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Volume 9, Issue 1 CONTENTS JAOS WINTER 2009

16 Impacted Incisors in Mixed Dentition
By Juan Carlos Echeverri, DDS

22 The Changing Face of Growth Modification 16

By Leonard J. Carapezza, DDS

26 The Benefits of Early Treatment

By Jeffrey H. Ahlin, DDS

32 Early Transitional Dentition Treatment

By Chris Baker, RN, DMD


8 Ortho Industry News

12 Orthobites
Interceptive Orthodontics:
Early Treatment in Orthodontics 26
By David W. Jackson, DDS, FAGD

38 AOS Membership News

42 AGpO Membership News

46 Patient’s Page 32
Oral Health and Diabetes
On the cover: Dr. James E. McIlwain provides
comprehensive pediatric dental care, specializing in
orthodontics. Dr. McIlwain explains to patient Samantha
Scott the Rapid Palatal Expander appliance and how it will
help her to achieve a beautiful smile. He has been in
This peer-reviewed journal is practice for more than 20 years and never has lost the
published as the official publication quest for new advancements in early patient treatment.
of the American Orthodontic Society Individual attention and comprehensive care for each
child are foremost priorities in his routine of treatment.
and the Academy of Gp Orthodontics. McIlwain Family Dentistry is located in Tampa, FL. Winter 2009 5

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Cynthia Bordelon
Greg Cannizzo, DDS, CDE, JAOS Editor AGpO Executive Director
3617 Municipal Drive, McHenry, IL 60050 Academy of Gp Orthodontics
Phone: (815) 344-2282 • Fax: (815) 344-5815 22233 Ridge Road, Suite 101
Rockwall, TX 75087
(800) 634-2027
fax: (888) 634-2028
During this past year, change was more great running
than just an election slogan. As the first was, and he Tom Chapman, CAE
decade of the new century comes to a would gladly AOS Executive Director
close, change is everywhere. Entire compa- answer anyone American Orthodontic Society
nies have disappeared resulting in thou- who asked why he ran (sometimes he 11884 Greenville Avenue
sands losing their jobs and benefits. would tell people even if they didn’t ask!) Suite 112
Consumer confidence appears to be in a He spoke of the mental and physical Dallas, TX 75243
tail spin. So how can we navigate through health benefits of running and how he (800) 448-1601
these times of change as storm clouds could do it for the rest of his life. He fax: (972) 234-4290
have begun to build on the horizon? The would educate and help others with their
answer to that would be attitude. You get training showing them how to improve EDITORIAL STAFF
to decide how this “economic soft spot” and be better runners. Soon, he had the
Greg Cannizzo, DDS .................AGpO
will affect you. As Helen Keller once said whole village running and enjoying every
“When one door of happiness closes, step of it.
another opens, but often we look so long If you start to feel an economic slow Jordan Balvich, DMD ......................AOS
at the closed door that we do not see the down, take the opportunity to use that Co-Editor
one which has been opened for us.” extra free time to reconnect with your
Attitude will be the compass that core patients of record. Don’t get stuck Jim Mcllwain, DDS, MSD ..........AOS
guides us through economic storminess staring at the closed door. Like the Co-Editor
and uncertainty. One of my favorite missionary, lace up and take the extra
stories on attitude begins with…Once time to connect with the people around Lisa A. Wright ..................AOS/AGpO
upon a time; there was a monk who ran. you. Talk with your patients and recon- Managing Editor
Everyday the monk would lace up his nect. Be enthusiastic, educate them. Email:
running shoes and head out along a People buy from people they like. Make
popular local path. He always keept to sure everyone in your practice and EDITORIAL REVIEW BOARD
himself, preferring to train alone. As community knows you offer compre-
hensive care including orthodontics. Azita Anissi, DDS ..............................AOS
other runners passed him or ran by him
So, in 2009, reconnect not only with Robert Allen, DDS..........................AGpO
they would nod, say hi, or ask how he
your patients but also with your fellow Ron Austin, DDS............................AGpO
was doing. But the monk was rarely
friendly and he scowled whenever members of the AOS and AGpO. This Chris Baker, RN, DMD......................AOS
anybody asked him why he ran. He year’s joint meeting will be this August 20- Eugene Boone, DDS.......................AGpO
usually mumbled his answer so that no 22, 2009 in Chicago. Make a point to Dan Dandois, DDS ........................AGpO
one could hear. He never offered to pace attend this year and touch base with Fred, Der, DDS ...............................AGpO
a fellow runner or talk about his train- colleagues and friends. They are your Corina Diaz-Bajsel, DDS ................AGpO
ing, he kept his work out and knowledge village. Being part of the annual meeting Drew Ellenwood, DDS ...................AGpO
of running and training to himself. gives you a chance to pick up so many Debra Ettle-Resnick, DDS .................AOS
Everyday, a missionary would lace up orthodontic pearls, participate in the best Joe Fallin, DDS...............................AGpO
his running shoes and head out along a CE available for Gps and pedodontists Robert G. Gerety, DDS......................AOS
neighboring popular path. The mission- who do orthodontics, and talk to others in Edward Gonzalez, DMD ...................AOS
ary was more outgoing and he ran with a your community. Sam Gutovitz, DDS........................AGpO
smile on his face. As other runners passed I’ll be looking for you in Chicago Art Gutierrez, DDS............................AOS
him or ran by him, he would greet them where we will enjoy every step of the Roy Holexa, DDS ...........................AGpO
by name and ask how their training was greatest meeting this year. David W. Jackson, DDS ....................AOS
progressing. The missionary was always Thomas Jacobson, DDS .................AGpO
enthusiastic and ready to talk about how Kyle McCrea, DDS .........................AGpO
Mitchell S. Parker, DDS.....................AOS
Leslie R. Penley, DDS .....................AGpO
Advertiser Index Kurt Raack, DDS ............................AGpO
Jon Romer, DDS ................................AOS
Academy of Gp Orthodontics ....................45 Ortho Arch ................................................11 Joseph R. Schmidbauer, DDS............AOS
American Orthodontic Society ..................41 Ortho Organizers ......................................47 Robert Shirley, DDS .......................AGpO
ClassOne Orthodontics ................................2 Ortho Technologies....................................19 Barry Sockel, DDS ..........................AGpO
Juan J. Solano, DDS ..........................AOS
Dolphin Imaging........................................37 Parkell ........................................................48
Kurt, Stodola, DDS.........................AGpO
Johns Dental Labs ................................30, 35 Rocky Mountain Orthodontics ....................4 David Thorfinnson, DDS..................AOS
Journal of Orthodontics..............................31 Space Maintainers ........................................3 Walter Tippen, DDS.......................AGpO
Myofunctional Research ............................21 Vector Dental ............................................29 Helen B. Tran, DDS........................AGpO
Ordont Ortho Labs ......................................9 Wild Smiles ................................................10 Michael Wilkerson, DDS ...............AGpO
William Wyatt, DDS .........................AOS

6 Winter 2009 JAOS

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Wright Publishing Group, Inc.
726 Pasadena Avenue South Dr. David W. Jackson graduated from Baylor College of
St. Petersburg, FL 33707 Dentistry in 1978. Dr. Jackson, a member of AOS and AGpO as
(727) 343-5600 well as other professional organizations, operates two highly successful practices in Farmersville and Rowlett, Texas and
employs over 25 people. He lectures extensively for the American
ADVERTISING SALES & ANNUAL Orthodontic Society and the International Association for
MEETING EXHIBIT MANAGER Orthodontics. His insight to the real world of orthodontics in the
general practice is honest and informative. Find out about upcom-
Kimberly Price ing seminars at
Integrity Media Group
4006 Majesty Palm Court
Tampa, FL 33624
Phone: 813-466-5521
Fax: 813-864-4454
Dr. Juan Carlos Echeverri is the owner of Echeverri Dental
ADVERTISING & EDITORIAL POLICY Center in Houston, TX. Fluent in English and Spanish, he has made
The American Orthodontic Society presentations in Colombia, Venezuela, Spain and USA in prosthesis,
welcomes advertising in its publications as implants and orthodontics and dental education for patients.
an important means of keeping the Echeverri is the creator and director of the dental education
orthodontic practitioner informed of new outreach program for the schools surrounding his practice. He is a
and better products and services for the member of the Greater Houston Dental Society, Texas Dental
practice of orthodontics. Such advertising Society, American Orthodontic Society, American Dental Association
must be factual, dignified, tasteful and and Academy of General Dentistry.
intended to provide useful product and
service information. These standards apply
to all product-specific promotional mate-
rial submitted to the American Orthodon- Dr. Leonard Carapezza has over 25 years of clinical experience
tic Society. The publication of an advertise-
in pediatric orthodontics and operates a successful private practice in
ment is not to be construed as an endorse-
ment or approval by the American Wayland, MA. He has degrees from Brandeis University and the
Orthodontic Society unless the advertise- University of Medicine and Dentistry of New Jersey. He served as a
ment specifically includes an authorized Teaching Fellow at the Harvard School of Dental Medicine and
statement that such approval or endorse- received a certificate in Pediatric Dentistry from Children’s Hospital.
ment has been granted. The fact that an Dr. Carapezza is currently an Associate Clinical Professor at Tufts
advertisement for a product, service or University, School of Dental Medicine and a contributing editor to
company has appeared in an American the Journal of Clinical Pediatric Dentistry. His lecture experience
Orthodontic Society publication will not includes the Senior Certified Instructor for both the American
be referred to in collateral advertising. The Orthodontic Society (AOS) and International Association for
American Orthodontic Society reserves the
Orthodontics (IAO).
right to accept or reject advertising at its
sole discretion for any product or service
submitted for publication.

