded to the 1.1-mm wire. The posterior mini-implant is a Dual Top Screw (2.0 ⫻ 8.0 mm) that
was coupled to the spider screw after insertion of the distalization appliance. No spaces appeared between the second premolars
and the first molars when the latter moved distally. In Fig 3c, distal movement can be observed by the length of the wire extending
distally out of the headgear tube.

the mini-implants were 7.0 to 9.0 mm pos-
teriorly and 9.0 to 11.0 mm anteriorly. To
minimize implant tipping, two mini-
implants were coupled (tandem implant)
in the direction of the estimated load.
At the same appointment, bands were
fitted to the maxillary molars. After appli-
cation of transfer caps (for the spider
screw, the abutment was used as a trans-
fer cap), an alginate or silicone (Provil,
Heraeus) impression was taken. For supe-
rior precision, silicone is preferred. The
angular relation of the transfer caps was
maintained by intraorally connecting
them with Transbond LR (3M).
After impression taking, the laboratory
analogs (for the spider screws, normal
mini-implants) were placed on the transfer
caps (Fig 1b). After pouring a plaster cast
with all necessary elements in place, the
bands were positioned in the impression
(Fig 1c).
The Beneslider appliance comprises
elements of the distal jet28,29 (two activa-
tion locks and two coil springs, American
Orthodontics) and the Keles slider 30
(headgear tubes, Forestadent), as well as
the two aforementioned mini-implants. A
1.1-mm stainless steel wire was bent and
laser-welded to the abutments. The head-
gear tube was positioned near the esti-
mated center of resistance of the
respective molar to avoid its tipping. Molar
distal movement was achieved by pressing
the activation locks against the coil
springs (Fig 1d).
Beneslider on spider screws
Spider screws (2.0 ⫻ 11.0 mm) with
acrylic abutments secured by tiny inner
screws (Fig 2) were inserted anteriorly.
Around the abutments, a small premolar
band was bonded and laser-welded to
the 1.1-mm wire. In these patients, the
posterior mini-implants were Dual Top
Screws (Jeil, 2.0 ⫻ 8.0 mm). After inser-
tion, this implant was coupled to the dis-
tal movement appliance with Transbond
LR. One of the four patients in whom spi-
der screws were used is shown in Fig 3.

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 Wilmes/Drescher WORLD JOURNAL OF ORTHODONTICS

Fig 4 Benefit system. (a) Mini-

implant; (b) laboratory analog; (c)
impression cap; (d) wire abutment; (e)
bracket abutment; (f) standard abut-
h ment; (g) slot abutment; (h) screw-
driver for fixation of the abutment.

g
f
e
d

a b

a b c

Fig 5 Beneslider on Benefit mini-implants (2.0 ⫻ 11.0 mm). Under the premise of stable mini-implants, the distal movement
of the molars can be verified by appraising the length of the wire extending distally out of the headgear tube.

Beneslider on the Benefit system tomography. To assess the extent and

To improve the mechanical coupling, the
Benefit abutment system was used (Fig
4). It also comprises transfer (impression)
caps (Fig 4c) and laboratory analogs (Fig
4b). The two Benefit mini-implants (Fig
4a) were again inserted in the anterior
area of the palate. For the Beneslider, the
so-called standard abutment was chosen
and mounted on top of the Benefit mini-
implant with an inner abutment–inte-
grated screw. One of the 14 patients in
whom the Benefit system was used is
illustrated in Fig 5.
Evaluation of the distal movement
and its adverse effects
Pre- and posttreatment plaster casts
were scanned with cone beam computed
type of molar movement, the 3D scans
were digitally superimposed using Digi-
Model software (OrthoProof) (Fig 6).
The distal movement was measured
on each side to identify corresponding
points at the molars before and after dis-
tal movement (Fig 7a). The amount of the
mesial rotation on each side was evalu-
ated by measuring the angle between the
buccal surfaces of the molars before and
after distal movement (Fig 7b). The trans-
verse effects were quantified by gauging
the distance of two corresponding points
at the first molars before and after they
were moved distally (Fig 7c).
The amount of molar tipping was
assessed on lateral cephalograms by
measuring the angle between the line
ApUpMol and CpUpMol before and after
distal movement (Fig 8).

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VOLUME 11, NUMBER 4, 2010 Wilmes/Drescher

Fig 6 Definition of three landmarks with the DigiModel

software in the 3D scans of the plaster casts before and
after moving the first molars distally for subsequent super-
imposition.

a b

Fig 7 (a) Superimposition of the plaster models from

before and after moving the first molars distally and mea-
surement of the movement distance by identification of
corresponding points. (b) Defining the amount of the
mesial rotation on each side by evaluating the angle
between the buccal surfaces of the molars before and after
distal movement. (c) Quantification of the expansion by
measuring the distance of corresponding points at the first
molar before and after distal movement.

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 Wilmes/Drescher WORLD JOURNAL OF ORTHODONTICS

Fig 8 Superimposition of pre- and post- Fig 9 Superimposition of the (black) pre-
distal movement cephalograms. Clinical and (white) postdistal movement cephalo-
example with spider screw mini-implants gram of a patient treated with the Benefit
(treatment duration 10 months). The system (treatment duration 8 months).
amount of molar tipping was evaluated
by measuring the angle between the line
ApUpMol to CpUpMol before (black)
and after (white) distal movement.

Fig 10 Schematic drawing of the

employed mechanics: To achieve a bodily
movement of the molars, these teeth are
guided by a 1.1-mm wire, since the force
vector runs through the center of resis-
tance. To prevent tipping of the mini-
implants, two large coupled ones should
be inserted to receive the counterforce.

Table 1  Mean molar distal movement, mesial rotation, transverse expansion

(mm, derived from 3D cast scans), and molar tipping (degrees, derived from
lateral cephalograms)
Mean distal Mean mesial Mean transverse Mean molar
movement (mm) rotation (degrees) expansion (mm) tipping (degrees)

Right 4.7 ± 1.5 3.1 ± 2.2

Left 4.5 ± 1.6 3.8 ± 1.8
Total 4.6 ± 1.5 3.4 ± 2.0 1.9 ± 1.0 1.9 ± 1.3

RESULTS The mean distal movement on the right

Achieving the intended molar distal
movement took between 6 and 10
months. In the first clinical example (spi-
der screws), treatment duration was 10
months (Fig 8); in the second (with the
Benefit system), it was 8 months (Fig 9).
side was 4.7 ± 1.5 mm, 4.5 ± 1.6 mm on
the left side, and 4.6 ± 1.5 mm in total.
The mean mesial rotation of the right first
molars was 3.1 ± 2.2 degrees, 3.8 ± 1.8
degrees of the left, and 3.4 ± 2.0 degrees
in total. Transverse expansion in the first
molar region was 1.9 ± 1.0 mm and tip-
ping 1.9 ± 1.3 degrees (Table 1).

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VOLUME 11, NUMBER 4, 2010
In one of the four patients with the spi-
der screw system, the appliance had to
be removed after 4 months due to exces-
sive mesial migration of the Beneslider.
The reason for this was a failure of the
Transbond coupling of the appliance with
the posterior Dual Top Screws. Obviously,
the spider screw cannot withstand the
reactive load alone.
DISCUSSION
The Beneslider with two mini-implants
with exchangeable abutments is an effec-
tive device to bodily move maxillary
molars distally with only small adverse
effects.
The evaluation of the distal and trans-
verse movement and rotation by 3D scans
is a very suitable method. In contrast to
lateral cephalograms, it allows separate
assessment of both sides, measuring the
rotation of the molars and their transverse
movement. However, the cephalogram
seems to be advantageous when molar
tipping needs to be evaluated.
The distal moving effect of the Benes-
lider (4.6 mm) is adequate and in the
upper third when compared to previous
studies that evaluated the effectiveness
of devices to move maxillary molars dis-
tally (1.4 to 6.1 mm).31 The observed tip-
ping of the first molars was very small
(1.9 degrees) in comparison with values
from other studies 31 (1.0 to 14.5
degrees). This can be attributed to the
fact that the force vector was near to the
estimated center of resistance of the
molars and the exact molar guidance
along the 1.1-mm wire (Fig 10). If the sec-
ond molars were not bonded, they
showed distinctive tipping.
The transverse expansion in the molar
region led to a tendency of a Brodie bite
in some patients. To reduce this problem,
a parallel arrangement of the 1.1-mm
wire (U-shape) seems to be advantageous
compared with the divergent design
(V-shape). However, the anatomy of the
palate in some patients limits such a
design. If a transverse expansion occurs,
the 1.1-mm wire on the side with the
Brodie bite tendency should be activated
accordingly with a three-prong pliers.
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Wilmes/Drescher
In all patients, including the adoles-
cents, the mini-implants were inserted in
the region of the midpalatal suture. This
leads to two queries: whether the mini-
implant is stable in this location and
whether the growth of the maxilla is influ-
enced by the mini-implant insertion.
In regard to the former, it should be
noted that only one mini-implant of 36
failed. Compared with failure rates in
other regions, this rate is very low (2.7%).
Also, the registered maximum insertion
moment in the anterior and median
regions of the suture ranged from 8.0 to
25.0 Ncm, which can be regarded as
adequate to achieve a sufficient primary
stability.
The question of a possible impairment
of transverse maxillary growth due to
implant insertion into the midpalatal
suture was investigated by Asscherickx et
al. 32 They inserted two Orthosystem
(Straumann) implants in the suture of
beagle dogs and observed an inhibition of
transverse maxillary growth.32 However,
this study had only one control animal
and one parameter differed.33 Secondly,
it is questionable whether Orthosystem
implants, with their greater diameter and
rough surface, can be compared to mini-
implants. Also, clinical observations never
revealed any tendency of reduced trans-
verse growth of the maxilla. Yet, further
studies should investigate this issue in
more detail. If necessary, mini-implants
can be inserted lateral of the suture
because sufficient bone volume is avail-
able up to 3.0 mm lateral to it.34
Tandem coupled mini-implants with-
stood the forces needed to move maxillary
molars distally without Nance buttons or
additional anchorage teeth. The Keles
slider combined with the Orthosystem35
palatal implant system achieved this, as
well.30 However, the application of tandem
mini-implants has some advantages,
including insertion with only minor surgery,
possible for orthodontists to insert, no lay-
time for osseointegration, easy removal
without surgical intervention, and low cost.
The only disadvantage of mini-implants
seems to be a somewhat higher failure
rate.35–40 However, it should be kept in
mind that reported failure rates are regis-
tered from various intraoral sites. It is
337
 Wilmes/Drescher
b tem. (a) A long Beneplate with
a Fig 12 (right) Beneslider
c movement; anterior bite
d
these authors’ clinical experience that the
failure rate in the anterior area of the
palate is lower compared to other inser-
tion sites. Consequently, it can be
assumed that, in the anterior palatal
region, failure rates of mini-implants and
Orthosystem implants are comparable. To
increase stability and avoid implant tip-
ping in the direction of loading, it is advis-
able to couple two mini-implants (tandem
implant) with a diameter of at least 2.0
mm in the line of force. The observed
mesial tipping of the mini-implants used
by Kinzinger et al12 for a distal jet appli-
ance can be explained by their small
diameter (1.6 mm) and the fact that they
were not coupled as tandem.
As demonstrated, the most advanta-
geous location for the posterior tube to
allow for a bodily movement of the molar
is near its estimated center of resistance.
Another aspect that needs to be dis-
cussed critically is the relatively long time
it takes to move molars distally. Usually, it
takes 3 months until any movement of
the molars becomes apparent. This can
be explained by the fact that the
transseptal fibers are stretched and thus
induce a simultaneous distal migration of
the premolars with the molars. Premolars
migrate mesially and spaces between the
second premolars and the first molars
open, which may falsely be interpreted as
distal movement of the first molars.
Besides this, any bodily tooth movement
takes more time than tipping. Last but
not least, friction can also be a reason
for the slightly longer time to move the
molars distally.
Although patients treated with the spi-
der screws generally revealed successful
distal movement of the molars, fixation of
the acrylic abutments with a premolar
338
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WORLD JOURNAL OF ORTHODONTICS
Fig 11 (left) Beneplate sys-
bracket in place; (b) short
Beneplate with wire (1.1 or 0.8
mm) in place; (c) short Bene-
plate; (d) fixing screw.
anchored with a Beneplate at
the end of the molar distal
blocks allow for unimpeded
movement.
band is inconvenient. Also, premolar
bands are very thin; hence, it is difficult to
weld them to the main wire. A stainless
steel abutment, as fixed on a Benefit mini-
implant, prevents this problem. Lastly, the
abutment fixing screw, which is integrated
into the Benefit abutment, makes inser-
tion of the appliance much easier.
Any error during impression taking,
cast pouring, or laboratory fabrication will
affect the appliance fit on the inserted
implants. In this case, one abutment can
be removed and refixed intraorally with
Transbond. An alternative to two coupled
abutments is the prefabricated Bene-
plate, which has minor precision require-
ments41 (Figs 11 and 12). Also, by using
the Beneplate, the appliace can be made
without any laborator y procedures
(impressions).
In any case, the indication for maxil-
lary molar distal movement has to be
evaluated properly. In skeletal Class II
patients with an unfavorable profile,
other mechanics (Mara or Herbst appli-
ances) are preferable.
CONCLUSION
Two coupled mini-implants with exchange-
able abutments and heavy wire guidance
are effective to bodily move maxillary
molars distally with negligible adverse
effects. The Benefit system is more secure
and more comfortable for the clinician
than the spider screw system.
ACKNOWLEDGMENT
Dr Benedict Wilmes is the codeveloper of the Benefit
mini-implant system.
VOLUME 11, NUMBER 4, 2010 Wilmes/Drescher

REFERENCES 17. Kanomi R. Mini-implant for orthodontic anchor-

age. J Clin Orthod 1997;31:763–767.
18. Melsen B, Costa A. Immediate loading of
1. Clemmer EJ, Hayes EW. Patient cooperation in
implants used for orthodontic anchorage. Clin
wearing orthodontic headgear. Am J Orthod
Orthod Res 2000;3:23–28.
1979;75:517–524.
19. Wilmes B. Anwendungsgebiete von Mini-
2. Egolf RJ, BeGole EA, Upshaw HS. Factors asso-
Implantaten. In: Ludwig (ed). Mini-Implantate in
ciated with orthodontic patient compliance
der Kieferorthopädie, Innovative
with intraoral elastic and headgear wear. Am J
Verankerungskonzepte. Berlin: Quintessenz,
Orthod Dentofacial Orthop 1990;97:336–348.
2007:89–120.
3. Bussick TJ, McNamara JA Jr. Dentoalveolar and
20. Wilmes B. Fields of application of mini-implants.
skeletal changes associated with the pendu-
In: Ludwig B, Baumgaertel S, Bowman J (eds).
lum appliance. Am J Orthod Dentofacial Orthop
Innovative Anchorage Concepts Mini-Implants in
2000;117:333–343.
Orthodontics. Berlin: Quintessenz, 2008.
4. Ghosh J, Nanda RS. Evaluation of an intraoral
21. Wilmes B, Drescher D. A miniscrew system with
maxillary molar distalization technique. Am J
interchangeable abutments. J Clin Orthod
Orthod Dentofacial Orthop 1996;110:639–646.
2008;42:574–580.
5. Byloff FK, Karcher H, Clar E, Stoff F. An implant
22. Buchter A, Wiechmann D, Koerdt S, Wiesmann
to eliminate anchorage loss during molar distal-
HP, Piffko J, Meyer U. Load-related implant
ization: A case report involving the Graz
reaction of mini-implants used for orthodontic
implant-supported pendulum. Int J Adult Ortho-
anchorage. Clin Oral Implants Res 2005;16:
don Orthognath Surg 2000;15:129–137.
473–479.
6. Gelgor IE, Buyukyilmaz T, Karaman AI, Dolan-
23. Wilmes B, Drescher D. Impact of insertion
maz D, Kalayci A. Intraosseous screw-sup-
depth and pedrilling diameter on primary sta-
ported upper molar distalization. Angle Orthod
bility of orthodontic mini-implants. Angle
2004;74:838–850.
Orthod 2009;79:609–614.
7. Karaman AI, Basciftci FA, Polat O. Unilateral
24. Wilmes B, Rademacher C, Olthoff G, Drescher
distal molar movement with an implant-sup-
D. Parameters affecting primary stability of
ported distal jet appliance. Angle Orthod 2002;
orthodontic mini-implants. J Orofac Orthop
72:167–174.
2006;67:162–174.
8. Kyung SH, Hong SG, Park YC. Distalization of
25. Wilmes B, Ottenstreuer S, Su YY, Drescher D.
maxillary molars with a midpalatal miniscrew.
Impact of implant design on primary stability of
J Clin Orthod 2003;37:22–26.
orthodontic mini-implants. J Orofac Orthop
9. Sugawara J, Kanzaki R, Takahashi I, Nagasaka
2008;69:42–50.
H, Nanda R. Distal movement of maxillary
26. Wilmes B, Su YY, Sadigh L, Drescher D. Pre-
molars in nongrowing patients with the skeletal
drilling Force and Insertion Torques during
anchorage system. Am J Orthod Dentofacial
Orthodontic Mini-implant Insertion in Relation to
Orthop 2006;129:723–733.
Root Contact. J Orofac Orthop 2008;69:51–58.
10. Kircelli BH, Pektas ZO, Kircelli C. Maxillary molar
27. Wilmes B, Su YY, Drescher D. Insertion angle
distalization with a bone-anchored pendulum
impact on primary stability of orthodontic mini-
appliance. Angle Orthod 2006;76:650–659.
implants. Angle Orthod 2008;78:1065–1070.
11. Escobar SA, Tellez PA, Moncada CA, Villegas
28. Carano A, Testa M, Siciliani G. The lingual dis-
CA, Latorre CM, Oberti G. Distalization of maxil-
talizer system. Eur J Orthod 1996;18:445–448.
lary molars with the bone-supported pendulum:
29. Carano A, Testa M, Bowman SJ. The distal jet
A clinical study. Am J Orthod Dentofacial
simplified and updated. J Clin Orthod 2002;36:
Orthop 2007;131:545–549.
586–590.
12. Kinzinger G, Gulden N, Yildizhan F, Hermanns-
30. Keles A, Erverdi N, Sezen S. Bodily distalization
Sachweh B, Diedrich P. Anchorage efficacy of
of molars with absolute anchorage. Angle
palatally-inserted miniscrews in molar distaliza-
Orthod 2003;73:471–482.
tion with a periodontally/miniscrew-anchored
31. Kinzinger GS, Eren M, Diedrich PR. Treatment
distal jet. J Orofac Orthop 2008;69:110–120.
effects of intraoral appliances with conven-
13. Velo S, Rotunno E, Cozzani M. The Implant Dis-
tional anchorage designs for non-compliance
tal Jet. J Clin Orthod 2007;41:88–93.
maxillary molar distalization: A literature
14. Kinzinger GS, Diedrich PR, Bowman SJ. Upper
review. Eur J Orthod 2008;30:558–571.
molar distalization with a miniscrew-supported
32. Asscherickx K, Hanssens JL, Wehrbein H,
distal jet. J Clin Orthod 2006;40:672–678.
Sabzevar MM. Orthodontic anchorage implants
15. Costa A, Raffainl M, Melsen B. Miniscrews as
inserted in the median palatal suture and nor-
orthodontic anchorage: A preliminary report.
mal transverse maxillary growth in growing
Int J Adult Orthodon Orthognath Surg 1998;13:
dogs: A biometric and radiographic study. Angle
201–209.
Orthod 2005;75:826–831.
16. Freudenthaler JW, Haas R, Bantleon HP. Bicorti-
33. Borsos G, Rudzki-Janson I, Stockmann P,
cal titanium screws for critical orthodontic
Schlegel KA, Vegh A. Immediate loading of
anchorage in the mandible: A preliminary report
palatal implants in still-growing patients: A
on clinical applications. Clin Oral Implants Res
prospective, comparative, clinical pilot study.
2001;12:358–363.
J Orofac Orthop 2008;69:297–308.

339

© 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Wilmes/Drescher
34. Bernhart T, Freudenthaler J, Dortbudak O,
Bantleon HP, Watzek G. Short epithetic
implants for orthodontic anchorage in the para-
median region of the palate. A clinical study.
Clin Oral Implants Res 2001;12:624–631.
35. Wehrbein H, Merz BR, Diedrich P, Glatzmaier J.
The use of palatal implants for orthodontic
anchorage. Design and clinical application of
the orthosystem. Clin Oral Implants Res 1996;
7:410–416.
36. Feldmann I, Bondemark L. Anchorage capacity
of osseointegrated and conventional anchor-
age systems: A randomized controlled trial.
Am J Orthod Dentofacial Orthop 2008;133:
339e19–e28.
37. Berens A, Wiechmann D, Dempf R. Mini- and
micro-screws for temporary skeletal anchorage
in orthodontic therapy. J Orofac Orthop 2006;
67:450–458.
340
© 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
WORLD JOURNAL OF ORTHODONTICS
38. Cheng SJ, Tseng IY, Lee JJ, Kok SH. A prospec-
tive study of the risk factors associated with
failure of mini-implants used for orthodontic
anchorage. Int J Oral Maxillofac Implants
2004;19:100–106.
39. Fritz U, Diedrich P, Kinzinger G, Al-Said M. The
anchorage quality of mini-implants towards
translatory and extrusive forces. J Orofac
Orthop 2003;64:293–304.
40. Miyawaki S, Koyama I, Inoue M, Mishima K,
Sugahara T, Takano-Yamamoto T. Factors asso-
ciated with the stability of titanium screws
placed in the posterior region for orthodontic
anchorage. Am J Orthod Dentofacial Orthop
2003;124:373–378.
41. Wilmes B, Nienkemper M, Drescher D. A mini-
plate system for improved stability of skeletal
anchorage. J Clin Orthod 2009;43:494–501.
Mauro Cozzani, DMD,
MScD1 EFFICIENCY OF THE DISTAL SCREW
Francesco Zallio, MD, DDS2 IN THE DISTAL MOVEMENT
Luca Lombardo, DDS3 OF MAXILLARY MOLARS
Antonio Gracco, DDS3
Aim: Conventionally, noncompliance distal movement of molars relies
exclusively on intraoral anchorage. The distal screw, a distal jet appli-
ance supplemented by two paramedian mini-implants, is an innova-
tive alternative. The aim of this study was to evaluate the suitability of
this device to move molars bodily and distally. Methods: The effects
of the distal screw were evaluated in a sample of 18 consecutively
treated preadolescent and adolescent individuals (nine females and
nine males; mean age at the start of treatment, 11.2 years). Two coni-
cal mini-implants (length 11.0 mm, diameter 1.5 to 2.2 mm) were placed
in the anterior paramedian area of the palate of each patient. The coil
springs of the device were activated to deliver a force of 240 cN per
side. The dental and skeletal effects were investigated on pre- and
posttreatment cephalometric radiographs. Results: The distal screw
produced a Class I occlusion of the first molars by moving them distally
4.7 mm, which is more than conventional appliances can accomplish.
Although this took longer than conventional devices (9.1 months), it
had the advantage of a roughly 2.1-mm premolar distal movement (ie,
no anchorage loss as with traditional techniques). Conclusions: The
distal screw anchored by two palatal mini-implants allows not only
translatory molar distal movement, but also distal movement of the
maxillary first premolars, thereby avoiding characteristic anchorage
loss. World J Orthod 2010;11:341–345.

Key words: maxillary molar distalization, mini-implant, skeletal anchorage

istal molar movement is useful in loss (a mesial displacement of the pre-

D resolving a Class II occlusion in
patients with dentoalveolar protrusion
molars, canines, and incisors),5 a situa-
tion that cannot be improved by
1Private Practice, La Spezia, Italy. and only slight skeletal discrepancy. 1 bracketing additional teeth.6
2Private Practice, Sestri Levante (GE), While the conventional approach One intraorally anchored device is the
Italy.
3Research
involves extraoral traction,2 comparable distal jet, an intramaxillary appliance
Assistant, Department of
results have been achieved using fixed, that is effective due to two Ni-Ti coil
Orthodontics, University of Ferrara,
Ferrara, Italy. esthetically acceptable appliances that springs attached to the bands on the
rely on intraoral anchorage, thereby elimi- maxillary first molars.7 If the distal jet is
CORRESPONDENCE nating the need for patient compliance.3 constructed according to Bolla et al, 1
Dr Mauro Cozzani In general, these devices exploit a combi- the force vector passes through the cen-
Via Fontevivo 21 N
La Spezia 19125
nation of dental (maxillary premolars) ter of resistance of these teeth, which
Italy and palatal (Nance button) anchorage.4 results in almost complete bodily move-
Email: maurocozzani@gmail.com This approach leads to an anchorage ment.8 Several authors, including those

341

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 Cozzani et al
Fig 1 Metallic plate to be inserted in the
resin of the Nance button; note that all
holes are designed to fit the head of the
specific mini-implant (Fig 3).
of the present study, have developed
skeletally anchored alternatives to the
conventional distal jet.4,9–11 The distal
screw uses two palatally inserted mini-
implants for skeletal anchorage. Numer-
ous studies have demonstrated that the
optimal sites for mini-implant are not only
the lingual interradicular spaces,12 but
also the paramedian region of the palatal
vault.13,14
The aim of this study was to clinically
evaluate the efficiency of the distal
screw.
METHOD AND MATERIALS
Eighteen consecutive patients (nine
males, nine females; mean age at begin-
ning of treatment 11.2 years) with a bilat-
eral dentoalveolar distal occlusion were
treated solely with a distal screw. In six of
these patients, the maxillary second
molars had fully erupted, while they had
erupted partially in four. They had not
erupted in the remaining eight patients.
No patients dropped out during the trial.
For all patients, intra- and extraoral
photographs, impressions, panoramic
radiographs, and lateral cephalographs
were obtained at the beginning and end
of the first molars’ distal movement.
342
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WORLD JOURNAL OF ORTHODONTICS
Fig 2 Intraoral photograph of
a distal screw, which is used
as anchorage to retract the
canines.
Fig 3 A 2-mm titanium screw
expressly designed for the dis-
tal screw.
The appliance was a modified distal
jet in which the metallic arms normally
used for dental anchorage were elimi-
nated and the Nance button altered to
enclose a moldable metal plaque fixed by
two mini-implants (Figs 1 and 2). The two
mini-implants were placed in the parame-
dian region of the anterior palatal vault
along a line connecting the two syner-
getic premolars. They were inserted by
predrilling and using a manual screw-
driver after the patients had rinsed with a
0.1% chlorhexidine gluconate solution.
Local anesthesia with an adrenalin-free
analgetic was performed.
The insertion site was selected on the
basis of various studies demonstrating
its safety, thereby eliminating the need
for any fur ther radiographic evalua-
tion.13,14 Also, according to Ardekian et
al, nasal floor perforations of less than 2
mm tend to heal spontaneously.15
The mini-implants employed were
made of titanium, measured 11.0 mm
long, and were shaped like a truncated
cone with a diameter of 1.5 mm at the
tip and 2.2 mm at the neck. The shank
was 1.0 mm in diameter, the threaded
part had a length of 8.0 mm, and the
head featured a hexagonal slot to house
the head of the screwdriver or contra-
angle handpiece (Fig 3).
VOLUME 11, NUMBER 4, 2010 Cozzani et al

Fig 4 Method suggested by

Ghosh and Nanda 16 to quan-
tify dental movements using
cephalometric superimposi- 43 2 SN
tions. SN 5

1 PTM
PP
4 3 2 1
A
7 5
6
PTV 8

9 B

MnPI

Table 1  Mean, standard deviation (SD), minimum, and maximum of all cephalometric
parameters between T1 (beginning) and T2 (end of molar distal movement)
Mean SD Minimum Maximum

T1–T2 (months) 9.1 2.7 4.0 13.0

PTV–U6 (mm) –4.7 1.6 –8.2 –2.7
PTV–U4 (mm) –2.1 1.8 –6.7 –0.1
SN–U6 (degrees) –2.6 2.3 –5.8 4.2
SN–U4 (degrees) –2.0 3.1 –8.4 4.9
SN–U1 (degrees) 0.3 2.9 –4.8 6.8
PP–U6 (mm) 0.7 1.9 –3.2 6.4
PP–U4 (mm) 1.3 1.5 –1.9 3.9
PP–U1 (mm) 0.4 0.8 –1.2 2.4
PTV–A (mm) 0.4 0.8 –0.5 2.4

The superelastic springs were com- RESULTS

pressed by adjusting the attachment
screws until a force of 240 cN could be
measured; reactivation was carried out at
4-week intervals.
To quantify the distal movement
achieved, any premolar or canine dis-
placement was evaluated according to
the methodology suggested by Ghosh
and Nanda16 (Fig 4). This method was
chosen to compare the results of this
study with those of other studies.1,17
Statistical analysis
Mean, standard deviation, and range of
each continuous variable were calculated
before (T1) and after (T2) distal move-
ment. Also, the absolute and relative fre-
quencies of the categoric variables were
determined.
The data from the cephalometric analyses
are listed in Table 1. It also shows that the
average time required to achieve a Class I
molar relationship was 9.1 ± 2.7 months.
The mean distal movement of the maxil-
lary molars (PTV–U6) was –4.7 ± 1.6 mm.
Simultaneously, the first premolar
(PTV–U4) moved distally on average –2.1 ±
1.8 mm. Distal tipping of the first molars
(SN–U6/U4/U1) amounted to –2.6 ± 2.3
degrees and –2.0 ± 3.1 degrees for the
first premolars. The incisors tipped labially
0.3 ± 2.9 degrees. Extrusion with respect
to the bispinal plane of the first molars
(PP–U6/U4/U1) was 0.7 ± 1.9 mm, 1.3 ±
1.5 mm for the first premolars, and 0.4 ±
0.8 mm for the incisors. The distance
PTV–A increased by 0.4 ± 0.8 mm.

