TWEED PROFILE
published by
Volume #8
2009
CONTENTS
39 GIVE ME BRACES, AND I’LL GIVE YOU BONE! — ELIE WILLIAM AMM
BEIRUT, LEBANON
2
GOALS, CONCEPTS, AND GUIDELINES FOR COMPREHENSIVE CORRECTION OF
CLASS II MALOCCLUSIONS
HERB KLONTZ
OKLAHOMA CITY, OK
The Class II malocclusion is a difficult problem for the balance, harmony and proportion. Facial balance can
specialty of orthodontics. If the practitioner can rou- be quantified by the use of Merrifield’s Z angle1. It
tinely and successfully correct Class II malocclusions, is an excellent guideline because it allows the ortho-
he/she generally has a good idea of treatment plan- dontist to quantify the soft tissue response to tooth
ning and the proper delivery of force systems. The movement. This patient (Fig. 1) has a very protru-
goals that one must establish prior to treatment of any sive Class II facial pattern. The initial Z angle is 54º.
Class II malocclusion are the same goals that must be After treatment with a proper treatment plan and force
achieved during the correction of a less difficult mal- system, the Z angle is 73º. This young man (Fig. 2)
occlusion. These goals are esthetics, health and func- has a pretreatment Z angle of 58º and a posttreatment
tion, stability, and treatment in harmony with growth. Z angle of 76º. The correction of his high angle Class
A good differential diagnosis will lead to a treatment II malocclusion required a well formulated treatment
plan that will insure successful treatment. All treat- plan and a force system that paid particular attention
ment plans, no matter what the malocclusion, should to vertical control during tooth movement.
be based on the dimensions of the dentition. This is a
fundamental concept, and it must not be violated if the
resolution of the malocclusion
is to be successful. When one is
treatment planning the Class II
malocclusion, it is important to
“compartmentalize” the various
aspects of the problem into a) the
face, b) the skeletal pattern, and
c) the dentition. The purpose of
this paper will be to share some
diagnostic, treatment planning Fig. 1
and force system guidelines that
will enable the practitioner to routinely and success- THE SKELETAL PATTERN
fully correct the difficult Class II malocclusion. An understanding of the skeletal pattern must be an
integral part of any orthodontic treatment plan. It is
THE FACE - FACES FIRST!! very difficult to change the vertical dimension of a
The goal of orthodontic treatment is to improve facial particular patient. Therefore, for the patient to have
balance, harmony and proportion, or to maintain facial good facial esthetics at the end of orthodontic treat-
3
Fig. 2
Fig. 4
ment, the clinician must carefully study and complete- An important part of the total dentition space analysis
ly understand the skeletal pattern and how it will im- is the cephalometric correction factor or cephalomet-
pact the posttreatment facial result. These specimens ric discrepancy. Dr. Tweed actually measured the
(Fig. 3) are illustrative of the type and divergence of amount of mandibular incisor uprighting that was
problems with which the orthodontist must work. The needed to position the mandibular incisor upright
high angle patient and the low angle patient, and all over basal bone (Fig. 5). He then measured, at the
patients in between these extremes, must be carefully occlusal plane, the amount of millimeters it would
evaluated and treatment planned so that the skeletal take to put the mandibular incisors at a proper inclina-
pattern does not adversely effect posttreatment facial tion and multiplied his measurement by two because
esthetics. there were two sides of the arches. In today’s world
it is much easier to use a correction factor of .8 rather
than to measure the
cephalometric x-ray.
For example, if the
FMA is 30º or more,
FMIA should be
65º. Therefore, for a
patient whose FMA
is 30º, FMIA is 53º,
and IMPA is 97º, if
Fig. 3 one takes the FMIA
to 65º, there is a dif-
ference of 12º from Fig. 5
THE DENTITION 65º to 53º. The 12º
The final piece of the puzzle is the dentition. A total of needed correction is multiplied by the correction
dentition space analysis must include a tooth/arch factor of .8. The cephalometric correction is 9.6 mil-
discrepancy, a cephalometric discrepancy, and a curve limeters. This 9.6 millimeters is the amount of space
of Spee correction space requirement. The dentition is in both sides of the arch that it will take to upright the
divided into the anterior, midarch, and posterior seg- mandibular incisors in this particular example so that
ments (Fig. 4). The available space is measured. The the FMIA will be 65º. If FMIA is 65º, the patient will
required space is measured. The difference is either have “balanced” facial esthetics.
a surplus or a deficit. The posterior dentition area
must be carefully measured, and the expected increase Another important part of the total dentition space
must be considered when the posterior discrepancy or analysis is the measurement of the depth of the curve
surplus is determined.
4
of Spee. It takes space to level a curve of Spee! If the
curve of Spee is 3 millimeters deep on one side and 2
millimeters deep on the other, these values are added
together and divided by 2. In this example it will take
2.5 millimeters of space to level the curve of Spee.