COPYRIGHT Dr. Jeffrey H. Ahlin has served on the Board of Directors and as
© 2009. Journal of the American an officer of the American Orthodontic Society and currently
Orthodontic Society. The material in serves on the Board of the AOS Foundation. He is a board certified
each issue of the JAOS is protected by diplomate of the AOS and of the American Academy of Pediatric
copyright. None of it may be duplicated, Dentistry. He has published over 50 papers in professional journals
reprinted or reproduced in any manner and two textbooks. He has taught at Harvard Schools of Dental
without express written consent from Medicine and Tufts Dental schools for 20 years and lives in
the publisher. All inquiries and/or
Gloucester, MA with his wife and two children.
requests should be submitted in writing
to Wright Publishing Group, Inc. or via
email at

The Journal of the American Orthodontic
Society is a benefit of membership for
Dr. Chris Baker, through her practice in pediatric dentistry
current American Orthodontic Society and and orthodontics in Lexington, KY, and as a national lecturer
Academy of Gp Orthodontics members. and author, enjoys her passions - connecting with the parents
Annual subscriptions to the quarterly jour- and child patients, educating professionals and parents in state-
nal (4 issues per year) are available at a rate of-the-art dental care and management to meet the needs of
of $40/year for US residents, $80 USD/year today’s parents and children. Dr. Baker’s greatest opportunities lie
for Canada and $100 USD/year interna- in providing diagnosis and treatment of poor craniofacial growth
tionally. Back issues are available at a rate patterns and airway obstructions in children as early as possible
of $5 per copy until supplies run out. to optimize each child’s beauty and aesthetics. Dr. Baker is an
To subscribe to the JAOS, please visit
AOS Board Examiner and Vice-president of the Society. Winter 2009 7

JAOSWin09 1/19/09 11:02 AM Page 8


Alginate Alternative: Designed for a Variety of

Indications Including Orthodontic Appliances
A new alginate crown and bridges, fabricating simple Silginat® is available in two
alternative removable prosthetic restorations, delivery systems – 362-mL foil bags
impression orthodontic appliances, splints and for Kettenbach’s Plug & Press®
material case study models, or for most automatic dispenser (5:1 ratio); and
from purposes where an alginate could 38-mL cartridges (1:1 ratio) with an
Kettenbach be used. optimal volume for a single full-
LP was Silginat® was designed arch or two quadrant impressions.
introduced with a low-tear resistance to The total set time for Silginat®,
to the U.S. avoid dislodging restorations when dispensed in cartridges, is 2
dental or orthodontic appliance inadver- minutes, 30 seconds. When Silgi-
market late tently. The material also has a high nat® is dispensed in foil bags, it has
last year. Silgi- dimensional stability so model a total set time of three minutes.
nat® is designed for a impressions can be kept for weeks For more information about
variety of indications such and poured multiple times. Silgi- Silginat® alginate alternative, please
as: anatomical models, opposing nat® is also highly thixotropic and call 877-KEBA-123 or visit
models, fabrication of temporary flows properly under pressure.

New Adhesive Dolphin 3D Offers

Removing Instruments Volume Stitching
surfaces while generating minimal
heat. This is due to its innovative
blade geometry. Its twisted blades,
made of durable tungsten carbide,
are suited for precise reduction of
soft materials and assure smooth
operation providing maximum Offering the ability to “stitch”
treatment comfort. together two separate volumetric
In order to avoid the risk of datasets to construct a larger view, this
damaging the gingiva, all adhe- new feature brings the full view of 3D
sive removers are provided with technology to a larger demographic of
smooth, non-cutting tips, and the practitioners. “Not all dental special-
safety chamfer at the head’s end ists have access to large field of view
eliminates the formation of (FOV) cone beam CT devices,” says
grooves. The tapered instrument Ken Gladstone, manager of Dolphin’s
is available for contra-angle and imaging software products. “But, there
turbine handpieces. The are times these doctors want a larger
KOMET USA’s adhesive remov- H22ALGK is designed specifically view, for example both condyles or
ing instruments were developed for canines and long anterior the entire arch.” The new Volume
as special instruments for teeth, and the egg-shape Stitching feature allows the practi-
orthodontists to remove tough (H379AGK) instrument is suited tioner to import two separate, smaller
adhesive residue. A study with for the palatinal reduction of scans and “stitch” them together to
Ralf Radlanski, DDS, at the adhesive in the lingual technique. create a single, larger FOV volume
University of Berlin, shows these KOMET is a recognized world- DICOM dataset. “Volume stitching is
instruments remove adhesive wide leader in the production of the perfect tool for smaller field of
quickly, and thanks to their highly specialized and precise view systems to generate larger and
special toothing, without damag- dental rotary instruments. For more useful volumes,” he adds.
ing the enamel. more information about adhe- Dolphin products are backed with
At low contact pressure, the sive removing instruments, round-the-clock, personalized techni-
instruments operate with low vibra- please call 888-556-3887 or visit cal support. For more information,
tion and achieve perfectly smooth visit
8 Winter 2009 JAOS
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Ergonomic Improve Bonding Experience

RMO’s Indirect Bonding system ®

Headrest (IDB) provides clinicians a simple and

consistent solution for maximizing

Receives practice efficiency while significantly

improving the patient bonding expe-
rience. The system allows for
Design Award extremely accurate bracket placement
under convenient setup conditions
working on a study model, and most
of the procedures can be conducted
by staff persons with modest training.
RMO’s® RMbond start-up kit is a
turnkey system that includes all of the
materials necessary to begin Indirect
Bonding for your patients immedi-
ately. For more information, please

Sirona introduced the new Multi-

Motion headrest as an available
option with the Sirona C8+ dental
treatment center. This innovative
headrest comfortably secures the
patient’s head in a natural position
and allows the practitioner optimal
views of previously inaccessible areas.
Designed in accordance with
Sirona Dental System’s Ergonomics
Program, the MultiMotion headrest
can be tilted and rotated in any
desired direction, enabling both
patient and practitioner to remain
in the optimal ergonomic position
throughout any procedure. With a
single, one-handed motion, the
practitioner can easily adjust the
headrest to gain visual access to all
four quadrants. Switching from the
upper to lower jaw is now quick and
simple. The MultiMotion headrest
improves workflow during basic
treatment scenarios, challenging
endodontic procedures and anytime
a treatment or location specific
instrument is required.
Recently, the MultiMotion headrest
received the 2008 iF Product Design
Award in the “Medicine/Health+Care”
category. The 26-member jury evalu-
ated the entries on the basis of the
following criteria: design quality,
workmanship, choice of materials,
degree of innovativeness, environ-
mental compatibility, functionality,
ergonomics, visualization of use,
safety, brand value/branding and
universal design.Visit
for more information about Sirona
and its products. Winter 2009 9
JAOSWin09 1/19/09 11:02 AM Page 10


Appliance Opens Blocked Airways Doctors Find A

The Thornton Adjustable Posi- opened to allow air to pass Way To Make
tioner® 3 (TAP® 3), available from through the throat. The American
Accutech Orthodontic Lab, Inc., is a Academy of Sleep Medicine recom- Early Treatment
mandibular advancement device that mends oral appliances like the
improves breathing and eliminates TAP® 3, as a first line of treatment Fun For Patients
snoring in 95 percent of all patients. in cases of mild and moderate WildSmiles brackets are creating a
The TAP® 3 sleep apnea buzz in the world of orthodontics.
Appliance also and in cases of Presenting a revolutionary concept to
helps prevent severe apnea enhance your practice by offering
conditions when CPAP patients the opportunity to create
their own orthodontic appliance, the
that are has not
patented stainless-steel designs,
linked to worked. which are currently available in
sleep apnea The TAP® 3 flower, heart, star, soccer ball, football
such as holds the and diamond shapes, were developed
chronic lower jaw in a by Dr. Clarke Stevens, a board certi-
sleepiness, forward posi- fied orthodontist in Omaha, NE.
high-blood tion so that it WildSmiles is about helping ortho-
pressure, heart does not shift dontists promote their practice in fun
attack, stroke, or fall open and exciting new ways, while realiz-
ing that patient-centered and patient-
heartburn, during the
driven health care is paramount. The
morning night. This brackets straighten teeth with preci-
headache and depression. It treats prevents the airway from collaps- sion and can be mixed and matched
these conditions without the need for ing. The TAP® 3 is the only to give everyone a truly unique smile.
surgery, continuous positive airway mandibular advancement device They also can incorporate color elas-
pressure (CPAP) or medication. that can be adjusted by the patient tic ties for added individuality.
The TAP® 3 is a custom-made or practitioner while in the mouth. WildSmiles appliances were
adjustable appliance that is worn The device provides doctors created from Dr. Stevens’ desire to
while sleeping. The appliance numerous options to create the make orthodontics fun —- he has
always had a keen interest in serving
trays, similar to whitening trays, best, customized treatment solu-
patients and creating a positive envi-
snap on over the upper and lower tion for their patients. ronment to care for them. “I devel-
teeth, and hook together. The For more information about oped WildSmiles brackets because
design is based on the same princi- Accutech or the TAP® 3 Appli- patients love to make choices.
ple as cardiopulmonary resuscita- ance, please visit Patients, parents, grandparents and
tion (CPR). The airway must be friends all enjoy choosing and even
referring, because of WildSmiles,”
said Stevens. And price should not be
a concern, as there is virtually no
cost difference to the patient, accord-
ing to Dr. Stevens. “WildSmiles
Brackets are placed cuspid to cuspid
in the maxillary arch only. Their cost
is identical to other esthetic brackets
like porcelain brackets so the patients
need not pay more.”
WildSmiles Brackets have been
engineered to provide optimum
aesthetic and functional benefits,
including a patented design, accurate
prescription, straight wire style (their
version of “Roth”), torque in base, 80
grade mesh bonding base, Axial Place-
ment Technology, compound
contoured surfaces and no sharp
corners that provide easy bonding
clean-up. For more information,
please contact Davin Bickford at 402-
505-8311 or visit

10 Winter 2009 JAOS

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E a r l y Tr e a t m e n t i n O r t h o d o n t i c s
By David W. Jackson, DDS, FAGD, IBO

FIG. 1 FIG. 2

Peer pressure and influence has never been so paramount in young

peoples’ daily lives than it is today. With that said, I would like to show
you a few cases in which I opted to perform interceptive orthodontics
and to explain the reasons why.

A s I lecture throughout the United States, I am

constantly asked if Phase I (interceptive
orthodontic treatment) is really necessary or
even indicated at all. Some doctors are very
passionate about the value of early treatment, expanding
the “parking lot” for the permanent teeth, correcting
permanent teeth to erupt, and exhibits little or no maxil-
lary constriction, then interceptive orthodontics would
not be indicated.
My prerequisites in my practices for interceptive
orthodontics are the following:
1. Does the child demonstrate severe sagittal issues –
transverse and sagittal issues early and holding the space
full step class II or III?
for the permanent teeth to erupt. Other doctors are just
as opinionated against interceptive orthodontics, stating 2. Does the child have a crossbite?
that it is just a waste of the parents’ money and time, 3. Is there an airway issue?
when everything can be accomplished in Phase II or
“plain Jane” orthodontic care when the child is 11 to 12 4. Are there social issues involved – are peers making
years old. fun of the child’s teeth?
Here are some of my thoughts about this topic. First 5. Am I doing a service for the child and parents?
and foremost, are you following the “golden rule”? Do
you feel you are doing the right thing for the patient, It is a fact that grade school age children are
parents and yourself? If the child has a relatively good more compliant than middle school children, and
smile, borderline Class II which has a 50 percent chance middle school children are more compliant than
of becoming a Class I as the lower E’s exfoliate, exhibits a high school adolescents. It is also a fact that young
normal overbite/overjet has adequate room for the people are more conscious of their appearance and
12 Winter 2009 JAOS
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FIG. 5