343

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 Cozzani et al
DISCUSSION
The introduction of skeletal anchorage to
orthodontics has permitted not only the
simplification of many procedures con-
ventionally employed to control anchor-
age, but also reduced the undesirable
effects of many appliances. 18 Initial
attempts were based on osseointegrated
implants,19,20 but the related costs, inva-
siveness, and delay of loading prompted
clinicians to seek alternatives.21,22 Thus,
mini-implants were used based on their
low cost, reduced invasiveness, and ver-
satility.23,24 Clinical and laboratory stud-
ies have demonstrated the usefulness of
mini-implants for or thodontic pur-
poses.25,26
Compared to Bolla et al,1 who treated
a similar number and type of patients
using a distal jet, the amount of molar
distal movement was greater with the dis-
tal screw (3.2 vs 4.7 mm). Moreover, the
patients treated with the distal screw did
not experience any anchorage loss of the
first premolar in contrast to those treated
with the distal jet (mean loss 1.3 mm).
Actually, the first premolars moved dis-
tally, too (2.1 mm). The fact that a Class I
occlusion was achieved in 5 to 6 months
in the study by Bolla et al1 as compared
to 9.1 months in this study could be
explained by the fact that the distal
occlusion might have been more severe
in the patients treated with the distal
screw. In any case, the distal movement
of the first molars was nearly the same in
both studies (0.5 vs 0.6 mm).
From the cephalometric perspective,
the distal screw conserves the positive
characteristics of the distal jet but over-
comes its negative aspect: the medioan-
terior anchorage loss.
Finally, the distal screw seems to
behave clinically differently than conven-
tional and other skeletally anchored dis-
tal movement devices. Authors who used
a pendulum with skeletal anchorage
achieved a greater distal movement in a
shorter time (5.4 mm in 6.5 months27),
344
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WORLD JOURNAL OF ORTHODONTICS
which was, however, accompanied by
severe first molar (5.6 to 12.2 degrees)
and first premolar tipping (3.8 to 7.9
degrees). 22,27,28 In contrast, this appli-
ance produced a tipping of only 2.6
(molars) and 1.9 degrees (premolars).
Similar results for molar distal move-
ment were documented in a study of 10
adolescent patients treated with a distal
jet anchored to the first premolars by two
palatal mini-implants. 2 It was also
reported that the second premolar moved
1.9 mm distally with about 3.0 degrees of
tipping.2 In contrast to the results of this
study, Kinzinger et al3 described a mesial
displacement of 0.7 mm for the first pre-
molar, which can be explained by the dif-
ferent anchorage setup.
Overall, the distal screw has numer-
ous advantages with respect to both con-
ventional appliances and other skeletally
anchored molar distal movement
devices. In fact, the distal screw not only
overcomes anchorage loss, but also sim-
plifies the treatment because premolar
banding is rendered unnecessary and
the same appliance, once inactive, can
further be employed for final premolar
and canine retraction. As these screws
are positioned in the palate, they do not
interfere with the distal movement of the
posterior teeth. All advantages of the dis-
tal screw are obtained without taking
additional radiographs.
CONCLUSIONS
The distal screw allows an almost com-
pletely bodily distal movement of the
maxillary first molars and a spontaneous
distal drift of the premolars. In compari-
son to the distal jet, the distal screw sim-
plifies the clinical procedure without any
special radiographic evaluation.
The longer time needed to achieve a
Class I relationship is compensated by
the simpler subsequent distal movement
of the remaining teeth because the pre-
molars need less distal movement.
VOLUME 11, NUMBER 4, 2010 Cozzani et al

REFERENCES 16. Ghosh J, Nanda RS. Evaluation of an intraoral

maxillary molar distalization technique. Am J
Orthod Dentofacial Orthop 1996;110:639–646.
1. Bolla E, Muratore F, Carano A, Bowman SJ. Eval-
17. Brickman CD, Sinha PK, Nanda RS. Evaluation
uation of maxillary molar distalization with the
of the Jones jig appliance for distal molar
distal jet: A comparison with other contempo-
movement. Am J Orthod Dentofacial Orthop
rary methods. Angle Orthod 2002;72:481–494.
2000;118:526–534.
2. Melsen B, Verna C. A rational approach to
18. Polat-Ozsoy O, Kırcelli BH, Arman-Özçırpıcı A,
orthodontic anchorage. Prog Orthod 1999;1:
Pektas ZO, Uçkan S. Pendulum appliances with
10–22.
2 anchorage designs: Conventional anchorage
3. Kinzinger GS, Gulden N, Yildizhan F, Diedrich
vs bone anchorage. Am J Orthod Dentofacial
PR. Efficiency of a skeletonized distal jet appli-
Orthop 2008;133:339.e9–339.e17.
ance supported by miniscrew anchorage for
19. Roberts WE, Smith RK, Silberman Y, Mozsary
noncompliance maxillary molar distalization.
PG, Smith RS. Osseous adaptation to continu-
Am J Orthod Dentofacial Orthop 2009;136:
ous loading of rigid endosseous implants. Am J
578–586.
Orthod 1984;86:95–111.
4. Kinzinger G, Wehrbein H, Byloff FK, Yildizhan F,
20. Roberts WE, Marshall KJ, Mozsary P. Rigid
Diedrich PR. Innovative anchorage alternatives
endosseous implant utilized as anchorage to
for molar distalization—An overview. J Orofac
protract molars and close atrophic extraction
Orthop 2005;66:397–413.
site. Angle Orthod 1990;60:135–152.
5. Ferguson DJ. Carano A, Bowman SJ, Davis EC,
21. Gelgor IE, Buyukyilmaz T, Karaman AI, Dolan-
Gutierrez Vega ME, Lee SH. A comparison of
maz D, Kalayci A. Intraosseous screw-sup-
two maxillary molar distalizing appliances with
ported upper molar distalization. Angle Orthod
the distal jet. World J Orthod 2005;6:382–390.
2004;74:838–850.
6. Melsen B, Bosch C. Different approaches to
22. Önçag G, Seçkin Ö, Dinçer B, Arikan F. Osseoin-
anchorage: A survey and an evaluation. Angle
tegrated implants with pendulum springs for
Orthod 1997;67:23–30.
maxillary molar distalization: A cephalometric
7. Carano A, Testa M. The distal jet for upper molar
study. Am J Orthod Dentofacial Orthop 2007;
distalization. J Clin Orthod 1996;30:374–380.
131:16–26.
8. Kinzinger GSM, Diedrich PR. Biomechanics of a
23. Cheng SJ, Tseng IY, Lee JJ, Kok SH. A prospective
distal jet appliance. Theoretical considerations
study of the risk factors associated with failure
and in vitro analysis of force systems. Angle
of mini-implants used for orthodontic anchorage.
Orthod 2008;78:676–681.
Int J Oral Maxillofac Implants 2004;19:
9. Kinzinger GS, Diedrich PR, Bowman SJ. Upper
100–106.
molar distalization with a miniscrew-supported
24. Miyawaki S, Koyama I, Inoue M, Mishima K,
distal jet. J Clin Orthod 2006;40:672–678.
Sugahara T, Takano-Yamamoto T. Factors asso-
10. Velo S, Rotunno E, Cozzani M. The implant dis-
ciated with the stability of titanium screws
tal jet. J Clin Orthod 2007;41:88–93.
placed in the posterior region for orthodontic
11. Gracco A, Luca L, Siciliani G. Molar distalisation
anchorage. Am J Orthod Dentofacial Orthop
with skeletal anchorage. Aust Orthod J 2007;
2003;124:373–378.
23:147–152.
25. Kinzinger GSM, Wehrbein H, Byloff FK,
12. Poggio PM, Incorvati C, Velo S, Carano A. ‘‘Safe
Yildizhan F, Diedrich P. Innovative anchorage
zones’’: A guide for miniscrew positioning in the
alternatives for molar distalization—An
maxillary and mandibular arch. Angle Orthod
overview. J Orofac Orthop 2005;66:397–413.
2006;76:191–197.
26. Ohashi E, Pecho OE, Moron M, Lagravere MO.
13. Gracco A, Lombardo L, Cozzani M, Siciliani G.
Implant vs screw loading protocols in orthodon-
Quantitative cone-beam computed tomography
tics. Angle Orthod 2006;76:721–727.
evaluation of palatal bone thickness for ortho-
27. Kircelli BH, Pektas ZO, Kircelli C. Maxillary molar
dontic miniscrew placement. Am J Orthod
distalization with a bone-anchored pendulum
Dentofacial Orthop 2008;134:361–369.
appliance. Angle Orthod 2006;76:650–659.
14. Schlegel KA, Kinner F, Schlegel KD. The
28. Escobar SA, Tellez PA, Moncada CA, Villegas
anatomic basis for palatal implants in ortho-
CA, Latorre CM, Oberti G. Distalization of maxil-
dontics. Int J Adult Orthodon Orthognath Surg
lary molars with the bone-supported pendulum:
2002;17:133–139.
A clinical study. Am J Orthod Dentofacial
15. Ardekian L, Oved-Peleg E, Mactei EE, Peled M.
Orthop 2007;131:545–549.
The clinical significance of sinus membrane
perforation during augmentation of the maxil-
lary sinus. J Oral Maxillofac Surg 2006;64:
277–282.

345

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A CLINICAL EVALUATION OF Ruchi Saxena, BDS, MDS1

ORTHODONTIC MINI-IMPLANTS Priyanka Sethi Kumar, BDS,

MDS1

AS INTRAORAL ANCHORAGE Madhur Upadhyay, BDS,

MDS, FAGE2
FOR THE INTRUSION OF MAXILLARY Vijay Naik, MDS3
ANTERIOR TEETH
Aim: To determine the efficacy of mini-implants as intraoral anchor-
age during en masse intrusion of the six maxillary anterior teeth.
Methods: Ten patients from the Department of Orthodontics, KLE
University, Belgaum, India, who required intrusion of their anterior
teeth were selected for this study. After initial alignment and leveling,
the maxillary arch was divided into one anterior segment and two
posterior segments. A 0.021 ⫻ 0.025-inch stainless steel wire was
placed in all three segments. In all patients, one mini-implant was
placed bilaterally between the lateral incisor and canine. An elastic
chain was used to deliver an intrusive force of 45 cN; it was supple-
mented by a distal force of about 20 cN per side. Patient records were
taken at the beginning and end of intrusion. Results: The amount of
intrusion was statistically and clinically significant. The canines were
more intruded (3.5 ± 0.9 mm) than the incisors (2.9 ± 1.0 mm). The
axial inclination of the incisors did not significantly change. The aver-
age duration to accomplish this intrusion was 4.0 ± 1.5 months, with
a mean rate of 0.9 mm per month for the canines and 0.7 mm per
month for the incisors. Conclusion: Mini-implants are an efficient and
stable source of anchorage for the en masse intrusion of the six max-
illary anterior teeth. World J Orthod 2010;11:346–351.

1Postgraduate Student, Department

Key words: anchorage, mini-implants, en masse intrusion, deep bite, of Orthodontics and Dentofacial
anterior teeth Orthopedics, Institute of Dental
Sciences, KLE University, Belgaum,
India.
2Assistant Professor, Department of

Orthodontics and Dentofacial Ortho-

eep bites are frequently seen, and
D correcting them is a challenge for
even the most competent orthodontists.
posterior teeth is more dif ficult to pedics, Institute of Dental Sciences,
accomplish and maintain in nongrowing
as compared to growing individuals with
KLE University, Belgaum, India.
3Professor, Department of Orthodon-

tics and Dentofacial Orthopedics,

The literature reflects a great number of
correction modalities. Some investiga-
tors resort to leveling and aligning with
continuous archwires, whereas others
insists that deep bites are best treated
by pure incisor intrusion, especially in
patients with vertical growth (and there-
fore extrusion of the posterior teeth is
detrimental).1,2
It is widely accepted that the correc-
tion of deep bites by extrusion of the
a hypodivergent skeletal facial pat- Institute of Dental Sciences, KLE
tern.3,4 The possible relapse might be University, Belgaum, India.
caused by the occlusion, which is under
CORRESPONDENCE
the influence of the existing muscle
Dr Ruchi Saxena
function. 5 Thus, in patients with a Department of Orthodontics and
brachycephalic facial configuration, a Dentofacial Orthopedics
segmental intrusion is preferred.2 Institute of Dental Sciences
True intrusion is difficult to achieve. KLE University
Belgaum 590010
Still, with a segmental arch technique,
Karnataka
intrusion of the anterior teeth is feasible India
with minimal effects on the molars.2 Email: sruchi112@yahoo.com

346

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VOLUME 11, NUMBER 4, 2010
Fig 1 Intraoral view of a typical setup for the intrusion in this study. Elastic chains from the implants to crimpable hooks on
the anterior wire segment deliver an intrusive force of 45 cN per side, which is supplemented by a distal force of about 20 cN
per side delivered by an elastic chain running between the molar hooks and hooks at the end of the anterior wire segment.
Conventionally, intrusion is restricted
(at least initially) to only the incisors. The
en masse intrusion of all six anterior teeth
is very difficult in terms of vertical anchor-
age. Therefore, incisor intrusion is followed
by a separate intrusion of the canines.
However, mini-implants have proven to
permit the simultaneous intrusion of all
anterior teeth without adverse effects.6–8
The present study was undertaken to
clinically and cephalometrically evaluate
the efficacy of mini-implants as a source
of anchorage during en masse intrusion
of all six maxillary anterior teeth and to
determine the amount of intrusion
achieved in 6 months.
METHOD AND MATERIALS
The study sample consisted of 10 sub-
jects from the Department of Orthodon-
tics, KLE University, Belgaum, India. Ages
ranged from 14 to 24 years. All patients
had a deep bite with a steep mandibular
plane angle requiring intrusion of the
maxillary anterior teeth. Patients with
flared incisors or with periodontal dis-
ease were excluded.
Custom-made mini-implants (SK Surgi-
cal) were used in this study. Their diame-
ter was 1.3 mm and their length 8.0 mm.
The most suitable implant placement site
for en masse intrusion was the alveolar
bone between the lateral incisors and
canines bilaterally at the junction of the
gingiva and oral mucosa (Fig 1). The
availability of sufficient interdental bone
made this the preferred location for
implant insertion. To keep the procedure
minimally invasive, no third implant was
placed between the roots of the maxillary
central incisors.7,8
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NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Saxena et al
The implant site’s bone quality and
quantity were evaluated with panoramic
and periapical radiographs. For every
patient, a surgical guide bar consisting of
a stainless steel wire embedded in
acrylic that rested on the palatal surface
of the maxilla was fabricated. The wire
indicated the potential implant site. Peri-
apical radiographs with the guide bar
were taken to identify the precise implant
location so as to avoid root trauma. All
implants were placed while the patients
were under local anesthesia.
After placement, the implants’ primary
stability was checked with a probe. Peri-
apical radiographs were taken again to
confirm the implants’ position. Lateral
cephalograms were also taken.
After initial alignment and leveling, the
maxillary dental arch was divided into two
posterior segments and one anterior seg-
ment extending from canine to canine. A
0.021 ⫻ 0.025-inch stainless steel arch-
wire was placed in all segments. In the
anterior segment, crimpable hooks were
fastened bilaterally between the lateral
incisors and the canines.
The mini-implants were immediately
loaded. A calibrated Dontrix gauge was
used to measure the intrusive force,
which amounted to 45 cN per side, using
prestretched elastic chains. To prevent
eventual flaring of incisors, an additional
distal force of about 20 cN per side was
applied using prestretched elastic chains
extending from the molar hooks to hooks
incorporated into the anterior wire seg-
ment distal to the canines. All patients
were recalled in 4-week intervals, at
which point the elastic chains were
replaced. The implants were also
checked for mobility at each appoint-
ment. Mobility can be a consequence of
347
 Saxena et al WORLD JOURNAL OF ORTHODONTICS

Fig 2 (left) Cephalometric

landmarks used in this study
for data acquisition. ANS, ante-
rior nasal spine; PNS, posterior
nasal spine; Ia, incisor root
apex; Io, incisor edge; and Co,
canine cusp tip.

Fig 3 (right) Maxillary incisor

PNS Ia ANS PNS ANS intrusion measured as the per-
pendicular distance between
Io and ANS–PNS (red).
Co
Io Io

Fig 4 (left) Maxillary central

incisor inclination measured as
posterior angle between Io–Ia
and ANS–PNS (red).

Fig 5 (right) Maxillary canine

intrusion measured as the per-
pendicular distance between
PNS ANS Co and ANS–PNS (red).
PNS ANS

Co
UL1

inflammation at the implant site due to Cephalometric data

poor oral hygiene. 9 Care was taken to
guarantee adequate hygiene.
At the end of intrusion, another lateral
cephalogram was taken and compared
with the preintrusion one to evaluate
changes.
Treatment changes
evaluation
Three cephalometric variables were ana-
lyzed on the pre- and posttreatment
cephalograms. The rate of intrusion in
mm per month was derived by dividing
the mean amount of intrusion by the
mean treatment time recorded.
The respective landmarks and measure-
ment planes are depicted in Figs 2 to 5.
The following measurements were per-
formed:
• Central incisor intrusion—decrease of
distance between the incisal edge of
the maxillary central incisor and the
palatal plane (Fig 3)
• Central incisor inclination change—
change in the posteroinferior angle
between the palatal plane and the long
axis of maxillary central incisor (Fig 4)
• Canine intrusion—decrease of dis-
tance change between the cusp tip
maxillary of the canine and the palatal
plane (Fig 5)

Means and standard deviations were

calculated, and inferential statistics such
as the paired t test and Wilcoxon test
were used.

348

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VOLUME 11, NUMBER 4, 2010 Saxena et al

Table 1  Amount of incisor intrusion (in mm) in Table 2  Amount of incisor inclination change
the individual patients, means, and standard (in degrees) in the individual patients, means,
deviations (SD) and standard deviations (SD)
Patient Preintrusion Postintrusion Difference Patient Preintrusion Postintrusion Difference
1 29.0 25.0 4.0 1 122 120 2
2 32.0 29.0 3.0 2 122 122 0
3 32.0 28.0 4.0 3 114 112 2
4 31.0 27.0 4.0 4 113 115 –2
5 35.0 32.0 3.0 5 108 99 9
6 29.0 27.5 1.5 6 120 120 0
7 32.0 30.0 2.0 7 111 103 8
8 29.0 27.0 2.0 8 113 111 2
9 29.0 27.5 1.5 9 122 120 2
10 32.0 29.0 3.0 10 122 122 0
Mean 31.0 28.2 2.8 Mean 116.7 114.4 2.3
SD 2.0 1.9 1.0 SD 5.5 7.9 3.6

Table 3  Amount of canine intrusion (in mm) in

the individual patients, means, and standard
deviations (SD)
Patient Preintrusion Postintrusion Difference

1 26.0 21.0 5.0

2 32.0 28.0 4.0
3 28.0 24.0 4.0
4 30.0 25.0 4.0
5 31.0 28.0 3.0
6 26.0 23.5 2.5
7 30.0 27.0 3.0
8 24.5 22.0 2.5
9 26.0 23.5 2.5
10 32.0 28.0 4.0
Mean 28.6 25.0 3.5
SD 2.8 2.6 0.9

RESULTS Amount of canine intrusion

Amount of incisor intrusion The amount of canine intrusion was 3.5 ±

The amount of incisor intrusion was 2.8 ±
1.0 mm. The P value (< .0001) and the t
value (8.806) for this variable show that
this change in value is statistically signifi-
cant (Table 1).
0.9 mm. The P value (< .0001) and the t
value (12.124) for this variable show that
this change in value is statistically signifi-
cant (Table 3).
Duration and rate of intrusion

Amount of incisor angular The average duration of intrusion was

change 4.0 ± 1.5 months; the intrusion rate of
the incisors and the canines was 0.7 mm
The mean incisor retrusion amounted to per month and 0.9 mm per month,
2.3 ± 3.6 degrees. The P value (.0985) and respectively.
the Wilcoxon test value (0.0937) for this
variable show that this change in value is
not statistically significant (Table 2).