All of these variables must be carefully considered
when treatment is being planned so that the Class II
patient will receive an esthetic, healthy, functional,
and stable result.
Fig. 6 Fig. 8
In summation, the clinician must carefully study the
face, the skeletal pattern, and the dentition in order to
arrive at a proper treatment plan for Class II malocclu-
sion correction. Growth and the effects of the treat-
ment plan, as well as the force system, on the patient’s
ability to manifest growth in a favorable direction
must be understood. All the pieces of the puzzle must Fig. 9
5
Fig. 10a
Fig. 12
of 30.9 millimeters. A summary of the space require- of the maxillary first premolars and the mandibular
ments along with the Class II occlusal disharmony second premolars. The pretreatment/recall facial pho-
(Fig. 12) illustrates a deficit of 16.4 millimeters in just tographs (Fig. 13) illustrate the drastic and dramatic
the anterior/midarch area. This 16.4 millimeters does improvement in facial esthetics. The cephalometic x-
not include the posterior discrepancy which can be rays and the tracings (Fig. 14a, b) confirm the correc-
resolved by extraction of third molars. The clinician tion of the malocclusion due to movement of the teeth.
must find 16.4 millimeters of anterior/midarch man- FMIA has increased from 59º to 72º. The Z angle has
dibular space to correct this young man’s problem. improved from 66º to 78º. ANB has been reduced
from 8º to 1º. The slides of the teeth after “settling”
of the dentition
(Fig. 15) illustrate
a healthy and func-
tional dentition.
Class II correction
cannot be accom-
plished without a
proper treatment
plan and a proper
force system, both
Fig. 11 of which allow the
clinician to take
Patient T.S. was treatment planned for the extraction advantage of the patient’s genetic potential for the
6
Fig. 14a Fig. 14b
Fig. 17
REFERENCE
Merrifield, L.L., The Profile as an Aid in Critically Evaluating Facial Esthetics, AJO/DO, 1966. 11, page 804-
822.
7
“IN PURSUIT OF A BEAUTIFUL FACIAL PROFILE”
KOHO HASE
KITAKAWABE SAITAMA, JAPAN
Fig. 4 - Not long ago gold teeth had been the symbol
of wealth and beauty
selves Yamato Minzoku (peace people) and have long
been affected by the philosophy of Zen, that requires
a spirit of acceptance of all nature. Therefore many
Japanese people might not criticize or discuss the mat-
Fig. 1 Fig. 2 ter of facial esthetics in public, or even in private.
After seeing the traditional Japanese dancing girl, the Our generation has changed its perception of facial
Geisha, (Fig. 2) Westerners might ask “What is the beauty. Caucasian stars like Hilary Duff, and Cam-
perception of Japanese facial beauty?” Is there any eron Diaz are very popular in Japan. Their lovely
difference between Japanese and western perceptions? facial beauty is quite acceptable.(Fig. 5) One of the
most popular young Japanese movie stars is Miss Ueto
Aya (Fig. 6). Her lateral profile was examined and it
8
was found that she has an Result
IMPA of 88°. Although Hase Dental Class I & II — 63 Samples
the profile of a Japanese is Tweed Value Before After Difference
different than the “Western FMIA 67 50.73 57.97 7.24
profile”, the perception
of good facial esthetics is FMA 25 33.67 34.10 0.43
virtually the same. Fig. 6 IMPA 88 95.60 87.98 -7.61SD4.3
SNA 82 82.34 81.48 -0.86
MATERIALS & METHODS SNB 80 76.80 77.23 0.43
The data from 80 patients treated with Tweed Mer- ANB 2 5.54 4.25 -1.30
rifield mechanics was studied and analyzed. These AO-BO 2mm 1.93 1.50 -0.43
80 patients, over the course of the past 13 years, have OCC PLANE 10 13.91 13.11 -0.8
enjoyed the success of the orthodontic treatment and Z ANGLE 75 56.58 67.51 10.94
are happy with their facial profiles. FAC. HT. INDEX .67 0.68 0.01
Fig. 8
In the sample are 27 Angle’s Class I malocclusions,
36 Angle’s Class II malocclusions and 17 Class III
malocclusions. Lat-
eral cephalograms Hase Dental Class III — 17 Samples
and study casts were Tweed Value Before After Difference
measured. The cepha- FMIA 67 59.53 67.35 7.82
logram measurements FMA 25 32.35 32.88 0.53
were performed by IMPA 88 90.08 82.17 -7.92
either traditional X-ray SNA 82 80.35 82.12 1.76
film tracing and/or by SNB 80 78.97 80.65 1.68
the software “Auto
Cad”. To know the ANB 2 0.76 0.89 0.13
deviation rate of the Fig. 7- Nose protrusion rate = AO-BO 2mm 4.35 0.82 3.53
length of nose tip to length of nose tip to SN/length OCC PLANE 10 11.47 10.24 1.24
SN line, a measure- of SN Z ANGLE 75 70.47 75.24 4.76
ment was made and the “protrusion rate of nose tip to FAC. HT. INDEX 0.69 0.69 0.00
SN” was calculated by the following equation (Fig. 7)
Protrusion rate of nose tip to SN= Length of the nose Fig. 9
tip to SN / Length of SN (%)
(Fig. 8). samples decreased 7.6° with a SD of 4.3°. Even the
Class III sample, which always requires an upright
The average pretreatment values of the 63 Class I mal- IMPA for dentition correction, had an IMPA decrease
occlusions and Class II malocclusions in the sample of 7.92° (Fig. 9).