FIG. 3

FIG. 6

Dentally, she had malposed anterior central incisors,

FIG. 4 gapping in the anterior teeth, dental Class II,
normal overbite, slight overjet, slight crowding, her
upper right central incisor overlapping her upper
right lateral incisor, and constriction in the maxilla
and mandible. She exhibited some airway issues:
venous pooling, minor mouth breathing, grade 3
tonsils and allergies. Her cephalometric values were
within normal limits. I opted to treat her inceptively
teeth than I was when I was a youth (and yes, I can by placing an upper Nitanium Palatal Expander
recall that far back). In my generation, we wore (NPE – Ortho Organizers) and a lower laboratory
blue jeans, white t-shirts, and high top black tennis fabricated Williams appliance to gain transverse
shoes in grade school. We began to wear white jeans width. A referral to an ENT was also advised. Note:
and white high top tennis shoes in middle school. Whether the parents follow through with an ENT
And in high school, white or black worked. Today’s evaluation does not change my approach. I know if
young people face a much more complex school I can widen the palate, I can cause room for the
maze to negotiate. Designer clothes, the right shoes, palatal shelves to fall down and increase the airway
the latest of the latest in fashion, and yes, even the space. I also banded the sixes and anterior teeth and
teeth and smile come into everyday interaction at placed prefabricated utility arch wires (Ortho Orga-
school. Peer pressure and influence has never been nizers) to enhance the smile as that was the parent’s
so paramount in young peoples’ daily lives. With major concern to begin with. Treatment time was 15
that said, I would like to show you a few cases in months. At the end of Phase I, I placed a Fixed
which I opted to perform interceptive orthodontics Removable Lingual Arch (Ortho Organizers) and
and to explain why. held the lower arch until I evaluated for Phase II.
Case #1 involves a 7.6 year-old female in which After three years, I did treat patient in Phase II
she and the parents did not like her smile. (Figures for 18 months. Was Phase I necessary? I could have
1-6) I had treated her older brother, the family had surely corrected the issues with only one treatment
been in practice for over 20 years (and still is), the phase, bypassing Phase I. However, the patient
patient was in cheerleading activities, and her smile would have continued with constriction in the
was an integral component of her social activities. arches and a smile less than the parents desired. Winter 2009 13

JAOSWin09 1/19/09 11:30 AM Page 14


FIG. 7 FIG. 10

FIG. 11

FIG. 8

FIG. 12

FIG. 13

FIG. 9

treat crossbites as soon as possible. This young man

was 9.4-years-old when his parents bought him in for
an orthodontic evaluation. He had an obvious ante-
rior crossbite, maxillary and mandibular crowding,
Case #2 is what I hope is a pretty apparent reason and minor transverse issues. Dentally, he was a Class I.
for interceptive orthodontics. (Figures 7 – 12) I always This type of anterior crossbite is often created by the

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FIG. 14

FIG. 17

FIG. 18

mentioned, advancing the upper utility arch wire by

bending the step down segments of the arch wires from
90 degrees to 45 degrees. This creates additional arch
length and tips the upper anterior teeth forward and over
the lowers. Occasionally, lower composite pads are
required on the lower sixes to open the bite, however,
because we have our mouth open most of the time, often
they are not required. Correcting the underbite usually
takes less than one month to accomplish. As a side
caveat, by increasing the arch length of the arch wire and
tying it into the anterior, a transverse expansion effect is
created. I placed a FRLA for retention. The total treatment
time was 15 months. The patient did not require Phase II.
FIG. 15 Case #3 shows a young female, age 8.6, with a full step
Class II dental malocclusion. (Figures 13-18) Again,
cephalometric measurements were within normal limits.
Her dental age was advanced in comparison to her
chronological age. I opted to treat her with utility arch-
wires and a mandibular advancement appliance, the Twin
Force appliance (Ortho Organizers). I kept her in this
appliance for six months, and then continued to keep her
lower jaw forward by employing one medium Class II
elastic per side on the utility archwires for an additional
six months. The elastics were from the lower first molar
hooks to prefabricated posts crimped onto the upper
prefabricated utility archwire. I placed a FRLA for reten-
tion. The total treatment time was 12 months. The patient
did not require Phase II. Results were very pleasing.
In summary, one has to ask oneself: Am I helping
the patient with interceptive orthodontics? I always
FIG. 16 stress to the parents and the patient that interceptive
orthodontics does not mean that full blown orthodon-
tic care will be avoided. I do tell them that my goal
with interceptive care is to minimize or eliminate
future orthodontics, but I make no guarantees. Am I
always successful with this goal? Of course, I am not.
We, as orthodontic caregivers, should shoot for the
ideal, but accept that reality exists and there are surely
upper anterior teeth erupting on top of the lower situations beyond our control. Do the right thing with
anterior teeth, and the uppers erupting lingually to your patients. What the right thing is depends upon
the lowers creating a pseudo Class III appearance. your orthodontic belief system and clinical experi-
My favorite way to correct this type of malocclusion is ence. I hope this orthobite column provides you
to employ the prefabricated utility arch wires previously some beneficial insight in your practice and life. Winter 2009 15

JAOSWin09 1/19/09 11:30 AM Page 16

Impacted Incisors
Mixed Dentition: in
Surgical & Orthodontic Management
By Dr. Juan Carlos Echeverri, D.D.S.

Using a patient treatment case and images, a clinician presents

guidelines for the diagnosis of impaction of a permanent incisor tooth
with a combination of orthodontics and surgical techniques.

F requently pediatric and

general dentists are faced
with a child that has an
incisor that fails to erupt in
the expected manner. The parents
will usually ask when will the tooth
erupt and why is it taking so long.
The doctor will also question why
the eruption of the tooth is delayed
and how they can assist and
manage the situation. This article
Fig 1, (Initial Exam/
will describe the rationale behind documentation)
the diagnosis process and how to
manage the situation from a surgi-
cal and orthodontic perspective.
Having impacted incisors has
many consequences for the child
patient. Several or all of the below
may affect the patient:
 Esthetic compromise.
 Improper development of As we evaluate the child who is one or two, we need to ask
the dentition. between 7 to 12 years of age, it is ourselves why? Is the delay normal
important to keep in mind that due to slow eruption, or is there a
 Improper formation of the incisor transition should be dental, bone or soft tissue interfer-
alveolar bone. complete by 8 years of age. This ence? Did the tooth or teeth run
 Space loss in the arch formation. allows the establishment of the out of eruption force? A compre-
mid-mixed dentition of perma- hensive clinical and radiographic
 Improper root formation.
nent molars and incisors along exam will allow the dentist to deter-
 Disturbance of the with the deciduous segment of mine the possible cause. (Fig 1) The
eruption potential. primary teeth (C-D-E) . best x-rays for this kind of evalua-
 Anterior-Posterior discrepancies. What does this mean in our clin- tion in the anterior area is a Periapi-
ical and radiographic exams? If the cal x-ray. It will be superior to a
 Possible facial asymmetry. patient who is being examined has panoramic film in its imaging clar-
 Self-esteem issues. almost all of his incisors, except for ity involving this area.

16 Winter 2009 JAOS

JAOSWin09 1/19/09 11:30 AM Page 17

If we as the treating or referring

dentist decide to proceed in the
correction of the problem, we must
keep several parameters in mind.
These are as follows:
 Remove the mesodens obstruc-
tion when no harm will come to
developing permanent teeth
(wait for eruption of first perma-
nent molars)
Fig 3, April 2005 Anterior recall PA X-ray
 Prefer to wait until there is 2/3
root development of the adjacent
permanent teeth
 Patient age and potential for
cooperation also factors in delay-
Fig 2. (Periapical image of supernumerary teeth) ing surgical intervention
Some of the causes for these  Watchful waiting allows time
eruption problems will include for possible eruption of the
supernumerary teeth, missing teeth, supernumerary, and the avoid-
tooth size/shape anomalies, ankylo- ance of surgical exposure Fig 4. May 2006, 8 years of age
sis, pathologic lesions, etc. Each and
every one of these will interfere and  When removed, the exposure
The orthodontic treatment will
be involved in the impaction of of permanent teeth with the
be used to create the space for the
incisors. (Fig 2) provision of an eruption channel proper eruption of the
The most common cause for the is recommended tooth/teeth and for the actual
impaction of incisors is the presence
of supernumerary teeth. The follow-  Up to 80 percent of permanent physical guidance of the
maxillary teeth will sponta- tooth/teeth into position.
ing reported statistics make them a
factor that we must consider in our neously erupt after the supernu-
Case Study
daily diagnosis and treatment plan- merary is removed
Using all
ning. Impacted incisors are:
 Orthodontic treatment is often of the above
 Reported in up to 3.6 percent necessary to make room for information,
of children unerupted teeth and to position let’s demon-
strate all of
 Occur 10:1 in the maxilla them properly.
the principles
vs. mandible mentioned
Taking into account that it is
 Occur 2:1 in boys vs. girls almost for sure that orthodontic
with the
 Usually due to a single Mesio- treatment will be needed with the
case report:
dens 80% of the time and two or patients that have had supernumer- Patient is
more 20% of the time. Mesodens ary teeth it is important to define a healthy,
usually present with cone-shaped interceptive orthodontics. Intercep- female Fig 5. Periapical X-ray 2007
crowns with a single root tive Orthodontics: Recognition of Hispanic
developing malocclusion factors and who is 7 years of age at her first
 More than 90 percent are implementation of treatment proce- presentation. Her X-ray of the ante-
lingually or palatally malpositioned dures to eliminate or minimize their rior teeth show a normal presenta-
 Approximately 75 percent effects on the final occlusion. tion of teeth with Stainless Steel
remain unerupted and need To face the problem of retained crowns on # E, F and G. (Fig 3)
surgical removal teeth, we must: 1) diagnose reten- One year later, the x-ray of her
tion of one or several incisors. 2) anterior teeth (PA) shows #8 is in
 Can be responsible for delayed determine the cause of the reten- a delayed eruption pattern,
eruption of permanent teeth, tion. 3) If it is a supernumerary compared to #9. Teeth #E & F
over-retention of primary teeth, tooth or teeth, we must then have been exfoliated. (Fig 4)
displaced teeth, diastemas, proceed to remove the cause, if it is In February 2007, the x-ray shows
abnormal root resorption, follic- within the scope of our abilities. a deviation of tooth #8 with the root
ular or dentigerous cysts, and 4) re-evaluate the need for touching #6 and the crown deviated
resultant malocclusion. orthodontic treatment. from its eruption path. (Fig 5) Winter 2009 17