349

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 Saxena et al
DISCUSSION
Intrusion of the anterior teeth
True intrusion takes place when forces are
directed through the center of resistance.1
If the intrusive force is applied anteriorly to
the center of resistance of a unit, flaring
results. However, there is no chance for
incisor flaring if implants are placed bilater-
ally between the lateral incisors and the
canines as they were in this study. The cen-
ter of resistance of the six maxillary anterior
teeth is estimated to be halfway between
the center of resistance of the four incisors
and that of the canines.10 To absolutely
exclude any flaring, a distal force of about
20 cN per side was additionally applied.
Very light forces of 15 to 20 cN per
tooth are recommended for intrusion.1,2 It
has been documented that the use of
heavier forces will not increase the rate of
intrusion, but may lead to root
resorption. 11 In the present study, en
masse intrusion was attempted, so an
intrusive force of 45 cN per side was
applied with a prestretched elastic chain.
Prestretching of elastomeric chains has
been suggested to reduce the rapid force
decay otherwise observed.12
The anterior teeth in this study were
intruded a mean of 2.9 ± 1.0 mm, which
is clinically and statistically significant.
According to a meta-analysis, 13 1.5 to
2.7 mm of incisor intrusion is routinely
attainable with conventional mechanics.
Buraiki et al,14 however, reported intru-
sion up to 4.0 mm. The results of this
study are in concurrence with others. The
major advantage in the present trial was
that all the six anterior teeth could be
intruded at the same time, thereby reduc-
ing the total treatment duration.
The incisors were retruded a mean
2.3 ± 3.6 degrees, which is not signifi-
cant. This angulation change is too small
to be of clinical importance, besides that
it obscures some of the intrusion. Angu-
lar changes up to 10 degrees do not have
a significant effect on any vertical linear
measurements.15 In this study, none of
the teeth changed angulation more than
10 degrees. This also means that the
applied force was enough to control
incisor inclination.
350
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WORLD JOURNAL OF ORTHODONTICS
Sayn et al16 and Iseri et al17 used the
Frankfort horizontal plane and the SN
line, respectively, as a reference line to
evaluate the vertical movement of the
canines, whereas in the present study,
the ANS–PNS line was used. Though all
six maxillary anterior teeth were intruded
en masse, the canines demonstrated
more intrusion (3.5 ± 0.9 mm) than the
incisors. Besides, the canines intruded
much earlier than the incisors, which
resulted in a slight curving of the wire
segment. The probable reason for this
observation is that the force application
point was closer to the canines than to
all four incisors.
Implant stability
Soft tissue overgrowth was minimized by
partial insertion, leaving two or three
threads out of the bone. Thus, hygiene
could be easily maintained,18 which is
why no periodontal complications were
observed.
All implants showed primary stability
and were immediately loaded.19 This is in
contrast to some clinicians who require a
waiting period between 2 weeks and 3
months.20–22
Two of the mini-implants in this study
showed mobility during intrusion, ie, they
tipped occlusally. A possible explanation for
this incident is that fibrous tissue may have
formed between the implant and the bone,
acting as a periodontal ligament.23 Accord-
ing to Liou et al,24 implants do not have to
remain stationary under loading as long as
the treatment objectives are achieved. How-
ever, any displacement can harm adjacent
periodontal ligaments. In this study, ade-
quate clearance between the mini-implants
and the roots was maintained. Neverthe-
less, even if roots come into contact with
implants, the roots are repaired once the
mini-implants are removed.17
This study was focused mainly on
attainable intrusion. By avoiding continu-
ous leveling, more true intrusion was
achieved. However, the amount of canine
intrusion has to be seen critically, as it is dif-
ficult to define their cusp tips on conven-
tional lateral cephalograms because they
are superimposed by various structures.
VOLUME 11, NUMBER 4, 2010
Elastomeric chains were used instead
of Ni-Ti coil springs for intrusion to prevent
soft tissue irritation of the upper lip. How-
ever, the superiority of Ni-Ti coil springs in
terms of light continuous force delivery on
a long range cannot be denied.
CONCLUSION
The following conclusions were drawn
from this study:
• The amount of intrusion achieved with
mini-implants as a rigid source of
anchorage for en masse intrusion of
the maxillary anterior teeth was statis-
tically and clinically significant.
• The amount of intrusion achieved
amounted to 2.9 ± 1.0 mm for the
incisors and 3.5 ± 0.9 mm for the
canines. The reason for this difference
is probably that the point of force appli-
cation in this study was closer to the
canines than the incisors. The inclina-
tion of the incisors hardly changed.
• The mean duration for intrusion was
4.0 ± 1.5 months; the mean rate of
canine intrusion was 0.9 mm per
month and that of the incisors was
0.7 mm per month.
REFERENCES
1. Burstone CB. Deep overbite correction by intru-
sion. Am J Orthod 1977;72:1–22.
2. Weiland FJ, Bantleon HP, Droschl H. Evaluation
of continuous arch and segmented arch level-
ing techniques in adult patients—A clinical
study. Am J Orthod Dentofacial Orthop 1996;
110:647–652.
3. Bell WH, Jacobs JD, Legan HL. Treatment of
Class II deep bite by orthodontic and surgical
means. Am J Orthod 1984;85:1–20.
4. McDowell EH, Baker IM. The skeletodental
adaptations in deep bite correction. Am J
Orthod Dentofacial Orthop 1991;100:370–375.
5. McNamara JA Jr. Histologic and cephalometric
responses to increased vertical dimension in
the mature face. J Dent Res 1974;53:147.
6. Creekmore TD, Eklund MK. The possibility of
skeletal anchorage. J Clin Orthod 1983;17:
266–269.
7. Ohnishi H, Yagi T, Yasuda Y, Takada K. A mini-
implant for orthodontic anchorage in a deep
overbite case. Angle Orthod 2005;75:444–452.
© 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Saxena et al
8. Kim, TW, Kim H, Lee SJ. Correction of deep
overbite and gummy smile by using a mini
implant with a segmented wire in a growing
Class II Division 2 patient. Am J Orthod Dento-
facial Orthop 2006;130:676–685.
9. Favero L, Brollo P, Bressan E. Orthodontic
anchorage with specific fixtures: Related study
analysis. Am J Orthod Dentofacial Orthop 2002;
122:84–94.
10. Melson B, Fortis V, Burstone CJ. Vertical force
considerations in differential space closure.
J Clin Orthod 1990;24:678–683.
11. Melson B, Agerbaek N, Makenstam G. Intrusion
of incisors in adult patients with marginal bone
loss. Am J Orthod Dentofacial Orthop 1989;96:
232–241.
12. Baty LD, Storie JD, von Fraunhofer AJ. Synthetic
elastomeric chains. A literature review. Am J
Orthod Dentofacial Orthop 1994;105:536–542.
13. Ng J, Major PW, Heo G, Flores-Mir C. True
incisor intrusion attained during orthodontic
treatment: A systematic review and meta-analy-
sis. Am J Orthod Dentofacial Orthop 2005;128:
212–219.
14. Buraiki HA, Sadowsky C, Schneider B. The
effectiveness and long-term stability of overbite
correction with incisor intrusion mechanics. Am
J Orthod Dentofacial Orthop 2005;127:47–55.
15. Bernstein RL, Preston CB, Lampasso J. Level-
ling the curve of Spee with a continuous arch-
wire technique: A long term cephalometric
study. Am J Orthod Dentofacial Orthop 2007;
131:363–371.
16. Sayn S, Beng O, Guton A, Ortakogen K. Rapid
canine distalization using distraction of the
periodontal ligament: A prelimnary clinical vali-
dation of the original technique. Angle Orthod
2004;74:304–315.
17. Iseri H, Kisnisci R, Bzizi N, Tuz H. Rapid canine
retraction and orthodontic treatment with den-
toalveolar distraction osteogenesis. Am J
Orthod Dentofacial Orthop 2005;127:533–541.
18. Kravitz ND, Kusnoto B: Risks and complica-
tions of orthodontic mini screw. Am J Orthod
2007;131:S43–S51.
19. Miano GB, Bednar J, Pagin P, Mura P. The spi-
der screw for skeletal anchorage. J Clin Orthod
2003;37:90–97.
20. Gainsforth BL, Higley LB. A study of orthodontic
anchorage possibilities in basal bone. Am J
Orthod Oral Surg 1945;31:406–417 .
21. Linkow L. Implanto-orthodontics. J Clin Orthod
1970;4:685–705.
22. Kyung HM, Park HS, Bae SM. Handbook for the
Absoanchor Orthodontic Microimplant, ed 3,
2004: 20–21.
23. Miyaki S, Koyana I, Inove M, Mishama K, Sug-
hara T, Yamamoto T. Factors associated with the
stability of titanium screws placed in the poste-
rior region for orthodontic anchorage. Am J
Orthod Dentofacial Orthop 2003;124:373–378.
24. Liou EJW, Pai BCJ, Lin JC. Do miniscrews
remain stationary under orthodontic forces. Am
J Orthod Dentofacial Orthop 2004;126:42–47.
351
EVALUATION OF THE STABILITY OF Abraham B. Lifshitz, DDS,
MS1

SELF-DRILLING MINI-IMPLANTS Mónica Muñoz, DDS, MS2

FOR MAXILLARY ANCHORAGE UNDER

IMMEDIATE LOADING
Aim: To evaluate the stability of self-drilling mini-implants used for
immediate en masse retraction of all anterior teeth. Methods: Six
patients with 12 self-drilling mini-implants (diameter 1.6 mm, length
6.0 mm), which were placed on each side between the maxillary first
molar and second premolar, were evaluated. The mini-implants were
loaded immediately after placement with a force of 200 cN. Lateral
cephalograms were taken upon loading (T1) and after 6 months of
retraction (T2). All T1 and T2 radiographs were analyzed by localizing
the anterior border of the mini-implant heads. Their vertical displace-
ment was measured in millimeters to the Frankfort plane; the hori-
zontal displacement was measured to a line perpendicular to the
Frankfort plane registered at sella. Results: Analysis of variance
revealed a significant difference for the horizontal (P < .05) but not for
the vertical pre- and posttreatment position. Conclusion: Mini-
implants provide good anchorage for the retraction of teeth. How-
ever, the self-drilling mini-implants used in this study did not remain
absolutely stationary like osseointegrated implants. With loading,
they moved in the direction of the applied force, but their displace-
ment had no clinical impact. World J Orthod 2010;11:352–356.

Key words: mini-implants, immediate load, en masse retraction, stability

number of authors1–4 have described
A the characteristics of an ideal skeletal
anchorage for orthodontic patients: bio-
compatibility, small dimension, easy clini-
cal application, favorable primary stability
and retention for ordinary orthodontic
forces, applicability with contemporary
orthodontic mechanics, equivalent or bet-
ter results than traditional anchorage sys-
vide clinicians with the smallest, easiest-
to-use, least invasive, most versatile, and
economical skeletal anchorage. They
also allow clinicians to load them imme-
diately after placement.1,13–16
1Professor, Department of Orthodon-
Mini-implants were introduced in
tics, College of Dental Medicine,
orthodontics as temporary anchorage Nova Southeastern University, Fort
devices for canine retraction, incisor Lauderdale, Florida, USA.
retraction, en masse anterior retraction, 2Former Graduate Student, Depart-

tems, easy removal, and reasonable cost.
Several variations of orthodontic
skeletal anchorage including osseous
wires, 5,6 flat screws, 7,8 or thodontic
implants, 9,10 plate systems, 1,11,12 and
miniscrews (mini-implants) now exist. All
have inherent advantages and disadvan-
tages, but it seems that mini-implants
meet the aforementioned requirements
better than all others. Mini-implants pro-
molar uprighting, and retraction and pro-
traction of posterior teeth.1,17–20 Their
small size allows their use in various
sites, while their simple placement and
removal and ability to be immediately
loaded adds to their attractiveness.
Orthodontists currently use two types
of mini-implants: self-drilling and those
that need a pilot hole prior to placement.
Both varieties remain stationary primarily
ment of Orthodontics, College of
Dentistry, Intercontinental Univer-
sity, Mexico City, Mexico.
CORRESPONDENCE
Dr Abraham B. Lifshitz
Department of Orthodontics
College of Dental Medicine
Nova Southeastern University
3200 South University Drive
Fort Lauderdale, Florida 33328
Email: al674@nova.edu

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VOLUME 11, NUMBER 4, 2010
Fig 1 (a) The self-drilling
mini-implant used in this study.
(b) A mini-implant placed
between the maxillary first
molar and second premolar.
a b
Fig 3 (right) Cephalogram
with reference planes (red) for
the horizontal and vertical dis-
placement measurement
(blue).
Fig 2 (left) Force measure-
ment with a Dontrix Orthodon-
tic Stress and Tension Gauge.
due to mechanical retention.17,21 Kim et
al 22 repor ted that self-drilling mini-
implants had less mobility and more
bone-to-implant contact. Liou et al23 stud-
ied the behavior of mini-implants under
loading 2 weeks after insertion in the
maxillary zygomatic buttress for en masse
retraction of the anterior teeth. They
showed that mini-implants provide stable
anchorage. Although the screw heads
tipped forward, they displayed overall
insignificant displacement.
The behavior of self-drilling mini-
implants under immediate loading is not
yet clarified, however, and this study
therefore evaluates that phenomenon.
PATIENTS AND METHODS
Mini-implants were placed bilaterally
between the maxillary first molar and sec-
ond premolar by the same, right-handed
operator as direct anchorage for en masse
retraction of the maxillary anterior teeth in
six patients (Figs 1a and 1b). The mini-
implants had a diameter of 1.6 mm and
were 6.0 mm long (MOSAS Dewimed Medi-
zintechnik). They were immediately loaded
with 200 cN of force using an elastomeric
chain. The force was measured with a pre-
cision spring scale (Dontrix Orthodontic
Stress and Tension Gauge, Ormco; Fig 2).
The patients were seen every 2 weeks,
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Lifshitz/Muñoz
at which point the retraction force was
readjusted. One mini-implant became
loose during the observation period, which
left 11 implants for the final analysis.
To asses the difference between the left
and right mini-implant, all lateral cephalo-
metric radiographs upon loading (T1) and
after 6 months of retraction (T2) were
taken with a 5-degree rotation to the right.
On these radiographs, the anterior border
of each mini-implant head was located and
its vertical distance to the Frankfurt hori-
zontal plane was measured in millimeters.
The horizontal changes were measured to
a line perpendicular to the Frankfort plane
registered at sella (Fig 3). All measure-
ments were registered with Sidexis XG
imaging software (Sirona Dental X-Ray
Imaging System neXt Generation).
RESULTS
Means, standard deviations, minimum
and maximum values, variance, and vari-
ation coefficients for each measurement
are found in Tables 1 and 2. The anterior
border of the mini-implants were 2.7 ±
2.1 mm horizontally displaced (variation
coefficient 0.8); the vertical displace-
ment amounted to 0.2 ± 2.7 mm (varia-
tion coefficient 17.1). Only the horizontal
displacement between T1 and T2 was
significant (P < .05) (Tables 3 and 4).
353
 Lifshitz/Muñoz WORLD JOURNAL OF ORTHODONTICS

Table 1  Descriptive statistics for the horizontal and vertical distances of the mini-implant heads to the respective
reference lines (compare to Fig 3) upon loading (T1) and 6 months later (T2)
T1 T2
Variation Variation
Mean SD Min Max Variance coefficient Mean SD Min Max Variance coefficient

Horizontal 50.7 8.5 38.5 63.3 72.0 0.2 53.4 8.0 41.5 64.9 63.4 0.1
Vertical 39.8 4.9 33.6 45.0 23.6 0.1 40.0 5.0 33.1 47.3 24.6 0.1

SD = standard deviation, min = minimum, max = maximum.

Table 2  Descriptive statistics for horizontal and vertical displacement of the mini-
implant heads to the respective reference lines (compare to Fig 3) between
loading (T1) and 6 months later (T2)
T2–T1

Mean SD Min Max Variance Variation coefficient

Horizontal 2.7 2.1 –0.7 5.5 4.4 0.8

Vertical 0.2 2.7 –5.2 3.3 7.4 17.1

SD = standard deviation, min = minimum, max = maximum.

Table 3  ANOVA for the horizontal displacement of the mini-implant heads to the
respective reference lines (compare to Fig 3)
Source of variation SS df MS F P F crit

Between groups 39.906 1 39.906 0.589 .451 4.351

Within groups 1353.529 20 67.676
Total 1393.435 21

SS = sum of squares, df = degrees of freedom, MS = mean square.

Table 4  ANOVA for vertical displacement of the mini-implant heads to the respective
reference lines (compare to Fig 3)
Source of variation SS df MS F P F crit

Between groups .013 1 0.139 0.005 .940 4.351

Within groups 481.656 20 24.082
Total 481.795 21

SS = sum of squares, df = degrees of freedom, MS = mean square.

DISCUSSION force to intrude maxillary central incisors

Orthodontists consider anchorage preser-
vation and loss to be most important. No
anchorage control concept (headgear, lip
bumpers, Nance holding arches, tip-back
bends, lingual arches, uprighting springs,
sectional mechanics, or dual-arch
mechanics) can completely prevent
anchorage loss.
The era of skeletal anchorage started
in 1945 with the failed experiment of
Gainsforth and Higley, 24 who placed
screws in mongrel dog jaws. It was only in
1983 that Creekmore and Eklund 25
inserted a surgical vitallium screw under
the nasal spine and used light continuous
6 mm. For 1 year, the surgical screw did
not move, and it was still stable during its
removal.
Wehrbein et al26 were the first to intro-
duce an implant system specific to ortho-
dontic use (Orthosystem, Straumann).
These implants were predominately
inserted in the palate.
Mini-implants are most frequently
placed interdentally in the maxilla.27–30
However, the infrazygomatic crest of the
maxilla,17,29–31 the area below the ante-
rior nasal spine, 1.33–35 and the hard
palate16 are also considered adequate
insertion sites.

354

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VOLUME 11, NUMBER 4, 2010
Although investigators have found
mild osseointegration with both predrilled
and self-drilling mini-implants, Kim et al22
recommended the use of self-drilling
mini-implants because they displayed
more bone-to-implant contact and less
mobility. Endosseous implants or palatal
onplants require a waiting period of 2 to
6 months33,36–41 for complete osseointe-
gration, after which the devices with-
stand forces and remain stable.42–44 In
another study, 23 17-mm self-tapping
mini-implants were inserted into the max-
illary zygomatic buttress. Two weeks
later, they provided stable anchorage for
orthodontic tooth movement; however,
they did not remain absolutely stationary
as is the case with endosseous implants.
Wang and Liou45 found similar loading
behavior with predrilled and self-drilling
mini-implants placed into the infrazygo-
matic crest of the maxilla that correlated
to the amount of displacement with the
duration of loading.
Some authors suggested not waiting
before loading orthodontic mini-implants
since the mechanical retention offers suf-
ficient resistance.17,21,42 Wu et al,46 on the
other hand, mentioned that osseous inte-
gration of titanium mini-implants is weak
during the first 2 weeks, and loading dur-
ing this time may therefore compromise
stability. The osseointegration of titanium
mini-implants increases until 4 weeks
after insertion, thereby offering more
safety upon loading. The biomechanical
stability and histomorphometric implant-
bone contacts continued to increase after
8 weeks of healing, suggesting that clini-
cians can apply forces between 4 to 8
weeks after implant placement.
The misplacement of mini-implants
can have serious consequences if adja-
cent structures, such as dental roots,
nerves, and blood vessels, are harmed.
The interradicular space between the first
molar and second premolar, 5 to 8 mm
from the alveolar crest,47 offers the best
site for the buccal placement of mini-
implants.
Since mini-implants provide only tem-
porary anchorage, clinicians remove them
after they are no longer needed. Thus,
mini-implants need to remain stable only
long enough to achieve the intended goal.
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NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Lifshitz/Muñoz
CONCLUSION
Mini-implants provide excellent anchor-
age for orthodontic tooth movements.
The self-drilling mini-implants used in this
study did not remain absolutely station-
ary like endosseous implants, but they
moved minimally according to the direc-
tion of the orthodontic force. Their dis-
placement did not have any clinical
significance.
REFERENCES
1. Kanomi R. Mini-implant for orthodontic anchor-
age. J Clin Orthod 1997;31:763–767.
2. Cope JB. Temporary anchorage devices in
orthodontics: A paradigm shift. Semin Orthod
2005; 11:3–9.
3. Gray JB, Smith R. Transitional implants for
orthodontic anchorage. J Clin Orthod 2000;34:
659–666.
4. Miyawaki S, Koyama I, Inoue M, Mishima K,
Sugahara T, Takano-Yamamoto T. Factors asso-
ciated with the stability of titanium screws
placed in the posterior region for orthodontic
anchorage. Am J Orthod Dentofacial Orthop
2003;124:373–378.
5. Melsen B, Petersen JK, Costa A. Zygoma liga-
tures: An alternative form of maxillary anchor-
age. J Clin Orthod 1998;32:154–158.
6. Sfondrini MF, Cacciafesta V, Sfondrini D. The
uprighting of mesially tipped and impacted
mandibular second molars. The use of the
mandibular ramus as orthodontic anchorage.
Orthodontics 2004;1:3–12.
7. Bondemark L, Feldmann I, Feldmann H. Distal
molar movement with an intra-arch device pro-
vided with the Onplant System for absolute
anchorage. World J Orthod 2002;3:117–124.
8. Triaca A, Antonini M. Ein nenes Titanflach-
schrauben-Implantat zur orthodontischen Ver-
ankerung am anterioren Ahumeen. Inf Orthod
Kieferorthop 1992;24:251–257.
9. Wehrbein H, Glatzmaier J, Mundwiller U,
Diedrich P. The Orthosystem—A new implant
system for orthodontic anchorage in the palate.
J Orofac Orthop 1996;57:142–153.
10. Maino BG, Mura P, Gianelly AA. A retrievable
palatal implant for absolute anchorage in
orthodontics. World J Orthod 2002;3:125–134.
11. De Clerck H, Geerinckx V, Siciliano S. The
Zygoma Anchorage System. J Clin Orthod
2002;36:455–459.
12. Erverdi N, Baysal B, Cajkirer B. Intrusion of
overerupted molars by zygomatic implant
anchorage in an adult orthoprosthetic patient.
Orthodontics 2003;1:99–105.
13. Bumann A. Mini-screws: A multitude of possibil-
ities. Ortho Tribune 2006;1:4–5.
355
 Lifshitz/Muñoz
14. Garagiola U, Nishiyama K, Szabo G. Skeletal
anchorage for tooth movements: Mini-implants
vs osseointegrated implants. World J Orthod
2005;6(suppl):117–118.
15. Herman R, Cope JB. Miniscrew implants: IMTEC
mini ortho implants. Semin Orthod 2005;11:
32–39.
16. Park HS, Jeong SH, Kwon OW. Factors affecting
the clinical success of screw implants used as
orthodontic anchorage. Am J Orthod Dentofa-
cial Orthop 2006;130:18–25.
17. Costa A, Raffainl M, Melsen B. Miniscrews as
orthodontic anchorage: A preliminary report.
Int J Adult Orthodon Orthognath Surg 1998;13:
201–209.
18. Park HS, Bae SM, Kyung HM, Sung JH. Micro-
implant anchorage for treatment of skeletal
Class I bialveolar protrusion. J Clin Orthod
2001;35:417–422.
19. Lee JS, Park HS, Kyung HM. Micro-implant for
lingual treatment of a skeletal Class II maloc-
clusion. J Clin Orthod 2001;35:643–647.
20. Lin JC, Liou EJ, Liaw JL. The survey and evalua-
tion for the implant-assisted orthodontics. J Tai-
wan Orthod Assoc 2001;13:14–21.
21. Melsen B, Verna C. A rational approach to ortho-
dontic anchorage. Prog Orthod 1999;1:10–22.
22. Kim JW, Ahn SJ, Chang YI. Histomorphometric
and mechanical analyses of the drill-free screw
as orthodontic anchorage. Am J Orthod Dento-
facial Orthop 2005;128:190–194.
23. Liou EJW, Pai BCJ, Lin JCY. Do miniscrews
remain stationary under orthodontic forces? Am
J Orthod Dentofacial Orthop 2004;126:42–47.
24. Gainsforth BL, Higley LB. A study of orthodontic
anchorage possibilities in basal bone. Amer
Jour Orthod Oral Surg 1945;31:406–417.
25. Creekmore TD, Eklund MK. The possibility of
skeletal anchorage. J Clin Orthod 1983;17:
266–269.
26. Wehrbein H, Glatzmaier J, Mundwiller U,
Diedrich P. The Orthosystem—A new implant
system for orthodontic anchorage in the palate.
J Orofac Orthop 1996;57:142–153.
27. Park HS, Bae SM, Kyung HM, Sung JH. Micro-
implant anchorage for treatment of skeletal
Class I bialveolar protrusion. J Clin Orthod
2001;35:417–422.
28. Lee JS, Park HS, Kyung HM. Micro-implant for
lingual treatment of a skeletal Class II maloc-
clusion. J Clin Orthod 2001;35:643–647.
29. Schnelle MA, Beck FM, Jaynes RM, Huja SS.
A radiographic evaluation of the availability of
bone for placement of miniscrews. Angle
Orthod 2004;74:832–837.
30. Park HS, Kwon TG, Sung JH. Nonextraction
treatment with miniscrew implant. Angle
Orthod 2004;74:539–549.
31. Melsen B, Costa A. Immediate loading of
implants used for orthodontic anchorage. Clin
Orthod Res 2000;3:23–28.
32. Kuroda S, Katayama A, Takano-Yamamoto T.
Severe anterior open-bite case treated using
titanium screw anchorage. Angle Orthod 2004;
74:558–567.
356
© 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
WORLD JOURNAL OF ORTHODONTICS
33. Kanomi R, Takada K. Application of titanium
mini-implant system for orthodontic anchorage.
In: Davidovitch Z, Mah J (eds). Biological
Mechanics of Tooth Movement and Craniofa-
cial Adaptation. Boston: Harvard Society for the
Advancement of Orthodontics, 2000:253–258.
34. Roberts WE, Marshall KJ, Mozsary PG. Rigid
endosseous implant utilized as anchorage to
protract molars and close an atrophic extrac-
tion site. Angle Orthod 1990;60:135–152.
35. Roberts WE, Nelson CL, Goodacre CJ. Rigid
implant anchorage to close a mandibular first
molar extraction site. J Clin Orthod 1994;28:
693–704.
36. Roberts WE, Arbuckle GR, Analoui M. Rate of
mesial translation of mandibular molars using
implant-anchored mechanics. Angle Orthod
1996;66:331–338.
37. Odman J, Lekholm U, Jemt T, Thilander B.
Osseointegrate implants as orthodontic anchor-
aged in the treatment of partially edentulous
patients. Eur J Orthod 1994;16:187–201.
38. Roberts WE. Bone tissue interface. J Dent Educ
1988;52:804–809.
39. Roberts WE. Adjunctive orthodontic therapy in
adults over 50 years of age. Clinical manage-
ment of compensated, partially edentulous mal-
occlusion. J Indiana Dent Assoc 1997;76:33–41.
40. Roberts WE. Bone dynamics of osseointegra-
tion, ankylosis, and tooth movement. J Indiana
Dent Assoc 1999;78:24–32.
41. Chen J, Esterle M, Roberts WE. Mechanical
response to functional loading around the
threads of retromolar endosseous implants uti-
lized for orthodontic anchorage: Coordinated his-
tomorphometric and finite element analysis. Int
J Oral Maxillofac Implants 1999;14:282–289.
42. Saito S, Sugimoto N, Morohashi T, et al.
Endosseous titanium implants as anchors for
mesiodistal tooth movement in the beagle dog.
Am J Orthod Dentofacial Orthop 2000;118:
601–607.
43. De Pauw GAM, Dermaut LR, Johansson CB,
Martens G. A hisotmorphometric analysis of
heavily loaded and nonloaded implants. Int J
Oral Maxillofac Implant 2002;17:405–412.
44. Costa A, Dalstra M, Melsen B. L’Aarthus
anchorage system. Ortognatodonzia Italiana
2000;9:487–496.
45. Wang Y-C, Liou EJW. Comparison of the loading
behavior of self-drilling and predrilled mini-
screws throughout orthodontic loading. Am J
Orthod Dentofacial Orthop 2008;133:38–43.
46. Wu J, Bai Y-X, Wang B-K. Biomechanical and
histomorphometric characterizations of
osseointegration during mini-screw healing in
rabbit tibiae. Angle Orthod 2009;79:558–563.
47. Poggio PM, Incorvati C, Velo S, Carano A. “Safe
zones”: A guide for miniscrew positioning in the
maxillary and mandibular arch. Angle Orthod
2006;76:191–197.
Tancan Uysal, DDS, PhD1
INVESTIGATION OF BACTEREMIA
Ahmet Yagci, DDS2
FOLLOWING INSERTION OF ORTHODONTIC
Duygu Esel, MD3
MINI-IMPLANTS
Sabri Ilhan Ramoglu, DDS,
PhD2
Aim: To investigate the incidence of bacteremia in the bloodstream
immediately after orthodontic mini-implant insertion, which can be
Aytekin Kilinc, MD4
an invasive procedure. Methods: Blood samples (10 mL) were taken
before and after mini-implant insertion from 40 patients (18 males, 22
females; mean age 21.3 ± 7.7 years). These samples were inoculated
into BacT/Alert aerobic and anaerobic blood culture bottles and
processed in a BacT/Alert 9240 Blood Culture System. The findings
were analyzed with the McNemar test. Results: No bacteremia was
detected in the pretreatment samples, but it was in one of the post-
procedure samples. The respective bacteria was Streptococcus san-
guinis, which is strongly associated with bacterial endocarditis.
Conclusion: Orthodontic mini-implant placement might possibly be
correlated to transitory bacteremia. Therefore, a very careful
approach seems indicated when dealing with patients who are at risk
for cardiopathic complications. World J Orthod 2010;11:357–361.