before treatment were: FMIA 50.73°, FMA 33.67°,
and IMPA 95.60°. The values of the 17 Class III The protrusion rate of the nose tip to SN for Japanese
malocclusion sample were: FMIA 59.53, FMA 32.35°, and Caucasian Clinical Norm Bioprogressive Diagno-
and IMPA 90.08°. After the treatment, the average sis, by Nezu et. al is 43% and 52% respectively. The
value of the 63 Class I and Class II malocclusions im- average Length of nose tip to SN is 28mm and 52mm
proved to the following measurements: FMIA 57.97°, respectively. In my clinic the protrusion rate for the
FMA 34.10°, and IMPA 87.98°. The Class III group pre. and post treatment patients was 44% ( SDTEV
saw improvements to FMIA 67.35 , FMA 32.88°, 4.2%) and 45% respectively.
and IMPA 82.17°. The IMPA of Class I and Class II
9
The average length of nose tip to SN is 27.4mm (Pre.)
and 28.7mm (post.) respectively. There was a 1.3mm
increase due to orthodontic treatment (Fig. 7).
All the patients and their parents were satisfied with
the improved facial balance and harmony. There are
two samples (Fig. 10 - 17) who have similar pretreat-
ment and posttreatment cephalometric values that
correspond with the average for the Class I and Class
II malocclusion samples.
10
Hase Dental Class I & II — 63 Samples
Before After Improvement
FMIA 50.73 57.97 7.24
FMA 33.67 34.10 0.43
IMPA 95.60 87.98 -7.61
(-8.79 away from Japan Norm 96.8)
11
Pre Post
FMIA 39 49
FMA 45 43
IMPA 96 88
SNA 80 75
SNB 71 71
ANB 9 4
AO-BO 8 5
0CC 23 20
Z 48 60
UL 14 13
TC 16 14 Fig. 24
PFH 40 47
AFH 70 68
INDEX .58 .69
Fig. 25
Fig. 22
Fig. 26
Fig. 23
12
Pre Post
FMIA 39 46
FMA 48 46
IMPA 93 88
SNA 82 82
SNB 76 76
ANB 6 6
AO-BO -1 4
0CC 23 18
Z 54 63
UL 12 10
TC 15 14
PFH 53 50
AFH 82 80
INDEX .65 .62
Fig. 27
Fig. 30
Fig. 28
Fig. 31
13
CONCLUSION
Due to the Japanese population having a high FMA
value, the use of Tweed Merrifield Mechanics has to
focus on the IMPA rather than the FMIA.
14
ESTHETICS AND DIRECTIONAL FORCES IN PATIENTS TREATED IN TWO PHASES
The increased awareness of craniofacial growth and orthodontic appliances in order to work on dental
the possibility of using growth as an “orthodontic compensations, the cant of the occlusal plane, and
appliance” offers the opportunity of treating younger functional interferences. This type of treatment will
patients. The opportunity to treat younger patients prepare the patient for a second phase treatment in
requires the orthodontist to understand that he/she is which growth is already “redirected” and ready to
treating not only teeth, but growing faces. Orthodon- contribute pure directional forces which is guaranteed
tics is changing facial balance and harmony in chil- by Tweed mechanics.
dren who are preparing to become adults. So, which
direction should the face be moved? Or, better, which The following clinical case reports illustrate this con-
direction should growth be moved? Growth can be an cept.
orthodontic appliance.
The plan of treatment in younger children must take Merrifield L:L:; Cross J:J:: Directional forces. Am J
into account the effects of “growth”. Is growth free to Orthod 1970; 57(5): 435-463
express itself or is there any necessity to give a new
direction, a new freedom? Is the natural growth of
the patient in the direction of the correction needed?
Are there any interferences or dental compensations
that might be able to push the face towards a pathway
which guarantees future facial esthetics, function and
stability?
15
Patient 1: This patient has an Angle’s Class II occlusion and bilateral posterior crossbites.
16
Patient 1: The palatal construction is corrected.
17
Patient 1: The posttreatment face and teeth.
18
Patient 1: Recall face and teeth.
19
Patient 2 – Pretreatment: Palatal constriction and a tooth arch discrepancy.