JAOSWin09 1/19/09 11:30 AM Page 18

correct the maxillary dental

midline. (Fig 7)
In February 2008, the patient
was intebateded using oral seda-
tion, to expose #8 and place an
attachment on the tooth. An enve-
lope flap was created using the T2
electrode tip with the Sensimatic
Electrosurge 600SE (Parkell, Inc.)
The flap was reflected with a Fig 9. Flap closed and sutured
Fig 6. Clinical presentation of # 8 impacted,
patient is 9 years old periostal elevator and the soft tissue
covering the tooth was removed The flap is sutured using Cat Gut
At this time, the treating with a soft tissue curette. The tooth sutures and the patient is placed on
doctor speaks to the parents was located with its incisal edge analgesics, antibiotics and clorhexi-
about the need for an orthodontic pointing toward the opposite direc- dine mouth wash to prevent pain
consultation and interceptive tion and the lingual surface was and infections. (Fig 9) The patient is
treatment. (Fig 6) The patient has toward the buccal. then seen one week later as a surgical
orthodontic records taken in May The tooth has an almost 180 follow-up visit, and then every two
2007 and an orthodontic plan is degree rotation from its normal weeks to reactivate the elastic ligature.
developed consisting of: position. Hemostasis is achieved The position of the tooth is
 Phase I (orthodontic records) using Astringent X ( Ultradent) monitored by the length of the
and pressure on any bleeding chain links remaining. These links
 Correct midline and create areas. The tooth surface was are counted at the initial place-
space for tooth #8. cleaned with alcohol impregnated ment, and are monitored with peri-
 Create the anchorage for the pellets and air dried. The surface apical x-rays as needed. (Fig 10)
traction of #8 was etched with 37% ortho phos-
phoric acid and “Single bond”
 Localize tooth with x-rays adhesive (3M) was placed on the
using the SLOB rule (Same etched surface. The pad was
Lingual Opposite Buccal) loaded with orthodontic bracket
cement (Unitek) and the pad with
 Surgical intervention to locate
a gold chain attached (Ortho-
the tooth and place an attach-
Traction Pads) was attached on
ment on the coronal portion of
the tooth on its lingual surface as
the impacted tooth. close as possible to the incisal
 Bring the impacted tooth into edge. (Fig 8)
the arch and occlusion
Fig 10. Monitoring movement counting links
 Place the patient in phase
I retention The tooth was guided into
position until the pad link was
Bands are placed on maxillary reached. (Fig 11) Due to the
molars and brackets on all avail- lingual placement of the pad, a
able teeth including primary new connection on the tooth
teeth, as described by Dr. Robert had to be achieved. This new
Geretty. Arch wire sequence as attachment would allow the
described by Dr. David Jackson tooth to be guided into the
was used (.14 NiTi, .18 NiTi, .20 Fig 8. Attached Pad and chain to tooth correct angulation.
SS) and coil spring force was used
with the .20 Stainless Steel arch The chain portion is pulled
to open the space for # 8 and toward the arch wire and cut
short by approximately 2 mm.
The chain is then tied to the arch
wire using .030 elastic thread by
Fig 7. Sept Ortho Organizers Inc., creating
2007 Coil tension on the chain. At this
spring on moment a third incision is made
0.20SS to allow the flap to be placed
Archwire back on the bone for first inten-
Fig 11. Pad level reached
sion healing.

18 Winter 2009 JAOS

JAOSWin09 1/19/09 11:30 AM Page 19

Fig 12. Chain of 5 directing tooth into position

A soft tissue diode laser (Zap

Laser) was used to remove the soft
placed on the buccal aspect. The Fig 14. September 08, Panoramic for
tissue covering the buccal surface. radiographic control
arch wire with a coil spring main-
Total hemostasis is achieved by
taining the space between teeth
combining the laser and the
#7 and #9 is maintained and a This arch wire is used until
astringent agent. A bracket is
power chain with an uneven tooth #8 has reached the same
number is used to continue guid- level of teeth #7, #9,and #10.
ing the tooth into position, as per This arch wire is then replaced in
the technique taught by Dr. the arch wire sequence with a
Gerety. (Fig 12) .018 NiTi followed by a 16 x 22
One month later, the lingual NiTi. These last arch wires are
pad is removed and the power used to correct the position and
chain traction is replaced by a the torque of the tooth before the
.014 NiTi arch wire to continue patient is placed in final reten-
with a constant activation as the tion. A panoramic film (Fig 14)
distance is now much reduced. was taken in the last sequence of
Fig 13. .014 NiTi Archwire
(Fig 13) the orthodontic therapy to check Winter 2009 19

JAOSWin09 1/19/09 11:30 AM Page 20

Fig 15. Pa x-ray showing dilaceration of root

all teeth and structures involved. Normal structures

are observed. An individual periapical film is taken
of #8. (Fig 15)
Root dilaceration is evident and probably caused
by the original mal position of the tooth.
The combined orthodontic therapy allowed for Fig 17. Extra oral view
the correction of the occlusal plane, the anterior
incisor alignment, the anterior open bite, the under-
developed alveolar bone and the esthetic challenge In conclusion, this article presented guidelines
for the patient. (Fig 16,17) Once the patient, parents for the diagnosis of impaction of a permanent
and doctor are satisfied with the position of the incisor tooth. It elaborated on the role of supernu-
teeth, including the impacted tooth, the patient will merary teeth in the impaction of permanent
be placed in a retainer for six months. This is incisors. It showed using a patient treatment case
adequate time to retain the position of the teeth, and images, how the tooth is diagnosed, located and
and avoid interference with growth, as this treat- treated with a combination of orthodontics and
ment was performed in early mixed dentition as a surgical techniques to bring the impacted tooth into
phase I treatment. the oral cavity.

Straight Wire Concepts: Diagnosis and Technique, by
Robert G. Gerety, 8th Edition,
September 2004

The Next Steps, a Three Session Continuum in Orthodon-

tics, by Dr. David W. Jackson, 2006

Comprehensive Advances Series: Concepts and Techniques

for the Orthodontic Practitioner, by Dr. Larry White & Dr.
William E. Wyatt, Sr. 2008

Orthodontic and Orthopedic Treatment in the Mixed

Dentition, by James A. McNamara, Jr., William L Brudon,
Needham Press, Inc 1993

The Handbook of Pediatric Dentistry, Third Edition, The

American Academy of Pediatric Dentistry edited by Arthur
J Nowak & Paul S Casamassimo, Chapters 10 and 11.

Fig 16. intraoral view 17 months of treatment

20 Winter 2009 JAOS

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JAOSWin09 1/19/09 11:30 AM Page 22

Class II Malocclusion

The Changing
Face of Growth

An Experience–Based, Evidence Approach

to Treatment Timing: Mother Helps
Daughter to Achieve A Healthy Smile S.K. /M.K.

By Dr. Leonard Carapezza

vidence-based clinical dentistry has become the Strategy & Protocol
new “paradigm”. Randomized clinical trials Do the benefits of early treatment as shown by this
(RCT) are considered to be the gold standard to specific treatment strategy and protocol justify the
acquire evidence. The first dental randomized intervention in the early mixed dentition stage of
clinical trials funded by The National Institute of development when compared with treatment in the
Dental and Craniofacial Research dealt with early late mixed or early permanent dentition? The comple-
Class II treatment. The results of these studies claim tion of this case report attempts to put into focus the
effectiveness of the early treatment Class II. The risk/benefit ratio of early versus late treatment.
lingering question posed by these studies was the effi-
ciency of treatment in a conventional specialized
orthodontic practice.
The case report presented in this article is the result
of the continuum of treatment of an early Class II Divi-
sion I case published in the Spring 2006 (Volume 6 Issue
2) of the Journal of the American Orthodontic Society.

An efficacious solution was found to this malocclu-
sion which displayed common Class II characteristics:
Fig. 1a: S.K. 8y 1m
 Maxilla – narrow – tapered – constricted arch form 11-11-2004 pre tx.
orthodontic records
 One-half to full Class II molar relationship facials and intra-orals
 Mesial lingual rotation of the maxillary molars
 Improper over-bite relationship
 Improper over-jet relationship
 Incompetent lip seal
 Retruded position of the mandible
22 Winter 2009 JAOS
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Fig. 1b: S.K.

8y 1m
11-11-04 Fig 4a: S.K. 11y 6m
pretreatment 4-24-08 post tx facial
study and intra-orals

Fig. 2: S.K. 9y 11m 9-01-06 Start of finishing phase

Fig. 4b: S.K. 11y 6m 4-24-08 post tx panelipse film

Review – 1st Phase Treatment (Fig.1a,b)

Orthodotic records were taken 11-11-2004 on a
healthy 8.11-year-old Caucasian female, named SK.
Treatment commenced on12-22-2004 with the use of a
Nitanium Palatal Expander (NPE). The NPE accom-
plished arch development and distal rotation of the
maxillary first permanent molars.
Treatment proceeded two months later with basic
Utility Arch Wire Mechanics. These mechanics estab-
lished the early treatment objectives of proper over- Fig. 4c: S.K. 11y 6m 4-24-08 post
bite, over-jet, molar relationship, lip seal and skeletal tx cephalometric film
relationship. Serial guidance was started on 7-5-05 with
the utility arch wires remaining as space maintainers.

Finishing Phase
The finishing phase with the continued use of a
fully programmed pre-adjusted straight arch appliance Fig. 4d: S.K. 11y 6m
4-24-08 post tx
began on 9-1-06. (Fig .2) The treatment continued with cephalometric tracing
leveling, aligning and rotation with proper attainment
of molar, cuspid and midline. Inclusion of bracketing
of the permanent second molars was accomplished
during that time period. Final tip, torque and bite
opening were completed on 4/15/08. (Fig.3 ) The case
was debracketed and retention records were then taken
on 4/24/08. (Fig.4 a,b,c,d,e)

Fig. 3: S.K. 11y 6m 4-15-08 F.T.T.B.O. Fig. 4e: S.K. 11y 6m 4-24-08 post tx study models Winter 2009 23

JAOSWin09 1/19/09 11:30 AM Page 24

Fig. 7a: M.K. 40y 5m 2-23-06 facials and intra-orals

Fig. 5: Levels of evidence

Fig. 7b: M.K.40y 5m
Retention Phase 2-23-06
McNarmara analysis
A maxillary Hawley retainer was placed for the upper
arch to be worn full time six months and then six
months during bed time. A 4x4 lower fixed retainer is
to remain until the summer of the junior or senior year
of high school when an evaluation of third molar
removal would be recommended. This customary reten-
tion strategy and protocol has resulted in a close to 20 to 30 years ago. The mother (M.K.) of the Early Class
zero base problem of lower anterior relapse. II Treatment Case being presented in this article is one
of those parents. (Fig. 6,7a,b)
There are educators who use the results of the Class
II Randomized Clinical Trials to fortify their beliefs that
In this important paradigm shift, the clinical
there are no benefits to Early Class II Treatment.
judgment of a skilled practitioner and the
The everyday practitioner starts off at a disadvantage
patient’s/parents’ individual preferences and values
because it is impractical, if not impossible, to conduct
should be given equal weight with the best evalua-
randomized clinical trials in a private practice setting.
tive scientific evidence in the decision making
These trials with large monetary grants are relegated to
process of whether to treat early or late. (Fig.9 )
the University under the auspices of a much protected
There are three generally-accepted delivery
guild with the temptation of strong bias and early treat-
systems in orthodontic care: growth modification by
ment protocols of their choosing. McNarmara stated
necessity needs early treatment, late Class II treat-
when the focus is on early Class II treatment, it is false
to say that all treatment protocols are the same. ment which presently is the gold standard of the
The private practitioner has to rely on the integra- orthodontic specialty and spoken of as camouflage
tion of the best research evidence available combined treatment (accepting the skeletal pattern and
with clinical expertise and patient values. At the making the teeth fit) and orthognathic surgery
present time, there is a minimum of so called “Best when the above can not be accomplished.
Evidence” in the orthodontic literature.
At the base of the hierarchy of evidence is the case
report, but this is the foundation upon which the levels
of the best evidence grows. (Fig.5 ) So, the best the
hands-on practitioner can do at this time is to rely on
the best available evidence to be
found in one’s practice.