Key words: bacteremia, mini-implant, blood sample, Streptococcus

sanguinis, endocarditis

he transient presence of bacteria (or Degling6 first investigated the risk of

1Associate Professor and Chair,
Department of Orthodontics, Faculty
of Dentistry, Erciyes University,
Kayseri, Turkey; Visiting Professor,
King Saud University, Riyadh, Saudi
Arabia.
2Assistant Professor, Department of
Orthodontics, Faculty of Dentistry,
Erciyes University, Kayseri, Turkey.
3Associate Professor, Department of
Microbiology, Faculty of Medicine,
Erciyes University, Kayseri, Turkey.
4Research Assistant, Department of
Microbiology, Faculty of Medicine,
Erciyes University, Kayseri, Turkey.
CORRESPONDENCE
Dr Tancan Uysal
Erciyes Universitesi
Dis Hekimligi Fak. Ortodonti AD
Melikgazi, Kayseri
Turkey 38039
Email: tancanuysal@yahoo.com
T other microorganisms) in the blood is
referred to as bacteremia. It is well
known that bacteria can enter the blood-
stream af ter dental procedures. 1–5
These procedures include local anesthe-
sia, extraction, periodontal surgery, root
scaling, root canal filling, and insertion
of orthodontic bands.6–12
In its 2007 recommendation on the
prevention of bacterial endocarditis, the
American Heart Association (AHA) stipu-
lates antibiotic prophylaxis for patients
who undergo any dental procedure that
involves the periapical region, bleeding
of the gingiva, or the oral mucosa. 13
Examples of such procedures are biop-
sies, suture removals, and placement of
orthodontic bands. Not included are rou-
tine injections through noninfected tis-
sue, dental radiographs, manipulations
of removable prosthodontic or orthodon-
tic appliances, orthodontic bonding, and
adjustment of orthodontic appliances.
bacteremia after orthodontic procedures.
He found that band placement did not
lead to bacteremia, though transient bac-
teremia was reported in several later clin-
ical investigations.7–12 The prevalence of
bacteremia following alginate impres-
sions amounted to 31%, 36% after place-
ment of separators, 44% after fitting and
inserting molar bands, and 19% after
archwire adjustments. However, none of
these were significantly different from
baseline.11 According to McLaughlin et
al,7 bacteremia prevalence after band
insertion is 10%, as compared to 8% and
7% following banding and debanding,
respectively. 8,9 These authors further
concluded that the application of
chlorhexidine mouthwash resulted in a
decrease of bacteremia, though it was
not significant.10 Finally, a recent study
by Rosa et al1 found a strong possibility
that removing Haas expanders might be
correlated to transitory bacteremia.

357

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 Uysal et al
Table 1 Exclusion criteria
Congenital heart disease
History of rheumatic fever
Aortic or mitral stenosis
Prosthetic heart valves
History of subacute bacterial endocarditis
Hypertrophic cardiomyopathy
Immunosuppression
Diabetes
Bleeding disorder
Pregnancy
Antibiotic usage within the past 3 months
Regular use of an antiseptic mouthwash
Mini-implants, which are used for
anchorage or anchorage reinforcement,
are useful adjuncts to fixed appliances in
the contemporary orthodontic practice.14
Compromised stability and safety can
develop during their placement and after
loading. A thorough understanding of opti-
mal preoperative preparation, proper
placement, and subsequent health main-
tenance of the peri-implant tissues are
imperative for optimal safety and suc-
cess. Healthy peri-implant tissues play an
important role as a biologic barrier to bac-
teria.15 Most orthodontic patients cannot
effectively control plaque, and mild to
moderate gingivitis therefore develops
during fixed appliance treatment.16 Tissue
inflammation and peri-implantitis can
also occur after mini-implant place-
ment,17 and some transient bacteremia
can be expected immediately after this
minor surgical procedure.
Variation in the handling of at-risk
patients may be due to lack of data con-
firming the need for antibiotic prophylaxis
before invasive orthodontic procedures.
This study aims to investigate the inci-
dence of bacteremia before and after the
insertion of orthodontic mini-implants.
METHOD AND MATERIALS
Before this study, a power analysis with
G*Power 3.0.10 (Franz Faul, Christian-
Albrechts-Universität) was performed to
estimate the sample size. It showed that
40 patients would give more than 80%
power to detect significant differences
with 0.40 effect size at an ␣ = .05 signifi-
cance level.
358
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WORLD JOURNAL OF ORTHODONTICS
Of these 40 patients, 18 were males
(mean age 22.9 ± 6.8 years) and 22 were
females (mean age 20.4 ± 8.1 years).
The total sample had a mean age of 21.3
± 7.7 years (range 14 to 34 years) and
malocclusions that required the bilateral
extraction of the two maxillary first pre-
molars and maximum anchorage. All
patients received routine orthodontic
fixed appliance treatment by postgradu-
ate students of the Erciyes University.
The local ethics committee permitted col-
lection of blood for the subsequent proto-
col after written consent was obtained
from the parents of minor patients or the
patients themselves. All individuals were
healthy and instructed not to brush their
teeth for 2 hours before the insertion of a
mini-implant. Exclusion criteria were pre-
determined according to Erverdi et al8
and are listed in Table 1.
Dual-Top Screws (Jeil Medical; diame-
ter 1.6 mm, length 8.0 mm) were placed
bilaterally between the first and second
molars without incision or predrilling by
one operator (AY) 1 month after extrac-
tion. Bleeding did not occur in any of the
patients. Screws and screwdrivers were
sterilized prior to the procedure. After
local infiltrative anesthesia but before
insertion of the mini-implants (approxi-
mately 5 minutes after anesthesia), 10
mL of blood was collected from the ante-
cubital vein using a 20 g sterile plastic
cannula (HECOS, Shanghai Medicines &
Health Products) and a sterile syringe.
Immediately after mini-implant place-
ment, the valve of the cannula was
reopened and a second 10 mL blood sam-
ple was drawn into a new syringe. Mini-
implant insertion and blood sampling were
VOLUME 11, NUMBER 4, 2010
completed within 2 minutes. All blood
samples were aseptically inoculated into
culture bottles that were connected with a
growth indicator and incubated at 37°C
for 5 days. Cultures were taken from posi-
tive bottles and plated on blood agar and
blood agar supplemented with 0.0005%
hemin (Sigma Chemical) and 0.00005%
menadione (Sigma Chemical). The petri
dishes were incubated under aerobic and
anaerobic conditions, respectively. Colony
morphology, gram-staining procedures,
standard microbiologic biochemical test-
ing techniques, and API Rapid ID 32 Strep
identification strips (BioMerieux) identified
the respective bacteria.
Pre- and postoperative findings were
statistically analyzed using the McNemar
test.
RESULTS
No significant difference between the pre-
and the postoperative samples was deter-
mined. No bacteremia was detected in
the preoperative blood samples; however,
in a postoperative sample, Streptococcus
sanguinis was detected.
DISCUSSION
According to AHA guidelines on medical
prophylaxis in dentistry,13 relatively few
procedures require antibiotic coverage.
Many of the antibacterial agents pre-
scribed by dentists are inappropriate,
and a number of studies have further
described misuse of antibiotics in den-
tistry.18–21 Overall, it is very important to
determine exactly which orthodontic pro-
cedures are likely to cause bacteremia so
that a sound decision can be made
regarding antibiotic prophylaxis for indi-
viduals at risk for bacterial endocarditis.
Weinstein and Brusch22 reported that
dental treatment–induced bacteremia
was responsible for about 15% of regis-
tered infective endocarditis. However, an
extensive review of the relevant literature
revealed merely four individuals whose
endocarditis developed during orthodon-
tic treatment. 23–25 The AHA suggests
antibiotic prophylaxis only during band
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NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Uysal et al
placement. 13 The current study is the
first to report bacteremia in orthodontic
mini-implant inser tion. That is why
explicit guidelines, including administra-
tion of antibiotics or antibacterial mouth-
washes, should be formulated for
mini-implant insertion.
Studies that tried to determine
whether oral hygiene and health were
related to bacteremia after intraoral
surger y are contradictor y. Although
increased prevalence of bacteremia was
ostensibly observed with poor oral health,
the contrary was also the case. 26–28
Lucas et al12 indicated that oral hygiene
has no impact on the prevalence and
nature of bacteremia following orthodon-
tic procedures because the placement of
full fixed appliances will always increase
the population of oral bacteria.29
Anesthetic procedures can cause bac-
teremia, depending on the technique
used. 2 Buccal infiltration led to bac-
teremia in 16%, modified intraligamental
analgesia in 50%, and conventional
intraligamental analgesia in 97% of
patients. Thus, to eliminate anesthesia
contamination of the blood samples in
this study, all screws were placed only
after a sufficient amount of time after
anesthesia. Thus, no bacteremia was
found at baseline.
A recent investigation demonstrated
that the maximum bacteremia level fol-
lowing extractions occurred between 30
and 60 seconds.30 For optimal detection
of bacteremia, Roberts et al31 suggested
that blood sampling must be performed
within 2 minutes. This was accomplished
in the present study, since screw place-
ment and blood sampling were com-
pleted in 2 minutes, as was the case in
the two studies by Erverdi et al.9,10
It is important to take blood samples
at baseline, because only then can the
true postprocedural bacteremia be deter-
mined.11 Both baseline and postopera-
tive prevalence of the current study are
similar to those repor ted by other
researchers who used the same analy-
ses.8,10 The higher baseline occurrence
of bacteremia in previous investigations
could be a result of state-of-the-art lysis
filtration, which is superior to pour plate
or other blood-culture techniques.11,30,32
359
 Uysal et al
Bacteremia incidence greater than
50% was found in Rosa et al 1 af ter
removal of Haas expanders. Similarly,
Lucas et al 12 observed postoperative
bacteremia in four of seven patients after
gold chain adjustment. It should be kept
in mind, though, that even normal daily
activities (such as chewing, brushing,
and flossing) can cause bacteremia. 33
Again, this difference might be linked to
the type of appliance, procedure, or
detection method.34
Okabe et al35 showed that the preva-
lence of bacteremia increased signifi-
cantly with the duration of surgical
intervention and the volume of blood
loss. That is why care was taken to not
harm the gingiva during mini-implant
insertion in this study; subsequently, no
gingival bleeding occurred. Previous stud-
ies showed that gingival bleeding does
not necessarily cause bacteremia, but
bacteremia can even develop in the
absence of bleeding.7,10
CONCLUSION
The following conclusions were drawn
from this study:
• Following insertion of orthodontic mini-
implants, one of 40 patients devel-
oped bacteremia.
• The identified bacteria was Streptococ-
cus sanguinis.
• The results of this study can be used
by expert committees to determine
whether antibiotic prophylaxis is indi-
cated in patients with cardiac lesions
undergoing mini-implant placement.
360
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NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
WORLD JOURNAL OF ORTHODONTICS
REFERENCES
1. Rosa EA, Rached RN, Tanaka O, Fronza F,
Fronza F, Araújo Assad R. Preliminary investiga-
tion of bacteremia incidence after removal of
the Haas palatal expander. Am J Orthod Dento-
facial Orthop 2005;127:64–66.
2. Roberts GJ, Simmons NB, Longhurst P, Hewitt
PB. Bacteraemia following local anaesthetic
injections in children. Br Dent J 1998;185:
295–298.
3. Tomás I, Alvarez M, Limeres J, Potel C, Medina
J, Diz P. Prevalence, duration and aetiology of
bacteraemia following dental extractions. Oral
Dis 2007;13:56–62.
4. Forner L, Larsen T, Kilian M, Holmstrup P. Inci-
dence of bacteremia after chewing, tooth
brushing, and scaling in individuals with peri-
odontal inflammation. J Clin Periodontol 2006;
33:401–407.
5. Savarrio L, Mackenzie D, Riggio M, Saunders
WP, Bagg J. Detection of bacteraemias during
non-surgical root canal treatment. J Dent 2005;
33:293–303.
6. Degling TE. Orthodontics, bacteremia, and the
heart damaged patient. Angle Orthod 1972;42:
399–402.
7. McLaughlin JO, Coulter WA, Coffey A, Burden
DJ. The incidence of bacteremia after orthodon-
tic banding. Am J Orthod Dentofacial Orthop
1996;109:639–644.
8. Erverdi N, Kadir T, Ozkan H, Acar A. Investigation
of bacteremia after orthodontic banding. Am J
Orthod Dentofacial Orthop 1999;116:687–690.
9. Erverdi N, Biren S, Kadir T, Acar A. Investigation
of bacteremia following orthodontic debanding.
Angle Orthod 2000;70:11–14.
10. Erverdi N, Acar A, Isgüden B, Kadir T. Investiga-
tion of bacteremia after orthodontic banding and
debanding following chlorhexidine mouth wash
application. Angle Orthod 2001;71:190–194.
11. Lucas VS, Omar J, Vieira A, Roberts GJ. The
relationship between odontogenic bacteraemia
and orthodontic treatment procedures. Eur J
Orthod 2002;24:293–301.
12. Lucas VS, Kyriazidou A, Gelbier M, Roberts GJ.
Bacteraemia following debanding and gold chain
adjustment. Eur J Orthod 2007;29:161–165.
13. Wilson W, Taubert KA, Gewitz M, et al. Preven-
tion of infective endocarditis: Guidelines from
the American Heart Association: A guideline
from the American Heart Association Rheumatic
Fever, Endocarditis and Kawasaki Disease Com-
mittee, Council on Cardiovascular Disease in the
Young, and the Council on Clinical Cardiology,
Council on Cardiovascular Surgery and Anesthe-
sia, and the Quality of Care and Outcomes
Research Interdisciplinary Working Group. J Am
Dent Assoc 2007;138;739–760.
14. Cope JB. Temporary anchorage devices in
orthodontics: A paradigm shift. Semin Orthod
2005;11:3–9.
VOLUME 11, NUMBER 4, 2010
15. Sánchez-Gárces MA, Gay-Escoda C. Periimplan-
titis. Med Oral Patol Oral Cir Bucal 2004;
9(suppl):69–74.
16. Zachrisson S, Zachrisson BU. Gingival condi-
tion associated with orthodontic treatment.
Angle Orthod 1972;42:26–34.
17. Costa A, Pasta G, Bergamaschi G. Intraoral hard
and soft tissue depths for temporary anchorage
devices. Semin Orthod 2005;11:10–15.
18. Sarkar C, Das B, Baral P. An audit of drug pre-
scribing practices of dentists. Indian J Dent Res
2004;15:58–61.
19. Harte H, Palmer NO, Martin MV. An investiga-
tion of therapeutic antibiotic prescribing for
children referred for dental general anesthesia
in three community National Health Service
trusts. Br Dent J 2005;198:227–231.
20. Sweeney L, Dave J, Chambers P, Heritage J.
Antibiotic resistance in general dental prac-
tice—A cause for concern? J Antimicrob
Chemother 2004;53:567–576.
21. Palmer NA, Pealing R, Ireland RS, Martin MV.
A study of therapeutic antibiotic prescribing in
National Health Service general dental practice
in England. Br Dent J 2000;188:554–558.
22. Weinstein L, Brusch JL. Infective Endocarditis.
New York: Oxford University Press, 1996.
23. Biancaniello TM, Romero JR. Bacterial endo-
carditis after adjustment of orthodontic appli-
ances. J Pediatr 1991;118:248–249.
24. Dajani AS. Bacterial endocarditis after minor
orthodontic procedures. J Pediatr 1991;119:
339–340.
25. Hobson RS, Clark JD. Management of the
orthodontic patient ‘at risk’ from infective
endocarditis. Br Dent J 1995;178:289–295.
26. Poveda-Roda R, Jiménez Y, Carbonell E,
Gavaldá C, Margaix-Muñoz MM, Sarrión-Pérez
G. Bacteremia originating in the oral cavity. A
review. Med Oral Patol Oral Cir Bucal 2008;13:
E355–362.
© 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Uysal et al
27. Lockhart PB. An analysis of bacteremias during
dental extractions. A double-blind, placebo-con-
trolled study of chlorhexidine. Arch Intern Med
1996;156:513–520.
28. Tomás I, Pereira F, Llucián R, Poveda R, Diz P,
Bagán JV. Prevalence of bacteraemia following
third molar surgery. Oral Dis 2008;14:89–94.
29. Bloom RH, Brown LR Jr. A study of the effects
of orthodontic appliances on the oral microbial
flora. Oral Surg Oral Med Oral Pathol 1964;17:
658–667.
30. Roberts GJ, Jaffray EC, Spratt DA, et al. Duration,
prevalence and intensity of bacteraemia after
dental extractions in children. Heart 2006;
92:1274–1277.
31. Roberts GJ, Radford P, Holt R. Prophylaxis of
dental bacteraemia with oral amoxycillin in chil-
dren. Br Dent J 1987;162:179–182.
32. Heimdahl A, Hall G, Hedberg M, et al. Detection
and quantitation by lysis-filtration of bac-
teremia after different oral surgical procedures.
J Clin Microbiol 1990;28:2205–2209.
33. Pallasch TJ, Slots J. Antibiotic prophylaxis and
the medically compromised patient. Periodon-
tol 2000 1996;10:107–138.
34. Burden DJ, Coulter WA, Johnston CD, Mullally
B, Stevenson M. The prevalence of bacter-
aemia on removal of fixed orthodontic appli-
ances. Eur J Orthod 2004;26:443–447.
35. Okabe K, Nakagawa K, Yamamoto E. Factors
affecting the occurrence of bacteremia associ-
ated with tooth extraction. Int J Oral Maxillofac
Surg 1995;24:239–242.
361
MINI-IMPLANT BEHAVIOR TO SHEAR Christopher W. Edwards,
DDS1

TENSILE FORCES IN THE PORCINE James K. Mah, DDS, MSc,

DMSc2
MANDIBLE
Aim: To determine the tangential tensile force loading behavior of
mini-implants relative to cortical bone thickness in the porcine
mandible. Methods: Eighteen mini-implants were placed both anteri-
orly and posteriorly perpendicular to the bone surface in porcine
mandibles and subjected to shear tests using a Universal Testing
Machine (Instron). Further, cone beam CT was used to measure cortical
bone thickness at each mini-implant site. Results: The shear strength
differed significantly between the anterior (mean 89.05 ± 35.9 N) and
posterior (mean 179.85 ± 29.01 N) sites. The same was true for the cor-
tical bone thickness (anteriorly, mean 3.59 ± 0.49 mm; posteriorly,
mean 4.24 ± 0.5 mm). Conclusion: The shear forces required to dislodge
mini-implants were much higher than forces typically applied for
orthodontic purposes. Therefore, mandibular cortical bone supporting
monocortical orthodontic mini-implants would most likely withstand
immediate loading with tangential shear forces. In addition, it seems
that mini-implants loaded tangentially continue to exhibit adequate
anchorage for orthodontic forces even after they are displaced. World J
Orthod 2010;11:362–368.

Key words: orthodontic, temporary anchorage device, implant, tensile force

linical anchorage with mini-implants
C effectively facilitates orthodontic
tooth movements, such as retraction,
protraction, extrusion, and intrusion. 1
Protocols for mini-implants generally
include immediate loading. 2 Unlike
osseointegrated implants, orthodontic
mini-implants do not have to remain
completely stationary. 3 Minor move-
have also been shown to exist among
varying lengths of mini-implants, though
Cornelius et al suggest that diameter—not
length—relates to stability.7 Mini-implants
placed without flap surgery have a higher
success rate with less pain and discom-
fort than those placed with flap surgery or
in conjunction with miniplates.8
Finite element analysis studies found
1Formerly, Resident, Orthodontics
and Dentofacial Orthopedics, School
of Dental Medicine, University of
Nevada, Las Vegas, Las Vegas,
Nevada, USA; currently, Private Prac-
tice, Fort Worth, Texas, USA.
2Associate Clinical Professor of

ments can occur, yet mini-implants con-
tinue to function as anchorage devices
throughout treatment.
The success rate of mini-implants can
be as high as 86.8%.4 Success is influ-
enced significantly by variables such as
initial mobility, placement site (maxilla vs
mandible, right vs left), and reaction of the
surrounding tissue.5 Local bone quality at
a specific site determines primary
stability.6 Differences in the success rate
that stress-strain interactions in orthodon-
tic retromolar implants were correlated
with the bone dynamics immediately sur-
rounding the implant.9 Stress levels are
predominantly higher in cortical bone
than in underlying trabecular bone.10 The
strain measured in the trabecular bone
was highest opposite the applied force.
Overall, cortical bone thickness is deci-
sive for the load transfer dynamic due to
its high Young modulus.10
Orthodontics and Dentofacial Ortho-
pedics, University of Nevada, Las
Vegas, Las Vegas, Nevada, USA;
Associate Clinical Professor of
Orthodontics, University of Southern
California, Los Angeles, California,
USA.
CORRESPONDENCE
Dr Christopher W. Edwards
411 W. 7th St, Suite 306
Fort Worth, TX 76102
Email: chriswedwardsdds@gmail.com

362

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VOLUME 11, NUMBER 4, 2010
Shear forces (tangential to the long
axis of the mini-implant) can be simu-
lated in vitro with cantilevered loading.
Axial pullout forces for mini-implants at
the mandibular anterior and posterior
sites in dogs have been measured.11 In
that study, the mean force was 134.5 ±
24.0 N in the anterior and 388.3 ± 23.1
N in the posterior region.11 Monocortical
screws would most likely withstand
immediate loading with or thodontic
forces.11 The pullout resistance of screws
in the maxillofacial region is also primar-
ily dependent on the thickness of the cor-
tical bone.12 Few studies have examined
the relationship of tangential forces, cor-
tical bone thickness, and the resultant
mini-implant behavior. In mandibles of
minipigs, failure after immediate loading
occurred when the tipping moment at the
bone rim exceeded 9 Nmm.13
Mini-implants are used successfully in
clinical orthodontics for anchorage; how-
ever, failures can occur. The relationship
between tangential forces and failure has
not been well-documented. The objective
of this study was to investigate this
aspect in connection with cortical bone
thickness in porcine mandibles.
METHOD AND MATERIALS
Sample selection, preparation,
and mini-implant placement
Ten fresh-frozen, food-grade porcine
mandibles were cleaned of gross tissue
and sectioned in the midsagittal plane
into a left and right side. Side differences
were not considered in this study. Self-
drilling and -tapping 6.0-mm mini-
implants (IMTEC) with a diameter of 1.8
mm were placed into the buccal alveolar
ridge at two sites predetermined by cone
beam CT (CBCT). This was to avoid inter-
proximal bone defects or root injury that
could adversely affect the test results.
Anterior sites (n = 18) were in the inter-
radicular space of the first premolar,
while posterior sites (n = 18) were in the
interradicular space of the second molar.
Each mini-implant was placed approxi-
mately halfway between the furcations
and the root apices of the respective
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Edwards/Mah
teeth and surrounded by at least 2 mm
of bone.
The mini-implants were inser ted
according to the manufacturer’s specifi-
cations perpendicular to the bone sur-
face to achieve monocortical anchorage.
All mini-implants were placed with an
Ortho Implant O-Driver (IMTEC) mounted
to a surveyor/parallelometer (JM Ney; Fig
1). To ensure that the bone surface at
the mini-implant site was perpendicular
to the direction of insertion, the mandibu-
lar halves were secured to a tilt-top sur-
vey table (JM Ney). After engaging the
mini-implants into the O-driver, the survey
table was turned with finger pressure
until the level of the interface of the prox-
imal thread and the polished transmu-
cosal collar came in contact with the
bone (Fig 2).
To aid fur ther investigation, the
mandibles were oriented anteroposteri-
orly with the occlusal plane being the
superior boundary of a bone square sur-
rounding the mini-implants. All speci-
mens were labeled with a Sharpie
permanent marker (Sanford) as anterior
or posterior samples, and the outlines of
the future cuts were marked. Cuts were
made with a band saw (Hitachi CB6Y).
For the fixation of the samples, a fast
curing dental resin (Jet repair powder
and liquid, Lang Dental Manufacturing)
was mixed and poured into a 40-mm flex-
iform rubber ring (Struers), which was
placed on the surveyor base. During fixa-
tion, all mini-implants stayed sufficiently
distant from any resin, while the bone
was completely embedded in it. The resin
was allowed to set according to the man-
ufacturer’s recommendations. Subse-
quently, it was immersed in a room-
temperature water bath to approximately
three-quarters of the acrylic base height.
Thus, the heat produced during the set-
ting reaction was allowed to dissipate
and desiccation was prevented.
Prior to testing, all specimens were
subject to CBCT using an ILUMA CBCT
machine (IMTEC). Images were acquired
at a preset calibration of 120 kVp and
3.8 mA. Scans were taken at 40 sec-
onds, and data were reconstructed at
0.3-mm voxel size. The cortical bone
thickness at the longitudinal center of
363
 Edwards/Mah WORLD JOURNAL OF ORTHODONTICS

4.0 mm

Retentive groove
3.0 mm
O-cap

O-ring
O-ball retention
2.4 mm 0.76-mm holes

Grooved neck
1.5 mm Square head
1.0 mm Polished transmucosal
collar
2 mm for 6 mm 1.8-mm-
4 mm for 8 mm diameter
6 mm for 10 mm body

Tapered Threaded
body body

4.0 mm

Corkscrew
shaped tip

Fig 1 Ortho Implant O-Driver Fig 2 3M Unitek mini-implant with its various parts
(IMTEC) mounted to a surveyor/ and dimensions.
parallelometer (JM Ney) for mini-
implant insertion.

3.73 mm

Fig 3 Cone beam CT of a bone block with inserted

mini-implant for cortical bone thickness measure-
ment at its longitudinal center.

the mini-implant was measured using custom-made, aluminum specimen-

InVivo Dental Application 3.0.51.0
(Anatomage; Fig 3).
Tensile strength was tested using the
MTS ReNew/Instron 4204 Universal Test
Machine with TestWorks 4 software (MTS
Systems). The method mode was an MTS
Simplified Tensile Test at a displacement
rate of 0.05 mm per second using a
1,000 N load cell. Data recorded were
peak load in Newtons (N). The load frame
setup included a side action grip and a
holding fixture (Figs 4 and 5). A loop was
bent from a 0.030-inch stainless steel
wire to go around the specimen. The wire
ends were placed into a wedge action
grip, which was connected to the load
cell of the crosshead. The wire was
raised from its passive position until the
MTS ReNew/Instron software meter
detected a force. The test continued until
the wire with the mini-implant came off.

364

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VOLUME 11, NUMBER 4, 2010 Edwards/Mah

Fig 4 (left) Frontal view of

load frame setup with side
action grip, custom-made alu-
minum holding fixture, and
curved wire attached to the
Instron machine.

Fig 5 (right) Magnified lateral

view of load frame setup.

Fig 6 (left) Macro image of a

mini-implant with obvious dis-
placement after a shear test.