20
Patient 2 – Posttreatment: The face and the teeth.
21
Patient 2 – Recall: The face and the teeth.
22
THE USE OF TEMPORARY ANCHORAGE DEVICES (“TAD’S”)
IN TWEED -MERRIFIELD DIRECTIONAL FORCE ORTHODONTICS
Daniel George
HOLLAND, MI
The purpose of this presentation is to illustrate the use TAD’s can be used to intrude teeth (Fig. 1a, b). The
of technology that can help us achieve our treatment maxillary canine to canine segment can be intruded
goals. Over the past several years, an alternative, ad- and retracted simultaneously. Treatment time is re-
junctive appliance, the Temporary Anchorage Device duced (Fig. 2a, b).
(TAD) has arrived. It is now possible to prepare the
ideal mandibular arch and not compromise it, as well It is possible to distalize the maxillary arch as far as
as to correct the Class II or Class III malocclusion by necessary without the use of headgear (Fig. 3a, b).
using TAD’s for skeletal anchorage.
Fig. 2a: TAD’s used to
TAD’s can provide virtually 100% skeletal anchorage. retract and intrude the
anterior segment. A new
They help increase control in all three planes of space.
way to reduce treatment
It is possible to retract, protract, intrude, upright im- time in a controlled man-
pacted teeth, etc., without patient cooperation. TAD’s ner.
have also reduced the need for orthognathic surgery to
correct some skeletal dysplasia’s. In some instances
TAD’s eliminate implants to replace congenitally
missing teeth — such as mandibular second premo-
lars.
Fig.1a: Absolute maxillary
incisor intrusion using TAD’s.
23
One can retract the mandibular arch to upright man-
dibular incisors to the desired position without head-
Fig. 3a: Distal “en masse” move-
ment with 1.5mm x 9.0mm TAD gear or Class III elastics (Fig. 4a, b, c).
and 250g Niti spring.
Open bite patients can be treated by intrusion of max-
illary (or mandibular) posterior teeth without using
the unstable biomechanics of extruding maxillary and
mandibular anterior teeth to close the bite (Fig. 5).
Fig. 3b: 5 months later. Note the
need for constant, active lingual These are just some of the possibilities of how TAD’s
root torque in the maxillary inci- can help orthodontics. TAD’s help eliminate the
sors during distal en masse force
application in order to prevent
patient compliance issue and can reduce the need for
lingual crown inclination.
headgear, elastics, and other non-compliant therapies.
Fig. 4a: Class III with TAD’s in the Oblique Ridge to retract the mandibular
arch.
Fig. 5: Open bite closure with TAD’s. Note: No upper anterior brackets to prove the bite was closed with up-
per posterior intrusion only.
24
EXTRACTION OF A MANDIBULAR INCISOR IN ADULT ORTHODONTIC TREATMENT:
AN ACCEPTABLE COMPROMISE?
GIOVANNI BIONDI
VARAGO DI MASERADA (TV), ITALY
During orthodontic treatment of adults, compromise However, when we analysed the group of 1,438 adult
can be a daily necessity. Extraction of a mandibular patients, the percentage of patients who had an with
incisor is a compromise extraction choice for some extraction of a mandibular incisor increased to 5.91%
patients. The aim of this study was to determine the and even reached 14.46% if one took into consider-
conditions in which this kind of compromise can be ation only the 588 adult patients for whom extraction
deemed acceptable. was mandatory.
MATERIAL AND METHOD Hence Kokich’s use of the terms “relatively rare”
A rapid review of the literature revealed that, as far makes sense and, in relation to the “proper situation”
back as 1959, Berger1 was questioning the wisdom of (Kokich’s words once again), one can mention Bahre-
extracting a mandibular incisor to treat patients with mann’s article in which he advocates the extraction
considerable mandibular dental crowding. Richardson2 of a mandibular incisor as the first therapeutic choice
in 1963 and Levin3 in the following year raised the in “…Class I malocclusions with normal maxillary
same question. In 1975, Brand and Safirestein4 fol- dentition and a good buccal interdigitation, which
lowed by Bahremann5 in 1977 presented a series of in- show arch length deficiency in the mandibular anterior
dications for which extraction of a mandibular incisor segment of over 4 to 5mm and an anterior ratio greater
could be regarded as the treatment of choice: therefore than 0.83 are the cases of first choice for extraction of
a shift occurred from “therapeutic compromise” to one mandibular incisor.”
“therapeutic indication”.