Experience-based Evidence
An on-going clinical research
project for the author has been
taking orthodontic records of the
parents of his pediatric orthodontic
patients. Most, if not all, of Fig. 9: Evidence based
these parents had conven- Fig. 6: M.K. 14y 8m 9th grade: decision
tional orthodontic treatment headgear, 4 bicuspid ext. making process

24 Winter 2009 JAOS

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A Mother’s Point of View Regarding Early Treatment

I am the mother of SK and here is my orthodontic story: I started wearing head-
gear sometime around age 11 then finishing up with braces at about age 16.
I remember that I had 10 baby teeth and four adult teeth pulled in preparation for,
and during the course of, my braces.When I remember my junior high school and
high school years, I remember that I had braces. I remember that my food at lunch got
stuck in them and that I had to make sure everything was all clear before smiling. I
remember having a night brace and having to sleep with it all the time. I remember it
always popping off at night and worrying that I would have it forever if I could not get
it to stay on when it was supposed to. I also remember worrying that if I had to have it
forever, I would have to take it on sleepovers with me. While I write this, I am certainly
laughing at myself now, but it is funny how the mind of a kid works.
It has come to my attention over the years that many of the constant and daily
headaches that I have had for years could be attributed to the positioning of my jaw
Fig. 8: S.K. 11-year-old (May 08)
because four of my adult bicuspids were removed, possibly unnecessarily due to late post treatment smile
treatment. Fortunately, the headaches are mostly controlled with daily medicine. I have
been told that I could have surgery to have my jaw realigned, which I will opt not to
do. I remember the exact day that SK’s orthodontist looked at my jaw and asked me,
without any prior knowledge, how long I had had daily headaches. When I told him the headaches were for as
long as I could remember, he told me that SK had my original jaw structure but because of early treatment, her jaw
would grow properly and remain properly aligned, resulting in no headaches. Possibly eliminating headaches from
my daughter’s future is an enormous gift, and we will always be thankful for it.
However, this gift did not come without research. When our dentist advised us in 2004 that SK, age 8,
needed braces we went to two orthodontists, both of whom advised us to wait until SK’s permanent bicuspids
came in, which would be at approximately age 11 or 12. After further discussions with our dentist, we were sent
to our current orthodontist for braces. SK is now 11 and her braces are coming off. Her teeth are beautiful and
her smile is infectious. She always lights up a room when she enters it, but now there is even more of a shine
because her teeth are not something you normally see on an 11-year-old. All her friends are starting to get
braces and even though they are all 11 or 12 years old, they are getting teeth pulled to correct the crowding.
SK is done at the time we were told to start her braces. I share our story with as many people as I can
because it is such a positive one. I want as many people to get to take advantage of her experience as possible.
It just does not appear that there is a downside at all. There is a small part of me that would like to bring SK to
the original orthodontists and have SK smile and ask them if they still think we should wait.

Proffit has stated that “clinical decisions such as the same playing field and allow the orthodontic practi-
optimal time to start treatment are inevitably difficult tioner and consumer to judge the risk/benefit ratio
because of the variability between patients and the of both of these approaches. The best clinical proto-
uncertainty about growth and treatment response.” cols should be based on the study of short term-long
The proposal from the author is to put fully docu- term treatment outcomes.
mented early treatment versus late treatment on the

Tulloch JF, Phillips C., Proffit WR. Benefit of early Class II treatment: University of North Carolina. RCT Class II, NIDCR RO1 type
Progress report of a two-phase randomized clinical trial. Am J grant. DE-08708 (UNC owns Data – not Federal Gov). “Written
Orthod Dentofacial Orthop 1998; 113: 62-72. request from Tufts Department of Pediatric Dentistry for
specific data denied.” September 22, 2005.
Ghafari J, Shofer FS, Jacobsson-Hunt U, Markowitz DL, Laster LL.
Headgear versus functional regulator in the early treatment Class McNamara JA. The Dr. Herbert J. Margolis Memorial Lectureship.
II, Division I malocclusion: A randomized clinical trial. AMJ Tufts Dent. Cont. Ed. April 12, 2008
Orthod Dentofacial Orthop 1998: 113: 51-61.
Forrest, JL and Miller, S. A.: Evidence-Based Decision Making: A
Keeling SD, Wheeler TT, King GJ. et al. Anteroposterior skeletal and Translational Guide for Dental Professionals. Lippincott,
dental changes after early Class II treatment with bionators and Williams and Wilkins, Philadelphia, 2008.
headgear. Am J Orthod Dentofacial Orthop 1998: 113L 40-50.
Papadopoulos. MA and G Kiaouris, I.: A Critical evaluation of
Proffit WR. Tulloch JF. Preadolescent Class II problems: Treat now or meta-analysis in orthodontics, Am. J. Orthod. 131: 589-599,
wait? AM J Orthod Dentofacial Orthop 2002: 121: 560-562. 2007.
Andrews LF. The Straight-wire appliance. J Clin Orthod 10: Feb – Carapezza L.J. Objectifying treatment of Malocclusion.
Aug 1976. J Pedod 1990; 15: 5-12.
Gianelly, AA., One-phase versus Two-phase Treatment. Am J Orthod
Dentofacial Orthop 1995: 108: 556-9. Winter 2009 25

JAOSWin09 1/19/09 1:36 PM Page 26

Open Bite Dental
By Jeffrey H. Ahlin, DDS

The long-term stability of the orthopedic and orthodontic

results in this case demonstrate that early treatment has
a place in a clinician’s treatment decisions. With
judicious use, early therapy should not prolong
treatment or be uncomfortable or costly for the patient.

T he benefits of early treatment of all types

of malocclusion have been long debated.
Both sides of the argument make salient
points. The detractors of early treatment
argue that waiting until all the permanent teeth
have erupted is less traumatic and less expensive for
the patient than starting in the early mixed denti-
tion. In addition, proponents of one phase treat-
ment emphasize that patient management is easier
for the clinician.
Early treatment proponents claim that correcting a
specific problem early leads to a less complicated Phase
II treatment. Specific claims are made that open bites,
deep bites, cross bites and Class II and III relationships
are more easily treated in the mixed dentition. If a
patient with a deep overbite Class II malocclusion also
suffers from temporalis muscle headaches, then some
authors strongly recommend early treatment to allevi-
ate the patient’s pain and suffering.1, 2
Perhaps more importantly, investigators have linked
deep bite Class II malocclusion with problems of snor-
ing, sleep apnea, hypertension, and other serious medi-
Fig.1: Katie with open bite cal conditions.3 The early treatment advocates also
at age 7
claim that there is a psychosocial benefit to correcting
obvious facial disharmony and oral-facial habits before
schoolmates have a chance to be critical or tease the
26 Winter 2009 JAOS
JAOSWin09 1/19/09 1:37 PM Page 27

& Facial Deformity

Fig.2: Katie’s anterior occlusion Fig.3: First appliance

at age 7

patient.4 The obvious financial benefit to the patient or her daughter would most
parents is that a more serious surgical procedure could likely need a second
well be avoided. phase of therapy with
The patient presented here, Katie N. (Fig. 1), came full orthodontic brackets
to our office at age 7 with a history of pacifier use for when all of her perma-
over three years. There was a very evident deforma- nent teeth had erupted.
tion of the premaxilla. The patient had no other The Phase I treatment
medical considerations and was taking no medica- plan for Katie included
tions. In addition to her malocclusion, the patient’s maxillary expansion with
dental history included small occlusal incipient two removable appliances,
lesions on her first molars. (fig. 3) over 10 months
Katie’s anterior open bite was 9mm. with bilateral and eight maxillary brack-
Fig.4: Katie at age 10
posterior cross bite. Her mother stated that Katie “used ets for four months in
to love her pacifier” and was having some difficulty order to reduce the open bite
eating her food. Some of the patient’s school friends malocclusion and correct the cross bite. This phase of
were beginning to make derisive comments. Katie’s treatment lasted for 20 months. The second maxillary
mother was informed of a corrective course of action expansion appli-
and treatment plan. ance had poste-
Mrs. N. was initially reticent about committing to a rior occlusal
two-phase treatment plan. However, after a definitive coverage. A
two-phase plan of treatment was explained to the Hawley retention
patient’s mother, including the time period and the appliance was
stability of the results, she agreed to go ahead with placed and the
Katie’s treatment. Mrs. N. was assured that with good patient was re-
patient cooperation, Katie would have a beautiful result photographed at
Fig.5: Age 10 occlusion
with a full smile. The mother was also informed that age 10. (Fig. 4 & 5) Winter 2009 27

JAOSWin09 1/19/09 1:37 PM Page 28

After the completion of the first phase

of treatment, Katie had a much more
acceptable appearance. Her cross bite and
open bite had been corrected and she was
more comfortable about her facial appear-
ance in school and with her ability to
incise food with her anterior teeth.
However, Katie still had a Class II molar
and canine relationship with a 3.5mm.
Fig.6: Occlusion at age 20
overjet. After Phase I correction, a Hawley
appliance was placed. Katie wore the
Hawley retainer during the 15-month rest-
ing phase.
Maxillary and mandibular brackets were
placed at age 12, after all the permanent
teeth (except third molars) had erupted. An
arch wire sequence beginning with an .014
NiTi wire with nickel titanium distalizing
springs to the maxillary second molars was
placed in order to lock in a Class I molar
relationship. After the mandibular arch had
an .018X.025 arch placed, interarch Class II
light 1/4” elastics were worn with a
.016X.016 maxillary arch until a Class I
canine relationship was achieved. The
distalizing springs on the maxillary arch
were advanced one tooth per visit until the
space was distal to the canines. Power
chain elastics were used to close in the
canines to a Class I canine relationship.
(Figures 6 & 7).

Fig.7: Katie at age 20 (full face)

28 Winter 2009 JAOS

JAOSWin09 1/19/09 1:37 PM Page 29


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Fig.8: Panorex taken at age 7

Fig.9: Panorex taken at age 20

A Class I molar and canine relationship was

achieved in 12 months. Figure 6 shows the anterior
occlusion at age 20, seven years post-treatment from
phase II. The panoramic films, taken at ages 7 and 16
(Figures 8 & 9), show the dental development with
excellent root parallelism and no developing third
molars. The patient’s mother declined cephalometric
pre- and post-treatment films in order to minimize
radiographic exposure to the patient. Dental retention
included a lower lingual bonded twisted wire and
removable maxillary Hawley retainer. The patient still
wears the maxillary retainer occasionally while sleep-
ing. (Figure 7 is a final full face of Katie at age 20).
The long-term stability of the orthopedic and
orthodontic results (figure 7) demonstrates that early
treatment has a place in our treatment decisions. With
judicious use, early therapy should not prolong treat-
ment, be uncomfortable or costly for the patient. The
use of early treatment regimes could also avert the need
for some surgical procedures for our patients.