Fig 7 (right) Macro image of

the void, which is the conse-
quence of the mini-implant
displacement.

Prior to testing, specimens were frozen
and stored in a sealable plastic bag. Dur-
ing testing, they were kept at 22°C and
kept hydrated by covering them with
moist paper towels inside the plastic bag.
Preparation of all specimens, testing, and
data recording was performed by one
investigator (CWE).
Photographs were taken with a
Keyence Digital Microscope VHX-100 using
the Keyence VH-Z25 (25⫻ to 175⫻ mag-
nification) zoom lens and the Keyence VH-
S10 multiview stage. Microphotography
shows the bone destruction and the void
remaining between the mini-implant and
bone interface after testing (Figs 6 and 7).
Statistical analysis
Statistical analysis was performed using
SPSS for Windows 16.0 (SPSS). Cortical
bone thickness and tensile forces at the
anterior and posterior locations were
analyzed using the two-tailed t test. Dif-
ferences between these parameters were
analyzed using the Levene test. Results
were considered significant at P = .05.

365

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 Edwards/Mah WORLD JOURNAL OF ORTHODONTICS

Table 1  Maximum measured force (F) and cortical 160

bone thickness at the anterior sites
Sites F (N) Thickness (mm) 140

1 70.07 3.10 120

2 116.00 3.76
3 39.57 3.12 100

Load (N)
4 38.36 3.86
5 83.53 3.32 80
6 63.54 3.21
7 71.42 4.15 60
8 108.86 4.31
40
9 110.30 3.31
10 89.01 4.39
20
11 65.89 3.87
12 94.73 3.97 0
13 167.39 4.33 0 1 2 3 4 5
14 165.40 3.55 Extension (mm)
15 69.08 3.06
16 97.27 2.95 Fig 8 Typical anterior site loading curve.
17 94.27 3.47
18 58.25 2.98
240

Table 2  Maximum measured force (F) and cortical 220

bone thickness at the posterior sites
200
Sites F (N) Thickness (mm)
180
1 148.84 4.21
2 201.68 4.80 160
3 229.26 4.19
4 187.78 4.61 140
Load (N)

5 127.46 4.73
120
6 180.75 4.98
7 213.01 4.67 100
8 198.87 3.82
9 182.55 3.73 80
10 185.71 4.02
11 163.62 3.79 60
12 183.42 4.17
13 157.21 4.34
40
14 225.05 5.02 20
15 168.58 3.43
16 198.20 4.65 0
17 147.94 3.47 0 1 2 3 4
18 137.36 3.81 Extension (mm)

Fig 9 Typical posterior site loading curve.

RESULTS
Cortical bone thickness and tensile strength
The data of the shear force and cortical bone thickness at
the anterior and posterior sites are found in Tables 1 and 2.
Mean tensile force was 89.05 ± 35.90 N in the anterior and
179.85 ± 29.01 N in the posterior site. Mean cortical bone
thickness was 3.59 ± 0.49 mm in the anterior and 4.24 ±
0.50 mm in the posterior site. The range varied between
2.95 and 4.39 mm at the anterior and 3.43 and 5.02 mm
at the posterior site. Typical loading curves for the anterior
and posterior sites are shown in Figs 8 and 9. Displacement
was measured at the mini-implant head. It could also be
estimated at the void between the bone surface and the
mini-implant. At approximately 90 N, the anterior specimens
were displaced 1 mm. This displacement increased to about
4 mm at the test end with a gradual force decrease to below
80 N (Fig 8). In contrast, the average posterior specimen dis-
placed about 3 mm total; force levels increased linearly and
peaked at nearly 180 N at the test end (Fig 9).

366

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VOLUME 11, NUMBER 4, 2010
DISCUSSION
Mini-implants have emerged as viable
or thodontic anchorage devices. 14 A
recent review documents their develop-
ment, preferred insertion sites, insertion
procedures, loading, removal, potential
complications, as well as their clinical
advantages and disadvantages. 15
Another systematic review of the experi-
mental use of skeletal mini-implants
showed that clinical forces varied from
25 to 500 g in animal experiments. 7
While the measured units are not directly
comparable, the clinical forces are far
less than the 38.36 N found in the pig
model of this study. Of the articles that
met the inclusion criteria, experiments
with off-axis forces relative to the mini-
implants were conducted with one
minipig, two monkeys, and five dogs.7
Pull-out testing is a viable method to
study the mechanical competency of a
mini-implant. In this study, the test was
simplified and the mini-implant was not
completely extracted from the specimens.
This simplification was based on the
assumption that typical orthodontic forces
have a relatively low range (1 to 3 N).16
Even with en masse movement, forces typ-
ically do not exceed 20 to 30 N.16 In these
experiments, anterior specimens 3 and 4
(Table 1) withstood tensile forces of
approximately 40 N. Therefore, it seems
that mandibular cortical bone supporting
monocortical mini-implants would most
likely withstand immediate loading and
support typical tooth-moving shear forces.
It has been demonstrated in human
cadavers that mini-implants loaded along
their long axes have the greatest stability
and resistance to failure compared to
those with an angulated or tangential
loading. As previously noted, however,
mini-implants can lose their primary sta-
bility, become displaced, and still provide
support for applied forces.17 In this study,
even shear forces as high as 165 N in the
anterior and 225 N in the posterior area
did not completely dislodge any mini-
implants. After a displacement greater
than 4 mm, mini-implants could still
remain relatively secure. The statement
that a mini-implant might be subtlely
mobile and yet display acceptable clinical
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Edwards/Mah
anchorage does not take into account any
biologic effects such as bacterial ingress
and increasing mobility due to normal
masticatory functions that could acceler-
ate the failure rate.
Testing revealed that anterior and pos-
terior sites in the porcine mandible
behaved quite differently. At posterior
sites, the load increased somewhat lin-
early throughout the entire test. At the
anterior sites, however, forces typically
peaked early and then gradually declined.
It can be surmised that the initial failure
occurred with bone breakage around the
mini-implant threads. The breakage was
followed by a compression of the bone
and an accumulation of bone particles,
which led the force to taper. It is possible
that bone quality and density play a larger
role than cortical bone thickness alone.
While no direct comparisons can be
made between the reactions of mini-
implants to shear forces in humans and
pigs, a relationship can be hypothesized.
In humans, the average cortical bone
thickness ranges from 1.6 to 3.0 mm
mesial and distal to the mandibular first
molar.18 It was also found that in dentate
cadaver mandibles, cortical bone thick-
ness averaged 2.0 mm in the molar, 1.2
mm in the premolar, and 1.0 mm in the
anterior area. 19 High forces diminish
over time. As the bone remodels, forces
could be increased again. A crucial
period for mini-implant success is proba-
bly this remodeling phase, during which
a disrupting infection could occur.
Mini-implant failures continue to
occur. Reasons include patient noncom-
pliance with oral hygiene and subsequent
inflammation and infection. Other factors
contributing to inferior mini-implant sta-
bility are an incomplete engagement in
cortical bone, torsional stress leading to
bending or fracture, and placement in
nonkeratinized tissue.20
367
 Edwards/Mah
CONCLUSION
From this study, the following conclusions
can be drawn:
• Mandibular cortical bone supporting
monocortical orthodontic mini-implants
would most likely withstand immedi-
ate loading and support tooth-moving
tangential shear forces.
• Mini-implants loaded tangentially can
be displaced, but continue to exhibit
adequate anchorage for orthodontic
forces applied to teeth.
ACKNOWLEDGMENTS
The authors would like to thank 3M Unitek for
donating the mini-implants, Brenda Coalwell and Dr
Susan Tzou for facilitating, James Cleary for design-
ing and Kevin Nelson for fabricating the specimen
holding fixture, Mark Floyd for assistance with the
tensile testing, and Dr Marcia Ditmyer for statistical
analysis.
REFERENCES
1. Lin JC, Liou EJ, Yeh CL, Evans CA. A comparative
evaluation of current orthodontic miniscrew sys-
tems. World J Orthod 2007;8:136–144.
2. Ohashi E, Pecho OE, Moron M, Lagravere MO.
Implant vs screw loading protocols in orthodon-
tics. Angle Orthod 2006; 76:721–727.
3. Liou EJW, Pai BCJ, Lin JCY. Do miniscrews
remain stationary under orthodontic forces? Am
J Orthod Dentofacial Orthop 2004;126:42–47.
4. Wiechmann D, Meyer U, Buchter A. Success
rate of mini- and micro-implants used for ortho-
dontic anchorage: A prospective clinical study.
Clin Oral Implants Res 2007;18:263–267.
5. Park HS, Jeong SH, Kwon OW. Factors affecting
the clinical success of screw implants used as
orthodontic anchorage. Am J Orthod Dentofa-
cial Orthop 2006;130:18–25.
6. Wilmes B, Rademacher C, Olthoff G, Drescher
D. Parameters affecting primary stability of
orthodontic mini-implants. J Orofac Orthop
2006;67:162–174.
7. Cornelis MA, Scheffler NR, De Clerck HJ, Tul-
loch JF, Behets CN. Systematic review of the
experimental use of temporary skeletal anchor-
age devices in orthodontics. Am J Orthod Dento-
facial Orthop 2007;131(4suppl):S52–58.
368
© 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
WORLD JOURNAL OF ORTHODONTICS
8. Kuroda S, Sugawara Y, Deguchi T, Kyung H,
Takano-Yamamoto T. Clinical use of miniscrew
implants as orthodontic anchorage: Success
rates and postoperative discomfort. Am J
Orthod Dentofacial Orthop 2007;131:9–15.
9. Chen J, Esterle M, Roberts WE. Mechanical
response to functional loading around the
threads of retromolar endosseous implants uti-
lized for orthodontic anchorage: Coordinated
histomorphometric and finite element analysis.
Int J Oral Maxillofac Implants 1999;14:282–289.
10. Dalstra M, Cattaneo PM, Melsen B. Load trans-
fer of miniscrews for orthodontic anchorage.
Orthodontics 2004;1:53–62.
11. Huja SS, Litsky AS, Beck FM, Johnson KA,
Larsen PE. Pull-out strength of monocortical
screws placed in the maxillae and mandibles of
dogs. Am J Orthod Dentofacial Orthop 2005;
127:307–313.
12. Shelton JC, Loukota RA. Pull-out strength of
screws from cortical bone in the maxillo-facial
region. J Mat Sci: Mat in Med 1996;7:231–235.
13. Buchter A, Wiechmann D, Koerdt S, Wiesmann
HP, Piffko J, Meyer U. Load-related implant
reaction of mini-implants used for orthodontic
anchorage. Clin Oral Implants Res 2005;16:
473–479.
14. McGuire MK, Scheyer ET, Gallerano RL. Tempo-
rary anchorage devices for tooth movement: A
review and case reports. J Periodontol 2006;
77:1613–1624.
15. Papadopoulos MA, Tarawneh F. The use of
miniscrew implants for temporary skeletal
anchorage in orthodontics: A comprehensive
review. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2007;103:e6–15.
16. Cope JB. Ortho TADs: The Clinical Guide and
Atlas. Dallas: Under Dog Media, 2005.
17. Pickard M, Dechow P, Rossouw E, Buschang P.
Effects of mini-screw orientation on implant
stability and resistance to failure. Am J Orthod
Dentofacial Orthop 2010;137:91–99.
18. Ono A, Motoyoshi M, Shimizu N. Cortical bone
thickness in the buccal posterior region for
orthodontic mini-implants. Int J Oral Maxillofac
Surg 2008;37:334–340.
19. Katranji A, Misch K, Wang HL. Cortical bone
thickness in dentate and edentulous human
cadavers. J Periodontol 2007;78:874–878.
20. Kravitz ND, Kusnoto B. Risks and complica-
tions of orthodontic miniscrews. Am J Orthod
Dentofacial Orthop 2007;131(4suppl):s43–51.
Narayan H. Gandedkar,
BDS, MDS, FCFO1 CORRECTION OF A SEVERE SKELETAL
Ameet V. Revankar, BDS, CLASS II OCCLUSION WITH A FIXED
MDS2

Sanjay V. Ganeshkar, BDS,

FUNCTIONAL APPLIANCE ANCHORED
MDS, MDORCPS3 ON MINI-IMPLANTS: A PATIENT REPORT
This report describes the treatment of a patient with a severe skeletal
Angle Class II occlusion with a 14-mm overjet, crowding, and protru-
sion of the mandibular anterior teeth. The Class II relationship was
caused mainly by a short corpus of the mandible. A fixed functional
appliance was directly anchored on mini-implants, which were
inserted in the mandible. A significant amount of mandibular
advancement was achieved, with no protrusion of the mandibular
anterior teeth. Facial esthetics improved considerably. This is the first
patient report to demonstrate that mini-implants can be applied to
anchor fixed functional appliances. The rationale to use mini-
implants with fixed functional appliances and the potential benefits of
this procedure are discussed. World J Orthod 2010;11:369–379.

Key words: mini-implants, fixed functional appliance, skeletal Class II,

glenoid fossa, remodeling

1Clinical and Research Fellow, Cran-

iofacial Center, Department of Cran-
iofacial Dentistry and Orthodontics,
Taipei, Taiwan; Assistant Professor,
Department of Orthodontics and
Dentofacial Orthopedics, SDM Col-
lege of Dental Sciences and Hospi-
tal, Sattur, Dharwad, India.
2Assistant Professor, Department of

Orthodontics and Dentofacial Ortho-
pedics, SDM College of Dental Sci-
ences and Hospital, Sattur,
Dharwad, India.
3Professor and Chair, Department of
Orthodontics and Dentofacial Ortho-
pedics, SDM College of Dental Sci-
ences and Hospital, Sattur,
Dharwad, India.
CORRESPONDENCE
Dr Narayan H. Gandedkar
Craniofacial Center
Department of Craniofacial Dentistry
and Orthodontics
199 Tun Hwa North Road
Taipei
Taiwan
Email: gandedkar.naru@gmail.com
ixed functional appliances are fre-
F quently used in the treatment of
skeletal Class II relationships arising
from a mandibular deficiency. 1 These
appliances result in very good treatment
outcomes. However, as they are directly
anchored to a mandibular archwire or an
outrigger, they invariably protrude the
mandibular anterior teeth,1–3 which jeop-
ardizes the stability of the achieved
result. This dentoalveolar adverse effect
is more pronounced with flexible fixed
appliances such as the Jasper jumper.4
The Forsus-Fatigue Resistance Device
(Forsus-FRD, 3M Unitek) described in
this paper was developed by Bill Vogt. It
is a hybrid of a rigid and flexible fixed
functional appliance. Hence, one can
expect similar dentoalveolar conse-
quences if the appliance is anchored to
a mandibular archwire.
Orthodontic mini-implants expanded
the horizon of orthodontic treatment
because they allow the completion of
treatments successfully with virtually no
untoward effects on any teeth since they
use bone as the anchoring unit.5 In an
effort to eliminate the dentoalveolar
components from fixed functional appli-
ance therapy, especially mandibular
anterior protrusion, Sung et al 6 first
used mini-implants as anchoring units.

369

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 Gandedkar et al WORLD JOURNAL OF ORTHODONTICS

Fig 1 Pretreatment extraoral photographs showing a severe convex profile with the lower lip trapped behind the maxillary incisors.

Fig 2 Pretreatment intraoral pho-

tographs showing a full-cusp Class II
relationship, 14-mm overjet, 100%
overbite, anterior crowding, and protru-
sion in both arches.

METHOD AND MATERIALS with protruding anterior teeth (Fig 2).

An 14-year, 2-month old boy in the accel-
eration phase of his pubertal growth
spurt (MP3-FG and CVMI-2) 7 reported
with the chief complaint of protruding
maxillar y front teeth and a small
mandible. His medical history was unre-
markable, and his temporomandibular
joint function was within the normal
range. He exhibited a severe convex pro-
file with his lower lip trapped behind his
maxillary incisors (Fig 1). The intraoral
photographs demonstrated a Class II
relationship without any missing teeth.
There was mild crowding in the maxilla
and severe crowding in the mandible,
Overjet and overbite measured 14.0 mm
and 100%, respectively. The patient
demonstrated a positive VTO (visual
treatment objective) on advancement of
his mandible.
The cephalometric analysis revealed a
severe skeletal Class II relationship (ANB
8 degrees) with a low mandibular plane
angle (FMA 21 degrees), a severely retro -
gnathic mandible (SNB 76 degrees), and
protrusive incisors (interincisal angle
113 degrees; U1–NA 30 degrees,
8.0 mm; L1–NB 28 degrees, 8.0 mm)
(Table 1, Fig 3). The panoramic radio-
graph showed a full complement of teeth
with all third molars.

370

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VOLUME 11, NUMBER 4, 2010 Gandedkar et al

Table 1  Values of the cephalometric analysis

Pretreatment Prefunctional Posttreatment 6-month follow-up 1-year follow-up

Anteroposterior
ANB (degrees) 8 7 2 2 2
Wits (mm) 11 11 2 2 2
NA-Pg (mm) 10 8 4 3 3
Co-Pg (mm) 102 103 110 110 111
Vertical
SNGoGn (degrees) 23 24 27 27 27
FHGoMe (degrees) 21 21 24 24 24
MM plane (degrees) 18 18 20 20 20
Jarabak ratio (%) 71 70 63 63 63
Y-axis (degrees) 86 86 90 90 90
Maxilla
SNA (degrees) 84 84 83 83 83
A–N (mm) 2 2 1 1 1
A–Ptm (mm) 52 52 51 51 51
S–Ptm (mm) 21 21 21 21 21
Mandible
SNB (degrees) 76 77 81 81 81
BN (mm) 16 15 4 4 4
GoPog (mm) 70 71 76 76 76
Dentition
U1–SN (degrees) 116 109 102 102 102
U1–NA (degrees/mm) 30/8 23/6 18/2 18/2 18/2
U1–APog (degrees/mm) 45/11 32/8 25/2 25/2 25/2
L1–MP (degrees) 106 94 95 9 94
L1–NB (degrees/mm) 28/8 12/4 22/2 22/2 22/2
LI–APog (degrees/mm) 23/3 12/3 22/2 22/2 22/2
U1–L1 (degrees) 113 141 136 136 136
Soft tissue
E line (mm) U–7 U–4 U–0 U–0 U–1
L*–6 L–3 L–2 L–3 L–3
H line (mm) L–3 L–2 L–2 L–2 L–2
S line (mm) U–8 L–7 U–7 L–6 U–4
L–4 U–4 L–4 U–4 L–4
Nasolabial angle (degrees) 78 100 105 104 105
Soft tissue profile angle (S’SnPog’) (degrees) 145 149 159 160 160

U = maxillary, L = mandibular.

Fig 3 Pretreatment lateral cephalometric radiograph revealing a skeletal

Class II relationship with a hypodivergent facial configuration.

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 Gandedkar et al
The patient was diagnosed with a
severe skeletal Class II occlusion due to
a short mandibular corpus, an increased
overjet and overbite with mandibular
anterior crowding, and severe protrusion.
Treatment objectives
The VTO was definitely positive, so the
patient needed a skeletal correction for
profile improvement by a mandibular
advancement. In addition, the protrusion
of the anterior teeth in both arches and
the crowding had to be corrected. Treat-
ment objectives were to establish good
skeletal proportions, functional efficiency,
and a stable occlusion; enhance facial
profile and lip closure; and improve smile
esthetics.
Treatment options
Four approaches were considered.
1. To treat the patient with a removable
functional appliance for mandibular
advancement because of his convex
profile and because his skeletal maturity
indicated that 65% to 85% of his puber-
tal growth was residual.7 However, this
approach would have meant two sepa-
rate treatment phases, as well as taxing
the patient’s compliance. Present data
indicate that in the treatment of Class II
Division 1, the efficiency and success
rate of removable functional appliances
is inferior to that of fixed functional appli-
ances.8 Intermittent condylar displace-
ments with removable functional
appliances in humans and animals pro-
duce variable results from extensive9 to
minor glenoid fossa remodeling. On
the contrary, continuous relocation
using fixed functional appliances rou-
tinely shows a remarkable change in the
glenoid fossa-condyle complex.10,11
2. To use a fixed functional appliance for
the advancement of the mandible. This
would have worsened the protrusion of
the mandibular incisors, however, as
this appliance would have been
anchored directly to the mandibular
archwire.1–3
372
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WORLD JOURNAL OF ORTHODONTICS
3. To extract all first premolars and use a
fixed functional appliance anchored on
mini-implants placed in the interradicu-
lar bone of the mandibular first premo-
lars and canines bilaterally. This
approach would eliminate adverse
dentoalveolar effects since the force of
the fixed functional appliance would be
directly transmitted to the mandible.
4. To advance the mandible surgically.
However, the patient’s growth status
and the absence of a progressive defor-
mity or of psychosocial distress pre-
cluded such a radical approach.12,13
Treatment progress
Because it was most advantageous, the
third treatment option was adopted. After
extraction of all first premolars, the
remaining teeth were bonded or banded
with a 0.022-inch slot preadjusted edge-
wise appliance (MBT prescription Gemini
brackets, 3M Unitek). Initial leveling was
accomplished in the mandible with a
0.016-inch Ni-Ti archwire (Orthoforce G4
Nickel Titanium, G&H) and a 0.018-inch
Ni-Ti archwire in the maxilla (Figs 4a to
4c). After leveling, the inclination of the
anterior teeth in both arches was cor-
rected using active tie-backs for partial
retraction on a 0.018-inch stainless steel
archwire. This prefunctional phase lasted
4 months, during which the Class II rela-
tionship was not changed.
Once the inclination was corrected,
0.019 ⫻ 0.025-inch stainless steel arch-
wires were placed, including the second
molars. Records were taken (Figs 4d to 4g
and 5) and analyzed to assess the amount
of decompensation (Table 1). A transpalatal
arch was placed between the maxillary
first molars to counteract the adverse
effects of the fixed functional appliance.
Mini-implants (1.4 ⫻ 14.0 mm) (SK-
Surgicals) were inserted as described pre-
viously and immediately loaded (Fig 6).
Figure 7 depicts the placement of the
mini-implant and how the functional appli-
ance was secured to it.
The functional phase lasted 11 months,
during which the patient did not complain
about any major discomfort. The stabil -
ity of the implants did not deter, either.
VOLUME 11, NUMBER 4, 2010 Gandedkar et al

a b c

Fig 4 (a to c) Intraoral photographs

after the insertion of the first archwire
(0.018-inch Ni-Ti). (d to g) Intraoral pho-
tographs after correcting the protrusion
of the incisors and before the start of
the functional treatment stage.

d e

f g

Fig 5 Lateral cephalograms (a)

before and (b) after the functional
treatment phase.

a b

a b c

Fig 6 Forsus-FRD anchored on mini-implants (1.4-mm diameter, 14.0-mm long).

373

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 Gandedkar et al WORLD JOURNAL OF ORTHODONTICS

a b c

d e f
Fig 7 Typodont demonstrating the placement of the mini-implants and anchoring the fixed functional appliance. (a) The mini-
implant is in the interradicular area of the canine, where the first premolar was originally found. (b) A 0.012-inch stainless steel
ligature is passing through the hole in the head of the mini-implant; (c to f) it is tightly secured to the hook of the push rod of
the fixed functional appliance.

a b c

d e f

Fig 8 (a to c) Intraoral photographs at

the end of the functional treatment
phase. (d to h) Intraoral photographs
after complete space closure.

g h

However, the patient had occasional episodes of bruising
his cheek mucosa. These bruises were treated with antibi-
otic and analgesic mouthrinses. Simultaneously, the resid-
ual extraction spaces in the mandibular arch were closed
by molar protraction. After completion of the functional
phase, the implants were removed and the implant sites
healed uneventfully. Again, records were taken (Figs 5 and
8a to 8c). The maxillary molars were then protracted into
the remaining extraction spaces (Figs 8d to 8h).
Seventeen months after initial bracket placement, the
promulgated objectives were achieved (Figs 9 to 12).

374

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VOLUME 11, NUMBER 4, 2010 Gandedkar et al

Fig 9 Intraoral photographs after com-

pletion of treatment.

Fig 10 Extraoral photographs after completion of treatment.

Fig 11 Lateral cephalogram (left) immediately after treatment and (center) 6 months and (right) 1 year after completion of
treatment.