By using this concept and by observing our own pa-
In 1984, Kokich and Shapiro6 wrote: “…although the tient pool, we looked for the dental and cephalometric
indications for this type of extraction are relatively parameters of the 85 patients treated with extraction of
rare, the possibility of mandibular incisor extraction a mandibular incisor.
should be a part of every clinician’s portfolio of treat-
ment techniques. If it is carefully planned and execut- Cephalometric parameters were (Table 1):
ed in the proper situation, mandibular incisor extrac- • FMA: the value ranged between 16° and 33° with
tion can be an effective way of satisfying a particular an average of 24.88° (normodivergent)
set of treatment objectives”. • IMPA: the value ranged between 88° and 103°
with an average of 93.08° (incisor slightly tipped
By subsequently analyzing the records of our patients, on its bony base)
we noted that, out of 3,925 patients in our practice, the • ANB: the value ranged between -2° and 6° with an
85 patients who had been treated with extraction of a average of 2.29° (skeletal Class I)
mandibular incisor represented 2.16% of our patients.
25
Table 1: Cephalometric Parameters
FMA 24.88 Range 16 33
IMPA 93.08 88 103
ANB 2.29 -2 6
Fig. 3
Fig. 1
Table 2: Dental – 85 Patients
Fig. 4
Crowding 5.38 Range 3 8
Bolton Index 79.02 74 86 Our experience has led us to
add another factor to this list,
Once the decision has been made to treat a patient
namely, incisor axis (Fig. 6).
by extracting a mandibular incisor, it is important to
In similar periodontal or end-
determine which incisor should be extracted. Bahre-
odontic situations, the choice
mann, the author who has contributed the most to
of extraction will involve the
codifying the choice for this type of treatment, advo-
incisor which will best facili-
cates four factors that need to be kept in mind:
tate uprighting of the remain-
• amount of mandibular anterior arch length defi-
ciency (Fig. 2) ing three incisors. It is there-
• amount of anterior root ratio (Fig. 3) Fig. 5 fore important to carefully
• periodontal and tooth health condition (Fig. 4) examine the axes of the teeth
• maxillary and mandibular midline relationship without being influenced exclusively by crowding
(Fig. 5) because to do so might lead one to extract the tooth
26
Fig. 6 Fig. 8
• skeletal Class I (or dental Class III)
• normodivergence of the bone base
• antero-inferior crowding ranging between 4 and
5mm
• a high Bolton index (ideally above 0.83)
• a judicious choice of the incisor to be extracted
bearing in mind periodontal and endodontic health,
as well as the axes and the shapes of the incisors.
27
CASE REPORT: NONSURGICAL CORRECTION OF A CLASS II, DIVISION 1
DEEP OVERBITE SKELETAL MALOCCLUSION IN AN ADULT PATIENT
Fig. 1
Fig. 3
28
molars was Angle’s Class II. Although clicking was suggested that the Cranial Facial Difficulty Total of
noted in the left joint during opening, the patient could 137 was attributable to unfavorable positions of the
open more than 40mm and had no spontaneous pain or maxilla and mandible in the horizontal and vertical
tenderness on motion. (Fig. 4) planes.
The initial orthopantomogram showed a small amount
Ceph. Difficulty
Normal Range Difficulty
Value Factor
FNA 22-28 31.5 5 17.5
29
obicularis oris and mentalis muscles on lip closure
disappeared. The opening click in the left joint re-
solved. The final intraoral photographs (Fig. 9) show
that the same occlusion as predicted with the pretreat-
ment “setup” casts was obtained. Favorable changes
were produced cephalometrically: FMIA from 45.5°
to 51.0°, FMA from 31.5° to 31.0°, IMPA from 103°
to 98°, AO-BO from 11.0mm to 5.5mm and Z Angle
from 54.0° to 66.0°. (Fig. 10, Fig. 11) The overjet and
overbite were also improved from 11mm to 4mm and
Fig. 7
The molar relationship would remain an Angle’s Class
II at the end of treatment.
TREATMENT RESULTS
After active treatment and 2 years of retention, the
convex profile with a protrusive upper lip and an
everted lower lip was improved to a balanced fa-
cial and lip profile. (Fig. 8) The severe strains of the
Fig. 10
Fig. 8
30
Fig. 11
Fig. 12
Fig. 13
31
CONCLUSION
A combination of orthodontic treatment and orthog-
nathic surgery would have been ideal for this patient.
However, the patient refused this plan because it
required hospitalization. She chose the compromise
option of only orthodontic treatment that was based on
the Tweed-Merrifield Philosophy. A pleasing pro-
file and a functional occlusion were obtained due to
extremely good patient compliance with a high-pull
Fig. 14
J-hook headgear.
REFERENCES
1. Vaden J.L., Dale J.G., Klontz H.A.: The Tweed-Merrifield
Edgewise Appliance: Philosophy, Diagnosis and Treatment.
In: Graber T.M., Vanarsdall R.L., Vig K.W.L.: Orthodontics:
Current Principles and Techniques. Elsevier Inc, 2005:675-
715.
2. Merrifield L.L., Klontz H.A., Vaden J.L: Differential di-
agnostic analysis system. Am J Orthod Dentofacial Orthop
106:641-648, 1994.