1. Ahlin, J. H., Atkins, G., A screening procedure for differentiating tem-
poromandibular joint related headache. J. Headache 1984; 24: 216-221.
2. Ahlin, J. H., The theoretical and practical application of a remold-
able craniomandibular appliance. Int. J. Orthod. 1984: 22: 21-23.
3. Roux, F., D’Ambrosio, C., Mohsenin, V., Sleep related breathing
disorders and cardiovascular disease. Am J Med 2000; 108: 396-402.
4. Shoroog, A., Locker, D., Streiner, D.L., & Thompson, B., Impact of self-
esteem on the oral-health-related quality of life of children with
malocclusion. J Orthod. & Dentofacial Orthoped. 2008. 134: 484-489.

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Early Transitional
Dentition Treatment
By Dr. Chris Baker, RN, DMD

It has been estimated that 50,000 patients are born in the U.S. every
year who will develop at least one impacted canine that will require
orthodontic attention by age 10.

B oth in skeletal and dental growth and devel-

opment, and in development of occlusion,
there are times when the extraction of
primary teeth may be an important treatment
consideration. The dramatic possibilities of well-timed
extractions can change your patients’ lives by:
Incisor Crowding & Alignment Instability
Incisor crowding/rotations are a common occurrence
with various negative sequelae and may be preventable
in patients through primary canine extractions. Ectopic
canines or impactions can be a devastating occurrence
in relationship to a normalized occlusion in our
patients, and
 decreasing risk of and preventing ectopic teeth, although often
treatable, they
 preventing rotated/crowded incisor positions, can result in
negative seque-
 improving the natural eruption of permanent
lae, including
teeth and decreasing the risk of impaction of
greatly extended
permanent teeth,
treatment times.
 reducing orthodontic treatment time and sequelae, The chal-
lenges involved
 improving gingival health and overall dental health. with crowded

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incisors - instability of anterior tooth alignment and a

high post-orthodontic treatment relapse rate in
mandibular incisors - involve first the shrinking arch
length in our culture. Today’s children exhibit frequent
incisor crowding and less arch length than their grand-
parents did 50 years ago.
Today, the incisors in the transitional dentition
have a high rate of relapse, rotations and crowding;
even bicuspids and canines often exhibit rotations.
[Little] Esthetic concerns are more prevalent, and func-
Note mandibular permanent lateral incisors and canines will not fit in the
tional contacts are diminished, resulting in an impact space of the primary laterals and canines. Extraction of the primary teeth
allows the laterals to erupt and become well-aligned/straight.
on occlusal harmony and TMJ health with the growth
of the aging skeleton
 Straighten permanent teeth if needed, as
The etiologies of mandibular incisor crowding soon as they have erupted and it is feasible. The
relapse include: sooner the tooth is aligned (straight), the more
likely the developing fibers will help hold the tooth
 leaving teeth rotated and allowing interseptal fibers in the aligned position.
to develop memory for crowded positions How do you straighten the teeth? First, extract
primary teeth as needed, allow natural eruptive posi-
 late forward mandibular growth and aging growth
tioning and then evaluate the need for further
changes, causing crown uprighting (lingualization) orthodontic movements. Then, use a lingual holding
and tipping of the mandibular incisors arch if orthodontic treatment is not begun as soon as
 Not holding ideal tooth positions with a lingual all incisors have erupted. Keep the arch in place until
orthodontic treatment is begun.
arch until all permanent bicuspids and canines have
It is a good option is to provide Phase I treatment as
erupted. soon as incisors are erupted: band the six-year molars,
 Not wearing retainers long enough. bracket the incisors, apply sectional and/or looped wire
(.014SS or TMA .0175 x .0175) from lateral incisor to
How do I reduce the risk of crowding? lateral incisor, using utility arch wire (UAW) to correct
You can reduce the risk of rotated and crowded incisors arch length and position incisors and molars.
through the following possible treatment options: Expand/tip as needed
to an idealized incisor
 Extract primary teeth if needed. If you make space positions and overbite
for permanent incisors to erupt and become and overjet. Create
straight naturally, almost always the natural erup- canine space, correct
tion will be into an aligned position. This requires molars to Class I and
extraction of primary teeth as needed before the use elastics as needed
eruption of permanent teeth is complete. Once the (Class II from kobiashi
DEJ of the erupting tooth passes the alveolar level, hooks on the maxillary
the intra-septal and trans-septal fibers are estab- permanent lateral
lished and tend to cause relapse of the incisor to incisors to mandibular
the eruptive position. If the eruptive position was six-year molars and
one of rotation, the incisor will most likely relapse Class III from kobiashi
to that position even after orthodontic correction. hooks on the mandibu-
Derotation of teeth just after emergence in the lar lateral incisors to
mouth implies correction before the transseptal maxillary six-year
fiber arrangement has been established. In refer- molars.) After Phase I
ring to the Dugoni study, Zacchrison says, “These treatment is completed
positive results may be related to the stage of use a lower lingual
development of the transseptal fibers. Kusters and holding arch as a
colleagues showed the transseptal fibers do not retainer with distal
develop until the CEJ of erupting teeth pass the extensions to hold
bony border of the alveolar process.” Foster and incisor positions, and
Wiley found that extraction of primary canines use an upper Doyle
had no detrimental effect on the eventual width of Hawley design remov-
the permanent canines. Numerous studies have able retainer. Both of
documented that mandibular incisors tip lingually these retainers should
as a result of serial extraction, but orthodontic be worn until all eruption is complete. At that time,
correction of lingual tip is stable while incisor remaining treatment needs (Phase II) can be evaluated.
derotation is not. Winter 2009 33
JAOSWin09 1/19/09 2:32 PM Page 34

extract primary canines when the permanent

 Expand and correct arch length as early as feasible. central incisors are ready to erupt. This means
two episodes of local anesthesia, but the eden-
 Utilize holding arches in the transitional dentition tulous spaces are not as large until permanent
to maintain arch length until all permanent bicus- laterals erupt.
pids and canines have erupted.
 Extract (canine to canine) any primary teeth
 Maintain the patient’s original arch form (evidenced that are in the space the permanent centrals
on mandibular arch). When the dental arch form is and laterals will need. This requires only one
changed with orthodontic tx, there is a post-reten- episode of local anesthesia, but does create
tion change to its pretreatment shape. In nearly larger spaces in esthetic planning until the
every case, arch length intercanine width and inter- permanent laterals erupt.
molar width changes prove unstable and return to
Children seem to have almost no post-operative
pre-tx dimensions. [Shapiro] concerns or complaints after the extraction of primary
incisors and canines. And they and their parents are
 Compliance with retainer wear, of course. pleased to see the beautiful smile with beautiful
straight teeth.
 Plan extraction of third molars if they are
impacted, in poor position or if space is insufficient
for their eruption. Ectopic Unerupted Teeth
We can find references going back to Edward Angle
Extractions as part of treatment for in his publication in 1907 involving treatment of
insufficient arch length : It is important to do a ectopic unerupted teeth. Today, Andreasen points out
clinical evaluation and diagnosis to evaluate the timing that eruption fails 1 out of 5 times (20%). This means
recommended for extraction of primary canines to that out of 52 eruptions in each patient (20 primary
prevent crowding and rotations of incisors. and 32 permanent teeth), statistically 10+ teeth will
be ectopic.
쏹 Evaluate the space and position of permanent
Ectopic teeth may increase the risk of:
incisors at the time the primary central incisors are
beginning to exfoliate. 쏹 Functional distur-
bances such as
쏹 Consider extractions if: 1) the primary incisors impactions,
have exfoliated, space appears inadequate and the resorption of
permanent incisors are not erupting or are erupt- adjacent roots
ing ectopically; 2) the primary incisors have not and poor occlu-
exfoliated, space appears inadequate and the sion.
permanent incisors are not erupting; 3) the perma-
nent incisors are erupting lingually to the primary 쏹 Inadequate
incisors; 4) the permanent central incisors are attached
erupted and space appears inadequate for the gingivae.
permanent lateral incisors.
쏹 Decreased esthet-
쏹 Timing of extractions should be as soon as the space ics such as gingi-
shortage and/or malposed incisors have been identi- val margin
fied. Remember that most lower incisor teeth will discrepancies.
correct their rotated positions naturally if the space
쏹 Future problems
is adequate and if the eruption is early enough that
including insuffi-
the CEJ of the erupting tooth has not passed the
cient attached
height of the alveolar bone.

쏹 Treatment Planning: The parent may be presented 쏹 And impacted

with three options for the child patient: teeth and related
 Do nothing now. Allow natural eruption, allow-
쏹 The need for
ing rotations/crowding to remain and consider
complex and
orthodontic correction later. This option increases
the likelihood of crowded/rotated incisors and
orthodontic relapse in the child’s lifetime.
 Extract whichever teeth are in the way of the with increased
central incisors (usually the primary laterals treatment
and maybe the primary centrals) and plan to time of at

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least 1-2 years,

placed attach-
ments, box
loops and
springs, molar
appliances and
TAD’s (tempo-
rary anchorage
Leite points out that of the population that has
eruption abnormalities of maxillary permanent canines,
85% are palatal, and have adequate arch length while
12.5% resorb incisor roots as they erupt.