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 Gandedkar et al
For retention, the patient was instructed
to wear full-wrap Begg’s retainers in both
arches. In addition, fixed lingual retainers
were bonded.
RESULTS
The treatment brought about an excellent
facial and occlusal result. The most signif-
icant changes were a dramatic increase
in mandibular length (Table 1, Fig 13) and
an improved occlusal function.
The posttreatment panoramic radi-
ograph confirms root parallelism (Fig 12a).
The mandibular incisors were retracted
from 106 to 94 degrees and the maxil-
lary ones from 116 to 102 degrees. The
ANB improved from 8 to 2 degrees, the
occlusal plane remained unchanged and
the lower anterior face height improved.
The achieved correction showed excel-
lent stability 6 months (Table I, Fig 11b)
and 1 year posttreatment (Fig 11c and
12b).
376
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WORLD JOURNAL OF ORTHODONTICS
Fig 12 Panoramic radiograph (a)
immediately after treatment and (b) 1
year after completion of treatment.
DISCUSSION
Various treatment options were explored
for this patient. The chosen therapy was
based on thorough diagnosis and biome-
chanical reasoning. Cope et al4 hypothe-
sized that the mechanisms for Class II
correction using a Jasper jumper were
restraint of maxillary growth, retraction of
the maxillary dentition, increased growth
of the mandibular condyle, remodeling of
the glenoid fossa in a downward and for-
ward direction, and lateral expansion of
the maxillary molars.
Karacay et al14 compared the skeletal
and dental effects of Forsus Nitinol Flat
Springs (FNFS) (3M Unitek) and Jasper
jumpers in the correction of Class II Divi-
sion 1 relationships in adolescents. They
concluded that both appliances have sim-
ilar effects and cause mandibular growth,
as well as displacement, restraint of max-
illary growth, intrusion and distal move-
ment of the maxillary molars, extrusion
and mesial movement of the mandibular
VOLUME 11, NUMBER 4, 2010
a b
Fig 13 (a) Pre- and (b) posttreatment
tracing and (c to e) superimposition of
the (black) pre- and (red) posttreatment
tracings on the anterior cranial base and
the stable structures of the maxilla and
mandible.
d e
molars, palatal tipping with extrusion of
maxillary incisors, and labial proclination
of the mandibular incisors. Heining and
Göz15 studied the effects of the Forsus
FNFS in adolescent patients with a skele-
tal Class II over a period of 4 months. They
deduced that the corrections were a com-
bination of skeletal and dental effects.
In contrast, this patient demonstrated
a dramatic increase in mandibular length,
a restraint of maxillary growth, a slight
clockwise tipping of the maxillary plane
with extrusion and retrusion of the
incisors, and most importantly, an overjet
reduction without protrusion of the
mandibular incisors. These differences
from the cited studies could be accounted
for by the fact that the functional phase
lasted for 11 months and that the push
rods of the functional appliance were
hooked onto the implant, thus eliminat-
ing any effect on the mandibular denti-
tion. Moreover, this functional appliance
is more rigid in comparison to others (For-
sus FNFS or Jasper jumper).
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Gandedkar et al
c
Voudouris et al 16 stated that the
modus operandi of fixed functional appli-
ances in correcting a Class II is far beyond
the classical theory of lateral pterygoid
hyperactivity.17 In fact, they demonstrated
decreased lateral pterygoid activity16 dur-
ing active treatment with fixed functional
appliances. They suppose that the vis-
coelastic tissue forces are decisive to cre-
ate new bone within the condyle and
glenoid fossa.18
According to Pancherz, posttreatment
stability is secured by stable cuspal inter-
digitation. Minor relapse of overjet and
overbite was a common finding in his
patients 1-year after treatment, usually
due to an uprighting of the mandibular
incisors.19 Here, no relapse was noted in
the 1-year retention period because the
prefunctional incisor inclination was
maintained.
This functional phase (11 months)
lasted much longer than that of most of
the previously mentioned studies (6
months on average). This explains the
377
 Gandedkar et al
excellent orthopedic response and stabil-
ity, as there is evidence suggesting that
additional growth occurs with longer treat-
ment times and that adequate time is
required to permit mineralization and also
adaptation of muscle attachments.16
Orthodontists are aware that fixed
functional appliances result in flaring of
the mandibular anterior teeth,16 which
leads ultimately to an unstable result.
Sung et al6 used mini-implants bilaterally
in the interradicular area of the first and
second mandibular premolars to anchor
a fixed functional appliance, but the
implants failed after 2 weeks. He theo-
rized that because such functional appli-
ances generate heavy intermittent forces
and good-quality cortical bone is not gen-
erally available in young patients, other
types of bone anchorage such as mini-
plates or bicortical bone screws would be
suitable. 6 However, these modalities
would require more elaborate surgical
procedures. Hence, in this patient, 1.4- ⫻
14.0-mm mini-implants were used to
increase the stability of the appliance
system. Fur ther, the implants were
placed 4 months after the extraction of
the first premolars.
The specific insertion site seemed to
be biologically safe because the mandibu-
lar first premolars were extracted and
there was no risk of root damage, as well
as no major neurovascular elements close
to this site (the nearest is the mental neu-
rovascular bundle, which lies apically).
This patient report demonstrates that
the implant dimension can resist the
force of a fixed functional appliance with-
out failure. The possibility of bicortical
anchorage of the mini-implant cannot be
ruled out, owing to their length (14.0 mm)
in comparison to the diameter of the
alveolar process in the anterior part of
the mandible.
Instability and fracture of the mini-
implants or traumatic injuries to the hard
and soft tissues during their placement and
removal should not be underestimated.
Despite the fact that these were not
encountered here, it seems advisable to
thoroughly understand their consequences.
378
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WORLD JOURNAL OF ORTHODONTICS
CONCLUSION
The treatment of a patient with a fixed
functional appliance attached to mini-
implants resulted in excellent soft tissue,
skeletal, and dental improvements with
good stability. Implants can act as
absolute anchorage load-bearing units
for functional orthopedic forces and allow
the mandible to express its full growth
potential without any undue adverse den-
toalveolar effects.
ACKNOWLEDGMENTS
The authors express their profound gratitude to
Prof C. Bhasker Rao for providing a stage to
express their talents, as well as Prof V.P. Jayade
and Dr Sangamesh Basalingappa for imparting
knowledge and helping develop critical minds.
REFERENCES
1. Pancherz H. The mechanism of Class II correc-
tion in Herbst appliance treatment. A cephalo-
metric investigation. Am J Orthod 1982;82:
104–113.
2. McNamara JA Jr, Howe RP, Dischinger TG. A
comparison of the Herbst and Frankel appli-
ances in the treatment of Class II malocclu-
sion. Am J Orthod Dentofacial Orthop 1990;
98:134–144.
3. Pancherz H, Hansen K. Occlusal changes during
and after Herbst treatment: A cephalometric
investigation. Eur J Orthod 1986;8:215–228.
4. Cope JB, Buschang PH, Cope DD, Parker J,
Blackwood HO 3rd. Quantitative evaluation of
craniofacial changes with Jasper Jumper ther-
apy. Angle Orthod 1994;64:113–122.
5. Chung KR, Nelson G Kim SH, Kook YA. Severe
bidentoalveolar protrusion treated with ortho-
dontic micro-implant-dependent en-masse retrac-
tion. Am J Orthod Dentofacial Orthop 2007;132:
105–115.
6. Sung JH, Kyung HM, Bae SM, Park HS, Kwon
OW, McNamara JA Jr. Clinical examples of
micro-implant anchorage. In: Micro-implants in
Orthodontics, ed 1. Korea: Dentos, 2006:163.
7. Rajagopal R, Kansal S. A comparison of modified
MP3 stages and the cervical vertebrae as growth
indicators. J Clin Orthod 2002;36:398–406.
8. von Bremen J, Pancherz H. Efficiency of early
and late Class II Division 1 treatment. Am J
Orthod Dentofacial Orthop 2002;121:31–37.
9. Weislander L. Intensive treatment of severe
Class II malocclusions with a headgear—Herbst
appliance in the early mixed dentition. Am J
Orthod 1984;86:1–13.
VOLUME 11, NUMBER 4, 2010
10. Baume LJ, Derichsweiler H. Is the condylar
growth center responsive to orthodontic therapy?
An experimental study in Macaca mulata. Oral
Surg Oral Med Oral Pathol 1961;14:347–362.
11. Ruf S, Pancherz H. Temporomandibular joint
remodeling in adolescents and young adults
during Herbst treatment: A prospective longitu-
dinal magnetic resonance imaging and
cephalometric radiographic investigation. Am J
Orthod Dentofacial Orthop 1999;115:607–618.
12. Proffit WR, Fields HW Jr, Sarver DM. Combined
surgical orthodontic treatment. In: Contempo-
rary Orthodontics, ed 4. St Louis: Mosby, 2007:
708–709.
13. Pancherz H. Dentofacial orthopedics or orthog-
nathic surgery: Is it a matter of age? Am J
Orthod Dentofacial Orthop 2000;117:571–574.
14. Karacay S, Akin E, Olmez H, Gurton UA,
Sagadic D. Forsus Nitinol Flat Spring and
Jasper Jumper corrections of Class II division 1
malocclusions. Angle Orthod 2006;76:666–672.
© 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Gandedkar et al
15. Heinig N, Göz G. Clinical application and
effects of the Forsus spring. A study of a new
Herbst hybrid. J Orofac Orthop 2001;62:436–450.
16. Voudouris JC, Woodside DG, Altuna G, et al.
Condyle-fossa modifications and muscle inter-
actions during Herbst treatment, Part 2.
Results and conclusions. Am J Orthod Dentofa-
cial Orthop 2003;124:13–29.
17. Auf der Maur HJ. Electromyographic recordings
of the lateral pterygoid muscle in activator
treatment of Class II Division 1 malocclusion
cases. Eur J Orthod 1980;2:161–171.
18. Buschang PH, Santos-Pinto A. Condylar growth
and glenoid fossa displacement during child-
hood and adolescence. Am J Orthod Dentofa-
cial Orthop 1998;113:437–442.
19. Pancherz H.The Herbst appliance—Its biologic
effects and clinical use. Am J Orthod 1985;
87:1–20.
379
TREATMENT OF A PATIENT WITH A Panchali Batra, BDS, MDS1

BILATERAL CLEFT LIP AND PALATE Vikas Agrawal, BDS, MDS2

H. Jyothi Kiran, BDS, MDS3

WITH IMPLANTS AND SURGERY
Shivalinga Barsapur
OF THE MAXILLARY ANTERIOR REGION Madanagowda, BDS,
MDS4
Caring for patients with bilateral cleft lips and palates requires an
interdisciplinary approach. The treatment of such a patient is
described. Therapy comprised maxillary expansion, mini-implant
insertion, premaxillary osteotomy, and vomeroplasty, which led to a
drastic improvement of the occlusion and facial appearance. World J
Orthod 2010;11:380–386.

Key words: bilateral cleft lip and palate, mini-implants, expansion

appliance, premaxillary osteotomy, vomeroplasty

1Senior Resident, Department of

Orthodontics, Maulana Azad Insti-
tute of Dental Sciences, New Delhi,
India.
2Postgraduate Student, Department

of Orthodontics, Jagadguru Sri

left lip and palate is the second most
C frequent major congenital anomaly
(1:750 to 1:1,000 live births), with club
Shivarathreeshwara (J.S.S.) Dental
aminopterin, and infections within the
first trimester are considered.4 Complete
clefts of the primary and secondary
College, Mysore, Karnataka, India.
3Associate Professor, Department of

Orthodontics, Jagadguru Sri

foot being the most common.1,2 Clefts of
the lip result from a failed fusion of the
medial and lateral nasal processes with
the maxillary process by mesenchymal
penetration between weeks 4 and 7 of
gestation. 3 The two basic etiologic
causes are gene defects and exogenic
factors. Genes have an influence on a
reduced facial mesenchymal volume,
increased facial width, high tongue posi-
tion, insufficient elevation of the palatal
shelves, and a delay of neck extension.
As exogenic factors, oligohydramnios,
steroids, anticonvulsants, diazepam,
palate are twice as common as isolated
clefts of the primary palate alone. Cleft
lips with or without cleft palates occur
twice as often in males as in females,
whereas the reverse is true for clefts of
the secondary palate.4
Some patient reports describe clefts
associated with syndromes 5–7or treat-
ments for just one phase, though multiple
stages are required to complete an optimal
therapy.8–10 This patient report presents
the comprehensive treatment plan of a
patient with a bilateral cleft lip and palate
to achieve a stable functional occlusion.
Shivarathreeshwara (J.S.S.) Dental
College, Mysore, Karnataka, India.
4Professor, Department of Orthodon-
tics, Jagadguru Sri Shivarathreesh-
wara (J.S.S.) Dental College, Mysore,
Karnataka, India.
CORRESPONDENCE
Dr Panchali Batra
Department of Orthodontics
and Dentofacial Orthopedics
Maulana Azad Institute
of Dental Sciences
Bahadur Shah Zafar Marg
New Delhi 110002
India
Email: panchali.batra@gmail.com

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VOLUME 11, NUMBER 4, 2010 Batra et al

Fig 1 Frontal and lateral

extraoral views of the patient
revealing a mesocephalic and
mesoprosopic form, a convex
facial profile, an open lip pos-
ture, and a depressed col-
umella and nose tip.

Fig 2 Pretreatment intraoral

views revealing the presence of
all teeth except the third molars,
severe mesiopalatal rotation of
the maxillary central incisors,
peg-shaped lateral incisors,
down and forward hanging of
the maxillary anterior region, a
collapse of the maxillary arch
and crossbite, edge-to-edge
occlusion of the incisors, and
mild anterior crowding in the
mandibular arch.

PATIENT REPORT to a crossbite, whereas the molars oc-

A 10-year-old girl presented with the chief
complaint of a forwardly displaced maxil-
lary anterior region with irregularly posi-
tioned teeth. The patient’s extraoral
examination revealed a mesocephalic
and mesoprosopic form, a convex facial
profile, and an open lip posture (Fig 1).
The columella and tip of her nose were
depressed due to scar tissue, resulting in
unequally sized nostrils. This scar tissue
extended bilaterally from the nasal sep-
tum to the vermillion border above the
lateral incisors. The intraoral examination
showed that all teeth except the third
molars were present. There was a severe
mesiopalatal rotation of the maxillary
central incisors. The lateral incisors were
also peg-shaped (Fig 2). The maxillary
anterior region was too far down and for-
ward. The maxillary arch was collapsed in
the canine and premolar region leading
cluded properly. The mandibular arch
was inconspicuous, aside from mild ante-
rior crowding. The incisors occluded edge-
to-edge.
The etiology of cleft was suspected to
be abortifacients taken by the mother in
her third month of pregnancy.
The patient underwent surgery for her
cleft lip in her third and ninth month. The
cleft palate was closed at 1.5 years of
age. When the patient was 5 years old, a
vestibuloplasty was carried out to
increase the sulcus depth. The anterior
premaxillary labial segment also received
a skin graft to compensate for the com-
promised blood supply.
Cephalometric examination revealed a
retrognathic maxilla and mandible with a
Class I relationship and vertical growth
pattern. The maxillary radiograph clearly
shows how much the maxillary anterior
region was protruded (Fig 3).

381

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 Batra et al WORLD JOURNAL OF ORTHODONTICS

a b

Fig 3 Maxillary radiograph

showing extreme protrusion
of the maxillary anterior
region.

c d

Fig 4 Intraoral views of the treatment steps. (a) Initial differential expansion with a fan-
shaped expander, (b) expansion with two transpalatal arches (on the canines and premo-
lars, (c) retraction of right canine with an elastic chain, and (d) further slow expansion with
a quadhelix.

The treatment plan was to expand the
collapsed maxillary arch, align the teeth,
and attempt a premaxillary osteotomy
with a secondary alveolar bone graft. Ini-
tially, a fan-shaped expander was used to
widen only the constricted area (Fig 4a). It
was activated with two, one-quarter turns
each morning and evening. Since the
appliance broke after 2 months and there
was not sufficient space for any other
expansion appliance, an active trans -
palatal arch (TPA) for the premolars was
inserted. It was later supplemented by a
second TPA for the canines (Fig 4b).
Besides that it requires very little space,
another advantage of a TPA is its low cost.
Because the patient did not like the
appearance of her rotated anterior teeth,
0.022-inch MBT brackets were bonded on
the four maxillary incisors, and a 0.016-
inch heat-activated Ni-Ti wire was ligated.
Since the lateral incisors were tipped dis-
tally and their roots at risk to penetrate
the premaxillary bone, the alignment was
later restricted to the central incisors (Fig
4c). One month later, brackets were
bonded to the remaining maxillary teeth,
onto which stainless steel wires were
placed, a 0.016-inch in the first and a
0.016
0.022-inch in the second quad-
rant. In the first quadrant, the canine was
retracted with an elastic chain.
As soon as suf ficient space was
gained, a quadhelix was placed to con-
tinue the maxillary expansion (Fig 4d).
Simultaneously, the mandibular arch was
aligned. Because of the lateral open bite
on the left side, a mini-implant was
placed in the third quadrant to extrude
the maxillary left buccal segment (Fig 5).
The overerupted maxillary anterior region
was not able to facilitate the extrusion of
the left buccal segment because the lat-
eral incisors had to be included in the
leveling wire, with the same risk for their
roots as described previously.

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VOLUME 11, NUMBER 4, 2010 Batra et al

Fig 5 (right) Placement of a mini-implant

between mandibular left canine and first
premolar to close the lateral open bite by
extruding the left maxillary buccal segment
with a vertical elastic traction.

Fig 6 (left) Intraoral frontal

view before surgery.

Fig 7 (right) Intraoral maxil-

lary occlusal view during pre-
maxillary osteotomy with
vomeroplasty.

Fig 8 Postsurgical views with

trihelix to maintain expansion.

Once the occlusion was improved (Fig
6), the inclination of the premaxillary seg-
ment was changed and it was superiorly
repositioned surgically; a vomeroplasty
was also performed (Fig 7). Further, bone
from the iliac crest was placed bilaterally
in the cleft region as a secondary alveolar
graft. For retention, a horseshoe-shaped
splint was used—a full-coverage splint
might have interfered with the vascularity
of the premaxillary segment. After 3
weeks of stabilization, a continuous
0.017
0.025-inch stainless steel wire
was placed with a trihelix to maintain the
expansion (Fig 8). After sequential use of
a 0.019
0.025-inch stainless steel wire
and a 0.021
0.025-inch TMA (beta-
titanium alloy) wire, bracket repositioning
and other finishing procedures led to a
drastic improvement of the patient’s
facial esthetics (Fig 9). After 4 years of
active treatment, the patient was
debonded.
Figure 10 shows the dentition of the
patient after the peg-shaped lateral
incisors were built up with composite. To
retain the maxillary situation, a splint (Fig
11a) with a TPA in the premolar region
was used. The appliance further con-
tained a scalloped wire that enveloped
the entire maxillary arch and ended in
buccal hooks in the molar area for Class
III elastics. The mandibular splint had
hooks between the lateral incisor and
canine bilaterally. Also, a Class III activa-
tor with lip pads in the maxillary anterior
sulcus was used for night-time wear (Fig
11b). Rhinoplasty will be carried out once
the patient is full-grown.

383

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 Batra et al WORLD JOURNAL OF ORTHODONTICS

a b

Fig 10 Intraoral views of the dentition after treatment and built-up, peg-shaped lateral
incisors with composite.

Fig 9 Posttreatment extraoral

view.

a b

Fig 11 Retention appliances. (a) For day-time wear, a splint retainer with hooks (and TPA
in the maxilla) for the engagement of Class III elastics, and (b) a Class III activator with lip
pads in the maxillary anterior sulcus for night-time wear.

DISCUSSION the patient’s esthetic concerns. A wide

Protrusion of the maxillary anterior region
is unique to humans with bilateral clefting
of the lip and palate. In lower mammals
with complete bilateral clefts, the relation-
ship of the maxillary anterior region with
the lateral maxillary processes remains
virtually undisturbed. In humans, the
nasal septum grows forward and takes
the maxillary anterior teeth with it.11 The
details of this entire development are
complicated and involve both anterior
positioning and lateral rotation.11–16
Patients with clefts need interdiscipli-
nary treatment. The initial step is usually
(as in this patient) the orthodontic expan-
sion of the collapsed maxilla. In this
patient, the rotation of the central incisors
was simultaneously corrected because of
variety of appliances can expand the col-
lapsed maxillary arches of patients with
clefts. These include both rapid and slow
expansion devices. Because of the dense
scar tissue. slow expansion was chosen
here. Also, all the expansion appliances
used in this patient were made chairside
(except the fan-shaped expander) to con-
trol the treatment expense.
A reduced need for alveolar bone
grafting by presurgical orthopedics and
primary gingivoperiosteoplasty has been
documented in the literature,17 and this
view is not unchallenged.
The vertical discrepancy on the left
side was not corrected by using the
mandibular posterior segment as anchor-
age, since these teeth did not need any
extrusion; an implant was used.

384

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VOLUME 11, NUMBER 4, 2010
One of the most important steps in
treatment planning is the retention
phase. Usually, patients with clefts need
long-term stabilization even if sufficient
positive overjet and overbite are
obtained. These contribute to stability,
but residual growth must still be taken
into consideration. This was accom-
plished by furnishing the maxillary splint
with a TPA and by supplying both splints
with hooks for the engagement of Class
III elastics (Fig 11a). Both splints were
worn during the day. Furthermore, the
patient received a Class III activator with
lip pads in the maxillar y anterior
vestibule for night-time wear (Fig 11b).
These lip pads were thought to generate
some periosteal stretch as the pads of
function regulators are assumed to do.
At 14 years of age, a good arch form
and satisfactory occlusion had been
achieved. However, the patient’s facial
profile still shows a protrusion of the
lower lip, which might necessitate
another surgical intervention after she is
full-grown. At the same time, a lip revision
and rhinoplasty could be performed to
improve the patient’s facial features.18–20
The ideal upper lip is characterized by
having a triangular shape with a central
elevation, yielding at least 2 to 3 mm of
the central incisors on rest, being some-
what shorter in its central part, and hav-
ing suf ficient vermillion volume. In
respect to the nose, the columella length
has to be sufficient enough to give the
nose tip a pointed projection.
CONCLUSION
Treatment of patients with cleft lips and
palates requires an interdisciplinary
approach with active participation of
geneticists, pediatricians, ENT special-
ists, plastic surgeons, speech therapists,
and orthodontists. The role of the ortho-
dontists includes expanding the maxilla,
protracting it if needed, correcting ante-
rior and posterior crossbites, aligning all
teeth, and dealing with supernumerary
and missing teeth. Further, the orthodon-
tist has to take care to maintain all
achieved corrections.
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Batra et al
This article describes the treatment of
a patient with a bilateral cleft lip and
palate. Her therapy presented several
challenges because of the severity of the
malocclusion in the transverse and verti-
cal dimension as well as the patient’s
esthetic concerns and financial situation.
The patient’s chief concerns were suc-
cessfully resolved in 4 years.
ACKNOWLEDGMENTS
The authors would like to thank Dr Krishna Murthy
Bonanthaya (Bhagwan Mahaveer Jain Hospital,
Bangalore) for surgical management.
REFERENCES
1. Ivy RH. Modern concept of cleft lip and cleft
palate management. Plast Reconstr Surg
1952;9:121–129.
2. Fogh-Anderson P. Inheritance of Harelip and
Cleft Palate. Copenhagen: Nordisk Forlag,
Arnold Busck; 1942.
3. Stark RB.The pathogenesis of harelip and cleft
palate. Plast Reconstr Surg 1954;13:20–39.
4. Georgiade G, Georgiade N, Riefkohl R, Barwick
W. Textbook of Plastic, Maxillofacial, and
Reconstructive Surgery, ed 2. Baltimore:
Williams & Wilkins, 1992.
5. Buss PW, Hughes HE, Clarke A. Twenty-four
cases of the EEC syndrome: Clinical presenta-
tion and management. J Med Genet 1995;32:
716–723.
6. Ogur G, Yüksel M. Association of syndactyly,
ectodermal dysplasia, and cleft lip and palate:
Report of two sibs from Turkey. J Med Genet
1988;25:37–40.
7. Lees MM, Winter RM, Malcolm S, Saal HM,
Chitty L. Popliteal pterygium syndrome: A clini-
cal study of three families and report of linkage
to the Van der Woude syndrome locus on
1q32. J Med Genet 1999;36:888–892.
8. Oyama T, Yoshimura Y, Onoda M, Hosokawa K,
Kanomi R. Stabilization of a mobile premaxilla
by cementing a bite splint with 1-stage bilateral
alveolar bone grafting. J Crianiofac Surg 2008
19:1705–1707.
9. Ilino M, Sasaki T, Kochi S, Fukuda M, Takahashi
T, Yamaguchi T. Surgical repositioning of the
premaxilla in combination with two-stage alveo-
lar bone grafting in bilateral cleft lip and palate.
Cleft Palate Crianiofac J 1998;35:304–309.
10. Aburezq H, Daskalogiannakis J, Forrest C. Man-
agement of the prominent premaxilla in bilat-
eral cleft lip and palate. Cleft Palate Crianiofac J
2006;43:92–95.
11. Atherton JD. The natural history of the bilateral
cleft. Angle Orthod 1974;44:269–278.
385
 Batra et al WORLD JOURNAL OF ORTHODONTICS

12. Scott JH. The cartilage of the nasal septum 18. Yuksel E, Matinez M, Guerra G, Farlane L.
(a contribution to the study of facial growth). Suspension and redraping of the free col-
Br Dent J 1953;95:37–43. umella-lip complex. Poster Presentation: Poster
13. Friede H, Pruzansky S. Longitudinal study of Session. ASPS Meeting 2007, Baltimore, 28
growth in bilateral cleft lip, and palate from October 2007.
infancy to adolescence. Plast Reconstr Surg 19. Mutaf M. V-Y in V-Y procedure: New technique
1972;49:392–403. for augmentation and protrusion of upper lip.
14. Ross RB, Johnston M. Cleft Lip and Palate. Bal- Ann Plast Surg 2006;56:605–608.
timore: Williams & Wilkins, 1972. 20. Haworth R. Customizing perioral enhancement
15. Lantham RA. Development and structure of the to obtain ideal lip aesthetics: Combining both
premaxillary deformity in bilateral cleft lip and lip voluming and reshaping procedures by
palate.Br J Plast Surg 1973;26:1–11. means of an algorithmic approach. Plast
16. Vargervik K. Growth characteristics of the pre- Reconstr Surg 2004;113:2182–2193.
maxilla and orthodontic principles in bilateral
cleft lip and palate. Cleft Palate J 1983;20:
289–302.
17. Nahai F, Williams J, Burstein F, Martin J,
Thomas J. The management of cleft lip and
palate: pathways for treatment and longitudinal
assessment. Semin Plast Surg. Cleft Lip
Repair: Trends and Techniques 2005;19:
275–285.

386

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NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Yoon-Ah Kook, DDS, PhD1
SIMPLIFIED ABUTMENT TOOTH
Mohamed Bayome, BDS,
MS2 EXTRUSION USING A MINI-IMPLANT
Seong-Hun Kim, DDS, This is the report of a patient with an anterior four-unit fixed partial
MSD3 denture in whom a screw was used to extrude a too-short abutment
tooth. Due to the mini-implant, fewer teeth needed to be bonded,
Dong-Hoon Lee, DDS, thereby keeping more teeth out of harm’s way. World J Orthod
MSD4 2010;11:387–392.

Yoon-Ji Kim, DDS, PhD5

Key words: forced eruption, abutment, mini-implant
Seok-Gyu Kim, DDS, PhD6

1Professor, Department of Orthodon-

tics, Seoul St Mary’s Hospital, The
Catholic University of Korea, Seoul,
Korea.
2Graduate Student, Department of

Orthodontics, Medical School, The

Catholic University of Korea, Seoul,
Korea.
3Associate Professor, Department of

Orthodontics, Uijongbu St Mary’s

Hospital, The Catholic University of
Korea, Seoul, Korea.
4Former Resident, Department of

Orthodontics, Seoul St Mary’s Hospi-

tal, The Catholic University of Korea,
Seoul, Korea.
nterior fixed partial dentures, espe- ficient biologic width, which is about
5Assistant Professor, Department of

Orthodontics, Seoul St Mary’s Hospi-

tal, The Catholic University of Korea,
Seoul, Korea.
6Associate Professor, Department of
Prothodontics, Seoul St Mary’s Hos-
pital, The Catholic University of
Korea, Seoul, Korea.
CORRESPONDENCE
Dr Yoon-Ah Kook
Department of Orthodontics
Seoul St Mary’s Hosptial
The Catholic University of Korea
505 Banpo-dong
Seocho-gu
Seoul 137-701
Korea
Email: kook190036@yahoo.com
A cially in the maxilla, have to fre-
quently be replaced as the gingival
margins of the abutment teeth gradually
recede, of ten leading to cervical
caries. 1,2 If the extraction of an abut-
ment tooth becomes unavoidable due to
extensive caries or periapical lesions, an
implant can be indicated. However, to
avoid implants (because of cost or other
reasons), patients often prefer an exten-
sion of their fixed partial denture.
To obtain adequate clinical crown
height, extrusion using a post or a pro-
visional crown can be required.3–5 The
amount of extrusion has to achieve suf-
2.0 mm.6,7 If 2.0 mm is needed for a
correct crown margin, the extrusion has
to amount to at least 3.0 to 4.0 mm to
have sufficient supra-alveolar tooth
structure available.
Fixed appliances with brackets on
adjacent teeth are often used for extru-
sion.8 However, if several adjacent teeth
are missing, a mini-implant can be used
instead. Such a mini-implant is placed
next to the tooth to be extruded, and
brackets are bonded to teeth on the
opposite side. Mini-implant–assisted
extrusion requires fewer brackets, so
adverse effects can be avoided (Fig 1).