3. Emrich SC. An adult nonsurgical patient whose treatment
required combined dental disciplines. Am J Orthod Dentofac
Orthop 1996; 110: 163-9.
4. Munoz AM. Correction of a Class II deep overbite skeletal
and dental asymmetric malocclusion in an adult patient. Am
J Orthod Dentofacial Orthop 2005;127:611-7.
32
TWEED-MERRIFIELD PHILOSOPHY: SOME CLINICAL DETERMINATIONS FOR
THE ADULT PATIENT TREATMENT
SERGIO A. CARDIEL RÍOS
MORELIA, MICHOACÁN, MEXICO
CASE DESCRIPTION
The case report of a 24-year old Mexican patient
is presented. He had a class II division 1 malocclu-
sion with a negative medical history. The patient’s
complaint was that he exhibited an unesthetic dental
appearance when smiling and he had some discomfort
when chewing. A “deficient” chin was also consid-
ered when evaluating the patient’s facial balance (Fig.
1).
33
The panoramic radiograph showed considerable
divergence in root parallelism, the presence of maxil-
lary third molars and the impacted mandibular left
third molar. According to the periodontist, the patient
showed acceptable bone levels except in edentulous
areas (Fig. 3).
Fig. 3
Cephalometrically, his maxillo-mandibular relation-
ship was retrognathic SNB (77°). His FMA (29°) and
FHI (72°) confirm a, normal vertical skeletal pattern.
Occlusal plane (16°) was high but the Z angle (67°)
was close to normal (Fig. 4).
Fig. 5
34
Maxillary lateral incisors were carefully managed
in order to consider a morphologic mesio-distal re-
lationship in shape, proportion, width and length for
the future prosthetic restorations. The dentist placed
laminate veneers during the retention period once gin-
gival recontouring was done and gingival health was
assured. The maxillary and mandibular first premolars
Pre Restorative Phase
were reshaped with a bur to give them a “canine ap-
pearance” (Fig. 6).
RESULTS
The face shows harmony and balance. The smile line
and buccal corridors have improved as has the nose-
Post Restorative Phase lip-chin spatial relationship (Figs. 7, 8, 12 and 13).
Teeth and gingiva are healthy and esthetic. Good “ar-
chitecture” of the gingival complex is evident. A Class
I occlusion on both sides was achieved along with
proper “canine” guidance. The occlusal plane was
controlled (Figs. 2, 8 and 10). Overbite and overjet
are ideal, thus providing for optimal anterior guidance
(Fig. 8).
Fig. 6
35
Fig. 9 Fig. 10
Fig. 11
Fig. 12
36
Fig. 13
The panoramic radiograph shows acceptable root Merrifield’s Z angle quantified the harmony, balance
parallelism with good health of the roots and the and improvement of the face (Figs. 10, 11 and 13).
alveolar bone (Fig. 9).The cephalometric tracing Superimposition on S-N verifies vertical control of the
confirms maxillo-mandibular and dental changes. maxillo-mandibular complex since teeth were moved
Control of FMA, ANB and facial height is confirmed. with vertical, sagittal and transverse control (Fig. 11).
REFERENCES
1. Kokich, V.: Esthetics and Anterior Tooth Position: An Orthodontic Perspective, Part I: Crown Length; Part II: Vertical Position;
Part III: Mediolateral Relationships, J. Esth. Dent. 5:19-23, 174-178, 200-207, 1993.
2. Kokich, V.: Esthetics: The Orthodontic- Periodontic- Restorative Connection. Semin. Orthod. 2:21-30. 1996.
3. Mathews, D.P., Kokich,V.: Managing Treatment for the Orthodontic Patient with Periodontal Problems. Semin. Orthod.. 3:21-28,
1997.
4. Gartrell, J.G., Mathews, d.p.: Gingival Recession: The Condition, Process and Treatment. Dental Clin. North AM., 1:199-
213,1976.
5. Vanarsdall,R.L.: Periodontal Problems Associated with Orthodontic Treatment. In Barrer H. Editor: Orthodontics: The State of
the Art, Philadelphia, 1981.
6. Vanarsdall, R.L.: Periodontal Considerations in Corrective Orthodontics. In Clark JW Editor: Clinical Dentistry, Vol 2, Hager-
stown, MD, 1978, Harper & Row.
7. Kokich, V., Nappen, D., Shapiro,P.: Gingival Contour and Clinical Crown Length: Their Effect on the Esthetic Appearance on
Maxillary Anterior Teeth. AJO. 86:89-94,1984.
8. Edwards, J.: A Surgical Procedure to Eliminate Rotational Relapse. AJO 57:35, 1970.
37
9. Zachrisson, B.U.: Orthodontics and Periodontics in Clinical Periodontology and Implant Dentistry. 3rd Ed. J. Lindhe, T. Karring,
and N:P: Lang, Munksgaard, Copenhagen, pp 741-793, 1997.