12.5% resorb incisors

The literature tells us that resorbed lateral

incisors adjacent to impacted canines typically
have normal crown size. In the majority of cases,
87% of aggressive lateral incisor root resorption,
there is normal mesiodistal crown size of the
lateral incisors. Peg-shaped, small or missing lateral
incisors have been shown to be a predisposing
factor in shorter root length and can result in
palatal canine impactions. It is speculated that the
normal-sized and early developing lateral incisor
roots obstruct the deviated eruption path of
canines and consequently stand a greater chance of
being damaged by resorption.
About Extraction of Primary Canines
Ericson and Kurol found that in cases of extrac-
tions of primary canines that 78% of ectopic erup-
tion changed to normal. Two-thirds of those changed
to normal within six months. The remainder
changed to normal within 12 months. After 12
months, there was no further improvement in
permanent canine positions.
The possibilities you offer your patients when you
extract primary canines include:
쏹 decreased ectopic eruption

쏹 decreased impaction of permanent teeth

쏹 reduced risk of impaction sequelae such as intrusion

of adjacent teeth and root resorption/pulpal prob-
lems of adjacent teeth
쏹 reduced orthodontic treatment time and sequelae Winter 2009 35

JAOSWin09 1/19/09 1:37 PM Page 36

Fig. 1 Extraction as At the American Association of Orthodon-

Part of Treat- tists’ (AAO) Early treatment conference, Feb.
ment of Ectopic 2002, researchers reported that.:
Unerupted Teeth: “An ongoing study shows that the early extraction
It is important to of primary canines will prevent the need for surgical
do a clinical evalua- exposure in as many as 80% of these patients – if they
tion and diagnosis to are diagnosed [and treated} early enough.”
evaluate the timing “Lesson learned: Diagnose and consider the need for
recommended for early treatment due to the severity of complications
extraction of primary that can be caused by unerupted and impacted teeth.”
canines to prevent It has been estimated that 50,000 patients are born
impaction, failure of in the U.S. every year who will develop at least one
eruption and impacted canine that will require orthodontic attention
other sequelae. by age 10. Most are palatal, but this does not even
First, evaluate include a high percentage of canines that do erupt, but
and diagnose the
Fig. 2 into ectopic/poor positions.
unerupted ectopic
By extracting primary teeth appropriately and judi-
ciously, you can transform lives!
tooth/teeth. On the radiograph, evaluate the
extended long axis of the permanent canine. At the
time of eruption of lateral incisors, take a panoramic
radiograph. Draw a long axis of the unerupted Behrents, Rolf G. Growth in the aging craniofacial skeleton. Monograph
17,Craniofacial Growth Series. Center for human growth and development.U
canine (figure 1) and extend past the occlusal plane. of Michigan . Ann Arbor . 1985.
If the extended long axis passes more than one adja-
Brin I, Becker A, Zilberman Y. Resorbed lateral incisors adjacent to impacted
cent crown width, (figure 2) consider bilateral canines have normal crown size. Am J Orthod Dentofacial Orthop. 1993 Jul;
extraction of primary teeth. Bilateral extractions 104(1): 60-6.
helps maintain midline positions. Dugoni SA et al. Early mixed dentition treatment: post-retention evaluation of
stability and relapse. Angle Orthodontist 65(5) 1995. 311-320.
Ericson S, Kurol J. Radiographic assessment of maxillary canine eruption in
children with clinical signs of eruption disturbances. Eur J Orthod. 1986
Ericson S, Kurol J. Early treatment of palatally erupting maxillary canines by
extraction of the primary canines. Eur J Orthod. 1988 Nov;10(4):283-95.
Ericson S, Kurol J. Resorption of maxillary lateral incisors caused by ectopic
eruption of the canines. A clinical and radiographic analysis of predisposing
factors. Am J Orthod Dentofacial Orthop. 1988 Dec;94(6):503-13.
Foster H and Wiley W. Arch length deficiency in the mixed dentition. AJO
1958. 68:61-8.
Before extractions of MX primary canines Ericson S, Bjerklin K, Falahat B. Does the canine dental follicle cause resorp-
tion of permanent incisor roots? A computed tomographic study of erupting
maxillary canines. Angle Orthod. 2002 Apr;72(2):95-104.
Ericson S, Kurol J. Incisor root resorptions due to ectopic maxillary canines
imaged by computerized tomography: a comparative study in extracted teeth.
Angle Orthod. 2000 Aug;70(4):276-83.
Kusters ST , Kuijpers-Jagman AM, Maltha JC. An experimental study in dogs
of transseptal fiber arrangement between teeth which have emerged in
reotated and non-rotated positions. J Dent Res. 1991.70: 192-197.
Leite L. Eruption abnormalities of maxillary permanent canines. JSSPD 6?3) 2000.
Leivesley WD. Minimizing the problem of impacted and ectopic canines.
ASDC J Dent Child. 1984 Sept-Oct;51(5):367-70.
After extractions of MX primary canines
Little, RM. Stability and relapse of mandibular anterior alignment: University
of Wash Studies . Seminars in Orthodontics. 5(3) September, 1999. 191-204.

Secondly, recommend extraction if the extended long Little, RM. Stability and relapse: Early treatment of arch length deficiency.
AJODO 121(6) 578-581. June 2002.
axis passes more than one adjacent crown width. (figure 2)
Shapiro P. Long term observation of orthodontically treated patients.
The extended long axis passes not only the lateral incisor Mandibular dental arch form and dimension treatment and post-treatment
at one crown width, but also into the central incisor changes. AJODO 1974: 66:411-430.
crown. Extended long axis evaluation may give us the abil- Turpin DL. Early treatment conference alters clinical focus. Am J Orthod
ity to predict the majority of unfavorable eruptive paths of Dentofacial Orthop. 2002
permanent canines earlier than previous analyses. This Turpin DL. Where has all the arch length gone? Editorial, AJODO March, 2001. 201.
analysis is done in the early rather than the late transi- Warren JJ, Bishara SE. Comparison of dental arch measurements in the
primary dentition between contemporary and historic samples. Am J Orthod
tional dentition and includes mid-alveolar paths that may Dentofacial Orthop. 2001 Mar;119(3):211
predispose laterals to root resorption. Treatment planning
Zachrisson BU. Important aspects of long-term stability. 1997 JCO
note: Always extract bilaterally to prevent midline shift! Sept;31(9): 562-583.

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JAOS Editor Earns Top Honor

In a ceremony became the fourth
during the recent person to be certified.
American Associa- Dr. Cannizzo has a
tion of Dental successful general
Editors Annual dental practice in
Meeting in San McHenry, IL. He and
Antonio, Dr. Greg wife Linda are the
Cannizzo of parents of two boys
McHenry, Illinois, and two girls. He has
received designa- been the Editor of the
Dr. Greg (at left) Cannizzo earns
tion as a Certified CDE designation.
Journal since January
Dental Editor(CDE). 2005 and was the Co-
The American To receive this award, you must Editor prior to that, as well as
Orthodontic Society complete 30 hours of continuing past-president of the AGpO. All
education in approved subject areas of us affiliated with the Ameri-
2008-09 Officers related to writing, editing and can Orthodontic Society are
& Directors communications. Dr. Cannizzo proud of Dr. Cannizzo for this
became only the 26th person to earn accomplishment and his
President this distinction and the second Editor commitment to make The Journal
Arturo R. Gutierrez, DDS of the JAOS to be so recognized. of the American Orthodontic Soci-
President-Elect In 2004, the late Dr. Roger ety the finest GP orthodontic
& JAOS Co-Editor Rupp, the Journal’s initial Editor, publication available today.
Jordan J. Balvich, DMD
Vice President AOS Course Corner
Tier Advancement Orthodon- Advanced Straight Wire for
Chris Baker, RN, DMD
tic Review Course AND the Assistants conducted in Dallas in
Secretary-Treasurer Financial Strategies Course will March. This course is a perfect
John N. Hanchon, DDS be taught in Dallas on April 3-4, complement to Dr. Gerety’s compre-
2009. To help you advance from hensive courses. However, Kay’s
Immediate Past President Achievement to Fellowship to Diplo- knowledge of GP orthodontics and
Jon P. Romer, DDS mate, we offer a two-day educational experience as a clinician makes her
course designed to increase your courses valuable whether or not you
Board of Directors orthodontic skills. We have also are a present or former student of
added the highly popular one-day Dr. Gerety.
Azita Anissi, DDS Financial Strategies course.
Debra Ettle-Resnick, DDS Learn intermediate concepts and
Robert G. Gerety, DDS Dr. David Jackson’s “Missing techniques from two outstanding
Piece of Your Practice” Compre- practitioners and teachers, Dr. Bill
Mitchell S. Parker, DDS hensive Orthodontic Education Wyatt and Dr. Larry White, begin-
Juan J. Solano, DDS Program is set to begin in Kansas ning in Dallas in January. Expand your
David M. Thorfinnson, DDS City and San Diego during March. orthodontic skills with a combination
This four-session course for general of lecture, case review, wire-bending,
William E. Wyatt, Sr., DDS and pediatric dentists will focus on and hands-on typodont workshops.
learning and implementing a proven
Board of Examiners system for orthodontic diagnosis and Learn the orthodontic basics with
Chris Baker, RN, DMD treatment. Dr. Leonard Carapezza beginning
in March in Wayland (Boston), MA.
Robert G. Gerety, DDS
Train your staff with Kay Gerety’s Both the beginning and advanced
W. Edward Gonzalez, Jr., DMD, PA Straight Wire for Assistants to courses provide a systematic orthodon-
David W. Jackson, DDS be conducted in Dallas and Atlanta tic approach to treating patients using
in February and March as well as the the Straight Wire philosophy.
Joseph R. Schmidbauer, DDS
Details on all of our AOS courses can be found at or by calling 800-448-1601.
Executive Director
Thomas N. Chapman, CAE ATTENTION
According to Society bylaws, any active member of the AOS may bring new business or old
JAOS Editor business before the Board for consideration. The next meeting of the Board of Directors is sched-
uled for April 2, 2009 at the Addison Crowne Plaza Hotel in Dallas. If you have items for Board
Greg Cannizzo, DDS consideration, please fax to the AOS office 972-234-4290 no later than Friday, March 6, 2009.

38 Winter 2009 JAOS

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Valuable Membership Benefits
Retention of membership We are… The voice for GP orthodontics. Wher-
is both the most important, ever we see discriminatory practices that threaten to
and yet, the most challeng- limit your right to practice, we’re there for YOU and
ing job for a professional ALL Society members.
association. In tough We are… The top publisher in GP orthodontics.
economic times, when every The Journal of the American Orthodontic Society is
practice expense must be stuffed with “take-away” orthodontic pearls AND infor-
Arturo Gutierrez, DDS AOS
President scrutinized, we know the mation on the latest in technology and industry trends.
cost of AOS membership is We do… Provide an achievable, but rigorous,
questioned and renewed based on the perceived path for tier advancement. Want to increase your
value that membership adds to your practice. I have patient base, while improving your orthodontic
been a member of AOS for 16 years and my skills? Follow our Society credentialing program
orthodontic practice has grown each year as a direct from Achievement to Fellowship to Diplomate.
result of the support and education this organiza- We do… Have the best patient information mate-
tion has provided. The AOS is my “go to” organiza- rials for your practice. Krames Communications
tion for orthodontics and I want it to be yours. publications, the leader in the patient information
Here’s what we offer that deserves your continued industry, are available to you AT OUR COST.
and committed membership in the American Most importantly… The AOS is large enough to
Orthodontic Society: be a voice in the industry, but small enough to value
We are... The largest “member-based” orthodon- your membership on an individual basis. In today’s
tic educational organization in America. Course world, that alone is worth the cost of membership.
content is always determined by the Society and not If you’ve not done so...RENEW NOW. Even better,
by special interest groups. This allows our members renew and bring a colleague along. You will experi-
to attend high-value education-FIRST programs, all ence the AOS Advantage! Have a happy and prosper-
recognized by the ADA Continuing Education ous 2009. R. Gutierrez, DDS
Recognition Program.