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 Kook et al WORLD JOURNAL OF ORTHODONTICS

Fig 1 Schematic drawing for simplified

tooth extrusion using a mini-implant. Sit-
uation (a) before initiation of treatment
and (b) after mini-implant insertion,
bracket placement, and wire engage-
ment.

a b

Fig 2 Initial intra- and extraoral

photographs

Fig 3 Initial panoramic radiograph.

DIAGNOSIS and 3). This tooth served as an abutment

to a 10-year-old, four-unit fixed partial
A 58-year-old woman complained of pain denture used to replace her maxillary
in her maxillary left lateral incisor (Figs 2 central incisors. After her abutment teeth

388

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VOLUME 11, NUMBER 4, 2010 Kook et al

a b c d

Fig 4 (a and b) Periapical radiographs of the abutment teeth at the beginning of treatment and (c and d) after revision of the
root canal fillings.

Fig 5 Components used for forced

eruption of the maxillary left lateral
incisor. (a) Frontal view with inserted
mini-implant, bonded button, and
bonded brackets and (b) detail view of
wire segment with vertical stop.

a b

were endodontically treated at a local premolar were bracketed (0.022-inch slot,

clinic, the patient returned 8 months
later (Figs 4a and 4b). Because the maxil-
lary right canine and both lateral incisors
showed periapical lesions, the existing
fixed partial denture was removed, the
root canal fillings were revised (Figs 4c
and 4d), and a provisional fixed partial
denture was inserted. Since the maxillary
left lateral incisor’s clinical crown was too
short to serve as an abutment, extrusion
was required.
TREATMENT
TOMY). A 0.018 ⫻ 0.022-inch stainless
steel wire with a welded metal stop (TOMY)
was inserted in the hole of the mini-
implant’s head. A power chain was initially
used for extrusion, but was later replaced
by an elastic thread, which was changed
weekly, that exerted a force of approxi-
mately 40 cN. It extruded the lateral
incisor 1.0 mm per week. With extrusion
(Fig 7), the incisor crown was shortened.
Finally, a crown lengthening procedure
was performed on the left lateral incisor
and both canines.

For this extrusion, a mini-implant with a TREATMENT RESULTS

hole (JA type: diameter 1.6 mm, length 8.0
mm) (Dual Top Anchor System, Jeil Med-
ical) was inserted under topical anesthe-
sia mesial to the left lateral incisor (Figs 5
and 6). For easy insertion of a wire seg-
ment, the hole was orientated vertically.
Further, a button was attached to the
crown of the left lateral incisor after it was
separated from the remaining provsional
denture and the left canine and the first
Rapid eruption was accomplished in 1
month and retained for 2 months. During
this time, gingivoplasty (Fig 8) was per-
formed in the area of the two central
incisors for a perfect fit of the definitive
restoration. Another 2 months later, ade-
quate soft tissue healing had occurred,
and an impression for the final six-unit
fixed partial denture was taken. It was

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 Kook et al WORLD JOURNAL OF ORTHODONTICS

a b

Fig 6 Periapical radiographs of the Fig 7 Periapical radiographs of the maxillary left lateral incisor (a) before and
setup for the forced eruption of the (b) after forced eruption. Red bar indicates supra-alveolar root length.
maxillary left lateral incisor.

Fig 8 Intra- and extraoral photo-

graphs after forced eruption and crown-
lengthening procedure.

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VOLUME 11, NUMBER 4, 2010
a b
Fig 9 (a) Definitive restoration fabricated with zirconia framework, and (b) intraoral frontal
view 6 months after insertion.
fabricated with zirconia framework (Lava,
3M ESPE; Fig 9a) and inserted using resin
cement. Soft tissue response and overall
performance of the new restoration were
evaluated 6 months later (Fig 9b).
DISCUSSION
With advances in medicine, the popula-
tion has grown older. As general socio-
economic conditions have improved,
older patients of ten demand highly
esthetic restorations. However, treatment
of elderly patients means clinicians must
consider reduced adaptive potential,
insuf ficient oral hygiene, and an
increased susceptibility to root caries
and periodontal disease.9
Whenever a crown or fixed partial den-
ture has to be restored, the abutment
tooth (or teeth) must have sufficient
length. This is not the case with subgingi-
val tooth fractures or root caries. In such
situations, compromised abutment teeth
can be extracted and the fixed partial
denture extended. However, the proper
crown-to-root ratio may be violated. A
more promising alternative is the inser-
tion of a prosthodontic implant or the
forced orthodontic eruption of the too-
short abutment tooth.
Although forced eruption will change
the crown-to-root ratio, this treatment
approach was chosen for its safety, short
duration, and low cost.
Treatment such as the one described
here generally requires a multidisciplinary
approach with endodontists, orthodon-
tists, periodontists, and prosthodontists.10
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Kook et al
Teeth can be extruded with a plethora of
removable or labial or lingual fixed appli-
ances.11–13 However, in the present case,
the long edentulous span mesial to the
maxillary left lateral incisor challenged the
placement of conventional fixed appli-
ances. Therefore, a mini-implant was used
for anchorage.
The stability of orthodontic extrusion
has been reported. 14,15 Stability was
even more likely, since the extruded tooth
served as an abutment and was perma-
nently retained.
Since the level of the gingival margin of
the maxillary right lateral incisor was ini-
tially higher than that of both canines and
the left lateral incisor, a crown-lengthening
procedure was performed to achieve a
harmonious gingival level among the ante-
rior teeth. Because any well-constructed
restoration requires good gingival esthet-
ics,16 gingivoplasty for the central incisor
pontics was also indicated.
If only a single abutment tooth of a
long-spanning partial denture needs to
be extruded, forced eruption with the use
of mini-implants is recommended.
CONCLUSION
Mini-implants allow for an easy extrusion
of abutment teeth, ie, it makes it unnec-
essary to extend a (partial) fixed appli-
ance over the span of a long restoration.
This is advantageous since fewer brack-
ets are needed and fewer teeth therefore
have the potential to experience adverse
effects.
391
Kook et al WORLD JOURNAL OF ORTHODONTICS

REFERENCES 10. Olsburgh S, Jacoby T, Krejci I. Crown fractures

in the permanent dentition: Pulpal and restora-
tive considerations. Dent Traumatol 2002;18:
1. Goodacre CJ, Bernal G, Rungcharassaeng K,
103–115.
Kan JY. Clinical complications in fixed prostho-
11. Poi WR, Cardoso LC, de Castro JCM, Cintra LTÂ,
dontics. J Prosthet Dent 2003;90:31–41.
Gulinelli JL, de Lazari JAB. Multidisciplinary
2. Rosen H. Dissolution of cement, root caries,
treatment approach for crown fracture and
fracture, and retrofit of post and cores. J Pros-
crown-root fracture—A case report. Dent Trau-
thet Dent 1998;80:511–513.
matol 2007;23:51–55.
3. Smidt A, Venezia E. The use of an existing cast
12. Mamber EK. Treatment of intruded permanent
post and core as an anchor for extrusive move-
incisors: A multidisciplinary approach. Endod
ment. Int J Prosthodont 2003;16:225–228.
Dent Traumatol 1994;10:98–104.
4. Ivey DW, Calhoun RL, Kemp WB, Dorfman HS,
13. Yüzügüllü B, Polat O, Ungör M. Multidisciplinary
Wheless JE. Orthodontic extrusion: Its use in
approach to traumatized teeth: A case report.
restorative dentistry. J Prosthet Dent 1980;43:
Dent Traumatol 2008;24:e27–30.
401–407.
14. Thosar NR, Vibhute P. Surgical and orthodontic
5. Potashnick SR, Rosenberg ES. Forced eruption:
treatment of an impacted permanent central
Principles in periodontics and restorative den-
incisor—A case report. J Indian Soc Pedod Prev
tistry. J Prosthet Dent 1982;48:141–148.
Dent 2006;24:100–103.
6. Ingber JS. Forced eruption: Part II. A method of
15. Wasserstein A, Tzur B, Brezniak N. Incomplete
treating nonrestorable teeth—Periodontal and
canine transposition and maxillary central
restorative considerations. J Periodontol 1976;
incisor impaction: A case report. Am J Orthod
47:203–216.
Dentofacial Orthop 1997;111:635–639.
7. Ingber JS, Rose LF, Coslet JG. The “biologic
16. Caudill R, Chiche G. Establishing an aesthetic
width”—A concept in periodontics and restora-
gingival appearance. In: Chiche G, Pinault A
tive dentistry. Alpha Omegan 1977;70:62–65.
(eds). Esthetics of Anterior Fixed Prosthodon-
8. Brown GJ, Welbury RR. Root extrusion, a practi-
tics. Chicago: Quintessence, 1994:177–198.
cal solution in complicated crown-root incisor
fractures. Br Dent J 2000:189:477–478.
9. Gilmour AG, Morgan CL. Restorative manage-
ment of the elderly patient. Prim Dent Care
2003;10:45–48.

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Cumhur Tuncer, DDS, PhD1
TENSILE BOND STRENGTH OF LINGUAL
Çağrı Ulusoy, DDS, PhD1
ORTHODONTIC BRACKETS WITH
ADHESIVE SYSTEMS
Aim: To study in vitro the bond strength of three adhesive systems on
lingual brackets. Methods: Forty-five extracted human mandibular
premolars were randomly divided into three groups of 15 specimens
each. All brackets (Stealth lingual brackets) were bonded with Trans-
bond XT Light Cure Adhesive. In group 1, the conventional primer
was used; in group 2, Transbond Moisture Insensitive Primer was
employed; and in group 3, an antimicrobial self-etching primer
(Clearfil Protect Bond) was used. Results: The highest mean bond
strength values were observed when Clearfil Protect Bond (13.54 ±
0.58 MPa) was used and the lowest after applying the conventional
Transbond XT primer (6.41 ± 0.43 MPa). The mean bond strength in
group 2 was 8.20 ± 0.50 MPa, which was significantly higher than that
of group 1. Conclusion: Besides its antimicrobial effect, Clearfil Pro-
tect Bond results in high bond strength values. Therefore, this prod-
uct might be preferable when bonding lingual brackets. World J
Orthod 2010;11:393–397.

Key words: lingual brackets, tensile force, bond strength, antimicrobial

adhesive, self-etching primer

he esthetics of fixed orthodontic economically efficient treatment con-

1Assistant
Professor, Department of
Orthodontics, University of Gazi,
Ankara, Turkey.
2Research Assistant, Department of
Orthodontics, University of Gazi,
Ankara, Turkey.
CORRESPONDENCE
Dr Cumhur Tuncer
Department of Orthodontics
Faculty of Dentistry
Gazi University
84.sokak Emek-Ankara
Turkey
Email: cumhurtu@yahoo.co.uk,
tuncer@gazi.edu.tr
T appliances have improved through
the introduction of plastic and ceramic
brackets, coated archwires, and lingual
appliances.1,2 Lingual brackets provide
superior esthetics, especially in adult
patients. However, there is substantial
evidence that lingual appliances cause
remarkable patient discomfor t. 1–5
According to Sinclair et al,3 this includes
tongue soreness, speech difficulties,
and increased plaque retention. Simi-
larly, Hohoff et al5 emphazised the need
for increased oral hygiene in patients
with lingual brackets.
Bracket loss is a severe complication,
particularly when using lingual appli-
ances. Therefore, Wiechmann 6 stated
that bonding lingual brackets with a
strong adhesive is an integral part of an
cept. It would be desirable if this bond-
ing system could simultaneously control
or reduce lingual plaque accumulation.
Previous studies have evaluated the
shear strengths of orthodontic brackets
bonded with adhesive systems.7–9 Two
publications emphasized that Clearfil
Protect Bond (Kuraray Medical) not only
has a high bond strength but also a
strong antibacterial effect because of its
MDPB (12-methacryloyloxy dodecylpyri-
dinium bromide) component.10,11
Adhesive failures can be the result of
contamination during bonding.12,13 This
led to the development of moisture-insen-
sitive primers (MIP).14 Indeed, two studies
revealed that Transbond MIP (3M Unitek
Orthodontic Products) shows superior
bond strength under wet conditions.15,16

393

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 Tuncer/Ulusoy WORLD JOURNAL OF ORTHODONTICS

Table 1  Composition of the study materials

Material Chemical composition

Transbond XT Light Cure
Adhesive System (3M)
Transbond Moisture
Insensitive Primer (MIP) (3M)
Clearfil Protect Bond (Kuraray)
Primer: Quartz silica, bisphenol A eiglycidyl ether dimethacrylate
Adhesive paste: Bisphenol A bis(2-hydroxyethyl ether) Dimethacrylate
Primer: Hydroxethyl methacrylate (HEMA) and maleic acid dissolved
in acetone
Primer: Methacryloxydecyl dihydrogen phosphate (MDP), MDPB, HEMA,
water, hydrophilic dimethacrylate
Bond: MDP, bis-GMA, HEMA, microfiller, surface-treated sodium fluoride

To these authors’ knowledge, the bond Group 1

strength of lingual orthodontic brackets
has not been investigated. Therefore, the
aim of this in vitro study was to evaluate
this aspect using a conventional adhe-
sive (Transbond XT Light Cure) with con-
ventional primer or MIP and with a new
antimicrobial, fluoride-releasing, self-
etching primer (Clearfil Protect Bond).
METHOD AND MATERIALS
Forty-five caries-free extracted human
mandibular premolars were stored at
room temperature in distilled water with
thymol crystals (1% wt/vol) to inhibit bac-
terial growth. The selection criteria
included that the enamel had no visible
cracks or irregularities and had not been
treated with any chemical agents.
The teeth were cleaned with a rubber
cup and fluoride-free pumice slurry for 10
seconds, thoroughly washed, and dried
with oil-free air. To ensure the absence of
caries and enamel cracks, every tooth
was examined under a light stereomicro-
scope at 10⫻ magnification. The total
sample was randomly divided into three
groups of 15 specimens each. All teeth
were embedded upright in cold-curing
acrylic (Orthocryl, Dentaurum) using a
metal ring mould.
Metal lingual premolar brackets
(Stealth lingual brackets, American Ortho-
dontics) with a mean surface base area of
11.81 mm2 were bonded with different
procedures.
The enamel was etched for 30 seconds
with 37% phosphoric acid gel (Gel Etch,
3M Unitek), rinsed for 20 seconds, and
dried with oil-free air. Conventional Trans-
bond XT primer (3M Unitek Orthodontic
Products) was rubbed with pressure onto
each tooth for 5 seconds and dried with
air. The bracket base was coated with
Transbond XT adhesive and positioned at
the center of the lingual surface. Excess
adhesive was removed with a scaler
before polymerization. The adhesive was
cured with a halogen unit (Hilux Ultra
Plus, Benlioğlu Dental) for 10 seconds
from each side.
Group 2
The same procedure as in group 1 was
performed, but instead of the conven-
tional, a moisture insensitive primer,
Transbond MIP, was used.
Group 3
The enamel was etched for 10 seconds
with 37% phosphoric acid gel, rinsed with
water for 20 seconds, and air dried. Sub-
sequently, the antibacterial self-etching
Clearfil Protect Bond Primer was applied
with a brush in a uniform thin layer, which
was lef t for 20 seconds and then
exposed to an air stream to evaporate
the solvent. Next, the bonding agent was
applied and light cured for 10 seconds.
Brackets were bonded with Transbond XT
adhesive as in the other two groups.
The composition of all materials used
in this study is given in Table 1.

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VOLUME 11, NUMBER 4, 2010 Tuncer/Ulusoy

Table 2  Mean tensile bond strength (in MPa), standard Table 3  Frequency of the modified Adhesive
deviation (SD), minimum, maximum, and upper and lower limits Remnant Index (ARI) scores
of 95% confidence interval ARI score
Group Mean SD Minimum Maximum Lower limit Upper limit 1 2 3 4 5
1 6.41 0.43 5.81 7.05 6.01 6.80 Group 1 3 6 5 1 0
2 8.20 0.50 7.60 8.99 7.74 8.66 Group 2 2 3 6 4 0
3 13.54 0.58 12.66 14.20 13.01 14.07 Group 3 0 0 9 3 3
Differences between groups 1 and 3 and groups 2 and 3 are
significant (P < .05).

After bonding, all specimens were RESULTS

stored in distilled water at room tempera-
ture for 24 hours. Tensile force in a gin-
givoocclusal direction was applied with a
universal testing machine (Instron) until
debonding occured. The crosshead speed
amounted to 1 mm/min; the maximum
tensile force was recorded in Newtons
and converted to megapascals (MPa).
After bracket removal, the enamel sur-
faces were examined by a blinded exam-
iner (ÇU) under a stereomicroscope
(Nikon) at 20⫻ magnification to assess
the bulk of residual adhesive. A modified
Adhesive Remnant Index (ARI) was used to
quantify the amount of remaining adhe-
sive17: 1 = all adhesive on tooth, 2 = > 90%
of adhesive on tooth, 3 = 10% to 90% of
adhesive on tooth, 4 = < 10% of adhesive
on tooth, and 5 = no adhesive on tooth.
Statistical evaluation was performed
with SPSS for Windows 10.0. Descriptive
statistics were calculated for each group.
The one-sample Kolmogorov-Smirnov test
was applied to evaluate the normal distri-
bution of variances. Comparisons of
bond strength were per formed with
analysis of variance (ANOVA) followed by
the post-hoc Tukey honestly significant
difference (Tukey HSD) multiple compari-
son test. The Kruskal-Wallis test was
used to evalute the differences in ARI
scores among groups. Pairwise compar-
isons were performed using the Bonfer-
oni adjusted Mann-Whitney U test. The
level of significance was set at P < .05.
Bond strength
The descriptive statistics (mean, standard
deviation, minimum, maximum, and 95%
confidence interval) are shown in Table 2.
The one-way ANOVA revealed that the dif-
ferences among all three groups were sig-
nificant. The highest bond strength values
were observed with Clearfil Protect Bond
(13.54 ± 0.58 MPa, P < .001), the lowest
with Transbond XT (6.41 ± 0.43 MPa,
P < .001). The mean bond strength value
for Transbond MIP was 8.20 ± 0.50 MPa.
ARI
The ARI scores are shown in Table 3. The
Kruskal-Wallis test showed significant differ-
ences among the groups ␹2 = 12.239,
P = .002). Mann-Whitney U tests reflected a
significant difference between groups 1
and 3 and groups 2 and 3 (P < .05).
DISCUSSION
Factors that influence bond strength
include anatomical structure of the
enamel, conditioning procedure, type of
applied adhesive, and design of the
bracket base.7 Besides contamination dur-
ing bonding, the fixation of lingual brack-
ets is influenced by tongue pressure.

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 Tuncer/Ulusoy
Clinical performance of orthodontic
adhesive systems is primarily based on
bond strength, as well as ease of excess
removal before setting and cleanup after
debonding. Additional features (fluorida-
tion and antimicrobial effect) should be
taken into consideration, too.9,10 A mini-
mum bond strength of 6.00 to 8.00 MPa
is considered clinically adequate.18,19
Previously, Della Bona and van
Noort 20 pointed out that testing bond
strength with tensile forces produces
more adhesive failures, thus reflecting
realistic bond strength. This method was
used in the present study to imitate the
forces exerted by intraoral elastics.
Faltermeier et al15 found that Trans-
bond XT without and with Transbond MIP
showed no significant difference in shear
bond strength under dry conditions,
which is in accordance with other stud-
ies. 21,22 However, in wet conditions,
Transbond XT with MIP revealed higher
bond strength values.12,13,15
Clearfil Protect Bond is the first self-
etching adhesive system that contains an
antibacterial monomer (MDPB). Two stud-
ies reported that the bond strength of
this product is sufficient.9,23 This fact, in
combination with its release of fluoride
and antibacterial effect, makes Clearfil a
considerably beneficial product.9
The outcome of this study indicates
that all tested adhesive systems have
sufficient bond strength. The fact that
Transbond XT with MIP gave a signifi-
cantly higher bond strength is consistent
with previous reports12,13 but in contrast
to one other investigation.24 This discrep-
ancy could be attributed to the morpho-
logic difference of the labial and lingual
tooth surfaces and the shape of the
bracket bases. The high bond strength of
Clear fil Protect Bond was observed
previously.9,10,23
Retief 25 stated that if the bond
strength of orthodontic brackets exceeds
14.00 MPa, more than sufficient reten-
tion is ensured, but the risk of enamel
fracture during debonding increases. The
mean bond strength of Clearfil Protect
Bond in this study was near this limit;
however, no enamel fractures were
observed. Moreover, Pickett et al 26
emphasized that in vivo bond strengths
396
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WORLD JOURNAL OF ORTHODONTICS
are significantly lower than those mea-
sured in vitro. This can explained by the
amount of time brackets spend in the
oral environment, their exposition to
acids and liquids in general, variable
patient habits, and masticatory forces.
Still, the high bond strength obtained
with Clearfil Protect Bond should be con-
sidered during debonding.
The mean ARI scores were between 2
and 3 in group 1, indicating that most of
the adhesive remained on the tooth. In
contrast, little or no adhesive was left
behind in groups 2 and 3. None of the
products led to enamel fractures during
debonding. This is clinically beneficial,
since the high bond strength is combined
with a minimal need to remove residual
resin after debonding.
CONCLUSION
The fluoride-releasing, antibacterial, self-
etching adhesive system Clearfil Protect
Bond showed better adhesion values
than the other two products tested. In
addition, its antibacterial feature is advan-
tageous in bonding lingual brackets.
REFERENCES
1. Caniklioglu C, Öztürk Y. Patient discomfort:
A comparison between lingual and labial fixed
appliances. Angle Orthod 2005;75:86–91.
2. Miyawaki S, Yasuhara M, Koh Y. Discomfort
caused by bonded lingual orthodontic appli-
ances in adult patients as examined by retro-
spective questionnaire. Am J Orthod
Dentofacial Orthop 1999;115:83–88.
3. Sinclair PM, Cannito MF, Goates LJ, Solomos
LF, Alexander CM. Patient responses to lingual
appliances. J Clin Orthod 1986;20:396–404.
4. Artun J. A post-treatment evaluation of multi-
bonded lingual appliances in orthodontics.
Eur J Orthod 1987;9:204–210.
5. Hohoff A, Stamm T, Kühne N, et al. Effects of a
mechanical interdental cleaning device on oral
hygiene in patients with lingual brackets. Angle
Orthod 2003;73:579–587.
6. Wiechmann D. Lingual orthodontics (Part 3):
Intraoral sandblasting and indirect bonding.
J Orofac Orthop 2000;61:280–291.
7. Sunna S, Rock WP. An ex vivo investigation into
the bond strength of orthodontic brackets and
adhesive systems. Br J Orthod 1999;26:47–50.
VOLUME 11, NUMBER 4, 2010
8. Faltermeier A, Behr M, Müssig D. A comparative
evaluation of bracket bonding with 1-, 2-, and
3-component adhesive systems. Am J Orthod
Dentofacial Orthop 2007;132:144.e1–144.e5.
9. Arhun N, Arman A, Sesen Ç, Karabulut E, Kork-
maz Y, Gokalp S. Shear bond strength of ortho-
dontic brackets with 3 self-etch adhesives. Am J
Orthod Dentofacial Orthop 2006;129:547–550.
10. Imazato S, Kinomoto Y, Tarumi H, Torii M, Rus-
sell RR, McCabe JF. Incorporation of antibacter-
ial monomer MDPB into dentin primer. J Dent
Res 1997;76:768–772.
11. Imazato S, Kuramoto A, Takahashi Y, Ebisu S,
Peters MC. In vitro antibacterial effects of the
dentin primer of Clearfil Protect Bond. Dent
Mater 2006;22:527–532.
12. Campomy D, Vicente A, Bravo LA. Effect of saliva
contamination on the shear bond strength of
orthodontic brackets bonded with a self-etching
primer. Angle Orthod 2005;75:865–869.
13. Rajagopal R, Padmanabhan S, Gnanamani J.
A comparison of shear bond strength and
debonding characteristics of conventional,
moisture–sensitive, and self-etching primers in
vitro. Angle Orthod 2004;74:264–268.
14. Frankenberger R, Kramer N, Obershachtsiek H,
Petschelt A. Dentin bond strength and marginal
adaption after NaOCL treatment. Oper Dent
2000;25:40–45.
15. Faltermeier A, Behr M, Rosentritt M, Reich-
eneder C, Müssig D. An in vitro comparative
assessment of different enamel contaminants
during bracket bonding. Eur J Orthod 2007;29:
559–563.
16. Zeppieri IL, Chung CH, Mante FK. Effect of
saliva on shear bond strength of an orthodon-
tic adhesive used with moisture-insensitive and
self-etching primers. Am J Orthod Dentofacial
Orthop 2003;124:414–419.
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NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Tuncer/Ulusoy
17. Oliver RG. The effect of different methods of
bracket removal on the amount of residual
adhesive. Am J Orthod Dentofacial Orthop
1988;93:196–200.
18. Özcan M, Vallittu PK, Peltomaki T, Huysmans
MC, Kalk W. Bonding polycarbonate brackets to
ceramic: Effects of substrate treatment on
bond strength. Am J Orthod Dentofacial Orthop
2004;126:220–227.
19. Cehreli ZC, Kecik D, Kocadereli I. Effect of self-
etching primer and adhesive formulations on
the shear bond strength of orthodontic brack-
ets. Am J Orthod Dentofacial Orthop 2005;127:
573–579.
20. Della Bona A, van Noort R. Shear vs. tensile
bond strength of resin composite bonded to
ceramic. J Dent Res 1995;74:1591–1596.
21. Littlewood S, Mitchell L, Greenwood D, Bubb N,
Wood D. Investigation of a hydrophilic primer
for orthodontic bonding: An in vitro study.
J Orthod 2000;27:181–186.
22. Kula KS, Nash TD, Purk JH. Shear-peel bond
strength of orthodontic primers in wet condi-
tions. Orthod Craniofac Res 2003;6:96–100.
23. Bishara SE, Soliman M, Laffoon J, Warren JJ.
Effect of antimicrobial monomer-containing
adhesive on shear bond strength of orthodon-
tic brackets. Angle Orthod 2005;75:397–399.
24. Karaman AI, Uysal T. Effectiveness of a hydro-
philic primer when different antimicrobial agents
are mixed. Angle Orthod 2004;74:414–419.
25. Retief DH. Failure at the dental adhesive-etched
enamel interface. J Oral Rehabil 1974;1:
265–284.
26. Pickett KL, Sadowsky PL, Jacobson A, Lacefield
W. Orthodontic in vivo bond strength: Compari-
son with in vitro results. Angle Orthod 2001;71:
141–148.
397
EFFECT OF FLUORIDE SOLUTIONS Christina Tziafa, DDS1