10. Kokich, V. Spear, F.: Guidelines for Managing the Orthodontic-Restorative Patient. Semin. Orthod. 3:3-20. 1997.
11. Zachrisson, B.U.: Esthetic Factors Involved in Anterior Tooth Display and the Smile: Vertical Dimension, JCO, Vol. 32-7, July
1998.
12. Janzen, E.K.: A Balanced Smile- a Most Important Treatment Objective, AJO, 72:359-372, 1977.
13. Merrifield, L. Klontz, H., Vaden,J.: Differential Diagnosis Analysis System. AJO-DO 1994; 106: 641-648.
14. Vaden, J., Dale, J.,Klontz,H.: The Tweed-Merrifield Edgewise Appliance. In Graber and Vanarsdall Eds. Orthodontics: Current
Principles and Techniques. 3rd ED. Mosby 647-707. 2003.
15. Jegou,I.: Smile… With Tweed Technics, J.Ch. Tweed Found., Vol 14. Pp. 97-109.1986.
16. Isaacson, Lindauer and Rubenstein: Incisor Torque Control, AJO- DO, May 1993, pp. 428-438.
17. James,R.: Evaluation: Tipped Teeth, Anchorage, and Tweed Occlusion. J Charles Tweed Foundation. 1983; 11:123-141.
18. Peretta, R.: Biomechanical Analysis of the Sequential Class II System. J Charles Tweed Foundation. 1992; 18: 15-35.
19. Lamarque, S.: The Importance of Occlusal Plane Control During Orthodontic Mechanotherapy. AJO DO 1995; 107: 548-558.
20. Lamarque, S.: Esthetic Prognosis and Edgewise Therapeutics. Int Orthodontics 2003; 1:257-284.
38
GIVE ME BRACES, AND I’LL GIVE YOU BONE!
Current practice trends for treatment of alveolar bone alternate proposal was orthodontic extrusion of #’s 23
deficiency before implant placement advocate surgi- and 24 until their extraction (Fig. 2 a, b, c).
cal procedures such as bone grafting, GBR, distraction During this type of orthodontic “extraction”, teeth
osteogenesis, etc. However, the usefulness of orth- bring with them new bone suitable for implant place-
odontic tooth movement in generating alveolar bone
and soft tissue suitable for implant placement may be
underestimated, even when properly indicated and
when traditional ways have their limitations.
Fig. 1a: “fake gum ─b: gingival recession ─c: vertical bone
defect
39
Fig. 5: a. extraoral and intraoral photographs showing lip incompetence and generalized spaces – b. x-ray
showing fractured right central incisor.
Fig. 6: a. endodontic treatment of the apical fragment – b. orthodontic extrusion of the apical fragment – c.
central incisor inset to guide the extrusion axis in the alveolar bone
40
Fig. 7: a. height of the bone gained after orthodontic extrusion – b. height of
the attached gingiva gained and soft tissue profile with 2 to 3 mm of over-
correction to be used by the periodontist at the time of implant placement
Fig. 8: extraoral and intraoral photographs after orth-
for better esthetics.
odontic treatment
But
the periodontist was facing three major problems (Fig.
10): a.) narrow crestal bone that required major sur-
gery for its enlargement b.) a large mesio-distal space
that was too large for one implant and too small for
two implants, and c.) a mental foramen position that Fig. 11: a. lateral view for distalising 44. b. Occlusal view show-
necessitated a short implant, or an attempt to avoid the ing the thickness and volume of the crestal ridge mesila to 44.
area entirely and place the implant in the middle of the c- d. implant placement in site of 44. e. x-ray of the implant in
place avoiding the mental foramen.
41
if a potential anterior cross bite was to be avoided. A bridge that used the lateral incisor implant abut-
After an initial phase of periodontal therapy the ex- ments was then fabricated (Fig. 16b).
traction of the “weakest” mandibular incisor and the
extraction of the maxillary central incisors (Fig.13a) These patient records illustrate the symbiotic relation-
was proposed. The extractions would be followed by ship between orthodontics and other specialties in
mesial movement of the maxillary lateral incisors into dentistry. Working in teams offers the best results for
the central incisor positions with anchorage provided our patients.
by molar implants. The laterals would bring bone
behind them suitable for two implants in their former
sites (Fig. 13a, b, c), (Fig. 14a, b, c), (Fig. 15a, b, c).
Fig. 15: 3-D topography of the implant site a: vertical bone height – b: hori-
zontal bone thickness during implant placement – c: implant axis inclination
42
SHOULD WE LEARN WIRE BENDING IN THE 21ST CENTURY?