New Vice-President and Directors Elected

During the recent Annual Meeting in New Orleans, the of New York at Buffalo Dental School in
general membership elected two new directors and a new 1990 and is currently teaching the resi-
vice-president in accordance with the bylaws of the Society. dency advancement program at
The new Vice-President who will Rochester General Hospital. More than
become the Society President in 2010 30 percent of her practice is dedicated
is Dr. Chris Baker. Dr. “Chris” is a to orthodontic treatment. Dr. Anissi
Diplomate, Board Examiner, Senior received her Diplomate from the AOS at
Instructor and Board Member. She is a the New Orleans Annual Meeting this Dr. Azita Anissi
registered nurse who received her past October.
DMD from the University of Kentucky, Elected for a term of four years as
then both her certificate in pediatric a Director is Dr. Dave Thorfinnson.
Dr. Chris Baker
dentistry and her fellowship in the Dr. Thorfinnson graduated from the
Department of Orthodontics from the University of University of Minnesota in 1988 and
Connecticut. She served on the University of Connecti- practices in East Grand Forks, MN.
cut faculty in the department of pediatrics for eight He has been a member of the AOS
years and currently serves on the faculty of the Univer- since 1992 and received his Fellow-
sity of Kentucky while also practicing in Lexington, KY. Dr. David M. Thorfinnson
ship in 2007. He is a member of the
Dr. Baker teaches comprehensive courses in both basic American Dental Association,
and advanced orthodontics. Minnesota Dental Association and past president of
Elected for a term of four years as a Director is Dr. the NW Minnesota District Dental Society, where he
Azita Anissi. Dr. Anissi is a general dentist practicing in has been involved with the district Ethics and
Rochester, NY. She graduated from the State University Bylaws committee and peer review. Winter 2009 39

JAOSWin09 1/19/09 11:08 AM Page 40


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Board Examination
Fellowship Award Recipient

Academy of
Gp Orthodontics
2009 Officers
Drew Ellenwood, DDS

President Elect
Marc Dandois, DDS

Vice President
Thomas Jacobsen, DDS

Secretary - Treasurer
Sam Gutovitz, DDS

Immediate Past-President
Keith Wilkerson, DDS

Board of Directors
This year, the Academy recognized Dr. Fred Der of Keswick, Ontario,
Eugene Boone, DDS Canada who achieved Fellowship status by passing the Fellowship Board
Greg Cannizzo, DDS Examination. Dr. Der is the host dentist of the comprehensive two-year,
hands-on orthodontic course taught in his office by Dr. Roy Holexa.
Corina Diaz- Bajsel, DDS
Fred Der, DDS
Kyle McCrea, DDS
Kurt Raack, DDS The Acacdemy of
Kurt Stodola, DDS
Helen Tran, DDS Gp Orthodontics
Advisory Board
Ron Austin, DDS
2009 Spring Referesher
Joe Fallin, DDS The Academy of Gp Orthodontics is pleased to present the 2009
Roy Holexa, DDS Spring Refresher Course featuring speakers on Tip-Edge Plus and
Orthodontic Appliances. This two day event will take place March 27th
Leslie R. Penley, DDS and March 28th at the Crowne Plaza Hotel in Addison Texas. Featured
Bob Shirley, DDS speakers and topics will include Dr. Richard Parkhouse on the Tip –
Barry Sockel, DDS Edge Plus Bracket. Dr. Edward Joneson will speak on The Tip – Edge
Experience – It makes more sense, and Paul Ruzicka of Ordent Laborato-
Walter L. Tippin, DDS ries speaking on Orthodontic Appliance Designs and Adjustments. To
register call the Academy headquarters at 800-634-2027. Don’t miss this
Executive Director
opportunity to improve and refresh your orthodontic skills and network
Cynthia Bordelon with other dentist and Pedodontists who practice orthodontics.

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Your Practice:
A Safe Investment in Tumultuous Times
Recently, my parents were talking about the current sour times and their incredible, shrinking
retirement. I gave my mother a fright by telling her I was heavily invested in a small company
and that if it went bust, so would I. She anxiously said I needed to immediately diversify. Too late,
I told her, I was too entangled in this group. However, I knew the CEO, and I thought I’d still just
make it. My father had to tell her the small company was my dental practice.
This is our investment: Ourselves, our practices. Right now, that is probably the best place for Dr. Drew Ellenwood
money. I have to remind myself to take time to sit quietly and think on my goals, to look from afar AGpO President
and evaluate and then come close to organize and refine. During spring cleaning, I jettison the trash; in my practice, I
work to keep the fat trimmed and the weeds out. Though, it’s not all about building that better mousetrap. Investing in
becoming a better dentist means pressing to become a better me all around. I have to keep connected to my patients as
humans, to my staff as partners in service, and to my family as my touchstone. And remember, the one next to you. That
is, don’t take your spouse for granted as your spouse is the most valuable asset in your human portfolio.
My daughter, a sophomore in college, asked me recently about the economy and what to do. I told her the best
place to be during an economic bad time is in school. So it is with you and me. Now is not the time for panic –
and believe me I’m one to panic – but to invest in our education. I advise you, and it’s just as good as you’ll get
from any financial guru, to plan and save now to attend the joint annual meeting of the AGpO and the AOS in
Chicago, August 20-23, 2009. This will be a fantastic investment in honing your skills and becoming more effec-
tive in your orthodontic practice.
Even earlier in 2009 is the Academy’s Spring Refresher. It will be held in Dallas on March 27 and 28. On the
first day, the agenda includes Dr. Edward Jones who will lecture on Diagnosing the Maxilla and Paul Ruzicka, Pres-
ident of Ordont, who will lecture on Appliance Designs and Adjustments. On Saturday, Dr. Richard Parkhouse, our
Tip-Edge friend from Wales, will lecture on Tip-Edge Plus.
Hopefully, this can be an ongoing tradition to keep us connected to each other and the best in orthodontic
continuing education. Meanwhile, strap yourself in the roller coaster. Soon the ride will be over.

Drew Ellenwood, DDS

12 Complete Tier Advancement Program

Recently, 12 doctors finished their comprehensive two-year, hands-on course in Kreswick, Ontario, Canada. All
doctors qualified for the Associate Fellowship level of the Academy of Gp Orthodontics Tier Advancement
Program. All recipients completed the Academy’s 12–session comprehensive hands–on course and earned a mini-
mum 155 CDE hours in Orthodontics and related topics. Also completed was a minimum of three cases during the
hands–on course, followed by passing a written and oral examination administered by course instructor Dr. Roy
Holexa and host dentist, Dr. Fred Der.
Back row, left to right:
Dr. Younes, Trenton, ON
Dr. Holexa, Fountain Hills, AZ
Dr. Parhar, Edmonton, AB
Dr. Bencak, Lasalle, ON
Dr. Yu, Keswick, ON
Dr. Der, Keswick, ON

Front row, left to right:

Dr. Hartwig-Villa,
Cambridge, ON
Dr. Hildago, London, ON
Dr. Yu, Keswick, ON
Dr. Young, South
Porcupine, ON

Graduates not shown:

Dr. Arrieta, Toronto, ON
Dr. Jeong, Toronto, ON
Dr. Leung, Burlington, ON
Dr. Wan–Chow–Wah,
Richmond Hill, ON Winter 2009 43

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AGpO Presents Awards at 20th Annual Meeting

The Academy of Gp Orthodon-

tics 20th Annual Meeting was
recently held in Dallas, TX. It was
a successful celebration of educa-
tion and connection with friends,
colleagues and industry partners.
Dr. Lori Trost, Dr. Keith Wilker-
son, Dr. Ralph Garcia, Dr. Larry
Kotlow, Dr. Leslie Penley, Dr. Ron
Austin, Dr. Roy Holexa, and Dr.
Robert Allen spoke on topics that
challenged and inspired the meet-
ing attendees. This years topics of
Airways, Minor Tooth Movement,
TMD, Lasers and Tip Edge Pearls
provided for three full days of
some of the best continuing
education available.
The Saturday night dinner and
Awards Banquet with dancing at
the Copper Bottom Grille, gave
everyone a chance for remember-
ing, recreation and reunion. Next
year’s annual meeting will be held
as a combined event in Chicago IL
on August 20 – 23, 2009 with the
American Orthodontic Society.

Mark Dandois, DDS
Hector Garza, DDS
Roy Holexa, DDS
Tom Jacobsen, DDS
Leslie Penley, DDS
Bob Shirley, DDS
Barry Sockel, DDS

Fred Der


Jeffrey Gerhardt, DDS

44 Winter 2009 JAOS

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Oral Health

iabetes is a great concern for both the medical
and dental professions. Millions of Americans
are affected each year by this disease. Over
the last two decades there has been a thirty to
These patients also lose more teeth than patients who
have good control of their diabetes.
Diabetes can also affect the amount of saliva in the
mouth, leading to dry mouth and resulting in an
forty percent increase in diagnosed cases of diabetes, increased risk for cavities. Recurrent canker sores, white
especially among overweight children and adolescents, patches on the cheeks, and fungal infections can be an
since obesity is a major risk factor. But how can indication of poor glycemic control in a diabetic
diabetes affect your oral health? patient. Taste may also be altered in diabetic patients,
The Centers for Disease Control defines diabetes as a making it difficult to maintain a proper diet.
disease in which blood glucose levels are above normal. Patients with poorly controlled diabetes are at an
Most of the food we eat is turned into glucose-or sugar- increased risk of other complications, such as infections
for our bodies to use for energy. The pancreas produces and reduced healing. This may make it necessary for
a hormone called insulin to help glucose absorb into them to take antibiotics prior to certain dental procedures
the cells of our bodies. When you have diabetes, your including oral surgery. For patients taking insulin, it may
body either doesn’t make enough insulin or can’t use be necessary to consult with their physician in order to
its own insulin as well as it should. This causes sugar to increase the dosage in the case of an oral infection. It is
build up in your blood. also important for your dentist to know if you take
Diabetes can cause serious health complications, insulin because the use of local anesthetic can influence
including heart disease, blindness, kidney failure, and the effects of insulin and can result in hyperglycemia.
lower extremity amputations, and it is the sixth lead- So, if you have diabetes, make sure you take care of
ing cause of death in the United States. Some classic your teeth and gums. You may require more frequent
signs of diabetes are excessive appetite, excessive visits to the dentist and more rigorous follow-up treat-
thirst, and excessive urination, but the condition may ment to ensure optimum dental health. To offset the
also cause weight loss, irritability, drowsiness, and greater risk of gingival and periodontal problems, it is
fatigue. Diabetes, as well as any other medical condi- vital to control your blood glucose levels and to brush
tion, should be reported to your dentist so that and floss daily. Finally, seek regular dental care to help
proper care can be delivered. keep your mouth healthy and to obtain advice on how
When diabetes is not controlled it can lead to a to manage your diabetes.
number of dental complications because the high
glucose levels in saliva may help bacteria thrive in the
mouth. Diabetes also reduces the body’s resistance to
infection, and the body’s tissues, including the gums,
are likely to be affected. The most common and
potentially harmful oral health problems associated
with diabetes are gingivitis, periodontitis and rapid
loss of the bone that supports the teeth. According to
the American Dental Association periodontitis is often
linked to the control of diabetes. Patients who have
inadequate blood sugar control appear to develop
periodontitis more often and with greater severity.

This message is brought to you by your dentist, a proud member of the American Orthodontic Society and the AGpO.

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