ON THE STRUCTURE AND HARDNESS Spiros Zinelis, PhD2

Margarita Makou, DDS,

OF PLASTIC BRACKETS MS, 3

Aim: To investigate the surface morphology, structure, molecular and

Theodore Eliades, DDS,
elemental composition, and hardness of plastic brackets exposed to
MS, Dr Med, PhD4
fluoride solutions. Methods: Two types of plastic brackets (Silkon
Plus and SpiritMB) were exposed to three fluoride solutions 10 times
George Eliades, DDS,
for 1 minute each and then subjected to attenuated total relectance-
Dr Dent5
Fournier transform infrared (ATR-FTIR) spectroscopy, scanning elec-
tron microscopy (SEM), x-ray energy dispersive microanalysis (EDS),
and Vickers hardness (HV) testing. Hardness data were analyzed via
two-way ANOVA and Tukey tests at the .05 level of significance with
brackets and fluoride solution as predictors. Results: ATR-FTIR spec-
troscopy showed that both bracket types consisted of polycarbonate.
After treatment with acidulated phosphate fluoride, an increased con-
tribution of –OH peaks at 3,200 cm–1(stretching [str]) and 1,640 cm–1 (a
type of vibration [b]) was observed in both brackets. SEM revealed
that the acidulated phosphate fluoride solution had a strong effect on
the morphology and surface structure of the two brackets; a general
deterioration with projections of the reinforcing fibers was observed.
EDS showed evidence of aluminum, calcium, silicon, magnesium,
and titanium, which could be attributed to the reinforcing glass fiber
constituents. Hardness ranged in the order of 20 HV with no differ-
ence among the two bracket types and the three fluoride exposures.
Conclusion: Repeated exposure of plastic brackets to fluoride solu-
tions has a pronounced effect on their structure and morphology, but
not their hardness. World J Orthod 2010;11:398–403.
1Private Practice, Thessaloniki,
Greece.
Key words: plastic brackets, hardness, morphology, fluoride exposure, 2Assistant Professor, Department of

SEM Biomaterials, School of Dentistry,

University of Athens, Athens,
Greece.
he demand for esthetic orthodontic The first plastic brackets, made of
T appliances stimulated interest in
ceramic and plastic brackets. The supe-
unfilled polycarbonate molding powder,
were introduced in the 1970s.2,3 Rein-
3Associate Professor, Department of

Orthodontics, School of Dentistry,

rior esthetics and inert character of
ceramic brackets have made them an
integral part of clinical practice.1 In spite
of their hardness, their tie wings fracture
easily, which often makes these brack-
ets inoperable. Alternatives include plas-
tic brackets, consisting mostly of
fiber-reinforced polycarbonate, which
possess a higher ductility than ceramic
brackets. However, the hardness and
stiffness of the former is reduced and
they are negatively affected by various
factors present in the oral cavity.
forced polycarbonate brackets gained
popularity in the 1990s when enamel
damage caused by ceramic brackets
during debonding became evident.4
The esthetic advantage of plastic
brackets, coupled with their low modulus
of elasticity that facilitates peel-off
debonding, made them particularly
appealing. However, the plastic brackets
currently available present too low a wear
resistance. In addition, their structural
integrity is compromised by various sub-
stances with which they come in contact.
University of Athens, Athens,
Greece.
4Associate Professor, Department of
Orthodontics, School of Dentistry,
Aristotle University of Thessaloniki,
Thessaloniki, Greece.
5Professor and Director, Department
of Biomaterials, School of Dentistry,
University of Athens, Athens,
Greece.
CORRESPONDENCE
Dr Theodore Eliades
57 Agnoston Hiroon
Nea Ionia 14231
Greece
Email: teliades@ath.forthnet.gr

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VOLUME 11, NUMBER 4, 2010
Their torque transfer to the teeth is
impaired because of their plastic defor-
mation, as well.5,6 Therefore, the develop-
ment of clear brackets synthesized of
high-crystalline polymers with increased
hardness and stiffness, decreased water
sorption, and improved resistance to
degradation is desirable.6 The resistance
of such brackets to fluctuating and low pH
in the presence of alcoholic beverages is
unknown and may compromise their
integrity and function, as polymers are
prone to plasticization and softening. No
evidence is available regarding the effect
fluoride has on plastic attachments.
Fluoride solutions are used in ortho-
dontics to protect against demineraliza-
tion. 7 The effect of fluorides on metal
has been investigated, revealing a delete-
rious effect on the integrity of the surface
oxide layer of titanium alloys, which may
facilitate corrosion.8
This study was initiated because no
data are available on the effect of fluo-
ride on plastic brackets, especially in
regard to morphology, structure, and
hardness. Specifically, the plasticization
of the material with the subsequent soft-
ening was to be evaluated.
METHOD AND MATERIALS
The plastic brackets investigated were:
Silkon Plus (American Orthodontics) and
SpiritMB (ORMCO). Sixteen specimens of
each brand were divided into four groups.
The first group served as a control,
whereas the three others were exposed
to acidulated phosphate fluoride (APF),
sodium fluoride (NaF), or stannous fluo-
ride (SnF2).
All brackets were embedded in epoxy
resin, ground with water-cooled silicon car-
bide (SiC) paper (220 to 2,000 grit), and
polished up to 0.05 alumina suspension
(Buehler) in a grinding/polishing machine
(Ecomet 3, Buehler). Each bracket type
was subjected to 10 immersion cycles
lasting 1 minute each. All specimens were
then subjected to the following:
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Tziafa et al
• Microattenuated total reflectance
Fourier transform infrared (micro-ATR-
FTIR) spectroscopy to characterize the
changes in the molecular composition
of the bracket surfaces induced by the
three fluorides. Spectra acquisitions
were performed on an FTIR spectrom-
eter (Spectrum GX) equipped with a
micro-ATR accessory (Golden Gate
MKII, Specac) operating under the fol-
lowing conditions: 4,000 to 400 cm–1
range, 4 cm –1 resolution, 50 scans
coaddition, diamond minicrystal, 45-
degree edge and single internal reflec-
tion, and 2.0 mm depth of analysis at
1,000 cm–1.
• Scanning electron microscopy (SEM)
to investigate the morphologic
changes induced by the three fluo-
rides. Backscattered electron images
were taken of the surface of speci-
mens employing an SEM (Quanta 200,
FEI) operated under 1 torr pressure,
30 kV accelerating voltage and 110 µA
beam current.
• X-ray energy dispersive microanalysis
(EDS) to assess the elemental composi-
tion of the brackets following exposure
to the three fluoride solutions. A liquid
nitrogen–cooled EDS detector (Sap-
phire, EDAX) with a super ultrathin
berylium (Be) window was used under
LV operation. Two EDS spectra were col-
lected from each specimen under 0.4
and 0.8 torr to subtract the LV back-
ground effect. The spectra were
acquired under 25 KV accelerating volt-
age, 110 µm beam current utilizing at
600
magnification (210
210 µm
sampling window), 150-second acquisi-
tion time, and 33% dead time. The
qualitative and quantitative analysis
was performed by Genesis 5.2 software
(EDAX) under a nonstandard mode,
employing ZAF correction methods.
• Vickers hardness (HV) testing with a
microhardness tester (HMV-2000, Shi-
madzu) for 15 seconds under a 20 g
load. Three measurements were
obtained from each bracket specimen.
Hardness data were analyzed with
two-way ANOVA and the Tukey test at the
.05 level of significance, with bracket
type and fluoride solution as predictors.
399
 Tziafa et al WORLD JOURNAL OF ORTHODONTICS

0.252 Fig 1 FTIR spectra of the (a)

0.24 Reference Silkon Plus and (b) SpiritMB
0.22 After APF brackets after various fluoride
0.20 After NaF treatments.
0.18 After SnF2
0.16
0.14
A 0.12
0.10
0.08
0.06
0.04
0.02

–0.005
4,000 3,600 3,200 2,800 2,400 2,000 1,800 1,600 1,400 1,200 1,000 800 600

a cm-1

0.274
0.26 Reference
0.24 After APF
0.22
After NaF
0.20
After SnF2
0.18
0.16
0.14
A
0.12
0.10
0.08
0.06
0.04
0.02
–0.005
4,000 3,600 3,200 2,800 2,400 2,000 1,800 1,600 1,400 1,200 1,000 800 600

b cm-1

Fig 2 SEM images of the (a)

Silkon Plus and (b) SpiritMB
brackets after cyclic immersion
in APF (original magnification

800).

a b

RESULTS immersion in APF. No significant effects

Figures 1a and 1b show the FTIR spectra
of the two brackets subjected to the
three fluoride solutions. The brackets
seem to share identical composition, and
show increased hydroxyl (–OH) peaks at
3,200 cm–1 (stretching [str]) and 1,640
cm–1 (a type of vibration [b]), following
were observed for the other two fluoride
solutions.
Figures 2a and 2b depict the SEM sur-
face of the two bracket types following
immersion in APF. Their surfaces show
porosities, irregularities, and multiple
projecting fibers relative to the controls
(not shown).

400

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VOLUME 11, NUMBER 4, 2010 Tziafa et al

14.1 6.0

11.3 4.8

C
C
8.5 3.6

KCnt KCnt

5.6 2.4

2.8 1.2
Si
Si Ca O Al
O
Ca Mg Ca
Al Na Ca
0.0 0.0
1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 10.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 10.00
Energy-keV Energy-keV
a b

3.7 Si
6.8

3.0
5.4

C
2.2 4.1

KCnt Ca KCnt

Si
1.5 2.7

Al O

0.7 1.4 Al Ca
O Mg
Na Ca
C Ca K Ti
Mg Ti F P K Ti
Na Ti
0.0 0.0
1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 10.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 10.00
c Energy-keV d Energy-keV

Fig 3 EDS spectra of the as-received (a) SilkonPlus and 13.9

(b) SpiritMB brackets with high carbon content, which is
attributed to their organic matrix; (c) a fiber of the SpiritMB
bracket showing its high inorganic content consisting mainly 11.1
of silicon, calcium, aluminium, magnesium, and titanium; and
(d) the SilkonPlus and (e) SpiritMB brackets following expo- C
sure to APF revealing residual fluorine peaks, which imply 8.3
adsorption of fluoride. KCnt

5.6

2.8 Si
Al
O Mg K Ca
Na Cl Ca
F Cl K
0.0
1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 10.00
e Energy-keV

Figures 3a and 3b depict the EDS tent (mainly silicon, calcium, aluminum,
spectra of as-received Silkon Plus and magnesium, and titanium). Figures 3d
SpiritMB brackets, respectively. The high and 3e illustrate the EDS spectra of
carbon content is attributed to their brackets after APF treatment with resid-
organic matrix. Figure 3c represents a ual fluorine peaks, which imply an
spot analysis of a fiber of the SpiritMB adsorption of fluoride complexes by both
bracket showing its high inorganic con- bracket types.

401

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 Tziafa et al WORLD JOURNAL OF ORTHODONTICS

Table 1  Two-way ANOVA table for hardness

Source df Seq SS Adj SS Adj MS F P*

Bracket 1 14.5 39.0 39.0 1.3 .26

Medium 3 124.6 140.9 46.9 1.6 .22
Bracket
medium 3 45.4 45.4 15.1 0.5 .67
Error 20 585.7 585.7 29.2
Total 27 770.3

*Numbers in that column represent the probability that the results have occurred by random chance.
SS = sum of squares, MS = mean square, df = degrees of freedom.

Table 2  Mean hardness, standard deviation (SD), and

Tukey grouping of the two bracket types without (control)
and after exposure to the three fluoride solutions
Bracket/fluoride solution group Mean (SD) Tukey grouping*

Silkon Plus–APF 22.1 (6.6) A

Silkon Plus–control 22.7 (3.6) A
Silkon Plus–SnF2 17.2 (2.6) A
Silikon Plus–NaF 20.2 (7.3) A
SpiritMB–APF 20.4 (3.3) A
SpiritMB–control 21.7 (4.3) A
SpiritMB–SnF2 19.9 (3.7) A
SpiritMB–NaF 22.9 (5.9) A

*Means with same letters are not significantly different at the .05 level.

Table 1 shows the two-way ANOVA for
hardness. None of the three solutions
seem to have a significant effect on the
hardness of both brackets. Table 2
demonstrates the Tukey grouping of the
bracket-solution combinations, which
were mostly in the order of 20 HV, with
no difference among the groups.
DISCUSSION
Despite the frequent application of plas-
tic brackets, no evidence exists on the
reactivity of polycarbonates with the vari-
ous substances they are exposed to
intraorally. Fluoride was chosen as the
factor to be examined because it is
applied routinely through toothbrushing
and as a preventive measure against
caries. Another reason was that fluoride
has demonstrated a deleterious effect on
other orthodontic materials, particularly
titanium alloys.8–11
The results of the present study show
that the hardness of the plastic was not
affected by the three fluoride solutions. It
should be noted, though, that the in vitro
environment of this study does not
reflect the intraoral conditions. Thus, a
direct extrapolation of these results to
clinical practice should not be attempted.
It could also be that throughout the
entire treatment, the number of fluoride
cycles imposed on a bracket exceeds the
value utilized in this investigation.
Polymeric brackets show distinctive dif-
ferences to metallic ones. The latter exhibit
cyclic hardening or softening depending on
their composition, previous cold work, and
temperature. In contrast, polymeric materi-
als display a cyclic softening effect.12,13
Polymer is also affected by loading and
ambient temperature changes, which
lead to a reduced fatigue life.
Hardness was studied because it is a
key property for the performance of a
bracket. The fact that most plastic brack-

402

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VOLUME 11, NUMBER 4, 2010
ets are manufactured from low modulus
raw material limits their per for-
mance.14,15 Vickers hardness is generally
minimal in plastic brackets, generally
about 20 HV. Most wires exceed this
value by a factor of 20 to 30, especially
nickel-titanium wires.15 Thus, it can be
projected that wires will impose severe
deformation of the slot walls when sliding
over the slot surfaces, which impedes
movement. Similarly, application and
maintenance of torque is impaired with
plastic brackets because of their perma-
nent deformation.16
The results of the SEM analysis
revealed an increased irregularity of the
bracket surfaces. The formation of micro-
porosities and projections precludes a
complete wire engagement. This may
jeopardize bracket effectiveness because
the prescribed preadjustments will not
be transferred.
The increased –OH peaks observed in
the APF group may be attributed to the
low pH value of that solution relative to
the others. Its acidicity may also be
responsible for its aggression on the sur-
faces of plastic brackets.
Polymers with higher crystallinity pre-
sent increased hardness and resistance
to wear.13 Brackets fabricated from poly-
xoymethylene consistently demonstrate a
lower roughness and a higher hardness
relative to their polycarbonate counter-
parts.6 However, polyxoymethylene brack-
ets lack adequate transparency and good
color stability.
CONCLUSION
The surfaces of plastic brackets exposed
to APF show an increase in irregularities
and complexity along with adsorption of
fluoride. Both facts may have a clinical
implication. However, exposure to the flu-
oride solutions tested does not influence
the hardness of the both plastic bracket
types investigated.
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Tziafa et al
REFERENCES
1. Eliades T, Viazis A, Lekka M. Failure mode
analysis of ceramic brackets bonded to enamel.
Am J Orthod Dentofacial Orthop 1993;104:
21–26.
2. Cohl ME, Green LJ, Eick JD. Bonding of clear
plastic orthodontic brackets using an ultravio-
let-sensitive adhesive. Am J Orthod 1972;62:
400–411.
3. Miura F. Direct bonding of plastic brackets.
J Clin Orthod 1972;5:446–454.
4. Arici S, Regan D. Alternatives to ceramic brack-
ets: The tensile bond strengths of two aesthetic
brackets compared ex vivo with stainless steel
foil-mesh bracket bases. Br J Orthod 1997;24:
133–137.
5. Feldner J, Sarkar N, Sheridan J, Lancaster D. In
vitro torque–deformation characteristics of
orthodontic polycarbonate brackets. Am J
Orthod Dentofacial Orthop 1994;106:265–272.
6. Zinelis S, Eliades T, Eliades G, Makou M, Silikas
N. Comparative assesment of the roughness,
hardness, and wear resistance of aesthetic
bracket materials. Dent Mater 2005;21:
890–894.
7. Shafi I. Fluoride varnish reduces white spot
lesions during orthodontic treatment. Evid
Based Dent 2008;9:81.
8. Huang HH. Variation in surface topography of
different NiTi orthodontic archwires in various
commercial fluoride–containing environments.
Dent Mater 2007;23:24–33.
9. Walker MP, White RJ, Kula KS. Effect of fluoride
prophylactic agents on the mechanical proper-
ties of nickelium-titanium-based orthodontic
wires. Am J Orthod Dentofacial Orthop 2005;
127:662–669.
10. Kwon YH, Jang CM, Jang JH, Park JH, Kim TH,
Kim HI. Effect of fluoride released from fluo-
ride–containing dental restoratives on NiTi
orthodontic wires, Dent Mater J 2008;27:
133–138.
11. Ramalingam A, Kailiasam V, Padmanabhan S,
Chitharanjan A. The effect of topical fluoride
agents on the physical and mechanical proper-
ties of NiTi and copper NiTi archwires. An in
vivo study. Aust Orthod J 2008;24:26–31.
12. Suresh S. Fatigue of Materials. Cambridge: Cam-
bridge Solid State Science Series, 1991:236.
13. Callister WD. Materials Science and Engineering:
An introduction. New York: Wiley, 1997:65–86.
14. Eliades T, Gioka C, Zinelis S, Eliades G, Makou
M. Plastic brackets: Hardness and associated
clinical implications. World J Orthod 2004;5:
62–66.
15. Eliades T, Eliades G, Brantley WA. Orthodontic
brackets. In: Brantley WA, Eliades T (eds).
Orthodontic Materials: Scientific and Clinical
Aspects. Stuttgart: Thieme, 2001:143–173.
16. Gioka C, Eliades T. Materials-induced variation
in the torque expression of preadjusted appli-
ances. Am J Orthod Dentofacial Orthop 2004;
125:323–328.
403
CORRECTION OF HORIZONTAL AND Vittorio Cacciafesta, DDS,
MSc, PhD1

VERTICAL DISCREPANCIES WITH A NEW M. Francesca Sfondrini,

DDS, PhD2
INTERACTIVE SELF-LIGATING BRACKET
SYSTEM: THE QUICK SYSTEM
In the past 10 years, self-ligating brackets have captured the interest of
many clinicians and enjoyed increasing popularity. These brackets
have been developed to overcome the disadvantages of stainless steel
or elastomeric ligatures in terms of ergonomics, efficiency, deforma-
tion, discoloration, plaque accumulation, and friction. A self-ligating
bracket does not require any type of ligature because it is has a
mechanical device that opens and closes the edgewise slot. Secure
archwire engagement may be accomplished by a built-in clip. Depend-
ing on the interaction between the bracket and archwire, self-ligating
brackets can be active and passive. The aim of this article is to describe
a new active self-ligating bracket system designed to noticeably
reduce the amount of friction that normally originates from archwire-
slot interaction, particularly during the correction of horizontal and
vertical discrepancies. World J Orthod 2010;11:404–412.

Key words: self-ligating brackets, friction, aligning, leveling, Quick brackets

riction is the resistance to motion All active and passive self-ligating

F when one object moves tangentially
against another. 1–4 Many factors con-
tribute to the frictional resistance of edge-
wise appliances,1–7 including bracket and
wire material, wire configuration, bracket
and wire surface condition, bracket-wire
interaction, the mode or force of ligation,
interbracket distance, presence or
absence of a lubricant (eg, saliva), and
functions of the oral environment.8–12
The first self-ligating bracket was
introduced by Russell in the mid 1930s
to reduce chair time and improve opera-
tor efficiency.13,14 More recently, multi-
ple self-ligating brackets have been
developed. SPEED (Strite), In-Ovation R
(GAC), and Time (American Orthodontics)
are active self-ligating brackets, while
Damon (Ormco) and Smart Clip (3M
Unitek) are passive.
brackets use the movable fourth wall to
convert the bracket slot into a tube. This
leads to a significant reduction in fric-
tion.3,15–21 Reduced friction can shorten
treatment time, especially in patients
whose teeth have been extracted and
subsequent tooth translation is to be
achieved by sliding mechanics.
The purpose of this repor t is to
describe a new self-ligating bracket sys-
tem designed to noticeably reduce the
1Private Practice, Milan, Italy.
amount of friction normally originated by 2Assistant Clinical Professor, Depart-
interaction between the archwire and ment of Orthodontics, Unversity of
slot, particularly in the correction of hori- Pavia, Pavia, Italy.
zontal and vertical discrepancies. This
innovative system enables clinicians to CORRESPONDENCE
Dr Vittorio Cacciafesta
apply forces without the resistance of
Viale Papiniano 44
conventional ligatures, reduce treatment 20123 Milano
time, and increase patient comfort. Italy
Email: vcacciafesta@hotmail.com

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VOLUME 11, NUMBER 4, 2010 Cacciafesta/Sfondrini

Fig 1 Quick bracket with highly pol- Fig 2 Opening the clip by inserting a director into the hole of the clip spring.
ished and rounded slot edges to reduce
binding of inserted archwire and auxil-
iary tube.

Fig 3 Opening the clip by pushing the clip mechanism with a director from the
gingival to incisal and occlusal aspects.

THE QUICK SYSTEM The clip can be opened in two ways—

Quick (Forestadent) is a twin metal
bracket manufactured by injection mold-
ing (Fig 1). It has well-polished and
rounded slot edges that allow free tooth
movement, even with severely deflected
archwires. The smooth edges and clip
surface improve patient comfort and pro-
vide good tooth-position control with mini-
mal friction, especially with round nickel-
titanium (Ni-Ti) wires. The clip is made of
cobalt-chromium and is interactive. It
remains passive up to an archwire dimen-
sion of 0.018 ⫻ 0.018-inch or 0.016 ⫻
0.022-inch. With increasing archwire
dimensions, the clip becomes more and
more active, providing clinicians with
maximum control.
by inserting a director in the buccal hole
(Fig 2) or by placing the director immedi-
ately on the clip mechanism and pushing
it incisally/occlusally (Fig 3).
The bracket is further equipped with
an auxiliary 0.016 ⫻ 0.016-inch tube
that can be used for double-arch
mechanics, power levers, uprighting, and
derotation springs (Fig 1). The design of
the bracket still allows the use of conven-
tional ligatures and lacebacks, though
the tie wings protect the clip in patients
with a deep overbite.

405

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Fig 4 Case 1. Extra- and intraoral views of a 14-year-old girl with a Class II malocclusion, deep overbite, and rotated and
mesially tipped maxillary central incisors.

Fig 5 Case 1. Stepwise correction of the rotation and mesial tipping of the maxillary central
incisors.

406

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VOLUME 11, NUMBER 4, 2010 Cacciafesta/Sfondrini

Fig 6 Case 1. Extra- and intraoral posttreatment views.

CASE 1 Quick brackets. The mesial tipping and

A 14-year-old girl with presented with a
Class II malocclusion, deep overbite, and
rotated and mesially tipped maxillary
central incisors (Fig 4).
Initially, maxillary and mandibular
0.012-inch Biostarter (Forestadent) Ni-Ti
archwires were inserted into preadjusted
rotation (Fig 5) of the maxillary central
incisors were fully corrected. Treatment
time was 20 months, and only three
archwires were used (0.012-inch Bio -
starter, 0.016 ⫻ 0.022-inch Biotorque,
and 0.019 ⫻ .025-inch stainless steel)
(Fig 6).

407

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Fig 7 Case 2. Extra- and intraoral views of a 16-year-old boy with a Class I malocclusion, deep overbite, and a palatally dis-
placed maxillary left canine.

Fig 8 Case 2. Maxillary and mandibular occlusal views after placement and full
engagement of initial 0.012-inch Biostarter Ni-Ti archwires.

Fig 9 Case 2. Occlusal views of stepwise correction of the palatal displacement of the maxillary left canine.

408

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VOLUME 11, NUMBER 4, 2010 Cacciafesta/Sfondrini

Fig 10 Case 2. Extra- and intraoral posttreatment views.

CASE 2 tube on the maxillary left canine (Fig 8).

A 16-year-old boy presented with a Class I
malocclusion, deep overbite, and a
palatally erupted maxillary left canine (Fig
7). Preadjusted Quick brackets were
bonded in both arches and 0.012-inch
Biostarter archwires placed. The maxillary
wire was fully inserted into the palatal
Within 5 months, enough space was
gained to align the canine in the arch (Fig
9). Treatment time was 21 months, and
only four archwires were used (0.012-inch
Biostarter, 0.016 ⫻ 0.022-inch Biotorque,
0.019 ⫻ 0.025-inch stainless steel, and
0.017 ⫻ 0.025-inch Twistflex) (Fig 10).

409

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Fig 11 Case 3. Extra- and intraoral views of a 15-year-old boy with a Class I malocclusion, reduced overbite, and bilateral high
ectopic maxillary canines.

a b

Fig 12 Case 3. (a) Frontal view at the placement of the initial 0.012-inch Biostarter Ni-Ti
archwires, and (b) situation at the placement of 0.016 ⫻ 0.022-inch Biostarter archwires
after 3 months.

CASE 3 ing and aligning was completed with

A 15-year-old boy presented with a Class I
malocclusion, a reduced overbite, and
ectopic maxillary canines (Fig 11).
At the start of treatment, maxillary
and mandibular 0.012-inch Biostarter
archwires were fully engaged into all
brackets (Fig 12a). After 1 month, the
canines were completely leveled. Level-
0.016 ⫻ 0.022-inch Biostarter archwires
(Fig 12b). In the finishing phase, 0.019 ⫻
0.025-inch stainless steel archwires were
employed for space closure and inclina-
tion control. Overall treatment time was
20 months, and only three archwires
were used (0.012-inch Biostarter, 0.016
⫻ 0.022-inch Biotorque, and 0.019 ⫻
0.025-inch stainless steel) (Fig 13).

410

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