CAMILLE MEDAWAR
PARIS, FRANCES
The 1970s was an exciting decade for orthodontics. wires are placed to realign the tooth, class II elastics
One development was the first “fully programmed” have to be discontinued. Instead, an off-set bend was
Andrews appliance. Commercial interest developed made on a .018X.025 S.S. wire. The retraction of the
rapidly around this approach to mechanics. While maxillary incisors continued with the patient wearing
Andrew’s stated that one prescription was not enough short and light elastics. No treatment time was wasted
to cover all common malocclusions, his admonitions on a realignment procedure. Figures 1b and 1c show
were, unfortunately, disregarded by the specialty. The satisfactory mandibular arch alignment and occlusal
“one fits all” logic prevailed and orthodontic compa- results.
nies invested literally millions of dollars into the de-
Fig. 1a – Lateral incisor rebonded and off-set bend is put on the arch
Fig. 1b – Lower arch alignment
Fig. 1c – Final occlusal results
velopment of pre-adjusted brackets that were supposed In the next example, this class I hyperdivergent patient
to give teeth their correct position with minimum wire had severely malpositionned maxillary and mandibu-
bending. This paper shows clinical examples in which lar left canines (Fig. 2a, 2b, 2c).
early individualized control is necessary in order to
reach acceptable occlusal results. Figures 3a, 3b, 3c show the evolution of the treatment.
Third order control is poor on both maxillary canines
All orthodontists have been confronted with very com- four weeks after the insertion of a .019X.025 NiTi
mon situations such as shown in Figure 1a. A bond wire. In the mandibular arch second premolar extrac-
failure occurred and the lateral incisor rotated. If light tion and routine alignment procedures gave enough
43
place for the left canine.
However, because of its
initial ectopic position,
the midline was deviated
2.5mm. An attempt to
correct the midline with
a power chain produced a
toe-out on the first molar
Fig. 2a, 2b, 2c on the same side.
44
Fig. 6a, 6b, 6c, 6d
Fig. 7a–7d. Severe midline deviation and total crossbite on the left side.
A careful look at Figures 5e shows poor arch coordi- result without orthognatic surgery. Treatment objec-
nation. The expanded mandibular arch and unsuffici- tives were to re-open space for an implant, rebuild
ant lingual crown torque in the mandibular right quad- arch coordination and close the space.
rant appear to be the problem. The adequate amount
of third order was placed on the canine and the first To push the left central incisor 5mm distally using an
premolar. Figures 6a - 6d show satisfactory occlusal undersized arch would necessitate 2nd order bends in
and facial results after individualized wire bending. the wire to keep the roots parallel. On the other hand,
non-individualized arches would only prepare the
In the last example, this 37 year old male patient pre- patient for surgery. Arch coordination was done with
sented with a minor skeletal Class III. The maxillary expanded maxillary arches along with lingual torque
arch collapse was due to the impacted maxillary right to prevent relapse in both arches. Post-retention photos
central incisor (Fig. 7a - 7d). The patient was aware of (Fig. 8a - 8d) show acceptable occlusal results despite
his midline deviation and asked for the best possible some bone loss around the implant.
45
CONCLUSIONS
These clinical examples show that normal torque and
angulation are different from one patient to another.
Final tooth position is directly related to the initial
malocclusion and the response of the teeth to forces
generated by wires and brackets. If better cusp in-
terdigitation is reached, research has demonstrated
that treatment results will show better stability. In-
dividualizing the forces and moments according to
the patient’s needs with wire bending helps solve the
problem of unequal tooth deviation from normality.
Wire manipulation must therefore be a concern during
all stages of treatment.
46
TWO PHASE TREATMENT IN CLASS TWO CORRECTION
ALBERTO CASALI
REGGIO EMILIA, ITALY
From time immemorial, orthodontists have tried to “correct” growth phase, 2) the dental crowding should
modify craniomandibular growth with fixed or re- be only mild to moderate, and 3) good compliance is
movable appliances, both in Class III and in Class II absolutely necessary.
patients, in order to improve skeletal deficits.
Choosing the correct time for Class II intervention is
essential. The clinician must recognize the pre-puber-
al growth peak in order to exploit the growth poten-
tial.1 It is not useful to begin therapy too early if the
goal is to gain significant mandibular growth.2
Orthodontics has various devices that attempt this The picture repre-
change sents the direction of
the force that acts on
• Intermaxilary class II elastics the maxilla’s center
• Fixed orthopedic appliances (Herbst, Jasper-Jump- of resistance with the
er, SUS, etc…) Sander appliance.
• Functional Appliances (Frankel, Bionator) If the inclination of
sledges is 60°, the
How does an activator work? — It positions the man- vector of the force
dible forward acts exactly on the
line of this resistance
There are three issues that must be addressed if activa- centre. If the inclina-
tor therapy is considered: 1) the patient must be in the tion of the sledges is
47
55°, the vector acts over the center of resistance. If an Here we present the cephalograms and the intraoral
open bite has to be reduced, it’s useful to increase the pictures before treatment, after BJA treatment and
angulation of the sledges to 65° in order to make the after refinement with an edgewise appliance.
vector act behind the center of resistance.
REFERENCES
48